Paediatric Protocols for Malaysian Hospitals PDF

PAEDIATRIC PROTOCOLS For Malaysian Hospitals 4th Edition Hussain Imam Hj Muhammad Ismail Hishamshah Mohd Ibrahim Ng Hoong Phak Terrence Thomas Kementerian Kesihatan Malaysia 2019 Print PAEDIATRIC PROTOCOLS For Malaysian Hospitals...

PAEDIATRIC PROTOCOLS For Malaysian Hospitals 4th Edition Hussain Imam Hj Muhammad Ismail Hishamshah Mohd Ibrahim Ng Hoong Phak Terrence Thomas Kementerian Kesihatan Malaysia 2019 Print PAEDIATRIC PROTOCOLS For Malaysian Hospitals 4th Edition Hussain Imam Hj Muhammad Ismail Hishamshah Mohd Ibrahim Ng Hoong Phak Terrence Thomas printed by the Malaysian Paediatric Association for Kementerian Kesihatan Malaysia i  4th Edition, 2018 2nd Print, August 2019 ii  FOREWORD BY THE DIRECTOR-GENERAL OF HEALTH, MALAYSIA 1. First and foremost, I would like to thank the Editorial Board and it is my pleasure to write the foreword for the Paediatric Protocols for Malaysia Hospital 4th Edition. 2. Since independence, the Malaysian health system has achieved remark- able outcomes in improving the health status of the population. Life expectancy at birth has increased by more than 10 years, driven by rapid declines in infant, child, and maternal mortality. However, over the past 15 years, the declines in maternal and child mortality rates have plateaued, with no further notable improvement. 3. Over the years, we have seen the introduction of new technologies in health system. Healthcare workers must keep up with current therapeutics developments and ensure that they provide safe, appropriate and effective treatment to their patients. Clearly, then, the development and maintenance of effective therapeutic skills is essential especially to those working in acute settings. 4. This pocket book is mainly aimed at doctors, clinical officers, nurses and other healthcare workers who are responsible for the care of sick newborns and young children. These protocols are meant to serve as a guide for clinical practice, based on the best available evidence at the time of development. Every healthcare worker is responsible for the management of their patient based on the clinical features presented by the patient and the management options available locally. We hope this handy pocket sized booklet will also be useful to students in medical schools and other training institutions. Datuk Dr Noor Hisham bin Abdullah Director-General of Health, Malaysia iii  FOREWORD TO THE FOURTH EDITION, 2ND PRINT It has been 13 years since we produced the first edition of a national protocol book for Paediatrics. This effort was of course inspired by the Sarawak Paediatric Protocols initiated by Dr Tan Poh Tin. The 3rd edition in 2012 has proven to be very popular and is now the standard reference for House officers and Medical Officers in Paediatrics. In producing a fourth edition we have retained the layout of the current version, updating the contents and colour scheme. Again it is targeted at young doctors in the service many of whom seem to have had a subopti- mal exposure to paediatrics in their undergraduate years. It is hoped that the protocol book will help them fill in the gaps as they prepare to serve in district hospitals and health clinics. The use of the book has extended way beyond its initial targeted audience. We want to thank the Ministry of Health of Malaysia which has once again agreed to support the printing of the book for distribution to MOH facilities. We will continue to make the full PDF version available for download on the Malaysian Paediatric Association website. We hope that in time the protocol will be available as an iOS and android app. As previously this new edition is only possible because of the will- ingness of busy clinicians to chip in and update the content for purely altruistic reasons and we hope this spirit will persist in our fraternity. We want to thank all the contributors and reviewers for this edition. Professor Frank Shann has graciously agreed for the latest edition of his drug dosages handbook to be incorporated into the 4th edition (only available in MOH prints). The Frank Shann-Drug Doses Book (17th edition) can also be purchased through orders@ drugdoses.com, the Apple App Store (iOS) or Google PlayStore (Android). See also www.drugdoses.com. The Director General of Health has also kindly provided a foreword to this edition. In the 2nd Print of the 4th Edition, we took the opportunity to make corrections for errors that were discovered after the document had been in circulation for some time. Minor corrections were made in a few documents. Substantial changes were made to three Chapters. In the Chapter 109 Common Poisons, an important correction was made to the N-Acetyl- cysteine dosage regimen for treatment of paracetamol poisoning and the Toxi- dromes table was expanded, amongst other corrections. Additional material and updates were also added to Chapter 32 Asthma and Chapter 36 Empyema Thoracis, at the request of the Paediatric Respiratory Physicians. We wish to thank all who have made this new edition possible and hope this combined effort will help in improving the wellbeing of the children entrusted to our care. Hussain Imam B. Hj Muhammad Ismail Hishamshah b. Mohd Ibrahim Ng Hoong Phak Terrence Thomas iv  LIST OF CONTRIBUTORS Dr. Ahmad Khaldun Ismail Dr. Chin Choy Nyok Consultant, Emergency Physician Consultant, Neonatologist Universiti Kebangsaan Malaysia & Head, Dept. of Paediatrics Hospital Tengku Afzan, Kuantan Dr. Ahmad Rithauddin bin Mohamed Consultant, Paediatric Neurologist Dr. Chong Sze Yee Hospital Kuala Lumpur Paediatric Gastroenterologist Hospital Raja Permaisuri Bainun, Ipoh Datuk Dr. Amar Singh HSS Consultant, Community Paediatrician Dr. Choo Chong Ming & Head, Dept. of Paediatrics Consultant, Pediatric Infectious Disease Hospital Raja Perempuan Bainun, Ipoh. & Head, Dept. of Paediatrics Hospital Sultan Abdul Halim , Sungai Dr. Amelia Bt Alias Petani Paediatric Cardiologist Hospital Raja Perempuan Zainab II, Kota Dr. Eric Ang Boon Kuang Bharu Neonatologist Hospital Sultanah Bahiyah, Alor Setar. Dr. Amir Hamzah Abd. Rahman Paediatric Cardiologist Dr. Fazila Mohamed Kutty Hospital Tengku Ampuan Afzan, Kuantan Neonatologist Hospital Serdang Dr. Ang Ee Lee Consultant, Neonatologist Dr. Fong Siew Moy Hospital Tengku Ampuan Rahimah, Klang Consultant, Paediatric Infectious Disease & Head, Dept. of Paediatrics Dr. Angeline Wan Seng Lian Sabah Women & Children’s Hospital Consultant, Neonatologist & Head, Dept. of Paediatrics Dr. Foo Hee Wei Hospital Pakar Sultanah Fatimah, Muar Paediatric Gastroenterology Fellow Selayang Hospital Dr. Anis Siham Zainal Abidin Consultant, Paediatric Intensivist Dr. Fuziah Md. Zain & Head, Dept. of Paediatrics Consultant, Paediatric Endocrinologist Fakulti Perubatan UiTM, Selangor Hospital Putrajaya Datuk Anne John Dr. Heng Hock Sin Consultant, Paediatric Surgeon Consultant, Paediatric Neurologist Hospital Umum Sarawak, Kuching Sabah Women & Children’s Hospital Dr. Asiah Kassim Dr. Hishamshah b. Mohd Ibrahim Consultant, Paediatric Respiratory Physician Consultant, Paediatric Haemato-Oncologist Hospital Kuala Lumpur & Head, Dept. of Paediatrics Hospital Kuala Lumpur Dr. Chan Lee Gaik Consultant, Neonatologist Dr. Hung Liang Choo & Head, Dept. of Paediatrics Consultant, Paediatric Cardiologist Hospital Umum Sarawak, Kuching Hospital Kuala Lumpur Dr. Chee Seok Chiong Dato’ Dr. Hussain Imam B. Hj Muhammad Consultant, Neonatologist Ismail Hospital Selayang Consultant, Paediatric Neurologist Hospital Pulau Pinang v Dr. Ida Shahnaz Othman Dr. Lim Chooi Bee Consultant, Paediatric Haemato-Oncologist Consultant, Paediatric Gastroenterologist Hospital Kuala Lumpur Hospital Selayang Dr. Irene Cheah Guat Sim Dr. Lim Han Nee Consultant, Neonatologist Paediatric Nephrologist Hospital Kuala Lumpur Hospital Sultan Ismail, Johor Dr. Janet Hong Yeow Hua Dr. Lim Poi Giok Consultant, Paediatric Endocrinologist Consultant, Paediatric Endocrinologist Hospital Putra Jaya Hospital Kuala Lumpur Dr. Jeanne Wong Sze Lyn Dr. Lim Yam Ngo Paediatric Endocrinologist Consultant, Paediatric Nephrologist Hospital Putra Jaya Hospital Kuala Lumpur Dr. Jeyaseelan Nachiappan Dr. Lynster Liaw Consultant, Pediatric Infectious Disease Consultant, Paediatric Nephrologist Hospital Raja Perempuan Bainun, Ipoh. Hospital Pulau Pinang Dato’ Dr. Jimmy Lee Kok Foo Dr. Mariana Daud Consultant, Neonatologist Consultant, Paediatric Respiratory Physician & Head, Dept. of Paediatrics Hospital Raja Perempuan Zainab II, Hospital Sultanah Nur Zahirah, Kota Bharu Kuala Terengganu Dr. Martin Wong Ngie Liong Dr. Kam Choy Chen Consultant, Paediatric Cardiologist Paediatric Gastroenterology Fellow Pusat Jantung Sarawak, Kuching Hospital Selayang Dr. Maznisah Bt Mahmood Dr. Keng Wee Teik Consultant, Pediatric Intensivist Consultant, Clinical Geneticist Hospital Kuala Lumpur Hospital Kuala Lumpur Dr. Mirunalini Appadurai Dr. Khoo Teik Beng Consultant, Paediatric Nephrologist Consultant, Paediatric Neurologist Hospital Kuala Lumpur Hospital Kuala Lumpur Dr Mohd Amin bin Itam Datuk Dr. Kuan Geok Lan Consultant, Paediatric Cardiologist Consultant, General Paediatrician Hospital Serdang Hospital Melaka Dr. Mohd Nizam Mat Bah Dr. Lee Chee Chan Consultant, Paediatric Cardiologist Paediatric Palliative Care Specialist Head, Dept. of Paediatrics Hospital Kuala Lumpur Hospital Sultanah Aminah, Johor Bharu Dr. Lee Ming Lee Dr. Nazrul Neezam Nordin Consultant, Paediatric Nephrologist Paediatric Gastroenterologist & Hepatologist Hospital Tuanku Jaafar, Seremban Hospital Kuala Lumpur Dr. Leong Jen Jen Dr. Neoh Siew Hong Consultant, Neonatologist Consultant, Neonatologist Hospital Seberang Jaya Hospital Kuala Lumpur vi Dr. Ng Hoong Phak Dr. Rohani Abdul Jalil Consultant, General Paediatrics & Child Health Neonatologist Hospital Umum Sarawak, Kuching Hospital Taiping Dr. Ngu Lock Hock Dato’ Dr. Rus Anida Awang Consultant, Paediatric Metabolic Diseases Consultant, Paediatric Respiratory Physician Hospital Kuala Lumpur Hospital Pulau Pinang Dr. Nik Khairulddin Dr. Sabeera Begum Bt Kader Ibrahim Consultant, Paediatric Infectious Disease Consultant, Paediatric Dermatologist & Head, Dept. of Paediatrics Hospital Kuala Lumpur Hospital Raja Perempuan Zainab II, K Bharu Dr. Sharifah Ainon Bt Ismail Mokhtar Dr Noor Khatijah Nurani Consultant, Paediatric Cardiologist Consultant, General Paediatrics & Child Health Hospital Pulau Pinang Hospital Raja Permaisuri Bainun, Ipoh Dr. Sangita Dharshini a/p Terumalay Dr. Nor Azni bin Yahya Paediatric Neurologist Consultant, Paediatric Neurologist Hospital Kuala Lumpur Hospital Raja Perempuan Zainab II, Dr. Sathyabama Ramachandram Kota Bharu Developmental Paediatrician Dr. Norliza Ali Hospital Pulau Pinang Paediatric Cardiologist Dr. See Kwee Ching Hospital Serdang Consultant, Neonatologist Dr. Norzila Bt. Mohd Zainudin Hospital Sungai Buloh Consultant, Paediatric Respiratory Physician Dr. Sheila Gopal Krishnan Hospital Kuala Lumpur General Paediatrics & Child Health Dr. Ong Gek Bee & Head, Dept. of Paediatrics Consultant, Paediatric Haemato-Oncologist Hospital Seri Manjung, Perak Hospital Umum Sarawak, Kuching Dr. Susan Pee Dr. Ong Sik Yong Consultant, Paediatric Nephrologist Paediatric Gastroenterologist Hospital Sultan Ismail, Johor Selayang Hospital Dr. Su Siew Choo Dr. Pauline Choo Paediatric Respiratory Physician Consultant, Neonatologist Hospital Tengku Ampuan Rahimah, Klang Hospital Tuanku Jaafar, Seremban Dr. Tajul Tajudin bin Arifin Datin Dr. Ranjini Sivaganabalan Paediatric Neurologist Consultant, Emergency Physician Hospital Sultan Ismail, Johor Hospital Tengku Ampuan Rahimah, Klang Dr. Tan Hui Siu Dr. Ranjini S Sivanesom Paediatrician Consultant, Developmental Paediatrician & Head, Dept. of Paediatrics Hospital Kuala Lumpur Hospital Teluk Intan Dr. Revathy Nallusamy Dr. Tan Kah Kee Consultant, Paediatric Infectious Disease Consultant, Paediatric Infectious Disease Hospital Pulau Pinang & Head, Dept. of Paediatrics Hospital Tuanku Jaafar, Seremban vii Dr. Tang Swee Ping Dr. Wong Ann Cheng Consultant, Paediatric Rheumatologist Paediatrician Hospital Selayang Hospital Kuala Lumpur Dr. Teh Chee Ming Dr Wong Ke Juin Consultant, Paediatric Neurologist Consultant, Pediatric Infectious Disease Hospital Pulau Pinang Sabah Women & Children’s Hospital Dr. Terrence Thomas Dr. Yap Hsiao Ling Consultant, Paediatric Neurologist Paediatric Emergency Medicine KK Women’s & Children’s Hospital, Hospital Kuala Lumpur Singapore Dr. Yap Yok Chin Dr Thahira Jamal Mohamed Consultant, Paediatric Nephrologist Consultant, Paediatric Infectious Disease Hospital Kuala Lumpur Hospital Kuala Lumpur Dr. Zulaiha Muda Dr Thiyagar Nagarajaw Consultant, Paediatric Haemato-Oncologist Consultant, Adolescent Medicine Hospital Kuala Lumpur & Head, Dept. of Paediatrics Dr. Zurina Zainudin Hospital Sultanah Bahiyah, Alor Setar Consultant, Neonatologist Dr. Vigneswari Ganesan Universiti Putra Malaysia Consultant, Paediatric Neurologist Hospital Kuala Lumpur Hospital Pulau Pinang Dr. Wan Jazilah Wan Ismail Consultant, Paediatric Nephrologist Hospital Selayang DISCLAIMER These protocols serve as a guideline for the management of some common childhood illnesses in Malaysia. The guideline is not a substitute for clinical judgement. Variation from the guideline, taking into account individual circumstances may be appropriate, depending on locally available resources and expertise, or with new evidence based research findings. viii  TABLE OF CONTENTS Section 1 General Paediatrics Chapter 1: Normal Values in Children 1 Chapter 2: Childhood Immunisations 9 Chapter 3: Paediatric Fluid and Electrolyte Guidelines 24 Chapter 4: Developmental Milestones in Normal Children 35 Chapter 5: Developmental Assessment 41 Chapter 6: Specific Learning Disorder 51 Chapter 7: The H.E.A.D.S.S. Assessment 59 Chapter 8: End of Life Care in Children 63 Section 2 Neonatalogy Chapter 9: Principles of Transport of the Sick Newborn 74 Chapter 10: General Pointers for Care and Review of Newborn Infants (NICU) 82 Chapter 11: The Premature Infant 89 Chapter 12: Late Preterm Infants 93 Chapter 13: Enteral Feeding in Neonates 95 Chapter 14: Total Parenteral Nutrition for Neonates 99 Chapter 15: The Newborn and Acid Base Balance 104 Chapter 16: Neonatal Hypoglycemia 108 Chapter 17: Neonatal Sepsis 114 Chapter 18: Guidelines for the Use of Surfactant 117 Chapter 19: Neonatal Encephalopathy 119 Chapter 20: Hypothermia Therapy for Neonates ≥ 35 Weeks Gestation 122 Chapter 21: Neonatal Seizures 127 Chapter 22: Neonatal Jaundice 134 Chapter 23: Exchange Transfusion 143 Chapter 24: Prolonged Jaundice in Newborn Infants 146 Chapter 25: Apnoea in the Newborn 154 Chapter 26: Vascular Spasm and Thrombosis 156 Chapter 27: Patent Ductus Arteriosus in the Preterm 162 Chapter 28: Persistent Pulmonary Hypertension of the Newborn 164 Chapter 29: Ophthalmia Neonatorum 167 Chapter 30: Congenital Syphilis 169 Chapter 31: Perinatally Acquired Varicella 171 Section 3 Respiratory Medicine Chapter 32: Asthma 182 Chapter 33: Viral Bronchiolitis 194 Chapter 34: Viral Croup 196 Chapter 35: Pneumonia 198 Chapter 36: Empyema Thoracis 202 ix  TABLE OF CONTENTS Section 4 Cardiology Chapter 37: Paediatric Electrocardiography 206 Chapter 38: Congenital Heart Disease in the Newborn 208 Chapter 39: Hypercyanotic Spell 215 Chapter 40: Heart Failure 216 Chapter 41: Acute Rheumatic Fever 218 Chapter 42: Infective Endocarditis 220 Chapter 43: Kawasaki Disease 230 Chapter 44: Viral Myocarditis 233 Chapter 45: Paediatric Arrhythmias 235 Section 5 Neurology Chapter 46: Status Epilepticus 243 Chapter 47: Epilepsy 245 Chapter 48: Febrile Seizures 254 Chapter 49: Meningitis 256 Chapter 50: Autoimmune Encephalitis 260 Chapter 51: Status Dystonicus 262 Chapter 52: Acute Demyelinating Syndromes 264 Chapter 53: Acute Flaccid Paralysis 266 Chapter 54: Guillain Barré Syndrome 268 Chapter 55: Approach to The Child With Altered Consciousness 270 Chapter 56: Childhood Stroke 272 Chapter 57: Brain Death 276 Section 6 Endocrinology Chapter 58: Approach to A Child with Short Stature 283 Chapter 59: Congenital Hypothyroidism 287 Chapter 60: Diabetes Mellitus 297 Chapter 61: Diabetic Ketoacidosis 309 Chapter 62: Disorders of Sexual Development 317 Section 7 Nephrology Chapter 63: Acute Glomerulonephritis 330 Chapter 64: Nephrotic Syndrome 335 Chapter 65: Acute Kidney Injury 341 Chapter 66: Acute Peritoneal Dialysis 348 Chapter 67: Neurogenic Bladder 354 Chapter 68: Urinary Tract Infection 360 Chapter 69: Antenatal Hydronephrosis 367 Chapter 70: Hypertension in Children 372 x  TABLE OF CONTENTS Section 8 Haematology and Oncology Chapter 71: Approach to a Child with Anaemia 384 Chapter 72: Thalassaemia 388 Chapter 73: Immune Thrombocytopenic Purpura 394 Chapter 74: Haemophilia 399 Chapter 75: Oncology Emergencies 404 Chapter 76: Acute Lymphoblastic Leukaemia 412 Section 9 Gastroenterology Chapter 77: Approach to Severely Malnourished Children 418 Chapter 78: Acute Gastroenteritis 422 Chapter 79: Chronic Diarrhoea 429 Chapter 80: Gastro-oesophageal Reflux 438 Chapter 81: Acute Hepatic Failure in Children 443 Chapter 82: Approach to Gastrointestinal Bleeding 450 Section 10 Infectious Disease Chapter 83: Sepsis and Septic Shock 456 Chapter 84: Paediatric HIV 460 Chapter 85: Malaria 473 Chapter 86: Tuberculosis 479 Chapter 87: BCG Lymphadenitis 485 Chapter 88: Dengue and Dengue Haemorrhagic Fever with Shock 487 Chapter 89: Diphteria 499 Section 11 Dermatology Chapter 90: Atopic Dermatitis 502 Chapter 91: Infantile Hemangioma 504 Chapter 92: Scabies 514 Chapter 93: Steven Johnson Syndrome 518 Section 12 Metabolic Disorders Chapter 94: Inborn errors metabolism (IEM): Approach to Diagnosis and Early Management in a Sick Child  521 Chapter 95: Investigating Inborn errors metabolism (IEM) in a Child with Chronic Symptoms 531 Chapter 96: Approach to Recurrent Hypoglycemia 543 Chapter 97: Down Syndrome 549 xi  TABLE OF CONTENTS Section 13 Paediatric Surgery Chapter 98: Appendicitis 555 Chapter 99: Vomiting in the Neonate and Child 557 Chapter 100: Intussusception 564 Chapter 101: Inguinal hernias, Hydrocoele 567 Chapter 102: Undescended Testis 568 Chapter 103: The Acute Scrotum 569 Chapter 104: Penile Conditions 572 Chapter 105: Neonatal Surgery 573 Section 14 Rheumatology Chapter 106: Juvenile Idiopathic Arthritis 587 Chapter 107: Systemic Lupus Erythematosus 594 Section 15 Poisons and Toxins Chapter 108: Snake Bite 606 Chapter 109: Common Poisons 616 Chapter 110: Anaphylaxis 630 Section 16 Sedation and Procedures Chapter 111: Recognition and Assessment of Pain 636 Chapter 112: Sedation and Analgesia for Diagnostic and Therapeutic Procedures 638 Chapter 113: Practical Procedures 642 xii  GENERAL PAEDIATRICS Chapter 1: Normal Values in Children VITAL SIGNS Normal Ranges forRespiratory Rate (RR) and Heart rate (HR) Age Guide weight RR at Rest HR (kg) Breaths per minute Beats per minute Boys Girls 5th to 95th Centile 5th to 95th Centile Birth 3.5 3.5 25 - 50 120 - 170 1 month 4.5 4.5 3 months 6.5 6 25 - 45 115 - 160 6 months 8 7 20 - 40 110 – 160 12 months 9.5 9 18 months 11 10 20 - 35 100 - 155 2 years 12 12 20 - 30 100 - 150 3 years 14 14 90 - 140 4 years 16 16 80 - 135 5 years 18 18 6 years 21 20 80 - 130 7 years 23 22 8 years 25 25 15 - 25 70 - 120 9 years 28 28 10 years 31 32 11 years 35 35 12 years 43 43 12 - 24 65 - 115 14 years 50 50 60 - 110 Adult 70 70 1 GENERAL PAEDIATRICS Blood Pressure (BP) Levels in Girls for Age and Height Percentile Age BP Percentile SBP (mmHg) DBP (mmHg) (Yr) Height Percentile or cm Height Percentile or cm Height 5% 50% 95% 5% 50% 95% Percentile 1 Height (cm) 75.4 80.8 86.1 75.4 80.8 86.1 50% 84 86 88 41 43 46 90% 98 100 102 54 56 58 95% 101 103 105 59 60 62 2 Height (cm) 84.9 91.1 97.4 84.9 91.1 97.4 50% 87 89 91 45 48 51 90% 101 103 106 58 60 62 95% 104 106 109 62 64 66 3 Height (cm) 91 97.6 104.6 91 97.6 104.6 50% 88 90 93 48 50 53 90% 102 104 107 60 62 65 95% 106 108 110 64 66 69 4 Height (cm) 97.2 104.5 112.2 97.2 104.5 112.2 50% 89 92 94 50 53 55 90% 103 106 108 62 65 67 95% 107 109 112 66 69 71 5 Height (cm) 103.6 111.5 120 103.6 111.5 120 50% 90 93 96 52 55 57 90% 104 107 110 64 67 70 95% 108 110 113 68 71 73 6 Height (cm) 110 118.4 127.7 110 118.4 127.7 50% 92 94 97 54 56 59 90% 105 108 111 67 69 71 95% 109 111 114 70 72 74 7 Height (cm) 115.9 124.9 134.7 115.9 124.9 134.7 50% 92 95 99 55 57 60 90% 106 109 112 68 70 72 95% 109 112 115 72 73 75 2  GENERAL PAEDIATRICS Blood Pressure (BP) Levels in Girls for Age and Height Percentile (cont.) Age BP Percentile SBP (mmHg) DBP (mmHg) (Yr) Height Percentile or cm Height Percentile or cm Height 5% 50% 95% 5% 50% 95% Percentile 8 Height (cm) 121 130.6 140.9 121 130.6 140.9 50% 93 97 100 56 59 61 90% 107 110 113 69 72 73 95% 110 113 117 72 74 75 9 Height (cm) 125.3 135.6 146.6 125.3 135.6 146.6 50% 95 98 101 57 60 61 90% 108 111 114 71 73 73 95% 112 114 118 74 75 75 10 Height (cm) 129.7 141 152.8 129.7 141 152.8 50% 96 99 103 58 60 62 90% 109 112 116 72 73 73 95% 113 116 120 75 76 76 11 Height (cm) 135.6 147.8 160 135.6 147.8 160 50% 98 102 106 60 61 64 90% 111 114 120 74 74 75 95% 115 118 124 76 77 77 12 Height (cm) 142.8 154.8 166.4 142.8 154.8 166.4 50% 102 105 108 61 62 65 90% 114 118 122 75 75 76 95% 118 122 126 78 78 79 13 Height (cm) 148.1 159.2 170.2 148.1 159.2 170.2 50% 104 107 109 62 64 66 90% 116 121 123 75 76 76 95% 121 124 127 79 79 81 These normative blood pressures figures were extracted from the guidelines “Clinical Practice Guideline for Screening and Management of High Blood Pres- sure in Children and Adolescents.” Flynn JT et al. Pediatrics. (2017) 3 GENERAL PAEDIATRICS Blood Pressure (BP) Levels in Boys for Age and Height Percentile Age BP Percentile SBP (mmHg) DBP (mmHg) (Yr) Height Percentile or cm Height Percentile or cm Height 5% 50% 95% 5% 50% 95% Percentile 1 Height (cm) 77.2 82.4 87.9 77.2 82.4 87.9 50% 85 86 88 40 41 42 90% 98 100 101 52 53 54 95% 102 103 105 54 55 57 2 Height (cm) 86.1 92.1 98.5 86.1 92.1 98.5 50% 87 89 91 43 44 46 90% 100 102 104 55 56 58 95% 104 106 108 57 59 61 3 Height (cm) 92.5 99 105.8 92.5 99 105.8 50% 88 90 92 45 47 49 90% 101 103 105 58 59 61 95% 106 107 109 60 62 64 4 Height (cm) 98.5 105.9 113.2 98.5 105.9 113.2 50% 90 92 94 48 50 52 90% 102 105 107 60 62 64 95% 107 108 110 63 66 68 5 Height (cm) 104.4 112.4 120.3 104.4 112.4 120.3 50% 91 94 96 51 53 55 90% 103 106 108 63 65 67 95% 107 109 112 66 69 71 6 Height (cm) 110.3 118.9 127.5 110.3 118.9 127.5 50% 93 95 98 54 56 58 90% 105 107 110 66 68 69 95% 108 111 114 69 71 73 7 Height (cm) 116.1 125.1 134.5 116.1 125.1 134.5 50% 94 97 99 56 58 59 90% 106 109 111 68 70 71 95% 110 112 116 71 73 74 4  GENERAL PAEDIATRICS Blood Pressure (BP) Levels in Boys for Age and Height Percentile (cont.) Age BP Percentile SBP (mmHg) DBP (mmHg) (Yr) Height Percentile or cm Height Percentile or cm Height 5% 50% 95% 5% 50% 95% Percentile 8 Height (cm) 121.4 131 141 121.4 131 141 50% 95 98 100 57 59 60 90% 107 110 112 69 71 73 95% 111 114 117 72 74 75 9 Height (cm) 126 136.3 147.1 126 136.3 147.1 50% 96 99 101 57 60 62 90% 107 110 114 70 73 74 95% 112 115 119 74 76 77 10 Height (cm) 130.2 141.3 152.7 130.2 141.3 152.7 50% 97 100 103 59 62 63 90% 108 112 116 72 74 76 95% 112 116 121 76 77 78 11 Height (cm) 134.7 146.4 158.6 134.7 146.4 158.6 50% 99 102 106 61 63 63 90% 110 114 118 74 75 76 95% 114 118 124 77 78 78 12 Height (cm) 140.3 152.7 165.5 140.3 152.7 165.5 50% 101 104 109 61 62 63 90% 113 117 122 75 75 76 95% 116 121 128 78 78 79 13 Height (cm) 147 160.3 173.4 147 160.3 173.4 50% 103 108 112 61 62 65 90% 115 121 126 74 75 77 95% 119 125 131 78 78 81 These normative blood pressures figures were extracted from the guidelines “Clinical Practice Guideline for Screening and Management of High Blood Pres- sure in Children and Adolescents.” Flynn JT et al. Pediatrics. (2017) 5 GENERAL PAEDIATRICS Age 5th centile Blood Pressure < 1 year 65 - 75 1-2 years 70 - 75 2-5 years 70 - 80 5-12 years 80 - 90 >12 years 90 - 105 The calculation for expected systolic blood pressure is: 65 + (2 x age in years) mmHg for 5th centile Reference: Advanced Paediatric Life Support: The Practical Approach To Emergencies, 6th Edition 2016 6  GENERAL PAEDIATRICS ANTHROPOMETRIC MEASUREMENTS Age Weight Height Head size Birth 3.5 kg 50 cm 35 cm 6 months 7 kg 68 cm 42 cm 1 year 10 kg 75 cm 47 cm 2 years 12 kg 85 cm 49 cm 3 years 14 kg 95 cm 49.5 cm 4 years 100 cm 50 cm 5-12 years 5 cm/year 0.33 cm/year Points to Note Weight In the first 7 - 10 days of life, babies lose 10 - 15% of their birth weight. In the first 3 months of life, the rate of weight gain is 25 gm/day Babies regain their birth weight by the 2nd week, double this by 5 months age, and triple the birth weight by 1 year of age Weight estimation for children (in Kg): Infants: (Age in months X 0.5) + 4 Children 1 – 10 years: (Age in yrs + 4) X 2 Head circumference Rate of growth in preterm infants is 1 cm/week, but reduces with age. Head growth follows that of term infants when chronological age reaches term Head circumference increases by 12 cm in the 1st year of life (6 cm in first 3 months, then 3 cm in second 3 months, and 3 cm in last 6 months) Other normal values are found in the relevant chapters of the book. References: 1. Advanced Paediatric Life Support: The Practical Approach Textbook, 5th Edition 2011 2. Nelson Textbook of Pediatrics, 18th Edition. 7  GENERAL PAEDIATRICS HAEMATOLOGICAL PARAMETERS Age Hb PCV Retics MCV fl MCH pg TWBC Neutrophil Lymphocyte g/dL % % Lowest Lowest x1000 Mean Mean Cord Blood 13-7-20.1 45-65 5.0 110 - 9-30 61 31 2 weeks 13.0-20.0 42-66 1.0 - 29 5-21 40 63 3 months 9.5-14.5 31-41 1.0 - 27 6-18 30 48 6 mths - 6 yrs 10.5-14.0 33-42 1.0 70-74 25-31 6-15 45 38 7 - 12 years 11.0-16.0 34-40 1.0 76-80 26-32 4.5-13.5 55 38 8 Adult male 14.0-18.0 42-52 1.6 80 27-32 5-10 55 35 Adult female 12.0-16.0 37-47 1.6 80 26-34 5-10 55 35 Differential counts Points to note < 7 days age neutrophils > lymphocytes Differential WBC: eosinophils: 2-3%; monocytes: 6-9 % Platelets counts are lower in first months of age; 1 wk - 4 years lymphocytes > neutrophils but normal range by 6 months 4 - 7 years neutrophils = lymphocytes Erythrocyte sedimentation rate (ESR) is < 16 mm/hr in > 7 years neutrophils > lymphocytes children, provided PCV is at least 35%.  Chapter 2: Immunisations NATIONAL IMMUNISATION SCHEDULE FOR MALAYSIA (MINISTRY OF HEALTH, MALAYSIA) Age in months Age in years Vaccine birth 1 2 3 5 6 9 12 18 21 7 yrs 13 yrs 15 yrs BCG 1 if no scar Hepatitis B 1 2 3 DTaP 1 2 3 4 DT (B) T (B) IPV 1 2 3 4 Hib 1 2 3 4 9 Measles Sabah MMR 1 2 MR* JE (Sarawak) 1 2 HPV 2 doses Legend: B, Booster doses; BCG, Bacille Calmette-Guerin; DTaP, Diphhteria, Tetanus, acellular Pertussis; DT, Diphtheria, Tetanus; T, Tetanus; IPV, Inactivated Polio Vaccine; Hib, Haemophilus influenzae type B; MMR, Measles, Mumps, Rubella; JE, Japanese Encephalitis; HPV, Human Papilloma Virus; * Until the present cohort (9 and 12 months MMR) reaches 7 years GENERAL PAEDIATRICS GENERAL PAEDIATRICS General Notes Vaccines (inactivated or live) can be given simultaneously (does not impair antibody response or increase adverse effect). Administer at different sites unless using combined preparations. Sites of administration - Oral – rotavirus, live typhoid vaccines - Intradermal (ID) - BCG. Left deltoid area (proximal to insertion deltoid muscle) - Deep SC, IM injections. (ALL vaccines except the above) Anterolateral aspect of thigh – preferred site in children Upper arm – preferred site in adults Upper outer quadrant of buttock - associated with lower antibody level production Immunisation : General contraindications Absolute contraindication for any vaccine: severe anaphylaxis reactions to previous dose of the vaccine or to a component of the vaccine. Postponement during acute febrile illness: Minor infection without fever or systemic upset is NOT a contraindication. Live vaccines: Absolute contraindications - Immunosuppressed children - malignancy; irradiation, leukaemia, lymphoma, post-transplant, primary immunodeficiency syndromes (but NOT asymptomatic HIV): need to defer (see below) - Pregnancy (live vaccine - theoretical risk to foetus) UNLESS there is significant exposure to serious conditions like polio or yellow fever in which case the importance of vaccination outweighs the risk to the foetus. - Live vaccines may be given together. If not administering simultaneously then an interval ≥ 4 weeks is required. - Tuberculin skin test (Mantoux test) and MMR: after a Mantoux test, MMR should be delayed until the skin test has been read. There should be ≥ 4 weeks interval for Mantoux test after MMR given. Killed vaccines are safe. Absolute contraindications: SEVERE local induration (involving > 2/3 of the limbs) or severe generalised reactions in previous dose. The following are not contraindications to vaccination Mild illness without fever e.g. mild diarrhoea, cough, runny nose Asthma, eczema, hay fever, impetigo, heat rash (avoid injection in affected area) Treatment with antibiotics, locally acting steroids or inhaled steroids Child’s mother is pregnant Breastfed child (does not affect polio uptake) Neonatal jaundice Underweight or malnourished Over the recommended age Past history of pertussis, measles or rubella (unless confirmed medically) Stable neurological conditions: cerebral palsy, mental retardation, febrile convulsions, stable epilepsy Family history of convulsions History of heart disease, acquired or congenital Prematurity (immunise according to schedule irrespective of gestational age) 10  GENERAL PAEDIATRICS IMMUNISATION: SPECIAL CIRCUMSTANCES Immunisation of the Immunocompromised child: Includes malignancy; leukaemia, lymphoma, post-transplant, congenital immunodeficiency syndromes (but NOT asymptomatic HIV), immunosuppressive therapy: BCG is contraindicated Non-live vaccines can be given but may need to be repeated depending on underlying condition and individual vaccine due to suboptimal response For oncology patients on chemotherapy Avoid live vaccines for two weeks before, during and for 6 months after completion of chemotherapy Safe to give influenza and pneumococcal vaccines, if indicated For post- Haematopoeitic Stem Cell Transplant (HSCT) and Solid Organ Transplant (SOT) : Non-live vaccines can be given 6 months after HSCT or SOT Live vaccines to be given at least 2 years after HSCT and no graft versus host disease and not on immunosuppressive therapy (and acceptable CD4 count and IgM levels) Live vaccines contraindicated in SOT as most likely on immunosuppressive therapy Patients on Corticosteroid Therapy On high-dose steroids i e. Prednisolone >or equal to 2 mg/kg/day for >14 delay live vaccines for at least 1 month after cessation of steroids On low-dose systemic steroids of 1mg/ kg/day < 2 weeks or EOD for > 2 weeks, can administer live vaccines Any dose for 28 days or longer delay live vaccines for at least 1 month after cessation of steroids Interval between administration of Immunoglobulins or blood products and measles- or varicella-containing vaccine 3 months: following IM Hepatitis B prophylaxis (HBIG) 8 months: following Normal Human Immunoglobulin (NHIG) at dose of 400 mg/kg IV 10 months: following NHIG at dose of 800-1000 mg/kg IV 11 months: following NHIG at dose of 1600-2000 mg/kg IV (e.g. Kawasaki disease) 6 months: following Packed RBCs 10 mL/kg transfusion 6 months: following Whole blood 10 mL/kg transfusion 7 months: following Plasma/platelets transfusion Note: If measles- or varicella-containing vaccine is given 40.5), fits within be given at Std 1 or local) and progressive 72 hours, persistent incon- and at Form 3 due neurological diseases. solable crying (0.1 to 6%), to increased cases hyporesponsive state. of Pertussis amongst adolescents in Acellular Pertussis vaccine 14 recent years associated with less side effects Inactivated All infants to be Allergies to neomycin, poly- Local reactions. Intramuscular. Polio Vaccine given 4 doses myxin and streptomycin (IPV) including booster at Previous severe anaphylactic 18 months. reaction Haemophilus All infants should Confirmed anaphylaxis to Local swelling, redness and Intramuscular Influenzae receive 4 doses previous Hib and allergies pain soon after vaccination type B (Hib) including booster at to neomycin, polymyxin and and last up to 24 hours in 18 months. streptomycin 10% of vaccinees Patients with splenic Malaise, headaches, fever, ir- dysfunction, and ritability, inconsolable crying. post splenectomy. Very rarely seizures.  Vaccine Indication/Dose Contraindication Possible Side Effects Notes Measles, All infants and 9 and Avoid in patients with Transient rash in 5%. Intramuscular. Mumps, 12 months. hypersensitivity to neomycin May have fever between D5- Can be given irrespective of Rubella Booster at 7 years and polymyxin or severe D12 post vaccination. previous history of measles, (MMR) reaction to hen’s eggs URTI symptoms. mumps or rubella infection. Measles vaccine at 6 month for Sabah, Pregnancy. Febrile convulsions (D6-D14) in 1:1000 – 9000 doses of vac- Long term prospective stud­ Orang Asli popula- Children with cine. (Natural infection 1:200) ies have found no association tion Immunodeficiency. Encephalopathy within 30 days between measles or MMR in 1:1,000,000 doses. (Natural vac­cine and inflammatory infection 1:1000 - 5000) bowel diseases, autism or SSPE. 15 Mumps Rarely transient rash, pruri- Intramuscular tis and purpura. Parotitis in 1% of vaccinees, > 3 weeks after vaccination. Orchitis and retro bulbar neuritis very rare. Meningoencephalitis is mild and rare. (1:800,000 doses). (natural infection 1:400). GENERAL PAEDIATRICS  GENERAL PAEDIATRICS Vaccine Indication/Dose Contraindication Possible Side Effects Notes Rubella Rash, fever, lymphadenopa- Given as MMR thy, thrombocytopenia, transient peripheral neuritis. Arthritis and arthralgia oc- curs in up to 3% of children and 20% of adults. Japanese Given in Sarawak at Immunodeficiency and Local redness, swelling, Live attenuated vaccine Encephalitis 9 and 21 months. malignancy, diabetes , acute pain, fever, chills, headache, (IMOJEV) (JE) exacerbation of cardiac, lassitude.. Subcutaneous. hepatic and renal conditions Protective efficacy > 95%. Human Pap- Indicated for Not recommended in Headache, myalgia, injec- 2 vaccines available: 16 illoma Virus females aged 9-45 pregnant patients. tion site reactions, fatigue, Cervarix (GSK): bivalent. (HPV) years. nausea, vomiting, diarrhoea, Gardasil (MSD): quadrivalent. abdominal pain, pruritus, - 3 dose schedule IM (0, rash, urticaria, myalgia, 1-2month, 6 month). arthralgia, fever. Recombinant vaccine. Protective efficacy almost 100% in preventing vaccine type cervical cancer in first 5 years.  Vaccine Indication/Dose Contraindication Possible Side Effects Notes Pneumo- Dosage: Children who have severe Decreased appetite, Listed in Blue Book coccal Infants 2-6 mth age. allergic reaction to previous irritability, drowsiness, Immunogenic in children (conjugate) 3-dose primary pneumococcal vaccine restless sleep, fever, inj site < 2 years vaccine: PCV series at least 1 mth erythema, induration or 13/ PCV 7 apart from 6 wks pain, rash. Inactivated vaccine. Healthy children under 6 of age. Intramuscular weeks and more than 59 Booster: 1 dose months of age High risk children: between 12-15 mths of age. immunosuppression (includ- Unvaccinated: ing asymptomatic HIV), infants 7-11 mths asplenia, nephrotic syndrome 2 doses 1 month and chronic lung or heart 17 apart, followed by a disease. 3rd dose at 12- 15 months; children 12- 23 months 2 doses at least 2 months apart; healthy children 2 - 5 years: Single dose Unvaccinated high risk children 2-5 yrs age may be given 2 doses (6-8 wks apart) GENERAL PAEDIATRICS  GENERAL PAEDIATRICS Vaccine Indication/Dose Contraindication Possible Side Effects Notes Pneumococ- Recommended for Age < 2 years old. Hypersensitivity reactions. Listed in Blue Book. cal (polysac- children at high risk. Revaccination within 3 years Intramuscular, Subcutaneous charide > 2 years old. has high risk of adverse Immunogenic in children ≥2 vaccine) Single dose. reaction; yrs. Against 23 serotypes. Booster at 3-5 years Avoid during chemotherapy High risk: immunosuppression, only for high risk or radiotherapy and less asymptomatic HIV, asplenia, patients. than 10 days prior to com- nephrotic syndrome, chronic mencement of such therapy lung disease. If these children – antibody response is poor. are 2 yrs, then the polysaccharide 18 vaccine is used. Rotavirus First dose given to Prior hypersensitivity to any Loss of appetite, irritability, Oral live-attenuated vaccine. infants ≥ 6 wks old. vaccine component. fever, fatigue, diarrhoea, Protective efficacy 88-91% Rotateq (3 doses) Uncorrected congenital GIT vomiting, flatulence, ab- for any rotavirus gastroen- Subsequent doses malformation, e.g. Meckel’s dominal pain, regurgitation teritis episode; 63-79% for all given at 4-10 wks in- diverticulum of food. causes of gastroenteritis. terval. 3rd dose given ≤ 32 weeks age. Severe combined immuno- Rotarix (2 doses). 2nd deficiency disease (reported dose to be given by prolonged shedding of vac- 24 weeks age. Inter- cine virus reported in infants val between doses who had live Rotavirus should be > 4 wks. vaccine)  Vaccine Indication/Dose Contraindication Possible Side Effects Notes Varicella 12 mths to 12 yrs: Pregnant patients. Occasionally, papulovesicu- Live attenuated vaccine. Zoster 2 doses at least Patients receiving high dose lar eruptions, injection site Subcutaneous. ≥ 4 wks apart. systemic immunosuppres- reactions, headache, fever, 70 – 90% effectiveness. sion therapy. paresthesia, fatigue Non immune sus- Patients with malignancy ceptible health care especially haematologi- workers who regu- cal malignancies or blood larly come in contact dyscrasias. with VZV infection Hypersensitivity to neomycin. Asymptomatic/mildly symptomatic children with HIV (with CD4% 19 > 15%); 2 doses at 3 mths interval. Children in remission from leukemia for ≥1 yr, have >700/ml cir- culating lymphocytes may receive vaccine under paediatrician supervision (2doses). Hepatitis A For children >1 yr. Severe hypersensitivity to Local reactions. Flu-like Intramuscular. 2 doses., given 6-12 aluminium hydroxide, phe- symptoms lasting 2 days in Inactivated vaccine. months apart. noxyethanol, neomycin 10% of recipients Protective efficacy 94%. GENERAL PAEDIATRICS  GENERAL PAEDIATRICS Vaccine Indication/Dose Contraindication Possible Side Effects Notes Cholera Children 2-6 yrs: Gastroenteritis Oral inactivated vaccine. 3 doses at 1-6 wk Protective efficacy 80-90% interval. after 6 mths waning to 60% Children > 6 yrs: after 3 yrs. 2 doses at 1-6 wks interval. Booster dose >2 yrs. Influenza Single dose. Hypersensitivity to egg or Transient swelling, redness, Intramuscular. Min age 6 mths. chicken protein, neomycin, pain and induration locally. Inactivated vaccine. Unprimed individuals formaldehyde. Myalgia, malaise and Protective efficacy 70-90% require 2nd dose 4 - Febrile illness, acute infec- fever for 1 – 2 days starting Require yearly revaccination tion. within a few hours post 20 6 wks after 1st dose. for continuing protection. Recommended for vaccination. Very rarely, children with: neurological (Guillain-Barre), chronic decompen- glomerulonephritis, ITP or sated respiratory or anaphylactic reaction occurs. cardiac disorders, e.g. cyanotic heart diseases chronic lung disease, HIV infection. In advanced disease, vaccination may not induce protective antibody levels.  Vaccine Indication/Dose Contraindication Possible Side Effects Notes Rabies Pre-exposure: 3 doses at Day 0, Headache, dizziness, malaise, Inactivated vaccine. 7, 28. Booster every 2-3 yrs. abdominal pain, nausea, my- (Available in Malay- Post-exposure treatment: algia. Injection site reactions sia as Purified Vero Fully immunised: 2 doses at such as itching, swelling, pain. Cell Rabies Vaccine Day 0, Day 3. Rabies Immune (PVRV). Globulin (RIG) unnecessary. Intramuscular. Unimmunised: 5 doses at Day 0, 3, 7, 14 and 28. RIG (20 IU/ kg given half around the wound and the rest IM. Meningococ- Single dose. Local reactions. Irritability, Intramuscular. cus A, C,Y & Immunity up to 3 yrs. fever and rigors for 1-2 days. 21 W-135 Very rarely, anaphylaxis. Typhoid Single dose. Seroconversion in Children < 2yrs. Local reactions. Myalgia, Intramuscular. (Typhim Vi) 85-95% of recipients; confers (Immunogenicity < 2 yrs of malaise, nausea, headaches Polysaccharide 60-80% protection beginning age has not been estab- and fever in 3% of recipients. vaccine 2 wks after vaccination. lished) Boosters every 3 yrs. Typhoid Three doses two days apart. Infant 1 year and months < 7 years 1st visit BCG BCG BCG BCG Hepatitis B Hepatitis B Hepatitis B Hepatitis B (1st dose) (1st dose) (1st dose) (1st dose) DTaP-IPV// DTaP-IPV// DTaP-IPV// Hib (1st dose) Hib (1st dose) Hib (1st dose) MMR MMR 2nd visit follow Hepatitis B Hepatitis B Hepatitis B (1 mth later) Immunisation (2nd dose) (2nd dose) (2nd dose) Schedule DTaP-IPV// DTaP-IPV// DTaP-IPV// Hib (2nd dose) Hib (2nd Hib (2nd dose) dose) MMR (2nd dose) 3rd visit follow DTaP-IPV// DTaP-IPV// DTaP-IPV// (1 mth later) Immunisation Hib (3rd dose) Hib (3rd dose) Schedule Hepatitis B Hepatitis B (3rd Dose) (3rd Dose) 4th visit follow Hepatitis B MMR (2nd (2 mths Immunisation (3rd dose) dose) later) Schedule 18 months follow follow DTaP-IPV// DTaP-IPV// of age or 6 Immunisation Immunisation Hib (booster) Hib (booster) months after Schedule Schedule completed DTaP-IPV// Hib 3rd dose For subsequent doses please refer to the Immunisation Schedule 22  GENERAL PAEDIATRICS SUGGESTED IMMUNISATION SCHEDULE FOR VACCINES NOT LISTED IN NATIONAL IMMUNISATION PROGRAM Vaccines listed below are available in private hospitals or clinics Pneumococcal Recommended to complete 3 doses within the (conjugate vaccine) first year of life starting at 6 weeks of age. Consult your doctor for the individual recommended schedule according to the age of child receiving the first dose. Meningococcal Recommended for children travelling to high risk area. Single dose provides immunity up to 3 years Rotavirus Recommended first dose to be given after 6 weeks of age. Consult your doctor for the subsequent doses and intervals according to the manufacturer recommendation. Varicella / For children 12 months and above: 2 doses more chicken pox than 4 weeks apart Hepatitis A For children above 1 year : 2 doses given 6-12 months apart. 23 GENERAL PAEDIATRICS Chapter 3: Paediatric Fluid and Electrolyte Guidelines Well children with Normal hydration Children who are well rarely require intravenous fluids (IV). Whenever possible, use an enteral (oral) route for fluids. These guidelines apply to children who are unable to tolerate enteral fluids. The safe use of IV fluid therapy in children requires accurate prescribing of fluids and careful monitoring because incorrectly prescribed or administered fluids are hazardous. If IV fluid therapy is required then maintenance fluid requirements should be calculated using the Holliday and Segar formula based on weight. However this should be only be used as a starting point and the individual’s response to fluid therapy should be monitored closely by clinical observation, fluid balance, weight and a minimum daily electrolyte profile. Prescribing Intravenous fluids Fluids are given intravenously for the following reasons: Circulatory support in resuscitating vascular collapse. Replacement of previous fluid and electrolyte deficit. Maintenance of daily fluid requirement. Replacement of ongoing losses. Severe dehydration with failed nasogastric tube fluid replacement (e.g. on-going profuse losses, diarrhoea or abdominal pain). Certain co-morbidities, particularly GIT conditions (e.g. short gut or previous gut surgery) Bolus 0.9% Sodium Chloride For Resuscitation Alternatively and ONLY under direction of Specialist: other crystalloids, e.g. balanced salt solutions, or colloids may be used Dehydration or ongoing losses For Replacement 0.9% Sodium Chloride or Ringer’s /Hartmann ‘s solution 0.9% Sodium Chloride + 5% Glucose +/- Potassium Chloride 20mmol/L For Maintenance Alternatively and ONLY under direction of Specialist: 0.45% Sodium Chloride + 5% Glucose +/- Potassium Chloride 20mmol/L or balanced solution A Balanced solution is made to a physiological pH and isotonic salt concentration. If electrolytes are outside the normal range, discuss with a specialist as necessary. 24  GENERAL PAEDIATRICS Electrolyte Composition (mmol/l), Osmolarity and Tonicity of commonly used intravenous solution (Crystalloid) Plasma 0.9% 0.45%NaCL Ringer’s Stero- Plasmalyte 0.9%NaCl Electrolyte NaCL + Dextrose Lactate/ fundin 148 + Hartmann’s Dextrose 5% 5% Sodium 140 154 77 131 140 140 154 Potassium 5 0 0 5 4 5 0 Chloride 100 154 77 111 127 98 154 Calcium 22 0 0 2 25 0 0 Magnesium 1 0 0 1 1 15 0 Bicarbonate 24 0 0 0 0 0 0 Lactate 1 0 0 29 0 0 0 Acetate 0 0 0 0 24 27 0 Gluconate 0 0 0 0 0 23 0 Maleate 0 0 0 0 5 0 0 Glucose g/L 0 50 0 0 0 50 Osmolarity 275- 308 406 273 309 294 560 (mosm/L) 295 Tonicity Isotonic Hypotonic Isotonic Isotonic Isotonic Isotonic Electrolyte Composition (mmol/l), Osmolarity and Tonicity of commonly used intravenous solution (Colloid) Electrolyte Albumin 5% Gelofusine Voluven Sodium 140 150 154 Potassium 0 5 0 Chloride 128 100 154 Calcium 0 0 0 Magnesium 0 0 0 Bicarbonate 0 0 0 Lactate 0 0 0 Acetate 0 0 0 Gluconate 0 0 0 Maleate 0 0 0 Octanoate 64 0 50 25 GENERAL PAEDIATRICS Resuscitation Fluids appropriate for bolus administration are: Crystalloids 0.9% Normal Saline Ringer’s Lactate @ Hartmann’s solution Sterofundin, Plasmalytes Colloids Gelafundin 4.5% albumin solution Blood products Whole blood, blood components *Do not use starch based solution i.e. voluven as resuscitation fluid. Fluid deficit sufficient enough to cause impaired tissue oxygenation (clinical shock) should be corrected with a fluid bolus of 10-20mls/kg. Always reassess circulation - give repeat boluses as necessary. Look for the cause of circulatory collapse - blood loss, sepsis, etc. This helps decide on the appropriate alternative resuscitation fluid. Fluid boluses of 10mls/kg in selected situations - e.g. diabetic ketoacidosis, intracranial pathology or trauma. If associated cardiac conditions, then use aliquots of 5-10mls/kg Avoid low sodium-containing (hypotonic) solutions for resuscitation as this may cause hyponatremia. Measure blood glucose: treat hypoglycaemia with 2mls/kg of 10% Dextrose solution. Measure Na, K and glucose at the beginning and at least 24 hourly from then on (more frequent testing is indicated for ill patients or patients with co-morbidities). Rapid results of electrolytes can be obtained from blood gases measurements. Consider septic work-up or surgical consult in severely unwell patients with abdominal symptoms (i.e. gastroenteritis). 26  GENERAL PAEDIATRICS Maintenance Maintenance fluid is the volume of daily fluid intake. It includes insensible losses (from breathing, perspiration, and in the stool), and allows for excretion of the daily production of excess solute load (urea, creatinine, electrolytes) in the urine. 0.45% Sodium chloride +/- glucose 5% may be used as maintenance fluid and is restricted to specialised areas (high dependency, renal, liver and intensive care unit) to replace ongoing loses of hypotonic fluids. Most children will tolerate standard fluid requirements. However some acutely ill children with inappropriately increased anti-diuretic hormone secretion (SIADH) may benefit from their maintenance fluid requirement being restricted to two-thirds of the normal recommended volume. Children at high risk of hyponatremia should be given isotonic solutions (0.9% saline ± glucose) with careful monitoring to avoid iatrogenic hyponatremia. These include children with: Peri-or post-operative Require replacement of ongoing losses A plasma Na+ at lower range of normal (definitely if < 135mmol/L) Intravascular volume depletion, Hypotension Central nervous system (CNS) infection Head injury Bronchiolitis Sepsis Excessive gastric or diarrhoeal losses Salt-wasting syndromes Chronic conditions such as diabetes, cystic fibrosis and pituitary deficits. Calculation of Maintanence Fluid Requirements The following calculations approximate the maintenance fluid requirement of well children according to weight in kg (Holliday-Segar calculator). Weight Total fluids Infusion rate First 10 Kgs 100 ml/kg 4 mls/kg/hour Subsequent 10 Kgs 50 ml/kg 2 mls/kg/hour All additional Kg 20 ml/kg 1 ml/kg/hour Example: A Child of 29 kg will require: 100mls/kg for first 10kg of weight 10 x 100 = 1000 mls 50mls/kg for second 10kg of weight 10 x 50 = 500 mls 20mls/kg for all additional weight 9 x 20 = 180 mls Total = 1680 mls = 1680/24 Rate = 70mls/hour 27 GENERAL PAEDIATRICS Flow Chart for Maintenance Intravenous Fluid Prescription Routine Intravenous Fluid maintenance in a child or young person Measure plasma electrolytes and blood glucose when starting IV fluids and at 24 hours after If using Body Surface Area (BSA): Using body weight (Holliday-Segar): Estimate insensible lossess within 100mls/kg for first 10 kg the range of 300-400mls/m2/24 50mls/kg for second 10kg and hours + urine output 20mls/kg for weight over 20kg. In 24hrs, males ≤2.5 L, female ≤2 L Initially use isotonic crystalloid that contains Sodium in the range 131-154mmol/l Risk of water retention associated with non-osmotic anti-diuretic hormone secretion No Base any subsequent IV Fluid prescription on plasma electrolytes and glucose Yes Consider either: Restrict fluids to 50-80% of routine maintenance Reduce fluids calculated on basis of insensible losses within the range 300-400mls/m2/24hrs + urinary output 28  GENERAL PAEDIATRICS Deficit A child’s water deficit in mls can be calculated following an estimation of the degree of dehydration expressed as % of body weight. Example: A 10kg child who is 5% dehydration has a water deficit of 500mls. Maintenance 100mls/kg for first 10 kg = 10 × 100 = 1000mls Infusion rate/hour = 1000mls/24 hr = 42mls/hr Deficit (give over 24hours) 5% dehydration (5% of body water): 5/100 × 10kg × 1000mls = 500mls Infusion rate/hour (given over 24 hrs) = 500mls/24 hr = 21mls/hr The deficit is replaced over a time period that varies according to the child’s condition. Precise calculations (e.g. 4.5%) are not necessary. The rate of rehydration should be adjusted with ongoing clinical assessment. Use an isotonic solution for replacement of the deficit, e.g. 0.9% saline. Reassess clinical status and weight at 4-6hours, and if satisfactory continue. If child is losing weight, increase the fluid and if weight gain is excessive decrease the fluid rate. Replacement may be rapid in most cases of gastroenteritis (best achieved by oral or nasogastric fluids), but should be slower in diabetic ketoacidosis and meningitis, and much slower in hypernatremic states (aim to rehydrate over 48-72 hours, the serum Na should not fall by >0.5mmol/l/hr). Ongoing losses (e.g. from drains, ileostomy, profuse diarrhoea) These are best measured and replaced. Any fluid losses > 0.5ml/kg/hr needs to be replaced. Calculation may be based on each previous hour, or each 4 hour period depending on the situation. For example; a 200mls loss over the previous 4 hours will be replaced with a rate of 50mls/hr for the next 4 hours). Ongoing losses can be replaced with 0.9% Normal Saline or Hartmann’s solution. Fluid loss with high protein content leading to low serum albumin (e.g. burns) can be replaced with 5% Human Albumin. 29 GENERAL PAEDIATRICS SODIUM DISORDERS The daily sodium requirement is 2-3mmol/kg/day. Normal serum sodium is between 135-145mmol/l. Hypernatremia Hypernatremia is defined as serum Na+ > 150mmol/l, moderate hypernatremia = serum Na+ is 150-160mmol/l, and severe hypernatremia = serum Na+ > 160mmol/l. It can be due to: Clinical signs of Hypernatremic dehydration water loss in excess of sodium (e.g. diarrhoea) Irritability water deficit Skin feels “doughy” (e.g. diabetes insipidus) Ataxia, tremor, hyperreflexia sodium gain Seizure (e.g. large amount of NaHCO3 infusion or salt poisoning). Reduced awareness, coma Children may appear sicker than expected for degree of dehydration. Shock occurs late because intravascular volume is relatively preserved. Signs of hypernatremic dehydration tend to be predominantly that of intracellular dehydration and neurological dysfunction. In hypernatremia due to central diabetes insipidus, consult Endocrinology. Management For hypernatremic dehydration with Na+> 150mmol/l: If the patient is in shock, give volume resuscitation with 0.9% Normal saline as required with bolus/es. Avoid rapid correction as may cause cerebral oedema, convulsion and death. Aim to correct deficit over 48-72 hours and fall of serum Na+ ≤ 0.5mmol/l/hr. Give 0.9% Sodium Chloride to ensure the drop in sodium is not too rapid. Remember to give maintenance fluids and replace ongoing losses Repeat blood urea and electrolytes every 6 hours until stable. If hypernatraemia worsens or is unchanged after replacing deficit, review fluid type and consider changing to a hypotonic solution (e.g. 0.45% Sodium Chloride with dextrose). If no evidence of dehydration and an isotonic fluid is being used, consider changing to a hypotonic fluid (e.g. 0.45% Sodium Chloride with dextrose). If the fluid status is uncertain, measure urine sodium and osmolality. When correcting hypernatraemia, ensure that the rate of fall of plasma sodium < 12 mmol/litre in a 24-hour period (0.5mmol/l/hour). Measure plasma electrolytes every 4–6 hrs for the first 24 hrs, and the frequency of further electrolyte measurements depends on response. Special considerations Use a slower rate in chronic Hypernatraemia (present for > 5 days). Measure Calcium and glucose as hypernatremia can be associated with hypocalcaemia and hyperglycemia, and need to be corrected concurrently. 30  GENERAL PAEDIATRICS Hyponatremia Hyponatremia is defined when serum Na+ < 135mmol/l. Hyponatremic encephalopathy is a medical emergency that requires rapid recognition and treatment to prevent poor outcome. Symptoms associated with acute hyponatraemia during IV fluid therapy: Headache, nausea, vomiting, confusion, disorientation, irritability, lethargy, reduced consciousness, convulsions, coma, apnoea. Calculating sodium correction in acute hyponatremia mmol of sodium required = (135-present Na level)× 0.6 × weight(kg) The calculated requirements can then be given from the following available solutions dependent on the availability and hydration status: 0.9% sodium chloride contains 154 mmol/l of Sodium 3% sodium chloride contains 513mmol/l of Sodium In acute symptomatic hyponatraemia in term neonates and children, review the fluid status, seek immediate expert advice (for example, from the paediatric intensive care team) and consider taking action as follows: A 2 ml/kg bolus (max 100 ml) of 3% Sodium Chloride over 10–15 mins. A further 2 ml/kg bolus (max 100 ml) of 3% Sodium Chloride over the next 10–15 mins if symptoms are still present after the initial bolus. If symptoms are still present after the 2nd bolus, check plasma sodium level and consider a third 2ml/kg bolus (max 100 ml) of 3% Sodium Chloride over 10–15 mins. Measure the plasma sodium concentration at least hourly. As symptoms resolve, decrease the frequency of plasma sodium measurements based on the response to treatment. Do not manage acute hyponatraemic encephalopathy using fluid restriction alone. After hyponatraemia symptoms have resolved, ensure that the rate of increase of plasma sodium does not exceed 12 mmol/l in a 24-hr period. Children with asymptomatic hyponatremia do not require 3% sodium chloride treatment and if dehydrated may be managed with oral fluids or intravenous rehydration with 0.9% sodium chloride. Children who are hyponatremic and have a normal or raised volume status should be managed with fluid restriction. For Hyponatremia secondary to diabetic ketoacidosis; refer DKA protocol. 31 GENERAL PAEDIATRICS POTASSIUM DISORDERS The daily potassium requirement is 1-2mmol/kg/day. Normal values of potassium are: Birth - 2 weeks: 3.7 - 6.0mmol/l 2 weeks – 3 months: 3.7 - 5.7mmol/l 3 months and above: 3.5 - 5.0mmol/l Hypokalemia Hypokalemia is defined as serum K+ < 3.4 mmol/l (Treat if < 3.0mmol/l or Clinically Symptomatic and < 3.4 mmol/l) Causes are: Sepsis Gastrointestinal losses ECG changes of Hypokalemia - diarrhoea, vomiting Iatrogenic- e.g. diuretic therapy, These occur when K < 2.5mmol/l + salbutamol, amphotericin B. Prominent U wave Diabetic ketoacidosis ST segment depression Renal tubular acidosis Flat, low or diphasic T waves Hypokalaemia is often seen with Prolonged PR interval (severe hypoK+) chloride depletion and metabolic alkalosis Sinoatrial block (severe hypoK+) Refractory hypokalaemia may occur with hypomagnesaemia. Treatment Identify and treat the underlying condition. Unless symptomatic, a potassium level of 3.0 and 3.4 mmol/l is generally not supplemented but rather monitored. The treatment of hypokalaemia will need to be individualized for each patient. Oral Supplementation Oral Potassium Chloride (KCL), to a maximum of 2 mmol/kg/day in divided doses is common but more may be required in practice. Intravenous Supplementation (1gram KCL = 13.3 mmol KCL) Potassium chloride is always given by IV infusion, NEVER by bolus injection. Maximum concentration via a peripheral vein is 40 mmol/l (concentrations of up to 60 mmol/l can be used after discussion with senior medical staff). Maximum infusion rate is 0.2mmol/kg/hour (in non-intensive care setting). Intravenous Correction (1gram KCL = 13.3 mmol KCL) K+ < 2.5 mmol/L may be associated with significant cardiovascular compromise. In the emergency situation, an IV infusion KCL may be given Dose: initially 0.4 mmol/kg/hr into a central vein, until K+ level is restored. Ideally this should occur in an intensive care setting. 32  GENERAL PAEDIATRICS POTASSIUM DISORDERS The daily potassium requirement is 1-2mmol/kg/day. Normal values of potassium are: Birth - 2 weeks: 3.7 - 6.0mmol/l 2 weeks – 3 months: 3.7 - 5.7mmol/l 3 months and above: 3.5 - 5.0mmol/l Hyperkalemia ECG changes in Hyperkalemia Causes are: Tall, tented T waves Dehydration Prolonged PR interval Acute renal failure