PEDIATRICS Rx GUIDE 2024
The "Pediatrics Rx Guide 2024" serves as a comprehensive resource for healthcare professionals specializing in pediatric care. This guidebook aims to provide up-to-date information on pharmaceutical treatments tailored specifically for pediatric patients.
With the rapidly evolving landscape of pediatric medicine, it's crucial for practitioners to have access to accurate and current medication guidelines. The "Pediatrics Rx Guide 2024".
Whether you're a pediatrician, nurse practitioner, pharmacist, or medical student, the "Pediatrics Rx Guide 2025" serves as an invaluable tool for navigating the complex world of pediatric medication management and delivering high-quality healthcare to young patie
Table of contents
- Vitamin K Deficiency Bleeding of the Newborn Rx
- Neonatal Polycythemia Rx
- Neonatal Hypocalcemia Rx
- Neonatal Respiratory Distress Syndrome (NRDS) Rx
- Neonatal Jaundice Rx
- Neonatal Seizures Rx
- Neonatal Sepsis Rx
- Acute Tonsillitis Rx
- Acute Epiglottitis Rx
- Laryngotracheobronchitis (Croup) Rx
- Bronchiolitis Rx
- Lower Respiratory Tract Infection (Chest Infection) Rx
- Urinary Tract Infection (UTI) Rx
- Allergic Rhinitis Rx
- Food Allergy Rx
- Child with Cold/Flu Rx
- Child with Dental Infection Rx
- Child with Ear Pain Rx
- Child with Ear Discharge/Infection Rx
- Acute Suppurative Otitis Media (ASOM) Rx
- Enteric Fever Rx
- Enteric Fever (Severe/Complicated) Rx
- Malaria Fever (Falciparum Malaria) Rx
- Severe (Complicated Malaria) Rx
- Pulmonary Tuberculosis Rx
- Chickenpox (Varicella) Rx
- Measles (Rubeola) Rx
- Mumps (Epidemic Parotitis) Rx
- Iron Deficiency Anemia Rx
- Infantile Colic Rx
- Vitamin-D Deficiency Rx
1 VITAMIN K DEFICIENCY BLEEDING OF THE NEWBORN Rx
C/C:
>Early onset: within 24 hours after birth; intracranial bleeding common
>Classic: within 4 weeks after birth; intracranial bleeding rare
>Late onset: between 2-8 months after birth; intracranial bleeding common.
Investigation:
Complete blood count
Coagulation studies:
↑ Prothrombin time (PT)
Normal or ↑ activated partial thromboplastin time (PTT)
Normal bleeding time
Factors II, VII, IX, and X
ETIOLOGY
The underlying cause is always a deficiency of vitamin K, which can be due to various factors:
Exclusive breastfeeding: low vitamin K levels in breast milk (most important in late-onset VKDB)
Low liver storage capacity
Poor placental passage of vitamin K
Vitamin-K deficiency in the mother (e.g., because of anticonvulsant
therapy; most important in early-onset VKDB; maternal malnutrition) Underdeveloped intestinal flora (which produces vitamin K), e.g., due to
premature birth
Chronic diarrhea of the newborn
Long-term antibiotic treatment in newborns
Cholestatic diseases (biliary atresia)
Rx
Transfusions as necessary
Administration of Vitamin K
2 NEONATAL POLYCYTHEMIA Rx
DEFINITION.Neonatal polycythemia (erythrocythemia) is defined as abnormal elevation of the circulating red blood cell mass. Venous hematocrit (HCT) greatly exceeding normal values for gestational and postnatal age
▲ Neonatal polycythemia C/C:
Asymptomatic
Respiratory distress
cyanosis, apnea
Poor feeding
vomiting
Hypoglycemia
Plethora (Reddish complexion)
Lethargy and irritability
Tremors or seizures
Feeding difficulties
Hypoglycemia
hypocalcemia
INVESTIGATION:
Venous Haematocrit (HCT) > 65%
Hemoglobin > 22 g/dL
Total serum bilirubin
Serum glucose & serum calcium
Urea, creatinine & electrolytes
Rx
Monitoring
Send all important labs, venous blood samples should be used always to confirm diagnosis of polycythemia.
IV hydration
Correction of Electrolytes: Hypocalcemia, Hypoglycemia
Correct underlying cause: E.g., Apnea, seizures, NEC.
Partial exchange transfusion: a procedure in which part of the blood is replaced with an isotonic fluid to lower the hematocrit
Indicated in asymptomatic patients with high hematocrit (> 75%) or
symptomatic patients with hematocrit > 65%
Increased risk of Necrotizing enterocolitis (NEC)
3 NEONATAL HYPOCALCEMIA Rx
C/C:
Recognition and Assessment
Term or preterm infants: Birth weight ≥1500g, total serum calcium <2 mmol/L or ionized fraction <1.1 mmol/L
Preterm infant: Birth weight <1500g, total serum calcium <1.75 mmol/L or ionized fraction <1 mmol/L
Symptoms and Signs
>> Early onset occurs in first <3 days of life and is usually asymptomatic.
Late onset develops after first >3 days of life and typically occurs at the end of the first week
>> Most infants are asymptomatic and identified on screening
>> Characteristic sign is increased
neuromuscular irritability including:
. Jitteriness, tetany and irritability
Generalised/focal seizures
Non-specific symptoms e.g.:
Poor feeding
Lethargy
Apnoea
Prolonged QT interval on ECG
. Abdominal distension
Rare presentations:
Stridor
Bronchospasm
Pylorospasm
INVESTIGATION:
Early onset < 3 days of life
>> Serum calcium
Serum Phosphate
>>> Serum Magnesium
Serum alkaline phosphatase
Persistent hypocalcaemia or severe hypocalcaemia despite adequate caicium therapy.
25-hydroxyvitamin D level
Renal function test
Serum parathyroid hormone
Urinary calcium: creatinine ratio
Mother tests
>>> Serum calcium
>>> Serum Phosphate
>> Serum alkaline phosphatase
>> 25-hydroxyvitamin-D level
>>> ECG: Prolonged QT interval
Rx
Asymptomatic but high risk infants
Most infants with early onset hypocalcemia recover with nutritional support; so early feeding provides adequate calcium.
Infants requiring IV fluid: add calcium gluconate 10% 2mL/kg/day (=0.46 mmol/kg/day) to IV fluid and give as continuous infusion
Infant tolerating oral feeds: Give elemental calcium 50 to 60mg/kg/day orally three divided doses.
Symptomatic hypocalcemia
Give inj. Calcium gluconate 10% x 0.5-2 ml/kg IV stat, diluted with Dextrose water 5% or Normal saline 0.9%. (1:1 dilution) over 15-20 min.
Followed by maintenance dose: inj. Calcium gluconate 10% x 1-2 ml/kg IV
stat, diluted with Dextrose water 5% or Normal saline 0.9%. (1:1 dilution) over 15-20 minutes x every 6 hours or 4-8ml/kg/day as continuous IV infusion for 48 hours with continuous cardiac monitoring.
Check serum calcium level after 48 hours → Hypocalcemia → Continues above same treatment for one more day.
Serum calcium level normal → Stable baby or following acute treatment consider oral calcium at dosage 50-60mg/kg/day in three
divided doses for 2-3 days. If prolonged hypocalcemia → Continue oral calcium supplement if
20 infant oral feed tolerated well, otherwise continue IV infusion and investigate further to determine the etiology (see Investigation)
If hypomagnesemia: Inj. magnesium sulfate at dosage 100 mg/kg or 0.2ml/kg x IV/IM 12-hourly for 2-3 divided doses
Vitamin-D deficiency: Give cholecalciferol 1000-2000 IU x daily and adjust
dose according to response.
Cholecalciferol Brands:
Infant Drops: Miura-D 400IU or D-max 400IU, or All-D 400IU x PO
Injection: Miura-D 5mg, D-All 5mg, Indrop-D 5mg x IM/PO
Hyperphosphatemia/increased phosphate load
Stop cow's milk, Breastfeeding is preferable, if not available, use infant formula milk with low phosphate 60/40 (Similac PM 60/40 milk) and oral calcium (Syp. Calcium-P 210 mg/5ml) Consider high calcium, low phosphate diet
Oral calcium and phosphate normalize in 3-5 days. Stop calcium after 1 week and switch to normal formula in 2-4 weeks
4 NEONATAL RESPIRATORY DISTRESS SYNDROME (NRDS)Rx
Neonatal respiratory distress syndrome (NRDS), or surfactant deficiency disorder, is a lung disorder in infants that is caused by a deficiency of pulmonary surfactant.
It is most common in preterm infants, with the incidence and severity decreasing Surfactant deficiency causes the alveoli to collapse, resulting in impaired blood gas exchange.
▲ NRDS
C/C:
>>> 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
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)
Rx
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
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
C/C:
Non-Specific features
>>> Lethargy, Poor cry
>> Refusal to feed/poor sucking
>> 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
Rx
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
Rx
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
Rx
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
Rx
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)
Dosage: 10-15mg/kg/Dose
OR
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.
Rx
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)
The recommended dose: 400 mcg/kg to maximum 5 mg 0.4 mL/kg to maximum 5mL of 1:1000 adrenaline injection, diluted in 3ml 0.9% NS, nebulised with oxygen, which can be used for all children. This may be repeated after 10 minutes if needed. Adrenalin Reduces airway swelling, faster onset than with dexamethasone and budesonide.
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
Rx
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:
1.
Antipyretic: Paracetamol (Panadol Infant drops 80mg/0.8ml)
2
. 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.
Rx
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
11 LOWER RESPIRATORY TRACT INFECTION (CHEST INFECTION) Rx
C/C:
>>> Fever
>>>> Cough and Irritability
>>>> 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)
Investigation:
CBC
Blood culture
Chest-X-ray PA view
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
Rx
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)
(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
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)
(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
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)
Dosage: 10-15mg/kg/Dose
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
C/C:
> 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
Rx
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)
Dosage: 10-15mg/kg/Dose
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
▲ Allergic Rhinitis
C/C:
Sneezing
Rhinorrhoea
Red itchy eyes.
Ask about family history, seasonal variance and if a trigger is identifiable.
Postnasal drip may produce a chronic dry cough
Rx
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
Rx
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
Rx
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
Rx
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)
2.
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
Rx
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
Rx
1.
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)
2.
(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
Rx
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
Rx
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
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
C/C:
>>> Fever with chill and rigor
>> Headache/Body ache
>>>>> Sweats
>>> Abdominal pain
>> Nausea and vomiting.
>> General malaise & Fatigue
>>> Loss of appetite
>>> Jaundice
>> Splenomegaly
Investigation:
CBC
>> 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
Rx
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
(Calpol 6 Plus, Panadol forte =250mg/5ml)
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
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 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
>> Fever
>> Wasting
>> Lymphadenopathy
>>> Chest signs
>> Cardiac tamponade
>> Ascites
>> Meningism
>> Ophthalmoplegia
>> Conjunctivitis
>>> Limited flexion of spine
>>> Kyphosis
>> Swollen joint
>>> Cold abscess
C/C:
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.
Rx
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.
Rx
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
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
C/C:
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)
Rx
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.
(Calpol 6 Plus, Panadol forte =250mg/5ml)
1.
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)
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
C/C:
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
Rx
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
Rx
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.
Rx
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
C/C:
Children
>> General muscular aches
>>> Weakness
± delayed motor milestones
>>> Bowed legs
>>> Short stature
Adolescents
>> General muscular aches
>> Weakness
>>> Long bone pain
Diagnosis
>> Vitamin-D <25 nmol/L >>✓ Calcium (often normal) >>↓ Phosphate (often normal) >>↑ ALP (high in rickets)
» ↑ PTH
Radiograph (in rickets): splaying and fraying of the metaphysis ± bowing of the legs.
Rx
Prevention
Increase safe sun exposure
Increase vitamin-D in diet (oily fish)
Increase Ca2+ intake (Milk)
Treat the underlying cause
Screen the siblings of affected children + offer prevention advice
1.
Syp. Ossein mineral complex Plus vitamin-D (Calone-D, Osnate-D) Or Syp. Mg + Vitamin-D + Zinc (Osteocare)
1-2 teaspoonful x BD
2
. Cholecalciferol (vitamin D3) Drops (All-D, D-Max, Miura-D3)
Dosage: Each drop contains 400 IU of Cholecalciferol
Infants: 1 drops daily
Children below 4 years: 1-2 drop daily.
Children above 4 years: 2-3 drops daily.
31 H.PYLORI INFECTION Rx
H.Pylori Infection
C/C:
>> After being infected with H. pylori, the child may have an inflammation of the stomach lining. This is called gastritis. But most people never have symptoms or problems from the infection.
>> When symptoms do occur, they may include belly pain, which can:
Be a dull, gnawing pain
Happen 2 to 3 hours after a meal
Come and go for a few days or weeks
Occur in the middle of the night when your child's stomach is empty
Be eased by eating or taking an antacid medicine
>>> Other symptoms may include:
Loss of weight
Loss of appetite
Swelling or bloating
Burping
Having an upset stomach or nausea
Vomiting
Recommended first-line treatment for Helicobacter pylori infection in children:
1. Amoxicillin + Clarithromycin + Proton pump inhibitor (e.g., Omeprazole)
2. Amoxicillin + Metronidazole + Proton pump inhibitor (e.g., Omeprazole)
3. Clarithromycin + Metronidazole + Proton pump inhibitor (e.g., Omeprazole)
Duration: 14 days
Clarithromycin based triple therapy (14 days)
Rx
1. Tab. Clarithromycin 250mg, 500mg (Klaricid, Claritek)
Dosage: 15mg/kg/day up-to 500mg twice daily 14 days 1-0-1 (twice daily)
2. Cap./Tab. Amoxicillin 250mg, 500mg (Amoxil, Zeemox)
Dosage: 50 mg/kg/day up-to 1g twice daily
3. Cap. Omeprazole 20mg (Risek, Ruling)
Dosage: 1 mg/kg/day up-to 20mg twice daily 1-0-1 (twice daily) 30 minutes before meals
Rx
Alternative Rx 2
1. Tab. Clarithromycin 250mg, 500mg (Klaricid, Claritek)
Dosage: 15mg/kg/day up-to 500mg twice daily 14 days 1-0-1 (twice daily)
2. Tab. Metronidazole 200mg, 400mg (Metrozine, Flagyl)
Dosage: 20mg/kg/day up-to 500 mg twice daily
1-0-1 (twice daily)
3. Cap. Omeprazole 20mg (Risek, Ruling)
Dosage: 1 mg/kg/day up-to 20mg twice daily
1-0-1 (twice daily)
30 vows before meals
Rx
Alternative Rx
1 Syp. Clarithromycin 125mg, 250mg (Klaricid, Claritek)
. Dosage: 15mg/kg/day up-to 500mg twice daily
1-0-1 (twice daily)
2. Syp. Amoxicillin 125mg, 250mg (Amoxil, Zeemox)
Dosage: 50 mg/kg/day up to 1g twice daily
1-0-1 (twice daily)
3.
Syp. Famotidine 10mg/5ml (Polypep, Peptiban, Reducid) Dosage: 1mg upto 2mg/kg/day (Maximum 80 mg/day)
1-0-1 (Two times a day)
30 minutes before meals
32 CONSTIPATION Rx
Constipation
C/C:
Painful passage of infrequent, hard stool.
Overflow faecal incontinence is common and produces small volume, soft stool.
Infrequent, hard stool passed in the absence of any Red Flag symptoms.
Enquire about Red Flag Symptoms specifically.
>>>> Present from birth
>> Delayed passage of meconium ≥48 hours)
>>>> 'Ribbon stools'
>>> Neurological symptoms or signs, such as locomotor delay or falling over/abnormal gait in older children
>> Vomiting
>> Abdominal distension
Abdominal Examination: Palpation of the abdomen may reveal an indentable mass, usually in the left lower quadrant (LLQ)
Polyethylene glycol 3350
Dissolve PEG powder 17 grams in 240 ml water or juice
Dose: 0.5-0.8 g/kg/day (15 ml/kg/day) up to 17 g/day divided
twice daily
Adjust dose until 1-2 soft painless
stools per day
Taper dose over time
Efficacy
Safe, well tolerated and effective
More effective and better tolerated than Lactulose
Rx
Constipation Rx
All parents and children should receive dietary and lifestyle advice
regular, scheduled toileting
Increasing dietary fibre and fluids
Increasing exercise.
Treatment revolves around the correction of the underlying Cause, dietary changes and behavioral training. In general, it needs to be ensured that child takes good deal of high residue diet and fluids and that the parents encourage him to use the toilet regularly.
Polyethylene glycol 3350 (Movicol, MiraLAX)
0.6 to 1g/kg/day for 3 days
Indicated for 2-11 years of child's with chronic constipation
For children aged 2 to 11 years, the maximum recommended dose needed does not normally exceed 4 sachets a day.
Method of administration: Each sachet 6.9g should be dissolved in 62.5 ml (quarter of a glass) of water or juice. The correct number of sachets may be reconstituted in advance and kept covered and refrigerated for up to 24 hours. For example, for use in faecal impaction, 12 sachets can be made up into 750 ml of water.
Syp. Lactulose (Duphalac, Lilac)
>> Dosage: 1-3ml/kg/day (10mg/15 ml) divided daily to twice daily
>>> Babies aged 1-11 months: The usual dose is 2.5ml twice a day
>>> Children aged 5-17 years: The usual dose is 5ml-20ml twice a day
>> Children aged 1-4 years: The usual dose is 2.5ml-10ml twice a day
Syp Wheat Dextrin (Fibo, Fibocon)
>> Upto 5-11 years: 1 teaspoonful once or twice a day.
>>> 12 years and above: 2 teaspoonful once or twice a day.
Glycerin suppository
Preferred agent in age under 1 year
>>> Dosage: 1/2 to 1 infant suppository (adult suppository for age over 6 years)
Enema
>> Dose: 6 ml/kg (up to 135 ml)
>> May repeat every 12-24 hours for 1-3 doses
>>> First dose often given 1 hour before bedtime
33 HYPOCALCEMIA Rx
▲ Hypocalcaemia C/C:
Asymptomatic
Symptomatic (usually level below 7 mg/dl)
>> Convulsions
>> Tetany
>> Hyper Or Hypotonia
>>> Irritability
» ICP
>>> Laryngospasm
>> Cardiac: Bradycardia, heart failure, oedema
>>> Signs of etiology
Rx
Symptomatic
10% Calcium gluconate x 2 ml/kg x IV
Dilute 1:4 with 5% Dextrose or water.
Give over 30 minutes
ECG monitor (if possible) or clinically for bradycardia or even arrest.
Then start infusion of 1mmol/kg/24hours in 5% Dextrose + 1/5 saline Or Give the total daily dose divided as 6 hourly infusions
Monitor patient and calcium 6 hourly.
IF SYMPTOMS CONTINUE
Give another infusion bolus of 1-2 ml/kg Or increase infusion rate to 1.25-1.5 mmol/kg/day
ASYMPTOMATIC
After infusion or from the start
Oral calcium 1mmol/kg/day
1 mmol calcium = 40mg of elemental calcium, Give 6 hourly
Check the concentration of preparations in your hospital (Osteocare 5 ml=150 mg)
33 LACTOSE INTOLERANCE Rx
Lactose intolerance
C/C:
Lactose intolerance is the reduced ability to digest milk sugars, due to insufficient amounts of the gut enzyme called lactase. Breastfed babies can be lactose intolerant, because lactose is found in breast milk as well as baby formula. Diarrhea can be a symptom of lactose intolerance in babies.
>> Watery diarrhea that follows gastroenteritis.
Abdominal discomfort and increased flatus.
>> Check the child is growing normally and is hydrated.
Abdominal bloating or distension
Rx
Switch to lactose-free diet/milk/formula.
Good hygiene, diet and supplementation (Zinc, Calcium, Vit-D)
If Dehydration: Give ORS to prevent dehydration.
1.
Syp. Metronidazole 200mg/5ml (Flagyl, Metrozine) Dosage: 7.5 mg/kg/dose three times a day (TDS)
1 Teaspoonful = 5ml
Or Syp. Qplex-Z (Gile Armani, Carbohydrate Complex and Zinc)
Dosage: 1 teaspoon 2 to 3 times a day, for older 2 teaspoon.
2. Enterogermina (Bacillus Clausii) oral solution
For infants: 1-2 mini bottles per day to be given at regular intervals.
For children: 1-2 mini bottles or 1-2 capsules a day to be administered at regular intervals.
How to take Enterogermina Oral Suspension
Unscrew and remove the top of the cap.
- Shake it before use.
Take the medicine as it is or dilute it with lukewarm water or any other drink such as milk or orangeade.
Treatment for Formula Fed Infants
Avoid cow's milk based formula (i.e Enfamil Lipil, Similac Advance, Nestle Good Start) until normal stools resume.
Soy based (i.e. Prosobee, Isomil) or Lactose free formulas are OK.
Offer oral rehydration solutions (Pedialyte) or other clear fluids (sugar water/tea).
For diarrhea, give her lactose free formula for now.
NL33 is a good option.
Do not switch to NAN-1 just yet. Also, as the baby is 6 months, start weaning diets gradually.
You can give yogurt as it is a natural probiotic, along with banana as well.
Take care of bottle hygiene, use boiled/ sterilized bottles each time along with boiled water.
Continue use of Zincat for 14 days, Enterogermina for 3-5 days.
Lactose free milk brands:
NL-33
NAN-1
Nutrafil LF
NAN-AL-110
Similac Isomil
Aptamil
34 SCABIES Rx
C/C:
Incubation period: approx. 3-6 weeks following infestation.
Intense pruritus that increases at night
> Burning sensation
Skin lesions
Elongated, erythematous papules
Burrows of 2-10 mm in length
Scattered vesicles filled with clear or cloudy fluid
Excoriations, pustules, and secondary infection
>>> Predilection sites
Wrists (flexor surface)
Medial aspect of fingers
Interdigital folds (hands and feet)
Male genitalia (e.g., scrotum, penis)
All other intertriginous areas of the skin (anterior axillary fold, buttocks)
Periumbilical area or waist
Additionally in children, elderly persons, and immunosuppressed patients: scalp, face, neck, under the nail, palms of hands, and soles of feet
Rx
Treat all house hold contacts whether symptomatic or
asymptomatic, Can provide family members with prescriptions for treatment based on physician's comfort
Wash all bed linens/clothing/towels with hot water and hot
drying cycles
Permethrin is safe for kids down to 2 months
Apply to scalp, face, palms and soles, Avoid the eyes
1. Permethrin 5% Cream, Lotion (Lotrix, Mitonil)
>> Day-1 take bath, dry your skin with separate towel and apply permethrin 5% cream/lotion below collar line (face spared) from behind the ears down to the toes including creases and web spaces and leave on overnight
» Day-2 Apply permethrin 5% cream/lotion only, without bath
Day-3 No application of permethrin 5%, take only bath with warm soapy water
2. Syp. Loratidine 5mg/5ml (Softin, Loril) Or Syp. Levocetrizine 5mg/5ml (Belair, Xyzal) OD (2 to <5 years), BD (>5 years)
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