Jinja Regional Referral Hospital
Paediatric
Placement
A Helpful Guide for the New Intern
-------------2015-2016
EMERGENCY Signs
Priority Signs
Queue (Children with none of these signs)
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ABC ASSESSMENT DURING LIFE SUPPORT
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Welcome to Jinja Regional Referral Hospital Paediatrics
Department - ‘Nalufenya’!
Welcome to a busy and interesting placement! The hospital consists of an
outpatient department, emergency ward, two general wards, a neonatal
room off Ward 1, a large malnutrition unit, an isolation room for tetanus
patients off Ward 2, a laboratory, a research unit (iNO), a small private wing
and outpatient HIV services. On the main hospital site there is the Special
Care Baby Unit next to maternity.
You will be rotating around the hospital wards with one week in Emergency
ward, one week in Ward 1 (general inpatients prolonged stay), one week in
Ward 2 (predominantly short stay patients), one week in Malnutrition
Ward and one week in the Special Care Baby Unit.
Your normal day starts at 8:30 am. Tuesday and Thursday mornings are
Continuing Medical Education presentations. During your 3 month rotation
you will be expected to give one presentation on a clinically topical subject.
Lunch at Taso (main hospital) is subsidised. If you are having a busy day,
you can ask Agnes to put aside a plate for you so that you can have a late
lunch (see her contact number below).
One night in five you will be on-call which means you will return to hospital
for the afternoon, evening and night shift. There is an intern’s office in
which you stay overnight. One weekend in five you will be first on-call
where you are on-call day and night for emergencies. One weekend in five
you will be second-on-call covering the wards. The intern who has been
covering Special Care for the week should also pass by there on the
weekend. You may find you are on call for both in which case you should
pass by to see Special Care patients first in the morning.
Please remember that this guide is not a replacement of the Ugandan
Paediatric Guidelines or WHO guidelines. We have arranged to have a copy
of the latter on the Emergency ward and in OPD where you see patients at
night. There are also soft copies of these and many other resources on the
intern USB flash drive as well as on the computer in the intern room.
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GENERAL ADVICE
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Look through this guide and other resources on the USB and
computer so that you know where you can find help if you do not
have senior support
Always remember supportive care: adequate and appropriate
feeding or fluids, oxygen in unwell neonates and severely
malnourished children, analgesia for children in pain (trauma,
sickle cell disease)
Explain to the caretakers what you are doing and why. Always be
polite and respectful and take the time to explore their beliefs and
concerns. This will lead to better care of the child and will ensure
that the caretaker returns to hospital in the future.
Remember handwashing or use alcohol gel between patients and
explain to them the importance of handwashing! This is especially
important in small babies and immunocompromised children
(malnutrition, HIV)
Remember to write clear discharge and followup plans for any
child with chronic disease
Be on time – for work and for meetings
Help each other – it is a busy but very rewarding rotation.
FOR EACH PATIENT, ALWAYS CHECK:
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Weight (if it does not seem accurate, reweigh and recalculate
dosages)
HIV status (RCT)
Immunisation status (see schedule on following page) – if
incomplete, direct the child to YCC on discharge
MUAC (mid upper arm circumference) done for any child with
suspected malnutrition
Sickle cell screening for all newborns and any other child you
suspect (for example, an anaemic child who is MPS negative)
OPD
The outpatient department is primarily run by a charity called Global. They
staff and supply the medications for the outpatient department as well as
support the emergency department. They check the emergency ward
Resuscitation Equipment and Drugs Bag twice every day to ensure it is
stocked (you can find this bag on the door inside the emergency ward).
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If you are looking for out of stock medications, medications for chronic
disease or for certain types of equipment eg cannulas, NG tubes, you can
check whether they have them in OPD.
For those families that cannot afford important investigations, necessary
medications or referrals, please note that in OPD there is a hardship fund
that can help to fund these cases. Please ask the Global nurses (especially
Sarah) in OPD if you need to use this.
CLINICS
Mondays – Sickle cell, HIV
Wednesdays – Epilepsy, Cerebral Palsyand TB
2nd Thursday of every month – HIV adolescent clinic
Thursday morning at main hospital – Paediatric Physiotherapy clinic
Weds – Surgical / orthopaedic clinic. Thurs and Friday morning to see
surgical consultant
WARDS
Emergency Ward
The expectation is that you see all patients on Emergency Ward. If there is a
Senior Paediatrician that day, you will see some or all of the patients with
them.
If you are on call, the expectation is that you will add the file of any child
that has died in the last 24 hours to the mortality database on the intern
computer. There is a box for you to put (and find) these files in the little
room off of the emergency ward
Suggestions:
On your week covering the Emergency Ward, ask the Student
Nurses and Sister in Charge to take Observations of all the children before
you start the round. This includes Temperature, Respiratory Rate, Heart
Rate and Oxygen Saturation. This will also help you prioritise which
children you need to see first.
Look at the blackboard to see who the nurses think are the sickest
See the sickest child first.
Learn the normal range of observations for children of different
ages. Please also find the table at the back of this booklet for easy reference.
We have not included Blood Pressure as this is currently not available to do
for all children. Please do remember to measure blood pressure (ask Sister
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in Charge or researchers in INO to use their machine) for children with
suspected hypertension (eg renal).
Malnutrition Ward Suggestions:
On your week covering the Malnutrition Ward, ask the nurses to
take Observations of any child they are worried about including
Temperature, Respiratory Rate, Heart Rate and perhaps most importantly,
Oxygen Saturation.
Remember that some children will need to be seen every day
and some are stable in nutritional rehabilitation.
These children are potentially some of the sickest children with the
least reserve. If a child is not improving or deteriorating despite treatment,
ask advice of your seniors. This can also be by phone. Move the child to
Emergency if they need oxygen.
Ward 1 and 2 Suggestions:
There may be a high turnover of patients, especially on Ward 2 so
make sure that you are clear on your discharge plan for common
presentations such as Pneumonia, Malaria, Anaemia and Sickle cell disease.
If you have a complicated patient, inform your senior early on. If
you have prepared a summary (it can be verbal), it makes it easier for your
senior to direct advice if they do not have time to see the patient on that
day. Also use the resources available in the resource pack.
You could write down any names of patients that need a review
somewhere on the ward so that if your senior comes at a time when you are
not there, they know which patients you wanted them to see.
If children deteriorate, do not hesitate in bringing them back
to emergency. If you do, make sure you hand them over properly to the
staff in emergency and ensure there is a plan in place.
Whichever ward you are covering that week, make sure to help each other
as it can be busy and stressful – remember: ‘a problem shared is a problem
halved’ or ‘two minds are greater than one’.
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Helpful phone numbers as of August 2015
Dr Ajuna Patrick (HIV/general
paeds)
Ambulance drivers
Look on the noticeboard for daily
rota of drivers and their numbers
CoRSU hospital in Entebbe Orthopaedic and Plastic Surgery
0794900131 (Ward) / 0794900106
(Admin) / 0794900158 (OPD) /
0794900111 (General Inquiries)
CURE hospital in Mbale Hydrocephalus, Spina Bifida, Brain
Tumours / Neurosurgery
0454435273 / 0772778813 /
0454435356 / info@cureuganda.org
/ ug.info@cure.org
EEG at Mulago Hospital – Olga
0772601603
Green’s Pharmacy (you can also SMS
your question regarding availability,
dosage and price), Main Street near
Post Office – NB they have ATS
0794473367
Hospice – eg for morphine Esther
0773444363
Head of Paediatric Dept –
Dr Harriet Nambuya
0772448247
Laboratory / Mr Bakimbi / Geofrey
(lab tech)
0772832102 / 0772832102 /
0776284501 / 0704774197
Medicare Jinja Diagnostic Centre –
for cultures
0702559991
Mulago Hospital - Cancer Institute
(Dr Noleb Mugisha)
0414 540 410 / 0706599544 /
0712123889
Mulago Hospital - Heart Institute
(Dr Emmanuel Tenywa)
0782840944
Mulago Hospital - Surgical Referrals
(Mr Ssekabira)
Nicholas – NDI (nurse and engineer
for oxygen machines and inverter)
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0782222560
Ophthalmology Referral (Dr Kikira)
0772536520
Orthopaedic Referrals (Mr Magada)
0772410875
Pharmacy (Mr Kiganda)
0772953491
Rapha
0752068737
Rippon
0434 120200
Sister in Charge – Margaret Oboke
0776187833
Soft Power Health NGO (Allan Stone
Community Health Clinic, Bujagali)
0779933303
Surgery (Main hospital) Mr Ekwaro
0772446402
Taso (Lunch – Agnes)
0784588732
TUSC (Transporting Ugandan Sick
Children) – Yakub
0779153378
Please note that there is a hospital phone that may be available for use – ask
the Sister in Charge.
Please add any other useful numbers below:
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Referrals and points of advice or support
CORSU hospital, Entebbe – for orthopaedics or plastics: fixed club foot
(refer in the first month of life), cleft lip / palate (refer at 2 to 3 months of
age, or sooner if they are not able to feed well), osteomyelitis, bow legs,
congenital dislocation of hip, congenital abnormalities, severe contractures
e.g. after a stroke or post-burns. Surgery and other treatments are free for
children at CORSU, but they charge 8000 per consultation plus the costs of
lab tests/xrays and 18,000 per night of hospital stay.
CURE hospital, Mbale – paediatric neurosurgery – eg for congenital
hydrocephalus, spina bifida, myelomeningocoele, brain tumours. They
charge around 1 million shillings spread over 12 months as a maximum
(e.g. for children needing surgery). They have financial counsellors and
price plans to make this affordable and no child in need who could benefit is
turned away.
Mulago hospital, Kampala – cardiac lesions, oncology patients for
diagnostic investigations and chemotherapy, complicated paediatric
surgical cases e.g. surgical jaundice (pale stools and dark urine, high total
and direct bilirubins – MUST refer ASAP eg before 5 weeks of age, as could
be biliary atresia).
If you have children for surgical referral, e.g. to Mulago, please first send
to Ward 9 at the Main Hospital. Make sure you have spoken to the interns
doing Surgery as well as the Surgical Consultant. If you need a consultant
surgical opinion, the best days to refer are clinic day (Wednesday) or
Thursday and Friday mornings.
If you have a neonate or child with a suspected cardiac lesion, they are
likely to need an Echocardiogram. Based on the results of this, they may
then need to be seen at the Heart Institute in Kampala. Please also note that
Dr Tenywa who works at the Uganda Heart Institute also works at
Nalufenya on Fridays, Saturdays and Sundays and is happy to be contacted
for advice. He can see cardiac patients at Nalufenya in OPD on a Friday (or
at SoftPower on a Sat).
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Also remember to use Transport for Ugandan Sick Children (contact
Yakub) to arrange free transport to other hospitals including Cure Hospital
in Mbale, Mulago Hospital in Kampala and CORSU in Entebbe.
The Allan Stone Community Health Clinic at Bujagali is part of the Soft
Power Health NGO. For a small membership fee they subsidise some
medical costs, and arrange TUSC transport, so for patients who need
referral to Mulago or other hospitals it can help make this more affordable.
In particular, the Ugandan heart institute is very expensive and is a
privately run organisation (an echo costs 44,000) and so patients can
benefit by going through Soft Power Health.
If you need to transfer a patient to the main hospital you can contact the
Driver / Ambulance (look on noticeboard for daily rota of drivers). If the
patient needs to be seen by the surgical team but needs to go with oxygen,
you may be able to take one of the concentrators with you. Check with
Sister in charge if this would be possible.
If a child has weakness, spasticity or muscle atrophy following cerebral
malaria, stroke, tetanus or trauma, refer to paediatric physiotherapy
which is on Thursday mornings at main hospital.
For any child with a terminal illness, you can refer to the hospice, which is
based on the site of the DHO’s office, but runs a home visiting service. The
hospice also provides morphine to any medical establishment that has
a need of it, on receipt of 2 copies of a signed requisition letter (must be
stamped with the departmental stamp which is kept in the head of
department’s office). There are examples of this type of requisition letter in
the sister in charge’s files – if the hospital ever runs out of morphine, ask
the in-charge and they should be able to get more supplies through the
hospice.
The Uganda Cancer Institute in Kampala sees children daily for diagnosis,
investigation and treatment of cancers. The services are all free unless the
child needs any investigation that is not available at the institute. The
institute however does not have inpatient facilities and therefore the
caretaker must bring small funds for upkeep. Contact TUSC to arrange
transport for the child – Yakub will normally leave very early in the
morning so that the child will be seen at the beginning of clinic day.
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Malnutrition ward – outpatient programme. There is an “OTC”
programme of outpatient care for children with moderate or severe
malnutrition who are clinically well and able to eat plumpynut (plumpynut
= RUTF).
Advice on specific patient cases. If you have access to the internet there is
an NGO which provides an email advice service for doctors working in
Africa. You can email Md2ndopinion@aol.com stating your professional
background and job, a brief outline of the case, and the clinical question that
you have, and they normally reply within 48 hours with advice. You can
include photos as well (and it is for any patient, not just paediatrics). There
are some world leading experts that give advice through this NGO, all for
free.
Seniors including the head of department are happy to be called for advice
if they are not on site.
And of course, you can always email the authors of this induction booklet,
Dr Johanna and Dr Jenny.
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General tips regarding medications:
Never forget that many of the most life-saving medications can be
given IM as well as IV so if you are struggling to get access, do not delay in
giving treatment while you keep trying. Also remember that everything that
can be given IV can also be given via intra-osseous route.
Drugs are restocked on Tuesdays. This means that there can
sometimes be stock-outs on Mondays and over the weekend. Please discuss
any patterns you see with the Sister in Charge and Pharmacist in Charge Mr
Kiganda. You may also consider keeping a log in the intern computer as an
audit.
When you are choosing antibiotics, first determine what is
available on the ward as it is better to prescribe something that is available
than the child does not get any treatment.
If your choice of antibiotic is unavailable, make sure that the family
can afford to buy the type that you have prescribed.
We recommend that you write 6hrly, 8hrly, 12hrly to make
communication clear.
If the drug sheet is becoming congested, please get a new one and
cross through the old one. This simple action can actually save lives!
As the wards and nurses can get very busy, it is important to
empower the parents to remind them of the times for treatment, especially
if the child is having regular painkillers (for example in sickle cell, tetanus).
Use the BNF and formulary (both attached in Emergency ward) and
make sure to help student nurses if they have questions regarding drugs.
Use the special tetanus treatment sheets for tetanus patients.
If babies need 2 hourly IV fluids consider drawing up a
personalised fluid chart for them and empowering the nursing staff to give
them 2 hourly. Put their names on the blackboard.
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Medications
Please find common dosages for most medications that you will use.
Adrenaline (for resuscitation if pulse absent or <60bpm with inadequate
breathing)
Ampoules come as 1mg adrenaline in 1 ml solution = 1:1000 strength.
Add 1ml of adrenaline from the vial (1:1000 solution) + 9mls normal saline
= 1mg adrenaline in 10mls total solution (1:10000)
GIVE INTRAVENOUSLY 0.1mls / kg of 1:10,000 solution
Repeat after 2 minutes if no improvement
Aciclovir (oral) for herpes encephalitis
Child 1 month–2 years 200 mg 4 times daily for 21 days
Child 2–6 years 400 mg 4 times daily for 21 days
Child 6–12 years 800 mg 4 times daily for 21 days
Albendazole
<2 years: 200mg one dose
≥2 years: 400mg one dose
Aminophylline (respiratory stimulant, can be used for apnoea of
prematurity and asthma)
All ages: Loading dose (oral or IV) 6mg/kg (maximum 300mg)
Neonates: Maintenance dose (oral or IV) 2.5mg/kg 12 hourly
Older babies and children: Maintenance dose 5mg/kg 6 hourly
Ampicillin (a broad spectrum antibiotic, first line to treat neonatal sepsis)
Neonates (<7 days old): 50mg/kg IV 12 hourly
Neonates 8 days to 28 days old: 50mg/kg IV 8 hourly
Older babies and children: 50mg/kg IV 6 hourly
Ampiclox (a combined antibiotic containing Ampicillin and Cloxacillin)
<1 year: 75mg 8 hourly IV
1 to 2 years: 250mg 6 hourly IV or oral
2 to 10 years: 250 – 500mg 6 hourly IV or oral
More than 10 years: 500mg – 1g 6 hourly IV or oral
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Artesunate (an antimalarial, first line in severe / complicated malaria)
Weight <20kg: 3mg/kg at 0,12,24 hours IV or IM
Weight>20kg: 2.4mg/kg at 0,12,24 hours. Give 3 IV / IM doses over 24
hours irrespective of patient’s ability to tolerate oral treatment. If unable to
take oral medication, continue IV or IM treatment once a day for a
maximum of 7 days.
Remember, this must be followed by 3 days of oral Coartem (below).
X Pen = Benzylpenicillin (Remember: iu/mega-u/mg are NOT the same)
50,000 iu / kg IV or IM 6 hourly is
0.05 mega units/kg IV or IM 6 hourly is
30mg/kg IV or IM 6 hourly
Note: in severe infection dose can be doubled to 100,000 iu/kg 6 hourly
Carbamazepine
1month – 12 years: Initially 5mg/kg at night, increased as necessary by 2.55mg/kg every 3-7 days; usual maintenance dose 5mg/kg 2-3 times daily.
The dose needs to be titrated up slowly and the drug should not be stopped
suddenly as it may cause side effects.
Ceftriaxone (a broad spectrum antibiotic used to treat meningitis and
severe pneumonia)
100mg/kg once a day IV or IM
Chloramphenicol (broad spectrum antibiotic)
12.5mg /kg 6 hourly IV
(can be doubled to 25mg/kg 6 hourly in sepsis/meningitis/epiglottitis)
Chlorpromazine (CPZ) (a sedative used for tetanus patients)
All ages: 12.5 to 25mg every 6 hours IV/IM/PO/NGT
Alternate with diazepam so one sedative is given every 3 hrs
Ciprofloxacin (antibiotic in bloody diarrhoea)
10mg/kg 8 hourly IV
Cloxacillin (broad spectrum antibiotic used in meningitis, severe skin
infections, a second line for neonatal sepsis)
Neonatal sepsis: 50mg/kg every 12 hours IV
All children and babies above 28 days old: 50mg/kg every 6 hours IV
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Co-artem (combined anti-malarial 20mg/120mg which should always be
given after Artesunate). <15kg: 1 tab BD for 3 days. 15 – 30 kg: 2 tabs BD
for 3 days. >30kg: 3 tabs BD for 3 days.
Diazepam (anti-convulsant and sedative used in tetanus)
Remember that this is a potent sedative. Be especially careful in children
with reduced consciousness as the risk of apnoea and respiratory
depression is high (use a smaller dose and if using IV route, GIVE DOSE
SLOWLY OVER AT LEAST 5 MINUTES SLOW IV PUSH). If respiratory
depression occurs, the child may need help (bagging) for a number of hours
as the main effect of the drug wears off.
Rectal suppository for convulsions: 0.5mg/kg
It is also safe and effective to give the undiluted IV solution of diazepam by
rectum. Can repeat after 10 mins if needed.
For convulsions: 0.2 – 0.3mg / kg IV given SLOWLY. If needed repeat after
10 minutes then PRN for a total maximum of 3 doses (max 2 doses if also
given phenobarbitone within 24 hours)
For tetanus spasms: 0.2mg/kg IV 6 hourly given SLOWLY. Give IV until
spasms mild/infrequent. 0.5 – 1mg/kg PO/NGT 6 hourly (alternate with
CPZ so one sedative is given every 3 hours).
Digoxin (250 microgram tablets)(used as a cardiac inotrope)
All ages: Load with 15 micrograms/kg stat, then 6 hours later start the
maintenance which is 5 micrograms/kg BD.
NB Digoxin is TOXIC in overdose, and it has a narrow therapeutic range. It
may be impossible in small babies to give a safe dose of oral digoxin using
the 250microgram tablets we have available – in that case ask the parents
to buy 62.5 microgram tablets.
Diclofenac
All children> 1 year: 1mg/kg IM TDS (max dose 50mg)
Fluconazole (anti fungal: second line for oral thrush, first line for HIV
thrush or oesophageal thrush). Syrup is 50mg/5ml.
All ages: 6mg/kg on the first day, then 3mg/kg daily for 7 – 14 days
Furosemide (a diuretic for heart failure, or given at the start of blood
transfusion to prevent heart failure if at risk eg. SAM)
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Neonate: 0.5 - 1mg/kg, 12 - 24 hourly IV
Older babies and children: 0.5 – 2mg/kg, 8 – 24 hourly IV
Gentamicin (a broad spectrum antibiotic, first line to treat neonatal sepsis)
Preterm / low birth weight less than 2.5kg: 3mg / kg od IV or IM.
Term neonate: 5mg / kg once a day IV/IM.
Older babies and children: 7.5mg/kg once a day IV / IM
Iron (for anaemic children and preterm babies on discharge)
200mg Ferrous sulphate tabs or 140mg/5mls Ferrous fumarate syrup
Weight
200 mg tabs
140mg/5mls
(twice daily)
syrup (twice daily)
3-6kg
2.5mls
7-9kg
¼
5mls
10-14kg
½
10mls
15-20kg
½
15mls
Ketoconazole
Use only as second line if nystatin or fluconazole fails or is not available
(1 in 1000 suffer severe liver toxicity as a side effect).
Children 2 years and above: 3 to 6mg/kg od.
(Can give 5 – 10mg/kg od in severe mucocutaneous candidiasis with AIDS.)
Mebendazole
>1 year: 100mg bd for 3 days or 500mg one dose
Metronidazole (an antibiotic that covers anaerobic bacteria. Used in
tetanus) Dose: 7.5mg/kg every 8 hours.
Nevirapine syrup for infants born exposed to HIV
Less than 2.5kg: 1ml od.
More than 2.5kg: 1.5ml od
Nystatin
100,000 iu/ml. Give 1ml 6 hourly after breastfeeds for 7 – 14 days
Phenobarbitone (used to stop convulsions that persist for more than 5
minutes, or multiple short convulsions within 30 minutes. First line in
neonatal convulsions. Can also be used for breakthrough spasms in tetanus)
Neonate loading dose (IM / IV) 20mg/kg. If convulsions do not stop after 30
minutes can give further 10mg/kg. Max dose in 24 hours is 40mg/kg.
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Paediatric loading dose: 15mg/kg IM / IV
Neonate and Paediatric maintenance dose: 5mg/kg once a day PO or IV
Prednisolone 5mg tablets
For treatment in asthma: 1mg/kg daily for 3-5 days
For nephrotic syndrome: 2mg/kg/day for 6 weeks (max 60mg). Then 1.5
mg/kg on alternate days for 6 weeks (max 40mg). Then stop (do not
wean).
For TB pericarditis: 1mg/kg od for 4 weeks then 0.5mg/kg od for 4 weeks,
then 0.25mg/kg od for 2 weeks then 0.08mg/kg od for 1 week.
For TB meningitis: Prednisolone 4mg/kg/day (OR dexamethasone IV or
oral 0.6mg/kg/day) for 4 weeks, then a tapering course over 4 weeks.
Salbutamol nebulisers (a bronchodilator for wheeze)
< 5 years: 2.5mg.
> 5 years and over: 2.5 to 5mg Can repeat up to every 10 minutes maximum
Maintenance dose: depending on improvement but between 6-8 hourly
TB Medications
Use RHZ for 2 months then RH for 4 months as standard pulmonary TB
therapy.
In cases of HIV positive or exposed with pulmonary TB, use RHZE for 2
months then RH for 4 months
TB Meningitis / spinal TB / abdominal TB: 2 months RHZE, 10 months RH
Tabs available: RHZ 60/30/150, RHZE 150/75/400/275, RH 60/30
Watch for liver toxicity.
Dose ranges:
Rifampicin (R): 10 – 20mg/kg od [max 600mg]
Isoniazid (H): 7 – 15mg/kg od [max 300mg]
Pyrazinamide (Z): 30 – 40mg/kg od
Ethambutol (E): 15 – 25mg/kg od
*NB Ethambutol can cause visual loss (optic neuritis) so do not exceed the
maximum safe ethambutol dose – if necessary, reduce doses of other drugs.
Number of tabs of RH or RHZ for kg ranges as follows:
4 – 6kg: 1 tab od / 7 – 10kg: 2 tabs od / 11 – 14kg: 3 tabs od /
15 – 19kg: 4 tabs od / 20 – 24kg: 5 tabs od
Number of tabs of RHZE for kg ranges as follows:
4 – 6kg: ¼ tab od / 7 – 10kg: ½ tab od / 11 – 14kg: 1 tabs od /
15 – 19kg: 1 and ¼ tabs od / 20 – 24kg: 1 and ½ tabs od
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RHZE continued – Go with the child and caretaker if you are starting a
child with suspected TB on treatment to make sure that the drugs are
available, dispensed and the caretaker knows correct number and dosage of
pills.You need to make sure the child has an exercise book before the
pharmacy will issue them anti TBs. (NB the drugs are dispensed directly
from the pharmacists, not through Global / OPD).
Tetanus Antitoxin (Anti-Tetanus Serum = ATS - Neutralises tetanus toxin)
Dose: 1500 units initial dose - give IM split into 2 sites, or give slowly IV
Can repeat doses up to a total of 10,000 units (but this is expensive!)
They are available at Green’s Pharmacy on Main Street. The cost is around
60,000 USH for 1,500 units – please approach Global in OPD if the family is
unable to afford this.
Zinc:
<6 months 10mg od for 10 days. >6 months 20mg od for 10 days. In severe
acutely malnourished children, you do not need to supplement Zinc as it is
part of the WHO F75 and F100 in sufficient and safe doses. Too much zinc
can be toxic.
Paracetamol
All children >3months 15mg/kg 6 hourly* (max 20mg/kg 6 hourly in severe
pain) PO
Ibuprofen
All children >3months 10mg/kg 8 hourly PO
Diclofenac
All children >6months 0.3 – 1mg/kg 8 hourly PO. * Can also be given IM.
Morphine
All children >6months: 0.2 – 0.3mg/kg 4 – 6 hourly PO
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Maintenance IV fluids
For children at risk of hypoglycaemia eg malnourished, NPO: Add 50 mls of
50% Dextrose to 450 mls Ringer’s Lactate to make 5% Dextrose + Ringer’s
Lactate maintenance fluids.
Give 100mls for every kg up to the first 10kg bodyweight plus
give 50mls for every kg between 10 and 20kg bodyweight plus
give 25mls for every kg above 20kg
Eg for a 34kg child give (100mls x 10) + (50mls x 10) + (25mls x 14) =
1850mls IV fluid is required every 24 hours as “maintenance”.
Drip rate =
Rate in mls per hour x 15
3600
Number of drops per second = 1 ÷ drip rate
E.g. 1 ÷ 0.125 = 8. There should be 1 drop every 8 seconds (i.e. there should be
8 seconds between each drop that falls through the giving set chamber)
24 hour fluid maintenance by weight
2kg
200mls
18kg 1400mls
4kg
400mls
20kg 1500mls
6kg
600mls
22kg 1550mls
8kg
800mls
24kg 1600mls
10kg 1000mls
26kg 1650mls
12kg 1100mls
28kg 1700mls
14kg 1200mls
30kg 1750mls
16kg 1300mls
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Special Care Baby Unit
Neonate: Up to 28 days (4 weeks) of life
Normal birth weight = ≥2.5kg
Low birth weight = 1.5kg – 2.5kg
Very low birth weight = <1.5kg
Extremely low birth weight = <1kg
Resuscitation of a Newborn (see previous page):
Remember that most babies will not need any resuscitation, some babies
will only need stimulation, a few babies will need help with ventilation (via
bag-valve-mask) and it is rare to need to do cardiac compressions and give
medications. Also remember that most newborn babies respond very well
to resuscitation so it is ALWAYS worth trying – EVEN if the baby is not
breathing at all, or has a weak or absent pulse.
Ward round expectations
On special care it is expected on ward rounds that you document:

Age of baby in days

Gestation at birth

Weight at birth if <1.5kg

Fluids plan including mls of milk mother should give, and
whether by cup/tube, and whether to breastfeed.

Temperatures over the previous 24 hours (see the
parental temperature chart) and a plan for thermal care eg
Kangaroo

Oxygen sats and how many litres the baby is receiving
There are some things that are especially important to monitor in babies –
temperatures and the baby’s weights (weigh on day 0, 3, 5, 7, then twice a
week). Mothers of any baby weighing <2kg should take the baby’s
temperature 4 times a day and record it on the parental recording chart.
Temperatures of less than 36.5 in a neonate increase the baby’s mortality,
and temperatures of 35.4 or less are very dangerous.
21
The temperature charts have a section on the back for the doctor to fill in to
communicate clearly to the parents how many mls of milk they should be
giving and how often, and how much kangaroo to do. Please fill it in daily.
Remember – cold babies are sick babies. Temp<36.5 is too cold!
Breastfeeding
Any child >1.5kg should be initiated on breastfeeding as long as they are
not unwell.
Make sure that you are happy to explain to mothers how to achieve good
attachment when breastfeeding. This includes supporting the baby’s body
well, holding the baby chest to chest, encourage the baby to open the mouth
wide to take both nipple and areola (especially below the nipple). See
picture below.
Explain to the mother the importance of exclusive breastfeeding for the first
six months of life (in accordance with WHO guidelines). You can
furthermore explain to her the benefits of breastmilk over formula feeds better immunity, fewer infections and improved neurodevelopmental
outcome. If a baby is failing to thrive on cow’s milk or formula feeds, review
the type and amount of powder the mother is adding as it may be too dilute.
22
Expressing Breastmilk
Mothers can start trying to express from month 7 of pregnancy - this will
make it easier for the milk to come when the baby is born.
Advise the mother to express from both breasts (this is also the advice if
she has breast engorgement).
Neonatal Fluids and Feeding
In premature and low birth weight babies, the fluids should be gradually
increased over the first week of life. Please refer to the tables on the
following page: the total volume of fluids per day as well as standard
feeding regimens for babies between 0.8kg and 2.5kg.
Keep in mind that the smallest babies might need 2 hourly feeds to decrease
the risk of hypoglycaemia and because their stomachs are too small to fit
the larger volumes (as in 3 hourly feeds).
Always use 10% Dextrose as the IV fluid in the first 48 hours. Then change
to fluids with added electrolytes = 1/3 Ringer’s Lactate + 2/3 10% Dextrose
Neonatal antibiotics
Ampicillin and Gentamicin are first-line antibiotics.
Add Metronidazole IV if suspecting Necrotising Enterocolitis.
Start Ceftriaxone IV if suspecting Neonatal Meningitis.
Start Benzylpenicillin if suspected congenital infection as the only one that
is easy to cure is Congenital Syphilis (hepatosplenomegaly,
thrombocytopenia).
Babies born to HIV positive mothers:
Start on Nevirapine 1.5ml OD(above 2.5kg) or 1ml OD (below 2.5kg) for 6
weeks only. Explain the importance of exclusive breastfeeding in decreasing
risk of transmission. All exposed children should be started on Cotrimoxazole prophylaxis (Septrin) from 6 weeks of age, and brought back to
EID (HIV) clinic at Nalufenya at 6 weeks of age for testing.
Hypoglycaemia
There is a glucometer in the Special Care Baby Unit, but strips are expensive
so use them wisely. In most cases, treat any unwell baby who may be
hypoglycaemic with an immediate breast-, cup or NG feed or give 5ml/kg
10% Dextrose IV. Make sure to have an ongoing feeding or fluid plan to
maintain the baby’s sugar level as the baby continues to be at risk of
hypoglycaemia.
23
24
Kangaroo Mother Care
The ideal is to do it all the time both day and night – however, the amount of
time the mother is willing and able to do it may vary a great deal between
mothers. We normally start trying 2 hours x1 or x2 in a day, and increase to
2hours x4. On discharge, explain to mothers that they can practice KMC at
night and when they are performing their normal chores and activities.
Explain also that they can breastfeed during Kangaroo, and can also express
breastmilk whilst the baby remains of Kangaroo. Cup feeds are easier when
not on Kangaroo, but it’s easy to do NGT feeds on Kangaroo. It’s easy also to
put twins onto Kangaroo with the same caregiver, as long as each baby is a
small premature they can fit together on Kangaroo very well. Make sure you
are happy to explain to the mother how to do Kangaroo – mother takes off
shirt and then places the baby (dressed only in nappy, hat and socks) in the
frog position (arms and legs bent) with baby facing the mother and
positioned between mother’s breasts. Add one or more thick blanketsfolded
on top of the baby if the baby is cold or is less than 1.5kg. Finally, wrap a
long cloth around the baby and mother and secure it well by tying it on her
back
NG feeding
NGT feeding is standard in any baby too weak to breastfeed / cupfeed, for
example severe birth asphyxia, and premature babies weighing less than
1.2kg. Babies of 1.2 – 2.0kg may be able to take cup feeds instead of NGT
feeds, however it is still very important to give extra milk to these small
babies as they won’t naturally be able to take enough from the breast.
Many parents are frightened of the feeding tube. Take the time (it will save
time in the long run) to explain to them the following points:
- Premature babies are small and weak and their suck is not strong.
This means they cannot take enough milk directly from the breast and we
need to give extra so that they can grow.
- Babies with difficulty in breathing often do not have the energy to
feed well, and in fact trying to breastfeed a child who has breathing distress
can easily make the breathing much worse
- Babies in a coma will be too weak to suckle and cup feeds are
dangerous as there is a significant risk of milk or food passing into the
lungs. This can lead to a type of pneumonia which is difficult to treat and
makes a sick baby even sicker.
- Describe (using the poster if possible) how the tube passes down
the throat into the stomach and helps protect the lungs by allowing food to
pass directly into the stomach past the lungs.
25
- Explain that the tube is thin and flexible and made of soft plastic,
and doesn’t damage any internal structures. It will be removed in a few
days or weeks once the baby is bigger or stronger and they can still
breastfeed with the tube inside, as they start to recover.
- Feeding well will increasing the child’s strength and help to recover
from their illness.
Apnoea of Prematurity
Babies less than 34 weeks gestation may have apnoeas where they stop
breathing for many seconds. They need to be stimulated and occasionally
resuscitated with the ambubag. Give prophylactic Aminophylline to all
premature babies of 7months gestation or less (around 1.5kg or less).
Always ensure the baby is treated for other possible causes of apnoeas like
RDS, sepsis, hypoglycaemia and hypothermia.
Respiratory Distress Syndrome
Respiratory Distress Syndrome (RDS) is one of the most common causes of
respiratory distress in the premature baby and is caused by immaturity of
the lungs and insufficient surfactant production. Treatment is with CPAP
and oxygen and it improves slowly over time.
Neonatal seizures
These can be subtle and may present with nystagmus of the eyes, twitching
of the lips or fingers, or sucking movements when there is nothing in the
baby’s mouth. If you are not sure then try to stop the abnormal movement if you cannot, then it is likely the baby is having a seizure.
Remember that seizures may be caused by hypoxic-ischaemic
encephalopathy (‘birth asphyxia’), hypoglycaemia or meningitis. Always
check the RBS or give 10% Dextrose to correct for possible hypoglycaemia
and give 2nd line antibiotics (ceftriaxone and cloxacillin) for possible
meningitis. Start Phenobarbitone IV loading dose (20mg/kg) if seizure
persists for more than 3 minutes, or multiple frequent convulsions each
shorter than 3 minutes. If convulsions do not stop after 30 minutes can give
further 10mg/kg dose. Diazepam can be used as second line (rectal dose is
safest) if continuing to convulse despite Phenobarbitone.
Neonatal jaundice
Physiological jaundice - delayed neonatal conjugation and clearance of
bilirubin. Happens 3-5 days after birth (not in the first 24 hours) and will
rarely rises to dangerous levels. In a preterm baby, the physiological
26
jaundice is exaggerated as the preterm baby is less able to conjugate and
clear the bilirubin. Furthermore, the neonatal brain is at more risk of
kernicterus (high levels of bilirubin causing brain damage) so it is
important to recognise and start treatment quickly.
A sensitive way to check jaundice levels and more importantly, the risk of
kernicterus is to check whether it has reached the baby’s palms and soles of
feet (rubbing the bottom of the foot shows the underlying colour).
Start phototherapy (blue light therapy available both in SCBU and in the
Neonatal room at Nalufenya). Undress the baby so it is only in a nappy.
Cover the eyes to prevent eye damage. Make sure the baby is warm and well
hydrated as this is important in clearing the bilirubin. Remember that
breastfeeding /NG / cup feeding should continue as normal – but add
10ml/kg/day to the total daily fluid requirements.
Necrotising Enterocolitis
Premature babies who have started feeding are at risk of developing
necrotising enterocolitis. Babies may present with intolerance of feeds,
temperature instability (high or low), bilious vomiting (green), blood in
stools and abdominal distension with shiny skin.
Treatment: put babies nil per os for at least 48 hours (make sure to explain
to caretaker the importance of not feeding), put NG tube on free drainage
and start IV fluids per fluids chart. Start triple antibiotics (Ampicillin,
Gentamicin, and Metronidazole for 10 days) and consider getting an
abdominal X-ray. If you suspect that the baby has perforated the intestine,
you need to discuss with Paediatric surgeons at main hospital. Consider
discussing with the Paediatric Surgical team at Mulago as well.
Cardiac failure
Presents with respiratory distress + hepatomegaly + oedema and
depending on the size of the lesion, a murmur (if the lesion is very large, a
murmur may not be present). Treat with Oxygen, Furosemide, Digoxin, fluid
restriction and positioning. The baby will require an Echocardiogram and
referral to the cardiac institute at Mulago Hospital.
Congenital abnormalities
Examine babies with failure to breastfeed for cleft palate. Advise mothers
on best way to feed the baby – some will tolerate breast, others cup or
spoon feeds – and refer to Mulago hospital for repair.
27
Exomphalos, gastroschisis, imperforate anus – these babies need referrals to
the Surgical team (at main hospital or Mulago). Do not initiate feeds for
these babies, instead insert an NG tube which is placed on free drainage
(tape a glove to the free end to act as container) and start them on IV fluids
until they have been seen by the surgical team. Remember to replace fluid
losses and consider starting on prophylactic antibiotics.
Follow up
Weight Remember that babies normally lose up to 10% of their birth
weight in the first week but should regain their birth weight by day 14.
When preterm babies come for follow up, you should expect them to have
gained 20 to 30 grams per day (the calculation is current weight in grams –
previous weight in grams / number of days between the two weights).
Ask about the feeding pattern (duration and frequency) and what it is
composed of. How many times in the day do they give cup feeds? How often
each night do they give by cup or do they only breastfeed at night? Does the
baby ever vomit? If there is poor weight gain concentrate on encouraging
the mother to give additional cupfeeds. If it is severely poor weight gain
<10grams per day, the baby should be admitted for NGT feeds.
We recommend delaying bathing in very small babies <1.2kg for around 2
weeks, and for any small baby <2kg it’s important to be careful to keep the
baby warm when they are bathed.
Kangaroo: Is the mother doing KMC? How many times a day, and does she
do it overnight? For babies on follow up, encourage mothers to do at least
2hours x 4 in the day, as well as overnight. Is the mother aware she can do
her daily tasks whilst the baby is on Kangaroo? What is the temperature at
follow up, does the mother know how to check the baby’s hands and feet to
see if it’s too cold?
Has baby gone for immunisations (same timetable for prematures as
term babies)? Does the baby sleep under a mosquito net at night?
Medication - give Haemofort or Sytron (Ferrous fumarate) 2.5ml OD and
Grovit 0.3ml OD until 6 months of age
28
Severely Impaired Circulation (Shock) without Diarrhoea
29
30
31
32
CONVULSIONS AND EPILEPSY
Convulsions are common in our setting. The most common paediatric
causes of convulsions seen in the Emergency ward are Cerebral Malaria and
Meningitis.
Do not forget to start Oxygen therapy for these children
When a child comes in with convulsions, establish whether or not the child
is known to have convulsions and if they are on regular anti-epileptic
medications. If they do, take a full seizure history and make sure you know
what doses of medications they take. What is the child’s functional
baseline? Look in their book to see what was noted at the last clinic
appointment. Ask the caretaker to describe how many types of tablets she
gives as well as the number (or half, or quarter). It may be that the child is
having a smaller or bigger dose than originally prescribed. Investigate and
treat other potential causes of increased seizure frequency (see below)
dosage for weight (is it up to date?)
any signs of intercurrent illness
started new medications (possible interaction)
degenerative condition
During admission, you can give the child 3 days of Phenobarbitone or
Diazepam to interrupt the current increase in seizure activity.
First line treatment of Epilepsy is Carbamazepine for focal / partial
convulsions and phenobarbitone for Generalised Tonic Clonic seizures
Remember to explain to the caretaker that some children will never be
entirely free of convulsions.
Investigation
Blood transfusion
Xray
Ultrasound
CBC
RFT, LFT
Lumbar puncture CSF protein, cell
count
Hb estimation
MPS and RDT
RCT
Glucose
Echo
33
Where available
Paediatric lab
Main hospital
Main hospital
Main hospital
Main hospital
Main hospital (Medicare on Main St
does CSF culture)
Paediatric lab
Paediatric lab
Paediatric lab
Paediatric ward and lab
Mulago hospital heart institute
Diarrhoea and Dehydration
34
35
Pneumonia
When a child presents in respiratory distress, independent of the cause,
they should be put upright (the back of two of the beds in emergency ward
can be put up) to increase the potential gas exchange in the lungs. You
should also take the opportunity to place a feeding tube early on as the
child will have difficulty meeting their fluid and feed requirement.
Remember, the flow rate and inspired oxygen concentration you can give is:
35-45% O2 concentration via nasal cannula (maximum rates 2L/min for
neonate, 4L/min for preschool children, 6L/min for school children),
40-60% via well-fitted face mask (Neonate/Infant/Child: 5-6L/min) and
80-90% if you are using a face mask with reservoir bag
(Neonate/Infant/Child: 10-15L/min).
*If you are struggling to meet the child’s oxygen requirement, you can use
both nasal cannula and face mask to deliver more.
36
HOW TO USE PULSE OXIMETER
If a child requires oxygen (SaO2 <90%), it is important to recheck
saturation after oxygen therapy has been started to ensure that it is
sufficient. In children who have improved you have to turn off the oxygen
for a few minutes before you can get an accurate saturation reading.
37
HOW TO USE RESERVOIR BAG
To use the face mask with reservoir bag, you must first inflate the reservoir
bag. This is done by pressing on the valve inside the mask where it attaches
to the reservoir bag.
HOW TO USE BUBBLE CPAP
If you have a neonate with respiratory distress that is not improving
despite using oxygen therapy, you can start the child on CPAP.
You can create bubble CPAP (continuous positive airway pressure) system:
take an empty and clean plastic bottle, fill it two thirds of the way with tap
water. Take the CPAP nasal cannula tube (it has one tied end and one cut-off
end). Put the cut-off end into the water bottle so that it is about 3cm under
the surface of the water. Attach the nasal cannula to the child and make
sure there is a good seal. You may have to tape the cannula to the nose of
the child. Once you have achieved this, you will see bubbles from the tubing
inside the bottle – this is where the name ‘bubble CPAP’ comes from.
HOW TO USE OXYGEN CONCENTRATORS (Devilbiss)
The oxygen concentrators have two outlets – one that delivers up to 5L/min
and one that delivers up to 2L/min. If the machine starts alarming, this
usually refers to a specific number of issues (you can troubleshoot):
 It may be that the machine is overloaded (designed to
maximum deliver 5L/min)
 Flowmeter is set too low
 Low power (power fluctuation)
 Blocked or defective humidifier bottles – make sure there is
water in the bottle.
 Blocked or defective nasal cannula, oxygen tubing or face mask
The filter at the back of the concentrator can easily be taken out and
cleaned of dust. Always check that the tubing is connected to a child,
otherwise turn off the oxygen or concentrator. These efforts may improve
how long the machine lasts and mean they require less maintenance. (Note
that usually turning the machine off and on again will stop the alarm.)
POWERCUT / LOAD SHEDDING
The inverter system in both Nalufenya (and soon) SCBU have been installed
to start working when there are power cuts (load shedding). They will
provide electricity to the lights (you must switch on lights by button in
OPD), the fridge for blood products, the microscope and the concentrators
38
in the emergency ward. When the inverter batteries are fully charged, there
will be enough electricity for around 8-12 hours. If the power has been off
for a long time, check whether there is fuel for the generator. Discuss with
sister in charge if there is not – this can then be organised in time.
TETANUS
Caused by spores from gram positive bacillus Clostridium tetani. Clean out
suspected wound. Nurse in a quiet, dark room (off Ward 2). Sedate the child
with Diazepam / Chlorpromazine (alternate doses every 3 hours). Please
use the Tetanus Treatment chart to ensure these medications are given
(copies should be in the Emergency Ward and in Sister’s office, otherwise
there is a soft copy on the USB and intern computer). Insert NG tube
straight away for feeding. Try to avoid triggering spasms during NGT
insertion, if it does occur give further Diazepam / CPZ and try again after
the child is more sleepy. Treat with Anti-tetanus serum (ATS) 1500 units by
giving half of the injection IM in each thigh. They are available at Green’s
Pharmacy on Main Street. The cost is around 60,000 USH for 1,500 units.
Immunise the child on recovery as they do not have immunity. Also please
note: there is a tetanus jobaid on the door of the tetanus room.
SICKLE CELL DISEASE
Newborn sickle cell screening has started in JRRH and is done in YCC. All
children suspected of having sickle cell disease should also be tested (for
example, children with dactylitis or with BS negative anaemia).
Remember that children with sickle cell disease have high levels of
morbidity and mortality and you should therefore have a low threshold to
admit and treat. Also remember that they are at increased risk of infection
due to hyposplenism. Admit children with sickle cell that have pain which is
not controlled by adequate analgesia (if they are requiring morphine they
should be admitted), not drinking/not tolerating oral fluids, significant
anaemia (Hb<5g/dl), breathlessness or exhaustion, jaundice or evidence of
haemolysis, priapism (>2 hours), chest pain, headaches, stroke, abnormal
neurology, chest pain, abdominal pain or distension or fever with
tachypnoea/tachycardia. Always look for signs of dehydration and shock. A
fever in a child with sickle cell disease may be due to malaria, septicaemia,
meningitis, pneumonia, osteomyelitis.
For most sickle cell presentations, the initial management is the same:
Admit the child. Check BS, Hb and Xmatch to transfuse 10ml/kg if
Hb<10g/dl. Treat with oxygen if SaO2 < 90%. Treat malaria as per normal
39
protocol. Start broad-spectrum antibiotics eg. Ceftriaxone and Gentamicin if
signs of infection.
In painful crises, encourage oral fluids (give 150% maintenance fluids as
ORS or IV Ringer’s Lactate if unable to drink. Consider changing to
Ciprofloxacin after 48 hours. Remember analgesia (make sure there is a
supply of morphine!)
Acute anaemia is most commonly due to splenic sequestration or aplastic
anaemia secondary to parvovirus B19 infection. The child will present with
an acute drop in haemoglobin and splenomegaly (document the size clearly
in the notes in order to demonstrate improvement). These children need
urgent blood transfusions to maintain the Hb close to 10g/dl.
Children with sickle cell disease should attend clinic every month
(Mondays) and be prescribed:
 Folic acid 5mg OD
 Fansidar tablets once a month
(<2yrs – ¼ tablet, 2-5 years – ½ tablet, 5-10 years – 1 tablet,
10-15 years 2 tablets, >15 years 3 tablets)
 Paracetamol 15mg/kg 4-6 hourly for pain or fever 3 days
 ORS – 3-6 packets (encouraged to drink plenty of fluids)
 Penicillin V <3 years 125mg bd, 3-5 years 250mg bd daily
 Pneumococcal vaccine at 2 years + every 5 years after that
STROKE
Many children may have neurological sequelae following cerebral malaria
or suffer a stroke as a complication of sickle cell disease.
Any child admitted with suspected stroke, examine neurology in an ageappropriate manner. Knowing your neuroanatomy (and common stroke
presentations) can be helpful both in diagnosis but also to assess recovery.
Remember to test if the child has any deficit of expressive or receptive
speech – this may be most effective if you ask the mother to give the
commands. Check whether there is homozygous hemianopia or neglect by
bringing your hand from the periphery – does the child blink? Will the child
follow an object you are holding with your eyes?
Make sure you are familiar with the Blantyre Coma Scale and Glasgow Coma
Scale as they can be important indicators of improvement or deterioration
and will be your way of demonstrating progress.
It is very important to stress to the caretakers the importance of the NG
tube to safely feed the child if they are showing any signs of aspirating
40
when they feed eg. Coughing after swallowing.. The child also needs to be
placed upright when feeding to minimise the risk of aspiration pneumonia.
Use the NG visual aid poster to help explain to the parents and to reassure
them that feeding by tube is not dangerous and is not permanent (see the
section on NG feeding above if you want further advice).
PHYSIOTHERAPY
When the child is waiting to be seen by the Physiotherapist (Thursday
mornings at main hospital) or as they are being discharged, you can give the
caretaker some helpful advice:

Children’s brains have a great deal of neural plasticity and there is
an important period of recovery and rehabilitation following brain
injury.

It requires consistent and patient work and both the caretaker and
child have to engage. It may therefore be a good idea for the
caretaker to set aside some time every day to concentrate on
exercises with their child or to incorporate them into the daily
chores and activities.

It is also important for the child to engage. This means the task has
to be appropriate (not too easy, not too difficult) and as much as
possible interesting and fun  if it can be made into a game, it is
more likely to keep the child’s attention.

Remember that contractures can be very painful and the best
treatment is to prevent them! Make sure you stretch each of the
affected muscle groups – both passive and if able, active
movements. Soft splints or orthotics can also be used, especially for
things like foot drop which can affect the child’s mobility.

If the child has right sided weakness and does not seem to
understand commands, the stroke may be affecting Wernicke’s
language area (receptive). If he is unable to speak but seems to be
understanding, the stroke may be affecting Broca’s area. Remember
(and explain to the caretaker) that this will be very distressing to
the child as they will not understand what has happened.
Example: you can tell the caretaker to tie a string with bottle caps on the
unaffected arm. Then you can set the child a game or task during which they
cannot make any noise. This means they will have to use their unaffected
hand as using their stronger, unaffected hand would make noise.
41
42
Treatment of Malnutrition
43
NOTES
44
NOTES
45
Please find many more useful resources on the laptop in the
intern office. These include the WHO Pocketbook, MCAI book,
the ETAT+ lectures and posters, lectures and guidelines
prepared by previous Global Links volunteers, health videos
prepared by MAF and Global Community Health.
You can also get a free WHO Pocketbook 2013 if you go into the
WHO office in Kampala and explain that you are a healthcare
provider.
This booklet was prepared by Dr Johanna Gaiottino and Dr
Jenny Woodruff with reference and thanks to work done by
previous Global Links volunteers Dr Jessica Morgan, Dr Colin
Powell, Dr Yetunde Odutolu and Dr Sarah Magowan.
Please feel free to contact us on the following emails:
Dr Johanna Gaiottino - johanna.gaiottino@gmail.com
Dr Jenny Woodruff - jkwoodruff@gmail.com
46
Normal Paediatric Observations
Age
<3 months
6 months
1 year – 4 year
6 year – 12 year
Heart Rate
110-170
105-165
85-150
70-135
Respiratory Rate
25-60
25-55
20-40
16-34
AVPU assessment of consciousness
A – Alert
V – responds to Voice
P – responds appropriately to Pain
(localises to pain  pushes away hand)
U – Unresponsive
From the Textbook of Paediatrics – Malawi
A Faces Pain Scale
47