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towards reduced death rates in children treated with amoxicillin plus gentamicin, but this was not signiicant.
6.4.2 Benefits and risks
Benefits Combination beta-lactam plus gentamicin reduces failure rates and may reduce
pneumonia mortality. Risks
Side efectstoxicity of recommended antibiotics as outlined in section 6.2
in the WHO Model Formulary for Children [WHO 2010].
6.4.3 Acceptability and feasibility
Value was placed on reduction in failure rates and likely reduction in mortality with beta-lactam and gentamicin combination. All drugs are in the Essential Medicines
for Children List. Ampicillin, gentamicin and chloramphenicol are the currently recommended options for management of very severe pneumonia.
Ampicillin and gentamicin are more expensive per dose than chloramphenicol. Median price [Management Science for HealthWHO 2010]:
— Ampicillin 250 mg: US 0.1786vial — Gentamicin 10mgml: US 0.0665ml
— Chloramphenicol 1 g: US 0.3600vial
6.5 Salbutamol for treatment of acute wheezeasthma and
bronchoconstriction
a Children with acute wheezeasthma and bronchoconstriction should be treated with inhaled salbutamol using a metered dose inhaler MDI with spacer devices
to relieve bronchoconstriction.
Strong recommendation, low quality evidence
b Oral salbutamol should not be used for treatment of acute or persistent wheeze except where inhaled salbutamol is not available but has no utility in testing
response to a bronchodilator.
Strong recommendation, low quality evidence 6.5.1
Evidence and summary of findings
he panel identiied a review undertaken for the Expert Committee on the Selection and Use of Essential Medicines 2008, focusing on whether oral salbutamol should
remain on the WHO Paediatric Model List [Sani, 2008]. he review identiied ive studies comparing lung function tests of asthmatics treated with oral, inhaled,
or combination oral and inhaled salbutamol. Most studies showed that inhaled salbutamol was superior in improving lung function, was efective at lower doses, and
therefore caused fewer side efects than oral salbutamol. However, oral salbutamol
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was still an efective bronchodilator and, in one study, the bronchodilatory efect of oral salbutamol lasted longer than inhaled salbutamol.
One study randomized 780 children with WHO-deined non-severe or severe pneumonia and wheeze to standard dosages of either oral 390 children or inhaled 390
children salbutamol. Children were sent home on antibiotics and a bronchodilator. Sixty-six children in the oral group and 62 children in the inhaled group failed
treatment by day 5, but this diference did not reach statistical signiicance RR 0.94, 95 CI 0.68 to 1.29
see GRADE table A7.13
. 6.5.2
Benefits and risks
Benefits Oral salbutamol is inexpensive taking into account the cost of metered-dose inhalers
for inhaled salbutamol, easy to store, easy to deliver, and therefore more likely to promote compliance.
Risks With delayed onset of action, a higher dose is required, and there is a greater
likelihood of side efects. Oral salbutamol cannot be used as a ‘trial of bronchodilator’ for which inhaled salbutamol should be used as recommended by IMCI for children
with wheeze and fast-breathing.
6.5.3 Acceptability and feasibility
Oral salbutamol is inexpensive, much easier to prescribe and deliver than inhaled salbutamol, and is likely to be more acceptable to parents and children. However, it
is an inferior mode of delivery. he emphasis should therefore be on making inhaled salbutamol and metered-dose inhalers more available globally.
