Clinical care at first-referral hospitals in low-income countries is often
provided by nurses, paramedical workers, and non-specialist general doctors with very
limited resources. There is often inadequate support from the central level, poor access
to information, little ongoing professional development or staff training, and most often low staff morale. The WHO Pocket Book of Hospital Care for Children was first published in 2005 to provide clinical guidance for the management of
common childhood illnesses and to improve quality of care in first-referral hospitals
in these settings. Since then, new evidence has emerged and there have been changes to several WHO guidelines requiring update of the Pocket Book.
In line with the current WHO Handbook for Guideline Development, key chapters in the Pocket Book were reviewed and clinical recommendations that required updating in view of the current evidence were identified. These were prioritized
by the Guidelines Steering Committee through a consultative process with regional
offices and implementation of the Pocket Book by external experts in an effort to
identify gaps, new evidence, or changes to clinical practice that required updating.
Several sections were identified as having priority and included management of common causes of fever (acute and chronic otitis media, typhoid fever and meningitis); treatment of acute respiratory infections; treatment of dysentery; use of
antibiotics in cases with severe acute malnutrition (SAM); and management of several common neonatal conditions. These priority areas were the basis of the evidence review,
and synthesis and development of these revised recommendations.
The development of the recommendations followed the WHO guideline development process and involved identification of review questions, retrieval of up-to-date relevant evidence, assessment and synthesis of the evidence, formulation and
external review of the recommendations, and discussion on dissemination, implementation and regular updating of the guidelines.
The scientific evidence for the recommendations was synthesized using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. For each preselected priority question, evidence profiles were
prepared based on up-to-date systematic reviews. The recommendations were formulated, peer reviewed and agreed on by consensus during the Guidelines Development Group (GDG) meeting held in Geneva, Switzerland, on 14–17 February 2011.
The group assessed the available evidence and, by consensus, made a total of
50 recommendations: management of newborn conditions (11); cough and difficult
in breathing (9); dysentery (2); fever (11); severe malnutrition (2); hypoglycaemia
(1); use of oxygen therapy (11); and choice of fluids (3). In addition, the GDG
identified knowledge gaps that needed further primary research and provided guidance on the implementation of the recommendations.
The GDG determined the strength of these recommendations based on the quality of evidence (graded as very low, low, moderate, or high) and additional factors
(including values and preferences, the magnitude of effect, the balance of benefits versus risks, resource use, and feasibility of implementation). The recommendations were consequently rated as either strong (confident of desirable effects),
weak/conditional (applicable to specific situations) or not recommended (further research
required). In addition, the panel made remarks in order to ensure that each recommendation
will be understood and used in practice in the context of its intended meaning.