Practical Approach to Care Kit

Primary Care Guideline for Children· 2017· Pilot version

Western Cape Edition
Acknowledgements
Shariefa Abrahams Elma De Vries Mary-Anne Jonkerman Jaco Murray Stephanus Serfontein
Shabirah Adriaanse Stewart Dix-Peek Sumaya Joseph Lenny Naidoo Liezl Smit
Florence Africa Kirsty Donald Ezna Josephus Zaida Naidoo Dusica Stapar
Lauren Anderson Sarah Driver-Jowitt Elrien Joubert Tracy Naledi Bennie Steyn
Andrew Argent Karen Du Preez Nina Klein Nomikazi Nkolisa Alvera Swartz
Ajibola Awotiwon Marjorie Dukhan Yulene Kock Mosedi Namane Caroline Taylor
Grant Baaitjies Rowan Dunkley Tracy Kritzinger Rene Nassen Marianne Tiemensma
Ronelle Bailie Oskar Edkins Max Kroon Kitty Niewoudt Vonita Thompson
Kate Balme Nicola Eley John Lawrenson Nobulele Nomnga Mike Urban
Nonthuthzelo Bashe Michelle Flowers Lilian Le Tape Sam-sam Nonqaba Riatha van As
Wiaan Bedeker Lisa Frigati Martha Lekay Sabelo Ntlabathi Sebastian van As
Denise Bester Sikhumbuzo Gangala Michael Levin Tracy Nupen Albertine van der Does
Astrid Berg Antony Garcia-Prats Vanessa Lomas James Nuttall Samantha van Deventer
Jonathan Bernheimer Janet Giddy Hermien Louw Shazia Peer Ben van Stormbroek
Arvin Bhana Hilary Goeiman Crick Lund Adriane Petersen Lourentia van Wyk
Vasanthy Bhana Srini Govender Jennifer Maarman Inge Petersen Ann van Eyssen
Sonia Botha Di Grey Phumeza Mabunzi Penny Petersen Pearl van Niekerk
Judy Caldwell Florence Groener Elmarie Malek Eva Perez Hildegard Van Rhyn
Anne Campbell Hetta Felix Mzuphela Malgas Sandy Picken Jackie Voget
Emma Carkeek Aletta Haasbroek Sherilee Maregele Leilanie Philips-Losch Cathy Ward
Rabia Cariem Juliet Hannington Nomonde Mbatani Travis Pollock Estelle Wasserfall
Michelle Carrihill Di Hawarden Stewart Mears Paul Potter Leigh Waterhouse
Janine Chester Helen Hayes Robyn Meissner Helena Rabie Camilla Wattrus
Louise Cooke Michael Hendricks Michelle Meiring Veruschka Ramanjam Volene Werely
Jacqui Cooper Nicolette Henney Lyndall Metherell Christy-Joy Ras Anthony Westwood
Ruth Cornick Carol Hlela Maye M Mhaka Andrew Redfern Madeleine Wildschutt
Gaynore Daniels Cornelia Horn Nomapha Mlungu Hermann Reuter Lyn Wilkinson
Miriam Daniels Justin Howlett Bulelwa Mpinda Natasha Rhoda Jo Wilmshurst
Neal David Val Hoy Nadia Mohamed Mark Richards Nicola Wilson
Alta Davids Abdul Isaacs Ann Moore Liezel Rossouw Somikazi Xaso
Willem De Jager Lizel Jacobs Jennie Morgan Simon Schaaf Xoliswa Yonya
Tersia De Kock Shahida Jacobs Vanessa Mudaly Arina Schlemmer Zimasa Zwide
Angela De Sa Shanaaz Jaffer Katy Murie Chris Scott
Preface
Contents: integrate routine care at every visit
Screen the child in the prep room 1 Child ≥ 2 months old: routine care 5
First assessment of the newborn 2 Assess growth 8
Baby < 2 months old: routine care 4

Contents: symptoms
A G N
Abdominal problems 45 Cough 41 Genital problems 51 Nappy rash 67 Sleeping problems 76
Abused child 70 Cough, recurrent 44 Glands, swollen 34 Naughty 72 Snoring 37
Anal symptoms 50 Crying 30 Glucose, abnormal 24 Nausea 47 Speech problems 73
Angry 72 Cyanosis 27 Neglect 70 Stiffness, joint 58
Anxious 72 H Newborn resuscitation 16 Stings 29
Arm problems 54 D Hand problems 54 Nose symptoms 37 Stressed 71
Decreased level of Headache 32
B consciousness 21 Head injury 25 O T
Back problems 53 Dehydrated child 20 Hearing problems 36 Overweight child 88 Talking problems 73
Behaviour problems 72 Depressed child 72 Hyperactivity 72 Teeth problems 40
Bites 29 Diarrhoea 48 Hypo/hyperglycaemia 24
P Throat symptoms 38
Blue child 27 Parenting difficulties 77 Tiredness 76
Breastfeeding 78 E I Poisoning 28
Breathing difficulty, newborn 16 Ear symptoms 36 Injured child 25 U
Breathing difficulty, child 41 Eating 81 Irritable child 30
R Unconscious child 21
Bullying 75 Emergency child 17 Rape 70 Unhappy child 71
Bump 64 Eye symptoms 35 J Rash 59 Urinary symptoms 52
Burns 26 Jaundice 46 Refluxing 47
F Joint symptoms 58 Respiratory arrest 18 V
C Face symptoms 39 Resuscitation, newborn 16 Vision symptoms 35
Cardiac arrest 18 Fatigue 33 L Resuscitation, child 18 Vomiting 47
Cardiopulmonary 18 Feeding, breast 78 Learning problems 73
resuscitation (CPR) Feeding, eating 81 Leg symptoms 55 S W
Choking 19 Feeding, formula 80 Limp 55 School problems 75 Walking problems 55
Coma 21 Fever 31 Lump, skin 64 Scrotal problems 51 Weakness 74
Confusion 21 Fits 22 Lymphadenopathy 34 Seizures 22 Weight loss 8
Communicating problems 73 Floppy child 74 Shock 20 Wheeze 42
Concentration problems 73 Foot symptoms 57 M Skin symptoms 59 Wheeze, recurrent 44
Constipation 49 Fracture 25 Miserable child 71 Worms 50
Convulsions 22 Mouth symptoms 38
Moving problems 74
Contents: long-term health conditions
Diagnose and give routine care to the patient with a long term health condition

Nutrition Allergy
Poor growth in the child < 2 months old 83 Child with allergy 106
The underweight child 84 Eczema 107
Not growing well/growth faltering: routine care 85 Asthma 108
Acute malnutrition: routine care 86
Overweight: routine care 88
Other long term health conditions
Chronic malnutrition: routine care 87
Bronchiectasis 109
Anaemia: diagnosis and routine care 89
Known heart problem 110
Chronic arthritis: routine care 111
Tuberculosis (TB)
Check for TB 92 Epilepsy 112
TB: routine care 95
TB medication 97
The child with close TB contact 90
Special needs
Drug-resistant (DR) TB contacts 91 Cerebral palsy: routine care 113
Down syndrome: routine care 116

HIV
HIV: diagnosis 98
Palliative care 117

HIV: routine care 99

Prevention of mother-to-child transmission (PMTCT) of HIV 104 Protect yourself from occupational infection 118
Post-exposure prophylaxis (PEP): HIV and hepatitis B 105 Protect yourself from occupational stress 119
Protect yourself from occupational infection 118 Communicate effectively 120
Prescribe rationally 121
Medication dosing tables 122
Helpline numbers 128
Screen the child in the prep room
• Manage the obvious emergency situation: child not breathing or responding to voice/stimulation, call for help 17, if fitting 22. If baby newly born 16.
• Triage the child according to reason for clinic visit:

Well child visit Sick child visit Trauma

(Injuries, burns and poisoning)
Does child have any of:
• Baby < 2 months old • Vomiting everything • History of convulsions (fits) in this illness Does child have any of:
• Consult in past 2 days • Unable to feed • Difficulty breathing (or history of apnoea1) • Burns • Extensive bruising
• Decreased level of consciousness • Diarrhoea • Sudden onset weakness of face, arm or leg • Suspected fracture/dislocation • Poisoning
• Head injury • Eye injury
• Bleeding wound • Severe mechanism of injury2
No Yes, prioritise this child:
• Check temperature, respiratory rate, • Check temperature, respiratory rate, pulse rate, oxygen
pulse rate, oxygen saturation (if saturation (if available) and look for pallor (129). Yes No
available) and look for pallor ( 129). • If lethargic/history of convulsion (fit), also check
• If pallor, also check fingerprick Hb. glucose 24.
Check temperature, respiratory rate, pulse rate,
• If pallor, also check fingerprick Hb.
oxygen saturation (if available) (129).
• If sats < 92%, give oxygen 2L/minute via nasal prongs.
All normal ≥ 1 abnormal

Notify clinician and fast track child to front of the queue

• Measure growth and record in RtHB: check weight at every visit (remove nappy). Check how often to measure MUAC3, height/length and head circumference 7.
• Clinician to now assess child and provide routine care: if < 2 months old 4, if ≥ 2 months old 5.

How to measure length/height, head circumference and Mid Upper Arm Circumference
How to measure length/height How to measure head How to take the Mid Upper Arm
Remove shoes/hair ornaments that will interfere with measurements. circumference Circumference (MUAC)
If < 2 years old, measure length:
• Lie baby on length board.
• Carer to hold head against head board.
• Gently hold down baby’s legs and move foot board
so that feet lie flat against it.
If ≥ 2 years old, measure height:
• Stand child against wall with head, shoulder blades, buttocks, calves Wrap tape measure around widest
and heels touching wall. part of head:
• Keep feet flat on ground. • Start from a point 2 fingers above 1 2 3 4
• Carer to hold knees and ankles. eyebrow, past top of ears to around • Find tip of shoulder and tip of elbow when elbow bent to 90°.
• Gently hold child’s chin to keep head straight. the widest part of back of head. • Mark midpoint between these then allow arm to hang straight down.
• Pull down headboard to rest firmly on child’s head and measure in cm. • Measure in cm. • Wrap tape around arm at midpoint and measure in cm.
1
Apnoea is episodes of no breathing > 10 seconds. 2For example: a car or pedestrian accident, fall from height, stab wound, gunshot wound. 3Mid Upper Arm Circumference.
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First assessment of the newborn
If baby needs help to breathe at birth 16. Otherwise assess the baby within 6 hours following birth.

Give urgent attention to the newborn with any of:

• < 2kg • Jaundice 46
• Baby < 34 weeks gestation • Irregular jerky movements
• Difficulty breathing: blue lips/tongue, respiratory rate > 60, • Reduced movements/lethargy
grunting, nasal flaring or chest indrawing • Open area over spine
• Rapid swelling of head • Abdominal distension
• Extensive bruising1

Manage and refer urgently:

• If difficulty breathing, give oxygen 1L/min via nasal prongs.
• Keep baby warm: place baby skin-to-skin with mother and cover with blanket or transport in incubator.
• Check heel prick glucose:
--If ≥ 2.6mmol/L and alert, encourage breastfeeding. Only, if breastfeeding if not possible, give formula/sugar water4 3mL/kg/hour orally. If baby too sick to feed, give via NGT. Feed at least 2
hourly until transfer.
--If < 2.6mmol/L, manage hypoglycaemia:
Glucose < 1.4mmol/L Glucose 1.4-2.6mmol/L

• Breastfeed or feed expressed breast milk. If breastfeeding if not possible, give formula 10mL/kg orally. If refusing, give via NGT.
• Recheck heel prick glucose after 15 minutes:

< 2.6mmol/L ≥ 2.6mmol/L

Continue milk feeds 2 hourly and repeat glucose just before next feed:

< 2.6mmol/L ≥ 2.6mmol/L

• Give a bolus of dextrose 10%2 2mL/kg IV. No further hypoglycaemia treatment

• Continue with dextrose 10%2 infusion at 3mL/kg/hour3 IV. needed.
• Recheck glucose after 15 minutes: Refer urgently.
--< 2.6mmol/L: repeat bolus of dextrose 10%2 2mL/kg IV and with dextrose 10%2 infusion 3mL/kg/hour3 IV and refer urgently.
--≥ 2.6mmol/L: continue with dextrose 10%2 infusion 3mL/kg/hour3 IV and refer urgently.

Then examine the baby not needing urgent attention 3.

1
If bluish grey patch/es just over lower back or buttocks, mongolian spots likely. Reassure carer that will fade completely by 2 years old. 2Neonatalyte. If dextrose 10% unavailable: in same 20mL syringe, draw up 4mL of dextrose 50% and 16mL of water
for injection in same syringe (syringe now contains 20mL of 10% dextrose). 3This is 3 drops/kg/minute. 4Dissolve 3 teaspoons of sugar (15g) into 200mL water.
2
 Assess the newborn not needing urgent attention
Assess Note (undress baby fully when examining but keep baby warm)
Mother/carer • Give mother routine postnatal care PACK Adult.
• If mother/carer or you are worried about how mother/carer and family will cope with baby, refer to social worker/community health worker.
• Look for increased psychosocial risk (mother unbooked, is ill/died, < 20 years old, unhappy about baby, family/relationship problems, violence at home, lack of partner/family support, financial
difficulty, difficult life event in last year, refugee status): provide additional support, review more often if needed and link with support services 128.
Feeding Assess suck/latch and give feeding advice 78.
TB risk If mother/close contact on treatment for < 2 months before delivery, refer/discuss with doctor/paediatrician. If mother on TB treatment for ≥ 2 months, start TB prophylaxis 90 (delay BCG vaccine
until IPT complete).
Measurements • Plot weight-for-age, weight-for-length, head circumference and record in RtHB. If head circumference > 39cm, refer urgently. If head circumference < 32cm, refer/discuss with doctor/paediatrician.
• If weight > 4.5kg, check glucose every hour for 6 hours. If < 2.6mmol/L, manage as hypoglycaemia 2.
Tone If not moving spontaneously or seems floppy, discuss with doctor.
Head • If doughy swelling on head, that crosses suture lines, caput likely. Usually resolves in few days. If round, fluctuant swelling on one side of head, cephalohaematoma likely, refer.
• Check anterior fontanelle. If bulging, refer urgently. If sutures overlapping, review in 2-3 days. If still overlapping after this, refer.
Face and neck If cleft/palate lip, refer same day. If unusual appearance, abnormal shape of face or neck swelling/webbing, discuss with doctor.
Eyes If thick yellow discharge present in eyes 35.
Nose If nose blocked, give sodium chloride 0.9% 1 drop in each nostril.
Abdomen If mass in abdomen, doctor to review. If soft collapsible mass around umbilicus or groin, hernia likely, doctor to review and book surgical OPD appointment.
Genitalia and anus • If ambiguous genitalia, refer/discuss with doctor/paediatrician. In male: if testes not felt in scrotum, review in 1 month. If still not felt, refer surgical OPD. Check urethral opening at tip of penis. If
displaced, refer.
• If imperforate anus, delay feeding and give dextrose 10%1 infusion at 3mL/kg/hour2 IV.
Limbs • If one arm rotated towards body or moving less than before, Erb’s palsy likely, doctor to review. Follow up after 2 days: if problem persists, refer to orthopaedic OPD.
• If extra digit with bone present, book surgical OPD appointment. If no bone present and on thin stalk of skin, doctor to tie off.
• If foot/feet bent with sole/s facing inward, clubfoot likely. Refer to orthopaedic specialist unless foot can be easily manipulated into normal position3, in which case refer to physiotherapist.
Hips Assess for hip dislocation (likely developmental dysplasia of hip):
• Hold knees bent at 90°, lightly grasping thigh (with index and middle finger over outer aspect of hip and thumb on inner thigh). Gently push downwards into the bed. If feeling of looseness or
palpable clunk felt, refer orthopaedic OPD. Next, move legs in frog-leg position and push hip upwards towards you from behind. If “click” heard/felt, refer orthopaedic OPD.
Bilirubin (TSB) Check baby’s total serum bilirubin 6 hours after birth if mother blood group O or rhesus negative. If bilirubin > 80mmol/L, refer for phototherapy.
HIV risk If HIV-exposed, do a birth HIV PCR and give PMTCT 104.
Syphilis If mother syphilis positive and untreated, give baby benzathine benzylpenicillin 50 000units/kg IM. If signs of congenital syphilis4, refer same day. Treat mother PACK Adult.

Advise the carer of the newborn:

• Encourage mother and father to hold, cuddle, talk/sing and make eye contact with baby. This helps with bonding and development. If mother finds this difficult, encourage her to return more frequently.
• Advise carer to keep infant warm using skin-to-skin contact. If birthweight ≤ 2.5kg, advise mother to practise Kangaroo Mother Care (KMC) until baby >2.5kg. Encourage father to also practise KMC.
• Advise carer to apply chlorhexidine glucose 0.5% in 70% alcohol (or surgical spirit) to the umbilical cord every 6 hours until it falls off.

Immunise newborn
Give BCG intradermally into right arm. If baby TB exposed, delay BCG until IPT5/TB treatment completed. Give OPV orally.

Discharge newborn and plan review

• If newborn is well, urine passed and breastfeeding established, discharge after 6 hours. Issue RtHB and explain contents. Refer to community health worker for home visit and breastfeeding support.
• Review within 6 days, then 2 weeks and at 6 weeks 4. If preterm (< 37 weeks) or < 2.5kg, doctor also to review 2 weekly until 2.5kg, then at 4 and 9 months old.
• Advise to return immediately if breastfeeding poorly, irritable/lethargic, fitting, vomiting everything, fever, cough with fast breathing, blood in stool or no stool passed within 48 hours of birth.
Neonatalyte. If dextrose 10% unavailable: in same 20mL syringe, draw up 4mL of dextrose 50% and 16mL of water for injection in same syringe (syringe now contains 20mL of 10% dextrose) 2This is 3 drops/kg/minute. 3This likely due to position of baby in uterus.
1

Signs of congenital syphilis: rash (red/blue spots of bruising especially on soles and palms), jaundice, pallor, distended abdomen (enlarged liver/spleen), low birth weight, respiratory distress, large, pale placenta. 5Isoniazid preventive therapy
4

3
Baby < 2 months old: routine care
Record all problems and plot growth measurements in notes and Road to Health Booklet: (RtHB): assess baby and mother within 6 days of delivery and at 2 and 6 weeks old. If never assessed 2.
Assess When to assess Note
Symptoms Every visit Manage symptoms on symptom page. If cough/breathing problems 41, diarrhoea 48, vomiting 47, fits 22.
Feeding Every visit Ask carer if feeding problem. If yes, assess and manage further: if breastfeeding (or mixed feeding) 78, if formula feeding 80.
Urine/stool 1st visit (within 6 days) Ask if baby passing urine and stool? If not, refer/discuss with doctor/paediatrician.
Growth Weight: every visit • Assess weight-for-age at every visit and plot in RtHB.
• If baby ≥ 10 days and has not regained birth weight, or if > 10% loss of birth weight2 in first week of life 83.
Routine visit Every visit Check if birth and 6 week immunisations are up to date in the RtHB. If missed immunisations, catch up missed doses 6. If adverse event following immunisation 121.
HIV If HIV-exposed: every visit Check that birth HIV PCR was done and follow up result. If HIV PCR not done, do PCR now 98.
TB Every visit • If mother/close contact on treatment for < 2 months before delivery, refer/discuss with doctor/paediatrician. If mother on TB treatment for ≥ 2 months, start TB
prophylaxis 90.
• If mother/close contact is symptomatic of TB and not on treatment, refer/discuss with doctor/paediatrician.
Carer Every visit Check mother received post-natal care PACK Adult. Ask about HIV status, contraceptive needs and TB symptoms.
Psychosocial risk First visit • If child support grant needed, advise to take child’s birth certificate and carer’s ID to SASSA1 to apply or link with helpline 128. If no birth certificate, refer social worker.
• Screen for increased maternal/parental risk (< 20 years old, family/relationship problems, violence at home, lack of partner/family support, financial difficulty, difficult life
event in last year, refugee status): provide additional support, review more often if needed and link with support services 128.
• If yes to ≥ 1 during the past month PACK Adult (depression and/or anxiety diagnosis page): 1) Have you been down, depressed or hopeless? 2) Have you had little
interest/pleasure in things? 3) Have you often felt nervous, anxious or panicky? 4) Have you been unable to stop worrying or thinking too much?
• During the past month, has mother/carer had thoughts of harming her/himself? If yes PACK Adult (suicide page).
Skin Every visit If yellow skin/eyes 46, pallor 89 or if blue 27. If rash/pustules 59.
Eyes Every visit If white eye/s (pupil hazy/cloudy), refer/discuss with doctor/paediatrician same day. If pus and/or eyelid swelling 35.
Mouth Every visit If white patches in the mouth (inside of cheeks/lips and on tongue), oral thrush/candida likely 38.
Umbilical cord If still present If skin around cord red/pus present, give cephalexin 12.5mg/kg 6 hourly for 5 days (table 8 123). Apply chlorhexidine solution 4% to cord every 6 hours and leave
exposed to dry.
Hearing screening If needed If mother has any concerns, book hearing test.

Advise the carer

• Support the breastfeeding mother 78 or the formula feeding mother/carer 80.
• Encourage mother/carer to keep infant warm using skin-to-skin contact. If birthweight ≤ 2.5kg, advise to practise Kangaroo Mother Care until baby > 2.5kg. Refer to community health worker.
• The first 1000 days of a child's life are vital to his/her development. Encourage mother/father to respond when baby cries and to hold, cuddle, talk, sing and make eye contact with baby. Help access
further information 128.

Immunise and treat the baby

• DTap-IPV-HB Hib IM into left thigh plus OPV orally plus RV orally plus PCV IM into right thigh. If missed immunisations, catch up missed doses 6.
• Multivitamins: if birth weight < 2.5kg or baby < 37 weeks gestation from 2 weeks old, give multivitamin 0.6mL once daily and ferrous gluconate 0.8mL once daily or ferrous lactate 0.3mL once daily
until 6 months old.

• Review mother/carer and baby around 2 weeks old and at 6 weeks old.
• Review more often if: premature, low birth weight, admitted for > 3 days after birth, known neurological/congenital problem or suspected bonding problem (carer reluctant to hold or look at baby).
1
South Africa Social Security Agency. 2Birth weight (kg) ÷ 10 = 10% of birth weight: if weight loss in first week of life more than this, baby has poor growth.
4
Child ≥ 2 months old: routine care
Record problems and plot growth measurements in notes and Road to Health Booklet (RtHB).
Assess When to assess Note
Symptoms If sick visit Manage symptoms on symptom page contents.
Feeding/nutrition 7 Ask carer if feeding problem. If yes, assess and manage further: if breastfeeding (or mixed feeding) 78, if formula feeding 80, if problem and eating solids 81.
Growth 7 Interpret measurements 8. If born premature, use corrected age2 until 2 years.
Development Every visit Ask if child is able to say and do things that other children of a similar age can do. If vision problem 35. If communication problem 73. If not moving or sitting properly 74.
14 weeks old If unable to follow a close object with eyes 35. If does not respond (stops sucking, blinks or turns) to sound 73. If unable to lift head when held against shoulder 74.
6 months old If unable to recognise familiar faces 35. If does not turn to look for sound 73. If unable to hold a toy in each hand 74.
9 months old If unable to focus on a far object or has a squint 35. If does not turn when called 73. If unable to sit and play without support 74.
15 months old If unable to stand on his/her own 74.
18 months old If not looking at or reaching for small objects or pictures 35. If unable to point to 3 simple objects, uses < 3 words, does not obey simple commands 73. If unable to walk
unsupported or if unable to feed using fingers 74.
3 years old If unable to see small shapes clearly from 6 metres 35. If unable to talk in simple 3-word sentences 73. If unable to run well or climb things 74.
5-6 years old If any problem with vision 35. If unable to speak in full sentences or not interacting with children and adults 73. If unable to hop on one foot, or draw a stick person 74.
Routine visit Every visit Check if immunisations, deworming, vitamin A are up to date in the RtHB. If missed immunisations, catch up missed doses 6. If adverse event following immunisation 121.
HIV Every visit if not •If no recent documented HIV negative result, decide if HIV test is needed 98.
known HIV •If HIV negative and breastfeeding, check that mother tests for HIV every 3 months.
•If HIV-exposed (mother HIV positive), check child has had routine HIV tests 98. Ensure the HIV-exposed baby is receiving PMTCT 104.
•If HIV positive, ensure child is taking ART and give routine HIV care 99.
TB Every visit If TB symptoms (cough or fever ≥ 2 weeks, not growing well/losing weight, tiredness/reduced playfulness) or close TB contact 92.
Mother/carer Every visit Ask about general health, HIV status, contraceptive needs and TB symptoms PACK Adult.
Psychosocial risk Every visit • If child support grant needed, advise to take child’s birth certificate and carer’s ID to SASSA1 to apply or link with helpline 128.
• Screen for increased maternal/parental risk (< 20 years old, family/relationship problems, violence at home, lack of partner/family support, financial difficulty, difficult life event in
last year, refugee status): provide additional support, review more often if needed and link with support services 128.
• If carer says yes to 1 or more of the following PACK Adult (Depression and/or anxiety diagnosis page): 1) During the past month, have you felt down, depressed, hopeless? 2)
During the past month, have you felt little interest or pleasure in doing things?
• If yes to both of the following 77: 1) Are you struggling with or feeling overwhelmed by parenting? 2) Would you like help with this?
• If child abuse or neglect suspected 70.
Mental health Every visit If over past few months, child has been miserable, stressed or angry 71 or if problematic change in behaviour 72.
School problems If ≥ 6 years old: • Check if child at school: if not enrolled in school, refer to social worker.
every visit • If poor attendance, bullying, learning problems, difficulty socialising at school 75.

South Africa Social Security Agency. 2Corrected age = actual age in months (or weeks) - number of months (or weeks) premature. To calculate corrected age of 9 month old baby, born premature at 32 weeks (this is 8 weeks or 2 months premature): 9
1

months - 2 months = 7 months.

5
 Advise the child and carer and provide health promotion messages
• Good parenting: stimulate development, especially during first 1000 days (conception - 2 years old): respond when baby cries, talk to baby, read daily, tell stories, sing songs, play with child. Establish
routines, provide discipline and actively listen to child. Avoid smoking in the house or near child. Help access further information on first 1000 days 128.
• Child safety: lock away toxic household substances, safeguard open fires/paraffin lamps and electricity sockets, teach child road safety, and use car seats and safety belts.
• Physical activity ≥ 1 hour/day (team sports/outside play) and limit TV, movies, video games, social media to less than 1-2 hours/day. Recommend no TV time for the child < 2 years old.
• Good hygiene: wash hands with soap and water, especially after using toilet when handling food and after cleaning wounds. Wash fruit/vegetables. If no access to clean water, boil and cool water.
• Oral hygiene: brush teeth twice daily, as soon as first tooth appears. If < 10 years old, carer to supervise/help child to brush. Floss from 3 years old.
• Good nutrition: ensure a healthy balanced diet. Limit sweets, chocolates, fizzy drinks and salt. If problems: breastfeeding 78, formula feeding 80, eating solids 81.

Immunise and treat the child

• Multivitamins: if < 6 months old and premature or low weight (< 2.5kg), give multivitamin 0.6mL once daily and ferrous gluconate or ferrous lactate 0.6mL once daily until 6 months old.
• Vitamin A: if 6 months - 5 years old, give vitamin A 6 monthly as a single dose: if 6-12 months old: give 100 000IU, if 12 months-5 years old: give 200 000IU.
• Deworm: from 12 months - 5 years old, give mebendazole 6 monthly: if 12-24 months old: give 100mg 12 hourly for 3 days, if ≥ 24 months old: give 500mg as a single dose.
• Immunise: give immunisations (see table), even if born premature, unwell (delay only if temperature ≥ 38.5°C) or RtHB missing. Issue a new RtHB if RtHB lost. If missed immunisation, manage as per table below.

Give routine immunisations: Catchup missed immunisation/s:

Refer to community health worker. If concerns about poor parental care, refer social worker.
Age Immunisation Site
Immunisation Give first dose Give next dose/s, if needed, according to minimum interval:
Birth BCG Intradermal right arm
according to age:
OPV 0 Oral Dose 2 Dose 3 Dose 4

6 weeks OPV 1 Oral BCG 1

If < 1 year, give now.

RV 1 Oral If ≥ 1 year, do not give.

Hexavalent 1: DTap-IPV-HB-Hib 1 IM left thigh OPV If < 6 months, give now. Give 4 weeks later.

PCV 1 IM right thigh If > 6 months, do not give.

10 weeks Hexavalent 2: DTap-IPV-HB-Hib 2 IM left thigh DTaP-IPV-HB-Hib If < 2 years, give now. Give 4 weeks later. 4 weeks Give at 18 months old.

14 weeks Hexavalent 3: DTap-IPV-HB-Hib 3 IM left thigh If 2-6 years, give now. Give 4 weeks later. Give 4 weeks later. Give 12 months later.

PCV 2 IM right thigh RV If < 20 weeks, give now. Give 4 weeks later.

RV 2 Oral If 20-24 weeks, give now.

6 months Measles 1 Subcutaneous left thigh If > 24 weeks, do not give.

9 months PCV 3 IM right thigh PCV If < 6 months, give now. Give 4 weeks later. Give at 9 months old.
If 6-11 months, give now. Give 4 weeks later. Give 8 weeks later.
12 months Measles 2 Subcutaneous right arm
If 12 months - 6 years , 2
18 months Hexavalent 4: DTap-IPV-HB-Hib 4 IM left arm
give now.
6 years Td IM left arm Measles3 If < 11 months, give now. Give at 12 months old.
9 years if a girl (given at school) HPV Repeat in 6 months. IM left arm If ≥ 11 months, give now. Give 4 weeks later.
12 years Td IM left arm Td If > 6 years, give now. Give at 12 years old.

BCG: Bacillus Calmette-Guérin (TB) OPV: Oral polio vaccine DTap: Diphtheria, Tetanus, acellular Pertussis IPV: Polio HB: Hepatitis B Hib: Haemophilus influenzae type b RV: Rotavirus vaccine
PCV: Pneumococcal conjugate vaccine Td: Tetanus, diphtheria HPV: Human papilloma virus vaccine

1
If baby TB exposed, delay BCG until isoniazid prevention therapy/TB treatment completed. 2If child has long-term health condition, give 3 doses of PCV: give dose 1 now, dose 2 in 4 weeks and dose 3, 8 weeks after dose 2. 3Avoid giving at same time as
other vaccines. If other vaccines needed at same time, give measles vaccine immediately and schedule visit to receive remaining vaccines 1 month later.
6
Routine care
Assess and treat the well child according the age
Age Check growth, plot on growth charts interpret results 8 If HIV exposed, test Check Check Immunise Give Deworm Check Arrange oral
Weight Length or Weight-for- BMI MUAC Head
for HIV 98. TB risk feeding 6 Vitamin A 6 development health visit,
height length/height circumference 92 6 5 refer dentist1.
3-6 days x x x
1 week x x
2 weeks x x
6 weeks x x x
10 weeks x x x x
14 weeks x x x x x x
4 months x x x
5 months x x x
6 months x x x x x x x x x
7 months x x
8 months x x
9 months x x x x x x x
10 months x x
11 months x x
12 months x x x x x x x x x x x x
14 months x x
15 months x x x x
16 months x x
18 months x x x x x x x x x x x
20 months x x
22 months x x
24 months x x x x x x x x
30 months (2 ½ years) x x x x x x x
36 months (3 years) x x x x x x x x x
42 months (3 ½ years) x x x x x x x
48 months (4 years) x x x x x x x x
54 months (4 ½ years) x x x x x x x
60 months (5 years) x x x x x x x x x
72 months (6 years) x x x x x x
9 years x x x x x (girls only)
12 years x x x x x x
1
Or dental therapist or oral hygienist
7
Assess growth
Assess and interpret growth of child by following steps 1-5 when indicated:

Step Weight Step Length/ height Step Weight-for-length/height

1 2 3
Measure weight-for-age at every visit: Measure length/height-for-age every Measure weight-for-length/height, according to age,
6 months: every 6 months:
Below - 2 line Between -2 line On or above
Child is likely and +2 line +2 line Below - 2 line On or above - 2 line Child < 5 years old Child ≥ 5 years old
underweight Look at growth Measure 87 Continue to monitor Plot weight-for-length/height: Calculate BMI1 and plot
84. curve pattern: length/ length/height-for- on BMI-for-age chart:
if growth curve height and age 6 monthly.
Below - 2 On or above
flattening, falling then look
line 84 +2 line 88 Below On or
or crossing at weight-
-2 line above +1
z-score lines on for-length/
Weight-for-age chart: girls 2 consecutive height Height-for-age chart: girls Weight-for-height charts: girls and boys
84 line 88
visits 85. step 3.

Taken from XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Taken from XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Taken from XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

9 12 11

Step MUAC Step Head circumference

4 5
Measure mid-upper-arm circumference (MUAC) every 3 months, Measure head circumference at 14 weeks old and 12 months old
from 6 months old.
Boy Girl
< 12.5cm 12.5cm-13.5cm > 21.5cm
84 85 88 14 weeks old 12 months old 14 weeks old 12 months old
Refer if < 38cm or > 43cm. Refer if < 43.5cm Refer if < 37cm Refer if < 42cm
or > 48.5cm. or > 42cm. or > 47.5cm.

1
Body Mass Index: is weight(kg) ÷ height (m) ÷ height (m).
8
Weight-for-age chart: girls

Department of Health South Africa. Road to Health Booklet for Girls. 2012
9
Weight-for-age chart: boys

Department of Health South Africa. Road to Health Booklet for Boys. 2012
10
Weight-for-height charts: girls and boys

Department of Health South Africa. Road to Health Booklet for Girls and Boys. 2012
11
Height-for-age chart: girls

Department of Health South Africa. Road to Health Booklet for Girls. 2012
12
Height-for-age chart: boys

Department of Health South Africa. Road to Health Booklet for Boys. 2012
13
BMI chart: girls

World Health Organization. BMI-for-age Boys 5-19 years (z-scores). 2007

14
BMI chart: boys

Taken from XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

15
 Help baby breathe at birth
Give urgent attention to the baby at birth
Do the following in the first 30 seconds:
• If meconium, clear airway.
• Stimulate and keep warm: dry thoroughly with towel. If weight ≤ 1500g, do not dry, wrap body (excluding head) in clear plastic bag.
60 seconds

• Note time. Remember to determine Apgar score at 1 and 5 minutes and record in Road to Health Book.
• Is baby crying?

Crying/breathing well Not crying

Check Apgar score and • Clear airway, stimulate.
give routine care below. • Then assess breathing (gasping/respiratory rate < 30):

Breathing Not breathing well

well/crying • Clamp and cut umbilical cord.
Check Apgar • Give 1 breath every 2 seconds with bag valve mask and room air (no oxygen). If preterm,
score and connect bag valve mask to oxygen at 5L/minute. Ensure chest rise with each breath.
give routine • Assess breathing every 30-60 seconds:
care below.
Breathing Not breathing well
Determine the Apgar score at 1 and 5 well • Improve bag with mask ventilation: check neck slightly extended and that
minutes and record in RtHB: mask seal is adequate, suction if secretions and bag with mask more firmly.
Score each criteria and add together to give • Check pulse rate:
1 and 5 minute score.
Pulse rate Pulse rate < 100
0 1 2 ≥ 100
No Continue Pulse rate < 60
Crying? Grimace Vigorous cry
response to bag with • Continue to bag with mask.
Slow or mask until • Start chest compressions; 3 compressions : 1 breath.
Breathing? Absent Good cry breathing • Assess breathing and heart rate every 30-60 seconds.
irregular
Blue or Pink but well.
Colour? Pink all over Pulse rate 60-100 Pulse rate < 60
pale blue feet
• Record Apgar score and give Continue to bag with mask with oxygen until referral. Continue compressions and bag with mask.
< 100/ ≥ 100/ routine care below.
Heart rate? Absent
minute minute • Refer urgently to MOU if: Refer urgently to MOU
Is baby Slight Active, --> 5 minutes to breathe well • Record Apgar score. Keep baby warm, do not overheat.
Limp
active? flexion moves --Apgar score ≤ 7 at 5 minutes • Give vitamin K 1mg IM and apply chloramphenicol eye ointment into both eyes.

Give routine care to the crying/breathing well baby at birth

• Place baby on mother’s chest skin-to-skin and cover. Keep warm and check breathing regularly. Clamp and cut the umbilical cord in 1-3 minutes. Start breastfeeding within 1 hour.
• Give vitamin K 1mg IM and apply chloramphenicol eye ointment into both eyes.
• Then fully assess baby in first few hours after birth 2.

16

EMERGENCY
The emergency child
Give urgent attention to the emergency child (if newborn baby 16)
Does child respond to voice or physical stimulation?

No Yes
Feel for pulse for maximum of 10 seconds: if < 1 year old feel brachial pulse, if ≥ 1 year old, feel carotid pulse.

No pulse felt or no signs of life. Pulse felt

Pulse rate < 60 Pulse rate ≥ 60

Call for help and start CPR 181 Check breathing:

Child gasping or not breathing Child breathing regularly

• Check airway clear. If history of choking 19.
• Give 1 breath with bag valve mask attached to
oxygen every 4 seconds.
• Recheck pulse every 2 minutes.

Assess and manage airway, breathing, circulation and level of consciousness:

Airway Breathing Circulation Glucose/level of

• If history of choking 19. • If difficulty breathing or sats ≤ 92%, give facemask • Establish IV access: try 3 times for < 90 consciousness
• If snoring/gurgling/noisy breathing, position oxygen 41. seconds each, if unsuccessful, insert • If glucose < 3mmol/L or
in ‘sniffing position’. If injured, keep neck • If respiratory rate decreased ( 129), or blue lips/ external jugular or intra-osseous line. ≥ 11mmol/L 24.
stable, use instead jaw-thrust2 only. tongue, assist each breath with bag valve mask • If ≥ 2 of 1) cold hands/feet, 2) weak/fast • Determine AVPU:
• Check for foreign body in mouth: if easy-to- attached to oxygen (at least every 4 seconds). pulse, 3) capillary refill > 3 seconds4, --A: is child alert?
reach, remove. Suction secretions. • If difficulty breathing does not improve, 4) decreased level of consciousness, --V: does child respond
• If unconscious, insert an oropharyngeal airway3. discuss intubation with referral centre. Decide shock likely 20. to voice?
• Discuss intubation with referral centre if: endotracheal tube size ( 129). • If actively bleeding or enlarging/ --P: does child respond
--Snoring/gurgling/noisy breathing with oro- • If decreased breath sounds/more resonant/pain on pulsating swelling, apply direct to pain?
or nasopharyngeal airway or 1 side/deviated trachea: tension pneumothorax pressure while calling doctor. If --U: is child unresponsive?
--Unresponsive or responds only to pain. likely: insert large bore cannula above 3rd rib in unsuccessful, compress at nearest • If child is not alert 21.
• Decide endotracheal tube size ( 129). mid-clavicular line and arrange urgent chest tube. vascular pressure point.
Manage further according to disability and symptoms and refer urgently:
• If injured:
--If head injury, neck/spine tenderness, reduced level of consciousness (not responding to voice) or weak/numb limb, immobilise head with tape and sandbags/bags of IV fluid on either side of
head. Use spine board if needing to move patient.
--Identify all injuries: undress child fully and assess front and back using log-roll to turn. Then cover and keep warm. Manage injuries 25.
• If pupils unequal or respond poorly to light, tilt bed to raise head by 30 degrees. If injured, avoid bending spine: keep body straight with head/neck in midline.
• Manage further according to symptoms: if fitting 22, If just had fit 23, if unconscious 21, if burn  26, if rash 59, if poisoning or accidental ingestion of harmful substance 28.

1
If child known with a life-limiting illness, follow advanced care plan directions in Road to Health Book. 2Lift chin forward with fingers under bony tips of jaw. 3Size oropharyngeal airway: flat rim at middle of mouth (front incisors), laid on side of face, tip at angle
of jaw. If child resists, coughs or gags, likely too alert to tolerate airway. 4Capillary refill time: hold hand/foot higher than level of heart. Press soft pad of finger/toe until it turns white, then release pressure and take note of time taken for colour to return.
17
Cardio-pulmonary resuscitation (CPR) of the child
In the unresponsive child with no pulse or pulse < 60, start chest compressions:
• Give cycles of 15 compressions and 2 breaths with bag valve mask attached to oxygen. If only one rescuer, give 30 compressions and 2 breaths.
• Continue until able to attach monitor/defibrillator paddles. Assess heart rhythm:

VF/VT Asystole/ Pulseless electrical activity

Give 1 shock at 4J/kg

• Immediately restart CPR starting with compressions. • Treat reversible causes: treat for shock 20, if glucose < 3mmol/L 24 and warm child.
• Establish IV/IO access. • Continue CPR for 2 minutes and recheck heart rate (as above)

Ensure correct technique :

• Record start time. < 1 year old ≥ 1 year old
• Push hard (≥ ⅓ of depth of chest) and fast (100/minute).
• If < 1 year old, use 2 fingers or 2 thumb-encircling hands technique.
• If ≥ 1 year, use heel of hand/s.
• Compress over lower sternum (not on xiphisternum). Allow full chest recoil.
• Minimise interruptions in compressions.
• Rotate compressor every 2 minutes to avoid fatigue.

Dose IV/IO epinephrine4 (1:10 000) according to age

Doctor to consider advanced life support : (1:10 000 concentration: draw 1 ampoule 1:1000 adrenaline into 10mL syringe with along with 9mL sodium chloride 0.9%)
• Consider intubation: decide endotracheal tube size ( 129). Age Volume
• Once intubated, give continuous chest compressions. 0-6 months 0.5mL
• Give epinephrine1 according to dose table IV/IO every 3 minutes.
6-18 months 1mL
• Check for and treat reversible causes:
--Hypoxia --Hydrogen ion (acidosis) --Tension pneumothorax --Trauma 18 months - 5 years 1.5mL
--Hypovolaemia --Hypo-/hyperkalaemia --Tamponade (cardiac) --Thrombosis (coronary) 5-7 years 2mL
--Hypothermia --Hypoglycaemia --Toxins --Thrombosis (pulmonary) 7-11 years 3mL
11-15 years 5mL

Decide when to stop CPR:

Return of pulse ≥ 60 No return of pulse after 20 minutes

17 • If hypothermia, near drowning or poisoning, continue prolonged CPR and transfer urgently.
• If no pulse and fixed dilated pupils after 20 minutes of effective CPR, stop CPR and pronounce dead.
• Arrange bereavement counselling for family.
1
Epinephrine is also known as adrenaline.
18
Choking
Give urgent attention to the child who is choking or has been choking
• Check in mouth: if object visible and easy-to-reach, carefully remove. Do not attempt blind finger sweeps.
• Continue to manage according to level of consciousness:

Alert and responsive Unresponsive

Is child breathing well?

Yes No

Child still able to breathe Child gasping or

Encourage child to cough repeatedly. has now stopped breathing

Obstruction Obstruction not obviously relieved or has now stopped breathing

relieved
Manage further according to age:

< 1 year old ≥ 1 year old

• Give 5 back slaps (see below). • Give 5 back slaps (see below).
• Then, if obstruction persists, give 5 chest thrusts. • Then, if obstruction persists, try the Heimlich manoeuvre 5 times.

Repeat until obstruction relieved or child becomes unresponsive:

Obstruction relieved Child becomes unresponsive

Observe for 2 hours: Start CPR 18, check for foreign body every 15 compressions.
• If persistent difficulty breathing or wheezing, refer.
• If no further breathing problems, discharge:
--Advise to return if develops any of: wheeze/difficulty breathing, persistent productive cough, fever.
--Advise how to prevent future choking: avoid choking hazards (hard sweets/candies, nuts, hard fruit pips), avoid
running/talking/laughing whilst eating and ensure small toys/objects (buttons/coins/lego) not left on floor.

If baby < 1 year old If child ≥ 1 year old

Back slaps Chest thrusts Back Heimlich manoeuvre
• Lay baby face • Give chest thrusts slaps • From behind child, wrap arms
down on arm or with two fingers Slap middle round child’s body.
thigh in head- on lower half of of child’s back • Form fist with one hand
down position. sternum. with heel of immediately below sternum.
• Slap middle of • Check baby’s mouth hand with child • Place other hand over fist and pull
baby’s back with for any obstruction sitting, kneeling upwards into abdomen. Repeat
heel of hand that can be easily or lying. this 5 times.
5 times. removed.

19
Assess and manage child’s fluid needs
Assess the child’s fluid needs if needing emergency attention, vomiting, diarrhoea, fever, injury, abdominal problem, or tiredness/lethargy:
Does child have ≥ 2 of 1) cold hands/feet, 2) weak/fast pulse, 3) capillary refill > 3 seconds1, 4) decreased level of consciousness?

Yes: shock likely No

• If child does not respond to voice/physical stimulation 17. • Check glucose 24.
• If injury is the likely cause of shock 25. • Does child have ≥ 2 of: 1) sunken eyes, 2) cannot drink well, 3) lethargic, 4) very slow skin pinch2 (≥ 2 seconds)?
• Establish IV access: try 3 times for < 90 seconds each, if unsuccessful, insert
external jugular or intra-osseous (IO) line. Yes No
• Does child have difficulty breathing, likely meningitis3 or severe acute malnutrition4? Severe dehydration (10%) likely Does child have ≥ 2 of: 1) sunken eyes, 2) thirsty/drinks
Does child have difficulty breathing, eagerly, 3) restless/irritable, 4) slow skin pinch2?
No Yes likely meningitis3 or severe acute
Give sodium chloride 0.9% Give sodium chloride 0.9% 10mL/kg malnutrition4? Yes No
20mL/kg bolus IV/IO rapidly. IV/IO over 10 minutes. Moderate dehydration (5%) likely Child not
No Yes Does child have difficulty breathing, likely dehydrated
• If sepsis likely (shock not due to trauma or simple watery diarrhoea), give Give sodium Give sodium meningitis3 or severe acute malnutrition4? Go back to
ceftriaxone 100mg/kg IV/IM as a single dose (table 7 123). chloride 0.9% chloride 0.9% relevant
• If signs of overhydration (increasing pulse or respiratory rate or puffy eyelids) 20mL/kg for first 10mL/kg for first No Yes symptom
at any time during shock management, give oxygen 2L/minute via nasal hour IV then ½ hour NGT then ½ Give ORS • Give ORS 10mL/kg/hour over page to
prongs, stop fluids and instead give ½ darrows dextrose5 4ml/kg/hour and darrows dextrose5 darrows dextrose5 20mL/kg/ 4 hours. assess and
discuss with doctor/paediatrician. 20mL/kg/hour for 10mL/kg/hour for hour over • Give single dose ceftriaxone manage
• Assess response to fluids: does child still have cold hands/feet, weak/fast pulse, next 3 hours. next 3 hours. 4 hours. 100mg/kg IV/IM (table 7 123). symptom/s.
and/or capillary refill > 3 seconds1?
• If unable to give IV, give ORS via NGT • Record weight.
Yes: still shocked No 20mL/kg (or 10mL/kg) every hour for • If < 2 years old, give 5mL of ORS every
No longer 4 hours while awaiting transfer. 2 minutes.
• Repeat fluid bolus as above. If bleeding, give blood 10mL/kg IV. shocked • Offer small sips of ORS every few • If ≥ 2 years old, give frequent, small sips
• Reassess response to fluids: minutes as soon as child can drink. from cup.
• If sepsis likely, (dehydration not • If vomits, wait 10 minutes, then continue slowly.
Still No longer shocked due simple watery diarrhoea), give • If breastfeeding, offer frequently.
shocked ceftriaxone 100mg/kg IV/IM as a • If refuses to drink, give via NGT.
Start maintenance fluids according to table. single dose (table 7 123). • Give more ORS if child wants it.
Give 3rd Decide on maintenance fluid rate • Reassess hourly while awaiting transfer.
fluid bolus. • Continue to assess for shock. Review in 4 hours:
Weight 24 hour fluid requirement
Then give • If becomes breathless, give oxygen • If still dehydrated or weight not increased,
20mL/kg/ Under 10kg 100mL/kg refer.
2L/minute via nasal prongs and
hour fluid 10-20kg 1000mL + (50mL for every kg body weight > 10kg) stop fluids. • If no longer dehydrated and child has
(or 10mL/ > 20kg 1500mL + (20mL for every kg body weight > 20kg) diarrhoea, advise carer to give ORS 10mL/
kg) until kg after each loose stool and continue
ambulance Refer urgently. While awaiting transfer: to manage as child not needing urgent
arrives. • Recheck glucose, if < 3mmol/L or ≥ 11mmol/L 24. attention 48.
• Keep warm: place child skin-to-skin with mother and cover with blanket. • If no diarrhoea, address symptoms on
• Continue to monitor for shock: reassess every half hour. Discuss further management with referral centre. relevant symptom page.

1
Capillary refill time: hold hand/foot higher than level of heart. Press soft pad of finger/toe until it turns pale, then release pressure and note time taken for colour to return. 2Skin pinch: pinch up skin on abdomen between 2 fingers. Release. Normal
skin pinch snaps rapidly back to its normal position. Slow skin pinch takes time to return to its normal position. 3Meningitis likely if ≥ 2 of: temperature ≥ 38°C, headache, decreased level of consciousness, neck stiffness/bulging fontanelle. 4Severe
malnutrition: swollen feet and/or wasting. 5If no ½ darrows dextrose available, give sodium chloride 0.9% + dextrose 50% (add 10mL dextrose to each 100mL of sodium chloride) instead.
20
Decreased level of consciousness
Give urgent attention to the child with an decreased level of consciousness
• If not already done, assess and manage airway, breathing and circulation 17.
• Place child in ‘rescue’ position: turn child onto his/her left side, place child’s left hand under his/her cheek with neck slightly extended and bend his/her right leg to stabilise position.
• Ask about possible causes and manage symptoms: trauma or injury 25, fitting 22, just had a fit 23, poisoning 28, burns 26, known allergy with exposure to allergen 106.
• Check glucose, temperature, pupils, and skin:

Glucose Temperature Pupils Skin rash

If < 3mmol/L or ≤ 35° C ≥ 38°C Both pupils Unequal Non-blanching1 purple/red rash Sudden
≥ 11mmol/L 24. dilated or or respond diffuse rash
• Place skin-to-skin with mother Treat for likely infection: pinpoint, poorly to light Meningococcal disease likely with/without
if possible or clothe including • Give ceftriaxone poisoning • Establish IV/IO. swelling of
head and cover with warmed 50-80mg/kg as a single likely 28. Tilt bed to • If ≥ 2 of 1) cold hands/feet, face/tongue
blankets. Place near heater/ dose (table 6 123). raise head by 2) weak/fast pulse, 3) capillary or wheezing
lamp. • If baby < 1 month old, 30 degrees. If refill > 3 seconds2, 4) decreased
• If available, give warm IV fluids also give ampicillin injured, avoid level of consciousness, shock Anaphylaxis
at maintenance rate (129). 25mg/kg IV/IM as a bending spine: likely 20. likely 106
• Give ceftriaxone 50-80mg/kg as single dose. keep body • Give ceftriaxone 100mg/kg IV/IM
a single dose (table 6 123). • If recent travel to straight with as a single dose (table 7 123).
• If baby < 1 month old, also give malaria area, urgently head and neck
ampicillin 100mg/kg IV/IM as a discuss with referral in midline.
single dose. centre.
• Consider child abuse  70, if any of: history inconsistent with examination, delay in presentation, skull fracture, old and new scars on body, unusual or patterned wounds, burns, wounds
around ano-genital region.
• If child aggressive or violent: ensure safety, assess child with help of other staff, use security personnel if needed. Discuss with doctor before sedating.
• Refer the unconscious child urgently with advanced life support ambulance.
• While waiting for transport:
--Check pulse ( 129), respiratory rate ( 129), saturation (sats if available) and capillary refill2 time every 15 minutes.
--If pulse/respiratory rate abnormal (129), sats drop ≤ 92%, or capillary refill time > 3 seconds, reassess airway, breathing and circulation 17.

1
Apply gentle pressure to rash. If the rash does not disappear, it is non-blanching. 2Capillary refill time: hold hand/foot higher than level of heart. Press soft pad of finger/toe until it turns pale, then release pressure and note time taken for colour to return.
21
Seizures/fits
Give urgent attention to the child who is unconscious and fitting:
• Open airway: clear mouth, chin lift/jaw thrust, suction secretions. Place in left lateral lying (recovery) position. Do not place anything in mouth.
• Give facemask oxygen with (non-rebreather) reservoir bag at 15L/min.
• Check glucose: if < 3.0mmol/L or unable to measure, manage as hypoglycaemia 24.

If fit has lasted > 5 minutes, give medication according to age to stop the fit:
• If neonate (< 28 days old): give phenobarbitone 20mg/kg IV over 5 minutes or IM (table 26 127) and refer urgently.
• If child ( or baby ≥ 28 days):
--Give buccal (between the cheek and gum) lorazepam 0.1mg/kg (table 20 125) or midazolam 0.5mg/kg (table 22 126) as a single dose or rectal1 diazepam 0.5mg/kg
as a single dose (table 12 124).
--Monitor breathing: if respiratory rate < 20, call doctor. If breathing stops or gasping, ventilate with bag-valve mask (1 breath every 3-5 seconds) 17.
--Establish IV access.
--Expect a response within 5 minutes:

Child still fitting Child stops fitting

• Give lorazepam 0.1mg/kg IV (table 20 125) or midazolam 0.25mg/kg IV (table 23 126) or diazepam 0.25mg/kg IV (table 13 124). Decide if child needs
• If cannot establish IV access, repeat same initial medication: urgent referral and
--Give buccal (between the cheek and gum) lorazepam 0.1mg/kg (table 20 125) or midazolam 0.5mg/kg (table 22 126) as a single dose or rectal1 diazepam manage 23.
0.5mg/kg as a single dose (table 12 124).
• Monitor breathing: if respiratory rate < 20, call doctor. If breathing stops or gasping, ventilate with bag-valve mask (1 breath every 3-5 seconds) 17.
• Expect a response within 5 minutes:

Child still fitting or repeated fits without regaining consciousness Child stops fitting

Manage for status epilepticus and refer urgently:

• Give phenobarbitone 20mg/kg IV over 5 minutes or IM (table 26 127).
• If IV phenobarbitone unavailable: give phenytoin 20mg/kg (table 28 127) in 50mL of sodium chloride 0.9% slowly over 30 minutes
with cardiac monitoring (may cause arrhythmias).
• Monitor breathing: if respiratory rate < 20, call doctor. If breathing stops or gasping, ventilate with bag-valve mask (1 breath every
3-5 seconds) 17.
• Expect a response within 5 minutes:

Child still fitting Child stops

fitting
• Give phenobarbitone 10mg/kg IV over 5 minutes or IM (table 26 127).
• If IV phenobarbitone unavailable: give crushed oral phenobarbitone tablets 20mg/kg via NGT (table 27 127). • Keep child in left lateral position with oxygen.
• Doctor to assess need for intubation 17. • Establish IV if not done already.
• Refer urgently. • Refer urgently.

1
Rectal administration: use 2mL syringe to draw up correct dose, remove needle, lubricate whole syringe barrel and insert into rectum, inject contents, remove syringe and hold buttocks together.
22
 Approach to the child who is not fitting now:
Confirm that child indeed had a fit: jerking movements, loss of consciousness, eyes open during fit, incontinence, post-fit drowsiness and confusion. If not, refer to specialist same week1.

Give urgent attention to the child with recent fit and any of:
• First seizure in child < 2 years old • More than one fit in 24 hours • Ingestion of medication/potentially harmful substance 28.
• Temperature ≥ 38°C and < 18 months old or ≥ 5 years old • Focal seizure (one limb or side of body affected) • Known with long term health condition
• Fit > 15 minutes • Focal signs (like weakness of arm/leg, even if resolved) • Recent travel to a malaria area: malaria likely
• Does not respond to voice > 1 hour after fit • HIV infected • Dehydration (≥ 2 of: 1) sunken eyes, 2) thirsty/drinks eagerly,
• Likely meningitis (≥ 2 of: temperature ≥ 38°C, headache, • Close TB contact 3) restless/irritable, 4) slow skin pinch2)
decreased level of consciousness, neck stiffness) • Head injury within the past week
Manage and refer urgently:
• Establish IV access.
• Check glucose: if < 3.0mmol/L 24.
• If meningitis likely, give ceftriaxone 100mg/kg IM/IV as a single dose (table 7 123).
• If temperature ≥ 38°C, give paracetamol 15mg/kg 6 hourly orally (table 25 127) or rectally if available.
• If dehydrated 20.

Approach to the child with recent fit not needing urgent attention
• If glucose < 3.0 24.
• Is temperature ≥ 38°C?

Yes No

• If child < 18 months old or ≥ 5 years old, refer same day. • If child known with epilepsy, give routine epilepsy care 112.
• If child ≥ 18 months - 5 years old: • Is there history of birth trauma, head injury, meningitis, family history of epilepsy3?

Simple febrile seizure likely Yes No

• Look for source of fever 31. If no clinical source of fever found, refer. Child has had ≥ 2 fits in the last year on 2 different days?
• Discharge if normal level of consciousness within 1 hour of fit.
• Reassure and advise carer:
Yes No
--Febrile seizures common from 6 months - 5 years old.
--Fit may recur with fevers: approximately 30% cases fit again in next 2 years.
--Very slight increased risk of developing epilepsy later. Refer to paediatrician Doctor to review
--Excellent prognosis with no effects on intellect, academic performance or behaviour. same week. • If talking/understanding problems, refer.
--Give regular paracetamol for fevers in future even though this will not prevent further fits. • If no obvious underlying cause, review in 3 months for
further fits, new symptoms or delayed milestones.
If frequent febrile seizures (> 3 in 6 months), refer to paediatrician. Do not start anticonvulsants.

Advise the carer on what to do if child fits at home

• Place child in safe place (on floor or bed) away from objects that may cause injury.
• Lie child on left side in recovery position. Do not place anything in his/her mouth. Wipe away secretions.
• Time fit: get help if fit continues for more than 3 minutes or child does not wake up properly between fits.
• Encourage carer/s to have a plan ready if medical attention needed urgently: know where nearest clinic is, have reliable transport plan.
1
Encourage carer to take a video of event to show specialist. 2Skin pinch: pinch up skin on abdomen between 2 fingers. Release. Normal skin pinch snaps rapidly back to its normal position. Slow skin pinch takes time to return to its normal position. 3Family
history of epilepsy refers to a parent or sibling with childhood onset epilepsy.
23
Manage glucose
Interpret and manage glucose according to random finger prick glucose reading (if newly born baby < 6 hours old 2)

Glucose ≤ 3mmol/L Glucose Glucose ≥ 11 mmol/L

Child has hypoglycaemia 3.1-10.9 mmol/L
Check if child needs urgent attention
Give urgent attention to the child with hypoglycaemia Is child urinating large • Does child have ≥ 2 of: 1) cold hands/feet, 2) weak/fast pulse, 3) capillary refill > 3
volumes, very thirsty, losing seconds5, 4) decreased level of consciousness? If yes, manage as likely shock:
Altered mental state, lethargy, seizures or weight and very tired?
is unable to drink? --Give sodium chloride 0.9% 20mL/kg bolus rapidly
--Reassess: if cold hands/feet, weak/fast pulse, capillary refill > 3 seconds persist, repeat
No Yes fluid bolus (20mL/kg) and reassess.
No Yes --If still shocked, give 3rd fluid bolus (20mL/kg). Then continue to manage fluids as below
until ambulance arrives.
• Breastfeed or feed expressed milk. Glucose
• If not shocked, does child have any of the following:
• If not breastfeeding: give formula or normal.
oral sugar solution1 or a therapeutic Reassure • Decreased level of consciousness • Vomiting • Rapid deep breathing
feed (F75) 5mL/kg orally. and manage • Dehydration6 • Abdominal pain • Fruity smelling breath
• If child refusing or not completing > 80% other
of feed within 1 hour, give via NGT. symptom/s
• Recheck glucose after 15 minutes: on symptom No Yes
pages.
≥ 3mmol/L < 3mmol/L Check urine for ketones

• Refer same • Give dextrose 10%2 5mL/kg IV/IO as No ketones Ketones present
day unless a single dose.
cause is • Then start ½ darrow’s dextrose3
obvious infusion at 3mL/kg/hour4 IV, unless Suspect diabetes Diabetic ketoacidosis likely
(child child has severe acute malnutrition Refer/discuss same day
has not (avoid continuous IV fluids). with specialist unit that
can manage child with Give urgent attention to the child with diabetic ketoacidosis
eaten for • If altered mental state 21, if
prolonged seizures 22. possible diabetes. • If no shock or after shock is Give sodium chloride 0.9% IV
period) and • Recheck glucose after 15 minutes: treated, give sodium chloride 0.9% according to weight
recurrence IV according to table.
Weight Rate (mL/hr)
• Reassess for shock every 15 minutes.
can be < 3mmol/L ≥ 3mmol/L 4-6kg 25
prevented. • Refer urgently with IV line and
drip running at planned rate. If 6-10kg 40
• If known Repeat dextrose Continue
diabetic referral will take > 2 hours: once 10-15kg 60
10%2 5mL/kg IV and infusion first hour of fluids complete,
on insulin, continue ½ darrow’s and refer 15-20kg 85
refer. recheck glucose hourly: if glucose 20-30kg 100
dextrose3 infusion at urgently. still ≥ 11mmol/L, give short acting
3mL/kg/hour4 IV and 30-45kg 150
insulin 0.1 units/kg IM (avoid using
refer urgently. insulin needle). ≥ 45kg 200

1
Dissolve 3 teaspoons of sugar (15g) into 200mL water. 2If dextrose 10% unavailable: in same 20mL syringe, draw up 4mL of dextrose 50% and 16mL of water for injection in same syringe (syringe now contains 20mL of 10% dextrose). 3If no ½ darrows
dextrose available, give sodium chloride 0.9% + dextrose 50% (add 10mL dextrose to each 100mL of sodium chloride) instead. 4This is 3 drops/kg/minute. 5Capillary refill time: hold hand/foot higher than level of heart. Press soft pad of finger/toe
until it turns pale, then release pressure and note time taken for colour to return. 6Signs of dehydration include: increased pulse rate, decreased blood pressure ( 129), dry mucous membranes or delayed capillary refill (2-3 seconds), irritability and/or
decreased urine output.
24
The injured child
Give urgent attention to the injured child with any of:
• Reduced level of consciousness • Pulsatile or growing swelling • Poor perfusion below injury (cold, pale, numb, no pulse)
• Difficulty breathing: abnormal respiratory rate (129), • Suspected fracture 56 • Weak/numb limb
grunting, nasal flaring or chest indrawing • Burns 26 • Stab or gunshot wound
• Distended abdomen • Weak/numb limb • Severe mechanism of injury: involved in high speed collision, ejected
• Active bleeding not responding to direct pressure • Multiple injuries from or hit by vehicle or fall from height > twice child’s height

Also give urgent attention to the child with a head injury and any of:
• Lethargy or decreased level of consciousness • Vomiting ≥ 2 times • Drug or alcohol intoxication
• History of loss of consciousness • Blurry/double vision • Severe headache
• Strange behaviour or memory loss since injury • Blood or clear fluid leaking from ear/nose • Pupils unequal or respond poorly to light
• Suspected skull fracture • Bruising around eyes or behind ears • Blood behind ear drum

Manage and refer urgently:

• Assess and manage airway, breathing, circulation 17. Establish IV access and assess and manage fluid needs 20.
• If actively bleeding or enlarging/ pulsating swelling, apply direct pressure while calling doctor. If unsuccessful, apply tourniquet above injury.
• If severe head injury, neck/spine tenderness, reduced level of consciousness or weak/numb limb, immobilise head with tape and sandbags/bags of IV fluid on either side of head. Use
spine board if needing to move patient.
• If pupils unequal/respond poorly to light, keep body straight, raise head by 30 degrees (do not bend spine) and keep head in midline.
• Identify all injuries: undress child fully and assess front and back using log-roll to turn. Then cover and keep warm.
• While awaiting transport, monitor every 15 minutes: pulse, respiratory rate, oxygen saturation (if available). If deteriorates, reassess and manage airway, breathing and circulation 17.

Approach to the injured child not needing urgent attention

Wound Head injury Painful limb

• Apply direct pressure to stop bleeding. If bite 29. • Advise carer to observe child • Rest and elevate limb.
• If open wound, give tetanus toxoid 0.5mL IM if none in past 5 years (check RtHB). carefully for 24 hours and limit • Apply firm, supportive
• Remove foreign material, loose/dead skin. Irrigate with sodium chloride 0.9% or if dirty, dilute povidone iodine solution. activity for at least 48 hours. bandage.
• If sutures needed: suture and apply non-adherent dressing for 24 hours. Plan to remove sutures after 5 days (face), 4 days (neck), • Advise to return immediately • If knee/hip injury, refer to
10 days (leg) or 7 days (rest of body). if any of: blurred vision, physiotherapist.
• Do not suture if wound > 12 hours old (or > 24 hours if on head/neck), infected, remaining foreign material or deep puncture: vomiting, headache not • Give paracetamol2 15mg/kg
--Pack wound with saline-soaked gauze and give amoxicillin/clavulanic acid1 15mg/kg/dose plus amoxicillin1 15mg/kg/dose 8 relieved by paracetamol, 6 hourly as needed up to 5
hourly for 5 days. difficult to wake, balance days (table 23 127).
--Review in 2 days. If no infection, suture now if still needed, unless deep puncture (irrigate and dress every 2 days instead). problem. • Review after 1 week: if no
• Advise to return if signs of infection (skin red, warm, painful). • Give head injury form (if better, arrange x-ray and
• Refer if unable to close wound easily, cosmetic concerns or child needs sedation to suture. available). doctor review.

Consider child abuse 70, if any of: clear history of abuse, history inconsistent with exam, delay in presentation, skull fracture, child has old and new scars, burns, unusual or patterned wounds,
grasp marks on arms/chest/face, bruises on trunk, bruises of different colours, wounds around ano-genital region.

1
If penicillin allergy (previous bronchospasm and/or severe rash), give azithromycin 10mg/kg daily for 3 days (table 5 122) and metronidazole 7.5mg/kg 8 hourly for 5 days instead (table 21 126). 2If pain uncontrolled with paracetamol, add
ibuprofen 10mg/kg 6 hourly as needed up to 5 days.
25
Burns
Calculate percentage total body surface area (%TBSA) burnt using below figure.

Give urgent attention to the child with burn/s and any of:
• Child < 1 year old, regardless of extent of burn • Electric/chemical burn • Unable to drink/breastfeed
• Burn > 5% TBSA in child 1-2 years old • Circumferential burn of chest/limbs • ≥ 2 of: cold hands/feet, weak/fast pulse
• Full-thickness burn (white/black, painless, leathery, dry) • Temperature ≥38°C and/or sudden onset swelling and capillary refill > 3 seconds1, decreased
• Partial thickness burn (pink/red, blistered, painful, wet) covering > 10% TBSA of area of skin with redness, pain and warmth level of consciousness, shock likely
• Likely inhalational burn (burns to face/neck, hoarseness, stridor or black sputum) • Burn involves face, hand, foot, genitals, joint
Manage and refer urgently:
How to calculate %TBSA of burn
• Remove burnt/hot and tight clothing. Immerse burnt skin in cool water or apply cool, wet towels for 30 minutes. Avoid hypothermia.
• Give give oxygen 2L/minute via nasal prongs via nasal prongs if TBSA burnt > 10%, inhalational burn, oxygen saturation ≤ 92%, drowsy/confused. Front Back
Doctor to consider early intubation.
• Give IV fluid:
Maintenance fluid volume over 24 hours
--If shock likely 20 7% 7%

--If > 10% TBSA: give sodium chloride 0.9% IV (4mL x < 1 year old 120mL/kg
weight(kg) x %TBSA] over first Child ≥ 1 year old - give the sum of the following:
24 hours. Give half this volume in first 8 hours from time For each kg of body weight under 10kg 100mL/kg 18% 18%
of burn. For each additional kg of body weight over 10kg 50mL/kg
--In addition, begin sodium chloride 0.9% + dextrose 50% For each additional kg of body weight over 20kg 20mL/kg 4.5% 4.5% 4.5% 4.5%
(add 10mL dextrose to each 100mL of sodium chloride)
according to table:
• Give paracetamol 20mg/kg (loading dose) followed by 15mg/kg 4 hourly (table 23 127). If severe pain, add tilidine 1mg/kg (1 drop =
2.5mg) or morphine sulphate 0.1mg/kg IV as needed (table 22 126). If respiratory rate decreases 18 or oxygen saturation ≤ 92%,
give oxygen via nasal prongs/facemask. 8% 8% 8% 8%
• Look for co-existing injuries 56.
• Clean burn well with water or sodium chloride 0.9% and chlorhexidine 0.05% and remove loose/dead skin:
--If hospital transfer within 12 hours, wrap child in clean dry sheets and keep warm.
--If delayed > 12 hours, apply paraffin gauze and cover with non-adherent dry gauze.
--If full thickness/>10%TBSA burn, cover with paraffin gauze occlusive dressing and cover with plastic wrap (cling film). Child's open hand is 1% TBSA. Do not include simple erythema
• Give tetanus toxoid 0.5mL IM if not had in last 5 years (check RtHB). (redness) in calculation. For each year of age over 1 year, take 1% off
• Refer same day to closest Burns Centre and reassess airway, breathing and circulation hourly 17. head value and add it to leg. Palm of hand represents 1% of TBSA.

Approach to the child with burn/s not needing urgent attention:

• Cool burnt area < 3 hours old with cold tap water for 30 minutes.
• Give paracetamol 15mg/kg 6 hourly as needed for up to 5 days (table 23 127).
• Clean burnt area well with water or sodium chloride 0.9% and chlorhexidine 0.05%. Cover burnt area with a paraffin gauze dressing.
• Give tetanus toxoid 0.5mL IM if not had in last 5 years (check RtHB).
• If imprint burns or cigarette burns, suspect child abuse 70.

Review daily the child with burn/s not needing urgent attention:
• Dress wound daily with paraffin gauze dressing. If increased pain/anxiety with dressing changes, give paracetamol 15mg/kg (table 25 127) 1 hour before changing dressing.
• Refer if signs of infection (redness, swelling, increasing pain, smelly or pus), rash develops, pain despite medication or burn not healing as expected/wound deeper than initially estimated.
1
Capillary refill time: hold hand/foot higher than level of heart. Press soft pad of finger/toe until it turns pale, then release pressure and note time taken for colour to return.
26
The blue child
Give urgent attention to the blue child with any of:
• Choking 19
• Newborn 16
• Fitting 22, or just had fit 23
• < 6 months old
• Difficulty breathing: abnormal respiratory rate ( 129), grunting, nasal flaring or chest indrawing 41
• Temperature < 35.5°C or ≥ 38°C
• Shock (if ≥ 2 of 1) cold hands/feet, 2) weak/fast pulse, 3) capillary refill > 3 seconds1, 4) decreased level of consciousness)
• Oxygen saturation ≤ 92%
• Known heart or lung disease
• Known with a life-limiting illness
Manage and refer urgently:
• Give oxygen 2L/min via nasal prongs. If decreased respiratory rate ( 129) or blue lips/tongue, assist each breath with bag valve mask attached to oxygen 17.
• If shocked 20.
• Doctor to check for decreased breath sounds/more resonant/pain on 1 side/deviated trachea: tension pneumothorax likely: insert large bore cannula above 3rd rib
in mid-clavicular line and arrange urgent chest tube. Assess need for intubation.
• Check glucose, if < 3mmol/L 24.
• If temperature < 35.5°C or ≥ 38°C, give ceftriaxone 50-80mg/kg as a single dose (table 6 123).
• Warm child: place skin to skin with mother or clothe warmly including head and feet and cover with warmed blanket.

Approach to the child with a history of turning blue

Does child have a persistently blocked nose, snore or stop breathing during sleep?

Yes No

Obstructive sleep apnoea likely Does child usually cry, then hold breath until s/he turns blue, then becomes limp , unconscious and may start fitting?
Refer for urgent ENT opinion.
Yes No

Breath holding spells likely Refer/discuss with

• Check Hb: if Hb < 10g/dL in child < 5 years old or Hb < 11g/dL in child ≥ 5 years old 89. doctor/paediatrician same day.
• Reassure carer that they are common in child 6 months - 4 years old. Although this is scary
to watch, no treatment is needed. During the spell, lay child on his/her side and remove any
close objects to prevent injury. Reassure carer that child will start to breathe on his/her own.
Advise to avoid putting anything in mouth, including fingers.
• Prognosis is excellent and development is normal.
• If fits occur, advise carer about what to do if child fits at home 23.
• Refer to paediatrician.

1
Capillary refill time: hold hand/foot higher than level of heart. Press soft pad of finger/toe until it turns pale, then release pressure and note time taken for colour to return.
27
Poisoning
Poisoning refers to exposure (swallowed, inhaled, injected, or absorbed) to a potentially harmful substance (medication, chemical/cleaning agent, toxin, pesticide, drug, gas, corrosive, plant).

Give urgent attention to the child with suspected poisoning and any of:
• Fitting 22 • Abnormal vitals: abnormal pulse or respiratory rate ( 129), glucose < 3mmol/L, temperature ≥ 38°C
• Lethargic or decreased level of consciousness 21 • Difficulty breathing: blue lips/tongue, stridor, grunting, nasal flaring or chest indrawing.
• Persistent vomiting • If ≥ 2 of 1) cold hands/feet, 2) weak/fast pulse, 3) capillary refill > 3 seconds1, 4) decreased level of consciousness,
• Drooling or sweating excessively manage for shock 20
• Agitation, severe restlessness or hallucinations • Dystonic reaction: neck twisting, upward gaze, facial grimace, clenched jaw, speech difficulty

Manage and refer urgently:

• While doing initial management, urgently contact Poisons Information helpline of the Western Cape 128.
• If skin exposure to poison, stop ongoing contact: remove clothes and wash skin with soap and water. Protect yourself: wear gloves, apron and mask.
• If poison in eyes, immediately flush under running water or sodium chloride 0.9% for at least 15 minutes. If available, put 1 drop oxybuprocaine 0.4% into eye/s and continue to flush.
• Record time of exposure and try to identify poison: obtain careful history and ask to see tablets, packets, containers of suspected agent. Ask about amount: determine if toxic dose2 ingested:
--If toxic dose ingested within past hour and child fully conscious, give activated charcoal 1g/kg with 100mL water (table 2 122). Avoid if ingested petrol/paraffin/iron/lithium/alcohol/corrosives.
--Avoid inducing vomiting/doing gastric lavage unless specifically instructed by poisons centre as this increases the risk of aspiration.
• If difficulty breathing, give oxygen 2L/min via nasal prongs.
• If organophosphate poisoning suspected (pinpoint pupils, excessive drooling/sweating, coughing up or choking on airway secretions, slow pulse rate ( 129): give atropine 0.02mg/kg IV (table
4 122). If secretions still copious/pulse rate remains slow, double the dose every 3 minutes until improving.
• Notify symptomatic poisonings from all types pesticides (organophosphates, rat poison).

Approach to a child with suspected poisoning not needing urgent attention

If child intentionally exposed him/herself to a poison with the aim of self-harm, refer same day.

• Try to identify poison: obtain careful history and ask to see tablets, packets, containers of suspected agent used. Record time of exposure and how much child exposed to.
• Contact Poison Information centre of the Western Cape 128. Determine if toxic dose has been ingested and manage according to symptoms:

Non-toxic dose and Poison/dose unknown or mild symptoms3 Toxic dose

asymptomatic
Observe for 4-6 hours. If child asymptomatic after this, discharge home unless: • Management will depend
Discharge child home. • Ingested unknown dose of ≥1 of: paracetamol, anti-epileptics, warfarin, tricyclic anti-depressants, sulphonylureas, iron. on poison, refer urgently.
• Child ingested paraffin and has increased respiratory rate ( 18). No need for antibiotics. • Discuss need for activated
• Symptoms persist or worsen, discuss with poison or referral centre. charcoal with poison centre.

• If concerns about poor adult/parental supervision at home, refer to social worker to arrange home visit.
• Prevent future poisoning, advise carer to lock away poisonous substances. Do the same at friends/family homes. Share poisons helpline number with carer 128.
• Advise carer to return if condition worsens.

If presents with poisoning more than once, history not consistent with findings, or concern that carer intentionally exposed child to poison, manage as suspected child abuse 70.
1
Capillary refill time: hold hand/foot higher than level of heart. Press soft pad of finger/toe until it turns pale, then release pressure and note time taken for colour to return. 2Poison centre can help to calculate this. 3Notify symptomatic poisonings from all
types pesticides (organophosphates, rat poison).
28
Bites and stings
Give urgent attention to the child with bite/sting and any of:
• Deep or large wound needing sutures • Scorpion sting
• Actively bleeding • Insect/spider bite1 or sting with weakness, drooping eyelids, difficulty swallowing/speaking, double vision
• Snakebite even if bite marks not seen • Sting with 2 or more of: 1) generalized itchy rash or face/tongue swelling, 2) difficulty breathing, 3) fainting/
• Venom in eyes dizziness/collapse, 4) abdominal pain/vomiting: anaphylaxis likely, remove stinger and 106.
Manage and refer urgently:
• Apply direct pressure to stop bleeding.
• Assess and manage child’s fluid needs 20.
• Wash wound well with chlorhexidine 0.05% or povidone-iodine 10% solution and irrigate under running water for 5 minutes and apply dressing. Do not suture.
• If snakebite1: avoid tourniquet and ice pack and do not attempt to incise, squeeze or suck out the venom. Contact Poisons Information helpline of the Western Cape 128.
• If venom in eyes: immediately flush under running water or sodium chloride 0.9% for 20-30 minutes. If available put 1 drop tetracaine 1% into affected eye and continue flushing.
• If pain, give paracetamol 15mg/kg orally as a single dose (table 23 127). If very painful scorpion sting1, doctor to inject lidocaine 2% 2mL around site.

Approach to the child with bite/sting not needing urgent attention

Bite/s Sting/s
• Wash wound thoroughly with chlorhexidine 0.05% or povidone-iodine 10% solution and irrigate under running water for 10 minutes. Do not suture wound Stings from bees, wasps,
unless wound is laceration (uninfected) on face < 24 hours old. Dress wound every 2 days. and other insects cause
• If immunisations not up to date, give tetanus toxoid 0.5mL IM. pain, redness, swelling
• Manage further according to type of bite: and itching.

Animal bite/s Human bite/s Spider or

insect bite/s
Is there ≥ 1 of: broken skin with visible blood; animal licked broken skin/eyes/mouth; • Give paracetamol
any close contact with a bat. If unsure, discuss with rabies hotline 128. 15mg/kg 6 hourly as • Reassure carer: usually non-venomous/ very mild venom and
needed for up to 5 do not need specific treatment (anti-venom).
days (table 23 127). • If pain, redness, swelling and itching severe, apply ice pack
Yes No and give:
• Check immunisation
• Give rabies immunoglobulin and vaccine (if not • Give rabies vaccine, 1 amp, IM (anterolateral --calamine lotion to apply to area.
up to date and give
available, refer urgently): thigh) on day 0, 3, 7, 14 (total of 4 doses). Stop --cetirizine once daily until symptoms resolve:
catch up doses if
--Inject rabies immunoglobulin 20 IU/kg at the if animal tests negative for rabies or is still well • 12-21kg: 5mg
needed 5.
site of the bite and after 10 days of observation • ≥ 21kg: 10mg
• If bite has broken skin
--Inject rabies vaccine, 1 amp, IM (anterolateral • If HIV positive, also give extra dose of --paracetamol 15mg/kg 6 hourly as needed (table 23 127).
and HIV status of biter
thigh) on day 0, 3, 7, 14 (total of 4 doses). If HIV rabies vaccine IM day 28 and inject rabies
unknown, give post
positive, also give a 5th dose on day 28. immunoglobulin 20 IU/kg at the site of the bite.
exposure prophylaxis
• Give paracetamol 15mg/kg 6 hourly as needed • Give paracetamol 15mg/kg 6 hourly as needed If spider bite with any signs of infection (increased redness/
for up to 5 days (table 23 127). for up to 5 days (table 23 127). 105. swelling with pus), give antibiotics:
• Also give antibiotics:
• Give antibiotics: • If bite involves hand, also give antibiotics:

• Give amoxicillin/clavulanic acid 15mg/kg/dose plus amoxicillin 15mg/kg/dose 8 hourly for 5 days or if penicillin allergy, give azithromycin 10mg/kg once daily for 3 days (table 5 122)
plus metronidazole 7.5mg/kg/dose 8 hourly for 5 days, or for 10 days if infected (table 20 126).
• If worsening despite antibiotics, refer.
1
Obtain description of spider/snake/scorpion as this may help with specific management once referred.
29
The inconsolable crying/irritable child
• The child who is crying/irritable/inconsolable child needs assessment if he/she cries continuously and frequently for no obvious reason.
• If baby < 3 months old and crying for only short periods of time and is easily consolable after quickly being calmed by carer and not left to cry alone, reassure.

Give urgent attention to the crying/irritable/inconsolable child with any of:

• Baby < 2 months and not feeding well • Tiring/sweating during feeds • Not moving properly 74
• Recent injury 25 • Dehydration (sunken eyes, thirsty/drinks eagerly or slow skin pinch1) • Abdominal distension
• Ingestion of potentially harmful substance 28 • Likely meningitis: • Cramping abdominal pain and
• Nasal flaring/chest in-drawing 41. --If < 2 years: bulging fontanelle (when not crying), refusing food/drink or lethargy lethargy and/or jelly-like stool
• Dark green/bile-stained vomiting --Any age, ≥ 2 of: temperature ≥ 38°C, headache, decreased level of consciousness, neck stiffness
Manage and refer urgently:
• Assess and manage child’s fluid needs 20
• If meningitis likely, give ceftriaxone 100mg/kg IM/IV as a single dose (table 7 123).
• If temperature ≥ 38°C, give paracetamol 15mg/kg 6 hourly orally (table 25 127) or rectally.

Approach to the crying/irritable/inconsolable not needing urgent attention:

• Ask about other symptoms: temperature ≥ 38°C or history of fever 31, vomiting 47, diarrhoea 48, burning urine 52,
constipation with pain on passing stool, faecal impaction, involuntary leakage of stool or voluntarily withholding stool 49.
• Assess growth parameters 5. If growth faltering 85.

Then check for source of pain/discomfort:

• Examine child from head to toe: check eyes, ears, mouth/throat, skin, groin, genitalia, anal and nappy area:
Check ears Look in mouth Check skin Look for groin swelling Check genitalia Check anus Check nappy Check teeth
If red, bulging and throat • Remove cause: If bulge in groin on If scrotal Check for area If < 3 years
eardrum or ear If white patches/ --Hair wrapped tightly around finger/ crying/cough/passing swelling, crack, lump/ If nappy rash old, consider
pain/discharge blisters/ulcers toe/penis or thorns/splinters stool, inguinal hernia refer/discuss pile or red/ 67. teething
36 or red throat • If bruising/skin marks, consider child likely, refer to surgical with doctor/ raw skin issue 40
38 abuse 70. OPD same week. paediatrician 50.
• If insect bites 26. same day.
• If no cause found and irritable baby, check urine. If nitrites or leucocytes on urine dipstick 52 .
• If child known with a life-limiting illness, refer/discuss with doctor/paediatrician.

Screen for social risk/stressors

• Screen for depression in carer: if yes to > 1 PACK Adult: 1) In past month, have you been down, depressed or hopeless? 2) In past month, have you had little interest/pleasure in things?
• Ask carer if aware of any abuse of child. Ask child ask if anyone hurts/upsets him/her. If yes to either, suspect child abuse 70.
• If violence or drug/alcohol abuse at home, involve social worker. If school problem, 75.
• If newborn/breastfeeding, ask about maternal substance abuse. If found, refer baby same day and involve social worker.

• If < 4 months old and crying for ≥ 3 hours/day on ≥ 3 days a week, consider colic 45. Do not leave a young child (< 2 years) to cry alone.
• If unable to find cause, refer/discuss with doctor/paediatrician.
1
Skin pinch: pinch up skin on abdomen between 2 fingers. Release. Normal skin pinch snaps rapidly back to its normal position. Slow skin pinch takes time to return to its normal position.
30
Fever
A child with a fever has an axillary temperature ≥ 38°C (or if ≤ 2 months old ≥ 37.5°C) now or in the past 3 days.

Give urgent attention to the child with a fever and any of:
• Baby < 2 months old • Non-blanching1 purple/red rash • Limping/difficulty moving limb
• Just had seizure/fit 22 • Increased respiratory rate 18 and/or difficulty breathing • If on abacavir, check for abacavir hypersensitivity reaction 101.
• Blue skin/lips 27. • Little or no urine 52. • ≥ 2 of joint pain/swelling that moves from joint to joint, strange
• Unable to feed/eat • Tenderness right lower abdomen, appendicitis likely movements of limbs/face, lumps over joints/tendons, rash (round
• Headache • Jaundice pink lesions with pale centre, rheumatic fever2 likely
• Decreased level of consciousness • Previous rheumatic fever or known with rheumatic heart disease
• Neck stiffness/bulging fontanelle • Painful/swollen joint
Manage and refer urgently:
• Assess and manage child’s fluid needs 20
• If headache, decreased level of consciousness, neck stiffness, bulging fontanelle and/or non blanching1 purple/red rash, meningitis likely, give ceftriaxone 100mg/kg IM/IV as a single dose (table 7 123).
• If baby < 2 months old or appendicitis likely, give ceftriaxone 50-80mg/kg as a single dose (table 6 123).
• If rheumatic fever, give benzathine benzylpenicillin2 IM, single dose according to weight: < 20kg, 600 000 IU and if ≥ 20kg, 1.2 MU and notify.
• Check glucose 52
• Keep warm.

Approach to the child with a fever not needing urgent attention

Ask about associated symptoms

• If cough 41, face pain/swelling 39, eye swelling 35, sore throat 38, sore tooth 40, skin rash/painful/red 59, blocked/runny nose 37,
ear pain 36, abdominal pain/swelling 45, diarrhoea 48, painful and swollen gland 34, urinary symptoms 52.
• Does child have a tick bite (small dark brown/black scab)?

Yes No

Tick bite fever likely • Check urine (get clean catch sample if possible): if leucocytes and/or nitrites 52. If blood on urine dipstick 52.
• Body pains, rash and localized lymphadenopathy may • Has child visited a malaria area in last 12 weeks?
also be present.
• Grip tick close to skin using a forceps and remove tick. Yes No
• Give treatment: Refer for malaria test • If fever for ≥ 5 days and ≥ 4 of: 1) red eyes, 2) rash, 3) swollen/red hands or feet, 4) swollen/
--If < 8 years old, give clarithromycin 10mg/kg 12 and treatment. cracked/red lips or tongue, 5) swollen glands in neck, Kawasaki disease3 likely. Refer urgently.
hourly for 5 days (table 11 123). • Exclude TB if fever for ≥ 2 weeks and unexplained cough ≥ 2 weeks, weight loss/not growing
--If ≥ 8 years old, give doxycycline 2mg/kg 12 hourly well, always tired/less playful or TB contact close contact with TB in last 12 months 92.
on first day, then 1mg/kg 12 hourly for 7 days. • If status unknown, test for HIV 98.
• Refer same day if difficulty breathing, passing small
amounts of urine or lethargy.
• Review in 3 days and refer if no better. Refer child with persistent fever and no obvious cause.

1
Apply gentle pressure to rash. If the rash does not disappear, it is non-blanching. 2If penicillin allergy (previous bronchospasm and/or severe rash), refer/discuss with doctor/paediatrician. 3Rheumatic fever occurs usually in a child 5-15 years old and in
Kawasaki disease the child is usually < 5 years old.
31
Headache
Give urgent attention to the child with headache and any of:
• Sudden severe headache • Pupils different size • Head trauma in last week 56.
• Temperature ≥ 38°C • Weakness of arm or leg • Abnormal head circumference 8.
• Decreased level of consciousness • Vision problems (e.g. double vision) • If recent travel to a malaria area: malaria likely
• Neck stiffness • Headache getting worse and more frequent • Elevated BP
• Head tilted to one side (torticollis) • Headache/vomiting on awakening or waking from sleep
Manage and refer urgently:
If temperature ≥ 38°C, decreased level of consciousness, neck stiffness, meningitis likely: give ceftriaxone 100mg/kg IV/IM as a single dose (table 7 123).

Approach to child with headache not needing urgent attention

Is headache throbbing, disabling and recurrent with nausea/vomiting or light/noise sensitivity, that resolves completely within 72 hours?

Yes No

Migraine likely Pain over cheeks, thick nasal (or postnasal) discharge, recent common cold, headache worse on bending forward?
• Give immediately and then as
needed: paracetamol 15mg/kg
Yes No
6 hourly (table 23 127) or if
≥ 20kg and able to swallow
tablet, ibuprofen1 200mg 6 Sinusitis likely Has child had a fever in last few days and tick bite (small dark brown/black scab) present?
hourly with food. Advise to • Give paracetamol 15mg/kg
return if no better after 24 hours 6 hourly as needed for up to
and refer same day. Yes No
5 days (table 23 127).
• Advise child/carer with migraine: • Give sodium chloride 0.9% drops
--Recognise migraine early and into nostrils as needed. Tick bite fever likely Consider tension headache and muscular neck pain
rest in dark, quiet room. • If no better, give oxymetazoline • Body pains, rash and localized
--Draw up a headache calendar 0.025% 2 drops in each nostril lymphadenopathy may also be present.
to identify and avoid triggers 8 hourly for up to 5 days. Tightness around head or Constant aching neck
• Remove tick if found: grip tick as near to
like lack of sleep, stress, • If symptoms > 10 days: give generalised pressure-like pain pain, tender neck muscles
skin as possible using a forceps and remove.
electronic screen time, hunger amoxicillin2 30mg/kg/dose • Give treatment:
and some food or drink. 8 hourly for 5 days (table 3 --If < 8 years old, give clarithromycin 10mg/kg Tension headache likely Muscular neck pain likely
--Migraine may occur at start of 122). 12 hourly for 5 days (table 10 123). • Give paracetamol 15mg/kg • Give paracetamol 15mg/
menstrual period. Reassure that • If > 1 episode, test for HIV 98. --If ≥ 8 years old, give doxycycline 2mg/kg 6 hourly as needed for up to 5 days kg 6 hourly as needed for
this is common. • Refer if poor response to antibiotic 12 hourly on first day, then 1mg/kg (table 23 127) up to 5 days (table 23
--Give letter with advice on care or > 4 episodes per year. 12 hourly for 7 days. • If child miserable/ stressed/angry 127).
if migraine occurs at school. • Refer same day if swelling around • Refer same day if difficulty breathing, 71. • Advise sleeping on
• If ≥ 2 attacks/month or no sinus/eye or tooth infection. passing little amounts of urine or lethargic. • If problem at school 75. different pillow.
response to treatment, refer. • Review in 3 days and refer if no better. • Book eye test to exclude poor vision. • Refer to physiotherapist.

If unsure or poor response to treatment refer/discuss with doctor/paediatrician.

1
Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease. 2If penicillin allergy (previous bronchospasm and/or severe rash), give azithromycin 10mg/kg once daily for 3 days instead (table 5 122).
32
The tired or lethargic child
• If child is not moving or sitting properly (limb/s not working properly) 74.
• The child who is tired or lethargic will feel tired for long periods of time, may be hard to wake for feeds or will lie down lazily and not move around for considerable periods.

Give urgent attention to the child with tiredness or lethargy and any of:
• Unable to drink/breastfeed • Increased respiratory rate/difficulty breathing 41
• Vomiting everything • Bone pain or continuous pain
• Decreased level of consciousness 21 • Easy bruising or bleeding
• Infant < 3 months old • Likely meningitis (≥ 2 of: temperature ≥ 38°C, headache, decreased level of consciousness, neck stiffness)
Manage and refer urgently:
• Assess and manage child’s fluid needs 20.
• Check glucose 24.
• If meningitis likely, give ceftriaxone 100mg/kg IV/IM as a single dose (table 7 123).

Approach to the child with tiredness or lethargy not needing urgent attention
• Assess and manage child’s fluid needs 20.
• Check child’s temperature: if ≥ 38°C or fever in last 3 days 31.
• Exclude heart problem: if < 1 year old and tiring/sweating with feeding or if ≥ 1 year old and breathlessness on exertion/exercise, refer/discuss with doctor/paediatrician same day.

If none of the above, ask about associated symptoms:

• If vomiting 47, diarrhoea 48, jaundice 46, headache 32, blocked/runny nose or sore throat 38, cough 41. Manage other symptoms on symptom pages.
• Check for swollen glands 34 and joints 58.
• Look for tick bite (small dark brown/black scab). If present, tick bite fever likely 31.
• If has child visited a malaria area in last 12 weeks, refer for malaria test.

Then exclude anaemia, TB, HIV, growth problem, allergy and vision problem:
Test for anaemia Screen for TB Screen for HIV Check for growth problems Exclude allergy: Exclude vision
Do Hb: if Hb < 10g/dL in child 92 If HIV unknown, test for • Assess growth 8 and attend to • If persistent itchy blocked/runny problems:
< 5 years old or Hb < 11g/dL HIV 98. If HIV 99 problem if found. nose and sneezing 37 Assess visual
in child ≥ 5 years old 89. • If rapid loss of weight, refer same day. • If eczema 107 milestones 5

• Check urine: if leucocytes, nitrites or blood on urine dipstick 52. If ketones or glucose, do finger prick glucose to exclude diabetes 24.
• If sleeping problem or if child is on any medication that could be causing tiredness 76.
• If child known with a life-limiting illness, also give palliative care 117.
• Assess child’s mood: if withdrawn or change in mood, behaviour/feelings or not coping 71.

If no cause found, review in a week. If no better, refer.

33
Lumps/swellings in neck, axilla or groin
Give urgent attention to the child with lumps/swellings in neck, axilla or groin:
Lump/swelling in groin with severe pain/vomiting/not passing stool, refer urgently.

Approach to the child with lumps/swellings in neck, axilla or groin not needing urgent attention:
• If lump/swelling is in the skin 59.
• If lump/swelling beneath the skin, first exclude thyroid mass and hernia:
--Lump in neck that moves when child swallows, thyroid mass likely: refer same week.
--Lump in groin that bulges out on crying/coughing/passing stool, inguinal hernia likely: refer to surgeon same week.
• If none of the above, a lump/swelling in neck, axilla or groin is likely an enlarged lymph node (lymphadenopathy). If unsure, refer. Manage further according to age of child:

< 1 month old ≥ 1 month old

• If generalised Is lymphadenopathy localised (neck or axilla or groin) or generalised ( ≥ 2 areas)?
lymphadenopathy (in
≥ 2 areas), and signs of
Localised lymphadenopathy Generalised
congenital syphilis1,
Is lymph node hot, red and painful? lymphadenopathy
notify and refer for
If joint pain 58.
procaine benzylpenicillin
50 000units/kg IM daily for Yes No
10 days. Treat mother Bacterial lymphadenitis • Look for sore throat 38, skin infection or rash 59, gums/teeth 40 and ask about face symptoms 39
PACK Adult likely • If lymph nodes in inguinal region and if child is sexually active2, treat child and partner for lymphogranuloma
--Also test baby for HIV • If painful neck venereum PACK Adult.
98. lymphadenopathy with
• If axillary lymphadenopathy sore throat 38.
If local cause If no cause found:
on BCG arm: • Give cephalexin 12-
found: • If fever ≥ 5 days and ≥ 3: 1)red eyes, rash, 2) swollen/red hands or feet, 3) swollen/cracked/red lips or tongue,
--Test baby for HIV 98. 25mg/kg 6 hourly for
• Manage as Kawasaki disease likely. Refer urgently.
--Report adverse event 7 days (table 8 123).
on symptom • If unexplained cough or fever ≥ 2 weeks, weight loss/not growing well, always tired/less playful) or TB contact
121. If penicillin allergy
page. (close contact with TB in last 12 months), exclude TB 92.
--If node < 1.5cm, reassure (previous bronchospasm
• Reassure that • If status unknown, test for HIV 98. If HIV positive, give routine care 99.
and review in one week. and/or severe rash), give
lymphadeno- • If none of the above:
--If ≥ 1.5cm or draining azithromycin 10mg/
pathy should
pus, refer. kg once daily for 3 days
resolve with
(table 5 122). Localised lymphadenopathy Generalised
treatment.
• Return in 2 weeks if no Any of weight loss, fever, night sweats, lymph node getting bigger quickly? lymphadenopathy
• Advise to
better and refer.
return if no
improvement No Yes
after 4 weeks
and refer. • Reassure patient. If lymph node (> 1cm) persists for > 2 weeks, refer. Refer/discuss with doctor/paediatrician
• Advise to return if new symptoms develop or lymph nodes same day.
increase in size.

1
Signs of congenital syphilis are rash (red/blue spots of bruising especially on soles and palms), jaundice, lymphadenopathy, pallor, distended abdomen due to enlarged liver or spleen, low birth weight, respiratory distress, large, pale placenta,
hypoglycaemia. 2If sexually active and any of following: not consensual or < 12 years old or 12-15 years old and partner not in peer group (partner is 12-15 years old or 16-17 years old with a < 2 year age gap); manage as sexual abuse and report (form 22A)
70. If ≥ 12 years old and consensual sex with partner in peer group advise reliable contraception PACK Adult.
34
Eye/vision problems
Give urgent attention to the child with eye or vision symptoms and any of:
• Single painful red eye • Whole eyelid swollen/red or bulging eye: • Corneal ulcer
• Shingles involving eye or tip of nose orbital/periorbital cellulitis likely • Hazy cornea
• Sudden loss or change in vision, including blurred or reduced vision • Baby < 1 month old with excessive pus from • Recent enlargement/eye bulging out
• Injury to eye: superficial foreign body, penetrating injury (with/without foreign body), eyelid laceration eyes or swollen eyelids, conjunctivitis of the • Sudden drooping of eyelid
• Chemical burn to eye/s: wash out the eye continuously for at least 20 minutes with clean water/saline. newborn likely • Recent onset squint in child > 5 years old
Manage and refer urgently:
• If conjunctivitis of the newborn likely, give single dose ceftriaxone 50-80mg/kg as a single dose (table 6 123). Irrigate with sodium chloride 0.9% hourly until referral. Treat parent with single
doses of ceftriaxone 250mg IM stat and azithromycin 1g orally. If occurs 24 hours after birth, treat both mother and partner. Test parents for HIV and STIs if suspected PACK Adult.
• If orbital/periorbital cellulitis likely and delay in referral expected > 6 hours, give single dose ceftriaxone 50-80mg/kg as a single dose (table 6 123).
• If penetrating / metallic foreign body in eye, do not attempt to irrigate or remove. Cover gently with protective shield if child allows it and avoid lying flat.

Approach to child with eye/vision symptoms not needing urgent attention

Both eyes are discharging/watery, is there prominent itch? Abnormal eye/eyelids Foreign body Poor vision

Yes No, is the discharge clear or pus? Red or swollen eyelid margins • If foreign body Book eye OPD appointment in
Associated with visible, wash 1 month if:
persistently blocked/ eye out with • Not meeting visual milestone
Pus Clear Yes No
runny nose? clean water according to age or showing
If both eyes red and red rash
or saline. lack of response to mother’s
Bacterial conjunctivitis likely and or red, swollen/cracked lips • Wash crusts Refer next
Allergic conjunctivitis • Remove it face, wandering eye
• If painful, give paracetamol or red tongue 63 on lid margin eye OPD
likely with cotton- movements, child pokes/prods
15mg/kg 6 hourly for up to twice a day appointment tipped stick or his/her eye, staring at bright
• Apply cold compresses
5 days (table 23 127). Viral conjunctivitis likely with warm if: bud. lights.
around eye.
• Give chloramphenicol 1% • Highly contagious: advise water. • White eye1: • If under eyelid, • HIV positive (f HIV unknown,
• If > 6 years old, give
ointment 6 hourly in each carer/child to avoid rubbing • Give chloram- cataract/ pull top eyelid test for HIV 98)
oxymetazoline
eye for 7 days. eyes and to wash hands phenicol 1% retino- over bottom • If cannot see in dark, dry eye
0.025% 1-2 drops in
• Advise carer/child to avoid regularly. ointment blastoma and release. or foamy patches on cornea,
each eye 6 hourly for
rubbing eyes and to wash • Apply cold compresses around 6 hourly for likely. Book • Refer within vitamin A deficiency likely:
up to 7 days.
hands regularly. eye to relieve symptoms. 7 days. appoint- 24 hours if: --Give vitamin A as a single dose:
• If symptoms
• Wipe eyes gently from inside • If painful, give paracetamol If yellow ment within --Removal if < 6 months old: 50 000IU, if
> 1 month, give
to outside with clean cotton 15mg/kg 6 hourly for up to lump in 2 weeks. unsuccessful 6-12 months old: 100 000IU, if
cetirizine once daily:
wool soaked in sodium 5 days (table 23 127). eyelid, apply • If a squint --Abnormal ≥ 1 year old: 200 000IU.
--12-21kg: 5mg
chloride 0.9% as often as • Give oxymetazoline eye frequent is present vision or --If recently had vitamin A, wait
--≥ 21kg: 10mg
needed until pus clears. drops 0.025% 1-2 drops warm (not sudden movement 1 month after last dose before
• Give routine care to
• May return to school after 6 hourly up to 7 days. compressions. onset). of eye giving routine vitamin A.
child with allergy 106.
2 days of antibiotic treatment • Advise to stay home from • Refer to • Eyelids bent --Foreign body --Give tears naturale 1 drop
• Refer urgently if:
(and if pus has cleared). school for one week or until eye OPD if out/in. not visible in each eye once daily.
--Corneal ulcer
• Refer to eye OPD if eye discharge has cleared. symptoms • Eyelashes --Unwilling If not available, give
--Extreme photophobia
symptoms do not improve • Refer if: do not rubbing on to open chloramphenicol 1%
--Poor vision
within 2 days. --No response after 5 days improve with cornea. eye after ointment in each eye 6 hourly
--Single red eye for > 1 day treatment. 24 hours. for 7 days.
1
If pupil white/hazy/cloudy or light reflex reflects white light.
35
Ear symptoms/difficulty hearing
Manage according to ear symptom: is ear itchy, painful, discharge from ear or is there difficulty hearing? Then look in ear.

Painful ear Discharge from ear Itchy ear Difficulty hearing/carer concerned about child's hearing
• If ear also itchy, consider otitis externa
• Able to view eardrum? Discharge Symptoms ≥ 2 weeks, Red ear canal or • Book hearing test.
for ≤ 2 hole in eardrum pus present. • If red canal/pain/hole eardrum, see left algorithm.
No Yes weeks • Look in ear for foreign body, wax or fluid behind eardrum.
Pain > 48 hours or pain waking child
at night? Wax or foreign body Fluid behind Normal
ear drum looking ear
No Yes If wax:
Is temperature ≥ 38°C? • Instil olive oil Otitis media with • Refer to
4 drops into ear effusion likely audiologist
No Yes 12 hourly for 4 days. • Keep ear dry. for hearing
• Review after 4 days: • Advise carer that screen.
Review Red bulging eardrum/eardrum not seen • if wax remains, usually resolves on • If carer
Chronic suppurative syringe3 ears with own. concerned
in 2 Otitis externa likely
otitis media likely warm water unless • If communication that child is
days • Clean ear1.
• Clean ear using dry child has grommets/ problem present completely
if no • Instil acetic acid 2%
mopping/wicking1. uncooperative/ 73. deaf, refer
better. in aqueous 4 drops
• Instil acetic acid 2% known with CSOM. • Refer if carer still same week.
in aqueous 4 drops in ear 8 hourly for • Stop and refer/call concerned about
in ear 8 hourly for 10 days. doctor if unsuccessful hearing after 3
10 days. • Give paracetamol after 3 attempts/ months or if child
• Refer if: 15mg/kg 6 hourly causes pain. clumsy/poor balance.
--No better after 4 for 5 days as
weeks needed (table 23
Acute otitis media likely 127). If foreign body:
--Large hole in
• Give paracetamol 15mg/kg 6 hourly for 5 days as • If severe pain, firm • Syringe ear with
eardrum
needed. red swelling or warm water.3
--Difficulty hearing
• Give amoxicillin2 30mg/kg 8 hourly for 5 days. temperature ≥ 38°C, • Avoid irrigation and
--Neck stiffness
• Clean ear1 if discharge and avoid getting ear wet. give cephalexin2 refer if:
--Pain in or behind ear
• If > 1 episode, test for HIV 98. 12-25mg/kg 6 --Hole in eardrum
instead
• Refer if no response to treatment, > 5 episodes per hourly for 5 days --Grommets
--Yellow/white
year, difficulty hearing or talking problem (table 8 123). --Battery/food in ear.
deposit on eardrum,
• Refer same day: • If blisters on ear, --Recent trauma to 3
How to syringe ears: fill a large syringe (50-
cholesteatoma likely 200mL) with warm water. Ask child/carer to
--If painful swelling behind ear, mastoiditis likely. Herpes zoster head or ear
--If responds poorly to hold container under ear against neck to catch
--Neck stiffness. likely, go to 59. --Neck stiffness
treatment, test for HIV water. Gently pull ear upwards and backwards
--Baby ≤ 1 month old • Refer if foreign body to straighten ear canal. Place tip of syringe at ear
98 and TB 92. remains in ear. canal opening (no further than 8mm into canal)
• If treated above but communication problem and direct water spray upwards in ear canal. Check
present, 103. ear drum after syringing to see if wax cleared.

1
Cleaning the ear (dry mopping): roll a piece of clean soft tissue into a wick. Carefully insert wick into ear with twisting action. Remove wick and replace with clean dry wick. Can also soak clean wick in acetic acid 1% and NaCl 0.9%, leave in for 1 minute,
remove and replace with dry wick. Repeat until wick is dry when removed. Never leave wick or other object inside the ear. The ear can only heal if dry. 2If penicillin allergy (previous bronchospasm and/or severe rash), give azithromycin 10mg/kg once
daily for 3 days instead (table 5 122).
36
Nose symptoms
Give urgent attention to the child with nose symptoms with any of the following:
• Newborn unable to breathe through nose
• Breastfeeding baby unable to feed
• Head trauma with clear watery discharge from nose
Refer urgently.

Approach to the child with nose symptoms not needing urgent attention

Blocked or running nose

Bleeding
Ask about duration and associated symptoms:

Sore throat and/or fever Thick nasal (or postnasal) If recurrent episodes One nostril blocked Snoring or • Check for foreign body.
• If rash 59 discharge, headache worse of sneezing or itchy/ or smelly discharge persistently blocked • If able, firmly pinch
on bending forward, pain blocked nose most from nostril nose and poor sleep nostrils together for 5-10
over cheeks. days for > 4 weeks minutes with child sitting
If ≥1 of: fever > 38.5°C, chills, nausea,
and leaning forward.
vomiting, headache, myalgia. Foreign body likely Obstructive sleep
• If still bleeding, give
Sinusitis likely Allergic rhinitis likely • Examine nostrils and apnoea likely
oxymetazoline 0.025%
• Give paracetamol 15mg/kg • Give budesonide ears using good light • If child with allergy
No Yes 2 drops in nostril/s and
6 hourly as needed for up nasal spray once and nasal speculum. 107.
repeat pinching nose.
to 5 days (table 23 127). daily in each nostril. Wrap child in sheet if • If overweight, plot
Common cold likely Influenza (flu) likely • If still bleeding, insert
• Give sodium chloride --If < 6 years old, needed. growth and 87.
bismuth iodoform
0.9% drops into nostrils as give 50 µg. • Gently remove • Refer if enlarged
paraffin paste (BIPP)
• If flu, keep child home. needed. --If ≥ 6 years old, give object with crocodile tonsils/adenoids or
soaked ribbon gauze into
• Use and discard tissues when sneezing/ • If no better, give 100 µg. Review forceps. If unable, ask stops breathing /
bleeding nostril/s.
coughing. oxymetazoline 0.025% 3 monthly. child to block clear chokes/gasps while
• If still bleeding or unable
• For pain/fever, give paracetamol 15mg/kg 2 drops in each nostril • If symptoms nostril and blow out. sleeping.
to do above procedures,
6 hourly as needed for up to 5 days (table 23 8 hourly for up to 5 days. > 1 month, give • Refer if unsuccessful
refer urgently.
• If symptoms > 10 days: give cetirizine once daily: or object not visible.
127). amoxicillin1 30mg/kg/dose --12-21kg: 5mg
• If stopped bleeding,
• Instil sodium chloride 0.9% drops into nostrils advise to return next day
as needed. 8 hourly for 5 days --≥ 21kg: 10mg
and remove BIPP gauze.
• Advise carer that antibiotics are not necessary. (table 3 122). • Give routine care to
• If recurrent bleeds:
• Advise to return if: • If recurrent episodes, test child with allergy
--If picking nose, advise
--Symptoms persist > 7 days. for HIV 98. 106.
to stop.
--Initially better but fever returns and: • Refer if poor response to
--If rubbing nose, consider
• Productive cough 40. antibiotic or > 4 episodes
allergic rhinitis.
• Ear pain, 35. per year.
--If no improvement, refer.
• Pain over face or thick nasal discharge, • Refer same day if swelling
consider sinusitis. around sinus/eye, neck
• If on ART, advise yearly influenza stiffness, visual problems
vaccination. or decreased level of
• If concerned, test for HIV 98. consciousness.

1
If penicillin allergy (previous bronchospasm and/or severe rash), give azithromycin 10mg/kg once daily for 3 days instead (table 5 122).
37
Mouth and throat symptoms
Give urgent attention to the child with mouth and throat symptoms with one or more of:
• Unable to open mouth or swallow at all • Red swelling blocking airway
Refer urgently.

Assess the child with mouth and throat symptoms not needing urgent attention
• If problem with teeth or young child likely teething 40.
• Examine mouth and throat for a red throat, white patches, blisters or ulcers.

Red throat White patches on cheeks, gums, tongue, Groups of painful blisters on lips/mouth Painful ulcer/s in
Is there pus or white patches on tonsils? palate, or cracks in corners of mouth. Are blisters also on palms and soles? mouth/throat with
central white patch
No: any of runny nose, cough, fine red rash, Yes Oral thrush/candida likely No Yes
hoarseness, conjunctivitis or diarrhoea? • Give nystatin suspension 1mL Herpes simplex likely Hand, foot Aphthous ulcer/s
6 hourly after meal/feed for 7 days. • Apply petroleum and mouth likely
Yes No • Keep inside mouth for as long as jelly to blisters on disease likely • Give paracetamol
Viral tonsillo- possible. outside of mouth to • Give 15mg/kg 6 hourly as
pharyngitis • If infant, advise carer to apply inside prevent spread. paracetamol needed for up to
Bacterial tonsillopharyngitis likely mouth with clean finger. If breastfeeding • Give paracetamol 15mg/kg 5 days (table 23
likely • Give paracetamol 15mg/kg 6 hourly as needed for up
• Give and nipple painful, apply clotrimazole 15mg/kg 6 hourly as 6 hourly as 127).
to 5 days (table 23 127). cream to nipples after feed. needed for up to 5 needed for • Rinse mouth with salt
paracetamol • Give amoxicillin1 50mg/kg once daily for 10 days. If
15mg/kg • Continue both for 48 hours after cure. days (table 23 127). up to 5 days water mouthwash1 for
difficulty swallowing or vomiting, give benzathine Give paracetamol 15mg/kg 6 hourly • If > 6 years old, (table 23 1 minute twice daily.
6 hourly as benzylpenicillin1,2: < 30kg, give 600000IU or ≥ 30kg,
needed for up as needed for up to 5 days (table 23 127). apply thin layer of 127). • If > 6 years old, apply
give 1.2MU IM as a single dose. • If child on inhaled corticosteroids, use tetracaine 1% to • Usually tetracaine 1% on
to 5 days • If mild, fine red rash after antibiotic, glandular fever likely.
(table 23 127). spacer and rinse mouth with water blisters 6 hourly. resolves in ulcers 6 hourly until
--Stop antibiotic. after use 43. • If HIV or <72hrs 10 days. healed.
• Salt water --Reassure will resolve spontaneously.
gargle may • If status unknown, test for HIV 98. onset, give aciclovir • If recurrent, consider
--Child may return to school when improved but can Give routine care to child with HIV 99. 20mg/kg 6 hourly HIV 98.
help. only resume sporting activities > 3 weeks from onset
• Explain that • If recurrent candida in child with a for 7 days (table 1 • Refer if:
of illness. life-limiting illness, also give palliative
antibiotics are 122). --Large and extensive
• Refer for ENT assessment if ≥ 5 episodes per year or care 117. • Refer if: ulcers.
not necessary. persistent snoring. --Extensive or --Not healed within
If difficulty/painful swallowing or if child recurrent 3 weeks.
Advise to return to clinic if any of: painful or swollen joint/s, strange movements has HIV or known with a life-limiting --No improvement • If recurrent ulcers
of limbs or face, lumps over joints/tendons or rash (round lesions with pale illness and refusing feeds, drooling or after 2 weeks. in child with a
centre). If ≥ 2 of symptoms present, rheumatic fever likely. hoarse cry, oesophageal candidasis • If status unknown, life-limiting illness,
• Give benzathinepenicillin2 IM, single dose according to weight: < 20kg, likely. Refer same week. test for HIV 98. also give palliative
600 000 IU and if ≥ 20kg, 1.2 MU, notify and refer same day. care 117.

• Advise carer to soothe throat with breastmilk if infant. If not exclusively breastfed, give warm water. Give older child bland, soft foods and advise to keep mouth and teeth clean by brushing and rinsing regularly.
• If sore mouth or bedbound in child with a life-limiting illness, use soothing liquids/ice chips and keep mouth moist. If unhelpful, give paracetamol 10-15mg/kg before meals (table 23 127).
1
If penicillin allergy (previous bronchospasm and/or severe rash), give azithromycin 10mg/kg once daily for 5 days instead (table 5 122). 2Salt water mouthwash: 1/2 teaspoon of salt in lukewarm water. 2For benzathine benzylpenicillin 1.2MU
injection: dissolve benzathine benzylpenicillin 1.2MU in 3.2mL lidocaine 1% without epinephrine (adrenaline).
38
Face symptoms
Give urgent attention to the child with face symptoms with any of the following:
• If sudden swelling of face with difficulty breathing, treat as anaphylaxis 106. • If swelling of face and temperature ≥ 38°C, cellulitis likely.
• Whole eyelid swollen, red and painful with difficulty moving eye or swelling around eye: • If swelling of face and dark red/ brown urine or unable to
possible orbital/periorbital cellulitis 35. pass urine, 52.
Manage and refer urgently:
• If cellulitis likely: give cephalexin 12-25mg/kg as a single dose (table 8 123).

Approach to child with face symptoms not needing urgent attention

• If rash on face 59
• If eye symptoms 35, if nose symptoms 37, if mouth symptoms 38.
• If abnormal looking face, check milestones on general assessment 5.
• Manage according to face symptom/s:

Face pain One side of face not Swelling of face

Ask about nasal discharge, teeth problems moving: unable to If sudden face swelling in last few hours, consider allergy 106
and jaw swelling. wrinkle forehead;
cannot close eye. May Whole face not swollen Whole face swollen
Thick nasal (or postnasal) discharge, Teeth have impaired taste or
headache worse on bending problem dry eye.
Look in mouth for gum or tooth problem: Check urine: if bloody/brown urine or
forward or pain over cheeks. and/or If gum or tooth problem 40. blood on urine dipstick, nephritis likely 52.
jaw Bell’s palsy likely
Sinusitis likely swelling • Give prednisone
40. 2mg/kg for 7 days. If Has child been unwell for last few days or for few weeks? < 3+ protein ≥ 3+ protein
• Give paracetamol 15mg/kg Face swelling
6 hourly as needed for up to no better after
2 weeks, refer. Few days Few weeks Assess growth 8: often around
5 days (table 23 127). both eyes,
• Give sodium chloride 0.9% drops • Refer for • Weight for height < -2 line or
physiotherapy. • Mid upper arm circumference worse in
into nostrils as needed. Mumps likely Usually cough mornings
• If no better, give oxymetazoline • Protect eye: • Fever and pain on opening mouth > 8 weeks: < 12.5cm
0.025% 2 drops in each nostril --Tape eyelid closed for 1-2 days before swelling. • If HIV status
8 hourly for up to 5 days. at night • Give paracetamol 15mg/kg 6 unknown, No Yes Nephrotic
• If symptoms > 10 days: give --Keep eye moist hourly as needed for up to 5 days test for HIV syndrome
amoxicillin2 30mg/kg/dose with drops (table 23 127). likely.
98. Growth Severe acute
8 hourly for 5 days (table 3 122). • Refer same day if: • Give soft foods and fluids. • Check for TB Refer/discuss
--Red ear drum normal malnutrition with doctor/
• If recurrent episodes, test for HIV • Advise to return to school 5 days 92. Manage and
--Any change in paediatrician
98. after swelling started. refer urgently
• Refer if poor response to antibiotic hearing • Symptoms usually resolve within Refer/discuss same day.
--Recent history of Lymphocytic with doctor/ 84
or > 4 episodes per year. 2 weeks. interstitial
• Refer same day if swelling around ear discharge or • Refer same day if: paediatrician.
pain pneumonitis
sinus/eye, neck stiffness, visual --Neck stiffness (LIP) likely.
problems or decreased level of --Recent head --Painful scrotal swelling
trauma Arrange x-ray
consciousness. --Loss of hearing and refer to
--Damage to cornea --If more than one episode
--Unsure of diagnosis doctor.
1
If penicillin allergy (previous bronchospasm and/or severe rash), give azithromycin 10mg/kg once daily for 3 days instead (table 5 122).
39
Gum or teeth problems
Give urgent attention to the child with gum and teeth symptoms and one or more:
• Temperature ≥ 38°C and red/painful skin over tooth/gum
• Unable to eat or drink
Refer urgently.

Approach to the child with gum and teeth symptoms not needing urgent attention:
• If no teeth in mouth by age 3, refer to dentist.
• If grinding teeth, reassure carer that it should resolve by 10 years old. If child stressed, unhappy or angry 71.
• Look in mouth (lift the lip gently) and manage according to symptoms and findings:

Child < 3 years old, drooling or biting Gums red and/or bleeding Brown/black staining of teeth at gumline and/ Pus in mouth/face and/or swelling
on hard objects. or holes and pits and/or missing teeth. next to tooth or on face/jaw
Gum problem likely
Teething likely • Ensure to brush and floss teeth twice daily.
• If child unwell, look for cause, • Rinse mouth with salt water mouthwash1
e.g. fever 31, diarrhoea 48. for 1 minute twice daily.
• Reassure carer that the teething • If ≥ 7 years old, rinse with chlorhexidine
process is normal. 0.2%, 15mL twice daily for 5 days. Do
• Advise carer to massage gum gently not swallow. If < 7 years old, apply
and encourage biting on objects chlorhexidine 0.2% with gauze to area.
(eg. teething ring). Avoid repeated use as can damage teeth.
• Cooled objects to bite on can help • Advise not to eat/drink immediately after
ease symptoms. for 30 minutes.
• Advise against using local numbing • If pain, give paracetamol 15mg/kg Dental abscess likely
preparations on gums. 6 hourly for up to 5 days (table 23 127). Start treatment:
Dental caries likely • Give paracetamol 15mg/kg
• Child might complain of tooth pain with hot/ 6 hourly as needed for up to 5 days
Refer to dentist if:
cold/sweet foods. (table 23 127).
• No better after 5 days
• Refer to dentist. • If painful facial swelling and redness,
• Foul-smelling breath
• If known with a heart valve problem, give give amoxicillin/clavulanic acid2
• Temperature ≥ 38°C
antibiotic prophylaxis before extraction 110. 15mg/kg/dose plus amoxicillin2
• Loss of supporting bone and gum
around tooth 15mg/kg/dose 8 hourly for 5 days..
• HIV • Check growth 8 and Hb. If Hb < 10g/dL Advise to return if temperature
in child < 5 years old or Hb < 11g/dL in child ≥ ≥ 38°C develops or red/painful skin
5 years old 89. over tooth/gum no better after
• Refer to dietician and give dietary advice 82. 2 days, refer.
• Help access further parenting advice 128. • Refer to dentist for tooth extraction.

1
Salt water mouthwash: 1/2 teaspoon of salt in lukewarm water. 2If penicillin allergy (previous bronchospasm and/or severe rash), give azithromycin 10mg/kg once daily for 3 days instead (table 5 122).
40
Cough and/or breathing problems
The child with breathing problems may have noisy breathing, wheeze, grunting, snoring or stridor (noisy, high-pitched breathing). If child not breathing 17.

Give urgent attention to the child with cough and/or breathing problems and any of:
• Lower chest indrawing • Blue lips/tongue • Stridor (noisy, high-pitched breathing) • Lethargy or impaired level of consciousness
• Nasal flaring • Oxygen saturation (sats) ≤ 92% • Unable to drink/feed • Restless or irritable
• Grunting • History of apnoea (episodes of no breathing > 10 seconds) • Baby < 2 months old • Tiring/sweating during feeds
Manage and refer urgently:
• Give oxygen 2L/minute via nasal prongs. If < 1 year old with blocked nose, instil sodium chloride 0.9% solution 1 drop into each nostril and suction the nose.
• Check glucose 24.
• Give ceftriaxone 50-80mg/kg as a single dose (table 6 123). If < 1 year old and HIV positive or unknown, also give co-trimoxazole (200/40mg per 5mL) 0.25mL/kg orally.
• Manage further if wheeze, stridor, swollen eyelids/lips, itchy rash or known heart problem:
Wheeze Stridor Swollen eyelids/lips, itchy rash Known heart problem

42 • Encourage carer to keep child calm. Anaphylaxis likely 110

• Give prednisone 2mg/kg as a single dose. 106.
• Give epinephrine1 (1:1000) 1mL in 1mL sodium chloride 0.9% via
nebuliser (oxygen 8L/minutes) every 15 minutes until stridor disappears.

Approach to the child with cough and/or breathing problems not needing urgent attention:
• If smoking in the house, alert to risks and encourage smoker to quit 128.
• If recent episode of choking, inhaled foreign body likely. Refer same day.
• If wheeze 42.
• If breathlessness on exertion/exercise, refer/discuss with doctor/paediatrician same day.
• If coughing attacks with “whoop” on breathing in, pertussis likely: give azithromycin suspension 10mg/kg (maximum 500mg/day) daily for 5 days (table 5 122), notify and isolate for 2 days.
• Ask about duration and number of episodes:

1 episode of cough and/or breathing problems lasting < 2 weeks Cough and/or breathing problems ≥ 2 weeks or repeated episodes
Is respiratory rate increased ( 129)? Exclude TB 92. While excluding TB consider other causes:

Yes No If recent cold: If blocked If known with long term

• With wet cough ≥ 4 nose or noisy health condition:
Pneumonia likely Runny/blocked nose Barking cough, may be hoarse weeks, refer. breathing • Asthma 108,
• Give amoxicillin2 30mg/kg • With dry cough, worse at • Bronchiectasis 109.
8 hourly for 5 days (table 3 122). post-infectious night and/or • Heart problem 110.
Viral cold likely Viral croup likely cough likely: should snoring • If life-limiting illness, also
• If > 2 episodes/year of pneumonia • Check ears 36, throat 38, nose 37. • Give prednisone 2mg/kg as
needing hospital stays, refer. resolve by 8 weeks. 37. give palliative care 117.
• Reassure carer antibiotics not needed. a single dose.
• Review after 2 days: if respiratory • Advise to drink warm liquids to relieve • Advise to return immediately
rate still raised, refer. symptoms. if worse or stridor develops. If none of above and repeated episodes of cough,
wheeze, difficulty breathing 44.

Refer if cause uncertain or any of: not growing well, chest deformity, cough > 8 weeks, coughs/chokes with feeds or cough worse despite treatment.
1
Epinephrine is also known as adrenaline. 2If penicillin allergy (previous bronchospasm and/or severe rash), give azithromycin 10mg/kg once daily for 3 days instead (table 5 122).
41
Wheeze
Give urgent attention to the child with wheeze and any of:
• Known with asthma and wheeze not responding to reliever • Grunting • Unable to drink • Lethargy or impaired level
• Lower chest indrawing • Blue lips/tongue • Difficulty talking of consciousness
• Nasal flaring • Oxygen saturation (sats) ≤ 92% • Baby < 2 months old • Restless or irritable
• History of apnoea (breathing pauses > 10 seconds) • Known heart problem 110 • Silent chest
Management:
Does child have all of the following: increased respiratory rate ( 129) with marked accessory muscle use1, inspiratory and expiratory wheeze with marked prolonged expiratory phase
(or silent chest) and sats < 92% (or blue lips/tongue).

No Yes

• Give salbutamol via spacer 6 puffs if < 4 years old or 10 puffs if ≥ 4 years old or Give oxygen via
• Nebulise (oxygen 8L/min) salbutamol solution 0.5%2 0.5mL if < 3 years old or 1mL if ≥ 3 years old in sodium chloride 0.9% 3mL. face mask and
• If known asthma, also give prednisone 2mg/kg (max 40mg) orally as a single dose. If unable to take orally, give hydrocortisone 4-6mg/kg IM/ slow IV as a single dose reservoir bag while
(table 14 125). preparing nebuliser.
• Assess response after 15 minutes:

Good response: respiratory rate < 40, no wheeze, no chest indrawing, sats ≥ 92% and able to drink and talk.
Assess every hour for next 4 hours:

Maintains good Poor response or unable to maintain good response: respiratory rate ≥ 40, wheeze, chest indrawing, sats < 92% or difficulty talking or drinking.
response and
no further nebs Child < 2 years old Child ≥ 2 years old
needed • Repeat salbutamol puffs/nebs.
Bronchiolitis • If not already given, give prednisone 2mg/kg (max 40mg) orally as a single dose.
• If known with likely • Assess after 20 minutes:
asthma, give • Give oxygen.
routine asthma • If blocked nose, Good response: assess every hour for next 4 hours:
care 108. instil sodium
• If not known chloride 0.9% Maintains good Poor response or unable to maintain good response:
with asthma, solution 1 drop response and no • Repeat salbutamol puffs/nebs and give oxygen via face mask and reservoir bag.
continue into each nostril further nebs needed • Assess after 20 minutes:
to assess as and suction
wheeze not nose. • If known with Good response Poor response or unable to maintain good response:
needing urgent • Refer urgently. asthma, give
attention 43. routine asthma • Refer for • Nebulise (oxygen 8L/min) salbutamol solution 0.5%2 1mL plus ipratropium bromide 1mL plus
care 108. overnight sodium chloride 0.9% 2mL if ≥ 3 years old. Use dose ratio of 0.5mL: 0.5mL: 3mL. If < 3 years old.
• If not known with observation in • If not already given, give prednisone 2mg/kg (max 40mg) orally as a single dose (if unable to
asthma, refer hospital. take orally, give hydrocortisone 4-6mg/kg IM or slow IV as a single dose (table 14 125).
for overnight • Continue nebs • Repeat salbutamol and ipratropium every 20 minutes and refer urgently.
observation in 1-4 hourly as • If child continues to deteriorate, discuss urgently with doctor for possible IV salbutamol and/
hospital. needed until or magnesium sulphate.
transfer.

1
Accessory muscle use is any of: subcostal recession, intercostal recession, tracheal tug, use of neck muscles. 2Fenoterol can be used instead of salbutamol 0.5% solution.
42
 Approach to the child with wheeze not needing urgent attention
Intermittent wheeze or wheeze present for short duration?

Yes No
• If history of choking with sudden onset of wheeze, refer same day. Longstanding
• If wheeze only on one side (unilateral), refer same week. persistent
• Manage further according to age: wheeze
present all
the time.
Child < 2 years old Child ≥ 2 years old
Refer same
week.
History of runny nose for 1-2 days before wheezing Respiratory Respiratory rate < 40
rate ≥ 40
Yes No 1st episode of wheeze Recurrent
Bronchiolitis likely Does child have any of: wheezing
• Assess bronchodilator response1: if • Hoarseness or recurrent croup episodes
• Assess bronchodilator
responsive, give salbutamol via spacer • Cough/wheeze with or after feeds (present before this illness)
response1: if responsive,
1-2 puffs 6 hourly when needed for • History of prematurity needing oxygen
give salbutamol via 44
5 days.
spacer 1-2 puffs 6 hourly
• If nose blocked, instil sodium chloride
Yes No when needed for 5 days.
0.9% solution 1 drop into each nostril
• If parent has history
and suction the nose as needed.
of- or child has eczema/
• Advise carer to give small feeds often. Refer to doctor/ Chest infection likely
allergic rhinitis/asthma
• If recurrent bronchiolitis, with persistent paediatrician. • Give amoxicillin2 30mg/kg 8 hourly for 5 days and
(atopic background)
symptoms between episodes or cough/ • Assess bronchodilator response1: if responsive, give salbutamol
44.
wheeze > 1 month, refer/discuss with via spacer 1-2 puffs 6 hourly when needed for 5 days.
• Review after 5 days: if
doctor/paediatrician. • Review after 2 days.
persistent symptoms,
refer to doctor.
Advise to return immediately if worse, poor feeding or no better after 2 days: refer.

How to use an inhaler with a spacer (with or without a mask)

• A spacer allows even the small child to use an inhaler. If < 3 years old, also use a face mask with spacer.
• Prime spacer initially with 20 puffs of medication. When medication is finished, replace only the canister.
• Clean spacer every 2 weeks: remove canister and wash spacer with soapy water. Do not rinse with water. Allow to drip dry (no need to re-prime).
• Demonstrate inhaler technique 2-3 times until child and/or carer understand. Then ask child and/or carer to show you how to use it.
• Remove cap • Hold infant on lap Press pump Remove inhaler Rinse mouth after
from inhaler and firmly hold down once and spacer using inhaled
and spacer. mask over infant’s and allow and wait for 30 Child rinsing corticosteroids
• Shake nose and mouth or 4 deep seconds before mouth out under (beclomethasone)
inhaler for • If > 3 years old, breaths repeat. Repeat a tap
5 seconds child to put spacer before for each puff
and insert into mouth and continuing. prescribed.
1 into spacer. 2a 2b close lips around it. 3 4 5

1
Give salbutamol via spacer 6 puffs and assess response after 15 minutes: if wheeze improves, child is “responsive” . If no improvement, child is bronchodilator “unresponsive”. 2If penicillin allergy (previous bronchospasm and/or severe rash), give
azithromycin 10mg/kg once daily for 3 days instead (table 5 122).
43
The child with recurrent respiratory symptoms
The child with recurrent respiratory symptoms has repeated episodes of cough or wheeze or difficulty breathing.

Approach to the child with recurrent respiratory symptoms (or child with 1st episode wheeze and atopic background):
Exclude TB 92. While excluding TB, consider other causes based on main symptoms:

Wheeze or recurrent dry cough/difficulty breathing Recurrent wet (productive) cough

If < 2 years old, recurrent bronchiolitis likely, manage as for bronchiolitis 43. ≥ 2 episodes/year

Does child ≥ 2 years old have any of: • If known with bronchiectasis, give routine
• History of eczema/allergic rhinitis • Symptoms triggered by: bronchiectasis care 109.
• Parents with history of eczema/allergic rhinitis/asthma --Smoking in the home, pets, pollen • Does each episode last ≥ 14 days?
• > 3 episodes/year --Perfume, paint, hairspray, cleaning agents
• Episode needing hospital admission --Change in weather or season
Yes No
• Symptoms worse at night and in early morning --Exercise, emotion, laughter or stress

• If HIV negative or • If cough follows

Yes No
unknown, test for viral colds, reassure
Are symptoms triggered by viral colds?
HIV 98. If HIV carer this is due to
positive, give routine viral cold and will
Yes No HIV care 99. resolve on its own.
Do symptoms persist for > 10 days after a viral cold or are there symptoms between colds? • Arrange chest X-ray • If not growing well
and doctor review: or cough persists >
--If TB excluded and 4 weeks, refer.
Yes No cause uncertain,
refer to specialist.
• Give a trial of treatment for 2 months: Does child have recurrent wheeze?
--Give inhaled corticosteroid: beclomethasone 100mcg 12 hourly if
≤ 5 years old and 200mcg 12 hourly if > 5 years old and
Yes No
--Give salbutamol via spacer 1-2 puffs 6 hourly as needed.
• Demonstrate inhaler technique 43.
• Encourage child/carer to identify and avoid triggers. Recurrent virus-induced wheeze Refer to specialist.
• Assess response to treatment: likely.
• If wheeze bronchodilator
responsive1 give salbutamol via
Symptoms improve with trial of treatment and Symptoms
spacer 1-2 puffs 6 hourly when
worsen when treatment is stopped. remain the
needed for 5 days.
same.
• Check ears 36, throat 38,
Asthma likely nose 37.
Give routine asthma care and start treatment 108. Refer to
specialist.
Refer to doctor within 1 month to confirm diagnosis.

1
Wheeze improves 15 minutes after salbutamol via spacer 6 puffs. If no improvement, child is not bronchodilator responsive.
44
Abdominal problems
Give urgent attention to the child with an abdominal problem:
• If recent injury/trauma 25 • Discoloured, tender, elevated testes • Vomiting, deep sighing respiration, fatigue, consider
• Peritonitis (guarding, rebound tenderness or rigidity of abdomen) • Painful groin swelling acidosis: check blood glucose 24.
• Tenderness in right lower abdomen and vomiting, appendicitis likely. • Abdominal pain, rash and joint pain • No stool or wind passed for last 24 hours and vomiting.
• Cramping/intermittent pain and jelly-like stool • Jaundice  46 • Bile-stained vomiting
Manage and refer urgently:
• Assess and manage child’s fluid needs 20
• Keep nil by mouth. Insert IV line and give maintenance fluids: sodium chloride 0.9% + dextrose 50% (add 10mL dextrose to each 100mL of sodium chloride) according to reference guide 18.
• If baby < 1 month old or peritonitis or appendicitis likely, give ceftriaxone 50-80mg/kg as a single dose (table 6 123).

Approach to the child with an abdominal problem not needing urgent attention
• If temperature ≥ 38°C or history of fever 31, check throat: if white patches/red throat 38. Check urine: if burning urine or nitrites/leucocytes/blood on dipstick 52.
• If TB symptoms (cough or fever ≥ 2 weeks, not growing well/losing weight, tiredness/reduced playfulness) or close TB contact 90.
• Is there abdominal swelling?

Yes No
Is it localized or generalised? • Assess if child constipated: stools infrequent and any of: pain, impaction, involuntary leakage or voluntary withholding 49.
• If no constipation, manage abdominal problem according to age of child:
Localized Generalised
• If mass felt in • Exclude TB 92. > 4 months old ≤ 4 months old
abdomen, refer • Do urine • Ensure regular deworming according to 6 monthly schedule 7. If history of worms,
to surgeon dipstick: give additional dose of mebendazole : if 12-24 months old: give 100mg 12 hourly for
If crying for ≥ 3 hours/day on ≥ 3 days a week,
same week. --≥ 3+ protein, 3 days, if ≥ 24 months old: give 500mg as a single dose.
doctor to assess baby:
• If bulge on nephrotic • If girl and started period and if pain around time of period, dysmenorrhoea likely.
• Exclude reflux 47 and assess growth 8. If baby
crying/cough/ syndrome --If ≥ 20kg, give ibuprofen1 200mg 8 hourly for 3 days.
growing well and appears well, consider colic.
passing stool: likely, refer/ --Reassure that is common and encourage child to carry on with normal everyday activities.
--If in groin discuss with • If girl and sexually active2:
area, inguinal doctor/ --If lower abdominal pain and/or vaginal discharge, pelvic infection likely, discuss with • Give feeding tips:
hernia likely, paediatrician doctor. --Avoid over/under feeding.
refer to same day. --If lower abdominal pain with amenorrhoea or vaginal bleeding 6-8 weeks after last period, --Burp adequately after each feed.
surgeon same Assess growth ectopic pregnancy likely, refer same day. --Breastfeed if possible and feed infant in semi-upright
week. 8. --If suspect abuse 70. position.
--If in umbilical • If growth • Is there pain with bloating and diarrhoea? • Assess and reassure the carer:
area, problem 85. --Discourage smoking in household and promote a
umbilical • If growth calm, quiet home environment.
Yes No
hernia likely, normal, refer/ --If carer seems depressed, screen for depression
Functional abdominal pain likely, Daily short-lasting pain not related to stool
refer to discuss with PACK Adult.
refer to specialist. pattern/meal times, screen for anxiety 71.
surgeon when doctor/ • Colic should resolve by 4 months old.
child ≥ 4 years paediatrician.
old.
If cause unclear or not resolved, refer.
1
Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease. 2If sexually active and any of following: not consensual or < 12 years old or 12-15 years old and partner not in peer group (partner is 12-15 years old or 16 or 17 years old provided
there is < 2 year age gap); manage as sexual abuse and report (form 22A1) 70. If ≥ 12 years old and consensual sex with partner in peer group advise reliable contraception PACK Adult.
45
Jaundice
Give urgent attention to the child with jaundice and any of:
• Easy bruising or bleeding • Hb < 7g/dL • Baby < 2 months old with total serum bilirubin
• Temperature ≥ 38°C • Newborn within first 24 hours above phototherapy threshold (see graph)
• Decreased level of consciousness • Glucose < 3mmol/L in a child ≥ 2 months old or < 2.6mmol/L in a baby < 2 months old • Baby ≤ 10 days old with ≥ 10% weight loss.
Manage and refer urgently:
Check glucose 24.

Approach to the child with jaundice not needing urgent attention

Is child on any medication?

No Yes
Manage according to age of child: • Stop medication.
• Is there vomiting,
abdominal pain or
≤ 10 days old > 10 days old - > 1 year old
nausea?
• Assess growth 8 1 year old
and feeding 78 • Check urine dipstick: if leucocytes/nitrites, refer same day.
• Look for abdominal No Yes
• Check total • Any of tiredness, loss of appetite, vomiting, nausea, abdominal
mass. serum pain, pale stools or dark urine or bilirubin on urine dipstick?
• Refer to hospital same bilirubin Refer
day if: and total same day.
--Abdominal mass felt. Yes No
conjugated
--Not feeding well. bilirubin.
• Do heelprick total • Discuss with Hepatitis A infection likely Refer/discuss with
serum bilirubin (TSB) doctor/ but need to confirm with IgM. doctor/paediatrician
and check graph: paediatrician Check blood hepatitis A IgM. same day.
--If TSB above same day.
phototherapy line,
refer same day. Manage as hepatitis A infection while
--If TSB on waiting for result:
phototherapy line, • Advise child and carer to wash hands after
refer to closest toilet and before eating/ preparing food to
hospital or MOU prevent spread.
(if available) for • Keep child home from school until jaundice
phototherapy. has cleared.
--If TSB under • Review blood results in 3 days: if IgM negative,
phototherapy line, hepatitis A infection unlikely, refer/discuss
refer to instructions with doctor/paediatrician same day.
above graph. • Avoid fatty foods and drink lots of fluid.
• Advise to return if persistent vomiting, starts
bleeding/bruising easily, behaving strangely
or drowsiness and refer urgently.
• Review in 2 weeks: if jaundice not resolved,
Taken from: Horn AR. Phototherapy and exchange transfusion for neonatal hyperbilirubinaemia. SAMJ.
2006; Vol. 96, No.9, figure 4, Phototherapy guidelines for all gestational ages. refer

46
Vomiting/refluxing
• A child is vomiting if there is tightening of stomach muscles and forceful expulsion of liquid/food.
• A child is refluxing if milk dribbles out mouth after a feed.

Give urgent attention to the child with vomiting and any of:
• Decreased level of consciousness • Headache • Painful groin swelling that will not reduce
• Vomiting blood • Neck stiffness/bulging fontanelle • Abdominal distension
• Unable to drink/breastfeed • Guarding/rebound tenderness or rigidity of abdomen: peritonitis likely • Abdominal mass
• Continuous vomiting/vomiting everything • Tenderness in right lower abdomen: appendicitis likely • Jelly-like stool
• < 2 months old and vomiting (not refluxing) • No stool or wind for last 24 hours • Dark green/bile stained vomiting
• Severe abdominal pain • Early morning vomiting
Manage and refer urgently:
• Check glucose 24.
• Assess and manage child’s fluid needs 20. If not dehydrated, give maintenance IV fluids, give ½ darrows dextrose1 IV according to reference guide 18.
• Keep nil by mouth.
• If meningitis likely (≥ 2 of: temperature ≥ 38°C, headache, decreased level of consciousness, neck stiffness/bulging fontanelle): give ceftriaxone 100mg/kg IV as a single dose (table 7 123).
• If likely appendicitis or peritonitis, give ceftriaxone 50-80mg/kg as a single dose.

Approach to child with vomiting not needing urgent attention

Is child vomiting or refluxing? If doing both together, refer.

Vomiting Refluxing
Check for dehydration: assess and manage child’s fluid needs 20. • Check growth 8 and feeding 80.
• If baby growing and feeding well, reassure carer that reflux causes
no harm. It may worsen between 4-6 months old.
• Look for underlying cause:
• If blocked nose at night or difficulty sleeping:
--If child bumped head in last few days 25.
--Thicken feeds (If ≥ 6 months old add rice cereal to expressed
--Check throat 38 and ears 36, if jaundice 46.
milk/formula).
--Ask about urinary symptoms and check urine dipstick: if burning urine or leucocytes/nitrites/blood on dipstick 52. If glucose,
--If breastfeeding, continue to offer on demand. If formula feeding,
check finger prick glucose 24, if bilirubin, hepatitis A infection likely 46.
avoid over-feeding: For how much/often to feed 80
• Manage further according to duration of vomiting:
--Position baby upright for 30 minutes after feed.
• Eradicate household cigarette smoke.
< 24 hours ≥ 24 hours
Gastroenteritis likely, especially if diarrhoea present. • If sexually active2 girl, exclude pregnancy.
Refer if:
• Reassure this is likely due to viral infection or food poisoning and will • If on ART, advise taking it with food. If vomiting
• Stridor
resolve on its own. persists, discuss with doctor.
• Irritability/ refusing feeds
• If not dehydrated, advise fluids at home: if breastfeeding, offer frequently. • If older child induces vomiting after eating, refer.
• Not growing well
Offer older child ORS/fluids frequently. • If child known with a life-limiting illness, also
• Episodes of no breathing > 20 seconds
• Review in 5 days unless child initially dehydrated, then review sooner after give palliative care 117.
• Recurrent wheeze/cough/chest infections
2 days. • Refer same day if vomiting > 3 days.
• If child known with cerebral palsy 113
• Advise to return immediately if unable to drink well/vomiting everything, • Refer if not growing well or if none of the above.
• Still refluxing at 18 months old.
becomes lethargic, sunken eyes, severe abdominal pain or vomiting blood.
1
If no ½ darrows dextrose available, give sodium chloride 0.9% + dextrose 50% (add 10mL dextrose to each 100mL of sodium chloride) instead. 2If sexually active and any of following: not consensual or < 12 years old or 12-15 years old and partner not in peer
group (partner is 12-15 years old or 16 or 17 years old provided there is < 2 year age gap); manage as sexual abuse and report (form 22A1) 70. If ≥ 12 years old and consensual sex with partner in peer group advise reliable contraception PACK Adult.
47
Diarrhoea
Confirm child has diarrhoea: watery stools and/or > 3 stools /day (changed from normal pattern).

Give urgent attention to the child with diarrhoea and one or more of:
• Blood in stool in child < 1 year old • Abdominal distension • Dehydration (≥ 2 of: 1) sunken eyes, 2) thirsty/drinks eagerly, 3) restless/irritable, 4) slow skin pinch2)
• Baby < 8 weeks old • ≥ 2 of: cold hands/feet, weak/fast pulse and capillary refill • Peritonitis (guarding/rebound tenderness or rigidity of abdomen)
• Unable to drink/breastfeed. > 3 seconds1, confused/unconscious, shock likely 20. • Wasting/swelling of both legs (oedema) in child < 1 year old
Manage and refer urgently:
• Assess and manage child’s fluid needs 20.
• Check glucose 24.
• If baby < 8 weeks old, temperature >38°C or < 35°C or peritonitis likely, give ceftriaxone 50-80mg/kg as a single dose.
• Give vitamin A as a single dose: if < 6 months old: 50 000IU, if 6-12 months old: 100 000IU, if ≥ 1 year old: 200 000IU.
• Give zinc: if < 10kg, give 10mg, if ≥ 10kg, give 20mg.

Approach to the child with diarrhoea not needing urgent attention

• Assess and manage child’s fluid needs 20.
• Ask about duration of diarrhoea:

Diarrhoea for < 7 days. Diarrhoea for ≥ 7 days

Is there blood in stool?
• If dehydrated or significant loss of weight 8, refer same day.
No Yes • If HIV status unknown, test for HIV 98. If HIV 99.
• If child on antibiotic, antibiotic could be causing the Dysentery likely --Lopinavir/ritonavir causes diarrhoea. Usually resolves within 6 weeks.
diarrhoea. Refer to doctor to stop/change antibiotic. • Give ciprofloxacin 15mg/kg/day 12 hourly for 3 days. • Check ears 36, check urine 52. If TB symptoms (cough or fever ≥ 2 weeks, not
• If not on antibiotic, viral gastroenteritis likely. • Check urine: if bloody urine or blood on dipstick, growing well/losing weight, tiredness/reduced playfulness) or close TB contact 92.
Reassure that this should resolve within 3 days. refer same day. • If known with a life-limiting illness, also give palliative care 117.

• Assess growth 8 and check for nappy rash 67.

• Advise the carer:
--Practise good hygiene: Wash hands before handling food, after using toilet/changing nappy, wash soiled clothing, bedding and dispose of dirty nappies.
--Feed child more frequently and if breastfeeding, feed for longer. If > 6 months of age, give soup, rice water or amasi. If diarrhoea > 7 days, give small, frequent meals 6 times/day.
--If repeated episodes of diarrhoea and no access to clean water, refer to health promotion officer/social worker.
• Give treatment:
--Give oral rehydration solution3 10mL/kg after each loose stool. Give extra fluids if child asks and continue until diarrhoea stops.
--Give zinc: < 10kg, give 10mg/day, if ≥ 10kg, give 20mg/day for 14 days.
--Give vitamin A as a single dose: if < 6 months old: 50 000IU, if 6-12 months old: 100 000IU, if ≥ 1 year old: 200 000IU. If diarrhoea > 14 days, give 2nd dose of vitamin A.

• If 5% dehydrated or dysentery, arrange review in 2 days, otherwise arrange review in 5 days. If no better, refer same day.
• If diarrhoea ≥ 7 days and well on review, review again in 14 days time and assess weight 8.
• Give an extra meal a day for a week.

Advise to return immediately if unable to drink well, sunken eyes, becomes lethargic or stools become bloody.
1
Capillary refill time: hold hand/foot higher than level of heart. Press soft pad of finger/toe until it turns pale, then release pressure and note time taken for colour to return. 2Skin pinch: pinch up skin on abdomen between 2 fingers. Release. Normal skin
pinch snaps rapidly back to its normal position. Slow skin pinch takes time to return to its normal position. 3Oral rehydration solution: Dissolve ½ teaspoon salt + 8 teaspoons sugar in 1 litre of cooled boiled water.
48
Constipation
The child is constipated if infrequent stools and any of: pain on passing stool, impaction, involuntary leakage of stool or voluntary withholding.

Give urgent attention to the child with constipation and any of:
• Abdominal distention and vomiting
• Mass in abdomen (not faecal mass)
• Newborn and no stool passed in first 2 days.
• Temperature ≥ 38°C
• Bruising and lacerations around anus, suspect child abuse 70.
Refer same day.

Approach to child with constipation not needing urgent attention

• If constipation from birth or early infancy, refer to specialist same week.
• Inspect anus: if crack 50. If rectal bleeding and no crack seen, refer.
• Refer to specialist same week if any of: anus does not tighten when child coughs/cries, abnormal spine, new urinary incontinence,
involuntary leakage of retained stool, weight loss/poor weight gain, or delayed milestones (check milestones in routine care) 8.

Is constipation associated with change in feeding, toilet training, starting school or is child in wheelchair, bed-bound or using morphine?

Yes No

Child in wheelchair, bed-bound Changed from breastmilk Introduction of solids Toilet-training toddler School entry
or using morphine to formula feeds
• Provide several servings • Explain to carer that forceful potty • Child may withhold stool as
• Advise a high fibre diet • Advise carer that baby daily of pureed training is ineffective. reluctant to use school toilet
(vegetables, fruit, wholemeal may pass less frequent vegetables, fruits, • Child may be fearful of painful defecation. or because change in schedule
cereals, bran and cooked stools on formula especially prunes. Advise on the following: interferes with toileting.
dried prunes), adequate fluid compared to breastmilk. • Ensure regular fluid --Ensure bench next to toilet for child to • If child miserable, stressed or
intake as far as possible. • Usually resolves in a intake. rest feet on. angry 71.
• Give lactulose 0.5mL/kg once week. For more feeding • For more feeding --Encourage unhurried time on toilet, • Encourage an unhurried
daily. If still constipated give advice 80. advice 80. after meals. routine of using toilet before or
twice a day. --Give child a reward after sitting on toilet. after school.
• If child known with a
• Advise to return if no
life-limiting illness, also give
stool after 3 days. • Check growth 8 and Hb: if Hb < 10g/dL in child < 5 years old or Hb < 11g/dL in child ≥ 5 years old 89.
palliative care 117.
• Give glycerine • Advise a high fibre diet (vegetables, fruit, wholemeal cereals, bran and cooked dried prunes), > 1 hour of brisk exercise everyday
suppositories: Insert one and avoid processed food and sweet drinks. Refer to dietitian if struggling with child's diet.
and repeat 12 hourly
until stool appears. If no
Review in 5 days:
stool after one day, refer.
• If still constipated and on solids, give lactulose 0.5mL/kg until constipation improves.
• Review in one week. If no improvement with lactulose, increase it to 12 hourly.
• Review in 3 months, if still needing lactulose, refer/discuss with doctor/paediatrician.

49
Anal problems
Give urgent attention to the child with anal symptoms and any of :
• Extremely painful lump on anus • Jelly-like stool
• Unable to pass stool because of anal symptoms • If bruising or laceration around anus, suspect child abuse 70.
Refer same day.

Assess child with anal symptoms not needing urgent attention

• If bloody diarrhoea 48. If nappy rash 59. If burning urine, check urine dipstick. If leucocytes/nitrites 52. Review RtHB: check deworming up to date and that child is attending clinic visits.
• Manage according to symptom/s:

Itch/irritation Pain or bleeding Perianal Red/raw skin

warts around anus
Normal looking anus, no Worms Lump Crack/s If rectal
suspected worms Manage • If lump painful at • Give lactulose 0.5mL/kg once a day until crack healed. bleeding Treat • Apply zinc and
• Exclude worms. as presentation, refer. • Apply lignocaine 2% gel to crack/s as often as possible. and no as for castor oil ointment
• Do not wipe anus below. • Review in 5 days: if • Refer if: crack/s genital after each nappy
excessively. lump no better, refer. --Severe pain or > 1 episode seen, warts change/bowel
• Avoid tight-fitting --Poor response to lactulose after one week. refer. 51. action.
underwear. • Do not wipe anus
• Keep area dry. • Give dietary advice to promote soft stools: High fibre diet (vegetables, fruit, wholemeal cereals, excessively.
• Avoid use of soaps, bran and cooked dried prunes), adequate fluid intake and > 1 hour of brisk exercise everyday. • Expose area to air as
detergents and perfumes. • Give advice on toilet habits: much as possible.
• Apply zinc and castor oil --Ensure bench next to toilet for child to rest feet on. • Keep area dry.
ointment to area twice a day. --Encourage unhurried time on toilet, after meals and give reward after sitting on toilet. • If ongoing
• Review in 2 weeks, if no --Address child’s anxiety: May be fearful of painful defecation. diarrhoea 48.
better refer. --Avoid straining when passing stool.

Worms
Carer may report seeing worm/s when child coughed, sneezed, vomited or was seen in stool.

• If worm flat and white worm segments (blunt ended), tapeworm infestation likely. Give albendazole once daily for 3 days according to age: if > 2years old 200mg or if ≥ 2 years old 400mg.
• If no worm seen or worm seen but not tapeworm, give mebendazole according to age: If 12-24 months: 100mg 12 hourly for 3 days and if ≥ 24 months: 500mg as a single dose.

• Repeat dose after 4 weeks if still infected.

• Assess and interpret growth 8. If palms pale, check Hb: if Hb < 10g/dL in child < 5 years or Hb < 11g/dL in child ≥ 5 years, 89.
• Advise good hygiene:
--Wash hands with soap and water before handling food and after using toilet/changing nappy, washed soiled clothing and bedding and dispose of faeces properly.
--Keep fingernails short and keep toilet seat clean.
• Refer if: abdominal tenderness or pain, abdominal mass felt or vomiting.

50
Genital symptoms
Before examining the child with a genital symptom, ensure that a chaperone is present.

Give urgent attention to the child with genital symptoms:

• Sudden testicular pain: torsion of testicle likely • Foreskin of penis is retracted, swollen and unable to be returned to its normal position. Glans is swollen and very painful: paraphimosis likely
• Painful swelling of groin or scrotum • History of rape/sexual assault: if wound or soft tissue injury needing urgent attention 56. Then go to abuse 70.
Manage and refer urgently:
If paraphimosis, try to replace foreskin: apply lidocaine 2% gel to glans, then wrap glans in gauze. Apply increasing pressure for 10-15 minutes until foreskin can be replaced over glans. If
unsuccessful or child not willing or glans blue/black: refer urgently.

Approach to child with genital symptoms not needing urgent attention

• If skin rash 59, if itching or red/raw skin around anal region 50, if burning/smelly urine 52, if lymph node 34, if soft swelling in groin 45.
• If testicle/testes not present in scrotum, review in one month. If still undescended, refer to surgical OPD.
• If girl with fused labia: reassure carer. If fused from birth, unable to see urethral opening, still fused after > 6 years old, recurrent urinary tract infections or if unsure, refer to gynaecologist.
• Manage according to genital symptom:

Sore/red/itchy vulva/vagina Vaginal discharge Urethral Warts Ulcers Scrotal/ Penis problem
discharge testicular
problem
Check urine: if leucocytes, nitrites or blood Discharge Discharge Discharge • If glans red and swollen,
on dipstick 52. If glucose, exclude white/thick/ not smelly copious/ balanitis likely: refer/discuss
diabetes 24. cheesy and clear or smelly/ • If firm lump, with doctor/paediatrician
white in girl green/ refer same same day.
≥ 8 years old yellow week. • If white patches on glans,
Vulvovaginitis likely
• If scrotum candida infection likely:
• Apply clotrimazole ointment at bed time until resolved.
soft, painless apply clotrimazole ointment
• Ask carer/child if foreign object in vagina and examine vulva/vagina. Physiological • If sexually active1, manage genital symptom
and fluid- at bed time for up to 14
• Treat for worms: from 12 months old, give mebendazole: discharge PACK Adult. filled, nights. Refer if no response.
if 12-24 months old: give 100mg 12 hourly for 3 days, if ≥ 24 likely. • If not sexually active or unsure, refer same week.
hydrocoele • If foreskin has become non-
months old: give 500mg as a single dose. Reassure this • If HIV unknown, test for HIV 98.
likely. retractile or if puberty and
• Advise to wipe from front to back, avoid tights/leotards/ leggings/ is normal. • Ask carer if aware of any abuse of child. Ask child
--If unsure or always been non-retractile,
wet swim-wear and bubble baths/perfumed soaps. Limit use of if anyone hurts him/her. If yes, suspect child
becomes phimosis likely. Book
soap on genital area, rinse well and pat dry. abuse 70.
painful, surgical OPD appointment
• Advise good hygiene: • If none of the above, refer.
refer. within next week
--Wash hands with soap and water before handling food and
--Otherwise
after using toilet/changing nappy.
refer to
--Keep fingernails short and keep toilet seat clean. Advise to wash daily with
surgeon
• If problem no better after 2 weeks or recurs, refer. water, avoid soap. Do not
when child
• If recurrent, exclude diabetes 24 and refer. forcibly retract foreskin for
> 1 year old.
• Ask carer if aware of any abuse of child. Ask child if anyone hurts cleaning- only clean when
him/her. If yes, suspect child abuse 70. it becomes freely retractile
• If none of the above, refer. (usually puberty).

1
If sexually active and any of following: not consensual or < 12 years old or 12-15 years old and partner not in peer group (partner is 12-15 years old or 16 -17 years old with a < 2 year age gap); manage as sexual abuse and report (form 22A1) 70. If ≥ 12
years old and consensual sex with partner in peer group advise reliable contraception PACK Adult. Check that he/she knows how to use condoms.
51
Urinary symptoms
The child with urinary symptoms may have pain on passing urine, urinating very often/large volumes, urgency, new incontinence, bed-wetting, bloody/brown urine, unable to pass urine or foul-smelling urine.

Give urgent attention to the child with urinary symptoms and any of:
• Only passing little amounts or unable to pass urine. • Swelling of face/feet and either blood in urine or
• Temperature ≥ 38°C/rigors/flank pain, pyelonephritis likely. passing little amounts of urine, nephritis likely
Manage and refer urgently:
• If nephritis likely and signs of fluid overload (increased pulse/respiratory rate ( 129) or puffy eyes), give oxygen 2L/minute via nasal prongs and give furosemide
1mg/kg IV over 5 minutes (do not give IV fluids). Then check BP ( 129). If increased, give nifedipine 0.25mg/kg squirted into the mouth.
• If pyelonephritis likely, give ceftriaxone 50-80mg/kg as a single dose (table 6  123).

Approach to the child with urinary symptoms not needing urgent attention
Check urine dipstick. If child too young to urinate into specimen jar, clean perineum and apply urine bag:
• If glucose/ketones in urine, check finger prick glucose 24.

Blood on dipstick Leucocytes and/ No leucocytes/nitrites in urine. Repeat dipstick in same urine sample.
or nitrites in
• If leucocytes/nitrites on dipstick, treat as urinary tract infection. urine, urinary If leucocytes/nitrites in second No leucocytes/nitrites
• Is there protein in urine? tract infection test, urinary tract infection likely. Is bed-wetting a problem?
likely
No Yes No Yes
• Send urine for microscopy, sensitivity and culture.
• If child < 1 year old, refer/discuss with doctor/
Has child been in a bilharzia area?1 paediatrician same day. Reassure • If < 5 years, reassure this is common and does
• Give amoxicillin clavulanic acid2 15mg/kg/dose plus and not need investigating.
Yes No amoxicillin 15mg/kg/dose 8 hourly for 7 days. reassess in • If previously dry, ask about recent stressful
--Refer if no response to treatment after 2 days. one week if events. Discuss possible solutions. If
• Advise to wipe from front to back always. not better. incontinence also in day, exclude diabetes
Schistosomiasis likely Refer/discuss with
• Offer child fluids to drink frequently. 24 and refer.
• Send urine for S. haematobium ova. doctor/paediatrician • If ≥ 5 years old, give advice:
• Give single dose praziquantel same day. • Avoid irritant soaps and bubble baths.
• Urinary tract infection might indicate an abnormal urinary --Reduce fluid intake during evening: avoid
40mg/kg. fluids 1 hour before bed-time so bladder
• Refer if child < 2 years old. tract, refer for investigation once antibiotic complete.
empty when going to bed.
• Advise to avoid contaminated --Teach child to wake with urination urge by
water to prevent re-infection. • If recurrent urinary tract infections: initially waking them to urinate.
• Review results in 3 days, repeat --Assess if child constipated: stools infrequent and any --Suggest a simple reward system such as a
dipstick and refer if: of: pain, impaction, involuntary leakage or voluntary star chart for a dry bed in morning.
--Urine schistosomiasis test negative withholding 49. --Reassure this is common, child should not
--Blood not cleared --Check anus 50 and genitals 51. be punished.
--Symptoms not resolved. --Refer to specialist. --Refer if above measures unhelpful.
• Advise to return if swelling of face
or feet and refer same day.
• Ask carer if aware of any abuse of child. Ask child if anyone hurts or upsets him/her. If yes to either, child abuse likely 70.
• If incontinence and child known with a life-limiting illness, also give palliative care 117.
1
Bilharzia areas include Limpopo, Mpumulanga, KwaZulu-Natal and isolated areas in Eastern Cape (Transkei). 2If penicillin allergy (previous bronchospasm and/or severe rash), give ciprofloxacin 10mg/kg/dose 12 hourly for 7 days (table 10 123)
52
Back problems
Give urgent attention to the child with back pain and any of:
• Sudden painful curvature of spine • Child < 5 years old
• Pain causing night waking • Fever/weight loss
• Pins and needles in limbs • Weakness in limbs
• Pain down leg • New onset limp
• Urinary or bowel incontinence
Manage and refer urgently:
If open area on spine, cover with sterile, saline-soaked gauze dressing. If difficulty breathing, give oxygen 2L/min via nasal prongs.

Approach to child with back pain not needing urgent attention

• If recent trauma or injury 25.

• Look at spine: if curved spine or deformity, refer to orthopaedic doctor.
• If asymmetric walk, refer to physiotherapist to check for leg length discrepancy.
• Check for contributing causes:

If carrying heavy weights: If < 1 hour/day of brisk exercise: Overweight

If carrying heavy school bag (especially on one shoulder), • Encourage child to: • If < 5 years old, plot weight and height 5. If WFL/H
advise to reduce weight of bag and --Go outside and play. is on or above +2 line 88.
carry on both shoulders. --Join a team sport. • If ≥ 5 years old, plot BMI 5. If BMI on or above the
--Take stairs instead of elevators or lifts, walk instead of +1 line 88.
taking transport.
• Limit TV, movies, video games, social media to less than
1-2 hours/day.

• Give paracetamol1 15mg/kg 6 hourly as needed for up to 5 days whilst addressing contributing causes.
• Refer if:
--Early morning stiffness or pain lasting > 15 minutes (refer same week).
--Back pain persists longer than a week or worsens despite above measures.

1
If pain uncontrolled with paracetamol, add ibuprofen 10mg/kg 6 hourly as needed up to 5 days.
53
Arm and hand symptoms
Give urgent attention to the child with arm or hand problem with any of:
• Temperature ≥ 38°C
• Trauma in past 48 hours and deformity or swelling 25.
• Sudden weakness or unable to move arm.
Manage and refer urgently:
Keep nil per mouth.

Approach to the child with arm or hand problem not needing urgent attention
If baby < 2 months old 2.

• If pallor of palms, do fingerprick Hb: if Hb < 10g/dL in child < 5 years old or Hb < 11g/dL in child ≥ 5 years old 89.
• Was there an injury?

Yes No
Manage according to site of injury Arm/hand swollen with no
history of trauma
Sudden pull of arm or forcefully lifted with straight arms and now refusing to move arm. Injury or blow to finger: Fall on outstretched hand
Finger may be painful, swollen Is there early morning
or deformed. stiffness lasting > 15 minutes?
Pulled elbow likely Is pain specifically over inside of
If any pain, swelling or deformity, fracture likely25 wrist (base of thumb)?
• Give paracetamol1 15mg/kg Yes No
6 hourly as needed up to
Yes No
5 days.
Juvenile Refer to
• Arrange x-ray and doctor
idiopathic orthopaedic
review. Distal Sprain/strain likely
arthritis OPD same
• If fracture and displaced (ends radius • Rest and elevate
likely. week.
of bone overlap by < 50%) or fracture limb.
Refer to
involves joint  25, buddy likely. • Apply firm,
specialist
strap are refer same day. 25 supportive bandage.
same
1 2 3 • Buddy strap finger to the • If knee or hip
week.
longer adjacent finger injury, refer to
Hold child's elbow bent at Next, firmly turn wrist so Then fully bend child's physiotherapist.
90° with child's palm facing that child’s palm is facing arm up his/her shoulder. • Give paracetamol1
downward and apply gentle upwards, maintaining A small click is often heard 15mg/kg 6 hourly as
pressure over radial head. pressure on radial head. or felt. needed up to 5 days.
• Review after 1 week:
if no better, arrange
Refer if not wanting to move arm 10 minutes after manoeuvre. • Review after one week. x-ray and doctor
review. If fracture
• Refer if unsure of diagnosis or problem no better. 25.
• If concerned about neglect/abuse 70.
1
If pain uncontrolled with paracetamol, add ibuprofen 10mg/kg 6 hourly as needed up to 5 days.
54
Leg symptoms/limp/walking problems
If problem is in joint 58. If problem is in foot 57. If not moving properly, e.g. abnormal tone, posture or weakness 74.

Give urgent attention to the child with leg symptoms with any of:
• Sudden refusal to sit, stand or walk • Leg pain and fever ≥ 38°C • Unable to bear weight
• Sudden onset weakness in leg/s • Limping and weight loss/lethargy after leg injury 25.
Refer urgently.

Identify leg problem

Problem walking Abnormal leg shape Leg pain Leg swelling

Is child limping?
• If bow-leg appearance: • If injury • If leg swelling in 1 leg and no history of
Yes No --Assess for forehead 25 trauma/injury, refer.
Ask about duration of limp. prominence, bowing of • If leg pain • If leg swelling in both legs, do urine dipstick:
upper limbs, bony lumps at night
along ribcage. If present, only and
Limp (< 48hrs) Limp (> 48hrs): is it painful? < 3+ protein ≥ 3+ protein
rickets likely. Do x-ray of active and
left wrist (not leg) and well during
Sprain/strain likely Yes No discuss with doctor. day in pre- Assess growth Nephrotic
• Ensure can bear weight on --If no signs or rickets, advise school or parameters 5. syndrome
leg, otherwise refer same day. that bow-leg appearance school going • Weight for height < -2 line likely.
• If pain in Ask about frequent falls.
• Rest and elevate leg. may be normal from age child, or Refer/discuss
joint/s 58.
• Apply pressure bandage.
• If pain not in 0-18 months old. growing • Mid upper arm with doctor/
• Look for neglect: of skin marks, No Yes --If persistent bow-legs pains likely, circumference < 12.5cm paediatrician
joint, refer/
bruises if different ages or > 3 years old, refer. reassure pain same day.
discuss with
poor growth 83, 70. Refer to • Refer to next • Advise that legs are will resolve
doctor/ Growth Growth
• Advise child to mobilise physio- level of care. generally straight from sponta-
paediatrician. normal abnormal
leg after 2-3 days if not too therapist • Arrange 18-24 months old. Refer if neously.
painful. for occupational legs not straight by 8 years • If continuous
• Give paracetamol1 15mg/ old. leg pain, Heart Severe acute
assess- therapy
kg 6 hourly as needed up to • Advise that a knock-knee refer/discuss failure malnutrition
ment. and physio-
5 days. appearance from 2-5 years with doctor/ likely. likely 86.
therapy
• Review after 1 week: if no old may be normal. paediatrician Refer
while
better, arrange x-ray and • If shape otherwise not same day. same
waiting for
doctor review, or sooner if normal or if legs painful, day.
appoint-
symptoms worsen. ment. refer

1
If pain uncontrolled with paracetamol, add ibuprofen 10mg/kg 6 hourly as needed up to 5 days.
55
The child with a fracture
Give urgent attention to the child with a fracture and any of:
• Poor perfusion (capillary refill > 3 seconds1/no pulse, cold, pale, numb) below fracture • Fracture of femur or pelvis • Open wound over fracture • >1 fracture
• ≥ 2 of: cold hands/feet, weak/fast pulse and capillary refill > 3 seconds1, confused/unconscious, shock likely 20. • Suspected spine fracture • Weakness/numbness/tingling • Deformity
Manage and refer urgently :
• If poor perfusion, deformity or weakness/numbness below fracture: doctor to give tilidine 1mg/kg (1 drop = 2.5mg) and re-align into position.
• If open fracture: remove foreign material, irrigate with sodium chloride 0.9% and cover with saline-soaked gauze. Give single dose ceftriaxone 50-80mg/kg as a single dose.
• Splint limb to immobilize joint above and below fracture. If pelvic fracture, tie sheet tightly around hips to immobilize.
• Give tetanus toxoid 0.5mL IM if not had in last 5 years (check RtHB). If very painful, give tilidine 1mg/kg (1 drop = 2.5mg). Keep nil per mouth.

Approach to the child with a fracture not needing urgent attention

Do x-ray and arrange doctor review:
• If no fracture seen, manage as sprain/strain, 25.
• If displaced fracture (bone ends overlap ≥ 50%) or fracture involves joint, apply backslab (and sling) and refer same day unless clavicle fracture (manage as below).
• Check pulses and nerve supply. If problem, refer same day.
• Manage common fractures according to site:

Clavicle fracture Elbow (supracondylar) fracture Wrist Ankle (fibula) fracture Foot fracture Finger or toe fracture
(undisplaced radius fracture)

Grade 1, fat pad sign2 Grade 2 • Buddy strap finger/toe

to the longer adjacent
• Stabilize and Grade 1 Grade 2 Backslab3 from foot finger/toe:
restrict shoulder Backslab3 Discuss to below knee,
movement using from hand manipulation ankle at 90°.
a sling. to below with orthopaedic Backslab3 from hand to
• Avoid contact shoulder, specialist before below elbow, keeping arm
sport for 1 month. elbow at 90°. backslab2. in line with hand. • Give paracetamol 15mg/
kg 6 hourly as needed
• Give paracetamol 15mg/kg 6 hourly as needed for up to 5 days. Elevate limb. for up to 5 days. Elevate
• Review next day. Check pulses and nerve supply. If problem, refer same day. If no response to paracetamol, add ibuprofen 10mg/kg 6 hourly as needed up to 5 days. hand/foot.
--If wrist, ankle or foot fracture remove backslab and apply full Plaster of Paris in same position. Recheck pulses and nerve supply. • Return next day if pain
• Review again in 3 weeks. Remove POP/sling. If still pain or not moving limb well, refer to orthopaedic OPD. not better.

• If concerns about poor adult/parental supervision at home, refer to social worker to arrange home visit.
• Consider child abuse 70, if any of: fracture in child < 1 year old, leg fracture in non-walking child, bilateral fractures, rib/skull fracture, multiple fractures in different stages of healing, any fracture out
of keeping with history.
Capillary refill time: hold hand/foot higher than level of heart. Press soft pad of finger/toe until it turns pale, then release pressure and note time taken for colour to return. 2The fat pad sign is the black shadows around the elbow joint. 3To apply backslab,
1

wrap limb in cotton. Prepare backslab by folding 10 layers if arm (14 layers leg) of Plaster of Paris long enough to reach past joints above and below fracture and wide enough to cover half limb circumference. Dip backslab in warm water, squeeze out and
mould with limb in position of function. Secure with bandage. Check pulses and nerve supply.
56
Foot symptoms
• If problem in joint 58.
• If problem is leg 55.

Give urgent attention to the child with foot symptoms with any of:
• Refusal to bear weight following injury.
• Foot pain and temperature ≥ 38°C
Refer urgently.

Approach to child with a foot problem not needing urgent attention

Identify foot problem

• If injury 25.
• If nail problem 69.
• Examine foot for hard areas underneath foot with black or white dot/s, foreign body and deformity and assess walking.

Hard, thickened area Foreign body Deformity Walking on toes No obvious cause of pain
underneath foot with in foot: glass,
black or white dots thorn, metal
If neonate 2 Ask about frequent falls. Ensure shoes fit properly.

Plantar wart likely. • Examine area

• Reassure warts often with good light. Can child walk on sides of No Yes Is pain mostly at night?
disappear spontaneously. Use forceps his/her feet?
• Soften wart by soaking in and attempt to Refer to • Refer/discuss Yes No
warm water at night and remove foreign No Yes physiotherapist with doctor/
remove loosened skin by body. for assessment. paediatrician.
light abrasion. • Clean wound with Refer/discuss Is pain related to exercise?
• Arrange
• Wash and dry well and sodium chloride Rigid flat • Reassure that with doctor/
occupational
apply salicylic acid 25% 0.9%. foot likely. foot is normal. paediatrician.
therapy and Yes No
ointment under a plaster. • Give tetanus Refer to • Encourage child
physiotherapy
Protect surrounding skin toxoid 0.5mL IM orthopaedic to go barefoot
while
with petroleum jelly. if not had in last OPD for where possible. Reassure carer If pain
waiting for
Keep plaster on for 24 5 years (check assessment. • Refer to that pain worse in
appointment.
hours. RtHB). physiotherapist will resolve early in
• Repeat process twice • Give if carer still spontaneously morning,
a week until warts paracetamol1 concerned. as heel bone juvenile
disappear. 15mg/kg 6 hourly fuses with age. idiopathic
• Refer if warts extensive. as needed up to arthritis
5 days. likely, refer
same week.

1
If pain uncontrolled with paracetamol, add ibuprofen 10mg/kg 6 hourly as needed up to 5 days.
57
Joint symptoms
Give urgent attention to the child with a joint problem with any of the following:
• Temperature ≥ 38°C • Trauma in past 48 hours with severe pain: arrange x-ray and doctor review • Night waking due to pain that
• Known haemophiliac • Any of strange movements of limbs or face, lumps over joints/tendons or rash does not resolve in day.
• Refusing to weight-bear (round pink lesions with pale centre), rheumatic fever likely • Sudden painful back curvature
Manage and refer urgently:
• If ≤ 2 months old and temperature ≥ 38°C , give one dose of ceftriaxone 50-80mg/kg as a single dose.
• If rheumatic fever, give benzathine benzylpenicillin1,2 IM, single dose according to weight: < 30kg, 600 000 IU and if ≥ 30kg, 1.2 MU and notify.

Approach to the child with a joint symptom not needing urgent attention
• Has there been any recent injury? If so 25.
• Check that problem is indeed in joint/s. If child old enough to understand, ask him/her to do the following: walk on heels then tip-toes. Make fist and open hand. Press palms together and back to
back with elbows lifted (should be able to flex/extend to 90°). Put hands behind head. Touch shoulder with ear. Reach up and “touch the sky” (with straight arms) and “look at ceiling”. Open mouth wide
enough to fit 3 fingers. Bend forward and touch toes. Squat then stand up. If unable to do any of these actions comfortably, joint problem likely.
• If pain not over joint: if arm problem 54, if leg problem 55, if foot problem 57.
• Screen for child abuse: ask carer if aware of any abuse of child. Ask child if anyone hurts or upsets him/her. If yes to either 70.
• Has child had a runny/blocked nose, sore throat or cough in last 2 weeks?

Yes No
Does child have any of: fever, weight loss, night sweats, weakness, fatigue, rash, bruising?
Viral reactive arthritis likely
• Reassure carer that it will resolve. No, manage according to site of joint problem: Yes
• Give pain relief: ibuprofen3 10mg/kg/
dose 4-6 hourly as needed up to 5 days.
Pain in hip, knee or thigh Pain in joint other than hip, knee or thigh Refer/discuss
• Follow up in 2 weeks.
• Refer if: with doctor/
--If joint pain persists on follow up. Is there pain on hip movement? paediatrician
--If temperature ≥ 38°C. Any signs of same day.
rheumatic fever appear (as above).
Yes No

• If available, do x-ray of pelvis Is there early morning stiffness lasting > 15 minutes?
(anterior/posterior) and frog
lateral of both hips.
No Yes
• Advise not to bear weight on
How long has joint been painful for?
painful side.
• Refer/discuss with doctor/
orthopaedic surgeon same < 6 weeks ≥ 6 weeks
week. • Reassure should resolve spontaneously.
• Refer if pain persists for ≥ 6 weeks or if temperature ≥ 38°C.
Refer same week.

1
If penicillin allergy (previous bronchospasm and/or severe rash), refer/discuss with doctor/paediatrician. 2For benzathine benzylpenicillin 1.2MU injection: dissolve benzathine benzylpenicillin 1.2MU in 3.2mL lidocaine 1% without epinephrine
(adrenaline). 3If ibuprofen not available, give paracetamol 15mg/kg 6 hourly as needed up to 5 days.
58
Skin symptoms
Start on this page for the child with skin symptoms.

Give urgent attention to the child with skin symptom/s and one or more of:
• Sudden generalized rash with difficulty breathing, swelling of face/lip/tongue or shock (cool hands/
feet with fast pulse): anaphylaxis likely.
• Non blanching1 purple/red rash with fever, headache, neck stiffness, nausea/vomiting or decreased

T
level of consciousness: meningococcal disease likely

AF
DR
• If baby < 1 month old and skin red and swollen around umbilical area, refer same day.
• If on any medication with any of the following, serious drug reaction likely:
--Temperature ≥ 38⁰C
--Shocked (cool hands/feet with fast pulse)
--Jaundice
--Abdominal pain/vomiting/diarrhoea
--Rash involving mouth, eyes or genitals
--Blisters or raw areas
Manage and refer urgently: Epinephrine dosing
• If anaphylaxis likely:
--Lie child flat and give 100% facemask oxygen, 2L/minute. Weight (kg) Injection (1mg/mL (1:1 000) Age
--Give epinephrine (1:1000 1mg/mL) according to table using 1mL syringe IM into mid-outer thigh. Repeat every 5 minutes if needed. < 9kg 0.05mL < 1 year
--Give sodium chloride 0.9% 20mL/kg IV/IO rapidly. 9-12kg 0.1mL 1-2 years
• If meningococcal disease likely: give ceftriaxone 100mg/kg IM/IV as a single dose. >12-18kg 0.2mL > 2-5 years
• Manage and assess child's fluid needs 20.
>18-40kg 0.3mL > 5-12 years

Approach to the child with skin symptom/s not needing urgent attention

Pain Itch Generalized Lumps Crusts Flaky Change Nappy Hair and
red rash and skin in skin rash scalp
bumps colour problems
60 No rash Rash
63 65 67
64 66 68
62 Generalized Localized

61 62

If status unknown, test for HIV 98, especially if rash is extensive, recurrent or difficult to treat.

1
Apply gentle pressure to rash. If the rash does not disappear, it is non-blanching.
59
Painful skin
Are there crops of blisters around mouth and on palms and soles? Firm, red lump which softens in the Sudden onset swelling of skin with redness, pain, warmth and temperature ≥ 38°C
centre to discharge pus.
No Yes Refer urgently if 1 or any of:
• Swelling
Painful blisters in • Loss of function
band along one side • Blisters
• Grey/black skin
• Decreased level of consciousness

Are borders poorly or clearly defined?

Poorly-defined borders Clearly-defined borders

Boil/abscess likely
• If lesion fluctuant, arrange incision
Shingles (Herpes Zoster) likely and drainage.
• If status unknown, test for HIV. Hand, foot and mouth • Give paracetamol 15mg/kg
• Advise to keep lesions clean and disease likely 6 hourly as needed for up to 5 days.
dry and avoid skin contact with • Give paracetamol 15mg/kg • Wash once with chlorhexidine
others until crusts have formed. 6 hourly as needed for up to solution 5% from neck down.
• Give aciclovir 20mg/kg 5 days. • If multiple lesions, cellulitis,
6 hourly for 7 days. • Keep home for 7 days to temperature ≥ 38°C, swollen lymph
• Give paracetamol 15mg/kg prevent spread. nodes in area, HIV or < 1 month old,
6 hourly as needed for up to • Usually resolves in 10 days. give cephalexin1 12-25mg/kg
5 days. 6 hourly for 5 days (table 8 123).
• If infected, give cephalexin1 • If recurrent boils or abscesses,
12-25mg/kg 6 hourly for 5 days test for HIV 98 and check Erysipelas likely
(table 8 123). fingerprick glucose 24. • Elevate area if possible.
• Refer same day if: • Advise to wash with soap • Give cephalexin1 12-25mg/
--Eye involvement and water, keep nails short and kg 6 hourly for 5 days
--Signs of meningitis (≥ 2 of: avoid sharing clothing Cellulitis likely (table 8 123).
temperature ≥ 38°C, or towels. • If baby < 1 month old and skin red and • Give paracetamol 15mg/kg
headache, decreased level of • Refer if: swollen around umbilical area. Refer same day. 6 hourly as needed for up to
consciousness, neck stiffness) --Difficult area to drain (face, • Elevate area if possible. 5 days.
--Rash involves > 1 region. genitals, hands) • Give cephalexin1 12-25mg/kg 6 hourly for • If needed add ibuprofen
--No response to treatment within 5 days (table 8 123). 10mg/kg 6 hourly for 3 days.
48 hours. • Give paracetamol 15mg/kg 6 hourly as
--Recurrent boils/abscesses needed for up to 5 days.

Refer if no response to treatment within 48 hours.

1
If penicillin allergy (previous bronchospasm and/or severe rash), give azithromycin 10mg/kg once daily for 3 days instead (table 5 122).
60
Generalised itchy rash
Bumps which become weeping blisters and Hyper-pigmented bumps, A widespread very rash with burrows Red raised wheals that appear suddenly,
crusts on face, scalp, trunk and limbs. May have skin often hyper-pigmented involving web-spaces of hand and feet, disappear and then reappear elsewhere.
history of fever, tiredness, sore throat or loss of axillae and genitalia.
appetite 1-2 days before rash.

R AFT
D
Papular pruritic eruption (PPE)
likely
• If HIV unknown, test for HIV 98.
• May temporarily worsen on
starting ART. Scabies likely Urticaria likely
Chicken pox likely • Exclude scabies. • Treat according to age: Commonly due to allergy to
• Highly contagious (spreads in air). • Apply hydrocortisone cream --< 1 year old: give sulphur ointment 5% once food/medication/insect sting
• Apply calamine lotion and give paracetamol 1% to face and betamethasone daily for 3-5 days.
15mg/kg 6 hourly for up to 5 days. If very itchy, ointment 0.1% to body in --1-2 years old: give half strength benzyl benzoate
give cetirizine daily for itch until controlled: morning and lotion 25% (dilute 1:2 with water) If sudden onset generalized rash with
12-21kg: 5mg, ≥ 21kg: 10mg. • Apply LPC ointment 5% at night --If ≥ 2 years old: give benzyl benzoate lotion 25%. difficulty breathing, swelling of face/lip/
• Usually resolves spontaneously within 10 days. until improvement. --Apply benzyl benzoate to whole body from neck tongue or shock (cool hands/feet with fast
• If rash and surrounding skin red, painful and • Give cetirizine once daily for itch to feet after hot bath and dry well. Wash off pulse): anaphylaxis likely 106
swollen with temperature ≥ 38°C, impetigo until controlled: next day and repeat next night. Put on cleaned
likely 60. --12-21kg: 5mg, ≥ 21kg: 10mg washed clothes after treatment.
• Refer same day if any of: --If < 2 years old, apply calamine --Repeat treatment after 1 week. • If recently started new medication, check for
--If < 28 days old. lotion. • Treat all house members at same time. drug reaction 63.
--If does not resolve by 10 days • If poor response, doctor to • Wash linen and clothes in hot water and expose • If < 5 years old, ensure deworming up to date
--Difficulty breathing. increase betamethasone bedding to direct sunlight. (check RtHB).
--Signs of meningitis (≥ 2 of: temperature ointment 0.1% to 12 hourly for • Give cetirizine once daily for itch until controlled: • Consider possible triggers1.
≥ 38°C, headache, decreased level of 7 days (do not apply to face). -- 12-21kg: 5mg, ≥ 21kg: 10mg • Apply calamine lotion directly on rash as needed.
consciousness, neck stiffness) • Reduce exposure to insect bites --If < 2 years old, apply calamine lotion in addition • Give cetirizine once daily for itch until controlled:
• Allow return to school once blisters crusted. (use bed net). to emulsifying ointment. -- 12-21kg: 5mg, ≥ 21kg: 10mg until 72 hours
• Avoid contact with pregnant women. • Explain to carer that PPE may be • If blisters and yellow crusts appear, impetigo likely after resolution of wheals.
• If recurrent, test for HIV 98. long-standing despite treatment. • If not better after 24 hours, refer to specialist
60.
• Keep finger nails short and clean. within one month.
• If repeated episodes, allergy likely 106.
• Advise to return immediately if any symptoms of
If no response to treatment, refer to specialist for review. anaphylaxis occur.

If patches of red, scaly, crusted skin in infant or dry scaly skin in older child, usually on flexor surfaces of elbows, knees and on cheeks, scalp and neck, eczema likely 107.

1
Possible triggers can be insect bites, dogs/cats in home, pollen, cigarette smoke, mould, cockroaches, peanuts, eggs, milk, fish.
61
Localised itchy rash
• If itchy rash on scalp/neck, look for nits/eggs in hair. If found, lice likely 68.
• Manage according to presenting symptom/s:

Scaling moist lesions between Round/oval patches, red, scaly edge Well demarcated pink raised plaques covered
toes and on soles of feet with a silvery scale.
Vesicles, pimples (pustules) in centre Pale centre

AFT FT DRAFT FT AFT

DR DR A DR A DR
Psoriasis likely
Pityriasis rosea likely Commonly found on extensor surfaces of knees,
Athlete’s foot likely Tinea (ring worm) likely
• Usually preceded by a few days elbows, sacrum and scalp.
Encourage open shoes/sandals. Occurs anywhere on body . If head/scalp involved or hair loss 68.
by one large oval scaly area. Confirm diagnosis with doctor.
• Apply clotrimazole cream • If multiple or large lesions, test for HIV 98.
• Lesions usually occur only on • Apply emulsifying ointment.
8 hourly for 2 weeks. • If HIV, give routine HIV care 99.
chest and back and rash often has • Expose skin to sunlight before 11am for
• Avoid sharing towels/clothes. • If affecting scalp 68.
a Christmas tree-like appearance. 30 minutes/day.
• Wash skin well before • Apply clotrimazole cream 8 hourly for 2 weeks.
• Inform carer that lasts for • Apply LPC 5% ointment once daily.
applying treatment and dry • Avoid sharing towels/clothes.
6-8 weeks but will resolve • If poor response, doctor to give betamethasone
well between toes. • Wash skin well before applying treatment.
spontaneously. 0.1% ointment (do not apply to face).
• Apply aqueous cream to lesions • Refer if extensive or not responding to treatment
If rash extensive, recurrent or responds poorly to treatment, refer. 8 hourly. after 1 month.

Itch with no rash

• Confirm there is no rash, especially scabies or insect bites.
• Is skin very dry?

No: review child’s medication Yes: dry skin/icthyosis likely

• Use emulsifying ointment or aqueous cream as moisturizer.
• All TB medicines can cause itch with no rash. If not on any • Use aqueous cream instead of soap to wash.
• Continue TB treatment. medication, refer • Avoid washing/bathing > once a day, use soft sponges and pat skin rather than rub dry.
• For itch, give cetirizine once daily for up to 5 days: 12-21kg: 5mg, ≥ 21kg: 10mg. for assessment of • Put mittens on small child to prevent scratching and avoid tight clothing.
If < 2 years old, apply calamine lotion in addition to emulsifying ointment. underling cause. • Keep creams and ointments in fridge.
• Advise to return if rash develops or if no better after 5 days. • If child known with a life-limiting illness, also give palliative care 117.
• Refer if no response to treatment

62
Generalised red rash
• Check throat. If red throat or white patches 38. If child has joint pain 58. If temperature ≥ 38°C in last 3 days, headache, body pains and tick bite
present (small dark brown/black scab, tick bite fever likely 31.
• If < 1 week old and tiny red bumps progressing to pustules, erythema toxicum likely. Reassure carer this will resolve spontaneously within in 1 week.
• Is child taking any medication and did rash appear after medication started?

Yes Not on medication or rash appeared before medication started.

Is temperature ≥ 38°C (or history of fever)
Drug reaction likely
Rash may be mild, patchy spots Yes, does child have conjunctivitis, runny nose and/or cough? No
or widespread (like burns)
Yes, did rash start on face and then spread to trunk and limbs? No Reassure
Give urgent attention carer and
to the child with a drug Yes, measles likely Are there painful lymph nodes advise to
reaction and any of: behind ears or return if
• Temperature ≥ 38°C back of head/neck? rash still
present

FT FT
• Shock (cool hands/feet

A A
with fast pulse) after 2

R R
No Yes

D D
• Difficulty breathing days.
• Face/tongue swelling
• Abdominal pain Non-specific
• Extensive rash viral rash likely
• Reassure carer

FT
• Vomiting/diarrhoea

DRA
• Blisters, peeling areas that rash
• Jaundice Give urgent attention to the child with measles and any of: will resolve
• Rash involving mouth, • Child < 6 months old • Wasting • Likely meningitis (≥ 2 of: temperature ≥ 38°C, headache, spontaneously.
eyes/genitals. • Difficulty breathing • Child has HIV decreased level of consciousness, neck stiffness) • Give
• Swelling of legs • Child has TB • Red, swollen/cracked lips or red tongue paracetamol
Manage as serious drug
15mg/kg Rubella likely
reaction 59 Manage and refer urgently: 6 hourly as • Isolate from
• Assess and manage child's fluid status 20. needed up to 5
• If difficulty breathing 41. pregnant women
Approach to the child with days. and keep home
• If meningitis likely, give ceftriaxone 100mg/kg IM/IV as a single dose. • Advise to
a drug reaction not needing for 7 days after
urgent attention return to clinic onset of rash.
• If newly started on ART 99 Approach to the child with measles not needing urgent attention if fever for > • Give
or TB treatment 95. • Notify and send clotted blood and throat swab (if available) to confirm diagnosis 128. 3 days or rash paracetamol
• If on epilepsy medication, • Isolate child for 5 days to prevent spread. persists > 1 15mg/kg 6
stop and refer/discuss with • If < 6 years old and no vitamin A in last month, give vitamin A as a single dose: if < 6 months old: week. hourly as needed
doctor/paediatrician. 50 000IU, if 6-12 months old: 100 000IU, if 1- 6 years old: 200 000IU. Carer to give second dose • If red, swollen/ up to 5 days.
• Give cetirizine once daily for following day. cracked lips • Reassure carer
5 days: 12-21kg: 5mg, ≥ 21kg: • Give paracetamol 15mg/kg 6 hourly as needed up to 5 days. or red tongue, illness will resolve
10mg. • Assess growth and check immunisations up to date 5. refer same day. spontaneously.
• Stop all other medication and • Give close contacts ≥ 6 months old measles vaccination within 72 hours of exposure. • If HIV exposed,
refer/discuss with doctor/ • Advise to return immediately if not better after 1 week. test for HIV 98.
paediatrician.
63
Lumps and bumps on skin
If pimples/pustules on scalp, folliculitis likely, go to 68.

Bright red or blue lump/bump, Raised and rough lumps and bumps, often Small, skin coloured pearly white Red itchy bump/s which blister and heal with
warm to the touch. on hands and fingers bump with central dimple darkening of skin.

Insect bites likely.

Usually occurs in crops and can take up to
2 months to resolve.
• Reduce exposure to insects: treat pets, use
bed nets, air bedding, use insect repellents.
Infantile haemangioma likely • If puddles of water around house, clear away.
• Grows rapidly over first year of • If extensive, test for HIV 98.
life, then starts to decrease in size. • For new, inflamed lesions, apply
Warts likely hydrocortisone 1% to lesions once daily for
• Reassure carer that no treatment • Often seen on hands and fingers. Molluscum contagiosum likely
is necessary and it should resolve 5 days.
• If wart underneath foot, plantar wart • If large crops present, test for • Give cetirizine once daily for itch until
by 5 years old but a small red likely 57. HIV 98.
mark might remain). controlled:
• Reassure warts often disappear • Reassure that lesions will often --12-21kg: 5mg
• Refer if: spontaneously. disappear spontaneously (may
--Lesion on lips, around eyes, nose, --≥ 21kg: 10mg
• Soften wart by soaking in warm water at disappear quickly with ART). -- If <2 years old, apply calamine lotion.
ear, over spine or over throat night and scrub gently with clean nail file. • If distressing to child: apply
--Ulceration • If blisters and yellow crusts impetigo likely
• Wash and dry well and apply salicylic tincture of iodine BP to core of 60.
--Bleeding acid ointment 5%. Protect surrounding lesion and cover with plastic wrap
--Appears infected. • Refer if no response to treatment.
skin with petroleum jelly and cover with until resolved.
--> 1 lesion plaster Keep plaster on for 24 hours. • If lesions on eyelid, refer to
• Repeat twice a week until warts disappear. ophthalmologist.
• Refer if warts extensive.

64
Crusts, flaky skin and ulcers
Look for blisters/honey coloured crusts, flaky/greasy crusts, flaky pink raised plaques or ulcers (bedsore)

Pus-filled blisters which dry to form honey coloured crusts Flaky or greasy crusts with Well demarcated, pink, raised plaques Child usually in bed and
underlying red base. May be itchy. covered with flaky silvery scale ulcer in common bedsore sites

Seborrhoeic dermatitis likely

• Reassure carer that it will resolve
spontaneously in few weeks/
months.
• If on scalp, 68. If over nappy Psoriasis likely Bedsore likely
area 67. • Commonly found on extensor • Relieve pressure on ulcer and reposition
• If extensive or > 1 year old, and surfaces of knees, elbows, sacrum child every 2 hours.
HIV unknown, test for HIV 98. and scalp. • Gently clean ulcer twice a week with
Impetigo likely • Trim nails and avoid scratching. • Confirm diagnosis with doctor. sodium chloride 0.9% solution apply silver
• Keep nails short. Wash and soak sores in soapy water to soften • Wash body with aqueous cream • Apply emulsifying ointment. sulphadiazine cream and cover with non-
and remove crusts. Cover draining lesions with saline-soaked and avoid perfumed soap. • Expose skin to sunlight before 11am adherent dressing.
gauze dressing. • If more extensive, apply for 30 minutes/day. • If infected (skin red, warm or tender), give
• Apply povidone iodine 5% cream 8 hourly and give cephalexin1 hydrocortisone cream 1% twice • Apply LPC ointment 5% once daily. amoxicillin/clavulanic acid 15mg/kg/dose
12-25mg/kg 6 hourly for 5 days (table 8 123). a day until improved. • If poor response, doctor to give plus amoxicillin 15mg/kg/dose 8 hourly for
• If rash does not resolve completely, repeat treatment. • Usually resolves spontaneously. betamethasone ointment 0.1% (do 5 days and clean ulcer daily as above until
• Look for cause: if insect bites 26, lice/nits 68, scabies 62, • Refer if extensive and no response not apply to face). infection better.
eczema 107. to hydrocortisone cream. • Refer if: • Give paracetamol 15mg/kg 6 hourly as
• Impetigo is contagious: --Extensive needed for up to 5 days.
--Ensure regular hand-washing to prevent spread to family members. --Not responding to treatment after • Refer if:
--May return to school 1 day after starting antibiotic. one month. --Fat, bone, muscle or tendon visible
• Refer if: --Yellow/grey/black tissue
--Extensive lesions/cellulitis/abscess/temperature ≥ 38°C --Extensive or worsening infection
--No better after 2 courses of cephalexin. --Ulcer not healing with treatment
• Advise carer to return with child immediately if blood in urine or • If child known with a life-limiting illness,
limb/face/feet swelling and refer same day. also give palliative care 117.

1
If penicillin allergy (previous bronchospasm and/or severe rash), give azithromycin 10mg/kg once daily for 3 days instead (table 5 122).
65
Altered skin colour
If yellow skin, jaundice likely 46.

• Plot weight to exclude malnutrition  8.

• Look at affected area of skin: is area of skin red/pink, dark, light or absent colour?

Red/pink Dark Light patches Absence of colour

patches
Red/pink flat area/s present from birth Where is patch on body? Is absence of colour patchy or generalized?

Sharply defined edge. No clear edge Trunk Face Patchy Generalized

Absence of

FT
colour, present

A
from birth.

DR Involves skin,
hair and eyes

Albinism likely
• Advise carer
Tinea versicolor likely to apply
sunscreen
Salmon patch/ • Apply selenium sulphide Vitiligo likely
daily and
Port wine stain likely storkbite likely shampoo to whole body Pityriasis alba likely • Advise use of
overnight once a week avoid sun
(congenital malformation) • Reassure carer it will • Mild form of eczema. camouflage cosmetics.
for 3 weeks. exposure.
• If around eye, refer child fade with time. • Reassure carer it will • Ensure carer and child
• Advise that colour may • Refer to
to next available date • No treatment needed. resolve in a few months. understand condition.
take months to return to specialist for
for eye examination. • Apply hydrocortisone • Enquire about child’s
normal, but absence of eye care.
• If history of fits, refer. 1% cream twice a day happiness at school and
• Advise carer that the scale indicates adequate until resolved. exclude bullying 75.
stain is permanent but treatment. • Advise to use sunscreen • Refer to dermatologist.
has no complications. • If itch and problematic, regularly.
give cetirizine once daily
until controlled:
--12-21kg: 5mg
--≥ 21kg: 10mg
• Recurrence is common.

Refer if diagnosis uncertain.

66
Nappy rash
Red rash
Is it flaky?

No Yes

Is it present in creases/many small red flat dots next to border of rash?

No Yes

R AFT R AFT
D D

Nappy eczema likely Candida infection likely

• After each nappy change, dry area well and apply petroleum • Apply clotrimazole cream 2% before applying
jelly and zinc and castor oil. the petroleum jelly and zinc and castor oil.
• Plot growth 8, if faltering, 85. • Refer if no improvement after 3 days.
• Advise carer to: • If repeated episodes, test for HIV 98.
--Change soiled nappy promptly. • Test for HIV.
--If towelling nappies, wash well and make sure dry before use. • Test blood glucose: if ≥ 11.1mmol/L, PACK Adult
--Expose nappy area to air as much as possible.
--Return if small red flat dots next to border of rash appear/
rash starts to involve creases and treat for candida infection.
Seborrhoeic dermatitis likely
Often involves the creases
• Apply hydrocortisone cream 1% before applying the
petroleum jelly and zinc and castor oil twice daily until
improved. Then apply once or twice weekly until resolved.
• Avoid perfumed soap.
• Refer if not resolved after one month.

Give paracetamol 15mg/kg 6 hourly as needed until rash improved or for up to 5 days.

67
Hair and scalp problems
If brown hair has turned reddish or hair become sparse/brittle, plot growth 8 to check for malnutrition.

Does child have scale, itch, patches of hair loss or pimples/pustules?

Scaly patches or plaques Itchy scalp Patches of hair loss Pimples/pustules

Is the scalp itchy? Are lice or nits seen? Is child perpetually pulling at hair?

No Yes No, Yes Yes No

but patches of
hair loss
• Apply permethrin 5% lotion to Traction alopecia Alopecia
scalp after bath at night: likely areata
--Comb into hair repeatedly until Ask about social/ likely
whole scalp is covered: risk stressors: Refer to
• Dip a fine-toothed comb in • If miserable, specialist. Folliculitis likely
vinegar and remove lice by stressed or angry • Keep area clean and dry.
combing entire head twice. 71, • Apply povidone-iodine
• Rinse lice comb in a white • If behaviour scrub to scalp.
bowl filled with hot water problem 72, • If extensive or redness/
between hair strokes to • Screen for child pain/swelling/temperature
identify removed lice. abuse: ≥38°C, give azithromycin
• Then rinse hair with lukewarm --Ask carer if 10mg/kg once daily for 3
water and wash permethrin aware of any days (table 5 122).
Seborrheic dermatitis likely. • Wash hands regularly to
• If < 6 months old, often out with normal shampoo. abuse of child.
• Avoid broken skin and contact --Ask child if prevent spread.
looks greasy and is known Tinea capitus likely
as cradle cap. Apply with eyes. anyone hurts or
• Give fluconazole 6mg/kg • Wash bed linen in very hot water. upsets him/her.
cetomacrogol cream once daily for 28 days.
to scalp, leave on for • Treat all household contacts. --If yes to either,
• Use povidone-iodine • If still a problem, shave hair. suspect child
45 minutes, then brush shampoo to reduce
scalp with fine-toothed • If ≤ 2 months old: abuse 70.
shedding of spores. --Comb wet hair with fine
comb or soft brush. Repeat • Avoid shaving head.
daily until resolved. toothed comb after
• Do not share combs and shampooing.
• If ≥ 6 months old, wash hairbrushes.
hair and scalp weekly with --Wash hair at least twice a week.
selenium sulphide 2% • Suspect child abuse if child with
suspension. Rinse off after lice on pubic, peri-anal area and
10 minutes. eyelashes /eyebrows 70.
• Usually resolves
spontaneously.

68
Nail symptoms
Asymmetrical Trauma to nail, blood and Pallor of nails/nail bed Thin black/brown longitudinal Transverse dents in
discoloured/ disfigured nails swelling under nail segment on nail nail plate

R AFT
FT D
R AFT DRA AFT AFT
D Exclude malnutrition DR DR
and/or anaemia
• Assess growth 8. If
Subungual haematoma likely faltering 86.
• Call doctor for management. • Test for anaemia: Do Hb: if
Fungal infection likely Hb < 10g/dL in child < 5
• If nail bed disrupted, attempt
• Fungal nail infection is difficult years old or Hb < 11g/dL in Pigmented naevus likely Exclude illness
removal of nail.
to treat. child ≥ 5 years old 89. • Ask about onset: • Assess growth 8. If
• Doctor to relieve pressure under
• Discuss referral with doctor. --If unchanged and present faltering, 86.
nail bed:
--Restrain arm and finger, clean for some time, review in • If fever, 31.
area, heat a piece of metal wire 6 months. If still unchanged, • If excluded above and child
(or paperclip). reassure. well, reassure that will grow
-- Press tip of wire into nail in --Refer if different appearance out with nail.
centre of haematoma. Enlarge at 6 months.
hole until fluid drains.
--Cover puncture site with sterile
gauze.
--Tell carer that will drain for up to
2 days.
• Do not relieve pressure if:
--Injury > 2 days old
--Spontaneously draining
--Not painful
• Refer if:
--Suspected finger fracture.
--Suspected injury to nerve or
blood supply.
--Unable to perform procedure.
• Advise to return if:
--Pain occurs
--Area becomes red, swollen or
temperature > 38°C, cellulitis
likely 60.

69
Suspected child abuse/neglect
Child abuse/neglect likely if:
• History of child abuse (carer or child discloses abuse) • Examination and history do not fit. • Abuse clear on examination • Interaction between carer and child odd

Give urgent attention to the child where abuse/neglect is very likely:

• Definite history of rape/sexual assault • If wound, head injury, soft tissue injury or bleeding needing urgent attention 25. • At risk of being harmed and in need of shelter
Management:
• If rape/sexual assault: make arrangement for referral to closest designated facility for management of rape/sexual assault.
--Ensure that child gets zidovudine, lamivudine and lopinavir/ritonavir (see PEP dosing table 105] )as soon as possible, if presenting within 72 hours of the alleged incident, to prevent HIV.
--Do not bath or wash child. Make sure child comfortable and be kind. No need to examine or ask further questions.

Approach to the child with suspected abuse/neglect

Look for warning signs that make abuse more likely and assess for other types of abuse simultaneously (do this in an area which is quiet):

• History of physical assault. • Any of the following with no other obvious cause: • Poor growth with no obvious cause. • Child excessively
• If ear drum ruptured, refer to ENT. --Vaginal/penile discharge or genital warts/ulcers 51 • Clothes are ill-fitting, dirty or withdrawn, fearful
• Old and new scars, grasp marks on --Persistent urinary frequency/burning urine 52 inappropriate for weather or anxious about
arms/chest/face, bruises, bruises • Knowledge/interest in sexual acts inappropriate for age, or seductive behaviour. • Unbathed, matted/unwashed hair, doing something
of different ages, burns/cigarette • If sexually active and any of the following: not consensual or < 12 years old or noticeable body odour wrong.
burns, unusual or patterned wounds 12-15 years old and partner not in peer group2. • Untreated illnesses or physical injuries. • Child frightened
specifically on skin, ears, eyes or in/ • Frequently left unsupervised or because of being
around mouth. Sexual abuse a possibility allowed to play in unsafe situations. bullied or exploited.
Doctor to examine with chaperone present (obtain consent): do not perform internal • Frequently late or missing from school
Physical abuse likely examination. If external tears in ano-genital area or unsure, book specialist OPD Emotional abuse
Manage injuries needing attention 25. appointment/refer to closest designated facility for management of rape/sexual assault. Neglect likely likely

• Assess overall wellbeing of the child 4.

• Assess the home environment: ask about carer substance abuse, or if carer/siblings being abused. If yes to any, refer to social worker.

Manage the abused/neglected child

• For all types of abuse and neglect:
--Health care worker legally required to complete form 22A1 and fax to social services agency in area 128. Ensure receipt of form with telephone call.
--If neglect and inadequate food, refer to nutritional support programme/NGO (like Philani) 128.
--If bullying at school, contact teacher to work with carer to stop the abuse. If bullying at home, refer carer/s and child to psychologist for family therapy.
• For physical and sexual abuse:
--Make careful notes: clearly record child and carer’s story in their own words: include identity of perpetrator and child’s name and date and sketch all injuries and scars. Inform carer/s of all relevant
investigations being done and referrals being made.
--Notify police: if police not present yet, phone SAPS (FCS number) to begin investigation. Fill in J88 if requested.
--Ensure place of safety and refer to available supportive resource:
• Involve social worker to arrange place of safety for child. If social worker unavailable, contact FCS ( 128). If unable to respond same day, refer to hospital until suitable placement arranged.
• Help carer identify sources of support for child. Refer to available trauma counsellor, mental health nurse, psychologist or helpline 128. Refer also to community health worker to do home visit.

1
A form 22 prompts a further detailed investigation into a case of suspected child abuse or neglect. Form may be completed by nurse or doctor. 2Partner is 12-15 years old or 16-17 years old provided there is < 2 year age gap.
70
The stressed, miserable or angry child
Give urgent attention to the stressed/miserable/angry child with 1 or any of:
• Suicidal thoughts or suicide attempt
• At risk of harming self or others
Manage and refer urgently:
If aggressive or violent, ensure safety: assess child with other staff, use security personnel if needed. Sedate with lorazepam 0.05-1mg/kg orally or IM stat (only if absolutely necessary). If sedation
given, monitor respiratory rate and level consciousness. If drops, assess airway, breathing and circulation XX.

Assess the stressed/miserable/angry child not needing urgent attention:

Assess Note
Symptoms Manage symptoms as on symptom page: if nausea, abdominal pain 45, if headache 32, if weakness or tiredness 33, if bedwetting > age 5 52.
Long term health conditions • Ensure any LTHC adequately treated. If asthma 108, if epilepsy 112, if eczema 107, if allergies 106.
(LTHC) • If child known with a life-limiting illness and also give palliative care 117.
Depression If > 2 weeks any of (for most of day), irritable, sad, unable to enjoy anything, crying a lot, feeling lonely, depression likely, refer.
Anxiety If > 6 months any of: excessive fear, worry, or difficulty concentrating that interferes with activities of daily living (school grades, home/social life), anxiety likely, refer.
Post traumatic stress disorder If previous traumatic event/accident and disturbed sleep, nightmares, irritability or difficulty concentrating for ≥ 1 month, refer.
Stressors • If child clings to carer, refuses school or anxious about bad things happening on separation from carer, discuss separation anxiety (below).
• If recently bereaved: Assess source of possible grief, losing a family member or a pet. Give advice.
• Substance abuse: if concerns about use of alcohol or drugs, link to psychosocial services (counsellor/social worker/ support group, helpline 128).
Home environment • Ask carer if aware of any abuse of child. Ask child if anyone hurts/upsets him/her. If yes to either child abuse likely 70.
• If violence or drug/alcohol abuse at home, involve social worker.
• Screen for depression in carer: if yes to > 1 PACK Adult: 1) In past month, have you been down, depressed or hopeless? 2) In past month, have you had little interest/pleasure in things?
Sleep If difficulty sleeping 76.
Bullying If being bullied at home or on streets, refer to social worker. If happening at school 75.
School problems If failing grades or problems attending school 75.
Weight • Plot growth. If underweight, 85, if overweight, 88.
• In older child, if persistently purging after eating or refusing to eat, refer.

Advise the carer and stressed/miserable/angry child

• In bereavement, reassure carer and child that sadness is part of normal bereavement process. Make sure child has support at home and school and opportunity to talk about his/her feelings and loved one.
• If separation anxiety likely, advise carer to be calm but firm during separation and avoid showing own anxiety. Refer to clinic counsellor or psychologist if needed.
• If struggling with discipline or parenting 77.
• Ask carer to explore what child enjoys most and focus on those activities.
• Ensure the following are present in child’s daily activities/routine:
--Good quality sleep and healthy food. --Encourage safe outdoor play and exercise.
--Creative or fun activity that child enjoys. --Time with supportive family and friends.
• If <2 years old and new caregiver, counsel parents to introduce child gradually over time to new care giver. Offer parenting advice 77 and link with support 128.
• Access support for child and carer. Helpline page 128.

Offer to review child in one month, or sooner if no improvement and refer.

71
Behaviour problems
Give urgent attention to the child with behaviour problems with any of:
• At risk of harming self or others • Just had fit 22 • Acutely intoxicated and needing • Fluctuating level consciousness 21
• If confused, 21 • Temperature ≥ 38⁰C restraint or sedation. • Hearing voices or seeing things that are not there.
Manage and refer urgently:
• Check glucose and oxygen saturation if available: if glucose < 3 mmol/L 24, if oxygen saturation ≤ 92%, give oxygen 2L/minute via nasal prongs.
• If temperature ≥ 38⁰C and headache, neck stiffness or vomiting, give ceftriaxone 100mg/kg IV/IM as a single dose.
• If aggressive or violent, ensure safety: assess child with other staff, use security personnel if needed. Sedate with lorazepam 0.05-1mg/kg orally or IM stat (only if
absolutely necessary). If sedation given, monitor respiratory rate and level consciousness. If drops, assess airway, breathing and circulation 17.

Approach to the child with behaviour problems not needing urgent attention

Look for medical causes:

Check for pain, problems with vision, difficulty hearing or communication problem, sleeping problem and developmental delay:

Look for pain Exclude vision, hearing, communication problems Exclude sleeping Assess milestones
• Ask about other symptoms and manage as per symptom page. • If vision problems, 35. problem if < 6 years old
• Check ears for foreign body 36, teeth for caries 40 and • If speech/language problems, 73. 76 5
mouth for painful blisters/ulcers 38. • If hearing problem, 36.

Then ask about emotional symptoms:

If angry/aggressive, withdrawn or change in mood, behaviour/feelings and now not coping 71.

And screen for social risk/stressors

Screen for bullying, child abuse, carer depression and substance abuse in carer:

• If school refusal/bullying/poor school grades 75. Ask carer if aware of any abuse Screen for depression in carer: if yes Screen for substance abuse in carer:
• If behaviour problem made worse by spending of child, carer or siblings. to > 1 PACK Adult: 1) In past month, if carer drinks every day or > 5 drinks/
time at particular house/with family member/ Ask child if anyone hurts or have you been down, depressed or session or > 14 drinks/week or loses
friend, try to explore and address problem. upsets him/her. If yes to either, hopeless? 2) In past month, have you control when drinking or misuses illicit or
child abuse likely 70. had little interest/pleasure in things? prescription drugs, PACK Adult.

Assess behaviour:

If struggling to sit still, not finishing tasks, doing If concerns about use of alcohol or drugs, consider substance abuse. If unsociable, poor eye contact with carer, unusually few
things without thinking and affecting school interests, repetitive behaviours (rocking, flapping hands,
and home life, refer to school doctor to assess Do urine drug screen (if available) and link to psychosocial services leg jiggling), refer to paediatrician to assess for autism
for attention deficit hyperactivity disorder. (counsellor/social worker/support group 128). spectrum disorder.

• If child disobedient or carer struggling with parenting 77.

• Review in 1 month. If no better and unable to find cause, refer to paediatrician/mental health practitioner

72
Communication problem
Give urgent attention to the child with a communication problem if:
Suddenly unable to communicate as before. Refer urgently.

Approach to child with a communication problem and not needing urgent attention:
Ask carer if child appears to hear as other children do.

Child does not appear to hear as other children do. Child appears to hear as other children do.
Check ears for pain, discharge or eardrum problem.
Arrange hearing test. If test abnormal,
Ear pain, No ear pain, discharge or eardrum problem ensure follow up with audiology and speech services.
discharge Refer to audiologist for hearing screen.
or
eardrum Test Test normal
problem abnormal
Then assess communication (talking) problem:
36 Ensure • If child ≥ 6 years old, ask if talking problem affecting school work (failing grades): refer to school based support team or speech therapist.
child has • If child < 6 years old, check if understanding is appropriate for age by asking the following:
follow
up with ≥ 1 year old 2 years old 3 years old 4 years old 5 years old
audiology • Points to • Points to a few body parts. • Understands opposites ("go-stop," "in-on,“ "big-little," "up-down"). • Understands words like • Speaks
and common items • Does a one-step • Follows 2 part command ("Pick up the book and give it to your “cold”, “hot”, “hungry”, clearly.
speech like cup, shoe, command e.g. fetch your mommy"). “tired”. • Answers
therapy bottle. bottle. • Answers simple questions: • Stranger can understand questions
services. • Uses simple • Uses 2 word combinations • "Who is your best friend?" ("Ngubani umhlobo wakho?") what child is saying. about
Help words such as such as “come mommy” and "What is your favourite food?" ("Yintoni na ukutya • Says his/her name, age, school.
access “mama, dada, ball.” ("yiza mama"). okuthandayo?"). sex.
support
(HiHopes)
128. Is child’s understanding appropriate for age?

No, understanding problem likely. Yes, but child has speaking problem
• Assess motor milestones as per general assessment 5. • Assess mouth and throat: look for cleft
• Refer to next level of care. palate. If found, refer to ENT same
• Assess other possible contributing causes while waiting for appointment: week.
--Ask who looks after child most of time. If any harm or neglect suspected 70 • If stuttering or other speaking
--If violence or substance abuse in home, refer to social worker. problem, refer to speech therapist.
--If behavioural problems (e.g. living in own world, repetitive movements) 72.
--If child miserable, stressed or angry 71.
--If carer struggling with parenting 77. Assess mental health of carer: screen for depression PACK Adult.
--Mental health of carer: screen for depression PACK Adult.
• Encourage carer to play and interact with child: provide contact/hold child regularly, sing/dance with child, encourage activity
outside, kick/throw a ball, read books daily.

73
Not moving or sitting properly
Give urgent attention to the child not moving/sitting properly:
• Acute onset (unable to move/sit properly for < 72 hours) • Baby < 2 months old • Injury 25
• Painful movement • Not talking or using hands as before • Headache
• Decreased level of consciousness • Recent loss of milestones • Temperature ≥ 38⁰C
Manage and refer urgently:
If temperature ≥ 38°C, decreased level of consciousness or baby < 2 months old, treat empirically for likely infection. Give ceftriaxone 50-80mg/kg as a single dose (table 6 123).

Approach to the child not moving/sitting properly not needing urgent attention:
• If problem only in leg/s 55.
• If problem only in arm/s 54.
• If painful or stiff joint, do joint screen 58.

Check the child’s motor milestones: if born premature, use corrected age1 until 2 years old.
14 weeks old 6 months old 9 months old 15 months old 18 months old 3 years old 5-6 years old
Lifts head when held against Holds toy in each hand. Sits and plays without support. Stands on own. Walks unsupported, uses Runs well, can climb. Hops on one foot, draws a
shoulder. fingers to feed. stick person.

Has child achieved milestone at the appropriate age?

Yes No

Refer to Check for HIV, TB, thyroid problem, anaemia, growth problems:
paediatrician.
Test for HIV Exclude TB If ≤ 1 year old, test for Test for anaemia Check for growth problems
If status unknown, test 92 thyroid problem Do Hb: if Hb < 10g/dL in child Measure and record weight-for-age,
for HIV 98. If HIV, Check TSH. If abnormally < 5 years old or Hb < 11g/dL in length/height-for-age,
give routine care 99. high, refer to doctor. child ≥ 5 years old 89 weight-for-length/height (or BMI) 8

Then check for abnormal spine, head circumference 5, tone (child floppy or stiff ) and posture.

Head circumference, tone, posture and spine are normal Abnormal head circumference, tone posture or spine
• Review motor milestones in 8 weeks: if child has not achieved milestone, refer to paediatrician (or • Check visual, hearing and communication milestones 8.
next level of care?) for assessment. • If abnormal behaviour 72.
--Arrange occupational therapy and physiotherapy appointments in meantime. • Refer same day if abnormal spine.
• Encourage carer to play and interact with child: provide contact/hold child regularly, sing/dance • Refer to next level of care.
with child, encourage activity outside, kick/throw a ball, read books daily.
• Check if carer coping. If struggling, check carer's mental health PACK Adult.

1
Corrected age = actual age in months (or weeks) - number of months (or weeks) premature. To calculate corrected age of 9 month old baby, born premature at 32 weeks (this is 8 weeks or 2 months premature): 9 months - 2 months = 7 months old.
74
School problems/bullying
The child with a school problem may be failing grades, not coping with school work or struggling with bullying or violence.

Assess the child with school problems

Assess Note
Hearing, talking, and vision • If hearing problems 36.
• If communicating/talking problems 73.
• If vision problems 35.
Deteriorating school work If no vision/hearing problem and repeatedly failing grades or not coping with school work, refer to school based support team.
Long term health conditions (LTHC) If HIV 99, if fits 22, if asthma 108, if allergic rhinitis 106 or eczema 107.
Behaviour If problem with behaviour 72.
Home environment • Ask about violence, abuse, parental substance abuse or other family crisis. If suspected, refer to social worker. If child abuse suspected 70.
• If not enough food at home or no lunch at school, assess growth 8 and refer to Nutritional Support Programme if needed.
Sleep If poor sleep 76.
Mental health If child miserable/stressed or angry or aggressive, look for underlying problem 71.
Substance abuse If child using alcohol or drugs, refer to social worker and link carer/child to support group 128.
Violence and abuse Ask about violence, sexual assault and bullying at school. See advice box below.
School refusal • Try to establish reason for not attending school, explore stressors e.g. bully at school, unsafe school premises and address these.
• If child frightened to go to school or reluctant to leave carer, screen for anxiety, depression or separation anxiety 71

Advise the carer of the child with school problems

• If struggling with parenting or child disobedient, 77.
• Establish regular daily routine for sleeping, eating and playing and limit time spent watching TV/playing video games. Set aside specific time for homework daily.
• If concentration problem, make sure nutrition adequate: ensure breakfast before school and lunch at school. Avoid fast foods, sugar and caffeine. If struggling to sit still, 72.
• Encourage safe after school care and encourage activities with peers such as sport and music, thereby reducing risk of gang/drug involvement.
• Ask who looks after child most of time. If any harm or neglect suspected  70.
• Address violence, sexual assault and bullying:
--Involve social worker, teacher/principal to take appropriate action.
--If physical or sexual abuse suspected 70.
--If cyber-bullying, advise carer to monitor activity on social media and take action to stop it.

If the school problem persists despite considering above measures, refer/discuss with doctor/paediatrician.

75
Sleeping problems
Approach to the child with sleep problems
Check medication (review with doctor)
• Phenobarbitone, valproate and carbamazepine may cause daytime sleepiness
• Methylphenidate (used in ADHD), salbutamol inhalers (used in asthma) may cause difficulty falling asleep.
Ask about social risk/stressors:
• Ask who looks after child most of time and if carer aware of any abuse of child. Ask child if anyone hurts/upsets him/her. If yes to either child abuse likely 70
• If violence or drug/alcohol abuse at home, involve social worker.
Determine the type of sleep problem:
• Difficulty falling asleep/staying asleep, bed-wetting/soiling, abnormal movements or behaviour or breathing problem/s:

Difficulty falling asleep or Bed-wetting or soiling Abnormal movements or behaviour Breathing problem
staying asleep
• If previously dry, ask about • If teeth grinding 40 • If cough/wheeze 41.
• Ask about tight chest 42, recent stressful events. • If child has fits 22. • If snoring 37.
persistent runny, itchy nose 37, Discuss possible solutions. • If wakes up suddenly screaming or confused and inconsolable and • If anal itch/irritation,
itchy skin 59. • If bed wetting and ≥ 5 years > 3 years old, night terrors likely. exclude worms 50.
• If miserable, stressed or angry 71. old, 52. If bed soiling --Advise carer there is no need to wake child and stay with child until • If episodes of no
• If behaviour problem, 72. and ≥ 4 years old, 49. he/she is asleep peacefully. breathing > 20
• Ask about fits 22. --Reassure night terrors are not dangerous and will resolve by age 12. seconds, apnoea likely,
refer/discuss with
doctor/paediatrician
If none of the above, disrupted sleep may be due to bad habits. See below for advice.
same day.

Advise the carer of the child with sleep problems to develop sensible sleep habits
Prepare the sleeping environment: Food:
• Make sure space is safe, warm, quiet and not brightly lit. Check child has enough space. • Check child has adequate food and not going to bed hungry.
• Advise on a quiet room with dim light (or dark room) and ensure child is warm enough. • Avoid caffeine and sugar. Move to above school environment
• Remove television, video equipment and cell phones from bedroom. School environment:
Establish a good bedtime routine: • Ensure child not worrying excessively about problems at school. If problem,
• Advise on a consistent bed time and wake up time. try to address it 75.
• Sit quietly with child and read story before bed time. An object of attachment, like a soft toy can help. Advise the carer with an infant:
• In older child, allow time to unwind/relax before bed without screen time. • Place infant on back to sleep (reduces risk of Sudden Infant Death Syndrome).
• If struggling with parenting or child disobedient 77. • Put infant to bed slightly awake, after a nappy change, food and comfort.
Physical activity: • If < 6 months old, ensure night-time feed/s continue.
• Ensure child has > 1 hour of brisk exercise every day.

If sleep problem is causing significant distress, unable to find cause and no response to sensible sleep habits, refer to paediatrician.

76
Parenting difficulties
Approach the family with parenting difficulties to identify a cause, give general parenting advice and help access support.

Assess the carer and child

Assess When to assess Note
General health of carer Every visit • If carer unwell, assess and manage with PACK Adult.
• If delivery in past 6 weeks, give postnatal care PACK Adult.
Mental health of carer Every visit • If yes to ≥ 1 during the past month PACK Adult (Depression and anxiety: diagnosis): 1) Have you been down, depressed or hopeless? 2) Have you had little interest/
pleasure in things? 3) Have you often felt nervous, anxious or panicky? 4) Have you been unable to stop worrying or thinking too much?
• During the past month, have you had thoughts to harm yourself? If yes PACK Adult (Suicidal client).
Risky alcohol/drug use Every visit If ≥ 1 of: drinks alcohol every day, > 14 drinks1/week, ≥ 5 drinks1/session, loses control when drinking; used illegal or misused over-the-counter or prescription drugs in
the past year PACK Adult.
Special needs If needed If child known with special needs , give routine care: cerebral palsy 113, if Down syndrome 116.
Social risk Every visit • If family or relationship problems, violence at home, difficult life event in last year, lack of partner/family support, carer < 20 years old, financial difficulty, refugee
status, bereavement, help access support below.
• Ask carer who looks after child most of time. If concerns about child abuse or intentional neglect 70.
Parent/child Every visit • If yes to either, refer to mental health nurse/psychologist/doctor/social worker:
relationship --1) Are you worried about this mother or child?
--2) Ask carer: “Are you worried about your relationship with your child?”
• If baby < 1 year old: If carer not interacting with baby or not responding appropriately to baby (like making good eye contact with baby or trying to comfort or feed
baby when baby crying), refer to mental health nurse/psychologist/doctor.
Behaviour/sleep If needed If problem that persists despite parenting strategies below, assess thoroughly: behaviour problem 72, sleep problems 76.
School If needed If school problem persists despite parenting strategies below 75.

Advise the carer with parenting difficulties

• If child has two parents encourage both to be actively involved in parenting.
• Encourage carer to discuss concerns with crèche, preschool and school staff.
• Help the carer to consider strategies to help cope with parenting:
Encourage a healthy Establish routine Provide consistent discipline Encourage carer to look after him/herself:
bond between carer and • Encourage routines for sleeping, • Be firm, kind, reasonable and Get active
baby eating, playing, homework and consistent.
Encourage carer to react chores. • Set clear boundaries. Explain Get
sensitively, • Encourage after school reasons for rules. enough
reassuringly, supervision. • Focus on good behaviour: sleep
and consistently praise, encourage and reward. Spend time Access support
to his/her baby, • Talk about issues. Avoid shouting and harsh punishments: with supportive Link client with
especially use ‘Time Out’ instead of smacking. friends or family. helpline (like the
during the 1st • Actively listen to child, respect his/her wishes and feelings Find a creative or Parent Centre)
year. and encourage him/her to express his/her opinions. fun activity to do 128.

Offer to review the client in 1 month.

1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer.
77
Breastfeeding
Give urgent attention to the baby with one or more of:
• Unable to feed at all • Difficulty breathing, blue lips or sweating during feeds • Cleft palate
• Vomiting everything 47. • Choking/coughing when feeding • Difficulty swallowing (milk pooling in mouth)
• No attachment/sucking
Manage and refer urgently:
If baby < 2 months old and unable to feed: give ceftriaxone 100mg/kg as a single dose (table 7 123) and keep warm. Check glucose: if < 2.6mmol 2, if
≥ 2.6mmol, prevent hypoglycaemia: give 3mL/kg of expressed breastmilk every hour via NGT.

Assess breastfeeding mother and baby to identify feeding problem

Assess When to assess Note
Routine care Every visit Integrate routine care of the child into every visit 4. If any other symptoms, manage as on symptom page.
Feeding frequency Every visit • If not feeding on demand (as often as baby wants day and night), there is a feeding problem.
• If baby < 6 weeks old not feeding at least 8 times in 24 hours, there is a feeding problem.
Solids Every visit • If baby < 6 months old getting other foods/fluids (especially if HIV-exposed baby is mixed feeding), there is a feeding problem.
• If baby ≥ 7 months old has not started solids, there is a feeding problem.
Mother Every visit • If mother has a low BMI1 < 18.5 or MUAC < 23cm, refer mother to Nutritional Therapeutic Programme.
• Screen for increased psychosocial risk and mental health problem 4 (if baby ≥ 2 months old 5).
• Check HIV status, contraceptive needs, TB symptoms and mental health (including substance abuse) 5.
• If breast problem (painful breast, breast lump or cracked nipples) PACK Adult.
Growth Every visit Measure and record weight-for-age, length/height-for-age, weight-for-length/height 5.
Baby’s mouth Every visit If white patches in mouth (inside of cheeks/lips and on tongue), oral thrush likely 38.
Breastfeeding At first visit, and if feeding problem If baby’s head turned, nose not opposite mother’s nipple, body far away from mother’s body, mother not supporting baby’s whole body, there is a feeding problem.
position
Attachment and At first visit, and if feeding problem • If blocked nose, clear with sodium chloride 0.9% solution 1 drop into each nostril and suction nose.
suckling • If not fed in the last hour, observe mother breastfeeding for 4 minutes and assess attachment and sucking:
Signs of good attachment/sucking Signs of poor attachment/sucking
• Mouth wide open • Baby sucking on nipple, not areola
• Lower lip turned outwards • Rapid shallow sucks
• More areola visible above than below baby’s mouth • Smacking or clicking sounds
• Chin touching breast • Cheeks drawn in
• Slow, deep sucks and swallowing sounds • Chin not touching breast
• If signs of poor attachment or sucking, there is a feeding problem.
HIV risk Every visit • If mother HIV unknown/negative, do HIV test in mother 3 monthly while breastfeeding PACK Adult.
• If mother tests HIV positive, do HIV PCR in baby same day 98, start post exposure prophylaxis (PEP) in baby and ART in mother PACK Adult.
• If mother known HIV positive, check HIV PCR test done on baby at birth (or at first presentation) and follow up result. Ensure PEP given 105.
• If baby has HIV, ensure baby on ART and give routine HIV care 99. Continue breastfeeding until 2 years old.

Advise the breastfeeding mother 79.

1
BMI is weight (kg) ÷ height (m) ÷ height (m).
78
 Advise the breastfeeding mother and correct feeding problems
If feeding problem, refer to lactation consultant (breastfeeding counsellor) or support group and advise on how to feed, what to feed and how often:

How to feed What to feed: How often to feed

(feeding frequency):
Position baby: 0-6 months old ≥ 6 months old
• Seat mother comfortably. Encourage exclusive breastfeeding for 6 months: baby gets only • From 6 months old, • Breastfeed on demand
• Baby faces mother’s breast (baby’s breastmilk and medicines if needed (no formula, water, cereal). This introduce solids as often as baby wants,
head should not be turned) with nose decreases risk of diarrhoea, pneumonia and allergies. Other foods may 81. day and night.
opposite nipple and body close to damage gut and allow infections (including HIV) in. • Continue to • A baby < 6 weeks old
mother’s body. breastfeed up to 2 should feed at least
• Mother supports baby’s whole body, years old. If baby 8 times in 24 hours.
If concerns about milk supply
not just neck and shoulders. HIV negative and • If poor growth, advise
• Reassure that mother naturally produces enough milk for child’s needs.
Help baby attach: mother on ART, mother to wake baby
• Increase frequency and length of feeds and feed day and night.
• Touch baby’s lips with mother’s nipple. breastfeed until 1 to feed after 3 hours if
• Advise to rest, drink plenty of fluids and encourage partner support.
• Express a few milk drops onto baby’s lip. year old. baby has not woken
• Wait until baby’s mouth opens widely, by him/herself (during
then move baby quickly onto mother’s day and night).
Expressed breastmilk:
breast. • If mother away from baby, give expressed breastmilk with cup.
• Aim baby’s lower lip well below nipple. • The exclusively breastfed baby takes in about 750mL/day between 1-6 months old.

If mother wants to formula feed instead, check that reliable resources in place for at least 12 months: good sanitation; safe water supply; support from family member who knows HIV status; money to
buy formula, feeding equipment, cleaning materials, fuel and equipment to prepare formula; money for travel for extra clinic/hospital visits; time to purchase and prepare formula.

• Review baby with newly diagnosed feeding problem in 2 days, thereafter review every 5 days until feeding problem corrected.
• If young infant has lost weight or feeding problem unlikely to be corrected, refer.

How to express breastmilk How to store breastmilk

To express, stimulate the milk reflex by massaging, stroking or gently shaking breasts. When milk/colostrum appears express the breast
until empty (at least 10 minutes/breast): • Use hard plastic (or glass) container with large
opening and tight lid to store the breastmilk.
• Boil container and lid for 10 minutes before use.
1 Wash hands. Position 2 Push straight 3 Roll thumb • Write time and date that milk expressed on
thumb just behind into chest wall. and fingers container.
the edge of areola Avoid spreading forward at • Store in fridge for up to 24 hours or in cool place for
(dark part of the fingers apart. the same 8 hours.
breast) and forefinger For large time bringing • When ready to use milk: warm by standing in
below to form the breasts, first lift the milk from container of clean warm water (do not microwave).
1 letter “C”. Avoid 2 and then push 3 the "back to Gently swirl.
cupping the breast back. the front". • Drop small amount milk on inside of wrist to check
4 Repeat rhythmically to completely drain reservoirs: position, push, roll... position, push, roll... position, push, roll... milk not too hot for baby before feeding.
5 Rotate thumb and fingers to milk other reservoirs, moving all around the areola. • Check person feeding baby knows how to cupfeed.
Avoid squeezing breast, sliding hands over the breast or pulling nipple.

79
Formula feeding
Give urgent attention to the baby with 1 or any of:
• Unable to feed • Choking/coughing when feeding • Difficulty swallowing (milk pooling in mouth)
• Vomiting everything 47. • Cleft palate • Difficulty breathing, blue lips or sweating during feeds
Manage and refer urgently:
If baby < 2 months old and unable to feed: give ceftriaxone 50-80mg/kg as a single dose (table 6 123) and keep warm. Check glucose: if < 2.6mmol 2,
if ≥ 2.6mmol, prevent hypoglycaemia: give 3mL/kg of expressed breastmilk every hour via NGT.

Assess the baby formula feeding to identify feeding problems

Assess When to assess Note
Routine care Every visit Integrate routine care of the child into every visit 4. If any other symptoms, manage as on symptom page.
Type of formula Every visit If child getting formula that is not appropriate for his/her age, there is a feeding problem.
Preparation Every visit Ask carer if s/he: washes hands, boils water for 3 minutes, measures water and formula according to tin instructions with scoop supplied, makes enough formula for only one feed at
a time. If no, there is a feeding problem.
Feeding frequency Every visit Ask about feeding frequency according to age: < 6 weeks old: 8 feeds/24 hours, < 6 months old: 6 feeds/24 hours, 6-12 months old: 4 times/24 hours. If baby fed less frequently than
this, there is a feeding problem.
Solids Every visit If solids have been started too early (< 6 months old) or have not started after 6 months old, there is a feeding problem.
Cleaning Every visit Ask carer if s/he: washes all containers with hot soapy water and rinse, sterilises cup at least once/day (or if using bottles, after each use), sterilises containers by boiling in pot of
water for at least 10 minutes and keeps pot covered until containers needed. If no, there is a feeding problem.
Social Every visit • If formula feeding not accepted at home, no access to clean water or carer cannot afford formula each month for 12 months, there is a feeding problem.
• If mother has died, is mentally disabled/poses threat to baby or is seriously ill/ on medications contraindicated in breastfeeding, refer to NTP1 for formula.
Growth Every visit Measure and record weight-for-age, length/height-for-age, weight-for-length/height, MUAC2 5.
Cup feeding Every visit Check that carer knows how to use a cup to feed as it is safer than bottle feeding.

Advise the carer formula feeding and correct feeding problems

What to feed How much and how often to feed How to prepare feeds How to clean containers
• Do not give other foods/fluids before Weight (kg) Number of feeds Amount per feed • Wash hands. Boil water for 3 minutes. • Wash containers with hot soapy water
6 months old. 0-3.9kg 8 50mL • Measure water and formula carefully using tin and rinse.
• Give infant formula appropriate for instructions and scoop supplied. • Sterilise cup at least once/day (if using
4-4.9kg 4 75mL
age as indicated on tin. • Mix formula while water still hot, use clean spoon bottles, after each use).
5-6.4kg 6 125mL
• From 6 months old, introduce solids to stir, cool to body temperature. • Cover containers with water in pot and
6.5-6.9kg 6 150mL
81. 7-7.9kg 6 175mL
• Make enough formula for one feed at a time. boil for at least 10 minutes.
• Continue with formula until 12 • Feed using cup as safer (cleaner) than bottle feeding. • Keep pot covered until containers
months old, then give pasteurised full 8-8.9kg 6 200mL • Discard formula leftover milk within two hours. needed.
cream milk. ≥ 9kg 4 250mL

• Review baby with newly diagnosed feeding problem in 2 days, thereafter review every 5 days until feeding problem corrected. If baby < 3 months old, consider feasibility of re-establishing breastfeeding.
• If young infant has lost weight or feeding problem unlikely to be corrected, refer.
1
Nutrition Therapeutic Programme. 2Mid Upper Arm Circumference.
80
Eating
Assess eating: ask carer to recall what child has eaten in the last 24 hours.
Assess When to assess Note
Routine care Every visit Integrate routine care of the child into every visit 5. If any other symptoms, manage as on symptom page.
Solids If 6-12 months old If solids have been started too early (< 6 months old) or have not started after 6 months old, there is a feeding problem.
Variety of food Every visit • If not introducing baby (6-12 months old) to variety of foods, there is a feeding problem: soft porridge, mashed vegetables, fruit, and protein-rich foods (mashed dried beans,
cooked egg, minced meat, fish, chicken or chicken livers).
• If not giving the child ≥ 12 months old, protein2 at least once/day and fresh fruit or vegetables twice/day, there is a feeding problem.
• If child not eating healthy family meals because of unhealthy snacking (sweets/chips/chocolates), there is a feeding problem.
Quantity of food Every visit If not getting at least half a cup (125mL) by 12 months old, there is a feeding problem.
Frequency of food Every visit • If 6-8 months old and getting fewer than 2 meals/day or not getting breast/formula milk as well as meals, there is a feeding problem.
• If 8-12 months old and not getting increasing number of meals so that by 12 months old they are getting 5 meals/day, there is a feeding problem.
• If ≥ 12 months old and getting less than 5 small meals/day (3 family meals/day and 2 nutritious snacks like bread with peanut butter, fruit, yoghurt), there is a feeding problem.
Fluids Every visit If drinking lots of juice, tea or sugary drinks, there is a feeding problem.
Social Every visit Ask who looks after child/feeds child most of time. If concerns about poor parental care, refer social worker/community health worker.
Mouth/teeth Every visit • If ulcers or white patches in mouth (inside of cheeks/lips and on tongue) 38.
• If sore throat or difficulty swallowing 38.
• If dental caries 40.
Growth Every visit Measure and record weight-for-age, length/height-for-age, weight-for-length/height (or BMI), MUAC1 5

Advise the carer on eating according to child’s age

6-12 months old 1-2 years old 2-5 years old ≥ 5 years old
When to start solids: • Breastfeed as often as child wants. • Give child his/her own What to eat:
• Start solids at 6 months old. • If no longer breastfeeding, give 2 cups full cream milk serving (1 cup) of family • Eat a variety of food.
• Continue breastfeeding/formula feeding (offer baby soft or maas every day (avoid too much milk as may reduce foods 3 times/day. • Eat plenty of fruit and vegetables every day.
foods then offer breastmilk/formula). appetite for food). • Also give 2 nutritious • Make starch part of most meals.
What to feed: How much and how often: snacks (bread with • Eat protein2 regularly.
• Introduce new food every 2-3 days in order: soft porridge/ Give 3 meals/day: ¾ to full cup per meal. Also give 2 peanut butter, fruit, • Have milk, maas or yoghurt every day.
cereal, mashed/pureed vegetables, fruit, protein2. nutritious snacks (bread with peanut butter, fruit, yoghurt). yoghurt). • Use fats (butter, margarine), sugar and salt
• Give clean safe water regularly. Avoid juice/tea/sugary sparingly.
drinks. • Avoid sweetened drinks.
What to feed:
How much and how often: • Give protein2 at least once a day. How much:
• Gradually increase amount and frequency of feeds: • Give fresh fruit/vegetables twice a day. • Eat 3 meals/day and 2 nutritious snacks
• 6-8 months old: give 2 meals/day plus breast/formula • Give foods rich in iron3, vitamin A4 and C5. (fruit, yoghurt).
milk. Start with 2-3 tablespoons per meal and slowly • Do not add salt or sugar to food. • Stop eating when full.
increase to half a cup. • Avoid sugary/fizzy drinks, give water instead. How often:
• 9-12 months old: increase to 3 meals/day. Give half a How to feed: • Do not skip meals, especially breakfast.
cup per meal. Also give 2 nutritious snacks (fruit, yoghurt) Actively feed child and encourage him/her to eat on their own. • Do not snack on food high in fat, sugar
between meals. and salt.
1
Mid Upper Arm Circumference. 2Protein-rich foods: chicken, fish, cooked eggs, beans, dahl, soya, peanut butter. 3Iron-rich foods: liver, kidney, dark green leafy vegetables like spinach, cooked egg, beans, peas, lentils, fortified cereals. 4Vitamin A-rich
foods: vegetable oil, liver, yellow sweet potatoes, dark green leafy vegetables like spinach (imifino), mango, pawpaw, full cream milk. 5Vitamin C-rich foods: oranges, naartjies, melons, tomatoes.
81
 If eating/weight problem, advise about correct eating habits
Help carer correct eating habits and weight problems:

If not growing well If poor appetite or fussy eater

• Offer meals when child alert and happy. Give more food if child shows interest. • Avoid unhealthy snacks If child has mouth ulcers/
• Use correct spoon size, put food within reach of child, (chips, sweets, sores, offer soft foods that
actively feed child, try sitting child on lap while eating. chocolates) in don’t burn mouth like eggs,
• If blocked nose, clear with sodium chloride 0.9% solution between meals. mashed potatoes, pumpkin
1 drop into each nostril. • Avoid juice/tea/ or avocado
sugary drinks
- these make
• Use varied, the child feel
favourite foods. full.
• Give foods • Avoid giving
• Add a teaspoon of margarine, vegetable oil of suitable too much
or peanut butter (or Imunut®) to porridge. consistency. formula/milk
• Increase frequency of feeds to at least 5 • Offer small as this may also
meals per day. frequent feeds. reduce appetite.

If overweight or obese
Help to lose weight: invite child/carer to address 1 lifestyle risk factor or dietary change at a time and build on these:
• Plan how to fit change into child’s day. Explore what might hinder or support this. Together set reasonable target/s for next visit.
• Emphasise that support from the parents is very important for success. Encourage parents to improve their own lifestyle choices, diet and weight.
• Emphasise that weight management is a lifelong process and not a brief period of change.
Eat a healthy balanced diet: Be active!

• Do not snack on chips, sweets, Limit screen time to

chocolates, fizzy drinks in < 2 hours per day:
between meals. • This includes TV,
• If hungry between meals, movies, video
snack on fruit, nuts or yoghurt games, phones,
(unsweetened). internet and
• Eat more fruit and vegetables. social media like
Reduce portion sizes - eat less.
Facebook.
• Encourage child
to go outside and
play or join a team
• Avoid
sport. Encourage whole family to get active:
sugar and
• Take the stairs • This is moderate intensity activity
fat (fried
instead of (brisk walking, dancing, housework,
food).
elevators or lifts. gardening) for at least 30 minutes/
• Avoid fast
• If safe, walk or ride day for adult and 60 minutes/day for
foods.
to school instead child. This can be accumulated in 10
Eat meals together as a family. Do not watch TV when eating. of taking transport. minutes sessions.

If eating/weight problem, review 1-2 monthly until eating habits have been corrected.

82
Poor growth in the child < 2 months old
The baby with any of the following has poor growth:
• > 10% loss of birth weight1 in first week of life • Weight gain unsatisfactory (growth curve flattening or crossing z-score lines)
• Weight below birth weight after 10 days of age • Any weight loss if birth weight < 2.5kg

Give urgent attention to the baby with poor growth with any of:
• Lethargic or decreased level of consciousness • Difficulty breathing: respiratory rate > 60, grunting,
• Vomiting everything nasal flaring or chest indrawing
• Unable to feed/drink • Apnoea (episodes of no breathing > 10 seconds)
• Temperature < 35.5°C or ≥ 37.5°C • Diarrhoea (> 3 watery stools/ 24 hours)
• Bulging fontanelle • Glucose < 3.0mmol/L
• Reduced movements • Tiring/sweating during feeds
Manage and refer urgently:
• If difficulty breathing, give oxygen 1L/minute via nasal prongs.
• Manage and assess child's fluid needs 20.
• Treat glucose < 3.0mmol/L 24.
• Prevent low glucose: if alert, encourage breastfeeding or give formula/F-75/sugar water2 3mL/kg/hour orally (use NGT if baby refusing). Feed at least 2 hourly until transfer.
• Treat for infection: give ceftriaxone 50-80mg/kg as a single dose (table 6 123).
• Keep baby warm: place baby skin to skin with mother or clothe warmly including head and feet and cover with blanket.

Approach to the baby with poor growth not needing urgent attention:
• If baby < 2.5kg, refer/discuss with dietician same day.
• Check for feeding problem: if breastfeeding 78, if formula feeding 80. Screen for psychosocial, mother-baby bonding and/or mental health problem/s 4.

Manage further according to age and presence of feeding problem:

Baby < 2 weeks old or feeding problem Baby ≥ 2 weeks old and no feeding problem

Review in 2 days Review in 7 days

Check if urgent attention needed (above). If urgent attention not needed, check weight and feeding: • If baby gaining weight, review again at next immunisation visit.
• If baby gaining weight and feeding problem corrected, review again in 2 weeks. • If baby not gaining weight, review again in 2 weeks.
• If baby not gaining weight or feeding problem persists, give feeding advice again and review again in 5 days. • If baby has lost weight since last visit, refer next level of care.
If still not gaining weight, refer next level of care.
• If baby has lost weight since last visit, refer next level of care.

If weight gain unsatisfactory or feeding problem persists on follow up, refer.

1
Birth weight (kg) ÷ 10 = 10% of birth weight: if weight loss in first week of life more than this, baby has poor growth. 2Dissolve 3 teaspoons of sugar (15g) into 200mL water.
83
The underweight child
This refers to a child with weight-for-age (WFA) below -2 line. If not already done, check length/height-for-age and plot child's measurements on the weight-for-length/height chart. Also measure MUAC3.

Approach to the underweight child

Does child have any of: wasting (WFL/H1 below -2 line), BMI2 below -2 line or MUAC3 < 12.5cm

Yes: does child have oedema of both feet? No

Yes No: does child have any of: severe wasting (WFL/H1 below -3 line), BMI2 below -3 line or MUAC3 < 11.5cm • If HFA4 below -2
Severe acute line 87.
malnutrition Yes: Severe Acute Malnutrition (SAM) likely No • If HFA4 on or
likely above the -2
line 85.
Does child have any of: Moderate Acute
• < 6 months old • Temperature < 35.5°C or ≥ 38°C • Diarrhoea (> 3 watery stools/ 24 hours) Malnutrition likely
• Weight ≤ 4kg • Glucose < 3mmol/L • Weeping skin lesions • If < 6 months old: check for
• Vomiting everything • Hb < 10g/dL • Lethargic or decreased level of consciousness feeding problem 78 (if
• Unable to feed/drink • Fast breathing ( 129) • Tiring/sweating during feeds formula feeding 80).
--If feeding problem, refer
Yes No: Severe Acute Malnutrition (SAM) without medical complications. Do appetite test (see below). (level 1 hospital).
--If no feeding problem 86.
• If ≥ 6 months old, do
Fail appetite test (see below).

Manage as Severe Acute Malnutrition (SAM) with medical complications: Pass Fail
• If fast breathing: give oxygen 2L/min via nasal prongs. Is outpatient care available, home
• Manage and assess child's fluid needs 20. circumstances reliable and carer willing?
• If glucose < 3mmol/L 24.
• Feed at least 2 hourly until transfer. If refusing, give formula/F-75/sugar water5 via NGT.
• Treat infection: give ceftriaxone 50-80mg/kg as a single dose (table 6 123). Yes No
• Give vitamin A as a single dose: if < 6 months old: 50 000IU, if 6-12 months old: 100 000IU, if ≥ 1 year old: 200 000IU.
• Keep warm: place child skin to skin with mother and cover with blanket. Give routine acute Refer same day for
• Refer urgently (level 2 or 3 hospital). malnutrition care inpatient care
86. (level 1 hospital).

Minimum amount to be given to child

How to do an appetite test Body weight
(kg)
Option 1: RUTF
Imunut® Sachet (92g)
Option 2: F75® Option 3:
10% Dextrose
4-6.9 23g 70mL 80mL
• The child must be ≥ 6 months old: give Ready-to-use-Therapeutic-Food (RUTF) according to weight (see table).
• Test may take up to one hour. Do not force child to eat. Offer child plenty of water to drink. 7-9.9 30g 100mL 150mL
• If child finishes minimum amount feed, he/she passes the appetite test. 10-14 45g 150mL 175mL
• If child does not finish minimum amount of feed: he/she fails the appetite test. 15 -9 70g 200mL 200mL
≥ 30 92g 250mL 250mL
1
Weight-for-length-/height. 2Body mass index in a child ≥ 5 years old. 3Mid Upper Arm Circumference. 4Height-for-age. 5Dissolve 3 teaspoons of sugar (15g) into 200mL water.
84

NUTRITION
Not growing well/growth faltering: routine care
This child has an abnormal growth curve pattern (flattening, falling or crossing z-score lines on 2 consecutive visits) or MUAC1 12.5 - 13.5cm.

Assess the child who is not growing well

Assess When to assess Note
Routine care Every visit Integrate routine care into each visit 5. If other long-term health conditions, ensure adequately treated.
Symptoms Every visit Manage symptoms as on symptom page. Ask specifically about diarrhoea 48, vomiting/refluxing 47, tired/lethargic 33.
Feeding Every visit Ask carer to recall what child has eaten in the last 24 hours and check for feeding problem: if breastfeeding 78, if formula feeding 80, if eating solids 81.
TB risk Every visit Exclude TB at diagnosis and if TB symptoms (cough or fever ≥ 2 weeks, not growing well/losing weight, tiredness/reduced playfulness) or close TB contact 90.
Carer Every visit Check HIV status, contraceptive needs, TB symptoms and mental health (including substance abuse) 5.
Social At diagnosis • If yes to both of the following 77: 1) Are you struggling with or feeling overwhelmed by parenting? 2) Would you like help with this?
• Ask who looks after child most of the time. If concerns about intentional neglect 70. Screen for psychosocial and/or mental health problem/s  5.
Oedema Every visit If child develops swelling of feet, hands or face, refer.
Weight-for-age At diagnosis and every visit • If child has lost weight or has not gained weight for 2 consecutive visits, refer.
• If child does not have an upwards growth curve by 3 months on Nutrition Therapeutic Programme (NTP), refer to dietician.
• If child does not reach weight curve appropriate for birth weight by 6 months on the NTP, refer to dietician.
Mouth/teeth At diagnosis If white patches in mouth (inside of cheeks/lips and on tongue), treat for likely oral thrush/candida 38.If dental caries 40.
Hb At diagnosis If Hb < 10g/dL in child < 5 years old or Hb < 11g/dL in child ≥ 5 years old 89. If Hb < 7g/dL, refer.
HIV At diagnosis Test for HIV 98. If HIV positive, give routine HIV care 99.

Advise the carer of the child who is not growing well

• Refer to social worker and link with local NGOs (like Philani) 128. If Child Support Grant needed, advise to take child’s birth certificate and carer’s ID to SASSA3 to apply or link with information line 128.
• For breastfeeding advice 78, for formula feeding advice 80, for healthy eating advice 81. Give general hygiene advice 5.
• Refer for community health worker support and physiotherapy/occupational therapy for rehabilitation and physical and emotional stimulation.

Treat the child who is not growing well

• Check that routine vitamin A, mebendazole (de-worming) and immunisations have been given 5.
• Refer to Nutrition Therapeutic Programme (NTP): ensure a weekly supply of correct product and amount: 0-6 months old: infant formula, 6-12 months old: infant formula plus infant cereal, ≥ 12 months old:
enriched porridge plus energy drink.

• If feeding problem, review in 5 days.

• Review every 2 weeks until growing well: WFA2 on or above -2 line with an upwards growth curve and WFL/H4 on or above -2 line.
• Then review monthly until weight remains on growth curve appropriate for birth weight for > 3 months.

Advise carer to return immediately if condition worsens at any point (unable to drink/feed, vomiting everything, fever, profuse watery diarrhoea, lethargic).

1
Mid upper arm circumference. 2 Weight-for age. 3South Africa Social Security Agency. 4Weight-for-length/height.
85
Acute malnutrition: routine care
• Check if the child with acute malnutrition needs urgent management and referral  84.
• Give routine nutrition care as below only once child referred back to primary care for catch up growth or if child with moderate acute malnutrition is stable and able to be managed as outpatient.
• Refer to dietician for initial assessment and again after 1 month. Give routine care in meantime:

Assess the child with acute malnutrition

Assess When to assess Note
Routine care Every visit Integrate routine care into each visit 5. If other long-term health conditions, ensure are adequately treated.
Symptoms Every visit Manage symptoms as on symptom page. Ask specifically about diarrhoea 48, vomiting/refluxing 47.
Feeding At diagnosis Check for feeding problem: if breastfeeding 78, if formula feeding 80, if eating solids 81.
TB risk Every visit Exclude TB at diagnosis and if TB symptoms (cough or fever ≥ 2 weeks, not growing well/losing weight, tiredness/reduced playfulness) or close TB contact 90.
Carer Every visit Check HIV status, contraceptive needs, TB symptoms and mental health (including substance abuse) 5.
Social At diagnosis • If yes to both of the following 77: 1) Are you struggling with or feeling overwhelmed by parenting? 2) Would you like help with this?
• Ask who looks after child most of the time. If concerns about intentional neglect 70. Screen for psychosocial and/or mental health problem/s 5.
Oedema Every visit If child develops swelling of feet, hands or face, refer.
Weight-for-age Every visit • If weight loss > 5%4 at any visit or child has lost weight on 2 consecutive visits, refer.
• If no weight gain for 3 consecutive visits, refer.
• After 2 months on Nutrition Therapeutic Programme (NTP): if WFA5 still below -2 line, discuss/refer with doctor/paediatrician.
Weight-for-length/height Monthly If WFL/H1 still below -2 line after 2 months on Nutrition Therapeutic Programme (NTP), refer.
MUAC3 Monthly If MUAC3 still < 12.5cm after 2 months on Nutrition Therapeutic Programme (NTP), refer.
Mouth/teeth At diagnosis If white patches in mouth (inside of cheeks/lips and on tongue), treat for likely oral thrush/candida 38.If dental caries 40.
Hb At diagnosis If Hb < 10g/dL in child < 5 years old or Hb < 11g/dL in child ≥ 5 years old 89. If Hb < 7g/dL, refer.
HIV At diagnosis Test for HIV 98. If HIV positive, give routine HIV care 99.

Advise the carer of child with acute malnutrition

• Refer to social worker and link with local NGOs (like Philani) 128. If Child Support Grant needed, advise to take child’s birth certificate and carer’s ID to SASSA6 to apply.
• For breastfeeding advice 78, for formula feeding advice 80, for healthy eating advice 81. Give general hygiene advice 5.
• Refer for community health worker support and physiotherapy/occupational therapy for rehabilitation and physical and emotional stimulation.

Treat the child with acute malnutrition

• Check child has received additional dose of vitamin A during this illness and that routine mebendazole (de-worming) and immunizations are up to date 5.
• If SAM (without medical complications), also give amoxicillin7 30mg/kg 8 hourly for 5 days at diagnosis.
• Refer to Nutrition Therapeutic Programme (NTP): ensure a weekly supply of correct product and amount: 0-6 months old: infant formula, 6-12 months old: infant formula plus infant cereal, ≥ 12 months old:
enriched porridge plus energy drink.

• Review weekly until stable (gaining weight at 3 consecutive visits). Then review every 2 weeks until growing well8.
• Once child growing well7 review monthly and continue on NTP until weight remains on growth curve appropriate for birth weight for > 3 months.

Advise carer to return immediately if condition worsens (unable to drink/feed, vomiting everything, fever, profuse watery diarrhoea, lethargic).
1
Weight-for-length/height. Body Mass Index. 3Mid Upper Arm Circumference. 4To calculate % weight loss: (weight lost ÷ weight at last visit) x 100. 5Weight-for-age. 6South Africa Social Security Agency. 7If penicillin allergy (previous bronchospasm and/
2

or severe rash), give azithromycin 10mg/kg once a day for 3 days instead (table 5 N122). 8Growing well: WFA on or above -2 line, upwards growth curve, WFL/H on or above -2 line and MUAC ≥ 12.5cm.
86
Chronic malnutrition: routine care
• The child with chronic malnutrition is stunted (L/HFA2 below the -2 line) and may or may not be underweight (WFA1 below -2 line). If child's parents are both very short or child is overweight, refer to
doctor for assessment.
• Refer to dietician for initial assessment. Give routine care in meantime:

Assess the child with chronic malnutrition

Assess When to assess Note
Routine care Every visit • Integrate routine care into each visit 5. If other long-term health conditions, ensure are adequately treated.
• If abnormal facial features, refer to doctor.
Symptoms Every visit Manage symptoms as on symptom page. Ask specifically about diarrhoea (especially if recurrent or chronic 48.
Feeding At diagnosis Check for feeding problem: if breastfeeding 78, if formula feeding 80, if eating solids 81.
TB risk Every visit Exclude TB at diagnosis and if TB symptoms (cough or fever ≥ 2 weeks, not growing well/losing weight, tiredness/reduced playfulness) or close TB contact 90.
Carer Every visit Check HIV status, contraceptive needs, TB symptoms and mental health (including substance abuse) 5.
Social At diagnosis • If yes to both of the following 77: 1) Are you struggling with or feeling overwhelmed by parenting? 2) Would you like help with this?
• Ask who looks after child most of the time. If concerns about intentional neglect 70. Screen for psychosocial and/or mental health problem/s 5.
Oedema Every visit If child develops swelling of feet, hands or face, refer.
Weight-for-age Every visit • If child has lost weight on 2 consecutive visits, refer to dietician.
• If child does not gain weight on 3 consecutive visits, refer to dietician.
Weight-for-length/height Monthly If no increase in WFL/H3 after 2 months on Nutrition Therapeutic Programme (NTP), refer to dietician.
Teeth At diagnosis If dental caries 40.
Hb At diagnosis If Hb < 10g/dL in child < 5 years old or Hb < 11g/dL in child ≥ 5 years old 89. If Hb < 7g/dL, refer.
HIV At diagnosis Test for HIV 98. If HIV positive, give routine HIV care 99.

Advise the carer of child with chronic malnutrition

• Refer to social worker and link with local NGOs (like Philani) 128. If Child Support Grant needed, advise to take child’s birth certificate and carer’s ID to SASSA4 to apply.
• Give hygiene advice: wash hands with soap and water regularly, especially when handling food/after using toilet. Wash fruit/vegetables and use boiled water if no access to clean water.
• For breastfeeding advice 78, for formula feeding advice 80, for healthy eating advice 81.
• Refer for community health worker support and physiotherapy/occupational therapy for rehabilitation and physical and emotional stimulation.

Treat the child with chronic malnutrition

• Check that routine vitamin A, mebendazole (de-worming) and immunizations have been given 5.
• If < 2 years old, refer to Nutrition Therapeutic Programme (NTP): ensure child weekly supply of correct product and amount: 0-6 months old: infant formula, 6-12 months old: infant formula plus infant
cereal, ≥ 12 months old: enriched porridge plus energy drink.

• If child < 2 years old: review 2 weekly until gaining weight on 3 consecutive visits. Then review monthly until growing well5.
• If child ≥ 2 years old: review 1-2 monthly until feeding/eating problem corrected.

1
Weight-for-age. 2Length/height-for-age. 3Weight-for-length/height. 4South Africa Social Security Agency. 5Growing well: WFA on or above -2 line, upwards growth curve, WFL/H on or above -2 line.
87
Overweight: routine care
• The overweight child has ≥ 1 of: WFL/H1 on or above +2 line, BMI2 on or above +1 line, MUAC3 > 21.5cm.
• The obese child has ≥ 1 of: WFL/H1 on or above +3 line, BMI2 on or above +2 line.
• Refer to dietician for initial assessment and healthy meal plan. Give routine care in meantime:

Assess the overweight child

Assess When to assess Note
Routine care Every visit Integrate routine care into each visit 5. If abnormal facial features, refer to doctor.
Symptoms Every visit Manage symptoms as on symptom page. Ask about hip/leg pain 55 or back pain 53.
Medications At diagnosis If on long term medications (steroids, anticonvulsants, antidepressants), discuss with doctor.
Diet Every visit Ask about diet and eating habits 82.
Activity Every visit If < 1 hour/day moderate intensity activity (brisk walking, dancing, housework, gardening) or > 2 hours/day screen time (TV, phone) 82.
Sleep At diagnosis If poor sleep with persistent snoring or breathing problems (apnoea4, gasping) at night 37.
Mental health Every visit If change in mood or feelings that has impacted on his/her usual function over the past month 71.
School problems At diagnosis If poor attendance, bullying, learning problems, difficulty interacting with other children, 75.
Carer At diagnosis If yes to both of the following 77: 1) Are you struggling with or feeling overwhelmed by parenting? 2) Would you like help with this?
Weight-for-age Every visit • If < 7 years old and no complications of being overweight, aim to keep weight same as child grows.
• If ≥ 7 years old or complications (glucose, liver or musculoskeletal problems), aim for a weight loss of 0.5kg/month.
Length/height-for-age Every 6 months If L/HFA5 below -2 line, refer to paediatrician same month.
Weight-for-length/height If < 5 years old: 3 monthly Aim to keep weight same as child grows until WFL/H1 eventually below +2 line. If < 2 years old and WFL/H1 on or above +3 line, refer to paediatrician.
BMI If ≥ 5 years old: 3 monthly BMI is weight (kg) ÷ height (m) ÷ height (m). Aim to keep weight same as child grows until BMI eventually below +1 line.
Teeth At diagnosis If dental caries 40.
Total cholesterol At diagnosis, 2 yearly If ≥ 5.2 mmol/L, refer for fasting lipid profile. If ≥ 4.4 mmol/L, repeat total cholesterol in 6 months after supportive measures to lose weight and improve diet.
Glucose If obese: at diagnosis, 2 yearly • If able, check fasting glucose after an 8-hour overnight fast. If not, check random glucose 24.
--If fasting glucose < 7mmol/L, reassure. If > 7mmol/L, diabetes likely, refer.
• Refer for oral Glucose Tolerance test (oGTT) if ≥ 1 of: BMI2 above +3 line (morbid obesity), family history of type 2 diabetes, dark discoloration of skin folds
and creases, symptoms of diabetes (thirst, urinary frequency).
ALT If obese: at diagnosis, 2 yearly If ALT > 100, refer.
Thyroid function At diagnosis Check TSH if any of: dry skin, brittle hair, constipation, facial puffiness, intolerant to cold, or thyroid enlargement. Refer to doctor if result abnormal.
Hb If pallor If Hb < 10g/dL in child < 5 years old or Hb < 11g/dL in child ≥ 5 years old 89. If Hb < 7g/dL, refer.

Advise the overweight child and/or carer

• Alert carer to increased risks associated with obesity in a child:
--Joint (hip, knee and back) and medical problems (hypertension, type 2 diabetes, cholesterol problems, heart attack, stroke, liver disease, heartburn, breathing problems).
--School and social problems (bullying, teasing, anxiety, depression, poor self-esteem, isolation, relationship problems).
• Encourage a balanced healthy diet and daily exercise 82. Encourage parents/carers and siblings to change to healthy lifestyle as well.

Review every 4 months.

1
Weight-for-length/height. Body Mass Index. Mid Upper Arm Circumference. History of episodes of no breathing > 10 seconds.5 Length/height-for-age.
2 3 4

88
Anaemia: diagnosis and routine care
The child with anaemia has a low Hb, < 10g/dL in child < 5 years old or Hb < 11g/dL in child ≥ 5 years old. If pale conjunctiva and/ or palms, check Hb.

Give urgent attention to the child with a low Hb and/or pallor and one or more of the following:
• Hb < 7g/dL • Bone or joint pain • Increased respiratory rate (129)
• Baby < 6 months old • Palpitations or chest pain • Widespread/easy bruising
• Jaundice • Lethargic or decreased level of consciousness • Petechiae (a small red or purple spots on skin)
• Swollen legs • Increased pulse rate ( 129), when not crying • Recent travel to a malaria area: malaria likely
Manage and refer urgently:
• If increased respiratory rate ( 129), give oxygen 2L/minute via nasal prongs.

Assess the child with anaemia

Assess When to assess Note
Routine care Every visit Integrate routine care into each visit 5. Pay particular attention to the growth assessment and developmental screen
FBC If ≥ 5 years old: at diagnosis • If < 5 years old, manage as for iron deficiency anaemia below.
(MCV1 result) • If MCV1 low: iron deficiency anaemia likely: refer as iron deficiency anaemia in child ≥ 5 years old often due to blood loss.
• If MCV1 normal: systemic disease or long-term health condition likely: exclude TB 92 and HIV 98.
• If MCV1 high: folate and/or vitamin B12 deficiency likely: refer same week.
Hb At diagnosis, 2 weeks, 1 month then monthly until Hb normal • If Hb improving, continue treatment for 3 months after Hb ≥ 10g/dL in child < 5 years old and ≥ 11g/dL in child ≥ 5 years old.
• If Hb drops or does not improve after 1 month of treatment, refer.

Advise the carer of child with likely iron deficiency anaemia

• Give foods rich in iron (liver, kidney, dark green leafy vegetables like spinach, egg yolk, beans, peas, lentils, fortified cereals).
• Give food rich in vitamin C as this helps with iron absorption (oranges, naartjies, melons, tomatoes). Avoid drinking tea/coffee with meals as this interferes with iron absorption.
• Treatment with iron can make child’s stools look black. Iron can be extremely dangerous if child overdoses - keep out of reach of child.

Treat the child with anaemia

If iron deficiency anaemia likely (low MCV1 or child < 5 years old):
• Deworm: from 12 months old, give mebendazole 6 monthly: if 12-24 months old: give 100mg 12 hourly for 3 days, if ≥ 24 months old: give 500mg as a single dose.
• Give ferrous gluconate or ferrous lactate or ferrous sulphate 8 hourly with food. Continue treatment for 3 months after Hb ≥ 10g/dL in child < 5 years old and ≥ 11g/dL in child ≥ 5 years old:
Weight (kg) Ferrous Gluconate elixir (40mg elemental iron per 5mL) Ferrous Lactate drops (25mg elemental iron per mL) Ferrous Sulphate tablets (60mg elemental iron per tablet)
3-5.9kg 1.25mL 8 hourly 0.3mL 8 hourly
6-9.9kg 2.5mL 8 hourly 0.6mL 8 hourly
10-24.9kg 5mL 8 hourly 0.9mL 8 hourly ½ tablet 8 hourly
If megaloblastic anaemia (high MCV ) and child is returning to clinic after hospital workup, continue treatment according to underlying deficiency:
1

• If folic acid deficiency: give folic acid 5mg once daily until haemoglobin returns to normal (≥ 10g/dL if < 5 years old and ≥ 11g/dL if ≥ 5 years old).
• Vitamin B12 deficiency: give vitamin B12 500mcg IM monthly until haemoglobin returns to normal (≥ 10g/dL if < 5 years old and ≥ 11g/dL if ≥ 5 years old).

Review in 2 weeks: if Hb drops, refer. If Hb the same or higher, continue treatment and review at 1 month and monthly thereafter.
1
MCV: Mean Corpuscular Volume. The MCV helps to decide the underlying cause of anaemia and can be found on FBC result sheet. Check if MCV value high, low or normal compared to the reference range for age of child.
89
The child with close TB contact
• A close TB contact is a household contact or regular contact with someone outside of household with TB (ideally confirmed with Isoniazid preventive therapy (IPT)
GeneXpert, smear or culture) in the past 12 months. Advise carer to crush tablets and dissolve in
• If newborn baby: water if needed.
--If mother/close contact on treatment for < 2 months before delivery, refer/discuss with doctor/paediatrician. Weight (kg) INH 100mg tablet INH 100mg in 8mL
--If mother on TB treatment for ≥ 2 months, give preventive therapy for TB (delay BCG vaccine until preventive therapy complete).
< 3kg Expert advice recommended
3-4kg ½ tablet 4mL
Decide if preventive therapy is needed in the child with a close TB contact 4-5kg ½ tablet 4mL
• Ask about other children living in household and advise that all children visit the clinic for screening.
• Does child have current symptoms of TB (cough, wheeze, fever, tiredness, reduced playfulness, weight loss, 5-6kg ¾ tablet 6mL
not growing well, lump/s in neck/axilla/groin)? 6-7kg ¾ tablet 6mL
7-8kg 1 tablet 8mL
Yes No 8-9kg 1 tablet 8mL
9-10kg 1 tablet 8mL
Check for Is child < 5 years old or HIV positive?
TB 92 . 10-11kg 1 ¼ tablet 10mL
11-12kg 1 ¼ tablet 10mL
Yes No
12-13kg 1 ½ tablet 12mL
Manage according to susceptibility results of TB contact (source client): Preventive 13-14kg 1 ½ tablet 12mL
therapy is 14-15kg 1 ¾ tablet 14mL
not needed.
Drug sensitive TB or INH mono-resistant Rifampicin 15-16kg 1 ¾ tablet 14mL
Advise to
unknown TB resistant TB 16-17kg 2 tablet 16mL
return if any
(including RR-TB,
symptoms 20-25kg 2 ½ tablet 20mL
MDR-TB, pre-XDR
• Give child isoniazid • If available, give develop.
TB, XDR-TB) 25-30kg 3 tablet 24mL
preventive therapy child rifampicin
(IPT) once daily for syrup 15mg/kg for
6 months according 4 months. • Arrange a chest RH prophylaxis for the child with an INH mono-
to weight (see table). • If rifampicin syrup X-Ray and resistant contact
• If susceptibility unavailable, give doctor review.
Weight (kg) RH 60/60 tablet
results of TB contact child rifampicin/ • If HIV unknown
(source patient) isoniazid (RH) for or tested < 3kg Expert advice recommended
unknown, follow up 4 months according negative, re/test 3-4kg ¾ tablet
results. to weight (see table). 98.
• Doctor to give 4-6kg 1 tablet
prophylaxis 6-8kg 1½ tablets
Review the child on preventive therapy monthly
according to 8-12kg 2 tablets
• If medication side effects, manage further 97.
source drug
• Record weight and adjust dose if needed (see table). If 12-15kg 3 tablets
susceptibility
not growing well or losing weight, refer to doctor.
patterns 91. 15-20kg 3½ tablets
• If any TB symptoms develop, refer to doctor.
20-25kg 4½ tablets
25-30kg 5 tablets

90

TB
Drug-resistant (DR) TB contacts
• A close DR-TB contact is a household contact or regular contact with someone outside of household with DR-TB (confirmed with GeneXpert or culture) in the past 12 months.
• The asymptomatic child < 5 years old or the child with HIV (regardless of age) needs DR-TB prophylaxis.

Doctor to review the child needing DR-TB prophylaxis

• Do clinical examination and baseline chest X-ray: if any symptoms/signs of TB or changes on chest X-Ray, avoid giving prophylaxis and refer to DR-TB specialist clinic.
• Determine prophylaxis according to drug-susceptibility results of source patient (DR-TB contact):

Rifampicin resistant

INH sensitive INH susceptibility unknown INH resistant

Give normal dose INH once daily Sensitive to ofloxacin and amikacin (MDR-TB) Resistant to ofloxacin
for 6 months according to weight and/or amikacin (Pre-XDR
(see table below). Give levofloxacin, high dose INH and ethambutol once daily for 6 months according to weight (see table below). or XDR-TB)

Review monthly Refer to DR-TB specialist

• If medication side effects, refer/discuss with MDR-TB specialist. • Refer if TB symptoms develop or not growing well/weight loss clinic for assessment .

Doctor to review at month 2, 4, 6, 9 and 12.

DR-TB prophylaxis
Prophylactic medication Normal dose INH Levofloxacin High dose INH Ethambutol
Weight (kg) 100mg tab 100mg in 8mL 250mg tab 250mg in 8mL 100mg tab 100mg in 8mL 400mg tab 400mg in 8mL
3-4kg ½ 4 ¼ 2 ½ 4 - 1.5
4-5kg ½ 4 ¼ 2 ½ 4 - 2
5-6kg ¾ 6 ½ 4 1 8 - 2
6-7kg ¾ 6 ½ 4 1 8 - 3
7-8kg 1 8 ½ 4 1½ 12 - 3
8-9kg 1 8 ¾ 6 1½ 12 ½ 4
9-10kg 1 8 ¾ 6 1½ 12 ½ 4
10-11kg 1¼ 10 ¾ 6 2 16 ½ 4
11-12kg 1¼ 10 1 8 2 16 ½ 4
12-13kg 1½ 12 1 8 2½ 20 ¾ 6
13-14kg 1½ 12 1 8 2½ 20 ¾ 6
14-15kg 1¾ 14 1 8 2½ 20 ¾ 6
15-16kg 1¾ 14 1 8 2½ 20 ¾ 6
16-20kg 2 16 1½ 12 3 24 1 8
20-25kg 2½ 20 1½ 12 4 32 1 8
25-30kg 3 24 2 16 4 32 1½ 12

91
Check for TB
If close TB contact1 in past 12 months 91.

Give urgent attention to the child with suspected TB and one or more of:
• Difficulty breathing: increased respiratory rate (129 ), • Fitting 22 • Neck stiffness • Focal signs (like weakness of arm/leg)
grunting, nasal flaring or chest indrawing • Altered mental state • Vomiting without diarrhoea • Abnormal curvature of spine
• Unable to drink/feed • Headache • Distended/swollen abdomen
Manage and refer urgently:
• Give oxygen 2L/minute via nasal prongs.
• Give ceftriaxone 50-80mg/kg as a single dose.
• If difficulty breathing in infant < 1 year old and HIV positive or unknown, also give co-trimoxazole (200/40mg per 5mL) 0.25mL/kg orally.

Approach to the child with possible TB not needing urgent attention:

Has child had 1 or more of the following for ≥ 2 weeks:
• Persistent, non-remitting cough or wheeze • Persistent fever
• Tiredness/reduced playfulness • Visible lump/s in neck/axilla/groin
• Not growing well/growth faltering/losing weight

No: Does child have a close TB contact1? Yes

No Yes
• Manage symptoms: cough/wheeze 41, not growing well 85, fever 31, tiredness 33, lump/s in neck/axilla/groin 34.
• Review in 1 week:

Symptoms Symptoms worse or persistent

resolved
Arrange a chest X-Ray2 and doctor review. If X-Ray unavailable 93.
Reassure and • Compare previous X-rays, use light box to view X-rays and ensure patient identity correct.
advise to return if • Assess X-ray quality (rotation/penetration/inspiration): check distance from anterior rib ends to chest wall equidistant, intervertebral spaces visible through heart shadow and 8th
symptoms recur. posterior or 6th anterior rib visible.
• Look especially at: trachea/bronchi for narrowing/displacement; size and position of hilum; right and left lung sizes/vascularity/shape; position/size/shape of heart; costo-phrenic angles.

AP/PA Hilar Lobar consolidation/ Cavitation (more likely

Lateral Pleural effusion Miliary TB Pericardial effusion
lymphadenopathy collapse in the older child)
Manage further according to X-Ray 93.
1
Household contact or regular contact with someone outside of household with TB confirmed with GeneXpert, smear or culture. 2Request AP/PA and lateral views.
92
 Manage according to X-Ray findings:

Chest X-Ray abnormal Chest X-Ray normal X-Ray unavailable

(similar to any of above)
Is child able to produce sputum?
Diagnose TB on chest
X-Ray
Yes No
• If miliary TB or
pericardial effusion
suspected, refer same Send 1 sputum for GeneXpert and culture and DST1 and review results in 2 days: Unable to produce sputum
day for further workup.
• Otherwise, start TB
treatment and give GeneXpert positive (MTB detected) GeneXpert negative
routine TB care 95. (MTB not detected)
• Send 1 sputum for Rifampicin Rifampicin Rifampicin
GeneXpert and culture sensitive inconclusive resistant • Exclude other cause for symptom/s: cough/wheeze 41, not growing
and DST1. well 85, fever 31, tiredness 33, lymphadenopathy 34.
• If lymphadenopathy ≥ 2cm, arrange for fine needle aspiration biopsy (FNAB).
Diagnose drug- Diagnose TB Diagnose drug-
• Consider referring for gastric washings or induced sputum if available.
sensitive TB • Send 2nd sputum for resistant TB (DR-TB)
• If no close TB contact2: Do a tuberculin skin test (Mantoux®3) (see below).
• Start TB treatment culture and DST1. • Send 2nd sputum for
• If cough, give azithromycin 10mg/kg/dose once daily for 3 days (table 5 122).
and give routine TB • Start TB treatment and give culture and DST1.
• Read Mantoux after 48-72 hours and review clinically after 2 week 94.
care 95. routine TB care 95. • Refer to DR-TB
• Follow up culture • Follow up culture and DST1 specialist clinic.
and DST1 result. result.

How to perform a tuberculin skin test (Mantoux®) and read the result
• Explain the procedure to the carer and child (if old enough) and explain the need to return in 48-72 hours for Mantoux®reading. If needed, ask an assistant to help keep child from moving.
• Use single-dose tuberculin syringe with short 27- gauge needle: draw up 2 units PPD-RT23 or 5 units PPD-S (0.1mL). Check expiry date. Inject between layers of skin (intradermally) as follows:

• Place left forearm on well-lit surface with • Insert needle slowly at an angle of After 48-72 hours, read result: • Use tape measure to measure widest
palm up. 5-15 degrees (needle bevel should be • Identify edges of induration (hardness distance across .
• Locate area midway between elbow and wrist. visible just below the surface of the skin). in skin, not redness) using a pen: draw • Record the result in millimetres (mm)
• Hold syringe and needle parallel to skin • Inject slowly to form a wheal/papule. If no a line from edge of arm towards TST • Positive test is ≥ 5mm in HIV positive
(almost flat) with bevel (hole) of needle wheal visible, injection too deep, repeat site. The raised edges of indurated area child or child with severe acute
pointing up. ≥ 5cm away from first injection site. will prevent pen from drawing further. malnutrition or ≥ 10 mm in HIV
• Pull skin taut. • Use pen to draw wide circle around wheal. • Repeat on both sides of TST site. negative child.
1
Drug susceptibility testing. 2Household contact or regular contact with someone outside of household with TB confirmed with GeneXpert, smear or culture in past year. 3If Mantoux unavailable, manage according history of close TB contact.
93
 Review after 2 weeks:
• If FNAB, gastric washing or induced sputum done, check results. If TB confirmed, start TB treatment and give routine care 95.
• Otherwise, manage according to history of close TB contact:

Close TB contact1 No close TB contact1

Symptom/s resolved Symptom/s Mantoux® positive Mantoux® negative or unavailable

worse or
persistent
• If < 5 years old or Symptom/s worse or persistent Symptom/s Symptom/s worse Symptom/s
HIV positive, give TB resolved or persistent resolved
prophylaxis 90.
• If ≥ 5 years old Does child have 2 or more of:
• Persistent, non-remitting cough or wheeze Refer/discuss with No further
and HIV negative,
• Tiredness/reduced playfulness doctor/paediatrician. management
reassure and
• Not growing well/growth faltering/losing weight needed. Reassure
advise to return if
• Persistent fever and advise
symptom/s recur.
• Visible lump/s in neck/axilla/groin to return if
symptom/s recur.
Refer if
symptom/s recur. Yes No

Diagnose TB X-Ray was Chest X-Ray

Start TB treatment same day and unavailable was normal
give routine TB care 95. Refer for chest
X-Ray and
• If < 5 years old or HIV positive, give TB
diagnosis.
prophylaxis 90.
• If ≥ 5 years old and HIV negative, reassure
and advise to return if symptom/s persist
or recur.

If sputum sent, check if culture results are available:

Culture positive (MTB confirmed) Culture pending Culture negative

Drug sensitive Drug resistant Follow-up every • If symptom/s persist, refer.

Diagnose TB (if not already done so) • Refer to DR-TB specialist clinic. 1-2 weeks until culture result • If TB diagnosed clinically, continue treatment.
Start TB treatment and give routine TB care 95. • Send 2nd sputum for culture and DST2. confirmed. • Otherwise, advise to return if symptoms recur.

1
Household contact or regular contact with someone outside of household with TB confirmed with GeneXpert, smear or culture in past year. 2Drug susceptibility testing.
94
TB: routine care
Refer the child with drug-resistant TB to a specialist DR-TB clinic.

Assess the child with TB at diagnosis, at 2 weeks and then once a month throughout TB treatment.
Assess When to assess Note
Register At diagnosis Notify and register according to method of diagnosis. If sputum sent, register as smear negative or positive depending on result. Also record in RtHB.
Routine care Every visit Integrate routine care into each visit 5.
Symptoms Every visit • Expect gradual improvement on TB treatment. Refer to doctor if symptoms worsen or do not improve. If persistent wheeze or new headache/vomiting, discuss with paediatrician.
• If symptoms are not improving, refer/discuss with doctor/paediatrician before changing to continuation phase at 2 months.
Contacts At diagnosis Check for TB in symptomatic adult contacts and all children at home.
Adherence Every visit Request carer brings all medication to each visit. Check adherence on the TB card. Manage the child who interrupts TB treatment 96.
Side effects Every visit Ask about side effects on treatment 97.
Carer Every visit Ask about health of the carer: if unwell, assess PACK Adult.
Growth Every visit • Check weight-for-age at every visit and interpret result 8: expect weight gain on treatment and adjust TB treatment dose 97. Refer same week to doctor if losing
weight or not growing well1.
• Decide how often to do full growth checks 7.
Chest X-Ray If needed If clinically not improving, repeat chest X-Ray and arrange doctor review: consider other diagnosis/co-morbidities, especially in child with HIV. Consider lymphoid interstitial
pneumonia (LIP), bronchiectasis, Pneumocystis jirovecii pneumonia (PJP)2. Refer/discuss with doctor/paediatrician if uncertain.
HIV risk At diagnosis • If HIV unknown or tested negatively previously, re/test for HIV 98.
• If HIV positive, check child is on ART and give routine care 99. If not on ART, start ART as soon as tolerating TB treatment (unless TB meningitis, where ART is delayed by
4-6 weeks and usually started in hospital).
• If child on lopinavir/ritonavir, check that child is receiving additional ritonavir while on TB treatment (continue until 2 weeks after TB treatment complete). Dose ritonavir 103.
If sputum smear positive • Week 7 • Send follow up sputum only if child able to produce sputum - no need to refer for induced sputum.
at diagnosis, send • End of month 5 • If week 7 sputum smear positive, ask about adherence and/or intolerance to medications and refer/discuss with doctor/paediatrician
1 sputum for smear if able • If month 5 sputum smear positive, refer/discuss with doctor/paediatrician.
Culture and DST3 Check result • If MTB (Mycobacterium tuberculosis) on culture, check DST3:
if sent during --If drug sensitive, continue treatment. If drug resistant, refer to specialist DR-TB clinic.
diagnostic • If culture contaminated, repeat if possible.
workup • If culture shows NTM (Nontuberculous mycobacteria), continue treatment, repeat culture and refer to doctor.
Decide on treatment At completion of • If TB diagnosed clinically or on chest X-Ray or smear negative at diagnosis and child well, register as treatment completed.
outcome TB treatment • If smear positive at diagnosis, smear negative at 7 weeks (or 12 weeks if taken) and smear negative at month 5, register as cured.
• If smear positive at diagnosis, smear positive at 12 weeks and smear negative at month 5, register as treatment completed.
• If smear positive at diagnosis and smear positive at month 5, register as treatment failure and refer for doctor review.

Advise the child with TB

• Arrange TB/HIV education and refer for community adherence support. Advise carer to keep child home from school for 2 weeks.
• Support the carer and child with poor adherence. Educate on adherence and the risks of resistance and refer for counselling. If treatment interrupted 96.
• Educate carer and child about TB treatment side effects 97 and advise to report these promptly if they occur.

Treat the child with TB 96.

1
Child has an abnormal growth curve pattern (flattening, falling or crossing z-score lines on 2 consecutive visits). 2 Previously known are Pneumocystis carinii pneumonia (PCP). 3Drug susceptibility testing.
95
 Treat the child with TB
Decide if child has complicated or uncomplicated TB:
Does child have HIV, smear positive TB, extensive lung disease on X-Ray, TB pericarditis, TB spine/bone/joint, TB meningitis, abdominal TB or miliary TB?

No Yes: child is usually started on TB treatment in hospital and referred down once stable.

Treat for uncomplicated TB Treat for complicated TB

(includes minimal lung involvement on chest X-ray, Does child have miliary TB or TB meningitis?
hilar lymphadenopathy, TB lymphadenitis and TB pleural effusion)
No Yes
Treat 7 days a week, for 6 months:
• Give intensive phase RHZ for 2 months (if child ≥ 8 years old, Treat 7 days a week: Treat 7 days a week:
give RHZE) • Give intensive phase RHZE for 2 months. Give RH, Z and
• Change to continuation phase RH for another 4 months. • Change to continuation phase RH for another 4 months. ethionamide, as a single
If symptoms are not improving, refer/discuss with doctor/ --If symptoms are not improving, refer/discuss with doctor/paediatrician before changing. phase for 6-9 months as
paediatrician before changing. --If TB spine, bone or joint or tuberculous pus collection, prolong continuation phase to guided by a specialist.
7-10 months as guided by a specialist.

• Dose TB treatment according to weight and adjust as weight increases 97. Refer to doctor if losing weight.
• Give the child with HIV or malnutrition pyridoxine according to age: If < 5 years old, give 12.5mg once daily; if ≥ 5 years old, give 25mg once daily until treatment completed.
R - rifampicin H - isoniazid Z - pyrazinamide E - ethambutol

Manage the child co-infected with TB and HIV

• Give co-trimoxazole and routine HIV care throughout TB treatment 99.
• If not on ART, start ART as soon as tolerating TB treatment (unless TB meningitis, where ART is delayed by 4-6 weeks and usually started in hospital).
• If child on lopinavir/ritonavir, check that child is receiving additional ritonavir while on TB treatment (continue until 2 weeks after TB treatment complete). Dose ritonavir 103.

Manage the child who interrupts TB treatment:

• Trace the carer/child and look for explanation for treatment interruption: if intolerance (vomiting medication) or treatment side effects 97; if neglect suspected 70; if substance abuse in the
home, refer to social worker.
• Give increased adherence support and educate the carer and child about the risks of drug resistance.
• Manage treatment interruption according to duration of interruption:

Interrupts for < 2 months Interrupted for ≥ 2 months

Ask about new TB symptoms
Repeat CXR and restart new course of TB treatment.
Child has no TB symptoms TB symptoms have returned • If child able to cough up sputum, send 1 sputum specimen for culture and DST1.
• Register as treatment defaulted and re-register as re-treatment after default.
Arrange repeat chest X-Ray and doctor review

Extend treatment phase by the number of weeks missed.

Review the child with TB at diagnosis, at 2 weeks and then once a month throughout TB treatment.
1
Drug susceptibility testing.
96
TB medication
Child < 8 years old Child ≥ 8 years old
Uncomplicated TB disease Complicated TB disease (excluding TB meningitis/miliary TB) Intensive phase: Continuation phase: 4 months
2 months
Intensive phase: Continuation phase: Intensive phase: 2 months Continuation phase:
2 months 4 months 4 months Weight (kg) RHZE RH RH
150/75/400/275 150/75 tablet 300/150 tablet
Weight (kg) RH Z RH RH Z Ethambutol (E) RH
tablet
60/60 500mg 60/60 tablet 60/60 500mg 400mg tablet or 60/60 tablet
tablet tablet tablet tablet 400mg/8mL solution 30-38kg 2 tablets 2 tablets
< 3kg Expert advice recommended 38-55kg 3 tablets 3 tablets
3-4kg ¾ ¼ ¾ ¼ ¼ 1.5mL ¾ 55-71kg 4 tablets 2 tablets
4-6kg 1 ¼ 1 1 ¼ 2mL 1 ≥ 71kg 5 tablets 2 tablets
6-8kg 1½ ½ 1½ 1½ ½ 3mL 1½ R - rifampicin H - isoniazid Z - pyrazinamide E - ethambutol
8-12kg 2 ½ 2 2 ½ ½ tablet 2
12-15kg 3 1 3 3 1 ¾ tablet 3
15-20kg 3½ 1 3½ 3½ 1 1 tablet 3½
20-25kg 4½ 1½ 4½ 4½ 1½ 1 tablet 4½
25-30kg 5 2 5 5 2 1½ tablets 5
R - rifampicin H - isoniazid Z - pyrazinamide E - ethambutol

Look for and manage TB treatment side effects TB meningitis/miliary TB (Child < 13 years) old
Side effect TB medication likely responsible Treatment Single phase treatment (6-9 months as guided by a specialist)
Jaundice Most TB drugs Stop all drugs and refer same day. Weight (kg) RH 60/60 tablet Z 500mg tablet Ethionomide 250mg tablet
Skin rash/itch Most TB drugs Assess and manage 63. < 3kg Expert advice recommended
Loss of colour vision Ethambutol Stop ethambutol and refer to eye specialist 3-4kg 1 ¼ ¼
same day. 4-6kg 1½ ¼ ½
Vomiting/ nausea with Ethambutol, rifampicin, isoniazid, Refer (to exclude liver injury). 6-8kg 2¼ ½ ½
abdominal pain pyrazinamide 8-12kg 3 ½ 1
Joint pain Pyrazinamide Give ibuprofen 10mg/kg/dose 4-6 hourly as 12-15kg 4 1 1
needed up to 5 days.
15-20kg 5 1 1½
Orange urine Rifampicin Reassure. 20-25kg 6 1½ 2
Burning feet Isoniazid Refer. 25-30kg 6 2 2
≥ 30kg 20mg/kg 40mg/kg 20mg/kg
R - rifampicin H - isoniazid Z - pyrazinamide

97
HIV: diagnosis
Decide when to test for HIV:

Known to be HIV exposed Not known to be HIV exposed

• Test routinely at: birth (within 48 hours or if not yet done, at first presentation), at • Risk factors for HIV: fed breast milk of woman with HIV/unknown status, suspected sexual assault,
10 weeks old, around 18 weeks old if on nevirapine for 12 weeks1, 9 months old, abandoned/fostered/ adopted, death of parent/sibling from HIV, father/sibling with HIV.
18 months old and if breastfed, 6 weeks after final breastfeed. • Feature/s of HIV: TB, growth problem, developmental delay, recurrent infections, persistent infections,
• If mother newly diagnosed HIV positive, test child same day. enlarged glands: parotid, lymph nodes (≥ 2 sites: groin, axilla, neck), oral thrush in baby ≥ 4 weeks old.
• If parent/guardian requests an HIV test.

Test for HIV

Give HIV information that is easy to understand and obtain consent to test:
• Educate carer/child (if old enough) about HIV/AIDS, modes of HIV transmission, risk factors, treatment and benefits of knowing HIV status.
• Explain test procedure. Children < 12 years old need parental/guardian consent. If consent is granted, proceed to testing immediately.
• Decide which HIV test to use according to age of child:

< 9 months old 9-18 months old ≥ 18 months old

• If mother is known HIV positive: Do HIV PCR test. Do rapid finger-prick Determine® HIV antibody screening test: Do rapid finger-prick HIV antibody screening test:
• If mother is HIV negative/status unknown2, first do a
Determine® rapid HIV test: if negative, advise breastfeeding Positive Negative Negative Positive
mother to do HIV test 3 monthly. If positive, do HIV PCR test: Do HIV PCR test: Do rapid finger-prick HIV antibody
confirmatory test3.
Negative Indeterminate Positive Positive Negative
Negative Positive
Child does not have HIV • Confirm with 2nd HIV PCR test. Do an HIV ELISA test.
• If on post-exposure • While waiting for result, give routine HIV care and
prophylaxis, continue start ART 102. Negative Positive
medication 104.
• If breastfeeding and:
--Mother HIV positive: Negative or Positive Child does not have HIV Child has HIV
repeat child’s HIV test indeterminate If breastfeeding follow up further according • Give routine HIV care
6 weeks after final mother’s HIV status: 99.
Child has HIV
breastfeed. Also ensure Child may have HIV • Advise mother to
• Continue routine HIV care and
mother on ART with a • Repeat HIV PCR and do an HIV Mother HIV positive Mother HIV breastfeed for 2 years4.
ART 102.
suppressed viral load (VL). viral load and refer/discuss with • Repeat child’s HIV test 6 weeks negative • If < 2 years old and
• Advise mother to breastfeed
If VL raised, discuss /refer. doctor/paediatrician same day. after final breastfeed. Repeat mother’s mother on a protease
for 2 years4.
--Mother HIV negative: • If on ART, continue. • Also ensure mother on ART HIV test inhibitor5, arrange
• If mother on protease
repeat mother’s HIV test with a suppressed viral load. 3 monthly. resistance test
inhibitor5, arrange resistance
3 monthly. for baby.
test for baby.

• Provide support for carers. Ensure he/she understands test results and knows where to access further care.
• Record tests and results in Road-to-Health Booklet. Check that carer knows when to re-test, if further test needed.
1
If nevirapine is extended beyond 12 weeks, repeat HIV test 6 weeks after final nevirapine. 2This includes an abandoned newborn/ orphan. 3Use a different test kit to the first rapid test. 4If mother formula feeding, consider feasibility of re-establishing
breastfeeding. 5Lopinavir/ritonavir or atazanavir/ritonavir or darunavir/ritonavir.
98

HIV
HIV: routine care
Assess the child with HIV
Assess When to assess Note
Routine care Every visit Integrate routine care at every visit 5. If other long-term health conditions, ensure adequately treated.
Symptoms If unwell Manage child’s symptoms as on symptom pages.
TB Every visit • Ask about TB contacts: if any TB contact in the last 12 months, exclude active TB and give IPT1 90.
• Screen for TB at diagnosis and if TB symptoms (cough or fever ≥ 2 weeks, not growing well/losing weight, tiredness/reduced playfulness) or close TB contact 90.
• If starting/on TB treatment and on lopinavir/ritonavir, add additional ritonavir until 2 weeks after TB treatment completed.
Adherence On ART: every visit Ask about missed doses, look at pharmacy refill records and count remaining pills. If poor adherence, give increased support 100 and ask the following:
• If over past few months, child has been miserable, stressed or angry 71 or if problematic change in behaviour 72.
• Consider depression in the carer PACK Adult if yes to ≥ 1 of: 1) During the past month, have you felt down, depressed, hopeless? 2) During the past month, have
you felt little interest or pleasure in doing things?
ART side effects On ART: every visit Ask about ART side effects 101. Manage side effects as on symptom pages. Refer to doctor if child on treatment for epilepsy or TB or contraception.
School problem If school-age: every visit If poor attendance, bullying, learning problems, difficulty socialising at school 75.
Disclosure Every visit Check child understands his/her status and the need for ongoing clinic attendance and adherence to medication.
Sexual health If sexually active • If genital symptoms2 51.
• If any of: 1) not consensual 2) child < 12 years old 3) child 12-15 years old with a partner not in peer group3; manage as sexual abuse 70.
• If ≥ 12 years old and consensual sex with partner in peer group3, advise reliable contraception PACK Adult. Check that he/she knows how to use condoms.
Carer Every visit Ask about health of the carer: if unwell, assess using PACK Adult. If parent with child, ask about HIV status and ensure on ART.
Growth • Weight: every visit • Check weight-for-age at every visit and interpret result 85.
• Routine growth checks 8 • Decide how often to do standard growth checks 8.
Development If < 6 years old 5 Assess motor development, vision, hearing and communication according to age 5.
Stage Every visit Check weight, mouth, skin, previous and current problems to determine HIV stage, see table below. If stage worsens on ART, refer.
• Stage 2: if 4 weeks - 4 years old, give co-trimoxazole 103 .
• Stage 3 and 4: if ≥ 4 weeks old, give co-trimoxazole 103. If stage 4, start ART within 7 days.
Bloods Check table 101 Check routine bloods tests and interpret results 101
Stage 1 Stage 2 Stage 3 Stage 4
• No symptoms • Recurrent/chronic sinusitis • Pulmonary TB or TB lymphadenopathy • Extrapulmonary TB (not TB lymphadenopathy)
• Persistent • Recurrent otitis media or chronic • Severe recurrent bacterial pneumonia • Cryptococcal meningitis
generalised suppurative otitis • Symptomatic LIP (Lymphoid interstitial pneumonitis) • Oesophageal thrush (pain on swallowing)
lymphadenopathy • Recurrent/chronic pharyngitis/tonsillitis • Bronchiectasis • ≥ 2 severe bacterial infections per year (not
• Fungal nail infections • Oral thrush in child > 6 weeks old pneumonia)
• Chronic dermatitis • Oral hairy leukoplakia • Pneumocystis jirovecii pneumonia (PJP)3
• Papular pruritic eruption (PPE) • Acute necrotising ulcerative gingivitis/periodontitis • Herpes simplex ulcers ≥ 1 month
• Extensive warts or molluscum contagiosum • Unexplained conditions unresponsive to treatment: • Kaposi’s sarcoma
• Shingles (Herpes Zoster) --Diarrhoea ≥ 14 days • HIV encephalopathy
• Recurrent mouth ulcers --Fever ≥ 1 month • Toxoplasma
• Angular cheilitis --Anaemia (Hb < 8g/dL), neutropaenia (< 0.5x109/L) or thrombocytopaenia (< 50x109/L) ≥ 1 month • Severe wasting, stunting or severe malnutrition
• Enlarged parotid glands • Moderate acute malnutrition not responding to treatment not responding to treatment
1
Isoniazid Preventive Therapy 2Genital discharge, rash, itch, lumps or ulcers. 3Partner either 12-15 years old as well or partner is 16 or 17 years old but there is < 2 year age gap. 3Previously known as Pneumocystis carinii pneumonia (PCP).
99
 Advise the carer/older child with HIV
Support disclosure:
• Help carer to disclose HIV status to the school child (explain what HIV is, the effects on the immune system, mode of transmission and its management).
• Use a step by step disclosure process (over months/years) with younger child based on individual maturity. Use basic language and illustrations to help explanation and refer to counsellor for support.
• Encourage carer/s to disclose own status to child and encourage disclosure at home. Recommend that at least one other adult is able to help with ART.
Support starting ART
• Identify a willing carer able to correctly administer/supervise ART when needed. If this is not possible and child needs ART, refer/discuss with doctor/paediatrician.
• Refer for adherence counselling and explain need for lifelong treatment adherence and risks of resistance.
• Educate about the signs of abacavir hypersensitivity reaction 101. Alert carer to special “patient alert card” in abacavir packaging.
Give increased adherence support if poor adherence (or viral load > 40):
• Explain need for adherence and dangers of resistance in a manner in which carer/child • Switch from syrup to tablets/capsules as soon as child able to swallow tablets/capsules.
can understand. • Consider adherence aids (disguise taste, pill-taking games, star charts, diaries, alarms).
• Check understanding and ask carer to demonstrate medication doses. • Explore any carer concerns about harms of ART and educate about ART side effects 101.
• Let child take part in choosing best way to take medication regularly. Adapt treatment • Ensure carer adherent to his/her own medication, if on ART.
schedule to lifestyle as far as possible. • If intentional neglect suspected 70.

Treat the child with HIV

• Start ART, regardless of CD4 or stage, using steps 1-5 102.
• If on ART:
--Check if dose needs to be increased as child grows 103.
--If child on lopinavir/ritonavir based regimen, no need to change regimen when child reaches ≥ 3 years old or ≥ 10kg.
--If starting/on rifampicin-based TB treatment and on lopinavir/ritonavir, doctor to add additional ritonavir until 2 weeks after TB treatment completed (see dosing table 103).
--If on stavudine, doctor to switch to abacavir if viral load (VL) < 400. If VL ≥ 400, refer/discuss with doctor/paediatrician.
• Give co-trimoxazole (see dosing table 103) if:
--4 weeks - 12 months old, regardless of CD4 or stage or
--1-5 years old: if stage 2,3,4 or CD4 ≤ 500 (or ≤ 25%) or
--> 5 years old: stage 3, 4 or CD4 ≤ 200. Decide when safe to stop (see below).
• If > 6 months old, give influenza vaccine yearly as a single dose according to age (ideally around April): 6 months - 3 years old: give 0.25mL IM, > 3 years old: give 0.5mL IM. If < 9 years old and never
had influenza vaccine, give 2 doses at least 1 month apart.

Decide when to stop or change medication in the child with HIV

• Co-trimoxazole prophylaxis:
--Child should take co-trimoxazole prophylaxis until at least 12 months old.
--If 1-6 years old, stop once CD4 > 500 on 2 occasions.
--If > 6 years old, stop once CD4 > 200 on 2 occasions.
--If previous PCP, stop at 5 years old.
• Fluconazole prophylaxis: if previous cryptococcal meningitis, discuss duration of prophylaxis with doctor/paediatrician.
• Adult ART regimen: consider switching the child on efavirenz-based regimen only once child is ≥ 15 years old and weight ≥ 40kg and viral load (VL) < 20:
--Check urine dipstix and send blood for creatinine to calculate CrCl: [height (cm) x 40] ÷ creatinine (µmol/L).
--If CrCl < 80 or > 1+ proteinuria or VL ≥ 20, refer/discuss with doctor/paediatrician. If CrCl ≥ 80, no proteinuria and VL < 20, switch to fixed dose combination: tenofovir/emtricitabine/efavirenz
(300mg/200mg/600mg) 1 tablet daily PACK Adult.

Decide when to review the child with HIV

• If starting ART: review in 1 week, then monthly until stable. If unwell or problems with adherence, see more often.
• If stable on ART (viral load < 400, adherent and well on ART): review 2 monthly. If available, refer to Family ART adherence club1.

1
Service for stable patients: non-clinical staff provides support, quick clinical assessment, supplies pre-packed ART every 2 months and referral if needed. Routine follow up with clinician once a year.
100
Monitor the child with HIV
Check routine blood tests
Age Before starting ART 4 months 1 year 6 monthly Yearly Age
< 5 years • CD4 (if not done in past 6 months) Viral load • CD4 Viral load • CD4 (stop once CD4 > 500 on 2 occasions) < 5 years
• FBC + diff • Viral load • LPV/r: cholesterol+ triglycerides
≥ 5 years • LPV/r: cholesterol + triglycerides • LPV/r: cholesterol + triglycerides CD4 only if CD4 ≤ 200 (stop once • Viral load ≥ 5 years
• ALT (if TB or jaundice) CD4 > 200 on 2 occasions) • LPV/r: cholesterol+ triglycerides
Note: if child on zidovudine (AZT): monitor Hb + diff at month 1,2,3 and 6 after starting AZT. LPV/r - lopinavir/ritonavir

Interpret routine blood results

FBC (or Hb) and diff If Hb < 8 g/dL, neutrophils < 1.0 x 10 /L or platelets < 50x10 /L, refer to doctor.
9 9

CD4 Use CD4 to guide co-trimoxazole prophylaxis: give co-trimoxazole 103 if: 1-5 years1 old with CD4 ≤ 500 (or ≤ 25%) or > 5 years old with CD4 ≤ 200 (or ≤ 15%). Decide when safe to stop 100
Random total cholesterol If on ART and random total cholesterol > 6.0mmol/L, check fasting HDL/LDL-cholesterol. If still raised, refer/discuss with doctor/paediatrician.
Random triglycerides If on ART and triglycerides > 5.6mmol/L, check fasting triglycerides. If still raised, refer/discuss with doctor/paediatrician.
ALT If baseline ALT ≥ 100: refer same day if unwell/signs of hepatitis (jaundice, abdominal pain, vomiting). If well, refer/discuss with doctor/paediatrician.
Viral load (VL) • If VL < 400, continue routine viral load monitoring as in table above.
• Lower than detectable limit • If VL 400-1000 for 1st time: give increased adherence support 100 and repeat VL in 6 months. If repeat viral load still 400-1000, discuss with ART doctor.
(LDL) is a VL < 20. • If VL > 1000 for the 1st time, give increased adherence support 100 and repeat VL within 3 months.
• If < 1mL blood sent to lab, • If repeat VL > 1000 despite increased adherence, manage further depending on regimen:
then LDL is a VL < 100. --On efavirenz: discuss a switch to 2nd line ART with ART doctor.
--On lopinavir/ritonavir2: continue with increased adherence support 100 and repeat VL after 3 months. If 3rd VL >1000 and good adherence, fill in motivation forms for resistance test.
Cryptococcal antigen (CrAg) Laboratory will automatically do this test if CD4 < 100. If CrAg positive, refer/discuss with doctor/paediatrician.

Look for and manage ART side effects

If on abacavir, Abacavir Hypersensitivity Reaction (AHR) likely if ≥ 2 of following groups: 1) fever 2) rash 3) constitutional (fatigue, myalgia) 4) gastrointestinal (abdominal pain, diarrhoea, nausea,
vomiting) 5) respiratory (sore throat, cough, difficulty breathing). Discuss/refer urgently (do not stop ART).
Side effect Medication likely to cause side effect Management
Jaundice or severe abdominal pain Lopinavir/ritonavir, efavirenz Stop medication and discuss/refer urgently.
Rash Abacavir, efavirenz • If on abacavir, consider Abacavir Hypersensitivity Reaction (see above).
• If blistering, peeling, involving mouth or eyes or associated fever/vomiting), stop medication and refer/discuss urgently.
• If mild rash, continue medication but review weekly. If worse or no better within 2 weeks, refer/discuss.
Nausea and vomiting Lopinavir/ritonavir Usually self-limiting, advise to give with food (high fat meal is best).Encourage oral fluid intake. If severe or persists > 2 weeks, refer/discuss.
Diarrhoea Lopinavir/ritonavir Usually resolves within 6 weeks. Maintain hydration 48.
Fever Abacavir If on abacavir, consider Abacavir Hypersensitivity Reaction (see above). If unlikely 31.
Headache Efavirenz Common, usually self-limiting. Give paracetamol 15mg/kg 6 hourly as needed. If persists > 2 weeks, discuss/refer.
Sleep problems, nightmares Efavirenz Advise to give medication at night. If persists > 2 weeks or worsens, refer/discuss. If confusion/abnormal thinking, refer urgently.
Tingling/numb/painful feet Stavudine, abacavir If new or worse on treatment, discuss/refer. If on stavudine, doctor to switch to abacavir if viral load (VL) < 40. If VL ≥ 40, discuss/refer.
Change in body shape Stavudine, zidovudine, efavirenz • If increased breast tissue in a male or before puberty in a female, refer/discuss.
• If on stavudine, doctor to switch to abacavir if viral load (VL) < 400. If VL ≥ 400, refer/discuss.
1
The baby < 1 year old should be on co-trimoxazole from 4 weeks old. 2An unsuppressed viral load in a child on lopinavir/ritonavir is most often due to poor adherence or intolerance of lopinavir/ritonavir solution.
101
Start ART
Start ART using steps 1 - 5

1. Decide which ART regimen the child needs

• If child has severe acute malnutrition, severe anaemia (Hb < 7g/dL), TB, is currently unwell or has defaulted ART previously, doctor to assess and start ART.
• If child is < 3kg, < 4 weeks old, discuss with doctor/paediatrician.
• Choose regimen according to age and weight of child:

Child < 3 years old or weight < 10kg Child ≥ 3 years old and weight ≥ 10kg

Did child receive nevirapine for 6 weeks or more for PMTCT?

Yes No

Plan to use the following: Plan to use the following:

• Abacavir • Abacavir
• Lamivudine • Lamivudine
• Lopinavir/ritonavir • Efavirenz

2. Check baseline bloods and check results before starting ART 101 2. Check baseline bloods and check results before starting ART 101
• Check bloods: FBC, CD4 (if not done in past 6 months), cholesterol and triglycerides. • Check bloods: FBC, CD4 (if not done in past 6 months)
• If on TB treatment or jaundice, also do ALT. • If on TB treatment or jaundice, also do ALT.

3. Decide when to start ART

• If no TB, start ART as soon as carer has attended adherence counselling and is willing and able to give ART, ideally within 2 weeks.
• Fast-track to start ART within 7 days if: child < 1 year old, CD4 ≤ 200 (or <15%), stage 4 or drug-resistant TB (DR-TB).
• If TB, start ART once tolerating TB treatment and ready for ART:
--If stage 4 or CD4 ≤ 50, start ART at 2 weeks of TB treatment. If child has TB meningitis, start ART after 4-6 weeks of TB treatment.
--If CD4 > 50 and not stage 4, start ART within 2-8 weeks of TB treatment.
• If child has cryptococcal meningitis, start ART after 4 weeks of treatment for meningitis.

4. Give ART
• Give a combination of 3 antiretroviral medications chosen in step 1. Dose according to weight as in table 103.
• If on TB treatment and starting lopinavir/ritonavir based ART regimen, doctor to add extra ritonavir until 2 weeks after TB treatment completed.

5. Review
Review in 1 week, then monthly 99.

102
Medication dosing chart
• If < 4 weeks old or child < 3kg, discuss medication selection and dosing with with doctor/paediatrician.
• Switch syrups to tablets/capsules as soon as child able to swallow these. Avoid chewing/crushing tablets - swallow abacavir (except 60mg), efavirenz, lopinavir/ritonavir and zidovudine tablets whole.

ART Abacavir1 Lamivudine Efavirenz1 Lopinavir/ritonavir1 Ritonavir Stavudine Zidovudine1 Nevirapine

Formulation • 20mg/mL solution • 10mg/mL solution • 50mg tablets/ • 80/20mg solution 80mg/mL • 1mg/mL solution • 10mg/mL • 10mg/mL
• 60mg dispersible tablets • 150mg tablets capsules • 100/25mg tablets solution for • 15mg, 20mg, solution solution
• 300mg tablets • 300mg tablets • 200mg tablets/ • 200/50mg tablets boosting 30mg capsules • 100mg capsules • 200mg
capsules • 300mg tablets tablets
Weight(kg) • 600mg tablets
3-4kg
2mL BD 2mL BD 1mL BD 1mL BD 6mL
4-5kg 6mL BD 5mL BD
5-6kg Avoid use in child 7.5mg BD: open
6-7kg 3mL BD 3mL BD < 10kg or < 3 years 15mg cap into 5mL
old water: give 2.5mL 9mL BD
1.5mL BD
7-8kg 10mg BD: open 8mL BD
8-10kg 4mL BD 4mL BD 1.5mL BD 20mg cap into 5mL
water: give 2.5mL
1 cap BD or
10-14kg Choose only one option: Choose only one option: 200mg nocte: 15mg BD: open
• 6mL BD or 2x60mg tabs BD • 6mL BD or 2mL BD 15mg cap into 12mL BD 10mL BD
(1x200mg cap/tab)
• 12mL OD or 4x60mg tabs OD • 12mL OD 5mL water
14-20kg Choose only one option: Choose only one option: Choose only one option: 2 caps mane + 1
• 8mL BD or 2½x60mg tabs BD • ½ x150mg tab BD or • 2.5mL BD or 2mL BD cap nocte or
• 5x60mg tabs OD or 15mL OD • 8mL BD or • 2 tabs (100/25mg paeds tabs) BD or 15mL BD
or 1x300mg tab OD • 1x150mg OD or 15mL OD • 1 tab (200/50mg adult tabs) BD
20mg BD
20-23kg Choose only one option: 300mg nocte: 1 tab mane
If unable to
• 10mL BD or Choose only one option: (1x200mg cap/tab + ½ tab
swallow: open
• 3x60mg tabs BD or • 1x150mg tab BD or + 2x50mg caps/ Choose only one option: nocte or
20mg cap into
• 1x300mg tab + 1x60mg tab OD • 15mL BD or tabs) • 3mL BD or 2 caps BD or 15mL BD
2.5mL BD 5mL water
23-25kg Choose only one option: • 2x150mg tabs OD or • 2 tabs (100/25mg paeds tabs) BD or 20mL BD
• 10mL BD or • 1x300mg OD or • 1 tab (200/50mg adult tabs) BD
• 3x60mg tabs BD or • 30mL OD
• 1x300mg tab + 2x60mg tab OD
25-30kg Choose only one option:
• 3.5mL BD or
• 3 tabs (100/25mg paeds tabs) BD or
• 1 tab (200/50mg adult tabs) BD + 1 tab (100/25mg paeds tabs) or
Choose only one option: • 2 tabs (200/50mg adult tabs) mane + 1 tab (100/25mg paeds tab) nocte
400mg nocte: 3mL BD 1x300mg tab
30-35kg • 1x150mg tab BD or Choose only one option:
Choose only one option: (2x200mg caps/tabs BD or
• 2x150mg tabs OD or • 4mL BD or
• 1x300mg tab BD or 30mg BD 1xAZT/3TC2 1 tab BD
• 1x300mg tab OD or • 3 tabs (100/25mg paeds tabs) BD or
• 2x300mg tabs OD 300/150mg tab
• 1xABC/3TC2 600/300mg • 1 tab (200/50mg adult tabs) BD + 1 tab (100/25mg paeds tab) BD or BD
tab OD • 2 tabs (200/50mg adult tabs) mane + 1 tab (100/25mg paeds tab) nocte
35-40kg Choose only one option:
≥ 40kg 600mg nocte: • 5mL BD or 4mL BD
(1x600mg tab) • 200/50mg adult tabs: 2 tabs BD

Adapted from antiretroviral drug dosing chart for children 2013, by

OD = once daily dosing Weight 3-4.9 5-13.9 14-29.9 ≥ 30 the Child and Adolescent Committee of the SA Clinicians Society in
BD = twice daily dosing Co-trimoxazole dose (200/40mL per 5mL or 400/80mg tablets) kg 2.5mL OD 5mL OD 10mL OD or 1 tab OD 2 tabs OD collaboration with the Department of Health
1
Currently available tablet formulations of abacavir (except 60mg), efavirenz, lopinavir/ritonavir and zidovudine must be swallowed whole and not chewed, divided or crushed. 2Abacavir/lamivudine fixed dose combination
103
Prevention of mother-to-child transmission (PMTCT) of HIV
Approach to the HIV-exposed baby (mother is known with HIV1)
• Do HIV PCR test on every HIV-exposed baby within 48 hours of birth. Ensure mother gets routine HIV care and starts/on ART PACK Adult.
• Encourage exclusive breastfeeding for first 6 months 78. If carer wants to formula feed, ensure it will be affordable, feasible, acceptable, safe and sustainable 80.
• Start post exposure prophylaxis (PEP) as soon as possible, ideally within 1 hour of birth:

Mother known HIV positive at delivery Mother Mother diagnosed

diagnosed HIV HIV positive while
positive during breastfeeding
Mother on ART for ≥ 12 weeks before delivery Mother on ART Mother not
labour or less
for < 12 weeks on ART at
than 72 hours • Do HIV PCR test on
Viral load done in last 12 weeks of pregnancy Viral load not before delivery delivery
post-partum baby3 same day.
done in last • If baby > 12 months
Viral load < 1000 Viral load ≥ 1000 12 weeks of Ensure mother old, advise to stop
Do HIV PCR on
Any of the following present at birth? Manage raised pregnancy has viral load breastfeeding (only
baby same day.
• Spontaneous preterm labour < 37 weeks VL result done at 6 weeks of
Check mother’s month 3
• Prolonged rupture of membranes > 18 hours PACK Adult. on ART. Ensure mother starts ART
prophylaxis needed
• Chorioamnionitis2 viral load4 for baby if mother
same day PACK Adult.
today. stops breastfeeding).
No Yes • Ensure mother starts
ART same day PACK
Adult.
Low risk of HIV transmission to baby High risk of HIV transmission to baby during labour and delivery • Give post exposure
during labour and delivery prophylaxis:
Formula feeding Breastfeeding
• Give nevirapine once daily for
6 weeks (see table). • Give zidovudine 12 hourly for 6 weeks4 (see table) and • Give zidovudine 12 hourly for 6 weeks4 (see table) and
• Repeat baby’s HIV PCR at 10 weeks old. • Give nevirapine once daily for 6 weeks (see table). • Give nevirapine once daily for at least 12 weeks4 (see table). Stop only once mother’s viral load < 1000.

Advise to return for HIV PCR result in 3-6 days:

• If HIV PCR positive, send 2nd HIV PCR and refer to doctor to switch from PEP to ART. Advise mother to breastfeed for 2 years. If formula feeding, consider feasibility of re-establishing breastfeeding.
• If HIV PCR negative, retest: at 10 weeks old, around 18 weeks old (if baby on 12 weeks of nevirapine), 9 months old, 18 months old and 6 weeks after final breastfeed 98.
• Start co-trimoxazole (see table) at 4-6 weeks old. Stop co-trimoxazole: if formula feeding, stop if HIV PCR negative at 10 weeks old. If breastfeeding, stop if HIV negative 6 weeks after final breastfeed.

Nevirapine syrup (10mg/mL) Zidovudine syrup (10mg/mL) Co-trimoxazole syrup (40/200mg/5mL)

Birth Weight Age Dose Birth Weight/ Age at exposure Dose Weight Dose
Birth - 2 weeks 0.2mL/kg daily Gestational Age < 5kg 2.5mL daily
< 2.0kg Gestation < 35 weeks Birth - 6 weeks 0.2mL/kg/dose 12 hourly
2-6 weeks 0.4mL/kg daily 5-15kg 5mL daily
2.0kg-2.5kg Birth - 6 weeks 1mL daily ≤ 3kg and ≥ 35 weeks Birth - 6 weeks 0.4mL/kg/dose 12 hourly
≥ 2.5kg Birth - 6 weeks 1.5mL daily > 3kg and ≥ 35 weeks Birth - 6 weeks 1.2mL/kg/dose 12 hourly
- 6 weeks - 6 months 2mL daily > 3kg ≥ 6 weeks Dose according to weight-based
- 6-9 months 3mL daily dosing chart (2013)
- 9-12 months 4mL daily
1
If abandoned baby or mother’s HIV status is unknown, do rapid Determine® HIV test on baby. If positive, send HIV PCR test and manage as high risk above. If negative, no need for PMTCT. 2Mother with temperature ≥ 38°C, pulse > 120, tender uterus,
offensive liquor. 3If HIV PCR positive, send a 2nd HIV PCR and start ART in baby 99. If negative, continue PEP if started and retest for HIV 6 weeks after stopping PEP and 6 weeks after final breastfeed. 4In the mother whose viral load unknown initially:
if result < 1000, stop zidovudine and give only 6 weeks of nevirapine.
104
Post-exposure prophylaxis (PEP): HIV and hepatitis B
• This refers to the treatment aimed at preventing infections (like HIV, hepatitis B) following sexual abuse or accidental exposure to potentially infectious blood or bodily fluids.
• Prevent mother-to-child transmission (PMTCT) of HIV in the baby with an HIV positive mother104.

Give urgent attention to the child possibly exposed in the last 72 hours to HIV or hepatitis B:
• Exposure through mucosa or non-intact skin to any of the following: blood/blood-stained fluid, semen, vaginal secretions, breast milk from woman other than mother, wound secretions
• Has received or given a human bite that has broken the skin.
• Sexual assault (oral, vaginal or rectal) 70
• Needle-stick or sharps injury
Management:
• Clean exposed area with soap and water or rinse mouth/irrigate eye thoroughly with water.
• If exposure involved intact skin, or if exposed to tears, sweat, urine, faeces, vomit, saliva (non-blood stained), PEP is not needed. If unsure, discuss with HIV hotline 128.
• Manage further according to HIV status:
Known HIV positive HIV negative or unknown
• Avoid giving HIV PEP, give Obtain consent to test or re-test HIV: do rapid finger-prick Determine® HIV antibody screening test:
routine HIV care 99.
• Send bloods for hepatitis B Negative Positive
surface antibodies and assess
need for hepatitis B prophylaxis: • Give PEP as < 18 months old ≥ 18 months old
below. Send bloods: HIV PCR, Do rapid finger-prick HIV antibody confirmatory test using different test kit:
• Send bloods: HIV hepatitis B surface
ELISA, hepatitis antibodies, Hb. Negative Positive
B surface Send bloods: HIV ELISA, hepatitis B surface antibodies, Hb • Avoid PEP.
antibodies, Hb • Send blood for hepatitis B
Give PEP until results available surface antibodies
• Give routine HIV care 99.
• Give zidovudine and lamivudine and lopinavir/ritonavir1 according to child’s weight 103.
• If pallor, do finger-prick Hb: if Hb < 8, avoid zidovudine, use instead stavudine. Manage anaemia 89.

• Check Road to Health Booklet: if child has not completed hepatitis B immunisations at 6, 10 and 14 weeks old, also give:\
--Hepatitis B immunoglobulin (HBIG) IM according to age: < 5 years old: 200IU, if 5-10 years old: 300IU, if ≥ 10 years old: 500IU (if unavailable, discuss/refer) and
--Hepatitis vaccine IM now (use different injection site to HBIG) and complete routine immunisations.
• Arrange review within 3 days.

Review child and blood results within 3 days, then at 2 weeks, 6 weeks and 4 months:
• Manage HIV exposure:
--If HIV positive: stop PEP and arrange routine HIV care 99. No need to give further HIV PEP follow-up.
--If HIV negative, continue PEP to complete 1 month. If Hb < 8: switch zidovudine to stavudine and manage anaemia 89.
--Manage side effects as for other ART 101. If pallor or unwell, take bloods for Hb, ALT and refer/discuss with doctor/paediatrician.
--Repeat HIV test at 6 weeks and 4 months after exposure 98.
• Manage hepatitis B exposure:
--If hepatitis B surface antibodies < 10 and child has completed hepatitis B immunisations at 6, 10 and 14 weeks old, refer/discuss with doctor/paediatrician. If ≥ 10, no further hepatitis
immunisations needed.
--If hepatitis vaccines were needed, also check hepatitis B surface antibodies and antigen at 6 months.
1
Advise to store in a cool place (preferably in fridge if possible), give with food and disguise taste with peanut butter/yoghurt or similar.
105
Child with allergy
Allergy likely if sneezing and runny/itchy/blocked nose, itchy watery or red eyes, sudden face swelling, cough and/or difficulty breathing, or itchy rash on skin.

Give urgent attention to the child with allergy and any of:
• Fainting/dizziness/collapse after exposure to known allergen1. Epinephrine (Adrenaline) 1:1000
• Sudden onset in last few hours of 2 or more of: 1) generalized itchy rash or face/tongue swelling, 2) difficulty breathing, 0.01mg/kg IM as a single dose
3) fainting/dizziness/collapse, 4) abdominal pain/vomiting. Weight (kg) Injection (1mg/mL) Age
Manage and refer urgently: < 9kg 0.05mL < 1 year
• Lie child flat and give 100% facemask oxygen at 2L/minute.
9-12kg 0.1mL 1-2 years
• Give epinephrine (1:1000) according to table using 1mL syringe IM into mid-outer thigh. Repeat every 5 minutes if needed.
• Give sodium chloride 0.9% 20mL/kg IV/IO rapidly. 12-18kg 0.2mL 2-5 years
• Continue above management until ambulance arrives. 18-40kg 0.3mL 5-12 years

Assess the child with allergy not needing urgent attention: record child's condition and care plan in RtHB.
Assess When to assess Note
Routine care Every visit Integrate routine care into each visit 5.
Symptoms Every visit • Skin: If patches of itchy, dry, scaly skin or if red raised wheals suddenly appear and reappear elsewhere 59.
• Eyes: If red or itchy, allergic conjunctivitis likely 35.
• Nose: If purple rings around eyes, runny/blocked nose, mouth breathing, line across nose from repeatedly rubbing nose, allergic rhinitis likely 37.
• Chest: if ≥ 2 years old and recurrent dry cough/wheezing/tight chest/difficulty breathing, asthma likely 44.
Triggers Every visit • Ask if new medication has been given. If yes then stop use. If sudden rash/face swelling following medication ingestion, refer to specialist.
• Consider other triggers2.
• If sudden rash/face swelling following ingestion of new food, refer to specialist.
• Refer to specialist if unable to identify trigger after 6 months.
Control Every visit Allergy uncontrolled if symptoms interfere with sleep, school or sport. Refer to specialist if poor response to maximum treatment.
Adherence Every visit If using creams or ointments, check being applied correctly. If using an inhaler, check technique 43.

How to use Epipen® (use immediately, before calling ambulance)

Advise the child/carer with allergy
• Pull off blue safety release cap.
• If trigger found, advise child/carer to try to avoid it.
• Make sure fingers are not over either end.
• Ensure carer/child understands need for medication and to bring medication and creams to every visit to ensure correct use.
• Remember “blue to the sky, orange to the thigh.”
• If epinephrine auto injector device (Epipen®) prescribed, check carer/child knows how to use it.
• Firmly push orange tip against outer thigh so it clicks. Inject through clothes.
• Arrange an emergency bracelet for child who has had anaphylaxis and phone MedicAlert® 128. Advise child to always wear it.
• Hold in place, count to 10, then remove.
• If allergic to medication, advise carer/child to always inform health care facilities.
• After use, call for ambulance.

Treat the child/carer with allergy

• If chronic allergy, check adherence before adjusting or adding medication. Review child 3 monthly.
• If new onset allergic reaction, give cetirizine once daily until symptoms resolve: if 12-21kg: 5mg, ≥ 21kg: 10mg. Refer if no improvement after 24 hours. If recurrent skin rash, refer to specialist.

1
Allergen can be an insect bite, ingesting a medicine or cleaning product or a new food in the last hour. 2Possible triggers can be insect bites, dogs/cats in home, pollen, cigarette smoke, mould, cockroaches, peanuts, eggs, milk, fish
106

ALLERGY
Eczema
Patches of red, scaly skin in infant or dry scaly skin in older child. Usually on inner surfaces of elbows, knees and on cheeks, scalp and neck.

Assess the child with eczema: record child's condition and care plan in RtHB.
Assess When to assess Note
Routine care Every visit Integrate routine care into each visit 5.
Skin infection Every visit • If skin oozing, crusting and scaly, infection likely. See treatment box below.
• If crops of ulcers/blisters, herpes simplex likely 38.
Skin symptoms to determine Every visit Eczema is uncontrolled if very itchy/thickened scaly skin/red and raw in creases. See advice and
if eczema is controlled. treatment box below.
Co-existing allergy Every visit • If recurrent episodes of sneezing, itchy and/or blocked nose most days for > 4 weeks, treat for
allergic rhinitis 37.
• If age ≥ 2 and recurrent dry cough/wheezing/tight chest/difficulty breathing, asthma likely 44.
Triggers Every visit Avoid scented creams/soaps/washing powder/perfumes. For other possible triggers 106.

Advise the child and/or caregiver with eczema

• Advise carer that keeping skin moisturized is key to improving eczema (maintaining the skin barrier is vital). One fingertip unit is the
• Avoid direct skin contact with woollen or rough clothes and overheating by blankets at night. Keep nails short and clean. amount of cream/ointment
• When applying steroid (hydrocortisone) cream, apply thin layer to area. See picture on right for amount to apply. Carer to avoid rubbing steroid squeezed from the tube
onto own palms. from the tip of the index
• Wash regularly to remove crusts and prevent infection. finger to the first crease

Treat the child with eczema

• Always use aqueous cream instead of soap.
• Use emulsifying ointment as a moisturizer as often as possible (more than twice a day) and
immediately after bathing.
• If uncontrolled and adherent to above treatment, prescribe hydrocortisone 1% cream twice a
day for 7 days. Apply only to eczema patches, use sparingly on face and do not apply around eyes.
Review in 7 days:
--If improved, continue treatment and review 3 monthly.
--If no improvement, doctor to prescribe betamethasone 0.1% cream twice a day for 7 days. Do
not apply to face. Review in 7 days. If no response after 14 days, refer to specialist. Face and neck Arm and hand Leg and feet Trunk (front) Trunk (back)
• Treat infection: including buttocks
--Use povidone-iodine scrub over infected areas then wrap in povidone-iodine soaked gauze twice Age Number of fingertip units (FTU)
a day for one week. Give cephalexin1 12-25mg/kg 6 hourly for 5 days (table 8 123). 3-6 months 1 1 1.5 1 1.5
--Review in 7 days. If no better or temperature ≥ 38⁰C, refer to specialist.
1-3 years old 1.5 1.5 2 2 3
• If still itchy with above treatment, manage itch:
--Give cetirizine once daily for itch until controlled: 12-21kg: 5mg, ≥ 21kg: 10mg 3-6 years old 1.5 2 3 3 3.5
--If < 2 years old, apply calamine lotion in addition to emulsifying ointment. 6-10 years old 2 2.5 4.5 3.5 5
• Ensure child adherent to treatment before adjusting or adding treatment. Adapted from Long C, C. and Finlay A. Y. The finger-tip unit – a new practical measure. Clinical and Experimental Dermatology,
1991; 16: 444-447.
1
If penicillin allergy (previous bronchospasm and/or severe rash), give azithromycin 10mg/kg once daily for 3 days instead (table 5 122).
107
Asthma
Once asthma diagnosed, ensure doctor confirms diagnosis within 1 month of starting treatment.

Assess the child with asthma: record child's condition and care plan in RtHB.
Assess When to assess Note
Routine care Every visit Integrate routine care into each visit 5.
Asthma symptoms to Every visit • If wheeze/tight chest or difficulty breathing, talking, eating/drinking or walking not responding to salbutamol inhaler, manage acute exacerbation 42.
determine asthma control • Asthma not controlled if acute exacerbations frequent (≥ 3 episodes in 3 months) or severe (hospitalised) or, if in past 4 weeks, any of:
--Daytime cough, wheeze or difficulty breathing > once a week if ≤ 5years old or > twice a week if > 5 years old
--Runs/plays less or tires easily due to asthma
--Inhaled salbutamol needed > once a week if ≤ 5years old or > twice a week if > 5 years old
--Night waking or night coughing due to asthma
• If none of the above, then asthma controlled.
Symptoms Every visit Manage other symptoms as on symptom pages. If child is on inhaled beclomethasone, ask about sore mouth 38.
Allergy At diagnosis If continuous sneezing and runny/itchy nose, itchy watery or red eyes, dry and itchy skin or red, itchy rash on skin 106.
Adherence Every visit • Check that the child and/or carer can use inhaler and spacer correctly 43.
• Ensure child is adherent to treatment before adjusting or adding treatment.

Advise the child with asthma and/or carer

• If smoking in the house, alert to risks and encourage smoker to quit PACK Adult helpline.
• Ensure child/carer understand medication. Short acting beta-agonist (e.g salbutamol) only relieves symptoms and does not control asthma. Inhaled corticosteroid (e.g beclomethasone) prevents but
does not relieve symptoms. It is the mainstay of treatment.
• Recognise and manage acute exacerbation: if wheeze/tight chest or difficulty breathing, talking, eating/drinking or walking not responding to salbutamol inhaler, go to nearest casualty urgently.
• Encourage child/carer to identify and avoid triggers (e.g pets, smoking, paints, perfumes). Avoid aspirin and non-steroidal anti-inflammatories (e.g ibuprofen, diclofenac).

Treat the child with asthma

• Give influenza vaccination (yearly).
• Give inhaled salbutamol 1-2 puffs 6 hourly when needed. If symptoms triggered by exercise: give salbutamol 1-2 puffs 5 minutes before exercise.
• If child has received prednisone (or hydrocortisone) for an acute exacerbation, continue prednisone 2mg/kg (max 40mg) once daily for 5 days (do not give antibiotics, as viral cause likely).
• Manage further according to control of asthma symptoms:

Asthma not controlled Asthma controlled

• Before adjusting treatment ensure child adherent and can use inhaler and spacer correctly 43. • Continue inhaled corticosteroids at same dose.
• Give beclomethasone 100mcg 12 hourly if ≤ 5 years old and 200mcg 12 hourly if > 5 years old. • If controlled for at least 3 months, decrease inhaled corticosteroids:
• If still uncontrolled after 3 months, arrange chest x-ray and doctor review. --Halve dose 12 hourly for 3 months.
• Doctor to increase to beclomethasone 200mcg 12 hourly if ≤ 5 years old and 400mcg 12 hourly if > --Then decrease to a daily dose for another 3 months.
5 years old. --If still controlled, discontinue treatment. If symptoms reappear, re-start treatment again.

Review monthly. If still not controlled after 3 months, refer to specialist. Review 3 monthly.

• If acute exacerbation not responding (symptoms persisting or worsening) to prednisone course within 2 days, refer.
• Advise to return before next appointment if symptoms suddenly worsen or do not respond to salbutamol inhaler.

108
Bronchiectasis
Bronchiectasis is a doctor diagnosis (usually diagnosed in hospital).

Assess the child with bronchiectasis

Assess When to assess Note
Routine care Every visit Integrate routine care into each visit 5.
Symptoms Every visit • Manage other symptoms as on symptom pages. If coughing up blood, refer urgently.
• If signs of respiratory distress (lower chest wall indrawing, nasal flaring, accessory muscle use1, difficulty feeding/talking, sats < 92%) 41.
• If worsening cough, increased sputum amount, change in sputum colour with or without fever, manage for acute exacerbation below.
TB risk Every visit • At diagnosis, check for TB regardless of symptoms or contact 89.
• If TB symptoms (cough or fever ≥ 2 weeks, not growing well/losing weight, tiredness/reduced playfulness) or close TB contact 90.
Adherence Every visit Check that the child and/or carer can use inhaler and spacer correctly 43.
Lung clearance Every visit Check if child/carer performing routine chest physiotherapy/lung clearance techniques at home. Refer to physiotherapy.
Palliative care If disease extensive/deteriorating If bronchiectasis severe enough to be life-limiting, also give palliative care 117.
Growth At diagnosis • Measure and record weight-for-age, length/height-for-age, weight-for-length/height (or BMI), MUAC3 8.
• Refer to dietician for nutritional support regardless of measurements.
HIV At diagnosis If HIV negative or unknown, test for HIV 98. If HIV positive, give routine HIV care 99.
Hb At diagnosis, if coughing blood If Hb < 10g/dL in child < 5 years old or Hb < 11g/dL in child ≥ 5 years old 89. If Hb < 7g/dL, refer.
Chest x-ray At diagnosis and yearly • At diagnosis, if disease localised to one area of the lung, refer to specialist.
• If chest X-ray progressively worsening, refer to specialist.
Sputum If frequent acute exacerbations If ≥ 3 exacerbations in 4 months, send early morning spot sputum specimen for microscopy, culture and sensitivity and refer to specialist.

Advise the child with bronchiectasis and/or carer

• If child smokes or smoking in the house, alert to risks and encourage smoker to quit PACK Adult helpline.
• Recognise and manage acute exacerbation: if worsening cough, increased sputum amount, change in sputum colour with or without fever, go to clinic same day.
• Demonstrate inhaler technique 43.
• Encourage chest physiotherapy and lung clearance techniques at home:
--Encourage child to blow bubbles in air or through a straw into soapy water or blow a piece of rolled up tissue or paper across the table.
--Ask child to take 10 deep breaths daily (as big as possible) and encourage deep cough.

Treat the child with bronchiectasis

• If acute exacerbation: give amoxicillin/clavulanic acid 15mg/kg/dose plus amoxicillin 15mg/kg/dose 8 hourly for 14 days.
• If wheeze, assess bronchodilator response2: if responsive, give salbutamol via spacer 1-2 puffs 6 hourly when needed.
• Give vaccines: influenza vaccination every year and 2 extra doses of pneumococcal vaccine (conjugated), 8 weeks apart.

• Review 3 monthly. Doctor to review at least once a year.

• If acute exacerbation not responding to antibiotics within 2 days, refer to specialist.
• If ≥ 3 exacerbations in 4 months, refer to specialist.
• Advise to return before next appointment if symptoms suddenly worsen.
1
Accessory muscle use is any of: subcostal recession, intercostal recession, tracheal tug, use of neck muscles. 2Give salbutamol via spacer 6 puffs and assess response after 15 minutes: if wheeze disappears, child is “responsive”. If no improvement, child is
bronchodilator “unresponsive”. 3Mid upper arm circumference.
109
Known heart problem
Give urgent attention to the child with a known heart problem:
• Blue skin/lips • Temperature ≥ 38°C or fever in last 3 days
• Difficulty breathing and increased pulse rate ( 129): heart failure likely • Sudden weakness of one side of body
• < 1 year old and difficulty feeding or sweating during feeds: heart failure likely • Fainting
• ≥ 1 year old and difficulty breathing when lying flat or chest in-drawing: heart failure likely • Chest pain
Manage and refer urgently:
• If heart failure likely, give furosemide 1mg/kg IV over 5 minutes. Do not put up drip or run in IV fluid.
• Assess and manage child’s fluid needs 20.
• If difficulty breathing/increased respiratory rate (129) and temperature ≥38°C or fever in last few days. Give ceftriaxone 50-80mg/kg as a single dose (table 6 123).
• Give oxygen 2L/minute via nasal prongs and raise head of bed to 45 degrees.

Routine care for the child with a known heart problem

Assess the child with a known heart problem: Record child's heart condition and care plan in RtHB.
Assess When to assess Note
Routine care Every visit Integrate routine care into each visit 5.
Symptoms Every visit • If sore/red throat 38, if cough 41
• If difficulty breathing at rest, child needs urgent attention above. If difficulty breathing only on exercise, refer for specialist assessment.
Long term health conditions Every visit If bronchiectasis 109, if HIV 99, if cerebral palsy 113, if down syndrome 116
Growth Every visit Assess growth 8.
Teeth Every visit If dental caries 40. If needing dental extraction, give prophylaxis (see below). Arrange annual dentist review if possible.

Advise the carer of child with a known heart problem

• Ensure child brushes teeth twice daily and encourage good feeding and eating 81.
• Advise carer/child to seek health care promptly: if sore throat, coughing or fever, always go to the clinic the same day.
• Ensure child attends regular specialist appointments. Encourage family to join a support group/s 128.
• Encourage child to do daily physical exercise, as guided by specialist.
• If previous rheumatic fever, explain the importance of treatment adherence and the risk of damage to heart valves.

Treat the child with a known heart problem:

• If previous rheumatic fever: give prophylaxis: give benzathine benzylpenicillin1,2 IM, single dose according to weight: < 20kg, 600 000 IU and if ≥ 20kg, 1.2 MU 4 weekly. Decide when to stop prophylaxis:
--If rheumatic valvular disease: give lifelong.
--If no rheumatic valvular disease:
• If first episode of rheumatic fever when child < 11 years old, give until age 21.
• If first episode of rheumatic fever when child ≥ 11 years old give for 10 years.
• If known with a heart valve problem, also give antibiotic prophylaxis:
--If requiring dental extraction give amoxicillin2 50mg/kg 1 hour prior to procedure.
--If child needs surgery, refer to specialist.
1
For benzathine benzylpenicillin 1.2MU injection: dissolve benzathine benzylpenicillin 1.2MU in 3.2mL lidocaine 1% without epinephrine (adrenaline). 2If penicillin allergy (previous bronchospasm and/or severe rash), refer to specialist.
110
OTHER LONG TERM
HEALTH CONDITIONS
Chronic arthritis: routine care
• The child with chronic arthritis has painful and/or swollen joints that usually limit daily activities, with joint problem present for ≥ 6 weeks.
• Ensure arthritis is diagnosed and managed by a specialist. Ensure regular specialist dates are in place; these are usually 6 monthly.

Assess the child with chronic arthritis

Assess When to assess Note
Routine care Every visit Integrate routine care into each visit 5.
Symptoms Every visit If joint pain, swelling, fever or worsening function, see treatment box below.
Eye test 4 monthly Ensure eye tests (at eye OPD) for first five years from diagnosis to watch for the complication of chronic (or juvenile idiopathic arthritis associated) uveitis occurring.
Growth Every visit Plot growth 8. If weight loss 85.
Teeth Yearly Arrange annual dentist review. If gum or tooth problem 40.
Joints • Arrange regular physiotherapy or occupational therapy to give child exercises to keep joint mobile and maintain muscle strength.
• Arrange splints if worried about permanent joint tightening/deformity. Refer to occupational therapist for hand, knee and elbow splints.
• Check if shoes are fitting well and walking easily. If problem, refer to orthopaedic nurse/ orthotist to arrange shoe inserts.
FBC, creatinine, ALT If on methotrexate: 2-4 monthly If results abnormal, arrange specialist referral. Specialist will determine frequency of blood tests.

Advise the carer of child with chronic arthritis

• Educate carer arthritis may take months to years to improve. Start treatment early to prevent joint damage and lessen length of illness.
• Stress importance of continuing the treatment and attending the clinic and specialist dates.
• If child well and no joint symptoms at visit, do not stop prescribed specialist medication as joint symptoms may flare up at anytime if medication is stopped.
• Encourage physical exercise on a daily basis. Swimming and cycling are helpful.
• Encourage a healthy and balanced diet. If unsure, see advice box in general assessment 5.
• Advise that child can live a full and happy life as long as joint symptoms are managed.
• Provide carer and child with social support services 128.

Treat the child with chronic arthritis

• Child may be on steroids (methylprednisolone) and/or methotrexate.
• If on methotrexate, give folic acid 5mg once daily.
• If joint pain, swelling, fever or worsening function, give ibuprofen 10mg/kg/dose 4-6 hourly for up to 5 days1 and refer to specialist same week.

• Record child's condition and care plan in RtHB.

• Arrange 6 monthly specialist review.

1
If ibuprofen not available, give paracetamol 15mg/kg 6 hourly as needed up to 5 days.
111
Epilepsy
• If child fitting now 22. If child is not known with epilepsy and has had a recent fit 23 to assess further.
• It is a doctor (usually paediatrician) decision to start long-term treatment in child with ≥ 2 fits with no identifiable cause.

Assess the child with epilepsy: record epilepsy diagnosis and care plan in RtHB
Assess When to assess Note
Routine care Every visit Integrate routine care into each visit 5. Manage symptoms as on symptom page.
Long term health conditions Every visit If other long-term health conditions present, ensure they are adequately treated. If known with cerebral palsy 113.
Adherence and side effects Every visit Ask if child taking medication every day. If not, explore underlying reasons for poor adherence. Ask about side effects of treatment (below).
Other medication Every visit If child has started TB or HIV treatment or antibiotics, refer to doctor to assess for drug interactions.
Fit frequency Every visit Review fit diary. If not fit free after 2 months and adherent to treatment (correct dose) with no obvious triggers1 or other medication interactions, refer to
specialist. Encourage carer to take a video of event to show specialist.
Mental health Every visit If over past few months, child has been miserable, stressed or angry 71 or if problematic change in behaviour 72.
School problems Every visit If failing grades, not coping with school work or bullying/violence at school 75.
Family planning If sexually active female If on valproate, child should be on reliable contraception PACK Adult.
Development 6 monthly Check milestones 5: if not talking properly 73, if not moving properly 74, if hearing problem 36, if vision problem 35.

Advise the carer of a child with epilepsy

• Explain what to do if child fits at home 23. Avoid possible triggers: lack of sleep, alcohol and drug use, dehydration and flashing lights.
• Educate about epilepsy and need for treatment adherence to become fit free. Advise to keep a home record/fit diary to record frequency of fits, length of fit, possible triggers and any changes in medication.
• Help carer to get Medic alert bracelet 106. Refer for support (Epilepsy SA) 128. Carer to inform school teachers, explain what to do if child fits and what activities child should avoid.
• Reduce chance of injury: supervise swimming/bathing/crossing roads (walking to school/shops), shield fireplaces/cookers, avoid contact sports (rugby), advise not to lock doors (bed/bathroom).

Treat the child with epilepsy

• A single medication is best. Start with low doses and increase slowly every 2 weeks until fit free or side effects intolerable (treatment usually initiated by specialist).
Medication Dose Maximum dose Indication Side effects
Phenobarbitone Start and maintain: 3-5mg/kg/dose as a single 5mg/kg/day • First line in infants < 6 months old (specialist review). Drowsiness, behaviour disturbances, hyperactivity.
dose at night. • Avoid in absence seizures and in child > 2 years old.
Valproate • Start dose: 5mg/kg/dose 8-12 hourly2 40mg/kg/day in • First line for generalised tonic and/or clonic seizures Urgent: jaundice, vomiting, abdominal pain, stop medications and refer
• Increase to: 15-20mg/kg/dose 8-12 hourly2 divided doses and absence seizures. Preferred choice on ART. urgently. If < 2 years old or lethargy or loss of appetite and nausea, check
• Maintenance dose: 20-30mg/kg/dose 8-12 hourly2 • Avoid if liver disease. ALT. Self-limiting: nausea, diarrhoea, constipation.
Carbamazepine • Start dose: 2mg/kg/dose 8-12 hourly3 10mg/kg/day in • First line for focal seizures. Urgent: skin rash 59 to manage and refer. Self-limiting: drowsiness, dry
• Increase to: 5-10mg/kg/dose 8-12 hourly3 divided doses • Avoid in absence, myoclonic seizures or if child mouth, dizziness, ataxia, nausea, loss of appetite, constipation, abdominal
• Maintenance:10-20mg/kg/day in divided doses3 on ART. pain. If drowsiness affecting school performance, refer to specialist.
• If fits worsening or persisting despite maximal treatment or if milestone lost (regression in development) refer to specialist.
• If fit free, review 6 monthly. If no fits for 2 years: discuss stopping treatment with paediatrician. Gradually decrease dose of anticonvulsant over 2 months. If fits recur, refer/discuss with paediatrician.
1
Triggers: lack of sleep, dehydration, flashing lights, recent illness (fever),alcohol and drug use. 2If too young to swallow tablet, give crushable formulation (100mg tablets) 8 hourly. If able to swallow, give controlled release (CR) formulation 12 hourly.
3
Give syrup formulation 8 hourly and tablet formulation 12 hourly
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EPILEPSY
Cerebral palsy: routine care
Assess the child with cerebral palsy
Assess When to assess Note
Routine care Every visit Integrate routine care into each visit 5.
Symptoms Every visit • If coughing 41. If constipation 49.
• If TB symptoms (cough or fever ≥ 2 weeks, not growing well/losing weight, tiredness/reduced playfulness) or close TB contact 90.
Seizures Every visit If known epilepsy or fitting/uncontrolled fits 22.
Vision Every visit If squint, cataracts or other problems with vision 35.
Talking, hearing problems Every visit If talking or hearing problem, ensure assessment by speech therapist or audiologist in place. If no previous assessment 73.
Social risk Every visit • If in need of full-time care, apply for child dependency grant. Advise to take child’s birth certificate and carer’s ID to SASSA1 to apply.
• If concerns about abuse or neglect, refer to social worker.
Rehabilitation, home needs Every visit • If struggling with activities of daily living and mobility, refer to physiotherapist and occupational therapist.
and equipment • If adaptation of home environment needed in terms of feeding, toileting and mobility or problem with equipment, refer to occupational therapist.
Behaviour problems Every visit • If problem or a noticeable change in behaviour 72.
• Exclude abdominal pain 45, joint 58 or teeth pain 40 as cause of problem.
Sleep Every visit If snores on most nights 37. If change in sleep pattern 76.
Schooling Every visit Check if in school (or in appropriate alternative placement) and if coping. If not, write referral letter to school-based support team or occupational therapy.
Carer Every visit Screen for depression and anxiety PACK Adult. Check family planning in place PACK Adult.
Feeding Every visit If difficulty swallowing, coughing/choking with feeds or unable to chew, refer to speech therapist and to dietitian if specialized feed required.
Palliative care At diagnosis and if deteriorating If degree of cerebral palsy life-limiting, also give palliative care 117.
Growth Every visit Weigh, plot and look at trend. If not walking, plot growth on special CP growth chart 114. If faltering try to identify problem.
Spine Every visit Check for curved spine (kyphosis and scoliosis). If found for first time, refer to physiotherapist.
Teeth Every visit If dental caries 40. Ensure that carer brushes child’s teeth twice daily.
Limbs/walking Every visit • Refer to paediatrician if marked stiffness in limb/difficulty moving joints, pain on moving limb/dressing child or if walking pattern has changed.
• If child was previously walking and now stopped, refer urgently.
Hips (if in wheelchair) If in wheelchair If pain or dislocation on movement, refer to paediatrician.
Skin Every visit Check skin over pressure areas, if pressure sore found 59. If sudden onset demarcated redness with pain/warmth 59.

Advise the child and carer with cerebral palsy

• CP can range from mild (one hand stiff ) to severe (quadriplegic). Having a child with CP does not mean that they’re stupid but a formal assessment must be done by a specialist.
• Ensure that life-long physiotherapy or occupational therapy is in place, especially if problems with spine or walking/limbs.
• CP can be difficult to deal with so allow carer time to express feelings and to ask questions. Encourage family to get involved in social support networks 128.

Treat the child with cerebral palsy

Continue treatment prescribed by specialist.

• Record child's condition and care plan in RtHB

• Ensure child attends 6-12 monthly paediatrician check-ups.
1
South Africa Social Security Agency.
113
Weight-for-age chart: Cerebal palsy (GMFCS IV)

SOURCE: Life Expectancy Project (2011). Based on data from the California Department of Developmental Services and California Bureau of Vital Statistics. http://www.LifeExpectancy.org/Articles/NewGrowthCharts.shtml
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SPECIAL NEEDS
Weight-for-age chart: Cerebal palsy (GMFCS V)

SOURCE: Life Expectancy Project (2011). Based on data from the California Department of Developmental Services and California Bureau of Vital Statistics. http://www.LifeExpectancy.org/Articles/NewGrowthCharts.shtml
115
Down syndrome: routine care
Assess the child with Down syndrome
Assess When to assess Note
Routine care Every visit Integrate routine care into each visit 5.
Symptoms Every visit • Manage symptoms as on symptom page.
• If child snores continuously, obstructive sleep apnoea likely 37. If constipation 49.
• Check ear and ear drum. If red ear drum or discharge present 36.
Feeding Every visit If struggles with feeding, refer to speech therapist for feeding assistance.
Heart disease At birth If neonate, refer to cardiology OPD for assessment.
Carer/mother Every visit Screen for depression and anxiety PACK Adult.
Vision Screen at 1-3 years old and • Refer to ophthalmologist for formal eye and vision screen between 1-3 years old.
7 years old • School nurse to do eye test at school entry and refer if problem found.
• If squint, cloudy cornea or absent red reflex 35.
Talking, hearing Screen before 3 months old and at • Refer to audiologist for hearing test before 3 months old and between 1-3 years old.
problems 1-3 years old • If talking problem, refer to speech therapist.
Behaviour Every visit If problematic behaviour or concerned about child’s behaviour 72.
Schooling and Every visit • At 5 years old, child must be assessed by a paediatrician to decide school placement.
learning problems • Check attending and coping at school. Refer to occupational therapist if problems.
• If learning problem, refer to remedial teacher/occupational therapist/school based support team.
Family planning From menarche If female child and menses commenced, refer to doctor to discuss contraception method.
Social risk Every visit • If severe disability and in need of full-time care, could qualify for child dependency grant. Advise to take child’s birth certificate and carer’s ID to SASSA1 to apply
or link with information line 128.
• If concerns about abuse or neglect, refer to social worker.
Growth Every visit • Measure and record weight-for-age, length/height-for-age, weight-for-length/height (or BMI) 5.
• Refer to dietitian for weight and nutritional assessment.
Teeth Every visit If dental caries 40. Ensure child (with carer help) brushes teeth twice daily.
TSH At 6 months old, then yearly until If TSH abnormal, refer.
3 years old and 2 yearly thereafter.
Haemoglobin Yearly If Hb < 10g/dL in child < 5 years old or Hb < 11g/dL in child ≥ 5 years old 89.

Advise the carer of child with Down syndrome

• Make carer aware child may always have weaker muscles than other children. Ensure regular occupational therapy is in place until walking and running well.
• Encourage family to join a support group/s. Help line numbers 128.
• Encourage carer to play and interact with child: provide contact/hold child regularly, sing/dance with child, read books, encourage activity outside, kick/throw a ball.

• Record child's condition and care plan in RtHB.

• Doctor to review child 6 monthly until 1 year old, annually from 1-3 years old and 2 yearly thereafter unless otherwise instructed.
1
South Africa Social Security Agency.
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Life-limiting illness: routine palliative care
• Child needs palliative care if known with a life-limiting or terminal illness. Palliative care can occur alongside curative care.
• If suspect new life-limiting illness, refer to doctor. A doctor should confirm the child with a life-limiting illness needs palliative care.

Assess the child needing palliative care

Assess Note
Symptoms Manage on symptom pages: constipation, nausea/vomiting, difficulty swallowing, difficulty breathing/cough, sore mouth, incontinence, fatigue, wounds.
Pain • Does pain limit activity, school attendance or disturb sleep? Is medication helping?
• If new or sudden pain, temperature ≥ 38°C, tender swelling, redness or pus, also treat on symptom page.
• If pain burning, shooting, stabbing, no better or uncertain of cause, refer. If pain related to muscle spasm, refer to physiotherapist.
Sleep If child has difficulty sleeping 76.
Mental health If over past few months, child has been miserable, stressed or angry 71 or if problematic change in behaviour 72.
Carer health • Screen for depression/anxiety in carer: If yes to ≥ 1 PACK Adult: 1) During the past month, have you felt down, depressed, hopeless? 2) During the past month, have you felt little interest or
pleasure in doing things. Have you often felt nervous, anxious or panicky? 4) Have you been unable to stop worrying or thinking too much?
• Ask how the carer and family are coping and what support they need now and in the future.
Side effects Manage side effects on symptom pages. Nausea, confusion and sleepiness on morphine usually resolve after a few days. If child constipated, give lactulose 0.5mL/kg 12 hourly.
Adherence Check adherence to treatment. Refer to nurse/doctor if carer/child struggling with any of the medications.
Social risk If care dependency grant needed, refer to social worker. If child abuse or neglect suspected 70.
Mouth Check oral hygiene. If dental caries 40 and look for ulcers and thrush 38.
Bed sores If child is bedridden, check common areas for damaged skin (change of colour) and bedsores. If child has bedsore 65.

Advise the child needing palliative care and his/her carer

• Discuss the condition and prognosis. Involve child as much as possible in decision making.
• Support child and carer to give as much self care as possible. Refer to available home and community based care provider, support group, counsellor or spiritual care 128.
• Aim to provide care in child’s home. If unable, ensure care is close to home. Emphasize importance of school and “normal” activities and encourage carer to play with, comfort and massage child daily.
• Ensure child has advanced care plan in Road to Health Book. If not, refer to doctor to write one. If unsure, refer/discuss with doctor/paediatrician.
• If bedridden/wheelchair bound: prevent bedsores: Wash and dry skin daily. Keep linen dry. Move (lift, do not drag) child every 1-2 hours if unable to shift own weight. Look daily for skin colour changes 65.
• Teach carer to wash out child’s mouth after meals. Rinse mouth with ½ teaspoon of salt in 1 cup of water. Brush teeth and tongue regularly using toothpaste/dilute bicarbonate of soda.
• Offer small meals frequently and in morning when appetite is better and allow to choose what s/he wants to eat from what is available. The child’s appetite will diminish as s/he gets sicker.

Treat the child needing palliative care

• Aim to have child pain free at rest, able to sleep and alert as possible. If any pain, start pain medication. Review 2 days after starting/changing.
• Emphasize the importance of giving pain medication by the clock (not as needed) and if using morphine to use a laxative daily to prevent constipation.
Step Medication Start dose Maximum dose Note
1 Give paracetamol 15mg/kg 4-6 hourly 60mg/kg daily Start paracetamol 15mg/kg in clinic and reassess pain after 4 hours. If no improvement, add ibuprofen.
2 Add ibuprofen 5mg/kg 6 hourly 40mg/kg daily Give with/after food. Avoid if asthma, heart failure, kidney disease. Discontinue if not effective after 2-3 days and refer.
3 Morphine < 1 year old: 0.2mg/kg 6 hourly None. If drowsy/confused, • If vomiting, refer.
≥ 2 months - 1 year old: start with 0.1mg/kg stop and discuss • If pain before next morphine dose, give extra dose and then keep on normal regime.
• If pain persists, increase morphine by 0.2mg/kg/dose. If no better after 2 days, or unsure about dose, discuss.

117
Protect yourself from occupational infection
Give urgent attention to the health care worker (HCW) who has been exposed to infectious fluids1:
•Clean exposed area with soap and water or rinse mouth/irrigate eye thoroughly with water if needed.
•If source child status unknown, do HIV do rapid finger-prick Determine HIV antibody screening test. Send blood for syphilis, hepatitis B (HBsAg) and C serology.
•Counsel HCW and obtain consent for HIV test. Send blood for: HIV ELISA, creatinine, syphilis, hepatitis B and C serology. Mark as urgent and indicate occupational exposure.
•If HCW HIV negative or unknown and source child HIV positive or unknown, give post-exposure prophylaxis (PEP) as soon as possible (first dose ideally within 1 hour, not after 72 hours):
--Give tenofovir/emtricitabine 300/200mg once daily plus atazanavir/ritonavir2 300/100mg once daily.
--If known kidney disease, use stavudine 30mg and lamivudine 150mg 12 hourly instead of tenofovir/emtricitabine.
--If source client on ART, start PEP for HCW as above and refer to experienced ART doctor to adjust PEP.
Arrange review with doctor within 3 days as below.

Adopt measures to diminish your risk of occupational infection

Protect yourself Protect your facility
Adopt standard precautions with every client Clean the facility
• Wash hands with soap/water or use alcohol-based cleaner after contact with clients or body fluid. Wash high-touch surfaces (including door handles, telephones, keyboards) daily with soap and
• Wear gloves when handling specimens. water, then wipe with 70% alcohol or chlorine-based disinfectant. Regularly clean extractor fans.
• Dispose of sharps in the correct manner. Ensure adequate ventilation
Get vaccinated • Open windows and use fans to increase air exchange.
Get vaccinated against hepatitis B and yearly against influenza. Organise waiting areas
Know your HIV status • Prevent overcrowding in waiting areas.
• If status unknown, test for HIV 98. ART and isoniazid prophylaxis can decrease the risk of TB. • Fast track influenza and TB suspects.
• If HIV positive, you are entitled to work in an area of the facility where exposure to TB is limited. Manage sharps safely
Wear a face mask Ensure sharps containers are easily accessible and regularly replaced.
• Wear a N95 respirator when in contact with TB suspects. Manage infection control in the facility
• Wear a surgical facemask with a visor or glasses if in contact with respiratory virus suspects. Appoint an infection control officer for the facility to coordinate and monitor infection control policies.

Manage possible occupational exposure promptly:

TB Doctor to review health care worker (HCW) exposed to infectious fluids within 3 days Respiratory viruses
Identify TB suspects promptly • If source child hepatitis B positive: give hepatitis prophylaxis according to vaccination status3. (including influenza)
• The child with cough/fever ≥ 2 weeks is a TB suspect. • If HCW is hepatitis B or C positive, refer/discuss with doctor/specialist. • Wash hands with soap and water.
• Separate TB suspect from others in the facility. • If HCW is HIV positive: stop PEP and give routine HIV care 99. • Wearing a surgical face mask over the
• Educate about cough hygiene and give surgical face • If HCW is HIV negative: continue PEP as above to complete 1 month of prophylaxis. mouth and nose may be protective
mask/tissues to cover mouth/nose to protect others. --Check creatinine results: if CrCl ≤ 50, refer/discuss with doctor same day. when performing procedures on child
Diagnose TB rapidly --Treat side effects: if jaundice develops, discuss with doctor. suspected of influenza.
• Complete TB workup 92 and start treatment as soon --Arrange follow-up and advise condoms for 4 months until results confirmed: • Encourage child to cover mouth/nose
• 2 weeks: creatinine with a tissue, to ensure used tissues
as diagnosed.
• 6 weeks: HIV ELISA. If source client hepatitis C positive, also do hepatitis C PCR. are disposed of correctly and to wash
Protect yourself from TB • 4 months: HIV ELISA, syphilis. hands regularly with soap/water.
• Wear an N95 respirator (not a surgical mask) if in contact • Keep child home from school.
with an infectious TB suspect.
1
Fluids that can transmit HIV, hepatitis B and C include blood and blood-stained fluid, semen, vaginal secretions, wound secretions/ breast milk/fluid drained from a body cavity (ascites/amniotic/cerebrospinal/pleural/pericardial). 2If atazanavir/ritonavir
unavailable, give instead lopinavir/ritonavir 400/100mg 12 hourly (with food). 3If HCW hepatitis B unvaccinated or hepBAb < 10IU/mL: give hepatitis B immunoglobulin (if available) as a single dose and hepatitis B vaccine now and 2 more doses at monthly
intervals. If HCW hepatitis B vaccinated and hepBAb > 10, no further hepatitis prophylaxis is needed.
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Protect yourself from occupational stress
Experiencing pressure and demands at work is normal. However if these demands exceed knowledge and skills and challenge your ability to cope, occupational stress can occur.

Give urgent attention to the health care worker with occupational stress and:
• Intoxicated at work - drugs, alcohol
• Aggressive or violent behaviour at work
• Marked inappropriate change in behaviour
• Suicidal thoughts/attempt

Adopt measures to diminish your risk of occupational stress

Protect yourself Protect your team
Look after your health: Decide on an approved way of behaving at work:
• Get enough sleep. • Communicate effectively with your clients and colleagues 120.
• Exercise, eat sensibly, minimise alcohol and don’t smoke. • Treat colleagues and clients with respect.
• Address your general health  PACK Adult. • Support each other. Consider setting up a staff support group.
Look after your chronic condition if you have one: • Don’t complain, rather focus on what can be done to effect a solution.
• Adhere to your treatment and your appointments. Cope with stressful events
• Don’t diagnose and treat yourself. • Develop or access policies or procedures to deal with events like complaints, harassment/bullying,
• If you can, confide in a trusted colleague/manager. accidents/mistakes, violence, or staff or client death.
Manage stress: Look at how to make the job less stressful:
• Delegate; learn to say ‘no’, develop coping strategies. • Examine the team’s workload to see if it can be better streamlined.
• Talk to someone (friend, psychologist, mentor), helpline PACK Adult. • Identify what needs to be remedied to make the job easier and frustrations fewer: equipment, drug
• Take time to do a relaxing breathing exercise each day. supply, training, space, décor in work environment
• Find a fun or creative activity to do. • Discuss each team member’s role. Ensure each one has a say in how s/he does his/her work.
• Spend time with supportive family or friends. • Support each other to develop skills to better perform your role.
Have healthy work habits: Celebrate:
• Manage your time sensibly. • Acknowledge the achievements of individuals and the team.
• Take a breath between clients and observe scheduled breaks. • Share client gratitude with team members.
• Remind yourself of your purpose as a clinician.
• Be sure you are clear about your role and responsibilities.

Identify occupational stress in yourself and your colleagues

Possible substance abuse Change in mood Recent distressing event Poor attendance at work Marked decline in work performance
• Drinks alcohol every day, > 14 drinks1/week, ≥ 5 • Indifference • Diagnosis of chronic condition • Frequent absenteeism • Forgetful
drinks1/session or loses control when drinking. • Irritability • Bereavement • Frequent lateness • Inattention to detail/carelessness
• Smells of alcohol • Low mood or sadness • Needlestick injury • Often takes sick leave • Fatigue
• Used illegal drug or misused prescription or over- • Loss of interest or pleasure • Traumatic event
the-counter medication in the past year. • Feeling tense, worrying a lot

The health care worker with any of the above may have substance abuse, stress, depression/anxiety or burnout and might benefit from referral for assessment and follow-up.

1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer.
119
Communicate effectively
Communicating effectively with your client during a consultation need not take much time or specialised skills.
Try to use straightforward language and take into account your client’s culture and belief system.

Integrate these four communication principles into every consultation:

Listen
Listening effectively helps to build an open and trusting relationship with the client.
Do The client might feel: Don’t The client might feel:
• give all your attention • ‘I can trust this person’ • talk too much • ‘I am not being listened to’
• recognise non-verbal behaviour • ‘I feel respected and valued’ • rush the consultation • ‘I feel disempowered’
• be honest, open and warm • ‘I feel hopeful’ • give advice • ‘I am not valued’
• avoid distractions e.g. phones • ‘I feel heard’ • interrupt • ‘I cannot trust this person’

Discuss
Discussing a problem and its solution can help the overwhelmed client to develop a manageable plan.
Do The client might feel: Don’t The client might feel:
• use open ended questions • ‘I choose what I want to deal with’ • force your ideas onto the client • ‘I am not respected’
• offer information • ‘I can help myself’’ • be a ’fix-it’ specialist • ‘I am unable to make my own decisions’
• encourage client to find solutions • ‘I feel supported in my choice’ • let the client take on too many problems • ‘I am expected to change too fast’
• respect the client’s right to choose • ‘I can cope with my problems’ at once

Empathise
Empathy is the ability to imagine and share the client’s situation and feelings.
Do The client might feel: Don’t The client might feel:
• listen for, and identify his/her feelings • ‘I can get through this’ • judge, criticise or blame the client • ‘I am being judged’
e.g. ‘you sound very upset’ • ‘I can deal with my situation’ • disagree or argue • ‘I am too much to deal with’
• allow the client to express emotion • ‘My health care worker understands me’ • be uncomfortable with high levels of • ‘I can’t cope’
• be supportive • ‘I feel supported’ emotions and burden of the problems • ‘My health care worker is unfeeling’

Summarise
Summarising what has been discussed helps to check the client’s understanding and to agree on a plan for a solution.
Do The client might feel: Don’t The client might feel:
• get the client to summarise • ‘I can make changes in my life’ • direct the decisions • ‘My health care worker disapproves of
• agree on a plan • ‘I have something to work on’ • be abrupt my decisions’
• offer to write a list of his/her options • ‘I feel supported’ • force a decision • ‘I feel resentful’
• offer a follow-up appointment • ‘I can come back when I need to’ • ‘I feel misunderstood’

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Prescribe rationally
Assess the child needing a prescription
Assess Note
Diagnosis Confirm the child’s diagnosis, that the medication is necessary and that the benefits outweigh the risks.
Other conditions If necessary change medication (e.g. avoid ibuprofen in asthma).
Allergies If known allergy or previous bad reaction to medication, discuss alternative with doctor.
Dose Ensure dose is calculated according to child’s weight.
Response to treatment • If the child’s condition does not improve, consider changing the treatment or an alternative diagnosis.
• Check for side effects and report a possible adverse reaction to the medication. Fax adverse drug reaction (ADR) form to 021 448 0506. Or phone 080 1111 452.
• If adverse event following immunisation, report to the district health office within 24 hours using Adverse Events Following Immunisation (AEFI) form.

Advise the child and carer needing a prescription

• Explain to the carer/child when and how to take the medication. Ask the carer to repeat your explanation to ensure s/he understands how to give the child the medication and use a syringe.
• Advise the carer/child of possible side effects to the medication and what to do if they occur.
• Educate the carer/child on the importance of adherence and that not adhering to medication may lead to relapse of the condition and in some instances, resistance to the medication.
• Over-the-counter medications and herbal treatments may interfere with prescribed medication. Encourage carer/child to discuss with prescriber before using them.

Treat the child needing a prescription

• Ensure that the appropriate prescriber writes the prescription in accordance with his/her scope of practice within a specified field.
• Consult the South African Medicines Formulary (SAMF) or MIC hotline (021 406 6829 or 0800 212 506) if unsure about your medicine choice and dosing, side-effects or drug interactions.
• Ensure that the prescription contains all the detail it needs- see sample prescription, Write legibly.

Facility details/patient sticker Child’s name, folder number, age, gender, weight

Date Dose, strength, frequency, route and

quantity of medicine and if applicable,
number of repeats of prescription

Generic name of medicine Prescriber name. qualification, practitioner number,

signature, contact number

Pharmacist signature

121
Medication dosing tables
A
Aciclovir Atropine
Oral 250mg/m2/dose 8 hourly for 7 days 1 IV 0.05mg/kg/dose 4
Weight (kg) Dose (mg) Use one of the following: Age (months/years) Weight (kg) Dose (mg) Use one of the following injections Age (months/years)
Susp Tablet (intravenously)
200mg/5mL 200mg 400mg 0.5mg/mL 1mg/mL
3.5-5kg 50mg 1.25mL - - 1-3 months 3.5-5kg 0.2mg 0.4mL 0.2mL 1-3 months
5-7kg 80mg 2mL - - 3-6 months 5-7kg 0.3mg 0.6mL 0.3mL 3-6 months
7-11kg 100mg 2.5mL ½ tablet - 6-18 months 7-9kg 0.4mg 0.8mL 0.4mL 6-12 months
11-14kg 120mg 3mL - - 18 months - 3 years 9-11kg 0.5mg 1mL 0.5mL 12-18 months
14-25kg 160mg 4mL - 3-7 years 11-14kg 0.6mg 1.2mL 0.6mL 18 months - 3 years
25-35kg 200mg 5mL 1 tablet ½ tablet 7-11 years 14-17.5kg 0.8mg 1.6mL 0.8mL 3-5 years
35kg-55kg 300mg 7.5mL 1½ tablets - 11-15 years ≥ 17.5kg 1mg 2mL 1mL ≥ 5 years
≥ 55kg 400mg - - 1 tablet ≥ 15 years
Azithromycin
Oral, 10mg/kg/dose daily for 3 days 5
Activated charcoal
1g/kg mixed as a slurry with water 2 Weight (kg) Dose (mg) Use one of the following: Age (months/years)
Weight (kg) Dose (mg) Age (months/years) Susp Tablet
3.5-7kg 5g 1-6 months 200mg/5mL 250mg 500mg
7-11kg 10g 6-18 months 7-9kg 80mg 2mL - 6-12 months
11-17.5kg 15g 18 months - 5 years 9-11kg 100mg 2.5mL - 12-18 months
17.5-35kg 25g 5-11 years 11-14kg 120mg 3mL - 18 months - 3 years
35-55kg 50g 11-15 years 14-18kg 160mg 4mL - 3-5 years
≥ 55kg 100g ≥ 15 years 18-25kg 200mg 5mL - 5-7 years
25-35kg 250mg - 1 tablet 7-11 years
Amoxicillin ≥ 35kg 500mg - - 1 tablet ≥ 11 years
Oral 30mg/kg/dose 8 hourly for 7 days 3
Weight (kg) Dose (mg) Use one of the following: Age (months/years)
Susp Capsule
125mg/5mL 250mg/5mL 250mg 500mg
2.5-3.5kg 75mg 3mL 1.5mL - - Birth-1 month
3.5-5kg 125mg 5mL 2.5mL - - 1-3 months
5-7kg 175mg 7mL 3.5mL - - 3-6 months
7-11kg 250mg 10mL 5mL 1 - 6-18 months
11-17.5kg 375mg 15mL 7.5mL - - 18 months - 5 years
17.5-25kg 500mg - 10mL 2 1 5-7 years
25-35kg 750mg - 15mL 3 7-11 years
≥ 35kg 1000mg - - 4 2 ≥ 11years
122
C
Ceftriaxone for suspected severe sepsis Cetirizine
IM 50-80mg/kg immediately as a single dose 6 Oral, once daily 9
Weight (kg) Dose (mg) Use one of the following injections mixed Age (months/years) Weight (kg) Dose (mg) Use one of the following: Age (months/years)
with water for injection WFI): Syrup Tablet
250mg/1mL 500mg/2mL 1mg/mL 10mg
(250mg diluted in (500mg diluted in
12-21kg 5mg 5mL - 2-6 years
1mL WFI) 2mL WFI)
≥ 21kg 10mg 10mL 1 tablet ≥ 6 years
< 3kg 125mg 1/2mL - Birth - 3 months
3 -6kg 250mg 1mL - Birth - 3 months Ciprofloxacin
6 -10kg 500mg - 2mL 3-12 months Oral, 15mg/kg/dose 12 hourly for 3 days 10
10 -15kg 750mg - 3mL 12-24 months Weight (kg) Dose (mg) Use one of the following: Age (months/years)
≥ 15kg 750mg - 4mL 2-5 years Susp Tablet
250mg/5mL 250mg 500mg
Ceftriaxone for suspected meningitis
IM 100mg/kg immediately as a single dose 7 9-11kg 150mg 3mL - - 12-18 months
Weight (kg) Dose (mg) Use one of the following injections mixed Age (months/years) 11-14kg 200mg 4mL - - 18 months - 3 years
with water for injection WFI): 14-17.5kg 250mg 5mL 1 - 3-5 years
250mg/1mL 500mg/2mL 17.5-25kg 300mg 6mL - - 5-7 years
(250mg diluted in (500mg diluted in ≥ 25kg 500mg 10mL 2 1 ≥ 7 years
1mL WFI) 2mL WFI)
< 3kg 250mg 1mL - Birth - 3 months Clarithromycin
3-6kg 500mg - 2mL Birth - 3 months Oral, 7.5mg/kg/dose, 12 hourly for 5 days 11
6-10kg 1000mg - 4mL 3-12 months Weight (kg) Dose (mg) Use one of the following: Age (months/years)
10-15kg 1500mg - 6mL 12-24 months Susp Tablet
≥ 15kg 2g - 8mL 2-5 years 125mg/5mL 250mg/5mL 250mg
3.5-5kg 30mg 1.2mL - - 1-3 months
Cephalexin 5-7kg 45mg 1.8mL - - 3-6 months
Oral, 12-25mg/kg/dose 6 hourly for 5 days. 8
7-9kg 62.5mg 2.5mL - - 6-12 months
Weight (kg) Dose (mg) Syrup Capsule Age (months/years) 9-11kg 75mg 3mL - - 12-18 months
125mg/5mL 250mg/5mL 250mg 11-14kg 100mg 4mL - - 18 months - 3 years
2.5-5kg 62.5 g 2.5mL - - Birth - 3 months 14-17.5kg 125mg 5mL 2.5mL - 3-5 years
5-11kg 125 g 5mL 2.5mL - 3-18 months 17.5-25kg 150mg 6mL 3mL - 5-7 years
11-25kg 250 g 10mL 5mL 1 capsule 18 months - 7 years 25kg-35kg 187.5mg 7.5mL 3.75mL - 7-11 years
≥ 25kg 500 g - - 2 capsules ≥ 7 years 35-55kg 250mg - 5mL 1 tablet 11-15 years

123
D E
Diazepam Epinephrine (adrenaline)
Rectal, 0.5mg/kg/dose for convulsions as a single dose. 12 1:1000, IM, 0.01mL/kg as a single dose 14
Weight (kg) Dose (mg) Ampoule 10mg/2mL Age (months/years) Weight (kg) Dose (mg) Injection 1mg/mL (1:1 000) Age (months/years)
3-6kg 2mg 0.4mL < 6 months 9-12kg 0.1mg 0.1mL 1-2 years
6-10kg 2.5mg 0.5mL 6 months - 1 year 12-18kg 0.2mg 0.2mL 2-5 years
10-18kg 5mg 1mL 1-5 years 18-40kg 0.3mg 0.3mL 5-12 years
18-25kg 7.5mg 1.5mL 5-8 years 40-55kg 0.5mg 0.5mL 12-15 years
25-40kg 10mg 2mL 8-12 years ≥ 55 g 1mg 1mL ≥ 15 years

Diazepam
IV, 0.25mg/kg/dose for convulsions as a single dose. 13 F
Weight (kg) Ampoule 10mg/2mL (=5mg/mL) Fluconazole
4-5kg 0.2mL Oral, 6mg/kg once daily 15
5-6kg 0.25mL Weight (kg) Dose (mg) Use one of the following: Age (months/years)
6-7kg 0.3mL Susp Capsule
7-8kg 0.35mL 50mg/5mL 50mg 200mg
8-9kg 0.4mL 3.5-5kg 25mg 2.5mL - - 1-3 months
9-10kg 0.45mL
5-7kg 30mg 3mL - - 3-6 months
10-11kg 0.5mL
7-9kg 50mg 5mL 1 capsule - 6-12 months
11-12kg 0.55mL
9-11kg 60mg 6mL 12-18 months
12-13kg 0.6mL
1-14kg 70mg 7mL - - 18 months - 3 years
13-14kg 0.65mL
14-17.5kg 100mg 10mL 2 capsules - 3-5 years
14-15kg 0.7mL
15-16kg 0.75mL 17.5-25kg 125mg 12.5mL - - 5-7 years
16-17kg 0.8mL 25-35kg 150mg 15mL 3 capsules - 7-11 years
17-18kg 0.85mL ≥ 35kg 200mg - - 1 capsule ≥ 11 years
18-19kg 0.9mL
Furosemide
19-20kg 0.95mL IV, 1mg/kg, over 5 minutes 16
20-25kg 1.0mL Weight (kg) Dose (mg) Injection 10mg/mL Age (months/years)
≥ 25kg 0.25 x weight ÷ 5 = number of mL to give
3.5-5kg 4mg 0.4mL 1-3 months
5-7kg 6mg 0.6mL 3-6 months
7-9kg 8mg 0.8mL 6-12 months
9-11kg 10mg 1mL 12-18 months
11-14kg 12mg 1.2mL 18 months - 3 years
14-17.5kg 15mg 1.5mL 3-5 years
17.5-25kg 20mg 2mL 5-7 years
25-35kg 30mg 3mL 7-11 years
≥ 35kg 40mg 4mL ≥ 11 years

124
H L
Hydrocortisone Lactulose
Slow IV, 4-6mg/kg immediately 17 Oral, 0.5mL/kg/dose once daily. If poor response, increase frequency to 12 hourly. 19
Weight (kg) Dose (mg) Injection 100mg/2mL Age (months/years) Weight (kg) Syrup 3.3g/5mL Age (months/years)
11-14kg 50mg 1mL 2-3 years 5-7kg 3mL 3-6 months
14-17.5kg 75mg 1.5mL 3-5 years 7-9kg 4mL 6-12 months
≥ 17.5kg 100mg 2mL ≥ 5 years 9-11kg 5mL 12-18 months
11-14kg 6mL 18 months - 3 years
I 14-17.5kg 7.5mL 3-5 years
17.5-35kg 10mL 5-11 years
Ibuprofen
Oral, 5-10mg/kg/dose 8 hourly with food 18 ≥ 35kg 15mL ≥ 11 years
Weight (kg) Dose (mg) Use one of the following: Age (months/years) Lorazepam
Syrup Tablet Buccal, IV or IM 0.1mg/kg as a single dose for convulsions or for sedation 20
100mg/5mL 200mg Weight (kg) Dose (mg) Injection/buccal administration 4mg/mL Age (months/years)
9-11kg 80mg 4mL - 12-18 months < 4kg 0.4mg 0.1mL < 1 month
11-14kg 100mg 5mL - 18 months - 3 years 4-6kg 0.5mg 0.15mL 1-3 months
14-17.5kg 120mg 6mL - 3-5 years 6-8kg 0.7mg 0.2mL 3-6 months
17.5-25kg 150mg 7.5mL - 5-7 years 8-10kg 0.9mg 0.25mL 6-12 months
25-40kg 200mg 10mL 1 tablet 7-12 years 10-12kg 1.1mg 0.3mL 12-18 months
≥ 40kg 400mg - 2 tablets ≥ 12 years 12-14kg 1.3mg 0.3mL 18 months - 3 years
14-16kg 1.5mg 0.4mL 3-4.5 years
16-22kg 1.8mg 0.5mL 4.5-7 years
22-30kg 2.6mg 0.6mL 7-10 years
30-34kg 3.2mg 0.8mL 10 -11 years
34-40kg 3.7mg 0.9mL 11-13 years
≥ 40kg 4mg 1.1mL ≥ 13 years

125
M
Metronidazole Midazolam
Oral, 7.5mg/kg/dose 8 hourly for 5 days 21 IV 0.25mg/kg 23
Weight (kg) Dose (mg) Use one of the following: Age (months/years) Midazolam 5mg/5mL ampoule Midazolam 15mg/3mL ampoule
Suspension Tablet (=1mg/mL) (=5mg/mL)
200mg/5mL 200mg 400mg Weight (kg) IV administration IV administration
9-11kg 80mg 2mL - - 12-18 months < 4kg - 0.2mL
11-14kg 100mg 2.5mL ½ tablet - 18 months - 3 years 4-5kg 1.0mL
14-17.5kg 120mg 3mL - - 3-5 years 5-6kg 1.3mL 0.3mL
17.5-25kg 160mg 4mL - - 5-7 years 6-7kg 1.5mL
25-35kg 200mg 5mL 1 tablet ½ tablet 7-11 years 7-8kg 1.8mL
0.4mL
35-55kg 300mg 7.5mL 1½ tablets - 11-15 years 8-9kg 2.0mL
≥ 55kg 400mg - - 2 tablets ≥ 15 years 9-10kg 2.3mL
0.5mL
10-11kg 2.5mL
Midazolam 11-12kg 2.8mL
Buccal 0.5mg/kg 22 0.6mL
12-13kg 3.0mL
Weight (kg) Dose (mg) Buccal administration 5mg/mL Age (months/years) 13-14kg 3.3mL
< 4kg 2mg 0.4mL < 2 months 0.7mL
14-15kg 3.5mL
4-7kg 3mg 0.6mL 2-6 months 15-16kg 3.8mL
7-9kg 4mg 0.8mL 6-12 months 0.8mL
16-17kg 4.0mL
9-11kg 5mg 1mL 12-18 months 17-18kg 4.3mL
11-14kg 6mg 1.2mL 18 months - 3 years 0.9mL
18-19kg 4.5mL
14-17.5kg 7.5mg 1.5mL 3-5 years 19-20kg 4.8mL
17.5-25kg 10mg 2mL 5-7 years 1.0mL
20-25kg 5.0mL
25-35kg 12.5mg 3mL 7-11 years 25-35kg 7.5mL 1.5mL
≥ 35kg 20mg 4mL ≥ 11 years 35-40kg 9mL 1.8mL

Morphine
Oral, 0.2-0.4mg/kg/dose 4-6 hourly 24
Weight (kg) Dose (mg) Use one of the following: Age (months/years)
Syrup Tablet
1mg/mL 10mg
7-9kg 2mg 2mL - 6-12 months
9-11kg 2.5mg 2.5mL - 12-18 months
11-14kg 4mg 4mL - 18 months - 3 years
14-17.5kg 5mg 5mL - 3-5 years
17.5-25kg 6mg 6mL - 5-7 years
≥ 25kg 10mg 10mL 1 tablet ≥ 7 years

126
P
Paracetamol Phenobarbitone
Oral, 10-15mg/kg/dose 6 hourly as needed for up to 5 days 25 Oral, crushed and given by nasogastric tube (NGT), 20 mg/kg as a single dose 27
Weight (kg) Dose (mg) Use one of the following: Age (months/years) Weight (kg) Dose (mg) Tablet 30mg Age (months/years)
Syrup Tablet 2.5-3.5kg 60mg 2 tablets Birth - 1 month
120mg/5mL 500mg 3.5-5kg 75mg 2½ tablets 1-3 months
3.5-5kg 48mg 2mL - 1-3 months 5-7kg 120mg 4 tablets 3-6 months
5-7kg 72mg 3mL - 3-6 months 7-11kg 180mg 6 tablets 6-12 months
7-9kg 96mg 4mL - 6-12 months 11-14kg 210mg 7 tablets 18 months - 3 years
9-11kg 120mg 5mL - 12-18 months ≥ 14kg 240mg 8 tablets ≥ 3 years
11-14kg 144mg 6mL 18 months - 3 years
Phenytoin
14-17.5kg 180mg 7.5mL 3-5 years
IV/IM 20mg/kg for status epilepticus if no phenobarbitone. Give once only. 28
17.5-25kg 240mg 10mL ½ tablet 5-7 years
Weight (kg) Injection 250mg/5mL
25-35kg 360mg 15mL 7-11 years
Mix in 50mL sodium chloride 0.9%
35-55kg 500mg - 1 tablet 11-15 years Give slowly over 30 minutes under ECG control
≥ 55kg 1 000mg 2 tablets 15 years 4kg 1.6mL
Phenobarbitone 5kg 2.0mL
IV/IM 20mg/kg over 5 minutes for convulsions. If still fitting, IV/IM 10mg/kg over 5 minutes 26 6kg 2.4mL
Weight (kg) Injection 200mg/mL 7kg 2.8mL
1st dose: 20mg/kg IV/IM 2nd dose: 10mg/kg IV/IM 8kg 3.2mL
Volume 0.1mg/kg Volume 0.05mg/kg 9kg 3.6mL
4kg 0.4mL 0.2mL 10kg 4.0mL
5kg 0.5mL 0.25mL 11kg 4.4mL
6kg 0.6mL 0.3mL 12kg 4.8mL
7kg 0.7mL 0.35mL 13kg 5.2mL
8kg 0.8mL 0.40mL 14kg 5.6mL
9kg 0.9mL 0.45mL 15kg 6.0mL
10kg 1.0mL 0.50nL 16kg 6.4mL
11kg 1.1mL 0.55mL 17kg 7.2mL
12kg 1.2mL 0.60mL 18kg 7.6mL
13kg 1.3mL 0.65mL 19kg 1.9mL
14kg 1.4mL 0.70mL 20kg 2.0mL
15kg 1.5mL 0.75mL
Praziquantel
16kg 1.6mL 0.80mL
Oral, 40mg/kg as a single dose 29
17kg 1.7mL 0.85mL
Weight (kg) Dose (mg) Tablet 600mg Age (months/years)
18kg 1.8mL 0.90mL
12-17.5kg 600mg 1 tablet 2-5 years
19kg 1.9mL 0.95mL
17.5kg-25kg 900mg 1½ tablet 5-7 years
20kg 2.0mL 1.00mL
25-35kg 1200mg 2 tablets 7-11 years
≥ 35kg 1800mg 3 tablets ≥ 11 years

127
Helpline numbers
Helpline Services provided Contact number/s
General counselling
Lifeline National Counselling Line Counselling for any life crisis and referral to relevant services 0861 322 322 (National helpline, 24 hour service)
Childline South Africa For children who are in crises, abuse or at risk of abuse and violence 0800 055 555 (24 hour toll-free); www.childlinesa.org.za
Family Services Directory Area specific directory of family services available with contact details provided www.pmhp.za.org/wp-content/uploads/Family-Services-Directory.updated.22.8.2016.pdf
First 1000 days Information on development, nutrition, health, safety and support during first www.westerncape.gov.za/first-1000-days
1000 days of child's life
The Parent Centre Parenting information, support and training 021 762 0116 (8am-4pm); www.theparentcentre.org.za
Health Care Worker
Poisons Information Helpline of the Western Cape Advice on the management of exposure to or ingestion of poisonous substances 0861 555 777 (24 hour line)
Suspected measles case Measles notification Ms Jacobs 021 483 3156/072 356 5146 (24hr) or Ms Desai 021 483 4266/082 770 5419 (24hr)
Medicines Information Centre For medicine advice (drug interactions, side effects, dosage, treatment failure) 021 406 6829 (8.30am-4.30pm); www.mic.uct.ac.za/MIC/Hotline
SASSA information line Assess and arrange grants 0800 601 011 toll-free (7.30-4pm); www.sassa.gov.za/
National HIV & TB Health Care Worker Hotline For HIV and TB related clinical queries 0800 212 506 (8.30am-4.30pm)
Rabies hotline NICD hotline for rabies advice 082 883 9920 (24 hour)
Philani Maternal, Child health and Nutritional Helps prevent and support child malnutrition with food aid and support 021 387 5124 (8.30am-4.30pm); www.philani.org.za
Project
Abuse
Provincial FCS number To notify police in the case of physical or sexual abuse www.ossafrica.com/esst/index.php?title=SAPS_WESTERN_CAPE
If unable to find number on website: 021- 417-7318 or 0860 010 111
Department of Social Development To notify a case of suspected child abuse or neglect and to obtain the fax 0800 220 250 (7.00am-7.00pm)
number to fax the form 22A to.
Safeline Abuse counselling, court preparation, anti-abuse awareness campaigns and 0800 035 553 (8am-3pm Monday to Thursday);
group therapy 072036704588 (24 hour crisis line)
Stop Gender Violence Support for children and carers experiencing domestic violence 0800 150 150 (24 hour toll-free)
Chronic Condition
Down Syndrome Association Advice and support groups for children with Down Syndrome and their families 0861 369 672 (8.30-4pm Monday to Thursday, 8.30am-1pm Friday); www.downsyndrome.org.za
Western Cape Cerebral Palsy Advice and support for parents and guardians of children with cerebral palsy 021 685 4150 (8.30am-3pm); www.wccpa.pl-dev.co.za
Hi Hopes Deaf children hearing support 0117173750 (8am-4.30pm); www.hihopes.co.za
Paedspal Care and support for children living with life-limiting illness 0212005873 (8.30am-4h30pm); www.paedspal.org.za
Epilepsy SA Education, counselling and support groups for child with epilepsy and their 0860 374537 (National Helpline, 8am-4.30pm Monday to Thursday, 8am-2pm Friday); www.
families epilepsy.org.za
Paediatric Cardiac Society of SA Advice, counselling and information for children with heart disease www.pcssa.org
Administration
MedicAlert® bracelets Assistance with application for MedicAlert® disc or bracelet 021 425 7328 (9am-4pm); 021 461 000 24 hour emergency line); www.medicalert.co.za
128
Quick Reference
If emergency situation, rather use a Broselow® Paediatric Emergency Tape, if available, to estimate weight, endotracheal tube size and emergency medicine doses.

Estimate weight according to age Decide if pulse rate is normal for age
0-12 months Weight (kg) = (0.5 x age in months) + 4 Age Pulse rate (beats/minute)
1-5 years Weight (kg) = (2 x age in years) + 8 Pulse rate decreased if: Pulse rate increased if:
5-12 years Weight (kg) = (3 x age in years) + 7 < 1 year < 110 ≥ 160
1-2 years < 110 ≥ 150
2-5 years < 95 ≥ 140
Decide if respiratory rate is normal for age
5-12 years < 80 ≥ 120
Age Respiratory rate (breaths/minute)
≥ 12 years < 60 ≥ 100
Respiratory rate decreased if: Respiratory rate increased if:
0-2 months < 30 ≥ 60
2-12 months < 30 ≥ 50 Decide on endotracheal tube (ETT) size and depth
Use cuffed tube if available. If uncuffed, use one size bigger than below formula.
1-5 years < 25 ≥ 40
ETT size (internal diameter (mm) ETT depth (cm)
5-12 years < 20 ≥ 25
3.5 + (age ÷ 4) (oral or nasal intubation) Oral intubation: (age ÷ 2) + 12
≥ 12 years < 15 ≥ 20
Nasal intubation: (age ÷ 2) + 15

Decide if blood pressure is normal for age

Decide on maintenance fluid rate
Age Systolic blood pressure (mmHg)
Weight 24 hour fluid requirement
Blood pressure decreased if: Blood pressure increased if:
Under 10kg 100mL/kg
< 1 year < 65 > 90
10-20kg 1000mL + (50mL for every kg body weight over 10kg)
1-2 years < 70 > 95
e.g.: if 14kg: 1000mL + (50 x 4)
2-5 years < 75 > 100 = 1200mL/24 hours
5-12 years < 80 > 110 ≥ 20kg 1500mL + (20mL for every kg body weight over 20kg)
≥ 12 years < 90 > 120 Maximum of 2000mL in females and 2500mL in males)
e.g.: if 23kg: 1500mL + (20 x 3)
= 1560mL/24 hours

129
 Primary Care Guideline for Adults· 2016-2017· Western Cape Edition
This PACK Primary Care Guideline for Adults is a clinical practice (see Acknowledgements inside front cover). A more thorough
tool designed for use in Western Cape public sector primary care explanation of the development process and role of contributors
consultations with adults. It uses a symptom-based approach to the can be found at www.knowledgetranslation.co.za.
client’s problem and a standardised integrated approach to the routine
care of the client with one or more chronic conditions, covering This PACK Primary Care Guideline for Adults was compiled by the
40 symptoms and 20 chronic conditions including HIV, TB, cardiovascular Knowledge Translation Unit, University of Cape Town Lung Institute.
risk and disease, mental health, chronic respiratory diseases, epilepsy, The Knowledge Translation Unit declares it has no competing interests
women's health, musculoskeletal disorders and palliative care. in pharmaceutical companies whose products or services are related
to the guideline topics.
PACK Primary Care Guideline for Adults complies with and integrates
Western Cape Provincial and South African National policies including This PACK Primary Care Guideline for Adults forms part of a pack of
recent updates for TB, HIV, diabetes and contraception. Prescribing clinical tools for use in primary care that includes a Community Care
provisions are displayed clearly for each medicine, its dose and Worker guide to assist CCWs to provide support to the client with a
indication, to capacitate staff to manage clients with common chronic chronic condition and Patient Information Leaflets designed to reinforce
conditions. treatment adherence and care-seeking messages for the client with a
chronic condition. These clinical tools are supported by PACK CCW and
The development and revision of the guideline was a collaborative adult guideline Training Manuals and an Implementation Toolkit to ensure
process with substantial input from managers, clinicians and the programme is embedded in the health system.
academics, as well as feedback from end-users of previous editions

Practical Approach to Care Kit

© 2016, Department of Health, Western Cape Government, South Africa - PACK Primary Care Guideline for Adults 2016-2017 (Western Cape Edition), as specifically
adapted for use in the Western Cape, South Africa in and during 2016/2017.

© 2016, University of Cape Town Lung Institute (Pty) Ltd - all rights of copyright vesting in all the original works and material used by the University of Cape Town Lung
Institute (Pty) Ltd in the preparation and development of the PACK Primary Care Guideline for Adults 2016-2017 (Western Cape Edition), in and during 2016/2017.