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419 Pages·2003·4.15 MB·English

PAEDIATRICS FOR DOCTORS
IN PAPUA NEW GUINEA
A GUIDE FOR DOCTORS PROVIDING HEALTH SERVICES
FOR CHILDREN
FRANK SHANN
Professor and Director of Intensive Care
Royal Children’s Hospital, Melbourne, Australia
Formerly Specialist Medical Officer (Paediatrics)
Goroka Base Hospital, Papua New Guinea
JOHN BIDDULPH
Formerly Senior Specialist Medical Officer (Paediatrics)
Health Department of Papua New Guinea
and
Professor of Child Health
University of Papua New Guinea
JOHN VINCE
Professor of Child Health
University of Papua New Guinea
Formerly Specialist Medical Officer (Paediatrics)
Health Department of Papua New Guinea
SECOND EDITION 2003
Copyright © 2003 by Frank Shann and John Vince
ISBN 9980-85-411-1
Cover photographs by Trevor Duke
Illustrations by Peter Kempthorne
Published by the PNG Department of Health with the funding assistance of AusAID

JOHN BIDDULPH
Sadly, John Biddulph died at the age of 62 in January 1998, well before this second edition of Paediatrics
for Doctors in Papua New Guinea was published. The first edition of the book was a result of
collaboration between John and Frank Shann, who was working as a Paediatrician at Goroka Base
Hospital, and incorporated much of John’s original book for Resident Medical Officers. John was
involved in the early stages of the preparation of the Second Edition.
John Biddulph spent almost the whole of his professional life working towards improving the health of
Papua New Guineans - particularly Papua New Guinean children and their mothers. He was a man of
extraordinary vision, determination and dedication, qualities coupled with those of compassion and self
discipline. Many of the ideas he believed in were years ahead of their time - but without exception these
ideas and his stance on important issues of health care and medical and nursing education have been
proven correct. Whilst the reasons for the substantial improvements in the health of children between the
1960s and the early 1980s were many and complex, there is no doubt that John Biddulph and his ideas
and drive played a substantial role.
John saw paediatrics and child health not just as a hospital specialty but as a subject covering all areas of
health care, education, and community and political involvement. He saw that doctors working in Papua
New Guinea must not only be excellent clinicians, but also supporters and educators of health staff, and
advocates for children at community and government levels. He wrote a number of practically based
textbooks, including Paediatrics for Health Extension Officers and Nurses, Paediatrics for Resident
Medical Officers and the first edition of the current book. As the first Professor in Child Health at the
University of Papua New Guinea, he set the foundations of the undergraduate and postgraduate courses
in child health. In addition, he was instrumental in the establishment of the Post-Basic Paediatric
Nursing course, and was personally involved in Health Extension Officer teaching. He was very much
involved in the development of the Standard Treatment Book for Common Illnesses of Children. At the
government and political level he was a prime mover in the introduction of the Baby Food Supplies
(Control) Act of 1976 - the landmark legislation protecting breastfeeding in Papua New Guinea. He was
also a member of many Health Department committees, such as the Immunisation Committee and
Pharmaceutical Committee, contributing his wisdom and experience to the development of policy
making in these areas of Public Health.
John Biddulph led by example. It has been a privilege to have worked with him as a colleague and a role
model.
We hope that doctors working with children in Papua New Guinea will find this edition of Paediatrics for
Doctors in Papua New Guinea useful. We hope, too, that they will appreciate and practice the broad
approach to child health that John Biddulph exemplified.
John Vince
Frank Shann
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ACKNOWLEDGEMENTS
Several people have helped in the production of this second edition of Paediatrics for Doctors in Papua
New Guinea. Drs Noel Yaubihi and Gertrude Didei helped with the revision of the section on paediatric
anaesthesia, and Dr Bage Yominao revised the section on eye diseases. Dr Paddy McMaster revised the
neonatal section and contributed to a number of other sections. Dr Graham Ogle revised previous
sections on paediatric endocrinology, and contributed a new section on diabetes (with Dr McMaster) and
hypoglycaemia. Dr Hanny Friesen contributed the section on HIV infection. We thank all these
colleagues. Whilst this second edition of Paediatrics for Doctors in Papua New Guinea was being
prepared, the seventh edition of Child Health for Health Extension Officers and Nurses in Papua New
Guinea by Biddulph, Stace and Danaya was also in preparation. A great deal of the practical advice
contained in both books is based on the experience of paediatricians in Papua New Guinea, and we wish
to acknowledge, with thanks, the indirect input of all our paediatric colleagues through the Paediatric
Society of Papua New Guinea.
The use of word processing has greatly facilitated the task of preparing a second edition. It has, however,
also created problems as a result of the use of different programmes at various stages and by different
people. We are indebted to Kim Ang for undertaking the job of creating uniformity in presentation, if
not in style.
Finally, we thank the Australian Agency for International Development (AusAID) for funding the book’s
production, and Dr John Christie of AusAID’s PNG Health Services Support Program (HSSP) for his
invaluable support.
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CONTENTS
JOHN BIDDULPH......................................................................................................................................i
ACKNOWLEDGEMENTS........................................................................................................................ii
CONTENTS...............................................................................................................................................iii
PREFACE.................................................................................................................................................vii
INTRODUCTION: CHILD HEALTH IN PAPUA NEW GUINEA.........................................................1
PAPUA NEW GUINEA - HEALTH INDICES..........................................................................................3
THE PROBLEMS OF CHILD HEALTH IN PAPUA NEW GUINEA......................................................5
THE 10-STEP CHECKLIST - ALL CHILDREN.....................................................................................11
RECOMMENDED BOOKS ON COMMUNITY CHILD HEALTH.......................................................12
ABBREVIATIONS...................................................................................................................................13
ABDOMINAL DISTENSION..................................................................................................................15
AMOEBIASIS..........................................................................................................................................16
ANAEMIA................................................................................................................................................17
ANAEMIA - PERSISTENT OR RECURRENT......................................................................................20
ANAESTHETHICS..................................................................................................................................22
ANAESTHETICS - DRUG DOSES.........................................................................................................27
ANAPHYLAXIS......................................................................................................................................29
ANTIBIOTICS..........................................................................................................................................31
ANTISEPTICS..........................................................................................................................................32
ARTERIAL PUNCTURE.........................................................................................................................34
ARTHRITIS (ACUTE) - ONE JOINT......................................................................................................35
ARTHRITIS OR ARTHRALGIA (ACUTE) - MORE THAN ONE JOINT............................................36
ARTHRITIS - CHRONIC.........................................................................................................................38
ASCITES - ASPIRATION - ABDOMINAL PARACENTESIS..............................................................39
ASCITES WITHOUT OTHER OEDEMA...............................................................................................40
ASTHMA..................................................................................................................................................41
ATAXIA - ACUTE OR SUBACUTE.......................................................................................................45
BIRD RESPIRATOR................................................................................................................................46
BLEEDING DISORDERS IN CHILDREN..............................................................................................50
BLOOD CULTURE..................................................................................................................................53
BLOOD PRESSURE MEASUREMENT IN INFANTS..........................................................................54
BLOOD TRANSFUSION - INDICATIONS............................................................................................55
BONE MARROW ASPIRATION............................................................................................................57
BOOKS.....................................................................................................................................................59
BURNS.....................................................................................................................................................60
CANCRUM ORIS.....................................................................................................................................62
CARDIAC ARREST.................................................................................................................................63
CARDIOMEGALY..................................................................................................................................66
CAROTID ANGIOGRAM.......................................................................................................................67
CENTRAL VENOUS CATHETERISATION..........................................................................................68
CEREBROSPINAL FLUID - EXAMINATION......................................................................................70
CEREBROSPINAL FLUID - RESULTS...............................................................................................71
CHILD ABUSE.........................................................................................................................................72
CHOLERA................................................................................................................................................75
CHRONIC RAISED INTRACRANIAL PRESSURE..............................................................................77
CISTERNAL PUNCTURE.......................................................................................................................80
COLOSTOMY AND ILEOSTOMY - STOMA MANAGEMENT..........................................................81
COMA.......................................................................................................................................................82
CONGENITAL MALFORMATIONS AND SURGICAL REFERRAL..................................................85
CONVULSIONS - ACUTE PRESENTATION........................................................................................88
CONVULSIONS - RECURRENT............................................................................................................92
CRETINISM (ENDEMIC)........................................................................................................................94
CROSSMATCH OF BLOOD...................................................................................................................95
CUT DOWN.............................................................................................................................................97
DEVELOPMENTAL MILESTONES......................................................................................................99
DIABETES MELLITUS.........................................................................................................................101
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DIARROHEA..........................................................................................................................................103
DIARRHOEA - DIAGNOSIS AND MANAGEMENT SUMMARY....................................................107
DROWNING...........................................................................................................................................108
ECG INTERPRETATION......................................................................................................................109
ENDOTRACHEAL INTUBATION.......................................................................................................113
EOSINOPHILIA.....................................................................................................................................115
EQUIPMENT..........................................................................................................................................117
EYES.......................................................................................................................................................122
FAMILY PLANNING............................................................................................................................126
FEMORAL VEIN PUNCTURE..............................................................................................................129
FEVER....................................................................................................................................................130
FEVER OF UNKNOWN ORIGIN.........................................................................................................131
FLUID AND ELECTROLYTE THERAPY...........................................................................................133
FOREIGN BODIES................................................................................................................................137
FROG BREATHING..............................................................................................................................139
GLUCOSE 6 PHOSPHATE DEHYDROGENASE DEFICIENCY (G6PD)..........................................140
HEAD CIRCUMFERENCE....................................................................................................................141
HEALTH CENTRE VISITS...................................................................................................................143
HEART DISEASE - CONGENITAL......................................................................................................147
HEART DISEASE - INNOCENT (FUNCTIONAL) MURMURS.........................................................150
HIV INFECTION....................................................................................................................................151
HOSPITALISATION..............................................................................................................................156
HYDROCEPHALUS..............................................................................................................................158
HYPERVENTILATION.........................................................................................................................160
HYPOGLYCAEMIA..............................................................................................................................161
HYPOTHYROIDISM.............................................................................................................................162
IMMUNISATION...................................................................................................................................163
INFANT FEEDING................................................................................................................................167
INTRAOSSEOUS INFUSION................................................................................................................171
INTRAVENOUS CATHETERS.............................................................................................................172
INTRAVENOUS PYELOGRAM...........................................................................................................175
JAUNDICE IN CHILDREN - SUMMARY...........................................................................................176
JAUNDICE IN CHILDREN - HAEMOLYSIS......................................................................................177
JAUNDICE IN CHILDREN - HEPATITIS............................................................................................178
JOURNALS.............................................................................................................................................180
LACTATION - DRUGS CROSSING INTO BREAST MILK...............................................................181
LACTATION INDUCTION...................................................................................................................182
LEPROSY...............................................................................................................................................184
LIMP.......................................................................................................................................................189
LIVER BIOPSY......................................................................................................................................190
LUMBAR PUNCTURE..........................................................................................................................192
LUNG ASPIRATION.............................................................................................................................193
MALARIA - SUMMARY.......................................................................................................................194
MALARIA - TREATMENT AND COMPLICATIONS........................................................................197
MALIGNANT DISEASE........................................................................................................................204
MALNUTRITION - INTRODUCTION.................................................................................................210
MALNUTRITION - MANAGEMENT - SUMMARY...........................................................................213
MALNUTRITION - DIAGNOSIS..........................................................................................................214
MALNUTRITION - INPATIENT TREATMENT.................................................................................215
MALNUTRITION - OUTPATIENT TREATMENT..............................................................................220
MEASLES...............................................................................................................................................221
MENINGITIS..........................................................................................................................................223
MENINGITIS - CRYPTOCOCCAL.......................................................................................................227
MICTURATING CYSTOURETHROGRAM.........................................................................................229
MILK FEEDS..........................................................................................................................................230
MILK MIXTURES..................................................................................................................................231
MYCOBACTERIUM ULCERANS........................................................................................................232
MYELOGRAM.......................................................................................................................................233
NEONATES - ADMISSION...................................................................................................................234
NEONATES - APNOEA.........................................................................................................................236
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NEONATES - ASPHYXIA....................................................................................................................238
NEONATES - BORN BEFORE ARRIVAL (BBA)...............................................................................240
NEONATES - CONVULSIONS............................................................................................................241
NEONATES - DRUG DILUTIONS.......................................................................................................243
NEONATES - DRUG DOSES................................................................................................................244
NEONATES - EXCHANGE TRANSFUSION......................................................................................247
NEONATES - FLUIDS AND FEEDS....................................................................................................250
NEONATES - INFECTION (NEONATAL SEPSIS).............................................................................251
NEONATES - JAUNDICE.....................................................................................................................254
NEONATES - LOW BIRTH WEIGHT..................................................................................................256
NEONATES - MECONIUM ASPIRATION..........................................................................................261
NEONATES - MENINGITIS.................................................................................................................262
NEONATES - MILK FEEDS.................................................................................................................264
NEONATES - NECROTISING ENTEROCOLITIS..............................................................................265
NEONATES - PATENT DUCTUS ARTERIOSUS...............................................................................267
NEONATES - PHOTOTHERAPY.........................................................................................................269
NEONATES - RESPIRATORY DISTRESS..........................................................................................271
NEONATES - RESUSCITATION.........................................................................................................273
NEONATES - TETANUS......................................................................................................................275
NEONATES - UMBILICAL VEIN CATHETERISATION..................................................................277
NEPHROTIC SYNDROME...................................................................................................................279
NORMAL VALUES...............................................................................................................................280
OEDEMA................................................................................................................................................282
OSTEOMYELITIS, PYOMYOSITIS AND SEPTIC ARTHRITIS.......................................................284
OTITIS MEDIA......................................................................................................................................285
PAEDIATRIC RULES............................................................................................................................286
PAEDIATRIC SURVEILLANCE UNIT................................................................................................288
PARALYSIS - ACUTE...........................................................................................................................289
PARALYSIS - CHRONIC - FLACCID..................................................................................................293
PARALYSIS - SPASTIC (HYPERTONIC)...........................................................................................295
PERICARDIAL EFFUSION AND PERICARDIOCENTESIS..............................................................297
PERITONEAL DIALYSIS.....................................................................................................................300
PERITONEAL TAP - DIAGNOSTIC....................................................................................................301
PERTUSSIS (WHOOPING COUGH)....................................................................................................302
PIGBEL (ENTERITIS NECROTICANS)..............................................................................................304
PLEURAL EFFUSION...........................................................................................................................308
PNEUMONIA.........................................................................................................................................310
PNEUMONIA - PROLONGED..............................................................................................................314
PNEUMOTHORAX...............................................................................................................................315
POISONING...........................................................................................................................................317
POISONING - BITES AND STINGS.....................................................................................................333
POISONING - PLANTS.........................................................................................................................335
POISONING - SEAFOOD INGESTION................................................................................................336
PRIMARY HEALTH CARE..................................................................................................................337
RABIES...................................................................................................................................................339
RENAL FAILURE - ACUTE.................................................................................................................340
RENAL FAILURE - CHRONIC.............................................................................................................343
RENAL TUBULAR ACIDOSIS............................................................................................................345
SEPTIC SHOCK.....................................................................................................................................346
SEXUALLY TRANSMITTED DISEASE.............................................................................................347
SKIN DISEASES....................................................................................................................................349
SNAKEBITE...........................................................................................................................................351
STRIDOR................................................................................................................................................354
STRONGYLOIDIASIS...........................................................................................................................356
SUBACUTE SCLEROSING PANENCEPHALITIS (SSPE).................................................................358
TETANUS...............................................................................................................................................360
THALASSAEMIA..................................................................................................................................362
TRACHEOSTOMY................................................................................................................................364
TROPICAL SPLENOMEGALY SYNDROME (TSS)...........................................................................366
TUBERCULOSIS...................................................................................................................................367
v
TYPHOID................................................................................................................................................373
ULTRASONOGRAPHY.........................................................................................................................375
UPPER RESPIRATORY TRACT INFECTION (URTI)........................................................................376
URETHRAL CATHETER......................................................................................................................377
URINARY TRACT INFECTION AND URINE COLLECTION..........................................................378
URINARY TRACT INFECTION - TREATMENT................................................................................381
URINE TESTS........................................................................................................................................382
VAGINAL DISCHARGE (PREPUBERTAL)........................................................................................384
WHEEZING............................................................................................................................................385
WHITE CELL COUNT OVER 40,000 PER CMM................................................................................386
YAWS.....................................................................................................................................................387
DRUG DOSES - HOSPITAL..................................................................................................................389
IV AND ORAL FLUIDS........................................................................................................................397
INDEX.....................................................................................................................................................398

vi
PREFACE
This book provides practical advice about how to deal with the day to day problems that face doctors
responsible for the health of children in Papua New Guinea, and is based on the practical experience of
the authors and their colleagues. Most of the information is directly relevant to the care of children in
other developing countries. The book is complementary to Paediatric Priorities in the Developing World
by David Morley, and no attempt has been made to duplicate Morley’s discussion of how to organize the
delivery of health care in countries such as Papua New Guinea.
The book is not intended to be comprehensive; the management of some conditions is discussed briefly
or not at all because it is intended that the reader refer to a standard work such as Stanfield’s Diseases of
Children in the Subtropics and Tropics, Nelson’s Textbook of Pediatrics or the Oxford Textbook of
Medicine. In some cases, the investigations and management suggested in this book will not be possible
at a small hospital; referral might then have to be considered, in consultation with a specialist
paediatrician. A number of procedures are described that are only infrequently performed at hospitals,
but they are included because, when they are indicated, it is often difficult to find information on how to
do them, particularly in children.
The book deals mainly with curative hospital paediatrics. As can be seen from the Introduction (p.1) the
authors do not regard curative hospital paediatrics as the only function of doctors working with children
in Papua New Guinea. You are strongly urged to read:
• Morley D. Paediatric Priorities in the Developing World, Butterworths (at least up to p.75) and
Lancet 2:1012-1014,1976.
• King M. Medical Care in Developing Countries, Oxford University Press (at least the first 13
chapters), Lancet 1:679-681,1972, and
• the Introduction to this book (p.1).
This second edition retains the problem-based format of the first. It has been updated and includes
several new sections.
References are by no means exhaustive. Some are to original work, some deal with matters of
controversy, some are up to date recommendations, and some are reviews. Doctors are encouraged to
become familiar with and to use Medline searches and to use the Internet to keep up with new
developments.
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