Ministry of Health

Republic of Rwanda.

Basic Paediatric Protocols

February 2014 Edition

Table of Contents.
Topic Page Number
Acknowledgements / Principles 3-5
Clinical Audit and Hand hygiene 6-8
Drugs
Basic Formulary 9 - 10
Emergency drugs – dose charts
 Diazepam and Glucose 11
 Phenobarbitone and Phenytoin 12
Intravenous antibiotics (age > 7 days) 13
Oral antibiotics 14
Maintenance Fluid / Feed Volumes – not malnourished 15
Triage 16
PaediatricManagement guidelines
Infant / Child resuscitation 17
Emergency care – Signs of Life 18
Intra-osseous line 19
Prescribing Oxygen 20
Convulsions 21
Diarrhea / dehydration 22
 Fluids for severe and some dehydration 23
Malaria 24
 AntiMalaria drug doses 25 - 26
Malnutrition 27 - 28
 Emergency fluids & feed recipes 29 - 30
 Feeding 31
Meningitis 32
Respiratory disorders
 Pneumonia 33-34
 Asthma 35
HIV – PITC and influence on acute treatment 36-38
Newborn Care Management Guidelines
 Newborn resuscitation 39
 Neonatal Sepsis / Prematurity / VLBW 40
 Neonatal Jaundice 41-43
 Newborn care notes, treatment and early nutrition 44
 Newborn feeds / fluids 45-47
 Newborn drugs 48
Weight for Length Charts for children aged 0–23 mo 49-50
Weight for Length Charts for children aged 2- 5 years 51-52
Weight for age estimation 53
Notes 54
Supportive institutions 55

2
Principles of good care:

1) Facilities must have basic equipment and drugs in stock at all times
2) Sick children coming to hospital must be immediately assessed
(triage) and if necessary provided with emergency treatment as soon
as possible.
3) Assessment of diagnosis and illness severity must be thorough and
treatment must be carefully planned. All stages should be
accurately documented.
4) The protocols provide a minimum, standard and safe approach to
most, but not all, common problems. Care needs to be taken to
identify and treat children with less common problems rather than just
applying the protocols without thinking.
5) All treatments should be clearly and carefully prescribed on patient
treatment sheets with doses checked by nurses before
administration. (Please write dose frequency as 6hrly, 8hrly, 12hrly
etc rather than qid, tid etc)
6) The parents / caretakers need to understand what the illness and its
treatment are. They can often then provide invaluable assistance
caring for the child. Being polite to parents considerably improves
communication.
7) The response to treatment needs to be assessed. For very severely ill
children this may mean regular review in the first 6 – 12 hours of
admission – such review needs to be planned between medical and
nursing staff.
8) Correct supportive care – particularly adequate feeding, use of
oxygen and fluids - is as important as disease specific care.
9) Laboratory tests should be used appropriately and use of
unnecessary drugs needs to be avoided.
10) An appropriate discharge and follow up plan needs to be made when
the child leaves hospital.
11) Good hand washing practices and good ward hygiene improve
outcomes for admitted newborns and children.
Specific policies:

 All children admitted to hospital and all newborns requiring medical

treatment – even if born in hospital – should have their own inpatient
number and set of medical records. Admission should ideally be
recorded using a standardized paediatric or newborn admission record
 Medical records are a legal document and entries should be clear,
accurate and signed with a date and time of the entry recorded
 All paediatric admissions should be offered HIV testing using PITC
 All newborn admissions aged < 14 days should receive Vitamin K unless
it has already been given.
 Routine immunization status should be checked and missed vaccines
given before discharge.
 All admissions aged >6m should receive Vitamin A unless they have
received a dose within the last 1-month. (Malnourished children with eye
signs receive repeated doses).

Admission and Assessment:

 All admitted children must have weight recorded and used for calculation
of fluids / feeds and drug doses.
 Length / Height should be measured with weight for height (WHZ) used
to establish nutritional status
 Respiratory rates must be counted for 1 minute.
 Conscious level should be assessed on all children admitted using the
AVPU scale where:
o A = Alert and responsive
o V = responds to Voice or Verbal instructions, e.g. turns head to
mother’s call. These children may still be lethargic or unable to
drink / 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 child’s sternum
should result in the child pushing the hand causing the pain away. In
a child 9 months and younger they do not reliably locate a painful
stimulus, in these children if they bend the arms towards the pain and
make a vigorous, appropriate cry they respond to pain = ‘P’. Children
in this categorymust be lethargic or unable to sit up or drink /
breastfeed (prostrate).
o U = Unconscious, cannot push a hand causing pain away or fail to
make a response at all.
 Children with AVPU <A should have their blood glucose checked. If this
is not possible treatment for hypoglycemia should be given.
 The sickest newborns / children on the ward should be near the nursing
station and prioritized for re-assessment / observations.

4
Clinical audit and use of the protocols
1. Clinical audit is aimed at self-improvement and is not about finding who
to blame.

2. The aims are for hospitals to diagnose

key problems in providing care - it is
essential that identifying problems is
linked to suggesting who needs to
act, how and by when to implement
solutions. Then follow up on whether
progress is being achieved with new
audits. Identify new problems and
plan new actions etc.

3. Hospitals should have an audit team comprising 4 to 8 members, led by

a senior clinician and including nurses, admin, lab, nutrition etc. 1-2
people, usually MO and nurses should be selected on a rotating basis to
perform the audit and report back to the audit team and department
staff. Deaths and surviving cases can be audited.
Records of all deaths should be audited within 24 hours of death

4. Use an audit tool to compare care given with recommendations in these

protocols and other guidelines ([Link] TB, HIV/AIDS) and the most up to
date textbooks for less common conditions.

5. Was care reasonable? Look for where improvements could be made in

the system of care before the child comes to hospital (referral), on arrival
in hospital (care in the OPD / MCH etc), on admission to a ward, or
follow up on the ward.

6. Look at assessments, diagnoses, investigations, treatments and whether

what was planned was done and recorded. Check doses and whether
drugs / fluids / feeds are correct and actually given and if clinical review
and nursing observations were adequate – if it is not written down it
was not done!

7. Look at several cases for each meeting and summarize the findings
looking for the major things that are common and need improving.
Then record the summaries for reporting.

5
Hand Hygiene

 Good hand hygiene saves lives

 Gloves can easily become contaminated too – they do not protect
patients
 Alcohol hand-rubs (or alcohol with glycerin) are more effective than
soap and water and are recommended
o If hands are visibly dirty they must be cleaned first with soap and
water before drying and using alcohol hand-rub
o The alcohol hand-rub must be allowed to dry off to be effective
o If alcohol hand-rub is not available then hands should be washed
with simple soaps and water and air-dried or dried with disposable
paper towels
 Hand hygiene should be performed:
o After contact with any body fluids
o Before and after touching a patient and most importantly before
and after handling cannula, giving drugs or performing a
procedure. Suction)
o Before and after touching potentially contaminated surfaces (e.g..
cot sides, dirty mattresses, stethoscopes)
 Patients and caregivers should wash hands carefully after visits to the
bathrooms or contact with body fluids

 Recipients for alcohol and soap should be regularly maintained

according to infection control guidelines
 Instruments (e.g. stethoscope) should also be cleaned with chlorate
solution
Use of Alcohol Hand rub / gel

6
Appropriate hand-washing with soap and water

7
Essential Drugs Doses
Adrenaline 1 in 10,000 To make this strength dilute 1 ml of 1 in 1000
adrenaline in 9 ml water for injection to make
10mls. Give 0.1ml/kg in resuscitation.
Albendazole Age < 2yrs, 200mg stat, Age ≥ 2yrs, 400mg stat
Aminophylline- iv Newborn Loading dose 6mg/kg IV over 1 hour or
ONLY used in hospital rectal, Maintenance (or oral): Age 0-7 days -
inpatients! 2.5mg/kg 12hrly, Age 7-28 days 4mg/kg 12hrly.
Astma: 6mg/kg IV first doseover 30 mins
Amoxicillin Neonate Page 46, other Page 15
Ampicillin 50mg/kg/dose 12hourly
Artemether- Lumefantrine Page 26
Beclomethasone Age < 2yrs 50-100 micrograms 12hrly, ≥ 2yrs
100-200 micrograms 12hrly
Benzyl Penicillin (X-pen) Neonate Page 46, other Page 14
Caffeine 20mg/kg loading dosis, from day 2 10mg/kg/d once a
day with ngt
Ceftriaxone Neonate Page 46, other Page 14
Chloramphenicol - Page 14 and 15
Ciprofloxacin - oral Dysentery dosing: Page 15
Clotrimazole 1% Apply paint / cream daily
Dexamethasone For severe croup 0.6mg/kg stat
Cloxacillin Neonate Page 46, other Page 15
Co-trimoxazole– 240mg/5ml syrup 480mg tabs
Weight
pneumonia dosing 12hrly 12hrly

(4mg/kg Trimethoprim & 2 - 3kg 2.5mls ¼

20mg/kg 4 - 10kg 5mls ½
sulphamethoxazole) 11 - 15 kg 7.5ls ½
16 - 20 kg 10mls 1

8
Diazepam - iv 0.3mg/kg (=300 mcg/kg) &See separate chart
Diazepam - rectal 0.5mg/kg (=500 mcg/kg) &See separate chart
Digoxin 5 mics/kg 12 hrly; No loading dose
Furosemide 0.5 to1mg/kg up to 6 hrly
Gentamicin Neonate Page 46, other Page 14
Ibuprofen 5 - 10 mg/kg 8 hourly
Iron 6 mg/kg/day for treatment; 2 mg/kg/day
in prophylaxis
Mebendazole (age > 1yr) 100mg 12 hrly for 3 days or 500mg stat,
Metronidazole - oral Neonate Page 46, other Page 14
Morphine <1 month, 150mcg/kg, 1-11 months 200mcg/kg,
1 - 5yrs 2.5 - 5 mg, 6 – 12 yrs 5 – 10 mg
Multivitamins <6 months 2.5mls daily, >6months 5mls 12 hrly
Nystatin (100,000 IU/ml) 1ml 6hrly (2 weeks in HIV positive children)
Paracetamol 10-15mg / kg 6 to 8 hrly
Pethidine, im 0.5 to 1mg / kg every 4- 6 hours
Phenobarbitone Page 13
Potassium - oral 1 - 4 mmol/kg/day
Prednisolone - tabs Asthma 1mg / kg daily (usually for 3 days)
Quinine Page 26
Salbutamol IV in hospital only over 5 min– <2yrs 5
IV therapy should only be microgram/kg, ≥ 2yrs up to 15 microgram/kg max
used on an HDU, ideally dose250 micrograms
with a monitor, and MUST
Nebulized2.5mg/dose as req’d (see ‘Page 32)
be given slowly as directed
Oral salbutamol should Inhaled (100 microgram per puff) 2 puffs via
ONLY be used if inhaled spacer repeated as req’d acutely – see page 32
therapy is not possible and for emergency use - or 2 puffs up to 4-6 hrly for

for a maximum duration of 1 short-term maintenance or outpatient treatment.

week. Use inhaled steroid Oral 1mg/dose 6-8hrly aged 2-11 months,
for persistent asthma 2mg/dose 6-8hrly aged 1 - 4 yrs (1 week only)

Vitamin A Age
Once on admission, not to < 6 months 50,000 u stat
be repeated within 1 month.
For malnutrition with eye 6 – 12 months 100,000 u stat

disease repeat on day 2 and > 12 months 200,000 u stat

day 14
Vitamin D – Rickets < 6 months 3,000 u = 75 micrograms
9
Low dose regimens daily for >6 months 6,000 u = 150 micrograms
8 – 12 wks or high dose
stat. Calcium 50mg/kg/day > 6 months stat 300,000 u = 7,500
for first week of treatment. regimen micrograms or 7.5 mg Stat

Vitamin D – Maintenance < 6 months 200 - 400 u (5 – 10 μg)

After treatment course >6 months 400 - 800 u (10 – 20 μg)
Vitamin K Newborns: 1mg stat im (for preterm, 0.4mg/kg
for a maximum dose of 1mg im stat)
For liver disease: 0.3mg/kg stat, max 10mg
Zinc Sulphate > 6 mths 20mg, ≤ 6mths 10mg once a day, 14
days

1
0
 Emergency drugs – Diazepam and Glucose (NB Diazepam is not used in neonates).
Diazepam Glucose,
(The whole syringe barrel of a 1ml or 2ml syringe should be inserted
gently so that pr DZ is given at a depth of approx. 4 - 5cm)
5mls/kg of 10% glucose over 5 - 10 minutes
Weight, Iv iv Per rectum Per rectum Iv
(kg)
ml of
Dose, Dose, ml of 10mg/2ml Total Volume of 10%
10mg/2ml To make 10% glucose
0.3mg/kg 0.5mg/kg solution Glucose
solution
3.00 1.0 0.20 1.5 0.3 15 50% Glucose and water
4.00 1.2 0.25 2.0 0.4 20 for injection:
5.00 1.5 0.30 2.5 0.5 25
6.00 1.8 0.35 3.0 0.6 30 10 ml syringe:
 2 ml 50% Glucose
7.00 2.1 0.40 3.5 0.7 35
 8 ml Water
8.00 2.4 0.50 4.0 0.8 40
9.00 2.7 0.55 4.5 0.9 45 20 ml syringe:
10.00 3.0 0.60 5.0 1.0 50  4 ml 50% Glucose
11.00 3.3 0.65 5.5 1.1 55  16 ml Water
12.00 3.6 0.70 6.0 1.2 60 50% Glucose and 5%
13.00 3.9 0.80 6.5 1.3 65 Glucose:
14.00 4.2 0.85 7.0 1.4 70
15.00 4.5 0.90 7.5 1.5 75 10 ml syringe:
4.8 8.0 80  1 ml 50% Glucose
16.00 0.95 1.6
 9 ml 5% Glucose
17.00 5.1 1.00 8.5 1.7 85
18.00 5.4 1.10 9.0 1.8 90 20 ml syringe:
19.00 5.7 1.15 9.5 1.9 95  2 ml 50% Glucose
20.00 6.0 1.20 10.0 2.0 100  18 ml 5% Glucose

10
 Anticonvulsant drug doses and administration

Weight Phenobarb, Phenobarb, Phenobarb Phenytoin, Phenytoin,

(kg) Loading dose, maintenance, maintenance loading dose, maintenance
15mg/kg 5mg/kg daily 2.5mg/kg daily 15mg/kg 5mg/kg daily
(use 20mg/kg for (high dose – (starting dose – fits in
neonates) chronic therapy) acute febrile illness)
im / oral im– mg oral - tabs im / oral iv / oral / ng iv / oral / ng
2.0 30 10 5 Tablets may be crushed and put
37.5 12.5 - 6.25 down ngt if required.
2.5
45 15 7.5 - 45 15
3.0
4.0 60 20 ½ tab 10 60 20
5.0 75 25 12.5 75 25
6.0 90 30 15 ½ tab 90 30
7.0 105 35 1 tab 17.5 105 35
8.0 120 40 20 120 40
9.0 135 45 22.5 135 45
10.0 150 50 1½ tab 25 1 tab 150 50
11.0 165 55 27.5 165 55
12.0 180 60 30 180 60
13.0 195 65 2 tabs 32.5 195 65
14.0 210 70 35 210 70
15.0 225 75 37.5 225 75
1½ tab
16.0 240 80 2½ tab 40 240 80
17.0 255 85 42.5 255 85
18.0 270 90 45 270 90
19.0 285 95 3 tabs 47.5 285 95
2 tabs
20.0 300 100 50 300 100

11
Intravenous / intramuscular antibiotic doses – AGES 7 DAYS AND OLDER (NN doses see Page 49).

Weight Penicillin* Ampicillin or Chloramphenicol Gentamicin Ceftriaxone iv/im Metronidazole

(kg) (50,000iu/kg) Flucloxacillin (25mg/kg) (7.5mg/kg) Max 50mg/kg 24hrly (7.5mg/kg)
(50mg/kg) im or iv over for neonates**
iv / im iv / im iv / im 3-5 min Mening / V Sev Sepsis iv
50mg/kg 12 hrly
12 hrly < 1m,
6 hrly 8 hrly 6hrly - meningitis 24 hrly 50mg/kg ≥ 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
16.0 800,000 800 400 120 800 120
17.0 850,000 850 425 125 850 125
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 Pen doses if treating Meningitis and age > 1 month ** Not recommended if jaundiced

12
 Oral antibiotic doses - For neonatal doses see Page 49.

Cloxacillin /
Amoxicillin, oral, Chloramphenicol Ciprofloxacin Metronidazole
Flucloxacillin
25mg/kg/dose 25mg/kg/dose 15mg/kg/dose 7.5mg/kg/dose
15mg/kg/dose
ml susp 250mg ml susp 250mg caps ml susp 250mg
250mg tabs 200mg tabs
125mg/5ml caps 125mg/5ml or tabs 125mg/5ml caps
Weight 12 hrly
12 hrly 12 hrly 8 hrly 8 hrly 6 hrly 6 hrly 8 hrly
kg (for 3 days)
3.0 5 1/2* 2.5 1/4 4 n/a
4.0 5 1/2* 2.5 1/4 4 n/a 1/4
5.0 5 1/2* 5 1/4 6 n/a 1/4 1/4
6.0 5 1/2* 5 1/2 6 n/a 1/4 1/4
7.0 7.5 1/2* 5 1/2 8 n/a 1/2 1/2
8.0 7.5 1/2* 5 1/2 8 n/a 1/2 1/2
9.0 7.5 1 5 1/2 8 n/a 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 2 10 1 12 1 1 1
15.0 15 2 10 1 15 1 1 1
16.0 15 2 10 1 15 1 1 1
17.0 15 2 10 1 15 1 1 1
18.0 15 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
*Amoxicillin syrup should be used and capsules divided ONLY if syrup is not available
13
Initial Maintenance Fluids/ Feeds – Normal Renal Function.

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

 Feeding should start as soon as safe and infants may rapidly increase
to 150mls/kg/day of feeds as tolerated (50% more than in the chart).
 Add 50mls 50% dextrose to 450mls Ringer’s Lactate to make RL/5%
dextrose a useful maintenance fluid (or Half Strength Darrow’s in function
of what fluid is available).

Drip rate* - Drip rate* - 3hrly bolus

Weight, Volume in Rate in
adult iv set, paediatric burette feed
kg 24hrs ml / hr
20 drops = 1ml 60 drops = 1ml 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
18 1400 58 19 58 175
19 1450 60 20 60 175
20 1500 63 21 63 185
21 1525 64 21 64 185
22 1550 65 22 65 185
23 1575 66 22 66 185
24 1600 67 22 67 200
25 1625 68 23 68 200

* Drip rate in drops per minute

14
Triage of sick children.
Emergency Signs:
If history of trauma ensure cervical spine is protected.

Airway &  Obstructed breathing

Breathing  Central Cyanosis
 Severe respiratory distress Immediate transfer to
Weak / absent breathing emergency area:
Start Life support
Cold Hands with any of: procedures
Circulation  Capillary refill > 3 seconds Give oxygen
 Weak + fast pulse Weigh if possible
Slow (<60bpm) or absent
pulse

Coma / convulsing / confusion: AVPU = ‘P or U’ or Convulsions

Diarrhoea with sunken eyes → assessment / treatment for severe dehydration

Priority Signs

 Tiny - Sick infant aged < 2 months

 Temperature – very high > 39.50C
 Trauma – major trauma Front of the Queue -
 Pain – child in severe pain Clinical review as
 Poisoning – mother reports poisoning soon as possible:
 Pallor – severe palmar pallor  Weigh
 Restless / Irritable / Floppy  Baseline
 Respiratory distress observations
 Referral – has an urgent referral letter
 Malnutrition - Visible severe wasting
 Edema of both feet
 Burns – severe burns

Non-urgent – Children with none of the above signs.

15
Infant / ChildBasic Life Support – Cardio-respiratory collapse.

Safe, Stimulate, Shout for Help! - Rapidly move child to emergency area

1) Assess and clear airway, 2) Position head / neck to open

Assess breathing – look, listen, feel for 5 seconds

No breathing Adequate breathing

Give 5 rescue breaths with bag and

mask – if chest doesn’t move check Support airway
airway open and mask fit and repeat. Continue oxygen

After at least 2 good breaths

Check the pulse for 10 seconds

Pulse palpable
and >60bpm
No or weak, slow pulse

Give 15 chest compressions then

continue giving 15 chest compressions 1) Continue 20 -30 breaths/min
for each 2 breaths for 1 minute. with oxygen,
2) Look for signs of dehydration
Improvement / poor circulation and give
Re-assess ABC emergency fluids as
No change necessary,
3) Consider treating
hypoglycemia,
1) Continue 15 chest 4) Continue full examination to
compressions : 2 Improvement establish cause of illness and
breaths for 2 minutes, treat appropriately.
2) Reassess ABC

No change Improvement

1) Consider iv 0.1ml/kg 1 in 10,000 Adrenaline if 3 people in team,

consider fluid bolus if shock likely and treatment of hypoglycemia
2) Continue CPR in cycles of 2 - 3 minutes after any intervention 16
3) Reassess every 2 – 3 minutes.
Management of the infant / child without trauma WITH SIGNS OF LIFE –
Assessment prior to a full history and examination.
Obs Safe Eye contact / movements
Stimulate – if not Alert Shout unless obviously alert
Shout for Help – if not Alert If not Alert place on rhesus couch
Setting for further evaluation If alert it may be most appropriate
to continue evaluation while child is
with parent
A Assess for obstruction by listening Position only if not alert and placed
for stridor / airway noises. on couch
Look in the mouth if not alert Suction (to where you can see) if
Position – if not Alert (appropriate indicated (not in alert child),
for age) Guedel airway only if minimal
response to stimulation
B Assess adequacy of breathing Decide:
 Cyanosis?  Is there a need for oxygen?
 Check oxygen saturation  Is there a need for immediate
 Grunting? bronchodilators?
 Head nodding?
 Rapid or very slow breathing?
 Indrawing?
 Deep / Acidotic breathing
If signs of respiratory distress
listen for wheeze
C Assess adequacy of circulation Decide:
 Large pulse – very fast or  Does this child have
very slow? hypovolemic shock due to
 Coldness of hands and line of diarrhea/dehydration? If yes,
demarcation? give Lactate Ringers over 15
 Capillary refill? min as rapid bolus and progress
 Peripheral pulse – weak or to Plan C fluids for
not palpable? diarrhea/dehydration (If no
 (Note initial response to severe malnutrition)
stimulation / alertness)  If there is respiratory distress
 Check for severe pallor and circulatory compromise
If signs of very poor circulation with severe pallor or Hb<5g/dl
 Check for severe pallor organize immediate transfusion
 Check for severe malnutrition  If there is circulatory
 Check for severe dehydration compromise but no shock
does the child need Step 1 fluids
for severe dehydration? (If no
severe malnutrition)
D Assess AVPU Decide:
Check glucose at bedside If blood glucose <2.5mmol/l or
AVPU<A
17
 Use of intra-osseous lines

 Use IO or bone marrow needle 15-18G

if available or 16-21G hypodermic
needle if not available
 Clean after identifying landmarks then
use sterile gloves and sterilize site
 Site – Middle of the antero-medial (flat)
surface of tibia at junction of upper and
middle thirds – bevel to toes and
introduce vertically (900)- advance
slowly with rotating movement
 Stop advancing when there is a
‘sudden give’ – then aspirate with 5mls
needle
 Slowly inject 3mls N/Saline looking for
any leakage under the skin – if OK
attach iv fluid giving set and apply
dressings and strap down
 Give fluids as needed – a 20mls /
50mls syringe will be needed for
boluses
 Watch for leg / calf muscle swelling
 Replace IO access with iv within 8
hours. Antibiotics should be considered
if infection control is not optimal
 Contraindicated if fracture or skin
infection on site

18
Prescribing Oxygen

Oxygen Administration Device Flow rate and inspired O2 concentration

Nasal prong or short nasal Neonate* 0.5L - 1L/min
catheter Infant / Child 1 – 3L/min
O2 concentration – approx 30-35%
Naso-pharyngeal (long) catheter Neonate* –not recommended
Infant / Child – 1 – 2 L/min
O2 concentration – approx 45%
Plain, good fitting oxygen face Neonate* / Infant / Child – 5 - 6 L/min (check
mask instructions for mask)
O2 concentration – approx 40 - 60%
Oxygen face mask with reservoir Neonate* / Infant / Child – 10 - 15 L/min
bag O2 concentration – approx 80 - 90%

* WHO is using extended neonatal period up to 2 months of age

19
Treatment of convulsions.
Convulsions in the first 1 month of life should be treated with Phenobarbitone
20mg/kg as loading dose; if no response, a further 10mg/kg can be given after 30
minutes up to a maximum of 40mg/kg. (Watch for apnea, always have a bag-
mask available) within 24 hours of the loading dose with maintenance doses of
5mg/kg daily.

Age > 1 month.

Child 1) Ensure safe and check ABC.

Y
convulsing for 2) Start oxygen.
more than 5 3) Treat both fit and hypoglycemia:
minutes Give IV diazepam 0.3mg/kg slowly over 1
min, OR rectal diazepam 0.5mg/kg.
N
Check glucose / give 5mls/kg 10% Dext
Child having 3rd 4) Check ABC when fit stopped.
convulsion lasting
<5mins in < 2 hours.*
Convulsion stops
N Y by 10 minutes?
Check ABC, observe and
investigate cause. N
Y
Treatment:

5) Give IV diazepam 0.3mg/kg slowly over 1 min,

OR rectal diazepam 0.5mg/kg.
6) Continue oxygen.
7) Check airway is clear when fit stopped.

Check ABC, observe and Convulsion stops

investigate cause. Y by 15 minutes?

N
Treatment:
8) Give im phenobarbitone 15mg/kg – DO NOT
* If children have give more than 2 doses of diazepam in 24
up to 2 fits hours once phenobarbitone used.
lasting <5 min 9) Maintenance therapy should be initially with
they do not phenobarbitone 2.5mg/kg/24h for 2 days.
require
emergency drug
10) Continue oxygen during active seizure.
treatment. 11) Check ABC when fit stopped.
12) Investigate cause.
20
Diarrhea / GE protocol (excluding severe malnutrition).
Antibiotics are NOT indicated unless there is dysentery or persistent diarrhea and proven
amoebiasis or giardiasis. Diarrhea> 14 days may be complicated by intolerance of ORS –
worsening diarrhea – if seen change to IV regimens. All cases to receive Zinc.

History of diarrhea / vomiting, age > 2 months

Hypovolaemic Shock due Ringers 20mls/kg over 15 minutes, a

to diarrhea/ dehydration Y second bolus may be given if required
All four of: Weak/absent before proceeding to Step 2 of Plan C
pulse; AVPUi) < A; Cold Hand (see below). Treat for hypoglycaemia.
+ Temp gradient; Capillary Start ORS 5ml/kg/hr once drinking
refill > 3 secs PLUS sunken
eyes and slow skin pinch
IV Step 1 - 30mls/kg
N
Ringer’s over 30 min if
SEVERE Dehydration. Y age ≥ 12m, over 60 min if
(Plan C) IV preferred age < 12m.
Unable to drink or AVPU OR
< A plus: iv Step 2 - 70mls/kg Ringer’s over 2.5
 sunken eyes hrs age ≥ 12m, over 5 hrs age <12m.
 return of skin pinch ≥2
sec ngt rehydration – 100mls/kg
ORS over 6 hours if unable to
put IV/IO line; refer if persistent
vomiting
N
Re-assess at least hourly, after 3 - 6 hours re-classify as severe,
some or no dehydration and treat accordingly.

SOME DEHYDRATION Y 1) Plan B, ORS by mouth at 75mls/kg

Able to drink adequately over 4 hours, plus,
but 2 or more of: 2) Continue breast feeding as
 Sunken eyes tolerated
 Return of skin pinch 1-2 Reassess at 4 hours, treat according
sec to classification.
 Restlessness / irritability
N

Diarrhoea/vomiting Y Plan A 10mls/kg ORS after each

without signs of loose stool.
dehydratation Continue breast feeding and
encourage feeding if > 6 months
21
 Urgent Fluid management – Child WITHOUT severe malnutrition.*
Plan C – Step 1 Plan C – Step 2 Plan B - 75mls/kg
Shock,
30mls/kg Ringer’s 70mls/kg Ringer’s or ng ORS Oral / ng ORS
20mls/kg
Ringer’s or Age <12m, Age ≥ 1yr,
Age <12m, 1 hour
Weight Saline over 5 hrs Volume over 2½ hrs Over 4 hours
Age ≥1yr, ½ hour
kg Immediately = drops/min** = drops/min**
2.00 40 50 10 150 ** Assumes 150
2.50 50 75 13 200 ‘adult’ iv 150
giving sets
3.00 60 100 13 200 200
where
4.00 80 100 20 300 20drops=1ml 300
5.00 100 150 27 400 55 350
6.00 120 150 27 400 55 450
7.00 140 200 33 500 66 500
8.00 160 250 33 500 66 600
9.00 180 250 40 600 80 650
10.00 200 300 50 700 100 750
11.00 220 300 55 800 110 800
12.00 240 350 55 800 110 900
13.00 260 400 60 900 120 950
14.00 280 400 66 1000 135 1000
15.00 300 450 66 1000 135 1100
16.00 320 500 75 1100 150 1200
17.00 340 500 80 1200 160 1300
18.00 360 550 80 1200 160 1300
19.00 380 550 90 1300 180 1400
20.00 400 600 95 1400 190 1500

*Consider Immediate blood transfusion if severe pallor or Hb<5g/dl on admission

22
 Malaria Treatment in malaria endemic areas.
If a high quality blood slide is negative then only children with severe
disease or those with severe anemia should get presumptive treatment.
Rapid test should be confirmed

Severe = Fever + any Treat with IV/IM Artesunate:

of: 1. 2.4mg H0, H12 and H24,
1. AVPU = ‘V, P,U’, or, 2. Then 2.4mg once per day
2. Unable to drink, or, 3. The treatment duration is 7days.
3. Respiratory distress Yes 4. When the patient can take oral
with severe anemia or medication, prescribe a full-3day course
acidotic breathing, or, of Coartem.
4. Hypoglycemia 5. Coartem should be taken between 8 -
(glucose ≤ 2.2mmols/l) 12 hours after the last injection of
5. 3 or more convulsions Artesunate
No

Severe anemia, Hb<5g/dl,

and respiratory distress Give AL transfuse 10-15 ml/kg red
Yes packed cells over 4 hr urgently
then Hb control after 24 hr and
No according the Hb, transfuse
again or iron in maintenance
Fever, none of the severe signs Antimalarial not
Test
above, able to drink / feed, AVPU = Negative required, look for
‘A’ then follow reliable malaria test another cause of
result (BS or Rapid Test): illness. Repeat test if
concern remains.
Test Positive
If Hb < 9g/dl treat with
oral iron for 14 days
Treat with Coartem initially.
If respiratory distress
develops and Hb < 5g/dl
transfuse urgently.
Treatment failure:
1) Consider other causes of illness / co-morbidity
2) A child on oral antimalarials who develops signs of severe malaria (Unable to sit or
drink, AVPU=U or P and / or respiratory distress) at any stage should be changed
to IV/IM artesunate or Quinine.
3) If a child on oral antimalarials has fever and a positive blood slide after 3 days
(72 hours) then check compliance with therapy and if treatment failure proceed to
second line treatment.

23
Anti-malarial drug doses and preparation - ** Please check the iv
or tablet preparation you are using – they may vary.

Artesunate: Artesunate typically comes as a powder together with a 1ml vial

of 5% bicarbonate that then needs to be further diluted with either normal
saline or 5% dextrose – the amount to use depends on whether the drug is to
be given iv or im (see table).
 DO NOT use water for injection to prepare artesunate for injection
 DO NOT give artesunate if the solution in the syringe is cloudy
 DO NOT give artesunate as a slow iv drip (infusion)
 YOU MUST use artesunate within 1 hour after it is prepared for injection

Preparing iv / im Artesunate IV IM
Artesunate powder (mg) 60mg 60mg
Sodium Bicarbonate (mls, 5%) 1ml 1ml
Normal Saline or 5% Dextrose (mls) 5mls 2mls
Artesunate concentration mg/ml 10mg/ml 20mg/ml

Quinine: For iv infusion typically 5% or 10% dextrose is used

 Use at least 1ml fluid for each 1mg of quinine to be given
 DO NOT infuse quinine at a rate of more than 5mg/kg/hour
o Use 5% Dextrose or N/saline for infusion with 0.5 – 1 ml of fluid for
each 1mg of quinine.
o The 20mg/kg loading dose therefore takes 4 hours or longer
o The 10mg/kg maintenance dose therefore takes 2 hours or longer

For im Quinine:
 Take 1ml of the 2mls in a 600mg Quinine suphate iv vial and add 5mls
water for injection – this makes a 50mg/ml solution.
 For a loading dose this will mean giving 0.4mls/kg
 For the maintenance dosing this will mean giving 0.2mls/kg
 If you need to give more than 3mls (a child over 8 kg for a loading dose or
over 15kg for maintenance doses then give the dose into two im sites –
do not give more than 3mls per injection site.

For oral Quinine 200 mg Quinine Sulphate = 200mg Quinine Hydrochloride

or Dihydrochloride but = 300mg Quinine Bisuphate. The table of doses below
is ONLY correct for a 200mg Quinine Sulphate tablet.

24
Malaria Treatment Doses

 Artesunate is given iv / im for a minimum of 24 hours

 As soon as the child can eat drink (after 24 hours for artesunate) then
change to a full course of artemisinin combination therapy (ACT)
typically the 1st line oral anti-malarial Artemether Lumefantrine

Artesunate, 2.4mg/kg Quinine, loading Quinine, tabs,

20mg/kg then 10mg/kg 10mg/kg
iv mls of im mls of 200mg QN
Dose in
Wt 60mg in 60mg in iv infusion / im sulphate**
mg
kg 6mls 3mls Loading 8 hrly 8 hourly
3.0 0.75 7.5 0.35 60 30 ¼
4.0 1 10 0.5 80 40 ¼
5.0 1.2 12 0.6 100 50 ¼
6.0 1.5 14 0.7 120 60 ½
7.0 1.7 17 0.8 140 70 ½
8.0 1.9 19 1.0 160 80 ½
9.0 2.1 22 1.1 180 90 ½
10.0 2.4 24 1.2 200 100 ¾
11.0 2.6 26 1.3 220 110 ¾
12.0 2.9 29 1.5 240 120 ¾
13.0 3.1 31 1.6 260 130 ¾
14.0 3.4 34 1.7 280 140 ¾
15.0 3.6 36 1.8 300 150 1
16.0 3.8 38 1.9 320 160 1
17.0 4.1 41 2.0 340 170 1
18.0 4.3 43 2.2 360 180 1
19.0 4.6 46 2.3 380 190 1¼
20.0 4.8 48 2.4 400 200 1¼

Artemether (20mg) + Lumefantrine Dihydroartemisinin-

(120mg) - Give with food piperaquine,
Stat, +8hrs, BD on Day 2 and Day 3 OD for 3 days
Weight Age Dose
Age Dose
5 – 15 kg 3 – 35mth 1 tablet
3 – 35mth 1 paed tab
15 – 24 kg 3 - 7 yrs 2 tablets
3 - 5 yrs 2 paed tabs
25 – 34 kg 9 - 11 yrs 3 tablets
6 - 11 yrs 1 adult tab

25
Measuring nutritional status

Anthropometry (body measurement) quantifies

malnutrition. In children, measurement of mid-
upper arm circumference (MUAC) is the most
simple. Weight and height measurements can be
useful to detect wasting and stunting and individual
monitoring over time e.g. growth velocity.

Mid upper arm circumference (MUAC)

MUAC is measured using a tape around the left
upper arm. MUAC is quicker in sick patients so use
MUAC in acute management.

Weight, Height and Age

 Weight for height (W/H): Measure length
(lying) if aged <2 y to give weight for length. Low W/H (or W/L) = wasting,
and indicates acute malnutrition.
 Weight for age (W/A): Low W/A does not distinguish acute from chronic
malnutrition. W/A is thus not used for diagnosis of acute malnutrition, but
plotted over time.

In the diagnosis of acute malnutrition we use W/H expressed as Z scores. Z

scores can be obtained from simple tables (pp 49 to 52)

Visible Severe Wasting (VSW) it tends to identify only severest cases of

SAM. It is better to use MUAC. Kwashiorkor = severe malnutrition at any
age

Classifying Malnutrition (for WHZ values see pp 49 to 52)

Acute Malnutrition -
MUAC cm WHZ
Severity

None >13.5 >-1

At Risk 12.5 to 13.4 -2 to -1

Moderate 11.5 to 12.4 -3 to -2

<11.5 <-3
Severe
Kwashiorkor

26
 Symptomatic severe malnutrition.(age 6 – 59 months).
Admit to hospital if there is a history of illness and either of:
 Visible severe wasting (buttocks) (WHZ < -3SD or W/A <-3z score or
MUAC < 115cm under 5y of age)

 Edema or other signs of Kwashiorkor (flaky paint skin / hair changes).

Check glucose and treat if <3mmol/l (5mls/kg 10%

Step 1 dextrose). If glucose test unavailable treat for hypoglycemia
if not alert. Oral / ngt glucose or feeds should as soon as
possible (not >30 min after admission.)

Step 2 Check for hypothermia, axillary temperature <350C. If

present warm with blankets, warm bags of fluid or a heater.

Check for dehydration and anemia – use Diarrhea /

Step 3 Dehydration flowchart to classify then USE fluid plans for
severe malnutrition. (Transfuse if Hb < 5g/dl, 10mls/kg
packed cells in 3hrs + furosemide 1mg/kg - for shock see
next page,)

Electrolyte imbalance. Use commercial F75. If not available

Step 4 mineral mix OR4mmol/kg/day of oral potassium may need to
be added to feeds, Never use Furosemide for edema!

Treat infection. All ill children with severe malnutrition should

Step 5 get IV Penicillin (or Ampicillin) AND Gentamicin Nystatin /
Clotrimazole for oral thrush
 Mebendazole after 7 days treatment.
 Tetracyclin eye ointment (+ atropine drops) for pus /
ulceration in the eye
 Zinc sulfate if no F 75/F100/RUTF

Step 6 Correct micronutrient deficiencies. Give:

 Vitamin A If visible eye signs on admission (and days 2 and 14).
 Multivits for at least 2 weeks if no Plumpy-nut or F75/F100
 Folic acid 2.5mg alt days if no Plumpy-nut or F75/F100 Start iron only
when ONLY when the child is gaining weight.

Step 7
Prescribe feeding needed (see chart) and place ngt.
Steps 8, 9 & 10: Ensure appetite and weight are monitored and start
catch-up feeding with Plumpy-nut (usually day 3 – 7). Provide a caring
and stimulating environment for the child and start educating the family
so they help in the acute treatment and are ready for discharge.
27
Fluid management in Severe Malnutrition with diarrhoea

Shock: AVPU<A, absent, or weak pulse plus prolonged capillary refilling

(>3s) plus cold periphery with temperature gradient
20 ml/kg in 2 hrs of Ringer’s Lactate (RL) in 5% dextrose. –
add 50mls 50% dextrose to 450mls Ringers (or 10%
Dextrose/HSD if no Ringers)
If severe anaemia start urgent blood transfusion not Ringers.

If not shocked or after treating shock

 If unable to give oral / ngt fluid because of very poor medical condition
use / continue with iv fluids at maintenance regimen of 4mls/kg/hr
If able to introduce oral or ng fluids / feeds:
o For 2 hours: Give Resomal at 10mls/kg/hour
o Then: Introduce first feed with F75 and alternate Resomal / F75
each hour at 7.5mls/kg/hr for 10 hours – can increase or
decrease hourly fluid as tolerated between 5 – 10 mls/kg/hr.
o At 12 hours switch to 3 hourly oral / ngt feeds with F75 (following
page)
Oral / ngt Emergency
Shock
Resomal Maintenance
20mls/kg 10mls/kg/hr 4mls/kg/hr
Ringer’s Lactate (RL) in 5% RL in 5%
Resomal
Dextrose Dextrose
iv Oral / ngt iv
Drops/min if 10mls/kg/hr for
Weight Shock Hourly until
20drops/ml
kg = over 2 hours giving set up to 10 hours transfusion
4.00 80 13 40 15
5.00 100 17 50 20
6.00 120 20 60 25
7.00 140 23 70 30
8.00 160 27 80 30
9.00 180 30 90 35
10.00 200 33 100 40
11.00 220 37 110 44
12.00 240 40 120 46
13.00 260 43 130 48
14.00 280 47 140 50
15.00 300 50 150 52

28
PREPARATION OF THE THERAPEUTIC MILK

Dried Skimmed Milk Vegetable Oil Sugar Water

F 75* 25g 27g 100g Make up to 1000mls
F 100* 80g 60g 50g Make up to 1000mls
* Ideally add electrolyte / mineral solution and at least add potassium

Components of RESOMAL:

Glucose 125 mmol/l

Sodium 45 mmol/l
Potassium 40 mmol/l
Chloride 70 mmol/l
Magnesium 3 mmol/l
Zinc 0.3 mmol/l
Copper 0.045 mmol/l
Citrate 7 mmol/l
Water 2l

Formula for making Resomal

To prepare Resomal, mix up the following components:

- 1 sachet of ORS (packaging for 1l of water)
- 2l of clean water
- 45mls of KCl 10%
- 50g of Sugar (of 5 soup spoons)

29
Feeding children with severe malnutrition
1) If aged <6 months use EBM or term formula or use diluted F100 - to each 100mls F100 add 35mls clean water
2) If respiratory distress or edema get worse or the jugular veins are engorged reduce feed volumes.
3) When appetite returns (and edema much improved) change from F75 to Plumpy-nut, if Plumpy-nut not available change to F100 for
the first 2 days use 130-150mls/kg of F100.
4) When using Plumpy-nut allow the child to nibble very frequently, the child can drink liberally and additional solid foods can be
introduced slowly in the first days and Plumpy-nut can be mixed into poridge or other foods

F75 – acute feeding F100 if no RUTF RUTF RUTF

No or moderate oedema Severe oedema, even face F100 @ 150mls/kg/day Transition Rehabil’n
(130mls/kg/day) (100mls/kg/day) Rehabilitation Phase Phase Phase
Total Feeds 3 hourly Total Feeds 3 hourly feed Total Feeds 3 hourly feed Packets per Packets
Wt (kg) / 24 hrs feed volume / 24 hrs volume / 24 hrs volume 24hrs per 24hrs
4.0 520 65 400 50 600 75
1.5 2.0
4.5 585 75 450 60 675 85
5.0 650 80 500 65 750 95
5.5 715 90 550 70 825 105
2.1 2.5
6.0 780 100 600 75 900 115
6.5 845 105 650 85 975 125
7.0 910 115 700 90 1050 135
7.5 975 120 750 95 1125 140 2.5 3.0
8.0 1040 130 800 100 1200 150
8.5 1105 140 850 110 1275 160
2.8 3.5
9.0 1170 145 900 115 1350 170
9.5 1235 155 950 120 1425 180
3.1 4.0
10.0 1300 160 1000 125 1500 190
10.5 1365 170 1050 135 1575 200
11.0 1430 180 1100 140 1650 210 3.6 4.0
11.5 1495 185 1150 145 1725 215
12.0 1560 195 1200 150 1800 225 4.0 5.0
30
 Meningitis – investigation and treatment.
Age ≥ 60 days and history of fever

LP must be done if there’s one of: Immediate LP to view by

 Coma, inability to drink / feed, eye +/- laboratory
Yes
AVPU = ‘P or U’. examination even if malaria
 Stiff neck, slide positive unless:
 Bulging fontanel,  Child requires CPR.
 Fits if age <6 months or > 6  Pupils respond poorly to
years, light,
 Evidence of partial seizures  Skin infection at LP site
No
Do an LP unless completely
 Agitation / irritability, Yes normal mental state after
 Any seizures
febrile convulsion.
Review within 8 hours
No
and LP if doubt persists.

Meningitis unlikely, investigate other causes of fever.

Interpretation of LP and treatment definitions:

Either Bedside examination:
 Looks cloudy in bottle (turbid) and not a blood stained tap,
And / or Laboratory examination with one or more of (if possible):
 White cell count > 10 x 106/L
 Gram positive diplococci or Gram negative cocco-bacilli,

Yes to one Classify as definite meningitis:

No to all
3rd generation cephalosporins
If not available chloramphenicol PLUS
One of:
Ampicillin minimum of 10 days of
 Coma,
treatment IV
 Stiff neck, Yes
 Bulging fontanel,
Classify
Steroidsprobable meningitis:
are not indicated.
+ LP looks clear
1) Chloramphenicol, PLUS,
Ampicillin – double dose if age >1m
None of these signs Minimum 10 days of treatment IV
Steroids are not indicated.
CSF Wbc + Gram stain result
If meningitis considered
All normal Tests not done possible:
No meningitis IV Chloramphenicol &
Ampicillin and senior review.

31
Pneumonia protocol for children aged 2 - 59 months.

For HIV exposed / infected children see page 34

History of cough or difficult

breathing, age > 60 days.

Y
Cyanosis,
Oxygen satn <90%, Y Very Severe Pneumonia
Inability to drink / Oxygen,
Wheeze

breast feed IV Ampicillin AND

AVPU = ‘V, P or U’, IV Gentamicin.
or Grunting

N
Y
Lower chest wall Severe Pneumonia–
indrawing, AVPU=’A’ Ampicillin ALONE
Wheeze

Age 2 – 11 months: Y
Respiratory rate ≥ 50, Pneumonia – Amoxicillin.
Age ≥12 months:
Wheeze

Respiratory rate ≥ 40

No pneumonia,
probable URTI.

Possible Asthma – Treat according to separate protocol p34 and

REVISE classification after initial treatment with bronchodilators

32
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 pneumonia
to very severe pneumonia
(development of cyanosis or Change treatment from
inability to drink in a child with Ampicillin alone and add
pneumonia without these signs on gentamicin.
admission)
Obvious cavitation on CXR Treat with Cloxacillin and
gentamicin iv for Staph. Aureus or
Gram negative pneumonia.
Investigate for TB
48 hours
Very severe pneumonia child Switch to Ceftriaxone / Cefotaxime
getting worse, re-assess unless suspect Staphylococcal
thoroughly, get chest X ray if not pneumonia then use Cloxacillin
already done (looking for empyema and Gentamicin.
/ effusion, cavitation etc).
Suspect PCP especially if <12m,
an HIV test must be done - treat
for Pneumocystis if HIV positive
Severe pneumonia without
improvement in at least one of:
 Respiratory rate, Change treatment from
 Severity of indrawing, Ampicillin alone and add
 Fever, Gentamicin.
 Eating / drinking.
Day 5. Transfer to higher level hospital
At least 3 of: a) If on Ampicillin +
 Fever, temp >380C Gentamicin change to
 Respiratory rate >60 bpm ceftriaxone or cefotaxime
 Still cyanosed or saturation b) Suspect PCP, an HIV test must
<90% and no better than be done - treat for
admission Pneumocystis if HIV positive.
 Chest indrawing persistent c) Consider TB, perform mantoux
 Worsening CXR and check TB treatment
guidelines

33
Possible asthma – management of the wheezy child.

Wheeze + history of cough or difficult breathing – likelihood of asthma

much higher if age > 12m and recurrent wheeze

Y
Immediate Management
Very severe:  Oxygen – measure saturation
Wheeze, AVPU < A, Y  Nebulize 2.5mg salbutamol
Cyanosis, Inability to every 20 minutes for 3 doses if
drink / breast feed or needed.
inability to talk  Start oral (prednisolone) or iv
steroids if cannot drink
N
Immediate Management:
Severe:  Oxygen if obvious use of accessory
Y
Wheeze + muscles - measure sat’n.
Lower chest  Salbutamol by nebulizer or inhaler +
wall indrawing. spacer + mask repeated up to 10
puffs in 30min (see box below)*.
 Start oral prednisolone
N

Mild: Reassess after 30-60 min and reclassify

Wheeze and fast severity – if now:
breathing  Very severe – continue oxygen, 1-4
Age 2 – 11 months: hourly salbutamol, early review,
Respiratory rate ≥ 50, antibiotics as for very severe pneumonia
Age ≥12 months:  Severe – 4 hourly salbutamol,
Respiratory rate ≥ 40 antibiotics as for severe pneumonia
 Mild - 4 hourly salbutamol, oral
antibiotics aim for discharge in 24 hrs
Y

 Salbutamol by inhaler, spacer + mask

 Reassess respiratory rate after 20-30 minutes, if persistently
elevated consider oral antibiotic
 Give education on use of inhaler, spacer + mask and danger signs
and discharge on salbutamol 4-6 hrly for no more than 5 days plus
if recurrent asthma consider inhaled steroid prophylaxis

* If a nebulizer is not available then 1 puff of salbutamol into a spacer

followed by 5-6 breaths can be repeated up to 10 times in 20-30 min
(shake inhaler every 2 puffs)
34
HIV – Provider Initiated Testing and Counseling (PITC), Treatment
and Feeding.

It is government policy that ALL SICK CHILDREN presenting to facilities with

unknown status should be offered HIV testing using PITC

PITC is best done on admission when other investigations are ordered. All
clinicians should be able to perform PITC and discuss a positive / negative result
Below is quick guide to PITC:
 As much as possible find a quiet place to discuss the child’s admission
diagnosis, tests and treatment plans
 After careful history / examination plan all investigations and then inform
caretaker what tests are needed and that HIV is common in Rwanda
 Explain MoH guidance that ALL sick children with unknown status should
have an HIV test – so their child is not being ‘picked out’
 That in this situation it is normal to do an HIV test on a child because:
o You came to hospital wanting to know what the problem was and find
the best treatment for it,
o Knowing the HIV test result gives doctors the best understanding of the
illness and how to treat it
o The treatment that is given to the child will change if the child has HIV
o If the child has HIV s/he will need additional treatment for a long time
and the earlier this is started the better
 That the HIV test will be done with their approval and not secretly
 That the result will be given to them and that telling other family / friends is
their decision
 That the result will be known only by doctors / nurses caring for the child as
they need this knowledge to provide the most appropriate care.
 Give the parent / guardian the opportunity to ask questions.
The person asking permission for HIV testing should then write in the
medical record that permission was given / refused.

Any child < 18 months with a positive rapid test is HIV exposed. The first PCR is
requested and the child is given Cotrimoxazole prophylaxis.

Ongoing Treatment / Feeding.

1) If breast fed encourage exclusive breast feeding until 6 months. If an alternative
to breast feeding is affordable, feasible, accessible, safe and sustainable
(AFASS) discuss this option before delivery.
2) Do not abruptly stop breast feeding at 6m, just add complementary feeds and
continue ARV’s for mother for life
3) Refer child and carers to an HIV support clinic – HAART should start in all HIV
infected children age < 18 months as soon as first PCR comes positive then
perform second PCR to confirm the diagnosis.

36
1) All HIV exposed / infected infants should start CTX prophylaxis from age 6 wks until
HIV is excluded

2) All HIV exposed infants should start Neviparine since birth for 6 weeks. If exposition
is discovered after birth, perform PCR. If PCR is negative, start ARV’s in any mother
breasfeeding and for life. If PCR is positive, start ART.

3) All HIV exposed infants should start Neviparine at birth

continue and stop 1 week after breast feeding stopped

Managing the HIV exposed / infected infant – Please check for updates – ARV doses
change fast!

PMTCT Nevirapine Prophylaxis:

If formula fed from birth give nevirapine for first 6 weeks only
If breastfeeding-continue and stop 1 week after breastfeeding stopped
-in discordant couples mothers on ART, Nevirapine shall be stopped at
6 weeks

1. < 2 weeks : 2 mg/kg/day

2. 2-4 weeks: 4 mg/kg/day Daily dosis of
3. > 4 weeks: 8 mg/kg/day nevirapine in one
dose
BODY WEIGHT (kg) (10 mg /ml solution)
From To ml
1 2 1
3 3 ,5 1
3,6 4,9 2
5 5,9 4
6 6,9 5
7 7,9 6
8 8,9 7
9 9,9 8
10 10,9 9
11 11,9 9
12 13,9 11
14 16,9 13

Pneumonia - All HIV exposed / infected children admitted with signs of severe / very
severe pneumonia are treated with:
1. Ampicillin and gentamicin first line, Ceftriaxone reserved as second line therapy
2. High dose cotrimoxazole if aged <5yrs (see below).
Steroids shall be given in patients who have severe P carinii pneumonia (PCP)
37
 as defined by a room air arterial oxygen pressure of less than 70 mm Hg or an
arterial-alveolar O2 gradient that exceeds 35 mm [Link] recommended
regimen for intravenous methyl prednisolone is 1 mg/kg/dose twice daily for 5
days, then 0.5 mg/kg/dose twice daily for 5 days then 0.5 mg/kg/dose once daily
for 5-10 days. This can be changed to oral prednisolone in the same doses
when oral feeding starts.

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

Weight CTX syrup CTX Tabs CTX Tabs CTX Frequency

240mg/5mls 120mg/tab 480mg/tab 800/160mg
1-4 kg 2.5 ml 1 tab 1/4 24hrly for
5-8 kg 5 ml 2 tabs 1/2 1/4 prophylaxis,
9-16 kg 10 ml - 1 1/2 6 hrly for 3wks
17-50 kg - 2 1 for PCP
treatment

Diarrhea - All HIV exposed / infected children admitted with acute diarrhea are
treated in the same way as HIV uninfected children with fluids and zinc. For
persistent diarrhea (≥14days) low-lactose or lactose free milks are recommended if
the child is ≥ 6 months of age

Meningitis –Request CSF examination for Cryptococcus antigen as well as

traditional microscopy and culture for bacteria.

HAART – See national guidelines for latest regimens

TB – See national guidelines for TB treatment in an HIV exposed / positive child

38
Newborn Resuscitation – for SINGLE Health Worker – Be Prepared!

39
Newborn Resuscitation – for TWO trained Health Workers – Be Prepared!

40
Neonatal Sepsis / Jaundice – see Page 45 for NN Antibiotic Doses

Age < 60 days

One or more of: Yes

 Change in level of activity
 Bulging fontanel Do LP unless severe respiratory
 History of convulsions distress
 Feeding difficulty
 Temperature ≥37.50C or 1) Check for hypoglycemia, treat if
<35.50C unable to measure glucose.
 Fast breathing / respiratory 2) Start gentamicin and penicillin
rate ≥ 60 bpm Yes
(see chart),
 Severe chest indrawing 3) Give oxygen if cyanosed / RR >
 Grunting 60 bpm.
 Cyanosis 4) Give Vitamin K if born at home
Also check or not given on maternity.
5) Keep warm.
 Jaundice (see page 37 & 38) 6) Maintain feeding by mouth or
 Capillary refill ngt, use IV fluids only if
 Severe Pallor respiratory distress or severe
 PROM >18hrs if aged < Yes
7d abdominal distension (see
 Weight loss chart).
Use information to decide -
does baby need fluids, feeds
(Page 40/41) or blood?
No signs of serious illness
Where appropriate:
Is there: 1) Treat for neonatal ophthalmia
 Pus from eye 2) Treat with oral antibiotic – one
 Pus from ear that covers Staph aureus if
 Pus from umbilicus and Yes large, pus-filled septic spots
redness of abdominal skin 3) Give mother advice and
 Multiple, large, pus-filled arrange review.
blisters / septic spots.
None of the above NB. A Newborn with weight <2kg &
premature delivery or small size for
No sign of severe illness, gestational age with reduced ability
review if situation changes. to suck as the only problem may only
require warmth, feeding support and
a clean environment.

41
Neonatal Jaundice

 Assess for jaundice in bright, natural light if possible, check the eyes, blanched skin on
nose and the sole of the foot
 Always measure serum bilirubin if age < 24 hours and if clinically moderate or severe -
Any jaundice if aged <24hrs needs further investigation and treatment
 Refer early if jaundice in those aged <24hrs and facility cannot provide
phototherapy and exchange transfusion
 See next page for guidance on bilirubin levels
 If bilirubin measure unavailable start phototherapy:
o In a well baby with jaundice easily visible on the sole of the foot
o In a preterm baby with ANY visible jaundice
o In a baby with easily visible jaundice and inability to feed or other signs of
neurological impairment and consider immediate exchange transfusion
Stop phototherapy – when bilirubin level is 50 micromol/L lower than phototherapy
threshold (see next page) for the baby’s age on day of testing

Phototherapy and Supportive Care - Checklist

1. Shield the eyes with eye patches. - Remove periodically such as
during feeds
2. Keep the baby naked
3. Place the baby close to the light source–45 cm distance is often
recommended but the more light power the baby receives the better
the effect so closer distances are OK if the baby is not overheating
especially if need rapid effect. May use white cloth to reflect light back
onto the baby making sure these do not cause overheating.
4. Do not place anything on the phototherapy devices– lights and
baby need to keep cool so do not block air vents / flow or light. Also
keep device clean – dust can carry bacteria and reduce light
5. Promote frequent breastfeeding. Unless dehydrated, supplements
or intravenous fluids are unnecessary. Phototherapy use can be
interrupted for feeds; allow maternal bonding.
6. Periodically change position supine to prone- Expose the
maximum surface area of baby to phototherapy; may reposition after
each feed.
7. Monitor temperature every 4 hrs and weight every 24 hrs
8. Periodic (12 to 24 hrs) plasma/serum bilirubin test. Visual testing
for jaundice or transcutaneous bilirubin is unreliable.
9. Make sure that each light source is working and emitting light.
Fluorescent tube lights should be replaced if:
a. More than 6 months in use (or usage time >2000 hrs)
b. Tube ends have blackened
c. Lights flicker.

42
Treatment of Jaundice if Gestational Age < 37 wks

 Initiate phototherapy earlier than for full term neonates – ideally consult a
gestational age specific chart
 Exchange transfusion if baby has gestational age < 37 wks AND age is
72 hours or more if:
Bilirubin in micromol/litre ≥ gestational age × 10

Treatment if 37 weeks or more gestational age

Bilirubin measurement in micromol/L

Age Repeat Consider Initiate Perform an

(in hours - measurement phototerapy - phototherapy exchange
round age in 6 hours especially if risk transfusion
up to factors - and unless the bilirubin
nearest repeat in 6 level falls below
threshold hours threshold while the
given) treatment is being
prepared
0 - - >100 >100
6 > 100 > 112 > 125 > 150
12 > 100 > 125 > 150 > 200
18 > 100 > 137 > 175 > 250
24 > 100 > 150 > 200 > 300
30 > 112 > 162 > 212 > 350
36 > 125 > 175 > 225 > 400
42 > 137 > 187 > 237 > 450
48 > 150 > 200 > 250 > 450
54 > 162 > 212 > 262 > 450
60 > 175 > 225 > 275 > 450
66 > 187 > 237 > 287 > 450
72 > 200 > 250 > 300 > 450
78 - > 262 > 312 > 450
84 - > 275 > 325 > 450
90 - > 287 > 337 > 450
96+ - > 300 > 350 > 450

43
Jaundice treatment if <37 weeks gestational age

 Any jaundice within 24 hours is of concern and should prompt rapid

treatment and a careful look for underlying causes
 The table below is a quick guide, more detailed information can be found at:
[Link]

Estimated Gestational Age

28 weeks 30 weeks 32 weeks 34 weeks 36 weeks

Age in hours
All values in micromol/L

12 hrs Any value above normal range

Start Phototherapy

24 hrs 80 90 100 110 110

36 hrs 110 120 130 140 150

48 hrs 140 150 160 170 180

60 hrs 160 170 190 200 220

72 hrs + 180 200 220 240 260

12 hrs 120 120 120 120 120

Exchange Transfusion

24 hrs 150 150 160 160 170

36 hrs 180 180 200 210 220

48 hrs 210 220 240 250 260

60 hrs 240 260 280 290 310

72 hrs + 280 300 320 340 360

44
Duration of Treatment for Neonatal / Young Infant Sepsis.

Problem Days of treatment

Signs of Young  Antibiotics could be stopped after 48 hours if all the signs
Infant Infection in a of possible sepsis have resolved and the child is feeding
baby breast feeding well and FBC results are normal, CRP negative, LP, if
well. done, is normal.
 Advise the mother to return with the child if problems
recur.
Skin infection with  IV antibiotics to be given for 7 days
signs of generalized
illness such as poor
feeding
Clinical or  IV antibiotics should be continued for 7 days or until
radiological completely well for 24 hrs.
pneumonia.  For positive LP see below.
Severe Neonatal  The child should have had an LP.
Sepsis  IV antibiotics should be continued for a minimum of 7
days or until completely well if the LP is clear
Neonatal meningitis  IV antibiotics should be continued for a minimum of 14
or severe sepsis and days.
no LP performed  If Gram negative meningitis is suspected treatment
should be IV for 21 days.

Fluids, Growth, Vitamins and Minerals in the Newborn:

Babies should gain a minimum of 10g / kg of body weight every day after the first 7
days of life. If they are 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.
Vitamin K
 All babies born in hospital should receive Vitamin K soon after birth
 If born at home and admitted aged <14d give Vitamin K unless already given
 1mg Vitamin K IM if weight > 1.5kg, (0.4mg/kg)IM for pretems
All premature infants (< 36 weeks or < 2kg) should receive:
 1- 2.5 ml of multivitamin syrup daily once they are on full milk feeding at the age
of about 2 wks plus Iron (3-6mg/kg) daily suspension starting at 4-6 weeks of
age for 12 wks.

45
Newborn Feeding / Fluid requirements:TERM BABY Age Total Daily Fluid / Milk Vol.
 Well baby - immediate milk feeding - Table A. For first feed give 7.5ml and increase
by this amount each feed until full daily volume reached Day 0 60 ml/kg/day
 Day 0 - Sick baby or Weight <1.5kg start with 24hrs iv 10%D – Table B
 From Day 1unless baby very unwell start NGT feeds - Begin with 3 mls each 3hrly Day 1 80 ml/kg/day
feed if weight<1.5kg; 5ml 3hrly if 1.5kg≤weight<2kg; and 10ml/3hrly if weight≥2kg.
Increase feed by the same amount every day and reduce iv fluids to keep within the Day 2 100 ml/kg/day
total daily volume until IVF stopped – Table C
 For IVF from Day 1use 2 parts 10% dextrose to 1 part Ringer Lactate (RL) (e.g.. 200
ml 10% D + 100 ml RL) if not able to calculate or give added Na+ (2-3mmol/kg/day) Day 3 120 ml/kg/day
and K+ (1-2mmol/kg/day) to 10% D.
 Please ensure sterility of iv fluids when mixing / adding Day 4 140 ml/kg/day
 Always use EBM for NGT feeds unless contra-indicated
 If signs of poor perfusion or fluid overload please ask for senior opinion on whether to Day 5 160 ml/kg/day
give a bolus, step-up or step-down daily fluids.
Day 6 180 ml/kg/day

A. Nasogastric 3 hrly feed for well TERM babies on full volume feeds on Day 0 and afterwards
Weight 1.5 to 1.7 to 1.9 to 2.1 to 2.3 to 2.5 to 2.7 to 2.9 to 3.1 to 3.3 to 3.5 to 3.7 to 3.9 to
(kg) 1.6 1.8 2.0 2.2 2.4 2.6 2.8 3.0 3.2 3.4 3.6 3.8 4.0
Day 0 12 14 15 17 18 20 21 23 24 26 27 29 30
Day 1 15 18 20 22 24 26 28 30 32 34 36 38 40
Day 2 19 23 25 28 30 33 35 38 40 43 45 48 50
Day 3 24 27 30 33 36 39 42 45 48 51 54 57 60
Day 4 28 32 35 39 42 46 49 53 56 60 63 67 70
Day 5 32 36 40 44 48 52 56 60 64 68 72 76 80
Day 6 36 41 45 50 54 59 63 68 72 77 81 86 90

44
B. IV fluid rates in mls / hr for sick newborns ≥ 1.5kg who cannot be fed

Weight 1.6 - 1.8 - 2.0 - 2.2 - 2.4 - 2.6 - 2.8 - 3.0 - 3.2 - 3.4 - 3.6 - 3.8 -
(kg) 1.5 1.7 1.9 2.1 2.3 2.5 2.7 2.9 3.1 3.3 3.5 3.7 3.9
Day 0 4 4 5 5 6 6 7 7 8 8 9 9 10
Day 1 5 6 6 7 8 8 9 10 10 11 12 12 13
Day 2 6 7 8 9 10 10 11 12 13 14 15 15 16
Day 3 8 9 10 11 12 13 14 15 16 17 18 19 20
Day 4 9 10 11 12 13 15 16 17 18 19 20 22 23
Day 5 10 11 13 14 15 17 18 19 21 22 23 25 26
Day 6+ 11 13 14 16 17 19 20 22 23 25 26 28 29

C. Standard regimen for introducing NGT feeds in a sick newborn ≥ 1.5kg after 24hrs IV fluids

Weight 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
(kg) IVF NGT IVF NGT IVF NGT IVF NGT IVF NGT IVF NGT IVF NGT IVF NGT
mls 3hrly mls 3hrly mls 3hrly mls 3hrly mls 3hrly mls 3hrly mls 3hrly mls 3hrly per
per feed per feed per feed feed per feed per feed per feed per feed hr
hr hr hr hr hr hr hr
Day 1 4 0 4 0 5 0 5 0 6 0 6 0 7 0 7 0
Day 2 3 5 3 8 4 8 4 10 4 10 5 10 6 10 6 10
Day 3 3 10 2 15 3 15 2 20 3 20 4 20 5 20 5 20
Day 4 3 15 1 22 2 22 0 30 2 30 3 30 4 30 5 30
Day 5 2 20 0 30 1 30 0 36 0 39 1 40 2 40 4 40
Day 6 2 25 0 34 0 38 0 42 0 45 0 50 1 50 3 50
Day 7+ 0 33 0 38 0 42 0 48 0 51 0 56 0 60 0 65

45
 Newborn < 1.5kg: Feeding / Fluid requirements. Age Total Daily Fluid / Milk Vol.
 Day 1 - Sick baby start with 24hrs iv 10%D – If you think iv feeding is
Day 1 80 mls/kg/day
unsafe then start immediate ngt feeding with colostrum
 From Day 2 unless baby very unwell start NGT feeds - Begin with 5mls
Day 2 100 mls/kg/day
3hrly as <1.5kg. Increase feed by the same amount every day and reduce
iv fluids to keep within the total daily volume until IVF stopped – see Table
Day 3 120 mls/kg/day
 For IVF from Day 2 use 2 parts 10% dextrose to 1 part HS Darrow’s (eg.
200mls 10% D + 100mls HSD) if not able to calculate or give added Na+
(2-3mmol/kg/day) and K+ (1-2mmol/kg/day) to glucose solution.
Day 4 140 mls/kg/day
 Please ensure sterility of iv fluids when mixing / adding
 Always use EBM for NGT feeds unless contra-indicated
Day 5 160 mls/kg/day
 It may be possible to increase volumes further to as much as
200mls/kg/day but seek expert advice.
Day 6+ 180 mls/kg/day

Hourly IV Fluid rates for Newborns < Standard regimen for introducing NGT feeds after first 24 hours IV
1.5 kg: Using a burette / soluset with 60 fluid for Newborns < 1.5 kg:
drops = 1ml then drip rate = mls/hr
0.8 - 0.9 0.9 - 1.0 1.1 - 1.2 1.3 - 1.4 1.4 - 1.5
Weight 0.8 - 0.9 - 1.1 - 1.3 - 1.4 - (kg)
3hrly mls 3hrly mls
(kg) 0.9 1.0 1.2 1.4 1.5
per hr feed per hr feed per hr feed per hr feed per hr feed
Day 1 3 3 4 4 5
0
Day 2 4 4 5 5 6
5
Day 3 5 5 6 7 8
10
Day 4 5 6 6 8 9 15
Day 5 6 7 7 9 10 20
Day 6 7 8 8 10 11 25
Day 7+ 7 8 8 10 11 33
46
Intravenous / intramuscular antibiotics aged < 7 days, easy to use chart (adapt dose if necessary)

Ampicillin* / Gentamicin
Penicillin
Cloxacillin (3mg/kg <2kg,
Ceftriaxone Metronidazole Acyclovir Amoxycillin
Weight (50,000iu/kg)
(50mg/kg) 5mg/kg ≥ 2kg)
(50mg/kg) (7.5mg/kg) (20mg/kg) Weight Ampicillin
kg Kg Cloxacillin
iv / im iv / im iv / im iv / im iv iv
12 hrly 12 hrly 24 hrly 24 hrly 12 hrly 8 hrly 25mg/kg
1.00 50,000 50 3 50 7.5 20
125mg/5mls
1.25 75,000 60 4 62.5 10 25
1.50 75,000 75 5 75 12.5 30 12 hrly
1.75 100,000 85 6 75 12.5 35 2.00 2
2.00 100,000 100 10 100 15 40 2.50 3
2.50 150,000 125 12.5 125 20 50 3.00 3
3.00 150,000 150 15 150 22.5 60
4.00 200,000 200 20 200 30 80 4.00 4

Ophthalmia Neonatorum: Warning:

Swollen red eyelids with pus  Gentamicin – Please check the dose is correct for weight and age in DAYS
should be treated with a  Gentamicin used OD should be given im or as a slow IV push – over 2-3 min.
single dose of:  If a baby is not obviously passing urine after more than 24 hours consider stopping
 Kanamycin or gentamicin.
Spectinomycin 25mg/kg  Penicillin dosing is twice daily in babies aged < 7 days
(max 75mg) im, or,  Chloramphenicol should not be used in babies aged < 7 days.
 Ceftriaxone 50mg/kg im  Ceftriaxone is not recommended in obviously jaundiced newborns – Cefotaxime is
a safer cephalosporin in the first 7 days of life
 Ampicillin * 150 mg/kg/d if meningitis, 12hrly
 Acyclovir 20 mg/kg 12 hrly if weight < 2 kg; 14d if localized herpes, 21d if general

47
Weight for Length (Height) Charts for children aged 0 – 23 months

Length Boys Girls

(cm) – 3SD –2SD –1SD – 3 SD –2SD –1 SD

For children who have a weight for height that is not ≤ -1 then classify as ‘normal’.

For children who have a weight for height that is not ≤ -1 then classify as ‘normal’.
45 1.9 2 2.2 1.9 2.1 2.3
46 2 2.2 2.4 2 2.2 2.4
47 2.1 2.3 2.5 2.2 2.4 2.6

For more precise WHZ scores please use Weight for Height Charts.
48 2.3 2.5 2.7 2.3 2.5 2.7
49 2.4 2.6 2.9 2.4 2.6 2.9
50 2.6 2.8 3 2.6 2.8 3.1

For more precise WHZ scores please use Weight for Height Charts.
51 2.7 3 3.2 2.8 3 3.3
52 2.9 3.2 3.5 2.9 3.2 3.5
53 3.1 3.4 3.7 3.1 3.4 3.7
54 3.3 3.6 3.9 3.3 3.6 3.9
55 3.6 3.8 4.2 3.5 3.8 4.2
56 3.8 4.1 4.4 3.7 4 4.4
57 4 4.3 4.7 3.9 4.3 4.6
58 4.3 4.6 5 4.1 4.5 4.9
59 4.5 4.8 5.3 4.3 4.7 5.1
60 4.7 5.1 5.5 4.5 4.9 5.4
61 4.9 5.3 5.8 4.7 5.1 5.6
62 5.1 5.6 6 4.9 5.3 5.8
63 5.3 5.8 6.2 5.1 5.5 6
64 5.5 6 6.5 5.3 5.7 6.3
65 5.7 6.2 6.7 5.5 5.9 6.5
66 5.9 6.4 6.9 5.6 6.1 6.7
67 6.1 6.6 7.1 5.8 6.3 6.9
68 6.3 6.8 7.3 6 6.5 7.1
69 6.5 7 7.6 6.1 6.7 7.3
70 6.6 7.2 7.8 6.3 6.9 7.5
71 6.8 7.4 8 6.5 7 7.7
72 7 7.6 8.2 6.6 7.2 7.8
73 7.2 7.7 8.4 6.8 7.4 8
74 7.3 7.9 8.6 6.9 7.5 8.2
75 7.5 8.1 8.8 7.1 7.7 8.4
76 7.6 8.3 8.9 7.2 7.8 8.5
77 7.8 8.4 9.1 7.4 8 8.7

48
Weight for Length (Height) Charts for children aged 0 – 23 months

Length Boys Girls

(cm) – 3SD –2SD –1SD – 3SD –2SD –1 SD

For children who have a weight for height that is not ≤ -1 then classify as ‘normal’.

For children who have a weight for height that is not ≤ -1 then classify as ‘normal’.
78 7.9 8.6 9.3 7.5 8.2 8.9
79 8.1 8.7 9.5 7.7 8.3 9.1
80 8.2 8.9 9.6 7.8 8.5 9.2
81 8.4 9.1 9.8 8 8.7 9.4
82 8.5 9.2 10 8.1 8.8 9.6
83 8.7 9.4 10.2 8.3 9 9.8

For more precise WHZ scores please use Weight for Height Charts.

For more precise WHZ scores please use Weight for Height Charts.
84 8.9 9.6 10.4 8.5 9.2 10.1
85 9.1 9.8 10.6 8.7 9.4 10.3
86 9.3 10 10.8 8.9 9.7 10.5
87 9.5 10.2 11.1 9.1 9.9 10.7
88 9.7 10.5 11.3 9.3 10.1 11
89 9.9 10.7 11.5 9.5 10.3 11.2
90 10.1 10.9 11.8 9.7 10.5 11.4
91 10.3 11.1 12 9.9 10.7 11.7
92 10.5 11.3 12.2 10.1 10.9 11.9
93 10.7 11.5 12.4 10.2 11.1 12.1
94 10.8 11.7 12.6 10.4 11.3 12.3
95 11 11.9 12.8 10.6 11.5 12.6
96 11.2 12.1 13.1 10.8 11.7 12.8
97 11.4 12.3 13.3 11 12 13
98 11.6 12.5 13.5 11.2 12.2 13.3
99 11.8 12.7 13.7 11.4 12.4 13.5
100 12 12.9 14 11.6 12.6 13.7
101 12.2 13.2 14.2 11.8 12.8 14
102 12.4 13.4 14.5 12 13.1 14.3
103 12.6 13.6 14.8 12.3 13.3 14.5
104 12.8 13.9 15 12.5 13.6 14.8
105 13 14.1 15.3 12.7 13.8 15.1
106 13.3 14.4 15.6 13 14.1 15.4
107 13.5 14.6 15.9 13.2 14.4 15.7
108 13.7 14.9 16.2 13.5 14.7 16
109 14 15.1 16.5 13.7 15 16.4
110 14.2 15.4 16.8 14 15.3 16.7
Weight for Length (Height) Charts for children aged 2- 5 years

49
Weight for Length (Height) Charts for children aged 2- 5 years

Length Boys Girls

(cm) – 3SD –2SD –1 SD – 3 SD –2 SD –1 SD

For children who have a weight for height that is not ≤ -1 then classify as ‘normal’.

For children who have a weight for height that is not ≤ -1 then classify as ‘normal’.
66 6.1 6.5 7.1 5.8 6.3 6.8
67 6.2 6.7 7.3 5.9 6.4 7
68 6.4 6.9 7.5 6.1 6.6 7.2

For more precise WHZ scores please use Weight for Height Charts.

For more precise WHZ scores please use Weight for Height Charts.
69 6.6 7.1 7.7 6.3 6.8 7.4
70 6.8 7.3 7.9 6.4 7 7.6
71 6.9 7.5 8.1 6.6 7.1 7.8
72 7.1 7.7 8.3 6.7 7.3 8
73 7.3 7.9 8.5 6.9 7.5 8.1
74 7.4 8 8.7 7 7.6 8.3
75 7.6 8.2 8.9 7.2 7.8 8.5
76 7.7 8.4 9.1 7.3 8 8.7
77 7.9 8.5 9.2 7.5 8.1 8.8
78 8 8.7 9.4 7.6 8.3 9
79 8.2 8.8 9.6 7.8 8.4 9.2
80 8.3 9 9.7 7.9 8.6 9.4
81 8.5 9.2 9.9 8.1 8.8 9.6
82 8.7 9.3 10.1 8.3 9 9.8
83 8.8 9.5 10.3 8.5 9.2 10
84 9 9.7 10.5 8.6 9.4 10.2
85 9.2 10 10.8 8.8 9.6 10.4
86 9.4 10.2 11 9 9.8 10.7
87 9.6 10.4 11.2 9.2 10 10.9
88 9.8 10.6 11.5 9.4 10.2 11.1
89 10 10.8 11.7 9.6 10.4 11.4
90 10.2 11 11.9 9.8 10.6 11.6
91 10.4 11.2 12.1 10 10.9 11.8
92 10.6 11.4 12.3 10.2 11.1 12
93 10.8 11.6 12.6 10.4 11.3 12.3
94 11 11.8 12.8 10.6 11.5 12.5
95 11.1 12 13 10.8 11.7 12.7
96 11.3 12.2 13.2 10.9 11.9 12.9
97 11.5 12.4 13.4 11.1 12.1 13.2
98 11.7 12.6 13.7 11.3 12.3 13.4
99 11.9 12.9 13.9 11.5 12.5 13.7

50
Weight for Length (Height) Charts for children aged 2- 5 years

Length Boys Girls

(cm) – 3SD –2SD –1 SD – 3 SD –2 SD –1 SD

For more precise WHZ scores please use Weight for Height
For children who have a weight for height that is not ≤ -1 then

For children who have a weight for height that is not ≤ -1 then
100 12.1 13.1 14.2 11.7 12.8 13.9

For more precise WHZ scores please use Weight for Height
101 12.3 13.3 14.4 12 13 14.2
102 12.5 13.6 14.7 12.2 13.3 14.5
103 12.8 13.8 14.9 12.4 13.5 14.7
104 13 14 15.2 12.6 13.8 15
105 13.2 14.3 15.5 12.9 14 15.3
106 13.4 14.5 15.8 13.1 14.3 15.6

classify as ‘normal’.

classify as ‘normal’.
107 13.7 14.8 16.1 13.4 14.6 15.9
108 13.9 15.1 16.4 13.7 14.9 16.3
109 14.1 15.3 16.7 13.9 15.2 16.6
110 14.4 15.6 17 14.2 15.5 17
111 14.6 15.9 17.3 14.5 15.8 17.3
112 14.9 16.2 17.6 14.8 16.2 17.7
113 15.2 16.5 18 15.1 16.5 18
114 15.4 16.8 18.3 15.4 16.8 18.4
115 15.7 17.1 18.6 15.7 17.2 18.8
116 16 17.4 19 16 17.5 19.2
117 16.2 17.7 19.3 16.3 17.8 19.6
118 16.5 18 19.7 16.6 18.2 19.9
119 16.8 18.3 20 16.9 18.5 20.3
120 17.1 18.6 20.4 17.3 18.9 20.7

51
 Emergency estimation of child’s weight from their age.

All babies and children

admitted to hospital Child looks well
should be weighed and nourished, average Child looks obviously
the weight recorded in size for age underweight – find age
the medial record and in Estimated but step back 2
the Maternal Child Health Age Weight (kg) weight/height
Booklet. categories and use the
1 – 3 weeks 3.0 weight appropriate for
Estimate the weight 4 - 7 weeks 4.0 this younger age-
group.
from the age only if 2 - 3 months 5.0
immediate life support 4 - 6 months Eg. Child thin and age
7.0
is required or the 10 months, use the
patient is in shock – 7 to 9 months 9.0 weight for a 4-6 month
then check weight as 10 to 12 months 10.0 well nourished child.
soon as stabilized.
1 to 2 yrs 11.0 If there is severe
All other children 2 to 3 yrs malnutrition this chart
13.0
will be inaccurate.
should have weight 3 to 4 yrs 15.0
measured.
4 to 5 yrs 17.0

52
 Emergency estimation of child’s weight from their age.

All babies and children

admitted to hospital Child looks well
should be weighed and nourished, average
the weight recorded in size for age Child looks obviously
underweight – find
the medial record and in Estimated age but step back 2
the Maternal Child Health Age Weight (kg) age/weight categories
Booklet. 1 – 3 weeks 3.0 and use the weight
appropriate for this
4 - 7 weeks 4.0
Estimate the weight younger age-group.
from the age only if 2 - 3 months 5.0
immediate life support Eg. Child thin and age
4 - 6 months 7.0
is required or the 10 months, use the
patient is in shock – 7 to 9 months 9.0 weight for a 4-6 month
well nourished child.
then check weight as 10 to 12 months 10.0
soon as stabilized. If there is severe
1 to 2 yrs 11.0
malnutrition this chart
All other children 2 to 3 yrs 13.0 will be inaccurate.
should have weight 3 to 4 yrs 15.0
measured.
4 to 5 yrs 17.0

53
The ETAT+ program in Rwanda was supported by the following institutions: