TREATMENT GUIDELINES i

REPUBLIC OF RWANDA

MINISTRY OF HEALTH

RWANDA STANDARD TREATMENT

GUIDELINES

PEDIATRICS
Volume 2

March 2022

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 TREATMENT GUIDELINES v
Acknowledgement
The Ministry of Health wishes to acknowledge the support of various stakeholders in
the making of the 2022 Standards Treatment Guidelines (STGs) and Essential Medi-
cines List (EML). Without their contributions, it wouldn’t have been possible to com-
plete this work despite the restrictions made necessary by the Covid-19 Pandemics.
The World Health Organization availed the required financial and technical support
throughout the project and was flexible to adjust to the challenges brought about by
the stringent environment.
World AIDS Campaign International (WACI) Health made a significant financial input
to allowing a smooth running of the project.
The Medicines, Technologies, and Pharmaceutical services program (USAID MTaPS)
financial intervention especially in the shaping of the rational use of antibiotic guide-
lines has been a great input in the current work.
Clinton health access initiative (CHAI) have been instrumental and played a major
role especially in developing the Clinical guidelines for hypoxemia screening and ox-
ygen therapy administration in Neonates, children and adults.
The Ministry wishes to thank specifically all Rwanda Health professionals and Phar-
macy Societies and Associations for their self-less spirit and gave their time to pa-
tiently review and update the previous 2013 STGs and 2015 EML spending very long
hours online very often late in the night.
The Ministry of Health wishes to acknowledge and thank the consultants, Prof Emile
Rwamasirabo, Dr. Raymond Muganga and Dr. Richard Butare who coordinated this
2022 STG/EML updates.
The Ministry also recognizes the important contribution of tertiary Hospitals includ-
ing CHUK, CHUB and KFH that availed their microbiology data over 5 to 7 years that
helped to profiling the antimicrobial resistance in Rwanda.
Special recognition goes also to the Experts Taskforce appointed by the MOH upon
recommendation by the Medical and Pharmacy Societies and Associations. The team
is composed as follows:

Societies and Associations Coordinators

1 The Rwanda Pediatric Association (RPA) Prof. Musiime S.
2. The Rwanda College of Physicians (RCP) Dr. Muvunyi B.
2 The Rwanda Society of Obstetrics and Gynecology Dr. Ruzigana G.
(RSOG)
3 The Rwanda Surgical Society Dr. Byiringiro F.
4 The Rwanda Psychiatric Society Dr. Mudenge C.
5 The Rwanda Dental Surgeon Association (RDSA) Dr. Bizimana A.
6 The Rwanda Ophthalmology Society (ROS) Dr. Mutangana F.
7 The Rwanda Oncology Society (in formation) Dr. Rubagumya F.
8 The Rwanda Otolaryngology and Neck Surgery Dr. Mukara Kaitesi
Society (ROHNSS
9 The Rwanda Dermatology Society (RDS) Dr. Amani A.
10 The Rwanda Society of Anesthesiologists (RSA) Dr. Rudakemwa A.
11 The National Pharmacy Council Dr. Hitayezu F.

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 TREATMENT GUIDELINES v
TABLE OF CONTENTS
FOREWORD................................................................................................... iii
TABLE OF CONTENTS..................................................................................... v
List of tables.................................................................................................. ix
List of figures................................................................................................. xi
Acknowledgement....................................................................................... xiii

RESPIRATORY DISEASES....................................1
--|Rhinitis and rhinopharyngitis.................................................................... 1
--|Pneumonia................................................................................................. 2
--| Wheezing child: bronchiolitis.................................................................... 6
--|Asthma...................................................................................................... 8

EAR NOSE AND THROAT CONDITIONS........ 12

--|Otitis externa........................................................................................... 12
--|Otitis media............................................................................................. 12
--|Chronic Suppurative Otitis Media............................................................ 14
--|Tonsillitis.................................................................................................. 15
--|Acute mastoiditis..................................................................................... 16
--|Epistaxis................................................................................................... 17
--|Laryngotracheobronchitis........................................................................ 19
--|Epiglottitis................................................................................................ 20
--|Sinusitis.................................................................................................... 21
--|Pertussis (whooping cough).................................................................... 22
--|Allergic Rhinitis....................................................................................... 23

GASTROINTESTINAL DISORDERS.................. 25
--|Acute gastroenteritis ............................................................................... 25
--|Persistent diarrhoea ................................................................................ 28
--|Bloody diarrhoea (dysentry).................................................................... 29
--|Amoebiasis ............................................................................................. 30
--|Constipation............................................................................................. 30
--|Constipation-associated faecal incontinence: ......................................... 32
--|Upper git bleeding .................................................................................. 33
--|Peptic Ulcer Disease................................................................................. 35
--|Gastroesophageal reflux......................................................................... 37
--|Tropical splenomegaly (hyperreactive malarious splenomegaly).......... 39
--|Herpes gingivostomatitis......................................................................... 40

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CARDIOVASCULAR DISEASES....................... 41
--|Heart failure (congestive cardiac failure)................................................ 41
--|Cardiogenic shock.................................................................................... 42
--|Pulmonary oedema................................................................................. 43
--|Congenital heart diseases....................................................................... 44
Acyanotic Heart Diseases................................................................. 44
Cyanotic heart diseases.................................................................... 45
Tetralogy of Fallot:............................................................................ 45
--|Acquired heart diseases.......................................................................... 47
Acute Rheumatic Fever..................................................................... 47
Rheumatic heart Diseases................................................................. 50
Infective endocarditis........................................................................ 50
--|Cardiomyopathies.................................................................................... 52
Dilated cardiomyopathy .................................................................. 53
Hypertrophic cardiomyopathy.......................................................... 53
Restrictive cardiomyopathy .............................................................. 54
Pericarditis/Pericardial Effusion:....................................................... 55
--|Hypertension in children.......................................................................... 56
--|Cardiac arrhythmias in children ........................................................... 60
--|Bradyarrhythmias.................................................................................... 63

GENITOURINARY SYSTEMS ........................... 64

--|Urinary tract infection (UTI)..................................................................... 64
Acute cystitis...................................................................................... 64
Acute pyelonephritis.......................................................................... 65
--|Acute kidney injury (acute renal failure)................................................. 66

DERMATOLOGY ............................................. 69
--|Eczema..................................................................................................... 69
--|Bacterial infections (Impetigo)................................................................. 71
--|Cellulitis................................................................................................... 72
--|Staphylococcal scalded skin syndrome................................................... 73
--|Steven-johnson syndrome (sjs)/toxic epidermal necrosis (ten)............... 73
--|Acne......................................................................................................... 74
--|Fungal infections..................................................................................... 77
Dermatophytes.................................................................................. 77
--|Viral infections......................................................................................... 78
Varicella Zoster Virus (Chicken pox, VZV)........................................ 78
--|Parasitic infections................................................................................... 80
Scabies.............................................................................................. 80

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INFECTIOUS DISEASES................................... 82
--|Malaria ................................................................................................... 82
--|Meningitis ............................................................................................... 87
--|Tetanus..................................................................................................... 89
--|Hepatitis .................................................................................................. 91
Hepatitis B......................................................................................... 92
Chronic hepatitis ............................................................................. 92
--|Acute liver failure.................................................................................... 94
--|Septicaemia ............................................................................................. 96
--|Septic arthritis ......................................................................................... 98
--|Acute Osteitis/Osteomyelitis................................................................... 99
--|Salmonella infections (typhoid fever):................................................... 101
--|Varicella (chicken pox) ........................................................................ 103
--|Mumps...................................................................................................104

ENDOCRINE SYSTEM CONDITIONS.............. 105

--|Diabetes mellitus ..................................................................................105
--|Diabetic ketoacidosis ............................................................................ 107
--|Hypoglycaemia .....................................................................................111
--|Guidelines for management of diabetics on sick days.......................... 113
--|Hypocalcaemia in Children.................................................................... 114

MUSCULOSKELETAL CONDITIONS................ 116

--|Juvenile rheumatoid arthritis................................................................. 116
--|Rickets....................................................................................................117

HAEMATOLOGICAL CONDITIONS................ 118

--|Anaemia................................................................................................118
--|Sickle cell anaemia................................................................................122
--|Idiopathic thrombocytopenic purpura ................................................... 124

CENTRAL NERVOUS SYSTEM........................ 127

--|Convulsions...........................................................................................127
--|Febrile seizures......................................................................................129
--|Epilepsy.................................................................................................130
--|Convulsive status epilepticus................................................................ 133
--|Cerebral palsy........................................................................................137

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MANAGEMENT OF THE SICK

NEONATES 0-7 DAYS ................................... 139
MANAGEMENT OF THE SICK YOUNG
INFANT AGED 1 WEEK TO 2 MONTHS ....... 146
CLASSIFIFICATION OF DIARRHEA IN
A SICK YOUNG INFANT.............................. 152
CLASSIFIFICATION OF FEEDING PROBLEMS
OR LOW WEIGHT......................................... 153
ASSSES ALL YOUNG INFANTS FOR RISK
FACTORS..................................................... 154
MANAGEMENT OF THE SICK CHILD
AGED 2 MONTHS UP TO 5 YEARS.............. 155

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List of tables
Table 1. Clinical staging of pneumonia......................................................................... 3
Table 2. Management summary of pneumonia............................................................ 4
Table 3. Treatment failure definition and the appropriate action to take.............. 5
Table 4. Normal rates of breathing in awake children............................................... 8
Table 5. Guide to limits of normal pulse rate in children........................................... 8
Table 8. Presentation...................................................................................................... 20
Table 9. Clinical evaluation of dehydration............................................................... 25
Table 10. severe dehydration without shock............................................................. 26
Table 11. How to administer ORS............................................................................... 26
Table 12. Different forms of dehydration................................................................. 27
Table 13. Causes of persistent diarrhoea................................................................. 28
Table 14. Common causes of heart failure in Neonates......................................... 46
Table 15. Revised Jones Criteria................................................................................. 47
Table 16. Recommended Secondary Prophylaxis Regimens................................... 49
Table 17. Major and minor clinical criteria used in the modified Duke
criteria for diagnosis of infective endocarditis (IE)................................ 51
Table 18. Interpretation of IE....................................................................................... 51
Table 21. Recommended medications and doses for patients with chronic
Hypertension................................................................................................. 59
Table 22. Recommended Hypertension medications for patients with Renal
Failure............................................................................................................ 59
Table 23. Normal heart rate/minute for age:........................................................... 61
Table 24. Diagnosis is based on these clinical signs and symptoms...................... 61
Table 25. Schematic diagram of COARTEM dosing according to the body
weight of the patient................................................................................... 83
Table 26. Summary of oral quinine dosing scheme................................................. 86
Table 27. Immediate clinical management of severe manifestations and
complications of P. falciparum malaria.................................................... 86
Table 28. Serologic responses to HBV infection....................................................... 92
Table 29. Causes of septic arthritis............................................................................ 98
Table 30. Alternative Rehydration plan................................................................... 109
Table 31. Doses............................................................................................................ 110
Table 32. Management of ITP according to risk category..................................125
Table 33. Management of transfusion reactions.................................................... 127
Table 34. Maintenance medicine treatment choices for different types of
epileptic seizures........................................................................................ 132
Table 35. Phasic management of status epilepticus.............................................. 135
Table 36. Management of the sick neonates 0-7 days........................................139
Table 37. Assess for severe disease or severe bacterial infection, moderate
hypothermia and local bacterial infection............................................ 141
Table 38. Check for feeding problem...................................................................... 142
Table 39. Asses for low birth weight........................................................................ 143
Table 40. Assess for eye infection............................................................................. 143
Table 41. Classifification of jaundice in newborn 0-7 days.................................144
Table 42. Check for HIV infection............................................................................. 144
Table 43. Assess for congenital problems................................................................ 144
Table 44. Assses all young infants for risk factors................................................. 145
Table 45. Management of the sick young infant aged 1 week to 2 months....146
Table 46. Classification of signs of serious illness in a sick young infant...........148

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Table 47. Classifification of jaundice in a sick young infant................................149

Table 48. Classifification of feeding problems or low weight.............................150
Table 49. Asses the neonate for hiv infection......................................................... 150
Table 50. Assess for congenital problems................................................................ 151
Table 51. classifification of diarrhoea in a sick young infant..............................152
Table 52. Classifification of feeding problems or low weight.............................153
Table 53. Assses all young infants for risk factors................................................. 154
Table 54. Management of the sick child aged 2 months up to 5 years............155
Table 55. Classification table for cough and/or difficult breathing..................157
Table 56. Classification table for dehydration....................................................... 157
Table 57. Classification table for persistent diarrhoea........................................158
Table 58. If blood in the stool.................................................................................... 158
Table 59. Classification table for high malaria risk............................................... 158
Table 60. Classification table for low malaria risk and no travel to a high
risk area....................................................................................................... 159
Table 61. Classification table for measles (if measles now or within the
last 3 months............................................................................................... 159
Table 62. Classification table for ear problem...................................................... 160
Table 63. Check for anaemia.................................................................................... 160
Table 64. Check for acute malnutrition.................................................................... 161

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List of figures
Figure 1. Sinus tachycardia................................................................................. 61
Figure 2. Supraventricular Tachycardia............................................................... 62
Figure 3. Ventricular Tachycardia........................................................................ 62
Figure 4. Sinus Bradycardia................................................................................ 63
Figure 5. Heart Block (Complete)....................................................................... 63
Figure 6. How to position an unconscious child............................................... 128
Figure 7. A flowchart showing medical management of Status Epilepticus..... 136

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 TREATMENT GUIDELINES 1
RESPIRATORY DISEASES
--|Rhinitis and rhinopharyngitis
Definition
Rhinitis and rhinopharyngitis are very common viral infections of the nasal or pharyngeal
mucosa, which occur with seasonal variations under 5 year olds (more frequent in cold and
rainy seasons).

Causes
• Commonest virus: Rhinoviruses
• Other viruses: Coronaviruses, respiratory syncytial viruses, human metapneumovirus,
influenza viruses, para influenza viruses, adenoviruses, enteroviruses rarely
• Other causes include allergy (in case of recurrence), Iron deficiency, Passive tobacco smoke

Signs and symptoms:

• Nasal congestion
• Sore throat
• Sneezing
• Productive Cough
• Fever sometimes
• Watery red eyes
• Headache
Note: Suspect allergic rhinitis in case of recurrent signs of rhinitis with itching of nose, eyes, ears
and palate.

Complications
• Otitis media
• Sinusitis (over 6 year old age)
• Tonsillitis
• Exacerbation of asthma

Management
At health centre
Investigations
• Malaria test and FBC/ Hb if fever is present
Treatment
• No specific treatment
• Nasal irrigation with 0.9% sodium chloride, 4 to 6 times/ day to clear the airway.
• Patients with fever give paracetamol as follow 10 to 15 mg/kg/dose 4-6 hourly (maximum
dose 60mg/kg/day),
• Air humidification using nebulization with 0.9% sodium chloride may help open the airways,
thin secretions, and loosen mucus in the lungs, making it easier to cough up or clear
• For allergic rhinitis only, give an antihistamine: Desloratadine for 3 to 5 days as follow:
o From 2 to 5 years: 1.25mg once a day
o Children from 6 to 12 years: 2.5 mg Once a day
o Children >12 years: 5 mg Once a day
o Avoiding the allergen

At district hospital level (Same as above)

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Recommendation:
• Antibiotics are not indicated in viral rhinitis and rhinopharyngitis except in case of evident
super-infection

--|Pneumonia
Definition
Pneumonia is infection of the lung parenchyma characterized by inflammation and consoli-
dation of lung tissue.

Causes
• Bacterial:
o Streptococcus pneumonia (most common at all ages)
o Chlamydia pneumonia
o Mycoplasma pneumonia (over 5 year old age)
o Chlamydia trachomatis (infant)
o Staphylococcus aureus
o Haemophilus influenza (in case of no vaccination)
o Pseudomonas aeruginosa (in immunocompromised patients)
o Klebsiella pneumonia …

• Viral:
o Respiratory syncytial Virus
o Adenovirus
o Influenzae A and B
o Parainfluenzae types 1 and 3
o Metapneumovirus

• Fungal Cryptococcus neoformans, Aspergillus spp,…

• Mycobacterial: Mycobacterium tuberculosis, Mycobacterium avium, Mycobacterium
intracellulare
• Parasites: Pneumocystis Jirovecii (in HIV infected children)

Signs and symptoms

• Fever
• Tachypnea
• Respiratory distress (inter-costal, sub-costal recession)
• Nasal flaring
• Use of accessory muscles
• Cyanosis and respiratory fatigue (in severe case especially for infant)
• Crackles and wheezing on auscultation
• Bronchial breathing

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Table 1. Clinical staging of pneumonia

Type Signs Symptoms

Cyanosis
Inability to drink/breastfeed
Very severe pneumonia AVPU = V, P or U
Grunting
Head bobbing History of cough or difficulty of
Lower chest indrawing breathing
Severe pneumonia Nasal flaring Fever
Grunting Abdominal/chest pain
(sometimes)
Fast breathing
Non severe Pneumonia
Presence or absence of crackles

Investigations
• FBC
• Chest x-ray
• Blood culture
• HIV test

Complications of pneumonia:
• Pneumothorax
• Pleural effusion/pleuritis
• Sepsis/ Meningitis / Arthritis
• Empyema
• Respiratory failure
• Bronchiectasis

Management:
At health centre (Follow IMCI guideline)
• For very severe and severe pneumonia
o Give first dose of an appropriate antibiotic. (Ampicillin 25mg/kg stat dose and
Gentamycin 5mg/kg stat)
o Treat to prevent hypoglycaemia
o Refer URGENTLY to hospital
• For Non-severe pneumonia
o Give an appropriate oral antibiotic for 5 days. (Amoxycillin 40mg/kg/day in 3
divided doses)
o Soothe the throat and relieve the cough with a safe remedy.
o Advice mother when to return immediately.
o Follow-up in 2 days
Factors for admission of children with pneumonia:
• Age < 6 months
• Sickle cell anaemia with acute chest syndrome

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• Multiple lobe involvement

• Immunocompromised state
• Toxic appearance
• Very severe or severe pneumonia (clinical staging)
• Severe respiratory distress:
o Supplemental oxygen
o Dehydration
o Vomiting
o No response to appropriate oral antibiotic therapy
At district hospital level (Follow ETAT+ guideline)

Table 2. Management summary of pneumonia

Type Management Comments
Hospitalization, Oxygen, Correct shock,
hypoglycaemia and dehydration, Fluid
maintenance
Duration 10 days
Ampicillin 200mg/kg Q6hr or Benzyl
penicillin 50,000 units/kg IM/IV Q6hr Switch to oral treatment with
Very severe
Plus Gentamycin IV 7.5mg/kg IV over amoxicillin 45mg/kg/dose Q12hr if
pneumonia
3-5 minutes Q24hr improvement in clinical symptoms
OR
Cefotaxime 50mg/kg/dose Q8hr (second
line)
Hospitalization
Duration 7 days
Oxygen
Switch to oral treatment with
Severe Correct hypoglycaemia and dehydration
amoxicillin 45mg/kg/dose Q12hr if
pneumonia
Fluid maintenance improvement in clinical symptoms
Ampicillin 200mg /kg/day ( 50mg/kg/
dose Q6h)

Non severe
Amoxycillin 25mg/kg/dose Q12hr Duration 5 days
Pneumonia

Note: If pneumonia due to staphylococcus is suspected give Cloxacillin 100mg/kg/day for in 3doses
and Gentamycin 7.5mg/kg. Use vancomycin as second line therapy if no response

Complications:
Recurrent/persistent pneumonia:
In case of persistent pneumonia (abnormal X-ray more than 30 days after treatment) the patient
should be referred for investigations (CT scan, bronchoscopy) to exclude:
• Foreign body
• Tuberculosis
• Congenital malformation (adenomatosis)
• Immotile cilia syndrome

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Likewise, in case of recurrent pneumonia, an underlying cause should be suspected and the child
referred for further investigations.

Pleural effusion:
In case of pleural effusion, think of Staphylococcus aureus, streptococcus pneumonia, mycoplasma
pneumonia, tuberculosis

Exclude Tuberculosis

Ultrasound to measure the volume of liquid and aspiration for culture, GeneXpert
Drainage of fluid is urgent to relieve the respiratory distress
Table 3. Treatment failure definition and the appropriate action to take

Treatment failure definition Action

Any time. Admit child

Progression of pneumonia to severe (development of • Change treatment from amoxicillin
cyanosis or inability to drink in a child with pneumonia • to Ampicillin and gentamicin to cover
without these signs on first contact. for Gram negative pneumonia

 Treat with Cloxacillin and gentamicin iv

for Staph. Aureus and Gram-negative
Obvious cavitation on CXR
pneumonia.
 Investigate for TB
48 hours
 Switch to Ceftriaxone / Cefotaxime
unless suspect Staphylococcal
Severe pneumonia child getting worse, reassess
pneumonia then use Cloxacillin and
thoroughly, get chest X ray if not already done
Gentamycin
(looking for empyema /effusion, Cavitation,
 Suspect PCP especially if <12 months,
Pneumothorax etc).
an HIV test must be done - treat for
Pneumocystis if HIV positive.
Severe pneumonia without improvement in at
least one of:
 Admit child
• Respiratory rate,  Change treatment from amoxicillin to
• Severity of indrawing, Ampicillin and gentamicin
• Fever,
• Eating / drinking

5 Days (or earlier if continued signs of worsening) Consider transfer to higher level hospital

At least three of: Re-evaluate and consider;

 If still on amoxicillin, admit the
 Fever, temp >38 0C child and change to Ampicillin and
 Respiratory rate >60 bpm Gentamycin
 Still cyanosed or saturation <90% and no  If on Ampicillin and gentamicin change
better than admission. to ceftriaxone or Cefotaxime.
 Chest in drawing persistent  Suspect PCP, an HIV test must be done -
 Worsening CXR treat for Pneumocystis if HIV positive.

After 1 week
 Consider TB, perform mantoux and
Persistent fever and respiratory distress.
follow TB treatment guidelines

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--| Wheezing child: bronchiolitis

Definition
A wheeze is a musical and continuous sound that originates from oscillations in narrowed airways.
Wheezing is heard mostly in expiration as a result of critical airway obstruction.

Causes/ differential diagnosis:

• Bronchiolitis
• Asthma
• Oesophageal foreign bodies
• Aspiration syndrome (gastro-oesophageal reflux diseases)

Definition: Bronchiolitis is an inflammation of the small airways due to acute viral infection affecting
children below 2 years of age. It occurs with seasonal variations and may lead to fatal respiratory
distress. Recurrent episodes of wheeze associated with bronchiolitis may occur, and some of these
children may develop asthma.

Causes
• Respiratory Syncytial Virus is the most common (>50% cases)
• Other agents: parainfluenza, adenovirus, Mycoplasma, and, occasionally, other viruses
especially Human metapneumovirus

Clinical signs
• Mild Bronchiolitis
o Cough and fast breathing (tachypnoea).
• Moderate Bronchiolitis: As above plus one of the following:
o Lower chest wall in-drawing;
o Nasal flaring;
o Grunting
• Severe Bronchiolitis: As above plus at least one of the following:
o Central cyanosis, oxygen saturation < 90% in room air;
o Inability to feed;
o Convulsions, lethargy or decreased level of consciousness;
o Severe respiratory distress (e.g. very severe chest wall in-drawing).
o Silent chest on auscultation (corresponding to an intense bronchospasm

Risk factors for severe bronchiolitis:

• Age less than 3 months
• Ex-preterm infants
• Chronic lung disease
• Congenital heart disease

Diagnosis: Is on clinical basis

• Prodrome of viral infection: irritability and rhinorrhoea.
• A wheeze that is slowly responsive or non-responsive to bronchodilators.
• Crepitations and signs of hyperinflation of the chest.
• Chest X-ray should be reserved for clinically severe or complicated cases
• Tachypnoea: age dependent:

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Investigations
• FBC
• CRP (Less contributory as viral infection)
• Chest X-ray: (Not mandatory) show hyperinflated lungs with patchy atelectasis

Complications:
• Bacterial secondary infection
• Atelectasis
• Apnoea especially in neonatal and infant period
• ARDS

Management: In Bronchiolitis treatment is symptomatic

At health centre level:

Outpatient management
• Nasal irrigation with 0.9% NaCl before each feed
• Small, frequent feedings to reduce vomiting triggered by bouts of coughing.
• Increased fluids if fever and/or significant secretions are present.
• Treat fever with paracetamol 10-15mg/kg/dose 6 hourly
• Counsel the care giver and advise to come back if the child deteriorates or does not
improve.
• Transfer all children with one of the following criteria to hospital:
o Presence of any sign of severity
o Pre-existing pathology (cardiac, Respiratory, malnutrition, HIV, etc.)
o Associated acute pathology (viral gastro-enteritis, bacterial infection, etc.)
o Age less than 3 months

At district hospital level

Hospitalize children if signs of serious illness
• Administer high humidified oxygen at 8L/min in 30 to 40 % oxygen
• Maintenance IV fluid
• Tube feeding when the respiratory distress improves
• In case of respiratory failure, use non-invasive naso CPAP or mechanical ventilation

Recommendation
• Antibiotic treatment only indicated for children with secondary infection according to
severity of clinical signs, high fever > 39°C, purulent sputum, aggravation of respiratory
symptoms.
• Give oral or parenteral antibiotics for 5 days based on severity and/or condition of the
patient as follow:
o Amoxicillin 25mg per dose/kg/day Q12hr PO OR
o Ampicillin IVI: 100 mg/kg/day in 3 divided doses
Alternative treatment:
• Erythromycin 30-50 mg per dose/kg/day x3/day/7-10days
Note: Treatment of bronchospasm:
Data does not support routine use of bronchodilators, steroids or antibiotics. If bronchodilators are
to be used, closely monitor effect as it might worsen the respiratory distress.

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--|Asthma
Definition
Asthma is a chronic inflammatory condition of the lung airways resulting in episodic airflow
obstruction.

Causes: unknown but the following factors have been identified:

• Allergens (e.g., house dust, perfumes, food, animal airs, mites),
• Medicines (e.g., propranolol and aspirin),
• Environmental (e.g., change of weather, polluants), Infections (viral or bacterial),
• Emotions,
• Family history (genetic factors),
• Gastro-esophageal reflux

Clinical signs and symptoms

• Breathlessness
• Wheezing/ prolonged expiratory
• Cough (chronic nocturnal cough)
• Exercise induced cough
• Chest tightness
• Sputum production

Table 4. Normal rates of breathing in awake children

< 2 months < 60/min

2-12 months < 50/min

1-5 years < 40/min

6-8 years < 30/min

Table 5. Guide to limits of normal pulse rate in children

Infants 2-12 months < 160/min

Preschool 1-2 years < 120/min

School age 2-8 years < 110/min

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 TREATMENT GUIDELINES 9
Severity of Asthma Exacerbations

Respiratory arrest
Parameter Mild Moderate Severe
imminent
Talking
At rest
Walking Infant - softer,
Infant stops
Breathless shorter cry;
Can lie down feeding
difficulty feeding
Hunched forward
Prefers sitting

Talks in Sentences Phrases Words

Alertness May be agitated Usually agitated Usually agitated Drowsy or confused

Respiratory rate Increased Increased Very Increased

Accessory
Paradoxical
muscles and
Usually not Usually Usually thoraco-abdominal
suprasternal
movement
retractions
Moderate, often
Wheeze Loud Usually loud Absence of wheeze
only expiratory

Pulse/min. <100 100 - 120 >120 Bradycardia

Often present>
Absence suggests
Absent < 10 mm May be present 10 25 mm Hg
Pulsus paradoxus respiratory muscle
Hg - 25 mm Hg (adult) 20 - 40
fatigue
mm Hg (children)
< 60%
PEF after initial
predicted or
bronchodilator
Over 80% Approx. 60-80% personal best or
% predicted or
response lasts <
% personal best
2 hrs
SaO2% (on air) >95% 91 - 95% <90%

Diagnosis:
Asthma is diagnosed on the basis of a patient’s symptoms and medical history.
Presence of any of these signs and symptoms should increase the suspicion of asthma:
• Wheezing: high-pitched whistling sounds when breathing out-especially in children. (A
normal chest examination does not exclude asthma.)
• History of any of the following:
o Cough, worse particularly at night
o Recurrent wheeze
o Recurrent difficulty in breathing
o Recurrent chest tightness
• Symptoms occur or worsen at night, awakening the patient.
• Symptoms occur or worsen in a seasonal pattern.
• The patient also has eczema, hay fever, or a family history of asthma or atopic diseases.
• Symptoms occur or worsen in the presence of:
o Strong emotional expression Animals with fur
o Aerosol chemicals
o Changes in temperature

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o Domestic dust mites

o Drugs (aspirin, beta blockers)
o Exercise
o Pollen
o Respiratory (viral) infections
o Smoke
• Symptoms respond to anti-asthma therapy
• Patients colds “go to the chest” or take more than 10 days to clear up

Investigations:
• FBC for exclusion of super-infection
• Chest X-ray ( where available for differential diagnosis and i
• Additional diagnostic tests:
• Lung function to confirm diagnosis and assess severity (where available)
• Peak expiratory flow rate can help diagnosis and follow up

Complication:
• Uncontrolled/poorly controlled asthma can lead to severe lung damage
• Severe asthma exacerbation can cause respiratory failure and death

Management:
Asthma exacerbation (asthma attacks) are episodes of a progressive increase in shortness of
breath, cough, wheezing or chest tightness or a combination of these symptoms.
• Asthma attacks require prompt treatment
• Categorize severity of attach and treat as per ETAT+ guidelines below

Very Severe Asthma

Any one with;
• Oxygen saturation <90%
• Central cyanosis
• Silent chest
• Inability to drink / breast feed
• AVPU= “V”, “P” or “U” or
• Inability to talk/complete sentences
• Pulse rate >200 bpm (0-3 years) and >180 bpm (4-5yrs)

Immediate Management

ADMIT
• Oxygen
• Nebulize 2.5 mg salbutamol or 6 puffs of Inhaler with spacer and mask give every 20
minutes up to 3 doses if needed
• Prednisolone 2mg/kg OR
• IVI Hydrocortisone 4mg/kg if unable to take orally
Alternative treatment:
• Ipratropium bromide (if available): nebulization increases effect of salbutamol or
Combivent (Ipratropium bromide and albuterol sulfate)
• Adrenaline in case of anaphylaxis but not indicated for asthma attack (10µg/kg IM
then infusion 0.1µg/kg/min)
Moderate to Severe asthmatic attack:
• Wheeze
• Lower chest wall indrawing

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Immediate Management
• Oxygen if obvious use of accessory muscles, measure oxygen saturation.
• Salbutamol by nebulizer or
• Inhaler + spacer + mask repeated up to 10 puffs in 30min min (shake inhaler every 2
puffs)
• Start oral prednisolone at 2mg/kg for 3-5 days. Max dose of 20mg/day for < 2 years
and 30mg/day for 2-5 years.

Reassess after 30-60 min and reclassify severity – if now:

• Very severe
o Continue oxygen, 1-4 hourly salbutamol, early review, antibiotics as for very
severe pneumonia
• Severe
o 4 hourly salbutamol, antibiotics as for severe pneumonia
• Mild:
o 4 hourly salbutamol, oral antibiotics aim for discharge in 24 hr
Mild asthmatic attack:
• Wheeze PLUS
• Fast breathing (RR 50 aged 2-11 months RR 40 aged 12-59 months)

Management of mild asthmatic attack

• Salbutamol by inhaler, spacer + mask
• Reassess respiratory rate after 20-30 minutes, if persistently elevated consider oral
antibiotic
• Counsel caregiver on signs of deterioration and schedule review within 48 hours
• Give education on use of inhaler, spacer + mask
• Discharge on salbutamol inhaler 4-6 hourly for no more than 5 days

NOTE:
• In recurrence of asthma symptoms consider inhaled corticosteroid (ICS) therapy or adjust
the doses if already on ICS and look out for other comorbidities
• Demonstrate MDI and spacer use to the caregiver before discharge
• Preferably use spacer with face masks for <3 years for 4-5 years use facemask or
mouthpiece.
• Advise on regular follow up
Maintenance treatment: see tables below
Clinical initial check- up
• Check risk factors
• Patient education: Discuss the management plan, importance of adherence to treatment
• Medication: inhaled corticosteroids. Example: start with Beclomethasone inhaled 250μg,
once to twice a day with inhalation chamber then step up or step down according to the
evolution (close follow up after discharge)
• Treatment of co-morbid conditions (Rhinitis, sinusitis, gastroesophageal reflux)

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EAR NOSE AND THROAT

CONDITIONS
--|Otitis externa
Definition
Inflammation of the external ear. Common precipitants of otitis externa are maceration, trauma
of the ear canal or presence of a foreign body or dermatologic diseases (such as eczema,
psoriasis).

Clinical features
May be one of the following:
• Diffuse: An infection of the ear canal, often due to Gram negative bacilli especially P
Aeruginosa
o Pain on chewing and movement of the tragus or pinna
o Lining of the canal is inflamed or swollen with dry or moist debris with or without
discharge.
o If visible, the tympanic membrane is normal
• Furuncular: Usually caused by Staphylococcus aureus.
o A painful localized swelling seen at the entrance to the ear canal
General measures
• Rule out chronic otitis media before treatment.
• Most cases recover after thorough cleansing and drying of the ear.
• Keep the ear clean and dry.
• Do not leave pieces of cotton wool, etc. in the ear.

Medical treatment
Diffuse
• Does not usually require an antibiotic.
• Clean and dry the ear using a dry cotton bud or a small piece of dry cotton wool.
• Consider ear irrigation only if the tympanic membrane is intact
o Acetic acid 2% in alcohol, 3–4 drops into the ear every 6 hours for 5 days.
OR
o Apply ciprofloxacin ear drops: 3 drops 12 hourly in the affected ear(s) for 7 days

Furuncular-
• Cefadroxil, oral, 15 mg/kg/dose 12 hourly for 5 days.
• OR
• Flucloxacillin, oral, 12–25 mg/kg/dose 6 hourly for 5 days.

--|Otitis media
Definition
It is the inflammation of the middle ear cavities
Causes:
• Bacterial (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis etc)
• Viral
Predisposing factors include poor living conditions, adenoids, sinusitis, allergic rhinitis, tonsillitis,
asthma etc

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Signs/symptoms
• Fever
• Retroauricular pain
• Crying with ear scrubbing
• Gastro intestinal signs
• Otalgia
• Cervical lymphadenopathy
• Otorrhea (if tympanic membrane perforated)
• Impaired hearing
• Redness of eardrum
• Sometimes bulging of the eardrum

Diagnosis:
• Clinical including otoscopy
• FBC and CRP if signs of sepsis

Complications:
• Secretory otitis media (ear glue)
• Chronic otitis media with perforation
• Acute mastoiditis sometimes with periosteal abscess
• Intracranial (meningitis, brain abscess, subdural abscess, etc)
• Facial paralysis
• Labyrinthitis

Management:
• General measures: Elimination of risk factors
• Medical
• Surgical: Myringotomy if necessary
Treatment of first choice
• Amoxicillin, Po 30mg/kg/dose P.O. Q8h for 7-10 days
• When associated with rhinitis add Xylometazoline (Otrivine) 0.05% nose drops or simple
argyrol drops 1% , 0.05%
• Paracetamol 10-15mg/kg/dose Q6hr if high fever or pain
Alternative treatment:
• Amoxyclav: 50mg/kg/day P.O , Q8h for 7 -10 days;
OR
• Cefadroxil: 25mg/kg/dose Q12h for 7 days
• Cefuroxime: 15mg/kg /dose Q12h for 7 days
• Azithromycine 5mg/kg/dose Q24h for 3 days
• Erythromycine 20 mg/kg/dose Q8h for 10 days

Recommendations:
• Avoid getting in the inside of the wet ear

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--|Chronic Suppurative Otitis Media

Definition
It is a chronic inflammation of the middle ear with recurrent ear discharges or otorrhoea through
a tympanic perforation for more than 2 weeks.

Predisposing risk factors:

• Inadequate management of otitis media
• Frequent upper respiratory tract infections
• Anatomic factor: Short Eustachian tube
• Poor living conditions, poor housing, hygiene and poor nutrition
• Immunosupression (ex: HIV infection)

Causes
• H. Influenza
• P. aeruginosa
• S.pneumoniae
• Staphyllococcus aureus
• Tuberculosis

Signs and symptoms:

• Recurrent pus ear discharge
• Large perforation of the eardrum on examination
• Progressive hypoacousia with Impaired hearing
• Buzzing (acouphene)
• History of recurrent otitis media
• Loss of transparency of tympanic membrane

Diagnosis:
• Clinical including Otoscopy
• Investigations :
o Bacterial Cultures
o Search for predisposing factors
o Audiogram
o CT-scan

Complications:
• Subperiosteal abscesses
• Facial nerve paralysis
• Lateral sinus thrombophlebitis
• Suppurative labyrinthitis
• Brain abscess
• Meningitis
• Mastoiditis
• Extradural and subdural Empyema
• Otitic hydrocephalus
• Hearing impairment
• Deafness

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Management
Non pharmacological management
• Dry mopping
• Aural toilet by medicines’ droppers (with Hydrogen peroxide or polyvidone iodine saline
solutions)
• Avoid getting the inside of the ear wet. E.g.: bathing and swimming
Pharmacological management
• Topical quinolones (Ciprofloxacin ear drops Q12h for 7 days)
• Systemic treatment: Ceftazidime IV or IM 50mg/kg/dose Q8h (max:6gr/day) for 7 days
• In case of mastoiditis: Refer to ENT surgeon for possible mastoidectomy
Recommendations:
• Proper management of acute otitis media
• Avoid getting the inside of the ear wet. E.g: bathing and swimming
• Refer to the tertiary health facility for further management

--|Tonsillitis
Definition
It is an inflammation of the tonsils

Causes:
• Bacterial infection (Group A β-hemolytic streptococcal, staphylococcal...)
• Viral infection (Rhinoviruses, influenza...)
• Fungal infection

Signs/symptoms
• Difficult and painful swallowing (Dysphagia)
• Refusal of breastfeeding
• Fever, chills
• Headache
• Vomiting
• Sore throat - lasts longer than 48 hours and may be severe
• Enlarged and tender submandibular lymph nodes
• Swollen red tonsils with white spots

Diagnosis os clinical
• It is not possible to distinguish clinically between viral and bacterial tonsillitis
• Investigations:
o Swab for laboratory analysis where possible
o Complete blood count
o Streptococcal screen ASOT/ASLO

Complications:
• Rheumatic heart disease
• Acute glomerulonephritis
• middle ear infections
• Peritonsillar abscess (quinsy)
• Abscess of the pharynx
• Sinusitis

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• Septicaemia
• Bronchitis or pneumonia
• Airway obstruction

Management:
• Ensure enough fluids to avoid dehydration
• Medical treatment: antibiotics, analgesics, anti-inflammatory
• Surgery
Treatment of first choice:
• Amoxicillin 15-30 mg/kg/dose Q8h for 10 days
OR
• Penicillin V tabs: 15mg/kg/dose Q12h for 10days
o In case of allergy to penicillins use:
• Erythromycin 15-20mg/kg/dose Q8h for 10 days
• OR Azithromycin 5mg/kg/dose Q24h for 3 days
• If fever or pain, give Ibuprofen: 2-3mg/kg/dose Q8h or Paracetamol 10-15mg/kg Q6h,
max 60mg/kg/day
If no response with the first choice,
• Amoxi-clav ( Augmentin) 15-20mg/kg/dose P.O , Q8h 7 -10 days;
OR
• Cefuroxime (Zinat): 15mg/kg /dose Q8h for 7 days
Surgical treatment:
• Tonsillectomy indicated in:
o Chronic repetitive tonsillitis
o Obstructive tonsils
o Peritonsilar abscess

Recommendations:
• Systematically give Antibiotherapy for children > 3 years in order to prevent rheumatic
heart disease
• For chronic and obstructive tonsillitis refer to the ENT specialist

--|Acute mastoiditis
Definition
Acute mastoiditis is sudden onset bacterial infections of the mastoid bone

Causes:
Spread of pathogens causing acute otitis media to the mastoid bone

Signs/symptoms
• Fever
• Pain,tenderness, discomfort and swelling behind the ear
• In some instances, the ear on the affected side seems pushed out and quite prominent. This
is caused by a high concentration of pus in the mastoid
• Sometimes associated suppurative otitis media
• Tympanic membrane is usually perforated with otorrhoea
• Occasionally, pus breaks through the mastoid tip and forms an abscess in the neck (Bezold’s
abscess)

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• Headache
• Hearing loss

Diagnosis: Clinical basis

• X-Ray of the mastoid bone
In selected cases,
• CT-scan of the middle ear
• Culture of the pus from the mastoid bone
• Blood culture
• LP if signs of meningitis

Complications:
• Facial paralysis
• Brain abscess
• Meningitis
• Neck abscess
• Extradural abscess
• Septicaemia
• Subdural abscess

Management: Should be managed in collaboration with ENT surgeon

• Pharmacological
Treatment of first choice:
• Ceftriaxone iv 100mg/kg/dose Q24h for 14 days+ Vancomycin are the recommended
treatment until culture and sensitivity results are available
If 3rd generation cephalosporin not available,
• Amoxiclav, for 14 days and Gentamycin iv 5mg/kg/dose Q24h 5 days
• If fever or pain, give Ibuprofen: 2-3mg/kg/dose Q8h or Paracetamol 10-15mg/kg Q6h,
max 60mg/kg/day
Surgical
• Mastoidectomy
• Incision of abscess
• When anaerobic infection is suspected : Add metronidazole IV 15-20 mg/kg/dose Q8h
and culture sensitivity where possible

--|Epistaxis
Definition
Epistaxis is nose bleeding

Causes:
• Local (trauma, inflammation, foreign bodies, tumours of the nose and rhinopharynx, chronic
use of nasal steroids, intra nasal growth like polyps,..)
• Systemic (cardiovascular diseases, blood diseases, liver diseases, kidney diseases, febrile
diseases)
• Upper respiratory disease ( sinusitis, allergic rhinitis )
• Juvenile nasopharyngeal angiofibroma if profuse unilateral epistaxis associated with a
nasal mass in adolescent boy
• Idiopathic (causes not known)

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Signs/symptoms:
• Blood coming from the nose or the rhinopharynx
• History of recurrent nasal bleeding

Diagnosis:
• Clinical: exploratory clinical examination, ENT and general examination
• Investigations in complicated or recurrent cases
o Full blood count, clotting time, bleeding time, prothrombin time
o CT scan and MRI if Juvenile nasopharyngeal angiofibroma
o Other investigations should be requested based on general examination findings

Complications
• Hypovolemic shock
• Anaemia

Management:
Non pharmaceutical treatment:
• Sit the patient up to avoid aspiration
• Cleaning of blood clots from the nose
• Direct pressure applied by pinching the soft fleshy part of the nose applied for at least five
minutes and up to 20 minutes
• Application of cold compresses on the nose
• Room humidifier
• Pack with ribbon gauze impregnated with topical ointments (Vaseline…) and remove it after
12-24 hours.
Pharmaceutical treatment:
• Application of a topical antibiotics ointment to the nasal mucosa has been shown to be an
effective treatment for recurrent epistaxis
• Topical vasoconstrictor: xylometazoline spray (otrivine) 0.5mg/ml
• Cauterization of the bleeding site with silver nitrate or 20% of solution trichloracetic acid
under topical anesthesia
• Electro coagulation
• If severe bleeding with shock/or anemia, immediate blood transfusion is recommended

Recommendations:
• Investigate for underlying causes
• Refer cases of severe and recurrent epistaxis
• Refer to ENT specialist for otolaryngologic evaluation if bilateral bleeding or hemorrhage that
not arise from Kiesselback plexus

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--|Laryngotracheobronchitis
Definition
Inflammation of the vocal cords and structures inferior to the cords. It is the common cause of
stridor in children aged between 6 months and 2 years leading to potentially life-threatening
airway obstruction.

Causes:
• Viral respiratory tract infection: Parainfluenza Virus Type 1 and 2, Rhinoviruses, Syncytial
Viruses, adenoviruses, measles and herpes simplex….)

Signs and Symptoms:

• Progressive shortness of breath following upper respiratory tract infection in a previously
well child, followed by a barking cough and stridor
• Stridor becomes softer as airway obstruction becomes more severe
• There may be a sore throat
• Mild fever may be present
• Erythema and oedema of larynx

The following features suggest a different diagnosis:

• Acute onset of obstruction without prodromal features (foreign body or angioneurotic
oedema)
• incomplete immunisation and a membrane in the upper airway (diphtheria),
• High fever, dysphagia, drooling or sitting position (epiglottitis, retropharyngeal abscess,
bacterial tracheitis)
• Recurrent upper airways obstruction (laryngeal papilloma).

Assessment of severity of airway obstruction in LTB

• Grade 1: Inspiratory stridor
• Grade 2 : Inspiratory and Expiratory stridor and passive expiration
• Grade 3 : Inspiratory and Expiratory stridor + pulsus paradoxus and active expiration
• Grade 4 : cyanosis, apathy, marked retractions, impending cardiorespiratory arrest

Diagnosis:
• Clinical signs as above
• Investigations:
o FBC + CRP
o Lateral Neck X-ray (not mandatory)

Management:
Leave child in carer’s arms as much as possible
(except if near respiratory arrest) as you manage the child

Supportive measures
• Humidified O2 therapy
• Monitor oxygen saturation, heart rate and respiratory rate
• Maintenance fluids and nutrition
• Avoid unnecessary stimulation
• Depending on severity, admit child to high care or intensive care ward.

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Medical treatment:
Grade 1 obstruction
• Prednisone, oral, 2 mg/kg as a single dose. OR
• Dexamethasone, IV/IM, 0.5 mg/kg as a single dose.
Note: Avoid steroids in patients with measles or herpes infection.
Grade 2 obstruction
• As above PLUS
• Adrenaline (epinephrine), 1:1000, nebulise with oxygen, every 15–30 minutes until
expiratory obstruction is abolished.
o 1 mL adrenaline (epinephrine) 1:1 000 diluted in 1 mL sodium chloride 0.9%.
Grade 3 obstruction
• As above:
• If improvement, treat as in grade 2 but reduce frequency of adrenaline (epinephrine)
nebulization with time,
• If no improvement within 1 hour, intubate, preferably under general anaesthesia
• If unable to intubate, bag and mask ventilate and refer urgently.
Grade 4 obstruction
As above and:
• Continue steroids
• Continue with adrenaline (epinephrine) nebulization with 100% warm humidified oxygen
• Intubate, preferably under general anaesthesia
• If unable to intubate, bag and mask ventilate and refer urgently

For suspected herpes:

• Acyclovir IV, 10–15 mg/kg/dose 8 hourly for 5–7 days.

For suspected bacterial infection in children < 20 kg:

• Ampicillin, IV, 12.5–25 mg/kg/dose 6 hourly for 5–10 days.

For suspected bacterial infection in children > 20 kg:

• Ampicillin, IV, 250–500 mg, 6 hourly for 7 days.

If bacterial tracheitis is suspected:

• Cloxacillin, IV, 50 mg/kg/dose 6 hourly for 7 days.

--|Epiglottitis
Definition
Acute epiglottitis is a life-threatening emergency due to respiratory obstruction. It is due to
intense swelling of epiglottis and surrounding tissues with septic signs.

Cause
It is caused by Haemophilus influenza type b. Since systematic vaccination, this condition has
become very rare.

Table 8. Presentation
Signs/symptoms: Croup (laryngitis) Epiglottitis
Onset Over days Over hours

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Preceding coryza Yes No
Cough Severe, barking Absent or slight
Able to drink Yes No
Drooling saliva No Yes
Appearance Unwell Toxic, very ill
Fever <38,5°C >38,5°C
Stridor Harsh, rasping Soft, whispering
Voice, cry Hoarse Muffled, reluctant to speak

Management:
Urgent hospital admission and treatment
Move the child only when ready for intubation under anesthaesia
Intubation by senior anesthaesist, paediatrician and ENT in theatre room
Urgent tracheostomy if intubation impossible
Antibiotic treatment: Cefotaxime iv 30-50 mg/kg/dose Q8h for 7-10 days
or
Ceftriaxone iv 100mg/kg/dose Q24h for 7-10 days

--|Sinusitis
Definition
Sinusitis is the inflammation of one or more sinus cavities.

Causes:
• Rhinitis (most common cause)
• Trauma with open sinuses
• Bacterial infections (Bacteria: S.pneumoniae, H. Influenza, Moraxella catarrhalis,
staphylococcus Aureus, anaerobies)
• Viral
• Common predisposing factors include: abscess and tooth extraction, chemical irritants, nasal
polyp, deviation of nasal septum, perfumes or paint fumes, and changes in the weather

Signs/symptoms:
• Non specific complaints
• Purulent nasal discharge (unilateral or bilateral)
• Fever and cough
• Nasal obstruction and congestion
• Frontal headache and heaviness of the head exaggerated on bending the head
• Persistant symptoms of upper respiratory tract infection
• On clinical examination, pressure on frontal and maxillary sinuses causes pain
• Decreased sense of smell
• Periorbital oedema
• Anterior rhinoscopy shows pus coming through the middle meatus

Diagnosis:
• Clinical
• Investigations:

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o Paranasal X-ray (shows opacification with air-fluid level)

o CT scan

Complications:
• Local: Osteomylitis, orbital cellulitis, orbital abscess
• Descending infections: pharyngitis, tonsillitis, bronchitis, pneumonia
• Systemic: septicemia, meningitis, brain abscess, thrombophlebitis of cavernous sinus, subdural
empyema

Management:
• Medical treatment consists of nasal decongestants and antibiotics

Treatment of first choice:

• Amoxicillin, Po 15-20mg/kg/dose Q8h 7-10 days
• Paracetamol 10-15mg/kg/dose Q6hr

Alternative treatment:
• Amoxicillin-clavulanate (amoxi-clav, augmentin®) 15-20 mg/kg/dose PO, Q8h 7 -10 days
• Add Xylometazoline (Otrivine) 0.05% nose drops or simple argyrol drops 0.1% , 0.05%
• OR
• Cefadroxyl (Oracefal): 25mg/kg/dose Q12h for 7 days
• Cefuroxime (Zinat): tabs 15mg/kg/dose Q12h for 7 days
• Azithromycin 5mg/kg/dose Q24h for 3 days
• Erythromycin 15-20 mg/kg/dose Q8h for 10 days
• Rovamycine 3MI units: 50000-100000 UI/kg/dose Q8h for 10 days
• Argyrol-ephedrin nasal drops 2% 3 drop x3/day/7 days

Recommendations:
• Do not use nasal decongestants taking a monoamine oxidase inhibitor in hypertensive patient

--|Pertussis (whooping cough)

Definition
This is a highly infectious form of bronchitis caused by bordetella pertussis. It has become rare
since vaccination but it is endemic with epidemics every 3-4 years. Particular attention to young
infants (before complete vaccination), adults (weaning effect of vaccine) and unvaccinated.

Cause: Bordetella pertussis

Signs/symptoms:
After one week of coryza (catarrhal phase), the child develops a characteristic paroxysmal
cough followed by characteristic inspiratory whoop (paroxysmal phase, 3-6 weeks). Worse at
night and occasional vomiting. During paroxysm, the face goes red or blue and mucus flows from
nose and mouth. May cause apnoea in young infants. The symptoms gradually decrease and
may persists for months (convalescent phase)

Diagnosis:
Clinical symptoms and signs
Culture if available
FBC: marked lymphocytosis (>15 109/l)

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Management:
• Admit to hospital if infant (risk of apnoea)
• Symptomatic treatment: O2, gavage
• Erythromycine 15-20 mg/kg/dose Q8h for 14 days
Or
• Azithromycin
o Infants aged <6 months: 10 mg/kg/dose Q24h for 5 days.
o Infants and children aged >6 months: 10 mg/kg (maximum: 500 mg) on day 1, followed
by 5 mg/kg/dose Q24h (maximum: 250 mg) on days 2-5.
• Prophylaxis for close contact (same)

--|Allergic Rhinitis
Definition
Recurrent inflammation of the mucous membranes of the nose and paranasal sinuses in response
to an inhaled allergen e.g. pollen, house dust, grasses and animal hair. Overuse of nasal
decongestants and viral infections may precipitate the symptoms

Signs/symptoms allergic rhinitis:

• Blocked stuffy nose/ Sensation of nasal obstruction
• Watery nasal discharge
• Frequent sneezing, often accompanied by nasopharyngeal itching and irritation
• Conjunctival itching and watering
• Oedematous pale nasal mucosa
• Mouth breathing
• Snoring at night
• Dry cough
• Headache
• Asthenia
• Thick, sticky mucus (after 3-days)

Diagnosis: Based on clinical signs

Investigations: Not indicated in our setting

Complications:
• Acute or chronic sinusitis.
• Otitis media.
• Sleep disturbance or apnoea.
• Dental problems (overbite): Caused by excessive breathing through the mouth.
• Palatal abnormalities.
• Eustachian tube dysfunction
• Sinusitis
• Pharyngitis
• Laryngo-bronchitis

Management:
• Avoid allergens
• There is no cure for allergic rhinitis; treatment is given for symptom relief
• Supportive care includes bed rest and drinking plenty of fluid

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Treatment of first choice:

• 2-5 years : Desloratadine syrup: 1.25mg once a day for 5 days;
• 6-11years: /Desloratadine syrup: 2.5mg once a day for 5 days
• 12 years: Desloratadine tab 5 mg once a day for 5 days
• Nasal steroids, 1-2 spray/nostril/dose Q12-24h
• Avoid local nasal decongestants as they have long term side effects

Alternative treatment:
During periods of exacerbation of symptoms, a short course of antihistamine can help:
• Cetirizine, oral, as a single dose at night if the predominant symptoms are sneezing, nasal
itching and rhinorrhoea:
o Children 3–12 years: 5 mg
o Children older than 12 years: 10 mg.mg.

If poorly controlled/severe:
• Corticosteroid aqueous nasal solution, e.g. Budesonide, 100 mcg, 1 spray into each nostril
12 hourly. OR Fluticasone nasal spray (Avamys) 27.5mcg 1 puff daily

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GASTROINTESTINAL DISORDERS
--|Acute gastroenteritis
Definition
Gastroenteritis is an inflammation of the stomach and intestines that causes diarrhoea, vomiting,
nausea and other symptoms of digestive upset.
Diarrhoea is the passage of three or more loose or watery stools per day. It can be watery,
bloody or containing mucus.

Causes:
• Viral gastroenteritis: Rotavirus and enterovirus), are the most likely cause of infectious
diarrhoea in children under age 5
• Bacterial gastroenteritis: Campylobacter, Salmonella or E. coli
• Intestinal parasites: Giardia lamblia,
• Others causes include life threatening conditions including intussusception; appendicitis…may
be initiated by diarrhoea.

Signs/Symptoms:
Table 9. Clinical evaluation of dehydration
Mild dehydration : 3 - 5% No signs of dehydration
Plan A)
• Able to drink (drinks eagerly) plus 2 or more of:
Moderate dehydration : 6-9% • Sunken Eyes
(Plan B) • Skin pinch 1 - 2 secs
• Restless / Irritable/Agitated
• Pulse weak or rapid and unable to drink plus:
Severe dehydration : 10-15% • Sunken Eyes
• Skin pinch ≥ 2 secs?
(Plan C) • Lethargic or decreased level of consciousness
unconscious
• Kussmal (acidotic) breathing

Complications:
• Hypovolemic shock (Tachycardia, cold hands, weak or absent pulse, capillary refill > 2 sec,
not alert )
• Electrolytes imbalance: severe hyponatraemia (<130mmol/L), severe hypernatraemia
(>150mmol/L), severe hypokalaemia (<3mmol/L), severe hyperkaelemia (>5.5).
• Cerebral œdema (headache, convulsions, vomiting, nausea, weakness) due to rapid
rehydration with hypotonic solutions. Common in hypernatraemia
• Intracerebral haemorrhage (due to severe dehydration in infants and young children)

Investigations:
• Stool exam: direct/culture (if blood or pus in stool )
• FBC, CRP, blood culture if suspicion of bacterial blood stream.
• Electrolytes (Sodium and Potassium )
• Random blood sugar , Urea/creatinine if shock
Note: Qualitative evaluation of dehydration (according to sodium level)
• Isotonic dehydration: Na 130 to 150 mmol/L
• Hypertonic dehydration: Na > 150 mmol/L
• Hypotonic dehydration : Na < 130 mmol/L

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Management:
At health centre level (Follow IMCI guidelines)
At district hospital level follow ETAT + guidelines

Admit the child: Absolute criteria of admission:

• Profuse diarrhoea (> 8 stools/24h) with vomiting
• Vomiting every feed
• Severe dehydration
• Failure of home oral rehydration

If dehydration and shock without signs of malnutrition, give appropriate treatment as follow:
• Consider ABCD
• 20ml/kg of normal saline (NS) or Ringers Lactate (RL) as quickly as possible IV or IO in 15
minutes (see table below for estimation of required volume for 20ml/kg):
• Repeat the bolus of NS or RL 3-4 times if persistence of signs of shock
• Treat as severe dehydration after correction of shock
If dehydration and shock with signs of malnutrition
AVPU<A, absent or weak pulses, prolonged capillary refilling (>3s) and cold periphery with
temperature gradient
• 20 ml/kg over 2 hours of Ringer’s Lactate (RL)/5% dextrose. – add 50mls 50% dextrose to
450mls Ringers (or 10% Dextrose/HSD if no Ringers).
• If severe anaemia start urgent blood transfusion not Ringers.
If severe dehydration without shock (Plan C);

Table 10. severe dehydration without shock

Normal Saline ( If unavailable)

Age < 12 months Age ≥ 12 months to 5 years
Full Strength Ringer Lactate

Step 1 30 mls / kg over 1 hour 30 mls / kg over 30 mins

Step 2 70 mls / kg over 5 hours 70 mls / kg over 2.5 hours
Then re-assess child – if still signs of severe dehydration repeat step. If signs improving treat for
moderate dehydration

If moderate dehydration (Plan B);

• Best treated with ORS 75ml/kg 4 hours
• Give RL 75ml/kg during 4 hours in case of uncontrolled /severe diarrhoea and/or vomiting
After 4 hours
• Reassess the child and classify the child for dehydration.

Table 11. How to administer ORS

Give 1/3 during 1st h, then 2/3 during 3 following hours.
By bottle Example: 10 kg; dehydrated 7%. Should receive 75 ml/kg = 750 ml ORS in 4h
Give 60 ml every 15 min during 1st hour
Then 170 ml every h during 3 following hours
Maybe effective if has severe vomiting
Spoon or Allows adequate volumes
syringe Ex: 5 ml every 1 to 2 min à 300 to 150 ml in 1 h!
Nasogastric vomiting +++
tube fatigue +++

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• Select the appropriate plan to continue treatment.
• Begin feeding the child in clinic.

NB ORS is
• Contra-indicated if ileus or decreased level of consciousness
• Able to correct the electrolyte imbalance (hypo and hypernatraemia)

If the mother must leave before completing treatment:

• Show her how to prepare ORS solution at home.
• Show her how much ORS to give to finish 4-hour treatment at home.
• Give her enough ORS packets to complete rehydration

Explain the 4 rules of home treatment

• Give extra fluid: Give to the child more to drink as he wants
• Give zinc supplements for 10–14 days:
o Up to 6 months: 1/2 tablet (10 mg) per day, 6 months and more 1 tablet (20 mg) per
day
• Continue feeding: initial 4-hour rehydration period, breastfed children should continue to
breastfeed frequently throughout
• When the child has to be returned to the health facility:
o Drinking poorly or unable to drink or breastfeed
o Becomes more sick
o Develops fever
o Has blood in the stool

If no dehydration (Plan A)
• Treat the child as an outpatient; give ORS 10ml/kg after each watery stool
• Counsel the mother on the 4 rules of home treatment:
o Give extra fluid,
o Give zinc supplements
o Continue feeding
o Give advice on when to return for review

Table 12. Different forms of dehydration

Type Intervention Comment

Na Deficit = 0.6 x W in kg x (Na+d -
Na+m) during 4 hours Do not correct too quickly to
Hyponatremia
W= weight avoid CNS complications
(Na < 130mmol/L)
d = desired sodium
m = measured sodium
Risk of convulsions/cerebral
Hypernatremia
Slowly correct dehydration over 48 hours oedema in case of rapid
(Na > 150mmol/L)
correction
If Potassium< 2.5 mmol/L give KCl 30-40 Give KCl if urine output is
Hypokalemia
mmol/L/24hours adequate

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--|Persistent diarrhoea
Definition
Persistent diarrhoea is a diarrhoea, with no signs of dehydration and severe malnutrition, with or
without blood, which begins acutely and lasts ≥ 14 days.

Table 13. Causes of persistent diarrhoea

Age Aetiologies
• Post gastroenteritis mal-absorption syndrome
• Cow’s milk/soy protein intolerance
Infancy • Secondary disaccharidase deficiencies
• Cystic fibrosis
• Secondary disaccharidase deficiencies
• Giardiasis
• Post gastroenteritis malabsorption syndrome
Childhood • Celiac disease
• Cystic fibrosis
• HIV
• Malnutrition
• Irritable bowel syndrome
Adolescence • HIV
• Inflammatory bowel disease

Complications:
• Dehydration
• Failure to thrive, malnutrition
• Immunosuppression

Investigations: will vary according to the suspected etiology

• Stool examination:PH, White blood count, Fat, Ova, osmolality, Culture
• FBC, CRP, electrolytes, urea and creatinine
• Urine culture
• Sweat chloride if suspicion of cystic fibrosis
• Barium study
• Small bowel biopsy
• Endoscopy: Sigmoidoscopy or colonoscopy with biopsy

Management:
• Oral rehydration
• Treat the cause

Step-wise empiric protocol for management of diarrhoea

Day 1−2
• Continue full-strength feeds with additional ORS as required.
Day 3−7
• Change to lactose-free feeds if not breastfed.
• Continue additional oral rehydration as required.
• If diarrhoea resolves, discharge, but continue with lactose-free feeds for 2 weeks.
Day 8−13
• Semi-elemental formula: sucrose- and lactose-free, protein hydrolysate, medium chain
triglyceride.
• Continue additional ORS as required.

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--|Bloody diarrhoea (dysentry)
Definition
Frequent (>3/day) passage of blood and/or mucus in the stools

Cause:
• Bacterial infections (e.g. Shigella, salmonella...)
• Parasitic infestations (e.g. amoebic dysentery)
• Milk allergy
• Chronic inflammatory bowel disease

Signs and symptoms:

• Sudden onset
• Abdominal cramps
• Peritonism urgency, fever and diarrhoea with blood and mucus in the stools
• Meningism and convulsions may occur
• Exclude intussusceptions which present as:
o pain or abdominal tenderness
o bile-stained vomitus
o red currant jelly-like mucus

Investigations
• Stool culture to confirm diagnosis of Shigellosis
• Stool microscopy reveals many polymorphs and blood
• Immediate microscopy of warm stool to diagnose amoebic dysentery

Treatment:

Non-pharmacological treatment:
• Ensure adequate nutrition and hydration
Pharmacological treatment
• Fluid and electrolyte replacement (see Acute Diarrhoea)
• Ciprofloxacin, oral, 15 mg/kg/dose 12 hourly for 3 days
OR
• Ceftriaxone, IV, 50 mg/kg as a single daily dose for 5 days (if hospitalised or if unable to
take oral antibiotics)

Complications include:
• Dehydration
• Convulsions
• Shock
• Toxic megacolon
• Acidosis
• Rectal prolapse
• Renal failure
• Haemolytic uraemic syndrome

Recommendation:
• Refer patient to a paediatrician, if dysentery with complications, e.g. persistent shock,
haemolytic uraemic syndrome and toxic megacolon

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--|Amoebiasis
Definition
Amoebiasis is a parasitic infection due to the intestinal protozoa Entamoeba histolytic.
Transmission is faecal-oral, by ingestion of amoebic cysts from food or water contaminated
with faeces. Usually, ingested cysts release non-pathogenic amoebae and 90% of carriers are
asymptomatic. In 10% of infected patients, pathogenic amoebae penetrate the mucous of the
colon: this is the intestinal amoebiasis (amoebic dysentery). The clinical picture is similar to that
of shigellosis, which is the principal cause of dysentery. Occasionally, the pathogenic amoebae
migrate via the blood stream and form peripheral abscesses. Amoebic liver abscess is the most
common form of extra-intestinal amoebiasis.

Clinical features
• Amoebic dysentery
o Diarrhoea containing red blood and mucus
o Abdominal pain, tenesmus
o No fever or mild fever
o Possibly signs of dehydration
• Amoebic liver abscess
o Painful hepatomegaly; mild jaundice may be present
o Anorexia, weight loss, nausea, vomiting
o Intermittent fever, sweating, chills; change in overall condition

Laboratory
• Amoebic dysentery: identification of mobile trophozoites (E. histolytica) in fresh stool samples
• Amoebic liver abscess: indirect haemoagglutination and ELISA

Treatment for Amoebic dysentery

Tinidazole PO
• Children: 50 mg/kg once daily for 3 days (max. 2 g daily)
• Adolescents: 2 g once daily for 3 days OR

Metronidazole PO
• Children: 15 mg/kg 3 times daily for 5 days
• Adolescents: 500 mg 3 times daily for 5 days

Note:
• If there is no laboratory, first line treatment for dysentery is for shigellosis
• Treat for amoebiasis if correct treatment for shigellosis has been ineffective
• The presence of cysts alone should not lead to the treatment of amoebiasis.
• Amoebiasis is confirmed with a parasitological stool examination: mobile trophozoites in
fresh stool

--|Constipation
Definition
Constipation is an acute or chronic condition in which bowel movements occur less often than
usual or consist of hard, dry stools that are painful or difficult to pass.

Causes:
• Lack of exercise
• Certain medicines

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• Metabolic, endocrine, neurogenic and lower bowel abnormalities
• Psychogenic disorders
• Chronic use of enemas
• Not drinking enough water
• Diet that does not include an adequate amount of fiber-rich foods
• Anal fissure (a tear or crack in the lining of the anus)
• Chronic kidney failure
• Hirschsprung disease
• Colon or rectal cancer
• Depression
• Hypercalcemia (abnormally high levels of calcium in the blood)
• Hypothyroidism (underactive thyroid gland)
• Illness requiring complete bed rest
• Irritable bowel syndrome
• Stress

Signs and Symptoms:

• A symptomatic bowel impaction
• Blood on the stools
• Changes in bowel patterns
• Abdominal pain, distension

Diagnosis: clinical based

• Non-tender deformable faecal masses palpable on rectal examination

Investigations: Not always indicated

• Abdominal X-ray
• Barium enema - reveals blockage inside the intestine in particular cases
• Laboratory analysis of blood and stool samples for internal bleeding
• Sigmoidoscopy (examination of the sigmoid area of the colon with a flexible tube equipped
with a magnifying lens), rarely indicated.

Complications:
• Bowel obstruction
• Chronic constipation
• Haemorrhoids
• Hernia
• Spastic colitis
• Laxative dependency

Treatment:
• Treatment involves 3 steps:
o Initial clearance of stools
o Prevent re-accumulation of hardened retained stool (Diet change with additional natural
fibre from fruit, vegetables and bran).
o Retraining of the gut to achieve regular toilet habits
• Management is long-term, and requires the active involvement of the parents

Pharmacological treatment:
• Enema twice daily for 3 days for faecal clearance if faecal loading
• Lactulose ( Duphalac) for 1 week but if passes 3 stools/day stop it
• Bowel re-training

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• In refractory cases:
o Lactulose, oral, twice daily
 < 1 year 2.5 mL
 1–6 years 5 mL
 > 6 years 10 mL
o Forlax (Macrogol 4000) 4g& 10g for childr4n above 8 years
o Determine and treat the underlying cause

Recommendation:
• Refer patient to the specialist, if an organic cause e.g. constipation from birth in a breast-
fed baby is suspected
• If faecal loading continues, maintenance therapy should be continued for months to years

--| Constipation-associated faecal incontinence:

encopresis
Definition
Encopresis also known as faecal soiling is the involuntary leakage of small amounts of soft or
watery stool in a child with chronic constipation

Causes
• Psycho social precipitants
• Functional ( Incorrect Diet, lack of exercise, poor fluid intake)
• Metabolic or Neurological Abnormalities
• Endocrine abnormalities ( Hypothyroidism)
• Chronic use of Laxatives
• Obstructive lesions (Acquired and congenital defects)

Signs and symptoms:

• Abdominal pain
• Most of the times associated with encopresis
• Infrequent defecation
• Pain or strain on defecation
• Hard stool
• Feeling of incomplete evacuation (Tenesmus)

Investigations
• Barium Enema
• Abdominal x-ray in suspected obstructive lesions
• Thyroid function tests when indicated
• Stool analysis
• Investigate other functional lesions

Complications
• Anal Fissure, ulcers and prolapse
• Over flow incontinence (Encopresis)
• Stasis syndrome with bacterial overgrowth

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Management

Non-pharmacolocal management
• Rehydrate to increase fecal bulk and soften stool
• Education of patients/parents on Diet, exercise, etc......
• Diet change with additional natural fibre from fruit and vegetables.
• Treatment involves 3 steps:
• Initial clearance of stools
• Prevent re-accumulation of hardened retained stool
• Retraining of the gut to achieve regular toilet habits

Pharmacological management:
• Glycerin Suppositories 1 suppository /dose according to occurrence of symptoms OR
• Lactulose syrup <1 yr: 5-10ml/24 hr PO OD; 1-6 Yrs 10-20 ml/24 hrs PO OD; 7-14 yrs
20-50ml/24 hrs PO OD OR
• Bisacodyl (Dulcolax) 0.3mg/kg/day PO OD maximum dose 30mg/24 hrs

Recommendation:
• Refer to tertiary health facility in cases of inadequate response to therapy for further
investigations
• If continued constipation therapy should be continued for months to years

--|Upper git bleeding

Definition
Bleeding arising proximal to the ligament of Treitz in the distal duodenum commonly manifested
by haematemesis and/or melena.

Causes

Neonates:
• False bleeding (maternal swallowed blood Vit K1 deficiency (Haemorrhagic disease of the
newborn)
• Stress or gastric ulcer
• Coagulopathy (infection, liver failure, coagulation disorder.
• Haemangioma

Infants and toddlers:

• Malory Weiss syndrome
• Non steroid anti-inflammatory drugs
• Oesophagitis
• Caustic ingestions, iron poisoning
• Oesophageal varices bleeding

Old children and adolescent:

• Malory Weiss
• Peptic ulcer/gastritis
• Rendu Osler syndrome
• Gastric polyps
• Oesophageal varices

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Clinical manifestations:
• Hematemesis
• Melena
• Other signs according to the causative agent

Assessment:

History: The clinical history should include information concerning:

• The time course of the bleeding episode
• Estimated blood loss, and any associated symptoms.
• Gastrointestinal symptoms including dyspepsia, heartburn, abdominal pain, dysphagia, and
weight loss. In infants, these features may be reflected in poor feeding and irritability.
The history should also include information about the following symptoms or signs which may
provide clues to an underlying disorder:
• Recent onset of jaundice, easy bruising or change in stool color, which may suggest underlying
liver disease
• Recent or recurrent epistaxis, to investigate the possibility of a nasopharyngeal source of
bleeding
• History of easy bruising or bleeding, which suggests a disorder of coagulation, platelet
dysfunction, or thrombocytopenia
• Personal or family history or liver, kidney or heart disease, or coagulation disorders
• A drug history is important to assess potential contributions from medications that may induce
ulceration (such as NSAIDs and corticosteroids); Tetracyclines, may cause a pill esophagitis
• If the patient has been taking drugs or has a cardiac condition that affects homeostatic
responses (such as beta-adrenergic antagonists), because these may mask tachycardia
associated with life-threatening hypovolemia and shock.

Physical examination: The physical examination should include the following elements:
• The skin for cutaneous signs of generalized vascular malformations/disorders (cutaneous
hemangiomas. mucocutaneous telangiectasia)
• Evidence of portal hypertension, (splenomegaly, prominent abdominal and haemorrhoid
vessels)
• Inspection of the nasopharynx
• Check for hemodynamic failure (signs of shock?)

Nasogastric tube:
• Sometimes used to confirm the diagnosis and determine if the bleeding is ongoing.
• The lavage will also remove particulate matter, fresh blood, and clots to facilitate endoscopy
and decrease the risk of aspiration.
• Ice water lavage (an older practice) does not slow bleeding and may induce iatrogenic
hypothermia, particularly in infants and small children, and is not recommended

Differentials:
• Swallowed maternal blood during delivery or while nursing
• Ingested epistaxis – nasopharynx bleeding

Investigations:
Depending on suspected cause and magnitude of the blood loss, laboratory assessment
should include:
• FBC, cross-match blood in case transfusion is required , LFTs, blood urea nitrogen, serum
creatinine , Coagulation tests
• Upper digestive endoscopy (diagnosis and interventional).

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Management:

Main objectives:
• Relieve or treat haemorrhagic shock if present
• Stop bleeding
• Treat the causative agent

Emergency treatment
• ABC (include Blood transfusion if necessary)
• Insert a nasogastric tube for aspiration and an IV line (big enough for age).
• If the haemodynamic state is stable (pulse and blood pressure are normal):
o Hydrate (Ringer lactate), monitor vitals, keep NPO for 12 hours.
o If there is no active haemorrhage, restart oral feeding after 12 hours
• Assess for possible causative agent and treat accordingly.
• If need of endoscopy, then refer to centre where it’s available.

Most common causes according to age and treatment

• Neonates (Stress ulcers secondary to severe illness):
o Cimetidine IV 5-20mg/kg divided in 2 doses OR Ranitidine IV 2mg/kg/24 divided in
2-3 doses
o Omeprazole, PO 0.5–1 mg/kg, 12– 24 hourly
• Infants and toddlers (common cause is gastric ulcers and other causes can be evaluated
after endoscopy)
o Octreotide, IV bolus, 1–2 mcg then 1–5 mcg/kg/hour by infusion, initiated by the
specialist in case of cases of variceal bleeding ( difficult to control, to help control
bleeding before endoscopy, or when endoscopy is unsuccessful, contraindicated, or
unavailable)
o Omeprazole, PO
 1 month–2 years 2.5mg, 12 hourly
 2–6 years 5 mg, 12 hourly initiated by the Specialist for post bleed prophylactic
management
• Old children and adolescent (common cause is gastric ulcers and other causes can be
evaluated after endoscopy)
o Omeprazole, PO < 20 kg: 10 mg QD >20 kg : 20 mg QD
Note: Endoscopy is recommended to be performed within 24 to 48 hours for infants and children
presenting with upper GIT bleeding that is acute and severe, it can be performed for diagnosis and
treatment (sclerotherapy in oesophageal variceal)

Alternative treatment:
• Propranolol oral, 2–8 mg/kg/24 hours in 3 divided doses (to reduce the pulse rate by 25%)
• Surgical oversewing if endoscopy and sclerotherapy or banding have failed

Recommendations:
• Refer all cases to the specialist for appropriate diagnosis and treatment
• Refer all bleeding varices - after commencement of resuscitation and octreotide, if available

--|Peptic Ulcer Disease

Definition
This refers to ulceration of gastric or duodenal mucosa that tends to be chronic and/or recurrent.
Peptic ulcers may be primary (e.g. Helicobacter pylori related) or secondary, (e.g. stress related
or associated with NSAID use).

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Signs and Symptoms:

• Peptic ulcers may present with dyspeptic or other gastrointestinal symptoms or may be
completely asymptomatic, sometimes until complications such as haemorrhage or perforation
occur. The symptoms associated with peptic ulcers are not sensitive or specific and the
differential diagnosis is broad.
• Most common: Ulcer-like or acid dyspepsia (burning pain; epigastric hunger-like pain; relief
with food, antacids, and/or anti-secretory agents)
• Food-provoked dyspepsia or indigestion (postprandial epigastric discomfort and fullness,
belching, early satiety, nausea, and occasional vomiting) : food-stimulated acid secretion
persists for three to five hours; thus, classic DU symptoms occur two to five hours after meals
• Reflux-like dyspepsia

Cause:
• Helicobacter pylori (H. pylori) -In developing nations, the majority of children are infected
with H. pylori before the age of 10

Diagnosis:
Clinical symptoms:
• Epigastric pain. Pain is often poorly localised in children, described as dull and aching and
frequently does not respond to antacids
• Haematemesis or melena is a relatively common presentation in children (up to 50%).

Investigations
• Stool analysis for occult blood
• FBC
• For Helicobacter Pylori:
o It is recommended that the initial diagnosis of H. pylori infection be based on positive
histopathology plus positive rapid urease test, or positive culture.
o A validated ELISA for detection of H. pylori antigen in stool is a reliable non-invasive test
to determine whether H. pylorus has been eradicated.
o Tests based on the detection of antibodies (IgG, IgA) against H. pylori in serum,
whole blood, urine and saliva are less reliable for use in the clinical setting.
NB: specialists recommend: In children with refractory iron deficiency anaemia, where other causes
have been ruled out, testing for H. pylori infection may be considered (Grade of evidence: low)

Complications:
The natural history of peptic ulcer ranges from resolution without intervention to development
of complications : acute or Chronic blood loss or perforation
• Iron deficiency anaemia

Management:
• Avoid any foods that cause pain to the patient’s (e.g. acid foods, cola drinks)
• Avoid gastric irritating drugs (NSAIDs)
• Give magnesium-based antacids or combined magnesium-aluminium

First line H pylori eradication regimens are:

• Triple therapy with a PPI + Amoxicillin + Imidazole;
• or PPI + Amoxicillin + Clarithromycin;
• or Bismuth salts + Amoxicillin + Imidazole;
• or Sequential Therapy Triple therapy for eradication of H. pylori by;
o Omeprazole PO

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- 15-30 kg: 10 mg twice daily
- >30 kg: 20 mg twice daily
Or
o cimetidine 20–40mg/kg/day
+
o Clarithromycin : 500mg BID (15mg/Kg/24 BID)
+
o Amoxicillin 1g twice daily
Or
o metronidazole 500 mg (15–20mg/kg/day ) BD
Duration: 10 – 14 days,
A reliable non-invasive test for eradication is recommended at least 4 to 8 weeks following
completion of therapy

Recommendations:
• Refer to a specialist, if there is severe haemorrhage
• Stabilize the patient before transfer
• Infuse IV fluids/blood to maintain normal volume/pulse
• Ensure continuous assessment of further blood loss (Persistent tachycardia, postural
hypotension, continuing haematemesis)
• Definitive treatment/Eradication of H. pylori

--|Gastroesophageal reflux
Definition
GER is the passage of gastric contents into the esophagus with or without regurgitation and
vomiting. GER is a normal physiologic process occurring several times per day in healthy infants,
children, and adults. Most episodes of GER in healthy individuals last <3 minutes, occur in
the postprandial period, and cause few or no symptoms. In contrast, Gastroesophageal reflux
disease GERD is present when the reflux of gastric contents causes troublesome symptoms and/
or complications.

Causes and risk factors:

• The cause is still unclear
• Anatomical abnormalities such as a hiatal hernia
• Long term use of nasal gastric tube
• Diet that stimulates gastric acid production
• Neurologic impairment (NI), obesity, certain genetic syndromes, esophageal atresia (EA),
chronic lung diseases, and those with a history of premature birth

Diagnosis: Based os Signs and Symptoms:

In infants and toddlers, there is no symptom or symptom complex that is diagnostic of GERD
or predicts response to therapy. In older children and adolescents, as in adult patients, history
and physical examination may be sufficient to diagnose GERD if the symptoms are typical. The
following suggestive:
• In newborn:
o Recurrent vomiting, stridor, apnoea
• In infant:
o Recurrent vomiting
o Respiratory manifestations, (dry cough, recurrent wheeze or cough, chronic obstructive
airway disease, recurrent aspiration pneumonia, stridor, apnoea

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• In children /adolescent:
o Heartburn, Epigastric or chest pain.
o Respiratory manifestations: dry cough, recurrent wheeze or cough, chronic obstructive
airway disease,

Complications:
• Dysphagia (difficulty in swallowing)
• Odynophagia (pain on swallowing)
• Weight loss
• Anaemia
• Esophagitis
• Aspiration pneumonia
• Barrett’s esophagus
• Abnormal posturing or opisthotonus (Sandifer syndrome)

Investigations: when GER is persisting despite basic management

• 24 hours esophageal PH monitoring
• Endoscopy with biopsy to rule out esophagitis
• Barium X-rays for severity of oesophageal stenosis
• FBC look for anaemia

Management:

Non-pharmacological management
• Postural treatment: prone and lateral positions are associated with an increased incidence
of sudden infant death syndrome (SIDS). The risk of SIDS outweighs the benefit of prone
or lateral sleep position on GER; therefore, in most infants from birth to 12 months of age,
supine positioning during sleep is recommended.
• Dietary measures such as thickened food – if not breastfeeding, frequent small volume of
solid foods

Pharmacological management
Less Severe or Non-Erosive;
• Anti-acids
o Sodium alginate (Gaviscon Enfant)/antacid combination
o 1-2 months 1.5 mls after each meal
o 2-4 months 2mls after each meal
• Aluminium and Magnesium hydroxide (Maalox) Syrup 0.5 ml/kg/dose PO QID
• H2 Antagonists: Cimetidine IV/syrup/tab
o Neonates 5-20mg/kg/24 hr divided in 2 doses
o Infants 10-20 mg/kg/24hrs divided in 2 doses
o Children 20-40mg/kg/24hr divided in 2 doses
Severe or Erosive
• Omeprazole, oral;
o Neonate 0.5–1 mg/kg, 12– 24 hourly
o Children 1- 16 years :
 5 kg to <10 kg: 5 mg once daily
 10 kg to ≤20 kg: 10 mg once daily
 >20 kg: 20 mg once daily
Alternate dosing: 1 mg/kg/dose once or twice daily; Higher doses may be necessary
in children between 1-6 years

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ADD
• Pro-Kinetics: Domperidone (Motilium) 0.3 – 0.6 mg/kg/24hrs PO Divided in 3 doses (TDS).
Maximum 30mg/24hrs
AND
• Metoclopramide IV/IM/PO 0.1-0.2mg/kg/dose TDS. Maximum dose 0.5mg/kg/24hr

Recommendation
• Refer to tertiary level gastro-oesophageal reflux not responding to treatment
• Education Parents/guardians on patient diet
• Eat small, frequent meals

--| Tropical splenomegaly (hyperreactive malarious

splenomegaly)
Definition
It is a massive enlargement of the spleen resulting from abnormal immune response to repeated
attacks of malaria

Signs and symptoms:

• Chronic abdominal distension and pain.
• Weight loss
• Intermittent fever
Some patients present with Anaemia, generalized weakness, cough, dyspnea, epistaxis,
headache, increased skin and respiratory infection

Diagnosis: is based on clinical signs

• Splenomegaly of at least 10cms
• Regression of the spleen by at least 40% by 6 months on antimalarial therapy.

Investigations:
• Blood smear
• Complete blood count (for Hb, Platelets)
• Serum levels of IgM (at least 2SD above normal limit)

Complications:
• Hypersplenism leading to anaemia, leukopenia and thrombocytopenia, bleeding
• Splenic lymphoma
• Death

Management:

Pharmacological treatment:
• Doxycycline tabs /day for 6 months
o Children >8 years (<45 kg): 5 mg/kg/day OD
o Children >8 years (>45 kg): treat as adults
OR
• Mefloquine 5mg/kg weekly without exceeding 250mg/week of adult dose for 6 months
NB: Generally, splenectomy in the management of HMS is not recommended as mortality is high
from sepsis and thrombocytosis UNLESS there is a splenic rupture.

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--|Herpes gingivostomatitis
Definition
Inflammation of the mouth structures with ulcers (which may be of various numbers and sizes),
caused by Herpes simplex virus infection. The normal course of the disease is 7–10 days.

Diagnosis Based on clinical symptoms and signs

• General inflammation of the mouth with multiple small ulcers on the buccal mucosa, palate,
anterior tonsillar pillars, tongue, inner lips and gingival margins.
• Fever, malaise and dysphagia.
• Tender, enlarged cervical lymph nodes.

Management

General and supportive measures

• Maintain adequate nutrition and hydration by encouraging fluid and food intake – use
foods and fluids that cause less pain ripe bananas, porridge, yoghurt, Milk.
• If oral nutrition cannot be maintained use oral/nasogastric and/or IV fluids, if necessary.

Medical treatment
• Chlorhexidine 0.2%, 10 mL as a mouthwash or gargle, 12 hourly. Do not swallow.
• For pain: Paracetamol, oral, 15 mg/kg/dose 6 hourly.
OR
• Ibuprofen, oral, 5–10 mg/kg/dose 6 hourly after meals.
If more than minor fever blisters:
• Acyclovir, oral
o If > 1month to 1 year old: 12.5 mg/kg/dose.
o If > 1 year to 6 years old: 10 mg/kg/dose.
o If > 6 years to 12 years old: 6 mg/kg/dose.
If very severe infection, consider:
• Acyclovir, IV, same dosage
For very painful oral herpes in children > 2 years:
• Lidocaine (lignocaine) 2% gel applied every 3 to 4 hours. Apply a thin layer on the
affected areas only. Do not exceed 3 mg/kg dose, i.e. maximum 0.15 mL/kg of 2% gel.

Referral
• Herpes gingivostomatitis not responding to therapy.
• Disseminating disease, especially if associated with encephalopathy or increasing liver span.

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CARDIOVASCULAR DISEASES
Definition
Cardiovascular diseases (CVD) are the disorders of heart and blood vessels. Most cardiac diseases
in young children are congenital, while those in older children may be acquired or congenital.

--|Heart failure (congestive cardiac failure)

Definition
It is a clinical syndrome reflecting the inability of the myocardium to meet the oxygen and
nutritional/ metabolic requirements of the body.

Causes:

In normal heart anatomy;

• Severe anaemia
• Infection/sepsis
• Volume overload
• Arrhythmia
• Cardiomyopathies/Myocarditis
• Hypertension
• Renal failure
• Acquired valvulopathies
• Hypothyroidism
• Kawasaki disease

In Congenital heart disease:

• Left to Right shunt (Ventricular Septal Defect, Patent Ductus Arteriosus… )
• Aortic coarctation
• Aortic valvular stenosis
• Supra valvular aortic stenosis
• Mitral stenosis, mitral regurgitation
• Pulmonary veins stensosis
• Single ventricle

Signs and Symptoms:

• Cough
• Sweating
• Excessive weight gain/oedema
• Poor feeding/ failure to thrive
• Pallor
• Weak pulses
• Cold extremities
• Prolonged capillary refill > 2seconds
• Hypotension
• Tachycardia
• Gallop rhythm with or without heart murmur
• Tachypnea/dyspnoea

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• Crepitations (in old children) / wheezing

• Hepatomegaly with or without increased jugular vein pressure
• Oliguria

Diagnosis: Based on the above clinical symptoms and signs

Investigations
• FBC, Electrolytes, Urea and Creatinine, Blood Gas if available.
• Chest X-ray
• ECG
• Echocardiogram

Management: Monitoring of vital signs: RR, HR, BP, O2 saturation, urine output is critical

Non pharmacological treatment

• Oxygen therapy
• Semi- Sitting position (cardiac bed)
• Restrict fluids to 2/3 of maintenance ( aim at urine output of 2ml/kg/h)
• Strict bed rest
• Low sodium diet
• Ensure adequate nutrition
• Recognize and treat the underlying conditions e.g. fluid overload, hypertension, infection

Pharmacological treatment
• Frusemide IV 1-4mg/kg divided in 2 doses (to be increased progressively)
• Digoxin per os 0.01mg/kg/day (no loading dose!!)
• Captopril 1-4mg/kg/day divided in 3 doses if normal creatinine (to be increased
progressively, beware hypotension)
• Carvedilol for stable older children > 30 kg: initiate with 3.125mg BID, increase every
15 days if good tolerance. Maximum dose: 12.5mg BID

Recommendation:
• If isolated Right sided heart failure: use furosemide (see dosage above) and aldactone
2mg/kg/day divided in 2 doses.
• Administration of carvedilol and aldactone should be discussed with the cardiologist.
• Any patient with heart failure due to heart disease must be referred to the cardiologist

--|Cardiogenic shock
Definition
It is a dramatic syndrome characterized by inadequate circulatory provision of oxygen due to
cardiac pump failure secondary to poor myocardial function, so that the metabolic demands of
vital organs and tissues are not met. The patient is often a known case of heart disease with signs
of heart failure but may be a new case with heart failure.
Signs and symptoms:
• Hypotension
• Tachycardia
• Gallop rhythm
• Hepatomegaly
• Crackles/wheezes
• Weak and fast pulses (or absent)

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• Cold extremities/ pallor
• Capillary refill > 2 seconds
• Oliguria/anuria
Management:
Non pharmacological management:
• Avoid excessive IV fluids, the patient is fluid overloaded in this case, give 2/3 of
maintenance (aim at urine output of 2ml/kg/h)
• Oxygen therapy: 10-15l/min with mask and reservoir bag
• Semi- Sitting position (cardiac bed)
• Low sodium diet
• Strict bed rest
• Ensure adequate nutrition
• Correct hypoglycemia with 3-5ml/kg IV of Dextrose 10%
Pharmaceutical treatment
• Dopamine IV 5-10 microgram/kg/min, may increase to 20 microgram/kg/min OR
• Dobutamine IV 2 to 20 microgram/kg/min
• If tissue perfusion and blood pressure do not improve satisfactorily on adequate fluid
volume replacement and inotropic support, consider: Epinephrine (adrenaline), IV
infusion, 0.01–1 mcg/kg/minute.
• Furosemide IV 2mg/kg/dose if adequate peripheral perfusion. Repeat the dose
according to estimated fluid overload up to 8mg/kg/day. This is done after discussion
with a cardiologist or paediatrician
• Correct arrhythmia if present with digoxin 0.04mg/kg/day in 3 devided doses(
maintenance: 0.01mg/kg/day)
• Monitor: Heart rate, Respiratory rate, BP, Urine output, Pulse Oximetry for oxygen
saturation

--|Pulmonary oedema
Definition
Pulmonary oedema is accumulation of fluid in the alveoli due to an increase in pulmonary capillary
venous pressure resulting from acute left ventricular failure.

Causes:
• Heart not removing fluid from lung circulation properly (cardiogenic pulmonary oedema)
• A direct injury to the lung parenchyma

Signs and symptoms:

• Breathlessness/ Respiratory distress
• Sweating
• Cyanosis (decreased oxygen saturation)
• Frothy blood-tinged sputum
• Ronchi, and crepitations/wheezes

Diagnosis: Mainly clinical: history, symptoms and signs

Investigations:
• Chest x-ray shows loss of distinct vascular margins, Kerley B lines, diffuse haziness of lung
fields, pleural effusion.
• ECG
• Echocardiography
• Blood Gas if possible

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Management:
• Maintain patient in a semi sitting position
• Oxygen by facial mask with reservoir bag if available
• IV furosemide 2mg/kg/dose, maximum 8mg/kg/day.
• Inotropic support with dopamine or dobutamine if signs of shock
• Transfer to paediatrician/cardiologist for further management.

--|Congenital heart diseases

Definition
Structural abnormalities of the heart or great vessels present at birth. They fall into 2 major
groups: Acyanotic and cyanotic

Acyanotic Heart Diseases

Common lesions:
• Ventricular Septal Defect (VSD) most common congenital heart disease
• Patent ductus arteriosus (PDA)
• Atrio-ventricular septal defect (AVSD) or endocardial cushion defect (common in trisomy 21)
• Atrial septal defect (rarely causes heart failure)
• Coarctation of aorta

Signs and symptoms:

Each condition has specific clinical, radiological and ECG findings. Large left to right shunts present
clinically with:
• Feeding difficulties (breast feeds and stops then starts again}
• Sweating during feeds.
• Failure to thrive
• Recurrent chest symptoms
• Tachypnoea and indrawing.
• Chest deformity: respiratory sulcus, precordial bulge.
• Tachycardia
• Heart murmur
• Gallop rhythm
• Hepatomegaly
• Increased jugular venous pressure.
• Chest X-ray: usually cardiomegaly with plethoric lung fields.

Diagnosis: Based on clinical signs and symptoms

Investigations:
• Chest X-Ray
• ECG
• Echocardiogram
• Cardiac catheterization/angioscan in special cases.

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Complications
• Failure to thrive
• Heart failure
• Recurrent chest infections
• Infective endocarditis
• Pulmonary vascular obstructive disease (pulmonary hypertension) which can lead to
Eismenger syndrome

Management: Treatment depends on the specific condition. Some congenital heart diseases can be
treated with medication alone, while others require one or more surgeries.
• Furosemide, oral, 1mg/kg/dose 8-12 hourly. Supplement with potassium chloride, oral, 25-
50 mg/kg/dose 8-12 hourly
• Captopril 1-3mg/kg/day (start with 1mg/kg)
• Pay special attention to nutrition/Increase calories in feeding
• Iron if Hb less than 10g/dl (preferably reach 15g/dl)
• Surgical repair generally before 1 year if possible

Cyanotic heart diseases

Definition
Cyanotic heart disease is a heart defect, present at birth (congenital), that results in low blood
oxygen levels (< 90 % even with oxygen).

Common lesions:

Decreased flow to the lungs (do not cause heart failure):

• Tetralogy of Fallot
• Pulmonary stenosis
• Pulmonary atresia

Increased flow to the lungs (cause heart failure and failure to thrive):
• Transposition of great vessels (TGA)
• Truncus arteriosus
• Single ventricle
• Tricuspid atresia

Tetralogy of Fallot:

Definition: Tetralogy of Fallot refers to a type of congenital heart defect comprising of:
• Large ventricular septal defect
• Pulmonary stenosis
• Overriding aorta
• Right ventricular hypertrophy

Signs and symptoms:

• Progressive cyanosis with pulmonary systolic murmur
• Digital clubbing occurs after long time
• Hallmark: Paroxysmal hyper cyanotic attacks (blue spells) with the following manifestations:

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o Hyperpnea and restlessness

o Increased cyanosis
o Gasping respiration
o Syncope or convulsions
o Spontaneous squatting position is frequent (in older children)
o Heart murmur disappears
Diagnosis: Clinical plus Echocardiography findings

Investigations:
• Chest x-ray
• Complete blood count (CBC)
• Echocardiogram
• Electrocardiogram (EKG)

Complications
• Delayed development/growth
• Polycythemia
• Hypercyanotic attack, sometimes associated with seizures and death
• Infective endocarditis
• Brain abscess

Management:
• Avoid dehydration and stress (treat early infections, quite environment)
• Propanolol 0.5-1mg/kg every 6 hours to prevent hypercyanotic attacks
• Iron 5mg/kg /day to prevent microcytosis
• Surgical repair, urgent as soon as spells begin.
• In case of Hypercyanotic attacks:
o Squatting position (hold the infant with the legs flexed on the abdomen)
o Oxygen 6l/min with mask
o Diazepam 0.3mg/kg IV or 0.5mg PR if convulsing,
o Normal saline 10-20ml/kg bolus over 30 minutes
o Sodium bicarbonate 8.5% 1ml/kg to correct acidosis
o Morphine 0.1mg/kg IV if persistent attacks (but risk of respiratory depression),
o Propranolol IV 0.1 – 0.2 mg/kg slowly then continue oral maintenance to relax the
infundibular spasms.

Table 14. Common causes of heart failure in Neonates

Clinical manifestations Likely lesions

• Hypoplastic Left Ventricle Syndrome
Very poor pulses • Critical aortic stenosis
Poor femoral pulses • Coarctation of aorta
• Patent ductus arteriosus (PDA)
• Truncus arteriosus
Bounding pulses • Severe anaemia

Recommendations:
• All children with cyanotic heart diseases who come with diarrhea and vomiting should be
admitted for closer observation. Furosemide is contra-indicated
• All new born babies with suspected cyanotic heart disease should be referred to a
cardiologist/ tertiary hospital immediately.

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--|Acquired heart diseases
Acute Rheumatic Fever
Definition
This is an acute, systemic connective tissue disease in children related to an immune reaction to
untreated group A Beta haemolytic streptococcus infection of the upper respiratory tract .The
initial attack of acute rheumatic fever occurs in most cases between the ages of 3 and 15 years.
It is the autoimmune reaction that damages the heart valves leading to Rheumatic heart diseases

Cause: Auto-immune disease

Table 15. Revised Jones Criteria

Major manifestations: Minor manifestations: Group A Strep(GAS) Infection:

Carditis Fever GAS on throat swab (culture)
Raised Anti-streptolysin O titre
Arthritis Arthralgia
(ASOT)
Prolonged P-R Raised Anti-deoxyribonuclease B
Sydenham’s Chorea
interval on ECG (Anti-DNase B)
Erythema marginatum Raised ESR or CRP
Subcutaneous nodules

Criteria for ARF diagnosis according to WHO

 The first episode of ARF can be confirmed if:
o 2 MAJOR, or 1 MAJOR and 2 MINOR manifestations are present plus evidence of
preceding Group A streptococcal infection.
 Recurrent ARF (with no RHD) can be confirmed if
o 2 MAJOR, or 1 MAJOR and 2 MINOR manifestations are present plus evidence of
preceding Group A streptococcal infection.
 Recurrent ARF (with existing RHD) can be confirmed if
o 2 MINOR manifestations are present plus evidence of preceding Group A
streptococcal infection.
Note:
• Chorea for which other causes have been excluded, provides adequate evidence of
rheumatic fever without the other criteria for diagnosis being required.
• In children with rheumatic heart disease with fever, it is critical to differentiate recurrence of
acute rheumatic fever from infective endocarditis (IE).
• For children with rheumatic heart disease, recurrence of some of the above criteria would
suggest a recurrence of rheumatic fever but other causes such as IE should be excluded.
Diagnosis is made on clinical basis

Investigations
• Throat swab for culture (positive throat culture of group A Streptoccocal infection)
• Raised ASOT/ASLO antibodies titre (Anti-streptolysin-0-titre – ASOT of 1:300)
• Anti DNase B
• FBC/ ESR/CRP
• Chest x-ray – Features of cardiomegaly
• ECG
• Echocardiogram

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Complications: Rheumatic heart disease

Management:
• The primary goal of treating an ARF attack is to eradicate streptococcal organisms and
bacterial antigens from the pharyngeal region
• Persons with symptoms of ARF should be hospitalized to ensure accurate diagnosis, and to
receive clinical care and education about preventing further episodes of ARF.
• The diagnosis should include an initial echocardiogram used to help identify and measure
heart valvular damage.
• Long-term preventative management should be organized before discharge.
• All cases of ARF should receive:
o A single injection of Benzathine penicillin G (Extencilline): 25,000–50,000 units/kg/
dose stat; maximum 1.2 mega units dose OR
o Oral Penicillin (Pen V) 25–50mg/kg/day in divided 3 doses for 10 days (Erythromycin
30-50mg/kg/day divided in 3 doses if penicillin allergy)

Relief of symptoms

Arthritis and fever

• Aspirin 75–100mg/kg/day in 4–6 divided doses. Treatment continued until fever and joint
inflammation are controlled and then gradually reduced over a 2-week period
• Add an antacid to reduce risk of gastric irritation e.g Omeprazole 1mg/kgOr
• Prednisolone 1-2mg/kg OD for 2 weeks then taper for 2 weeks with good response
begiAspirin in the 3rd week and continue until 8th week tapering in the final 2 weeks

Chorea
• Most mild-moderate cases do not need medication
• Provide calm and supportive environment (prevent accidental self-harm)

For severe cases:

• Carbamazepine per os:
o <6 years: 10-20mg/kg/day divided in 3 doses,
o Y-ears: 400-800mg/day divided in 3 doses,
o >12 years: 200mg x 2/day
• Valproic acid 20-30mg/kg/day divided in 2 doses
• Duration: 2 weeks

Carditis
• Bed rest if in cardiac failure
• Anti-failure medication as above
• Anti-coagulation medication if atrial fibrillation is present

Management plan when the acute episode is controlled

• Administer the first dose of secondary prophylaxis
• Register the individual with the local health authority or RHD Programme;
• Provide disease education for the person with ARF and the family
o Understanding of ARF and RHD and risks of ARF recurrence
o Importance of regular secondary prophylaxis and medical review
o Recognising own signs and symptoms of ARF and RHD
o Risks associated with future RHD (e.g. pregnancy, surgery and high level of aftercare)
o Importance of dental health

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• Include an ARF diagnosis alert on computer systems and/or medical files (if applicable);
• Refer to local health facility for ongoing management;
• Arrange dental review (and provide advice about endocarditis prevention);

Long-term Management
• Regular secondary prophylaxis (refer to 5.5 Table 6 Recommended Secondary Prophylaxis
Regimen)
• Regular medical review
• Regular dental review
• Echocardiogram (if available) following each episode of ARF, and routine echocardiogram:
every 2 years for children (sooner if there is evidence of cardiac symptoms)

Secondary prophylaxis
Aim:
• Prevents the occurrence of GAS infections which can lead to recurrent ARF
• Reduces the severity of RHD
• Helps prevent death from severe RHD.

Indications for Use

Secondary prophylaxis is indicated for people who have
• ARF confirmed by the Jones Criteria
• RHD confirmed on echocardiogram
• ARF or RHD not confirmed, but highly suspected.

Doses:
Benzathine Penicillin G IM every 4 weeks:
• 1,200,000 units for ALL people ≥30kg
• 600,000 units for children <30kg
Penicillin V if Benzathine Penicillin G IM injections not tolerated or contraindicated:
Dose: 250mg oral, twice-daily for ALL children.
Erythromycin if proven allergy to Penicillin: 250mg oral, twice-daily for ALL people.

Table 16. Recommended Secondary Prophylaxis Regimens

Disease Classification Duration of Secondary Prophylaxis

• Minimum of 5 years after last ARF, or
ARF (No proven Carditis)
• Until age 18 years (whichever is longer)

Mild-moderate RHD • Minimum 10 years after last ARF, or

(or healed carditis) • Until age 25 years (whichever is longer)

Severe RHD and following Cardiac

• Continue medication for life
Surgery for RHD

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Rheumatic heart Diseases

Definition
It is an inflammatory damage of the heart valves, as a complication of acute rheumatic fever.
The mitral valve is the most commonly involved valve, although any valve may be affected.

Types of valvular lesions;

• Mitral regurgitation/stenosis
• Aortic regurgitation/stenosis
• Tricuspid regurgitation
• Mixed regurgitation and stenosis
• Multivalvular heart diseases

Signs and symptoms:

• May be asymptomatic when minor lesions
• Heart murmurs over affected valve

Complications:
• Congestive cardiac failure with pulmonary oedema
• Bacterial endocarditis.

Diagnosis: on clinical basis

Investigations:
• Chest x-ray
• ECG
• Echocardiography

Management:
• Treat underlying complication, e.g., heart failure, pulmonary oedema
• Continue prophylaxis against recurrent rheumatic fever
• Ensure oral hygiene
• Endocarditis prophylaxis if dental procedures, urinary tract instrumentation, and GIT
manipulations;
o Above the diaphragm;
- Amoxicillin 50mg/kg (Max 2gr) 1 hour before the procedure OR
- Erythromycin 50mg/kg (max 1.5gr) – if allergic to penicillins
o Below the diaphragm:
- Ampicillin 50mg/kg IV or IM (max 2gr) with Gentamycin, 2mg/kg (max 120mg)
30minutes before the procedure then,
- Amoxycillin per os 25mg/kg (max1gr) 6 hours after the procedure
• Ensure good follow up by cardiologist

Infective endocarditis

Definition
Infection of the endothelial surface of the heart. Suspect infective endocarditis in all children
with persistent fever and underlying heart disease.

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Cause/predisposing factors:
• Rheumatic valvular disease
• Congenital heart disease

Signs and symptom:

• Persistent low grade fever without an obvious underlying cause
• Fatigue, joint pain, new murmurs, clubbing, splenomegaly and haematuria

Table 17. Major and minor clinical criteria used in the modified Duke criteria for diagnosis of infective endocarditis (IE)

Major criteria Minor criteria

• Positive blood culture: • Predisposing heart condition or
o typical micro-organisms from two separate blood • IV drug use
cultures: S. viridans, including nutritional variant • Fever ≥ 38ºC.
strains, S. bovis, *HACEK group, S. aureus, or • Vascular phenomena:
o Enterococci, in the absence of a primary focus, or o major arterial emboli,
o persistently positive blood culture with a micro- o septic pulmonary infarcts,
organism consistent with IE o mycotic aneurysm,
o from blood cultures drawn > 12 hours apart, or o intracranial haemorrhage,
o all 3 or a majority of 4 or more separate blood o conjunctival haemorrhages,
cultures, with the first and last drawn at least one o Janeway lesions.
hour apart, or • Immunologic phenomena:
o positive serology for Q fever, o Osler’s nodes,
o Single positive blood culture for Coxiella burnetti o Roth spots,
or anti-phase 1 IgG antibody titre > 1:800. o glomerulonephritis,
• Evidence of endocardial involvement: o Rheumatoid factor.
o positive echocardiogram for IE (transoesophageal • Microbiologic evidence:
echocardiography is recommended for patients o positive blood culture but not
with prosthetic valves): oscillating intracardiac meeting major criterion, or
mass, on valve or supporting structures, or in the o Serologic evidence of active
path of regurgitant jets, or on implanted infection with organism consistent
o materials, in the absence of an alternative with IE.
anatomic explanation, or
o abscess, or
o new partial dehiscence of prosthetic valve, or
o New valvular regurgitation.

Table 18. Interpretation of IE

Definite IE Possible IE Rejected
Pathological criteria
• Micro-organisms
o by culture or histology in a • Alternative diagnosis for
vegetation, or in a vegetation that manifestation of endocarditis,
has embolised, or or
• At least one
o in an intracardiac abscess, or • resolution of manifestations,
major and one
lesions with antibiotic therapy ≤ 4
minor criterion,
• Vegetation or intracardiac abscess days, or
or
present – confirmed by histology • No pathologic evidence of IE
• 3 minor
showing active IE. at surgery or autopsy, after
Clinical criteria – see Table above antibiotic therapy for ≤ 4
• 2 major criteria, days.
• 1 major and 3 minor, or
• 5 minor.

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Limitations of the Duke Criteria in children

The clinical criteria rely heavily on relatively rare clinical features.
In contrast, common clinical features like splenomegaly, clubbing and haematuria have not been
included.

Investigations:
• Blood cultures (at least 3 cultures) before antibiotics
• FBC /CRP/ESR
• Urine test strips – haematuria
• Echocardiography

Management:
Non-pharmacological management
• Bed rest/limit physical activity
• Ensure adequate nutrition
• Maintain haemoglobin > 10 g/dL
• Measures to reduce fever

Pharmacological management
• Paracetamol, oral, 20 mg/kg at once, then 10–15 mg/kg/dose, 6 hourly as required
• Antibiotics regimen: IV antibiotics are always given, based on culture and sensitivity results
o Native valve endocarditis ( NVE) due to Streptococci:
 Benzylpenicillin (Penicillin G), IV, 300 000 units/kg/day divided in 4 doses for 4
weeks OR
 Ceftriaxone 100mg/kg/day as single dose (maximum 2g) for 4 weeks
PLUS
 Gentamicin, IV, 3mg/kg/day divided in 3 doses (maximum 240mg/day) for 2wks
 Patients allergic to penicillin and cephalosporins: Vancomycin 40mg/kg/day divided
in 3 doses (max 2g/day) for 4 weeks.
o NVE due to staphylococci
 Cloxacillin 200mg/kg/day divided in 4 doses 6 for 4 weeks
PLUS
 Gentamicin 3mg/kg/day divided in 3 doses (maximum 240mg/day) for
first 5 days .OR
 Cloxacillin-resistant strains or allergy to penicillin: Vancomycin 40mg/kg/
day divided in 3 doses (max 2g/day) for 6 weeks.
Note: All highly suspected cases of infective endocarditis must be referred to the cardiologist
where bloodcultures and proper management will be done.

--|Cardiomyopathies
Definition
Cardiomyopathies are diseases characterized by structural and functional abnormalities of the
myocardium.

Classification: Classification based on the predominant structural and functional abnormalities:

• Dilated cardiomyopathy: primarily systolic dysfunction,
• Hypertrophic cardiomyopathy: primarily diastolic dysfunction,
• Restrictive cardiomyopathy: primarily diastolic but often combined with systolic dysfunction

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Dilated cardiomyopathy
Dilated cardiomyopathy refers to a group of conditions of diverse etiology in which both
ventricles are dilated with reduced contractility

Causes:
• Infections (e.g. Viral+++, Rickettsia, Chagas disease…)
• Neuromuscular disorders (e.g. Duchenne dystrophy, Becker dystrophy, …)
• Endocrine, metabolic and nutritional (e.g. hyperthyroidism, beriberi, kwashiorkor…)
• Diseases of coronary arteries (e.g. Kawasaki, Aberrant Left Coronary Artery)
• Autoimmune diseases (e.g. Rheumatic carditis, juvenile rheumatoid arthritis, systemic lupus
erythematosus, dermatomyositis, systemic lupus erythematosus…)
• Drugs toxicity (e.g. doxorubicin, cyclophosphamide, IPECA…)
• Hematologic diseases (e.g. anaemia, Sickle cell anaemia, hypereosinophilic syndrome:
Löffler syndrome)

Signs and symptoms: see signs of congestive heart failure

Diagnosis:
• ECG: prominent P wave, LV or RV hypertrophy, nonspecific T-wave abnormalities.
• Chest X-ray: cardiomegaly, pulmonary oedema
• Echocardiogram: confirm diagnosis and shows LA and LV dilation, poor contractility
• FBC, Urea and creatinine, Electrolytes (Na, K),
• Myocardial biopsy, PCR, genetic… according to the etiology

Management:
• Treatment: Refer to principles and medications of congestive heart failure

Hypertrophic cardiomyopathy

Definition
Hypertrophic cardiomyopathy is a genetic disorder that is characterized by left ventricular
hypertrophy unexplained by secondary causes and a non-dilated left ventricle with preserved
or increased ejection fraction

Causes:
• Left ventricle obstruction (Coartation of aorta, hypertension, aortic stenosis)
• Secondary (infants of diabetic mothers, corticosteroids in premature infants)
• Metabolic (Glycogen storage disease type II (Pompe disease)
• Familiar hypertrophic cardiomyopathy
• Syndroms (Beckwith - Wiedman syndrom, Friedereich, ataxia…)

Signs and Symptoms:

• Weakness
• Fatigue
• Dyspnea on effort
• Palpitations
• Angina pectoris
• Dizziness and syncope
• Increased risk of sudden death

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Diagnosis:
• ECG: LV hypertrophy
• Chest X-ray: Mild cardiomegaly
• Echocardiogram: LV hypertrophy, ventricular outflow tract gradient
• Doppler flow studies may demonstrate diastolic dysfunction before the development of
hypertrophy.

Management:
• Prohibit competitive sports and strenuous physical activities
• Propranolol 0.5 -1mg/kg/day devised in 3 doses or atenolol
• Implantable cardioverter-defibrillator if documented arrhythmias or a history of unexplained
syncope
• Open heart surgery for septal myotomy: rarely indicated

Restrictive cardiomyopathy

Definition
Restrictive cardiomyopathy (RCM) is a myocardial disease, characterized by impaired filling of
the ventricles in the presence of normal wall thickness and systolic function.

Cause/Etiologies:
• Idiopathic, Systemic disease (scleroderma, amyloidosis, or sarcoidosis)
• Mucopolysaccharidosis
• Hypereosinophilic syndrome; malignancies
• Radiation therapy
• Isolated noncompaction of the left ventricular myocardium

Signs and symptoms:

• Dyspnea
• Edema and ascites
• Hepatomegaly with increased venous pressure
• Pulmonary congestion

Diagnosis: clinical basis

Investigations
• ECG: Prominent P waves, ST segment depression, T-wave inversion
• Chest X-ray: mild to moderate cardiomegaly
• Echocardiogram: markedly enlarged atria and small to normal-sized ventricles with often
preserved systolic function but highly abnormal diastolic function

Complications
• Arrhythmias
• Mitral regurgitation
• Progressive heart failure
• Tricuspid regurgitation

Management:
• Lasix 2mg/kg divided in 2 doses
• Aldactone 1-2mg/kg devised in 2 doses

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• Antiarrhythmic agents / biventricular pacing are used as required
• Aspirin or warfarin in case of noncompaction LV with an increased risk of mural thrombosis
and stroke
• Cardiac transplantation where possible and indicated

Pericarditis/Pericardial Effusion:

Definition
Accumulation of fluid in the pericardial space, usually secondary to pericarditis..

Causes:
• Infection such as viral, bacterial (tuberculosis…)
• Inflammatory disorders, such as lupus
• Cancer that has spread (metastasized) to the pericardium
• Kidney failure with excessive blood levels of nitrogen
• Heart surgery (postpericardectomy syndrome).

Signs and symptoms:

• Pericardial tamponade:
• Chest pressure or pain and signs of congestive heart failure with sometimes shock.
Note: Many patients with pericardial effusion have no symptoms. The condition is often discovered
on a chest x-ray or echocardiogram that was performed for another reason.

Diagnosis:
• Most patients present with a prolonged history of:
o Low cardiac output,
o Distended neck veins,
o Muffled or diminished heart sounds.
• Patients with HIV may be asymptomatic and incidentally diagnosed on chest Xray.
• Often associated with TB.
• Acute septic pericarditis may occur in patients with septicaemia

Investigations
• ECG
o Small complexes tachycardia
o Diffuse T wave changes
• Chest X-ray: “water bottle” heart, or triangular heart with smoothed out borders
• Echocardiogram
• Tuberculin skin test
• Diagnostic pericardiocentesis
o in all patients with suspected bacterial or neoplastic pericarditis and patients whom
diagnosis is not readily obtained
• Cell count and differential, culture, gram stain, PCR

Management
Non-pharmacological treatment
• Semi-sitting position if tamponnade suspected
• Pericardiocentesis
o preferably under ultrasound guidance
o Performed by an experienced person
o indicated in children with symptomatic pericardial effusion

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Pharmacological treatment:
• If hypotensive, rapidly administer intravenous fluids 20ml/kg of Normal saline over 30min
to 1 hour,
• If suspected TB pericarditis: standard anti TB treatment + steroids
• In case of purulent pericarditis: cloxacillin, IV 50 mg/kg/dose 6 hourly for 3 – 4 weeks +
ceftriaxone, IV, 100 mg/kg as a single daily dose, to adapt according to culture results.
• Treat heart Failure (See Section on heart failure)
Recommendation: All patients with pericardial effusion should be referred to a cardiologist

--|Hypertension in children
Definition
Hypertension is defined as systolic and/or diastolic blood pressure ≥ the 95th percentile for
gender, age and height percentile on at least three consecutive occasions.
A sustained blood pressure of > 115/80 is abnormal in children between 6 weeks and 6 years
of age.

Hypertensive emergency/crisis exists when CNS signs of hypertension appear such as

encephalopathy, convulsions, retinal haemorrhages or blindness. Great care is required to
reduce the blood pressure in a controlled manner to avoid potentially serious consequences of
impaired auto-regulation of cerebral blood flow.

Hypertensive urgency is defined as a significant elevation of blood pressure without accompanying

end organ damage. Patients are generally symptomatic with complaints of headache, blurred
vision and nausea, despite the lack of end organ involvement

Accurate measurement of BP:

• Use the widest cuff that can be applied to the upper arm
• The cuff bladder must encircle at least 80% of the upper arm and should cover at least
75% of the distance between the elbow and the shoulder joints
• It is better to use a cuff that is slightly too large than one that is too small

Causes:
• Severe hypertension suggests renal disease
• Coarctation of aorta
• Rarely pheochromocytoma
• Long term steroid therapy

Most common causes of secondary hypertension by age:

New born:
• Renal abnormalities
• Coarctation of the aorta
• Renal artery stenosis
• Renal artery or veinal thrombosis
First year:
• Coarctation of the aorta
• Renal vascular desease
• Tumor
• Medications (steroids…)

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1-6 years:
• Renal vascular diseases
• Renal parenchymal diseases (glomerulonephritis, hemolytic-uremic syndrome…)
• Coarctation of the aorta
• Medications
• Essential hypertension

6-15 years:
• Renal vascular diseases
• Renal parenchymal diseases (glomerulonephritis, hemolytic-uremic syndrome…)
• Essential hypertension
• Coarctation of the aorta
• Endocrine causes
• Nutritional causes (obesity)

Signs and symptoms:

• Headache
• Convulsions, coma and visual symptoms
• Oedema, haematuria, proteinuria
• Acute heart failure and pulmonary oedema
• Some children may be asymptomatic

Table 19. Blood pressure in children correlates with body size and age.

Table 20. 95th Percentile of systolic and diastolic BP correlated with Height

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Diagnosis: Mainly Clinical

Symptoms and signs of any of the following systems:
• Central nervous
• Cardiovascular
• Respiratory
• Urogenital

Investigations:
• Urea, creatinine, electrolytes (Na+, K+),
• Fundoscopy
• ECG
• Echocardiogram
• Abdominal ultrasound (focused on kidneys).
• Others according to the suspected etiology

Management of acute hypertension (hypertension of sudden onset)

Non-pharmacological treatment
• Admit patient to paediatric high dependence care unit
• Monitor BP every 10 minutes until stable – thereafter every 30 minutes for 24 hours
• Insert two peripheral intravenous drips
• Rest on cardiac bed
• Control fluid intake and output (restriction)
• Restrict dietary sodium

Pharmacological treatment: Do not combine drugs of the same class

• Frusemide, IV, 1–2 mg/kg as a bolus slowly over 5 minutes increase up to 8 mg/kg/day. If
oliguric; Max 5mg/kg/day
• Nifedipine 0.25-0.5mg/kg (max: 10mg) sublingual OR
• Amlodipine, oral, 0.2 mg/kg/dose. May be repeated 6 hours later, thereafter every 12
hours.
• Refer the patient to a specialist when the patient is stable

Recommendations:
• For acute or chronic hypertension blood pressure needs to be lowered cautiously
• Aim to reduce the SBP slowly over the next 24 - 48 hours
• Do not decrease BP to < 95th percentile in first 24 hours
• Advise a change in lifestyle
• Institute and monitor a weight reduction programme for obese individuals
• Regular aerobic exercise is recommended in essential hypertension
• Dietary advice
• Limit salt and saturated fat intake
• Increase dietary fiber intake

Management of Chronic Hypertension

Non-pharmacological management:
• Introduce physical activity, diet management and weight reduction, if obese.
• Advise against smoking in teenager
• Follow up to monitor blood pressure and educate patient on hypertension
• If blood pressure decreases, continue with non-drug management and follow up
• If BP is increasing progressively, reinvestigate to exclude secondary causes or refer to the
specialist

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• If BP is stable but persistently > 95th percentile and secondary causes have been excluded,
start drug treatment after failed non-drug management for 6 months
• Consider earlier initiation of drug treatment if positive family history for cardiovascular
disease, essential hypertension or diabetes mellitus

Pharmacological management:

Table 21. Recommended medications and doses for patients with chronic Hypertension.

Drug Dosage Side effect/comment

First line: 1-2mg/kg/day once daily
Hypokalemia
Hydrochlorothiazide (maximum 25mg/day).
Second line: Nifedipine 0.3-1mg/kg/day divided in 3
OR doses Not well studied in children less
0.1mg/kg/day (maximum dose than 6 years of age
Amlodipine 10mg/day) once daily
• Hyperkalaemia
• Check renal function and
Third line: Captopril 0.5 – 4mg/kg/day divided in 2 Serum-K periodically,
OR doses • Not used in bilateral
renal artery stenosis,
Lisinopril 0.07- 0.6mg/kg daily contraindicated in renal
failure
• Can cause cough

0.5-1mg/kg/day once daily

Forth line: Atenolol (max up to 2mg/kg/day, do not • Bradycardia
exceed /100mg/day).

Furosemide (Lasix) if
associated oedema or
stage 4 chronic kidney
disease. 1-4mg/kg/day in 2 to 4 divided • Hyponatremia
doses • Hypokalemia
Note: Do not associate
Furosemide with
Hydrochlorothiazide

Table 22. Recommended Hypertension medications for patients with Renal Failure

For CKD 1-3 (GFR ≥30, creatinine <2x normal value for age
First- line drug Lisinopril
Second -line drug Hydrochlorothiazide
Third- line drug Amlodipine
Forth- line drug Atenolol ( use half of normal recommended dose)
For CKD 4 or 5 (GFR < 30, creatinine ≥2x normal value for age
First-line drug Furosemide
Second-line drug Amlodipine
Third-line drug Atenolol (use half of normal recommended dose).

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Recommendations:
• All patients with hypertension and persistent proteinuria should be treated with an ACE
inhibitor
• Always exclude bilateral renal artery stenosis before treating with an ACE inhibitor
• Renal function must be monitored when an ACE inhibitor is prescribed because it may cause
a decline in GFR resulting in deterioration of renal function and hyperkalaemia
• Patients with hypertension due to a neuro-secretory tumour (phaeochromocytoma or
neuroblastoma), should receive an α-blocker either as single drug or in combination with
ß-adrenergic blocker
• For patients with persistent hypertension despite the use of first line drugs, a second/third
drug should be added
• Specific classes of antihypertensive drugs should be used according to the underlying
pathogenesis or illness
• For patients with predominantly fluid overload: use diuretics with/without ß-blocker

--|Cardiac arrhythmias in children

Definition
Heart rate that is abnormally slow or fast for age or irregular.
There are three types of arrhythmias in children;
• Heart block
• Ventricular arrhythmias
• Paroxysmal atrial tachycardia

Type of Arrhythmia cause Signs and symptom

• Chest pressure or pain
• Idiopathic and familial
• Fainting, also known as syncopy,
Heart block: A • Electrolyte disturbances (hyperkalaemia),
or near-syncope
delay or complete • Digoxin toxicity
• Fatigue
block of the • Congenital heart disease, particularly
• Light headedness or dizziness
electrical impulse transposition of the great arteries, and
• Palpitations, which can be
as it travels from especially after surgery
skipping, fluttering or pounding
the sinus node to • Myocarditis
in the chest
the ventricles • Post infective, for example in endocardial
• Shortness of breath
fibroelastosis or rheumatic fever
• May be asymptomatic
Ventricular • Chest discomfort (angina)
arrhythmias: A • Heart attack • Fainting (syncope)
rapid heart rate, • Cardiomyopathy • Light-headedness or dizziness
usually with a • Heart failure • Sensation of feeling the heart
regular rhythm, • Heart surgery beat (palpitations)
originating • Myocarditis • Shortness of breath
from above the • Valvular heart disease • Absent pulse
ventricles • Loss of consciousness
• Normal or low blood pressure
• Rapid pulse
Paroxysmal atrial
tachycardia: A
• Palpitation
rapid heart rate,
• lightheadedness
usually with a
• Weakness
regular rhythm,
• Shortness of breath
originating
• Chest pressure
from above the
ventricles.

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Table 23. Normal heart rate/minute for age:

Age Heart rate

Newborn 100–160
< 1 year 110–160
1–2 years 100–150
2–5 years 95–140
5–12 years 80–120
> 12 years 60–100

Table 24. Diagnosis is based on these clinical signs and symptoms

Infants:
Color changes (pale, mottled) Irregular pulse
Irritability Tachycardia
Feeding difficulties Bradycardia
Sweating Signs of cardiac failure
Tachypnoea/apnoeic spells
Children:
Dizziness Tachycardia
Palpitations Bradycardia
Fatigue Syncope
Chest Pain Signs Of Cardiac Failure
Note: All patients with arrhythmias should be referred to a cardiol

Investigations
• ECG is essential for diagnosis, preferably a 12 lead ECG
• Echocardiogram
• Other according to the suspected etiology

Tachyarrhythmias:

Figure 1. Sinus tachycardia

ECG Criteria
Rate: > upper limit for age P wave: present and normal
Rhythm: regular QRS: normal

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Figure 2. Supraventricular Tachycardia

ECG Criteria
Rate: usually > 200 beats per minute P wave: abnormal
Rhythm: regular QRS: narrowed

Figure 3. Ventricular Tachycardia

ECG Criteria
Rate: generally 100–220 beats per minute P wave: mostly not seen
Rhythm: generally regular QRS: abnormal, large with QRS > 120 millisecond

Management
Non-pharmacological treatment
• Sinus tachycardia usually requires management of the underlying condition
• ABC of resuscitation
• Admit to high care or intensive care unit
• Monitor ECG, Oxygen saturation, Blood pressure, Haemoglobin, Heart rate, Acid–base
status and blood gases, Respiratory rate, Maintain adequate nutrition and hydration, Treat
pyrexia

Pharmacological management:

Emergency treatment
Narrow Complex Tachycardia (supraventricular tachycardia):
Stable patient: Attempt vagal stimulation
• Place icebag on face, or
• Infants: immerse face in ice-cold water for a few seconds
• Older children: try a valsalva manoeuvre, e.g. asks the patient to blow through a straw.
• Place NGT if other means are not available
• Note: Eye-ball pressure and carotid massage is contraindicated in children.
• In consultation with a paediatrician or Cardiologist: Adenosine, IV, 0.1 mg/kg initially,
increasing in increments of 0.05 mg/kg to 0.25 mg/kg. Follow with a rapid flush of at least
5 ml Normal saline.

Unstable patient: Heart failure / shocked

• DC synchronised cardioversion in increments of 0.5–1–2 J/kg
• Empty the stomach before cardioversion is attempted
• Amiodarone, IV, 5 mg/kg slowly over 20 minutes (NEVER as a rapid infusion )

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--|Bradyarrhythmias
Causes:
• Hypoxia
• Hypothermia
• Head injuries and increased intracranial pressure
• Toxins and drug overdose
• Post operative
• Congenital excessive vagal stimulation
• Electrolyte disturbances (Hypo- or hyperkalaemia, Hypocalcaemia)

Figure 4. Sinus Bradycardia

ECG Criteria
Rate: < lower limit for age P wave: present, all look the same
Rhythm: regular QRS: normal, 80–120 millisecond

Figure 5. Heart Block (Complete)

ECG Criteria
Rate: low, usually < 60 beats per minute P wave: independent P waves
QRS’s with no relationship between the two (AV dissociation)

Management
• If syncope and Heart rate - below 50/min:
• Start i.v. Isuprel (Isoprenaline) 0. 05 – 0. 4 microgram/kg/min.
OR
• Dobutamine (Dobutrex) 2 - 20 microgram/kg/min
• Insert pacemaker if ineffective

References
1. Larry M. Baddour at al. Infective Endocarditis. Diagnosis, Antimicrobial Therapy, and
Management of Complications. A Statement for Healthcare Professionals From the Committee
on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease
in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery
and Anesthesia, American Heart Association. Circulation. 2005;111:e394-e434
2. Guidelines on Prevention, Diagnosis and Treatment of Infective Endocarditis Executive
Summary. The Task Force on Infective Endocarditis of the European Society of Cardiology.
European Heart Journal (2004) 25, 267–276.
3. Gene Buhkman. The PIH guide to Chronic Care Integration for Endemic Communicable
Diseases. Rwanda Edition, 2011

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4. http://www.uptodate.com
5. GREGORY B. LUMA et al. Hypertension in Children and Adolescents. American Family
Physician. May 1, 2006 .Volume 73, Number 9
6. Brian W. McCrindle. Assessment and Management of Hypertension in Children and
Adolescent. Nature Reviews cardiology 2010.

GENITOURINARY SYSTEMS
--|Urinary tract infection (UTI)
Definition
UTI is significant bacteriuria of a clinically relevant uropathogen in a symptomatic patient.
It is classified as:
• Uncomplicated UTI (Cystitis), which is the inflammation and infection of the bladder to the
bladder and urethra OR
• Complicated urinary tract infection (Pyelonephritis), an infection of the urinary tract involving
the renal parenchyma

Acute cystitis
• Affects mainly girls from 2 years of age and there are no associated urological anomalies
• Escherichia coli is the causative pathogen in at least 70% of cases. Other pathogens include
Proteus mirabilis, Enterococcus sp, and Klebsiella sp

Clinical features
Signs and symptoms are related to the age of the child and often non-specific.
• Burning sensation/pain on urination, urinary urgency and frequency; in children: crying when
passing urine; involuntary loss of urine, cloudy urine and lower abdominal discomfort. PLUS
• No fever (or mild fever), no flank pain; no systemic signs and symptoms in children.
It is essential to rule out pyelonephritis
The symptom ‘burning pain on urination’ alone is insufficient to make the diagnosis.

Laboratory
Urine dipstick test:
• Perform dipstick analysis for nitrites (which indicate the presence of enterobacteria) and
leukocytes (which indicate an inflammation) in the urine.
• If dipstick analysis is negative for both nitrites and leukocytes, a urinary infection is unlikely.
• If dipstick analysis is positive for nitrites and/or leukocytes, a urinary infection is likely.
• Microscopy/culture: when a dipstick analysis is positive, it is recommended to carry out urine
microscopy/culture in order to confirm the infection and identify the causative pathogen,
particularly in children and pregnant women.
• When urine microscopy is not feasible, an empirical antibiotherapy should be administered
to patients with typical signs of cystitis and positive dipstick urinalysis (leucocytes and/or
nitrites).

Treatment
Cystitis in girls 2 years and above:
• Cefixime PO: 8 mg/kg once daily for 3 days Or
• Amoxicillin/clavulanic acid PO 25 mg/kg 2 times daily for 3 days

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Acute pyelonephritis
• Pyelonephritis is more common in females.
• May be associated with underlying congenital anomalies of the kidneys and urinary tract.
• It may result in significant short-term morbidity, including septicaemic shock and acute renal
failure, especially in infants.
• Permanent renal damage may occur in children who have recurring episodes of pyelonephritis.
• The pathogens causing pyelonephritis are the same as those causing cystitis above
• Pyelonephritis is potentially severe, especially in neonates and infants.
• Management depends on the presence of signs of severity or complications or risk of
complications.

Clinical features

Neonates and infant

• Symptoms are not specific: fever, lethargy, irritability, poor oral intake, vomiting, loose stools
and jaundice. Palpation of the lower abdomen may show abdominal tenderness.
• The absence of fever does not rule out the diagnosis. On the other hand, fever with no
obvious cause– may be the only manifestation.
• Neonates may present with fever or hypothermia, altered general condition, altered
conscious state, pale/grey colour, shock etc.
• In practice, a urinary tract infection should be suspected in children with unexplained fever
or septic syndrome with no obvious focus of infection.

Older children
• Signs of cystitis (burning pain on urination and urinary urgency and frequency, etc.
• Fever > 38 °C
• Flank pain or abdominal tenderness
• Nausea and/or vomiting are common.

Laboratory: As for cystitis above Plus

• Full Blood count, where possible Urine culture, blood urea and creatinine levels
• Renal and bladder ultrasound where possible in:
o Children < 2 years of age with a first febrile UTI
o Children of any age with recurrent febrile UTIs
o Children of any age with a UTI who have a family history of renal or urologic disease,
poor growth, or hypertension
o Children who do not respond as expected to appropriate antimicrobial therapy

Treatment

Criteria for hospital admission:

• Patients at risk of complications: Neonates, infants and children with immunodeficiency
• Patients with complicated pyelonephritis: urinary tract obstruction, renal abscess,
• Patients with signs of severe infection: sepsis and septic shock, dehydration or vomiting

Neonates
Ampicillin slow IV (3 minutes) for 7 to 10 days
• Neonates 0 to 7 days (< 2 kg): 50 mg/kg every 12 hours
• Neonates 0 to 7 days (≥ 2 kg): 50 mg/kg every 8 hours
• Neonates 8 days to < 1 month: 50 mg/kg every 8 hours

PLUS Gentamicin slow IV for 5 days

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• Neonates 0 to 7 days (< 2 kg): 3 mg/kg once daily

• Neonates 0 to 7 days (≥ 2 kg): 5 mg/kg once daily
• Neonates 8 days to < 1 month: 5 mg/kg once daily

Or
Cefotaxime slow IV for 7 to 10 days
• Neonates 0 to 7 days (< 2 kg): 50 mg/kg every 12 hours
• Neonates 0 to 7 days (≥ 2 kg): 50 mg/kg every 8 hours
• Neonates 8 days to < 1 month: 50 mg/kg every 8 hours

Children one month and over

• Ceftriaxone IM or slow ivi 50 mg/kg once daily until the child’s condition improves then
change to oral route to complete 10 days of treatment with:
• Amoxicillin/clavulanic acid PO
o Children < 40 kg: 25 mg/kg 2 times daily
o Children ≥ 40 kg: 2 tablets of 500/62.5 mg 2 times daily

Uncomplicated pyelonephritis
• Ceftriaxone IM: 1 g single dose or Gentamicin IM: 5 mg/kg single dose
PLUS Ciprofloxacin PO: 500 mg 2 times daily for 7 days
Or
• Cefixime PO: 200 mg 2 times daily or 400 mg once daily for 10 to 14 days
Pyelonephritis with criteria for hospital admission
• Ampicillin slow IV 50mg/kg (Max 2g) every 6 hours for at least 3 days PLUS
• Gentamicin IM: 5 mg/kg once daily for 3 days then change to Amoxicillin/clavulanic acid
PO (or another antibiotic depending on the antibiotic susceptibility test) to complete 10 to
14 days of treatment
Or
• Ceftriaxone IV 1 g once daily for at least 3 days PLUS Gentamicin IM: 5 mg/kg once daily
for 3 days in the event of sepsis then change to amoxicillin/clavulanic acid PO (or another
antibiotic depending on the antibiotic susceptibility test) to complete 10 to 14 days of
treatment

--|Acute kidney injury (acute renal failure)

Definition
Acute kidney injury (AKI) is a syndrome characterised by a rapid decline in glomerular filtration
rate and retention of fluid and nitrogenous waste products.
AKI is classified as prerenal, renal and postrenal failure. In neonates exclude congenital
abnormality of the urinary tract

Clinical presentation
• Oliguria is the most common manifestation, i.e.:
o Neonates: output < 1 mL/kg/hour.
o Older children: output ≤ 0.3 mL/kg/hour.
• Prerenal: shock and dehydration.
• Postrenal: exclude obstruction, e.g. palpable bladder.
• Intrinsic kidney disease: oedema, volume overload, hypertension.
• Signs of underlying infection/septicaemia, e.g. fever, skin rash, etc.

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Investigations
• Full blood count
• Serum urea, creatinine, electrolytes, calcium and phosphate (Look for typical biochemistry
complications: hyperkalaemic metabolic acidosis, hyponatraemia, hypocalcaemia,
hyperphosphataemia)
• Urine macroscopic appearance: brownish with acute tubular necrosis.
• Urine microscopy: red blood cell casts, leukocyte, hyaline and granular casts.
• Urine culture to exclude pyelonephritis.
• Ultrasound of kidneys and bladder.

Management
Non pharmacological
• Treat the underlying cause.
• Monitor fluid intake and output, blood pressure.
• Weigh daily.
• Nutritional support: High-energy diet. Give supplementary nasogastric feeds, if required.
• Restrict salt, potassium and phosphate intake.
• Avoid nephrotoxic or renally excreted medicines, e.g. NSAIDs, aminoglycosides, vancomycin,
cough and cold mixtures, radiocontrast drugs.
• Fluid management:
o Depends on volume status, urine output and extra-renal losses.
o Never use a potassium-containing solution in an anuric patient.
o Only use parenteral fluids if oral intake is not possible
o Fluid balance is critical. Assess at least every 12 hours to make appropriate changes to
fluid prescription.
o Fluid management is done according to fluid status
• Insensible water loss is calculated as:
o Neonates and young babies: 30 - 40 mL/kg/day
o Older children: 25 mL/kg/day (400 mL/m2/day)
• Pulmonary oedema plus oliguria/anuria: Do not give fluid.
• Hydrated anuric patient without extra-renal fluid losses: Oral fluid to replace insensible
water losses only.
• Normally hydrated plus oliguria: Oral fluid intake to replace insensible water loss plus urine
output of previous 24 hours.
• Dehydrated, oliguric and ongoing extra-renal fluid losses:
• Replace fluid losses with an appropriate solution which mirrors losses e.g.:
o For diarrhoea: ½ Darrows/dextrose 5%, IV or oral rehydration solution;
o For vomiting/gastric fluid losses: sodium chloride 0.9%/dextrose 5%.
• Normally hydrated plus normal urine output: Give normal fluid intake.
• Polyuria, (urine output > 4 mL/kg/hour): which usually occurs during the recovery (diuretic)
phase of acute tubular necrosis: Replace fluid and electrolyte losses with ½ Darrows/
dextrose 5%, IV. Volume to replace is equal to urine output of preceding 12 hours.

Management of Hyperkalaemia
• Monitor ECG for signs of hyperkalaemia.
• Discontinue all sources of intake of potassium.
• Treat when serum potassium ≥6.5 mmol/L.
• Monitor response to treatment and adjust accordingly.
o Calcium gluconate 10 %, IV, 0.5mL/kg/dose slowly over 3–5 minutes.
o Salbutamol, solution, 2.5–5 mg/dose, nebulise over 20 minutes. OR
• Sodium bicarbonate 4.2%, IV, 4 mL/kg administered over 4 hours.
o Do not mix calcium and sodium bicarbonate-containing solutions.

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• Check Potassium level, if still no improvement

• Dextrose 10%, IV, 5 mL/kg over 20 minutes with/without insulin, soluble, 0.1units/kg
depending on the blood glucose level.
o If insulin is used -monitor for hypoglycaemia hourly.
• Sodium polystyrene sulphonate (Kayexelate), oral/rectal, 1 g/kg in dextrose water.
• If hyperkalaemia persists despite above treatment refer the patient urgently for dialysis.

Other complications
Metabolic acidosis: serum pH ≤ 7.1
• Sodium bicarbonate 4.2 %, IV, 4 mL/kg administered over 2–4 hours.
Infection
• Avoid nephrotoxic antibiotics.
Pulmonary oedema, volume overload and hypertension
• Do not give fluid to anuric patients with pulmonary oedema.
• Intubate and initiate positive pressure ventilation as necessary.
• Furosemide, IV, 2–5 mg/kg administered over 5 minutes. Maximum daily dose: 8 mg/
kg/24 hours.
• Morphine, IV, 0.1 mg/kg. Repeat after 4 hours, if required.
• Oxygen, 100%, 2–3 L/minute by nasal cannula.
Note: Pulmonary oedema is an indication for dialysis in non-responsive cases.

Referral
• All children with AKI should be referred to a tertially hospital

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DERMATOLOGY
--|Eczema
Definition
Eczema, also known as dermatitis, is a syndrome characterized by superficial inflammation of the
epidermis and itching.
It is an inflammatory itchy skin condition characterised by:
• Vesicles, weeping and crusting during the acute stage.
• Scaling and lichenification during the chronic stage.

Types:
Atopic Dermatitis: Chronic disease that affects the skin and often occurs together with asthma,
dermatitis, rhinitis and Conjunctivitis.
• Contact Dermatitis: Acute or chronic inflammation caused by allergens or irritants
• Napkin (Or Diaper area) dermatitis

Diagnostic criteria: Based on clinical history and signs

• Family history of allergies.
• Reaction after exposure to allergens.
• Typical distribution: face, flexures of knees and elbows, and creases of neck

Signs and Symptoms:

• Pruritus (constant symptom)
• And any of the following:
o Blisters
o Exudates and Erosions
o Crusting/Excoriations
o Xerosis
o Erythroderma

Complications
• Secondary infection (bacterial, viral, fungal, etc)
• Post inflammatory Hypo or Hyper pigmentation
• Lichenification

Investigations
• Full blood count (Increase of Eosinophils is common)
• Identification of allergens (Prick Skin Test or Patch test not practical in our setting

Management

General and supportive measures

• Avoidance measures: use neutral soaps and rinse clothes properly after wash.
• Keep fingernails short to prevent scratching.
• Wrap with dressings soaked in sodium chloride 0.9%.
• Avoid sunlight and recommend use of sunscreen

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For atopic dermatitis:

Non-pharmacological management
• Patient education
• Recommend Emollient to restore cutaneous barrier
• Aqueous cream: Apply > 2 times/day
• Emulsifying Ointment: apply > 2 times/day

Pharmacological management
• Local Treatment:
o Antiseptic – Exudative lesions, Potassium permanganate diluted at 1/10,000 (500mg
Tablet in 5 liters)
o Antibiotics – Impetiginized lesions, Fucidine 2% 1 application/day/5 days.
o Topical steroids: According to topography and thickness of the lesion
o No long-term topical steroid treatment (local side effects and gradual loss of efficiency).
Prefer short courses
First choice:
 Betamethasone dipropionate (Diprosone, Diprolene) Cream/Ointment 2
applications/day for 3-4 days, then 1 application/day for 3 days then 1
application every 2 days/week for 2 weeks
Alternatives: According to the severity of the lesions and location:
 Betamethasone valerate (Betneval) Cream/Ointment 2 applications/day for
3-4 days, then 1 application/day for 3 days then 1 application every 2 days/
week for 2 weeks OR
 Methylprednisolone (Advantan) Cream/Ointment 1 application/day/3-4days
then every 2 days/week for 1 week OR
 Hydrocortisone Cream/Ointment 2 applications/day for 3-4 days, then 1
application/day for 3 days then 1 application every 2 days/week for 2 weeks

Side effects of topical steroids;

o Skin atrophy
o Skin Bleaching
• Systemic treatment:
o Antihistamine for relief of the itching

 Desloratadine
-Children 6 months - 6 years: 1.25 mg once a day
-Children 6-12 years: 2.5 mg once a day
-Above 12 years: 5 mg once a day
OR
 Cetirizine/ Ebastine oral, as a single dose..

 Combined Phototherapy UVAB in erythrodermic atopic dermatitis

Recommendation
• Short duration of topical steroids whenever possible (Stop topical steroids as soon as skin
lesions disappear)
• Encourage use of emollient
• Avoid medicated soap
• Other eczema, consider topical steroids as indicated in atopic dermatitis above

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--|Bacterial infections (Impetigo)
Definition
A contagious intra-epidermal infection caused by streptococcus or staphylococcus and presenting
as bullous lesions which rupture and crust. It comprises two types:

Non Bullous Impetigo:

• More common form and is a superficial infection of the skin that appears first as a discrete
papullovesicular lesion surrounded by a localized area of redness.
• The vesicle become rapidly purulent and covered with crust.
• The lesions may occur anywhere but is more common on the face and extremities.
• There is usually no fever nor systemic signs.
• Also occurs in traumatized skin that forms vesicles or pustules initially and rapidly develops
crust.

Bullous Impetigo:
• Less common and occur most often in neonates and young infants on a previously healthy
skin.
• It is characterized by transparent bullae usually < 3cm diameter. The distribution involves
the face buttocks trunk and perineum. Staphylococcus aureus usually responsible.

Signs and symptoms:

Non Bullous Impetigo
• Honey coloured crusters
• Lymphadenopathy
• Bullous Impetigo
• Flaccid and purulent bullous

Complications:
• Ulcerations
• Septicaemia
• Staphylococcal scaled skin syndrome (SSSS)

Investigations:
• Diagnosis is Clinical based on history and physical examination
• Swab for bacterial culture and sensitivity test

Management:

General measures
• Good personal and household hygiene to avoid spread of the infection and to reduce
carriage of organisms.
• Trim finger nails.
• Wash and soak sores in soapy water to soften and remove crusts.
• Continue with general measures until the sores are completely healed.

Local Treatment:
• Antibiotics: Fucidic acid ointment (Fucidine 2%) 2 applications/day for 7 days
• Disinfectant with antiseptic solution;
• Potassium Permanganate diluted at 1/10,000 (500mg in 5 litres) OR
• Chlorhexidine solution (dermobacter) 2 applications/ Day for 7-10 da

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Systemic treatment: Diffuse lesions

• Cefadroxil, oral, 15 mg/kg/dose 12 hourly for 5 days.
• Cloxacillin : <40 kg: 12.5-25 mg/kg/day PO divided q6hr (Severe infection: 50-100 mg/
kg/day PO divided q6hr)
: ≥40 kg: 125-500 mg PO q6hr
Penicillin allergy:
Children ≤ 18 kg
Erythromycin, oral, 10–15 mg/kg/dose 6 hourly for 5 days.
Children > 18–35 kg (able to take tablets)
• Azithromycin, oral, 250 mg daily for 3 days.
Children > 35 kg and adults
• Azithromycin, oral, 500 mg daily for 3 days. If impetigo has improved, but has not completely
cured, give a 2nd 5-day course of antibiotics.

Referral
• No improvement after second course of antibiotics.
• Presence of blood in urine test or clinical features of glomerulonephritis.

Recommendation:
• Follow-up is important to ensure complete clearing of lesions

--|Cellulitis
Definition
A diffuse, spreading, acute infection within skin and soft tissues, commonly caused by streptococci
and staphylococci.
• It is characterised by: oedema, redness, increased local temperature and no suppuration
• Frequently associated with lymphangitis and regional lymph node involvement.
• Commonly occurs on the lower legs, but may occur elsewhere.
• May follow minor trauma.
• There may be significant systemic manifestations of infection:
• Fever, tachycardia, hypotension, chills and delirium/altered mental state

Management
General measures
• Elevate the affected limb to reduce swelling and discomfort.
Medication
• Children ≤ 7 years of age
o Cefadroxil, oral, 15mg/kg/dose 12 hourly for 5 days. OR
• Cloxacillin <40 kg: 12.5-25 mg/kg/day PO divided q6hr  Severe infection: 50-100 mg/
kg/day PO divided q6hr: ≥40 kg: 125-500 mg PO q6hr
Penicillin allergy:
Children ≤ 18 kg
• Erythromycin, oral, 10–15 mg/kg/dose 6 hourly for 5 days.
Children > 18–35 kg (able to take tablets)
• Azithromycin, oral, 250 mg daily for 3 days.
Children > 35 kg and adults
Azithromycin, oral, 500 mg daily for 3 days.
Severe cases: Refer for parenteral antibiotics.

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Referral
Urgent
• Children who have significant pain, swelling or loss of function (to exclude osteomyelitis).
• Necrosis.
• Extensive cellulitis.
• Recurrent cellulitis associated with underlying conditions, e.g. lymphoedema.
• Cellulitis with systemic manifestations, e.g. confusion, hypotension.
• Poorly controlled diabetic patients.
• Involvement of the hand, face and scalp.
Non-urgent
• Inadequate response to initial antibiotic treatment

--|Staphylococcal scalded skin syndrome

Definition
Blistering skin condition that presents like scalded skin.
General and supportive measures
• Appropriate wound care.
Medication
• Cloxacillin, IV, 50 mg/kg/dose 6 hourly for 5 days.
• Neonates
o Week 1–2 of age: administer 12 hourly.
o Week 2–4 of age: administer 8 hourly.

--|Steven-johnson syndrome (sjs)/toxic epidermal ne-

crosis (ten)
Definition
Life-threatening, acute hypersensitivity reaction with systemic upset, epidermal necrosis, and
mucous membrane involvement.
TEN and SJS are different ends of the same spectrum: in TEN epidermal necrosis involves >30%
of body surface area, while in SJS the involvement is <10%.
This condition is usually due to medication, e.g. sulphonamides, Nonnucleoside reverse
transcriptase inhibitors (especially Nevirapine), Mebendazole, antiepileptics (phenytoin,
Phenobarbitone, carbamazepine, lamotrigine), Allopurinol, laxatives (phenolphthalein).

Complications include:
• Dehydration, electrolyte disturbances and shock,
• Hypoalbuminaemia,
• Hypo and more commonly hyperthermia,
• High output cardiac failure,( resting cardiac output greater than 8 L/min)
• Secondary infection and sepsis; and
• Adhesions and scarring.

Diagnostic criteria
• Cutaneous lesions may start as a dusky red macular rash, progressing to confluence with
epidermal necrosis and large flaccid blisters which rupture, leaving large areas of denuded
skin. Mucous membrane erosions are common and multi- organ involvement may be present

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General and supportive measure

• May require care in high or intensive care unit.
• Examine daily for systemic involvement, infection and ocular lesions.
• If infection is suspected, send blood and skin lesion specimens for culture and sensitivity
before initiating antibiotic therapy.
• Do not puncture bullae or vesicles.
• Cool compresses and wet dressings.
• Regular supervised oral, genital and eye care to prevent adhesions and scarring.
• Encourage oral fluids, to prevent adhesions.
• Maintain fluid balance. Beware of shock.
• Nasogastric feeds if unable to eat, IV alimentation if enteral feeds are not possible.
• Stop all potentially causative medicines.

Medications
• These patients require effective pain control especially during change of dressing
• Skin hygiene, daily cleansing and bland, non-adherent dressings as needed.
• Do not use silver sulfadiazine if Stevens - Johnson syndrome is thought to be due to
Cotrimoxazole or other sulphonamide.
• Empiric antibiotic therapy

For secondary infections

o Cefadroxil , oral: 15mg/kg/dose 12 hourly Or
o Cloxacillin oral: 25-50 mg/kg/day divided 6 hourly
• Use IV antibiotics if the oral route cannot be used.
o Cloxacillin, IV, 50 mg/kg/dose 6 hourly. OR
o Cefazolin IV 100-150 mg/kg/day divided 8 hourly
• Reconsider choice of antibiotic when the results of cultures become available or the child
does not improve.
For oral lesions:
• Chlorhexidine 0.2%, 15 mL as a mouthwash.
o Use as needed.
o Do not swallow.
Note: The use of systemic corticosteroids is not recommended.

Referral
• All cases with signs of respiratory distress
• Discuss with a specialist, if considering re-initiation of medicine treatment

--|Acne
Definition
Acne is a skin disease characterized by pimples on the face, chest, and back. It occurs when the
pores of the skin become clogged with oil, dead skin cells and bacteria, caused by changes in
skin structures consisting of a hair follicle and its associated sebaceous gland. It can present in
inflammatory or non-inflammatory forms.
Acne is most common during adolescence but may continue into adulthood. For most people,
acne improves over time and tends to disappear in the early twenties. The most common sites
for acne vulgaris are the forehead, cheeks, nose, and chin; the chest and back may sometimes
be involved.

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Causes and aggravating factors
• Sebum overproduction during puberty
• Altered hormonal status in adolescence with increased androgens in males
• Increased androgenic properties of progesterone in premenstrual females or those taking
progesterone-containing contraceptives
• Some medicines (e.g., steroids) and cosmetics
• Family history
• Infection by Propionibacterium, mainly P. acnes

Signs and symptoms

Acne can be categorised as mild, moderate, and severe.

Mild
• Open and closed comedones (i.e. whiteheads and blackheads)
• Some papules and pustules (pimples), commonly on face, chest, back and shoulders

Moderate
• More frequent papules and pustules
• Mild scarring

Severe
• All of the above plus nodular abscesses
• Leads to more extensive scarring that may be keloidal in some cases

Management objectives
• Alleviate symptoms by reducing the number and severity of lesion
• Limit duration and recurrence
• Decrease sebaceous gland activity
• Decrease bacterial infection and inflammation
• Minimise cosmetic disfigurement and psychological suffering

Nonpharmacological management
Advise patients to:
• Avoid squeezing pimples because doing so may increase the risk of scarring
• Avoid excessive use of cosmetics and use only water-based products
• Wash face with mild soap and water 3 times/day; minimise scrubbing
• Get some sun (sunshine is helpful), but avoid sunburn
• Shave as lightly and as infrequently as possible.

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Pharmacological management

For mild acne:

• Start with topical benzoyl peroxide cream or lotion 5%, once daily (use overnight).
• Treatment should be assessed after 4 weeks and, if beneficial, should be continued for at
least 4–6 months.
• If no satisfactory response with benzoyl peroxide, use topical antibiotics or a combined
preparation:
o Erythromycin lotion or solution 1.5% or 2% applied twice daily to the affected area OR
o Benzoyl peroxide 5%/erythromycin 3% gel applied twice daily to the affected area.

For moderate acne:

• Use topical treatment as for mild acne.
• If poor response to topical treatment, give oral antibiotics for at least 3 months:
o Erythromycin 250 mg twice a day for 4 weeks OR
o Doxycycline 100 mg once daily; can be taken with food or milk
Severe acne
• Use the topical treatment as for mild acne.
• Give also
o Tetracycline 250-1,000 mg/day
o Erythromycin 250–1,000 mg/day
• Duration of treatment depends on response. It may require 6 months to a year.
• Topical retinoid, e.g. Tretinoin cream/gel 0.05%, topical, applied sparingly once daily at
bedtime until substantial improvement. Avoid contact with eyes and mucous membranes.
Referral
• All mild and moderate acne with poor response after 3 months of treatment
• All severe cases of acne
• Psychologically disturbed or depressed patient.
• Young females with premenstrual flare or with clinical signs of hyperandrogenism for
consideration of oral contraceptives.

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--|Fungal infections
Dermatophytes

Definition
Fungal infection often seen as Tinea or Ringworm with clinical entities/forms depending on the
anatomic site and etiologic agents involved. It is of two types;
• Tinea Capitis: Fungal Infections of the Scalp or head and often found in children.
• Tinea Corporis: Fungal infection of the glabrous skin ( Hairless part of the body)

Signs and symptoms:

Clinical forms
Type Signs and symptoms
(Causative Agent)
• Large patches/ plaques
Microsporic Tinea
Tinea Capitis • Hair Fracture at few millimetres above surface
(Microsporum spp)
of scalp (No alopecia)
• Multiple small patches
Tricophytic Tinea
• Hair Fracture at the scalp giving black dots
(Tricophyton Spp)
aspect

Inflammatory Tinea/
kerion • Severe Inflammatory reaction with deep
abscess causing hair loss with permanent
(Microsporum spp and alopecia after healing.
Tricophyton Spp)

• Yellow cup shaped crusts known as scotula

• Hair is eliminated leading to permanent
alopecia.

Favus (Tricophyton Raised borders with Central normal skin, ring itself is
schonleini) red with dryness and scaling (Circinate lesions)

• Itching
• Skin rash
• Small area of red, raised spots and pimples
• Rash which slowly becomes ring-shaped, with
Tinea
All spp a red-colored, raised border and a clearer
Corporis
center
• The border of rash may look scaly
• Rash may occur on the arms, legs, face, or other
exposed body areas

Diagnosis:
• Clinical based on history and physical examination

Investigations:
o Looking at a skin scraping of the rash under the microscope using a potassium
hydroxide (KOH)test
o Skin biopsy for histological exams

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Management:
Types Therapeutic options

Topical treatment (always combined to systemic treatment).

• Ketoconazole (Nizoral) shampooing, 3times/week apply to moist hair
after shower, and then wash off after 15 minutes OR
• Whitefield ointment , apply BID
Systemic treatment: First choice:
Tinea capitis • Griseofulvin (tabs 125mg,250mg, 500mg): 20 mg/kg/ day , 6 to 8
weeks taken once daily with fatty meal
Alternatives:
• Fluconazole (Flucazol syrup 50mg/ml) 6 mg/kg/day, 6 to 8weeks
once a day.
• If inflammatory Tinea: add systemic antibiotics to antifungal above
mentioned

Local treatment:
• Miconazole nitrate 2% cream, 2 applications/day for 15 days OR
• Clotrimazole cream, 2 applications/ day for 10 days. OR
• Ketoconazole cream, 2 applications/ day for 10 days.
Systemic treatment(≥3 lesions):
Tinea Corporis
First choice:
• Griseofulvin 20 mg/kg/ day, 3-4 weeks taken with fatty meals.
Alternative:
• Fluconazole (Flucazol suspension, 50mg/ml) 6 mg/kg/day, 6 to
8weeks once a day.

Recommendation:
• Avoid sharing combs and towels to prevent Tinea capitis

--|Viral infections
Varicella Zoster Virus (Chicken pox, VZV)

Definition
An acute, highly contagious, viral disease caused by herpes varicella-zoster.
It spreads by infective droplets or fluid from vesicles. One attack confers permanent immunity.
Varicella is contagious from about 2 days before the onset of the rash until all lesions crusted.
Re-activation of the virus may appear later as herpes zoster or shingles (in children, consider
immunosuppression if this occurs). Incubation period is 2–3 weeks.
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Complications are more common in immunocompromised patients and include:
• Secondary skin infection,
• Pneumonia,
• Necrotizing fasciitis,
• Encephalitis,
• Haemorrhagic varicella lesions with evidence of disseminated, intravascular coagulation.
• Two important bacteria causing complications are Staphylococcus aureus and Streptococcus
pyogenes

Diagnostic criteria

Clinical
• Mild headache, fever and malaise.
• Characteristic rash.
• The lesions progress from macules to vesicles in 24–48 hours.
• Successive crops appear every few days.
• The vesicles, each on an erythematous base, are superficial, tense ‘teardrops’ filled with
clear fluid that dries to form fine crusts.
• The rash is more profuse on the trunk and sparse at the periphery of extremities.
• At the height of eruption, all stages (macules, papules, vesicles and crusts) are present at
the same time.
• The rash lasts 8–10 days and heals without scarring, unless secondarily infected.
• Mucous membranes may be involved.
• Pruritus may be severe.
• Patients are contagious from 1–2 days before onset of the rash until crusting of lesions

Management
• Isolate the patient.
• Maintain adequate hydration.

Medications
• Antiviral therapy
• Indicated for immunocompetent patients with complicated varicella and for all
immunocompromised patients.
• Initiate as early as possible, preferably within 24 hours of the appearance of the rash.
• Neonates, immunocompromised patients and all cases with severe chickenpox (not
encephalitis)
• Acyclovir, oral, 20 mg/kg/dose 6 hourly for 7 days. Maximum dose: 800 mg/dose.
• In severe cases or in cases where oral medicine cannot be given: Acyclovir, IV, 8 hourly
administered over 1 hour for 7 days
o If 0 – 12 years: 20 mg/kg/dose 8 hourly.
o If > 12 years: 10 mg/kg/dose 8 hourly

For mild pruritus:

• Calamine lotion, topical, applied 8 hourly.

For severe pruritus:

• Less than 2 years: Chlorphenamine, oral, 0.1 mg/kg 6–8 hourly for 24–48 hours.
• Over 2 years: Cetirizine, oral, 2.5-5 mg 12-24 hourly.

Secondary skin infection

• Cefadroxil, oral, 15 mg/kg/dose, 12 hourly for 5 days.

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• Prophylaxis: Post exposure prophylaxis must be given to:

o Neonates whose mothers develop varicella from 5 days before delivery to 2 days after
delivery:
o Varicella-zoster immunoglobulin, IM, 1 mL (100 units) given within 96 hours of exposure.
o If varicella-zoster immunoglobulin is not available: Acyclovir, oral, 20 mg/kg/dose 6
hourly for 10 days.
o Note: In neonates, prophylaxis may not prevent disease.

Infants and children > 28 days

• Immunocompromised children exposed to varicella:
o Acyclovir, oral, 20 mg/kg/dose 8 hourly for 10 days given in the second week after
exposure.
• Hospitalised immunocompetent children exposed to varicella (to limit spread).
o Acyclovir, oral, 20 mg/kg/dose 8 hourly for 10 days given in the second week after
exposure.

Referral: All patients with complications.

--|Parasitic infections
Scabies

Definition
Scabies is a contagious skin condition caused by a tiny mite (Sarcoptes scabei). It burrows into the
outer layer of the skin and deposits its eggs there. It spreads easily through person-to-person
contact. It is particularly problematic in areas of poor sanitation and overcrowding.

Signs and symptoms

• Nocturnal intense pruritus
• Lesion distribution:
• Interdigital web spaces.
• Around the nipples.
• Genital region.
• Lesion characteristics:
o Papules, pustules or excoriations.
o The pathognomonic sign: intradermal tunnel called scabietic “burrow”

Diagnosis
• Based on clinical history and physical examination.
o The history particularly itching of recent onset, and careful scrutiny of hands and wrists
will usually establish the diagnosis.

Investigation:
• Microscopic identification of skin scrapings

Complications:
• Secondary skin infection
• Sepsis

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Management objectives
• Prevent re-infection or further spread of the disease
• Relieve the itching

Non pharmacological management

• All close family and skin-to-skin contacts must be treated at the same time to prevent re-
infection, even if symptoms are not evident.
• The patient should be advised to wash, boil, dry in the sun, and iron all clothing, bedding,
and bed linens after each use.
• The mattress, pillows, and chair cushions must be placed in the sun for at least 3 consecutive
days.
• Advise the patient to keep his or her nails short and clean.
• Instruct the patient to dry his or her skin thoroughly after bathing and to put on clean clothes.
• The whole house should be cleaned and disinfected with a disinfectant spray.

Pharmacological management
• Use benzyl benzoate lotion 25%.
o Adults and children >6 years: full strength 25% solution
o Children <6 years: 12% solution (dilute 25% solution 1 part solution: 1 part water
o Infants: 1:3 dilution
o Apply benzyl benzoate lotion to the entire body, excluding the face and nipple area of
breastfeeding women, for 3 consecutive evenings.
o Leave on overnight and wash off the next day.
o Attention should be paid to the toes, fingers, genital area and areas where the rash is
seen.
o A scrub bath must be taken before and after the 3 days of application.
o Repeat the treatment after 10 days.
• Itching may persist for some weeks after completing the treatment. This can be relieved by
taking Chlorpheniramine
o Give Chlorpheniramine (4 mg tablets; 2 mg/5 ml syrup) PO every 4–6 hours daily.
- Adults: One 4 mg tablet 4–6 times/day, not to exceed 24 mg/day
- Children
 2–5 years: 1 mg (. teaspoon) syrup 4–6 times/day, not to exceed 6 mg/
day
 6–12 years: 2 mg (. tablet or 5 mL—1 teaspoon—syrup) 4–6 times/ day,
not to exceed 12 mg/day
• Note: Itching usually starts to abate after 1 week and the rash after 3 weeks.

Referral
• If there are signs of treatment resistance, refer the patient to the specialist.

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INFECTIOUS DISEASES
--|Malaria
Definition
Malaria is a febrile haematozoid parasitic illness due to Plasmodium parasites. It may be
simple or severe form. In Rwanda, the main species is Falciparum (98% and the cause of severe
malaria cases. In Rwanda, there 3 forms of malaria:

Simple Malaria
• Axillary temperature 37.5 °C or history of fever in the last 24 hours with or without the
following signs: headache, weakness, chills, loss of appetite, stiffness, and muscular pains
• Laboratory confirmation using either a blood smear or a rapid test is compulsory in all cases
without exception.

Simple malaria with minor digestive symptoms

• Characterized by signs of simple malaria with vomiting that prevents oral medication with
or without associated moderate diarrhoea.
• The confirmation of Plasmodium by either blood smear or rapid test is compulsory without
any exception.

Severe malaria
• All severe malaria cases must be admitted to hospital.
• It is characterized by positive parasitaemia due to Plasmodium falciparum, accompanied
by one or more of the following signs of severity or danger in the absence of an identified
alternative cause:
o Inability to drink or suckle;
o Prostration; Generalized weakness with inability to sit, stand or walk without support
o Vomiting every feed
o Convulsions (≥ 2 convulsions in 24 hours);
o Lethargy and unconsciousness.
o Respiratory distress syndrome/Pulmonary oedema
o Metabolic acidosis
o Hypoglycaemia <2.2Mmol/L or < 40mg/dl
o Renal impairment
o Significant bleeding from any site
o Signs of shock
o Hyperparasitaemia of Falciparum> 10%
• Severe malaria is a medical emergency. Delay in diagnosis and inappropriate treatment,
leads to rapid worsening of the situation.
• The keys to effective management are early recognition, assessment and appropriate
antimalarial and supportive therapy.

Management of different forms of malaria

Management of simple malaria; First line treatment:

• Artemisinin combination therapy (ACT): Artemether 20 mg and Lumefantrine 120 mg
(COARTEM®), taken preferably during meals twice a day for 3 days

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 TREATMENT GUIDELINES 83
Table 25.Schematic diagram of COARTEM dosing according to the body weight of the patient

Number of tablets of COARTEM per dose

Category of body Day 1 Day 2 Day 3

Type of blister
weight of the patient
administered
in kg 8 hours 24 hours 36 hours 48 hours 60 hours
First
after first after first after first after first after first
dose
dose dose dose dose dose

5 kg ≤ weight < 14 kg 6*1 (5-15 kg) 1 1 1 1 1 1

15 kg ≤ weight < 24 kg 6*2 (15-25kg) 2 2 2 2 2 2
25 kg ≤ weight < 34 kg 6*3 (25-35 kg) 3 3 3 3 3 3
≥ 35 kg 6*4 (> 35 kg) 4 4 4 4 4 4

Important instructions to follow:

• Respect the dose prescribed by the health provider;
• Artemether-lumefantrine is contraindicated in:
o Children weighing less than 5 kg
o During first trimester pregnancy
o In cases of allergy to one of the two drugs in the combination
o In severe liver or renal disease
• In such cases, oral quinine sulphate is indicated, 10 mg per kg body 3 times for 7 days;
• If there is no improvement after 48 hours of treatment Artemether-Lumefantrine, verify if
the patient swallowed the drugs correctly, re-examine the patient carefully and do another
peripheral blood smear, and if the test is positive, change the treatment to oral quinine
sulphate at 10 mg per kg body weight per dose, taken three times a day over seven
consecutive days.
• If the peripheral blood smear is negative, exclude and treat other causes of illness and/or
refer the patient to the specialist
• If there is no improvement after 48 hours of treatment with quinine probably due to
associated pathologies other than malaria, refer the patient to the specialist

Recommendation:
Monotherapy using artemisinine derivatives is not allowed for the management of simple malaria in
Rwanda.

Management of simple malaria with minor digestive symptom:

Artesunate IV: 2.4 mg/kg body weight as a single dose on admission (time= 0) then at 12 hour, then
daily thereafter.
• If the patient’s condition improves, change to oral Artemether-lumefantrine twice a day for
three consecutive days.
• If the patient’s condition does not improve within 24 hours of treatment, refer the patient to
the specialist

Note: Preparation: Artesunate will be diluted in 1 ml 5% sodium bicarbonate (provided in the package),
and then further diluted with 5% dextrose or 0.9% normal saline to a total volume of 6 ml, giving a
final concentration of 10 mg/ml.

In case of contra indications of Arthemether derivatives give;

• Quinine dihydrochloride (Salt) intra-rectal: 15mg/kg body weight diluted in 4 ml of distilled
water or physiological saline and administered rectally with a 5 ml syringe every eight
hours. The drug is administered slowly through the anus, and the buttocks are held together

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for 5 minutes to prevent a premature reflex ejection of the drug.

• If the patient’s condition improves, change to oral COARTEMR, 2 times a day for 3 consecutive
days, or in the case of contraindications to COARTEMR, administer oral quinine
• If no improvement after 24 hours of treatment, refer to the hospital

Recommendation:
• If the drug is ejected during the first 10 minutes following its administration, administer
another half dose;
• Diarrhoea and anal lesions contraindicates utilisation of intra-rectal route, then give Quinine
dihydrochloride (salt) intravenous: 10 mg /kg body weight per dose, diluted in 5 to 10 ml
of 5% or 10% glucose, every 8 hours.
• Rapid administration of Quinine is unsafe.
• If the patient’s condition does not improve within 24 hours of treatment, refer the patient to
hospital
• Quinine IM is contraindicated

Supportive treatment:
In case of diarrhoea and/or vomiting;
• Evaluate and monitor the hydration status of the patient
• Rehydrate the child with ORS or other available liquids, encourage breast feeding and
other modes of feeding and if necessary use a nasogastric tube
• Anti-emetics should be avoided as necessary
• In case of fever, give oral Paracetamol 15 mg/ kg per dose
Management of severe malaria;

Recommendations:
• Treatment must be initiated based on malaria positive blood smear or rapid diagnostic test
results
• Meanwhile, other investigations to determine severity and prognosis should be undertaken
• The management of severe malaria must be done in either district hospital or referral
hospital (private or public).

Pre-transfer treatment at the health centre:

• It is indicated to administer antimalarial treatment only after obtaining a positive blood
smear or positive rapid diagnostic test
• While preparing for the transfer of the patient, urgently administer IV Artusinate or quinine
intrarectally IR or IV (IV infusion) if there is a contraindication to artemesinine derivates and
depending on the general condition of the patient (weak pulse or not, dehydration or none),
the health centre staff will administer, either:
o Artesunate3.2 mg /kg IV as a single dose before transferring the patient OR
o Quinine by intrarectal route in children, 20mg per kg body weight diluted in 4ml of
distilled water of physiological saline, administered with a 5 ml syringe without a needle
OR
o Give quinine IV, preferably by intravenous infusion as a loading dose of 20 mg /kg
body weight to run in 4 hours (not exceeding a total dose of 1200 mg for the loading
dose);

Recommendation:
• Give parenteral antimalarial in the treatment of severe malaria for a minimum of 24h,
once started (irrespective of the patient’s ability to tolerate oral medication earlier), and,
thereafter, complete treatment by giving a complete course of artemether plus lumefantrine
orally.

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• For cerebral malaria, administer the first dose of antibiotics; Ampicillin 50 mg/kg body
weight per dose, four times a day accompanied by - chloramphenicol 25 mg/ kg body
weight per dose, four times a day.
• In case of hypovolaemia (severe anaemia, rapid breathing, coma or systolic BP < 80 mm
Hg), start with normal saline or Ringer’s lactate infusion in a dose of 20 ml/kg to run for 15
minutes to move the patient out of shock.
• For malnourished children (kwashiorkor or marasmas), give the loading dose of quinine in IV
perfusion without fluid replenishment (to avoid the risk of circulatory overload).
• The administration of quinine intravenous infusion is preferable in severe cases (repeated
convulsions, coma. respiratory distress, shock)
• If an intravenous line is not possible, use intramuscular artemether or intrarectal quinine.

Note: The intramuscular use of Quinine is prohibited in all health facilities in Rwanda.

Supportive treatment:
• If the temperature is ≥38°C;
o Do tepid sponging
o Give Paracetamol 15 mg /kg body weight by oral route or suppository and injectable
forms
• To prevent hypoglycemia (characterized by lack of consciousness, severe weakness);
o Give 3-5ml/kg body weight of 10% glucose bolus or if not available 1 ml/kg of 50%
glucose diluted in 4ml of water for injection Or
o Administer water with 10% sugar per mouth or with nasogastric tube, at a rate of 5 ml/
kg (Preparation of 10% sugar/water: take 100 ml of boiled clean water and add 10
g of sugar or 2 coffee spoons

Treatment of the severe malaria in the hospital;

• Artesunate 2.4 mg/kg IV or IM given on admission (time = 0), then at 12h and 24h, then
once a day; Quinine is an acceptable alternative if parenteral Artusinate is not available

If Quinine is indicated:
• Loading dose of 20 mg/kg body weight of quinine dihydrochloride (do not exceed 1200
mg) diluted in an isotonic solution or 5 or 10% glucose on the basis of 5 to 10 ml/kg body
weight to run for 4 hours in IV perfusion.
• Then run IV glucose 5 or 10% for 4 hours as maintenance drip. Thereafter, a maintenance
dose of 10 mg/kg body weight of quinine dihydrochloride, to run for 4 hours repeated
every 8 hours until the patient can swallow, within 48 hours
• After 48 hours, if the patient’s state does not permit the patient to take quinine orally,
continue the drip of quinine by reducing the doses to 7 mg/kg every 8 hours to run for 4
hours.
• Give parenteral antimalarials in the treatment of severe malaria for a minimum of 24h,
once started (irrespective of the patient’s ability to tolerate oral medication earlier), and,
thereafter, complete treatment by giving a complete course of oral Artemether 20 mg and
Lumefantrine 120 mg, as recommended for the treatment of simple malaria
• Change to oral quinine 10 mg/kg of quinine sulphate every 8 hours as soon as the patient
can swallow; to complete the 7 days of treatment in case of contraindication in artemesinin
derivates

Recommendation:
• For the patient with weight ≥ 60kg give the loading dose, and decrease the dose from
1200mg to 800mg not to exceed 2000mg per day,

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• The loading dose of quinine is not administered if the patient received quinine the past 12
hours or Mefloquine in the 7 past days
• Never exceed 2 g of daily dose of quinine
• For cerebral malaria, concurrent IV antibiotics is recommended; (Cefotaxime 50 mg/kg/
dose IV 6 hourly or Ceftriaxone 50mg/kg 12 hourly until meningitis and sepsis have been
excluded
• For the anaemic form of severe malaria antibiotics are not indicated.
• Syrup Quinine is not recommended

Table 26. Summary of oral quinine dosing scheme

Body weight of patient in kg Number of tablets of quinine 300 mg per dose

Weight ≤10 kg ¼ tablet

10 kg < weight ≤ 15 kg ½ tablet

15 kg < weight ≤ 21 kg ¾ tablet

21 kg < weight ≤ 31 kg 1 tablet

31 kg < weight ≤ 36 kg 1+ ¼ tablet

36 kg < weight ≤ 47 kg 1+ ½ tablet

Weight > 48 kg 2 tablets

Management of complications (World Health Organization 2015). Guidelines for the Treatment of
Malaria. 3rd edition.

Severe malaria is associated with a variety of manifestations and complications, which must be
recognized promptly and treated as shown below.

Table 27. Immediate clinical management of severe manifestations and complications of P. falciparum malaria
Manifestation or
Immediate management
complication
Maintain airway, place patient on his or her side, exclude other treatable
Coma (Cerebral
causes of coma (e.g. hypoglycaemia, bacterial meningitis); avoid harmful
malaria)
ancillary treatments, intubate if necessary.
Hyperpyrexia Administer tepid sponging, fanning, a cooling blanket and Paracetamol.
Maintain airways; treat promptly with intravenous or rectal diazepam
Convulsions 0.5 mg/kg body weight Intra-rectal; If convulsions persist, give
Phenobarbital 10-15 mg/kg IVI/IM; Check blood glucose.
Check blood glucose, correct hypoglycaemia and maintain with glucose-
containing infusion. Although hypoglycaemia is defined as glucose < 2.2
Hypoglycaemia
mmol/L, the threshold for intervention is < 3 mmol/L for children < 5
years and < 2.2 mmol/L for older children and adults.
Transfuse with packed cells 10ml/kg or screened fresh whole blood
Severe anaemia
20ml/kg

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Manifestation or
Immediate management
complication
Prop patient up at an angle of 45°, give oxygen, give a diuretic, stop
Acute pulmonary
intravenous fluids, intubate and add positive end-expiratory pressure or
oedema
continuous positive airway pressure in life-threatening hypoxaemia.
Exclude pre-renal causes, check fluid balance and urinary sodium; if in
Acute kidney injury
established renal failure, refer for haemodialysis/peritoneal dialysis.
Spontaneous
Transfuse with screened fresh whole blood (cryoprecipitate, fresh frozen
bleeding and
plasma and platelets, if available); give vitamin K injection.
coagulopathy
Exclude or treat hypoglycaemia, hypovolaemia and septicaemia. If
Metabolic acidosis
severe do haemodialysis.
Suspect septicaemia, take blood for cultures; give parenteral broad-
Shock
spectrum antibiotics, correct haemodynamic disturbances.

Reference
1. (World Health Organization 2015). Guidelines for the Treatment of Malaria. 3rd edition.
2. Rectal versus Intravenous Quinine for the Treatment of Childhood Cerebral Malaria in
Kampala, Uganda: A Randomized, Double-Blind Clinical Trial Jane Achan, Justus Byarugaba, Hubert
Barennes, James K. Tumwine Clinical Infectious Diseases, Volume 45, Issue 11, 1 December 2007,
Pages 1446–1452, https://doi.org/10.1086/522972

--|Meningitis
Definition
Meningitis is the inflammation of the meninges usually due to infection

Causes
• Bacteria (H.influenzae, streptococcus pneumoniae, meningococcus…)
• Viruses (Herpes group…)
• Fungi (Cryptococcus Neoformans)
• Protozoa (toxoplasma gondii…)
Note:
• Hemophilus Influenza and Streptococci are common causes in infants while Neisseria
meningitides is responsible for epidemics in older children …)
• Mycobacterium tuberculosis, Fungal and protozoa infections are more common in
immunocompromised children like in HIV/AIDS and malnutrition

Signs and symptoms

In younger infants
• Nonspecific features e.g. vomiting, restlessness, irritability and poor feeding
• Convulsions and bulging fontanel are more reliable signs in this age group
In older children
• Headaches
• Fever
• Convulsions
• Stiffness of the neck

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Diagnosis
• Based on symptoms and signs

Investigations
• Lumber puncture and laboratory analysis of cerebral spinal fluid
• FBC, serum glucose, electrolytes (Na and K)
• Blood culture

Interpretation of the CSF results:

Either Bedside examination:
• Looks cloudy in bottle (turbid) and not a blood stained tap, and /or laboratory examination
with one or more of:
o White cell count more than 10x106/l
o Gram positive diplococci or gram negative coco bacilli
 If one is positive: definitive meningitis
 If all lab negative but one of the following (coma, stiff neck, bulging fontanel and
LP looks clear : probable meningitis
 If all of the clinical signs mentioned above, and CSF not done: possible meningitis
Complications:
• Convulsions
• Brain oedema
• Coma
• Syndrome of inappropriate ADH secretion
• Brain abscess
• Cranial nerve palsies
• Psycho-motor retardation
• Hydrocephalus
• Epilepsy

Management:

General supporting measures:

• Admit in high dependence unit
• Follow ABC guidelines for unconscious patient
• Correct hypoglycemia if present
• Give maintenance fluids IV
• Stop convulsions with diazepam 0.5mg/kg intra rectal or Phenobarbital10 15mg/kg IV
Feeding by NGT with milk, soup and porridge, if stabilized (then, stop IV fluids)

Antibiotics:
• Definitive meningitis: Cefotaxime 50 mg/kg/dose IV 6 hourly for 10 to14 days) or
Ceftriaxone 50mg/kg 12 hourly for10 to 14 days
• If not available Ampicillin 50 mg/kg IV 6 hourly + Chloramphenicol 25mg/Kg IV 6 hourly
for 10 to 14 days
• Probable meningitis: Same as definitive meningitis
• Possible meningitis: Same as definitive meningitis

Dexamethasone
• Reduces the risk of hearing loss in patients with H. influenzae or S. pneumoniae.
o Given with or before the first dose of antibiotics except in neonates
o Children > 1 month: 0.15 mg/kg (max. 10 mg) every 6 hours for 2 to 4 days
o Monitor;

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 Vital signs (temperature, RR, HR, level of consciousness, diuresis)
 Fluid input and output
• If suspected viral meningoencephalitis; Add Acyclovir IV 20mg/kg 8 hourly for 3 weeks
• If tuberculous meningitis, fungal and protozoal meningitis treatment refer to the respective
treatment services
• Raised intracranial pressure or cerebral oedema (Must be managed in HDU/ICU)
o Elevate head of bed ± 30°.
o Maintain PaCO2 at 30–35 mmHg; intubate and ventilate if necessary.
o Avoid fluid overload.
o Mannitol, IV, 250 mg/kg administered over 30–60 minutes.
o Dexamethasone, IV, 0.5 mg/kg 12 hourly.

Contraindications to performing LP:

• Focal neurological signs (strabismus, focal convulsions, unequal pupils…)
• Papilledema
• Glasgow coma scale less than 8/15 or Blantyre scale <3

--|Tetanus
Definition
Tetanus is an acute spastic paralytic illness caused by tetanospasmin, the neurotoxin produced
by Clostridium tetani. The toxin prevents neurotransmitter release from spinal inhibitory neurons.
It occurs in several clinical forms including generalized, localized and neonatal disease.
Cause
• Clostridia tetani

Signs and symptoms:

• Trismus ( lock jaw)
• Opisthotonos ( Rigid arching of back mucles)
• Dysphagia
• Laryngospasm
• Autonomic nervous system instability with hypertension, tachycardia and dysrhythmias

Diagnosis:
The diagnosis is made on clinical grounds.
• Unimmunised/incompletely immunised child.
• History of wound/trauma or unhygienic care of umbilical cord/stump.
• Trismus/False smile
• Stiffness of the neck, back and abdominal muscles.
• Pharyngospasm, laryngospasm, dysphagia, inability to suck, chew and swallow which
severely compromises feeding and eating activities.
• Spontaneous muscle contractions/spasms or muscle contractions/ spasms triggered by
minimal stimuli such as touch, sound, light or movement.
• No involvement of sensorium, i.e. consciousness is not disturbed.
• Autonomic nervous system instability with hypertension, tachycardia and dysrhythmias

Complications
• Asphyxia and Brain damage due to hypoxia spasms
• Inability to suck, chew and swallow leading to dehydration.
• Heart failure from arrhythmias
• Pneumonia, Laryngospasms, Respiratory failure
• Fractures

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Investigations:
• No specific lab test is available to determine the diagnosis of tetanus
• Other tests done to rule out meningitis, rabies, strychnine poisoning e.t.

Management:
Non-Drug Treatment
• Admit to high or intensive care unit/High Dependency unit, in a tertially hospital
• Oxygen to prevent hypoxia and ventilatory support if needed
• Monitor:
o Temperature ○ blood pressure
o Respiration ○ blood glucose
o Heart rate ○ electrolytes
o Blood gases ○ acid–base status
o SaO2
• Protect the patient from all unnecessary sensory and other stimuli
• Ensure adequate hydration and nutrition
• Wound care and debridement/umbilical cord care
• Educate parents/caregivers regarding prevention of tetanus by vaccination

Pharmacological
• Tetanus immunoglobulin, IM, 500–2 000 IU as a single dose
• Eliminate toxin production
o Benzylpenicillin (Penicillin G), IV, 50000IU/kg/day ( Neonate 12hourly and in older
children 6hourly)
o Metronidazole 40mg/kg/day IV in three divided doses for 7-10 days
Neonates less than 7 days old:
Weight Dosage
<1.2 kg 7.5mg/kg/ i.v 48 hours
1.2-2 kg 7.5kg/kg ivi 0.d
> 2kg 15kg/kg/day 12 hourly
Neonates 7 days and older
Weight Dosage
<1.2kg 7.5kg/kg 48 hourly
1.2-2 kg 15mg/kg/day 12 hourly
>2kg 30mg/kg/day 12 hourly
Infants and children Metronidazole 30mg/kg/24 hr ivi 6 hourly
o Diazepam, IV, 0.1–0.2 mg/kg/dose 4–6 hourly, titrated according to response.
Do not exceed dose of 10 mg/dose. Alternating with chlorpromazine 0.5 mg/kg 6
hourly PO (NGT)
After recovery from tetanus, patients should be actively immunized as the disease does not confer
immunity
NB: Don’t remove the NGT from the child until at least one-week seizure free.

Prevention of tetanus

Minor Wounds:
• Children with clean minor wounds do not require tetanus immunoglobulin or antibiotics
• Tetanus vaccine should be given, except in fully immunized patients who have received a
booster within the past 5 years
For more severe wounds
• If child with penetrating wound is fully not immunized give tetanus immunoglobulin
o < 5 years 75 IU
o 5–10 years 125 IU
o > 10 years 250 IU
o Tetanus toxoid vaccine (TT), IM, 0.5 mL

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o phenoxymethylpenicillin, oral, 12.5 mg/kg/dose 6 hourly for 7 days
OR
o Erythromycin, oral, 6.25–12.5 mg/kg/dose, 6 hourly for 7 days (if allergic to penicillins)

Recommendation
• Refer all cases of tetanus to intensive care /High dependency unit

--|Hepatitis
Definition
It is an acute inflammation of the liver with varying degrees of hepatocellular necrosis. The most
commonly known are hepatitis A, B and less commonly C, D and E viruses. Hepatitis A

Cause:
• Hepatitis A RNA (virus)
• Vaccination does exist but provided in developed countries
• HAV is spread via the faecal-oral route

Symptoms and signs:

• Abrupt onset with nonspecific symptoms, such as fever, malaise, anorexia, vomiting, nausea,
abdominal pain or discomfort, and diarrhoea.
• Jaundice occurs one week after onset of symptoms, along with choluria (bilirubin in the urine)
and mild hepatomegaly.
• Young children are asymptomatic; Symptomatic 30 percent of infected children younger
than six years, jaundice usually lasts for less than two weeks. Conjugated bilirubin and
aminotransferases return to normal within two to three months
• In contrast, older children and adults with HAV infection are usually symptomatic for several
weeks. Approximately 70 percent are jaundiced, and 80 percent have hepatomegaly.
Symptoms last for a longer time
• The most common extrahepatic manifestations include an evanescent rash (11 percent) and
arthralgias (14 percent). and less common extrahepatic manifestations include vasculitis,
arthritis, optic neuritis, transverse myelitis, encephalitis, and bone marrow suppression

Complications:
• Acute liver failure is rare in developed countries , but account for 60% of liver failure in
Latin America
• Death

Diagnosis: Made based on clinical symptoms and signs

Investigations
• Liver Function tests
• Anti-HAV IgM in a patient with the typical clinical presentation
• Serological tests for Hepatitis A

Management:
• improved sanitary conditions, adherence to sanitary practices, hand washing +++ (virus
may survive for up to four hours on the fingertips )
• No specific treatment for Hepatitis A
• Bed rest may be recommended but does not alter the course of the illness
• Human immunoglobulin prophylaxis for those who had contact
• Isolate patient of Hepatitis A for 7–10 after the onset of jaundice
Patients rarely require hospitalization except for those who develop fulminant hepatic failure.

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Hepatitis B

Cause:
• Hepatitis B DNA virus (HBV)
• Perinatal transmission is the most common cause of chronic infection
• Infants born to women with HBV infection (HBeAg positive or negative) should be tested for
hepatitis B at 9-18 months even if vaccinated ( at least 5% develop chronic HBV)
• All pregnant women should be screened for HBV infection

Symptoms and signs:

Infection with HBV is associated with characteristic changes in the serum levels of hepatitis B
antigens and antibodies. These markers are used to define different clinical states

Acute hepatitis
• Acute HBV infection in children ranges from asymptomatic infection to fulminant hepatitis.
• Constitutional symptoms, anorexia, nausea, jaundice and right-upper-quadrant discomfort.
• The symptoms and jaundice generally disappear after one to three months, but some
patients have prolonged fatigue even after normalization of serum aminotransferase
concentrations. Older children and adolescents have mild constitutional symptoms during
acute HBV infection.

Chronic hepatitis
• Commonly asymptomatic and grow and develop normally.
• Vague right upper quadrant discomfort and fatigue, loss of appetite, jaundice.
• Extrahepatic manifestations including polyarteritis nodosa and glomerulonephropathy.

Diagnosis:
• Based on persistence of HBsAg for more than six months; IgG anti-HBc is positive, while IgM
anti-HBc is negative
• Some carriers have large numbers of HBV in their serum and liver without symptoms or signs
and without antibodies in their serum.

Investigations
Table 28. Serologic responses to HBV infection

• Left panel: Acute infection:

o HBeAg (hepatitis B e antigen), HBsAg (hepatitis B surface antigen), and HBV DNA
beginning in the preclinical phase.

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 TREATMENT GUIDELINES 93
o IgM anti-HBc (hepatitis B core antigen) appears early in the clinical phase; the
combination of this antibody and HBs Ag makes the diagnosis of acute infection.
o Recovery: normalization of the serum ALT, the disappearance of HBV DNA, HBeAg to
anti-HBe seroconversion, and subsequently HBsAg to anti-HBs seroconversion and switch
from IgM to IgG anti-HBc. Then previous HBV infection is characterized by anti-HBs and
IgG anti-HBc.

• Right panel: Chronic infection:

o Persistence of HBsAg for more than six months after acute infection
o Persistence of HBeAg (for a variable period), HBsAg, and HBV DNA in the circulation
o Anti-HBs is not seen.

• Other tests
o Liver Function tests (Prothrombin time, Bleeding time)
o Glycemia if severe
o HBV tests (refer to figure )
o Blood ammonia
o Urea and electrolytes in cases of liver failure
o CBC to determine severity of anaemia

Complications:
• Chronic Liver Disease: In children born from infected mother 76 percent of them are HBeAg
positive at 10 years of age. The frequency of spontaneous seroconversion increases during
puberty (Cirrhosis)
• Liver failure (hepatic encephalopathy)
• Portal hypertension (GIT bleeding, hematemesis and melena stools)
• Hepatorenal syndrome /reduced glomerular filtration rate.
• Liver cancer

Management:
General measures:
• Counseling of the patient about alcohol use in adolescents and family, surveillance for
disease progression and development of complications,
• Regular monitoring of liver function tests every 3 months
• Patients who are in the inactive carrier phase of hepatitis B infection (ie, HBsAg positive,
HBeAg negative, anti HBe positive, persistently normal ALT/AST levels, serum HBV DNA
<10(5) copies/mL) should undergo monitoring of liver biochemical tests every 6 to 12
months.

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Selection of patients for treatment:

• Treatment is generally considered in patients with HBV DNA positive chronic hepatitis who
are in the immune active phase (usually defined as ALT >2 x ULN and HBV DNA >20,000
IU/mL or 10(5) copies/mL, for at least six months)
• Children with ALT values greater than 10 times the upper limit of normal but with concomitant
low HBV DNA levels may be in the process of spontaneous seroconversion, and may not
require treatment. These patients should be observed for several months with serial serologic
testing.
• If there is evidence of hepatic decompensating, such as jaundice or coagulopathy, treatment
should be initiated earlier
• Several other considerations may be relevant to treatment decisions ( co-infected with HCV,
HIV or HDV)

Choice of treatment:
• Lamivudine, TDF and interferon (IFN), are licensed for use in children Adefovir approved for
use in those over 12 years of age.
• IFN alfa as the first-line treatment for the patients with serum ALT more than twice the upper
limit of normal, have positive HBeAg, who are committed to adhering to the treatment, and
have no comorbid diseases that might be exacerbated by an immunostimulatory agent
• If the patient does not respond to IFN alfa (defined by detectable HBV DNA and elevated
serum ALT six months after completion of the course of IFN alfa), a nucleoside/nucleotide
analog such as lamivudine or adefovir can be used – this shall be considered as primary
treatment if IFN alpha not available

--|Acute liver failure

Definition
Acute liver failure is the rapid deterioration of liver function due to massive necrosis of liver cells
resulting into coagulopathy and alteration in the mental status of a previously healthy individual.

Causes:
• Hepatotoxicity due to drugs like acetaminophen
• Viral (hepatitis, cymegalovirus, hemorrhagic fever viruses, herpes simplex virus)
• Autoimmune hepatitis
• Miscellaneous causes
• Poisons e.g. Mushrooms

Signs and symptoms:

• Malaise
• Vomiting
• Anorexia
• Stupor/Encephalopathy
• Foetor hepaticus
• Bleeding tendency
• Ascites
• Jaundice often present but not always
• Ascites

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Diagnosis: Based on the above clinical signs and symptoms

Investigations:
• Raised or low liver enzymes, low serum albumin, raised bilirubin, raised blood ammonia
• Hypoglycaemia
• Prolonged prothrombin time
• Low fibrinogen
• FBC
• Urea-creatinine and electrolytes

Management

Non-pharmacological treatment:
• Admit to high care or intensive care unit
• Monitor blood pressure, urine output, heart rate, neurological state, respiration, gastrointestinal
bleeding, haematocrit, blood glucose (3 hourly if comatose), acid–base status, liver and
renal functions, coagulation, competence (INR), electrolytes: sodium, potassium, calcium and
phosphate
• Maintain hydration
• Aim to reduce ammonia production by the gut and optimise renal excretion for patients with
encephalopathy
• Withdraw protein completely initially followed by restricted intake if level of consciousness
improves, i.e. 0.5–1 g/kg/24 hours
• Stop medium chain triglyceride supplements but maintain an adequate energy intake
• Stop sedatives, diuretics and hepatotoxic drugs, if possible

Pharmacological treatment:
• Lactulose, oral, 1 g/kg/dose 4–8 hourly via nasogastric tube, then adjust dose to produce
frequent soft stools daily (to reduce intestinal protein absorption)
OR
• Polyethylene glycol solution with sodium sulphate and electrolytes, oral/via nasogastric tube,
10–25 mL/kg/hour over 6 hours. Follow with lactulose.
• Neomycin, oral, 12.5 mg/kg/dose 6 hourly for 5 days
• Mannitol, IV, 250 mg/kg administered over 30–60 minutes (if cerebral Oedema with serum
osmolality < 320)
• Fresh frozen plasma, IV, 20 mL/kg over 2 hours (pre-operative)
• Vitamin K1, IV/oral, 2.5–10 mg daily never gives IM
o Monitor response to vitamin K1 with INR and PTT
• Platelet transfusion (if platelet count < 10 x 109/L or if < 50 and with active bleeding
• Ranitidine, IV/oral 3–4 mg/kg/day 8 hourly
OR
• Omeprazole, oral initiated by the specialist;
o Neonate 1–2 mg/kg, 12– 24 hourly
o 1 month–2 years 5 mg, 12 hourly
o 2–6 years 10 mg, 12 hourly
o 7–12 years 20 mg, 12 hourly

AND/OR
• Sucralfate, oral, 250–500 mg 6 hourly
• Dextrose 10%, IV bolus 2 mL/kg (for patient with hypoglycaemia
• Ringers lactate with dextrose 5%, IV, 60–80mL/kg/day, ensure a minimum of 3–6 mmol/
kg/day of potassium

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• Avoid diuretics
• Packed red cells, 10 mL/kg over 3 hours if haemoglobin < 7 g/dL For anaemia
• For sedation, if essential;
o Midazolam, IV, 0.1 mg/kg Amelioration of liver injury, especially in idiopathic/toxin
cases
o Ampicillin, IV, 25 mg/kg/dose, 6 hourly + Cefotaxime, IV, 25–50 mg/kg/dose, 6–8
hourly + Nystatin 100 000 units/mL, oral, 0.5 mL after each feed. Keep nystatin in
contact with affected area for as long as possible
Recommendation
• All cases of liver failure should be managed in a referral /Tertially hospital

--|Septicaemia
Definition
Septicemia is a suspected or proven infection plus an uncontrolled systemic inflammatory response
syndrome, SIRS (e.g., fever, tachycardia, tachypnea, and leukocytosis).

Causes:
• Bacterial: (Streptococcus pneumoniae, Haemophilus influenzae type b, Neisseria meningitidis,
group A streptococcus, S. aureus, Salmonella)
• Viral infection: (influenza, enteroviruses, hemorrhagic fever group, HSV, RSV)
• Encephalitis: (arboviruses, enteroviruses, HSV)
• Vaccine reaction (pertussis, influenza, measles)
• Toxin-mediated reaction (toxic shock, staphylococcal scalded skin syndrome)

Clinical evaluation:
• Assess Air way, Breathing ( RR, signs of respiratory distress and pulse oximetry),
• Circulation (HR, BP, Skin for signs of dehydration, JVP)
• SIRS a is systemic inflammatory response with at least two of the following four criteria, one
of which must be abnormal temperature or leucocyte count:
o Core temperature of < 36ºC or > 38.5ºC,
o Tachycardia,
o Tachypnoea,
o Increased WBC (>12,000/mm3) or decreased (<4000/mm3) PLUS, one of the following:
 Cardiovascular dysfunction,
 Acute respiratory distress syndrome, or
 ≥ 2 other organ dysfunctions
• Identify source of infection e.g pneumonia, abdominal abscess, meningitis e.t.c
• Assess organ function e.g. CNS (LOC, focal signs) , Renal function for urinary output

Diagnosis: Based on signs and symptoms complemented by laboratory investigations

Clinical
On examination, look for the following:
• Fever with no obvious focus of infection
• Blood film for malaria is negative
• No stiff neck or other specific signs of meningitis (or a lumbar puncture for meningitis is
negative)
• Signs of systemic upset (e.g. inability to drink or breastfeed, convulsions, lethargy or vomiting
everything)

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• Purpura may be present.
• Always fully undress the child and examine carefully for signs of local infection before
deciding that no cause can be found.

Laboratory evaluation
• Identify SIRS; CBC and White-cell differential
• Identify source of infection; Blood and urine culture and sensitivity, sputum, CSF analysis,
Chest radiography and Ultrasonography when indicated
• Assess organ function;
o Renal function: Electrolytes, BUN, creatinine
o Hepatic function: Bilirubin, AST, alkaline phosphatase
o Coagulation: INR, PTT, platelets

Complications:
• Convulsions
• Confusion or coma
• Dehydration
• Multiorgan failure
• Disseminated intravascular coagulation(with bleeding episodes)
• Pneumonia
• Septic shock; which is the main cause of death

Management:
• Assess for Air way, Breathing, Circulation, and Dehydration followed by appropriate
management.
• Treat the source of sepsis e.g abscess, peritonitis
• First choice treatment
o Neonates: Cefotaxime, IV, 75 mg/kg/dose, 8 hourly
o Children > 1 month: Ceftriaxone, IV, 50 mg/kg/dose, 12 hourly.
Alternative:
o Give IV ampicillin at 50 mg/kg every 6 h plus IV gentamicin 7.5 mg/kg once a day for
7–10 days
• If staphylococcal infection is suspected use Cloxacillin, IV, 50 mg/kg/dose 6 hourly for at
least 14 days, (longer courses often required).

Monitoring
• The child should be checked by nurses at least every 3 hours and by a doctor at least twice
a day.
• Check for the presence of complications such as shock, reduced urine output, signs of
bleeding (petechiae, purpura, bleeding from venepuncture sites), or skin ulceration.

Recommendation:
• Immunization with the conjugate H. influenzae type b and S. pneumoniae vaccines is for all
infants

N.B Use of Corticosteroids in patients with sepsis has adverse effects like hyperglycemia and
immunosuppression thus leading to nosocomial infection and impaired wound healing. Studies reveal
that early use of short-course, high-dose corticosteroids does not improve survival in severe sepsis.

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--|Septic arthritis
Definition
Septic arthritis is defined as an acute articular suppurative infection caused by pyogenic
microorganisms. It may occur as a result of haematogenous seeding of the synovium during
transient periods of bacteraemia and often part of a generalised septicaemia which may
involve more than one joint

Table 29. Causes of septic arthritis

Neonates S.aureus, Group B. Streptococci, E. coli, fungi

Infants/children S.aureus, H. influenzae, Group A Streptococci, S. pneumonia
Children - Sexually active N. gonorrhoea
Brucella, tuberculosis, atypical mycobacteria, fungi and other
Chronic septic arthritis
uncommon organisms

Risk factors:
• Trauma
• Rheumatoid arthritis or osteoarthritis
• Sickle cell disease
• Skin infections
• Sexual activity
• Immune deficiency (HIV, etc.)

Symptoms and signs:

• Fever, local pain, loss of function and toxic/septic looking child.
• In neonates and infants signs and symptoms may be nonspecific and subtle (not well
remarked)
• Malaise, irritability, feeding problems and pseudoparalysis
• Local tenderness, warmth, swelling at a joint with restriction of passive and active movement.
• Poor weight gain

Old infants and children:

• Acute onset of pain, warm, and swollen joint
• Usually monarticular and affecting large weight-bearing joints (knee, shoulder or hip)

Complications:
• Sepsis
• Osteomyelitis
• Destruction of articular cartilage, permanently damaging the joint
• Secondary infectious site (bacterial endocarditis, brain abscess, etc.)

Investigations:
• Joint ultrasonography
• Aspiration of pus under sonar guidance for microscopy, Gram stain, culture and sensitivity.(
Done by a specialist/orthopedic surgeon)
• FBC and CRP
• X-ray
• Blood culture and sensitivity before starting antibiotic treatment
• Scintigraphy
• MRI

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Management:
Non- pharmacological management:
• Emergency surgical drainage of pus from infected joints

Pharmacological management:
Antibiotics: Minimum duration of therapy is 4–6 weeks.
Neonates:
• Cloxacillin IV:
o 1st -2nd week of life: 50 mg/kg/dose 12 hourly,
o 3rd – 4th week of life: 50mg/kg/dose 8 hourly
o > 4 weeks of life 50mg/kg/dose 6 hourly + Cefotaxime, IV, 50 mg/kg/dose ( preterm
12 hourly, 1st week of life 8 hourly and > 2 weeks 6 hourly)
Infants and children:
• Cloxacillin IV 50mg/kg/dose, 6 hourly PLUS Cefotaxime IV 25–50mg/kg/dose, 6 hourly
• Do arthrocentesis and culture to treat appropriately to sensitivities
Antipyretics and anti-inflammatories:
• Ibuprofen, oral, 5–10 mg/kg/dose, 6 hourly

Recommendations:
• Penicillin antibiotic given for up to 6 weeks, with the first 2 weeks administered intravenously
followed by a switch to oral treatment if an oral option exists and clinical signs, symptoms,
and inflammatory markers are settling
• IV antibiotics regimen is adjusted based on the results of culture and sensitivity testing
Alternative:
• Vancomycin 50mg/kg/day divided in 3 doses. Maximum dose is 1g/dose

--|Acute Osteitis/Osteomyelitis
Definition
Osteitis is inflammation of the bone while osteomyelitis is an infection of the bone
Most cases result from haematogenous deposition of organisms in the bone marrow after a
transient bacteraemia episode. Osteomyelitis most commonly begins in the metaphyses of long
bones which are highly vascular. The spread of infection through the epiphysis can result in
septic arthritis.

Causes:
• Neonates: S. aureus, Group B Streptococci, Gram negative (E. coli).
• Infants/children: S. aureus, H. influenzae, Group A Streptococci, S. pneumoniae.
• Traumatic direct infection: P. aeruginosa (penetrating foot wounds).
• Co-existing medical conditions e.g. diabetes, HIV, leucopoenia: M. tuberculosis, fungi.
• Sickle cell disease: Salmonella, pneumococcus.

Diagnostic criteria

Clinical
• Local pain and tenderness, loss of function, general toxicity and fever.
• If lower extremities are involved (development of a limp or refusal to bear weight).
• In neonates, early signs may be subtle or non-specific, e.g. irritability, feeding problems and
pseudoparalysis.
• Investigate for multi-organ disease, e.g. endocarditis, pericarditis and pneumonia.

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Investigations
• Full blood count (raised white cell count)
• CRP raised
• Aspiration of pus for microscopy, Gram stain, culture and sensitivity.
• Blood culture
• X-ray after 2 weeks.
• Bone scan (Tc99).
• MRI.

General Management
• Immobilize affected limb in position of function.
• Supportive and symptomatic care.

Medications
• Minimum duration of therapy: 4–6 weeks.
• Initiate IV antibiotic treatment immediately as diagnosis is made and blood and pus
specimens have been collected.
• Adjust antibiotic therapy based on culture results or if response to antibiotic treatment is
unsatisfactory.
• Where a single agent has been found to be sensitive, continue treatment on that single
agent.
• Continue with IV antibiotics until there is evidence of good clinical response and laboratory
markers of infection improve. Once clinical improvement and inflammatory markers have
normalized, patients can be switched to oral antibiotic therapy.
• Ongoing fever suggests an undrained focus of pus.

Neonates:
• Cloxacillin, IV, 50 mg/kg/dose
o If 1st week of life: 12 hourly.
o If 2nd–4th week of life: 8 hourly.
o If > 4 weeks old: 6 hourly.
PLUS
• Cefotaxime, IV, 50 mg/kg/dose.
o Preterm: 12 hourly.
o If 1st week of life: 8 hourly.
o If > 2 weeks old: 6 hourly.

Infants and children:

• Cloxacillin, IV, 50 mg/kg/dose 6 hourly.
PLUS
• Ceftriaxone, IV, 50 mg/kg/dose 12 hourly.

Special Circumstances
• If MRSA, replace Cloxacillin with vancomycin.
o Vancomycin IV, 15 mg/kg/dose administered over 1 hour given 8 hourly (Monitor renal
function)
• Penetrating foot bone injuries: replace cefotaxime with ceftazidime plus an aminoglycoside:
o Ceftazidime, IV, 50 mg/kg/dose 6 hourly.
PLUS
o Gentamicin, IV, 6 mg/kg once daily.

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Oral antibiotics
• Can transition to oral therapy once there is sustained clinical improvement, resolution of
fever, normal white cell count and CRP 4-6 weeks of treatment.
• Flucloxacillin, oral, 25 mg/kg/dose, 6 hourly.
Referral: Refer or discuss all cases with an orthopaedic surgeon

References
1. James A. Russell. Management of Sepsis: N Engl J Med 2006; 355:1699-1713
2. WHO: POCKET BOOK OF Hospital care for children
3. Dellinger RP, Carlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for management
of severe sepsis and septic shock. Crit Care Med 2004;32:858-73.
4. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe
sepsis and septic shock. N Engl J Med 2001;345:1368-77.
5. Meduri GU, Headley AS, Golden E, et al. Effect of prolonged methylprednisolone therapy
in unresolving acute respiratory distress syndrome: a randomized con-trolled trial. JAMA
1998;280:159-65.
6. Steinberg KP, Hudson LD, Goodman RB, et al. Efficacy and safety of cortico-steroids for
persistent acute respiratory distress syndrome. N Engl J Med 2006;354:1671-84.

--|Salmonella infections (typhoid fever):

Definition: is a systemic infection with the bacterium Salmonella enterica serotype typhi.

Causes and risk factors

• Salmonella typhi causes typhoid. The bacteria survives only in humans.
• More than 95% of all transmission occurs through food, especially eggs.
• Water contaminated by faeces from an infected person carries the disease.
• Symptoms are most severe in infants and those with other comorbidities
• Immune compromised patients are frequently affected and have recurrences.

Signs and symptoms

Initial signs and symptoms:
• Prolonged or high fever (≥38.8), with profuse sweating, in a previously healthy individual,
lasting>1 week; the person may become delirious and possible convulsions
• A slower pulse rate than expected with the level of fever
• Dull frontal headache
• Poorly localized abdominal pain, constipation, anorexia, nausea and diarrhoea later in the
illness; may be accompanied by frank bleeding
• A coated tongue, abdomen tenderness and hepatosplenomegaly are common findings
• Jaundice may occur
Signs of complications
• Intestinal perforation—abdominal tenderness, with sudden increase in pulse rate and
hypotension
• Altered mental status
NB: there is no typhoid fever without fever or hypothermia in infants !!!

Diagnosis:
On examination, key diagnostic features of typhoid are:
• Fever with no obvious focus of infection
• No stiff neck or other specific signs of meningitis, or a lumbar puncture for meningitis is
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negative (note: children with typhoid can occasionally have a stiff neck
• Signs of systemic upset, e.g. inability to drink or breastfeed, convulsions, lethargy,
disorientation/confusion, or vomiting everything
• Rose spots on the abdominal wall in light-skinned children
• Hepatosplenomegaly, tense and distended abdomen.

Note:
• Typhoid fever can present atypically in young infants as an acute febrile illness with shock
and hypothermia.
• The differential diagnosis is broad and includes malaria, amoebiasis, dengue fever,
leishmaniasis, and other causes of bacterial gastroenteritis

Laboratory evaluation
• FBC (may show leukocytosis or leucopenia, thrombocytopenia, severe anaemia follows
intestinal bleeding)
• Blood culture( Gold standard) will isolate the bacteria during the first 2 weeks of illness
• Stool culture will isolate the bacteria during the later period of illness.
• Plain X-rays of abdomen in erect position will show gas under the diaphragm if there is
gut perforation
Note:
• Serologic tests such as the Widal test are of limited clinical utility in endemic areas because
positive results may represent previous infection. Positive serology alone shall never be a
base for treatment of typhoid fever

Complications:
• GIT: gastrointestinal bleeding, intestinal perforation, abdominal mass due to abscess
formation
• CVS: Asymptomatic electrocardiographic changes, Myocarditis, Shock
• CNS: Encephalopathy, Delirium, Psychotic behaviour, Meningitis, Impairment of coordination
• Haematologic: Anaemia, Disseminated intravascular coagulation
• Respiratory: Bronchitis, Pneumonia (Salmonella enterica serotype typhi, Streptococcus
pneumoniae)
• Others: Focal abscess, Pharyngitis, Relapse and Chronic carriage
• Chronic carriers frequently have high serum antibody titers against the Vi antigen, which is
a clinically useful test for rapid identification of such patients

Management:
Management objectives:
• Reduce the fever
• Prevent dehydration
• Prevent the spread of the disease in the community

Nonpharmacological management
• Encourage adequate oral fluids or initiate IV infusion.
• Ensure appropriate nutrition.
• Tepid sponging with lukewarm water (32-35oC) to reduce the fever.
• Isolate the patient
• Identify and treat all carriers

Pharmacological
• Paracetamol to reduce fever
• Rectal Diazepam if there are convulsions

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• blood transfusion in case of severe bleeding
• Ciprofloxacin ivi 10mg/kg/dose (max400mg) 12 hourly or 15mg/kg (max500mg) orally
12 hourly for 7-10 days
• Ceftriaxone 50 mg/kg 12 hourly IV for 7-14 days OR
• Cefotaxime 50 mg/kg IV 6 hourly for 7-14days

Follow up review: check for the following:

• Efficacy of treatment: fever
• Perforation (abdominal pain, tenderness,)
• Myocarditis (heart rate, gallop rhythm )

--|Varicella (chicken pox)

#? Transfer to Dermatology

Definition
An acute, highly contagious, viral disease caused by herpes varicella-zoster.
It spreads by infective droplets or fluid from vesicles. One attack confers permanent immunity.
Varicella is contagious from about 2 days before the onset of the rash until all lesions crusted.
Re-activation of the virus may appear later as herpes zoster or shingles (in children, consider
immunosuppression if this occurs). Incubation period is 2–3 weeks.

Complications are more common in immunocompromised patients and include:

• Secondary skin infection,
• Pneumonia,
• Necrotizing fasciitis,
• Encephalitis,
• Haemorrhagic varicella lesions with evidence of disseminated, intravascular coagulation.
• Two important bacteria causing complications are Staphylococcus aureus and Streptococcus
pyogenes

Diagnostic criteria
Clinical
• Mild headache, fever and malaise.
• Characteristic rash.
• The lesions progress from macules to vesicles in 24–48 hours.
• Successive crops appear every few days.
• The vesicles, each on an erythematous base, are superficial, tense ‘teardrops’ filled with
clear fluid that dries to form fine crusts.
• The rash is more profuse on the trunk and sparse at the periphery of extremities.
• At the height of eruption, all stages (macules, papules, vesicles and crusts) are present at
the same time.
• The rash lasts 8–10 days and heals without scarring, unless secondarily infected.
• Mucous membranes may be involved.
• Pruritus may be severe.
• Patients are contagious from 1–2 days before onset of the rash until crusting of lesions

Management
• Isolate the patient.
• Maintain adequate hydration.

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Medications
• Antiviral therapy
• Indicated for immunocompetent patients with complicated varicella and for all
immunocompromised patients.
• Initiate as early as possible, preferably within 24 hours of the appearance of the rash.
• Neonates, immunocompromised patients and all cases with severe chickenpox (not
encephalitis)
• Acyclovir, oral, 20 mg/kg/dose 6 hourly for 7 days. Maximum dose: 800 mg/dose.
• In severe cases or in cases where oral medicine cannot be given: Acyclovir, IV, 8 hourly
administered over 1 hour for 7 days
o If 0 – 12 years: 20 mg/kg/dose 8 hourly.
o If > 12 years: 10 mg/kg/dose 8 hourly

For mild pruritus:

• Calamine lotion, topical, applied 8 hourly.

For severe pruritus:

• Less than 2 years: Chlorphenamine, oral, 0.1 mg/kg 6–8 hourly for 24–48 hours.
• Over 2 years: Cetirizine, oral, 2.5-5 mg 12-24 hourly.

Secondary skin infection

• Cefadroxil, oral, 15 mg/kg/dose, 12 hourly for 5 days.
• Prophylaxis: Post exposure prophylaxis must be given to:
o Neonates whose mothers develop varicella from 5 days before delivery to 2 days after
delivery:
o Varicella-zoster immunoglobulin, IM, 1 mL (100 units) given within 96 hours of exposure.
o If varicella-zoster immunoglobulin is not available: Acyclovir, oral, 20 mg/kg/dose 6
hourly for 10 days.
o Note: In neonates, prophylaxis may not prevent disease.

Infants and children > 28 days

• Immunocompromised children exposed to varicella:
o Acyclovir, oral, 20 mg/kg/dose 8 hourly for 10 days given in the second week after
exposure.
• Hospitalised immunocompetent children exposed to varicella (to limit spread).
o Acyclovir, oral, 20 mg/kg/dose 8 hourly for 10 days given in the second week after
exposure.
Referral: All patients with complications.

--|Mumps
Definition: A viral infection primarily involving the salivary glands.
Incubation period: 14–21 days.

Signs and symptoms:

• Fever.
• Pain on opening the mouth or eating.
• About two days later a tender swelling appears below the ears at the angle of the jaw.
Often first on one side and later on the other.
• The swelling disappears in about 10 days.

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General measures
• Bed rest during febrile period.
• Advise on oral hygiene.
• Recommend plenty of fluids and soft food during acute stage.
• Patient is infectious from 3 days before parotid swelling to 7 days after it started.
• Isolate until swelling subsides.
• Children may return to school 1 week after initial swelling.
Medication
Children
• Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required.

Referral
• Abdominal pain (to exclude pancreatitis).
• Painful swollen testes (orchitis).
• Suspected meningoencephalitis.

ENDOCRINE SYSTEM CONDITIONS

--|Diabetes mellitus
Definition
Diabetes mellitus is disorder of absolute or relative insulin deficiency that results in increased
blood glucose and disruption of energy storage and metabolism. Diabetes Mellitus is generally
divided into two classifications: Diabetes Mellitus I and Diabetes Mellitus Type II.

Diabetes Mellitus Type I: This results from the destruction of the pancreatic beta cells that leads to
absolute insulin deficiency. Type IA is secondary to the autoimmune destruction of the beta cells.
Type IB is secondary to non-autoimmune destruction of the beta cells. Type I diabetes accounts
for approximately 2/3 of the new diagnosis of diabetes in patients < 19 years old. There is a
component of genetic susceptibility and close relatives of patients with type I DM are at higher
risk of developing the disease.

Diabetes Mellitus Type II: This is secondary to varying degrees of insulin resistance and insulin
deficiency and is related to both genetic and environmental influences including predisposing
medications such as steroids and some ARVs. It is the most common type of diabetes mellitus
in adults.

Neonatal diabetes: This is defined as persistent hyperglycaemia occurring in the first months of
life that lasts more than 2 weeks and requires insulin therapy for management. The majority of
affected infants are small for gestational age and present with weight loss, volume depletions,
hyperglycaemia and glycosuria with or without ketonuria and ketoacidosis.

Signs and Symptoms

History of:
• Polyuria: This occurs when the serum glucose concentration rises above 180 mg/dl
exceeding the renal threshold for glucose and leads to increased urinary glucose excretion
and a subsequent osmotic diuresis. This may present as nocturia, bedwetting, or daytime
incontinence in a previously toilet trained child, or heavy diapers.

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• Polydipsia: This is secondary to increased thirst from increased serum osmolality and
dehydration.
• Polyphagia: This is due to an increased appetite that occurs initially secondary to loss of
calories from glycosuria. This symptoms is not always present.
• Weight loss: This is due to hypovolemia and increased catabolism.
• Weakness/Lethargy with ultimate progression to coma: This is secondary to hypovolemia
and electrolyte disturbances including progressive acidosis.
• Visual disturbances: This is secondary to osmotic changes in the lens.
• Further history to exclude other co-existing autoimmune disease such as hypothyroidism,
vitiligo, rheumatoid arthritis, etc., and to further ask about family history of endocrinopathies
or autoimmune diseases
Physical examination:
• Full general and systemic examination
• Fundoscopy: to rule out diabetic retinopathy.
• Foot examination: for features of diabetic neuropathy and diabetic wounds

Diagnosis:
Clinical: The diagnosis should be suspected based on the signs and symptoms described above.
Any of the above signs or symptoms should prompt further investigations.

Investigations:
• Blood sugar: Diagnostic criteria for diabetes mellitus:
o Symptoms of DM plus random plasma glucose ≥200 mg/dl (11.1 mmol/L) OR
o Fasting plasma glucose ≥126 mg/dl (7.0 mmol/L). Fasting is defined as no oral intake
for at least 8 hours.
OR
o Two-hour plasma glucose ≥200 mg/dl during an oral glucose tolerance test (OGTT) as
described by the WHO.
OR
o HgA1C > 6.5 percent. This laboratory should be performed in a certified laboratory
with an assay standardized to the diabetes control and complications trial (DCCT).
• Additional studies to evaluate severity and complications of the disease:
o Blood gas if concern for diabetic ketoacidosis (where) available.
o Electrolytes
o Renal function tests (urea and creatinine) to evaluate for diabetic nephropathy and
dehydration.
o Urine analysis to check for glycosuria, ketones, and protein
o HbA1c: This can be used for diagnosis (see below) or to assess severity of disease and
to assess response to therapy.
o Lipid profile
o Thyroid-stimulating hormone (TSH): This should be performed in type 1 diabetics as
autoimmune diseases may occur together.

Complications:
Short-term complications:
• Diabetic ketoacidosis (DKA): Occurs more frequently in type I diabetes mellitus, but may
occur in some forms of type I diabetes mellitus.
• Hyperosmolar hyperglycaemic state (HHS): Occurs in type II diabetes mellitus.
• Insulin resistance secondary to hyperglycaemia: This occurs in both type I and type II diabetes
mellitus.
• Infections due to immunosuppression and commonly include oral candidiasis and urinary
tract infections.

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• Death: Patients presenting with DKA or HHS have a high mortality rate.

Long Term complications:

• Vascular complications including both microangiopathy and macroangiopathy:
o Nephropathy
o Retinopathy
o Neuropathy
o Cardiovascular disease
o Hypertension
• Dyslipidaemia
• Growth retardation or obesity depending on the insulin therapy. Patients may also have
delayed puberty secondary to poor growth.
• Psychiatric disorders including depression related to their chronic disease.

Management:
General objectives:
• Maintain normal glycaemia with insulin therapy or oral medications (in type II diabetes
mellitus) to prevent both the signs and symptoms of uncontrolled hyperglycaemia and the
complications mentioned above.
Non pharmaceutical management
• Assess A-B-C-D (Airway, Breathing, Circulation, Disability)
• If patient has signs or symptoms of diabetic ketoacidosis (DKA) or hyperosmolar
hyperglycaemic state, this is an emergency and treatment must be initiated immediately.
• The patient and the family should be counselled on the cause and the treatment of diabetes
and its management. The patient and the family should be taught how to monitor blood
glucose, record the test results, administer and adjust insulin doses based on blood glucose
values and food intake.
• They family should be counselled on the complications of diabetes mellitus and how to manage
them. In particular, they should know the signs and symptoms of acute hypoglycaemia and its
management. They should also understand the importance of maintaining normoglycemia to
avoid long-term complications. They should be instructed on how to manage acute illnesses
in the context of diabetes mellitus, for example how to manage their insulin dose if they are
unable to tolerate oral intake.
• Diet modification is important in both type I and type II diabetes mellitus. A nutritionist
should be involved in providing individualized recommendations.
Pharmaceutical management
• The majority of children with diabetes mellitus have type I diabetes and may present with
diabetic ketoacidosis (DKA). The management of DKA is detailed below.
• Diabetes Mellitus Type I: Children with Diabetes Mellitus Type I require insulin therapy. The
patient is insulin dependent and while the insulin therapy may be adjusted based on the
clinical condition and blood glucose results, the insulin therapy should NEVER be stopped
completely as this could result in the development of DKA and death.

--|Diabetic ketoacidosis
Definition
DKA is the increase in the serum concentration of ketones greater than 5 mEq/L, a blood
glucose level greater than 250 mg/dL and a blood pH less than 7.3.
Other features include: Ketonaemia, ketonuria and low serum bicarbonate level <18 mEq/L.

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Causes:
• Previously undiagnosed diabetes
• Interruption of insulin therapy
• Underlying infection and intercurrent illness
• Poor management of DM type 1
• Stress
• Medication like corticosteroids

Signs and Symptoms:

The signs and symptoms of DKA can develop suddenly and include:
• Polydipsia
• Polyuria
• Nausea and vomiting
• Abdominal pain
• Weakness or fatigue
• Rapid deep breathing
• Fruity-scented breath
• Confusion or drowsiness
• Hot, dry skin
• Blurred vision
Suspect DKA even if the blood glucose is normal in a child with known diabetes and any of the
following:
• Nausea or vomiting
• Abdominal pain
• Hyperventilation
• Dehydration
• Reduced level of consciousness

Investigations:
• Blood glucose
• Urine dipsticks for glucose and ketones
• Blood urea and electrolytes
• Malaria
• Full blood count
• Blood and urine cultures

Management:
DKA treatment goals
• Management of A,B, C
• Admission to HDU/ICU if possible for close monitoring
• Correct dehydration with intravenous fluids
• Correct hyperglycaemia with insulin and ivi fluids
• Correct acidosis and reverse ketosis
• Monitor for complications of DKA (cerebral oedema).
• Correct electrolyte imbalances, especially potassium loss
• Restore blood glucose to near normal.
• Identify and treat any precipitating event.

Fluid requirements
• Fluids for resuscitation in shock:
o Sodium chloride 0.9%, IV, 10–20 mL/kg over 10–30 minutes.
o Repeat if shock persists.

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• Fluid requirements after resuscitation
o Fluid requirement = deficit + maintenance
o Calculate deficit = estimated % dehydration x body weight (e.g. 10kg with 5%
dehydration 10 x 50 = 500mL)
o Calculate maintenance (mL): use the Holliday–Segar formula (max wt.75kg :
 ≤1 year: 120 mL/kg/24 hours
 All children older than 1 year; it is the sum of the following:
 First 10 kg body weight: 100 mL/kg/24 hours
 Second 10 kg body weight: 50 mL/kg/24 hours
 Additional weight > 20 kg body weight: 20 ml/kg/24 hour
• Add the deficit to 48 hour maintenance and replace this volume evenly over 48 hours,
initially with sodium chloride 0.9%.

Example 6 year old with 24kg

Deficit after resuscitation is 50 x 24 = 1200ml
Maintenance (100 x 10) + (10 x 50+ (4 x20) = 1580ml/24hour
Maintenance in 48 hours = 1580 x 2 = 3160ml
Deficit + maintenance = 3160+1200 = 4360
Rehydration will be 4360/48 = 91ml/hour
• When blood glucose falls to < 15 mmol/L change the infusion to a dextrose containing
maintenance fluid, e.g. dextrose 5% in sodium chloride 0.45%.
• Assess hydration status at least every 3 hours

Table 30. Alternative Rehydration plan

AGE 1st hour Next 7 hours Next 16hours

< 1 yr 20 ml/kg 15 ml/kg 7 ml/kg

1 - 7 yrs 20 ml/kg 10 ml/kg 5 ml/kg

8 – 14 yrs 20 ml/kg 9 ml/kg 5 ml/kg
> 15 yrs 20 ml/kg 8 ml/kg 4 ml/kg

Emergency Insulin Therapy:

• Delay insulin until serum K+ is > 3,5 mmol/l
• Insulin should only be started after 30-60 minutes of fluid therapy, provided shock has been
treated.
• Use regular Insulin short-acting (Actrapid or Humulin R), IV, 0.1 unit/kg, hourly
• If the rate of blood glucose fall exceeds 5 mmol/ L/hour or the blood glucose falls to 14
mmol/L:
o Add a dextrose-containing fluid.
o Do not stop the insulin while dextrose is being infused.
• If the blood glucose falls below 4 mmol/L:
o Give a bolus of 2 mL/kg of dextrose 10% and increase the concentration of dextrose
in the infusion.
• If glucose fall is inadequate, ie. a fall of < 4 mmol/l/hr - double the dose of insulin
• If glucose fall is excessive, ie a fall of > 5,5 mmol/l/hr - halve the dose of insulin
• Continue with IV insulin until:
o Base deficit is < 5 or bicarbonate is ≥15 mmol/L,
o There is no ketonuria,
o Blood glucose is ≤10 mmol/L.

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• If blood glucose stable and urine ketones negative, then start standard insulin regimen

Potassium (K+):
• If hyperkalaemia (serum K+ or ECG) withhold potassium supplementation
• If serum K+ is normal or low and patient is passing urine: Start K+ supplementation
immediately
• K+ replacement will be necessary in all cases (even with initial hyperkalaemia)

Table 31. Doses

Serum Potassium Required potassium supplement as KCL added to each litre of ivi fluids
<3,0 mmol/l 40 mmol
3,0 - 4,0 mmol/l 30 mmol
4,1 - 5,0 mmol/l 20 mmol
5,1 - 6,0 mmol/l 10 mmol
6,0 mmol/l None

Changing from intravenous to subcutaneous insulin

• When oral fluids are tolerated, reduce intravenous fluids.
• Subcutaneous insulin can be started once the child is well hydrated and able to tolerate a
normal diet

Transitional insulin therapy (Sliding Scale):

Monitor Blood Glucose 4−hourly and give the corresponding amount of Soluble/Regular insulin
subcutaneously

Blood Glucose Result Amount of Soluble/Regular Insulin to be given

Less than 6 mmol/L No Insulin
6.1 − 9.0 mmol/L 0.06 units/kg body weight
9.1 − 12.0 mmol/L 0.09 units/kg body weight
12.1−15.0 mmol/L 0.12 units/kg body weight
15.1−18.0 mmol/L 0.15 units/kg body weight

Sliding scale is considered when the patient is;

• Out of coma and no acidosis
• Continue the sliding scale, making appropriate adjustments to the doses of insulin, until
the patient is eating normally and the urine is free of ketones. This may take on average
between 12 − 24 hours.

Maintenance insulin therapy:

• Determine dose on normal requirement: 1 units/kg/day
• 2 Injections regimen:
o Administer subcutaneously in the form of 50% intermediate acting insulin (NPH or Lente)
and 50% rapid insulin. Total dose divided in 2 doses:
 2/3 before breakfast (1/2 rapid insulin and 1/2 intermediate acting insulin)
 Remaining 1/3 before the evening meal ( 1/2 Rapid insulin and 1/2 intermediate
acting insulin)

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OR
• 4 Injections regimen (Prandial regimen):Total dose divided in 4 doses:
o 50% of intermediate acting insulin at bed time
o 50% of rapid acting insulin dived in 3 doses – 20% before breakfast, 10% before
lunch and 20% before dinner

Treatment of intercurrent infection:

• Start empiric antibiotics on suspicion of infection until culture results are available: Cefotaxime
100mg/kg/day/7days

Recommendation:
• Regular follow-up of all diabetics is important to assess their blood sugar control
• Dietary education
• Physical activity
• Diabetes education
• Keep urine free of ketones

--|Hypoglycaemia
Definition
Blood glucose levels below the lower limit of the normal range (blood glucose < 2.2 mmol/L, for
malnourished children <3 mmol/L).

Causes/Risk factors:
Individuals with diabetes
• Excessive dose of medication anti−diabetic medication
• Omitted or inadequate amount of food
• Unaccustomed physical over activity
• Alcohol intake

Signs and symptoms:

• Dizziness • Sweating

• Blurred vision • Tremors

• Headaches • Tachycardia

• Palpitation • Confusion

• Irritability and abnormal • Unconsciousness

behaviour
• Convulsions

Note: Patients with frequent hypoglycaemic episodes develop hypoglycaemia unawareness, where
the symptoms above do not occur despite a dangerously low blood sugar level.

Nocturnal hypoglycaemia
Nightmares and headaches may be suggestive of nocturnal hypoglycaemia.

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Blood glucose concentrations fall to their lowest levels between 02h00 and 04h00.
Grading of severity:
Mild (Grade 1)
• Child or adolescent is aware of, responds to and self-treats the hypoglycaemia.
• Children < 6 years of age can rarely be classified as grade 1 because they are unable to
help themselves.
Moderate (Grade 2)
• Child or adolescent cannot respond to hypoglycaemia and requires help from someone
else, but oral treatment is successful.
Severe (Grade 3)
• Child or adolescent is semiconscious or unconscious with or without convulsions and may
require parenteral therapy with glucagon or intravenous glucose.
Diagnosis: is made on clinical signs and investigations

Investigations:
• Blood glucose

Management:

Outside the hospital

Mild or moderate hypoglycaemia:

• Glucose, oral, 5–15 g or 1-3 level teaspoons of sugar (depending on child’s age) in a small
amount of water.
• Wait 10–15 minutes.
• If blood glucose has not risen to 6-8 mmol/L, repeat above.
• As symptoms improve, the next meal or oral complex carbohydrate should be taken, e.g.
fruit, bread, cereal, milk, etc.

Severe hypoglycaemia
• Glucagon, IM/SC, 0.1–0.2 mg/10 kg body weight.
o If < 12 years of age: 0.5 mg.
o If > 12 years of age: 1.0 mg.
• If glucagon is not available:
o A teaspoon of sugar moistened with water placed under the tongue, every 20 minutes
until patient awakes
In hospital
• 10% Glucose, IV, 2−4 ml/kg 1 to 3 minutes followed by 5−10% Glucose, IV, according to
total daily fluid requirement until the patient is able to eat normally (Dextrose 50% 1 mL +
water for injection 4 mL = 5 mL 10% dextrose solution).
• If IV dextrose cannot be given; give glucagon, IM/SC, 0.1–0.2 mg/10 kg body wt
o If < 12 years of age: 0.5 mg.
o If > 12 years of age: 1.0 mg.

Recommendation
• Monitor blood glucose every 15-30 minutes until stable, then repeat 1–2 hourly.
• Keep blood glucose between 6 and 8 mmol/L

Referral
• Recurrent episodes of hypoglycaemia.

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--|Guidelines for management of diabetics on sick days

Definition
Illness associated with fever tends to raise blood glucose because of higher levels of stress
hormones, gluconeogenesis and insulin resistance.
Illness associated with vomiting and/or diarrhoea may lower blood glucose, with the possibility
of hypoglycaemia and the development of starvation ketones.

Diagnostic criteria
• Unstable blood glucose measurements as a result of illness, stress or starvation.
• Increased insulin requirements are induced by a catabolic state and stress.
• Ketonuria may also indicate the following:
o In the presence of hyperglycaemia, it is indicative of severe insulin deficiency and calls
for urgent therapy to prevent progression into ketoacidosis;
o In the presence of low blood glucose levels, it is indicative of a starvation state or is the
result of a counter-regulatory response to hypoglycaemia.

General and supportive measures

• Monitor glucose more frequently.
• Test urine for ketones.
• Ensure adequate intake of calories and fluids on sick days to prevent ketogenesis. If
insufficient calories are consumed, ketones will appear in the urine without hyperglycaemia.
In this circumstance encourage the patient to eat whatever he/she feels like.
• Treat underlying intercurrent illness.

Special circumstances:

Gastroenteritis:
• If hypoglycaemia occurs especially with gastroenteritis, and there is mild ketonuria, ensure
that the child takes regular frequent amounts of carbohydrate, using oral rehydration
solution or intravenous fluids.
Loss of appetite:
• Replace meals with easily digestible food and sugar-containing fluids.
Vomiting:
• If the patient has difficulty eating or keeping food down and the blood glucose is < 10
mmol/L, encourage the patient to take sugar containing liquids. Give small volumes. Some
glucose will be absorbed. If there is no vomiting, increase the amount of liquid.

Medications

Insulin therapy
• Insulin must be given every day. Insulin injections should not be omitted because of sickness
and/or vomiting. If vomiting occurs, IV fluids may be needed to avoid hypoglycaemia
• During an infection, the daily requirement of insulin may rise by up to 25%.

Moderate urine ketones

• The extra dose of insulin is usually 10–20% of the total daily dose given as short acting
insulin every three hours.
• If the blood glucose drops < 8.3 mmol/L, it may be necessary to sip regular juice or other
sugar-containing drinks. This is done to raise the blood glucose before giving the next insulin
injection.

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Large amount of urine ketones

• Give 20% of the total daily insulin dose.
• Repeat as above if necessary.

Extra fluids
In addition to taking extra insulin, extra fluids, e.g. water and fruit juices are important to prevent
acidosis. These fluids replace the fluids lost in the urine and prevent dehydration.

Referral
In a child with inter-current illness urgent specialist advice must be obtained when:
• Patient is unable to carry out the advice regarding sick days;
• he diagnosis is unclear
• Vomiting is persistent, particularly in young children;
• Blood glucose continues to rise despite increased insulin;
• Hypoglycaemia is severe;
• Ketonuria is heavy or persistent;
• The child is becoming exhausted, confused, hyperventilating, dehydrated or has severe
abdominal pain.

--|Hypocalcaemia in Children
Definition
The adjusted serum calcium levels below the normal ranges (calcium is 2.2 - 2.6mmol/L).
Symptoms of hypocalcaemia, such as muscle cramps, paraesthesia, tetany and carpopedal
spasm, typically develop when serum adjusted calcium falls below 1.9mmol/L. However, this
threshold varies and symptoms also depend on the rate of fall.

The main causes of hypocalcaemia in children are:

• Vitamin D deficiency
• Calcium deficiency
• Magnesium deficiency
• Reduced parathyroid hormone production or resistance,
• Impaired renal function.

Diagnosis: Based on clinical signs and symptoms

Signs and symptoms of tetany include:
• Paraesthesia
• Weakness
• Lethargy
• Cramps
• Laryngospasm
• Seizures
• Positive Trousseau’s sign
• Carpopedal spasm
• positive Chvostek’s sign
• Prolonged QT interval on the ECG.

Investigations
• Calcium
• Albumin

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• Phosphate
• Kidney function
• Magnesium
• 25 Hydroxyvitamin D.

Medication

Acute hypocalcaemia
• Calcium gluconate 10%, IV, 1–2 mL/kg administered over 5–10 minutes, 6–8 hourly.
Maximum dose: 10 mL.
• ECG monitoring is advised.

If hypomagnesaemic:
• Magnesium sulphate 50%, IV/IM, 0.2 mL/kg every 12–24 hours.

Chronic therapy
• Long-c therapy depends on the cause.
• Manage hypophosphataemia or hyperphosphatemia, depending on the cause of
hypocalcaemia, before long-term calcium is initiated.
• Elemental calcium oral, 50 mg/kg/day until normal calcium level is achieved (given with
meals).
• Maintenance dose: 30 mg/kg/day
• If vitamin D deficient:
o Vitamin D, oral:
 Under 6 months 2500 IU/day
 6 months -12 years 5 000 IU/day
 12 - 18 years 10 000 IU/day
• For hypoparathyroidism and pseudohypoparathyroidism:
o Calcitriol, oral, 0.01–0.04 mcg/kg/day. OR
o Alfacalcidol, oral, 0.05 mcg/kg/day.
 If < 20 kg: 0.05 mcg/kg/day.
 If > 20kg: 1 mcg/day.

Referral
• Chronic hypocalcaemia.

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MUSCULOSKELETAL CONDITIONS
--|Juvenile rheumatoid arthritis
Definition
Juvenile rheumatoid arthritis is a chronic non-suppurative inflammatory condition of the synovium.
Occurs in different forms
• Systemic onset arthritis (still’s disease), occur at any age (mostly at 2−4 years old)
• Polyarticular onset arthritis, typically involves five or more joints, usually small joints
• Pauciarticular onset arthritis, commonest type of juvenile rheumatoid arthritis (50 %), less
than five joints affected

Systemic onset arthritis:

Symptoms & signs:
• Arthritis in one or more joints.
• Plus 2 weeks of daily fever.
• With one of the following:
o Erythematous macular rash, or
o Serositis, i.e. pericarditis and pleuritis, or
o Hepatosplenomegaly, or
o Generalized lymphadenopathy

Polyarticular onset arthritis:

Signs and symptoms:

• Affects ≥ 5 joints in the first 6 months
• Involves large and small joints
• Rheumatoid factor either positive or negative
• Aggressive form of diseases with chronic course persisting into adulthood

Pauciarticular onset arthritis:

Signs and symptoms:
• Involves the large joints.( wrists, knees, ankles or elbows)
• Often asymmetrical distribution
• ≤ 4 joints are involved
• Associated with an increased risk of iridocyclitis/uveitis

Diagnosis
• Based on clinical signs

Investigations
• FBC, differential, ESR
• Rheumatoid factor
• X−ray of affected joints
• Anti-nuclear antibodies (ANA)

Complications
• Leg length discrepancy
• Scoliosis
• Contractures
• Iridocyclitis/uveitis

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Management:

Non-pharmaceutical management
• Occupational and physiotherapy are essential
• Education of the patient and their families

Pharmaceutical management
• First choice: Brufen 5-10 mg/kg/dose x 3/day
• Alternative: Prednisone p.o. 2 mg/kg as a single daily dose for 1–2 weeks, continue with
0.3–0.5 mg/kg/day as single dose for 3 months
• If arthritis not controlled;
• Give methotrexate p.o, 0.3 mg/kg/week as a single dose on an empty stomach, increase
at monthly intervals up to 1 mg/kg/week until there is satisfactory response, maximum dose
is 25 mg/week + folic acid 5mg daily for methotrexate treatment

Recommendation
• Refer patient for rheumatology specialist consultation and adequate management
(methotrexate treatment)

--|Rickets
Definition
Failure to calcify osteoid tissue in a growing child, usually due to deficiency of vitamin D, its
active metabolites, calcium, phosphorus or other rare causes. This leads to bone deformity.
Occurs in ex-premature babies during infancy and in children with developmental disability, on
anticonvulsants or not exposed to sunlight. In older children it is caused by renal tubulopathy
and other rare conditions.

Diagnosis

Clinical signs
• Bowing of long bones, widening of metaphyses and cranial bossing.
• Rachitic rosary
• Occasionally convulsions or tetany due to hypocalcaemia.

Investigations:
• FBC
• Urea & Electrolytes, Creatinine
• Bone profile (Ca, Mg, Phosphate, Alkaline phosphatase)
• 25-OH Vitamin D levels (combined vitamin D2 and D3 (where possible)
• X-ray of wrists

General and supportive measures

• Prevent vitamin D deficiency.
• Exposure to sunlight, at least 3 hours a week.

Note: Breast milk does not contain adequate vitamin D to prevent deficiency.
• Ensure adequate sunlight exposure of infant or provide vitamin D until weaning.
• Normal vitamin D-containing diet for lactating mothers.

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Medications
Prophylaxis
• For premature babies:
o Vitamin D, oral, 800 IU, once daily.
• Infants who are exclusively breastfed or not on adequate volume of commercial milk formula:
o Vitamin D, oral, 400 IU once daily.

Treatment of active rickets

• Treat only after confirmation of active rickets on x–ray.
• Vitamin D, oral, 5 000 IU once daily, in addition to milk in the diet.
• Repeat X–ray after 6–8 weeks.
o If no radiological improvement, further investigation is required.
o If healing occurs, continue for 3 months. Confirm complete healing and adequate diet
for the future.

Note: Children with low levels of calcium should have both calcium and Vit D. This intervention shows
a complete recovery within 3 months of supplementation.

HAEMATOLOGICAL CONDITIONS
--|Anaemia
Definition
Anaemia is defined as a haemoglobin (Hb) level below reference values, which vary depending
on sex, age and pregnancy status

Haemoglobin level reference ranges

• 0-2 weeks: 12-20 g/dL
• 2-6 months: 10-17 g/dL
• months-1 year: 9.5-14 g/dL
• 1-6 years: 9.5-14 g/dL
• 6-18 years: 10-15.5 g/dL

Causes of anaemia
• Decreased production of red blood cells:
o Iron deficiency, nutritional deficiencies (folic acid, vitamin B12, vitamin A)
o Depressed bone marrow function, certain infections (HIV, EBV), renal failure;
• Loss of red blood cells
o Acute or chronic haemorrhage
• Increased destruction of red blood cells (haemolysis)
o Parasitic (malaria), bacterial and viral (HIV) infections
o Haemoglobinopathies (sickle cell disease, thalassaemia)
o Reaction to certain drugs (co-trimoxazole, etc.)
In tropical settings, the causes of anaemia are often interlinked.

Clinical symptoms and signs

• Dizziness, fainting
• Headache
• Shortness of breath on exertion (exercise intolerance)

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• Visual disturbances
• Poor growth
• Confusion, decreased mental activity
• Mood or sleep disturbances
• Pale mucous membranes, palms and nail beds
• Rapid heartbeat or palpitations
• Dyspnoea, tachypnea
• Signs of heart failure if severe anaemia
• Other signs of severe anaemia include: Heart murmur, sweating, thirst, cold extremities,
oedema in the lower limbs and shock
• Some signs may indicate the likely cause of the anaemia:
o Cheilosis (cracking of the corners of the mouth) and glossitis (nutritional deficiency)
o Jaundice, hepatosplenomegaly, dark coloured urine (haemolysis)
o Melena, haematuria, etc. (bleeding.)

Classification of anaemia
• Anaemia is classified according to physiologic process (decreased production, increased
destruction or blood loss).
• In practice, classifying anaemia according MCV is a useful approach to assessing the
common causes of anaemia in children

Algorithm for classification of anaemia

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Investigations

Investigate according to clinical situation

• FBC, reticulocyte count and peripheral blood smear examination
• Blood film for malaria parasites/RDT
• Blood urea and serum creatinine
• Stool examination for eggs of hookworm, ova, parasites and occult blood,

Other tests that can be done at a tertially level depending on the clinical presentation
• Sickling test/ Hemoglobin electrophoresis
• Analysis for nutritional deficiencies
• Bone marrow aspiration to assess the decreased production of red cells
• Coombs direct and indirect (in cases of haemolytic anaemia)
• Iron studies (Fe, Ferritin, TIBC, transferrin % saturation)

Reticulocytes
• Reticulocytes are circulating immature RBC. Reticulocyte count helps to categorize the
anaemia into hypo-or hyper-proliferative type. Normal 0.5-1.5%

Hypoprolifearative:
• Decreased reticulocytes
• Bone marrow unable to produce the required number of RBC’s
• Lack of essential substance (iron, B12, folate) or Bone marrow infiltration such as in leukemia
, Aplastic anaemia

Hyperproliferative:
• Increased reticulocytes
• Cause of anaemia outside marrow
o Hemolytic anemia
o Hemorrhage
o Post anaemia treatment
• Decreased survival of RBCs
• Marrow normal and responds adequately by increasing the output

Corrected reticulocyte count (CRC) calculations:

• CRC = Reticulocyte % x (Patients’ Hematocrit/Normal hematocrit per age). A CRC >1.5
suggests increased red blood cells production as a result of haemolysis and blood loss.

Management

At health centre: Follow IMCI guidelines

Refer the child urgently if:

• There is severe anaemia (Hb <5), oedema or the child is very unwell
• Has recurrent or persistent anaemia
• Has severe acute malnutrition

Management at district hospital level:

• Obtain a detailed history from the patient or care givers
• Examine the anaemic patient carefully and perform the appropriate investigations with a
goal of;
o Confirming that the patient is anaemic
o Establishing the type of anaemia
o Determining the cause of the anaemia
o Determining whether or not there are complications arising from the anaemia, the cause
of the anaemia or both

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o Treat or correct the underlying cause
o Always investigate cause of anaemia before initiating treatment
o In an emergency, take all blood samples before treatment

Therapeutic objectives:
• Treat underlying cause of anaemia
• In sickle cell disease patients restore haemoglobin to steady state level
• In iron deficiency replenish iron stores after correction of anaemia (continue to treat for 2-3
months)

Non-Pharmaceutical management:
• Advise on a balanced diet especially iron-rich foods such as liver; beef kidneys; molasses;
meat; sardines; eggs, fish; fresh green leafy vegetables..
• Malaria prevention
• Encourage exclusive breastfeeding until 6 months, then supplementation with iron rich food.
• Discourage use of cow’s milk before 12 months and excessive intake of cow’s milk.

Pharmaceutical management:
• For iron deficiency anaemia:
o Elemental Iron 4-6 mg/kg/day divided in 3 doses daily until the Hb has reached the
normal range.
 Ferrous Sulphate has 20% elemental iron
 Ferrous Fumarate has 33% elemental iron
 Ferrous gluconate has 12% elemental iron.
o Continue for 2-3 months after normalization of Hb to build up iron stores.
o Side effects of iron therapy: Diarrhea, abdominal discomfort, constipation, or black
stools
• Sickle cell disease patients should receive iron tablets only if there is evidence of iron
deficiency. They should however, receive folic acid. Similarly, patients whose anaemia is
possibly due to malaria should receive folic acid
o Folic acid, oral: 5 mg every 2 days for 30 days or for as long as required.
• If anaemia is due to hookworms
o Albendazole:
 Children 1-2 years of age 200 mg as a single dose
 Children over 2 years of age 400 mg as a single dose
o Or Mebendazole 100 mg orally 12h x 3 days).
• Vitamin B12 deficiency:
o Hydroxycobalamin injection IM: Initially 100mcg/day for 10-15 days. Maintenance
dose 30-50 mcg/month. Lifelong treatment may be required.
• Severe anaemia with signs of cardiac failure will need treatment of the heart failure in
addition to blood.
o Transfusion with packed cells. Look for signs of decompensation before deciding to
transfuse and look for these signs during transfusion.
o Transfuse the patient if Hb < 5 g/dl and decompensation signs are present:
 Packed cells: 10-20 ml/kg body weight slowly over 4 hours
 To calculate the volume needed to increase Hb: Volume of packed red cells =
(desired Hb – actual Hb) x weight x 0.4
o Furosemide 1mg/kg IV should be given at the beginning of transfusion:
 If signs of heart failure or
 If there is normal circulating volume, such as in chronic severe anaemia
o Make sure the CORRECT bag of blood is given and never transfuse blood that has been
out of the refrigerator for more than 2 hours.
o Make baseline recordings of temperature, respiratory rate and pulse rate, then observe
patient closely every 15 minutes for transfusion reactions

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Referral:
• Refer all patients with anaemia related to poor diet to a nutritionist or a health center for
nutritional follow-up
• Refer all patients with recurrent anaemia or with anaemia of unknown cause to a referral
hospital

--|Sickle cell anaemia

Definition
Chronic haemolytic anaemia characterized by sickle shaped red blood cells as a result of
mutation in the β chain of Hemoglobin

Cause:
• Homozygous inheritance of mutated HbS (amino acid valine is substituted for glutamic acid
in the position 6 of the β−chain)

Signs and symptoms:

• Impaired growth and development
• Anaemia and mild jaundice
• Hepatosplenomegaly (in younger children)
• Bone pain (especially long bones in children)
• Pain and swelling of the hands and feet (hand - foot syndrome) in children between 6
months and 3 years old.
• Arthralgia with fever
• Severe abdominal pain with vomiting
• Acute chest syndromes (sudden onset of fever, cough, chest pain, tachypnea leukocytosis
and pulmonary infiltrates on x−ray): Must be aggressively treated may be fatal
• Tower shaped (“frontal and parietal bossing”) skull

Investigations:
• Full blood count
• Peripheral blood smear
• Sickling test (Test d’Emmel)
• Hb electrophoresis

Complications:
• Infections (especially from encapsulated organism such as Streptococcus pneumoniae:
o Osteomyelitis (Streptococcus pneumonia and Salmonella )
o Meningitis
• Aplastic crisis (commonly due to Parvovirus B19 infection)
• Stroke (infarctive) with hemiparesis and convulsions
• Gangrene (vaso-occlusive)
• Pulmonary hypertension
• Acute chest syndrome (sudden onset of fever, cough, chest pain, tachypnea leukocytosis
and pulmonary infiltrates on X-ray): Must be aggressively treated as may be fatal
• Gall bladder stones +/- cholecystitis
• Splenic sequestration (in 5 first years of life): onset of life threatening anaemia with
rapidly enlarging spleen and high reticulocyte counts
• Avascular necrosis of the femoral head is common
• Occlusion of major intracranial vessels may lead to hemiplegia

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• Cranial nerve palsies and other neurological deficits
• Priapism

Management:
• At health centre: Refer all suspected sickle cell cases to a district hospital

Management aims at 4 types of crisis

• Thrombotic (vaso−occlusive, painful or infarctive),
• Aplastic
• Hyperhaemolytic due to Hypersplenism
• Acute splenic sequestration

Non-pharmacological treatment:
• IV or oral fluids 2L/m2/day
• Oxygen if in respiratory distress

Pharmaceutical treatment:
• Analgesics (WHO Step wise pain management)
o Paracetamol 10-15mg/kg/dose orally every 4-6 hours associated with Brufen 5-10mg/
kg/dose every 6-8 hours
o Codeine 0.5-1mg/kg/dose every 6 hours
o Pethidine 0.5−2mg/kg 4hrly)
o Morphine (titrate to effect) PO: 0.2-0.5 mg/kg/dose every 4-6 hours, IV, IM, SC: 0.1-
0.2 mg/kg/dose every 2-4 hours
• If patient has an infection treat according to the bacteria, the site and the severity of the
infection
• Aggressively search for cause of infection (blood and urine cultures, chest X ray) and start
empiric antibiotic treatment if child has fever
• Blood Transfusion: Transfusion should be reserved for the following circumstances:
o Urgently for sudden, severe anaemia due to acute splenic sequestration, parvovirus B19
infection, or hyperhaemolytic crises.
o Transfusion is indicated in the following situations:
 Acute infarctive stroke
 Severe acute chest syndrome
 Multiorgan failure syndromes
 Perioperative.
 Priapism that does not resolve after adequate hydration and analgesia

Additional treatment:
• Give supplementary folic acid (5 mg oral daily) but AVOID iron (risk of hemochromatosis).
• Hydroxyurea should be given to patients with more than 3 crises per year. Start at a dose
of 10 mg/kg PO daily and titrate by 5mg/kg every 8 to 12 weeks to a maximum dose of
25mg/kg/day.
• Homozygous should be vaccinated for salmonella, Pneumococcal and Haemophilus influenza

Recommendation:
• Education of patient on sickle cell disease and crisis to avoid complications
o Should drink much water daily
o Avoid getting cold (dress with warm clothes in cold weather)
• Sickle cell screening before marriage for suspected carriers and genetic counseling if
possible
• Heterozygote carriers should have family members screened for sickle cell disease

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--|Idiopathic thrombocytopenic purpura

Definition
Immune thrombocytopenia purpura (ITP) is an immunologically mediated bleeding disorder in
which autoantibodies against platelet antigens cause premature platelet destruction that leads
to thrombocytopenia.
Children often develop ITP after a viral infection and usually recover fully without treatment.

History:
• A previously healthy child who has sudden onset of generalized petechiae and purpura
• A history of a preceding viral infection 1–4 weeks before the onset of thrombocytopenia
• Acute bleeding from the gums and mucous membranes

Clinical manifestations:
• Findings on physical examination are normal, other than the finding of petechiae and
purpura.
• Splenomegaly is rare, as is lymphadenopathy or pallor.
• Fewer than 1% of patients have intracranial hemorrhage
• The severity of bleeding in ITP is based on symptoms and signs, but not on platelet count
• Symptoms can be categorized as:
o No symptoms (identified on routine blood tests showing severe thrombocytopenia)
o Mild symptoms: bruising and petechiae, occasional minor epistaxis, very little interference
with daily living
o Moderate: more severe skin and mucosal lesions, more troublesome epistaxis and
menorrhagia
o Severe: bleeding episodes—menorrhagia, epistaxis, melena—requiring transfusion or
hospitalization, symptoms interfering seriously with the quality of life

Diagnosis:
• Diagnosis is based on the history, physical examination, full blood count with leukocyte
differential, and examination of the peripheral smear

Laboratory:
• FBC with differential (should not show any anaemia (unless significant bleeding) or anomaly
of WBC count) - Profound thrombocytopenia (platelet count <10 × 109/L).
• Peripheral blood film examination (will show large or giant platelets
• HIV test
• Additional investigations are done as clinically indicated
• Bone marrow biopsy is only indicated if the patient has other cytopenias, suspicious findings
on the peripheral smear, or other clinical features associated with bone marrow failure
syndrome

Differential diagnosis: ITP is a diagnosis of exclusion

• HIV infection
• Bacterial or viral infections
• Leukemia
• Aplastic anaemia
• Systemic lupus erythematosus (SLE
• Wiskott-Aldrich syndrome (WAS)) must be considered in young males found to have low
platelet counts, particularly if there is a history of eczema and recurrent infection.

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Management
The goal of therapy is to reduce the risk for bleeding so that patients can live a normal life
The decision to treat a child should be based on the clinical symptoms and not the platelet count.

Table 32. Management of ITP according to risk category

Risk
Symptoms Management
category

• Many petechiae or large

bruises • Outpatient without medical treatment (unless
• Painless oral/palatal significant psychosocial or safety concerns)
Low
petechiae or purpura. • Repeat FBC and review in 1 week
• Dry blood clots in the • Provide family education
nostril/nares

• Admission to hospital
• Discuss with Paediatrician/Paed
Haematologist
• Transfuse with Platelets to stop bleeding
Prednisolone 2 mg/kg (max 60 mg) for 4–7
days
• If poor response or rapid platelet rise is
• Epistaxis >5 minutes
required e.g. before surgery: IVIG 0.8–1.0 g/
• Haematuria
kg/day for 1–2 days
Moderate • Haematochezia
• IV Rh (D) immune globulin can be used in
• Painful oral purpura
Rh positive patients at a dose of 50-75
• Significant menorrhagia
microgram/kg.
• Additional treatments:
o Epistaxis: oral tranexamic acid 25 mg/kg
(max 1.5 g), ENT consult where possible
o Heavy menstrual bleeding: tranexamic
acid (must not be used if haematuria is
present)

• Urgent transfer to a tertiary hospital after

stabilisation
• Suspected internal
• Combination IVIG 0.8–1 g/kg and pulse IV
haemorrhage (brain,
Severe Methylprednisolone 15–30 mg/kg (max 1 g)
lung, muscle, joint, etc.)
daily for 3 days
Life- OR
• Platelet transfusion 20 mL/kg, continuous if
threatening • Mucosal bleeding that
required
requires immediate
IV tranexamic acid 15 mg/kg
intervention
• Urgent surgical intervention or referral
depending on site of bleeding

Splenectomy in ITP
• Splenectomy removes the primary site of platelet clearance and autoantibody production
and offers the highest rate of durable response (50% to 70%) compared with other ITP
therapies
• It should be reserved for 1 of 2 circumstances:
o The older child (> 4 yrs.) with severe ITP that has lasted >1 yr. (chronic ITP) and
whose symptoms are not easily controlled with steroids and IVIGs is a candidate for
splenectomy.

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o Splenectomy must also be considered when life-threatening hemorrhage (intracranial

hemorrhage) complicates acute ITP, if the platelet count cannot be corrected rapidly
with transfusion of platelets and administration of IVIG and corticosteroids.
Family education
• On the illness/diagnosis
• Restrict activities to minimise the risk of head injury
o Avoid contact sports (e.g. Rugby, Soccer)
o Limit activities that have a risk for traumatic injury (e.g. Bicycle riding)
• Avoid anti-platelet, non-steroidal and anticoagulant medications.
• Avoid intramuscular injections
• Monitor for significant bleeding symptoms and go immediately to the emergency department
if they occur
• Monitor for signs of ICH and go immediately to the emergency department if head injury
or severe headache
• Consider discharge when family understands the condition, management, activity restrictions,
follow-up plan and when to go to the emergency department
Splenectomy in ITP
• Splenectomy removes the primary site of platelet clearance and autoantibody production
and offers the highest rate of durable response (50% to 70%) compared with other ITP
therapies
• It should be reserved for 1 of 2 circumstances:
o The older child (> 4 yrs.) with severe ITP that has lasted >1 yr. (chronic ITP) and
whose symptoms are not easily controlled with steroids and IVIGs is a candidate for
splenectomy.
o Splenectomy must also be considered when life-threatening hemorrhage (intracranial
hemorrhage) complicates acute ITP, if the platelet count cannot be corrected rapidly
with transfusion of platelets and administration of IVIG and corticosteroids.

General transfusion policy management:

Red blood cells:
In children and adolescent:
• Low Hb and symptomatic
• Asymptomatic but Hb <5 g/dl
• Fever and Hb <8.0 g/dl
• Hb <8.0 g/dL in the perioperative period
• Serious infection and Hb <10.0 g/dl
o Volume packed cells necessary = 3 x weight in Kg x requested rise in Hb.
o Keep volume within limits e.g. do not transfuse 3 litre blood for chronic anaemia
• Postpone blood transfusion at diagnosis if WBC >100x109/l (Leukaemia is likely and high
risk of increased viscosity).
• In infants within the first 4 months of life:
o Hb <10 g/dL and major surgery
o Hb < 10 g/dL and pulmonary disease
Platelets:
• Asymptomatic but platelets. <10.0x109/
• Symptomatic (petechiae, fever from serious mucositis) and platelet <20.0x109/l
• Before LP if platelets <30.0x109/l or DIC or high WCC.
• Before surgical procedure if platelets <50.0x109/l

Reference
Hume: Clinical Practice of Transfusion Medicine Petz LD et al (eds) 3rd edition. New York, Churchhill
Livingstone 1996: 705 – 732.

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Table 33. Management of transfusion reactions

Severity Signs Transfusion Treatment

• Promethazine 0.125mg/Kg ( Max 25mg)
Mild Itchy rash Slow rate
• Continue if stable after 30minutes
Severe rash • Promethazine 0.125mg/Kg ( Max 25mg)
Fever • Hydrocortisone 4mg/kg IV (max 100mg)
Moderate Stop
Rigor • Nebulize with salbutamol if wheezing
Tachycardia • If stable restart with new blood
• Maintain airway and give oxygen
• Normal saline bolus 20ml/kg
• Adrenaline 1:1000 at 0.01 mg/kg
(Max 0.3mg) every 2-5 minutes IM. In
Shock
refractory cases, drip (0.1 mcg/kg/min)
Haemolysis
Severe Stop • Promethazine 0.125mg/Kg ( Max 25mg)
Bleeding
• Hydrocortisone 4mg/kg IV (max 100mg)
Collapse
• Nebulize with salbutamol if wheezing
• Consider and treat for sepsis
• Preferably observe in high dependency
unit

CENTRAL NERVOUS SYSTEM

--|Convulsions
(For neonatal convulsions refer to neonatal protocol)

Definition:
A convulsion is an involuntary change in movement, attention or level of awareness that is
sustained or repetitive and occurs as a result of abnormal and excessive neuronal discharges
within the brain. Convulsions may be focal (Partial) or generalised

Generalised seizures may be:

• Tonic-clonic,
• Absence (typical or atypical),
• Clonic,
• Tonic or atonic,
• Myoclonic

Focal seizures:
• Affect one part of the body but may progress to generalised tonic-clonic seizures and this
is known as secondary generalisation.

Signs & symptoms of convulsions

• Shaking of body; can be generalised or focal
• Unresponsive, eyes rolling back, biting tongue or frothing of mouth
• Followed by post-ictal period (sleepiness after)

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Causes
• Febrile convulsions
• Malaria
• Meningitis/Encephalitis
• Hypoglycaemia
• Hyponatraemia/ Hypernatraemia/Hypocalcaemia
• Epilepsy
• Poisoning
• Head injury, hypoxic injury

Investigation
• Bedside blood sugar level
• Malaria slide or Rapid Diagnostic Test (RDT)
• Full Blood count
• Urea, Creatinine, sodium, potassium and calcium (where possible)
• Consider lumbar puncture:
o If signs of meningitis (fever, neck stiffness, bulging fontanelle or irritability)
o DON’T do a lumbar puncture if the child is very sick or there are signs of raised
intracranial pressure (unequal or unresponsive pupils, papilloedema, abnormal
breathing)

Management
During seizure management
• Airway and Breathing: Clear airway; place child on side, protect from trauma, loosen
clothing and suction secretions if possible
• Make sure child is breathing; if not, give breaths using bag and mask
• Give oxygen
• Check blood sugar & treat as per the hypoglycaemia guideline
• Most seizures are quickly self-limited. Immediate administration of an anticonvulsant is not
systematic.
• If generalized seizure lasts more than 5 minutes, use diazepam to stop it:
o Diazepam
 Infants and Children 6 months to 5 years: Rectal: 0.5 mg/kg rectally without
exceeding 10 mg
 Children 6 to 11 years: Rectal: 0.3 mg/kg.
 Children ≥12 years and Adolescents: Rectal: 0.2 mg/kg.
o In all cases if seizure continues, repeat dose once after 10 minutes.
o Monitor respiratory rate.
• If still fitting after 20 minutes
o IV Phenobarbitone (loading 20mg/kg over 15 mins, max 1g) OR
o IV phenytoin (loading dose 20mg/kg in Normal saline over 60 mins)
o If seizure continues after Phenobarbitone/Phenytoin, treat as status epilepticus.

Figure 6. How to position an unconscious child

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--|Febrile seizures
Definition
Seizures occurring in children between the ages of 6 months and 6 years associated with a fever
but without evidence of intracranial infection or defined cause for the seizure. Febrile seizures
can be simple or complex febrile seizures.

Simple febrile seizures:

• Are generalised tonic-clonic seizures
• Are self-limiting, usually less than 5 minutes and always less than 15 minutes
• Cause no neurological deficit after the convulsion
• Have a good prognosis and very rarely develop into epilepsy
• Consist of only one seizure during the febrile illness which needs no specific treatment
• There is often a family history of febrile seizures.

Complex febrile seizures:

Febrile seizures with one or more of the following:
• Last longer than 15 minutes
• Are recurrent within the same febrile illness or occur within 24 hours
• Have a focal (partial) onset
• Have post-ictal, focal neurological abnormalities.

Risk factors for recurrent febrile seizures include:

• Seizure disorder in a first degree relative,
• Onset before 12 months of age

Diagnostic criteria
Clinical
• Exclude intracranial, extracranial and biochemical causes of fever or seizure.
• Signs of meningism are unreliable in children < 2 years of age.
• Treat children empirically for meningitis if suspected.

Investigations
• Bedside blood sugar level
• Malaria slide or Rapid Diagnostic Test (RDT)
• Full Blood count
• Urea, Creatinine, sodium, potassium and calcium (where possible)
• Lumbar puncture is indicated in:
o All children with clinical features of possible meningitis,
o Children where meningitis cannot be excluded, e.g. < 1 year of age or those who have
received a course of antibiotics prior to the event.
In children > 1 year of age, where a focus of extracranial infection is present and intracranial infection
such as meningitis has been excluded clinically, no further investigation is required.

Neuroimaging
• All children with complex febrile seizures and persistent lethargy require Brain CT scan
before doing a lumbar puncture to exclude raised intracranial pressure
• Based on clinical findings, investigate complex febrile seizures for possible underlying
conditions such as meningitis, focal brain lesions, cerebral malaria and epilepsy.

Note: An EEG is of no value in simple febrile seizures, but consider in recurrent complex febrile
seizures.

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General and supportive measures

• Reassure parents and caregivers.
• Educate parents and caregivers regarding the first aid management of seizures.

Medicines
• Treat fever with Paracetamol, oral, 15 mg/kg/dose 6 hourly.
• If convulsing: Infants and children 6 months to 5 years: Rectal Diazepam 0.5 mg/kg without
exceeding 10 mg

Note: For children with recurrent complex febrile seizures, discuss the treatment options with a
Paediatrician.

--|Epilepsy
Definition:
Epilepsy is a condition characterized by recurrent seizures associated with abnormal paroxysmal
neuronal discharges. When seizures are recurrent, persistent or associated with a syndrome,
then the child may be diagnosed with epilepsy.

Causes:
• Idiopathic (70-80%)
• Secondary causes:
o Cerebral dysgenesis or malformation
o Cerebral vascular occlusion
o Cerebral damage like hypoxic ischaemic encephalopathy (HIE), intraventricular
haemorrhage or ischemia, head injury, infections
o Cerebral tumors
o Neurodegenerative disorders

Types of epilepsy and their clinical presentation

Infantile spasms (West’s Syndrome) Clinical Signs/Symptoms:
• Onset is during the first year of age
• Epileptic spasms (flexion and extension) associated with hypsarrhythmia on the EEG
• Developmental regression
• Child appears to stare, with a sudden flexion of the trunk and head, limbs either flung in or
out but held in a tonic spasm for a few seconds
• Red appearance in the face and may cry out

Generalized epilepsy with febrile seizures

Clinical Signs/Symptoms:
• Febrile convulsions which persist beyond 6 years
• Often family history of febrile convulsions
• Occasionally associated with afebrile convulsions

Primary generalized absence seizure of childhood (Petit mal)

Clinical Signs/Symptoms:
• Onset 4 - 6 years of age
• Short spells of motor arrest of maximum 15 seconds duration with little or no associated
movements and no post-ictal effect

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Benign Rolandic epilepsy with centrotemporal spikes
Clinical Signs/Symptoms
• Onset usually between 6–10 years but can occur before 6 years of age
• Sleep related events of hemi-facial clonic spasm
• Inability to speak with retained awareness
• Usually resolves by late adolescence
Severe Myoclonic Epilepsy of Infancy
Clinical Signs/Symptoms:
• Occur in children under 1 year of age
• Recurrent clusters of febrile convulsions, severe neuro-regression and other non-febrile
seizures by 2-3 years of age

Lennox-Gastaut syndrome
Clinical Signs/Symptoms:
• Onset between 2 - 3 years of age
• Combination of generalized tonic clonic seizures, atypical absences, myoclonic seizures,
atonic drop attacks and occasionally complex partial seizures
• Behavioral problems and neuro-regression

Note: Infantile spasms, Severe Myoclonic Epilepsy of Infancy and Lennox-Gastaut syndrome are
regarded as malignant forms of epilepsy and are associated with neuro-regression and behavioral
problems.

Complications:
• Status Epilepticus
• Trauma secondary to loss of consciousness during seizures
• Mental retardation

Diagnosis:
• Detailed clinical history and physical examination

Investigations:
• Blood work up : Full Blood count, blood sugar, malaria test, Urea, Creatinine, sodium,
potassium and calcium depending on the type of epilepsy
• Electroencephalogram (EEG)
• CT scan of the brain /MRI of the brain

Management:
Non Pharmaceutical
Acute management:
• Manage Airway-Breathing-Circulation-Disability and continue to monitor throughout the
seizures
• Place patient on side at 20 – 30° head up to prevent aspiration
• Monitor heart rate, respiratory rate, blood pressure, oxygen saturation (SaO2), neurological
status, fluid balance
• Monitor laboratory values including blood glucose, electrolytes, if available blood gases
toxicology screen and if indicated anticonvulsant blood levels
• Control fever with Paracetamol with or without tepid sponging
• Administer oxygen to maintain SaO2 of ≥ 95%
• If unable to protect airway or poor ventilation, consider use of an oral airway, bag-mask
ventilation and/or intubation
• Admit to pediatric ward or to intensive care unit if indicated

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Long-term management:
• Minimize the impact of the epilepsy by obtaining complete seizure control to maximize
child’s full potential
• Educate/counsel the patient and caregiver about epilepsy and associated complications
(i.e. learning difficulties)
Pharmacological treatment in children >1 month of age:
*Please refer to neonatology protocols 3rd Edition June 2019 for management of convulsions in children
<1 month of age.

Monotherapy is preferred but combination therapy may be necessary. Combination therapy should
be initiated by or in close consultation with a pediatric specialist or neurologist. Drug levels are
rarely indicated unless there is concern about toxicity or compliance.
For acute generalized tonic clonic seizures in children > 1 month of age:
• Diazepam rectal 0.5 mg/kg once OR IV 0.2-0.3mg/kg once
• Repeat after 10 minutes same dose only once
• Monitor airway and breathing closely

Alternative Medications (in the absence of diazepam):

• Lorazepam IV 0.05- 0.1 mg/kg once, may repeat in 5 minutes for a total of 3 doses
• Clonazepam IV 0.1 -0.15 mg/kg loading dose by slow IV injection
• For refractory status epilepticus: Midazolam IV 0.1-0.3 mg/kg bolus followed by a continuous
infusion starting at 1 ug/kg/minute. The infusion can be titrated upwards every 5 minutes
as needed.

If persistent seizure activity after benzodiazepines, start:

• Phenobarbital 15-20 mg/kg IV or by NG tube loading dose over 15minutes, may use a
dextrose containing solution. If no response after 30 minutes, may repeat a 10 mg/kg IV
loading dose.
• Phenytoin 15-20 mg/kg IV infused over 30 minutes in Normal saline
• If seizures persist after loading of dose of either Phenobarbital or Phenytoin, manage as
status epilepticus below and arrange to transfer to a centre with high dependency unit/
intensive care unit
• Monitor for bradycardia, arrhythmias, and hypotension and pause the infusion if they occur
and restart at 2/3 of the initial loading dose.

Ongoing seizure control: Children with epilepsy require maintenance anticonvulsants

Table 34. Maintenance medicine treatment choices for different types of epileptic seizures.

Type of epilepsy First line treatment Second line treatment

Generalised • Valproate OR • Lamotrigine
tonic and/or clonic • Phenobarbitone (< 6 months old)
• Lamotrigine
Focal seizures • Carbamazepine • Topiramate
Infantile epileptic • Stabilize then consult paediatric neurologist
spasms
Myoclonic • Stabilize then consult paediatric neurologist
Lennox-Gastaut syndrome • Stabilize then consult paediatric neurologist

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Maintenance medicine treatment dosage
• Valproate, oral, 5 mg/kg/dose (starting dose), 8–12 hourly.
o Increase by 5 mg/kg weekly to 15–20 mg/kg/day given 8–12 hourly over 4 weeks.
o Maximum total daily dose: 40 mg/kg/day.
o Exclude liver dysfunction prior to initiating therapy (at least ALT),
o Monitor at least clinically for hepatotoxicity.

• Carbamazepine, oral, 5 mg/kg/dose (starting dose), 8-12 hourly.

o Increase slowly by 0.2 mg/kg at 2 weekly intervals to 5–10 mg/kg/dose 8–12 hourly.
o Usual maintenance total daily dose: 10–20 mg/kg/day.
o Maximum total daily dose: 20 mg/kg/day.
o Dosage intervals: syrup 8 hourly, tablets 12 hourly.
o Exacerbates myoclonic seizures and absence seizures..

• Phenobarbitone, oral, 2.5–5 mg/kg/dose as single dose at night.

o May be used in children under six months of age.
o Is not recommended as maintenance therapy for children older than 2 years due to
undesirable side effects such as sedation, behaviour disturbances, hyperkinesia and
dependence, except in situations where there is poor adherence to other drugs.
o Exacerbates absence seizures
Note:
• Patients not responding to these medications should be referred to a referral hospital for
possible use of second line drugs like Lamotrigine and Topiramate
• Avoid prescribing carbamazepine, phenobarbital, and phenytoin for patients receiving
NNRTIs or PIs, as there are serious interactions involved
Referral
• All cases of suspected infantile spasms or myoclonic seizures.
• If there is concern for a secondary cause of epilepsy requiring further evaluation (examples
include brain tumors, tuberous sclerosis, brain abscess, cysticercosis, etc.). This is particularly
true in partial seizures where there may be a focal neurological problem.
• Seizures that are not controlled on first-line medications within 1 month.
• Seizures associated with neuro-regression.
• Mixed seizure types within one patient.

--|Convulsive status epilepticus

Definition
Status epilepticus is a generalized epileptic seizure lasting 5 or more minutes, or the presence
of two or more seizures without recovering consciousness within 30 min, or a focal seizure that
persists for >10 min, or with altered consciousness lasting for 60 min or more

Causes:
Epilepsy syndromes may present first as status epilepticus or status epilepticus may occur with
inadequate anti-epileptic drug levels
• CNS infection
• Hypoxic ischemic insult
• Traumatic brain injury
• Cerebrovascular accidents
• Metabolic disease including severe hypoglycemia and inborn errors of metabolism
• Electrolyte imbalance

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• Intoxication
• Cancer including primary brain tumors and metastatic disease

Signs and Symptoms

• Seizure lasting > 30 minutes or repetitive seizure activity without return to baseline
consciousness.

Diagnosis
• Clinical evaluation

Investigations
• Blood work up : Full Blood count, blood sugar, malaria test, Urea, Creatinine, sodium,
potassium and calcium depending on the type of epilepsy
• Lumbar puncture if infectious cause is suspected.
• Electroencephalogram (EEG)
• CT scan of the brain /MRI of the brain

Complications:
• Hypoxic ischaemic damage to brain, myocardium and muscles
• Cerebral oedema
• Long term neurologic morbidity including persistent seizures or encephalopathy
• Respiratory depression or failure due to neurologic status or aspiration
• Blood pressure disturbances including severe hypotension or severe hypertension
• Hyperthermia
• Metabolic derangement including hypoglycemia, alterations in sodium, and acidosis
• Inappropriate antidiuretic hormone (ADH) secretion
• Renal failure
• Death

Non-pharmaceutical

Acute Management:
• Carefully evaluate vital signs as convulsions may cause alterations in blood pressure or
interfere with breathing resulting in a decrease in oxygen saturation levels
• Manage Airway-Breathing-Circulation-Disability and continue to monitor throughout seizures
• Place patient on side at 20–30° head up to prevent aspiration
• Monitor heart rate, respiratory rate, blood pressure, oxygen saturation (SaO2), neurological
status, fluid balance every 15 minutes or as frequently as possible
• Monitor laboratory values including blood glucose, electrolytes, blood gases, toxicology
screen and if indicated anticonvulsant blood levels
• Control fever with Paracetamol
• Administer oxygen to maintain SaO2 of ≥ 95%
• If unable to protect airway or poor ventilation, consider use of an oral airway, bag-mask
ventilation and/or intubation
• Admission to intensive care if possible

Pharmacological treatment of status epilepticus

o Diazepam
 Infants and Children 6 months to 5 years: Rectal: 0.5 mg/kg rectally without
exceeding 10 mg
 Children 6 to 11 years: Rectal: 0.3 mg/kg.
 Children ≥12 years and Adolescents: Rectal: 0.2 mg/kg.
o In all cases if seizure continues, repeat dose once after 10 minutes.
o Monitor respiratory rate.
• If still fitting after 20 minutes

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o IV Phenobarbitone (loading 20mg/kg over 15 mins, max 1g) OR
o IV phenytoin (loading dose 20mg/kg in Normal saline over 60 mins)
o If seizure continues after Phenobarbitone, load with Phenytoin or if it persists after
Phenytoin loading dose, load with Phenobarbitone if seizures continue despite the
above, transfer to ICU for Endotracheal intubation and thiopental infusion
It is important to continue to address and manage the following:
• ABCs
• Hypoxia: Administer oxygen, oral airway, bag-mask ventilation or intubation.
• Haemodynamic: Assess for shock or hypertension and manage accordingly.
• Hyperthermia: Treat with paracetamol 10-15 mg/kg orally or rectally every 4-6 hours as
required.
• Hypoglycemia: Treat with IV dextrose solution.
• Electrolyte imbalance: Assess aetiology and manage accordingly.
• If cerebral oedema and normal renal function, consider mannitol IV 0.5-1 gram/kg
administered over 30–60 minutes.
• If there is a known space-occupying lesion, consider dexamethasone IV 1-2 mg/kg IV as a
single dose then 1-1.5 mg/kg/day divided into 4 doses after discussion with a neurosurgeon

Recommendations
• Once status epilepticus is resolved, consider maintenance therapy with an appropriate anti-
epileptic drug depending on the aetiology of seizure.
• Referral to a specialist is always appropriate in the case of status epilepticus. If possible,
control seizures and stabilize the patient before referral. If status epilepticus has resolved,
further work-up by a neurologist may be indicated.

Table 35. Phasic management of status epilepticus

Phase Management Goals
Early status Early stabilisation phase
0-5 minutes • Immediate ABC
• Diagnose hypoglycaemia
• Establish IV access
• Maintain oxygen saturation
• Lorazepam, IV, 0.1 mg/kg
• Maintain cerebral perfusion
• Diazepam 0.3 mg/kg over 3 minutes
pressure
Emergent (rectal is preferred)
• Support haemodynamic status
initial If no IV access:
antiepileptic • Diazepam, rectal, 0.5 mg/kg
drug (AED) • OR
5 minutes • Lorazepam, IM, 0.1 mg/kg
If still convulsing after 5-10 minutes
• Repeat Lorazepam, IV, 0.1 mg/kg
OR
Established • Diazepam, rectal, 0.5 mg/kg
Status • And load with Phenytoin, IV, 20mg/kg • Stop seizure
5-30 minutes (infused in normal saline over 30 minutes
• Control status epilepticus
Urgent Status OR
Control • Phenobarbitone, IV, 20mg/kg
Therapy If still convulsing after
15-20 minutes (use alternative option
to what was used above)
• Refer ICU
Refractory ICU
Status • Consideration for Midazolam infusion • Stop seizure
30-60 • Endotracheal intubation and thiopental • Support haemodynamic status
minutes infusion

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Figure 7. A flowchart showing medical management of Status Epilepticus

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 TREATMENT GUIDELINES 137
--|Cerebral palsy
Definition
Cerebral palsy is a group of non-progressive clinical syndromes due to brain abnormalities
from a variety of causes that is characterized by motor and postural dysfunction of varying
severity. Though it is not progressive, the appearance of the brain lesions and the clinical
manifestations may change over time as the brain matures.

Causes:
• The etiology of the disorder is unknown in 70% of the cases
• Congenital infections (TORCH)
• Obstetric complications leading to perinatal hypoxia (toxemia, placenta previa,
abruptio placentae, etc.)
• Teratogenic substances
• Congenital abnormalities including brain malformations and hereditary disorders
• Prematurity with Intracranial hemorrhage
• Cerebral trauma
• Infections (Bacterial sepsis, meningitis, herpes)
• Metabolic disturbances (kernicterus, severe prolonged hypoglycemia, Reye’s syndrome)
• Intoxication

Clinical Signs/Symptoms:

Findings are consistent with a specific CNS lesion and commonly include:
• Spastic syndromes : diplegia, hemiplegia, or quadriplegia
• Dyskinetic syndromes : athetosis, chorea or dystonia
• Ataxic syndromes
• Atonic syndromes
• Abnormal persistence or absence of infantile reflexes

Associated Disorders & Complications may include:

• Cognitive impairments. Intellectual disability, learning problems and perceptual
difficulties are common. There is a wide range of intellectual ability and children with
severe physical disabilities may have normal intelligence
• Psychiatric disorders : Behavioral, emotional or psychiatric disorders
• Epilepsy: This occurs in 45% of patients with CP and the onset is generally in the first 2
years of life.
• Gastro-oesophageal reflux can result in oesophagitis or gastritis, causing pain, poor
appetite and aspiration.
• Speech, swallowing, vision and hearing problems
• Constipation
• Drooling (poor saliva control).
• Incontinence. Children may be late in achieving bowel and bladder control because of
cognitive deficits or lack of opportunity to access toileting facilities because of physical
disability or inability to communicate. Some children have detrusor over activity causing
urgency, frequency and incontinence.
• Growth failure: This is generally due to poor nutrition.
• Pulmonary disease: This is usually due to chronic aspiration and chronic pulmonary
disease is a leading cause of death in patients with CP.
• Orthopedic disease: This includes hip and foot deformities and spinal curvatures. Patients
may have chronic back, neck, and joint pain.

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• Osteopenia: This is multifactorial related to poor nutrition, lack of motility and chronic
medication use.
• Visual problems e.g. strabismus, refractive errors, visual field defects and cortical visual
impairment
• Hearing deficits

Diagnosis:
• Based on history and clinical examination of the patient.

Investigations:
• Neuro-imaging including brain ultrasound, CT or MRI
• Lumbar puncture if indicated
• Basic lab-work to exclude other abnormalities (liver and renal function tests)
• Genetic screening depending on the clinical and family history
• Metabolic screening depending on the clinical and family history and basic lab work
• EEG
• Audiogram and visual evaluation to exclude correctable hearing or vision loss
• X-rays if indicated

Common reasons to come to hospital

• Respiratory problems particularly pneumonia
• Uncontrolled seizures / status epilepticus
• Unexplained irritability - consider acute infections, oesophagitis, dental disease, hip
subluxation, pathological fracture.

Management:

Management involves a team approach with health professionals and teachers. Input from the
family is paramount
• Perinatal asphyxia may be managed by passive or active hypothermia as per the
neonatology protocols.
• Pharmacologic management of seizures (see above)
• Multidisciplinary services to address and promote social and emotional development,
communication, education, nutrition, mobility and maximal independence and normal
appearance.
o Physical, occupational, and speech language therapy as necessary
o Social services provided in a variety of context to aid in the coordination of care.
o Nutritional assessment and support for those with dysphagia and/or poor growth
o Mobility aids including crutches, walkers, or wheelchairs as needed
o Surgical procedures to correct spasticity, contractures, scoliosis, or hip disorders
• Pharmacologic management of spasticity:
o Botulinum toxin injections: Must be done by trained provider.
o Dantrolene oral 0.5 mg/kg/dose once daily for 7 days, then increase to 1.5 mg/kg
divided 3 times/day for 7 days, then increase to 3 mg/kg/day divided 3 times/
day for 7 days, then increase to 6 mg/kg/day divided 3 times/day. Do not exceed
400 mg/day.
o Benzodiazepines: Dose varies based on medication. Diazepam may be used: If 5
years: <8.5 kg: 0.5-1 mg at bedtime; 8.5-15 kg: 1-2 mg at bedtime; >5 years:
1.25 mg given 3 times per day up to 5 mg given 4 times per day.
o Baclofen oral: <2 years: 10-20 mg divided every 3 times per day, titrate dose every
3 days in increments of 5-15 mg/day to a maximum of 40 mg daily; 2-7 years: 20-
30 mg/day divided 3 times per day, titrate dose every 3 days in increments of 5-15

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 TREATMENT GUIDELINES 139
mg/day to a maximum of 60 mg/day, >8 years: 30-40 mg/day divided every 8
hours, titrate dose every 3 days in increments of 5-15 mg/day to a maximum of
120 mg/day.
o Intrathecal baclofen: Requires neurosurgical intervention to place pump to deliver
medication. The benefits and complications should be discussed in detail with the
neurosurgeon.

MANAGEMENT OF THE SICK

NEONATES 0-7 DAYS
Name: Age: Weight (kg): Temperature (°C):
Ask: What are the infant’s problems?: Initial Visit? Follow-up Visit

Table 36. Management of the sick neonates 0-7 days.

ASSESS (Circle all signs present) CLASSIFY

CHECK FOR SEVERE DISEASE, SEVERE BACTERIAL INFECTION , MODERATE

HYPOTHERMIA AND LOCAL BACTERIAL INFECTION
• Is the infant having difficulty in feeding?
• Has the infant had convulsions?
• Has the infant had any attacks where s/he stops breathing, or becomes
stiff or blue (apnoea)?
• Count the breaths in one minute. __breaths per minute Repeat if
elevated: _ Fast breathing?
• Look for severe chest indrawing.
• Look and listen for grunting.
• Look for pus draining from the eyelids/Swollen eyes/ No eye swelling
• Movement only when stimulated or no movement even when stimulate
• Look and feel for bulging fontanelle
• Look at the umbilicus. Is it red or draining pus? Look for discharge from
the eyes. Is there a purulent or sticky discharge? Is there abundant pus?
Are the eyelids swollen
• Fever (temperature 37.5°C or above feels hot) or
low body temperature (below 35.5°C or feels cool)
• Look for skin pustules. Are there many or severe pustules?

CHECK FOR JAUNDICE

• When did the jaundice appear first? 24h of life, > 24h of life
• Look for jaundice (yellow eyes or skin)
• Look at the young infant’s palms and soles. Are they yellow?

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DOES THE YOUNG INFANT HAVE CONGENITAL ABNORMALITIES?

• Ask the mother if she has any concerns
• Ask for any identified birth defects or other problems
• Was the mother’s RPR tested in pregnancy? If yes, was it positive or
negative? If positive, did she receive treatment? If yes, how many
doses? How long before delivery did she receive the last dose?

LOOK FOR PRIORITY SIGNS

• Cleft lip or palate
• Imperforate anus Yes _ No _
• Nose not patent
• Macrocephaly or Microcephaly or (birth head circumference more than
39 cm or <32cm)
• Ambiguous Genitalia
• Abdominal distention
• Look for other abnormal signs

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT If the infant has no
indication to refer urgently to hospital
• Is there any difficulty feeding? Yes ___ No ___
• Is the infant breastfed? Yes _ No_ If yes, how many times in 24 hours?
__ times
• Is the infant suckling effectively (that is, slow deep sucks, sometimes
pausing)? no suckling at all, not suckling effectively, suckling effectively
• Is the infant able to attach? no attachment at all, not well attached,
good attachment
• Look for ulcers or white patches in the mouth (thrush).
• Does the infant usually receive any other foods or drinks? Yes ___ No
___ If yes, how often?
• What do you use to feed the child?
• Determine weight for age. Low ___ Not low ___

ASSESS FOR LOW BIRTH WEIGHT

• Look at the current weight of the newborn; is it <1500 grams?
• Is it between 1500g and 2500g
• Is it above 2.5kg

CHECK FOR HIV INFECTION Note mother’s and/or child’s HIV status:
• Mother’s HIV test: NEGATIVE /POSITIVE/ NOT DONE/KNOWN
• Child’s virological test: Child’s serological test: NEGATIVE/ POSITIVE/
NOT DONE
• If mother is HIV positive and NO positive virological test in young
infant: Is the infant breastfeeding now? Was the infant breastfeeding
at the time of test or 6 weeks before it? If breastfeeding: Is the mother
and infant on ARV prophylaxis?

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ASSESS BREASTFEEDING
• Has the infant breastfed in the previous hour? If the infant has not fed
in the previous hour, ask the mother to put her infant to the breast.
Observe the breastfeed for 4 minutes. Is the infant able to attach?
• To check attachment, look for: Chin touching breast: Yes ___ No ___
Mouth wide open: Yes ___ No Lower lip turned outward: Yes ___ No
___ More areola above than below the mouth: Yes ___ No ___ not
well attached good attachment
• Is the infant sucking effectively (that is, slow deep sucks, sometimes
pausing)? not sucking effectively sucking effectively

Return
CHECK THE CHILD’S IMMUNIZATION STATUS (Circle immunizations needed for next
today) BCG OPV-0 Hep B 0 immunization
on: _ (Date)

MANAGEMENT OF THE SICK NEONATE 0-7 DAYS OLD

Table 37. Assess for severe disease or severe bacterial infection, moderate hypothermia and local bacterial infection

SIGNS CLASSIFY AS IDENTIFY TREATMENT

Presence of one of the following
signs;
Administer the first pre-transfer dose of
• Convulsions antibiotics in IM (Ampicillin 50mg/kg stat
• Unable to eat and Gentamycin 5mg/kg stat)
• Fast breathing (> = 60 cycles Administer phenobarbital IM in case of
per minute) OR SEVERE BACTERIAL
ongoing seizures
• Severe costal recessions OR INFECTION
(15mg/kg)
• Grunting OR Start warming the newborn if hypothermia
• No movements even if stimulation OR
Prevent hypoglycaemia (G 10% 2ml/Kg
OR stat)
• Movements if stimulation OR VERY SEVERE
Explain to the mother how to keep baby
• Fever (≥37, 5 ° C) OR DISEASE
warm during the transfer
• Severe hypothermia (<35.5 ° C) URGENTLY transfer the baby to the
• Bulging fontanelle hospital
• Apnoeic attacks
• Severe pustules

• Give an appropriate antibiotic by

mouth
• (Amoxycillin 25mg/g/dose 12hourly)
• Red umbilicus or pus discharge • Teach the mother how to treat local
LOCAL BACTERIAL
from the umbilicus. infections at home
INFECTION
• Skin pustules. • Advise the mother on the care of the
newborn at home
• Explain when to return immediately
• Review in 2 days

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• Warm the baby by skin-to-skin contact

(follow guidelines on hypothermia
• Moderate hypothermia MODERATE • Reassess after 1 hour and follow
(temperate35.5-36.5) HYPOTHERMIA guidelines on hypothermia
• Explain when to return immediately
• Review in 2 days
• Treat the newborn for any other
Bacterial infection
No sign of serious or local problem
unlikely
bacterial infection • Advise the mother on home care of the
And
No hypothermia newborn
No hypothermia
• Explain when to return immediately

Table 38. Check for feeding problem

SIGNS CLASSIFY AS IDENTIFY TREATMENT
• Give first dose of two intramuscular antibiotics.
SERIOUS ILLNESS
Ampicillin 50mg/kg stat and Gentamycin 5mg/
• Not able to feed OR
kg stat)
• No attachment at all SERIOUS
• Advise the mother how to keep the young infant
• No suckling at all. BACTERIAL
warm on the way to hospital.
INFECTION
Refer URGENTLY to hospital.

• If the attachment is not good or the sucking is not

effective:
- explain the good position and the good
attachment.
- help the mother to treat nipple abnormalities
if they exist
- Clean the nose if it is blocked
• If the mother is breastfeeding less than 8 times
within 24 hours, advise her to breastfeed more
often.
• If the newborn receives other foods or liquids in
• Attachment not well done addition to breast milk:
or - advise the mother to breastfeed more, reduce
• Ineffective sucking or other foods and fluids, and use a cup.
• Less than 8 feedings in 24 - give appropriate advice if the mother is HIV
hours or FEEDING positive
• Receives other foods or PROBLEM • If no breastfeeding: Refer for Breast feeding
liquids or counselling
• Ulcerations or white - Advise and encourage mother on
patches in the mouth or breastfeeding and possibly relactation if
• Malformation in the mouth mother is HIV-negative.
- Teach the mother to correctly prepare a
breast-milk substitute and use a cup especially
if the mother is HIV-positive
• In case of thrush, teach the mother to treat him at
home.
• In case of malformation to the mouth, refer
better management
• Teach the mother how to care for the newborn at
home.
• Explain when to return immediately
• Review the newborn in 2 days

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 TREATMENT GUIDELINES 143
Congratulate the mother for the good nutrition of
Normal weight for age the newborn
NO FEEDING
and no any other sign of Encourage the mother to breastfeed more and
PROBLEMS
inadequate feeding. reinforce hygiene.
Explain when

Table 39. Asses for low birth weight

SIGNS CLASSIFY AS IDENTIFY TREATMENT
• Ensure enough warm ( skin to skin) before and during
transfer
VERY LOW • Test for low blood sugar, and treat or prevent it
Less 1.5kg BIRTH WEIGHT • Teach the mother how to keep the infant warm on
way to hospital
• Refer the new born to hospital in KMC position
• Teach the mother to keep the baby warm at home
(Kangaroo)
• Encourage the mother to breastfeed every 2 or 3
hours
Weight between LOW BIRTH • Review the newborn every day until good
1500g and 2500g WEIGHT breastfeeding, gaining weight and body
temperature remains stable
• Then see the newborn 14 days after the last visit
• Explain when to return immediately
• Treat the newborn for any other problem
NO LOW • Advise the mother on the care of the newborn at
Weight ≥ 2500 g WEIGHT
home
• Explain when to return immediately

Table 40. Assess for eye infection

SIGNS CLASSIFY AS IDENTIFY TREATMENT
• Administer the appropriate antibiotic systemically
(Ceftriaxone 50mg/kg IM x 1 dose Max 125mg
OR cefotaxime single dose of 100 mg/kg)
PROBABLE • Teach the mother how to look after the eyes of the
Swollen and GONOCOCCAL newborn at home
purulent eyes EYE INFECTION • Advise the mother to keep the newborn warm
• Explain when to return immediately
• Review the child 2 days later
• Treat parents for Gonococcal genital infection
• Apply the first dose of local antibiotic into the
eyes(Gentamycin eye drops 1 drop 8h for 7 days
• Show the mother how to look after the child at
Purulent eyes CONJUNCTIVITIS
home
• Explain when to return immediately
• Review the child 5 days later
• Treat the newborn for any other problem
No swollen or NO EYE • Advise the mother on the care of the newborn at
purulent eyes INFECTION home
• Explain when to return immediately

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CLASSIFIFICATION OF JAUNDICE IN NEWBORN 0-7 DAYS

1. SEVERE JAUNDICE 2. JAUNDICE 3. NO JAUNDICE

Table 41. Classifification of jaundice in newborn 0-7 days

SIGNS CLASSIFY AS IDENTIFY TREATMENT

Jaundice appearing within
24 hours of life • treat to prevent hypoglycaemia
OR Pink: SEVERE • Refer URGENTLY to hospital
Jaundice on the palms and JAUNDICE • Teach the mother how to keep the infant warm
soles of the feet at any on way to hospital
age.
• Advise the caregiver to return immediately if
Jaundice appearing after palms and soles appear yellow
24 hours of age Yellow: • Follow-up in 2 days
AND JAUNDICE
Palms and soles not yellow • Teach the mother home care

Green: Advise the mother to give home care for the

No jaundice NO young infant
JAUNDICE

Table 42. Check for HIV infection

SIGNS CLASSIFY AS IDENTIFY TREATMENT
HIV test of the mother POSSIBLE • Treat the infant according to guidelines/
and / or father of the HIV classification
child is positive TRANSMISSION • Refer the infant to the HIV clinic
HIV status of parents is
unknown • Start treatment for other classifications/
OR HIV guidelines
HIV test of one of the TRANSMISSION
parents is negative and PROBABLE • Counsel parents on HIV prevention and
it is positive for an other voluntary testing
parent
HIV test of the mother
and father of the HIV • Give advice to the mother on newborn care.
child is negative TRANSMISSION • No specific interventions for HIV
during pregnancy or NOT PROBABLE • Counsel on HIV Prevention
breastfeeding

Table 43. Assess for congenital problems

SIGNS CLASSIFY AS IDENTIFY TREATMENT

Any one of the PRIORITY
SIGNS: • Keep warm, skin to skin or transport in
Cleft palate or lip incubator
Imperforate anus Pink: • Test for low blood sugar, and treat or
Nose not patent MAJOR prevent
Macrocephaly ABNORMALITY
Ambiguous genitalia OR SERIOUS • Encourage mother to continue
Abdominal distention ILLNESS breastfeeding or give EBM 3ml/kg per
Ompholocaele / hour
gastroschidis • Refer URGENTLY

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 TREATMENT GUIDELINES 145
• Keep warm, skin to skin
• Assess breastfeeding If not able to
Yellow: breastfeed, give EBM 3ml/kg per hour on
Other abnormal signs BIRTH the way
ABNORMALITY • Address any feeding problems and
support mother to breastfeed successfully
• Refer for assessment
Mother’s RPR positive and
she is • Check for signs of congenital syphilis and
Untreated/Partially
treated (fewer if present refer to hospital
than three doses) / Yellow: • If no signs of congenital syphilis, give
Treatment completed less POSSIBLE intramuscular penicillin
than 1 month before CONGENITAL • Ask about the caregiver’s health, and treat
delivery SYPHILIS as necessary.
OR • Ensure that the mother receives full
Mother’s RPR is not known,
and it is not possible to get treatment for positive RPR.
the result now
Green: Counsel the caregiver on home care for the
No risks nor abnormal signs NO BIRTH young infant
ABNORMALITIES

Table 44. Assses all young infants for risk factors

SIGNS CLASSIFY AS IDENTIFY TREATMENT

• If mother has received TB treatment for more than 2
months, is smear negative and baby is well, give baby
BCG and follow the baby every month for 2 months
• If mother has received TB treatment for less than 2
months before delivery or smear positive, refer to
Mother or is on TB hospital to check the baby for signs of congenital TB;
treatment Yellow: o Those that are symptomatic should be
Mother has TB and TB EXPOSED treated for TB
not on treatment o Those without active TB disease should be
on IPT for 6 months.
• Give BCG 2 weeks after completion of INH or TB
treatment
• Ask about the caregiver’s health, and treat as
necessary
Infant weighed
less than 2 kg at
birth
OR • Monitor growth and health more frequently
Admitted to • Assess feeding and encourage breastfeeding
hospital for more Yellow: • Conduct home visits to assess feeding and growth
than three days AT RISK • Encourage mother to attend follow-up appointments
after delivery INFANT and refer to other services if indicated (further medical
OR assessment, ECD centre, support groups )
Known
neurological
or congenital
problem

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Mother has died

• Assess breastfeeding and support mother to
or is ill
breastfeed successfully
OR
Yellow: • If not breastfeeding, counsel and explain safe
Infant not
POSSIBLE replacement feeding
breastfed
SOCIAL • Monitor growth and health more frequently
OR
PROBLEM • Conduct home visits to assess feeding and growth
Teenage caregiver
• Refer to other available services if indicated (social
OR
worker, ECD centres or community based organisations)
Social deprivation
Green:
No risk factors NO RISK Counsel the caregiver on home care for the young infant
FACTORS

MANAGEMENT OF THE SICK

YOUNG INFANT AGED 1 WEEK TO
2 MONTHS
Name: Age: Weight (kg): Temperature (°C):
Ask: What are the infant’s problems?: Initial Visit? Follow-up Visit

Table 45. Management of the sick young infant aged 1 week to 2 months
ASSESS (Circle all signs present) CLASSIFY
CHECK FOR SEVERE DISEASE AND BACTERIAL INFECTION
• Is the infant having difficulty in feeding?
• Has the infant had convulsions?
• Has the infant had any attacks where s/he stops breathing, or becomes
stiff or blue (apnoea)?
• Count the breaths in one minute. __breaths per minute Repeat if
elevated: _ Fast breathing?
• Look for severe chest indrawing.
• Look and listen for grunting.
• Look for pus draining from the ear.
• Movement only when stimulated or no movement even when stimulate
• Look and feel for bulging fontanelle
• Look at the umbilicus. Is it red or draining pus? Look for discharge from
the eyes. Is there a purulent or sticky discharge? Is there abundant pus?
Are the eyelids swollen
• Fever (temperature 38°C or above feels hot) or
low body temperature (below 35.5°C or feels cool)
• Look for skin pustules. Are there many or severe pustules?

CHECK FOR JAUNDICE

• When did the jaundice appear first?
• Look for jaundice (yellow eyes or skin)
• Look at the young infant’s palms and soles. Are they yellow?

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DOES THE YOUNG INFANT HAVE DIARRHOEA?
• For how long?
• Is there blood in the stool?
• Look at the young infant’s general condition.
• Does the infant: move only when stimulated?
• Does not move even when stimulated?
• Lethargic or unconscious
• Is the infant restless and irritable?
• Offer the child fluid: Not able to drink or drinking poorly? Drinking Yes _ No _
eagerly, thirsty?
• Look for sunken eyes.
• Pinch the skin of the abdomen. Does it go back: Very slowly? Slowly?

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT If the infant has no
indication to refer urgently to hospital
• Is there any difficulty feeding? Yes ___ No ___
• Is the infant breastfed? Yes _ No_ If yes, how many times in 24 hours? __
times
• Is the infant suckling effectively (that is, slow deep sucks, sometimes
pausing)? no suckling at all, not suckling effectively, suckling effectively
• Is the infant able to attach? no attachment at all, not well attached,
good attachment
• Look for ulcers or white patches in the mouth (thrush).
• Does the infant usually receive any other foods or drinks? Yes ___ No
___ If yes, how often?
• What do you use to feed the child?
• Determine weight for age. Low ___ Not low ___

CHECK FOR HIV INFECTION Note mother’s and/or child’s HIV status:
• Mother’s HIV test: NEGATIVE /POSITIVE/ NOT DONE/KNOWN
• Child’s virological test: Child’s serological test: NEGATIVE/ POSITIVE/
NOT DONE
• If mother is HIV positive and NO positive virological test in young infant:
Is the infant breastfeeding now? Was the infant breastfeeding at the
time of test or 6 weeks before it? If breastfeeding: Is the mother and
infant on ARV prophylaxis?

ASSESS BREASTFEEDING
• Has the infant breastfed in the previous hour? If the infant has not fed in
the previous hour, ask the mother to put her infant to the breast. Observe
the breastfeed for 4 minutes. Is the infant able to attach?
• To check attachment, look for: Chin touching breast: Yes ___ No ___
Mouth wide open: Yes ___ No Lower lip turned outward: Yes ___ No
___ More areola above than below the mouth: Yes ___ No ___ not well
attached good attachment
• Is the infant sucking effectively (that is, slow deep sucks, sometimes
pausing)? not sucking effectively sucking effectively

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Return
CHECK THE CHILD’S IMMUNIZATION STATUS (Circle immunizations needed for next
today) BCG OPV-0 DPT+HIB-1 OPV-1 Rotavirus 1 immunization
on: _ (Date)
RISK FACTORS IN ALL YOUNG INFANT
• Has the mother been on TB treatment in the last 6 months? If so, for how
long was she on treatment before the infant was born?
• How much did the infant weigh at birth?
• Was the infant admitted to hospital after birth? If so, for how many
days?
• Who is the child’s caregiver?
• How old is the mother/caregiver?
• Is the infant exclusively breastfed?
ASSESS OTHER PROBLEMS: Ask about mother’s own health

MANAGEMENT OF THE SICK YOUNG INFANT AGED 1 WEEK TO 2 MONTHS

CLASSIFICATION OF SIGNS OF SERIOUS ILLNESS IN A SICK YOUNG INFANT
1. VERY SEVERE DISEASE OR POSSIBLE BACTERIA INFECTION
2. LOCAL BACTERIAL INFECTION
3. NO SEVERE DISEASE OR LOCAL INFECTION UNLIKELY

VERY SEVERE DISEASE OR POSSIBLE BACTERIA INFECTION

Table 46. Classification of signs of serious illness in a sick young infant

SIGNS CLASSIFY AS IDENTIFY TREATMENT

Any one of the following signs
• Convulsions OR
• Apnoea or breathing < 30 per
minute OR
• Fast breathing (> 60 per
minute), chest indrawing, nasal
flaring or grunting.OR
• Bulging fontanelle. OR
• Give first dose of antibiotic IMI
• Fever (37.5° or above or feels
(Ampicillin 50mg/kg stat and
hot) or low body temperature
Gentamycin 5mg/kg stat)
(less than 35.5° or feels cold). Pink:
• Give an anti convulsant
OR POSSIBLE
(Phenobarbital IM 15mg/kg)
• Only moves when stimulated or VERY SEVERE
• Treat to prevent hypoglycaemia
unconsciousness, OR DISEASE
• Breastfeed if possible
• Abundant pus/purulent
• Keep the infant warm on the way
discharge from eyes, or swollen
• Refer URGENTLY
eyelids OR
• Pus draining from ear OR
• Umbilical redness extending
to the skin and/or draining pus
OR
• Many or severe skin pustules
OR
• Unable to feed

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• Treat skin pustules and a red
umbilicus with oral Cloxacillin
• Red umbilicus or purulent Yellow: LOCAL 50mg/kg 8h for 5 days
OR BACTERIAL • Teach the caregiver to treat local
• Skin pustules. INFECTION infections at home and counsel on
home care for the young infant
• Follow-up in 2 days
Green: SEVERE
None of the signs of very severe DISEASE OR Advise mother to give home care
disease or local bacterial infection LOCAL INFECTION and when to come back
UNLIKELY

CLASSIFIFICATION OF JAUNDICE IN A SICK YOUNG INFANT

2. SEVERE JAUNDICE 2. JAUNDICE 3. NO JAUNDICE

Table 47. Classifification of jaundice in a sick young infant

SIGNS CLASSIFY AS IDENTIFY TREATMENT

• Test for low blood sugar, and treat or
Any jaundice if age less
Pink: SEVERE prevent it (G10% 2ml/kg)
than 24 hours or Yellow
JAUNDICE • Keep the infant warm
palms and soles at any age
• Refer URGENTLY
• Advise the caregiver to return immediately if
Jaundice appearing after palms and soles appear yellow
Yellow:
24 hours of age and Palms • Follow-up in 1 day
JAUNDICE
and soles not yellow • If the young infant is older than 14 days,
refer for assessment
Green: Advise the mother to give home care for the
No jaundice
NO JAUNDICE young infant

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Table 48. Classifification of feeding problems or low weight

SIGNS CLASSIFY AS IDENTIFY TREATMENT

• Give first dose of intramuscular antibiotics
SERIOUS ILLNESS
IMI (Ampicillin 50mg/kg stat and
Not able to feed or No OR Gentamycin 5mg/kg stat)
attachment at all or Not • Treat to prevent low blood sugar.
SERIOUS
suckling at all. • Advise the mother how to keep the young
BACTERIAL
infant warm on the way to hospital.
INFECTION
• Refer URGENTLY to hospital.
• Advise the mother to breastfeed as often
and for as long as the infant wants, day and
night
 If not well attached or not suckling
effectively, teach correct positioning and
attachment.
 If breastfeeding less than 8 times in 24
Not well attached to hours, advise to increase frequency of
breast or feeding
Not suckling effectively • If receiving other foods or drinks, counsel
or mother about breastfeeding more, reducing
Less than 8 breastfeeds FEEDING PROBLEM other foods or drinks, and using a cup.
in 24hours or OR LOW WEIGHT • If not breastfeeding at all:
Receives other foods or  Refer for breastfeeding counselling and
drinks or possible relactation.
Low weight for age or  Advise about correctly prepared breast
Thrush milk substitutes and using a cup.
• If thrush, teach the mother to treat thrush at
home.
• Advise mother to give home care for the
young infant.
• Follow-up any feeding problem or thrush in
2 days.
• Follow-up low weight for age in 14 days.
Not low weight for age • Advise mother to give home care for the
NO FEEDING
and no other signs of young infant
PROBLEM
inadequate feeding • Praise the mother for feeding the infant well.

Table 49. Asses the neonate for hiv infection

SIGNS CLASSIFY AS IDENTIFY TREATMENT
• Give Cotrimoxazole prophylaxis from age
4–6 weeks
• Assess the child’s feeding and counsel as
CONFIRMED HIV necessary
Child has Positive PCR
INFECTION • Refer to HIV clinic for staging, assessment
and initiation of ART
• Advise the mother on home care
• Follow-up in 14 days

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• HIV test of Mother • Give co-trimoxazole prophylaxis from age
and/or father is 4–6 weeks
positive POSSIBLE HIV • Assess the child’s feeding and give
• OR INFECTION/HIV appropriate feeding advice
• Child has positive EXPOSED • Refer to HIV clinic to confirm infant’s HIV
HIV antibody test status
• (seropositive) • Follow-up in one month
Start treatment according to the current
HIV status for both Probable HIV classification
parents not known infection Advise parents to do HIV testing and encourage
HIV prevention
Negative HIV test for Treat, counsel and follow-up existing infections
mother and father HIV INFECTION Advise the mother about feeding and about her
during pregnancy or UNLIKELY own health
breastfeeding period No specific intervention for HIV

Table 50. Assess for congenital problems

SIGNS CLASSIFY AS IDENTIFY TREATMENT
Any one of the PRIORITY
SIGNS:
• Keep warm, skin to skin or transport in
Cleft palate or lip
Pink: incubator
Imperforate anus
MAJOR • Test for low blood sugar, and treat or
Nose not patent
ABNORMALITY prevent
Macrocephaly
OR SERIOUS • Encourage mother to continue breastfeeding
Ambiguous genitalia
ILLNESS or give EBM 3ml/kg per hour
Abdominal distention
• Refer URGENTLY
Very low birth weight (≤
2kg)
• Keep warm, skin to skin
• Assess breastfeeding If not able to
Yellow: breastfeed, give EBM 3ml/kg per hour on
One or more abnormal
BIRTH the way
signs
ABNORMALITY • Address any feeding problems and support
mother to breastfeed successfully
• Refer for assessment
Mother’s RPR positive and
she is
Untreated/Partially
treated (fewer • Check for signs of congenital syphilis and if
than three doses) / present refer to hospital
Treatment completed less Yellow: • If no signs of congenital syphilis, give
than 1 month before POSSIBLE intramuscular penicillin
delivery CONGENITAL • Ask about the caregiver’s health, and treat
OR SYPHILIS as necessary.
Mother’s RPR is not • Ensure that the mother receives full treatment
known, for positive RPR.
and it is not possible to
get
the result now

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Green:
No risks nor abnormal Counsel the caregiver on home care for the
NO BIRTH
signs young infant
ABNORMALITIES

CLASSIFIFICATION OF DIARRHEA
IN A SICK YOUNG INFANT
Table 51. classifification of diarrhoea in a sick young infant
SIGNS CLASSIFY AS IDENTIFY TREATMENT
• If the infant is classified as NO POSSIBLE
SEVERE BACTERIAL INFECTION:
• - Give liquids and treat as severe
Two of the following signs: dehydration ( Plan C) OR
• Lethargic or unconscious. • If the infant is classified as POSSIBLE
• Sunken eyes. SEVERE BACTERIAL INFECTION: Give
Pink: SEVERE
• Skin pinch goes back first dose of intramuscular antibiotics IMI
DEHYDRATION
very lowly. (Ampicillin 50mg/kg stat and Gentamycin
• Young infant less than 5mg/kg stat)
one month of age. • Refer urgently to the Hospital
• Breastfeed or give frequent sips of ORS on
the way if possible
• Keep the infant warm on the way to hospital
• Give fluid for some dehydration ( Plan B)
• If the infant is classified as POSSIBLE
SEVERE BACTERIAL INFECTION: Give
Two of the following signs: first dose of intramuscular antibiotics IMI
Yellow:
• Restless, irritable. (Ampicillin 50mg/kg stat and Gentamycin
Signs of
• Sunken eyes. 5mg/kg stat)
• Skin pinch goes back • Refer urgently to the Hospital and advise
DEHYDRATION
slowly. the mother to give frequent sips of ORS
on the way if possible and to continue
breastfeeding Explain how to come back
immediately
• Give fluids to treat for diarrhoea at home
• If exclusively breastfed, do not give other
Not enough signs to Green: fluids
classify as some or severe NO • Give zinc for 14 days
dehydration. DEHYDRATION • Counsel the caregiver on home care for the
young infant
• Follow-up in 2 days
Pink:
• Refer after treating for dehydration if
Diarrhoea lasting 14 days SEVERE
present
or more PERSISTENT
• Keep the infant warm on the way to hospital
DIARRHOEA
Pink: • Treat hypoglycaemia
Bloody • Keep the infant warm on the way to hospital
Blood in the stool.
diarrhoea • Refer URGENTLY.

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CLASSIFIFICATION OF FEEDING
PROBLEMS OR LOW WEIGHT
Table 52. Classifification of feeding problems or low weight

SIGNS CLASSIFY AS IDENTIFY TREATMENT

• Give first dose of IM (Ampicillin

50mg/kg stat and Gentamycin 5mg/
kg stat)
Not able to feed or No NOT ABLE TO FEED—
• Treat to prevent low blood sugar.
attachment at all or Not POSSIBLE SERIOUS
• Advise the mother how to keep the
suckling at all. BACTERIALINFECTION
young infant warm on the way to
hospital.
• Refer URGENTLY to hospital.

• Advise the mother to breastfeed as

often and for as long as the infant
wants, day and night
 If not well attached or not suckling
effectively, teach correct positioning
and attachment.
 If breastfeeding less than 8 times
in 24 hours, advise to increase
frequency of feeding
Not well attached to
• If receiving other foods or drinks,
breast or
counsel mother about breastfeeding
Not suckling effectively
more, reducing other foods or drinks,
or
and using a cup.
Less than 8 breastfeeds FEEDING PROBLEM OR
• If not breastfeeding at all:
in 24hours or LOW WEIGHT
 Refer for breastfeeding counselling
Receives other foods or
and possible relactation.
drinks or
 Advise about correctly prepared
Low weight for age or
breast milk substitutes and using a
Thrush
cup.
• If thrush, teach the mother to treat
thrush at home.
• Advise mother to give home care for
the young infant.
• Follow-up any feeding problem or
thrush in 2 days.
• Follow-up low weight for age in 14
days.

• Advise mother to give home care for

Not low weight for age
the young infant
and no other signs of NO FEEDING PROBLEM
• Praise the mother for feeding the
inadequate feeding
infant well.

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ASSSES ALL YOUNG INFANTS FOR

RISK FACTORS
Table 53. Assses all young infants for risk factors

SIGNS CLASSIFY AS IDENTIFY TREATMENT

• If mother has received TB treatment for more than
2 months, is smear negative and baby is well,
give baby BCG and follow the baby every month
for 2 months
• If mother has received TB treatment for less than
2 months before delivery or smear positive, check
the baby for signs of congenital TB;
Mother is on TB Yellow: o Those that are symptomatic should be treated
treatment TB EXPOSED for TB
o Those without active TB disease should be on IPT
for 6 months.
• Do an HIV PCR test at 6 weeks, or earlier if the
child is sick
• Give BCG on completion of INH or TB treatment
• Ask about the caregiver’s health, and treat as
necessary
Infant weighed less
than 2 kg at birth • Monitor growth and health more frequently
OR • Assess feeding and encourage breastfeeding
Admitted to hospital Yellow: • Conduct home visits to assess feeding and growth
for more than three • Encourage mother to attend follow-up
AT RISK
days after delivery appointments and refer to other services if
OR INFANT indicated (further medical assessment, ECD centre,
Known neurological support groups )
or congenital
problem
Assess breastfeeding and support mother to
Mother has died or
breastfeed successfully
is ill
If not breastfeeding, counsel and explain safe
OR Yellow:
replacement feeding
Infant not breastfed POSSIBLE
Monitor growth and health more frequently
OR SOCIAL
Conduct home visits to assess feeding and growth
Teenage caregiver PROBLEM
Refer to other available services if indicated
OR
(social worker, ECD centres or community based
Social deprivation
organisations)

Green:
Counsel the caregiver on home care for the young
No risk factors NO RISK
infant
FACTORS

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MANAGEMENT OF THE SICK CHILD
AGED 2 MONTHS UP TO 5 YEARS
Names:
Age: Weight (kg): Height/Length (cm): Temperature (°C):
Ask: What are the child’s problems? Initial Visit? Follow-up Visit
Table 54. Management of the sick child aged 2 months up to 5 years

ASSESS (Circle all signs present) CLASSIFY

CHECK FOR GENERAL DANGER SIGN

• Not able to drink or breastfeed General danger
• Vomits everything sign present
• Convulsions lethargic or unconscious Yes _ No _
• Convulsing now.

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how

long? ___ Days
Count the breaths in one minute: ___ breaths per minute.
Fast breathing? Look for chest indrawing Yes __ No __
Look and listen for stridor
Look and listen for wheezing

DOES THE CHILD HAVE DIARRHOEA?

For how long? ___ Days Is there blood in the stool?
Look at the child’s general condition. Is the child: Lethargic or
unconscious?
Restless and irritable? Look for sunken eyes. Offer the child fluid; Not
able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin
of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? Yes _ No _
Slowly?

DOES THE CHILD HAVE FEVER? (by history/feels hot/

temperature 37.5°C or above)
Decide malaria risk: High ___ Low ___ No___
For how long? ___ Days If more than 7 days, has fever been present
every day?
Has child had measles within the last 3 months?
Do a malaria test, if NO general danger sign in all cases in high malaria
risk or NO obvious cause of fever in low malaria risk: Test POSITIVE? P.
falciparum P. vivax NEGATIVE?
Look or feel for stiff neck
Look for runny nose
Look for signs of MEASLES: Generalized rash and One of these: cough,
runny nose, or red eyes
Look for any other cause of fever.

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If the child has measles now or within the last 3 months::

• Look for mouth ulcers. If yes, are they deep and extensive? Look
for pus draining from the eye. Look for clouding of the cornea.
DOES THE CHILD HAVE AN EAR PROBLEM? Yes __ No __ Is there ear
pain? Is there ear discharge? If Yes, for how long? ___ Days
Look for pus draining from the ear Feel for tender swelling behind the
ear
CHECK FOR ACUTE MALNUTRITION
Look for oedema of both feet. Determine WFH/L z-score: ____ Less
than -3? Between -3 and -2? -2 or more? For children 6 months or older
measure MUAC ____ mm.

If child has MUAC less than 115 mm or WFH/L less than -3 Z scores or
oedema of both feet:

Is there any medical complication: General danger sign? Any severe

classification? Pneumonia with chest indrawing? Child 6 months or older:
Offer RUTF to eat. Is the child: Not able to finish? Able to finish? Child
less than 6 months: Is there a breastfeeding problem?

Signs of severity
- Prostration,
- Unconsciousness,
- Convulsion,
- Signs of pneumonia (rapid breathing, stridor, chest pain),
- Diarrhoea,
- Hypothermia,
- Sign of dehydration,
- Shock sign (cold end, uncollected pulse),
- fever,
- pallor,
- Difficulty to eat.
OTP ** Outpatient Therapeutic Program,
SFP *** Supplementation Feeding Program

CHECK FOR HIV INFECTION

Note mother’s and/or child’s HIV status
Mother’s HIV test: NEGATIVE/POSITIVE /NOT DONE/KNOWN
Child’s virological test: NEGATIVE/POSITIV/ NOT DONE
Child’s serological test: NEGATIVE/POSITIVE/NOT DONE
If mother is HIV-positive and NO positive virological test in child: Is the
child breastfeeding now? Was the child breastfeeding at the time of test
or 6 weeks before
CHECK THE CHILD’S IMMUNIZATION STATUS (Circle immunizations
needed today)
BCG OPV-0 Hep B0 ; DPT+HIB-1 OPV-1 Hep B1 RTV-1 Pneumo-1;
DPT+HIB-2 OPV-2 Hep B2 RTV-2 Pneumo-2; DPT+HIB-3
OPV-3 Hep B3 Pneumo-3; Measles1 Measles 2 Vitamin A
Mebendazole

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Check for anaemia
• Look for palmar pallor. Is she: Severe? Mild? No pallor)
ASSESS FEEDING if the child is less than 2 years old, has MODERATE
ACUTE MALNUTRITION, ANAEMIA, or is HIV exposed or infected
Do you breastfeed your child? Yes ___ No ___ If yes, how many times
in 24 hours? ___ times. Do you breastfeed during the night? Yes ___ No
___
Does the child take any other foods or fluids? Yes ___ No ___ If Yes, FEEDING
what food or fluids? How many times per day? ___ times. PROBLEMS
What do you use to feed the child?
If MODERATE ACUTE MALNUTRITION: How large are servings? Does the
child receive his own serving? ___ Who feeds the child and how?
During this illness, has the child’s feeding changed? Yes ___ No ___ If
Yes, how?

ASSESS OTHER PROBLEMS: Ask about mother’s own health

Table 55. Classification table for cough and/or difficult breathing

SIGNS CLASSIFY AS IDENTIFY TREATMENT

• Give first dose of an appropriate antibiotic
• Any danger signs or
SEVERE (Ampicillin 50mg/kg stat and Gentamycin
• Chest indrawing or
PNEUMONIA OR 5mg/kg stat)
• Stridor in calm child.
SEVERE DISEASE • Treat to prevent hypoglycaemia
• Grunting
• Refer URGENTLY to hospital.
• Give an appropriate oral Amoxycillin
25mg/kg/dose 12hourly for 5 days.
• Soothe the throat and relieve the cough with
• Fast breathing PNEUMONIA
a safe remedy.
• Advice mother when to return immediately.
• Follow-up in 2 days.
• If coughing more than 14 days, refer for
NO assessment.
No signs of pneumonia or PNEUMONIA: • Soothe the throat and relieve the cough
very severe disease. COUCH OR with a safe remedy. Advise mother when to
COLD return immediately
• Follow-up in 5 days if not improving.
Table 56. Classification table for dehydration

SIGNS CLASSIFY AS IDENTIFY TREATMENT

1. If child has no other severe classification;
Two of the following signs: • Give fluid for severe dehydration (Plan C).
• Lethargic or unconscious
• Sunken eyes 2. If child also has another severe classification:
SEVERE
• Not able to drink or • Refer URGENTLY to hospital with mother giving
DEHYDRATION
drinking poorly frequent sips of ORS on the way.
• Skin pinch goes back • Advise the mother to continue breastfeeding
very slowly 3. If child is 2 years or older and there is
cholera in your area, give antibiotic for cholera

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Two of the following signs: • Give fluids to treat dehydration ( Plan B)

• Give Sulphate de Zinc
- Agitated, irritable • If the child is classified as severe disease and
- Sunken eyes DEHYDRATION need a transfer:
- Drink strongly with thirst • Refer URGENTLY to hospital with mother giving
- Skin pinch goes back frequent sips of ORS on the way.
slowly • Advise the mother to continue breastfeeding

• Give fluids and treat diarrhoea ( plan A)

No signs to classify as
NO • Give Zinc Sulphate
dehydration or severe
DEHYDRATION • Explain the mother when to return immediately
dehydration
• Review in 3 days if no improvement

Table 57. Classification table for persistent diarrhoea

SIGNS CLASSIFY AS IDENTIFY TREATMENT

• Treat dehydration before referral
unless the child has another severe
SEVERE DIARRHOEA
Dehydration present classification.
PERSISTENT
• Give Zinc Sulphate
• Refer to hospital.
• Advise the mother on feeding a child
who has PERSISTENT DIARRHOEA.
• Give Zinc sulphate and multivitamins for
PERSISTENT
No dehydration 14 days
DIARRHOEA
• Explain to the mother when to return
immediately
• Follow-up in 5 days.

Table 58. If blood in the stool

SIGNS CLASSIFY AS IDENTIFY TREATMENT
• Treat for 5 days with
Ciprofloxacin, oral, 15 mg/kg/
dose 12 hourly
Bloody diarrhoea • Give Sulphate de Zinc
Blood in stool • Explain to the mother when to
return immediately
• Review in 2 days
Table 59. Classification table for high malaria risk
SIGNS CLASSIFY AS IDENTIFY TREATMENT
• Give quinine or Artesunate for severe malaria (first dose).
• Give first dose of Ampicillin 150mg/kg stat and
Any Gentamycin 5mg/kg
general VERY SEVERE (Preferably Cefotaxime 100mg/kg stat)
danger sign FEBRILE DISEASE • Treat the child to prevent low blood sugar
Stiff neck • Give one dose of paracetamol in clinic for high fever
(38.5° C or above).
• Refer URGENTLY to hospital.

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• If NO cough with fast breathing, treat with oral
antimalarial (Coartem)
Fever (by
• If cough with fast breathing, treat with Amoxycillin (25mg/
history or
kg/dose 12hourly) for 5 days
feels hot or
MALARIA • Give paracetamol for high fever (38.5° C or above).
temperature
• Advise mother when to return immediately.
37.5° C or
• Follow-up in 2 days if fever persists.
above)
• If fever is present every day for more than 7 days, REFER
for assessment.

Table 60. Classification table for low malaria risk and no travel to a high risk area

SIGNS CLASSIFY AS IDENTIFY TREATMENT

• Give quinine or Artesunate for severe malaria (first

dose).
• Give first dose of Ampicillin 150mg/kg stat and
Any general Gentamycin 5mg/kg
VERY SEVERE
danger sign (Preferably Cefotaxime 100mg/kg stat)
FEBRILE DISEASE
Stiff neck • Treat the child to prevent low blood sugar
• Give one dose of paracetamol in clinic for high fever
(38.5° C or above).
• Refer URGENTLY to hospital.

• If NO cough with fast breathing, treat with oral

antimalarial
NO runny nose • If cough with fast breathing, treat with Amoxycillin
and 25mg/kg/dose (or Cotrimoxazole) for 5 days
NO measles. MALARIA • Give paracetamol for high fever (38.5° C or above).
NO other • Advise mother when to return immediately.
cause of fever • Follow-up in 2 days if fever persists.
• If fever is present every day for more than 7 days,
REFER for assessment.

Runny nose • Give one dose of paracetamol in clinic for high fever
present or (38.5° C or above)
FEVER— • Advise mother when to return immediately.
measles
MALARIA
present or
UNLIKELY • Follow-up in 2 days if fever persists.
Other cause of • If fever is present every day for more than 7 days
fever present REFER for assessment

Table 61. Classification table for measles (if measles now or within the last 3 months

SIGNS CLASSIFY AS IDENTIFY TREATMENT

• Give vitamin A
• Give first dose of Give first dose
Any general danger sign
of Ampicillin 150mg/kg stat and
or SEVERE
Gentamycin 5mg/kg
Clouding of cornea or COMPLICATED
• If clouding of the cornea or pus draining
Deep or extensive mouth MEASLES
from the eye, apply tetracycline eye
ulcers.
ointment
• Refer URGENTLY to hospital

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• Give vitamin A
• If clouding of the cornea or pus draining
Pus draining from the eye MEASLES WITH
from the eye, apply tetracycline eye
or EYE AND MOUTH
ointment
Mouth ulcers COMPLICATIONS
• If mouth ulcers, treat with gentian violet.
• Follow-up in 2 days.
Measles now or within the
MEASLES • Give vitamin A.
last 3 months.

Table 62. Classification table for ear problem

SIGNS CLASSIFY AS IDENTIFY TREATMENT

• Give first dose of Give first dose of
Ampicillin 150mg/kg stat and Gentamycin
Tender swelling behind the
MASTOIDITIS 5mg/
ear.
• Give first dose of paracetamol for pain.
• Refer URGENTLY to hospital.
Pus is seen draining.
• Give Amoxycillin25mg/kg/dose12h for 5
from the ear and discharge
days
is reported for less than 14 ACUTE EAR
• Give paracetamol for pain.
days INFECTION
• Dry the ear by wicking.
or
• Follow-up in 5 days
Ear pain.

Pus is seen draining.

Dry the ear by wicking
from the ear and discharge CHRONIC EAR
Follow-up in 5 days
is reported for 14 daysor INFECTION
more

No ear pain and No pus NO EAR No additional treatment.

seen draining from the ear. INFECTION

Table 63. Check for anaemia

SIGNS CLASSIFY AS IDENTIFY TREATMENT
Severe palmar Treat the child to avoid hypoglycaemia
SEVERE ANEMIA
pallor *Refer urgently to the hospital

• If the child is less than 2 years old, evaluate the

child’s diet and advise the mother to feed her
child as per guidelines
• Give iron / folic acid
Palmar pale pallor
MILD ANEMIA • Give Mebendazole if the child is 12 months old
or older (if he has not received it in the previous 6
months).
• Explain to the mother when to return immediately
• Review the child in 14 days.

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• If the child is under 2 years of age, evaluate the
child’s diet and advise the mother to feed the
child as per guideline
• If feeding problem, review the child in 5 days.
No palmar pallor NO ANAEMIA
• Give Mebendazole if the child is 12 months old
or older (if he has not received it in the previous 6
months).
• Explain to the mother when to return immediately

Table 64. Check for acute malnutrition

SIGNS CLASSIFY AS IDENTIFY TREATMENT

• Treat the child to avoid
Oedema of both feet
hypoglycaemia
• Sign of severity • Warm the child to avoid
WITH SEVERE ACUTE hypothermia
• Weight for age ≤-3 DS and / or MALNUTRITION WITH • Refer URGENTY to the
• MUAC <115 mm (11.5cm) COMPLICATION hospital
[MUAC for HIV child, TBC <120 mm
(12cm)]

Sign of severity Treat the child to avoid

WITH hypoglycaemia
• Weight for age between -2 and -3 MODERATE ACUTE Warm up the child to avoid
DS AND / OR MALNUTRITION WITH hypothermia
• MUAC between 115 and 125 COMPLICATION Refer URGENTLY to the
[MUAC for HIV child, TBC between hospital
120 and 130 mm]

Weight for age ≤-3 DS and / or SEVERE ACUTE • Keep the child warm to
• MUAC <115 mm (11.5cm) MALNUTRITION avoid hypothermia
[MUAC for HIV children, TBC <120 WITHOUT • Transfer to the nutritional
mm (12cm)] COMPLICATIONS service (OTP)

Weight for age between -2 and -3 DS

AND / OR • Transfer to the SFP service
MODERATE ACUTE
(Igikoni cy’umudugudu)
MALNUTRITION
• MUAC between 115 and 125 mm • Mother’s Education
WITHOUT
on Child Feeding and
[MUAC between 120 and 130 mm for COMPLICATIONS
Hygiene
children HIV and TB]
• Transfer to the SFP service
Size over age ≤ -3 DS
(Igikoni cy’umudugudu)
SEVERE CHRONIC
OR • Mother’s Education
MALNUTRITION
on Child Feeding and
• Weight for age ≤-3 DS
Hygiene

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Weight-age between -2 and -3 DS

(-2≤DS <-3)
• Mother’s Education on
MODERN CHRONIC
OR Child Nutrition and
MALNUTRITION
Hygiene
• Weight for age between -2 and -3
DS (-2≤DS <-3)

• If the child is less than 2

years old, evaluate the
child’s diet and advise the
Weight for height and height-age mother to feed the child
and normal weight-age (Greater than as per protocol
NO MALNUTRITION
- 2 DS), normal MUAC and without • If feeding problem,
bilateral pitting oedema review the child in 5 days
• Explain to the mother
when to return
immediately.

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REFERENCES
1. Hadjiloizou and Bourgeois. Antiepileptic drug treatment in Children.
Expert Rev Neurotherapeutics 2007. Updated to 2011.
2. Loddenkemper, T., & Goodkin, H. (2011). Treatment of Pediatric
Status Epilepticus. In H. S.
3. Singer (Ed.), Pediatric Neurology. In Current Treatment Options
in Neurology. Springer Science + Business Media. DOI 10.1007/
s11940-011-0148-3
4. Miller, G. Clinical Features of Cerebral Palsy. In: UpToDate.,
Patterson, MC (Ed), UpToDate, Waltham, MA.
5. Miller, G. Epidemiology and Etiology of Cerebral Palsy. In UpToDate.,
Patterson, MC (Ed), UpToDate, Waltham, MA.
6. Miller, G., Management and Prognosis of Cerebral Palsy. In
UpToDate., Patterson, MC (Ed), UpToDate, Waltham, MA.
7. Miller, G., Diagnosis of Cerebral Palsy. In UpToDate., Patterson, MC
(Ed), UpToDate, Waltham, MA.
8. Pocket Book of Hospital Care for Children. World Health Organization
(2005). Geneva, Switzerland: WHO Press.
9. Wilfong, A., Management of status epilepticus in children. In
UpToDate., Nordii, D (Ed), UpToDate, Waltham, MA.
10.Wilfong, A., Clinical features of status epilepticus in children. In
UpToDate., Nordii, D (Ed), UpToDate, Waltham, MA.
11.Wilfong, A. Treatment of seizures and epileptic syndromes in children.
In UpToDate., Nordii, D (Ed), UpToDate, Waltham, MA.

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The list of contributors

Ministry of Health and Stakeholders
Names Institution
1 Dr Corneille NTIHABOSE MOH
2 Dr Parfait UWALIRAYE MOH
3 Dr Nathalie UMUTONI MOH
4 Dr MUVUNYI Zuberi MOH
5 Theobald HABIYAREMYE MOH
6 Eliezer NSENGIYUMVA MOH
7 Dr Felix SAYINZOGA RBC
8 Dr Francois UWINKINDI RBC
9 Dr Evariste NTAGANDA RBC
10 Dr Jean Louis MANGARA RBC
11 Marc HAGENIMANA RBC
12 Frederic MUHOZA RFDA
13 Dr Lysette UMUTESI RSSB
14 Alexis RULISA RSSB
15 Esperance MUKARUSINE RSSB
16 Dr Emmanuel SABAYESU MMI
17 Diane MUTONI RMS
18 Jean Bernard MUNYANGANZO RMS
19 Julie KIMONYO NCNM
20 Prof. Annette UWINEZA RMDC
21 Jean Damascene GASHEREBUKA RAHP
22 Prof. Emile RWAMASIRABO Consultant
22 Dr Raymond MUGANGA Consultant
23 Dr Richard BUTARE Consultant
24 Prof. Charlotte M. BAVUMA RCP
25 Stella Matutina TUYISENGE WHO
26 Dr William NIRINGIYIMANA RHIA
27 Patrick RUGAMBYA MPC
28 Eugene R. Abinene USAID
29 Theogene NDAYAMBAJE RFDA
30 Jean D’Amour URAMUTSE NUDOR
31 Ines MUSABYEMARIYA FHI
32 Dr Georges RUZIGANA RSOG

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Pediatrics
No Names Specialty
1 Prof.. Stephenson Musiiime Pediatrics
2 Phn Damaris Uwase Pharmacy
3 Dr. Nkuranga John Baptist Pediatrics
4 Dr Emmanuel Rusingiza Pediatrics
5 Dr. Manzimpaka Albert Pediatrics
6 Dr. Butare Richard Expert
7 Phn. Hitayezu Felix Pharmacy
8 Prof. Emile Rwamasirabo Lead Expert
9 Dr. Raymond Muganga Expert
10 Dr Florent Rutagarama Pediatrics
11 Phn. Fredric Muhoza Pharmacy
12 Dr. Christian Umuhoza Pediatrics
13 Phn Esperance Mukarusine Pharmacist
14 Dr Anabel Kayirangwa Pediatrics
15 Phn Noel Rutambika Pediatrics
16 Dr Oscar Mwizerwa Pediatrics
17 Phn.Denyse Niyoturamya Pharmacy
18 Dr Febronie Mushimiyimana Pediatrics
19 Dr. Hippolyte BWIZA MUHIRE Pediatrics
20 Dr Aimable Kanyamuhunga Pediatrics
21 Dr Nyalihama Alain Pediatrics

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