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Kanekal, Andra Pradesh, India. 2006-04-10
Dr. M. de Aranzabal

1- Malnutrition and nutrition counselling
2- Diarrhea, dysentery and dehydration
3- Parasites
4- Anaemia
5- Typhoid fever
6- Urinary tract infections
7- Nephrotic Syndrom
8- Vaginitis
9- Postestreptococical glomerulonephritis
10- Reumatic Fever
11- Cardiac failure
12- Dermatologic problems
13- Eye infection
14- Chikun Gunya
15- Seizures
16- Neurocisticercosis
17- HIV examination
18- Malaria
19- Osteomyelitis
20- Dog bite
21- Tuberculosis
22- Pneumonia
23- Asthma
24- Severe Bronchiolitis
25- Septicemia and Meningitis and Severe Infections

List of commonly used abbreviations
Availability of medicines
Work Schedule



A.- Causes of malnutrition
Economical factors.
Abrupt weaning because death or illness in mother, pregnancy, work…
Late weaning with exclusive breast feeding until 2 years age.
Lack of feeding culture.
Lack of animal proteins.
Lack of fruits.
Working mother.
Superstition, habits…

B.- Classification of malnutrition

· B1-. Severe malnutrition: if visible severe wasting, oedema of both feet and severe pallor. 60-80% weight for age and oedema (Marasmus, Kwashiorkor)
· B2-. Malnutrition: if some pallor and 60-80% weight for age with no oedema.
· B3-. Chronic malnutrition: normal weight for height and low height for age
· B4-. If both are present (W for A and W for H), then it is combined chronic and acute malnutrition.
It has not been possible to get specific Indian charts for children. In the future, classification could be done by standard deviations from the median at a given age.
In annex, I clip the new WHO charts for international use in which 2000 indian children have taken part.

· B1-, Severe malnutrition
Hb, TC, DC, ESR, Platelets, RBC, RBS, blood group, Total proteins, globulins, Alb/ glob.
For emergency treatment, see a specialised textbook because the amount of calories, liquids, proteins or nutrients are very especific.
Treatment is needed for hypoglycaemia, hypothermia, dehydration, electrolytes, infection, micronutrients, feeding, sensory stimulation.
Frequent small feeds of low osmolality and low lactose.
Oral or naso-gastric feeds in the first days with 100 kcal/kg/day and 130 ml/kg/day liquid. If breast feeding, continue doing.
ORS or IV fluids, Vit A injection, Vitamins, Zinc, Cooper, Furosemide if oedema, and once gaining weight, ferrous sulphate.

· B2-. Chronic Malnutrition
Chronic Malnutrition is usual in Andra Pradesh. Most of the visited children are 2 or 3 standard deviation under their appropiate weight.
The task for health workers, doctors and nurses in Andra is to give counselling and advice on feeding using words the mother understands, in each visit to the outpatients room.
It should be advisable to print “models” with an example of nutritious diet adapted to the local food and distribute them on the visits.
Also, hospital admission wards should be an example for families and a way for education in nutrition.

· The general needs for children are:

Calories: Less than 1 year age: 100 cal/kg
1 year: 1000 cal
2-10 years: add 75 calories per year
Proteins: 2,5 gr/kg

· In a varied and balanced diet which should also include fats, iron, Vit A, B complex and minerals.
· Breast feeding should be checked in the presence of a nurse or CHW if the child has any weight problem.
· Exclusive breast feeding (with no other fluids or food) is recommended as long as the mother decides it but from 6 months of age they should add complementary food.
· The number of servings should be 5 a day for infants (to 2 years old) and 3 servings and two nutritious foods between meals.
· During illness and specially in diarrhea, continuation of feeding is essential and child should receive energy dense foods with fats, oils and sugar.
· Nutritious available foods in this area are : iddlies, chapatis and any wheat or maiz bread, fruits, eggs, vegetable, sugar, oil, dhals, raggy malt, kichiri with oil, rice with milk or yoghurt, mashed banana, mashed potato with lentils and oil…
· Example of 1 year old baby (8 kg) with 5-6 times-food/day, taking into account the possibilities of the families:

7am 2 iddlies (100 cal) + 2 ts sugar (32 cal) + 1ts ghee (50cal)
9am 150 ml milk (100 cal) + 2ts sugar (32 cal)
1pm 1 cup coocked rice (90 cal) + 4 tsp coocked dhals (50cal) + 1tsp ghee or oil (50 cal) + 5 tsp greens (25 cal)
4pm 1 banana (50cal)
8pm repeat 1 pm
9pm repeat 9 am

Total: around 900 cal and 22 gr protein.

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Is mucose or bloody (*) stools or gastroenteritis for more than 48 hours and excesive looses. Usually goes with fever and abdominal pain.

A-. Ethiology:
Virus: (rotavirus is the first cause in Indian infants…)
Bacterias: ( Campylobacter*, E.colli*, Salmonella*, Shigella*, Yersinia )
Parasites: ( Giardia, Ameba*)

B.- Classification of the dehydration:
- Very severe: sunken eyes, skin pinch slower than 2 seconds, child lethargic and not able to drink or drinks poorly. Treat with IV fluids and ORS as soon as the child can swallow.
- Severe: sunken eyes, skin pinch slow, irritable and drinking eagerly. Treat with ORS rapid rehydration for the first 4 hours.
- Not dehydration: give fluid and food to treat diarrhea at home

C.- Treatment for any diarrhea:
There are three essential elements in the management: rehydration therapy, zinc and continued feeding.

C.1 Rehydration therapy: WHO guidelines.

Always better absortion in oral rehydration. Only if lethargy or not able to drink, switch to IV fluids if naso gastric tube is not available.

· If possible, oral rehydration is always better:

Breast feed infant and give Oral Rehydration Serum (ORS) at the clinic. Start with a rapid rehydration in the first 4 hours

- 200-400 ml for less than 4 months babies
- 400-700 ml for 4-to 12 months
- 700- 900 ml for 12 to 2 years
- 900-1400 ml for 2-5 years

After 4 hours, if recovery, continue giving ORS every 10 minutes.
If vomits occur, stop for 30 minutes and start again. Add soups, rice water, yoghurt…
Add 50- 100 ml for each loose stool passed.
If outpatient, and not need admission, give 2 packets to the mother and explain how to use.
Always teach the mother on preparation and administration of ORS

· If child can not swallow, put in a naso gastric tube measuring the distance mouth-nose-end of sternon. Passing the serum in a continuous way because is better tolerated. The amount is the IV amount multiplied by 3 and divided by 2. If vomiting, stop 20 minutes and start again.
Do not forget potassium: 1-1,5 ml K 15%/ 100ml of serum. Usually 1meq/kg.

· If the child can not swallow and the naso gastric tube is not available, IV perfusion Ringer, Isolyte or normosaline serum:

30ml/kg in 60 minutes for infants under 12 months and in 1 hour for children between 1 and 5 years.( if not detectable radial pulse repeat this step).
70ml/kg in next 2,5 and 5 hours respectevily.
Add 50-100ml for any loose motion.

Asses the child every 30 minutes. Check the urine. If not urine, pass the serum slower. Bigger the kid, faster the serum.

C.2 Zinc

ZINC is lost in a greater quantity during diarrhea. Replacement of the lost zinc is important to help the child recover and to keep him healthy and to avoid diarrhea in the coming 3 months.

Give always Zn for 14 days: - less than 6 months 10mg a day.
- more than 6 month 20 mg a day.

C.3 The decrease in food intake and nutrient absortion and the increase in
requirements often combine to cause weight loss and failure to thrive. In turn, malnutrition can make a diarrhea more severe, prolonged or frequent. Give nutrient rich foods during the diarrhea and after, and enhance breast feeding in infants.
Offer cereals or other starch with pulses, vegetables, meat or fish. Add 1-2 spoons of oil.
Offer fruit juices, or banana to give potassium.
Encourage the child to eat and offer nutrition six times a day during and after the diarrhea.

D.- Persistent diarrhea: lasting more than 14 days.
-If dehydrated, admit for ORS or IV fluids as explained up.
Some children can have impaired glucose absorption. In this case, stools volume increases, thirst increases and signs of dehydration worsens. These children require IV treatment.
-If no dehydration, give ORS and careful attention to feeding at least 5-6 times a day.
Some of them can have difficulty in digesting animal milk other than breast milk. If possible, give other fermented milk products with less amount of lactose. If not possible reduce the amount of animal milk to 50ml/kg/day.
Give animal proteins (egg or chicken) finely ground, and rice, vegetable oil, and sugar. Ensure an adequate caloric intake.
The most important criterion for improvement is weight gain during at least 3 successive days.

-Routine treatment of persistent diarrhea with antibiotics is not effective and should not be given. Check, however, for other extra intestinal infection that require specific antibiotic treatment.
If severe diarrhea persist, think in ameba or giardia (look for trophozoites in stools). If blood in stools, think in Shigella.

- Give micronutrients and vitamins (for 1 year old child give folate 50 microgrames, zinc 10 mg, vit A 400mg, iron 10 mg, cooper 1mg and magnesium 80 mg)

E-. Drugs
- Never use anti-diarrheal, antihemetic or opiaceous analgesic drugs and rarely antiprotozoal drugs. Antibiotics should not be given routinely, only in bloody or severe cases for they can cause clostridium difficcile diarrhea.
- If suspected dysentery treat as a Shigella. Oral cotrimoxazol, aminoglucosides, first and second generation cephalosporines are often resistant.
Less than 6 months children: give Ceftriaxone (100 mgr/kg/day OD for 5 days ).
More than 6 months children: oral ciprofloxacine (admitted in children for this purpose) 15 mg/kg/day in 2 doses for 3 days. Ceftriaxone and Ciprofloxacine are also active against Salmonella and other enterobacteria like E Colli.
Ciprofloxacine covers also V. Chollera.
If suspicions go only for E Colli, oral first and second generation cephalosporines (like cefaclor, cefuroxime or cefalexine) are good enough or IV aminoglucosides if child is very sick.
- If suspected or proved Entamoeba histolytica, treat with Metronidazol (10 mg/kg TID, 30ml syrup 5ml=200mgr, tablets 400 or 200 mg for 5 days) or Timidazol.
Amebiasis gives bloody or mucose stools with pain, tenesm, abdominal pain and moderate fever. In case of hepatic abcess, hepatomegaly, hepatic pain, nausea, vomiting, night chills, high fever.
- If cysts or trophozoites of Giardia are seen in the stools, metronidazol. It ussually goes with symptoms of persistent diarrhoea.
Drug treatment for diarrhea is not easy. The decission should be made with clinical bases most of the times or by blood, white cells or oco found in stools

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Transmission may be fecal-oral (dirty hands), directly or indirectly by contaminated water or foods.
Symptoms are inespecific or abdominal pain, nausea, cramps, diarrhea, anoemia, bad smelling or big feces, and malabsortion in severe cases.

A.- Preventive treatment:
Cut nails, wash hands very often specially before and after meals, do not move bowels around the house.
Albendazol 400 mg, one dose

B.- Infestation treatment
Albendazol (tab 200 and 400 mg, syrup 5ml/200mg):
For less than 2 years old, 200 mg first dose and 200mg tab after 14 days.
For > 2 years 400 mg first dose and 400mg after 14 days.
Or Mebendazol 100mg BD for 3 consecutive days.
Always remain to cut nails and wash hands.
Treat other members of the family.

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Young children less than 6 years old are anaemic if their haemoglobin is < 9,3 g/dl.
A blood transfusion is required if Hb is <4 gr/l or if child is less than 7 but with respiratory distress or other dangerous symptoms.
Except if the child is severly malnourished (first they have to recover), give treatment with elemental iron. Give 3-6 mg /kg/day OD or BD of iron/folate (Livogen tab 152 mgr ferrous fumerate/1.5 folate) or elemental iron syrup (Tonoferon 1ml/50mg elemental iron).
Ask the parents to return every 14 days. After 2-4 weeks anaemia corrects but treatment should be given for 3 months when iron stores are built up.
Give Mebendazole in older than 2 years if child has not received in the last 6 months (hookworm or whipworm).
Advise the mother about good feeding habits.

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Again enteric fever is a frequent and difficcult diagnosis that most of the times should be done based in clinical findings.Abdominal pain, diarrhea or constipation, or even neurologic disfunction (confussion…)
Long duration fever, headache, asthenia, anorexia, epixtasis Inespecific symptoms not always releated to enteric pathology.
Complications: pericarditis, septicaemia, peritonitis.
Differencial diagnosis with Malaria, Dengue fever, Pneumonia, UTI

A-. Diagnosis: Relative decreased white blood cell count (normal leucocytes total number), blood culture and feces culture.
Widal is valid when H is 1:320 and O is 1: 160 or bigger. Better if tube and not slide. Better at end of first week and repeat at end of second week. Here doctors do not trust in Widal and make diagnosis only by clinical suspicions

B-. Treatment: always oral if possible (is more effective).
Kids: ciprofloxacine 30ml/kg/ day BD, adults 1gr/day bd. 5-7 days.
Alternative: oral cefixime 15-20 mg/kg/day BD or if Quinolone resistant, Ceftriaxone 100mg/kg/day IM or IV OD for 10-14 days.
Isolation and paracetamol.
If neurologic complications: Dexamethasone IV 1-3 mg/kg first dose and then 1mg/kg every 6 hours for 2 days.

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Common in young female infants (E. Colli and other Gram- negative bacilli)

A.- Pyelonephritis
A1-. Diagnosis and treatment: Culture is not available. Fresh urine shows more than 5 white cells per high power field or a positive dipstick for leucocytes.
Less than 12 months old child, non specific symptoms: vomiting, no breast feeding, hypo or hyperthermia…
Admission and Ampycilline IV 200mg/kg/ day in 3 doses for 10 days and Gentamycine IM 5mg/kg/ day OD for 5 days or a parenteral cephalosporine.
If improving, change to oral treatment with cotrimoxazol, amoxicillin or cefalexine.
Investigate or send to another hospital for further evaluation if male child or repeated UTI.
More than 12 months old child, burning sensation, frequent mictions, high fever, chills, renal pain.
and Ceftriaxone IV or IM 80mg/kg/ day OD for 5 days and then oral Cefixime 8mg/kg/day in 2 doses till a total of 14 days.
Encourage to breastfeed and drink regularly.

B.- Cistitis
B1-. Admission only if high fever or systemic upset. Ussually low fever and urine pass pain and blood.

B2-. Treatment: drink plenty of water and give oral Nitrofurantoine or Cotrimoxazole 4mg trim/20mg sulpham /kg BD for 15 days. If no response change to IM Ceftriaxone.

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A.- Diagnosis

Proteinuria > 50mg/kg/24 hours in children or 3 gr in adults
Hypoalbuminemia > 30 gr /litter or > 3 g / dl
Hypoproteinemia > 60 g / litter or > 5 g/ dl
Oedema and oliguria some times
Hypercholesterolemia > 220 mg/dl

B.- Treatment

Ussually is not a Pure Nephrotic Syndrome where treatment is oral prednisolone 2mg/kg/day in 2 doses (maximum 60mg) for 4 weeks and then 2mg/kg OD every 48 hours for a total of 4-5 months (refer to a nephrologists if needed).
Non-pure nephritic syndrome:
Only if important oedema: oral furosemide 1mg/kg/day with espironolactone 2-3 mg/kg/day in 2 doses
In hypovolemia: macromolecules followed by furosemide.
Hydrosaline restriction
Hypercaloric diet with big proportion of proteins
Thromboembolic risk if resting in bed
Treat complications and infections

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Itching and white discharge
Trichomona (if posible sexual intercourse): Metronidazol 2gr OD
Candida: Clotrimazol 500mg pessary in vagina or Clotrimazol ointment.

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Most of the cases in older than 3 years. 10-15 days after a throat or skin infection
Almost always good prognosis

A.- Clinical features
Hydrosaline retention: variable, sometimes mild palpebral oedema or feet oedema smooth, not painful and with fovea, sometimes acute pulmonary or cerebral oedema with seizures…
High blood pressure
Macroscopic hematuria
Concentrated urine, oliguria
Proteines in the urine (proteinuria) usually severe.

B.- Treatment
Rest, hydrosaline restriction, oral furosemide 1-2 mg/kg/ day in 1-2 doses
(adults 40-60 mg/day).
Infectious focus treatment if there is one, and treatment of the complications: elevated blood pressure, lung oedema, seizures.

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Heart murmur which can change over time
Artritis / arthralgia
Cardiac Failure
Fast pulse rate
Pericardial friction rub
Recent streptococical infection (very high ASO and increasing)
Long lasting fever
ECG: prolonged PR interval (cardiac blockage)
Increased ESR (Erythr sedim rate) and C reactive protein

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Can be the consequence of congenital heart disease (usually in the firs months of live), acute rheumatic fever, myocarditis, acute glomerulonephritis, very severe pneumonia, severe anaemia and severe malnutrition.

A.- Diagnosis
Tachicardia: >160/min in younger than 12 months,
> than 120/ minute in a child aged 12 months to 5 years
Gallop rhythm with basal crackles on auscultation
Changing heart murmurs
Enlarged, tender liver
In infants fast breathing, in older children oedema of feet, hands or face or distended neck veins.
Severe palmar or conjunctival pallor if anoemia
Enlarged heart on X-ray
Raised blood pressure if acute glomerulonephritis

B.- Treatment
Diuretics: Furosemide 1mg/kg/first dose. If no increased urine flow, repeat after 2 hours with 2mg/kg and repeat if necessary in 12 hours. For faster action give IV. Continue, if needed with 1-2 mg/kg orally.(Lasix tablets 40 mg)
Digoxine, consider digoxine treatment: loading dose 15mcg/kg once, maintenance dose 5 mcg/kg six hours latter and then the same every 12 hours. Maximum 250mcg/dose. (tablets: 250mcg tablets or 50 mcg per 1 ml syrup)
Supplemental potassium 2-4 mmol/kg/day only if more than 5 days furosemide.(50 mgr tablets)
Acute Reumatic fever: Penicillyne one month: starting dose 1.200.000 Im or oral benzatyl penicillin.

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A.- Abcess, impetigo or forunculosis
Treat the skin by washing two or three times a day with water and soap. Then apply gentian violet or Povidone-iodine solution or ointement.
Give an oral antibiotic like cloxacylline 25-50mg/kg/6hours for 5 days if severe impetigo or abcess. In the last case, incision and drainage can be needed.
If impetigo or normal abcess, 15 mg/kg/6 hourly. (Capsules 250 and 500 mg)
If not severe infected dermatitis, bethametasone 0,1%- neomycine 0,5% ointment or dexamethasone –framycetine oint.

B.- Pediculosis
Permethrine 1% lotion

C.- Scabies
Permethrine 5%

In both cases leave in affected skin surface for 12 hours and wash. Do not apply on mucose and face. Check other members of the family. Wash clothes and bed linen with very hot water or boil it and dry under the sun. Some times may require a second treatment after 7 days.
Treat superinfection if needed before treating infestation.

D.- Muget or oral candidiasis
Nistatine solution or Clotrimazol solution or ointment 4 times a day. Also Gentian Violet 3 times a day may be enough.

E.- Tinnae Capitis or Skin Tinnae
Kethoconazol shampoo and/or Clotrimazol oint (Triben) for 15 days.
If severe, add Griseofulvine 10-20 mg/kg once a day for 6 weeks (tablets 250mg).
If nails tinnae treatment should be given for 3 months.

F.- Ptiriasis
Clotrimazol oint and Kethoconazol shampoo OD for 7 days.

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Clean the draining pus with clear water in a clean cloth.
Ciprofloxacyne oint (there are no drops), Gentamycine, Neomycine or Cloramphenicol drops TID, until the conjunctiva is perfectly white .

A-. Eye Allergy
Prednisolone acetate ophthalmic oint, Tropicamide eye drops, Fluconazol 0,3% eye drops or the combination Neomycine and bethametasone

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Artropode transmitted arbovirus. Epydemic.
Joints pain, fever, decreased platelets count.
Last for at least 2 weeks till 6 months.
The diagnosis is clinical and the treatment is symptomatic.

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A-. Ethiology
- Very often patients come for chronic treatment and usually they are not well controlled and they have not had a good initial diagnosis. Investigate the history and send them for EEG or CT scan if suspect of neurocisticercosis or if partial seizures.
-Hypoglycaemia, diabetic ketoacidosis, cerebral malaria, meningitis, head injury, birth asphyxia, neurocisticercosis
-Very frequent febrile convulsions. No rectal diazepam, nor paraldehyde, nor Phenobarbital avaliables.

B-. Treatment
For convulsions use IV phenytoine (2ml amp/50mg) 20mg/kg first dose and then 3-9 mg/kg/day, never mixed with glucose solution) or IV diacepan 0,1-0,3 mg/kg, 3mg/minute directly and repeated no more than 3 times.

-For status Diacepan or Phenitoyne or valproic. No rectal diazepam, nor paraldehyde, nor Phenobarbital avaliables

-Other antiepileptic used in chronic epilepsy. Remember that antiepileptic drugs can never be stopped suddenly:
Carbamazepine : Generalized tonic-clonic or partial
10 mg/kg/day starting dose and then increase slowly to 20-30 mg/kg/day TID
Side effects: hepatotoxicity, dizziness, anemia… (Tegretol 200mg tablets, 100ml syrup with 100mg/5 ml)

Valproate: generalized tonic-clonic, partial
10mg/kg/day start dose and then increase slowly to 5-10 mg /kg/ week. Usual dose 30-60 mg/kg/day TID
Side effects: hepatotoxycity, vomiting, anorexia, sedation.

Phenytoine : generalized tonic-clonic, partial, status
20mg/kg IV starting dose for status and then 3-9mg/kg/day BD
Side effects Hirsutism, gum hypertrophy, skin rash, Stevens-Johnson, nystagmus

Manitol if status: 5ml/kg starting dose and 2,5 ml/kg after 8 hours.

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16.- NEUROCISTICERCOSIS (Taenia Saginata)

A-. Diagnosis
CT scan with contrast

B-. Treatment:
Albendazol 15 mg/kg/ day BD 28 days.
Previous 48 hours and in the same day prednisolone 1ml/kg to avoid cerebral reactions.

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Two major and two minor criteria: ask for TRIDOT.


Fever > 1 month
Diarrhea > 1 month
Recurrent or severe pneumonia
Weigh loss or failure to thrive


Generalised lymphadenopaties
Recurrent infections like otitis, faringitis
Generalised pruriginous dermatitis
Confirmed maternal HIV
Oral candidiasis

A.- Treatment
A1-. Treatment for childs of HIV mother
Nevirapine 200mg/squarrel meter one dose
Zidovudine 2mg/kg/dose QID during 6 weeks
Cotrimoxazol 6mg/kg OD, 3 times a week since the 6th week till 18 months of age
A2-. HIV suspected TRIDOT (100 IR), 98% sensivity.
If positive, 2 ELISA should be positive (2500IR)

A3-. Post- exposure prophylaxis: TRIDOT on 0, 1, 3 and 6 months after exposition. Treatment: 3 antiretrovirales for 28 days

A4-. 3 or 4 categories:
CD count and viral replication.
If CD count > 200 and or viral replication > 50.000 copies: antiretroviral treatment.
Treatment is free for pregnant mothers, children and widows.
Otherwise 2000 IR/ month. CD count 200IR.

A5-. Symptomatic treatment:
Metronidazol and norfloxacine 400 mg/day for 5 days if bloody dysentery.

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Fever Picks in morning, afternoon and night or any long duration fever.
Headache, nausea, vomiting, weakness.
Sleepy, severe anaemia, spleno-hepatomegaly, abdominal pain.

A.- Diagnosis
Strip test or Malaria smear should be positive in 1 of 3-5 samples. Better with fever pick. Repeat every 12 hours.
Slide is more exact and accurate but it takes more time and technique to be done.

B. Treatment

Chloroquine: (Lariago 250 mg and 500 mg tablets or 50mg-5ml syrup)
10 mg/kg - first dose
5 mg/kg - 6 hours latter
5 mg/kg - next day
5 mg/kg - next day

Primaquine to kill trophozoytes (15mg tablets) 0,33mg/kg/day OD, for 14 days.

If chloroquine resistant: Mefloquine in 2 doses 20-25 mg/kg.
Only in older than 6 months
Primaquine one dose 0,33mg/kg/day.


Oral Quinine (300 mg and 600 mg tablets)
30mg/kg/day in 3 doses for 7 days and 600mg TID > 50 kg child.
If Quinine resistant add Doxicycline in older than 8 years:
100mg/day OD for 7 days (or Clindamicine)

In falling conventional malaria treatment, give Artemether as below.


If more severe, hyperpyrexia, neurological symptoms, severe anaemia, hepato-esplenomegaly renal failure, respiratory distress, bleeding manifestations…
Cerebral malaria may have encephalitis or meningitis symptoms, cranial nerve palsies behavioural changes or coma and in 99% of patients splenomegaly and very severe anoemia. In failing of conventional malaria treatment:

IV Quinine 20 mg/kg in 4 hours in 20 ml/kg of 5% dextrose.
Still sick after 12 hours 10mg/kg in 4 hours in 10ml/kg of 5% dextrose TID
Following by 10 mg/kg TID for 7-10 days oral or IV depending on the severity.


Artemeter (Larither) 3.2 mg/kg IM firs dose
1.6 mg/kg/day OD Im for 3-5 days


Primaquine one oral dose after 7 days: 0.33mg/kg

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Usually bacterial infection. Approximately 50% of cases in pre-school children.
Chronic or sub-acute osteomyelitis is frequent in developing countries where medical and surgical treatments are not commonly accessible.
Long bones affected often, fever, swelling, tenderness and guarding the affected body part are common.
For subacute and chronic infections, fever is not present, only pseudo-palsis and pain on movements.
X-ray can be normal for the first 10 days.

A-. Ethiology:
Staphylococus aureus is the most common pathogen followed by Streptococus pneumoniae and streptococcus pyogenes.
Gram-negative bacteria and group B streptococci in newborns
Pseudomona aeruginosa following penetrating wounds of the foot.
Inmunocompromised children are prone to fungi and bacteria, and malaria areas and sickle cell diseases infants to Salmonella.
Tuberculotic osteomyelitis is slow onset of swelling and a chronic course that do not respond to usual treatment.

B-. Treatment:
- Select one or more antibiotics that provide adequate coverage for common pathogens at a good dose and for long term: 5-8 weeks for osteomyelitis and 4 weeks for septic arthritis.
- Once symptoms and signs of bone and joints have subsided and ESR is falling, consider switching to oral antibiotics if the compliance it is going to be good.
- In failure of treatment or children and adolescents with penetrating trauma of the foot, perform surgical debridement before considering antipseudomonal treatment.
In arthritis think in aspiration of the joint if failure of treatment.
Also if chronicity of illness leads to necrotic bone, surgical debridement is required.
- Rest of the limb
- The usual choice is an antistaphylococical antibiotic: IV nafcillin (150 mg/kg/day in 4 doses), vancomycin ( 40 mg/kg/day in 4 doses), cefazoline ( 75-100 mg/kg/day in 3 doses) or cloxacylline (200 mg/kg/dose in 3-4 doses) and is more sure if third generation cephalosporine is added (cefotaxime 100-150 mg/kg/day in 3-4 doses or ceftriaxone 80mg/kg OD )
In younger than 3 years old babies, think that they are not inmunised against Haemophilus influenzae type B and add a third generation cephalosporins: cefotaxime, ceftriaxone or oral cefalexine (cefuroxime is not available), Samonella is also covered by cefotaxime, also for resistant S pneumoniae, and for neonatal osteomyelitis (enterobacteria, B streptococci or staphylo) the combination of vancomycin or nafcillin and cefotaxime or ceftriaxone will work.

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If superinfection, treat with cloxacillyne (tab 250 mg, syrup 5 ml/ 125 mg) 20 mg/kg/dose, 4 doses a day for 7 days.
Rabies IM vaccine on days: 0, 3, 7, 14, 28, 90.
Tetanus Toxoide 0,5 ml IM one dose if previous inmunizations already administered.

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Tuberculosis is frequent and difficult to diagnose. In my opinion is not well diagnosed in Kanekal Hospital.
It is more frequent in HIV patients, malnourished, very young children or recent measles.
A child with a positive contact should be evaluated for Tb, as the child with persistent fever and sings of pneumonia or long lasting cough more than 30 days or fever for 15 days or more, failure to thrive or loss of weight.
Sputum is almost always negative in children.

A-. Examination
Fluid on one side of the chest
Enlarged non-tender lymph nodes or a lymph-node abscess especially in the neck.
Signs of meningitis
Progressive swelling or deformity in the bone or joint, including the spine.

B-. Investigations
-Try to obtain 3 consecutive early morning fasting gastric aspiration or CSF (if clinical symptoms) or pleural or ascitis fluid for microscopic Ziehl-Nielsen (acid fast bacilli)
-Obtain chest X-ray: milliary pattern of infiltrates or persistent consolidation, pleural effusion or a primary complex.
- PPD skin test > 10mm. Remain that milliary TB, HIV children, big malnutrition, or recent measles can give a Mantoux test negative even in TB cases.

C-. Treatment
Give a total course of treatment to all confirmed or highly suspected cases, or to children who fail to respond to other likely diagnosis (like pneumonia or even abdominal parasitation).

There is a TB National Program and an Indian Paediatric Academy programme.
I will explain the last:

Group 1
Preventive therapy : Isoniacide + Rifampicine for 6 months
Asymptomatic Mantoux positive or Mantoux negative but history of contact in younger than 3 years or younger than 5 years if malnourished (III/IV).
Mantoux positive, recent converter, no signs (healed lesion, normal x-ray)
Children less than 6 years with contact.
Isoniacide 3 months, repeat mantoux. If positive 3 more months Isoniacide; if negative stop treatment.

Group 2
Primary Complex (lungs)
Isolated lymphadenitis
Pleural efussion
Simptomatic Mantoux + without any localization in less than 3 years old children or less than 5 years with risk factors.
Isoniacide and Rifampicine and Pirazynamide 2 months
Isoniazide + Rifampicine 4 months

Group 3
Progressive pulmonary disease
TB lymphadenitis multiple
Isoniacide + Rifampicine + Pirazinamide + Ethambutol 2 months
Isoniacide+ Rifampicine 4 months

Group 4
Milliary disseminated disease
Cavitatory disease
Osteoarticular disease
Abdominal, pericardial or genitourinary disease.
Isoniacide + Rifampicine +Pirazinamide+ Etambuthol 2 months
Isoniacide + Rifampicine 7 months

Group 5
Isoniacide + Rifampicine+ Pirazinamide+ Etambuthol 2 months
Isoniacide + Rifampicine 10 months

All the treatments are taken once daily (OD) fasting.
Visits to the hospital for follow-up every 15 days

INH- Isoniacide 5 mg/kg (tab 300 and 600mg)
RMP- Rifampicine 10 mg/kg (tab combining R/I: 100/50mg and 450/ 300mg)
PZA- Pirazinamide 25mg/kg (tab 500mg)
EMB- Etambutol 20mg/kg
Prednisolone 1mg/kg/day: 4-8 weeks in neuroTB, endobronchial or gen-uriny TB)
Oral calcium recommended
Vit D 100.000 units/month improves macrophages function
Vit A 50.000-100.000 units a month (decreases morbidity due to non-TB bacteria)

Default ttm between 1 week and 1 month: continue the same phase for an additional month
Default for more than 1 month , restart full treatment
Contact child is considered when living with a patient taking or who has taken TB ttm in the past 2-3 years.

Breast feeding
Give BCG vaccine
Chest X-ray normal: 6 month HNH + RMP
Chest X-ray abnormal : 2 month INH + RMP + 7 month INH + RMP

2 month INH + RMP + PZA and 7 month INH + RMP

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A-. Not severe pneumonia:
WHO recommendation: Cotrimoxazole 3 days or Amoxicillyne 50mg/kg/day in 2 doses for 5 days.
A more severe pneumonia could require amoxicylline at a higher dose of 75mg/kg/day in 2 doses for 7 days or even amoxi-clavulanic (at a high dose of amoxicilline) for 7 days.

B-. Severe pneumonia:
WHO recommendation: benzylpenicillin (50.000 units/kg IM or IV every 6 hours) for at least 3 days and then oral amoxicillin.
If the child does not improve switch to chloramphenicol (25mg/kg every 8 hours IM or IV) and then oral ttm till complete 10 days.

A severe pneumonia in children is caused in general by Pneumococo or estreptococus. Atypical bacteria are never very severe and in general we do not need to use macrolides (wich, besides, are bacteriostatic and not bactericides).

Pneumococal resistances to amoxicilline are unknown in this area as it is the haemophilus influenzae incidence.

Those, the recommendation is for precocious treatment with oral amoxicylline at very high dose (100mg/kg/day in 3 doses) or oral amoxi-clavulanic acid .

IV treatment is always recommended for very severe disease because given dose may be bigger and faster. If child improves, no long treatment is needed, 7 days of IV ampicilline or IV amoxicilline is enough.

If suspected staphilococal pneumonia (rapid deterioration despite of treatment, pneumothorax with efussion or pneumatocoele) add cloxacilline (50 mg/kg QID), doxicicline or vancomicine or other antistafilococal antibiotic (or Cefotaxime or ceftriaxone which also covers stafilococus).
Very young Infant: in the very young infant coverage is also needed for stafilococo and E. Colli: cloxacilline or vancomicyne and cefotaxime or amynoglucoside.

Except for these special cases or suspected central nervous system infections, there is no need of cefotaxime or ceftriaxone

A child with persistent fever for longer than 2 weeks and signs of pneumonia should be evaluated for tuberculosis. If another cause of the fever cannot be found, Tb should be considered and treatment for TB started and response to TB treatment evaluated.

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History of recurrent wheeze, hyperinflation of the chest, prolonged expiration, reduced air entry, good response to bronchodilators and no fever.

A-. Outpatient treatment:
There are no spacer devices but they will bring you on request.
- Inhaled medications:
- Salbutamol inhaled
- Beclomethasone inhaled
- Rotahaler to use with:
Rotacaps with salbutamol and beclomethasone(100 mcg of each/ caps)
Or plain beclomethasone (100 mcg/caps)
Or plain salbutamol (200 mcg/caps)
Or salmeterol rotacaps 50 mcg
Or salmeterol-fluticasone (50/250 mcg and 25/125 mcg)
- Salbutamol tablets 2 and 4 mg
- Salbutamol syrup 100 ml (5 ml/2mg)
- Prednisone tablets 30 mg

B-. Asthma attack:
- Nebulised salbutamol
- Nebulised epinephrine (adrenaline) 2ml/dose or 0,1 mg/kg with 9ml normosaline solution in oxigene 6-7 l/min
- Subcutaneous epinephrine (adrenaline) (0,01ml/kg of 1:1000solution). Repeat if no response.
- Aminophyline IV (5mgr/kg QID given over 30-60 minutes)
There is no 6- Metyl prednisolone IV but they can bring you on request.

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Same signs as asthma but first wheezing before the age of 2 years, not responding to bronchodilators and epidemic.
Remember that secondary bacterial infection is common in this area and very often we have to add antibiotics like in pneumonia. If the child fails to respond check for pneumothorax.

A-. Treatment:
- IV fluids if difficult swallowing or continuous vomiting to avoid aspiration.
- Oxigene 5-6/ l minute nebulized by nasal prongs or at least an appropriate size of the mask.
- 6-metil prednisolone IM or IV 0,2 mg/ kg/dose and repeat every 6 hours or switch to oral prednisone 2 mg/kg/day in 2 doses.
- Salbutamol nebulised 0.03 ml/kg/dose every 4-6 hours with normo-saline solution till a total of 3 ml in 6-8 l/min oxygen.
- Adrenaline nebulized 1:1000, 2 ml /dose and complete till 9 ml NS solution in 6-8 l/min oxygen. Adrenaline 1:1000 can also be given subcutaneously at 0,01 ml/kg /dose

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Meningitis is diagnosed by fever, stiff neck or bulging fontanelle, headache, convulsions, irritability, lethargy, a petechial rash or purpur, or an evidence of head trauma suggesting skull fracture or neurologic signs of raised intracranial pressure.

Consider septicaemia in a child with acute fever who is severily ill, when no cause is found. Meningococal septicaemia must be made if petechiae or purpura are present. Non thyphoidal Salmonella is another cause in malarious areas.

Third generation cefalosporines like Ceftriaxone (IM mixed with xilocaine or IV, 100 mg/kg/day in 1 or 2 doses ) or Cefotaxime (IV 50 mg/kg every 6 hours), are very usefull in hospital treated severe infections even with a unique dose and also as prophylaxis. They also have a good diffusion to central nervous system.
Bigger the generation, bigger the efficacity against Gram negative (big infant severe pathology) but less efficacy against Gram positives (young infant, stafilococus and streptococcus)

Thus, for neonatal Septicaemia caused in general by Klebsiella and staphilococo. Cefotaxime and cloxacilline or other antiestafilococal drug are recommended.
And for a bigger child where the causal bacteria could be streptococo or gram negatives, B-lactamic (cloxa, ampicilline) and aminoglucoside (amycacine, gentamicine) wich has a big coverage on Gram positives and Gram negatives is recommended. As it is the association of cefotaxime and cloxacillin if stafilococo is a probability (because third generation cefalosporines are not so effective against gram positives).

Quinolones are also a very good antibiotic for severe infections but is not recommended for infants because of its possibility of growth impairment. However for severe infections and in given circumstances like salmonella or Shigella it use may be advisable.

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The aim of this writing is only to help doctors who are not paediatricians and foreign paediatricians who come here for a short time, in the management of common illnesses in children.

They are based on:
· Clinical and Therapeutic Guide for developing countries. Medecins sans Frontieres. 4th Edition 2006.
· Hospital care for children. Guidelines for the Management of Common Illnesses with limited resources. World Health Organization. 2006.
· And my colleagues and my own experiences.

Some of the guidelines do not mention diagnosis or supportive care because it is supposed to be known.
Of course they may and should be modified with the knowing and background of other colleagues. I encourage -and hope- they will collaborate.

List of commonly used abbreviations




some of them are sponsored children

two times a day





when the patient goes home

at night

no abnormal findings




once a day


low cast, sponsored child-free




if necessary






three times a day


admitted children




37º Celsius




Every child has his own health chart when coming to the OP. On it, there is no vaccinations schedule status, nor development chart for weight and length, nor counselling on nutritionally adequate diets.
On this chart we write briefly the complains and the physical findings.
On discharging day, we have to write on this chart:

DOA: Date of admission
DOD: Date of discharge
Dx: Diagnosis
Ttm given: Treatment given
Ttm proposed: Treatment proposed.

Availability of medicines

Most of the medicines are available but there are not generic medicines.
The misuse of “low or not demonstrated effectivity medicines” in children is big extended, as it is the combination of antibiotics.

Work Schedule

The ward visit start at 8 o’clock. From there, the doctor goes to outpatient room until 13,30 and after the lunch break, from 14,30 to 17 or 17,30.
During the evening and nighttime, the doctor should be available for calls.

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List of commonly used abbreviations
BC BD Bot Discharge
some of them are sponsored children
two times a day
bottle when the patient goes home
at night
no abnormal findings
once a day

low cast, sponsored child-free
if necessary

Tid TSP Ward 98,3ºF
three times a day
admitted children
37º Celsius

Every child has his own health chart when coming to the OP. On it, there is no vaccinations schedule status, nor development chart for weight and length, nor counselling on nutritionally adequate diets.
On this chart we write briefly the complains and the physical findings.
On discharging day, we have to write on this chart:
DOA: Date of admission
DOD: Date of discharge
Dx: Diagnosis
Ttm given: Treatment given
Ttm proposed: Treatment proposed.

Availability of medicines
Most of the medicines are available but there are not generic medicines.
The misuse of “low or not demonstrated effectivity medicines” in children is big extended, as it is the combination of antibiotics.

Work Schedule
The ward visit start at 8 o’clock. From there, the doctor goes to outpatient room until 13,30 and after the lunch break, from 14,30 to 17 or 17,30.
During the evening and nighttime, the doctor should be available for calls.

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