Sie sind auf Seite 1von 124

Edition 2

June, 2010

Standard
Treatment
Guidelines
Standard Treatment
Guidelines
Disclaimer Table of Contents
Whereas all care has been taken in the compilation on this document, it is 1. Resuscitation guidelines..................................................................................................... 1
advised that any user of this book must exercise their clinical judgment in the
2. Emergencies............................................................................................................................ 12
management of each patient. Gertrude’s Children’s Hospital will not take any 1. Acute upper airway obstruction................................................................................... 12
responsibility for the use of information that is herein contained. 2. Anaphylaxis................................................................................................................. 13
3. Hereditary angiodema ................................................................................................. 14
4. Near drowning............................................................................................................. 16
5. Fluid management....................................................................................................... 18
6. Endocrine Emergencies................................................................................................ 21
Review 3. Poisoning guidelines......................................................................................................... 40
1. Poisoning Management ............................................................................................... 40
In case you would like to propose amendments to this protocol please send 4. Gastrointestinal diseases................................................................................................. 43
your request to: 1. Acute vomiting ........................................................................................................... 43
2. Diarrhoea.................................................................................................................... 43
3. Cholera....................................................................................................................... 47
The Secretary 4. Dysentery.................................................................................................................... 47
5. Typhoid fever............................................................................................................. 48
Drugs and Therapeutics Committee 6. Management at point of discharge for all diarrhoea.................................................... 49
7. Acute abdominal pain................................................................................................. 51
Gertrude's Children's Hospital 8. Constipation............................................................................................................... 52
P.O. Box 42325, 00100, Nairobi 9. Oral candidiasis........................................................................................................... 53
10. Stomatitis................................................................................................................... 55
E-mail: dtc@gerties.org 11. Peptic ulcer disease..................................................................................................... 56
12. Hepatitis a infection.................................................................................................... 57
5. Ear Nose Throat................................................................................................................... 59
1. Tonsillo-Pharyngitis.................................................................................................... 59
2. Otitis media................................................................................................................ 60
3. Allergic rhinitis........................................................................................................... 63
4. Sinusitis...................................................................................................................... 64
5. Epistaxis..................................................................................................................... 66
6. Ludwig's angina.......................................................................................................... 68
7. Menierre's Disease....................................................................................................... 69
6. Respiratory tract conditions.......................................................................................... 70
1. Pneumonia................................................................................................................. 70
2. Asthma...................................................................................................................... 72
3. PCP............................................................................................................................ 79
4. Tuberclosis................................................................................................................ 80
5. Viral croup................................................................................................................ 83
6. Viral pneumonia/bronchiolitis................................................................................... 84
7. Genitourinary disorders................................................................................................ 85
1. Urinary tract infection.............................................................................................. 85
2. Minor penile inflammation....................................................................................... 86
3. Balanitis................................................................................................................... 86
4. Acute urine retention............................................................................................... 87
5. Zipper injury ........................................................................................................... 87
6. Phimosis.................................................................................................................. 89
Standard Treatment Guidelines Booklet First Edition Copyright © 2009
7. Paraphimosis........................................................................................................... 89
Designed and printed for Gertrude's Children's Second Edition Copyright © 2010
8. Acute scrotal pain.................................................................................................... 90
Hospital Gertrude's Children's Hospital, Muthaiga
By All rights reserved. No part of this book may 8. CNS .......................................................................................................................................... 92
Lila Creative Design Agency be reproduced, stored in a retrieval system, 1. Status epilepticus..................................................................................................... 92
or transmitted in any form or by any means, 2. Febrile convulsions................................................................................................... 93
Printed in Nairobi, Kenya electronic, electrostatic, magnetic tape, 3. Bacterial meningitis.................................................................................................. 94
mechanical, photocopying, recording or otherwise, 4. Coma....................................................................................................................... 95
without permission in writing from the Gertrude’s 5. Cerebral palsy........................................................................................................... 96
Children’s Hospital.
Table of Contents Compiled by
Dr. Rashmi Kumar, Paediatrician, Gertrude’s Children’s Hospital
9. CVS.......................................................................................................................................... 100 Dr. Edwine Barasa, Drug Information Pharmacist, Gertrude’s Children’s Hospital
1. Rheumatic fever....................................................................................................... 100 Dr. David Kiptum, Paediatrician, Gertrude’s Children’s Hospital
2. Infective endocarditis................................................................................................ 102
3. Congestive heart failure............................................................................................ 103 Dr. Paul Laigong, Paediatrician, Gertrude’s Children’s Hospital
4. Hypertension............................................................................................................ 105 Dr. Robert Nyarango, Chief Pharmacist, Gertrude’s Children’s Hospital
10. Burns....................................................................................................................................... 107
11. Infectious diseases........................................................................................................... 113
Reviewed by
1. Viral infections........................................................................................................... 113 Dr. Adil Waris, Consultant Paediatric Pulmonologist
2. Fungal infections....................................................................................................... 115
3. Parasitic infections..................................................................................................... 117 Dr. Admani Bashir, Consultant Paediatric Nephrologist
12. Neonatology......................................................................................................................... 130 Dr. Berlinda Nganga, Pharmacist, Gertrude’s Children’s Hospital
1. Neonatal sepsis......................................................................................................... 130 Dr. Bernadette Kimotho, Medical Officer, Gertrude’s Children’s Hospital
2. Ophthalmia neonatorum............................................................................................ 130
3. Neonatal jaundice...................................................................................................... 131 Dr. Collins Jaguga, Pharmacist, Gertrude’s Children’s Hospital
4. Crying baby............................................................................................................... 132 Dr. Dan Alaro, Medical Officer, Gertrude’s Children’s Hospital
5. Neonatal feeding....................................................................................................... 133
Dr. Doreen Karimi, Medical Officer, Gertrude’s Children’s Hospital
13. Eye disorders....................................................................................................................... 135
Dr. Evans Amukoye, Consultant Paediatric Pulmonologist
1. Acute eye injuries in children..................................................................................... 135
2. Ocular burns – thermal, chemical............................................................................... 136 Dr. Hanna Wanyika, Consultant Dermatologist
3. The acute red eye...................................................................................................... 137 Dr. Humar Darr, Medical Officer, Gertrude’s Children’s Hospital
14. Haematology........................................................................................................................ 141
Dr. Joel Lesan, Consultant Paediatric Surgeon
1. Anaemia.................................................................................................................... 141
2. Iron deficiency anaemia............................................................................................. 142 Dr. Jonathan Mwambire, Medical Officer, Gertrude’s Children’s Hospital
3. Haemophilia.............................................................................................................. 143 Dr. Margaret Njuguna, Consultant Ophthalmologist
4. Sickle cell disease...................................................................................................... 148
5. Blood product transfusion......................................................................................... 155 Dr. Melanie Miyanji, Consultant Dermatologist
15. Dermatology........................................................................................................................ 161 Dr. Michelle Ogola, Medical Officer, Gertrude’s Children’s Hospital
1. Bacterial skin infections (pyoderma).......................................................................... 161 Dr. Mureithi Muchiri, Consultant ENT Surgeon
2. Nappy rash................................................................................................................ 163
3. Atopic eczema........................................................................................................... 164 Dr. Noel Orata, Medical Officer, Gertrude’s Children’s Hospital
4. Scabies...................................................................................................................... 165 Dr. Osman Miyanji, Consultant Paediatric Neurologist
5. Fungal skin infections................................................................................................ 165
6. Viral infections.......................................................................................................... 166 Dr. Pauline Samia, Paediatrician, Gertrude’s Children’s Hospital
16. Bone and connective tissue disorders...................................................................... 168 Dr. Peter Ngwatu, Consultant Paediatric Gastroenterologist
17. Endocrine disordrers........................................................................................................ 170 Dr. Renson Mukhwana, Paediatrician, Gertrude’s Children’s Hospital
1. Hypothyroidism......................................................................................................... 170 Dr. Thomas Ngwiri, Paediatrician & Head Clinical Services, Gertrude’s Children’s
2. Hyperglycaemia......................................................................................................... 171
3. Diabetes mellitus....................................................................................................... 172
Hospital
4. Diabetes insipidus..................................................................................................... 175 Dr. Timothy Panga, Pharmacist, Gertrude’s Children’s Hospital
5. Weight management................................................................................................. 178
Dr. Moraa Bisase, Medical Officer, Gertrude’s Children’s Hospital
18. Malnutrition.......................................................................................................................... 183
Mr. Protus Letoya, Pharmaceutical Technologist, Gertrude’s Children’s Hospital
19. Procedures............................................................................................................................ 187
1. Analgesia and sedation.............................................................................................. 187 Edited by
2. Lumbar puncture...................................................................................................... 190
3. Suprapubic aspirate................................................................................................... 195 Dr. David Kiptum, Paediatrician, Gertrude’s Children’s Hospital
4. Needle thoracocentesis............................................................................................. 197
Dr. Paul Laigong, Paediatrician, Gertrude’s Children’s Hospital
20. Appendices.......................................................................................................................... 200
Dr.Robert Nyarango, Chief Pharmacist, Gertrude’s Children’s Hospital
1. Appendix I................................................................................................................ 201
2. Appendix II............................................................................................................... 212
3. Appendix II............................................................................................................... 217 A publication of The Drugs and Therapeutics Committee, Gertrude’s
4. Appendix IV.............................................................................................................. 224
Children’s Hospital

I
STANDARD : CLINICAL GOVERNANCE 1. RESUSCITATION GUIDELINES
DEPARTMENT : CLINICAL SERVICES
PROTOCOL NO. : CGP/CS/PRO/2
CARDIORESPIRATORY ARREST
PROTOCOL : STANDARD TREATMENT GUIDELINES ●● Signs of shock, cyanosis, bradycardia / tachycardia, apnoea or
AUTHOR : DRUGS AND THERAPEUTICS COMMITTEE increasing tachypnoea are warning signs and an indication for
OWNER : HEAD CLINICAL SERVICES urgent resuscitation.
VERSION : 2 ●● The majority of arrests in children are due to hypoxia,
ACTIVE DATE : DECEMBER 1, 2009 hypotension and acidosis. The most common dysrhythmias
REVIEWED DATE : JUNE, 2010 are severe bradycardia, pulseless electrical activity or asystole.
NEXT REVIEW : JUNE, 2011 Ventricular arrhythmias (Ventricular fibrillation (VF) and
pulseless ventricular tachycardia (VT)) are seen with pre-existing
NOTES cardiac disease (cardiomyopathies, hereditary prolongation of
QT interval, congenital heart disease), poisoning (e.g. tricyclic
Approval: antidepressants) and low voltage electrocution (less than 1000
This protocol has been approved for use by the Head of Clinical volts), and may occur during resuscitation. SVT may cause
Services who is herein identified as the protocol owner. This he has shock in newborn infants.
done in consultation with the Drugs and Therapeutics Committee.
Assessment
Author:
Whereas the Drugs and Therapeutics Committee appears as the A - Airway
protocol author, the actual development was done by a number ●● Position the head - neutral position (<1 year old), or sniffing
of people as acknowledged in the document. The Drugs and position (1 year of age)
Therapeutics Committee coordinated the development. The Drugs ●● Open airway – head tilt or chin lift or jaw thrust
and Therapeutics Committee is a sub-committee of the Medical ●● Use Oropharyngeal airway if required.
Advisory Committee.
Accountability: B - Breathing
●● Signs of respiratory inadequacy
The Head of Clinical Services is accountable for the implementation
of this protocol ●● If respiration is adequate, administer oxygen by face mask at 10
Description: L/min. Do not use self-inflating bags in spontaneously breathing
patients. They are designed to deliver O2 only if squeezed.
This protocol contains standard treatment guidelines to be used
●● If the child is not breathing, commence artificial ventilation.
in the management of the described diseases/conditions as will be
encountered at Gertrude’s Children’s Hospital.

II 1
Initial Management Artificial Ventilation
Assessment and Management of the airway and breathing are the ●● Select the appropriate sized resuscitator bag
initial priorities ○○ Infant up to 2 years - 500 mL bag
○○ Child > 2 years - 2 litre bag
Initial Assessment and Management Table 1
●● Select an appropriate sized mask.
Call for help
●● Obtain an airtight seal
●● O2 flow rate of 10-15 l/min and attachment of a reservoir
assembly will give nearly 100% O2.
●● An Oropharyngeal airway will facilitate maintenance of the
airway.
Stimulate and assess response
●● Brief suction of the mouth and pharynx if needed, using a
yankeur sucker under direct vision
●● Ventilate to have normal chest rise and fall. Do not over
ventilate
●● Intubation should only be attempted by those credentialed and
Airway opening manoeuver
Check breathing skilled to do so

Endotracheal Intubation
Select the correct tube size:
Correct endotracheal tube size Table 2
Bag valve mask ventilation Age Weight (Kg) Tube size (mm) Length at lip (cm)
Newborn 3.5 3.0 8.5
2 months 5 3.5 9
6 months 8 4.0 10
1 year 10 4.0 11
Assess for pulse and signs of circulation
Older than 1 year: Tube size (mm) = (age in yr/4) + 4
Length at lip (cm) = (age in yr/2) + 12

C - Circulation
●● If there are no signs of circulation, i.e. no pulse, slow pulse
(<60) or you are not sure, commence external cardiac
compression and determine the cardiac rhythm - attach an ECG
monitor and display the ECG
●● Signs of circulatory inadequacy
2 3
External cardiac compression Other drugs to consider
●● DO NOT interrupt except for defibrillation.
Atropine
●● Place the child on a firm surface. If on a bed, place the cardiac
massage board under the patient, not under the mattress For persistent asystole / bradycardia (20mcg/Kg) (Minimum
●● Apply massage to the lower half of the sternum in all patients 100mcg, Maximum 600mcg)
including newborns Amiodarone
●● Compress sternum one third the depth of the chest.
Used for shock refractory ventricular fibrillation
●● Use the hand technique that allows you to achieve this.
Dose 5mg/Kg over 1 to 2minutes, may repeat up to 20mg/Kg
1. With large children use the “heel” of one hand with the other maximum 300mg
superimposed.
If patient responds, start an infusion at 10 to 15mg/Kg/ day
2. For small children use the heel of one hand
Lignocaine
3. For infants use two fingers.
4. For newborn infants the best technique is a two-handed hold Never give lignocaine after Amiodarone. Amiodarone is the
(encirclage) in which both thumbs compress the sternum. preferred agent

●● Gain IV or IO access as soon as possible - at least the second Same indications as Amiodarone. Dose (1mg/Kg) (0.1mL/Kg of 1%
dose of adrenaline should be given via this route Lignocaine)

●● Frequent changes of personnel (every few minutes) is desirable Magnesium Sulphate


●● During resuscitation do not stop to check for a pulse unless for For hypomagnesaemia or for polymorphic VT (torsade de pointes)
defibrillation or the ECG shows an organised rhythm.
50% solution: 0.05-0.1mL/Kg (0.1-0.2mmol/Kg) (Maximum 2 g)
●● After DC shock, continue CPR for 2 minutes prior to checking
Infuse over 5 mins.
rhythm.
Sodium bicarbonate, calcium and high doses of adrenaline
During resuscitation (>10mcg/Kg/ dose) have no place in routine resuscitation.

Correct treatable causes (6H, 4T) Other issues


●● Hypoxaemia
Blood gas analysis
●● Hypovolaemia
●● It is not a priority in initial resuscitation attempts and
●● Hypo/hyperthermia obtaining a sample should not distract from other resuscitation
●● Hypo/hyperkalaemia manoeuvres.

●● Tamponade ●● Arterial (and to some extent venous) blood gas analysis can
help determine degree of hypoxaemia, adequacy of ventilation,
●● Tension pneumothorax
degree of acidosis and presence of electrolyte abnormalities
●● Toxins/poisons/drugs such as of Sodium and Potassium.
●● Thrombosis
4 5
6
Continuous CPR
Pre intubation
• ~100 compressions/minute

Diagram 1.
• 15 compressions then 2 breaths
• Pause compressions for each breath

Obtain IV or IO
access

Assess
rhythm
for maximum
of 10 seconds

Shockable Non-Shockable
VF or pulsess VT Asystole or
Pulseless Electrical Activity

One DC Shock
2mls/Kg (Adult 200J) Adrenaline - #
Immediatly resume 0.1mls/Kg 1:10,000 IV or IO
CPR for 2 minutes Continue CPR for
2 minutes

Assess
rhythm
for maximum
of 10 seconds
Amiodarone
5mg/kg
(max 300mg)
after 3rd DC
shock and # - Adrenaline
adrenaline Shockable 0.1 mls/Kg of 1:10,000 IV or IO
VF or pulseless VT Adults: 1mg (1ml 1:10,000)
ETT adrenaline may be used for
1st dose if IV or IO access not
One DC Shock readily obtained. It is not the
4 J/Kg (Adult 200j) preferred route.
Immediatly resume CPR 0.1 mls/Kg 1:1000 diluted to 3ml
and give Adults: 5mg (5ml 1:1000)
Adrenaline - #
0.1mls/Kg 1:10,000 IV or IO
Continue CPR for
2 minutes
7
Table 3
ADRENALINE

Catheter
Newborn: 0.1 – 0.3 mL/kg of 1:10,000 IV/ IO
Suction

Appropriate internal diameter (mm) of ET tube = (Age in years/ 4) + 4; NB: For ET tube size, you choose a size larger and a size smaller in addition to the
8 – 10
Child: 0.1 mL/kg of 1:10,000 IV/ IO; 0.1 mL/kg of 1:1,000 ET

5–6

6–8

Appropriate length of Oral tube (cm) = Newborn = 6 + weight (kg); In infant and child = (Age in years/2) + 12 or three times internal tube diameter
10

10

10

10

12

12

14

14
Adult 10 mL of 1:10,000 IV/ IO; 2.0-2.5 mL of 1:1,000 ET Table 4

8
Age Endotracheal Intravenous Anaphylaxis (IM)
Tube

5–8
NG

10

10

12

12

14

14

18

18

18
5

8
1:1,000 1:10,000 1:1000

Pre-term 0.5 mL (1:10,000) 0.2 – 0.mL 0.15 mL (150 mcg)

3–4

3–4
LMA

4-5
3- 4
1.5

2.5
1

3
Term NB 1 mL (1:10,000) 0.5 – 1 mL 0.15 mL (150 mcg)
Laryng

6 months 0.7 mL 0.7 mL 0.15 mL (150 mcg)


Blade

3–4

3–4
1 year 1 mL 1 mL 0.15 mL (150 mcg)
0

3
3 years 1.5 mL 1.5 mL 0.15 mL (150 mcg)
11 – 12

13 – 14

14 – 15

15 – 16

17 – 18

19 – 20

20 – 24

22 – 24
(cm tip

22 - 24
6 + WT

6 + WT
to tip)
depth

5 years 1.8 mL 1.8 mL 0.15 mL (150 mcg)


(kg)

(kg)
ET

11

6 years 2 mL 2 mL 0.30 mL (300 mcg)


(mm)
tube

8 years 2.5 mL 2.5 mL 0.30 mL (300 mcg)


2.5

3.0

3.5

4.0

4.5

5.0

5.5

6.0

6.5

7.0

7.5

8.0
ET

12 years 2.5 mL 4 mL 0.30 mL (300 mcg)


34.0 – 38.0

34.0 – 38.0

34.0 – 38.0

36.1 – 37.8

36.1 – 37.8

36.1 – 37.8

36.1 – 37.8

35.9 – 37.6

35.9 – 37.6

35.9 – 37.6

35.9 – 37.6
Temp. (ºC)

34.0– 38.0

16 years 2.5 mL 5 mL 0.50 mL (500 mcg)

Adult 2 – 2.5 mL 10 mL 0.5 0mL (500 mcg)

Table 5
IM or slow IV/ IO CHLORPHENIRAMINE HYDROCORTISONE
(diastolic)

35 – 45

55 – 75

65 – 80

70 – 85
40 - 45

40 - 45

50 - 65

55 - 75

65 - 80

70 - 85

70 - 90

70 - 90 < 6 months 250 mcg/kg 25 mg


mmHg
BP

6 months – 6 Years 2.5mg 50 mg

6 - 12 years 5 mg 100 mg
(systolic)

95 – 105

96 – 110

96 – 110

97 – 112
83 - 105

97 - 112
60 – 90
50 - 60
mmHg

Adult or child >12 years 10 mg 200 mg


112 -

112 -

112 -

112 -
128

128

130

130

Appropriate length of Nasal tube (cm) = (Age in years/ 2) + 15


BP

AMIODARONE: 5mg/kg IV/ IO; rapid bolus for pulseless VF/ VT; over 20-60min for perfusing
40 – 60

40 – 60

30 – 60

26 – 34

20 – 24

20 – 24

20 – 24

12 – 20

12 – 20

12 – 20

12 – 20
24 - 26

tachycardia. MAXIMUM SINGLE DOSE: 300 mg. May repeat to MAX DOSE= 15 mg/kg/Day (2.2g/Day).
Resp.

DO NOT combine with procainamide.


(Adult: 300mg rapid bolus for VF/VT; may repeat 150mg after 3-5min prn; 150mg over 10minutes for
perfusing tachycardia; may repeat. Follow both by an infusion. MAX DOSE = 2mg/day)
100–180

100–180

100–160

80 – 110

70 – 110

70 – 110

65 – 110

65 – 110

60 – 100

60 – 100
60 –100

60 –100
Pulse

ATROPINE: 0.02 mg/Kg IV/ IO or ET (MINIMUM DOSE =0.1mg; MAX SINGLE DOSE = 0.6mg for child
and 0.9 mg for adolescent); May repeat x 1
(Adult: 0.5-1.0mg; may repeat Q3-5min to MAX TOTAL= 3mg)
75- 100
50 – 75

LIDOCAINE: 1.0-1.5mg/kg IV /IO or ET; follow by an infusion.


Weight

1-2

3-4

> 50

(Adult: 1.0- 1.5mg/kg IV/ IO; repeat 0.5-0.75mg/kg q 5-10min if needed up to MAXIMUM TOTAL
(kg)

10

15

18

20

25

40
7

DOSE = 3mg/kg. ET dose = 2-4 mg/kg)


Length

ELECTRICITY
(cm)

110

115

127

150

indicated size.
50

67

75

95

DEFIBRILLATION: 4 Joules/kg (monophasic or biphasic waveform) should be used for all shocks. The
MAXIMUM DOSE for the first shock is 360 J (monophasic) or 150 – 200 J (biphasic) and subsequent
Newborn

6months

12 years

16 years
Pre-term

shocks is 360 J (monophasic) or 200 J (biphasic)


3 years

5 years

6 years

8 years

Female
1 year

Adult

Adult

(Adult: 200 joules; then 200 – 300 joules; 360 joules thereafter)
Term

Male
Age

8 9
CARDIOVERSION: 0.5 joules/kg; increase to 1 joule/kg if needed Post resuscitation care
(Adult: 50 Joules for SVT or atrial flutter; 100 Joules for monomorphic VT or A-fib; 200 joules for
polymorphic VT; increase to 300 and 360 joules if needed) ●● Ensure airway and breathing are managed effectively including
intubation if not already performed. Do not extubate. Use
CRYSTALOID FLUID CHALLENGE
Choose an ISOTONIC, non-glucose-containing solution (Ringer’s lactate, Hartman’s solution, Normal
adequate sedation and analgesia.
Saline 0.9%)! ●● Ventilate to normal carbia
Newborn: 10 mL/kg;
Infant or child: 20 mL/kg; repeat as needed ●● Circulation - maintain adequate blood pressure with use of
(ADULT; 500-1,000 mL or 10-20 mL/kg; titrate to effect)
inotropes as needed. Monitor for further arrhythmias.
BOLUS MEDICATIONS ●● Aim for core temperature of 35 degrees (do not actively warm if
ADENOSINE: 0.1mg/kg rapid IV/ IO push; increase to 0.2mg/kg if needed; MAXIMUM SINGLE DOSE =
core temp >32 degrees)
12mg
(Adult: 6mg; increase to 12mg if no effect; may repeat 12 mg x 1) ●● Ongoing anti arrhythmic drugs
CALCIUM CHLORIDE: 20mg/kg (= 0.2 mL/kg of 10% solution) IV/ IO ●● Ensure normal glycaemia
GIVE slowly IV / IO over 5 – 30minutes; may repeat after 10 minutes
(Adult: 2 – 10 mL; may repeat q 10minutes)

CEFOTAXIME or CEFTRIAXONE: 50mg/kg IV/ IO/IM


(Adult: 2gms)

DEXTROSE: Infant/ child 10mL/kg IV/ IO (Newborn: 5 mL/kg) of 10 % solution.


(Adult: 1 mL/kg up to 50 mL of 50% solution)

ADRENALINE, IM or SQ: (for anaphylaxis): 0.01 mL/kg of 1:1,000 solution up to max of 0.5 mL
(Adult: 0.3- 0.5 mL of 1: 1,000 solution)

FENTANYL: 2mcg/kg IM or slow IV/ IO push; consider increase to 5 – 10mcg/kg for better analgesia
(Adult: 2 – 10 mcg/kg)

PHENYTOIN: 15 – 20 mg/kg IV/ IO push at max rate of 100mg/min or IM; then 2 -3 mg /kg q 12
hours (Adult: same as child)

MIDAZOLAM: 0.05 – 0.15 mg/kg slow IV/ IO push with prn repeat upto MAXIMUM TOTAL DOSE =
6mg for child < 5 years, 10 mg for older child; Intramuscular dose for seizures: 0.2mg/kg IM up to
MAXIMUM DOSE 7mg
(Adult: 1.0 – 32.5 mg; repeat prn to MAXIMUM TOTAL = 10 MG)

NALOXONE: 0.1 mg/kg for newborn – 5 years (MAXIMUM 2mg)


2mg for older child; IV/ IO, IM, or ET
(Adult: 0.2 – 2.0 mg; may repeat to total of 10mg)

PROCAINAMIDE: 15mg/kg over 30-60 minutes


(Adult: 20 mg/ minute until endpoint or 17 mg/kg TOTAL DOSE)

SALBUTAMOL: (0.5% solution): 0.10- 0.15mg/kg in 3 mL Normal Saline via nebulizer; MINIMUM DOSE
= 0.5mL/2.5 mg; MAXIMUM DOSE = 1.0 mL/5mg
(Adult: 0.5 – 1.0 mL/2.5mg-5mg)

10 11
2. EMERGENCIES 2). ANAPHYLAXIS

Description
1). ACUTE UPPER AIRWAY OBSTRUCTION
Anaphylaxis is a multi-systemic allergic reaction characterised by:
Description ●● At least one respiratory or cardiovascular feature and
The signs of partial acute upper airway obstruction are: ●● At least one gastrointestinal or skin feature.
●● Stridor For reactions which do not fulfill this definition, see Urticaria
●● Increased work of breathing as evidenced by suprasternal, guidelines
intercostal and subcostal retraction along with an increased use
Management
of accessory muscles of respiration.
•• Supplemental oxygen
Management
•• Intra-muscular adrenaline 0.01mL/Kg of 1/1000
•• Allow child to settle quietly on parent’s lap in the position (maximum 0.5mL), into lateral thigh is the treatment of
the child feels most comfortable. choice for anaphylaxis which should be repeated after 5
•• Observe closely with minimal interference. minutes if patient not improving - Do not use subcutaneous
adrenaline as absorption is less reliable than the
•• Treat specific cause
intramuscular route. Do not use IV bolus adrenaline unless
•• Call ICU if worsening or severe obstruction. cardiac arrest is imminent.
•• Oxygen may be given while awaiting definitive treatment. •• An adrenaline infusion should be considered if repeated
This can be falsely reassuring because a child with quite doses of IM adrenaline are required at 0.05 - 1 mcg/Kg/min
severe obstruction may look pink in oxygen.
•• In addition to adrenaline, repeated 10-20 mL/Kg boluses of
Notes
0.9% saline may be required for shock
•• Intravenous access should be deferred – upsetting the child •• Nebulised adrenaline is not recommended as first-line
can cause increasing obstruction. therapy but may be a useful adjunct to IM adrenaline if
•• Lateral cervical soft tissue x-rays do not assist in upper airway obstruction is present.
management. •• If airway oedema is not responding to parenteral and
•• In severe airways obstruction x-rays cause undue delay in nebulised adrenaline, early intubation is indicated.
definitive treatment and may be dangerous (positioning may •• Corticosteroids or antihistamines should never be relied
precipitate respiratory arrest). upon as first line treatment of anaphylaxis
•• ICU should be notified if children require 2 adrenaline
doses or 30 mL/Kg fluid bolus for the management of
anaphylaxis or if ongoing airway concerns.

12 13
Other therapies to consider medicines (including oestrogen-containing contraceptives and
●● Nebulised salbutamol is recommended if the patient has ACE-inhibitors) or may have no clear trigger.
respiratory distress with wheezing. ●● HAE is a rare autosomal dominant condition in which C1
●● Anti-histamines may be given for symptomatic relief of pruritus. esterase inhibitor levels are reduced (HAE type I) or poorly
Second generation anti-histamines are preferred (promethazine functional (HAE type II). HAE is diagnosed by the finding of
can cause hypotension). low C1 esterase inhibitor level or function. C4 level is also low
during episodes of angioedema.
●● Corticosteroids may be considered at the discretion of the
treating physician especially for bronchospasm although the Management
limited evidence available does not support their use.
Mild/moderate angioedema episodes
Admission Treatment is conservative:
All children with anaphylaxis should be admitted. At least 6-12
hours observation is recommended and overnight admission should ●● Hospital admission is not usually required
be considered if any of the following circumstances apply: ●● Other causes of abdominal pain may need to be excluded and
●● Greater than one dose of adrenaline (including nebulised abdominal ultrasound may help by showing intestinal wall
adrenaline) required. oedema or ascites in HAE-related angioedema.

●● A fluid bolus required ●● A 3 day course of tranexamic acid may be considered to shorten
the duration of symptoms (12-25mg/Kg/dose (max 1.5g) 3-4
●● The child lives a long distance from medical services times per day)
Discharge Plan and Follow up Severe angioedema episodes
●● Outpatient follow up is recommended.
Severe angioedema episodes can be fatal. Management includes:
Reference ●● Hospital admission for all severe angioedema episodes
1. Advanced Paediatric Life Support: A practical approach. ●● If upper airway obstruction is present, notify a colleague
Advanced life support group. Fourth ed. London: Blackwell experienced in endotracheal intubation
Publishing, 2005. ●● Intravenous C1 esterase inhibitor concentrate should be
administered (see below for dosing)
3). HEREDITARY ANGIOEDEMA
Planned Surgery or Oropharyngeal Procedures
(C1 Esterase Inhibitor Deficiency, HAE) Surgery or any traumatic procedure of the oropharyngeal area
such as dental work should be carefully planned. The use of a
Description
prophylactic agent prior to such procedures reduces the risk of
●● HAE causes recurrent episodes of angioedema in the upper precipitating angioedema.
respiratory, gastrointestinal tract or in subcutaneous tissues.
●● Consult with an ICU intensivist before the procedure
●● Acute episodes of angioedema may be triggered by infection,
stress, menstruation, surgery, dental work, trauma and some

14 15
●● For planned procedures, Danazol is the first choice of ●● Intubate and ventilate if:
prophylactic agent, (10mg/Kg/day for 5-10 days before and 2-5 ○○ Inadequate respiration
days after the procedure).
○○ Falling arterial Oxygen concentration (PaO2) despite increased
●● For emergency or high-risk procedures, C1 esterase inhibitor fractional inspired Oxygen
concentrate (25units/Kg infusion given 1 hour prior to the
○○ Persisting depressed level of consciousness
procedure)
●● Monitor Oxygen saturation and perform arterial blood gas
●● Due to the risk of precipitating laryngeal oedema,
oropharyngeal procedures should usually involve general ●● Do a chest x-ray
anaesthesia with endotracheal intubation
Circulation
Notes ●● Assess pulse rate and volume, blood pressure and capillary
refill.
Antihistamines and Corticosteroids
●● Insert intravenous line.
●● Antihistamines and corticosteroids have no role in the
management of HAE related angioedema. ●● Perform Haemogram, serum glucose, electrolytes and
creatinine.
●● The role of adrenaline in the treatment of HAE is not well
established. ●● If circulation is inadequate give fluid bolus of 20 mL/Kg Ringers
Lactate.
●● There are anecdotal reports of efficacy using nebulised or
intramuscular adrenaline to treat upper airway angioedema, ●● Consider early ionotropic support
however C1 esterase inhibitor is the treatment of choice for
Cerebral support
airway angioedema caused by HAE.
●● Avoid any further episodes of hypoxia and hypercarbia.
4). NEAR DROWNING ●● Optimise circulation as best possible.
All children should receive full resuscitative efforts after an episode ●● Once shock is reversed restrict fluids to 75% of maintenance.
of immersion or near drowning. ●● Monitoring and control of intracranial pressure is occasionally
required.
Assessment and management
●● Rapidly assess airway, breathing, circulation and level of Temperature
consciousness ●● Actively rewarm children slowly to a core temperature of 34
●● If child is in cardiorespiratory arrest proceed immediately with degrees.

cardiopulmonary resuscitation ●● Passively rewarm over 34 degrees.

Airway and breathing (protect cervical spine if any possibility of General


injury) ●● Admit to appropriate inpatient unit.
●● If spontaneously breathing, administer 100% oxygen by face ●● Corticosteroids are not recommended.
mask.

16 17
Adverse Prognostic Factors 2. Body Weight Method of Calculating Maintenance Fluid
●● Immersion time > 10 minutes. Volume Table 7

●● Rectal temperature < 30°C.


Body weight (Kg) Fluid Therapy per Day (mL)
●● Absence of any initial resuscitative efforts.
●● Arrival in hospital with CPR in progress or in coma 0-10 100 mL /Kg
●● Requirement of cardiopulmonary resuscitation
1000 mL + 50 mL/Kg for each Kg
11- 20
●● Initial serum pH < 7.0 greater than 10 Kg

1500mL+ 20 mL/Kg for each Kg


5). FLUID MANAGEMENT >20Kgs
greater than 20Kg

1. Composition of IV Fluids Table 6


3. Maintenance Electrolyte Requirements
Fluid Na Cl K Ca Lactate Osmolality
●● Sodium: 2-3 meq /Kg/24hr
●● Potassium 1-2 meq/Kg/24hr
Normal Saline 154 154 _ _ _ 308 ●● Calcium 1-2mmol/Kg/24hr
(0.9% )
●● (Glucose 4-6mg/Kg/Min)

½ Strength 77 77 _ _ _ 154
4. Types of Dehydration
Normal Saline 1. Hypernatremic dehydration

a. Restore intravascular volume


¼ Strength 38.5 38.5 _ _ _ 77
Normal Saline If in shock, administer Normal Saline 20 mL / Kg over 20 minutes.
Repeat until out of shock
Ringers 130 109 4 3 28 275 b. Determine time for correction based on the initial sodium
Lactate
concentration
145 – 157 meq/L: 24 Hours
Half strength 62 17 _ _ 25 170
Darrows 158 – 170 meq/L: 48 hours
171 – 183 meq/L : 72 Hours
5%Dextrose - - - - - 253 184 – 196 meq/L: 84 Hours

c. Administer fluid at constant rate over the time for correction


●● Typical fluids 5% dextrose + ¼ strength normal saline or 5%
dextrose + ½ normal saline (both with 20 Meq/l potassium
chloride unless contraindicated)

18 19
●● Typical rate: 1.25 -1.5 times maintenance 6). ENDOCRINE EMERGENCIES
●● Monitor serum sodium concentration 4 hourly
1). DIABETIC KETOACIDOSIS
d. Adjust fluid based on clinical status and serum sodium
concentration:
Assessment
Signs of volume depletion: Administer normal saline (20 mL/Kg) Degree Of Dehydration - (often overestimated)
If Sodium decreases too rapidly, ●● Mild (<4%) No clinical signs
1. Increase sodium concentration of IV fluids ●● Moderate (4-7%) easily detectable dehydration - reduced skin
turgor, poor capillary return
2. Decrease IV fluids infusion rate
●● Severe (>7%) poor perfusion, rapid pulse, reduced blood
If Sodium decreases too slowly, pressure - in shock
1. Decrease sodium concentration of IV fluids
Investigations
2. Increase IV fluids infusion rate
●● Blood glucose, urea, and electrolytes
3. Replace ongoing losses as they occur
●● Arterial or capillary acid/base status
Fluid replacement in shock ●● Urine - Ketones, microscopy, culture
●● Fix an IV line ●● Check for precipitating cause e.g. Infection (Urine, Full
●● Draw blood for analysis Haemogram, blood cultures; consider Chest x-ray)
●● Infuse 20 mL /Kg of isotonic fluid (normal saline or ringers ●● Islet cell antibodies, insulin antibodies, GAD antibodies, Total
lactate) IgA, antiendomysial IgA antibody and Thyroid function test for
●● Reassess after 1st infusion: If no improvement, repeat 20 mL/ all newly diagnosed patients
Kg as quickly as possible
Management
●● Reassess after 2nd infusion: If no improvement, repeat 20 mL/ ●● Airway, Breathing and Circulation - ABCs
Kg as quickly as possible
●● Reassess after 3rd infusion: if no improvement, consider giving Fluid Requirements
blood 20 mL/Kg over 30 minutes ●● If in shock, give Normal Saline at 10-20mL/Kg stat
●● Reassess after 3rd infusion ●● Repeat until perfusion is re-established (warm, pink extremities
with rapid capillary refill).

Commence rehydration with Normal Saline as below


Fluid rates (mL/hour) including deficit and maintenance fluid
requirements, to be given evenly over 48 hours

20 21
Fluid volumes for the subsequent phase of rehydration Table 8 After initial resuscitation and assuming 10% dehydration, the total
Give maintenance plus 5% of body weight per 24hours amount of fluid should be given over 48 hours. The above table
Weight(Kg) mL/24 h
mL/24hr mL/hr gives volumes for maintenance and rehydration per 24 hours and
4 325 530 22 per hour. If fluid has been given for resuscitation, the volume
5 405 650 27 should not be subtracted from the amount shown in the table.
6 485 790 33 Fluids given orally (when patient has improved) should be
7 570 920 38 subtracted from the amount in the table. The table is based on
8 640 1040 43 maintenance volumes according to Darrrow. For body weights >32
9 710 1160 48 kg, the volumes have been adjusted so as not to exceed twice the
10 780 1280 53 maintenance rate of fluid administration.
11 840 1390 58
Keep nil by mouth (except ice to suck) alert and stable. Insert a
12 890 1490 62
nasogastric tube if patient is comatose or has recurrent vomiting;
13 940 1590 66
leave on free drainage.
14 990 1690 70

15 1030 1780 74
Rehydration may be completed orally after the first 24 - 36 hours if
16 1070 1870 78
the patient is metabolically stable.
17 1120 1970 82
Bicarbonate
18 1150 2050 85
This is usually not necessary if shock has been adequately
19 1190 2140 89
corrected. Continuing acidosis usually means insufficient
20 1230 2230 93
resuscitation. In extremely sick children (with pH < 6.9 with or
22 1300 2400 100
without HCO3 < 5mmol/L), small amounts may be given after
24 1360 2560 107
discussion with the endocrinologist.
26 1430 2730 114

28 1490 2890 120 HCO3 dose (mmol) = 0.15 x body weight (Kg) x base deficit. Give
30 1560 3060 128 over 30 min with cardiac monitoring. Reassess acid base status.
32 1620 3220 134 Remember risk of hypokalaemia
34 1680 3360 140
Admission to ICU
36 1730 3460 144

38 1790 3580 149


●● Admit to ICU if age < 2 years, coma, cardiovascular
40 1850 3700 154
compromise, seizures.
45 1980 3960 165
Ward Transfer Instructions
50 2100 4200 175

55 2210 4420 184


●● Strict fluid balance
60 2320 4640 193 ●● Check all urine for Ketones
65 2410 4820 201 ●● Hourly observations: pulse, BP, respiratory rate, level of
70 2500 5000 208 consciousness and pupils
75 2590 5180 216

80 2690 5380 224

22 23
●● Hourly glucose (Glucometer) while on insulin infusion; other Aim to keep the blood sugar at 10-12 mmol/L
biochemistry as clinically indicated If the blood glucose falls below 10-12 mmol/L and the patient is
●● 4-hrly temperatures still sick and acidotic, increase the dextrose in the infusate to 7.5-
10%. Do not turn down insulin infusion
Inpatient Treatment
Hazards
Insulin
●● Hypernatraemia
Note: Beware the rare entity of hyperglycaemic-hyperosmolar non-
ketotic coma: Insulin should ONLY be used after discussion with Measured serum sodium is depressed by the dilutional effect of
endocrinologist the hyperglycaemia. To "adjust" sodium concentration, use the
following formula:
Add 50 units of clear/rapid-acting insulin (Actrapid HM or Humulin
R) to 49.5 mL 0.9% NaCl (1 unit/mL solution). Ensure that the Adjusted (i.e. actual) sodium = measured sodium + 0.3 (glucose
insulin is clearly labeled. - 5.5) mmol/L ie 3 mmol/L of sodium to be added for every 10
mmol/L of glucose above 5.5 mmol/L
Start at 0.1 units/Kg/hr in newly diagnosed children, and those
already on insulin who have glucose levels > 15 mmol/L. Children If Na is > 160 mmol/L, discuss with the Endocrinologist.
who have had their usual insulin and whose blood sugars are Sodium should rise as the glucose falls during treatment. If
< 15 mmol/L should receive 0.05 units/Kg/hour. Adjust the this does not happen or if hyponatraemia develops, it usually
concentration of dextrose to keep blood glucose 10-12 mmol/L. indicates overzealous volume correction and insufficient electrolyte
Adequate insulin must be continued to clear acidosis (Ketonaemia). replacement. This may place the patient art risk of cerebral
Insulin dose may be halved for children < 5yrs of age oedema.
The insulin infusion can be discontinued when the child is alert and ●● Hypoglycaemia
metabolically stable (blood glucose < 10-12 mmol/L, pH > 7.30 If blood glucose < 2.2 mol/L give IV 10% dextrose 5 mL/Kg. Do
and HCO3 > 15)The best time to change to SC insulin is just before not discontinue the insulin infusion. Continue with a 10% dextrose
meal time. The insulin infusion should only be stopped 30 minutes infusion until stable. Insulin infusion may be reduced to 0.05Units/
after the first SC injection of insulin. Kg/hour
●● Potassium ●● Cerebral Oedema
Start Potassium Chloride after initial fluid at a concentration of Some degree of subclinical brain swelling is present during most
40 mmol/L of fluid infusion if body weight less than 30Kg, or 60 episodes of diabetic ketoacidosis. Clinical cerebral oedema occurs
mmol/L of fluid infusion if 30 Kg or more. Measure levels 2 hours suddenly, usually between 6 and 12 hours after starting therapy
after starting therapy and 2-4 hourly thereafter. Specimens should (range 2 - 24 hr). Mortality or severe morbidity is very high without
in general be arterial or venous. Give no Potassium if the serum early treatment
level is > 5.5 mmol/L or if the patient is anuric
●● Prevention
●● Fluids
Slow correction of fluid and biochemical abnormalities. Optimally,
If the blood sugar falls very quickly, i.e. within the first few hours, the rate of fall of blood glucose and serum Osmolality should not
change to Normal Saline with 5% dextrose. When the blood sugar exceed 5mmol/L/hr, but in children there is often a quicker initial
reaches 12-15 mmol/L, use 0.45% Normal Saline with 5% dextrose. fall in glucose. Patients should be nursed head up

24 25
Warning signs ●● Mineralocorticoid deficiency: dehydration, hyperkalaemia,
●● First presentation, long history of poor control, young age (< 5 hyponatraemia, acidosis and prerenal renal failure
yr)
Investigations
●● No sodium rise as glucose falls, hyponatraemia during therapy, ●● Immediate blood glucose using a Glucometer
initial adjusted Hypernatraemia
●● Serum glucose, urea, sodium and potassium
●● Headache, irritability, lethargy, depressed consciousness,
incontinence, thermal instability ●● Arterial or capillary acid base

●● Very late - bradycardia, increased BP and respiratory Where the underlying diagnosis not known, collect at
impairment. least 2 mol of clotted blood for later analysis (cortisol and
17-hydroxyprogesterone and ACTH)
Treatment
Management
●● Mannitol 20% 0.5 g/Kg IV stat. Give immediately when the
clinical diagnosis is made - do not delay for confirmatory brain Susceptible patients who present with vomiting but who are not
scan otherwise unwell should be considered to have incipient adrenal
crisis. To attempt to prevent this from developing further:
●● Severely reduce fluid input
●● Administer IV/IM Hydrocortisone 2 mg/Kg
●● Nurse head up
●● Give oral fluids and observe for 4–6 hours before considering
●● Transfer immediately to ICU discharge
2). ADRENAL CRISIS ●● Discuss with endocrinologist

An adrenal crisis is a physiological event caused by an acute For all other children:
relative insufficiency of adrenal hormones Give intravenous fluids

It should be considered in patients with: Shock or severe dehydration:


●● Congenital adrenal hyperplasia ●● Normal Saline 20 mL/Kg IV bolus. Repeat until circulation is
●● Hypopituitarism on replacement therapy restored

●● Those previously or currently on prolonged steroid therapy. ●● Administer remaining deficit plus maintenance fluid volume as
Normal Saline in 5% dextrose evenly over 24 hours
It may occur in previously undiagnosed adrenal/pituitary
insufficient patients, or acutely in a previously well patient ●● Check electrolytes and glucose frequently
●● After the first few hours, if serum sodium is greater than 130
Assessment
mmol/L, change to half Normal Saline
History and physical examination – look for: ●● 10% dextrose may be needed to maintain normoglycaemia
●● Glucocorticoid deficiency: weakness, anorexia, nausea and/or
Moderate dehydration:
vomiting, hypoglycaemia, hypotension (particularly postural)
and shock ●● Normal Saline 10 mL/Kg IV bolus. Repeat until circulation is
restored
26 27
●● Administer remaining deficit plus maintenance fluid volume as are present (e.g. peaked T waves, wide QRS complex), give 10%
Normal Saline in 5% dextrose evenly over 24 hours calcium Glucometer 0.5 mL/Kg IV over 3–5 mins. Commence
infusion of insulin 0.1units/Kg/hr IV together with an infusion of
Mild or no dehydration: 50% dextrose 2 mL/Kg/hr
●● No bolus
If the serum Potassium is above 7 mmol/L with a normal ECG, give
●● 1.5 times maintenance fluid volume administered evenly over Sodium bicarbonate 1–2 mmol/Kg IV, over 20 mins with an infusion
24 hours of 10% dextrose at 5 mL/Kg/hr

Hydrocortisone Identify and treat potential precipitating causes such as sepsis.


Administer Hydrocortisone intravenously. If IV access is difficult,
Admit to appropriate inpatient facility.
give IM while establishing intravenous line.
●● Neonate: 25 mg stat and then 10–25 mg, 6 hourly Prevention

●● 1 month – 1 year: 25 mg stat, then 25 mg, 6 hourly Prevention of a crisis if possible, is essential and may involve:

●● Toddlers (1–3 years): 25-50 mg stat then 25–50 mg, 6 hourly ●● Anticipating problems in susceptible patients

●● Children (4–12 years): 50–75 mg stat, then 50–75 mg, 6 hourly ●● Giving triple normal oral maintenance steroid dose for 2–3 days
during stress (e.g. fever, fracture, laceration requiring suture)
●● Adolescents and adults: 100 – 150 mg stat, then 100 mg, 6
hourly ●● Giving intramuscular Hydrocortisone when absorption of oral
medication is doubtful like in vomiting or severe diarrhoea
When stable reduce IV Hydrocortisone dose, then switch to
triple dose oral Hydrocortisone therapy, gradually reducing to ●● Increasing parenteral Hydrocortisone (1–2 mg/Kg) before
maintenance levels (10–15 mg/m2/day). anaesthesia, with or without an increased dose postoperatively

In patients with mineralocorticoid deficiency start Fludrocortisone 3). PHAEOCHROMOCYTOMA CRISIS


at maintenance doses (usually 0.1 mg daily) as soon as the patient
is able to tolerate oral fluids Crisis is caused by the action of unopposed high circulating levels
of catecholamines acting at adrenoreceptors: α-receptors cause a
Treat hypoglycaemia pressor response with increases in blood pressure, while β-receptor
Hypoglycaemia is common in infants and small children. Treat with activation has positive inotropic and chronotropic effects, any
IV bolus of 2- 5 mL/Kg 10% dextrose. Maintenance fluids should patient presenting with acute hypertension and tachycardia should
contain 5–10% dextrose be considered at risk of Phaeochromocytoma, especially if young or
in an at risk group
Treat hyperkalaemia
Hyperkalaemia usually normalises with fluid and electrolyte Risk factors
replacement. Spontaneous
If potassium is above 6mmol/L perform an ECG and apply cardiac Associated conditions:
monitor as arrhythmias and cardiac arrest may occur.
●● Multiple Endocrine Neoplasia type 2.
If potassium is above 7 mmol/L and hyperkalaemia ECG changes
●● Neurofibromatosis type 1.

28 29
●● Von Hippel-Lindau syndrome. Treatment
●● Ataxia telangiectasia. ●● Should not wait for biochemical confirmation
●● Tuberous sclerosis. ●● Phenoxybenzamine (alpha blocker) is the drug of choice, with
a starting dose of 0.25-1.0mg/kg orally three times a day,
●● Sturge-Weber syndrome.
increasing to a maximum dose of 240 mg/24 hour. Doses
Precipitating factors above 40 mg three times a day are seldom required. Dose
●● Spontaneous titration is performed every 48 hours until control of blood
pressure is achieved
●● Haemorrhage into Phaeochromocytoma
●● After the first 48 hours addition of Propranolol 0.5-4 mg/kg/
●● Other
day PO/ divided every 8hours; not to exceed 60 mg/day orally
○○ Exercise. three times a day may be added
○○ Pressure on abdomen.
Important pharmacological issues in treatment
○○ Urination.
●● It is vital that 48 hours of a-blockade precede β-blockade to
○○ Drugs: Guanethidine, glucagon, Naloxone, Metoclopramide, avoid exacerbating a crisis through the unopposed action of
ACTH, cytotoxics, tricyclic antidepressants catecholamines at α-receptors

Clinical features ●● Alpha-antagonists such as doxazosin, and calcium channel


antagonists, while increasingly used for maintenance
●● Hypertension, palpitations, sweating, pallor, pounding
therapy before operation for Phaeochromocytoma, are not
headache, anxiety and tremulousness, pulmonary oedema,
recommended for management of crisis.
feeling of impending death, hyperhydrosis, nausea and
vomiting, abdominal pain (tumour haemorrhage), paralytic ●● Labetalol is not recommended as this has relatively greater
ileus, hyperglycaemia, altered consciousness (hypertensive β-blocking action compared to its α-blocking action, and hence
encephalopathy), myocardial infarction, and stroke can even precipitate or worsen Phaeochromocytoma crisis.

●● Flushing is not a feature of Phaeochromocytoma. 4). ACUTE HYPERCALCAEMIA


●● The attacks last between 15 60 minutes.
●● Causes of hypercalcaemia
●● Signs of end organ hypertensive damage; hypertensive
retinopathy and papilloedema, left ventricular hypertrophy, ○○ Endocrine
renal impairment, and proteinuria ○○ Hyperparathyroidism (adenoma, hyperplasia, carcinoma)
○○ Multiple endocrine Neoplasia
Biochemical diagnosis
Biochemical diagnosis is made by: ○○ PTH related protein production by solid tumours

●● Collecting urine into acidified bottles for estimation of 24-hour ●● Neoplastic


free catecholamines and metanephrines ○○ Carcinoma and bone invasion.
●● Plasma metanephrines and catecholamines are also increasingly ○○ Myeloma.
be used for this diagnosis.

30 31
●● Granulomatous Treatment
○○ Sarcoidosis ●● Any precipitating drugs should be stopped
○○ Tuberculosis ●● The mainstay of treatment is adequate volume repletion with
intravenous Normal Saline
○○ Berylliosis
●● Loop diuretics such as Frusemide, which has calciuretic effects,
●● Iatrogenic
should only be used after initial volume expansion
○○ Vitamin D toxicity
●● Intravenous bisphosphonates, such as sodium pamidronate at
○○ Thiazides a dose of 30–90 mg are extremely effective in the treatment of
○○ Vitamin A hypercalcaemia of malignancy, with duration of action that lasts
●● Renal failure days to weeks

○○ Tertiary hyperparathyroidism. ●● It is important to remember that serum PTH will rise after an
acute fall in serum calcium induced by such treatment and
○○ Aluminium toxicity
hence it is vital that the initial sample for PTH is obtained before
●● Miscellaneous bisphosphonate treatment
○○ Paget’s disease of bone ●● Cases of primary Hyperparathyroidism should be referred to
○○ Familial hypocalciuric hypercalcaemia. endocrine surgeons

○○ Hypophosphataemia. ●● Corticosteroids (Prednisolone 1-2mg/Kg each day) are the drugs


of choice If granulomatous diseases such as Sarcoidosis, or
History vitamin A or D intoxication are considered
History of polyuria and polydipsia, and there can be dehydration, ●● In subcutaneous fat necrosis, intravenous fluids, diuretics, and
bone pain, confusion, anorexia, and constipation. Relevant drug corticosteroids should be used
and family histories must be taken
The cornerstone of differential diagnosis is the measurement of 5). THYROID STORM
serum parathyroid hormone (PTH)
Precipitating factors
Investigations at presentation should include;
General
●● Parathyroid Hormone, PTH
●● Infection
●● Serum total protein with immunoglobulin electrophoresis for
myeloma, Albumin, Phosphate, Magnesium ●● Non-thyroidal trauma or surgery

●● Erythrocyte sedimentation rate, full blood count ●● Psychosis

●● ECG ●● Parturition

●● Chest radiography ●● Myocardial infarction or other acute medical problems

●● Fractional excretion of Calcium Thyroid specific

32 33
●● Radioiodine ●● Supportive treatment includes the use of external cooling,
●● High doses of iodine-containing compounds (for example, possibly supplemented by chlorpromazine, cautious intravenous
radiographic contrast media) fluids, or Oxygen as determined by appropriate assessment and
empirical administration of intravenous Hydrocortisone 100 mg
●● Discontinuation of antithyroid drug treatment
every eight hour
●● Thyroid injury (palpation, infarction of an adenoma)
6). MYXOEDEMA COMA
●● New institution of Amiodarone therapy

Cardinal features Precipitating factors


Include severe tachycardia, fever (usually 38.5˚C), gastrointestinal ●● Hypothermia
dysfunction (vomiting, diarrhoea, and occasional jaundice), ●● Infections especially pneumonia
agitation, confusion, delirium, or coma. Congestive heart failure
●● Myocardial infarction or congestive heart failure
may occur, particularly in the elderly, and most patients have
systolic hypertension ●● Cerebrovascular accident
●● Respiratory depression due to drugs (for example Anaesthetics,
Biochemical features
sedatives, tranquillizers)
Include hyperglycaemia, leucocytosis, high free T3 and T4, low TSH,
●● Trauma or gastrointestinal blood loss
mild hypercalcaemia, and abnormal liver function tests. Adrenal
reserve may be impaired Clinical features
Treatment The three main features are:
●● Carbimazole/Methimazole 0.5-1mg/kg/day orally in 2 or ●● Altered mental state ranging from poor cognitive function
3divided doses, or Propylthiouracil in a dose of 5-7 mg/Kg/day through psychosis to coma
is given. They inhibit thyroid hormone synthesis and conversion
●● Hypothermia (as low as 23˚C) or absence of fever in spite of
of thyroxine to tri-iodothyronine
severe infection (prognosis worsens as the core temperature
●● One hour after starting any of the above medications, iodide fall)
(like, eight drops of Lugol’s iodine every six hours) is given to
●● The presence of a precipitating event.
inhibit thyroid hormone release
●● High doses of b-blocker should be given, and Propranolol at a Other features
dose of 2-4mg/Kg/day every six hours is recommended ●● The physical signs of hypothyroidism are usually obvious and
●● Cholestyramine, 4 g every 6–12 hours, binds thyroid hormone in most patients have respiratory depression secondary to a
the gut and thus interrupts the modest enterohepatic circulation decreased hypoxic ventilatory drive and an impaired response to
of thyroid hormone; its use will lead to a more rapid lowering of hypercapnia: the more severe the latter, the more likely coma is
circulating thyroid hormones ●● Cardiac enlargement, bradycardia, decreased ventricular
●● In exceptional cases, peritoneal dialysis or plasmapheresis may contractility, hypotension, and ECG changes (low voltage, non-
be needed specific ST wave changes and sometimes torsades des pointes
with a long QT interval) are common
●● Treatment of any underlying illness follows the usual lines

34 35
●● Many patients have anorexia, abdominal pain and distention, Treatment of the underlying precipitant is usually straightfor-
and constipation and these changes may rarely lead to paralytic ward
ileus and megacolon All patients should be admitted to intensive care or the HDU: most
patients require ventilatory support for 1–2 days
Biochemical abnormalities include:
Hypothermia should be treated with space blankets, since active
●● Hyponatraemia, normal or increased urine sodium excretion,
rewarming leads to circulatory collapse
●● Raised creatine phosphokinase and lactate dehydrogenase
Cautious volume expansion using intravenous saline usually
●● Hypoglycaemia suffices, but hypertonic saline may need to be considered if the
●● Normocytic or macrocytic anaemia serum sodium is very low (< 120 mmol/L) and intravenous glucose
may be required for hypoglycaemia
●● Thyroid stimulating hormone values may only be modestly
raised (and will be normal or low in secondary hypothyroidism) There is often a degree of temporarily impaired adrenal function,
but free thyroxine levels are usually very low and most authorities advocate routine intravenous administration
of 50–100 mg Hydrocortisone every eight hours until recovery
Treatment
The three principles of management are; 7). ACUTE PITUITARY APOPLEXY
●● Rapid institution of thyroid hormone replacement
Causes
●● Treatment of the precipitating cause
Acute pituitary apoplexy occurring in
●● Provision of ventilatory and other support
●● 0.6%–9.1% of all surgically treated pituitary tumours, but is
Thyroxine institution may be done in two ways: potentially life threatening
1. High dose replacement thus; ●● Haemorrhagic infarction of a pituitary tumour
○○ Intravenous thyroxine can be given as a bolus of 300–500 ●● Normal pituitary gland
mcg, followed by 50–100 mcg daily
Risk factors include
○○ Intravenous dose of tri-iodothyronine is 10–20 mcg initially,
●● Spontaneous
followed by 10 mcg every four hours for 24 hours, then 10 mg
every six hours ●● Anticoagulation—pre-existing haemodialysis, cardiac surgery

2. Give 200 mcg thyroxine with 10 mcg tri-iodothyronine ●● Hypertension


initially, and then tri-iodothyronine 10 mcg every 12 hours and ●● Raised intracranial pressure
thyroxine 100 mcg every 24 hours, until the patient resumes
●● Dynamic pituitary testing—insulin tolerance test, thyroid
normal thyroxine orally
releasing hormone test, gonadotrophin releasing hormone test,
Oral treatment with similar doses is also possible corticotrophin releasing hormone test

The ‘‘low dose’’ approach would suggest 25 mcg of thyroxine ●● Drugs—oestrogens, Bromocriptine, Aspirin.
daily for a week, or 5 mcg of tri-iodothyronine twice daily with a ●● Pituitary radiotherapy
gradually increasing dose.

36 37
Treatment Hypotonia, bradycardia, decreased skin and nipple pigmentation,
If pituitary apoplexy is suspected muscle weakness, vomiting, nausea, constipation, hypothermia,
and hypoventilation
●● Hydrocortisone 2mg/kg IV/IM stat, then 100mg/m2 in 4-6hrly
doses intramuscularly six hourly, or 4 mg/hour intravenously A postpartum galactic is often the first sign of Sheehan's syndrome
should be administered without delay and continued until the
Investigations
crisis is over
●● TBC, serum electrolytes
●● Before administration bloods should be drawn for cortisol,
prolactin, follicle stimulating hormone, luteinising hormone, ●● Cortisol level, prolactin level
oestradiol (women), testosterone (men), sex hormone binding ●● Evaluate the hypothalamic-pituitary-adrenal axis -corticotropin
globulin, free thyroxine, thyroid stimulating hormone, insulin- stimulation test
like growth factor-1, and preferably ACTH (needs immediate ●● Assess thyroid function- serum thyrotropin (TSH) and thyroxine
cold centrifugation and freezing at -220˚C), urinary and plasma (T4)
Osmolality blood glucose should be monitored and treated
●● 24hour fluid balance then a water deprivation test and an
accordingly
aqueous vasopressin stimulation test
●● Standard cardiopulmonary supportive measures are needed
●● Early neurosurgical intervention is associated with improved Radiologic
neuro-ophthalmic outcome ●● A lateral skull film can delineate contours of the sella turcica
●● Both MRI and CT scans should be obtained with intravenous
8). PITUITARY CRISIS
contrast to increase sensitivity of the tests.

Causes Treatment
●● Not matching Glucocorticoid dose to stress in known patient ●● Standard resuscitation with IV fluids, Vasopressors
with pituitary deficiency ●● Hypoglycemia must be sought and treated
●● Undiagnosed Hypopituitarism ●● Electrolyte imbalance is corrected following the usual guidelines
○○ Pituitary adenomas or other intrasellar and parasellar tumors
Hormone replacements
○○ Inflammatory and infectious destruction
●● Hydrocortisone – high dose
○○ Surgical removal and traumatic brain injury (TBI)
●● Thyroxine
○○ Radiation-induced destruction of pituitary tissue
●● ADH analogues
○○ Subarachnoid hemorrhage
Note
○○ Postpartum agalatasia pituitary necrosis (Sheehan syndrome)
Do not start on thyroxin therapy before confirmation of normal
Clinical presentation; cortisol levels, or Hydrocortisone replacement
Weakness, fatigue, or altered mental status without a clear
diagnosis,

38 39
3. POISONING GUIDELINES ○○ Glucose to reverse the effects of drug-induced hypoglycaemia:
Dose is 25 mL of glucose 50% solution in adults or 0.5-1g
glucose/kg body weight in children (e.g. 5-10 mL/kg of 10%
POISONING MANAGEMENT glucose)
The management of acute poisoning is discussed in detail in the ○○ Naloxone in cases of possible opioid toxicity
Gertrude’s Children’s Hospital Poisoning Management Guidelines. ○○ Flumazenil in cases of coma known to be caused by
Below is summary guideline. The actions below are not necessarily benzodiazepines ALONE (because of the risk of provoking
outlined in any particular order of implementation. convulsions or arrhythmias, flumazenil should not be given
1. Manage patients as per general guidelines below and specific when the patient is suspected of having taken other drugs as
management as per the Gertrude’s Children’s Hospital well).
Poisoning Management Guidelines ●● Correct metabolic abnormalities. The following metabolic
2. Refer to the Gertrude’s Children’s Hospital Poisoning abnormalities should be corrected:
Management Guidelines ○○ Hypokalaemia
3. Call the Gertrude’s Drug and Poison Information unit on ○○ Hyperkalaemia
extension 237/240 or 020 7206237/ 0207206240 for
○○ Hypomagnesaemia
information support
○○ Hypothermia
4. Consult consultant on call
○○ Hyperthermia
5. Admit patient
○○ Hypoglycaemia
General Management
○○ Hypocalcaemia
●● Maintain adequate airway
○○ Acid-base abnormalities, particularly metabolic acidosis
●● Provide adequate oxygenation
●● Prevent absorption of poisons by gut decontamination using
●● Treat convulsions in any and make efforts to establish the single-dose activated charcoal or gastric lavage as may be
etiology of the seizures so that appropriate treatment can be indicated if a patient has taken a potentially toxic amount of a
administered poison up to one hour following ingestion. Avoid emesis. Wash
●● Treat coma if patient is in coma. It is important to consider off skin and/or eye exposure of poisoning if indicated.
other causes of depressed sensorium, including ruling out ●● Enhance elimination of poison through multiple activated
structural lesions such as subdural haematoma. The following charcoal doses if indicated.
agents can be utilized in the poisoned patient with altered level
●● Provide supportive care as will be indicated
of consciousness:
○○ Monitor vital signs (blood pressure, heart rate, respiratory
○○ 100% oxygen in suspected cases of poisoning with carbon
rate, temperature)
monoxide, hydrogen sulphide, cyanide and asphyxiants
○○ Monitor fluid input and output
○○ Thiamine to prevent Wernicke’s encephalopathy in an alcohol
intoxicated patient: Dose is 100 mg IV ○○ Monitor level of consciousness, pattern of breathing and
regularity of the heart rate

40 41
○○ Monitor oxygen saturation using a pulse oximeter 4. GASTROINTERSTINAL DISEASE
○○ Administer intravenous fluids for maintenance and fluid loss
replacement
1). ACUTE VOMITING
○○ Carry out intensive nursing care to avoid aspiration or the
development of bed sores Description
○○ Treat metabolic disturbances such as electrolyte Vomiting of abrupt onset
abnormalities, hypoglycaemia and metabolic acidosis
Management
○○ Manage underlying illnesses that may be aggravated by
●● Oral rehydration: oral: child 1month- 1yrs;
existing problem of poisoning
●● 1-1.5times usual feed volume. Child 1-12yrs; 200mLs after
●● Use specific antidotes if indicated
every loose motion. Child 12-18yrs; ORS 200-400mLs after
every loose motion.
●● NB: After reconstitution, the oral rehydration solution should be
discarded in an hour after preparing or after 24hrs if stored in
the refrigerator
●● Use IV fluids if necessary
●● Investigate cause and manage appropriately

2). DIARRHEA
Diarrhoea is defined as increased fluidity and frequency of stool.
There is a significant variability in stooling frequency among babies
and children. Breastfed babies usually stool more frequently.

Types of diarrhoea presentation


●● Acute diarrhoea with severe, some and no dehydration
●● Severe persistent diarrhoea with and without malnutrition
●● Non severe diarrhoea with and without malnutrition

Acute diarrhea with severe dehydration

Description
●● Diarrhea of abrupt onset associated with frequent passage of
loose or watery stools, fever, chills, anorexia, vomiting and
malaise
●● Diarrhea associated with two or more of the following signs
present
42 43
•• Lethargy or unconsciousness If a child has any one of the above signs and one of the signs of
•• Sunken eyes/unable to drink or drinks poorly severe dehydration, then that child has some dehydration

•• Skin pinch goes back very slowly (> 2 seconds) Management


●● In the first 4 hours, administer ORS at a dose of 75ml/kg: If the
Management
child wants more ORS, this is given
●● Administer oral rehydration fluids while setting up drip
●● Show the mother how to give the ORS solution, a teaspoonful
●● Administer IV fluids immediately Hartman’s solution or Normal
every 1-2 minutes if the child is under 2 years, frequent sips
saline (0.9% Nacl) if Hartman’s is not available: This should be
from a cup for an older child
given at a dose of 100ml/kg as follows
●● If the child vomits, wait 10 minutes, then resume ORS more
Rehydration fluid volume and duration Table 9
slowly
First give 30 ml/kg in: Then , give 70 ml/kg in:
●● If the child becomes puffy, stop ORS and give plain water or
<12 months 1 hour* 5 hours
breast milk
≥ 12 months 30 minutes* 2 ½ hours
●● Advice breast feeding mothers to continue breastfeeding
*Repeat again if radial pulse is still very weak or not detectable whenever the child wants
●● Reassess the child after every 15 – 30 minutes. If rehydration ●● Reassess the child after 4 hours, checking for signs of
status is not improving, give the IV drip more rapidly. dehydration
●● Give ORS at 5ml/kg/hour as soon as the child can drink ●● Discharge on zinc supplementation:
●● Reassess an infant after 6 hours and a child after 3 hours. •• < 6 months – 10mg elemental zinc per day for 10 – 14 days
Classify dehydration and treat appropriately •• ≥ 6 months - 20mg elemental zinc per day for 10- 14 days
●● A normally breastfed child should be breastfed regularly
Feeding
●● Zinc supplementation when able to tolerate orally:
●● In the first 4 hours, do not give any food except breast milk
•• <6 months – 10mg elemental Zinc per day for 10 – 14 days
●● Breastfed children should continue to breastfeed frequently
•• ≥ 6 months - 20mg elemental zinc per day for 10- 14 days throughout the episode of diarrhea

Diarrhea with Some Dehydration ●● After 4 hours, if the child still has some dehydration, continue
and give food every 3 – 4 hours
Description
If the child has two or more of the following signs, the child has Diarrhea with no Dehydration
some dehydration Description
●● Restlessness/irritability Should be diagnosed if the child does not have two or more of the
●● Thirsty and drinks eagerly following signs:
●● Sunken eyes ●● Restlessness/irritability
●● Skin pinch goes back slowly ●● Lethargy or unconsciousness

44 45
●● Not able to drink or drinks poorly Management
●● Thirsty and drinks eagerly ●● Treat as outpatient
●● Sunken eyes ●● Give multivitamins plus micronutrients for 14 days.

●● Skin pinch goes back slowly Prevent dehydration

Persistent Diarrhea ●● Give fluids as for acute diarrhea with no dehydration (ORS)
●● Identify and treat specific infections
Severe persistent diarrhea without malnutrition
Persistent Diarrhea with Malnutrition – Refer to section on
Description malnutrition
●● Diarrhea, with or without blood which begins acutely and lasts
for 14 days or longer 3). CHOLERA
●● When there is some or severe dehydration, persistent diarrhea is
Description
classified as severe
An acute infectious disease caused by Vibrio cholera.
Management Characteristics include severe diarrhea with extreme fluid and
●● Assess the child for signs of dehydration and manage with electrolyte depletion, muscle cramps and prostration. Vomiting may
fluids appropriately be a feature

●● Investigate for intestinal infections and treat appropriately Usual course:


●● Investigate for non – intestinal infections such as pneumonia, Acute; chronic; relapsing
sepsis, urinary tract infections, oral thrush and Otitis media and Cholera should be suspected in children over 2 years with acute
treat appropriately watery diarrhea and signs of severe dehydration, if cholera is
●● Give multivitamins plus micronutrients supplementation for occurring in the local area
2weeks
Management
●● Treat persistent diarrhea with blood in the stool with an oral
antibiotic effective for Shigella ●● Assess and treat dehydration as for other acute diarrhea
●● Give an oral antibiotic guided by culture and sensitivity
Feeding
●● Zinc supplementation when able to tolerate orally:
Feeding is essential for all children with persistent diarrhea
•• <6 months – 10mg elemental Zinc per day for 10 – 14 days
Non – severe Persistent Diarrhea without Malnutrition •• ≥6 months - 20mg elemental Zinc per day for 10- 14 days
Description
4). DYSENTERY
Children with diarrhea lasting 14 days or longer who have no signs
of dehydration and no severe malnutrition ●● Usually of infective cause.
●● Most commonly Bacillary, Amoebic or due to Salmonella.

46 47
●● Identify the causative organism by stool examination and/or •• ≥6 months - 20mg elemental Zinc per day for 10- 14 days
blood culture and refer to relevant section for management. •• Continue feeding
●● Maintain hydration.
Follow up – ask the mother to return to clinic immediately if:
5). TYPHOID FEVER ●● The child becomes more sick
This is caused by Salmonella typhi and Salmonella paratyphi. ●● Is unable to drink or to breast feed
Consider typhoid fever if a child presents with fever, plus any of ●● Drinks poorly
the following: diarrhoea or constipation, vomiting, abdominal pain,
●● Develops a fever
headache or cough, particularly if the fever has persisted for 7 or
more days and malaria has been excluded ●● Shows blood in the stool
If the child shows none of these signs but is still not improving,
Complications
advice the mother to return for follow – up after 5 days
Complications of typhoid fever include convulsions, confusion or
coma, diarrhoea, dehydration, shock, cardiac failure, pneumonia, 6). ACUTE ABDOMINAL PAIN
Osteomyelitis and anaemia. In young infants, shock and
hypothermia can occur. ●● The assessment of the child with acute abdominal pain depends
on a good history and careful examination.
Treatment
●● Typical features of some important causes of acute abdominal
●● Supportive care pain in children are described in table 6.
●● If the child has high fever, give Paracetamol. Notes
●● Monitor haemoglobin level and, if they are low and falling,
●● Acute appendicitis must be considered in any child with severe
consider transfusion
abdominal pain. In the very young child, in whom the risk of
●● Third generation Cephalosporins such as Ceftriaxone 80 mg/kg perforation is higher the presenting symptoms are less specific.
IM or IV, once daily or Cefotaxime 50mg/Kg IV once a day The diagnosis is clinical - no laboratory or radiological tests are
●● Ciprofloxacin may be used in areas where there is known required.
resistance to these drugs
●● The peak age for Intussusception is 6-12 months. Plain
●● If there are signs of gastrointestinal perforation, pass a abdominal x-ray may show signs of bowel obstruction with
nasogastric tube, keep nil per oral and get surgical opinion decreased gas in the right colon. The diagnosis is confirmed
by air insufflation or barium enema with reduction usually
MANAGEMENT AT POINT OF DISCHARGE FOR ALL
possible by the same means (unless signs of peritonitis - risk of
DIARRHOEA
perforation).
Counsel the mother on: ●● Midgut volvulus is commonest in the newborn period, but
●● Giving extra fluid (as much as the child can take) can occur in later childhood. Predisposing factors include
●● Give Zinc supplements: malrotation and abnormal mesentery.
•• <6 months – 10mg elemental Zinc per day for 10 – 14 days ●● Vomiting is rarely due to constipation.

48 49
Differential diagnosis of acute abdomen Table 10 ●● Some children suffer recurrent non-specific abdominal pain
Diagnosis Typical features with no organic cause identifiable. Constipation is often an
History Examination important contributing factor. Psychogenic factors (e.g. family,
school issues) need to be considered. These children should be
Acute Abdominal pain Tenderness, guarding and
appendicitis becomes increasingly rebound. Tenderness usually referred for general paediatric assessment.
severe and often greatest in right iliac fossa, ●● Some less common diagnoses need to be considered in patients
localizes to right iliac though may be more diffuse.
fossa with certain underlying chronic illnesses. Hirschsprung’s
disease can be complicated by enterocolitis, with sudden
Intussusception Intermittent colicky Pallor, lethargy. A sausage-
abdominal pain, shaped mass is palpable in painful abdominal distension and bloody diarrhoea. These
vomiting and the about two-thirds of cases, patients can become rapidly unwell with dehydration, electrolyte
passage of blood crossing the midline in the disturbances, and systemic toxicity and are at risk of colonic
and/or mucus epigastrium or behind the perforation. Primary bacterial peritonitis can occur in children
per rectum. There umbilicus
is frequently a with Nephrotic syndrome, post splenectomy and those with
preceding respiratory ventriculo-peritoneal shunts.
or diarrheal illness.
7). CONSTIPATION
Midgut volvulus Bowel obstruction Distension, tenderness
- abdominal pain, Description
distension; usually
bile-stained vomiting Constipation is defined variably on the basis of the frequency of
defecation, discomfort in passing stools, delayed intestinal transit
Constipation Can present with Firm stool palpable in lower and weight of the stools. Children complaining of constipation can
quite severe abdomen (sometimes entire describe stools that are too small, too big, too infrequent, painful
abdominal pain colon)
or difficult to expel or that leave a feeling of incomplete evacuation
in children; often
recurrent
Management
UTI Infants: Fever, Fever; suprapubic tenderness; General measures
vomiting, lethargy. loin tenderness if associated
Older children: pyelonephritis; leukocyte ●● Eliminate medications that may cause or worsen constipation
dysuria, haematuria esterase, and nitrites may be
positive
●● Encourage exercise/activity
●● Eliminate foods identified that may cause constipation
Pneumonia Fever; may have Fever; tachypnea, chest
cough, vomiting indrawing focal signs at one ●● Encourage adequate fluid intake
base
●● Encourage high fibre diet
Gastroenteritis Vomiting, diarrhea, Tenderness, increased bowel
fever sounds; signs of dehydration ●● Encourage toilet habits; sit on the toilet 5-10min after meals;
takes advantage of the gastrocolic reflex

50 51
Medicines times daily. Retain near lesion for as long as possible, before
1. Check for fecal impaction: If there is fecal impaction; swallowing. Child 6-12yrs: 5ml 4 times daily. Child 12-18yrs:
5-10ml 4 times daily.
○○ Enema rectally
●● NB: Miconazole should be given after food or feeding. Treatment
2. Maintenance
should continue for at least 48hrs after lesions have healed.
○○ Give osmotic laxatives – Lactulose or magnesium hydroxide Orthodontic appliances should be removed at night and also
○○ Stimulant laxatives may be used intermittently as rescue brushed with the gel.
therapy to prevent recurrence of impaction but be avoided for
2nd line (severe or refractory)
long-term, daily use
●● Fluconazole oral/iv: Neonates below 2 weeks: 3- 6mg/kg/
○○ Lubricant laxatives; for those with hard painful/blood streaked
day. Neonates of 2-4 weeks 6mg/Kg stat, then 3-6mg/kg/day.
stools; liquid paraffin
Child 1month – 12yrs: 3- 6mg/kg/day start (day 1) then 3mg/
○○ Bulk laxatives; for those with low fibre in diet; bran, ispaghula kg (max 100mg)/daily for 7-14days. Maximum 14 days unless
○○ Drugs acting locally on rectum for anal fissures to relieve pain; in immunocompromised. Child 12-18yrs: 50mg daily (100mg in
lignocaine creams/ointments unusually difficult infections) for 7-14 days.
○○ If no improvement, refer to a gastroenterologist
9). STOMATITIS
8). ORAL CANDIDIASIS
Description
Description Generalized inflammation of the oral mucosa of many possible
etiologies
An Oral mucocutaneous disorder (in the oral cavity) caused by
infection with various species of Candida. Treatment
Treatment Supportive
1st line ●● Oral toilet – quarter strength hydrogen peroxide (6% - approx.
●● Nystatin: Age <30 days 0.5 mL on each side of the mouth four 20vol): Rinse the mouth for 2-3min. With 15ml diluted in a
times a day for ten days. Continue for at least three days after tumblerful of warm water 2-3 times daily.
you no longer see any signs of thrush. Age > 30 days 1mL on ●● Topical anesthetic gel: Mostly combinations of Choline
each side of the mouth four times a day for ten days or salycilate, Benzalkonium chloride and Lignocaine hydrochloride.
●● Clotrimazole paint: 10-20 (1/2 – 1 ml) drops to be applied This serves as a local analgesic, antiseptic and surface
to affected lesions in the mouth 3-4 times daily. Apply till anaesthetic respectively. 1-2 drops or paste is applied to the
symptoms disappear completely. index finger and gently rubbed on the affected areas when
necessary.
●● Miconazole oral gel: Neonates, 1ml to be applied to affected
lesions in the mouth 2-4 times daily. Child: 1-2yrs: 2.5ml to be Analgesics: Paracetamol 10-15mg/kg 6- 8 hourly
applied to affected lesions in the mouth three times daily. Retain Children over 10years can rinse mouth and gargle with a
near lesion for as long as possible before swallowing. Child: Chlorhexidene or iodine based gargle: Chlorhexidene should be
2-6yrs: 5ml to be applied to affected lesions in the mouth three
52 53
used half an hour before or after brushing teeth. Rinse mouth with ●● Investigate cause and treat appropriately
10-15mL held in the mouth for about 30seconds twice daily. •• Micronutrient deficiency – vitamin C and B complex:
Povidone-iodine; Age 6-18yrs;upto 10mL undiluted or diluted with Vitamin C oral; child 1month-4 yrs, 125-250mg daily in
an equal quantity of warm water held for about 30 seconds upto 4 1-2 divided doses. Child 4-12yrs; 250-500mg daily in 1-2
times daily for upto 14 days divided doses. 12-18yrs 500mg – 1 gm daily in 1-2 divided
doses. Vit B complex oral: child 1 month-1 yr 5ml 3 times
Specific daily , child 1-12yrs 10ml 3 times daily, 12-18yrs 10-
●● Viral – acyclovir oral (tablets/suspension): child 1month – 2 yrs: 15ml 3 times daily. The above dosages are for treatment.
100mg 5 times daily usually for 5 days. Child >2yrs: 200mg Prophylaxis is 5ml once daily, twice daily and thrice daily as
5 times daily for 5 days. Duration may be longer if healing per the age groups above respectively.
incomplete or new lesions appear. Dose may be doubled in
•• Iron deficiency: Elemental Iron 6mg/Kg/day
immunocompromised or if absorption is impaired.
●● Oral cream: The cream is to be applied to the infected areas 10). PEPTIC ULCER DISEASE
5 times per day at intervals of 4 hrs omitting the night time
application. Treatment should be continued for 5 days, but if Description
healing is not complete, treatment may continue for 5 more A chronic ulcer in the lining of the gastrointestinal tract
days at most.
Duodenal ulcer (DU): Most located in the duodenal bulb
●● Septic – amoxicillin + Metronidazole: 1 Amoxicillin oral: Neonate
Multiple ulcers and if distal to the bulb raise the possibility of
under 7 days, 30mg/kg (max. 62.5mg for oral) twice daily. Dose
Zollinger-Ellison syndrome
doubled in severe infection. Neonate 7-28days 30mg/kg (max.
62.5 mg for oral) three times daily; dose doubled in severe Gastric ulcer (GU): Much less common than DU (in NSAID absence).
infection. Child 1 month- 1 yr 62.5 mg three times daily; dose Commonly located along lesser curvature of the antrum near the
doubled in severe infection. Child 1-5 yrs, 125mg three times incisura and in the pre-pyloric area
daily; dose doubled in severe infection. Child 5-18yrs: 250mg Esophageal ulcers: A peptic ulcer in the distal esophagus may
three times daily; dose doubled in severe infection. be part of Barrett’s epithelial change due to chronic reflux of
●● IM Amoxicillin: Child 1 month – 18 yrs: 30mg/kg every 8 hrs gastroduodenal contents
(max 500mg 8 hourly). Ectopic gastric mucosal ulceration: May develop in patients with
●● IV Amoxicillin: Neonate under 7 days, 30mg/kg every 12hrly Meckel diverticula or other sites of ectopic gastric mucosa
dose doubled in severe infections. Neonate 7-28days 30mg/
kg three times daily; dose doubled in severe infections. Child 1 Treatment
month – 18 yrs 20-30mg/kg (max. 500mg) every 8hours, dose ●● Aluminium/Magnesium hydroxide: As for gastro-esophageal
doubled in severe infections. (Max. 4g daily). reflux
●● Metronidazole; oral: Neonate initially 15mg/kg then 7.5mg/ ●● H2 receptor antagonists; Ranitidine, Cimetidine
kg twice daily. Child 1 month – 12yrs; 7.5mg/kg (max 400mg)
8 hourly. 12-18 yrs: 400mg 8 hourly. By i.v: Neonate 15mg/ Refer to gastroenterologist for assessment and follow-up
kg stat followed after 24hrs, by 7.5mg/kg every 12hours
thereafter.
54 55
11). GASTRO-OESOPHAGEAL REFLUX DISEASE 12). HEPATITIS A INFECTION

Description Treatment
Reflux of gastroduodenal contents into the esophagus, larynx or Medical Care
lungs with or without esophageal inflammation
●● Treatment is supportive because no specific therapy is available
Management ●● Hospitalization is indicated for patients with significant
●● Refer to Gastroenterologist dehydration due to vomiting or those with fulminant hepatitis

Supportive ●● Medications that have known liver toxicity should be avoided

●● Proper positioning Consultations


●● Weight reduction if obese in the older child ●● Consultation with a subspecialist for those with prolonged
jaundice >1month or with features of hepatic encephalopathy
Drug Therapy
H2 antagonist – Ranitidine: Oral: Neonate; 2mg/Kg (max.3mg/ Diet
Kg) 3 times daily. Child 1-6 months; 1mg/Kg (max 3mg/Kg) 3times ●● No specific dietary changes are needed
daily. Child 6 months-3yrs 2-4 mg/Kg twice daily. Child 3-12yrs; ●● In euvolemic patients with vomiting (but without dehydration
2-4mg/Kg (max 150mg) twice daily increased up to 5mg/Kg (max that requires intravenous fluid therapy) appropriate intake of
300mg) in severe gastro-esophageal reflux. Child 12-18yrs; 150mg oral fluid is recommended, as with other viral illnesses
twice daily or 300mg at night. Doses are adjustable in moderate to
severe conditions Activity
Proton pump inhibitor (Omeprazole): Dose: Oral: Neonates; ●● Activity can be resumed as tolerated
700mcg/Kg once daily increased if necessary after 7-14 days up
Medication
to 1.4-2.8 mg/Kg once daily. Child 1-2 yrs, 700mcg/Kg once daily,
increased up to 3mg/Kg (max 20mg) once daily. Child body- ●● No specific medications are indicated
weight 10-20Kg; 10mg once daily increased to 20mg once daily
Follow-up
in severe condition. Maximum of 12 weeks at higher dose Body
weight >20Kg, 20mg once daily, up to 40mg in severe conditions ●● Further Inpatient Care
Max12 weeks at higher dose IV injection given over 5 minor by IV ●● Inpatient care is not needed for most patients with hepatitis A
infusion. Child 1month- 12 yrs500mcg/Kg(max .20mg) once daily virus (HAV) infection
up to 2mg/Kg(max 40mg) once daily when necessary. Child 12-18 ●● Some patients may require hospitalization for intravenous
yrs40mg once daily rehydration. Once emesis subsides and the patient can tolerate
oral fluids, discharge is appropriate

Further Outpatient Care


●● Follow-up liver enzyme studies should be performed at monthly
intervals until levels normalize. If elevations persist longer than

56 57
●● 3 months, complications or additional diagnoses should be 5. EAR NOSE AND THROAT
considered

Prevention 1). TONSILLO-PHARYNGITIS


●● General prevention measures consist of good personal hygiene,
hand washing, ingestion of safe drinking water and proper Description
sanitation ●● Inflammation of the pharynx most commonly caused by acute
●● Prevention specific to hepatitis A infection includes the use of infection.
HAV immune globulin (IG) and HAV vaccine ●● Group A streptococcus is a focus of diagnosis due to its
●● IG is given as an intramuscular injection of 0.02 mL/Kg potential for preventable rheumatic sequelae.
●● HAV vaccine is currently licensed for use in children aged 12 ●● Chronic low grade symptoms usually related to reflux disease or
months or older vocal abuse.

Specific measures to prevent HAV can be divided into 2 groups: Management


Pre-exposure prophylaxis and post exposure prophylaxis
Supportive treatment
●● Pre-exposure prophylaxis with HAV vaccine is recommended for
●● Normal Saline gargle – use 10 to 15mL every 4 - 6hours for all
persons aged 1 year or older. If the trip is shorter than 2weeks
children who can gargle usually above 4years
or if the patient is younger than 1 year, IG should be given. If
the trip is longer than 3 months, a larger dose of IG (0.06 mL/ ●● Children over 10years can rinse mouth and gargle with a
Kg) is needed for those who cannot receive the vaccine Chlorhexidene or iodine based gargle: Chlorhexidene should be
used half an hour before or after brushing teeth. Rinse mouth
●● Post exposure prophylaxis consists of the administration of IG
with 10-15mL held in the mouth for about 30seconds twice
to contacts as soon as possible, but not longer than 2 weeks
daily. Povidone-iodine; 6-18yrs; upto 10mL undiluted or diluted
after exposure
with an equal quantity of warm water held for about 30 seconds
upto 4 times daily for upto 14 days
●● Oral analgesic in pain: Paracetamol 10-15mg/Kg/dose every 4 -
6 hours as needed

Definitive Treatment
●● Oral amoxicillin 90 mg/Kg/day in divided doses every 8 hours
for 7 days
●● Oral Cefadroxil 30mg/Kg/day in 2 divided doses for 7days

Penicillin Hypersensitivity
●● Oral erythromycin 20 – 40 mg/Kg/day in divided doses every 6-
8 hours for 7 days

58 59
2nd line antibiotics Supportive Treatment
●● Oral Coamoxiclav 90mg/Kg/day in 2 divided doses for 10days ●● If there is pus draining from the ear, advice the mother to
●● Oral Azithromycin 10mg/Kg once daily for three days wick the ear repeatedly until the wick is dry and keep doing it
severally in a day to keep the ear dry
●● Oral Cefuroxime 30mg/Kg/day in 2 divided doses for 10days
Definitive treatment
3rd line antibiotics
●● Pain and fever should be managed with oral Paracetamol 10-
●● Intravenous Ceftriaxone 50 - 80mg/Kg/day as a once daily dose
15mg/Kg/dose every 4 – 6 hours or Ibuprofen 4 - 10mg/Kg
2). OTITIS MEDIA every 6 to 8 hours

1st line antimicrobial therapy


Description
●● Oral Amoxicillin 90 mg/Kg/day in divided doses every 8 – 12
Infection or inflammation of the middle ear
hours for 10 days
●● Acute Otitis Media (AOM): Usually a bacterial infection
accompanied by viral upper respiratory infection; rapid onset of Penicillin hypersensitivity
signs and symptoms ●● Oral Azithromycin 10mg/Kg/day once daily for 3 days or
●● Recurrent AOM: 3 or more AOM episodes in 6 months or 4 or ●● Oral Erythromycin 30-40mg/Kg/day in divided doses every 6 – 8
more AOM episodes in 1 year
hours for 5 – 7 days
●● Otitis media with effusion (OME): Persistent inflammation
manifested as asymptomatic middle ear fluid that follows AOM 2nd line Antimicrobial Therapy
or arises without prior AOM ●● Oral Coamoxiclav 90mg/Kg/day in divided doses every 12 hours
●● Chronic Otitis media with or without cholesteatoma for 10 days or
●● Oral Cefprozil 30mg/kg/day in divided doses every 12 hours
a. Acute Otitis Media
●● Oral Cefuroxime 30mg/Kg/day in divided doses every 12 hours
Description Alternative antibiotics
Otitis media described by: ●● Cefixime 8 mg/Kg/day bid or single daily dose - effective
●● History of ear pain or pus draining from the ear for a period of against resistant H. influenzae and M. catarrhalis less effective
less than 2 weeks than amoxicillin for pneumococci
●● Fever ●● Cefpodoxime 10 mg/Kg/day bid - less effective in vivo against
●● Systemic signs may or may not be present H. influenzae than other drugs
●● Ear drum is red, inflamed, bulging and opaque or perforated Follow up
with discharge on otoscopy
●● Follow up after 5 days, if ear pain and discharge persists, treat
Management with same antibiotics for 5 more days and follow up after 5 days

60 61
b. Chronic Suppurative Otitis Media 3). ALLERGIC RHINITIS
Description Description
An Otitis media associated with : An immediate and/or delayed reaction to airborne allergens,
●● A history of pus draining from the ear for more than 2 weeks beginning with the generation and presence of specific antigen-
●● Confirmation by otoscopy responsive IgE antibody receptors on mast cells of the nasal
mucosa and associated with
Management
●● Stuffy nose, sneezing, itching, runny nose, cough, halitosis and
Supportive treatment repeated throat clearing,
●● Advice the mother to wick the ear repeatedly until the wick is ●● Sensation of plugged ears and wheezing may occur
dry ●● Red and itchy eyes suggestive of allergic conjunctivitis
*Consult an E.N.T specialist ●● Seasonal, perennial or episodic symptoms and exacerbating
factors may help identify allergen
Definitive Treatment
●● Family history of atopic disease supports diagnosis
●● Oral Coamoxiclav 90mg/Kg/day in divided doses every 12 hours
for 10 days Management
●● Instill topical antibacterial ear drops: Ciprofloxacin ear drops
Supportive treatment
once daily for two weeks
●● Avoidance therapy – identify and eliminate known/suspected
Reference allergens
1. Integrated management of childhood diseases IMCI 2006
Definitive treatment
2. Rudolf paediatrics 21st edition ●● Normal saline nasal drops; 2-3 drops into both nostrils 3-4
3. Currents pediatrics 16th edition times daily when necessary.
4. McConaghy JR. The evaluation and treatment of children with ●● Steam inhalation
acute Otitis media. J Fam Pract 2001;50(5):457-9, 463-5 ●● Menthol with Eucalyptus drops sprinkled onto the pillow, a
5. Kozyrsky AL, Hildes-Ripstein GE, et al. Treatment of acute handkerchief or into steaming water. The child is then allowed
Otitis media with a shortened course of antibiotics. JAMA to breath in the vapor for some time. Not recommended for
1998;279(21):1736-41 infants and not more than 4doses to be used
6. Stool SE, Berg AO, Bernan S, et al. Otitis media with effusion in ●● Non- sedating Antihistamines – Loratadine, Cetrizine:
young children. Clinical practice guideline. AHCPR Publication ●● Loratadine; oral; child 2-6yrs, 5mg once daily. Child 6-18 yrs
no 94-0622, 1994 10mg once daily. Desloratadine can be used at half the dose of
7. Rosenfield RM, Vertrees JE, Carr J, et al. Clinical efficacy of Loratadine. Cetrizine; oral; child 1-2yrs; 250mcg/Kg twice daily.
antimicrobial drugs for acute Otitis media: Meta analysis Child 2-6yrs; 5mg daily in 1-2 divided doses. Child 6-18 yrs;
of 5400 children from 33 randomized trials. J Paediatric 10mg once daily in 1-2 divided doses.
1994;124:355-67
62 63
●● Mast cell Stabiliser - Montelukast ●● Intravenous therapy with third-generation cephalosporin such
as Cefotaxime should be initiated until culture results become
Corticosteroid Nasal Sprays available
1. Fluticasone, 4 years and above 1 spray (50 mcg) in each
●● Less severe cases of acute sinusitis should be treated with oral
nostril once daily. Double the dose to 100mcg in severe
antibiotics for 10 days
symptoms and reduce to 50mcg once symptoms are
controlled. A preparation of Fluticasone with a lower dose First line
(25mcg) per spray is available
●● Coamoxiclav at 90 mg/Kg/day in 2 divided doses
2. Budesonide 32mcg in children less than 12 years: 4 sprays
(2 in each nostril once daily). In children above 12 years, 8 Second line
sprays (4 in each nostril once daily) for a max of 3 months ●● 3rd generation cephalosporins Ceftriaxone or Cefpodoxime.
Recurrence of allergic rhinitis needs follow up by the ENT sur-
●● Patients with underlying allergic rhinitis may benefit from
geons or an Allergist
intranasal corticosteroid nasal spray

References ●● Paracetamol or Ibuprofen if in pain to permit sleep until


drainage is achieved
1. Middleton E. Jr, Reed CE, Ellis EF: Allergy Principles and Practice.
4th Ed. St. Louis, C.V. Mosby Co., 1993 ●● The application of ice over the sinus may help to relieve pain
2. Baraniuk JA: Pathogenesis of allergic rhinitis. J of Allergy and Chronic or recurrent sinusitis
Clinical Immunology 1997;99(2):S763-S772
●● Recurrent acute bacterial sinusitis is defined as successive
3. JAMA. Primer on Allergic and Immunologic Diseases. 1992 episodes of bacterial infections of the sinuses, each lasting less
4. Rudolfs pediatrics -21st edition than 30 days and separated by intervals of at least 10 days,
during which the patient is asymptomatic
5. Current paediatric diagnosis and treatment 16th edition
●● Chronic sinusitis is defined as episodes of inflammation of the
4). SINUSITIS paranasal sinuses lasting more than 90 days.

Treatment
Acute bacterial Sinusitis
●● Antibiotic therapy is similar to that used for acute sinusitis, but
the duration is longer.
Description
●● Adjuvant therapies such as saline nasal irrigations,
Acute bacterial infection of the paranasal sinuses lasting less than
antihistamines and topical intranasal steroids may be helpful
30 days and in which symptoms resolve completely
depending on the underlying cause.

Management ●● Refer to the ENT surgeons


●● Patients with evidence of invasive infection or any CNS
complications should be hospitalized immediately

64 65
5). EPISTAXIS anterior pack using 1/2 x 72 inch ribbon gauze impregnated
with petroleum jelly (Vaseline) or nasal tampons may be used
Description ●● Use bayonet forceps and nasal speculum to insert in folding
Hemorrhage from nostril, nasal cavity or nasopharynx layers as far back as possible. Press each layer firmly down on
the last in one continuous strip with the folded ends alternating
●● Anterior bleed: Originates from anterior nasal cavity, usually
front and back
little’s area (kiesselbach’s plexus)
●● Posterior bleed: Originates from posterior nasal cavity or Posterior bleed
nasopharynx usually under the posterior half of the inferior ●● Various balloon systems.
turbinate or the roof of the nasal cavity
●● Posterior packing is very effective if balloon systems fail to
control bleeding.
Management

General measures Intractable bleed


●● Bilateral packing to achieve adequate compression (admission
●● Resuscitation as indicated required)

●● Sedation, analgesic, antihypertensive or anticoagulant reversal ●● Bleeding from roof may be controlled by placing double balloon
as needed system with small anterior pack placed above anterior balloon.
●● Intractable bleed will require surgical cauterization or arterial
●● Patient should be gowned and sitting, if stable.
ligation (ideally after visual identification of bleeding site to
●● Clear nasal cavity of blood with suction, forceps withdrawal of define appropriate arterial supply)
clot or patient blowing nose
Medication Management
If bleeding has stopped,
1. Vasoconstrictor: Cocaine 4%, Phenylephrine 0.25%,
●● Rub suspicious areas with wet cotton tipped applicator to Xylometazoline 0.1%, epinephrine 1:1000
identify site. Diffuse ooze or multiple sites suggests systemic
cause 2. Anesthetic: Tetracaine 2%, lidocaine laryngeal spray, Lidocaine
jelly 2%, Lidocaine solution 4%, Lidocaine viscous 2%
●● In cases of posterior bleed, identify as either roof or low
posterior site since each has different arterial supply (will be 3. Systemic antibiotics and decongestants to prevent sinusitis with
packs or balloons
important if arterial ligation is necessary).
4. Consider iron supplementation for patients with considerable
Anterior bleed blood loss
●● Place pledget soaked in vasoconstrictor and local anesthetic in
cavity and pinch nostril for several minutes to stop bleeding by Prevention/avoidance
direct pressure ●● Liberal application of petroleum jelly (Vaseline) to nostril to
prevent drying and picking.
●● Remove pledget and visualize vessel. Cauterize with silver
nitrate stick directly on vessel with firm pressure for 30 seconds ●● Humidification at night.
●● If unsuccessful, apply second dose of anesthetic and place ●● Cut fingernails.

66 67
References 7). MENIERE’S DISEASE
1. Votey R, Dudley JP: Emergency Ear, Nose and Throat
procedures. Emerg. Clin. NA 1989;7(1)117-154 Description
2. Perretta LJ, et al: Emergency evaluation and management of An inner ear (labyrinthine) disorder in which there is an increase
epistaxis. Emerg. Clin. NA 1987;5(2)265-277 in volume and pressure of the inner-most fluid of the inner ear
3. Nelsons textbook of paediatrics (endolymph) resulting in recurrent attacks of hearing loss, tinnitus,
vertigo, and fullness.
4. Current diagnosis and treatment – 16th edition
5. Rudolfs paediatric 21st edition Management

General measures
6). LUDWIG’S ANGINA
●● Reassurance
Description ●● Medications are given primarily for symptomatic relief of vertigo
Ludwig angina is a rapidly progressive cellulitis affecting the and nausea.
submandibular, submental and sublingual spaces that can cause ●● For attacks, bed rest with eyes closed and protection from falling.
airway obstruction and death. It is characterized by:
Surgical measures:
●● Tongue elevation,
Refer to an ENT Specialist
●● Difficult eating and swallowing,
●● Oedema of the glottis, Medication management
●● Fever, tachypnea and moderate leukocytosis. Acute attack

Management For severe episode, one of the following may be used. Adult doses
are indicated
●● Admit for ENT Specialist management
●● Atropine 0.2-0.4 mg IV or
●● Broad-spectrum intravenous antibiotics
●● Diazepam 5 -10 mg IV slowly
●● Maintain airway
●● Tracheostomy if necessary Maintenance
Meclizine 25-100 mg orally, either at bedtime or in divided doses
Medical Management
●● High doses of intravenous Clindamycin or Nafcillin until the Monitoring and follow up
results of cultures and sensitivity tests are available ●● Monitor the status of their hearing, since it is at risk

Monitoring ●● Consider the possibility of a more serious underlying problem

●● The patient must be monitored closely in the intensive care unit such as an acoustic tumor.
and intubation provided for progressive respiratory distress
●● An otolaryngologist should be consulted to identify and perform
a drainage procedure.
68 69
6. RESPIRATORY TRACT CONDITIONS Management
●● Supportive – oxygen, rest
1). PNEUMONIA ●● Antibiotic therapy

1st line
Bacterial Pneumonia
●● Crystalline penicillin 50,000 – 100,000IU/Kg/day in divided
Description doses every 6hours or amoxicillin 90mg/Kg/day in 3 divided
An acute bacterial infection of the lung parenchyma. doses.
Infection may be community acquired or nosocomial (hospital ●● Add IM Gentamicin 5 – 7mg/Kg once a day if age under 3
acquired by an inpatient for at least 48 hours or inpatient in the months, severe malnutrition, immunosuppression and very
previous 3 weeks). severe disease
In the Neonatal period the following organisms are common
2nd line
causes: Group B streptococcus, Escherichia coli (and other enteric
Gram negative bacilli), Listeria monocytogenes, Streptococcus ●● Coamoxiclav 30mg/Kg/dose (oral 90mg/Kg/day in two divided
pneumoniae, Haemophilus influenzae, Staphylococcus aureus, doses) 12 hourly for 7 – 10 days
Neisseria meningitides and Salmonella spp. ●● Cefuroxime 90mg/Kg/day (Oral 30mg/Kg/day) in three divided
In the age 1 – 3months, the following organisms are common doses for 7 – 10 days
causes of infection: Streptococcus pneumoniae, Group B ●● Azithromycin 10mg/Kg/day once daily or Erythromycin 30-
streptococcus, Neisseria meningitides, Salmonella spp, 40mg/Kg/day in divided doses every 6 – 8 hours for suspected
Haemophilus influenzae and Listeria monocytogenes mycoplasma pneumoniae
In the age above 3months, the following are commoner causes:
Note
Streptococcus, Pneumoniae, Haemophilus influenzae, Neisseria
●● Consider tuberculosis if response is poor, or prolonged history
meningitides, and Salmonella species
e.g. cough over 2 weeks
Hospital-acquired pneumonia is usually due to gram negative rods
●● Adjust drugs to specific organism identified by laboratory tests
such as Pseudomonas or other times Staphylococcus
Follow-up/monitoring
Classification
●● Review one week after discharge for severe pneumonia and very
All will present with cough, fever
severe disease.
Classification will depend on physical examination findings thus;
●● If there are complications, follow-up should be scheduled.
●● No pneumonia, normal RR
Aspiration Pneumonia
●● Pneumonia - Tachypnoea,
●● Severe pneumonia - tachypnoea, lower chest wall indrawing Description

●● Very severe disease - tachypnoea, lower chest wall indrawing Aspiration syndromes can be divided into two types: The aspiration
of oropharyngeal flora or infected secretions and the aspiration of
and clouded consciousness
gastric contents
70 71
In both cases, the aspiration event may not be witnessed or is ●● Maintain normal activity levels
accompanied by few if any acute symptoms. ●● Maintain pulmonary function

Management ●● Prevent asthma exacerbations

Antibiotic for pneumonia and not pneumonitis ●● Avoid adverse effects of asthma medications
●● Prevent asthma mortality
1st line antibiotics
Crystalline Penicillin 50,000 – 100,000IU/Kg/day in divided doses Notes
every 6 hours plus Gentamicin 5 -7mg/Kg/day in a single dose for ●● The patient’s current level of asthma control and current
7 days treatment determine the selection of pharmacologic treatment
Use Oral erythromycin 20 – 40 mg/Kg/day in divided doses every 6- Stepped approach to Asthma management Table 11
8 hours for 7 days in penicillin hypersensitivity Step 1 Step 2 Step 3 Step 4 Step 5
As needed As needed rapid acting beta 2 agonist
2nd line antibiotics
rapid Select one Select one Add one or Add one or both
●● Clindamycin 3 - 6mg/Kg/day 6hourly and Metronidazole 7.5mg/ acting beta more
Kg every 8hours 2 agonist
Low-dose Low-dose ICS Medium-or Oral
inhaled plus high-dose glucocorticosteroid
●● Coamoxiclav 90mg/Kg/day in 3 divided doses and (lowest dose)
ICS long-actingβ2- ICS plus
Metronidazole 7.5mg/Kg every 8hours agonist long-acting 1mg/Kg
●● Oral Cefuroxime 90mg/Kg/day in 3 divided doses and β2-agonist
Metronidazole 7.5mg/Kg every 8hours Leukotriene Medium-or Leukotriene Anti-IgE
modifier high-dose ICS modifier treatment
●● Supportive care - Oxygen, respiratory support as necessary Low-dose ICS Sustained
plus release
●● Suction of oropharyngeal/tracheal airway Leukotriene Theophylline
modifier
2). ASTHMA Low-dose ICS
plus
Description sustained
release
Asthma in children is a disease of the respiratory tract theophylline
characterized by recurrent and/or chronic episodes of airway
inflammation and obstruction (manifested by wheeze or cough, or Step 1: As-needed reliever medication.
demonstrated upon pulmonary function testing) and evidence of ●● Treatment with an as-needed reliever medication is reserved for
reversibility of obstruction untreated patients with occasional daytime symptoms (cough,
wheeze, dyspnoea occurring twice or less per week, or less
Stepped approach to the management of asthma frequently if nocturnal) of short duration (lasting only a few
hours) comparable with controlled asthma
Goals
●● Achieve and maintain control of symptoms ●● Reliever medication is used relief of symptoms in all patients
diagnosed to have hyperactive airway disease or asthma

72 73
●● Between episodes, the patient is asymptomatic with normal lung ●● Another option is to combine a low-dose inhaled
function and there is no nocturnal awakening glucocorticosteroid with Leukotriene modifiers
●● A rapid-acting inhaled beta 2-agonist (Salbutamol) is the ●● The use of sustained-release theophylline given at low-dose may
recommended reliever treatment be considered for inpatients only
●● An inhaled Anticholinergic (Ipratropium bromide) may be added Step 4: Reliever medication plus two or more controllers.
to the beta 2 agonist
●● Patients who are not controlled on Step 3 treatments should be
●● When symptoms are more frequent, and/or worsen periodically, referred to a specialist.
patients require regular controller treatment (see Steps 2 or
higher) in addition to as-needed reliever medication GENERAL GUIDELINES FOR THE MANAGEMENT OF ASTHMA
Step 2: Reliever medication plus a single controller
Notes
●● Treatment Steps 2 through 4 combine an as-needed reliever
●● Inhaled route is the preferred route
treatment with regular controller treatment.
●● Increased use of relievers is indicative of a deteriorating
●● At Step 2, a low-dose inhaled glucocorticosteroid is
condition
recommended as the initial controller treatment for asthma
patients of all ages ●● A metered dose inhaler with spacer is preferred to nebulization

●● Alternative controller medications include Leukotriene modifiers Choosing an inhaler device for children Table 12
appropriate particularly for patients who are unable or unwilling Age group Preferred device Alternate device
to use inhaled glucocorticosteroids, or who experience <1year Orange Spacer with Nebuliser with Face
intolerable side effects from inhaled glucocorticosteroid Face mask mask
treatment and those with concomitant allergic rhinitis 1 – 5years Yellow Spacer with Nebuliser with Face
●● Leukotriene modifiers may be used as an add on treatment Face mask mask
>5years Able spacer with Nebuliser with mouth
Step 3: Reliever medication plus one or two controllers mouth piece pisece
●● For all children but particularly those aged 5 years and
below, it is recommended to use a medium dose of inhaled The spacer device should be cleaned with soapy water and drip
glucocorticosteroids (up to 200 mcg to 400mcg Budesonide 12 dried without rinsing every 2weeks to reduce hydrostatic charge
hourly)
The number of doses remaining must be counted accurately to
●● The low-dose of glucocorticosteroid is usually sufficient, and avoid using the propellant as the active drug when the doses are
need only be increased if control is not achieved within 15 – 30 over
days with this regimen
●● Another option is to combine a low-dose inhaled Controller medications
glucocorticosteroid with Leukotriene modifiers Inhaled corticosteroids
●● For adolescents, at this stage combine a low-dose of inhaled ●● Most effective and recommended for treatment of children of all
glucocorticosteroid with an inhaled long-acting Beta 2-agonist, ages

74 75
Severe Acute Asthma Assessment and management Table 13
Severe Primary Oxygen.
Severity Signs of Severity Management Agitated/distressed Salbutamol by MDI/spacer- 1
Mild Primary Salbutamol by MDI/spacer Moderate-marked dose (10puffs) every 20 minutes
Normal mental state 10puffs once (1dose) and review accessory muscle use/ for 1 hour
Subtle or no accessory after 20 mins. Ensure device/ recession Use Ipratropium bromide by
muscle use/recession technique appropriate. Secondary nebulizer (dose age specific) from
Secondary Good response - discharge on ß2- Oxygen saturation < 92% the 3rd dose of MDI Salbutamol
Oxygen saturation > 95% agonist as needed. in air Oral Prednisolone (1 mg/
in air Poor response - treat as moderate. Tachycardia Kg daily); if vomiting give IV
Able to talk normally Provide written advice on what to Marked limitation of Methylprednisolone 1mg/Kg
do if symptoms worsen. ability to talk Arrange admission after initial
Arrange follow-up as appropriate. Note: wheeze is a poor assessment
predictor of severity.

Moderate Primary Give Oxygen if saturation is < Critical Primary Oxygen.


Normal mental state 92%. Need for Oxygen should be Confused/drowsy Continuous nebulised
Some accessory muscle reassessed. Maximal accessory salbutamol diluted 1:1 in Normal
use/recession Salbutamol by MDI/spacer - 1 muscle use/recession Saline 0.15mg/Kg minimum
Secondary dose (10puffs) every 20 minutes Exhaustion 2.5mg/dose maximum 7.5mg/
Oxygen saturation 92- for 1 hour; review 10-20 min after Secondary dose
95% in air 3rd dose to decide on admission = SaO2 < 90% in air Nebulised ipratropium every 4 –
Tachycardia or discharge. Marked tachycardia 6hours added to Salbutamol
Some limitation of ability Oral Prednisolone (1 mg/Kg daily Unable to talk Methylprednisolone 1 mg/Kg IV
to talk until 48hours after symptoms 6-hourly.
subside maximum 5 days) If deteriorating give
The few children of moderate Aminophylline 10 mg/Kg IV (max
severity who can go home dose 500 mg) over 60 min.
must be discussed with the Following loading dose give
Paediatrician and should not leave continuous infusion (1-9 yr: 1.1
Emergency until at least one hour mg/Kg/hr, 10+ yr: 0.7 mg/Kg/hr).
after their last inhaled dose. If currently taking oral
Arrange home treatment and theophylline, do not give IV
follow-up as above. aminophylline - take serum level.
If poor response IV salbutamol
5 mcg/Kg/min for one hour as a
load, followed by 1-2 mcg/Kg/min
Aminophylline and salbutamol
must be given via separate IV lines

76 77
Equipotent doses of ICS for children Table 14 Rapid acting beta 2 agonist and short acting oral beta 2 agonists
Drug Low daily Medium daily High daily
Rapid acting inhaled beta 2 agonist
dose(ug) dose(ug) dose(ug)
Beclomethasone 100-200 >200-400 >400
●● Most effective bronchodilators (relievers) and preferred drug for
management of acute asthma
Budesonide* 100 – 200 >200-400 >400
Budesoinide neb 250 – 500 >500-1000 >1000 Anticholinergics
Mometasone furoate 100-200 >200-400 >400 ●● Ipratropium bromide – not recommended for long-term
Triamcinolone 400-800 >800-1200 >1200 management
Ciclesonide* 80-160 >160-320 >320 ●● Can be used as relievers in acute asthma as an addition to the
Fluticasone 100-200 >200-500 >500 beta 2 agonist
Flunisolide 500-750 >750-1250 >1250 * Treat precipitating or underlying conditions like infection and
dehydration
*Approved for once daily dosing in mild patients. Clinical judgment or
response to therapy is required for determining appropriate dosing Admit to ICU if:
level
●● In impending respiratory failure
Children under 5 years ●● Requiring continuous nebulisations for > 1 hour or requiring
Daily doses of ≤ 400 ug of budesonie or equivalent result in near Salbutamol more frequently than every 30 minutes after 2
maximum benefit hours.
●● Use of Magnesium sulphate or Terbutaline infusions may be
Leukotriene modifiers considered
Children older than 5 years
Arterial blood gas and spirometry are rarely required in the as-
●● Montelukast 5 mg once daily dosing: sessment of severe acute asthma in children
●● Partial protection against exercise induced bronchoconstriction
3). PNEUMOCYSTIS CARINII PNEUMONIA
●● As add on therapy in children uncontrolled by ICS alone
Description
Children under 5 years
●● A pneumonia arising in immunosuppressed persons caused by
●● Montelukast 4mg once daily dosing
Pneumocystis jirovecii (PCP).
Long acting inhaled beta 2 agonist ●● This is one of the most common opportunistic infections
●● Add – on therapy for patients whose asthma is not controlled on occurring in patients with human immunodeficiency virus (HIV)
low to high doses of ICS. Examples include: infections.

○○ Formeterol ●● Pneumocystis infection can cause organ involvement and


disseminated disease as well as pneumonia
○○ Salmeterol

78 79
Management ●● Anti TB drugs are abbreviated thus: Isoniazid (H), rifampicin (R),
Pyrazinamide (Z) and Ethambutol (E)
Supportive
●● Streptomycin should be avoided when possible in children
●● Oxygen, nutrition, intravenous fluids
because the injections are painful and irreversible auditory
Definitive nerve damage may occur
●● Cotrimoxazole 20 - 25mg/Kg (Trimethoprim) 6 hourly IV/Oral ●● The use of streptomycin in children is mainly reserved for the
for 2weeks (3weeks for immunocompromised patients. Give first 2 months of treatment of TB meningitis
prophylaxis (4 – 5mg/Kg of Trimethoprim) indefinitely after
Corticosteroids
treatment
●● Corticosteroids may be used for the management
Use Prednisone 1 – 2mg/Kg/day when symptoms are present. extrapulmonary forms of TB like TB meningitis, complications of
airway obstruction by TB Adenitis, and TB Pericarditis
4). TUBERCULSOSIS – TB
●● Prednisone, in a dosage of 2mg/Kg daily, increased up to 4 mg/
Kg daily in the case of the most seriously ill children, with a
Description
maximum dosage of 60mg/day for 4 weeks
An infectious disease caused predominantly by mycobacteria
●● The dose should then be tapered over 1–2 weeks before
tuberculosis
stopping
Anti-TB treatment in children Anti TB drug doses Table 15
The main objectives of anti-TB treatment are to: Recommended Dose
Drug
●● Cure the patient of TB (by rapidly eliminating most of the Daily Three Times Weekly
bacilli); Dose and Maximum Dose and Daily
●● Prevent death from active TB or its late effects; range (mg) range maximum
(mg/Kg body (mg/ (mg)
●● Prevent relapse of TB (by eliminating the dormant bacilli); weight) Kg body
weight)
●● Prevent the development of drug resistance (by using a
combination of drugs); Isoniazid 5 - 10 300 10 (8–12) –
Rifampicin 10 - 15 600 10 (8–12)
●● Decrease TB transmission to others.
Pyrazinamide 25 (20–30) – 35 (30–40) –
Recommended treatment regimens as per case definitions Ethambutal children 20 – 30 (25–35) –
Anti-TB treatment is divided into two phases: (15–25)

○○ An intensive phase and Streptomycin 15 (12–18) – 15 12–18) –

○○ Continuation phase
●● The number at the front of each phase represents the duration
of that phase in months (see table 11).

80 81
Treatment of Tuberculosis Table 16 5). Viral Croup
TB TB Regimen
diagnostic Cases Description
category Int ens i v e C o n t i n u a t i o n
phase phase A condition classified and characterized as:
Fever, hoarse voice, backing or hacking cough, stridor that is heard
III ●● New smear- 2HRZ 4HR or 6HE
negative
only when the child is agitated
pulmonary TB ●● Mild – symptoms on excertion
(other than in
category I). ●● Moderate – expiratory wheeze
●● Less severe forms
of extrapulmonary ●● Severe – expiratory and inspiratory wheeze
TB
Management
I ●● New smear-positive 2HRZE 4HR or 6HE ●● Mild croup can be managed at home with supportive care,
pulmonary TB including encouraging oral fluids, breast feeding or feeding, as
●● New smear-
negative appropriate.
pulmonary TB with
●● extensive Severe croup
parenchymal
involvement ●● Steroid treatment: Give one dose of IM Dexamethasone 0.6mg/
●● Severe forms of Kg
extrapulmonary
TB (other than TB ●● Nebulized Adrenaline 0.1 – 0.3mg (1:1000 solutions) every hour
meningitis – see with monitoring of response.
below)
●● Severe concomitant
HIV disease A child with severe croup who is deteriorating
I ●● TB meningitis 2RHZS 4RH ●● Oxygen should be given.
●● If there is incipient airway obstruction tracheostomy should be
II ●● Previously treated 2HRZES/ 5HRE
smear-positive 1HRZE performed
pulmonary TB:
●● Severe indrawing or lower chest wall and restlessness likely
relapse treatment
after interruption indicate the need of tracheostomy or intubation
treatment failure ●● Nasal prongs or nasal/nasopharyngeal catheter can upset the
IV ●● Chronic and MDR- Specially designed standardized or child and precipitate obstruction of the airway
TB individualized regimens (refer to
consultant)
Intubation and tracheostomy
●● Intubation should be done immediately if there are signs of
incipient airway obstruction, such as severe indrawing of the

82 83
lower chest wall and restlessness. 7. GENITOURINARY DISORDERS
Supportive care
1). URINARY TRACT INFECTIONS
●● Minimize disturbance
●● If temperature is ≥39Oc, give Paracetamol 10 – 15m/Kg every Description
4 – 6hours
Paediatric urinary tract infection (UTI) may involve the urethra,
●● Encourage breastfeeding and oral fluids. bladder or kidney.
●● Encourage the child to eat as soon as it is possible. Urinary tract infections present with non – specific signs such us:
●● Vomiting
Monitoring
●● Fever
●● Child should be assessed every three hours
●● Irritability
6). VIRAL PNEUMONIA/BRONCHIOLITIS ●● Failure to thrive

Classification Older children

Depends on causative organism commonest causes include: ●● Abdominal pain

●● Respiratory syncytial virus (RSV) and parainfluenza 1, 2 and 3 ●● Pain on passing urine

Management Management

●● Salbutamol nebulization for wheeze Supportive care


●● IV fluids if dehydrated ●● Encourage the child to drink or breastfeed regularly in order to
●● Acyclovir if Varicella pneumonia is suspected maintain a good fluid intake

●● Oseltamivir for influenza A and B ●● Pain should be managed by Paracetamol 10-15mg/Kg/dose


every 6 hours or as necessary
●● Respiratory support if required
●● Oxygen for hypoxaemia severe cases Definitive Treatment

Prevention 1st line


●● Oral Amoxicillin 25 – 45 mg/Kg/day in divided doses every 8
Vaccination hours for 10 days,
●● Influenza for selected cases
●● Oral Cefuroxime 30mg/Kg/day in divided doses every 12 hours
●● Measles for 10 days, depending on culture and sensitivity.
●● Varicella Repeat urine culture 10 days after completion of antibiotic course
Refer all patients with a second episode UTI to a paediatrician
for further evaluation and management

84 85
2). MINOR PENILE INFLAMMATION ●● Streptococci (including Group A), staphylococci, and gram
negative organism are most often responsible
Description
Management
Minor redness or soreness of the tip of the foreskin is very
●● Swabbing the discharge is unhelpful because the normal
common.
foreskin is usually colonised with multiple organisms.
●● Contributing factors include: irritation from wet soiled nappies,
●● Most cases respond to oral antibiotics (Amoxicillin 15 mg/Kg/
inappropriate attempts at retracting the foreskin for cleansing,
dose 8hourly).
bubble bath, soap residue etc.
●● Analgesia( Paracetamol 10-15mg/Kg/dose 8 hourly) is indicated
Management
●● Sitting in a warm bath may ease dysuria.
●● Avoiding these factors, reassurance, and application of a napkin
●● Significant recurrent balanitis may be an indication for
barrier cream to the tip of the foreskin will help.
circumcision and thus should be referred to the surgeons.

3). BALANITIS 4). ACUTE URINE RETENTION


Description
Clinical presentation
A severe inflammation of the glans penis foreskin often due to
Urinary retention of acute onset characterized by lower abdominal
infection. pain and hesitancy and incomplete voiding for several days before
presentation
Management
●● Soaking in a warm bath with the foreskin retracted (if retractile Treatment:
and not too painful) will help with cleaning and urination may ●● Control pain and consult Paediatric surgical urologist
be easier in the bath.
●● Do suprapubic aspiration to relieve bladder pressure
Candida infection ●● Urine to be sent for urinalysis and culture and antibiotic
●● Candida infection may be responsible in some infants. treatment initiated if indicated
●● It is usually associated with more generalised napkin candidiasis ●● Once acute retention is relieved, underlying problem should be
and the presence of satellite lesions. appropriately evaluated.
●● Topical anti yeast creams like Nystatin, Clotrimazole,
5). ZIPPER INJURY
Miconazole) are indicated.
The tip of the foreskin or other skin like scrotal skin may become
Bacterial Infection
entrapped in the teeth of a zipper. This is painful.
●● If there is significant cellulitis of the whole of the foreskin or
the skin of the penile shaft then bacterial infection is likely and Management
antibiotics should be given ●● Prior to these procedures, adequate analgesia with or without
●● Pain and swelling sometimes produce marked dysuria sedation should be given.

86 87
●● Local infiltration may be necessary (never use local anaesthetic 6). PHIMOSIS
agents with adrenaline on the penis).

If trapped between teeth below the slider: Description


●● Cutting the median bar of the zipper with wire cutters. The ●● True Phimosis is when scar tissue is present in the distal
median bar is the part at the top of the slider which joins the foreskin and this prevents retraction
front and back plates of the slider. Once cut, the slider falls off ●● Non-retractile foreskin is a normal variation
and the zipper can be separated
●● It may result from attempts to forcibly retract the foreskin
●● Cutting through the material either side of the zipper below before it has become naturally retractile
the entrapped skin and then cutting across the zipper with wire
cutters/strong scissors. Then the zipper can then be separated Indicators of true Phimosis (rather than simple non-retractile
from below. foreskin)
●● Foreskin not retractile by the time of established puberty.
●● Previously retractile foreskin becomes non-retractile
●● Obvious ring of scar tissue visible at foreskin opening
●● Inability to visualise urethral meatus when foreskin opening is
lifted away from glans
●● Ballooning of foreskin on micturition, with pinhole foreskin
opening, and very narrow urinary stream. (Minor ballooning may
occur in normal non-retractile foreskin).

Management
Refer to the Paediatric surgeons

7). PARAPHIMOSIS

Description
Diagram 2.
●● This occurs when the foreskin is left in the retracted position.
If trapped between slider and teeth of zipper: ●● The glans and the foreskin distal to the tight area become
●● Liberal application of topical anaesthetic cream, then ease slider oedematous.
down ●● Pain and swelling make it difficult to return the foreskin to the
●● Always check for injury to urethral meatus. non-retracted position

Management
●● Adequate analgesia with or without sedation should be given
then referral to the Paediatric surgeons

88 89
●● Surgical options include needle puncture to release oedema ●● Henoch Schonlein purpura. Check urinalysis and blood pressure.
fluid or incision of the tight band of the foreskin These children need close paediatric surveillance as abdominal
●● Once reduced, a single episode of Paraphimosis is not an pathology can be quite severe acutely and nephritis may
indication for circumcision develop in the convalescent period

8). ACUTE SCROTAL PAIN

Description
●● A condition characterized by abrupt onset of scrotal pain
●● Any acute scrotal swelling requires immediate surgical
assessment for torsion of the testis or strangulated inguinal
hernia, which are surgical emergencies.

Management
Early surgical consultation is vital, as delay in scrotal exploration
and detorsion of a torted testis will result in testicular infarction
within 8-12 hours. Keep the child fasted.

Specific management of other causes depends on the diagnosis:


●● Suspected torsion of the appendix testis usually requires
surgical exploration.
●● Incarcerated inguinal hernia must be reduced or the contents of
the hernia may become gangrenous.
●● Epididymoorchitis should be managed with antibiotics
once a suitable urine sample has been sent. Young infants
or systemically unwell children should be admitted for IV
antibiotics (e.g. amoxicillin and gentamicin). Adolescents with
epididymoorchitis should have a first-pass urine sample (ideally
first morning urine) for chlamydia and gonococcus.
●● Idiopathic scrotal oedema usually resolves spontaneously over a
couple of days. No intervention is required
●● Hydroceles will often resorb and the tunica vaginalis close
spontaneously in the first year. If still present at 2 years,
surgical referral should be made for consideration of repair

90 91
8. CENTRAL NERVOUS SYSTEM DISORDERS ●● If the seizures do not recur, a maintenance dose of 3- 9 mg /Kg
divided into two equal doses should be given 12- 24 hours later

1). STATUS EPILEPTICUS Important


Serum phenytoin and Phenobarbital levels should be monitored
Description
Epileptic seizure longer than 30 minutes or absence of full recovery If seizures persist (refractory status):
of consciousness between seizures. ●● Admit to ICU for paralysis, sedation and ventilation

Management 2). FEBRILE CONVULSIONS


General measures
Description
●● Manage airway, breathing and circulation (ABCs). Monitor pulse
oximetry, blood pressure, and temperature. Give Oxygen. Seizure occurring with fever in children aged between the ages of
Intubate and ventilate if hypoventilation, hypoxia and/or 6months and 5years without evidence of other underlying cause.
hypercarbia occur or if aspiration is a concern ●● Simple febrile seizure - single episode in 24 hours, lasting less
●● Observe and confirm the fit is Status Epilepticus than 15 minutes and generalized tonic-clonic activity

●● Pursue available drug history ●● Complex febrile seizure - multiple episodes in 24 hours with
localizing signs and lasting more than 15 minutes.
●● Establish intravenous or intra osseous line
●● Obtain blood samples for initial laboratory studies Management
Medical management General management
Start with Supportive care
●● Iv diazepam 0.3mg/Kg over 1 minute, or rectal diazepam ●● If seizure ended with recovery of consciousness, determine the
0.5mg/Kg. A maximum of three doses at 15 minute intervals or source of the fever and treat appropriately
●● Lorazepam : 0.05-0.1 mg/Kg IV at 2 mg/min to a maximum of ●● Expose to lower temperature in conjunction with antipyretic use
4 mg. May repeat q 10 min X 2. ●● If seizure continues apply supportive measures with laying
on side, protecting from injury, maintaining airway, low flow
If this fails
Oxygen
●● Phenobarbital loading dose of 15 – 20 mg/Kg or in neonates, 20
– 30 mg/Kg IV over 10 – 30 minutes
Medication management
●● With control of seizures, maintenance dose is 3- 5 mg/Kg/24
●● Rectal or oral Paracetamol for fever 10-15 mg/Kg/4hours or
hours divided into 2 equal doses
●● Ibuprofen 10 mg/Kg/6hours
If not effective, ●● Anticonvulsants rarely indicated. See topic Status Epilepticus for
●● Phenytoin loading dose.15 – 30 mg/Kg IV at a rate of 1mg/Kg/ treatment of prolonged seizures
min
92 93
3). BACTERIAL MENINGITIS should be given for two days, one to two hours before initiation of
antibiotics
Description
Supportive care
An Inflammation in response to bacterial infection of the pia
●● Manage airway, breathing and circulation (ABCs). Monitor pulse
arachnoid and its fluid and the fluid of the ventricles. Meningitis is
oximetry, blood pressure, and temperature.
always cerebrospinal
●● Daily neurological assessment, laboratory investigation Urea,
Management electrolytes, Creatinine, Calcium, magnesium, HCO3, urine
output, specific gravity, Haemogram, coagulation profile,
General measures
●● Closely monitor the hydration state and serum Sodium levels.
●● Inpatient often admitted in ICU Restrict IV fluids to between half and two-thirds maintenance or
●● If diagnosis is suspected, lumbar puncture should be done 800 – 1000 mL per M2 per 24 hours only if SIADH is confirmed.
immediately with antimicrobial therapy being begun empirically Revert to normal fluid allowances when serum Sodium level is
●● If signs of increased intra-cranial pressure (altered level of normal.
consciousness, bradycardia, Hypertension) or focal neurological
Complications
findings present, antibiotics to started without lumbar puncture
●● If in shock, aggressive treatment indicated
●● Increased ICP should be treated simultaneously (IV Mannitol,
Hyperventilation) ●● Features of raised ICP Intubate , hyperventilate, give IV
furosemide at 1mg/Kg or manitol 0.5 – 1g/Kg
●● Antibiotic choice for empirical therapy is determined by
susceptibility to streptococcus pneumonia ●● In case of seizures – manage as appropriate

Uncomplicated Meningitis Repeat LP in:


●● Gram negative bacillary meningitis in neonates,
Empirical therapy
●● Beta lactams resisitant s.pneumo infection
●● Ceftriaxone 100mg/Kg/24 hours OD or divided into two doses
for 10 -14 days ●● Gram negative bacillary meningitis should be treated for 21
days or two weeks after CSF sterilization
●● Or cefotaxime 200mg/Kg/24 hours in four divided doses

If not sensitive to beta lactams, use


4). COMA

●● Chloramphenicol 100mg/Kg/24 hours QID for 10 – 14 days A state of altered consciousness from which a person cannot be
aroused. It is reliably graded using the Glasgow coma scale.
In infants 1-2 months old, with suspected listeria infection:
1. Coma is a symptom, not a diagnosis
●● Ampicillin 200mg/Kg/24 hours given QID with ceftriaxone or
2. The aim of immediate management is to minimize any ongoing
cefotaxime
neurological damage whilst making a definitive diagnosis
●● IV cotrimoxazole is an alternative
3. Elements of the history, examination, investigation and
In all cases Dexamethasone 0.15mg/Kg/dose every six hours treatment will therefore occur simultaneously

94 95
●● The aim of immediate management is to minimise any ongoing of manifestations of the motor disorder and various associated
neurological damage whilst making a definitive diagnosis. problems.
●● Elements of the history, examination, investigation and *Cerebral palsy is not a single disorder but a group of disorders
treatment will therefore occur simultaneously. with diverse implications for children and their families.
Immediate management Management
●● Attend to airway, breathing and circulation – (see Resuscitation Management involves a team approach with health professionals
guidelines). and teachers. Input from the family is important.
●● If traumatic cause is possible immobilize cervical spine and 1. Accurate diagnosis and genetic counselling.
arrange urgent neurosurgery involvement
Establish the cause of cerebral palsy if possible. Table 17
●● Insert IV line
History of pregnancy, birth and neonatal period, along with physical
●● Perform blood glucose; if Glucometer Glucose < 2.5 mmol/L examination.
in a non-diabetic, send specific bloods tests and administer IV
Cause clear, No further investigation
10%dextrose 10mL/Kg stat
●● For example, massive antepartum
●● Consider Naloxone 0.1mg/Kg (maximum 2mg) IV can be haemorrhage followed by
neonatal encephalopathy:
repeated
●● Assess and monitor pulse, respiratory rate, BP, temperature, ●● Cause not clear: Urine / plasma metabolic screen
oximetry ± ECG monitoring and conscious state. Consider congenital infections
Chromosomal analysis
●● Look carefully for subtle signs of a continuing convulsion . Radiological investigation - MRI
●● Vascular lesion
Ongoing care ●● Malformation
●● Periventricular leucomalacia
●● Will be determined by the diagnosis, level of consiousness and 2. Management of the associated disabilities, health problems
degree of ventilatory and circulatory support needed and consequences of the motor disorder
●● See specific guidelines if diagnosis becomes clear.
Associated disabilities
Consider Lumbar puncture, imaging and antibiotics. ●● All children require hearing and visual assessments

5). CEREBRAL PALSY ●● Assess and review anticonvulsants for epilepsy


●● Formal cognitive assessment is beneficial. Children often need
Description help with their educational program
Cerebral palsy is a persistent but not unchanging disorder of
Health problems
movement and posture due to a defect or lesion of the developing
brain. It is accepted that children up to five years, who acquire ●● Monitor growth and provide dietary advice. Failure to thrive is
permanent motor impairment due to non-progressive neurological frequent. Consider nasogastric or gastrostomy feeds if there
insults, have cerebral palsy. There are many causes, a wide range is difficulty in achieving satisfactory weight gains, or there are
major feeding problems. Obesity interferes with progress in
motor skills
96 97
●● Gastro-oesophageal reflux can result in oesophagitis or •• The ankle. Equinus deformity is the commonest orthopaedic
gastritis, causing pain, poor appetite and aspiration. problem in children with cerebral palsy. Toe walking is
●● Constipation treated conservatively in young children with orthoses,
inhibitory casts, and Botulinum toxin A therapy. Older
●● Some children with severe cerebral palsy develop chronic lung
children benefit from surgery.
disease, due to aspiration from oromotor dysfunction or severe
gastro-oesophageal reflux. Coughing or choking during meal •• Children may require multi-level surgery (for example, hip,
times or wheeze during or after meals may signal aspiration. It knee and ankle), usually between 8 and 12 years. The aims
can also occur silently. of surgery are to correct deformities and to improve both
the appearance and efficiency of walking.
●● Monitor ventriculo-peritoneal shunts
•• A number of procedures are available for the upper limb.
●● Osteoporosis and pathological fractures occur in severe
cerebral palsy •• Correction of scoliosis is sometimes necessary.

●● Monitor dental health ●● Spasticity management aims to improve function, comfort and
care and requires a team approach. Options include:
●● Emotional problems can be responsible for suboptimal
performance either with academic tasks or self care. •• Oral medications, for example, diazepam, dantrolene
sodium and baclofen.
Consequences of the motor disorder •• Inhibitory casts, for example, below knee casts increase
●● Drooling (poor saliva control). Speech therapists assist with joint range and facilitate improved quality of movement.
behavioural approaches. Medication (anticholinergics) and
•• Botulinum toxin A reduces localised spasticity.
surgery may be helpful
•• Intrathecal baclofen is suitable for a small number of
●● Incontinence. Children may be late in achieving bowel
children with severe spasticity and may enhance quality of
and bladder control because of cognitive deficits or lack of
life.
opportunity to access toileting facilities because of physical
disability or inability to communicate. Some children have •• Selective dorsal rhizotomy is a neurosurgical procedure
detrusor overactivity causing urgency, frequency and whereby anterior spinal roots are sectioned to reduce
incontinence. spasticity.
●● Orthopaedic problems. Contractures may develop and require 3. Assessment of the child’s capabilities and referral to the
orthopaedic intervention. Surgery is more commonly undertaken Gertrudes Child Development Center (CDC)
on the lower limb. 4. Common presentations to the Emergency Department
•• The hip. Non-walkers and those partially ambulant are at ●● Respiratory problems particularly pneumonia
risk for hip subluxation and dislocation. Perform hip Xrays
●● Uncontrolled seizures / status epilepticus
at yearly intervals. Refer children to an orthopaedic surgeon
if there is evidence of subluxation or dislocation. Ambulant ●● Unexplained irritability – consider acute infections,
children occasionally develop hip problems. oesophagitis, dental disease, hip subluxation, pathological
•• The knee. Flexion contractures at the knee may require fracture. Review medications.
hamstring surgery.

98 99
9. CARDIOVASCULAR DISEASE allowed to ambulate as soon as signs of acute inflammation have
subsided
Antibiotic therapy: Once diagnosis is established and regardless of
1). RHEUMATIC FEVER
throat culture results, the patient should receive:
Description ●● Oral Penicillin V 7.5 – 15mg/Kg/dose PO 6hourly or
Erythromycin 10mg/Kg 6hourly for 10 days. Or
●● The diagnosis of acute rheumatic fever can be established by
the Jones criteria. ●● Single IM injection of Benzathine Penicillin
After this initial course, long-term antibiotic prophylaxis should be
Modified Jones Criteria for Rheumatic Fever
initiated.
Major Criteria
The regimen of choice for secondary prevention:
○○ Migratory polyarthritis
●● IM Benzathine penicillin G every 3-4 weeks. Or
○○ Carditis
○○ Subcutaneous nodules In compliant patients:
●● Penicillin V 7.5 – 15mg/Kg/dose PO 12 hourly Or
○○ Erythema marginatum
●● Sulfadiazine 500-1000mg OD or
○○ Sydenham’s chorea
●● Erythromycin 10mg/Kg 12 hourly
Minor Criteria
●● Patients who did not have carditis with their initial episode of
○○ Fever acute rheumatic fever have a relatively low risk of recurrences.
○○ Arthralgia (only if no arthritis) ●● Antibiotic prophylaxis may be discontinued in these patients
○○ High ESR, High WBC, High CRP when they reach their early 20s and after at least 5 years have
○○ Abdominal pain, Epistaxis elapsed since their last episode of acute rheumatic fever.

○○ First degree heart block ●● The decision to discontinue prophylactic antibiotics should be
made only after careful consideration of potential risks and
●● Two major criteria or one major and two minor criteria and benefits and of epidemiological factors such as the risk of
evidence of streptococcal infection (High ASO Titre), meets the exposure to group A streptococcal infections
absolute requirement
●● Chorea may occur as the only manifestation. Anti-inflammatory therapy:

●● Indolent carditis may be the only manifestation in patients who ●● Should be withheld if arthritis or atypical arthritis is the only
first come to medical attention months after the onset of acute clinical manifestation – premature treatment interferes with
development of characteristic migratory polyarthritis and
rheumatic fever.
obscures diagnosis.
Management ●● Patients with typical migratory polyarthritis and those with
All patients with acute rheumatic fever should be placed on bed carditis without cardiomegaly or CCF should be treated with
rest and monitored closely for evidence of carditis. They can be oral Salicylates: Aspirin 100mg/Kg/24hrs divided qid PO for 3-5
days, followed by 75mg/Kg/24hrs divided qid PO for 4 weeks.
100 101
●● Patients with carditis and cardiomegaly or CCF should receive 3). CONGESTIVE HEART FAILURE
corticosteroids: Prednisone 2mg/Kg/24hrs in 4 divided doses
for 2-3 wks followed by a tapering of the dose that reduces Description
the dose by 5mg/24hrs every 2-3 days. At the beginning of
As the demands on the heart outstrip the normal range of
the tapering of the dose, aspirin should be started at 75mg/
physiologic compensatory mechanisms, signs of CHF occur. These
Kg/24hrs in 4 divided doses for 6 weeks
signs include: tachycardia; venous congestion; high catecholamine
●● Supportive therapies in mod-severe carditis include Digoxin, levels; and, ultimately, insufficient cardiac output.
fluid and salt restriction, diuretics and Oxygen.
Specific treatment
Termination of anti-inflammatory therapy may be followed
by reappearance of clinical manifestations or of laboratory Acute CHF in the neonate or infant - The evaluation and treatment
abnormalities. These ‘rebounds’ are best left untreated unless of these patients should be in the neonatal or pediatric intensive
care unit.
clinical manifestations are severe.
Acute CHF in the older child - Intensive care for diuresis with IV
Chorea: Anti-inflammatory agents not indicated if it is an isolated
Frusemide and IV dopamine infusion at a rate of 5-10 mcg/Kg/
manifestation. Sedatives are helpful early in the course of chorea.
min are appropriate until stabilization is achieved. Older children
●● Haloperidol 0.01-0.03mg/Kg/24 hrs divided BD PO may require the placement of a central venous catheter to monitor
venous pressure and cardiac output during stabilization.
2). INFECTIVE ENDOCARDITIS
To note:
Description ●● Supplemental potassium chloride may be required when high
●● Is often a complication of congenital or rheumatic heart disease doses of diuretics are used.
but can also occur in children without any abnormal valves or ●● Because ACE inhibitors cause potassium retention,
cardiac malformations. Spironolactone and supplemental potassium should be avoided
●● Viridans-type streptococci (α-hemolytic streptococci) and except in the presence of documented hypokalaemia in patients
Staphylococcus aureus are the leading causative organisms. taking these medications.
●● Sodium supplementation is almost never indicated in infants
Management
or children with CHF except in emergency situations. Severe
●● Specific antibiotic therapy guided by culture and sensitivity or hyponatraemia is generally best managed by reducing the dose
●● If culture results are negative, empirical therapy with antibiotics of diuretics or by restricting fluid intake, although the latter has
to cover common causative organisms – use Benzyl Penicillin little utility in small children
and Gentamicin.
Supportive care
●● Nutrition is crucial in the management of chronic CHF. Enhanced
caloric content feedings and, in some cases, nasogastric
or gastrostomy feedings may be necessary to maintain the
patient's growth.

102 103
Table 18 ●● Anemia aggravates CHF. Careful attention to iron stores or the
Agent Pediatric Dose Comment administration of red cell transfusions results in a significant
Preload reduction improvement. The success of medical therapy of CHF in infants
Frusemide 1 mg/Kg/dose PO or IV May increase to 6hrly
and small children is judged according to the child's growth.
A failure to thrive is an indication for increased medical
Hydrochlorthiazide 2mg/Kg/d PO in 2 divided May increase to 6hrly
doses management or, when the option exists, surgical repair of
Metolazone 0.2 mg/Kg/dose PO Used with loop diuretic, may structural heart disease
increase to bid
Inotropic 4). HYPERTENSION
Digoxin Loading Dose ●● For IV use 75% of the oral
●● Preterm infants<1.5Kg: dose Description
0.025mg/Kg/d PO in 2 ●● Maintenance dose: 20 – ●● Hypertension is defined as systolic or diastolic systemic arterial
divided doses 25% of the Loading dose
●● Preterm infants 1.5- given once a day blood pressure above normal for age
2.5Kg: 0.03mg/Kg PO ●● Note: BP measurements repeated on several different occasions
in 2 divided doses
●● Term Neonates to are required to diagnose hypertension. Formula for calculating
2years: 0.045mg/Kg PO BP is found in the appendix
in 1 or 2 divided doses
●● Child age 2 to 5years: .
0.035mg/Kg PO in 1 or
2 divided doses Management
●● Child age 5 to 10years:
0.025mg/Kg PO in 1 or Hypertension in children is usually secondary. Look for the cause
2doses
Asymptomatic hypertension
Dopamine 5-28 mcg/Kg/min IV Gradually titrate upward to ●● No treatment required acutely. Investigate and manage as out-
desired effect
patient.
Dobutamine 5-28 mcg/Kg/min IV Gradually titrate upward to
desired effect Acute severe hypertension
Amrinone 5-10 mcg/Kg/min IV Load: 1 mg/Kg IV over 2-3
min
●● These patients require admission to HDU for urgent treatment.
Milrinone 0.5-1 mcg/Kg/min IV Load: 50 mcg/Kg IV slowly ●● Hypertensive encephalopathy presents as severe headache,
over 15 min visual disturbance and vomiting, progressing to focal
Afterload reduction neurological deficits, seizures and impaired conscious
state, with grossly elevated BP, papilloedema and retinal
Captopril 0.1-0.5 mg/Kg/d PO -
divided q8h
haemorrhages
Enalapril 0.1 mg/Kg/d PO divided Adults: 2.5-5 mg/d PO qd-bid, ●● These patients almost always have chronic renal disease and are
qd/bid, not to exceed 0.5 not to exceed 40 mg/d on dialysis.
mg/Kg/d
●● The differential diagnosis includes uraemic encephalopathy and
Lisinopril Not established Adults: 10 mg PO qd
metabolic disturbance.
Nitroprusside 0.5-10 mcg/Kg/min IV May need to monitor cyanide
level

104 105
●● BP should be lowered in a controlled fashion, with 10. BURNS
anticonvulsants given for seizures

Antihypertensives First Aid


Choice includes:
●● Inhalational burns – maintain airway and give oxygen
●● Intravenous Hydrallazine:
●● Surface burns, cool the area with running water for 20 minutes
○○ IV Hydrallazine at a dose of 0.15mg/kg (maximum 10mg) but avoid hypothermia (useful up to 3 hours after burn).
diluted in normal saline given over 30 minutes is indicated for
●● Cold water compresses (changed frequently) useful for
severe hypertension Continue with 4 - 6 micrograms/Kg/min
analgesia for localised burns.
(max 300micrograms/min). Hydrallazine is contraindicated in
Systemic Lupus Erythematosus due to the risk of convulsions. ●● Do not apply ice or ice slush
Hydrallazine may cause tachycardia, nausea and fluid retention ●● For chemical and eye burns, irrigate with copious volumes of
●● Intravenous Labetalol: water

○○ 0.2 mg/Kg initially; later 0.4 mg/Kg by slow push every 10min ●● Plastic (cling) wrap useful after cooling (limits evaporation and
up to 3-4mg/Kg (max. 100 mg) total dose. Avoid if there is heat loss)
heart failure, asthma or bradycardia. ●● Burns to the eyes require early copious irrigation with Normal
●● Oral Captopril: Saline or water and ophthalmologic opinion.

○○ 0.1 mg/Kg initially, increasing to a maximum of 1 mg/ Assessment


Kg (max. 50 mg), thereafter 0.1-1.0 mg/Kg/dose 8-hourly.
Captopril is usually effective within 30 - 60 min. Airway and Breathing
●● Assess for presence of stridor, hoarseness, black sputum or
respiratory distress, burnt nasal hairs or facial swelling.
●● Oropharyngeal burns and significant neck burns usually require
immediate intubation even if the airway is not yet compromised;
Admit to ICU early
●● Immobilise cervical spine if associated trauma.

Circulation
●● Early hypovolaemia is rarely related to the burn injury and other
sources of bleeding should be sought.
●● For circumferential burns, check for signs of circulatory
obstruction and the need for an escharotomy; elevate the limb.
●● For electrical burns, monitor ECG continuously. If high voltage
limb burn, early fasciotomy might be required.

106 107
The Lund and Browder Chart Diagram 3. Estimation of Surface Area
●● Use a burn diagram to accurately calculate the burnt surface
area, however do not count skin with isolated erythema (no
blistering)
Date ●● As a rough measure, the child's palm represents about 1% of
Completed by total body surface.
Shallow + Indeterminate = Depth of Burn Table 19
or Deep
Depth Surface/color Pain sensation
Shallow (Pink, Painful,
Moist) Superficial Dry, minor blisters, Painful
erythema, brisk
Indeterminate or Deep
capillary return
(Dry, Less Sensation, white,
Dark red, brown or Black Partial thickness- Moist, reddened with Painful
Leather) superficial broken blisters, brisk
Percenta surface area burned (superficial dermal) capillary return
(berkow formula)
Partial thickness- Moist white slough, Painless
deep red mottled, sluggish
(deep dermal) capillary return

1 1-4 5-9 10 - 14 Y 15 Adult Shallow Indeterminate


Year Years Years Years of deep
Full thickness Dry, charred whitish. Painless
Absent capillary
Head 19 17 13 11 9 7 return
Neck 2 2 2 2 2 2
Ant. Trunk 13 13 13 13 13 13 Management
Post. Trunk 13 13 13 13 13 13
Pain relief
R. Buttock 2.5 2.5 2.5 2.5 2.5 2.5
L. Buttock 2.5 2.5 2.5 2.5 2.5 2.5 ●● Paracetamol and codeine (PO) - 20-30 mg/Kg Paracetamol, 0.5-1
Genitalia 1 1 1 1 1 1 mg/Kg codeine
R.U. Arm 4 4 4 4 4 4
●● Morphine (IV) - 0.1 mg/Kg given in titrated boluses
L.U. Arm 4 4 4 4 4 4
R.L. Arm 3 3 3 3 3 3 ●● Morphine (IM) - 0.2 mg/Kg (useful if anticipated to only need a
L.L. Arm 3 3 3 3 3 3 single dose)
R. Hand 2.5 2.5 2.5 2.5 2.5 2.5
L. Hand 2.5 2.5 2.5 2.5 2.5 2.5 Management of Minor Burns
R. Thigh 5.5 6.5 8 8.5 9 9.5
L. Thigh 5.5 6.5 8 8.5 9 9.5
●● Analgesia should be adequate; children may require morphine
R. Leg 5 5 5.5 6 6.5 7 initially before assessment and initial dressings.
L. Leg 5 5 3.5 6 6.5 7 ●● Immobilisation with sling and splinting is suggested for upper
R. Foot 3.5 3.5 3.5 3.5 3.5 3.5 limb burns as well as early occupational therapy consultation.
L. Foot 3.5 3.5 3.5 3.5 3.5 3.5
Total ●● Check tetanus status

108 109
●● Closed dressings are recommended for partial thickness ●● All burns to face, ears, eyes, hands, feet, genitalia, perineum or
burns. The wound exudate determines the number of dressing a major joint, even if less than 5-10%.
changes. ●● Circumferential burns.
●● The depth of a partial thickness burn may only be declared after ●● Chemical burns.
7-10 days.
●● Electrical burns (including lightening). Extensive tissue damage
Blisters can occur to underlying structures.
●● Have a protective function, and reduce pain if they are left intact ●● Burns associated with significant fractures or other major injury.
for a few days ●● All inhalation burns.
●● If blisters are small, not near a joint and not obstructing the ●● Burns in children under the age of 12 months.
dressing, leave alone
●● Small burns in patients with social problems
●● Large blisters and those overlying a joint should be de-roofed.
●● Opaque blister fluid occurring after a few days suggests Transfer of patients from other hospitals for assessment
infection. The burn should then be de-roofed and dressed. If time from burn to arrival is <6 hours and the burn area is clean:
●● Wash with saline, cover with plastic cling wrap for transfer,
Superficial burns with erythema only:
allowing for easy assessment without undue discomfort from
●● Can be treated by exposure. In infants who show a tendency to removal of dressings.
blister or scratch, a protective, low-adherent dressing with crepe
bandage may be helpful. If transfer is likely >6 hours or burn is dirty:
●● Dirty or charred burns should be washed with aqueous
Partial thickness burns
Chlorhexidene 0.1% and dressed.
●● Cleanse the burn and surrounding surface with saline and pat
●● Clean burns should be dressed with a low-adherent dressing
dry. If treatment is delayed or wound is dirty, use aqueous
Chlorhexidene 0.1% then saline. ●● The patient should receive analgesia and then ideally proceed
without delay to the ward.
●● For small, superficial partial thickness burns, a low adherent
dressing then crepe bandage or adhesive paper. ●● Notify the burns consultant
●● For more extensive or deeper partial thickness burns, a low-
Management of Major Burns
adherent silver sulphadiazine dressing should be applied.
●● Airway and Breathing
Full thickness burns
●● For signs of airway burn or lung injury, arrange intubation as
●● All require admission and early debridement.
soon as possible and before airway swelling occurs.
Burns requiring admission
Fluids
●● Partial thickness (superficial) burns with a surface area greater
●● If >10% of body surface involved, commence burns fluid
than 10%, except very superficial burns.
resuscitation and calculate fluid requirements from the time of
●● All full thickness burns, except those that are extremely small. injury. Preferably insert IV line through uninvolved skin.

110 111
●● Initial fluid resuscitation in first 24 hours 11. INFECTIOUS DISEASES
○○ Lactated Ringers or 0.9% Normal Saline
○○ 4mL/kg/TBSA over 24 hours 1). VIRAL INFECTIONS
○○ Half within first 8 hours. Begin timing from when the burn
occurred. Remainder within the next 16 hours a) Aseptic Meningitis
○○ Add the maintenance fluid requirements if not able to take
orally Description

●● Insert urinary catheter if burn > 15% SA or if significant perineal This is a viral infection of the meninges. The usual cause is acute
burn. and may be relapsing.

●● Insert an NGT if > 10% deep partial thickness or full thickness Management
burns, start feeding within 6-18 hrs ●● Paracetamol 10-15 mg/Kg/dose every 4 – 6hours.
Investigations ●● Antiemetic - Dexamethasone 0.25MG/Kg/6hours and
●● Haemoglobin, electrolytes, blood glucose, blood group and Ondasetron 0.15mg/Kg/6hours may be used
cross match ●● Start empirical IV Acyclovir 500mg/M2/day in 3divided doses
●● Carboxyhaemoglobin and cyanide levels (if fire in confined and a broad spectrum antibiotic with good CSF penetration as
space) you await laboratory results

Document the following: b). Herpes Simplex


●● Time of burn
Description
●● Extent – burns diagram
●● Viral disease usually seen as painful vesicles that often occur in
●● Depth clusters on skin, cornea, or mucous membranes; may occur as
●● First aid encephalitis, pneumonia, or disseminated infection
●● Tetanus status ●● Usual course of primary disease is 2 weeks;

Follow up ●● Newborns or individuals with immune compromise are at risk


for major morbidity or mortality.
●● If a superficial burn has not healed in 7 - 10 days, it has either
become infected or is deeper than anticipated. If in doubt, Management
consult the surgeons
Acyclovir

By mouth
●● 1 month to 2 years 100mg 5 times daily for 5 days
●● Dose doubled if immunocompromised or if absorption is
impaired

112 113
●● 2 – 18 years 200mg 5 times a day for 5 days Nutritional support
●● Assess the nutritional status
Primary herpes Gingivostomatitis, recurrent herpes labialis and
other HSV skin infections: ●● Encourage continued breastfeeding.
●● IV Acyclovir 500mg/M2/day in 3divided doses or ●● Encourage the child to take frequent small meals.
●● 20mg/Kg PO q4h x 5 doses daily for 10 days ●● Check for mouth ulcers and treat them, if present

c). Measles d). Mumps

Description Description
●● An acute epidemic viral exanthem which classically presents ●● Acute generalized paramyxovirus infection usually presenting
as a confluent erythematous maculopapular rash which begins with unilateral or bilateral parotitis.
over the head and spreads inferiorly to involve the trunk and
extremities. Management

●● The rash is preceded by the triad of cough, coryza, and General measures
conjunctivitis plus a pathognomonic enanthem ●● Supportive and symptomatic care
Management ●● Patients with orchitis, need surgical referral, ice packs to
●● Children with severe complicated measles require treatment in scrotum can help relieve pain
hospital. ●● Scrotal support with adhesive bridge while recumbent and/or
athletic supporter while ambulatory
Vitamin A therapy.
●● Use IV fluids if severe nausea or vomiting accompanies
●● Give oral vitamin A once a day for two days, to all children with pancreatitis
measles
○○ 50 000 IU for a child aged <6 months Medication

○○ 100 000 IU 6–11 months ●● Ibuprofen 4-10mg/Kg/6hours for pain and swelling in acute
orchitis and arthritis mumps
○○ 200 000 IU 12 months up to 5 years
●● Paracetamol 10-15mg/Kg/4-6hours for fever and/or pain.
●● If the child shows any eye signs of vitamin A deficiency or is
severely malnourished, a third dose must be given 2–4 weeks 2). FUNGAL INFECTIONS
after the second dose to be given when the child comes for
follow-up.
a). Candidiasis
Supportive care
●● In normal or immunosuppressed children
Fever ●● Superficial infections (oral thrush or ulcerations; vulvovaginitis;
●● If the temperature is ≥39°C, give Paracetamol 10 – 15mg/ Kg PO erythematous intertriginous rash with satellite lesions)
every 4 – 6hours. ●● Fungaemia related to intravascular devices

114 115
●● In immunosuppressed individuals: systemic infections (renal, Systemic Infection
hepatic, splenic, pulmonary, or cerebral abscesses); cotton-wool
First line
retinal lesions; cutaneous nodules
●● Fluconazole loading dose 12mg/Kg followed by 6mg/Kg IV for
●● In either patient population: budding yeast and pseudohyphae
7-14 days
seen in biopsy specimens, fluid, or scrapings of lesions; positive
culture Second line
Management ●● In invasive fungal infection unresponsive to Fluconazole therapy
●● Voriconazole 4mg/Kg/day IV for 7 – 14 days
Oral Candidiasis

First line b). Cryptococcosis


In infants, oral Nystatin suspension 100,000units four to six times
Description
a day in the buccal fold after feeding until resolution. Refer to oral
Candidiasis guidelines ●● Cryptococcus neoformans infection
●● Cryptococcal meningitis is one of the most common AIDS-
Second line defining infections in HIV seropositive persons.
Oral Fluconazole 6 mg/Kg stat then 3mg/Kg/day as a single dose
for 1week Treatment

Discontinuation of antibiotics or corticosteroids is advised when First line


possible. ●● Fluconazole 6mg/day (oral or intravenous) until a total of 8
Cutaneous infection: weeks of primary therapy has been completed

First line Second line

Clotrimazole cream/ointment applied two times a day for 7 – 14 ●● In invasive fungal infection unresponsive to Fluconazole
days therapy:
●● Voriconazole 4mg/Kg/day iv for 7 – 14 days
Second line
Miconazole cream/ointment applied two times a day for 7 – 14 days 3). PARASITIC INFECTIONS,
Associated inflammation, such as severe diaper dermatitis, is also
helped by concurrent use of a topical mild corticosteroid cream, a). Protozoal Infections
such as 1% Hydrocortisone
1. Malaria
Vaginal Infections
Uncomplicated Malaria (non-severe Malaria)
1. Vaginal infection is treated with Clotrimazole, Miconazole,
triazoles, or Nystatin suppositories or creams, applied once Treatment
nightly for 3-7 days
First line treatment
2. Oral azole therapy is equally effective
116 117
●● Treat as out patient ●● Confirmed cases of treatment failure should be treated with the
Artemether/Lumefantrine: Combined tablets (20 mg of 2nd line medications
Artemether and 120 mg of Lumefantrine): Second Line treatment
05–14 Kg 1 tablet two times a day for 3 days; ●● Treat as severe malaria
15–24 Kg 2 tablets two times a day for 3 days SEVERE MALARIA
25 -35 Kg 3 tablets two times a day for 3 days Severe malaria is a medical emergency.
> 34 Kg 4 tablets two times a day for 3 days Description
Notes Common presentations of severe malaria are anemia, respiratory
●● Malaria patients with HIV/AIDS should be managed according to distress and cerebral malaria.
the same regimen above Malaria associated with one or more the following clinical and
●● In children below 5 Kg (under 2 months of age), malaria is not laboratory features should be considered to be severe
a common cause of fever. Evaluation of other causes should ●● Prostration
be undertaken. Where malaria is diagnosed, the recommended ●● Altered level of consciousness
treatment is oral quinine
●● Multiple convulsions
Treatment failure ●● Respiratory distress
●● Treatment failure can be defined as a failure to achieve the
●● Circulatory collapse
desired therapeutic response after the initiation of therapy
●● Pulmonary oedema
●● Development of symptoms 14 days after initiation of therapy
where there has been prior clearance of symptoms should be ●● Jaundice
considered as a new infection and be treated with the first line ●● Abnormal bleeding
drug ●● Laboratory findings:
●● Treatment failures should be suspected if patient deteriorates ○○ Hypoglycaemia (blood glucose < 2.2 mmol/l or < 40 mg/dl)
clinically at any time or
○○ Metabolic acidosis (plasma bicarbonate < 15 mmol/l)
●● Symptoms persist 3-14 days after initiation of drug therapy in
○○ Severe anaemia (Hb < 5 g/dl)
accordance with the recommended treatment regimen.
○○ Haemoglobinuria
●● Malaria microscopy should be used to assess suspected
treatment failures ○○ Hyperparasiteamia (> 1% or 100 000/μL or 3+)
●● Other potential differential diagnosis should be sought for and ○○ Hyperlactataemia (lactate > 5 mmol/l)
adequately managed ○○ Renal impairment
●● In cases of non-adherence with or non completion of medicine, ○○ Haemoglobinuria
repeat a full course of the first line drug

118 119
Management Give parenteral antimalarials in the treatment of severe malaria
Manage complications appropriately for a minimum of 24 h, once started (irrespective of the patient’s
ability to tolerate oral medication earlier), and, thereafter, com-
ANTI-MALARIAL TREATMENT OF SEVERE MALARIA plete treatment by giving a complete course of: Artemether plus
Lumefantrine
IV Quinine or IV Artesunate should be used for the treatment of
severe Malaria. IV Artemether is an alternative only if IV Quinine Second line treatment
and IV Artesunate are not available.
IM Artemether
IV Quinine Artemether administered by the intramuscular route at a loading
Infusion Quinine 15 mg/Kg body weight loading dose in 10 - 20mL/ dose of 3.2 mg/kg start then 1.6 mg/kg/daily for five days.
Kg of 5% dextrose to run over 3 - 4hours. Infusion rate should not Use only if the other alternatives not available due to its poor
exceed 5mg/Kg per hour. 8hours after commencing initial dose, absorption
give 10 mg/Kg of Quinine 12 hourly until patient can take oral
medications(minimum 24hours), and then give a complete course Follow up
of Artemether/Lumefantrine as for non severe Malaria. ●● Monitor haemoglobin levels and give haematinics
●● The preferred route of Quinine administration is the intravenous ●● Monitor and rehabilitate patients with neurological sequelae
route. The intramuscular route can be used as an alternative
where intravenous route is not feasible. In this case the Quinine
Malaria prophylaxis
should be diluted to 1:5 ratio
Mefloquine
Quinine Administration Caution
●● Mefloquine is administered as a weekly dose of 5mg /Kg body
●● Quinine should only be given as an intravenous infusion and
for children below 36 Kg and 250mg for children above 36Kg
NEVER given as an intravenous (bolus) injection.
●● Mefloquine prophylaxis is started 2 – 3 weeks before departure,
●● Loading dose should be omitted if patient have received quinine
throughout the stay and continued for 4 weeks after departure.
in the last 24hr or has received Mefloquine in the last 7 days
●● Dosing schedule using 250 mg tablet Table 20
●● Quinine is not contraindicated in severe anemia
●● In renal insufficiency the dose of quinine remains unchanged WEIGHT AGE No. OF TABLETS

●● In hepatic insufficiency, the dose of quinine should be reduced < 5 Kg or < 3 months Not recommended
by 25%
5 – 12 Kg 3 – 23 months ¼
●● Hypoglycaemia is a potential side effect of quinine

administration
13 – 24 Kg 2 – 7 yrs ½
IV Artesunate 25 – 35 Kg 8 – 10 yrs ¾

Artesunate 2.4 mg/kg body weight IV or IM given on admission
(time = 0), then at 12 h and 24 h, then once a day; 36 and above 11 yrs and above 1

120 121
Proguanil Doxycycline
●● Proguanil is administered at a daily dose of 3mg/Kg beginning Dosing schedule Table 23
two days before travel
●● Continuing daily throughout and then continued for 4 weeks Weight in Kg No. of tablets
after departure. <25 Contraindicated

Dosing schedule 25 – 35 ½ a tablet


Table 21
36 – 50 ¾ a tablet
WEIGHT AGE No. OF TABLETS >50 1 tablet
5 – 8 Kg < 8 Months ¼
Doxycycline should NOT be used in children under 8 years of age
9 – 16 Kg 8 months – 3 years ½
2. Amoebiasis
17 – 24 Kg 4 – 7 yrs ¾
25 – 35 Kg 8 – 10 yrs 1 Description
36 – 50 Kg 11 – 13 yrs 1 1/2 ●● Infection by the protozoon Entamoeba hystolytica.
50 + Kg 14+ yrs 2 Characterized either one or some or all of
●● Acute dysentery: diarrhea with blood and mucus, abdominal
Atovaquone – Proguanil
pain, tenesmus
●● Atovaquone – Proguanil is administered as a daily dose
●● Chronic nondysenteric diarrhea.
commencing 1 day before departure to a malaria endemic area,
throughout the stay and continuing 7 days after leaving. ●● Hepatic abscess
Paediatric tablet of 62.5 mg Atovaquone and 25 mg Proguanil ●● Laboratory detection
Table 22 ○○ Amoebas or cysts in stool or abscesses
WEIGHT (Kg) TABLETS STRENGTH
○○ Amoebic antigen in stool
<11 - Not recommended
○○ Serologic evidence of amoebic infection.
11 – 20 1 62.5 mg A + 25 mg P
21 – 30 2 125 mg A + 50 mg P Can present as
31 – 40 3 187.5 mg A + 75 mg P ●● Intestinal Amoebiasis
●● Extraintestinal Amoebiasis
The drug should be taken with food or milk at the same time
each day.
Management
●● Oral Metronidazole 7.5mg/Kg combined with Diloxanide furoate
three times a day for 5 days only if stool microscopy reveals
trophozoites of Entamoeba hystolytica

122 123
3. Giardiasis ●● Sodium antimony gluconate 20mg/Kg IM or IV once daily
maximum 850mg for 20days
Description
Infection by the protozoa Giardia lamblia characterized by: Second line

●● Chronic relapsing diarrhea, flatulence, bloating, anorexia, poor ●● Amphotericin B IV: 0.5-1 mg/Kg on alternate days or
weight gain. ●● Pentamidine 3-4 mg/Kg IV over 2hours or deep IM, daily for 10
●● Absence of fever and haematochezia. – 14days

●● Detection of trophozoites, cysts, or Giardia antigens in stool. 6. Cryptosporidiosis

Treatment Description

If cysts or trophozoites of Giardia lamblia are seen in the faeces, Infection by the protozoon Cryptosporidium parvum. It is
characterized by:
●● Oral Metronidazole 1 – 3yr 5mg/Kg OD, 4 – 7yr 6 – 8 mg/Kg
OD, Immunocompetent persons:
●● 7 – 10yr 1g OD all for 3days ●● Self-limited diarrhea with or without abdominal cramps
●● Nitazoxanide 100mg 1 – 4yr 12hourly, 4 – 11yr 200mg ●● Low-grade fever, nausea, vomiting, loss of appetite, and malaise
12hourly, above 12yr 500mg 12hourly all for 3days)
Immunocompromised patients
4. Trichomoniasis
●● Prolonged disease
Treatment ●● Cholecystitis, pancreatitis, hepatitis, and respiratory symptoms.
First line ●● Subsides only after the immunodeficiency is corrected.
Metronidazole as for Amoebiasis Management
5. Leishmaniasis
Treatment & Prevention
Description
Immunocompetent patients:
An infective condition caused by several species of the protozoan
●● Antidiarrheal agents and hydration.
Leishmania. Can present as either:
●● Visceral Leishmaniasis Immunocompromised patients:
●● Cutaneous leishmaniasis ●● Parenteral nutrition in addition to hydration and nonspecific
antidiarrheal agents
●● Mucocutaneous leishmaniasis
●● Nitazoxanide 100mg 1 – 4yr 12hourly, 4 – 11yr 200mg
●● Diffuse cutaneous leishmaniasis
12hourly, above 12yr 500mg 12hourly all for 3days)
Treatment ●● For patients with AIDS, institution of effective antiretroviral
therapy eliminates symptomatic cryptosporidiosis
First line

124 125
B). Nematode Infections ●● Pyrantel Palmoate (a single dose of 11 mg/Kg, maximum 1 g),
3. Trichuriasis (Whipworm)
1. Enterobiasis (Pinworms)
Description
Helminth infection by pinworms (enterobius vermicularis), often
characterized by: A helminthic infection by the whipworm (Trichuris trichura),
●● Anal pruritus characterized by:

●● Worms in the stool or eggs on perianal skin ●● Symptoms are not present unless the infection is severe:
●● Pain,
Management
●● Diarrhea, and mild abdominal distention
●● Give treatment to all household members at the same time to
prevent re-infections ●● Massive infections may also cause rectal prolapse and dysentery

●● Therapy should be repeated after 2 weeks to kill the recently Management


hatched adults. ●● Albendazole (400 mg in a single dose) or
First line therapy ●● Mebendazole (100 mg orally twice daily for 3 days) or
●● Pyrantel Palmoate as a single dose of 11 mg/Kg, maximum 1 g 4. Hookworm

Second line Description


●● Mebendazole, a single oral dose of 100 mg or Helminthic hookworm infection often associated with:
●● Albendazole a single oral dose of 400 mg ●● Iron deficiency anemia
●● Abdominal discomfort, weight loss
General Measures
Personal hygiene must be emphasized. Nails should be kept ●● Ova in the feces
short and clean. Children should wear undergarments to bed to Management
diminish contamination of fingers; bedclothes should be laundered
●● Mebendazole (100 mg orally twice daily for 3 days) or
frequently.
●● Pyrantel Palmoate (11 mg/Kg, maximum 1 g, daily for 3 days)
2. Ascariasis
are the drugs of choice
A helminthic infection by the worm ascaris lumbicoides
●● Albendazole is useful for creeping eruption
(roundworms), often characterized by:
5. Strongyloidiasis
●● Abdominal cramps and discomfort
●● Large, white or reddish, round worms or ova in the feces. Description
Helminthic infection by the worm strongyloides stercolaris
Management
●● Albendazole (400 mg in a single dose) or
●● Mebendazole (100 mg twice daily for 3 days), or

126 127
Management Management

First line ●● Definitive therapy of E multilocularis requires meticulous


surgical removal of the cysts
●● Ivermectin (200 mg/Kg/d for 1 or 2 days)
●● This is preceded by careful injection of the cyst with formalin,
●● In the hyperinfection syndrome, 2-3 weeks of therapy may be
iodine, or 95% alcohol solution to sterilize infectious
necessary
protoscoleces
6. Trichinosis
●● Freezing the cyst wall and injecting silver nitrate prior to
Infection by Trichinella spiralis, removal is another technique

Management Medication
●● Mebendazole at a dose of 200-400 mg three times daily for 3 ●● Albendazole (15 mg/Kg/d for 28 days with repeat courses as
days followed by 400-500 mg three times daily for 10 days. necessary following a 14-day rest period)

●● Concurrent corticosteroids to prevent the Herxheimer reaction ●● If the cyst leaks or ruptures, the allergic symptoms must be
associated with treatment managed immediately

7. Taeniasis C). Trematode Infections


Description 1. Schistosomiasis
Taeniasis is caused by infection by either the beef tapeworm
(Taenia saginata) or the pork tapeworm (Taenia solium) Description
Schistosomiasis, is caused by several species of Schistosoma flukes
Management
Praziquantel (5-10 mg/Kg once) is the drug of choice. Management

8. Cysticercosis ●● Praziquantel at a dosage of 40 mg/Kg/d in two divided doses (S


mansoni or S haematobium) or
●● Specific treatment is reserved for patients with meningitis or
parenchymal cysts ●● 20mg/Kg three times in 1 day (S japonicum or S mekongi) or

●● Those with inactive disease require only symptomatic treatment Oxamniquine (20mg/Kg/d in two doses once per day) is an
(anticonvulsants) Albendazole (15 mg/Kg divided into three alternative regimen for treatment of S mansoni infection
doses daily for 8 days) cause disappearance of cysts.
●● A short course of Dexamethasone 0.15mg/Kg/6hours to
manage inflammatory edema due to larval death
9. Echinococcosis

Infection due to Echinococcus granulosus

128 129
12. NEONATOLOGY 3). NEONATAL JAUNDICE
1. Classification
1). NEONATAL SEPSIS ●● Indirect or unconjugated hyperbilirubinaemia – direct
Management component <35µmol/L or <15%of the total serum bilirubin. May
be physiologic or pathologic
Systemic infection in a child aged ≤60days. All neonates with
neonatal sepsis need admission ●● Direct or conjugated hyperbilirubinaemia – direct bilirubin ≥15%
of the total serum bilirubin. It is nearly always pathologic
Supportive
2. Goals of assessment
●● Ensure hydration/ electrolyte balance
●● Identify sepsis and dangerous obstructive causes
●● Thermal – neutral environment
●● Differentiate conjugated form unconjugated hyperbilirubinaemia
●● Ensure nutrition (parenteral if indicated)
●● Initiate diagnostic testing to determine the possible causes
●● Isolate/barrier nursing
3. Physiological jaundice.
Definitive Management ●● Jaundice is very commonly noted in the first 2 weeks of life. It is
1st line part of a normal physiological process.
●● Benzyl penicillin 50,000 IU/Kg/dose every 12 hours plus ●● Mild jaundice with onset after 24 hours of life and which is
Gentamicin 5mg/Kg once daily fading by 14 days needs no investigation or treatment.
4. Conjugated hyperbilirubinaemia
2nd line
●● Must be excluded as the causes of this pattern need urgent
●● 3rd generation cephalosporins; ceftazidime or ceftriaxone as
evaluation and treatment.
guided by culture and sensitivity
●● Surgery for biliary atresia is most successful when the condition
2). OPHTHALMIA NEONATORUM is diagnosed and treated early.
●● Ask about the colour of urine and stools. View a dirty nappy
Features: Purulent eye discharge in a neonate yourself if possible
Management: ●● Phototherapy has no role in the management of conjugated
●● Pus swab for microscopy, culture and sensitivity hyperbilirubinaemia

●● Wash with warm saline swabs 5. Treatment of unconjugated hyperbilirubinaemia -


Phototherapy or rarely exchange transfusion
●● Antibiotics: IM Ceftriaxone 30-50 mg/Kg stat. Add Erythromycin
50mg/kg/day, in 4 divided doses for 14 days (Ceftriaxone is not ●● The aim of treatment is to prevent neurological complications
to be used in preterm babies) ●● Sunlight exposure has no proven benefit and should not be
encouraged as it may delay diagnosis and treatment
●● May be necessary in a baby with severe unconjugated jaundice

130 131
associated with prematurity, haemolytic disease, or rare ●● Avoid excessive stimulation - noise, light, and handling.
disorders such as Crigler-Najjar. Excessive quiet should also be avoided. Most babies find a low
●● Outside these conditions unconjugated jaundice is unlikely to level of Background noise soothing
lead to CNS or hearing problems, and no treatment is usually ●● Carry baby in a papoose in front of the chest
necessary ●● Baby massage / rocking / patting
American academy of paediatrics recommendations for photo-
●● Play gentle music
therapy and exchnage transfusion for unconjugated hyeprbiliru-
binaemia Table 24 ●● Respond before baby is too worked up
●● Have somebody else care for the baby for brief periods to give
Age (hours) Phototherapy (µmol/L) Exchange Transfusion
(µmol/L) the parents a break
24 205 325 Notes
48 256 376 Medication is rarely indicated. COLIC MIXTURES ARE OF NO PROVEN
72 308 410 BENEFIT
>96 342 427 Formula changes are usually not helpful unless there is proven
Follow up mild to case in the OPD with monitoring of bilirubin cow’s milk allergy or lactose intolerance.
levels Weaning from breast milk has no benefit.

4). CRYING BABY – INFANT DISTRESS Provide printed information if possible, as parents are unlikely to
remember much given their state of mind at the time.
●● Excessive crying (colic) is defined as >3 hours/day for >3 days/
week. However many babies are presented with lesser amounts 5). NEONATAL FEEDING
of crying, as the parents perceive it as excessive
Positive fluid balance in the first few postnatal days is unnecessary
●● Infants with "colic" are well and thriving. There is usually no and is associated with more severe RDS and higher risk of
identifiable medical problem. The parents are often distressed, PDA, congestive heart failure, pulmonary oedema, necrotising
exhausted, and confused, having received conflicting advice enterocolitis and chronic lung disease (BPD). Term newborns have a
from various health professionals and lay sources urine output of 1mL/Kg/hour for the first few days of life.
Management Feeding should start at 60-100mL/Kg/day depending on the
The parents require careful explanation and reassurance that their maturity and respiratory status. This should increase gradually and
infant is not unwell or in pain, and that the unsettled behaviour as the baby’s fluid input and output are monitored. As a guideline,
will improve with time. At the same time they need empathic use the table below
acknowledgement of their anxiety and stress, and ongoing support
from within and outside the family.

Suggestions that may be helpful include:


●● Establish pattern to feeding/settling

132 133
Nasogastric 3 hourly feed volumes for babies on full volume 13. EYE DISORDERS
feeds Table 25

1). ACUTE EYE INJURIES IN CHILDREN


Weight (Kg)

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0
The following traumatic conditions threaten vision:
●● Ruptured globe
Day 1 3 4 4 5 5 6 6 7 7 8 8 9 9 10
1 ●● Foreign body either intraocular or deep corneal
0
●● Large hyphaemas (causing acute glaucoma)
Day 2 4 5 5 6 7 7 8 9 9 10 11 11 12 13
1
3
●● Retinal detachment
Day 3 5 6 7 8 8 9 10 11 12 13 13 14 15 16
1
7 ●● Corneal burns, either chemical or thermal - alkalis penetrate
Day 4 6 7 8 9 10 11 12 13 14 15 16 17 18 19
2
0
deeper and have greater potential for serious and delayed
burns.
Day 5 7 8 9 11 12 13 14 15 16 18 19 20 21 22
2
3
●● Contact lens - related corneal infections (bacterial keratitis)
Day 6 8 9 11 12 13 15 16 17 19 20 21 23 24 25
2
7
Management
Day 7 9 11 12 14 15 17 18 20 21 23 24 26 27 29
3
0
Corneal abrasions/ Foreign bodies
When the baby is not feeding, the same fluid volume is calculated and ●● If very large or deep defect seen, presume full thickness.
given as an IV infusion proving dextrose at a minimum of 6-8mg/Kg/min
and only add electrolytes from day 2 if passing urine ●● Exclude foreign body, including under eyelid.
●● Avoid removing large, deep or central corneal foreign bodies,
refer these to the Ophthalmologist.
●● Gently use moistened cotton bud for small superficial foreign
body. A small gauge needle may be used in older, cooperative
children, using slit lamp with approach to the patient from the
temporal aspect of the eye.
●● Chloramphenicol ointment/drops or Tobramycin ointment/
drops
●● Pad the eye for four hours (to prevent accidental further eye
injury due to anaesthetic effect). Occasionally, prolonged eye
pad may help ease pain, but be aware not to apply too tightly as
this can impair epithelial healing.
●● Cycloplegic eye drops (Cyclopentolate 1% or Homatropine 2%)
can be used for relief of a very painful eye
●● Patients need daily review until corneal ulceration healed

134 135
2). OCULAR BURNS – THERMAL, CHEMICAL Reference
1. Willis Eye manual
Discuss all eye burns with the Ophthalmologist.
2. Eye Care in Developing Countries 3rd Edition by Larry
a). Chemical (Strong Acid/ Alkali) Burns Schwals

●● Extensive immediate irrigation: Urgent copious irrigation after 3). THE ACUTE RED EYE
local anaesthetic drops including under the upper eyelid is to
be done. Use sterile high osmotic solutions like Ringers Lactate ●● Common causes of a red eye include conjunctivitis (viral,
through a fluid giving set over 15 – 30minutes or until the PH bacterial, allergic or chemical), foreign body, corneal ulceration
normalises (PH 6 – 8). and subconjunctival haemorrhage

●● Sedation or urgent GA may be required. Particulate alkaline ●● Uncommon causes include iritis, scleritis, episcleritis and
matter needs urgent, total removal glaucoma.

●● Immediate treatment is required to reduce pain, inflammation ●● A discharging non-red eye in infants is most likely due to
and risk of infection nasolachrymal duct obstruction

Systemic Analgesics a). Conjunctivitis (non neonatal)


●● Course of steroids drops 2 – 4hourly for 10days
●● May be difficult to clinically differentiate bacterial, viral and
●● Cycloplegic – Cyclopentolate eye drops or Atropine eye drops allergic conjunctivitis.
●● Prophylactic topical antibiotic – Ofloxacin eye drops 4hourly for ●● Suspect bacterial conjunctivitis if discharge is purulent. Treat
1week or Tetracycline eye ointment to be applied 8hourly with eye toilet with warm clean water every 2 – 4hours and
topical Chloramphenicol.
b). Thermal Burns
●● Suspect herpes simplex infection if there are lid vesicles. If a
●● If corneal damage present, manage as for other corneal dendritic ulcer is present treat with acyclovir eye ointment and
abrasions. contact Ophthalmologist.
●● Suspect allergic conjunctivitis if bilateral watery discharge with
c). Contact Lens Associated Red Eye
burning or foreign body sensation and eyelid swelling, itching
●● Anaesthetise eye and remove contact lenses if possible especially in an atopic child. Consider treating with mast cell
stabilisers, antihistamines (oral or topical) and artificial tears.
●● Stain eye and check for corneal abrasions or Foreign body
●● DO NOT PRESCRIBE STEROID EYE DROPS UNLESS ADVISED BY AN
●● Swab if discharge present- Gram-negative bacteria including P.
OPTHALMOLOGIST
aeruginosa are frequently the cause, thus requiring broader-
spectrum antibiotics like Ofloxacin b). Conjunctivitis (neonatal)
●● If ulcer identified refer urgently to ophthalmologist
●● Pathogens include staphylococcus, haemophilus, Chlamydia,
●● Start topical antibiotics and arrange for follow-up streptococcus, gonococcus and herpes simplex

136 137
●● Obtain conjunctival scrapings for gram stain, Giemsa stain and ●● Pupil may be small and poorly reactive.
cultures ●● May occur in association with juvenile chronic arthritis.
●● Use Chlamydia kit for immmunofluorescence and treat ●● Consult the ophthalmologist
Chlamydia conjunctivitis with eye toilet with warm clean water
and oral erythromycin for 3days f). Scleritis and Episcleritis
●● Consider Gonococcal conjunctivitis if severe purulent discharge
●● Present with localised areas of inflammation with tenderness
with conjunctival and lid oedema. Perform an urgent gram stain
and lacrimation.
and contact Ophthalmologist. May need septic work up and
systemic Cefotaxime or Ceftriaxone ●● Strongly associated with systemic disease.

●● Treat other organisms with topical Chloramphenicol ●● Consult the ophthalmologist

c). Foreign Body g). Glaucoma

●● Anaesthetise conjunctiva with Amethocaine 1% ●● Presents with an enlarged, hazy cornea, photophobia and
lacrimation.
●● Examine surface of eye and under lids, using slit lamp if
possible ●● Contact ophthalmology

●● Stain with fluroscein to assess corneal injury h). Trauma


●● Remove foreign body with moistened cotton bud, apply
Chloramphenicol ointment and pad for four hours ●● Consider if hyphaema or focal conjunctival injection.

●● Need daily review until epithelium healed ●● Consider penetrating injury

●● Refer embedded or metallic foreign bodies to ophthalmologist ●● Contact ophthalmology

d). Corneal Ulceration i). Stye

●● May be caused by trauma (including foreign body) or herpes ●● Infection of the eyelash follicle or glands at the eyelash root.
simplex infection. Usually caused by staphylococcus aureas. Presents as an acute
painful lid margin swelling.
●● Visible after fluroscein staining.
●● Supportive treatment is by use of warm compresses
●● If traumatic apply Chloramphenicol ointment and review in 24
hours. ●● Use antibiotic eye ointment or drops (Tobramycin,
Chloramphenicol 8hourly for 1week)
●● If any ulcer associated with hypopyon or is very large, contact
Ophthalmologist. j). Eyelid Cellulitis
e). Iritis ●● This is infection of the eyelid secondary to trauma, insect
bites, upper respiratory tract infections or spread from a stye.
●● Presents with pain, photophobia, blepharospasm and
Presents with a tender periorbital swelling. The rest of the eye
lacrimation.
examination is normal.

138 139
●● Treatment is by use of systemic broad spectrum antibiotics for 14. HAEMATOLOGY
1 week
●● Oral anti-inflammatory analgesics should be used for pain and
1). ANAEMIA
swelling
Definition: Anemia is defined as a decrease in red blood cell (RBC)
k). Congenital Nasolachrymal Duct Obstruction mass, or Hb less than the lower limit of the reference range for age.
It is a symptom of disease that requires investigation to determine
●● Usually a thin mucous membrane at the lower end of the
the underlying etiology.
nasolachrymal duct is the cause.
Lower Normal Limit of Haemoglobin for Age Table 26
●● Presents by the age of 1month with tearing and sticky mucoid
or mucopurulent discharge on the lid margins and eyelashes Age Lower limit of normal range (g/dl)

●● Digital pressure over the lachrymal sac may produce reflux of 2 months 9.0
mucoid material.
2 - 6 months 9.5
●● Treatment is by use of Broad-spectrum antibiotic eye drops
6 - 24 months 10.5
(Ofloxacin, Chloramphenicol) 6houly for 2weeks.
●● Digital massage of the lachrymal sac – 10strokes 6hourly for 2 - 11 years 11.5
3months > 12 years Girls – 12.0 Boys – 13.0
●● If any swelling at the lachrymal sac, persistent tearing or
discharge, refer to the Ophthalmologist. Causes include
●● Genetic; Hemoglobinopathies, Thalassemias,
References Abetalipoproteinemia, Fanconi anemia, etc
●● Paediatric Ophthalmology and Strabismus by Kenneth Wright
●● Nutritional e.g. Starvation and generalized malnutrition
●● Clinical Ophthalmology by JJ Kanski 4th Edition
●● Hemorrhage
●● Paediatric Ophthalmology and Strabismus ( American academy
●● Immunologic - Antibody-mediated abnormalities
of Ophthalmology series, section 6 2007 -2008)
●● Physical effects e.g. Trauma, Burns, Prosthetic valves and
surfaces
●● Drugs and chemicals, Aplastic anemia, Megaloblastic anemia
●● Chronic diseases and malignancies; e.g. Celiac disease, Chronic
Renal Failure, Leukemia
●● Infections e.g. malaria, hookworm infestation,
●● Thrombotic thrombocytopenic purpura and hemolytic uremic
syndrome

140 141
The following diagram will help to identify the type of The best sources of iron include:
anaemia. Diagram 4 ●● Breast milk (the iron is very easily used by the child) ,Infant
cereals and other iron-fortified cereals, Baby formula with iron,
Low MCV Normal MCV High MCV Liver, meats including poultry ,Dried beans and lentils, Eggs,
Fish, Molasses, Peanut butter, Soybeans

Treatment
●● Stop blood losses e.g. acute haemorrhage, GIT bleeding,
Serum Reticulocyte Serum Folate infestations, infections,
Ferritin count RBC Folate
Vit. B12 level ●● Transfusion with packed cells if severe and symptomatic e.g.
CCF

Normal
No

●● Iron infusions if malabsorption of iron is the cause


Low

rm

Increased
al

BM hypoplasia ●● Oral iron supplements if not severe and asymptomatic. Iron


Leukaemia, inflitrate (elemental) at 6mg/kg/day for at least 3 months after correction
of haemoglobin (to replace stores)

Iron Haemolysis Folate or B12


●● Counsel on diet
Thalassemia
Deficiency minor Blood loss Deficiency
Follow-up
2). IRON DEFICIENCY ANAEMIA ●● Refer all children with anaemia for Paediatrician follow-up
●● If not responding as expected in 2 months on adequate
Causes treatment then re-evaluate and refer to haematology clinic
●● Blood loss, either from disease or injury ●● Monitor growth and development and refer as needed
●● Not getting enough iron in the diet
3). HAEMOPHILIA
●● Not being able to absorb the iron in the diet
Note: Description
Iron deficiency that lasts more than 2 months while being treated ●● Haemophilia A is Factor VIII (8) deficiency.
should be considered chronic anaemia and other explanations must ●● Haemophilia B is Factor IX (9) deficiency
be sought
Management
Basic laboratory Tests ●● Most bleeds will require factor replacement except for bruises
●● Hematocrit and PBF for reticulocyte count and minor soft tissue injuries that do not impact on function
●● Serum ferritin reveals the amount of iron stored in body and mobility.

●● Serum iron shows how much iron is in blood ●● Invasive procedures such as arterial puncture, lumbar puncture
must only be performed after clotting factor replacement.
●● Total iron binding capacity (TIBC)
●● Do not give IM injections.
142 143
1. Clotting Factor Replacement ●● Undiagnosed abdominal pain
Recombinant clotting factor concentrates are the product of choice. ●● Persistent haematuria
Doses should be rounded up to the nearest vial size ●● Bleeds causing severe pain
●● Do not discard any product (use whole vial). e.g. 20 Kg child 3. General Measures - Joint and Muscle Bleeds
requiring 30 units/Kg factor VIII, give 750 units
For muscle and joint bleeds R.I.C.E.S will limit bleeding and reduce
●● Specify product type and name e.g. 750 units Recombinant pain. Initiate on arrival.
Factor VIII (Recombinate). See table below for list of products
●● R = Rest (in position of comfort)
Note that there are three recombinant Factor VIII products
available. Whilst it is recommended that patients maintain ●● I = Ice (Cold pack to reduce bleeding and pain)
treatment with their established brand of FVIII product, ●● C = gentle compression bandage
in an emergency situation administration of any brand of ●● E = Elevation
recombinant FVIII is acceptable. Table 27
●● S = splint (severe/recurrent bleeds)
Product type Comment 4. Venous Access

Recombinant FVIII ED alert system will indicate ●● Venous access is often the major fear and stressor for children
patient’s treatment product. with haemophilia and their parents. Treat veins with care; they
Should plasma FVIII level be are the lifeline for patients with haemophilia. Apply pressure
required, indicate product name on for 3 minutes post venepuncture.
pathology request form.
Recombinant FIX
5. Analgesia
●● Paracetamol/codeine is sufficient in most cases, however
Plasma derived FVIII Also contains von Willebrand factor morphine, Tramadol can be used for severe pain
●● Splinting/immobilization is an effective adjunct for reducing
Plasma derived FIX severe pain
●● Do not use products containing aspirin or NSAIDS (e.g.
Recombinant VIIa Once reconstituted must be used
immediately. Ibuprofen, Diclofenac)
6. DDAVP (Desmopressin)
Recommended clotting factor dosage
●● Releases stored FVIII (and von Willebrand factor) into the
2. Bleeds requiring admission
circulation
●● Suspected intracranial haemorrhage
●● Used in patients with mild haemophilia A where there is
●● Bleeding into neck/throat documented evidence in the medical record of safe and
●● Forearm/calf bleed with suspicion or evidence of compartment satisfactory response (DDAVP challenge). DAVP challenge can be
syndrome performed from around 5 years of age
●● Bleeding into hip or inguinal area, suspected ileopsoas ●● Not adequate for haemostasis in major bleeding
haemorrhage ●● Generally not recommended in young children (< 3 years) due to

144 145
Table 28

146
Type of bleed Haemophilia A Haemophilia B Comment

Recombinant FVIII Recombinant FIX

Joint 40 units/Kg Day 50 units/Kg Day 1 Factor replacement may be modified when
1 intravenous access is difficult, particularly
25 units/Kg or usual in toddlers. E.g. 40 units/Kg Day 1 & Day
20 units/Kg or home prophylaxis 2. Intravenous cannula may be left insitu
usual home dose Day 2 & 5 with patient returning for Day 2 dose. (As an
prophylaxis dose outpatient, intravenous cannula should not be
Day 2 & 4 left insitu for > 24 hours.)

Muscle (minor) 30 units/Kg 50 units/Kg

Muscle (major) 50 units/Kg 75 units/Kg Calf and forearm bleeds may lead to
compartment syndrome and be limb
threatening. Arrange haematology and surgical
reviewInvolvement of ileopsoas muscle may
be associated with significant blood loss and
mandates haematology review.

Type of bleed Haemophilia A Haemophilia B Comment


Oral Mucosa & 30 units/Kg 50 units/Kg Antifibrinolytic therapy is critical.
Dental

Epistaxis (active) 30 units/Kg 50 units/Kg Apply local measures (pressure). Antifibrinolytic


therapy effective in preventing recurrence.

Gastrointestinal 50 units/Kg 75 units/Kg Haematology and gastroenterology review


required. Lesion is usually found. Antifibrinolytic
therapy may be helpful.

Genitourinary 50 units/Kg 75 units/Kg Evaluate for all causes however lesion not usually
found. Antifibrinolytic therapy contraindicated
in haematuria.

CNS/head 75 units/Kg 125 units/Kg Always treat with factor replacement prior to
CNS imaging. Haematology & Neurosurgical
review.

Trauma or 50 – 75 units/Kg 75 – 125 units/Kg Consultation with haematologist essential.


surgery
147
documented reports of hyponatraemia and seizures Relatively ●● Sickle ß Thalassemia
contraindicated in children with previous seizure disorders ●● Sickle haemoglobin C disease
●● DDAVP Dose: 0.3 microgram/Kg (max 20 microgram) in
50mL 0.9%NaCl given by intravenous infusion over at least 30 a. Fever
minutes. (Available as 4microgram/mL injection)
7. Antifibrinolytic Therapy (Tranexamic acid) Background

●● Reduces breakdown of blood clots and is effective for Patients are functionally asplenic and thus at greater risk for
preventing recurrence of mouth bleeds and epistaxis. invasive disease particularly by encapsulated organisms (e.g.
pneumococcus).
●● Contraindicated for treatment of haematuria
●● Dose of Tranexamic acid (500mg tabs) 25mg/Kg/dose Management
(max:1.5g/dose) tds orally for 5-7 days ●● Give high flow Oxygen
Table 29
●● Do a haemogram including reticulocyte count
Weight (Kg) Tranexamic acid
●● DO a blood culture, Urine culture and culture other sites, as
< 20 250 mg tds
indicated
20 – 30 500 mg tds
●● Obtain chest IM if respiratory signs or symptoms, or high fever
30 – 40 750 mg tds
with no focus of infection
> 40 1 g tds
●● Consider parenteral antibiotic(s) (Flucloxacillin 50mg/Kg 6
Notes
hourly + Gentamicin 7.5mg/Kg (6mg/Kg if >10yrs) daily; do not
Regular follow-up is required. delay for FBC or urine culture results
●● Consult a Haematologist
Physiotherapy
●● All children with fever > 38.5 degrees should be admitted
Referral to physiotherapist for joint and muscle bleeds is essential.
Following severe joint/muscle bleeds, the affected joint should be
rested. For other joint bleeds, physiotherapy should commence as b. Painful Vaso-Occlusive Crisis
soon as pain has subsided and bleed has been controlled
Background
4). SICKLE CELL DISEASE All episodes of pain should be treated initially as vaso-occlusive
disease. Other diagnoses may need to be considered later. Pain
Description may be on a limb, back, chest or abdomen
Sickle cell disease is caused by structurally abnormal haemoglobin NB: Chest pain should be treated as an acute chest syndrome and
(Hb S) that causes a rigid distorted red blood cell (sickle cell). There not simply as a vaso-occlusive disorder.
are 3 common types
Management
●● Sickle cell anaemia (SS disease) is the most common
●● Start analgesics promptly to provide effective relief of pain.

148 149
Mild pain Management
●● Paracetamol 10 – 15mg/Kg + codeine 1mg/Kg every 6hours ●● Give high flow Oxygen
●● Encourage plenty oral fluids ●● Maintain and treat airway, breathing and circulation problems
●● If not settling then add Ibuprofen 10mg/Kg every 6hours first

●● If still not settling then move to severe pain ●● Maintain hydration with IV + oral intake at maintenance rate
●● Treat pain aggressively by giving adequate analgesia to control
Moderate to severe pain pain
●● Give high flow Oxygen.
●● Obtain CXR
●● Take blood for FBC, Reticulocyte count, group/cross match and
●● All patients with chest pain should be admitted, irrespective of
bilirubin.
CXR findings
●● Give bolus of 10-20mL/Kg of 0.9% Normal Saline followed by
●● Cross match for possible exchange or simple transfusion
maintenance rate 6mL/Kg/hour (including oral intake) of 5%
Dextrose in 0.45%Normal Saline. Patients with cardiomyopathy ●● Consider broad-spectrum antibiotics (see fever and sickle cell
will require less fluid. guideline)
●● Consult Haematology urgently and prior to transfusion or
Recommended analgesics: admission
●● Morphine 0.05mg/Kg/dose IV. Repeat as necessary (see
analgesia and sedation guideline) d. Acute Splenic Sequestration
●● Some patients may require higher individual doses, based on
prior history or may benefit from continuous infusion via PCA Background
(Patient Controlled Analgesia). This is defined as a haemoglobin drop of at least 2g/dL below
●● May need blood transfusion using WBC filtered blood patient’s baseline level with an acutely enlarged spleen. Mild to
moderate thrombocytopenia is often present. Reticulocyte count
●● Discuss with haematologist on call
is equal to or greater than patient’s usual baseline. Consider co-
existent aplastic anaemia if reticulocyte count is low
c. Acute Chest Syndrome
Most common in infants and young children. It has a high mortality
Background rate

Sickle cell disease can produce an acute illness related to infarction Management
of the lung tissue. Usually associated with lower respiratory
●● Investigations
symptoms, hypoxaemia and a new infiltrate on CXR. Chest pain and
hypoxaemia may be the only signs. ●● Cross match

Chest pain should be treated as an acute chest syndrome and not ●● FBC including platelet count
simply as a vaso-occlusive disorder. ●● Reticulocyte count
NB: This is a life threatening illness and patients may deteriorate ●● Blood and urine cultures if febrile; Chest x-ray if febrile and
quickly respiratory symptoms

150 151
●● While waiting for blood, give 0.9% Saline to treat hypovolaemia. f. Stroke and Sickle Cell Disease
(10-20mL/Kg) Be careful in patients who have pre-existing
cardiomyopathy Background
●● Suggest initial transfusion of 10mL/Kg of packed red cells for Acute neurological events occur in about 10% of patients with Hb
patients with haemoglobin <5g/dL or signs of shock. SS.
●● Do not raise Hb above baseline, since the spleen will shrink and These can present as
autotransfusion will occur. This will result in an increase in the
●● Hemiparesis
percentage of HbS and risk of stroke (due to hyperviscosity)
●● Monoparesis
●● Treat with antibiotics if febrile (see fever & sickle cell), and
analgesics for pain ●● Aphasia or dysphasia
●● Seizures
e. Aplastic Crisis ●● Cranial nerve palsies
●● Coma
Background
Acute illness associated with Hb below baseline for that patient Can occur suddenly or as a complication of acute chest syndrome
and associated with a substantially decreased reticulocyte count or aplastic crisis
(usually <1%). Usually associated with acute infection in particular NB. Consider other causes as well (see coma and seizure guidelines)
parvovirus
Management
May be associated with enlarged spleen as well
●● Give high flow Oxygen
Management ●● Maintain and treat airway, breathing and circulation problems
●● Give high flow Oxygen first
●● Maintain and treat airway, breathing and circulation problems ●● Investigations:
first ○○ Haemogram
●● IV + oral fluids at maintenance rates – do not add potassium to ○○ Cross match
IV fluid
●● Arrange for partial exchange transfusion but remember not to
●● Transfuse patient if symptomatic anaemia or Hb < 5g/dL over transfuse (e.g. Hb < 10g/dL)
(usually 5mL/Kg over 4 hrs). The blood product used should
●● Do a head CT without contrast to exclude intracranial
be WBC filtered and, if the patient is on Hydroxyurea should be
haemorrhage
irradiated also. Close observation for fluid overload. Transfusion
may need to be repeated. ●● Notify Haematologist urgently
●● Treat fever and pain as required (see fever and vaso - occlusive ●● May need admission to ICU for immediate exchange transfusion
crisis guidelines)
●● Discuss with Haematologist

152 153
g. Priapism ●● Consult Urologist and Haematologist if priapism has lasted
more than 3-4 hrs (may require aspiration and drainage)
Background
●● If no response to treatment, arrange for partial exchange
●● Priapism is prolonged painful erection of the penis often transfusion.
starting in the early hours of the morning and not due to sexual
●● Admit under Haematology Unit
stimulation.
●● Occurs in 2 forms Notes
○○ Stuttering episodes which last 2-4 hrs but are often recurrent Simple measures should be tried first at home, particularly if
and may precede a severe episode less than 3-4 hrs since onset:
○○ An attack lasting longer than 4 hrs and can result in ●● Encourage plenty oral fluids
impotence. ●● Analgesia
●● Recurrent episodes should be evaluated by haematologist and ●● Urination
Paediatric surgeon
●● Moderate exercise
Assessment ●● Take a bath or shower
●● Length of current episode
●● Associated symptoms – fever, dysuria, dehydration or pain at
5). BLOOD PRODUCT TRANSFUSION
other locations.
Background
●● History of prior episodes and the previous treatments and
●● Blood and blood product transfusions may be required for acute
effectiveness
blood loss, or for failure of production such as bone marrow
●● Symptoms of obstructive sleep apnoea. suppression.
Investigations (should not wait for results before treating pa- ●● Blood product therapy should only be given when the expected
tient) benefits to the patient are likely to outweigh the potential
●● Check haemogram and reticulocyte count hazards.

●● Cross match Blood products


●● Cultures and chest x-ray as required ●● Red blood cells

Management ●● Platelets

●● Administer intravenous fluids at maintenance rate. ●● Fresh Frozen Plasma

●● Give analgesia – Morphine 0.05mg/Kg IV titrated to effect ●● Cryoprecipitate

●● Encourage emptying of the bladder; catheterize, if unable to Indications for Red Blood Cells
empty bladder. Hb <7g/dL; although lower thresholds may be acceptable in
●● Do not use ice or ice packs patients without symptoms and where specific therapy (e.g. iron) is
available.

154 155
Transfusion may be indicated at higher thresholds for specific ●● Liver disease
situations:
●● Acute disseminated intravascular coagulation, DIC
●● Hb <7-10g/dL during surgery associated with major blood loss
●● Following massive transfusion
or if evidence of impaired Oxygen transport
●● Cardiac bypass
●● Hb <8g/dL; patients on a chronic transfusion regimen or
during marrow suppressive therapy (for symptom control and Indications for Cryoprecipitate
appropriate growth)
●● Fibrinogen deficiency, in the setting of clinical bleeding, an
●● Hb <10g/dL; only for very select populations (e.g. neonates) invasive procedure, trauma or DIC
●● Leukocyte depleted blood products should be given to:
Indications for Platelets
Indications for Platelet transfusion Table 30 ●● Immunocompromised patients (oncology, transplant recipients,
ICU patients, and other congenital and acquired immune
Clinical Situation Indication for Platelet Transfusion
deficiencies)
Bone marrow failure Platelet <10x109/L if no other risk factors for
bleeding (see below) ●● Patients requiring chronic transfusions
●● Infants under 12 months
Platelet <20x109/L if risk factors present
(fever, antibiotics, haemostatic failure, risk of ●● Intrauterine or exchange transfusions
intracranial haemorrhage)
●● Irradiated blood products should be given to:
●● All immunocompromised patients, including all oncology
Surgery/invasive Platelet <50x109/L. However, higher counts may patients, cardiac neonates and all patients in ICU, to prevent
procedure be needed in surgery with high risk of bleeding graft-versus host disease.
e.g. neurosurgery
●● CMV negative products:
Platelet function Transfuse if there is bleeding or high risk of
Defects bleeding, regardless of actual platelet count ●● Leukocyte depleted blood products, are considered an
acceptable alternative to CMV seronegative products

Bleeding/Massive Maintain Platelet >50x109/L if Pre-transfusion Assessment


transfusion thrombocytopaenia likely contributing to
●● The indication to transfuse (see above)
bleeding
Maintain Platelet >100x109/L in the presence ●● Discuss re the reason for transfusion and its consent (also
of diffuse microvascular bleeding (DIC) or CNS see hospital guideline: Blood transfusion, consent and
trauma
documentation)
●● Collect pre-transfusion sample and document
Indications for Fresh Frozen Plasma, FFP
●● A sample for cross-matching must be collected in a 1.4mL
FFP is appropriate for bleeding with coagulation in the following: red EDTA tube. Patients known to have red cell antibodies or
●● Warfarin effect, in addition to the use of vitamin K and vitamin-K haemolytic anaemia will require a larger sample
dependent clotting factor

156 157
●● Correctly identify the patient during the collection of the

Table 31

3mL/Kg/hr over 2-3 hours.

given over 30 minutes, but

reactions (fever/chills) and


(occasionally platelets are
pre-transfusion sample. Identification must include 3 unique

this may contribute to an


increased risk of some
identifiers i.e. full name, date of birth and Registration number.

15 minutes, unless an
Start at no more than

Start at no more than

Start at no more than


5mL/min for the first
This, together with completing the bedside check prior to blood
administration are the most vital steps in preventing serious

fluid overload)
transfusion errors.

emergency.

5mL/min.

5mL/min.
●● Request the appropriate blood product component and special
requirements

Rate
●● Calculate and prescribe the transfusion volume with
consideration to pack sizes

●● Paediatric (single donor) -40 - 60 mL

●● Apheresis (single donor) >200mL or


•• Unstable patient

●● Pooled from 4-5 donors - >160mL


●● Apheresis (single donor) split into
•• Stable patient (see Table 2 below)

Neonatal/ paediatric <40Kg patients:

split into 2 x > 100mL packs


●● Prescribe the blood product and rate of administration on the
fluid order chart (see Table 2 below)

4 - 8 x 40 - 60 mL packs

50mL/pack (for neonatal use)


○○ All transfusions must be completed within 4 hours of spiking

Paediatric > 40Kg or adult:


a pack.

50 -60 mL/Pedipack
Management of Transfusion

250-300mL/pack;
The key steps include:

30-40 mL/pack
300mL/pack
1. A formal checking process prior to commencement of

Pack sizes
transfusion
2. The use of correct equipment (filters, pump, consideration of
blood warmer)
3. Correct transfusion documentation including patient

will raise platelet


rise required(g/
= wt (Kg) x Hb

10 - 20 mL/Kg
observations, start and finish times

(5 - 10 mL/Kg

count by 50 -
5 - 20 mL/Kg

100x 109 /L)


Packed cells
Formula for

transfusion

5-10 mL/Kg
calculating
4. Complications during transfusion

volume

dL) x 4
5. The most common immediate adverse reactions to

(mL)
transfusion are fever, chills and Urticaria
6. The most potentially significant reactions include acute

Cryoprecipitate
haemolytic transfusion reactions, bacterial contamination of
Blood product

Packed Cells
blood products and transfusion related acute lung injury

Platelets
7. During the early stages of a reaction it may be difficult to
ascertain the cause

FFP
Transfusion volumes and rates - Table 32

158 159
8. All suspected transfusion reactions must be reported to the 15). DERMATOLOGY
issuing blood bank immediately. Consult the haematologist
provide advice regarding investigation and ongoing
transfusion support 1). BACTERIAL SKIN INFECTIONS (PYODERMA)
9. After transfusion ●● Bacterial skin infections can be primary secondary (to damaged
10. Document the effect of transfusion on the patient's condition skin from injury or other skin diseases)
including haemoglobin level if repeated. ●● Some bacteria like Staphylococcus aureus act as super-antigens
triggering off eczematous lesions in atopic dermatitis
●● The presence of bacterial infection in an existing skin condition
may not always be very obvious to the untrained eye
●● The extent and severity of infection and other factors will
determine whether a topical antibiotic is sufficient or systemic
antibiotic are also indicated

Descriptions of Pyoderma
●● Cellulitis is a spreading infection of the skin extending to
involve the subcutaneous tissues. The most common causes are
group A β-haemolytic streptococci (GABHS) and Staphylococcus
aureus. Predisposing factors include skin abrasions, lacerations,
burns, eczematous skin, etc, although the portal of entry of
organisms is often not seen.
Allergic reactions/contact dermatitis (e.g. to insect bites, immun-
isations, plants, etc) are frequently misdiagnosed as Cellulitis. If
there is itchiness and no tenderness, Cellulitis is unlikely.

●● Erysipelas is a specific superficial form of cellulitis usually


caused by GABHS. There may be lymphatic involvement.
●● Impetigo (commonly called "school sores") is a highly
contagious infection of the epidermis, particularly common in
young children. Causative organisms are GABHS and S. aureus.
Can be limited (primary or secondary
●● Staphylococcal scalded skin syndrome (SSSS) is a blistering skin
disorder induced by the exfoliative (epidermolytic) toxins of S.
aureus. It primarily affects neonates and young children.
●● Necrotising fasciitis is a rapidly progressive soft tissue infection
characterised by necrosis of subcutaneous tissue. Aetiology

160 161
is often polymicrobial. Causative organisms include GABHS, S. Carbuncles – Furuncles
aureus and anaerobes. It can cause severe illness with a high
(Staphylococcus aureus or mixed infections)
mortality rate (25%)
●● Flucloxacillin (dosage by age/weight) or Clindamycin
●● Consider herpetic infection when vesicles are present, and
send appropriate specimens for immunofluorescence and viral ●● Carbuncles may require surgical incision and drainage
culture.
Erysipelas
There are many other forms of skin infection that are not covered
●● As for cellulitis
in this guideline.
Impetigo
Management of Pyoderma
●● Uncomplicated localized: wash crusts off - topical Mupirocin 2%
Cellulitis ointment or Fucidin 12hourly
Involves subcutaneous lesions several organisms are implicated ●● If extensive multiple lesions present not responding to topical
●● Systemic therapy and inpatient treatment required. Several other treatment,: treat as for cellulitis
bacterial infections of the skin with a mixture of gram positive ●● Impetigo is very contagious - the child should be excluded from
gram negative bacteria and anaerobes are seen. child care/kindergarten/School until treatment has started and
●● Broad spectrum antibiotics may be necessary and therapy the sores are completely covered with watertight dressings.
directed towards culture sensitivity of specimens taken
Staphylococcal Scalded Skin Syndrome
●● Widespread recurrent and non responding infection be referred
●● As for cellulitis
●● Flucloxacillin 25 mg/Kg (max 500mg) PO 6hourly for 7 days
Necrotising fasciitis
●● If severe/extensive, systemically unwell or not responding
to oral treatment; admit and put on IV Flucloxacillin 50 mg/ ●● Admit
Kg (max 2g) 6hourly (consider adding Clindamycin if rapidly ●● IV Flucloxacillin 50 mg/Kg (max 2g) IV 6hourly plus
progressive to inhibit toxin production) ●● IV Clindamycin 10 mg/Kg (max 600 mg) IV 6hourly
●● For facial/periorbital cellulitis: consider adding Cefotaxime if: ●● Refer to surgical team if pus collection is present
< 5years and non-Haemophilus influenza type b immunised, or
not responding to Flucloxacillin alone 2). NAPPY RASH
●● For suspected or confirmed MRSA infection use IV Vancomycin
15mg/Kg every 8hours Description
●● Nappy rash is a dermatitis confined to the area covered by the
Folliculitis
nappy.
●● If mild and localized – topical antibiotics may be sufficient.
●● It is most commonly characterised by confluent erythema of
●● When widespread or with systemic symptoms – systemic the convex surfaces of the buttocks, the areas of skin in closest
antibiotics also. contact with the nappy and it spares the groin folds.

162 163
●● Nappy rash is not one distinct diagnosis, but is a multifactorial ●● Tacrolimus 0.03% cream is used on affected eczematous areas
problem. for short periods and monitored

Management Important
●● Use disposable nappies. ●● Avoid topical combinations with corticosteroids
●● Increase the frequency of nappy changing and cleansing the ●● Cold water or lukewarm compresses are good antipruritics
skin ●● Caution with systemic antihistamines, many are not to be given
●● Use disposable towels or face washers soaked in water or olive under 2 years of age
oil to cleanse the area ●● Topical antihistamines are not to be used
●● Application of a barrier cream like Zinc in castor paste at every
change. Apply extremely thick layer and should not be removed 4). SCABIES
completely after each nappy change, rather apply another layer
over the top Caused by the mite; Sarcoptes scabiei var hominis
●● Letting the child spend as long as possible without a nappy on, 1. Itchy condition with papules on fingers, soles, sides of hands,
lying on a soft absorbent sheet that is changed as soon as it is feet, axillary areas, wrists and can be all over the body, often
wet. Sunlight plays a role excoriated from scratching
●● If there is associated Candida infection, leading to erythema 2. Mites or eggs spread the infection by close contact with
in the folds and satellite pustules then topical anti-candidal infected persons, or infected articles.
therapy (Clotrimazole or Nystatin) should be applied. This 3. All clothing and infected articles should be properly laundered
therapy is often combined with 1% Hydrocortisone to reduce the
4. Crotamiton cream or lotion is mild and relatively safe in
associated inflammation
children
●● Antibiotic creams used when bacterial infection is present.
5). FUNGAL SKIN INFECTIONS
3). ATOPIC ECZEMA
The most common fungal infection in children is Tinea Capitis
Contact (irritant or allergic) dermatitis, Seborrhoiec dermatitis (dermatophyte infection of scalp)
●● Neutralizing balancing creams; moisturizers that restore and ●● Other dermatophyte infections are Tinea corporis (body) Tinea
maintain optimal conditions of moisture lipid and PH of the skin cruris (groin) and Tinea pedis (feet)
should be used regularly ●● Dermatophytes respond best to Terbenafine cream
●● Avoid allergens or irritants in contact with the skin Clothing ●● In more complicated or deeper infections Terbenafine tablets
should be of soft fabric (cotton) and loose fitting may be given once daily for 2 – 4 weeks dosage by weight
●● Topical or systemic antibiotics should be given when bacterial ●● If Terbenafine is given for more than 4 weeks, liver function
infection is present tests must be done
●● Antifungal creams should be used where indicated ●● In mixed fungal skin infections yeasts, moulds like Candida and
Pityriasis versicolor.

164 165
●● Topical preparations of Nystatin, Clotrimazole, Isoconazole, Management:
Bifonazole, Miconazole can be used for treatment ●● Isolation of skin contact, soothing agents like calamine lotion,
Crotamiton, stop soon as lesions crust
Duration of treatment
Duration of treatment for superficial dematophytes (tineasis) ●● Widespread disease is treated with systemic Acyclovir 20mg/Kg
depends on region affected. Broadly tinea corporis is curable PO 5times a day for 7 days. Oral antihistamines and antipyretics
by topical antifungal for 4 – 6 weeks. Tinea capitis (hair) for 4 – with Paracetamol are desirable
6weeks, onychomycon (nail) for 2 to 3months
Classes of antifungals Molluscum Contagiosum
●● Topical agents – shampoo and topical antifungal creams ●● Umblicated skin lesions: refer if multiple, advice against
(azoles) manipulation
●● Systemic antifungals
Common warts
○○ Antifungal antibiotics
Condylomata acuminata: >/ 3 lesions or persistent lesion. Advice
○○ Azoles against purring and manipulation. Treat with topical duofilm
○○ Allylamine solution or Podophylin to be applied 3times weekly for 4 weeks
○○ Newer ones – Benzylamine

6). VIRAL INFECTIONS

Herpes simplex
●● Herpes simplex is characterized by grouped vesicles around oral
or genital area, recurrent infection in common.

Treatment
●● Acyclovir 5% cream for primary infection 2 or 3times a day for
7days.
●● Oral Acyclovir for recurrent infections – See infectious diseases
section for further discussion

Chicken pox
This is varicella infection with widespread vesicles at different
stage of development and a positive history of contact.

Prevention
●● Immunization at the age of 1year

166 167
16. BONE AND CONNECTIVE TISSUE DISEASE resolve or the diagnosis becomes clear
Any child with symptoms not resolved after four weeks or any
child in whom NSAIDs do not provide adequate relief of symptoms
1). THE ACUTELY SWOLLEN JOINT
should be re-evaluated
Notes

Acutely swollen joints may reflect local pathology (e.g. trauma,


sepsis) or generalised pathology localised to a joint(s) (vasculitis,
post-infective arthritis)
●● Often the diagnosis only becomes apparent with time and initial
treatment is on a presumptive basis
●● For a significant number of patients this involves symptomatic
measures only

Management
In the acute phase the most important tasks are to identify those
conditions requiring more than just symptomatic treatment, and to
ensure that those being treated symptomatically have appropriate
follow-up.

Consider outpatient referral to Rheumatologist if:


●● Symptoms for >4 weeks
●● A significant joint effusion
●● Significant limitation of activity
●● Multiple joint involvement
●● Evidence of joint contractures
●● Vasculitis other than HSP
In many cases there may not be a clear diagnosis by the end of the
child’s assessment in the emergency department - the results of
some investigations may not be available for days, and others may
help only in ‘ruling-out’ certain conditions
For such children, symptomatic outpatient treatment with non-
steroidal anti-inflammatory drugs (e.g. Ibuprofen) with careful
follow-up is appropriate
These children should be followed closely until their symptoms

168 169
17. ENDOCRINE DISORDRERS ○○ 6-12 years: 4-6mcg/Kg PO once a day
○○ >12 years: 2-3mcg/Kg PO once a day
1). HYPOTHYROIDISM
2.) HYPERTHYROIDISM
Definitions
Definitions
Hypothyroidism is a common endocrine disorder resulting from
●● Hyperthyroidism refers to overactivity of the thyroid gland
deficiency of thyroid hormone
leading to excessive synthesis of thyroid hormones and
Cretinism refers to untreated congenital hypothyroidism, which accelerated metabolism in the peripheral tissues.
affects about 1 per 4000 newborns.
●● Thyrotoxicosis, on the other hand, refers to the clinical effects
Subclinical hypothyroidism, also referred to as mild hypothyroidism of an unbound thyroid hormone, whether or not the thyroid
or compensated hypothyroidism, is defined as normal serum free gland is the primary source.
T4 levels with raised serum TSH concentration.
Investigations
Investigations
●● Free T4, Free T3, and TSH measurements.
●● Thyroid function test
●● Diagnostic radioiodine I 131 uptake is performed rarely
○○ TSH assays
●● Either technetium Tc 99m or 123I scan may be useful if the
○○ Free T4 gland does not have a uniform consistency
○○ TRH stimulation tests (to be done by an endocrinologist)
Medical Treatment
●● Imaging studies
Starting dose; then refer to Endocrinology clinic
○○ Thyroid ultrasound scan
●● Propylthiouracil (PTU) 5-7 mg/Kg/day given every 8-12 hours
○○ Iodine Isotope scans
●● Methimazole 0.5-0.7 mg/Kg/day given every 8-12 hours
●● Fine needle biopsy
●● Carbimazole, 0.25-0.7 mg/Kg/day given every 8-12 hours
Treatment ●● Lugols Iodine Solution 1-5drops PO 8hourly
Thyroid hormone replacement ●● Radioiodine (I 131, Iodotope), 4-10 microCi, One to 2 doses is
Effects are seen in 4-5 days and maximal effects in 6 weeks sufficient. Patient will need thyroxine replacement
TSH corrects in about 4 weeks ●● Propranolol, 80 mg/m2/d, or 2-4 mg/Kg/d PO in 2divided doses
in patients with marked cardiac manifestations
Starting dose; then refer to Endocrinology clinic
●● Hydrocortisone, 100-200 mg/m2/d PO/IV (in very severe
●● Levothyroxine given preferably in the morning (Titrate the dose
conditions)
to individual requirements)
○○ Neonate to 6 months: 12-18mcg/Kg PO once a day Treatment options
○○ 6-12 months: 8-12mcg/Kg PO once a day ●● Dosage of PTU or Methimazole is titrated to maintain T4
concentration within the normal range. As the disease comes
○○ 1-5 years: 6-8mcg/Kg/ PO once a day
170 171
under control and TSH levels rise, the dose is decreased and Ongoing Treatment
eventually discontinued ●● Once normoglycaemia is achieved and ketonuria disappears,
●● Use high doses to cause hypothyroidism and use thyroxine change insulin to twice daily mixture of short and intermediate
replacement (block and replace method) insulins.
●● Methimazole and Carbimazole may cause agranulocytosis, ●● Give insulin as twice daily mixture of short and intermediate
treatment must be stopped if this happens insulin, usually at 1 unit/Kg but may need modification. Given
as: Two-thirds in the morning, one-third at night, two thirds
Surgical Treatment of each dose intermediate-acting, one-third as short-acting.
●● Total thyroidectomy Occasionally older adolescents go onto a basal bolus regimen:
●● Surgical complications can include hypoparathyroidism and 30-40% intermediate acting insulin given at 2200hr, rest given
damage to the recurrent laryngeal nerve. as short-acting insulin in 3 equal doses before meals.
●● Consultant an Endocrinologist
3). DIABETES MELLITUS
Hyperglycaemic, mildly ill diabetic patients (already on insulin)
Definition Usually advised to take 10% of total daily dose as rapid-acting
This is a disorder of metabolism resulting from impaired utilization insulin every 2 hours until normoglycaemic (in addition to usual
of glucose from the bloodstream as a result of impaired insulin insulin). Notify endocrinologist if there are any management issues
activity that you want to discuss

New presentation, mildly ill Hypoglycaemia guidelines

Assessment Background

< 3% dehydration, no acidosis and not vomiting ●● Beyond the neonatal period, hypoglycaemia is defined as blood
glucose less than 2.5mmol/L
Management ●● There should be a low threshold for performing a Random Blood
Initial Treatment: Sugar (Glucometer) in the acutely unwell child
●● 0.25 units/Kg of quick-acting insulin SC. stat. If within 2 hr of a Assessment
meal give mealtime dose only. Halve dose if < 4 yr old.
Effects
●● Use anaesthetic cream for initial doses of insulin in a newly
diagnosed child ●● CNS Effects - irritability, coma, depressed level of
consciousness, convulsions
●● Before breakfast and lunch (7.30 am, 11.30 am) give 0.25 units/
Kg of quick-acting insulin. Before the evening meal (5.30 pm) ●● Adrenergic overdrive - tremor, jitteriness, pallor, sweating
give 0.25 units/Kg of quick-acting insulin and 0.25 units/Kg
Causes
of intermediate-acting insulin. If this is first insulin dose, give
0.25 units/Kg quick-acting insulin only, followed by further 0.25 ●● Measure height and weight. Look for midline defects,
units/Kg quick-acting insulin at midnight followed by a snack. micropenis, optic nerve hypoplasia (hypopituitarism),
●● Cataracts (galactosaemia),
172 173
●● Hepatomegaly (glycogen storage disease) and generally remits spontaneously before the age 8 or 9
●● Hyperpigmentation (adrenal insufficiency). years. A presumptive diagnosis is made by documenting a low
blood sugar in association with ketonuria, ketonaemia and
●● Hemihypertrophy, exomphalos, macroglossia and transverse ear
typical symptoms of hypoglycaemia. The definitive diagnosis
creases (Beckwith-Wideman syndrome).
is established by demonstrating an inability to tolerate a
Investigations provocative ketogenic diet, or a fast. Susceptible or affected
children develop severe hypoglycaemia and ketosis on this diet
Blood within 24 hours
●● Glucose and lactate (fluoride oxalate tube, 1mL )
4). DIABETES INSIPIDUS
●● Insulin, cortisol, growth hormone (plain tube, 2-4 mL)
●● Ammonia (heparinized tube, 1mL) Background
●● Ketones and free fatty acids (fluoride oxalate tube, 1mL) Diabetes insipidus (DI) is an uncommon condition with either
●● Amino acids, electrolytes (heparinized 1-2mL) relative or absolute lack of anti-diuretic hormone (ADH) leading
to inability to concentrate the urine and subsequent polyuria/
●● Acid-base (heparinized sample, 1mL)
polydypsia and potentially fluid and electrolyte imbalance.
●● Blood drops onto a Guthrie test card (for acyl-carnitine profile)
This can be seen in a variety of conditions in the paediatric
Urine population, most commonly in patients post neurosurgery or with
cerebral malformations. It may be central or nephrogenic
●● Ward test for ketones, glucose, reducing substances
●● 10-20mL for amino acids and organic acids Assessment

Management Consideration should be given to:


Symptomatic hypoglycaemia should be treated with an IV bolus 1. Hydration status/fluid balance/urine output
of 5mL/Kg 10% Dextrose (0.5g/Kg Dextrose). The expected 2. Presence of intercurrent illness like urinary tract infection,
maintenance infusion rate is 3-5mL/Kg/hr of 10% Dextrose (6-8mg/ pneumonia, meningitis
Kg/min). A required infusion rate above 10mg/Kg/min is consistent
3. Causes of excess fluid loss like gastroenteritis and surgical
with hyperinsulinism
drains
All patients with hypoglycaemia presenting to Emergency require
4. Past history of diabetes insipidus with similar episode
admission.
5. Change in weight as marker of fluid status
Notes
Baseline investigations;
●● Hyperinsulinism is the commonest cause of hypoglycaemia
under two years old, except preterms and small for gestational 1. Urea and electrolytes
age newborns. This diagnosis is excluded by presence of 2. Urinalysis
ketonuria
3. Paired serum and urine Osmolality
●● "Accelerated starvation" (ketotic hypoglycaemia) classically
manifests itself between the ages of 18 months and 5 years,
174 175
Diabetes insipidus is suspected if the serum Osmolality is raised 7. Nasal administration is operator dependent - also need to
(>295 mOsmol/Kg water) with inappropriately dilute urine (urine consider effectiveness if problems with nasal mucosa like
Osmolality < 700 mOsmol/Kg water). The serum sodium is often intercurrent URTI, hayfever, or post operatively
elevated due to excess free water losses 8. Careful fluid balance needs to be maintained to prevent fluid
Management overload/hyponatraemia

1. Rehydration Ongoing management of patients on DDAVP - General principles


After assessment of level of dehydration and ongoing losses, 1. At a minimum, daily serum electrolytes and Osmolality and
adequate rehydration therapy should be commenced. If the serum daily urine osmolality are required until stable - consider more
Na is > 150, rehydration should occur over 48 hours frequent electrolytes if hypernatraemic or concerns about fluid
If Na >170, admit to ICU state

2. DDAVP (1-deamino-8-Arginine Vasopressin) administration 2. Ensure most recent serum sodium result is above 135 mmol/L
prior to administration of DDAVP
All patients should be discussed with the endocrinologist prior to
the commencement of DDAVP therapy 3. Need to have 1 - 2 hrs of diuresis prior to administration
of next dose to allow free water clearance and avoid
DDAVP acts on the distal tubules and collecting ducts of the kidney
hyponatraemia
to increase water reabsorption, as a long acting analog of ADH
4. All urine specific gravity checked and documented
There are several formulations available: 5. Strict fluid balance chart
1. Intranasal solution - 100 mcg/mL
6. Patient weighed daily
2. Intranasal spray (10 mcg/spray)
Complications of management
3. Parenteral (IV/IM) - 4 mcg/mL - used rarely
1. Hyponatraemia
4. Oral - 200 mcg tablets
2. Hypernatraemia
(Roughly 10 mcg intranasal = 200 mcg oral)
3. Fluid overload
Administration principles
Inform the Endocrinologist if:
1. For infants discuss with an endocrinologist
1. Urine output > 4mLs/Kg/hr for two consecutive hours - may
2. Under 2 yrs, dose is usually 2 - 5 mcg intranasal
need repeat serum sodium
3. From 2 yrs on, dose similar to adult dose (5 - 10 mcg/day)
2. If DDAVP due and there has been no urine output for previous
4. Oral dose 50mcg to 2mg per dose, given 2 0r 3times a day. 12 hours, or urine output less than <1.5ml/Kg/hr may need to
5. Dosage effect is all or nothing - in general, the dose reduce or omit the dose
determines the duration of action NOT the degree of 3. If serum electrolytes are not within normal range
response.
4. If child is exhibiting signs and symptoms of dehydration or
6. Oral dose has slower onset/offset of action, therefore NOT fluid overload
useful in acute situation (delete this point.)

176 177
5). WEIGHT MANAGEMENT dyslipidaemia, non-alcoholic steatohepatitis, orthopaedic
disease, obstructive sleep apnoea infertility
1. Introduction
Aetiology of childhood overweight
●● Childhood obesity and overweight are emerging as common
The large increase in the prevalence of obesity in the last three
problems in children attending Gertrude’s Children Hospital
decades points to
However the prevention and management of childhood
obesity is not adequately addressed despite a rapid rise in its 1. Widespread environmental factors
prevalence 2. Lifestyle changes
●● This guideline is to be used by medical, nursing and allied 3. Genetic predisposition
health staff at the GCH to assist them in assessing and
4. Rarely, specific chromosomal or genes defects.
addressing issues of weight and obesity in patients. It
provides a simple but evidence based clinical approach for Risk factors include:
the identification of childhood overweight and obesity and an Genetics: At least 5 single gene defects have been found but
opportunistic approach to addressing these issues with the these are all extremely rare and all are associated with severe and
family and patient very early onset obesity and should prompt referral for further
assessment.
2. Definition of terms
Body Mass Index: Body Mass Index (BMI) is currently seen by Environment/Lifestyle: Physical inactivity, increase in sedentary
health professionals as the most appropriate measure of adiposity behaviour (especially screen based activities), increased
in children consumption of high fat foods and sugar sweetened drinks,
children’s food advertising.
Calculating Body Mass Index: BMI is calculated by dividing the
weight (Kg) by the squared of the height (M2). However calculated Other risk factors for obesity: Early infant feeding, parental
BMI values need to be compared with age and sex reference obesity, parental encouragement of children to eat, higher
standards due to BMI changes that occur in normal growth. socioeconomic status

Overweight: Overweight is defined as a BMI greater than the 85th Underlying medical conditions: (v rare) secondary obesity may
percentile. occur due to hypothyroidism, hypercortisolism, growth hormone
deficiency and hypothalamic damage
Obesity: Obesity is defined as a BMI greater than the 95th
percentile for age Drugs: Steroids, antipsychotic drugs (Risperidone) and some
antiepileptic medications.
3. Background
4. Assessment
Consequences of childhood overweight
The Body Mass Index (BMI) is recommended as a practical measure
●● Much greater risk of adult obesity (a 5 yr old who is obese has 8
of overweight and obesity in children
times increased risk of adult obesity)
●● Rapid changes in BMI can occur in normal growth
●● Psychosocial morbidity (bullying, teasing, lower self esteem,
poorer socioeconomic prospects) ●● BMI varies with age and sex

●● Range of physical morbidities: type 2 diabetes, hypertension,

178 179
●● BMI rises in the first year of life, then falls during the preschool concerned about the issue. This is when you can discuss
year, before rising again into adolescence (adiposity rebound) specific behaviour changes and arrange referral.
Therefore calculated BMI values need to be compared with age and 2. They may instead state that they think her growth is fine.
sex reference standards (use BMI charts). Then your goal is to raise their awareness of the health
1. Calculate BMI using the formula BMI = Wt (Kg)/ [Height or issues, not necessarily to solve the problem!
length (M)] 2. (You will need to know the patients weight Some behaviour change ideas you can discuss with families
and height or length) Physical activity; any increase in activity is an improvement!
2. Compare and chart BMI on percentile chart 1. Aim for ‘lifestyle’ exercise: using the stairs, walking to
school, walking the dog
5. Addressing the Issue of Obesity
The issue of obesity as an important health concern is often not 2. Involve the whole family (everyone can benefit regardless of
addressed in the clinical setting. Once you have noted that the weight status)
child is overweight you may address the issue using the following 3. Use after school time to get outdoors and be active
approach 4. Decrease screen based activities (TV, Computer, Play station)
1. Do no harm! Approach with respect but address the issue! 5. Have bikes, helmets and balls ready to go, by the door!
2. Assess child and parent’s perceptions of the issue - do they
even see it as a concern? - Do they have differing awareness/ Nutrition, and don’t forget drinks!
concerns? 1. Water is the best drink for kids: cut out cordial, soft drink,
fruit juice
3. Highlight the issue of weight in the context of health,
show the growth chart to the family and explain what the 2. Better to eat the fruit rather than drink fruit juice
healthiest weight for their child would be; explain they are 3. Low fat (2%fat) milk (<500mLs/day) is preferred for children
still growing in height, so probably do not need to actually over 2 years of age
lose weight rather they need to grow into their weight
4. Importance of breakfast, regular meals and healthy snacks
4. Ask what they think they could do and possibly suggest
5. Basic food label reading, and awareness of the ‘traps’ i.e.
some behaviour change ideas
‘no fat’ might mean large amounts of sugar and therefore
5. Organise follow up - the options are local doctor, dietician, the same number of calories
paediatrician or a weight management clinic.
6. Serving sizes (does the 5 yr old get served as much as Mum
Parental Perception or Dad?)
We know that approximately 50% of parents of obese children do 7. Planning ahead, avoiding regular take-away fast food
not perceive that their child is overweight. It is therefore useful
6. Management
to gauge their opinion and experience of this issue as this can
shape the ensuing discussion e.g. ‘What do you think about your Management of obesity is complex and ongoing.
daughter’s weight?’
The aim of this guideline is to provide clinicians with an approach
1. They (and the child) may respond that they are aware and for identifying and addressing issues of overweight and obesity in

180 181
the clinical setting. Weight management is most successful when 18. MALNUTRITION
addressed in the context of the whole family
Feeding children with severe malnutrition – use EBM and / or infant
7. Follow up Review and Referral
Formula, if aged < 6 months
Obesity is a chronic disease that may require comprehensive
multidisciplinary assessment; management and long term follow ●● If respiratory distress or oedema get worse or the jugular veins
up. Health care professionals involved should include: are engorged reduce feed volumes
●● Maternal child health nurse ●● When appetite returns and oedema much improved change from
F75 to F100, for the first 2 days use the same feed volumes
●● Paediatrician
as for F75Then give at least the minimum F100 volume and
●● Local doctor continue increasing feeds by 10mLs per feed stopping when the
●● Dietician child is not finishing the feeds or if the maximum is reached
Include a copy of growth chart and BMI calculation with referral Admit to hospital if there is a history of illness and either of:
letter Visible severe wasting (buttocks)
Oedema and low weight for age or other signs of Kwashiorkor
(flaky paint skin / hair changes)

182 183
184
Admit to hospital if there is a history of illness and either of:
√ Visible severe wasting (buttocks)
√ Oedema and low weight for age or other signs of Kwashiorkor (flaky paint skin / hair changes).

Diagram 5
Check glucose and treat if <3mmol/l (5mls/kg 10% dextrose). If glucose test unavailable treat for
Step 1 hypoglycaemia if not alert. Oral /NGT glucose or feeds should as soon as possible (not >30 mins
after admission.)

Check for hypothermia, axillary temperature <350C. If present, warm with blankets, warm bags of
Step 2
fluid or a heater.

Check for dehydration and correct – use fluid plans for severe malnutrition. (Transfuse if Hb < 4g/dl,
Step 3
or shock + severe pallor, 10mls/kg whole blood in 3hrs + Frusemide 1mg/kg)

Correct electrolyte imbalance. Ideally add Mineral mix to feeds, but at least give 4mmol/kg/day
Step 4
extra of oral Potassium.Never use Frusemide to treat oedema!

Treat infection. All ill children with severe malnutrition should get iv Penicillin (or Ampicillin) AND
Gentamicin AND oral Metronidazole . Add:
√ Nystatin / Clotrimazole for oral thrush
Step 5
√ Mebendazole after 7 days treatment.
√ 1% TEO (+ atropine drops) for pus / ulceration in the eye

Correct micronutrient deficiencies. Give:


√ Vitamin A on admission (and days 2 and 14 if eye signs).
√ Multivitamins for at least 2 weeks
Step 6
√ Folic acid 2.5mg every other day
√ Start iron ONLY when the child is gaining weight.

Step 7 Prescribe feeding needed (see chart) and place ngt.

Steps 8, 9 & 10: Ensure appetite and weight are monitored and start catch-up feeding (usually day 3 – 7). Provide a
caring and stimulating environment for the child and start educating the family so they help in the acute treatment
and are ready for discharge.
185
19. PROCEDURES
Table 32

220mL/Kg/day
Max

110
120
135
150
165
175
190
205
220
230
245
260
275
285
300
315
330
3 hourly feed volume

80
95
1). ANALGESIA AND SEDATION
F100 – catch-up feeding

Analgesia and behavioural strategies should be used in all children


150mL/Kg/day

prior to painful procedures, with sedative drugs added where


necessary

105
115
125
135
140
150
160
170
180
190
200
210
215
225
Min

55
65
75
85
95
Analgesia
a. Paracetamol
150mL/Kg/

Total Feeds

●● Neonate under 32weeks postmenstrual age: 15mg/kg 12hourly


/ 24 hrs

1050
1125
1200
1275
1350
1425
1500
1575
1650
1725
1800
450
525
600
675
750
825
900
975
day

(max 30mg/kg/day)
●● Under 3months: 15 mg/kg 6 – 8hourly orally or PR (max. 60
mg/kg)
3 hourly feed

●● Children above 3 months: 15 mg/Kg 4 -6hourly orally or PR


Severe oedema, even face

volume

100
(max 90 mg/Kg/day
110
115
120
125
135
140
145
150
40
45
50
60
65
70
75
85
90
95

b. Non Steroidal Anti-Inflammatory Drugs


●● Ibuprofen 2.5 - 10 mg/Kg 6-8hrly orally (max 30mg/Kg/day)
Total Feeds
/ 24 hrs

1000 c. Opioids
1050
1100
1150
1200
300
350
400
450
500
550
600
650
700
750
800
850
900
950
F75 – acute feeding

●● Codeine 0.5 - 1 mg/Kg/dose 6hourly orally


●● Pethidine 0.5–2 mg/kg/IM or 0.25 - 0.5 mg/Kg IV
3 hourly feed

●● Morphine 0.1 mg/Kg IM or 0.05 - 0.1 mg/Kg IV


No or moderate oedema

volume

100
105
115
120
130
140
145
155
160
170
180
185
195
Note:
50
60
65
75
80
90
130mL/Kg/day

●● Use IV if older child/adolescent with easy intravenous access.


●● Titrate boluses (i.e. give 1/2 of dose first to see effect, then
Total Feeds

repeat at 5 - 10 minute intervals as required up to maximum


/ 24 hrs

1040
1105
1170
1235
1300
1365
1430
1495
1560
390
455
520
585
650
715
780
845
910
975

total dose).
●● Respiratory depression risk - reduce doses if combined with
sedatives. May get delayed respiratory depression after treating
Weight (kg)

cause of pain.
10.0
10.5
11.0
11.5
12.0
3.0
3.5
4.0
4.5
5.0
5.5
6.0
6.5
7.0
7.5
8.0
8.5
9.0
9.5

●● Multiple trauma - do not withhold but give with caution,


particularly if hypovolaemic.

186 187
d. Sucrose Oral sucrose combined with non-nutritive sucking for infants under
three months
●● Oral sucrose reduces pain in infants less than three months of
age during minor procedures. Lumbar puncture
●● Oral sucrose may be given to infants during procedures such Topical anaesthetic cream for 30 - 45 mins, 1% Lignocaine with 25G
as blood collection, IV insertion, eye examination and lumbar needle.
puncture
Oral sucrose combined with non-nutritive sucking for infants under
●● Sucrose may be more effective if given with a dummy as the three months
dummy promotes non-nutritive sucking which contributes to
calming. Removal of nasal/pharyngeal foreign body
●● Other strategies, which assist in calming infants and can be Topical Phenylephrine (0.5%) & Lignocaine spray or nebulised
used as an adjunct to sucrose, include feeding (if allowed), Lignocaine (1.0%) 1mL in 3mL 0.9% NaCl.
cuddling, and wrapping.
Earache
●● Other appropriate local or systemic analgesic agents should be Topical 1% Lignocaine 2 drops
administered as required.
Eye
Dose:
Topical Amethocaine 0.5% to examine; patch +/- atropine (to relieve
●● Maximum 2mL Sucrose 24 – 33% (0.5mL for infants below 1500 iris spasm)
grams) administered orally for each procedure.
Oral sucrose combined with non-nutritive sucking for infants under
●● Two minutes prior to a painful procedure, administer a small three months
amount (around 0.25mL) of sucrose onto the infant's tongue.
Offer a dummy if this is part of the infants care. Regional anaesthesia
●● Continue giving remainder of sucrose slowly during the ●● Systemic analgesia – nitrous oxide
procedure for a total dose of 2mL, until the procedure is f. Sedation - Midazolam
completed.
Note: Indications
●● Procedures such as suturing, removal of foreign body among
●● Sucrose is only effective if given orally. There is no effect if
others
given via an oral or nasogastric tube
●● The addition of non-nutritive sucking enhances the analgesic Dose
effect of sucrose ●● By iv injection over 2–3 minutes 5–10 minutes before procedure
e. Specific uses of Analgesia ○○ Child 1 month–6 years, initially 25–50 micrograms/kg,
increased in small steps (max. total dose 6 mg)
IV insertion
○○ Child 6–12 years initially 25–50 micrograms/kg, increased if
Topical anaesthetic cream for 30 - 45 mins; distraction e.g. calico necessary in small steps (max. total dose 10 mg)
dolls.

188 189
○○ Child 12–18 years initially 25–50 micrograms/kg, increased if give antibiotics for meningitis even if the CSF is normal is normal
necessary in small steps (max. total dose 7.5 mg) initial tests
●● Oral /buccal 0.5 - 1.0 mg/Kg. (max 20mg) The clinical findings that suggest you should give Dexamethasone
●● Intranasal 0.6mg/Kg (max 10mg) - may have more rapid onset. and antibiotics immediately, and delay lumbar puncture for 1-2
days until the child is improving are:
●● Draw up solution (5 mg/mL) in a 1 or 2 mL syringe. May be
mixed with small volume of cordial to disguise acid taste. ●● Coma: absent or non-purposeful response to painful stimulus
- squeeze ear-lobe hard for up to one minute. A child over 3
Cautions months of age should push you away and seek a parent.
●● Observe the child in Emergency until fully alert (usually recover ●● Signs of raised intracranial pressure like abnormal pupillary
by 60 minutes) responses, unilateral or bilateral motor posturing or
●● Midazolam will potentiate the effects of other sedative drugs papilloedema (NB papilloedema is an unreliable and late sign of
e.g. Opiates. raised ICP in meningitis; a bulging fontanelle in the absence of
other signs of raised ICP, is not a contraindication).
●● Midazolam should not be given to children with pre-existing
respiratory insufficiency, or neuromuscular problems such as ●● Cardiovascular compromise / shock
myasthenia gravis. ●● Respiratory compromise
●● Focal neurological signs or seizures
2). LUMBAR PUNCTURE
●● Recent seizures (within 30 minutes).
Notes ●● Coagulopathy/thrombocytopenia
Lumbar puncture may be performed as part of the initial work up ●● Local infection (in the area where an LP would be performed)
of a sick child, or later in the course of an illness once the child has
●● The febrile child with purpura where meningococcal infection is
stabilised if there were initial contraindications.
suspected.
It is preferable to obtain a CSF specimen prior to antibiotic
administration; however this should not be unduly delayed in a Assessment prior to Lumbar Puncture for contraindications
child with signs of meningitis or sepsis. ●● Head CT Scans if focal neurological signs
○○ CT Scans are not helpful in most children with meningitis

Indications: ○○ A normal CT scan does not tell you that the patient does not
have raised ICP
●● Suspected meningitis or encephalitis
○○ Herniation may occur even in the presence of a normal scan.
●● Suspected Sub-arachnoid haemorrhage with a normal head CT
scan Complications:

Contraindications: Informed verbal consent should be obtained. Complications of LP


may include:
Do not do a lumbar puncture if the child is so sick that you would
●● Failure to obtain a specimen / need to repeat LP/ Traumatic tap
(common)

190 191
●● Post-dural puncture headache (fairly common) - up to 5-15% Spinal Needles
●● Transient/persistent paraesthesia/numbness (very uncommon) ●● 22G bevelled spinal needles with stylet (the use of needles
without a stylet has an associated risk of spinal epidermoid
●● Respiratory arrest from positioning (rare)
tumours)
●● Spinal haematoma or abscess (very rare)
●● Consider 25G pencil point needles for older children/
●● Tonsillar herniation (extremely rare in the absence of adolescents
contraindications above)
●● Pencil-point (blunt) needles reduce the risk of headache in
Analgesia, anaesthesia and sedation for Lumbar Puncture adults, however the evidence is not convincing in children. Their
●● Non-pharmacological techniques should be used where use may be appropriate in adolescents
possible, including explanation (in an older child), distraction,
Procedure
and the presence of a parent.
The most important determinant of a successful lumbar puncture is
●● All children should have some form of local anaesthetic for a strong, calm, experienced assistant to hold the patient. Position
lumbar puncture. of the patient is critical.
○○ Use topical anaesthetic cream except where specimens are
required urgently Position:
●● Lumbar puncture may be performed with the child lying on their
○○ Subcutaneous Lignocaine may be used in addition to or
side or sitting up.
instead of topical anaesthetic.
●● Aim for maximum flexion of the spine (curl into fetal position),
●● Use up to 0.4mL/Kg of 1% Lignocaine (4mg/Kg)
but avoid over flexing the neck, especially in infants as this may
●● Oral Sucrose 24 – 33% should be used for infants <3 months cause respiratory compromise. Ask an adolescent to slouch
●● Sedation, including nitrous, should be considered for children rather than bend from their hips
older than 6 months with normal conscious state ●● Ensure that the plane of the back is exactly at 90 degrees to the
Monitoring: bed (i.e. not leaning towards or away from you). Make sure the
hips and shoulders are in line
●● Monitor all sedated or seriously ill children with continuous
pulse oximetry ●● Draw an imaginary line between the top of the iliac crests. This
intersects the spine at approximately the L3-4 interspace (mark
Equipment this if necessary)
●● At least one trained assistant to hold the child ○○ The conus medullaris finishes near L3 at birth, but at L1-2 by
●● Sterile gloves adulthood

●● Sterile drapes and procedure tray ○○ Aim for the L3-4 or L4-5 interspace

●● Skin preparation: Povidone iodine solution or Chlorhexidine Preparation:


●● Local anaesthetic Lignocaine, 2mL syringe, 25G needle ●● Wash hands and aseptically put on sterile gloves
●● CSF tubes (2) ●● Prepare the skin with Povidone-iodine or chlorhexidine and set
●● Spinal needle up sterile drapes.

192 193
●● Allow adequate time for the skin preparation to dry ●● Send specimens urgently to the lab for microscopy, protein,
●● Take the tops off the tubes, ensuring that they remain sterile glucose, culture, bacterial antigen tests, and viral tests if
encephalitis is suspected
●● Infiltrate the skin with 1% Lignocaine using a 25G needle
Post-Procedure Care
Lumbar Puncture:
Cover the puncture site with a band-aid or occlusive dressing
●● Position the needle in the midline with the bevel pointing
towards the ceiling (lateral decubitus position) or to the side Bed-rest following lumbar puncture is of no benefit in preventing
(sitting) headache in children or adults.

●● Pierce the skin with the needle and pause. Wait for the child to 3). SUPRAPUBIC ASPIRATE
stop wriggling
●● Reorientate (ensure that back is vertical, needle is parallel to the Notes
bed and perpendicular to the back). Aim for the umbilicus (i.e. Suprapubic aspiration is the gold standard for obtaining urine
slightly cephalad) specimens for culture.
●● Advance the needle into the spinous ligament (increased Any growth of pathogenic bacteria in an SPA specimen is felt to be
resistance). Continue to advance the needle within the ligament significant
until there is a fall in resistance. Remove the stylet. If CSF is not
obtained replace the stylet and advance the needle slightly then Indications:
recheck for CSF ●● Any child (regardless of age) who is unable to void on request,
○○ An alternative technique is to remove the stylet once the who requires a urine specimen for the diagnosis or exclusion of
needle is in the ligament and advance very slowly without urinary tract infection
stylet watching for CSF to flow back. This has the advantage of
Contraindications:
making it harder to go unintentionally past the subarachnoid
space ●● Bleeding diathesis

○○ If the needle meets resistance, withdraw the needle slowly ●● Abdominal distension
whilst watching for CSF. If none is obtained, replace the stylet, ●● Massive organomegaly
re-orient the needle and re-try
Complications:
○○ If blood stained fluid is obtained collect some for culture. If it
clears it can be used for a cell count. If it fails to clear another Include:
attempt at a different level may be required ●● Macroscopic haematuria (infrequent — not usually clinically
●● If CSF is flowing, collect into 2 numbered sterile tubes (5-10 significant)
drops each is usually adequate) ●● Bladder haematoma (rare)
●● Replace the stylet (this may reduce risk of headache), and ●● Bladder haemorrhage (very rare)
remove the needle and stylet
●● Intestinal perforation (rare — not usually clinically significant)
●● Apply brief pressure to the puncture site
●● Anaerobic bacteraemia or abscess formation (very rare)

194 195
Equipment B. Suprapubic Aspirate Procedure
●● One assistant to hold the infant (not parent) ●● Ask assistant to hold infant supine with legs extended
●● Specimen jar for urine ●● Ask parent to be ready to catch urine if the patient voids
●● 23G needle (25 G for premature infants) ●● Wipe the skin with an alcohol swab
●● 5 mL syringe ●● Identify the puncture point

Analgesia, Anaesthesia, Sedation ○○ Midline

●● Topical anaesthetic cream should be used except where ○○ Lowest abdominal crease
specimens are required urgently (e.g. prior to starting antibiotic ●● Insert needle perpendicular to the skin, aspirating gently as you
treatment in a septic infant) advance the needle
●● Oral Sucrose should be used for infants <3 months ●● If no success, withdraw the needle to just under the skin, and
●● Sedation should be considered for children older than 6 months advance at an angle with the needle aimed more away from the
especially where several procedures are required (e.g. lumbar pelvis
puncture, IV cannulation) ●● If urine is obtained, remove needle and squirt urine into sterile
●● Non-pharmacological techniques should be used where urine jar
possible, including explanation (in an older child), distraction,
Post-Procedure Care
and the presence of a parent.
●● Place a bandaid over the puncture site (optional)
Procedure ●● Warn parents that there may be a small amount of blood in the
Rules: urine in the next day, but that they should return if there are
large amounts or if they are concerned.
1. Never undo the nappy until you have a urine jar handy and
someone ready to catch 4). NEEDLE THORACOCENTESIS
2. Do the suprapubic aspirate before collecting blood or CSF as
the child may void while having venepucture/lumbar puncture Indications:
○○ The use of ultrasound increases the chance of success ●● Primary spontaneous pneumothorax
○○ Ultrasound does not tell you where to put the needle - only ●● Tension pneumothorax
whether there is likely to be enough urine present.
Relative contraindications:
A. What to do if no bladder ultrasound is available Thoracocentesis should be considered only in consultation with a
●● History of no voiding in the past 30 minutes, and the presence senior emergency physician in the following:
of a dry nappy increases the chance of a successful tap ●● Spontaneous pneumothorax in patients with underlying lung
●● Pre-hydration increases the chance of a successful blind tap disease
●● If bladder is dull to percussion, there is a higher chance of ●● Traumatic pneumothorax without tension
successful aspiration

196 197
Equipment ●● Secure cannula/CVC with tape
●● Dressing pack ●● Attach 3 way tap and 50mL syringe
●● Aspiration device ●● Drain until no further drainage or to a maximum of 30mL/Kg
●● Large bore cannula (12 or 14 gauge) (max 2.5L)

●● Central venous catheter (CVC) or Pigtail catheter are alternatives Post-Procedure Care
●● 20mL or 50mL syringe
Reassess ABCs
●● 3 way tap ●● Consider need for further analgesia
●● Antiseptic solution ●● Plan for chest drain (intercostal catheter insertion) in patients
●● 1% Lignocaine with tension pneumothorax
Organise appropriate patient disposition
Analgesia, Anaesthesia, Sedation
Analgesia and local anaesthesia are mandatory except with tension
pneumothorax, which is immediately life-threatening.
●● Use topical local anaesthetic
●● Consider oral or parenteral analgesia pre- and post-procedure

Procedure
●● Place patient on continuous cardiac monitoring and pulse
oximetry
●● Place trauma patient in a head-up, supine position
●● All other patients should be placed in 45-degree, sitting position
●● Palpate landmark (the upper border of the 3rd rib in the
midclavicular line) and antiseptically prepare the area
●● Attach a 5mL syringe to the catheter device
●● Puncture the skin at the level of above landmark
●● Carefully insert the needle at a slightly downwards angle into
the pleural space while aspirating the syringe
●● In tension pneumothorax, often you will feel a pop or a change
in resistance
●● Withdraw the needle while gently advancing the cannula
downwards into position

198 199
APPENDICES APPENDIX I

200 201
202 203
204 205
206 207
208 209
210 211
●● Formulas for normal blood pressure 50th centile from 6 years.
○○ Systolic = 90mmHg + (2 x age in yrs)
○○ o Diastolic= 70mmHg + (2 x age in yrs)
●● Formulas for high blood pressure 95th centile from 2years.
○○ Systolic = 100mmHg + (3 x age in yrs)
○○ Diastolic=Calculated systolic minus 20mmHg
Age HR/min RR/min BP mmHg

0 -1 mo 93 -182 26 -65 45 – 80/33 – 52

1 – 3 mo 120 – 178 28 – 55 65 – 85/35 – 55

APPENDIX II
3 – 6 mo 107- 197 22 – 52 70 – 90/35 – 65

6 – 12 mo 108 – 178 22 – 52 80 – 100/40 – 65

1 - 2 yrs 90 – 152 20 – 50 80 – 100/40 – 70

2 – 3yrs 90 – 152 20 – 40 80 – 110/40 – 80

3 – 5 yrs 74 – 138 20 – 30 80 – 115/40 – 80

5 – 7 yrs 65 – 138 20 – 26 80 – 115/40 – 80

8 – 10 yrs 62 – 130 14 – 26 85 – 125/45 – 85

11 – 13 yrs 65 – 130 14 – 22 95 – 135/45 – 85

14 – 18 yrs 62 – 130 12 – 22 100 – 145/50 - 90

212 213
Blood Pressure Centiles for Boys Blood Pressure Centiles for Girls

214 215
Hypertension Treatment Algorithm

APPENDIX III

216 217
ADMISSION CRITERIA ●● Recurrent seizures. Children who have had more than one
convulsion during an episode of illness

Suggested General Admission Criteria ●● Focal neurological deficits following a seizure


●● Children with a persistently altered level of consciousness
●● Serious bacterial infection requiring IV antibiotics – Meningitis, exceeding two hours after termination of the seizure
Pyelonephritis, Neonatal Sepsis, Severe Pneumonia,
●● Any Child who was drowsy before the seizure
Osteomyelitis
●● Children who have received multiple doses of diazepam,
●● Oral feeding not desired or possible
intravenous Phenobarbitone or Phenytoin for control of seizures
●● Intravenous fluid therapy
●● Convulsion associated with trauma.
●● A new infiltrate on chest x-ray in a patient with Sickle Cell
●● Parents who are not reassured despite an apparent recovery
Disease
after seizure
●● Oxygen requirement of FIO2 more than 40% to maintain
●● Children with seizures living in “inadequate / at risk” home
saturations of ≥95%
environments
●● Continuous Salbutamol nebulization in acute bronchospasm
●● Convulsions with suspected Non accidental injury
●● Worsening Asthma Or severe acute asthma
●● Children known to have poorly controlled convulsive disorders
●● Burns – more than 10%BSA, Perineum, hands, feet, face, joints.
●● Convulsions associated with illnesses that require management
3rd degree, Electrical, Chemical, Inhalational, co-morbidities,
such as severe dehydration, Otitis media, Bronchopneumonia,
●● Questionable social support and unlikely to follow up and severe malnutrition etc
●● Concerns about the parent's ability to monitor their child's ●● Recurrent vomiting with dehydration
condition and to provide appropriate care, consider admission
●● Head injury
to hospital
●● Suspicion of child abuse Suggested Admission Criteria for Malaria
●● High fever >38.3OC in a child less than 3months old and
●● Prostration (inability or difficulty to sit upright, stand or walk
>38.9OC in an older child
without support in a child normally able to do so, or inability to
●● Altered mental status AVPU <A drink in children too young to sit)
●● History of Apnoea ●● Alteration in the level of consciousness – AVPU less than A

Suggested Admission Criteria for Neurological Disease ●● Cerebral malaria (unarousable coma not attributable to any
other cause in patients with falciparum malaria)
●● Status Epilepticus ●● Respiratory distress (acidotic breathing)
●● Any child having a first convulsion needs observation and ●● Multiple generalized convulsions (2 or more episodes within a
exclusion of meningitis 24 hour period)
●● Children having prolonged convulsions exceeding 30 minutes ●● Circulatory collapse (shock, septicaemia)

218 219
●● Pulmonary oedema 6. After high-risk cardiovascular and intra-thoracic procedures
●● Abnormal bleeding (Disseminated Intravascular Coagulopathy) (ICU)

●● Jaundice 7. Need for monitoring of arterial, central venous, or pulmonary


artery pressures
●● Haemoglobinuria (black water fever)
8. Need for temporary cardiac pacing
●● Acute renal failure – presenting as oliguria or anuria
●● Severe anaemia (Hb <5g/dl or Hct < 15%) Central Nervous System

●● Hypoglycaemia (blood glucose level < 2.2.mmol/l) 1. Seizures requiring continuous infusion of anticonvulsive
agents (ICU)
●● Hyperparasiteamia (parasitaemia of >3+ or >1%)
2. Acutely deterioration of consciousness (ICU)
●● Hyperlactataemia
3. After neurosurgical procedures requiring invasive monitoring
●● For the patients sent home on antimalarials but on subsequent
or close observation
review found to be having:
4. Head trauma with increased intracranial pressure
•• Persistent vomiting or
5. Preoperative neurosurgical conditions with neurologic
•• Persistent fever
deterioration
ICU and HDU Admission Criteria 6. Progressive neuromuscular dysfunction (ICU)
7. Spinal cord compression or impending compression
Respiratory System
8. Placement of external ventricular drainage device
1. Endotracheal intubation (ICU)
Hematology/Oncology
2. Severe Respiratory distress
1. Exchange transfusions, Plasmapheresis or leukapheresis
3. Rapidly progressive respiratory failure (ICU)
2. Severe coagulopathy
4. High supplemental oxygen requirement (FIO2 0.5)
3. Severe anemia resulting in hemodynamic and/or respiratory
5. Newly placed tracheostomy
compromise
6. Acute barotrauma (ICU)
4. Severe complications of sickle cell crisis (ICU)
Cardiovascular System 5. Initiation of chemotherapy with anticipated tumor lysis
1. Shock (ICU) syndrome
2. Post cardiopulmonary resuscitation 6. Tumors or masses compressing or threatening to compress
vital vessels or airway (ICU)
3. Life-threatening dysarrhythmias (ICU)
4. Unstable congestive heart failure Endocrine/Metabolic
5. Congenital heart disease with unstable cardio-respiratory 1. Severe diabetic ketoacidosis (ICU)
status 2. Hyperkalaemia (ICU)

220 221
3. Severe hypo- or hypernatraemia (ICU) Others
4. Hypo- or hypercalcaemia (ICU) 1. Toxic ingestions and drug overdose with potential acute
decompensation of major organ systems
5. Hypo- or hyperglycemia requiring intensive monitoring
2. Multiple organ dysfunction syndrome (ICU)
6. Severe metabolic acidosis (ICU)
3. Suspected or documented malignant hyperthermia
7. Complex intervention required to maintain fluid balance
4. Electrical or other household or environmental (e.g.,
8. Inborn errors of metabolism
lightning) injuries
Gastrointestinal 5. Burns covering >10% of body surface (consider transfer to a
1. Severe acute gastrointestinal bleeding burn units)
2. After emergency endoscopy for removal of foreign bodies
3. Acute hepatic failure leading to coma, hemodynamic, or
respiratory instability

Surgical
1. Cardiovascular surgery
2. Thoracic surgery
3. Neurosurgical procedures (ICU)
4. Otolaryngologic surgery
5. Craniofacial surgery
6. Orthopedic and spine surgery
7. General surgery with hemodynamic or respiratory instability
8. Organ transplantation
9. Multiple trauma with or without cardiovascular instability
(ICU)
10. Major blood loss, either during surgery or during the
postoperative period

Renal System
1. Acute Renal failure
2. Requirement for acute dialysis
3. Acute rhabdomyolysis with renal insufficiency

222 223
LABORATORY REFERENCE VALUES
BIOCHEMISTRY REFERENCE VALUES
REFERENCE
ANALYTE SPECIMEN AGE
INTERVALS
Adrenocorticotropic Plasma (EDTA) Cord 11-125 pmol/L
hormone (ACTH)
Newborn 2.2 - 41 pmol/L
Child < 26 pmol/L
Adult < 26 pmol/L
Alanine aminotransferase Serum Males 0 - 40 U/L
(ALT, SGPT)
Females 0 - 35 U/L
Albumin Serum 0 - 4 days 28 - 44 g/L

APPENDIX IV
≥1 year 35 - 50 g/L
Urine (24hr) 3.9 - 24 mg/dL
Aldolase Serum 10 months - 10-40 U/L
2 yrs
2- 16 yrs 5-20 U/L
Adult 2.5-10
Alkaline phosphatase Serum 4-15 yr (Male 54 -369 U/L
and female)
Male:20-50 yr 53-128 U/L
Female: 20- 42 -98 U/L
50 yr
Amylase Serum 1–13 years: 8-79U/L
≥14 years: 21-110U/L
Adult 30-110U/L
Aspartate transaminase Serum Males: 1–13 0- 60 U/L
(AST, SGOT) years:
≥14 years 0 - 48U/L
Female: 1–13 0 - 50 U/L
years
≥14 years 0 - 43 U/L
Bilirubin Total Serum Cord < 34.2µmol/L
Premature: 0 17 - 187µmol/L
-1 day

224 225
Premature ; 103 - 205µmol/L 1-2 years 0.07 - 1.5
1 - 2 days
2-3 years 0.06 - 1.4
Premature: 171 - 240 µmol/L
3 - 5 days 3-5 years 0.05 - 1.1
Full term: 0 34 - 103 µmol/L 5-7 years 0.04- 0.8
-1 day
> 7 years 0.04 - 0.7
Full term: 1 103 - 171µmol/L
-2 days Adult <0.75
Full term: 3 - 68 - 137µmol/L Chloride Serum, Plasma Child 95 -110mmol/L
5 days
Adult 98 - 107mmol/L
Adult 3 - 17µmol/L
Cholesterol (Total) Serum Coronary
Bilirubin Conjugated Serum 0 - 3.4µmol/L heart
disease risk
Calcium (Total) Serum, Plasma Neonate 1.85 -
2.75mmol/L Child: < 4.4mmol/L
Desirable
Infant/child 2.35 -
2.65mmol/L Borderline 4.40 -
high 5.15mmol/L
Adult 2.10 -
2.60mmol/L High > 5.15mmol/L
Adjusted Adult: <5.18mmol/L
Calcium Desirable
= Total
Borderline 5.18 -
Calcium +
high 6.19mmol/L
0.015 (40 –
Albumin) High > 6.19mmol/L
Urine calcium Urine (24hr) Cortisol (Total) Serum, Plasma Cord 138 - 469nmol/L
Neonate Upto 1 mmol/L Infant 53 - 304nmol/L
Child and 2.5 - 1 - 16 years 83 - 580nmol/L
Adult 7.5mmol/24hrs (AM)
Spot Urine Calcium/ Adult: AM 138 - 635 nmol/L
creatinine Adult: PM 83 - 441nmol/L
ratio:
in 2nd C-Reactive protein Serum Child/Adult < 10 mg/L
morning Creatine Kinase Serum, Plasma Neonatal upto 900 IU/L
urine
mmol/ Infant 100 - 480 IU/L
mmol Child/Adult
< 6 months < 2.42 mmol/ Male 30 - 200IU/L
mmol
Female 29 - 168IU/L
6-12 0.09 - 2.2
months

226 227
Creatinine Serum, Plasma Cord 53 - 106µmol/L Ferritin Serum Newborn 20 -200ug/L
newborn 27-88µmol/L 1 month 200-600ug/L
Infant 18-35µmol/L 2 -5 months 50 - 200ug/L
Child 27-62µmol/L 6months - 7 - 140ug/L
15yrs
Adolescent 44-88µmol/L
Adult males 30 - 400ug/L
Adult 53-97µmol/L
female Adult 15 - 150ug/L
females
Adult Male 62-115µmol/L
FSH Serum Males:
Urine (24hr) Child 71 -177µmol/Kg/
day 1 - 10yrs 0.3 - 4.6IU/L
Adolescent 71 - 165µmol/ >13yrs 1.4 -18.1IU/L
Kg/day
Females
Adult 124 - 230µmol/
1-10yrs 0.7 - 6.7IU/L
Kg/day
Follicular 2.5 - 10.2IU/L
Dehydroepiandrosterone Serum, Plasma Male:
sulphate phase
Tanner
Stages Mid-cycle 3.4 - 33.4IU/L
1 5 - 265 ug/dL Luteal 1.5 - 9.1IU/L
phase
2 15 - 380
Pregnant <0.3IU/L
3 60 - 505
Post 19.3 - 116IU/L
4 65 - 560
menopause
5 165 - 500 Gamma Glutamyl Serum Neonate upto 215U/L
Adult (18 - 125 - 619 transferase (GGT)
30yrs) Infant upto 107IU/L
Females Child upto 50 U/L
Tanner
stages Adult males < 60U/L

1 5 - 125ug/dL Adult < 38 U/L


female
2 15 -150
Glucose Plasma Fasting
3 20 - 535 (Fluoride)
4 35 - 485 Neonate 2.5 -5.5 mmol/L
5 75 - 530 Child 3.5 - 6.5 mmol/L
Adult (18 - 45 - 380 Adult 3.5 - 5.5 mmol/L
30 yrs)
CSF Infant/child 3.3 - 4.5mmol/L
Digoxin Serum (Trough) All ages 0.8 - 2.0ng/mL
Adult 2.2 - 3.9mmol/L

228 229
Glycosylated Haemoglobin Whole blood Non- 4 - 6% Adult 0.7 - 2.5mmol/L
(HbA1c) (EDTA) diabetic Lactate dehydrogenase Serum Newborn 125 - 765U/L
range
2 - 12yrs 125 - 220U/L
In diabetics
– >12yrs 180 - 360U/L
good < 6.5% LDL-Cholesterol Serum Desirable <2.59mmol/L
glycaemic
Near 2.59 -
control
optimal 3.34mmol/L
borderline 6.5 - 7.5%
Borderline 3.37 -
control
high 4.12mmol/L
poor >7.5%
High >4.12mmol/L
control
Magnesium Serum, Plasma Newborn 0.62 -
Growth Hormone Serum Basal 2 - 5ng/mL
0.91mmol/L
(Fasting)
6 - 12yrs 0.7 - 0.91mmol/L
HDL-Cholesterol Serum Desirable >1.2mmol/L
>12yrs 0.8 - 1.0mmol/L
Immunoglobulin A Serum 1 month 0.1 - 3.2g/L
Urine (24hr) Adult 3 - 5mmol/24hrs
6months - 0.2 - 3.4g/L
1yr Oestradiol Serum 6months - <55pmol/L
10yrs
>6yrs 1.1 - 6.6g/L
Adult
Immunoglobulin G Serum 1 month 4 - 16g/L
Female
6months - 5 - 19g/L
Follicular 0 - 979pmol/L
1yr
phase
>15yrs 10 - 23g/L
Mid-cycle 430 -
Immunoglobulin M Serum 1 month 0.05 - 2.2g/L 1300pmol/L
6months - 0.06 - 2.5g/L Luteal 95 - 606pmol/L
1yr phase
>6yrs 0.05 - 2.5g/L Post 0 - 150pmol/L
menopausal
Iron Serum Newborn 17.9 -
44.8µmol/L Adult Male 0 - 150pmol/L
Infant 7.2 - 17.9µmol/L Osmolality Serum Newborn 275 - 300mmol/
kg
Child 9 - 21.5µmol/L
7days - 1 274 - 305mmol/
Adult 10 - 30µmol/L
month kg
Lactate Plasma 1- 1.1 - 2.3mmol/L
(Fluoride) Adult 280 - 295mmol/
12months
kg
1 - 7yrs 0.8 - 1.5 mmol/L Urine Random 50 - 1200mmol/
7 - 15yrs 0.6 - 0.9 mmol/L specimen Kg

230 231
Phenytoin Serum Trough 10 - 20ug/mL Triglycerides Serum, Plasma 0 - 9yrs 0.34 -
sample 1.13mmol/L
Phosphate Serum Child 1.30 - 10 - 14 yrs 0.36 -
2.26mmol/L 1.41mmol/L
Adult 0.81 - 15 - 20yrs 0.42 -
1.45mmol/L 1.67mmol/L
Urine, 24hr (in Adult, 29 -42mmol/day Adults 0.5 - 1.5mmol/L
acid) unrestricted Urea Serum Newborn 1.4-4.3mmol/L
diet
Child 1.7 - 8.3mmol/L
Potassium Serum, plasma Newborn 3.7-5.9mmol/L
Adult 2.1-7.1mmol/L
Infant 4.1-5.3mmol/L
Uric acid Serum Child 0.12-0.32mmol/L
Child 3.4-4.7mmol/L
Adult male 0.21-0.42mmol/L
Adult 3.5-5.1mmol/L
Adult 0.15-0.35mmol/L
Protein (Total) Serum Neonate 46- 86g/L
female
1 month - 48 - 76g/L HAEMATOLOGY REFERENCE
1 yr VALUES
1 - 18yrs 60 - 80g/L
Adult 60 -85g/L TOTAL BLOOD COUNT(FBC) Whole blood
(EDTA)
Sodium Serum, plasma Newborn 126-166mmol/L
(cord) one month 2months- >1yr-6yrs
Child/Adult 135-146mmol/L 1yr

Testosterone Serum Male: 6 < 0.9 nmol/L


months - RBC (millions/mm3) 3.0-5.4 3.0-4.6 3.9-5.3
8yrs
HB (g/dl) 11.0 - 17.0 9.5-13.5 11.0-14.0
Female: 0 - < 0.9 nmol/L
PCV (%) 31-55 28-42 34-40
8 yrs
MCV (femtolitres) 85-123 74-108 75-87
Adult: Male 8.4 - 28.7 nmol/L
MCH (pg) 28-40 25-35 24-30
Adult: 0 - 2.8 nmol/L
Female MCHC (g/dl RBC) 29-37 29-40 31-37
TSH Serum Cord 0.4-12 UIU/L RETICULOCYTE (%) 0.3-1.0 0.4-1.0 0.2-2.0
Newborns 0.4-39 UIU/L WBC (x109/L) 4.1-15.8 4.1-15.8 4.9-13.6
1-11 0.8-6.3UIU/L NEUTROPHILS (x109/L) 1.3-7.5 1.3-7.5 1.3-7.5
months LYMOPHOCYTES (x109/L) 2.0-10 2.0-10 2.5-9.0
>1yr 0.25 - 4.7UIU/L MONOCYTES (x109/L) 0.2-1.8 0.2-1.8 0.2-1.0
Free T3 Serum 2.6 - 5.4pg/mL EOSINOPHILS (x109/L) 0.1-1.0 0.1-1.0 0.1-1
Free T4 Serum 0.8 - 2.0 ng/dL BASOPHILS (x109/L) <0.1 <0.1 <0.1

232 233
These reference values were extrapolated from published ranges Notes
and reagent package inserts

References:
1. Tietz Textbook of Clinical Chemistry and Molecular Diagnostics
( 2006)
2. Mosby's Manual of Diagnostic and Laboratory tests 2002

234 235
Notes Notes
Gertrude’s Children’s Hospital, Muthaiga
Tel: 0722 898948, 0713 222244, 07140714274; 0733 639444, 0733 222244;
020 7206000/1/2; 7206548, 2445350/1; 3763474, 3763400, 3764110
Lavington Clinic
Tel: 3876827; 3870460; 0721 394306; 0736 993100

Pangani Clinic
Tel: 6768801/2/3; 0711463020; 0737186688; 020 2384071

Doonholm Clinic
Tel: 789250/4/6; 0734 222022; 0723719612; 202 2385758

Nairobi West Clinic


Tel: 0710 200081; 0735 639063; 0750 898948; 020 6006327/8

Embakasi Clinic
Tel: 020 820784, 820795; 0714 333300

Komarock Clinic
Tel: 0720 939357; 0743 800491

E-mail: info@gerties.org
Web: www.gerties.org