PEDIATRICS Rx GUIDE 2024

>>> History of premature birth

>>> Onset of symptoms: usually immediately after birth (<4 hours) but can occur within 48-72 hours postpartum

>>> Distressed and unwell infant.

>> Poor feeding.

>> Signs of increased breathing effort

Tachypnoea (>60 breaths/minute).

Hypoxia.

Nasal flaring; and moderate to severe subcostal/intercostal and jugular retractions

>> Typical expiratory "grunting" (in an attempt to increase airway pressure and open collapsed alveoli).

>> Auscultation: decreased breath sounds

>> Cyanosis due to pulmonary hypoxic vasoconstriction.

Diagnosis:

>>> Clinical: Integration of typical physical examination findings and patient history

>> Chest x-ray

Interstitial edema: especially perihilar,

given the appearance of bilateral perihilar streaking

Diffuse, fine, reticulogranular (ground- glass) densities with low lung volumes and air bronchograms

Blood gas analysis (ABGs)

Hypoxia with respiratory acidosis; can lead to increased lactate levels

Evaluate for partial respiratory failure or global respiratory failure

→ Amniocentesis for prenatal testing of NRDS:

screening for markers of fetal lung immaturity → Lecithin-sphingomyelin ratio <

1.5 (2 2 is considered mature)

Antenatal maternal administration of steroids >24 hours and <7 days prior to delivery, has been shown to

decrease neonatal morbidity and mortality.

>> Generally, either two doses of Inj. Betamethasone 4mg/1ml (Betnesol) x 12 mg x IM x OD for 2 days or four doses of Inj. Dexamethasone 4mg/1ml (Decadron) x 6mg x IM x BD for 2 days.

5 NEONATAL JAUNDICE Rx

Types of neonatal jaundice

Features	Physiological neonatal jaundice	Pathological neonatal jaundice
Type of hyperbilirubinemia	Always unconjugated hyperbilirubinemia	Can be either conjugated or unconjugated hyperbilirubinemia
Onset	>24 hours after birth	Can present < 24 hours after birth
Peak total serum bilirubin	< 15 mg/dL (in the case of a full-term breastfed infant)	May rise > 15 mg/dL
Daily rise in bilirubin levels	< 5 mg/dL/day	>5 mg/dL/day
Etiology	Hemolysis of fetal hemoglobin and an immature hepatic metabolism of bilirubin	↑ production of bilirubin, ↓ conjugation, Impaired excretion, ↑ enterohepatic circulation

Neonatal jaundice

C/C:

Physical examination for icterus: The American Academy of Pediatrics (AAP) recommends regular assessment of all neonates for jaundice (every 8- 12 hours) while in the hospital.

Symptoms

Look for symptoms of an infective cause.

Neurological symptoms indicate kernicterus.

Signs

Yellow skin and sclera (it is not possible to accurately assess the level of bilirubin from how jaundiced a child looks; you must get lab levels).

Hepatomegaly (hepatic, infective/metabolic

causes).

> Hepatosplenomegaly (haemolytic causes).

> Pallor/Pale conjunctiva (if haemolytic cause).

Investigation:

> Bilirubin test: Transcutaneous bilirubin measurement (TCB) & serum bilirubin test

> CBC (reticulocyte count, Haematocrit)

> Blood group

> Direct and indirect Coombs' test

> Markers of inflammation: ESR, CRP, Albumin, Transferrin and antithrombin

" Liver enzymes (LFTS)

* Total serum protein & serum albumin

> TSH and free T4

> G6PD activity (in patients with G6PD deficiency)

" Septic profile (see neonatal sepsis)

1. Supportive therapy most jaundiced babies (especially term)

do not require treatment. They can have bilirubin monitored to ensure this does not rise above the treatment threshold. They may need support with breastfeeding. Dehydration should be addressed. Treatment is targeted at reducing the risk of kernicterus and hence permanent neurological sequelae.

2. Phototherapy:

> Phototherapy → Reduces unconjugated bilirubin,

> 'Blue light' has the ability to convert toxic unconjugated bilirubin to non-toxic.

3. Exchange Transfusion: Most rapid method for lowering serum bilirubin concentrations

> Venesection: baby's blood volume removed

> PLUS Blood transfusion

4. IV Immunoglobulin (IVIG)

> Indications:

Used in cases with immunologically mediated conditions, or in the presence of Rh, ABO, or other blood group

incompatibilities that cause significant neonatal jaundice

> Dose range for IVIG: 500-1000 mg/kg

5. IV fluids therapy: should be given to those neonates who are clinically dehydrated or who have a Total serum bilirubin (TSB) approaching the Exchange transfusion level by 2 mg/dl or with a rapidly rising bilirubin level (>0.5 mg/dl/hour).

> Monitor input/output record

5. Correct underlying cause: Sepsis, Seizures, Hypoglycemia

7. If indicated - Liver Transplant & Prevention by Protein-rich nutrition in the form of breast milk or special formula feeds.

6 NEONATAL SEIZURES RX

A. Airway:

>>> Ensure patient is maintaining own airway

Assess and secure stable airway

B. Breathing: Check SpO, & Give high flow 02 as appropriate

C. Circulation:

Maintain IV line (IV cannula)

Vitals monitoring: Check BP, PR, RR, Temperature, SpO

Send labs: CBC, U/C/E, LFTS, Blood sugar level, Calcium, magnesium, Phosphorus.

If Hypoglycemia (Blood sugar level <40 mg/dL): Administer inj. Dextrose 10% IV 2-4 ml/kg IV as bolus,

followed by maintenance infusion 6-8 mg/kg/minute. If Hypocalcaemia (total Ca <1.7 mmol/L or ionized Ca <0.64 mmol/L): Administer Inj. calcium gluconate 10% 0.5 to 2 mL/kg IV over 5-10 min with cardiac monitoring.

If Hypomagnesaemia (<0.68 mmol/L): Administer magnesium sulphate 100 mg/kg x IV or deep IM (also use for refractory hypocalcemic fit)

First line anti-epileptic: IV Phenytoin OR Phenobarbitone and IV Levetiracetam.

When to start anticonvulsants: Seizure burden of >30-60 second per hour should be considered as an indication to start anticonvulsants, importance of EEG in subclinical seizures.

Inj. Phenobarbital (Phenobarb) 200mg/1ml x 20 mg/kg x IV over 15-20 minutes → there are 2 possibilities (For more detail see Paediatrics drug dosages)

1. Seizures settle starts maintenance dose 2.5-5mg/kg/dose x IV/PO x OD after 12 hour.

2. If seizures persist or recur Reload with Phenobarbitone 10mg/kg/dose x IV over 5-10

minutes (Maximum dose is 40 mg/kg) BUT if the seizures persist or recur after maximum dose

of Phenobarbitone → Give IV Phenytoin sodium

Give Inj. Phenytoin 250mg/5ml (Epigran) x at Dosage: 20mg/kg/dose in 50-100 ml 0.9% N/S x IV

Over 20 min. (For more detail see Paediatrics drug dosages)

1. Seizures settle starts maintenance dose after 12 hour in a COMBINATION Phenobarbitone

& Phenytoin at 2.5mg-5mg/kg/dose x IV/PO x OD.

2. If seizures persist or recur reload ONCE with IV Phenytoin 10 mg/kg over 20 minutes. The after that, If the seizures settle the maintenance need to be started after 12 hours

BUT If the seizures persist or recur THE NEXT DRUG should be given → Levetiracetam

Give Inj. Levetiracetam 500mg/5ml (Epilapsa, Lerace) loading dose 10mg/kg/dose diluted in 20- 30ml of 0.9% NS or Dextrose 5% x IV Over 15 minutes there are 2 possibilities

1. Seizures settle → starts maintenance with all THREE DRUGS Levetiracetam 10 mg/kg, Phenobarbitone & Phenytoin at 2.5mg-5mg/kg x IV/PO x OD after 12 hour.

. If seizures persist or recur → Give Inj. Pyridoxine (Neurobion)

2 Inj. Pyridoxine 50-100mg x IV Slow Infusion, EEG monitoring, can be given to babies unresponsive

to conventional anticonvulsants or seek neurologist opinion.

If The Seizures Settle → Continue Pyridoxine 15-30mg/kg/day x OD lifelong (Max 500mg/d

IF THE SEIZURES PERSIST Inj. Midazolam 5mg/5ml (Dormicum) 0.1-0.4mg/kg/hour x IV Infusion and Prepare for mechanical ventilation.

Transfer to PICU: Consider induction of Anesthesia (Propofol, Thiopental + Midazolam)

D. Disability & Exposure

Monitor pupillary reflexes and GCS level

> Correct underlying cause: hypoglycemia, hypocalcemia, electrolytes abnormalities & infection

>> Consider IV thiamine: Inj Neurobion x IV

Radiology: CT/MRI Brain, EEG (Best)

7 NEONATAL SEPSIS Rx

▲ Neonatal Sepsis

>> Refusal to feed/poor sucking

Non-Specific features

>>> Lethargy, Poor cry

>> Fever/Hypothermia

>>> Severe chest indrawing

>> Absent reflexes

>>> Bradycardia/tachycardia

>> Convulsion

>> Movements only when stimulated or no movements

Specific feature:

>> CNS: irritability, vacant stray, Seizures, hyporeflexia, hypotonia

>> CVS: Hypotension, poor perfusion, mottling and shock.

>> Respiratory: apnea/tachypnea, retraction, grunt, cyanosis

>>> GIT: Feed intolerance, Diarrhea, ileus, Neonatal Entero-colitis (NEC)

>>> Liver: Jaundice, hepatomegaly

>> Blood: pallor, petechiae, purpura, Bleeding, splenomegaly

>>> Skin: multiple pustules, abscess.

Investigation of choice

Blood Culture, should be done before antibiotics. Three blood samples from different sites for blood culture.

Septic screen:

Panel of test 5 Parameter

>>> WBC count: <5000 to >34000/mm3

>> Absolute neutrophils count (ANC):

<1500/mm3

>> Micro ESR: 215mm in 1st hour

>> CRP: > 1 mg/dl

>> Immature to total neutrophil ratio: ≥20%

N.B. Cefotaxime can be added for better CNS penetration if gram- negative meningitis is suspected or if renal dysfunction precludes the use of an aminoglycoside.

Ceftriaxone should be avoided in neonates due to possibility of exacerbating hyperbilirubinemia as a result of bilirubin displacement from albumin, and the possibility of precipitating sludging in the gallbladder, leading to pseudolithiasis

A. Airway:

Ensure patient is maintaining own airway

>>> Assess and secure stable airway

B. Breathing: Check SpO2 & Provide O₂ supplementation and assist ventilation e.g., bag valve mask devices as needed

C. Circulation:

Pass IV line (IV cannula)

30 Vitals monitoring: Check BP, PR, RR, Temperature, SpO,

Send labs: CBC, Urea, Creatinine & Electrolytes (U/C/E), Blood sugar, procalcitonin, ESR, CRP, and Blood C&S.

Haemodynamic support:

1. IV fluid administration with 0.9% NS 10mL/kg (20mL/kg in infant) bolus as a push, then reassess, if required repeat as needed, to a maximum total volume of 40 mL/kg. Repeat assessment of fluid status. PERFUSION (Heart rate, Capillary refill time (CRT), urine output), clinical condition & assessment for signs of fluid overload.

2. Consider inotropic agent: if haemodynamic instability persist despite after 40mL/kg fluid resuscitation, start IV Infusion Inj. Dopamine (begin at 5 mcg/kg/minute and titrate up to 20 mcg/kg/minute as needed)

Prophylactic Antibiotics Rx: No need to wait for C&S report, Duration of antibiotics for culture - ve sepsis 5-7 days and 10-14 days for culture + sepsis without meningitis.

Inj. Ampicillin (Amplus) x IV x TDS

Dosage: 100-150mg/kg/day

PLUS Inj. Amikacin (Gracil or Amkay) x IV x OD

Dosage: 15mg/kg/day (Alternative: Gentamicin 7.5mg/kg)

Available Strength: 25mg, 50mg, 100mg, 250mg, 500mg. OR Inj. Cefotaxime 1g (Claforan, Cefotax) x IV x TDS/BD

Dosage: 150-200MG/kg/day

20 If Seizures: Inj. Midazolam 5mg/5ml (Dormicum) x IV slow Dosage: 0.1-0.4mg/kg/dose (Maximum dosage: 10mg)

D. Disability & Exposure

Positioning and temperature maintenance (warmth)

Monitor pupillary reflexes and GCS level

Monitor Input/output record

Correct electrolytes imbalance

Correct underlying cause: i.e UTI, Pneumonia, meningitis etc.

Investigation: Chest X-ray, Urine & stool analysis, Urine culture,

CSF analysis, CT scan brain plain if altered mental status

CHOICE OF EMPIRICAL ANTIBIOTICS MUST BE BASED UPON LOCAL DATA OF ETIOLOGICAL ORGANISM & THEIR ANTIBIOGRAM

1st line: Inj. Ampicillin/Sulbactam (Ambac) PLUS Gentamicin or Amikacin 2nd line: Inj. Ampicillin/Sulbactam (Ambac) PLUS Cefotaxime (Claforan)

3rd line as well in resistant cases: inj. Piperacillin/Tazobactam + Amikacin 4th line: Inj. Meropenem or Inj. Imipenem PLUS Vancomycin (If MRSA)

8 ACUTE TONSILLITIS Rx

C/C:

Most commonly seen in school going children

Most common cause-viral infections: Tonsilitis initially starts with viral infection followed by secondary bacterial infection.

The leading symptoms tend to be mild and non-specific, and include:

>> Fever, malaise, headache

>>> Sore throat (acute phase)

>> Runny nose, Dry Cough in 1/3

>> Nasal obstruction

>>> Headache

>>> Low-grade fever

>> Cough (dry) in 1/3

>>> Particularly in very young children, feeding may be affected

Signs

>> inflamed tonsils, pillars, soft palate, uvula

>>> Bilateral jugulodigastric lymph nodes are enlarged and tender.

>>> Most of the infections are due to Streptococcus and penicillin is the DOC.

>> Patients allergic to penicillin can be treated with Macrolides: Erythromycin OR Clarithromycin.

> Other: Cephalexin, Cefadroxil

>> Improvement can be expected within 3-4 days.

>> Antibiotics should be continued for 5-7 days (10 days)

>>> Azithromycin only for 5 days

Self-limited; Antibiotic therapy for acute Group 'A' Streptococci pharyngitis recommended to prevent rheumatic fever

Patient are kept on bed rest

Encourage good oral hydration and food intake

Steam inhalation may be benefited

1 Syp. Co-Amoxiclav 312.50mg/5ml (Augmentin DS, Calamox DS)

156.25mg/5ml (Augmentin, Calamox) .

Dosage: 25-40 mg/kg/day x divided every 8-12 hourly. TDS/BD (1 Teaspoonful = 5ml)

OR Syp Cefadroxil 125mg/5ml, 250mg/5ml (Cedrox, Duricef)

Dosage: 30mg/kg/day divided every 12 hourly PO (Max: 2g/day). BD (1 Teaspoonful = 5ml)

2. Syp. Paracetamol (Calpol=120mg/5ml, Panadol =160mg/5 ml)Calpol 6 Plus, Panadol forte =250mg/5ml) TDS/QID (1 Teaspoonful = 5ml) Dosage: 10-15mg/kg/Dose

If symptoms of allergy, hay fever, cough & common cold.

3. Syp. Dextromethorphan + Chlorpheniramine Maleate (Babynol) 1-2 teaspoonful TDS

2nd alternative Rx

1. Syp. Azithromycin 200mg/5ml (Azomax, Zetro, Azitma) Dosage: 10 mg/kg on day 1 (Max: 500 mg/day) followed by 5mg/kg/day once daily for 5 days (Max: 250 mg/day). OD (1 Teaspoonful = 5ml)

Or Syp. Clarithromycin 125mg/5ml, 250mg/5ml (Claritek, Klaricid) Dosage: 15mg/kg/day x BD (Maximum dose 1g/Day) BD (1 Teaspoonful = 5ml)

2. Syp. Ibuprofen (Brufen = 100mg/5ml, Brufen DS = 200mg/5ml) Dosage: 10mg/kg/dose x 6-8 hourly (max daily dose:40 mg/kg/day) TDS/QID (1 Teaspoonful = 5ml)

If symptoms of allergy, hay fever, cough & common cold.

3. Syp. Dextromethorphan + Chlorpheniramine + Ephedrine (Corex-D) 1-2 teaspoonful x TDS

9 ACUTE EPIGLOTTITIS Rx

Epiglottitis C/C:

>> Acute onset of high fever (39-40°C; 102-104°F)

>> The patient looks unwell.

>> Tripod position: eases respiration as the airway diameter is increased by leaning forward and extending the neck in a seated position

>>> Sore throat

>>> Dysphagia & Odynophagia

>> Drooling

>>> Muffled voice (resembling a "hot- potato" voice) with painful speech

>> Respiratory Distress: Nasal flaring, tracheal tug, raising the shoulders, intercostal recession, & inspiratory stridor is a late sign, → indicates upper airway narrowing.

>>> Restlessness and/or anxiety

>> General examination may elicit cervical lymphadenopathy.

The hallmarks of epiglottitis are the 3D's: Dysphagia, Drooling, & Distress.

Swabs: from the throat for MC&S.

Confirm infective cause: CBC, CRP, blood culture.

Fibre-optic laryngoscopy is the gold standard and should be performed in an area that has access to an emergency airway

X-Ray neck lateral view: Thumbprint sign

1. Airway:

Ensure patient is maintaining own airway

» Ass Assess and secure stable airway, to prevent impending complete obstruction. Intubation is first line for airway management and is usually done at laryngoscopy.

Extubation can usually be accomplished in 24-48 hours, when direct inspection shows a significant reduction in the size of the

epiglottis. Surgical tracheostomy may be required in patients with severe airway obstruction in whom intubation has not been possible.

2. Breathing:

Check SpO2, maintain saturations between 94 & 98%.

Give high flow 02 supplementation as appropriate via through a non-rebreather mask.

>> If tolerated, nebulized adrenaline can afford temporary improvement

3. Circulation:

Maintain Intravenous line (IV cannula)

Vitals monitoring: Check BP, PR, RR, Temperature, SpO2

Send labs: CBC, U/C/E, Blood sugar level, ABGS (Acidosis)

IV fluid resuscitation: 20 mL/kg of isotonic fluids as the patient is nil by mouth: R/L or N/S 0.9%

১) First line IV empirical antibiotic: coverage to include gram positive cocci & Haemophilus influenzae-Type-B.

IV antibiotics should be continued for 2-3 days, followed by oral antibiotics to complete a 10-day course.

➤Inj. Ceftriaxone 1g (Rocephin, Titan) x IV x BD/OD Dosage: 75mg-100mg/kg/day

➤ Or Inj. Cefotaxime 1g (Claforan, Cefotax) x IV x BD/TDS Dosage: 150-200mg/kg/day

Or Inj. Cefuroxime 750mg (Zinacef, Zecef) x IV x BD/TDS

Dosage: 50-75mg/kg/day

Or Inj. Ampicillin-Sulbactam 1.5g, 3g (Ambac) x IV x QID

Dosage: 150-200mg/kg/day

Consider empiric steroids

Inj. Dexamethasone 4mg/ml (Decadron) x IV x BD/TDS

Dosage: 0.15mg/kg

If fever: Inj Paracetamol 1g/100ml (Provas) x SOS/TDS Dosage: 15mg/kg/dose

4. Disability & Exposure

Consider early PICU Admission

Monitor pupillary reflexes and GCS level

Continuous monitoring: pulse oximetry, serial pulmonary examination

Keep the patient calm and in the sitting position. Correct underlying cause «

Radiology: X-ray neck lateral view (Thumbprint sign), CXR

10 LARYNGOTRACHEOBRONCHITIS (CROUP) Rx

C/C:

>>> Rhinitis with nasal discharge and congestion

>>> Low-grade fever

Harsh bark/seal-like cough

>> Hoarse voice

>>> Inspiratory stridor

>>> Symptoms worse at night

>> Child does not look toxic

Assessment

Record croup severity:

* C: Cyanosis

* R: Recession of chest

* O: Oxygen saturations (keep >92%)

* UP: Upper airway obstruction e.g. stridor

>>> Respiratory rate

>>> Heart rate

>>> Level of consciousness

>> Do not examine throat as it may cause acute severe/total obstruction

>> Do not distress child

SEVERITY OF CROUP

1. MILD CROUP

. Seal-like Barking cough

Mild stridor

. Hoarseness

. No recession

. No cyanosis

2. MODERATE CROUP

. Intermittent stridor at rest

Mild recession

Alert and responsive

3. SEVERE CROUP

Stridor at rest

Cyanosis

Oxygen saturation <92% in air

Moderate to severe recession

Apathetic/restless

If no sustained improvement with adrenaline and dexamethasone than Transfer to NICU airway intubation

Intubation is indicated when airway compromise is imminent (required in < 3% of infants with severe croup)

Intubation in severe croup is difficult due to subglottic narrowing anesthesiologist required!

'Rebound' phenomena may occur, where the upper airway obstruction may recur as the effect of the adrenaline wears off after 1-2 hours. While in the past it was recommended that any child who received adrenaline for croup should be admitted

X-ray A.P view: Steeple sign

Mild to Moderate CROUP

Admit/observe moderate croup for 4 hr and reassess

Counseling/Leaflet on croup and reassurance

Decrease infant's anxiety

Cool mist inhalation

Placing infant to sleep in an upright position

Adequate fluid intake and Breathing cool air at night (especially in the winter) helps to soothe symptoms

Analgesic for discomfort: Paracetamol OR Ibuprofen

1. Syp Paracetamol (Calpol=120mg/5ml, Panadol =160mg/5 ml) TDS/QID (1 Teaspoonful = 5ml)

Syp. Ibuprofen (Brufen = 100mg/5ml, Brufen DS = 200mg/5ml)

Dosage: 10 mg/kg/dose x 6-8 hourly (max daily dose:40 mg/kg/day) TDS/QID (1 Teaspoonful = 5ml)

2. Inj Hydrocortisone 100 mg (Solu-Cortif, Hyzonate) x IV state, may be useful to relieve oedema (Ref: PL Dhingra) OR Inj Dexamethasone 4mg/1ml (Decadron) x IV/IM

>> Reduces airway swelling within 6 hours, Long-lasting effect

>> Dosage: 150 mcg/kg

Dexamethasone dose can be repeated after 12 hr or if well, patient can be discharged with a single dose of Prednisolone 1 mg/kg (Syp Rapicort 5mg/5ml, Syp Steron 5mg/5ml) rounded up to nearest 5 mg to take 12-24 hr later.

If not available the Tab. Deltacortril 5mg/Rapicort 5mg

If Secondary infection

3. Syp. Co-Amoxiclav 156.25mg/5ml (Augmentin, Calamox)312.50mg/5ml (Augmentin, Calamox DS)

Dosage: 25-40 mg/kg/day x divided every 8-12 hourly.

TDS/BD per orally (1 Teaspoonful = 5ml) OR Syp Cefadroxil 125mg/5ml, 250mg/5ml (Cedrox, Duricef)

Dosage: 30mg/kg/day divided every 12 hourly (Max: 2g/day).

BD per orally (1 Teaspoonful = 5ml)

Admit if <6 months old, graded 'severe', stridor at rest, respiratory distress or the child looks very unwell.

SEVERE CROUP

Patients with Severe Croup should always BE HOSPITALIZED

1. Airway:

30 Ensure patient is maintaining own airway

Assess and secure stable airway

Intubation needs to be considered in the child who has increasing upper airway obstruction, hypoxia, decreasing conscious state or fatigue despite nebulised adrenaline.

2. Breathing:

Check SpO,

30 Give high flow 02 supplementation as appropriate

15 L/min via mask with reservoir bag to maintain saturations between 94 and 98%.

Nebulized racemic inj. adrenaline (1mg/1ml)

3. Circulation:

Maintain Intravenous line (IV cannula)

Vitals monitoring: Check BP, PR, RR, Temperature, SpO2

>>> Send labs: CBC, U/C/E, LFTs, Blood sugar level, ABGS

>> A single dose of corticosteroid: Dexamethasone 150 mcg/kg oral (or if child refuses to swallow oral medication, nebulized budesonide 2 mg)

IV fluid resuscitation: at dose 20 mL/kg (R/L or N/S 0.9%)

NO ROLE OF ANTIBIOTICS, Only in secondary infection.

➤Inj. Ceftriaxone 1g (Rocephin, Titan) x IV x BD/OD Dosage: 75mg-100mg/kg/day

Or Inj. Cefotaxime 1g (Claforan, Cefotax) x IV x TDS/TDS

Dosage: 150-200mg/kg/day

If fever: Inj Paracetamol 1g/100ml (Provas) x IV x SOS/TDS

Dosage: 15mg/kg/dose

If no sustained improvement with adrenaline and dexamethasone: REFER TO Paediatrics ICU

Disability & Exposure

>> Consider early PHDU/PICU Admission

>> Monitor pupillary reflexes and GCS level

> Correct underlying cause

11 BRONCHIOLITIS Rx

▲ Bronchiolitis

C/C:

Initially presents with upper respiratory tract symptoms:

. Rhinorrhea

■ Low-grade fever

* Cough

>> Respiratory distress (usually occurs in infants)

* Tachypnea or apnea

* Prolonged expiration

* Nasal flaring

* Intercostal retractions

■ Cyanosis

>> Poor feeding in breastfed infants

>> Auscultatory findings: wheezing, crackles

>>> Chest X-ray: hyperinflation of the lungs, interstitial infiltrates, atelectasis

There is no indication for antibiotic use, including azithromycin, for bronchiolitis unless there is good evidence of secondary bacterial infection.

Infants with bronchiolitis should not be administered beta 2-agonists as there is high-quality evidence that their use does not result in any change in the rate of hospitalization.

Ribavirin: currently not recommended for routine treatment of bronchiolitis; may be considered in immunocompromised patients

Mild - moderate cases

Feeding, Adequate hydration

Relief of nasal congestion/obstruction

Counsel/Monitoring: heart rate, respiration, urine output

1. Syp Cough suppressants (Hydrillin, Syp Corex-D) 1-2 Teaspoonful TDS

2. Syp Loratidine 5mg/5ml (Softin, Lorin NSA) 0+0+1,1+0+1 (2-5 years = 5mg x OD/ > 5 years 5mg x BD)

3. Syp Paracetamol (Calpol =120mg/5ml, Panadol =160mg/5 ml 1-2 )(Calpol 6 Plus, Panadol forte =250 mg/5mlTeaspoonful TDS, Dose: 15mg/kg

For Infant:

Antipyretic: Paracetamol (Panadol Infant drops 80mg/0.8ml)

. Anti-allergic: Cetirizine (Rigix Infant drops 10mg/ml)

3. Cough suppressant: Coferb cough Drops, Hylixia cough drops

The vast majority of children with bronchiolitis will recover ove 7-10 days.

Severe cases

Indications for hospitalization

Toxic appearance, poor feeding, dehydration, lethargy

Marked respiratory distress

Age < 12 weeks and/or history of prematurity (< 34 weeks)

Pre-existing heart, lung, or neurological conditions

Immunodeficiency

The role of ipratropium bromide is equally unclear, there is no clear-cut benefit to use.

Nebulised adrenaline (epinephrine) and dexamethasone in combination have been shown in a multicentre trial in Canada

to have some potential beneficial effect on the severity of the illness as determined by hospital admission

BRONCHIOLITIS SEVERITY MANAGEMENT

Mild Bronchiolitis

Moderate Bronchiolitis

Severe Bronchiolitis

Alert

Feeding >50% normal

Mild respiratory distress

SaO2 ≥92%

NOT high-risk patient

Age >6 weeks

Management

Discharge home

Smaller/frequent feeds

Review in primary care

Lethargic, tired

Feeding <50% normal

Marked respiratory distress

Dehydrated

SaO2 <92%

High-risk patient

Management

Admit

02 to keep SaO2 92%

Minimize handling

Consider NG or IV fluids

Close observation

Features of moderate

Increasing 02 requirement

Fatigue

Signs of CO2 retention

Apnoeic episode

Management

Maintain ABCD

Cardiorespiratory monitor

Consider blood gas measurement

Liaise with PICU

11 LOWER RESPIRATORY TRACT INFECTION (CHEST INFECTION) Rx

>>>> Cough and Irritability

>>> Fever

>>>> Poor feeding

>>>> Vomiting

>>> Tachypnoea at rest (most useful sign)

<2 months: >60/min

2-11 months: >50/min

1-5 year: >40/min

>>>> Bronchial breathing

>>> Inspiratory crackles

>> Recession

>>> Abdominal pain (referred pleural pain)

Admit children with sats <92%, RR >70, ↑ ↑ HR, ↑ CRT or apnoea/grunting

ILL CHILD if ANY of the following:

Poor perfusion

Altered level of consciousness

Respiratory failure:

Hypoxia, Hypercapnia and Acidosis

Admit to hospital

Resuscitate

Start IV antibiotics & antipyretic

Discuss case with PICU

1 Syp.(Augmentin, Calamox)56.25mg/5ml Co-Amoxiclav 312.50mg/5ml (Augmentin DS, Calamox DS)

Dosage: 25-40mg/kg/day x TDS/BD (1 Teaspoonful = 5ml) Or Syp. Cefuroxime 125mg/5ml (Zecef, Kefrox, Evorox)

Dosage: 20-30mg/kg/dose (Max: 500 mg/dose) x BD Or Syp. Cefixime 100mg, 200mg (Cefspan, Cefiget)

Dosage: 8-10mg/kg/day x BD

1-0-1(OD)

2. Syp. Paracetamol (Calpol =120mg/5ml, Panadol =160mg/5 ml) TDS/QID (1 Teaspoonful = 5ml)

3. Syp. Antitussive (Cough suppressants) (Hydrillin, Babynol, Corex-D) 1-2 Teaspoonful x TDS

2nd alternative Rx

1. Syp. Azithromycin 200mg/5ml (Azitma, Zetro, Azomax)

Dosage: 10 mg/kg/day x once daily

0-0-1(OD)

Or Syp. Clarithromycin 125mg, 250mg (Klaricid, Claritek)

Dosage: 15 mg/kg/day x BD (1 Teaspoonful = 5ml)

1-0-1(OD)

2. Syp. Paracetamol (Calpol =120mg/5ml, Panadol =160mg/5 ml) TDS/QID (1 Teaspoonful = 5ml)

3. Syp. Antitussive (Cough suppressants) (Hydrillin, Cofrest, Corex-D) 1-2 Teaspoonful x TDS

3rd alternative Rx

Neonate/infant prescription

(Augmentin, Calamox, Amclav infant drops)

. Co-Amoxiclav 62.5mg/ml Infant drops 1

Dosage: 30mg/kg/day x TDS

Or Syp. Cefaclor 50mg/ml infant drops (Ceclor, Cefalor, Hiclor)

Dosage: 30-40mg/kg/dose x BD/TDS

Or Syp. Cefixime 100mg (Cefspan, Cefiget)

Dosage: 8-10mg/kg/day x BD

(Panadol (80mg/0.8ml) infant drops) 2. Paracetamol (Tempo) 100 mg/ml infant drops)

3. Antitussive/cough suppressants infant drops: (Coferb, Cofif, Hylixia) Dosage - Children 6 months to 1 year: 12-14 drops 3 times a day

12 URINARY TRACT INFECTION (UTI) Rx

UTI

> Vomiting (in children aged >3 months)

> Poor feeding (infant)

> Lethargy

> Irritability

> Abdominal pain or tenderness

> Urinary frequency or Painful urination (Dysuria)

> Offensive urine or haematuria

> Mild fever -/+ with chills

> Burning micturition

> Frequent urination but very little urine comes out

> Urgent urination

Duration of antibiotics: 3-5 days

Investigation:

Urine D/R

Urine C/S

1. Syp. Nalidixic acid 250mg/5ml (Negram, Nalacid) TDS/BD (1 Teaspoonful = 5ml)

Dosage:

>> Children >3 months: 50-55mg/kg/day divided every 6-8 hourly

Prophylaxis of UTI: 25-30 mg/kg/day divided every 8 hourly.

Or Syp. Co-Trimoxazole(Septran = 40/200 mg/5ml, Septran DS = 80/400mg/5ml) (Trimethoprim/sulfamethoxazole) TDS/BD (1 Teaspoonful = 5ml)

Dosage: Children > 2 month PO.

>> Mild to moderate: 6-12mg/kg/day divided every 12 hourly.

>> Severe Infection: 15-20mg/kg/day divided every 6-8 hourly.

(Calpol 6 Plus, Panadol forte =250mg/5ml) 2. Syp Paracetamol (Calpol=120mg/5ml, Panadol =160mg/5 ml) TDS/QID (1 Teaspoonful = 5ml)

3. Syp. Cran-berry extract (Cranmax aqua, Cenova) 1-0-1(BD)/1-1-1 (TDS)

2nd alternative Rx

1. Syp. Ciprofloxacin 125mg/5ml, 250mg/5ml (Novidat, Mytil, Ciplet) BD (1 Teaspoonful = 5ml)

Dosage: 15-30 mg/kg/day divided 12 hourly (Max: PO; 1.5 gm/day (Cefspan DS, Cefiget DS= 200mg/5ml) Or Syp. Cefixime 100mg, 200mg (Cefspan, Cefiget = 100mg/5ml) BD (1 Teaspoonful = 5ml)

UTI Dosage: 16mg/kg/day x BD on day 1, then 8mg/kg/day for 13 days.

2. Syp. Ibuprofen (Brufen = 100mg/5ml, Brufen DS = 200mg/5ml) Dosage: 10mg/kg/dose x 6-8 hourly (max daily dose: 40 mg/kg/day)

3. Syp. Cran-berry extract (Cranmax aqua, Cenova) 1-0-1(BD), 1-1-1 (TDS)

If abdominal pain add on

4. Syp. Hyoscine butyl bromide 5m/5ml (Spasler-P)

Dosage:

Infant: 1 Teaspoonful = 5ml x 3 times daily

6 years: 1-2 Teaspoonful 3 times daily

Over 6 years: 2 Teaspoonful 3-5 times daily

13 ALLERGIC RHINITIS Rx

Ask about family history, seasonal variance and if a trigger is identifiable.

Postnasal drip may produce a chronic dry cough

Limit allergen exposure.

Bed rest is essential to cut down the course of illness

Plenty of fluids are encouraged

Symptoms can be easily controlled with antihistamines and nasal decongestants.

Analgesics are useful to relieve headache, fever and myalgia.

Non-aspirin containing analgesics are preferable as aspirin causes increased shedding of virus.

Antibiotics are required when secondary infection supervenes.

Severe cases may require systemic leukotriene receptor antagonists (montelukast).

Management of other atopic conditions if present (asthma, eczema)

1. Syp. Cetirizine 5mg/5ml (Rigix, Zyrtec) Or Syp. Loratidine 5mg/5ml (Softin, Lorin-NSA) 0+0+1,1+0+1(2-5 years = 5mg x OD/ > 5 years 5mg x BD)

2. Syp. Paracetamol (Calpol 6 Plus, Panadol forte =250mg/5ml) (Calpol =120mg/5ml, Panadol =160mg/5 ml) TDS/QID (1 Teaspoonful = 5ml)

Dosage: 10-15mg/kg/Dose Or Syp. Ibuprofen (Brufen = 100mg/5ml, Brufen DS = 200mg/5ml) Dosage: 10mg/kg/dose x 6-8 hourly (max daily dose: 40 mg/kg/day) TDS/QID (1 Teaspoonful = 5ml)

2nd alternative Rx

1. Syp. Levocetirizine 2.5mg/5ml (T-Day, Neo-sedil, Ocitra) Or Syp. Desloratadine 0.5mg/5ml (Jordin-D, Neo-Initial, Deslora) 1-2-teaspoon OD/BD (1 Teaspoonful = 5ml)

2. Syp. Ibuprofen 100 mg + Pseudoephedrine 15mg/5ml (Arinac) Or Syp. Paracetamol 80mg + Triprolidine (1.25mg, Pseudoephedrine (HCI) 30mg/5ml (Actifed-P) 1-2-teaspoon BD/TDS (1 Teaspoonful = 5ml)

14 FOOD ALLERGY Rx

C/C:

Onset of symptoms 10-15 minutes after food ingestion.

Typically, urticaria and a rash.

In anaphylaxis:

Angioedema of the eye/mouth/face

Voice change

.Sensation of tight chest

Cough/wheeze

Stridor develops as the airway closes from laryngeal oedema

Treat as Anaphylaxis

A. Airway:

Ensure patient is maintaining own airway

Assess and secure stable airway

B. Breathing:

Check SpO2

Give high flow 02 as appropriate

C. Circulation:

Pass IV line (IV cannula)

Vitals monitoring: Check BP, PR, RR, Temperature, SpO2

Send labs: CBC, U/C/E, LFTS, Blood sugar, Serum IgE

» Inj. adrenaline 1:1000 x IM (Repeat as needed)

0.15ml up to 6 years

0.3ml 6-12 years

0.5ml >12 years

Start IV fluid: Normal Saline 0.9% Or Ringer Lactate x IV

Dosage: 20 ml/kg IV fluid bolus

Inj. Hydrocortisone 100mg (Solu-cortef) x IV x Stat

Dosage: 4mg/kg/dose

Inj. Pheniramine maleate 50 mg/2ml (Avil)

Dosage: 0.3-0.5 mg/kg/day

Bronchospasm: Nebulization with Salbutamol (Ventolin)

D. Disability & Exposure

Monitor pupillary reflexes and GCS level

Education on avoiding offending allergens.

" Testing to identify other allergens may be indicated in difficult-to-diagnose cases.

Dietitian input if multiple allergies/failure to thrive.

>> Correct underlying cause

Radiology: CXR (not required)

15 CHILD WITH COLD/FLU Rx

C/C:

Fever

Sneezing

Cough

Nasal Discharge

Watery eyes

1. Syp. Loratidine 5mg/5ml (Softin, Lorin-NSA) Or Syp. Cetirizine 5mg/5ml (Rigix, Zyrtec) 0+0+1,1+0+1 (2-5 years = 5mg x OD/> 5 years 5mg x BD)

2. Syp. Cough suppressants (Babynol, Combinol Junior) 1-2-teaspoon BD/TDS

3. Syp. Paracetamol (Calpol =120mg/5ml, Panadol =160mg/5 ml)(Calpol 6 Plus, Panadol forte =250mg/5ml)

TDS/QID (1 Teaspoonful - 5ml)

Dosage: 10-15mg/kg/Dose Or Syp. Ibuprofen (Brufen = 100mg/5ml, Brufen DS = 200mg/5ml)

Dosage: 10mg/kg/dose x 6-8 hourly (max daily dose:40 mg/kg/day) TDS/QID (1 Teaspoonful = 5ml)

If sore throat or any sign of secondary infection than add 156.25mg/5ml (Augmentin, Calamox)

4. Syp. Co-Amoxiclav 312.50mg/5ml (Augmentin DS, Calamox DS)

Dosage: 25-40 mg/kg/day x divided every 8-12 hourly. TDS/BD (1 Teaspoonful = 5ml)

16 CHILD WITH DENTAL INFECTION Rx

▲ Dentoalveolar Infections

C/C:

Toothache

Fever and sickness

Cheek swelling/swollen gums

» Tooth sensitivity to hot, cold or pressure

>> Swollen lymph nodes

Redness or swelling of the gums next to a tooth.

Loss of appetite

Pus formation

Avoid chilled carbonated drinks, chocolates and candies.

If your children are young don't allow them to sleep with a milk bottle in their mouth, this way carbohydrate content in the milk reacts with acids in saliva and starts eating the tooth enamel and this leads to tooth decay.

Duration of antibiotics: 4-7 days

156.25mg/5ml (Augmentin, Calamox, Co-Amoxiclave 312.50mg/5ml (Augmentin DS, Calamox DS)

1. Syp.

Dosage: 25-40 mg/kg/day x divided every 8-12 hourly.

TDS/BD (1 Teaspoonful = 5ml)

Or Syp. Cefadroxil 125mg/5ml, 250mg/5ml (Cedrox, Duricef)

Dosage: 30mg/kg/day divided every 12 hourly PO (Max: 2g/day). BD (1 Teaspoonful = 5ml)

Syp. Paracetamol (Calpol =120mg/5ml, Panadol =160mg/5 ml)(Calpol 6 Plus, Panadol forte =250mg/5ml)

Dosage: 10-15mg/kg/Dose TDS/QID (1 Teaspoonful = 5ml)

Or Syp. Ibuprofen (Brufen=100mg/5ml, Brufen DS=200mg/5ml)

Dosage: 10mg/kg/dose x 6-8 hourly

Maximum daily dose: 40mg/kg/day

TDS/QID (1 Teaspoonful = 5ml)

PLUS/MINUS (Reduced gum swelling and abscess)

3. Syp. Metronidazole 200mg/5ml (Flagyl, Klint, Metrozine)

Dosage: 7.5 mg/kg/dose three times a day

TDS (1 Teaspoonful = 5ml)

16 CHILD WITH EAR PAIN Rx

C/C:

Ear pain/Otalgia

Irritability

Incessant crying

Refusal to feed

Fever sometime

1. Lidocaine Ear drops (Otocain, Lidosporin)

2-3-drops 3-4 time a day

2. Syp. Paracetamol (Calpol =120mg/5ml, Panadol =160mg/5 ml)(Calpol 6 Plus, Panadol forte =250mg/5ml)

TDS/QID (1 Teaspoonful = 5ml)

Dosage: 10-15mg/kg/Dose

OR Syp. Ibuprofen (Brufen = 100mg/5ml, Brufen DS = 200mg/5ml)

Dosage: 10mg/kg/dose x 6-8 hourly (max daily dose:40 mg/kg/day) TDS/QID (1 Teaspoonful = 5ml)

18 CHILD WITH EAR DISCHARGE / INFECTION Rx

C/C:

Ear pain: Older children will most frequently report ear pain; in infants and nonverbal children symptoms can be nonspecific, and may be easily confused with other conditions.

General symptoms

>>> Otalgia/earache, commonly described as throbbing pain

>>> Hearing loss in the affected ear

>> Fever

>> Otorrhea (Ear discharge) in the case of a ruptured tympanic membrane

Typical presentation in infants

>> Irritability, Incessant crying

>> Refusal to feed (anorexia)

>> Repeatedly touching the affected ear

>>> Fever and febrile seizures

>> Vomiting and Fever and febrile seizures

Duration of Antibiotics: 5-7 days

156.25mg/5ml (Augmentin, Calamox) Syp. Co-Amoxiclav 312.50mg/5ml (Augmentin DS, Calamox DS)

Dosage: 25-40 mg/kg/day x divided every 8-12 hourly. TDS/BD (1 Teaspoonful = 5ml) Or Syp. Cefadroxil 125mg/5ml, 250mg/5ml (Cedrox, Duricef)

Dosage: 30mg/kg/day divided every 12 hourly PO (Max: 2g/day). BD (1 Teaspoonful = 5ml)

(Calpol 6 Plus, Panadol forte =250mg/5ml) Syp. Paracetamol (Calpol =120mg/5ml, Panadol =160mg/5 ml) TDS/QID (1 Teaspoonful = 5ml)

Dosage: 10-15mg/kg/Dose Or Syp. Ibuprofen (Brufen=100mg/5ml, Brufen DS=200mg/5ml)

Dosage: 10mg/kg/dose x 6-8 hourly (Maximum Dose:40 mg/kg/day) TDS/QID (1 Teaspoonful = 5ml)

3. Ciprofloxacin + Lidocaine Ear drops (Cipocain) Or Ciprofloxacin + Lidocaine Ear drops (Cipocain) 2-3-drops 3-4 time a day

19 ACUTE SUPPURATIVE OTITIS MEDIA (ASOM) Rx

Acute inflammation of middle ear cleft <3 weeks, infective in origin.

One of the most common infectious disease seen in children

Peak incidence - first 2 years of life

Most common route of infection is through Eustachian tube Organism

Bacterial: Streptococcus pneumoniae (Most common), H. influenzae (2nd most common), Moraxella catarrhalis

Viral: Syncytial virus, Influenza virus, Rhino and adenovirus

Stages of ASOM

1. Stage of tubal occlusion

2. Stage of pre-suppuration

3. Stage of suppuration

4. Stage of resolution

5. Stage of complication

C/C

Ear Pain: Older children will most frequently report ear pain; in infants and nonverbal children symptoms can be nonspecific, and may be easily confused with other conditions.

General symptoms

Otalgia/Earache, commonly described as throbbing pain.

Hearing loss in the affected ear

Fever

Otorrhea (Ear Discharge) in the case of a ruptured tympanic membrane.

Examination findings

Otoscopy

>>> Bulging tympanic membrane (TM) with loss of landmarks

>>> Opacification and loss of light reflex

>>> Retracted and hypomobile TM

>>>> Purulent/serosanguineous

discharge in the external auditory canal or visible perforation

>>> Distinct erythema of the TM

>>> Additional findings that may be present: Yellow spot on the TM, Cartwheel TM, Blisters/bullae on the Tympanic membrane (TM)

Tuning fork test: hearing loss

secondary to an effusion.

CBC: Leukocytosis maybe present

Gram stain and culture of middle ear fluid - if patient not responded to Rx

Blood cultures: indicated only in severe infection

Duration of antibiotics: 7-10 days

1. Syp. Amoxicillin 125mg/5ml, 250mg/5ml (Amoxil, Zeemox) Dosage: 40mg/kg/day in three divided doses TDS (1 Teaspoonful = 5ml)

312.50mg/5ml (Augmentin DS, Calamox DS)

Or Syp. Co-Amoxiclav 156.25mg/5ml (Augmentin, Calamox) Dosage: 25-40 mg/kg/day x divided every 8-12 hourly. TDS/BD (1 Teaspoonful = 5ml)

(Calpol 6 Plus, Panadol forte =250mg/5ml)

2. Syp. Paracetamol (Calpol=120mg/5ml, Panadol=160mg/5 ml) TDS/QID (1 Teaspoonful = 5ml) Dosage: 10-15mg/kg/Dose

Or Syp. Ibuprofen (Brufen=100mg/5ml, Brufen DS=200mg/5ml),

Dosage: 10mg/kg/dose x 6-8 hourly Maximum daily dose: 40mg/kg/day TDS/QID (1 Teaspoonful = 5ml)

3. Polymyxin + Lidocaine Ear drops (Otocain) Or Ciprofloxacin + Lidocaine Ear drops (Cipocain) 2-3-drops 3-4 time a day

2nd ALTERNATIVE Rx

1. Syp. Cefaclor 125mg/5ml, 250mg/5ml (Ceclor, Cefaclor) Dosage: 20mg/kg/day 2-3 times a day BD/TDS (1 Teaspoonful = 5ml)

(Cefspan DS, Cefiget DS = 200mg/5ml) Or Syp. Cefixime (Cefspan, Cefiget = 100mg/5ml)

Dosage: 16mg/kg/day every 12 hourly on day 1, then 8 mg/kg/day for 13 days. BD (1 Teaspoonful = 5ml) (Ponstan DS 100mg/5ml, Dollar DS 100mg/5ml)

2. Syp. Mefenamic acid (Ponstan 50mg/5ml, Dollar 50mg/5ml)

Dosage: 3mg/kg/dose OR in some Books >6 months 6.5-25 mg/kg daily 3-4 times daily for not longer than 7 days. TDS (1 Teaspoonful = 5ml)

3. Tobramycin + Dexamethasone Ear drops (Dexatob) Or Ciprofloxacin+Dexamethasone Ear drops (Cipotec-D) 2-3-drops 3-4 time a day

20 ENTERIC FEVER Rx

C/C:

Fever low then gradually increases to 104.9 F

Headache

>> vomiting

Weakness and fatigue

Muscle aches

Relative bradycardia

Loss of appetite

Abdominal pain

Rash (Rose spot)

>> Diarrhea

Hepatosplenomegaly

Incubation period: 5-30 days (most commonly 7-14 days)

Treatment duration: 7-14 days

For severe infection, I/V Ceftriaxone (Titan, Rocephin)

Dose: 50-75 mg/kg

Diagnosis: Mnemonic 'BASU'

1st week: Blood culture

2nd week: Antigen test/Widal

3rd week: Stool culture

4th week: Urine culture

Blood culture is the most important diagnostic test at disease onset, as stool cultures are often negative despite active infection.

Gold standard test is Bone Marrow culture

Complete Blood Count (CBC) >>>> Anemia

>>> Leukopenia or leukocytosis

Absolute eosinopenia Relative lymphocytosis

LFTs: maybe Abnormal

USG whole abdomen: Hepatosplenomegaly

1. Syp. Cefixime 100mg, 200mg (Cefspan, Cefiget = 100mg/5ml)(Cefspan DS, Cefiget DS= 200mg/5ml) BD (1 Teaspoonful = 5ml)

Typhoid Dosage: 15-20 mg/kg/day x OD/BD Or Syp. Ciprofloxacin 125mg, 250mg (Novidat, Mytil) BD (1 Teaspoonful = 5ml)

Dosage: 15-30 mg/kg/day divided 12 hourly (Max: PO; 1.5 gm/day

Treatment Duration: 7-14 days

(Calpol 6 Plus, Panadol forte =250mg/5ml)

2. Syp. Paracetamol (Calpol =120mg/5ml, Panadol =160mg/5 ml) TDS/QID (1 Teaspoonful = 5ml)

Dosage: 10-15mg/kg/Dose

Or Syp. Ibuprofen (Brufen = 100mg/5ml, Brufen DS = 200mg/5ml)

Dosage: 10mg/kg/dose x 6-8 hourly Maximum Daily dose: 40 mg/kg/day) TDS/QID (1 Teaspoonful = 5ml)

3. Syp. Multivitamins/appetite stimulant (Lysovit, Glyvisol) 1-2 Teaspoonful x BD/OD

2nd alternative Rx

1. Syp. Azithromycin 200mg/5ml (Zetro, Azomax, Azitma) OD (1 Teaspoonful = 5ml) Typhoid Dosage: 10mg/kg/day x OD Treatment duration: 7-10 days

(Calpol 6 Plus, Panadol forte =250mg/5ml)

2. Syp. Paracetamol (Calpol =120mg/5ml, Panadol = 160mg/5 ml)

TDS/QID (1 Teaspoonful = 5ml) Dosage: 10-15mg/kg/Dose

Or Syp. Ibuprofen (Brufen = 100mg/5ml, Brufen DS = 200mg/5ml)

Dosage: 10mg/kg/dose x 6-8 hourly

Maximum Daily dose: 40 mg/kg/day)

TDS/QID (1 Teaspoonful = 5ml)

3. Syp. Multivitamins/appetite stimulant (Tresorix forte, Trimetabol 1-2 Teaspoonful x BD/OD

21 ENTERIC FEVER (SEVERE/COMPLICATED) Rx

A. Airway:

Ensure patient is maintaining own airway

Assess and secure stable airway

B. Breathing: Check SpO, & Give high flow 02 as appropriate

C. Circulation:

Pass IV line (IV cannula)

Vitals monitoring: Check BP, PR, RR, Temperature, SpO2

Send labs: CBC, U/C/E, LFTS, Blood sugar level

" Inj Ringer Lactate OR Inj 0.9% Normal saline x IV x OD

Patients often require supportive care with IV fluid

Dose: 20 ml/kg IV fluid bolus

Inj Ceftriaxone 1g (Rocephin, Titan) x IV x BD

Dosage: 50-75mg/kg/day

Alternative:

Inj. Cefotaxime 1g (Claforan, Cefotax) x BD/TDS

Dosage: 40-80mg/kg/day

Inj. Cefoperazone 1g (Cefobid) x BD

Dosage: 50-100mg/kg/day

Inj. Ciprofloxacin 200mg/100ml (Ciplet, Novidat) x IV x BD

Dosage: 15mg/kg/day (maximum of 20 mg/kg/day)

Inj. Azithromycin 500mg (Azitma) diluted in 100 ml 0.9%

Normal saline x IV x OD

Dosage: 8-10 mg/kg/day, (Drug Resistant 10-20 mg/kg/day)

Fever: Inj. Paracetamol 1g/100ml (Provas) IV x TDS

Dosage: 10-15mg/kg/dose

If Vomiting: Inj Dimenhydrinate 50mg/1ml (Gravinate) x IV x TDS, (Dosage: 0.5-1 mg/kg/dose) if not controlled/severe vomiting than Inj Ondensetron 8mg/4ml (Onset) x over 15 minutes is given by IV infusion diluted in 25 to 30 ml of 0.9% N/S Or 5% Dextrose. (Dosage: 0.15 mg/kg/dose)

>> If severe/indicated: Inj. Dexamethasone (Decadron 4mg/1ml) is administered at doses of 0.6 mg/kg x every 6 hours for 48 hours.

D. Disability & Exposure

Encourage oral feeding

Correct underlying cause

22 MALARIA FEVER (FALCIPARUM MALARIA) Rx

▲ Malaria fever

>>> Fever with chill and rigor

>> Headache/Body ache

>>>>> Sweats

>>> Abdominal pain

>> Nausea and vomiting.

>> General malaise & Fatigue

>> Malaria Parasite: If malaria is diagnosed on blood film, but type unclear, treat as falciparum malaria

MP ICT Rapid test

Do not treat unless ICT or blood film positive

If negative and clinical suspicion of malaria, send a repeat after 12-24 hr and third after further 24 hr

Treat malaria as falciparum until proven otherwise

1. Syp Artemether 15 mg + Lumefantrine 90mg (Artheget junior 15+90 mg/5ml)(Artem 15+90 mg/5ml) OD/BD (See standard dosage below)

Available brands: Syp. Artem/Artheget junior/Gen-M 15+90mg/5ml in preparation of 30ml and 60ml bottle

2. Syp. Paracetamol (Calpol =120mg/5ml, Panadol =160mg/5 ml) TDS/QID (1 Teaspoonful = 5ml)

Dosage: 15mg/kg/Dose

OR Syp. Ibuprofen (Brufen = 100mg/5ml, Brufen DS = 200mg/5ml)

Dosage: 10mg/kg/dose x 6-8 hourly Maximum daily dose: 40 mg/kg/day) TDS/QID (1 Teaspoonful = 5ml)

3. Syp Multivitamins/Appetite stimulant (Lysovit, Tresorix forte) 1-2 Teaspoonful BD/OD

23 SEVERE (COMPLICATED MALARIA) Rx

C/C:

Non-Specific symptoms

>> Fever with chill and rigor

>>> Headache/Body ache

>> Sweats

>> Abdominal pain

>> Nausea and vomiting.

>>> General malaise & Fatigue

>>> Loss of appetite

>>> Jaundice & splenomegaly

Features of severity

>>> Persistent vomiting

>>> Severe dehydration

>> Shock

>> Renal failure (oliguria <0.5 mL/kg/hr)

>>> Depressed conscious state, seizures

>>> Tachypnoea or increased work of breathing

>>> Hypoxia (SpO2 <95%)

>>> Metabolic acidosis (base deficit >8)

>>> Severe hyperkalaemia (K+ >5.5 mmol/L)

>> Hypoglycaemia (glucose <3 mmol/L)

>> Severe anemia (Hb <80 g/L)

>>> Unable to walk

>> Parasitaemia >2% or schizonts on film

CEREBRAL MALARIA

Impaired level of consciousness

>> Correct hypoglycaemia

>> Monitor GCS, reflexes, pupils

>> Plan for intubation and transfer to PICU if:

signs of raised ICP

persisting shock after 40

mL/kg fluid or

pulmonary oedema

A. Airway:

Ensure patient is maintaining own airway

Assess and secure stable airway

B. Breathing:

Check SpO, & Give high flow 02 as appropriate

C. Circulation:

>> Maintain Intravenous line (IV cannula)

Vitals monitoring: Check BP, PR, RR, Temperature, SpO2

Send labs: CBC, Urea, creatinine & electrolytes (UCE), LFTS, Blood sugar & Blood film for malaria parasite daily

IV fluid if electrolytes imbalance

Inj Artesunate 30mg, 60mg, 120mg (Gen-M) x IV slow

Diluted in 1 mL sodium bicarbonate vial provided with drug (Do not dilute in any other solution because will lead to bubble formation and wastage of injection), dilute further in 5mL sodium chloride 0.9% to make 10 mg/mL solution and inject dose over approximately 3-4 minute at 0, 12 and 24 hour and then daily.

When parasitaemia resolving and patient improving, switch to

oral agent: Syp. Artem, Syp. Artheget junior

Dosage:

➤ Body weight <20 kg: 3 mg/kg/day

➤ Body weight 220 kg: 2.4 mg/kg/day

Alternative drug/If Artesunate unavailable

Inj. Quinine Dihydrochloride 200mg/2ml (Zafquin) x IV ➤ Diluted to 2 mg/mL with 0.9% N/S or Dextrose 5%

➤ Loading dose 20 mg/kg (maximum 1.4 g) as infusion over 4 hr (NEVER as IV bolus)

If Shock: Inj Ceftriaxone 1g (Rocephin, Titan) x IV x BD

If Hypoglycaemia: common, give Dextrose 10% 2 mL/kg IV bolus then glucose 10% 5 mL/kg/hr with 0.9% N/S. Remove 50mL from 500mL bag of Dextrose 5%, 0.9% N/S & add 50mL of Dextrose 50%

Anemia: common, transfuse if symptomatic anemia

>> Thrombocytopenia: expected, transfuse only if bleeding and platelets <20 x 109/L

D. Disability & Exposure

>> Consider early HDU/ICU Admission

Pass Nasogastric tube and folly's catheter

» Monitor pupillary reflexes and GCS level

Correct underlying cause

>> Radiology: US abdomen, CXR

24 PULMONARY TUBERCULOSIS Rx

CLINICAL MANIFESTATION

SYMPTOMS

Suspect TB when following symptoms persist for weeks:

>>> Persistent, unremitting cough for 2-4 weeks

>>> Weight loss

>>> Failure to thrive

>>> Lack of energy

>>> Fever and sweats

>>>> Lymph nodes, especially if painless and matted

>>>> Headache or irritability for >1 week

>>> Limp, stiff back

>>> Joint swelling

>>>> Abdominal distension

>>> Symptoms may be non-specific in infants (increased susceptibility)

SIGNS

>>> Delayed growth: plot weight and height on growth chart and compare with earlier records

>>> Limited flexion of spine

1. Latent Tuberculosis Infection: By definition, there are no symptoms or signs of LTBI, and diagnosis occurs in the context of a positive skin or blood test on TB screening.

2. Pulmonary

3. Miliary: This manifestation of disseminated disease is common in young children and can be rapidly progressive. Affected children have fever, weight loss or failure to thrive, and can become systemically unwell. Diagnosis is suggested by the classic "snowstorm" or "millet seed" appearance of lung fields on radiograph, although early in the course the chest radiograph may show only subtle abnormalities. Other tissues may be affected to produce osteomyelitis, arthritis, meningitis, tuberculomas of the brain, enteritis, or infection of the kidneys and liver.

4. Meningitis: Symptoms include fever, vomiting, headache, lethargy, and irritability, with signs of meningeal irritation and increased intracranial pressure, cranial nerve palsies, convulsions, and coma.

5. Lymphatic: Enlarged cervical lymph nodes usually present in a subacute manner. Involved nodes may become fixed to the overlying skin, suppurate, and drain.

Refer all cases of suspected or proven TB to pediatric infectious diseases team

Discuss treatment with local TB team & lead pediatrician for TB

Most regimens for active TB infection begin with four drug therapy for the first 2 months.

For example, In children with active pulmonary disease, treatment with Isoniazid (10 mg/kg/day), Rifampin (20 mg/kg/day), Pyrazinamide (25-30 mg/kg/day), and Ethambutol (25 mg/kg/day) in single daily oral doses for 2 months. (for drug brands see - Pulmonology - chapter 6 Tuberculosis)

Followed by Isoniazid Plus Rifampin (either in a daily or twice-weekly regimen) for 4 months appears effective for eliminating isoniazid susceptible organisms.

> Syp. Rifapin-H (Rifampicin 100 mg + Isoniazid 50mg)

Or Tab. Rifapin-H junior (Rifampicin 60 mg + Isoniazid 30mg)

For more severe disease, such as miliary or CNS infection, higher doses of drugs are used, and the duration of the two drug continuation phase is increased to 10 months or more.

The duration of therapy is prolonged in immunocompromised children and if drug resistance necessitates alternative regimens.

25 CHICKENPOX (VARICELLA) Rx

▲ Chickenpox

C/C:

Incubation period: 2 weeks (11- 21 days)

Prodromes

>>> 1-2 days prior to the onset of exanthem

>> Presents with constitutional symptoms (fever, malaise)

>> More common with primary infection in adults (less typical in children, in which rash is often the first sign of infection)

Exanthem phase

Duration: ~6 days

Presentation

>> Widespread rash starting on the trunk, spreading to the face, scalp, and extremities.

>> Simultaneous occurrence of various stages of rash:

Erythematous macules →

papules vesicles filled with

a clear fluid on an

erythematous base →

eruption of vesicles →

crusted papules →

hypopigmentation of healed lesions

Severe pruritus

Fever, headache, and

muscle or joint pain.

General

Maintain Oral hydration/↑ fluid intake with acyclovir

Isolation, Children suffering from chickenpox must be restrained from attending the school for 6 days after the appearance of the rash, i.e. until all lesions are converted into crusts/scabs

Itching may be relieved by systemic antihistaminics and/or local application of calamine lotion, potassium permanganate, and sponge baths with antiseptic detergents.

Nails must be cut short

Mouth/perineal regions may be treated by rinses/gargles & saline soaks. Secondary bacterial infections with S. Aureus require appropriate

antibiotics: Co-Amoxiclave or macrolide (Azithromycin/Clarithromycin) Acyclovir claims to accelerate rate of clinical and skin lesion improvement, to reduce number of skin lesions, and to cause speedy defervescence.

1. Syp. Acyclovir 200mg/5ml (Acylex, Acyclovir) QID (1 Teaspoonful = 5ml)

Dosage: 2-16 years = 20mg/kg/Dose 4 times daily for 5 days. Maximum daily dose: 800mg

2. Syp. Paracetamol (Calpol =120mg/5ml, Panadol =160mg/5ml) TDS/QID (1 Teaspoonful = 5ml)

Dosage: 10-15mg/kg/dose

3. Syp. Cetirizine 5mg/5ml (Rigix, Zyretic) Or Syrup Loratidine 5mg/5ml (Softin, Lorin-NSA)

Dosage: 2-5 years 5mg OD, >5 years 5mg BD Or 10mg OD

If secondary bacterial infection: 156.25mg/5ml (Augmentin, Calamox)

4. Syp. Co-Amoxiclav 312.50mg/5ml (Augmentin DS, Calamox DS)

Dosage: 25-40 mg/kg/day x divided every 8-12 hourly.

TDS/BD (1 Teaspoonful = 5ml) Or Syp. Azithromycin 200mg/5ml (Zetro, Azomax, Azitma) OD (1 Teaspoonful = 5ml)

Dosage: 10mg/kg/day x OD

26 MEASLES (RUBEOLA) Rx

▲ Measles (Rubeola)

C/C:

Incubation period: 10-14 days

Prodromal/catarrhal stage: 4-7 days

Coryza, cough, and conjunctivitis

Fever

Koplik spots: Pathognomonic enanthem of the buccal mucosa → Tiny white or bluish- gray spots on an irregular erythematous background that resemble grains of sand

Exanthem stage: Duration is 7 days

(develops 1-2 days after enanthem)

High fever, malaise

32 Generalized lymphadenopathy

Erythematous maculopapular, blanching, partially confluent exanthem

Begins behind the ears along the hairline

Disseminates to the rest of the body towards the feet (palm and sole involvement is rare)

Fades after ~5 days of onset, leaving a brown discoloration and desquamation in severely affected areas

Recovery stage: The cough may persist for another week and may be the last remaining symptom.

CBC: leukocytes, platelets

Serology is Gold standard: detection of Measles-specific IgM antibodies.

Administration of vitamin A has been reported to reduce seroconversion in vaccinees and should therefore be avoided at or after immunization.

The efficacy of ribavirin administration in severe measles is unproven.

Rx is supportive therapy, such as Antipyretics, vitamin-A supplementation, and cough suppressants.

Bacterial superinfection should be promptly treated with appropriate antimicrobials, but prophylactic antibiotics to prevent superinfection are of no known value and are therefore not recommended.

Supplementation with Vitamin A, 200,000 IU administered orally to children once daily for 2 days, has been reported to decrease the severity of measles, especially in those with vitamin A deficiency

< 6 months old should receive 50,000 IU for 2 days.

Children 6 months to 1 year x 100,000 IU for 2 days.

1. Syp. Azithromycin 200mg/5ml (Azomax, Zetro)

Dosage: 10 mg/kg on day 1 (Max: 500 mg/day) followed by 5mg/kg/day once daily for 5 days

Maximum daily dose: 250 mg/day.

0-0-5 ml OD (1 Teaspoonful = 5ml)

(Calpol 6 Plus, Panadol forte =250mg/5ml) (Calpol=120mg/5ml, Panadol =160mg/5 ml)

2. Syp Paracetamol

Dosage: 10-15mg/kg/Dose TDS/QID (1 Teaspoonful = 5ml)

(Brufen DS OR Bludol DS = 200mg/5ml)

3. Syp. Ibuprofen (Brufen OR Bludol = 100mg/5ml)

Dosage: 10mg/kg/dose x 6-8 hourly (max daily

dose:40 mg/kg/day) TDS/QID (1 Teaspoonful = 5ml)

If symptoms of allergy, hay fever, cough & common cold.

4. Syp Dextromethorphan + Chlorpheniramine + Ephedrine (Corex-D, Cofrest) x TDS

5. Vitamin-A supplementation (A-MAX Drops)

27 MUMPS(EPIDEMIC PAROTITIS Rx

Pathogen: Mumps virus from the Paramyxoviridae family.

Transmission:

Humans are the sole host and the virus is transmitted via airborne droplets.

Direct contact with contaminated saliva or respiratory secretions

Contaminated fomites

Infectivity: Highly infectious, Affected individuals are contagious ~3 days before and up to 9 days after disease onset (when the parotid gland becomes swollen).

Diagnostics

Laboratory tests, if available, should be conducted to confirm the suspected cases (especially if presentation is atypical or there is a mumps outbreak).

Pathogen detection

Real-time reverse transcriptase PCR (rRT-PCR) on serum or buccal or oral swab

Viral culture (e.g., on CSF, throat, urine, or saliva maybe positive for at least 1 weeks)

Serology: Positive serum IgM suggests recent infection and confirms the diagnosis.

CBC (Relative lymphocytosis), 1 CRP, ↑ ESR, and ↑ Amylase

▲ Mumps

Most cases: 5-15 years age group.

Incubation period: 16-18 days.

Prodrome:

>>> Duration: 3-4 days.

>> Symptoms: Low-grade fever, malaise, headache

Classic course: inflammation of the salivary glands, particularly parotitis

>> Duration of parotitis: at least 2 days (may persist >10 days)

>> Symptoms

May initially present with local tenderness, pain, & earache.

Unilateral swelling of the salivary gland (Lateral cheek and jaw area)

During the course of disease, both salivary glands are usually swollen.

Redness in the area of the parotid duct

Possible protruding ears

>>> Chronic courses are rare.

Subclinical presentation:

>>> Nonspecific or predominantly respiratory symptoms

>>> Asymptomatic (in 15-20% of cases)

Mumps is usually self-limited with a good prognosis. (Unless complications arise).

Rx is mainly supportive care.

Medication for pain and fever

Isolation and Bedrest

Adequate fluid intake

Avoidance of acidic foods drinks

Topical application of warm or cold packs to the parotid may also relieve discomfort.

If Orchitis: Support of the inflamed testis with a "bridge," and ice packs make the patient feel more comfortable.

Syp. Paracetamol (Calpol = 120mg/5ml, Panadol = 160mg/5 ml) TDS/QID (1 Teaspoonful = 5ml)

OR Syp. Ibuprofen (Brufen=100mg/5ml, Brufen DS-200mg/5ml)

Dosage: 10mg/kg/dose x 6-8 hourly

Maximum daily dose: 40mg/kg/day

TDS/QID (1 Teaspoonful = 5ml)

Prophylaxis

Active immunization is given in the form of MMR at 15-18 months, some experts do not favor vaccination against mumps. They feel that there is no need for its prevention.

Immunization, they argue, may postpone the infection to later age when the disease often runs a severe course.

Passive protection can be given by convalescent -globulin in a dose of 2.5 mL (IM) as soon as possible after exposure.

28 PICA EATING DISORDER Rx

PICA

Pica is an eating disorder characterized by the appetite for and ingestion of non-food items like (e.g., hair, clay, mud, soil, chalk, soap, paper, paint).

Persistent ingestion of nonnutritive substances for > 1 month that is inappropriate for developmental age and not part of culturally or socially normative practice.

Pica poses a risk for parasitic infections, micronutrient deficiency, intestinal obstruction, and heavy metal poisoning.

Investigation

CBC to rule out Iron deficiency anemia

Calcium level to rule out hypocalcemia

Zinc level - Zinc deficiency

First line Rx is Cognitive behavioral therapy (CBT)

Nutritional rehabilitation

Use 5-6 weeks than do CBC and Calcium level again

1. Syp. Iron supplementation (Iberet-500, Maltofer) Dosage:

>> Age <4 years = 1-0-1(1 Teaspoonful x BD)

Age >5 years = 2-0-2 (2 Teaspoonful x BD)

2. Syp. Calcium supplementation (Calcium-P, Calone-D) 1-0-1,2-0-2

If not responded than second line Rx = SSRIS

Syp. Fluoxetine 20mg/5ml (Rize, Depricap) Or Syp. Escitalopram 10mg/1ml (Prolexa, Citanew)

28 IRON DEFICIENCY ANEMIA Rx

C/C:

Signs and symptoms of anemia

>> Fatigue, lethargy

> Pallor (primarily seen in highly vascularized mucosa, e.g., the conjunctiva)

>>> Cardiac: tachycardia, angina, dyspnea on exertion

>> Brittle nails, koilonychia (spoon-like nail deformity), hair loss

>> Pica, dysphagia

>> Angular cheilitis: inflammation and fissuring of the corners of the mouth

>> Atrophic glossitis: erythematous, edematous, painful tongue with loss of tongue papillae (smooth, bald appearance)

investigation

>> CBC: Low Hb, Low MCV

>>> Iron studies: Low Ferritin level, High TIBC

>>> Ultrasound Abdomen

1. Iron supplementation Brand Name:

>> Syp. Iberet-500 (Ferrous sulfate + B-Complex)

>> Or Syp. Sangobion (Iron + B-Complex)

>> Or Syp. Maltofer (Iron Polymaltose)

>> Or Syp. Malcifer-F (Iron Polymaltose + folic acid)

Dosage:

>> Age <4 years = 1-0-1 (1 Teaspoonful x BD)

>> Age >5 years = 2-0-2 (2 Teaspoonful x BD)

29 INFANTILE COLIC Rx

surgical cause, presenting in

between 10 and 30% of infants. It typically begins in the first few weeks of life and resolves spontaneously by

4-5 months of age.

Etiology:

Unknown

Age under five years

Gastrointestinal: overfeeding or underfeeding, aerophagia, cow's milk intolerance

Biologic: ↑ serotonin levels, tobacco exposure, dysfunctional motor regulation related to immaturity Psychosocial (exposure to stress) factors are suspected

Infantile colic

C/C:

>> Otherwise healthy infant with appropriate weight gain

>> Paroxysmal episodes of loud and high pitched crying, piercing sound that often occur at the same time each day (usually in the late afternoon or evening)

>>> Hypertonia (e.g., clenched fists, stretched legs) during episodes

>> Difficult to comfort

>>> Grimacing/frowning

>>> Excessive gas

>>>> Infant is not easily consoled

On Examination

>>> Infants are well and growing normally.

>> There should be no other findings on examination

Diagnosis: "rule of three" Characterized by paroxysmal crying:

>>>> Crying for ≥ three hours per day

>>> Crying for 2 three days per week, and

>> Crying for ≥ three weeks in an infant who is well-fed and otherwise healthy.

Parental education and reassurance: The parents must be informed that the infant is not sick and that the excessive crying is a behavioral problem and is not harmful, and that colic will resolve on its own with no long-term adverse effects. Physicians should also offer reassurance that they understand how stressful a colicky infant can be for parents. It usually resolves by sixteen weeks (four months) of age. Continued inconsolable crying in infants can lead to anxiety, frustration, and feelings of inadequacy in parents. These feelings should be acknowledged and properly addressed.

Soothing techniques

>> Rock the baby, hold the baby close or walk with the baby.

Stand up, hold the baby close and repeatedly bend your knees.

Sing or talk to the baby in a soothing voice.

>> Gently rub or stroke the baby's back, chest or tummy.

» Offer a pacifier or try to distract the baby with a rattle or toy.

Physical measures (rocking, swinging, swaddling, shush & sucking) can be tried, as May dietary changes; response to these measures varies, and often colic resolves only with time.

Trial of various feeding techniques: Bottle-fed infants may benefit from a hydrolysed formula, particularly if there is a suspicion that the diagnosis may be cow's milk protein intolerance

Supportive therapy for symptomatic relief of gas/colic/bloating

Colorest drops or Cholidrop or Pro-Colic drops

Recommended Dosage:

1-6 months: (0.5 ml) 10 drops - Twice daily

>>6-12 months: (1ml) 20 drops - Twice daily

➤ 1-2 years: (2 ml) 40 drops - Twice daily

Alternative: Beta D-galactosidase drops (Ez-Colic, Sposmad)

30 VITAMIN-D-DEFICIENCY Rx

▲ Vitamin-D Deficiency