World Health Organization · Updated edition, 2016 (published 2020) · 74 pages
Evidence-based guidance on oxygen therapy, fluid resuscitation and seizure management for front-line health workers in resource-limited settings.
- Issuer
- World Health Organization
- Edition
- Updated edition, 2016 (published 2020)
- Audience
- Non-specialist health workers, clinicians, nurses, clinical officers managing sick children in low-resource settings; national policy-makers and programme managers
- Evidence
- GRADE-rated recommendations based on systematic reviews; one high-quality RCT (FEAST) and observational studies; expert consensus where evidence limited
- Reviewed
- 23 Oct 2026 · GMJ
What this guideline says
GMJ summary
This updated WHO guideline addresses three priority areas in paediatric emergency care: detection of hypoxaemia and oxygen therapy; fluid management in children with impaired circulation or shock; and management of acute seizures. It is intended for use by non-specialist health workers in low-resource settings where equipment and human resources may be limited.
The guideline makes 17 evidence-based recommendations using the GRADE methodology. Key updates include: use of pulse oximetry with specific oxygen saturation thresholds (SpO₂ <90% for respiratory distress alone, 3 s AND weak, fast pulse); and guidance on non-intravenous routes for benzodiazepine administration when IV access is unavailable.
The recommendations are based primarily on the FEAST trial, which demonstrated that rapid fluid boluses increased mortality in African children with febrile illness and impaired circulation (but not severe dehydration or malnutrition). The guideline emphasizes the importance of accurate triage, continuous reassessment, and identification of underlying causes such as severe anaemia, malaria, pneumonia or meningitis. Implementation requires training, equipment (pulse oximeters, oxygen sources) and adequate staffing for monitoring.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Use pulse oximetry for all children with ETAT emergency signs; give oxygen if SpO₂ <90% (respiratory distress alone) or <94% (other emergency signs with or without respiratory distress).
- Stop oxygen when the child no longer has emergency signs and maintains SpO₂ ≥90% in room air for 15 minutes.
- Deliver oxygen by nasal prongs at 0.5–1 L/min (neonates), 1–2 L/min (infants), 2–4 L/min (older children), or face mask (>4 L/min) to reach SpO₂ ≥94%; humidification not needed for standard flow but required if >4 L/min for >1–2 hours.
- Children with only one or two signs of impaired circulation (cold extremities OR capillary refill >3 s OR weak, fast pulse) should NOT receive rapid fluid boluses—give maintenance fluids only and reassess within 1 hour.
- Children in shock (ALL three signs: cold extremities AND capillary refill >3 s AND weak, fast pulse) should receive 10–20 mL/kg isotonic crystalloid over 30–60 min; stop if signs of fluid overload; reassess after infusion.
- Children in shock with severe anaemia (Hb <5 g/dL or haematocrit <15%) should receive blood transfusion as early as possible and only maintenance IV fluids.
- For acute seizures without IV access, use non-parenteral benzodiazepines: rectal diazepam, oral or intranasal midazolam, or rectal/intranasal lorazepam; IM lorazepam or midazolam are alternatives.
- For benzodiazepine-resistant status epilepticus, use IV valproate (preferred), IV phenobarbital or IV phenytoin with appropriate monitoring; IM phenobarbital if IV not feasible.
Updated WHO recommendations on paediatric ETAT (summary of all 17 recommendations)
Table extracted from the guideline
| Recommendation | Strength | Quality of evidence |
|---|---|---|
| 1.1 Pulse oximetry recommended; oxygen if SpO₂ <90% (respiratory distress) or <94% (other emergency signs) | Strong | Very low |
| 1.2 Stop oxygen when no emergency signs and SpO₂ ≥90% in room air | Conditional | Very low |
| 1.3 Standard-flow oxygen by nasal prongs or face mask to reach SpO₂ ≥94% | Strong | Very low |
| 1.4 Humidification not needed for standard flow | Strong | Very low |
| 1.5 Add heated humidification if flow >4 L/min for >1–2 h | Strong | Very low |
| 2.1 Children with 1–2 signs of impaired circulation: NO rapid fluids, give maintenance only | Strong | High |
| 2.2 Rapid IV fluids may be harmful in severe febrile illness, pneumonia, malaria, meningitis, malnutrition, severe anaemia, heart failure, renal failure, DKA | Strong | High |
| 2.3 Children with any sign of impaired circulation: reassess within 1 h | Strong | High |
| 2.4 Children in shock (all 3 signs): 10–20 mL/kg isotonic crystalloid over 30–60 min; full assessment; monitor; stop if overload | Conditional | Low |
| 2.5 Shock + severe anaemia (Hb <5 g/dL): blood transfusion, maintenance fluids only | Strong | Low |
| 2.6 Shock + severe malnutrition: 10–15 mL/kg over 1 h; if no improvement, blood transfusion 10 mL/kg over ≥3 h | Strong | Low |
| 3.1 No IV access for seizures: use non-parenteral benzodiazepines (rectal diazepam, oral/intranasal midazolam, rectal/intranasal lorazepam, or IM) | Strong | Low |
| 3.2 IV access available for seizures: use IV diazepam or IV lorazepam | Conditional | Very low |
| 3.3 Status epilepticus after 2 benzodiazepine doses: IV valproate (preferred), IV phenobarbital or IV phenytoin; IM phenobarbital if IV not feasible | Conditional | Low |
| 3.4 Do NOT use prophylactic antipyretics or anticonvulsants (intermittent or continuous) for febrile seizure recurrence | Strong | Low |
| 3.5 Perform blood glucose, sodium (if dehydrated/diarrhoea), lumbar puncture (if signs of meningitis) in seizures with altered consciousness | Strong | Very low |
| 3.6–3.8 Lumbar puncture criteria; defer if coma, focal signs, raised ICP, shock; neuroimaging if altered consciousness or new focal deficit | Strong | Very low |
Source: World Health Organization, Paediatric emergency triage, assessment and treatment: care of critically-ill children. Reproduced in summary form.
What changed in this edition
Versus the previous edition
- Introduction of specific oxygen saturation thresholds for starting (SpO₂ <90% or <94%) and stopping (≥90%) oxygen, replacing reliance on clinical signs alone.
- Major revision of fluid resuscitation guidance based on FEAST trial: restrictive approach for children with impaired circulation not meeting full shock criteria; conditional recommendation for judicious 10–20 mL/kg boluses in true shock.
- Expanded guidance on non-IV anticonvulsant routes (intranasal, oral, rectal midazolam and lorazepam) when IV access unavailable.
- New recommendation for IV valproate as preferred second-line agent in benzodiazepine-resistant status epilepticus.
- Strong recommendation against prophylactic antipyretics or anticonvulsants for febrile seizure recurrence.
- Clarification that rapid fluid boluses may be harmful in severe febrile illness, malaria, pneumonia, meningitis, severe anaemia, malnutrition and heart failure.
From the guideline
Verbatim
“Children with only one or two signs of impaired circulation should not receive any rapid infusion of fluids but should still receive maintenance fluids appropriate for their age and weight.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Editor-in-Chief of the Georgian Medical Journal and a WHO consultant, I consider this guideline a critical update for Georgian paediatric emergency care. The FEAST trial evidence fundamentally challenges traditional Soviet and post-Soviet fluid resuscitation practices still taught in many of our medical schools, and national protocols must be revised accordingly. I would stress to Georgian clinicians the conditional recommendation on fluid management in shock: the 10–20 mL/kg range allows clinical judgment, but the emphasis must be on cautious administration, continuous monitoring and readiness to stop if signs of overload appear—this requires adequate nurse-to-patient ratios that are often lacking in our district hospitals. The oxygen saturation thresholds are immediately implementable where pulse oximeters are available, though rural facilities in Racha, Tusheti and other mountain regions still struggle with reliable oxygen supply and electricity for concentrators. One realistic implementation caveat for Georgia: while the guideline correctly restricts fluid boluses based on African data (high malaria, anaemia prevalence), our disease epidemiology differs—bacterial meningitis and pneumococcal sepsis remain significant, and we must train clinicians to distinguish hypovolaemic shock (e.g. from dehydration, where fluids are life-saving per existing WHO diarrhoea guidelines) from distributive shock in febrile illness (where boluses may harm). National adaptation will require collaboration between the MoH, National Center for Disease Control, paediatric and emergency medicine societies, and regional clinical hospitals to ensure context-appropriate protocols and robust training before rollout.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026
Applicability
Georgia and the South Caucasus
These recommendations are highly applicable to Georgia and the South Caucasus, where district hospitals often have limited intensive-care capacity and paediatric emergencies are managed by general practitioners, emergency physicians and nurses. The guideline’s emphasis on pulse oximetry (increasingly available in Georgian facilities since 2010s), judicious fluid management and non-IV anticonvulsant routes aligns with resource constraints in rural raions. National adaptation should consider: local disease epidemiology (e.g. lower malaria prevalence than sub-Saharan Africa but significant pneumonia and meningitis burden); availability of oxygen concentrators versus cylinders in mountain regions; cold-chain requirements for lorazepam in settings with unreliable electricity; and integration with Georgia’s emergency medical services protocols. The restrictive fluid approach contradicts some Soviet-era paediatric training but is supported by high-quality evidence. Implementation will require updating national clinical protocols, training programmes (including for feldshers in remote areas) and essential medicines lists to include intranasal midazolam preparations.
Questions this guideline answers
Quick answers
When should I give oxygen to a child with pneumonia and fast breathing but no cyanosis?
Measure oxygen saturation with a pulse oximeter. If the child has only respiratory distress (fast breathing, chest indrawing) with no other emergency signs, give oxygen if SpO₂ <90%. If the child also has other emergency signs such as inability to feed, altered consciousness or signs of shock, give oxygen if SpO₂ <94%.
A febrile child has cold hands and weak pulses but capillary refill is 2 seconds—should I give a fluid bolus?
No. The child has only two of the three signs needed for the WHO definition of shock (needs cold extremities AND capillary refill >3 s AND weak, fast pulse). Give maintenance fluids appropriate for age and weight, prioritize full assessment to identify the underlying cause (e.g. malaria, pneumonia, meningitis), treat the cause, and reassess within 1 hour. Rapid fluid boluses in this situation may cause harm.
What fluid volume should I give to a 15 kg child in shock from severe malaria?
If the child meets all three criteria for shock and does not have severe anaemia (check haemoglobin), give 150–300 mL (10–20 mL/kg) of isotonic crystalloid (Ringer's lactate or normal saline) over 30–60 minutes. Reassess immediately after: if still in shock, consider one further bolus of 10 mL/kg (150 mL) over 30 min. If shock resolves, switch to maintenance fluids only. If the child has severe anaemia (Hb <5 g/dL), give blood transfusion urgently and only maintenance IV fluids—not boluses.
I cannot get IV access in a convulsing child—what should I do?
Use a non-IV benzodiazepine: rectal diazepam 0.5 mg/kg (or 5 mg if <3 years, 10 mg if ≥3 years), or buccal/intranasal midazolam 0.5 mg/kg (often given using the IV preparation), or rectal/intranasal lorazepam. If available and you are trained, IM midazolam (0.2 mg/kg, max 10 mg) or IM lorazepam can be used. These routes are as effective as IV and allow faster treatment when IV access is difficult.
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- Issuer
- World Health Organization
- Type
- Guideline
- Edition
- Updated edition, 2016 (published 2020)
- Replaces
- Paediatric emergency triage, assessment and treatment (ETAT) guidelines, 2005
- Status
- Current
- Published
- 2020-12-06
- Languages
- English (original)
- Scope
- Detection of hypoxaemia and oxygen therapy; fluid management in impaired circulation and shock; management of acute seizures and status epilepticus; diagnostic tests for seizures with altered consciousness
- Audience
- Non-specialist health workers, clinicians, nurses, clinical officers managing sick children in low-resource settings; national policy-makers and programme managers
- Pages
- 74
- Licence
- © World Health Organization 2016; all rights reserved
- ISBN
- 978 92 4 1510219
- Evidence
- GRADE-rated recommendations based on systematic reviews; one high-quality RCT (FEAST) and observational studies; expert consensus where evidence limited
- Next review
- Stated for 2019 (may have been updated subsequently)
- Record history
- Created 23 Oct 2026 · updated 23 Oct 2026 · next check Apr 2027
World Health Organization. Guideline: updates on paediatric emergency triage, assessment and treatment: care of critically-ill children. Geneva: WHO; 2016. 74 p. ISBN 978-92-4-151021-9.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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