Final Basic Pediatric Protocol

BASIC PAEDIATRIC PROTOCOLS
September 2023
5th Edition
TABLE OF CONTENTS
Foreword................ ..................................................................................................................... 5
Acknowledgement ..................................................................................................................... 6
Abbreviations............................................................................................................................. 7
Principles of good care: ............................................................................................................. 8
Specific policies: ........................................................................................................................ 8
Admission and assessment: ...................................................................................................... 9
Clinical audit and use of the protocols .....................................................................................10
Hand hygiene ........................................................................................................................... 12
Use of alcohol hand rub / gel/ soap. Wash hand when visibly soiled ..................................... 13
Essential drugs ........................................................................................................................ 18
Emergency drugs – diazepam and glucose (nb diazepam is not used in neonates). ................ 20
Anticonvulsant drug doses and administration........................................................................ 22
Intravenous / intramuscular antibiotic doses – ages 7 days and older .................................... 22
Oral antibiotic doses - ................................................................... ........................................... 26
Initial maintenance fluids / feeds in normal renal function ..................................................... 28
Triage of sick children.............................................................................................................. 28
Infant / child basic life support – cardio-respiratory collapse ................................................. 30
Management of the infant / child without trauma with .......................................................... 30
Signs of life – assessment prior to a full history ..................................................................... 30
And examination ...................................................................................................................... 32
Use of intra-osseous lines ....................................................................................................... 33
Treatment of convulsions ........................................................................................................ 34
Diarrhoea / GE protocol (excluding severe malnutrition).......................................................... 35
Dehydration management – child without severe malnutrition/severe anaemia * ................. 36
Persistent diarrhoea, points to remember................................................................................ 38
Treatment of severe malaria.................................................................................................... 39
Anti-malarial drug doses ......................................................................................................... 40
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Malaria treatment doses ......................................................................................................... 42
Assessment of nutritional status ............................................................................................. 44
Classification and admission of acute malnutrition in children 6 – 59 months ....................... 45
Classification, outpatient and inpatient admission criteria for infants <6 months classify
nutritional status in under six months ..................................................................................... 46
Classification, outpatient and inpatient admission criteria plw .............................................. 46
Classification and admission of acute malnutrition in children 6 – 59 months ....................... 47
Complicated severe acute malnutrition ................................................................................... 48
Emergency fluid management in severe acute malnutrition .................................................... 48
Feeding children with severe acute malnutrition..................................................................... 50
Meningitis – investigation and treatment. .............................................................................. 51
Pneumonia protocol for children aged 2 - 59 months without severe acute malnutrition ....... 52
Pneumonia treatment failure definitions ................................................................................. 52
Possible asthma – admission management of the wheezy child ............................................. 54
Hiv – provider initiated testing and counselling (pitc), ............................................................ 54
Treatment and feeding ............................................................................................................ 56
Managing the hiv exposed / infected infant – please check for updates – arv doses change
fast! ......................................................................................................................................... 58
Newborn resuscitation – for trained health workers ..................... ...................................... 59
Neonatal sepsis / jaundice .................................... .............................................................. 60
Neonatal jaundice.................................................................................................................... 61
Treatment if 37 weeks or more gestational age ...................................................................... 62
Duration of treatment for neonatal / young infant sepsis ....................................................... 65
Continuous positive airway pressure ....................................................................................... 67
Nasogastric 3 hrly feed amounts for well babies on full volume feeds on day 1 and afterwards
................................................................................................................................................. 67
B. Iv fluid rates in ml / hr for sick newborns who cannot be fed orally/via ngt on full volume 68
C. Standard regimen for introducing ngt feeds in a vlbw or sick newborn after 24hrs iv fluids
................................................................................................................................................. 70
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2
Poisoning/envenoming ............................................................................................................ 72
Emergency estimation of child’s weight from their age .......................................................... 74
Appendix 1: .............................................................................................................................. 74
Prescribing oxygen ................................................................................................................... 75
Appendix 2: .............................................................................................................................. 75
Summary of antibiotics for severely malnourished children .................................................... 76
Appendix 3: .............................................................................................................................. 76
Preparation of therapeutic feeds for severely malnourished children ..................................... 76
3. Preparation of local therapeutic feeds recipes for f-75 and f-100 ....................................... 82
Rutf reference card. ................................................................................................................. 87
Other paediatric emergencies.................................................................................................. 87
Diabetic ketol acidosis (dka) management in children & adolescents ..................................... 88
Choking .................................................................................................................................... 89
How to manage the choking child (over 1 year of age) ............................................................ 90
Annex 7: body mass index for adults (=w/h2) wt in kg and height in metres ........................... 91
Annex 8: infant young child feeding recommendations ........................................................... 91
Iycf feeding recommendations of family diet after 2 years of age .......................................... 92

FOREWORD
Uganda has made considerable progress in reducing under-five and infant mortality from 128/1,000
live births and 71/1,000 live births in 2006 to 52/ 1,000 live births and 36/ 1,000 live births in 2022,
respectively. However, these rates are still significantly higher than the National Development Plan
III, the Ministry of Health Strategic Plan, and the Sustainable Development Goal targets. Most
reported health facility childhood deaths occur within the first 24 hours of admission and are attribut-
ed to common treatable conditions. It is known that rapid triage for all children presenting at health
facilities to identify the very sick children and initiate appropriate treatment can avert these deaths.
The Ministry of Health and stakeholders have revised and updated the Basic Pediatric Protocol
Handbook. These protocols are based on the latest evidence-based practices and provide a
structured approach to assessesment and treatment of sick children in emergency situations. They
encompass a broad spectrum of conditions, empowering healthcare providers to make informed
decisions swiftly and effectively.
The Basic Pediatric Protocol handbook represents a pivotal step towards standardizing and optimiz-
ing the delivery of pediatric emergency care in our healthcare facilities. The ability to promptly and
accurately triage sick children is essential for ensuring that those in critical need receive timely,
appropriate interventions. This document also serves as a vital resource for training and
capacity-building efforts. By adhering to the principles outlined herein, healthcare professionals at
all levels will be equipped with the knowledge and skills necessary to excel in emergency care,
ultimately saving lives and reducing morbidity.
I extend my sincere gratitude to all those who have contributed to developing these protocols. Their
dedication and expertise have been instrumental in ensuring that this resource meets the highest
standards of quality and relevance.
Finally, I encourage all healthcare facilities, both public and private, to embrace these protocols as a
cornerstone of pediatric emergency care in a bid to improve the quality of care for sick children in
Uganda.
Dr. Henry Mwebesa

Director General of Health Services
Ministry of Health
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ACKNOWLEDGEMENT
I am pleased to extend my heartfelt appreciation to all those who have contributed to the review and
update of the Basic Pediatric Protocol Handbook. This invaluable resource represents a significant
milestone in our collective efforts to improve the quality of care for pediatric emergencies.
The dedication, expertise, and tireless commitment demonstrated by the team of experts, healthcare
professionals, and partners involved in creating these protocols are commendable. Their collabora-
tive spirit and unwavering focus on evidence-based practices have resulted in a comprehensive
guide that will undoubtedly profoundly impact the quality of emergency care provided to our children.
I would like to extend special thanks to Jesca Nsungwa, Richard Mugahi, Bodo Bongomin, Deogra-
tias Munube, Elias Kumbakumba, Deogratias Migadde, Chris Ebong, Agnes Namagembe, Robert
Mutumba, Tom Ediamu, Nasur Mubarak, Kagimu Richard, Mary Nyantaro, Harriet Ajilong, Emmanuel
Mugisa, Fred Kagwire, Florence Namuwaya, Elizabeth Ayebale, Florence Alaroker, Florence Oyella
Otim, Pauline Achom, Samuel Kabugo, Jalia Serwadda, Shadia Nagawa, Emily Tumwakire, Akello
Irene, Ndagire Kisakye Gloria, Amoit Specioza, Godfrey Kakaire, Bagala John Paul, Doreen
Tukamushaba, Mukama Gideon, Deogratias Lubowa Ssemuju, Acam Jane Frances, William Oyang,
Divine Kemigisa, Lydia Namwanse, John Vianney Owayezu, Busingye Olive, and Caroline Aujo
whose invaluable insights and contributions have been instrumental in shaping these guidelines into
a resource of the highest caliber. Their expertise has ensured that the protocols are relevant,
practical, and aligned with the evolving needs of our healthcare system.
I also extend my gratitude to the dedicated healthcare providers who will utilize these protocols in
their daily practice. Your commitment to delivering exceptional pediatric care is vital to the success
of this endeavor, and I am confident that the Basic Pediatric Protocol handbook will serve as a
valuable tool in your efforts.
Finally, I sincerely thank all stakeholders who have supported and endorsed this initiative. Special
thanks to the Uganda Pediatric Association, USAID MCHN Activity, UNICEF, and WHO. Together, we
are working towards a stronger, more resilient healthcare system that prioritizes the well-being and
safety of our patients.
I am confident that the Basic Pediatric Protocol handbook will serve as a cornerstone in advancing
pediatric emergency care services nationwide. Let us continue to collaborate, innovate, and strive for
excellence in healthcare delivery.
Dr. Richard Mugahi

Assistant Commissioner
Reproductive and Infant Health Division

ABBREVIATIONS
CTX Cotrimoxazole prophylaxis treatment

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

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

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

1. Clinical audit is aimed at self-improvement and is not about finding who to
blame.
2. The aims are for health facility to diagnose key problems in providing care -it is
essential that identifying problems is linked to suggesting who needs to act,
how and by when to implement solutions. Then follow up on whether progress
is being achieved with new audits. Identify new problems and plan new actions
etc.

3. Health facilities should have an audit team comprising 4 to 8 members, or bigger
depending on the size of the health facility (in line with the paediatric death
audit guidelines).led by a senior clinician and including nurses, admin, lab,
nutrition etc. the 1-2 people should be selected to "summarize the case (record of
care) for the audit team" ; NOT carry out the audit and report back to the audit
team and department staff. Deaths and surviving cases can be audited.
Records of all deaths should be audited within 24 hours of death
4. Use appropriate tools (perinatal and paediatric death audit tools) to compare
care given with recommendations in the national protocols and guidelines and
the most up to date textbooks for less common conditions.
5. Was care reasonable? Look for where improvements could be made in the
system of care before the child comes to health facility (referral), on arrival in
health facility (care in the OPD / MCH etc), on admission to a ward, or follow up
on the ward.
6. Look at assessments, diagnoses, investigations, treatments and whether what
was planned was done and recorded. Check doses and whether drugs / fluids /
feeds are correct and actually given and if clinical review and nursing
observations were adequate – if it is not written down it was not done!
7. Look at several cases for each meeting and summarize the findings looking for
the major things that are common and need improving. Then record the
summaries for reporting.
HAND HYGIENE
• Good hand hygiene saves lives
• Gloves can easily become contaminated too – they do not protect patients
• Alcohol hand-rubs are more effective than soap and water and are recommended
o If hands are visibly dirty they must be cleaned first with soap and water
before drying and using alcohol hand-rub
o The alcohol hand-rub must be allowed to dry off to be effective
o If alcohol hand-rub is not available then hands should be washed with
simple soaps and water and air-dried or dried with disposable paper towels
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• Hand hygiene should be performed:
After contact with any body fluids.
o Before and after touching a patient and most importantly before and after
handling cannulae, giving drugs or performing a procedure (eg. Suction).
o Before and after touching potentially contaminated surfaces (eg. cot sides,
dirty mattresses, stethoscopes and phones)
• Patients and caregivers should wash hands carefully after visits to the bathrooms
or contact with body fluids.
• Posters and other prompts should be placed on the wall where hand washing
takes place and should be provide the correct procedure for carrying out hand
washing using soap and water or using alcohol hand rub.

Use of Alcohol Hand rub / gel/ soap. Wash hand when visibly soiled
WHO guidelines on hand hygiene in health care 2009
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Essential drugs Doses
Adrenaline 1 in Dilute 1; 9 (1 in 1000 adrenaline in water for injection).
10,000 Give 0.1ml/kg in resuscitation.
Adrenaline 1 in Severe viral croup 2ml of 1:1000 nebulized If effective
1,000 repeat with careful monitoring
Albendazole Age < 2yrs, 200mg stat, Age ≥ 2yrs, 400mg stat
Amikacin 15mg/kg once daily. Slow IV over 3-5min If serious

gram -ve infection/resistance to gentamicin higher
doses may be used with monitoring.
Aminophylline- Preterm (less than 34weeks or 1.5kg) Loading
iv ONLY used in dose 6mg/kg iv over 20 minutes , Maintenance (or
health facility oral): Age 0-7 days -3mg/kg 12hrly starting 24hrs
inpatients! after loading, until they reach 34 weeks of gestation
or 1.5kg.
Amoxicillin 40mg/kg every 12 hours
Ampicillin Neonate: 50mg/kg/dose 12 hourly IV if aged <7 days
and 8 hourly if aged 8- 28 days. Aged 1month and
over: 50mg/kg/dose ( Max 500mg) 6hrly
Artemether-
See page 42
Lumefantrine
Artemisinin- If < 20kgs give 3.0mg/kg/dose and if >20kg give
Piperaquine/ 2.4mg/kg/dose at 0, 12, 24hrs
Artesunate - IV See page 39
Azithromycin 10mg/kg max 500mg PO daily for 3 days
Beclomethasone Age < 2yrs 50-100 micrograms 12hrly, ≥ 2yrs 100-200
micrograms 12hrly
Budesonide MDI with a spacer 200 micrograms daily
Benzyl Penicillin See page 23

(X-pen)
Calcium Symptomatic hypocalcemia (tetany/convulsions) Iv
bolus of 10% calcium gluconate 0.5 ml/kg ( 0.11
mmol/kg) to a maximum of 20ml over 5-10min then
continuous IV infusion over 24h of 1.0 mmol/kg
(maximum 8.8 mmol).
Mild hypocalcemia
50mg/kg/day of elemental calcium PO in 4 divided
doses.
Cefotaxime Preferred to ceftriaxone in treatment of neonatal
meningitis if aged < 7 days
Pre-term: 50mg/kg 12 hrly
Term aged < 7 days : 50mg/kg 8 hrly
Age < 7 days or weight <1200g: 50mg/kg IV 12 hrly.
Ceftazidime Age > 7 days or weight > 1200g: 50mg/kg IV 8 hrly
1 month- 12yrs: 30-50mg/kg IV 8 hrly (Max: 6g/day)
(for pseudomonas infections)
Ceftriaxone Refer to appropriate page

Chloramphenicol Refer to appropriate page
iv
7.1% 4% Chlorhexidine (ambigel) apply once daily until cord
Chlorhexidine separates
Digluconate
Ciprofloxacin - Dysentery dosing: refer to appropriate page
oral
Clotrimazole 1% Apply paint / cream daily
Dexamethasone For severe croup 0.6mg/kg stat
Flucloxacillin Refer to appropriate pages
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Diazepam – iv 0.3mg/kg (=300 mcg/kg) & See separate chart
Diazepam – 0.5mg/kg (=500 mcg/kg) & See separate chart

rectal
Digoxin 15 mics/kg loading dose then 5 mics/kg 12hrly
Erythromycin 30-50mg/kg/day in 3 -4 divided doses: max 2g/day
Gentamicin 5mg/kg/24hrly IM or slow IV

Ibuprofen 5 - 10 mg/kg 8 hourly
Iron tabs / syrup Weight 200mg Syrup 140mg/5ml twice daily
tabs
twice
daily
200mg Ferrous 3-6kg - 2.5ml
sulphate tabs 7-9kg 1/4 5ml
140mg /5ml 10- 1/2 10ml
Ferrous fumarate 14kg 1/2 15ml
syrup 15-
20kg
Ketoconazole 3mg/kg daily
Mebendazole 100mg 12hrly for 3 days or 500mg
(age > 1yr)
Metronidazole – refer to appropriate pages
oral
Morphine <1 month, 150mcg/kg, 1-11 months 200mcg/kg, 1 -
5yrs 2.5 - 5 mg, 6 – 12 yrs 5 – 10 mg
Multivitamins <6 months 2.5ml daily, >6months 5ml 12 hrly
Nystatin (100,000 1ml 6hrly (2 weeks in HIV positive children)

IU/ML)

Paracetamol 10-15mg / kg 6 to 8 hrly
Pethidine, I.V 0.5 to 1mg / kg every 4- 6 hours
Phenobarbitone Refer to appropriate page
Potassium Oral: 1 - 4 mmol/kg/day (same dose for i.v route)
Prednisolone – Asthma 1mg/kg daily (usually for 3 days)

tabs
Quinine Refer to appropriate page
Salbutamol IV in health facilicity only over 5 mins - <2yrs 5
IV therapy should microgram/kg, ≥ 2yrs up to 15 microgram/kg max
only be used on an dose 250 micrograms
HDU, ideally with a
monitor, and Nebulised 2.5mg/dose as required (see ‘Page 54)
MUST be given
slowly as directed Inhaled (100 microgram per puff) 4 - 10 puffs for
Oral salbutamol 30 min and repeated every 20 min for an hour via
should ONLY be spacer repeated as req’d acutely – see page 54 for
used if inhaled emergency use - or 4-6 puffs up to 4-6 hrly short-
therapy is not term maintenance or outpatient treatment.
possible and for a Oral 1mg/dose 6-8hrly aged 2-11 months, 2mg/dose
maximum duration 6-8hrly aged 1 - 4 yrs (1 week only)
of week Use
inhaled steroid for
persistent asthma
Vitamin A Age
Once on <6 months 50,000iu stat
admission, not to 6-12 months 100,000iu stat
be repeated within >12 months 200,000iu stat
1 month
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For malnutrition
with eye disease
repeat on day 2
and day 14
Vitamin D – <6 months 3,000iu = 75 micrograms
Rickets
Low dose regimens >6 months 6,000iu = 150 micrograms
daily for 8 – 12 wks >6 months stat 300,000iu IM = 7,500 micrograms or
or high dose stat. regimen 7.5mg stat
After treatment <6 months 150,000iu IM stat
Vitamin D – <6 months 200 - 400 iu (5 – 10 μg)
Maintenance
Calcium >6 months 400 - 800 iu (10 – 20 μg)
50mg/kg/day for
first week of
treatment
Vitamin K Newborns 1mg stat im (<1500g, 0.5mg im stat)
For liver 0.3mg/kg stat, max 10mg

disease:
Zinc Sulphate > 6 mths 20mg,
Tabs ≤ 6mths 10mg od, 10 days

EMERGENCY DRUGS – DIAZEPAM AND GLUCOSE (NB DIAZEPAM IS NOT USED IN NEONATES).
Weight Diazepam Glucose,
(kg) (The whole syringe barrel of a 1ml or 2ml syringe should be inserted 5ml/kg of 10% glucose over 5 - 10
gently so that pr DZ is given at a depth of approx. 4 - 5cm) minutes
IV IV PR PR IV
Dose ml of Dose ml of Total volume. To make 10% glucose
0.3mg/kg 10mg/2ml 0.5mg/kg 10mg/2ml 10% glucose The ratio of water for
injection to 50%
solution solution Glucose is 1:4
3.00 1.0 0.20 1.5 0.3 15 50% Glucose and
4.00 1.2 0.25 2.0 0.4 20 water for
5.00 1.5 0.30 2.5 0.5 25 injection:
6.00 1.8 0.35 3.0 0.6 30 10ml syringe:
7.00 2.1 0.40 3.5 0.7 35  2ml 50% Glucose
8.00 2.4 0.50 4.0 0.8 40  8ml Water
9.00 2.7 0.55 4.5 0.9 45
10.00 3.0 0.60 5.0 1.0 50 20ml syringe:
11.00 3.3 0.65 5.5 1.1 55  4ml 50% Glucose
 16ml Water
12.00 3.6 0.70 6.0 1.2 60 50% Glucose and
13.00 3.9 0.80 6.5 1.3 65 5% glucose:
14.00 4.2 0.85 7.0 1.4 70
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15.00 4.5 0.90 7.5 1.5 75 10ml syringe:
16.00 4.8 0.95 8.0 1.6 80  1ml 50% glucose
17.00 5.1 1.00 8.5 1.7 85  9ml 5% glucose
18.00 5.4 1.10 9.0 1.8 90
19.00 5.7 1.15 9.5 1.9 95 20ml syringe:
20.00 6.0 1.20 10.0 2.0 100  4ml 50% glucose
 18ml Water
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ANTICONVULSANT DRUG DOSES AND ADMINISTRATION
Phenobarb,
loading Phenobarb
Phenobarb, Phenytoin,
dose, maintenance
maintenance, 5mg/kg loading Phenytoin, maintenance
15mg/kg 2.5mg/kg 12hrly
daily (high dose – dose 5mg/kg daily
(use (fits in acute
Weight chronic therapy) 15mg/kg
20mg/kg for febrile illness)
(kg)
neonates)
ORAL – IV/ORAL/N
IM/ORAL IM – MG IM/ORAL IV/ORAL/NG
TABS G
2.0 30 10 5 Tablets may be crushed

- and put down ngt if
2.5 37.5 12.5 6.25
- required.
3.0 45 15 7.5 45 15
4.0 60 20 ½ tab 10 60 20
5.0 75 25 12.5 75 25
6.0 90 30 15 ½ tab 90 30
7.0 105 35 1 tab 17.5 105 35
8.0 120 40 20 120 40
1 tab
9.0 135 45 1 ½ tab 22.5 135 45
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10.0 150 50 25 150 50
11.0 165 55 27.5 165 55
12.0 180 60 30 180 60
13.0 195 65 2 tabs 32.5 195 65
14.0 210 70 35 210 70
15.0 225 75 37.5 225 75
1 ½ tab
16.0 240 80 2 ½ tabs 40 240 80
17.0 255 85 42.5 255 85
18.0 270 90 45 270 90
19.0 285 95 3 tabs 47.5 285 95
2 tabs
20.0 300 100 50 300 100

INTRAVENOUS / INTRAMUSCULAR ANTIBIOTIC DOSES – AGES 7 DAYS AND OLDER
(NN DOSES SEE APPROPRIATE PAGE).
Ceftriaxone
iv/im max
Benzyl Ampicillin or
Gentamicin 50mg/kg 24hrly Metronidazole
Penicillin* Flucloxacillin Chloramphenicol
(7.5mg/kg) IM for neonates** (7.5mg/kg)
Weight (50,000iu (50mg (25/kg)
or IV over 3-5 meningitis/ V IV
(kg) /kg) /kg) IV/IM
mins sev sepsis, 12 hrly < 1m,
IV/IM IV/IM 6 hrly – meningitis
24 hrly 100mg/kg over ≥1m 8hrly
6 hrly 8 hrly
30-60 min. OD
50mg/kg
3.0 150,000 150 75 20 150 20
4.0 200,000 200 100 30 200 30
5.0 250,000 250 35 250 35
6.0 300,000 300 150 45 300 45
7.0 350,000 350 175 50 350 50
8.0 400,000 400 200 60 400 60
9.0 450,000 450 225 65 450 65
10.0 500,000 500 250 75 500 75
11.0 550,000 550 275 80 550 80
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12.0 600,000 600 300 90 600 90
13.0 650,000 650 325 95 650 95
14.0 700,000 700 350 105 700 105

15.0 750,000 750 375 110 750 110
16.0 800,000 800 400 120 800 120
17.0 850,000 850 425 125 850 125
18.0 900,000 900 450 135 900 135
19.0 950,000 950 475 140 950 140
20.0 1,000,000 1000 500 150 1000 150
*NB. Double Pen doses if treating Meningitis and age > 1 month ** Not recommended if jaundiced

ORAL ANTIBIOTIC DOSES - FOR NEONATAL DOSES SEE APPROPRIATE PAGE.
High dose
Cloxacillin/ amoxicillin for
Amoxicillin, oral, Ciprofloxacin Metronidazole
flucloxacillin pneumonia and
25mg/kg/dose 15mg/kg/dose 7.5mg/kg/dose
15mg/kg/dose severe infections
40-45mg/kg/dose
Weight
250mg
(kg) 250mg
ml susp 250mg ml susp caps ml susp
tabs – 250mg tabs 200mg tabs
125mg/5ml caps 125mg/5ml or 125mg/5ml
disp
tabs
12 12 hrly (for 3
12 hrly 8 hrly 8 hrly 12 hrly 8 hrly
hrly days)
3.0 5 ½* 2.5 ¼ 5 ½ tab
4.0 5 ½* 2.5 ¼ 7.5 ¼
5.0 5 ½* 5 ¼ 10 ¼ ¼
6.0 5 ½* 5 ½ 10 1 tab = ¼ ¼
7.0 7.5 ½* 5 ½ 15 250 ½ ½
8.0 7.5 ½* 5 ½ 15 ½ ½
9.0 7.5 1 5 ½ 15 ½ ½
10.0 10 1 5 1 20 2 tabs ½ ½
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11.0 10 1 10 1 20 = 500 1 ½
12.0 10 1 10 1 20 1 ½
13.0 10 1 10 1 25 1 ½
14.0 15 2 10 1 25 1 1
15.0 15 2 10 1 25 1 1
16.0 15 2 10 1 1 1
3 tabs
17.0 15 2 10 1 1 1
= 750
18.0 15 2 10 1 1 1
19.0 20 2 10 1 1 1
20.0 20 2 10 1 1 1
*Amoxicillin syrup should be used and tablets divided ONLY if syrup is not available

INITIAL MAINTENANCE FLUIDS / FEEDS IN NORMAL RENAL FUNCTION
Note:
• Feeding should start as soon as safe and infants may rapidly increase to
150ml/kg/day of feeds as tolerated (50% more than in the chart).
• Add 50ml 50% dextrose to 450ml Ringer’s Lactate to make Ringer’s/5% dextrose
a useful maintenance fluid.
• Drip rates are in drops per minute
Drip
rate – Drip rate –
Rate
Weight Volume adult iv paediatric 3 hrly bolus
in
kg in 24hrs set, 20 burette 60 feed volume
ml/hr
drops = drops = 1ml
1ml
3 300 13 4 13 40
4 400 17 6 17 50
5 500 21 7 21 60
6 600 25 8 25 75
7 700 29 10 29 90
8 800 33 11 33 100
9 900 38 13 38 110
10 1000 42 14 42 125
11 1050 44 15 44 130
12 1100 46 15 46 140
13 1150 48 16 48 140
14 1200 50 17 50 150
15 1250 52 17 52 150
16 1300 54 18 54 160
17 1350 56 19 56 160

18 1400 58 19 58 175
19 1450 60 20 60 175
20 1500 63 21 63 185
21 1525 64 21 64 185
22 1550 65 22 65 185
23 1575 66 22 66 185
24 1600 67 22 67 200
25 1625 68 23 68 200
the 5th Edition 28

TRIAGE OF SICK CHILDREN
Emergency Signs:
If history of trauma ensure cervical spine is protected.
Airway &  Obstructed breathing

breathing  Central cyanosis
 Severe respiratory distress
Immediate transfer to
 Weak/absent breathing
emergency area:
Start life support procedures
Give oxygen
Cold hands with ANY of: Weigh if possible
Capillary refill >3 seconds
Weak + fast pulse
Slow (<60bpm) or absent pulse
Disability: Coma/convulsing/confusion: AVPU = ‘P or U’ or Convulsions
Diarrhoea with sunken eyes assessment/treatment for severe dehydration
Priority signs
 Tiny - Sick infant aged < 2months
 Temperature – very high > 38.50C, very
 low < 35.50 C
 Trauma – major trauma  Front of the Queue: clinical
 Pain – child in severe pain review as soon as possible
 Poisoning – mother reports poisoning  Weigh
 Pallor – severe palmar pallor  Baseline observations
 Restless / Irritable / Floppy
 Respiratory distress
 Referral – has an urgent referral letter
 Malnutrition - Visible severe wasting
 Oedema of both feet
 Burns – severe burns
Non-urgent – Children with none of the above signs

INFANT / CHILD BASIC LIFE SUPPORT – CARDIO-RESPIRATORY
COLLAPSE
Safe, stimulate, shout for Help! Set – Rapidly move child to emergency
1) Assess and clear airway, 2) Position head/neck to open airway
Assess breathing – look, listen, feel for 5 seconds
Adequate breathing
No breathing
Give 5 rescue breaths with bag and mask – if

chest doesn’t move check airway open and Support airway
mask fit and repeat Continue oxygen
After at least 5 good breaths
Check large pulse for 5 – 10 seconds

Pulse palpable and >60bpm
No or weak, slow pulse (<60bpm)
Give 15 chest compressions then continue giving 15 chest

compressions for each 2 breaths for 1-2 minute(s).
Continue 20 -30 breaths/min with oxygen,
Look for signs of dehydration / poor circulation
Improvement and give emergency fluids as necessary,
Reassess ABC Consider treating hypoglycaemia
Continue full examination to establish cause of
No change illness and treat appropriately.
1) Continue 15 chest Improvement

compressions: 2 breaths for 2
minutes
2) Reassess ABC
Improvement
No change
Consider iv 0.1ml/kg 1 in 10,000 [mix 1ml (1 in 1,000) in 9ml of sterile water] Adrenaline if 3 people in team,
Consider fluid bolus if shock likely and treatment of hypoglycaemia
Continue CPR in cycles of 2 - 3 minutes after any intervention
Reassess ABC every 2 – 3 minutes.
Consider advanced life support/care; ( +/- referral to next level)
the 5th Edition 30

MANAGEMENT OF THE INFANT / CHILD WITHOUT TRAUMA WITH
SIGNS OF LIFE – ASSESSMENT PRIOR TO A FULL HISTORY
AND EXAMINATION
Obs Safe Eye contact/ movements
Stimulate – if not alert Shout unless obviously alert
Shout for help – if not alert If not alert place on resus couch
Setting for further evaluation If alert it may be most
appropriate to continue
evaluation while child is with
parent
A Assess for obstruction by Position only if not alert and
listening for stridor / airway placed on couch
noises. Suction (to where you can see) if
Look in the mouth if not alert indicated (not in alert child),
Position – if not Alert Guedel airway only if minimal
(appropriate for age) response to stimulation
B Assess adequacy of Decide:

breathing • Is there a need for oxygen?
• Cyanosis? • Is there a need for
• Grunting? immediate bronchodilators?
• Head nodding or
bobbing?
• Rapid or very slow
breathing?
• Indrawing?
• Deep / Acidotic
breathing
If signs of respiratory distress

listen for wheeze
C Assess adequacy of Decide:
circulation If shock (at least 3/4 signs) and
• Large pulse – very fast Give 20ml/kg Ringer’s over 15
or Diarrhoea. very slow? minutes and progress to Plan C
• Coldness of hands and fluids for diarrhoea/dehydration
line of demarcation? (step 2) If severe pallor anaemia
• Capillary refill? >3 sec with deep breathing/resp.
• Peripheral pulse – weak distress, transfuse
or not palpable?
• (Note initial response to If shock (at least 3/4 signs) and
stimulation / alertness) No diarrhoea or severe anaemia,
• Check for severe pallor give 20ml/kg Ringer’s over 1-2
If signs of very poor hours
circulation
• Check for signs of If No diarrhoea or anaemia & <
severe malnutrition 3/4
(oedema/ visible signs shock, give maintenance
wasting) fluids (NO BOLUS)
If not shock but significant
circulatory compromise
• Check for severe
dehydration
D Assess AVPU Decide:
If AVPU = A, reassess ABC • Does this child need 10%
If AVPU < A, give 10% dextrose? (if AVPU < A)
dextrose
the 5th Edition 32

USE OF INTRA-OSSEOUS LINES
Use IO for all children in shock if no IV access to avoid delays in initiation of fluid
therapy
 Use IO or bone marrow needle 15-18G if

available or 16-21G hypodermic needle
 Clean after identifying landmarks then use
sterile gloves and sterilize site
 Sterility - Use antiseptic and sterile gauze
to clean site (alcohol 70% or iodine or
chlohexidine)
 Site – Middle of the antero-medial (flat)
surface of tibia at junction of upper and
middle thirds – bevel to toes and introduce
vertically (900)- advance slowly with
rotating movement
 Stop advancing when there is a ‘sudden
give’ – then aspirate with 5ml needle
 Slowly inject 3ml N/Saline looking for any leakage under the skin – if OK attach
iv fluid giving set and apply dressings and strap down
 Give fluids as needed – a 20ml or 50ml syringe will be needed for boluses
 Watch for leg / calf muscle swelling
 Replace IO access with iv within 8 hours

TREATMENT OF CONVULSIONS
Convulsions in the first 1 month of life should be treated with Phenobarbitone
20mg/kg stat, a further 5-10mg/kg can be given within 24 hours of the loading dose
with maintenance doses of 5mg/kg daily.
Age > 1 month

Child convulsing Y 1) Ensure safety and check ABC.
for more than 5 2) Start oxygen.
minutes 3) Treat both fit and hypoglycaemia:
Check glucose / give 5ml/kg 10% Dextrose Give i.v
N diazepam 0.3mg/kg slowly over 1 minute, OR rectal
diazepam 0.5mg/kg.
Child having 3rd 4) Check ABC when fit stops.
convulsion lasting
<5mins in < 2 hours*
N Convulsion stops by
Check ABC, observe and Y 10 minutes?
investigate cause
N
Treatment:
5) Give iv diazepam 0.3mg/kg slowly over 1 minute, OR
Y rectal diazepam 0.5mg/kg
6) Continue oxygen
7) Check airway is clear when fit stopped
Check ABC, observe and Y Convulsion stops by 15

investigate cause minutes?
N
Treatment:
8) Give im phenobarbitone 15mg/kg – DO NOT give more than
* If children 2 doses of diazepam in 24 hours once phenobarbitone used.
have up to 2 fits (If given iv, give over 20mins)
lasting <5 mins 9) Maintenance therapy should be initially with
they do not phenobarbitone 5mg/kg OD x 48 hrs.
require 10) Continue oxygen during active seizure.
emergency drug 11) Check ABC when fit stops.
treatment. 12) Investigate cause (Blood slide, RBS, lumber puncture.
the 5th Edition 34

Diarrhoea / GE protocol (excluding severe malnutrition)
Antibiotics are NOT indicated unless there is dysentery or persistent diarrhoea and proven amoebiasis
or giardiasis. If dysentery but unable to do stool analysis, cover for shigella first as is the commonest cause
Diarrhoea > 14 days may be complicated by intolerance of ORS – worsening diarrhoea – if seen (increase
in stool volumes, new/worsening dehydration) change to iv regimens. cases to receive Zinc
History of diarrhoea / vomiting, age > 2 months
Hypovolaemic SHOCK.
Ringers 20ml/kg over 15 minutes, (for neonates
All four of Y give 10ml/kg) a second boluses may be given if
• Cold hands + temp grad weak / required before proceeding to step 2 of plan C
absent pulse • Treat for hypoglycaemia
• Capillary refill > 3 secs • Start ORS 5 ml/kg/hr once able to drink
• AVPU < A
NB if Hb<5g/dl tr sf s r tly
N IV Step 1 - 30ml/kg Ringer’s

Y over 30 mins if age ≥ 12m, over
60 mins if age < 12m.
SEVERE Dehydration.
(Plan C)
Unable to drink or AVPU < A IV Step 2 - 70ml/kg Ringer’s over 2.5 hrs
plus: OR
age ≥ 12m, over 5 hrs age <12m.
• Sunken eyes
• Slow skin pinch ≥2
secs If no iv access/ iv fluids: ngt
rehydration – 100ml/kg ORS
N Re-assess at least hourly, after 3 - 6 hours re-classify as severe, some or

no dehydration and treat accordingly.
SOME DEHYDRATION Plan B,

Able to drink adequately but 2 1) ORS by mouth at 75ml/kg over 4 hours,
or more of: Y plus,
• Sunken eyes 2) Continue breast feeding and encourage
• slow skin pinch 1-2 secs feeding if > 6 months
• Restlessness / irritability Reassess at 4 hours, treat according to
N
Y Plan A
NO DEHYRATION 10ml/kg ORS after each loose stool Continue
Diarrhoea/GE with fewer than 2 breast feeding and encourage feeding if > 6
of the above signs of dehydration months

DEHYDRATION MANAGEMENT – CHILD WITHOUT SEVERE
MALNUTRITION/SEVERE ANAEMIA *
Shock, Plan C –
Plan B
20ml/kg step 1 Plan C – step 2
–
Ringer’s or 30ml/kg 70ml/kg Ringer’s or ngt ORS
75ml/kg
Weight saline Ringer’s
kg Age <12m, Age ≥1 yr,
Age <12m,
1 hour over 2 ½ hrs Over 4
Immediately over 5hrs = Volume
Age ≥1 yr, = hours
drops/min**
½ hour drops/min**
2.00 40 50 10 150 **Assumes 150
2.50 50 75 13 200 ‘adult’ iv 150
3.00 60 100 13 200 giving sets 200
where 20
4.00 80 100 20 300 drops = 1ml 300
5.00 100 150 27 400 55 350

6.00 120 150 27 400 55 450
7.00 140 200 33 500 66 500
8.00 160 250 33 500 66 600
9.00 180 250 40 600 80 650
10.00 200 300 50 700 100 750
11.00 220 300 55 800 110 800
12.00 240 350 55 800 110 900
13.00 260 400 60 900 120 950
14.00 280 400 66 1000 135 1000
15.00 300 450 66 1000 135 1100
16.00 320 500 75 1100 150 1200
17.00 340 500 80 1200 160 1300
18.00 360 550 80 1200 160 1300
19.00 380 550 90 1300 180 1400
20.00 400 600 95 1400 190 1500
*Consider Immediate blood transfusion if severe pallor or Hb <5g/dl on

admission*
the 5th Edition 36

Persistent diarrhoea, points to remember
• Diarrhoea with or without blood lasting 14 days or more.
• Asses for signs of dehydration and give fluids as per treatment plans
A, B, or C. (remember to watch out for worsening of diarrhoea with
ORS).
• Asses for infections such as pneumonia, sepsis, oral thrush, otitis
media, asses for severe malnutrition.
• Obtain samples for CBC, electrolytes, HIV, blood slide, blood culture,
stool microscopy, urine microscopy.
• Provide medical treatment and Antibiotic cover as appropriate
• All children should receive daily supplementary multivitamins and
minerals for two weeks.
• Monitor daily the body weight for gain, food taken, temperature and
number of diarrhoea stools.
Feeding in persistent diarrhoea
Infants < 6 months

• Encourage exclusive breastfeeding as much as possible
• If not breastfeeding, give low lactose breast milk substitute such as
yoghurt, or lactose free milk
• Encourage use of cup or spoons as opposed to feeding bottle.
Children 6 months and above
• Give reduced lactose diet, as the first option, for at least 7 days.
• If there is no improvement after 7 days, change to the second diet,
which is lactose free.

1st diet -Starch based, low lactose diet for persistent diarrhoea*.
Item Amount Local approximate
measures
Powder milk, or whole milk 27.5g 3 tablespoons full
170ml
Raw rice 30g 3 tablespoons full
Vegetable oil 8.75g 1 tablespoon full
Water 500ml cup
*Adapted from WHO guidelines 2013, quantities modified to aid measurement

Give 130 ml/kg /day
2nd diet – lactose free with reduced cereal*

Item Amount Local approximate measures
Whole egg 160g 2 egss

Raw rice 7.5g 1 tablespoon full
Vegetable oil 10g 1 tablespoon full
Sugar 7.5g 1 tablespoon full
Water To make 500ml 500ml
* Adapted from WHO guidelines 2013, quantities modified to aid measurement

Give 145ml/kg/ day.
the 5th Edition 38

Treatment of severe malaria
If a high-quality blood slide is negative with signs of Severe malaria,
do RDT to confirm absence of malaria infection. Investigate for other causes of
fever
**Severe malaria = Fever + Treat with I.V/I.M artesunate (or quinine if not available):
any of: 1. Artesunate: 2.4mg/kg for >20kg or 3.0mg/kg for
1. AVPU = ‘V, P, U’, or, <20kg (at 0,12 & 24 hrs) if no improvement after the 3
2 . Unable to drink, or, doses switch to iv 10mg/kg quinine 8hrly
3 . Respiratory distress with Yes 2. Treat hypoglycaemia.
severe anaemia or 3. Maintenance fluids / feeds.
acidotic breathing, or, 4. Assess hydration status and manage as appropriate,
4. Hypoglycaemia (glucose DO NOT give bolus iv fluid unless diarrhoea with
≤ 2.2mmols/l) signs of SEVERE Dehydration
5. 3 or more convulsions 5. If Respiratory distress & Hb < 5 g/dl transfuse 20
ml/kg whole blood or 10ml/kg of packed cells
No
Severe anaemia, Hb<5g/dl, alert Give DP (dihydro artemisinin + piperaquine) (or

Yes
(AVPU= ‘A’), able to drink oral second line if not available) and iron, if Hb
and breathing comfortable. <4g/dL, transfuse 20 ml/kg whole blood (or
10ml/kg packed cells) over 4hrs urgently after
No transfusion give haematenics
Fever, none of the severe signs above, Antimalarial not required,

Test
able to drink / feed, AVPU = ‘A’ then look for another cause of
follow reliable malaria test result illness. Repeat test if
concern remains.
Test positive
If Hb < 9g/dl treat with oral iron for
Treat with recommended 1st line oral 14 days initially. If respiratory
antimalarial, or 2nd line if 1st line treatment distress develops and Hb < 5g/dl
transfuse urgently.
Treatment failure:
1) Consider other causes of illness / co-morbidity
2) A child on oral antimalarials who develops signs of severe malaria (Unable to sit or drink,
AVPU=U or P and / or respiratory distress) at any stage should be changed to i.v artesunate.
3) If a child on oral antimalarials has fever and a positive blood slide after 3 days (72 hours)
then check compliance with therapy and if treatment failure proceeds to second line treatment
**There are other forms of severe malaria, AKI, Haemoglobinuria,

ANTI-MALARIAL DRUG DOSES
Artesunate
Artesunate typically comes as a powder together with a 1ml vial of 5%
bicarbonate that then needs to be further diluted with either normal saline or 5%
dextrose- the amount depends on whether the drug is to be given iv or im (see
table below)
• Do not use water for injection to prepare artesunate for injection
• Do not give artesunate if the solution in the syringe is cloudy
• Do not give artesunate as a slow iv drip (infusion)
• You must use artesunate within 1 hour after it is prepared for injection
Preparing iv/ im Artesunate IV IM

Artesunate powder (mg) 60mg 60mg
Sodium Bicarbonate (ml, 5%) 1ml 1ml
Normal Saline or 5% Dextrose (ml) 5ml 2ml
Artesunate concentration (mg/ml) 10mg/ml 20mg/ml
Quinine
For iv infusion typically 5% or 10% dextrose is used
• Use at least 1 ml fluid for each 1mg of quinine to be given
• Do not infuse quinine at a rate of more than 5mg/kg/hour
o Use 5% dextrose or N/saline for infusion with 0.5-1ml of fluid for each
1mg of quinine
o 10mg/kg dose takes 4 hours
For I.M quinine on the muscle (thigh, deltoid)
Note: Avoid the buttocks
• Take 1ml of the 2ml in a 600mg quinine sulphate iv vial and add 5ml water
for injection – this makes a 50mg/ml solution
• If you need to give more than 3ml in a child, divide the doses and give into
two i.m sites
the 5th Edition 40

MALARIA TREATMENT DOSES
• Artesunate is given IV/IM for a maximum of 24 hours
• As soon as the child can eat drink (after 24 hours for artesunate) then change
to a full course of artemisinin combination therapy (ACT) typically the 1st
line oral anti-malarial dihydroartemisinin+ piperaquine or AL
• Weight <20kg- 3mg/kg and >20kg – 2.4mg/kg of artesunate
Artesunate, 3mg/kg at 0, 12 and 24 Quinine, Quinine, tabs,
hr 10mg/kg 10mg/kg
Weight
IV ml of IM ml of
kg Dose IV infusion / 300mg QN
60mg in 60mg in
in mg IM 8 hrly sulphate 8 hrly
6ml 3ml
3.0 0.9 09 0.45 30 ¼
4.0 1.0 12 0.60 40 ¼
5.0 1.5 15 0.70 50 ¼
6.0 1.8 18 0.70 60 ¼
7.0 2.1 21 0.80 70 ¼
8.0 2.4 24 1.00 80 ¼
9.0 2.7 27 1.10 90 ¼
10.0 3.0 30 1.20 100 ½
11.0 3.3 33 1.30 110 ½
12.0 3.6 36 1.50 120 ½
13.0 3.9 39 1.60 130 ½
14.0 4.2 42 1.70 140 ½
15.0 4.5 45 1.80 150 ½
16.0 4.8 48 1.90 160 ½
17.0 5.1 51 2.00 170 ½
18.0 5.4 54 2.20 180 ½
19.0 5.7 57 2.30 190 ½
20.0 6.0 60 2.40 200 1

AL (Artemether +
Lumefantrine) (20:120mg) Dihydroartemisinin – piperaquine,
Give with food or milk stat, (20:160) OD for 3 days
+8hrs, BD on day 2 and day 3
Weight Age Dose Age Dose
½
<5kg - 3-35 mths 1 paed tab
tablet
3-35 1
5-14kg 3-5 yrs 2 paed tab
mths tablet
3-7 2
15-24kg 6-11 yrs 1 adult tab
yrs tablets
9-11 3
25-34kg
yrs tablets
>12 4
>34kg
yrs tablets
NB: For IM Artesunate = MG/20mg/ml
the 5th Edition 42

Assessment of nutritional status
Assessment of nutrition status involves history taking, physical examination for signs
of malnutrition and anthropometry. Anthropometry is the measurement of body
parameters in comparison to reference standards to indicate nutrition status. These
include:
• Mid-upper-arm circumference (MUAC)
• Body Weight
• Length (for children below 2years or less than 87cm) or height (for children above
2years, or > 87.0 cm, adolescents and adults)
Weight and height measurements can be useful to detect wasting and stunting
and individual monitoring over time (growth velocity).
Determine the child’s age from child health card or recall from the caregiver.
Mid-upper arm circumference

MUAC is used to measure wasting using a tape around the left upper arm. It is quick
and simple to perform in sick patients. It is essential to use the age limit of 6 months
for arm circumference because there are no standard measurements for infants
below six months of age.
Weight, Height and age

• Weight for height (W/H): = measure of wasting, and indicates acute
malnutrition.
• Height for age (H/A): measure of stunting and indicates chronic
malnutrition Weight for age (W/A): indicative of both acute and chronic malnutrition.
• W/A is thus not used for diagnosis of acute malnutrition but plotted
over time in the diagnosis of acute malnutrition, we use W/H expressed as Z-scores
obtained from WHO growth reference standards and MUAC.
• Visible severe wasting tends to identify only severe cases of SAM. It is
better to use MUAC.

Bilateral Pitting oedema
Oedema is swelling from excess fluid in the tissues. Oedema is usually seen in the
feet and lower legs and arms. In severe cases it may also be seen in the upper limbs
and face.
Observation Classification
No oedema (0)
Bilateral oedema in both feet (below the ankles) + / (Grade 1)
Bilateral oedema in both feet and legs, (below ++ / (Grade 2) moderate

the knees) hands or lower arms
Bilateral oedema observed on both feet, legs, +++ / (Grade 3) severe
arms, face
the 5th Edition 44

Classification and Admission of Acute Malnutrition in Children 6 – 59
Months
Age category Nutritional Not Acutely Moderate Acute Severe
indicator Malnourished Malnutrition Malnutrition
(NAM) (MAM) (SAM)
Children 6-59 MUAC cut-off ≥12.5cm 11.5cm to 12.5cm Less than 11.5cm
months in 6-59
And any child with months
age ≥60 months W/H or W/L Greater than or Greater or equal to -3 Less than -3 Z-score
whose height is (see Annex equal to -2 Z-score Z-score and less than (<-3 SD)
≤120cm 4.2) (≥-2 SD) -2 Z-score (≥-3 SD &
<-2 SD)
Bilateral No bilateral pitting No bilateral pitting Presence of bilateral
pitting oedema oedema pitting oedema (rule
oedema out medical causes)

Classification, Outpatient and Inpatient Admission Criteria for Infants
<6 Months Classify nutritional status in under six months
Normal nutritional Moderate acute Severe acute malnutrition (SAM)
status (NAM) malnutrition(MAM)
• WLZ ≥ –2 Z- • WLZ ≥ –3 to < Bilateral pitting oedema of any degree (+. ++. +++),
score –2 OR weight for length z-score (WLZ) < -3
• No • No OR any of the following:
breastfeeding breastfeeding • Weight loss
difficulties difficulties • Failure to gain weight
• Weight gain • Weight gain • Drop across the infant’s growth line;
• Alert and well • Alert and well With any danger signs or symptoms of severe disease
according to IMNCI
OR with breastfeeding difficulties after mother’s counselling.
OR referral from outpatient care according to action protocol
Admission criteria of infants less than 6 months in OTC or ITC

OTC ITC
WLZ < -3 with: Bilateral pitting oedema of any degree (+. ++. +++)
ANY of the following: weight for length z-score (WLZ) < –3
Moderate weight loss or recent (days to a
week), OR any of the following:
Failure to gain weight in a week, • Recent severe weight loss within 1 week
Moderate drop across WAZ lines • Prolonged failure to gain weight in weeks to months.
Moderate, mild or possible breastfeeding Sharp drop across the infant’s growth line WAZ
difficulties according to Box 4. WITH any danger signs or symptoms of severe disease according
• Infant not well attached to IMNCI
• Infant not suckling effectively OR WITH severe breastfeeding problems after mother’s
• Fewer than eight breastfeeds in 24 counselling in Box 3 and 4.
hours • Structural (anatomical) abnormalities e.g. Cleft lip or
• Infant receiving other foods or drinks palate.
• Abnormality of tone, posture and movement interfering
AND mother-infant pair clinically well and with breastfeeding
alert • Infant’s arms and legs falling to the side when infant is
Careful review and close follow-up held.
guaranteed • Infant’s body stiff, hard to contain or move
Infants whose carers who decline • Unable to support head or control trunk
admission • Excessive jaw opening or clenching
Referred from ITC after stabilization • Unwillingness or inability to suckle on breast
• Coughing and eye tearing while breastfeeding (sign of
unsafe swallowing)
OR referral from outpatient care according to action protocol
the 5th Edition 46

Classification, Outpatient and Inpatient Admission Criteria PLW
Normal nutritional status Moderate acute Severe acute malnutrition (SAM)
(NAM) malnutrition (MAM)
MUAC ≥23.0cm MUAC ≥19.0cm and Bilateral pitting oedema of any degree (+. ++. +++),
No bilateral pitting oedema <23.0cm MUAC <19.0cm
No bilateral pitting
oedema
Classify SAM in PLW for OTC and ITC admissions

OTC ITC
MUAC <19.0cm Bilateral pitting oedema (only in non-pregnant mother)
OR MUAC: <19.0 cm
OR Presence of Moderate or mild anaemia OR Severe anaemia
OR Presence of moderate or mild depression OR Severe depression
OR Has no breastfeeding difficulties OR Other medical complications
Has Social support With breastfeeding difficulties
OR Lack of social support.
Classification and Admission of Acute Malnutrition in Children 6 – 59

Months
Age category Nutritional Not Acutely Moderate Acute Severe Malnutrition
indicator Malnourished Malnutrition (SAM)
(NAM) (MAM)
Children and BMI for age >-2 SD Z score ≥ -3 SD & < -2 SD Z < -3 SD Z score
adolescents 5 – (See Annex score
19 years, and any 7)
child aged ≥5 Bilateral No bilateral No bilateral pitting Presence of bilateral
years whose pitting pitting oedema oedema pitting oedema (+ & ++
height >120 cm oedema admission to OTC; +++
admission to ITC)
Adults (>19 years) BMI (see >17 kg/m2 ≥16 cm and <17 < 16 kg/m2
Annex 8) kg/m2
Bilateral No bilateral No bilateral pitting Presence of bilateral
pitting pitting oedema pitting oedema (rule out
oedema medical causes)

Complicated Severe Acute Malnutrition
Admit to inpatient therapeutic care centre/hospital if there is:
• WHZ < - 3 or MUAC below cut off for age
• Oedema grade 3 ( +++)
• Medical complications or IMCI danger signs
Treat/prevent hypoglycemia: check blood glucose and treat if <3mmol/l

(5ml/kg 10% dextrose). If glucose test unavailable treat for hypoglycaemia if
Step 1
signs present. Oral/NGT glucose (sugar water) immediately and therapeutic
feeds should be given within 30mins
Treat/prevent hypothermia: check for hypothermia, axillary temperature <

Step 2 35°C. If present, warm with blankets or, kangaroo. Start therapeutic feeds
within 30 mins. Maintain room temperature at 36°C.
Treat/prevent dehydration: Check for dehydration- use IMAM guidelines to

classify then USE fluid plan for severe malnutrition. If dehydrated, give
Step 3
5ml/kg of resomal every 30 mins for first 2 hrs then 5-10ml/kg of resomal
every 1 hr for up to 10hrs
Electroplyte imbalance. Use F75. If not available milk with mineral mix or
Step 4 4mmol/kg/day of oral potassium. ( see appendix 3 for preparation of feeds for
severely malnourished children.)
Treat/prevent infection. All ill children with severe acute malnutrition should
Step 5 get iv ampicillin and gentamicin. Add nystatin/ketoconazole for oral thrush if
present. TEO (+atropine drops) for pus/ulceration in the eye.
Correct micronutrient deficiencies. Give high dose Vitamin A on admission

Step 6 and days 2 and 145 if eye signs are present. Delay vitamin A until oedema
subsides. Multivits and Folic acid if no F75/F100 or RUTF
Start cautious feeding with F75. See feeding chart. Prescribe the feeds.
Step 7
(Feed 2 hourly for first 24hrs, then 3 hrly thereafter)
Steps 8,9,10: Ensure appetite and weight are monitored. Start catch-up feeding with F-100 or RUTF.
Provide a caring and stimulating environment for the child and start educating the family on nutritional
needs of the child. Discharge on RUTF
the 5th Edition 48

EMERGENCY FLUID MANAGEMENT IN SEVERE ACUTE MALNUTRITION
Shock: AVPU < A, plus Cold hands with temperature gradient plus absent or weak
pulse plus capillary refill >3secs
• Give oxygen, Give 10% dextrose, 5ml/kg IV
• Give IV fluids: 15ml/kg in 1 hour Half Strength Darrow’s (HSD) in 5% dextrose or
Ringers lactate. If HSD in 5% Dextrose not available it can be made by adding
50ml 50% dextrose to 450ml HSD or ringers lactate.
If severe anaemia, start urgent blood transfusion not Ringers

If improves: Give 15ml/kg for another 1 hour of half strength Darrow’s in 5%
dextrose or ringers lactate then switch to oral ReSomal at 5-10ml/kg every hour
alternating with F-75 therapeutic feeds for up to 10 hours.
If does not improve

• Give maintenance iv fluid at 4ml/kg/hr
• when blood is available, stop all oral and IV fluids, Transfuse 10ml/kg whole
blood over 3 hours.
• Introduce F75 after transfusion complete.
Emergency
Shock Oral/ngt Resomal
maintenance
15ml/kg 10ml/kg/hr 4ml/kg/hr
Weight
Half-strength darrows in 5% D Resomal HSD in 5% D
kg
IV ORAL/NGT IV
Shock = over 1 Drops/min if 20 drops/ml 10ml/kg/hr for up to 10 Hourly until
hour giving set hours transfusion
4.00 60 20 40 15
5.00 75 25 50 20
6.00 90 30 60 25
7.00 105 35 70 30
8.00 120 40 80 30
9.00 135 45 90 35
10.00 150 50 100 40
11.00 165 55 110 44
12.00 180 60 120 46
13.00 200 65 130 48
14.00 220 70 140 50
15.00 240 80 150 52
*See appendix 3 for procedures in preparation of F-75
Dry skimmed milk Vegetable oil Sugar Water
F75* 25g 27g 100g Make up to 1000ml
F100* 80g 60g 50g Make up to 1000ml
* Ideally add electrolyte / mineral solution and at least add potassium

FEEDING CHILDREN WITH SEVERE ACUTE MALNUTRITION
Meningitis – investigation and treatment.

Age ≥ 60 days and history of fever
Immediate LP to view CSF by eye and
laboratory examination even if malaria slide
LP must be done if there’s one of: One of: positive unless:
• Coma, inability to drink/feed, AVPU = ‘P or Yes • Child has severe resp. distress
U’. • Pupils respond poorly to light,
• Stiff neck, unequal pupils
• Bulging fontanelle,
• Skin infection at LP site
• Fits if age <6 months or > 6 years,
• GCS < 7/15
• Any seizures
No
Do an LP unless completely normal
Yes mental state after febrile convulsion.
Agitation / irritability
Review within 8 hours and LP if doubt
persists.
No
Meningitis unlikely, investigate other causes of fever.
Interpretation of LP and treatment definitions:

Either Bedside examination:
• Looks cloudy in bottle (turbid) and not a blood-stained tap,
And / or Laboratory examination with one or more of (if possible):
• White cell count > 10 x 106/L
• Gram positive diplococci or Gram negative cocco-bacilli,
Yes to one Classify as definite meningitis:
No to all
1) Ceftriazone, OR
One of: 2) Chloramphenicol + Penicillin – double dose if age
• Coma >1mo
• Stiff neck Minimum 10 days of treatment I.V/I.M
• Bulging fontanelle, + LP
Classify probable meningitis:
looks clear Yes 1) Chloramphenicol + Penicillin – double dose if
None of those signs age > 1 month
Minimum 10 days of treatment I.V / IM
CSF Wbc + Gram stain result Steroids are not indicated.
All Tests not done

If meningitis considered possible –I.V /IM
Chloramphenicol & Penicllin and senior review.
No meningitis
NB: If gram negative organism presents in CSF treat for 21 DAYS
505th Edition
the 50
1. Feeding must be started cautiously, in frequent, small amounts. F-75 is the
starter feed.
2. When the child is stabilized (usually after 2-7 days), the “catch-up” formula
F-100 or Ready-to-Use-Therapeutic-Food (RUTF) is used to rebuild wasted
tissues.
3. If respiratory distress or oedema get worse or the jugular veins are engorged
reduce feed volumes.
F75 – acute feeding F100 RUTF if
Weight No or grade + or ++ oedema F100 @ 150ml/kg/day no F100
(kg) 3 hourly feed 3 hourly feed
Total feeds /24hrs Total feeds /24hrs 20mg/kg
volume volume
4.0 520 65 600 75 -
4.5 585 75 675 85 -
5.0 650 80 750 95 100
5.5 715 90 825 105 110
6.0 780 100 900 115 120
6.5 845 105 975 125 130
7.0 910 115 1050 135
7.5 975 120 1125 140
8.0 1040 130 1200 150
8.5 1105 140 1275 160 170
9.0 1170 145 1350 170 180
9.5 1235 155 1425 180 190
10.0 1300 160 1500 190 200
10.5 1365 170 1575 200 210
11.0 1430 180 1650 210 220
11.5 1495 185 1725 215 230
12.0 1560 195 1800 225 240
13.0 1690 211 1950 243 260
13.5 1755 219 2025 253 270
14.0 1820 228 2100 262 280
14.5 1885 236 2175 271 290
15.0 1950 244 2250 281 300
15.5 2015 252 2325 290 310
16.0 2080 260 2400 300 320
16.5 2145 268 2475 309 330
17.0 2210 276 2550 318 340
17.5 2275 284 2625 328 350
18.0 2340 293 2700 337 360
18.5 2405 301 2775 346 370
19.0 2470 309 2850 356 380
19.5 2535 317 2925 365 390
20.0 2600 325 3000 375 400
20.5 2665 333 3075 384 410

Pneumonia protocol for children aged 2 - 59 months without severe
acute malnutrition
For HIV exposed / infected children, see page 57&58
History of cough or difficulty breathing, age > 60 days.
Yes
Yes
One of the danger signs *Severe Pneumonia
Wheeze
Oxygen sat. <90% Cyanosis, • Oxygen,
Inability to drink / breast feed • Ampicillin or Benzylpenicillin
AVPU = ‘V, P or U’, or Grunting AND Gentamycin
No
Yes *Pneumonia –
Lower chest wall in drawing, • Oral Amoxicillin, high dose 40-
and/or fast breathing 45mg/kg
Wheez
No
No pneumonia, probable URTI.
Possible Asthma – Treat according to separate protocol see page 54 and REVISE
classification after initial treatment with bronchodilators
Revised WHO classification for the management and treatment of childhood pneumonia
February 2014
525th Edition
the 52
Pneumonia treatment failure definitions
HIV infection may underlie treatment failure – testing helps the child.
See HIV page for indications for PJP treatment.
Definition Action required
Anytime
Progression of pneumonia to severe pneumonia Change treatment from Penicillin alone to
(development of cyanosis or inability to drink in a chloramphenicol AND Gentamycin.
child with pneumonia without these signs on
admission)
Obvious cavitations on CXR Treat with oral cloxacillin* and gentamicin iv for
Staph. Aureus or gram-negative pneumonia
48 hours
Severe pneumonia child getting worse, re-assess Switch to Ceftriaxone unless suspect
thoroughly, get chest X ray if not already done Staphylococcal pneumonia then use oral
(looking for empyema / effusion, cavitations etc). cloxacillin* and gentamicin.
Do CBC and blood culture.
Suspect PJP especially if <12m, an HIV test
must be done - treat for Pneumocystis if HIV
positive/ sero-exposed
Severe pneumonia without improvement in at Change treatment from penicillin to
least one of: chloramphenicol
• Respiratory rate,
• Severity of indrawing,
• Fever >37.5°C,
• Eating / drinking.
Day 5
At least 3 of: a) If only on penicillin change to
• Fever, temp >37.50C chloramphenicol.
• Respiratory rate >60 bpm b) If on chloramphenicol change to
• Still cyanosed or saturation <90%, consider ceftriaxone.
cardiac disease c) Suspect PJP, do HIV test (must) - treat for
• Chest indrawing persistent PCP if HIV positive or sero-exposed.
• Worsening CXR, d) Consult cardiologist if? cardiac
• Persistent fever and respiratory distress. Consider TB, perform mantoux and heck TB
treatment guidelines.
* IV
cloxacillin can cause phlebitis, oral route recommended

POSSIBLE ASTHMA – ADMISSION MANAGEMENT OF THE WHEEZY
CHILD
Wheeze + history of cough or difficult breathing – likelihood of asthma much higher if age > 12
months and recurrent wheeze
Y
Immediate Management
• Oxygen – measure saturation
Severe:
• Nebulize 2.5mg salbutamol every 20 minutes
Wheeze, AVPU < A, Y Cyanosis,
for 3 doses in one hour if needed or inhaler +
Inability to drink / breast feed or
Y spacer + mask (1 puff every 3 minutes up to
inability to talk Oxygen sats.
10 puffs in 30 minutes.)
<90%. Pulse rate >200 bpm (0-3
• Consider ipratropium bromide 250mcg if poor
yrs) >180 bpm (4-5 yrs)
response
• Start oral (prednisolone) or iv steroids if
cannot drink
• Salbutamol 2 puffs of inhaler ( or 2.5mg

Mild or Moderate nebulized) every 20 mins up to 3 doses if
Wheeze and fast breathing Y needed
or lower chest wall
• Oxygen
indrawing Age 2 – 11
months: Respiratory rate ≥
50, Age ≥12 months:
Respiratory rate ≥ 40 Monitor closely for 1-2 hours
If mild symptoms allow

If lack of response, refer to immediate
home on MDI
management above
• Salbutamol by inhaler, spacer + mask

• Reassess respiratory rate after 20-30 minutes, if persistently elevated give antibiotics for
pneumonia and give maintenance fluids
• Give education on use of inhaler, spacer + mask and danger signs and discharge on salbutamol
4-6 hrly for no more than 5 days plus if recurrent asthma, consider inhaled corticosteroid
prophylaxis Look out for co-morbidities. Prednisolone administered for 3- 5 days.
the 5th Edition 54

HIV – PROVIDER INITIATED TESTING AND COUNSELLING (PITC),
TREATMENT AND FEEDING
It is government policy that ALL SICK CHILDREN presenting to facilities with

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

The person doing PITC should record HIV testing results in the medical
record and indicate whether the caretakers has been informed of the
result.
Any child < 18 months with a positive rapid test is HIV exposed and is treated as
though infected until definitive testing rules out HIV infection.
Ongoing Treatment / Feeding.

1) If breastfed encourage exclusive breastfeeding until 6 months then
introduce complementary feed, breastfeed until 12 months of age.
2) Do not abruptly stop breast feeding at 6months, just add complementary
feeds.
3) Refer child and caregiver to an HIV support clinic – ART should be started in
all HIV infected children as soon as the diagnosis is confirmed.
4) All HIV exposed / infected infants should start cotrimoxazole (CTX)
prophylaxis from 6 weeks of age.
the 5th Edition 56

MANAGING THE HIV EXPOSED / INFECTED INFANT – PLEASE CHECK
FOR UPDATES – ARV DOSES CHANGE FAST!
PMTCT Nevirapine Prophylaxis:

• If formula fed from birth give nevirapine (NVP) for first 6 weeks only
• If breastfeeding – give NVP from birth until 6weeks of age. For high-risk
infants, give NVP from birth until 12weeks of age. High risk infants are those
whose mothers either: have received ART for 4weeks or less before delivery;
or have a viral load (VL) > 1000copies/ml in 4weeks before delivery; or are
diagnosed with HIV during the 3rd trimester or postnatal period.
Age Nevirapine Dosing (10mg/ml formulation)
0 - 6 weeks 1 ml (10 mg) once daily (Birth weight <2,500 grams) 1.5
ml (15 mg) once daily (Birth weight >2,500 grams)
6 w to 6 months 2 ml (20 mg) once daily
6 – 9 months 3 ml (30 mg) once daily
9 – 12 months 4 ml (40 mg) once daily
Pneumonia - All HIV exposed / infected children admitted with signs of severe
pneumonia are treated with:
1. Ampicillin + Gentamicin as first line therapy, Ceftriaxone being reserved for
second line therapy
2. Empiric high dose co-trimoxazole for suspected Pneumocystis jirovecii
pneumonia (see table below) is recommended as additional treatment for
HIV-infected and HIV exposed infants aged 2months – 1year with severe
pneumonia.

Treat and prevent Pneumocystis jirovecii pneumonia (PCP) with Co-
trimoxazole (CTX)
Weight CTX syrup CTX Tabs CTX Tabs Frequency
240mg/5ml 120mg/tab 480mg/tab
1-4 kg 2.5ml 1 tab ¼ 24 hrly for
5-8 kg 5ml 2 tabs ½ prophylaxis,
9-16 kg 10ml - 1 6hrly for 3
17-50 kg 2 weeks for
PCP
treatment
Meningitis – Request CSF examination for cryptococcus as well as traditional

microscopy and culture for bacteria.
ART – See national guidelines for the latest regimens

TB – See national guidelines for TB treatment in an HIV exposed / infected child
the 5th Edition 58

Newborn Resuscitation – for trained Health Workers – Be Prepared!
Prepare Before delivery – Equipment, Warmth, Getting Help
Breathing should be started within 60 sec
If the baby has not taken a breath at all think- Is there MECONIUM
No Yes
Use warm cloth: dry and stimulate, Before first breath and before drying/
observe activity, colour and breathing, stimulating- Suck oro-pharynx under
wrap in dry warm cloth with chest direct vision. Do not do deep, blind
exposed suction
Skin to skin with mother to keep warm:

Baby now active and taking breaths? Y observe and initiate breast feeding
N
Check airway if clear – if secretions/
meconium visible use suction to clear
A Put head in neutral position
Keep warm, count rate of

breathing and heart rate –
B Is the baby breathing well? Y give oxygen if continued
respiratory distress
Poor or No Breathing / Gasping – Call for Help!
ABC OK
B Person 1 – Start ventilation Give 5 slow

breaths – the chest must rise – continue at 30 Continue with ventilation until 30 – 50
– 50 breaths / min Person 2 – Check chest breaths / min, Reassess ABC every 1-2 mins,
rise, check heart rate at 45 – 60sec stop using bag when breathing is 30-50
breaths/min and heart rate is >100bpm
V
Y ABC NOT OK
Give 1 EFFECTIVE breath for every 3 chest

C Is the heart N compressions for 1 min, Reassess ABC every 1-2
rate >60bpm? mins, stop compressions when HR >60 bpm and
support breathing until 30-50 breaths/min

NEONATAL SEPSIS / JAUNDICE – see Page 70 for NN Antibiotic Doses
Age < 60 days
Yes Do LP unless severe respiratory distress

One or more of:
• Change in level of activity
• Bulging fontanelle
• History of convulsions
• Feeding difficulty
• Temperature ≥37.50C or <35.50C
• Fast breathing / respiratory rate ≥60 bpm 1) Check for hypoglycaemia, treat if
• Severe chest in drawing
Yes unable to measure glucose.
• Grunting 2) Start gentamicin and penicillin (see
• Cyanosis chart),
3) Give oxygen if cyanosed / RR > 60
bpm.
Also check
4) Give Vitamin K if born at home or not
given on maternity.
5) Keep warm.
• Jaundice (see page 61 & 62) 6) Maintain feeding by mouth or ngt, use
Capillary refill iv fluids only if respiratory distress or
• Severe Pallor severe abdominal distension (see
• PROM >18hrs if aged < 7d
chart).
• Weight loss >10% of birth wt
Use information to decide -does
baby need fluids, feeds (Page 67,68&69)
or blood?
No signs of serious illness

Where appropriate:
Is there: 1) Treat for neonatal ophthalmia
• Pus from eye
Yes 2) Treat with oral antibiotic –cloxacillin, if
• Pus from ear large, pus-filled septic spots (suspect
• Pus from umbilicus and redness of S.aureus)
abdominal skin 3) Give mother advice and arrange review
• Pus-filled blisters / septic spots
None of the above

NB. A Newborn with weight <2kg & premature
No sign of severe illness, review if situation delivery or small size for gestational age with reduced
changes. ability to suck as the only problem may only require
warmth, feeding support and a clean environment.
the 5th Edition 60

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

threshold (see next page) for the baby’s age on day of testing
Phototherapy and Supportive Care - Checklist

1. Shield the eyes with eye patches. - Remove periodically such as during
feeds
2. Keep the baby naked but cover the gentalia
3. Place the baby close to the light source – 30 cm distance is often
recommended but the more light power the baby receives the better the
effect so closer distances are OK if the baby is not overheating especially
if need rapid effect. May use white cloth to reflect light back onto the baby
making sure these do not cause overheating.
4. Do not place anything on the phototherapy devices – lights and baby
need to keep cool so do not block air vents / flow or light. Also keep device

clean – dust can carry bacteria and reduce light
5. Promote frequent breastfeeding. Unless dehydrated, supplements or
intravenous fluids are unnecessary. Phototherapy use can be
interrupted for feeds; allow maternal bonding.
6. Periodically change position supine to prone - Expose the maximum
surface area of baby to phototherapy; may reposition after each feed.
7. Monitor temperature every 4 hrs and weight every 24 hrs
8. Periodic (12 to 24 hrs) plasma/serum bilirubin test. Visual testing for
jaundice or transcutaneous bilirubin is unreliable.
9. Make sure that each light source is working and emitting light.
Fluorescent tube lights should be replaced if:
a) More than 6 months in use (or usage time >2000 hrs)
b) Tube ends have blackened
c) Lights flicker.
the 5th Edition 62

Treatment of Jaundice if Gestational Age < 37 wks
• Initiate phototherapy earlier than for full term neonates – ideally consult a
gestational age specific chart
• Exchange transfusion if baby has gestational age < 37 wks AND age
is 72 hours or more if:
Bilirubin in micromol/litre ≥ gestational age × 10 or bilirubin level of
≥20mg/dl or more for the full term babies or ≥15mg/dl or more for the
preterms.
Treatment if 37 weeks or more gestational age

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

DURATION OF TREATMENT FOR NEONATAL / YOUNG INFANT SEPSIS
Problem Days of treatment
Signs of Young Infant Infection in a • If all the signs of possible sepsis have resolved and the
baby breast feeding well. child is feeding well, the LP done is normal and the blood
culture is negative; stop IV antibiotics at 72 hours.
• Give oral treatment to complete 5 days in total. Advise the
mother to return with the child if problems recur.
Skin infection with signs of • IV / IM antibiotics could be stopped after 72 hours if the
generalised illness such as poor child is feeding well without fever and has no other
feeding problem and LP, if done, is normal. Blood culture negative.
• Oral antibiotics should be continued for a further 5 days.
Clinical or radiological pneumonia. • IV / IM antibiotics should be continued for a minimum of 5
days or until completely well for 24 hrs.
• For positive LP see below. For positive blood culture see
sensitivity report.
Severe Neonatal Sepsis • The child should have had an LP and a blood culture
• IV / IM antibiotics should be continued for a minimum of 7
days or until completely well if the LP is clear
Neonatal meningitis or severe • IV / IM antibiotics should be continued for a minimum of 14
sepsis and no LP performed days.
• If Gram negative meningitis is suspected treatment should
be iv for 21 days.
NB: IM antibiotics for pre-referral treatment
the 5th Edition 64

Newborn Care
For Detailed Management of Newborn Care, refer to the National Essential
Newborn guidelines
Fluids, Growth, Vitamins and Minerals in the Newborn:
Babies should gain about 10g / kg of body weight every day after the first 7 days
of life. If they are not rule out feeding issues to ensure that the right amount of
feed is being given and whether they are unwell.
Vitamin K: All newborns aged < 14 days should receive Vitamin K on admission
if not already given.
• All babies born in health facility should receive Vitamin K soon after birth
• If born at home and admitted aged <14days give Vitamin K unless already
given
• 1mg Vitamin K IM if term neonate, 0.5mg im if preterm neonate below 1.5kg
All premature babies (< 36 weeks or < 2kg) should receive:

• 0.3 ml of multivitamin syrup daily once they are on full milk feeding at the
age of about 2 weeks plus folate 2.5mg weekly
• 2 mg per kg of elemental iron should be given daily starting 14 days
onwards.

CONTINUOUS POSITIVE AIRWAY PRESSURE
(For maximum benefit start as soon as symptoms are identified)
Newborn with severe respiratory distress Defer CPAP if any of the following
with all of these Uncontrollable seizures, floppy
Weight >1000gm, APGAR score of >4 at 5 infant or apnoeic or gasping
mins and Respiratory distress defined as respiration
Initiate CPAP
Monitor every three hours

• Vital signs- temp., heart rate, resp. rate
• Pulse oximetry
• Silverman Anderson Scoring
• Need of nasal clearing/suction
• Ensure the CPAP seal and

Continue CPAP and monitor
equipment is working well
until Silverman Anderson score
• Senior review for further
of <4
evaluation
Transition from CPAP to oxygen by

nasal prongs
Silverman Anderson Score

Feature Score 0 Score 1 Score 2
Chest movement Equal Respiratory lag Seesaw respiration
Intercostal retraction None Minimal Marked
Xiphoid retraction None Minimal Marked
Nasal flaring None Minimal Marked
Expiratory grunt None Audible with stethoscope Audible **
Score of >6 initiate CPAP (consider transfer for mechanical
the 5th Edition 66

Newborn Feeding/Fluid requirements Age Total Daily Fluid/milk vol.
• Well baby - immediate milk feeding - Table A. For first feed give 7.5ml and increase by this Day 1 60ml/kg/day
amount each feed until full daily volume reached Day 2 80ml/kg/day
• Day 1 - Sick baby or Weight <1.5kg start with 24hrs iv 10%D – Table B Day 3 100ml/kg/day
• From Day 2 unless baby very unwell start NGT feeds - Begin with 5ml Day 4 120ml/kg/day
• each 3hrly feed if <1.5kg; 7.5ml 3hrly if ≥1.5kg <2kg; and 10ml 3hrly if ≥ 2kg. Increase feed by the Day 5 140ml/kg/day
same amount every day and reduce iv fluids to keep within the total daily volume until IVF stopped Day 6 160ml/kg/day
– Table C Day 7 180ml/kg/day
• For IVF from Day 2 use 2 parts 10% dextrose to 1 part HS Darrow’s (eg. 200ml 10% D + 100ml
HSD) if not able to calculate or give added Na+ (2-3mmol/kg/day) and K+ (1-2mmol/kg/day) to
glucose solution.
• Please ensure sterility of iv fluids when mixing / adding
• Always use EBM for NGT feeds unless contra-indicated
• If signs of poor perfusion or fluid overload please ask for senior opinion on whether to give a bolus,
step-up or step-down daily fluids.

Nasogastric 3 hrly feed amounts for well babies on full volume feeds on Day 1 and afterwards
1.5 to 1.7 to 1.9 to 2.1 to 2.5 to 2.5 to 2.7 to 2.9 to 3.1 to 3.3 to 3.5 to 3.7 to 3.9 to
Weight (kg)
1.6 1.8 2.0 2.2 2.4 2.6 2.8 3.0 3.2 3.4 3.6 3.8 4.0
Day 1 12 14 15 17 18 20 21 23 24 26 27 27 30
Day 2 15 18 20 22 24 26 28 30 32 34 36 36 40
Day 3 19 23 25 28 30 33 35 38 40 43 45 45 50
Day 4 24 27 30 33 36 39 42 45 48 51 54 54 60
Day 5 28 32 35 39 42 46 49 53 56 60 63 63 70
Day 6 32 36 40 44 48 52 56 60 64 68 72 72 80
Day 7 36 41 45 50 54 59 63 68 72 77 81 86 90
B. IV fluid rates in ml / hr for sick newborns who cannot be fed orally/via ngt on FULL volume
3.6 – 3.8 –
Weight 1.0 – 1.2 – 1.4 – 1.6 – 1.8 – 2.0 – 2.2 – 2.4 – 2.6 – 2.8 – 3.0 – 3.2 – 3.4 –
3.7 3.9
(kg) 1.1 1.3 1.5 1.7 1.9 2.1 2.3 2.5 2.7 2.9 3.1 3.3 3.5
Day 1 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10
Day 2 4 4 5 6 6 7 8 8 9 10 10 11 12 12 13
Day 3 5 5 6 7 8 9 10 10 11 12 13 14 15 15 16
Day 4 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Day 5 6 8 9 10 11 12 13 15 16 17 18 19 20 22 23
Day 6 7 9 10 11 13 14 15 17 18 19 21 22 23 25 26
Day 7 8 10 11 13 14 16 17 19 20 22 23 25 26 28 29
the 5th Edition 68

C. Standard regimen for introducing NGT feeds in a VLBW or sick newborn after 24hrs IV fluids
1.0 – 1.1 1.2 – 1.3 1.4 – 1.5 1.6 – 1.7 1.8 – 1.9 2.0 – 2.1 2.2 – 2.3 2.4 – 2.5
Weig NGT NGT NGT NGT NGT NGT 3 NGT NGT 3
IVF
ht IVF 3 IVF 3 IVF 3 IVF 3 IVF 3 IVF hrly IVF 3 hrly hrly feed
ml/h
(kg) ml/hr hrly ml/hr hrly ml/hr hrly ml/hr hrly ml/hr hrly ml/hr feed ml/hr feed
r
feed feed feed feed feed
Day 1 3 0 3 0 4 0 4 0 5 0 5 0 6 0 6 0
Day 2 2 5 3 5 3 5 3 8 4 8 4 10 4 10 5 10
Day 3 1 10 2 10 3 10 2 15 3 15 2 20 3 20 4 20
Day 4 1 15 2 15 3 15 1 22 2 22 0 30 2 30 3 30
Day 5 0 18 1 20 2 20 0 30 1 30 0 36 0 39 1 40
Day 6 0 21 0 25 2 25 0 34 0 38 0 42 0 45 0 50
Day 24 30 33 38 42 48 51 56
0 0 0 0 0 0 0 0
7+

Intravenous/intramuscular antibiotics aged <7 days Oral antibiotics aged <7 days
Ampicillin/ Gentamicin
Penicillin Ceftriaxone Metronidazole
cloxacillin (3mg/kg <2kg, Ampicillin/
Weight (50,000iu/kg) (50mg/kg) (7.5mg/kg) Amoxycillin
(50mg/kg) 5mg/kg ≥2kg) cloxacillin
kg Weight
iv/im iv/im iv/im iv/im iv
kg
12 hrly 12 hrly 24 hrly 24 hrly 12 hrly 25mg/kg 25mg/kg
1.00 50,000 50 3 50 7.5 125mg/5ml 125mg/5ml
1.25 75,000 60 4 62.5 10 12 hrly 12 hrly
1.50 75,000 75 5 75 12.5 2.00 2 2
1.75 100,000 85 6 75 12.5 2.50 3 3
2.00 100,000 100 10 100 15 3.00 3 3
2.50 150,000 125 12.5 125 20 4.00 4 4
3.00 150,000 150 15 150 22.5
4.00 200,000 200 20 200 30
Ophthalmia Neonatorum: Warning:

Swollen red eyelids with pus should be treated with Gentamicin – Please check the dose is correct for weight and age in DAYS
a single dose of: • Gentamicin used once a day should be given im or as a slow iv push – over 2-3 mins.
• Amikacin 7.5-10 mg/kg/dose 12 hourly or, • If a baby is not obviously passing urine after more than 24 hours consider stopping gentamicin.
• Ceftriaxone 50mg/kg iv or im • Penicillin dosing is twice daily in babies aged < 7 days
• Chloramphenicol should not be used in babies aged < 7 days.
• Ceftriaxone is not recommended in obviously jaundiced newborns – Cefotaxime is a safer
cephalosporin in the first 7 days of life
the 5th Edition 70

POISONING/ENVENOMING
History: Obtain full details of the poisoning agent, amount and time of ingestion.
SAFETY: WEAR GLOVES/masks (see below: organophosphates)
Examination: A, B, C, D approach
Airway – Check for burns in/around mouth and stridor (corrosives), consider
anaesthetic airway support. Breathing – If respiratory distress, give oxygen (NB:
some poisons depress breathing: support with bag valve mask
ventilation). Corrosives and petroleum compounds may cause pulmonary oedema
that may take some hours to develop. Circulation – Assess and treat for shock
Disability – AVPU scale (some poisons cause coma). Check and treat for
hypoglycaemia (5ml/kg 10% dextrose). If eyes involved (conjunctival/ corneal
damage) refer to hospital
Caution Method
Activated • Unprotected airway in • Ideally use within 1 hour of ingestion. Do not
charcoal an unconscious child induce vomiting. May need NGT.
(unless intubated) • Mix charcoal in 8-10 volumes of water. E.g.
• Do NOT use with 5g in 40ml water.
ingestion of corrosives ≤1 year 1g/kg
or petroleum products 1-12 years 25-50 grams
>12 years 25-100 grams
Gastric • Do NOT use with • Use in life-threatening poisoning.
lavage ingestion of corrosives • Ideally within 1hour of ingestion
or petroleum products • Left lateral head down position. Insert large
• Have suction available bore NGT, check position, give 10ml/kg
as child may vomit N/saline, aspirate same volume, repeat until
aspirated solution is clear.
Organophosphates and carbamates (e.g Malathion, parathion, tetra ethyl

pyrophosphate, mevinphos (Phosdrin), carbamates)
• Wear gloves: can be absorbed through skin
• Wash contact surface e.g. eye or skin
• Give activated charcoal within 4hours if ingested (when unavailable carefully
aspirated stomach via NGT)
• Do not induce vomiting.

• If parasympathetic activation (salivation, excess respiratory secretions,
respiratory compromise, sweating, slow pulse, small pupils, convulsions,
muscle weakness, incontinence) give atropine: 20micrograms/kg (maximum
dose 2000 micrograms) every 5-10mins until secretions reduce, pupils dilate
and heart rate increases. May need repeated dosing every 1-4 hours for at least
24hours. Give oxygen.
• With muscle weakness, consider IV pralidoxime 25-50mg/kg infusion over
30mins, may be repeated once/twice.
Petroleum compounds (e.g. Paraffin/kerosene, petrol, turpentine)

• Do not induce vomiting or give activated charcoal, may cause aspiration
leading to pulmonary oedema or pneumonitis.
o Give oxygen and treat wheeze.
o May cause encephalopathy: treat convulsions with diazepam + 10%
dextrose.
Corrosive compounds (e.g Bleaches, acids, disinfectants, hydroxides)

• Do not induce vomiting or give activated charcoal, may cause further burns to
mouth, throat, lungs, oesophagus.
• Give milk or water as soon as possible to dilute the corrosive
• Give nothing orally.
o Get a surgical review to assess damage
the 5th Edition 72

Specific drugs with antidotes:
Paracetamol
- If within 4hrs give activated charcoal
- If ingested ≥ 150mg/kg: If not vomiting and conscious and within 8hrs: PO methionine 4 hourly
for 4 doses (<6yrs:1g; ≥6yrs:2.5g)
Otherwise use IV acetylcysteine, treatment duration 20hours:
Loading 150mg/kg in 3ml/kg 5% dextrose over 15mins
then 50mg/kg in 7ml/kg 5% dextrose over 4hrs
then 100mg/kg in 14ml/kg 5% dextrose over 16hrs
Over 20kg child volume of glucose can be increased
Continue infusion beyond 20hrs if late presentation or evidence of liver toxicity
Aspirin and salicylates
• Treat symptomatic cases or if ingested more than 125mg/kg
• Can cause vomiting, tinnitus, acidotic breathing, cardiac dysrhythmias, coma.
• May need several doses of activated charcoal (if unavailable use gastric lavage) - If severe
acidosis: IV sodium bicarbonate 1mmol/kg over 4hrs + PO potassium 2-5mmol/kg/day divided
into 3 doses.
Give IV maintenance fluids, monitor blood glucose. IM or IV Vit K 10mg STAT.
Iron
- Ingestions of ≥20mg/kg elemental iron is potentially toxic - If asymptomatic after 6hrs; unlikely
to need antidote
- Activated charcoal doesn’t work. Consider gastric lavage.
- Use deferoxamine only if clinical evidence of poisoning (vomiting, diarrhoea, abdominal pain,
GI bleeding, drowsiness, convulsions, acidosis). Can give IV or IM.
- IV infusion: 15mg/kg/hr for 4hours, then reduce rate so total dose in 24 hours is not greater
than 80mg/kg (Maximum dose: 6g/day)
- IM 50mg/kg every 6 hours (Maximum dose: 6g/day)
Snake bite
• First aid: splint the limb, apply firm bandage, avoid tourniquet, clean wound
• If systemic or severe local signs draw up IM adrenaline (0.15ml 1:1000) before
giving IV antivenom over 1hr (dilute in 2-3 volumes N/saline). Start slowly,
monitor for anaphylaxis, if this occurs, stop antivenom and give adrenaline.
Consider salbutamol, hydrocortisone, chlorphenamine.
• When stable, restart antivenom slowly. Repeated doses maybe required.
• Ongoing treatment: hydration, surgical review, analgesia, anti-tetanus toxoid.

Emergency estimation of child’s weight from their age
All babies and Child looks well Estimated Child looks
children admitted to nourished, average size Weight (kg) obviously
health facility should for age underweight – find
be weighed and the Age age but step back 2
weight recorded in 1 – 3 weeks 3.0 age /weight
the medical record 4 - 7 weeks 4.0 categories and use
and in the Maternal 2 - 3 months 5.0 the weight
Child Health Booklet. 4 - 6 months 7.0 appropriate for this
7 to 9 months 9.0 younger age-group.
Estimate the weight 10 to 12 months 10.0
from the age only if Eg. Child thin and
1 to 2 yrs 11.0
immediate life age 10 months, use
2 to 3 yrs 13.0
support is required or the weight for a 4–
3 to 4 yrs 15.0
the patient is in shock 6-month well-
4 to 5 yrs 17.0
– then check weight nourished child.
as soon as stabilised.
If there is severe
All other children malnutrition this
should have weight chart will be
measured. inaccurate.
the 5th Edition 74

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

Appendix 2:
SUMMARY OF ANTIBIOTICS FOR SEVERELY MALNOURISHED CHILDREN
IF: Give:
NO COMPLICATIONS Amoxicillin oral: 25mg/kg every 12 hours for 5 days
COMPLICATIONS Gentamicin 1 IV or IM (5mg/kg), once daily for 7 days,
plus:
(shock, hypoglycaemia, hypothermia, Ampicillin IV or IM Followed by: Amoxicillin 2
severe dermatosis, infections, IMCI (50 mg/kg), Oral:25 mg/kg, every 12 hours for
danger signs, severe anaemia, cardiac every 6 hours for 2 5 days
failure, and corneal ulceration) days
If resistance to amoxicillin and See details of drug use below the drug kit (support
ampicillin, and presence of medical material):
complications: In the case of sepsis or septic shock: IM ceftriaxone or
cefotaxime (For children / infants beyond one month: 50
mg / kg every 8 to 12 hours) + oral ciprofloxacin (5 to
15 mg / kg 2 times per day).
If suspected staphylococcal infections: Add: cloxacillin
(12, 5 to 50 mg /kg / dose four times a day, depending on
the severity of the infection).
If a specific infection requires an Specific antibiotic are directed on the drug kit (see
additional antibiotic, ALSO 3 GIVE: support materials). Refer to the drug kit for severe acute
malnutrition with medical complications.
1 If the child is not passing urine, gentamicin may accumulate in the body and
cause deafness. Do not give the second dose un�l the child is passing urine.
2 If amoxicillin is not available, give ampicillin, 50 mg/kg orally every 6 hours for 5
days.

Appendix 3:
PREPARATION OF THERAPEUTIC FEEDS FOR SEVERELY MALNOURISHED
CHILDREN
1. Dietary management of infants < 6 months with acute malnutrition
All infants with acute malnutrition that are less than six months with or without
prospect of breastfeeding should be managed on diluted F100 (also known as
specially diluted therapeutic milk – SDTM) during hospital care. After
discharge from health facility, infants without prospect of breastfeeding are
fed on replacement feeds .
Preparation of diluted F100 (SDTM)
Mix one sachet of F100 (410g) in 2.8L of water to make 3.2 L of SDTM. OR Add
350 ml of water to 1 l of prepared F 100 to make 1.335 L of SDTM
Note: SDTM can be used as an alternative to F75 in case of shortage
of F75
(In an event that F100 is phased off, will the utilisation of commercial feeds be
considered?)
2. Dietary management of infants > 6 months and children with acute

malnutrition
Preparation of therapeutic feeds F75 and F100
F75 and F100 contain all the elements (milk, fat, sugar, minerals and vitamins)
needed for the treatment of acute severe malnutrition. The milk must be diluted
in warm chlorinated or boiled water. Make sure that the temperature is not
above 40°C to avoid damaging the vitamins.
PREPARATION
Add one sachet of powder (410g) to 2L of water to make 2.4L of milk. Sachets
should not be spilt. If you have few patients and you have to prepare small
quantity of milk, follow the instructions below. Smaller volumes can be mixed
using the red scoop (4.1g) included with the F75 package (add 20 ml water/ red
scoop (4.1g) of F75)
the 5th Edition 77

3. Preparation of Local Therapeutic Feeds recipes for f-75 and f-100
Use one of the following recipes for F-75 (Note that cooking facilities are needed):
Alternatives Ingredient Amount for F-75
If you have dried whole milk Dried whole milk 35g
Sugar 70g
Cereal flour 35g
Vegetable oil 20g
Combined mineral and vitamin mix* ½ levelled scoop
Water to make 1000ml 1000ml**
If you have fresh cow’s milk, Milk 300ml
or full-cream (whole) long Sugar 70g
life milk Cereal flour 35g
Vegetable oil 20g
Use one of the following recipes for F-100:
If you have fresh cow’s milk, Fresh cow’s milk, or full-cream (whole) long 880ml
or full-cream (whole) long life milk
life milk Sugar 75g
Vegetable oil 20g
If you have dried whole milk Dried whole milk 110g
Sugar 50g
Vegetable oil 30g
* Where CMV is not available, a mineral mix should be used (20 ml for one litre of
preparation). Contents of mineral mix are given in Annex 3 of the Introduction Module *
**Important note about adding water: Add just the amount of water needed to make
1000 ml of formula. (This amount will vary from recipe to recipe, depending on the other
ingredients.) Do not simply add 1000 ml of water, as this will make the formula too
dilute. A mark for 1000 ml should be made on the mixing container for the formula, so
that water can be added to the other ingredients up to this mark.

Directions for making cooked F-75 with cereal flour (top recipes) You will
need a 1-litre electric blender or a hand whisk (rotary whisk or balloon whisk), a 1-
litre measuring jug, a cooking pot, and a stove or hot plate. Amounts of ingredients
are listed on the previous page. Cereal flour
may be maize meal, rice flour, or whatever is the staple cereal in the area.
It is important to use cooled, boiled water even for recipes that involve cooking. The
cooking is only 4 minutes of gentle boiling, and this may not be enough to kill all
pathogens in the water. The water should be cooled because adding boiling water
to the powdered ingredients may create lumps.
If using a hand whisk:

1. Mix the flour, milk or milk powder, sugar and oil in a1-litre measuring jug. (If
using milk powder, this will be a paste.)
2. Slowly add boiled, cooled water up to 1000 ml mark.
3. Transfer to cooking pot and whisk the mixture vigorously.
4. Boil gently for 4 minutes while stirring continuously.
5. Some water will evaporate while cooking, so transfer the mixture back to the
measuring jug after cooking and add enough boiled cooled water to make 1000
ml. Add the CMV and whisk again
the 5th Edition 79

Directions for making non-cooked F-100 recipes If using an electric blender:
1. Put about 200 ml of the boiled, cooled water into the blender. (If using liquid
milk instead of milk powder, omit this step.)
2. Add the required amounts of milk or milk powder, sugar, oil, and CMV.
3. Add boiled cooled water to the 1000 ml mark and then blend at high speed. *
If using a hand whisk:

1. Mix the required amounts of milk powder and sugar in a 1-litre measuring jug;
then add the oil and stir well to make a paste (If you use liquid milk, mix the
sugar and oil, and then add the milk.)
2. Add CMV, and slowly add boiled, cooled water up to 1000 ml mark, while
stirring all the time 4.*
3. Whisk vigorously.
4
Whether using a blender or a whisk, it is important to measure up to
the 1000 ml mark before blending/whisking. Otherwise, the mixture
becomes too frothy to judge where the liquid line is.

the 5th Edition 81
Appendix 4
RUTF REFERENCE CARD.
Quantities of RUTF in Transition.
Child’s Daily weight of RUTF (g) Number of RUTF sachets per day (if one
weight sachet = 92g).
3 83 1
3.2 88 1
3.4 94 1
3.6 99 1.2
3.8 105 1.2
4.0 110 1.5
4.2 116 1.5
4.4 121 1.5
4.6 127 1.5
4.8 132 1.5
5 138 1.5
5.2 144 1.5
5.4 149 1.75
5.6 155 1.75
5.8 160 1.75
6 166 1.75
6.2 171 2
6.4 177 2
6.6 182 2
6.8 188 2
7 193 2.2
7.2 199 2.2
7.4 204 2.2
7.6 210 2.5
7.8 215 2.5
8 221 2.5
8.2 226 2.5
8.4 232 2.5
8.6 237 2.75
8.8 243 2.75
9 248 2.75
9.2 254 2.75
9.4 259 3
9.6 265 3
9.8 270 3
10 276 3
the 5th Edition 83

4. Preparation of kitoobero
Kitoobero is a multi-mix food prepared from a carbohydrate and two protein
sources (plant and animal origin). It is fed to children six months and above.
How to prepare kitoobero using beans, meat and matooke mixture.
Ingredients: 1 palm of dry beans or peas ( 90g), 1 fist of meat ( 60g), 3 fingers
of matooke (300-500g), 1 pinch of salt, ½ mug of water ( 250ml).
1. Measure the dry beans and soak overnight for about 6 hours. Remove
the skins and wash them. The skinned beans will now become 2 palmful
(180g).
2. Scrape the meat, mix it with water which had been boiled and cooled,
in a container and try to separate the particles of the meat
3. Peel the matooke, cut into small pieces and wash them.
4. Mix all the ingredients in a clean saucepan. Cover and steam for 3 hours.
5. When the food is ready, mash and divide it into two equal halves, one
for lunch and the other for supper. Any tuber (irish potatoes, sweet
potatoes, cassava, yams) can be prepared in a similar way. Dry peas can
be prepared the way as dry beans.
Adapted from the Uganda IMAM guidelines for the management of dehydration in malnutrition 2016

the 5th Edition 85
the 5th Edition 87
Appendix 5
OTHER PAEDIATRIC EMERGENCIES
Diabetic Ketol Acidosis (DKA) management in children & adolescents
Clinical History Clinical Signs Biochemical features &
Polyuria Assess dehydration Investigations
Polydypsia Deep sighing Elevated blood glucose
Respiration (kussmaul) Ketones in urine
Weight Loss (weigh)
Smell of ketones
Abdominal pain
Tiredness
Diagnosis Confirmed
Diabetic ketoacidosis
YES Weigh Patient, put up 2 IV access cannula points. NO

IV fluids available?
Assess peripheral Urgent transfer to another facility.

circulation Oral rehydration with ORS 5ml
NO /kg/hr in small sips or via NGT.
YES Give ½ as fruit juice if ORS is not
Rehydrate slowly over 48hr. Begin with
available
0.9% Nacl in 1st IV cannula
Shock 4-9 kg: 6ml/kg/hr
Y 10-19 kg: 5ml/kg/hr
20-39 kg: 4ml/kg/hr No transport available or possible or
0.9% NaCl 40-59 kg: 3.5ml/kg/hr transport > 6-8 hrs.
20ml/kg/hr N 60 -80 kg: 3ml/kg/hr Insulin available?
0.9% NaCl 10ml/kg/h over 1-2 hr

ORS 5ml/kg/hr in small sips or via
NGT. Give ½ as fruit juice or coconut
water if ORS unavailable. Give sc
IV insulin available? Begin with insulin in the 2nd IV insulin(soluble) 0.05U/kg every 1-2 hr
access 1-2 hrs after fluid treatment has been (0.025U/kg if < 5yrs)
YES NO
NO
Improving condition?
IV dose insulin IM dose 0.1U/kg every 1- Decreasing blood glucose &
(soluble)0.1U/kg/h 2 hrs (0.05U/kg if <5 yrs
(0.05u/kg if <5 yrs urine ketones – resolving
acidosis
YES
IV potassium available? Begin K+ replacement at the same time as NO
insulin treatment Sc insulin (mixtard)
0.7 – 1 u/kg/day 1-2 Transport
hr before stopping IV must be
YES Monitor Electrolytes, glucose, RR, HR, insulin infusion arranged
Give K+ LOC. when the plasma glucose falls to
40mmol/l 14-17mmol (250–300 mg/dL), give e.g 5% When ISPAD Guidelines
glucose in 0.45% saline. If BG < 5 mmol acidosis 2009 for DM in Chn &
(90mg/dl) give 5% dextrose. Don’t stop resolves Adol
insulin.

Appendix 6
CHOKING
How to manage the choking infant

Lay the infant on your arm or thigh in a head down position
■ Give 5 blows to the infant’s back with heel of hand
■ If obstruction persists, turn infant over and give 5 chest thrusts with 2 fingers,
■ one finger breadth below nipple level in midline (see diagram)
If obstruction persists, check infant’s mouth for any obstruction which can be
■ removed
If necessary, repeat sequence with back slaps again
■
the 5th Edition 89

HOW TO MANAGE THE CHOKING CHILD (OVER 1 YEAR OF AGE)
• Give 5 blows to the child’s back
with heel of hand with child
sitting, kneeling or lying
• If the obstruction persists, go
behind the child and pass your
arms around the child’s body;
form a fist with one hand
immediately below the child’s
sternum; place the other hand
over the fist and pull upwards
into the abdomen (see diagram);
repeat this Heimlich maneuver 5
times
• If the obstruction persists, check the child’s

mouth for any obstruction which can be
removed
• If necessary, repeat this sequence with
back slaps again

Annex 7:
BODY MASS INDEX FOR ADULTS (=W/H2) WT IN KG AND HEIGHT IN METRES
Height BMI Height BMI
(cm) 18.5 18 17.5 17 16.5 16 (cm) 18.5 18 17.5 17 16.5 16
Weight in Kg Weight in Kg
140 36.3 35.3 34.3 33.3 32.3 31.4 165 50.4 49.0 47.6 46.3 44.9 43.6
141 36.8 35.8 34.8 33.8 32.8 31.8 166 51.0 49.6 48.2 46.8 45.5 44.1
142 37.3 36.3 35.3 34.3 33.3 32.3 167 51.6 50.2 48.8 47.4 46.0 44.6
143 37.8 36.8 35.8 34.8 33.7 32.7 168 52.2 50.8 49.4 48.0 46.6 45.2
144 38.4 37.3 36.3 35.3 34.2 33.2 169 52.8 51.4 50.0 48.6 47.1 45.7
145 38.9 37.8 36.8 35.7 34.7 33.6 170 53.5 52.0 50.6 49.1 47.7 46.2
146 39.4 38.4 37.3 36.2 35.2 34.1 171 54.1 52.6 51.2 49.7 48.2 46.8
147 40.0 38.9 37.8 36.7 35.7 34.6 172 54.7 53.3 51.8 50.3 48.8 47.3
148 40.5 39.4 38.3 37.2 36.1 35.0 173 55.4 53.9 52.4 50.9 49.4 47.9
149 41.1 40.0 38.9 37.7 36.6 35.5 174 56.0 54.5 53.0 51.5 50.0 48.4
150 41.6 40.5 39.4 38.3 37.1 36.0 175 56.7 55.1 53.6 52.1 50.5 49.0
151 42.2 41.0 39.9 38.8 37.6 36.5 176 57.3 55.8 54.2 52.7 51.1 49.6
152 42.7 41.6 40.4 39.3 38.1 37.0 177 58.0 56.4 54.8 53.3 51.7 50.1
153 43.3 42.1 41.0 39.8 38.6 37.5 178 58.6 57.0 55.4 53.9 52.3 50.7
154 43.9 42.7 41.5 40.3 39.1 37.9 179 59.3 57.7 56.1 54.5 52.9 51.3
155 44.4 43.2 42.0 40.8 39.6 38.4 180 59.9 58.3 56.7 55.1 53.5 51.8
156 45.0 43.8 42.6 41.4 40.2 38.9 181 60.6 59.0 57.3 55.7 54.1 52.4
157 45.6 44.4 43.1 41.9 40.7 39.4 182 61.3 59.6 58.0 56.3 54.7 53.0
158 46.2 44.9 43.7 42.4 41.2 39.9 183 62.0 60.3 58.6 56.9 55.3 53.6
159 46.8 45.5 44.2 43.0 41.7 40.4 184 62.6 60.9 59.2 57.6 55.9 54.2
160 47.4 46.1 44.8 43.5 42.2 41.0 185 63.3 61.6 59.9 58.2 56.5 54.8
161 48.0 46.7 45.4 44.1 42.8 41.5 186 64.0 62.3 60.5 58.8 57.1 55.4
162 48.6 47.2 45.9 44.6 43.3 42.0 187 64.7 62.9 61.2 59.4 57.7 56.0
163 49.2 47.8 46.5 45.2 43.8 42.5 188 65.4 63.6 61.9 60.1 58.3 56.6
164 49.8 48.4 47.1 45.7 44.4 43.0 189 66.1 64.3 62.5 60.7 58.9 57.2
190 66.8 65.0 63.2 61.4 59.6 57.8
BMI INTERPRETATION
< 16.0 severe thinness
16.0 - 16.9 moderate thinness
17.0 - 18.4 marginal thinness
18.5 - 24.9 Normal
Source: WHO (1995) Physical status: the use and interpretation of anthropometry, Report of a WHO
expert committee, WHO
the 5th Edition 91

Annex 8:
INFANT YOUNG CHILD FEEDING RECOMMENDATIONS
IYCF Feeding Recommendations of Family Diet Up to 2 Years of age and IMNCI
Feeding Recommendations of Family Diet after Two Years of Age IYCF Feeding
Recommendations of Family Diet Up to 2 Years of age
Age Frequency (per Amount of at Each Serving Texture (Thickness/ Variety

day) (In addition to Breast Milk) Consistency)
6 months (181 At least 2 times ½ bowl (250 ml) Thick porridge/pap Breastfeeding + Every
days) to 8 Mashed family Mashed/ pureed family day (rice, lentils,
months food foods colourful and dark
9-11 months At least 3 times ½ bowl (250 ml) Finely chopped family green leafy
foods and to 2 foods Finger foods vegetables, fish,
times nutritious Sliced foods meat, eggs, liver) at
snacks least four types of
12-24 months At least 3 times 1 bowl (250 ml) Family foods foods
foods and 1 to 2 Slice foods
times nutritious
snacks
Responsive Be patient and encourage your baby to eat actively
Active feeding
Hygiene Feed your baby using a clean cup and spoon, never a bottle as this is difficult to clean and
my cause your baby to get diarrhoea.
Wash your hands with soap and water before preparing food, before eating and before
feeding young children.
IYCF Feeding Recommendations of Family Diet After 2 Years of age

Age Frequency (per Amount of at Each Texture Variety
day) Serving (In addition to (Thickness/
Breast Milk) Consistency)
3 to 4 times Give at least 1 bowl (250 Family foods Animal-source foods and
2 years foods and ml) at each meal vitamin A rich fruit and
and older 1 to 2 times vegetables
nutritious snacks
If your child refuses a new food offer “tastes” several times. Show that you like the food. Be
patient.
Talk with your child during a meal and keep eye contact.
A good daily diet should be adequate in quality and in quantity and include an energy-rich
food (for example: thick cereal with added oily, egg, fish, or pulses; and fruits and vegetables.

MINISTRY OF HEALTH
Plot 6, Lourdel Road, Nakasero
P. O. Box 7272, Kampala Uganda

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BASIC PAEDIATRIC PROTOCOLS

2 Basic Paediatric Protocols | Sept 2023

the 5th Edition 3

4 Basic Paediatric Protocols | Sept 2023

Dr. Henry Mwebesa

the 5th Edition 5

Dr. Richard Mugahi

6 Basic Paediatric Protocols | Sept 2023

CTX Cotrimoxazole prophylaxis treatment

the 5th Edition 7

8 Basic Paediatric Protocols | Sept 2023

ADMISSION AND ASSESSMENT:

the 5th Edition 9

CLINICAL AUDIT AND USE OF THE PROTOCOLS

10 Basic Paediatric Protocols | Sept 2023

the 5th Edition 11

12 Basic Paediatric Protocols | Sept 2023

WHO guidelines on hand hygiene in health care 2009

the 5th Edition 13

Amikacin 15mg/kg once daily. Slow IV over 3-5min If serious

14 Basic Paediatric Protocols | Sept 2023

Ceftriaxone Refer to appropriate page

the 5th Edition 15

Diazepam – 0.5mg/kg (=500 mcg/kg) & See separate chart

Erythromycin 30-50mg/kg/day in 3 -4 divided doses: max 2g/day

Gentamicin 5mg/kg/24hrly IM or slow IV

Nystatin (100,000 1ml 6hrly (2 weeks in HIV positive children)

16 Basic Paediatric Protocols | Sept 2023

Prednisolone – Asthma 1mg/kg daily (usually for 3 days)

the 5th Edition 17

For liver 0.3mg/kg stat, max 10mg

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2.0 30 10 5 Tablets may be crushed

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the 5th Edition 23

14.0 700,000 700 350 105 700 105

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Airway &  Obstructed breathing

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

Diarrhoea with sunken eyes assessment/treatment for severe dehydration

Non-urgent – Children with none of the above signs

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

Assess breathing – look, listen, feel for 5 seconds

Give 5 rescue breaths with bag and mask – if

After at least 5 good breaths

Check large pulse for 5 – 10 seconds

Give 15 chest compressions then continue giving 15 chest

1) Continue 15 chest Improvement

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B Assess adequacy of Decide:

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 Use IO or bone marrow needle 15-18G if

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