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Bedside Clinical Guidelines Partnership

In association with

Paediatric
Guidelines
2010-12

This copy belongs to


(Name):..........................................................................................................
Further copies can be obtained from Partners in Paediatrics via
www.partnersinpaediatrics.org.uk
Published by the Bedside Clinical Guidelines Partnership and
Partners in Paediatrics
NOT TO BE REPRODUCED WITHOUT PERMISSION
Partners in Paediatrics comprises:
Alder Hey Childrens NHS Foundation Trust
Birmingham Childrens Hospital NHS Foundation Trust
Burton Hospitals NHS Foundation Trust
East Cheshire NHS Trust
Mid Staffordshire NHS Foundation Trust
NHS Dudley
NHS Stoke on Trent
NHS Telford & Wrekin
NHS Walsall
Robert Jones & Agnes Hunt Orthopaedic & District Hospital NHS Trust
South Staffordshire & Shropshire Healthcare Foundation NHS Trust
South Staffordshire PCT
The Royal Wolverhampton Hospitals NHS Trust
The Shrewsbury & Telford Hospital NHS Trust
University Hospital of North Staffordshire NHS Trust
Walsall Hospitals NHS Trust
Wolverhampton City PCT
The Bedside Clinical Guidelines Partnership comprises:
Ashford & St Peters Hospitals NHS Trust (Surrey)
Dudley Group of Hospitals NHS Trust
East Cheshire NHS Trust (Macclesfield)
Heart of England NHS Foundation Trust (Birmingham)
Hereford Hospitals NHS Trust (Hereford)
Hillingdon Hospital NHS Trust (Hillingdon)
Ipswich Hospitals NHS Trust
Lancashire Teaching Hospitals NHS Foundation Trust
Mid Cheshire Hospitals NHS Trust (Leighton, Crewe)
Mid Staffordshire General Hospitals NHS Trust
North Cumbria Acute Hospitals NHS Trust
Plymouth Hospitals NHS Trust
Portsmouth Hospitals NHS Trust
Princess Alexandra Hospital NHS Trust (Harlow, Essex)
Queens Hospital NHS Trust (Burton-on-Trent)
Royal Wolverhampton Hospitals NHS Trust
St Lukes Hospital, Kilkenny (Ireland)
Tameside and Glossop Acute Care NHS Trust
The Shrewsbury and Telford Hospital NHS Trust
The University Hospitals of Morecambe Bay NHS Trust
United Lincolnshire Hospitals NHS Trust
University Hospitals Birmingham NHS Foundation Trust
University Hospital of North Staffordshire NHS Trust
Walsall Hospitals NHS Trust

CONTENTS 1/3
Preface.......................................................................................................................... 6
Acknowledgements....................................................................................................... 8

A: ANAESTHETICS AND CRITICAL CARE


APLS - cardio-respiratory arrest................................................................................... 9
APLS - recognition and assessment of the sick child............................................... 12
Intraosseous infusion.................................................................................................. 16
Apparent life threatening events (ALTE)..................................................................... 18
Anaphylaxis................................................................................................................. 20
Pain assessment......................................................................................................... 22
Analgesia.................................................................................................................... 23
Sedation...................................................................................................................... 27
Flushing intravenous lines...........................................................................................29
IV Fluid therapy New for 2010-12 ....................................................................................... 32
Long line insertion.......................................................................................................33
Pre-op fasting..............................................................................................................36
Post GA monitoring ex-premature infants ..................................................................37

B: BREATHING (RESPIRATORY DISEASE)


Asthma acute management..................................................................................... 38
Bronchiolitis................................................................................................................. 42
Croup...........................................................................................................................45
Cystic Fibrosis Admission........................................................................................ 47
Cystic Fibrosis Exacerbation................................................................................... 49
Cystic Fibrosis Microbiology.....................................................................................51
Cystic Fibrosis Distal intestinal obstruction syndrome (DIOS)................................ 53
Pneumonia.................................................................................................................. 54
Pleural effusion........................................................................................................... 57
Pneumothorax............................................................................................................. 60

C: CARDIOVASCULAR DISEASE
Cyanotic congenital heart disease.............................................................................. 62
Heart failure and weak pulses.................................................................................... 64
ECG interpretation...................................................................................................... 66
Tachycardia and bradycardia...................................................................................... 70
Endocarditis prophylaxis............................................................................................. 75

D: DRUGS AND POISONING


Poisoning and drug overdose......................................................................................76
Alcohol poisoning........................................................................................................ 78
Iron poisoning..............................................................................................................79
Paracetamol poisoning................................................................................................81
Phenothiazine poisoning/side effects..........................................................................85
Salicylate poisoning.................................................................................................... 86
Tricyclic poisoning....................................................................................................... 88

E: ENDOCRINE/METABOLISM
Diabetes and fasting................................................................................................... 90
Diabetic ketoacidosis...................................................................................................93
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CONTENTS 2/3
Diabetes new (non-ketotic)......................................................................................... 99
Hypoglycaemia .........................................................................................................101
Ketone monitoring..................................................................................................... 107
Steroid dependence .................................................................................................108

G: GASTROENTEROLOGY
Abdominal pain......................................................................................................... 110
Constipation.............................................................................................................. 112
Diarrhoea and vomiting............................................................................................. 116
Nutritional first line advice ........................................................................................ 122
Failure to thrive..........................................................................................................125
Jaundice ...................................................................................................................127

H: HAEMATOLOGY
Blood and platelet transfusions.................................................................................130
Febrile neutropenia................................................................................................... 131
Henoch-Schnlein purpura....................................................................................... 134
Idiopathic thrombocytopenic purpura (ITP)...............................................................136
Haemophilia.............................................................................................................. 138

I: INFECTION
Antibiotics.................................................................................................................. 141
Bites.......................................................................................................................... 142
Cervical lymphadenopathy........................................................................................ 143
Fever New for 2010-12 .................................................................................................... 147
Hepatitis.................................................................................................................... 150
HIV and hepatitis B post-exposure prophylaxis (PEP)............................................. 151
New for 2010-12
HIV infection testing .................................................................................................
153
Immunodeficiency......................................................................................................155
Kawasaki disease......................................................................................................157
Malaria...................................................................................................................... 159
Meningitis.................................................................................................................. 161
Notifiable infectious diseases and food poisoning.................................................... 165
Orbital cellulitis.......................................................................................................... 167
Osteomyelitis and septic arthritis.............................................................................. 168
Petechial/purpuric rashes..........................................................................................173
Septicaemia (including meningococcal)....................................................................174
Tuberculosis.............................................................................................................. 177

N: NEUROLOGY
Facial palsy................................................................................................................180
Epilepsy..................................................................................................................... 181
Status epilepticus...................................................................................................... 186
New for 2010-12
Neuromuscular disorders .........................................................................................187
Glasgow coma score.................................................................................................189

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CONTENTS 3/3
P: PROTECTION
Child protection......................................................................................................... 190
Child sexual abuse.................................................................................................... 194
New for 2010-12
Self-harm .................................................................................................................
197

R: RENAL
Glomerulonephritis.................................................................................................... 198
Haemolytic uraemic syndrome..................................................................................200
Hypertension.............................................................................................................202
Nephrotic syndrome.................................................................................................. 206
Renal calculi..............................................................................................................210
Renal failure.............................................................................................................. 213
Renal investigations.................................................................................................. 216
Urinary tract infection................................................................................................ 219

R: RHEUMATOLOGY
Arthritis...................................................................................................................... 223
Limping child............................................................................................................. 224
Index..........................................................................................................................227

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PREFACE 1/2
This book has been compiled as an aide-mmoire for all staff concerned with the
management of general medical paediatric patients, especially those who present as
emergencies.
Guidelines on the management of common medical conditions
No guideline will apply to every patient, even where the diagnosis is clear-cut; there will
always be exceptions. These guidelines are not intended as a substitute for logical
thought and must be tempered by clinical judgement in the individual patient.

The guidelines are advisory, NOT mandatory


Prescribing regimens and nomograms
The administration of certain drugs, especially those given intravenously, requires great
care if hazardous errors are to be avoided. These guidelines do not include all guidance
on the indications, contraindications, dosage and administration for all drugs. Please
refer to the British National Formulary for Children (BNFc).

Practical procedures
DO NOT attempt to carry out any of these Practical procedures unless you have been
trained to do so and have demonstrated your competence

Evidence base
These have been written with reference to published medical literature and amended
after extensive consultation. Wherever possible, the recommendations made are
evidence based. Where no clear evidence has been identified from published literature
the advice given represents a consensus of the expert authors and their peers and is
based on their practical experience

Supporting information
Where possible the guidelines are based on evidence from published literature. It is
intended that the evidence relating to statements made in the guidelines and its quality
will be made explicit.
Where supporting evidence has been identified it is graded I to V according to standard
criteria of validity and methodological quality as detailed in the table below. A summary
of the evidence supporting each statement is available, with the original sources
referenced (ward-based copies only). The evidence summaries are being developed on
a rolling programme which will be updated as each guideline is reviewed.

Level of evidence

Strength of evidence

Strong evidence from at least one systematic review of multiple


well-designed randomized controlled trials
Strong evidence from at least one properly designed randomized
controlled trial of appropriate size
Evidence from well-designed trials without randomization, single
group pre-post, cohort, time series or matched case-control studies
Evidence from well-designed non-experimental studies from more
than one centre or research group
Opinions of respected authorities, based on clinical evidence,
descriptive studies or reports of expert committees

II
III
IV
V

JA Muir-Gray from Evidence Based Healthcare, Churchill Livingstone London 1997

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PREFACE 2/2
Feedback
Evaluating the evidence-base of these guidelines involves continuous review of both
new and existing literature. The editors encourage you to challenge the evidence
provided in this document. If you know of evidence that contradicts, or additional
evidence in support of the advice given in these guidelines please contact us.
The accuracy of the detailed advice given has been subject to exhaustive checks.
However, if any errors or omissions become apparent contact us so these can be
amended in the next review, or, if necessary, be brought to the urgent attention of users.
Constructive comments or suggestions would also be welcome.

Contact
Partners in Paediatrics, via www.partnersinpaediatrics.org.uk or Bedside clinical
guidelines partnership via e-mail: bedsideclinicalguidelines@uhns.nhs.uk

Issue 4
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ACKNOWLEDGEMENTS 1/1
Contributors
Mona Abdel-Hady
John Alexander
Maggie Babb
Sue Bell
Robert Brown
Deepak Chandra
Alistair Cranston
Karen Davies
Shireen Edmends
Sarah Goddard
Melissa Hubbard
Deirdre Kelly
Jackie Kilding
Aswath Kumar
Warren Lenney
Paddy McMaster
Andy Magnay
David Milford
Angela Moore
Ros Negrcyz
Tina Newton
Anna Pigott
Pawel Politylo
Ros Quinlivan
Parakkal Raffeeq
Clive Ryder
Martin Samuels
Ravi Singh
Tricia Smith
Andy Spencer
Sarah Thompson
Eve Tsouna

Pharmacist
Helen Haley

Microbiology reviewer
Krishna Banavathi

Paediatric Editors
Loveday Jago
Andrew Cowley
John Alexander
Paddy McMaster

Bedside Clinical Guidelines


Partnership
Paddy McMaster
Naveed Mustfa
Charles Pantin

Clinical Evidence Librarian


David Rogers

Partners in Paediatrics
Loveday Jago
Andrew Cowley
Andy Spencer
Lesley Hines

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APLS-CARDIO-RESPIRATORY ARREST 1/3


MANAGEMENT

Breathing (B)

l Stimulate patient to assess for signs


of life and shout for help
l Establish basic life support: Airway
Breathing Circulation
l Connect ECG monitor: identify rhythm
and follow algorithm
l Control airway and ventilation:
preferably intubate
l Obtain vascular access, peripheral or
intraosseous
l Change person performing chest
compressions every few minutes

Airway (A)
l Inspect mouth: apply suction if
necessary
l Use either head tilt and chin lift or jaw
thrust
l Oro- or nasopharyngeal airway
l Intubation:
l endotracheal tube sizes
l term newborns 33.5 mm
l aged 1 yr 4.5 mm
l aged >1 yr: use formula [(age/4) + 4]
mm for uncuffed tubes; 0.5 smaller for
cuffed
l If airway cannot be achieved by other
means, cricothyrotomy

Adrenaline doses for asystole


Route

Aged <12 yr

IV rapid bolus/ 10 microgram/kg


intraosseous
(0.1 mL/kg
of 1 in 10,000)

Endotracheal
tube (ETT)

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l Self-inflating bag and mask with


100% O2
l Ventilation rate
l unintubated: 2 inflations for every
15 compressions
l intubated: 1012/min, with continous
compressions
l Consider foreign body or
pneumothorax

Circulation (C)
l Cardiac compression rate:
100120/min depressing lower half of
sternum by at least one third: push
hard, push fast
l Peripheral venous access: one to two
attempts (<30 sec)
l Intraosseous access: 23 cm below
tibial tuberosity (see Intraosseous
infusion guideline)
l Use ECG monitor to decide between:
l a non-shockable rhythm: asystole or
pulseless electrical activity (PEA) i.e.
electromechanical dissociation
OR
l a shockable rhythm: ventricular
fibrillation or pulseless ventricular
tachycardia
Algorithm for managing these rhythms
follows:
l If arrest rhythm changes, restart
algorithm
l If organised electrical activity seen,
check pulse and for signs of circulation

Aged 12 yr adult

Notes

1 mg
(10 mL of 1 in
10,000)

Initial and
usual
subsequent
dose

If given by
intraosseous route
flush with sodium
chloride 0.9%

100 microgram/kg
(0.1 mL/kg of 1 in 1000
or
1 mL/kg of 1 in 10,000)

5 mg
(5 mL of 1 in
1000)

Maximum dose is
5 mL of 1 in 1000

100 microgram/kg
(0.1 mL/kg of 1 in 1000
or
1 mL/kg of 1 in 10,000)

5 mg
(5 mL of 1 in
1000)

Exceptional
circumstances
(e.g. betablocker
overdose)
-

APLS-CARDIO-RESPIRATORY ARREST 2/3


SAFETY
Approach with care
Free from danger?
STIMULATE
Are you alright?
SHOUT
for help
Airway opening
manoeuvres

Look, listen, feel

5 rescue breaths

Check for signs of life


Check pulse
Take no more than 10 secs

Brachial pulse aged <1 yr


Carotid pulse aged >1 yr

CPR
15 chest compressions: 2 ventilations

VF/
pulseless VT

2 min CPR

DC Shock 4J/kg

Assess
rhythm

Asystole/
PEA

High flow O2
IV/IO access
If able intubate

Adrenaline after 3 DC
shock and then every
alternate DC shock
10 microgram/kg
IV or IO
rd

Amiodarone after 3rd and 5th


DC shock only
5 mg/kg IV or IO

2 min CPR

Continue CPR
High flow O2
IV/IO access
If able intubate

Return of
spontaneous
circulation
(ROSC)
see Postresuscitation
management

Adrenaline
immediately and
then every 4 min
10 microgram/kg
IV or IO

Consider 4 Hs and 4 Ts
If signs of life, check rhythm
If perfusable rhythm, check pulse

Modified from ALSG 2010, reproduced with permission

10

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APLS-CARDIO-RESPIRATORY ARREST 3/3


Defibrillation
l Use hands-free paediatric pads in
children, may be used anteriorly and
posteriorly

l Resume 2 min of cardiac


compressions immediately after giving
DC shock, without checking monitor
or feeling for pulse
l Briefly check monitor for rhythm
before next shock: if rhythm changed,
check pulse
l Adrenaline and amiodarone are given
after the third and fifth DC shock, and
then adrenaline only every other DC
shock

l Automatic external defibrillators (AEDs)


do not easily detect tachyarrythmias in
infants but may be used at all ages,
ideally with paediatric pads, which
attenuate the dose to 5080 J

PARENTAL PRESENCE
l Evidence suggests that presence at
their childs side during resuscitation
enables parents to gain a realistic
understanding of efforts made to
save their child. They may
subsequently show less anxiety and
depression
l Designate one staff member to
support parents and explain all
actions

l Team leader, not parents, must decide


when it is appropriate to stop
resuscitation

WHEN TO STOP
RESUSCITATION
l Unless exceptions exist, it is
reasonable to stop after 30 min of
CPR if you find:

l no detectable signs of cardiac output


and
l no evidence of signs of life (even if
ECG complexes)
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l Exceptions include:

l hypothermia (<32oC)

l overdoses of cerebral depressant


drugs (successful resuscitation has
occurred with 24 hr CPR)

l Discuss difficult cases with consultant


before abandoning resuscitation

POST-RESUSCITATION
MANAGEMENT
Identify and treat underlying
cause
Monitor
l Heart rate and rhythm
l O2 saturation

l CO2 monitoring

l Core and skin temperatures


l BP

l Urine output

l Arterial blood gases

l Central venous pressure

Request
l Chest X-ray

l Arterial and central venous gases


l Haemoglobin and platelets
l Group and save serum for
crossmatch

l Sodium, potassium, urea and


creatinine
l Clotting screen
l Blood glucose
l LFTs

l 12-lead ECG

l Transfer to PICU
l Hold a team debriefing session to
reflect on practice

11

APLS-RECOGNITION AND ASSESSMENT OF THE


SICK CHILD 1/4
SUMMARY OF RAPID CLINICAL
ASSESSMENT

l Reassessment of ABCDE at frequent


intervals necessary to assess
progress and detect deterioration

Assessment
Airway (A) and Breathing (B)
l Effort of breathing
l respiratory rate
l recession
l use of accessory muscles
l additional sounds: stridor, wheeze,
grunting
l flaring of nostrils
l Efficacy of breathing
l chest movement and symmetry
l breath sounds
l SpO2 in air

Circulation (C)
l
l
l
l
l
l
l

Heart rate
Pulse volume
peripheral
central (carotid/femoral)
Blood pressure
Capillary refill time
Skin colour and temperature

Disability (D)
l Conscious level
l Posture
l Pupils

Exposure (E)
l Fever
l Skin rashes, bruising

Dont Ever Forget Glucose


(DEFG)
Actions
l Complete assessment should take
<1 min
l Treat as problems are found
l Once airway (A), breathing (B) and
circulation (C) are clearly recognised as
being stable or have been stabilised,
definitive management of underlying
condition can proceed
12

CHILD AND PARENTS


l Give clear explanations to parents and
child
l Allow and encourage parents to
remain with child at all times

RECOGNITION AND
ASSESSMENT OF THE SICK
CHILD
Weight
Anticipated weight in relation to age
Age

Weight

Birth

3.5 kg

5 months

7 kg

1 yr

10 kg

Weight can be estimated using following


formulae:
l 012 months: wt (kg) = [age (m) / 2] + 4
l 16 years: wt (kg) = [age (y) + 4] x 2
l 714 years: wt (kg) = [age (y) x 3] + 7

Airway
Primary assessment of airway
l Vocalisations (e.g. crying or talking)
indicate ventilation and some degree
of airway patency
l Assess patency by:
l looking for chest and/or abdominal
movement
l listening for breath sounds
l feeling for expired air

Re-assess after any airway


opening manoeuvres
l Infants: a neutral head position; other
children: sniffing the morning air
l Other signs that may suggest upper
airway obstruction:
l stridor
l intercostal/subcostal/sternal recession
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APLS-RECOGNITION AND ASSESSMENT OF THE


SICK CHILD 2/4
Breathing
Primary assessment of
breathing

l Assess
l effort of breathing
l efficacy of breathing
l effects of respiratory failure

Effort of breathing
l Respiratory rates at rest at different
ages
Age (yr)

Resp rate (breaths/min)

<1

3040

12

2535

35

2530

612

2025

>12

1520

l Respiratory rate:
l tachypnoea: from either lung or
airway disease or metabolic acidosis
l bradypnoea: due to fatigue, raised
intracranial pressure, or pre-terminal
l Recession:
l intercostal, subcostal or sternal
recession shows increased effort of
breathing
l degree of recession indicates severity
of respiratory difficulty
l in child with exhaustion, chest
movement and recession will
decrease
l Inspiratory or expiratory noises:
l stridor, usually inspiratory, indicates
laryngeal or tracheal obstruction
l wheeze, predominantly expiratory,
indicates lower airway obstruction
l volume of noise is not an indicator of
severity
l Grunting:
l a sign of severe respiratory distress
l can also occur in intracranial and
intra-abdominal emergencies
l Accessory muscle use
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l Gasping (a sign of severe


hypoxaemia and can be pre-terminal)
l Flaring of nostrils
Exceptions
l Increased effort of breathing
DOES NOT occur in three
circumstances:
l exhaustion
l central respiratory depression
(e.g. from raised intracranial
depression, poisoning or
encephalopathy)
l neuromuscular disease (e.g.
spinal muscular atrophy, muscular
dystrophy or poliomyelitis)

Efficacy of breathing
l Breath sounds on auscultation:
l reduced or absent
l bronchial
l symmetrical or asymmetric
l Chest expansion and, more
importantly in infants, abdominal seesawing
l Pulse oximetry

Effects of respiratory failure on


other physiology

l Heart rate:
l increased by hypoxia, fever or stress
l bradycardia a pre-terminal sign
l Skin colour:
l hypoxia first causes vasoconstriction
and pallor (via catecholamine release)
l cyanosis is a late and pre-terminal sign
l some children with congenital heart
disease may be permanently
cyanosed and O2 may have little effect
l Mental status:
l hypoxic child will be agitated first,
then drowsy and unconscious
l pulse oximetry can be difficult to
achieve in agitated child owing to
movement artefact

13

APLS-RECOGNITION AND ASSESSMENT OF THE


SICK CHILD 3/4
Circulation
l Heart rates at rest at different ages
Age (yr)

Heart rate (beats/min)

<1

110160

12

100150

35

95140

612

80120

>12

60100

Pulse volume
l Absent peripheral pulses or reduced
central pulses indicate shock

Capillary refill
l Pressure on centre of sternum or a
digit for 5 sec should be followed by
return of circulation in skin within
2 sec
l can be prolonged by shock or cold
environmental temperatures
l not a specific or sensitive sign of
shock
l should not be used alone as a guide
to response to treatment

BP
l Cuff should cover >80% of length of
upper arm
l expected systolic BP = 80 + (age in
yrs x 2)
l Hypotension is a late and pre-terminal
sign of circulatory failure

Effects of circulatory
inadequacy on other
organs/physiology

l Respiratory system:
l tachypnoea and hyperventilation
occurs with acidosis
l Skin:
l pale or mottled skin colour indicates
poor perfusion

14

l Mental status:
l agitation, then drowsiness leading to
unconsciousness
l Urinary output:
l <1 mL/kg/hr (<2 mL/kg/hr in infants)
indicates inadequate renal perfusion

Features suggesting cardiac


cause of respiratory
inadequacy
l Cyanosis, not relieved by O2 therapy
l Tachycardia out of proportion to
respiratory difficulty
l Raised JVP
l Gallop rhythm/murmur
l Enlarged liver
l Absent femoral pulses

Disability
Primary assessment of
disability
l Always assess and treat airway,
breathing and circulatory problems
before undertaking neurological
assessment:
l respiratory and circulatory failure will
have central neurological effects
l central neurological conditions (e.g.
meningitis, raised intracranial
pressure, status epilepticus) will have
both respiratory and circulatory
consequences

Neurological function
l Conscious level: AVPU (Figure 1); a
painful central stimulus may be
applied by sternal pressure or by
pulling frontal hair

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APLS-RECOGNITION AND ASSESSMENT OF THE


SICK CHILD 4/4
Figure 1: Rapid assessment of level of consciousness

Alert

- responds to Voice

- responds to Pain

this level is equivalent


to 8 or less on GCS

Unresponsive

l Posture:
l hypotonia
l decorticate or decerebrate postures
may only be elicited by a painful
stimulus
l Pupils look for:
l pupil size, reactivity and symmetry
l dilated, unreactive or unequal pupils
indicate serious brain disorders

Respiratory effects
l Raised intracranial pressure may
induce:
l hyperventilation
l Cheyne-Stokes breathing
l slow, sighing respiration
l apnoea

Circulatory effects
l Raised intracranial pressure may
induce:
l systemic hypertension
l sinus bradycardia

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15

INTRAOSSEOUS INFUSION 1/2


INDICATIONS
l Profound shock or cardiac arrest,
when immediate vascular access
needed and peripheral access not
possible (maximum 2 attempts)
l allows rapid expansion of circulating
volume
l gives time to obtain IV access and
facilitates procedure by increasing
venous filling

EQUIPMENT
l Intraosseous infusion needles for
manual insertion or EZ-IO drill on
resuscitation trolley
l Alcohol swabs to clean skin
l 5 mL syringe to aspirate and confirm
correct position
l 10 mL sodium chloride 0.9% flush
l 20 mL syringe to administer fluid
boluses
l Infusion fluid

Insertion is painful, so use local


anaesthetic unless patient
unresponsive to pain.
Infiltrate with lidocaine 1%
12 mL (maximum dose
0.3 mL/kg) and wait 90 sec

16

PROCEDURE
Preferred sites
Avoid fractured bones and
limbs with fractures proximal to
possible sites
Proximal tibia
l Identify anteromedial surface of tibia
13 cm below tibial tuberosity
l Direct needle away from knee at
approx 60 to long axis of tibia
l Needle entry into marrow cavity
accompanied by loss of resistance,
sustained erect posture of needle
without support and free fluid infusion
l Connect 5 mL syringe and confirm
correct position by aspirating bone
marrow contents or flushing with
sodium chloride 0.9% 5 mL without
encountering resistance
l Secure needle with tape
l Use 20 mL syringe to deliver bolus of
resuscitation fluid

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INTRAOSSEOUS INFUSION 2/2


Figure 1: Access site on proximal tibia lateral view

Figure 2: Access site on proximal tibia


oblique view

Figure 3: Access site on distal tibia

Distal tibia

COMPLICATIONS

l Access site on medial surface of tibia


proximal to medial malleolus

Distal femur
l If tibia fractured, use lower end of
femur on anterolateral surface, 3 cm
above lateral condyle, directing
needle away from epiphysiss

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l Bleeding
l Infection
l revert to central or peripheral venous
access as soon as possible
l Compartment syndrome
l observe and measure limb
circumference regularly
l Palpate distal pulses and assess
perfusion distal to IO access site
17

APPARENT LIFE THREATENING EVENT (ALTE)


1/2
DEFINITION
A sudden, unexpected change in an
infants behaviour that is frightening to
the observer and includes changes in
two or more of the following:

Urgent
l Nasopharyngeal aspirate for virology
l Per-nasal swab for pertussis

l breathing, e.g. apnoea

l Urine microscopy and culture


(biochemistry: store urine for possible
further tests)

l consciousness

l ECG

l colour

l movement

l muscle tone

INVESTIGATION OF FIRST ALTE

l Chest X-ray

l Save blood and urine, if events recur


during admission, send for metabolic
and toxicology investigations

MANAGEMENT
Clinical history or examination
l If diagnosis apparent from clinical
history or examination, investigate
diagnosis

l If diagnosis not apparent from clinical


history or examination, perform
following assessment:

Assessment
l SpO2

l Fundoscopy by paediatric
ophthalmologist if:
l recurrent

l severe events (e.g. received CPR)

l history or examination raises concern


of child protection issues (e.g.
inconsistent history, blood in
nose/mouth, bruising or petechiae,
history of possible trauma)

l anaemic (because of intracranial bleed)

Investigations
Immediate
l FBC

l Blood glucose

l Plasma lactate
l Blood gases

l Blood culture
18

Admit for observation


l SpO2, ECG monitoring

l Liaise with health visitor (direct or with


liaison HV on wards)
l Check whether child is subject to a
child protection plan

After 24 hr observation
l If event brief and child completely well:
l reassure parents and offer
resuscitation training

l discharge (no follow-up appointment)

l All patients in following categories


should have consultant review and be
offered Care of Next Infant (CONI)
Plus programme and/or home SpO2
monitoring:
l parents remain concerned despite
reassurance
l recurrent ALTE

l severe ALTE (e.g. needing


cardiopulmonary resuscitation/PICU)
l extremely preterm (<32 weeks
gestation at birth)

l a sibling was either a sudden


unexplained death (SUD) or had
ALTEs
l family history of sudden death

Issue 4
Issued: November 2010
Expires: November 2012

APPARENT LIFE THREATENING EVENT (ALTE)


2/2
If events severe (e.g. CPR
given) or repeated events
l Multi-channel physiological recording

Further investigation
Exclude following disorders:
Gastro-oesophageal reflux
Seizures
Intracranial abnormalities
Cardiac arrhythmias
Upper airway disorder
Hypocalcaemia
Metabolic assessment

Abuse

Issue 4
Issued: November 2010
Expires: November 2012

pH study
EEG
CT or MRI brain
ECG and 24 hr ECG
Sleep study
Ca and bone screen
Urinary amino and organic acids
Plasma amino acids and carnitine metabolites
(e.g. MCAD)
Skeletal survey (including CT brain)
Blood and urine toxicology
Continuous physiological or video recordings

19

ANAPHYLAXIS 1/2
DEFINITION
Sudden onset systemic life-threatening
allergic reaction to food, medication,
contrast material, anaesthetic agents,
insect sting or latex, involving either:
l Circulatory failure (shock)
l Difficulty breathing from one or more
of following:
l stridor
l bronchospasm
l rapid swelling of tongue, causing
difficulty in swallowing or speaking

IMMEDIATE TREATMENT
Widespread facial or peripheral
oedema with a rash in absence
of above symptoms do not
justify adrenaline or
hydrocortisone. Give
chlorphenamine orally
l See Management of anaphylaxis
algorithm
l Remove allergen if possible
l Call for help
l IM adrenaline: dose by age (see
algorithm) or 10 microgram/kg:
l 0.1 mL/kg of 1:10,000 in infants (up
to 10 kg = 1 mL)
l 0.01 mL/kg of 1:1,000 (max 0.5 mL
= 0.5 mg)
l give in anterolateral thigh
l ABC approach: provide BLS as needed
l monitor SpO2, non-invasive blood
pressure and ECG (see algorithm)
l Repeat adrenaline after 5 min if no
response

Do not give adrenaline


intravenously except in cardiorespiratory arrest or in resistant
shock (no response to two
intramuscular doses)
SUBSEQUENT MANAGEMENT

l severe reactions with slow onset


caused by idiopathic anaphylaxis
l reactions in individuals with severe
asthma or with a severe asthmatic
component
l reactions with possibility of continuing
absorption of allergen
l patients with a previous history of
biphasic reactions
l patients presenting in evening or at
night, or those who may not be able
to respond to any deterioration
l patients in areas where access to
emergency care is difficult
l Monitor SpO2, ECG and non-invasive
BP, as a minimum
l Sample serum (clotted blood) for
mast cell tryptase at following times
and send to immunology:
l immediately after reaction
l 12 hr after symptoms started when
levels peak
l 624 hr after exposure or in
convalescence
l If patient presenting late, take as
many of these samples as time since
presentation allows
l Write mast cell tryptase on
immunology lab request form with
time and date of onset and sample to
allow interpretation of results

DISCHARGE AND FOLLOW-UP


l Discuss all children with anaphylaxis
with a consultant paediatrician before
discharge
l Discharge with an emergency plan,
including 2 adrenaline pen autoinjectors after appropriate training
l If still symptomatic give oral antihistamines e.g. loratidine or cetirizine
and steroids for up to 3 days
l Refer for out-patient to a consultant
paediatrician with an interest in
allergy

l Observe for a minimum of 6 hr to


detect potential biphasic reactions
and usually for 24 hr, especially in
following situations:
20

Issue 4
Issued: November 2010
Expires: November 2012

ANAPHYLAXIS 2/2
Management of Anaphylaxis
Remove
allergen

Intubation
or surgical airway

Complete
obstruction

Adrenaline IM
Partial
obstruction/ Nebulised adrenaline
Repeat nebuliser every
stridor
10 min as required
Hydrocortisone

Assess
A

No problem

Bag-mask ventilation
Adrenaline IM
Hydrocortisone

Apnoea

Assess
B

Wheeze

Assess
C

Shock

Adrenaline IM
Nebulised salbutamol
Repeat salbutamol as
required
Hydrocortisone
Consider salbutamol IV or
aminophylline IV

No problem

Basic and advanced


life support

No pulse

Adrenaline IM
Crystaloid
Adrenaline IV infusion

No problem

Re-assess No problem
ABC

Drugs in
anaphylaxis
Adrenaline IM:
pre-hospital
practitioners

Antihistamine 48 hr to
prevent recurrence

Dosage by age
<6 months

6 months6 yr

150 micrograms
(0.15 mL of 1:1,000)

612 yr

>12 yr

300 micrograms
(0.3 mL of
1:1,000)

500 micrograms
(0.5 mL of
1:1,000)

Adrenaline IM:
in-hospital
practitioners

10 micrograms/kg
0.1 mL/kg of 1:10,000 (infants and young children) OR
0.01 mL/kg of 1:1,000 (older children)1

Adrenaline IV

1 microgram/kg = 0.01 mL/kg of 1:10,000 over 1 min

Crystalloid
Hydrocortisone
(IM or slow IV)
1

20 mL/kg
25 mg

50 mg

100 mg

200 mg

Strength of IM adrenaline not intended to be prescriptive, 1:1,000 or 1:10,000 could be used


depending on what is practicable. Problem with keeping solely to 1:1,000 is that when used in
infants you are drawing up very small volumes
ALSG: APLS Anaphylaxis Algorithm: Updated January 2010

Issue 4
Issued: November 2010
Expires: November 2012

21

PAIN ASSESSMENT 1/1


SUGGESTED AGE GROUP:

FLACC
Behavioural

CATEGORIES

No particular expression or
smile
Normal position or relaxed

Face
Legs

2 months to 7 years
SCORING
1

Occasional grimace or frown,


withdrawn, disinterested
Uneasy, restless, tense

Frequent to constant quivering


chin, clenched jaw
Kicking, or legs drawn up

Lying quietly, normal position,


moves easily
No cry (awake or asleep)

Squirming, shifting back and


Arched, rigid or jerking
forth, tense
Crying steadily, screams or
Moans or whimpers, occasional
Cry
complaint
sobs, frequent complaints
Content, relaxed
Reassured by occasional
Difficult to console or comfort
Consolability
touching, hugging or being talked
to, distractible
Each of the five categories: (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability; is scored from 0 - 2 which results in
a total score between 0 and 10
(Merkel et al, 1997)

Activity

WONG AND BAKER PAIN ASSESSMENT SELF REPORT


l Suggested age group 4 yr
l Point to each face using the words to describe the pain intensity
l Ask child to choose a face that best describes their own pain and record the
appropriate number

10

From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong's Essentials of Pediatric
Nursing, ed. 6, St. Louis, 2001, p. 1301. Copyrighted by Mosby, Inc. Reprinted by permission

Analgesic interventions
Analgesic ladder
Increasing Pain
0
1-3
4-7
8-10

=
=
=
=

No pain
Mild pain
Moderate pain
Severe pain

Moderate

Mild

Paracetamol,
NSAID +
weak opioid
e.g. Codeine

Play Specialist
Intervention by play staff

Severe
Paracetamol,
NSAID +
potent opioid
e.g. Morphine
(PCA / NCA)

Preparation aid used: doll, verbal


Explanation, photos
Distraction: toys, bubbles, music, multi sensory,
books,
Refer all in need of analgesia and with
behavioural concerns

Paracetamol,
+NSAID

Slight
Paracetamol

NB: Check BNFc for contraindications/interactions/precautions etc

22

Issue 4
Issued: November 2010
Expires: November 2012

ANALGESIA 1/4
l For combination of analgesics to use, see Analgesic ladder in Pain assessment
guideline

TOPICAL
Age group
<1 month

Time to onset
During procedure

111 months
15 yr

Preparation
Glucose syrup on pacifier
(available as a tootsweet)
Ametop
EMLA

>5 yr

Ethyl chloride

Immediately

30 min
1 hr

Comments
For venepuncture or
cannulation
Causes itch, lasts 4 hrs
Remove after 1 hr
(see instructions leaflet)
If cannot wait for EMLA

MILD PAIN (pain score 1-3)


Drug and
preparation
Paracetamol
[oral/nasogastric
(NG)]
l Suspensions:
l 120 mg/5 mL
l 250 mg/5 mL
l Tablets/soluble
500 mg

Paracetamol
(rectal)
l Suppositories
l 60 mg
l 125 mg
l 250 mg
l 500 mg
l1g

Dose
l First dose 20 mg/kg
THEN
l 1520 mg/kg/dose 4-6 hrly:
l aged 311 months:
60120 mg/dose
l aged 15 yr: 120240 mg/dose
l aged 612 yr: 250500 mg/dose
l aged >12 yr: 500 mg1 g/dose

l First dose 30 mg/kg


THEN
l birth3 months: 20 mg/kg
8 hrly
l aged 3 months12 yr:
20 mg/kg 4 hrly
l aged >12 yr: 500 mg1 g
4 hrly

Paracetamol (IV) l <10 kg: 7.5 mg/kg


6 hrly
10 mg/mL
l 1050 kg: 15 mg/kg
46 hrly over 15 min
l >50 kg: 1 g 46 hrly

Issue 4
Issued: November 2010
Expires: November 2012

Maximum dose
Max total dose
in 24 hr
l Aged
<3 months:
60 mg/kg
l Aged
3 months:
90 mg/kg
l Aged
>12 yr: 4 g
l reduce after
48 hr
l Max total
dose in 24 hr:
l aged
<3 months:
60 mg/kg
l aged
3 months:
90 mg/kg
for 48 hr then
60 mg/kg
l aged >12 yr:
4g
l Max 30
mg/kg/day
l Max total
dose 60
mg/kg/day
l Up to 4 g
daily

Comments
l For mild pain
l Increase dose
interval in renal
impairment
l Avoid large doses in
hepatic impairment

l As for oral
paracetamol
l For mild pain when
oral/NG route not
possible

l As for oral
paracetamol
l For mild pain when
oral/NG/PR route not
possible

23

ANALGESIA 2/4
MODERATE PAIN (pain score 47)
Drug and preparation
Ibuprofen
l Liquid 100 mg/5 mL
l Tablets 200 mg and
400 mg

Dose
l Aged 3
months12 yr:
5 mg/kg
68 hrly
l Aged 12 yr:
200600 mg
68 hrly

Diclofenac
l Aged >6
months: 300
l Tablets:
micrograms1
l dispersible 50 mg
mg/kg 8 hrly
(can be used to give
smaller doses)
l enteric coated 25 mg
and 50 mg
l Suppositories
12.5 mg, 25 mg,
50 mg and 100 mg
Codeine
l Liquid 25 mg/5 mL
l Tablets 15 mg, 30
mg and 60 mg

Maximum
dose
l Aged
<12 yr:
max 30
mg/kg/day
l Aged
12 yr:
max
2.4 g/day

l Max
150
mg/day

l Max
l Aged <12 yr:
240
500 micrograms
mg/day
1 mg/kg
46 hrly
l Aged 12 yr:
3060 mg
46 hrly

Comments
l If aged <3 months or <5 kg use
only if recommended by consultant
l Avoid in renal dysfunction
l Contraindications:
l shock
l bleeding disorders
l hypersensitive to aspirin or other
NSAID
l Can be given to asthmatics if no
history of NSAID-induced
wheeze and chest clear on
auscultation
l As ibuprofen

l For moderate pain


l Caution in hepatic impairment
l If aged <1 yr, use only if
recommended by consultant
l Repeated doses increase risk of
respiratory depression
l Caution if renal impairment
l Contraindications:
l acute respiratory depression
l paralytic ileus
l Not to be given with other opioids
l Prescribe laxatives if given for
>24 hr

SEVERE PAIN IN CHILDREN >1 YR (pain score 810)


In head injuries/respiratory difficulties/upper airway obstruction, use
opioids only with consultant advice. Monitor children needing O2
and parenteral opioids with SpO2 +/- TcCO2 in an HDU setting
Analgesic method and
technique
Oral morphine
l Single dose before painful
procedure may be useful
l Use if no IV access or for
weaning from IV opioid
l If to be taken regularly
consider use of
prophylactic laxative

24

Dose
l
l
l
l

Aged 12 yr:
200400 microgram/kg 4 hrly
Aged 212 yr:
200500 microgram/kg 4 hrly
(max 20 mg)
l Aged >12 yr:
l 520 mg 4 hrly

Monitoring
l
l
l
l

Respiratory rate, maintain:


aged 12 yr, >16 breaths/min
aged 29 yr, >14 breaths/min
aged 1016 yr, >12
breaths/min
l if rate reduced, contact
medical staff

Issue 4
Issued: November 2010
Expires: November 2012

ANALGESIA 3/4
Analgesic method and
technique
Morphine patient/nursecontrolled analgesia
(PCA/NCA)
l PCA suitable for children
aged >5 yr (understand
and will press button);
NCA otherwise
l Nurses must be certified
competent in use of
PCA/NCA
l Use anti-reflux valve
unless dedicated cannula
l Use morphine 1 mg/kg
made up to 50 mL with
sodium chloride 0.9%
l thus 1 mL =
20 microgram/kg
l maximum of 50 mg/50 mL
Morphine infusion
l Use for severe pain when
unable to use PCA/NCA
l Use anti-reflux valve
unless dedicated cannula
l Use anti-syphon valve on
line
l Use morphine 1 mg/kg
made up to 50 mL with
sodium chloride 0.9%
l 1 mL/hr = 20
microgram/kg/hr; 2 mL/hr
= 40 microgram/kg/hr
l max 50 mg/50 mL
IV intermittent morphine
l Infusion preferable

SC intermittent opioid
l IV preferable
l Site 22/24 g SC cannula
at time of surgery or using
EMLA cream
l suitable sites: uppermost
arm, abdominal skin

Issue 4
Issued: November 2010
Expires: November 2012

Dose
l
l
l
l
l
l
l

If loading dose required:


experienced staff only
50100 microgram/kg
Background infusion if used
410 microgram/kg/hr
Bolus dose
1020 microgram/kg
(0.5-1 mL)
l Lockout time
l 530 min
l Maximum dose in 4 hr of
400 microgram/kg

l Loading dose of
100200 microgram/kg given
over 520 min
l Continuous infusion of
1040 microgram/kg/hr
l Start at 1 mL/hr
(= 20 microgram/kg/hr)
except after major surgery
when start at 2 mL/hr
(= 40 microgram/kg/hr) and
adjust according to pain and
sedation scores

l
l
l
l
l

Monitoring
Hourly observations
l Pain score
l Sedation score
l Pump displays
l Syringe movement
l Respiratory rate
l SpO2 if needed
l TcCO2 if needed
4 hourly observations
l Vomiting/itching
l Urinary retention
l Inspection of IV site

Hourly observations
l Pain score
l Sedation score
l Respiratory rate (as above)
l SpO2 monitoring
l Syringe movement
l IV site for infection
l Urinary retention

Give slowly over 5 min


Aged 112 yr:
100200 microgram/kg 4 hrly
Aged >12 yr:
2.510 mg 4 hrly

Hourly observations
l Pain score
l Sedation score
l Respiratory rate (as above)
l SpO2 monitoring

l Give slowly over 5 min


l Flush with 0.3 mL sodium
chloride 0.9%
l Prime cannula with
morphine solution
l Morphine:
l 100200 microgram/kg 3 hrly
l max 6 times in 24 hr

l Pain score
l Sedation score
l Respiratory rate (as above)

25

ANALGESIA 4/4
SEVERE PAIN IN CHILDREN AGED <1 YR (pain score 810)
In head injuries/respiratory difficulties/upper airway obstruction,
only use opioids with consultant advice. Monitor children requiring
O2 and parenteral opioids with SpO2 +/- TcCO2 in an HDU setting
Analgesic method and
technique
Oral morphine
l Use if no IV access or for
weaning from IV opiate

Morphine infusion
l Use anti-reflux valve
unless dedicated cannula
l Use anti-syphon valve on
line
l Use morphine 1 mg/kg
made up to 50 mL with
sodium chloride 0.9%
l thus 1 mL/hr =
20 microgram/kg/hr

IV intermittent morphine
l Infusion preferable

SC intermittent opiate
l IV preferable
l Site 24 g SC cannula at
time of surgery or using
EMLA cream
l suitable sites:
uppermost arm,
abdominal skin

26

Dose
l Aged 112 months:
l 100 microgram/kg 4 hrly
l max 5 doses in 24 hr

l Aged 36 months:
l loading dose 2550
microgram/kg over 3060 min
l continuous infusion of 1030
microgram/kg/hr (0.51.5
mL/hr)
l Aged 712 months:
l loading dose 100
microgram/kg over 3060 min
l continuous infusion of
1040 microgram/kg/hr
(0.52 mL/hr)
l Adjust in increments of
5 microgram/kg/hr according
to response
l
l
l
l
l
l

Aged 12 months:
25 microgram/kg 6 hrly
Aged 36 months:
50 microgram/kg 6 hrly
Aged 712 months:
100 microgram/kg 4 hrly

l Give slowly over 5 min


l Flush with 0.3 mL sodium
chloride 0.9%
l Morphine:
l aged 3-12 months
150 microgram/kg
l aged <6 months
6 hrly maximum
l aged 6 months
4 hrly maximum

Monitoring
l
l
l
l

Pain score
Sedation score
Respiratory rate, maintain:
if aged <6-months,
>20 breaths/min
l if aged 6-months,
>16 breaths/min
l if rate reduced, contact
medical staff
l SpO2 as appropriate
Hourly observations
l Pain score
l Sedation score
l Respiratory rate (as above)
l SpO2 monitoring
l Syringe movement
l Site for infection
l Urinary retention

l Hourly observations for


24 hr then 4 hrly if stable
l Pain score
l Sedation score
l Respiratory rate (as above)
l SpO2 monitoring
l
l
l
l

Pain score
Sedation score
Respiratory rate (as above)
SpO2 as appropriate

Issue 4
Issued: November 2010
Expires: November 2012

SEDATION 1/2
ASSESSMENT
Sedation and anaesthesia belong to the
same spectrum of impaired
consciousness
l In sedation, patient maintains the
following vital functions without
assistance:
l protection of airway, swallowing,
cough reflex
l respiration
l cardiovascular stability

Cautions
Discuss with anaesthetist before
sedation if any of following present:
l Abnormal airway (including large
tonsils)
l Sleep apnoea
l Respiratory failure
l Respiratory disease with significant
functional compromise
l Active respiratory tract infection
l Cardiac failure
l Raised intracranial pressure
l Decreased conscious level
l Neuromuscular disease
l Bowel obstruction
l Significant gastro-oesophageal reflux
l Renal impairment
l Liver impairment
l Previous adverse reaction to sedation
l Very distressed child

Potential difficulties
Sedation can be difficult in children:
l Taking anti-epileptics (can result in
increased or reduced effect of
sedating drug)
l Already taking sedating drugs
l With behavioural difficulties

Issue 4
Issued: November 2010
Expires: November 2012

PREPARATION FOR SEDATION


Information required
l Age
l Weight
l Procedure for which sedation required
l Previous sedation history
l Other drugs being taken
l Other major diagnoses and
implications in terms of respiratory
function and upper airway
competence
l Current health, including coughs,
colds, pyrexia
l Oral intake status

Consent for sedation (all cases)


Discuss with parent(s):
l Unpredictable response to medication
l Paradoxical excitation
l Failure of sedation (may need repeat
dose or general anaesthetic at future
date)
l Over-sedation (maintaining airway,
aspiration)

Fasting for moderateheavy


sedation

l There should be the following interval


before procedure:
l after a full meal: 6 hr
l after milk: 4 hr
l after clear fluids: 2 hr

For short, painless procedures


(e.g. CT or X-ray), give infants
aged <4 months normal milk
feed only and allow them to
sleep naturally
EQUIPMENT

l Portable oxygen
l Portable suction
l Appropriately sized face mask and
self-inflating resuscitation bag

27

SEDATION 2/2
SEDATION DRUG CHOICE
Drug
Chloral
hydrate

Route
l Oral
l Rectal

Melatonin

l Oral

Temazepam l Oral

Midazolam l Oral

Onset
Duration Dose
Comments Night
30 min1 hr 1-2 hr
l Night sedation
l more efficacious in
30 mg/kg
infants <15 kg or aged
l Pre-anaesthesia
<18 months
50 mg/kg
l Scans 70 mg/kg
l Maximum dose 2 g
l use for sedation before
l Aged 5 yr: 5 mg
1530 min 2-5 hr
EEG
l Aged >5 yr: 10 mg
l use 5 mg initially, if no
response, give further
5 mg
l 0.5 mg/kg
l CT, MAG3 scan
4590 min up to
l Up to 1 mg/kg for
4 hr
scans
l Max 30 mg
1530 min 12 hr

l Rectal
l Buccal

l IV

IV 23 min

l Nebuliser
Morphine
l Oral
15 min
sulphate

23 hr

MONITORING
l Keep under direct observation
l Once asleep or if <1 yr, monitor
saturation continuously
l Record saturation, heart rate and
colour every 15 min
l Discontinue once conscious level
returned to normal

SUBSEQUENT MANAGEMENT
Failed sedation

28

l Oral: 500
microgram/kg (max
20 mg) aged 1
month18 yr
l Rectal: 300500
microgram/kg
l Buccal:
l aged 6 months
10 yr: 200300
microgram/
kg (max 5 mg)
l aged >10 yr: 67 mg
l IV: 2550 microgram/
kg (max 6 mg aged
1 month6 yr; max
10 mg aged 612 yr;
max 7.5 mg aged
1218 yr)

l IV cannulation
(+EMLA or local
anaesthetic)
l more suitable for older
children
l not for CT scan
l repeat
100 microgram/kg IV
if necessary up to max
5 mg

l 200400
microgram/kg for
children >1 yr
l Max 20 mg

l may be combined with


midazolam 500
microgram/kg for
painful procedures

l Repeat maximum dose of initial drug


used after expected period of onset
l If repeat dose fails:
l call anaesthetist who may give IV
sedation (apply EMLA), or
l reschedule procedure for later date
under general anaesthetic

Paradoxical excitement

l Do not attempt further drug dose


l Discuss with anaesthetist. If unavailable
that day, reschedule procedure for later
date under general anaesthetic

Issue 4
Issued: November 2010
Expires: November 2012

FLUSHING INTRAVENOUS LINES 1/3


Ensure aseptic technique used
follow Trust standard
operating procedures for
infection control
l For drugs incompatible with sodium
chloride 0.9% flush before and after
with 5 mL of compatible solution
l Heparin flush must be prescribed and
recorded on the intravenous
prescription chart
l Small babies, multilumen catheters
and when flushing required several
times daily:
l sodium chloride 0.9% flush with
double the volume of lumen + 1 mL
l heparin flushing solution 0.5 mL
greater than volume of catheter and
any other equipment attached to it
(e.g. one-way tap, short extension)
l Older children use volumes below
unless serum sodium high

Heparin is potentially a
dangerous drug. Higher
strengths of heparin given
regularly to small babies could
lead to full anticoagulation.
Ensure that the correct strength
of heparin is prescribed. Do not
use heparin if any history of an
adverse reaction to it, e.g.
heparin induced
thrombocytopenia
PERIPHERAL IV CANNULAE
Flushing volume
l 3 mL

Continuous infusion in progress


l No flush required

Intermittent administration of
drugs

l Flush with sodium chloride 0.9%


injection after drug administration
(and between drugs if more than one
administered)
Issue 4
Issued: November 2010
Expires: November 2012

Not in use (preferable to


remove cannula)
l Flush every 8 hrs with sodium
chloride 0.9% injection

PERIPHERALLY INSERTED
LONG VENOUS CATHETER
(long line)
Continuous infusion in progress

l No flush required

Intermittent administration of
drugs within a 24 hr period
l Flush with sodium chloride 0.9% 5 mL
injection before drug administration
l Flush with heparin 10 units/mL 5 mL
after drug

Not in use

l Flush daily with sodium chloride 0.9%


2 mL injection followed by 2 mL
heparin 10 units/mL in sodium
chloride 0.9% injection

Draw up 2.5 mL heparin


solution and inject 2 mL. This
ensures flushing is completed
on the down stroke of the
syringe plunger. If plunger
allowed to reach end of the
barrel it can bounce back and
draw blood into catheter tip
SHORT-TERM CENTRAL
VENOUS CATHETERS
Acute care setting single, double and
triple lumen configurations

Continuous infusion in
progress
l No flush required

Intermittent administration of
drugs within a 24 hr period
l Flush with sodium chloride 0.9% 1 mL
injection before the drug, and sodium
chloride 0.9% 3 mL injection after
drug administration
29

FLUSHING INTRAVENOUS LINES 2/3


Intermittent blood sampling
l Flush with sodium chloride 0.9% 1 mL
injection after blood sampling and then
administer 2 mL of heparin 10 units/mL
in sodium chloride 0.9% injection

Not in use
l Flush daily via appropriate injection
membrane or needle-free device with
sodium chloride 0.9% 1 mL injection
followed by 2 mL heparin 10 units/mL
in sodium chloride 0.9% injection

Notes
l If additional extensions or ancillary
equipment are attached to catheter,
increase flushing volumes to take
account of extra volume of this
equipment. Exceed total volume
calculated by 0.5 mL
l Treat each lumen of catheter
separately

BROVIAC AND HICKMAN TYPE CENTRAL VENOUS CATHETERS


Flushing volumes
For sodium chloride 0.9% injection alone
Broviac 46 Fr

Draw up sodium chloride 0.9% 3.5 mL and inject 3 mL

Hickman 10 Fr

Draw up sodium chloride 0.9% 4.5 mL injection and inject 4 mL

For sodium chloride 0.9% injection followed by heparin 10 units/mL


solution
Broviac 46 Fr

Sodium chloride 0.9% 1.5 mL injection then draw up 2 mL heparin


10 units/mL solution and inject 1.5 mL

Hickman 10 Fr

Sodium chloride 0.9% 2 mL injection then draw up 2.5 mL heparin


10 units/mL solution and inject 2 mL

l For oncology patients >3.5 kg, 5 mL


of heparin 10 units/mL in sodium
chloride 0.9% injection may be used

Continuous infusion in progress


l No flush required

Intermittent administration of
drugs within a 12 hr period in
hospital
l Flush with sodium chloride 0.9%
injection before and after drug
administration via lumen, appropriate
injection membrane or needle-free
device

30

l For patients with pro-coagulant


condition, e.g. nephrotic syndrome,
flush with sodium chloride 0.9%
injection before and after drug
administration and then flush with
heparin 10 units/mL in sodium
chloride 0.9% injection

Intermittent administration of
drugs >12 hr apart in hospital
l Discard 3 mL before drug
administration

l Flush sodium chloride 0.9% 10 mL


before and after each drug

l Flush heparin 100 units/mL with


volume of line +0.5 mL (i.e. 12 mL)
Issue 4
Issued: November 2010
Expires: November 2012

FLUSHING INTRAVENOUS LINES 3/3


Insertion flush
l Flush with sodium chloride 0.9%
injection during procedure. At end of
procedure, lock with heparin 10 units/mL
in sodium chloride 0.9% injection in
appropriate volume as detailed above

Intermittent administration of
drugs within a 24 hr period in
the community
l Flush with sodium chloride 0.9%
injection before and after drug
administration and then flush with
heparin 10 units/mL in sodium
chloride 0.9% injection via lumen,
appropriate injection membrane or
needle-free device

Intermittent blood sampling


l Flush with sodium chloride 0.9%
injection after blood sampling and
then flush with heparin 10 units/mL in
sodium chloride 0.9% injection

Not in use
l Flush once weekly with 5 mL heparin
10 units/mL in sodium chloride 0.9%
injection. Always inject 0.5 mL more
of heparin solution than the volume of
the catheter plus the volume of
attached equipment e.g. one-way tap,
short extension

IMPLANTABLE PORT
(e.g. Portacath)
Continuous infusion in progress
l No flush required

Intermittent administration of
drugs
l Flush with sodium chloride 0.9%
10 mL injection before and after drug
administration and then flush with
5 mL heparin 10 units/mL in sodium
chloride 0.9% injection. After the last
intravenous dose of a course of
treatment, flush with sodium chloride
0.9% 5 mL injection followed by 5 mL
heparin 100 units/mL (e.g. Canusal
not Hepsal)

Not in use
l Flush monthly with sodium chloride
0.9% 5 mL injection followed by 4 mL
heparin 100 units/mL in sodium
chloride 0.9% injection

Insertion flush
l Flush with sodium chloride 0.9%
injection during procedure. At end of
procedure, lock with 2.5 mL heparin
100 units/mL in sodium chloride 0.9%
injection

GROSHONG CENTRAL
VENOUS CATHETER
l This special catheter has a slit valve
at the tip to prevent backflow of blood
into catheter. Heparin is not required
to maintain patency and sodium
chloride 0.9% should be used for
flushing (manufacturer recommends
sodium chloride 0.9% 5 mL injection
once weekly)

CENTRAL VENOUS
HAEMODIALYSIS CATHETERS
l Use heparin 100 units/mL in sodium
chloride 0.9% injection for heparin lock,
volume dependent on catheter size

Issue 4
Issued: November 2010
Expires: November 2012

31

IV FLUID THERAPY 1/1


For previously well children aged 1 month 16 yr (excluding renal, cardiac,
endocrinology, diabetic ketoacidosis and acute burns patients)
Hyponatraemia
may develop as
a complication
of any fluid
regime

If shock present administer 20 mL/kg sodium chloride 0.9% or


compound sodium lactate (Hartmanns)
(10 mL/kg in the setting of trauma)
Repeat if necessary and call for senior help
Consider blood or colloid if relevant

Symptomatic
hyponatraemia
is a medical
emergency

Estimate any fluid deficit and replace as sodium chloride 0.9% OR


compound sodium lactate (Hartmanns) over a minimum of 24 hr
Check plasma electrolytes
Calculate volume of maintenance and replacement fluids and select fluid type
VOLUME OF INTRAVENOUS MAINTENANCE FLUID
First 10 kg:
Subsequent 10 kg:
Each additional kg:

100 mL/kg/day
50 mL/kg/day
20 mL/kg/day

Up to a maximum of 2500 mL/day (males) or


2000 mL/day (females)
Use bags with potassium chloride premixed
Check serum potassium
VOLUME OF INTRAVENOUS REPLACEMENT FLUID
(to replace losses, reassess every 4 hr)
Fluids used to replace ongoing fluid losses should
reflect the composition of fluid being lost. Sodium
chloride 0.9% or sodium chloride 0.9% with potassium
0.15% will be appropriate in most cases

TYPE OF INTRAVENOUS MAINTENANCE FLUID


Many children may be safely administered sodium
chloride 0.45% with glucose 5% and potassium
0.15%, but see below:
In some circumstances children should be
administered isotonic fluids such as sodium
chloride 0.9% with potassium 0.15%, these include:
Plasma sodium <135 mmol/L
Intravascular volume depletion
CNS infection
Peri- and post-operative patients
Hypotension
Head injury
Bronchiolitis
Sepsis
Excessive gastric or diarrhoeal losses
Salt wasting conditions

Patients requiring both maintenance fluids and replacement of ongoing losses should receive a single isotonic
fluid such as sodium chloride 0.9% with potassium 0.15% or sodium chloride 0.9% with glucose 5%
Monitoring
Weigh patient before starting fluid therapy, then daily if possible
Check plasma electrolytes before commencing infusion, except before majority of elective surgery
Check plasma electrolytes every 24 hr whilst intravenous fluids are being administered
if abnormal or if plasma sodium <130mmol/L measure every 46 hr
Check plasma electrolytes immediately if clinical features suggestive of hyponatraemia; features include nausea,
vomiting, headache, irritability, altered level of consciousness, seizure or apnoea
Maintain fluid balance chart to record input and output. Oliguria may be due to inadequate fluid, renal failure,
obstruction or effect of ADH
Some acutely ill children with increased ADH secretion may benefit from restriction of maintenance fluids to 2/3 of
normal recommended volume
Contact senior paediatrician, PICU or paediatric anaesthetist if uncertain or ongoing fluid losses

When using syringe pump to administer IV fluids

l Do not leave bag of fluid connected (blood components excepted)


l Nurse to check following hourly:
l infusion rate

l infusion equipment
l site of infusion

l Close all clamps and switch off pump before removing giving set

32

Issue 4
Issued: November 2010
Expires: November 2012

LONG LINE INSERTION 1/3


INDICATIONS
l Use peripherally sited long lines in
patients requiring prolonged (>5 day)
courses of IV antibiotic therapy either
in hospital or at home (e.g. patients
with cystic fibrosis or bronchiectasis)
l Long line with tip in a central vein for
drugs that have to be given centrally
(e.g. if they cause phlebitis) or if risk
of infection high (e.g. parenteral
nutrition)
l in patients with difficult venous
access, or as compromise between a
standard and long line, it may be
easier to insert a shorter Leaderflex
line. These can last as long as
standard long lines

l Sterile clear dressing (e.g.


Opsite/Tegaderm)
l Incontinence pad
l 2 extra packs gauze swabs
l Alcoholic chlorhexidine (or other skin
antiseptic)
l 1 injectable bung
l 3 wide Steristrips (optional to secure
line)
l Sterile untoothed forceps (to feed line
up butterfly)

PROCEDURE
PIC Line preparation

EQUIPMENT
l Assistant
l Long line several types are in
common use: choose widest bore
possible
l Vygon PICC 3, 4 or 4.5 F 60 cm
Lifecath (Expert silver coated)
l Vygon Nutriline 2, 3 or 4 F 30 cm
l Leaderflex 22G (2.5 F) line 8 or 20 cm
l Vygon Neocath or Epicutaneo-cave
catheter 2 F (23G) 15, 30 or 50 cm
has different insertion technique, not
recommended except neonates

DO NOT ATTEMPT INSERTION


UNLESS YOU ARE FULLY
TRAINED
Use whichever line you have
been trained to use
l Flush solution: sodium chloride 0.9%
5 mL
l Single dressing pack
l Sterile gloves
l Sterile scissors
l 2 extra sterile towels
l 5 mL syringe/green needle
l Tape measure
Issue 4
Issued: November 2010
Expires: November 2012

l Assess whether patient will need


sedation. Rarely, children with needle
phobia will need the line inserted
under general anaesthetic. Arrange
appropriate person to administer
sedation
l If necessary, shave arm to avoid hair
plucking when dressing removed
l Specify exactly where you would like
topical local anaesthetic cream (e.g.
EMLA) sited. Basilic vein (medial) is
usually best. Apply anaesthetic cream
to chosen veins (3 sites) at least 1 hr
before starting procedure
l A BP cuff inflated to 80 mmHg is a
more reliable tourniquet than either
an elastic strip or a nurses squeeze
l Check patients notes for comments
about previous line insertions. Some
veins can be particularly difficult and
patient can often provide guidance
l Check whether blood samples are
required
l Gather all necessary equipment
including a spare line (unopened)

33

LONG LINE INSERTION 2/3


Consent

l Explain procedure and reassure


patient
l Obtain and record consent

Premedication and position of


patient
l Position patient seated in chair or
lying with his/her arm stretched out
and supported by table or bed (on a
utility drape)
l ensure patient in position and
comfortable, and lighting optimal
l Measure distance from site of
insertion to sternal notch (if inserting
in arm) or xiphisternum (if inserting in
leg) so catheter tip is placed outside
heart

Aseptic technique
l Wash hands, and put on apron/gown
and sterile gloves
l Clean patients skin thoroughly with
alcoholic chlorhexidine and allow to
dry in area of planned insertion
l Drape sterile sheet to expose only
chosen vein, and cover surrounding
areas to provide working room and a
flat surface on which to rest your line,
forceps and flush

Nutriline PIC line


l Assemble line fully and flush with
sodium chloride 0.9% 1 mL to ensure
patency
l Place everything you will need onto
sterile sheet within reach
l Ask assistant to apply tourniquet (or
squeeze patients arm), but remain
ready to release
l Check patient is ready for you to start
l Be careful: introducer for the PIC line
is much stiffer than a standard
cannula and more likely to perforate
the entire vein

34

l Insert peelable cannula until blood


flowing freely (it is not necessary to
thread needle into vein) in some
patients this will come quite quickly so
have catheter ready
l Ask assistant to release tourniquet to
reduce blood flow
l Taking the PIC line in forceps, pass it
up through cannula. At about 5 cm,
you will reach tip of the cannula. If
line passes easily beyond 6 cm, you
have probably succeeded. Resistance
at any point usually indicates failure
to thread vein, or curling of line.
Rotating butterfly needle so that the
bevel faces downwards may help to
introduce line into vein if it will not
thread more than 5 cm
l Insert line to previously measured
distance from site of insertion
l When tip of line is judged to be in
correct position, carefully withdraw
sheath and remove from around line
by pulling apart the two blue wings
l Pressing firmly on insertion site with a
piece of gauze, remove cannula
l Without releasing pressure on entry
site (it may bleed for a few minutes),
reassemble line and flush with sodium
chloride 0.9% 2 mL
l With sterile scissors, cut rectangle of
gauze (1 x 2 cm) to prevent hub of
line rubbing skin
l Check all connections are firmly
tightened. Coil any unused line next
to insertion site and secure with
Steristrips
l Cover entry site, connections and all
exposed line with one piece of clear
dressing (e.g. Opsite)
l X-ray line with 0.5 mL of contrast (e.g.
Omnapaque 240) in the line to check
tip position if near heart or if no blood
flushes back up line. Do not draw
blood back up line (this increases risk
of line blockage)
l Flush once more and line is then
ready to use
Issue 4
Issued: November 2010
Expires: November 2012

LONG LINE INSERTION 3/3


Leaderflex lines
l These are inserted using Seldinger
technique
l Cannulate target vein with either
needle provided or a blue cannula
l Feed guidewire into vein through
cannula sheath and remove sheath
leaving wire in situ
l Feed line over guidewire and into vein
with a gentle twisting action. It is
important that, at any time, operator
is able to grasp directly either free
end of wire or wire itself as it passes
through skin, to ensure that it does
not pass entirely into vein
l Remove guidewire and secure line in
place
l It is not necessary to verify position of
8 cm lines radiologically

Use an aseptic technique when


accessing the system or for
dressing changes
AFTERCARE
l Aim to insert to 20 cm and tape
remaining silastic length to skin with
an adhesive dressing e.g. Steristrip
l Place a folded half gauze swab under
the blue hub before taping down with
adhesive, then cover with transparent
dressing, minimising contact between
gauze and transparent dressing in
case removal is required for troubleshooting
l Flush after each use with sodium
chloride 0.9% 2 mL

Issue 4
Issued: November 2010
Expires: November 2012

LONG LINE CARE

l Keep dressing clean and intact


l Maintain aseptic technique for
accessing system and dressing
changes. Before accessing system,
disinfect hub and ports with
disinfectant compatible with catheter
(e.g. alcohol or povidone iodine)
l Assess site at least daily for any signs
of infection and remove if signs of
infection are present (only short-term
CVCs)
l Replace administration sets every
24 hr and after administration of
blood, blood products and lipids.
Routine catheter replacement is
unnecessary
l Assess need for device daily and
remove as soon as possible
l If hypersensitivity reaction to line
indicated by local redness or rash,
give hydrocortisone 5 mg made up to
5 mL with sodium chloride 0.9% after
antibiotics and leave in line until next
dose of antibiotics. Repeat if redness
persists
l Document insertion and all
interventions in patient notes

35

PRE-OP FASTING 1/1


PRINCIPLES
l Do not fast patients for longer than
necessary for their safety under
general anaesthesia
l Do not deny fluids for excessively long
periods; allow patients to drink within
these guidelines
l Use theatre time efficiently

Ideally give all children


(especially those aged <2 yr)
clear fluids up to 2 hr preoperatively. Liaise closely with
theatre to discover approximate
time of patients operation
POLICY
l Patients may take solid food and milk
(including formula) up to 6 hr before
elective surgery
l Patients may take breast milk up to
4 hr before elective surgery
l Encourage patients to take clear oral
fluids up to 2 hr before elective
surgery. Thereafter, sips of water may
be taken to enable tablets to be
swallowed
l clear fluids do not include fizzy drinks

l Clear fluids (e.g. water or fruit juice)


should be allowed according to thirst,
to finish before 1130 hr

Infants/children aged <1 yr


Morning operating lists
l Last formula milk feed before 0300 hr
l Last breast milk feed before 0500 hr
l Fruit juice (diluted as necessary) to
finish before 0700 hr

Afternoon operating lists


l Last formula milk feed before 0730 hr
l Last breast milk feed before 0930 hr
l Fruit juice (diluted as necessary) to
finish before 1130 hr

Nursing and medical staff


should ensure that all children
are encouraged to drink clear
fluids until 2 hr before
anaesthesia/surgery

PROCEDURE
All children aged 1 yr
Morning operating lists
l No solid food after midnight
l Allow clear fluids (e.g. water or fruit
juice) according to appetite, to finish
before 0700 hr

Afternoon operating lists


l Light breakfast (including toast,
continental breakfast or small bowl of
cereal), to finish before 0730 hr

36

Issue 4
Issued: November 2010
Expires: November 2012

POST GA MONITORING EX-PREMATURE INFANTS


1/1
l Risk of apnoea after general
anaesthetic (GA)
l increased if anaemic

l with chronic lung disease who have


required O2 treatment within last 6
months

MANAGEMENT
Pre-operative
l Check haemoglobin

l if Hb <9 g/dL, arrange transfusion

l Arrange overnight stay for postoperative monitoring if age (weeks)


<[3 x (38 gestational age in weeks)]
e.g. baby born at 30 weeks gestation
would be kept overnight after GA if
<24 weeks old. A 36 week baby
would be allowed home after GA if
>6 weeks old

Immediate post-GA period


l Transfer patient with O2 supply,
continuous SpO2 monitoring and full
resuscitative equipment

Subsequent post-GA
management
l High dependency nursing care
l Monitoring to include:

l continuous pulse oximetry


l continuous ECG

l continuous respiratory rate


l transcutaneous CO2
l If apnoea >15 sec:

l immediate respiratory support by


nurse (airway manoeuvres, bag and
mask ventilation)
l contact on-call SpR

l liaise with anaesthetist responsible for


patient
l review period of HDU care

DISCHARGE AND FOLLOW-UP


l Discharge patient home same day or
next day as calculated by above
formula providing there have been no
apnoeic episodes

l Admit patient to a designated HDU


ward area

Issue 4
Issued: November 2010
Expires: November 2012

37

ASTHMA ACUTE MANAGEMENT 1/4


RECOGNITION AND
ASSESSMENT
Definition
Asthma is a chronic inflammatory disorder
of the airways with reversible obstruction

Symptoms and signs


l
l
l
l
l
l
l
l
l
l
l

Breathlessness
Wheeze
Cough
Nocturnal cough
Tight chest
Bilateral wheeze
Symptoms and signs tend to be:
variable
intermittent
worse at night
provoked by triggers, including
exercise

Mild/moderate
l Normal vital signs
l Mild wheeze
l Speaks in complete sentences or
feeding
l SpO2 >92% in air
l PEF >75% in patient aged 7 yr

Severe
l Too breathless to talk/feed
l Tachypnoea (>50 breaths/min if aged
<5 yr; >30 breaths/min if aged >5 yr)
l Tachycardia (>130 beats/min if aged
<5 yr; >120 beats/min if aged >5 yr)
l Use of accessory muscles, recession
subcostal and intercostal, flaring of
alae nasi
l SpO2 <92% in air
l Peak expiratory flow (PEF) 50%
predicted/best

Life threatening
l Cyanosis/pallor
l Decreased air entry/silent chest
l Poor respiratory effort
38

l Altered conscious level


l Irritable/exhausted
l SpO2 <92% in air
l PEF 33% in those aged 7 yr

Patients with severe or life


threatening attacks may not be
distressed and may not have all
these abnormalities. Presence
of any one of these should
alert doctor
Differential diagnosis
l
l
l
l
l
l
l

Foreign body
Pneumonia
Pneumothorax
Aspiration
Cystic fibrosis
Tracheobronchomalacia
Gastro-oesophageal reflux

Investigations
l
l
l
l
l
l

Record:
respiratory rate
heart rate
air entry
O2 saturation in air
if aged 7 yr, peak expiratory flow
(PEF)
l conscious level

Do not take any samples for


routine blood tests or routine
blood gases.
Routine chest X-ray is
unnecessary in a child with
asthma
IMMEDIATE TREATMENT
l Follow algorithm Management of
acute wheezing

Senior assessment
If you are worried about childs conscious
level or there is no response to nebulised
salbutamol or poor respiratory effort:
l Call senior doctors for further
assessment
Issue 4
Issued: November 2010
Expires: November 2012

ASTHMA ACUTE MANAGEMENT 2/4


l Site an IV line
l Initial dose of IV salbutamol over
5 min (max 250 microgram)
l aged <2 yr: 5 microgram/kg
l aged >2 yr: 15 microgram/kg
l Using 500 microgram/mL injection
preparation dilute to a concentrate of
50 microgram/mL with sodium
chloride 0.9%
l e.g. withdraw 250 microgram = 0.5 mL
and make up to a total volume of 5 mL
using sodium chloride 0.9% =
250 microgram in 5 mL

Not responding

Monitoring
l Record heart rate and respiratory rate
every 10 min
l Continuous SpO2
l Cardiac monitoring
l Baseline U&Es (capillary blood gas
for potassium)

SUBSEQUENT MANAGEMENT
Follow the algorithm Management of
acute wheezing

Previous history

l Salbutamol 2 microgram/kg/min
continuous infusion
l use 1 mg/mL solution for IV infusion
dilute 10 mg (10 mL) to concentration
of 200 microgram/mL made up to
50 mL with sodium chloride 0.9%
l If not responding increase to
5 microgram/kg/min for 1 hr then
reduce back to 2 microgram/kg/min
l If requiring >2 microgram/kg/min
admit to PICU
l Use TcCO2 monitor
l Continue with high flow O2 and
continuous salbutamol nebuliser while
waiting

l When recovering, ask about:


l previous episodes of wheeze, similar
episodes
l triggering factors, seasonal variation
l nocturnal cough
l family history of asthma, hay fever,
eczema, other atopy
l smokers in the family (including child)
l days off school because of asthma
l number of courses of prednisolone
used in last year
l pets
l drug history (device and dose)
especially any bronchodilators/inhaled
corticosteroids, particularly the need
to use beta-agonists and their effect

Drug doses

DISCHARGE AND FOLLOW-UP

l Salbutamol nebulised driven by


68 L/min O2:
l aged <5 yr, 2.5 mg
l aged >5 yr, 5.0 mg
l Ipratropium bromide (Atrovent)
nebulised:
l aged <12 yr, 250 microgram
l aged >12 yr, 500 microgram
l Prednisolone 0.5 mg/kg oral:
l aged 15 yr, max 20 mg
l aged >5 yr, max 30 mg

Discharge criteria
l SpO2 in air >92%
l Respiratory rate: <50/min aged <5 yr;
<30/min aged >5 yr
l Heart rate: <130/min aged <5 yr;
<120/min aged >5 yr
l Peak flow: 75% predicted/best
l Stable on 4 hrly treatment

l Hydrocortisone slow IV injection:


l aged <2 yr, 4 mg/kg (max 25 mg) 6 hrly
l aged 25 yr, 50 mg 6 hrly
l aged 518 yr, 100 mg 6 hrly
Issue 4
Issued: November 2010
Expires: November 2012

39

ASTHMA ACUTE MANAGEMENT 3/4


Discharge home same day if:

l Child has made a significant


improvement and has remained stable
for 4 hr
l Parents:
l understand use of inhalers
l have a written plan
l know how to recognise signs of
deterioration

Discharge treatment
l Prescribe beta-agonist with spacer
l Give prednisolone 0.5 mg/kg daily for
35 days
l Educate on use of PEF meter if aged
>6 yr (not if child has never used one
before)
l Follow-up in either nurse-led asthma
clinic (if available) or consultant clinic

40

Chronic management
l Give inhaled corticosteroid if any of
following:
l frequent episodes
l bronchodilators used most days
l nocturnal and/or exercise-induced
symptoms
l other atopic symptoms and strong
family history of atopy
l If recurrent upper respiratory tract
problems or allergic rhinitis triggering
attacks, give steroid nasal spray

Issue 4
Issued: November 2010
Expires: November 2012

ASTHMA ACUTE MANAGEMENT 4/4


MANAGEMENT OF ACUTE WHEEZING
MILD/MODERATE

l Salbutamol MDI (metered


dose inhaler) 210 puffs
(2001000 microgram) via
large volume spacer (LVS)
+/- face mask
l O2 if SpO2 <92% in air
l Once daily oral
prednisolone

Reassess
1530 min

Discharge criteria met? (see


Discharge and follow-up)
YES
NO

SEVERE

l High flow O2 via mask or nasal


cannula
l Salbutamol MDI 10 puffs (1000
micrograms) via LVS +/- face
mask
OR
l Nebulised salbutamol driven by
68 L/min O2
l If poor response, give nebulised
ipratropium bromide
l Once daily oral prednisolone
l If oral steroids not tolerated give
hydrocortisone

ADMIT
l Continue high flow O2
via mask or nasal
cannula
l Nebulised salbutamol
15 min4 hrly
l If poor response repeat
ipratropium bromide
every 2030 min for
first 2 hr

LIFE THREATENING

l Inform on-call consultant


l High-flow O2 via mask or
nasal cannula
l Continuous nebulised
salbutamol driven by
68 L/min O2
l Nebulised ipratropium
bromide (see Drug
doses)
l Slow intravenous injection
of hydrocortisone (see
Drug doses)
l If signs of shock
20 mL/kg sodium
chloride 0.9% IV infusion

Reassess

Symptoms
improving

l Continuous nebulised
salbutamol
l IV salbutamol (see
Immediate treatment)
l Blood gases
l Chest X-ray

Re-assess frequency of
bronchodilator therapy

Symptoms
improving

No change/
worsening

l Check patient has


received:
l continuous nebulised
salbutamol
l nebulised ipratropium
bromide
l IV hydrocortisone

No
improvement

Is patient still not


improving/worsening?
DISCHARGE
HOME
Salbutamol bolus
(see Immediate treatment)
Symptoms improving
Reassess
Salbutamol infusion
(see Immediate treatment)
Issue 4
Issued: November 2010
Expires: November 2012

No improvement

41

BRONCHIOLITIS 1/3
RECOGNITION AND
ASSESSMENT
Definition
l Acute inflammatory illness of small
airways that occurs in winter
epidemics and affects children aged
<2 yr, with peak incidence at around
6 months
l Respiratory syncytial virus (RSV) is
causative agent in >50% of cases,
with parainfluenza 3, influenza and
adenovirus types 3, 7 and 21 causing
the remainder

Symptoms and signs


l Coryzal symptoms for two to five days
before presentation
l Cough (often paroxysmal)
l Intermittent wheeze
l Irritability and poor feeding
l Mild pyrexia rarely higher than
38.5C
l Respiratory distress with progressive
tachypnoea, flaring of alae nasi and
intercostal recession
l Apnoea or hypoventilation
l Hyperinflated chest on examination
l Widespread fine crackles and wheeze
over both lung fields

Differential diagnosis
l Recurrent viral-induced wheeze
l Early asthma
l Cystic fibrosis
l Pertussis
l Recurrent aspiration
l Foreign body in trachea
l Congenital lung anomaly

42

Investigations
l SpO2 while breathing air
l If respiratory rate >80 breaths/min,
transcutaneous PCO2 >6 kPa, SpO2
<92% in >50% inspired oxygen or
severe respiratory distress, measure
arterial or capillary blood gases
l Avoid tests that do not contribute to
immediate management. Perform
following only for specific indications:
l viral throat swab for RSV and
influenza if admission required for
oseltamivir if H1N1
l nasopharyngeal aspirate for
respiratory virus immunofluorescence
in severely immunocompromised
patient to plan antiviral treatment
l chest X-ray if there are localising
signs, cardiac murmur or atypical
presentation (e.g. aged >18 months)
l U&E if there is a plan for IV fluids
l blood cultures if signs of sepsis or
temperature >38.5C

IMMEDIATE TREATMENT
l Nurse in cubicle, or in bay with
children with same proven diagnosis
l Strict hand washing to support
infection control and use apron for
patient contact
l Nurse head up to reduce splinting of
diaphragm
l Clear airway by suction of nares and
mouth
l Use sodium chloride 0.9% nose drops
before suction

Respiratory
l If O2 saturation 92% in air, give O2
via face mask with a reservoir bag
l humidify oxygen
l if mask not tolerated, use nasal
prongs for oxygen flow up to 1 L/min
in children 5 kg body weight or up to
2.0 L/min in children >5 kg
Issue 4
Issued: November 2010
Expires: November 2012

BRONCHIOLITIS 2/3

l use humidifier if available to warm


oxygen
l In patients with impending respiratory
failure, review hourly. Consider
additional respiratory support with
CPAP if two or more of following are
present:
l respiratory rate >60 breaths/min
l bradypnoea or cyanotic episodes
(with or without bradycardia) despite
supplemental O2

l severe intercostal recession and


indrawing
l need for >2 L/min O2 via nasal prongs
l rising PaCO2 (>3 kPa from baseline)
l respiratory acidosis (pH <7.20)

Circulation and hydration


l Assess circulation and treat shock if
present
l Correct dehydration if present
l If oral fluids not tolerated, use IV
fluids
l restrict intake to 80% of estimated
maintenance requirements (see IV
fluid therapy guideline) using sodium
chloride 0.9% with 10 mmol
potassium chloride per 500 mL
l check U&E at least once every 24 hr
while giving intravenous fluids (more
frequently if abnormal), and adjust
volume and potassium content
accordingly

Feeds
l Normal feeds (breast, bottle, solids) if
tolerated
l NG tube feeds if:
l oral intake by normal route insufficient
and
l airway protective reflexes test normal
on suctioning
and
l patient well enough to tolerate NG
feeds
l IV fluids (as above) if:
Issue 4
Issued: November 2010
Expires: November 2012

l persistent respiratory rate


>80 breaths/min
l persistent vomiting
l O2 saturation <92% despite
supplemental O2

l deterioration of respiratory status


during nasogastric feeding
l marked increase in work of breathing
with poor coordination of sucking,
swallowing and breathing

Drug treatment
l In immunocompetent patients, drug
treatment and physiotherapy (in acute
phase) are ineffective. DO NOT
ROUTINELY PRESCRIBE
bronchodilators, antibiotics or steroids
l In severely immunocompromised
patient, request consultant approval
before prescribing ribavirin
l For babies aged <6 weeks or patients
with temperature >39C, discuss
antibiotics with consultant
l If symptoms <48 hr and influenza test
positive or high prevalence influenza
(see www.hpa.org.uk) and risk factors
(chronic respiratory, renal, liver,
neurological or cardiovascular disease,
diabetic or immunocompromised) give
oseltamivir

Criteria for admission


Absolute
l Apnoea
l Underlying cardiac defects, especially
large left to right shunt
l SpO2 <92% in air in a child in the
early phase of the illness
l Inadequate feeding
l Dehydration
l Diagnostic uncertainty

43

BRONCHIOLITIS 3/3
Relative
l Re-attends A&E in <48 hr
l Aged <6 weeks (corrected gestational
age)
l Unsatisfactory family circumstances
and impaired ability to care for unwell
child
l Younger children (i.e. aged
<6 months), presenting earlier in
illness (<3 days symptoms)
l Pre-existing lung disease, including
chronic lung disease, ex-preterm,
cystic fibrosis: inform speciality
consultant
l Other pre-existing chronic disease
for example neurodegenerative

MONITORING TREATMENT
l Standard nursing observations
l Continuous O2, saturation monitoring
if patient requires supplemental O2

l Transcutaneous CO2 monitoring if


patient using O2 via nasal prongs at
2 L/min (approximately 60% O2) or
has history of apnoea or colour
changes
l Continuous heart and respiratory rate
monitoring if patient requires
additional respiratory support

44

SUBSEQUENT MANAGEMENT
l Nurse in cubicle, or in bay with
children with same proven diagnosis
l Strict hand washing to support
infection control and use apron for
patient contact
l Fluid balance
l Oxygen support:
l test the need for support 6 hrly
l keep oxygen saturation 92% in
recovery phase
l wean from nasal prongs to air as
tolerated

DISCHARGE AND FOLLOW-UP


l Discharge home when:
l fully fed orally
l SpO2 >92% in air
l Hospital follow-up if:
l ventilated on PICU
l consolidation on chest X-ray (first
reassess clinically, do not request
routine follow-up X-ray)
l ex-preterm with chronic lung disease
l GP follow-up in all other cases

Issue 4
Issued: November 2010
Expires: November 2012

CROUP 1/2
DEFINITION

CROUP

l Acute viral inflammation of upper


airway causing oedema of larynx and
trachea and presenting with stridor

Symptoms and signs

l Causative agent: parainfluenza virus


(sometimes influenza, respiratory
syncytial virus, rhinovirus)

Aetiology
l Aged 6 months6 yr (peak age 2 yr)
l Seasonal peak: Spring and Autumn
l Transmission: usually by droplet
spread
l Incubation period 26 days

STRIDOR
Assessment

l Preceding coryzal illness


l Fever

l Harsh bark/seal-like cough


l Hoarse voice

l Inspiratory stridor

l Symptoms worse at night


l Child does not look toxic

Assessment
l Record croup severity:
l C Cyanosis

l R Recession of chest

l O Oxygen saturations (keep >92%)

l On crying/exertion

l UP Upper airway obstruction e.g.


stridor

l Severe/biphasic

l heart rate

l At rest

Differential diagnosis of stridor


Acute
l Croup

l Epiglottitis (rare since immunisation


against Haemophilus influenzae type
B)
l Bacterial tracheitis
l Foreign body

l level of consciousness

l Do not examine throat


l Do not distress child

l Any clinical concerns call consultant


paediatrician immediately

Severity
Mild croup
l Barking cough

Chronic
l Allergic airways disease (recurrent
croup)
l Congenital abnormality
l Laryngomalacia
l Foreign body

l respiratory rate

l Nil/intermittent stridor
l No recession
l No cyanosis

Moderate croup
l Stridor at rest

l Mild recession

l Alert and responsive

Issue 4
Issued: November 2010
Expires: November 2012

45

CROUP 2/2
Severe croup
l Stridor at rest
l Cyanosis

l Oxygen saturation <92% in air


l Moderate to severe recession
l Apathetic/restless

Investigations
l No investigations necessary, do not
attempt to take blood or put in cannula
l If diagnosis unclear, or child severely
unwell, call consultant as an
emergency measure

IMMEDIATE MANAGEMENT
Mild to moderate croup
l Antipyretics

l Adequate fluid intake

l Leaflet on croup and reassurance

l Oral dexamethasone
150 micrograms/kg, can be repeated
12 hr later if symptoms persist
l Admit/observe for 4 hr and reassess

l If better, discharge with 1 dose of oral


dexamethasone 150 microgram/kg
telling parents to use if symptoms
persist 1224 hr later

If parents do not clearly


understand what to do, do not
discharge

l Oral dexamethasone
150 micrograms/kg (or if child refuses
to swallow oral medication, nebulised
budesonide 2 mg)
l High flow oxygen 15 L/min via mask
with reservoir bag

l Contact on-call consultant paediatrician


urgently to assess clinical situation
l discuss whether to involve on-call
paediatric anaesthetist and ENT
surgeon
l If no sustained improvement with
adrenaline and dexamethasone:
l secure airway in theatre by
experienced anaesthetist
l transfer to PICU

DISCHARGE AND FOLLOW-UP


l Leaflet on croup

l Advise paracetamol to control fever


and encourage oral fluid intake

l Advise parents to seek help urgently


if:
l drooling

l laboured breathing
l persistent fever

l biphasic/worsening stridor
l cyanosis

l reduced level of
consciousness/confusion
l No follow-up

Severe croup
l Keep child and parents calm: do not
upset child e.g. by forcing oxygen
mask onto face or examining throat;
nurse on parents lap and in position
they find comfortable
l Nebulised adrenaline
400 micrograms/kg to max 5 mg
(0.4 mL/kg to max 5 mL 1:1000)
relieves symptoms, but short
duration of action
46

Issue 4
Issued: November 2010
Expires: November 2012

CYSTIC FIBROSIS ADMISSION 1/2


ARRANGING ADMISSION
l Via CF nurse specialist with ward sister
l Refer to admission plan in notes or
clinic letter
l Always admit to a cubicle

ADMISSION PROCEDURE
l Plot baseline weight, height
l Perform flow volume loop spirometry
on admission day (aged >67 yr)
l Write up drug chart before parents
leave
l Check whether annual bloods could
conveniently be taken now (see
Annual bloods)
l Ask nursing staff to inform
physiotherapist and dietitian on day of
admission
l Check specific aspects of
management or investigations, as
described by CF team
l for IV antibiotics, see Cystic fibrosis
Exacerbation guideline
l for bowel blockage, see Cystic fibrosis
Distal intestinal obstructive
syndrome (DIOS) guideline

INVESTIGATIONS
Annual bloods
l All children attending CF clinics have
annual blood screening
l Perform annual bloods if admission
within a month of annual screening
(usually at time of birthday):
l during insertion of a long line or Porta-cath needle
l when taking tobramycin levels

All ages
l FBC and film
l Vitamins A, D, E
l Parathyroid hormone
l U&E, creatinine, chloride, calcium,
magnesium, phosphate, albumin, total
protein, alkaline phosphatase,
bilirubin, AST/ALT, GGT, CRP
l Glucose
Issue 4
Issued: November 2010
Expires: November 2012

If aged >5 yr
All of the above plus:
l If symptoms could be caused by
allergic bronchopulmonary
aspergillosis, specific IgE to
aspergillus and aspergillus precipitins
l If diabetic, HbA1c

If aged 10 yr

l Add glucose tolerance test (at 0, 60


and 120 min)
l Baseline DEXA scan (repeated every
23 yr)

Chest X-ray
l Most children have chest X-ray every
612 months so another may not be
necessary
l Check when latest was taken and, if
in doubt, discuss with CF consultant

Lung function and O2


saturations
l Measure FVC and FEV1 using ward
spirometer (physiotherapist can take
these measurements if requested):
l in all children who can blow reliably
(usually from 67 yr)
l on admission and at least weekly,
preferably before ward rounds
l towards the end or after completion of
a course of IV antibiotics, take
measurements before and after
inhalation of salbutamol MDI
48 puffs via a spacer
l Monitor O2 saturations overnight for
first 2 nights after admission
l if saturations <91%, give O2 via nasal
cannulae or face mask

Microbiology
l In hospital, request twice weekly
sputum/cough swab
l usually performed by physiotherapist
but check this has been done
l If new pathogen found, see Cystic
fibrosis Microbiology guideline
and cross-infection
47

CYSTIC FIBROSIS ADMISSION 2/2


Screening for hyperglycaemia
About 8% of children with CF
develop diabetes after age
10 yr, usually manifests as
weight loss; ketoacidosis is rare
l If taking regular oral corticosteroids,
screen for glucose intolerance at
admission
l During first 24 hr after admission,
request glucose stick profile before
breakfast, 12 hr after every meal,
and at 0200 hr if on overnight feeds
l If prednisolone started or dosage
increased during admission, repeat
glucose stick profile
l If blood glucose elevated, discuss
with CF team

NUTRITION
l Involve dietitians closely
l Weigh twice weekly, in nightwear and
before breakfast (weigh babies
naked if possible)
l Continue normal supplements

Pancreatic enzyme supplements


l Continue same type and dose of
pancreatic supplement as already
prescribed

Starting dosage for newly


diagnosed child

l Infants
l Creon Micro for children 1/2 scoop
(2500 units lipase) to 1 scoop
(5000 units lipase) per 120 mL milk or
breast feed
OR
l Creon 10,000 one-quarter (2500 units
lipase) to one-half capsule (5000 units
lipase)/120 mL milk or breast feed

l Dose titrated with fat content of


meals and snacks to control
symptoms of malabsorption
l maximum 10,000 units lipase/kg/day,
higher doses can result in colonic
strictures

Signs of malabsorption
l Fatty pale stools, frequent, smelly,
orange oil, excess flatulence,
abdominal pains
l discuss with CF team

H2-receptor antagonists
l If taking large doses of pancreatic
enzymes (e.g. >10,000 units lipase),
discuss with CF team need for
concurrent ranitidine to reduce
deactivation of pancreatin

Vitamins A, D and E
Starting dosage for newly-diagnosed
l Infants
l 0.6 mL Dalivit or/and 0.5 mL (50 mg)
Vitamin E
l Children
l 1.2 mL Dalivit or 3 BPC
multivitamins capsules and 100 mg
Vitamin E (2 x 50 mg capsule)
OR
l continue dose as prescribed in CF
clinic
l Vitamin levels are checked annually
and dosage adjusted accordingly

Oral sodium chloride


l Only if prescribed by CF team
l Often needed in first year of life after
diagnosis has been made

l Children
l starting dose Creon 10,000 2 capsules
per meal, 1 capsule per snack

48

Issue 4
Issued: November 2010
Expires: November 2012

CYSTIC FIBROSIS EXACERBATION 1/2


RESPIRATORY
INFECTION/EXACERBATION
If unusual symptoms, such as
haemoptysis, abdominal pain (distal
intestinal obstruction syndrome), or
bleeding varices, discuss with CF
consultant

Symptoms and signs


l Increasing cough and sputum
l Increasing dyspnoea
l Weight loss with loss of appetite
l Thick, tenacious sputum
l Clubbing
l Coarse crepitations
l Haemoptysis
l Signs of right heart failure

Investigations
l See investigations in Cystic fibrosis
Admission guideline

Differential diagnosis
l Non-CF bronchiectasis
l Chronic obliterative bronchiolitis

ADDITIONAL ADMISSION
PROCEDURE
l If IV antibiotics required, discuss with
CF team re procedure:

l agree a clear individualised procedure


for every patient
l whether liaison with the anaesthetic
team needed for needle-phobic
patients

l Trained nursing staff to needle Port-acath

IMMEDIATE TREATMENT
l Use IV antibiotic regimen suggested
following discussion with CF team

l If no discussion possible, stop oral


antibiotics and give first-line regimen
(see below)
Issue 4
Issued: November 2010
Expires: November 2012

l Take into account any past allergic


reactions and current sputum
sensitivities

First-line regimen
l Sputum culture
l Pseudomonas aeruginosa: ceftazidime
50 mg/kg 8 hrly (max 9 g/day) and
tobramycin 10 mg/kg once daily (max
660 mg) given over 30 min (if
converting from 8 hrly to once daily,
use previous total daily dose)
l no Pseudomonas aeruginosa:
cefuroxime 50 mg/kg 8 hrly (max 1.5 g)

l Courses usually last 2 weeks


l For cephalosporins, (but not
tobramycin), aim to use whole vials by
rounding doses +10% considering vial
size
l After satisfactory tobramycin blood
levels established CF team will teach
parents to give antibiotics at home.
Discuss with pharmacy as well

Nebulised antibiotics
l Give children colonised with
Pseudomonas, colomycin 1 million
units made up to 4 mL with sodium
chloride 0.9%, nebulised 12 hrly

Oral antibiotics
l Children are rarely given oral
antibiotics during admission but may
resume an oral agent on discharge

Bronchodilators
l Prescribe salbutamol by MDI and
spacer 8 hrly before chest
physiotherapy in hospital

Inhaled corticosteroids
l There is no evidence these are of
benefit. Discuss with CF team re
stopping

49

CYSTIC FIBROSIS EXACERBATION 2/2


TOBRAMYCIN MONITORING
Once daily regimen:
l Trough level immediately before 2nd
and 8th dose
l Should be <1 mmol/L
l High levels need to be discussed with
CF consultant
l No need to determine peak
l Always discuss dose changes with CF
team
l Do not check tobramycin dose via
Port-a-cath or long line

SUBSEQUENT MANAGEMENT
l Do not change antibiotics before
discussing with CF team

Oral corticosteroids
l If no chest improvement after a week
of IV antibiotics, consider starting 7 day
course of prednisolone 1 mg/kg/day
l If already taking alternate-day
prednisolone at lower dosage, review
dosage needed at discharge
l For children with allergic
bronchopulmonary aspergillosis
(ABPA), continue prednisolone for
longer (e.g. at least one month)

Dornase alfa (DNAse)


l Discuss need for dornase alfa with
CF team
l Indications for use are:
l FEV1 <80% predicted for height
l cough productive of sputum or
sputum difficult to expectorate
l requiring IV antibiotics more than
every 3 months
l aged 518 yr
l Give dornase alfa (2.5 mg/daily) via
nebuliser after morning physiotherapy
l Patients should bring their own
nebuliser (usually a modified
Sidestream) and compressor into
hospital

50

DISCHARGE AND FOLLOW-UP


l On advice of CF team

Self-administration of IV
antibiotics home IV therapy

l Service managed by CF nurse in


conjunction with hospital pharmacy
l Discuss fully with CF nurse before
making any changes or arrangements

Criteria for home administration


of IV antibiotics
l Ensure that:
l CF team and ward staff happy for
patient to be discharged from hospital
l patient and parents entirely happy,
confident and competent to
administer IV antibiotics at home
l patient/parent has been assessed
before discharge by CF team
l parents have written guidelines and
24 hr contact numbers
l if patient considered responsible
enough to self-administer IV
antibiotics, important that parent/carer
also has adequate instruction and
guidance
l anaphylaxis kit at home and family
know how to use
l notify CF liaison nurses of any patient
discharged on home antibiotic therapy
so they can arrange support at home
or at school if necessary
l CF liaison nurse will visit patient at
home during his/her course of IV
therapy, to monitor progress
l feedback any concerns to CF team

Issue 4
Issued: November 2010
Expires: November 2012

CYSTIC FIBROSIS MICROBIOLOGY 1/2


l In addition to standard precautions
and hand hygiene, the following
precautions are required for patients
infected/colonised with transmissible
pathogens
l do not share equipment between
patients
l nurse children with CF in a cubicle
l limit contact between CF patients

PATIENT NEWLY DIAGNOSED


WITH CF
l Prophylaxis with flucloxacillin 50 mg/kg
12 hrly orally until aged 2 yr
l If newly diagnosed CF patient has
chest infection (no pathogens)
l cefuroxime IV for 2 weeks, then
co-amoxiclav orally for 34 weeks
l Subsequent treatment depends on
microbiology

PSEUDOMONAS AERUGINOSA

Nebulised antibiotics
l If colonised with Pseudomonas, give
colomycin 1 million units made up to
4 mL with sodium chloride 0.9%,
nebulised 12 hrly
l Tobramycin, decided by CF team

BURKHOLDERIA CEPACIA
COLONISATION
l Report any new cases to CF team
l Nurse children with B. cepacia
colonisation in a cubicle on a
separate ward from other CF children
l Use separate spirometer with
disposable filters

MRSA COLONISATION
l Report any new cases to CF team
l Use normal spirometer with a
disposable filter

CHICKENPOX AND CF
First isolations in sputum or
cough/throat swabs
l If asymptomatic with first isolation
from sputum/cough swab:
l ciprofloxacin aged 1 month1 yr
15 mg/kg, aged >1 yr 20 mg/kg (max
750 mg) 12 hrly orally and colomycin
aged <2 yr 1 million units 12 hrly and
aged 2 yr 2 million units 12 hrly via
nebuliser for 3 months
l If asymptomatic with recurrent
isolation from sputum/cough swab:
l ciprofloxacin and colomycin
l If symptomatic:
l tobramycin and ceftazidime
(according to sensitivities) IV for 2
weeks, and on discharge from
hospital: ciprofloxacin and colomycin

Pseudomonas colonisation

l Varicella infection can have serious


consequences in immunosuppressed
children
l CF patients taking oral corticosteriods
are at high risk
l If no history of chickenpox and no
antibodies, vaccinate

Exposure
l Ask about exposure to a known case:
l being in the same room (e.g. in the
house, classroom or hall in school) for
15 min
l face-to-face contact, for example
whilst having a conversation
l If exposure significant, check notes to
determine immune status (history of
chickenpox or antibody status before
corticosteroids)

l 3 or more isolations in 6 months in


sputum samples taken at least 1
month apart

Issue 4
Issued: November 2010
Expires: November 2012

51

CYSTIC FIBROSIS MICROBIOLOGY 2/2


l If non-immune and taking a high dose
of oral corticosteroid (prednisolone
1 mg/kg/day for one month or
2 mg/kg/day for 1 week), and
exposure occurred <1 week earlier,
give varicella-zoster immunoglobulin
(VZIG) aged <6 yr 250 mg; aged
610 yr 500 mg; aged 1114 yr
750 mg; aged >15 yr 1 g, or IV
immunoglobulin 0.2 g/kg
l If non-immune and taking a modest
dose of oral corticosteroid
(prednisolone <1 mg/kg/day), give
aciclovir prophylaxis 6 hrly: aged
<2 yr 200 mg; aged >2 yr 400 mg
721 days after exposure

Infected
l If chickenpox appears in a child not
taking oral corticosteroid, give oral
aciclovir (20 mg/kg/dose aged
<12 yr 6 hrly, aged >12 yr 5 times/day,
max 800 mg/dose) for 7 days and a
course of oral antibiotics (e.g.
amoxicillin and flucloxacillin) as for
acute exacerbation

PORT-A-CATH
l Use in children requiring frequent IV
antibiotics
l Manufacturer's instructions found on
ward
l Observe sterile precautions whenever
Vascuport accessed
l accessed only by trained nursing staff

Routine flushing of Port-a-cath


(usually by nursing staff)
l Every 4 weeks (coincide with clinic
appointment where possible)
l Use a straight Port-a-cath needle and
4 mL heparinised sodium chloride
0.9% 100 units/mL (e.g. Canusal, not
Hepsal), withdrawing needle while
injecting last mL

INFLUENZA AND
PNEUMOCOCCAL VACCINE
l Influenza vaccine every October
l follow advice on any current
pandemic flu
l Conjugate pneumococcal vaccine
(Prevenar 13)
l For all children with CF
l Usually prescribed by patients own
GP but obtainable from pharmacy

52

Issue 4
Issued: November 2010
Expires: November 2012

CYSTIC FIBROSIS DISTAL INTESTINAL


OBSTRUCTION SYNDROME (DIOS) 1/1
RECOGNITION AND
ASSESSMENT
l Faeces can accumulate in distal ileum
and caecum causing varying degrees
of intestinal obstruction
l Patients present with intermittent
abdominal pain, constipation and
faecal masses, usually in right or left
iliac fossa

MANAGEMENT
l If symptoms very mild, prescribe daily
macrogol laxative (e.g. Movicol) and
encourage fluids
l Consider adjusting pancreatic
enzymes
l If unresponsive, or symptoms more
severe, proceed as follows:
single dose of Gastrografin:
aged 1 month2 yr: 1530 mL
1525 kg 50 mL
>25 kg 100 mL
l repeat dose after 1218 hr,
encourage drinks, monitor fluid
balance and allow food
l If no effect after 2448 hr or if patient
deteriorates, give balanced electrolyte
solution:
l bowel lavage with Kleen-Prep or
Golytely (usually requires a
nasogastric tube)

Issue 4
Issued: November 2010
Expires: November 2012

l Dosage of Kleen-Prep or Golytely:


l 10 mL/kg/hr for 30 min
l then 20 mL/kg/hr for 30 min
l then 25 mL/kg/hr up to max total dose
of 100 mL/kg/hr or 4 L
l start early in the morning and
continue until stools are yellow,
watery and free of solid matter
l 2 L in first instance, increasing to 3 or
4 L depending on response, age and
size of child (most children with DIOS
will be teenagers)
l withhold food but, if success not
achieved after 12 hr, stop, give an
evening meal and resume following
morning
l monitor effectiveness with pre- or
post-plain abdominal X-ray before and
after lavage
l if signs of complete intestinal
obstruction, stop lavage, give IV fluids
and discuss contrast enema with CF
team

53

PNEUMONIA 1/3
If aged <1 month-old, refer to
Neonatal guidelines

l Aged >5 yr, headache, arthralgia,


sore throat (suggests mycoplasma)

Investigations
RECOGNITION AND
ASSESSMENT
Definition
l Inflammation and consolidation of the
lung caused by a bacterial, viral or
mycoplasma infection
l Absence of clinical signs AND
negative CXR makes pneumonia
unlikely

l Up to 35% of lower respiratory tract


infections have single virus as
causative organism

l Can be presenting illness in cystic


fibrosis and immunodeficiency states

Symptoms and signs

l Pulse oximetry
l CXR

l Full blood count, blood culture

l Serum electrolytes (may have


hyponatraemia owing to SIADH), CRP
l If mycoplasma pneumonia suspected,
mycoplasma titre (indicate date of
onset on request form)

l Sputum if able to provide good quality


specimen
l Nasopharyngeal aspirate for
respiratory viruses

l If pertussis suspected, pernasal swab


in charcoal transport medium
l Pleural fluid culture and PCR if
aspirated

l If severe pneumonia, pneumococcal


antigen in urine

l Cough
l Fever

l Irritability

Differential diagnosis

l Poor feeding
l Vomiting

l Tachypnoea at rest (most useful sign)

Beware: awake or unsettled


infants can have high
respiratory rate on a single
measurement; measure at
rest/repeat

l Bronchiolitis with atelectasis (usually


aged <1 yr)
l Foreign body aspiration

l Tumour (round pneumonia)


l Empyema/lung abscess
l Tracheobronchitis
l Whooping cough

IMMEDIATE TREATMENT
Table 1: WHO definition of tachypnoea
Age
<2 months
211 months
15 yr

See flowchart 1

Counted breath rate


60/min
50/min
40/min

Pleural effusion
l See Pleural effusion guideline

l Bronchial breathing, inspiratory


crackles
l Recession

l Abdominal pain (referred pleural pain)

54

Issue 4
Issued: November 2010
Expires: November 2012

PNEUMONIA 2/3
SUBSEQUENT MANAGEMENT

DISCHARGE AND FOLLOW-UP

l Change route of amoxicillin from IV to


oral within 2448 hr

l Follow-up within 68 weeks with CXR


if:

l If atypical or staphylococcal
pneumonia, treat for 14 days
uncomplicated CAP and 1421 days
for severe CAP

l significant pleural effusion

l Total antibiotic course 57 days

l Physiotherapy once cough productive


l important if neuromuscular
impairment results in poor clearance
l Maintain hydration

l oral fluids if tolerated

l if unable to take oral fluids, sodium


chloride 0.45% with glucose 5% and
potassium chloride 10 mmol/500 mL
via IV infusion

l lobar collapse

l round pneumonia on CXR

l previous lower respiratory tract


infections
l failure to thrive

l GP follow-up for all others within


68 weeks

l Convalescent mycoplasma titre can


be obtained at this visit (indicate date
of onset on request form)

l restrict IV fluid replacement to 80%


maintenance
l monitor electrolytes

MONITORING TREATMENT
l Continuous SpO2 monitoring if
needing O2

l 14 hrly observation depending on


severity of illness

l If no improvement in 2448 hr, review


diagnosis (repeat chest X-ray) or
treatment

Issue 4
Issued: November 2010
Expires: November 2012

55

PNEUMONIA 3/3
Flowchart 1: Management of community acquired pneumonia in a previously
well patient aged >1 month-old
ANY of following apply:
l Aged <3 months
l SpO2 <92% in air
l Intermittent apnoea/grunting
l Tachypnoeic
l Pleural effusion
l Very unwell*

l
l
l
l
NO

YES

Admit to hospital
l Poor perfusion
l Altered level of consciousness
l Respiratory failure: hypoxia,
hypercapnia, acidosis

*'Very unwell' implied by:


Drowsiness/lethargy
Lower chest indrawing
Nasal flare
Poor feeding/dehydrated

l Consider out-patient management


l If aged <1 yr, arrange review by
senior doctor before discharge

l Resuscitate
l Discuss case with PICU

NO

l O2 sats <92% air: Give oxygen


l Gentle suctioning to clear nasal secretions
l Paracetamol for pyrexia

Pleural effusion?

YES

Pleural effusion guideline

l Oral amoxicillin
l If vomiting or severe
symptoms, IV co-amoxiclav +
clarithromycin
l FBC, U&E
l Fluid balance/observations

Clinical picture of Mycoplasma


pneumonia**or penicillin allergy

**Mycoplasma pneumonia
suggested by:
l Aged >5 yr
l Subacute onset
l Prominent cough
l +/- headache
l +/- sore throat
YES

YES

Suspected Staph. aureus


e.g. bullae on CXR
YES

Aspiration
YES

Hospital acquired

Improves in 24-48 hr

YES

NO

l Discuss with consultant


l Review chest X-ray
l ?organism

56

YES

Add oral clarithromycin for


10 days
Add flucloxacillin

Add metronidazole

Change to piperacillin/tazobactam
l
l
l
l

Discharge
Change from IV to oral antibiotics
Total antibiotic course for 57 days
Follow up within 68 weeks. See
Discharge and follow-up

Change to meropenem
Issue 4
Issued: November 2010
Expires: November 2012

PLEURAL EFFUSION 1/3


RECOGNITION AND
ASSESSMENT
l Discuss with respiratory paediatrician
about management and research

Definition
l A collection of fluid in pleural space,
for example:
l parapneumonic effusion pleural fluid
collection in association with
underlying pneumonia
l empyema presence of pus in
pleural cavity

Symptoms and signs


l Persistent pyrexia 48 hr after
treatment started for pneumonia
l Fever
l Cough
l Breathlessness
l Pleuritic chest pain
l Unilateral chest signs decreased
expansion and breath sounds,
dullness to percussion
l Positional splinting

l If history, chest X-ray or US


suggestive of malignancy, request CT
chest
l Pleural fluid analysis for:
l microbiology (including PCR and
AAFB if patient recently in contact
with TB or from TB endemic area)
l biochemical analysis (LDH, protein,
glucose) and pH (via ABG analyser)
l at same time, blood samples for
FBC, clotting screen, U&E, LDH,
protein, albumin, glucose
l CRP
l Blood cultures
l Sputum culture, if possible

It is not necessary to obtain


sample for pleural fluid culture
routinely before chest drain
insertion if cause likely to be
infective. If alternative cause
suspected, try to avoid
unnecessary chest drain
insertion by obtaining
diagnostic aspirate of pleural
fluid

Differential diagnosis
l Uncomplicated pneumonia
l Malignancy
l Effusion with alternative cause (e.g.
congestive cardiac failure,
pancreatitis)
l Pulmonary embolism

Investigations
l Chest X-ray
l Ultrasound (US) scan to:
l confirm presence of effusion
l ascertain volume
l indicate optimal position for chest
drain
l differentiate between simple and
complicated effusion (e.g. loculations,
heterogeneous material)
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Expires: November 2012

57

PLEURAL EFFUSION 2/3


Table: Fluid/serum protein and LDH ratios are best discriminators between
transudate and exudate
Appearance
Leucocyte count
Protein
Fluid/serum protein ratio
LDH
Fluid/serum LDH ratio
Glucose
pH
Gram stain/culture

Transudate
Serous
<10,000/mm3
30 g/L
0.5
200 IU
0.6
3.3 mmol/L
7.4
No organisms

IMMEDIATE TREATMENT
Supportive
l ABC
l O2 and fluid resuscitation as indicated
l Analgesia

Exudate
Cloudy, bloody
>50,000/mm3
>30 g/L
>0.5
>200 IU or >2/3 local upper limit of serum LDH
>0.6
<3.3 mmol/L
7.3
Organisms on stain or culture

Refer to respiratory
paediatrician
l Remember that underlying cavitating
disease may lead to bronchopleural
fistulae. Assess likelihood of this
problem before inserting any chest
drain

Antibiotic therapy
Type of effusion suspected
Effusion following community-acquired
pneumonia
Effusion following hospital-acquired
pneumonia or in immune-compromised child
Effusion possibly tuberculous

Chest drain insertion


l Discuss with respiratory team,
consultant paediatrician, paediatric
anaesthetic team (usually GA used),
support may also be required from
cardiothoracic team
l Obtain consent

l Consider simultaneous insertion of


long line during general anaesthetic, if
possible
l Ensure vascular access before
starting procedure

l Consider support of interventional


radiologist

58

Choice of antibiotics
IV co-amoxiclav
Discuss with respiratory paediatrician
Discuss with specialist

l If required, engage paediatric


anaesthetist to give general
anaesthetic

l Insert pigtail drain using Seldinger


technique at site suggested and
marked during ultrasound scan
(usually mid-axillary line)
l Send pleural fluid for:

l microbiology culture and


sensitivities (including AAFBs),
pneumococcal polymerase chain
reaction (PCR)
l histology differential cell count

l biochemistry LDH, protein, glucose


and pH with blood samples for LDH
and protein
Issue 4
Issued: November 2010
Expires: November 2012

PLEURAL EFFUSION 3/3


Chest drain management
l Ensure nursing staff trained in care of
children with chest drains
l Attach chest drain to low level suction
(510 cm H2O) via underwater seal
l If Altitude Chest Drainage System
used, set wall suction to
160 mmHg/22 kPa and set dial on
drainage system to 20

l After 10 mL/kg has been drained,


clamp chest drain for 1 hr to prevent
re-expansion pulmonary oedema

l Never clamp a bubbling chest drain


this indicates presence of
pneumothorax
l Ensure adequate analgesia (see
Analgesia guideline) and encourage
patient to move freely when well
enough

Intrapleural fibrinolytics
l Instill urokinase in all patients, as
follows:

l aged 1 yr, urokinase 40,000 units in


40 mL sodium chloride 0.9%
l aged <1 yr, urokinase 10,000 units in
10 mL sodium chloride 0.9%
l administer via chest drain 12 hrly for
3 days (total 6 doses)

l clamp chest drain for 4 hr after


instillation of urokinase, then drain for
8 hr

l Record fluid volumes into and out of


pleural space carefully and accurately

SUBSEQUENT MANAGEMENT
Act on response to treatment and
clinical assessment of patient

l Monitor symptoms and re-examine


patient to assess progress
l Repeat CRP as needed

l if falling rapidly, continue with current


regimen
Issue 4
Issued: November 2010
Expires: November 2012

l if not falling after 72 hr, treat as nonresolution (see below)


l Chase pleural fluid aspirate results

l if unexpected organisms grown,


adjust antibiotic therapy in
accordance with antibiotic sensitivities
l if differential cell count shows
lymphocytosis, exclude TB (Mantoux
test) and malignancy (send aspirate
for cytology and consider CT scan of
chest)
l Chase blood and sputum culture
results if no growth, continue
empirical treatment until patient
improves

l Remove chest drain when drainage


minimal and in agreement with
respiratory paediatrician: appose skin
with Steristrips rather than sutures

l Continue IV antibiotics at least until


afebrile. Change to oral antibiotics
when clinical improvement obvious.
Complete 14-day course of antibiotics
l Continue antibiotics until CRP <10

Non-resolution
l Non-resolution of effusion after 3
days or further complications occur,
consider CT scan of chest

l Discuss referral for thoracotomy with


respiratory paediatrician

Surgery
l Discuss with paediatric thoracic
surgeon if:
l effusion has not resolved
l child is clinically unwell

l inflammatory markers are increasing

DISCHARGE AND FOLLOW-UP


l Arrange review by respiratory
paediatrician, initial appointment 6
weeks after discharge (CXR on arrival)
l if symptoms persist or recur, early
referral to respiratory paediatrician

59

PNEUMOTHORAX 1/2
Spontaneous pneumothorax

RECOGNITION AND
ASSESSMENT
Symptoms and signs
Tension pneumothorax
(very rare)
l Severe dyspnoea
l Circulatory compromise
l Trachea +/- apex beat displaced
Treat immediately:
l Give O2 15 L/min with mask with
reservoir bag
l Insert a large bore cannula of at least
4.5 cm in length into 2nd anterior
intercostal space, midclavicular line
l Insert intercostal tube
l Remove emergency cannula when
bubbling in underwater seal system
confirms intercostal tube system
functioning

l Sudden onset, occasionally at rest


l Chest pain (unilateral)
l Dyspnoea
l Resonance on percussion, with
reduced vocal fremitus and breath
sounds (if moderate-large)

Investigation
l PA chest X-ray
l If findings are unclear on PA, lateral
(if possible, decubitus) film may help
l If findings obscured by surgical
emphysema or complex bulla disease,
CT scan may help

BEWARE: suspected basal


pneumothorax usually implies a
bulla. CT scan will differentiate
bullae from pneumothorax

IMMEDIATE TREATMENT
Chest X-ray

Large collapse
Rim of air 2 cm

Small collapse
Rim of air <2 cm

Significant dyspnoea

Yes

Aspirate
Successful?
(asymptomatic)

No

No

Chronic lung
disease

No

Intercostal
tube drainage

Yes

Observe for 4 hr
Follow-up

60

No

Chronic lung disease

Yes

In-patient
observation

Issue 4
Issued: November 2010
Expires: November 2012

PNEUMOTHORAX 2/2
Management of intercostal drains
X-ray next morning
Yes

Still bubbling?

No

Re-expanded?

Yes

Yes

Still bubbling or swinging, or


surgical emphysema?

No
No

Wait 24 hr
If no bubbling remove drain 2

Check drain and underwater


seal 3

Repeat X-ray
Collapsed again?

Yes

No

Follow-up 4

Respiratory opinion 5

Do not clamp chest tube unless


advised by respiratory
paediatrician or thoracic
surgeon
l 1: Chest X-ray
l always keep underwater seal below
chest
l 2: Removal of chest drain:
l bubbling stopped for at least 24 hr
l cut drain-securing suture
l withdraw tube while patient holds
breath in expiration
l close wound with remaining sutures
l 3: Check drain:
l if lung not re-inflated and no
bubbling in underwater bottle: Try
to remove block or kink
l if unsuccessful, remove drain. Insert
new drain through clean incision

Issue 4
Issued: November 2010
Expires: November 2012

l 4: Follow-up:
l at clinic in 710 days
l patient given discharge letter and
written advice to return immediately if
deteriorates
l no air travel until chest X-ray resolved
l 5: Respiratory paediatricians
opinion:
l why no re-expansion (e.g. air leak,
displaced/blocked tube, bronchopleural fistula, underlying pulmonary
disease)?
l use of high volume/low pressure
suction, 12 kPa/Barr, (816 mmHg;
820 cm H2O)

l if Altitude Chest Drainage system


used, set wall suction to
160 mmHg/22 kPa and set dial on
drainage system to 20
l early thoracic surgery. Refer when
pneumothorax fails to resolve after 5
days of above management or after 3
days if patient has chronic lung
disease

61

CYANOTIC CONGENITAL HEART DISEASE 1/2


RECOGNITION AND
ASSESSMENT
Symptoms and signs
l Central cyanosis may be respiratory
or cardiac in origin
l Respiratory illness producing
cyanosis will usually have signs of
respiratory distress (e.g. cough,
tachypnoea, recession and added
respiratory sounds)
l Cardiac decompensation may occur
with a respiratory infection: they may
co-exist
l Cyanosis more likely due to cardiac
disease if:
l SpO2 responds poorly to high flow
oxygen (15 L/min) via face mask and
reservoir bag
l marked tachycardia
l enlarged heart (clinically or on CXR)
l gallop rhythm/murmur
l enlarged liver/raised JVP
l basal crackles
l absent femoral pulses
l finger clubbing occurs after a few
months (also consider endocarditis)

Causes of cardiac cyanosis


Significant right-to-left shunt
l Transposition with inadequate mixing,
pulmonary or tricuspid atresia
l Fallots tetralogy: hypercyanotic
episodes follow emotional or painful
upset

Duct-dependent pulmonary
circulation
l Commonly presents in first
1014 days of life
l severely blue, breathless or shocked
l pulmonary atresia
l critical pulmonary valve stenosis
l tricuspid atresia
62

l severe Fallots tetralogy


l transposition of the great arteries
without septal defect
l single ventricle anatomy

Acute pulmonary outflow


obstruction (cyanotic episodes)
l Fallots tetralogy or other complex
congenital cyanotic heart disease
l very pale
l lose consciousness
l convulse

Physical examination
l Remember to check femoral pulses
l If coarctation of the aorta suspected:
check BP in upper and lower limbs
normal difference <15 mmHg

Investigations
If infant cyanosed or in heart
failure, discuss urgency of
investigations with consultant
SpO2

l Check pre- (right arm) and postductal (lower limbs)


l when breathing air before O2 given
l after giving 15 L/min O2 by mask with
a reservoir bag for 10 min

Chest X-ray
l For cardiac conditions, specifically
record:
l cardiac situs (normal or right side of
chest)
l aortic arch left or right-sided
l bronchial situs (is right main bronchus
on the right?)
l cardiac size and configuration
l size of pulmonary vessels and
pulmonary vascular markings

Issue 4
Issued: November 2010
Expires: November 2012

CYANOTIC CONGENITAL HEART DISEASE 2/2


Electrocardiogram
l See ECG interpretation guideline.
Check:
l P-wave size and axis
l Axis of QRS complex
l R-S pattern in chest leads
l P-R, QRS and Q-T intervals
l P- and T-wave configuration
l size of QRS in chest leads

Nitrogen washout in cyanosed


babies
l Monitor SpO2 in air then in headbox
after breathing 100% O2 for 10 min

l in cyanotic congenital heart disease,


PaO2 will remain below 20 kPa with
SpO2 unchanged
l not as reliable as echocardiogram

Echocardiogram

l Locally, if available, or refer to


regional paediatric cardiac centre

l May cause apnoea and patients may


need ventilation
l Beware of giving high concentrations
of O2 as this encourages duct closure

Acute pulmonary outflow


obstruction (cyanotic episodes)
l Immediate treatment before transfer
to a paediatric cardiac centre:
l do not upset child
l give morphine 100200 microgram/kg
IV over 5 min or IM
l provide high concentration face mask
O2 (15 L/min with reservoir bag)
l if Fallots tetralogy has been
diagnosed by echocardiography,
discuss with cardiologist use of IV
beta-blocker

SUBSEQUENT MANAGEMENT

l On advice of consultant and


paediatric cardiac centre

IMMEDIATE TREATMENT
If infant cyanosed or in heart
failure, discuss urgency of
referral to local paediatric
cardiac surgical centre with
consultant
Duct-dependent congenital
heart disease
l Immediate treatment before transfer
to a paediatric cardiac centre:
l open duct with Prostin [prostaglandin
E1 (alprostadil) or E2 (dinoprostone)
same dose]:
l 510 nanogram/kg/min IV infusion to
start
l increasing in steps of
510 nanogram/kg up to max
100 nanogram/kg/min
l then reducing to lowest dose needed
Issue 4
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Expires: November 2012

63

HEART FAILURE AND WEAK PULSES 1/2


COMMON DIFFERENTIAL
DIAGNOSES
l Aortic stenosis
l Coarctation of the aorta
l Hypoplastic left heart
l Pericardial effusion
l Myocarditis
l Cardiomyopathy

RECOGNITION AND
ASSESSMENT
Presentation
l Usually during first few weeks of life
l Later triggered by an intercurrent
infection, with associated myocarditis
or prolonged arrhythmia

Symptoms and signs


l Failure to thrive
l Rapid weight gain
l Sweating
l Breathlessness, particularly during
feeding
l Rapid respiratory rate
l Tachycardia
l Absent or low volume peripheral or
central pulses
l Enlarged heart
l Prominent cardiac impulses
l Quiet heart sounds in pericardial
effusion
l Thrill
l Gallop rhythm
l Enlarged liver

INVESTIGATIONS

l Check BP in upper and lower limbs


(normal <15 mmHg difference)

SpO2

l Check pre- (right arm) and postductal (lower limbs)


l In air and after giving O2

64

Chest X-ray

l For cardiac conditions, specifically


record:
l cardiac situs (normal or right side of
chest)
l aortic arch left- or right-sided
l bronchial situs (is right main bronchus
on the right?)
l cardiac size and configuration
l size of pulmonary vessels and
pulmonary vascular markings

Electrocardiogram
l See ECG interpretation guideline
l Axis of QRS complex
l P-wave
l R-S pattern in chest leads
l P-R, QRS and Q-T intervals
l P- and T-wave configuration
l size of QRS in chest leads

Echocardiogram

l Locally, if available, or refer to local


paediatric cardiac centre

HEART FAILURE AND


CARDIOGENIC SHOCK
Causes
l Congenital heart malformations
l Cardiomyopathies
l Myocarditis
l Arrhythmias
l Hypoxia
l Acidosis
l Toxins

Recognition of cardiogenic
shock

l For definition of shock see


Septicaemia guideline
l Following cardiopulmonary
resuscitation with adequate fluid
replacement in patients with:

Issue 4
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Expires: November 2012

HEART FAILURE AND WEAK PULSES 2/2


l septic shock that fails to improve after
adequate fluid replacement
(e.g. 40 mL/kg)
l a known heart condition and shock
l a large heart on chest X-ray but
previously well
l shock, who have a history of
poisoning
l a murmur or pulmonary oedema, or
both

MONITORING
l ECG monitor
l Non-invasive BP
l Pulse oximetry
l Core-skin temperature difference
l Daily weights
l Intra-arterial BP for continuous
pressure monitoring and arterial blood
gas sampling
l CVP: if shocked or 40 mL/kg fluid
resuscitation has been needed
l Urine output (1 mL/kg/hr)

THERAPEUTIC MEASURES
Progressive measures: 18 for all
patients; 911 if cardiogenic shock
1. If breathless, elevate head and trunk
2. If infant not feeding well, give
nasogastric feeds
3. In moderate-to-severe failure or if
patient hypoxic or distressed, give O2
therapy via nasal cannulae (up to
2 L/min) or via a face mask with
reservoir bag (up to 15 L/min)
4. Diuretics: furosemide 1 mg/kg orally
or by slow IV injection and amiloride
100 microgram/kg (max 10 mg) orally
12 hrly (doses can be repeated if not
responding to initial dose)
5. If serum potassium <4.5 mmol/L,
give additional potassium chloride
1 mmol/kg 12 hrly enterally
6. Correct acidosis, hypoglycaemia and
electrolyte imbalance
7. Relieve pain with morphine: loading
dose 100 microgram/kg slow IV,
followed by 50 microgram/kg slow IV
Issue 4
Issued: November 2010
Expires: November 2012

46 hrly or 10 microgram/kg/hr via IV


infusion (doses can be doubled if
necessary)
8. If anaemic (Hb <10 g/dL), correct
with slow infusion of packed cells to
bring Hb to 1214 g/dL
9. Monitor CVP and ensure adequate
pre-load: give Human Albumin
Solution (HAS) 4.5% 10 mL/kg as IV
bolus or, if HAS not available,
sodium chloride 0.9% 10 mL/kg as IV
bolus
10.If shock severe (see Septicaemia
guideline), start mechanical
ventilation with positive endexpiratory pressure early; if
pulmonary oedema present, start
urgently
11.If shock severe, give early inotropic
drug support: dopamine,
dobutamine, adrenaline or
noradrenaline as per NNU/PICU
protocols

DUCT-DEPENDENT
CONGENITAL HEART DISEASE
l May present in first two weeks of life

Duct-dependent systemic
circulation
l Breathless, grey, collapsed, poor
pulses
l severe coarctation of the aorta
l critical aortic stenosis
l hypoplastic left heart syndrome

Duct-dependent pulmonary
circulation
l Blue, breathless or shocked
l pulmonary atresia
l critical pulmonary valve stenosis
l tricuspid atresia
l severe Fallots tetralogy
l transposition of the great arteries

Treatment
l See Cyanotic congenital heart
disease guideline

65

ECG INTERPRETATION 1/4


PAPER SPEED

Causes

l ECG normally recorded at 25 cm/sec


l 1 mm (1 small square) = 0.04 sec
l 5 mm (1 large square) = 0.2 sec

P WAVE
l Reflects atrial activity
l Duration shorter than in adults
l infants: 0.040.07 sec
l adolescents: 0.060.1 sec
l Height 2.5 mm
l Varying P wave morphology may
indicate wandering atrial pacemaker

l Pulmonary hypertension
l Pulmonary stenosis
l Pulmonary atresia
l Tricuspid atresia

Left atrial hypertrophy (LAH)


l Biphasic P wave (later depolarization
of LA)

Causes
l Mitral valve disease
l LV obstruction and disease

Right atrial hypertrophy (RAH)


l Increased P wave amplitude in leads
II, V1, and V4R

P-R INTERVAL
l Atrial depolarization varies with age
and rate

Normal range of P-R interval (time in sec)


Heart rate
01 month
0.080.11
0.080.11
0.080.09

<60
6099
100139
140180
>180

Prolonged interval
l Normal
l Myocarditis
l Ischaemia
l Drugs
l Hyperkalaemia

Short interval
l Wolff-Parkinson-White syndrome
l Lown-Ganong-Levine syndrome
l Glycogen storage disease

P-R interval (sec)


012 months
112 yr
0.10.16
0.080.12
0.10.14
0.080.12
0.10.14
0.080.11
-

1216 yr
0.10.19
0.10.17
-

QRS COMPLEX
l Ventricular activity
l Duration: 0.060.08 sec

Prolonged
l Ventricular hypertrophy
l Bundle branch block
l Electrolyte disturbance
l Metabolic disease
l Drugs (e.g. digoxin)

Variable interval
l Wandering atrial pacemaker
l Wenckebach phenomenon

66

Issue 4
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Expires: November 2012

ECG INTERPRETATION 2/4


Normal range of R and S waves (height in mm)
Age
V4-R
412
27
07
06

Birth
6-12 months
1-10 yr
>10 yr

R and S waves (height in mm)


V1-R
V1-S
V5-R
520
020
220
317
125
1028
216
112
530
112
125
540

Q WAVE
l Normal in II; III; aVF; V5-6
l Depth 23 mm
l pathological if >4 mm (i.e. septal
hypertrophy)
l May be found in other leads in:
l anomalous coronary arteries
l hypertrophic obstructive
cardiomyopathy
l transposition of great arteries (with
opposite polarity)

Q-T INTERVAL
Inversely proportional to rate
l Calculate ratio of Q-T interval to R-R
interval
l QTc = Q-T
R-R1
l QTc is usually less than 0.44 s
l prolonged QTc is associated with
sudden death: alert consultant
immediately

Prolonged interval
l Hypocalcaemia
l Myocarditis
l Jervell-Lange-Nielsen syndrome
l Romano-Ward syndrome
l Head injuries or cerebrovascular
episodes
l Diffuse myocardial disease
l Antiarrhythmics

Short interval
l Hypercalcaemia
l Digitalis effect
Issue 4
Issued: November 2010
Expires: November 2012

V6-R
113
525
525
530

V6-S
015
010
07
05

T WAVE
l Ventricular repolarization

Normal
l T inversion V4R/V1 (from third day of
life until 10 yr)
l Amplitude is 2530% of R-wave
l Aged <1 yr: V5 11 mm; V6 7 mm
l Aged >1 yr: V5 14 mm; V6 9 mm
l Adolescence reduces amplitude

Peaked T wave
l Hyperkalaemia
l LVH
l Cerebrovascular episode
l Post-MI

Flat T wave
l Normal newborn
l Hypothyroidism
l Hypokalaemia
l Hyper/hypoglycaemia
l Hypocalcaemia
l Peri/myocarditis
l Ischaemia
l Digoxin effect

MEAN QRS AXIS


Vertical plane (limb leads)
Normal axis in vertical plane
l Birth
+60 to +180 (av +135)
l Aged 1 yr +10 to +100 (av +60)
l Aged 10 yr +30 to +90
(av +65)

67

ECG INTERPRETATION 3/4


Right axis deviation
l Right ventricular hypertrophy (RVH)
l Left posterior hemiblock
l Ostium secundum atrial septal defect
(ASD)/right bundle branch block (RBBB)

Left axis deviation


l Left ventricular hypertrophy (LVH)
l Ostium primum ASD (+ RBBB)
l Often in conduction defects

Horizontal plane
(anterior chest leads)
Normal
l Transition at around V3

Clockwise rotation
l S>R in V4 = RA/RV hypertrophy

Anticlockwise rotation
l R>S in V2 = cardiac shift (e.g.
pneumothorax)

RIGHT VENTRICULAR
HYPERTROPHY
Diagnosis
l
l
l
l
l
l
l
l
l

RAD and RV1 > SV1 (aged >1 yr)


SV6 above maximum for age:
06 months
15 mm
>6 months
10 mm
>12 months
7 mm
10 yr
5 mm
R waves in V4R/V1 >normal
T wave changes
upright in V1/V4R (aged from 3 days
to 10 yr)

Causes include
l Pulmonary stenosis/atresia
l Transposition of great arteries
l Pulmonary regurgitation
l Total anomalous pulmonary drainage
l Tricuspid regurgitation
l Fallot's tetralogy
l Pulmonary hypertension

LEFT VENTRICULAR
HYPERTROPHY

BIVENTRICULAR
HYPERTROPHY

Diagnosis

Diagnosis

l SV1 + RV5 40 mm (30 mm aged


<1 yr)
l +/- prolonged QRS
l Flat T wave
l T wave inversion V5-V6 (LV strain)
l Left bundle branch block

l R + S >50 mm in V3-V4
l LVH + bifid R <8 mm in V1
l RVH + LV strain
l Q waves V3-V6 imply septal
hypertrophy

Causes include
l Aortic stenosis
l Aortic regurgitation
l Hypertension
l Moderate VSD
l Hypertrophic obstructive
cardiomyopathy
l Patent ductus arteriosus
l Mitral regurgitation
68

Issue 4
Issued: November 2010
Expires: November 2012

ECG INTERPRETATION 4/4


TYPICAL ECG ABNORMALITIES
Heart lesion
PDA
VSD
ASD
Eisenmengers
Aortic stenosis
Aortic regurgitation
Coarctation
Mitral regurgitation
Pulmonary stenosis
Ebsteins anomaly
Fallot's tetralogy
Pulmonary atresia
Tricuspid atresia

Issue 4
Issued: November 2010
Expires: November 2012

ECG abnormalities
LVH > RVH; LAH
LVH > RVH; +/- RBBB; T inv LV. leads
Secundum RAD; RBBB; +/- increased P-R; AF
Primum
LAD; RBBB; BVH; RAH
RVH; P pulmonale
LVH + strain
LVH
Newborn:
RVH
Older:
Normal or LVH +/- strain; RBBB
LVH
RVH; RAH
Prolonged P-R interval; gross RAH; RBBB
Newborn:
Normal or T +ve V1
Older:
RVH; RAH
RAH
LAD; RAH; LVH

69

TACHYCARDIA AND BRADYCARDIA 1/5


SUPRAVENTRICULAR
TACHYCARDIA
Early diagnosis and effective
management of
supraventricular tachycardia
(SVT) are vital as there is a
small risk of mortality
RECOGNITION AND
ASSESSMENT
Symptoms and signs
l Recurrent condition
l family may identify as another attack
l Infants
l gradual onset of increasing
tachypnoea
l poor feeding
l pallor
l occasionally more dramatic
presentation with a rapid onset of
severe cardiac failure
l Toddlers
l recurrent episodes of breathlessness,
cold sweats and pallor
l Older children
l recurrent palpitations, episodes of
dizziness and pallor

Investigations
l Confirm diagnosis with 12-lead ECG
l Continuous ECG monitoring is
essential
l Assess for cardiac failure

Differential diagnosis
l Sinus tachycardia, particularly in
infants, can be >200/min. However,
rates of 220300/min are more likely
to be SVT
l If first presentation, check for any
other cause of cardiac failure

70

l Failure to respond to adenosine can


be used to distinguish origin of a
tachycardia in a stable patient

Causes of tachyarrhythmias
l Re-entrant congenital conduction
pathway abnormality (common)
l Poisoning
l Metabolic disturbance
l After cardiac surgery
l Cardiomyopathy
l Long QT syndrome

ECG DIAGNOSIS
Infants
l Majority have a P wave before every
QRS complex, usually by >70 msec
(2 mm at 25 mm/sec)
l QRS complexes are generally normal
but may be wide
l Accessory pathway frequently
capable of anterograde as well as
retrograde conduction
l this will be revealed during normal
sinus rhythm by short P-R interval
and presence of a delta wave (classic
Wolff-Parkinson-White syndrome)

Older children
l Nodal tachycardias become more
common with increasing age
l characterised by fast, regular, narrow
QRS complexes without visible P
waves
l Wide QRS complex or bundle branch
block in childhood is rare
l changes also present in sinus rhythm
l review previous ECGs

If in doubt, seek more


experienced help

Issue 4
Issued: November 2010
Expires: November 2012

TACHYCARDIA AND BRADYCARDIA 2/5


IMMEDIATE TREATMENT
l Resuscitate (ABC) first
l If first presentation, refer to consultant
l See following algorithms

Vagal manoeuvres
These may include:
l Diving reflex
l wrap infants in a towel and immerse
their whole face into iced water for
about 510 sec
l in children, place a bag or rubber
glove containing iced water over face
l One side carotid massage
l Valsalva manoeuvre
l Where possible, maintain ECG
monitoring and recording during all
procedures

Other drugs
l If adenosine ineffective, seek advice
from a paediatric cardiologist
l In refractory Wolff-Parkinson-White
tachycardia, flecainide is particularly
useful
l In refractory atrial tachycardia,
amiodarone is useful

Do not use verapamil and


propranolol in same patient as
both have negative inotropic
effects. Do not use verapamil in
children aged <1 yr

Do NOT use eyeball pressure


because of risk of ocular
damage
Adenosine
l Drug of choice as it has a rapid onset
of action and not negatively inotropic
l Very short half-life (1015 sec) giving
short-lived side-effects (flushing,
nausea, dyspnoea, chest tightness)
l Effective in >80% of junctional
tachycardias and will not precipitate
ventricular tachycardias into
ventricular fibrillation
l Can be used in broad-complex
tachycardia of uncertain origin
l Must be given as a rapid bolus IV via
a large peripheral or central vein and
followed by sodium chloride 0.9%
flush
l In patients with sinus tachycardia,
heart rate will slow to bradycardia but
will rapidly increase again

Issue 4
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Expires: November 2012

71

TACHYCARDIA AND BRADYCARDIA 3/5


Supraventricular tachycardia
Shock
present

Yes

No

Vagal manoeuvres
(if no delay)

Vagal manoeuvres

Adenosine
100 microgram/kg

Yes

Establish vascular
access if quicker
than obtaining defib

2 min
No

Adenosine
200 microgram/kg
2 min

Adenosine
300 microgram/kg

l Discuss with cardiologist


l Consider:
l adenosine 400500 micrograms/kg
(aged >1 month)
l synchronous DC shock
l amiodarone or procainamide
l other anti-arrhythmics (seek advice)

WIDE COMPLEX TACHYCARDIA


RECOGNITION AND
ASSESSMENT
Definition
l Ventricular tachycardia
l 3 successive ectopic ventricular
beats
l sustained if it continues >30 sec

72

Synchronous DC shock
1 J/kg

Synchronous DC
2 J/kg shock

Amiodarone

l Adenosine may be used in preference


to electrical shock
l An anaesthetic must be given for DC
shock if patient responsive to pain

Causes
l Underlying cause (e.g. myocarditis,
cardiomyopathy, or patient with
congenital heart disease)
l Poisoning (e.g. phenothiazines,
tricyclic antidepressants, quinidine
and procainamide)
l Electrolyte disturbance (e.g.
hypokalaemia, hypomagnesaemia)
l Ventricular tachycardia can
degenerate into ventricular fibrillation
Issue 4
Issued: November 2010
Expires: November 2012

TACHYCARDIA AND BRADYCARDIA 4/5


Diagnosis
l Wide-QRS SVT (SVT with aberrant
conduction) is uncommon in infants
and children. Correct diagnosis and
differentiation from VT depends on
careful analysis of at least a 12-lead
ECG +/- an oesophageal lead
l Assess patient and obtain family
history to identify presence of an
underlying condition predisposing to
stable ventricular tachycardia
l SVT or VT can cause haemodynamic
instability: response to adenosine can
help identify underlying aetiology of
the arrhythmia, but adenosine should
be used with extreme caution in
haemodynamically stable children
with wide-complex tachycardia
because of the risk of acceleration of
tachycardia and significant
hypotension. This should not delay
definitive treatment in children with
shock

l Seek advice
l Ventricular tachycardia not always
obvious on ECG, clues are:
l rate varies between 120 and 250
beats/min (rarely 300 beats/min)
l QRS complexes are almost regular
though wide
l QRS axis abnormal for age (normal
for aged >6 months is <+90)
l no preceding P wave, or A-V
dissociation
l fusion beats (normally conducted
QRS complex merges with an
abnormal discharge)

IMMEDIATE TREATMENT
Ventricular tachycardia
VF protocol

No

Pulse present
An anaesthetic must be
given for DC shock if
patient responsive to
pain

Yes

Hypotensive
No

Yes

Amiodarone
5 mg/kg (max 300 mg)
over 30 min

Synchronous DC
shock
1 J/kg

Consider:
l synchronous DC shock
l seek advice

Synchronous DC
shock
2 J/kg

Amiodarone
Issue 4
Issued: November 2010
Expires: November 2012

73

TACHYCARDIA AND BRADYCARDIA 5/5


l Treatment of haemodynamically
stable child with ventricular
tachycardia should always include
early consultation with a paediatric
cardiologist. They may suggest
amiodarone: can cause hypotension,
which should be treated with volume
expansion
l Use synchronous shocks initially, as
these are less likely than an
asynchronous shock to produce
ventricular fibrillation. If synchronous
shocks are ineffectual, and child is
profoundly hypotensive, subsequent
attempts will have to be
asynchronous
l Treatment of torsade de pointes
ventricular tachycardia is magnesium
sulphate 2550 mg/kg (up to 2 g)
diluted to 100 mg/mL in sodium
chloride 0.9% over 1015 min
l Amiodarone 5 mg/kg may be given
over 3 min in ventricular tachycardia if
child in severe shock

74

BRADYARRHYTHMIAS
l Urgently manage:
l pre-terminal event in hypoxia or shock
l raised intracranial pressure
l vagal stimulation

Investigations
l ECG to look for:
l conduction pathway damage after
cardiac surgery
l congenital heart block (rare)
l long QT syndrome

Management
l ABC approach: ensure adequate
oxygenation and ventilation
l If vagal stimulation is cause, give
atropine 20 micrograms/kg (min
100 micrograms; max 600 micrograms)
l Consider IV isoprenaline infusion
l Contact paediatric cardiologist for
advice
l fax ECG to cardiologist

Issue 4
Issued: November 2010
Expires: November 2012

ENDOCARDITIS PROPHYLAXIS 1/1


INDICATIONS
Cardiac factors
l Acquired valvular heart disease with
stenosis or regurgitation
l Valve replacement
l Structural congenital heart disease,
including surgically corrected or
palliated structural conditions, but
excluding isolated atrial septal defect,
fully repaired ventricular septal defect
or fully repaired patent ductus
arteriosus, and closure devices
judged to be endothelialised
l Previous infective endocarditis
l Hypertrophic cardiomyopathy

If there is uncertainty, seek


advice from cardiology team at
local paediatric cardiac surgical
centre

MANAGEMENT
l Patients at risk of endocarditis should
be:
l advised to maintain good oral hygiene
l told how to recognise signs of
infective endocarditis, and advised
when to seek expert advice
l Investigate promptly any infection in
patients at risk of endocarditis and
treat appropriately to reduce the risk
of endocarditis
l If patients at risk of endocarditis are
undergoing a gastro-intestinal or
genito-urinary tract procedure at a
site where infection suspected, give
appropriate antibacterial therapy that
includes cover against organisms that
cause endocarditis (see table)

Suggested antibiotic prophylaxis in patients at risk of endocarditis for


procedures where infection may exist
Antibiotics
Amoxicillin

Dose/route
Single dose IV
Aged <5 yr: 250 mg
Aged 59 yr: 500 mg
Aged 10 yr: 1 g
plus
plus
gentamicin
2 mg/kg IV single dose (120 mg aged 1018 yr)
If allergic to penicillin Single dose IV
Aged <14 yr: 6 mg/kg (max 400 mg)
teicoplanin
Aged 14 yr: 400 mg
plus
plus
2 mg/kg single dose IV
gentamicin

l Antibacterial prophylaxis and


chlorhexidine mouthwash are not
recommended for prevention of
endocarditis in patients undergoing
dental procedures

Procedures no longer requiring


routine antibiotic prophylaxis

l Antibiotic prophylaxis against infective


endocarditis is no longer
recommended:
Issue 4
Issued: November 2010
Expires: November 2012

Comment
Give just before
procedure or at induction
of anaesthesia

Give just before


procedure or at induction
of anaesthesia

l for people undergoing dental


procedures
l for people undergoing non-dental
procedures at following sites:
- upper and lower gastrointestinal tract
- genitourinary tract; this includes
urological, gynaecological and
obstetric procedures, and childbirth
- upper and lower respiratory tract;
this includes ear, nose and throat
procedures and bronchoscopy
75

POISONING AND DRUG OVERDOSE 1/2


The poisoned
l Toddlers (accidental poisoning)
l Older children, particularly girls
(intentional self-poisoning)

The poisoners
l Most childhood poisonings are
accidental
l Intentional poisoning may be by the
child or an adult
l Inadvertent poisoning may occur in a
medical setting

The poison
l Children will eat and drink almost
anything

RECOGNITION AND
ASSESSMENT
Symptoms and signs
l Depressed respiration suggests
centrally-acting drug
l Skin blisters (between knees/toes)
common after barbiturates and tricyclics
l Hypothermia after exposure or
barbiturates
l Venepuncture marks and pinpoint
pupils suggest opioid overdose
l Burns around mouth

Life-threatening features
l Coma
l Cyanosis
l Hypotension
l Paralytic ileus

Identify likely poison(s)/drug(s)


l Ask patient, relatives, GP, ambulance
crew. Retain any containers found
l if identification doubtful, send parents
home for poison
l Ask about visitors to the house/visits
to other houses (e.g. grandparents)

Quantity ingested

l Difficult to quantify but parents may


know how full a bottle should have been
76

l assume child has ingested something


even if found with a few tablets and
an empty bottle

Investigations
l U&E
l Blood gases and acid-base
l Save blood and urine for toxicological
analysis. Urgent measurement of
plasma/serum concentrations
essential in diagnosis and
management of poisoning with
ethylene glycol, iron, lithium,
methanol, paracetamol, theophylline
and salicylate. With exception of
paracetamol, no need to measure
concentrations of these substances
unless clear history of ingestion

Request plasma paracetamol


concentration in all
unconscious patients in whom
drug overdosage considered
Seek advice
l Use Toxbase on the internet: site
address www.toxbase.org access and
password available in A&E
l if further information required, contact
National Poisons Information Service
(0844 892 0111)

Always admit a child who is


symptomatic or who has
ingested iron, digoxin, aspirin
or a tricyclic antidepressant. If
child not admitted always
consult paediatric SpR on-call
before sending home
IMMEDIATE TREATMENT
Separate guidelines give more
detailed advice on management
of overdosage with alcohol,
iron, paracetamol,
phenothiazines, salicylates and
tricyclic antidepressants
Issue 4
Issued: November 2010
Expires: November 2012

POISONING AND DRUG OVERDOSE 2/2


Assess airway, breathing and
circulation
l Maintain airway
l if airway not protected, may need
intubation and ventilation
l if cyanosed or rate and depth of
respiration obviously low, arterial
blood gases indicated
l if PaCO2 high or rising, mechanical
ventilation indicated
l Correct hypotension
l raise foot of bed
l if in haemodynamic shock, give IV
bolus of sodium chloride 0.9%
(20 mL/kg over 10 min). Assess and
repeat if still in shock
l consider need for central venous
pressure (CVP) monitoring

Neurological
l Control convulsions
l if unconscious, treat as head injury
until proved otherwise

Drug absorption
l Give antidote if appropriate
l Decrease absorption. Consider
gastric lavage only in patients whose
airway can be protected and who
have ingested life-threatening
amounts of a toxic agent up to 1 hr
previously, provided they are cooperative and have not ingested
petroleum distillates or corrosives
l If gastric lavage contraindicated,
consider activated charcoal in patients
who have ingested life-threatening
amounts of a toxic agent up to 1 hr
previously, provided patient conscious
or airway can be protected. Give 1 g/kg
(max 50 g) orally (disguised with soft
drink/fruit juice) or via nasogastric tube.
Activated charcoal does not affect
absorption of acids, alkalis, alcohols,
cyanide, ethylene glycol, iron or lithium
l Do not give ipecacuanha, it does not
empty the stomach reliably and can
be dangerous
Issue 4
Issued: November 2010
Expires: November 2012

l Stop any regular medication that


might enhance effect of substance
taken in overdose

SUBSEQUENT MANAGEMENT

l If unconscious, admit to a highdependency nursing area and attach


an ECG monitor
l Supportive care alone required for
majority of acutely poisoned patients

MONITORING TREATMENT

l Monitor conscious level, temperature,


respiration, pulse and BP until these
return to normal
l No need to monitor drug concentrations
other than to guide use of measures to
enhance drug elimination
l If unconscious, make full head injury
observations
l Record pulse, respiratory rate, BP,
pupil size and reaction, and level of
consciousness hourly for at least 4 hr
then increase interval if stable

PSYCHIATRIC REVIEW
l Offer all patients admitted after
deliberate acute self-poisoning or
drug overdose an interview with the
psychiatric priority referral team within
24 hr of admission or regaining
consciousness

DISCHARGE AND FOLLOW-UP


l When discharged from hospital
patients should have:
l been conscious and alert with normal
vital signs for at least 6 hr
l no evidence of significant organ
dysfunction as a result of
poisoning/drug toxicity
l been interviewed by a member of the
psychiatric priority referral team
where indicated
l follow-up appointment in psychiatric
clinic (if recommended by
psychiatrist)
l follow-up appointment in paediatric
clinic (if persistent sequelae of
poisoning require review)
77

ALCOHOL POISONING 1/1


All children with features of alcohol intoxication should be referred
to hospital
RECOGNITION AND ASSESSMENT
Symptoms and signs
Table 1: Assessment of alcohol poisoning
Mild toxicity
Moderate toxicity

Severe toxicity

Potentially fatal

l Impaired visual acuity and co-ordination


l Emotional lability
l Slurred speech, diplopia, blurred vision, ataxia, lack of co-ordination,
blackouts, sweating, tachycardia, nausea, vomiting, incontinence
l Acidosis, hypoglycaemia, hypokalaemia
l Cold clammy skin, hypothermia, hypotension, stupor, coma, dilated
pupils, depressed or absent tendon reflexes
l Severe hypoglycaemia, convulsions, respiratory depression,
metabolic acidosis
l Cardiac arrhythmias (e.g. atrial fibrillation, atrio-ventricular block)
l Deep coma, respiratory depression or arrest, circulatory failure

Alcoholic drinks/preparations
l Spirits are particularly dangerous
l Ask about alcopops

IMMEDIATE TREATMENT
l Ensure clear airway and adequate
ventilation
l Gut decontamination is unlikely to be
of benefit
l activated charcoal does not
significantly reduce rate of absorption
l Correct hypoglycaemia as quickly as
possible
l if awake, give oral glucose
l if drowsy or unconscious, give glucose
10% 5 mL/kg IV
l check blood glucose hourly until
consciousness regained
l Correct hypotension (see Poisoning
and drug overdose)
l Correct acid-base and metabolic
disturbance
l Correct hypothermia using conventional
means (e.g. Bair Hugger, blankets)
l Control convulsions with IV lorazepam
l If blood ethanol >5 g/L (108.5 mmol/L)
or if arterial pH <7.0, consider
haemodialysis
l discuss with National Poisons
Information Service (0844 892 0111)

78

INVESTIGATIONS
l Blood glucose
l In moderate to severe toxicity
l U&E
l arterial blood gases
l blood ethanol concentration
l 12-lead ECG

Assessment of severity
l Blood ethanol is a guide to severity of
poisoning
l <1.8 g/L (39 mmol/L) mild toxicity
l 1.83.5 g/L (3976 mmol/L) moderate
toxicity
l 3.54.5 g/L (7698 mmol/L) severe
toxicity
l >4.5 g/L (98 mmol/L) potentially fatal
l Observe for at least 4 hr if >0.4 mL/kg
body weight of absolute ethanol had
been ingested (i.e. 1 mL/kg 40% spirit,
4 mL/kg 10% wine or 8 mL/kg 5% beer)
l Monitor pulse, blood pressure and
body temperature

SUBSEQUENT MANAGEMENT
l See Poisoning and drug overdose
guideline
l Follow guidance on www.toxbase.org
(password from A&E)
l Further advice from National Poisons
Information Service (0844 892 0111)
Issue 4
Issued: November 2010
Expires: November 2012

IRON POISONING 1/2


RECOGNITION AND ASSESSMENT
Symptoms and signs
Time
<6 hr after ingestion

Symptoms and signs


l Nausea, vomiting, abdominal pain and diarrhoea
l Vomit and stools often grey or black
l Polymorph leucocytosis and hyperglycaemia suggest toxicity but
their absence does not exclude it
612 hr after ingestion
l Early features improve in mild cases
l Possibly persistent hyperglycaemia/metabolic acidosis in more
serious cases
>12 hr after ingestion
l In serious cases, evidence of hepatocellular necrosis appears
with jaundice, bleeding, hypoglycaemia, encephalopathy and
metabolic acidosis. Hypotension may occur
25 weeks after ingestion l Gastric stricture or pyloric stenosis may start to cause obstructive
symptoms

Investigations

l If ingested dose >20 mg/kg elemental


iron, measure serum iron 4 hr after
ingestion
l U&E, creatinine
l INR
l Blood glucose
l If presenting within 2 hr of ingestion,
request plain abdominal X-ray
l tablets are sometimes visible in the
stomach or small bowel
l if patient could be pregnant, do NOT
X-ray

Assessment of severity
Review both clinical and
laboratory features

l Estimate ingested dose of elemental


iron, BNFc lists quantity of elemental
iron in various preparations
l <20 mg/kg mild or no toxicity
l 20 mg/kg toxicity likely
l >200 mg/kg severe toxicity, possibly
fatal
l Coma and shock indicate severe
poisoning: urgent treatment required
l Serum iron taken at 4 hr after
ingestion is best laboratory measure
l <3 mg/L (55 micromol/L) mild toxicity
l 35 mg/L (5590 micromol/L)
moderate toxicity
Issue 4
Issued: November 2010
Expires: November 2012

l >5 mg/L (90 micromol/L) severe


toxicity
l Absence of visible tablets on X-ray
does not eliminate possibility of
ingestion

Action
l If clinical features and/or serum iron
concentration suggest severe toxicity,
contact National Poisons Information
Service (0844 892 0111) for advice

IMMEDIATE TREATMENT
Unconscious or in shock
l Assess airway, breathing, circulation
l Secure airway, treat shock, control
seizures
l IV fluids to replace losses
l Commence desferrioxamine IV (see
Desferrioxamine)
l if this is before time when serum iron
should be taken (4 hr), take sample
for serum iron immediately before
commencing desferrioxamine
l do not delay starting desferrioxamine
IV
l Gastric lavage only if ingested dose
>60 mg/kg and/or tablets seen on Xray and child presents within 1 hr
l do not use activated charcoal as it
does not adsorb iron

79

IRON POISONING 2/2


Conscious and not in shock
l Check serum iron concentration at
4 hr
l Interpret serum iron concentration in
view of childs clinical condition and
history

Moderate poisoning: serum iron


35 mg/L

l Repeat serum iron measurement after


further 2 hr, even if asymptomatic
l If concentration falling, no further
treatment required
l If concentration rising and child
symptomatic, give desferrioxamine IV
(see Desferrioxamine)

Severe poisoning: serum iron


>5 mg/L

l If asymptomatic, repeat serum iron


after 2 hr: if concentration falling
treatment unlikely to be required
l If symptomatic, give desferrioxamine
IV (see Desferrioxamine)

SUBSEQUENT MANAGEMENT
l See Poisoning and drug overdose
guideline
l If slow release preparations ingested,
repeat serum iron after further 68 hr
l In patients with severe toxicity:
l arterial blood gases and correct
acidosis
l If metabolic acidosis persists despite
correction of hypoxia and adequate
fluid resuscitation, give IV sodium
bicarbonate 1 mL/kg 8.4%
bicarbonate diluted in glucose 5% or
sodium chloride 0.9% 500 mL at
2-3 mL/kg/hr
l monitor renal and liver function
l be alert for evidence of gut
perforation or infarction
l Follow guidance on www.toxbase.org
(password from A&E)
l Further advice from National Poisons
Information Service (0844 892 0111)

Desferrioxamine
l Before starting treatment, contact
National Poisons Information Service
(0844 892 0111) for advice
l Starting dose is 15 mg/kg/hr
l Reduce after 46 hr
l maximum 80 mg/kg in 24 hr
l desferrioxamine commonly causes
hypotension if infused more rapidly
than recommended rate and turns
urine red/orange but rarely causes
rashes or anaphylactic reactions

80

Issue 4
Issued: November 2010
Expires: November 2012

PARACETAMOL POISONING 1/4


RECOGNITION AND
ASSESSMENT
Symptoms and signs
l Common: nausea and vomiting
l Rare: coma and metabolic acidosis
l Late: abdominal pain

Management for
l Paracetamol dose >12 g or 150 mg/kg
(>75 mg/kg in those at high risk)
l Symptomatic
l Or INR >1.3, ALT >150 IU/L,
abnormal acid/base or bicarbonate
l Follow guidance on www.toxbase.org
(password from A&E)
l Further advice from National Poisons
Information Service (0844 892 0111)*
l If there is absolute certainty that a
single dose of paracetamol of <12 g or
150 mg/kg (<6 g or 75 mg/kg in high
risk children) has been ingested,
plasma paracetamol need not be
measured and child requires no
treatment

Investigations
l Plasma paracetamol 416 hr after
overdose (but not before or after this
interval) is a reliable guide to the
need for treatment
Time from
overdose (hr)
<1
47
814
1524
Multiple/
staggered
overdose
>24

l If patient presents >8 hr after


overdose, request baseline:
l FBC, INR
l U&E, liver function, phosphate
l acid-base (venous sample)

IMMEDIATE TREATMENT
l Compare plasma paracetamol with
treatment graph (Figure 1)
l use high risk treatment line for
patients who have existing liver
disease; are underweight with failure
to thrive, whatever the cause;
anorexia nervosa; cystic fibrosis; HIV
positive; and those taking enzymeinducing drugs (e.g. barbiturates,
phenytoin, carbamazepine, rifampicin,
St Johns Wort) or who chronically
abuse alcohol; they are at higher risk
of hepatic necrosis
l if above, on, or even slightly below
relevant treatment line, give IV
acetylcysteine in glucose 5%
l Time interval is critical in assessing
need for treatment. Detailed
questioning essential

If there is doubt about timing


or need for treatment, treat

Guidance on use of acetylcysteine


Give activated charcoal 1 g/kg (max 50 g) orally or via nasogastric tube (gastric
lavage is not indicated)
Await paracetamol concentration result if this will be available within 8 hr. Treat if
above, on, or even slightly below appropriate treatment line'
Give at once while awaiting paracetamol concentration result. Cease if
concentration well below appropriate treatment line
Give at once. Cease at 24 hr after ingestion if patient asymptomatic, plasma
paracetamol <10 mg/L and INR 1.3
Plasma paracetamol will confirm ingestion but cannot be related to nomogram.
Start acetylcysteine and discuss with NPIS*
Give if taken >150 mg/kg or paracetamol still detectable in the blood or INR >1.3
or ALT >150 IU/L or symptomatic
If patient has, or is at risk of developing, fulminant hepatic failure (see Lifethreatening features), continue to give 50 mg/kg in 500 mL every 8 hr.
Discuss with NPIS*

Issue 4
Issued: November 2010
Expires: November 2012

81

PARACETAMOL POISONING 2/4


Acetylcysteine dosage
Table 1: Administration of acetylcysteine (dose capped at 110 kg body weight)
Weight <20 kg

Aged <12 yr
with weight
>20 kg

Aged 12 yr

l
l
l
l
l
l
l
l
l

150 mg/kg IV in 3 mL/kg glucose 5% over 15 min (max 16.5 g) then


50 mg/kg IV in 7 mL/kg glucose 5% over 4 hr (max 5.5 g) then
100 mg/kg IV in 14 mL/kg glucose 5% over 16 hr (max 11 g)
150 mg/kg IV in 100 mL glucose 5% over 15 min then
50 mg/kg IV in 250 mL glucose 5% over 4 hr then
100 mg/kg IV in 500 mL glucose 5% over 16 hr
150 mg/kg IV in 200 mL glucose 5% over 15 min then
50 mg/kg IV in 500 mL glucose 5% over 4 hr then
100 mg/kg IV in 1000 mL glucose 5% over 16 hr

l If for any reason glucose 5% unsuitable, substitute sodium chloride 0.9%

Prepare and check infusion bags carefully. Administration errors


are common
Acetylcysteine can cause a pseudo-allergic reaction (wheezing,
flushing, hypotension) that is usually relieved by stopping infusion but
occasionally chlorphenamine and hydrocortisone are required. Once
reaction has subsided, recommence infusion at 50 mg/kg over 4 hr
MONITORING TREATMENT

l Severe liver damage in the context of paracetamol poisoning has been defined as
a peak plasma ALT activity exceeding 1000 iu/L
Time of
presentation
after overdose
(hr)
<8

815

82

Monitoring/continued treatment

Discharge policy

Single IV dose
l INR, AST/ALT, creatinine,
l Discharge if INR 1.3, AST/ALT and
bicarbonate 24 hr after overdose or
plasma creatinine normal at 24 hr
when antidote treatment complete
after overdose, or after antidote
l if INR >1.3 or creatinine raised, or
treatment complete, with warning to
patient acidotic, continue treatment
return if vomiting or abdominal pain
(IV acetylcysteine 150 mg/kg over
occur
24 hr)
l recheck INR and U&E 12 hrly until
clearly falling
l If INR 1.3, AST/ALT and plasma
l INR, AST/ALT, creatinine,
creatinine normal:
bicarbonate and phosphate 24 hr
l discharge asymptomatic patients
after overdose or when antidote
12 hr after antidote treatment with
treatment complete
warning to return if vomiting or
l if INR >1.3 or creatinine raised, or
abdominal pain occur
patient acidotic, continue treatment
l if INR >1.3 and rises, and/or plasma
(IV acetylcysteine 150 mg/kg over
creatinine raised after antidote
24 hr)
treatment, monitor and observe until
l recheck INR and U&E 12 hrly until
these indices are falling and INR <2.0
clearly falling
l discuss with NPIS

Issue 4
Issued: November 2010
Expires: November 2012

PARACETAMOL POISONING 3/4


16

l Observe for signs of


encephalopathy (mental confusion,
drowsiness, spatial disorientation,
asterixis)
l Urine output
l Capillary blood glucose 4 hrly
l Blood gases and acid-base daily
l INR, AST/ALT, creatinine,
bicarbonate and phosphate 24 hr
after overdose or when antidote
treatment complete
l if INR >1.3 and rises, or creatinine
raised, or patient acidotic, continue
treatment (IV acetylcysteine 150
mg/kg over 24 hr) until INR <2.0
l recheck INR and U&E 12 hrly until
clearly falling

l If INR 1.3, AST/ALT and plasma


creatinine normal:
l discharge asymptomatic patients
72 hr after antidote treatment with
warning to return if vomiting or
abdominal pain occur
l if INR >1.3 and rises, and/or plasma
creatinine raised after antidote
treatment, monitor and observe until
these indices are falling and INR <2.0
l Patients presenting 2436 hr after
overdose can develop hepatic
dysfunction after this time, even if
INR, ALT and creatinine normal at
time of presentation repeat these
indices 12 hr later

Life-threatening features

Psychiatric review

l A poor prognosis indicated by:


l INR >3.0
l serum creatinine >200 mol/L
l blood pH <7.3
l signs of encephalopathy
l If any of these features are present
after overdose, seek advice from local
tertiary liver unit
l insert urinary catheter to monitor
urine flow and rehydrate to maintain
urine output >2 mL/kg/hr or 100 mL/hr
whichever is smaller
l if unresponsive to IV fluids, give
furosemide and consider low-dose
dopamine
l insert CVP line to monitor response
to IV fluids only if INR normal
l Patients with incipient or established
hepatic failure may be candidates for
liver transplantation
l Treat haemorrhage with fresh frozen
plasma
l Hypophosphataemia usually occurs
after paracetamol poisoning and
correlates well with degree of hepatic
damage

l All patients admitted after acute selfpoisoning or deliberate drug overdose


should be offered an interview with a
member of the psychiatric priority
referral team within 24 hr of
admission or regaining consciousness

Issue 4
Issued: November 2010
Expires: November 2012

DISCHARGE AND FOLLOW-UP

l See Poisoning and drug overdose


guideline
l Advise all patients to return to
hospital if vomiting or abdominal
pains develop or recur

83

PARACETAMOL POISONING 4/4


Figure 1: Treatment graph for paracetamol overdose

Plasma
paracetamol
(mg/L)

84

Plasma
paracetamol
(mmol/L)

Issue 4
Issued: November 2010
Expires: November 2012

PHENOTHIAZINE POISONING/SIDE EFFECTS 1/1


RECOGNITION AND
ASSESSMENT
Symptoms and Signs
l Drowsiness
l Confusion

Common preparations
l Chlorpromazine
l Perphenazine
l Prochlorperazine
l Promazine
l Trifluoperazine
l Metoclopramide

Extrapyramidal side effects


Not dose-related
l Dystonia (e.g. oculogyric crises,
spasmodic torticollis)
l Dyskinesia
l Appear after only a few doses

l Correct acid-base and metabolic


disturbance with bicarbonate infusion
(see Salicylate poisoning guideline)
l Control convulsions with IV lorazepam

Treatment of extrapyramidal
side effects
l Procyclidine orally
l in severe reactions give IV or IM
l subsequent oral doses may be
needed for 23 days
l if procyclidine not available, give
benztropine or diazepam

MONITORING
TREATMENT/SUBSEQUENT
MANAGEMENT

l See Poisoning and drug overdose


guideline
l Follow guidance on www.toxbase.org
(password from A&E)
l Further advice from National Poisons
Information Service (0844 892 0111)

Complications
l Convulsions
l Hypothermia
l Hypotension
l Arrhythmias (e.g. sinus tachycardia,
QT and QRS prolongation, VT/VF,
bundle branch/atrio-ventricular block)
l Respiratory depression
l Rhabdomyolysis
l Renal failure

IMMEDIATE TREATMENT

l If patient presents within 1 hr of


ingesting a potentially toxic dose, give
activated charcoal 1 g/kg (max 50 g)
l Maintain clear airway and adequate
ventilation
l Correct hypotension (see Poisoning
and drug overdose guideline)
l Correct hypothermia using
conventional means (e.g. Bair Hugger,
blankets)
Issue 4
Issued: November 2010
Expires: November 2012

85

SALICYLATE POISONING 1/2


RECOGNITION AND
ASSESSMENT
Symptoms and signs
Common features
l Vomiting
l Dehydration
l Tinnitus
l Vertigo
l Deafness
l Sweating
l Warm extremities with bounding pulse
l Increased respiratory rate
l Hyperventilation
l Acid-base disturbance:
l aged >4 yr usually mixed respiratory
alkalosis and metabolic acidosis with
normal or high arterial pH
l aged <4 yr usually a dominant
metabolic acidosis with low arterial pH

Uncommon features
l Haematemesis
l Hyperpyrexia
l Hypoglycaemia
l Hypokalaemia
l Thrombocytopenia
l Increased INR/PTR
l Intravascular coagulation
l Renal failure
l Non-cardiac pulmonary oedema
l Confusion
l Disorientation
l Coma
l Convulsions

Preparations
l Aspirin tablets
l Methylsalicylate (Oil of Wintergreen),
very toxic
l Choline salicylate (dental gels)
l Numerous over-the-counter
analgesics/antipyretics contain aspirin

86

Investigations
l U&E, creatinine
l INR
l Arterial blood gases
l Blood glucose (capillary)
l In asymptomatic patients with a
reliable history of ingestion of
<120 mg/kg of aspirin, plasma
salicylate not required
l In those who have ingested
>120 mg/kg, measure plasma
salicylate at least 2 hr (if
symptomatic) or 4 hr (if
asymptomatic) after ingestion
l If coincident paracetamol overdose
requiring infusion of antidote, sample
before administration of Nacetylcysteine
l Urine pH

Assessment of severity
l Severity cannot be assessed from
plasma salicylate concentrations alone
l Neurological features (e.g. confusion
and impaired consciousness),
metabolic acidosis, and high
salicylate concentrations indicate
severe poisoning
l Risk factors for death include:
l aged <10 yr
l CNS features
l acidosis
l hyperpyrexia
l late presentation
l pulmonary oedema
l salicylate concentration >5.1 mmol/L

IMMEDIATE TREATMENT
l If ingested >125 mg/kg salicylate
within previous hr, give oral activated
charcoal 1 g/kg (maximum 50 g),
mixed with soft drink/fruit juice if
necessary to disguise taste
l Consider gastric lavage if taken
>500 mg/kg within 1 hr
l Rehydrate orally (IV if vomiting)
Issue 4
Issued: November 2010
Expires: November 2012

SALICYLATE POISONING 2/2


Interpretation of plasma
salicylate concentrations

l Clinical presentation is most


important factor
l Late presenting patient may have a
subtoxic salicylate concentration, but
serious acid-base or CNS
disturbances
l Plasma salicylate <350 mg/L
(2.5 mmol/L) and mild clinical effects:
l continue maintenance management
l Plasma salicylate 350700 mg/L
(2.55.0 mmol/L) and moderate
clinical effects:
l continue maintenance management
and start alkaline diuresis in children
aged <5 yr
l in older children start alkaline diuresis
if plasma salicylate >500 mg/L
(3.6 mmol/L)
l Plasma salicylate >700 mg/L
(5.0 mmol/L) and severe clinical
effects
l use haemodialysis

Children aged <10 yr have an


increased risk of salicylate
toxicity and may require
haemodialysis at an earlier stage
Alkaline diuresis
l If serum potassium low, give
potassium chloride 1 mmol/kg orally
l or if not tolerated sodium chloride
0.45%/glucose 5% with 20 mmol
potassium in 500 mL at 100%
maintenance
l If serum potassium within normal
range, alkalinise urine to enhance
salicylate excretion (optimum urine
pH 7.58.5)
l give sodium bicarbonate 8.4%
1 mL/kg (1 mmol/kg) in 500 mL sodium
chloride 0.9% or glucose 5% at
23 mL/kg/hr, and repeat if necessary
to maintain urine pH 7.58.5
Issue 4
Issued: November 2010
Expires: November 2012

Do not use volumes of IV fluids


above maintenance
requirements (forced diuresis)
they do not increase salicylate
elimination and can cause
pulmonary oedema
Haemodialysis
Use in patients with severe poisoning
l Plasma concentrations >700 mg/L
(5.0 mmol/L)
l Renal failure
l Congestive cardiac failure
l Non-cardiogenic pulmonary oedema
l Convulsions
l CNS effects not resolved by
correction of acidosis
l Persistently high salicylate
concentrations unresponsive to
urinary alkalinisation
l Severe metabolic acidosis
l Children aged <10 yr who have an
increased risk of salicylate toxicity

MONITORING
TREATMENT/SUBSEQUENT
MANAGEMENT
l See Poisoning and drug overdose
guideline
l During alkaline diuresis, check U&E,
blood glucose, acid-base hourly
l Repeat plasma salicylate 2 hrly until
falling
l if plasma salicylate continues to rise,
consider a second dose of activated
charcoal
l Continue therapy until patient
improving and plasma salicylate
falling
l Follow guidance on www.toxbase.org
(password from A&E)
l Further advice from National Poisons
Information Service (0844 892 0111)

87

TRICYCLIC POISONING 1/2


RECOGNITION AND
ASSESSMENT
Symptoms and signs
Early in poisoning
l Anticholinergic effects (tachycardia,
hot, dry skin, dry mouth and tongue,
dilated pupils, urinary retention)
l Ataxia, nystagmus
l Drowsiness

l Metabolic acidosis
l Hypokalaemia

Severe cases
l Hypotension

l Increased tone, hyperreflexia


l Coma

IMMEDIATE TREATMENT
If a benzodiazepine has also
been taken, do NOT give
flumazenil
l Correct any hypoxia

l if PaCO2 >6 kPa in respiratory failure


arrange assisted ventilation
l If high dose (e.g. amitriptyline
>4 mg/kg) within previous hour, give
activated charcoal 1 g/kg (max 50 g)
either orally (mixed with soft drink/fruit
juice if necessary to disguise taste) or,
if drowsy or unconscious, by
nasogastric tube (provided airway can
be protected)
l Admit to HDU

l Treat arrhythmias by correction of


hypoxia and acidosis

l resist temptation to treat with drugs

l Seizures

l Respiratory depression
l Cardiac arrhythmias

Preparations
l Amitriptyline
l Amoxapine

l Clomipramine
l Dosulepin
l Doxepin

l Imipramine

l Lofepramine
l Nortriptyline

l Trimipramine

l correct hypoxia and acidosis, inform


consultant
l consult a cardiology SpR at local
paediatric cardiac centre

Prolonged resuscitation may be


successful after cardiac arrest
MONITORING TREATMENT
l See Poisoning and drug overdose
guideline
l Cardiac monitor for at least 6 hr

l asymptomatic patients with normal


ECG after 6 hr are unlikely to develop
late complications

Investigations
l U&E

l Arterial blood gas

l 12-lead ECG, large doses cause


prolongation of P-R and QRS intervals

88

Issue 4
Issued: November 2010
Expires: November 2012

TRICYCLIC POISONING 2/2


SUBSEQUENT MANAGEMENT
l See Poisoning and drug overdose
guideline

l Follow guidance on www.toxbase.org


(password from A&E)

l Further advice from National Poisons


Information Service (0844 892 0111)
l Consider second dose of charcoal
after 2 hr if:

l sustained-release formulation taken


l CNS/respiratory depression

l In severe cases, correct hypotension


by raising foot of bed or, if necessary,
expanding intravascular volume

Issue 4
Issued: November 2010
Expires: November 2012

l Control convulsions with IV lorazepam


l If patient hypothermic, rewarm slowly
using conventional means (e.g. Bair
Hugger, blankets)
l Treat skin blisters as burns

l monitor for rhabdomyolysis (look for


coca-cola coloured urine testing
positive for blood, measure creatine
kinase)
l Forced diuresis, haemodialysis or
haemoperfusion are of no value

l Agitation and visual and auditory


hallucinations are common during
recovery and may require treatment
with high doses of diazepam

89

DIABETES AND FASTING 1/3


Management of children with diabetes
undergoing surgery and other
procedures that require fasting

PRINCIPLES
Reasons to control diabetes well in perioperative period
l To prevent hyperglycaemia and ketoacidosis, resulting from:
l omission of insulin
l stress hormone response to surgery
l catabolic state
l To minimise risk of infection,
enhanced by hyperglycaemia
l To prevent hypoglycaemia, resulting
from:
l starvation pre- and post-operatively
l anorexia post-operatively

Careful regular monitoring of


blood glucose is required
throughout peri-operative
period
l Diabetic patients should preferably be
first on morning list
l Give usual insulin evening before
procedure
l Recommend normal age-dependent
fasting see Pre-op fasting guideline

If any concerns, contact


diabetes team
MINOR SURGERY (able to eat
within 4 hr of procedure)
Pre-operative care
First on the morning list

l Advise usual doses of insulin on night


before procedure
l On day of procedure omit insulin and
breakfast
l Allow clear fluids, including sweet
drinks, up to 0600 hr
l Measure and record capillary blood
glucose pre-operatively and half-hrly
during operation

90

First on the afternoon list

l Advise usual doses of insulin evening


before procedure
l Advise child to have normal breakfast
no later than 0730 hr
l Breakfast insulin dose
l if using multiple daily injection (MDI)
regimen, give usual breakfast insulin
l if using twice daily insulin regimen
give one-third of total morning dose as
rapid-acting insulin (e.g. Novorapid)
l Allow clear fluids until 3 hr before
operation
l Measure and record capillary blood
glucose on arrival in theatre
l Measure and record capillary blood
glucose hourly once nil-by-mouth and
half-hrly during operation
l If any concerns (e.g. vomiting,
prolonged operation), start IV fluids and
insulin as for Major surgery (see below)

Post-operative care

l Monitor capillary blood glucose in


recovery and then hourly for 4 hr
l If well on return to ward and using
multiple daily injection (MDI) regimen
l give dose of rapid-acting insulin
appropriate for carbohydrate content
of next meal (if advice needed,
contact diabetes team) and
l give next dose of long-acting insulin
at usual time
l If using twice daily premixed insulin
regimen and able to eat by lunch on
same day of procedure, give one-third
of total morning dose as rapid-acting
insulin (e.g. Novorapid)
l with meal
l teatime on same day of procedure, it
may be appropriate to give childs
usual insulin dose or a reduced dose:
contact diabetes team for advice
l If any concerns (e.g. vomiting or
prolonged operation), start IV fluids and
insulin as for Major surgery (see below)
l when child ready to eat, see Major
and emergency surgery postoperative care
Issue 4
Issued: November 2010
Expires: November 2012

DIABETES AND FASTING 2/3


MAJOR SURGERY (unable to
eat within 4 hr of start of
procedure

l Measure and record capillary blood


glucose hourly once nil-by-mouth and
half-hrly during operation

EMERGENCY SURGERY
Pre-operative care

l Admit on day before surgery


l Check pre-meal and bedtime capillary
blood glucose measurements on ward

First on the morning list

l If using multiple daily injections (MDI),


give usual mealtime short-acting insulin
but half usual dose of long-acting
insulin evening before procedure
l If using twice-daily insulin regimen,
give usual doses of insulin with meal
evening before procedure
l On day of procedure, omit insulin and
breakfast
l Allow clear fluids, including sweet
drinks, up to 0600 hr
l Insert 2 IV cannulae if possible. These
can be inserted in theatre, if necessary
l Start a glucose and sliding scale
insulin infusion in theatre see below
l Measure and record capillary blood
glucose pre-operatively and half-hrly
during operation

First on the afternoon list


l Advise usual doses of insulin evening
before procedure
l Advise child to have a normal
breakfast no later than 0730 hr
l Breakfast insulin dose
l if using multiple daily injection (MDI)
regimen, give usual breakfast insulin
l if using twice daily insulin regimen,
give one-third of total morning dose as
rapid-acting insulin (e.g. Novorapid)
l Allow clear fluids until 3 hr before
operation
l Measure and record capillary blood
glucose on arrival in theatre
l Insert 2 IV cannulae if possible. These
can be inserted in theatre, if necessary
l Start a glucose and sliding scale
insulin infusion in theatre see below
Issue 4
Issued: November 2010
Expires: November 2012

Emergency procedures differ from


elective ones as children run the risk of
developing ketoacidosis if they are ill.
Prolonged starvation associated with
delayed surgery poses additional
complications

Pre-operative care
l Inform diabetes team immediately
l Do not give any SC insulin while child
starved
l Check venous U&E, glucose, blood
gas when child cannulated
l Commence glucose and sliding scale
insulin infusion see below
l Measure and record capillary blood
glucose hourly once nil-by-mouth and
half-hrly during operation

If patient ill or diabetes not well


controlled, follow Diabetic
ketoacidosis guideline and
postpone operation until patient
stabilised.
Operate once patient
rehydrated, with stable blood
pressure, serum sodium and
potassium within normal range
and blood glucose <17 mmol/L
INTRAVENOUS INSULIN AND
FLUIDS
Maintenance fluid infusion

l Use premixed 500 mL bags of sodium


chloride 0.45% and glucose 5% with
10 mmol/L of potassium chloride

Insulin infusion
l Add 50 units soluble insulin (e.g.
Actrapid) to 50 mL of sodium chloride
0.9% to make a 1 unit/mL solution
l Administer via syringe pump, do not
add directly to fluid bag
91

DIABETES AND FASTING 3/3


l Insert 2 cannulae, so that insulin
infusion given by a dedicated vein
rather than via a 3-way connection
l If this not possible, use Y connector
with one-way valve (e.g. VygonProtect-a-Line 2 extension)
l Determine infusion rate from hourly
capillary blood glucose results,
according to sliding scale see Table 1
l Insulin sliding scale should always to
be given in conjunction with a
glucose infusion
l If blood glucose >15 mmol/L, check
for ketones, if positive, contact doctor

Do not switch off insulin and/or


maintenance fluids in transit to
and from theatre
Do not give ANY SC insulin
until child ready to come off
sliding scale
Monitoring
l Adjust insulin infusion rate according
to blood glucose see Table 1. Aim
to keep blood glucose between 4 and
12 mmol/L
l Check capillary blood glucose halfhrly during surgery and adjust insulin
infusion according to Table 1

Post-operative care
l Check capillary blood glucose halfhrly for the first 2 hr and then hourly
l Continue glucose and sliding scale
insulin infusion until taking adequate
oral fluids and snacks. While on
insulin sliding scale, child may safely
eat and drink

l If taking adequate oral fluids and


snacks and using multiple daily
injection (MDI) regimen
l give dose of rapid-acting insulin
appropriate for carbohydrate content
of next meal (if advice needed,
contact diabetes team) and
l give next long-acting insulin dose at
usual time. If child was treated using
a sliding scale overnight, and usual
dose of long-acting insulin was
omitted previous night, give half usual
dose of long-acting insulin with
breakfast if ready to eat
l If using twice daily premixed insulin
regimen and taking adequate oral
fluids and snacks by:
l lunch on same day of procedure, give
one-third of total morning dose as
rapid-acting insulin (e.g. Novorapid)
l teatime on same day of procedure or
breakfast on next day, it may be
appropriate to give childs usual
insulin dose or a reduced dose
contact diabetes team for advice

Give non-analogue insulin 30


min before meal. Give analogue
insulin 5 min before meal. After
30 min stop infusion
Patients unlikely to resume
eating and drinking
l If after 48 hr, patient still unable to eat
or drink enough post-operatively:
l assess for enteral or parenteral feeding
contact nutrition support team
l contact diabetic nurse specialist for
advice on prescribing regular SC insulin

Table 1
Capillary blood glucose (mmol/L)
28.1
18.128
12.118
8.112
4.18
4

92

Insulin infusion rate (mL/kg/hr)


Call Doctor
0.1
0.075
0.05
0.025
Stop insulin, treat hypo. Recheck blood
glucose after 30 min and follow sliding scale
Issue 4
Issued: November 2010
Expires: November 2012

DIABETIC KETOACIDOSIS 1/6


ALGORITHM (cross-referenced to text)

l Remember paediatric type 2 patients can present in DKA

Resuscitation 2
l Airway + NG tube
l Breathing (100% O2)
l Circulation (sodium
chloride 0.9% 10
mL/kg repeated until
circulation restored,
max 3 doses)
No improvement

Re-evaluate
l Fluid balance + IV
therapy
l If continued acidosis,
may require further
resuscitation fluid
l Check insulin dose
correct
l Consider sepsis

Dehydration <5%
Clinically well
Tolerating fluid orally
pH >7.3

Diabetic ketoacidosis
Call senior staff
Immediate treatment 1

Shock
See 2 for definition

Dehydration >5%
Vomiting or
Biochemically acidotic

Therapy
l Start with SC insulin
l Give oral fluids

Intravenous therapy 3
l Calculate fluid requirements
l Correct over 48 hr, never less
than 12 hr
l Sodium chloride 0.9%
l Use premixed bags with KCl
l Insulin 0.050.1 units/kg/hr by
infusion (after first hour of fluids).
Starting dose 4 (alter as per local
policy)

l
l
l
l

No improvement
Blood ketones rising
Looks unwell
Starts vomiting

Neurological
deterioration
l Warning signs:
l headache, irritability,
slowing heart rate,
reduced conscious
level
l Specific signs
l raised intra-cranial
pressure

Monitoring 5
Blood glucose half-hrly, then
hourly
Neurological status at least
hourly
Fluid input/output hourly
Electrolytes 2 hr after start of IV
therapy, then 4 hrly

Blood glucose <14 mmol/L

Exclude hypoglycaemia
? cerebral oedema

Subsequent management 6
l Change to sodium chloride 0.9%/0.45% + glucose 5%
l Use premixed bags containing KCl
l Continue monitoring as above

Insulin 7 8
Start SC insulin then
stop IV insulin

Issue 4
Issued: November 2010
Expires: November 2012

Improvement 8
l Clinically well, drinking
well, tolerating food
l Blood ketones <1.0 mmol/L
or pH normal
l Urine ketones may still be
positive

l
l
l
l

Management
Give sodium chloride
2.7% 5 mL/kg or
0.51g/kg mannitol
Call senior staff
Restrict IV fluids by half
Move to PICU
CT scan when stabilised

93

DIABETIC KETOACIDOSIS 2/6


RECOGNITION AND
ASSESSMENT
Symptoms and signs
l
l
l
l
l
l
l
l
l
l
l
l
l
l

Thirst
Weight loss
Polyuria
Abdominal pain/vomiting
Tachypnoea
Sighing respiration (Kussmaul breathing)
Odour of ketones
Dehydration
Drowsiness
Coma
Biochemical signs:
ketones in urine or blood
elevated blood glucose (>11 mmol/L)
acidaemia (pH <7.3)

Assessment
l Airway, breathing, circulation
l record respiratory rate, heart rate, BP,
peripheral pulse volume
l Conscious level: look for signs of
cerebral oedema (see Glasgow
coma score)
l Headache, confusion, irritability,
abnormal movements, slow pulse,
high BP, papilloedema, small and
irregular pupils
l Presence of infection
l Height, weight

Degree of dehydration
l Assessment degree of dehydration as
3%, 5% and 8% (for most children use
58% dehydration to calculate fluids)

Investigations
l Insert IV cannula (as large as
appropriate for child)

All cases
l Capillary blood glucose
l FBC
94

l Blood glucose
l Blood gas
l Haemoglobin A1c
l Blood osmolality, sodium, potassium,
urea, bicarbonate, creatinine, pH
l Urine ketones on urinalysis
l Blood ketones
l Infection screen: blood and urine
culture; if meningism consider lumbar
puncture

Moderate and severe cases


l Liver function tests and amylase
l Group and save

Newly diagnosed case


l Thyroid and coeliac disease antibody
screen
l Islet cell antibodies
l GAD antibodies
l Thyroid function tests, TSH, Free T4
l Immunoglobulins G, A and M

IMMEDIATE TREATMENT

Inform senior staff


Admission
l If alert and not shocked, admit to
ward/HDU
l If shock or GCS <8, admit to PICU

General
l Nil-by-mouth for first 812 hr
l if vomiting, complaining of abdominal
pain or has silent abdomen, insert
nasogastric tube
l Place on weigh-bed (if available)
l Strict fluid balance: catheterise
children requiring HDU or PICU
l Start flow-sheet to record
biochemistry and blood gases
l Monitor ECG for T wave changes
l Initiate IV fluids and insulin (see
below)

Issue 4
Issued: November 2010
Expires: November 2012

DIABETIC KETOACIDOSIS 3/6


Shock and resuscitation
l
l
l
l
l
l
l
l
l

l When no longer shocked and


circulated blood volume has been
restored, calculate volume of fluid
required (see below)

Patient is shocked (very rare in DKA):


tachycardia
reduced peripheral pulse volume
mottled cool peripheries
prolonged capillary refill time (poor sign)
altered state of consciousness
AND acidosis
with or without hypotension
Give sodium chloride 0.9% 10 mL/kg
rapidly and reassess; repeated until
circulation restored, max 3 doses

INTRAVENOUS FLUIDS
Volume of fluid

l Total fluid requirement is the addition


of four categories:
l fluid to re-expand circulating volume if
shocked
l maintenance fluids
l deficit
l continuing losses, do not include
continuing urinary losses at this stage

If still shocked despite giving


2 boluses of sodium chloride
0.9% 10 mL/kg, discuss with
consultant

Weight (kg)

Maintenance fluids
l Patient will be nil by mouth and will
need normal fluid requirement IV

Rate (mL/kg/24 hr)

Rate (mL/kg/48 hr)

012.9

80

160

1319.9

65

130

2034.9

55

110

3559.9

45

90

>60

35

70

Fluid deficit
l Estimated amount of fluid patient has
lost, (i.e. how dehydrated see
Assessment)
l Calculate from weight loss
l Most accurate method
l weigh child and compare with recent
weight
l gives good estimate of fluid loss (1 kg
weight loss = 1 L fluid deficit)
l Clinical assessment
l deficit in mL = % dehydration x body
weight (kg) x 10 (e.g. for a 10 kg child
with 5% dehydration, the deficit is
5x10x10 = 500 mL)
l do not use more than 8% dehydration
in calculations
Issue 4
Issued: November 2010
Expires: November 2012

Total Amount
l Hourly rate of fluid replacement =
(48 hr maintenance requirements +
deficit resuscitation fluid already
given)/48
l Weight should rise gradually with
rehydration
l If available use weigh-bed to record
weight hourly to obtain accurate
assessment

Type of fluid
l Initially use sodium chloride 0.9% with
potassium chloride, and continue this
concentration for at least 12 hr

95

DIABETIC KETOACIDOSIS 4/6


Table 1
Time (hr)
Use hourly rate

K+ <3.5
500 mL sodium
chloride 0.9% with
potassium chloride
40 mmol
(commercially
premixed bag)

If serum potassium
<2.5 mmol/L, transfer to PICU.
Discuss with consultant
whether to give potassium
chloride 0.2 mmol/kg in sodium
chloride 0.9% by separate
infusion over 1 hr. Before
infusing bag containing
potassium, connect patient to
cardiac monitor.
If possible, use commercially
premixed bag to approximate
calculated strength of
potassium chloride. Only in
exceptional circumstances
(with consultant agreement and
2 doctors checking procedure)
should potassium chloride be
added on the ward to a bag of
sodium chloride 0.9% (mix well)
l Further fluid and K+ as dictated by the
patients condition and serum K+
(Table 1), repeated until glucose
fallen to 14 mmol/L, then move to
Subsequent management

YOU MUST obtain consultant


authorisation before using
bicarbonate infusion (not
recommended)
Insulin infusion

l Soluble insulin (e.g. Actrapid) infusion


1 unit/mL in sodium chloride 0.9% via
IV syringe pump at 0.05 units/kg/hr
(or 0.1 units/kg/hr if local policy)

96

K+ 3.55.5
1 L sodium chloride
0.9% with potassium
chloride 40 mmol/L
(commercially
premixed bag)

K+ >5.5
1 L sodium chloride
0.9%

l If no fall in glucose after 2 hr (very


unusual, check pump and patency of
IV cannula), increase by 20%. If no
fall after 4 hr, consult senior medical
staff and re-evaluate (e.g. sepsis,
insulin errors)
l If blood glucose fall exceeds
5 mmol/L/hr, reduce insulin infusion rate
by 20%. Do not stop insulin infusion.
Check capillary glucose in 1 hr
l If IV fluids and insulin given through
same cannula use anti-syphon valve

Do not give insulin bolus. Do not


add insulin directly to fluid bags
MONITORING TREATMENT

l Hourly capillary blood glucose


l Check U&E, glucose, osmolality pH
and capillary ketones 2 hrly until
improving, then 4 hrly
l Neurological status hourly
l Complete DKA summary sheets

SUBSEQUENT MANAGEMENT 6
After a minimum 12 hr of initial
intravenous therapy, if plasma
sodium level stable or
increasing, change sodium
concentration to sodium
chloride 0.45%
When blood glucose falls below
14 mmol/L add glucose to fluid
l Once blood glucose has fallen below
14 mmol/L, use fluid regimen in Table 2

Issue 4
Issued: November 2010
Expires: November 2012

DIABETIC KETOACIDOSIS 5/6


Table 2

K+ 5.5
500 mL glucose 5% with
sodium chloride 0.45% and
potassium chloride 20 mmol
(commercially premixed bag)

Time (hr)
Use hourly rate

If serum potassium is
<2.5 mmol/L, discuss with
consultant. Follow instructions
under Table 1
l Keep insulin infusion rate at or reduce
to 0.05 units/kg/hr
l Blood glucose may rise as a result,
but do not revert to sodium chloride
0.9% unless plasma pH falls

K+ >5.5
1 L glucose 5% with sodium
chloride 0.45%

l if pH falls, reassess fluid deficit and


regimen

l If glucose falls below 6 mmol/L,


reduce insulin infusion rate by 20%.
Check capillary glucose in 1 hr. If
glucose continues to fall, change fluid
regimen to glucose 10% (Table 3)

Table 3
Time (hr)
Use hourly rate

K+ <3.5
If serum potassium is
<3.5 mmol/L, discuss
fluid management with
consultant

l To make glucose 10% with sodium


chloride 0.45%: remove 50 mL from
500 mL bag of glucose 5%, sodium
chloride 0.45% and add 50 mL of
glucose 50%
l Continue with IV fluids and insulin
infusion until urine is negative for
ketones and child tolerating oral fluids
and food

l Continue IV insulin pump after first


SC dose of insulin for 1 hr if SC dose
was soluble (e.g. Humulin S) or
10 min if SC dose of insulin was
aspart or lispro (e.g. Novorapid)

If acidosis not improving,


consider:

l Insufficient insulin to switch off


ketones

K+ 3.55.5
500 mL glucose 10%
with sodium chloride
0.45% and potassium
chloride 10 mmol

K+ >5.5
1 L glucose 10% with
sodium chloride
0.45%

Cerebral oedema

l Observe for headache, any change in


symptoms, pH <7.2, or persistently
low serum sodium as glucose
corrects
l Exclude hypoglycaemia

l If cerebral oedema suspected, inform


consultant immediately

l Give 5 mL/kg of sodium chloride 2.7%


l if not available give mannitol 0.5 g/kg
(2.5 mL/kg of 20%) over 30 min,
repeat mannitol once or twice after
48 hr if required
l restrict IV fluid intake to half
maintenance and replace deficit over
72 hr

l Inadequate resuscitation

l if patient unconscious, insert urethral


catheter

l Hyperchloraemic acidosis

l consider CT scan/MR scan

l Sepsis

l Salicylate or other prescription or


recreational drugs
Issue 4
Issued: November 2010
Expires: November 2012

l admit to PICU

97

DIABETIC KETOACIDOSIS 6/6


Converting to SC insulin

l Inform diabetes team (consultant,


diabetic nurse and dietitian)

l Children usually require insulin


0.251.0 units/kg/day (pre-pubertal
usually 0.60.8 units/kg/day; higher in
puberty)
l if child has been given IV insulin,
amount given over previous 24 hr
gives an approximate value of
requirement as long as they have
been eating reasonably well

l If converting to biphasic insulin


regimen divide total daily dose as
follows:

l 2/3 dose 20 min before breakfast (give


insulin analogues 5 min before meal)
l 1/3 dose 20 min before evening meal
(give insulin analogues 5 min before
meal)
l If converting to multiple daily dose
regimen
l give 40% as long-acting insulin at
night

DISCHARGE AND FOLLOW-UP


l Prescribe following as TTO for all new
patients:
l brand and strength of regular insulin:
specify if pre-filled pen or cartridges
l brand of soluble insulin: specify if
pre-filled pen or cartridges
l needles 5 mm or 8 mm

l 1 pack hypostop triple pack


l 1 packet glucose tablets

l 1 box lancets (e.g. Microfine plus)

l 1 kit GlucaGen HypoKit (glucagon


1 mg; 500 micrograms <25kg, 1 mg
25 kg) if local policy
l 1 box blood glucose sticks (e.g.
MediSense Optium Plus strips),
appropriate to glucose monitor

l 1 box ketostix (for urine ketones)


l 1 box blood ketone strips if
appropriate

l Organise out-patient follow-up

l 20% short-acting insulin with each of


the 3 main meals
l Adjust ratio if necessary, depending
on childs eating patterns
l Choose insulin preparation most
suitable for child: discuss with
diabetes team

l Continue IV insulin pump after first SC


dose of insulin for 60 min if SC dose
was soluble (e.g. Actrapid) or 10 min if
SC dose of insulin was aspart or lispro
(e.g. Novorapid/Humalog)

98

Issue 4
Issued: November 2010
Expires: November 2012

DIABETES NEW (NON-KETOTIC) 1/2


Any child or young person
presenting to GP or A&E with
symptoms suggestive of
diabetes should be referred (by
phone) immediately to
paediatric diabetes team
RECOGNITION AND
ASSESSMENT
Definition
Elevated blood glucose with no
ketonuria/blood ketones

l Symptoms + random plasma glucose


11 mmol
l Or symptoms + fasting plasma
glucose 7 mmol

l No symptoms but random plasma


glucose 11 mmol
l No symptoms but fasting plasma
glucose 7 mmol on 2 tests on
2 separate days

Symptoms and signs


l Change in school performance
l Thirst

l Weight loss
l Thrush

l Polyuria

l Nocturia

l May be absent

l if obese, no ketonuria or evidence of


insulin resistance (e.g. acanthosis
nigricans), consider type 2 diabetes

Investigations
l Height and weight

l haemoglobin A1C
l FBC

l cholesterol and triglycerides


l TSH and FT4

l immunoglobins A, G and M

l autoantibody screen for thyroid,


coeliac GAD and islet cell antibodies
l Urine

l ketones
l glucose

l C-peptide if considering type 2 diabetes

Do not arrange a fasting blood


glucose or glucose tolerance test
IMMEDIATE TREATMENT
l Admit under admitting consultant of
day/week

l Inform diabetes team, consultant or


diabetes nurse specialist

l Start on SC insulin, total daily dose of


0.60.8 units/kg
l If converting to biphasic insulin
regimen divide total daily dose as
follows:
l 2/3 of total dose 1020 min before
breakfast (give insulin analogues
5 min before meal)

l 1/3 of total dose 1020 min before


evening meal (give insulin analogues
5 min before meal)
l If converting to multiple daily dose
regimen:
l give 40% as long-acting insulin at
night

l Blood:

l 20% short-acting insulin with each of


the 3 main meals

l electrolytes

l Adjust ratio if necessary, depending


on childs eating patterns

l glucose
l pH

l ketones
Issue 4
Issued: November 2010
Expires: November 2012

l For advice on which insulin to use,


discuss with consultant with special
interest in diabetes

99

DIABETES NEW (NON-KETOTIC) 2/2


SUBSEQUENT MANAGEMENT
l If tolerating food, allow patient to eat
according to appetite for first 2448 hr
l Adjust insulin according to childs
eating habits
l Refer to dietitians

MONITORING TREATMENT
l Glucose stick monitoring pre-meals
and at 0000 and 0400 hr

DISCHARGE AND FOLLOW-UP


l Out-patient appointment to see
consultant 12 weeks after discharge
l Prescribe as TTO:

l brand and strength of regular insulin,


specify if pre-filled pen or cartridges
l brand of soluble insulin, specify if
pre-filled pen or cartridges
l needles 5 mm or 8 mm

l 1 pack glucogel triple pack


l 1 packet glucose tablets

l 1 box lancets (e.g. Microfine plus)

l GlucaGen HypoKit (glucagon) 1 kit


500 microgram <25 kg, 1 mg >25 kg
(dependent on local policy)

l 1 box blood glucose sticks


appropriate to blood glucose monitor
(e.g. MediSense Optium Plus strips)
l 1 box ketostix (ketones in urine)

l if appropriate, 1 box blood ketone


sticks (particular to local policy)

100

Issue 4
Issued: November 2010
Expires: November 2012

HYPOGLYCAEMIA 1/6
Unexplained and prolonged

RECOGNITION AND
ASSESSMENT
Definition

l For the purposes of this guideline,


hypoglycaemia defined as a blood
glucose <2.6 mmol/L in child aged
>1 month-old

Symptoms and signs

l Neuroglycopenia:
l lethargy
l lassitude
l tremulousness
l loss of consciousness
l seizure
l Autonomic effects:
l sweating
l shaking
l trembling
l tachycardia
l anxiety
l hunger

Previous history
l Ask about:
l antenatal history (e.g. small-for-dates)
l prematurity
l history of hypoglycaemia on the
neonatal unit
l early or prolonged jaundice
l family history of sudden death
(MCAD, LCAD)
l history of neuroglycopenia/autonomic
symptoms when glucose intake
decreased, (e.g. during minor
illnesses)
l development, especially
developmental regression
l medication
l access to glycopenic agents (e.g.
metformin)
l oral hypoglycaemics
l nutritional intake
Issue 4
Issued: November 2010
Expires: November 2012

Investigations
Certain pointers to cause of
unexplained hypoglycaemia are
detectable only during episode.
Take blood samples BEFORE
correcting blood glucose
Immediate samples
l Before treating hypoglycaemia, take
venous blood for assay using correct
blood bottles (Table 1)
l once samples have been obtained,
correct hypoglycaemia. See
Immediate treatment

l inform laboratory immediately so


samples arrive as quickly as possible
(within 20 min)

l Ensure first voided urine specimen


after hypoglycaemia episode is
obtained to test for ketone bodies,
organic/amino acid metabolites
and reducing substances. Check
with laboratory
Table 1: Total blood requirement
(5 mL minimum)
Fluoride

1.3 mL

Lithium heparin
Clotted

1.3 mL
2.6 mL

101

HYPOGLYCAEMIA 2/6
Investigations1

l In all prolonged unexplained


hypoglycaemia:
l glucose sticks
l capillary blood gas
l true glucose
l lactate
l ACTH
l growth hormone
l insulin
l C-peptide
l cortisol
l urea and electrolytes
l urinary ketones
l 17 O HP in infant if hyponatraemia
present

Physcial examination
l Height and weight
l Midline defects, micropenis, optic
nerve hypoplasia (pituitary disorder)
l Dysmorphic features: macroglossia,
macrosomia, ear lobe crease
(Beckwith-Wiedemann)
l Skin hyperpigmentation (adrenal
insufficiency)
l Hepatomegaly (glycogen storage
disorder)

l Store blood and urine for these


investigations depending on above
results:
l IGF1
l beta-hydroxybutyrate
l free fatty acids
l carnitine
l urinary-reducing substances
l organic and amino acids

UHNS: use laboratory request forms with hypoglycaemia sticker and complete
clinical details requested

102

Issue 4
Issued: November 2010
Expires: November 2012

HYPOGLYCAEMIA 3/6
Differential diagnosis
First-line investigations
before correcting glucose:

lInsulin
lGrowth hormone
lC-peptide
lCortisol
lUrinary ketones
lACTH

Ketones absent

Ketones present

See algorithm on
next page

Urinary non-glucose-reducing substances

Present

Absent

Serum insulin elevated

Hereditary
fructose
intolerance or
galactosaemia

Issue 4
Issued: November 2010
Expires: November 2012

Serum insulin not elevated

Serum insulin
>510 micro
units/mL

Serum insulin >100


micro units/mL

Fasting
glucagon test
(refer to
specialist
centre)

C-peptide

Hyperinsulinaemia

High

Insulinoma

Low

Exogenous
insulin

Fatty acid
oxidation or
carnitine defect

103

HYPOGLYCAEMIA 4/6
Differential diagnosis
Ketones present

Growth
hormone and
cortisol normal

Cortisol <50 mmol/L +/- growth


hormone <10 mmol/L in presence of
confirmed hypoglycaemia

Hepatomegaly

ACTH level

Yes

Glycogen
storage
disease

104

No

Ketotic
hypoglycaemia

Low

High

Hypopituitarism

Adrenal
insufficiency

Issue 4
Issued: November 2010
Expires: November 2012

HYPOGLYCAEMIA 5/6
IMMEDIATE TREATMENT
Glucose sticks
<2.6 mmol/L
GCS 8
and well

GCS <8
(seek help)

IV access
l Take blood for hypoglycaemia
investigation and obtain urine sample for
ketones
l If available check blood for ketones

Feed or, if not interested in


solids, give Lucozade
(flat) or Glucogel

Recheck glucose sticks


after 10 min

2.6 mmol/L

<2.6 mmol/L

l Take blood for hypoglycaemia


investigation and obtain urine sample for
ketones
l If available check blood for ketones

Glucose 10% 5 mL/kg IV bolus followed by


infusion of glucose 10% and sodium
chloride 0.45%* at 45 mL/kg/hr

Recheck glucose
sticks after 10 min

<2.6 mmol/L

2.6 mmol/L

Continue
glucose
infusion
Reassess
ABCD and
discuss further
management
with consultant

Continue to reassess. Discuss further


management with consultant

l Failure of blood glucose to respond to extra glucose suggests possible underlying metabolic
problem related to either:
l excessive insulin production or exogenous insulin
l inability to utilise glucose owing to hypopituitarism or adrenal insufficiency
l In either case further therapeutic manoeuvres need to be used see Subsequent
management
* Add 7.5 mL sodium chloride 30% to 500 mL glucose 10%

Issue 4
Issued: November 2010
Expires: November 2012

105

HYPOGLYCAEMIA 6/6
SUBSEQUENT MANAGEMENT

<2.6 and ketone body production not known

Bolus dose of hydrocortisone 4 mg/kg IV

Recheck glucose sticks after 10 min

<2.6 mmol/L

>2.6 mmol/L

Consider hydrocortisone infusion at


25 mg/24 hr for <10kg,
50 mg/24 hr if 1020 kg,
100 mg/24 hr >20kg

l
l
l
l

Continue glucose infusion


Reassess ABCD
Correct electrolyte imbalance
discuss with consultant re
further management (e.g.
hydrocortisone orally at
4 mg/m2 8 hrly or
hydrocortisone IV boluses at
4 mg/kg 6 hrly)

If still no response in blood glucose

Increase glucose content to


1420% (>14% needs to go through
a central line)

A high glucose load (>10 mg/kg/min)


suggestive of hyperinsulinism

l
l
l
l
l

106

Endocrine opinion
Consider:
octreotide
diazoxide
glucagon

Issue 4
Issued: November 2010
Expires: November 2012

KETONE MONITORING 1/1


Applicable for all subcutaneous insulin regimes and insulin pump therapy
Blood glucose 14 mmol/L, or blood glucose <14 mmol/L with associated dehydration or
symptoms of illness
Test blood ketones (beta-hydroxybutyrate)

0.11.0
mmol/L

1.13.0
mmol/L

Acceptable levels

>3.0
mmol/L

Need to reduce
blood ketones to
1 mmol/L

Treat high
blood glucose

Contact on-call
paediatric SpR to
childrens
diabetes team

If unwell refer to
sick day dose
flowchart

Are signs and


symptoms of
DKA present?
NO

YES

Start DKA
protocol
Give additional rapid acting insulin by SC injection
and refer to sick day dose flowchart
Dose calculation: either
(a) 10% of total daily dose to maximum of 10 units/dose
OR
(b) 0.1 unit of insulin/kg body weight
If pump user, administer by insulin pen or syringe, then replace infusion set and check
insulin pump

Retest blood glucose and blood ketones in 1 hr

Blood ketones
falling

Recheck blood
ketones in 1 hr
1.0
>1.0
mmol/L mmol/L

Blood ketones
falling

Blood ketones not


falling
l Repeat further
SC insulin dose
as above
l Blood ketones
should fall by
1 mmol/L/hr

Recheck blood
ketones in 1 hr

Contact
on-call
paediatric
SpR or
childrens
diabetes
team

Blood
ketones not
falling

If unsure, especially if child aged <5 yr, contact childrens diabetes team
Issue 4
Issued: November 2010
Expires: November 2012

107

STEROID DEPENDENCE 1/2


Pituitary-adrenal axis impairment

RECOGNITION AND
ASSESSMENT
Definition
l Children with the following conditions
are corticosteroid-dependent with a
depressed or absent pituitary-adrenal
axis:
l hypopituitarism

l adrenal insufficiency

l congenital adrenal hyperplasia


l growth hormone insufficiency

l prolonged corticosteroid use for


immunosuppression

l severe asthma requiring oral


corticosteroids or high-dose inhaled
corticosteroids

When shocked or stressed


corticosteroid-dependent
children cannot mount an
appropriate adrenal response
l Corticosteroid-dependent children are
encountered in a number of ways:
l at presentation and first diagnosis

l for elective surgical and investigative


procedures
l for emergency surgery or when
acutely unwell

l with hyponatraemia, hyperkalaemia


+/- hypoglycaemia and hypotension

MANAGEMENT
Elective surgical and
investigative procedures

l if no plan for corticosteroid


manipulation, prescribe
hydrocortisone 24 mg/kg IV at
induction then 6 hrly until child
capable of taking oral medication,
then give double usual daily
maintenance dosage of
hydrocortisone for subsequent 48 hr
l Continue usual medication with:
l fludrocortisone

l growth hormone
l levothyroxine

l desmopressin

Acute illness
l During illness, corticosteroiddependent children can usually be
managed at home

l Moderate illness with temperature no


greater than 38C give double
hydrocortisone dose, if temperature
>38C give treble hydrocortisone
dose

l if unable to take oral corticosteroids


(e.g. vomiting or acute collapse),
parents to administer IM
hydrocortisone 2 mg/kg or aged <1 yr
25 mg, 15 yr 50 mg, 100 mg
thereafter

l If IM hydrocortisone required, hospital


assessment necessary with training of
parents to administer IM
l Continue usual dose of other
medication
l failure to do so may lead to
hypoglycaemia

Some units do not prescribe IM


hydrocortisone. Check locally

l Check whether pre-operative


discussion of endocrine management
has taken place

108

Issue 4
Issued: November 2010
Expires: November 2012

STEROID DEPENDENCE 2/2


Algorithm for the management of unwell corticosteroid-dependent
children
Resus ABC
BP, GCS

IV access

If glucose stick
<2.6 give bolus of
glucose 10%
5 mL/kg

l
l
l
l
l
l

Take blood for


glucose stick
FBC
blood culture
renal profile
blood gas

Correct electrolyte
abnormalities (see
Diarrhoea and
vomiting guideline)

Hydrocortisone
4 mg/kg IV bolus

Calculate maintenance + deficit fluids


(see Diarrhoea and vomiting guideline)
Commence infusion of glucose 10% and sodium chloride 0.45%
Once electrolytes are known, it may be necessary to change to
glucose 10% and sodium chloride 0.9%

Commence
hydrocortisone
24 mg/kg 6 hrly
IV

l Regularly monitor BP
and blood glucose
l Titrate infusion
accordingly, i.e. low
BP and/or glucose
stick then increase
infusion rate

l Once able to tolerate oral fluids, convert to oral corticosteroids (at double the patients normal
daily dose)
l consider treble usual corticosteroid dose initially
l for simplicity, double patients highest dose of the day (as may be different doses throughout
day)
l Continue double/triple normal daily dose of corticosteroid until two to three days after
recovery from acute episode

Issue 4
Issued: November 2010
Expires: November 2012

109

ACUTE ABDOMINAL PAIN 1/2


RECOGNITION AND
ASSESSMENT
Symptoms and signs
l Pain may be localised or generalised
l Vomiting

Mid-gut volvulus
l Presents mainly in neonatal period
l History of:

l bowel obstruction
l abdominal pain
l distension

l Anorexia

l bilious vomiting

l Fever

l Crying and irritability

Typical features of some


important causes of acute
abdominal pain in children
Appendicitis
l History of localised pain with
increased severity on RIF
l On examination:
l fever

l On examination

l abdominal distension, tenderness

Pneumonia and empyema


l History of fever and cough
l On examination:
l tachypnoea

l recession +/- focal signs at one base


l decreased breath sounds and
dullness to percussion

l mid-abdominal pain migrating to RIF

Differential diagnosis

l young children may not have typical


features

Surgical problems

l guarding and rebound tenderness

Intussusception
l Typical age of presentation:
2 months2 yr

l History of intermittent colicky


abdominal pain

l Lethargic between episodes of pain

l Vomiting and passage of blood and/or


mucus per rectum following
respiratory or diarrhoeal illness
(redcurrant jelly stools)
l Clinical features of intestinal
obstruction
l On examination:

l a sausage-shaped mass crossing


midline in the epigastrium or behind
umbilicus
l may be associated with HenochSchnlein purpura

110

l Acute appendicitis
l Intussusception

l Intestinal obstruction

l Torsion of ovary or testis


l Meckels diverticulitis
l Hydronephrosis
l Renal calculus

l Enterocolitis secondary to
Hirschprungs disease

Medical problems relatively


common
l Mesenteric adenitis
l Constipation

l Gastroenteritis

l Inflammatory bowel disease


l Lower lobe pneumonia
l Acute pyelonephritis

Issue 4
Issued: November 2010
Expires: November 2012

ACUTE ABDOMINAL PAIN 2/2


l Henoch-Schnlein purpura
l Hepatitis

l Acute cholecystitis

Medical problems rare but


important
l Lead poisoning
l Diabetes

l Sickle cell crisis


l Acute porphyria
l Pancreatitis

l Primary peritonitis

l Non-accidental injury

INVESTIGATIONS
l
l
l
l

Urine testing and analysis


FBC, ESR
Blood culture
CRP, U&E, amylase, glucose, LFT

Imaging
l Only if bowel obstruction or
perforation suspected: abdominal
X-ray
l If child stable and suspect
appendicitis, intussusception, torsion
of ovary or testis, renal problems,
pancreatitis or cholecystitis:
ultrasound scan of abdomen
l If respiratory symptoms: chest X-ray
l Do not delay surgical review awaiting
scans if acute surgical problem
suspected (e.g. torsion of the testis)

Issue 4
Issued: November 2010
Expires: November 2012

MANAGEMENT

l If present, treat hypotension and


shock
l Stop feeding if you suspect surgical
problem (feeding will delay operation)

Indications for surgical review


l Localised right iliac fossa pain
l Rebound tenderness/pain on
percussion
l Migration of pain
l Redcurrant jelly stools and bleeding
per rectum
l Bile-stained vomiting
l Abdominal distension
l Inguino-scrotal pain or swelling

Observation
l If stable, period of observation may
be useful to make diagnosis

Analgesia
l Do not withhold analgesia pending
surgical review: opioids may be
necessary (see Analgesia guideline)

DISCHARGE AND FOLLOW-UP


l Discharge usually within 24 hr of
symptoms settling (e.g. fever,
abdominal pain)
l Follow-up usually appropriate in
primary care/GP

111

CONSTIPATION 1/4
RECOGNITION AND
ASSESSMENT
Definition
l Constipation: infrequent bowel
evacuation of hard faeces or
difficult/painful defaecation for 1 month
l Faecal soiling: (overflow as a result
of faecal impaction): passage of liquid
or formed stools in childs underwear
over which child has no control
l Encopresis: (functional non-retentive
soiling): inappropriate passage of
normal stools in inappropriate places.
Often associated with behavioural
problems
l Faecal incontinence: soiling in the
presence of an anatomical or organic
lesion
l Faecal impaction: hard faecal mass
in lower abdomen, a dilated rectum
impacted with stool or excessive stool
in the colon identified radiologically

KEY POINTS IN HISTORY


l Frequency, volume and type of stool
using Bristol stool chart
l Distress on stooling
l Bleeding per rectum
l Any trigger factors i.e. diet change,
infection, potty training or starting
nursery/school
l Overflow soiling

KEY POINTS IN PHYSICAL


EXAMINATION

l Abdominal examination to look for


abdominal distension, faecal loading
l Lower limb neuromuscular
examination in long standing cases
l Inspection of perianal area for
appearance, position of anus or
evidence of streptococcal infections

Symptoms and signs


suggestive of organic
constipation (red flags)

l Early onset of constipation (first few


weeks of life)
112

l Failure to thrive/growth failure


l Neuropathic bowel:
l lack of lumbosacral curve
l pilonidal dimple or tuft of hair
l sacral agenesis
l flat buttocks
l patulous anus
l absent cremasteric reflex/absent anal
wink
l decreased lower extremity tone
and/or strength
l absence or delay in relaxation phase
of lower extremity deep tendon reflex
l urinary symptoms
l Hirschsprungs disease
l delayed passage of meconium for
more than 24 hr after birth in a term
baby
l abdominal distension
l tight empty rectum in presence of
palpable faecal mass
l gush of liquid stool and air from
rectum on withdrawal of finger
l Anteriorly displaced anus
l Anal stenosis:
l tightness or stricture felt when per
rectum digital examination done using
lubricated fifth finger in newborn and
infants up to 6 months

DIFFERENTIAL DIAGNOSIS
l Idiopathic functional constipation
(9095%). Most common cause of
constipation beyond neonatal period

Organic constipation (suspected


in presence of red flags)
l Constipation secondary to anal
anatomic malformation (ano-rectal
examination required)
l Neurogenic constipation due to spinal
cord anomalies or trauma,
neurofibromatosis and tethered cord
(lower limb neurological examination
required)
l Constipation secondary to
endocrine/metabolic disorders
(hypothyroidism, hypercalcaemia,
hypokalemia, CF)
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Expires: November 2012

CONSTIPATION 2/4
l Constipation induced by drugs (opioids)
l Coeliac disease

INVESTIGATIONS
l Most children with chronic
constipation require minimal
investigation:
l careful history and physical
examination will help determine
appropriate investigation

Abdominal X-ray
l Has little or no value in the diagnosis
of idiopathic constipation
l lower spine X-ray may be useful in an
encopretic child with no faecal
masses on abdominal and rectal
examination

When to consider referral for


rectal biopsy

l History of delayed passage of


meconium
l Constipation since neonatal period
l History of abdominal distension and
vomiting
l Failure to thrive or faltering growth
l Family history of Hirschprungs

MANAGEMENT OF
FUNCTIONAL CONSTIPATION

l See Constipation management


flowchart
l Refer children with organic cause to
gastroenterologist

Principles of treatment
l
l
l
l
l

Education
Diet and lifestyle
Behavioural management
Medication
Supporting child and family

Education
l Give parents clear explanation of
pathophysiology of constipation and
soiling
Issue 4
Issued: November 2010
Expires: November 2012

Diet and lifestyle


Use in combination with laxatives
l Ensure adequate fluid intake
l High fibre diet is recommended
l Juices that contain sorbitol such as
prune, pear and apple juices, may
improve constipation in infants
l Encourage physical activities

Behavioural management
l Use of behavioural management in
combination with medications
decreases time to remission

l regular toileting: unhurried time on the


toilet after meals
l maintain diaries of stool frequency
combined with reward system
l regular review and positive
reinforcement

l discourage negative responses to


soiling from family
l encourage older children to take
responsibility

l May need counselling or a


psychology referral in case of
motivational or behavioural problems

Medication
l In the presence of impacted stools

Disimpaction
Aged <1 yr, refer to paediatric
gastroenterologist
1. A macrogol laxative [polyethylene
glycol (e.g. Movicol paediatric plain)];
faecal impaction dose, see below up
to a maximum of 7 days
2. Use stimulant laxative, senna or
sodium picosulphate (Picolax) if no
result with macrogol or if not
tolerated

113

CONSTIPATION 3/4
Disimpaction dosage (number of Movicol paediatric plain sachets daily divided into
2 doses 12 hrly)
AGE (yr)
15
512

Day 1
2
4

Day 2
4
6

Day 3
4
8

Rectal disimpaction
(only if oral disimpaction fails)

l Sodium citrate micro-enemas (Relaxit)


l Small volume sodium citrate enemas
(Microlax) is preferable to large
volume phosphate enemas
l Phosphate enemas (only if oral
medications and Microlax enemas
failed). May require sedation and
therefore preferably administered in
hospital under specialist supervision

Manual evacuation
l If all above have failed, consider
manual evacuation under general
anaesthetic. Consult with paediatric
gastroenterologist or paediatric surgeon

MAINTENANCE THERAPY
l After disimpaction, or if child had no
impaction, focus treatment on
prevention of recurrence and
establishment of a regular bowel habit
to allow bowel to regain normal tone
and sensation
l Continue maintenance therapy for 46
months then reduce dosage gradually
l half the dismpaction dose of Movicol
is a useful guide for initial
maintenance dose

Laxatives

l Use macrogols as first line


maintenance treatment
l If not improved within a month or to
prevent recurrence of impaction, add
a stimulant laxative such as senna,
bisacodyl or sodium picosulphate
syrup. Using stimulants is
recommended only for short periods
of time and intermittently. Use with
faecal softener e.g. sodium docusate
and/or fibre
114

Day 4
6
10

Day 5
6
12

Day 6
8
12

Day 7
8
12

l Aim for soft/loose stools initially daily

l High doses (up to 46 sachets daily of


macrogols) may be required and doses
may need frequent adjustment by child
and parent to maintain a regular bowel
action. Advise parents to reduce doses
gradually and to increase again if no
bowel action in 3 days
l If macrogols not tolerated, use
sodium docusate or lactulose

Supporting child and family


l Organise review within a week then
regular and frequent local contact
and by telephone to prevent reimpaction
l discuss timing of doses for
convenience with bowel action

l emphasise need for good compliance


l Use outreach nursing support

l Child psychology support when


available is invaluable

Withdrawal of laxatives
l Once regular bowel habit has been
established for a few months, and
child has good sensation to pass
stools, gradually withdraw laxatives

INDICATIONS FOR SEEKING


ADVICE OF PAEDIATRIC
GASTROENTEROLOGIST
l Organic cause of constipation
suspected
l Disimpaction orally/rectally
unsuccessful

l Soiling/abdominal pain continues


despite treatment
l Regular enemas required

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CONSTIPATION 4/4
CONSTIPATION MANAGEMENT
l History
l Physical
examination

Red flags for underlying organic disease?

Yes

Evaluate
further

No

FUNCTIONAL CONSTIPATION
Is there faecal impaction?
No

Yes

l Disimpact orally
l Only use rectal preparations if oral
medication fails. Ensure child consents
and is not distressed

l Movicol or docusate for 5 days to


soften stools if not used previously
l Movicol or stimulant laxatives to
evacuate

l
l
l
l
l
l

Treatment:
education
diet and lifestyle
oral medication
behavioural therapy
close follow-up

l Use Movicol +/ stimulant


l Aim initially for one or
more sloppy stools per
day
Yes

Effective?
No

Treatment effective?
Is there faecal impaction?

No

Yes
Yes

No

l
l
l
l

Re-assessment
Compliance
Re-education
Change medication

Reduce dose after few


weeks and monitor closely

Yes

Relapse?

Treatment effective?

Yes
No

No

l
l
l
l

l Wean
l Observe

Blood tests:
T4 and TSH
Coeliac antibodies
calcium and lead
Yes

Abnormal blood tests?

Evaluate further

No

Consultation with paediatric gastroenterologist


and/or paediatric surgeon
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115

DIARRHOEA AND VOMITING 1/6


RECOGNITION AND
ASSESSMENT
Definition of diarrhoea
l Passage of loose watery stools at
least three-times in 24 hr

l Most common cause is acute infective


gastroenteritis

Diarrhoea and vomiting in


infants may be a sign of sepsis
Symptoms and signs
l Sudden onset of diarrhoea (D) or
vomiting (V), or both (D&V)
l Fever, malaise, lethargy
l Abdominal cramps

l weight loss

l underlying problems e.g. low birthweight, malnutrition, neuro-disability

Inform public health if outbreak


of gastroenteritis suspected
Assessment
l Weight, including any previous recent
weight
l Temperature, pulse, respiratory rate

l Degree of dehydration (see Table 1)


and/or calculate from weight deficit
l Complete systemic examination to
rule out other causes of D&V

l Children aged <1 yr are at increased


risk of dehydration

l Loss of appetite

Patient history
l Ask about:

l duration of illness

l frequency of stools and associated


vomiting (>6 stools more likely to
become dehydrated)

l colour of vomit (green bilious vomit


indicates obstruction should be
considered)

l nature of stools, including presence


of blood in stool
l feeds (fluid and food intake)

l urine output (number of wet nappies)


l contacts/exposure to infection
l recent travel abroad

l recent antibiotic use

l symptoms of other causes of D&V


(e.g. high pyrexia, shortness of
breath, severe/localised abdominal
pain or tenderness, symptoms of
meningitis/septicaemia)

116

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DIARRHOEA AND VOMITING 2/6


Table 1 Assessment of degree of dehydration
Increasing severity of dehydration

Symptoms (remote
and face-to-face
assessment)

No clinically
detectable
dehydration (<5%)

Clinical shock
>10% dehydration

Appears well

Appears to be unwell
or deteriorating

Alert and responsive

Altered responsiveness
(e.g. irritable, lethargic)

Decreased level of
consciousness

Normal urine output

Decreased urine output

Skin colour unchanged

Skin colour unchanged

Pale or mottled skin

Warm extremities

Warm extremities

Cold extremities

Alert and responsive

Signs
(face-to-face assessment)

Clinical dehydration
510% dehydrated

Altered responsiveness
(for example, irritable,
lethargic)

Decreased level of
consciousness

Skin colour unchanged

Skin colour unchanged

Pale or mottled skin

Warm extremities

Warm extremities

Cold extremities

Eyes not sunken

Sunken eyes

Moist mucous membranes


(except for mouth
breather')

Dry mucous membranes


(except after a drink)

Normal heart rate

Tachycardia

Tachycardia

Normal breathing pattern

Tachypnoea

Tachypnoea

Normal peripheral pulses

Normal peripheral pulses

Weak peripheral pulses

Normal capillary refill time Normal capillary refill time

Prolonged capillary refill


time

Normal skin turgor

Normal blood pressure

Calculating fluid deficit


l Deficit in mL = % dehydration x
weight (kg) x 10

l e.g. for a 10 kg child with 5%


dehydration deficit is 5 x 10 x 10 =
500 mL

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Expires: November 2012

Reduced skin turgor


Normal blood pressure

Hypotension
(decompensated shock)

Calculating maintenance fluids


l 100 mL/kg/day for first 10 kg

l 50 mL/kg/day for second 10 kg

l 20 mL/kg/day for each subsequent kg

117

DIARRHOEA AND VOMITING 3/6


Investigations
l If vomiting a major feature or vomiting
alone, or if baby aged <3 months:
urine for MC&S
l If septicaemia suspected, child
immunocompromised, or if stools
bloody, mucous or chronic diarrhoea
present, send stools for MC&S and
virology
l If recent antibiotics, send stool for
Clostridium difficile toxin
l If severe dehydration, possible
hypernatraemic dehydration or
diagnosis in doubt:
l FBC, U&E, chloride, glucose, blood
and urine cultures. Blood gas or
venous bicarbonate
l if decreased level of consciousness
consider lumbar puncture, especially
in babies

IMMEDIATE TREATMENT
See flowchart Management of acute
gastroenteritis in young children

General advice to parents


l Adequate hydration important
l Encourage use of oral rehydration
solution (ORS)
l clear fluids (water alone/homemade
solutions of sugar and fruit) lack
adequate sodium content and are
inappropriate
l sugar, fruit juices and cola have a
high osmolar load and little sodium,
and can worsen diarrhoea
l Recommend early refeeding with
resumption of normal diet (without
restriction of lactose intake) after 4 hr
rehydration
l Do not use anti-diarrhoeal agents

Continue breastfeeding
throughout episode of illness,
ORS can be given in addition

118

Treatment of dehydration
l Admit if:
l patient 10% dehydrated
l failure of treatment (e.g. worsening
diarrhoea and/or dehydration)
l other concerns (e.g. diagnosis
uncertain, child aged <3 months,
irritable, drowsy, potential for surgery)

Step 1: Mild dehydration (<5%)


l Can be managed at home
l Emphasise to parents importance of
adequate hydration
l Rehydrate orally using ORS
(prescribe sachets and give clear
instructions: if not tolerated, parents
may substitute other fluids child likes)
l calculate fluid deficit and replace over
4 hr with frequent small volumes
(5 mL every 12 min)
l continue to supplement with ORS for
each watery stool/vomit (10 mL/kg per
watery stool)
l Do not withhold food unless vomiting
l full feeding appropriate for age well
tolerated with no adverse effects

Step 2: Moderate dehydration


(610%)

l If improving after 4 hr observation, can


be managed at home provided social
circumstances are appropriate/parents
are happy. Otherwise, admit
l Calculate deficit and aim to replace
with ORS 50 mL/kg orally over 4 hr
l Give small frequent feeds (5 mL every
12 min)
l If not tolerating oral rehydration
(refuses, vomits, takes insufficient
volume), use NG tube
l Review after 4 hr
l if rehydrated start a normal diet, and
continue maintenance fluids and
supplementary ORS for each watery
stool or vomit (10 mL/kg per watery
stool)
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DIARRHOEA AND VOMITING 4/6


l if dehydration persists, continue the
same regimen but replace fluid deficit
with ORS over the next 4 hr
l if this fails, e.g. vomiting ORS,
consider IV rehydration (see below)
l If improving move to Step 1

Step 3: Severe dehydration


(>10%) see flowchart
Beware hypernatraemic
dehydration. See Hypernatraemic
dehydration section
l If child in shock, first resuscitate with
sodium chloride 0.9% (20 mL/kg) and
reassess
l If >10% dehydration, obtain IV
access, especially if child drowsy

l Calculate deficit using uncorrected


weight

l skin feels warm and doughy, child


lethargic and irritable/jittery with
hypertonia and hyperreflexic. They
may have seizures

l if in shock, resuscitate with sodium


chloride 0.9% 20 mL/kg bolus
l if Na >170 mmol/L, contact PICU

In hypernatraemic dehydration,
aim to reduce sodium by no
more than 10 mmol in 24 hr
l After initial resuscitation, give ORS:
replace deficit (+ maintenance) over
48 hr via NG if necessary
l Check U&E after 1 hr

l If ORS not tolerated or sodium drops


>0.5 mmol/L/hr, start IV rehydration
with sodium chloride 0.9%, replacing
deficit (+ daily maintenance) over 48 hr

l If alert, rehydrate orally with ORS,


replacing deficit (plus maintenance
requirement) over 4 hr

l Recheck U&E after 14 hr (depending


on rate of drop of serum sodium and
starting value)

l If oral/NG rehydration not possible,


replace deficit with sodium chloride
0.9% with glucose 5% over 24 hr

l Once rehydrated, start normal diet


including maintenance fluids orally

l Use NG tube if necessary

l If sodium dropping by >0.5 mmol/L/hr,


reduce rate by 20%

l give maintenance sodium chloride


0.9% with potassium chloride
(10 mmol/500 mL), if hypokalaemic
use sodium chloride 0.9% with
20 mmol potassium chloride in 500 mL

l if hypoglycaemic use sodium chloride


0.45% with glucose 5% and potassium
chloride
l start normal diet as soon as tolerated
l continue to replace ongoing losses
with ORS for each watery stool or
vomit (5 mL/kg per watery stool)
l when improves move to Step 2

Hypernatraemic dehydration
(Na >150 mmol/L)
l In hypernatraemic dehydration, there
are fewer signs of dehydration
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Expires: November 2012

119

DIARRHOEA AND VOMITING 5/6


MANAGEMENT OF SEVERE DEHYDRATION
Yes

Shock

Sodium chloride 0.9%


20 mL/kg fast

Reassess

No

Oral/NG tube
rehydration possible

No

Start sodium chloride


0.9% with potassium chloride
(10 mmol/500 mL) IV

Yes

Rehydrate orally or
via NG tube

Measure
serum sodium

Low/normal
(<150 mmol)

Maintenance and
replacement over 24 hr

High (>150 mmol/L)


Maintenance and replacement over 48 hr

DISCHARGE AND FOLLOW-UP


l If dehydration was >5%, ensure child
has taken and tolerated two breast or
bottle feeds, or at least one beaker of
fluid
l Check child has passed urine
l Tell parents diagnosis and advise on
management and diet
l Explain nature of illness, signs of
dehydration, and how to assess and
deal with continuing D&V (explain
flagged symptoms in table of
dehydration)
l Emphasise importance of adequate
hydration. If dehydration recurs will
need further rehydration
l If symptoms persisting, aged <1 yr or
low birth weight, continue to
supplement with ORS at 5 mL/kg per
watery stool or vomit

120

l Do not withhold food, (especially


breast milk), full feeding appropriate
for age if well tolerated after initial
rehydration
l Advise parents how to prevent
transmission to other family members
and contacts
l patient should not share towels with
others
l hand-washing with soap and warm
water after using toilet or changing
nappy. Dry hands properly
l Exclude from school/nursery 48 hr from
last episode of diarrhoea or vomiting
l Exclude from swimming for 2 weeks
following last episode of diarrhoea
l Give open access if appropriate,
ensure parents aware of how to seek
help if needed
l If diarrhoea persists for >10 days,
advise to return for medical
reassessment
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Expires: November 2012

DIARRHOEA AND VOMITING 6/6


MANAGEMENT OF ACUTE GASTROENTERITIS
IN YOUNG CHILDREN
Detailed history
and examination

Clinician estimates %
dehydration and
current weight

One or more of
following present?
l >10% dehydration
l Signs of shock
l Patient drowsy

Yes

l Hospitalise
l Give sodium chloride 0.9% IV bolus if
shock
l Re-evaluate and repeat if necessary
see Management of acute dehydration
l Begin ORS, replacing deficit (up to
100 mL/kg) over 4 hr plus replacement of
ongoing losses (oral/NG)

No
Is patient 69%
dehydrated by weight
loss or by clinical
estimation?

Yes

Begin ORS, replacing


deficit (up to 100 mL/kg)
over 4 hr plus
replacement of ongoing
losses (oral/NG)

No
Is patient 35%
dehydrated by weight
loss or by clinical
estimation?

Yes

Begin ORS, replacing


deficit (up to 50 mL/kg)
over 4 hr plus
replacement of ongoing
losses (oral/NG)

No
Patient with diarrhoea
and <3% dehydration on
clinical
estimation/current weight
Yes
l Continue childs regular diet
l Consider adding ORS to
replace ongoing losses

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Expires: November 2012

Patient
tolerating
ORS

Yes Continue ORS


for 46 hr or
until rehydrated

No
l Continue breastfeeding
l Resume foods
l NG rehydration
l Institute IV infusion l Replace ongoing
losses with ORS

121

NUTRITIONAL FIRST LINE ADVICE 1/3


Initial guide to feeding when child not able to eat normally and dietitian not available
Gut
functioning?
NO

YES

TPN
Pharmacy
manufacturing
Mon-Fri

If not available,
use sodium
chloride 0.45% +
glucose 5%
with 10 mmol
potassium
chloride in
500 mL (use
commercial premixed bags)
monitor U&E
Breast milk
Nutramigen
If MCT * needed
use Peptijunior/
Pregestimil
feeds above are
peptide based
If not tolerated,
try Neocate
L-amino acid

Aged
<1 yr

Malabsorption

Normal gut

Pre-digested/
hydrolysed
protein feed

Whole protein
feed

Aged 1 yr
Wt 820 kg

Peptamen
junior
Pepdite 1+
Paediasure
Pepdite

OR use <1 yr
feeds until
dietitian
review

Aged >6 yr
Wt >20 kg

Peptisorb,
Peptamen
peptide
based
Elemental
028 Extra-L
amino
acids

Aged
<1 yr

Breast
milk**/std
infant
formula
If failure to
thrive or fluid
restriction,
use Infatrini/
Similac
High Energy
SMA
High Energy

Aged 1 yr
Wt 820 kg

Nutrini
Paediasure
Frebini
original

Aged >6 yr
Wt >20 kg

Tentrini up
to 45 kg
Paediasure
up to 30 kg
Frebini
original up
to 30 kg
Nutrison
Standard
Fresubin
original
Osmolite

l Contact dietitian to assess individual requirements and appropriate feed at the first available
opportunity MondayFriday
l Feeds in bold must be prescribed
l Hospital pharmacy will advise which feed is used locally (all similar composition for ages but
different manufacturer)
l See Table 1 for daily fluid and nutritional requirements
*Indications for MCT: malabsorption, or problems with digestion, absorption or transport of long
chain fats e.g. cholestasis, short gut, pancreatic insufficiency
** Dietitian to advise on fortification of breast milk if fluid restricted or failure to thrive
l Nutriprem breast milk fortifier 1 sachet (2.1 g) per 50 mL expressed breast milk (EBM) can be
added until dietitian advice given

122

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Expires: November 2012

NUTRITIONAL FIRST LINE ADVICE 2/3


Table 1: Nutritional and fluid requirements
Age

Average
weight
(kg)
03 months
6
46 months
7.5
79 months
9
1012
10
months
13 yr
female
12
male
12.5
4 yr
female
16
male
16.5
5 yr
female
18
male
18.5
6 yr
female
20.5
male
21
710 yr
female
27
male
27
1114 yr
female
43
male
40
1518 yr
female
56
male
62.5

Fluid
Energy
mL/kg per *EAR/day
day
150
130
120
110

Energy
Kcal/kg
per day
100115
95
95
95

Protein
g/kg per
day
2.1
1.6
1.5
1.5

95
1165
1230

95
95

1460
1520

87
94

1550
1720

82
88

1620
1810

76
84

1740
1970

70
70

1845
2220

47
55

2110
2755

40
45

95

95

85

75

55

Sodium Potassium
mmol/kg mmol/kg
per day
per day
1.5
3.4
1.6
2.8
1.6
2.0
1.5
1.8

1.1

1.7

1.6

1.1

1.9

1.6

1.1

1.9

1.6

1.1

1.9

1.6

1.0

1.8

1.8

1.0

1.6

1.8

1.3
1.0

1.6
1.4

1.0

50

*EAR - estimated average requirements = BMR (basal metabolic rate) x 1.41.5


Nutritional composition of milks for further information use BNFc
Per 100 mL
Breast milk (mature)
Cow & Gate Premium
Infatrini
Similac High Energy
SMA High Energy
Nutramigen
Peptijunior
Neocate
Nutrini
Paediasure
Nutrison Standard
Osmolite
Paediasure Pepdite
Peptamen junior
Pepdite 1+
Peptisorb
Peptamen
Aged >6 yrs
Elemental Extra 028
Issue 4
Issued: November 2010
Expires: November 2012

Kcal

Protein
g

Fat
g

CHO
g

Na
mmol

K
mmol

Osmolality

70
67
100
101
91
68
67
71
100
100
100
100
100
100
100
100
100

1.3
1.4
2.6
2.6
2.0
1.9
1.8
2.0
2.8
2.8
4.0
4.0
3.0
3.0
3.1
4.0
4.0

4.2
3.5
5.4
5.4
4.9
3.4
3.6/50% MCT
3.5
4.5
5.0
3.9
3.4
4.0/50% MCT
3.9/60% MCT
3.9/35% MCT
1.7/47% MCT
3.7/70% MCT

7.2
7.5
10.4
10.3
9.8
7.4
6.9
6.6
12.2
11.2
12.3
13.6
13.0
13.8
13.0
17.6
12.7

0.6
0.8
1.0
1.1
1.0
1.4
1.4
0.9
2.3
2.6
3.5
3.83
3.0
2.9
2.1
4.3
2.6

1.5
1.7
2.6
2.3
2.3
1.9
1.9
1.6
2.6
2.8
3.5
3.8
3.9
3.5
3.0
3.8
2.8

276
330
310
333
415
290
190
360
250
320
310
288
320
260
465
520
240

85

2.5

3.5/35% MCT

11

2.7

2.4

700

1.5

123

NUTRITIONAL FIRST LINE ADVICE 3/3


How to calculate energy
requirements for tube feeds
l Choose appropriate feed for weight
age. If large discrepancy use
appropriate feed for actual
bodyweight
l Calculate amount of feed to use in
24 hr based on:
l Kcal/kg in children aged <1 yr

l estimated average requirements

(EAR) for age/weight for aged >1 yr


l Calculate fluid requirement; if
restricted continue to use feeds above
until reviewed by dietitian

l Check plasma electrolytes daily with


particular reference to phosphate,
potassium and magnesium, correct
accordingly. Stop once clinical
condition stable
l Bolus feed can be given 1, 2, 3, 4
hourly intervals depending on
tolerance

l If on continuous feeds (i.e. over 24 hr)


start feed at a quarter final hourly
requirement increase to half
requirement, three-quarters, and full
every 46 hr as tolerated. When full
feeds tolerated aim to give full
requirement over 20 hr

l if extra fluid required give water

l Feeding method depends on clinical


condition of child:

l if child at risk of re-feeding syndrome

(e.g. anorexia nervosa, Crohns)


introduce feed slowly over 34 days
starting at 25% of Kcal intake day 1
increasing daily by 25% until full feeds
at day 4

124

Issue 4
Issued: November 2010
Expires: November 2012

FAILURE TO THRIVE 1/2


RECOGNITION AND
ASSESSMENT
Definition
l An infant or older child who fails to
gain weight as expected
l Growth below the 3rd percentile or a
change in growth that has crossed
downwards 2 major growth percentiles
in a short time (approximately 4
months, or longer period in older child)
l Associated features include:
l developmental delay
l apathy
l misery

Symptoms and signs


l Gastrointestinal problems
l vomiting
l voracious appetite
l anorexia
l diarrhoea
l Physical examination
l dysmorphic features
l heart murmurs
l abdominal distension
l wasting
l bruising

Measurements
Measurements must be carried out
properly and checked if there is doubt
l Record birth weight and gestation
l some light-for-dates infants fail to
catch up, and grow parallel but below
the 3rd percentile
l Measure and plot
l weight (unclothed)
l head circumference
l length or height
l Infant may be a small, normal child
growing below but parallel to the 3rd
percentile
l parents are often also small
l record height of parents and
grandparents
Issue 4
Issued: November 2010
Expires: November 2012

Single set of measurements of


limited value and does not
justify complex investigations.
Serial measurements of more
value and should be plotted on
percentile charts
Patient and family history
l Take a full feeding history
l type of milk given (breast milk, baby
milk, cows milk)
l volume given at each feed
l frequency of feeding
l method of making up the feeds
(correct strength)
l introduction of solids: age and type of
solid
l any difficulty with feeding process (e.g.
breathless, uncomfortable)
l Ask about social factors
l were either of the parents in care
during childhood or had learning
disability?
l is there a lack of money in the home
or other stress?
l do parents have a history of
psychiatric illness or depression
(including post-natal depression)?
l ask parental ages, health, siblings
ages/health
l did siblings experience FTT?

Investigations
Routine tests
l Faeces: culture and sensitivity,
microscopy for ova and cysts and
parasites
l Urine: dipstick for protein, nitrites and
blood
l Haemoglobin, blood film (for signs of
iron deficiency), WBC and ESR
l Biochemical profile including creatinine,
bicarbonate, calcium and albumin
l Coeliac screen (anti-tTG and IgA)

125

FAILURE TO THRIVE 2/2


Further tests

MANAGEMENT

l Chest X-ray
l Bone age
l If underlying pathology indicated by
history or clinical examination or
results of routine investigations,
request further tests, such as:
l sweat test/cystic fibrosis (CF) gene
l Further gastrointestinal investigation or
management of malabsorption
disorders should be undertaken by
referral to specialist gastroenterology
team who will undertake as
appropriate:
l endoscopy or jejunal biopsy
l gastrointestinal imaging

l Most patients can be managed as


outpatients
l record height and weight at each visit
l seek dietitian opinion
l significant weight gain after admission
(>180 g/week in infant) supports
parenting issues as cause
l if treatable cause identified, treat
appropriately
l If social problems responsible,
consider:
l admission to ward to demonstrate
good weight gain out of home
environment
l health visitor support
l social work support
l day care and nursery provision
l case conference
l care proceedings

Differential diagnosis
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l

Low genetic growth potential:


familial
light-for-dates baby
genetic syndrome
Social factors:
maternal depression
poor parenting skills
abuse
Malabsorption:
CF
coeliac disease
other protein intolerance
lactose intolerance
infestation
Vomiting/severe regurgitation
Any chronic underlying disorder:
renal failure
congenital heart disease
severe asthma
immunodeficiency
other rare conditions e.g.
chromosomes or metabolic tests if
dysmorphic features present

126

Issue 4
Issued: November 2010
Expires: November 2012

JAUNDICE 1/3
RECOGNITION AND
ASSESSMENT

Investigations
All

Symptoms and signs


l Yellow colouration of skin in a paleskinned infant observed in natural
light
l Yellow conjunctivae in dark-skinned
infants

Assess
l Pallor (haemolysis)

l Poor feeding, drowsiness (neurotoxicity)


l Hepatosplenomegaly (blood-group
incompatibility or cytomegalovirus)
l Splenomegaly (spherocytosis)

l Stools (pale, chalky) and urine colour


(dark stains nappy: conjugated
hyperbilirubinaemia)

Causes
l Physiological
l Prematurity

l Total bilirubin if bilirubinometer


250 micromol/L

l Conjugated bilirubin on all babies with


chalky stools

Jaundice in first 24 hours of life


or requiring treatment

l Urgent bilirubin (result within 2 hr)


l Full blood count and film

l Babys blood group and direct


Coombs test

l Mothers blood group and antibody


status (should be available from
maternal case notes)

l Full infection screen (in an ill baby)

l G6PD concentration (if indicated by


ethnic origin: Mediterranean, Middle
Eastern, South East Asian, and local
hospital policy)

Persistent jaundice

l Increased bilirubin load (e.g. bruising,


blood group incompatibility)

l >14 days old term infants;


>21 days preterm infants

l congenital spherocytosis

l Liver function test (ALT, Albumin,


GGT)

l Rarely infection (e.g. UTI, congenital


infection)

l Urine M,C&S

l G6PD deficiency and other red cell


enzyme deficiencies
l cephalhaematoma
l Metabolic disorder

Persistent jaundice after 14 days


of age
l Breast milk jaundice
l Hypothyroidism

l Liver disease (e.g. extra hepatic biliary


atresia and neonatal hepatitis)
l Alpha-1-antitrypsin deficiency
l Galactosaemia

l TPN-induced cholestasis
Issue 4
Issued: November 2010
Expires: November 2012

l Total and conjugated bilirubin

l FBC, blood group, direct Coombs test


and coagulation profile
l Document stool colour

l Check routine metabolic screening


has been performed

2nd line investigations

l If conjugated bilirubin >25 mmol/L


seek specialist advice
l G6PD screen in African, Asian or
Mediterranean patients

l Thyroid function tests: ask for FT4


priority and then TSH

127

JAUNDICE 2/3
l Congenital infection screen:

l CMV PCR: in urine first 2 weeks life,


later use Guthrie card
l toxoplasma ISAGA-IgM and

l throat swab for HSV culture/PCR


l Metabolic investigations:

l blood galactose-1-phosphate

l urine for reducing substances


l alpha-1-antitrypsin

If conjugated bilirubin elevated


(>20% of total or
>20 micromol/L), discuss with
consultant urgently

Limits (micromol/L) for phototherapy and exchange transfusion for term infants
Age
(hours)

Repeat transcutaneous
bilirubin/serum bilirubin
(612 hours)*

Consider
phototherapy #

Phototherapy

Exchange
transfusion

>100

>112

>100

>100

>125

12

>100

>150

>125

>150

18

>200

>100

>137

>175

>250

24

>100

>150

>200

>300

30

>112

>162

>212

>350

36

>125

>175

>225

>400

42

>137

>187

>237

>450

48

>150

>200

>250

>450

54

>162

>212

>262

>450

60

>175

>225

>275

>450

66

>187

>237

>287

>450

72

>200

>250

>300

>450

78

>212

>262

>312

>450

84

>225

>275

>325

>450

90

>237

>287

>337

>450

96+

>250

>300

>350

>450

* result in this category repeat transcutaneous measurement in 612 hr


# result in this category repeat serum bilirubin measurement in 6 hr whether or not
phototherapy started

128

Issue 4
Issued: November 2010
Expires: November 2012

JAUNDICE 3/3
TREATMENT <7 DAYS
l Adequate fluid and energy intake
l Phototherapy

Jaundice presenting in first


24 hr of life
l Visible jaundice can be treated with
phototherapy after sample taken for
bilirubin measurement

l Bilirubin >100 micromol/L: repeat in


612 hr

After first 24 hr
l Commence phototherapy according to
following equation:
l for infants <37 weeks, start if serum
bilirubin (micromol/L) phototherapy
level [(gestational age in completed
weeks x 10) 100]
l for infants 37 weeks, start if serum
bilirubin >340 micromol/L
(phototherapy level)

Phototherapy
l If bilirubin near exchange threshold or
still rising:

MONITORING TREATMENT
l If haemolysis present, check bilirubin
46 hrly until rate of rise flattens

l If bilirubin concentration approaching


threshold for exchange transfusion, or
rising rapidly (>10 micromol/hr), check
4 hrly

SUBSEQUENT MANAGEMENT
l When bilirubin concentration has fallen
below threshold for phototherapy (see
above), discontinue phototherapy
l If jaundice persists after 14 days of
age, review and treat cause

DISCHARGE AND FOLLOW-UP


l GP follow-up with routine examination
at 68 weeks
l If exchange transfusion necessary or
considered, request development
follow-up and hearing test

l In babies with positive Coombs test


who require phototherapy, check
haemoglobin at 2 and 4 weeks of age
because of risk of continuing
haemolysis and give folate

l increase power number of lights

l increase area exposed (e.g. biliblanket


and overhead)

Exchange transfusion
l See Exchange transfusion in
Neonatal guidelines

IVIG
l Use as an adjunct to multiple
phototherapy in rhesus disease when
bilirubin continues to rise by
>8.5 micromol/L/hr

Issue 4
Issued: November 2010
Expires: November 2012

129

BLOOD AND PLATELET TRANSFUSIONS 1/1


Always check front sheet in
patient notes before prescribing
any blood product
Before transfusion

l Explain indications for blood products


to parents
l Document indications and verbal
consent
l Make sure child is well, not suffering
from active infection
l If previous reactions to blood
products have occurred, pre-medicate
with chlorphenamine oral or IV, and
hydrocortisone

BLOOD TRANSFUSION
When to transfuse
Oncology children

l If haemoglobin 8 g/dL or if >8 g/dL


and symptomatic, transfuse
l If having radiotherapy, transfuse if Hb
<10 g/dL

Non-oncology children

l If haemoglobin <6 g/dL or >6 g/dL


and symptomatic

Target Hb and volume to be


transfused

l Aim for target haemoglobin of 12 g/dL or


for 10 g/dL if initial haemoglobin <6 g/dL
l In newly diagnosed patients with
leukaemia/profound anaemia, aim for
target Hb 89 g/dL
l Calculate volume to be given as:
(round to nearest unit)
[Target Hb actual Hb (g/dL)] x
weight x 3 mL
l Total volume should not exceed
20 mL/kg

Rate of infusion
l Give total over 34 hr. Max rate
5 mL/kg/hr

130

l If Hb <6 g/dL, give blood over 48 hr


(each unit must be used within 4 hr
once removed from fridge)
l Give furosemide 1 mg/kg orally if
tolerated or IV half-way through

Use irradiated blood if


l Allogenic bone marrow transplant (BMT)
from start of conditioning regimen
l Allogenic BMT donors
l If <7 days pre-harvest for autologous
BMT and stem cell transplant patients
(e.g. stage IV neuroblastoma)
l Hodgkins disease or if patient has
received fludarabine
l Children with severe immunodeficiency
(e.g. SCID)
l HLA-matched platelets
l For high risk neonates e.g. post
intrauterine transfusion

Leucodepleted blood
l All packed cells are leucodepleted
and therefore CMV negative

PLATELET TRANSFUSION IN
ONCOLOGY CHILDREN
Transfuse platelets if
platelet level

l <10 x 109/L oncology children except


brain tumour
l <20 x 109/L above and unwell
l <30 x 109/L brain tumour
l <50 x 109/L brain tumour and unwell
l <50 x 109/L for lumbar puncture and
bone marrow aspiration

Dosage and rate

l <15 kg: 15 mL/kg round off the


nearest unit
l 15 kg: one pack
l Transfuse within 1530 min

Idiopathic thrombocytopenic
purpura (ITP) transfuse
platelets only if bleeding

Issue 4
Issued: November 2010
Expires: November 2012

FEBRILE NEUTROPENIA 1/3


Regular clinical assessment of
patients is a vital part of
effective management of febrile
neutropenia in children
RECOGNITION AND
ASSESSMENT
Definition
l Temperature:

l 38C on two separate occasions


separated by >1 hr OR
l 38.5C at any time
l Neutrophils <1x109

IMMEDIATE TREATMENT
See Table 1 and Figure 1

All patients
l Culture both lumens/portacath, FBC,
CRP, urine dipstick. CXR if respiratory
signs
l Follow local microbiology advice: if
local microbial resistance to 1st line
antibiotics start with 2nd line
l Repeat blood culture before any
change in antibiotics

No obvious line infection


l Start piperacillin with tazobactam and
gentamicin (Table 1 and Figure 1)
unless penicillin allergy
l If clinically well and afebrile, and no
growth in blood cultures after 48 hr:

l add liposomal amphotericin (AmBisome)


l Discharge once afebrile for continuous
48 hr

Suspected line infection


l Erythema at exit site/tracking along
line or flushing-associated rigors

l If patient unwell (e.g. with signs of


septic shock) start treatment with
piperacillin/tazobactam and gentamicin
as above
l If patient well, start
piperacillin/tazobactam and teicoplanin
(Table 1 and figure 1)

l If clinically stable and afebrile after 48 hr:


l continue first-line antibiotics
(piperacillin/tazobactam and
teicoplanin see Table 1 and Figure 1)

l If during first 48 hr, child remains


febrile or shows signs of severe
sepsis, or fever settles and then recurs
after 48 hr:
l change antibiotics to meropenem and
vancomycin

l If febrile after 96 hr or clinically unwell


between 48 and 96 hr:

l add liposomal amphotericin (AmBisome)


l if blood cultures positive and patient
remains febrile despite adequate
antibiotics, repeat blood culture and/or
consider removal of suspected line
l If respiratory signs/symptoms request
CXR with low threshold for CT chest
(aspergillus)

l Discharge once afebrile for continuous


24 hr in otherwise well child

l stop antibiotics

l If during first 48 hr, child remains


febrile or is clinically unstable, or fever
settles and then recurs after 48 hr:
l change antibiotics to meropenem and
vancomycin
l If febrile after 96 hr or clinically
unstable between 48 and 96 hr:
Issue 4
Issued: November 2010
Expires: November 2012

131

FEBRILE NEUTROPENIA 2/3


Table 1: Antimicrobials
Antibiotic (IV)
Piperacillin/
tazobactam

Gentamicin

Teicoplanin

l
l
l
l
l
l
l
l
l
l
l

Meropenem
Vancomycin

Antifungal therapy
Liposomal
amphotericin
(AmBisome)

l
l

90 mg/kg 6 hrly
Reduce frequency in renal impairment
Maximum single dose 4.5 g
If rash with penicillin use ceftazidime
If anaphylaxis with penicillin use aztreonam
7 mg/kg once daily based on IBW
Pre-dose level before third dose or, if creatinine clearance <70 mL/min,
before second dose
No post-dose level required
Target pre-dose level <1 mg/L
Staphylococcal CVL infections well enough to be treated as an outpatient if sensitive (if MIC >8 mg/mL use vancomycin)
10 mg/kg (max 400 mg/dose) 12 hrly for three doses followed by
10 mg/kg/day (max dose 400 mg/day)
20 mg/kg 8 hrly
Maximum of 3 g/day

l 15 mg/kg 8 hrly
l Dose should be given over at least 60 min at maximum rate of
10 mg/min
l Maximum of 2.1 g/day until concentration known
l Pre-dose sample before third dose
l No post-dose sample required
l Adjust dose as follows:
l pre-dose concentration (mg/L)
l <10 give 6 hrly and recheck concentration in 2448 hr
l 1015 continue current dose and recheck concentration in 35 days
l 1520 reduce frequency of dosing and recheck concentration in 2448 hr
l >20 stop vancomycin and recheck concentration next day to see if
therapy can be restarted
l Give test dose 100 microgram/kg
l 1 mg/kg/day
l If strong clinical/microbiological evidence of fungal infection, increase
to 3 mg/kg/day

There is no role for empirical use of metronidazole in febrile


neutropenic patients with diarrhoea

132

Issue 4
Issued: November 2010
Expires: November 2012

FEBRILE NEUTROPENIA 3/3


SUBSEQUENT MANAGEMENT
l Change antibiotics according to
results of culture and sensitivity
reports

l Discuss culture-positive patients with


microbiologist or infectious diseases
consultant for advice on appropriate
treatment. Where blood cultures
positive for yeast in presence of
suspected line infection, remove
suspected lines promptly

l Give culture-positive patients at least


seven days treatment
l Patients who are afebrile for
continuous period of 24 hr and are
otherwise clinically stable can be
discharged, no requirement to
achieve a particular neutrophil
concentration

l No need for routine in-patient


observation after stopping antibiotics

Figure 1: Management of febrile neutropenic patients. If renal impairment, see


text for adjusted doses

FIRST
LINE

No obvious line infection or


patient unwell

Suspected line infection AND


patient well

Piperacillin with tazobactam


(Tazocin*) 90 mg/kg 6 hrly (max
4.5 g/dose)
gentamicin 7 mg/kg once daily

Piperacillin with tazobactam (Tazocin*)


90 mg/kg 6 hrly (max 4.5 g/dose)
teicoplanin 10 mg/kg 12 hrly for 3 doses
then daily (max dose 400 mg)

Unwell or
febrile at
48 hr
SECOND
LINE

Change antibiotics to meropenem


20 mg/kg 8 hrly (max 1 g/dose) and
vancomycin 15 mg/kg 8 hrly
(max 700 mg/dose)
Febrile at 96 hr or
clinically unstable
4896 hr

Clinically stable
and apyrexial at
48 hr
Continue first line
antibiotics

Chase
blood
cultures

Antifungal therapy

Discharge when clinically appropriate


(oncology team decision)

Discharge once continuously afebrile


for 24 hr and if blood cultures
negative

* If patient penicillin allergic, start ceftazidime 50 mg/kg 8 hrly (max dose 2 g) and gentamicin
7 mg/kg once daily

If receiving nephrotoxic drugs or has renal impairment, substitute teicoplanin for vancomycin

Issue 4
Issued: November 2010
Expires: November 2012

133

HENOCH-SCHNLEIN PURPURA 1/2


RECOGNITION AND
ASSESSMENT
Definition
l Vasculitic condition of unknown
aetiology
l 50% have a preceding upper
respiratory tract infection

l Affects skin, gastrointestinal tract,


joints and renal tract

Symptoms and signs


Rash
l Purpuric, raised on extensor surfaces
of legs, and buttocks, with surrounding
erythema

Gastrointestinal tract
l Abdominal pain mostly idiopathic,
typically resolves in 72 hr

l if severe or persistent, exclude


intussusception, testicular torsion or
pancreatitis (rare)
l Nausea and vomiting

l Intestinal haemorrhage:
haematemesis, melaena, bloody stools
(rare)

Joints
l Arthralgia and swelling of large joints,
especially ankles and knees. Pain
typically resolves in 2448 hr
l Oedema of hands, feet, sacrum and
scrotum

Renal
l Microscopic haematuria (common)

l Proteinuria can present 46 weeks


after initial presentation
l Hypertension

l Nephritic syndrome haematuria with


at least one of following:
l raised urea and creatinine
l hypertension
l oliguria

Neurological
l Headache (common)

l Seizures, paresis, coma (rare)

Differential diagnosis
l Purpuric rash:

l meningococcaemia clinical diagnosis


l thrombocytopenia FBC (rash looks
different, ITP not vasculitic)

l rarer vasculitides more difficult to


exclude; differentiation requires review
over a period of time
l pancreatitis suspect in abdominal
pain lasting >3 days

Investigations
All patients
l BP

l Urine dipstick

l if proteinuria, send urine for early


morning protein:creatinine ratio
l if haematuria, send urine for
microscopy

Additional investigations
Blood tests if urinalysis abnormal or
diagnosis uncertain
l FBC+ film
l U&E

l Albumin

l If fever, blood culture and ASO titre


l Coagulation

l Throat swab

l Nephrotic syndrome proteinuria +/oedema and hypoalbuminaemia

134

Issue 4
Issued: November 2010
Expires: November 2012

HENOCH-SCHNLEIN PURPURA 2/2


IMMEDIATE
TREATMENT/SUBSEQUENT
MANAGEMENT
l Condition is self-limiting, symptomatic
relief only
l Mortality <1% usually related to
kidneys

l Long-term morbidity related to renal


disease
l 1% of those with renal involvement
progress to end stage renal failure

l HSP accounts for 515% of patients


with end stage renal failure in children

Joint pain
l NSAIDs (ibuprofen first-line,
indometacin or diclofenac second-line)

Abdominal pain
l Give prednisolone as for nephrotic
syndrome. Renal involvement not a
contraindication
l If severe and persists, exclude
pancreatitis, intussusception. or
spontaneous bowel perforation

MONITORING
Uncomplicated HSP (e.g. urine
analysis 1+ blood and protein,
and normal BP)

l No hospital follow-up required but GP


to follow-up as below

HSP with haematuria or


proteinuria >1+
l GP follow-up in 12 weeks. Monthly
BP for 6 months and weekly urine
dipsticks until urine clear

l If blood or protein >1+, routine followup in childrens outpatients

Issue 4
Issued: November 2010
Expires: November 2012

Refer to nephrologist if
l Urinalysis blood or protein >1+ after
6 months
l Macroscopic haematuria or heavy
proteinuria at presentation
l Hypertension (see Hypertension
guideline)

l Significant proteinuria (early morning


urine protein:creatinine ratio
>100 g/mmol or 3+ proteinuria for
three days)
l Impaired renal function

Refer to rheumatologist if
l Atypical or rapidly resolving rash

DISCHARGE AND FOLLOW-UP


l Inform parents condition may fluctuate
for several months but recurrence rare
once settled properly
l Very rare risk of renal failure, hence
importance of monitoring urine

l Seek medical advice if child develops


headache, PR bleeding or severe
abdominal pain

Uncomplicated HSP
l GP follow-up in 12 weeks. Monthly
BP for 6 months and weekly urine
dipsticks until urine clear

HSP with complications or


haematuria or proteinuria
>1+

l GP follow-up as for uncomplicated


HSP and follow-up in general
paediatric outpatients in 68 weeks

l If persistent proteinuria/haematuria or
abnormal renal function, refer to
nephrologist

135

IDIOPATHIC THROMBOCYTOPENIC PURPURA


(ITP) 1/2
RECOGNITION AND
ASSESSMENT
Definition
l Platelets <100 x 109/L, usually <20 x
109/L
l Self-limiting disease with shortened
platelet survival and increased
megakaryocytes
l Good prognosis
l Acute 03 months
l Persistent 312 months
l Chronic >12 months

Symptoms and signs


l Acute onset bruising, purpura and
petechiae
l serious mucosal bleeding unusual,
look for other causes
l Preceding infection
l Absence of:
l hepatosplenomegaly
l lymphadenopathy
l evidence of serious cause/chronic
underlying illness

Investigations
l FBC, blood film and clotting
l CMV and EBV IgM
l Consider HIV, Hepatitis B and C if risk
factors
l If ITP, headache and neurological
signs, urgent CT scan of head
l Bone marrow aspiration unnecessary
unless:
l neutropenia or severe anaemia
l hepatosplenomegaly
l lymphadenopathy
l pallor and lassitude
l pain limb/abdomen
l limp

IMMEDIATE TREATMENT
l None regardless of platelet count,
unless life-threatening owing to
significant bleeding
l If significant bleeding (e.g.
uncontrollable epistaxis, GI
haemorrhage, intracranial bleed), give:
l platelets (see Blood and platelet
transfusions guideline)
l immunoglobulin 1 g/kg (see Trust
policy)
l If moderate bleeding e.g. prolonged
mucosal bleeds, give prednisolone
4 mg/kg (max for 4 days)
l Avoid aspirin and ibuprofen
l Reassure parents
l Discuss treatment with platelets with
haematologist in event of:
l essential operations
l emergency dental extractions

SUBSEQUENT MANAGEMENT
l 7580% resolve in 6 months
l favourable outcome irrespective of
treatment
l Avoid contact sports
l impossible to prevent fighting/rigorous
knockabout games at home

MONITORING TREATMENT
l FBC only if bleeding or increased
bruising

DISCHARGE AND FOLLOW-UP


l Discharge when platelets >100 x 109/L
and asymptomatic
l Advise of risk of relapse (20%)
l Note that mothers with history of ITP
(even if they have normal platelet
counts) can give birth to
thrombocytopenic babies

Bone marrow mandatory before


corticosteroid administration

136

Issue 4
Issued: November 2010
Expires: November 2012

IDIOPATHIC THROMBOCYTOPENIC PURPURA


(ITP) 2/2
CHRONIC IDIOPATHIC
THROMBOCYTOPENIC
PURPURA

l Avoid NSAID's
l Avoid contact sports
l Investigate for autoimmune disease
and immune deficiency
l Treat only:
l profound thrombocytopenia
(<10 x 109/L) with repeated mucosal
bleeding
l older girls with menorrhagia
l trauma
l acute neurological signs
l If treatment indicated, give
prednisolone 12 mg/kg/day until
count responds
l reduce gradually
l must have bone marrow aspirate
before treatment

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137

HAEMOPHILIA 1/3
INTRODUCTION
l Haemophilia is a serious disease.
Each child with haemophilia must:
l have open access

l be treated without delay

l be registered with designated tertiary


haemophilia unit
l be registered locally (if shared care
appropriate) for local registration,
there will be two copies of the
treatment sheet, one copy at front of
patient notes and a second copy on
ward

Inform haemophilia nurse of


any patient attending for
treatment

l Haemarthrosis, especially weightbearing joints (e.g. hips and knees)

l Any lesion requiring 12 hrly or more


frequent replacement therapy

MANAGEMENT OF ACUTE
BLEEDING
l Patients present for treatment,
particularly when developing a
haemarthrosis before any physical
signs are present

l give immediate replacement therapy


as haemarthrosis are very painful and
any delay may increase severity of
bleed and risk of joint damage
l if any doubt, contact haemophilia
nurse or haematologist

Replacement therapy dosage


INDICATIONS FOR ADMISSION
l Bleeding in mouth, neck, respiratory
passages or gastro-intestinal tract
l Suspected internal bleeding
(intracranial, intra-thoracic or intraabdominal)

l Haemorrhage endangering a nerve


(e.g. carpal tunnel median nerve,
iliopsoas femoral nerve) or other vital
structure

l When deciding dose, consider:


l type of lesion

l time of onset of symptoms

l factor level required to sustain


haemostasis

l half-life of therapy (varies with each


concentrate)

l Requiring surgical treatment, including


dental surgery
Type of lesion
l Uncomplicated bleeding into joints and
muscles
l Haematoma in potentially serious
situations:
l bleeding in mouth
l neck
l respiratory passages
l endangering nerves
l Pre-dental extraction
l Major surgery
l Serious accident
l Head injury

138

Level of factor desired


l Non-weight bearing joint 30%
l Weight bearing joint 50% (may need twice
daily infusion)
l 3050%

l 50%
l 80100%

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HAEMOPHILIA 2/3
Calculation of replacement factor
l Most boys with haemophilia receive
recombinant factor
l Calculate units of factor needed, X,
using following formula:

l X = % rise in factor required x wt (kg)


K
(where K is the recovery constant)

l Recovery constants vary. Common


factors used are:

l haemophilia A: Factor VIII


concentrates are: Kogenate, ReFacto,
Helixate and Recombinate, with
recovery constant (K) = 2

l haemophilia B: Factor IX concentrate


BeneFIX, with recovery constant (K)
= 0.8. It often has a short half-life in
children (aim 60% rise)
l Factor X deficiency: Beriplex blood
product, with recovery constant (K)
= 2.2

l von Willebrands disease: use


Haemate P, with recovery constant (K)
= 1.5
l For any other Factor concentrate,
contact haematologist on-call to
discuss treatment and ascertain
correct recovery constant

Other treatment
l On advice of consultant haematologist
for those with inhibitors to factors VIII
or IX
l Factor VIIa (recombinant: Novoseven)
90 micrograms/kg 2 hrly with frequent
review

Administration of factor
concentrate
l Give intravenously over about 3 min
l adverse reactions rare but include
anaphylactic shock

l During prolonged treatment screen for


inhibitors every 5 doses
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Expires: November 2012

Duration of treatment
l Decided by local on-call haematologist
or designated tertiary haemophilia unit
(on-call haematologist). If in doubt, ask

DESMOPRESSIN IN MILD
HAEMOPHILIA A AND VON
WILLEBRANDS DISEASE
l Intranasally or IV

l may be used to raise Factor VIII


concentration

l response usually fourfold rise (IV) or


twofold rise (intranasal) in Factor VIII
and von Willebrand's antigen
concentration

Patient selection
l Consider only in mild (NOT severe)
haemophilia A

l Not appropriate in Factor IX deficiency


(haemophilia B)
l Do not use in child aged <1 yr
l caution in children aged <2 yr

l Check notes for outcome of previous


desmopressin challenge

Administration of desmopressin
l Intravenously: 0.3 micrograms/kg IV in
sodium chloride 0.9% 50 mL over
20 min. May be repeated after 12 hr
l Intranasally: 4 micrograms/kg IV once
l Side effects include hypertension

l measure pulse and BP every 5 min


during infusion. If either rises
unacceptably, reduce rate of infusion

l Ensure blood samples taken before


and after infusion to measure Factor
VIII level and ensure therapeutic level
reached

l tachyphylaxis can occur with depletion


of stored Factor VII with consecutive
days. After 3 days there may be an
inadequate rise of Factor VIII

139

HAEMOPHILIA 3/3
VON WILLEBRANDS DISEASE
l More common than haemophilia

l caused by deficiency (qualitative or


quantitative) of vWF protein, which
binds to Factor VIII (prolonging half-life)
and platelets

l Contraindicated in presence of frank


haematuria (>2+blood)
l Decrease dose in renal failure

l For minimal mucosal bleeding,


transexamic acid mouth wash may be
sufficient to stop initial bleeding

l Before treatment, consider:

l Oral transexamic acid alone can be


used to treat minor problems such as
recurrent epistaxis, but main use is in
combination with desmopressin if
appropriate

l bleeding history, including previous


response to any treatment

l Intravenous tranexamic acid 10 mg/kg


(max 1 g) 8 hrly over 10 min

l Can present with acute episodes of


mucosal bleeding, helping to form
initial clot

l von Willebrands disease (vWD) subtype


l nature of haemostatic challenge

l Treatment is often a combination of


tranexamic acid and desmopressin or
Haemate P

Tranexamic acid
l Anti-fibrinolytic agent
vWD Type
Type 1
Type 2A
Type 2B
Type 3

l
l
l
l
l
l
l

l oral dose 1525 mg/kg 8 hrly (max


dose 1.5 g) for max 5 days

Desmopressin
l Treatment of choice in responsive
patients for spontaneous bleeding,
trauma and minor surgery

l For administration see


Administration of desmopressin

Advice
Most patients responsive
Some patients responsive
ask about previous challenge
DO NOT GIVE desmopressin
it causes platelet agglutination and thrombocytopenia
Not all responsive and some can be severe
ask about previous challenge

Haemate P (blood product)


l Avoid if at all possible
l Use in patients not responsive to, or
unsuitable for, desmopressin (e.g.
aged <2 yr)
l See above for administration of
replacement factor. Recovery constant
for Haemate P = 1.5

140

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Expires: November 2012

ANTIBIOTICS 1/1
EMPIRICAL ANTIBIOTICS
Once organism identified, change antibiotic to narrowest spectrum appropriate for
site of infection
Oral unless unavailable or IV stipulated; if not tolerating oral fluids use same
antibiotic IV
Pneumonia:
Community acquired
aged 5 yr
aged 5 yr
?aspiration

Mild

Severe

amoxicillin
amoxicillin +/- clarithromycin
Co-amoxiclav

Co-amoxiclav IV
Co-amoxiclav IV + clarithromycin IV
Co-amoxiclav IV + metronidazole

Hospital acquired/2nd line

Piperacillin/tazobactam

Meropenem

Empyema

Co-amoxiclav IV

Allergy
l For rash with penicillin give cephalosporin:
l clarithromycin instead of amoxicillin
l cefuroxime instead of co-amoxiclav (+ metronidazole for aspiration)
l ceftazidime instead of piperacillin/tazobactam
l For anaphylaxis with penicillin or rash with cephalosporin give:
l clarithromycin instead of amoxicillin or co-amoxiclav
l aztreonam and vancomycin instead of piperacillin/tazobactam or meropenem
Meningitis

Sepsis from:
Community

Hospital
UTI: Mild
Severe
Osteomyelitis
and septic arthritis
Orbital cellulitis
Endocarditis

Penicillin allergy
Cefotaxime
Chloramphenicol IV
or ceftriaxone (aged >1 month) or vancomycin + rifampicin
+ amoxicillin (aged <3 months) (for anaphylaxis with penicillin or
cephalosporin)
Cefotaxime

Piperacillin/tazobactam
Co-amoxiclav
Co-amoxiclav IV
Flucloxacillin IV

Chloramphenicol IV
(for anaphylaxis with penicillin or
cephalosporin)
Aztreonam+ vancomycin
Trimethoprim
Gentamicin
Clindamycin

Cefotaxime
Chloramphenicol IV
Flucloxacillin IV
Vancomycin + gentamicin (low dose)
+ gentamicin (low dose)
Prosthesis or ?MRSA Vancomycin + rifampicin + gentamicin (low dose)
GI surgical prophylaxis Co-amoxiclav
Gentamicin + metronidazole
and treatment
e.g. peritonitis
Neonatal sepsis
1st line: benzylpenicillin + gentamicin (presenting <72 hr old)
Not responding to above after 24 hr and no organism isolated:
2nd line: flucloxacillin IV + gentamicin or (presenting >72 hr old)
Not responding to above after 24 hr and no organism isolated:
3rd line: cefotaxime + vancomycin
(CSF clear) piperacillin/tazobactam + vancomycin
Not responding to above after 24 hr and no organism isolated:
4th line: meropenem + vancomycin
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141

BITES 1/1
Prevention of infection after bites from
humans and other animals

Give prophylactic antibacterials


to:
l All human bite wounds 72 hr old,
even if no sign of infection

l Animal bite wounds if wound 48 hr


old and risk of infection high as follows:
l bites to hand, foot, and face; puncture
wounds; wounds requiring surgical
debridement; crush wounds with
devitalised tissue; wounds in genital
areas; wounds with associated
oedema; wounds involving joints,
tendons, ligaments, or suspected
fractures
l wounds that have undergone primary
closure

l give asplenic patients prophylaxis even


after trivial animal bites
l patients with prosthetic implants e.g.
heart valve, VP shunt

l antibacterials are not generally needed


if wound 2 days old and no sign of
local or systemic infection

Source is known or suspected


to be positive for HIV, hepatitis
B or C, or Rabies
l Seek advice from consultant
microbiologist or consultant in
infectious diseases

l Advise patient and carers of signs of


developing infection and to attend
urgently for review should this happen

l patients at risk of serious wound


infection (e.g. immunosuppressed)

Antibacterial prophylaxis
Type of bite
Specimen
Treatment

Duration

Human, dog or cat*


Tissue, aspirate or swab for bacterial cultures if clinical infection present
Blood cultures if the patient systemically unwell
Tetanus vaccine and immunoglobulin if indicated (see current BNFc)
First line
Alternative (penicillin allergy)
Co-amoxiclav
Metronidazole and erythromycin
5 days

*For bites from other mammals, contact consultant microbiologist or consultant in


infectious diseases

142

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CERVICAL LYMPHADENOPATHY 1/4


Enlargement of cervical lymph nodes
>1 cm

Acute lymphadenitis
l Short history (usually <2 weeks)
l Neck mass with features of acute
inflammation

Subacute lymphadenopathy
l History variable
l Often non-tender but with overlying
erythema

Chronic lymphadenopathy
l Longer history (usually >1 month)
l No feature of acute inflammation

HISTORY
Symptoms
l Duration
l Symptoms of URTI
l Fever
l Weight loss
l Night sweats
l Eczema/skin infection
l Bruising
l Pallor
l Bone pain
l Pruritis

Social
l Contact with TB or cats
l Travel

EXAMINATION
l Site of node(s) (see figure 1)
l Size of node(s)
l ENT examination
l Skin especially eczema
l Axillae and groin for other nodes
l Abdomen for hepatosplenomegaly

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Expires: November 2012

DIFFERENTIAL DIAGNOSIS
Acute unilateral
l Reactive
l URTI (Strep)
l skin infection (Strep, Staph)
l dental infection (anaerobes)
l Kawasaki (see Kawasaki disease
guideline)
l Cat scratch disease (Bartonella)
l Kikuchi-Fujimoto disease (histocytic
necrotising lymphadenitis)

Acute bilateral
l Reactive
l viral URTI
l EBV

Subacute
l Non-tuberculous mycobacteria
l Mycobacterium tuberculosis

Chronic
l Reactive
l Neoplasia
l lymphoma
l leukaemia
l soft tissue tumours

INVESTIGATIONS
l See flowchart
l Serology for Bartonella, toxoplasma,
CMV and EBV
l CXR
l Hilar lymphadenopathy significantly
increases likelihood of neoplastic
disease
l Ultrasound
l high sensitivity and specificity for
abscess formation in acute
lymphadenitis
l value in chronic lymphadenopathy for
assessing size, site, shape and
vascularity
l CT only if suspected deep neck space
infection

143

CERVICAL LYMPHADENOPATHY 2/4


Surgical excision biopsy
l Atypical mycobacterial infection
l Features highly suggestive of
neoplasia:
l lymph nodes >3 cm diameter
l all supraclavicular nodes
l constitutional symptoms
l hepatosplenomegaly
l generalised lymphadenopathy

Children undergoing surgical


biopsy for suspected
neoplastic disease
l FBC and film
l U&E
l CXR

Figure 1 Node sites

AT:
PT:
SM:
SC:
LC:
MC:
UC:
P:

144

Anterior triangle
Posterior triangle
Submandibular triangle
Supraclavicular triangle
Lower cervical chain
Mid cervical chain
Upper cervical chain
Parotid

Issue 4
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Expires: November 2012

CERVICAL LYMPHADENOPATHY 3/4


Acute cervical
lymphadenitis

No

Yes
Fluctuant

Refer to
ENT
l Well
l Older child
l Small mass

Yes

No
Manage as
outpatient

Refer to
guideline

Admit

Yes

Kawasaki?

No
Pus

l FBC, U&E, CRP


l Blood cultures
l Serology for Bartonella,
EBV, CMV, toxoplasma*

?atypical
mycobacteria

Solid
IV co-amoxiclav
for 24 hr

USS

Check
cultures

No

Improved?

Yes

*for storage pending repeat titre in chronic course

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Discharge on
PO co-amoxiclav

145

CERVICAL LYMPHADENOPATHY 4/4


Chronic cervical
lymphadenopathy

Clinical
assessment

l All of:
l <1 cm
l mobile
l well child

l Any of:
l >3 cm
l supraclavicular
l constitutional symptoms
l generalised LN
l hepatosplenomegaly

Does not meet either


criteria

l CXR
l USS neck
l FBC & film
l Serology for:
l EBV
l CMV
l Toxoplasma
l Bartonella
l Co-amoxiclav for
2 weeks

l CXR
l FBC
l U&E

Review with results at


2 weeks

Discharge

146

Yes

Improved or
positive
serology

No

Refer to ENT for


urgent surgical
biopsy

Issue 4
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FEVER 1/3
This guideline applies until
underlying condition
diagnosed, at which point treat
child according to the guidance
for that condition
ASSESSMENT AND INITIAL
MANAGEMENT

l Fever, in child aged <5 yr, usually


indicates underlying infection

l Parental perceptions of fever are


usually accurate and must be taken
seriously

IDENTIFYING RISK OF
SERIOUS ILLNESS
3 stages of clinical assessment
1. Identify life-threatening features
(utilising Airway, Breathing, Circulation
and Disability assessment)
2. Assess risk of serious illness (see
table Traffic light system for
assessment)
3. Attempt to identify source of
infection/features of specific serious
conditions

Traffic light system for assessment


Low risk

l Skin, lips and tongue


Colour
normal
l Responds to normal
Activity
social cues
l Is content or smiles
l Stays awake/wakes
quickly
l Strong normal cry/
settled/smiles
Respiration l Normal

Intermediate risk

l Pallor reported by
carer
l Not responding normally
to social cues
l Wakes only with
prolonged stimulation
l Decreased activity
l No smile
l
l
l
l

Hydration

l Normal

Other

l No amber/red features

l
l
l
l
l
l
l
l
l
l

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Expires: November 2012

High risk

l Pale, mottled, ashen or


blue
l No response to social
cues
l Looks ill
l Unrousable/doesnt stay
awake after rousing
l Weak, high pitched or
continuous cry
l Grunting/nasal flare
Nasal flare
l Tachypnoea
Tachypnoea
respiratory rate 50/min l respiratory rate >60/min
(any age)
(aged <1 yr)
respiratory rate 40/min l Chest wall recession
(moderate/severe)
(aged >1 yr)
Oxygen saturation 95%
Crackles on auscultation
Dry mucous membranes l Reduced skin turgor
Poor feeding (infants)
CRT 3 sec
Reduced urine output
Fever 5 days
l Temperature 38C
(aged <3 months)
New lump >2 cm
diameter
l Temperature 39C
(aged 36 months)
Swelling of joint/limb
Not using a limb/weight l Non-blanching rash
bearing
l Bulging fontanelle
l Neck stiffness
l Status epilepticus
l Focal neurological signs
l Focal seizures
l Bilious vomiting

147

FEVER 2/3
Child aged
<3 months

l Observe and
monitor:
l temperature
l heart rate
l respiratory rate

l
l
l
l
l

Perform:
full blood count
C-reactive protein
blood culture
urine test for urinary
tract infection
l if respiratory signs
present, chest X-ray
l if diarrhoea present,
stool culture

l Admit, perform
lumbar puncture and
start parenteral
antibiotics if child:
l aged <1 month
l aged 13 months,
appearing unwell
l aged 13 months,
with white blood cell
count of <5 or >15 x
109/L

Assess: look for life-threatening, traffic light


and specific diseases symptoms and signs
see table Traffic light system for
assessment

If all green features


and no amber or red

l Perform urine test


for urinary tract
infection
l Assess for
symptoms and
signs of
pneumonia
l Do not perform
routine blood
tests or chest
X-ray

l If no diagnosis
reached, manage
child at home with
appropriate care
advice
l Advise
parents/carers
when to seek
further attention
from healthcare
services

If any amber
features and no
diagnosis reached

l Perform:
l urine test for
urinary tract
infection
l full blood count
l blood culture
l C-reactive protein
l if fever >39C
and white blood
cell count >20 x
109/L chest
X-ray
l if child aged
<1 yr, consider
lumbar puncture

Child aged
3 months

If any red features


and no diagnosis
reached

l
l
l
l

Perform:
blood culture
full blood count
urine test for
urinary tract
infection
l C-reactive protein
l Consider (guided
by clinical
assessment):
l lumbar puncture
in children of all
ages
l chest X-ray
irrespective of
white blood cell
count and body
temperature
l serum
electrolytes
l blood gas

Wherever possible,
perform lumbar
puncture before
administration of
antibiotics
l Consider admission according to clinical and social circumstances and treat see
Subsequent management
l If child does not need admitting but no diagnosis has been reached, provide parent/carer with
verbal and/or written information on warning symptoms and how to access further healthcare
l Liaise with healthcare professionals (including out-of-hours) to ensure parent/carer has direct
access for further assessment of child
l Arrange follow-up appointment

148

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Expires: November 2012

FEVER 3/3
Observations
l Measure and record in all febrile
children:

l temperature
aged <4 weeks electronic
thermometer in the axilla
aged >4 weeks infrared tympanic or
electronic thermometer in the axilla
l heart rate

l capillary refill time

IMMEDIATE TREATMENT
Antipyretic treatment
l Tepid sponging not recommended

l Do not over or under-dress a child with


fever
l If child appears distressed or unwell,
consider either paracetamol or
ibuprofen

l Do not routinely administer both drugs


at the same time with the sole aim of
reducing fever or preventing febrile
convulsions

Signs of shock
l Give immediate IV fluid bolus of
sodium chloride 0.9% 20 mL/kg. Give
additional boluses as necessary

SUBSEQUENT MANAGEMENT

l Give parenteral antibiotics (e.g.


cephalosporin) to child with fever and:
l signs of shock

l who is unrousable

l has signs of meningococcal disease


l aged <1 month

l aged 13 months with a white blood


cell count <5 or >15 x 109/L
l aged 13 months appearing unwell

l If serious bacterial infection suspected


and immediate treatment required, give
cefotaxime 50 mg/kg (max 3 g) 6 hrly

l If child aged <3 months, add


amoxicillin 50 mg/kg (max 2 g) 6 hrly IV
l Consider parenteral antibiotics in
children with decreased level of
consciousness. Look for symptoms
and signs of meningitis and herpes
simplex encephalitis

l if herpes simplex encephalitis


suspected, give aciclovir aged
<3 months 20 mg/kg IV 8 hrly; aged
>3 months12 yr 500 mg/m2

l If rates of antibacterial resistance are


significant refer to local guidelines
l See Septicaemia and Meningitis
guidelines

l If signs of shock, SpO2 <92% or


clinically indicated, give O2
l See Septicaemia guideline

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149

HEPATITIS 1/1
Follow-up for children diagnosed with
Hepatitis B or C

HEPATITIS C

HEPATITIS B

Diagnostic tests

Diagnostic tests

(For neonates see Neonatal guidelines)

l HBsAg (Hepatitis B surface antigen)


and HBcAb (IgM and IgG)

l HBsAb (antibody) indicates previous


immunisation or infection
l If HBsAg positive, refer to Regional
Liver Unit and request following
investigations:

Yearly follow-up
l Clinical assessment

l Serology (clotted specimen)


l HBsAg

l Hepatitis C Virus (HCV) antibody (ab)


l HCV PCR

l if HCV ab negative and HCV PCR


negative, not infected. Discharge

l if HCV ab positive and HCV PCR


negative in two samples taken 6
months apart, not infected (resolved
infection or maternal antibody if aged
<18 months). Discharge

l if HCV PCR positive, refer to Regional


Liver Unit

Yearly follow-up

l if previously HBeAg positive, HBeAg

l Clinical assessment

l Hepatitis B DNA PCR (EDTA)


including viral load

l LFT

l HBeAb

l LFT (bilirubin, ALT, AST, GGT, albumin)


l FBC

l Alpha-fetoprotein
If LFT abnormal, inform Regional Liver
Unit

150

l HCV PCR
l FBC

l Alpha-fetoprotein

5 yearly follow-up
l Abdominal ultrasound looking for
nodules or signs of portal
hypertension

Issue 4
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Expires: November 2012

HIV AND HEPATITIS B POST-EXPOSURE


PROPHYLAXIS (PEP) 1/2
INDICATIONS FOR PEP
Any of the following in preceding 72 hr
l Unprotected ano-genital sex with
known HIV +ve partner
l Unprotected ano-genital sex with
partner from sub-Saharan Africa
l Unprotected ano-genital sex with man
who has sex with men
l Unprotected ano-genital sex with
partner who is current or ex-IVDU
l Victim of unprotected sexual assault
l Unprotected receptive oral sex with
ejaculation with known HIV +ve man
l Significant exposure to blood or body
fluids from source known to be HIV +ve

Following are NOT indications


for PEP for children from
community where contact is not
known to be HIV +ve
l Mucous membrane or conjunctival
contact with blood or body fluids
l Superficial (intradermal) injury
associated with needle or instrument
contaminated by blood or body fluid
l Skin-penetrating needle contaminated
with blood or body fluid
l Wound causing bleeding, produced by
sharp instrument visibly contaminated
with blood

PEP
l <35 kg: Zidovudine AND lamivudine or
35 kg: Truvada 1 tab daily AND
l Kaletra [>35 kg 2 x (200/50 tab) 12 hrly]
l If index case has drug-resistant virus,
seek expert help

HIV PEP drugs


Drug

Dose

Formulation

Side effects

Intake
recommendation
Can be given with
Zidovudine (ZDV 180 mg/m2/dose
Caps. 100,
Neutropenia +/or AZT)
(max 250 mg)
250 mg Susp.
anaemia, nausea, food; capsules
can be opened
12 hrly
10 mg/mL
headache,
and dissolved in
hepatitis
water
myopathy, nail
pigmentation
Lamivudine (3TC) 4 mg/kg/dose
Tab. 100, 150 mg; Peripheral
Can be given with
12 hrly; max dose Susp. 10 mg/mL; neuropathy,
food
150 mg
nausea,
5 mg/mL (room
12 hrly
diarrhoea,
temp)
headache
Can be given with
Tab. 300 mg
Headache,
Truvada
1 tab daily
or without food
Tenofovir (TDF)
diarrhoea,
(TDF and FTC)
200 mg
nausea, renal
Emticitabine
tubular
(FTC)
dysfunction
2
Tab
200
mg
LPV/
Diarrhoea,
Give with or after

+
300
mg
LPV/m
Kaletra
headache,
food
50 mg RTV
75 mg RTV/m2
[lopinavir
12 hrly
Paed tab 100 mg nausea, vomiting
(LPV)/ritonavir
Caution in liver
LPV/25 mg RTV
Max dose 5 mL,
(RTV)]
disease
2 x 200/50 tab
12 hrly
Liq 5 mL =
400 mg LPV/
100 mg RTV
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151

HIV AND HEPATITIS B POST-EXPOSURE


PROPHYLAXIS (PEP) 2/2
HEPATITIS PEP
If HIV PEP indicated give:
l Hepatitis B vaccine accelerated course
(0, 1, 2 and 12 months)
l Hepatitis B immunoglobulin only if
source known to be HBsAg +ve

FOLLOW-UP
l Before discharge, provide families
embarking on HIV PEP with:

l appointment to see a paediatrician


with experience in antiretroviral drugs
or member of ID/GUM team the same
day or next working day

l contact telephone number in case of


concerns about any aspect of HIV PEP
l enough antiretroviral medication to last
until clinic appointment
l letter for GP

l Arrange HBV, HCV and HIV antibody


test within 72 hrs and 3 months after
exposure
l If source is HCV RNA PCR positive,
arrange the following enhanced HCV
follow-up:

l at 6 weeks: 8 mL EDTA blood for HCV


PCR
l at 12 weeks: 8 mL EDTA blood for
HCV PCR and 4 mL clotted blood for
anti-HCV antibodies
l at 24 weeks: 4 mL clotted blood for
anti-HCV antibodies

152

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Issued: November 2010
Expires: November 2012

HIV INFECTION TESTING 1/2


INTRODUCTION

l HIV is a treatable medical condition,


the majority of those living with the
virus are well

l Many are unaware of their HIV


infection. Their own health remains at
risk and they may pass the virus
unwittingly to others
l Late diagnosis is a major problem

l HIV testing can be done in any


medical setting and all doctors can
obtain informed consent for an HIV
test in the same way they do for any
other medical investigation

HOW
Who can test?

l Doctor, nurse, midwife or trained


healthcare worker

Who should be offered a test?

l First-line investigation for suspected


immune deficiency: unusual type,
severity or frequency of infection. See
Table 1

Primary HIV infection

l Symptoms typically occur 24 weeks


after infection:
l fever

l rash (maculopapular)
l myalgia

l pharyngitis

l headache/aseptic meningitis

l Resolve spontaneously within


23 weeks

Source patient in a needlestick


injury or other HIV risk exposure
l Consent must be obtained from
source patient before testing

l The person obtaining consent must be


a healthcare worker, other than person
who sustained the injury
Issue 4
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Expires: November 2012

Pre-test discussion with


parents and children able to
give consent

l Purpose of pre-test discussion is to


establish informed consent and should
cover:
l benefits of testing

l details of how result will be disclosed


l Lengthy pre-test HIV counselling is
not a requirement

l Document patients consent to testing


l If patient refuses test, explore why
and ensure decision has not resulted
from incorrect beliefs about the virus
or consequences of testing

l Advise that, if negative, testing will not


affect patients insurance
l Some patients, (e.g. those whose first
language is not English) may need
additional help to reach a decision
l Document the offer of an HIV test in
medical notes, together with any
relevant discussion and reasons for
refusal

l Written consent not necessary but


record on laboratory request form
that consent has been obtained

l Arrange appointment for result to be


disclosed personally by testing clinician

POST-TEST
HIV negative result: post-test
discussion

l If still within window period after a


specific exposure, discuss need to
repeat test

l for definitive exclusion of HIV infection


a further test after three months is
recommended
l If reported as reactive or equivocal,
refer to infectious
diseases/genitourinary medicine (may
be seroconversion)

153

HIV INFECTION TESTING 2/2


HIV positive result: post-test
discussion
l For all new HIV positive diagnoses,
carry out appropriate confirmatory
assays and test a second sample

l Testing clinician must give result


personally to patient in a confidential
environment and in a clear and direct
manner
l arrange follow-up programme with
infectious diseases/genitourinary
specialist before informing patient of
positive result

Table 1: Clinical indicator diseases for HIV infection

Neurology

AIDS-defining conditions
Pneumocystis pneumonia
Tuberculosis
Cerebral toxoplasmosis
Primary cerebral lymphoma
Cryptococcal meningitis
Progressive multifocal
leucoencephalopathy

Dermatology

Kaposis sarcoma

Respiratory

Gastroenterology Persistent cryptosporidiosis

Oncology

Non-Hodgkins lymphoma

Gynaecology

Cervical cancer

Haematology
Ophthalmology
ENT

Cytomegalovirus retinitis

Other

154

Others where testing should be offered


Bacterial pneumonia
Aspergillosis
Aseptic meningitis
Space occupying lesion of unknown cause
Guillain Barr syndrome
Transverse myelitis
Peripheral neuropathy
Dementia
Leucoencephalopathy
Severe/recalcitrant
seborrhoeic dermatitis/psoriasis
Multidermatomal or recurrent herpes zoster
Oral candidiasis
Oral hairy leukoplakia
Chronic diarrhoea/weight loss of unknown cause
Salmonella, shigella or campylobacter
Hepatitis B/C infection
Anal cancer/intraepithelial dysplasia
Lung/head and neck cancer
Seminoma
Hodgkins lymphoma
Castlemans disease
Vaginal intraepithelial neoplasia
Cervical intraepithelial neoplasia Grade 2 or
above
Any unexplained blood dyscrasia
Infective retinal diseases
Lymphadenopathy of unknown cause
Chronic parotitis
Lymphoepithelial parotid cysts
Mononucleosis-like syndrome
Pyrexia of unknown origin
Anyone with a mother who is HIV +ve no
matter what age
Anyone who has a partner who is HIV +ve
Men who have sex with other men
Female sexual contacts of men who have sex
with men
Patients reporting use of injecting drugs
Anyone from a country of HIV prevalence >1%
Anyone who has had sex in a country of HIV
prevalence >1%
Anyone who has had sex with someone from a
country of HIV prevalence >1%
All pregnant women
Issue 4
Issued: November 2010
Expires: November 2012

IMMUNODEFICIENCY 1/2
RECOGNITION AND
ASSESSMENT

l SPUR to recognition: Serious,


Persistent, Unusual, or Recurrent
infections
l The younger the onset, the more
life-threatening the immune defect
likely to be
l bacterial infection; early presentation:
antibody defect
l viral/fungal infection; later
presentation: cellular defect

Symptoms and signs


Warning signs of primary
immunodeficiency:

l 8 new bacterial ear infections 1 yr


l 2 serious sinus infections 1 yr
l 2 months on antibiotics without
resolution of symptoms
l 2 episodes of pneumonia 1 yr
l Severe failure of an infant to gain
weight or grow normally: recurrent
gastroenteritis
l Recurrent, deep skin or organ abscess
l Persistent candida in mouth or napkin
area
l Failure of IV antibiotics to clear
infections
l 2 infections, such as meningitis,
osteomyelitis, cellulitis or sepsis
l Family history of primary
immunodeficiency

Previous history
l Recurrent fever
l Diarrhoea
l Delayed umbilical cord separation of
3 wks, omphalitis
l Severe adverse reaction to
immunisation e.g. BCGitis
l Unusually severe course of measles or
chickenpox
l Family history of any syndrome
associated with immunodeficiency,
(e.g. DiGeorge anomaly or WiskottIssue 4
Issued: November 2010
Expires: November 2012

Aldrich syndrome); or of death during


early childhood
l High risk group for HIV and antenatal
HIV testing (a negative antenatal HIV
test does not exclude HIV in the child)
l Autoimmune liver disease, diabetes,
vasculitis, ITP
l Abscess: deep or recurrent
l Poor wound healing

Physical examination
l Congenital abnormalities: dysmorphic
features, congenital heart disease,
situs inversus, white forelock
l Children who appear chronically ill,
underweight or short in stature
l Scarring or perforation of tympanic
membranes from frequent infection
l Periodontitis
l Enlargement of liver and spleen
l Hypoplastic tonsils and small lymph
nodes
l Lymphadenopathy
l Telangiectasia, severe eczema,
erythroderma, granuloma, acneiform
rash, molluscum, zoster
l Bronchiectasis, pneumatoceles
l Delayed 2ry dentition/skeletal fractures

Other investigations
l Haemolytic anaemia
l Neutropenia
l Eosinophilia
l Hypocalcaemia

Unusual organisms
l Viruses: CMV, EBV, VZV, warts
l Fungi: candida, aspergillus,
cryptococcus, pneumocystis, nocardia
l Protozoa: cryptosporidium, toxoplasma
l Bacteria: salmonella, giardia,
mycobacterium (inc BCG), serratia
l Recurrent infection with common
organisms: H. influenzae,
S. pneumoniae, N. meningitidis,
S. aureus

155

IMMUNODEFICIENCY 2/2
Table 1: Investigations
Investigations

Sample

Initial tests
FBC (note absolute lymphocyte
EDTA
count) and ESR
IgG, IgM, IgA
Clotted
IgG function (antibody response to Clotted
tetanus, Hib +/- pneumococcus)
Retest 4 wks after vaccination
Clotted
HIV antibody
Second-line tests (with immunology advice)
EDTA
Lymphocyte subsets

Lymphocyte proliferation
Enzyme assay (ADA, PNP)

Lithium heparin
EDTA

Neutrophil function test for CGD

EDTA

Adhesion molecule assay

EDTA

CH50 & Complement components


(if recurrent or case with family
history of meningococcal disease)

Clotted

SUBSEQUENT MANAGEMENT
l Avoid live vaccines (e.g. BCG, MMR
and varicella)
l Ensure that any blood products given
to patients with suspected or proven
T-cell immunodeficiency are irradiated
and CMV negative
l For specific infections, use same
antibiotics as in immunocompetent
patients, at higher recommended
dosage
l Obtain throat, blood and other culture
specimens before starting treatment
l Treat infectious episodes for longer
than usually recommended
(approximately double)

156

Volume
Minimum

Ideal

1.3 mL

4 mL

0.5 mL
0.5 mL

4 mL
4 mL

0.5 mL

4 mL

1 mL
Haematology

4 mL

Discuss with local immunology centre


3.5 mL
1 mL
Discuss with Guys Hospital
0.25 mL
4 mL
Discuss with local immunology centre
0.25 mL
4 mL
Discuss with local immunology centre
1 mL to reach
4 mL to reach
lab within 2 hr
lab within 2 hr
or separate
and freeze
immediately

l In patients with B-cell, T-cell or


phagocytic defects, request regular
pulmonary function tests and home
treatment plan of physiotherapy and
inhalation therapy similar to that used
in cystic fibrosis
l In children with significant primary or
secondary cellular (T-cell)
immunodeficiency (e.g. aged <1 yr
CD4 <25%, aged 15 yr CD4 <15% or
aged >5 yr <200 CD4 cells/mm3), give
Pneumocystis jiroveci (PCP)
prophylaxis with co-trimoxazole

Issue 4
Issued: November 2010
Expires: November 2012

KAWASAKI DISEASE 1/2


Early treatment reduces
mortality from coronary artery
aneurysms
RECOGNITION AND
ASSESSMENT
Symptoms and signs

l Fever for at least 5 days and 4 of the


following:
l bilateral non-exudative conjunctival
infection

l oral changes (red lips/pharynx/ tongue)


l peripheral oedema followed by
desquamation 1015 days after onset
of fever
l polymorphous rash

l acutely enlarged cervical lymph nodes


with individual node(s) >1.5 cm
diameter
l absence of another diagnosis [e.g.
group A streptococcal infection (GAS),
measles]
l The presence of a coronary artery
aneurysm with any one of the above
features is diagnostic

Other features
l Most common in children aged <5 yr
l Atypical cases may not fulfil all the
above criteria

l Fever usually precedes the other signs


and is characteristically unresponsive
to antipyretics
l Other symptoms include irritability,
aseptic meningitis, uveitis, cough,
vomiting, diarrhoea, abdominal pain,
urethritis, arthralgia and arthritis

Investigations
None is diagnostic

l Throat swab for Gp A strep

l Anti-streptolysin O titre (ASOT) or antiDNase B for evidence of streptococcal


infection
Issue 4
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Expires: November 2012

l If rash present, measles IgM antibody


test
l FBC: platelets often high for 1015
days after onset of fever
l ESR

l CRP

l ECG

l If full diagnostic criteria found,


echocardiogram not required until
6 weeks from onset of signs and
symptoms

l If criteria incomplete or presentation


atypical, aneurysms on echo are
diagnostic: discuss with a cardiologist

IMMEDIATE TREATMENT
l Aspirin 7.512.5 mg/kg orally 6 hrly
until afebrile or a minimum of 2 weeks

l Intravenous immunoglobulin (IVIG)


2 g/kg administered as described below
Rate
0.6 mL/kg/hr
1.2 mL/kg/hr
2.4 mL/kg/hr*
4.8 mL/kg/hr*

=...mL/hr
=...mL/hr
=...mL/hr
=...mL/hr

Duration
30 min
30 min
30 min
To completion

* up to a maximum rate of 180 mL/hr

Start IVIG as soon as possible


(delayed treatment increases
risk of aneurysm)
MONITORING IVIG INFUSION
l Monitor temperature, heart rate, BP
and respiratory rate:
l every 5 min for first 15 min

l then every 15 min for first hour

l Anticipate anaphylaxis, flushing, fever,


headache, shivering
l If tolerated, increase infusion rate to
give total dose over remaining 10 hr
and monitor hourly
l If mild reaction, stop infusion for
15 min then restart at slower rate

157

KAWASAKI DISEASE 2/2


SUBSEQUENT MANAGEMENT
l After 2 weeks, reduce dose of aspirin
to 5 mg/kg orally as single daily dose
for 6 weeks (until result of
echocardiogram known)
l If fever persists, consider a single
repeat dose of IVIG

DISCHARGE AND FOLLOW-UP


l Discharge when fever settles

l Echocardiogram at 6 weeks from


onset of signs and symptoms

l Out-patient appointment 1 week after


echocardiogram
l Advise to avoid excessive strenuous
activity until out-patient appointment
after echocardiogram

l Advise to avoid all live vaccines (e.g.


MMR) for three months following IVIG
therapy

158

OUT-PATIENT MANAGEMENT
l No aneurysms at 6 weeks
echocardiogram
l stop aspirin

l no restriction on activity

l Single aneurysm <7 mm diameter

l aspirin 15 mg/kg (max 75 mg) once


daily until aneurysm disappears

l cardiologist will advise on limitation of


activity
l annual echocardiogram

l Multiple or giant aneurysm


l avoid strenuous activity

l discuss need for anticoagulation,


stress test and repeat echocardiogram
with cardiologist

Issue 4
Issued: November 2010
Expires: November 2012

MALARIA 1/2
A medical emergency: immediate treatment essential

Diagnosis
l Fever

l travelled to a malarial area within last 12 months

l febrile neonate or infant whose mother has travelled to a malarial area in pregnancy

Clinical features
Non-specific
l Fever
l Malaise
l Headache
l Sweating
l Diarrhoea
l Vomiting
l Abdominal pain
l Splenomegaly
l Anaemia
l Thrombocytopenia
l Jaundice

Severe (complicated) malaria


l Persistent vomiting
l Depressed conscious state
l Seizures
l Tachypnoea or increased work of breathing
l Hypoxia (SpO2<95%)
l Shock
l Severe dehydration
l Metabolic acidosis (base deficit >8)
l Severe hyperkalaemia (K >5.5 mmol/L)
l Hypoglycaemia <3 mmol/L
l Severe anaemia
l Parasitaemia >5%

Investigations
l EDTA blood sample sent to
haematology for an urgent thick blood
film
l 3 blood films 12 hr apart

If malaria is diagnosed on
blood film, but type unclear,
treat as falciparum malaria
Admit all patients with definite
or possible falciparum malaria
to hospital as they can
deteriorate rapidly into a coma
SEVERE (COMPLICATED)
MALARIA
Anti-malaria treatment

l Quinine dihydrochloride IV
l loading dose 20 mg/kg max 1.4 g as
infusion diluted to 2 mg/mL (sodium
chloride 0.45% + glucose 5%) over
4 hr (NEVER as IV bolus)
l then 8 hr after start of loading dose,
10 mg/kg infusion (max 700 mg) over
4 hr every 8 hr
Issue 4
Issued: November 2010
Expires: November 2012

l until patient can swallow then oral


medication can be commenced (as in
uncomplicated malaria)
l omit loading dose if mefloquine or
quinine used in previous 24 hr
l continue quinine for 7 days
l when able to swallow give clindamycin
713 mg/kg (max 450 mg) 8 hrly for
7 days

CEREBRAL MALARIA
Impaired level of consciousness
l Correct hypoglycaemia
l Monitor GCS, reflexes, pupils
l Plan for intubation and transfer to
PICU if:
l signs of raised ICP
l persisting shock after 40 mL/kg fluid
l or pulmonary oedema

159

MALARIA 2/2
TREATMENT OF UNCOMPLICATED FALCIPARUM MALARIA
(no clinical features of severe malaria)
l If the child can tolerate oral intake:
l Malarone (proguanil with atovaquone) once a day for 3 days
Weight (kg) 58

910

1120

2130

3140

>40

Dose

3 paed
tablets

1 adult
tablet

2 adult
tablets

3 adult
tablets

4 adult
tablets

2 paed
tablets

Paediatric tablet contains proguanil 25 mg and adult tablet 100 mg

If in doubt treat as severe (complicated) malaria


NON-FALCIPARUM MALARIA

G6PD-deficient patients

l Complications are rare


l Usually sensitive to chloroquine
(chloroquine-resistant P. vivax reported
in Indonesia, New Guinea and some
adjacent islands)

l In mild G6PD-deficiency, primaquine


750 microgram/kg (max 45 mg) once a
week for 8 weeks
l Otherwise contact ID specialist

Treatment of non-falciparum
malaria
l If chloroquine resistance suspected
then refer to non-complicated
falciparum management
l Chloroquine oral 10 mg (base)/kg
initial dose (max 620 mg) then,
5 mg/kg (max 310 mg) after 68 hr
then once daily for 2 days
l Then give primaquine oral
250 microgram/kg (max 15 mg) daily
for P. ovale and 500 microgram/kg
(max 30 mg) daily for P. vivax for
14 days

Before giving primaquine,


check and review G6PD
concentration, as severe
haemolysis can occur if
G6PD-deficient

160

Issue 4
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Expires: November 2012

MENINGITIS 1/4
RECOGNITION AND
ASSESSMENT
If aged <28-days-old see Neonatal
meningitis in Neonatal Guidelines

Symptoms, especially in
infants, are often vague and
non-specific. Be alert
Symptoms and signs
l Pyrexia
l Petechial rash
l Evidence of raised intracranial
pressure in the older child
l disc oedema (often late sign), any
localising neurological features,
reduced conscious level
l Neck stiffness
l Kernig's sign positive
l Irritability
l Focal neurological signs including
squints
l Infants:
l poor feeding
l vomiting
l irritability
l fever
l fits
l full fontanelle (unless dehydrated)
l Older child may also have:
l severe headache
l photophobia
l confusion
l lower backache

Differential diagnosis
l If rash or severely ill, consider
Meningococcal septicaemia
l Look for signs of viral meningitis e.g.
resolving mumps
l It is not possible to differentiate viral
from bacterial meningitis clinically
l Other intracranial sepsis
l Encephalitis
l Systemic sepsis
Issue 4
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Expires: November 2012

l Malaria in travellers
l Other causes of confusion or raised
intracranial pressure

INVESTIGATIONS
Lumbar puncture
If any doubt about need for
lumbar puncture (LP) discuss
with consultant
l Perform LP before giving antibiotics if
child stable, do not delay antibiotics by
>1 hr
l Discuss with consultant if any of
following:
l signs suggesting raised intracranial
pressure
- GCS <9 or drop >2
- relative bradycardia and hypertension
- focal neurological signs
- abnormal posture or posturing
- unequal, dilated or poorly responsive
pupils
- papilloedema
- abnormal dolls eye movements
l shock
l extensive or spreading purpura
l convulsing
l coagulopathy, on anticoagulants or
platelets <100 x 109/L (if already
obtained do not wait for results
otherwise)
l local infection over lumbar spine
l respiratory insufficiency
l coagulopathy or thrombocytopenia
suspected (e.g. purpuric rash)
l If no clinical response after 48 hr of
therapy, consider repeat LP

Specimens
l 1 fluoride tube (and 4 CSF bottles)
l If tap traumatic, may need more
samples
l If insufficient CSF discuss priorities
with microbiology

161

MENINGITIS 2/4
Table 1: Collection of specimens (stated volumes represent minimum required)
Department
Biochemistry

Microbiology

Virology

Specimens (6 drops = approx 0.2 mL)


l 0.2 mL in a fluoride tube for glucose (also send blood glucose)
l 0.2 mL in a CSF bottle for protein
l 0.2 mL for lactate if metabolic disorder suspected
l 0.2 mL in a CSF bottle for MC&S
l 0.2 mL for meningococcal and pneumococcal PCR
l 0.2 mL for TB culture if high clinical suspicion of TB meningitis,
l If possible viral meningitis or encephalitis:
l 0.2 mL in a CSF bottle for viral culture
l 0.2 mL for herpes simplex virus PCR
l 0.2 mL for enterovirus PCR
l 0.2 mL for VZV if history of contact with case of chickenpox or rash
l 0.3 mL for Human Herpes Virus 6 if rash, high temperature or rapid
recovery

Interpretation of cerebrospinal
fluid results
l White cell count showing
polymorphonuclear leucocytosis usually
indicative of bacterial meningitis but can
also be seen in viral meningitis
l lymphocytosis can occur in partiallytreated pyogenic, TB and viral
meningitis and inflammatory conditions

Other
l FBC and differential WBC

l Blood cultures before start of antibiotics


l U&E, glucose and CRP

l If meningococcal disease suspected,


refer to Septicaemia guideline; send
EDTA blood for meningococcal DNA
PCR

l Protein usually elevated in bacterial


meningitis (upper limit of normal is
20 mg/L in infants and children, and up
to 60 mg/L in neonates)

l Viral titres plus mycoplasma IgM if


indicated or store to assay if other
results negative

l CSF glucose normally about 1 mmol/L


below serum level

IMMEDIATE TREATMENT

l very high levels of CSF protein are


sometimes seen in TB meningitis

l Stool or rectal swab and throat swab for


viral culture, if viral meningitis suspected

Corticosteroids

l CSF glucose likely to be depressed in


bacterial meningitis including TB
(lymphocytosis) or

l Give in children aged >3 months with:

l CSF glucose usually normal in viral


meningitis

l raised CSF WBC count and protein


greater than 1 g/L

l herpes or mumps encephalitis

CT scan
l Not routine, does not exclude raised
intracranial pressure
l indicated in presence of focal
neurological signs to rule out space
occupying lesion

162

l frankly purulent CSF

l CSF WBC count >1000/microlitre


l bacteria on Gram stain

l Dexamethasone sodium phosphate


150 microgram/kg (max 10 mg) IV
6 hrly for 4 days

l first dose before antibiotics or as soon


as possible up to 12 hr afterwards

Issue 4
Issued: November 2010
Expires: November 2012

MENINGITIS 3/4
Antibiotics
Start immediately without
waiting for identification of
organisms or sensitivities
l Cefotaxime or ceftriaxone until certain
it is not bacterial meningitis

l infants aged <3 months, add amoxicillin


to cover listeriosis. If suggestive of
herpes encephalitis (period of
decreased level of consciousness with
fever or focal signs) add aciclovir
500 mg/m2 8 hrly IV over 1 hr
l If suggestive of TB (contact with TB,
other features of TB, long history),
discuss with infectious diseases team

l If recent travel outside UK, or


prolonged or multiple antibiotics in last
3 months add vancomycin

l If definite history of anaphylaxis to


cephalosporin give chloramphenicol IV
or vancomycin and rifampicin if
chloramphenicol not immediately
available

l If unusual cause suspected, contact


infectious diseases team/microbiologist

Intensive care
l Inform PICU if:

l depressed conscious level

l shock does not respond to initial


resuscitation

MONITORING TREATMENT
l In a semi-conscious patient, monitor
following hourly until improvement
evident:
l respiratory rate
l pulse and BP

l level of consciousness and pupils


l in young infants, measure head
circumference daily

l If persistent pyrexia look for other foci


l repeat blood cultures and other
investigations according to signs

l CT scan at 10 days for microabscess


or hypodensity
l if CT normal, repeat LP

SUBSEQUENT MANAGEMENT
Length of antibiotic course

Anticonvulsants
l Drugs of choice if child has seizures
(prophylaxis not recommended):
l phenytoin

l lorazepam for acute control

Other supportive measures


l If child shocked, give human albumin
4.5% or if not immediately available
sodium chloride 0.9%:
l initial dose 20 mL/kg over 510 min
and reassess

Do not give excessive fluid


boluses: risk of cerebral oedema

Issue 4
Issued: November 2010
Expires: November 2012

l Meningococcus: 7 days

l Haemophilus influenzae: 10 days


l Pneumococcus or Group B
Streptococcus: 14 days
l Gram-negatives 21 days

l Listeria: 21 days (with gentamicin for


first 7 days)

l No organism identified: >3 months old


10 days; <3 months old 14 days
l Other, discuss with microbiologist

l If all cultures negative and patient well,


meningitis unlikely, stop antibiotics
after 48 hr

163

MENINGITIS 4/4
Steroids
Continue dexamethasone if:
l CSF WCC >1000/microlitre
l CSF protein >1 g/L

l Bacteria on Gram stain or culture

Eradication treatment
l Meningococcal meningitis

l if ceftriaxone given as treatment,


eradication treatment not required for
patient

DISCHARGE AND FOLLOW-UP


l Organise formal hearing test 6 weeks
after discharge from hospital

l If severely ill during admission, discuss


with consultant about follow-up to
monitor developmental progress
l If viral cause unconfirmed but still
possible, repeat viral titres 6 weeks
after day of admission

l Family: rifampicin orally (12 hrly for


2 days) (warn re staining contact
lenses and oral contraceptive pill)

l ciprofloxacin or ceftriaxone in adults on


liver inducing drugs (warfarin)
l ceftriaxone for pregnant women
l Haemophilus influenzae

l if children aged <4 yr in the family,


give rifampicin orally daily for 4 days

Fluid restriction
l Restrict fluid to 80% maintenance if:
l severe illness

l hyponatramia

l Measure urine and plasma


osmolalities daily whilst severely ill

Public health
l Inform Public Health consultant of a
case of suspected meningitis

l Public Health Department will arrange


prophylaxis for close contacts

164

Issue 4
Issued: November 2010
Expires: November 2012

NOTIFIABLE INFECTIOUS DISEASES AND FOOD


POISONING 1/2
URGENT NOTIFICATION
l Urgent out-of-hours notifications (to be
followed by normal paper notification
later)
l meningitis (suspected bacterial)
l meningococcal infection (clinical
diagnosis)
l haemolytic uraemic disease
(suspected)
l infectious bloody diarrhoea

NOTIFIABLE DISEASES
Admitting doctor is required to notify
suspected or confirmed cases of the
following to Health Protection Unit within
24 hr of presentation:
l Cluster or outbreak suspected (two or
more cases epidemiologically linked)
l Any other case where the potential for
transmission is significant (e.g. highly
infectious)
l Where contacts are particularly
susceptible (e.g. healthcare worker,
school)
l Where public health action is known to
be effective (e.g. prophylaxis,
immunisation)
l Other infections or contaminations (e.g.
chemical) not listed below if potential
risk of further harm
l Acute encephalitis
l Acute poliomyelitis
l Anthrax
l Cholera
l Diphtheria
l Dysentery (amoebic and bacillary)
l Food poisoning (or suspected food
poisoning: inform public health if
acquired abroad or if family member is
a food handler or healthcare worker)
l Leprosy
l Leptospirosis
l Malaria

Issue 4
Issued: November 2010
Expires: November 2012

l Measles
l fever, maculopapular rash for 3 days
and two or more of the following:
Kopliks spots, coryza, conjunctivitis,
raised measles IgM, measles
encephalitis or pneumonitis. Inform
public health of MMR or measles
vaccination history
l Meningitis (viral, bacterial or fungal)
l Meningococcal septicaemia (without
meningitis)
l Mumps
l Ophthalmia neonatorum
l Paratyphoid fever
l Plague
l Rabies
l Relapsing fever
l Rubella
l rash and occipital lymphadenopathy or
arthralgia (if not parvovirus), or
congenital rubella or raised IgM to
rubella. Inform public health of MMR
vaccine history
l Scarlet fever
l tonsillitis, fever, rash with either culture
of Streptococcus pyogenes from throat
or raised ASO or anti-DNaseB titre
l Smallpox
l Tetanus
l Tuberculosis
l TB diagnosed on X-ray, microscopy or
culture from any source (i.e. not just
sputum)
l (atypical mycobacterial infection or
patients given chemoprophylaxis but
not thought to have TB are not
notifiable)
l Typhoid fever
l Typhus
l Viral haemorrhagic fever
l Viral hepatitis
l either diagnosed clinically or by positive
serology. Inform public health if
acquired abroad or in UK, risk factors
and immunisation against Hepatitis A
and B
165

NOTIFIABLE INFECTIOUS DISEASES AND FOOD


POISONING 2/2
l Whooping cough
l cough with a whoop with history of
contact with similar illness or positive
pernasal swabs for Bordetella pertussis
or raised IgM to B. pertussis in an adult
or child. Inform public health of
pertussis immunisation history
l Yellow fever

Non-statutory notifiable
diseases
It has been agreed that, although they are
not statutorily notifiable, the following
diseases will nevertheless be reported to
the consultant in communicable disease
control:
l AIDS/HIV infection
l Legionnaires disease
l Listeriosis
l Psittacosis
l Cryptosporidiosis
l Giardiasis
l Creutzfeldt-Jakob disease and other
prion diseases
l SARS

CONTACT DETAILS
Contact details for your nearest HPU can
be found on the Health Protection Agency
website (www.hpa.org.uk)
West Midlands
Birmingham and Solihull HPU

0121 224 4670/4685

Black Country HPU

01384 454300

Coventry and Warwickshire HPU

01926 493491 ext 234

Herefordshire and Worcestershire HPU

01905 760024

Shropshire and Staffordshire HPU

01785 221120/01785 221126

166

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Expires: November 2012

ORBITAL CELLULITIS 1/1


RECOGNITION AND ASSESSMENT
Preseptal

Orbital

Facial erythema and tenderness

Painful eye movements

Normal eye movements

Orbital pain and tenderness

Normal vision

Visual impairment
(red-green colour differentiation lost early)

Preceding superficial trauma

Proptosis
Chemosis
Ophthalmoplegia
Preceding sinusitis

Definition
l Infection of soft tissues surrounding the
eye
l
l
l
l

Complications
Intracranial abscess
Meningitis
Cavernous sinus thrombosis
Periorbital abscess

Investigations

l Eye swab (send pus if present)


l FBC
l Blood culture
l CT scan if:
l orbital involvement suspected
l central neurological signs
l unable to assess eye movements/vision
or if eyelid cannot be opened
l bilateral oedema
l deterioration despite treatment

MANAGEMENT
Preseptal peri-orbital cellulitis

l Ophthalmology review within 24 hr


l Review eye movements and red-green
colour vision twice daily
l IV antibiotics for 48 hr:
l cefuroxime if aged 4 yr
l benzylpenicillin and flucloxacillin if aged
>4 yr and has received Hib vaccination
Issue 4
Issued: November 2010
Expires: November 2012

l if improving, convert to oral high dose


co-amoxiclav
l if penicillin allergy give clindamycin
l Total duration of treatment (including
IV) 14 days

Orbital cellulitis
l Urgent ophthalmology review within 4 hr
l ENT review
l IV cefotaxime or ceftriaxone
l If toxaemic add clindamycin
l If history of anaphylaxis to penicillin
give aztreonam and vancomycin
l Consider surgical drainage
l if improving, convert to oral high dose
co-amoxiclav
l if penicillin allergy give clindamycin
l Total duration of treatment (including
IV) 21 days

Intracerebral complications

l Urgent neurosurgical review

Sinusitis
l Follows viral URTI (80%) or allergy
l URTI symptoms >10 d and >1 of:
l nasal congestion and discharge
l persistent cough (often nocturnal)
l Treat with co-amoxiclav oral high dose
l Severe if also:
l ill, temperature >39C, purulent
discharge
l Urgent CT, ENT, neurosurgical review
167

OSTEOMYELITIS AND SEPTIC ARTHRITIS 1/5


RECOGNITION AND
ASSESSMENT
Symptoms and signs

l Fever
l Loss of function
l Pain in bone or joint
l Restricted range of movement
l Soft tissue swelling
l Point tenderness of bone
l Effusion

The above symptoms and signs


are indicative of osteomyelitis
or septic arthritis (in absence of
clear history of obvious
trauma) irrespective of WBC,
CRP, ESR and fever or
radiological appearance

Further investigations
Perform as soon as possible
(must be within 36 hr)
l If plain X-ray normal, infection clinically
localised and urgent MR is available:
l consultant paediatrician or orthopaedic
surgeon to authorise urgent MR of bone
l if deep sedation or general
anaesthetic required, contact
paediatric anaesthetist on-call
l If plain X-ray normal, and infection
clinically localised and MRI not available,
request ultrasound scan of bone
l If localising signs poor or possible
multifocal infection, request bone scan
l If cardiac murmur or multifocal Staph.
aureus, request echocardiogram

IMMEDIATE TREATMENT
Previous history

l Ask about:
l duration of symptoms
l injuries
l fever

Urgent Investigations

l FBC
l ESR
l CRP
l Blood culture (before antibiotics)
l If cause of fever uncertain, collect
other specimens (e.g. urine) for culture
before antibiotics

Osteomyelitis

l Plain X-ray AP and lateral of the


affected part
l Tissue or pus for Gram stain and
culture if surgically explored or drained

Septic arthritis

l Aspiration of joint for Gram stain and


culture
l interventional radiologist or
orthopaedic registrar
l for sedation and analgesia contact
paediatric registrar or on-call paediatric
anaesthetist
168

l Admit
l Nil-by-mouth and maintenance fluids IV
l Bed rest
l Refer immediately to orthopaedic and
paediatric registrar on-call
l confirm they will assess child within
4 hr of admission
l Early involvement of on-call consultant
orthopaedic surgeon

Antibiotics

l Severe sepsis with organ dysfunction


(e.g. hypotension, oxygen requirement,
GCS <12, platelet <80, creatinine x 2
normal, abnormal LFTs)
l after blood and urine cultures taken,
start cefotaxime 50 mg/kg 6 hrly (high
dose; max 12 g/day) IV over 34 min
l No organ dysfunction:
l aged >6 yr: start flucloxacillin
50 mg/kg IV (max 2 g/dose) as soon
as possible (must be within 4 hr)
l aged 3 months6 yr: cefuroxime
50 mg/kg 8 hrly (max 1.5 g/dose)
l if <3 months: cefotaxime
l Targeted antibiotic therapy
l If organism identified, use narrowest
spectrum possible with good bone/joint
penetration
Issue 4
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Expires: November 2012

OSTEOMYELITIS AND SEPTIC ARTHRITIS 2/5


l Staph aureus sensitive to flucloxacillin:
flucloxacillin 50 mg/kg 6 hrly IV (high
dose max 2 g/dose)
l Penicillin allergy, instead of flucloxacillin:
l history of rash: cefuroxime 50 mg/kg
6 hrly (high dose max 1.5 g/dose) IV
l history of anaphylaxis: clindamycin
6 mg/kg 6 hrly oral aged <12 yr;
450 mg 6 hrly oral aged >12 yr

Analgesia
l If necessary initially, to allow splintage
use morphine IV (see Analgesia
guideline)
l Elevate and splint affected limb
l plaster backslab for peripheral joints
l rest in skin traction on a pillow for
central joints

Surgery
Ask parent(s) to stay with child until
consent obtained
l Resuscitate severe sepsis
l Emergency theatres to be alerted as
soon as possible (must be within 36 hr
of admission)
l Contact:
l anaesthetic office to arrange paediatric
anaesthetist
l orthopaedic RSO to book patient onto
planned emergency list
l consultant paediatrician and
orthopaedic surgeon
l transfer to Trauma Theatre (nurse
escort)

SUBSEQUENT MANAGEMENT
Inform paediatric orthopaedic surgeon
and paediatrician

Uncomplicated septic arthritis


(not complicated by associated
osteomyelitis)
l Aspirate or drain joint in theatre
l If treatment started within 24 hr of first
symptoms and clinically improving,
discuss with consultant about
changing IV to oral antibiotics:
Issue 4
Issued: November 2010
Expires: November 2012

l recovery of joint movement


l absence of pyrexia after 4 hrly
monitoring for 48 hr
l WCC <11, CRP and ESR falling on two
successive specimens 24 hr apart
l If agreed by consultant, give oral
antibiotic to complete 3 weeks
treatment
l no organism identified: co-amoxiclav
(high dose)
l organism identified: narrowest
spectrum with good bone penetration
- if Staph. aureus sensitive to
flucloxacillin: oral flucloxacillin (high
dose)
l allergic to penicillin: clindamycin oral
l Stop at 3 weeks only if CRP is normal

Early-presenting osteomyelitis
l If IV antibiotics started within 24 hr of
onset of symptoms
l If abscess drained and full
debridement achieved with a good
clinical response as above, follow
Uncomplicated septic arthritis but
continue for 4 weeks minimum

Established osteomyelitis or
complicated septic arthritis

l Presentation >24 hr after onset of


symptoms or partial treatment (e.g.
oral antibiotics)
l Formal debridement in theatre with
insertion of Hickman line
l Antibiotics IV as above and add:
l rifampicin 10 mg/kg 12 hrly (max
600 mg), orally if tolerated or same
dose IV, or as soon as oral fluids
tolerated then sodium fusidate if
organism cultured is sensitive
l Discuss with consultant about switch to
oral antibiotics after 14 days, if afebrile,
pain free for 48 hr and CRP <20
l Continue antibiotics until ESR
<20 (minimum 6 weeks)
l Continue oral antibiotics until all
inflammatory markers are normal and
clear evidence of healing established
on radiographs
169

OSTEOMYELITIS AND SEPTIC ARTHRITIS 3/5


Septic arthritis or osteomyelitis
(deteriorating condition/failure
to improve within 48 hr)
l Inform orthopaedic team for
exploration to drain pus
l Review culture result
l Discuss with consultant microbiologist
and paediatrician
l Arrange for repeat blood cultures
l consider a change of antibiotic therapy
or targeted antibiotic therapy
l Complete or repeat any investigations
listed above
l Consultant paediatric medical and
orthopaedic review
l Exclude important differential diagnoses
l systemic inflammatory response as
seen in juvenile chronic arthritis
l transient synovitis, associated with
intercurrent infection
l acute leukaemia, septicaemia,
multifocal disease, endocarditis
l Continuing problems with local sepsis
l return to theatre for further
debridement and insertion of Hickman
line

170

MONITORING TREATMENT
l Peripheral colour, warmth, movement
of affected limb: hourly for first 4 hr
then 4 hrly for 24 hr
l Respiratory rate, pulse, temperature
4 hrly

Issue 4
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Expires: November 2012

OSTEOMYELITIS AND SEPTIC ARTHRITIS 4/5


Flowchart 1
SUSPECTED UNIFOCAL OM or SA

BLOOD INVESTIGATIONS
l FBC
l CRP (+/ ESR)
l Blood culture (4 mL minimum unless neonatal 2 mL)

IMAGING AVAILABLE?
OM
l MR (gold standard)
l Ultrasound (if no urgent MR and expertise available)
l Plain X-ray (baseline)
SA
l Ultrasound
l Consider need for 99Tc bone scan

SURGERY ONLY IF INDICATED


l Radiological finding (where result available)
l pus or effusion
l bony destruction
l Take standard culture and PCR where available

Neonatal to aged <3 months


MEDICAL REVIEW
IV cefotaxime PLUS if sepsis
meningitis considered: IV
amoxicillin

Aged 3 months to 5 yr
IV cefuroxime
50 mg/kg 8 hrly

Aged 6 yr
IV flucloxacillin 50 mg/kg 6 hrly
(max 2 g 6 hrly)
OR
IV clindamycin 10 mg/kg 6 hrly
(max 1.2 g 6 hrly)

Daily clinical review, monitor fever, CRP daily until improving, consider surgery indications

Consider IV to oral switch after 1421


days if:
Afebrile and pain free for at least 24 hr
AND
CRP <20 or CRP decreased by 2/3 of
highest value
OM and SA
6 weeks total antibiotic therapy
CRP (+/ ESR) normal

Issue 4
Issued: November 2010
Expires: November 2012

Consider IV to oral switch after 48 hr if:


Afebrile and pain free for at least 24 hr
AND
CRP <20 or CRP decreased by 2/3 of
highest value
OM: 46 weeks total antibiotic therapy
SA: 3 weeks total antibiotic therapy
CRP (+/ ESR) normal

171

OSTEOMYELITIS AND SEPTIC ARTHRITIS 5/5


Flowchart 2: Complex disease
SUSPECTED COMPLEX OM or SA
COMPLEX DISEASE
l Multifocal
l Significant bone
destruction
l Resistant/unususal
pathogen
l Immunosuppressed
sepsis or shock

BLOOD INVESTIGATIONS
l FBC
l CRP (+/ ESR)
l Blood culture (4 mL minimum unless neonatal 2 mL)

IMAGING AVAILABLE?
OM
l MR (gold standard)
l Ultrasound (if no urgent MR and expertise available)
l Plain X-ray (baseline)
SA
l Ultrasound
l MR
l Consider need for 99Tc bone scan

SURGERY WHERE INDICATED


l Radiological finding (where result available)
l pus or effusion
l bony destruction
l Take standard culture and PCR where available

Neonatal to aged <3 months


MEDICAL REVIEW
IV cefotaxime PLUS if sepsis
meningitis considered: IV
amoxicillin

Aged 3 months to 5 yr
IV cefuroxime
50 mg/kg 8 hrly

Aged 6 yr
IV flucloxacillin 50 mg/kg 6 hrly
(max 2 g 6 hrly)
OR
IV clindamycin 10 mg/kg 6 hrly
(max 1.2 g 6 hrly)

Consider 2nd line/additional antibiotics with specialist microbiologist/infectious disease advice


Daily clinical review, monitor fever, CRP daily until improving, consider surgery indications

Consider IV to oral switch after 1421


days if:
Afebrile and pain free for at least 24 hr
AND
CRP <20

Consider IV to oral switch after 14 days


(21 days if PVL) if:
Afebrile and pain free for at least 48 hr
AND
CRP <20

OM and SA
6 weeks to many months therapy may be
required, tailored to individual response.
CRP (+/ ESR) normal

OM and SA
6 weeks to many months therapy may be
required, tailored to individual response. CRP
(+/ ESR) normal

172

Issue 4
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Expires: November 2012

PETECHIAL/PURPURIC RASHES 1/1


RECOGNITION AND ASSESSMENT
Non-blanching rash
Yes
Purpura (>3 mm)
No
Unwell?
l Meningism
l Lethargy
l Irritable
l Capillary refill time >5 sec
l Respiratory rate >40/min
l Tachycardia

Treat as meningococcal disease


(see Septicaemia guideline)
l FBC
l U&E
l Coagulation screen
l Blood culture
l CRP
l Meningococcal PCR
l IV antibiotics

Yes

No
Treat
underlying
illness

Mechanical?
l Local trauma
l Superior vena cava distribution after
vomit/cough

Yes

No
Rash progressing?

Yes

No
l Check FBC
l Coagulation screen
l Blood culture
l CRP

Treat as
necessary

Yes

Abnormal platelets/coagulation
screen?
No
l
l
l
l
l

Observe over 46 hr
Registrar review
Discharge if:
no purpura
patient remains well with nonprogressive rash
l WCC 515 and CRP <10

Issue 4
Issued: November 2010
Expires: November 2012

173

SEPTICAEMIA (INCLUDING MENINGOCOCCAL)


1/3
Meningococcal septicaemia: be
alert for septicaemia in any
child presenting with a purpuric
rash (see Petechial rash
guideline).
In the early stages of
meningococcal septicaemia, a
macular rash that DOES blanch
on pressure is often present
first. When in doubt, seek an
experienced opinion urgently.
Treat IMMEDIATELY as delay
can be fatal
RECOGNITION AND
ASSESSMENT
l Assess Airway, Breathing, Circulation
and resuscitate as required
l Disability: be alert to coexisting
meningitis, see Meningitis guideline

l on admission and at least hourly for


first 4 hr then if improving at least
4 hrly for next 24 hr
l a score >8 indicates high risk of
mortality: refer to PICU

Investigations
l FBC and differential
l Blood culture (important to put in
maximum amount of blood bottle
designed to take)
l Blood gas and lactate
l Blood glucose
l Meningococcal PCR
l Group and save
l Clotting profile
l U&E, LFT, Ca++, Mg++, PO4, CRP
l Save for serum cortisol

If purpuric rash
l Treat immediately

Meningococcal septicaemia
l Assess severity of disease on
Glasgow Meningococcal Septicaemia
Prognostic Score:
Glasgow Meningococcal Septicaemia Prognostic Score (GMSPS)
Criteria
Systolic BP (cuff width >2/3 upper arm length)
if <75 mmHg in child aged <4 yr
or <85 mmHg in child aged >4 yr
Skin/rectal temperature difference (measure for 2 min)
if axilla/rectal temperature difference >3oC
Modified coma scale (see Glasgow coma scale guideline)
if initial score <8
or deterioration of 3 points at any time
Deterioration in last hour (subjective)
ask parents or nurse; if yes, score
Neck stiffness
if no neck stiffness, score
Extent of purpura
widespread ecchymoses or extending lesions on review
Base deficit
if deficit >8 mmol/L
Maximum score

174

Score

3
3

3
2
2
1
1
15
Issue 4
Issued: November 2010
Expires: November 2012

SEPTICAEMIA (INCLUDING MENINGOCOCCAL)


2/3
If no rash
l Chest X-ray
l Urine culture (in severe sepsis,
catheterise)
l Lumbar puncture if not contraindicated
and where cardiovascularly and
haematologically stable

Differential diagnosis
l Toxic shock syndrome
l Malaria

IMMEDIATE TREATMENT
l Ensure patent airway and adequate
breathing
l Administer 15 L/min O2 through a
reservoir mask
l if airway and breathing remain
compromised despite simple airway
manoeuvres and 100% O2, contact
consultant and anaesthetist on-call
l Assess circulation, if severe sepsis or
extensive rash, insert two large IV
cannulae or establish intraosseous
access and give human albumin 4.5%
20 mL/kg or if not immediately available
sodium chloride 0.9% over 510 min

Antibiotics
l Give IV cefotaxime 50 mg/kg (max 3 g
6 hrly) over 20 min
l if history of anaphylaxis to
cephalosporin give chloramphenicol IV
or vancomycin and rifampicin if no IV
chloramphenicol immediately available
l if pseudomonas suspected add
gentamicin
l if MRSA suspected, add vancomycin
l if anaerobic infection suspected, add
metronidazole
l if multiple-resistant organisms give
meropenem
l If hypotension continues, peripheries
remain cool, rash continues to evolve,
and capillary refill >2 sec, give further
human albumin 4.5% or sodium
chloride 0.9% 20 mL/kg over 510 min
Issue 4
Issued: November 2010
Expires: November 2012

SUBSEQUENT MANAGEMENT
Circulation still compromised
l Contact paediatric consultant and
anaesthetist on-call and inform PICU
l Give further human albumin 4.5% or
sodium choride 0.9% 20 mL/kg
boluses if hypotension continues and
start inotropes
l Dopamine 520 microgram/kg/min
(7.5 mg/kg in 50 mL sodium chloride
0.9% at 28 mL/hr peripherally)
l start at 5 microgram/kg/min
l increase in 5 microgram/kg/min
increments every 5 min
l up to 20 microgram/kg/min as required
l If still hypotensive, start adrenaline
0.1 microgram/kg/min (0.3 mL/kg of
1:1000 in 50 mL sodium chloride
0.9% at 1 mL/hr)
l If still hypotensive, give hydrocortisone
0.25 mg/m2 6 hrly

Reassess ABC
l If still unstable, arrange immediate
intubation with senior anaesthetist
l prepare atropine 20 microgram/kg
(max 600 microgram)
l if no neck stiffness, ketamine 1 mg/kg;
if neck stiffness, thiopental sodium
3 mg/kg
l suxamethonium 2 mg/kg
l then morphine 20 microgram/kg/hr
(1 mg/kg in 50 mL sodium chloride
0.9% at 1 mL/hr)
l and midazolam 12 microgram/kg/min
(6 mg/kg in 50 mL sodium chloride
0.9% at 0.51 mL/hr)
l and vecuronium 1 microgram/kg/min
(1.5 mg/kg in 25 mL sodium chloride
0.9% at 1 mL/hr)
l Site nasogastric tube and urinary
catheter
l Prepare for central venous line with
portable ultrasound

175

SEPTICAEMIA (INCLUDING MENINGOCOCCAL)


3/3
l Monitor blood glucose hourly for first
6 hr: give glucose 10% 5 mL/kg bolus
and start maintenance fluids
l Give IV fluids (sodium chloride 0.9% at
100% maintenance requirement)
l If passing urine, give IV fluids with
potassium 10 mmol/L if hypokalaemic,
give 0.2 mmol/kg over 1 hr (use
commercial pre-mixed bags)
l If hypocalcaemic, give calcium
gluconate 10% (0.22 mmol/mL)
0.5 mL/kg (max 20 mL) IV over
510 min (do not give ceftriaxone in
same line)
l If INR >2, give fresh frozen plasma
(FFP) 10 mL/kg
l after 60 mL/kg, give packed cells
20 mL/kg

Patient stabilises with


<40 mL/kg bolus fluids

l Inform consultant paediatrician on-call


l Admit to general paediatric ward for
monitoring and continue treatment
l Administer O2 via face mask or nasal
cannula to maintain continuous O2
saturation >95%
l Treat poor perfusion and hypotension
with 20 mL/kg aliquots of human
albumin 4.5% solution

MONITORING
l Monitor the following every 30 min for
first 2 hr, hourly for next 2 hr, then 4 hrly:
l conscious level
l temperature
l respiratory rate
l heart rate
l BP
l capillary refill time
l Monitor urine output hourly
l Monitor blood glucose and electrolytes
6 hrly until stable. Treat hypoglycaemia
with bolus IV glucose
l Monitor clotting screen 12 hrly. Treat
deranged clotting with FFP 10 mL/kg IV

176

SUBSEQUENT MANAGEMENT
l Adjust antibiotic treatment once culture
results available
l if meningococcal or no organism
identified give 7 days: cefotaxime
50 mg/kg 6 hrly IV
l or ceftriaxone 80 mg/kg IV daily, over
3060 min (not with calcium IV; not
aged <3 months)
l Treat S. aureus sepsis for 2 weeks
l Give antibiotics to treat carrier states in
haemophilus sepsis (see Meningitis
guideline)
l Avoid enteral feeds until acute shock
has resolved
l Do not hesitate to contact consultant
paediatrician on-call for advice

Public health
l Meningococcal: inform Public Health
consultant available 24 hr/day
l Public Health Department will arrange
prophylaxis for close contacts

DISCHARGE AND FOLLOW-UP


l Organise formal hearing test after
discharge from hospital
l Arrange appointment in follow-up clinic
in 812 weeks to review problems with:
l hearing loss
l orthopaedic complications
l scarring
l psychosocial
l neurology and development
l Renal function
l Test for complement deficiency if:
l >1 episode meningococcal disease
l meningococcus other than type B
l other recurrent or serious bacterial
infections
l family history immune deficiency

Issue 4
Issued: November 2010
Expires: November 2012

TUBERCULOSIS 1/3
Latent infection
l Contact with TB
l Asymptomatic
l Normal CXR
l Mantoux positive (15mm with BCG/
6 mm no BCG)
l or Interferon gamma positive
l For chemoprophylaxis and all aged
<2 yr discuss with specialist

RECOGNITION AND
ASSESSMENT
History is most important factor
in diagnosing tuberculosis
Symptoms
Suspect TB when following symptoms
persist for weeks:
l Weight loss +/ cough
l Persistent, non-remitting cough for 24
weeks
l Failure to thrive
l Lack of energy
l Fever and sweats
l Painless lymph nodes, especially if
matted
l Headache or irritability for >1 week
l Limp, stiff back, swelling of joint
l Swollen abdomen

Signs

l Delayed growth: plot weight and height


on growth chart and compare with
earlier records
l Swollen joint
l Fever
l Wasting
l Lymphadenopathy
l Chest signs
l Cardiac tamponade
l Ascites
l Meningism
l Conjunctivitis
l Limited flexion of spine
l Kyphosis
Issue 4
Issued: November 2010
Expires: November 2012

Family and social history

l Ask about recent contact with any


family member (specifically
grandparent or parent) who has:
l chronic cough
l previous treatment for TB especially
multi-drug resistant (MDR) TB,
failed/defaulted TB treatment, or
recurrent TB
l travelled to regions/countries with a
high prevalence of TB/MDRTB
l recently died

INVESTIGATIONS
l Chest X-ray: look for hilar
lymphadenopathy, apical consolidation,
pleural effusion, miliary nodules
l If large matted nodes present, arrange
ultrasound scan, then biopsy. Ask
surgeon to send for mycobacterial
culture and histology
l Urinalysis: if blood and leucocytes
present, send for smear and culture
l non-tuberculous acid-fast bacteria
common in urine
l FBC, LFTs
l Tuberculin skin test:
l Mantoux tests: use tuberculin PPD
2 units (0.1 mL of 2 units/0.1 mL)
intradermally
l can be negative in miliary TB
l avoid if other tests positive or definite
clinical diagnosis of TB

Children with cough


l Sputum: for AFB and TB culture in
cooperative child expectoration may
require physio +/- nebulised sodium
chloride 0.9% as necessary (with
FFP3 mask and hepafiltered ventilation
if available)
l If unable to cough, send gastric
aspirate (for TB culture only as
microscopy is unreliable) early
morning before feed, daily for 3 days
l if no aspirate, rinse stomach with small
volumes of sodium chloride 0.9%
(5 mL aliquots maximum 20 mL)
177

TUBERCULOSIS 2/3
l do not send saliva
l Discuss broncho-alveolar lavage for
AFB and TB culture via bronchoscopy
with respiratory consultant

Children with pleural effusion


l Pleural tap +/- biopsy for histology and
microbiology (AFB and TB culture)
l Discuss with cardiothoracic surgeons
about pleural biopsy

Children with lymphadenopathy


l Lymph node aspirate: fine needle
aspiration biopsy (FNAB; 23 G needle)
l low risk, high yield with sedation and
local anaesthetic
l Send aspirate in two separate bottles:
l one to microbiology for TB culture with
no preservative
l one to histology in 10% formalin
l If atypical mycobacterial infection
suspected, prefer complete excision
biopsy, if possible, to aspiration biopsy

Children with meningism


l CSF: request staining for acid-fast
bacilli (AFB) AND culture and
sensitivity for TB (Note: TB meningitis
extremely rare in the UK; often AFB
negative)
l PCR: expensive, consider for CSF if
highly suspicious of TB meningitis,
poor sensitivity

IMMEDIATE MANAGEMENT
l Admission not mandatory but useful to
ensure compliance with treatment. If
supervision can be guaranteed, allow
treatment at home
l Pre-pubertal children are not an
infection risk but their families may be
l notify case to public health and
infection control
l Inform Public Health through TB clinic,
who will organise chest X-ray and
Mantoux for all close and visiting
contacts
l Advise anyone with cough to avoid
visiting ward
178

Discuss treatment with


specialist in respiratory or
infectious diseases
l Add pyridoxine to prevent isoniazid
neuropathy in malnourished or
breastfed infants, diabetes, HIV or
renal failure
l Inform patients/parents of both
common and rare but important side
effects (staining of secretions, signs of
hepatotoxicity)
l Advise patients/parents and GP of
indications for seeking advice: fever,
malaise, vomiting, jaundice or
unexplained deterioration. Consider
co-existent viral hepatitis. If AST/ALT
level rises to 5 times normal, stop
treatment and seek advice re:
alternate regimen

Drugs
l Round up doses to give easily
measured volumes of syrup or
appropriate strengths of tablet.
Re-calculate doses with weight gain
l Supplement pyridoxine if breastfed
and/or malnourished
l Isoniazid: 10 mg/kg/day up to max
300 mg
l (suspension; 50 mg, 100 mg tab)
l Rifampicin: 10 mg/kg/day up to max
450 mg if <50 kg; 600 mg 50 kg
l (suspension; 150 mg, 300 mg tab)
l Pyrazinamide: 35 mg/kg/day up to max
1.5 g if <50 kg; 2 g 50 kg
l (crush 500 mg tablets)
l Ethambutol: 15 mg/kg/day (crush
100 mg, 400 mg tablets)
l check renal function first, do not round
dose up
l Consider drug combinations (e.g.
Rifinah, Rifater) if at all possible to
ensure compliance (see BNFc)

Issue 4
Issued: November 2010
Expires: November 2012

TUBERCULOSIS 3/3
Presentation
Respiratory TB: lungs,
pleural cavity,
mediastinal lymph nodes
or larynx
Meningeal TB

Other extra pulmonary


lesions

Treatment
Rifampicin and isoniazid for 6 months
Pyrazinamide and ethambutol for 1st 2 months

Rifampicin and isoniazid for 12 months


Pyrazinamide and ethambutol for 1st 2 months
Prednisolone 12 mg/kg max 40 mg, with gradual withdrawal of
prednisolone, starting within 23 weeks of initiation
As for respiratory TB

SUBSEQUENT MANAGEMENT
l HIV test

l Other drugs may be necessary once


sensitivities available: if resistant, seek
specialist advice

MONITORING TREATMENT
l Check LFT only if vomiting, nausea,
lethargy, jaundice, etc

DISCHARGE AND FOLLOW-UP


l Discharge if tolerating treatment and
compliance guaranteed
l Review to ensure compliance:

l at least monthly for first 2 months

l 2-monthly until treatment complete

l for 3 months after end of treatment


l further as clinically indicated

l raised transaminases are to be


expected: check and stop treatment
only if symptomatic

l If on ethambutol and unable to report


visual problems check visual evoked
response

Issue 4
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Expires: November 2012

179

FACIAL PALSY 1/1


RECOGNITION AND
ASSESSMENT
Definition
l Idiopathic lower motor neurone facial
nerve palsy (Bells palsy)

Symptoms and signs


l Asymmetry of face or smile and loss
of nasiolabial fold on same side
l Increased or decreased lacrimation
l Hyperacusis

INVESTIGATIONS
l If all history/examination
unremarkable, no investigations
needed
l If difficulty in closing eye,
ophthalmology referral

l Bilateral facial palsy consider Lyme


disease, Guillain-Barr syndrome,
brain stem pathology: discuss further
investigations with senior
l Recurrent facial palsy: discuss with
senior

l Recurrent infections: 1st line immune


deficiency investigations

l Altered taste
l Facial pain

l Difficulty in closing eye

l Loss of wrinkles on forehead

History
l History of prior viral infection may be
present
l Abrupt onset with no progression

l No history of preceding seizure or


head injury

Examination
l Full neurological examination,
including other cranial nerves, and
fundoscopy

l demonstrable weakness in lower motor


neurone distribution (includes loss of
wrinkles on forehead)

IMMEDIATE TREATMENT
l If difficulty in closing eye, provide eye
patch and hypromellose eye drops
l If no other signs, no other treatment
necessary
l If vesicles suggest HSV, prescribe
aciclovir, test for immune deficiency

l Within 72 hr prednisolone 1 mg/kg/day


for 10 days discuss with a senior

DISHCHARGE AND FOLLOW-UP


l 4 weekly GP follow-up until symptoms
and signs have resolved
l If facial palsy does not improve
considerably within 4 weeks discuss
imaging

l loss of nasiolabial fold on same side

l Ears, nose and throat to exclude


cholesteatoma, mastoiditis or herpes
infection

l Blood pressure to exclude hypertension


l Check for lymphadenopathy,
hepatosplenomegaly, pallor or bruising
to exclude malignancy

180

Issue 4
Issued: November 2010
Expires: November 2012

EPILEPSY 1/5
DEFINITIONS
l Seizures/convulsions: paroxysmal
disturbance of consciousness,
behaviour, motor function, sensation
singly or in combination
l Epilepsy: recurrent seizures without
any provoking factor and happening in
different situations
l Seizure type: (focal or generalised or
any other type) based on history and
EEG
l Try to categorise into one of epilepsy
syndromes

RECOGNITION AND
ASSESSMENT

l Detailed and accurate history from an


eyewitness (beginning, middle and end
of the episode)
l When the history is unclear, recording
the episode with a camcorder can be
very useful
l Episodes occurring only in certain
situations with certain provoking
factors (such as fall, emotions, certain
posture etc., except photosensitive
stimuli) are likely to be non-epileptic
l Any underlying problem: learning
difficulties, cerebral palsy, HIE, head
injury or other CNS insult
l Look for any co-morbidity
l Family history may be positive in
certain idiopathic generalised
epilepsies, some symptomatic
epilepsies (tuberous sclerosis),
autosomal dominant frontal epilepsies
l Genetic conditions (e.g. Angelmans
syndrome)
l Neurocutaneous syndromes, caf-aulait spots/depigmented patches, use
Woods Light
l Neurological examination
l If in doubt about diagnosis, do not
label as epilepsy but watch and wait or
refer to specialist

Diagnosis of epilepsy is clinical


Issue 4
Issued: November 2010
Expires: November 2012

Seizure types
Generalised
l Tonic-clonic/tonic
l Clonic
l Atonic
l Absence
l Myoclonic

Focal
l Without impairment of consciousness
(focal motor, sensory or other types)
l With impairment of consciousness
(previously known as complex partial)
l Focal with secondary generalisation
(clinically look like generalised
seizures) history of aura, Todds
paralysis, focal features on EEG

Underlying cause
l In most cases epilepsy is idiopathic but
a few cases have an underlying cause
l actively look for the cause to guide
prognosis, other treatment and
recommendation for epilepsy surgery

EPILEPSY SYNDROMES
Identification
l Based on:
l seizure type
l age of onset
l neurodevelopmental status
l appearance of EEG ictal and interictal

Childhood absence epilepsy


l Usually presents aged 38 yr
l More common in girls
l Several (up to 100) brief episodes in a
day
l No post-ictal features
l Typical EEG 3 per sec spike and wave
l 1030% of children have generalised
seizures at some stage, usually at a
later age
181

EPILEPSY 2/5
Juvenile absence epilepsy
l Usually presents after age 910 yr
l Absence frequency is less than in
childhood absence epilepsy
l Cluster after awakening
l 90% of children have generalised
seizures in the same period while they
have absences
l EEG faster spike and wave

Juvenile myoclonic epilepsy


(JME)

l Usually presents between ages 1218 yr


l Myoclonic jerks are hallmark of this
syndrome
l Jerks after awakening (myoclonic jerks)
common and often go unrecognised
l 90% of children have generalised
seizures at some stage
l 1530% of children will have absences

Benign epilepsy of childhood


with rolandic spike

l Usually nocturnal seizures


l Unilateral focal motor seizures of face
and arm with gurgling and salivation
l May become secondary generalised
l Spikes in one or the other centro
temporal areas
l Awake inter-ictal EEG could be normal
and sleep EEG would usually show
the abnormality

Panayiotopoulos syndrome
l Younger children (peak age 5 yr)
l Autonomic seizures and behavioural
disturbances usually nocturnal
l Usually starts with vomiting and child
initially conscious
l Subsequent deviation of eyes to one
side, impaired consciousness or may
end in hemiclonic seizure or (rarely)
generalised seizure
l Child looks unwell, unresponsive
l Other autonomic features very
common (e.g. dilated pupils, pale skin
or flushing, incontinence)

182

l Usually lasts for a few to 30 min,


occasionally for several hours

Temporal lobe epilepsy (TLE)


l Focal seizures with impaired
consciousness and complex
automatism
l Children with history of prolonged
febrile seizure in the early years of life
may have mesial temporal sclerosis as
a cause of their seizures
l Other known causes: cortical
dysplasia, gliomas, disembryonic
neuroectodermal tumour

Frontal lobe epilepsy


l Usually focal motor seizures
l Either tonic or clonic seizures may
have speech arrest and head rotation
or complex partial seizures or focal
with secondary generalisation
l Multiple brief seizures in the night
l Nocturnal seizures are a characteristic
feature of frontal lobe epilepsy
l Ictal EEG can be normal
l Can mimic pseudoseizures

Other epilepsy syndromes


l Epileptic encephalopathy in newborns
(myoclonic or Ohtohara syndrome)
l Wests syndrome (infantile spasms)
l Severe myoclonic epilepsy of infancy
(Dravet's syndrome)
l Lennox-Gastaut syndrome
l Laundau-Kleffner syndrome
l For other epilepsy syndromes see
International League against Epilepsy
website (http://www.ilae-epilepsy.org)

INVESTIGATIONS
Indications for EEG
l Clinically diagnosed epilepsy
l After an episode of status epilepticus
l Unexplained coma or encephalopathy
l Suspicion of non-convulsive status in
children with learning difficulties and
epilepsy
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Expires: November 2012

EPILEPSY 3/5

l Acquired regression of speech or


language function
l Developmental regression suspected
to have neuro-degenerative condition
l To monitor progress in Wests
syndrome and non-convulsive status

EEG not indicated


l Funny turns, apnoeic attacks, dizzy
spells, strange behaviour
l Non-convulsive episodes [e.g. syncope,
reflex anoxic seizures, breath-holding
episodes (ECG more appropriate)]
l Febrile seizures
l Single uncomplicated generalised
tonic-clonic seizures
l To monitor progress in well-controlled
epilepsy
l Before stopping treatment

Indications for MRI of brain


l Focal epilepsy (including TLE) except
rolandic seizures
l Epilepsy in children aged <2 yr
l Myoclonic epilepsy
l Intractable seizures
l Loss of previous good control
l Seizures continuing in spite of first-line
medication
l Associated neurological deficits or
appearance of new neurological signs
l Developmental regression in children
with epilepsy
l Infantile spasms (Wests syndrome)

Other investigations
l Sleep or sleep-deprived EEG useful in
all children in whom there is a high
clinical suspicion but awake EEG normal
l sleep EEG useful to pick up some
focal/generalised epilepsies and sleepdeprived EEG useful in generalised
epilepsies in young adults including
JME. Perform sleep EEG with melatonin
l Video telemetry useful if diagnostic
dilemma, pseudoseizures or before
surgery
l Drug levels phenytoin, phenobarbitone
(other anticonvulsants only if concerns
about compliance and overdose)
Issue 4
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Expires: November 2012

l Biochemistry: glucose, calcium, LFT,


lactate, ammonia; metabolic and
genetic investigations where suspicion
of metabolic disorder (e.g. progressive
developmental delay)
l Epileptic encephalopathies, such as
West's Syndrome, need a series of
investigations (discuss with paediatric
neurologist)

TREATMENT
General guidelines
l Discuss treatment with a consultant
before starting
l Start antiepileptic only if diagnosis
certain (two or more unprovoked
seizures)
l Preferably after initial EEG results
obtained
l Start with small dose and build up to
half maintenance. If seizures continue,
increase to full maintenance
l Increase dose stepwise every
23 weeks

First line drugs (see table for


choice of anti-epileptic drug)

l Carbamazepine start with


2.55 mg/kg/day in two divided doses
increasing to 2030 mg/kg/day
OR
l Valproate start with 510 mg/kg/day in
two divided doses increasing to
40 mg/kg/day
l Avoid polypharmacy; do not add a
second medication unless the full or
maximum tolerated dose of the first
medication has been reached (discuss
with a paediatrician with special
interest or paediatric neurologist
before adding second drug)
l Aim to switch to monotherapy after a
period of overlap
l Give liquids as sugar-free preparations
l Make sure you discuss potential
adverse effects with parents and
document these in notes
l If child develops adverse effects,
discuss and reduce dose
183

EPILEPSY 4/5
Discussion with child and
parents

l Provide additional advice regarding


safety (e.g. supervision when
swimming) and document discussion
in notes
l Discuss and prescribe rescue
treatment, especially in generalised
epilepsy, with training for parents

l Provide written information, including


information about national or local
epilepsy associations
l Explain how to gain access to epilepsy
specialist nurse
l Allow parents and children to ask
questions, especially about sensitive
issues such as sudden death

Table 1: Drugs of first, second and third choice in treatment of seizure types
Seizure type
First
Generalised epilepsy Sodium valproate
OR
Carbamazepine
Childhood absence
Sodium valproate
Ethosuximide
epilepsy
Focal epilepsy
including TLE

Infantile spasms

Carbamazepine

Second
Carbamazepine
OR
Sodium valproate
Lamotrigine*

Sodium valproate
Lamotrigine
Topiramate
Levetiracetam
Prednisolone/tetracosactide Sodium valproate
Nitrazepam
OR
Vigabatrin

Third
Lamotrigine*
Levetiracetam
Topiramate
Levetiracetam
Topiramate
Clobazam
Phenytoin

Trial of pyridoxine

* Lamotrigine can increase myoclonic seizures in some myoclonic epilepsy syndromes


Carbamazepine should be avoided in childhood absences, juvenile absences and
juvenile myoclonic epilepsy and can increase seizures in some epileptic
encephalopathies and generalised epilepsies

Epilepsy in adolescence
additional factors to be
considered

l Compliance
l Career choices
l Driving
l Contraception and pregnancy,
including pre-pregnancy counselling
l Alcohol and drugs

OUT-PATIENT MANAGEMENT

l Initial follow-up at 68 weeks


l Subsequent follow-up/structured
review every 312 months based on
clinical need

FURTHER OPINION/REFERRAL
TO SPECIALIST SERVICE OR
TERTIARY CENTRE (NICE
GUIDELINES)

SUBSEQUENT MANAGEMENT

l Increase dose of antiepileptic


gradually towards full dose or
maximum tolerated dose until control
good
l If control suboptimal with one drug or
unacceptable side effects, start
second-line drug

184

Refer immediately
l Behavioural or developmental
regression
l Epilepsy syndrome cannot be
identified

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Expires: November 2012

EPILEPSY 5/5
Refer soon
l When one or more of the following are
present:
l child aged <2 yr
l seizures continuing despite being on
AED (anti-epileptic drug) for 2 yrs
l 2 AEDs have been tried and are
unsuccessful
l risk of unacceptable side effects of
medication
l unilateral structural lesion
l psychological or psychiatric comorbidity
l diagnostic doubt about seizure type
and/or syndrome

Refer
l Refer specific syndromes such as:
l Sturge-Weber syndrome
l Rasmussens encephalitis
l Hypothalamic hamartoma

Issue 4
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Expires: November 2012

WITHDRAWAL OF
ANTIEPILEPTIC DRUGS

l Consider when child has been seizure


free for two years
l Discuss the risks of recurrence
(2530%), if this occurs, recommence
treatment
l Recurrence is very high in some
syndromes (e.g. juvenile myoclonic
epilepsy, 7080% usually requires
lifelong treatment)
l Postpone withdrawing antiepileptic
medication if important events such as
GCSEs are looming
l Gradual withdrawal over 23 months
usual
l Some drugs (phenobarbital or
benzodiazepines) need very slow
withdrawal over 612 months

185

STATUS EPILEPTICUS 1/1


ACUTE SEIZURE MANAGEMENT
Follow each step until fits resolve, but do not treat post-ictal posturing as fitting
Flowchart
Airway
High flow O2
Glucose sticks

Vascular access?
Yes

No

Lorazepam
0.1 mg/kg IV/IO (max 4 mg)
over 6 min (dilute 1:1 with
sodium chloride 0.9%)

Diazepam PR
OR Midazolam buccal
(see table below for exact dose)

10 min
10 min

YES

Lorazepam
0.1 mg/kg IV/IO

Vascular access?

10 min

No

Paraldehyde PR
50:50 ready mixed solution or diluted with equal volume of olive oil
(see table below for exact dose, expressed as volume of paraldehyde)

Phenytoin 20 mg/kg IV/IO over 20 min with cardiac monitoring


If already taking phenytoin, give phenobarbital 20 mg/kg IV/IO over 20 min
diluted 1:1 with water for injection
Call anaesthetist

RSI with thiopental


4 mg/kg IV/IO

Diazepam (rectal)
Aged 1 month2 yr: 5 mg
Aged 212 yr:
Aged >12 yr:

186

Midazolam (buccal)
Age <6 months:
300 microgram/kg (max 2.5 mg)

510 mg Aged 6 months1 yr: 2.5 mg


5 mg
10 mg Aged 15 yr:
Aged 510 yr:
7.5 mg
Aged >10 yr:
10 mg

Paraldehyde (rectal)
Aged 13 months: 0.5 mL
Aged 36 months:
1 mL
Aged 6 months1 yr: 1.5 mL
Aged 12 yr:
2 mL
Aged 25 yr:
34 mL
510 mL
Age 518 yr:

Issue 4
Issued: November 2010
Expires: November 2012

NEUROMUSCULAR DISORDERS 1/2


ON ADMISSION
l Ask parents if they have a copy of a
care plan
l Inform childs long-term consultant

CLINICAL HISTORY
l Adequacy of cough and swallowing

l Previous sleep difficulties, wakefulness


at night (nocturnal hypoventilation)
l Difficulty waking in morning, early
morning headache (nocturnal
hypoventilation)

l Poor appetite, weight loss (chronic


respiratory failure)

l Learning or behavioural problems,


school attendance (chronic respiratory
failure)
l Palpitations, breathlessness, chest
pain (cardiomyopathy)

l Muscle cramps, skeletal pain, back


pain (for fractures)

l Abdominal pain, distension, melaena


(GI perforation)

ASSESSMENT
l May not show overt signs of
respiratory distress such as
tachypnoea, recessions and use of
accessory muscles even in respiratory
failure
l Assess adequacy of chest wall
excursion and cough

l Look for pallor, tachycardia, signs of


circulatory compromise

l Assess for abdominal signs (GI bleed,


perforation, gastritis)
l Measure:

l SpO2 in air

l CO2 by blood gas, transcutaneous CO2


or end-tidal CO2, especially if on O2
l spirometry: FVC most useful if
previous readings available
Issue 4
Issued: November 2010
Expires: November 2012

l ECG

l Blood gas for cardiac status

l Chest X-ray: clinical signs can fail to


detect
collapse/consolidation/cardiomegaly
l Consider skeletal/spinal X-rays for
possible fractures

Medical problems commonly


found in children with myopathy
l Respiratory failure (hypoxaemia and
hypercapnia) without signs of
respiratory distress. Susceptibility to
respiratory failure due to:
l muscle weakness (upper airway,
intercostals, diaphragm)
l scoliosis

l poor secretion clearance

l aspiration, chest infections

l sleep disordered breathing


l cardiac failure

l Lower respiratory infection, aspiration


pneumonitis
l Cardiomyopathy and cardiac
decompensation

l Gastro-oesophageal reflux, gastritis


and gastric ulceration (especially if on
corticosteroids)
l Adrenal insufficiency (if on
corticosteroids)

l Fractures, especially vertebral, if on


long-term corticosteroids
l Malignant hyperthermia following
anaesthesia in certain muscular
dystrophies and myopathies

MANAGEMENT
l If unwell, on long-term
corticosteroids, double usual daily
dose of steroids for 23 days. If
unable to tolerate oral steroids, use IV
hydrocortisone

187

NEUROMUSCULAR DISORDERS 2/2


Respiratory failure
l Carefully titrated administration of
oxygen by mask/nasal cannulae to
achieve SpO2 between 9498%.
Monitor CO2 and respiratory effort as
risk of rising CO2 and respiratory
failure (despite normal O2 saturations)
if hypoxic respiratory drive overcome
by oxygen therapy
l Mask ventilation (bi-level positive
airway pressure, BIPAP)

l Chest physiotherapy and postural


drainage

l Use in/ex-sufflator (e.g. Cough Assist)


if patient has one
l Suction

l if copious loose secretions use


glycopyrrolate 40100 microgram/kg
orally (use 200 microgram/mL IV
solution)
l Antibiotics

l obtain cough swab or sputum


specimen, ideally before starting
treatment
l check previous culture results

l choice same as for community


acquired pneumonia

l if bronchiectasis use broad spectrum


for 14 days to cover pseudomonas
(discuss with senior)

GI tract bleed: prevention and


treatment
l Nil-by-mouth and IV fluids

l Ranitidine (omeprazole if reflux)


l Senior advice

Fractures
l Analgesia

l Orthopaedic consultation

l IV biphosphonates for vertebral


fractures, discuss with metabolic bone
expert

Malignant hyperthermia
Malignant hyperthermia is a
medical emergency
l Occurs following general anaesthesia
and may be first presentation of a
neuromuscular disorder

l Check creatine kinase, calcium, renal


function, urine output and for
myoglobinuria: dialysis may be needed
l In addition to temperature control and
general life support measures, use IV
dantrolene to control excessive muscle
contraction
l Obtain senior anaesthetic advice and
liaise with PICU

l if not improving on 1st line antibiotics


add macrolide for atypical pneumonia

l Consult senior to discuss need for ITU


care, escalation of respiratory support

Cardiac failure
l Fluid restriction
l Diuretics

l Oxygen and respiratory support


l Cardiology consultation

188

Issue 4
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Expires: November 2012

GLASGOW COMA SCORE 1/1


Response aged 4 yr

Response aged <4 yr

Eye opening
Spontaneously
To speech
To pain
Never

Score
4
3
2
1

Eye opening
Spontaneously
To speech
To pain
Never

Score
4
3
2
1

Best motor response


Obeys commands
Localises pain
Withdrawal
Flexion to pain
Extension to pain
None

Score
6
5
4
3
2
1

Score
6

Best verbal response


Orientated and converses
Disorientated and converses
Inappropriate words
Incomprehensible sounds
None

Score
5
4
3
2
1

Best motor response


Obeys commands (or
spontaneous, purposeful <2 yr)
Localises pain or withdraws to
touch
Withdrawal
Flexion to pain
Extension to pain
None
Best verbal response
Alert and babbles, words to usual
ability
Less than usual words,
spontaneous irritable cry
Cries only to pain
Moans to pain
None

Score
5

Issue 4
Issued: November 2010
Expires: November 2012

5
4
3
2
1

4
3
2
1

189

CHILD PROTECTION 1/4


Always follow the Child
Protection Policy and
Procedures in your Trust

l 4 recognised categories of abuse


(rarely seen in isolation)

l physical abuse (non-accidental injury)


l sexual abuse (see Child sexual
abuse guideline)
l emotional abuse
l neglect

NON-ACCIDENTAL INJURY
Definition
Physical abuse may involve hitting,
shaking, throwing, poisoning, burning or
scalding, drowning, suffocating or
otherwise causing physical harm to a child.
Physical harm may also be caused when a
parent fabricates the symptoms of, or
deliberately induces, illness in a child

Recognition and assessment


Unless there is an appropriate
explanation, discuss injuries
with a senior doctor. All child
protection cases must be dealt
with by an SpR or above
There may be direct information from the
child or carer. The following presentations
need to be considered
l Delay in seeking medical attention
following an injury

l History incompatible with injury seen


l Numerous explanations suggested for
injury
l Changes in the history
l Parents shopping around for medical
help (e.g. from GP, A&E, different
hospitals)
l Odd or aggressive parental behaviour
l Any fracture in an infant without a
satisfactory explanation

l Any bruise on a child aged <6 months


old or pre-mobile
190

l Patterns of bruising, injury or


explanation not compatible with childs
development

l Recurrent injuries
l Evidence of other forms of abuse (e.g.
failure to thrive, neglect)
l Previous evidence of injury or neglect
(check if child known to local authority
childrens social care or is the subject
of a child protection plan)

Referrals
l Discuss referrals by GP with
consultant before arranging medical
assessment by on-call team

l consultant will decide whether referral


should be made to the child protection
agencies first
l Referrals from A&E or surgical wards
should be taken by a doctor SpR
grade or above

l discuss with a consultant first to


determine who should carry out initial
examination and whether social care
or police should be present

Always discuss referrals with


the consultant on-call for child
protection duties
Immediate action
l If there is an urgent or life-threatening
situation, start necessary emergency
treatment
l Refer to your Trust on-call child
protection arrangements

l if you suspect harm, refer to social


care, and police if they are not already
involved
l if recommended by police, examine
child jointly with the Forensic Medical
Examiner
l Keep any social worker or police
officer present informed

l Always consider potential risks to


siblings or other children

Issue 4
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Expires: November 2012

CHILD PROTECTION 2/4


History
l Where a referral is made from social
care and police Child Protection
Teams, child may have given a full
history, often on video recording

l ask for this information from social


worker or police officer at beginning of
examination. It may not be necessary
to repeat this information unless
further detail is required
l If child first presents in a health
setting, particularly if story unclear,
SpR or consultant should take history
and examine child before discussing
with social care

How
l Record findings accurately during or
immediately after examination, using a
dedicated child protection proforma
with body charts if possible
l Complete and sign each page and
include:
l full family history

l persons present at interview

l source of your information (including


the child)
l person giving consent

Take care when talking to the


child not to ask leading
questions or make suggestions
that could contaminate
evidence in a subsequent trial
Examination
l There should be only one examination.
Repeated examinations are not in the
child's interest
l Keep your immediate senior informed

Issue 4
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Expires: November 2012

If this is a planned medical


assessment at the request of
child protection agencies,
carers with parental
responsibility and the child
(depending on age and
understanding) must give their
consent (usually written) for
examination to take place. If
consent not forthcoming, social
care may obtain a legal order
giving permission for the child
to be examined. This does not
apply where a child needs
urgent assessment and
treatment
l Must include:

l state of child: cleanliness, appropriate


clothing, etc
l all body areas

l accurate description of all injuries


(size, colour, position and pattern) on
body charts

l mouth (torn frenulum of lip and tongue


especially)
l fundi: look particularly for
haemorrhages. With small children,
especially where head injuries are
suspected, this is usually the role of
the paediatric ophthalmologist
l a note of any birth marks, etc

l a full paediatric systemic examination


l plotting height and weight and head
circumference on growth charts
l child's emotional state, demeanour
and degree of co-operation

l a comment on the developmental state


(or school progress)
l observations on relationships or
behaviour between parents and child

191

CHILD PROTECTION 3/4


Investigations
A selection of the following tests will
usually be necessary; seek advice from
consultant as to which are appropriate:
l FBC and clotting screen (APTT, PT,
thrombin time, fibrinogen)

l If significant unexplained bruising then


further investigations e.g. vW Act, AG,
Factor 8, 9 and 13 and blood group
l If personal bleeding history or
concerning family history, discuss with
haematologist
l Bone biochemistry if there are
unexplained fractures

l Investigations into other suspected


abuse (e.g. failure to thrive)

l Skeletal survey in small children with


unexplained injuries
l Head CT scan in children aged <6
months (only on consultant
recommendation)
l Photographs (often a police
photographer is used)

EMOTIONAL ABUSE
Recognition and assessment
Definition
l Habitual harassment of a child by
disparagement, criticism, threat and
ridicule

l Present in most cases of physical and


sexual abuse, and neglect
l presents difficulties in definition,
recognition and management

l long-term consequences upon social,


emotional and cognitive development
can be more harmful than other forms
of abuse

Presentation
l Part of the differential diagnosis if a
child presents with the following nonspecific behaviours:

192

l unhappy
l disturbed
l poor concentration leading to learning
difficulties/school failure
l poor social interactions
l unable to play
l problems with attachment to parents
or caretakers

l over-friendly or craving affection from


strangers

Assessment
l Assessment is complex and requires a
multidisciplinary approach
l social care take the investigative lead

NEGLECT
Neglect may not always be
intentional (e.g. parental mental
health problems)
Recognition and assessment
Definition
l Neglect is persistent failure to meet a
childs physical and/or psychological
needs
l Lack of care of physical needs that
can result in failure to thrive

l important to eliminate organic causes


l neglect of physical care most likely to
come to Child Health attention along
with developmental delay

Presentation
l Child's appearance
l note condition of clothing, hair, skin
l Growth
l height, weight, serial measurements to
check growth rate
l head circumference
l mid-upper arm circumference

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CHILD PROTECTION 4/4


Physical examination
l Signs of medical problem not
appropriately treated

l Evidence of other forms of abuse


l Development
l gross motor skills, fine motor skills,
vision, hearing, language, behaviour,
play

SUBSEQUENT MANAGEMENT
l Majority of children seen will be
allowed home if it is safe and after
discussion with social care

l some children who have been abused


will be admitted while problems are
investigated
l Always keep parents and children
informed of concerns and what next
actions will be

l Be open and honest with parents


where possible unless this could put
child (or others) at risk of further harm

Keeping children safe


l If there is clear evidence of child
abuse and parents attempt to remove
child there are two courses of action:
l in an emergency, dial 999, the police
can use police protection powers to
keep child safe

l if there is time, a social worker can


obtain an Emergency Protection Order
from Court (Section 44, Children Act
1989)

DISCHARGE AND FOLLOW-UP


Only a consultant may allow
child to go home
l Consultant should make decision
regarding discharge, usually after
discussion with police and social care

Communication is vital
l Send written report to GP, without
delay with a copy for social care and
police

l If child referred from A&E, send copy


of report to them for feedback

l Ensure notes and dictation tape taken


to child protection secretary marked
for urgent attention
l Complete ward discharge forms
l Check with consultant if follow-up is
required

Child protection conference


l May be convened following a child
protection investigation to consider:

l child protection issues


l whether child needs to be the subject
of a child protection plan
l Medical and nursing staff will be
invited if child has been admitted
l expected to contribute, usually in
person, or via a written report

l ensure reports are available for future


reference

l Put the child's safety first


l Communicate with other staff involved
(e.g. nursing staff) so that situation can
be supervised
l Consider the safety of siblings
l usual for siblings to be examined at
same time as index child

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Expires: November 2012

193

CHILD SEXUAL ABUSE 1/3


Always follow the Child
Protection Policy and
Procedures in your Trust
RECOGNITION AND
ASSESSMENT
Definition

l Forcing or enticing a child or young


person to participate in sexual
activities, whether or not the child is
aware of what is happening
l may involve physical contact, including
penetrative (e.g. rape or buggery) or
non-penetrative acts
l may include non-contact activities (e.g.
involving children in looking at, or in
production of, pornographic material,
watching sexual activities, or
encouraging them to behave in sexually
inappropriate ways)

Presentation

l Information given by child


l Symptoms resulting from local trauma or
infection (e.g. bruises, bleeding,
discharge)
l Symptoms resulting from emotional
effects (e.g. behavioural changes,
enuresis, encopresis, self-harming, eating
disorders or psychosomatic symptoms)
l Sexualized behaviour or sexual
knowledge inappropriate to age
l Under-age pregnancy

Referrals

l Referrals usually come from local authority


childrens social care or the police
l refer to your departmental child
protection rota

If a child presents in a medical


setting and there are concerns
about sexual abuse, call the
consultant on-call for child
protection immediately. Depending
on any urgent medical needs child
protection agencies may need to
be contacted before medical
assessment

194

IMMEDIATE ACTION HISTORY


AND EXAMINATION
Preparation
l Where sexual abuse suspected,
whoever examines the child must have
experience in this field
l junior doctors (always SpR grade or
above) must discuss the situation with
consultant paediatrician on-call before
proceeding to any examination
l Siblings:
l discuss with consultant and social
care/police whether they need to be
examined
l Examine child in designated child
protection assessment area with nurse
chaperone

Forensic sampling
l Depending on local arrangements, the
police will determine whether this is
performed by a paediatrician trained in
forensic sampling or by a Forensic
Medical Examiner (FME)
l The FME will have forensic kits to take
necessary specimens for tests on
blood, semen, etc

Consent
Carers with parental
responsibility and child
(depending on age and
understanding) must give their
consent (usually written) for
examination to take place. If
consent not forthcoming, social
care may obtain a legal order
giving permission for child to
be examined. In an emergency,
consent to treat is not required
l An examination of this nature requires
preparation with due regard to child
l a young child may not comprehend
what is happening to him/her and there
is a risk that the investigation may be
as traumatic as the alleged incident
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CHILD SEXUAL ABUSE 2/3


l make every effort to obtain child's
informed consent to examination, in
accordance with their age and
understanding
l co-operation of child is best achieved
by telling them exactly what is
happening
l in exceptional cases, particularly
where there is acute trauma and
bleeding that may require surgical
management, it may be appropriate for
the examination to be carried out
under anaesthetic by a gynaecologist
after discussion with the FME

History

l Record findings during or immediately


after history and examination, using a
dedicated child protection proforma
with body charts, if available
l Complete and sign each page

Include details of:

l Incident or symptoms
l where referral made from social care
or Police Child Protection Teams, the
child may have already given a full
history, often on video, with
appropriate non-leading questions.
Discuss this information at beginning
of history and examination. If further
clarification required, use non-leading
questions and record all questions and
responses verbatim
l General health and emotional wellbeing, with particular emphasis on
genito-urinary or bowel symptoms (e.g.
constipation and secondary enuresis)
l Past medical history, including A&E
attendances
l Developmental history or school
progress
l Medication and immunisation history
l Family history (other children) may
require assessment. Complete a
genogram

Issue 4
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Expires: November 2012

Examination
l Purpose of medical examination is to:
l detect traumatic or infective conditions
that may require treatment
l evaluate the nature of any abuse
l secure forensic evidence
l reassure the child
l start process of recovery

Record

l General health
l Growth: height, weight and sexual
maturity, plotted on a centile chart
l Developmental, emotional and
behavioural assessment
l Evidence of non-genital trauma (e.g.
bruises) or neglect
l Evidence of genital and anal trauma
(see below)
l A variety of signs can be associated
with sexual abuse that will vary with:
l type of abuse
l age of child
l degree of force used
l use of lubricant
l presence of infection
l time since last assault

How to examine genitalia and


anus

l For a genital examination, lie child in


supine frog-legged position, usually on
a bed but, in the case of a small child,
on a parent's lap: encourage parents
to flex and abduct childs hips
l when labia are separated the hymen
may be clearly visible. If it appears
closed the margins can be revealed by
applying gentle pressure laterally to
labiae, or by holding labiae and
applying gentle downwards pressure
for a few seconds
l posterior hymen is seen more easily
with child in the knee-chest position,
which helps to smooth out any natural
folds which may first appear as
abnormal

195

CHILD SEXUAL ABUSE 3/3


l digital or internal examination not
indicated routinely. If deemed
necessary, it should be undertaken
only by a senior doctor experienced in
these assessments
l a colposcope can be used to magnify
and obtain a visual record
l Examine anus with child lying in left
lateral position, flexed with knees
towards chest
l if anal dilatation is to be assessed,
part buttocks gently and observe for
30 sec (up to 2.5 cm of dilatation has
been noted after anal abuse)
l significance of minor dilatation is
uncertain; remember that there may
be a medical aetiology
l check for any other signs of injury or
abnormality (e.g. anal fissures, dilated
veins at anal margin etc)

l Following an acute assault, refer to


your Trusts policy or consult your local
genito-urinary or sexual health
department on post exposure
prophylaxis if possible should be
started within 1 hr of assault if
indicated (can be given up to 72 hr
after assault)

The implication of any


abnormal findings needs to be
thought through carefully
Absence of relevant abnormal
findings on examination does
not rule out abuse

Communication is vital

INVESTIGATIONS
Consider:
l Mid-steam urine
l Pregnancy test. If assault within 72 hr,
offer post-coital contraception
l levonorgestrel 1.5 mg stat dose (needs
to be prescribed if aged <16 yr)
l Forensic tests (FME to determine)
l Photos/video recordings obtained with
a colposcope, stored in accordance
with local policy

Sexually-transmitted diseases

SUBSEQUENT MANAGEMENT
l Discuss findings with the parent(s) and
child (depending on age and
understanding)
l Inform social care/police of initial
findings

DISCHARGE AND FOLLOW-UP


l Consultant must agree discharge,
usually after discussion with police and
social care
l Send written report to GP without
delay with a copy for police and social
care
l If a child referred from A&E, send
copy of report to them for feedback
l Ensure notes and dictation tape are
taken to secretary marked for urgent
attention
l Complete ward discharge forms
l Examining doctor should discuss
appropriate follow-up with consultant
on-call
l referral to genito-urinary medicine
l referral to counselling services may be
indicated
l older girls will usually be given
information from the police regarding
witness support, and agencies such as
Victim Support

l Investigate particularly if penetration


and/or passage of bodily fluids are
suspected
l examining doctor should contact
genito-urinary medicine department
and arrange an appointment. It may be
possible to arrange a joint examination
196

Issue 4
Issued: November 2010
Expires: November 2012

SELF HARM 1/1

l Self-harm can take a number of forms,


including:
l cutting or burning
l self-poisoning with medicines or tablets
l punching
l self-strangulation
l pulling out hair or eyelashes
l scratching or picking at skin
l inhaling or sniffing harmful substances
l swallowing non-food substances
l inserting objects into the body either
through orifices or the skin
l head banging

MANAGEMENT ON ADMISSION

l Admit patients who have self-harmed


overnight

Assessment

l Identifying behaviour, intended


behaviour or self-harming thoughts
l Who knows about the behaviour
l How often this occurred
l If at risk from others
l Stressors e.g. bullying, bereavement,
relationships
l Difficulties, abuse, sexuality issues
l General health
l Use of drugs and alcohol
l Education
l Family and social issues
l Support network available
l Child protection issues

Management

l See Poisoning guidelines


l Advise carers to remove all medications
or other means of self-harm
l Manage Child protection issues
according to local policy and
procedures. On-call consultant available
24 hr for child protection advice
l Assess risk/need for ongoing
psychological treatment or support.
The Child and Adolescent Mental
Health Services (CAMHS) Priority
Referral Team (PRT) provides service
for patients aged <16 yr, or <18 yr if
still in full-time education
Issue 4
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Expires: November 2012

l obtain valid consent for a referral to


CAMHS from parent/other adult with
parental responsibility or the young
person if they are deemed to have
capacity (Gillick competence). Clearly
document in medical records who
obtained consent, who consent was
taken from and when it was obtained
i.e. date and time

Documentation
l Clearly document assessment in notes
with any decisions made and reasons

REFERRALS
Criteria for referral to PRT
l Deliberate self-harm (e.g. overdose,
self-strangulation, serious cuts)
l Deliberate harm from substance
misuse (e.g. poisoning from excessive
alcohol and/or illicit drugs if intention
was to self-harm)
l Mental health symptoms:
l depression/low mood with active
suicidality
l psychotic symptoms
l low weight anorexia nervosa i.e. BMI
<15 or accompanied by rapid weight
loss
l Referrals must be phoned through to
PRT before 1000 hr to be seen that day

DISCHARGE AND FOLLOW-UP


l Discharge when medically fit and have
been assessed by PRT
l Discuss with CAMHS to ensure child
has an agreed plan in place
l If there are safety concerns, refer to
childrens social care
l Ensure health professionals i.e. GP
and school nurse are aware of
admission and management plan
Local contact:
UHNS: PRT are based at Blurton Health
Centre and can be contacted via 01782
227777

197

GLOMERULONEPHRITIS 1/2
RECOGNITION AND
ASSESSMENT
Definition
l Acute inflammatory process affecting
the kidneys leading to haematuria,
proteinuria, oedema, hypertension and
renal insufficiency

Symptoms and signs


l Reduced urine output
l Macroscopic haematuria, coca-cola
coloured urine
l Headache/breathlessness, indicative of
severe disease
l History of sore throat in preceding
23 weeks
l Oedema variable, periorbital/pedal
l check weight, trend is useful
l check jugular venous pressure (JVP),
if raised, indicates volume overload
(cardiac failure)
l Oliguria (urine output <300 mL/m2 per
day)
l Hypertension +/- features of
encephalopathy (headache, nausea,
vomiting, visual disturbance,
restlessness, confusion)
l Signs of cardiac failure (tachypnoea,
raised JVP, gallop rhythm, basal
crackles, enlarged liver)

Investigations
l Urine dipstick: large amounts of blood
and protein
l Urine microscopy: red cell casts
l U&E
l sodium may be low (dilutional effect)
l potassium, urea and creatinine
l bicarbonate may be low
l phosphate, uric acid
l albumin usually normal
l FBC: low haemoglobin (dilutional effect)
l Immunology: complement C3, ANA
and IgG, A and M

198

l Serology: hepatitis B, VZV


l ASO titres and Anti-DNAase B
l Throat swab for Group A
streptococcus
l Renal ultrasound scan for evidence of
pre-existing disease

Differential diagnosis
l Sequelae of other bacterial/viral
infections
l Chronic renal failure with acute
exacerbation
l Henoch-Schnlein purpura
l IgA nephropathy
l Alports hereditary nephritis

IMMEDIATE TREATMENT
l Admit
l Strict fluid balance monitoring and
management
l see Renal failure guideline
l Treatment of volume
overload/hypertension
l furosemide
l see Hypertension guideline
l severe cases of fluid overload will
require dialysis
l Treatment of abnormal chemistry
consequent to renal failure
l see Renal failure guideline
l Oral antibiotics:
phenoxymethylpenicillin if able to take
tablets or amoxicillin suspension (if
penicillin allergic erythromycin) for
10 days
l Nutrition: encourage high carbohydrate
intake

DISCHARGE FROM HOSPITAL


l BP under good control
l Passing urine normally on free fluids
l Renal function improving
l Normal serum potassium

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GLOMERULONEPHRITIS 2/2
SUBSEQUENT MANAGEMENT
Follow-up/progress
l Gross haematuria, oliguria and
abnormal chemistry usually resolves
by 23 weeks
l BP usually normal by 34 weeks
l Serum C3 usually normal by
46 weeks
l Proteinuria resolves by 6 months
l Microscopic haematuria resolves by
12 months

Tertiary referral
Refer to nearest paediatric renal centre if:
l Atypical presentation
l Evidence of serious degree of renal
failure requiring dialysis
l Poorly-controlled hypertension/cardiac
failure/encephalopathy
l Heavy or persistent proteinuria leading
to hypo-albuminaemia
l Normal serum C3 at presentation (i.e.
not post-streptococcal)
l Associated vasculitis
l Delay in recovery as indicated by
timescales above
l Recurrent episodes

DISCHARGE FROM FOLLOW-UP


l Normal BP (when not receiving antihypertensive treatment)
l Normal renal function
l Normal urinalysis

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Expires: November 2012

199

HAEMOLYTIC URAEMIC SYNDROME 1/2


RECOGNITION AND
ASSESSMENT
Definition
l Triad of features

l haemolytic anaemia
l thrombocytopenia

l renal insufficiency

Symptoms and signs


l Diarrhoea with blood and mucus (HUS
can occur in absence of diarrhoea)
l Vomiting

l Abdominal pain
l Pallor, lethargy

l Bleeding tendency

l Reduced urine output/facial puffiness


l Pallor

l Muco-cutaneous bleeding
l Tachycardia

l Reduced consciousness: consider


cerebral oedema, intracranial
haemorrhage

l Convulsions: consider hyponatraemia,


cerebral oedema, intracranial
haemorrhage
l Paralysis: consider intracranial
haemorrhage
l Over-hydration

l oedema (periorbital/pedal) variable


l weight gain, observe trend

l raised jugular venous pressure (JVP)


indicates volume overload (cardiac
failure)
l oliguria (urine output <1 mL/kg/hr)
l tachypnoea

l liver enlargement

l dehydration if diarrhoea has been


severe, see Diarrhoea and vomiting
guideline

Investigations
l FBC and blood film

l low Hb and platelets

l fragmented red cells


l Clotting studies

l U&E, creatinine
l Bicarbonate

l Calcium, phosphate, uric acid


l Glucose

l Liver function tests

l E. coli 0157 serology acute and


convalescent (10 days after onset of
symptoms)
l Urine stick test for significant blood
and protein (indicating glomerular
damage) and leucocytes

l Stool culture for E. coli (and typing for


0157 strain)

IMMEDIATE TREATMENT
l Admit, discuss with regional paediatric
nephrology team in all cases
l Strict fluid balance monitoring and
management
l See Renal failure guideline
l Dehydration

l if signs of hypovolaemic shock give


circulatory support (sodium chloride
0.9% 20 mL/kg IV immediately)
l correct dehydration, see Diarrhoea
and vomiting guideline
l Over-hydration

l if signs of overload/cardiac failure,


furosemide IV 24 mg/kg (max rate
4 mg/min, max dose 1 g), repeated
6 hrly if response obtained
l if furosemide ineffective, discuss
dialysis with regional renal centre

l Hypertension see Hypertension


guideline

l check BP: hypotension


200

Issue 4
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Expires: November 2012

HAEMOLYTIC URAEMIC SYNDROME 2/2


l Anaemia

l daily FBC: only transfuse after


discussion with regional paediatric
nephrology team as may require
dialysis. If asymptomatic, Hb can drop
as low as 6 g/dL
l Thrombocytopenia

l do not transfuse platelets unless there


are life threatening bleeds
l AVOID antibiotics

l Observe for non-renal complications


e.g. encephalopathy and seizures,
cardiomyopathy

DISCHARGE FROM HOSPITAL


l Patient may be discharged when:

l diarrhoea/abdominal pain resolved


l Hb stable (haemolysis ceased)

l drinking fluids freely and passing


normal amounts of urine

l urea and electrolytes improving with


serum potassium normal

Follow-up
l Weekly until renal function stable

l if impaired renal function or proteinuria


persists, arrange paediatric renal
follow-up
l Once renal function normal, arrange
GP or general paediatric follow-up
every year to check BP and early
morning urine (protein:creatinine ratio)
with a detailed renal specialist review
every 5 years
l Advise that women with history of
haemolytic uraemic syndrome require
close monitoring during pregnancy

DISCHARGE FROM
FOLLOW-UP
l Renal function normal
l No proteinuria

l Renal growth and function satisfactory


at 5-yrly review for 15 yr

SUBSEQUENT MANAGEMENT
Tertiary referral
l If significant renal impairment (anuria,
rising creatinine) dialysis required (see
Renal failure guideline), refer to
nearest paediatric renal centre

Issue 4
Issued: November 2010
Expires: November 2012

201

HYPERTENSION 1/4
RECOGNITION AND
ASSESSMENT

Hypertensive encephalopathy
(accelerated hypertension)

Diagnosis is difficult because symptoms


can be minimal and often go unrecognised

l Any neurological sign associated with


grossly elevated blood pressure, most
commonly:

l Severe hypertension can cause:


l loss of consciousness

l severe generalised headache

l hemiplegia

l seizure

l convulsion

Definition
l Depends on a knowledge of normal
range for age or height of child (Table 1)

Symptoms and signs


Severe hypertension
Listed in order of frequency with
common presenting features first:
l Infants

l visual disturbance (+/- retinal changes)

Do not delay initiation of


treatment pending investigations
once diagnosis has been made
Investigations
l Check for evidence of renal disease

l serum creatinine, urea and electrolytes


l urinalysis for blood and protein
l renal ultrasound scan

l congestive cardiac failure

l DMSA scan may be required to


exclude scarring

l failure to thrive, vomiting

l check femoral pulses

l respiratory distress

l Exclude coarctation of aorta

l irritability

l right arm and leg blood pressure

l convulsions

l Older children
l headaches

l nausea, vomiting

l hypertensive encephalopathy (see


below)
l polydipsia, polyuria
l visual problems

l tiredness, irritability
l cardiac failure
l facial palsy
l epistaxis

l poor growth, weight loss


l cardiac murmur
l abdominal pain
l enuresis

202

l ECG for left ventricular hypertrophy


(LVH)
l echocardiogram

l Exclude catecholamine excess

l urine VMAs (contact biochemistry


department for details of how to
perform test)

l urine metadrenalines (performed at


Manchester Childrens Hospital)
l Exclude corticosteroid excess

l 24 hr urinary free cortisol and/or


discuss with endocrinologist for further
investigations

Differential diagnosis
l Incorrectly sized (too small) or placed
BP cuff
l Transient hypertension secondary to
pain, anxiety, distress

Issue 4
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Expires: November 2012

HYPERTENSION 2/4
IMMEDIATE TREATMENT
Hypertensive encephalopathy
(accelerated hypertension)
Urgent treatment necessary but
bring BP under control slowly
Abrupt BP reduction can result in
cerebral ischaemia with the risk of
permanent neurological sequelae, owing
to failure of cerebral autoregulation after
sustained elevation of BP
l Excess BP = actual BP acceptable
BP (Table 1)
l acceptable BP given by the 90th
percentile according to height
l Reduce BP gradually. Aim to reduce
excess BP by 1/3 in first 8 hr, another 1/3
in next 12 hr, and final 1/3 in next 48 hr
l Mark target BP ranges on chart so
nurses know when to ask a doctor to
review
l Discuss choice of drug treatment with
consultant
l Options comprise in following order:
(Table 2)
l sodium nitroprusside infusion
- give in high dependency or intensive
care unit as close monitoring required
- starting dose 500 nanogram/kg/min
- increase in increments of
200 nanogram/kg/min
- maximum 8 microgram/kg/min for first
24 hr, reducing to 4 microgram/kg/min
thereafter
- only effective whilst infused as short
half-life
- stop infusion slowly over 1530 min
to avoid any rebound effects
l labetalol infusion
- do not use in heart failure
- starting dose 0.51 mg/kg/hr
- increase by 1 mg/kg/hr every 30 min
until effective

Issue 4
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Expires: November 2012

- maximum dose 3 mg/kg/hr


(max 120 mg/hr)
- stop infusion when effective
- restart as BP starts to rise again
- normally lasts 46 hr
l nifedipine oral
- quick acting: use modified release to
prevent large drop in BP
- may be used to clip peaks of BP
- dose varies with product: check with
pharmacy

SUBSEQUENT MANAGEMENT
Essential hypertension
l Indications for treatment are
controversial, particularly in well child
with mild hypertension (>90th
percentile) and no identifiable cause
l Treat if child has symptoms and a BP
>90th percentile, or BP consistently
well above 95th percentile (Table 1)
l start with simple measures such as
weight loss, limitation of sodium intake
and exercise
l add drug therapy only after discussion
with a consultant

Renal hypertension
l In children with impaired renal
function, keep BP within same target
range as for children with normal renal
function

203

HYPERTENSION 3/4
OUT-PATIENT MANAGEMENT
th

th

Table 1: BP 90 and 95 percentiles


Boys
Height
(cm)
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180

204

Girls
90th centile
Sys
Dias
100
54
102
56
103
59
104
61
106
63
107
65
108
67
110
69
111
71
112
73
113
74
114
74
116
75
118
76
119
76
122
77
124
77
126
79
127
79
130
80
132
81

95th centile
Sys
Dias
103
58
105
60
107
63
109
65
110
67
111
69
112
71
114
73
115
76
116
77
117
78
118
79
120
80
122
80
123
81
125
82
127
83
130
83
131
84
134
85
137
85

Height
(cm)
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170

90th centile
Sys
Dias
101
56
102
58
102
60
103
62
104
64
106
66
107
67
108
69
109
70
111
71
112
73
114
74
115
74
117
75
119
76
120
78
121
78
122
79
124
80

95th centile
Sys
Dias
104
60
105
62
106
64
107
66
108
68
109
70
110
71
111
73
113
74
115
75
116
77
118
77
119
78
121
79
123
80
124
82
125
83
127
83
130
85

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HYPERTENSION 4/4
Table 2: Drugs commonly used for management of hypertension in children
Mechanism of action
Advice
Beta-adrenoceptor blocker l Reduces heart contractility contraindicated in early
stages of hypertensive heart failure
l Avoid in confirmed asthmatics
Labetalol Non-cardioselective beta- l Combining alpha- and beta-blockade reduces
tachycardia that can be a problem without betablocker with additional
blockade
alpha-blocking properties
l Contraindicated in asthmatics and in heart failure
l Can be used in heart failure as any negative inotropic
Nifedipine Calcium channel blocker
effect offset by a reduction in left ventricular work
l Recommended in children with renal hypertension.
Enalapril Angiotensin-converting
First dose should be given at night to prevent
enzyme (ACE) inhibitor
transient hypotension
l In children with impaired renal function, check serum
creatinine and potassium two to three days after
starting treatment and consider withdrawal if they
have risen
l Contraindicated in bilateral renal artery stenosis
l Second line if enalapril contraindicated or not
Losartan Angiotensin II receptor
tolerated
blocker
l In children with impaired renal function, check serum
creatinine and potassium two to three days after
starting treatment and consider withdrawal if they
have risen
l Contraindicated in bilateral renal artery stenosis
Drug
Atenolol

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Expires: November 2012

205

NEPHROTIC SYNDROME 1/4


RECOGNITION AND
ASSESSMENT
Definition
A triad of features:
l Oedema
l Hypoalbuminaemia: plasma albumin
<25 g/L
l Heavy proteinuria, defined as:
l dipstick 3+ or more, or
l urinary protein >40 mg/m2/hr, or
l early morning protein/creatinine ratio
>200 mg/mmol

Symptoms and signs


Oedema
l Peri-orbital, pedal, sacral, scrotal
l Also ascites or pleural effusion

Cardiovascular: difficult to
assess due to oedema
Assess for hypovolaemia carefully
l Child with diarrhoea and vomiting and
looks unwell
l Abdominal pain: strongly suggestive
l Poor peripheral perfusion and capillary
refill >2 sec
l Pulse character: thready, low volume,
difficult to palpate
l Tachycardia or upward trend in pulse
rate
l Hypotension: a late sign
l Jugular venous pressure (JVP) low

Muffled heart sounds suggest


pericardial effusion
Respiratory
l Tachypnoea and recession: suggest
pleural effusion

Abdomen
l Swelling and shifting dullness: suggest
ascites
206

l Tenderness with fever, umbilical flare:


suggest peritonitis
l Scrotal oedema: stretching can cause
ulceration or infection

Investigations
Femoral blood sampling is
contraindicated because of risk
of thrombosis
Urine
l Urinalysis
l Early morning urine protein/creatinine
ratio first morning after admission
l normal value <20 mg/mmol; nephrotic
>200 mg/mmol and more usually
>600 mg/mmol

Baseline bloods
l
l
l
l
l
l
l

U&E and creatinine


Albumin
FBC
Immunoglobulins
Complement C3 and C4
Zoster immune status: as a baseline
Hepatitis B and C serology

Second-line tests
Request only if features suggestive of
more aggressive nephritis (hypertension,
macroscopic haematuria, high creatinine,
no response to corticosteroids)
l Anti-streptolysin O titre
l Antinuclear antibodies
l Anti-ds DNA antibodies

Interpretation
l High haematocrit suggests
hypovolaemia
l Raised creatinine or urea suggests
hypovolaemia, tubular plugging or
other nephritis
l Serum cholesterol and triglycerides:
often elevated
l IgG usually low
l C3 normal
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NEPHROTIC SYNDROME 2/4


Differential diagnosis
l Minimal change disease (95%)
l Focal glomerular sclerosis
l Multisystem disorders (e.g. HSP,
diabetes mellitus, SLE, and malaria)
l Congenital nephrotic syndrome very
rare

IMMEDIATE TREATMENT
General
l Admit
l Strict fluid balance monitoring
l daily weight: mandatory
l Avoid added salt, but a low salt diet
not indicated
l Manage hypovolaemia see
Complications
l seek senior advice before volume
resuscitation, as a risk of volume
overload

Fluid restriction
l Restrict to usual maintenance intake
(insensible losses plus output)
l If not tolerated, aim for:
l 600 mL/day in children aged <5 yr
l 800 mL/day in children aged 510 yr
l 1000 mL/day in children aged >10 yr

Medication
l Prednisolone 60 mg/m2 orally once
daily (maximum 80 mg), in the
morning (see BNFc for surface area)
l Phenoxymethylpenicillin (Penicillin V)
for pneumococcal prophylaxis
l If oedema upsetting to patient or
causing breathlessness, add
furosemide 12 mg/kg orally or IV
l may intensify hypovolaemia, in which
case also use 20% albumin: discuss
with consultant
l If disease severe, especially with
hypovolaemia, as judged by poor
perfusion, high haemoglobin (Hb),
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Expires: November 2012

thrombophilia, or abdominal pain or if


relapse for >2 weeks, start
dipyridamole at 2.5 mg/kg 12 hrly to
reduce risk of thrombotic complications

COMPLICATIONS
Acute hypovolaemia
l Abdominal pain, looks unwell,
tachycardia, poor perfusion, high Hb
l Seek senior advice before volume
resuscitation, as a risk of volume
overload
l give human albumin 4.5% (if available)
10 mL/kg immediately or sodium
chloride 0.9% 10 mL/kg immediately

Do not confuse 4.5% albumin


with 20% as the latter is
hyperosmolar and can easily
cause fluid overload

l Start dipyridamole

Chronic hypovolaemia
l More common in corticosteroidresistant disease
l Looks unwell, abdominal pain and
vomiting
l Low JVP, rising urea and creatinine,
and poor response to diuretics
l Treatment: check with consultant first
l salt-poor hyperosmolar albumin 20%
0.51.0 g/kg (2.55.0 mL/kg) over
24 hr with furosemide 12 mg/kg IV
midway through infusion
l regular observations for signs of
circulatory overload (e.g. raised JVP,
tachycardia, gallop rhythm,
breathlessness)
l often required daily or twice daily:
liaise with a specialist centre
l Start dipyridamole

Peritonitis
l Difficult to recognise
l steroids may mask signs, including
fever, or cause leucocytosis

207

NEPHROTIC SYNDROME 3/4


l Abdominal pain
l consider hypovolaemia and appendicitis:
request an early surgical opinion
l Obtain blood culture and peritoneal
fluid if possible, then start coamoxiclav IV plus metronidazole IV
pending culture results

Thrombosis
l Renal vein: an important differential in
abdominal pain
l Cerebral vasculature
l Pulmonary vein
l Femoral vein: femoral blood sampling
contraindicated
l A fall in platelets, rise in D-Dimers and
reduced PTT are suggestive
l USS with Doppler study to look at
perfusion and to image renal vein and
IVC can be helpful. If in any doubt,
seek advice from nephrologist
regarding investigation/management

DISCHARGE POLICY AND


SUBSEQUENT MANAGEMENT

l Discharge once in remission


l defined as trace/negative urine protein
for 3 days
l patients with normal BP and stable
weight who are well may be allowed
home on ward leave with consultant
approval. Normally twice weekly
review will be required until in
remission
l Arrange plan of care with patient and
carers see below
l Out-patient review in four weeks

New patients
l Prednisolone 60 mg/m2 (maximum
80 mg) once daily for 6 weeks
l Then 40 mg/m2 (maximum 60 mg)
alternate days for 6 weeks
l gradually reduce dose
l Response usually apparent in 710 days
l No response after four weeks
suggests corticosteroid resistance
208

Relapsing patients
l Relapse
l three consecutive days of 3+ or more
early morning proteinuria, having
previously been in remission
l Start prednisolone 60 mg/m2
(maximum 80 mg) once daily
l continue until nil or trace proteinuria for
three days
l then 40 mg/m2 (maximum 60 mg)
alternate days for a further four weeks
l If relapses frequent despite alternateday corticosteroids for a month
l try short courses of high dose
corticosteroids
l discuss with a paediatric nephrologist

Oral prednisolone
l While on prednisolone 60 mg/m2 once
daily advise to:
l carry a corticosteroid card
l seek prompt medical attention for
illness, especially zoster contacts

Other management
l Urine testing
l teach technique and provide
appropriate dipsticks
l test only first daily urine sample
l keep a proteinuria diary
l Corticosteroid diary with instructions
regarding corticosteroid dosage

Infectious precautions
l Avoid live immunisations for 3 months
after period of treatment with highdose corticosteroids
l Benefit of inactivated vaccines can be
impaired by high-dose corticosteroids
and so a similar delay advisable where
possible
l where not possible because of
frequent relapse, give INACTIVATED
vaccines after a shorter delay and
check for an antibody response
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NEPHROTIC SYNDROME 4/4


l Continue penicillin prophylaxis until
oedema has resolved
l If zoster non-immune (VZV IgG
negative) and on high-dose
corticosteroids, give intramuscular
zoster immunoglobulin:
l after definite zoster contact, a contact
will be infectious 2 days before onset
of rash, and cease when all lesions
are crusted over
l can be given up to 10 days after
exposure. Contact consultant
microbiologist on duty for release of
VZIG
l if zoster immunoglobulin not available,
use aciclovir
l varicella vaccine (live vaccine)
available and should be given if a
suitable opportunity arises between
relapses
l Pneumococcal vaccine in children
see BNFc for schedule

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Expires: November 2012

Refer for specialist advice if:


l Corticosteroid-resistant disease
l non-responsive after four weeks of
daily prednisolone, but start
discussions with specialist centre in
third week
l Corticosteroid-dependent disease
l two consecutive relapses during
corticosteroid treatment or within 14
days of cessation
l Significant corticosteroid toxicity
l Aged <1 yr or >12 yr at first
presentation
l Mixed nephritic/nephrotic picture:
macroscopic (not microscopic)
haematuria, renal insufficiency or
hypertension
l Low complement C3/C4

209

RENAL CALCULI 1/3


RECOGNITION AND
ASSESSMENT
Definition
l Presence of crystalline material within
urinary tract

Symptoms and signs


l Non-specific recurrent abdominal pain
l Dysuria or painful micturition
l Classical renal colic
l Urinary infection (particularly Proteus
spp)
l Macroscopic or microscopic
haematuria
l Passage of stones
l Renal failure

Initial investigations
l Renal ultrasound scan
l Plain abdominal film
l Urine microscopy and culture

Further investigations
l DMSA scan
l to determine function when calculi
multiple or large
l Repeat renal ultrasound scan
l to see if stones have been passed
l to monitor progress of stones
l six weeks after treatment (see below)

IMMEDIATE TREATMENT
l Analgesia for severe pain
l If obstruction is present, urgent referral
to urology at Renal Specialist centre
l Cefalexin orally if symptomatic for
urinary tract infection, adjusted once
sensitivities available
l antibiotic treatment unlikely to
eradicate organism in presence of
stones

210

OUT-PATIENT MANAGEMENT
Investigations in patients with
proven renal calculi
l Fasting (before breakfast) blood
sample for:
l creatinine
l calcium
l phosphate
l alkaline phosphatase
l uric acid
l magnesium
l venous bicarbonate
l pH (warm arterialised capillary sample
to coincide with urine pH)
l Random mid-stream urine
l microscopy, culture and sensitivity
l Early morning urine (first voided
specimen) and 24 hr collection
(request urinary stone screen and
record height and weight on request
form) for:
l sodium
l potassium
l urea
l calcium
l magnesium
l oxalate
l phosphate
l citrate
l uric acid
l cystine
l creatinine
l pH (to coincide with blood pH)

Stone analysis
l May give useful information about
aetiology, discuss with biochemistry
department first
l If stone passage is frequent or
associated with symptoms, ask
parents to strain urine

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Expires: November 2012

RENAL CALCULI 2/3


Table 1: Characteristics of urinary stones
Type
Magnesium
ammonium
phosphate
Calcium oxalate
Calcium
phosphate

Cystine
Uric acid

Appearance

Causes

Radioopaque*
No

Very soft, white,


toothpaste consistency or
gravel fragments
Hard grey-brown rough
surface
Large, smooth, pale,
friable

Infection with urea-splitting


organisms, especially in children
with urinary stasis
Hypercalciuria (any cause)
Hyperoxaluria
Infection
Renal tubular acidosis
Vitamin D toxicity
Idiopathic hypercalciuria
Immobilisation
Hyperparathyroidism
Sarcoidosis

Pale-yellow, crystalline
Maple syrup
Hard, yellow

Cystinuria

Yes

Lesch-Nyhan syndrome
Dietary
Induction in haematological
malignancies
Xanthinuria

No

Adenine phosphoribosyl
transferase deficiency

No

Smooth, soft,
brown yellow
Dihydroxyadenine Friable, grey-blue
Xanthine

Yes
Yes

No

* Radiolucency depends on amount of calcium in the stone and individual patient can
have more than one type of stone, each with different radiolucencies

Interpretation of results
l Urinary pH
l pH <5.3 in presence of normal
capillary pH and bicarbonate excludes
distal renal tubular acidosis
l when above criteria not met, a more
formal test of renal acidification
required in those with nephrocalcinosis
or in recurrent stone formers
l pH >6 with capillary bicarbonate
<18 mmol/L is seen in mild distal
tubular acidosis
l Calcium:creatinine (mmol/mmol) ratio
consistently >0.7 indicates
hypercalciuria
l Oxalate:creatinine (mmol/mmol) ratio
is age-dependent, and suggestive of
hyperoxaluria if it exceeds following
thresholds:
l aged <6 months: 0.35
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l aged 611 months: 0.2


l aged 12 yr: 0.18
l aged 36 yr; 0.11
l aged 714 yr: 0.08
l aged >14 yr: 0.065
l Uric acid/creatinine (mmol/mmol) ratio
is age-dependent, and suggestive of
hyperuricaemia if it exceeds following
thresholds:
l aged <1 yr: 1.5
l aged 12 yr: 1.26
l aged 36 yr: 0.83
l aged 710 yr: 0.67
l aged 1114 yr: 0.45
l aged >14 yr: 0.4
l Magnesium:creatinine ratio <0.2 may
increase stone formation
l Calcium:citrate ratio <0.6 may increase
stone formation
l Cystine, if present, is indicative of
cystinuria
211

RENAL CALCULI 3/3


l Overall solubility index (RS value)
l negative value: stable urine
l value 01: metastable (liable to
precipitate if seeded)
l value >1: spontaneous precipitation

TREATMENT
l Treat any metabolic disorder identified
by above investigations, seek advice
from Regional Nephrology Service
l Keep urine free from infection,
particularly in those with history of
Proteus infection by prompt treatment
if symptomatic
l Advise liberal fluid intake
l adolescent 3 L/day
l pre-puberty 1.5 L/day
l Additional measures for recurrent
stone formation or idiopathic
hypercalciuria (in order):
l dietary assessment to optimise
oxalate, vitamin C, calcium, and
vitamin D intake
l reduced sodium intake in idiopathic
hypercalciuria, if sodium excretion
>3 mmol/kg/day
l high fibre diet with cellulose or whole
wheat flour to reduce calcium and
oxalate absorption
l potassium citrate in patients with low
urinary citrate
l bendroflumethiazide to reduce calcium
and oxalate excretion (unlicensed)
l For large stones that are unlikely to
pass, surgical removal or lithotripsy
may be required
l modality of treatment determined by
location and size of stone
l generally, stones <2 cm suitable for
lithotripsy
l larger stones treated by percutaneous
nephrolithotomy (PCNL) or by open
operation
l nephrectomy may be advised where
kidney function poor

212

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RENAL FAILURE 1/3


RECOGNITION AND
ASSESSMENT
Definition
l Acute renal failure: sudden
deterioration in renal function
associated with retention of
nitrogenous waste and acute
disturbance of water and electrolyte
balance

Presentation
l Poor/absent urine output (oliguria) with
puffiness/oedema:
l neonates <0.6 mL/kg/hr
l infant/child <0.5 mL/kg/hr

Differential diagnosis
Pre-renal
l Secondary to hypotension (e.g.
hypovolaemia from gastroenteritis or
septicaemia)
l Urine osmolality >300 mOsm/kg
l Urine:plasma urea ratio >5
l Urine sodium <20 mmol/L
l Good response to diuretics after
correction of hypovolaemia

Renal
l Haemolytic uraemic syndrome see
Haemolytic uraemic syndrome
guideline
l Acute nephritis see
Glomerulonephritis guideline
l Acute tubular necrosis or renal vein
thrombosis
l Unrecognised chronic renal failure
(oliguria usually not a feature)
l Acute-on-chronic renal failure (e.g.
dehydration or infection)

Post-renal
l Urinary tract obstruction (rare)

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Expires: November 2012

Assessment
l
l
l
l
l
l
l

Hydration (under/over)
Weight
Skin (turgor/oedema)
Ascites
BP/capillary refill
Jugular venous pressure (JVP)
Urine output

Immediate investigations
l See separate guidelines for specific
causes
l Blood
l U&E, creatinine, calcium, phosphate,
uric acid, magnesium, LFTs and
bicarbonate
l FBC
l venous blood gas
l Urine
l urinalysis for blood, protein, nitrites
and leucocytes
l osmolality
l electrolytes
l Renal ultrasound scan
l size and appearance of kidneys
l inflammation and swelling
l evidence of obstruction

IMMEDIATE TREATMENT
l Correct volume status and maintain
fluid and electrolyte balance
l Prevent hyperkalaemia
l Treat underlying cause where
appropriate
l Maintain adequate nutrition

Fluid and sodium balance


Initial correction
l Dehydration
l for shock, give sodium chloride 0.9%
20 mL/kg immediately
l for correction of dehydration see
Diarrhoea and vomiting guideline

213

RENAL FAILURE 2/3

l Volume overload/hypertension
l low serum sodium usually indicates
fluid overload
l furosemide 1 mg/kg IV immediately
(max rate: 500 microgram/kg/min up to
4 mg/min): if no urine output after
30 min, give a further 1 mg/kg and if still
no urine a third 1 mg/kg after 30 min

Metabolic acidosis
l Sodium bicarbonate may be required
discuss with consultant on-call

Potassium
l Hyperkalaemia can lead to cardiac
arrest or serious arrhythmias
l severely restrict potassium intake by
introducing low potassium diet and
avoiding potassium in IV fluids unless
serum potassium <3.5 mmol/L or there
are ongoing losses
l If potassium >6.0 mmol/L, ECG
monitoring essential

l watch for development of prolonged


P-R interval and/or peaked T wave
l as toxicity worsens, P wave is lost,
QRS widens and S-T depression
develops
l Once toxicity develops, the following
(see Table 1) are holding measures
whilst dialysis is set up
l give salbutamol either by nebuliser or
IV as first-line emergency treatment,
followed by calcium resonium (even if
salbutamol effective) to start to reduce
potassium load
l if ECG still unstable, give calcium
gluconate
l if patient acidotic pH <7.30, give
sodium bicarbonate
l if further reduction required after other
measures implemented, use insulin
and glucose
l After starting treatment discuss with
consultant on-call

Table 1: Emergency treatment of hyperkalaemia


Treatment
Salbutamol
nebuliser
Salbutamol
infusion
Calcium
gluconate 10%

Dose
2.55 mg as single dose

Onset
5 min

4 microgram/kg over 5 min

Immediate. Effect
maximal at 60 min
5 min

0.5 mL/kg IV (max 20 mL)


over 510 min. Monitor ECG
Do NOT administer through
same line as bicarbonate
Sodium
1 mmol/kg IV
bicarbonate 4.2% (2 mL/kg of 4.2%)
infusion (only if Do NOT administer through
patient acidotic) same line as calcium
Glucose/insulin Glucose 10% 0.5 g/kg
infusion
(5 mL/kg) over 30 min and
Insulin 0.1 units/kg over 30 min

Polystyrene
sulphonate
resins

214

Calcium resonium
250 mg/kg 6 hrly (max
15 g/dose) orally/rectally

Mode of action
Shifts potassium into
cells
Shifts potassium into
cells
Antagonises effect of
high potassium

Shifts potassium into


5 min
Effect may last several cells
hrs
30 min
Effect may last several
hrs
Frequent glucose stick
checks
Orally 2 hr
Rectally 30 min (irrigate
to remove residue)

Shifts potassium into


cells

Removes potassium
from body

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RENAL FAILURE 3/3

l Hypokalaemia is also dangerous


l if patient becomes potassium depleted
from heavy ongoing losses (fistula or
diuretic phase), it is most important
that replacement is given
l amount and rate of replacement
depend on estimation of losses and
response to initial supplementation. If
in doubt, discuss with consultant oncall

SUBSEQUENT MANAGEMENT
Fluid and sodium balance
l Once normal hydration restored, aim
to replace insensible loss
(300400 mL/m2/day) + urine output
+ other losses
l In anuric patients (as opposed to
oliguric), give fluids that are free of
electrolytes to compensate for
insensible loss; in patients having IV
fluids, glucose 5% is most appropriate
initially, although glucose 4%/sodium
chloride 0.18% may be required later
to compensate for sodium loss from
sweat
l Replace sodium losses in urine and in
other fluids (diarrhoea, gastric aspirate,
fistula)
l in most patients, dietary sodium will
suffice
l in those with large fluid losses,
consider IV sodium to match losses

l Potassium toxicity (as indicated by


features listed previously)
l Metabolic acidosis (pH <7.2)
unresponsive to base supplementation
l Convulsions
l Loss of general well being +/alteration in conscious level see
Glasgow coma score guideline
l Spontaneous resumption of renal
function likely to be delayed
l acute-on-chronic renal failure
l haemolytic-uraemic syndrome

MONITORING TREATMENT
l Accurate fluid balance maintain strict
input-output chart
l Re-assess fluid intake at least 12 hrly
l Record weights, plasma sodium and
PCV as indicators of hydration
l Check K+ hourly if >6 or <3 mmol/L
l Check U&E 12 hrly if K+ 36 mmol/L in
renal failure
l Respond promptly to increase in urine
volume, fall in serum creatinine and
increase in urine osmolality by
increasing fluid intake to prevent
prolonged oliguria
l Once diuresis begins, increase
electrolyte replacement, including
potassium
l once stable, reduce fluid intake
gradually to avoid prolonged diuretic
phase

Nutrition
l Involve a paediatric dietitian
l A low-protein high-energy diet is ideal
(aim for energy intake of 400 kcal/m2)
l Avoid high potassium foods
l Be realistic about what a child will take

Indications for dialysis


l Fluid overload
l Uncontrolled hypertension (for heightrelated 97th centiles see
Hypertension guideline)
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215

RENAL INVESTIGATIONS 1/3


PROTEIN EXCRETION
l As a diagnostic indicator in any child
thought to have an underlying renal
disorder
l To monitor progress in renal disorders
l Normally glomerular, rarely tubular in
origin
l Investigate as below in patients with
persistent proteinuria where cause is
unknown
l Request albumin:creatinine ratio (must
be first urine specimen voided in the
morning) elevation confirms
glomerular proteinuria

Protein:creatinine ratio
l Best performed on first urine specimen
voided in the morning
l Upper limit of normal <20 mg/mmol
l Significant proteinuria >100 mg/mmol
l Heavy proteinuria (nephrotic)
>200 mg/mmol

Timed collection
l Only appropriate for older patients (out
of nappies)
l Night-time collection to rule out
orthostatic proteinuria
l empty bladder at bedtime and discard
sample
l collect all specimens passed during
the night
l empty bladder on rising in morning
and collect sample
l record time from bladder emptying at
night to bladder emptying in morning
l Calculate protein output as mg/m2/hr
(see BNFc for surface area)
l Upper limit of normal = 2.5 mg/m2/hr
l Heavy proteinuria >40 mg/m2/hr

216

Tubular proteinuria
l Request retinol binding protein
(RBP):creatinine ratio elevation
confirms tubular proteinuria

OSMOLALITY
l Used to exclude urinary concentrating
disorders
l patients with polyuria (may present as
wetting or excessive drinking)
l Test early morning urine after
overnight fast >870 mOsm/kg virtually
excludes a concentrating defect
l if concern re diabetes insipidus, do
water deprivation tests during the day

SODIUM EXCRETION
l Fractional sodium excretion (FENa)
assesses capacity to retain sodium
l ensure normal sodium intake (dietitian
to advise)
l stop any existing supplements 6 hr
before taking samples
l document weight loss after
supplements stopped, may provide
useful supporting evidence
l random urine sample for urinary
sodium (UNa) and creatinine (UCr)

l blood sample immediately after voiding


for plasma sodium (PNa) and creatinine
(PCr)

l enter results into equation (using same


units for U and P; 1000 micromol =
1 mmol)
l FENa = UNa .PCr x 100
PNa .UCr
l normal values for FENa
aged 0 to 3 months <3
aged >3 months <1

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RENAL INVESTIGATIONS 2/3


PLASMA CREATININE
l Mean and upper limit dependent on height but can be determined roughly from
childs age if height not available
Table 1:
Age
Up to 2 weeks
2 weeks to 6 months
6 months to 1 yr
2 yr
4 yr
6 yr
8 yr
10 yr
12 yr
Adult female
Adult male

Height (cm)

Mean (mol/L)
66
44
34
28
33
38
42
46
52
68
86

50
60
87
101
114
126
137
147
163
174

Upper limit
87
58
49
39
43
52
57
62
69
89
108

GLOMERULAR FILTRATION RATE (GFR)


l Serial measurements of glomerular filtration rate (in mL/min per 1.73 m2) predict rate
of deterioration when renal function impaired
Table 2:
Age

Mean GFR
(mL/min/1.73 m2)
48
Up to 1 month
77
16 months
103
612 months
127
12 yr
127
212 yr

Range (2 SD)
2868
41103
49157
63191
89165

Plasma creatinine method


l Estimates GFR in children with
reasonable accuracy from PCr and
height, using following formula:
GFR (mL/min 1.73 m2) =
40 x height (cm)
PCr (mol/L)
l Not suitable for children:
l aged <3 yr
l with muscle disease/wasting
l with normal kidneys

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Cr-EDTA slope clearance

51

l Use only when GFR needs to be


determined very accurately
l Complete nuclear medicine request
card
l Provide height and weight of child
l correct result for surface area and
expressed as per 1.73 m2
l if result expressed as mL/min correct
for surface area

217

RENAL INVESTIGATIONS 3/3


RENAL ULTRASOUND MEASUREMENTS
Table 3: Normal values for renal ultrasound measurement
Age
Up to 3
months
36 months
69 months
912 months
13 yr
36 yr
69 yr
912 yr

Length (mm)
45

Range (mm)
3560

50
55
58
65
75
80
86

5060
5260
5464
5472
6488
7386
73100

l Measurements of pelvicalyceal size at


hilum of kidney:
l <5 mm definitely normal
l 510 mm equivocal
l >20 mm implies hydronephrosis

ISOTOPE SCANS
Dynamic imaging (MAG3)
Indications

l To assess differential renal function


between and within each kidney
l To assess obstruction in dilated
system if excretion delayed
l To assess drainage six months after
pyeloplasty
l Indirect cystography in older children
before and/or after surgical correction
of reflux

Operational notes

l Complete nuclear medicine request


card
l SHO or nurse required to insert
venous cannula in young children
l Consider sedation if child has had
previous problems lying still during
examinations
l Maintain good hydration

218

l When assessing obstruction in dilated


system or outcome of pyeloplasty, give
furosemide 0.5 mg/kg slow IV bolus
over 310 min (max rate 4 mg/min)
15 min before giving isotope. Helps to
differentiate genuine obstruction from
isotope pooling, provided function of
affected kidney not severely impaired
l Do not use furosemide for indirect
cystography

Static imaging (99mTc-DMSA)


Indications

l To assess function and prognosis in a


multicystic kidney
l To locate an ectopic kidney
l To identify renal scars after recovery
from acute infection

Operational notes

l Complete nuclear medicine request


card
l Scan kidney 26 hr after injection
l Sedation rarely required

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Expires: November 2012

URINARY TRACT INFECTION 1/4


RECOGNITION AND ASSESSMENT
Treat symptomatic UTI in infants promptly to reduce risk of renal
scarring
Symptoms and signs
Age group
Infants aged
<3 months

>3 months
pre-verbal

Older verbal

Most common
Fever
Vomiting
Lethargy
Irritability
Fever

Intermediate
Poor feeding
Failure to thrive

Frequency
Dysuria

Dysfunctional voiding
Changes to continence
Abdominal pain
Loin tenderness

Abdominal pain
Loin tenderness
Vomiting
Poor feeding

Risk factors for UTI and serious


underlying pathology
l The following should always be
recorded in suspected cases of UTI:
l poor urine flow
l history suggesting recurrent UTI
l recurrent fever of uncertain origin
l antenatally diagnosed renal
abnormality
l family history of vesico-ureteric reflux
(VUR) or renal disease
l constipation
l dysfunctional voiding
l enlarged bladder
l abdominal mass
l evidence of spinal lesion
l poor growth
l high blood pressure

Investigations
l Dipstick test fresh urine for leukocytes
and nitrites in:
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Least common
Abdominal pain
Jaundice
Haematuria
Offensive urine
Lethargy
Irritability
Haematuria
Offensive urine
Failure to thrive
Fever
Malaise
Vomiting
Haematuria
Offensive urine
Cloudy urine

l all symptomatic children (see table


above)
l all unexplained febrile admissions with
temp >38C
l Culture urine if:
l +ve nitrites or
l +ve leukocytes
l If child seriously unwell, measure
serum electrolytes, take blood cultures
and insert cannula

Collection of specimens
Do not delay treatment if a sample
cannot be obtained and child at high risk
of serious illness
l Clean catch in sterile container is
recommended method:
l in babies too young to co-operate
eliciting lateral abdominal reflex may
provoke micturition
l Collect mid-stream urine in those old
enough to co-operate

219

URINARY TRACT INFECTION 2/4


l Pad urine specimens can be used in
babies and young children (only useful
if negative)
l make sure napkin area thoroughly
cleaned before applying pad
l urine extracted from specially designed
pads with a syringe
l always follow manufacturers
instructions
l do not use cotton wool balls or home
made equipment
l for urinalysis (do not send for culture: if
+ve nitrites and +ve leukocytes collect
another urine by clean method)
l Suprapubic aspiration only required to
obtain urgent specimens in very ill
child or where there is continuing
diagnostic uncertainty
l always check there is urine in bladder
by ultrasound first
l lie patient supine with legs held in frog
position by assistant
l cleanse suprapubic skin with alcohol
l use 21 G 3.5 cm needle
l insert midline 12 cm above
symphysis pubis, with needle
perpendicular to skin
l advance needle whilst applying gentle
suction, urine aspirated on insertion

Handling specimens

l Use plain white-topped sterile bottles


for hospital-collected samples
l Use borate (red top) only when child
large enough to fill bottle
l Keep specimen in fridge at 4C until
transfer to laboratory
l During working hours, transfer
specimens to laboratory within 2 hr
l out-of-hours, keep specimen in fridge
until laboratory open
l State date and time of collection on
specimen bottle

220

Interpretation of results
Always take clinical symptoms into
account when interpreting results
Stick testing (NICE recommend only
in children >3 yr)
l Negative for leukocytes and nitrites
excludes urinary tract infection
l Positive for leukocytes and nitrites gives
high probability of infection
l Positive for either leukocytes (more than
1+) or nitrites requires culture or
microscopy if no other focus of infection

Microscopy of fresh sample

l Very useful method of confirming


acute infection
l bacteria and leukocytes (UTI)
l bacteria only (UTI or contaminant)
l leukocytes only (treat if symptomatic)
l no bacteria or leukocytes (no UTI)
l Pyuria
l normal <10 x 106/L in boys, <20 x
106/L in girls
l vulvitis, vaginitis or balanitis can also
give rise to high counts
l viruses (echovirus, adenovirus and
CMV) can cause sterile pyuria
l Colony counts
l organism count >105 organisms/mL
pure growth confirms infection in
properly collected and stored midstream sample
l certainty reduced to 80% with pad
urine
l low counts do not exclude infection

IMMEDIATE TREATMENT
If child systemically unwell, do not delay
treatment while trying to obtain urine
specimen
l Ensure good hydration with
maintenance fluids

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URINARY TRACT INFECTION 3/4


l Antibiotics
l If pyelophephritis: serious systemic
disturbance (fever >39C, pale/mottled,
drowsy, vomiting)
l aged <3 months: cefotaxime
l aged >3 months: co-amoxiclav oral if
tolerated or IV for 7 days
- if penicillin allergic give gentamicin IV
(once daily dosage regimen) over
30 min for 48 hr minimum
- if shocked refer to Septicaemia
guideline
- ongoing treatment depends on
response
l if cystitis: minor systemic disturbance,
give co-amoxiclav orally for 3 days
depending on culture sensitivities
l when child on prophylaxis already,
always give an alternative antibiotic for
acute infection
l Imaging: urgent ultrasound imaging is
only indicated in atypical cases with:
l seriously ill child
l poor urine flow
l abdominal or bladder mass
l raised creatinine
l septicaemia
l failure to respond to treatment within
48 hr
l infection with organisms other than
E. coli

SUBSEQUENT MANAGEMENT
Imaging
Dependent of age and type of infection
l Simple UTI: responds within 48 hr
l Atypical UTI: where initial symptoms
suggest upper tract infection or there
are other symptoms such as voiding
difficulty, not responding within 48 hr
l Recurrent UTI: 2 episodes of UTI with
systemic upset, 1 systemic and
1 simple, 3 simple UTIs

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Expires: November 2012

Test
Simple UTI UTI +
Aged 06 months
US
Yes
Yes
DMSA No
Yes
MCUG No
Yes
Aged 6 month to 3 yr
US
No
Yes
DMSA No
Yes
MCUG No
No
Aged >3 yr
US
No
Yes
DMSA No
No
No
MCUG No

Recurrent UTI
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No

l US 6 weeks after infection when not


indicated urgently (see above)
l DMSA (dimercaptosuccinic acid) scan
6 months after infection
l MCUG (micturating cystourethrography) 6 weeks after infection
l also required where there are voiding
problems or abnormalities on US scan
requiring further investigation (discuss
with consultant)
l requires 3 days of prophylactic
antibiotics with test on middle day

DISCHARGE AND FOLLOW-UP

l Home when:
l symptoms mild, or severe symptoms
controlled
l taking oral antibiotics and tolerating them
l renal function normal or returning to
previous values in those with impaired
function
l discuss and advise to avoid risk factors
at discharge:
- constipation
- poor hygiene
- low fluid intake
- infrequent bladder emptying
l Repeat urine test not required on
asymptomatic children
l Prompt treatment of recurrences with
co-amoxiclav
l Out-patient review
l not required for simple UTI
l in 810 weeks where ultrasound
imaging has been indicated

221

URINARY TRACT INFECTION 4/4


l Prophylactic Antibiotics
l not required following first simple UTI
l Required for:
l child aged <3 yr awaiting results of
imaging
l proven grade 3+ reflux until aged 2 yr
(provided infections well controlled)
l urinary tract obstruction pending
surgical management
l any child with frequent symptomatic
infections (>3 urinary tract infections
per year)
l give trimethoprim 2 mg/kg orally at
night (max 100 mg)
l alternatively, for those with resistant
organisms, (aged >3 months)
nitrofurantoin 1 mg/kg orally at night
(max 100 mg)
l Surgical management of reflux
l not routinely indicated
l obstructive mega-ureters with reflux
l failure to control infections with
prophylaxis in grade 3+ reflux
l neuropathic bladder

222

Management of children with


renal scars
l No follow-up for minor unilateral
parenchymal defect unless recurrent
UTI or family history or lifestyle risk
factors for hypertension
l In cases of significant scarring:
l annual BP measurement
l females must book early when
pregnant and inform obstetric team
l Where scarring bilateral:
l annual BP measurement
l assessment of urinary protein excretion
and renal function every 34 yr
l long-term follow-up in the renal clinic
l transfer to adult service

Issue 4
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Expires: November 2012

ARTHRITIS 1/1
RECOGNITION AND
ASSESSMENT
Definition
l Acute, chronic or recurrent
inflammation of a one or more joints

Symptoms and signs


l Pain
l Stiffness
l Refusal to participate in usual activities
l Joint may be swollen, hot, red and/or
tender
l Affected joint(s) will usually have
reduced range of movement (beware
of hypermobility)

Differential diagnosis
l Juvenile idiopathic arthritis (JIA): arthritis
of unknown aetiology before age 16 yr
persisting for 6 weeks or more
l Reactive arthritis (self-limiting in
response to an infection)
l Non-accidental injury
l Systemic rheumatic diseases, such as
SLE, dermatomyositis, vasculitis
(including HSP and Kawasaki disease)
l Arthritis associated with inflammatory
bowel disease
l Malignancy, especially leukaemia or
neuroblastoma
l Rickets and other endocrine disease
(e.g. type 1 DM, thyroid disease)
l Infectious causes (e.g. TB, rheumatic
fever, Lyme disease)

Rarer causes

l Inherited metabolic diseases and other


genetic disorders
l Chronic recurrent multifocal osteomyelitis
l Auto-inflammatory diseases, including
chronic infantile neurological
cutaneous and arthritis syndrome

INVESTIGATIONS
l X-rays of joints most affected if child
has features of other differential
diagnoses that have radiological
Issue 4
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Expires: November 2012

changes and, if severe, as a baseline


assessment to look for erosions
l FBC, ESR, CRP, ASOT, rheumatoid
factor, ANA and if SLE suspected,
ds-DNA auto-antibodies to exclude
differential diagnoses or for JIA
classification purposes (not useful to
confirm the diagnosis of JIA)

ACUTE MANAGEMENT
l Telephone local paediatric
rheumatology team for advice for
management of musculoskeletal
conditions and assessment of pyrexia
of unknown origin
l Analgesia/anti-inflammatory
medication in order of increasing risk
of side effects but also clinical
effectiveness:
l ibuprofen naproxen piroxicam (see
BNFc for dose based on weight)

If JIA is a possible diagnosis,


arrange early referral to local
ophthalmologist to start
screening program for uveitis
chronic anterior uveitis can be
asymptomatic initially and can
progress to irreversible loss of
vision if referral delayed
DISCHARGE AND FOLLOW-UP
l Refer all children with suspected JIA
and autoinflammatory connective
tissue diseases (e.g. SLE,
dermatomyositis, scleroderma and
sarcoidosis) to paediatric
rheumatology service for urgent
appointment
l Management will involve:
l exploring differential diagnoses
l disease education
l physiotherapy and rehabilitation
l optimising medical treatment including
corticosteroid joint injections (nearly
always under general anaesthetic),
methotrexate, and the institution of
shared care monitoring

223

LIMPING CHILD 1/3


INTRODUCTION
Differential diagnosis varies with age

Common/important diagnoses
l
l
l
l
l
l
l
l
l
l
l
l
l

Any age

Aged 0-4 yr

Aged 4-10 yr
Aged 11-16 yr

Trauma (including NAI)


Septic arthritis
Reactive arthritis
Juvenile idiopathic arthritis (JIA)
Malignancy
Referred pain (e.g. from hip to knee)
Developmental dysplasia of hip (DDH)
Transient synovitis
Non-accidental injury (NAI)
Perthes
Transient synovitis
Slipped upper femoral epiphysis (SUFE)
Gonococcal septicaemia

HISTORY

Musculoskeletal

Ask about:

Check:

l Fever: shivering/sweating

l Joint swelling

l Trauma

l Recent viral illness


l Swollen joints
l Stiff joints
l Sickle cell

l Delayed presentation

EXAMINATION
General
Look for:

l Fever
l Rash

l Pallor

l Bruising

l Impaired growth

l Gait

l Range of movement
l Leg lengths
l Weakness

l Spinal configuration/movement

INITIAL INVESTIGATIONS
l FBC and film
l ESR

l CRP

l If febrile, blood cultures

l X-ray symptomatic joint (and normal


side) and, if origin of pain uncertain,
request X-rays of adjacent joints

l where SUFE a possibility, request AP


and frog views of hips
l if effusion suspected, confirm with
ultrasound scan,

l Other investigations (e.g. muscle


enzymes, bone scan) may be useful
dependent on clinical assessment

224

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LIMPING CHILD 2/3


MANAGEMENT
l If there are any features consistent
with septic arthritis:
l severe pain or local tenderness

l range of movement <75% normal


l temperature >37.5C
l WBC >13 x 10 /L
9

l ESR >20 mm/first hr


l CRP >10 mg/L

l effusion on USS
OR

l X-ray abnormal or suggests


orthopaedic problem (e.g. Perthes,
SUFE)

l Refer to Orthopaedics for diagnostic


aspiration/washout before starting
antimicrobials (see Osteomyelitis and
septic arthritis guideline)

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DISCHARGE AND FOLLOW-UP


l If blood tests and X-ray normal,
irritable hip (reactive arthritis) likely
l discharge with analgesia and
reassurance

l advise return if fever occurs or


problem becomes worse

Review after 5 days


l If worse, refer for orthopaedic opinion
l If no worse, review after a further 5
days
l If still no better, arrange joint
orthopaedic/paediatric review, and
consider referral for paediatric
rheumatology opinion

l If normal at 5 or 10 days, discharge

225

LIMPING CHILD 3/3


Thorough history and examination

l FBC and film


l ESR

l CRP

l Blood cultures if fever

l Plain films of affected joints (bilateral,


consider adjacent joints)
l USS if indicated and available

Any abnormality?
l Abnormal X-ray
l Severe pain

l Local tenderness

l Range of movement <75% of normal


l Temp >37.5C

l WCC > 13 x 109/L


l ESR >20 mm/h
l CRP >10

l Effusion on USS
YES

NO
Discharge home with
analgesia
WORSE
Review at 5 days

To return if much worse


or develops fever
NO
Not worse

Normal
DISCHARGE

Orthopaedic opinion
(withholding
antimicrobials)

Review at 10 days
Abnormal

Normal
Joint
orthopaedic/paediatric
review
Consider paediatric
rheumatology referral

226

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Expires: November 2012

INDEX 1/3
A
Abdominal pain
Abuse

110
19, 190-193, 194-196, 197

Adrenaline

911, 2021, 46, 175

Alcohol poisoning

78

ALTE

18

Amiodarone

10, 11, 7174

Anaesthesia

2728, 36,75,187,188

Analgesia

Coarctation

62, 65

Codeine

22, 24

Congenital heart disease

45

Cyanotic congenital heart disease

62

Cystic fibrosis

141

Antipyretics

112

Croup

20

Antibiotics

62

Constipation

23

Anaphylaxis

189

Coma scale

149

Admission

47

Distal intestinal obstruction

53

Exacerbation

49

Microbiology

51

APLS
Cardio-respiratory arrest

Recognition and assessment of


the sick child

12

Apparent life threatening events (ALTE) 18


Arthritis

223

Arthritis septic

168

Arthritis JIA

223

Asthma acute management

38

Asystole

9, 10

AVPU

14, 15

B
Bacterial infection

149, 155, 176

Bites
Blood pressure

142
12, 180, 202

Blood and platelet transfusions


Bradycardia
Bronchiolitis

130
70, 71
42

D
Dental endocarditis prophylaxis

75

Diabetes and fasting

90

Diabetes new (non-ketotic)

99

Diabetic ketoacidosis

116

Diclofenac
Dietitian referral

24, 135
47, 100, 122

Distal intestinal obstruction

53

DKA

93

Duct dependant congenital heart disease

62

E
ECG interpretation
EEG

66
181, 182, 183

Effusion

5759

Electromechanical dissociation (EMD)


Empyema
Encephalitis

93

Diarrhoea and vomiting

Encopresis

54, 110, 141


161164, 165
112, 194

Calculi renal

210

Cardiac arrest

Epiglottitis

45

64

Epilepsy

185

Epilepticus, status

186

Cardiogenic shock
Cardiopulmonary resuscitation (CPR)
Cellulitis orbital
Cervical lymphadenopathy
Chickenpox
Child protection
Child sexual abuse
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Expires: November 2012

10, 11

Endocarditis prophylaxis

75

167
143
51, 52
190
194

F
Facial palsy

180

Faecal impaction

112, 113, 115

Failure to thrive

125

227

INDEX 2/3
Fallots tetralogy

62, 63, 68, 69

Iron poisoning

79

Fasting and diabetes

90

IV fluid therapy

32

Fasting pre-operatively

36

Febrile neutropenia

131

Fever

147

Fits

161, 186

Fluid therapy

32

Flushing intravenous lines

29

Food poisoning

165

G
General anaesthesia (GA)

37

Glasgow coma score

189

Glomerulonephritis

198

J
127

Jaundice
Juvenile idiopathic arthritis (JIA)

223, 224

K
Kawasaki disease

157

Ketone monitoring

107

L
Limping child

224

Long line insertion

33

Lumbar puncture

H
Haematuria

94, 148, 161, 175

Lymphadenopathy

143146, 178

134, 135, 198, 199

Haemolytic uraemic syndrome

200

Haemophilia

138

Heart failure and weak pulses

64

Henoch-Schnlein purpura

134

Hepatitis

150

Herpes simplex encephalitis

149

HIV and hepatitis B post-exposure


prophylaxis (PEP)

151

HIV infection testing

153

Hyperkalaemia

66, 214

Hypernatraemic dehydration

118, 119

M
Malaria

159

Malignant hyperthermia

187, 188

Meningitis

161

Meningococcal septicaemia

161, 165, 174

Morphine

2426, 28

N
Nephrotic syndrome

206

Neuromuscular disorders

187

Hypertension

202

Neutropenia, febrile

Hypoglycaemia

101

Nocturnal hypoventilation

187

Non accidental injury

190

Notifiable infectious diseases


and food poisoning

165

Nutritional first line advice

122

Hyponatraemia

32, 54, 200

I
Ibuprofen

131133

24

Idiopathic thrombocytopenic
purpura (ITP)

136

Imaging renal

218

Oncology

130

Immunodeficiency

155

Orbital cellulitis

167

Insulin

9092, 9398, 107

Intraosseous infusion
Intravenous (IV) lines, flushing
Ipratropium bromide

228

16

Osteomyelitis and septic arthritis


Overdose

168

7677, 8184, 197

29
39, 41
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INDEX 3/3
Stones - renal

P
Pain assessment

22

Paracetamol

22, 23, 81

Paracetamol poisoning

Surgery and diabetes

90, 92

81

Patient controlled analgesia (PCA)


Petechial/purpuric rashes

25
173

Phenothiazine poisoning/side effects


PIC line

85
33, 34

T
Tachycardia and bradycardia

136

Transfusion

130

108

Tricyclic poisoning

Platelet transfusion

130

Tuberculosis

Pleural effusion

57

Pneumonia

54

Pneumothorax

60

Poisoning and drug overdose

76

Post GA monitoring
ex-premature infants

37

36

Varicella (VZV)

Pre-op fasting
Pulseless electrical activity (PEA)

9, 10

134, 136, 173

70

Thrombocytopenic purpura (ITP)

Pituitary-adrenal axis impairment

Purpura

210, 212

Supra ventricular tachycardia (SVT) 70, 72, 73

88
177

U
Urinary tract infection (UTI)

Ventricular fibrillation (VF)


Ventricular tachycardia (VT)

219

51, 52, 156, 209


9, 71, 72, 74
9, 7074

R
Rash

173

Renal calculi

210

Renal failure

213

Renal investigations

216

Respiratory syncytial virus (RSV)

42, 45

Resuscitation

10, 11

S
Salbutamol
Salicylate poisoning
Sedation
Seizure
Self harm

21, 3841, 49, 214


86
27
181185, 186
197

Septicaemia (including meningococcal)174


Septic arthritis

168172, 224

Sexual abuse

194

Shock IO access

174

Sinusitis

167

Speech arrest

182

Status epilepticus

186

Steroid dependence

180

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229

NOTES

230

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NOTES

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231

NOTES

232

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NOTES

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233

NOTES

234

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Paediatric Guidelines 2010-12

ISBN 978-0-9567736-0-9

These guidelines are advisory, not mandatory.


Every effort has been made to ensure accuracy. The authors
cannot accept any responsibility for adverse outcomes.
Suggestions for improvement and additional guidelines would
be most welcome by Partners in Paediatrics, please contact via
www.partnersinpaediatrics.org.uk

ISSUE 4

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