Paediatric protocol 2014

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Guidelines for Management of Common Paediatric Problems
Department of Pediatrics
Patan Hospital
3rd edition; Shrawan, 2071 (July, 2014)
If you find any error in this manual, or if you have any suggestions, please, inform Dr Suchita
Joshi (suchitajoshi@pahs.edu.np).

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Contents
1. WHEEZING ............................................................................................................................4
2. STRIDOR ................................................................................................................................6
3. BRONCHIAL ASTHMA ........................................................................................................8
4. TRAUMA ..............................................................................................................................10
5. STATUS EPILEPTICUS.......................................................................................................13
6. COMA....................................................................................................................................14
7. NEUROCYSTICERCOSIS...................................................................................................17
8. DRUG/ FLUID DELIVERY IN A SICK CHILD.................................................................20
9. INITIAL ASSESSMENT OF A SICK CHILD.....................................................................22
10. BASIC LIFE SUPPORT (AHA guideline, 2013)................................................................23
11. CHOKING...........................................................................................................................24
12. NUTRITION REQUIREMENTS FOR CHILDREN..........................................................25
13. IV FLUID RESCUSITATION IN DEHYDRATION ...................................................27
14. URINARY TRACT INFECTION.......................................................................................31
15. NEPHROTIC SYNDROME................................................................................................34
16. MANAGEMENT OF DIABETIC KETOACIDOSIS IN CHILDREN ..............................38
17. SEPTIC SHOCK..................................................................................................................41
18. RECOGNITION OF MENINGOCOCCAL DISEASE.......................................................44
19. ORGANOPHOSPHATE (OP) POISONING......................................................................45
20. MANAGEMENT OF CONGENITAL HYPOTHYROIDISM...........................................48
NORMAL VALUES FOR THYROID FUCTION TESTS IN CHILDREN...........................................................48
21. MANAGEMENT OF A CHILD WITH CONGENITAL ADRENAL HYPERPLASIA...49
22. EYE INFECTIONS .............................................................................................................50

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23. OTHERS..............................................................................................................................51
I. RULES OF THUMB FOR EXPECTED INCREASE IN WEIGHT....................................................................51
II. RULES OF THUMB FOR EXPECTED INCREASE IN HEIGHT ...................................................................51
III. RULES OF THUMB FOR EXPECTED INCREASE IN HEAD CIRCUMFERENCE ...................................52
IV. PAEDIATRIC NORMAL VALUES FOR VITAL SIGNS ..............................................................................52
V. NORMAL HEMOGLOBIN LEVELS................................................................................................................52
VI. NORMAL BLOOD PRESSURE IN CHILDREN ............................................................................................53
VII. NORMAL HEART RATE IN CHILDREN ....................................................................................................53
VIII. BLOOD PRESSURE CENTILE CHART FOR BOYS..................................................................................54
IX. BLOOD PRESSURE CENTILE CHART FOR GIRLS ...................................................................................55
X. NORMAL RESPIRATORY RATE IN CHILDREN .........................................................................................57
XI. APPROXIMATE AVERAGE HEIGHT AND WEIGHT FOR NORMAL CHILDREN.................................57
XII. GROWTH CHART FOR BOYS .....................................................................................................................58
XIII. GROWTH CHART FOR GIRLS ...................................................................................................................62
XIV BODY SURFACE AREA IN CHILDREN.....................................................................................................66
XV INTRAVENOUS FLUID REQUIREMENTS..................................................................................................67
XVI. DAILY ELECTROLYTE REQUIREMENTS...............................................................................................67
XVII. PLEURAL EFFUSIONS...............................................................................................................................67
XVIII. ASCITIC FLUID .........................................................................................................................................67
XIX. PERICARDIAL EFFUSIONS........................................................................................................................68
XX. BLOOD CULTURE COLLECTION ..............................................................................................................68
XXI. ASSESSMENT OF DEVELOPMENTAL MILESTONES ...........................................................................70
XXII. GUIDELINES FOR PHOTOTHERAPY IN NEONATAL JAUNDICE......................................................74
XXIII. GUIDELINES FOR EXCHANGE4 TRANSFUSION IN NEONATAL JAUNDICE................................75
XXIV. INDICATIONS FOR PICU ADMISSSION................................................................................................76

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1. WHEEZING
First wheezing & severe respiratory distress
• Start oxygen
• Give salbutamol nebulization (< 2years: 0.2 -0.6 mg/kg/day divided q4-6 hourly, > 2years:
0.6-2.5 mg 4-8 hourly)
• A trial of epinephrine nebulization can be given if bronchiolitis is suspected
• No CXR or blood tests in ER
• Pediatric resident will likely admit and decide if CXR and blood tests are needed
• Avoid IV lines in children <5 years if possible (it may cause un-necessary agitation); at least
wait until trial of bronchodilator
Recurrent wheezing and severe respiratory distress
• Immediate oxygen
• Immediate continuous salbutamol nebulization for 1 hour
• Ipratropium nebulization
• Steroids: hydrocortisone 10 mg/kg IV (max 200 mg) or oral prednisone 2 mg/kg (max 60 mg).
o Children who do not require intravenous access for other reasons should receive systemic
glucocorticoids orally. Oral administration is preferred because it is less invasive and the
effects are equivalent.
o Intramuscular administration of glucocorticoids may be warranted in patients who vomit
orally administered glucocorticoids, yet do not require an intravenous line for other purposes.
o Children who have an IV catheter, or are likely to need one placed because of critical
illness, should receive systemic glucocorticoids intravenously.
o Oral dexamethasone phosphate is an alternative for children who vomit oral prednisolone
(dose: 0.6 mg/kg; max 16 mg).
• No CXR or tests in ER
• No Antibiotics in ER & avoid IV lines if possible
Wheezing (1st
/recurrent) but NOT severe
• Nebulized salbutamol up to 3 times in l hr; document response
• Steroids for recurrent wheezers
• No initial CXR, CBC, or antibiotics
• Possible complications? call pediatric resident
• Most small babies with bronchiolitis will be admitted
CXRs for wheezers
• Try to hold CXRs until after 6 hours of treatment
• If no response, then consider CXR if any suspicion of complication
• Clinical judgment may need CXR sooner, but NOT before treatment of wheezing!

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CBCs for wheezers
• Hold CBCs at least until 6 hours after arrival
• If no response, then consider CBC if suspicion of secondary infection
Antibiotics for wheezers
• Only after clear indications
• None, if no fever
• Do not interpret bronchial mucus as alveolar crepitations
• Yes, if acute otitis media, bacterial sinusitis, or other bacterial infection (such as typhoid)
• Yes, if consolidation
ER Steroids for wheezers
• No, if 1st time wheezing & <2 y age
• Yes, if recurrent wheezing
• Yes, if on any steroid now
• Yes, if on steroids in last 3 to 6 months
Advanced treatment for severe wheezing
• Ipratropium bromide nebulization (< 12 years: 250mcg, ≥12 years: 500 mcg). Can be given
every 20 minutes for 3 doses followed by PRN.
• May need SC adrenaline (1:1000 solution: 0.01mg/kg SC)
• If no improvement call PICU on call
• Magnesium sulfate only in the ward if unresponsive to above treatment. Dose: 25 – 50 mg/kg
IV slow over 10-20 minutes (max 2 grams). Consider PICU admission.
• For those who fail to respond to above
o Terbutaline (10 microgram/kg IV loading dose administered over 10 minutes, followed by
an infusion of 0.1 to 0.4 microgram/kg per minute), and/or
o Aminophylline and no history of administration of theophylline in the past 24 hours (6
mg/kg IV loading dose, followed by infusion of 0.6 to 1.5 mg/kg per hour)
• Antibiotics (if clear indications), hydration, chest physical therapy, mucolytics, or sedation.
Discharge from ER
For recurrent or non-severe cases:
• If the child responds well to a trial of bronchodilator treatment (salbutamol nebulization)
• If there are no signs of respiratory distress off 02, can be discharge on:
o Salbutamol (inhaler with spacer) 1-2 puffs 4-6 hourly as and when needed, and Prednisolone
1 mg/kg/day for 3-5 days (if given in ER)

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2. STRIDOR
Differentiating CROUP from EPIGLOTTITIS
Croup Epiglottitis
Etiology Mostly Parainfluenza virus Haemophilus influenzae B
Onset Over days Over hours
Preceding coryza Yes No
Cough Severe, barking Absent or slight
Able to drink Yes No
Drooling No Yes
Appearance Unwell Toxic and ill
Fever <38.5° C (101.3° F) >38.5° C (101.3° F)
Stridor Harsh, rasping Soft
Voice Hoarse Reluctant to speak, muffled
Wheeze Often present Absent
Position Irritable, active Sitting forward, neck extended
Management of acute epiglottitis
• Call for help from pediatric, anesthetist and ENT teams if required
• Do not do anything else unless the patient obstructs his/her airway
• Keep the child calm and reassure; do not upset with blood tests, CXRs etc
• Do not examine the throat
• Nurse upright
• If the patient obstructs his/her airway, the child needs ET intubattion, which can be difficult to
perform. Go for cricothyroidotomy if ET intubation cannot be performed (Get help from ENT and
anaesthetic teams)
• Definitive management will include intubation by an anaesthetist, blood culture and epiglottis
swabs, intravenous antibiotics, and chemoprophylaxis for household contacts

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Management of croup
• Admit if there is stridor at rest
• Keep calm. That includes the child, carers, nurses, and doctors
• Nurse in a warm, humidified room, & in an upright position. Keep hydrated.
• Treatment:
o For children with moderate stridor at rest and moderate retractions,
dexamethasone (0.15mg/kg is as effective as 0.3 mg/kg or 0.6 mg/kg, maximum of 10 mg)
by the least invasive route possible: oral if oral intake is tolerated, intravenous if IV access
has been established, IM if oral intake is not tolerated and IV access has not been
established. If severe symptoms, higher dose of 0.6mg/k is preferred. Patan Hospital has
0.5 mg dexamethasone tablets. Small infants may not like this tablet form. The intravenous
preparation (4 mg per mL) can be given orally.
o For children with moderate stridor at rest and moderate retractions, or more severe
symptoms, nebulized epinephrine should be given in addition to dexamethasone:
o L-epinephrine is administered as 0.5 mL/kg per dose (maximum of 5 mL) of a 1:1000
dilution. It is given via nebulizer over 15 minutes.
o Nebulized epinephrine can be repeated every 15 to 20 minutes. The administration of three
or more doses within a two- to three-hour time period should prompt initiation of close
cardiac monitoring if this is not already underway.
o Oxygen should be instituted in children with clinical evidence of hypoxia. Do not rely on
oxygen saturations. Humidify the oxygen.
o Intubation is the last resort and is indicated if there is hypoxia with progressive airway
obstruction, fatigue, or worsening hypoxia.
• Where to monitor? Admission to PICU is indicated if there is hypoxia, the child is ill
enough to require nebulized adrenaline, or if it looks like intubation will be necessary.
• What does not help? Steam inhalation, antibiotics, sedation, blood tests, X-rays.
Differential diagnosis of upper airway obstruction
Croup (laryngotracheobronchitis), Bacterial tracheitis, Acute epiglottitis, Laryngeal foreign body,
Diphtheria, Retropharyngeal abscess, Angioneurotic oedema, Laryngomalacia

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3. BRONCHIAL ASTHMA
Management of acute severe asthma
No improvement Improves
Improves
No improvement
No improvement
Indications for intubation
• Hypoxemia despite provision of high concentrations of oxygen
• Severe and unremitting work of breathing (eg, inability to speak)
• High flow oxygen
• Salbutamol nebulization x 3
• Ipratropium ( <20 kg: 250 mcg/dose; >20 kg or >6 yrs 500 mcg)
if no improvement with first dose of salbutamol
• Steroids (IV only if not able to take/tolerate orally)
• Consider admission
• Continue steroids and salbutamol nebulization as indicated
• Continue ipratropium 6 hourly if it has already been given
• Admit to children ward
• Continue oxygen, steroids and salbutamol nebulizations
• Also continue ipratropium 6 hourly
• Give adrenaline SC if no improvement
• Admit to PICU
• Magnesium sulphate IV (25 - 50mg/kg; max 2 gm)
• If no improvement, Aminophyllin IV(6 mg/kg loading followed by infusion of 0.6 – 1.5
mg/kg/hour)
• Consider intubation if no improvement

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• Altered mental status
• Respiratory or cardiac arrest
Judging the severity of asthma
Mild / Moderate Severe Life threatening
Altered level of consciousness Nil Evolving Yes
Exhaustion Nil Evolving Yes
Cyanosis Nil Evolving Yes
Wheeze + + silent Chest
Retraction Absent/mild Present Obvious
Accessory muscle use Absent Present Obvious
Initial PEFR (% predicated or usual) >50-60 <50 <33
SaO2 <92%

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4. TRAUMA
Prioritizing in trauma
A = Clear airway, protect C-spine BEFOREassessing and treating the patient
B = Assess and treat breathing
C = Assess and treat hemorrhage, which may require laparotomy/ thoracotomy to control
D = Asses and treat minor and/or extremity injury
Assess AVPU
After ABCD satisfactory and stable
• Complete head to toe examination, including front and back
• Complete X-rays
• Complete investigations
• Reassess ABCD
• Transfer or refer for definitive care
If there is any deterioration at any stage reassess ABCDE
Initial assessment and management
Airway with cervical spine control
Is the airway clear? i.e. speaking or crying. If so give high flow oxygen. If the airway is
not clear give high flow oxygen and perform the following sequential maneuvers to clear
it:
• Chin lift, jaw thrust (do not tilt head - may have cervical spine fracture!)
• Rigid suction
• Oropharyngeal airway (measure from the incisor teeth to angle of jaw - do not use if it
makes the child gag)
• Intubation by the most experienced person available
• Needle cricothyroidotomy may be necessary
• Immobilise the neck with
o Hard collar
o Blanket roll or sandbags or fluid bags
o Tape across head and collar onto a spinal board
• If combative, use a hard collar only
Breathing
Once the airway is clear and the C-spine is immobilized, see if breathing is present and
adequate? - if not, ventilate using a bag-valve-mask system connected to high flow oxygen,
using a tight-fitting face mask - this works best with one person holding the mask and one
squeezing the bag. Intubation may be required. See if trachea is central. Auscultate in both
axillae to see if there is significant difference in air exchange. Count the respiratory rate.
Assess the work of breathing – nasal flare, head nodding, subcostal/intercostals/suprasternal
recession? Check if there are wounds, marks or fractures. If tension pneumothorax is
suspected clinically do a needle thoracentesis followed by chest drain - do not wait for
chest X-ray.
Circulation and hemorrhage control
• Stop obvious external hemorrhage with direct pressure and elevation if possible

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• Insert two or more large bore IV cannulae and draw blood for CBC, cross-match, glucose
and urea and electrolytes, and amylase if required.
• Take a set of arterial blood gases
• Look for features of shock – tachycardia, hypotension, delayed CRT (>3sec in neonate,
>2sec in older child)
• If in shock, replace fluid as follows:
NS 20ml/kg bolus
Reassess; if still in shock
NS 20 ml/kg bolus
Reassess; if still in shock
Blood 10 ml/kg and contact surgical team
• If you cannot establish IV access, get intraosseous access or perform a saphenous cutdown.
Avoid attempting central venous cannulation in shocked children.
• If the patient is shocked & intoxicated, has reduced conciousness, or is otherwise
difficult to assess he or she should have intra-abdominal haemorrhage excluded.
Diagnostic peritoneal lavage should be performed by the surgeon who will perform any
necessary operation.
Disability (neurological status)
• Rapid assessment
o A– Alert
o V– Responds to verbal stimuli
o P– Responds to painful stimuli
o U– Unresponsive
• Pupils
• Children's coma scale
Exposure
Completely undress the child but cover with blanket as all necessary procedures and
examination are completed.
X-rays
• Lateral cervical spine (pull arms gently so C7/T1 can be seen)
• Chest X-ray
• Pelvis X-ray
Nasogastric tube
Gastric dilation is very common in traumatized children. Pass orally if you are worried
about basal skull fracture.

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Urinary catheter
Urinary catheter is required if the child is unconscious or shocked or has an abdominal
injury. Do not attempt if you suspect urethral injury.
Analgesia
Severe pain should be relieved as soon as possible. The presence of a head injury is not an
absolute contraindication provided airway and breathing are closely monitored.
Intravenous morphine is the drug of choice( 0.1 mg/kg in an infant or 0.2 mg/kg in the
older child). Give the calculated dose in small increments until the pain is relieved.
Never give morphine IM in trauma. Always record the time and dose given. The effects
can be reversed rapidly with naloxone if required. Femoral nerve block can be used for shaft
of femur fractures.
Tetanus Immunization may be required.
Arterial blood gases: All patients with breathing problems should have ABGs measured as
early as possible and repeated if there is any change in clinical

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5. STATUS EPILEPTICUS
Time (min) Intervention
0–5 Stabilize the patient
Assess airway, breathing, circulation, and vital signs
Administer oxygen. Obtain intravenous or intraosseous access
Correct hypoglycemia if present (dextrose 10% @ 5 mL/kg)
Obtain laboratory studies: Glucose, electrolytes, calcium, magnesium,
BUN, creatinine, and LFTs, CBC, blood culture (if infection is suspected)
Initial screening history and physical examination
5–15 Lorazepam, 0.05–0.1 mg/kg IV over 2-5 minutes every 5-10 minutes if
required (max: 4mg/dose)
Diazepam, 6 months-5years: 0.2–0.5 mg IV (0.5 mg/kg rectally) up to
5mg, > 5 years: 5-10mg IV every 5-10 minutes (maximum 30 mg). May
be repeated 2-4 hours later PRN
15–35 If seizure persists, load with
Phenytoin15–20 mg/kg IV slowly, or
Phenobarbitone 15–20 mg/kg IV slowly (not to exceed 2mg/kg/min)
45 If seizure persists:
Load with phenobarbitone if phenytoin was previously used
Additional phenobarbitone 5 mg/kg/dose every 15–30 min (maximum total
dose 30 mg/kg; be prepared to support airway and breathing)
Between doses of phenobarbitone, paraldehyde (0.4 ml/kg rectally in an
equal volume of cocconut oil or as a 10% enema in normal saline) may be
used
60 If seizure persists, consider midazolam continuous infusion or general anesthesia in
ICU
If seizure was controlled with diazepam or lorazepam, a loading dose of phenytoin
should be given to maintain effect and a maintenance dose of 5 mg/kg/day IV
divided into two equal doses daily is begun 12 hr later
This maintenance dose should also be given to those who were controlled with
phenytoin
If phenobarbitone controlls the seizure, a maintenance dose of 5 mg/kg of
phenobarbitone divided into two equal doses daily is begun 12 hr later

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6. COMA
Coma is a state of ‘unarousable unresponsiveness’.
Children's coma scale
Sign GCS Paediatric GCS Score
Eye
opening
Spontaneous Spontaneous 4
To command To sound 3
To pain To pain 2
None none 1
Verbal
response
Oriented Age-appropriate vocalization, smile, or
orientation to sound, interacts (coos, babbles),
follows objects
5
Confused, disoriented Cries, irritable 4
Inappropriate words Cries to pain 3
Incomprehensible
sounds
Moans to pain 2
None None 1
Motor
response
Obeys commands Spontaneous movements (obeys verbal command) 6
Localizes pain Withdraws to touch (localizes pain) 5
Withdraws Withdraws to pain 4
Abnormal flexion to
pain
Abnormal flexion to pain (decorticate posture) 3
Abnormal extension to
pain
Abnormal extension to pain (decerebrate posture) 2
None None 1
BEST TOTAL SCORE 15

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Some causes of coma in children
• Infections: Bacterial meningitis, viral encephalitis, post infectious encephalomyelitis, syphilis,
sepsis, typhoid fever, malaria.
• Hypoxic: Ischemic brain injury following respiratory or circulatory failure, near-
drowning.
• Epileptic seizures
• Trauma: Intracranial hemorrhage, cerebral edema or contusion.
• Poisons: Lead, thallium, mushrooms, cyanide, methanol, ethylene glycol, carbon
monoxide.
• Drugs: Sedatives, barbiturates, other hypnotics, tranquilizers, bromides, alcohol, opiates,
paraldehyde, salicylate, psychotropics, anticholinergics, amphetamines, lithium,
phencyclidines, monoamine oxidase inhibitors.
• Metabolic: Renal or hepatic failure, Reye's syndrome, hypoglycemia, diabetic acidosis,
hypothermia, Addison's disease, Acute hypo- or hypernatraemia, rare childhood
metabolic disorders.
• Hypertension
• Vascular or space occupying lesions
Evaluation:
General examination:
• Temperature, heart rate, respiration, blood pressure, skin
• Fundoscopy
• Meningismus
Neurologic examination:
• Level of consciousness
• Motor responses
• Brain stem reflexes
• Pupils
• Eye movement
Screening tests
• CBC, Blood glucose, electrolytes, Urea, creatinine, LFTs, Blood culture
• Urine analysis
• Urine for toxicology where appropriate
• CT scan of head (do emergently if focal neurological signs or papilledema is present)
• Lumbar puncture (do emergently after ensuring absence of papilledema or other signs of raised

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ICP, if fever, high white cell count and meningismus)
• Other laboratory tests: Coagulation profile, metabolic screening, drug concentrations if indicated
• EEG if non-convulsive seizure is suspected
Management:
• ABC
o Intubate if GCS is ≤ 8or respiratory failure
o Cervical spine stabilization (if there is history of trauma)
o Oxygen
o IV access
o Blood pressure support as indicated
• Dextrose: 10% Dextrose 5ml/kg iv after drawing blood (Do NOT wait for the results to give
dextrose)
• Treat definite seizures:
o Lorazepam: 0.1 mg/kg iv (max single dose 5 mg) or
o Diazepam: 6 months to 5 years: 0.2-0.5 mg IV, > 5 years 5-10 mgIV
(Can also be given PR: 2-5 years: 0.5 mg/kg, 6-11 years: 0.3 mg/kg, ≥ 0.2mg/kg)
Emperic treatments:
• For possible infection
o Ceftriaxone (100 mg/kg IV, maximum single dose 2 g), Vancomycin (age specific dose), and
Acyclovir (age specific dose)
• For possible ingestion
o Naloxone: (If opiate intoxication is suspected: miosis, repiratory dipression, hypotonia):
<20 kg: 0.1 mg/kg IV, IM, SC, or ET (maximum dose, 2 mg), >20 Kg or > 5 years: 2 mg
IV, IM, SC or ET. Repeat as necessary, keeping in mind its short half life
• For possible increased ICP
o Mannitol: 0.5 to 1 gram/kg IV
• For possible non-convulsive status
o Lorazepam: 0.1 mg/kg IV (max single dose 5 mg) or
o Diazepam: 6 months to 5 years: 0.2-0.5 mg IV, > 5 years 5-10 mg IV
(Can also be given PR: 2-5 years: 0.5 mg/kg, 6-11 years: 0.3 mg/kg, ≥ 0.2mg/kg)
If suspicion of seizures continue, treat as status epilepticus
• For possible Wernicke encephalopathy
o Thiamin: 100 mg IV (before starting glucose). Consider in adolescents for deficiencies
secondary to alcoholism or eating disorders.
• If ingestion of toxic substances is suspected, airway must be protected before GI
decontamination
• Monitor Glasgow Coma Scale and reassess frequently

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7. NEUROCYSTICERCOSIS
Differential diagnosis:
• Brain abscess
• Cerebral amebiasis
• Central nervous system (CNS) tumors
• CNS toxoplasmosis
• Mycotic granulomas
• Neurosarcoidosis
• Tuberculosis of the CNS
• Carotid disease and stroke
General considerations:
• Administer antiepleptic therapy to all patients with seizure
• Always give steroids if antiparasitic treatment is admininstered
• If cerebral edema is present, treat cerebral edema before administering antiparasitic treatment
Treatment of parenchymal NCC
• Antiepileptic therapy: Phenytoin or Carbamazepine (monotherapy is usually sufficient)
o Administered to all patients with NCC who present with seizures or
o If seizure is absent but multiple lesions are seen in the CT scan, specially degenerating
lesions and those with surrounding inflammation
o Continue for 6-12 months after radiographic resolution of active parasitic infection
o If the patient has recurrence of seizure during trial off of antiepileptic treatment, long-term
treatment should be re-instituted
• Antiparasitic therapy: Consider in all patients with NCC and always use together with
corticosteroids
o Single lesion:
Albendazole: 15 mg/kg/day for 7 days
Prednisolone: 1 mg/kg/day for 5-10 days
Or Dexamethasone 0.1 mg/kg/day for 5-10 days followed rapid taper

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o Multiple lesion:
Albendazole: 15 mg/kg/day in two divided doses for 10-15 days
Dexamethasone high dose
**For subarachnoid disease, Albendazole should be given for 28 days**
• Anti-inflamatory therapy: Indications for corticosteroids
o Along with antiparasitic therapy
o Cysticercal encephalitis
o Subarachnoid cystecercosis
Things to do before initiating corticosteroids
o Mantoux test (and other investigations as indicated) to rule out tuberculosis
o If indicated, screen for strongyloidiasis
o Ophthalmologic examination to rule out ocular cystecercosis
Indications for surgical intervention
• Altered mental status or impaired herniation due to hydrocephalus secondary to NCC
• Intraventricular cysts with hydrocephalus
• Subarachnoid cysticercosis (giant cysticerci)
• Ocular cysticercosis
• Spinal cysticercosis
Follow-up
• CT scan
o In 1-2 months and then after 6 months of diagnosis of parenchymal or subarachnoid

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cysticercosis. Once lesions have resolved, imaging is less useful.
o Before discontinuing antiepileptic drugs
o New, worsening or persistent symptoms
• Patients with VP shunts should be educated to seek prompt medical advice for symptoms of
hydrocephalus

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8. DRUG/ FLUID DELIVERY IN A SICK CHILD
Intravenous access:
If cannot be established within 90 seconds, go direct to intra-osseous access!
• In children any IV access anywhere is effective if drugs are flushed through after
administration.
• Central venous access is the best route of administration; but should only be attempted
by experienced personnel and is relatively contraindicated in trauma patients.
Intraosseous access:
• After giving drugs, flush them through. Dilute strong alkalis and hypertonic solutions.
Setting up intraosseous infusion
Equipment:
Alcohol or Betadine swabs:
Intraosseous needle or 16-gauge cannula at least 1.5 cm in length
20 ml syringe with normal saline
Infusion fluid
Procedure:
Identify the infusion site. Avoid fractured bones, or limbs with proximal fractures. If
possible avoid areas of infected burns or cellulitis.
Proximal tibia: Anteromedial surface, 2-3 cm below the tibial tuberosity.
Distal tibia: Proximal to the medial malleolus.
Distal femur: Midline, 2-3 cm above the external condyles.
• Prepare the skin and if necessary use local anesthetic.
• Insert the needle through the skin, perpendicularly and slightly away from the growth
plate into the bone with a screwing motion. There is a feeling of ‘giveway’ as the marrow
cavity is entered. Unscrew the trocar and confirm position by aspirating bone marrow
or by flushing with 5-10 ml normal saline.
• Secure the needle and splint the limb.
Fluids can be infused through an intraosseous needle as through a standard intravenous

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cannula. If rapid fluid replacement is required, infuse under pressure using a 50 ml syringe.
Dilute strong alkalis and hypertonic solutions.
After giving any drug- flush it through.
Contraindications: Ipsilateral fracture, ipsilateral vascular injury, osteogenesis imperfect,
osteoporosis.
Complications: Failure to enter the bone marrow, extravasation or sub-periosteal infusion.
Osteomyelitis is rare with short term use. Local infection, skin necrosis, pain, compartment
syndrome; fat and bone marrow microemboli have all been reported.
Doses of pharmacologic agents in pediatric resuscitation
Oxygen 100% initial dose, wean as clinically
indicated
Glucose Newborns: 10% Dextrose 2ml/kg IV
Children: 10% Dextrose 5 ml/kg IV
Epinephrine 0.01 mg/kg IV/IO (0.1 mL/kg of the 1:10,000
solution). Repeat every 3-5 min as required
0.1 mg/kg endotracheal (ET) (0.1 mL/kg of
the 1:1000 solution)
Atropine 0.02 mg/kg IV or IO (minimum 0.1 mg,
maximum single dose 0.4mg)
Sodium bicarbonate 1meq/kg IV/IO initial dose over 1-2 minutes,
then
0.5 mEq/kg subsequent doses every 10
minutes of arrest. Maximum 8 meq/kg/day
Endotracheal tube sizes
Rough guide: Tube diameter = Diameter of child's little finger
or nostril
Internal diameter (mm) = (Age/4) + 4 in a child over one year
Length (cm) = (Age /2) + 12 for an oral tube
Length (cm) = (Age/2) + 15 for a nasal tube

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9. INITIALASSESSMENT OFA SICK CHILD
Airway and Breathing:
Obstruction?
Work of breathing - grunting, nasal flaring, recession or in drawing
Respiratory rate
Auscultation
Cyanosis?
Circulation:
Heart rate
Pulse volume
Capillary refill
Skin temperature
Disability:
Posture and tone
Pupils
Mental status - the AVPU scale
A - Alert
V - Responds to verbal stimuli
P - Responds to painful stimuli
U - Unresponsive
It should be possible to perform this assessment within the first minute. If the child is very sick,
CALL FOR HELP. It is better to call for help early. You can then go on to:
Initial management
Initial formal observations: pulse, respiration, BP, temperature, O2 saturations, BM stix,
weight
Initial investigations
Definitive management

23
10. BASIC LIFE SUPPORT (AHA GUIDELINE, 2013)
Component Recommendations
Children Infants
Recognition Unresponsive
No breathing or only gasping
No pulse felt within 10 seconds
CPR sequence Chest compressions, Airway, Breathing (CAB)
Compression rate At least 100/min
Compression depth At least 1/3 AP diameter
About 2 inches (5 am)
At least 1/3 AP diameter
About 1 ½ inches (4 cm)
Chest wall recoil Allow complete recoil between compressions
Attempt to limit interruptions to <10seconds
Compression interruptions Minimize interruptions in chest compressions
Attempt to limit interruptions to <10 seconds
Airway Head tilt-chin lift (suspected trauma: jaw thrust)
Compression-ventilation
ratio (until advanced
airway placed)
30:2 (Single rescuer)
15:2 (2 rescuers)
Ventilation with advanced
airway
1 breath every 6-8 seconds (8-10 breaths/min)
Asynchronous with chest compressions
About 1 second per breath
Visible chest rise
Defibrillation Attach and use AED as soon as available.
Minimize interruptions in chest compressions before and after shock;
Resume CPR beginning with chest compressions immediately after each shock

24
11. CHOKING
Do not perform blind finger sweeps. Back blows are delivered between the shoulder blades.
The child's head should be lower than the abdomen.
Chest thrusts are similar to chest compressions except they are sharper and more vigorous.
They should be performed at a rate of one every 3 seconds.
Abdominal thrusts can be performed in children over a year of age. Use the Heimlich
maneuver in conscious children or lay the unconscious child supine. Direct the thrusts
upwards towards the diaphragm.
CONTINUE THE CIRCUITS UNTIL THE FOREIGN BODY IS CLEARED.
5
abdominal
thrusts
Open
airway Breathe
5 back
blows
Check
Mouth
5 Chest
thrusts
2nd time around
in children over 1
year

25
12. NUTRITION REQUIREMENTS FOR CHILDREN
Adapted from "Dietary Reference Values for Paediatrics",
The Hospitals for Sick Children, London, 1992.
Normal requirements High requirements
Energy Protein Energy Protein
4-12
mont
hs
95 kcals/kg/d 1.5 g/kg/d 130-150
kcals/kg/d
3-4.5 g/kg/d
1-4
years
95 kcals/kg/d 1.1 g/kg/d 120-150%
normal require.
2 g/kg/d
4-6
years
85 kcals/kg/d
Suggested use of Paustik Sanjivvani (as nutrition supplement):
Children aged 5 - 1 0 years, 500 ml/day
Children aged >10 years, 1000 ml/day
Special mil': initial feed for severely malnourished children >6 months 130 ml/kg/day (=99
kcals, 1.4 g. protein, /kg/day) divided as 3 hourly feeds
Ward Food Values
Energy
Kcals
Protein
G
Tea ( Sugar – free) 80 (40) 2
Haluwaa 264 5
Sugar – Free Porridge 249 11
Milk 120ml 80 4
Yoghurt 120ml (140g) 84 4
Lito : full 150 ml 209 6
Half 75 ml 105 3
Khichiri 359 11
Rice meal : full 807 19

26
(Information can be obtained from nutiondata.self.com)
Half 505 12
Quarter 296 8
Chicken (Per cup = 140g) 231 43
Mutton (1 serving = 270g) 691 66
Egg (per 1 medium egg) 72 6.3
Banana (per 100g) 89 1.1
Afternoon Snack : full 436 11
Half 286 8
Quarter 244 6
Special milk 100ml 76 1
Paustik Sanjiwani : 500ml 754 27
Sugar free 634

13. IV FLUID RESCUSITATI
Laboratory investigations
Serum sodium
• Hyponatraemia (serum Na <130mEq/L)
• Isonatraemia (serum Na 130
• Hypernatraemia (serum Na >150mEq/L)
Serum potassium
Both hypokalaemia or hyperkalaemia can occur in dehydration. If the child has
oligurea or anuria, do not add potassium in the iv fluid until serum potassium is
determined.
IV FLUID RESCUSITATION IN DEHYDRATION
Laboratory investigations
Hyponatraemia (serum Na <130mEq/L)
Isonatraemia (serum Na 130-150mEq/L)
Hypernatraemia (serum Na >150mEq/L)
hypokalaemia or hyperkalaemia can occur in dehydration. If the child has
27
ON IN DEHYDRATION
hypokalaemia or hyperkalaemia can occur in dehydration. If the child has

28
Serum bicarbonate (can be measured by capillary or venous blood gas)
Serum bicarbonate <17 mEq/L almost always suggests moderate to severe
dehydration
Serum urea and creatinine may be warranted to assess renal function in cases of
severe dehydration
Calculate deficit and maintenance requirements:
• Maintenance of water = 100/50/20 rule
100cc/kg/day for 1st 10 kg, 50/kg for the 2nd 10 kg, 20/kg rest
• Deficit of water = wet weight x percent dehydration x 10
• Maintenance of Na (sodium) = 3-4 mEq/kg/day
• Deficit of Na =110 to 120 mEq Na loss/L of H20 loss
if Hyponatraemia:
Sodium deficit = (135 - measured sodium) X weight X 0.6 in meq/L
If serum sodium is <125mmol/L, consider correction with 3% saline to increase
level to 125mmol/L
1.2ml/kg of 3% NaCl will increase level by 1meq/L. Correction volume should be
given over 15-20 minutes
Initial treatment for children in hypovolumic shock
What fluid? 0.9% Saline
How much? 20ml/kg Re-assess and repeat as necessary until adequate
perfusion is restored
What route? Preferably by intravenous route. If IV access cannot be
obtained, use intraosseous route without delay
How fast? Rapid infusion
Follow-on fluid management: Depends upon degree of dehydration as well as
serum sodium and potassium values.

29
Example #1: isotonic dehydration (sick 2 days)
Pre-illness weight 10kg, but on admission 9 kg (therefore 10% dry)
H2O Na
Deficit 1000 cc 110-120 (serum sodium normal)
Maintenance +1000 cc +40 (4mEq/kg X 10kg = 40 mEq)
Total 2000 cc 150-160 mEq
Initial Tx -400 cc in 1 hour - 62 (62 mEq Na in 400 cc NS)
Rest1600 cc - 88-98 mEq ( 8 8 - 9 8 / 1 . 6L = 55-61 mEq/L
= 28-30/500cc) >1/3 & <1/2 NS
ORDERS : 1. NaCI 400 cc in 1 hour
then, 5% Dextrose in 0.45% NaCI + 5cc KCI/500 cc-- 500 cc
every 8 hours X 3
Example #2: HYPONATREMIC dehydration (sick 3 days)
-pre-illness weight 6.0 kg, but on admission 5.5 kg (therefore -8% dry)
-serum sodium is 119 mEq (135-119 X 6.0kg X 0.7 = 67 mEq added deficit)
H2O Na
Deficit 500 cc 50 +67 =117 (use 100 Na/L H2O loss
Maintenance + 600 cc +24
Total 1100 cc 141 mEg
Initial Tx -250 cc in 1hors - 39
Rest 850 cc 102mEq (102/85 L= 120 /l = 60/500cc)
1/2NS=37.5mEq/500cc, so need 22 mEq more/bottle
ORDERS 1. NaCI 250 cc in 1 hour
then, 2. 5% Dext 1/2 NaCI + 20 cc NaHCO3 (max 3mEq/kg/12 hours is safe)
+ 5cc KCI/500 cc bottle - one bottle every 14 hours X 2

30
Example #3: HYPERNATREMIC dehydration
• RESTORE INTRAVASCULAR VOLUME
NS 20ml/kg IV over 20 min if circulation is poor. Repeat if necessary.
• How quickly to restore depleted volume?(Time for correction)
145-157 mEq/L = 24hr
158-170 mEq/L = 48hr
171-183 mEq/L = 72hr
184-196 mEq/L = 84hr
• ADMINISTER FLUID AT CONSTANT RATE OVER TIME FOR CORRECTION
Typical fluid: D51/2 NS with 5mlKCl/500ml IVF unless contraindicated (No urine output).
Typical rate: 1.25-1.5 times maintenance
It is necessary to correct hypernatremia slowly to prevent cerebral oedema.
Formula for correcting free water deficit:
(Wt in kg x 0.6) x 1- (145/ actual sodium) (1000ml/L)
OR,
4ml x wt in Kg x (Measured sodium – 145) in ml (Because, 4ml/kg of free water will drop
sodium by 1 mEq/L)
Amount of free water in different fluids:
1L of ½ normal saline = 500ml of free water
1L of ¼ normal saline = 750ml of free water
1L of D5 ½ normal saline = 400ml of free water (This is a good starting point)
HYPOKALEMIA
K <3.5
If serum K+ level = 2.5 to 3.5 -> Do ECG
If ECG normal -> Increase maintenance K oral/iv 3-4 meq/kg/day
If ECG abnormal or symptomatic ->K rapid correction to be given.
If serum K+ <2.5 Get ECG done
Give K rapid correction as follows, 0.3meq/kg/hr.
Stock solution (90 ml NS + 10 cc Kcl)- 0.5ml/kg/hr, under ECG monitor & increase
maintenance dose
K+ to 3-4 meq/kg /day. K rapid correction can be repeated as necessary.
1 Abnormal ECG—flat T waves, U waves depressed ST segment, arrhythmia
2 Symptomatic—paralytic ileus, muscular weakness.

31
14. URINARY TRACT INFECTION
Any newborn over 72hrs of age with fever should have a urine culture taken as part of the septic
screen. This can be collected by catheterisation, suprapubic aspiration or in older children by a
clean void.
Criteria for diagnosis are as follows:
Method Colony count (pure culture)
Suprapubic aspiration any gram negative organism is positive, more than a few
thousand gram positive organisms is positive
Catheterized specimen >100,000 organisms infection likely
< 10,000 unlikely, repeat culture.
Clean Void Boy- > 10,000 infection likely
Girl- > 100,000 infection likely
Antibiotics
• Infants < 2 months: IV antibiotic (<2 months: amikacin , or cefotaxime)
• > 2months: Oral ofloxacin if not vomiting. IV amikacin or ceftriaxone if vomiting
• If enterococcal UTI is suspected or proven: Add Ampicillin
Duration of antibiotics
• Infants <2 months: Continue IV antibiotics for 10 days
• > 2 months and febrile or immunocompromised: If on iv antibiotics, continue IV antibiotics
until afebrile. Change to oral antibiotics once afebrile and continue for a total duration of 10
days
• > 2months and afebrile in immune competent children: Oral antibiotics for 5 days
Repeat urine culture:
• No need to repeat urine culture if the pathogen is susceptible to the antibiotic being used and
the patient is responding as expected
• Repeat urine culture after 48 hours of treatment if the pathogen is not susceptible to the
antibiotic being used or if the patient is not responding to the treatment

32
Indications for hospitalization:
• Age <2 months
• Clinical urosepsis (eg, toxic appearance, hypotension, poor capillary refill)
• Immunocompromised patient
• Vomiting or inability to tolerate oral medication
• Lack of adequate outpatient follow-up (eg. Lives far)
• Failure to respond to outpatient therapy
ANTIBIOTICS USED FOR UTI PROPHYLAXIS
Indications:
• Grade III VUR
• Recurrent UTI in children without VUR: three febrile UTIs in six months or four total
• Consider in children less than 2 months if USG is abnormal till MCUG is done to exclude
renal tract abnormalities (no clear recommendation available at present).
ANTIBIOTIC DOSAGE
Co-trimoxazole 2 mg/kg of trimethoprim HS
Nitrofurantoin 1-2 mg/kg HS
Cephalexin 25mg/kg HS
In pseudomonas UTI, consider
Ciprofloxacin
3.75mg/kg HS
Cefadroxil Under 1 year: 12.5mg/kg HS
1 to 6 years: 125mg HS
• Continue prophylaxis for 6 months. If UTI does not occur during prophylaxis, discontinue
prophylaxis. Re-start if infection recurs after discontinuation of prophylaxis
• If UTI develops while on prophylaxis it should be treated with a different antibiotic and the
prophylactic antibiotic should be changed according to sensitivities.
Always check that the infecting organism is sensitive to what the patient is being treated
with.
Indications for renal and bladder USS
• Children younger than two years of age with a first febrile UTI
• Children of any age with recurrent febrile UTIs
• Children of any age with a UTI who have a family history of renal or urologic disease, poor

33
growth, or hypertension
• Children who do not respond as expected to appropriate antimicrobial therapy
When to perform the USS?
• As soon as possible during the acute phase of illness in patients with unusually severe illness
or those not responding to antimicrobial treatment as expected
• After the acute phase of illness in those who respond to appropriate treatment
Indications for MCUG
• Children of any age with two or more febrile UTIs.
• Children of any age with a first febrile UTI who have a family history of renal or urologic
disease; children with poor growth or hypertension.
• Children with abnormal voiding pattern (dribbling of urine).
• Urinary tract anomalies are more frequent among children with UTI caused by pathogens
other than E. coli
• If the renal and bladder utrasonography reveals hydronephrosis, scarring, or other findings
that suggest either high grade VUR or obstructive uropathy.
• In children less than 2 months if USG of kidney and bladder is abnormal (no
recommendations available at present).
When to perform MCUG?
• During the last days of antimicrobial therapy or immediately after completion of the
antimicrobial therapy for UTI (early imaging does not increase the false positive diagnosis of
VUR and helps to avoid use of prophylactic antibiotics in those without VUR)

34
15. NEPHROTIC SYNDROME
EVALUATION OF CHILDREN WITH SUSPECTED NEPHROTIC SYNDROME
Recommendations for initial evaluation include:
● Urinalysis
● First morning urinary protein /creatinine ratio (normal value for 6 months to 2 years: <0.5 mg
protein/mg creatinine , > 2 years: <0.2 mg protein/mg Creatinine)
-The child should be instructed to void before bed and collect the first morning sample
● Serum electrolytes, serum urea nitrogen, creatinine, and glucose
● Serum cholesterol
● Serum albumin
● *Serum Complement 3 level
● *Antinuclear antibody level* (for children aged >=10 years or with any other signs of systemic
lupus erythematosus);
● *Hepatitis B, hepatitis C, and HIV serology in high-risk populations*
● *Purified protein derivative level* and
*These tests should be sent only after the diagnosis of nephrotic syndrome
- Kidney biopsy should be considered for children aged ≥12 years who are diagnosed with
nephrotic syndrome
Criteria for diagnosis of nephrotic syndrome
• Nephrotic range proteinuria : Urinary protein excretion greater than 50 mg/kg per day or
40mg/m2
/hr (measured in 24 hour urine sample) or,
Urinary protein/creatinine ratio >3mg protein/ mg creatine in early morning spot urine sample
• Hypoalbuminemia : Serum albumin < 3 g/dL
Other associated features are
• Edema and
• Hyperlipidemia
DEFINITIONS
The following are terms commonly used for management of nephrotic syndrome.
Remission: Urine protein/creatine <0.2 or dipstix urine albumin negative or trace for 3 days.
Relapse: After remission, an increase in the first morning urine protein/creatinine to ≥2 or
urinary dipstix albumin ≥2 for 3 of 5 consecutive days.
Frequently relapsing: 2 or more relapses within 6 months after initial therapy or >4 relapses in
any 12-month period.
Steroid dependent: Relapse during taper or within 2 weeks of discontinuation of steroid
therapy.
Steroid resistant: Inability to induce a remission with 4 weeks of daily steroid therapy.

35
Criteria for minimal change disease
• Age older than 1 year and younger than 10 years of age
• None of the following findings: hypertension, gross hematuria, and a marked elevation in
serum creatinine
• Normal complement levels
• No extra-renal symptoms such as malar rash or purpura
Kidney Disease Improving Global Outcomes (KDIGO) 2012 guidelines to manage children
with steroid-sensitive nephrotic syndrome as follows:
Initial therapy:
• Prednisolone 60 mg/m2
or 2 mg/kg per day for four to six weeks (maximum dose of 60
mg/day) followed by,
• Alternate-day prednisone of 40 mg/m2
or 1.5 mg/kg (maximum dose of 40 mg/day) and
continued for two to five months with tapering of the dose.
Infrequent relapses:
• Prednisone 60 mg/m2
or 2 mg/kg per day (maximum dose of 60 mg/day) until the urine
protein tests are negative or trace for three consecutive days, followed by
• Alternate-day prednisone of 40 mg/m2
or 1.5 mg/kg (maximum dose of 40 mg/day) for at
least four weeks.
Frequent relapses or steroid-dependent disease:
• Prednisone 60 mg/m2
or 2 mg/kg per day (maximum dose of 60 mg/day) until the urine
protein tests are negative or trace for three consecutive days, followed by
• Alternate-day prednisone for at least three months.
• The dose of alternate-day prednisone should be the lowest dose needed to maintain remission
without adverse side effects. In patients in whom alternate-day therapy is not effective in
maintaining remission, the lowest possible dose of daily prednisone is given to maintain
remission to minimize adverse side effects. Daily prednisone should be given to patients
during episodes of upper respiratory tract infection and other infections that are associated
with relapse.
• Corticosteroid-sparing agents should be given to children with frequently relapsing or steroid-
dependent disease who develop steroid-related adverse effects. Data are insufficient to choose
among the following agents. Drug selection is based on the reported efficacy, adverse effects,
local availability, and cost.
Corticosteroid sparing agents:
• Cyclophosphamide (dose of 2 mg/kg per day for 8 to 12 weeks [maximum cumulative dose of
168 mg/kg]) or
• Chlorambucil (dose of 0.1 to 0.2 mg/kg per day for 8 weeks [maximum cumulative dose 11.2
mg/kg]).
• Levamisole (dose of 2.5 mg/kg on alternate days for at least 12 months).
• Calcineurin inhibitors include cyclosporine (initial dose of 4 to 5 mg/kg per day given in two
divided doses) or tacrolimus (initial dose of 0.1 mg/kg per day given in two divided doses

36
• Mycophenolate mofetil (initial dose of 1200 mg/m2 per day given in two divided doses for at
least 12 months).
• Rituximab (an anti-CD20 monoclonal) should be considered only in children who have failed
combination therapy of prednisone and other corticosteroid-sparing agents and have serious
adverse effects of therapy.
Both mizoribine and azathioprine are NOT recommended in the management of children with
NS)
Steroid-Resistant Nephrotic Syndrome Management
● Kidney biopsy;
● Tailor therapeutic regimen according to kidney histology; and
● Provide optimal supportive therapy.
Treatment for steroid-resistant nephritic syndrome:
• Immunosuppressive
o Alkylating agents
o Calcineurin inhibitors (CNIs)– Cyclosporin and tacrolimus
o Mycophenolate mofetil
o Rituximab
• Nonimmunologic antiproteinuric therapy
o Angiotensin-converting enzyme inhibitors (ACE-Is)
o Angiotensin receptor blockers (ARBs)
Symptomatic treatment of nephrotic syndrome
• Oedema
o Salt restriction
o Fluid restriction (Insensible loss + urine output)
Maybe helpful in stabilizing patient’s weight and
If serum sodium ≤ 130 mEq/L
o Diuretics (Frusemide is the first choice)
Particularly useful when fractional excretion of sodium (FeNa) >2% indication volume
expansion
o Frusemide with albumin
Anasarca with respiratory compromise due to ascites and/or pleaural effusion
Severe scrotal oedema
Peritonitis
Severe tissue breakdown
• Hypercoagulability: Patients with severe hypoalbuminaemia (serum a albumin <2g/dl) and
fibrinogen level >6g/L are at high risk.
o Mobilisation
o Avoidance of haemoconcentration
o Early treatment of hypovolaemia and sepsis
Prophylactic anticoagulation is not indicated unless there is H/O thromboembolic phenomena
• Infection: Prophylactic antimicrobials are not recommended.
o High risk for development of Pneumococcal or E.Coli infection (Peritonitis, pneumonia,
sepsis)

37
o High risk for varicella infection- treat with Acyclovir if varicella infection develops while
on steroid therapy
**Pneumococcal and varicella vaccines are recommended**
• Hyperlipidaemia: Statins are indicated for only those children who remain persistently
nephrotic and have hyperlipidaemica
• Hypertension: Children with persistent hypertension in nephrotic syndrome are more likely to
develop chronic kidney disease. Therefore, antihypertensive of choice are
o ACE inhibitors or
o Angiotensin II receptor blockers
(Discontinue these drugs if hyperkalaemia cannot be controlled or creatinine clearance is
>30% of the baseline)
• Other dietery measures: No clear role. Low fat diet can be suggested to prevent excessive
weight gain.

38
16. MANAGEMENT OF DIABETIC KETOACIDOSIS IN
CHILDREN
Diagnostic criteria for diabetic ketoacidosis (DKA)
• Hyperglycemia, serum glucose of >200 mg/dL (11 mmol/L)
AND
• Metabolic acidosis, defined as a venous pH <7.3 and/or plasma bicarbonate <15 mEq/L (15
mmol/L)
Initial assessment
• Neurologic status: GCS ≤7 has poor prognosis
• Acid-base status
• Volume status
• Duration of symptoms
Severity of DKA
Fluid replacement
Deficit assessment: In a patient with moderate to severe DKA, estimate water deficit of 7-
10%
1.Initial volume expansion: In patients with moderate to severe DKS
o 0.9% saline 10ml/kg iv over 1 hour and reassess
o 2nd
bolus of 0.9% saline 10ml/kg IV over 1 hour can be given if required
**Do NOT give >20ml/kg of saline bolus unless the patient’s cardiovascular status is
compromised**
Subsequent fluid administration:
Type of Fluid:
• For the 4 to 6 hours- Normal saline
• After 6 hours- Change to 0.45% saline provided the sodium concentration is rising as the glucose
concentration decreases, and the patient’s circulatory and mental status are stable.
• If Serum Na < 130 or > 150- Consider continuing with normal saline
• If Serum Na does not increase with treatment- consider continuing with normal saline
• Once Serum glucose decreases to 250- 300 mg/dl - add 5% dextrose
(Hyperglycaemia falsely decreases Serum Na. For each 100mg/dl rise in sugar, serum Na will
decrease by 1.6mg/dl)
Defining features Mild Moderate Severe
Venous pH 7.2-7.3 7.1-7.2 <7.1
Serum bicarbonate (mEq/L) 10-15 5-10 <5

39
• The rate of fluid administration should not exceed 1.5 to 2 times the maintenance rate
• Should not include urinary losses
• The hourly rate of fluid administration should never exceed two times the maintenance rate
(about 3000 ml/m2/day, including the initial bolus) unless there is objective evidence of shock
* Excessive fluids may increase the risk for cerebral edema*
Potassium supplementation: After the initial bolus
Serum Potassium (in mEq/L) Potassium added per Litre of fluid
<3 40-50 mEq/L
3-4 30-40 mEq/L
4-5 20-30 mEq/L
5-6 10-20mEq/L
Insulin therapy
Insulin therapy is required to correct metabolic decompensation. Do NOT give sodium
bicarbonate to correct metabolic acidosis in a patient with DKA
• It should start after the first bolus, i.e. from 2nd
hour of the treatment
• Too rapid correction of blood sugar can lead to cerebral edema
• Add 50 units of short acting (Regular insulin) to 50 ml of 0.45% saline (1ml=1unit)
o Do NOT give initial bolus of regular insulin
o Start with 0.05 to 0.1 units/kg/hour
• Do NOT decrease the rate of infusion of insulin until metabolic acidosis is corrected, even
if the serum glucose is falling
• When the serum glucose concentration decreases to 250 to 300 mg/dL ,change the IV fluid to
5% dextrose in normal saline
• If the serum glucose falls below 250 mg/dL, before complete resolution of the ketoacidosis, the
concentration of dextrose in the IV fluid should be increased to up to 10 to 12.5% Dextrose
(The purpose of adding dextrose to the intravenous solution is to prevent hypoglycemia while
continuing to administer insulin to correct ketoacidosis)
• Desired rate of fall of blood glucose: 50-100 mg/dl/hour.

40
• The insulin infusion should continue at 0.05 to 0.1 units/kg per hour until the following
conditions are met [9-11]:
o Serum anion gap reduced to normal (12 ± 2 meq/L)
o Venous pH is >7.30 or serum HCO3 is >15 meq/L
o Plasma glucose 100-150in older children, and 150-200 in younger children
o Tolerating oral intake
• Stop IV insulin infusion only after 1 hour of the first dose S/C insulin.
Monitoring:
• Blood glucose: Hourly for the first 4-6 hours of insulin and fluid therapy
• Serum electrolytes and venous pH: Hourly for the first 3-4 hours, then 2-4 hourly as directed
by the results
• Clinical parameters: Heart rate, respiratory rate, blood pressure, oxygen saturation, and
neurologic status should be monitored continuously.
• In patients with severe DKA or altered mental status, frequent neurologic examinations are
recommended.
• Monitor for warning signs and symptoms of cerebral edema including headache,
inappropriate decrease in heart rate, recurrence of vomiting, changes in neurologic status,
rising blood pressure, and decreased oxygen saturation
Borderline DKA
• Venous pH >7.30, serum bicarbonate >16 meq/L
• No neurologic impairment
• Estimated volume deficit less than 3 percent
• Not vomiting
These patients may be managed in an ambulatory setting under the supervision of an experienced
medical team. However, hospitalization may appropriate for young children (eg, <5 years of age)
because of their sensitivity to insulin as compared with older children, and because of their
increased risk for cerebral edema. Children of any age should be treated in hospital if the home
environment does not provide close supervision and monitoring.

41
17. SEPTIC SHOCK
Definition of septic shock:
Septic shock is defined as sepsis with cardiovascular dysfunction that persists despite
administration of >40ml/kg isotonic fluid in one hour.
Cardiovascular dysfunction:
• Hypotension
• Reliance on vasoactive drug administration to maintain a normal blood pressure
Or, two of the following
• Prolonged capillary refill,
• Oliguria,
• Metabolic acidosis, or
• Elevated arterial lactate
Rapid recognition of septic shock:
Inadequate tissue perfusion in a seriously ill child
• Fever
• Tachycardia or bradycardia
• Decreased peripheral pulses compared with central pulses
• Mottled or cool extremities
• “Flash” or >3 second capillary refill
• Dry mucus membranes, sunken eyes, and decreased urine output
• Tachypnea, bradypnea, or apnea
• Hypotension
• Altered mental status (irritability, anxiety, confusion, lethargy, somnolence, apnea)
• Hypothermia (especially neonates)
Signs of infection
Suggestive laboratory findings
• Lactic acidosis (>3.5 mmol/L)
• Age-specific leukocytosis or leukopenia (table 1)
• Platelet count <80,000/microL or a decline of 50 percent from highest value recorded over the
past three days
• Disseminated intravascular coagulopathy
• Renal insufficiency suggested by a serum creatinine ≥2 times upper limit of normal for age or
twofold increase in baseline creatinine
• Liver dysfunction implied by a total bilirubin ≥4 mg/dL (not applicable to newborn) or alanine
aminotransferase (ALT) >2 times upper limit of normal for age

44
18. RECOGNITION OF MENINGOCOCCAL DISEASE
Figure: Algorithm for the early management of meningococcal infection. (Copyright Pollard AJ, Nadel S, Habxbi
P, Faust I, Maconochie I, Britto Levin M 1998. Department of paediatrics, Imperial College School of Medicine, Si
Mary' Hospital london.) .
Purpuric or petechial rash or signs of meningitis/septicaema
Call consultant in A&E, paediatrics, anaesthetics or intensive care
Shock ?
Tachycardia, cold peripheries, increased
capillary refill time (> 4 s) decreased urine
output,(<1ml/kg/h)
tachypnoea/hypoxia
confusion and decreasing conscious level hypotension
(late sign)
Raised ICP?
Decreasing or fluctuating level of consciousness,
hypertension and relative bradycardia,unequally dilated
or poorly responsive pupils, focal neurological signs,
seizures, abnormal posture, papilloedema
No
ABC and oxygen (10 l/min)
and Dextrostix, insert 2 large iv cannulae (or
intra-osseous)
Cefotaxime/Ceftriaxone
(80 mg/kg)
Volume
resuscitation
(use 20 ml/kg of colloid as a
bolus and repeat)
Observe closely for
Clinical features of meningitis ?
ABC and oxygen (10 l/min) and BM Stix
Steroids (Dexamethasone, 0.4 mg/kg bd for 2 days)
Cefotaxime or Ceftriaxone (80 mg/kg)
Treat shock if present
DO NOT LUMBAR PUNCTURE
Give Mannitol (0.25 g/kg) as a bolus
[or Frusemide (1 mg/kg) if no urine output)
AND repeat if raised ICP persists
Intubate and ventilate to control PaCO2 (4-4.5 KPa)
Sedate (and muscle relax for transport),
NG tube
30
0
Head-up position, midline and avoid neck lines
Still shocked ?
after 40 ml/kg volume replacement
Continue volume resuscitation (boluses of 10-20
ml/kg of colloid)
Call anaesthetist and contact PICU
Will need elective intubation and ventilation
Commence inotropes peripherally
Nasogastric tube
Dexamethasone
(0.4 mg/kg bd
for 2 days)
Cautious fluid resuscitation, but
correct coexisting shock Phenytoin
(18 mg/kg over 30 mins) for
seizures (ECG monitoring) Urinary
catheter (especially after
mannitol/frusemide)
Anticipate and correct:
raised intracranial pressure
hypoglycaemia
acidosis
hypokalaemia
hypocaicaemia
hypomagnesaemia
hypophosphataemia
anaemia
coaguiopathy (fresh frozen plasma 10 ml/kg
and vitamin K)
Central venous access required,
CXR, and urinary catheter
Consider adrenaline infusion
if poor response to volume replacement
and dopamine/dobutamina infusion
Cefotaxime/Ceftriaxone (80
mg/kg) Close observation
Transfer to intensive care
Repeated review

45
19. ORGANOPHOSPHATE (OP) POISONING
OP compounds and carbamates are two main classes of insecticides.
Commonly used organophosphates: methyl parathion (metacid) and dichlorovos (nuvan)
PATHOPHYSIOLOGY
Inhibition of the cholinesterase (AchE) by irreversibly binding to it; accumulation of acetylcholine
at the neural synapses; initial over stimulation eventual exhaustion and disruption of neural
transmission.
If left untreated OP forms a permanent bond with this enzyme inactivating it. This process, called
'aging' occurs 2-3 days after exposure; wks to months are required for the body to regenerate
inactivated enzymes. In contrast carbamates form a temporary bond to the enzyme allowing
regeneration over several hours.
Symptoms caused by carbamate toxicity are usually less severe than those seen with OP.
Muscarinic, nicotinic and CNS receptor stimulation.
ACUTE TOXICITY
The muscarinic (cholinergic) signs (caused by Organophosphates and Carbamates) can be
remembered by use of one of two mnemonics
SLUDGE/BBB
Salivation, Lacrimation, Urination, Defecation, Garlic odor, Emesis (with Pin-point
pupils), Bronchorrhea, Bronchospasm, Bradycardia
DUMBELS
Defecation, Urination, Miosis, Bronchorrhea/Bronchospasm/Bradycardia, Emesis,
Lacrimation, Salivation
The nicotinic effects: fasciculations
CNS effects (probably through muscarinic and nicotinic receptors in the brain):
Respiratory depression, lethargy, excitability, seizures, coma
(2) INTERMEDIATE SYNDROME (IMS)
IMS occurs 24-96 hours after exposure. It arises between the early cholinergic syndrome
and late onset peripheral neuropathy. Bulbar, respiratory and proximal muscle weakness is
prominent. This resolves in 1-3 weeks.
(3) DELAYED PERIPHERAL NEUROPATHY

46
Occurs several weeks after exposure. Primarily motor involvement. May resolve
spontaneously or result in permanent neurological dysfunction
TREATMENT OF ACUTE TOXICITY
Therapy depends on severity; mildest cases need only observation, aggressive
cardiorespiratory support for seriously intoxicated.
Identify the type of ingestion, time interval, current symptoms, amount ingested.
Average swallow 5-10 ml (young child) 10-15 (older child)
Protect yourselves with gloves
ABC
Give 100% oxygen, early intubation may be required
Skin decontamination; wash with soap and water twice, remove contaminated clothes.
Gastric lavage: If ingestion within one hour of presentation
• Single dose of activated charcoal 1g/kg (maximum dose 50 gm) is given for gastric lavage. If
the patient is vomiting persistently, lavage is not necessary. Ensure that airway is protected.
• Forced emesis is contraindicated because of the risk of aspiration and seizures
Atropine: Specific antidote for muscarinic effects
• >12 yrs initial dose 1-2 mg; <12 yrs 0.05 mg/kg IV
• Repeat the dose every 3-5 minutes until atropinization occurs which is indicated by clearing of
bronchial secretions and ceasation of wheezing. Do not rely on pupillary changes;
• Maintain atropinization by giving every hour 20-30% of the total amount that was required to
atropinize. Maintain full atropinization for 2-3 days. Then atropine dose is daily reduced by 1/3
to ¼ of the dose given on the previous day.
• Continuous intravenous infusion of atropine may be necessary when atropine requirements are
massive and the dose is 0.02 to 0.08 mg/kg/hr, depending on the degree and stage of
intoxication. Hundreds of milligrams may be needed over several days in severe poisonings
• Signs of improvement after 12-24hrs are indications to begin gradual tapering of atropine doses.
• TACHYCARDIA AND MYDRIASIS ARE NOT CONTRAINDICATIONS TO ATROPINE
USE
• Inhaled ipratropium 0.5 mg with parenteral atropine may be helpful for bronchospasm; may
repeat

47
• Atropine blocks the acetylesholine receptor and so is effective in both OP and carbamate
poisoning.
Pralidoxime: Bound AchE is reactivated by this drug; relieves nicotinic as well as muscarinic
effects; should be administered as early as possible in severe poisoning
• >12 yrs 1 - 2 g IV infusion over 30 min; <12 yrs 25 mg/kg over 30 min
• May repeat after 30 minutes or give continuous infusion if severe
• Continuous infusion at 10 mg/kg/hour in children
• If no IV access, give pralidoxime 15 mg/kg IM in children <40 kg (>40 kg- 600mg). Rapidly
repeat as needed to total of 1800 mg or 45 mg/kg in children.
• Pralidoxime should NOT be administered without concurrent atropine in order to prevent
worsening symptoms due to transient oxime-induced acetylcholinesterase inhibition
It chemically breaks the bond between the OP and the enzyme liberating the enzyme and
degrading the OP. Only effective before the bond 'ages' and becomes permanent. Not necessary
for carbamate because bond between insecticide and enzyme degrades spontaneously.
Benzodiazepine:
• Diazepam 0.1 to 0.2 mg/kg, repeat as necessary if seizures occur. Do not give phenytoin.
Patient should be observed for 24 hrs after the last dose of atropine.

48
20. MANAGEMENT OF CONGENITAL HYPOTHYROIDISM
For term babies,
• If TSH >50mU/L, this is usually permanent form of congenital hypothyroidism and needs
immediate treatment
• If TSH 20-30mU/L, hypothyroidism may be transient but the baby needs treatment
• If TSH <20mU/L and T4 is normal, repeat TSH and T4 weekly. If improving, repeat and
follow up till normal. If TSH remains≥10mU/L, or rising, treat the baby
Levothyroxin Dose: 10-15 microgram/kg/day orally
It will take about 2 weeks for TSH to normalize after treatment.
Follow up investigations: Repeat TSH and T4 1 week after starting therapy, 2 weeks after
any dose change, and every 1-2 months in the first year of life.
For children suspected of transient congenital hypothyroidism, a trial off of medicine can
be tried after 3 years of age.
In preterm babies, if TSH is borderline high (10-20mU/L), start treatment. The starting
dose is 8 micrograms/kg/day
(Ref: Cloherty 7th
edition)
NORMAL VALUES FOR THYROID FUCTION TESTS IN CHILDREN
(Harriet Lane Handbook, 19th
Edition
Test Age Normal Comments
Total T4 (mcg/dl) Birth – 3d
4d-4wk
1-12mo
1-5yr
5y-adult
11.0-21.5
8.0-20.0
7.2-15.6
7.3-15.0
4.5-12.5
Measures T4 by
radioimmunoassay
Total T3 (ng/d) 0-3d
4-30d
31d-12mo
13mo-5yr
6-10yr
>10yr
96-292
62-243
81-281
83-252
92-219
71-180
Measures T4 by
radioimmunoassay
TSH (mIU/ml) 0-3d
4-30d
31d-12mo
13mo-5yr
6-10yr
>10yr
5.17-14.6
0.430-16.1
0.62-8.05
0.54-4.53
0.66-4.14
0.45-4.50

49
21. MANAGEMENT OFA CHILD WITH CONGENITAL
ADRENAL HYPERPLASIA
• When to suspect congenital adrenal hyperplasia (CAH)?
o Anytime a neonate presents with hyponatremia, hyperkalemia, hypoglycemia, and
acidosis
o Presence of ambiguous genitalia in a female baby
• Classification:
21Hydroxylase deficiency accounts for 90% of cases. There are two major types of CAH
o Classical CAH (complete enzyme deficiency)
Occurs with or without salt loss
Symptoms occur even in absence of shock
Adrenal crisis occurs at 2-3 weeks of life in untreated patients
Elevated levels of 17-hydroxyprogesterone (170OH) levels
Elevated testosterone in girl and androstenedione in boys and girls
For apparent male infants with classic CAH, a karyotype should be done
to rule out the possibility of a severely masculinized female
o Non-classical (partial enzyme deficiency)
Adrenal insufficiency tends to occur under stress
May manifest as adrenal excess (precocious pubarche, irregular mense,
hirsutism, acne, advanced bone age)
Morning 17-OHP levels maybe elevated, but diagnosis may require ACTH
stimulation test
A significant rise in 17-OHP level 60 min after ACTH injection is
diagnostic
• Management
o Glucocorticoid maintenance
Hydrocortisone: 10-20mg/m2
/day per oral (Tablet form available in Patan
Hospital pharmacy)
o Mineralocorticoid maintenance
Fludrocortsone: 0.1-0.2mg per oral once daily
(Note: Intravenous hydrocortisone 50mg/m2
/day will supply maintenance
amount of mineralocorticoid activity. Prednisolone and dexamethasone do
not provide appropriate mineralocorticoid effects)
Infants also require 1-2g (17-34 meq) of sodium
Always monitor blood pressure and electrolytes when supplementing
mineralocorticoids
o Stress dose glucocorticoid: In patients with fever or other illness
Hydrocortisone: 25-50mg/m2
/day IV/IM or 50-75mg/m2
/day PO divided
q6-8hr
For surgery or severe illness: 50-125mg/m2
/day IV
(Ref: The Harriet Lane Handbook 19th
edition)

50
22. EYE INFECTIONS
If an ocular infection occurs soon after birth and following a vaginal delivery, it was probably
acquired perinatally. The most important infections to consider are chlamydia, gonococcus and
herpes simplex virus (HSV).
A swab for culture and gram staining should be taken. Obtain results of gram stain before starting
treatment. If results are positive, consider treating mother and her partner. Bacterial conjunctivitis
should respond to frequent topical antibiotics. Use Gentamicin eye drops unless there is a specific
contraindication. Specific infections should have specific treatment as follows:
1. Gonococcal infections. These are very serious and can cause perforation of the eye.
Treatment is cefotaxime 100mg/kg single dose IM.
2. Chlamydia can give a sticky eye and may not present until the second postnatal week. Suspect if
persistent symptoms and no growth on routine swab. Although it is
normally a lower grade infection than gonococcus, it may be difficult to distinguish
them except by swab and scrape results. Treatment is normally topical tetracycline
ointment for 3 weeks as well as systemic erythromycin for 2 weeks.
3. HSV will require treatment with acyclovir ointment five times a day to the eye and
systemic treatment with acyclovir ointment five times a day to the eye and systemic
treatment may need to be considered.
Intra-uterine infection with toxoplasmosis, syphilis, rubella, can produce corneal opacities,
cataract and chorio-retinal scarring. There is no treatment which will restore retinal tissue
structure. Flare ups of posterior uveitis from congenital toxoplasmosis can occur in later life
causing reduced vision. Parents should be told about such disease as future flare ups, if sight
threatening, will need systemic treatment.

51
23. OTHERS
I. RULES OF THUMB FOR EXPECTED INCREASE IN WEIGHT
Age Expected Weight Increase
Birth -3 months 30g/day
Regain birth weight by 2 weeks
3-6 months20 g/day
Double birth weight by 4-6 months
6-12 months 10g/day
Triple birth weight by 12 month
1-2 years 250g/month
2 years- adolescence 2.3 kg/year
30 g = 1 ounce body weight
II. RULES OF THUMB FOR EXPECTED INCREASE IN HEIGHT
Age Expected Height Increase
0-12 months 25 cm/year
Birth length increases by 50% at 12 months
13-24 months 12.5 cm/year
2 years-adolescence 6.25 cm/year
Birth length doubles by age 4 years
Birth length triples by age 13 years

52
III. RULES OF THUMB FOR EXPECTED INCREASE IN HEAD CIRCUMFERENCE
Age Expected Height Circumference Increase
Preterm upto 40 wks gest. 0.75 to 1.25 cm/week
0-2 months 0.5 cm/week
2-6 months 0.25 cm/week
By 12 months Total increase = 12 cm since birth
IV. PAEDIATRIC NORMAL VALUES FOR VITAL SIGNS
Age
(years)
Resp rate
(breaths/mi
Heart rate
(beats/min
Systolic BP
(mm Hg)
Blood vol
(ml/kg)
<1 30-40 110-160 70-90 85-90
2-5 20-30 95-140 80-100 75-80
5-12 15-20 80-120 90-110 65-70
>12 12-16 60-100 100-120 65-70
V. NORMAL HEMOGLOBIN LEVELS
Hemoglobin
(G/dl)
Hematocrit
(%)
Age Mean -2 SD Mean -2 SD
Birth (Cord Blood) 16.5 13.5 51 42
1 to 3 days (Capiliary) 18.5 14.5 56 45
1 week 17.5 13.5 54 42
2 weeks 16.5 12.5 51 39
1 months 11.5 9.0 43 31
2 months 11.5 9.0 35 28
3 to 6 months 11.5 9.5 35 29
0.5 to 2 years 12.0 10.5 36 33
2 to 6 years 12.5 11.5 36 33
6 to 12 years 13.5 11.5 40 35
12 t 18 years
Female 14.0 12.0 41 36
Male 14.5 13.0 43 37
18 to 49 years
Female 14.0 12.0 41 36
Male 15.5 13.5 47 41
• These data have been compiled from several sources

53
VI. NORMAL BLOOD PRESSURE IN CHILDREN
Age Systolic Diastolic
Birth (12hrs, <1000gm) 39-59 16-36
Birth (12hrs, 3kg) 50-70 25-45
Neonate (96hrs) 60-90 20-60
Infant (6mths) 87-105 53-66
Toddler (2yrs) 95-105 53-66
School age (7yrs) 97-112 57-71
Adolescent (15yrs) 112-128 66-80
VII. NORMAL HEART RATE IN CHILDREN
Age Awake rate Mean Sleeping Rate
Newborn - 3mths 85-205 140 80-160
3mths - 2yr 100-190 130 75-160
2yrs – 10 yrs 60-140 80 60-90
>10yrs 60-100 75 50-90

54
VIII. BLOOD PRESSURE CENTILE CHART FOR BOYS

55
IX. BLOOD PRESSURE CENTILE CHART FOR GIRLS

57
X. NORMAL RESPIRATORY RATE IN CHILDREN
Age RR
Newborn 40
lyr 30
5yrs 20
10yrs 18
>10yrs 18
XI. APPROXIMATE AVERAGE HEIGHT AND WEIGHT FOR NORMAL CHILDREN
Age Kg
3 - 12mths Age (months) + 9
2
1 - 6yrs Age (yrs) x 2 +8
7 - 12yrs Age (yrs) x 7 - 5
2
Age Length/ Height (cm)
At birth 50cm
lyr 75cm
2-12yrs Age(yrs) x 6+77

62
XIII. GROWTH CHART FOR GIRLS

66
XIV BODY SURFACE AREA IN CHILDREN
(Ref: BNF for children 2010-2011, values are calculated using Boyd equation)
Body weight (Kg) Surface area (m2
)
1 0.10
1.5 0.13
2 0.16
2.5 0.19
3 0.21
3.5 0.24
4 0.26
4.5 0.28
5 0.30
5.5 0.32
6 0.34
6.5 0.36
7 0.38
7.5 0.40
8 0.42
8.5 0.44
9 0.46
9.5 0.47
10 0.49
11 0.53
12 0.56
13 0.59
14 0.62
15 0.65
16 0.68
17 0.71
18 0.74
19 0.77
20 0.79
21 0.82
22 0.85
23 0.87
24 0.90
25 0.92
26 0.95
Body weight (Kg) Surface area (m2
)
27 0.97
28 1.0
29 1.0
30 1.1
31 1.1
32 1.1
33 1.1
34 1.1
35 1.2
36 1.2
37 1.2
38 1.2
39 1.3
40 1.3
42 1.3
43 1.3
44 1.4
45 1.4
46 1.4
47 1.4
48 1.4
49 1.5
50 1.5
51 1.5
52 1.5
53 1.5
54 1.6
55 1.6
56 1.6
57 1.6
58 1.6
59 1.7
60 1.7

67
XV INTRAVENOUS FLUID REQUIREMENTS
Body weight Fluid requirement per Fluid requirement per
First 10 kg 100 ml/kg/day 4 ml/kg/hr
Second 10 kg 50 ml/kg/day 2 ml/kg/hr
Subsequent kg 20 ml/kg/day 1 rnl/kg/hr
The standard fluid bolus in shock is 20 ml/kg for children and 10ml/kg for neonates
XVI. DAILY ELECTROLYTE REQUIREMENTS
Sodium 2-3 mmol/kg/day , Potassium 2-3 mmol/kg/day
XVII. PLEURAL EFFUSIONS
Transudate Purulent Empyema Complicated
WBC 1000 5300 25900 55000
PMN% 50% >90% >95% >95%
Pr(fluid):Pr (Serum) <0.5 >0.5 >0.5 >0.5
LDH <200 >200
Glu >60 <60 <60 <40
PH 7.4-7.5 7.35-7.45 7.2-7.35 <7.2
Investigations to be sent: Serum: Protein and Glucose, CBC, ESR (+- Blood culture,
mantoux test)
Plural fluid: Protein, Glucose, pH, microscopy (Gram staining and AFB), culture
Indications for chest tube: PH 7.0 - 7.2, Glucose <40, gram stain shows organisms,
purulent fluid
XVIII. ASCITIC FLUID
Transudate Exudate
SpGr <1.016 >1.016
<3G% >3G%
A fluid (Gradient) >1.1 <1.1
Fluid : serum Glucose >i <1
LDH <200IU >200IU
WBC <250-500 >1000 Usually with inf. PMN >250 (Nelson
says >250 cells with >50% PMN)
PH with Peritonits<7.35
Investigations to be sent Serum: Albumin and Glucose
Ascitic fluid: Albumin, Glucose, pH, microscopy (Gram staining and AFB, culture)
If exudative, consider TB. If transudative, possible differential diagnoses include CHF, liver
disease, hypoalbunimaemia.

68
XIX. PERICARDIAL EFFUSIONS
Transudate Exudates
Cells Low High
Pr gm/dc < 3g/dc >3
Fluidr:Serum Pr <0.5 >0.5
Fluid:Serum glucose >1 <1
Specific gravity <1.015 >1.015
Fluid:Serum LDH <0.6 >0.6
Investigations to be sent:
Blood for CBC, glucose,(+_BC if probable Dx of staph),ESR
Mantoux, CXR, Echo
Pericardial fluid - Protein / Glucose, microbiology (Gm stain), culture
If acute History, with high fever and exudative fluid start clox and gent. If History is suggestive
of TB, the fluid is a transudate, and the patient is comfortable wait for TB investigations, if the
child is in distress start Category 1 ATT plus steroids.
XX. BLOOD CULTURE COLLECTION
Aim - collection of appropriate blood volume to allow growth of significant bacteria, using a
sterile technique to avoid contamination by skin flora.
Blood culture draw should be done PRIOR to antibiotic administration
1) Apply tourniquet, palpate and identify peripheral vein for blood draw.
2) Wearing gloves (non-sterile) clean overlying skin with 2% Iodine and wait 30
seconds. Alternatively, use Betadine but you must wait 1 minute, 10% iodine-
povidine 2 min; 0.5% chlorhexidine lmin. Cleaning the skin well pre-culture draw is
the most important factor in reducing contamination rates.
3) Remove plastic cap from Bactec bottle and clean rubber cap with 2%iodine/betadine
(leave to dry as for skin).
4) Without re-palpating vein, draw l-3ml blood with needle/butterfly and syringe or if
inserting a NEW cannula, it is acceptable to withdraw the first blood flush through

69
the hub using a clean needle attached to a syringe. DO NOT TAKE BLOOD
CULTURE SAMPLES FROM EXISTING CANNULAS/LINES.
5) NOTE: for each extra lml of blood (up to 3ml) there is an extra 10% yield
6) Inject blood into Bactec bottle. There is no need to change needles. (Evidence
suggests contamination rates are un-altered and risk of needlestick injury is higher
with needle change.)
7) Ensure bottle fully labeled and send to lab as quickly as possible. Bacteria may die if not
stored at appropriate temperature.

70
XXI. ASSESSMENT OF DEVELOPMENTAL MILESTONES

74
XXII. GUIDELINES FOR PHOTOTHERAPY IN NEONATAL JAUNDICE
(Modified from NICE guidelines, 2010)
Gestational age 12 HOL 24 HOL 36 HOL 48 HOL 60 HOL ≥72 HOL
27 weeks 3.3 4.4 5.5 7.2 8.3 9.4
28 weeks 3.3 5.0 6.1 7.2 8.8 10.0
29 weeks 3.3 5.0 6.3 7.7 9.1 10.5
30 weeks 3.8 5.0 6.6 8.3 9.4 11.1
31 weeks 3.8 5.5 6.9 8.3 10.0 11.6
32 weeks 3.8 5.5 7.2 8.8 10.5 12.2
33 weeks 3.8 5.5 7.5 9.1 11.1 12.7
34 weeks 4.0 6.1 7.7 9.4 11.6 13.3
35 weeks 4.0 6.1 7.7 10 11.9 13.8
Total serum bilirubin values have been converted to mg/dl
For, premature babies, NICE guidleline graphs are available. Before plotting in the NICE guideline
graphs, multiply by 17 to convert bilirubin from mg/dl to micromol/L.
Manual of Neonatal Care (Cloherty). Seventh Edition

75
XXIII. GUIDELINES FOR EXCHANGE4 TRANSFUSION IN NEONATAL JAUNDICE
(Modified from NICE guidelines, 2010)
Gestational age 12 HOL 24 HOL 36 HOL 48 HOL 60 HOL ≥72 HOL
27 weeks 6.1 8.3 9.7 11.1 13.3 15.0
28 weeks 6.1 8.3 10.0 11.6 13.8 15.5
29 weeks 6.1 8.3 10.2 12.2 13.8 16.1
30 weeks 6.1 8.3 10.2 12.7 14.4 16.6
31 weeks 6.6 8.3 10.2 12.7 15.0 17.2
32 weeks 6.6 8.8 11.1 13.3 15.5 17.7
33 weeks 6.6 9.1 11.3 13.6 16.1 18.3
34 weeks 6.6 9.4 11.6 13.8 16.6 18.8
35 weeks 6.6 9.4 11.6 14.4 16.9 19.4
Total serum bilirubin values have been converted to mg/dl
Guideline for exchange transfusion in >35 wk Manual of Neonatal Care (Cloherty). Seventh Edition

76
XXIV. INDICATIONS FOR PICU ADMISSSION
Respiratory
1. Endotracheal intubation or potential need for endotracheal intubation and mechanical
ventilation
2. Rapidly progressive pulmonary disease with risk of progression to respiratory failure
and/or total obstruction
3. High supplemental oxygen requirement needing continuous moitoring
4. Newly placed tracheostomy with or without the need for mechanical ventilation
5. Requirement for more frequent or continuous inhaled or nebulized medications than can
be administered safely in pediatric ward (as in severe asthma, croup etc)
6. Pneumothorax requiring chest tube insertion
Cardiovasular
1. Shock not responding to fluid resuscitation
2. Postcardiopulmonary resuscitation;
3. Life-threatening dysrhythmias
4. Unstable congestive heart failure
5. Congenital heart disease with unstable cardiorespiratory status
6. Patients requiring pericardiocentesis
Neurological
1. Seizures (including status epilepticus), unresponsive to therapy or requiring continuous
infusion of anticonvulsive agents
2. Coma with the potential for airway compromise
3. Progressive neuromuscular dysfunction requiring cardiovascular monitoring and/or
respiratory support (e. g. ascending paralysis in GBS)
4. Patients with an acutely diminished level of consciousness or a decreasing level of
consciousness
5. Raised ICP

77
Renal
1. Acute renal failure with significant fluid/electrolyte imbalance
Postoperative
1. Patients who have undergone major surgery
2. Patients requiring intensive cardiorespiratory care and monitoring
3. Severe coagulopathy
4. Severe anemia resulting in hemodynamic and/or respiratory compromise
Endocrine/Metabolic
1. Severe diabetic ketoacidosis
2. Other severe electrolyte abnormalities, such as:
a. Hyperkalemia, requiring cardiac monitoring and acute therapeutic intervention
b. Severe hypo- or hypernatremia
c. Hypo- or hypercalcemia
d. Hypo- or hyperglycemia requiring intensive monitoring
e. Severe metabolic acidosis requiring bicarbonate infusion or intensive monitoring
f.Need for central venous or arterial catheter insertion
Gastrointestinal
1. Severe acute gastrointestinal bleeding leading to hemodynamic or respiratory instability
2. Acute hepatic failure leading to coma, hemodynamic, or respiratory instability
Others
1. Toxic ingestions and drug overdose with potential acute decompensation of major organ
systems
2. Multiple organ dysfunction syndrome
3. Electrical or other household or environmental (eg, lightning) injuries

78
References:
1. Nelson Text Book of Pediatrics, 19th
edition.
2. O. P Ghai, 8th
edition.
3. Principles of Pediatric & Neonatal Emergencies, 2nd
edition.
4. The Harriet Lane Handbook, 19th
edition
5. Up To Date 18.2

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