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Paediatrics
Paediatric presentation
Section 6.
Paediatrics
Contents
History and physical examination - child
Child with fever
Child with cough
Child with stridor
Child with vomiting
Child with abdominal pain
Child with chronic diarrhoea
Meningitis
Respiratory problems
Immune complications
Ear problems
Gastrointestinal problems
Urinary tract problems
Bone and joint problems
Abuse and neglect - child
Paediatric presentation
Recommend
Use of Childrens Early Warning Tools (CEWT) appropriate to age for rural and remote
facilities ordered through: qheps.health.qld.gov.au/psq/rmdp/html/rmdp_homepage.
htm or by email at: RMDP@health.qld.gov.au
Consult MO immediately about any baby under 3 months of age who is at risk
or febrile
Always check the immunisation status of children at every opportunity
Believe the child or parent / carer: no matter the time of day or night or the circumstance,
make sure the patient and their parent / carer feels he or she has been listened to
and done the right thing in bringing the child regardless of the concern
Background
Small children, especially young babies, get sick very quickly
Risk signs in children are:
-- temperature > 38C or < 35.5C
-- irritability
-- high pitched cry or weak cry
-- drowsiness
-- decreased activity
-- reduced feeding
-- breathing fast / noisy, respiratory distress, apnoea
-- persistent vomiting
-- dehydration (< 4 wet nappies in 24 hours)
-- sunken eyes
-- cold extremities
-- capillary refill > 2 seconds
-- uses eyes (rather than head) to follow you
-- abdominal distension
Other high risk children include those with:
-- lots of diarrhoea (> 8 watery stools in 24 hours)
-- congenital or chronic disease e.g. cardiac, gastrointestinal, neurological
-- where social conditions are concerning and / or where parents may have difficulty
managing at home
-- a history of repeated or prolonged separations from their primary caregiver(s)
-- psychosocial risk factors including family violence, poverty, homelessness,
parents with intellectual disability or mental health problems
Related topics
Immunisation program
545
Paediatric presentation
Rate pain level in children using faces, numbers and behavioural observations. Physiological
changes e.g. altered HR, RR, BP are not good indicators to use in isolation [2]. Non - verbal
children are very vulnerable to having their pain under estimated [2]
Refer to Childrens Early Warning tools (CEWT) for pain assessment tools
546
Paediatric presentation
Presentation
When a child presents for health care the clinician is required to gather an orderly
collection of information to identify the patients health status. The following is essential
to achieve this:
-- taking a patient history
-- performing standard clinical observations and other vital signs
-- perform physical examination
-- using diagnostic and pathology services, and
-- collaboration with other members of the team
-- note: not all children are at the same stage of development in areas of physical,
cognitive and psychosocial development
It is a requirement that all clinicians document their findings in a clear and concise way.
This section is set out to assist. It is recommended the page number of HMP / CCG is
referred to in the documentation
Types of history
There are four types of history taking [3] See History and physical examination - adult
History taking
The purpose of a full history is to ascertain the cause of the child's illness. A careful
history will make the cause clear in the vast majority of cases.
The first priority is to assess whether the child is:
-- seriously ill and needs immediate management or,
-- is a non urgent presentation, and there is time for a complete patient history and
health education
Obtaining a full history is done in conjunction with examining the patient
-- In a sick child this entails a full assessment of all systems
-- In a child who has a localised problem it is reasonable to examine the relevant
system only. However, always be guided by the history and be prepared to examine
other systems as necessary. This is particularly important for children who often
present with generalised symptoms and signs
-- Ask open ended questions
-- Believe the carer
Presenting concern
Ask the child or carer what the problem is
Ask about length of illness and exact details of symptoms and signs. For each symptom
the following details are important [4]
Site - where is the pain / symptom? does it go anywhere else?
Onset - when did it start, gradual or sudden onset?
Character e.g. sharp, dull or burning
Radiation - does the pain radiate anywhere else?
Alleviating factors - what makes it better e.g. sitting up, medicines?
Timing - how long did it last, have they had it before?
Exacerbating factors - what makes it worse?
Severity - mild, moderate or severe pain. Pain score 0 - no discomfort to 10 - unbearable
pain or use facial diagrams
547
Paediatric presentation
Past history
Past medical and
surgical history
Medications
Allergies
Immunisations
548
Was delivery normal and were there any immediate neonatal problems?
Any problems with growth and development?
Significant illnesses in the past? What and when?
Hospital admissions? Why and when?
Operations or injuries? What and when?
Mothers alcohol history during pregnancy?
Health problems in the family - especially siblings and parents
Who looks after the child, what is the social situation?
Mental health problems in carers / child?
Household smokers?
Recent contacts or trips away
If medicines are given, will they be taken?
Regular medicines (prescribed, herbal, bush medicines, over the counter)
generic name(s), dose, frequency?
Are they taken correctly?
May need to ask about other medicine(s) in the home the child may have
taken
See Medication reconciliation / Medication history checklist for more details
Adverse drug reactions:
-- adverse reactions / allergies to medicines?
-- attach adverse drug reaction sticker to medication chart if required
Allergens e.g. bee stings, tapes, sticking plaster, nuts:
-- specific reaction e.g. skin reaction, bronchospasm
-- is an Epi-pen / medication used to treat the allergy?
Check if up to date
Documented evidence of immunisation status should be obtained, follow
up with opportunistic immunisation See Immunisation program
Paediatric presentation
Physical examination
May be best done with the child on the carers knee. If the child is irritable perform
the examination opportunistically i.e. do what you can when you can. Leave the most
disruptive parts (ears and throat) until last
In general, examination of a child is not a good screening test. Use the history
to guide you to areas where you think you will find an abnormality
In any sick child a thorough and complete examination is required. All clothing will
need to be removed at some stage during the complete examination
In a child who is not sick, examine the relevant system first and proceed to further
examination as guided by the history and your findings
549
Paediatric presentation
Gastrointestinal and
reproductive
systems
550
Paediatric presentation
551
Paediatric presentation
Point of care testing is available in some facilities for example iSTAT blood gases
Pathology request forms
-- all pathology requests made by SM R&IP must be compliant with the specific Health
Management Protocol
-- if in the clinicians opinion other pathology is required this must be ordered by a MO
Pathology results / follow up:
-- if a SM R&IP has initiated pathology testing according to the Health Management
Protocol they are responsible for the follow up of pathology results
-- MO should be consulted if results are abnormal
Refer to the Pathology Queensland Specimen Collection Manual available at:
qis.health.qld.gov.au/DocumentManagement/Default.aspx?DocumentID=10021&Doc
umentInstanceID=45973
Consulting the MO
References
1. Pemsoft. Normal vital signs. 2008-2011 [cited 2011 August].
2.
The Royal Childrens Hospital. Acute Pain Management 2010 [cited 2011 April].
3.
Estes M. and Schaefer K.P., Health assessment & physical examination. 2nd ed. 2002, Albany, NY
Delmar.
4.
Talley N. and OConnor S., A systematic guide to physical diagnosis: clinical examination. 6th ed. 2010,
Australia: Churchill Livingstone: Elsevier.
5.
Murtagh J. and Rosenblatt J., John Murtaghs general practice 5th ed. 2011, Australia: McGaw Hill.
6.
Corrales A.Y. and Starr M., Assessment of the unwell child. Australian Family Physician, 2010. 39(5): p.
270-275.
7.
Douglas G., Nicole F., and Robertson C., Macleods clinical examination 12th ed, ed. Douglas G., Nicole
F., and Robertson C. 2009: Churchill Livingstone: Elsevier.
8. Advanced Paediatric Life Support Group, Advanced Paediatric Life Support The Practical Approach.
5th ed, ed. Samuels M. and Wieteska S. 2011: Wiley-Blackwell.
552
See
Meningitis
Headache,
photophobia
+/Rash
Neck stiffness
or bulging
fontanelle
Rapid onset
high fever
May have
history of URTI
like illness
See
Epiglottitis
Stridor,
drooling,
unable to
eat,
drink or talk,
reluctant to
move neck
Child unwell
Child unwell
See
Pneumonia
No other
significant
features
No other
significant
features
See
UTI
Tachycardia
Rapid
breathing,
chest
recession
Cough
Child unwell
Positive
urinalysis
Dysuria,
frequency,
smelly
urine
Child
unwell
See
Bacterial
skin infections
No other
significant
features
Obvious
abscess or
cellulitis
Basically
well child
No
Yes
See Acute
gastroenteritis
No other
significant
features
Vomiting and
diarrhoea
Basically
well child
See
Acute
otitis media
No other
significant
features
Bulging ear
drum on
examination
URTI type
symptoms may
be present
Basically
well child
Consult MO
See
URTI
Basically
well child
Fever is usually an indicator of infection. Two or more infections may co-exist, e.g. URTI plus meningitis
Babies less than 3 months of age contact MO immediately
Consult MO for the child with a fever with no obvious source of infection or a fever that is persistent despite measures taken
Paediatric presentation
553
554
Tonsillar
enlargement
Usually there
is a history of
ingesting or
choking on
something
Unable to eat,
drink or talk
Reluctant to
move neck
Cough may be
absent
See
Epiglottitis
No other
significant
features
See
Croup
Mild / moderate
stridor
Fever, red
inflamed throat
Airway
compromised
See
Acute upper
airway
obstruction /
choking
See
URTI
No other
significant features
Cervical
lymphadenopathy
Mild fever
Stridor,
drooling
Fever
See
Pneumonia
No other
significant
features
Tachycardia
Rapid breathing
with chest
recession
Child unwell
Yes
Mild URTI
symptoms
Sudden onset
in previously
well child
Rapid onset
high fever
Child unwell
Barking cough
Basically
well child
No
See
Asthma
No other
significant
features
Wheeze, rapid
breathing
Nocturnal
or exercise
induced
cough
Consult MO
See
Whooping
cough /
pertussis
No other
significant
features
Apnoea
Paroxysmal
cough
whoop
Paediatric presentation
Slow onset
See
Croup / epiglottitis
Rapid onset
Weak or no cough
Temp >38.5C
Septicaemia
Drooling saliva
Unable to eat or drink
Doesnt talk
Any age
Reluctant to move neck
As the condition
deteriorates the stridor
may decrease
See
Croup / epiglottitis
See
Anaphylaxis
See
Acute upper airway
obstruction / choking
Consult MO
In the meantime, consider epiglottitis
Yes
No
Obtain full history, including Hib immunisation status. Limit examination. Do not examine mouth or throat
Stridor is a harsh vibrating sound originating from the large upper airways and occurring on inspiration. It occurs due to upper airway
obstruction. Consider the following causes: croup common, inhaled foreign body, epiglottitis rare but important, trauma, angioneurotic
oedema, mass (tumour or abscess)
Paediatric presentation
555
556
Cough
Rapid
breathing
Fever
May have
history of URTI
like illness
Tachycardia
No other
significant
features
See
Pneumonia
Headache,
photophobia
+/-
Neck stiffness
+/Rash
See
Meningitis
Chest
recession
Child unwell
Child unwell
See
Acute
gastroenteritis
No other
significant
features
Fever
Diarrhoea
Basically well
child
See
UTI
No other
significant
features
Positive
urinalysis
Dysuria
frequency
smelly urine
No
See
Pyloric
stenosis
No other
significant
features
Weight loss or
poor gain
Projectile
vomits,
hungry
following
feed
Intussusception
See
No other
significant
features
Red currant
jelly stool
Abdominal
pain
intermittently
3 mths - 3 yrs
Yes
See Gastroesophageal
reflux
No other
significant
features
Vomiting and
irritable after
feeds
Unweaned
Well baby
See
Diabetes
Ketones on
urinalysis
High
capillary BGL
Moderate or
severe
dehydration
Child unwell
Vomiting is a common and important symptom, which may indicate serious illness especially in a very young child.
Consider the following causes: infection (pneumonia, UTI, meningitis, otitis media), obstruction (pyloric stenosis, intussusception, appendicitis,
hernia), reflux oesophagitis, raised intracranial pressure (trauma, abscess or tumour), metabolic (diabetic ketoacidosis, poisoning)
Paediatric presentation
Paediatric presentation
Yes
Yes
Consult MO
Yes
Consider UTI
See Urinary tract infection - child
Yes
Consider pneumonia
See Pneumonia - child
Yes
Consider gastroenteritis
See Child with vomiting / fever /
chronic diarrhoea
Yes
Consider constipation
See Constipation
No
Bile-stained vomiting?
Bloody stool?
Localised tenderness?
Distension?
Guarding?
Rebound tenderness?
Palpable mass?
Inguinal-scrotal pain or swelling?
No
Positive urine dipstick for
leukocytes, nitrates or blood;
or bacteria on microscopy
No
Fever +/Tachypnoea
Recession
Cough
Chest pains
No
Diarrhoea +/- vomiting / fever
No
Firm stool palpable in lower abdomen?
No
Consult MO
557
Paediatric presentation
Yes
Consult MO
Yes
Treat if positive
for giardia or
intestinal
worms.
Consult MO if
other +ve result
Yes
See Lactose
intolerance
No
Well hydrated, normal growth and
development, adequate diet
Is test positive?
No
Test for lactose intolerance
See Lactose intolerance
Is test positive?
No
Consider significant features
of asssessment
558
Perianal itch
Sighting of worms
in faeces
Foul smelling,
watery diarrhoea
Flatulence
Nausea
Bloody diarrhoea
Mucus in diarrhoea
Abdominal pain
See
Intestinal worms
See
Giardiasis
Consult
MO
Meningitis
Meningitis
Recommend
Consult MO immediately:
-- if a sick looking child has no obvious source of infection, which would explain
their symptoms - the diagnosis is meningitis until proven otherwise
-- if the child has been treated with antibiotics but is still not well (they may have
partly treated meningitis with masking of signs)
-- if the child is unwell with prolonged URTI symptoms
Restrict fluids to 50% of maintenance (10mg / kg) unless there are signs of shock MO to discuss as soon as possible with a Paediatrician
Parents or carers may notice early, subtle changes in the childs conscious state.
Their concerns should not be ignored
Perform hearing test 3 months after discharge from hospital
Background
Mortality is probably 5 - 10% in bacterial meningitis. Most children will make
a full recovery, if appropriately treated. Deafness is the most common long term
complication
Hyponatraemic solutions e.g. 4 % dextrose and one-fifth normal saline or one-quarter
normal saline, have no place in the management of meningitis as they may worsen
hyponatraemia and increase the risk of cerebral oedema [1]
Related topics
Fits / convulsions / seizures
Upper respiratory tract infection child
Immunisation program
2. Immediate management
onsult MO immediately
C
If altered level of consciousness See DRS ABCD resuscitation / the collapsed
patient
If fitting see Fits / convulsions / seizures
Give O2 to maintain O2 saturation >95%. If >95% not maintained consult MO.
See O2 delivery systems
Insert IV / IO cannula and take FBC, U/E, blood cultures, PCR for Neisseria
meningitis (meningococcal bacteria)
559
Meningitis
I n the critically ill, shocked or septic child with suspected meningitis e.g.
unresponsive, poorly perfused, purpuric rash, it is appropriate to first give a bolus
of intravenous or intraosseous fluids (initially 10 - 20 mL / kg of normal saline [1])
before giving antibiotics. Otherwise restrict total fluids to 10 mL / kg.
MO to consult as soon as possible with Paediatrician
3. Clinical assessment
4. Management
5. Follow up
560
equipped hospital
Notify the Public Health Unit of any suspected case of bacterial meningitis as
soon as possible
Chemoprophylaxis will be required for close contacts of a patient with either
meningococcal or Hib meningitis. Unvaccinated contacts of Hib meningitis <5
years should be immunised as soon as possible - Public Health Unit will advise
Arrange paediatric follow up, after discharge from hospital
Perform hearing test 3 months after discharge
Controlled copy V1.0
Respiratory problems
6.
Referral / consultation
References
1.
The Royal Childrens Hospital. Fluid management in meningitis. 2005 [cited 2011 March ].
2.
The Royal Childrens Hospital. Meningitis guideline. 2009 [cited 2011 March ].
3.
Therapeutic Guidelines. Meningitis: empirical therapy (organism or susceptibility not yet known). 2010
[cited 2011 March].
Recommend
Remember the symptoms and signs of an upper respiratory tract infection (URTI)
may be a precursor to more serious illnesses such as meningitis
Always be alert to the relationship between group A streptococcal sore throat and ARF
/ APSGN. These complications are common and serious but potentially avoidable in
Aboriginal and Torres Strait Islander children
Ten (10) days of oral antibiotics, or one dose of benzathine penicillin IM, is required
to eradicate group A streptococcus
Background
The vast majority of URTI are caused by viruses and do not require antibiotics.
However a viral URTI can be complicated by secondary bacterial infection such as
otitis media or pneumonia, requiring antibiotics
Other complications include exacerbation of asthma
Related topics
Meningitis
Immunisation program
Pneumonia
Acute otitis media
561
Respiratory problems
-- p
alpate the head and neck for enlarged lymph glands
-- auscultate the chest for air entry and any added sounds - crackles or wheezes
-- inspect all skin surfaces for any skin rash especially at pressure points and
under nappies and clothing Note: petechiae and purpura do not fade on
pressure
Check vaccination status. See Immunisation program
4. Management
onsult MO if
C
-- < 3 months of age
-- < 1 year with respiratory rate more than 40 respirations per minute (rpm)
1 - 2 years more than 35 rpm
2 - 5 years more than 30 rpm
5 - 12 years more than 25 rpm
12 years and older more than 20 rpm
respiratory distress or apnoea
-- if child looks sick, not alert or interactive and has temperature over 38C
-- if child still looks sick when temperature reduced
-- if child has any rash
-- if child has a cough productive of mucopurulent sputum, may need further
investigations for possibility of chronic respiratory disease
-- if child has tonsillitis and is sick
If child has cough as the main feature; consider other diagnoses. See Pertussis
(whooping cough), croup, acute asthma
If child has an increased respiratory rate, or any chest findings consider other
diagnoses. See Bronchitis / pneumonia
If child has evidence of secondary ear infection. See Acute otitis media
For the child with URTI, indications for antibiotic treatment are:
-- sore throat and red swollen tonsils, with or without pus, with fever (>38C)
and local lymphadenitis
-- sore throat with red swollen tonsils in a child with existing rheumatic heart
disease
-- Scarlet fever - has a characteristic and striking red blanching rash and
strawberry tongue due to streptococcal infection; rash usually starts after the
sore throat and lasts a week
-- Quinsy (severe infection of the tonsils causing massive enlargement). If
quinsy is present, consult MO (may need evacuation / hospitalisation for IV
penicillin and / or surgical drainage of pus)
For the child with uncomplicated URTI, treatment is symptomatic [1]:
-- encourage rest and increase fluid intake
-- paracetamol for analgesia if uncomfortable (do not use aspirin in children)
-- topical nasal decongestants can be helpful for sleeping and eating particularly
in young infants; however their use should be limited to short periods of time
(5 days max.). Nose drops of normal saline or cool boiled water can also be
helpful and are safe
-- other symptomatic treatments, nebulised saline, and lemon and honey drinks
may have some subjective benefit in some children
See Simple analgesia back cover
562
Respiratory problems
For the child with indicators for antibiotic treatment present and if not allergic treat
with oral penicillin:
DTP
IHW / SM R&IP / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NP
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed
Route of
Recommended
Form
Strength
Duration
administration
dosage
250 mg
Child
Capsule
500 mg
Oral
15 mg / kg / dose bd
10 days
Suspension 150 mg / 5 mL
to a max. of 500 mg bd
Provide Consumer Medicine Information: should be taken on an empty stomach; to 1 hour before meals.
Ensure full course is completed
Management of associated emergency: as for severe allergic reactions See Anaphylaxis
[1]
Schedule
Phenoxymethylpenicillin
Benzathine penicillin
DTP
(Bicillin LA)
IHW / SM R&IP / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NP
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed
Route of
Recommended
Duration
Form
Strength
administration
dosage
3 kg - < 6 kg 225 mg
6 kg - < 10 kg 337.5 mg
Disposable
10 kg - < 15 kg 450 mg
Stat
900 mg
IM
syringe
15 kg - < 20 kg 675 mg
>20 kg 900 mg
Use a concentration of 442 mg / mL when measuring part doses. Refer to product information
Provide Consumer Medicine Information
Management of associated emergency: as for severe allergic reactions See Anaphylaxis
Administration tips - as per patient preference:
-- apply EMLA cream to the injection site 30 - 60 minutes prior to injection and allow medication to warm
up to room temperature or
-- allow medication to warm up to room temperature, apply pressure with thumb (to the exact injection
site) 30 seconds prior to the injection, use 21 gauge needleand deliver injection very slowly (2 minutes)
[1]
Schedule
563
Respiratory problems
DTP
IHW / SM R&IP / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NP
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed
Route of
Recommended
Form
Strength
Duration
administration
dosage
Tablet for
50 mg
Child
suspension
Oral
4 mg / kg / dose bd
10 days
150 mg
Tablet
to a max. of 150 mg bd
300 mg
Provide Consumer Medicine Information: should be taken on an empty stomach, 15 minutes before food;
ensure course is completed
Management of associated emergency: consult MO
[1]
Schedule
Roxithromycin
5. Follow up
R
eview next day, if not improving consult MO
If antibiotics have been given for sore throat:
-- r eview in 2 weeks
-- ask about sore joints, chest pain, breathlessness and check urinalysis
-- consult MO if symptoms persist see Rheumatic fever or if abnormal urinalysis
see Acute post streptococcal glomerulonephritis
6. Referral / consultation
C
onsult MO as above or if symptoms persist despite symptomatic treatment
If recurrent tonsillitis (>6 episodes per year) MO may consider prolonged course
564
Respiratory problems
URTI symptoms
Cough (typically paroxysmal i.e. intermittent episodes of prolonged coughing
followed by the characteristic inspiratory whoop as the child catches his / her
breath)
Vomiting, typically after an episode of coughing
Cyanosis, typically during an episode of coughing
Young babies usually do not have the characteristic whoop but are likely to be very
distressed by coughing and vomiting. They can develop apnoea (stop breathing)
and become cyanosed during a coughing bout
Adults usually have a persistent troublesome cough only, without a whoop. A
cough of several weeks duration, that is worse at night, in an adult, is pertussis
until proven otherwise
2. Immediate management
3. Clinical assessment
4. Management
5. Follow up
6. Referral / consultation
Consult MO on all occasions whooping cough is suspected
565
Respiratory problems
Croup / epiglottitis
Recommend
Keep the child as calm as possible
Do not examine the mouth or throat and do not lie the child flat
Background
Croup usually follows 3 or 4 days of a mild URTI when the infection spreads to affect
the upper airways; it is usually mild and self limiting
Epiglottitis (cellulitis of the epiglottis) is caused by Haemophilus influenza type B
infection and is fatal if untreated. It is rare since Hib vaccination was introduced
Related topics
Acute upper airway obstruction and choking
Acute epiglottitis
-- weak or no cough
-- temperaure >38.5C
-- septicaemia
-- looks sick
-- drooling saliva
-- unable to eat or drink
-- doesnt talk
-- any age
-- reluctant to move neck
Croup
-- croupy (barking) cough
-- temperature <38.5C (however viral croup
often has a high temperature)
-- no systemic disturbance
-- able to swallow
-- will usually drink
-- normal or hoarse voice
2. Immediate management
3. Clinical assessment
566
Respiratory problems
4. Management
Consult MO
If epiglottitis:
-- have the parents / carer stay with child to comfort
-- handle the child as little as possible
-- MO will organise evacuation by skilled MO with paediatric airway management
and IV insertion for IV ceftriaxone [4]
If croup:
-- symptomatic treatment as per URTI
-- for mild to moderate cases MO may advise:
prednisolone 1 mg / kg / dose stat with a second dose for the next
evening or
a single dose of oral dexamethasone 0.15 mg / kg / dose
-- for severe cases MO may advise:
0.6 mg / kg / dose (max. 12 mg) IM / IV dexamethasone
5 mL of adrenaline 1:1,000 solution via nebuliser [5]
evacuation / hospitalisation
5. Follow up
If child with croup is not evacuated / hospitalised, review next day and consult MO
if not improving
6. Referral / consultation
Bronchiolitis
Recommend
Consult MO immediately if severe
Background
In bronchiolitis, generally the child is distressed without looking sick or toxic
A viral infection of the chest affecting infants <12 months of age
Can occur throughout the year in north Queensland (in southern Australia more
common in winter - spring)
More significant in babies < 4 months of age and those with underlying heart or lung
problems
Related topics
Acute asthma
Upper respiratory tract infection - child
Pneumonia
2. Immediate management
Consult MO
If severe give O2 to maintain O2 saturation >95%. If >95% not maintained consult
MO. See O2 delivery systems
567
Respiratory problems
3. Clinical assessment
4. Management
5. Follow up
P
atients who are not evacuated / hospitalised should be reviewed daily
Consult MO if the patient is not improving
6. Referral / consultation
Consult MO on all occasions bronchiolitis is suspected
Pneumonia - child
Recommend
If baby < 3 months of age contact MO immediately
Severe dehydration is unusual in pneumonia unless there are abnormal fluid losses
from frequent diarrhoea or vomiting
Background
Children with co-existent illnesses are more at risk. Examples are bronchiolitis and
chronic lung disease e.g. due to prematurity
Related topics
Upper respiratory tract infection - child
Immunisation program
Bronchiolitis
568
Respiratory problems
2. Immediate management
3. Clinical assessment
4. Management
onsult MO using the following flow chart as a guide only, to be used in conjunction
C
with CEWT for rural and remote facilities
Child
< 3 months
Contact MO
immediately
Child
3 months - 1 yr
Child
1 - 4 yrs
Child
over 4 yrs
Resps
Resps
Resps
Resps
40 / min
30 / min
25 / min
40 / min
and / or
and / or
and / or
and / or
Resps
Resps
Resps
Resps
recession
recession
recession
recession
<40 / min
<40 / min
<30 / min
<25 / min
grunting
grunting
grunting
grunting
apnoea
apnoea
apnoea
apnoea
cyanosis
cyanosis
cyanosis
cyanosis
Moderate
or severe
pneumonia
569
Respiratory problems
Mild pneumonia
MO may advise:
-- chest x-ray if available
-- oral or IM antibiotics
-- antibiotics may not be indicated if typical of viral infection or bronchiolitis
Encourage rest and increase oral fluids
Treat fever with regular paracetamol to make more comfortable
Moderate / severe pneumonia
Give O2 to maintain O2 saturation >95% (if not already in place). If > 95 % not
maintained consult MO. See O2 delivery systems
Give oral fluids as tolerated
MO may advise:
-- insert IV cannula - if possible take blood cultures prior to commencing
antibiotics
-- IV fluids - it is usual to start with normal saline or Hartmanns solution; MO will
advise quantities and rate
-- to commence IV antibiotics
Evacuation / hospitalisation
Give analgesia
See Simple analgesia back cover
5. Follow up
Patients with mild pneumonia who are not evacuated / hospitalised should be
reviewed daily
C
onsult MO if the patient is not improving
See next MO clinic
6. Referral / consultation
C
onsult MO on all occasions pneumonia is suspected
Some children with pneumonia will require a paediatric referral
References
1.
Therapeutic Guidelines. Pharyngitis and/or tonsillitis. 2010 [cited 2011 January].
2.
Queensland Health, Expansion of Free Pertussis Vaccine Program, in Immunisation Program. 2011:
Brisbane.
3.
Therapeutic Guidelines. Pertussis. 2010 [cited 2011 March].
4.
Therapeutic Guidelines. Acute epiglottitis (supraglottitis). 2010 [cited 2011 March].
5.
The Royal Childrens Hospital. Croup (Laryngotracheobronchitis). 2009 [cited 2011 March ].
570
Immune complications
Recommend
Early treatment of skin infections is essential for prevention of acute post-streptococcal
glomerulonephritis (APSGN)
Background
APSGN is common among Aboriginal and Torres Strait Islander children in northern
Australia
Inflammation of the kidneys results from immune complexes forming after a group A
streptococcal infection causing blood to not filter properly and blood cells and protein
leaking into urine
Related topics
Bacterial skin infections
2. Immediate management
3. Clinical assessment
103 106
56 61
111
69
114
74
> 17years
16 years
14 years
8 years
116
78
12 years
systolic
diastolic
10 years
BP upper level
of normal
6 years
4 years
2 years
1 year
119
80
571
Immune complications
2 years
4 years
6 years
8 years
10 years
12 years
14 years
16 years
> 17years
BP
upper level
of normal
1 years
104
105
108
111
115
119
123
126
128
129
diastolic
58
63
70
74
76
78
80
82
84
84
572
Consult MO who:
--
will advise to treat streptococcal infection with IM benzathine penicillin
[3] regardless of whether skin sores / sore throat are present at the time
of presentation or not; or if allergic to penicillin a full 10 day course of oral
roxithromycin [3]
-- may advise to treat hypertension and / or heart failure (initial treatment is
usually frusemide)
All cases with hypertension should be evacuated / hospitalised
Restrict fluids and salt intake (usually patient is fluid overloaded)
Notify all cases of APSGN to the Public Health Unit
Immune complications
Benzathine penicillin
DTP
(Bicillin LA)
IHW / SM R&IP / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NP
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed
Route of
Recommended
Form
Strength
Duration
administration
dosage
3 kg - < 6 kg 225 mg
6 kg - < 10 kg 337.5 mg
Disposable
900 mg
IM
10 kg - < 15 kg 450 mg
Stat
syringe
15 kg - < 20 kg 675 mg
20 kg > 900 mg
Use a concentration of 442 mg / mL when measuring part doses. Refer to product information
Provide Consumer Medicine Information
Management of associated emergency: as for severe allergic reactions See Anaphylaxis
Administration tips - as per patient preference:
-- apply EMLA cream to the injection site 30 - 60 minutes prior to injection and allow medication to warm
up to room temperature or
-- allow medication to warm up to room temperature, apply pressure with thumb (to the exact injection
site) 30 seconds prior to the injection, use 21 gauge needleand deliver injection very slowly (2 minutes)
[1]
Schedule
DTP
IHW / SM R&IP / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NP
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed
Route of
Recommended
Form
Strength
Duration
administration
dosage
Tablet for
50 mg
Child
suspension
Oral
4 mg / kg / dose bd
10 days
150 mg
Tablet
to a max. of 150 mg bd
300 mg
Provide Consumer Medicine Information: should be taken on an empty stomach, 15 minutes before food.
Ensure full course is completed
Management of associated emergency: consult MO
[1]
Schedule
Roxithromycin
573
Immune complications
5. Follow up
M
ost children will require evacuation / hospitalisation
If not evacuated / hospitalised the child requires close follow up with daily review
R
efer to next MO clinic
Following discharge, most children will require at least monthly weight, BP and
6. Referral / consultation
C
onsult MO on all occasions of suspected glomerulonephritis
Most will need paediatric referral and follow up
If C3 does not return to normal refer to Paediatrician
References
1.
National High Blood Pressure Education Program Working Group on High Blood Pressure in Children
and Adolescents, The Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure
in Children and Adolescents. Pediatrics, 2004. 114 (2): p. 555.
2. Queensland Government. Acute Post-streptococcal Glomerulonephritis Control of Communicable
Diseases Protocol Manual 2009 [cited 2011 May]; Available from: qheps.health.qld.gov.au/cdpm/index/
apsgn.htm.
3.
Therapeutic Guidelines. Impetigo. 2009 [cited 2010 December].
574
Immune complications
575
Immune complications
3. Clinical assessment
576
Immune complications
Australian guidelines for the diagnosis of Acute rheumatic fever in high risk groups [1]
For an initial episode of ARF to be confirmed there must be 2 major manifestations or 1 major and 2
minor manifestations, plus evidence of a recent group A streptococcal infection.
Since Sydenhams chorea can occur after all other signs and symptoms have resolved, it can be used
alone to confirm the diagnosis
A recurrent episode of ARF (known past ARF or chronic RHD) requires 2 major or 1 major and 2 minor
or 3 minor manifestations plus evidence of a recent GAS infection
Major manifestations
Minor manifestations
Polyarthritis or aseptic monoarthritis or
History of fever or presenting fever >38C
polyarthralgia. Usually migratory i.e. finishes
Laboratory / other clinical findings:
in one joint, begins in another
-elevated acute phase reactants - ESR
Chorea - strange jerky movements of the
30 mm/hr or CRP 30 mg / L
trunk and / or limbs which the patient cannot
-prolonged PR interval on ECG
control
Carditis - (including subclinical evidence of
rheumatic valve disease on echocardiogram)
Erythema marginatum - pink skin rash with
definite rounded borders, occurring mainly
on the trunk, never on the face, and blanches
under pressure
Subcutaneous nodules - small painless pea
sized nodules over bony prominences (e.g.
elbows)
Carditis identified on echocardiogram may
be included as a major manifestation [1]
Supporting evidence of group A streptococcal infection
Group A streptococcus isolated on throat culture
Elevated or rising streptococcal antibody titre. See link for age related levels www.heartfoundation.
org.au/Professional Information/Clinical Practice/ARF RHD/Pages/default.aspx
These serological titres are often high at baseline in Aboriginal and Torres Strait Islander community
children because of repeated infections with GAS. So acceptable evidence for recent GAS infection are
either:
-- titres of > 2 x reference e.g. ASOT > 400 IU / mL or Anti-DNase B > 600 U / mL or
-- a rising titre when repeated after 10 - 14 days
4. Management
577
Immune complications
DTP
IHW / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NP
Route of
Recommended
Form
Strength
Duration
administration
dosage
Schedule
Disposable
syringe
Stat
Adult / child 20 kg
900 mg
Use a concentration of 442 mg / mL when measuring part doses. Refer to product information
Provide Consumer Medicine Information
Management of associated emergency: as for severe allergic reactions. See Anaphylaxis
Administration tips - as per patient preference:
-- apply EMLA cream to the injection site 30 - 60 minutes prior to injection and allow medication to warm
up to room temperature or
-- allow medication to warm up to room temperature, apply pressure with thumb (to the exact injection
site) 30 seconds prior to the injection, use 21 gauge needleand deliver injection very slowly (2 minutes)
[1] [2]
900 mg
Child < 20 kg
450 mg
IM
DTP
IHW / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NP
Schedule
Form
Strength
Capsule
250 mg
Suspension
200 mg / 5 mL
Erythromycin
Route of
administration
Recommended
dosage
Duration
500 mg bd
Oral
20 mg / kg / dose bd
to a max. of 500 mg bd
10 days
5. Follow up
578
Immune complications
presence of RHD
Place person on Recall Register and monitor closely
Recommended duration of secondary prophylaxis.
Provide education and support to patient and family. Resources available include;
Strong Heart, Strong Body books, DVD and reminder cards (from Tropical Public
Health)
Contact the ARF / RHD Control Program (arfregister@health.qld.gov.au) in your
district or Public Health Unit for help, even if ARF only suspected
Antenatal patients with RHD may deteriorate because of the increased cardiac
workload during pregnancy. Pregnant women known to have RHD need to be
assessed early in pregnancy and monitored closely with 2 weekly follow up.
The woman will also need antibiotic cover if prolonged labour and / or ruptured
membranes [1]
Primary prevention:
-- have a low threshold for treating throat infections with penicillin in Aboriginal
and Torres Strait Islander and Pacific Islander children. See URTI - child /
URTI - adult
-- reduce the prevalence of scabies and impetigo
Give influenza and pneumococcal vaccines according to the current edition of the
NHMRC Australian Immunisation Handbook. See Immunisation program
6. Referral / consultation
References
1.
National Heart Foundation, RF/RHD Guideline Development Working Group, and Cardiac Society of
Australia and New Zealand, Diagnosis and management of acute rheumatic fever and rheumatic heart
disease in Australia: An evidence based review. 2006, National Heart Foundation Australia.
2.
Therapeutic Guidelines. Rheumatic fever in children. 2010 [cited 2011 January].
579
Ear problems
Examination
Outer ear
Inspect the external ear - is there any sign of inflammation?
Palpate the ear - is it warm to touch? Is there pain on moving the pinna?
Palpate behind the ear? Is the mastoid bone swollen? hot?
Palpate the occiput, around the ears, both sides of the neck for lymph glands
Is there auricular tenderness? pain? tenderness on palpation of mastoid?
Ear canal
Inspect the ear canal for discharge, redness / swelling, fungal membrane or debris,
lumps or bony growths, foreign body, extruding grommets, wax, fluid
If pain levels allow, inspect the ear canal for inflammation, exudates, lesions or foreign
bodies
Tympanic membrane (ear drum)
Colour of drum - is it normal - transparent and shiny, or dull?
Cone of light - right ear at 5 oclock, left ear at 7 oclock
Handle of malleus - right ear 1 oclock, left ear 11 oclock
Is the ear drum intact? bulging? retracted?
Is there fluid or air / fluid or bubbles behind the ear drum?
Right
580
Left
Ear problems
Clean the ear using tissue spears until all pus has been removed and the drum and
perforation can be seen. Document the size and position of perforation on a diagram
in the case notes. If an unsafe perforation (in the attic region) of the ear drum is
found consult MO immediately
Attic perforation - unsafe perforation
Safe perforation
Related systems
Nose and throat
Examine the nose and throat - is there any discharge from nose? describe
Chest
Auscultate the chest for air entry and any added sounds (crackles or wheezes)
Note other injuries if present e.g. cause of traumatic rupture of the ear drum
Hearing screening and assessment commences from birth across the life span. Refer to
current edition of Chronic Disease Guidelines available at www.health.qld.gov.au/cdg for
procedures in performing:
Otoscopy
Audiometry to assess hearing level
Tympanometry to test middle ear function
If a person is under the care of an Ear Nose and Throat Specialist or Audiologist ensure
they are up to date with appointments / care
581
Ear problems
Ear infections
Recommend
Language and speech develop in the 0 - 5 year age group. Assessment for possible
middle ear disease, hearing impairment and speech and language problems should
be a routine part of the primary care of children aged 0 - 5 years
Prevention of otitis media through [1]:
-- encouraging family or care giver to present child for treatment early if there are
features of otitis media. Informing family of risk if child is in a high risk group
(includes Aboriginal and Torres Strait Islander children)
-- informing family and carers that onset of otitis media can occur within the first
months of life. Baby may have pain, irritability, fever or ear discharge
-- there is an increased risk of acute otitis media during respiratory infections
-- the family or care giver should be advised that ear pain may be absent and that
regular clinic attendance for ear examinations is recommended
-- personal hygiene - childrens hands and faces should be washed. Transmission
of bacteria causing otitis media is often from other childrens hands
-- breastfeeding for at least three months reduces the risk of otitis media and should
be encouraged
-- smoke exposure is a risk for otitis media in children. Adults should be encouraged
to quit smoking or smoke outside away from children
-- swimming should not be discouraged unless it is known to be associated with
new infections in that person
-- full immunisation; 23 valent pneumococcal vaccine (Pneumovax 23) for children
4 - 5 years of age who are at risk of pneumococcal infections
Definitions [1]
Acute otitis media (AOM) - presence of fluid behind the ear drum plus at least one of
the following: bulging ear drum, red ear drum, recent discharge of pus, fever, ear pain
or irritability
Recurrent acute otitis media (rAOM) - the occurrence of three or more episodes of
acute otitis media in a six month period
Otitis media with effusion (OME, glue ear) - presence of fluid behind the ear drum
without any symptoms or signs of acute otitis media
Acute otitis media with acute perforation (AOM with perforation less than 6 weeks) discharge of pus through a perforation (hole) in the ear drum within the last six weeks
Chronic suppurative otitis media (CSOM discharging more than 6 weeks) - persistent
discharge of pus through a perforation (hole) in the ear drum for at least six weeks
despite appropriate treatment for acute otitis media with perforation
582
Ear problems
Recommend
Consult MO immediately if child is < 3 months of age, who is sick or hot, or meets
any of the other criteria outlined at beginning of paediatric section
All children with AOM should be reviewed after four to seven days of treatment or
earlier if deterioration [1]. A second review should take place after completion of
therapy [1]
Health clinics have targeted hearing health programs to focus on day care and pre
school children where intervention may prevent ear damage and hearing loss
Personal hygiene in children - washing hands and face is important
Background
In some rural and remote Aboriginal communitites complications of otitis media
are much more common. They include tympanic membrane perforations, CSOM,
OME and mastoiditis. This is the reason that antibiotics are recommended in these
children, while in low risk populations the advantage of antibiotics is small
Related topics
Upper respiratory tract infection - child
Pneumonia
Acute asthma
Bronchiolitis
Assessment of the ear
4. Management
onsult MO if child:
C
-- < 3 months of age, who is sick or hot
-- temperature over 38 C or below 36C
-- has any rash, increased respiratory rate or respiratory distress or meets any
of the other criteria as outlined at beginning of paediatric section - this child
needs to be managed as a septic infant
Spontaneous resolution of AOM is unlikely in high risk populations therefore if not
allergic to penicillin treat with amoxycillin [1]
583
Ear problems
Talk to the family about the need to complete the full course of antibiotics and to
return at 4 - 7 days for the ear to be checked
Give or help to give the first dose in the clinic and ensure the family know the right
dose to give. If family do not have a fridge at home they may have to return to the
health service for medicine each day
DTP
IHW / SM R&IP / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NP
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed
Route of
Recommended
Form
Strength
Duration
administration
dosage
250 mg
Capsule
Adult and child
500 mg
Oral
25 mg / kg / dose bd
7 days
125 mg / 5 mL
Suspension
to a max. of 1 g bd
250 mg / 5 mL
Provide Consumer Medicine Information
Management of associated emergency: as for severe allergic reactions. See Anaphylaxis
[4] [6]
Schedule
Amoxycillin
I f parent or Health Care Worker think it will be difficult to comply with oral antibiotics
or if the child has significant diarrhoea or vomiting, treat with IM procaine penicillin
with the option to return to oral antibiotic once vomiting settles
DTP
IHW / SM R&IP / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NP
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed
Route of
Recommended
Duration
Form
Strength
administration
dosage
Adult
1.5 g daily
Disposable
5 days
1.5 g
IM
Child
syringe
50 mg / kg / dose daily
to a max. of 1.5 g daily
Provide Consumer Medicine Information
Management of associated emergency: as for severe allergic reactions. See Anaphylaxis
Administration tips - as per patient preference:
-- apply EMLA cream to the injection site 30 - 60 minutes prior to injection and allow medication to warm
up to room temperature or
-- allow medication to warm up to room temperature, apply pressure with thumb (to the exact injection
site) 30 seconds prior to the injection, use 21 gauge needleand deliver injection very slowly (2 minutes)
[3] [4]
Schedule
584
Procaine penicillin
Ear problems
DTP
IHW / SM R&IP / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NP
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed
Route of
Recommended
Form
Strength
Duration
administration
dosage
150 mg
Adult
Tablet
300 mg
300 mg daily
Oral
10 days
Child
Tablet for
50 mg
4 mg / kg / dose bd
suspension
to a max. of 150 mg bd
Provide Consumer Medicine Information: should be taken on an empty stomach, 15 minutes before food.
Ensure course is completed
Management of associated emergency: consult MO
[5]
Schedule
Roxithromycin
5. Follow up
R
eview the patient in 4 - 7 days
If not improving consult MO who may consider alternative or increased dose of
antibiotic
At next MO visit. If child not improved needs weekly review. Child < 2 years of
age may need many weeks of antibiotics [6]
Review after completion of treatment at the 1 week mark
Ask family about childs hearing, speech development, behaviour, school progress.
If there are concerns about any of these refer for formal hearing assessment if not
done recently
To prevent recurrent otitis media and transmission of bacteria to other children
encourage personal hygiene in children - washing hands and face
Breathe, blow and cough (BBC) program is targeted at school aged children
Review at 3 months to identify those with chronic disease [1]
6. Referral / consultation
C
onsult MO as above
If otitis media is recurrent (more than 3 episodes in 6 months or more than 4 in 12
585
Ear problems
Recommend
Review children with bilateral OME at 3 monthly intervals and refer if required
Health clinics have targeted hearing health programs to focus on day care and
pre school children where intervention may prevent ear damage and hearing loss.
Personal hygiene in children - washing hands and face and keeping face clear of
nasal discharge is most effective
Provide full immunisation
Background
OME is diagnosed if thick fluid persists in the middle ear usually after AOM
OME results in thick glue like material filling the middle ear which may take many
months to resolve. It is important because children with OME will have impaired
hearing. If hearing is impaired for a significant length of time especially at the critical
age of language learning in the first 5 years it may result in significant long term
disability
Decongestants and antihistamines are not recommended [7]
Steroids are not recommended [1] but inhaled steroids may be trialed in children
where significant nasal obstruction, sneezing etc. suggests allergic rhinitis
Related topics
Acute otitis media
Immunisation program
Usually is asymptomatic
Parents may be concerned about the childs hearing
Diagnosis may also be suspected at routine ear examination, in a child being
followed up after AOM, or in a child referred for medical assessment because of
hearing impairment on testing
Child may have:
-- past history of recurrent otitis media
-- concerns about speech or language development
Reported decrease in hearing
Reported poor hearing leading to learning difficulties
586
Ear problems
4. Management
Give amoxycillin
Arrange for audiology if there are concerns about hearing or speech or OME is
persistent for > 3 months
Refer to ENT specialist:
-- if hearing test shows moderate impairment in both ears for more than 3
months
-- if there is speech delay and effusion persists more than 3 months or
-- if there is more severe hearing impairment or concerns about the appearance
of the drum
Encourage personal hygiene in children - washing hands and face and keeping
face clear of nasal discharge
Breathe, blow, cough (BBC) program is for school aged children
Check immunisation status particularly Pneumovax and perform catch up
immunisation if required
DTP
IHW / SM R&IP / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NP
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed
Route of
Recommended
Duration
Form
Strength
administration
dosage
250 mg
Capsule
Adult and child
500 mg
Oral
25 mg / kg / dose bd
14 days
125 mg / 5 mL
Suspension
to a max. of 1 g bd
250 mg / 5 mL
Provide Consumer Medicine Information
Management of associated emergency: as for severe allergic reactions. See Anaphylaxis
[4] [6]
Schedule
Amoxycillin
5. Follow up
3
monthly
If OME persists for > 3 months arrange - audiometry and tympanometry
See the current edition of the Chronic Disease Guidelines available at:
www.health.qld.gov.au/cdg
6. Referral / consultation
N
ext MO visit
Refer to ENT specialist if:
587
Ear problems
4. Management
588
Ear problems
Amoxycillin
[4]
If parent or Health Care Worker thinks it will be very difficult to comply with oral
antibiotic treatment or if the child has significant diarrhoea or vomiting, treat with
IM procaine penicillin with the option to return to oral antibiotic once vomiting
settles
DTP
IHW / SM R&IP / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NP
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed
Route of
Recommended
Duration
Form
Strength
administration
dosage
Adult
1.5 g daily
Disposable
5 days
1.5 g
IM
Child
syringe
50 mg / kg / dose
to a max. of 1.5 g daily
Provide Consumer Medicine Information
Management of associated emergency: as for severe allergic reactions. See Anaphylaxis
Administration tips - as per patient preference:
-- apply EMLA cream to the injection site 30 - 60 minutes prior to injection and allow medication to warm
up to room temperature or
-- allow medication to warm up to room temperature, apply pressure with thumb (to the exact injection
site) 30 seconds prior to the injection, use 21 gauge needleand deliver injection very slowly (2 minutes)
[4]
Schedule
Procaine penicillin
589
Ear problems
If allergic to penicillin and has perforation for less than 6 weeks treat with
roxithromycin
DTP
IHW / SM R&IP / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NP
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed
Route of
Recommended
Form
Strength
Duration
administration
dosage
150 mg
Adult
Tablet
300 mg
300 mg daily
Oral
10 days
Child
Tablet for
50 mg
4 mg / kg / dose bd
suspension
to a max. of 150 mg bd
Provide Consumer Medicine Information: should be taken on an empty stomach, 15 minutes before food.
Ensure course is completed
Management of associated emergency: consult MO
[5]
Schedule
Roxithromycin
If discharge present for longer than 14 days MO may add ciprofloxacin drops
Ciprofloxacin hydrochloride
DTP
ear drops
IHW
Ciprofloxacin hydrochloride ear drops must be ordered by MO / NP. MO / NP note restrictions
Authorised Indigenous Health Workers can only administer on MO / NP order
Route of
Recommended
Form
Strength
Duration
administration
dosage
Ear drops
Instil 5 drops in
Until the ear is dry
Ear drops
Topical
(0.3%)
affected ear bd
or 9 days
Provide Consumer Medicine Information: if not drying in 2 weeks check with family on ability to clean and
instil drops
Management of associated emergency: as for severe allergic reactions. See Anaphylaxis
Administration tip
-- The patient should be sitting or lying down with the affected ear upwards
-- Once the drops have been instilled maintain position for 30 - 60 sec.
-- Apply tragal pressure (pressing several times on the flap of skin in front of ear canal) after the drops
have been instilled to assist the drops through the perforation
[8]
Schedule
5. Follow up
590
Ear problems
6.
Referral / consultation
C
onsult MO as above
If concerns about hearing, speech, language development or the child has had
Recommend
Consult MO immediately if unsafe perforation of the eardrum found (in the attic
region). See Assessment of the ear
Use antibiotic ear drops with tissue spears (dry mopping) to reduce the production
of pus [1]
Document the duration of ear discharge and size and position of perforation [1]
Treat discharging ears actively
Background
CSOM is diagnosed in children who have discharging ears for more than 6 weeks [1]
Related topics
Acute otitis media with perforation
Chronic suppurative otitis media
(CSOM)
Cholesteatoma
Cleaning technique for ears with chronic
discharge
Assessment of the ear
Intermittent and continuous ear discharge often associated with poor hearing
leading to learning difficulties
2. Immediate management
3. Clinical assessment
4. Management
Dry mopping twice daily until tissue is dry, followed by ciprofloxacin ear drops
twice per day
1. Ciprofloxacin ear drops
2. Use Sofradex ear drops only if ciprofloxacin drops not available
Consult MO for ciprofloxacin order
For removal of pus and debris from ear canal See Cleaning techniques for ears
with chronic discharge
591
Ear problems
I n young children it may be difficult for family members to adequately clean the
ears and instil the drops - clinic staff are advised to do this daily for 7 days
Encourage personal hygiene in children - washing hands and face
Avoid swimming or immersing head under water
Consult MO if perforation found in attic region (unsafe perforation) of the ear drum
Ciprofloxacin hydrochloride
DTP
ear drops
IHW
Ciprofloxacin hydrochloride ear drops must be ordered by MO / NP. MO / NP note restrictions
Authorised Indigenous Health Workers can only administer on MO / NP order
Route of
Recommended
Form
Strength
Duration
administration
dosage
Instil 5 drops in
Until the ear is dry or
Ear drops
0.3 %
Topical
affected ear bd
9 days
Provide Consumer Medicine Information
Management of associated emergency: as for severe allergic reactions. See Anaphylaxis
Administration tip
The patient should be sitting or lying down with the affected ear upwards
Once the drops have been instilled maintain position for 30 - 60 secs
Apply tragal pressure (pressing several times on the flap of skin in front of ear canal) after the drops
have been instilled to assist the drops through the perforation
[8]
Schedule
or
592
Ear problems
5. Follow up
Children < 5 years of age, review and treat daily for 7 days. If not drying in older
children consider daily treatment in the clinic. Suction under direct vision is very
useful to clear the ear if clinics have the equipment and staff have experience and
training
If not improving consult MO
Teach patient / carer cleaning technique and instillation of drops
See next MO clinic
Review weekly thereafter until ear is dry
If the ear is still discharging, consult MO
When the ear dries review at 3 months
To prevent recurrent otitis media encourage personal hygiene in children - washing
hands and face
Breathe Blow Cough (BBC) program is targeted at school aged children
6. Referral / consultation
F
or hearing assessment - audiometry and tympanometry when ear dry
With education staff
Consult MO as above including a presentation with perforation in the upper drum
593
Ear problems
Suction under direct vision is the most effective technique but this requires special
equipment and training
Dropper method
The ear canal can be cleaned by irrigating with clean water using an eye dropper
An eye dropper uses a small volume of wash solution at low pressure and is therefore
relatively safe in unskilled hands
Eye droppers are cheap and easy to obtain and to clean for use at home
Equipment
A clean eye dropper and bulb. This can be washed with soap and water or an antiseptic
A clean container of clean water (sterile or cool boiled) (some rainwater tanks may be
contaminated)
Clean container for the dirty water from the ear
Technique
1. The patient should be sitting or lying down with the affected ear upwards
2. Using a clean dropper filled with clean water, squirt water into the discharging ear.
Only the tip of the dropper needs to be in the canal. Without withdrawing the dropper
and just by releasing the bulb, suck the water and pus back into the dropper
3. Discard the contents of the dropper into the container for dirty water. Do not squirt the
water in and out of the ear. When all the pus has been washed out of the ear, the water
sucked back into the dropper is clear
4. Repeat the above steps until there is clean return from the ear
5. Dry the ear canal using tissue spears (see details)
This can safely be done by a child on their own or by the parent. It should be done
whenever the ear discharges. The tissue paper actively absorbs the moisture
In the management of chronic suppurative otitis media, the tissue spear method should
be used in conjunction with regular eye dropper irrigation by the Health Care Worker
Technique
1. Make a spear by twisting corner of tissue paper
2. Insert into ear gently, twisting slowly
3. Stop when child blinks
4. Leave in place for 30 seconds then remove and repeat until tissue tip is dry
5. Perform at least twice per day until the ear is dry
594
he patient should be sitting or lying down with the affected ear upwards
T
Clean and dry the ear canal as per dropper method and tissue spears
Instil the ear drops
Apply tragal pressure (pressing several times on the flap of skin in front of ear canal)
after the drops have been instilled to assist the drops through the perforation [1]
Keep the patient in position for several minutes
Use of cotton wool as a plug just soaks up the medication. Let excess run out
Ear problems
4. Management
5. Follow up
As per MO instructions
Advise no swimming. If this is not possible in a hot tropical climate, ear plugs with
a swimming cap for swimming are recommended for children with grommets.
Effective ear plugs can be custom built or made from silicon putty, cotton wool
with Vaseline, or Blu-Tack
6. Referral / consultation
As above
Cholesteatoma
Recommend
Be aware of cholesteatoma when performing all otoscopic examinations
Cholesteatoma is treated surgically and success is highly dependent on early
recognition and the extent of the lesion
Background
Most patients who acquire cholesteatomas have a history of recurrent acute otitis
media and / or chronic middle-ear perforation
Patients with a family history of chronic middle ear disease and / or cholesteatoma
are at increased risk [9]
Related topics
Acute otitis media with perforation
595
Ear problems
2. Immediate management
3. Clinical assessment
4. Management
5. Follow up
If confirmed, surgical treatment is required
6. Referral / consultation
Acute mastoiditis
Recommend
Urgent referral to hospital with paediatric and ENT Specialist for management
Background
Mastoiditis is inflammation in the mastoid air cells and typically occurs after acute
otitis media
Related topics
Acute otitis media
2. Immediate management
Consult MO immediately
3. Clinical assessment
596
Ear problems
4. Management
5. Follow up
As per post discharge orders
6. Referral / consultation
Urgent referral to Paediatrician and ENT Specialist
Otitis externa
4. Management
entle cleaning with dry mopping to keep the ear canal dry, then installation
G
of drops or in severe cases, a wick soaked with sofradex or cortocosteriod +
antibiotic ointment to remove pus and debris. The ear should be kept dry for at
least two weeks after treatment [10]. Advise not to swim until healed
597
Ear problems
Topical - drops
3 drops tds
7 days
Topical - earwick
Soaked gauze
598
or
Ear problems
Ear drops
As above
Soaked gauze
[10]
or
Triamcinolone compound
DTP
(Kenacomb)
IHW / SM R&IP / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NP
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed
Route of
Recommended
Duration
Form
Strength
administration
dosage
Triamcinolone 0.1 %
Neomycin 0.25 %
Ointment
The wick is left in the canal
Ointment Gramicidino 0.025 % Topical - ear wick
soaked gauze
for 2 days then review
Nystatin 100,000
units / g
Provide Consumer Medicine Information
Management of associated emergency: consult MO
Administration tip - earwick
Remove the wick using forceps. Inspect and clean the ear. Reinsert if required
[4]
Schedule
5. Follow up
R
eview in 2 days and in 1 week
Advise not to swim and keep ears dry until healed
Next MO visit if ear canal not back to normal at 1 week, or if recurrent
6. Referral / consultation
O
titis externa can become chronic or recurrent, especially in hot humid climates
General prevention involves keeping the ear canal dry and protected by a lining
of wax. Use drying ear drops e.g. Aqua-ear / Vosol, after swimming and
showering will help prevent recurrence
Advise patient to keep foreign objects such as cotton buds out of their ears;
remove built-up wax, if necessary with e.g. Waxsol
Patients with recurrent infections often have a chronic fungal infection present.
This infection may be seen with fungal hyphae looking like wet blotting paper or
dry like cotton wool or the infection may be suspected even if the canal looks
clean and normal but is itchy
Suction ear toilet followed by Sofradex or flumethasone 0.02% + clioquinol
1% or triamcinolone compound (Kenacomb) ointment to prevent further acute
bacterial infection
Primary Clinical Care Manual 2011
599
Ear problems
Head injuries
Eye injuries
Fractured mandible / jaw
2. Immediate management
3. Clinical assessment
4. Management
onsult MO who will advise antibiotic ear drops if water penetrated the perforation
C
e.g. fall into water. The ear should be kept dry until healed. Antibiotic eardrops are
not necessary if hole was caused by dry trauma (blow to head)
5. Follow up
R
eview in 2 days and then weekly
If perforation not healed in 2 weeks, consult MO
6. Referral / consultation
600
Ear problems
4. Management
onsult MO unless small object and seen to be near external ear opening and
C
easily removable using e.g. nasal packing forceps
Larger foreign bodies and those further down the canal require special equipment
and training for removal and may even require a general anaesthetic (send to
hospital with ENT facilities)
A live insect in the ear canal should be drowned using Sofradex eardrops or
cooking oil or 2 mL of 1% lignocaine introduced by the blunt end of a syringe or
via a cut-off butterfly needle (or other plastic tubing is also effective) [11]. Do not
syringe with water as can cause insect to swell
After removal of foreign body or insect, instil Sofradex ear drops to prevent
infection secondary to the trauma caused to the skin of the ear canal
601
Ear problems
5. Follow up
6. Referral / consultation
References
1.
Office for Aboriginal and Torres Strait Health. Recommendations for Clinical Care Guidelines on the
Management of Otitis Media (middle ear infection) in Aboriginal and Torres Strait Islander Populations.
2001 [cited 2011 March].
2.
Therapeutic Guidelines. Otitis media. 2010 [cited 2011 March].
3.
Australian Medicine Handbook. Procaine penicillin. 2011 [cited 2011 May].
4.
Dr A White, Paediatrician. 2011.
5.
Dr E. Binotto, Infectious Diseases & Clinical Microbiology. 2011.
6.
CRANA plus, Clinical Procedure Manual for remote and rural practice. 2nd ed. 2009, Alice Springs.
7.
Griffin, G., Flynn C A., and Bailey R E. Antihistamines and / or decongestants for otitis media with
effusion (OME) in children. Cochrane Database of Systemic Reviews 2006 [cited 2011 March].
8.
Australian Medicine Handbook. Ciprofloxacin (ear). 2011 [cited 2011 March].
9.
Isaacson G., Diagnosis of pediatric cholesteatoma. Pediatrics 2007. (3): p. 603-608.
10. Therapeutic Guidelines. Otitis externa. 2010 [cited 2011 March].
11. Murtagh J., Practice Tips. 4th ed. 2004: The McGraw-Hill Inc.
602
Gastrointestinal problems
Recommend
Always contact MO immediately if baby is < 3 months or the child has any of the
following:
-- is sick or febrile with temperature over 38C or under 35.5C
-- irritable
-- high pitched or weak cry
-- sleepy
-- not feeding well
-- increased respiratory rate:
<1 year >40 rpm
1 - 2 years >35 rpm
2 - 5 years > 30 bpm
5 - 12 years >25 rpm
12 years and older >20 rpm
-- respiratory distress
-- apnoea
-- dehydration
-- abdominal distension
-- persistent / bilious vomiting and no diarrhoea (consider other diagnoses)
Other high risk children include:
-- excessive diarrhoea (> 8 watery stools in 24 hours)
those with congenital or chronic disease e.g. cardiac, gastrointestinal or
--
neurological
-- where social conditions are concerning and / or where the parents may have
difficulty managing at home
Always consider other infections. Any infection can cause diarrhoea or vomiting
Related topics
Intraosseous cannulation
Vomiting
Diarrhoea
Cramping abdominal pain
Irritability in the young child
Fever
Dehydration
Lethargy, floppy, unresponsive
2. Immediate management
603
Gastrointestinal problems
3. Clinical assessment
No signs
Mild < 5%
Some signs
Moderate 5 - 10%
Definite signs
Severe > 10%
Eyes
normal
sunken
moist
dry
very dry
Condition
alert
restless, irritable,
lethargic
extreme lethargy
ragdoll appearance
drinks normally,
may be thirsty
drinks poorly or
not able to drink
Respiratory rate
normal
increased
fast
Pulse
normal
fast
Capillary return
normal ( 2 seconds)
Management
Consult MO
Require urgent
rehydration usually
nasogastric / IV
Consult MO
Requires resuscitation
Thirst
604
Gastrointestinal problems
4. Management
onsult MO immediately - for those children with risk factors or moderate / severe
C
dehydration
Children and babies with watery diarrhoea lasting 2 - 3 days should have bloods
taken for electrolytes. Take bloods earlier if indicated
Do not use:
--
anti-diarrhoeal agents
metoclopramide or prochlorperazine in young children. MO may order
--
ondansetron if vomiting is preventing oral intake [2]. Ondansetron not
recommended for children <6 months of age or < 8kg [1]
-- antibiotics (rarely indicated)
4.1 Mild dehydration (<5% loss of body weight)
The main treatment is to keep child drinking small amounts of fluids often. Give
enough fluids to cover normal requirements and to replace what is lost through
vomiting and diarrhoea [3]
-- oral rehydration fluids e.g. Gastrolyte, Hydralyte, Pedialyte
-- continue breastfeeding / bottle feeding
-- diluted commercial cordials or diluted (35%) fruit juice drinks, lemonade if oral
rehydration fluids not available
-- do not use low-joule or diet carbonated beverages, sports drinks, Lucozade,
or undiluted lemonade, cordials, or fruit juices
It is important for the fluids to be taken even if the diarrhoea seems to get worse
Children with mild / no dehydration can be looked after at home or with close
monitoring by facility. However significant ongoing vomiting and / or diarrhoea
minimise the chance of success at home
Consider early nasogastric rehydration in these children [1] if oral replacement is
not successful
Maintain a record of fluid intake and output - by staff and family
How to prepare suitable fluid for rehydration [3]
Fluid
Dilution
Example
1 part in 20 parts
1 part in 5 parts
20 mL (1 tablespoon) plus 80 mL
water
605
Gastrointestinal problems
Yes
No
Significant
co-morbidities or risk
factors such as age
< 3 months, febrile
Yes
No
Vomiting
prominent?
No
Yes
Assess dehydration
606
Consult MO
for input on
management
MO may
consider
ondansetron
wafer
Trial of oral
fluids 10 - 20 mL
/ kg for 1 hour
unless severe
dehydration
Mild
Moderate
Severe
Consult MO
Requires urgent
rehydration
nasogastric / IV.
MO may organise
evacuation /
hospitalisation
Consult MO urgently
who will organise
evacuation /
hospitalisation
IV / IO insertion
Commence bolus of
20 mL / kg
normal saline
Gastrointestinal problems
0 - 6 hours
Give oral / NGT fluid replacement
(mL / hr)
3
4
5
6
7
8
9
10
12
15
20
30
30
40
50
60
70
80
90
100
120
150
200
300
7 - 24 hours
(following previous column doses)
Give oral / NGT fluid replacement
(mL / hr)
20
30
35
40
45
50
55
60
65
70
85
90
607
Gastrointestinal problems
5. Follow up
dehydration
Children with mild dehydration i.e. < 5% and no clinical signs review in 24 hours
608
Gastrointestinal problems
6. Referral / consultation
609
Gastrointestinal problems
Lactose intolerance
Recommend
Continue breastfeeding (lactase can be tried). For formula fed infants use low lactose
formula
Consider other causes of chronic diarrhoea
Background
Lactose intolerance commonly follows acute diarrhoea in Aboriginal and Torres Strait
Islander children
Related topics
Acute gastroenteritis and dehydration
Failure to thrive
Nappy rash
Child with chronic diarrhoea flow chart
4. Management
610
Gastrointestinal problems
5. Follow up
6. Referral / consultation
C
onsult MO on all occasions lactose intolerance suspected
Dietitian if available
Giardiasis
Recommend
If treatment with tinidazole or metronidazole fails a longer course may be required or
reconsider the diagnosis
Related topics
Anaemia - child
4. Management
611
Gastrointestinal problems
DTP
IHW / SM R&IP / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NP
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed
Route of
Recommended
Form
Strength
Duration
administration
dosage
Adult
2g
Tablet
500 mg
Oral
Child
Stat
50 mg / kg / dose
to a max. of 2 g
Provide Consumer Medicine Information: take dose after food. When possible, the tablets should be dosed
whole as the drugs taste is very bitter. However, when a part tablet is required, tablets can be crushed.
The tablets are film coated, so must be peeled then crushed.The appropriate dose can then be weighed
and mixed with flavouring
Management of associated emergency: consult MO
[4]
Schedule
Tinidazole
or
DTP
IHW / SM R&IP / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NP
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed
Route of
Recommended
Duration
Form
Strength
administration
dosage
200 mg
Adult
Tablet
400 mg
2 g daily
Oral
Child
3 days
Suspension 200 mg / 5 mL
30 mg / kg / dose daily
to a max. of 2 g daily
Provide Consumer Medicine Information: avoid alcohol while and for 48 hours after taking this drug. Take
with food or immediately after food
Management of associated emergency: consult MO
[4]
Schedule
Metronidazole
5. Follow up
R
eview next day
Consult MO if diarrhoea not settling
Provide education and advice concerning handwashing before handling food,
eating and after toilet; avoiding food preparation and public swimming pools until
diarrhoea has settled
6. Referral / consultation
Consult MO as above
612
Gastrointestinal problems
Intestinal worms
Recommend
Use only pyrantel (Combantrin) in children under 6 months and in pregnant women
[7]
Perform de-worming in three situations:
-- as part of a community eradication program
-- symptomatic children
-- on the basis of faeces specimen result, sent as part of investigation for anaemia
or weight loss / failure to thrive
Related topics
Anaemia - child
Failure to thrive
2.
Perianal / perineal itch - pinworm (thread worm), small threadlike worm may be
seen (doesnt cause diarrhoea or failure to thrive)
Anaemia - hookworm
Acute diarrhoea - strongyloides
Failure to thrive - strongyloides can contribute
3. Clinical assessment
4. Management
613
Gastrointestinal problems
Mebendazole (Vermox)
Albendazole
Praziquantel
Ivermectin
Worm
Threadworm (pinworm)
Hookworm
Roundworm
Threadworm (pinworm)
Hookworm
Roundworm
Whipworm
Threadworm (pinworm)
Hookworm
Roundworm
Strongyloidiasis
Whipworm
Beef tapeworm and pork tapeworm
Dwarf tapeworm
Strongyloidiasis
Pyrantel embonate
DTP
(Combantrin)
IHW / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic may proceed
Route of
Recommended
Form
Strength
Duration
administration
dosage
125 mg
Stat
Tablet
10 mg / kg / dose
250 mg
Oral
Repeat after 7 days if
to a max. of 1 g
Suspension 50 mg / mL
heavy infestation
Schedule
Provide Consumer Medicine Information: for use in children < 6 months of age and pregnant women
Management of associated emergency: consult MO
614
[5]
Gastrointestinal problems
DTP
IHW / SM R&IP / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NP
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed
Route of
Recommended
Form
Strength
Duration
administration
dosage
Threadworm (pinworm),
hookworm, roundworm
Adult
Stat
400 mg
Child
200 mg
10
kg
give 200 mg
Tablet
Oral
400 mg
Strongyloidiasis, whipworm
Adult
400 mg daily
3 days
Child
10 kg give 200 mg daily
Provide Consumer Medicine Information: women should use effective contraception during and one month
after treatment. To increase absorption for systemic indications i.e. strongyloides, take medication with
fatty meal. For other indications take on an empty stomach
Management of associated emergency: consult MO
[5]
Schedule
Albendazole
or
Mebendazole
DTP
(Vermox)
IHW / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic may proceed
Route of
Recommended
Form
Strength
Duration
administration
dosage
Theadworm (pinworm)
Adult
Tablet
100 mg
100 mg
Stat
Child
10 kg give 50 mg
Oral
Whipworm, hookworm,
roundworm
Adult
Suspension 100 mg / 5 mL
3 days
100 mg bd
Child
10 kg give 50 mg bd
Provide Consumer Medicine Information
Management of associated emergency: consult MO
Schedule
[5]
5. Follow up
6. Referral / consultation
Consult MO as above
615
Gastrointestinal problems
Constipation
Recommend
Maintenance programs consisting of medication, toileting program, dietary advice
and follow up to prevent recurrence
Background
Constipation is the difficult passage of infrequent dry, hard stools that often cause
pain and discomfort. The most common cause is functional - no underlying cause [8]
Constipation starts a vicious cycle - passing hard stool is painful, so the child avoids
straining at stool, the constipation gets worse and so on. Part of the battle is forming
a habit for the child to go to the toilet each day
Straining is normal in babies
616
Gastrointestinal problems
4. Management
Dietary interventions:
-- encourage a healthy diet with fruit and vegetables and wholegrain cereals
-- encourage drinking plenty of water
-- pears (fresh or pureed) or prunes will stimulate the gut gently and soften
stools
-- excessive dietary intake can cause constipation in children
Encourage physical activity
Toileting programs:
-- take advantage of the gastrocolic reflex. Most people, especially children
have the urge to pass a motion after eating a meal, especially breakfast
-- advise that the child should sit on the toilet after each meal and attempt to
pass a motion without straining
-- positively reinforce good behaviour. A reward for sitting on the toilet and
passing a motion is often beneficial
Disimpaction:
-- oral laxatives
liquid paraffin, chocolate flavoured liquid paraffin i.e. Parachoc. Avoid
in infants under 12 months of age
lactulose, senna, Movicol Half
-- enemas
micro-enemas such as Microlax
Most constipation in children will resolve with these measures. If it persists, refer
to the next Child Health Nurse or MO clinic or Continence Advisor
5. Follow up
Children with constipation should be reviewed regularly to assess progress.
Once the problem settles remember to continue with dietary improvement and
increased water intake to prevent recurrence
Advise parent / carer to use appropriate gentle fibre or laxative (prune / pear juice
/ psyllium) for at least 3 months to regulate peristalsis
6. Referral / consultation
617
Gastrointestinal problems
Pyloric stenosis
Recommend
Consult MO immediately
May need rehydration
Evacuate for investigation. Will need surgical treatment if diagnosis confirmed
Background
Most common in babies between 2 and 6 weeks of age. Rarely occurs after 12
weeks of age
Related topics
Acute gastroenteritis and dehydration
2. Immediate management
3. Clinical assessment
4. Management
5. Follow up
All babies with suspected pyloric stenosis must be managed in hospital. Diagnosis
6. Referral / consultation
618
Gastrointestinal problems
Intussusception
Background
Suspect in a young child who looks unwell and has intermittent severe abdominal
pain
In 15 % of cases the classic triad of abdominal pain, palpable sausage shaped
abdominal masses and red currant jelly stool is present. The small bowel telescopes
into itself (as if it were swallowing itself)
Most common cause of obstruction in children 6 - 36 months of age (60% <12 months
of age)
Intermittent severe abdominal pain (may settle and appear well between bouts
of pain 10 - 20 minutes apart)
Intermittent inconsolable crying
Poor feeding
Vomiting
Blood per rectum (classically red currant jelly but is often a late sign)
Child may look pale and unwell
2. Immediate management
Consult MO
3. Clinical assessment
4. Management
5. Follow up
Monitor child on return to community
6. Referral / consultation
619
Gastrointestinal problems
Failure to thrive
Recommend
Refer to Poor growth in children care plan in the latest edition of the Chronic Disease
Guidelines www.health.qld.gov.au/cdg
MO / Dietitian to perform complete examination and calculate the degree of failure to
thrive - mild, moderate or severe, using weight for age, and weight for height, for Z
score
Provide nutritional supplements for management of failure to thrive depending on
severity
It is important in an underweight child to differentiate wasting (thin child) of acute
failure to thrive from stunting (short child) due to chronic failure to thrive. Often both
are present, and can be assessed on anthropometric measurements of weight and
height for age and sex
Background
Suite of Growing Strong resources available at:
www.health.qld.gov.au/ph/documents/hpu/growingstrong.asp
Failure to thrive (FTT) refers to child whose weight is less than normal for gestational
corrected age / gender and past medical history. Children with genetic short stature,
intrauterine growth retardation or prematurity, who have appropriate proportional
weight for length and normal growth velocity, are not regarded as FTT
Related topics
Anaemia
Giardia
Intestinal worms
Lactose intolerance
Urinary tract infection - child
Any condition
A child whose weight has crossed down 2 or more major centile lines on standard
growth charts (and who is not overweight or obese) [7]
620
Gastrointestinal problems
4. Management
621
Gastrointestinal problems
Food prescription
Drinks
Nutritional supplement - usually Pedisure at least one 237 mL can or one cup
250 mL of supplement every day or 5 scoops of powder in 200 mL water
Water, breast milk, infant formula, cows milk if over 12 months
Food
Meals - breakfast, lunch, dinner, snacks containing fruit, vegetables
5. Follow up
Place child on individualised care plan, setting out actions, targets and who is
6. Referral / consultation
C
onsult MO. Child may need hospitalisation
Child development unit for developmental screening of gross and fine motor,
Dietitian to conduct thorough diet history, feeding history and nutrition advice
May need referral to a community based specialised nutrition program e.g. Mums
and bubs
See current edition of Chronic Disease Guidelines at:
www.health.qld.gov.au/cdg
Anaemia - child
Recommend
Aim to achieve haemoglobin level above 110 g / L [8]
Treat with iron
-- babies aged 6 -12 months with haemoglobin < 105 g / L
-- children over 1 year of age with haemoglobin < 110 g / L
Consult MO immediately
-- if any child has haemoglobin < 80 g / L
See next MO clinic
-- if child has haemoglobin 80 -100 g / L
Suite of Growing Strong resources, especially iron rich food available at:
www.health.qld.gov.au/ph/documents/hpu/growing_strong.asp
Regular calibration of haemoglobinometer (HemoCue)
622
Gastrointestinal problems
Background
Nutrient requirements are very high in young children, especially for iron between
the ages of 6 months and 24 months
Anaemia is common in Aboriginal and Torres Strait Islander children particularly in
the 6 to 30 months age group
Childhood anaemia is more likely if mother had low iron status or was anaemic in
pregnancy and/or if baby was premature or low birth weight
Anaemia is largely due to dietary deficiency in iron and / or folate and the inhibitory
effects of infestations and infections
There are higher rates of iron deficiency and anaemia in infants and toddlers where
high cows milk intake is encouraged or allowed [11]
Failure to thrive may or may not co-exist
Overweight and obesity may or may not co-exist
Iron deficiency of any degree affects child development
Related topics
Giardia
Intestinal worms
Failure to thrive
623
Gastrointestinal problems
-- check length and do head circumference and plot against growth chart
--
check haemoglobin on haemoglobinometer (HemoCue) (if not already
done)
-- collect stool for lactose intolerance testing
Perform a complete physical examination:
-- from head to toe assessing current state of health and looking for evidence of
undetected illness
4. Management
reat with oral iron supplement for 1 month under supervision (taking iron daily is
T
problematic as child is often asymptomatic. Do not give during diarrhoeal illness.
Parents to be advised about the risk of iron ingestion by children and to store
safely out of reach)
Treat with IM ferrum H if family unable to give oral iron or child will not take oral
iron:
-- babies aged 6 - 12 months with haemoglobin <105 g / L
-- children over 1 year of age with haemoglobin <110 g / L
Consult MO immediately
-- if any child has haemoglobin <80 g / L
See next MO clinic
-- if child has haemoglobin 80 -100 g / L
Collect:
-- if severe anaemia collect blood for FBC / film (look for microcytic hypochromic
picture - low MCV, serum and RBC folate)
-- mid stream urine for MC/S
-- faeces specimen for MC/S and OCP
If faeces specimen:
-- positive for intestinal worms, treat accordingly
-- other positive result, consult MO
-- if in region with high rates of hook worm - treat with 3 days of albendazole.
See Intestinal worms
Refer to Dietitian to conduct thorough diet and feeding history and nutrition advice
Ferrous Sulphate
DTP
(Ferro-Liquid)
IHW / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NP
Route of
Recommended
Form
Strength
Duration
administration
dosage
Child under 2 years
30 mg
only on MO advice
(equiv. to 6 mg
Continue for 3 months
of elemental
Child 2 - 6 years
after Hb has returned to
Liquid
Oral
normal to
iron) per mL
up to 5 mL daily
replenish stores
Child 7 - 12 years
150 mg / 5 mL
5 - 20 mL daily
Provide Consumer Medicine Information: keep iron mixtures and tablets out of reach of children. Warn
patient / carer about dark, tarry stools and constipation. Oral absorption of iron is enhanced by Vitamin C
Management of associated emergency: consult MO - overdose of iron is very toxic.
[9]
Schedule
624
Gastrointestinal problems
DTP
IHW / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NP
Route of
Recommended
Form
Strength
Duration
administration
dosage
500
Child
Long term according
Tablet
microgram
Oral
0.5 mg / kg / dose daily
to response on MO / NP
5 mg
to a max. of 5 mg daily
order
Provide Consumer Medicine Information
Management of associated emergency: consult MO
[10]
Schedule
Folic Acid
ive nutrition advice. Use Growing Strong resources - breastfeeding, iron rich
G
foods, healthy food and drinks and many more available at:
www.health.qld.gov.au/ph/documents/hpu/growingstrong.asp
Recommend breastfeed exclusively for first 6 months
Appropriate iron rich first foods at around 6 months
-- foods rich in iron and or folate:
red meat, beef / lamb liver or kidneys, bush meat
chicken, fish
egg yolks
iron fortified baby cereal
green vegetables
fruit and vegetables (to help iron absorption)
breast milk or infant formula (NOT normal cow or goat milk unless over
1 year of age)
No turtle or dugong liver or kidneys or intestines - as concern about
cadmium content
No cows milk or Sunshine milk before 1 year old
No tea or coffee
No soft drink, juice or cordial
5. Follow up
Place child on individualised care plan, setting out actions, targets and who is
6. Referral / consultation
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Gastrointestinal problems
Iron injection procedure See manufacturer's product information for accompanying diagrams
1.
2.
3.
4.
5.
6.
7.
The length of the needle should be at least 5 to 6 cm. The lumen of the needle should not be too wide
Ventrogluteal injection according to Hochstetter is recommended in the top outer quadrant of the
gluteus maximus muscle
The site of injection is determined as follows. First point A is found, corresponding to the ventral iliac
spine. If the patient lies on the right side, for instance, the middle finger of the left hand is placed on
point A. The index finger is extended away from the middle finger, so that it comes to lie below the iliac
crest, at point B. The triangle lying between the proximal phalanges of the middle and index fingers
represents the site of injection. This is disinfected in the usual way
Before the needle is inserted, the skin over the site of injection is pulled down, about 2 cm, to give
an S-shaped puncture channel. This prevents the injected solution from running back into the
subcutaneous tissues and discolouring the skin
The needle is introduced more or less vertically to the skin surface, angled to point towards the iliac
crest rather than the hip joint
After the injection, the needle is slowly withdrawn and pressure from a finger applied beside the
puncture site. This pressure is maintained for about one minute
The patient should move about after the injection
[11]
Schedule
Form
Strength
Ampoule
100 mg / 2 mL
50 mg / mL
Iron polymaltose
(Ferrum H, Ferrosig)
Route of
administration
IM
Non DTP
Must consult MO / NP
Recommended
dosage
Duration
Stat
or alternate days
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4. Management
5. Follow up
I f not evacuated review daily for next 2 days - if not improving, consult MO
Check results of urine MC/S (24 - 48 hours) and discuss with MO - advice on
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S
ee next MO clinic
Routine prophylaxis is no longer recommended [1]
6. Referral / consultation
References
1.
The Royal Childrens Hospital Melbourne. Urinary Tract Infection Guideline. 2008 [cited 2011 January];
8th edition: Available from: www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5241.
2.
Therapeutic Guidelines. Urinary tract infections: children 2010 [cited 2011 January].
3.
NHS choices. Urinary tract infection, children. 2010 [cited 2011]; April]. Available from: www.nhs.uk/
Conditions/Urinary-tract-infection-children/Pages/Symptoms.aspx.
4.
Royal Childrens Hospital, AntibioCard. 2011: Brisbane.
Recommend
Referral to Orthopaedic Specialist if suspected osteomyelitis / septic arthritis [1]
An important consideration if a skin infection is taking a long time to resolve, or
occurs over a joint
Background
Osteomyelitis and septic arthritis can affect any joint or bone, but most commonly
involve the lower limbs [1]
Polyarthritis or aseptic monoarthritis or polyarthralgia, usually migratory (finishes in
one joint and then begins in another) is a major manifestation of acute rheumatic
fever (ARF) [2]
Related topics
Bacterial skin infections
Acute rheumatic fever (ARF)
Septic arthritis
Acute onset of limp / non-weight
bearing / refusal to use limb
Pain on movement and at rest
Limited range / loss of movement
Soft tissue redness / swelling often
present
Fever
2. Immediate management
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Consult MO
3. Clinical assessment
4. Management
5. Follow up
hospital
6. Referral / consultation
confirmed [1]
References
1.
2.
The Royal Childrens Hospital Melbourne. Osteomyelitis and Septic Arthritis. 2008 [cited 2011 January]; 8th edition:
Available from: www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5234.
National Heart Foundation, RF / RHD Guideline Development Working Group, and Cardiac Society of Australia and
New Zealand, Diagnosis and management of acute rheumatic fever and rheumatic heart disease in Australia: An
evidence based review. 2006, National Heart Foundation Australia.
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hysical abuse - injuries which dont fit childs developmental level or description
P
provided by parent, punching, slapping, kicking, shaking, biting, applying physical
discipline or punishment causing harm or injury. Patterned injuries including
burns and bruises
Emotional or psychological abuse - constant criticism, scapegoating, name
calling, belittling, excessive teasing, ignoring, punishing normal behaviour,
exposure to domestic and family violence, withholding praise and affection
Neglect - failing to meet the childs basic needs for adequate supervision, food,
clothing, shelter, safety, hygiene, medical care, education, love and affection and
failure to use available resources to meet those needs
Sexual abuse or exploitation - pregnancy, STI, disclosure of abuse, behaviour
change, sexualised behaviour, any sexual act or sexual threat imposed upon a
child including exposure, indecent phone calls, voyeurism, persistent intrusion of
a childs privacy, penetration, rape, incest, involvement with pornography, child
prostitution
Controlled copy V1.0
2. Immediate management
I f you suspect abuse always obtain advice. Consider discussing the case with
your line manager, Paediatrician, CPLO (Child Protection Liaison Officer) or CPA
3. Assessment
4. Management
Phone number
1300 678 801
1300 683 259
1300 683 596
1300 704 514
1300 705 201
1300 705 339
1300 683 042
Fax number
3884 8802
4616 1796
4039 8320
4799 7273
5420 9049
3259 8771
4938 4697
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5. Follow up
6. Referral / consultation
When considering management of children who have been abused or at risk of abuse, it
can be helpful to consider the following factors. Note: it is not the role of the MO to make a
full assessment of risk and protective factors. If abuse is suspected it must be reported to
Department of Communities - Child Safety Services, to investigate further
Risk factors and protective factors associated with child abuse and neglect
Protective indicators are safety factors that may reduce the likelihood of harm or risk
of harm to a child. They are characteristics that prevent or balance risk-producing
conditions [1]
The presence of risk factors does not confirm abuse or neglect. They are common
features of families, parents or caregivers, children and environments that research and
clinical experience have shown to increase the likelihood of child abuse and neglect [1]
It is important to remember factors need to be considered in the context of a childs personal
history. For more detail See Protecting Queensland Children: Policy Statement and
Guidelines on the management of child abuse and neglect in children and young people
0 - 18 years www.health.qld.gov.au/csu/policy.htm [1]
Resources
Queensland Health, Child Health and Safety Unit
qheps.health.qld.gov.au/csu/home.htm
Department of Communities Child Safety Services
www.childsafety.qld.gov.au
Commission for Children, Young People and Child Guardian
www.ccypcg.qld.gov.au/index.aspx
NSW Department of Community Services
w w w. c o m m u n i t y. n s w. g o v. a u / p r e v e n t i n g c h i l d a b u s e a n d n e g l e c t /
reportingsuspectedabuseorneglect.html
132 111 (24 hours)
Victorial Office For Children
www.education.vic.gov.au/officeforchildren
131 278 (24 hrs)
References
1. Queensland Health. Protecting Queensland Children: Policy Statement and Guidelines on the
management of child abuse and neglect in children and young people (0-18 years). 2008 [cited 2011
January]; Available from: www.health.qld.gov.au/csu/policy.htm.
2.
Queensland Government. What is child abuse? 2008 [cited 2011 January ]; Available from: www.
childsafety.qld.gov.au/child-abuse/index.html
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