Paed Intern Manual

Manual for Paediatric Interns and Residents 5th edition
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Manual for Paediatric Interns and

Residents
5th edition (Jul 2021)
To be reviewed in Jan 2024
The University of Hong Kong

Department of Paediatrics and Adolescent Medicine
Queen Mary Hospital
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PREFACE
Welcome to the Department of Paediatrics and Adolescent Medicine (UPAM)!
Our department, like any other units in this teaching hospital, strives for excellence in quality of
patient care, academic and educational pursuits. However, we differ in that we deal with children.
Hospitalisation is a very distressing event for both the children and their family. Not only do we
need to have the knowledge and technical skills to treat the physical conditions, we must also
develop skills in handling the social and emotional needs of the children and their families.
Be motivated as this is the pre-requisite for being a good doctor. It is our aim that you will develop
clinical competence in managing common paediatric problems through working under supervision
and we hope you will share with us the joy of helping children and their families through their
illness.
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CONTENTS
PREFACE .................................................................................................................... 2
CONTENTS .................................................................. Error! Bookmark not defined.
SECTION 1: GENERAL INFORMATION ..................................................................... 5

1.1 OUR DEPARTMENT - UPAM ................................................................................. 6
1.2 GENERAL INSTRUCTIONS TO INTERNS AND RESIDENTS .............................. 7
1.3 ORIENTATION TO MEDICAL STAFF IN HKWC .................................................... 8
1.4 GOOD CLINICAL DOCUMENTATION AND CASEMIX .......................................... 9
1.5 DISEASE CODING AND COMMON ERRORS IN MAR /IPMOE ..........................11
1.6 INFECTION CONTROL IN PAEDIATRIC WARD ................................................. 13
1.7 ADMISSION OF PAEDIATRIC PATIENTS............................................................ 18
SECTION 2: PROCEDURES IN PAEDIATRICS........................................................ 20

2.1 BLOOD SPECIMEN COLLECTION ..................................................................... 21
2.2 CAPILLARY PUNCTURE (HEEL PRICK) ............................................................ 22
2.3 BLOOD TAKING FROM CENTRAL VENOUS CATHETER.................................. 23
2.4 PRE-TRANSFUSION COMPATIBILITY TEST IN NEONATES – CROSS MATCH25
2.5 URINE EXAMINATION ......................................................................................... 26
2.6 URINARY BLADDER CATHETERISATION ......................................................... 28
2.7 LUMBAR PUNCTURE ......................................................................................... 29
2.8 MANTOUX TEST ................................................................................................. 31
2.9 SEDATION FOR PROCEDURES ...................................................................... 333
2.10 STEROID PREMEDICATION IN RADIOLOGICAL INVESTIGATIONS .............. 38
2.11.PRE-OPERATIVE FASTING FOR PATIENTS UNDERGOING ANAESTHESIA..40
2.12 CARDIAC PULMONARY RESUSCITATION ......... Error! Bookmark not defined.
2.13 MANAGEMENT OF ANAPHYLAXIS .................................................................. 42
SECTION 3: COMMON PAEDIATRIC PROBLEMS ................................................ 466
SECTION 3.1: RESPIRATORY SYSTEM ............................................................... 477

3.1.1: MANAGEMENT OF CHRONIC ASTHMA ........................................................ 48
3.1.2: MEDICATION FOR CHILDHOOD ASTHMA………………………………………54
3.1.3: MEDICATION FOR ALLERGIC RHINO-CONJUNCTIVITIS ........................... 577
3.1.4 ACUTE ASTHMATIC ATTACK ........................................................................... 59
3.1.5 ACUTE RESPIRATORY DISTRESS ................................................................. 63
3.1.6 ACUTE UPPER AIRWAY OBSTRUCTION...................................................... 644
3.1.7 ACUTE VIRAL BRONCHIOLITIS ....................... Error! Bookmark not defined.6
SECTION 3.2: INFECTION ...................................................................................... 488

3.2.1 ANTIMICROBIAL THERAPY ............................................................................. 69
3.2.2 COMMONLY USED ORAL ANTIBIOTICS ......................................................... 72
3.2.3 FEVER .............................................................................................................. 74
SECTION 3.3: CARDIOLOGY ................................................................................. 755

3.3.1 SHOCK .............................................................. Error! Bookmark not defined.6
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3.3.2 CYNOTIC SPELL .............................................................................................. 79
3.3.3 INFECTIVE ENDOCARDITIS PROPHYLAXIS ................................................. 80
3.3.4 HEART FAILURE .............................................................................................. 81
SECTION 3.4:NEUROLOGY………………………………………………………………82
3.4.1 FEBRILE CONVULSIONS ................................................................................ 83
3.4.2 STATUS EPILEPTICUS .................................................................................... 85
3.4.3 ACUTE ENCEPHALOPATHY ............................................................................ 88
3.4.4 INTERPRETATION OF CSF RESULTS IN CNS INFECTION…………………...90
3.4.5 ACUTE FLACCID PARALYSIS………………………………………………………93
SECTION 3.5: GENERAL PAEDIATRICS ................................................................. 96

3.5.1 DIARRHOEA ..................................................................................................... 97
3.5.2 FLUID AND ELECTROLYTES........................................................................... 99
3.5.3 CHILD ABUSE................................................................................................. 103
3.5.4 URINARY TRACT INFECTION ....................................................................... 106
3.5.5 NEPRHOTIC SYNDROME.............................................................................. 109
3.5.6 NEPRHRITIC SYNDROME ..............................................................................113
3.5.7 ACUTE POISONING ........................................................................................114
3.5.8 ANOREXIA NERVOSA: ACUTE MANAGEMENT IN PAEDIATRIC SETTING..120
3.5.9 INFANT FORMULA TABLE……………………………………………………..…..127
3.5.10 KAWASAKI DISEASE……………………………………………………………..139
3.5.11 ATOPIC DERMATITIS……………………………………………………………..143
3.5.12 DRUG ALLERGY…………………………………………………………………..146
3.5.13 FOOD ALLERGY………………………………………………………………..…148
SECTION 3.6 : PAEDIATRIC HAEMATOLOGY & ONCOLOGY......................... 12050

3.6.1 MANAGEMENT OF NEUTROPENIC FEVER ............................................. 15051
3.6.2 MANAGEMENT OF HAEMOPHILIA ........................................................... 15253
3.6.3 MANAGEMENT OF IMMUNE THROMBOCYTOPENIA (ITP)... Error! Bookmark
not defined.55
3.6.4 MANAGEMENT OF THALASSEMIA MAJOR ............................................. 15657
3.6.5. MANAGEMENT OF TRANSFUSION THERAPY .............. Error! Bookmark not
defined.63
SECTION 3.7 : NEONATOLOGY………………………………………………………..166

3.7.1 QUEEN MARY HOSPITAL INFANT FEEDING POLICY (SUMMARY)………..167
3.7.2 SCBU ADMISSION (FROM lw & pn WARD) & MANAGEMENT GUIDE…...…170
3.7.3 NEONATAL INFECTION .................................. Error! Bookmark not defined.76
3.7.4 PREVENTION AND MANAGEMENT OF NEONATAL HYPOGLYCAEMIA…..179
3.7.2 MANAGEMENT OF NEONATAL JAUNDICE ... Error! Bookmark not defined.93
SECTION 3.8 : PAEDIATRIC ENDOCRINOLOGY .................................................. 210

3.8.1 MANAGEMENT OF NEWLY DIAGNOSED DIABETES MELLITUS………...…211
3.8.2 HYPOGLYCAEMIA ......................................................................................... 152
SECTION 4 : UPAM USEFUL TELEPHONE NUMBERS ........................................ 217

NOTES ..................................................................................................................... 219
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SECTION 1: GENERAL INFORMATION
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1.1 OUR DEPARTMENT - UPAM
A. Locations:
I. Wards:
North (N) South (S)
K7 General Paediatrics ward: General Paediatrics ward:
Infection control/ Isolation ward Infection neutral ward
K8 Special Care Baby unit (SCBU),
Day Centre
K10 Special Care Baby unit (SCBU) Paediatric Intensive Care unit
(PICU),
Neonatal Intensive Care unit
(NICU)
II. Out-patient Clinic: in K block, Ground floor

III. UPAM Office: in 1/F, New Clinical Building
B. Admission policy
1. According to age:
 Day 0 to 1 month old: NICU/SCBU
 1 month to 18 years old: general ward K7
2. Direct admission without going through A&E: to be arranged with team head on call
C. Departmental Meetings and educational activities

The following departmental meetings are held in 1/F, New Clinical Building:
 Journal Club: Monday 12:45pm (NCB Seminar room 120)
 Grand Round: Thursday 8:30am (NCB Seminar room 120)
 History Meeting: Friday 12noon (NCB Seminar room 120)
 Each specialty area will have their own specialty meetings and ward rounds.
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1.2 GENERAL INSTRUCTIONS TO INTERNS AND RESIDENTS
1. Good medical care
 Make the care of your patient your first concern. Be considerate in handling sick
children.
 Minimize the number of painful procedures by careful organization of investigation
and treatment and perfection of skill in carrying out such procedures. Don't be
over-persistent in repeating venipunctures.
 Avoid separation from parents.
 Talk and explain to the parents. Good rapport is important for good treatment
outcome.
1. Develop your clinical competence in dealing with common paediatric problems

 "Common sense" need
 Be the first line of defense.
 Prioritize your work. Attending to a sick child is your first priority.
 Technical/practical skills: start with supervision (refer to log sheet of clinical
procedures)
 Discuss with senior in case of doubt.
2. Develop good communication skills.

 With patients and parents: be sensitive to their needs. Listen and give appropriate
information.
 With fellow colleagues: "coverage at the same level". Handover ill cases/unfinished
procedures to intern on call.
 With seniors: report any significant clinical/laboratory findings once spotted; report
problems with parents; confirm whether your decisions made were appropriate.
 With nursing staff: discuss with nurses on patient management and procedures with
patience and courtesy.
 With referring doctors and doctors from other department: be courteous.
 Tell your team head or supervisor of any grievances or conflicts early.
 Remember that quality patient care is achieved through collaborative teamwork.
3. Always respond to calls promptly.
4. Recognize one’s own limitations and know when to seek advice.
5. Maintain good medical practice by continuous learning

 Evidence-based practice: understand the relevance of evidence to support patient
care
 Keep your professional knowledge and skills up to date
6. Be honest and open and act with integrity.
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1.3 ORIENTATION TO MEDICAL STAFF IN HKWC
Please refer to the Orientation Handbook for Medical staff in the HKWC website
http://hkwc.home/TnOD/HKWCTnOD/trainingPrograms.aspx
http://hkwc.home/TnOD/HKWCTnOD/Docs/q_and_i/orientation_handbook_medical.pdf
On the following topics:
1. Good partnership with patients and complaints management

2. Quality clinical practice
3. Clinical management system
4. The management of medical records & proper documentation
5. Discharge summary and coding
6. DNACPR policy
7. CPR policy
8. How to deal with DAMA
9. Clinical audit
10. Potential medico-legal situation
11. Reportable deaths under coroners ordinance
12. Crises management and disaster plan
13. Infection control
14. Intern orientation & training
15. Core competencies for medical officers/residents
16. Rules & regulations for using houseman quarters at QMH
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1.4 GOOD CLINICAL DOCUMENTATION AND CASEMIX
Good clinical documentation
Clinical information should be documented accurately, consistently & comprehensively to reflect
the patient’s condition & the treatment given
• Documentation of the Principal Diagnosis
• Documentation of Secondary Diagnoses
• Documentation of Principal & Other Significant Secondary procedures performed
When assigning these using ICD9CM codes be specific

• As vague & missing diagnosis & procedures may lead to a lesser DRG assignment
• Which does not reflect the complexity of the patient cohort you are treating &
• Leads to fewer resources being allocated to the cluster
For Clinical documentation coding education, please refer to:

https://hkwc.home/webapps/Dept/QandS/p-Q&S_sub1_jumpmenu_2.html
Casemix refers to the number and type of patients treated by a hospital

 Output is generally grouped according to a classification such as Diagnosis Related
Groups (DRGs)
 DRGs are used to classify patients into clinically meaningful groups based on ICD
diagnosis, treatment & operative procedures codes
 A hospital’s DRG profile is typically known as its casemix
 When transposed to ICD9CM it is the basis of complexity & reimbursement
measurement of a hospital
 Casemix Index – A measure of a hospitals casemix complexity
CMI = Weighted Episodes (i.e. Cost Weights x Number of Episodes)
Number of Episodes
Please refer to: http://fin.home/casemix/CE/0.aspx for more details.
Reporting the Principal diagnosis

• Definition of Principal Diagnosis (from 1 Jan 2001): The condition, diagnosed at/after
discharge, which is primarily responsible for the patient's need for treatment or
investigation in that episode of hospitalization.
• The principal diagnosis is always sequenced first
• It might not be the admitting diagnosis but rather the diagnosis found after work up or
surgery that proves to be the reason for hospitalization
• If there is more than one condition which accounts for the reason for hospitalization, select
the most severe condition or the most acute condition
• If no diagnosis was made, the main symptom, abnormal finding or problem should be
selected as the principal diagnosis
• Example 1 : After investigation, the underlying condition is the principal diagnosis
A patient was admitted to hospital for pleural effusion. After investigation, doctors
discovered that the patient had lung cancer. Lobectomy of lung was performed immediately
• Principal Diagnosis • Secondary Diagnosis • Procedure
• Lung Cancer • Pleural effusion • Lobectomy
• Example 2: The most complex condition is the principal diagnosis

A patient was admitted to hospital for acute appendicitis and peritonitis. Appendicectomy
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was initially performed. Whilst in hospital, the patient had a heart attack and coronary bypass
surgery was performed
Principal Diagnosis Secondary Diagnosis Procedures
Acute Myocardial Appendicitis & 1. Coronary Bypass Surgery

Infarction Peritonitis 2. Appendicectomy
Reporting secondary diagnosis

• Definition of Secondary Diagnosis: Secondary Diagnoses are those for which the patient
received clinical evaluation, diagnostic evaluation, treatment (co-morbid condition),
& affected the patient's treatment care plan, and/or increase the length of stay;
• They might have:
• Existed at the time of the patient's admission to hospital
• Developed during the patient's hospitalization;
• Developed as a complication of the care provided to the patient whilst in hospital
• Diagnoses that need not be reported as secondary diagnoses:
• Those that relate to an earlier episode that have no bearing on the current hospital
stay
Reporting Procedures
• Definition of Principal Procedure: The most significant procedure that was performed for
treatment of the principal diagnosis.
• Significant Procedures:
• A significant procedure is defined as one that meets one of the following conditions:
– Is surgical in nature;
– Carries a procedural or anesthetic risk; or
– Requires special facilities, equipment or specialized training.
• Where procedures are undertaken both as a form of treatment & for diagnostic purposes,
the principal procedure is the most significant procedure that was performed for
definitive treatment rather than for diagnostic or exploratory purposes.
• When no procedure was performed for treatment of the principal diagnosis, use the
following hierarchy:
– Procedure performed for treatment of additional diagnoses
– Diagnostic/exploratory procedure related to the principal diagnosis
– Diagnostic/exploratory procedure related to additional diagnoses
– Do not report the procedures which are not done in the reported episode
• Extracted from “The Importance of Good Clinical Documentation & the Role of the
Clinician”, Performance Office, HKWC (2010)
• Reference: HA intranet site – see casemix project for more detail
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1.5 DISEASE CODING AND COMMON ERRORS IN MAR /IPMOE
Pitfall in disease coding

1. Diagnostic code and procedure code must be completed for all discharge summaries and to
be printed out on or before the day of discharge, including all those Day-patients.
2. Choose the appropriate principle diagnosis and code each disease separately.
3. Pick previous diagnosis if available, for chronic patients e.g. Epilepsy, mental retardation.
4. Code the identified causative organism if possible (double coding).
e.g. Upper respiratory tract infection 465.9

Influenza A (Influenza with other respiratory manifestation) 487.1
e.g. Urinary tract infection 599.0

E. coli 041.4
5. For most of the common diseases, use clinical data framework for coding. Be careful about
congenital pneumonia.
6. All diagnostic code 800-999 must be accompanied by an E-code.
7. All procedure code must be accompanied by diagnostic code.
8. Code G6PD deficiency with V71.8 and enter the data in the “Alert” page.
9. Code nursing mother/father/maid with V65.0, minimal requirement for the case summary.
10. Code “Isolation status” for isolation cases.
11. Use V71.9 as code for observation without treatment for all age group.
12. Useful link in the CMS: http://cs4/mastertable
Special point about coding for neonates

1. Remember to code prematurity when gestational age < 36 weeks
2. Code the birth weight when BW < 2500 gm, 765.XX
3. Code inborn V30.00 for those babies born in QMH by pick previous diagnosis
4. Code outborn V30.1 for those babies born in other hospitals
Special point for neonates in K8 Day centre

1. Still need to code V30.00 for inborn and V30.1 for outborn if they are admitted within 28 days or
44 weeks of corrected age
2. Code day-patient V72.9 for those admitted for NNJ assessment, ROP assessment and
procedures
3. Those babies admitted for ROP screening, pick previous diagnosis for prematurity, birth weight
and inborn/outborn
How to arrange S5 follow-up for inborn neonate

1. Check the S5 follow-up date of the mother.
2. Find the baby’s name in the ward list.
3. Go to the <Out-patient Appointment Booking> window through the ward list.
4. Change the <Specialty> to <OBS Obstetric Clinic>.
5. In the <Subspecialty clinic>, choose <BBNZ Neonatal Assessment S5>
6. Enter the follow-up date, preferably the same as that of the mother.
7. In the box of <Appointment Type>, click <Subsequent>.
8. Then press <Search>.
9. Click <Accept> if the date is appropriate and then <OK>.
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IPMOE
http://hkwc.home/ipmoe/qmh/qmh/info/list/TrainingMaterials/Forms/FileDirectoryList.aspx
1. Input patient’s body weight and height in IPMOE

2. Medical officer should input medication instead of interns
3. Take special notice on the units of the medication. Please use alternating ordering unit.
4. Use template to order if available
5. Be careful of drug names with similar spelling
6. Set time of dispension
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1.6 INFECTION CONTROL IN PAEDIATRIC WARD
Refer to QMH Infection Control Manual (Access through CMS station at HKWC website
home page  click icon” Infection Control”)
Own immune status

All workers in the pediatric ward have to be immune to varicella, measles, mumps and rubella.
Indication for Isolation in K7N

All patients admitted to K7N should have an order for Isolation on admission. Patients
can be preemptively isolated based on epidemiology and syndromes suggesting certain
infectious etiology pending microbiologic confirmation.
Standard Precaution
Practised in all patients regardless of infective status. Infections include: UTI, bacteremia,
gastroenteritis other than those indicated for Contact Precaution, CMV, HIV.
All other specific isolation precaution entails Standard Precaution plus that additional
precaution if needed.
Droplet Precaution
Theoretically all children with infections transmitted via the droplet route should be hospitalized
in a private room. Since in QMH, the majority of the beds are in open cubicles, droplet
precaution in K7N is practiced by having patient beds at least 3 feet apart, no mixing of patients
in the ward, and staff and visitors wearing a surgical mask. Examples include influenza, S.
pneumoniae, pertussis (although CHP seems to want the child isolated in a single room), Group
A Streptococcus, rubella.
Airborne Precaution (negative pressure isolation)

Infections spread by airborne (aerosol) route: measles, varicella, disseminated zoster (usually
in an immunocompromised host) and TB in a child with 1) cavitary pulmonary TB, 2) positive
sputum AFB smear 3) laryngeal involvement 4) extensive pulmonary infection.
Contact Precaution
Organisms that commonly contaminate large surfaces around the patient or with potentially
serious infection control implications, including rotavirus, norovirus, salmonella in a diapered or
incontinent child, Salmonella typhi, varicella, scabies, enterovirus, RSV, parainfluenza,
adenovirus, MRSA, ESBL.
Examples of preemptive contact precaution: a baby with acute bronchiolitis (suspicious for
RSV), a child with vomiting and diarrhea in winter (suspicious of rotavirus), a child with vomiting
and diarrhea (suspicious of norovirus).
These children should be placed in a room or cohorting in a cubicle if there are many patients
with the same etiology (e.g. rotavirus gastroenteritis in winter).
Reverse isolation
This is indicated for an immunocompromised host to protect the patient from other patients who
may be infectious. Patients with transient neutropenia secondary to a viral infection do not need
reverse isolation.
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HEPA filter
Bone marrow transplant recipients to prevent spores of filamentous fungi such as Aspergillus.
None of the negative pressure rooms in K7N has HEPA filter.
HIV testing: counseling and informed consent
Testing for HIV infection carries the risks for discrimination in jobs, school and child care. The
parents or guardian and the patient, if old enough to comprehend, should be counseled about
the possible risks (as stated above) and benefits (early effective treatment if infected, ruled out
infection if not) of testing a child and the consequences of HIV infection. Consent should be
obtained from the parent or legal guardian and recorded in the patient’s medical chart. No
signed consent is necessary. Maintaining confidentiality in all cases is essential to preserving
patient and parent trust and consent. Since this test creates a lot of anxiety in parents and
patients, the results should be given to the parents and patient, if appropriate according to age,
as soon as they are available. The turnaround report time for HIV serology is about 1 week and
that of HIV RNA is about 2 weeks. Follow up appointments for testing result should be made
accordingly.
Varicella Outbreak
There is a standard template for plan of action that should be prepared when there is an
outbreak such as varicella in the ward. (See Appendix for sample.)
Contact
Infection Control Unit (x3553)
Dr. Susan Chiu (through Hospital Operator)
By Dr S Chiu
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Appendix: Sample of action plan for chicken pox exposure
Index patient: CCC Female/ age (ID 1234567)

Diagnosis: 1st episode of chickenpox, EBV associated hemophagocytic syndrome
1st day of skin eruption: 17/3 morning
1st day of being infectious: 15/3 morning
Background
She was admitted to K8N on 5/3 1:00pm for chemotherapy till now. She had been given IVIg
(1gm/kg) from 18-20/2, then on IV acyclovir 500mg Q8H since 1/3 for the EBV infection. She
did not have any history of chickenpox. She was managed in single/double door room, but she
went out of her room for walking exercise during evening. She developed vesicular lesion on
17/3 morning. She was then transferred to K7N for isolation. Microbiologist and ICN informed.
Ward arrangement
K8 will house the immune and clean cases.
K7N isolation room will be used for quarantine patients.
Line care and routine blood taking will be done at K8S special room for those under quarantine.
Action for patients

Mainly for susceptible patients and potentially contacted by the index patient in K8N during
period 15/3 to 17/3. They will be given varicella-zoster immune globulin (VariZIG) for 1 dose.
They will be put under quarantine for the specified period.
The following summarized the data of these patients and quarantine status:
Name Age Dx History of VZV Quarantine Remark
(ID) chickenpox antibody
SJP 5y ALL - - 25/3-14/4 susceptible
LCM 15y ALL - - 25/3-14/4 susceptible
KCH 7y ALL - - 25/3- 12/4 susceptible
YCH 2yr Neuro- - - 27/3- 14/4 Susceptible

blastoma (mother pregnant,
pending Ab result)
Immune group: no special action.

Name Age Dx History of VZV Quarantine Remark
(ID) chickenpox antibody
WHM 11 ALL + + - immune
KSL 14 Rhabdo + + - immune
TWT 4 ALL - +(vaccine) - immune
HMY 10 PBMT + + - immune
HKH 6 ALL + +(vaccine) - immune
LOK 7 AML + + - immune
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Quarantine period: 25/3 to 12/4 ( + 2days if the last contact is 17/3), inclusive (10 days from
first day of contact to 28 days after the last contact. Those who require quarantine and hospital
admission will be admitted to K7N isolation.
OPD attendance
If the patient who require quarantine attend out-patient follow-up, they should be advised to wait
outside the OPD clinic rather than coming into the waiting areas.
Distribution
COS
K7 and K8 Team heads and WM
KGOPD WM
Reported by Dr XXX
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Sick Leave recommendation for children with communicable

diseases
Disease Incubation Sick leave recommendation

period (days)
Acute conjunctivitis 1-12 Until no abnormal secretion from the eyes
Acute poliomyelitis* 7-14 At least 14 days from the onset of symptoms
Bacillary dysentery * 1-7 Until diarrhoea ceases and stool samples are
tested negative for such bacteria (test is to be
done on three stool samples collected at least 24
hours apart)
Chickenpox * 14-21 About one week or until all vesicles have dried up
Cholera * 1-5 Until non-infection is confirmed (test is to be done
on three stool samples collected at least 1 day
apart following 48 hours after the completion of the
antibiotic course)
Diphtheria * 2-7 Until non-infection is confirmed by negative result
on sample culture test (test is to be done on two
nasopharyngeal swabs collected at least 24 hours
apart following 24 hours after the completion of the
antibiotic course)
Hand, foot and 3-7 Until all vesicles dry up or as advised by the
mouth doctor. If enterovirus 71 is confirmed to be the
disease pathogen, take 2 more weeks of sick leave after all
vesicles have dried up
Hepatitis A * 15-50 Until at least 1 week from the appearance of
jaundice or as advised by the doctor
Measles * 7-18 4 days from the appearance of rash
Meningococcal 2-10 Until the completion of the bacteria removal
infections course
(invasive)*
Mumps * 12-25 9 days from the appearance of swelling
Rubella* 14-23 7 days from the appearance of rash
Scarlet fever * 1-3 5 days from starting the antibiotic course
Tuberculosis * Not definite As advised by the doctor
Typhoid fever * 7-21 Until at least three consecutive stool samples
collected no less than 24 hours apart are tested
negative for such bacteria (the first stool sample
has to be collected 48 hours after the completion
of the antibiotic course)
Viral gastroenteritis 1-10 Until 48 hours after the last episode of diarrhoea or
vomiting
Whooping cough * 7-10 5 days from starting the antibiotic course
# The recommendation made above is based on the general infection period only. Other factors,
such as the clinical conditions of the sick child, have to be considered as well. The attending
doctor should exercise his / her professional judgment when making the final decision on the
length of sick leave.
* Diseases to be reported to the Centre for Health Protection, Department of Health as required
by the law. Reference: http://www.chp.gov.hk/files/pdf/School_full_eng_20090115.pdf
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1.7 ADMISSION OF PAEDIATRIC PATIENTS
Admission procedure
1. Interns: Attend to admissions immediately when called. Resident should see new
admissions within one hour of admission.
2. Identify cases that require immediate isolation e.g. suspected SARS, chickenpox, measles.
These should be admitted to the negative pressure rooms in K7N.
3. Take a full history and perform a thorough physical examination. You can use the Template
for General pediatric admission on the CMS.
4. Document the time of attendance (e.g. 09:00). Sign and write your name and staff number.
5. Identify any drug allergy and G-6PD deficiency. Enter into CMS Alert. Apply red coloured
label onto medical record and drug charts.
6. Write down the name of the referring doctor on the Admission Sheet so that reply letter can be
sent for better communication and patient care. Write down the name of your team head in the
column "Doctors I/C".
7. Chart the growth parameters. You will be surprised how frequently you pick up abnormalities
hitherto unsuspected!
8. Admission of adolescent patient: Fill in the Adolescent Medicine Supplemental History
HEADSS.
9. Admission of child abuse cases: Use the Child Abuse Form.
10. Formulate a working diagnosis and manage accordingly.
11. Get help from senior if the child is sick.
Medical Orders
1. Write medical orders clearly and legibly.
2. Label each entry with time (e.g. 09:00) and date. Sign properly and write down your staff
number or the personal chop provided.
3. An incorrect entry should be cancelled by drawing a single line through it and the order
rewritten nearby to avoid confusion.
4. Properly written medical orders should cover the diagnosis and treatment. The following
schemes may be used:
 Diet
 Dispositions: includes the monitoring of vital signs, weighing the patient, special
observations, isolation procedures and permitted activities.
 Diagnostic tests: Group in logical sequence (e.g. blood and radiographic).
 Drugs:
i. Oxygen
ii. Enter IPMOE by MO
 Note any history of drug allergy and G-6-PD deficiency. Enter to CMS if any
Refer to the “Medication Manual” from QMH Pharmacy for details on drug information services,
24 hours Emergency Drug Cupboard, procedure guidelines on prescribing, handling of cytotoxic
drugs and drug allergy. (Access through CMS Station: Click on QMH intranet > Clinical
Information> Drugs> Medication Manual.)
Investigations and procedures

1. Explain to the patient and parents clearly and patiently the necessary procedures to
alleviate undue anxiety.
2. All procedures should be performed in the treatment room if possible.
3. Allow parents to stay with the child if they request.
4. Minimize the number of painful procedures by good organization of work and perfection of
skill. Get help when needed - don't be over persistent.
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5. Get the proper specimen/blood samples into the appropriate bottles. It is NOT acceptable
that the patient is subjected to another venepuncture because you send the wrong
specimen.
6. All laboratory request forms and specimens should be clearly labeled.
Consultation to subspecialty teams and other departments

 Neurology consultation
o Send the neurology consultation form by fax to Duchess of Kent Child Assessment Centre (Fax no:
2974 0330) and contact the acute neurology on-call doctor listed in the time-table
 Consultation to other subspecialties
o Contact respective subspecialty team heads/fellows by phone. (See time-table.)
 Consultation to other departments

o Consultations to other departments should only be initiated after assessment by MO. All urgent
consultations should be initiated after discussing with the most senior doctor of the team /on-call.
Category Response time of the department being Your action

consulted
Ultra-urgent Within 30 min Inform senior.
Urgent Within 2 hr Call doctor-on-call of other
departments and send
consultation form by fax.
Semi-urgent Within 1 calendar day disregard of Sat, Sun, Send consultation form by fax.
public holiday (should only use this during
weekends & PH)
Non-urgent Within 1 working day
Updated by Dr Q See
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SECTION 2: PROCEDURES IN PAEDIATRICS
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2.1 BLOOD SPECIMEN COLLECTION

Proper specimen collection
 Correct patient
 Correct technique
 Correct specimen bottles and labeling
 Correct laboratory request forms/GCR-LRS label
 Correct method of transport and accurate timing where necessary.
Methods of blood specimen collection

1. Capillary puncture (Heel prick)
2. Venipuncture
3. Arterial line
4. Central line
Preparing for blood taking

1. Identify patient.
2. Clarify orders and calculate the total volume of blood required.
3. Prepare appropriate specimen bottles and equipment.
4. Informed consent
5. Universal precautions
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2.2 CAPILLARY PUNCTURE (HEEL PRICK)
Equipment
1. Gloves
2. Alcohol swabs
3. Sterile gauze pads
4. Sterile lancets
 Microtainer – safety flow lancet with spring loaded and depth control design, suitable
for neonate
 Monolet – needle type, for collection of a few drops of blood only e.g. for
haemoglucostix
 Feather blood lancet – no safety depth, used with caution
5. Specimen bottles
6. Bandaid
Procedure
1. Select the puncture site
 Heel (neonates and infants)
Avoid penetrating the calcaneus by using a lancet puncture
smaller than 2.5 mm and by performing the puncture on the medial
or lateral plantar surface (shaded area as illustrated). The limits of
the calcaneus are defined by two lines, one drawn parallel to the
lateral margin of the heel from the space between the fourth and fifth
toes and the other drawn parallel to the medial margin of the heel
from the center of the great toe.
 Avoid the bottom of the heel.
 Avoid site of infection and edema
 Choose the warm and well-perfused foot. Warming
the extremity or placing it in a dependent position may
facilitate specimen retrieval.
 The maximum volume of blood collected is about
1.5ml.
2. Disinfect puncture site with alcohol swab. Allow to air dry.

3. Grasp the heel; slightly occlude the veins by flexing the ankle.
4. Puncture skin with sterile disposable lancet placed perpendicular to the plane of the heel. Make
a clean, superficial and small cut. DO NOT rotate or make a cross with the lancet.
5. Wipe away the initial drop of blood with dry gauze. Massage to express blood, allowing enough
time for capillaries to refill. Collect subsequent drops in a microtube. Avoid air getting into the
sample tube as this will affect air venting and blood flow.
6. DO NOT squeeze the wound as this alters blood composition and invalidates test values.
7. You can improve the blood flow
 by flexing the ankle.
 by wiping away the clotted blood on the puncture wound.
8. After finishing blood collection, press the wound with dry gauze to stop bleeding. Cover with
Bandaid. Make sure that bleeding has stopped before leaving patient.
9. Tidy up the place. Put lancet to sharp box.
10. Label specimen properly. Send specimen away with appropriate forms and bags.
Dr YK Ng
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2.3 BLOOD TAKING FROM CENTRAL VENOUS CATHETER
HICKMAN CATHETER BLOOD TAKING (non-touch sterile technique)

Purpose: To draw blood from Hickman Catheter with safe and effective method.
** Wash hands before& after procedure. Sterile items, close system. Very careful for critical
area.
 "Clamp Here". No pulling. No scissors. Use of a 10ml or larger syringe is
recommended.
 Blood culture from red lumen, white lumen, peripheral site.
 Blood for clotting profile: E.g. discard 3ml blood, take 1.5ml for CBP, LRFT, then
another syringe 2ml for clotting
 Use betadine for blood culture, TPN. Check with staff of K7, K10.
Equipment
 Alcohol wipe 70% (3+3+1+1). Gloves for Standard Precaution. Heparinized saline 50 units / 5ml.
 Two different size syringes: one syringe to discard blood, one syringe for blood sampling.
 Two 10 cc syringes - one for flushing l ml Heparinized saline, then one for flushing 4ml Heparinized
saline (in paediatric).
 Jelco to block the line or sterile needle to cap the IV tubing tip.
 Blood bottles. Patient labels.
Procedure
1. CHECK PATIENT INDENTITY. Wash hands thoroughly with antimicrobial soap and water.
2. Prepare all items in a big tray. Draw up heparinized saline in 10ml syringes. Wear gloves.
3. For continuous infusion: Stop all IV drip, clamp another lumen to avoid the blood result
interference with the IV infusion. e.g. TPN, dextrose, electrolyte. (Press RESET Lifecare pump).
4. Swab the catheter junction with Alcohol wipe vigorously with friction for 3 times. Allow the
antiseptic to air dry. Ensure that the smooth-edged clamp of the catheter is closed.
5. Disconnect the luer lock cap / IV tubing. Cap the IV tubing end with new needle. Swab the hub
thoroughly with Alcohol wipe vigorously with friction for 3 times. Allow the antiseptic to air dry.
Connect an empty 5ml syringe.
6. Release the clamp, aspirate 3ml blood to clear the catheter. (2 ml for neonate, re-infuse later).
7. Connect another syringe, unclamp the catheter, and draw the blood sample.
8. Clamp the catheter and change 1 ml heparinized saline syringe to flush the catheter. Then clamp
it. Alcohol wipe swab hub.
9. Release the clamp and inject the heparinized saline 4 ml into the catheter. (Create turbulent)
10. Clamp the catheter while flushing the last 0.5ml heparinized saline, to maintain positive pressure.
11. Close the clamp and remove the syringe. Alcohol wipe swab hub, and allow the antiseptic to air dry.
Connect a new injection cap to the end of catheter, or to connect with infusion tubing.
12. For continuous infusion, OPEN the catheter clamp first. To prevent accidentally rupturing of the
catheter by infusion pump. (Check drip rate if applicable. Press START.).
13. Secure the catheter to the position to patient’s chest.
14. Mix blood well inside the syringe. Then put the blood sample into appropriate blood bottles and mix
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well with the medium immediately. Label specimen and send with lab form. Document in patient's
record.
Ms SY Chiu
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2.4 PRE-TRANSFUSION COMPATIBILITY TEST IN NEONATES – CROSS
MATCH
1. Four-months rule
 Apply to all babies up to 4 months of age
 Both mother’s and baby’s blood samples are required for the first cross-match process
 If maternal antibody screening is negative, no further sample is required for subsequent
transfusion up to the age of 4 months
2. Baby’s blood sample

 The minimal volume is 0.8-1 ml of clotted blood for babies less than 4 months
 If maternal blood is not available, 1.5-2 ml of blood is needed and inform blood bank
 Enter <Investigation Request> with GCRS blood bank module in the CMS, enter mother’s name
and ID
 Print out the job sheet and generate the 2-D barcode label
 Write mother’s name, mother’s ID, the blood sampling date and sign your name on the label;
remember to sign on the job sheet after blood taking and put on the date
 Special arrangement required for unmatched blood, urgent whole blood for exchange transfusion
 Essential information for <paper request form>:
Name as B/O ……. Name of doctor taking

the blood
ID number Staff number
Hospital number Signature
Sex / Date of birth Date of blood sampling
Ward / Bed
number
Mother’s name
Mother’s ID
number
3. Mother’s blood sample

 Scenario 1: mother as in-patient in OBS unit of QMH
- Process cross-match with GCRS
 Scenario 2: mother as in-patient in another hospital
- Process cross-match with <paper request form>
- Double check the mother’s name and ID number, special attention to the blood sample provide
- Cross-match form preferred to be filled by referring hospital, do not accept GCRS form from
another HA hospital
 Scenario 3: mother accompanies the baby
- Process cross-match with <paper request form>
- If other just recently discharged from QMH OBS unit, can check with blood bank if mother’s blood
is needed, special attention to mother’s ID number, is it UN… or passport number
 Scenario 4: mother not available
- Special arrangement with blood bank
Dr YK Ng
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2.5 URINE EXAMINATION
Principles
1. Urine examination should be done by interns in indicated cases.
2. All infants and young children with febrile illness without localizing source should have urine
screened as early as possible.
3. All urine cultures should be sent to the laboratory within 20 minutes of collection.
Method of urine examination

 Urine that has been standing for > 1 hour is best discarded.
 Uncentrifuged, well-mixed urine should be examined using a counting chamber.
 Routine chemistry with multistix.
Procedure Guides of Using Counting Chamber in Urine Examination

External supports
The counting chamber and cover glass should be cleaned before use.
a. How to fill the counting chamber
Sliding on the cover glass

 The external supports are moistened with water
and the cover glass is gently pushed onto
the counting chamber from the front (see Fig. 1). Fig. 1 Interference lines
 Check the cover glass in correct position by the formation
of interference lines (Newton rings) between the external Caution! The cover glass is fragile!
support of the chamber and the cover glass.
Feeding
 Draw few drops of well mixed urine sample using a disposable plastic pipette.
 Wipe the pipette and hold it at an angle until the tip is placed between the cover glass and the
counting chamber as indicated in Fig. 2.
 The urine between the cover glass and the chamber is filled up by
capillary action. Before the overflow of urine at the edges of the chamber, the tip of the pipette must
be removed.
 The chamber must be cleaned and re-fed if air
bubbles are seen in the chamber or urine overflows
into the grooves. Fig. 2
Possible sources of error:

 The counting chamber is not clean
 The cover glass is not placed correctly onto the chamber
 The chamber is not filled free of bubbles
 The chamber is overfilled
 There is not enough time for sedimentation of the urine particles
b. How to clean the counting chamber

 Immerse the counting chamber and the cover glass into a 10% Clorox solution for 10 minutes
for disinfection.
 Discard the Clorox solution and then rinse the cover glass and counting chamber with tap
water.
 Dry the cover glass and chamber with soft tissue or kimwipes and return it to the box.
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Using a counting chamber (Improved Neubauer Counting Chamber)
1 mm
1 mm 3 mm
1 mm
Depth = 0.1 mm
 There are 9 large squares and each square is 0.1 ul in volume. Therefore, the total
volume of 9 squares is 0.9 ul.
 Use 40x amplification to identify cells morphology.
 Use 10x amplification for counting.
 Count all 9 large squares and calculate as follow:
Number of cells
----------------------------------- = cells per ul
0.9
Dr S Chim
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2.6 URINARY BLADDER CATHETERISATION
Indications
1. to obtain urine for urinalysis and culture sterilely
2. to monitor urine output
3. for voiding cystogram
Complications
1. trauma to urethra or bladder
2. vaginal catherisation
3. infection
4. intravesical knot of catheter ( rarely occurs, but it has happened!)
Procedure
1. Prepare the urethral opening using sterile technique.
2. Lubricate the catheter.
3. In boys, gently retract the foreskin. If it cannot be fully retracted, follow the general
guideline that the urethra is on the ventral side of the penis. Slide the catheter along that
track. Apply gentle traction to the penis to straighten the urethra. Slowly advance the
catheter until resistance is met at the external sphincter. Continued pressure will overcome
this resistance and the catheter will enter into the bladder. Insert a few cm longer than the
shaft of the penis.
4. In girls, labial traction (gentle grasping of the labia and pulling towards you) allows better
visualization of the introitus than labial separation. The vaginal opening is more
pronounced than the urethral opening. The urethral opening is slightly superior to the
vaginal opening. ( Figure 1) Advance the catheter for a few cm to reach the bladder.
5. Carefully remove the catheter once specimen is collected.
Figure 1
Dr A Tsang
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2.7 LUMBAR PUNCTURE

Equipment
1. Sterile gloves
2. Povidone-iodine
3. Lumbar puncture set: Sterile drapes, cotton wool swabs, sterile gauze, sterile
collecting tubes
4. Spinal needle
Spinal needle size by age
Premature infant 22 gauge or smaller, 1.5 inch, plastic hub
preferred
Neonate – 2 year 22 gauge or smaller, 1.5 inch, plastic hub
preferred
2 – 12 years 22 gauge, 2.5 inch
> 12 years 20 or 22 gauge, 3.5 inch
5. Manometer – separate sterile set to be added and assembled for measuring opening
pressure
Procedure
1. Informed consent (Pamphlet explaining the procedure available in the ward)
2. Prepare the child for the procedure and apply EMLA.
3. A key component of a successful lumbar puncture is adequate restraint of the patient.
Get a good assistant.
4. Place the patient either in the sitting position or in a lateral recumbent position with the
head flexed, knees drawn up to the abdomen and back arched. This helps to increase
the space between the lower lumbar vertebrae. DO NOT compromise infant’s
cardiorespiratory status by positioning. Monitor the heart rate, respirations and
oxygen saturation during procedure especially in neonates, young infants and
children with any degree of cardiorespiratory compromise.
5. Palpate the upper aspect of the posterior superior iliac crests. The imaginary line
joining the iliac crests intersects the midline just above L4. Identify the interspace
between the L3 to L4 and L4 to L5 and one site is chosen for puncture.
6. Aseptic technique
7. Cleanse the site thoroughly with povidone-iodine. Allow to air dry. Drape the
surrounding area with sterile towels.
8. The selected interspace is palpated with the sterilely gloved forefinger. Insert the
spinal needle with stylet through the skin between the spinous processes.
 Lateral recumbent position - Angle the needle about 15 degrees cephalad towards
the umbilicus, keeping it level with the mid-sagittal plane of the body. Bevel of
needle is placed horizontally so that dura mater is pierced parallel to its fibers.
 Sitting – perpendicular to skin (slightly cephalad), bevel of needle held vertically
9. Advance the needle slowly, removing the stylet frequently to check for cerebrospinal
fluid (CSF). If you hit the bone, withdraw the needle slightly and change its angle. In
a median puncture, the needle punctures through the following structures (in order):
skin, subcutaneous fat, supraspinal ligament, interspinal ligament, ligamentum flavum,
dura mater and arachnoid mater into the subarachnoid space. There is a slight “pop”
felt as the spinal needle penetrates the dura. In infants, a pop may not be felt and the
spinal needle should be advanced approximately 1 to 2 cm.
10. Once in the subarachnoid space, CSF will flow freely. If necessary, connect to
manometer to measure the CSF pressure. Have the patient straighten the legs and
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relax so as not to artificially elevate the opening pressure.
11. Collect the smallest volume of CSF necessary, controlling the rate of flow of CSF with
the stylet. Allow the CSF to drip into collection tubes for diagnostic studies. If CSF
does not flow, rotate the needle 90 degree. If rotation of the needle does not result in
CSF flow, replace the stylet and advance a little farther.
12. Once you have obtained enough CSF, replace the stylet and withdraw the needle.
13. Apply a small sterile dressing to the puncture site.
14. Label the tubes properly and deliver to laboratory immediately.
15. Record procedure start and completion times, patient’s status, CSF appearance, and
CSF pressure readings.
16. The patient should lie prone (flat or horizontal, or on the abdomen) for approximately
4 to 8 hours. Observe for neurologic changes such as altered level of consciousness,
change in pupils, change in temperature, increased blood pressure, irritability, and
numbness and tingling sensations, especially in the lower extremities.
17. Check the puncture site for leakage.
18. A traumatic tap occurs when the needle penetrates the dura too far to one side into an
epidural venous plexus or when the needle is advanced through the subarachnoid
space into or adjacent to the vertebral body. If blood is seen during fluid collection but
the spinal needle is in proper position, the CSF will usually clear and the specimen
does not clot. If the body fluid does not clear and clots in the specimen bottle, the
spinal needle is in the wrong position and should be removed.
Contraindications
1. Local lumbar skin infection
2. Raised ICP (except pseudotumor cerebri)
3. Supratentorial mass lesions (evaluate by CT scan first)
4. Severe bleeding diathesis (relative contraindication)
5. Platelet count < 50,000/mm3
Dr A Tsang
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2.8 MANTOUX TEST
(Extracted from “Mantoux test – do it the right way” by the Centre of Infection HKU)
available at http://www.hku.hk/hkucoi
Procedure
1. Observe universal precautions.
2. Draw up 0.1 ml Tuberculin PPD RT23 into a 1ml syringe. [Each 0.1ml of PPD RT23 contains
2 tuberculin units(MT2) which is equivalent to 5 tuberculin units of PPD-S (MT5)].
3. Cleanse the skin on the volar aspect of the mid-forearm with alcohol and allow to dry
thoroughly.
4. Stretch the skin taut.
5. Hold the syringe at 10-15 degree to the skin and introduce the needle just below the epidermis
(about 2mm). Inject the tuberculin into the intradermal skin layer to produce a well-defined bleb
of 6 to 10 mm in diameter. If the bleb is <6mm, repeat the process 2.5cm from the first site.
6. Document the time and site of test in the patient’s record.
7. Read the test results in 48 to 72 hours. Measure the size of the induration. Disregard
erythema. Rub a finger lightly from the normal skin area to the indurated zone and mark the
zone of induration. Measure the diameter in millimeters perpendicularly to the long axis of the
forearm. DO NOT just write down “positive” or “ negative”.
8. Document the result (report on the size of the induration) in the case record (and the CMS).
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2.9 SEDATION FOR PROCEDURES
Admission Protocol for Sedation and Diagnostic procedures in K10 Day ward
1. When arranging the diagnostic procedure for the patient, also assess his/her risk for
sedation.
2. Inform parents about the risk of sedation and the risk of the procedure; prescribe steroid for
steroid cover if necessary.
3. The parent-ward booking the procedure will inform patient of the appointment when it
returns; instruct on the duration of fasting and advise on sleep deprivation.
4. When sedation under general anaesthesia (GA) is required, followed the instruction for
consultation to anaesthetist.
5. On admission to Day ward, approach by nursing staff; confirm patient’s identity, procedure
and appointment.
6. Confirm time of last meal and drink.
7. Document admission condition, vital signs, measure body weight and body height.
8. Evaluation screening with medical history and focused examination of all patients by
interns.
9. Assess the patient risk by a trained resident; to decide on the sedation to be used and
degree of monitoring required.
10. Obtain informed consent for the procedure, explained the risk of the procedure.
11. Also explain possible risk of sedation and provide parents with the sedation leaflet.
12. Indicate special point for care on patient record to staff of Radiology Department
(RD), such SpO2 limits for cyanotic heart patients.
13. Intern will prescribe antibiotic cover and oral sedative drugs under supervision of the
trained resident; dosage should be cross-checked by nurse.
14. Intern will set up intravenous block as necessary.
15. Check if steroid cover has been prescribed and taken for indicated patients.
16. Prescribe iv fluid if prolonged fasting is expected, especially for neonates.
17. Prescribe iv fluid bolus as requested for respective investigations.
18. Check and document vital signs and oxygen saturation of those low risk patients after oral
sedation given.
19. Check again and document before transport to diagnostic departments.
20. Advised to have continuous oxygen saturation monitor for all sedated patients.
21. All moderate and high risk sedated patients will also have ECG +/- End tidal CO2
monitoring continuously and documented.
22. Set and check appropriate alarm limits and alarm volume for the monitors during transport.
23. When oral sedation failed, resident will be informed and shall attend RD as soon as
possible.
24. IV Midazolam will be given by the resident.
25. RD will inform the ward when iv sedation has been given; ward will prepare nurse to escort
patient back from RD with appropriate monitor and resuscitation kit.
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26. The choice of further sedation will depend on:
i. The accumulated dose of iv Midazolam given.
ii. The time laps after the last dose of iv Midazolam.
iii. Cautious in prescription of further doses unless the dosing interval is long
enough, otherwise it is advised to use IV Ketamine.
iv. Postpone the procedure if adequate sedation cannot be achieved.
v. Put the patient on continuous monitor and consider escalation to the next line of
sedation.
27. Contact the resident for any adverse effect related to the procedure and activates
emergency pager when resuscitation is necessary.
28. Document the adverse events and resuscitation process.
29. Set and check appropriate alarm limits and alarm volume for the monitors during recovery.
30. Continue the observation and documentation of vital signs, oxygen saturation and
conscious state till patient fully conscious and alert or return to his/her usual neurological
state.
31. Assess the patient, document the discharge condition when they meet the criteria.
32. Instruct on post-sedation home care with information leaflet.
33. Document any adverse event during the procedure and complete TROOPS table in
Sedation Record.
34. Enter appropriate procedural codes in CMS, e.g., Oral sedation (99.99)
Two trained residents will be assigned to K10 Day ward to cover the regular Paediatric RD
sessions.
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Allocation of Sedation Risk
I. Increased risk patients (Presence of experienced medical practitioners or anaesthesiogist

strongly recommended)
 ASA Physical Status III or IV
 Procedures requiring deep sedation
 History of airway obstruction (e.g., large tonsils), difficult tracheal intubation, loud snoring,
obstructive sleep apnoea and central apnoea
 History of failed sedation, over-sedation or paradoxical response to sedation
 Prematurity or ex-premature infant, especially those with post conceptual age < 60 weeks
 Active pulmonary, cardiovascular, gastrointestinal, neurologic problems
 Poorly controlled asthma
 Obesity
 Poorly controlled seizures
 Uncontrolled gastro-oesophageal reflux
 Severe developmental delay
 Sedation in patients with a full stomach
II. Standard risk patients (ASA class I or II)

 Patients without the above-mentioned risk factors
American Society of Anesthesiology (ASA) Classification of Physical Status

Class Risk description
I A normal healthy person (STANDARD RISK)
II A patient with mild systemic diseases (e.g., a child with controlled reactive airway
disease) (STANDARD RISK)
III A patient with severe systemic disease (e.g., a child who is actively wheezing)
(INCREASED RISK)
IV A patient with severe systemic disease that is a constant threat to life (e.g., status
asthmaticus) (INCREASED RISK)
V A moribund patient who is not expected to survive without the operation (INCREASED
RISK)
E Patient requires emergency procedure (INCREASED RISK)
1. Only standard risk patients can be admitted to day ward for procedural sedation and
analgesia.
2. The increased risk patients are advised to have the procedure as in-patient.
3. Increased risk patients may indicate consultation to anaesthetist and GA session for
procedures:
a. Difficult airway, airway malformations
b. Intractable convulsion
c. Required assisted ventilation
d. Neuromuscular diseases
e. Require prolonged sedation
f. Difficult sedation such as hyperactivity
g. History of failed sedation with third line sedatives
h. History of adverse effect with sedation
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Pharmacological intervention
1. Pharmacological intervention for non-painful procedures

a. Neonates:
Single dose: Chloral hydrate 50 mg/kg oral 30 minutes before examination
Reduce to 20-30 mg/kg for at risk or premature neonates
Consider to be increased risk patient when oral sedation fails
b. Children < 8 years:

First line: Chloral hydrate 75 mg/kg oral 30 minutes before examination
A top up dose of 25 mg/kg oral after 30 minutes
Maximum total dose 100 mg/kg or 2 grams
Second line: Midazolam 0.1 mg/kg slow IV
Titrate and repeat doses of 0.1 mg/kg after 2-3 minutes
Up to maximum total dose of 0.4 mg/kg or 5 mg
Third line: Ketamine 1-2 mg/kg IV
Addition boluses of 1 mg/kg after 10 minutes
Up to maximum total dose of 2-4 mg/kg IV
May give Atropine 0.01-0.02 mg/kg IV 2 minutes before Ketamine injection to
reduce salivation
c. Children > 8 years:

First line: Midazolam 0.1 mg/kg slow IV
Titrate and repeat doses of 0.1 mg/kg after 2-3 minutes
Up to maximum total dose of 0.4 mg/kg or 10 mg
Second line: Ketamine 1-2 mg/kg IV
Addition boluses of 1 mg/kg after 10 minutes
May give Atropine 0.01-0.02 mg/kg IV 2 minutes before Ketamine injection to
reduce salivation
2. Pharmacological intervention for short painful procedures

a. Ketamine 1-2 mg/kg IV
Addition doses of 1 mg/kg after 10 minutes
May give Atropine 0.01-0.02 mg/kg IV 2 minutes before Ketamine injection to reduce
salivation
OR
b. Ketamine 2-4 mg/kg IM

Do not repeat the dose if it fails as the first IM dose is expected to have prolonged sedative
effect
OR
c. Midazolam 0.1 mg/kg IV in addition to local anaesthetic infiltrate
OR
d. Fentanyl 1 microgram/kg IV, maximum 50 microgram/dose

Titrate with Midazolam 0.05-0.1 mg/kg IV, maximum 0.2mg/kg IV
Addition doses after 3 minutes
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3. Pharmacological intervention for prolonged procedures
a. Ketamine 1-2 mg/kg IV and Midazolam 0.05 mg/kg IV

Addition doses of Ketamine 1 mg/kg after 10 minutes
May give Atropine 0.01-0.02 mg/kg IV 2 minutes before Ketamine injection to reduce
salivation
OR
b. Fentanyl 1 microgram/kg IV, maximum 50 microgram/dose

Titrate with Midazolam 0.05-0.1 mg/kg IV
Addition doses after 3 minutes
Updated by Dr CY Chow
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2.10 STEROID PREMEDICATION IN RADIOLOGICAL INVESTIGATIONS
Extracted from Guidelines from COC (Radiology) HA 2019. available online: Click EKG>
Clinical Guidelines> Radiology > Guidelines on Iodinated Contrast Media and Use of
Steroid Premedication
Indications and contraindication

Indications*
- History of prior allergic-like or unknown-type contrast reaction to the same
class of contrast medium
Relative Contraindications*
- Diabetes Mellitus –especially patients with vascular and renal complications
- Acute tuberuculosis
- Acute leukaemia and lymphoma
- Compromised immune system
- Systemic fungal disease or other systemic infection
- Peptic ulcer disease or diverticulitis within the past year
*Decisions subject to collaboration with referring clinicians
Recommendation for oral steroid premedication
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Recommendation for IV steroid premedication
Glucocorticoid comparison
Agent Equivalent Route of Relative Relative Biologic

Dose Administration Anti-inflam Mineralo- al
(approx. mg) IM – intramuscular matory corticoid Half-life
IV – intravascular Potency Potency (hours)
PO – per oral
Betamethasone 0.6-0.75 IM, IV, PO 20-30 0 36-54
Dexamethasone 0.75 IM, IV, PO 25-30 0 36-54
Hydrocortisone 20 IM, IV, PO 1 2 8-12
Methyl-prednisolone 4 IM, IV, PO 5 0 18-36
Prednisolone 5 PO 4 1 18-36
Prednisone 5 PO 4 1 18-36
Updated by Dr Q See
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2.11 PREOPERATIVE FASTING REGIMEN FOR PATEINTS REQUIRING
ANAESTHESIA
(Extracted from Guidelines for preoperative fasting 2021, COC in Anaesthesiology, available
online: Click EKG> Clinical Guidelines> Anaesthesiology >Preoperative fasting)
For all elective patients requiring anaesthetic care who are NOT at increased risk of pulmonary
aspiration:
1. Break the “nil by mouth (NPO) after midnight” rule.
2. Implement “1-4-6-8” rule for children under 3 years of age undergoing elective
procedure
 Clear fluids include water, fruit juices without pulp, and carbonated beverages up to
10ml/kg can be taken 1 hours prior to operation.
 Breast milk can be taken 4 hours prior to operation
1. For infant under 6months of age, breast milk fasting policy of 3hours and
formula milk fasting policy of 4hours
 Solid food (including milk/ jelly) can be taken 6 hours prior to operation
 Fatty food can be taken 8 hours prior to operation.
3. Implement “1-6-8” rule for adults and children above 3 years of age
For morning session, no food after midnight.
 Clear fluid allowed up to 1 hours prior to operation.
 Clear fluids include water, fruit juices without pulp, carbonated beverages, clear tea
and black coffee. Clear fluid should not include alcohol.
 Only clear fluids allowed between 1 to 6 hours before anaesthesia.
For afternoon session commencing after 13:00, light breakfast at 7am.
 Light breakfast includes either a toast without butter or rice porridge without meat.
 Clear fluid is allowed up to 11:00, or 1 hours before scheduled time of operation
4. No fluid allowed within 1 hours before anaesthesia except for oral premedications
with sips of water.
5. Start IV fluid if operation schedule is unpredictable or fasting period is expected to be longer

than 12 hours for a whole day list.
Updated by Dr Q See
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2.12 CARDIOPULMONARY RESUSCITATION

Successful resuscitation depends on establishing adequate circulation and ventilation before
irreversible cerebral and cardiac damage has occurred. Every medical staff must be able to
perform external chest compression (ECC) and artificial ventilation.
Immediate steps: GET HELP. Call senior. CPR hotline (ext. 3333) should be activated by bedside
staff.
CPR sequence: Chest compressions, Airway, Breathing (C-A-B)
1. Maintain CIRCULATION (ECC)
2. Maintain AIRWAY (clear mouth & pharynx, lift chin up & forward, oropharyngeal airway)
3. Maintain BREATHING (face mask bagging with 100% O2 is effective in most condition, do not
hurry with intubation especially if you are not competent)
The following steps should take place simultaneously:

1. Note time of arrest.
2. Attach ECG & SaO2 monitoring.
3. Diagnose rhythm - asystole, VF, pulseless VT, pulseless electrical activity (PEA)
4. Establish vascular access for drugs & fluids - IV/ intraosseous (IO).
5. Give appropriate drugs according to rhythm.
6. Asystole: Adrenaline (1:10,000) 0.1 ml/kg IV / IO or 0.1 ml/kg of 1:1000 ET every 3-5 minutes
7. VF/pulseless VT: Defibrillation with shock energy 2 J/kg
8. PEA: adrenaline as above
9. Other drugs (e.g., 8.4% NaHCO3 1 ml/kg, 10% Ca gluconate 0.5 ml/kg)
Updated by Dr CY Chow
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2.13 MANAGEMENT OF ANAPHYLAXIS
Protocol for Management of Anaphylaxis: a Quick Guide
For complete reference, please refer to HA COC Guideline “Management Guideline for Childhood
Anaphylaxis”
http://hacgl.home/getDMSPDF.aspx?FileUrl=http://hadms.home/HAHO/PAE/PDF%20DMS%20D
ocument/3e58fef0-3828-4353-888e-38aa382b169d/HACOCPaedAnaphylaxisGuideline_1.pdf
What is anaphylaxis?
Severe, potentially life-threatening systemic hypersensitivity reaction, characterized by being rapid
onset with life-threatening airway, breathing, or circulatory problems and is usually, although not
always, associated with skin and mucosal changes.
Definition of Anaphylaxis
Signs and Symptoms of Anaphylaxis
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Possible Triggers
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Measurement of Serum Tryptase

- Maybe useful for distinguishing anaphylaxis from other conditions e.g. vasovagal reactions, septic
shock, seizures, myocardial shock, benign flushing, or carcinoid syndrome
- Total tryptase should be measured within 15 minutes to 3 hours after onset of anaphylaxis
symptoms
Quick references for medications

1. Adrenaline
a. 0.01 mg/kg (0.01 mL/kg of 1:1000) by IM, maximum 0.3 mg for children and 0.5 mg for
adult-sized adolescents
b. There is no good evidence to recommend a dosage for infants <1 year of age
c. Never give 1:1000 adrenaline intravenously due to high risk of toxicity.
d. Time frame recommended is 5-10 minutes after the 1st dose.
2. Corticosteroids
a. Prednisolone (oral) - 0.5 mg / kg / day
b. Methylprednisolone (IV) - 1-2 mg / kg / day (maximum: 100 mg for >12 yrs old and 50
mg for 12 yrs old)
c. Hydrocortisone (IM or slow IV) - 2-4 mg / kg / dose (maximum: 200 mg for >12 yrs old
and 100 mg for 12 yrs old)
3. Anti-histamines (Anti-H1) – IV or IM chlorpheniramine
a. >12 years old: 10 mg;
b. 6 - 12 years old: 5 mg
c. ≤5 years old: 0.1 mg/kg, up to maximum 2.5 mg
** Caution - antihistamine use in infants younger than 6 months old requires close observation
4. Anti-H2
a. Most consider there is no solid evidence to recommend its routine use.
b. Ranitidine 1 mg/kg IV over 5 minutes
c. No dosage recommendation for cimetidine
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Prescription and use of JEXT® adrenaline auto-injector
- Preparations: 0.15mg in yellow and 0.3mg in red
- Dosage suggestion
Adrenaline autoinjector Dosage guide in Additional Recommendations

drug information (EAACI 2014 guidelines)
0.15mg (Jext pen yellow) 15-30kg may be prescribed to 7.5-<15kg
if indicated
0.3mg ( Jext pen red) >/=30kg to be considered when patient is >
25kg
- Who should be prescribed?

o Previous anaphylaxis with known trigger (e.g. food, latex, aeroallergens or unavoidable
triggers)
o Previous idiopathic anaphylaxis
o Exercise-induced anaphylaxis
o Co-existing unstable or moderate to severe persistent asthma with food allergy
o Venom allergy inadults with previous systemic reactions (unless receiving maintenance
venom immunotherapy [VIT]) and children with more than systemic cutaneous reactions
o Underlying mast cell disorder or elevated baseline serum tryptase concentration
together with any previous systemic allergic reactions to insect stings, even in VIT-treated
patients
- Provide action plan with instruction of use to carry with medication
- Refer to clinical pharmacists for education. Demonstration kit also available in ward A6 if clinical
pharmacists are not available during weekend or long holiday.
Prescription
 Prescribe via CMS MOE, approval by specialist
 Prescribe one JEXT® for each patient at one time. More than one JEXT® pen may be
prescribed if needed to be kept in other places e.g. at school.
 Note expiry date – shelf life usually ranges between 12-18months
 Consult clinical pharmacist on technique of auto-injector use.
 Education tool and pamphlets are also available in A6 ward in case clinical pharmacists
are not available during weekend or public holidays.
Steps to use JEXT®
1. Grasp the injector with dominant hand with thumb closest to the yellow cap
2. Remove the yellow cap with the other hand
3. Push the black tip firmly at 90 degrees angle at the upper lateral thigh until a “click” sound is
heard. The needle can penetrate most garments including denim.
4. Push firmly for 10 seconds then remove. The black tip will extend and hide the needle.
5. Massage the injection area for 10 seconds
6. Call 999 for an ambulance and indicate to para-medics that patient is suffering from
anaphylaxis
7. Use a second JEXT® pen if symptoms not improve.
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SECTION 3: COMMON PAEDIATRIC PROBLEMS
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SECTION 3.1: RESPIRATORY SYSTEM
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3.1.1: MANAGEMENT OF CHRONIC ASTHMA = recurrent + reversible (by bronchodilator) +

Long term management of Asthma bronchospasm (wheeze, cough, breathlessness)
General principles:
1. Asthma education and advocate partnership in asthma care

2. Avoid provoking factors where possible e.g. house-dust mite control / environmental
tobacco smoke / incense burn. Parents should be advised to QUIT smoking (smoking
cessation hotline information available in KGOPD clinic)
3. Selection of best inhaler device with consideration of age of patient, the type and dosage
of inhaled steroids used
4. Choose the step most appropriate to the initial severity of asthma, aiming to control
symptoms as quickly as possible
5. Step up treatment as necessary to achieve good control
6. Step down treatment if there is good control of asthma (refer to table 1: level of asthma
symptom control)
7. Assess for comorbidities e.g. allergic rhinitis, obstructive sleep apnoea, GERD
Table 1: Level of asthma symptom control
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Pharmacological management
The British asthma guideline (2019), produced by the British Thoracic Society (BTS) and the
Scottish Intercollegiate Guidelines Network (SIGN), suggest a step-wise pharmacological
management of asthma in children (see figure below).
The primary aim of asthma management is to achieve good control of the disease. But every
asthma review should also involve an assessment on the factors that put an individual at an
increased risk of a future asthmatic attack.
Before stepping up treatment, make sure:

- Check drug compliance
- Check inhaler technique
- Eliminate trigger factors as far as possible
Point to note*
Another international asthma guideline, the Global Initiative for Asthma (GINA), made a major
change in treatment recommendation in 2019, which was considered to be the most fundamental
change in asthma management over the past 30 years. They no longer recommend treatment of
asthma in adolescents and adults with short-acting beta-agonist (SABA) alone. Instead, to reduce
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the risk of serious exacerbations, all adults and adolescents with asthma should receive either
symptom-driven (in mild asthma) or daily inhaled corticosteroid (ICS)-containing treatment.
The new treatment recommendation for adults and adolescents 12 years and above can be seen
in the table below.
*At the moment, our department adopts this approach in few selected patients, especially those
with concern of possible SABA overuse. Please discuss with senior before initiating this treatment.
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Stepping down of treatment
 Patients should be maintained at the lowest possible dose of inhaled steroid to

achieve good asthma control
 When deciding which drug to step down first and at what rate, things to consider
include: the severity of asthma, side effects of treatment, therapeutic effect of each
drug and patient preference
 Reduction in inhaled steroid dose should be slow as patients deteriorate at
different rates
 Reduction should be considered every three months, decreasing the dose by
approximately 25-50% each time
Discharge criteria and arrangement:
1. Consider discharge if the patient has stopped regular inhaled steroids for > 1 year and has
maintained good asthma control
2. Asthma is mild or infrequent episodes only
3. Referral to GP / government OPD / family clinic
4. If the patient still requires regular follow up, refer to:
- Other paediatrics unit upon parental request
- Adult medical unit if >= 18 years
Inhaler devices for ICS for children of different ages
Age (years) Devices
<1 Spacer with mask (MDI) – aerochamber (infant)
Nebulizer
1-6 Spacer with mask (MDI) – aerochamber (children)
>6 Spacer (MDI) – space chamber
Dry powder inhaler
.
INHALER TECHNIQUE
General principles
 Provide demonstration and illustrated instructions whenever a new inhaler device is

prescribed
 Technique should be checked regularly for all types of inhaler device
 MDI + spacer device is strongly recommended for paediatric patients of all ages. A
face mask is required until the child can breathe reproducibly using the spacer
mouthpiece. Where this is ineffective, a nebuliser may be required.
 Advise mouth rinse for all types of inhaled steroids (although some types are shown
to have minimal systemic effect); wipe the face if face mask is used instead of mouthpiece
for spacer device
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 Home nebuliser is not encouraged. Please discuss with respiratory team before
prescribing it
METER DOSE INHALER (MDI)
Steps
1. Remove the mouthpiece cover

2. Shake the inhaler vigorously
3. Breath out deeply
4. Hold MDI upright
5. Put mouthpiece between lips
6. Head tilt slightly back
7. Actuate MDI
8. At the same time, inhale slowly and deeply via the mouth
9. Hold breath for 10 seconds
10. Exhale through the nose
11. Replace the cover
12. If more than 1 puff is required, wait for at least 30 seconds, repeat step 2 to 10
Common errors
1. Forget to shake well the canister

2. Poor coordination of actuation and inhalation
3. Stop inhalation when the cold aerosol hits the soft palate (cold Freon effect)
4. Actuation of the aerosol into the mouth followed by inhalation through the nose
5. Too rapid inhalation
SPACER DEVICES ( SD ) WITH MOUTHPIECE / FACE MASK
Steps
1. Assemble SD
2. Remove the cap of meter dose inhaler ( MDI )
3. Shake well the canister of MDI
4. Connect MDI to SD securely upright
5. Hold SD horizontally or with MDI side pointing slightly upwards
6. For use with mouth piece:
 Seal lips around mouthpiece of SD
 Actuate MDI
 Perform tidal breathing slowly through SD immediately after actuation with
rocking sound of SD heard
 Perform 5-10 tidal breaths before removal of SD
7. For use with face mask:
 Gently place the face mask over the child’s face covering the nose and chin, secure
tightly
 Actuate MDI
 Let the child breath in 5-10 times through the mask
If more than 1 puff is required, repeat steps 3 to 7
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Common errors
 Actuate before applying mask to face or put mouthpiece to lips

 Lip / face seal not tight enough
 Multiple actuation
 Breath too fast through SD
 Forget to shake the canister of MDI for the subsequent dose
Remarks
 Use of spacer device reduces oropharyngeal deposition of drugs by about 50%.

 Spacers should be cleaned as per manufacturer’s recommendations. They should be
washed in detergent and allowed to air dry
 Prime the spacer with few puffs of a reliever puffer after washing or before use for a spacer
that is only used occasionally
TURBUHALER ( TH )
Steps
1. Unscrew and lift off the cover

2. Check the window on the TH to ensure that it is not empty
3. Hold TH upright
4. Turn the basal rotating disk clockwise and anticlockwise once, with a click sound heard
5. Breath out
6. Seal the mouthpiece around the lips
7. Inhale deeply and rapidly through the mouth
8. Remove the inhaler
9. Hold breath for 10 seconds
10. Breath out slowly
11. If more than one dose is required, repeat step 2 to 8
Common errors
1. Shake TH
2. Forget to check the window
3. Replace the mouthpiece with training whistle
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3.1.2 COMMON MEDICATIONS FOR CHILDHOOD ASTHMA
*Please cross check drug dosage with drug formulary and check with senior if necessary
Medications Age Dosage MDI (doses) DPI (dry powder inhaler) Oral/Injection
Salbutamol Acute mild to mod attack: 100mcg (200) Accuhaler 200mcg (60) syrup:2mg/5ml
( Ventolin ) MDI with spacer tablet:4 mg
<6yo: 6 puffs (equivalent to 2.5mg nebule)
>6yo: 12 puffs (equivalent to 5mg nebule),
q2-4hourly
Severe attack: can repeat MDI q20min in first 1-2

hours. Space out 1-4 hourly if condition settles
Nebulised Ventolin can be considered in severe

attack:
<6yo: 2.5mg
>6yo: 5mg
Dose can be repeated q20min in first 1-2 hours.

Taper to q1-2h thereafter according to response
Terbutaline ≥5 500mcg inh every 4-6 hourly Turbuhaler syrup:0.3mg/ml
( Bricanyl ) yr 500mcg(100) durule:5mg,
7.5mg
Salmeterol + ≥4 Depending on ICS requirement and age Seretide Lite MDI Accuhaler
Fluticasone yr 25mcg/50mcg Seretide 100
(Seretide) (120) 50mcg/100mcg (60)
Seretide Medium Seretide 250
MDI 50mcg/250mcg (60)
25mcg/125mcg Seretide 500
(120) 50mcg/500mcg (60)
Seretide Forte
MDI
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25mcg/250mcg
(120)
Budesonide + ≥ 12 Depending on ICS requirement and age Turbuhaler

Formoterol yr 160mcg/4.5mcg (60)
(Symbicort) SMART therapy 320mcg/9mcg (60)
Only use 160mcg/4.5mcg preparation for this
purpose:
(total not more than 8 inhalations per day)
\
Ipratropium For acute exacerbation: MDI 20mcg/puff
(Atrovent ) Neb 250 mcg/ml
By nebulization route:
Children:
250 mcg q20-30min
Adolescents: 500 mcg q20-30min
for the first few hours with nebulized Ventolin,
then space to 4-6hrly or discontinued
MDI if nebulization route not available (less

effective):
Children: 4 puffs q20min prn for up to 3 hrs
Adolescents: 8 puffs q20min prn for up to 3 hrs
Tiotropium ≥6 5mcg inh once daily Soft mist inhaler: Inhalation capsule
(Spiriva) yr Respimat 18mcg
2.5mcg (60)
Beclomethasone 100mcg to 200mcg inh b.d.* (common starting 50mcg (200)
dipropionate* dose) 250mcg (200)
(Becotide,
Becloforte )
Fluticasone* ≥4 50mcg to 100mcg inh b.d.* (common starting 50mcg (120)
( Flixotide ) yr dose) 125mcg (60)
250mcg(120)
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Theophylline Slo-theo:
30 months-8yrs: 10-14mg/kg/day divided BD
9-16yrs: 10-12mg/kg/day divided BD
Montelukast ≥ 6m 6m-5y: 4mg nocte

6-14y: 5mg nocte
15-17y: 10mg nocte
Aminophylline Loading dose: 5mg/kg (max. 500mg)

**Loading dose is only required for patients NOT
previously treated with theophylline**
Maintenance dose:
1m-11yo: 1mg/kg/hr
12-17yo: 0.5-0.7mg/kg/hr
Adjust according to plasma concentration
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3.1.3 MEDICATIONs FOR ALLERGIC RHINO-CONJUNCTIVITIS
SEDATING Syrup Tablet Unit Cost Dosage

ANTI-HISTAMINE HK$
Chlorpheniramine 2mg/5ml 4mg $0.04 1-2yr 1mg b.d
( Piriton ) 2-6yr 1mg 4-6 hrly
6-12yr 2mg 4-6 hrly
>12 yr 4mg 4-6 hrly
2mg $0.24 2-6yr 0.5mg 4-6 hrly.
Dexchlorpheniramine( Polarami 6-12yr 1mg 4-6 hrly
ne) >12 yr 2mg 4-6 hrly
NON-SEDATING ANTI-HISTAMINE Syrup Tablet Unit Cost Dosage

HK$
Cetirizine ( Zyrtec ) 1mg/ml 10mg $0.19
1 yr 0.25mg/kg b.d.
2-5 yr 2.5mg b.d.
6-11 yr 5mg b.d.
≥ 12 yr 10mg once daily
Loratadine ( Clarityne ) 1mg/ml 10mg $0.09
2-11 yr
<31 kg 5mg once daily
≥ 31 kg 10mg once daily
≥12 yr 10mg once daily
TOPICAL NASAL DECONGESTANT Conc. Amount / bottle

Xylometazoline ( Otrivin Paed ) 0.05% 10ml
( Otrivin Adult ) 0.1% 10ml
Oxymetazoline HCl (Afrin ) 0.5mg/ml
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TOPICAL STEROID NASAL SPRAY Age Dosage Dose ( per bottle )

( to each nostril )
Beclomethasone ( Aqueous ≥ 6 years old 50mcg to 100mcg 50mcg (200)
Beconase ) b.d.
Budesonide ( Aqua Rhinocort ) ≥ 6 years old 32mcg to 64mcg b.d. 32mcg (120)
64mcg (120)
Fluticasone propionate ( Aqueous ≥ 4 years old 50mcg daily 50mcg (150)
Flixonase )
Fluticasone furoate (Avamys) ≥ 2 years old 27.5mcg to 55mcg 27.5mcg (120)
daily
Mometasone (Nasonex) ≥ 2 years old 50mcg daily 50mcg (140)
TOPICAL EYEDROPS Amount ( per bottle )

Hypromellose 10ml
Olopatadine 0.2% (Pataday) 2.5ml
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3.1.4 MANAGEMENT OF ACUTE ASTHMATIC ATTACK
Asthma exacerbations (acute asthmatic attacks) are episodes of progressive increase in shortness
of breath, cough, wheezing, or chest tightness, or some combination of these symptoms.
Treatment depends on the severity of attack.
Aims of treatment are:

 To relieve airflow obstruction and hypoxaemia as quickly as possible
 To prevent future asthmatic attacks
Assessment of severity (BTS 2019)
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Hypercapnea (hypoventilation) develops more readily in young children than in adults and
adolescents.
Management of mild / moderate asthma attack
1. DAT
2. AR/RR Q4h
3. Check SpO2 – keep SpO2 ≥ 95%
4. Peak Flow BD
5. Oral prednisolone 1 mg/kg/day (max 2mg/kg daily up to 60 mg daily) – usually for 3-5 days for
moderate asthmatic attack
6. Inhaled beta-2 agonist : pMDI + spacer is the preferred option for children with mild to
moderate asthma
Age Dose of Ventolin MDI and method of administration

< 6 years old up to 6 puffs i.e. 6 x 100 microgram (equivalent to 2.5mg nebule)
Load the spacer one puff at one time and the child should have 5 tidal
breaths each time for efficient drug delivery.
> 6 years old up to 12 puffs i.e. 12 x 100 microgram (equivalent to 5mg nebule)
Load the spacer one puff at one time and the child should have 5 tidal
breaths or a single vital capacity breath each time for efficient drug delivery.
If the initial response is inadequate, Ventolin can be administered every 20 minutes for a total of 3
doses. Then space out 1-4 hourly until condition settles.
Severe asthma attack
Consider the following investigations:
 CXR
o Suspect pneumothorax or pneumomediastinum
o Life threatening signs
o Unsatisfactory response to treatment
o Signs of pneumonia
 Blood gas – consider if SpO2 < 92% in room air or with any life threatening signs
Investigations are rarely needed for immediate management and are not routinely indicated.
Do not rely on blood gas to decide on the initial management in children.
Close clinical monitoring is more important.
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Management of severe asthma attack
Immediate treatment
 High flow oxygen via face mask (up to 100%)

 β2 agonist (ventolin): pMDI vs nebulizer
o Consider pressurized metered dose inhaler (pMDI) via a spacer with a mouthpiece
or tightly fitting face mask
 Ventolin pMDI dosage: 6 to 12 puffs, up to Q15-20mins, depending on age
and severity
 Atrovent pMDI can be added on as an adjuvant therapy (see common
medications of childhood asthma)
o Nebulizers are aerosol-generating, which increases the risk of disseminating virus
to other patients AND to health care professionals. Therefore, they are only to be
used in single isolation room. Please discuss with senior before prescribing
nebulized Ventolin
 Nebulised Ventolin (1mg/ml nebule)
 0.15mg/kg/dose (max 5mg/dose)
 <6 years old: 2.5 mg
 >6 years old: 5 mg
 Consider using nebulizer in the following situations:
 Clinical features of severe/life threatening asthma on admission
 Patient fails to respond to ventolin via spacer device, especially if
< 2 years old
 Can be repeated every 20 minutes in first few hours
 If there is poor response to nebulized β2 agonists, can add on nebulized
ipratropium bromide (atrovent 250mcg/dose mixed with nebulised ventolin
solution)
 When patient shows improvement, nebulized ventolin dose should be tapered
to one to two hourly thereafter according to clinical response The
ipratropium dose should be tapered to four to six hourly or discontinued
 Once improving on two to four-hourly nebulized ventolin, patients should be
switched to a pMDI and spacer treatment as tolerated
 Steroid
o Give oral steroids EARLY in the treatment of acute asthma attacks in children
o Oral prednisolone 1 mg/kg/day oral (max 2mg/kg daily up to 60 mg daily) – usually
for 3-5 days
o IV hydrocortisone 4 mg/kg/dose (max 100mg) Q6H in severe cases who are
unable to tolerate oral medications
 In children who respond poorly to first-line treatments, consider the addition of IV magnesium
sulphate as first-line intravenous treatment (40 mg/kg, max dose 2g, as single dose). An
alternative intravenous treatment is IV aminophylline (please refer to table “common
medications for childhood asthma” for drug dosage), less preferred due to side effects
 Close monitoring and reassessment is always needed in patients requiring frequent
doses
Life threatening features
If life threatening features are present, inform senior for assessment for ICU admission!
 Deteriorating PEF, worsening/persisting hypoxia or hypercapnia
 Exhaustion, confusion or drowsiness
 Coma or respiratory arrest
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Discharge plan
1. Underlying cause of exacerbation identified and the problem rectified (e.g. environmental
tobacco smoke and refer for smoking cessation accordingly)
2. Regular asthma medication adjusted if necessary
3. Compliance reinforced. Watch out for any underlying psychosocial issues affecting adherence
to treatment.
4. Inhalation technique checked and recorded
5. Written Asthma Action Plan for instructions on subsequent asthma attacks
6. PEF > 75% predicted or best (from OPD record) and diurnal variability <25%
7. Stable on 4-hourly inhaled bronchodilator for the past 24 hours
8. Follow up arrangement:
1. Mild to moderate attack : respiratory / asthma clinic within 2 months
2. Severe attack: respiratory / asthma clinic within 4 weeks
References
1. GINA 2021.British Guideline on management of asthma

2. British Thoracic Society and Scottish Intercollegiate Guidelines Network 2019
3. Uptodate. Asthma in children younger than 12 years: Quick-relief (rescue) treatment for
acute symptoms
(Revised June 2009, last revised June 2021)
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3.1.5 ACUTE RESPIRATORY DISTRESS
Differential diagnosis
1. Respiratory: upper or lower
* Upper (stridor)
 foreign body
 viral laryngotracheobronchitis / croup
 acute epiglottitis
 bacterial tracheitis
 spasmodic croup
 others: angioneurotic edema, retropharyngeal abscess, diphtheria (in
non-immunised child)
* Lower (wheeze)
 asthma
 bronchiolitis
 pneumonia
2. Cardiac
Heart failure
 congenital heart disease
 rhythm problems e.g. SVT, heart block
 myocarditis
 cardiomyopathy
 secondary to severe anaemia, thyrotoxicosis, sepsis
3. Metabolic
* acidotic breathing
 Diabetic ketoacidosis (test urine x sugar and ketone)
 Salicylate (aspirin) poisoning
 Uraemia
 Fulminating sepsis
 Other metabolic disorders: MSUD
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3.1.6 ACUTE UPPER AIRWAY OBSTRUCTION
Important causes
1. Foreign body aspiration

2. Infection
- Croup (laryngotracheobronchitis)
- Acute epiglottitis
Acute epiglottitis
1. A clinical diagnosis: Tripod position, drooling, high fever, toxic appearance

2. A medical emergency!
3. Priority is to secure the airway
4. No manipulation including throat examination / XR neck / IV placement, which may
precipitate complete obstruction
Management of acute epiglottitis
1. Supplemental O2 / secure airway

2. Have parent accompany child. Keep child propped up and undisturbed
3. Have physician accompany patient at all times
4. Call: senior ICU paediatrician, anaesthetist and ENT surgeon
5. Escort patient to Operating Theatre where intubation will be done under anaesthesia
6. Place IV catheter in OT before induction of anaesthesia, with patient fully monitored and
ENT surgeon present with tracheostomy set ready
7. After airway is secured:
a. Take blood for
i. CBC D/C
ii. Culture
b. Broad spectrum antibiotics (cover for H. influenza, Strep. Pneumonia, Staph. Aureus):
IV Cefotaxime +/- IV Vancomycin (if suspicious of MRSA)
c. To ICU
d. Rifampicin prophylaxis for close contacts
Reference
Epiglottis. BMJ Best Practice. Last updated Jan 2018
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Acute laryngotracheobronchitis (croup)
 Most commonly caused by a respiratory virus e.g. Parainfluenzae, which leads to swelling
of the larynx and trachea
 Peak age: 6 months to 3 years
Clinical classification of severity
Mild: barky cough with no stridor / sternal or intercostal recession at rest
Moderate: barky cough with stridor and sternal recession at rest
Severe: barky cough with stridor and sternal / intercostal recession, associated with agitation or
lethargy
Signs of impending respiratory failure
 Sternal / intercostal retraction

 Asynchronous chest and abdominal movement
 Fatigue (may present with diminished stridor / retraction / absent breath sound)
 Signs of hypoxia – pallor, cyanosis, tachycardia
 Signs of hypercarbia – decrease GC
 Diminished stridor / retraction
Management of moderate to severe croup
1. Minimal handling
2. Clinical diagnosis – no x-ray in child with typical signs & symptoms
3. NO manipulation including throat examination. Any procedures like XR neck,
venipuncture or IV placement may precipitate immediate respiratory failure.
4. Oxygen as needed
5. AR/RR Q1h
6. SpO2 monitoring
7. Steroid on admission:
 Dexamethasone PO/IM 0.6 mg/kg
 Neb Budesonide (Pulmicort) 2mg (consider in children with severe hypoxia,
persistent vomiting, respiratory distress preventing oral dose)
8. Nebulized adrenaline 1:1000 0.5ml/kg (max 5 ml) for temporary relief (effect subsides in 2
hours)
9. To ICU if progressive deterioration or signs of severe obstruction
Investigations (only when patient is stable)
1. CBP D/C
2. (Blood C/ST)
3. Blood gas, RFT as indicated
4. Portable CXR, lateral XR neck
5. NPA x viral IF
Recurrent croup or slow to resolve croup – Consult ENT for airway evaluation
Reference:
Croup. BMJ Best Practice – Last Reviewed April 2018
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3.1.7 ACUTE BRONCHIOLITIS
 Occurs in infants under 2 years old
 Common etiologic agents: RSV, human metapneumovirus, rhinovirus, parainfluenza
virus, adenovirus
 Child with coryzal prodrome lasting 1 to 3 days, followed by persistent cough AND
tachypnea AND either wheeze or crackles (or both)
 Fever in only 30% of cases
 Watch out for complications e.g. apnoea in young infants, especially in RSV bronchiolitis
 Patients at risk of more severe disease include: chronic lung disease, congenital heart
defects with significant hemodynamic shunting, neuromuscular disease,
immunodeficiency
 Consider the diagnosis of early-onset asthma in young children if they have persistent
wheeze without crackles / recurrent episodic wheeze / personal or family hx of atopy.
 Explore and counsel caregivers about environmental tobacco smoke and smoking
cessation
Management
* Supportive treatment
1. DAT / Nasogastric or IV Isotonic fluid for infants who cannot maintain oral hydration /
NPO with IV Isotonic fluid (if in significant respiratory distress)
2. AR/RR Q1-4H
3. SpO2 monitoring
4. Nasal O2 to keep SpO2 > 92%  
5. Supportive management is the mainstay of treatment
6. Consider 3% Nebulised hypertonic saline (1ml H2O +1ml 5.85% NaCl) in selected
cases with significant resp distress / need of resp support / prolonged length of stay
7. No evidence for routine use of salbutamol. A therapeutic trial can be considered in
severe cases, especially those with atopic hx / family hx of asthma / suspicion of reactive
airway component. Reassess for response for continuing treatment
8. Antibiotics indicated only for secondary bacterial pneumonia (high fever / persistent
focal crackles)
9. Leukotriene receptor antagonists (LRA) – Montelukast are not recommended for routine
use in the treatment of bronchiolitis
10. Systemic or inhaled corticosteroids are not recommended for routine use in the
treatment of bronchiolitis
11. Chest physiotherapy is not routinely recommended (consider in children with relevant
comorbidities e.g. neuromuscular patients who have difficulty in clearing secretions)
Investigations
1. NPA x viral IF
2. CXR in patients with the following features:
a. severe respiratory distress
b. unexpected clinical deterioration
c. suspected alternate cause of respiratory distress
d. underlying cardiopulmonary diseases
3. Capillary blood gas (consider in children with severe respiratory distress)
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References:
1. American Academy of Pediatrics. Clinical Practice Guideline: The Diagnosis, Management,

and Prevention of Bronchiolitis. Pediatrics 2014;134(5):e1474–1502.
2. National Institute for Health and Care Excellence. Bronchiolitis: diagnosis and
management of bronchiolitis in children, Clinical Guideline NG9, 2015.
3. Australasian bronchiolitis guideline. J Paediatr Child Health 2019;55(1):42-53.
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SECTION 3.2: INFECTION
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3.2.1 ANTIMICROBIAL THERAPY
General principles
 Ask for any history of allergies before prescribing.
 If possible, collect specimens for microbiological examination before starting antimicrobial
therapy.
 When initiating therapy, consider
o severity of condition
o possible infecting pathogens – know the local epidemiology and resistance pattern
 Modify treatment according to child's progress and bacterial sensitivities.
Suggested initial treatment
Meningitis
Age Usual organisms Empiric therapy Remarks
< 1 month Gp B streptococci(GBS), IV Penicillin 200,000 GBS & Listeria : 14-21
Enterobacteriaceae, units/kg/day div Q6h (for days’ treatment.
Listeria monocytogenes neonates > 7 days and > 2kg) Enterobacteriaceae: 21
or IV Ampicillin 200mg/kg/day days’ treatment
div Q6H (>7 days and > 2 kg)
AND IV Cefotaxime
150mg/kg/day div Q6H (>7
days and > 2 kg)
Alternative: Penicillin/
Ampicillin + aminoglycoside
1-3 GBS, Streptococcus IV Vancomycin 60 mg/kg/day Hib : 7-10 days
month pneumoniae, div Q6-8H+ IV Cefotaxime S. pneumoniae: 10-14
Haemophilus influenzae 300mg/kg/day div Q6H for days
b, Neiserria meningititidis, possible penicillin-resistant S. N. meningititidis: 7 days
Enterobacteriaceae pneumoniae until susceptibility
is known.
Infants > S. pneumoniae, IV Cefotaxime 300mg/kg/day Watch out for Salmonella
3 months Haemophilus influenzae div Q6H or in infants and TB in older
and b, Neiserria meningititidis IV Ceftriaxone 100mg/kg/day children.
children div Q12H PLUS
IV Vancomycin 60mg/kg/day
div Q6-8H for possible
penicillin-resistant S.
pneumoniae until susceptibility
is known.
Pharyngitis/Tonsillitis
Usual organisms Empiric therapy Remarks
Gp A Streptococci Penicillin VK 20-50 mg/kg/day 10 days
div TID or QID po
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Pneumonia
Age Usual organisms Empiric therapy Remarks
Neonate GBS, E. coli, Staph IV Penicillin + Gentamicin or Use Ampicillin instead of
aureus, Listeria IV Penicillin + Cefotaxime Penicillin if suspect
monocytogenes Listeria. Give 10-21 days.
Infant/ Usually respiratory No antibiotics
child (< 4 viruses.
years)
S. pneumoniae, H. Amoxicillin/clavulanate PO 7-10 days
influenzae, Moraxella (35-45mg amoxicillin/kg/day
catarrhalis BD; high does of 80-90 mg
amoxiciilin/.kg/day div BD for Augmentin = Amoxicillin
PCN-nonsusceptible S. 400mg + clavulanate
pneumoniae) or Cefuroxime 57mg per 5ml, ratio 7:1
20-30 mg/kg/day div BID
IV: Cefuroxime 100-150
mg/kg/day div Q8H,
Cefotaxime 50-180 mg/kg/day
div Q6-8H, Ceftriaxone
50-75mg/kd/day div Q12-24H
Consider Chlamydia Erythromycin PO

trachomatis in infants < 3 30-50mg/kg/day TDS/QID
months
Child > S. pneumoniae, H. Amoxicillin/clavulanate PO (40 7-10 days
4yr influenzae, Moraxella mg amoxicillin/kg/day div BD;
catarrhalis high does of 80-90 mg
amoxiciilin/kg/day div BD for
PCN-nonsusceptible S.
pneumoniae)
IV: Cefuroxime, Cefotaxime,
Ceftriaxone
Mycoplasma pneumoniae Erythromycin PO 14 days

(Atypical pneumonia) 30-50mg/kg/day TDS/QID or
Clarithromycin PO
15mg/kg/day BD, or
Doxycycline2-4 mg/kg/day div No data but suggest 7

Q12 H the first day, then ½ days for uncomplicated
dose Q24H (for >7 yr, but pneumonia and good
consider for macrolide resistant response
M. pneumoniae) or
Ciprofloxacin (for > 18 yr, but
consider for macrolide resistant
M. pneumoniae)
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Acute Otitis media/ Acute sinusitis

S. pneumoniae, H. 1st line: Amoxicillin, or high dose Amoxicillin 5-7 days for OM (≥ 6 yr
influenzae 80-90mg/kg/day if likely to have with mild to moderate
(nontyepable), PCN-nonsusceptible S. pneumoniae disease); 10 days for
Moraxella catarrhalis Alt for Penicillin allergy: Cefuroxime, azithromycin younger or with severe
Persistent OM: Amoxicillin/clavulanate, disease
Cefuroxime, or Ceftriaxone (IM/IV) 10-14 days for sinusitis (or
Consult ENT 7 days after clinical
improvement)
Cellulitis

Gp A Streptococci, PO: Cephalexin 7- 10 days
Staphylococcus Alt: Amoxicillin/clavulanate.
aureus If Penicillin allergic, clindamycin
IV: Cloxacillin 50-100 mg/kg/day div Q6H (for ≥ 1
yr, maximum 4 gm/day). Alt: Cefazolin 50-100
mg/kg/day div Q8H, Clindamycin 20-40mg/kg/day
div Q6-8H
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3.2.2 COMMONLY USED ORAL ANTIBIOTICS
Drug Dosage
Amoxicillin(Amoxil) 40mg/kg/day div BID or TDS
125mg/5ml 80-90 mg/kg/d div BID or TID for PCN nonsusceptible S.
250mg capsule Pneumoniae
Adult: 250-500mg/dose TDS

Amoxicillin & Clavulanic Dosage based on Amoxicillin component
acid (Augmentin) 40mg/kg/day div BID or TDS
457mg/5ml (400mg 80-90 mg/kg/d div BID or TID for PCN nonsusceptible S.
Amoxicillin/57mg Clavulanic Pneumoniae
acid)
Adult: 250-500mg/dose TDS or 750mg/dose BD
Azithromycin (Zithromax) 10mg/kg daily loading dose, then a5 mg/kg/day (for otitis media
200mg/5ml and pneumonia)
250mg capsule 12 mg/kg/day Q24H (for pharyngitis)
Single dose of 1 g for STD caused by Chlamydia trachomatis
Ceftibuten(Cedax) 9mg/kg/day daily

180 mg/5ml
400mg capsule Adult: 400mg/dose daily
Cefuroxime(Zinnat) 20-30mg/kg/day div BID

125mg/5ml
125mg, 250mg tablet Adult 250-500mg/dose BD
Cephalexin 25-50mg/kg/day div BID

125mg/5ml(Keflex)
250mg, 500mg capsule 100mg/kg/day QID (max 1g) for follow-up oral therapy of
(Ceporex) osteoarticular infection
Ciprofloxacin(Ciproxin) 15mg/kg/day div BID

250mg, 500mg tablet
*given only when benefits outweigh risk of arthropathy
Clarithromycin 15mg/kg/day div BiD

(Klacid)
125mg/5ml Adult: 250-500mg/dose BD
250mg, 500mg tablet
Clindamycin 10-30mg/kg/day div TID or QID
150mg capsule
Adult: 150-450mg/dose TDS or QID
Co-trimoxazole (Septrin) Dosage based on TMP component

240mg/5ml(i.e. 40mg 8-10mg/kg/day BD
trimethoprim /200mg
sulphamethoxazole) UTI prophylaxis: 2-4mg/kg/dose, single dose nocte (or just use
480mg tablet trimethoprim)
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Adult: 160mg/dose BD i.e. 2 tablets BD
Doxycycline 2-4 mg/kg/day, Q12H on 1st day, then ½ dose Q24H (for patients
> 7 yrs or benefits of therapy outweighs risk of teeth staining)
Erythromycin 40mg/kg/day div QID
200mg/5ml
250mg tablet Adult: 500mg/dose QID
Flucloxacillin Children >12y and > 40 kg :1000-2000 mg/day div QID

125mg/5ml ≤ 12 yr and ≤ 40 kg: 25-50mg/kg/day div QID
Infants < 6m: 25mg/kg/day div QID
Adult: 250-500mg/dose QID
Nalidixic acid (Wintomylon) 55mg/kg/day div QID

500mg tablet
Adult: 1gm /dose QID initially then 500mg/dose QID
Nitrofurantoin 5-7mg/kg/day div QID

50mg tablet
UTI prophylaxis: 1-2mg/kg/dose, single dose nocte
Phenoxymethylpenicillin 25-50mg/kg/day div TDS or QID

Potassium (Penicillin V)
125mg/5ml Adult: 250-500mg/dose TDS or QID
250mg tablet
Updated by Dr S Chiu
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3.2.3 FEVER
DDx:
1. Infections
- Respiratory tract infections (commonest) - URI, otitis media, pneumonia
- UTI
- Meningitis
- Gastroenteritis
- Infective endocarditis
- Bone & joints: septic arthritis, osteomyelitis
- Other viral diseases: EBV
If prolonged fever, think of
- TB
- Typhoid
- Malaria
2. inflammatory: Kawasaki disease, collagen vascular disease e.g. SLE, JIA
3. Malignancy
Investigations:
1. CBP D/C, smear
(thick & thin smear if suspect malaria)
2. ESR, CRP
3. LFT, RFT
4. Blood C/ST (x 3 if suspect SBE)
5. NPA x viral IF
6. Urine x R/M C/ST
7. CXR
If prolonged fever,
1. Widal test
2. C3 C4 Ig pattern
3. CRP
4. ANA, anti-DNA, RF
5. Viral titre, EBV panel
6. Mantoux test
7. Stool x C/ST
8. Urine x VMA, HVA (neuroblastoma)
Treatment
1. Symptomatic :
 Paracetamol (Panadol ) 10 mg/kg/dose Q4h prn
 Tepid sponging, ice pack
2. Treat underlying cause.
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SECTION 3.3: CARDIOLOGY
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3.3.1 SHOCK
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Above algorithm reference
https://www.apls.org.au/page/algorithms
Investigations 
A 12 lead ECG - regular narrow complex tachycardia (HR usually >180/min)
Signs of shock
Pallor, cool / clammy skin, weak pulse, decreased capillary refill, hypotension, change in mental status
General supplementary management

Continuous cardiac and SpO2 monitoring
Record blood pressure
Supplementary oxygen at up to 10L/min
 
Vagal maneuvers
Get child to perform valsalva maneuver if old enough:
- Try to blow out plunger of 20ml syringe
Administer an ice-pack over the face (max. 30 seconds)
DO NOT USE eyeball pressure   
IV adenosine 
Give IV adenosine as rapid bolus at 0.1mg/kg/dose into a large peripheral vein (e.g. antecubital) via
3-way tap; followed immediately with a 10ml NS flush.
Repeat with dosage increment of 0.1mg/kg every 2 minutes until tachycardia is terminated
(maximum dose 0.3 mg/kg/dose or up to 18mg absolute dose). Document any rhythm change using
continuous printed long lead ECG recording. Mark the timing of adenosine administration on the ECG
recording.
Perform a 12-lead ECG post reversion to look for pre-excitation and other abnormalities.
If these measures fail to revert the SVT, consult cardiology.
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Above algorithm reference

https://www.apls.org.au/page/algorithms
Call for help via switchboard immediately by calling ****

Tell operator to put out a cardiac arrest call immediately, and state the location of the arrest.
Post resuscitation care: admit to PICU for continued care
Updated by Dr P Hui
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3.3.2 Cyanotic spells
Cyanotic spells occur in children with Tetralogy of Fallot. They usually occur early in the morning, or in the
context of stress or dehydration. The pathophysiology is not fully understood, but relates to decreased
pulmonary blood flow. Most episodes are self-limiting.
Assessment
 Severe cyanosis / pallor
 Distress / hyperpnoea (not tachypnoea).
 Signs of dehydration.
 Lethargy / depressed conscious state.
 Known or evidence suggesting structural heart disease.
 Lessening or absence of previously heard heart murmur.
 Previous history of squatting.
Management
Initial
 Knee to chest position
 High flow oxygen
 Avoid exacerbating distress
 Morphine 0.1-0.2 mg/kg IV/IM
 Continuous ECG and oxygen saturation monitoring, monitor BP.
If prolonged
 Consult cardiology
 Intravenous fluids - 10ml/kg bolus followed by maintenance fluids.
 Sodium bicarbonate 2-3 mmol/kg IV
Updated by Dr P Hui
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3.3.3 Prophylaxis against infective endocarditis (IE)
This is reasonable before dental procedures that involve manipulation of gingival tissue, manipulation
of the peri-apical region of teeth or perforation of the oral mucosa in patients with the following:
1. Prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts.

2. Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords.
3. Previous IE.
4. Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with
residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic
patch or prosthetic device.
5. Cardiac transplant with valve regurgitation due to a structurally abnormal valve.
Taking antibiotics just to prevent infective endocarditis is not recommended for patients who have procedures
involving the reproductive, urinary or gastrointestinal tracts.
2017 AHA recommended IE prophylaxis treatment protocol:
Single dose to be
taken 30-60min
before procedure
Situation Agent Adults Children
Oral Amoxicillin 2g 50mg/kg
Unable to take oral Ampicillin 2g IM or IV 50mg/kg IM or IV
medication OR
Cefazolin or 1g IM or IV 50mg/kg/IM or IV
Ceftriaxone
Allergic to penicillins Cephalexin*+ 2g 50mg/kg
or ampicillin - oral OR
Clindamicin 600mg 20mg/kg
OR
Azithromycin or 500mg 15mg/kg
clarithromycin
Allergic to penicillins Cephazolin or 1g IM or IV 50mg/kg IM or IV
or ampicillin and Ceftriaxone+
unable to take oral OR
medications Clindamicin 600mg IM or IV 20mg/kg IM or IV
* Or other first – or second – generation oral cephalosporin in equivalent adult or

pediatric dosage
+ Cephalosporins should not be used in an individual with a history of anaphylaxis,

angio-oedema, or urticarial with penicillins or ampicillin
Updated by Dr P Hui
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3.3.4 Heart failure
Causes:
1. Congenital heart disease total anomalous pulmonary venous drainage
- High pulmonary blood flow: VSD, PDA, AVSD, TAPVD
- Left heart obstruction: AS, CoA
2. Myocardial causes
- Cardiomyopathy
- Myocarditis
- Myocardial ischaemia
3. Valvar lesions
- Infective endocarditis
4. Cardiac arrhythmias: SVT, complete heart block
5. Non-cardiac causes
- E.g. Thyrotoxicosis, severe anaemia, severe sepsis, systemic AV fistula
Management
1. Bed rest
2. SpO2 monitoring +/- supplementary oxygen
3. Regular BP measurements
4. Cardiac monitoring
5. DAT with fluid restriction at 70-80% maintenance. NPO + IV fluid / NG tube feeding if in
respiratory distress
6. Strict I/O
7. Treat arrhythmia if present
8. Medication:
- Diuretics: frusemide +/- spironolactone
- Digoxin, vasodilator e.g. Captopril, hydralazine
9. Treat inter-current illness
Investigations:
1. Send blood x CBP + D/C, LRFT, CaPO4, CK, TnT, LDH, ABG and lactate
2. CXR
3. 12-lead ECG
4. (If febrile or signs of IE) take blood x ESR, CRP, 3 sets blood cultures for suspected SBE
5. Consider virus study and viral titre (esp. enterovirus) for suspected myocarditis
6. Others: Digoxin level, urine RBC, metabolic screening including carnitine, echocardiogram
Updated by Dr P Hui
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Section: Paediatric Neurology
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3.4.1 Febrile seizure (FS)
Definition
 Seizure during first day of fever > 38 C0
 Most common between 6 months to 5 years
 Generalized tonic clonic seizure, < 15 min, did not recur within 24 hours (simple FS)
 Focal, prolonged seizure (>=15 min), and or recurrent within 24 hours or the same febrile
illness (complex FS)
 Seizure more than 30 min (Febrile status epilepticus)
 No evidence of CNS infection or metabolic causes
 No significant prior neurodevelopmental disability
 No history of afebrile seizure
Management
 DAT if fully conscious
 Convulsion chart
 Monitor vital signs
 Panadol prn
 Identify and investigate the focus of infection and treat accordingly
 Rectal diazepam for convulsion = or > 5 min
 For those with recurrent complex FS or history of prolonged FS, or with risk factors for
recurrent FS, consult paediatric neurologist for consideration of benzodiazepine prophylaxis
and further neurological investigations such as CNS imaging
Investigations
 Blood test including CBC, urea, electrolytes, calcium, phosphate, magnesium, random
glucose may not be routinely indicated for simple FS
 Arranged infective workup depending on symptoms
 Lumbar puncture (LP) is not routinely needed for children with simple FS but should be
considered for children with signs of CNS infection (neck stiffness, photophobia, altered
consciousness, focal neurological signs. In children < 2 years of age, meningeal signs may be
absent in meningitis. If there is uncertainty, LP should be performed. in infants between 6-12
months of age with seizure and fever, as meningeal signs are absent, LP is an option if the
baby has not received any haemophilus influenzae type b (Hib) or Streptococcus pneumoniae
immunizations so has increased risk of meningitis; or has been pre-treated with antibiotics).
 EEG is not routinely needed for children with simple FS unless encephalopathy is suspected
 Neuroimaging is not routinely needed for children with simple FS. If suspected CNS infection,
urgent CT brain for those patients suspected to have increase ICP.
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Counselling of parents
 Simple FS is common and has good prognosis. It is self-limiting and do not affect cognitive
outcome. Without risk factor, the risk of developing epilepsy is low (1:40)
 Risk factors for recurrent febrile seizures includes:

₋ Age at onset < 18 months
₋ Family history of febrile seizure in a first degree relative
₋ Low grade fever (< 39 0) associated with seizure
₋ Multiple seizures during the same febrile illness
 Risk factors of developing epilepsy include:

₋ Family history of epilepsy
₋ Complex febrile seizures
₋ Neurodevelopmental problem/ delay
 For those with febrile seizures persist beyond 6 years old, need to consider genetic epilepsies
with febrile seizure plus (GEFS+) and to evaluate for genetic cause
References:
1. Subcommittee on Febrile Seizure. Clinical Practical Guideline – Febrile seizures: Guideline for the
neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics 2011; 127: 389-384
2. Nikhil Patel, et al. Febrile seizures. BMJ 2015;351:h4240 doi: 10.1136/bmj.h4240
3. Jun Natsume, et al. New guidelines for management of febrile seizures in Japan. Brain & Development
2017:39:2-9
Updated by Dr A Chiu, A Ho, S Chan
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3.4.2 Status epilepticus
Definition
Status Epilepticus (SE) is a medical emergency. It is defined as ‘a seizure that persists for a sufficient
length of time or is repeated frequently enough that recovery between attacks does not occur’
(International League Against Epilepsy ILAE). ILAE has redefined status epilepticus with two-time
points (t1) and (t2) in 2015. Impending / premonitoring SE (t1) is referred to seizures that fail to stop
spontaneous after 5 minutes for generalized tonic seizures and required first line benzodiazepine
treatment. Established SE (t2) is defined as epileptic activity persisting after 10-15 to 30 minutes and
failed to response to the early 1-2 doses of benzodiazepine treatment. Prolonged seizures lasting
longer than 5-10 minutes and serial seizures (brief, repetitive seizures with recovery of consciousness
between seizures, 3 or more in an hour) are unlikely to subside spontaneously so prompt treatment
should be given.
Management
 ABC
 Impending SE (> =5 minutes): one of the following
- Preferred: IV lorazepam 0.05-0.1mg/kg/dose (max 4mg/ dose)
- If above not available: IV diazepam 0.1-0.3mg/kg/dose (max 10mg/ dose)
- IV assess not available: Rectal diazepam 0.5mg/kg/dose (max 10mg/dose) or buccal
midazolam 0.2-0.3 mg /kg (max 10mg/dose)
 Start to establish IV access
 Collect blood x D’stix, blood gas, LRFT/ CaPO4/ Mg, NH3, CBC, blood culture, trough drug
levels (if on anticonvulsant), toxicology and urinalysis (1-2ml plasma, 1-2ml serum and 10ml
urine saved for later analysis including immunological or metabolic)
 Another 5-10min: repeat one of the steps for impending SE
 Established SE (15-30 minutes): one of the following
o IV phenytoin 15-20mg/kg (dilute in NS 0.9%, not exceeding 10mg/ml, not exceeding
1mg/kg/min; or 50 mg/min)
 Preferred option, unless the patient is on regular phenytoin, has second
degree heart block, severe hypotension, tricyclic antidepressant overdose or
with Dravet syndrome
o IV phenobarbital 15-20 mg/kg (not more than 1mg/kg/min; maximum 1000mg/dose)
 Watch out for respiratory depression and hypotension
o Alternatives if the above have already been given and ICU admission is not readily
available, but the seizure is not yet terminated (Paediatric fellow and ICU should be
involved or even earlier depending on the clinical situation!)
o IV valproic acid 20-40mg/kg (maximum 300 mg/dose) over 5-10 minutes. Followed by
IVI 20 – 40 mg/kg per day in 2-4 divided doses if seizures are terminated. If seizures
continue, a continuous infusion of 5 mg/kg/hr may be effective.
 Avoid its use in patients with thrombocytopenia, hepatic dysfunction,
hyperammonaemia or suspected to have underlying metabolic or
mitochondrial diseases. The risk of further thrombocytopenia, hepatic and
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pancreatic toxicity, and valproate-induced encephalopathy# may be dangerous
or even fatal
o IVI levetiracetam: for children > 4. Initial dose 20-60 mg/kg (Max 3000 mg) over 10
minutes, then 10-30mg/kg q12H
 Refractory SE: Need PICU
o Midazolam 0.1-0.2mg/kg followed by continuous infusion of 1-2 microgram/kg/min and
increased as needed up to 30 microgram/kg/min
o Thiopentone 3-5mg/kg bolus followed by infusion 3-5mg/kg/hr
o Propofol 1-2mg/kg (max 10mg/kg) followed by infusion of 1-2mg/kg/hr (max
5mg/kg/hr)
 Other agents such as regular IV valproate acid
 Consider discussion with neurologist for trial of pyridoxine and other vitamin responsive
epilepsies in children less than 3 years old (and for workup of other underlying causes)
Possible causes
 Febrile status
 Trauma (intracranial haemorrhage)
 Hypoglycaemia and electrolyte imbalance
 Meningitis/ encephalitis and uncommon infections
 Suboptimal compliance to anti-epileptics/ sudden withdrawal of anti-epileptics
 Inborn errors of metabolism
 Immune mediated diseases
 Genetic disorders
 Brain tumour
 Hypertension
 Toxins including drugs
 Hypoxic ischaemia / Intracranial bleeding
Investigations
Please refer to below HA guidelines and the section on encephalopathy as status epilepticus is a cause
of encephalopathy
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Protocol for in-hospital management of Convulsive SE
Antiepileptic drug General measures Investigations
Early / impending IV access Seizure continue 5 min No IV access Airway: oxygen Glucostix
SE (5 -15 min) Cardio-respiratory function
Lorazepam or Diazepam (rectal) and regular monitoring: Blood investigations:
Diazepam IVI* ECG, blood pressure and AED level (know epilepsy)
SaO2 Intravenous access Blood glucose, blood gas
Physical examination and Urinalysis
Seizure continue 5-10 min
history RFT/LFT
Still no IV access Calcium and magnesium
Plasma ammonia
Lorazepam or diazepam IVI* Diazepam (rectal)
Complete blood picture
Midazolam (buccal)
Blood culture
(If pre-hospital benzodiazepine has been
1-2ml plasma, 1-2ml
given, early initiation of treatment for
serum and 10 ml urine
established SE is recommended) saved for later analysis
Established SE Intravenous* phenytoin (preferred) of / and Cardio-respiratory function Arrange EEG
(15 - 30 min) phenobarbitone (for patients already on and monitoring If no contraindication and
phenytoin) Metabolic disturbances clinically indicated:
Intravenous sodium valproate or intravenous should be identified and Neuroimaging +/- CSF
keppra corrected studies
Arrange ICU admission
Intravenous pyridoxine for
children <3yr with unknown
aetiology
Call paediatric fellow
Refractory SE Midazolam infusion ICU care EEG monitoring
(30 - 60 min) Or Ventilatory and
Thiopentone infusion hemodynamic support Monitor electrolytes and
Or Monitor metabolic blood gas
Other medications (propofol, valproate, etc.) disturbances and systemic
can be considered (See text) complications
*Intraosseous route if intravenous route cannot be established
References:
1. Eugen Trinka , Reetta Kalviainen. 25 years of advances in the definition, classification and
treatment of status epilepticus. Seizure 2017;44:65-73
2. Glauser T, Shinnar S, Gloss D, et al. Evidence-based guideline: treatment of convulsive status
epilepticus in children and adults: report of the Guideline Committee of the American Epilepsy
Society. Epilepsy Curr 2016;16(1):48-61
3. Smith DM, McGinnis EL, Walleigh DJ, Abend NS. Management of Status Epilepticus in Children. J
Clin Med. 2016;5(4):47. Published 2016 Apr 13. doi:10.3390/jcm5040047\
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3.4.3 Encephalopathy
Importance
The encephalopathic child is a paediatric emergency. Encephalopathy is not a diagnosis but a
descriptive term for a syndrome of global brain dysfunction with different causes. Prompt
recognition of the encephalopathic state and appropriate and timely investigations help to identify
treatable causes and minimal further neurological complication.
Presentation
A child can present with encephalopathy at any age. The onset can be acute or insidious. The defining
feature is altered mental status. There may be decreased or altered level of consciousness, lethargy or
change in personality or behaviour, deterioration in cognitive function and possible localizing
features such as seizures, ataxia and other focal motor signs. There may also be other systemic
features such as headache, fever and vomiting.
Causes
 Infection: meningitis, encephalitis, cerebral abscess, sepsis
 Para-infectious/ auto-immune:ADEM; Anti-NMDAR encephalitis, Voltage gated potassium
antibody encephalitis, Hashimoto encephalitis, other autoimmune antibody encephalitis
 Trauma: accidental and non-accidental injury
 Seizure-related: Non- convulsive status, post -ictal, epileptic encephalopathy
 Toxins: heavy metal poisoning, carbon monoxide poisoning
 Drugs: therapeutic (sedatives, hypnotics, anticonvulsants, antihistamines, anticholinergic),
recreational (substance abuse)
 Metabolic:
- organ failure (uraemia in renal failure, liver failure)
- electrolyte disturbance (hyper/hyponatremia, hyper/hypocalcaemia, hyper/ hypomagesemia,
hypophosphatemia)
- hyperammonemia
- hyperglycaemia (e.g. DKA), hypoglycaemia
- Endocrine (hyper/ hypothyroidism; adrenal insufficiency, pituitary apoplexy)
- inborn errors of metabolism (defect in glyconeongenesis, fatty acid oxidation disorder, amino
acid disorders, organic acidemias, urea cycle disorders, carbohydrate disorder,
mitochondrial disorders, peroxisomal disorders, lysosomal storage disorders, purine &
pyrimidine disorders, metal metabolism defects, porphyrias)
 Hypertensive: Renal disease, cardiac diseases
 Haemorrhage: Traumatic, stroke, arteriovenous malformation, bleeding diathesis
 Neoplasm: primary brain tumour, metastatic disease to the brain
 Hypoxic/ ischaemia: HIE, near drowning, near miss sudden death syndrome, post arrest,
vascular (stroke, venous thrombosis)
History
 Is this encephalopathy? Ask detail history of pre-existing neurological and mental status and
the current neurological and mental status. The timing and nature of deterioration.
 Is there associated neurological symptoms? Ask for seizures, headache, vomiting, tremor,
weakness, abnormal muscle tone, abnormal movement, etc.
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 Is there relevant exposure history: recent febrile illness or ongoing infection; any travel
history or contact with animals or insects (e.g. tics/ mosquito bites); drug history (prescribed,
over the counter or recreational), toxin exposure; history of trauma
 Past medical history of metabolic, neurological, vascular, haematological and neoplastic
diseases
 Family history of metabolic, neurological, vascular, haematological diseases, and ask for
parental consanguinity
 Social history: is important when considering NAI. Housing situation is important if suspected
lead poisoning
 Vaccination history
Assessment and examination

 Observation
₋ Assess the alertness, watch how the child communicates, and observe their movement
and behaviour.
₋ For older kids, we can talk to the child and ask simple questions to assess orientation
and memory
 Assessment of conscious state with Paediatric Glasgow Coma Scale
1 2 3 4 5 6 Total
Score
Eye No To pain To voice Spontaneous N/A N/A 4
Opening response
Verbal No Incompre-hen Inappropriate Confused/ Oriented N/A 5

(>5yr) response sible sounds words Disoriented
Verbal No Grunts Persistent cries Inappropriate Appropriate N/A
(2-5yr) response and screams words words / phrases
Verbal No Grunts, Persistent cries Cries and Smiles/ coos N/A
(0-2yr) response agitated, and screams consolable appropriately
restless
Motor No Extension to Flexion to pain Flexion Localises pain Normal 6
response pain (decorticate) withdrawal spontaneou
(flaccid) (decerebrate) from pain s movement
(<5yr) or
obeys
commands
(>5yr)
Scores: Total Pediatric Glasscow Coma Score (3-15) 15
Remarks: C: eye closed (by swelling/ bandage); T: intubated
 Vital signs: BP, HR, RR, Temp

 Full neurological examination such as
₋ Alertness
₋ Pupils and eye movement
₋ Facial symmetry and gag reflex
₋ Fundi
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₋ Assess for meningeal signs
₋ Observed for involuntary movement and voluntary movement
₋ Assess limb power and DTR
₋ Assess for focal neurological signs
 Full physical examination such as cardiovascular, respiratory and abdominal examination
 Bedside D’stix
Investigations
 Initial investigations
₋ Bedside D’stix and lab glucose
₋ CBC and film, CRP, ESR, RFT including electrolytes, CaPO4, LFT, NH3, VBG/ iCa, Mg
 Specific investigations depending suspected possible cause(s)
₋ Sepsis workup: Blood C/ST, urine C/ST; NPA for respiratory viruses and mycoplasma,
Viral study (throat, nasal, rectal swab), viral titre. For the immunocompromised (in
consultation with microbiologist), consider CMV PCR, HHV6/7 PCR, HIV PCR(CSF),
cryptococcal antigen, Toxoplasma gondii serology and/or PCR, MTB testing, fungal C/ST
₋ LP if suspected:
 CNS infection (CT brain before LP as suspected risk of raised ICP).
- Measure CSF opening pressure, send CSF gram stain & C/ST, protein/
glucose (with paired blood glucose), total cell count, VZV, HSV and
enterovirus PCR, mycoplasma PCR, viral culture and others depending
on clinical suspicion
 Immune-mediated encephalopathy: CSF oligoclonal band (paired with blood),
CSF further studies (eg NMDA Ab and other Ab, paired with blood, in
consultation with neurologist)
o Metabolic workup if IEM suspected including blood for NH3, lactate, venous blood gas,
glucose, ketone, plasma amino acid, acylcarnitine and urine for organic acid and amino
acid, and CSF for lactate, glucose, and amino acid, and further study depending on
clinical situation. To consult IEM specialist or neurologist if necessary.
 Endocrine workup including TFT, anti-thyroid Ab and workup for adrenal insufficiency
 If the child presented as stroke, consider complete blood picture, inflammatory markers,
clotting profile, autoimmune screen, in addition to total homocysteine, cholesterol,
triglyceride, and thrombophilic screening (protein C, protein S, factor V Leiden,
anti-phospholipid and anti-cardiolipin antibodies) and echocardiogram .
 CT brain (urgent) to rule out SOL, acute haemorrhage, cerebral oedema, fracture
 MRI brain (urgent) if suspected ADEM, immune-mediated encephalopathy, brain tumour,
metabolic cause of encephalopathy, brain abscess
- With contrast to look for evidence of demyelination, leptomeningeal enhancement etc
- If possible, also with MRA (as vasculitis and AVM cannot be seen on plain MRI)
- MR spectroscopy e.g. for abnormal lactate peak in metabolic cause of encephalopathy
- MRV if cerebral venous thrombosis is suspected
 EEG (urgent) for evidence of encephalopathy and seizures
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3.4.4 Interpretation of CSF results in CNS infection
Normal Viral Bacterial Tuberculous Fungal
meningoencephalitis meningitis meningitis meningitis
Opening <25cmH2O Normal-high High High Very high
pressure
Cell <5 5-1000 100-50000 5-500 5-1000
count
(10^6/L)
Cell type Lymphocyte/ Lymphocytes Neutrophils Lymphocytes Lymphocytes
monocyte, predominate predominate predominate predominate
no (neutrophils if early)
neutrophils/
RBC
Glucose Normal Normal Low Very low Normal –
(CSF: (>0.5) (>0.5) (<0.4) (<0.3) low
plasma)
(mmol/L)
Protein <0.5 0.5-1.0 >1.0 1.0-5.0 0.2-5.0
(g/L)
Correcting for traumatic tap: for every 1000 RBC/mm3, minus CSF protein by 1.1mg/dL; for every
500 RBC, minus CSF WCC by 1
Remarks: In immune-mediated encephalopathy, CSF will have positive oligoclonal bands and raised
cell counts but usually normal protein.
Management
 Discuss with senior +/- to ICU if there is evidence of rapid deterioration, compromised vital
signs or uncontrolled seizures
 NPO
 Strict IO
 IVF: Unless dehydrated or with unstable vitals, keep total fluid at 50-70% maintenance
 Management of raised ICP
 Neuro-observation Q1H
 SaO2 & cardiac monitor
 D’stix – given D10 if hypoglycaemic (Watch out for children that is on ketogenic diet, or
suspected to have mitochondrial disease or pyruvate dehydrogenase deficiency, or underlying
insulinoma)
 Toxin antidote if required
 Seizure control
 Treat underlying cause
 Empirical antimicrobial coverage after complete sepsis workup
- Broad spectrum antibiotics (3rd generation cephalosporin)
- Empirical acyclovir
- Antibiotic cover for mycoplasma if clinically suspected
Discuss with neurologist regarding empirical IVIG or steroid (pulse methylprednisolone) and 2 nd/ 3rd
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line immunomodulating therapy if there is evidence of para-infectious or immune-mediated
encephalopathy
Rehabilitation
Once the condition of the child has been stabilized, the rehabilitation involving the multi-disciplinary
team should be started as soon as possible in the acute ward. Psychological support to the child and
family are important.
References:
Davies E, et al. Encephalopathy in children: an approach to assessment and management. Arch Dis Child
2012;97:452-458
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3.4.5 Acute Flaccid Paralysis

Importance
1. Clinical importance: Acute flaccid paralysis (AFP) is a clinical syndrome characterized by rapid
onset of limb weakness, which may also affect respiratory and bulbar muscles. AFP is a
neurological emergency and has many diagnostic possibilities. An early and accurate diagnosis
with prompt management has important bearing on the prognosis.
2. Public health importance: Immediate reporting of all AFP cases to the polio surveillance team
under Centre for Health Protection, Department of Health, is required. All notified subjects
will receive full epidemiological and laboratory investigations.
Definition (according to WHO)

Acute: Rapid progression of weakness from onset to maximal paralysis
Flaccid: loss of muscle tone
Paralysis: Weakness with loss of voluntary movement of one or more limbs and decreased or absent
deep tendon reflexes of the affected limb(s)
Major neuroanatomical differential diagnoses of acute flaccid paralysis in children

(This list is not meant to be exhaustive)
Spinal cord Compression: trauma, haematoma, abscess, tumor,
arterio-venous malformation
Inflammation: transverse myelitis (infection /
immune-mediated)
Anterior horn cells Infection: Polio, enterovirus infection
Nerves Inflammation: Guillain Barre Syndrome (GBS)
Neuromuscular junctions Immune-mediated cause: myasthenia gravis (MG)
Toxins: Botulism
Muscles Infection: viral myositis
Inflammation: inflammatory myopathy (e.g. polymyositis)
Channelopathy: hypokalemic periodic paralysis
Important history
Onset of paralysis, distribution To confirm acute flaccid paralysis and assess its severity
and progression Ascending weakness is more suggestive of GBS
Fatigability is more suggestive of MG
Associated symptoms: altered To assess extent of involvement
conscious state, double vision, Early oculobulbar involvement is more suggestive of MG
facial weakness, breathing or botulism
difficulty, swallowing difficulty,
Associated symptoms: sensory Presence of these symptoms are more suggestive of
loss / sensory level, bladder / compressive myelopathy / transverse myelitis
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bowel involvement
Fever / other symptoms of Presence of these symptoms are more suggestive of
infection infections
Need to consider enteroviral myelitis in patients with
diarrhoea
Need to consider viral myositis in cases of Flu B infection
Need to consider parainfectious causes like GBS if there is
history of recent infection
History of trauma to spine Trauma causing compressive myelopathy
Exposure to drugs / toxins Drugs / toxins causing neuropathy
(E.g. chemotherapy, lead, arsenic)
Immunization history Children who have not received polio vaccine are at risk of
poliomyelitis
Symptom onset after use of live attenuated oral polio
vaccination is suggestive of vaccine associated
poliomyelitis
Important elements of physical examination

 General condition (any encephalopathy) and vital signs
 Signs of respiratory failure and autonomic dysfunction
 Neurological exam (muscle power, tone, deep tendon reflexes, plantar response, sensory
level, palpable bladder, abdominal reflexes, anal tone, ataxia, cranial nerves (particularly
ophthalmoplegia and facial weakness) and fatigability)
Examination findings may come up with patterns which are helpful to diagnosis
 Flaccid paraparesis with sensory level (with bladder / bowel symptoms) – compressive
myelopathy, transverse myelitis
 Ascending flaccid symmetric paraparesis/quadriparesis with areflexia – GBS
 Ophthalmoplegia, ptosis, bulbar weakness, motor weakness – Miller Fisher syndrome
overlapping with GBS, MG, botulism
 Proximal muscle weakness, muscle tenderness without sensory symptoms – Viral myositis,
inflammatory myopathy
 Acute spinal cord involvement with upper motor neuron signs – Acute disseminating
encephalomyelitis
Investigations
History and physical examination guide the workup. The following list is not exhaustive.
 Blood tests for electrolytes (low serum K in hypokalaemic periodic paralysis), creatine kinase
(elevated CK is suggestive of myositis / inflammatory myopathy)
 Lumbar puncture (CSF pleocytosis is suggestive of CNS inflammation; cytoalbumin
dissociation is suggestive of GBS)
 Urgent MRI spine (with contrast) (suspect compressive myelopathy, transverse myelitis)
 Urgent MRI brain if there is encephalopathy
 Urgent Nerve conduction study / electromyography (helpful in diagnosing GBS, virus induced
anterior horn cell disease and other causes of neuritis or neuropathy)
 Appropriate microbiological workup
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 Notify Acute Flaccid Paralysis Surveillance Team. Save 2 adequate stool samples (24 hours
apart) for viral study, within 14 days of onset of paralysis. Rectal swabs are NOT considered
as adequate samples by the WHO.
Acute Management
Management depends on the underlying cause
 Secure ABC. Ensure airway protection and adequate ventilation, especially if there is
respiratory muscle weakness, bulbar weakness, weak gag or cardiovascular instability.
 Monitor blood pressure, pulse, respiratory rate, SpO2, PFR and ECG rhythm.
 Monitor neurological state.
 Beware of spinal shock with loss of reflexes and autonomic dysfunction with hypotension
and bradycardia.
 NPO with IV fluid if there is bulbar weakness or when the patient is unstable.
 Insert Foley catheter if there is difficulty in bladder emptying.
 Consult neurology team.
 Consider PICU support if patient is not stable or rapid deterioration is anticipated.
 Consult neurosurgeon for compressive myelopathy.
 Specific therapies
₋ Compressive myelopathy – neurosurgical intervention
₋ Transverse myelitis – IV methylprednisolone, plasmapheresis
₋ Guillain Barre Syndrome – IVIG, plasmapheresis
₋ Myasthenia gravis / immune mediated myopathy – immunomodulatory treatment
including IVIG and steroids
₋ Hypokalemic periodic paralysis – correct electrolyte disturbance, arrange early ECG
Reference:
1. Singhi SC et al. Approach to a child with acute flaccid paralysis. Indian Journal of Pediatrics
2012;79(10):1351-1357
2. The National Committee for the certification of wild Poliovirus eradication in Hong Kong. Fifteen years of
acute flaccid paralysis surveillance in Hong Kong: findings from 1997 to 2011. Journal of Paediatrics and Child
Health 2014; 50: 545-552
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SECTION 3.5: GENERAL PAEDIATRICS
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3.5.1 DIARRHOEA
DDx of acute diarrhoea:

1. Gastroenteritis - bacterial, viral, parasitic
2. Food poisoning
3. Systemic infection (especially in young infants)
4. Others : antibiotics-associated, Hirschsprung colitis..
5. Watch out for intussusception
Consider any of the following as possible indicators of diagnoses other than

gastroenteritis:
1. Fever: ≥38 °C or higher in children <3 months or ≥39 °C children >3 months
2. Shortness of breath
3. Altered conscious state
4. Neck stiffness
5. Bulging fontanelle in infants
6. Non-blanching rash
7. “Bloody diarrhoea” (red currant jelly stool)
8. Bilious (green) vomit
9. Severe or localised abdominal pain
10. Abdominal distension or rebound tenderness.
Management
1. Contact precaution for rotavirus, norovirus, salmonella in a diapered or incontinent child,
Salmonella typhi.
2. ORS (oral rehydration solution)
- for mild/ moderate dehydration
Rehydration therapy
Mild to moderate dehydration: 50ml/kg ORS within 4 hours
Start maintenance therapy (100 ml/kg for infants) after signs of dehydration have gone.
Maintenance fluids can be given as breast milk, formula, or other fluids appropriate for
age, offered ad libitum.
Ongoing losses
- can be replaced by normal diets given ad libitum in children with mild diarrhea and no
signs of dehydration
- For those with persistent profuse diarrhea or vomiting, replace ongoing loss with ORS:
For each watery or loose stool 5ml/kg

For each episode of emesis 2ml/kg
3. IV fluid (Deficit + maintenance + ongoing loss) if

- shock
- diminished consciousness
- intractable vomiting
- massive stool output
Refer to section on "Fluid and electrolytes".
4. In infants less than 3 months old with significant diarrhoea
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- Perform blood x C/ST even when afebrile
- If fever + bloody diarrhoea, consider full sepsis workup (Blood x C/ST, LP, tap
urine) and start IV antibiotics
5. Antibiotics are not recommended for uncomplicated diarrhoea.
Pathogen Indication for antibiotics : Drug of choice

Salmonella  Consider in young infants < 3 3rd generation cephalosporins
months, any ill or septic looking -Cefpodoxime
patient and immunocompromised (or oral Ciprofloxacin 15
patient mg/kg/dose BD in Salmonella
 Salmonella typhi typhi)
Campylobacter  Only of value if given early
Erythromycin
 In institutional settings to shorten
bacterial excretion
Shigella  In ill patients Co-trimoxazole
 Those still symptomatic when
pathogen is detected
Stop associated antibiotics.
Clostridium
Metronidazole 30mg/kg/day
difficile
Q6h If fails, use Vancomycin po
40mg/kg/day Q6h (Max 2g/day)
Giardiasis
TDS
Amoebiasis
TDS
6. Antidiarrhoeal agents are not recommended for acute diarrhea in children. They
should not be used in children with fever, toxaemia or blood in stool.
Investigations
1. CBP D/C
2. Blood x C/ST (if febrile or < 3 months old)
3. Na K Blood gas
4. Urea creatinine
5. Stool x C/ST, virus
6. Fresh stool x ova & cyst (Giardia, amoeba)
References
“Guidelines for the Management of Acute Diarrhoea in Young Children” by the HK College of
Paediatricians July 2003
NICE guidelines (last update Oct 2010)
Dr A Tsang,
Updated by Dr R Wong
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3.5.2 FLUID AND ELECTROLYTES

Maintenance requirement
1. Fluid
 Holliday-Segar method:estimates caloric expenditure from weight alone and assuming
that for each 100 calories metabolized, 100 ml water will be required. Not suitable for
neonates < 14 days.
BW Fluid maintenance (ml/kg/day)
1st 10kg 100
2nd 10kg 50
Each additional kg 20
Example: 8 year old weighing 25 kg

1st 10 kg: 100 ml x 10 = 1000ml
2nd 10 kg: 50ml x 10 = 500ml
additional 5 kg: 20ml x 5 = 100ml
Total = 1600ml/day
 Body surface area method: assuming caloric expenditure is proportional to surface

area. Should not be used for children < 10kg.
 Water required = 1500ml/m2/day (Insensible water loss = 400ml/m2)
 Body surface area = square root of (height in cm x body weight in kg) divided
by 60
2. Sodium 2 - 3 mmol/kg/day
3. Potassium 2 mmol/kg/day
* 5.85% NaCl 1 ml = 1 mmol Na

* 14.9% KCl 1 ml = 2 mmol K
Commonly used IV fluids

Dextrose solutions : 5%, 10% (D5, D10)
Normal saline (NS): 0.9% NaCl
1/5 solution: NaCl 0.18%+ Dextrose 4.3% (Na 31 mmol/L)
1/3 solution : NaCl 0.3% + Dextrose 3.3% (Na 51 mmol/L)
1/2 : 1/2 solution : NaCl 0.45% + Dextrose 2.5% (Na 77 mmol/L)
Others
Hartmann’s solution : Na 131 mmol/L, K 5 mmol/L, Cl 111 mmol/L, lactate 29 mmol/L, Ca 2
mmol/L
8.4% sodium bicarbonate ( 1mEq/ml) : Na 1000 mmol/L, HCO3 1000 mmol/L
3% NaCl : Na 513 mmol/L, Cl 513 mmo/L
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Principles of management
1. Total fluid required = Maintenance requirement + Deficit replacement

2. Calculate the amount of water, sodium and potassium required over a 24 to 72 hour period.
The speed of rehydration depends on the type of dehydration, chronicity of the problem and
whether patient is acutely symptomatic.
3. Symptomatic hyponatremia and hypernatremic dehydration demands extra caution for fear
of central pontine myelinosis and cerebral edema respectively.
4. Extreme caution where there is cardiac failure &/or renal impairment
Assessment of degree of dehydration
% dehydration Clinical signs
Mild (~ 5%) HR 10-15% above baseline

Slightly dry mucous membrane
Concentrated urine
Moderate (6-9%) Increased severity of above

Decreased skin turgor
Oliguria
Sunken eyeball/ anterior fontanelle
Severe (10% or more) Marked severity of above signs

BP drop
Delayed capillary refill
Acidosis (large base deficit)
Parenteral rehydration
Phase 1
Where necessary, rapid volume expansion to improve circulation & renal function:
10 - 20 ml /kg bolus NS IV
Phase 2
1. Calculate deficit
Volume of rehydrating fluid (ml) = BW (kg) x % dehydration x 10
2. Add on maintenance requirement and ongoing losses.
3. Rate of rehydration depends on type of dehydration:
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Case Examples
1. Normonatremic dehydration
10kg infant with gastroenteritis presented with vomiting and diarrhoea for 3 days.
Estimated to have 10% dehydration. Na 140. K 3.6. Urea 6.5
Water (ml) Na (mmol)

Deficit BW x 100ml/kg for 10% dehydration Na deficit associated with the
= 10kg x 100ml/kg isotonic loss of fluid
= 1000ml =145 x BW loss (kg) x 0.6
=145 x 10 x 0.1 x 0.6
=87 mmol
Maintenance BW x 100ml/kg/day BW x 3mmol/kg/day
=10kg x 100ml/kg =10 x 3
=1000ml =30 mmol
Total required 2000ml 117mmol
 Add maintenance potassium: 3-4 mmol/kg/day and monitor RFT.
 Prescription:
2000 ml fluid + 117mmol Na + 40mmol K per day (i.e. 58 mmol/L Na)
= 1/3 solution 500 ml + 5 ml 5.85% NaCl + 5ml 15% KCl added to each pint, run at
83ml/hr
 Ongoing loss to be replaced accordingly – e.g. with ORS.

 Need careful ongoing careful monitoring of clinical state and serum electrolytes.
2. Hyponatremic dehydration (Na < 130)- correct over 24 hours
10kg infant with gastroenteritis presented with vomiting and diarrhoea for 3 days.
Estimated to have 10% dehydration. Na 125. K 3.6. Urea 6.5
 Same calculation as case 1 except to add the Na required to correct the

hyponatremia (e.g. aim at correcting Na to 135)
 Na deficit (mmol) = (Proposed serum Na - current serum Na) x BW (kg) x 0.6 =
(135-125) x10x0.6 = 60mmol
 Total Na = 87 + 30 + 60 = 177 mmol
 Prescription: 2000ml water + 177 mmol Na + 40 mmol K per day = ½: ½ solution

500ml + 5 ml 15% KCl + 8ml 5.85% NaCl added to each pint, run at 83ml/hr
 If the patient is symptomatic, correct it with 3% hypertonic saline. Aim at 6mmol rise
per attempt.
o Na required to treat symptomatic hyponatremia= target Na rise x BW x 0.6=

6x10x0.6 = 36 mmol
o Give 72ml half diluted 5.85% NaCl over 30 min to 3 hours depending on urgency
of situation.
Hypernatremic dehydration (Na > 150)

 Circulatory disturbance is seen later as circulatory volume is relatively preserved at the
expense of cellular water.
- Give 1/2NS as the rehydrating solution.
- Slow correction of rehydration over 48-72 hr. Avoid dropping serum Na >15 mmol/L
over 24 hr.
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Hypokalemia (serum K+ < 3.0 mmol/L)
 CAUTION: Administration of Potassium Chloride in undiluted solution or rapid

 infusion will be fatal
 Put on ECG monitor, assess heart rate and rhythm & recheck K + level
 Identify cause of hypokalaemia
 Ensure adequate renal function & urine output before K+ replacement
 Note that serum potassium is a poor indicator of body potassium status.
Potassium Replacement: **Always consider replacement via oral route rather than IV route**
Oral Preparation: Syrup KCl 1gm/10ml (1gm = 13.3mmol)

Tab KCl 600mg/tab (600mg = 8 mmol)
IV Preparation : IV KCl 14.9% (1ml = 2 mmol)
1. Usual daily requirement 2mmol/kg/day over whole day fluid

2. Oral replacement
i. Recommended dose 75mg/kg/day (~1mmol/kg/day) in divided dose & adjust
accordingly
ii. For SYRUP – dilute with milk /juice.
iii. For TAB SLOW K – do not chew/crush to ensure slow release
3. Rapid bolus IV replacement ONLY IF patient is symptomatic or K+ < 2.5mmol/L
i. Maximum concentration
- Peripheral line : 40mmol/L (14.9% KCl 0.2ml in 10ml IVF)
- Central line : 80mmol/L (14.9% KCl 0.4ml in 10ml IVF)
ii. Recommended dose 0.5mmol/kg over 1 hr
iii. Monitor patient closely – vital signs, IV site, serum K + level
Hyperkalemia
1. Stop all potassium administration ( IV or oral)

2. IV calcium chloride 25mg/kg to antagonize the effect.
3. IV NaHCO3 1 mEq/kg
4. IV insulin glucose – insulin 0.1 unit/kg + glucose 0.5g/kg
5. Promote potassium excretion by resin, dialysis or hemofiltration
6. Treat underlying cause.
Metabolic acidosis
- Metabolic acidosis associated with dehydration will usually resolve with rehydration.
- Treat only if acidosis is severe especially when there is circulatory impairment.
- HCO3 (mmol) = Base deficit x BW (kg) x 0.3
Usually give half the dose.
Updated by Dr S Lau
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3.5.3 CHILD ABUSE
Cases of suspected abuse can be admitted directly to the ward through the Medical Co-ordinator
of Child Abuse, MCCA (Dr Patrick Ip, Dr Almen Lam, Dr Anita Tsang or Dr Maria Wong) or the
2nd call MO, without going through the A&E.
Refer to “Protecting Children from Maltreatment ---- Procedural Guide for Multi-disciplinary
Co-operation” (Revised 2020) at the HKSAR Social Welfare Department website for details.
https://www.swd.gov.hk/en/index/site_pubsvc/page_family/sub_fcwprocedure/id_1447/
Physical abuse
Suspect physical abuse if the following features are found:
1. Fractures in a child < 2 years old
2. A history inconsistent with physical findings
3. A history of repeated accidents
4. Delay in seeking medical help
5. Multiple injuries and bruises (especially bruises around face and mouth, over back)
6. Signs of emotional deprivation, neglect or failure to thrive
7. Retinal haemorrhages in the absence of head injury - "Shaken baby syndrome"
Management
1. Take a full history. Note especially :
- Mode of injury & antecedent events (severity)
- Previous abuse history(frequency) and history of neglect (Ask a single day activity
routine to understand child care situation)
- Psychosocial background (assess risk and protective factors)
- Prior contact with social services
- Safety of the child and siblings
2. Thorough physical examination.
- Look carefully for any hidden injuries (e.g. bruises behind the ears, torn frenulum,
pharyngeal injuries). Document all the injuries precisely with diagrams and
clinical photos (obtain consent).
- Chart growth parameters.
- Look for retinal haemorrhages in inflicted head injury.
3. Avoid confrontation and repeated interrogation, but be honest. Tell parents that notification is
being made. Explain the assessment procedure.
4. Consult QMH Medical Social Worker (MSW) – fax the notification form to MSW. May consult
Family and Child Protective Services Unit of Social Welfare Department (FCPSU, SWD) directly
if required. (FCPSU Central/Western/Southern/Island: Telephone no. 9460 4013, 2835
2733)(SWD Hotline at 2343 2255 outside office hours)
5. Consult Child Psychiatrist.
6. Consult Eye or other specialists if indicated.
7. Notify the Police (after discussion with team-head and social worker). The 1 st informant is the one
to report to the Police. Consult Child Abuse Investigation Team (CAIU, Police)/Child Protection
Special Investigation Team (CPSIT = CAIU + FCPSU) in serious abuse (OC CAIU HK Island:
Telephone no. 2860 7815, 2860 7814).
8. Investigations if indicated:
- CBP D/C
- PT /APTT (if there is history or family history of bleeding tendency)
- L/RFT, amylase and urine for RBC if suspect intra-abdominal injuries
- Skeletal survey for those under 2 years old
- CT scan brain (if suspect intracranial injury) /CT Scan abdomen (if suspect
intra-abdominal injuries)
9. Multidisciplinary Case conference (MDCC) will be held. Welfare of the child is the primary
concern.
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Child Sexual abuse (Victims < 18 years old)
In handling child sexual abuse, inform senior and consult MCCA if in doubt.
Assessment after admission (most relevant to adolescent victims)

1. Attitude
 Be sensitive and supportive. Experiencing sexual assault is a traumatic experience.
The investigation for sexual assault can be equally traumatic if not handled properly.
 Be non-judgemental. The victim must never be blamed for invoking the incident even
though they may be involved in high risk behaviour.
2. Requiring the child to describe the abuse incident(s) repeatedly should be avoided as far as
possible and the number of examination should be kept to the minimum.
3. Consent
 The patient and parents/guardian should be given full explanation of the medical
evaluation and consent obtained whenever appropriate or possible.
History
1. The Incident
 Gather information from the referrer and parents. Do not enquire the child
about details of the incidents. Avoid contaminating the evidence.
 Obtain essential information of the incident from the referrer/parents that is relevant
to the immediate well-being of the patient:
i. Form of assault – fondling, genital contact, vaginal/anal penetration (details
not necessary)
ii. Immediate symptoms after the incident – pain, bleeding, discharge
iii. ? intoxicated just before the incident
2. Medical history
 Menstrual history: LMP
 Sexual history, use of contraception, history of STD and pregnancy
 Use of cigarette, alcohol, substance
 Past health
Physical Examination
 Allow the child to have a trusted adult accompanying him/her during PE. Explain to the child
what you are going to do. Be gentle.
 General PE to identify injuries or conditions that require immediate treatment. Perform
general inspection of genital area for any obvious injuries or bleeding. Detailed examination
should be performed by experienced personnel.
 Consult Gynaecologist if immediate medical attention is required for significant genital
injuries
 Genital examination or colposcopy should be performed by trained personnel.
 Consult Forensic Pathologist (through Police) if sexual assault occurred within 72
hours prior to admission for collection of forensic evidence.
Investigations
 Pregnancy test
 Toxicology screen if indicated
 Screening for sexually transmitted diseases
o HVS for gram smear and culture, Trichomonas vaginalis (Consult gynaecologist for PV
examination)
o Prepubertal child:
 Culture for gonorrhea: pharynx, anus, urethra in boys; pharynx, anus, vagina in
girls
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 Chlamydia for culture and IF/PCR: anus in boys; anus and vagina in girls
o Adolescents:
 Throat, anus, vagina/endocervical, (urethra for boys) for gonorrhoea and
Chlamydia
o VDRL
o HIV 1 & 2 antibody
o Hepatitis B serology
Medical Treatment
 Emergency contraception to be given within 72 hours of incident
o Preferred: Levonorgestrel 1.5mg po once (or 0.75mg po 12 hours apart)
o Alternative: Eugynon 2 tab 12 hours apart po for 2 doses
(1 tab = Norgestrol 0.5mg + ethinylestradiol 0.05mg)
o Consult Gynaecologist for IUCD placement when incident occurred beyond 3 days but
within 5 days
 Prophylaxis for STD to be given for adolescents likely to be lost to follow up:
o Ceftriaxone 250 mg imi single dose (for gonorrhoea)
o Single dose of Azithromycin 1gm po (for Chlamydia)
o Single dose of Metronidazole 2 gram po (for Trichomonas)
 Treatment for confirmed cases:
o Gonorrhoea: Ceftriaxone 500 mg x 1 (25 mg/kg for < 45kg)
o Chlamydia: Azithromycin 1gm po x 1 (20mg/kg for < 45kg)
o Syphilis: Benzathine Penicillin G 2.4 million units x1
o Trichomonas: Metronidazole 500mg BD for 7 days (15mg/kg/day for < 45kg)
Other management:
1. Consult MSW. Consult FCPSU.
2. Notify Police. CAIU(Police) & FCPSU(SWD) will form CPSIT to conduct the video-recorded
interview.
3. Consult Child Psychiatrist.
Discharge and follow up

 For adolescents, FU Adolescent Clinic in 4 weeks to see if menses return. Repeat HIV
serology test at 12 weeks. Monitor for psychosocial issues.
Updated by Dr A Tsang in Jan 2021
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3.5.4 URINARY TRACT INFECTION
Common presentation:
<2years old: fever (>38°C) with no identifiable focus of infection
older children: symptoms referable to urinary tract
Diagnostic strategies:
1. If febrile infant with no apparent source of infection looks septic, urine should be collected for
urinalysis and culture by catheterization (less invasive and more preferable) or suprapubic
aspiration (SPA), +/- perform blood and CSF culture, if indicated, and initiate antibiotics
immediately
2. If immediate antibiotics is not required, in infant and toddler urine can be collected by an urine
bag and tested by urinalysis (including leucocyte esterase, nitrite, and microscopy). Any positive
test results indicate the need to collect a proper urine sample for culture (by catheterized urine
or suprapubic aspiration, though proper clean void urine is also acceptable). Another acceptable
option is to obtain urine directly by SPA or catheterization for urinalysis and culture for patients
with definite fever with no other source of infection. In either option, empirical antibiotic therapy is
commenced if urinalysis is positive, to be revised when culture results are available.
3. Mid-stream urine in a toilet trained child is considered a proper urine sample for culture.
Diagnostic criteria
The diagnosis of UTI should be proven by both positive urinalysis results indicating inflammation
(i.e. pyuria), and a positive bacterial culture from a properly collected urine sample.
a. Any positive growth of uropathogens from culture of suprapubic aspirated urine confirms
UTI.
b. For culture of clean void urine, a colony count of >10^5 CFU/ml of a single uropathogen
indicates definite UTI. Lower counts of >10^4 CFU/ml or growth of >1 uropathogens indicates
probable UTI.
c. For culture of catheter urine, a colony count of >10^4 CFU/ml of a single uropathogen
indicates definite UTI. Lower counts of >10^3 CFU/ml or growth of >1 uropathogens indicates
probable UTI.
Probable UTI should be interpreted taking into account the clinical picture
and inflammatory markers.
Culture of bag urine has high contamination rates and should not be used for confirming UTI.
Treatment
1. Indication for intravenous antibiotics: appears toxic, vomiting, aged <2 months.
2. For those age>2 months, can opt to switch to oral therapy and consider discharge once
fever is subsided and drug compliance can be ensured.
3. Fluid therapy as indicated if dehydrated
4. Oral antibiotics for non-toxic patients who are: age >2months, can tolerate oral treatment,
likely to be compliant with medications and follow up
5. Treatment should last for 7-14 days
6. Most commonly used antibiotics regimens for UTI include i) IV or oral Augmentin; or ii) IV
second or third generation cephalosporin; or iii) IV aminoglycoside plus ampicillin. These
provide adequate coverage of common uropathogens including gram negative coliforms and
enterococci.
7. Patients with UTI who do not show the expected clinical response to antibiotics therapy
should have urine re-cultured. The co-existence of septicaemia and meningitis should be
considered, and ultrasound kidneys should be performed on an urgent basis. Surgical
intervention may be indicated for unresolved urosepsis if renal abscess, obstructive
hydronephrosis or complicated malformations are present.
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Fig 1. Risk factors leading to consideration of VCUG

after first febrile UTI
 Presenting with severe sepsis or proven
septicaemia
 Palpable abdominal mass
 Impairment of baseline renal function
 History of abnormal urine stream
 UTI due to non-E.coli organisms
 No clinical response to appropriate antibiotic
treatment within 48 hours
 VUR in first degree relatives
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Investigation after febrile UTI in age 2months – 24months
See fig 1
Reference:
Paediatric UTI Guideline Working Group. Clinical Guideline on The

Diagnosis and Initial Management of Urinary Tract Infections in
Infants and Children aged 2 to 24 months, HAHO COC guidelines 2014
Updated by Dr HL Lee 2020
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3.5.5 Nephrotic syndrome

Diagnostic criteria
 Heavy proteinuria (proteinuria ≥3+ on dipstick OR protein/creatinine ratio ≥ 200mg/mmol
OR ≥ 1g/m2/day)
 Hypoalbuminaemia (serum albumin <25g/L)
 Edema
Epidemiology
 17-61 children per year in HK
 Typical age 1-10years old
 Most common age for presentation is 2yo
 70-80% occurs <6yo
Classification
 Secondary nephrotic syndrome comprised of 10% of cases

 Mostly SLE and HSP
Definitions
 Remission: Urine albumin nil or trace (or proteinuria ≤4 mg/m2/h or Up/Cr ≤ 20mg/mmol) for
3 consecutive early morning samples.
 Relapse: Urine albumin 3+ or 4+ (or ≥ 40mg/ m2 /hr, or Up/Cr ≥ 200mg/mmol) for 3
consecutive early morning samples, having been in remission previously.
 Frequent relapses: 2 or more relapses in initial 6 months; 4 or more relapses in any 12
months.
 Steroid dependence: 2 consecutive relapses when on alternate day steroids or within 14
days of its discontinuation.
 Steroid resistance: Absence of remission despite therapy with daily prednisolone for 4
weeks.
Key assessment in an admission

 Intravascular volume depletion:
Dizziness
Abdominal cramps
Peripheral hypoperfusion (cold hands/feet, mottling, CR >2s)
Tachycardia, reduced urine output, hypotension(late sign)
 Severe or symptomatic edema
Abdominal discomfort/severe scrotal or vulval edema
Ascites
Gross limb edema with potential skin breakdown/cellulitis
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Increased work of breathing from pleural effusion
 Increased risk of concurrent infection
Cellulitis
Spontaneous bacterial peritonitis
 Increased risk of thrombosis
 Features suggesting other diagnosis than INS
Age<18mth or >12years
Systemic symptoms of fever, rash, joint pains (SLE/HSP)
Persistent hypertension
Features of nephritic syndrome (macroscopic haematuria, hypertension, and renal impairment)
 Immunization history, Past VZV infection
 Family history of renal disease
Initial investigation
 Blood:
CBC, LRFT, CaPO4
full lipid profile
C3, C4, ANA, Anti dsDNA, ANCA, Ig pattern
ASOT
Urgent hepatitis B serology (HBsAg, Anti HBs Ab, Anti HBc Ab) to QMH microbiology lab, anti
HCV, HIV 1 / 2 serology
Measles and varicella IgG antibody serology
 Urine:
R/M
First morning urine protein/creatinine ratio (need first void after waking up)
Urine osmo, urine sodium
 MT5
 CXR
 Other management plan
Low salt diet
Strict IO with close attention to fluid status
Renal chart (daily BW, urine dipsticks)
BP q4h
Manage complication first

 Edema and ascites
Low salt diet
Fluid restriction to around 60% maintenance (provided child not hypovolemic/in pre-renal failure)
If severe/symptomatic/worsening edema or ascites => give Lasix 1-2mg/kg/day in two divided
dose
If skin breakdown/cellulitis, significant pleural effusion, troublesome genital edema AND not
nephritic picture (volume overload, hypertension) AND not in those with cardiac/pulmonary
premorbidities => give 20% albumin (0.5-1g/kg) over 4 hour with IV Lasix 1mg/kg midway
infusion
 Hypovolemia
Easily missed
Blood finding: elevated haematocrit, urea/creatinine
Urinary finding: urine osmo>800, sodium <20mmol/L, FeNa <1%
If circulatory failure: 5% albumin 10-20ml/kg over 30-60mins iv, repeated if necessary, until
volume status restored
Then, give 20% albumin (0.5-1g/kg) over 4hour with IV Lasix 1mg/kg midway infusion
 Infection due to loss of globulin
Treat cellulitis
Spontaneous bacterial peritonitis
Fever, severe abdominal pain, peritoneal signs
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Definitive diagnosis of peritonitis requires gram stain, cell count and culture of peritoneal fluid and
blood for concurrent bacteremia
Most common organism is strep pneumoniae, but gram-ve organisms also cause a significant
percentage
Treat with cefotaxime
No data supporting the efficacy of prophylactic penicillin in preventing peritonitis in childhood
nephrotic syndrome
Indication of renal biopsy

A biopsy is not indicated as long as the child respond to steroids and continues to do so with each
relapse.
A biopsy may be considered if:
Aged < 12 months >10 years
Steroid resistant
Low serum C3
Clinical evidence of systemic disease e.g. HSP, SLE
Concern regarding CNI nephrotoxicity
Persistent renal impairment, persistent hypertension
family history of FSGS
Initial treatment: steroid regime

 Prednisolone 60 mg/m2/day (max 60mg/day) in two divided dose for 4wks (even if
proteinuria remits)
 Then reduced to 40 mg/m2 (max 40mg) alternate days for the next 4wks
 Wean within the next 4wks
 30mg/m2/day (max 30mg/d) x 7d -> 20mg/m 2/day (max 20mg/d) x 7d -> 10mg/m2/day (max
10mg/d) x 7d -> 5mg/m2/day x 7d (max 5mg/d) -> stop
A "steroid warning card" should be provided for the patient to carry

Put in CMS alert that patient is on long term steroid
Famotidine while on daily steroids
Supplementary calcium and vitamin D (calcichew D3)
Precaution on immunization
Avoid live vaccines if deemed to be immunosuppressed:
A child who is receiving or has received in the last 3 months the following
P 2mg/kg/d for >1week
P 1mg/kg/d for >1month, roughly = 40mg/m2 alternate day
Lower doses of P combined with cytotoxic drugs
Long term lower dose immunosuppression e.g. P >10mg/m 2 alternate day
Inactivated influenza vaccine annually
In those >2yo, give an additional dose of PPV23 at point of diagnosis
There still appears to be an adequate response in active disease and on steroids
If VZV IgG –ve, give VZV vaccine if a window of opportunity between steroid courses appears
Postexposure VZIG for non-immune immunocompromised patients
Give IV acyclovir for immunosuppressed children at the onset of chicken pox lesions
Response to treatment
 Most response to steroid within 2-4 weeks
 Remission: Urine albumin nil or trace (or proteinuria ≤4 mg/m2/h or Up/Cr ≤ 20mg/mmol) for
3 consecutive early morning samples.
 Diuresis and weight reduction
 Reduction in albustix positive level
 Reduction in urine P/Cr ratio
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Relapse
 Can occur after immunization or viral infection
If no symptomatic edema, can observe for 1-2 weeks for possible spontaneous remission after
infection subsided
 Blood test not routinely required
 Treatment: Prednisolone
Full dose 60mg/m2/day (max 60mg/d) till remission (neg/trace x 3/7)
Then 40mg/m2/day (max 40mg/d) alternate day x 4wks
Then wean in 4 wks
Slower weaning in frequent relapser
Frequent relapse/steroid dependent
Notice the ‘Steroid threshold’ = dose of steroid in which the child is actually relapsing on.
Prednisolone
Full dose 60mg/m2/day (max 60mg/d) till remission (neg/trace x 3/7)
Then 40mg/m2/day (max 40mg/d) alternate day x 4wks
Taper by 10mg/m2/month until a maintenance dose of 10-30mg/m2 alternate day, decided on the
‘steroid threshold’
Keep on the same dose for at least 6 months
Aim: low dose, alternate day, single morning steroid to reduce toxicity
If frequent viral triggered relapse
Change steroid from alternate to daily dose for 7days during viral infection to reduce chance of
relapse
Indication of steroid sparing agent:

Steroid threshold > 0.5mg/kg/day
Steroid toxicity: growth impairment, cataracts, excessive weight gain, cushingoid features,
hypertension, osteopenia
If steroid use >6months, refer eye to screen for cataracts, refer DEXA scan
 Sequence of steroid sparing agent:
levamisole -> MMF -> tacrolimus -> rituximab
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3.5.6 NEPRHITIC SYNDROME
Clinical features: haematuria, proteinuria, hypertension(headache, visual disturbance, altered

mental state), oedema(SOB due to pulmonary edema, abd distension due to ascities) , oliguria
and renal insufficiency
Pathogenesis: Due to direct antibody binding to an antigen expressed or trapped in the

glomerulus OR due to localization of a circulating complex in the kidney, causing glomerular
inflammation due to antigen-antibody reaction, activating inflammatory mediators, causing
proliferation of resident glomerular cells and infiltration by lymphocytes and neutrophils. Reduce
in GFR leads to increase in urea/creatinine and retention of salt and water.
Common causes: acute post-streptococcal GN, post infectious GN, sub-acute bacterial
endocarditis, HSP, lupus, ANCA related, IgA nephropathy
Physical examination: Measure blood pressure, Tachycardia and tachypnea points to systemic
fluid overload, look for edema, throat and cervical LN examination, fine crackles in pulmonary
edema, ascites, hepatosplenomegaly in some systemic disease, Skin rash, joint
swelling/tenderness
Investigation:
Urine routine/microscopy for red cell cast, Spot urine protein/creatinine ratio/24-hour urine
protein
Blood: CBC d/c, LFT, RFT, albumin, Ca PO4, blood gas, ESR, C3, C4, ASOT
2nd tier if indicated (blood c/st, ANA, Anti DsDNA, ANCA, Ig GAM)
Pre steroid workup if indicated (HBV/HCV status, MT5)
Throat swab for c/st
CXR
Management
Renal chart
Strict I & O
BP/P Q1-4h
Bed rest if hypertensive or with significant oedema
Restrict fluid: insensible water loss (400 ml/m 2/day) + previous day urine output
Low salt diet
Oral Penicillin 50 mg/kg/day QID x 10 days
IV Lasix 1-4 mg/kg/day Q6h to promote diuresis

Control BP by Nifedipine (Adalat) 0.25 mg/kg/dose
Consider renal biopsy for doubtful cause and give specific treatment
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3.5.7 ACUTE POISONING
Resource: HA Toxicology Service
Tel Fax Website

HK Poison 2635 1111 3513 5649 Ha.home/hkpic
Information Center
(HA)
PWH Poison 2632 6209 2145 7160
Treatment Center
Toxicology Reference 2990 1941 2990 1942 trl.home
Laboratory
HAHO Duty Officer 71163328 call 999
 eKG : Toxicology
Toxic syndromes (Toxidrome)
Sympathomimetic (e.g. aminophylline, Opioid (e.g. codeine, Lomotil, Heroin,

amphetamines, caffeine, cocaine) morphine)
 Agitation  Respiratory depression
 Diaphoresis  Miosis
 Fever  Coma
 Mydriasis  Bradycardia
 Tachycardia
Anticholinergic (e.g. antihistamines, Cholinergic

Tricyclic antidepressants
 D-efecation
 Blind as a bat—mydriasis
 U-rination
 Dry as a bone—dry skin
 M-iosis, muscle fasciculations,
 Hot as Hades—fever muscle weakness
 Red as a beet—red  B-ronchorrhea, bradycardia,

bronchospasm
 Mad as a hatter—central nervous
system stimulation  E-mesis
 Decreased gastrointestinal  L-acrimation

motility—decreased bowel
sounds  S-alivation
o Urinary retention—full bladder
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Agents that cause seizure

 P—phenothiazine, phencyclidine, pesticides, propranolol
 L—lithium, lidocaine, lindane
 A—anticholinergics, alcohol withdrawal, amphetamine
 S—salicylate, sedative-hypnotic withdrawal, sympathomimetics, strychnine
 T—theophylline
 I—insulin, isoniazid
 C—carbon monoxide, camphor, cocaine
Principles of Management
A. resuscitation—attention to the ABCs (airway, breathing, and circulation) and D
(disability—altered mental status and seizures),
B. decontamination,
C. administration of specific antidotes,
D. enhanced elimination, and
E. supportive care.
- Identify the suspected poison

- Note the dose, likely time of ingestion
GI decontamination
1. Gastric lavage
- Performed when risk of toxicity is high, likelihood of recovering toxin is high, or
other treatment modalities are unavailable
- Certain agents such as anticholinergic agents or opioid agents may delay gastric
emptying and slow GI transit time -may remain in the stomach for more than an
hour and available for removal by lavage.
- Contraindicated in caustic/hydrocarbon ingestion
- Airway protection important
- Lavage with NS 15 ml/kg/cycle (max 200-400 ml in adult) till clear.
2. Activated charcoal (Mainstay of treatment)

- Dose: (1 g/kg in water slurry diluted at least 1:4)
Small children : 15-30 g po
Adolescents: 50-60 g po
*Emesis (Ipecac) –
 No longer recommended.
- Contraindicated in unconscious/convulsing patient, ingestion of caustics/acids,
TCA
Enhanced elimination
1. Forced alkali diuresis -May be effective in salicylate or phenobarbital
overdoses
2. Haemodialysis
3. Hemoperfusion
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Specific antidote
Substance Antidote/ Dose Remarks

Acetaminophen N-acetylcysteine SE: vomiting (PO); anaphylactoid reaction (IV).
IV protocol requires large volumes of free water,
IV: 150 mg/kg over 15 min,
may cause hyponatremia and seizures in children.
then 50 mg/kg over 4 hr,
then 100 mg/kg over 16 hr
PO: 140 mg/kg load, then

70 mg/kg/dose every 4 hr
for 17 doses
Anticholinergic Physostigmine
May repeat dose after 15 min.
agents (eg,
Child: 0.5 mg IV slowly
atropine) SE: cholinergic symptoms occur with
Adult: 2 mg IV slowly excessive dosing.
Benzodiazepines Flumazenil
Titrate to effect or maximal dose. May not
Child: 0.01 mg/kg IV slowly reverse respiratory depression. If positive
every min (max 1 mg) response is of short duration, may give a
continuous infusion.
Adult: 0.1-0.2 mg IV slowly
every min (max 1 mg) SE: withdrawal symptoms in dependent or
chronic use; seizures or dysrhythmias in
cyclic antidepressant overdose.
Opioids Naloxone
Can repeat dose every 2-3 min until response
0.5-2 mg IV/IM/SC/ET (max 10
or max dose. If no response to total 10-mg
mg)
dose, unlikely opioid intoxication. If positive
response is of short duration, may give a
continuous infusion. In setting of possible
opioid dependence, consider initial dose of
0.05 mg to avoid withdrawal.
SE: opioid withdrawal (piloerection, agitation,

vomiting).
Cholinergic agents Atropine

Double dose every 3-5 min. Titrate to
(eg, malathion) Child: 0.02 mg/kg IV initial reduced bronchorrhea or improved oxygen
dose (minimum 0.1 mg) saturation. May require total doses 5 or 10
times the initial dose or higher.
Adult: 0.5-1 mg IV initial
dose SE: anticholinergic toxicity.
Pralidoxime Pralidoxime should be administered in addition to

atropine. Continue therapy for 24-72 hr.
Child: 25-50 mg/kg over
30-60 min, then 20 mg/kg/hr
Adult: 1-2 g IV over 15-30

min, then 0.5 g/hr
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General supportive measures:

1. Maintain Airway, Breathing, Circulation.
2. NPO
3. IV fluid
4. BP/P/RR/SaO2 monitoring/cardiac monitoring or neuro-observation Q1h till
stable
Investigations
1. CBP D/C
2. Na K Blood gas
3. Blood sugar
4. L/RFT
5. Drug level if indicated e.g. salicylate, paracetamol, theophylline or
anticonvulsants (arrange with lab for urgent test)
6. Blood, urine, gastric lavage for toxicology
7. ECG
8. (Urine for pregnancy test)
Psychosocial assessment
1. Psychosocial history -HEADSS
 H: Home
 E: Education, Employment
 A: Activities
 D: Drugs
 S: Sex
 S: Suicide
2. Consult Psychiatrist for all cases of drug overdose.
3. Consult MSW if necessary.
4. Watch out for child abuse.
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Acute Acetaminophen (Panadol) overdose
1. Stages of acute acetaminophen poisoning
Stage Time Post-ingestion Clinical features

I 0-24 hr Anorexia, nausea, vomiting
II 24–72 h RUQ abdominal pain (common)
AST, ALT, and, if poisoning is severe, bilirubin and PT elevated
III 72-96 hr Vomiting and symptoms of liver failure
Peaking of AST, ALT, bilirubin and INR
Sometimes renal failure and pancreatitis
IV > 5 days Hepatic dysfunction resolves or progress to multi-organ failure
( sometimes fatal)
2. Likelihood and severity of toxicity predicted by

i. Amount ingested : Toxic dose : ≥ 150 mg/kg (about 7.5 g in adults) within 24
hours
ii. plasma acetaminophen level (More accurate)
 For a single acute overdose of traditional or rapid-relief acetaminophen
(absorbed 7 to 8 min faster), measure level at ≥ 4 h after ingestion and plot
on the nomogram (Check BNF in ward).
 Hepatotoxicity is very unlikely if level ≤ 150 μg/mL (≤ 990 μmol/L) and
absence of toxic symptoms.
 Higher levels indicate possible hepatotoxicity.
 For a single acute overdose with extended-relief acetaminophen (which
has 2 peak serum levels about 4 h apart), measure levels at ≥ 4 h after
ingestion and 4 h later; if either level is above the Rumack-Matthew line of
toxicity, treatment is required.
3. Antidote: N-acetylcysteine (NAC) most effective if given within 8 hours of ingestion.

After 24 hours, questionable benefit.
4. Therapy
- 1-4 hr of ingestion: Give charcoal and draw level at 4 hrs
- > 4 hr of ingestion : Draw level and treat with NAC (* Charcoal adsorbs oral NAC;
avoid simultaneous administration)
- Oral NAC (PO/ NG):
Give NAC diluted 1:4 in carbonated beverage/fruit juice as a loading dose
of 140 mg/kg, then 70 mg/kg Q4H for 17 doses. If vomiting occurs within
1 hr of ingestion, repeat the dose.
- IV NAC : (20 % NAC solution)
Give 150 mg/kg in 200 ml D5 over 15 min. Then 50 mg/kg in 500 ml D5
over 4 hr, then 100 mg/kg in 1000 ml D5 over next 16 hrs.
- Small risk of anaphylaxis
- Check plasma level at 24 hrs.
– Liver failure is treated supportively. Patients with fulminant liver failure may require
liver transplantation.
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Rumack-Matthew nomogram for single acute acetaminophen poisoning.

Semilogarithmic plot of plasma acetaminophen levels vs time. Cautions for use of
this chart: (1) The time coordinates refer to time of ingestion. (2) Serum levels
drawn before 4 h may not represent peak levels. (3) The graph should be used only
in relation to a single acute ingestion. (4) The lower solid line 25% below the
standard nomogram is included to allow for possible errors in acetaminophen
plasma assays and estimated time from ingestion of an overdose. Adapted from
Rumack BH, Matthew H: Acetaminophen poisoning and toxicity. Pediatrics 55(6):
871–876, 1975.
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3.5.8 ANOREXIA NERVOSA: ACUTE MANAGEMENT IN PAEDIATRIC
SETTING
DIAGNOSTIC CRITERIA (DSM-V) : Anorexia Nervosa (AN)
1. Restricted caloric intake relative to energy requirements, leading to significantly low body weight
for age, sex, projected growth, and physical health
2. Intense fear of gaining weight or behaviors that consistently interfere with weight gain, despite
being at a significantly low weight
3. Altered perception of one’s body weight or shape, excessive influence of body weight or shape on
 self-value, or persistent
Anorexia nervosa (AN) islack of acknowledgment
a serious of the
disease with life seriousness
threatening of one’s
physical andlow body weight
psychological
complications. Patients with AN commonly present with weight loss, amenorrhoea, syncope or
Subtypes: restricting type and binge-eating/purging type
pre-syncope, edema, or generalised weakness.
 For any child or adolescent presenting with significant weight loss, it is important to exclude
other causes:
1. GI: Inflammatory bowel disease, malabsorption, coeliac disease
2. Endocrine causes: diabetes, hyperthyroidism, hypopituitarism, Addison’s
3. Malignancy
4. Chronic infection e.g. TB, HIV
5. Other psychiatric disorders: depression, obsessive compulsive disorder, anxiety
MEDICAL ASSESSMENT
1. HISTORY
1. Body weight (BW) • Premorbid BW, maximum and minimum BW and when. (Obtain
history – Review the previous growth chart for comparison.)
weight loss trajectory to • Onset and rate of weight loss, time line
assess risk • Goal/ideal BW
• Feeling about current weight
• Frequency of weighing and feeling towards weight changes
2. Diet History and fluid • Dietary intake before disease onset
intake • Time line of dietary restriction, portion, progression, triggers,
calories
• Food groups avoided, safe/unsafe food, new
vegetarianism/veganism
• 24-h dietary recall, fasting
• Fluid intake: restriction or excess, caffeine
3. Eating attitudes and • Eat slowly, cut into small pieces, small bites
behaviour • Strict time schedule, eat alone
• Prepare own food, cook for others and not eating themselves
• Count calories, read food label, measure portions, habits/rituals
around food
4. Exercise history • Timeline, increase, type, frequency, intensity, duration
• Reasons for exercise, stressed when miss-out
5. Purging behaviour • Self-induced vomiting, laxatives, diuretics, diet pills
• Method, frequency, circumstances/triggers, increase,
progression
6. Bingeing behaviour • Frequency, foods, approximate amount, circumstances/triggers,
sense of loss of control, guilt
7. Body image • Happy with/dislike own look, dislike/stressed about certain body
parts, body checking e.g. pinching, mirror checking, distorted body
image
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• Relentless pursuit of thinness, fear of gaining weight
8. Insight • Low BW, medical instability
9. Menstrual history • Menarche, cycle regularity and duration, change in cycle
• LMP (weight at LMP)
10. System review • CVS/Resp: postural dizziness, fainting, palpitations, chest pain,
SOB, exercise intolerance, blue/swollen extremities
• GI: vomiting, diarrhoea, constipation, early satiety, bloating, pain
• Renal: polyuria, polydipsia
• Neurological: poor concentration, memory loss, headache,
insomnia
• Haematological: pallor, easy bruising, frequent infections
• Endocrine: cold intolerance, low energy/fatigue
• Musculoskeletal: muscle cramps, joint pain/stiffness
• Skin: hair loss, dry skin, rash, night sweats
11. Psychosocial • Home, Education/employment, Activities, Drugs, Sex,
assessment: HEADSSS Suicide/Self-harm, Safety
12. Past medical history • Birth, developmental milestones, hospitalisations, allergy
13. Past psychiatric • Anxiety, depression, OCD, ASD
history
14. Family history • Endocrine (Thyroid, T1DM), GI (IBD), celiac disease, genetic short
stature
• Psychiatric disorders: eating disorder, anxiety, depression, OCD
PHYSICAL EXAMINATION

Assess for signs of starvation and medical instability. Refer to Junior MARSIPAN Risk
Assessment. Appendix 1
1. Growth centiles  BW, BH, BMI=BW(kg)/BH(m)2 . Plot on growth chart.
 Calculate % median BMI = (actual BMI / 50th centile BMI for sex and
age] x 100%
 Malnutrition: severe (< 70% median BMI), moderate (70-79%), mild
(80-90%)
2. Vital signs  Temperature: hypothermia
 Lying and standing BP and HR for orthostatic changes
3. General, skin,  Pallor, bruising
hair  Cachexia: facial wasting, decreased subcutaneous fat, muscle wasting
 Dry skin and hair, lanugo hair, carotenemia (yellow discoloration of
palms and soles), thinning of hair, callus on dorsum of hands( Russell’s
sign), parotid swelling, dental caries
 Sacral pressure ulcers, bruising/abrasions over spine, poor wound
healing
 Signs of self-harm
4. Hydration status  Capillary refill, skin mottling, perfusion, urine output
5. CVS  Acrocyanosis, delayed capillary refill, dependent edema
 Heart sounds, bradycardia, hypotension, cardiac murmur (1/3 with
mitral valve prolapse)
6. Respiratory  Air entry to lung bases ( pleural effusion)
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7. Neurological  Mental state
 CNS: PEARL, fundoscopy, cranial nerves; PNS: gait, tone, power, reflexes
 Sit-Up-Squat-Stand (SUSS) test: score 0 (unable), 1 (able only using
hands to help), 2 (able with noticeable difficulty), 3 (able with no
difficulty)
Sit-Up: Patient lies down flat on the floor and gets up, if possible, without using
hands.
Squat-Stand: Patient squats down and rises, if possible, without using hands
8. GI/abdomen  Scaphoid abdomen, mass, organomegaly, bowel sounds

9. GU  Tanner staging
Initial laboratory investigations: to assess for medical complications of AN and to exclude

alternative causes
1. CBC
2. ESR or CRP
3. L/RFT Ca PO4 Mg CK
4. Random BG
5. Blood gas
6. TFT ( fT4 fT3 TSH)
7. Amylase, lipase (if vomiting and abdominal pain)
8. ECG : Look for bradycardia/ tachycardia, arrhythmia; prolonged QTc; changes of hypokalemia
9. Urine R/M +/- pregnancy test +/- toxicology screen
10. CXR
On next blood draw:

1. Hormones: morning cortisol, prolactin, LH, FSH , estradiol (girls) or testosterone(boys), PTH
2. Vitamins and minerals : 25 OH Vitamin D, Vitamin B12 and folate, iron profile , ferritin, Zinc
3. Celiac screen : IgA anti-tTG
4. Carnitine and acylcarnitine profile (if hypoglycaemia)
Other investigations: Echocardiogram, US pelvis, DXA scan for girls with amenorrhoea > 6
months
Goal of hospitalisation
1. medical stabilisation
2. nutritional rehabilitation and monitor for refeeding syndrome
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Refeeding syndrome (RFS)
 Refeeding syndrome is a potentially fatal complication that occurs during nutritional
rehabilitation in a malnourished patient. The major manifestations are: delirium, chest pain,
heart failure in association with hypophosphatemia, hypokalemia and hypomagnesemia.
 RFS usually occurs at day 2- 5 but can occur up to 2 weeks. Monitor urea, creatinine, Na, K, Mg,
Ca, PO4 daily in first 5 days. Repeat at 7-10 days for late onset refeeding.
 Those at high risk for RFS:
o Less than 80% median BMI
o Greater than or equal to 10% weight loss in past 1-2 months
o Persistent hypothermia(< 36°C)
o Bradycardia
o Caloric intake < 500 kcal/day prior to admission
o HypoK, hypoPO4, hypoMg at baseline
Monitor for medical instability:

1. Hypothermia : Temperature < 35.5 degree Celsius
2. Severe bradycardia: < 50bpm awake, < 45 bpm asleep
3. Hypotension: < 90/45 mmHg
4. Orthostatic instability: HR changes of >35bpm or systolic BP changes of > 20mmHg
5. Weak pulses or poor peripheral perfusion
6. Evidence of abnormalities on initial labs
In-patient care protocol

1. Cardiac monitoring.
2. AR/RR/BP Q4h (more frequent if unstable). Supine and erect BP daily till no postural hypotension
3. Strict I &O
4. Encourage oral fluid to a minimum of daily maintenance requirement. May need to limit free
water to 1 litre/day (excluding milk supplement). No water intake 30 minutes before
meals/snacks.
5. Complete bed rest. Wheelchair to bathroom in 1st 48 hours, then review.
6. Weigh (blind to patient) in purple gown ( and underwear only) twice weekly (e.g. on Tuesday and
Friday morning) before breakfast and after void
7. Urine for specific gravity on the morning of weighing days (to assess fluid status and any water
loading)
8. Ask to go to bathroom before meals/snacks. Bed rest for 45 minutes after main meals and snacks
and not allowed to toilet.
9. Time allowed for
a. Main meals: 30 mins
b. Snacks : 20 mins
c. Milk supplement : 15 mins
d. Shower: 15 mins
10. Diet: NO outside food or drink, chewing gum, caffeine or artificial sweetener. NO food
substitution.
a. FOOD is the MEDICINE.
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b. Consult dietitian for meal plan.
c. Before meal plan available, start with 20-40 kcal/kg (or estimated previous day intake
+ 500 kcal). Previous idea of “Start slow and go slow” resulted in underfeeding. Higher
starting calories and quicker step-up is advocated without increase in RFS. Can start
with 1200 kcal/ day and step up 200 -300 kcal every day, in form of 3 main meals + 3
snacks
d. Patient should complete the prescribed diet. Any unfinished portion will be replaced
by nutrition supplement.
e. If food portion/supplement not completed for more than 3 days, consider nasogastric
feeding.
f. Nutrition supplement drink e.g. Isocal ( 1ml=1 kcal) 150 ml -200ml Q4h when HR < 40
bpm during sleep
11. Activity level
Level Activity
Strict medical Complete bedrest with commode at bedside. May stand only for
bedrest daily weight and vitals; bed bath only, no shower.
(Level 1)
Bedrest and Pushed in a wheelchair by staff/parent on the floor; may take
Wheelchair Activity seated shower (< 15 min); walk to toilet in bathroom and briefly
(Level 2) stand to brush teeth or use sink; sit in chair for activities (e.g.,
meals, crafts, games, etc.); Otherwise on bedrest.
Bedrest and Take walks around the floor accompanied by staff/parent, per
Ambulation medical orders; may use toilet in bathroom and take standing
Activity (Level 3) shower (< 15 min); may be up in room for short periods.
Otherwise on bedrest.
12. Consult Child psychiatrist and clinical psychologist

13. Medications:
a. Multivitamin ( Daily-one-plus) 1 tablet daily
b. Thiamine 100mg daily
c. Replace phosphate if needed: Phosphate 2-3 mmol/kg/day ( max 97mmol for 5-17
years) in 2-4 divided doses (Each 500mg Phosphate Sandoz effervescent tablet contains
PO4 16.1 mmol, K 3.1 mmol, Na 20.4 mmol)
14. Aim at weight gain of 0.5- 1kg/week
15. Target BW range : around BMI 18.5 or 50th centile weight for height
Prepared by Anita Tsang

June 2021
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By Dr A Tsang
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Appendix 2 : Hong Kong BMI Chart for girls
Reference:
1. Identification and Management of Eating Disorders in Children and Adolescents. THE
COMMITTEE ON ADOLESCENCE Pediatrics Jan 2021, 147 (1) e2020040279; DOI:
10.1542/peds.2020-040279
2. Academy for Eating Disorders Medical Care Standards Committee. Eating Disorders: A Guide
to Medical Care. 3rd ed. Reston, VA: Academy for Eating Disorders; 2016. Available at:
https://www.aedweb.org/learn/publications/medical-care-standards.
3. Golden NH, Katzman DK, Sawyer SM, et al.; Society for Adolescent Health and Medicine.
Position Paper of the Society for Adolescent Health and Medicine: medical management of
restrictive eating disorders in adolescents and young adults. J Adolesc Health.
2015;56(1):121–125
4. Fifteen minute consultation: A structured approach to the management of children and
adolescents with medically unstable anorexia nervosa. Arch Dis Child Educ Pract Ed. 2017
Aug;102(4):175-181.
5. Junior MARSIPAN: Management of Really Sick Patients under 18 with Anorexia Nervosa.
2012 Royal College of Psychiatrists.
https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-repo
rts/college-report-cr168.pdf?sfvrsn=e38d0c3b_2
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3.5.9 INFANT FORMULA TABLE
Disclaimer: Breastmilk is best

Name Company Age Energy (kcal) Carbohydrate (g) Protein (g) Fat (g) Remarks (Packaging details)
Breastmilk (per From birth 72 +/- 5 7.2 +/- 2.5 1.5 +/- 0.2 3.9 +/- 0.4
100ml)
Whey: casein
60:40
Infant Formula From Birth
Cow & Gate 1 Cow and From birth 64 7.3 1.3 3.3
(Powder) (per Gate
100ml)
Enfamil A+ 1 Mead From birth 66 7.7 1.39 3.4
(Powder) (per Johnson
100ml)
Frisolac Gold 1 Friso From birth 66 7.3 1.4 3.5
(Powder) (per
100ml)
Nutrient Dense Formulas

Enfamil Mead Preterm/LBW 81 8.8 (42%) 2.4 (14%) 4.1 (44%) Indication: premature or LBW
Premature Lipid Johnson (24kcal/oz) infants
(per 100ml) Available in Hospital ONLY
Infatrini Nutricia 0-18 months 101 10.3 (40.7%) 2.6 (10.3%) 5.4 (47.9%) Indications: Disease related
(per 100ml) (30kcal/oz) undernutrition, growth failure in
infancy and malabsorption.
Contains medium chain
triglycerides (MCT) and long-chain
polyunsaturated fatty acids (LCPs)
Nutren Junior Nestle 1-10 years 102 11.2 (44%) 3 (12%) 4.8 (44%) Indications: Mild to moderate
(per 100ml) reflux; growth failure, inadequate
18.5% MCT oral intake.
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Fat source soybean oil, canola oil,
MCT (coconut and/or palm kernel
oil)
Pediasure 1+ Abbott 1-10 years 100 13.1 3 3.91 Indications: Growth failure
(vanilla)
(per 100ml)
Extensively Hydrolysed Formulas
Gastrojunior Cow and From birth 66 6.8 1.8 3.5 Indications: Malabsorption related
(per 100ml) Gate conditions (e.g. GI conditions, liver
99.5% lactose free 46% MCT disease) and suspected cow’s milk
intolerance or allergy.
Low osmolality (210mOsmol/kg
H20)
Contains LCPs
Nutramigen Mead From birth 68 7 (41%) 1.9 (11%) 3.6 (48%) Indications: suspected cow’s milk
(per 100ml) Johnson 2.8% MCT allergy, multiple food allergies
Suitable for babies with
galactosemia
Alfare Nestle From birth 68 7.3 2 3.4 Indications: combined allergy to
(per 100ml) cow’s milk protein and soy protein;
40% MCT maldigestion and malabsorptive
disorders (e.g. chronic diarrhea,
cystic fibrosis, biliary atresia)
Peptamen Junior Nestle 1-10 years 100 13.6 (55%) 3 (12%) 3.8 (33%) Indications: Malabsorption related
(per 100ml) 51% MCT conditions
Fat source: MCT (coconut and palm
kernel oil), soybean oil, canola oil
Vivoplex Plus Nestle Ages 3 and up 80 12.8 2.4 2.4 Indications: severely compromised
(per 100ml) GI tracts.
Low quantities of fat (6% of total
calories) (for improved tolerance &
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reduced pancreatic stimulation).
Peptamen Prebio Nestle Ages 4 and up 100 12.8 4 4 Indications: Oral supplement in
(adult) critically ill patients or those with
(per 100ml) malnutrition/maldigestion.
Protein source 100% whey protein
Hydrolysed, peptide-based feed
Contains 70% of fat as MCT
Contains soluble fibre
Elemental Formulas (amino acid formulas)
Neocate LCP Nutricia 0-12 months 67 7.2 1.8 3.4 Indications: Cow’s milk protein
(per 100ml) allergy, multiple food protein
100% FAA allergies, and other GI conditions.
Expensive
Neocate Junior Nutricia >1 year 100 12 2.8 4.6 Indications: Proven cow’s milk
(per 100ml) protein allergy, short bowel
100% FAA syndrome, intractable malabsorption
and other GI disorders.
Expensive
Lactose-Free Formulas
Enfamil Mead From birth 68 7.4 (43.5%) 1.4 (8.5%) 3.6 (48%) Indication: lactose intolerance
LactoFree Johnson NOT for galactosemia
(per 100ml)
AL 110 Nestle From birth 67 1.4 NOT for galactosemia

(per 100ml)
Lactose-Free, Soy Protein Isolate Formulas
Isomil 1 (with Abbott 0-12 months 68 7.0 1.66 3.7 Indications: soy-based formula for
DHA) infants with cow’s milk protein
(per 100ml) allergy, lactose intolerance,
galactosemia, diarrhea, infant colic
Nursoy Wyeth From birth 67 1.8
(per 100ml)
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High MCT Formulas
Monogen Nutricia From birth to 73.5 12 2.2 1.9 Indications: Hyperlipoproteinaemia
(per 100ml) 1 year old type 1, long chain fatty acid
oxidation disorders, chylous ascites,
chylothorax, fat malabsorption
Ingredients: 84% MCTs, 16% LCTs,

whey protein (4.9g/100g), fibre free
Portagen (per Mead >1 year 470 54 16.5 22 Indications: For children and adults
100g) Johnson with defects in the intraluminal
MCT (87%), hydrolysis of fat (decreased
corn oil pancreatic lipase, decreased bile
(13%) salts); defective mucosal fat
absorption (decreased mucosal
permeability, decreased absorptive
surface); and/or defective lymphatic
transport of fat (i.e. intestinal
lymphatic obstruction).
NOT nutritionally complete

Formulas for Regurgitation
Frisolac Gold Friesland 0-12 months 67 7.4 1.4 3.5 For infants with GI reflux,
Comfort constipation and/or colic. Contains
(per 100ml) carob bean gum, prebiotics and easy
digestible protein to alleviate these
symptoms and to support gut health.
Also contains nutrients like iron,
DHA, AA and nucleotides.
Nutrient Modules
Polycal Nutricia 384kcal (per 96g (per 100g) 0 (per 100g) 0 (per 100g) Indications: conditions where a high
(per 100ml) 100g) energy, low fluid or modular diet is
needed.
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Ingredients: Maltodextrin
Calogen (LCT) Nutricia 450 0.1 0 50 A high energy LCT emulsion
(per 100ml)
Vegetable oil Indications: malnutrition, conditions
(rapeseed requiring a high energy intake with
oil, or without fluid and electrolyte
sunflower restriction, protein restricted diets
oil)
Liquigen (MCT) Nutricia 450 0 0 50 A high energy MCT emulsion
(per 100ml)
Refined Indications: conditions where MCTs
vegetable oil are part of dietary management.
(Modified Conditions managed by the
Palm Kernel ketogenic diet. Long chain fatty-acid
and/or oxidation disorders. Other inborn
coconut oil errors of metabolism where MCTs
(MCT) may beneficial
Thickener
Thicken Up Nestle >1 year 365 90 <0.5 <0.15 Indication: dysphagia
(per 100g) Ingredients: Modified food starch
(maize).
Thicken Up Clear Nestle >3 year 306 62 1 0 Indication: dysphagia
(per 100g) Ingredients: Maltodextrin (corn,
potato), xanthan gum, KCl
Adult Formulas that may be used in Adolescent Wards
(Can be used with caution in children >6 years and BW >20kg; protein and some micronutrient intakes may be
inappropriately high)
Ensure (per Abbott 100 17 3.7 2.6 Nutritionally complete
100ml) Indications: For individuals at risk
of developing disease related
malnutrition
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Fresubin Original Fresenius 100 13 3.8 3.4 Nutritionally complete
Drink Kabi Indication: disease related
(per 100ml) malnutrition, short bowel syndrome,
proven inflammatory bowel disease,
following total gastrectomy, bowel
fistula
Ultracal Nestle 101 13 4.4 3.5 Nutritionally complete
(per 100ml) Indication: dietary management of
conditions with increased nutritional
needs
High Protein; contains fibre
20% MCT
Isocal HN Nestle 105 13.5 4.4 3.7 Nutritionally complete
(per 100ml) Indications: dietary management of
malnutrition
High Protein; 20% MCT
Breastmilk (per From birth 72 +/- 5 7.2 +/- 2.5 1.5 +/- 0.2 3.9 +/- 0.4
100ml)
Whey: casein
60:40
Infant Formula From Birth
Cow & Gate 1 Cow and From birth 64 7.3 1.3 3.3
(Powder) (per Gate
100ml)
Enfamil A+ 1 Mead From birth 66 7.7 1.39 3.4
(Powder) (per Johnson
100ml)
Frisolac Gold 1 Friso From birth 66 7.3 1.4 3.5
(Powder) (per
100ml)
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Nutrient Dense Formulas
Enfamil Mead Preterm/LBW 81 8.8 (42%) 2.4 (14%) 4.1 (44%) Indication: premature or LBW
Premature Lipid Johnson (24kcal/oz) infants
(per 100ml) Available in Hospital ONLY
Infatrini Nutricia 0-18 months 101 10.3 (40.7%) 2.6 (10.3%) 5.4 (47.9%) Indications: Disease related
(per 100ml) (30kcal/oz) undernutrition, growth failure in
infancy and malabsorption.
Contains medium chain
triglycerides (MCT) and long-chain
polyunsaturated fatty acids (LCPs)
Nutren Junior Nestle 1-10 years 102 11.2 (44%) 3 (12%) 4.8 (44%) Indications: Mild to moderate
(per 100ml) reflux; growth failure, inadequate
18.5% MCT oral intake.
Fat source soybean oil, canola oil,

MCT (coconut and/or palm kernel
oil)
Pediasure 1+ Abbott 1-10 years 100 13.1 3 3.91 Indications: Growth failure
(vanilla)
(per 100ml)
Extensively Hydrolysed Formulas
Gastrojunior Cow and From birth 66 6.8 1.8 3.5 Indications: Malabsorption related
(per 100ml) Gate conditions (e.g. GI conditions, liver
99.5% lactose free 46% MCT disease) and suspected cow’s milk
intolerance or allergy.
Low osmolality (210mOsmol/kg
H20)
Contains LCPs
Nutramigen Mead From birth 68 7 (41%) 1.9 (11%) 3.6 (48%) Indications: suspected cow’s milk
(per 100ml) Johnson 2.8% MCT allergy, multiple food allergies
Suitable for babies with
galactosemia
Alfare Nestle From birth 68 7.3 2 3.4 Indications: combined allergy to
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(per 100ml) cow’s milk protein and soy protein;
40% MCT maldigestion and malabsorptive
disorders (e.g. chronic diarrhea,
cystic fibrosis, biliary atresia)
Peptamen Junior Nestle 1-10 years 100 13.6 (55%) 3 (12%) 3.8 (33%) Indications: Malabsorption related
(per 100ml) 51% MCT conditions
Fat source: MCT (coconut and palm
kernel oil), soybean oil, canola oil
Vivoplex Plus Nestle Ages 3 and up 80 12.8 2.4 2.4 Indications: severely compromised
(per 100ml) GI tracts.
Low quantities of fat (6% of total
calories) (for improved tolerance &
reduced pancreatic stimulation).
Peptamen Prebio Nestle Ages 4 and up 100 12.8 4 4 Indications: Oral supplement in
(adult) critically ill patients or those with
(per 100ml) malnutrition/maldigestion.
Protein source 100% whey protein
Hydrolysed, peptide-based feed
Contains 70% of fat as MCT
Contains soluble fibre
Elemental Formulas (amino acid formulas)
Neocate LCP Nutricia 0-12 months 67 7.2 1.8 3.4 Indications: Cow’s milk protein
(per 100ml) allergy, multiple food protein
100% FAA allergies, and other GI conditions.
Expensive
Neocate Junior Nutricia >1 year 100 12 2.8 4.6 Indications: Proven cow’s milk
(per 100ml) protein allergy, short bowel
100% FAA syndrome, intractable malabsorption
and other GI disorders.
Expensive
Lactose-Free Formulas
Enfamil Mead From birth 68 7.4 (43.5%) 1.4 (8.5%) 3.6 (48%) Indication: lactose intolerance
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LactoFree Johnson NOT for galactosemia
(per 100ml)
AL 110 Nestle From birth 67 1.4 NOT for galactosemia

(per 100ml)
Lactose-Free, Soy Protein Isolate Formulas
Isomil 1 (with Abbott 0-12 months 68 7.0 1.66 3.7 Indications: soy-based formula for
DHA) infants with cow’s milk protein
(per 100ml) allergy, lactose intolerance,
galactosemia, diarrhea, infant colic
Nursoy Wyeth From birth 67 1.8
(per 100ml)
High MCT Formulas
Monogen Nutricia From birth to 73.5 12 2.2 1.9 Indications: Hyperlipoproteinaemia
(per 100ml) 1 year old type 1, long chain fatty acid
oxidation disorders, chylous ascites,
chylothorax, fat malabsorption
Ingredients: 84% MCTs, 16% LCTs,

whey protein (4.9g/100g), fibre free
Portagen (per Mead >1 year 470 54 16.5 22 Indications: For children and adults
100g) Johnson with defects in the intraluminal
MCT (87%), hydrolysis of fat (decreased
corn oil pancreatic lipase, decreased bile
(13%) salts); defective mucosal fat
absorption (decreased mucosal
permeability, decreased absorptive
surface); and/or defective lymphatic
transport of fat (i.e. intestinal
lymphatic obstruction).
NOT nutritionally complete
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Formulas for Regurgitation
Frisolac Gold Friesland 0-12 months 67 7.4 1.4 3.5 For infants with GI reflux,
Comfort constipation and/or colic. Contains
(per 100ml) carob bean gum, prebiotics and easy
digestible protein to alleviate these
symptoms and to support gut health.
Also contains nutrients like iron,
DHA, AA and nucleotides.
Nutrient Modules
Polycal Nutricia 384kcal (per 96g (per 100g) 0 (per 100g) 0 (per 100g) Indications: conditions where a high
(per 100ml) 100g) energy, low fluid or modular diet is
needed.
Ingredients: Maltodextrin
Calogen (LCT) Nutricia 450 0.1 0 50 A high energy LCT emulsion
(per 100ml)
Vegetable oil Indications: malnutrition, conditions
(rapeseed requiring a high energy intake with
oil, or without fluid and electrolyte
sunflower restriction, protein restricted diets
oil)
Liquigen (MCT) Nutricia 450 0 0 50 A high energy MCT emulsion
(per 100ml)
Refined Indications: conditions where MCTs
vegetable oil are part of dietary management.
(Modified Conditions managed by the
Palm Kernel ketogenic diet. Long chain fatty-acid
and/or oxidation disorders. Other inborn
coconut oil errors of metabolism where MCTs
(MCT) may beneficial
Thickener
Thicken Up Nestle >1 year 365 90 <0.5 <0.15 Indication: dysphagia
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(per 100g) Ingredients: Modified food starch
(maize).
Thicken Up Clear Nestle >3 year 306 62 1 0 Indication: dysphagia
(per 100g) Ingredients: Maltodextrin (corn,
potato), xanthan gum, KCl
Adult Formulas that may be used in Adolescent Wards
(Can be used with caution in children >6 years and BW >20kg; protein and some micronutrient intakes may be
inappropriately high)
Ensure (per Abbott 100 17 3.7 2.6 Nutritionally complete
100ml) Indications: For individuals at risk
of developing disease related
malnutrition
Fresubin Original Fresenius 100 13 3.8 3.4 Nutritionally complete
Drink Kabi Indication: disease related
(per 100ml) malnutrition, short bowel syndrome,
proven inflammatory bowel disease,
following total gastrectomy, bowel
fistula
Ultracal Nestle 101 13 4.4 3.5 Nutritionally complete
(per 100ml) Indication: dietary management of
conditions with increased nutritional
needs
High Protein; contains fibre
20% MCT
Isocal HN Nestle 105 13.5 4.4 3.7 Nutritionally complete
(per 100ml) Indications: dietary management of
malnutrition
High Protein; 20% MCT
By Dr S Yeow and C Mok 2020
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3.5.10 Kawasaki disease (KD)
Background
Acute vasculitis of childhood predominantly affects children most commonly <5 years of age
Coronary artery aneurysms in 25% of untreated cases
- Incidence reduced to around 4% with timely treatment with IVIG
Leading cause of acquired heart disease in paediatrics
Diagnosis
No laboratory test is diagnostic
Other conditions may mimic KD and needed to be considered: viral infection (adenovirus, EBV,
measles, parvovirus, etc), scarlet fever/toxic shock syndrome, other infections (Rickettsia
infection, leptospirosis, etc), cervical lymphadenitis, drug hypersensitivities (SJS or serum
sickness), other autoimmune diseases, etc
Complete KD (typical/classic)
1) ≥5 days of fever
2) ≥4 of the 5 principal clinical features (do not need to occur simultaneously)
a. Conjunctivitis: bilateral, limbic-sparing, bulbar non-exudative injection
b. Rash: maculopapular, diffuse erythroderma, or erythema multiforme-like
c. Cervical lymphadenopathy: usually unilateral, ≥1.5cm in diameter, over the anterior
cervical triangle
d. Oral changes (red, cracked lips or oropharyngeal mucosa)
e. Extremity changes: erythema +/- tenderness, followed by desquamation
Other features of KD:

- General condition: extreme irritability
- CNS: aseptic meningitis
- Respiratory: non-specific infiltrates in CXR
- GI: hepatitis, gallbladder hydrops, pancreatitis, abdominal pain, vomiting and diarrhea
- Genitourinary: urethritis, aseptic pyuria
- MSK: arthralgia, arthritis
- Other: BCG scar changes, macrophage activation syndrome
Incomplete KD
- More common in infants <6 months of age
- Algorithm for reaching diagnosis included below
- Incomplete KD should be considered in prolonged unexplained fever with <4 principal clinical
findings and compatible laboratory or echocardiographic findings
- Coronary artery aneurysms are suggestive of the diagnosis
o Normal echocardiogram in the first week of illness may be falsely negative
o Coronary artery z scores ≥2.5 of the left anterior descending or right coronary artery
branches are of poor sensitivity but highly specific
Common laboratory findings (nonspecific, providing support only):

- CBC
o Leukocytosis with neutrophilia in the acute stage, +/- immature granulocytes
(leukopenia/lymphocyte predominance is suggestive of alternative diagnosis)
o Normochromic and normocytic anaemia (common, resolves with resolution of
inflammation)
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o Thrombocytosis, occurs until the 2nd week, normalized by 4 to 6 weeks
(thrombocytopenia is possible if DIC occurs)
- Inflammatory markers
o High CRP and ESR
- LRFT
o Elevated transaminase (40-60%)
o Hypoalbuminemia (common, and associated with severe and prolonged acute disease)
- Urinalysis
o Aseptic pyuria
- CSF
o Pleocytosis with mononuclear cell predominance, normal glucose and protein levels
- Joint aspirates
o Aseptic arthritis with a normal glucose level
McCrindle BW, Rowley AH, Newburger JW, Burns JC, Bolger AF, Gewitz M, Baker AL, Jackson MA, Takahashi M, Shah PB, Kobayashi T,
Wu MH, Saji TT, Pahl E; American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on
Cardiovascular Disease in the Young; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Surgery and
Anesthesia; and Council on Epidemiology and Prevention. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A
Scientific Statement for Health Professionals From the American Heart Association. Circulation. 2017 Apr 25;135(17):e927-e999. doi:
10.1161/CIR.0000000000000484. Epub 2017 Mar 29. Erratum in: Circulation. 2019 Jul 30;140(5):e181-e184. PMID: 28356445.
Treatment
Goals:
- To reduce inflammation and arterial damage
- To prevent thrombosis in those with coronary artery abnormalities
Primary treatment:
Intravenous immunoglobulin (IVIG): 2 grams/kg as the first single dose
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- As early as possible, or at least within the first 10 days of illness when the diagnosis is established
o No outcome difference or need for retreatment with IVIG if treated earlier than day 5
of illness
- Side effects of high-dose IVIG: headache, fever, hypersensitivity reaction, Coombs-positive
hemolytic anaemia, aseptic meningitis (rare and self-limiting)
- Remember to write letter to defer live vaccines (MMR and varicella immunization) for at least 11
months after the last dose of 2 grams/kg of IVIG
Aspirin
- First check that the patient does not have G6PD deficiency and influenza or chickenpox infections
(consider dipyridamole if the patient has these conditions)
- An anti-inflammatory moderate dose of 30-50 mg/kg/day divided every 6 hours until fever
resolves for at least 48-72 hours, and up to 14 days total is now the recommended initial
treatment dose for QMH Dept of Paediatrics and Adolescent Medicine
- Then switch to a subsequent anti-platelet dose of 3-5 mg/kg/day once daily until no evidence of
coronary changes by 6-8 weeks after the onset
- High-dose aspirin should be avoided in the setting of active infection with influenza or varicella in
view of high risk of Reye’s syndrome
Inadequate IVIG response

- 10-20% of patients
- Recurrence or persistent fever at least 36 hours after the end of IVIG infusion
- Consider:
o 2nd dose of 2 grams/kg IVIG, or
o IVIG + steroid (methylprednisolone 20-30 mg/kg/dose IV once daily for 3 days +/-
taper), or
o Infliximab, or
o other immunomodulatory therapy, e.g. anakinra, cyclosporin, plasma exchange, etc
Prognosis
- 5% will still develop coronary artery aneurysms
- 1% will still develop giant aneurysms
Antithrombotic and fibrinolytic therapy

The use of anticoagulant (warfarin or low molecular weight heparin) and/or dual antiplatelet
therapy (aspirin + clopidogrel) is reserved for selected cases with large or giant aneurysms, and
requires specialist consultation.
Echocardiogram and follow up
- Consult QMH Paed Cardiac team for echocardiogram assessment and follow up plan +/-
any recommendation on restriction of physical activity
- Usual intervals of follow-up echocardiogram assessment: 2 weeks, 6-8 weeks, 6 months
and 12 months after the onset
- If there is coronary artery involvement, more frequent echocardiogram assessments are
needed; severe cases may require myocardial perfusion scan and/or angiogram
Reference:
1. McCrindle BW, Rowley AH, Newburger JW, Burns JC, Bolger AF, Gewitz M, et al. Diagnosis,
treatment, and long-term management of Kawasaki disease: A scientific statement for
health professionals from the American Heart Association. Vol. 135, Circulation. 2017.
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927–999 p.
2. UpToDate: Kawasaki disease: Clinical Features and Diagnosis
3. UpToDate: Kawasaki disease: Initial treatment and Prognosis
By Dr F Wong, J Rosa Duque, D Soo in 2021
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3.5.11 Atopic Dermatitis
Diagnosis
 Differential diagnosis: keratosis pilaris, allergic contact dermatitis, irritant dermatitis,
fungal dermatitis, seborrheic dermatitis, psoriasiform dermatitis, lichen simplex chronicus,
pityriasis rubra pilaris, asteototic eczema, pityriasis rosea, scabies, HIV-associated
dermatitis, infective dermatitis with HTLV-1, Langerhans cell histiocytosis, cutaneous T
cell lymphoma, gluconoma/glucogonoma, Letterer-Siwe disease, Wiskott-Aldrich
syndrome, SCID (e.g., Omenn syndrome), Hyper-IgE syndromes, IPEX, acrodermatitis
enteropathica, niacin deficiency, pyridoxine deficiency, multiple carboxylase deficiency,
phenylketonuria, kwashiorkor, dermatitis herpetiformis, Comel-Netherton syndrome,
Hartnup syndrome
 Diagnosis of AD supported by findings in Table 1:
 In equivocal cases, may require referral to dermatology, other subspecialists for

evaluation, skin biopsy or other workup (microscopic exam of hair, patch testing,
laboratory testing), etc for diagnosis
Testing for Food Triggers

 ~1/3 young patients have clinically relevant reactivity to a common food allergen
 NIAID guideline: consider testing children <5 yrs old with moderate-severe AD for milk,
soy, egg, wheat, and peanut if AD is refractory to optimal treatment or if there is a
recurrent, history of immediate exacerbation after ingestion of a specific food
 In older children/adults, Birch pollen-related foods have been described as potential
triggers of AD (even when cooked)
 Elimination diet x 4 weeks, by empiric elimination of milk and egg and milk vs directed by
allergy testing (per algorithm below):
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 Avoid unnecessary, prolonged avoidance of common food allergens which can increase
the risk of developing true food allergy (per LEAP and other recent studies)
Treatment
 Focus on avoidance of known triggers (dust mite control measures if sensitized to dust
mite, limit food allergens clearly exacerbating AD), skin hydration and moisturization,
topical immunosuppressive therapies (corticosteroids, calcineurin inhibitors, etc)
 Dilute bleach baths 2-3x/week for patients with suspected S Aureus sensitization
 Wet wrap for severe cases (adequate training may require inpatient hospitalization)
 Consider treatment for bacterial superinfection and/or eczema herpeticum, if present
 UVB phototherapy per dermatology
 Systemic immunosuppressive therapy (e.g., cyclosporine, azathioprine, MTX, MMF) for
severe cases refractory to above treatments
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Potency Classification Medication Name Strength and Formulation
I
Very high potency Clobetasol propionate 0.05% ointment
up to 600X more potent than hydrocortisone 0.05% cream
II
High potency Mometasone furoate 0.1% ointment
100-150X more potent than hydrocortisone Betamethasone dipropionate ------ 0.05% ointment
III
High potency Betamethasone dipropionate ------ 0.05% cream
2-25X more potent than hydrocortisone Betamethasone valerate 0.1% ointment
Clobetasone butyrate 0.05% cream
IV
Mid potency Mometasone furoate 0.1% cream
Mometasone furoate 0.1% lotion
V
Mid potency Fluticasone propionate 0.05% cream
Betamethasone valerate 0.1% cream
Fluocinolone acetonide 0.025% cream
VI
Low potency Fluocinolone acetonide 0.0125% cream
Triamcinolone acetonide 0.02% cream
VII Hydrocortisone 1% ointment

Low potency Hydrocortisone 1% cream
Hydrocortisone 1% lotion
Updated by Dr J Rosa Duque, Mar 2020
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3.5.12 Drug Allergy
General Algorithm for Approach to Drug Allergy
Contraindications
 Do not rechallenge patients with a history of any of the following reactions triggered by
the drug in question:
 Bullous pemphigoid
 Pemphigus vulgaris
 Linear IgA bullous disease
 Drug-induced lupus
 Acute generalized exanthematous pustulosis
 Sweet’s syndrome - acute febrile neutrophilic dermatosis
 Stevens–Johnson syndrome/toxic epidermal necrolysis
 Drug rash with eosinophilia and systemic symptoms (DRESS)
 Exfoliative dermatitis
 Serum sickness
 Leukocytoclastic vasculitis
 Churg-Strauss
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 Cytopenias
 Hepatitis
 Nephritis
 Pneumonitis
Skin Testing
 Performed to rule out IgE-mediated, immediate type hypersensitivity
 Performed for if non-irritating concentrations have been studied and published (only
penicillin major and minor determinants have been systematically validated and
standardized)
Graded Challenge
 Objective is to cautiously introduce a drug given in 2-3 steps to patients who
are unlikely to be allergic to it
 Protocols
o Should be done under close monitoring
o Choose starting dose:
Likelihood of true allergy to drug Starting dose
and risk
Unlikely or high risk 1/100 or 1/1000th of final dose
Very unlikely and low risk 1/10 or 1/2 of final dose
Extremely unlikely and low risk Full dose to negate history
o Interval between doses depends on history of original reaction
 Immediate - 1 hour
 Delayed - hours to days
o If the graded challenge is tolerated, the patient may return to regular
administration of the the drug
Drug Desensitization
 Requires several hours for IgE-mediated, immediate type hypersensitivity and several
days, weeks, or months for delayed-type hypersensitivity
 Not considered for other adverse drug reactions/hypersensitivity
 Consult an allergist for consideration, planning, and management
by Dr J Rosa Duque, Mar 2020
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3.5.13 Food Allergy

Food Allergy
 8 food allergens account for 90% of food allergies: milk, soy, egg, wheat, peanut, tree
nuts, fish, shellfish
 Diagnosed by clinical history, history, history, history of elevated serum tryptase 1-3 hours
after food allergen ingestion, then testing (skin prick, specific IgE, gold standard: double
blind placebo controlled food challenge)
 Skin or laboratory testing for food allergies: PPV ~50-75%, NPV ~90%.
Oral Food Challenge

General Approach
 Obtain baseline vital signs (peak flow measurement, if indicated), and physical exam
 Consider IV placement in history of FPIES or anaphylaxis, severe asthma, difficult IV
access, anticipated need for IV medications for resuscitation
 Nurse to supervise the patient and physician on standby readily available
 Dosing per established QMH UPAM protocols for routine OFC, or discuss with allergist for
special cases (unique foods without protocols, or FPIES challenge, etc)
 Re-examine prior to each dose
 In case of subjective complaints (throat itching, mouth itching, skin itching, or nausea), a
period of observation to allow for resolution of symptoms before a subsequent dose
 PRACTALL: In case of subjective symptoms:
o Continue the challenge, in spite of until the subject exhibits objective symptoms
o If the patient is unable or unwilling to continue the challenge because of the
subjective symptoms, then discontinue the challenge and consider the final
administered dose to be right censored (how much more the patient could tolerate
and remain symptom free would be unknown)
Interpretation of Results
 Negative OFC:
o if the patient tolerates the entire challenge and post-observation period
o Longer observation periods may be necessary in patients with later onset of
symptoms in previous reactions, such as GI complaints and/or eczema
Depending on the severity of the previous delayed reactions, observation may be
warranted under physician supervision, or a patient may be discharged home and
instructed to keep a log (standard of two days at QMH UPAM) of symptoms
 OFC positive:
o if 1 of the following is observed within 2 hours of ingestion of a dose during food
challenge:
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 3 or more perioral urticaria or 1 elsewhere
 Perioral or periorbital angioedema
 Vomiting (excluding gag reflex)
 Evidence of circulatory or respiratory compromise
Post-Challenge Care
 Negative OFC:
o for routine cases, can discharge after ≥2 hrs if asymptomatic and continue food
challenge at home for 2 days per established QMH UPAM protocol
 Positive OFC:
o treatment per anaphylaxis page
o remain under observation 2-4 hrs (depending on severity) after resolution of
symptoms
o long-term care: continue strict avoidance of the food, ensure patient is given Rx
and teaching on adrenaline autoinjector use, a food allergy emergency care plan
form, education on the possibility of biphasic reaction and appropriate home
management steps, and Allergy clinic follow-up within 6-12 months
by Dr J Rosa Duque, Mar 2020
References:
Food Allergy
ACAAI. Food allergy: a practice parameter. Ann Allergy Asthma Immunol. 2006 Mar;96(3 Suppl
2):S1-68.
Sampson HA, Aceves S, Bock SA, James J, et al. Food allergy:
a practice parameter update-2014. J Allergy Clin Immunol. 2014 Nov;134(5):1016-25.e43.
B. Niggemann. When is an oral food challenge positive? Allergy. 2010 Jan;65(1):2-6.
Sampson HA1, Gerth van Wijk R, Bindslev-Jensen C, et
al. Standardizing double-blind, placebo-controlled oral food challenges: American Academy of
Allergy, Asthma & Immunology-European Academy of Allergy and Clinical
ImmunologyPRACTALL consensus report. J Allergy Clin Immunol. 2012 Dec;130(6):1260-74.
Drug Allergy
Joint Task Force on Practice Parameters; AAAAI; ACAAI; Joint Council of Allergy, Asthma and
Immunology. Drug allergy: an updated practice parameter. Ann Allergy Asthma Immunol. 2010
Oct;105(4):259-273.
Hong DI, Dioun AF. Indications, protocols, and outcomes of drug desensitizations for
chemotherapy and monoclonal antibodies in adults and children. J Allergy Clin Immunol
Pract. 2014 Jan-Feb;2(1):13-9.
Castells M. Rapid desensitization for hypersensitivity reactions to medications. Immunol Allergy
Clin North Am. 2009 Aug;29(3):585-606.
Atopic Dermatitis
Schneider L, Tilles S, Lio P, et al. Atopic dermatitis: a practice parameter update 2012. J Allergy
Clin Immunol. 2013 Feb;131(2):295-9.e1-27.
Williams HC. Clinical practice. Atopic dermatitis. N Engl J Med. 2005 Jun 2;352(22):2314-24.
Bergmann MM, Caubet JC, Boguniewicz M, et al. Evaluation of food
allergy in patients with atopic dermatitis. J Allergy Clin Immunol Pract. 2013 Jan;1(1):22-8.
Arkwright PD, Motala C, Subramanian H, et al. Management of difficult-to-treat atopic
dermatitis. J Allergy Clin Immunol Pract. 2013 Mar;1(2):142-51.
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SECTION 3.6: PAEDIATRIC HAEMATOLOGY & ONCOLOGY
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3.6.1 MANAGEMENT OF NEUTROPENIC FEVER
Definitions:
a. Neutropenia: Absolute neutrophil count (ANC) <1x109/L
b. Fever: Core temperature >=38.5oC once, or >=38oC twice in 1 hour
Neutropenic fever is an oncologic emergency as infection (especially by Gram negative

bacteria) can progress rapidly resulting in significant morbidity and mortality.
Investigations:
a. Evaluate the patient’s condition, paying particular attention to vital signs and possible source
of infection, which commonly include oral mucosa, perineal/perianal area, and central or
peripheral venous catheter exit sites.
b. Blood cultures from central venous catheter (2 sets, aerobic cultures only)
 For bi-luminal central venous catheter, take blood culture from both lumens.
 For single lumen central venous catheter, take blood culture from the lumen and inject
into 2 aerobic culture bottles.
 3 – 5 ml blood for each blood culture bottle
 Peripheral blood culture is not required for the usual case of neutropenic fever at first
instance. Peripheral blood culture may be required subsequently to distinguish
catheter-related infection from genuine bacteremia.
c. Other investigations according to possible focus of infection
d. Stool surveillance culture for drug resistant organism (label “BMT surveillance culture”), also
note result from recent samples
Anti-microbial treatment:
Commence broad-spectrum antibiotics within 1 hour of fever onset (after patient evaluation by
house-officer/medical officer and blood cultures)
First-line antibiotics: Tazocin 90mg/kg iv Q6H (max single dose 4.5g)
Use meropenem 20mg/kg iv Q8H (max single dose 2g) instead of tazocin in the following
situations:
1. life-threatening sepsis, hypotension or septic shock
2. history of infection with ESBL producing organisms or suspected infection with such
organisms
3. Allergy to penicillin or cephalosporin
Add amikacin 20mg/kg iv Q24H (max single dose 1.5g) in the following situation:
1. history of Pseudomonas infection or suspected Pseudomonas infection
Add vancomycin 10-15mg/kg iv Q6H (max single dose 500mg) in the following situations:
1. life-threatening sepsis, hypotension or septic shock.
2. severe mucositis (due to risk of streptococcus viridans infection)
3. blood or site-specific isolates of MRSA, coagulase-negative Staphylococcus, Enterococcus,
Bacillus or Gram positive cocci or bacilli pending identification (repeat line culture before starting
vancomycin, if repeated culture is negative in 2 days, stop vancomycin)
4. obvious catheter-related infection (ie. tunnel or exit site infection) or soft tissue infection.
As patient’s condition can change rapidly after initiation of antibiotics, patient should be
reassessed at 4-6 hours after the first evaluation. Familiarize with management of septic shock
and establish early communication with senior colleagues on unstable cases. Monitoring of
central venous pressure valuable if fluid boluses required. Consider transfusion in anemic
patients even if haemoglobin is above the usual transfusion threshold of 7g/dL.
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If fever persists after 48-72 hours, repeat blood culture and consider switching tazocin to
meropenem, adding amikacin and/or vancomycin
If fever persists after 4-7 days, repeat blood culture for bacteria and fungus and consider adding
empirical antifungal therapy with either micafungin or ambisome after discussion with senior:
1. Micafungin 2mg/kg iv Q24H if BW </=40kg; 100mg iv Q24H if BW > 40kg
2. Ambisome 3mg/kg iv Q24H (one vial = 50mg)
Timing of Stopping Antibiotics if no positive blood culture

a. ANC<0.5: If afebrile for 3 consecutive days, can stop antibiotics one at a time (if >1
antibiotics).
If afebrile for 5 consecutive days, can stop all antibiotics.
b. ANC>0.5: Can stop antibiotics if afebrile
Microbiologist should be consulted in case of persistent fever, or problems in cultures or

antibiotic regimen.
References :
1. Paul M, Schlesinger A, Grozinsky S, et al. Beta-lactam versus beta-lactam-aminoglycoside
combination therapy in cancer patients with neutropenia. Cochrane Database of Systematic
Reviews 2009, 3.
2. Paul M, Borok S, Fraser A, et al. Additional anti-Gram-positive antibiotic treatment for febrile
neutropenic cancer patients. Cochrane Database of Systematic Reviews 2009, 3.
3. Goldberg E, Gafter-Gvili A, Robenshtok E, et al. Empirical antifungal therapy for patients with
neutropenia and persistent fever: systematic review and meta-analysis. European Journal of
cancer 2008; 44: 2192-2203.
4. NCCN Practice Guidelines in Oncology. Prevention and treatment of cancer related
infections. http://www.nccn.org/professionals/physician_gls/PDF/infections.pdf.
5. Queiroz-Telles, Flavio, et al. "Micafungin versus liposomal amphotericin B for pediatric
patients with invasive candidiasis: substudy of a randomized double-blind trial." The Pediatric
infectious disease journal 27.9 (2008): 820-826.
Updated by Dr A Liu in 2018
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3.6.2 MANAGEMENT OF HAEMOPHILIA
Haeophilia is an inherited bleeding disorder in which there is a deficiency of factor VIII (haemophilia A) or
factor IX (haemophilia B)
Degree of severity % of normal factor activity
Normal 50-150%
Mild 5-40%
Moderate 1-5%
Severe Less than 1%
Treatment options:
 Replacement of missing clotting protein (On demand vs prophylaxis)
 DDAVP (for mild haemophilia or VWD with adequate DDAVP response)
 Antifibrinolytic Agents eg Tranexamic acid (for mucosal bleeding or mild surface bleeding)
 Supportive measures (Ice, immobilization)
A The desired level of coagulation factors to be achieved :
Minor trauma / Haemorrhage 20 to 30%

Dental extraction / Minor Surgery 30 to 80%
Severe haemathrosis / bleeding 30 to 80%
Major surgery / serious accidents 80 to 100%
B Dose Calculation of Coagulation Factors
Number of unit required = % rise required x wt. in Kg

*K
*K : Factor VIII : 2.0, Factor IX : 1.0
ie. A 10 Kg boy with Haemophila A & acute haemarthorsis of left ankle
No. of unit required = 50 % x 10 = 250 units

2
But if it is Haemophilia B, then it will be 50% x 10 / 1.0 = 500 units
* Factor VIII is given by IV bolus q8 - 12 hrs

* Factor IX is given daily or q12 hr due to its longer half life
C. Measure of response
Response = Measured rise x wt in Kg
Units Given
ie. After the above 10Kg boy was given 250 units of Factor VIII, the 1 hr post-level was 45%
Response = 45 x 10Kg = 1.8 (up to 1.5 is acceptable)

250
Since the maximum response is 2
1.8 x 100% = 90% response (if < 75% rise, has to screen for inhibitor)
2
D. Reminder
 In short, every unit of Factor VIII / Kg body weight will increase the plasma Factor VIII
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level by 2%
 If in doubt, better treat first !
 Double the initial dose at all time (Loading dose)
 Be careful of thrombosis when using intermediate purity Factor IX concentrate
 Following major surgery, level should not fall below 50% for at least 10 days
 For haematuria, treat with forced diuresis first if it is not severe. Beware of urinary
tract obstruction when using coagulation factor
E. Follow-up guidelines for Haemophilia

3 monthly review : clinical review and *full blood screen (all HIV + patients)
6 monthly review : clinical review and *full blood screen (all severe haemophilia)
Annual review : clinical review and *full blood screen (mild haemophilia)
*Full blood screen : CBC, R/LFT, IgG,A,M, virology (HIV, HCV, HBV), VIII Ab screen
Updated by Dr Q See in 2018
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3.6.3 MANAGEMENT OF IMMUNE THROMBOCYTOPENIA (ITP)
IWG 2009 Definition:
Newly diagnosed ITP <3months
Persistent ITP 3-12months
Chronic ITP >12months
Acute ITP
1. Check complete blood count, blood smear, mean platelet volume (MPV), LRFTm clotting
profile, viral serology, anti platelet antibody, auto-immune markers (eg. ANA, anti-dsDNA,
IgGAM) and 3ml EDTA to paed lab for DNA banking
2. No specific treatment if there is no clinical evidence of bleeding (except bruises & petechiae)
and platelet count is >=20 x 10^9/L
3. Bone marrow examination is not needed for diagnosis
Start treatment if :
a. Clinical evidence of bleeding with platelet count <20x 10^9/L
1) Nose bleeding cannot be stopped for > 15 min.
2) Oral mucosal bleeding (eg. Gum bleeding, blood retention cyst)
3) GI bleeding (eg. Melena)
b. Severe bleeding disregards the platelet count (eg. Intracranial hemorrhage, retinal
hemorrhage)
Treatment options
a. IVIG induces a rapid rise of platelet count (within hours) but the effect is transient (1 to
2weeks).
b. Never give platelet transfusion except in emergency situation (eg. Intracranial hemorrhage).
c.Steroid induces a slower rise of platelet count (median: 4 days) but the effect is more sustained.
d. Rhogam has similar efficacy as IVIG but is associated with higher incidence of
therapy-induced haemolytic anemia
IVIG
a. When a rapid rise of platelet is indicated or when there is concomitant active infection
(ie.Fever)
b. No difference in using small dose (500 mg/Kg) or high dose (2 gm/Kg)
c. Give it over one or 2 days rather than 4 days
d. Infuse the drug gradually
5 ml/15 min, then 10 ml/15 min, then 15 ml/15 min, then 20 ml/15 min
Rest over 4 - 5 hrs
e. Pre-medication : Piriton 0.2 mg/Kg 30 min before infusion
f. Anti-Rh(D) is a special form of Ig that can be used but is associated with alloimmune
haemolysis secondary to anti-Rh(D) and is not indicated for routine clinical use
Steroid treatment
a. Has to perform bone marrow aspirate to rule out leukaemia before starting
b. Use prednisolone 2 mg/Kg/day for 2 weeks and then taper over another 1 week
c. Monitor BP and urine sugar q2wks
d. Advice to take after food intake or with antacid
Chronic ITP
1. Perform bone marrow aspirate (rule out marrow pathology)
2. Consider alternative diagnosis eg WAS, MYH9-related platelet disorder, haemic malignancies,
lupus)
2. No treatment if there is no clinical evidence of bleeding (except bruises and petechiae) and
platelet count is > 10x 10^9/L
3. Treatment options
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 Highly controversial with no universally accepted approach
 Cyclosporin
 Eltrombopag
 Rituximab
 Splenectomy (if age >=5years old and ITP for >= 2 years)
 Cytotoxic drugs
Updated by Dr A Liu in 2018
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Manual for Paediatric Interns and Residents 5th edition (2018)
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3.6.4 MANAGEMENT OF THALASSEMIA MAJOR
A. Blood transfusion
1. Use plasma reduced blood (PRB)
 Pre-filtered: to minimize WBC induced febrile reaction and preferably < 10 days old
 All scheduled transfusion will be provided with pre-filtered blood by Red Cross
2. Amount: Volume in ml = [14(expected Hb) - pre-transfusion Hb] x BW(kg) x 4.7*
e.g. 10 kg patient with pre-transfusion Hb 9 g/dL requires (14-9) x 10 x 4.7 = 235 ml PRB
* 4.7 is a constant which is determined by the PCV of the RBC component available
 Avoid wastage of blood, the calculated volume should be rounded off according to the unit
volume available. One unit of PRB is around 250 - 350 ml. Single unit preferred except small
children (caution about volume) i.e. transfuse 1 unit of packed cells instead of 235ml for the
above 10kg patient with pre-transfusion Hb 9 g/dL.
3. Rate of transfusion
(a) No cardiac problem: 2-3 hrs/unit (max. 5ml/kg/hr)
(b) With cardiac problem: 2 ml/kg/hr, may give transfusion 2 weekly instead of 4 weekly
4. Pre-medication
(a) Chlorpheniramine (Piriton) 0.1-0.2 mg/kg IV or PO 30 min before transfusion
(b) Furosemide (Lasix) 0.5 mg/Kg IV (max. 20mg) at the start of transfusion
5. Transfusion interval: at 4 weekly interval
(5 - 6 weekly interval are acceptable in individual patient)
6. Target haemoglobin level
(a) Pre-transfusion Hb at 9.5-10gm/dL
(b) Post-transfusion Hb at 14gm/dL (to suppress marrow hyperactivity)
Avoid post-transfusion Hb higher than 15 gm/dl (increase risk of viscosity & thrombosis)
7. No folate supplement once on regular transfusion
B. Chelation
 1 blood unit contains 200–250 mg iron (normal adult has 4000 mg iron in body)
 Iron overload occurs after around 20 transfusions, or age 2; leading to serum ferritin levels
of about 1,000 ng/ml (2,200 pmol/L)
1. Monitoring parameters
Adequately chelated Inadequately chelated
I. Systemic
Serum ferritin  3,000 pmol/L > 3000 pmol/L
II. Organ-specific
(a) Heart
MRI T2* heart T2* > 20 ms (normal) T2* 10-14 ms (moderate loading)
T2* 14-20 ms (mild loading) T2* < 10 ms (severe myocardial loading)
Ejection fraction by Risk of cardiac dysfunction if
MRI or MUGA  EF < 50%
  10% decline in interval assessment
 Shortening fraction < 30%
(b) Liver
MRI T2* liver T2* > 6.3ms (normal) T2* 1.4-2.7 ms (moderate hepatic loading)
T2* 2.7-6.3ms (mild loading) T2* <1.4ms (severe hepatic loading)
Liver iron (done  7ng/gm dry weight > 7ng/gm dry weight
occasionally)
(c) Pancreas
MRI T2* pancreas T2* > 23ms (normal)
(d) Pituitary
MRI T2* pituitary T2* > 5.9ms (normal)
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2. Chelating agents
Agent Deferoxamine (DFO) Deferiprone (DFP) Deferasirox (DFX)
Desferal® Ferriprox® / L1 Exjade®  JadenuTM
Property Hexadentate iron chelator Bidentate iron chelator
^ *
Tridentate# iron chelator
binding iron in a 1:1 ratio binding iron in 3:1 ratio binding iron in 2:1 ratio
(form the most stable (form the least stable
iron-chelate complexes) iron-chelate complexes)
(1gm desferal can bind to
93mg of iron)
Usual 20–60 mg/kg/day 75 mg/kg/day 10–40mg/kg/day (exjade)
dose 7–28mg/kg/day (jadenu)
Route SC/IV 8-12 h, 5-7 days/wk Oral, 3 times daily Oral, once daily
Can give bd dose
Half-life 20–30 min 3–4 h 8–16 h
Excretion Urinary, faecal Urinary Faecal
Adverse Local reactions, allergy, Nausea and abd Rash, renal
effects growth retardation, discomfort, impairment@, vision and
skeletal changes agranulocytosis/ hearing impairment,
(osteodystrophy), neutropenia, arthralgia, elevated liver enzymes,
ferrophilic bacterial elevated liver enzymes, GI disturbances
infection+ (Yersinia, trace elements
Klebsiella), visual and deficiency (Zn)
hearing impairment
Monitoring Annual eye follow up CBP weekly x first 2 yrs RFT, Ca, PO4, Mg, urine
ANA/RF, serum Zn β2-microglobulin
half-yearly monthly
*Bidentate: 2 polar interaction sites in the binding pocket, requires 3 drug molecules each bind to 2 out of 6 iron binding sites of iron(III) ion
# Tridentate: 3 polar interaction sites in the binding pocket, requires 2 drug molecules each bind to 3 out of 6 iron binding sites of iron(III) ion
^ Hexadentate: 6 polar interaction sites in the binding pocket, requiring only 1 drug molecule to bind with six coordination sites of iron(III) ion
+ Desferal is a siderophore produced by Streptomyces pilosus and thus prone to ferrophilic bacterial infection
@ Renal impairment includes: elevated urine β-2 microglobulin, hypokalemia, ypophosphatemia, hypocalcemia, fanconi syndrome (renal tubular
dysfunction & metabolic acidosis

Notes on transitioning chronically transfused patients from Exjade ® to JadenuTM
from 1 January 2018
Although both Exjade and Jadenu are formulations of deferasirox, their dosing differs and Jadenu
has a higher bioavailability then Exjade:
Exjade® JadenuTM
Formulation Once-daily dispersible tablets taken at Once-daily film coated tablets
the same time each day taken at the same time each day
Fasting Fasting until 30 min after administration Taken with or without a light meal
Preparation Multistep preparation requiring a glass, No preparation required
spoon and liquid
Mixing Must be thoroughly mixed with water, No mixing or measuring required,
orange juice, or apple juice until fine can be swallowed whole with water
suspension is obtained or other liquid
Starting dose 10–30mg/kg/day 7–21mg/kg/day (70% dose
conversion from exjade)
Titrating 5–10mg/kg/day 3.5–7mg/kg/day
increments
Max dose 40mg/kg/day 28mg/kg/day
Strengths 125mg tab (white), 500mg tab (white) 90mg tab (white), 360mg tab (blue)
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3. Desferal therapy
Nowadays we generally start chelation at age 2. We usually start deferasirox (exjade/jadenu)
as first-line instead of desferal (see Appendix 1). However, desferal is still in use due to its
excellent profile of iron-chelation efficacy and safety.
(I) Intravenous desferal (continuous in-hospital treatment)
a. IV desferal during blood transfusion is no longer used. It may be used for heart failure
patients (rarely occur nowadays except patient previously not well transfused or chelated)
or thalassemia patients in preparation for transplant during pre-conditioning phase
b. 50-100mg/kg/dose over a minimal period of 10 hrs
c. Not to exceed 15 mg/Kg/hr via portacath or Broviac/Hickman catheters with special
infusion set required
d. Given as piggy-back
(II) Subcutaneous desferal (home treatment): aim at serum ferritin between 1000 to 2000 ng/ml
a. Average daily dose 20-60mg/kg/day
b. Frequency: preferably 5-7 days per week as sole chelator, or reduced frequency for
combination therapy
d. Example: patient 50 Kg on 4 ampules/day, 5 days/week = 4 x 5 x 500 = 28.6 mg/Kg/day
weekly no. of ampules x 500
Average daily dose (mg/Kg/day) =
BW (kg) x 7
e. Toxicity index (T.I.): not to exceed 0.025 to avoid desferal toxicity
Average daily dose (mg/Kg/day)
Toxicity index (TI) =
Ferritin level (ng/ml)*
* ferritin in umol/L ÷ 2.2 = ng/ml
f. Vitamin C: give only if desferal is given (2-5 mg/kg daily, max 200 mg/day)
In general, 50 mg for < 10 yrs, 100 mg for > 10 yrs
(to augment the renal excretion of chelated iron)
(without desferal, vitamin C will increase Fe absorption in the gut)
g. Recommended desferal dilution: 500 mg / 5 ml distilled water for injection
If develop persistent local reaction, report to the senior doctor
Add hydrocortisone (max. 2 mg/ml) in infusion solution if indicated
i.e. 4 ampules in 20 ml water and add 40 mg hydrocortisone
C. Infective complications
 Disease transmission through transfusion (e.g. window period donation) is possible with
incidences quoted below based on estimated residual risk in Hong Kong:
Infection Incidence
Hepatitis A virus (HAV) 1 in 1,000,000
Hepatitis B virus (HBV) 1 in 58,000+
Hepatitis C virus (HCV) 1 in 8,000,000+
Human immunodeficiency virus (HIV) < 1 in 2,400,000+
Human T-cell lymphotropic viruses I and II (HTLV I, II) 1 in 10,000,000+
Parvovirus B19 1 in 10,000
 Clinical manifestations of transfusion-related infections depend on the disease acquired,
usually as incidental findings during follow-up or investigation for liver derangement.
 Management includes treatment for the infectious disease and report through hospital blood
bank to Hong Kong Red Cross Blood Transfusion Service (HKRCBTS) for investigations.
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D. Half year review for thalassaemia major patients
 Review would be conducted in ward K8S on half-yearly basis when patients come back for
regular transfusion on Wednesday afternoon by Team A team head or resident.
 Aim of the review is to have more systematic monitoring of treatment / complications
and to reduce OPD attendance for the patients as they have already other clinic FU / and
investigation appointments
 Patients to be reviewed would be registered one month before hand (<7 patients/session)
Routine biochemical monitoring period Review period
February March-April (annual review of past 1 year)
August September-October (half year review Feb-jun)
 Routine biochemical (blood/urine) monitoring includes the following
1. Weekly / bi-weekly If on deferiprone (L1): CBP+D/C
2. Monthly Pre-Hb, type & screen, RFT/LFT, urine glucose, albumin,
weight, height; if DM: add fructosamine
If on Exjade/jadenu: add CaPO4, Mg, urine β2-microglobulin
3. Alternate (odd) month Check serum ferritin; if HCV or HBsAg +ve: add AFP
4. Half-yearly Both Feb and Aug: LRFT, Ca,PO4, Mg, fructosamine, T4,
TSH, PTH, Cortisol, post-Hb
If on deferiprone (L1): check ANA/RF, serum Zn
Feb only: fasting glucose and insulin, 5 ml clotted blood to
Paed Lab to store serum
Aug only: HBsAg, anti-HBs, HCV, HIV-1 & 2
5. Other arrangements Cardiac monitoring (age >10yrs): MRI T2* every 1-2 years
or more frequent if indicated, e.g. cardiac T2* <20ms
Oral Glucose Tolerance Test (OGTT) (age>10yrs): annual
Ophthalmology check: annually if on desferal
Bone age: at age 5 and 10 yrs or as Ix of short stature or
delayed puberty, only perform if not done within last 12m
What to do at half year review?
1. K8S ward clerk to retrieve OPD record for use before the review day. Team A team
head + MO to be responsible for the review. Team B team head + MO may be required
to help out if team A staffs have other duties.
2. Use the two CMS stations available in K8S; partition between the 2 stations by screen
for patient privacy. Medical doctors click on CMS system, enter ID number of patient.
3. Choose “QPB” (i.e. blood clinic) for entering review data regard as OPD attendance.
Do not do the review on discharge summary of that admission.
4. Remark in the summary sheet that this is “half year review”.
5. Review blood transfusion data in Data summary sheet (available as a separate sheet
prepared by Phoenix). Enter the following data into patient’s CMS + transfusion record:
(a) Annual blood consumption (ml/kg/yr) (b) Average pre-transfusion haemoglobin
(c) Average post-transfusion haemoglobin
6. Review transfusion record sheet one on growth, glycosuria, liver iron result, ferritin,
toxicity index, etc.
7. Check transfusion record sheet two and review on complications (e.g. cardiac,
endocrine, infection).
8. Enter relevant information and recent laboratory data into patient’s record sheet and
also the duplicate sheets which are kept in ward.
9. Check whether patient has got regular cardiac / eye / hearing monitoring and other
relevant clinic FU (e.g. endocrine).
10. Check the drugs patient is taking and any research study patient is participating.
11. Print the review sheet from CMS, ask ward clerk to file in blood clinic session of patient’s
active folder
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E. Haemopoietic stem cell transplant (HSCT)
 HSCT is currently the only cure for TDT. Gene therapy is on the horizon.
 HSCT is associated with risks and benefits as compared with standard therapy of
transfusion-chelation as shown in the table below:
Transfusion and chelation HSCT
Nature Life-long Tx (poor compliance) Curative
Survival Life expectancy >60+ years Depends on the HSCT (types,
matching, pre-transplant risk group)
 Overall survival (OS) 90-95%
 Transplant-related mortality
(TRM) 5-10%
 Transfusion-free survival 80-90%
Cost High cost Lower cost and better cost
Lack of human resources and effectiveness
blood banking facilities in limited
resources countries
Complications Reversible and less if well Unpredictable transplant related Cx
chelated (chronic GVHD, increased risk of
hypogonadism and malignancy)
QOL Poor for both patients and parents Better QOL
when compared to HSCT
 Careful counseling is required before HSCT. Patients’ values should be respected and
misunderstanding needs to be corrected.
by Dr Wilson Chan in 2018
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Appendix 1 Chelation Protocol for Thalassemia Patients (2011 UPAM, QMH)
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3.6.5. TRANSFUSION THERAPY
A. Indications and thresholds
Blood product Indications and thresholds Dosage
Red blood cells Pre-transfusion Hb <7g/dL Single unit* preferred
(RBC) except small children
(caution about volume)
Platelet (1) <10x109/L in all stable patients (usually not (1) 1 unit/10kg up to 4
indicated in ITP, SLE; contraindicated in TTP, units of random donor
HUS, HIT) platelet, or
(2) <20x109/L (fever or sepsis) (2) 1 unit of single
(3) <50x109/L (invasive procedures: LP, BMA) donor platelets, or
(4) <100x109/L with clinical bleeding (e.g. (3) 10-20ml/kg
retinal or CNS), especially peri-op & post-CPB
(5) For premature neonates:
<50x109/L if stable; <100x109/L if sick
(6) Other indications: clinical bleeding in
cases of ?platelet dysfunction or deficiency,
trauma, acute DIC
Fresh frozen (1) Clotting factor deficiency (other than 12-20ml/kg
plasma (FFP) haemophilia A/B) with active bleeding Order methylene
(2) PT / APTT > 1.5x mean of reference interval blue treated FFP if
with active bleeding available
(3) DIC, TTP, massive transfusion, hepatic
failure, warfarin overdose
* Previously recommended according to calculation with pre-transfusion Hb and targeted Hb level
B. Choice of specific blood products
(a) CMV negative product

Rationale: to prevent CMV infection in severe immuno-compromised patients
Indications: CMV -ve patients who will undergo autologous BMT, or both patient and donor
are CMV –ve for allogeneic BMT
Source: blood from CMV-ve donor or filtered (high efficiency filter) product
(b) Filtered product

Rationale: to remove white blood cell down to 106/unit
Indications: 1) when CMV neg product is needed, or
2) recurrent febrile transfusion reaction, or
3) severe aplastic anaemia patients awaiting for BMT (WBC sensitization will
increase chance of graft rejection)
Source: either pre-storage or bedside filter
(c) Irradiated blood

Rationale: to prevent transfusion associated graft versus host disease (GVHD) in severe
immunocompromised patients by inactivating lymphocytes in donor's blood product
Indications: 1) candidates for allogeneic or autologous BMT (Day 0 to 6 months post BMT,
or longer if on immunosuppressant or has cGHVD)
2) severe immunodeficiency
3) intrauterine transfusion
4) transfusion from near relatives or platelet from HLA matched donors
(resemble HLA-Ag may allow donor lymphocytes to escape the detection of
recipient's lymphocytes but not vice versa)
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5) patients on intensive chemotherapy regimen (e.g. AML, neuroblastoma)
6) autologous marrow or PBSC harvest (7 days before and during harvesting)
7) patients with Hodgkin lymphoma
8) patients given heavily immunosuppressive medications (e.g. clofarabine,
fludarabine, ATG, alemtuzumab, etc)
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C. Management of transfusion reactions
Conditions Causes Onset Management
1. Fever +/- chills i.e. Most commonly >1oC rise from basal 1. Stop transfusion if core
febrile non-hemolytic encountered (1%) temp during or <24 temp >38.5oC
transfusion reaction Due to anti-WBC Ab in hrs post-transfusion 2. Sepsis work-up
(FNHTR) patient’s plasma (Dx by exclusion) 3. Panadol 10-15 mg/kg po
4. Resume Tfx 30 min later
when fever down
5. Use piriton premed and
WBC filter
2. Urticaria / allergic Almost as common as Usually manifested as IV piriton 0.1-0.2 mg/kg  IV
transfusion reaction FNHTR, due to infused itchiness, local hydrocortisone2-4mg/kg
plasma protein or erythema and hives
allergens (IgE or IgG) with or without fever
 histamine & during transfusion
leukotrienes release
3. Anaphylactoid Ab to IgA During transfusion Stop transfusion, give O2,
reaction / anaphylaxis (life threatening 1:1000 adrenaline 0.01
requiring ml/kg IM & normal saline
resuscitation) 10 ml/kg if hypotension or
bronchospasm
4. Infection Contamination* (1 in Usually appear 1. Stop transfusion
Septicaemia 2000 for platelet as rapidly within 30 2. Treat shock
stored in room temp, min after 3. Blood culture and culture
less for RBC as stored transfusion of blood product bags
at 4oC) Manifested initially as (microbiology lab)
fever, flushing, chills, 4. Start broad spectrum Abx
myalgia, GI upset, 5. Inform Blood Bank, send
and hypotension blood specimens x check
haemolytic reactions
5. Acute haemolytic ABO mismatch Fever, chills, flushing, Manage as ARF and DIC
transfusion reaction (transfusion of SOB, chest pain, 1. Stop transfusion
(Intravascular incompatible blood back pain, 2. Monitor vitals and U/O
haemolysis) product is uncommon hypotension, oliguria (foley) +/- forced diuresis#
but can be fatal) & generalized oozing 3. Take blood^, correct
shortly after electrolytes and acid-base
transfusion (a few ml)
* Bacteria are capable of growing in cold temperature (psychrophilic). Common bacterial contamination includes: bacillus and CONS for
platelet transfusion, Pseudomonas species, E. coli and Yersinia enterocolitica for RBC transfusion
^ Blood x RFT, coagulation profile, direct Coomb's test, compatibility test (pre- & post), blood culture (patient & blood product); repeat
coagulation profile and blood chemistry q2-4hrs. If patient is severely anaemic, can give another unit of blood, no increased risk of Rx.
# Hydration with 125ml/m2/hr isotonic solution then IV lasix. If urine output < 0.5 ml/Kg/hr x 2 hrs, manage as acute renal failure. If urine
output > 0.5 ml/Kg/hr, adjust intravenous fluid infusion rate accordingly. Preferably monitor CVP and keep at 5-10 cm water.
Please refer to the latest version of HAHO transfusion guidelines at HA webpage

version 2.0, effective date 13 Dec 2013; also Handbook of Internal Medicine by COC
(Medicine), Hospital Authority, 7th edition (2015) for more details
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SECTION 3.7 : NEONATOLOGY
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3.7.1 Queen Mary Hospital Infant Feeding Policy (Summary)
Covey written Infant Feeding Policy that is routinely communicated to all health care staff in the hospital.
Provide orientation and training on the implementation of this policy to health care staff in accordance to their roles.
Inform all pregnant women about the benefits and management of breastfeeding.
Help mothers to initiate an uninterrupted skin-to-skin contact with their infants for at least one hour immediately after birth.
Show mothers how to breastfeed and maintain lactation even if they should be separated from their infants.)
Encourage exclusive breastfeeding by not giving newborn food or drink other than breast milk unless medically indicated.
Practice 24 hours rooming-in.
Promote ‘Baby-led feeding’ / ‘Demand feeding’.
Give no artificial teats or pacifiers to breastfeeding infants.
Refer mothers to community breastfeeding support groups on discharge from the hospital or clinic.
Respect and support mothers who made an informed choice not to breastfeed.)
Promote and support Mother Friendly Care.
Encourage and facilitate staff to continue breastfeeding when they return to work.
Comply with the International Code of Marketing of Breastmilk Substitutes of the World Health Organization.
Support mothers to breastfeed their infants in public areas of the hospital and provide baby care room when necessary.
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TEN STEPS TO SUCCESSFUL BREASTFEEDING(WHO/UNICEF 2009)

Every facility providing maternity services and care for newborn infants should:
○
1 Have a written breastfeeding policy that is routinely communicated to all health care staff.
○
2 Train all health care staff in skills necessary to implement this policy.
○
3 Inform all pregnant women about the benefits and management of breastfeeding.
○
4 Help mothers initiate breastfeeding within a half-hour of birth.
○
5 Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.
○
6 Give newborn infants no food or drink other than breastmilk unless medically indicated.
○
7 Practice rooming in - allow mothers and infants to remain together - 24 hours a day.
○
8 Encourage breastfeeding on demand.
○
9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
○
10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or
clinic.
Adopted from: Baby-Friendly Hospital Initiative, WHO/UNICEF 2009. Revised, Updated and Expanded for Integrated Care. Section 1 Background and
Implementation.
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The International Code of Marketing of Breast-milk Substitutes

Summary of the main points (WHO/UNICEF 2009)
1 No advertising of breastmilk substitutes, bottles or teats to the public
2 No donations of breast-milk substitutes and supplies to maternity hospitals

3 No free samples to mothers
4 No promotion in health services
5 No company personnel to advice mothers.
6 No gifts or personal samples to health workers
7 No use of space, equipment or educational materials sponsored or produced by companies when teaching mothers
about infant feeding
8 No pictures of infants or other pictures idealizing artificial feeding on labels of the products
9 Information to health workers should be scientific and factual

10 Information on artificial feeding, including labels, should explain benefits of exclusive breastfeeding and the costs and
dangers associated with artificial feeding
11 Unsuitable products, such as sweetened condensed milk, should not be promoted for babies.
Adopted from: Baby-Friendly Hospital Initiative, WHO/UNICEF 2009. Revised, Updated and Expanded for Integrated Care. Section 4 Hospital Self-Appraisal
and Monitoring
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3.7.2 SCBU Admission (from LW & PN ward) and management guide

Conditions Need for Observation (SpO2 Investigations Minimum Period of
Admission monitor & NEWS chart observation/Discharge
for all SCBU admission)
/ Treatment
Infection
Babies born to GBS colonized Refer to management guidelines of the department
mother
Prolonged rupture of membrane Yes Clinical observation, SpO2 CBC at >6 hours 12 hours observation
(≥24 hours, no maternal fever, Discharge if CBC normal and
GBS negative) asymptomatic
Clinical chorioamnionitis Yes SpO2, observation CBC, CRPx2 (24-48 hours 48 hours of antibiotics treatment,
(maternal fever ≥ 38C, tender empirical antibiotics after apart), blood culture, off if asymptomatic and all sepsis
uterus, foul smelling liquor, sepsis workup CXR if resp symptoms screening negative even if surface
maternal or fetal tachycardia) Consider LP if ill culture positive.
Maternal fever > 38C Yes Clinical observation, SpO2 CBC at >6hours 8-12 hours
(irrespective of mode of
anaesthesia or baby fever)
Maternal cervical wart No -- -- --
Maternal VDRL positive Yes if high or Clinical observation Screening (Red Book Until infection excluded or treated
(suspected or confirmed moderate risk (Red Treatment according to reference)
syphilis) Book reference) Red Book algorithm
Isolation if high risk
Maternal chlamydial infection No -- NPA and conjunctival NNC FU one week for symptoms
(treated or untreated) scrapping (to be done by
neonatal doctor) for
chlamydia before
discharge if untreated
Suspected or confirmed AIIR Investigations and treatment according to Red Book
maternal active TB
Suspected or confirmed AIIR Investigations and treatment according to Red Book
maternal varicella zoster
infection
Maternal HIV infection Yes Investigations and treatment according to management guideline
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Liquor
Meconium stained liquor Yes for moderate / Clinical observation, SpO2 Nil if asymptomatic 8 hours observation if
(irrespective of ET suction) thick MSL Can observe briefly (1-2 CBC or sepsis screening if asymptomatic
hours) for mild resp more symptomatic
distress before CXR if aspiration
investigations suspected
Blood stained liquor No need if normal -- nil --
examination at birth
(no pallor or hypoxia)
Growth disturbance/
preterm
SGA (BW 5 - 10th centile) or BW No unless if there is Clinical observation, SpO2 PN ward and SCBU: D’stix When feeding and D’stix are
2.3-2.5kg or slightly preterm additional risk (e.g. prefeed q3h for 4, then stable
35+0 -36+6 week maternal diabetes q6h for 2.
requiring insulin or Screen urine CMV if SGA Trace CMV results in one week (if
significant or microcephalic. saved)
polycythaemia. *No routine CMV
screening for LBW
BW <2.3kg or preterm <35+0 Yes Clinical observation + D’stix prefeed q3h for 4, When feeding and D’stix stable
weeks or BW <5th percentile SpO2 then q6h for 2
Consider CBC as workup Trace CMV result in one week (if
for preterm/LBW saved)
Save urine for CMV if
BW<5th percentile
LGA (BW ≥ 90th percentile) Admit SCBU if there Clinical observation Dstix prefeed q3h for 4,
is maternal diabetes then off if stable When feeding and D’stix stable
requiring insulin.
Otherwise observe in
PN ward
Macrosomia BW >4kg Admit SCBU if there Clinical observation SCBU: Dstix prefeed q3h When feeding and D’stix stable
is maternal diabetes for 4 , then q6h for 2.
requiring insulin or PN ward: D’stix prefeed
Beckwith q3h for 4, then off if stable
Wiedemann
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syndrome; otherwise
observe in PN ward
Neonatal malformation
Echogenic bowel (persistent Yes Clinical observation AXR beyond 6 hours old 2 days
during serial antenatal USG) Can start feeding if initial or when abdominal signs When feeding tolerated
** DDx: Swallowed blood, exam normal and no present
aneuploidy, congenital infection, strong antenatal suspicion - CMV screening
GI malformation, IUGR of primary bowel - CBC >6 hours
pathology
Antenatal diagnosis of dilated Yes, only if BP tds for one day RFT on day 1-2 24 hours
renal pelvis (>5mm AP (1) bilateral Monitor urine output and Early elective USG urine passed ;
diameter) involvement urine stream flow kidneys (within 2-4 weeks)
(2) Gross Consider surgical referral Bedside USG on day 1
hydronephrosis if significant obstruction
(AP>15mm)
Antenatally or postnatally Yes as indicated (if Clinical observation As indicated Medically stable
diagnosed congenital major)
abnormality
Cleft lip/palate Yes Clinical observation Consultation to OT and Feeding well by parents
Feeding training plastic team Counseling given
Cleft clinic referral
Maternal medical
diseases
Maternal thrombocytopenia Yes if platelet <100 Clinical observation Check CBC in postnatal
(non-SLE/ITP) ward
if plt <100 -> admit SCBU
if plt 100-150 -> repeat
CBP in PN ward the next
day, admit SCBU if falling
plt or symptomatic
Give IM injection as
routine if platelet >100
Maternal ITP Yes Send urgent CBC Withhold IM injection at birth
Resume IM injection if first plt
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count > 100

Discharge neonate to mother if plt
>150
Repeat plt count on D3-5 despite

a normal plt count on D1
Maternal SLE (no fetal heart No unless HR Clinical observation, SpO2 In postnatal ward: Check
block) or other autoimmune persistently below Full cardiopulmonary CBC and ECG before 24-48 hours when stable
disease 110/min during monitor if heart block discharge FU NNC 3-monthly for 2 times to
postnatal SpO2 suspected; Full lead ECG look for symptoms of neonatal
monitor in labour lupus
ward
Maternal thyroid disease Yes if persistent Clinical observation, SpO2 As indicated if signs of 12-24 hours when stable
(autoimmune) tachycardia monitor thyrotoxicosis
(>160/min) during Check TFT on D5-7
labour ward
observation
Maternal myasthenia gravis Yes Clinical observation, Anti-Ach receptor Ab 5 days
SpO2, cardiopulmonary
monitor
Social factors
CCDS case Yes according to Clinical observation Urine for toxicology When CCDS issues cleared and
prior CCDS screen as indicated medically stable
discussion
maternal substance abuse Yes if positive Clinical observation Urine for toxicology Medically stable
maternal urine Withdrawal chart CBC and LRFT as Social issue cleared
toxicology (Finnegan score) indicated
antenatally or
suggested by CCDS
team
Other familial adverse social individualised individualised As indicated When social issues cleared
factors
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__________________________________________________________________________________
Birth trauma
Birth trauma – Erb’s palsy, Yes Clinical observation, SpO2 As indicated Medically stable
suspected subaponeurotic Cardiopulmonary monitor
haemorrhage, other severe for subaponeurotic
birth trauma haemorrhage
Perinatal adaptation
Perinatal depression requiring Yes Clinical observation, SpO2 As indicated by the 12 hours minimum
resuscitation with IPPV at birth severity
Resp distress after elective CS Admit only if RD Clinical observation, SpO2 CXR to rule out Until RD resolves & feeding well
(presumed TTNB) persists beyond one pneumothorax if clinical tolerated
hour of life sign suggests.
Postnatal conditions
Babies at risk of hypoglycaemia Refer to management guidelines on hypoglycaemia
NNJ Refer to guidelines on Neonatal Jaundice
Tongue tie Refer to management guidelines on tongue tie
Feeding intolerance (vomiting, Yes Clinical observation,SpO2 AXR, sepsis workup, i-stat Feeding tolerated and medically
blood in stool) NPO and antibiotics if if clinically indicated stable
clinically indicated
Decrease BW Yes if baby is PN ward: BF supervision SCBU: check i-stat and Satisfactory weight gain and
clinically ill or BW and supplementation if RFT +/- sepsis workup medically stable
>10% indicated
SCBU: as above + IVF /
antibiotics if indicated
No urine output for the first 24 No (assess by doctor
hours during daytime if
baby is on
exclusively breast
feeding; earlier
assessment if on
formula)
Respiratory distress / Apnoea / Yes Clinical observation,SpO2 CXR for persistent Medically stable
desaturation / grunting O2 and antibiotics as symptoms, blood gas and
173
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indicated sepsis workup if indicated

Stridor Yes Clinical observation,SpO2 CXR / neck X ray / ENT
O2 / CPAP if indicated consultation if indicated
Hoarseness of voice Yes clinical observation,SpO2 Direct laryngoscopy
+/- ENT assessment
Jitteriness Yes Clinical observation,SpO2 D’stix, i-stat including iCa, Jitteriness resolved / clinically
CBP stable
Other investigations (urine
toxicology, US brain,
sepsis workup) as
clinically indicated
Others Please consult Paed -- -- --
team heads/fellows
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3.7.3 NEONATAL INFECTION
Guidelines on Prevention and management of early-onset neonatal infection

 All babies with signs or symptoms of neonatal sepsis should be admitted promptly to SCBU
 Clinical Chorioamnionitis (i.e. maternal fever ≥38°C, tender uterus, foul smelling liquor,
maternal or foetal tachycardia) and prolonged leaking >24 hours irrespective of maternal
GBS status warrants observation in SCBU
 Completed intrapartum antibiotic prophylaxis (IAP)* (defined as Penicillin given ≥4 hours
before delivery) – routine postnatal care and discharge home after 48 hours of life
 Incomplete IAP and well at birth – Requires additional monitoring of the newborn
o To mother if no additional risk factors are present and baby is well immediately after
delivery
o Admit to SCBU if there are one or more additional risk factors:
o Prolonged rupture of membranes (>18 hours)
o Prematurity <37 weeks gestation
o For all admitted babies check: Blood culture, CRP and CBP
o Consider empiric antibiotics and LP depending on clinical assessment
 GBS counselling before discharge
Management in Post-natal (PN) ward

 Inform on-call neonatal doctor (Ext 1278) for first assessment either in Labour Ward (LW) or within
1 hour of admission to PN ward
 Continue exclusive breastfeeding / milk as tolerated (MAT)
 Continuous SpO2 monitoring for at least 12 hours after delivery
 Use neonatal observation chart to record temperature, heart rate and SpO2 every hour for the first
2 hours, then if stable, every 4 hours for at least 12 hours
 Inform on-call neonatal doctor (Ext 1278) if any of the following arise:
o Respiratory distress (i.e. grunting) or desaturations (SpO2 < 95%)
o Respiratory rate >60/min at rest, or <20/min
o Axilla Temperature >37.5C or <36.5C (persistent after re-check 30mins later)
o Heart rate persistently >160 bpm or HR <90 bpm at rest
o Abnormal movements (including excessive jitteriness, jerkiness, seizures etc.)
o Any ongoing concerns from either mother or postnatal staff (e.g. vomiting, lethargy, irritable
cries, and poor feeding)
 Baby to be examined on the morning after delivery during postnatal paediatric round (please
alert neonatal team when they arrive)
 Keep in hospital for observation for at least 48 hours after birth
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Summary of Management Plan in Progress Note
0Prevention & Management of Early-onset Neonatal Group B Strep. Infection

 To Postnatal Ward  To SCBU Management in Labour ward (LW)
Indication: Indication: or Postnatal (PN) ward
 Completed IAP  Irrespective GBS status if -

(Penicillin given present with: nform on-call neonatal doctor (Ext
≥ 4 hours before delivery) - 1278)
in LWfor 1storassessment
within either
1hour of
aternal admission to PN ward
- To mother; For (maternal fever ≥38C,
Chorioamnionitis
routine baby care. tender uterus, foul - Exclusive BF/MAT
smelling liquor, maternal or - GBS counselling before discharge
fetal tachycardia)
- Prolong Leaking >24 -
hours ontinuous SpO2 monitoring for at
 Incomplete IAP if  Incomplete IAP with - least 12 hours
NO additional risk factors ≥ 1 risk factors below: emp/HR/RR Q1H x 2, if stable then
- To mother; For SpO2, 1. Q4H
if 1st episode of axilla temp <36.5C,
Vital Signs monitoring rematurity <37weeks to warm baby, recheck after 30mins;
2. gestation Inform neonatal doctor if any of
rolong leaking >18 the following arise:
hours 
espiratory distress (i.e. grunting) or
 desaturation
RR > (SpO2<95%)
60bpm at rest, or
<20bpm

echecked Axilla T >37.5C or
 <36.5C
HR persistently >160bpm or
<90bpm at rest
 Abnormal movements
 Any ongoing concerns from

either mother or postnatal staff
(e.g. vomiting, lethargy, irritable
cries and poor feeding)
Management in SCBU
- Inform neonatal doctor for first
assessment
-
(after MO assessment)
-
pO2 monitoring
- Blood Temp/
culture,HR/RR
CRP &Q3H CBP
(± LP, ± empiric antibiotics
depending on clinical condition)
- GBS counselling before discharge

Informed Paediatric Dr ____________ at___________
by Nurse ____________________(K9N / K9S / K6S)
Doctor’s Name and Signature
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Prevention & Management of Early-onset Neonatal

Group B Streptococcal (GBS) Infection
3.7.2 MANAGEMENT OF NEONATAL

JAUNDICE
Remarks:
 Maternal Chorioamnionitis:
≥38°C, Tender uterus, Foul smelling liquor, Maternal or foetal tachycardia
 Maternal GBS Prophylaxis is indicated:
A. Previous baby with invasive neonatal GBS disease

B. Known GBS status
 GBS colonization in the current pregnancy (except in elective caesarean delivery that are not in labour or
without rupture of amniotic membranes).
 GBS bacteriuria in the current pregnancy
C. Unknown GBS status with:
 Preterm labour < 37weeks (spontaneous / iatrogenic), including women with PPROM, who have already
been given oral erythromycin except those with a negative GBS screening result
 Prolonged rupture of membranes ≥18 hours
D. Maternal Fever ≥38°C
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3.7.4 Prevention and Management of Neonatal Hypoglycaemia
1 Background
1.1 Healthy term infants often feed infrequently in the first 24 hours of life.
1.2 In the majority of newborn infants, low blood glucose concentration reflects normal
processes of adaptation to extrauterine life. Glycogenolysis takes place soon after
the umbilical cord is clamped and placental supply of glucose is stopped. Most
neonates can compensate “physiological” hypoglycaemia by utilizing alternative
fuels including ketone bodies for cerebral metabolism.
1.3 Breastfeeding on-demand does not pose additional risk on blood glucose
homeostasis in healthy term infants. On the other hand, there is evidence to
suggest that breastfeeding enhances counter-regulatory responses to
hypoglycaemia.
1.4 Clinical significance of asymptomatic transient hypoglycaemia is unknown. There

is no specific plasma glucose concentration or duration of hypoglycaemia that can
predict acute symptoms or permanent neurologic injury. Most neurologic sequelae
occur in prolonged or severe hypoglycaemia.
1.5 Infants with impaired counter-regulatory response are at risk of developing more
prolonged and severe hypoglycaemia.
1.6 Clinical signs of hypoglycaemia include a wide range of nonspecific manifestations

that are common in sick neonates (Table1). Since the principal concern in
hypoglycaemia is avoidance of cerebral energy deficiency, greatest attention
should be paid to neurologic signs such as seizures.
2 Definition
2.1 We adopt an operational threshold of plasma glucose 2.2mmol/L for babies < 4
hours of life and 2.5mmol/L for those > 4 hours of life as suggested by the latest
American Academy of Pediatrics (AAP) guidelines.
2.2 The same threshold is used for both term and preterm babies.
3 Monitoring for Hypoglycaemia in ‘At Risk’ Infants

3.1 Healthy term infants do not require routine blood glucose monitoring.
3.2 Some infants have an impaired counter-regulatory response to low blood glucose
or cannot be relied on demand-feed. These infants are at risk of developing
hypoglycaemia and need monitoring of blood glucose regardless of their modes of
feeding (Table 2).
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3.3 Extra care is needed in ‘at risk’ infants for the prevention of hypoglycaemia (Table
3).
4 Diagnosing Hypoglycaemia
4.1 Gold standard of blood glucose measurement is plasma glucose which is
measured by glucose oxidase method in Clinical Biochemistry Unit, QMH.
Minimum blood volume needed is 0.17ml using fluorinated bottles.
4.2 Correlation between glucometer and laboratory measurement is weaker in the

hypoglycaemic range. A higher cut-off value is used in the screening for
hypoglycaemia by point-of-care glucose test strips.
4.3 Contour Plus 7618B (Bayer) glucometer is used in QMH as the point-of-care test
for blood glucose. In neonates at low range of blood glucose, 99% of the test strip
results fall within +/- 0.8mmol/L of plasma glucose value.
4.4 For the sake of rapid detection and timely treatment of hypoglycaemia, bedside
reagent test-strip glucometer can be used for screening. Correlation and
confirmation of glucometer readings with paired measurements of plasma glucose
by laboratory tests are necessary if baby: 1) is symptomatic or 2) has significant
hypoglycaemia (D’stix < 2.2mmol/L at <4 hrs of life or < 2.8mmol/L at >=4 hrs of life)
or 3) has D’stix below target range after 2 doses of Dextrose gel.
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Overview of Screening and Management of Hypoglycaemia (Table 4)

5 Screening of Hypoglycaemia in ‘At Risk’ Infants (Appendix 1)
5.1 Neonatal glucose concentration decreases after birth and reaches a nadir at
around 2-3 hours of life. It then rises and stabilizes by 12 hours of life. It is
controversial whether to screen for hypoglycaemia during this normal physiological
nadir.
5.2 The first blood glucose screening is done at 2-3 hours of life for at risk infants when
blood glucose is the lowest. A lower operational threshold of blood glucose
2.2mmol/L (D’stix 3mmol/L) is used. Thereafter blood glucose is monitored every
2-3 hours before feeding. A higher threshold of blood glucose 2.5mmol/L (D’stix
3.3mmol/L) is used after 4 hours of age.
5.3 Glucose monitoring is continued for 12 hours in infants of diabetic mothers or

macrosomic babies as most of these infants would develop hypoglycaemia within
this period. Infants with other risk factors such as small for date or late preterm
infants may present with hypoglycaemia later and are monitored for 24 hours.
6 Caring of infants for the Prevention of Hypoglycaemia (Table 3)

6.1 Management to prevent hypoglycaemia should not unnecessarily disrupt
breastfeeding.
6.2 Infants at risk of hypoglycaemia should be identified and blood glucose should be
monitored. Babies under blood glucose monitoring should not be separated from
their mothers unless clinical condition warrants more intensive monitoring or
treatment in the neonatal unit such as recurrent or symptomatic hypoglycaemia.
6.3 Extra care including thermoregulation should be taken in these high-risk infants to
avoid hypoglycaemia. Breastfeeding should be started early (within the first hour
of life), given frequently (q1h to q3h) and supervised constantly.
7 Management for Hypoglycaemia in the First 48 hours (Appendix 2)

7.1 Prompt intervention is necessary for infants who manifest clinical signs and
symptoms of hypoglycaemia. These babies require immediate admission to the
neonatal unit for treatment and close monitoring. We use an arbitrary cutoff of
blood glucose lower than 2.2 mmol/L (D’stix <=3 mmol/L) for treating symptomatic
infants. Paired plasma sample should be obtained for laboratory measurement
before intravenous glucose (bolus D10 2ml/kg) is given.
7.2 Transient mild hypoglycaemia (blood glucose level 1.4-2.2mmol/L or D’stix

2.2-3mmol/L within 4 hours; or blood glucose level 2.0-2.5mmol/L or D’stix
2.8–3.3mmol/L after 4 hours) can be treated with dextrose 40% gel 0.2g/kg
(0.5ml/kg) and placing baby skin-to-skin to mother and early feed. If parents refuse
dextrose gel, immediate feeding of 10ml/kg (breast milk preferably, formula if
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breast milk not available) should be given. Breastfeeding should be continued and
supervised.
7.3 For recurrent hypoglycaemia with blood glucose level 2.0-2.5mmol/L (D’stix
2.8-3.3mmol/L), give another dose of dextrose 40% gel 0.2g/kg (0.5ml/kg) and
place baby skin-to-skin to mother and early feed. If parents refuse dextrose gel,
feed baby immediately with milk (10ml/kg). Continue q2-3h feeding.
7.4 Intravenous (IV) glucose (Bolus D10 2ml/kg) should be given for asymptomatic
hypoglycaemia if blood glucose was <1.4mmol/L (D’stix <2.2mmol/L) in the first 4
hours of life or blood glucose <2.0mmol/L (D’stix <2.8mmol/L) after 4 hours of life
or if there is recurrent hypoglycaemia refractory to 2 doses of dextrose 40% gel /
2 feeds of milk at 10ml/kg. IV glucose should also be given if babies display
symptoms of hypoglycaemia and blood glucose < 2.2mmol/L (D’stix 3mmol/L).
7.5 Continuous IV glucose infusion should be given if feeding is inadequate or if there

is recurrent hypoglycaemia. Glucose infusion rate should be increased to achieve
normoglycaemia. Maximum concentration of glucose allowed via peripheral vein is
12.5%. Central venous catheter should be used for higher glucose concentrations.
7.6 To facilitate the clinical team in monitoring and managing neonatal hypoglycaemia
promptly, the standing order is pre-printed in the progress note. (Appendix 3)
8 Prescription and Administration of Buccal Dextrose 40% Gel

8.1 Dextrose 40% gel can only be prescribed in gm via the Inpatient Medication Order
Entry (IPMOE) system. Standing order for dextrose 40% gel according to the
weight-based dosing guide is as follows.
Dosing guide
BW (kg) 2 2.5 3 3.5 4 4.5 5
Dose
1 1.25 1.5 1.75 2 2.25 2.5
(ml)
Dose
0.4 0.5 0.6 0.7 0.8 0.9 1
(gm)
8.2 The dextrose 40% gel product - GLUCOGEL is available in the pharmacy of QMH
for ordering.
8.2.1 GLUCOGEL’s preparation is 32gm glucose per 80ml bottle, 40% dextrose
monohydrate, i.e. 0.4 gm/ml
8.2.2 GLUCOGEL should be stored in room temperature
8.2.3 Once a bottle of GLUCOGEL is opened, it can be used until the

best-before-end date printed on the bottle provided that the top is securely
refastened each time after use.
8.3 Administration
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8.3.1 Explain and provide the information pamphlet (Appendix 4) on Dextrose 40%
gel to parent
8.3.2 Check the best-before-end date of the bottle of GLUCOGEL
8.3.3 Squeeze small amount of gel into a medicine cup, then fasten the cap
securely to avoid contamination
8.3.4 Check doctor’s prescription in the IPMOE and prepare the correct dose of
dextrose gel according to the ‘5 Rights’ principle on administration of
medication (AOM)
8.3.5 Draw up desired amount of dextrose 40% gel using 2.5 ml oral enteral syringe
8.3.6 Put on clean glove
8.3.7 Dry baby’s buccal mucosa of both sides with gauze
8.3.8 Divide the measured dose into 4 quarters
8.3.9 Administer one quarter at a time using syringe in either right or left buccal
cavity
8.3.10 Massage the baby’s cheek to stimulate absorption (Appendix 4)
8.3.11 Repeat the steps on alternate buccal cavity until completing the dose
8.3.12 Document accordingly

9 Investigations for Causes of Hypoglycaemia (Table 5)
9.1 Critical blood sampling should be performed when hypoglycaemia occurs despite
glucose infusion rate >8-10mg/kg/minute.
9.2 Make use of hypoglycaemic kit for critical sampling. Treatment for hypoglycaemia
should follow immediately after blood sampling. If blood taking is difficult, treatment
for hypoglycaemia should be offered first.
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TABLES
Table 1. Clinical manifestations of hypoglycaemia

o Irritability, tremors, jitteriness
o Exaggerated Moro reflex
o High-pitched cry
o Seizures/myoclonic jerks
o Lethargy, listlessness, limpness, hypotonia
o Coma
o Cyanosis
o Apnoea or irregular breathing
o Tachypnoea
o Hypothermia / temperature instability
o Poor sucking or refusal to feed
Table 2. Infants at risk for hypoglycaemia – routine monitoring of blood glucose

Rooming in with mother in Postnatal Ward Admission to neonatal unit
Maternal Diabetes with suboptimal glycaemic Maternal diabetes requiring insulin
control, e.g. infants being large for gestational
age, polyhydraminos, mothers requiring
obstetric interventions due to diabetes
Macrosomia (4kg) Perinatal asphyxia
BW ≥ 90th percentile Neonatal sepsis
Late Preterm 35 -36 6/7 weeks Preterm < 35weeks
SGA (5-10th percentile) with BW2.3 – 2.5kg SGA with BW < 2.3kg
Maternal Drug use e.g.  blockers,

BW < 5th percentile
high glucose infusion during labour
Restricted/ poor feeding
Significant polycythaemia
Severe Rh incompatibility
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Table 3. Caring for ‘at risk’ babies

o Skin-to-skin contact and early feed (within 1hr), then on frequent demand
feeding q2-3h
o Supervise BF. If direct BF is difficult, give EBM by cup & teach mother to
express
o Keep warm
o Monitor vital signs (heart rate, respiratory rate, temperature q8h + prn)
o Blood glucose monitoring
o BF is encouraged during dextrose gel and iv glucose therapy
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Table 4. Screening & Management of Neonatal Hypoglycaemia (QMH guidelines 2020)

Gestational age >=35 weeks & Postnatal age <=48 hrs
Symptomatic & D’stix < 3 mmol/L => inform Paed
Asymptomatic
Birth to 4 hours 4 – 24 hours or beyond
Target D’stix: > 3 mmol/L Target D’stix: > 3.3 mmol/L
□ Keep warm □ Keep warm
□ Skin contact & early feed (within 1 hour), then frequent feeding q1-3h as tolerated □ Continue feeds q2-3h
□ Monitor HR, RR, Temp q8h + prn □ Monitor HR, RR, Temp q8h + prn
Screen D’stix before feeds
Screen 1st D’stix before feed at 2-3h of life (mmol/L) □ Q3h x 3 for IDM or macrosomia (monitor x 12h)
□ Q3h x 3, then Q6h x 2 for other risk factors (monitor x 24h)
D’stix < 2.2 D’stix 2.2 – 3 D’stix < 2.8 D’stix 2.8 – 3.3
□ Dextrose gel, place skin-to-skin & feed □ Dextrose gel, place skin-to-skin & feed
□ Repeat D’stix 30min post feed □ Repeat D’stix 30 min post feed
□ Inform Paed for urgent SCBU □ Inform Paed for urgent SCBU
□ Repeat above steps once if needed □ Repeat above steps once if needed
admission & IV glucose admission & IV glucose
□ If D’stix <3 after 2 doses of dextrose gel □ If D’stix <3.3 after 2 doses of dextrose gel
□ Check blood glucose □ Check blood glucose
o Inform paed for SCBU admission o Inform paed for SCBU admission
o Check blood glucose o Check blood glucose
 Dextrose 40% gel (0.2gm/kg i.e. 0.5ml/kg); if parents refuse Dextrose gel, give milk feed 10ml/kg
 Feed – breastfeeding, expressed breast milk, formula
 IV glucose D10 2ml/kg +/- continuous IV glucose infusion
Dextrose 40% gel (0.2gm/kg or 0.5ml/kg). Dry the baby’s mouth and massage the gel into the buccal mucosa.
Maximum: 2 doses. Inform paed if D’stix < 3.3 after 2 doses. 1st dose by ________ at ________ 2nd dose by ________ at ________
Dosing guidelines
BW (kg) 2 2.5 3 3.5 4 4.5 5
Dose (ml) 1 1.25 1.5 1.75 2 2.25 2.5
Dose (g) 0.4 0.5 0.6 0.7 0.8 0.9 1
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Table 5. Investigations for Recurrent Hypoglycaemia beyond 48 hours of life

Critical sample in order of priority (to be taken when D’stix <3.3mmol/L in babies with GIR
>8mg/kg/min
o Blood glucose
o Bedside urine for ketone
o Beta hydroxybutyrate (BOHB) (1ml fluoride / oxalate)
o I-stat / gas (on ice)
o Insulin (1ml clotted blood)
o Free Fatty Acids (1ml EDTA)
o Ammonia (on ice) (1ml heparinized / no gel)
o Carnitine / Acylcarnitine profile (1ml heparinized / no gel + 3ml clotted blood)
o Cortisol (1ml heparinized / no gel)
o Growth hormone (1.5ml clotted blood)
o Lactate
o Urine organic acids
o +/- Glucagon stimulation test:
 Check D’stix at 0min, then give glucagon 1mg IM/IV for all body weight
 Check D’stix at 10min, 20min, 30 min and 40 min after glucagon injection
 If glucose increment <1.1mmol/L by 20 min: stop the test and resuscitate with IV
D10 2ml/kg over 20 min and repeat D’stix afterwards
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APPENDIX
Appendix 1. Monitoring of Blood Glucose & Feeding Management for at Risk Infants for Hypoglycaemia
Early feeding within 1 hour of life

Frequent feeding on demand
at least q1-3h
No
st
1 D’stix before feed st
1 D’stix < 2.2 mmol/L?
at 2-3 hours of life
st
If 1 D’stix 2.2-3.0 mmol/L OR
Yes Subsequent D’stix 2.8-3.3mmol/L
1. Give Dextrose 40% gel
2. Place skin-to-skin and continue
URGENT SCBU admission; Check feed
blood glucose (fluoride bottle) + IV glucose 3. Repeat D’stix 30mins post–feed
If repeated D’stix 2.8-3.3mmol/L
Yes  Repeat step 1-3 once
Continue D’stix monitor before feed
IDM, LGA: No
• q3h x 3 times (monitoring for 12 hrs) Subsequent D’stix No
Other risk factors: < 2.8 mmol/L? Repeated D’stix
• q3h x 3 times, then ≤ 3.3 mmol/L? Stay with mother
• q6h x 2 times (monitoring x 24 hrs)
Yes
Inform Paed for SCBU admission +

Check blood glucose (fluoride bottle)
187
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Appendix 2. Clinical Pathway for management of hypoglycaemia in term/late preterm infants >=35 weeks in first 48 hrs.
(blood glucose 2.5mmol/L or D’stix 3.3mmol/L)
Symptomatic Asymptomatic *Breastfeeding to be continued & supervised

Blood glucose < 2.2 mmol/L Hypoglycaemia unless specified by Paed.
OR D’stix < 3 mmol/L
Blood glucose < 1.4 mmol/L Blood glucose 1.4 - 2.2 mmol/L < 4 hours of life
OR D’stix <2.2 mmol/L OR D’stix 2.2 – 3 mmol/L
• Dextrose gel
• Place skin-to-skin & feed
Inform Paed • Repeat D’stix 30mins post-feed
True blood glucose • Continue D’stix monitoring
IV glucose (D10 2
ml/kg)
Blood glucose < 2.0mmol/L Blood glucose 2.0 - 2.5 mmol/L

OR D’stix < 2.8mmol/L OR D’stix 2.8 – 3.3 mmol/L 4 -24 hours of life
• Dextrose gel
• Place skin-to-skin & feed
• Repeat D’stix 30mins post-feed
Treatment:
• Continue D’stix monitoring
- Dextrose 40% gel: 0.2gm/kg (0.5ml/kg)
- If parents refuse Dextrose gel:
• formula 10ml/kg (or as directed by Paed)
- IV glucose: D10 2ml/kg +/- continuous infusion D’stix < 3.3mmol/L after
2 doses of Dextrose gel? Stay with mother in PN
N
o
Yes
Inform Paed for SCBU

admission & true blood glucose
188
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Appendix 3.
Standing order for monitoring and management of babies at risk of hypoglycaemia in
SCBU or PN Ward
Standing order for Monitoring and Treating

Neonatal Hypoglycaemia with Dextrose Gel OR Bolus Milk
Risk of Hypoglycaemia
- Feeding within 1 hr after birth, then encourage
□ To Postnatal Ward □ To SCBU
q1h - q3h (from birth) feeding as tolerated
- Keep warm / Skin-to-skin care (STSC)
Indication: Indication:
Monitor HR, RR & Temp q8h + PRN
□ Maternal diabetes □ Information on Dextrose gel explained to
□ Maternal diabetes with
requiring insulin parents
suboptimal glycaemic □ Mother declined giving Dextrose gel
□ Perinatal asphyxia
control, e.g. infant
- 1st D'stix (pre-feed) at 2 to 3 hrs of life,
being large for gestational age, □ Neonatal sepsis
then q3h x 3, then
→ Stop for infants of diabetic mothers or
polyhydramnios, mother □ Preterm < 35 weeks
macrosomia (monitoring x12hrs)
→ Continue q6h x 2 for other risk factors
requiring obstetric □ SGA with BW < 2.3 kg
(monitoring x 24hrs)
intervention due to diabetes □ BW <5th percentile

If D'stix < 2.2 mmol/L (< 4 hrs of life)
OR D'stix < 2.8 mmol/L (≥ 4 hrs of life)
□ Macrosomia ( ≥ 4kg ) □ Restricted / Poor feeding
- Inform Paed for URGENT SCBU admission,
check blood glucose and IV glucose
□ BW ≥ 90th percentile □ Significant polycythaemia
If D'stix 2.2 - 3 mmol/L (< 4 hrs of life)

□ Late Preterm 35 – 36 6/7 □ Severe Rh incompatibility
OR Symptomatic
weeks - Give one dose 40% Dextrose gel 0.5ml/kg OR
□ Others - specify
Give one bolus feed of 10ml/kg EBM/Formula
- Place STSC & continue feed as tolerated
□ SGA (5-10th percentile)
- Repeat D'stix 30mins post feed then q3h x 2,
with BW 2.3 - 2.5kg then q6h x 2
→ if D'stix 2.2 - 3 mmol/L, repeat one dose
of Dextrose gel / bolus feed of 10ml/kg
□ Drug use, e.g.β blockers,
high glucose infusion during If D'stix 2.8 - 3.3 mmol/L (≥ 4 hrs of life)
labour etc. OR Symptomatic
- Give one dose 40% Dextrose gel 0.5ml/kg OR
□ Others - specify Give one bolus feed of 10ml/kg EBM/Formula
- Place STSC & continue feed as tolerated
- Repeat D'stix 30mins post feed then q3h x 2,
then q6h x 2
→ if D'stix 2.8 - 3.3 mmol/L, repeat one dose
of Dextrose gel / bolus feed of 10ml/kg
If D'stix remains 2.2-3 mmol/L(<4hrs of life) OR

2.8-3.3 mmol/L (≥4 hrs of life) after 2 doses
of Dextrose gel /2 bolus feed OR Symptomatic
- Inform Paed for SCBU admission + checking
blood glucose
Informed Paed / OBS Doctor ________________at_____________
Doctor's Name & Signature:

by Nurse _______________________(K9N / K9S / K6S / K8S)
189
__________________________________________________________________________________
Appendix 4.
Information Pamphlet - Dextrose Gel for Treating Babies with Hypoglycemia
使用葡萄糖啫喱治療初生嬰兒低血糖小冊子
190
__________________________________________________________________________________
REFERENCES
1. American Academy of Pediatrics. Committee on fetus and newborn. Clinical
report-postnatal glucose homeostasis in late preterm and term infants. Pediatr
2011;127: 575-579.
2 UNICEF, UK Baby Friendly Initiative. Guidance on the development of policies and
guidelines for the prevention and management of hypoglycaemia of the newborn.
July 2013.
3 Queensland Maternity and Neonatal Clinical Guidelines Program. Newborn
hypoglycaemia. August 2013.
4. Performance of Three Bayer Blood Glucose Monitoring Systems with Blood
Samples from Neonates. May 2013
5 Oral dextrose gel for the treatment of hypoglycaemia in new born infants. Cochrane
Database of Systematic Reviews 2016, Issue 5. Art. No.: CD011027
6 Identification & Management of Neonatal Hypoglycaemia in the Full Term Infant – A
Framework for Practice. British Association of Perinatal Medicine. April 2017.
7 Robinson CS, Hon BSc, Sharp P. Tighter Accuracy Standards within Point-of-Care
Blood Glucose Monitoring: How Six Commonly Used Systems Compare. Journal of
Diabetes Science and Technology 2012; 63(6):547-554
191
3.7.5 MANAGEMENT OF NEONATAL JAUNDICE
Please refer to the action guidelines on “Indications for Phototherapy (PT)” and “Indications for Exchange
Transfusion (ET)” for term and preterm infants (Chart 1).
Major changes:
(1) Intervention based on Total Serum Bilirubin (TSB) which is roughly equal to Unconjugated Bilirubin
(Bu) + Conjugated Bilirubin (Bc).
(2) For babies born at or after 35+0 weeks of gestation (the upper two lines), the thresholds of treatment
are elevated (compared with old guidelines).
(3) In the of presence of risk factors e.g. dehydration, abnormal neurologic behaviours, asphyxia, low
serum albumin (if ever measured), temperature instability, G6PD deficiency or other hemolysis
settings (maternal blood group O), or follow up cannot be ensured, consider starting intervention at a
lower TSB level.
Indications for PT/ET for babies with GA 35 weeks
>38 weeks of gestation

24 hours 48 hours 72 hours 96 hours 120 hours
PT level 165 220 265 300 310
(mol/L)
ET level 280 325 370 385 385
(mol/L)
35+0 – 37+6 weeks of gestation

PT level 130 200 230 250 255
(mol/L)
ET level 255 290 315 325 325
(mol/L)
Day-Phototherapy in SCBU (K8S when mother discharged)

Giving PT during daytime while allowing home leave at night to facilitate breastfeeding without adverse effect.
Breastfeeding area / corner is available to facilitate breastfeeding.
Please check BuBc at 4pm and decide on suitability of home-leave during afternoon ward round. Cases with
borderline TSB (very near PT level) can be admitted for day-PT.
Stopping PT
PT can be stopped when the TSB level is around 250 mol/L or 30-40 mol/L below PT level, whichever
lower.
Rebound jaundice – TSB should be checked (6-24 hours after stopping PT) if possible, especially when there
is a suspicion of hemolysis or if the rise of TSB before PT is significant.
General management of NNJ – to be covered in separate file (Appendix 4)
192
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Chart 1. Indications for PT and ET (2016)

Indication for Phototherapy
350
>=38+0w
300
35-37+6w
250
32-34w;1501-2000g
200
umol/L
28-31w;1001-1500g
150
<28w;<1000g
100
50
0
0 1 2 3 4 5 6 7
Days
Indication -- Exchange Transfusion

450
400 >=38+0w
350
35-37+6w
300 32-34w;1501-2000g
30-31w;1251-1500g
250
umol/L
28-29w;1001-1250g
200
<28w;<1000g
150
100
50
0
0 1 2 3 4 5 6 7
Days
193
Management and Assessment of NNJ – Inborn K6 and K9
0-24 hours (Day 1) 24-48 hours (Day 2) > 48 hours
․ Visual assessment Assess risk factors and arrange

․ JM at least once follow up
Follow up 1 day if #:
Repeat JM - Bu+Bc20mol/L below PT
No (BuBc if JM level and 1 risk factor*
145 for 38wks
200 for 38wks
110 for
180 for Follow up 2 day if:
35-37wks
- Bu+Bc20mol/L below PT
without risk factors*, or
Yes - Bu+Bc 21-40mol/L below
Treatment PT
BuBc+Hb
needed?
No Risk factors:
- G6PD deficiency
No - mother’s blood group “O”
Treatment - wt loss ≥8%
needed? - cephalohematoma / bruises
- GA <38 weeks
Yes Yes
# consider admission if follow up
cannot be arranged e.g. long
Inform Paed for assessment * holiday, living far away.
*In order to facilitate exclusive breastfeeding and minimize mother-baby separation,

1. Babies with borderline hyperbilirubinaemia can receive biliblanket phototherapy treatment in the postnatal ward.
2. Breastfeeding mothers can be allowed to defer their discharge for 1-2 days if the babies are in-patients for phototherapy treatment
194
__________________________________________________________________________________
Referral for NNJ Assessment to QMH

There are three sites where NNJ can be assessed, depending on opening hours of individual site:
Opening hours Eligibility

S5 Day service (OBS) Monday 9am-5pm Babies born at QMH and younger
Tuesday to Friday than 10 days old
1:30 pm–5:00pm;
K10N Paediatric Day 9:00am to 5:00pm, Monday to All other newborns

center Friday
K8S Other times All newborns
Babies can also be followed up at Neonatal Clinic (NNC) in KGOPD.
For newborns that require further follow up because of high or increasing jaundice, they can be
referred for NNJ assessment as above accordingly. In cases of weekends or long holidays, the baby
can be referred to K8S for assessment. The medical record of previous assessment should
preferably be provided e.g. jaundice meter level, serum bilirubin level.
Assessment at K8S/K10N (see Appendix 1)

Babies with NNJ referred from MCHC (or S5 occasionally) to K8S/K10N will be seen by interns and
neonatal residents.
PT by biliblanket should be started for babies with JM>250 while awaiting BuBc results.
Serum bilirubin (Bu+Bc) should be checked as early as possible, preferably within 1 hour after
admission
195
__________________________________________________________________________________
(A.) Short term follow up

Follow up should be ensured for the following categories:
When Bu+Bc level is close to PT level
 Less than 20 mol/L below PT level and +risk factors  follow up 24 hours
 21-40 mol/L below PT level or 20mmol/L without risk factors follow up 24 - 48
hours
 The follow up can be done at Day Service (S5), K8S (as day patient), K10N, private
paediatricians, or NNC (if time slots available)
If follow up cannot be ensured, call neonatal resident to consider admission for PT at lower
TSB level.
Follow up schedule
Babies with GA >38 wks
then
FU in24 hr FU in 24-48 hr *FU routine
If
TSB at 48 hrs 200-219 with risk factor 180-199; 200-219 (no risk factor) <180
TSB at 72 hrs 245-264 with risk factor 225-244; 245-265 (no risk factors) <225
Babies with GA 35+0 – 37+6 wks

then
FU in24 hr FU in 24-48 hr *FU routine
If
TSB at 48 hrs 180-199 160-179 <160
TSB at 72 hrs 210-229 190-209 <190
TSB at 96 hrs 230-249 210-229 <210
TSB at 120 hrs 235-254 215-234 <215
*FU Routine: according to physicians’ discretion, depending on age of patients, abnormal physical
signs, or suspicion of pathological causes of jaundice.
(B.) Long term follow up
Long term follow up should be arranged for patients whose TSB has reached or exceeded Day
4 ET level (e.g. 385mol/L for babies with GA >38 weeks, and 325 mol/L for babies born at
35+0 – 37+6 weeks)
A formal elective BAEP should be booked on discharge to detect hearing loss even though
he/she has passed his/her hearing screening.
Follow up schedule;
1 week after discharge (if jaundice has not yet resolved before discharge)
Refer to Integrated Developmental Care Program (IDCP) if appropriate
․ 4-month (with AIMS physiotherapist assessment)
․ 8-month (with AIMS physiotherapist assessment)
․ 12-month (with AIMS physiotherapist assessment).
Case can be closed when the child’s physical assessment is normal at 12 months old.
Kernicterus:
 Specific movement disorder – dystonic cerebral palsy
 Hearing loss
 Upward gaze palsy
 Enamel staining
196
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Appendix 1 K10N (Paediatric Day Centre) Management

of Neonatal Jaundice
MCHC Jaundice referred for

A&E blood test and assessment
Others
․ JM
․ Clinical assessment by intern (General)
and neonatal Resident*
․ TSB (Bu+Bc)  other blood tests if
indicated
K8S
No (weekends,
JM 250
PH)
Yes
Biliblanket
MCHC
Trace blood result
Inform Private
Neonatal Yes
resident PT
(Dect 1278) needed?
Admit K8S
No
Scheduled follow up*
․ 1 day
․ 2 days
․ routine
* Inform Neonatal Resident (1278) *Follow up

immediately if baby is ill e.g. lethargic, pale, (1) within 20 mol/L below PT level with risk factors
dehydrated, septic FU 24 hrs
(2) 21-40 mol/L below PT level or within 20umol/L
without risk factors  FU 24-48 hrs
(3) >40 mol/L below PT level  FU routine
197
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Appendix 2 S5 (Day Service) Guideline for Management of

Babies with NNJ
 Clinical assessment as usual (history, feeding pattern etc)
Checklist for abnormal clinical signs or history
 body weight loss of >10%; signs of dehydration
 poor feeding
 lethargy / irritability / high pitched cry
 pallor
 temperature instability
 G6PD deficiency /maternal blood group O
 siblings with severe NNJ
 Jaundice meter (JM)
 Call Neonatal resident immediately if there are clinical suspicion of abnormalities e.g. dehydration,
irritability, temperature instability
 Otherwise check Bu+Bc
Yes call Neonatal resident and send pt

Presence of abnormal signs to K10N
(for biliblanket PT, assessment, and
No TSB)
TSB
No within 20mol/L below PT FU 24 hours

PT level level with risk factors
21-40 mol/L below PT FU 24-48 hours

Yes level or within 20 mmol/L
without risk factors
borderline
>40 mol/L below PT level Routine FU
Inform Neonatal resident for admission

to K8S
Call Neonatal resident to consider Day-PT e.g.

breastfeeding, living far away etc. Ask pt to come early
next morning (to KS) for PT.
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Appendix 3 Referral for Assessment of Prolonged Jaundice

Etiologies
(1) Breast milk jaundice
(2) Infection especially urinary tract infection, CMV
(3) Hemolysis
(4) Neonatal hepatitis syndrome
(5) Obstructive jaundice e.g. biliary atresia, choledochal cysts
(6) Others e.g. Gilbert syndrome, Hypothyroidism, IEM
Jaundice by Day 14 for formula fed or

Day 28 for BF
(clinical or JM)
Worrying signs and Yes

symptoms
e.g. Clay colour stool,
hepatosplenomegaly,
No
Breastfeeding
(exclusive or partial) No
Yes
Monitor at MCHC by clinical assessment + JM
(serum bilirubin)
Day 28
Persistent or No
MCHC
progressive routine
Yes
․ Refer to QMH as new case (NNC or General)
․ Appointment available in 1-2 weeks
․ Refer to A&E if emergency
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Appendix 4 Inpatient Treatment of NNJ
Assessment of a newborn with jaundice
(A) History
 Age (in hours) and gestational age
 Antenatal risk factors e.g. gestational DM, pregnancy induced hypertension, IUGR, multiple
pregnancy, Rhesus incompatibility
 Peripartum risk factors e.g. prolonged rupture of membrane, delayed cord clamping for prolong
period, traumatic delivery
 Feeding – breast /formula feeding; adequacy of feeds; feeding problems e.g. vomiting, number
of bowel motions, use of parenteral nutrition;
 General signs of wellbeing e.g. general activity, sleeps
 Drug intake especially herbs, exposure to naphthalene in G6PD deficient subject
 Neonatal screening results (G6PD, Thyroid function)
 Family history e.g. NNJ, G6PD deficiency
(B) Physical examination

Confirm jaundice and assess severity
Visual (useful but less reliable than transcutaneous bilirubinometry)
 yellow sclera and skin
 cephalocaudal progression
 greenish hue (cholestatic jaundice)
 pale yellow (with anemia, suggests hemolytic jaundice)
Transcutaneous bilirubinometer TcB
 Good predictor of TSB particularly when TSB level is less than 250mol/L; higher discrepancy
in severe jaundice
 Needs blood tests (TSB) for confirmation and direct treatment, yet obviate the need for blood
tests in mild jaundice for infants  35 weeks
 Not reliable during phototherapy (recovery needs 18-24 hours)
Look for causes of jaundice

 General status – hydration, fever, general activities, features of sepsis, hypothyroidism
 Head – cephalohematoma
 Skin – bruises
 Abdomen – enlarged liver, spleen
 Enquire /inspect stool and urine colour
Look for features of acute bilirubin encephalopathy

 Fever, poor sucking
 Conscious state: lethargy  irritable; high pitched cry  stupor, coma
 Muscle tone: hypotonia  hypertonia, neck stiffness, opisthotonus
 Convulsion
Further investigations based on clinical suspicion

 blood picture, reticulocyte count and smear – hemolysis, infection
 end-tidal carbon monoxide/carboxyhaemoglobin -- hemolysis
 blood group, direct antiglobulin test (direct Coombs test)
 bilirubin: albumin ratio (an estimation of free bilirubin)
 conjugated (or direct reacting) bilirubin and hepatic enzymes – when hepatitis or cholestasis
suspected
200
__________________________________________________________________________________
unconjugated bilirubin conjugated bilirubin
look for causes of hemolysis look for hepatobiliary

or enterohepatic circulation disease
 full liver function tests, including albumin and coagulation profiles – when liver disease
suspected
 sepsis screening – including urine and blood culture
 viral studies, syphilis serology – congenital infection syndrome
 imaging of hepatobiliary system – for evidence of surgical obstruction
 endocrine and metabolic screening – thyroid function, urine for reducing substance,
1-antitrypsin phenotype etc
Feeding management during hyperbilirubinaemia

When TSB level reaches phototherapy threshold or when there is weight loss of >10%, supplementation
with formula is reasonable. Mothers should be encouraged to continue breastfeeding or maintain
lactation by expression. Breastfeeding should be assessed and supervised by nurses experienced in
breastfeeding support.
 Supplementation of breastfeeding
i. Cow’s milk-based formula has been shown to inhibit intestinal absorption of bilirubin. Small
amount can be used to lower serum bilirubin
ii. Avoid excessive amount to maintain frequent breastfeeding. If mother is not producing
adequate milk or infant wt loss (>10%), then larger quantities of formula should be offered to
ensure adequate caloric and fluid intake.
iii. Supplementation by cup or use of a supplemental nursing device simultaneously with each
breastfeed. Nipples / teats and bottles should be avoided where possible.
 Temporary interruption of breastfeeding

i. Interruption for 24-48 hrs with full formula feeding will generally lower serum bilirubin
concentration more rapidly than supplementation
ii. Interruption of breastfeeding is generally not recommended as bilirubin concentration usually
comes down with phototherapy and adequate hydration
iii. With temporary interruption of breastfeeding, it is critical to maintain maternal milk production
by teaching the mother to effectively and frequently express milk manually or by pump
Treatment of Neonatal jaundice

The goal of therapy is to prevent bilirubin encephalopathy in high risk infants and avoid unnecessary
treatment to low risk infants.
 Specific Treatment options

for unconjugated hyperbilirubinemia
(A) Phototherapy (PT)

 blue (special) /green /turquoise /white
 fluorescent tubes/ fibreoptic biliblankets / LED / tungsten-halogen
 works by photo-isomerisation and photo-oxidation of unconjugated bilirubin into water-soluble
forms (lumirubin) and excreted without need of conjugation
 effectively reduces need for exchange transfusion
 higher power (intensity) associated with a quicker fall in TSB
o double (two units) or triple (three units) in combinations more effective than single
o use of reflective curtain also effective in enhancing phototherapy effect
 the greater the body surface area exposed, the greater the decline of bilirubin
201
__________________________________________________________________________________
 intensive PT (defined as  30 W/cm2 per nm in 430- to 490- nm band) more effective and
reduce the need of ET
 intermittent PT appears to be effective
Indications of PT – referred to chart for PT
Monitoring during PT
 Regular intake and output, hydration state
 Body temperature
 Body weight daily
 Eye-patch position and respiration
 TSB regularly (every 6-24 hours depends on the severity)
Complications usually well tolerated

 corneal /retinal damage (use eye-shield)
 increase in insensible water loss (encourage liberal milk intake)
 hyperthermia/ thermal skin injury (monitor body temperature, use halogen PT units at
recommended distance)
 transient skin rash
 loose stool
 bronze baby syndrome (when significant conjugated bilirubin present)
 rebound hyperbilirubinemia after cessation (especially when there is evidence of hemolysis)
 bullous eruption in porphyria
Discontinuation of PT:
 Intermittently check TSB to decide for discontinuation of PT at a level that is safe while
considering the age, gestation, presence of risk factors, and the possibility of rebound when PT
is discontinued. (see practice guideline)
 Follow up assessment at 12-24 hours may be necessary for high-risk cases.
(B) Exchange transfusion (ET)

 Rapid way of removing serum bilirubin (and antibody-coated red cells)
 Indications
o severe or extremely high hyperbilirubinemia (Figure 2 and 4) despite intensive PT, or
o in addition, a high bilirubin: albumin ratio (Table 1)
o when there is already evidence of acute bilirubin encephalopathy (ET should be
performed for all infants who manifest signs of acute bilirubin encephalopathy even if TSB is
falling with PT)
Table 1. Bilirubin/albumin ratio (B/A) can be added when considering indication for ET
B/A mg/dL: g/dL mol/L:mol/L
Infants  38 weeks
o Well 8.0 0.94
o Hemolysis 7.2 0.84
Infants 35-37 6/7 Weeks
o Well 7.2 0.84
o Hemolysis 6.8 0.80
Procedures (refer to appendix on ET)

 double blood volume exchange (traditional)
o single volume exchange: 60% of blood exchange
o double volume exchange: 85% of blood exchange
 use fresh whole blood (<3-5 days) or reconstituted blood components (washed red cells with
plasma)
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 use wide bored intravenous catheters and exchange blood in small aliquots (central or
peripheral)
 needs cardiopulmonary monitoring during and immediate after the procedure
Complications varies with different patient’s status, higher rate in preterm infants
 Procedure associated mortality <1% (well term infants) to 12% (ill or preterm infants)
 Complications
o Catheter induced: thrombosis, embolism, bleeding, cardiac arrhythmia
o Transfusion related: blood compatibility problems, thrombocytopenia, hypothermia,
apnea, bradycardia, cyanosis, metabolic acidosis, hypocalcemia, hyperkalemia,
necrotizing enterocolitis
o Infection
 Risk and benefit must be weighed and explained to parents before decision for exchange
transfusion, and a formal consent obtained
 The procedure must be performed by trained personnel in a neonatal intensive care unit with
full monitoring and resuscitation capabilities
Procedure: Exchange transfusion (ET)

 Clarify indications and contraindications
 Obtain consent
o Cross match
 Required volume should be 2 80ml/kg body weight (double blood volume) + dead space of
blood tubings (30-50ml)
 (blood volume of preterm infant is 100-120ml/kg)
 use type O, Rh compatible blood (with low anti-A and anti-B titre) for ABO hemolytic disease
 use ABO type specific Rh-negative blood for Rhesus hemolytic disease
o Use fresh whole blood (<3-5 days old)
o Warm blood with blood warmer to 27-37deg C
o Consider white cell filter
o Freshly irradiated blood may reduce chance of graft-vs-host disease
Preparation of baby
o Fast 2-4 hours before procedure. Empty stomach by feeding tube immediately before procedure.
o Stabilize vital signs e.g. supplementary oxygen, glucose infusion for hypoglycemia etc. before
starting procedure
o Place baby under open incubator with radiant heater
o Connect baby to continuous cardiopulmonary monitor.
o Use restrainer if necessary
o Consider setting arterial catheter for continuous blood pressure monitoring or for isovolumetric
method (see below)
o Keep IV glucose infusion during the procedure if necessary (to prevent hypoglycemia)
Keep baby warm with radiant heat warmer. Do not hang blood pack directly in the heat path of radiant
warmer
Procedure
o Universal precautions, use strict aseptic technique for setting up exchange system.
o Prepare
 Syringes with heparinized saline
 Appropriately sized syringes (3ml, 10ml or 20ml) for drawing of blood
 Wastage bag
 Stopcocks (three ways) X 2
 10% Calcium gluconate IV (optional)
Exchange using umbilical venous catheter (single lumen push-pull method)

o set up three-way exchange system as shown
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o catheterize umbilical vein – preferable in IVC or at a site where blood can easily have aspirated and
infused for more emergency situations (usually 4-5cm from umbilical stump in term infants)
o start aliquots of exchange (aliquot volume should be <10% of blood volume each shift; use lower
volume for unstable patients)
 >2500gm: 20ml
 1801-2500gm: 15ml
 1201-1800gm: 10ml
 <1200gm: 5ml
 volume of blood withdrawn and transfused must be accurately measured and should be
documented by an assistant
o save the first and last aliquot for investigations
 draw blood from baby slowly
 push blood into wastage bag
 draw same volume of blood from donor pack
 slowly inject blood into umbilical vein over 1 minute watching out for bubbles
 wait for 30 seconds and repeat above steps until the desired volume exchanged
 NOTE: patient’s blood should not be left inside the circuit since it will clot quickly
o shake blood pack every 15 minutes to prevent early settling of red cells
o Use of calcium gluconate infusion (optional, and may not be necessary in normocalcaemic patients):
 For every 100ml blood exchanged, give 1ml 10% calcium gluconate IV SLOWLY and
CAUTIOUSLY (bradycardia or cardiac arrest if given too quickly)
 or give 0.5ml IV slowly for every 50ml exchanged if baby is small
 followed by SLOW saline flush afterwards
o Monitor baby’s vital signs throughout the procedure, including central venous pressure if possible.
o Expose the baby for easier observation rather than cover up.
o Accurately document volumes of blood in-and-out, number of cycles, drugs given and vital signs of
baby
o Total duration 90-120 minutes
o End of exchange
 Send last aliquot of blood for investigations
 Decide the need for second exchange – keep umbilical catheter if necessary (by saline
infusion).
Specimens to be collected
(1) Pre-ET
a. Blood for CBC, LFT, blood culture,
b. Na K Ca blood gas, spot glucose
c. Coagulation profile
d. Genetic studies (if necessary)
(2) Post-ET
a. Blood for CBC, LFT, blood culture,
b. Na K Ca blood gas, spot glucose
c. Coagulation profile
d. Repeat cross match if necessary
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Monitoring after exchange

1. Vital signs: continuously for at least 4-6 hours
2. Hypoglycemia (rebound hypoglycemia due to dextrose containing blood preservatives): q2h- q4h
blood glucose for 12 to 24 hours
3. Rebound hyperbilirubinemia: check TSB 4-6 hours after procedure while continuing intensive
phototherapy
4. Feeding can be resumed 2-4 hours after procedure, and feeding tolerance closely monitored (if
umbilical catheters used)
(C) Intravenous immunoglobulin (IVIg)

 has been used effectively to reduce need for exchange transfusion in Rh and ABO isoimmune
hemolytic disease
 dose 0.5-1g/kg over 2 hours; may be repeated in 12 hours if necessary
(D) Other drugs

 Metalloporphyrin heme oxygenase inhibitors – not yet available
 Phenobarbital has been used successfully for mothers antenatally to reduce the severity of
jaundice in fetal hemolytic disease. It has also been used for patients with Crigler-Najjar
syndrome.
 Albumin infusion has not been shown to be effective in reducing bilirubin encephalopathy in well
studied trials, although theoretically it may alter the bilirubin: albumin ratio. In some studies, a
dose of albumin at 1g/kg 1 hour before ET has been shown to increase the efficiency of
exchange by 40%.
(E) Other supportive measures

 Counseling and support for breast feeding and NNJ
 Ensure adequate hydration by liberal intake of milk;
 Consider additional supplementary formula milk/ expressed breast milk or intravenous fluid if
dehydrated
 Routine water supplement has not been shown to benefit breast fed jaundiced infants
205
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Appendix 5. Guidelines of NNJ Monitoring and PT in
Postnatal Ward
(A) Monitoring of NNJ – use of Jaundice Meter (JM)
1. Measure 2 readings from sternum, and take the higher reading
2. Measure at least once daily for all neonates during the first five days of hospital stay
>38weeks of gestation
PT level 165 220 265 300 310
(mol/L)
CHECK BLOOD FOR BUBC WHEN
JM-103/105 >135 >190 >235 >260 >260
(mol/L)
35+0 – 37+6 weeks of gestation

PT level 130 200 230 250 255
(mol/L)
CHECK BLOOD FOR BUBC WHEN
JM-103/105 >100 >170 >200 >210 >210
(mol/L)
(B) Phototherapy (PT) in postnatal wards

Goals of PT in postnatal ward:
1. To decrease the baby’s serum bilirubin level
2. To administer phototherapy via neoBLUE blanket LED Phototherapy System effectively and safely
3. To prevent maternal baby separation
4. To facilitate the mother to offer responsive feeding
Expected outcome:
1. The baby was commenced and maintained on PT treatment in a safe and effective manner
2. The infant’s serum bilirubin levels were decreased
3. Maternal baby separation was avoided and breast feeding maintained
Selection of candidates:
1. Well infants with onset of jaundice after 24 to 48 hours of age
2. Without risk factors for severe jaundice such as haemolysis, infection and asphyxia
3. Priority for infants on breastfeeding
Indications for PT: – refer to Appendix 4
Procedure:
1. Explain procedure and indication for PT to mothers / parents (give parent information sheet)
2. Pre-warm the fiber optic blanket mattress to body temperature if appropriate.
3. Remove all the baby’s clothes (except nappy)
4. Carefully place the baby on top of the neoBLUE blanket covered mattress with their head at the
other end from where the cable is attached (see below)
206
__________________________________________________________________________________
5. Swaddle the baby and then cover with a light blanket /bed sheet if needed
6. No need to put on eye shield if baby is using SleepSack Swaddle
7. Switch on the PT unit only when baby is swaddled.
8. Make sure that the swaddle is well covering the infant’s body and the eyes cannot be exposed to
the light.
9. Educate mother on how to use the swaddle properly and prevent exposure to light.
Observation and monitoring during phototherapy:

1. Monitor the infant’s temperature before and one hour after PT started
2. Maintain Heart Rate, Respiratory Rate observation 4-hourly & temperature 8-hourly while receiving
phototherapy.
3. Turn the photo unit off when:
 Checking the infant’s condition and visualizing skin color.
 Moving the baby out from the swaddle
 Performing care procedure for the baby e.g. bathing, changing napkin
4. Check baby’s eyes for risk of exposure to the blue light periodically.
5. Medical attendance by neonatal residents/fellows on start of PT and ward round at least once/day
6. Any concerns regarding hydration of the baby should be referred to neonatal doctors
7. No oil, cream or lotions are to be applied to the baby’s skin during PT.
Guidelines for breast-fed babies receiving PT:

Infants should be fed regularly, with a maximum interval of four hours. Breastfeeding can be continued
during PT. If baby is removed from the swaddle, avoid prolonged duration of feeding to facilitate PT
treatment. Admission to SCBU should be considered in infants who require PT for more than 1 day
Maintenance and safety instructions on the use of neoBLUE Blanklet LED

(Refer to the manufacturer’s user guide and the instruction of ward’s routine.)
Monitoring and discontinuation of PT treatment:

1. Off PT at 4am the next day
2. Repeat BuBc at 8am in the morning and await assessment by Neonatal doctor
207
__________________________________________________________________________________
REFERENCES
1 Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of

Gestation. Pediatrics 2004; 114: 297-316
2 Lee Wai-hong. Neonatal Jaundice, Phototherapy, Exchange Transfusion.
Neonatal Manual, Chiu Man-chun, Fok Tai-fai(ed.), 183-197. Hong Kong: The
Chinese University Press, 1992.
3 ABM Clinical Protocol #22: Guidelines for Management of Jaundice in the
Breastfeeding Infant Equal to or Greater than 35 weeks’ Gestation. Breastfeeding
Medicine, 2010, Vol. 5(2).
4 Consensus Guideline on Management of Unconjugated Hyperbilirubinemia in
Hong Kong HA Hospitals in Newborn Infants 35 or more Weeks of Gestation. 2015
208
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209
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3.8.1 MANAGEMENT OF NEWLY DIAGNOSED DIABETES MELLITUS
Definition of Diabetes Mellitus (Both Type 1 and type 2)
- Random glucose >11.1mmol/l with evidence of chronicity/persistence (rather than just transient
stress-induced hyperglycaemia) including HbA1c> 6.5%, hyperglycemic symptoms, persistently high
glucose
- OGTT: Fasting blood glucose >7mmol/l or 2 hour glucose>11.1mmol/l
History
- Polydipsia, polyuria, polyphagia
- Weight loss
Hints on T1 vs. T2DM
Physical examination T1DM T2DM
- General condition, alertness Not obese Obese
- Hydration status No acanthosis Acanthosis
- Acanthosis nigricans nigricans nigricans
- BMI Evidence of ketosis Family history of
T2DM
Investigations
1. RG
2. Ketone (BOHB) [can be ordered in CMS GCR]
3. Blood gas
4. Insulin and C-peptide
5. HbA1c and fructosamine
6. Anti-islet cell antibody
7. TSH, fT4, anti-Tg, anti-TPO antibody
8. Fasting full lipid profile
9. Urine for ketone (bedside)
10. MSU for R/M & C/ST
11. Celiac panel if Caucasian: anti-tTG IgA and anti-tTg IgG (available in CMS GCR)
12. LRFT, CaPO4, Mg, amylase
13. CBC
Definition of DKA
1. Hyperglycemia, blood glucose >11.1mmol/L
2. Metabolic acidosis, HCO3<15mmol/L
3. Ketosis, ketone in urine or blood
Degree of DKA
mild moderate severe
HCO3 (mmol/L) 10-15 5-10 <5
Alertness alert alert to drowsy stupor/coma
General criteria for considering ICU care

 Cases fulfilling the criteria of DKA as stated above
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Management for newly diagnosed T1DM and ketosis but no acidosis or T2DM with ketosis in general ward
1. Diet
Age Daily calories Carbohydrate allocation
(gram)
1 - 2 year old 1000 calories 40/0/40/0/50/0
3 - 4 years old 1200 calories 40/0/55/0/55/0
>12 years old 2000 calories 70/0/90/0/90/0
*Consult dietitian during the day/next morning
2. Rehydration
- While waiting for blood VBG and ketone results: give IV NS bolus 10-20ml/kg over 1 hour
- Then recheck D’stix
- Encourage oral fluid intake
- Continue IVF if needed, use NS or 1/2:1/2 solution for extra hydration
3. Monitoring
-D’sitx before and 2 hours post breakfast, lunch and dinner + 0am + 3am
-Urine ketone every void for new case
-Strict I/O
-BP/P Q4H
-Daily BW
4. Starting subcutaneous insulin injection (basal/bolus regimen)

Step 1. Calculate Total Daily dose (TDD)
Starting dose 0.2unit/kg/day
Blood glucose>11.1mmol/L +0.2unit/kg/day
Urine ketone>trace or blood BOHB +0.2unit/kg/day
>0.5mmol/L
Acidosis(HCO3<18mmol/L) +0.2unit/kg/day
Obesity +0.2unit/kg/day
Puberty +0.2unit/kg/day
Step 2. Calculate Insulin to Carb Ratio (ICR)

-ICR: Number of gram of carbohydrate that can be covered by 1 unit of insulin
-400 rule: ICR=400/TDD
Step 3. Determine the basal bolus insulin regimen

-40% of TDD as basal insulin (e.g. Glargine/Levemir)
-Bolus insulin (e.g.Lispro/novorapid) is used to cover carbohydrate in each meal
Step 4. Calculate insulin sensitivity factor (ISF)

-ISF: blood glucose to be dropped by 1 unit of fast acting insulin (e.g.Lispro/novorapid)
-100 rule: ISF=100/TDD
-Use ISF to determine extra insulin dose for correcting hyperglycemia
-Correction aims at a target blood glucose of ~9mmol/L in 2-3 hrs, hence repeat d’stix 2-3 hrs later
211
__________________________________________________________________________________
Correction dose = (Current d’stix- target d’stix)/ISF = (Current d’stix -9mmol/L)/ISF
*Always repeat d’stix after fluid bolus when calculating the correction dose: d’stix can drop quickly just
with fluid rehydration alone
*For patients at risk for hypoglycemia (especially those young patients): omit correction dose prn
*Fast-acting bolus insulin is normally given before main meals. However, for children with poor appetite
or unpredictable oral intake, post-meal insulin could be considered.
*Round off insulin dose, use 0.5unit as a step for fast-acting insulin and use 1unit as a step for
long-acting insulin
5. Hypoglycemia management
-If pre-meal glucose <4mmol/L, allow patient to eat 15gram simple sugar (juice/candies) before the fast
acting insulin for main meal
-If glucose <4 during the night or during the day not before meal, allow patient to eat 15gram rapidly
digestible carbohydrate, then recheck glucose within 30mins
-If severe hypoglycemia cannot be treated with oral carbohydrate, given slow IV D20 50ml or IM
glucagon 1mg, then recheck glucose 15min later
Counselling
-T1DM is a lifelong disease but totally manageable with adequate knowledge, good compliance to
medication and healthy lifestyle.
-Consult Clinical psychologist during the day
Working Example
15kg normal body build 3-year-old boy presented with 2 weeks history of polyuria and polydipsia. He is
alert and he can tolerate oral diet.
Ix in AED:
 Blood glucose 32mmol/L repeated d’stix after NS bolus 20ml/kg IV: 20mmol/L
 Urine ketone: moderate
 VBG: pH 7.4, HCO3 20mmol/L
Management for this Patient

1. Rehydration: IV or oral: encourage clear fluid
2. Diet: 1200kcal diet: CHO: 40g/10g/50g/10g/50g/10g
1. Insulin regimen
Starting dose 0.2unit/kg/day √
Blood glucose>11.1mmol/L +0.2unit/kg/day √
Urine ketone>trace or blood BOHB >0.5mmol/L +0.2unit/kg/day √
Acidosis(HCO3<18mmol/L) +0.2unit/kg/day x
Obesity +0.2unit/kg/day x
Puberty +0.2unit/kg/day x
 TDD=(0.2+0.2+0.2)units/kg/day=0.6units/kg/day=0.6 units x 15kg=9unit

 ICR=400/TDD=400/9= 44(i.e. 1 unit of insulin cover 44gram of carbohydrate)
 ISF=100/TDD=100/9=11(i.e. 1unit of rapid acting insulin lower blood glucose by 11mmol/L)
Since his current d’stix is 20mmol/L, using target blood glucose of 9mmol/L and an ISF of 1: 11, the
correction dose (using fasting-acting insulin of either lispro/novorapid) will be:
(Current d’stix- target d’stix)/ISF= (20mmol/L- 9mmol/L)/11=1 unit
212
__________________________________________________________________________________
 Correction dose = Lispro/novorapid 1unit (aim to drop d’stix to ~9mmol/L)
Glargine/levemir=9 x 40%=~3.6unit= round off to 4 units before bed

Breakfast: Lispro/novorpaid=1unit (for 40g CHO)
Lunch: Lispro/novorapid=1.5unit (for 50g CHO)
Dinner: Lispro/novorapid=1.5unit (for 50g CHO)
**Discuss with seniors/on-call DM hotline doctor PRN
by Dr. SL Ng/Dr. YL Tung
213
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3.8.2 HYPOGLYCAEMIA
Defined by Whipples’ Triad:
1. Presence of symptoms of hypoglycaemia:
a. Autonomic: Pallor, sweating, shakiness, tachycardia, weakness, nausea, vomiting
b. Neuroglycopenic: seizures, headache, vision change, lethargy, difficulty with speech, confusion, loss of
consciousness, death
2. Documented low blood glucose*
3. Relief of symptoms when the glucose level is corrected
*In those too young/unable to express symptoms, operationally defined in our hospital as < 3.0mmol/L
Critical samples - drawn at time of symptomatic hypoglycemia or D’stix < 3.0 mmol/L*
- Ideally, samples below should be all taken during hypoglycaemic episode, however in the event of difficult blood
taking, arrange in the priority below and do not delay correction of hypoglycaemia
Sample ordered in priority Amount of blood, bottle Special things to note
Should be taken prior to correction of hypoglycaemia
Random Glucose, lactate 1ml, Fluoride Urgent
Liver and renal function, CaPO4, 1ml, Lithium Heparin, non gel On Ice; urgent
Ammonia, BOHB
Venous blood gas/iSTAT Heparinised capillary tube On Ice; urgent
Insulin 1ml, Clotted blood
Free fatty acids 1ml, EDTA Inborn Errors Metabolism biochemistry form
Cortisol 1ml, Lithium Heparin, non gel
Acylcarnitine** 1ml, Lithium Heparin, non gel Inborn Errors Metabolism biochemistry form
Free Carnitine** 1ml, Lithium Heparin, non gel Inborn Errors Metabolism biochemistry form
Plasma Amino Acids ** 1ml, Lithium Heparin, non gel Inborn Errors Metabolism biochemistry form
**If difficult blood taking, get dried blood spots (Guthrie Card) instead of plasma sample
Growth Hormone 1.5ml, Clotted blood In the setting where history/physical exams suggest
suboptimal growth parameters, hypopituitarism
features
C Peptide 1ml, Clotted blood When suspected inappropriate use of exogenous
insulin e.g. overdose/non accidental use
First urine passed after episode/catheterized urine
Urine Ketone Urine ketostix strip Can still save even after treatment of
hypoglycaemia
Urine Organic Acid 10ml, Plain bottle
Acute Monitoring/Management:
- If conscious:
o Glucose: 0.2g/kg should be given by mouth
[D20: 100ml = 20gram; D10: 100ml = 10gram]
i.e. D20 1ml/kg; D10 2ml/kg; Polycal 10% 2ml/kg
- Set HB with blood taking of critical blood samples
- If unconscious or oral treatment not tolerated:
o IV Dextrose bolus: IV D10 2ml/kg over 20min
o FOLLOWED BY IV D10 + ½ NS (D20 250ml mixed
with NS 250ml) at full maintenance
- Close monitoring of H’stix
Next step:
- Endocrine/metabolic team consultation
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Hypoglycaemia beyond 48 hours of life
Critical sample for recurrent hypoglycemia (in the order of priority)
To be taken when d’stix <3.3mmol/L in babies with persistently high GIR >8mg/kg/min
 Random glucose
 Bedside urine for ketone
 BOHB (1ml Fluoride/oxalate)
 Istat/gas (on ice)
 Insulin (1ml clotted blood)
 Free Fatty Acids (1ml EDTA)
 Ammonia (on ice) (1ml heparinized/no gel)
 Carnitine/Acylcarnitine profile (1ml heparinized/no gel + 3ml clotted blood)
 Cortisol (1ml heparinized/no gel)
 Growth hormone (1.5ml clotted blood)
 Lactate
 Urine organic acids
 +/- Glucagon stimulation test:
 Check d’stix at 0min, then give glucagon 1mg IM/IV for all body weight
 Check d’stix at 10min, 20min, 30min and 40min after glucagon injection
 If glucose increment <1.1mmol/L by 20min: stop the test and resuscitate with IV D10 2ml/kg over
20min and repeat d’stix afterwards
Hyperinsulinism (HI)
Hyperinsulinism (HI) is the commonest causes of recurrent/persistent hypoglycaemia in neonates.
Biochemical features suggestive of HI include:
- Inappropriately detectable insulin and/or c-peptide level at times of hypoglcaema
- Suppressed ketones
- Suppressed free fatty acids
- Positive glycaemic response to glucagon (glucose increment of >1.6mmol/L)
- Ammonia levels could be elevated in hyperinsulinism/hyperammoniemia (HI/HA) syndrome
First Line medical treatment for HI:

- Diazoxide 5-15mg/kg/day in two divided doses
o If the underlying defect is due to a recessive mutation in the K ATP channel,
diazoxide will not work. Common side effects of diazoxide include fluid retention
(hydrochlorothiazide is often initiated with diazoxide), hypertrichosis, and
appetite suppression. Rare side effects include bone marrow suppression,
increases in uric acid, and liver dysfunction. Patients on diazoxide should have a
CBC, LRFT Ca Po4, and uric acid checked annually.  
- Hydrochlorothiazide 2-4mg/kg/day in two divided doses

o RFT should be checked few days after initiation
Discharge plan for patients with HI:

- Safety fast (6-hr for baby on q3h feeds, 8-hr for babies on q4h feeds)
215
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o Check baseline d’stix
o Then give the usual milk feed
o Check d’stix again 3 hours (if q3h feeds) or 4 hours (if q4h feeds) later
o Omit the next milk feed and continue checking d’stix q1h until 3 hours (if q3h
feeds) or 4 hours (if q4h feeds) later
o Check RG and BOHB at the end of a fast
o Resume the next feed at 6th hour (if q3h feeds)/8th hour (if q4h feeds) or at
anytime d’stix <3.5mmol/L
o Definition of passing a safety fast: all d’stix ≥3.5mmol/L
- Glucometer teaching
- Glucagon teaching (0.5mg IMI for all babies)
- Refer dietitian for hypoglycaemia management with 10% polycal (appendix 1)
- Blood glucose logbook
- DM hotline (tel: 22553440)/email ([email protected]) for glucose-related
problems
- Wrapping up by endocrine team before discharge
- Book endocrine clinic follow-up (Monday morning ENC1) in 2 weeks
by Dr. YL Tung
216
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SECTION 4 : UPAM USEFUL TELEPHONE NUMBERS
Paediatric general on-call MO: DECT phone # 1279
Neonatal on-call MO: DECT phone # 1278
PICU on-call MO: DECT phone # 1280
Ward/Office Ext
K7S
3439/ 3440
K7N
3434/3435
K8S Day centre
3450/3451
K8 SCBU
3468/3469
K10S
3480/3481
KGOPD 3237/ 3386 ( Appointment)
3241/3343 ( Nurse)
UPAM office 4482 (Teresa)
UPAM IT Lab 4299/4945
(Clinical photo)
DKCAC 2974 0328
217
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NOTES
218
__________________________________________________________________________________
NOTES
219
__________________________________________________________________________________
220

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Manual for Paediatric Interns and Residents 5th edition

Manual for Paediatric Interns and

The University of Hong Kong

Welcome to the Department of Paediatrics and Adolescent Medicine (UPAM)!

SECTION 1: GENERAL INFORMATION ..................................................................... 5

SECTION 2: PROCEDURES IN PAEDIATRICS........................................................ 20

SECTION 3: COMMON PAEDIATRIC PROBLEMS ................................................ 466

SECTION 3.1: RESPIRATORY SYSTEM ............................................................... 477

SECTION 3.2: INFECTION ...................................................................................... 488

SECTION 3.3: CARDIOLOGY ................................................................................. 755

SECTION 3.5: GENERAL PAEDIATRICS ................................................................. 96

SECTION 3.6 : PAEDIATRIC HAEMATOLOGY & ONCOLOGY......................... 12050

SECTION 3.7 : NEONATOLOGY………………………………………………………..166

SECTION 3.8 : PAEDIATRIC ENDOCRINOLOGY .................................................. 210

SECTION 4 : UPAM USEFUL TELEPHONE NUMBERS ........................................ 217

SECTION 1: GENERAL INFORMATION

II. Out-patient Clinic: in K block, Ground floor

C. Departmental Meetings and educational activities

1. Develop your clinical competence in dealing with common paediatric problems

2. Develop good communication skills.

3. Always respond to calls promptly.

4. Recognize one’s own limitations and know when to seek advice.

5. Maintain good medical practice by continuous learning

6. Be honest and open and act with integrity.

On the following topics:

1. Good partnership with patients and complaints management

When assigning these using ICD9CM codes be specific

For Clinical documentation coding education, please refer to:

Casemix refers to the number and type of patients treated by a hospital

Please refer to: http://fin.home/casemix/CE/0.aspx for more details.

Reporting the Principal diagnosis

• Example 2: The most complex condition is the principal diagnosis

Acute Myocardial Appendicitis & 1. Coronary Bypass Surgery

Reporting secondary diagnosis

• Reference: HA intranet site – see casemix project for more detail

Pitfall in disease coding

e.g. Upper respiratory tract infection 465.9

e.g. Urinary tract infection 599.0

Special point about coding for neonates

Special point for neonates in K8 Day centre

How to arrange S5 follow-up for inborn neonate

1. Input patient’s body weight and height in IPMOE

Own immune status

Indication for Isolation in K7N

Airborne Precaution (negative pressure isolation)

HIV testing: counseling and informed consent

Appendix: Sample of action plan for chicken pox exposure

Index patient: CCC Female/ age (ID 1234567)

Action for patients

LCM 15y ALL - - 25/3-14/4 susceptible

KCH 7y ALL - - 25/3- 12/4 susceptible

YCH 2yr Neuro- - - 27/3- 14/4 Susceptible

Immune group: no special action.

Sick Leave recommendation for children with communicable

Disease Incubation Sick leave recommendation

Investigations and procedures

Consultation to subspecialty teams and other departments

 Consultation to other departments

Category Response time of the department being Your action