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TREATMENT PROTOCOLS FOR COMMON PEDIATRIC CONDITIONS

S.
No

Disease

First line drug

Remarks/ Comments

1.

Empyema

Inj. Cloxacillin with Inj. Amikacin

-Staphylococcus most likely.


-Cloxacillin covers both
Staphylococcus and
Pneumococcus
-Amikacin for synergistic effect
as well as gram negative
coverage

OR
Inj. Augmentin
(Inj. Vancomycin if critically sick or MRSA)
2.

Pneumonia

a) Age less than 3 months


Inj. Cefotaxime/Ceftriaxone with
Gentamicin/Amikacin
b) Age 3 months to 3 yearsInj. Ceftriaxone
c) Age more than 3 yearsInj. Ampicillin/Inj. Augmentin

a) Age less than 3 monthsgram negative infections


likely
b) Age 3 months to 3 yearsHib most likely
c) Age more than 3 yearsPneumococcus most
likely

At any age, if rapidly worsening


pneumonia/suspicion of staphylococcal
pneumonia- Start Inj Cloxacillin with Inj.
Amikacin
3.

Pyogenic
Meningitis

a) Age less than 3 monthsInj. Cefotaxime/Ceftriaxone with


Gentamicin/Amikacin
b) Age 3 months to 3 yearsInj. Ceftriaxone/Cefotaxime
c) Age more than 3 years*Inj. Ceftriaxone/Cefotaxime

a) Age less than 3 monthsgram negative infections


likely
b) Age 3 months to 3 yearsHib most likely
c) Age more than 3 yearsPneumococcus most
likely

*If Meningococcal meningitis suspected (e.g


rash) - start Inj. Crystalline Penicillin.
-If CSF is turbid AND addition of Inj.
Cefriaxone does not lead to clinical improvement
in 48 hours, addition of Inj. Vancomycin may be
considered

4.

Enteric
fever

Inj. Ceftriaxone/ Cefotaxime

IAP Task Force Report:


Management of Enteric Fever
DO NOT ADD SECOND LINE DRUGS TILL 5-7 inChildren. Indian Pediatr 2006;
days OF FIRST LINE DRUGS
43: 884.
(Ofloxacin/ Azithromycin/ Chloramphenicol may
be used as second line drugs)

5.

Liver
abscess

Inj. Cloxacillin with Inj. Amikacin and Inj.


Metronidazole

Staphylococcal, gram negative


and anaerobic coverage

6.

Rickettsial
infections

Doxycycline/Azithromycin

7.

Complicated
malaria
(smear
positive/
Parasight F
positive)
Neonatal
seizures

Inj. Quinine/ Artesunate with Clindamycin

Rickettsial infections: Indian


perspective.Indian Pediatr. 2010
;47:157-64.
Management of Malaria in
Children : Update 2008. Indian
Pediatr 2008; 17: 731

8.

Use anticonvulsants in following order:


1. Inj. Phenobarbitone (upto 40 mg/kg)
2. Inj. Phenytoin (15 mg/kg loading
initially, then 10 mg/kg)
3. Inj. Midazolam intravenous infusion
4. Inj. Valproate
If myoclonic seizures, use valproate

9.

Seizures in
older child

GTCS/ partial seizures: Inj. Phenytoin as first


line drug for initial control;
maintenance with phenytoin (if GTCS)/
carbamazepine (if partial, or if GTCS in female)
Myoclonic seizures/ infantile spasms:
Start valproate.Add ACTH/ steroids if EEG
shows hypsarrhythmic pattern

-Following tests should be


performed:
-Blood glucose
-Serum calcium
-Serum sodium/ potassium
-Serum ammonia, Blood gas,
urinary ketones if IEM suspected
-EEG/ ultrasound cranium
-LP if indicated
-Following tests should be
performed:
-Blood glucose
-Serum calcium
-Serum sodium/ potassium
-Neuroimaging/EEG if indicated
-LP if indicated

Febrile seizures: No long term antiepiletics


10.

Invasive
diarrhea/
dysentery

Oral- Cefixime
Parenteral- Inj. Ceftriaxone
Second line: Inj. Cefoperazone plus sulbactam

WHO guidelines for treatment of


dysentery in children 2002

11.

UTI

Complicated UTI in any age or simple UTI


below 3 months of ageInj. Ceftriaxone/Cefotaxime for 10-14 d

Consensus statement on
management of UTI. Indian
Pediatr 2001; 38:1106

Simple UTI above 3 months of ageOral Cefixime/Augmentin for 7-10 days

12

Nephrotic
syndrome

First episode- 6 weeks of daily prednisolone (2


mg/kg) followed by 6 weeks of alternate day
prednisolone (1.5 mg/kg)

Consensus statement on steroid


sensitive nephrotic syndrome.
Indian Pediatrics 2008

Infrequently relapsing nephrotic syndromeDaily prednisolone (2 mg/kg) till


remissionfollowed by 4 weeks of alternate day
prednisolone (1.5 mg/kg)
Frequently relapsing nephrotic
syndrome/Steroid dependent nephrotic
syndromeDaily prednisolone (2 mg/kg) till
remissionfollowed by 4 weeks of alternate day
prednisolone (1.5 mg/kg) followed by tapering of
prednisolone
Along with (in the following order):
1. Tab. Levamisole
2. Tab. Cyclophosphamide
3. Tab. Mycophenoplatemofetil
4. Tab. Cyclosporin
5. Inj. Rituximab
Steroid resistant nephrotic syndrome1. Renal biopsy
2. If MCD/FSGS/MesPGN on renal biopsy,
Either Tab. Cyclosporin/intravenous
cyclophosphamide
3. Second line- Tab.
Mycophenoplatemofetil/ Inj. Rituximab
4. Enalapril in all cases

13.

14.

Acute
glomerulone
phritis

1.
2.
3.
4.

Intake-output charting
Tab. Penicillin V
Inj. Furosemide if clinically indicated
Hypertension management-Tab.
Amlodipine/Enalapril/Atenolol/Prazosin/
Clonidine. If hypertensive emergency,
sodium nitroprusside intravenous
infusion
5. Inj. Methylprednisolone if suspicion of
rapidly progressive glomerulonephritis

Uncomplicat Non severe: observation for 48hrs or oral

C3, ASO, Anti-DNAse B, throat


swab
ANA/ANCA/HBsAg if clinically
indicated
Blood urea/serum
creatinine/urinalysis in all cases

ed acute
otitis
media(6mo
to 12 years)

15

16

17

18

Croup

Group A
streptococc
al
pharyngitis
Acute
Bacterial
Rhinosinusit
is

Acute
Severe
Asthma

amoxicillin 90 mg/kg/day (6 mo-23 mo). The


child should not have received amoxicillin in the
last 30 days and absence of purulent
conjunctivitis and allergy to penicillin should be
documented
Severe: oral amoxicillin and follow up after 4872 hrs for resolution of symptoms. If no
resolution, antibiotics to be changed
Mild to moderate: prednisolone(1mg/kg) or
dexamethasone (0.15mg/kg) if stridor free after
half hour, discharge
Severe: nebulization with adrenaline (4ml of 1 in
1000 solution) and 0.6 mg/kg of IV/IM
dexamethasone. OBSERVE for 4 hrs, if stridor
free, discharge. If no improvement, admission,
continue further doses of adrenaline
nebulization
Children: penicillin V 250 mg BD for 10 days or
oral amoxicillin 50 mg/kg/day for 10 days
Adolescents: Penicillin V or amoxicillin 500mg
BD for 10 days
Amoxicillin+clavulanate 40mg/kg/day for 10-14
days. If no improvement or systemic features of
toxemia, 90mg/kg/day for 10-14 days
In penicillin allergy, levofloxacin or combination
of clindamycin+cefixime or cefopodoxime can be
used
OXYGEN by face mask

Clinical practice guideline for the


diagnosis and management of
AOM by the American Academy
of Pediatrics 2013

Clinical practice guideline RCH


Australia 2011

IDSA guidelines 2012

IDSA guidelines 2012

GINA Guidelines 2011/ NHLBI


2007

Nebulized salbutamol 3 doses at 20 min intervals


along with ipratropium nebulization followed by
as needed
Oral glucocorticoids 1-2 mg/kg/day intravenous
steroids if oral intake is poor
(hydrocortisone/methyl prednisolone)
IV aminophylline 6mg/kg loading dose followed
by 0.9 mg/kg/hr infusion ICU monitoring

19

Chronic
Asthma

Intermittent: as needed salbutamol


Mild Persistent: lowdose ICS or monteleukast
Moderate Persistent: medium dose ICS or

GINA Guidelines 2011/ NHLBI


2007

lowdose ICS+ LABA/ MONTELEUKAST


Severe Persistent: high dose ICS or medium dose
ICS + LABA or monteleukast
ICS= inhaled corticosteroids
LABA=Long acting beta-agonists
20

21

Thalassemia
Major

Iron
deficiency
Anemia

Packed RBC transfusion every 3-4 weekly


Tab Folic Acid daily
Iron Chelation therapy

Oral Iron 3-6mg/kg given for 6months

Hematopoietic Stem Cell


Transplantation(HSCT) is
curative therapy which is not
readily available
Iron Chelators
Inj Desferrioxamine;
Oral Deferasirox and
Deferiprone
Most common anemia in
children
Deworming also should be done
in all children with IDA

22

Aplastic
Anemia

Anti Thymocyte Globulin 30 mg/kg for 4 days


Tab Cyclosporine 5mg/kg daily for 6 months

23

24

Hemophilia
A

Immune
Thrombocyt
openic
Purpura
(ITP)

For Primary Bone Marrow failure


(e.g. Fanconi Anemia) HSCT is
curative

Tab Prednisolone 1mg/kg for 2 weeks

For secondary aplastic anemia


cause should be identified and
rectified if possible

Recombinant Factor VIII therapy 30-50 IU/kg


depending upon the site and severity of bleed

Primary prophylaxis also


available to prevent bleeding.

Factor VIII is given 10-20 IU/kg


three times per week
Pulse i. v. methyl prednisolone therapy 30 mg/kg Mild or no symptoms need no
for 3 days followed by 20 mg/kg for 4 days
therapy irrespective of platelet
count
IVIG 1gm/kg for 2 days or
Platelet transfusion is
Anti D immunoglobulin 75g/kg single dose or
contraindicated unless life
threatening bleeding is present
Oral prednisolone 4 mg/kg for 5 days

25

Congenital

Assess the child for any acute

acyanotic

complications like congestive heart

heart

failure (CCF) and if present treat the

disease with

same with diuretics (frusemide) and

Left to right

inotropes (Dobutamine for cardiogenic

shunt (ASD,

shock; digoxin in patients not in

VSD, PDA)

cardiogenic shock, but CCF not


improving with diuretics alone)

If no complications, assess the severity


of shunt based on clinical features and
echo findings

Start medical therapy (frusemide 1-2


mg/kg/day in divided doses) in
symptomatic children and add afterload
reducing agents (ACE inhibitors) if still
symptomatic after diuretics

Treat anemia if present

Obtain opinion of pediatric cardiologist


regarding appropriate timing and need
for surgical interventions

Have regular follow up visits atleast


once in three months with growth
monitoring and attention to dental
hygiene

26

Congenital

If presented with cyanotic spell, treat

Cyanotic

the acute complication and refer

heart

immediately to pediatric cardiologist for

disease

appropriate surgical intervention.

In infants with increased pulmonary


blood flow, assess the child for any

acute complications like congestive


heart failure (CCF) and if present treat
the same with diuretics (frusemide) and
inotropes (Dobutamine for cardiogenic
shock; digoxin in patients not in
cardiogenic shock, but CCF not
improving with diuretics alone)

Start medical therapy (frusemide 1-2


mg/kg/day in divided doses) in
symptomatic children and add afterload
reducing agents (ACE inhibitors) if still
symptomatic after diuretics

Treat anemia if present

Obtain opinion of pediatric cardiologist


regarding appropriate timing and need
for surgical intervention

Have regular follow up visits atleast


once a month with regular growth
monitoring and attention to dental
hygiene

27

Rheumatic

heart
disease

Look for evidence of acute rheumatic


fever as per Jones criteria.

(RHD)

In case of acute rheumatic fever, start


on anti-inflammatory therapy (aspirin
and/or steroids) for 12 weeks
depending on the presence and severity
of carditis

If no evidence of acute rheumatic fever


and child has established RHD, start
secondary prophylaxis (Tab Penicillin V

Consensus guidelines on
pediatric acute rheumatic fever
and rheumatic heart
disease.Indian Pediatr.
2008;45:565-73

250 mg bd)

If child has symptomatic valvular


lesions, consult pediatric cardiologist
regarding need for any surgical
interventions

Medical management will include


secondary prophylaxis for all patients.
In addition diuretics & ACE inhibitors for
regurgitate lesions should be given if
symptomatic.

Have regular follow up visits atleast


once in three months with regular
growth monitoring and attention to
dental hygiene

28

Acute

Assess dehydration

watery

Look for blood in stools-If present, start

diarrhea

on Inj. Ceftriaxone or syrup cefixime

PLAN A-No dehydration-ORS 5-10


mL/kg for every watery stool

PLAN B- Some dehydration- 75 mL/kg


ORS over 4 hours

PLAN C- Intravenous Ringer Lactate to


be given as follows:

If child is less than 12 months, 30 mL/kg RL


to be given i.v. over 1 hour followed by 70
mL/kg over 5 hours.
If child is more than 12 months, 30 mL/kg
RL to be given i.v. over 30 min followed by
70 mL/kg over 2 hours 30 minutes.

World Health Organization


guidelines on management of
diarrhea in children