Most important topics 2020 – 2022 Alphabetically arranged

Dr.Ahmed Bakry
 Anaphylaxis ( COM and History )
 Def: It is severe type I hypersensitivity reaction, ocuured due to exposure to a trigger
 Trigger: food – drugs – contrast material – anesthesia – insect sting – latex ( all of them
must be taken in details in allergic history )
? Anaphylaxis ‫امتي تقول ان الطفل ده دخل في‬
 If one of the following involved in minutes to several hours:
1) Skin/MM + one of respiratory compromise, -- BP or end organ dysfunction
2) Equal or > 2 of following, Skin/MM – Resp - -- BP – persistent GIT symptoms
3) Decreased BP after exposure to known allergen
 Symptoms and signs: all of them must be asked in systemic review
 Management of anaphylaxis
‫الزم بنفس الترتيب‬
1) Remove allergen if possible
2) Call for help
3) Adrenaline IM
4) ABC
5) Subsequent management
6) Discharge plan
Adrenaline
 Given IM or by auto injector
 Do not give it in widespread rash or facial edema in absence of other symptoms
 Adrenaline IV given only in: Cardiorespiratory arrest - Resistant shock after two doses of
adrenaline IM
 Dose:
 IM:
 Prehospital according to the age:
o 6M to 5 Y: 150 mic
o 6 – 12 Y: 300 mic
o > 12 Y: 5OO mic
 Hospital dose: 10 mic/Kg
 IV: 1 mic /Kg

ABC
1) Airway:
 Suspected AW compromise in facial edema
 If airway edema call anesthesia
 Face mask oxygen
 Monitor by SPO2, ECG and BP
 If complete obstruction: intubation or surgical airway
 If partial obstruction after first rescue dose:
 Repeat adrenaline IM dose
 Adrenaline nebs every 10 min
 Hydrocortisone IV according to the age: < 6M: 25 mg -
o 6M – 5 Y: 50 mg
o 6Y – 12Y: 100 mg
o > 12 Y: 200 mg
2) Breathing:
 Apnea:
 Bag and mask
 Repeat adrenaline IM
 Hydrocortisone IV
 Wheeze:
 Repeat adrenaline IM
 Adrenaline nebs every 10 min
 Hydro IV
 Salbutamol or aminophylline IV
3) Circulation:
 No pulse : BALS
 Shock:
 Repeat IM adrenaline if no response >> adrenaline IV infusion
 Crystalloid

Subsequent management
1) Admit for 6 – 24 H for fear of biphasic reaction especially in:
 Idiopathic anaphylaxis with severe and late onset presentation
 KCO severe asthma
 Past H/O biphasic reaction
 Pt came at night
2) Monitor: Spo2 – BP – ECG
3) Immediate sample to immunology department: Mast cell tryptase two samples, one after
1 to 2 hours of symptoms and the other after 24 H

Discharge and FU

1) Discus with the consultant before discharge

2) Written leaflets detailed about symptoms, how to use the Epipen
3) Allergy nurse
4) Meeting with Dietitian
5) Two Epipens
6) Liase with the school
7) Refer to immunology unit
8) Bracelet
9) Advice: Read labels on any food – All care givers must know about his condition and how
to use the Epipen – If eating out must tell the chief about his allergenic food
 Epipen
 it is a pen has blue cap and orange end, also there a black window to check for the expiry
date and transparent window to check for the medicine.

 Ok, when should I use it?

 You will use it when he has snoring breathing, getting all of sweats, if he had fainting attack
 if he has a rash?
 Rash alone is not an indication to use an Epipen, but if any doubt it is better to use it
 How to apply?
 Hold it in your dominant hand making a fist with the blue cap up and orange down, you
can remember it with blue to the sky orange to the thigh.Then you will remove the blue
cap, inject the medicine directly into the outer side of middle third of the thigh, even on
clothes, then press firmly till you hear a click and you will count for 3 seconds 1 2 3 , after
that you will remove the Epipen, there will be a needle on orange side do not try to touch
it, it will be reduced by itself, then you will call the ambulance
 First you have to carry the Epipen everywhere with you, you have to make sure it is not
expired, you have to be sure that the medicine is crystal clear like water, if it is discolored
or disturbed you should not to use it
 And when you go to the emergency room, do not forget to replace the used Epipen, also
he should avoid eating all types of ………….., raw or cooked, also the caregivers should be
involved and informed as ……….allergic to ……………, and should know how to use Epipen as
well, they should check the food label before giving him food and if any doubt they should
tell the chief he is allergic to ………
 Some children may have what is called secondary reaction, so if …………did not improve
within 15 minutes or he improved and he had another reaction he should use the second
Epipen
 Acute management of asthma
 S/S: cough – wheezes – tight chest ( worsening at night, provoked by triggers )
 DD: inhaled FB – Pneumonia – Pneumothorax – Aspiration – CF – Tracheobronchomlacia – GER -
Hyperventilation
 Assessment and reassessment every 15 min: RR – Respiratory effort – AE – SPO2 – PEFR if >5 Y – HR –
Conscious level – CXR if severe or life threatening not improved on ttt
 Mid/moderate: normal vitals – mild wheezes – speaks with complete sentences – spo2 >92% RA – PEFR
>50% in children equal or above 5 Y
 Severe: ++ RR ++ HR – Cannot talk or feed – SPO2 < 92% - PEFR equal or < 50%
 Life threatening: pallor – cyanosis – poor respiratory effort – DCL – SPO2< 92% RA – PEFR equal or < 30%
 Monitoring:
 If treated with nebulized or IV salbutamol: HR – RR every 10 min – SPO2 – ECG – CBG and lactate –
Baseline UE – K every 12 H
 If treated with IV Mgso4: RR – HR – BP – SPO2 – ECG – CBG and lactate – Baseline UE
 Discharge criteria: stable for 4 hours - Vitals normal – SPO2> 94% RA – PEFR equal or > 75%
 Management according to the degree of severity:
Mild/moderate:
 Salbutamol MDI 2 to 10 puffs via spacer + - face mask
 O2 support if SPO2< 94%
 Once daily oral prednisolone and continue for 3 to 5 days after discharge
 Discharge if meeting discharge criteria with review long term asthma control
Severe:
 Oxygen by NC or mask - Salbutamol 10 puffs by spacer or by mask or by nebulization on oxygen
 Ipratropium if poor response
 Oral prednisolone >> IV hydrocortisone if not tolerated oral prednisolone
 Reassess:
 if meeting discharge criteria >> discharge on same plan of previous one.
 If not meeting discharge criteria: admit – back to back nebs – oxygen – reassess if no improving
>> deal as life threatening asthma
Life threatening:
 Inform on call consultant and PICU Oxygen - Continuous salb and ipra nebs - Hydrocortisone IV
 Reassess, if not improving after above measures:
 Salbutamol IV bolus - Magnesium IV if not improve on IV salb
 Salbutamol IV infusion if no improve on Mg IV bolus
 Blood gases – CXR
 Discharge plan:
 Beta 2 agonist with spacer - Prednisolone daily for 3 to 5 days
 Prescribe preventer (inhaled corticosteroids) – if allergic rhinitis, oral antihistaminic and nasal
steroid spray
 Educate how to use PEFR
 Written personal asthma action plan, Written discharge/weaning salbutamol leaflet
 Refer to respiratory specialist if was admitted with life threatening asthma
 FU with GP within two days
 Refer smokers to smoking cessation services
 Bronchiolitis
 Def: Acute viral inflammation of small airway in children < 2 y with peak incidence
around 6m, occur in winter epidemics
 S/S: Mild pyrexia – Coryza for 2 to 5 days – RD – apnea – intermittent wheezes – poor
feeding – widespread fine crackles
 DD: Viral induced wheezes – Early asthma – CF – Pertussis – FB – Recurrent aspiration
 Investigations:
 SPO2 – CBG
 Nasal RSV PCR: when flu prevalence is high and in immunocompromised pts
 CXR: in localized crackles – cardiac murmur – atypical presentation
 UE: if IVF started
 Blood CS: if sisgns of sepsis or temp > 38.5
 When to admit:
 Dehydration Absolute: Apnea – underlying cardiac disease – Spo2<92% RA – Feeding<
75% -
 Relative: repeated visits to AE in < 48 H – Age < 6W – Age < 6m with < 3 days symptoms
- Underlying lung disease
 Management:
 Admit all babies with same condition within same room - Strict hand washing
 Gentle suction of mouth and nose after putting NS 0.9 nasal drops
 Oxygen: if <90% with no comorbidity and if <92% with comorbidity + SPO2 monitor
 CPAP or HFNC if detotoriating on oxygen support
 Hydration: oral >> NGT if not tolerated >> IVF if RR > 80, SPO2<92% or intolelerated
oral or NGT
 Not recommended routinely: antibiotics – nebulization
 Antibiotics: only if baby < 3 months and fever>39 c after discussion with the consultant
 Oseltamivir: if symptoms < 48 H – influenza test positive – other chronic disease
 When to discharge:
 Spo2 > 90% RA
 Full feeding
 Hospital FU in:
 PICU admitted cases
 Consolidation in CXR
 Expreterm with CLD
 Cervical lymphadenopathy
 Def: enlargement of cervical LN = or > 2 cm
 Classification:
o Acute:
 < 2 W + signs of inflammation
 Unilateral: Reactive – KD – Cat scratch disease
 Bilateral: Reactive – Viral as in EBV and CMV
o Subacute:
 Variable time + non tender but with overlying erythema
 TB – Toxoplasma – Non MTB
o Chronic:
 6 W + no features of acute inflammation
 Reactive – Neoplasm
 History: OCD – Constitutional symptoms – Bone pain – Bruising – Pallor – Pruritus
 Exam: Site – Size – Skin – ENT exam – Other LNs – Abdomen for HSM – Testis in males
 Investigations:
 Indications of urgent investigations: CBC with film – ESR – CRP – CXR – U/S abdomen
 Nodes:
 Supraclavicular or suprasternal
 > 2cm at 4 – 6 weeks
 Growing in size for = or > 2 weeks
 Not returned to base line ( < 1cm ) at 8 – 12 weeks
 S/S:
 Petechiae – purpura – Persistent fever > 2 weeks
 Respiratory compromise - Dysphagia
 Constitutional symptoms – HSM
 Others according to suspected etiology:
 LFTs: if suspected viral infection
 Serology for toxoplasma, CMV and EBV
 CT: if suspected deep neck space infection
 Surgical excisional biopsy:
o In case of non MTB or ?? neoplasm
o After discussion with ENT
o Doing some labs: FBC with film – UE – Uric acid – LFTs – CXR
 Congenital hypothyroidism
Screening by TSH:
 Normal: < 8 IU/L
 Borderline: 8 – 20 IU/L, repeat 7 to 10 days
 Suspected: > 20 IU
 For baby born< 32 W >>repeat at 28 days postnatal or on discharge, whichever sooner
S/S:
 Asymptomatic at birth
 Sleepiness – Poor feeding – Cold extremities – Neonatal jaundice
 Hypotonia – Tongue protrusion – Umbilical hernia – Constipation – Dry skin
Management:
 Detailed history about mother’s diet and thyroid status
 Book urgent thyroid U/S scan
 Obtain results of NB hearing screen
 Take blood sample for confirmation at same day:
o From baby: TSH and T4
o From mother: TSH, FT4 and if autoimmune add thyroid receptor Abs
 Provide leaflet to parents for CHT
 Treatment by levothyroxine 10 – 15 mic/ kg daily max 50 mic:
 In severe CHT ( TSH > 40 ): start with higher dose
 Give first dose at same day and next doses at every morning
 Tablets crushed and mixed with milk
 Liquid form is available but tablet is better
 Do not add the tablet to bottle of formula
 If baby vomits or regurgitates immediately after administration, repeat the dose
 If diagnosed in first sample, TTT must start within 14 day
 If diagnosed in second sample, TTT must start within 21 days
 TSH must be normalized within one month
 Follow up:
o By clinical and biochemical (TSH and T4): TSH in average age specific reference and T4 at
the upper half of specific age reference
o Time:
 In infants: after two weeks from starting the ttt then at 2,4,6,9 and 12 M of age
 1 Y: every 4 months
o If TSH suppressed or baby showed signs of over ttt, dose of thyroxine may need to be
reduced
o Regular FU in pediatric endocrinology clinic
o In case of confirmation of non-persistence hypothyroidism: gradual stopping of the ttt at
age of 2 – 3 years with subsequent monitoring of TSH without ttt
 Constipation
Definitions:
 Constipation: passing hard faeces infrequently/ painful or difficult defecation > 1M
 Fecal soiling: overflow due to fecal disimpaction
 Encopresis: functional non retentive soiling
 Fecal incontinence: soiling in presence of organic cause
 Fecal impaction: hard fecal mass in lower abdomen with fully dilated rectum with stool
What to take in history?
 Volume, frequency and type of stool using Bristol chart
 Overflow or soiling
 Straining or holding during toileting
 First time of passing meconium - FH of HSD
 Bleeding per rectum
 Triggering factors: diet change, potty training, starting nursery/school
What will I examine?
o WT and HT
o Abdominal examination: abdominal distension – fecal masses
o LL neurological exam: in long standing cases
o Inspection of perianal area: for position of anus or any perianal infection
Red flags:
 Early onset constipation: in first few weeks of life - FTT
 Delayed CMPA in 1st 3 years of life
 Anal findings: anal stenosis – anteriorly displaced – patulous anus
 Neuropathic bowel: absent anal wink, impaired LL exam, urinary symptoms, flat buttocks
DD of chronic constipation:
o Idiopathic/functional constipation
o Organic constipation: secondary to neuro or anatomical problem
o Endocrinal or metabolic: hypothyroidism – hypokalemia – hypercalcemia
o Celiac – CF
Investigations:
 Minimal investigations will be needed if careful history and exam done
 TFT and celiac screen: in refractory constipation
 Sweat test: in case of delayed passage of meconium
 Abdominal X ray: not usually required except history suspicious and clinical exam difficult
 Rectal biopsy in: delayed passage of meconium – constipation since neonatal period – FTT –
FH of HSD
Refer to pediatric gastroenterologist:
 Organic cause of constipation suspected
 Disimpaction failed orally or rectally
 Soiling and abdominal pain persist despite the ttt
 Children< 1 Y, with fecal impaction or failed to respond to maintenance therapy
 Management:
 Education: give parents clear explanation about pathophysiology of constipation
 Diet and life style: adequate fluid intake – high fiber – encourage physical activities
 Behavioral:
 Regular unhurried toileting
 Correct toilet position
 Reward system for good behavior – Regular review with +VE enforcement
 Encourage older children to take responsibility
 Discourage negative responses from family
 May need psychological support
 Disimpaction:
o Oral: for 7 days and review in hospital or by GP
 Macrogol( movicol )

 Stimulant laxatives as senna or sodium picosulphate

o Rectal: if oral failed
 Sodium citrate enema preferred
 Phosphate enema if the above enema failed
o Manual evacuation under GA:
 If all above measures failed
 Consult pediatric gastroenterologist and pediatric surgeon
 Maintenance:
 Given after disimpaction to prevent recurrence of impaction
 Aim, soft loose stool initially daily
 First line of ttt: Macrogol 0.5 – 1 sachet daily in children aged < 1 year
 Review after one month: if not improved add stimulant laxatives only for short periods +
using fecal softener as sodium docusate
 High doses, up to 4-6 sachets may be required and dose need frequent adjustment
 Advice parents if improved to reduce gradually and to increase again if no bowel action in 3
days
 If macrogol not tolerated, use sodium docusate or lactulose
 In infants < 6 M: give infant glycerol suppository – hydrolyzed formula if delayed cow’s
allergy suspected
 Withdrawal of laxatives: over period of months
o Once regular bowel habits has been established for few months
o When the child has good sensation of need to open bowels
 Cystic fibrosis admission in general
 Where to admit: always to a cubicle
 Which team I will consult: CF team, discus with them urgently if DIOS suspected
 WT and HT: plot baseline then twice weekly
 Medications: Review and prescribe all the he is on including his supplementation:
Pancreatic enzymes:
 Prescribe the same regimen he is on
 If newly diagnosed:
 Infants >> 2500 to 5000 units added to 120 ml AF or 5 ml BF
 Children >> 10000 per meal and 5000 per snack
 Do not add to the bottle feeding
 Asses if there are signs of malabsorption after starting dose, discus with CF team
Vitamin A, D, E
Oral NaCL: only if prescribed by CF team, usually in 1st year of life after diagnosis
 Physiotherapist and dietitian: to be informed
 Investigations:
 FBC, CRP, UE, LFT, and blood CS ( if IV antibiotics will be given)
 Sputum CS ( repeated 1 – 2 times per week after admission )
 If indicated: nasal and throat viral swab – total and specific IgE for aspergillus – Sputum
CS for NTM
 CXR: only if new clinical signs appeared – always compare with previous one
 Spirometry for whom > 6 years: on admission then weekly
 Overnight saturation: if < 91% , give oxygen supplementation
 Hyperglycemia screening for whom on regular corticosteroids
 Annual blood tests: if not done before the admission
o FBC with blood filmCRP, UE, LFT, glucose and Mg
o Vitamin A, D, E levels
o PTH
o OGTT if equal or > 10 years
o Pseudomonas aeruginosa Abs
o Aspergillus total and specific IGE
DIOS
 acute complete or incomplete fecal obstruction in ileocecal
 S/S: constipation, intermittent abd pain, abd distension and fecal masses
 Radiology: abd x ray – CT if doubt – discus with radio and CF team
 If mild >> macrogol on daily basis - ++ fluid intake
 If severe: Gastrografin oral >> if no response Gastrogarfin rectal
 If complete obstruction: IVF – discus contrast enema with CF team
 Respiratory exacerbation
 S/S: ++ cough and sputum production - ++ dyspnea – decreased appetite – WT loss – Coarse
crackles – hemoptysis
 Admission plan as before
 CXR: not routinely needed unless suspected collapse or pneumothorax
 Discus with CF team in:
 On admission for plan
 Starting or changing the IV antibiotics
 Change nebulized antibiotics or mucolytics
 Use of bronchodilators and inhaled corticosteroids
 Tobramycin level
 Discharge
 Home IV therapy
 Antibiotics:
o Oral prophylactic not to be stopped
o Nebulized which routinely used
o IV: to be discussed with CF team, if discussion not possible start with last one used
during the last admission – used for two weeks
o Sputum CS:
 Pseudomonas aeruginosa >> Ceftazidime and Tobramycin
 Non pseudomonas >> cefuroxime
o Tobramycin monitoring:
 Trough level before 2nd and 8th dose ( should be < 1 mmol )
 No need for peak level
 Do not check the level by porta cath or long line
 Corticosteroids:
o Inhaled: if no benefit, discus with CF team to stop
o Oral: used for 7 days if no improvement of chest condition after 7 days of IV Abs – in
ABPA use for one month
 Nebulized mucolytic: use routinely prescribed one – discus with Cf team if need to change
the type mucolytic
 Discharge after discussion with CF team
 Home IV antibiotics administration if needed after liaise with CF team:
 CF microbiology
 Infection control measures:
o Hand hygiene
o Do not share equipment between patients
o New children with CF in a cubicle
o Prevent contact between CF patients
 Newly diagnosed CF:
o Flucloxacillin 125 mg BID until age of two years
o Cefuroxime for two weeks: if need admission and IV antibiotics
 Pseudomonas aeruginosa:
o First isolation:
 Asymptomatic: Ciprofloxacin oral for 6 weeks + nebulized colistimethate sodium for 3
months
 Symptomatic: IV Tobramycin and ceftazidime for two weeks >> if not succesfuly
eradicated for 2 months, consider nebulized tobramycin for 4 weeks
o Chronic: defined as > 50% of samples positive for PA, discus with CF team about suitable
prophylaxis nebulized antibiotics
 Burkheria Cepacia Complex ( BCC ):
o First isolation: report to CF immediately – Disscus with them suitable IV and nebulized
antibiotics according to CS
o Chronic: as in PA
 MRSA:
o First isolation: report then see if
 Asymptomatic: nebulized vancomycin for 5 days followed by 2 or 3 oral Abs for 6 weeks
according to CS
 Symptomatic: 2 weeks IV Abs according to CS
o Chronic: as PA and BCC
 Chicken pox: high risk who are on oral corticosteroids
o Exposure defined if being in same room > 15 min or face to face contact
o If symptomatic:
 Not taking oral corticosteroids: oral acyclovir(IV if severe) for 7 days and course of oral
Abs(e.g co amoxcalv )
 On oral corticosteroids: acyclovir + VZIG after discuss
o If asymptomatic and non-immune:
 On high dose steroids (prednisolone 1mg/kg/day for 1M or 2mg for 2W) + exposure less
than 4 days: VZIG
 On modest dose of steroids(<1mg/kg/day) or high dose > 4 days >> acyclovir for 7 to 21
days
 Influenza and pneumococcal vaccine: Influenza every October – conjugate pneumococcal
 Porta cath: used in children need frequent IV antibiotics – Flushed every 4W
 DKA
 Diagnosis: clinic lab
 Clinical: thirst – polyuria – polydipsia – abdominal pain – vomiting – kaussmaul breathing –
dehydration – drowsiness – coma
 Lab: ++ BG>11mmol/L - ++ ketones in urine/blood – PH < 7.3
 Assessment: clinic lab
 Clinical:
 A B C – WT and HT
 GCS: basic and every 1 H
 Signs of brain edema: headache, confusion, irritability, abnormal movements, slow pulse,
high BP, papilledema, small and irregular pupils
 Signs of sepsis
 Estimate dehydration based on PH value:
 Mild to moderate DKA = 5 % dehydration = PH 7.1 – 7.29
 Severe DKA = 10% dehydration = PH < 7.1
 Lab:
 Insert two IV cannulas
 For all cases: Capillary BG – BG – Blood gases – FBC – HBA1c – Electrolytes – Blood
osmolality – Blood ketones – Sepsis screen – LP if meningism – LFT – Amylase
 For newly diagnosed: Thyroid and celiac antibody screen – IgA – TSH, T4 – Islet cell Abs –
GAD Abs
 Management:
Admission:
 Ward/HDU: if alert and not shocked
 PICU: if GCS <8 – PH< 7.1 – Age < 2 Y
General measures:
 Inform senior staff
 NPO
 NGT: if abdominal pain, vomiting, no bowel sounds or decreased GCS
 Fluid balance + - catheterization in children requiring HDU/PICU
 Flow sheet: for recording biochemistry and blood gases
 ECG monitoring for T wave changes
Monitoring and FU:
 Clinically face to face:
o At start of ttt then 4H, but check frequently if age < 2 Y, severe DKA
o Neurological assessment hourly, HR and BP hourly by nurses, if any concern inform
o Review vital signs, labs, ECG and fluid balance sheet, daily WT check
o Complete DKA summary sheet
 Lab:
o After start of ttt hourly Capillary blood glucose and gases, then 4 hourly BK, UE,
capillary blood gases and serum glucose( may need 2 H if severe DKA )
Intravenous fluids: to be continued until blood ketones <1mmol/L
o Types of fluids:
 NS 0.9%: in Shock – Bolus – Deficit and maintenance – compensation ++ diuresis
 NS 0.9% + D5%: if BG <14mmol/L and blood ketones<3mmol/L +0.05 iu/kg insulin
 NS 0.9 + D10%: if BG <14mmol/L and blood ketones>3mmol/L+0.1iu/kg insulin
 NS 0.45% + KCL: as a compensation in case of large volume gastric aspirate
o Shocked:
 20ML/KG NS 0.9% over 10 – 15m and not subtracted from total fluid requirement
 Consider inotropes after 40 ML /KG, 20 >> 10 >> 10 >> inotropes
 Call most senior - HDU admission
o Bolus NS 0.9%:
 10 ml/kg over 30 minutes
 In mild/moderate/severe DKA
 Subtracted from the total fluid requirement
o Deficit/48 H and maintenance/24 H:
 Deficit: calculated by estimation of dehydration by degree of PH
 Maintenance: calculated by using Holiday Segar formula
o Fluid losses:
 In massive diuresis for several hours, replaced by NS 0.9%
 If large volume of gastric aspirate, replaced by NaCl 0.45% + Kcl
o Oral fluids:
 Can be given if dehydration 3% + Pt can tolerate orally + SC insulin
 Do not give in case of DKA on IVF till no ketosis + abdominal pain/vomiting
 NGT in case of gastric paresis
 If oral fluids given before the 48 hours’ rehydration period, subtract the taken amount
of oral from the IV infusion
Insulin infusion: using the soluble insulin
o Previous insulin:
 If on insulin pump to be stopped during the IV insulin infusion
 If on long acting insulin: continue same dose and time in addition to the IV insulin
infusion
o Do not: Give insulin bolus - Add insulin directly to fluid bags
o Start:
 After 1 – 2 hours after the IV fluids
 Start with 0.05 iu/kg/h
 Start with 0.1 iu/kg/h in case of severe DKA or in adolescence
o Modification:
 If no fall of glucose by 2 hours from starting the IV insulin infusion: check cannula patency
and IV pump, increase by 20%. reevaluate after 4 H, if still no fall, increase to 0.1 unit/ml
 If BG falls>5mmol/L: reduce insulin infusion rate and adjust as necessary
 If BG > 14 + KB >3mmol/L: insulin to be 0.1 iu/kg/h + NS 0.9%, D10%
 If BG < 14 + KB <3mmol/L: insulin to be 0.05 iu/kg/h + NS 0.9%, D5%
 If BG < 6 + still acidosis: ++ GIR
 If BG < 4: give 2ml/kg D10% + stop insulin infusion for 1H and recheck BG
 If PH>7.3 and the child on 0.1u/kg/h: reduce to 0.05 iu/kg/h
o If still acidosis, consider:
 Insufficient insulin or Inadequate resuscitation
 Sepsis
 Hyperchloaremic acidosis ( not an indication to continue insulin infusion )
 Other drugs adding to the decrease in PH as salicylate
o Stop:
 When BK< 1mmol/L
 Child tolerate oral fluids and food
o Converting: before stopping the IV insulin infusion
 30 min: to SC
 60 min: to insulin pump with changing SC site and the cartridge
Potassium:
 Expected hypokalemia for 48 H from starting ttt of DKA
 All fluids must have potassium except in: Bolus fluids – Anuria – K > 5.5
 3.5 – 5.5mmol/L: put 40mmol/L
 <3.5mmol/L: Senior consultation – CVL for >40mmol/L
 <2.5mmol/L: Transfer to PICU – Consult about rapid correction over one hour,
0.2mmol/kg+NS0.9% by separate infusion
 Sodium:
 All patients with DKA may have false hyponatremia
 Corrected sodium to be measured = measured Na + ( G – 5.6 / 3.5 )
 If ++ Na> 5mmol/L in 4 to 8 hours: caused by too much fluid loss or inadequate replacement
>> increase the fluid rate
 If - - Na > 5mmol/L in 4 to 8 hours: caused by too much fluid given or too rapid replacement
>> decrease the fluid rate
NaHco3: given only in very limited situations after contact the consultant
 Life threatening hyperkalemia
 Impaired cardiac contractility
Cerebral edema:
 Clinically: headache, irritability, -- HR, -- conscious level, ++ICP symptoms and signs
 Exclude the hypoglycemia
 Inform the consultant immediately
 Admit to PICU, may need intubation and ventilation
 NGT – Urinary catheter
 Consider CT / MRI brain
 Restrict IVF to 50% maintenance and to be given over 72 H
 NS 2.7% 5ml/kg over 10 – 15 minutes, if not available give mannitol 0.5g/kg over 15
minutes, to be repeated after 2 hours if needed
Antibiotics:
 Not routinely used in DKA
 Used only in suspected systemic infection: fever, raised lactate and inflammatory markers
Abdominal pain: treat according to the cause, may gastritis, bladder retention, ileus,
appendicitis or pancreatitis
Discharge:
 On multiple daily dose injections: basal bolus regimen
 Add correction doses
 Inform the diabetic team: consultant, diabetic nurse and dietitian
 Prescribe: cartridges of insulin – glucose gel and tablet – free style and its requirements
 Written leaflets: how to deal with hyper, hypo and sick days
 Epilepsy
Definitions:
 Seizures/convulsions: paroxysmal disturbance of consciousness, behavior, motor function,
sensation singly or in combination
 Epilepsy:
 = or > 2 unprovoked seizures > 24 H apart
 I unproved seizure + probability of further seizure in = or > 60%
 One of epilepsy syndromes
Recognition: Diagnosis of epilepsy is clinical
 Detailed history: what is happening before, during and after
 Any video recording will be very useful
 Ask about provoking factors
 Any association: Learning difficulties, CP, Head injury, meningitis or neuro cutaneous
 Any FH of epilepsy or genetic disorders
 Full neurological examination
Seizures types:
 Generalized: Tonic – Clonic – Tonic/clonic – Atonic – Myoclonic – Myoclinic/atonic
 Focal: characterized by = or > 1 of: Aura, motor, autonomic, alert
 Unknown: epileptic spasm
Epilepsy syndromes:
 Investigations:
 EEG indicated in:
o Clinically diagnosed epilepsy
o After an episode of status epilepticus
o Unexplained coma or encephalopathy
o Suspicion of non-convulsive status in children with learning difficulties
o Acquired regression of development, speech or language
o Monitor progress in west syndrome
 EEG not indicated in:
o Funny turns, apneic attacks, dizzy spells, strange behavior
o Syncope, reflex anoxic, breath holding spells
o Febrile seizures
o Single uncomplicated GTC seizures
o To monitor progress in well controlled epilepsy
o Before stopping the TTT
 MRI indication:
 Focal epilepsy except Rolandic seizures
 Myoclonic or intractable seizures
 Seizures continue in spite of 1st line TTT
 Epilepsy in children < 2 Y
 Associated with neurological deficits
 Developmental regression
 West syndrome
 Other investigations:
o Sleep or sleep deprived EEG: in high suspicious and normal awake EEG
o Video telemetry in pseudo seizures
o Drug level
o Biochemistry: G, Ca, Ammonia, Lactate, Metabolic workup
General rules in TTT:
 First line: Carbamazepine 2.5 – 5mg/kg/day(max 20mg/kg) or Na valproate 5 to 10 mg(max 20mg)
 Avoid polypharmacy: do not add new one unless reach to maximum dose of 1 st one
 You should discuss the side effects of the drugs with parents
 Discus TTT with females in childbearing period, for potential risk of NB malformation
 Additional factors to be considered: Compliance, career choices, driving, alcohol and drugs
 Withdrawal of TTT over 2 to 3months after being seizures free for two years, others need 6 to12M
 Recurrence after withdrawal about 25 to 30%, in some syndromes reach 80%
FU:
 Initial every 3 montha
 Subsequent every 3 – 12 M according to the clinical need
Indications of referral:
 Immediately: if regression or epilepsy syndromes
 Soon, if = or > one of following: Age < 2 Y – Seizure continue despite TTT for 2 Y – Unsuccessful 2 AEDs
– Unacceptable SE of drugs – Unilateral structural lesion – Psychological or psychiatric association
 Routine if specific syndrome like sturge weber, Rasmussen or hypothalamic hamartoma
 Febrile neutropenia
Def: Temp = or 38C + Neutrophils < 0.5 X 10 ^9
Frequent clinical assessment is a vital part in management
Door to needle is to be < 1 H, do not wait for results, administer IV antibiotics
Investigations:
 CBC, CRP, UE, LFT, Blood group, lactate and urine analysis
 Blood CS – Culture of both lumens/portacath in case of Pts with CVL
 Coagulation profile: if in sepsis
 CXR: if respiratory symptoms
 RVP: if coryzal symptoms
Treatment: follow individual trust antibiotic policy or patient plan
 Low risk patients:
 No CVL + Neutrophils >0.5 x 10^9 + asymptomatic
 Discus with consultant for discharge on oral antibiotics
 Hemodynamically stable:
 Not on chemo contain IV methotrexate: Piperacillin tazobactam
 On chemo contain IV methotrexate, pencillin allergy or tazo resistant:
 Meropenam first line
 Add vanco or teicoplanin if previous MRSA documented
 Hemodynamic unstable: Inform senior consultant
 ABC - Sodium chloride 20ml/kg – monitor UOP
 Meropenam
Follow up: reassess after 24 H – Chase blood CS
 If afebrile for = or > 24 h + Negative Blood CS after 48H >> stop Abs + discharge
 Positive blood CS:
 Discus with ID consultant or oncology team for appropriate antibiotics
 At least 7 days IV antibiotics
 Feverish + Negative blood CS: do not switch empirical antibiotics unless clinical
deterioration
 Febrile after 48 H:
 Repeat blood CS
 Discus with the consultant
 Change tazocin to meropenam
 Febrile after 96H or unwell between 48H to 96H:
 Initiate investigations for fungal infections : US abdomen – CXR/CT chest
 Repeat blood culture
 Add liposomal amphotericin
 If profound neutropenic: G – CSF after discussion with oncology team
 GOR
Key points in history:
 In infants:
 Term or preterm – BF/AF – Volume and number of feeds
 Vomiting: volume expelled – color – projectile or not
 Chocking or gagging
 Recurrent chest infections
 Excessive crying during feeding
 Sandifer syndrome symptoms
 Associated diarrhea, constipation or blood in stool
 FTT - FH of atopy
 Older children:
 Abdominal pain, heart burn, epigastric pain
 Dental enamel problems – halitosis – hoarseness of voice
Examination:
 Growth - Hydration – perfusion
 Abdomen masses or tenderness
 Skin eczema – perianal erythema
 Hernia sites
 Phone recording
Red flags:
o Vomiting: projectile or bilious - Hematemesis - Blood in stool
o Abdominal distension, tenderness or palpable masses - FH of atopy
o Dysphagia – intolerance to lumpy food during weaning
o Late onset>6M or persistent after 1Y
o Fever - Dysuria
o Bulging fontanel – increase in HC - Persistent morning headache
High risk group: preterm, Neurodisable, FH, obesity, Hiatus hernia, Operated CDH, operated
esophageal atresia
Refer for specialist opinion: red flags – unexplained feeding difficulties – persistent FTT – Feeding
aversion – chronic cough – 2nd episode of pneumonia with regurgitation – recurrent OM – Sandifer
Investigations done by specialist: 24h PH study and 24h impendence study – upper GI contrast
study or barium swallow – flexible GI endoscopy
Treatment:
 Non pharmacological ttt: reduce volume – small frequent feeds – trial of thickened formula –
do not use positional management in sleepy infant – in FH of atopy, trial of extensively
hydrolyzed formula for 4 weeks, if no improvement shift to AA formula, if BF mother excluded
from cow milk in her diet for two weeks
 Pharmacological: trial of alginate therapy for 2 weeks >> H2 receptor antagonist or PPI ( omi,
lanso, esmo ) for 4 weeks >> if no improvement or recurrence on ttt >> refer
 Surgical for refractory Pts: fundoplication or jejunostomy
 Headache
S/S:
 Headache: Location – Intensity – Quality – Duration – Frequency – Effect of
impairment – Other symptoms
 Associated symptoms: DCL – Seizures – Persistent vomiting – New visual symptoms –
Recent change in gait or behavior – Systemic symptoms
Red flags:
 Headache:
 Recent onset of severe headache
 Change in headache severity or frequency
 Early morning or awaken him from sleep
 Postural headache
 Fixed or unusual location
 Ophthalmological S/S
 School/Personality deterioration
 Parental worry
Examination:
 General exam:
 Vitals: Temp – HR – RR – SPO2
 Anthropometric: WT – HT – BMI
 Pubertal status
 Skin: Rash – Marker of neuro cutaneous syndrome
 Head for abnormal position – Neck – Face
 Full ENT exam
 Neurological exam: look for Squint – CN palsy – Focal neurological signs – Cerebellar
signs – Meningeal signs
 Fundus exam: if abnormal/uncertain >> discus with ophthalmologist
Indications of brain imaging:
 If any red flags
 First/worst headache
 Short H/O progressively worse headache
 Presence of new neurological S/S
 Idiopathic intracranial hypertension
 Def: Papilledema + - 6th CN palsy – Intact conscious level – Any pattern of headache
 S/S:
 Papilledema – Transient visual loss/Blurring
 Normal neurological exam apart from 6th CN palsy and papilledema
 Features of ++ ICP
 Additional features: Ataxia – Tinnitus – Dizziness – Back/neck pain or stiffness –
Waking up from sleep with headache
 Causes:
 Obesity
 Drugs: Steroids – GH – OCP
 Endocrine: Hypo/hyper T3 – Hypo/hyper PTH – Adrenal insufficiency – Cushing
 Hematological: IDA – Sickle cell anemia
 Infections: OM – Lyme disease – HIV
 Systemic disorders: SLE – CKD
 OSA
 Cerebral venous thrombosis
 Investigations:
 Lab:
 Initial: FBC – UE – TFT – PTH – Bone profile
 Others: as clinically indicated
 Imaging:
 MRI: modality of choice
 MRV: after discussion with consultant and radiologist
 CT: if there is CI to MRI or there is significant urgency on exam
 Lumbar puncture:
 Do not diagnose IIH in presence of ++ CSF pressure alone in absence of typical
clinical features
 Findings: high opening pressure >28 cm H2o – Normal cell and count
 False high: Distress – Anxiety – Valsalva – Sedation
 False negative: Hyperventilation
 Treatment: Acetazolamide
 Heart fauilure
 Common causes:
 In infancy: Congenital heart defects – Severe LT sided obstructive lesions in first month of life,
may need PGs – LT to RT shunt lesions
 In age > 1 Y: Myocarditis – Dilated cardiomyopathy – Post surgical cardiac Pts
 Symptoms: Poor feeding – FTT - Dyspnea on excretion – Sweating –- ++ HR, RR
 Signs: Weak thready pulse – Gallop rhythm – Murmur – Basal crackles – Cold and wet skin –
Hepatomegaly - Poor peripheral circulation in cardiogenic shock
 Cardiogenic shock: considered with S/S of shock in the following situations,
 Failure to improve after adequate fluid replacement
 Respiratory symptoms after fluid resuscitation
 With known cardiac condition
 Murmur, pulmonary edema or both
 CXR showed cardiomegaly
 With history of poisoning
 Investigations:
 Imaging:
 CXR: cardiomegaly
 ECG: ventricular enlargement – Arrhythmias
 Echo if available: refer to regional pediatric cardiac center if Echo not available
 Laboratory: FBC – UE – LFT – CBG for PH and Lactate
 Monitoring: Cardiac monitoring – Noninvasive BP – Pulse oximetry – Core skin temp – Fluid
balance, urine output and daily WT
 Management: all Pts with HF to be discussed with Pediatrician expertise in cardiology or regional
tertiary cardiology centre:
 HF:
 Elevate head and trunk: if RD
 NGT: in infants who not feeding well
 Oxygen support: in moderate to severe distress aiming for SPO2 94 – 98% - in some complex
CHD, accepted low sat after discussion with the cardiologist
 Diuretics: Furosemide oral or IV 1mg /kg/bid + Amiloride 100 mic/kg/Bid
 Potassium: if he is on furosemide to e checked 12 H and 4 -6 H if outside normal range –
Add KCL 0.5 mmol/kg or IV after consultation
 Acidosis, hypoglycemia and electrolyte disturbances: to be corrected
 Cardiogenic shock:
 Urgent input from cardiologist and PICU specialist
 Invasive monitoring
 Inotropes ( dobutamine, epinephrine ) + vasodilators ( milirinone )
 MV with PEEP: if pulmonary edema
 Transfer to specialist center with ECMO: may be needed
 Heart murmur
 Innocent murmur:
 Common in older children > 1 Y
 Children are healthy and asymptomatic
 Gets louder when child becomes unwell with fever and infection
 Systolic or continuous, never to be diastolic
 Change with position and respiration
 No thrill or radiation
 No need for investigations
 FU with GP after 2-3 W in infants and 6-8 weeks in children, if murmur persist refer him
to pediatrician expertise in cardiology
 Pathological murmur:
 Symptoms in infant:
 More likely to be pathological
 Feeding difficulties – FTT
 Sweating during feeds
 Recurrent respiratory infections
 Symptoms in children:
 Weak femoral pulses
 O2 sat < 94% RA
 ++ RR
 Loud murmur with thrill
 Diastolic murmur
 Hepatomegaly
 Investigations:
 CXR: cardiomegaly
 ECG: chamber enlargement
 Management:
 Asymptomatic: refer to pediatrician expertise in cardiology
 Symptomatic: admit and discus with the consultant

Endocarditis prophylaxis

Any prosthetic valve or any prosthetic material used during valve repair
Any previous episode of IE
Any type of cyanotic CHD
Any type of CHD repaired with prosthetic material: up to 6 M after the procedure
Any residual shunt or valve regurgitation: lifelong prophylaxis
 HSP
 Vasculitis of unknown etiology, typical age 2 – 8 Y
 S/S:
 Rash: raised purpuric with surrounding erythema over extensor surfaces of legs, buttocks and arms
 GIT: Abdominal pain, nonspecific typically resolved in 72H, if severe to exclude intussusception,
testicular torsion or pancreatitis - Nausea and vomiting - Intestinal hemorrhage: hematemesis,
melena or bloody stool
 Renal:
o Microscopic hematuria
o Proteinuria, can be present 4 – 6 W after initial presentation
o HTN
o Nephritic or nephrotic
o Edema of hands, feet, sacrum or scrotum
 CNS: headache – seizures – paresis – coma
 DD: Other causes of purpuric rash like meningococcemia – ITP
 Investigations:
 Initial:
o BP – Urine dipstick for hematuria and proteinuria
o Protein/creat ratio: early morning, in case proteinuria in dipstick
o Urine microscopy: in case of hematuria
 Additional: if abnormal UA or diagnosis is uncertain
o FBC – Blood film - UE – Albumin
o Coagulation profile
o Throat swab
o Blood CS and ASOT if fever
 Indications for admission:
o Orchitis – Arthritis > 2 joints – inability to ambulate
o Moderate/severe abdominal pain – clear evidence of GI bleeding
o Proteinuria
 Treatment:
o Arthritis: ibuprofen, but used with caution in case of renal involvement
o Abdominal pain: prednisolone 1mg/kg/day for two weeks, if severe exclude GI complications
 Monitoring and FU:
o Uncomplicated HSP (e.g UA = or < +1 blood or ptn + normal BP): FU with GP the BP monthly for
6M and urine dipstick weekly till be urine clear
o Complicated HSP: FU in children clinic
 Parents education:
o Condition will fluctuate for several months; recurrence is rare
o Close urine monitoring, as rarely AKI may occur
o Seek medical advice if: headache, severe abdominal pain or GI bleeding
 Refer to nephrologist if:
o Abnormal urinary finding > 6 months
o Macroscopic hematuria - Heavy proteinuria at presentation – Hypertension Impaired RFT
 Refer to rheumatology if: atypically or rapidly evolving rash
 HUS
 Def: triad of MAHA + Thrombocytopenia + AKI
 S/S:
 GIT: vomiting – diarrhea – abdominal pain – rectal prolapse – toxic mega colon –
perforation – intussusception
 Renal: oliguria
 CVS: ++ JVP – Cardiomyopathy - ++ HR – Hypotension
 CNS: lethargic – reduced consciousness/limb weakness in intracranial thrombosis
 Blood: pallor – purpura
 Over hydration: periorbital edema – weight gain – liver enlargement - ++ RR – UOP--
 Investigations:
 FBC – Blood film to look for fragmented RBCs
 UE – Creatinine - Urine dipstick to detect renal injury
 Coagulation profile
 Glucose – Phosphate – HCO3 – LFT – Amylase
 Serum E.Coli O157 LPS antibodies - Stool CS and typing for E.coli
 Management:
 Admit and discus with regional nephrology team
 Strict fluid balance – Protein and potassium restriction
 Correct dehydration and shock (20ml/kg NS)
 Overhydrating: furosemide bolus 2 – 4 mg/kg, can be repeated 6 hourly if response
obtained – Dialysis if furosemide not effective
 Treatment of HTN
 Anemia: daily FBC needed – allowed drop of HB to 60gram/L if asymptomatic – discus
with nephrology team before any transfusion
 Thrombocytopenia: transfer of platelets only in life threatening conditions
 Avoid antibiotics, antidiarrheal, NSAIDs and nephrotoxic drugs
 Refer to tertiary hospital: Significant renal impairment – Non diarrheal HUS
 Discharge when: diarrhea/abdominal pain resolved – HB stable – Drinking fluid freely and
passing normal amount of urine – Improving U/E and normal K
 Follow up:
o Weekly for BP and KFT till normal then yearly for BP and KFT
o Every 5 years with pediatric nephrologist for formal GFR
o Folic acid 2.5 – 5 mg daily until HB normal
o Close monitoring during pregnancy in female
o Avoid smoking and obesity
o Discharge from FU when: RFT normal – No proteinuria – Renal growth and function
satisfactory at 5 yearly review until age of 15 Y
 ITP
 PLT<100,000 – acute 0-3M – Persistent 3-12M – Chronic >12M
 Self-limiting with good prognosis – 75% - 80% resolve in 6Ms – 20% relapse
 Usually preceded by infection, followed by purpura, petechial rash or bruising
 Unusual serious mucosal bleeding
 No lymphadenopathy – No HSM
 Investigations:
 Initial: FBC – Blood film – Coagulation profile,
 May need virology screen, CMV, EBV IgM, HIV, HCV, HBV
 BMA indicated only if: Bi or pancytopenia – HSM or lymphadenopathy – Limping –
Decide to give steroids
 CT brain urgently: if headache + - neurological signs
 In case of chronic ITP: investigate for autoimmune diseases
 Management:
o Discus with pediatric hematologist in case of:
 Newly diagnosed ITP
 Decide to treat with platelets in case of emergency or before dental extraction
o Reassure parents
o Avoid NSAIDs and contact sports
o Treatment not related to number of platelets, but to the degree of bleeding:
 Mild: tranexamic acid
 Moderate (as in prolonged mucosal bleeding): prednisolone 4 mg/kg/day or IVIG
0.8 gram/kg single dose
 Significant (uncontrollable epistaxis – GI hemorrhage – ICH ): Platelets transfusion
plus methylprednisolone 30mg/kg/day for 3 days or IVIG 0.8 – 1 gram/kg, can be
repeated once within 3 days
o FU:
 FBC and film monthly till diagnosis clear or recovery
 Repeat sooner if bruising or bleeding
 Discharge from FU if PLT>100,000 and asymptomatic
o In case of chronic ITP:
 Treat only if: PLT<10,000 with repeated mucosal bleeding – menorrhagia – acute
neurological signs
 Before treatment: BMA is indicated
 Treated by: prednisolone 2mg/kg/day for 14 days, then taper over 21 days or
dexamethasone 0.6mg/kg oral for 4 days
 If not responsive to corticosteroids: Rituximab or thrombopoietin after discussion
with hematologist
 Kawasaki disease
Complete Kawasaki, fever for = 0r > 5 days + 4 of: ‫عينه وبقه وايده حمراء‬
 Conjunctivitis: bilateral non purulent
 Oral changes: red lips/pharynx/tongue
 Peripheral edema: Erythema of palms and soles, followed by desquamation 10 -14 Ds
 Rash: polymorphous with no vesicular no crust
 LN: acutely enlarged cervical LNs > 1.5 cm
Incomplete Kawasaki:
o Children with fever = or > 5 days + 2 or 3 criteria
o Infants with fever = or > 7 days + other explanation
o CRP < 30 and ESR < 40 , if fever persist serial lab and clinical FU, if peeling >> Echo
o CRP=or > 30 and ESR = or > 40 , treat if: anemia – PLT =or> 450000 after D7 fever –
WBCs > 15000 – elevated ALT - Alb < 30g/L – Urine =or> 10000wbc/microliter
Other features:
 Ds Common age: less than 5 Y, peak at 18 – 24 M
 Fever usually precedes other signs with no improvement on antipyretics
 Atypical presentation: persistent raised CRP and no other diagnosis
 Irritability – Erythema of BCG site
 Other features: aseptic meningitis – uveitis – AGE – Cough – Urethritis – Arthritis
High risk factors:
 Age < 1 Y – Shock – Coronary or peripheral aneurysm – Features
 Failed IVIG – Prsistent CRP despite IVIG
 Liver dysfunction – hypoalbuminemia
 Kobayashi score > 5

Investigations: None is diagnostic

 FBC – ESR – CRP – LFT – Alb – Urine sterile pyuria – CSF Lymphocytosis
 Cultures: Urine – blood
 ASOT – Throat swab
 Virology screen if rash persist: Enterovirus, parvovirus, EBV, CMV, Measles PCR
 ECG: ST depression, T wave inversion, HB
 Echo: do not delay therapy before Echo
Ask for advice from rheumatologist: incomplete KD - Age > 1 y – failed 1st dose IVIG
Management:
 Aspirin:
o 7.5 – 12.5 mg/kg 6H until afebrile or minimum 2 weeks,
o to be decreased to 2 – 5 mg/kg OD for 6 weeks
 IVIG:
o 2 grams/kg, monitored by RR, HR, BP – Take care of allergy – given gradually
o Can be repeated if fever persist 36 H after 1st dose
 Methylprednisolone:
o 0.8 mg/kg/12H, after discussion with rheumatology
o Given in high risk Pts or if fever persist after 2nd dose of IVIG
o Followed by Prednisolone 2mg/kg/day, weaned over 2 weeks
 Infliximab:
o After discussion with pediatric rheumatology
o Given in case of methylprednisolone failure
Discharge and FU:
 When fever settled
 Echo: at 2 w and 6 w from onset of S/S
 Advise: avoid excessive exercise till echo appointment – avoid all LAV 3M after IVIG
Outpatient management:
 No aneurysm at 6 W echo:
 Stop aspirin
 No restriction of activity
 FU after 1 year
 Single aneurysm<8mm:
 Aspirin 2-5mg/kg till aneurysm disappear
 Activity level determined by cardiologist
 FU every 6M with ECG and echo
 Multiple or giant aneurysm or stenosis:
 Lifelong aspirin
 warfarin
 Limping child
 Def: abnormal gait usually caused by pain, weakness or deformity
 History should be taken:
 OCD
 Birth history including hip screening
 Trauma
 Tiredness – WT loss
 Fever – Recent viral infection
 Developmental disorders e.g CP
 Joint swelling – Joint stiffness
 Sickle cell status
 Examination should be done:
o Temperature – WT
o Rash – Pallor – Lymphadenopathy – Hepatosplenomegaly
o Testis: as torsion may come with limping
o PGALS screening
 DD:
  Transient synovitis: Diagnosis of exclusion, always consider septic arthritis
 Usually between 3 – 8 Y - below 3 Y diagnosis with caution – above 8 SUFE suspected
 Male > Female
 Recent H/O URTI (not always) – Afebrile – Systemically well
 Can bear WT, but with pain – Mild reduction of hip IR
 No need for investigations unless symptoms > 48 H
 Septic arthritis: Urgent TTT is needed, unless joint destruction will occur
o Joints most affected: Hip – Ankle – Shoulder - Elbow
o Staph.aureus is the commonest organism – By hematogenous spread
o Fever > 38.5 C – Unable to bear WT – ESR>40 – CRP>20 – Wbc>12000
o Blood CS: Positive in majority of cases
 Perth’s disease: Idiopathic avascular necrosis of capital femoral epiphysis
 More common in boys aged 4 – 8 years – Symptoms >2W – 20% Bilateral
 Diagnosed by plain X ray, but may need bone scan/MRI
 Slipped capital femoral epiphysis:
 More common in males > 10 Y – Often overweight – Can be bilateral
 May be associated with hypothyroidism and GH deficiency
 May be present with knee pain
 Hip can appear shortened and extremely rotated
 AP X ray may be normal, so lateral film may be needed
 Urgent fixation improves the outcome
 Red flags:
o Child < 3 Y
o Age > 9 years with pain/restricted hip movement
o Unable to bear WT
o Pseudo arthrosis
o Fever – Systemically unwell – Night sweats – Lymphadenopathy – HSM
o Multiple joints affected, symptoms lasting > 6 weeks
 Investigations:
 CBC with blood film - ESR – CRP - Blood CS if febrile
 CK – Sickle screen
 X ray 2 views: AP and lateral
 In SUFE: AP and Frog lateral views X ray
 Joint aspiration and CS: if suspicion of septic arthritis or transient synovitis
 MRI – Bone scan – CT: if osteomyelitis/Other abnormality suspected or persisting
symptoms
 FU: If plain x ray and lab normal, review after days if no worsening – if worsening refer to
orthopedic – If normal after 5 – 10 days discharge from FU
 Lyme disease
 History:
 Ticks found in grassy and wooded areas, including urban gardens and parks
 Bites may not always be noticed
 Most tick bites do not transmit Lyme disease
 Prompt, correct removal of the tick, reduce the risk of transmission
 High risk areas, south of England and Scottish Highlands
 More prevalent in Europe, parts of Asia, USA and Canada
 S/S: do not diagnose Lyme without symptoms even they have had a tick bite
 Rash: two types

 Organ affection:
 CNS: Facial palsy – Meningitis – Encephalitis – Neuropsychiatric
 CVS: Heart block – Pericarditis
 MSK: inflammatory multiple joints, may be migratory
 Skin: Acrodermatitis chronica atrophicans – lymphocytoma
 Eye: uveitis – keratitis
 Other symptoms: fever – malaise – fatigue – muscle aches – headache – neck pain – Paraesthia
 Investigations
 Erythema Migrans + High clinical suspicion: No need for lab testing
 No erythema Migrans:
o < 4 weeks from symptom onset + high clinical suspicion: No need for lab
o > 4 weeks from symptom: ELISA for Lyme, if negative
o ELISA test for Lyme:
 If negative dose not rule out Lyme disease
 If negative>12W from symptom onset >> Immunoblot test
 If positive >> Immunoblot test
o Immunoblot test:
 Negative: Consider alternative diagnosis or refer to pediatric ID specialist
 Positive >> antibiotics
 Management:
 Doxycycline: in = or > 9 years
 For 21 days: Erythema migrans only – Carditis and hemodynamically stable
 For 28 days: Arthritis - acrodermatitis chronica atrohicans
 After ceftriaxone ttt in CNS affection and symptoms resolved
 Amoxicillin: in < 9 years
 For 21 days: Erythema migrans only
 For 28 days: as in Doxycycline
 Ceftriaxone: for 21 days in CNS affection till symptoms free - Carditis and hemodynamically unstable
 Nephrotic syndrome
 Def: Edema + Alb < 25 g/L + heavy proteinuria + - hypocholesteremia
 Heavy proteinuria, one of:
 Urine Dipstick Ptn = or > 3
 Urinary Ptn > 40 mg/m2/h
 Urinary Ptn/Creat ratio early morning > 200mg/mmol
 S/S:
 Edema: periodic (periorbital, pedal, sacral and scrotal) - Ascites – pleural effusion
 Hypovolemia:
o Child with vomiting, diarrhea and unwell
o Abdominal pain
o Thready pulse – Poor peripheral circulation, CRT>2sec
o ++ HR ++ BP early – -- BP late
 Abdomen:
o Distension: ascites
o Pain: may hypovolemia or peritonitis (fever and tenderness)
 Respiratory, tachypnea:
o Pleural effusion
o Pneumonia
o Pulmonary embolism
 Cellulitis: one of complications due to decreased immunity
 Thrombotic events: ++ D dimer – decrease in PLT and PTT
o Renal: RVT, loin pain and hematuria
o CNS: stroke
o Pulmonary embolism
o Femoral vein: so femoral blood sampling is CI
 DD: MCNS: 95% - FSGS – Congenital NS – Multisystem disorder as HSP, SLE, DM
 Investigations:
 First line:
o Urine analysis – Early morning urinary Ptn/creat ration – Urinary Na (<10mmol, --BV)
o UE – Albumin – FBC ( ++ HCT in hypovolemia and shock) – Creatinine ( High creat>> --
BV, Nephritis , RVT)
o IgG, A and M – C3, C4 (normal C4)
o HBC, HBV serology – Zoster immune status
 Second line: done if?? Nephritis >> ASOT – ANA – Anti DSDNA
 To rule out the complications:
o Abdominal US + - centesis: if ?? peritonitis
o US Doppler of kidneys: If ?? RVT
o CT angiography: if pulmonary embolism or stroke
 Immediate treatment:
 General: Admit – Avoid added salt – Daily weighing
 Fluid restriction: insensible water loss + UOP, but if not tolerated, aim for;
 600ml/day in < 5 Y
 800ml/day in 5 – 10 Y
 1000ml/day in > 10 Y
 Treatment of shock: Senior advice - 4.5% Albumin 20 ml/kg over 30 min, if not
available 10ml/kg normal saline + Dipyridamole
 Treatment of hypovolemia:
 Senior advice
 First line: prednisolone
 Second line: Albumin 20% 0.5 – 1gram/kg + Furosemide 1mg/kg mid transfusion
 Plus: Dipyridamole
 Treatment of edema:
 Prednisolone 60mg/m2 oral once daily in the morning
 Furosemide 1mg/kg oral or slowly IV + - Albumin 20%: If edema distressing the Pt,
after discussion with consultant or nephrologist
 Penicillin V: till edema resolved, in first presentation only
 Dipyridamole: if hypovolemia with edema
 Omeprazole: for Pts on high dose steroids
 Peritonitis:
 Surgical consultation
 Blood CS – Sonar guided peritoneal fluid aspiration + CS
 Start piperacillin tazobactam, if allergic to penicillin discus with local microbiology
 Discharge:
 Once in clinic lab remission, defined as trace protein in urine for 3 days then review
outpatient after 4 weeks
 May continue remission in home with 3 conditions:
o BP normal
o Consultant agreement
o Twice weekly review till remission
 Education for parents about how to use urine dipsticks at home( only first urine
sample in the day )
 Diary: for proteinuria and corticosteroid use and dosage
 Indications of nephrologist referral:
 Age: < 1 or > 12 y
 Corticosteroid dependent, resistant or significant toxicity
 Mixed nephrotic nephritic
 Low C3/C4 – Positive ANA
 Corticosteroid regime: advice to carry corticosteroid card
o New patients:
 60mg/k/m2(max 80) for 4 – 6 weeks,
 Response usually after 4 – 7 days, if no within 4w, consider steroid resistance
 Then 40mg/m2/day alternative days for 4 – 6 weeks
 Gradually reduce the dose, aiming to stop after 3 – 4 weeks
o Relapse: as in new patients, but if relapse occur in alternative days, discus with
pediatric nephrologist
 Vaccinations:
 LAV: given 3 months after completion of ttt by high dose corticosteroids
 Inactivated vaccines: better to be delayed as LAV, as it impaired by the high doses
of corticosteroids, unless frequent relapse we can give inactivated vaccines with
short delay and check for antibody reponse
 Pneumococcal vaccine: if the child did not receive Pn.conjugated vaccine
 Chicken pox:
 Acyclovir IV: if rash appear or Pt fever and unwell
 VZIG: for on high dose corticosteroids after exposure to definite zoster case, 2 – 10
days
 Vaccine: if suitable opportunity between the relapses
 Osteomyelitis and septic arthritis
 S/S:
 Fever or H/O fever: not always present
 Loss of function - Pain in joint/bone - Restricted range of movement
 Soft tissue swelling – Effusion
 Previous history: OCD – Fever – Injuries – Antibiotics – Antipyretics/Anti-inflammatory –
Haemoglobinopathies
 DD:
 Transient synovitis of hip: age 4 – 10 Y – Usually can bear Wt – History of URTI 2weeks
back – Nontoxic – Temp <38.5 – CRP<20mg
 Trauma: H/O trauma – Bruises – No fever
 Lyme arthritis: Epidemiology – Usually knee – No fever
 Baker’s cyst: CRP<40
 Cellulitis: Erythema precedes pain – Skin tenderness and edematous
 Malignancy: Constitutional symptoms
 JIA: onset over weeks – Symmetric joints
 SLE: Fever – Wt loss – Rash – Ulcers
 Reactive: 2 – 3 weeks after GI or GU infection
 Post streptococcal: 3 – 14 days after infection – Polyarticular – Responds to NSAIDs
 Chronic recurrent multifocal osteomyelitis: Pain worse at night – Unusual site (Clavicle
jaw or scapula)
 Investigations:
o FBC – CRP – ESR – Blood CS
o Plain x ray AP and lateral
o MRI if available and plain x ray normal – Whole body MRI in multifocal
o U/S joint: if MRI not available and plain x ray normal
o Aspiration and CS
o Echocardiography: if cardiac murmur or multifocal staph
 Immediate treatment:
 Admit – NPO – Bed rest – Involve on call register – Refer urgently to orthopedic
 Analgesics: Splint and elevate affected limb – IV morphine if needed
 Antibiotics: within 4 hours
 Severe sepsis and organ dysfunction: Cefotaxime 50mg/kg/6H
 No organ dysfunction:
 < 3 M: cefotaxime 50 mg/kg/6h or ceftriaxone 50 – 100mg/kg/OD
 3M – 5 Y: Cefuroxime 50mg/kg/8h
 > 5 y: Flucloxacillin 50mg/kg/6h
 If penicillin allergy : if just rash >> cefuroxime or ceftriaxone – if anaphylaxis: Clinda
 Subsequent management:
 Septic arthritis only: inform pediatric consultant on call and orthopedic surgeon
 Aspiration under anesthesia
 Change IV to oral Abs after 72 H if recovery of joint movement and no fever
 Oral Abs for 3 – 4 weeks ( 6 weeks in hip joint):
o Co amoxiclav: if no organism identified
o If staph: flucloxacillin
o If allergic to penicillin: clindamycin
 Septic arthritis complicated by osteomyelitis: IV antibiotics for 14 days then shift to
oral antibiotics if improved clinical and lab – Duration of oral dteremined by
orthopedics
 Deteriorating septic arthritis or osteomyelitis after 48 H ttt:
 Inform orthopedic team
 Review culture result and discus with microbiologist
 Repeat blood culture
 Exclude other causes: JIA – Leukemia – Malignancy
 Monitoring of ttt:
 Peripheral color – Warmth and movement of the affected limb: hourly for first 4
hours then 4 hourly for 24 H
 RR – HR – Temp: 4 hourly
 If not improving: Repeat blood CS – Additional imaging for metastatic infection –
Asses for DVT
 Pleural effusion
S/S: Persistent fever or being unwell 48 H after starting ttt of pneumonia
DD: Uncomplicated pneumonia – HF – Malignancy – Pancreatitis – Pulmonary embolism
Investigations:
 Laboratory:
 FBC - CRP – UE - LDH
 Total protein – Albumin – Glucose
 Cultures: blood – Sputum if possible
 Pleural fluid analysis: only if suspected infective cause after pleural tapping >>
Cytology – Culture for bacteria and TB – Gram satain – AAFB and TB PCR
 Imaging:
 CXR
 US: Diagnostic and therapeutic
 CT: if suspected malignancy
Management:
1. Any pleural effusion should refer to respiratory pediatrician
2. Supportive: ABC and analgesia
3. Antibiotics: first empirical then according to cultures and sensitivity
 Co amoxiclav IV and Clindamycin IV ( if penicillin allergy give clinda only): in case of
effusion following community acquired pneumonia
 Piperacillin/Tazobactam ( Clinda IV if allergy to penicillin ): if effusion following
hospital acquired pneumonia
 Discus with TB team: if effusion following TB
4. Chest drain insertion with underwater seal:
 Involve resp pedia , consultant, anesthesia + - interventional radiology + well trained
nurse for chest tube
 Ensure vascular access before starting the procedure - CXR after insertion
 Ensure adequate analgesia
 Clamp if drain >10ml/kg/h and do not clamp if bubbling
 Intraperitoneal fibrinolytic: if thickened fluid with loculations or pus
 Remove when drainage is minimal and agreement of respiratory pediatrician
 Continue IV antibiotics till afebrile then shift oral co amoxiclav or oral clinda if
penicillin allergy for minimum 14 days and CRP < 10
 If no resolution within 3 days >> CT chest – Refer for thoracotomy after discussion
with respiratory pediatrician and thoracic surgery if still persistent significant effusion
after replacement of the chest drain
 FU after 6 weeks by respiratory pediatrician with CXR, but if symptoms persist or
recur, refer early to respiratory pediatrician
 Pneumonia
 Def: inflammation and consolidation of the lung caused by bacterial, viral or mycoplasma. Up to
35% of LRTI have a single virus as a causative agent
 Absence of clinical signs and normal CXR >> pneumonia unlikely
 S/S: Cough – fever – irritability – poor feeding – vomiting and abdominal pain – tachypnea at rest
– recession – Bronchial breathing and inspiratory crackles
 Tachypnea at rest is the most useful sign: < 2M: > 60 2 -11m: > 50 1 -5 y: > 40
 Severe pneumonia diagnosed if > 2 of following:
 Temp >38.5
 One of RD signs: RR>50 ( infant>70 ) – nasal flaring – severe recession – grunting
 Apnea or cyanosis
 Tachycardia – CRT< 2 sec
 Poor feeding or dehydration
 Unwell patient if: age < 3 m – Spo2<92% RA – intermittent grunting, apnea or tachypnea
 Very unwell: Drowsy/lethargy – nasal flaring – poor feeding/dehydration
 Ill : DCL – poor perfusion – respiratory failure
 Investigations only in severe pneumonia:
 Pulse oximetry
 FBC, CRP, Blood CS - Electrolytes: to exclude SIADH
 CXR: not recommended in CAP and not admitted pts – repeated in rounded pneumonia,
collapse or persistent symptoms
 Nasopharyngeal aspirate: if viral pneumonia suspected
 Mycoplasma titre if mycoplasma suspected
 Pleural fluid CS if pleural effusion
 DD: bronchiolitis – FB – Tumor – Empyema – Tracheobronchitis – Whooping cough
 Management: Admission in regular ward if unwell or very unwell - Admission in PICU if ill
 Oxygen if spo2 < 92% RA with continuous spo2 monitoring
 Observation 1 to 4 hourly according to the severity
 Gentle suction of nasal secretions
 Physiotherapy: if productive cough
 Maintain hydration: oral if tolerated or IV 80 % if not tolerated with electrolytes monitoring
 Antibiotics: total 7 days – if complicated or staph to be 14 days 21 day for severe CAP
 Amoxicillin oral first choice – macrolides if allergic
 IV benzyl penicillin: if vomiting
 IV amoxclav + macrolides if severe symptoms
 Oseltamivir If influenza suspected
 Flucloxacillin: if staph
 Amoxclav: if severe aspiration
 Piperacillin tazobactam : if HAP
 If no improvement within 24 to 48 H: review diagnosis or ttt
 If improvement: change IV to oral and discharge
 Follow up: with GP after 6 to 8 weeks – with hospital if previous LRTI or FTT
 SVT
S/S:
 Episodes are usually recurrent and paroxysmal (rapid onset and offset)
 Infants: ++HR – Poor feeding – Pallor – May rapid onset of HF
 Toddlers: episodes of ++RD, pallor and cold sweats
 Older children/teenager: palpitation +- pallor or dizziness
Diagnosis:
 ECG 12 lead with rhythm strip:
 During SVT:
o Regular narrow complex tachycardia, rate in infant > 220 and in children >180
o P wave is not visible
o P wave if visible, its axis will be abnormal and either precedes or follow the QRS
complex
o Rarely regular broad complex tachycardia( if in doubt treat as VT )
 During rest:
o WPW: in 10 – 20%
o Can be normal
 Blood: CBG for acid base disturbance – Lactate – Electrolytes – Ionized calcium
 Echocardiography: to assess structural anatomy and cardiac function
Management:
 ABC
 Follow APLS protocol
 Continuous cardiac monitoring with ECG recording with each intervention
 Vagal maneuvers:
 Infant: Diving reflex, by using ice bag over the head and nasal bridge or wrapping the
infant in a towel and immersing the face in iced water for 5 seconds
 Children: blowing in a 50 ml syringe for 15 seconds whilst lying down
 Not recommended: Ocular pressure – Carotid massage – Gag reflex by NGT
 Adenosine:
 Most safe and effective treatment
 Extremely short half-life, 10 – 15 secs, must go to the heart very quickly
 Two syringes used, one for adenosine, the other for rapid flushing by NS
 Need large cannula with 3-way lock in antecubital fossa
 Never test the cannula by aspiration of blood as it may cause adenosine breakdown
 Can be used in regular broad complex tachycardia
 If SVT resistant to adenosine, seek advice from specialist pediatric cardiology center
 Synchronized DC shock: General anesthesia must be given if responsive to pain
 Subsequent management:
 Admit in HDU
 Continuous cardiac monitoring
 Discus with pediatric cardiologist
 UTI

Risk factors for serious UTI:

 Poor urine flow in males – Poor growth
 Recurrent UTI – Recurrent fever of uncertain origin
 FH of VUR – Antenatal diagnosis of urinary tract anomalies
 Constipation – Dysfunctional voiding – Enlarged bladder
 Spinal lesion – Abdominal mass – High BP
Classification of UTI:
 Simple UTI: responds within 48 H
 Atypical UTI:
 Seriously ill child – Septicemia
 Failure to respond to treatment within 48 H – Infection with organisms than E.coli
 Poor urine flow – Abdominal or bladder mass – Raised creatinine
 Recurrent UTI:
 = or > 2 Upper UTI
 1 upper + = or > lower
 = or > 3 lower UTI
Investigations:
 Collection of sample:
 Collect urine before antibiotics unless severe sepsis
 Clean catch in sterile container is the recommended method
 Pad urine specimen is useful if negative, if came positive repeat the sample
 Catheterization in severe sepsis
 Urine dipstick for: All symptomatic children - All unexplained febrile admissions + temp > 38 C
- With an alternative site of infection but who remain unwell
 Microscopy of fresh sample:
 Indications:
o Age < 3 Y with fever
o Age > 3 Y with fever + one of: Specific urinary symptoms – H/O recurrent UTI – Seriously
ill – Positive LE or nitrate
 Interpretation:
o Bacteriuria + leucocytes = UTI
o Bacteriuria only = Presumed UTI if symptomatic, but may be concomitant
o Leucocytes only = UTI and treat if symptomatic
o No bacteriuria or leucocytes = no UTI if culture also positive
 Pyuria:
o Normal < 10 x 10^6/L
o Vulvitis, vaginitis or balanitis: can give rise to high counts
o Viruses like, echo adeno or CMV: can cause sterile pyuria
 Colony count:
o Organism > 10^5/ml of single organism in properly collected midstream sample
o With pad urine, count reduce to 80%
o Low count does not exclude infection
 Urine culture indications:
 Single positive LE or nitrate
 Recurrent UTI
 Infection that doesn’t respond to treatment within 24 – 48 H
 Clinical and dipstick not correlate
 Suspected pyelonephritis
 Electrolytes and Blood CS: in seriously ill children
Imaging:
 Treatment: Start empirical Abs and do not delay
 Upper UTI:
o < 3 M: Cefotaxime or Ceftriaxone 50 mg/kg
o > 3 M: oral Co Amoxiclav or IV for 7 days if not orally tolerated
o If penicillin allergy: Cefurixime IV 8 H or Gentamycin IV
 Lower UTI: Oral cephalexin for 3 days
 If the child on prophylaxis: always give alternative drug for acute infection
 Once systemically well and tolerate oral, we can discharge
 Advice to avoid risk factors: constipation – low fluid intake – poor perianal hygiene –
infrequent bladder emptying
 No need for outpatient review for simple UTI, but needed in others FU with BP
 No need for repeat UA in asymptomatic children
Antibiotics prophylaxis: trimethoprim or nitrofurantoin
 Not required for first simple UTI
 Required for:
o Grade 3 reflux
o UT obstruction pending surgical management
o Recurrent symptomatic UTI > 3 / year
o Before MCUG
Surgical management:
 Obstructive mega ureters with reflux
 Failure to control infections with prophylactic antibiotics in grade 3 reflux
 Neuropathic bladder
 Circumcision may be needed in in recurrent UTI in males with structurally abnormal UT
FU children with renal scars:
 No FU in unilateral minor scar unless recurrent UTI or FH or life risk factors for HTN
 Unilateral significant scarring: annual BP measurement
 Bilateral scarring: Long term FU in renal clinic
o Annual BP measurement
o Urinary Pt and RFT: every 3 – 4 years