Table 4. Essential principles of pediatric care in resource-limited settings.

Oxygen therapy	1. Know from where the oxygen source is coming and what the maximum possible liter flow is 2. Consistent electricity is a must if you are depending on oxygen concentrators 3. Nasal cannulas work best with low-flow systems such as concentrators 4. Non-rebreather/partial rebreather masks require high-flow oxygen to use
Pulse oximetry	1. Important monitoring tool for both the ward and the operating room 2. Heart rate reading must match the patient's actual heart rate in order for pulse oximeter readings to be accurate 3. Set the limits appropriate to child's condition and the limits the nurse should respond to (i.e., if a HR of 180 is acceptable in 14 mo with asthma, then set the high heart rate at 180 not 140 and expect the nurse to respond to the alarm 4. Pulse oximeter readings are dependent on pulsatile flow and usually accurate at 70–99%. Below 70 or at 100%, they are not accurate. Make pulse oximeter monitor audible with saturation changes which can be helpful in noting that a patient is having desaturation episodes 5. Potential inaccuracies with pulse oximetry may include decreased pulsatile flow caused by severe vasoconstriction in situations such as hypovolemia, hypotension, cold; cardiac failure can result in inability of pulse oximeter to pick up; bright overhead lights can cause the pulse oximeter to read inaccurately and pulse oximeter cannot distinguish between different forms of hemoglobin such as carboxyhemoglobin (CO poisoning) or methemoglobin. Nail polish, venous congestion of limbs, and badly placed lead can affect readings 6. Pulse oximetry is not affected by dark skin, jaundice, or anemia 7. Teach staff to respond to all alarms by checking patient first before assuming that the pulse oximeter reading is wrong!
Delivery of drugs	1. Know which drugs can be IV, IM, or po 2. Know whether something is to be given IM vs. subcutaneous vs. intradermal 3. Whenever giving IV drips, use either an IV pump (ideal) or if IV pumps unavailable look for microdrip giving sets with buretrol/burette or chamber. Calculate carefully how to dilute drug and how to ensure that rate is correct 4. Dilute drugs the same way every time when possible. If diluting IV aminophylline ampoule for neonate and ampoule is 250 mg/10 mL, then 1 mL = 25 mg; if you add 9 mL of sterile water to 1 mL of aminophylline, you now have 1 mL = 2.5 mg which is then easy to dose for a neonate
BP	1. Low normal BP for a neonate is < 60; for a 1–2 y is 60, and child is 70 + 2X age in years 2. BP in a child with shock is the last thing to deteriorate and BP cuffs often not available in the developing world. Look for other signs of decreased end organ perfusion such as change in mental status, decreased peripheral perfusion and capillary refill, tachycardia, decreased urinary output, and hypoxia
Glucose dilutions	1. Use D 10 W for neonates and young infants (can make by diluting D 50 W, i.e., take 2 mL of D50W and add 8 mL of sterile water) 2. D 25 W in children (10 mL of D50 + 10 mL sterile water) 3. D 50 W in adolescents/adults 4. Research glucometers before purchasing—ensure strips are available and affordable
Fluid management	1. Calculate maintenance fluids total; first 10 kg–100 mL/kg, second 10 kg–50 mL/kg, and greater than 20 kg–20 mL/kg 2. Microdrip giving set = 60 drops/mL (gtts/min = mL/h. Microdrip giving set has a tiny wire in the drip chamber) 3. The standard giving set is often 20 drops/mL (mL ÷ 3 = no. of gtts/min) 4. Blood giving set is often 15 drops/mL (mL ÷ 4 = no. of gtts/min) 5. If unsure about the drops/mL, then place drops in a cup and measure with a syringe, i.e., if the giving set is a 20 gtts/mL giving set, then 20 drops in a syringe should be about 1 mL 6. Teach calculating and writing fluids as mL/h and drops per min and amount per unit time, i.e., mL in 4 or 8 h
Blood products	1. Must be screened for at least HIV and hepatitis B or do not give 2. Determine if whole blood, settled cells or true packed cells as this will determine the volume needed for a given patient
Strict intake and output	1. Urine output is one of most valuable tools longitudinally to help determine adequacy of cardiac output and tissue perfusion 2. If Foley catheter in place must follow intake and output
Nebulizers and MDIs	1. Delivery of nebulized drug is facilitated by use of a commercially available nebulizer. When using wall oxygen or air to deliver drugs, correct gas flow rate is crucial. Most devices require 10–12 L/min gas flow to generate correct particle size 2. Homemade spacers are useful in therapy for children with acute asthma. 23 Use of bottle spacers should be incorporated into guidelines for asthma management in developing countries. (A) Homemade spacers can be made utilizing 500 mL plastic cold drink bottles. (B) Cut hole in base to fit size and shape of MDI. (C) Seal bottle-MDI perimeter with glue, and (D) Use opposite end as mouthpiece 3. For infants and young children MDI can be placed in the mouthpiece end and a mask created from the cut end of the bottle
Body temperature maintenance	1. Except in the case of hypoxic ischemic encephalopathy of the newborn or postcardiac arrest, cold infants and children should be warmed 2. External warming is essential in hypothermic infants/children 3. Skin-to-skin care can be used for infants and even young children beyond the neonate and when coupled with a hat and wrap around the infant provides one of the most effective ways to warm 4. Beware of hot water bottles as can cause severe burns; never put skin-to-skin (always wrap)
Nutrition	A good estimation of maintenance calories is maintenance fluids based on ideal body weight, i.e., 10 kg child needs about 1,000 mL/d and about 1,000 calories/d
Universal precautions	1. Good hand washing and/or hand sanitation must be made available to all health care workers 2. Gloves must be worn whenever potential contact with blood or body fluids (minimum) 3. Sharps must be disposed of in puncture proof containers which can be homemade if needed 4. Dispose of all blood and body fluids in a way that others can not be accidentally exposed 5. Have HIV prophylaxis and testing available 24/7 for all health care workers

Abbreviations: BP, blood pressure; HIV, human immunodeficiency virus; IM, intramuscular; IV, intravenous; HR, heart rate; MDI, metered-dose inhaler.