o Usually causes about 1/3 of radiographically-confirmed
pneumonia in children <2 years of age
PNEUMONIA - COMMUNITY-ACQUIRED (PEDIATRIC)
Community-acquired pneumonia is the presence of signs and symptoms of
lower respiratory tract infection acquired outside of the hospital.
The most common bacterial cause of childhood pneumonia is Streptococcus
pneumoniae. It usually causes about 1/3 of radiographically-confirmed
pneumonia in children <2 years of age.
Viruses commonly affects children <1 year of age than those aged > 2 years,
respiratory syncytial viruses (RSV) being the most frequently detected virus.
Mixed infection may occur in 8-40% of community-acquired pneumonia
cases.
Introduction
Diagnosis
 A previously healthy child presenting w/ signs & symptoms of
lower respiratory tract infection, acquired outside of the hospital
Etiology
 The most common bacterial cause of childhood pneumonia
is Streptococcus pneumoniae
o Pneumonia secondary to group A streptococcus
& Staphylococcus aureusare more frequently
associated w/ empyema or pediatric intensive care unit
(PICU) admission
 Viruses commonly affects children <1 year of age than those aged
>2 years; respiratory syncytial viruses (RSV) being the most
frequently detected virus
o Adenoviruses, bocavirus, human metapneumovirus,
influenza A & B viruses, parainfluenza viruses,
coronaviruses & rhinovirus are less frequently
identified
 Mixed infection may occur in 8-40% of community-acquired
pneumonia (CAP) cases
 Diagnosis of community-acquired pneumonia (CAP) is primarily
based on history & physical findings (eg signs & symptoms of
respiratory distress, fever)
o Laboratory & radiographic exams may aid in the
diagnosis of severe cases or in patients who failed to
show clinical improvement after initiation of antibiotic
therapy
Assessment

 Necessary to identify patients who may be effectively treated as outpatient & who may need hospitalization
 Patient’s history, presentation & physical examination are the major determinants of the severity of illness & appropriate site of care
 Severity should be based on patient’s overall clinical appearance & behavior (eg degree of alertness & eagerness to feed)

Infants Older Children

Mild to Moderate
Severe CAP Mild to Moderate CAP Severe CAP
CAP

Temperatur
<38.5 °C >38.5 °C <38.5 °C >38.5 °C
e

Resp rate <50 breaths/minute >70 breaths/minute <50 breaths/minute >50 breaths/minute

o Severe
o Moderate-severe difficulty in
chest recession breathing
Breathing o Mild chest o Nasal flaring o Nasal flaring
effort recession o Cyanosis
o Mild breathlessness
o Cyanosis
o Intermittent apnea o Grunting
o Grunting

o W/ signs of
dehydration
o Not feeding o Increased
Other o Taking full o Increased heart rate heart rate
features
o No vomiting o Capillary refill
feeds o Capillary refill time
≥2 seconds time ≥2
seconds

Modified from: Harris M, Clark J, Coote N, et al, on behalf of the British Thoracic Society Standards of Care Committee. British Thoracic Society
guidelines for the management of community acquired pneumonia in children: update 2011. Thorax. 2011;66(2):ii16.
History B & S pneumoniae are less likely to be infected w/
these pathogens

 Patient’s age, immunization status

 Symptoms may include fever, difficulty in breathing, cough, chest
or abdominal pain w/ or w/o vomiting, headache
o Age is a good predictor of the causative agent
o Patients w/ cough or difficulty of breathing w/ either
lower chest indrawing, nasal flaring, or grunting are
 Viruses are often linked in up to 50% of
considered to have severe pneumonia
pneumonia in young children
o Patients w/ cough or difficulty of breathing w/ either
 S pneumoniae followed by atypical cyanosis, severe respiratory distress, inability to drink
pneumonia (eg Mycoplasma & Chlamydia) is or vomits everything, or lethargy, unconsciousness,
the most likely pathogen in older children convulsions have very severe pneumonia
w/ pneumonia of bacterial origin
o Immunization status is important because children
 Should also take note of the season of the year, daycare
attendance, exposure to tobacco smoke or infectious diseases (eg
fully immunized against Haemophilus influenza type
tuberculosis), history of travel, or coexisting illnesses (eg cardiac
 or pulmonary disorders, immunodeficiencies, neuromuscular
diseases)
Physical Examination
 Combination of clinical findings are more predictive in diagnosing
community-acquired pneumonia (CAP)
 Check for temperature
o Fever in viral pneumonia is generally lower than in
bacterial pneumonia
 Respiratory rate (RR)
o Study shows significant correlation between RR &
oxygen saturation
o Less sensitive & specific in the first 3 days of illness
o Criteria for tachypnea based on age as defined by
World Health Organization (WHO):
 ≥60 breaths/minute in <2 months old
 ≥50 breaths/minute in 2-11 months old
 ≥40 breaths/minute in 1-5 years old
 >20 breaths/minute in ≥5 years old
o Tachypnea may be a marker for respiratory distress
&/or hypoxemia but may also be secondary to fever,
dehydration or concurrent metabolic acidosis
 Respiratory signs may include intercostal, subcostal, or
suprasternal retractions, nasal flaring, crackles or wheezing on
auscultation
o Decreased breath sounds, scattered crackles, or
rhonchi are usually heard over the affected lung field
in the early course of illness
o Dullness on percussion & decreased breath sounds are
usually appreciated when increased consolidation &
complication develops
Laboratory Tests
 May not be necessary in uncomplicated pneumonia
Microbiology
 Aids in determining the causative agent to provide a narrow-
spectrum antimicrobial therapy that targets a specific bacteria or
virus
 Blood culture is not routinely done in a nontoxic, fully immunized
children w/ community-acquired pneumonia (CAP)
o Recommended in patients requiring hospitalization for
presumed moderate to severe bacterial CAP,
specifically those w/ complicated pneumonia
o Should also be performed in outpatients who do not
show clinical improvement & in those w/ progressive
symptoms or clinical deterioration even after starting
the antibiotic therapy
o Follow-up blood culture is necessary to document
resolution of bacteremia caused by S aureus,
regardless of patient’s clinical status
 Sputum Gram stain & culture is recommended in hospitalized
older children & adolescents w/ more severe disease or in those in
whom outpatient therapy has failed
Tests for Viral Pathogens
 Tests that are specific & sensitive to rapidly identify influenza
virus & other respiratory viruses should be done to evaluate
children w/ CAP
o Positive influenza test will guide appropriate antiviral
agents to be used in both inpatient & outpatient
settings, & may also decrease the need for additional
diagnostic studies & antimicrobial use
Tests for Atypical Bacteria
 School-aged children & adolescents presenting w/ signs &
symptoms of possible M pneumoniae should be tested to identify
the appropriate antibiotic to use
o However, no single currently available test (eg culture,
cold agglutinating antibodies, serology & molecular-
based methods) offers the sensitivity & specificity
desired in a clinically relevant time frame
Ancillary Diagnostic Tests
 Complete blood count (CBC) provides evaluation of white blood
cells & determines presence of anemia or thrombocytopenia
which may guide antimicrobial intervention & identify presence
of hemolytic-uremic syndrome, a rare complication of
pneumococcal pneumonia
 Acute-phase reactants [eg peripheral white blood cell (WBC)
count, erythrocyte sedimentation rate (ESR), C-reactive protein
(CRP) concentration, procalcitonin concentration] should not be
routinely done in fully immunized patients w/ CAP
o May provide useful information in managing patients
requiring hospitalization or those w/ complications
o May be helpful in assessing patient’s response to
therapy in conjunction w/ clinical findings
 Pulse oximetry gives an estimate of arterial oxygenation in a non-
invasive manner
o More directly relevant in evaluating severity of disease
in CAP
o Should be done in all children w/ pneumonia &
suspected hypoxemia
 Presence of hypoxemia will determine the
diagnostic tests needed & if hospitalization
is warranted
 Hypoxemia is a well established
determinant for poor outcome in children &
infants w/ systemic disease
o Usually monitored continuously in a child w/ increased
work of breathing or significant distress especially if
the patient has a decreased level of activity or
agitation
Imaging
Chest X-ray
 Not necessary to confirm suspected community-acquired
pneumonia (CAP) in outpatient setting since diagnosis of CAP is
strongly suspected based on clinical findings
o Cannot differentiate viral from bacterial CAP nor
among different possible bacterial pathogens
 Postero-anterior (PA) or lateral chest x-rays are indicated in
patients w/ suspected or documented hypoxemia or significant
respiratory distress, & in patients who did not respond to initial
antibiotic therapy to confirm presence of possible complications
(eg parapneumonic effusions, necrotizing pneumonia,
pneumothorax)
o Also recommended in hospitalized patients to
determine the presence, size & character of
parenchymal infiltrates, & to document possible
complications
  Daily chest x-ray is not required in stable patients w/ pneumonia
complicated by parapneumonic effusion after chest tube
placement or after video-assisted thoracoscopic surgery (VATS)
 Follow-up chest X-ray should not be done routinely in patient
who improved uneventfully from CAP but is recommended in
patients who do not show clinical improvement & in those w/
progressive symptoms or clinical deterioration w/in 48-72 hours
after starting the antibiotic therapy
o Should also be obtained in patients w/ complicated
pneumonia who has worsening respiratory distress or
clinical instability or in those who are consistently
febrile even after 48-72 hours of antibiotic use
o Recommended after 4-6 weeks in patients w/
recurrent pneumonia in the same lobe & in patients w/
lobar collapse at first chest x-ray w/ suspicion of an
anatomic anomaly, chest mass, or foreign body
aspiration
Other Imaging Studies
 Chest ultrasound is the imaging study of choice to assess pleural
fluid loculations
o Chest ultrasound has no ionizing radiation; hence,
considered a safer imaging procedure than CT
o May be used as a guide in percutaneous needle
aspiration for direct culture of infected lung tissue,
chest tubing or thoracentesis
 Computed tomography (CT) may also be used to confirm the
presence of pleural fluid
Principles of Therapy
 Therapy is usually empiric & is based on age-specific causes of
community-acquired pneumonia (CAP), disease severity & local
resistance patterns of predominant pathogens
o If blood or respiratory tract specimen culture has
identified the causative agent, a safe, narrow-
spectrum & effective therapy should be given
 Oral route is safe & effective for outpatients w/ bacterial
pathogen that most commonly cause lower respiratory tract
infections
 Parenteral route is preferred in patients w/ severe disease or are
unable to tolerate oral drug intake (eg vomiting) to ensure
adequate blood & tissue concentrations
 Antimicrobials are not warranted, may cause drug toxicity, & may
facilitate development of antimicrobial resistance in young
patients w/ clinical features suggestive of upper & lower
respiratory tract viral infections
 Empiric therapy for some children require both antimicrobial &
antiviral agents
Indications for Hospital Admission
 Children & infants who have moderate to severe community-
acquired pneumonia (CAP), as defined by the presence of
respiratory distress (eg tachypnea, dyspnea,
suprasternal/intercostal/subcostal retractions, grunting, nasal
flaring, apnea, altered mental status, pulse oximetry
measurement <90% on room air)
 Patients <3-6 months old w/ possible bacterial CAP
 Children & infants w/ suspected or documented CAP caused by an
agent w/ increased virulence [eg community-associated
Methicillin-resistant Staphylococcus aureus (CA-MRSA)]
 Patients whom there is concern about careful observation at
home or who may be unable to comply w/ medications or cannot
be followed-up
 Presence of significant comorbid conditions
 Presence of dehydration, vomiting, inability to take oral
medications
 Patients w/ unsuccessful outpatient oral antimicrobial treatment,
& those w/ new & progressive respiratory distress
Indications for Intensive Care Unit Admission1
 Patient w/ ≥1 major or ≥2 minor criteria should be transfered to an
intensive care unit or a unit w/ continuous cardiorespiratory
monitoring
o Major criteria: Invasive mechanical ventilation, fluid
refractory shock, acute need for noninvasive positive
pressure ventilation (NIPPV), hypoxemia requiring
fraction of inspired oxygen (FiO2) > inspired
concentration
o Minor criteria: Tachypnea, apnea, retractions,
dyspnea, nasal flaring, grunting, arterial oxygen
pressure (PaO2)/FiO2 <250, multilobar infiltrates,
Pediatric Early Warning Score (PEWS) >6, altered
mental status, hypotension, presence of effusion,
comorbid conditions, unexplained metabolic acidosis
1 Adapted
from: Bradley JS, Byington CL, Shah SS, et al. The management of
community-acquired pneumonia in infants and children older than 3 months
of age: clinical practice guideline by the Pediatric Infectious Diseases Society
and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53(7):e5.
Pharmacotherapy
Penicillins
Amoxicillin
 1st-line agent at any age if S pneumoniae is the likely pathogen
o May also be given to patients w/ pneumonia caused by
β-lactamase-negative strains (eg H influenza)
 Has broader spectrum of activity, better oral pharmacokinetics
(better absorption from gastrointestinal tract) & tolerability (less
frequent dosing & better taste) as compared w/ Penicillin
 Preferred step-down oral therapy for hospitalized patients
initially treated w/ Ampicillin for S pneumoniae or β-lactamase
negative H influenza infection
o May also be given as step-down therapy in patients
initially treated w/ broad-spectrum antimicrobials in
whom no cultures are obtained or mere only obtained
after starting antibiotics
Ampicillin or Penicillin G
 Recommended for hospitalized, fully immunized infants &
school-aged children when local epidemiologic data shows lack of
resistance for invasive S pneumoniae
o Also considered as 1st-line option in hospitalized
patients w/ group A Streptococcus infections
 Ampicillin is the preferred agent for infections caused by β-
lactamase negative H influenza
 Penicillin G represents the most narrow-spectrum & effective
antibiotic for pneumococcal infections but requires a more
frequent dosing interval
 Also active against S pyogenes that causes severe necrotizing
pneumonia
Antistaphylococcal Penicillin
 Eg Oxacillin [intravenous (IV)], Nafcillin (IV)
  Used for patients admitted in the hospital for Methicillin-
susceptible S aureus(MSSA) infection
Penicillin w/ beta-lactamase inhibitor
 Eg Amoxicillin/clavulanic acid, Ampicillin/sulbactam
 Amoxicillin/clavulanic acid is the preferred oral step-down
therapy for infections caused by β-lactamase producing H
influenza
o May also be given through intravenous route in
patients w/ severe CAP which has been shown to be as
effective as Ceftriaxone for strains w/ Amoxicillin
minimum inhibitory concentration (MIC) of up to 2
micrograms/mL
Macrolides
 Eg Azithromycin, Clarithromycin, Erythromycin, Roxithromycin
 1st-line agent in school-aged children & adolescents w/ atypical
pneumonia eg M pneumoniae
 Not advised as empiric therapy for pneumococcal CAP because
currently isolated strains of S pneumoniae have shown significant
resistance against macrolides
 Azithromycin is the preferred agent for M pneumoniae, C
pneumoniae or C trachomatis infections
Cephalosporins
 1st generation drugs (eg Cefazolin IV) may be used for inpatients
w/ MSSA infection
 2nd generation (eg Cefuroxime) or 3rd generation (eg
Ceftriaxone, Cefotaxime) agents are active against both β-
lactamase-negative & -positive strains
o Parenteral Ceftriaxone or Cefotaxime are
recommended in hospitalized infants & children that
are incompletely immunized, in places where local
epidemiology shows lack of resistance for invasive S
pneumoniae, or in infants & children w/ life-
threatening infection (eg empyema)
 Also the preferred agent for infections
caused by β-lactamase producing H
influenza
o IV Ceftriaxone is the preferred agent for penicillin-
resistant S pneumoniae
o Intramuscular (IM) injection of Ceftriaxone may be
given once a day as an outpatient therapy
o Oral Cefpodoxime, Cefprozil or Cefuroxime may be
considered as alternative agents in patients w/
allergies to Amoxicillin
 Also active against S pyogenes causing severe necrotizing
pneumonia
Quinolones
 Eg Levofloxacin
 May be used as an alternative to patients w/ history of severe
allergy to Amoxicillin
 Have comparable effect as w/ macrolides & tetracyclines in
treating patients w/ M pneumoniae infection
 Preferred oral step-down therapy in patients infected w/
Penicillin-resistant S pneumoniae
Tetracyclines
 Eg Doxycycline
 For childn >8 years w/ Macrolide-resistant M pneumoniae
Other Antibiotics
 Vancomycin is the 1st-line agent for infections caused by
community-acquired Methicillin resistant S aureus (CA-MRSA)
 Linezolid is the preferred oral step-down therapy & an alternative
parenteral agent for CA-MRSA infections
o Useful especially in patients w/ pre-existing renal
impairment or is receiving other nephrotoxic drugs
o May be given to children w/ severe allergy to β-lactam
drugs who can not tolerate Vancomycin or
Clindamycin but should be used w/ caution since it has
relatively high adverse effect profile
 IV Clindamycin may be used as an alternative agent in patients w/
infections caused by susceptible MSSA or MRSA but is not
recommended in patients w/ empyema
Influenza Antiviral Therapy
 Should be administered as soon as possible to patient w/
moderate to severe CAP caused by Influenza virus infection,
specifically to those w/ clinically worsening CAP during outpatient
visit
 Should not wait for the results of confirmation test since early
treatment has been shown to provide maximal advantage
 May still be of benefit when used after 48 hours of symptomatic
infection in patients w/ more severe disease
Combination Therapy
 Macrolide plus β-lactam antibiotic may be given to inpatients w/
probable M pneumoniae & C pneumoniae
 Vancomycin or Clindamycin should be added to β-lactam
antibiotic in patients highly considered to have S aureus infection,
depending on local susceptibility data
o Clindamycin plus β-lactam is recommended in children
w/ toxic-like syndrome
Duration of Therapy
 10 days treatment course have been well studied but shorter
period may be similarly effective for mild CAP
 CA-MRSA infections may require longer treatment duration than
those caused by S pneumoniae
Supportive Therapy
 Parents of children who does not require hospitalization should
be advised about:
o Use of antipyretics to manage fever
o Preventing dehydration
o Determining signs of deterioration or signs of other
serious illness
 Patients admitted in the hospital, whose oxygen saturation is
<92% while breathing air should be given oxygen via nasal
cannula, head box, or face mask to sustain oxygen saturation
>92%
 Fluid therapy is recommended in patients who are unable to
maintain their fluid intake secondary to breathlessness, fatigue,
or vomiting
o Plasma sodium, potassium, urea &/or creatinine
should be measured at baseline & at least daily in
patients on intravenous fluids
Prevention
Vaccination
 Children should be given vaccines against bacterial pathogens
including S pneumoniae, H influenzae type b, & Bordetella
pertussis
 Pneumococcal conjugate vaccine & combination vaccine against
pertussis may be given as early as 6 weeks old & influenza vaccine
at 6 months of age as part of the recommended routine
immunization schedule
 Parents & caretakers of infants <6 months of age should be
vaccinated against influenza virus & pertussis to protect the
infants from exposure to these pathogens
Influenza vaccine
 Children ≥6 months of age should be given influenza virus vaccine
yearly
 Two doses separated by a 4-week interval should be administered
to children 6 months to 8 years receiving influenza vaccine for the
1st time, then 1 dose yearly after initial dose
Pertussis vaccine
 Given as part of the combination vaccine DTaP (diphtheria,
tetanus, acellular pertussis) of the recommended routine
immunization schedule & w/ the booster dose Tdap or Td
annually for children w/ complete immunization
Pneumococcal vaccine
 Introduction of pneumococcal vaccine greatly reduced the
incidence of community-acquired pneumonia (CAP) in children
caused by S pneumoniae
 Recommended as a 3-dose series given at 4-week intervals w/
booster dose given at 12-15 months of age for primary
immunization
Immunotherapy
 Respiratory syncytial virus (RSV)-specific monoclonal antibody
(eg Palivizumab) may be considered as prophylaxis during RSV
season in premature infants & in those w/ comorbid diseases (eg
underlying lung pathology, congenital abnormalities of the
airways, hemodynamically significant congenital heart disease,
neuromuscular diseases)
Other Preventive Measures
 Frequent handwashing, breastfeeding, limiting exposure to other
children, & reducing exposure to smoking are important
measures that should be done
Follow Up
 Predictors of treatment response are decrease in respiratory signs
& defervescence w/in 48-72 hours of antimicrobial therapy
 Switch to oral therapy may be considered once there is
improvement in fever, cough, tachypnea, supplemental oxygen
dependency, & increased activity & appetite, concurrent w/
decrease in white blood cell (WBC) counts &/or C-reactive protein
(CRP) levels
Specialist Referral
 Consultation w/ a pediatric pulmonologist or infectious diseases
specialist is considered if the patient has allergies, other
coexisting illnesses or presence of complications (eg effusion)

ASTHMA (PEDIATRIC)
Asthma is a chronic inflammatory disease of the airways in the lungs of
children and adults.
The patient usually complains of shortness of breath, chest tightness and
coughing with wheezing.
A diagnosis of asthma in young children is more likely if they have symptom
patterns, presence of risk factors for development of asthma and
therapeutic response to controller treatment.
Goals of treatment are effective symptom control with minimal or no
exacerbations, minimal or no nocturnal and daytime symptoms, no
limitations on activities, minimal or no need for reliever treatment, and
minimal adverse effects of medication.
Introduction
 A heterogeneous disease with chronic inflammatory disorder of
the airways
 Characterized by history of respiratory symptoms (eg wheeze,
shortness of breath, chest tightness & cough) that vary over time
& in intensity, together with variable expiratory airflow limitation
 Symptoms occur with exercise, laughing or crying in the absence
of an apparent respiratory infection
Signs and Symptoms
Recurrent episodes
 Wheezing
 Breathlessness
 Cough that is recurrent or persistent non-productive that may be
worse at night
 Chest tightness
 Reduced activity
Diagnosis
 A diagnosis of asthma in children is more likely if they have:
o Symptom patterns [wheeze, cough, breathlessness
(typically manifested by activity limitation), &
nocturnal symptoms or awakenings]
o Presence of risk factors for development of asthma
o Therapeutic response to controller treatment
o Episodic symptoms of airflow obstruction or airway
hyperresponsiveness
o Airflow obstruction is at least partially reversible
o Alternative diagnoses are excluded
History
 Identify the symptoms likely to be due to asthma
 Support the likelihood of asthma (eg patterns of symptoms,
family history of asthma & atopic disease)
 Determine symptom pattern for the past 3-4 months
o Focus on symptoms that occurred in the past 2 weeks
 History of variability is essential in the diagnosis of asthma
o Variability refers to improvement or worsening of
symptoms & lung function occurring over a period of
time (eg day to day, month to month or seasonally)
Key Indicators for Considering a Diagnosis of Asthma
 Episodes of wheezing occurring more than once a month
 Activity-induced cough or wheeze
 Nighttime cough in the absence of viral infection
 Absence of seasonal variability of symptoms (eg wheeze)
 Persistence of asthma symptoms beyond age 3 year
 Symptoms triggered or exacerbated by animal fur, aerosol, temp
changes, dust mites, drugs, etc
 Cold lasting longer than 10 days
 Symptoms improve with asthma medication
Physical Examination
 Perform a thorough exam with focus on observation of forced
expiration & nasal inspection
 Hyperexpansion of the thorax
 Wheezing during normal breathing or prolonged forced
exhalation
 Increased nasal secretion, mucosal swelling or nasal polyps
 Signs of allergic skin condition
 Occasionally, wheezing may not be seen in severe asthma attacks
due to markedly reduced airflow & ventilation
o Other signs may be present (eg cyanosis, drowsiness,
tachycardia, difficulty speaking)
Laboratory Tests
Allergy Tests
 Presence of food-specific immunoglobulin E (IgE) &/or atopic
dermatitis increases the risk of sensitization to inhaled allergens
& may be predictive of developing asthma
In vivo Test
 Skin prick test
In vitro Test
 IgE panel test/radioallergosorbent test (RAST)
o May be done if in vivo test cannot be performed (eg
cases of severe dermatitis)
o May be performed if current antihistamine therapy
cannot be discontinued, or if there is a known
possibility of a life-threatening reaction to food or
inhalant
Asthma diagnosis in children ≤5 years
 Objective measurements of lung function may be difficult in this
age group
 Atopy is a major risk factor for subsequent development of
asthma in this age group & it also predicts severity once asthma
develops
  To help establish a diagnosis of asthma, a diagnostic trial of
asthma medications, in addition to a thorough medical history &
physical exam, may be useful
 Consider asthma if >3 episodes of reversible bronchial obstruction
have been noted within the last 6 month
o Patients may have virus-induced asthma which is
common in this age group
Screening
Other Tests
 There are several lung function tests that do not rely on patient’s
cooperation or the ability to perform the required maneuvers
o May be valuable in children 2-5 years of age
o These are not evaluated as diagnostic tests for asthma
o Commonly used in research studies & specialist
centers
o Eg impulse oscillometry, specific airway resistance,
measurements of residual volume

Pulmonary Function Testing Differential Diagnosis

Spirometry Upper Airway Diseases

 Preferred diagnostic method  Allergic rhinitis & chronic rhinosinusitis

o Measures airflow limitation & determines reversibility Large-airway Obstruction

o All measurements should be done before & after
administration of inhaled short-acting bronchodilator
 Generally valuable in children ≥5 years of age  Foreign body obstruction of trachea or bronchus
o Some children cannot correctly execute the required  Vocal cord dysfunction
maneuvers until age 7 years  Vascular rings or laryngeal webs
 Forced vital capacity (FVC) is a measure of the maximal volume of  Laryngotracheomalacia, tracheal stenosis or bronchostenosis
air exhaled from the point of maximal inhalation  Enlarged lymph nodes or tumor
 Volume of air exhaled during the 1st second of this maneuver is
called forced expiratory volume in 1 second (FEV1)
Small-airway Obstruction
o FEV1 indicates risk for exacerbations
 FEV1/FVC appears to be a more sensitive measure of severity of
impairment  Bronchiolitis (viral or obliterative)
 Increase in FEV1 ≥12% after administration of a bronchodilator  Cystic fibrosis
indicates reversible airflow limitation  Bronchopulmonary dysplasia
 Congenital heart disease
Peak Expiratory Flow (PEF) Measurements
Other Causes
 Important in diagnosis & monitoring of asthma
 Recurrent viral lower respiratory tract infection
Bronchodilator Response  Tuberculosis
 Aspiration due to dysfunction in swallowing mechanism or
 Determines reversibility of airflow limitation in response to gastroesophageal reflux
treatment  Immune deficiency
Principles of Therapy

Management Plans for Long-Term Asthma Control:

Recommended Medications Based on Level of Control 1

Daily Controller Medications
Treatment Steps
Children ≤5 years1 Children ≥6 years1

Step 1  No daily medication required  No daily medication required

Reliever Reliever

 As needed beta2-agonist (inhaled, short-acting)  As needed beta2-agonist

(inhaled, short-acting)2

Other controller options:

 Consider corticosteroid
(inhaled, low-dose)

Step 2 Preferred Controller Preferred Controller

 Corticosteroid (inhaled, low-dose)  Corticosteroid (inhaled, low-

dose)
Reliever
Reliever

 As needed beta2-agonist (inhaled, short-acting)

 As needed beta2-agonist
(inhaled, short-acting)2
Other controller options:

Other controller options:

 Leukotriene modifier
 Intermittent corticosteroid (inhaled)
 Leukotriene modifier
 Theophylline (low-dose)3

Step 3 Preferred Controller Preferred Controller

 Corticosteroid (inhaled, moderate-dose  Corticosteroid (inhaled, low-

[doubled low-dose]) dose) plus beta2-agonist
(inhaled, long-acting)3
Reliever
Reliever (any of the following):

 As needed beta2-agonist (inhaled, short-

acting)2  As needed beta2-agonist
(inhaled, short-acting)2
Other controller options:  Corticosteroid (inhaled, low-
dose) plus Formoterol4

 Corticosteroid (inhaled, low-

Other controller options (any one of
dose) plus leukotriene modifier
the following):

 Corticosteroid (inhaled,
high- or medium5-dose)
 Corticosteroid (inhaled, low-
dose)

Plus any one of the

 following:

 Leukotriene
modifier
 Theophylline (low-
dose, extended-
release)3

Step 4  Continue controller treatment Preferred Controller

 Specialist referral
 Corticosteroid (inhaled,
Reliever medium-/high-
dose) plus beta2-agonist
(inhaled, long-acting)
 As needed beta2-agonist (short-acting)
Reliever (any one of the following)
Other controller options:
 As needed beta2-agonist
 Plus any one of the following: (inhaled, short-acting)2
 Corticosteroid (inhaled, low-
dose) plus Formoterol4
 Leukotriene modifier
 Increase corticosteroid (inhaled) frequency
Other controller options:
 Intermittent corticosteroid (inhaled)

 Tiotropium bromide5
 Corticosteroid (inhaled,
high-dose)

Plus any one of the

following:

 Leukotriene modifier
 Theophylline (extended-
release, long-acting)3

Step 5 N/A Step 4 therapy

Plus any one of the following:

 Tiotropium bromide3
 Corticosteroid (oral, lowest
dose)
 Anti-IgE/IL-5 (Omalizumab,
Mepolizumab3)

Notes:

 Patients with symptoms not controlled with step 3 treatment should be referred to a specialist for further management.
 Tiotropium by mist inhaler is only to be given to patients ≥12 years of age with a history of exacerbations.

1
Modified from: Global strategy for Asthma Management and Prevention. Global Initiative for Asthma (GINA) 2017. pp 43 & 111.
2
Short-acting inhaled beta2-agonists should be used as required to relieve symptoms. Other options for reliever medications include
anticholinergic (inhaled), beta2-agonist (oral, short-acting), or Theophylline (≥12 years old).
3
Contraindicated in children <12 years of age.
4
Preferred for patients previously given low-dose Budesonide/Formoterol or low-dose Beclomethasone/Formoterol combination as
maintenance & reliever regimen.
5
Medium-dose inhaled corticosteroids preferred in children 6-11 years old.
  Goals of asthma management are achieved through a cycle of:
o Assess (diagnosis, symptom control, risk factors,
inhaler technique, adherence, parent preference)
o Adjust treatment (medications, non-pharmacological
strategies, treatment of modifiable risk factors)
o Review regularly response including medication
effectiveness & side effects
Pharmacotherapy
Stepwise Therapy Based on Control
Step 1 - Use of Reliever, as Needed
 For children who have infrequent viral wheezing episodes & no or
few interval symptoms
 Intermittent inhaled corticosteroids may be an option for children
with intermittent viral-induced wheezing
Step 2 - Initial single controller treatment plus as needed beta2-agonist
(short-acting)
 For patients who require controller medications everyday in order
to maintain control of their asthma
 For children with not well controlled asthma symptoms or ≥3
exacerbations/year
 For children with symptom pattern not consistent with asthma
but with frequent wheezing episodes
 May be used as initial therapy for treatment-naive patients with
persistent symptoms
 Low-dose daily inhaled corticosteroid is preferred for children ≤5
years old
o As needed inhaled corticosteroids may be considered
in pre-schoolers with increased frequency of wheezing
secondary to viral infections
 It should be given for at least 3 months to achieve good asthma
control
 Leukotriene modifiers may reduce symptoms in pediatric
patients with persistent asthma
Step 3 - Double the daily low dose inhaled corticosteroids
 Before stepping up, re-confirm asthma diagnosis, check inhaler
technique & compliance to medications & inquire about exposure
to risk factors
 For patients whom symptoms were not controlled by low dose
inhaled corticosteroids after 3 months of initial therapy or if
exacerbations persisted
 If symptoms are not controlled by step 3 medications, patient
should be referred to a specialist for further diagnostic evaluation
 Addition of oral leukotriene modifiers to low dose corticosteroids
may be considered
Step 4 - Controller treatment continued
 Reassess inhaler technique, medication adherence, trigger
factors & reinvestigate diagnosis
 Consider expert referral if doubling the dose of inhaled
corticosteroids fails or if symptom control remains poor &/or
flare-ups persist
 Addition of oral leukotriene modifiers, low-dose oral
corticosteroids, or Theophylline in children >12 years old may be
considered if symptoms are still not controlled
Step 5 - Use of Reliever, as needed & Additional Controller Options
 For children ≥6 years of age
 Tiotropium via mist inhaler may be considered for adolescent
patients ≥12  years w/ a history of exacerbations despite
combination therapy in Step 4
 Addition of anti-IgE (Omalizumab) may be considered in pediatric
patients ≥6 years of age diagnosed w/ moderate-severe asthma
when control is not achieved despite combination treatments
 Additional anti-IL5 (Mepolizumab) may be considered for
patients ≥12 years of age w/ severe uncontrolled eosinophilic
asthma despite adherence to step 4 regimen
 Treatment may be reassessed based on the patient’s eosinophilia
seen during sputum exam
o May be applied if w/ previous history of high-dose
inhaled corticosteroid or inhaled corticosteroid w/
long-acting beta2-agonist therapy
Reliever Medications
Preferred Therapy
 Beta2-Agonists (Inhaled, Short-Acting)
o Most effective bronchodilator
o Agents of choice for relief of bronchoconstriction
during acute episodes of asthma & are useful for pre-
treatment prior to exercise with effects lasting for 0.5
to 2 hours
o Used only when necessary; increased use indicates
that management should be re-assessed
Alternative Therapy
 Anticholinergic (Inhaled)
o Eg Tiotropium bromide, Ipratropium bromide
o Considered alternative to short-acting inhaled beta2-
agonists because they may have a slower onset of
action &/or higher risk for side effects
o Have an additive effect when nebulized together with
a short-acting beta2-agonists for exacerbations of
asthma
o Considered in patients who experience adverse effects
(eg tachycardia, arrhythmia, tremor) from short-acting
beta2-agonists
o Tiotropium may help improve lung function &
decrease interval to next asthma exacerbation
o Not for long term management of asthmatic children
 Beta2-Agonists (Oral, Short-Acting)
o Reserved for children in whom inhaled therapy is not
well-tolerated
 o More side effects than inhalation route
Controller Medications
Preferred Therapy
 Corticosteroids (Inhaled)
o These are the most effective anti-inflammatory
medications used for asthma & are the preferred
controller medications for patients with persistent
asthma of all levels of severity
o Discontinuation is followed by deterioration of control
within weeks to months in some patients
o To minimize side effects, upon achievement of
control, corticosteroids should be titrated carefully to
lowest effective dose to maintain control
 Ciclesonide, a prodrug that is activated only
in the lungs, may be an alternative with
decreased oropharyngeal side effect
o Addition of long-acting inhaled beta2-agonist is
preferred when medium-dose inhaled corticosteroid
fails
 Improves lung function & symptoms,
reduces exacerbations, decreases need of
short-acting beta2-agonists, achieves faster
clinical control of asthma, & may also be
used to prevent exercise-induced asthma
o Combination inhalers are available which may increase
compliance
Alternative or Add-On Therapy
 Beta2-Agonists (Inhaled, Long-acting)
o Has no effect on airway inflammation, hence not used
as a monotherapy
o Most efficacious when given together with inhaled
corticosteroids
 Rapid clinical control of asthma is achieved
than when inhaled glucocorticosteroids are
given alone
 Studies have shown increased mortality risk
when given alone; should not be used as a
substitute for corticosteroids
 Causes improved symptom scores,
decreased nocturnal asthma symptoms,
improved lung function, decreased use of
short-acting beta2-agonists, & reduced
number of exacerbations
 Beta2-Agonist (Oral, Long-acting)
o May be considered as an alternative add-on therapy &
should always be given with inhaled corticosteroids
o Only used on rare occasions when more
bronchodilation is needed
o Less effective than inhaled beta2-agonists & poses
increased risk of side effects
Inhalation Devices
INHALATION DEVICES
 Corticosteroids (Oral)
o Long-term use (>2 weeks) may be required for
severely uncontrolled asthma
o Long-term use should be used at the lowest possible
dose
 Cromones (Inhaled)
o Limited use in long-term treatment of asthma
o May be used for patients with mild persistent asthma
& exercise-induced bronchoconstriction
o Weak anti-inflammatory effect, less effective than
low-dose inhaled corticosteroids
 Leukotriene Modifiers (Oral)
o When used as add-on therapy, may reduce the
required dose of inhaled corticosteroid for patients
with moderate to severe symptoms
 When used as monotherapy for control of
asthma, leukotriene modifiers are less
effective than low-dose inhaled
corticosteroids
 Monoclonal Antibodies (Omalizumab, Mepolizumab)
o Reduces asthma symptoms & exacerbations, & the
need for rescue medications
o Omalizumab is indicated for moderate to severe
asthma w/ allergic component not controlled by
inhaled corticosteroids
o Mepolizumab may be considered for patients ≥12
years old w/ severe eosinophilic asthma not controlled
by inhaled corticosteroids
o Use of Reslizumab in patients <18 years of age w/
asthma has not been established
 Theophylline (Oral, Extended-Release)
o Treatment option for patients >12 years of age
o Bronchodilator, which at low dose, has anti-
inflammatory effects
Allergen-Specific Immunotherapy
 Therapeutic option after strict avoidance of triggers & medical
intervention have failed
 May be given as subcutaneous immunotherapy (SCIT) or
sublingual immunotherapy (SLIT)
o Life-threatening anaphylactic reactions have been
reported with SCIT use
o SLIT has been associated with mild oral &
gastrointestinal (GI) symptoms
 May reduce symptoms, medication use, improve allergen-specific
& non-specific airway hyperresponsiveness & can possibly
prevent asthma development in children with allergic
rhinoconjunctivitis
 Benefits must be weighed against adverse effects &
inconvenience of length of therapy
 Age Device
Preferred: Pressurized metered-dose inhaler plus dedicated spacer w/ face mask
0-3 years
Alternate: Nebulizer w/ face mask
Preferred: Pressurized metered-dose inhaler plus dedicated spacer w/ mouthpiece
4-5 years
Alternate: Pressurized metered-dose inhaler plus dedicated spacer w/ face mask or nebulizer w/ mouthpiece or face mask
Modified from: Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2017. p114.
Dosage Guidelines

ANTICHOLINERGICS (INHALED)1
Available
Drug Dosage Remarks
Strength
Long-Acting Adverse Reactions
Tiotropium 1.25 mcg/puff ≥12 yr: 2 puffs
bromide 24 hrly  Resp effects [upper respiratory tract infection (URTI), bronchitis,
sinusitis]; CV effects (chest pain, palpitation); CNS effects (headache,
Short-Acting dizziness); GI effects (dry mouth, bad taste, dyspepsia, nausea);
Ipratropium 20 mcg/puff 2 puffs 6 hrly Hypersensitivity reactions (urticaria, angioedema, rash,
bromide MDI Max dose: 12 bronchospasm)
puffs/day
Special Instructions
250 mcg/2 mL 1 unit dose (250-
& 500 mcg/2 500 mcg) via
mL inhalation nebulizer 6-8  Use w/ caution in patients w/ prostatic hyperplasia, patients
soln unit dose hrly as required predisposed to narrow-angle glaucoma, bladder neck obstruction,
myasthenia gravis
0.025% <6 yr: 0.4-1 mL
inhalation soln (100-250 mcg)  Avoid contact of eyes w/ inhalation soln
via nebulizer 6-8  Check patient's inhaler technique for optimum delivery of drug
hrly as required  Not used as 1st-line treatment
6-12 yr: 1 mL o Should be added to beta2-agonist therapy
(250 mcg) via
nebulizer 6-8
hrly as required
1
Bronchodilator combinations are available. Please see the latest MIMS for specific formulations.

BETA2-AGONISTS (BRONCHODILATORS) (INHALED)1

Drug Available Strength Dosage*
Short-Acting
Fenoterol 100 & 200 mcg/puff Approved in some
MDI countries for childn >6
yr: 1-2 puff 8 hrly as
required
1.25 mg/2 mL soln for 10-20 drops via nebulizer
inhalation up to 6 hrly as required
6-14 yr: 10 drops 8 hrly
1-6 yr: 5-10 drops 8 hrly
<1 yr: 3-7 drops 8 hrly
Orciprenaline 750 mcg/puff MDI 1-2 puffs 8 hrly as required
(Metaproterenol) Max dose: 12 puffs/day
Procaterol 10 mcg/puff MDI Approved in some
countries for childn: 1
puff 6-12 hrly as required
Salbutamol 100 mcg/dose Immediate relief/prior to
(Albuterol) (autohaler/evohaler) exertion: 100 mcg as
single dose
100 & 200 mcg/dose For chronic or preventive
easyhaler treatment: 100 mcg 6-8
100 mcg/dose MDI
hrly
May increase to 200 mcg 6-
100 & 200 mcg/dose 8 hrly if necessary
DPI Max dose: 1.2 mg/day
Remarks
Adverse Reactions
 CV effects (tachycardia, palpitations, cardiac
arrhythmias especially in susceptible
patients); CNS effects (headache,
hyperactivity); Resp effects (mouth & throat
irritation, paradoxical bronchospasm); Other
effect (fine skeletal muscle tremor)
 Potentially severe hypokalemia may result
esp in acute severe asthma
 Orciprenaline is less selective for beta2-
receptors & therefore, side effects may be
more common
Special Instructions
 Use w/ caution in patients w/
hyperthyroidism, DM, myocardial
insufficiency or arrhythmias
 Monitor K levels in acute severe asthma
 Check patient's inhaler technique for optimum
delivery of drug

200 mcg/dose accuhaler

DPI
 200 mcg/dose diskhaler
DPI
200 mcg/cap DPI
1 mg/mL, 2.5 mg/2.5 2.5-5 mg via nebulizer 6-8
mL, 5 mg/2.5 mL hrly as required
inhalation soln unit dose
5 mg/mL (0.5% soln) 10-15 kg: 0.25 mL (1.25
inhalation soln mg)
>15 kg: 0.5 mL (2.5 mg)
>12 yr: 0.5-1 mL (2.5-5
mg)
Dilute required amount of
soln w/ normal saline to
final volume of 2-3 mL via
nebulizer over 10 min as
required
Terbutaline 250 mcg/puff MDI 1-2 puffs 6-8 hrly as
required
Max dose: 8 puffs/day
500 mcg/dose DPI, 3-12 yr: 1 dose inhaled 6
turbuhaler DPI hrly as required
For severe
exacerbations:2 doses
Max dose: 8 doses/day
2.5 mg/2 mL, 5 mg/2 mL <20 kg: 2.5 mg via
inhalation soln nebulizer up to 6 hrly as
required
>20 kg: 5 mg via nebulizer
up to 6 hrly as required
Long-Acting2
Formoterol 4.5 mcg/dose turbuhaler Approved in some Adverse Reactions
DPI countries for childn ≥6
yr: 1-2 doses inhaled 12-24
hrly  CV effects (tachycardia, palpitations, cardiac
Max dose: 4 doses/day arrhythmias especially in susceptible
patients); CNS effects (headache,
9 mcg/dose turbuhaler Approved in some hyperactivity); Resp effects (mouth & throat
DPI countries for childn ≥6 irritation, paradoxical bronchospasm); Other
yr: 1 dose inhaled 12-24 effect (fine skeletal muscle tremor)
hrly  Potentially severe hypokalemia may result
Max dose: 2 doses/day especially in acute severe asthma
12 mcg/cap DPI Approved in some
countries for childn ≥5 Special Instructions
yr: 1 cap inhaled 12 hrly
Salmeterol 25 mcg/puff MDI ≥4 yr: 2 puffs 12 hrly  Use w/ caution in patients w/
hyperthyroidism, DM, myocardial
50 mcg/dose accuhaler ≥4 yr: 1 dose inhaled 12
insufficiency or arrhythmias
DPI, diskhaler DPI hrly
 Monitor K levels in acute severe asthma
 Check patient's inhaler technique for optimum
delivery of drug

*Please note: Doses for acute exacerbations can be higher than the recommended maintenance doses listed here.
1
Inhaled bronchodilator combinations are available. Please see the latest MIMS for specific formulations.
2
Should be used as an adjunct to inhaled corticosteroids in the management of asthma. Please see the latest MIMS for specific
formulations of different combination products.

BETA2-AGONISTS (BRONCHODILATORS) (ORAL)1

Drug Dosage Remarks
Short-Acting Adverse Reactions
Clenbuterol 1.2 mcg/kg/day PO divided 12
hrly  CNS effects (headache, sleep disturbances, agitation,
hyperactivity & restlessness); CV effects (palpitations,
Fenoterol Approved for use in some cardiac arrhythmias especially in susceptible patients);
countries for childn:
 <1 yr: 1.25 mg PO 8-12 hrly Other effect (fine skeletal muscle tremor)
1-6 yr: 1.25-2.5 mg PO 8 hrly  Potentially severe hypokalemia may result especially in
6-14 yr: 2.5 mg PO 8 hrly acute severe asthma
Hexoprenaline Approved for use in some  Orciprenaline is less selective for beta2 receptors &
countries for childn: therefore side effects may be more common
3-6 mth: 0.125 mg PO 12-24 hrly
6-12 mth: 0.125 mg PO 8-24 hrly Special Instructions
1-3 yr: 0.125-0.25 mg PO 8-24
hrly
3-6 yr: 0.25 mg PO 8-24 hrly  Use w/ caution in patients w/ hyperthyroidism, DM,
6-10 yr: 0.5 mg PO 8-24 hrly myocardial insufficiency or arrhythmias
Orciprenaline 3-10 yr: 10 mg PO 6 hrly  Monitor K levels in acute severe asthma
(Metaproterenol)
Procaterol <6 yr: 1.25 mcg/kg/dose PO 12
hrly
>6 yr: 25 mcg PO 12-24 hrly
Salbutamol2(Albuterol) 2-6 yr: 1-2 mg PO 6-8 hrly
Max dose: 12 mg/day
6-12 yr: 2 mg PO 6-8 hrly
Max dose: 24 mg/day
>12 yr: 2-4 mg PO 6-8 hrly
Max dose: 32 mg/day
Terbutaline <12 yr: 0.05 mg/kg/dose PO 8
hrly
Max dose: 5 mg/day
≥12 yr: 2.5-5 mg PO 8 hrly
Max dose: 15 mg/day
Long-Acting
Bambuterol Approved for use in some
countries for childn 2-12 yr: 5-
10 mg PO 24 hrly
Max dose for childn 2-5 yr: 10
mg/day (Doses >10 mg/day PO is
not recommended in Asian childn
2-12 yr)
Formoterol 4 mcg/kg/day PO divided 8-12
hrly
Salbutamol (Albuterol) Extended-release:
<12 yr: 0.3-0.6 mg/kg/day
divided 12 hrly
>12 yr: 4 mg PO 12 hrly
1
Oral bronchodilator combinations are available. Please see the latest MIMS for specific formulations.
2
Combination w/ other cough preparation is available. Please see the latest MIMS for specific formulations.

BRONCHODILATORS (PARENTERAL)
Drug Dosage Remarks
Beta2-Agonists
Hexoprenaline 5-10 mcg slow IV inj x 3-4 doses in 24 hr Adverse Reactions
Salbutamol 250 mcg slow IV inj, may repeat as required
500 mcg IM/SC, may repeat 4 hrly as  Fine skeletal muscle tremor, palpitations,
required cardiac arrhythmias esp in susceptible patients,
IV infusion: 3-20 mcg/min IV infusion headache, sleep disturbances, agitation,
hyperactivity & restlessness
Terbutaline 2-15 yr: 10 mcg/kg/dose SC/slow IV up to 6
hrly as required  Potentially severe hypokalemia may result esp
Max dose: 300 mcg/dose in acute severe asthma
IV infusion: 25 mcg/kg/day IV as a  Epinephrine: Dyspnea, hyperglycemia,
continuous infusion restlessness, palpitations, tachycardia, tremors,
sweating, hypersalivation, weakness, dizziness,
Nonspecific Sympathomimetic headache, coldness of extremities, hypertension,
flushing, hypotension
Epinephrine 10 mcg/kg up to 300-500 mcg SC/IM every
(Adrenaline) 20 min x 3 doses
Special Instructions

CORTICOSTEROIDS (INHALED)1
Drug Available Strength
Beclomethasone 50, 100, 250 mcg/puff MDI
dipropionate
100, 200 mcg/cap DPI; 100,
200 mcg/dose diskhaler DPI;
200 mcg/dose easyhaler DPI
Budesonide 100, 200 mcg/puff MDI
100, 200, 400 mcg/dose
turbuhaler DPI; 200 mcg/dose
swinghaler;
200 mcg/dose easyhaler;
100, 200, 400 mcg/cap DPI
 Use w/ caution in patients w/ hyperthyroidism,
DM, myocardial insufficiency or arrhythmias
 Monitor K levels in acute severe asthma
Dosage Remarks
Childn <5 yr: Adverse Reactions
HFA-based
Low dose: 100 mcg
Medium dose: >200-  Local effects (oropharyngeal candidiasis,
400 mcg cough from upper airway irritation,
High dose: >400 dysphonia); paradoxical bronchospasm
mcg (rare)
 Long-term use of high-dose steroids may
result in cataracts, glaucoma, skin thinning,
Childn 6-11 yr:
easy bruising, adrenal suppression, increased
CFC-based
bone loss & osteoporotic fractures
Low dose: 100-200
mcg  Risk of systemic effects will depend on
Medium dose: >200- dose, potency of the corticosteroid,
400 mcg absorption from the gut, delivery system, the
High dose: >400 use of spacers & the drug’s
mcg pharmacokinetics
HFA-based Special Instructions
Low dose: 50-100
mcg
Medium dose: >100-  Local effects may be minimized by using a
200 mcg spacer, gargling & spitting out w/ water, or
High dose: >400 gargling w/ 1:50 dilution of Amphotericin B
mcg
Childn >12 yr &
Adults:
CFC-based
Low dose: 200-500
mcg
Medium dose: >500-
1000 mcg
High dose: >1000
mcg
HFA-based
Low dose: 100-200
mcg
Medium dose: >200-
400 mcg
High dose: >400
mcg
Childn <5 yr:
Low dose: 200 mcg
Medium dose: >200-
400 mcg
High dose: >400
 250 mcg/2 mL, 500 mcg/2 mL, mcg
500 mcg/mL, 1 mg/2 mL soln
for inhalation unit dose
Nebules
Low dose: 500 mcg
Medium dose: >500-
1000 mcg
High dose: >1000
mcg

Childn 6-11 yr:

Low dose: 100-200
mcg
Medium dose: >200-
400 mcg
High dose: >400
mcg

Nebules
Low dose: 250-500
mcg
Medium dose: >500-
1000 mcg
High dose: >1000
mcg

Childn >12 yr &

Adults:
Low dose: 200-400
mcg
Medium dose: >400-
800 mcg
High dose: >800
mcg
Ciclesonide 80, 160 mcg/actuation MDI Childn <5 yr:
Low dose: 160 mcg
Medium dose:>160-
320 mcg
High dose: >320
mcg
Once-daily dosing in
patients w/ mild
severity of asthma

Childn 6-11 yr:

Low dose: 80 mcg
Medium dose: >80-
160 mcg
High dose: >160
mcg

Childn >12 yr &

Adults:
Low dose: 80-160
mcg
Medium dose:>160-
320 mcg
High dose: >320
mcg
Flunisolide 500 mcg/puff MDI Childn <5 yr:
Low dose: 500-750
mcg
Medium dose:>750-
1250 mcg
High dose: >1250
mcg
Fluticasone furoate 50, 100, 250 mcg/dose Childn >12 yr &
accuhaler DPI; Adults:
50, 250 mcg dose diskhaler Low dose: 100 mcg
DPI; High dose: 200 mcg
50, 125, 250 mcg/dose evohaler
Fluticasone 50, 125, 250 mcg/puff MDI Childn <5 yr:
propionate 50, 100, 250 mcg/dose Low dose: 100 mcg
accuhaler DPI; Medium dose:>200-
50, 250 mcg dose diskhaler 500 mcg
DPI; High dose: >500
50, 125, 250 mcg/dose evohaler mcg
0.5 mg/2 mL, 2 mg/2 mL soln
for inhalation unit dose Childn 6-11 yr:
Low dose: 100-200
mcg
Medium dose:>200-
500 mcg
High dose: >400-500
mcg

Childn >12 yr &

Adults:
Low dose: 100-250
mcg
Medium dose: >250-
500 mcg
High dose: >500
mcg
Mometasone 50, 100, 200 mcg/dose for Childn 6-11 yr:
furoate2 inhalation unit dose Low dose: 100 mcg
Medium dose:≥220-
<440 mcg
High dose: ≥440
mcg

Childn >12 yr &

Adults:
Low dose: 110-220
mcg
Medium dose: >220-
440 mcg
High dose: >440
mcg
Triamcinolone 75, 200 mcg/dose for inhalation Childn 6-11 yr:
acetonide2 unit dose Low dose: 400-800
mcg
Medium dose: >800-
1200 mcg
High dose: >1200
mcg

Childn >12 yr &

Adults:
Low dose: 400-1000
mcg
Medium
dose:>1000-2000
mcg
High dose: >2000
mcg
1
Corticosteroids combined w/ bronchodilators are available. Please see the latest MIMS for specific formulations.
2
Approved for once-daily dosing in patients w/ mild severity of asthma.
Modified from: Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2017. p44.

CORTICOSTEROIDS (SYSTEMIC)
Drug Dosage Remarks
Adverse Reactions

Childn: 0.08-0.3 mg/kg

Dexamethasone BW/day IV/IM, divided 6-  CNS effects (excessive mental stimulation, insomnia & psychic
12 hrly disturbances); CV effect (tachycardia); Other effects (increased
appetite, wt gain, muscle weakness)

Hydrocortisone Asthma exacerbations in Adverse Reactions

 emergency dept:
2-4 mg/kg/dose slow IV/IV
infusion 6 hrly x 24 hr
Adjust dose according to
response & reduce over 4-5
days to oral dose when
tolerated
Special Instructions
1-2 mg/kg/day PO divided
Methylprednisolone,
6-8 hrly x 3-10 days
Prednisolone, Prednisone
Max dose: 60 mg/day
COUGH & COLD PREPARATIONS
Drug Dosage
Ambroxol ≤6 mth: 1.25 mL PO 12 hrly
7 mth-2 yr: 2.5 mL PO 12
hrly
2-6 yr: 2.5 mL PO 8 hrly
7-12 yr: 5 mL PO 8-12 hrly
Bromhexine <5 yr: 2 mg PO 8 hrly
5-10 yr: 4 mg PO 8 hrly
>10 yr: 8 mg PO 8 hrly
Dried ivy leaf extract Syr
6-10 yr: 5 mL PO 8 hrly
1-5 yr: 2.5 mL PO 8 hrly
Effervescent Tab
6-12 yr: 32.5 mg PO 12 hrly
Guaifenesin Infant: 25 mg PO 6 hrly
2-6 yr: 10-50 mg PO 4-6
hrly
≥7 yr: 20-100 mg PO 4-6
hrly
Max Dose ≥6 yr: 600
mg/day
Lagundi (Vitex negundo) 15 mg/kg/dose or
2.5 mL/kg/dose 8 hrly
 GI effect (gastritis). If administered long-term: adrenocortical
insufficiency, osteoporosis, muscle wasting, pain or weakness,
increased susceptibility to infection, impaired wound healing,
electrolyte imbalances, wt gain, DM, skin thinning leading to
striae & easy bruising, cataracts, glaucoma
 Should be taken w/ food
 Patients on long-term corticosteroids should receive preventive
treatment for osteoporosis
Remarks
Adverse Reactions
 GI effect (N/V, diarrhea); Other effects (headache, polyuria,
fatigue)
Special Instruction
 Should not be taken in an empty stomach
 Use w/ caution in patients w/ gastric ulcer
Adverse Reactions
 GI effect (GI irritation); Metabolic effect (transient increase of
serum transaminases)
Special Instruction
 Use w/ caution in patients w/ gastric ulcer
Adverse Reactions
 Rarely, laxative effect due to sorbitol content
Special Instructions
 Use w/ caution in patients w/ fructose/sorbitol intolerance
Adverse Reactions
 GI effects (GI discomfort; N/V); CNS effects (drowsiness;
headache)
Special Instruction
 Use w/ caution in childn <2 years old & in patients w/
persistent or chronic cough
Adverse Reactions
  GI effects (N/V, diarrhea); Dermatologic effect (rash)

Special Instruction

 Use w/ caution in patients w/ hypersensitivity to Lagundi

CROMONE (INHALED)
Drug Available Dosage Remarks
Strength
Cromoglicic acid 5 mg/puff 2 puffs 6 hrly Adverse Reactions
(Cromolyn Na, Na MDI May increase to 2 puffs 6-
cromoglicate, Na 8x/day in more severe cases
cromoglycate) & reduce to 1 puff 6 hrly  Resp effects (transient bronchospasm, cough &
once asthma has been irritation of throat, rarely, severe bronchospasm,
stabilized angioedema, laryngea l edema & anaphylaxis);
Other effects (unpleasant taste, nausea,
headache)

Special Instructions

 Should not be used for acute asthma attacks

LEUKOTRIENE MODIFIERS (ORAL)

Drug Dosage Remarks
5-Lipoxygenase
Zileuton ≥12 yr: 600 mg PO 6 hrly Adverse Reactions
Extended-release: 1.2 g
PO 12 hrly
 CNS effect (headache); GI effects (GI upset, raised liver enzymes);
Other effects (rashes, leukopenia has occurred in a few patients)

Special Instructions

 Avoid in patients w/ hepatic impairment/disease

 Monitor liver enzymes before & periodically during therapy
 Should not be used for acute asthma attacks

Leukotriene Receptor Antagonists

Montelukast 6 mth-5 yr: 4 mg PO 24 Adverse Reactions
hrly before bedtime
6-14 yr: 5 mg PO 24 hrly
before bedtime  Generally well-tolerated: headache, GI upset
≥15 yr: 10 mg PO 24 hrly  Less commonly: generalized pain, arthralgia, myalgia, fever, dizziness;
before bedtime hypersensitivity reactions
Pranlukast 3.5 mg/kg PO 12 hrly  Zafirlukast: raised liver enzymes, rarely symptomatic hepatitis,
Max dose: 10 mg/kg/day hyperbilirubinemia
 Very rarely: agranulocytosis, bleeding, bruising & edema, systemic
Zafirlukast 5-11 yr: 10 mg PO 12 eosinophilia consistent w/ Churg-Strauss disease
hrly
≥12 yr: 20 mg PO 12 hrly
Special Instructions

 Should not be used for acute asthma attacks

 Zafirlukast: Avoid in patients w/ hepatic impairment or cirrhosis
 MAST CELL STABILIZER/ANTIHISTAMINE (ORAL)
Drug Dosage Remarks
Ketotifen 6 mth-3 yr: 0.5 mg PO 12 hrly Adverse Reactions
>3 yr: 1 mg PO 12 hrly
Extended-release:
>3 yr: 2 mg PO at bedtime  CNS effects (drowsiness, dizziness, CNS stimulation); GI effects
(dry mouth, increased appetite, wt gain)

Special Instructions

 Should not be used for acute asthma attacks

METHYLXANTHINES (ORAL)
Drug Dosage Remarks
Acefylline 500 mg-2 g/day PO in Adverse Reactions
divided doses
Aminophylline Dosage should be  GI effects (irritation, N/V, abdominal pain, diarrhea, gastroesophageal
individualized reflux); CNS effects (CNS stimulation, headache, anxiety,
restlessness, dizziness, tremor); Other effect (palpitations)
Choline 100 mg PO 6-8 hrly
Theophyllinate  Serum concentration >15-20 mcg/mL (85-110 micromol/L) are
associated w/ increased risk of adverse effects including lethal adverse
Diprophylline 15 mg/kg/dose PO 6 hrly reactions
(Dyphylline)
Doxofylline <12 yr: 6-9 mg/kg/dose PO Special Instructions
12 hrly
>12 yr: 200 mg PO 8-24 hrly
 Use w/ caution in patients w/ peptic ulcer, hyperthyroidism,
Heptaminol >15 yr: 500 mg-1 g PO 8 hypertension, cardiac arrhythmias or other CV disease, epilepsy, heart
acefyllinate hrly failure, hepatic dysfunction, acute febrile illness, in neonates
 Many drug interactions occur w/ Theophylline including smoking
Theophylline1 Acute bronchospasm: o Increases Theophylline clearance
Loading dose in patients
not taking  Serum concentration monitoring is necessary to ensure that
methylxanthine: 5 mg/kg concentration are within therapeutic range
PO o Serum concentration needs to be measured if a patient is
Maintenance dose: changed from one extended-release product to another
6 mth-<1 yr: 12-18  Optimal therapeutic concentration: 5-15 mcg/mL (28-85 micromol/L)
mg/kg/day
1-<9 yr: 20-24 mg/kg/day
9-<12 yr (including
adolescent smokers): 16
mg/kg/day
12-16 yr (nonsmokers): 13
mg/kg/day
1
Different formulations for Theophylline are available. Please see the latest MIMS for specific formulations.

METHYLXANTHINES (PARENTERAL)
Drug Dosage Remarks
Acefylline 1.5-2 g/day IM Adverse Reactions
0.5-1 g/day IV
Aminophylline Loading dose: 5 mg/kg  GI effects (irritation, N/V, abdominal pain, diarrhea, gastroesophageal
IV infusion over 20-30 reflux); CNS effects (CNS stimulation, headache, anxiety, restlessness,
min dizziness, tremor); Other effect (palpitations)
Maintenance dose:  Serum concentration >15-20 mcg/mL (85-110 µ/L) are associated w/
6 mth-9 yr: 1 mg/kg/hr increased risk of adverse effects including lethal adverse reactions
10-16 yr: 0.8 mg/kg/hr
Proxyphylline 400-800 mg IM or slow Special Instructions
IV 8 hrly

 Administer IV inj very slowly to prevent dangerous CNS & CV side

effects
 Use w/ caution in patients w/ peptic ulcer, porphyria, hyperthyroidism,
 hypertension, cardiac arrhythmias or other CV disease, epilepsy, heart
failure, hepatic dysfunction, acute febrile illness, in neonates
 Serum concentration monitoring is necessary to ensure concentration are
within therapeutic range
 Optimal therapeutic concentration: 5-15 mcg/mL (28-85 µ/L)

MONOCLONAL ANTIBODIES
Drug Dosage Remarks
Anti-Immunoglobulin E (Anti-IgE) Antibody
Omalizumab ≥12 yr: 150-375 mg Adverse Reactions
SC every 2 or 4 wk
Max dose: 375 mg
every 2 wk  CNS effect (headache); Resp effects (resp infections, sinusitis, pharyngitis);
Dose depends on Other effects (local site reaction, viral infection, anaphylaxis, malignancies)
pretreatment IgE
level & body wt Special Instructions

 Max of 150 mg should be delivered per inj site

 Should not be used for the treatment of acute bronchospasm or status asthmaticus
 Contraindicated in patients w/ severe hypersensitivity to the drug & in children
<12 years old
 Corticosteroids should be tapered gradually
 Use w/ caution in patients at risk of parasitic infections

Interleukin Inhibitor
Mepolizumab ≥12 yr, ≥45 kg: 100 Adverse Reactions
mg SC 24 hrly every
4 wk
 Dermatologic effects (pruritus, eczema, inj site reaction including erythema,
swelling, itching, burning); Musculoskeletal effects (muscle spasm, back pain);
Resp effects (nasal congestion, dyspnea, allergic rhinitis, bronchospasm); Misc
effects (UTI, headache, toothache, infection)

Special Instructions

 Not for acute asthma treatment

 Use w/ caution in patients w/ uncontrolled worsening asthma, helminth infection,
children <12 years old, <45 kg, abrupt steroid withdrawal

Monitoring

Periodic Assessment & Monitoring  Nocturnal awakening as a result of asthma symptoms

 Periodic assessment & monitoring of asthma control should be
performed to determine whether the goals of therapy are met (ie
reduction of current impairment & future risk, & achievement of
normal activity levels including exercise)
o Several tools are used that allow patient & parents to Pulmonary Function
record & describe the symptoms [eg asthma control
test (ACT), childhood ACT, asthma quiz for kids,
diaries]
 Improvement of symptoms may be observed within days while
max benefit may be achieved after 3-4 months
 Regular follow-up is recommended to determine minimum
controlling dose & necessary dose adjustments
Monitoring Signs & Symptoms
 Daytime asthma symptoms (wheezing, cough, chest tightness or
shortness of breath)
 Frequency of use of beta2-agonist (inhaled, rapid-acting) for relief
of symptoms
 Inability or difficulty in performing normal activities because of
asthma symptoms
 Results in children 5 year of age & younger are unreliable or may
not be reproducible
 Spirometry
o Low forced expiratory volume in 1 second (FEV1) is
associated with increased risk of severe exacerbations
 Peak Flow Monitoring
o Peak flow meters function best as tools for ongoing
monitoring, not diagnosis
o Refer to the patient’s written asthma action plan for
the patient’s personal best peak flow
 o Because measurement of peak expiratory flow (PEF) is  Annual influenza vaccination may help reduce acute exacerbation
dependent on effort & technique, patient instructions, in patients with moderate-severe asthma
demonstrations & frequent reviews are recommended
Pollutants
Quality of Life

 Smoking during pregnancy has a strong effect on young children

 Any school day missed because of asthma while post-natal maternal smoking has an effect only to asthma
 Any reduction in usual activities (eg home, school, recreation, development in older children
exercise)  Avoid exposure to environmental tobacco smoke during
 Any sleep disturbance due to asthma pregnancy & the first year of life
 Any change in the caregiver’s activities due to asthma  There is an increased risk of asthma associated with exposure to
outdoor pollutants (eg residence near a main road)
History of Asthma Exacerbations
Microbial effects

 Frequency
 Rate of onset  Exposure to microbiota may be of benefit in the prevention of
asthma
 Severity
 Children exposed to potential allergens early in life (eg farm
 Cause
stables & animals, unprocessed milk) present with lower risk for
asthma development compared to other children
Monitoring Adherence to Therapy  Infants born via vaginal delivery may be at lesser risk for asthma
than those born by caesarean section (C-section)
 Adherence to drug regimen
o The mode of delivery may be associated with the
 Patient concerns about drug regimen differences between infants’ gut microflora
 Adverse effects experienced with the drug regimen
Medications & Other Factors
Monitoring Patient-Provider Communication & Patient Satisfaction

 Paracetamol/Acetaminophen, analgesic & broad-spectrum

 Patient’s negative attitude toward medication &/or reluctance antibiotics use in the 1st-2nd year of life is discouraged
towards self-management are risk factors for severe
exacerbations
Psychosocial Factors

Prevention
 There is an increased risk of asthma development if there is
maternal distress that persists from birth through to early school
 It is believed that asthma development & persistence are driven age
by gene-environment interactions thus interactions during
pregnancy & early in life has a great influence
Severity Assessment of Asthma Exacerbation
 Preventing the onset of disease is called primary prevention

Nutrition
 Asthma exacerbation is an acute or sub-acute deterioration in
symptom control that is sufficient to cause distress or risk to
health & would need specialist consult or requires treatment with
Breastfeeding systemic corticosteroid

 It may decrease wheezing episodes in early life but may not

o Episode of progressive increase in wheeze & shortness
of breath, cough especially when the child is asleep,
prevent developing asthma
lethargy or reduced exercise tolerance, impairment of
 It is still encouraged for all of its positive benefits daily activities (including feeding) & poor response to
reliever medication
Vitamin D
 Severity must be assessed immediately through history, physical
 Some studies show that maternal intake of vitamins D & E lowers examination, & objective measures of lung function
the risk wheezing illnesses in children
o Peak expiratory flow (PEF) or forced expiratory volume
in 1 second (FEV1) & arterial oxygen saturation should
Allergens
be measured to determine the degree of hypoxemia

 There are conflicting evidences on the effect of pet allergens on  PEF or FEV1 are more reliable indicators of
patients with asthma airflow limitation severity & may also help
 Dampness, visible mold & mold odor should be eliminated as determine patients who require
studies suggested that exposure to these home allergens increase hospitalization (eg patients with pre-
the risk of developing asthma treatment FEV1 or PEF <25% predicted or
personal best or patients with post-
treatment FEV1 or PEF <40% predicted or
Vaccinations personal best)
 o Evaluate patient’s severity for risk of death based on Initial assessment of acute asthma exacerbation
the following:
Mild-Moderate
 Past history of near-fatal asthma requiring
intubation & mechanical intubation
 Prior (within 1 year) hospitalization or  No altered consciousness
emergency care visit due to asthma  Arterial O2 saturation (SaO2) at >90-95% (>92% for children <5
exacerbation years)
 Currently using or recently stopped oral  Talks in phrases/sentences
glucocorticosteroids  Pulse rate <100 beats/minute; <200 bpm (0-3 years)/<180 bpm (4-
 Currently not on inhaled 5 years) pulse rate
glucocorticosteroids
 No central cyanosis
 Overdependent on rapid-acting inhaled
beta2-agonists (eg use of >1 canister per
 Increased respiratory rate
month)  Variable wheeze intensity
 History of psychiatric disease or
psychosocial problems Severe
 History of poor compliance with asthma
medication or asthma action plan
 Difficult to perceive airflow obstruction or
 Agitated
severity  SaO2 at <92%
 Talks in words
 Severe asthma attack requires close supervision as it may be life  Pulse rate >200 beats/minute (0-3 years) or >180 beats/minute (4-
threatening 5 years)
 Cyanosis may likely be present
o Treatment should continue until PEF or FEV1 has  Subcostal &/or subglottic retractions present
returned to their previous ideal value or plateau  Respiratory rate >30/minute
 Wheeze may not be present
 Immediate medical attention is needed when:
Life-threatening
o There is a presence of acute distress in the child
o Inhaled bronchodilator did not relieved promptly the
child’s symptoms  Unable to speak
o Progressively shorter period of relief after doses of  Drowsy, confused or silent chest
rapid acting beta2agonist
o There is a need for a child <1 year to have repeated
inhaled rapid acting beta2 agonist administration over
several hours

Nonspecific urinary tract infection symptoms in infants <3 months are fever,
feeding difficulties, vomiting, lethargy, irritability and failure to thrive.
Toddlers and preschoolers have unusual odor of urine, abdominal or flank
pain, frequency, dysuria, and urgency.
School-age children have the classical symptoms of fever, frequency,
urgency and dysuria.
Consider UTI in all seriously ill children even when there is evidence of
URINARY TRACT INFECTION (PEDIATRIC) infection outside the urinary tract.
Etiology
Probable pathogen  Serious illness
 Poor urine flow
 E coli is the causative agent of the majority of urinary tract  Abdominal or bladder mass
infection (UTI)  Elevated creatinine
 Klebsiella spp, Citrobacter spp, Enterococcus spp, Pseudomonas  Septicemia
aeruginosa, Staphylococcus saprophyticus, S aureus, Proteus sp
 Failure to respond w/in 48 hours to appropriate antibiotic therapy
 Infection w/ non-E coli organisms
Probable non-pathogen

Recurrent Urinary Tract Infection (UTI)

 Coagulase-negative staphylococci, Viridans sterptococci
 Diphtheroids, lactobacilli
C-reactive protein
 May help differentiate upper urinary tract infection (UTI) from
lower urinary tract infection (UTI) & other causes of bacteriuria
 A concentration of >20 ug/mL signifies a serious bacterial
infection; may be useful in ruling out acute pyelonephritis/upper
urinary tract infection (UTI) in patients w/ pyuria & fever who may
have viral infection
Risk Factors
 ≥2 episodes of urinary tract infection (UTI) w/ acute
pyelonephritis/upper urinary tract infection (UTI) or
 1 episode of urinary tract infection (UTI) w/ acute
pyelonephritis/upper urinary tract infection (UTI) plus ≥1 episodes
of cystitis/lower urinary tract infection (UTI) or
 ≥3 episodes of urinary tract infection (UTI) w/ cystitis/lower
urinary tract infection (UTI)
Assessment
Signs & symptoms consistent w/ urinary tract infection (UTI) based on
patient’s age

 Temperature ≥39°C
 Uncircumcised boys <1 year old Infants <3 months
 Sexual activity among young girls
 Fecal & perineal colonization  Nonspecific: Fever, feeding difficulties, vomiting, lethargy,
irritability, failure to thrive
 Urinary tract malformation, functional urinary abnormalities [eg
vesicoureteral reflux (VUR), neurogenic bladder], enlarged  Less common: Abdominal pain, jaundice, hematuria, strong-
bladder smelling urine, sepsis syndrome, shock
 History of urinary tract infection (UTI), dysfunctional voiding
 Presence of a spinal lesion, abdominal mass Toddlers & preschoolers
 High blood pressure (BP)
 Fever of uncertain origin  Unusual odor of urine
 Abdominal or flank pain
Diagnosis  Frequency, dysuria, urgency
 Nonspecific signs may be present
Presumed Urinary Tract Infection (UTI)
School age

 Diagnosed while urine culture results are pending in a patient w/  Classical symptoms more common: Fever, frequency, urgency,
abnormal lab exams & clinical findings consistent w/ urinary tract dysuria
infection (UTI)
 Strong-smelling urine, new onset urinary incontinence, changed
behavior
Definite Urinary Tract Infection (UTI)  Abdominal or flank pain

Consider urinary tract infection (UTI) in all seriously ill children even when there
 Diagnosis requires both positive results from urinalysis & culture is evidence of infection outside the urinary tract
obtained through catheterization or suprapubic bladder
aspiration (SPA)
Signs & symptoms consistent w/ urinary tract infection (UTI) based on
severity
o Culture results should have presence of >50,000
cfu/mL

Simple urinary tract infection (UTI)

 Acute pyelonephritis is suggested in a patient who presents w/
dysuria & urinary frequency associated w/ flank pain, high-grade
fever (temp >38.5oC) & chills  Mild pyrexia, good fluid intake, mild dehydration, good treatment
 An immunocompromised patient or patient <2 months is compliance
assumed to have acute pyelonephritis or complicated urinary
tract infection (UTI) Severe urinary tract infection (UTI)

Atypical Urinary Tract Infection (UTI)

  Fever ≥39°C, persistent vomiting, severe dehydration, poor o Diapered, uncircumcised boys whose urethral
treatment compliance openings are difficult to see
o Patients w/ urgent indications for treatment who
cannot produce a clean-catch midstream urine
Urine Specimen Collection
specimen & cannot be catheterized

 It is difficult to obtain an uncontaminated urine specimen

 It is difficult to obtain an uncontaminated urine specimen

Bag
Laboratory Tests

 Least traumatic method Urine dipstick test

 Useful in infants
 A plastic bag is taped at the perineal area & urine is collected after
the child voids  May reduce the need for culture especailly in patients w/ a low
 Because of high risk of contamination, a bagged specimen is not likelihood of urinary tract infection (UTI) (eg vague urinary
useful in accurately documenting urinary tract infection (UTI) complaints, w/ an alternative cause of fever)
 Useful in ruling out urinary tract infection (UTI) when result is  Urine dipstick may have lower sensitivity in infants
negative
 Not ideal for urine culture: 88% false positive result, 63% Leukocyte esterase
specificity; 95% false positive rate for febrile boys, 99% false
positive rate for circumcised boys
 Produced by activated white blood cells (WBC)
Clean-catch midstream urine specimen  May be falsely negative if white blood cells (WBC) are not present
during a urinary tract infection (UTI)
 Sensitivity of 48-86% & specificity of 17-93%
 May be obtained from toilet trained patients w/ no apparent
infection or abnormality of the external genitalia
Nitrite
 Cleansing before specimen collection is not needed
 Likely to be contaminated by periurethral & preputial organisms,
esp in young girls & uncircumcised boys  Gram negative bacteria reduce dietary nitrates to nitrites
 Useful in ruling out urinary tract infection (UTI) when result is  May be falsely negative if pathogen is Gram positive or bacterial
negative metabolism has not yet produced nitrites
 Sensitivity of 45-60% & specificity of 85-98%
Urethral catheterization
Urine microscopy
 Traumatic & invasive procedure that may introduce periurethral
organisms into an otherwise sterile urinary tract
 95% sensitivity, 99% specificity of urine sample when used for  Findings supportive of urinary tract infection (UTI)
culture
 Requires cleansing & strict aseptic technique o ≥5-10 white blood cells (WBC)/high power field
 Initial portion of urine should be discarded because it may be o Any bacteria seen on Gram stain of unspun urine, w/
contaminated by periurethral organisms sensitivity of 93% & specificity of 95%

Suprapubic aspiration (SPA)  Urine specimen should have been collected <1 hour after voiding
or <4 hours after voiding when refrigerated
 White blood cells (WBC) casts are almost pathognomonic of
 Gold standard for identifying bacteria w/in the bladder
pyelonephritis
 Traumatic, difficult to perform
 Recommended for the following:

Urine culture

 Gold standard for urinary tract infection (UTI) diagnosis

 Results may take 24-48 hours
 Indicated in the following patients:

o Diagnosed w/ acute pyelonephritis or upper urinary tract infection (UTI)

o Have a high to intermediate risk of serious illness
 o <3 years of age
o W/ a high likelihood of urinary tract infection (UTI) (eg classic urinary symptoms)
o Have cloudy urine or single positive results for leukocyte esterase or nitrite activity
o W/ recurrent symptoms
 Diagnostic thresholds for urine culture based on method of specimen collection:
Collection method
Clean-catch voiding 105 colony forming units (cfu)/mL Repeat testing if 104-105 cfu/mL
Urethral catheterization 105 cfu/mL
Suprapubic bladder aspiration (SPA) Any number of cfu/mL (>10 identical colonies)
Additional lab exams
Blood culture
 Unnecessary in most children w/ urinary tract infection (UTI)
 Must be done in children w/ septic syndrome or septic shock &
febrile infants
Complete septic work up
 Must be done in neonates to avoid missing a diagnosis of
meningitis & in children w/ septic syndrome or septic shock
Imaging
 In the acute setting, diagnostic urinary tract imaging is generally
not necessary unless the diagnosis of urinary tract infection (UTI)
is equivocal
 Imaging studies can most often be done after the resolution of
the acute infection because management during this time is
based on patient’s clinical profile
 Routine imaging for patients w/ a first urinary tract infection (UTI)
is not recommended because imaging has not been shown to
alter outcomes; also, it is not cost-effective
Indications for early imaging during urinary tract infection (UTI)
 Persistence of signs & symptoms of urinary tract infection (UTI)
after 48 hours of appropriate antibiotic therapy
o To identify conditions that require invasive therapy (eg
renal abscess, anatomic abnormalities) that may be
corrected surgically
 Possible urinary tract obstruction (eg abdominal mass, elevated
creatinine, poor urine flow, sepsis)
 In rare cases when localization is clinically important
 Atypical urinary tract infection (UTI) in all patients
 Recurrent urinary tract infection (UTI) in patients <6 months
Indications for delayed imaging
Diagnostic threshold
 Atypical urinary tract infection (UTI) in patients <3 years
 Recurrent urinary tract infection (UTI) in all patients
Types of Imaging Studies
Ultrasound (US)
 Identify abnormalities in renal size & shape, scars, duplication
anomalies, ureteric dilatation
 May reveal bladder diverticula or ureteroceles
 Doppler ultrasonography can detect small areas of inflammation
in the kidneys
 Recommended early imaging test in infants & children w/ atypical
urinary tract infection (UTI) to identify structural urinary tract
abnormalities
 Recommended for febrile infants if evaluation of the renal
parenchyma & size are needed
 Advantages: Noninvasive & radiation-free
 Disadvantage: Results are operator-dependent
Voiding cystourethrogram (VCUG)
 Invasive procedure requiring urethral catheterization; should only
be done when hydronephrosis, scarring, findings suggestive of
high-grade vesicoureteral reflux (VUR)/obstructive uropathy,
atypical/complicated disease are seen w/ renal & bladder
ultrasound (RBUS)
 Detects & grades vesicoureteral reflux (VUR) accurately & can
show bladder & urethral anatomy, periureteral diverticula, spinal
abnormalities
 Disadvantages: Radiation exposure, possibility of introducing
infection into the urinary tract, retrograde filling of the bladder
may be necessary
 In a patient for voiding cystourethrogram (VCUG) prophylactic
antibiotics should be given for 3 days, w/ the procedure taking
place on the 2nd day
Radionuclide cystography
 May be considered for patients w/ reflux
 Advantages: Less radiation exposure
  Disadvantages: Poor image resolution, low sensitivity for lower Penicillins
urinary tract infection (UTI) & other abnormalities

Tc 99m dimercaptosuccinic acid renal scintigraphy (DMSA)  Eg Amoxicillin, Ampicillin, Co-amoxiclav

 Gold standard for localizing infection to the renal parenchyma Quinolones

 More sensitive in detecting cortical scarring than ultrasound (US)
& intravenous pyelogram (IV) pyelogram
 Radiolabeled Tc 99m dimercaptosuccinic acid renal  Eg Ciprofloxacin, Nalidixic acid
scintigraphy (DMSA) is injected intravenously & binds to renal  Provides excellent coverage against Gram-positive & Gram-
proximal tubular cells, after which renal cortical images are taken negative organisms in the urinary tract
 Drug-induced arthrotoxicity shown in animal models has
o An area of decreased uptake delineates an area of discouraged use in children, although they may still be considered
focal defect in the renal parenchyma in the treatment of urinary tract infection (UTI)
o Star-shaped defect in the renal parenchyma may
indicate acute pyelonephritis
o A focal defect in the renal cortex may signify chronic Others
lesion or renal scar

 Renal scarring may indicate that vesicoureteral reflux (VUR) is  Co-trimoxazole

likely to persist in patients w/ reflux  Nitrofurantoin

Principles of Therapy
o Not considered adequate for pyelonephritis because
of poor tissue penetration
o May be used to treat cystitis in older children
Consider hospital admission in the following patients:
Treatment Modification
 Who need intravenous (IV) fluids
 Who need intravenous (IV) antibiotics because of severe illness
 Unresponsive to oral antibiotics  Antibiotic treatment may need to be modified based on urine
 ≤4 months of age culture, however changing antibiotics may not be necessary if
 W/ questionable compliance w/ treatment clinical resolution occurs
 W/ difficulty w/ follow-up  If the patient’s condition does not improve after 24-48 hours of
treatment, re-evaluation should be done
 W/ whom clinician or family is uncomfortable managing the
patient as an outpatient
Duration of Treatment

Outpatient Pharmacotherapy

Lower urinary tract infection (UTI)/cystitis

 Starting empiric treatment w/ a broad-spectrum antibiotic is
recommended in a patient w/ presumptive urinary tract infection
(UTI) once a specimen for culture & urinalysis, preferably  Short courses (2-4 days) of treatment may be equally effective as
obtained from catheterization or suprapubic bladder aspiration longer courses (7-14 days) for older patients
(SPA), is sent
 The agent to be given should be based on the antibiotic Upper urinary tract infection (UTI)/acute pyelonephritis
susceptibility patterns of the infecting pathogen
 Timely treatment w/ antibiotics decreases the severity of renal
 A 7-14 day course of antibiotics should be given to patients w/
scarring upper urinary tract infection (UTI)/acute pyelonephritis
 Local resistance patterns must be considered when choosing an
antibiotic
Inpatient Pharmacotherapy
 Practicality should be considered when deciding which route of
administration of treatment is to be chosen
 An immunocompromised patient or infant younger than 2 mth is
o Oral treatment has the same efficacy as that of assumed to have acute pyelonephritis or complicated urinary
parenterally administered therapies tract infection (UTI) & should be managed in the hospital
o Parenteral outpatient treatment may be administered
to patients w/ acute pyelonephritis but do not require Parenteral Antibiotic Therapy
hospital admission

Cephalosporins
 Ampicillin or cephalosporin plus aminoglycoside (eg Gentamicin,
Tobramycin) cover most urinary tract pathogens

o Once-daily dosing is recommended for patients

 1st-, 2nd- & 3rd-generation cephalosporins may be used in the receiving aminoglycosides
treatment of urinary tract infection (UTI) o Ampicillin provides coverage against Gram-positive
 Oral Cefixime has been shown to be cost-effective & efficacious cocci or Enterococcus
  3rd- or 4th-generation cephalosporin may be used as an
alternative initial treatment when antimicrobial resistance is
increasing or when there is concern about adverse reactions (eg
nephrotoxicity)
o Eg Ceftazidime, Cefotaxime, Ceftriaxone
 Co-amoxiclav may also be used
 If intravenous (IV) treatment is not possible in a patient who
requires parenteral therapy, then intramuscular (IM) treatment
should be considered
Shifting to Oral Antibiotic Therapy (Switch Therapy)
 Parenteral treatment is given until patient is clinically stable &
afebrile for 48-72 hours
 A short course of intravenous (IV) antibiotics followed by oral
antibiotics is as effective as a longer duration of intravenous (IV)
antibiotics
o Please see Pharmacological therapy – Outpatient for
options for oral antibiotic therapy
Duration of Treatment
 A 7-14 day course of antibiotics should be given to patients w/
upper urinary tract infection (UTI)/acute pyelonephritis
Prevention
 Goal of antibiotic prophylaxis is to prevent infection, renal
damage & scarring by sterilizing urine
 Routine antibiotic prophylaxis in patients w/ first-time urinary
tract infection (UTI) is not recommended
 Asymptomatic bacteriuria in a patient w/ a normal urinary tract is
not an indication for antibiotic prophylaxis
BASIC LIFE SUPPORT - PEDIATRIC
Basic life support (BLS) is the fundamental approach to saving
lives following cardiac arrest. Primary aspects of BLS include
immediate recognition of sudden cardiac arrest and activation of
the emergency response system, early cardiopulmonary
resuscitation, and rapid defibrillation with an automated
external defibrillator.
 Antibiotic prophylaxis may reduce the number of positive urine
cultures but has not been clearly shown to reduce the number of
new symptomatic urinary tract infection (UTI) or new renal
parenchymal defects
 Possible drawbacks of antibiotic prophylaxis:
o Patient inconvenience
o Poor compliance
o Colonization w/ resistant organisms
 Prophylaxis may be considered in the following patients:
o W/ history of vesicoureteral reflux (VUR)
o Immunosuppressed
o W/ partial urinary tract obstruction
o W/ recurrent urinary tract infection (UTI)
 Antibiotics used for prophylaxis should ideally be administered
orally & achieve high concentrations in the urine while
maintaining low fecal concentrations
 Antibiotics that may be used for prophylaxis: Co-trimoxazole,
Nalidixic acid, Nitrofurantoin, cephalosporins, fluoroquinolones
Vesicoureteral Reflux
 Not all cases of vesicoureteral reflux (VUR) require treatment
 Intervention for vesicoureteral reflux (VUR) does not always
prevent complications
 Long-term antibiotic therapy may be given to prevent infections
in a child who is expected to outgrow reflux
 Surgery is recommended for higher grades of reflux
o Open surgical repair including ureteral implantation
o Endoscopic treatment
 Correction of dysfunctional elimination, ie constipation has been
shown to decrease recurrent urinary tract infection (UTI)
Evaluation for Response
Check Child's Responsiveness
 Quickly check for the "signs of life": normal breathing, coughing
or spontaneous movement of the child
 Gently stimulate the child
o Do not shake child if spinal cord injury is suspected
 Ask loudly "Are you all right?"
Assessment
Assess Child & Get Help
Responsive Child
 Allow the child to remain in the most comfortable position
 Check condition
 If alone, get help or if available, send someone for help
 Reassess regularly
Unresponsive Child
 Shout for help
 Leave child in present position if able to assess
 If unable to assess in present position, turn child on to his back
o Roll child as a unit so head, shoulders & torso move
together without causing the body to twist
 If head or neck injury is suspected, move the child only if
necessary
Assess Breathing & Circulation
Check child’s breathing
 While evaluating for responsiveness, briefly check for signs of
abnormal breathing or absence of breathing
o Note that gasping is NOT normal breathing
 Assessment should take <10 seconds
Check child for signs of circulation
 Check for pulse
o Infants: feel for brachial pulse
o Children: feel for carotid or femoral pulse
 Palpation of pulse is not the only determinant for the need to do
chest compressions
 No more than 10 seconds should be spent checking for circulation
o If no pulse is felt or rescuer is not sure if pulse is
present, begin chest compressions
 If a palpable pulse ≥60/minute is present but there is inadequate
breathing, rescue breaths should be given
o Reassess the pulse about every 2 minutes (but do so in
<10 seconds)
 If the pulse is <60/minute and with signs of poor perfusion (eg
pallor, cyanosis, mottling) despite ventilation support, initiate
chest compressions
Recovery Position
 Recovery position aims to decrease the chance of saliva, vomitus
or secretions from entering the upper airway & prevent airway
obstruction
 If alone, get help or if available, send someone for help
 Observe for continued breathing
If spinal injury is not suspected, turn child to recovery position:
 Unconscious child should be placed on his side with care for the
possibility of spinal injury
 Place child as close as possible to a true lateral position
 Mouth should be in position to allow free drainage of fluid
 Infants may need a small pillow or rolled-up blanket along his
back to stabilize his position
 Child should be on a firm surface if chest compressions are
necessary
o If child is found on the floor, manage where found; if
on a mattress, deflate mattress or move the child &
place on the floor if possible
o Your forearm may be used for small infants
Chest Compressions & Ventilations
 If not alone, send one rescuer for help
 If alone, administer 5 cycles or about 2 minutes of
cardiopulmonary resuscitation (CPR) before going for help
o If child has known heart disease & collapses suddenly,
it is best to seek help immediately
 May be possible to carry child while getting help
 Carefully remove any obvious airway obstruction from the child’s
mouth
 Recommended sequence of resuscitation for children without
normal breaths & pulses is (1) chest compressions, (2) airways, &
(3) breathing
o Decreases the “no blood flow” time
o Interval between pulselessness & initiation of chest
compression is reduced
 For an infant or child in cardiac arrest, compression-only CPR may
be considered if unable or unwilling to deliver rescue breaths
Chest Compressions
 Start chest compressions if:
o No signs of circulation
o Unsure that pulse is present
o Pulse <60 bpm with poor perfusion (eg cyanosis,
pallor)
 There is actually no known absolute heart
rate at which chest compressions are
started; this recommendation is based on
ease of retention of skills
 Place patient on a firm surface in a horizontal supine position
(which may be your forearm if it is a small infant)
Infants (<1 year old)
For Lone Rescuer
Locate the lower sternum
 Two-finger technique: 2 fingers placed just below the
intermammary line
Perform compressions
 With the 2 fingers, apply pressure down at least 1/3 the depth of
the anterior-posterior diameter of the infant’s chest
(approximately 4 cm or 1.5 inches)
 Release completely after each compression to allow chest to
recoil fully
o Allows the heart to refill with blood
 Repeat at a rate of about 100-120 compressions/minute
 Compressing and releasing should take equal amounts of time
 Actual number of compressions will be <100 because of time
taken to give rescue breaths
Combine Compressions & Rescue Breathing
 After 30 compressions, administer 2 effective breaths
More Than One Rescuer (Two-Thumb Method)
Locate the lower sternum
 Put both thumbs side by side flat side down on the lower sternum
1 finger breadth below an imaginary line connecting nipples
 Thumb tips should point towards the infant’s head
 With the rest of the fingers together, spread both hands around
the lower part of the infant’s rib cage
Perform compressions
 Press down on sternum with thumbs & apply pressure down at
least 1/3 the depth of the infant’s chest (approximately 4 cm or 1.5
inches)
 Release pressure without removing your hands from infant
 Repeat at a rate of about 100 times/minute
 Compressing and releasing should take equal amounts of time
 Actual number of compressions will be <100 because of time
taken to give rescue breaths
Combine Compressions & Ventilations
 Ratio of compressions to breaths should be 15:2, with the
shortest possible pause in compressions
Children (>1 year old until puberty)
Locate Sternum & Position Yourself
 Place heel of 1 hand or of 2 hands on the lower half of sternum
(do not push on the xiphoid or the ribs)
 Extend fingers away from body to ensure pressure is not applied
to ribs
 Position yourself vertically above the child’s chest
 Keep your arms straight with elbows locked
Perform Compressions
 Using the heel of one or both hands, press down on sternum &
apply pressure down approximately 1/3 of the AP dimension of
the child’s chest or about 5 cm (2 inches)
 Release pressure to allow chest to recoil fully
 Repeat at a rate of about 100 times/minute
o Slightly <2 compressions/second
 Counting out loud may be helpful
 Compressing & releasing should take equal amounts of time
Combine Compressions & Rescue Breathing
 For 2-rescuer resuscitation, rotate roles between rescuers every 2
minutes
 After 15 compressions administer 2 effective breaths
 Ratio of compressions to breaths should be 15:2 or 8-10
breaths/minute
o For lone rescuers, 30:2 is recommended
 Stop & check for signs of breathing or circulation after 20 cycles
of compressions & every few minutes after that
Open the Airway
 Put hand on forehead & gently tilt head back
 Using fingertips under chin point, lift chin to open airway
 Check for patency while doing the head tilt-chin lift maneuver
If neck injury is suspected:
 Avoid head tilt
 Open the child’s mouth if it is not yet open
 Use jaw thrust maneuver: Put first 2 fingers of both hands on
each side of child’s jaw bones & push jaw forward
o This maneuver is not recommended for lay rescuers
since it may cause spinal movement, often ineffective
in opening the airway & is difficult to learn & perform
 If jaw thrust does not open the airway, healthcare professionals
may do the head tilt-chin lift maneuver with caution
Inadequate breathing with circulation (presence of a definite pulse)
 Do rescue breathing at a rate of 12-20 breaths/minute until child
breathes on his own (1 breath every 3-5 seconds)
o Technique will depend on child’s age
 If patient starts to breathe, but remains unconscious, place in
recovery position
 Child should be reassessed regularly
Inadequate breathing in the presence of bradycardia or poor perfusion
  Give 2 slow, effective breaths
 Clear airway of any obvious obstruction
 Technique will depend on child’s age
Infants: Mouth to Mouth & Nose Rescue Breathing Technique
 Confirm head tilt & chin lift
 Take a breath & place lips around infant’s mouth & nares ensuring
a good seal
 If both nose & mouth can’t be covered, attempt to seal around
only mouth or nose
o Ensure mouth is closed if breathing in nose
o Pinch the nose closed if breathing in mouth
 Blow steadily into the infant’s mouth/nose for about 1-1.5
seconds
 Watch chest to rise with breath (if chest does not rise, reposition
the head, ensure a better seal & try again)
 Keeping head tilt & chin lift, remove your mouth & watch for
chest to fall
 Repeat to give 2 effective rescue breaths
Children: Mouth to Mouth Rescue Breathing Technique
 Do head tilt & chin lift
 Using your thumb & index finger of hand placed on forehead,
pinch close the soft part of nose
 Open child’s mouth slightly while maintaining chin lift
 Take a breath & place lips around patient’s mouth ensuring good
seal
 Blow steadily into the child’s mouth for about 1-1.5 seconds
 Watch chest to rise with breath (if chest does not rise, reposition
the head, ensure a better seal & try again)
 Keeping head tilt & chin lift, remove mouth & watch for chest to
fall
 Repeat to give 2 effective rescue breaths
Mobilize Automated External Defibrillator (AED)
 For witnessed sudden collapse wherein ventricular fibrillation or
pulseless ventricular tachycardia is considered (also called
“shockable rhythms”)
 May be treated by monophasic or biphasic shocks with initial
dose of 2 J/kg & subsequent dose of 4 J/kg
 For infants & children <8 years of age, a manual defibrillator or an
AED with pediatric attenuator is preferred
o Evidence to support use of AED in children <1 year is
limited to case studies
 Administer 1 shock then resume chest compressions immediately
for about 2 minutes to minimize the no-flow time
 Check or reassess rhythm every 2 minutes
Continue Resuscitation
Continue resuscitation until:
 Qualified help arrives & takes over
 Child shows signs of life or recovery (eg child starts to move,
wake up, opens eyes, normally breathes, or with definite pulse)
 You become exhausted
Foreign Body Airway Obstruction (FBAO) Sequence
If unable to give effective breaths after rechecking the airway:
 May need to perform foreign body airway obstruction (FBAO)
sequence
 Active interventions to relieve foreign body airway obstruction
(FBAO) are recommended only when coughing becomes
ineffective and there is complete obstruction of airway
 Signs of foreign body airway obstruction (FBAO) include sudden
onset of resp distress with gagging, coughing, wheezing or stridor
Foreign Body Airway Obstruction Sequence in Infants
Partial Airway Obstruction
 If infant is breathing on his own, allow him to attempt to clear
obstruction by coughing on his own
Complete Airway Obstruction: Infant stops breathing or coughing
 Rescuer must act to relieve obstruction
 Do not use blind finger sweep in mouth or upper airway to
remove foreign body as this may push objects further down the
airways
Conscious Infant
Healthcare worker rescuing conscious infant with known foreign body
airway obstruction: use back blows followed by chest thrusts if back blows
are not effective
 5 back blows
o Rest infant in a prone position on your forearm making
sure head is lower than chest
o Support infant’s head by supporting the jaw firmly (do
not press on the infant’s throat)
o To support infant, rest your forearm on your thigh
o Administer 5 slaps using the heel of your hand to the
mid back between the shoulder blades
o If 5 blows fail to remove foreign object, try chest
thrusts
 5 chest thrusts
o Turn infant as a whole unit by placing other forearm on
infant’s back & the palm of your hand supporting the
infant’s head
o Place infant in supine position & if possible, head lower
than chest
o Administer 5 chest thrusts to sternum (position is
similar to chest compressions)
 Check mouth after a sequence of 5 back blows & 5 chest thrusts
o Using care, remove any foreign objects in mouth
Unconscious Infant
Healthcare worker rescuing unconscious infant with known foreign body
airway obstruction: use chest thrusts
 Use 5 back blows followed by 5 chest thrusts
  Check mouth for foreign object by using tongue jaw lift
o Grasp both the tongue & lower jaw between your
thumb & fingers & lift the mandible
o If foreign object is visible, carefully remove it (do not
use blind sweep)
 Open airway
o Put hand on forehead & gently tilt head back
o Using fingertips under chin point, lift chin to open
airway or use jaw thrust
o Attempt up to 5 rescue breaths
o If airway still obstructed repeat 5 back blows & 5 chest
thrusts
Foreign Body Airway Obstruction Sequence in Children
Partial Airway Obstruction
 If child is breathing on his own, encourage him to clear
obstruction by coughing on his own
Complete Airway Obstruction: Child stops breathing or coughing
 Do not use blind finger sweep in mouth or upper airway to
remove foreign body as this may push objects further down the
airways
Conscious Child
Several techniques are used, check with local protocol
 Abdominal thrusts used alone
 5 back blows followed by 5 abdominal thrusts
 5 back blows followed by 5 chest thrusts (see Chest Thrust
Technique)
Abdominal Thrusts
 Stand or kneel behind patient
 Make fist with 1 hand
 Place fist with thumb side in against the patient’s midline
abdomen slightly above the navel making sure to be well below
the bottom tip of the sternum
 Place other hand over fist & press fist into the abdomen with a
quick inward & upward thrust
 Continue until foreign object is removed or patient loses
consciousness
 Avoid applying pressure to the xiphoid process or lower rib cage
to prevent causing abdominal trauma
 Child should seek medical attention after abdominal thrusts are
performed to rule out any internal injury
Back blows
 Position the child’s head down for more effective back blows
 As with the infants, place the child across rescuer’s lap
 If above position is not possible, place the child in a forward
leaning position & perform the back blows from behind
Unconscious Child
Healthcare worker rescuing unconscious child with known foreign body
airway obstruction: use abdominal thrusts
 Place patient in supine position
 Facing towards the patient’s head, straddle his thighs
 Place the heel of 1 hand in the middle of upper abdomen
 While supporting with the other hand, give sharp push up & back
towards center of chest for 5 thrusts
 Check mouth for foreign object by using tongue jaw lift
o Grasp both the tongue & lower jaw between your
thumb & fingers & lift the mandible
 If foreign object is visible carefully remove it (do not use blind
sweep)
 Open airway & if still unable to administer effective breaths,
repeat sequence
Resuscitation in Special Cases
Drowning
 Carefully remove patient from water as quickly as possible
 Rescue breathing while in water may be attempted by trained
rescuers; however, this should not delay removing the victim
from the water
 Chest compressions should never be done while in the water
 Start resuscitation as soon as victim is removed from water
o Lone rescuer may administer 5 cycles of chest
compressions and rescue breathing for 2 minutes
o If more than 1 rescuer are present, one may start
mobilizing AED while the other is doing CPR
Trauma
 Basic life support resuscitation for children w/ trauma or injury are
governed by the same principles as the non-injured child, taking
into account the following:
o Jaw thrust is the preferred technique in opening &
maintaining the airway; if this does not open the
airway, use the head tilt-chin lift
o Airway obstruction should be anticipated; a suction
device may be necessary
o As much as possible, avoid movement of the head &
neck in cases of spinal injury; secure the shoulders,
pelvis & thighs to the immobilization board
o Apply direct pressure for presence of any external
bleeding
 It is recommended to transport the patients with potential for
serious trauma to a trauma center
CONSTIPATION IN CHILDREN
Constipation is a delay or difficulty in bowel movement persisting for ≥2
weeks.
It is a common digestive problem, not a disease, and usually not serious
caused by changes in diet and early toilet training.
Constipation in children generally first happens in the toddler stage,
between ages 2 and 4 years, with studies showing variation in gender-
specific prevalence.
Functional constipation is the one that cannot be explained by any
anatomical, physiological, radiological or histological abnormalities.
Organic constipation is with identifiable physiological or organic cause.
Chronic constipation is the constipation that lasts for >8 weeks.
Introduction
o Constipation that cannot be explained by any
anatomical, physiological, radiological or histological
abnormalities
 Organic constipation
o Constipation with an identifiable physiological or
organic cause; presence of red &/or amber flags
 Chronic constipation
o Constipation lasting for more than 8 weeks

 A delay or difficulty in bowel movement persisting for ≥2 weeks
 A common digestive problem, not a disease, & usually not serious
 Constipation in children generally first happens in the toddler
stage, between ages 2 & 4 years, with studies showing variation
in gender-specific prevalence
Etiology
 Factors that may cause constipation:
o Pain
o Dehydration
o Psychological issues (eg depression, attention-deficit
disorder, sexual abuse)
o Toilet training
o Fever
o Dietary & fluid intake
o Cow’s milk protein allergy
o Medicines (eg opioids, antidepressants,
anticholinergics)
o Family history of constipation
o Withholding that may result from ignoring the urge to
defecate due to toilet phobia, being too busy, toilet
unavailability, & pain from bowel movement
o Changes in routine (eg travel, stress, hot weather)
o Medical conditions (eg intestinal, rectal or anal,
metabolic or endocrine diseases)
Evaluation
 When thorough & complete, the history & physical exam findings
are usually sufficient to allow the healthcare professional to
decide if the child has functional constipation or needs further
evaluation
 The younger the infant, the higher the risk of an anatomic or
organic cause of constipation
 Establishing whether constipation is functional or organic helps
direct diagnostic tests & treatment plan
 Organic causes of constipation in infants & children have warning
signs or “red flags”
History
 The following key components are essential in history taking:
o Children <1 year old
 Stool patterns (<3 complete stools/week,
hard large stool, “rabbit droppings”)
 Symptoms associated with defecation
(distress while defecating, bloody hard
stools, straining)
 Previous history of constipation or
previous/current anal fissure
o Children >1 year old

 Stool patterns (<3 complete stools/week,

Signs and Symptoms overflow soiling, “rabbit droppings”, large
hard infrequent stools)
 Absence of bowel movement for several days (may be normal in  Symptoms associated with defecation
breastfed infants) (poor appetite that improves with passage
of large stool, waxing & waning of
 Encopresis - soiling of undergarments due to the involuntary
abdominal pain with passage of stool,
leakage of feces
straining, anal pain)
 Large, hard, & dry stools or frequent small pellets
 Previous episode(s) of constipation,
 Irregular stool texture previous/current anal fissure, painful bowel
 Foul smelling wind & stools movements with bleeding associated with
 Blood in stool hard stools)
 Pain while defecating  Medical history taking should also include previous treatment
(diet, medications, adherence), family history, medical history
 Excessive flatulence
(time of passage of meconium, condition at birth, growth),
 Withholding or straining to stop passage of stools developmental history (school performance), & psychosocial
 Abdominal pain history (family & peer interactions, temperament)
 Distension or discomfort
 Poor appetite Physical Examination
 Crankiness or unhappy, irritable mood
 Lack of energy  Perform a complete physical examination with focus on the
 Body malaise abdomen (distention, palpate liver & spleen, fecal mass), anus
(position, presence of stool, erythema, skin tags, fissures), rectum
(anal wink, anal tone, fecal mass, presence & consistency of stool,
Diagnosis explosive stool on removal of finger), back & spine (dimple, tuft of
hair), neurology (tone, strength, cremasteric & deep tendon
Types of Constipation reflexes)
 A digital rectal exam (DRE) is done to assess tone in the rectum &
presence of impaction
 Functional constipation
 o A DRE should be done only by healthcare
professionals capable of interpreting anatomical
abnormalities or diagnosing Hirschsprung’s disease
o Not to be performed in children >1 year with red flag
signs/symptoms
o Advisable for <1 year old patients diagnosed with
idiopathic constipation unresponsive to optimum
treatment within 4 weeks
o No confirmatory imaging tests are indicated if fecal
impaction is present on DRE
o An abdominal x-ray may be needed if a rectal exam
cannot be done or is traumatic for the child
“Red Flag” Signs Indicative of Organic Constipation
 Perianal area
o Abnormal appearance/position/patency of anus:
Fistulae, bruising, multiple fissures, tight or patulous
anus, anteriorly placed anus, absent anal wink,
pilonidal dimple
 Abdominal exam
o Gross abdominal distention
o Tight, empty rectum in presence of palpable
abdominal fecal mass
 Spine/lumbosacral region/gluteal exam
o Abnormal asymmetry or flattening of the gluteal
muscles, evidence of sacral agenesis, discolored skin,
nevi or sinus, hairy patch, lipoma, central pit, scoliosis
 Lower limb neuromuscular exam
o Deformity (eg talipes)
o Decreased lower extremity tone and/or strength
o Abnormal reflexes (absent cremasteric reflex, absence
or delay in relaxation phase of lower extremity deep-
tendon reflexes)
Hirschsprung’s Disease
 Most common cause of obstruction in the lower intestines in
neonates & a rare cause of difficult-to-control constipation in
children ≥2 years
 Suspected when the following is present: Meconium passage ≥48
hours after birth, small stools, failure to thrive, fever, bloody
diarrhea, bilious vomiting, tight anal sphincter, & palpable fecal
mass in the abdomen with empty rectum
Spinal Cord Abnormalities
 Eg tethered cord, spinal cord tumor
 May be considered if there is presence of decreased lower
extremity reflexes or muscular tone, negative anal wink, positive
pilonidal dimple or hair tuft
Hypothyroidism
 Suspected if there is fatigue, intolerance to cold, slow heart rate,
poor growth
Diabetes Insipidus
 May be considered if there is increased urination & thirst
Cystic Fibrosis
 Suspected if there is diarrhea, failure to thrive, rash, fever,
recurrent pneumonia
Anal Abnormalities
 Eg congenital anorectal malformation, imperforate anus, anal
stenosis
 Suspected if there are physical exam findings of abnormal
position or appearance of anus
Laboratory Tests
 Generally unnecessary unless in confirming alternative diagnosis
or organic causes of constipation
 Unless an organic disease is suspected from history & physical
exam & the child is unresponsive to adequate treatment, it is
generally not necessary to have laboratory studies
 Fecal occult blood tests may be done in infants & children with
constipation who have diarrhea, abdominal pain, failure to thrive,
or positive family history of colorectal cancer or polyps
 Organic, metabolic, & endocrine diseases can be confirmed by
performing thyroxine, thyroid stimulating hormone (TSH),
calcium & lead levels, celiac disease antibodies, & a sweat test
Imaging
Abdominal Radiography
 For assessment of bowel disease & to diagnose fecal impaction
 Shows the amount of stool present
 Useful in obese children & those who cannot have a digital rectal
exam (DRE) done
 If child’s history is unsure, it can help determine efficacy of
treatment
 Has limited value in clinically assessing constipation due to poor
correlation between radiological & clinical diagnosis
Barium Enema
 A contrast dye (barium) coats the lining of the bowel for clear
visualization on an x-ray
 Useful in diagnosing Hirschsprung’s disease by demonstrating the
transition zone (change in diameter of the colon from the narrow
aganglionic segment to a dilated ganglionic segment)
 Helps evaluate motility of colon (slow motility in megasigmoid &
impacted stool)
 Less reliable during the first months of life due to insufficient
dilation of the proximal colon for the transition zone to be
demonstrable
Colon Transit Time (Radiopaque Markers)
  Involves swallowing of a capsule containing radiopaque markers
followed by serial x-rays taken over several days
 Most markers are removed by the fifth day & delayed removal
indicates slow motility of the colon
 Useful in children with chronic difficult-to-control constipation &
in children with bowel movements that are infrequent & negative
signs of constipation
Rectal Biopsy
 A small sample of a full-thickness biopsy is taken about 3 cm
above the anal verge
 Definitive means of diagnosing Hirschsprung’s disease
 Presence of hypertrophied nerves on microscopy establishes the
diagnosis of Hirschsprung’s disease
 Not indicated when clinical & imaging findings are suggestive of
functional constipation
Other Tests
 Magnetic resonance imaging (MRI) of the lumbosacral spine can
identify intraspinal problems like sacral agenesis, tumors, or a
tethered cord
 Flexible sigmoidoscopy & colonoscopy can demonstrate colonic
structural problems like fissures, tumors, or strictures
Functional Constipation
 Constipation that cannot be explained by any anatomical,
physiological, radiological or histological abnormalities
 Also known as idiopathic constipation, functional fecal retention
or fecal withholding
 Most common cause of constipation
 Commonly caused by painful bowel movements with resultant
voluntary withholding of feces by a child who wants to avoid
unpleasant defecation
 Present if the following are detected:
o History: Passage of stool within 2 days of birth, hard
large-caliber stools, encopresis, painful defecation,
bloody stools, decreased appetite, abdominal pain
with bowel movement, diet low in fluid & fiber, high in
milk products, avoids the toilet
o Physical exam: Normal appearance of the anus & the
surrounding area, soft or mild distention of the
abdomen, stool palpable in the left lower quadrant,
normal anal placement & sphincter tone, rectum
distended & filled with stool, positive anal wink &
cremasteric reflex
 Rome III diagnostic criteria for functional constipation in children
<4 years of age:
o ≥2 of the following present for at least 1 month:
 Two or fewer defecations per week
 At least one episode of fecal incontinence
per week after being potty-trained
 History of retentive posturing or excessive
volitional stool retention
 History of painful or hard bowel
movements
 Presence of a large fecal mass in the rectum
 History of large diameter stools that may
obstruct the toilet
 Rome III diagnostic criteria for functional constipation in children
≥4 years with insufficient criteria for irritable bowel syndrome:
o ≥2 of the following present for at least once/week for
at least 2 months prior to diagnosis:
 Two or fewer defecations in the toilet per
week
 At least one episode of fecal incontinence
per week
 History of retentive posturing or excessive
volitional stool retention
 History of painful or hard bowel
movements
 Presence of a large fecal mass in the rectum
 History of large diameter stools that may
obstruct the toilet
Principles of Therapy
 Treatment goals in general include evacuation, pain-free bowel
movement, & formation of regular bowel habits
Pharmacotherapy
Disimpaction
 If fecal impaction is present, initial therapy is to evacuate the
colon
o Fecal impaction is identified through a physical exam
finding of palpable stool on abdominal & rectal exam
& excessive stool on abdominal x-ray
 Disimpaction may be done with oral or rectal medications or a
combination of these two & in uncontrolled clinical trials, these
had been effective
o It is important to discuss options with the family
regarding treatment choice
Oral Disimpaction
 Eg high-dose Mineral oil, Polyethylene glycol (PEG) electrolyte
solutions, high-dose Magnesium citrate, Magnesium hydroxide,
Sorbitol, Lactulose, Senna, or Bisacodyl
 Preferred due to its non-invasiveness but adherence may be
difficult
 PEG is the recommended 1st-line therapy for children presenting
with fecal impaction
Rectal Disimpaction
 Considered only when oral medications have failed & only with
the child or family’s consent
 May be done with saline or phosphate soda enemas or a mineral
oil enema followed by a phosphate enema
o Glycerin suppositories in infants is recommended but
enema to be avoided
o Bisacodyl suppositories in older children are used
o Soap suds, tap water & magnesium are potentially
toxic & are not recommended
 Digital disimpaction is not recommended or discouraged
 Follow-up is needed within one week for children undergoing
disimpaction
Maintenance Therapy
 Following disimpaction, maintenance therapy is then started &
may be needed for several months
 Monitoring is essential during this time to ensure the child does
not become reimpacted & to address issues such as adherence &
toileting
 Frequency of clinic visits is individualized based on the child’s
needs & of the family’s
 It is recommended that the same person or team perform the
reassessment
 Laxatives are advantageous in children until they are able to
maintain regular toilet habits
 Clear evidence is lacking as to which laxative is superior
 Discontinuation of maintenance therapy may be considered if the
child has developed regular bowel habits
Bulk-forming Laxatives
 Eg Ispaghula (Psyllium), Methylcellulose
 Used for treatment & prolonged prophylaxis of patients with
constipation without outlet obstruction
 Often used as first-line treatment & only used if increased dietary
fiber is ineffective
 Water-absorbing organic polymers that increase fecal mass &
make it softer & easier to pass, adequate intake of fluid is
important
Enemas
 Eg Glycerol, Sodium chloride, Sodium phosphate, Phosphate
enemas
 Not recommended for infants
o Increases risk for mechanical trauma to rectal wall,
abdominal distention, vomiting
 Disimpaction with enemas is a recommended option for children
 Phosphate enemas are used after disimpaction with the use of
other enema
Lubricants
 Eg Mineral oil
 Not recommended in infants
 Used for managing acute or subacute constipation
 Soften stool & ease its passage by decreasing water absorption
from the gastrointestinal (GI) tract
Osmotic Laxatives
 Eg poorly absorbed electrolytes Magnesium hydroxide,
Magnesium citrate, Magnesium sulfate, & poorly absorbed
disaccharides Lactulose & Sorbitol, & PEG 3350/4000
 For long-term treatment of constipation that is difficult to
manage, low-dose Polyethylene glycol (PEG) electrolyte solution
may be used
 PEG with or without electrolytes is recommended as first-line
maintenance therapy & Lactulose should be considered if PEG
solutions are not available
 Lactulose & Sorbitol are used in infants as stool softeners
 Produces an osmotic effect in the colon resulting in distention &
peristalsis promoting bowel emptying
 Changes water distribution in the stool causing fluid retention in
the colon through osmosis, good fluid intake is essential
Stimulant Laxatives
 Eg Anthraquinones (Senna, Cascara, Danthron),
diphenylmethanes (Bisacodyl), Castor oil, Glycerol, Sodium
picosulfate
 In the maintenance period, it is not recommended to use
stimulant laxatives for a prolonged time
o It is also not recommended in infants
 Used as a “rescue therapy” when taken intermittently or for short
periods
 Directly stimulates colonic nerves, increase peristalsis in the GI
tract, induce water & salt secretion in the colon
Stool Softeners
 Eg Docusate sodium, Liquid paraffin
 Stool softeners may be combined with a stimulant
o While softening stool, the stimulant increases
peristaltic activity in the GI tract
 Used for prophylaxis in acute & subacute settings
 Surface-active agents that allow absorption of fat & water into
the stool making it softer & easier to pass
Follow Up
 Since relapses are common & bowel movement difficulty may
persist into adolescence, follow-up plan of children & their
parents should be individualized, tailored based on the child’s
treatment response measured by consistency, frequency, &
amount of stool
 Discuss preventive measures for relapse of constipation
Prognosis
 In a recent systematic review, majority of children with
constipation recover within 6-12 months of starting treatment &
recovery rate is not related to age of onset, frequency of bowel
movement, positive family history, & presence of fecal
incontinence
 Another study noted that less than half of affected children
continued to be symptomatic beyond puberty with associated
several complications
 Relapse rate is high as functional constipation is difficult to treat
 Underlying organic disorders exacerbate constipation resulting in
difficult long-term management
Timing
 Advise parents/guardians of infants <6 months with functional
constipation to bring patient for follow-up after 2-4 weeks &
infants ≥6 months with functional constipation without fecal
impaction after 2 weeks for re-evaluation & evaluation of
treatment efficacy
Specialist Referral
 Consultation with a pediatric gastroenterologist is indicated if the
child’s history or exam findings suggest an organic cause, when
the child fails therapy, or for complex management
  Symptoms not improving after 6 months of good compliance to Diet
therapy warrants a pediatric gastroenterology consult

o The pediatric gastroenterologist further evaluates the  Although commonly recommended for treatment of functional
child for underlying organic problems, does specialized constipation, it is discouraged to use dietary modification alone
tests, & gives counseling; review of previous treatment as first-line treatment
regimen may lead to adjustment of medications
 For infants, the following are recommended:
 Referral to other types of specialists including a pediatric surgeon
may be done if other medical problems are identified
o Continue breastfeeding
o For formula-fed infants, partially or extensively
Patient Education hydrolyzed infant formulas with prebiotics w/o palm
oil offer a good alternative for managing functional
constipation
 Family education includes providing information on the
o Helpful for infants are complex carbohydrates &
mechanism of constipation
sorbitol present in some juices, eg apple, prune, pear,
 Encourage parents to have a consistent, positive & supportive which increase stool frequency & fecal water content
attitude during treatment o Barley malt extract or corn syrup can be used as stool
 Knowing the precipitating factors of constipation helps remove softeners
anxiety of parents & caregivers & encourages them to be involved  A high-fiber diet is encouraged to help form soft bulky stool in
in its management children
 Treatment may be long & irregular & characterized by o A 0.5 g/kg body weight intake of fiber is
improvement alternating with relapses recommended in children >2 years
o A balanced diet with fruits, vegetables, & whole grains
Lifestyle Modification is appropriate for treatment
 A double-blind crossover study demonstrated intolerance to
cow’s milk results in constipation; however, withholding milk
Behavioral Therapy
from the diet should be done only on the advice of a specialist
 Increased intake of fluids is also recommended; however, studies
 Aims to regularize toilet habits, discourage stool withholding & have shown that doing so only increased urine output & had no
improve understanding of defecation dynamics effect in output or consistency of stool & did not improve stool
 To establish a regular bowel habit, recommend scheduled frequency
toileting appropriate for the child’s developmental stage, with o Increase intake of absorbable & non-absorbable
adequate time for bowel movement carbohydrates esepecially sorbitol, found in some
juices like prune, pear & apple juice
o Encourage the child to sit on the toilet for 5-10
minutes after meals; when in school, it is alright for the
child not to go to the toilet
o Advise parent to give child enough time to spend in
the toilet when child shows signs of withholding stool
 Straining techniques such as relaxation of legs & feet, taking a
deep breath then pausing while pushing while holding one’s
breath, should be taught to the child
 Maintain a bowel diary of stool frequency & consistency which
can be discussed during clinic visits
o For positive reinforcement, encourage & reward the
child’s efforts & not the results
 It may be of benefit to refer to a mental health provider for
intervention if behavioral problems interfere with treatment, but
it is discouraged to do it routinely

Biofeedback Therapy

 Uses devices (electrical or mechanical) in order to increase

awareness of physiological functions of anal sphincter by
providing the patient with visual, verbal &/or auditory information
& enhances self-control on body functions
 W/ the rise of the rectal pressure, patients are taught external
anal sphincter relaxation
 Demonstrated efficacy in correcting abnormal defecation
dynamics in previous studies but failed to show additional benefit
in the treatment of chronic childhood constipation
 Currently used only for children with pelvic floor dyssynergia &
short-term treatment of intractable constipation
 Not to be used for ongoing treatment of children with functional
constipation