1) The document provides updates to the basic paediatric protocol including revisions to neonatal resuscitation procedures, treatment of neonatal sepsis, CPAP use, and fluid administration for shock. 2) Key revisions include introducing a minimum of two rescuers for neonatal resuscitation, caution against rapid bag mask ventilation, and introducing trophic feeding for newborns on day 0 of life. 3) The document identifies needed corrections such as noting ceftriaxone can cause hyperbilirubinemia in premature babies and adding dosing information for cefotaxime. It also requests additions like a skills session on CPAP use.

1. BASIC PAEDIATRIC PROTOCOL
JUNE 2020 EDITION

2. Neonatal care

3. Neonatal Resuscitation
New update (2020 edition):
- Resuscitation should be done by 2 people minimum
- Using a BMV to deliver breaths should be done at a rate around 30
breaths/minute. Rapid bag mask ventilations can be harmful to the baby.
NB:
- 1 person-resuscitation: that person should focus on airways and breathing
alone during resuscitation (A&B alone)

4. Neonatal sepsis
New update:
- Table 16 on Duration of treatment for neonatal sepsis (including neonatal skin
infections) (Page 61)
- Antibiotic treatment of newborns at risk for infection (Page 61)
What needs to be corrected:
- Ceftriaxone may induce hyperbilirubinemia. We need to add an asterisk
mentioning that it should not be used in premature babies and neonates with
jaundice (Page 17, Page 73)
- We need to add a column on Cefotaxime (Appendix 1, page 73).

5. Fluid/Feeding newborn
What is new:
- Newborns (even unstable babies, unless there is a medical or surgical
contraindication) can be fed on Day 0 of life through trophic feeds (2020
edition)
➔ Unstable/critically ill babies were not fed on day 0 of life in 2014
guidelines

6. CPAP use
New update
- The CPAP machine use was introduced in the new protocols (2020 edition)
What needs to be added
- Needs to have a PPT presentation and Skill Teaching session on the use of
CPAP

7. Infant/child

8. ABC Collapsed infant/ child
What is new
- If 1 rescuer in case of pulseless victim, the Chest compressions/ ventilations
rate should be 30/ 2 (versus 15:2 in 2014)

9. Collapsed infant/ Child
5 initial rescue breaths (Page 28):
- In case we maintain the initial 5 rescue breaths, do we maintain them for 1-
person resuscitation versus 2-person resuscitation?

10. Oxygen
New updates
- SPO2 is mandatory for any child displaying signs of respiratory distress
- The rate of Oxygen delivered through nasal prongs for NEWBORNS is 1-3 L/’
in revised Rwandan ETAT protocols (Page 31) (used to be 1-2 L in 2014
guidelines.

11. WHO Revised ETAT+ Guidelines
Pulse oximetry is recommended to determine the presence of hypoxaemia in all
children with ETAT emergency signs.
- When the child has only some degree of respiratory distress, oxygen
supplementation is recommended at SpO2 < 90%.
- Children presenting with other ETAT emergency signs with or without
respiratory distress should receive oxygen therapy if their SpO2 is < 94%.

12. Shock
- Fluid therapy in case of HYPOVOLEMIC shock without malnutrition is still given within 15 minutes (2014
and 2020)
- Normal Saline or Lactate Ringer’s are the preferred fluid
What needs to be addressed:
- What about shock that are NOT associated with diarrhoea?
- What about shock that is in the febrile context?
- What about shock in the context of severe anemia?
- How many boluses in case hypovolemic shock is not resolving?
- What about shock that does not respond to the first fluid bolus in case of severe malnutrition?

13. WHO revised recommendations
Children who have shock, ie, who have all the following signs: cold extremities and a weak and fast
pulse and capillary refill >3 s, should receive intravenous fluids and consideration for other treatment
as follows:
- Give high-flow oxygen
- 10–20 mL/kg of isotonic crystalloid fluids over 30–60 min
- if severe anaemia (severe palmar or conjunctival pallor), give blood as soon as possible and do
not give other boluses of intravenous fluid
- Monitor the effect of fluid, fully assess to look for an underlying cause of shock
- If the child is still in shock after initial fluid therapy, then consider a further infusion of 10 mL/kg
over 30 min, and at the same time assess the need for other emergency treatments.
- Children with severe acute malnutrition who are in shock should receive 10–15 mL/kg bw of
intravenous fluids over the first hour. Children who improve after the initial infusion should
receive only oral or nasogastric maintenance fluids. Any child who does not improve after 1 h
should be given a blood transfusion (10 mL/kg bw slowly over at least 3 h)

14. Severely impaired circulation, no
diarrhoea, no severe anaemia and
with or without severe malnutrition
If infant / child has all of these:
• AVPU < A
• Weak / absent peripheral pulse
• Coldness of skin
• Cap Refill >3 secs
20 mls/kg Ringer’s Lactate slowly
(over 2 hours – fast boluses may do harm)
Kenya ETAT Protocols
Revised

15. Impaired circulation, no diarrhoea, no
severe anaemia and with or without
severe malnutrition
If infant / child has some but not all of these:
• AVPU < A
• Weak / absent peripheral pulse
• Coldness of skin
• Cap Refill >3 secs
Do not give bolus or extra fluids they cause
harm – give only maintenance fluids / feeds
Kenya ETAT Protocols
Revised

16. Fluid summary – no trauma etc
• Fast bolus of 20mls/kg Ringers in 15 minutes is only used in
diarrhoea complicated by severely impaired circulation (shock)
• Severely impaired circulation in other febrile children or in
severe malnutrition is treated with 20mls/kg Ringers over 2
hours (Ringers/5% dextrose in SAM)
• Blood is urgently required for severe anaemia with acidotic
breathing / respiratory distress
• Even if signs suggest impaired circulation (not severe) in
febrile illness just give maintenance fluids
Kenya ETAT Protocols
Revised

17. Fluid Summary –No trauma
Diarrhoea with
severely impaired
circulation:
Hypovolaemic
Shock
Fast bolus of
20mls/kg Ringers in
15 minutes
Severely impaired
circulation, no diarrhoea,
no severe anaemia and
with or without severe
malnutrition
20mls/kg Ringers over
2 hours (Ringers/5%
dextrose in SAM)
Impaired circulation, no
diarrhoea, no severe
anaemia and with or
without severe malnutrition
maintenance fluids

18. Hypoglycemia
New updates
- The current recommended dose of D10% for clinically symptomatic child with
hypoglycemia is 2.5 mls/kg bolus (versus 5 ml/kg in 2014 guidelines)
NB: However, the doses reported in the Algorithm are still based on D10% at
5 ml/kg (see page 15)

19. Hypoglycemia
What should be added: Use of sublingual sugar
If iv access is not possible or delayed:
- Give one teaspoon of sugar moistened with one or two drops of water
sublingually.
- If swallowing occurs repeat the sugar dose. • Repeat every 20 min or start
oral or NGT feeds to prevent rebound hypoglycemia

20. Convulsions
- Diazepam is still the first line drug for status epilepticus and can be given IV
or IR
New updates
- Second line therapy is either Phenobarbital or Phenytoin depending on local
resources (2020 edition)

21. Malaria
New updates
- Artesunate dosage for neonates and children <20 kg : 3 mg/kg/dose
- Addition of Weight-based artesunate and quinine doses table on Page 37
(2020 edition)

22. Pneumonia
New updates
1. Pneumonia is classified into 2 groups (page 46):
- Severe/very severe pneumonia
- Pneumonia
1. Addition of Table 10: Pneumonia treatment failure definitions

23. Definitions of SAM
MUAC cm WHZ
None >13.5 >-1
At Risk 12.5 to 13.4 -2 to -1
Moderate 11.5 to 12.4 -3 to -2
Severe
<11.5 <-3
Kwashiorkor

24. Advantages of MUAC
over WHZ score
• More (in screening) acceptable
to children compared to height
or weight
• Can be done by one person
• No reference table required,
single cut off applied independent
of age, sex, height
• Colour-coded tapes
• Not affected by condition that affect
weight e. g oedema, dehydration

25. MUAC
• MUAC is a better predicator of death than any of the other
measurement –H/A, W/A, W/H Score.
• MUAC appears to show consistently better predictive
power.
• Correcting MUAC for age or weight is not superior to
MUAC alone in predicting mortality.
• Combining MUAC with other anthropometric measurement
does not increase the predictive power
• MUAC-based and WHZ-based malnutrition diagnosis correlates
poorly. Diagnosis made consistently in 40% of the SAM

26. Definitions of Severe Acute Malnutrition
Aged <6 months Aged 6-59months
WHZ score <-3SD or
edema of both feet
MUAC <115 mm or
edema of both feet

27. Indications for hospital admission (SAM)
• Medical complications
• Inadequate breathing
• Severe or some circulatory compromise
• Altered consciousness
• inability to feed
• Convulsions
• Loss of appetite/unwilling to feed

28. Other
Doses of medication/Fluid
- The dose of Ampicillin for age>1 month on page 75 is different from the dose of the same drug at
the same age on page 18
- The total amount of fluids given to neonates do not match with the addition of 24 hourly EBM +
Parenteral fluids
PARs and NARs
- Outdated NARs and PARs scenarios
- Those scenarios need to be updated:
➔ Names should be revised
➔ They should incorporate additional information: height (to be used to calculate growth in term
of w/ht)