Guideline

Recommendations for management of common childhood conditions : evidence for technical update of pocket book recommendations : newborn conditions, dysentery, pneumonia, oxygen use and delivery, common causes of fever, severe acute malnutrition and supportive care

Year of Publication

2012

Issuing Institution

World Health Organization

Links

WHO IRIS,WHO IRIS

Recommendations

54 included recommendations

All newborns should be given 1 mg of vitamin K intramuscularly (IM) after birth (i.e. after the first hour by which the infant should be in skin-to-skin contact with the mother and breastfeeding should be initiated).

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

Neonates requiring surgical procedures, those with birth trauma, preterm newborns, and those exposed in utero to maternal medication known to interfere with vitamin K are at especially high risk of bleeding and must be given vitamin K (1 mg IM).

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Moderate

A neonate with risk factors for infection (i.e. membranes ruptured > 18 hours before delivery, mother had fever > 38 °C before delivery or during labour, or amniotic fluid was foul smelling or purulent) should be treated with the prophylactic antibiotics ampicillin (IM or intravenously, IV) and gentamicin for at least 2 days. After 2 days, the neonate should be reassessed and treatment continued only if there are signs of sepsis (or a positive blood culture).

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

Newborns without complications should be kept in skin-to-skin contact with their mothers during the first hour after birth to prevent hypothermia and promote breastfeeding.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Low

Term and preterm newbors with hyperbilirubinaemia should be treated with phototherapy or exchange transfusion guided by the following cut-off levels of serum hyperbilirubinaemia (see the full guideline for more details)

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

Clinicians should ensure that all newborns are routinely monitored for the development of jaundice and that serum bilirubin should be measured in those at risk: — in all babies if jaundice appears on day 1 — in preterm babies (<35 weeks) if jaundice appears on day 2 — in all babies if palms and soles are yellow at any age

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Very low

(Term and preterm newbors with hyperbilirubinaemia) Phototherapy should be stopped once serum bilirubin is 50 mmol/l (3 mg/dl) or below the phototherapy threshold

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

Neonates with signs of sepsis should be treated with ampicillin (or penicillin) and gentamicin as the first line antibiotic treatment for at least 10 days

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Low

If a neonate with sepsis is at greater risk of staphylococcus infection (e.g. extensive skin pustules, abscess, or omphalitis in addition to signs of sepsis), they should be given cloxacillin and gentamicin instead of penicillin and gentamicin

Status

Retired

Recommended in favor

Strong

(Neonate with sepsis).Where possible, blood cultures should be obtained before starting antibiotics. If an infant does not improve in 2–3 days, antibiotic treatment should be changed, or the infant should be referred for further management

Status

Updated

Recommended in favor

Strong

Head or whole body cooling (in management of hypoxic ischaemic encephalopathy) should not be done outside well-resourced, tertiary neonatal intensive care units, because there is potential for harm from this therapy in low-resource settings

Status

Updated

Recommended against

Strong

Certainty of evidence

Moderate

Young neonates with suspected necrotizing enterocolitis (NEC) should be treated with IV or IM ampicillin (or penicillin) and gentamicin as first line antibiotic treatment for 10 days

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Low

Low birth weight (LBW) neonates weighing < 2000 g who are clinically stable should be provided Kangaroo Mother Care (KMC) early in the first week of life.

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Moderate

Low birth weight neonates weighing >1200g who do not have complications and are clinically stable should be put in skin-to-skin contact with the mother soon after birth and after drying them thoroughly to prevent neonatal hypothermia

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

Antibiotics are not routinely recommended for children aged 2–59 months with nonsevere pneumonia (i.e. fast breathing with no chest indrawing or danger sign) with a wheeze but no fever (< temperature 38 °C), as the cause is most likely to be viral.

Status

Updated

Recommended against

Strong

Certainty of evidence

Low

Children with non-severe pneumonia (i.e. fast breathing with no chest indrawing or danger sign) should be treated with oral amoxicillin. The exception is in patients with HIV: - With low HIV prevalence, give amoxicillin at least 40mg/kg/dose twice daily for 3 days. - With high HIV prevalance, give amoxicillin of at least 40mg/kg/dose twice daily for 5 days

Status

Retired

Recommended in favor

Conditional

Certainty of evidence

Moderate

Children with non-severe pneumonia who fail on the first line treatment with amoxicillin should have the option of referral to a facility where there is appropriate second line treatment

Status

Updated

Recommended in favor

Conditional

Children aged 2–59 months with severe pneumonia (chest indrawing) should be treated with oral amoxicillin at least 40mg/kg/dose twice daily for 5 days.

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Moderate

In HIV/AIDS infected children, specific guidelines for treatment of severe pneumonia in the context of HIV should be followed

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Low

Children aged 2–59 months with very severe pneumonia should be treated with parenteral ampicillin (or penicillin) and gentamicin as a first line treatment. — Ampicillin: 50 mg/kg, or Benzyl penicillin: 50,000 units per kg IM/IV every 6 hours for at least 5 days — Gentamicin: 7.5 mg/kg IM/IV once a day for at least 5 days

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Moderate

Ceftriaxone should be used as a second line treatment in children with severe pneumonia with failure on the first line treatment

Status

Updated

Recommended in favor

Strong

Children with acute wheeze/asthma and bronchoconstriction should be treated with inhaled salbutamol using a metered dose inhaler (MDI) with spacer devices to relieve bronchoconstriction.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Low

Oral salbutamol should not be used for treatment of acute or persistent wheeze except where inhaled salbutamol is not available. Oral salbutamol is not useful in testing response to bronchodilators

Status

Updated

Recommended against

Strong

Certainty of evidence

Low

Children with diarrhoea and blood in stool (i.e. dysentery) should be treated with ciprofloxacin as a first line treatment. Ceftriaxone should be given as a second line treatment in severely ill children where local antimicrobial sensitivity is not known. — Ciprofloxacin: 15 mg/kg/dose twice daily for 3 days — Ceftriaxone: 50–80 mg/kg daily for 3 days

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Low

Recommendations for treatment of dysentery (in children). Where local antimicrobial sensitivity is known, local guidelines should be followed

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Low

Children with acute bacterial meningitis should be treated empirically with 3rd generation cephalosporins. — Ceftriaxone: 50mg/kg per dose IV every 12 hours or 100 mg/kg once daily, or — Cefotaxime: 50mg/kg per dose every 6 hours for 10–14 days.

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Moderate

(Children with acute bacterial meningitis) .Where it is known that there is no significant resistance to chloramphenicol and beta lactam antibiotics among bacteria-causing meningitis follow national guidelines or choose any of the following two regimens: — Chloramphenicol: 25 mg/kg IM (or IV) every 6 hours plus ampicillin: 50 mg/ kg IM (or IV) every 6 hours OR — Chloramphenicol: 25 mg/kg IM (or IV) every 6 hours plus benzyl penicillin: 60 mg/kg (100 000 units/kg) every 6 hours IM (or IV).

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Moderate

Children with acute otitis media should be treated with oral amoxicillin at 40 mg/ kg twice per for 7–10 days.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Low

(Children with acute otitis media) .Where pathogens causing acute otitis media are known to be sensitive to cotrimoxazole, this antibiotic could be used as an alternative given twice per day for 7–10 days.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Low

Children with chronic suppurative otitis media (CSOM) should, in addition to aural toilet by dry wicking, be treated with instillation of drops containing quinolones (such as ciprofloxacin, norfloxacin, ofloxacin) three times daily for two weeks.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Low

Children who fail to respond to treatment should be referred for further evaluation for other causes of chronic suppurative otitis media, especially tuberculosis

Status

Updated

Recommended in favor

Strong

Topical antiseptics and steroids should not be used for the treatment of chronic suppurative otitis media in children.

Status

Updated

Recommended against

Strong

Certainty of evidence

Low

Topical steroids should not be used in treating chronic suppurative otitis media

Status

Updated

Recommended against

Conditional

Certainty of evidence

Very low

Children with typhoid fever should be treated with a fluoroquinolone (i.e. Ciprofloxacin, Gatifloxacin, Ofloxacin, and Perfloxacin) as a first line treatment for 7–10 days. — Ciprofloxacin: orally 15 mg/kg/dose twice daily for 7–10 days.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Moderate

(Children with typhoid fever) .If the response to treatment is poor, consider drug-resistant typhoid, and treat with a second line antibiotic like 3rd generation cephalosporins or azithromycin. — Cetriaxone (IV): 80 mg/kg per day for 5–7 days, OR — Azithromycin: 20 mg/kg per day for 5–7 days.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Moderate

(Children with typhoid fever). Where drug resistance to antibiotics among salmonella isolates is known, follow the national guidelines according to local susceptibility data

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Moderate

In children with severe acute malnutrition (SAM) without complications, manage according to the current community case management guidelines

Status

Updated

Recommended in favor

Conditional

In children with severe acute malnutrition with complications, give parenteral antibiotics as follows: — Benzyl penicillin: 50 000 U/kg IM/IV every 6 hours, or ampicillin: 50 mg/kg IM/IV every 6 hours for 2 days, then oral amoxicillin: 15 mg/kg/dose every 8 hours for 5 days. AND — Gentamicin: 7.5 mg/kg IM/IV once daily for 7 days

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

Pulse oximetry is recommended to determine the presence of hypoxaemia and to guide administration of oxygen therapy in infants and children with hypoxaemia

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Low

Use pulse oximetry wherever possible for the detection of hypoxaemia in children with severe, lower respiratory infections. If oximetry is not available, then the following clinical signs could be used to guide the need for oxygen therapy: — central cyanosis — nasal flaring — inability to drink or feed (where this is due to respiratory distress) — grunting with every breath — depressed mental state (i.e. drowsy, lethargic)

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Low

In some situations and depending on the overall clinical condition, children with the following less-specific signs may also need oxygen: — severe lower chest wall indrawing — respiratory rate of 70/min or above — head nodding

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Very low

Children with hypoxaemia should receive appropriate oxygen therapy

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Low

(Children with hypoxaemia) .Effective oxygen delivery systems should be a universal standard of care, and should be made more widely available

Status

Updated

Recommended in favor

Strong

(Children with hypoxaemia). Administering oxygen therapy should be guided by pulse oximetry where available and thresholds for giving oxygen may vary depending on the altitude

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Very low

Children living at ≤ 2500 m above sea level should receive oxygen therapy if their oxygen saturation is ≤ 90%, as measured by pulse oximetry

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Very low

In children living at high altitude (> 2500m above sea level), the normal oxygen saturation is lower than those living at sea level. At these altitudes, a lower level of saturation, such as SpO2 ≤ 87%, could be used as a threshold for giving oxygen

Status

Updated

Not specified

Certainty of evidence

Very low

Nasal prongs are the preferred method for delivering oxygen in infants and children under 5 years of age with hypoxaemia who require oxygen therapy.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Moderate

(Delivering oxygen in infants and children under 5 years of age with hypoxaemia who require oxygen therapy.) Where nasal prongs are not available, nasal or nasopharyngeal catheters could be used as alternative delivery methods. Face masks or head-boxes are not recommended.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Moderate

Children with hypoxaemia should be closely monitored using pulse oximetry

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Very low

(Children with hypoxaemia) .Oxygen therapy should be discontinued when oxygen saturation remains stable above recommended levels of 90% (≤ 2500M above sea level) or 87% (> 2500M above sea level) for at least 15 minutes on room air in a clinically stable child

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Very low

Sublingual sugar may be used as an immediate first aid measure in managing hypoglycaemia in children in situations where intravenous administration of glucose may be impossible or delayed

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Low

Resuscitation: Children severely dehydrated or with signs of shock should be resuscitated using isotonic intravenous (IV) solutions such as sodium chloride 0.9% or ringers lactate

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Low

Intravenous maintenance fluid: For children who require IV fluids for maintenance, options include ringers lactate solution with 5% dextrose, sodium chloride 0.45% with glucose 5%, sodium chloride 0.45% with glucose 2.5%, or 0.9% sodium chloride with glucose 5%.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Low

(Children who require IV fluids for maintenance) .Low sodium-containing solutions, such as sodium chloride 0.18% with glucose 4%, or 5% glucose in water, should not be used as there is an increased risk of hyponatraemia leading to cerebral oedema

Status

Updated

Recommended against

Strong

Certainty of evidence

Low