Paediatric Manual

PAEDIATRIC
MANUAL
PAEDIATRIC MANUAL
Abdominal Pain - Acute
Key points
Repeated examination is useful to look for the persistence or evolution of signs and evaluate
response to treatment
Analgesia should be used and will not mask potentially serious causes of pain
Investigations are guided by the most likely cause. Most children do not need investigations
True bilious vomiting is dark green and warrants urgent surgical input
Background
The key consideration in acute abdominal pain is the differentiation between surgical and
non-surgical causes
Non-specific abdominal pain is very common but is a diagnosis of exclusion once red flags
are considered
Symptoms in neonates may be attributed by parents as abdominal pain. A thorough

examination and a broad differential should be considered in this group
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Common and time critical causes of abdominal pain by age
Neonates Infants and Children Adolescents
Hirschprung enterocolitis Appendicitis

Abdominal trauma
Incarcerated hernia Abdominal trauma
Appendicitis
Intussusception Cholecystitis/
Constipation
Necrotising enterocolitis Cholelithiasis
Gastroenteritis
Volvulus Constipation
Incarcerated hernia
Ectopic pregnancy
Intussusception
Gastroenteritis
Meckel's diverticulum
Inflammatory bowel disease
Mesenteric adenitis
Ovarian cyst – torsion/rupture
Ovarian torsion
Pancreatitis
Pyloric stenosis
Pelvic Inflammatory Disease
Testicular torsion
Renal calculi
Volvulus
Testicular torsion
Important non-abdominal causes of abdominal pain to consider:
DKA
Headache (Migraine)
Henoch Schonlein Purpura
Hip pathology
Pneumonia
Psychological factors
Sepsis
Sexually transmitted infection

Sickle Cell Disease (vaso-occlusive crisis)
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PAEDIATRIC MANUAL
Toxin exposure or overdose

UTI/pyelonephritis
Assessment
History
Symptoms and signs with associated differential diagnoses (the following diagram is not an
exhaustive list and presentations can overlap)
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Underlying condition Potential complications causing abdominal pain
Hirschprung disease Enterocolitis

(presents with sudden painful abdominal distension and bloody
Cystic fibrosis diarrhoea. These children can rapidly deteriorate with
dehydration, electrolyte disturbances and systemic toxicity and
are at risk of colonic perforation)
Liver disease and/or ascites Primary bacterial peritonitis
Nephrotic syndrome
Splenectomy
VP shunt
Chemotherapy Pancreatitis
On immunosuppressants
PEG / NG / NJ fed
Inflammatory bowel disease Toxic megacolon

(especially if
concurrent Clostridium
difficile)
Immunocompromised
Sickle cell disease Vaso-occlusive crisis (acute painful episodes of abdominal pain)
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PAEDIATRIC MANUAL
Examination
Observe the child's movements, gait, position and level of comfort
Examine the abdomen for:
Focal vs generalised tenderness
Rebound tenderness*
Guarding or rigidity*
Abdominal masses
Distension
Palpable faeces
Assess for non-abdominal causes (list above)
*Peritonism:
Child will often not want to move in the bed and will be unable to walk or hop
comfortably, and will have abdominal tenderness with percussion, internal rotation of
the right hip can irritate an inflamed appendix
Rectal or vaginal examination is rarely indicated in a child, this should be discussed with
a senior clinician and if needed should only be performed once
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Management
Investigations
Most children need no investigations
Investigations to consider, depending on differential diagnosis, may include:
Urine analysis (+/- culture +/- pregnancy test if indicated)
Electrolytes +/- LFTs
lipase for pancreatitis
venous blood gas
blood sugar for DKA
LFTs, lipase and UEC in abdominal injury
Imaging
o AXR if obstruction suspected. It is not helpful in diagnosing constipation
o CXR if pneumonia is suspected
o Ultrasound may be requested after discussion with a senior clinician (very low
yield if used indiscriminately)
 It is not clinically indicated for testicular torsion and may delay time
critical surgery
 May be appropriate in suspected ovarian torsion
 Useful if the history is suggestive of intussusception, even if examination

is normal
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PAEDIATRIC MANUAL
Treatment
Treatment will be guided by the likely aetiology
Fluid resuscitation may be required
Provide adequate analgesia. IV morphine or intranasal fentanyl may be required as

initial analgesia in severe pain
Keep children fasting. Consider enteral or intravenous fluids if assessment or diagnosis

is delayed (consult local fasting guidelines)
Early referral of children with possible diagnoses requiring surgical or gynaecological

management
Consider a nasogastric tube if bowel obstruction is suspected
Consider consultation with local paediatric / surgical team when
Surgical cause suspected
Severe pain not responding to analgesia
Child requiring admission
Consider transfer when
Child requires care beyond the comfort level of the local hospital
Note: Prior to transferring infants or children with possible surgical conditions, ensure the
child has adequate analgesia, venous access and intravenous fluids
Consider discharge when
There are no concerning clinical features
Presentation consistent with non-specific abdominal pain (see Additional notes below)
A clear follow-up plan has been arranged, often with a local GP
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Parents have been given advice regarding when to seek medical attention
Additional notes
Appendicitis in young children
Often a late diagnosis
May not present with classical symptoms
Often presents as perforation or sepsis
Requires careful attention to fluid and antibiotic management
Non-specific abdominal pain
Some children suffer recurrent non-specific abdominal pain, with no organic cause
identifiable
Occurs in 10-15% of children (usually primary school aged)
Diagnosis can only be made if pain remits completely and there is no associated vomiting,
fever and change in bowel habit or oral intake
Psychological factors (eg family, school or other stressful issues) need to be considered in
some cases
Investigations are usually not indicated
Non-pharmacological measures (reassurance, relaxation, rubbing and heat packs) can be

tried and often help
Follow-up is important. Consider outpatient general paediatric / adolescent referral
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PAEDIATRIC MANUAL
Acceptable Ranges for Physiological Variables
Key points
The table below provides acceptable ranges for systolic BP, heart rate and respiratory rate
for unwell children
Patterns of change in physiological variables are as important as the thresholds shown here
Background
There are many publications giving normal or acceptable ranges for physiological variables in
children
Published values are quite disparate and probably reflect differing populations and
assessment methods
Assessment
The pattern of change in variables is often more important than the value itself. For
example, a heart rate that is steadily rising through the acceptable range should trigger
attention
Repeated observations are essential
Look at previous measurements in the same child, earlier in the admission, or during
prior admissions
Consider measurements in the clinical context of the child
These values are generally the 5th and 95th percentile values for each paediatric variable,
rounded to more workable values
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Acceptable ranges for physiological variables
Approximate Systolic Heart Respiratory

Age
Weight (kg) BP (mmHg) Rate (Beats/min) Rate (Breaths/min)
Term 3.5 60-95 120-185 25-60
3 months 6 60-105 115-180 25-60
6 months 8 75-105 110-180 20-55
1 year 10 70-105 105-180 20-45
2 years 12 70-105 95-175 20-40
4 years 15 75-110 80-150 17-30
6 years 20 80-115 75-140 16-30
8 years 25 80-115 70-130 16-30
10 years 30 85-120 60-130 15-25
12 years 40 90-120 65-120 15-25
14 years 50 90-125 60-115 14-25
16 years 60 90-130 60-115 14-25
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17+ years 65 90- 135 60-115 14-25
Acquired Torticollis
Key Points
If torticollis occurs in setting of trauma, manage as Cervical spine assessment
If the child has signs of fever, infection or abnormal neurology, appropriate imaging should
be performed to establish a cause
Most children will have a muscular torticollis and can be managed with simple analgesia
Background
Torticollis (twisted neck), is a non-specific sign with a large spectrum of aetiologies
Causes of acquired torticollis include:
Muscle spasm (wry neck)
Trauma: fracture/dislocation, spinal haematoma
Atlantoaxial rotary subluxation/fixation
Infection: head and neck, spine, CNS or upper lobe chest
Inflammation: juvenile idiopathic arthritis
Neoplasm: CNS (posterior fossa) and bone tumours
Dystonic syndromes (idiopathic spasmodic torticollis, drug reactions)
Ocular dysfunction
Benign paroxysmal torticollis
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PAEDIATRIC MANUAL
Assessment
Red flag features in Red
History
Time course: uncomplicated acute torticollis should resolve within 7-10 days
History of awkward position eg recent flight, different sleeping arrangement
History of trauma
Infective symptoms: fever, increased drooling, sore throat, dysphagia
Neurological symptoms: headache, strabismus, diplopia, photophobia, ataxia
Medications associated with acute dystonic reactions e.g. metoclopramide
Examination
Midline tenderness, general neck palpation and attempt active ROM
Location of tenderness may assist with diagnosis, however deep pathology (eg infection) may
have no external signs
Neurologic examination
Ophthalmologic examination
ENT examination including dentition and lymph nodes
Chest examination
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PAEDIATRIC MANUAL
Management
Investigations
Consider:
Cervical Spine X-ray: particularly if there is cervical spine tenderness, severe pain,
persistent symptoms (≥1 week) or the child has a risk of atlantoaxial instability (eg
Down syndrome, Morquio syndrome, Larsen syndrome, Marfan syndrome)
CT neck and/or the brain if:
o Associated neurological symptoms are present
o Severe pain is not alleviated by analgesia or relaxants
o Bone anomaly is suspected clinically or abnormal cervical xray
o There is suspicion of a retropharyngeal abscess
Depending on the presentation, consultation with, general medicine, orthopaedics, ENT,

ophthalmology or neurology will help with decisions about imaging
Treatment
For most children, heat pack, massage and basic analgesia is appropriate treatment
Diazepam can be effective with some cases of spasm of the sternocleidomastoid
Management depends on suspected cause
Stabilisation may be required
Infectious cause: appropriate antibiotic therapy
Refer to ENT if a retropharyngeal or parapharyngeal abscess is suspected
Atlantoaxial rotatory fixation: rest, use of a soft collar
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Injury or congenital bony cause: refer to orthopaedics
Dystonic reactions: benztropine
Consider consultation with local paediatric team when
Trauma cases
Deep space infection of the neck suspected
Cause unknown or prolonged symptoms
Child requires care beyond the comfort level of the local provider
No features present on history or examination requiring further investigation
Appropriate follow up arranged: GP/paediatric follow up is advisable in children discharged

from ED with a diagnosis of torticollis
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PAEDIATRIC MANUAL
Acute Asthma
Key points
If unsure if anaphylaxis or asthma, treat as anaphylaxis. Treatment of both is critical
Children <12 months of age presenting with wheeze are likely to have bronchiolitis
Preschoolers should only be given steroids for wheeze that is bronchodilator responsive and
requires admission
Background
Asthma is a chronic inflammatory disease of the airways characterised by reversible airways

obstruction and bronchospasm
Exacerbations in children are often precipitated by a viral infection
Assessment
History
Duration and nature of symptoms
Treatments used (relievers, preventers), treatment adherence and effectiveness
Trigger factors (including upper respiratory tract infection, passive smoking, exercise,
cold air, aero-allergen exposure). Sudden onset of symptoms after insect sting or
ingestion of food/medication may suggest anaphylaxis, and not just asthma
Pattern and course of previous episodes (eg frequency, utilisation of health services,
need for hospitalisation, IV treatment or ICU admission)
Parental understanding of how to provide asthma treatments via metered dose inhaler
(MDI) +/- spacer, the presence and use of an asthma action plan
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Presence of interval symptoms, school attendance and performance, participation in

physical activity
Risk factors for severe disease include
Previous ICU admission
Poor adherence to asthma treatment
Poor control (significant interval symptoms)
Past history of anaphylaxis
Examination
Wheeze is not a good marker of severity
The best measures of severity are general appearance, mental state and work of
breathing (accessory muscle use, recession)
Wheeze intensity, pulsus paradoxus, and peak expiratory flow rate are NOT reliable. A silent
chest with no wheeze may herald imminent respiratory collapse
Initial SpO2 in air, heart rate and ability to talk are helpful but less reliable additional
features
Tachycardia can be a sign of severity but is also a side effect of beta agonists such as
salbutamol
Asymmetry on auscultation is often found due to mucus plugging, but persistent asymmetry
may indicate other causes such as inhaled foreign body or pneumothorax
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Management
Investigation
Chest x-ray is not required in asthma, but persistent asymmetry may indicate other causes
such as foreign body. Also consider in critical asthma or severe asthma that does not respond
to initial treatment
Bloods are rarely performed
Blood gases are distressing and can cause a child with respiratory compromise to
deteriorate further. They are not usually required and the child's clinical state is more
important in guiding treatment
Electrolytes for potassium levels may be indicated when there has been prolonged or
frequent salbutamol use. Hypokalaemia rapidly corrects when salbutamol dosing
reduces Spirometry is not usually required in the assessment of acute asthma in
children. It cannot be reliably performed in children under 6 years old
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PAEDIATRIC MANUAL
Treatment
Children with respiratory distress should have minimal handling
Severity Signs of severity Management
Mild Normal mental state Salbutamol by MDI/spacer - give one dose (see dosing
below) and review after 20 mins. Ensure device /
Subtle or no increased work
technique appropriate. Nebulised salbutamol (5 mg) may
of breathing
be considered in children with severe asthma who
Able to talk normally
cannot coordinate MDI use
Good response:
Discharge on short acting B2-agonist as needed
Provide an Asthma Action Plan (see Resources

section below). Consider overall control and
family's knowledge. Arrange follow-up as
appropriate
Poor response:
Treat as Moderate
Consider oral prednisolone
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Moderate Normal mental state Oxygen (humidified) if SpO2 persistently <90%

Ongoing need for oxygen should be reassessed regularly
Some increased work of
Oxygen may be required for low saturations. DO NOT
breathing
give oxygen for wheeze or increased work of
Tachycardia
breathing. (See Additional notes: SpO2)
Some limitation of ability
Salbutamol by MDI/spacer - 1 dose every 20 min for 1 hr;
to talk
review 10-20 min after 3rd dose to decide on timing of
next dose
Ipratropium by MDI/spacer - 1 dose every 20 min for 1

hr only
Consider oral prednisolone (see below)
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Severe Agitated/distressed Involve senior staff
Moderate-marked increased Oxygen (humidified) as above

work of breathing Salbutamol by MDI/spacer - 1 dose (see below) every 20
Accessory muscle min for 1 hr; review ongoing requirements 10-20 min
use/recession after 3rd dose. If improving, reduce frequency. If no
change, continue 20 minutely
Tachycardia
Nebulised salbutamol (5 mg doses) may be considered in
Marked limitation of ability
children requiring oxygen
to talk
If deteriorating at any stage, treat as critical
Note: wheeze is a poor
predictor of severity Ipratropium by MDI/spacer - 1 dose every 20 minutes for
1 hour only
Oral prednisolone (see below)

If vomiting, give IV corticosteroid
Methylprednisolone 1 mg/kg (max 60 mg) 6

hourly
Hydrocortisone 4 mg/kg (max 300 mg) 6 hourly
If poor response to the above treatment give:
Other signs of Anaphylaxis Magnesium sulfate 50%* (500 mg/mL = 2 mmol/mL)

Dilute to 0.8 mmol/mL (by adding 1.5 mL of sodium
chloride 0.9% to each 1 mL of magnesium sulfate) for
intravenous administration
0.2 mmol/kg over 20 mins (maximum 8 mmol)
If going to ICU, this may be continued with 0.12

mmol/kg/hour by infusion
*Magnesium sulfate 49.3% (493 mg/mL) is used in some
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areas
Be careful with dosage, volumes and concentrations. See

Additional notes below
Aminophylline
Loading dose: 10 mg/kg (max 500 mg) IV over 60 min
Unless markedly improved following loading dose, give
continuous infusion (usually in ICU), or 6 hourly dosing
(usually in ward)
Consider Adrenaline 10 microg/kg or 0.01 mL/kg of

1:1000 (maximum 0.5 mL) IM, into lateral thigh which
should be repeated after 5 min if the child is not
improving
Arrange admission after initial assessment
Critical Confused/drowsy Involve senior staff and consider transfer to an

appropriate children's facility/PICU
Maximal work of breathing
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Accessory muscle Oxygen (humidified)

use/recession Continuous nebulised salbutamol: Place 2 nebules into
Exhaustion nebuliser chamber and give via continuous nebulisation
Marked tachycardia 6 months – 6 years, use 2.5 mg nebules
Unable to talk ≥6 years, use 5 mg nebules
SILENT CHEST: wheeze may Monitor for hypokalaemia and toxicity

be absent if there is poor Nebulised ipratropium added to salbutamol, every 20
air entry minutes for 3 doses only
<6 years old: 250 microg
≥6 years old: 500 microg
Methylprednisolone 1 mg/kg (max 60 mg) IV 6 hourly
Magnesium sulfate as above

Other signs of Anaphylaxis
Aminophylline as above
May also consider IV salbutamol. Limited evidence for

benefit
5-15 microg/kg (max 300 microg) over 10 minutes
Repeat dose if required or follow with IV infusion

1-2 microg/kg/min (max 200 microg/min)
Adjust infusion according to response and heart

rate, increase if necessary, up to 5 microg/kg/min
(max 200 microg/min)
Alternatively, can give the IV infusion as initial

treatment
Aminophylline, magnesium and salbutamol must be given
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via separate IV lines
Consider Adrenaline 10 microg/kg or 0.01 mL/kg of

1:1000 (max 0.5 mL) IM, into lateral thigh which should
be repeated after 5 minutes if the child is not improving
Intensive care admission for respiratory support

(facemask CPAP, BiPAP, or intubation/IPPV) may be
needed
Doses:
Salbutamol (100 mcg/puff) dose:
<6 years old: 6 puffs MDI
6 years or older: 12 puffs MDI
Ipratropium bromide (21 mcg/puff) dose:
<6 years old: 4 puffs MDI
6 years or older: 8 puffs MDI
Oral prednisolone
2 mg/kg (max 60 mg) initially, only continuing with 1 mg/kg daily for further 1-2 days
if there is ongoing need for regular salbutamol
Other management considerations:
If there is any concern about anaphylaxis give adrenaline
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Beware salbutamol toxicity: tachycardia, tachypnoea, metabolic acidosis. Can occur

with both IV and inhaled treatment. Lactate levels are commonly high. Consider
stopping/reducing salbutamol as a trial, if you think this may be the problem
Beware severe hypokalaemia: can occur with frequent Salbutamol use, as this draws
potassium into cells. Consider monitoring potassium levels. If the child is on IV fluids,
consider adding 20-40 mmol of potassium chloride to prevent hypokalaemia in
children likely to require frequent salbutamol
Careful salbutamol dosing
Moderate or severe asthma
Poor response to inhaled salbutamol
Oxygen requirement
Severe or critical asthma requiring intravenous treatment or respiratory support
Children with escalating O2 requirement
Children poorly salbutamol responsive or unable to wean salbutamol requirement
Children requiring care above the level of comfort of the local hospital
Consider discharge from Emergency Department when
One hour after initial assessment, if mild presentation and no risk factors for severe disease
Adequate oxygenation: mild hypoxia (SpO2 90-94) should not preclude discharge if child is
clinically well and has responded well to treatment
Adequate parental education and ability to administer salbutamol via spacer
Adequate oral intake
Discharge requirements:
Observe inhaler and spacer technique
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Give a written action plan with education on reliever use. This can be generated using
the action plan generator
Organise follow-up with a GP and/or paediatrician
Advise parents to seek further medical attention (preferably from their GP) should the
child's condition deteriorate or if there is no significant improvement within 48 hours
Give carers written information (see Parent information), including advice regarding
maximising adherence, reducing exposure to asthma triggers (eg avoidance of tobacco
smoke) and immunisation
Additional notes
IV magnesium sulfate 50% dosing
Check doses carefully
0.1 mmol/kg = 25 mg/kg = 0.05 mL/kg
Check concentrations carefully
0.4 mmol/mL = 100 mg/mL
0.5 mmol/mL = 125 mg/mL
For IV MgSO4 50% 1 mL = 2 mmol = 500 mg
E.g. For a 25 kg child, the dose will be 25 kg x 50 mg/kg (0.1 mL/kg)
= 1250 mg of MgSO4 50%
= 2.5 mL of MgSO4 50%
Thus, total volume = volume MgSO4 50% (mL) + volume of 0.9% sodium chloride (mL)
= 2.5 mL of MgSO4 + 3.75 mL 0.9% sodium chloride
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= 6.25 mL
If going to ICU, Magnesium sulfate may be continued as a 0.12 mmol/kg/hour infusion. Aim
to keep serum magnesium between 1.5 and 2.5 mmol/L
Long term asthma control
The frequency of acute episodes and any interval or persistent symptoms should be reviewed
Specific questions should be asked about sleep disturbance (due to asthma), early morning
symptoms, exercise induced cough or wheeze, easy fatiguability, parental smoking and
frequency of bronchodilator use
Higher body mass index (BMI) may be associated with increased asthma severity
Preventive Treatment
Consider preventive treatment if there are interval or persistent symptoms (more than one
disturbed night per week, difficulty participating in physical activities, or bronchodilator use
on more than one day per week). There is a limited role in children with viral induced
asthma, even with frequent exacerbations
First line treatment: low dose inhaled corticosteroids or leukotriene inhibitors

(montelukast). Combined steroids and long acting beta agonists (eg fluticasone/salmeterol)
should NOT be first line treatment
Careful attention must be paid to the delivery system chosen
Spacers
A spacer device should be used for children of all ages whenever they use a MDI
Small volume spacers are suitable for children of all ages
Small volume spacers should be fitted with a well-sealing face mask for younger children
who cannot reliably seal their lips around the mouthpiece. A mask is usually not needed in
children older than 5 years
Oxygen Saturations
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Oxygen saturation (SpO2) may be reduced in the absence of significant airway obstruction
due to factors such as atelectasis and mucous plugging of airways
SpO2 is purely a measure of oxygenation, which may be preserved in the presence of

deteriorating ventilation (with CO2 retention)
Use humidified oxygen. Indiscriminate use of non-humidified oxygen may also lead to drying
of the upper airways leading to worsening bronchoconstriction. The use of humidified
O2 might mitigate this
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PAEDIATRIC MANUAL
Acute Behavioural Disturbance: Acute Management
Key points
Management should focus on verbal and non-verbal de-escalation and emphasise the child's
safety with carer involvement and existing behaviour or communication plans where
appropriate
Consider underlying neurodevelopmental diagnoses (autism, ADHD) or a history of adverse

childhood experiences
A stepwise approach should be used if pharmacological treatment is required. Physical

restraint should be a last resort, only to facilitate rapidly effective pharmacological
treatment
Background
The most important initial action is to reduce the distress to reduce the behaviour, and to
reduce the risk of harm
Once the distress is reduced, further assessment and specific management of the underlying
cause should occur
Behavioural distress can present and progress in a variety of ways. There are often many
predisposing, precipitating and perpetuating factors that need to be considered in de-
escalation strategies. Behavioural distress and its underlying causes are distinct in children
as compared to adults
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Assessment
History
Are there any underlying neurodevelopmental conditions such as autism, ADHD, receptive
or expressive language delay, intellectual disability or any mental health issues such
as anxiety or depression?
Are there supports already in place: communication tools/aides, behaviour management

plans, sensory considerations? What has worked in the past?
Is there a history of adverse childhood experiences or psychosocial difficulties which may

impact on the flight-fight-freeze response? Children may appear calm when they are actually
in a frozen or dissociated phase
History of episode: recent health/triggers/changes, what has happened today, what has
worked in the past?
Current medications and past adverse reactions. Is there access to medications/toxins?

Consider intoxication with alcohol, illicit drugs or prescribed medication
Could the child be in pain?
Examination
Brief assessment to exclude obvious focal neurology, acutely painful condition or evidence of
a toxidrome
A comprehensive examination should occur once distress has been reduced
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Management
Approach to De-escalating Behavioural Disturbance
Aims Verbal and non-verbal de-escalation is first line intervention
Treat the underlying cause
Debrief the child/family and staff
Involve senior staff early
Environment Private location, remove other children, visitors and staff
A calming space: quiet room, soft/decreased lighting, eliminate triggers for

agitation
Family member presence: on case-by-case basis
Safety: remove weapons, obstacles; be aware of exit to avoid further

escalation and ensure your own safety
One senior staff member communicates with the child and family
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Child The most important initial action is to reduce the behaviour to minimise
distress and any possible risk of harm
Listen and talk simply and in a calm manner
Respect personal space
Check for any child alerts and familiarise yourself with the child's history (eg
previous incidents of agitation, known medical, developmental or behavioural
issues)
Consider child's individual needs including language, cognitive ability or trauma

history
Consider the use, where appropriate, of:
Age-appropriate distraction techniques, familiar toys and objects
Offers of food, drink, icy-pole, or attention to physical needs
Crisis prevention: anticipate and identify early irritable behaviour, consider

past history and involve mental health expertise early for assistance if
appropriate
Offer planned 'collaborative' sedation (eg ask the child if they would take some
oral medication)
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Investigations
Investigations may be necessary to exclude underlying cause
Blood alcohol assessment or urine drug screen if appropriate
Code response
If de-escalation strategies (see table below) are unsuccessful or there are any safety
concerns, a Code Response may be required with appropriate leadership and allocation of
roles
Possible need for sedation
If de-escalation strategies are unsuccessful or there are any concerns for safety, oral or
intramuscular sedation may need to be considered. A stepwise approach should be taken
depending on level of agitation
Consent
Obtaining consent for any medical procedures, including giving sedation, should be sought at
all times, even in unsafe situations, wherever possible
Consent should be ideally sought from the child and/or guardians
Common law recognises that adolescents can give consent if they have capacity
In an unsafe situation when the child or adolescent is a danger to themselves or others, no

consent is necessary, but clinicians should be aware of the relevant duty of care and Mental
Health Act in their jurisdiction
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Acute Behavioural Disturbance Management Flowchart
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Medication Adverse Effects
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Side-effect Medication association Management
Common with benzodiazepines, but also

olanzapine or rapid administration of ketamine
Respiratory Reversible with flumazenil if
Droperidol can potentiate respiratory
depression caused by benzodiazepines
depression if used with opioids or other
sedative medications
Extrapyramidal Common with droperidol but can be seen with

Reversible with benzatropine
reactions olanzapine, risperidone and quetiapine
Neuroleptic Seen with antipsychotics MET/ICU

Malignant Syndrome Check for elevated CK
Can be seen particularly in children with

Paradoxical autism, developmental delay or history of
reactions escalating behaviour – benzodiazepines can
result in increased agitation and anxiety
Post-sedation monitoring
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PAEDIATRIC MANUAL
Appropriate sedation monitoring should be performed in a safe environment within the

clinical setting and assessing for side-effects as listed above
Do not unnecessarily wake or irritate the child further to permit sufficient rest
Alert child should have 30 minutely observations for 2 hours post sedation medication
Agitated children need continuous clinical observation
The child with a low level of consciousness should have appropriate 1:1 support and regular
medical review
Follow local hospital protocols for post-sedation monitoring
Following medication, the child must undergo a medical and mental health assessment to
guide subsequent management
Principles of possible need for restraint
Physical restraint may need to be considered if behaviour poses an imminent risk of harm to
self, others or property
As physical restraint and sedation deprives the child of autonomy, it should only be
contemplated as a last resort
A child who is 'acting out' and who does not need acute medical or psychiatric care
should be discharged from the hospital to a safe environment rather than be restrained
or sedated
Documentation
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Include:
Reasons for sedation (in medical notes)
Medications used: dose and route
What worked? What was unsuccessful?
As applicable, additional documentation may be required to address:
o Code Response
o Patient safety / Local risk incident reporting system
o Staff safety / OHS
o Consent (in investigations section above)
o Mental Health Act (in Additional notes below)
o Restraint Register (NSW)
o Staff safety / OHS
Needing assistance in determining whether acute mental health admission would be

beneficial
Ongoing care of behaviourally disturbed child is required and to ensure appropriate

community follow-up
A child may require admission for treatment of a medical problem causing behavioural
disturbance, or for observation until drug toxicity has resolved
Consider transferring care when
~ 37 ~
PAEDIATRIC MANUAL
Behavioural disturbance is reduced, and child requires transfer to a tertiary mental health
centre (to be facilitated by local mental health clinicians)
Complications from sedation medication
Child requires care beyond the comfort level of the hospital
Behavioural distress has reduced or resolved
Significant medical or psychiatric illness is excluded
Any identified underlying cause treated
Carers are capable of and willing to take the child home
A clear plan for medical and/or mental health follow-up is in place
Additional Notes
The polyvagal theory of response
The polyvagal theory proposes that the evolution of the mammalian autonomic nervous
system provides the neurophysiological substrates for adaptive behavioral strategies. It
further proposes that physiological state limits the range of behavior and psychological
experience
~ 38 ~
PAEDIATRIC MANUAL
The theory links the evolution of the autonomic nervous system to affective experience,
emotional expression, facial gestures, vocal communication, and contingent social behavior.
In this way, the theory provides a plausible explanation for the reported covariation
between atypical autonomic regulation (eg, reduced vagal and increased sympathetic
influences to the heart) and psychiatric and behavioral disorders that involve difficulties in
regulating appropriate social, emotional, and communication behaviors
The polyvagal theory provides several insights into the adaptive nature of physiological
state. First, the theory emphasizes that physiological states support different classes of
behavior. For example, a physiological state characterized by a vagal withdrawal would
support the mobilization behaviors of fight and flight. In contrast, a physiological state
characterized by increased vagal influence on the heart (via myelinated vagal pathways
originating in the nucleus ambiguus) would support spontaneous social engagement
behaviors. Second, the theory emphasizes the formation of an integrated social engagement
system through functional and structural links between neural control of the striated
muscles of the face and the smooth muscles of the viscera. Third, the polyvagal theory
proposes a mechanism—neuroception—to trigger or to inhibit defense strategies
~ 39 ~
PAEDIATRIC MANUAL
Acute Behavioural Disturbance: Code Response
Key points
The procedure should emphasise safety and non-restraint strategies in the first instance
The Code Response team should perform this procedure
Any physical restraint is a last resort, and should only be used to facilitate rapidly effective
pharmacological treatment
The terms Code Grey and Code Black are used interchangeably across states; here we refer
to Code Response as a universal approach
Background
Principles
Physical restraint should only be used to facilitate rapidly effective pharmacological

treatment
A key principle of medical ethics is that a child's autonomy should be respected. As physical
restraint and sedation deprives the child of autonomy, it should only be contemplated as a
last resort
A child who is 'acting out' and who does not need acute medical or psychiatric care should be
discharged from the hospital to a safe environment rather than be restrained
When physical restraint is required, a coordinated team approach is essential, with roles
clearly defined and swift action taken. Staff members should never attempt to restrain the
child without the Code response team resource on hand
~ 40 ~
PAEDIATRIC MANUAL
Management
Alternative means of calming a child
Crisis prevention: Anticipate and identify early irritable behaviour (and past history). Involve
mental health expertise early for assistance
Provide a safe 'containing' environment. This includes a confident reassuring approach by

staff without added stimuli
Listen and talk simply and in a calm manner
Offer planned 'collaborative' sedation (eg ask the child if they would take some oral
medication to reduce behavioural distress)
Emergency sedation
Indications for emergency sedation and physical restraint
Physical restraint should only be used to facilitate rapidly effective pharmacological

treatment
Cautions and contraindications to physical restraint and emergency sedation
A child who is 'acting out' and who does not need acute medical or psychiatric
care should be discharged from the hospital to a safe environment (home, police,
child protective care) rather than be restrained
Be aware of previous medications and possible substance use
Safe containment is possible via alternative means (including voluntary, collaborative

oral sedation)
Inadequate personnel/unsafe setting/inadequate equipment
Situation judged as too dangerous eg the child has a weapon
~ 41 ~
PAEDIATRIC MANUAL
Consent
Obtaining consent for any medical procedures including giving sedation and any further
intervention should be sought at all times, even in unsafe situations wherever possible
Consent should be ideally sought from the child and/or guardians
Common law recognises that adolescents can give consent if they have capacity
In an unsafe setting when the child or adolescent is a danger to themselves or others, no

consent is necessary but clinicians should be aware of the relevant Mental Health Act in
their jurisdiction
Procedure
The Code response team should perform this procedure
Team leader will designate roles before approaching child
All members should ensure own safety, with gloves and goggles
Draw up medication
Secure the child quickly and calmly using the least possible force. At least five people are
required
The child should be held supine
Prone positions should be avoided as they are dangerous, causing increased risk of
asphyxiation
Administer the medications by intramuscular injection into the lateral thigh (other options -
ventrogluteal or dorsogluteal). Beware of the risk of needle stick injury. Further titrated
doses of medication may be required depending on clinical response (If medication can be
given IV this may be an option if the child is safe to cannulate)
Post sedation care
~ 42 ~
PAEDIATRIC MANUAL
A child who has needed emergency restraint and sedation may also require mechanical
restraint in extremely rare circumstances. Not all emergency departments support this
practice. It should not occur without specialist mental health input and presence
Code response procedure
Complications of physical restraints include
~ 43 ~
PAEDIATRIC MANUAL
Pressure effects of physical restraints
Complications of being held supine: respiratory depression, risk of asphyxiation, inability to

clear vomitus from airway
Ongoing care
Following restraint, the child must undergo a detailed medical and mental health assessment
to guide subsequent management
In some cases, recommendation and transfer to an inpatient mental health facility may be
required
The need for sedation should be reviewed on an ongoing basis and the child should be cared
for in the least restrictive modality so as to provide safety
Physical restraints should be used only for administration of medication
As the sedation wears off, the child's risk status should be carefully monitored throughout
the entire process
Documentation
Document fully in the child's medical record and medication chart when appropriate:
The child's response to sedation and complications thereof
On-going observations documented at least 15 minutely
Time and length of physical restrain when giving medication
There may be a specific code response reporting form
Defusing and debriefing
The need to physically restrain a behaviourally distressed child can be extremely distressing
for staff involved
A critical incident stress debriefing session may be required
It is ideally chaired by an objective facilitator who was not involved in the restraint process.
See your health service’s Human Resources Employee Assistance Program (EAP)
~ 44 ~
PAEDIATRIC MANUAL
Children require ongoing observation or stabilisation of an underlying medical cause eg

resolution of drug toxicity
Local mental health clinicians are involved in the ongoing care of behaviourally distressed
children
The behavioural disturbance is reduced, some children will require transfer to a tertiary
mental health facility
There are complications from sedation
Child requires care beyond the comfort level of the hospital
~ 45 ~
PAEDIATRIC MANUAL
Acute Eye Injury
Background
Serious eye injuries can be under-appreciated when children present with a painful eye or
blurred vision
The following traumatic conditions threaten vision:
Ruptured globe
FB- either intraocular or deep corneal
Large hyphaemas (causing acute glaucoma)
Retinal detachment
Corneal burns, either chemical or thermal- alkalis penetrate deeper and have greater
potential for serious and delayed burns
Contact lens-related corneal infections (bacterial keratitis)
Assessment
History
When assessing the painful eye, the following questions should be asked
Proximity to chemicals or high velocity projectiles (particularly lawn-mowers, power

tools, hammering or motor vehicle accidents)
Prolonged contact lenses use
Pain, foreign body sensation, tearing or photophobia
Visual disturbance, either temporary or persisting, including flashes (retinal

detachment) or floaters (intra-ocular) in vision
Eye discharge
~ 46 ~
PAEDIATRIC MANUAL
First aid provided
Eye examination
If an adequate examination is not possible due either to the child's age or cooperation level,
specialist assistance should be sought
Adequate analgesia will aid assessment. Topical anaesthetic such as amethocaine 1%

(one drop) may be used once in the emergency department (local anaesthetic causes
direct epithelial toxicity and should not be used repeatedly)
Globe
For obvious penetrating eye injuries
Signs of potential globe rupture or perforation
o Severe loss of vision or loss of red reflex
o Loss of ocular motility
o Asymmetric pupil
o Hyphaema
o Distorted appearance of globe
o Localised conj. haemorrhage or chemosis (bulging of the conjunctiva)
Eye movements
Exclude entrapment of extraocular muscles with orbital fractures
Fields
Four quadrant confrontation testing in older children. Traumatic visual field loss is usually
gross, however subtle changes may occasionally occur with retinal detachment and intra-
ocular FB
~ 47 ~
PAEDIATRIC MANUAL
Visual Acuity
Use age-appropriate charts and the patient's normal corrective lenses or pinhole
Snellen charts: from school-age
'E' chart: useful from about 3 years of age
Kay picture book (available in ED), useful from 2-3 years of age
Fingers or fix and follow, <2- 3 years of age
A young child may become distressed if the 'good' eye is occluded
Test each eye separately, then together (for diplopia) with appropriate chart
A difference of greater than 2 lines (on an eye chart) between the eyes is likely to be
significant
Lids, conjunctiva and sclera
Examine the lids including the undersides for trauma and foreign bodies. A topical
anaesthetic may aid examination
For lid lacerations, examine to exclude full-thickness laceration and penetration of globe
Subconjunctival haemorrhage- if localised, may suggest penetrating injury (but can be due
to valsalva manoeuvre). If the posterior extent of the haemorrhage cannot be visualised, an
orbital or base of skull fracture is possible
Cornea, Anterior Chamber, Iris and Pupil
Before fluoroscein: Look for pupillary light reflex, pupil shape and size, symmetry with other
eye, presence of hyphema or cloudy cornea (prior to blood settling) or epithelial defects
After fluoroscein: For corneal, conjunctival abrasions or lacerations (apply fluoroscein 1

drop to each eye, or for strips- wet strip and touch to lower lid only)
Look particularly for vertically-linear corneal abrasions, as these particularly suggest a FB

under the upper-lid
~ 48 ~
PAEDIATRIC MANUAL
Fundus
Vitreous haemorrhage can cause diminished red reflex, difficulty visualising fundus or red
splotches on retina
Retinal detachment may be seen as a grey flap out of focus with optic disc on direct
ophthalmoscopy
Management
For potential blunt or penetrating eye injuries, see flow chart below and penetrating eye
injury
Corneal abrasions/ Foreign bodies
If very large or deep defect seen, presume full thickness
Exclude foreign body, including under eyelid
Avoid removing large, deep or central corneal foreign bodies, refer these to ophthalmology
Gently use moistened cotton bud for small superficial FB. A small gauge needle may be used
in older, cooperative children, using slit lamp with approach to the patient from the
temporal aspect of the eye
Chloramphenicol ointment/ drops
Pad the eye for four hours (to prevent accidental further eye injury due to anaesthetic
effect). Occasionally, prolonged eye pad may help ease pain, but be aware not to apply too
tightly as this can impair epithelial healing
Cycloplegic eye drops (cyclopentolate 1% or homatropine 2%) can be used for relief of a very
painful eye
Patients need daily review until corneal ulceration healed
Corneal burns
Discuss all eye burns with the ophthalmologist
~ 49 ~
PAEDIATRIC MANUAL
Chemical (strong acid/ alkali)
Urgent, copious irrigation, after local anaesthetic, including under top lid. Use 3 litres of N.
saline through an open giving set over about 15 minutes and until pH normal (6-8). A urine
dipstick can be used to measure tear pH (carefully trimmed to the pH marker, avoiding
sharp edges of the strip). Sedation or urgent GA may be required
Particulate alkaline matter needs urgent, total removal
Thermal burns
If corneal damage present, manage as for other corneal abrasions
Contact lens associated red eye
Anaesthetise eye and remove contact lenses if possible
Stain eye and check for corneal abrasions or FB
Swab if discharge present- Gram-negatives including P. aeruginosa are frequently the cause,
thus requiring broader-spectrum antibiotics
If ulcer identified refer urgently to ophthalmology, and discuss other patients with
Ophthalmology prior to discharge
Start topical antibiotics and arrange for follow-up
~ 50 ~
PAEDIATRIC MANUAL
Acute eye injuries in children-flow chart
~ 51 ~
PAEDIATRIC MANUAL
Acute Management of An Oesophageal Variceal Bleed
Introduction
Oesophageal variceal bleeds (and indeed any variceal bleeds) are a rare but serious
complication of portal hypertension. Portal hypertension is defined by an increase in
pressure within the portal circulatory system. This increase is caused by vascular resistance
in blood flow through the liver. In RCH’s patient population, portal hypertension is
frequently a result of biliary atresia, but it can also be a manifestation of post-hepatic, pre-
hepatic (eg portal vein obstruction), or other intra-hepatic problems such as cystic fibrosis,
congenital hepatic fibrosis or other cirrhosis. With increased resistance in the portal vascular
system, blood begins to shunt through collateral systemic vessels to return to the vena cava.
Prolonged elevation in portal vein pressure causes dilatation of the collateral vessels, which
can form internal haemorrhoids at the rectum, caput medusae at the umbilicus and varices
in the fragile gastro-oesophageal veins. Ruptures occur when the variceal wall tension
exceeds the wall strength. Children with liver disease also have liver dysfunction, which
results in clotting cascade problems and a deficit in Vitamin K-dependent factors. This adds
to the risk of significant haemorrhage in this patient group
In several large studies of children with portal hypertension, approximately 2/3 presented
with haematemesis or melaena, usually from rupture of an oesophageal varix. Twenty to
thirty percent of children with biliary atresia have variceal bleeds and they tend to develop
varices early, with an estimated risk of bleeding of 15% before the age of two. Mortality
rates associated with large bleeds range from 0-15%
Aim
The aim of this guideline is to assist nurses and other health professionals in the acute
management of infants and children experiencing an oesophageal variceal bleed. The
guideline will also outline ongoing assessment and adjunctive therapies for the ongoing care
of this patient group
~ 52 ~
PAEDIATRIC MANUAL
Definition of Terms
ANTT – Aseptic Non-touch technique
NGT – Nasogastric tube
PPIs – Proton pump inhibitors (eg., omeprazole, pantoprazole)
RBC –Red blood cells
TIPSS – Transjugular Intrahepatic Porto-Systemic Shunt
Assessment – ABCDE
Initial acute
Airway – Does the patient have a patent airway? Are they at significant risk of losing their
airway?
Breathing – Respiratory rate, oximetry, respiratory effort, air entry?
Circulation – Heart rate, blood pressure, central and peripheral capillary refill time? IV
access? How much blood is the patient losing?
Disability: Level of consciousness? Are they distressed? Irritable (consider encephalopathy)?

Are they in pain? Are they febrile? Receiving antibiotics? Antihypertensives? Clotting agents?
PPIs? Have they had recent endoscopy?
Gastrointestinal: Are they vomiting blood (fresh or coffee ground)? Is there fresh (bright) or
old (dark) blood in their stool? How much? Is the patient known to have varices? Do they
have a history of bleeding? Do they have an NGT insitu? Is their abdomen more distended
than usual? Do they have ascites? Do they have protruding umbilical veins?
Investigations
FBE, UEC, VBG, Coagulation Screen, Group & hold, blood cultures, BGL, ammonia.
~ 53 ~
PAEDIATRIC MANUAL
Social history/issues
Is there any family present? Have they been contacted?
Has caregiver consent for theatre or blood transfusion been obtained?
What are the education needs (patient and caregiver)?
Management
Acute management
Seek urgent medical/ ICU review/ MET
Protect airway, support breathing as required. Give oxygen to patients with significant
circulatory impairment or shock
Secure large bore IV access
Consider need to activate Massive Transfusion Procedure
Correct hypovolaemia, remembering the potential for harm with excessive fluid
administration (no more than 20ml/kg NaCl bolus then albumin, RBCs if Hb <70g/L).
Maintain strict fluid balance
Consider vasoactive therapy (Octreotide, 1-2mcg/kg bolus followed by 1-5mcg/kg/hr, max

1.5mg/kg/day). Always discuss with a fellow or consultant before commencing vasoactive
therapy
Continuous cardio respiratory monitoring
Biochemistry investigations
If NGT insitu, place on free drainage. Do NOT aspirate. NGT should only be inserted under
endoscopic guidance or with gastroenterologist consent
Consider prophylatic intravenous antibiotics
Consider treating coagulopathies (vitamin K, platelets, cryoprecipitate and FFP)
~ 54 ~
PAEDIATRIC MANUAL
If bleeding is ongoing and uncontrollable, patient will require Balloon Tamponade (Foleys
Catheter if child <15kg or Sengstaken Blakemore tube if child >15kg). This will ideally be
performed in the ICU or theatre environment
Transfer to ICU or theatre for management as clinically appropriate
Post Resuscitation Care
Continuous cardio respiratory monitoring
Monitor bloods as clinically indicated (FBE, UEC, albumin, coags, ammonia, BGLs Patients
receiving octreotide should have 4-6/24 BGLs monitoring)
Gut rest may be ordered
Adjunctive (Non-acute) Therapies
Diagnostic and surveillance endoscopy by gastroenterology team ±Sclerotherapy or Variceal

Ligation
TIPPS or other surgical shunts if clinically indicated
Prophylactic PPIs and beta-blockers
Existing NGT should be left in-situ and only removed in the ICU or surgical environment
The Liver and Transplant Clinical Nurse Consultant will lead education and support for
patients and caregivers. Reinforcement will be provided by ward nurses. General advice to
parents: new medication actions, side effects, what concerns caregivers should report to the
health care team
Safety initiatives
ANTT for CVAD management
Contact precautions for body fluid exposure
Blood transfusion safety adherence
~ 55 ~
PAEDIATRIC MANUAL
Algorithm
~ 56 ~
PAEDIATRIC MANUAL
Acute Meningococcal Disease
Key Points
IV ceftriaxone/cefotaxime should be given as soon as meningococcal disease is suspected. If

unavailable, give penicillin
If IV access cannot be obtained within 15 minutes, administer IM or IO
Collect blood cultures prior to antibiotics if possible, but do not delay antibiotic
administration
Background
Acute meningococcal disease may present as severe sepsis with a progressive non-blanching
petechial/purpuric rash, or meningitis with or without a rash
Rarer presentations include septic arthritis, pneumonia, pharyngitis and occult bacteraemia
There are 13 serogroups of Neisseria meningitidis (the cause of meningococcal disease) in

Australia - the 5 most common are A, B, C, W and Y
Assessment
Red flags in red
History
Rapid onset (<12 hours) of headache, loss of appetite, nausea, vomiting, sore throat and
coryza
Fever
Infants may have reduced feeds, irritability
Leg pain or myalgia
~ 57 ~
PAEDIATRIC MANUAL
Examination
Signs of sepsis
Abnormal skin colour (pallor or mottling) and/or cool peripheries
Late signs (>12 hours)
Altered conscious state
Neck stiffness, headache, photophobia, bulging fontanelle
Non-blanching rash: petechiae/purpura
Note: a blanching rash does not exclude meningococcal disease (can initially be macular or
maculopapular)
~ 58 ~
PAEDIATRIC MANUAL
Management
Investigations
Investigations should NOT delay antibiotic administration
Blood (or IO)
Culture: should be obtained prior to antibiotic administration if possible.
PCR (separate EDTA tube, minimum volume 0.2 mL)
CSF (once initially stabilised and no contraindication to lumbar puncture): Gram stain (Gram
negative diplococci), biochemistry, culture, and meningococcal PCR
Treatment
Resuscitate as appropriate
Antimicrobial recommendations may vary according to local antimicrobial susceptibility

patterns
Administer:
Ceftriaxone 100 mg/kg (4 g) IV daily or 50 mg/kg (2 g) IV 12H or cefotaxime 50 mg/kg

(2 g) IV 12H (week 1 of life), 6-8H (week 2-4 of life), 6H (>week 4 of life)
If no IV/IO access, give IM (may need two injections due to volume/muscle

size and repeat the dose once IV access available)
If ceftriaxone/cefotaxime unavailable, administer Benzylpenicillin 60 mg/kg IV 12H

(week 1 of life) 6H (week 2–4 of life) 4H (>week 4 of life) (max 2.4 g)
If meningococcal infection is not yet confirmed treat as per Sepsis
Duration of antibiotics is 5 days
~ 59 ~
PAEDIATRIC MANUAL
Ward management / other treatment considerations
Isolation
Meningococcal disease is spread person-to-person by respiratory droplets.

Patients should be isolated and droplet precautions continued for 24 hours after
administration of appropriate antibiotics.
Notification
All cases of presumed or confirmed meningococcal disease require immediate

notification to the local state authority
Chemoprophylaxis
Chemoprophylaxis should be given to contacts as soon as possible
Vaccination
MenB vaccine
MenC vaccine
Hib-MenC vaccine (combined with Haemophilus influenzae type b)
MenACWY (quadrivalent) vaccine
Meningococcal B and ACWY immunisations are recommended as per the Australian

Immunisation handbook. MenACWY vaccine has been provided free through the
National Immunisation Program (NIP) to all children since 2018. From July 2020 the
meningococcal B vaccine is also provided free to Aboriginal and Torres Strait Islander
children. There is currently no vaccine against serogroup X
~ 60 ~
PAEDIATRIC MANUAL
All cases of suspected meningococcal disease in children
All cases of acute meningococcal disease should be managed in a facility with the capacity
to provide intensive care
If these facilities are unavailable, the patient should be stabilised and transferred as
appropriate
Acute Otitis Media
Key Points
~ 61 ~
PAEDIATRIC MANUAL
Do not accept otitis media as the sole diagnosis in a sick febrile young child without
exclusion of more serious causes
Diagnosis requires acute onset and an abnormal ear examination with signs of middle ear
inflammation and middle ear effusion
Avoid the routine use of antibiotic treatment for acute otitis media
Background
Acute Otitis Media (AOM) is a common problem in early childhood
75% of children have at least one episode by school age
Peak age prevalence is 6-18 months
Causes of acute otitis media are often multifactorial. Exposure to cigarette smoke from
household contacts is a known modifiable risk factor
Assessment
History
Recent onset ear pain (irritability in pre-verbal children)
Fever
Loss of appetite
Vomiting
Lethargy
Cochlear implant
Immunocompromise
Examination
Systemically unwell
~ 62 ~
PAEDIATRIC MANUAL
Ear examination:
Signs of acute inflammation of the tympanic membrane (TM): bulging, red, opaque TM
A red TM alone is not AOM. The most common cause is a viral upper respiratory
tract infection (URTI)
Otoscopic Images of Tympanic Membranes (TM):
Normal Tympanic Membrane
TM is translucent
The handle of the malleus is vertical
No erythema
Injected Tympanic Membrane
Pink/red TM
Often seen with fever, eustachian tube

obstruction or viral URTI
TM is transparent (there is no middle ear

effusion)
The handle of the malleus is well seen and is

more horizontal
~ 63 ~
PAEDIATRIC MANUAL
Bulging and red tympanic membrane in

AOM
Loss of the TM landmarks, especially the

handle of the malleus
TM is opaque, may be red from inflammation

or white from pus in the middle ear
Otitis Media with Effusion (OME) “glue ear”
TM is retracted with prominence of the

handle of the malleus, which is also drawn
in/more horizontal
TM may be bulging or have an air-fluid level

behind the TM
Yellow/amber appearance is consistent with

fluid
Light reflex on otoscopic examination
Perforated Tympanic Membrane with

otorrhoea
~ 64 ~
PAEDIATRIC MANUAL
Otitis Externa
Ear is tender to examine
Skin of the external ear canal is swollen and

there can be thin pus
Management
In Infants, especially <6 months old, the diagnosis of AOM and OME can be inaccurate. Other
diagnoses should be fully considered
Management may also differ for children from higher risk groups, such as those living in
Aboriginal or Torres Strait Islander communities
Investigations
There is no role for routine diagnostic investigation for AOM
Diagnostic imaging such as CT and MRI is usually only required in children with suspected
intracranial complications
Treatment
Most cases of AOM in children resolve spontaneously and antibiotics are not recommended
Treat pain with adequate and regular simple analgesia
As an adjunct, short-term use of topical analgesia eg 2% lignocaine, 1-2 drops applied to

an intact tympanic membrane, may be effective for severe acute ear pain
Decongestants, antihistamines and corticosteroids are not effective in AOM
~ 65 ~
PAEDIATRIC MANUAL
Complications
~ 66 ~
PAEDIATRIC MANUAL
Tympanic membrane perforation
AOM with TM perforation is common and results in otorrhoea and frequently, relief of pain
Otorrhoea due to TM perforation should be distinguished from Otitis Externa
Acute Mastoiditis (AM)
Acute mastoiditis, although rare, is the most common suppurative complication of AOM and
may be associated with intracranial complications
The diagnosis of AM is based on post auricular inflammatory signs (erythema, oedema,

tenderness or fluctuance), a protruding auricle often with external auditory canal oedema
and signs of AOM
Requires prompt treatment with appropriate intravenous antibiotics (e.g. flucloxacillin plus
3rd generation cephalosporin)
Consult ENT as may require surgical treatment
Acute mastoiditis
Other complications
Other suppurative complications including intracranial spread of infection are rare
Facial nerve palsy secondary to AOM should be discussed with ENT
Long-term non suppurative complications include atelectasis of the TM and cholesteatoma
Otitis Media with Effusion (OME)
~ 67 ~
PAEDIATRIC MANUAL
OME, previously termed serous otitis or glue ear, is fluid in the middle ear without signs and
symptoms of infection, other than transient hearing impairment
The presence of a middle ear effusion is not a diagnostic sign of AOM (an effusion may not
resolve for up to 12 weeks following AOM)
Antibiotics and ENT referral are not routinely required for OME, as the majority of cases
occur after an episode of AOM and resolve spontaneously with no long-term effects on
language, literacy or cognitive development
Persistent effusion beyond 3 months should trigger a hearing assessment and ENT
involvement/referral
Children who are systemically unwell
Neonates
Children with signs of acute mastoiditis or who have a cochlear implant should be discussed
with ENT
Children requiring care beyond the level of comfort of the local hospital
No signs of complications
~ 68 ~
PAEDIATRIC MANUAL
Acute Pain Management
Key points
The key to effective acute pain management is regular assessment of pain and response to
interventions
Multi-modal strategies following a step-wise approach should be used to provide pain relief
to children
Background
Pain is difficult to differentiate from anxiety and distress, especially in the pre-verbal or
non-verbal child. It is therefore important to consider a child’s cognitive ability,
environment and cause of pain
Under-treated pain has a lasting impact on a child’s experience of pain and subsequent
medical encounters
Assessment
Use self-reporting to measure pain where possible
Take into account parental report of pain and previously successful pain management
strategies
~ 69 ~
PAEDIATRIC MANUAL
Management
Multi-modal strategies combining non-pharmacological and pharmacological methods are

most effective
When pain is constant, prescribe analgesia at regular intervals as opposed to “as needed”
Non-pharmacological methods
Age appropriate techniques should be used in all children with pain
These include:
Parental presence and comforting touch when possible
Engaging child life specialist if available or using distraction therapy (eg video, music,
toys, blowing bubbles, storytelling by the child, counting)
Swaddling, feeding, skin to skin care and dummy use for infants
Breathing techniques
In the case of injuries, useful strategies include:
Immediate immobilisation for potential fractures
Applying ice and elevating injured limbs
Prompt dressing of burns
Pharmacological agents
Use a stepwise approach to guide pain management with plan to escalate agents according
to pain severity
~ 70 ~
PAEDIATRIC MANUAL
Analgesic Route Dose Maximum dosing Notes
Mild to moderate pain
Children 0–18 months

(most effective in
<3 months: younger children)
5 mL/day Provide dose 2
Sucrose oral 0.1–0.5 mL increments
≥3 months: minutes prior to
10 mL/day painful procedure
(with dummy if
available)
and / or
Paracetamo Birth - 1 month:

l 60 mg/kg/day Dose on IBW
15 mg/kg (max 1 g)
oral >1 month: Dose commercial
4–6 hourly
90 mg/kg (up to 4 syrup carefully
g/day)
PR 15–20 mg/kg (max 1 g) Birth - 1 month: If oral not tolerated

6 hourly Dose on IDW
60 mg/kg/day
125 mg, 250 mg, 500
> 1 month:
mg suppositories
90 mg/kg (up to 4
PR medication should
g/day)
be avoided in
immunocompromised
children
~ 71 ~
PAEDIATRIC MANUAL
If oral/PR not
tolerated
< 1 month:
<1 month Dose on ideal body
10 mg/kg 6 hourly 40 mg/kg/day weight
IV >1 month > 1 month: Dose (mg) and volume
15 mg/kg 6 hourly (mL) errors have
60 mg/kg (up to 4
(max 1 g) caused significant
g/day)
overdoses in young
children
and / or
Precautions include
renal impairment,
dehydration, bleeding
>3 months: and anticoagulant use
10 mg/kg 30 mg/kg (up to 2.4 Asthma is not a
Ibuprofen oral
(max 400 mg) g/day) contraindication
6–8 hourly with food Dose commercial
syrup carefully as
available in several
strengths
Moderate to severe pain
~ 72 ~
PAEDIATRIC MANUAL
Use medications above, and consider adding the following
For short term use

Do not prescribe for
1–12 months: 0.05–0.1
outpatient use if no
mg/kg,
5–10 mg clear diagnosis
Oxycodone oral >12 months:
4 hourly Higher / more
0.1–0.2 mg/kg
frequent dosing can
4 hourly
be used in inpatient
settings
Or
Cumulative maximum
<1 month:
Higher / more
0.05 mg/kg 0.1 mg/kg 4–6 hourly
frequent dosing can
Morphine IV / subcut >12 months: up to 0.2 1–12 months:
be used in inpatient
mg/kg (max 5–10 mg) 0.1 mg/kg 2–4 hourly
settings
>12 months:
0.2 mg/kg 2–4 hourly
Or
Fentanyl Intranasal >12 months: Total dose of 3 Rapid onset (5

0.75–1.5 microg/kg microg/kg minutes)
~ 73 ~
PAEDIATRIC MANUAL
Divide dose between

nostrils
Consider alternative
(max 75 microg)
ongoing analgesia
10 minutely
after second dose
Not recommended
<12 months of age
Or
Can give up to 2
mg/kg if no risk
sleep apnoea/risk
factors for
1–18 years respiratory
0.5–1 mg/kg (max 8 mg/kg (up to 400 depression
Tramadol oral / IV
100 mg) mg/day) Avoid in epilepsy
6–8 hourly (lowers seizure
threshold) and
patients on SSRIs
(risk of serotonin
syndrome)
Topical agents
~ 74 ~
PAEDIATRIC MANUAL
Context Suggested topical agent
Open wounds in preparation Amethocaine, lignocaine and adrenaline (ALA/Laceraine®)

for closure
Prior to intravenous access Anaesthetic creams, ice, Coolsense® or BUZZY®

and venepuncture
Prior to suprapubic aspirate Anaesthetic creams

and lumbar puncture
Nasal / pharyngeal foreign Lignocaine - Phenylephrine (CoPhenylcaine Forte®) nasal spray

body removal, NGT insertion
Teething Salicylate teething gels (NB risk of Reye syndrome)
Gingivostomatitis Lignocaine viscous gel
Mouth ulcers Triamcinolone acetonide (Kenalog® in Orabase®)
Eye pain / corneal abrasions Topical amethocaine eye drops
Severe, acute ear pain Short-term use of topical 2% lignocaine, 1–2 drops applied to an
intact tympanic membrane
~ 75 ~
PAEDIATRIC MANUAL
Inadequate analgesia achieved
Analgesic requirements and care are above the level of comfort of the local centre
Pain has been appropriately managed
~ 76 ~
PAEDIATRIC MANUAL
Acute Red Eye
Common causes of a red eye include conjunctivitis (viral, bacterial, allergic or chemical),
foreign body, corneal ulceration and subconjunctival haemorrhage
Uncommon causes include iritis, scleritis, episcleritis and glaucoma
A discharging non-red eye in infants is most likely due to nasolachrymal duct obstruction
Assessment
Obtain a history concentrating on the possibility of ocular trauma, contact lens wear, time
course of the redness, and the presence of eye pain, itch and discharge.
Eye examination
Carefully inspect eyelids, everting to examine the undersurface
Examine the conjunctiva, pupil, iris and cornea, using the slit lamp whenever possible
Stain with fluroscein if corneal abrasion or ulcer possible
If trauma is possible examine for enophthalmos, diplopia, subconjunctival haemorrhage,

hyphema and retinal detachment
Always measure the visual acuity with age-appropriate charts
Signs and symptoms Diagnoses to be considered
~ 77 ~
PAEDIATRIC MANUAL
Pain, photophobia, watery discharge Foreign body
Traumatic corneal ulcer
Herpetic ulcer
Acute glaucoma
Purulent discharge Infective conjunctivitis
Itchiness, eyelid swelling and redness, watery Allergic conjunctivitis

discharge
Dull, aching eye pain Iritis, scleritis, episcleritis
Subconjunctival haemorrhage Trauma
Vigorous coughing or vomiting
Focal conjunctival injection or iris injury Trauma
~ 78 ~
PAEDIATRIC MANUAL
Conjunctivitis (non-neonatal)
May be difficult to clinically differentiate bacterial, viral and allergic conjunctivitis
Suspect bacterial conjunctivitis if purulent discharge. Treat with eye toilet and topical
chloramphenicol
Suspect herpes simplex infection if lid vesicles. If a dendritic ulcer is present treat with
acyclovir ointment and contact ophthalmology
Suspect allergic conjunctivitis if bilateral watery discharge with burning or itchy sensation
and eyelid swelling, especially in an atopic child. Consider treating with antihistamines (oral
or topical) and artificial tears
Chloramphenicol eye drops can cause contact hypersensitivity reactions; if a hypersensitivity

reaction is suspected, cease chloramphenicol and seek advice from an ophthalmologist
Conjunctivitis (neonatal)
Pathogens include staphylococcus, haemophilus, chlamydia, streptococcus, gonococcus and

herpes simplex
Obtain conjunctival scrapings for gram stain, giemsa stain and cultures
Use chlamydia kit for immmunofluorescence and treat chlamydial conjunctivitis with eye
toilet and oral erythromycin
Consider gonococcal conjunctivitis if severe purulent discharge with conjunctival and lid
oedema. Perform an urgent gram stain and contact ophthalmology þ may need septic work
up and systemic Ceftriaxone 50 mg/kg/dose (2g) iv 12H
Treat other organisms with topical chloramphenicol
Foreign body
~ 79 ~
PAEDIATRIC MANUAL
Anaesthetise conjunctiva with amethocaine 1% or benoxinate 0.4%. (one drop)
Examine surface of eye and under lids, using slit lamp if possible
Stain with fluroscein to assess corneal injury
Remove foreign body with moistened cotton bud, apply chloramphenicol ointment and pad
for four hours
Need daily review until epithelium healed
Refer embedded or metallic foreign bodies to ophthalmologist
Corneal ulceration
May be caused by trauma (including foreign body) or herpes simplex infection
Visible after fluroscein staining
If traumatic apply chloramphenicol ointment and review in 24 hours
If dendritic ulcer contact ophthalmology
Chemical burns
Irrigate eye with copious amounts of saline for at least 15 minutes, until pH normal
Particulate alkaline matter must be totally removed (may require GA)
Assess damage with fluroscein staining and slit lamp examination þ if corneal damage
contact ophthalmology
Iritis
Presents with pain, photophobia, blepharospasm and lacrimation
Pupil may be small and poorly reactive
May occur in association with juvenile chronic arthritis
Contact ophthalmology
Scleritis and episcleritis
~ 80 ~
PAEDIATRIC MANUAL
Present with localised areas of inflammation with tenderness and lacrimation
Strongly associated with systemic disease
Glaucoma
Presents with an enlarged, hazy cornea, photophobia and lacrimation
Trauma
Consider if hyphema or focal conjunctival injection
Consider penetrating injury
~ 81 ~
PAEDIATRIC MANUAL
Acute Scrotal Pain or Swelling
Key Points
Testicular torsion is an emergency. It requires immediate referral to a surgeon
Surgical evaluation should be undertaken in all cases where testicular torsion cannot be
confidently excluded
Ultrasound should only be considered in selected cases of testicular pain, after surgical
assessment, to avoid delays in management
Scrotal trauma/bruising, especially in infants or where the causal mechanism is unclear,

should prompt the clinician to consider child abuse
Background
The most common causes of acute scrotal pain and/or swelling are torsion of the testicular
appendage (appendix testis), epididymitis and testicular torsion
Delays in surgical management of testicular torsion result in higher rates of testicular loss
~ 82 ~
PAEDIATRIC MANUAL
Assessment
Scrotal pain +/- swelling
Trauma eg
Torsion of
Testicular Irreducible Epididymo- testicular or
testicular
torsion hernia orchitis epididymal
appendage
rupture
<2 years and

Typical age Pubertal (and Pre-pubertal post-pubertal
Infants -
group rarely neonates) (7-12 years) (rarely pre-
pubertal)
Severe
Usually sudden
onset Usually sudden Sudden or
May radiate to onset subacute onset
Pain Irritable May be delayed
iliac fossa or Usually minimal May improve
thigh at rest with elevation
May be painless
in neonates
Yes
Swelling Yes May extend to Yes Yes May be delayed
scrotum
Fever Unusual Unusual Unusual Common Unusual
~ 83 ~
PAEDIATRIC MANUAL
Nausea and
Common (90%) Common Uncommon Uncommon Uncommon
vomiting
Dysuria or
No No No Common No
discharge
Gait Impaired - - - -
Position of High riding or

- Normal - -
testis horizontal
Focal
Tender Firm and tender
tenderness of Tender postero-
Palpation Thickened Swelling not Tender
upper pole of lateral testis
spermatic cord reducible
testis
Oedema
crosses No No No Possible Possible
midline
Bruising
Discoloratio Red/blue (consider

- Blue dot sign Red
n Dark in neonate causes, eg NAI)
Cremasteric
Usually absent Usually present Usually present Usually present Usually present
reflex
~ 84 ~
PAEDIATRIC MANUAL
Reactive
Possible No No Possible Possible
hydrocele
Non-painful scrotal swelling
Idiopathic scrotal Tumour/

Hydrocele Varicocele
oedema leukaemia
Typical age
Infants Peri-pubertal 3-7 years 1-8 years
group
Fever Unusual Unusual Unusual Possible
Hard
Soft "Bag of Worms" Non-tender
Non-tender
Palpation Non-tender Occasionally May have low-
May be painful if
Fluctuant tender grade discomfort
rapidly growing
Can extend across

Predominantly midline and into Unilateral or
Swelling pattern Scrotal
left-sided perineum, groin, bilateral
penis
Discoloration No No Bland, purplish No
Transilluminabl
Brightly No No No
e
Reactive
- No No Possible
hydrocele
~ 85 ~
PAEDIATRIC MANUAL
Management
Investigations
Blood tests, ultrasound and Doppler ultrasound are not useful in the acute setting
Once testicular torsion and irreducible hernia have been confidently excluded, ultrasound
may be considered if the diagnosis remains unclear
Colour doppler flow ultrasound may assess blood flow, anatomy, and may localise
swelling and fluid collections
Consider urinalysis and urine MCS
For suspected epididymo-orchitis
Urine MCS (ideally first pass urine collection)
o Bacterial infection more likely in child with structural urinary tract

abnormalities, recent instrumentation of urinary tract, or STI
o A normal urine does not exclude epididymo-orchitis
Urine chlamydia and gonorrhoea PCR testing (if STI clinically suspected)
Viral causes include enterovirus, adenovirus and rarely mumps (mumps orchitis occurs
4-6 days after parotitis). If mumps is suspected: RT-PCR and/or IgM
~ 86 ~
PAEDIATRIC MANUAL
Treatment
Diagnosis Management
If suspected, or cannot be confidently excluded:

Urgent surgical review
Testicular torsion Fasting or clear fluids until surgical review
Provide adequate analgesia
Urgent surgical review

Fasting or clear fluids until surgical review
Irreducible hernia Consider a nasogastric tube on free drainage if bowel obstruction is
suspected
Provide adequate analgesia
May be difficult to distinguish from testicular torsion

Requires surgical exploration if unable to confidently exclude testicular
Torsion of testicular torsion
appendage Once diagnosis confirmed, treatment is supportive, with analgesia and
rest
Pain should resolve in 2-10 days
Surgical review for all testicular trauma, unless the testis is clearly felt
Trauma
to be normal and without significant tenderness
Suspected epididymo- Antibiotics - IV if systemically unwell/young infant, oral if well

orchitis Second episode - renal tract ultrasound and urological review
Slow to resolve. May have weeks of gradually subsiding scrotal discomfort
~ 87 ~
PAEDIATRIC MANUAL
and swelling
Spontaneous resolution in the first year; 90% by 2 years

Hydrocele Consider outpatient surgical referral for repair if present after 2 years of
age
Varicocele Refer to surgical outpatients
Scrotal oedema can occur in setting of systemic disease eg nephrotic

Idiopathic scrotal syndrome
oedema If idiopathic, resolves spontaneously over 1-5 days. No intervention
required
Surgical evaluation should be undertaken in all cases where testicular torsion cannot be
confidently excluded
Surgical evaluation unavailable at local hospital
Surgical advice has been provided
Follow up plan in place and review scheduled (if required)
~ 88 ~
PAEDIATRIC MANUAL
Spinal Cord Injury (Acute Management)
Introduction
Spinal cord injury (SCI) in children is a rare injury that can result in permanent loss of motor
and sensory function, and dysfunction of the bowel and bladder. Impairment of these
functions result in significant social and psychological consequences for the child and their
family. SCI is often associated with a traumatic brain injury. In children and adolescents SCI
is most commonly a result of road traffic accidents, falls or diving into water
Children with SCI experience multiple health care problems including autonomic instability,
complications of immobility and bowel or bladder dysfunction. Management in the acute
phase is aimed at preventing further spinal cord injury, maintaining physiological stability,
and commencing routine care of the skin and establishing good bladder and bowel care
Aim
This guideline is aimed at the acute management of children with injury to the spinal cord
Definition of terms
AIS: ASIA (American Spinal Injury Association) Impairment Scale. An international

classification system for level of impairment as a result of spinal cord injury. There are five
classifications for traumatic spinal cord injury: A-E
Quadriplegia (also referred to as tetraplegia): Dysfunction of arms, legs, bowel & bladder
due to SCI in the cervical region
Paraplegia: Dysfunction of lower body, bowel & bladder due to SCI in the thoracic, lumbar or
sacral region
Spinal shock: Temporary areflexic state with loss of autonomic control, and muscle tone
below the level of the injury which lasts up to six weeks after injury. It usually occurs in
spinal cord injury to cervical & upper thoracic spinal cord. Functional recovery may improve
after spinal shock resolves
~ 89 ~
PAEDIATRIC MANUAL
Neurogenic shock: Hypotension as a result of bradycardia and vasodilation due to loss of

thoracic sympathetic innervation following SCI. Profound effects are noted if injury is at
level of T6 or above. Most dramatic effects noted in the first few weeks with most patients
stabilizing in 7-10 days
SCI Pathophysiology and Presentation
Complete/incomplete injury
A complete SCI results in loss of all motor and sensory function below the level of injury (AIS
A)
An incomplete SCI results in preservation of sensory function below the level of injury (AIS
B), or a combination of varying degrees of sensory and motor preservation below the level of
injury (AIS C or D)
Cause of injury
The spinal cord can be injured by transection, distraction, compression, bruising,

haemorrhage or ischaemia of the cord or by injury to blood vessels supplying it. These
injuries can all result in permanent cord injury and may be complete or incomplete
Concussion of the spinal cord can result in temporary loss of function for hours to weeks
Pathophysiology
Injury results from primary & secondary insults
Primary injury occurs at the time of the traumatic insult
Secondary injury occurs over hours to days as a result of a complex inflammatory process,
vascular changes and intracellular calcium changes leading to oedema and ischemia of the
spinal cord. Irreversible damage occurs to nerve cells leading to permanent disability
Spinal cord injury may occur without evidence of bony injury on x-ray or CT. Paediatric
injuries are more commonly associated with injury to ligaments discs and growth plates and
often require a MRI to define the injury pattern
~ 90 ~
PAEDIATRIC MANUAL
Signs and symptoms of acute SCI
Flaccid paralysis below level of injury
Loss of spinal reflexes below level of injury
Loss of sensation (pain, touch, proprioception, temperature) below level of injury
Loss of sweating below level of injury
Loss of sphincter tone and bowel & bladder dysfunction
Management
Initial assessment
Be aware the loss of thoracic sympathetic innervation (T1-T5) may inhibit tachycardia and
vasoconstriction as signs of hypovolaemia. Thus haemorraghic injuries may not be indicated
by the usual signs
Referrals
Neurosurgical, orthopaedics & trauma service should be notified prior to or on admission to

the Emergency department
Rehabilitation service to be notified within 24 hours of admission
Admission location
These patients will usually require admission to PICU (Rosella)
If not requiring PICU admission, then this will usually be Cockatoo (Neurosurgical ward)
unless multiple abdominal injuries are present, in which case the child will be admitted to
Platypus (General surgical ward)
~ 91 ~
PAEDIATRIC MANUAL
Spinal immobilisation
Initial care - immobilisation
Immobilize the entire spine of any patient with known or potential SCI
Immobilize neck with a hard collar
Use log roll with adequate personnel to turn patient while maintaining spine
alignment
For children < 8 years of age use an airway pad to promote neutral cervical spine
position
Remove from spinal board on arrival in ED or as soon as resuscitation allows
Maintain neck in neutral position by use of a hard collar, but change to two-piece
collar for comfort and avoidance of complications (e.g. pressure area, venous
obstruction, aspiration) within 6 hours of admission
Early surgery
Surgery may be required in the situation of a reversible compression injury, or

deteriorating neurology with a spinal injury amenable to some form of reduction and
or fixation
Halo and Orthotic devices
Some patients may have Halo devices applied by surgeons, or a brace made by
orthotics to maintain correct alignment of the spine. These devices are fixed to the
child’s chest
Ensure you know how to open devices to perform chest compressions in the event of a
cardiac arrest, and that spinal immobilisation is maintained manually throughout any
resuscitation
Move patient using slide sheets or pat slide with adequate number of personnel to
maintain spinal alignment
~ 92 ~
PAEDIATRIC MANUAL
No pharmacological agent has been proven to limit damage and optimize recovery of
function. If steroids have already been given, cease them when resuscitation
completed. Aim for normal perfusion pressure and oxygenation of SC
Once the extent and stability of the injury has been determined a documented plan
should be formulated to ensure immobilisation and stabilisation
Imaging
Multiple levels of injury in the spine are common. In the under 8 age group especially, there
is a high proportion of missed craniocervical injuries with/ without associated cranial nerve
involvement
Plain film imaging of the entire cervical, thoracic and lumbar spines
Further early imaging will at least involve an urgent MRI of the entire spine looking for
remediable lesions
CT scan may be used to further identify the extent of bony injury
Neurological assessment
Neurological assessment and documentation in the EMR including
Sensory level
Motor function
o After 72 hours, the ASIA guide should be completed documenting sensory and
motor levels. Contact the rehabilitation registrar to assist with this assessment
Glasgow coma score
Pupil response
Perform hourly for 1st 24 hours then decrease to 4 hourly if condition stabilised
Note evidence of brain injury as well as spinal cord injury
~ 93 ~
PAEDIATRIC MANUAL
Vital Signs (and autonomic control)
Vital signs can be quite abnormal following SCI. In addition to the usual causes in trauma
such as pain, bleeding and distress, this can be due to loss of autonomic control, which
occurs particularly in cervical or high thoracic injuries. The autonomic nervous system
controls our HR, BP temperature etc. Autonomic instability is most acute in the first few
days to weeks of the injury.
Particular implications of autonomic instability to be aware of are:
Heart rate
Bradycardia can easily occur , for example on endotracheal tube or tracheostomy suction,
due to unopposed vagal activity (Thoracic sympathetic input may have been damaged)
Patient needs continuous HR monitoring in PICU or ward
Treatment with anticholinergic medication is often required
Blood pressure
Loss of autonomic control results in loss of vasomotor tone. Patient may be quite vasodilated
and hypotensive. This phase of neurogenic shock can last up to several weeks. Hypotension
should be treated to prevent secondary poor perfusion of the spinal cord
Blood pressure monitoring should be:
Continuous in PICU
At least hourly in the ward
Ensure patient is adequately fluid resuscitated but not overloaded
Patient may need vasopressor drugs such as nor-adrenaline or intravenous fluids to maintain
BP (but excessive fluids will cause pulmonary oedema). Patients requiring vasopressors
should be managed in PICU
~ 94 ~
PAEDIATRIC MANUAL
Temperature
The loss of temperature control e.g. ability to sweat, shiver, vasodilate, vasoconstrict or
position self to maintain temperature. Consequently, the child will take on the temperature
of the environment
Hypothermia is common
Temperature measurement should be preformed 4hrly in the acute stage of admission
Ensure adequate clothing or bedding in cool environment
Ensure artificial cooling in a hot environment
Breathing
Respiratory difficulty is common in the early stages of spinal shock but will ultimately
depend on injury level
C1-C4: paralysis of diaphragm and intercostal muscles: will need mechanical

ventilation via endotracheal intubation or tracheostomy. May need long-term
ventilation of phrenic/diaphragm pacing
C5-T6: paralysis of intercostals, diaphragm OK – may need some form of respiratory

support
T6-12: abdominal muscles paralysed, may have some decreased function
Asses respiratory status including pattern, effort, ability to cough, auscultate chest, Monitor
SpO2 ETCO2, ABG
Intubate and ventilate if respiration is inadequate
Maintain strict ventilator associated pneumonia (VAP) prevention strategies
Nurse head up, but tilt entire bed so that spine remains in line & immobilised-do not just
simply raise head of bed up
Note at later stage of admission when patient is allowed to sit up, that if abdominal
muscles are paralysed, breathing difficulty may be worsened when sitting up and
eased when semi-recumbent
~ 95 ~
PAEDIATRIC MANUAL
Give O2 as required
Ensure abdomen not distended (NG should be inserted)
Refer to physiotherapist to establish a regimen of chest physiotherapy, assisted coughing and

BiPAP
Skin
A patient who has a SCI is at high risk of damage to their skin integrity. The SCI causes loss
of sensation of pain, pressure & temperature. The patient may also have lost motor control
and have poor autonomic nervous system function. The end result is a lack of sensory
warning mechanisms, an inability to move and circulatory changes all impacting on skin
integrity
High risk for pressure areas, measures need to be implemented to assess and prevent skin
breakdown:
A baseline skin assessment should be completed on admission
For all patients a Pressure Injury Prevention Plan must be commenced
Pressure mattress (low air loss or alternating pressure) or gel mat if approved
o Air or alternating pressure mattresses should not be used for unstable spines
Reposition 2 hourly
o This should occur from the time of admission
o Reduce friction and shear during repositioning and transfers
If skin breakdown occurs it can progress rapidly. Pressure must be kept off this area.
Refer to stomal therapy for advice on appropriate dressing
Take care with water temperature for washes, and use of hot or cold devices against skin
~ 96 ~
PAEDIATRIC MANUAL
The patient will not feel the temperature extreme, or be able to withdraw from it
Hygiene
Daily wash to keep skin clean
o Dry thoroughly after washing
o Do not leave patient in damp/wet bed
o Commence bowel regime as outlined below
Hard collar needs to be removed & skin underneath checked and washed daily
o Manually immobilised head whenever the hard collar is off
o Collar fit and position to be checked each shift
o Inspect the skin of the occiput each shift
Refer to surgeons and orthotics for advice on access to skin under halo jackets and
braces
Adequate nutrition is important for good skin integrity. Enteral nutrition is preferred.
Skin should be fully inspected once per shift
Bladder
Urinary bladder function may be affected by SCI. The muscles and sphincters of the bladder
are normally controlled by neurological input and spinal reflexes. Loss of this normal
neurological control of the bladder is commonly referred to as a neurogenic bladder. The
aim of bladder care is to prevent infections, minimise and contain incontinence and find an
appropriate way to empty the bladder. This will need to be related to the child’s
developmental level, lifestyle, and family needs. For the adolescent patient sexual function
also needs to be considered
Bladder dysfunction depends on the level of spinal cord injury
~ 97 ~
PAEDIATRIC MANUAL
o Some patients will have a contractile/reflex bladder which contracts when the
bladder muscle (detrusor) is under a certain amount of pressure. Depending on
the urethral sphincter function these patients will leak in between catheters
o Some patients will have an acontractile/flaccid bladder that stretches and

holds a large volume of urine but the bladder muscle (detrusor) does not
contract and bladder emptying occurs usually by overflow
o Some patients will have a combination bladder
In the early acute phase of the SCI an indwelling urinary catheter will be used. Always
use lignocaine lubricant to insert catheter
Once patient has stabilised and opioids reduced consider change to intermittent
catheter 4-6/24
o Refer to Urology to enable Stomal therapy involvement to assist in establishing

a routine
Long term management can include clean intermittent catheterisation (by carer or
child if able); condom drainage or other options used more for adults dependant on
care, such as bladder tapping or use of a suprapubic catheter
Occasionally if clean intermittent catheterisation is difficult or impractical a

mitrofonoff stoma might be considered
Some patients will be prescribed Oxybutin to reduce bladder spasm & thus increase
holding capacity and continence between catheters
Complications
o Recurrent UTI
o Renal & bladder calculi
o Vesico ureteric reflux
o Latex allergy development due to increased latex exposure: use latex free
catheters
~ 98 ~
PAEDIATRIC MANUAL
Prevention of complications
o Maintain good hydration to reduce the risk of UTI & Kidney stones
o Good hand hygiene by carers, and ensuring goog hygiene of the patients
perineal area to reduce infection
Priaprism (erection) may occur in boys and is usually self-limiting & not a
contraindication to catheterisation. Referral to urology if priaprism prolonged
Bowels
Bowel function will be affected by loss of neurological control of its function (neurogenic
bowel). In addition, medications such as antibiotics and opioids, immobility, alterations is
food, fibre and fluid intake may affect function. Patients are at risk of constipation,
impaction and diarrhoea. It is important to achieve regular bowel emptying. Constipation is
not only troublesome but can also trigger major complications such as autonomic hyper-
reflexia (dysreflexia)
Commence bowel management as soon as bowel sounds are present and enteral/oral
feeds begin
o In the acute phase of spinal shock
 Aperients should be commenced with enteral feeding
 Refer to Dietician early to ensure adequate nutrition, fluid & fibre in the
feeds
o When spinal shock has resolved (and helpful if patient able to sit)
 Refer to stomal therapy for assistance in establishing a bowel routine if

the ward/rehabilitation routine is not satisfactory in the early phase; or
when discharge is being discussed.
 Routine will depend on age, bowel function, level of injury, pre injury
function & family/carer support
Bowel dysfunction
~ 99 ~
PAEDIATRIC MANUAL
o Some patients may have a ‘reflex’ bowel. Although peristalsis will move stool
through bowel, the anal sphincter may not relax. It may need stimulation to
relax & allow passage of stool
o Some patients may have a ‘flaccid’ bowel. Reflexes that move stool through
the bowel are impaired and the anal sphincter is relaxed preventing stool being
held in the rectum
o Some patients have a combination of bowel function problems
Constipation
o Caused by: insufficient fluid & fibre intake, insufficient aperients, ineffective
evacuation of stool, medications (anticholenergics, opioids), immobility
o Treatment: increase fluids & fibre, increase aperients
Impaction
o Caused by: chronic constipation. Will often have liquid overflow
o Treatment: contact stimulant, movicol or osmotic laxative; Assisted evacuation

only if necessary (e.g. microlax, large volume enema, manual disimpaction)
Diarrhoea
o Change in diet, antibiotics, bacteria, excess aperients, high impaction
o Treatment: adjust diet, reduce aperients, stool specimen, abdominal x-ray if

impaction suspected; possibly consider probiotics
Type of bowel management aperients
~ 100 ~
PAEDIATRIC MANUAL
o Contact stimulants help to move faeces through the bowel (peristalsis) e.g.,
senokot
o Bulking agents regulate bowel by increasing water content e.g. Metamucil
o Softeners increase water penetration of stool e.g. coloxyl very good for
children
o Iso-osmotic laxative e.g. Movicol
o Osmotic laxative e.g. lactulose
o Suppositories & enemas can stimulate bowel action & lubricate faeces for
easier evacuation e.g. microlax, glycerol suppositories
o Other: if above management suggestions are ineffective discuss with stomal

therapy to consider peristeen bowel washout system or Malone stoma-bowel
washouts
Nutrition
Insert naso/oro gastric tube early to limit risk of vomiting and aspiration as patient will
often have paralytic ileus initially. NG placement also allows for enteral feeding to
commence
Refer to Dietician early to ensure adequate nutrition, fluid & fibre in the feeds
Consider gastric ulcer prophylaxis
Re-introduce oral feeding after ensuring ability to swallow and protect airway
Gastrostomy may be required
Thromboprophylaxis
Refer to the Clinical Haematology Department for consideration of thrombotic risk and
development of an individualised thromboprophylaxis plan
Consider the use of antiembolic stockings or sequential calf compression devices (SCCD)
~ 101 ~
PAEDIATRIC MANUAL
Postural hypotension
Patients with SCI are at risk for postural hypotension when moving from supine to sitting
upright. This is due to loss of sympathetic autonomic nervous system innervation and include
an inability to regulate BP normally with vasoconstriction. Do not attempt to start sitting
patient up until medical approval given.
To avoid problems with postural hypotension:
Anti embolic stockings and/or SCCD’s will encourage venous return from the legs
Abdominal binders encourage venous return through the IVC
o Orthotics can make these to fit
Slowly increase bed angle to sitting position, rather than in one quick move. It may
take weeks for the patient to tolerate sitting upright
o Involve physiotherapy team in this process
Joint contractures
Abnormal muscle tone and lack of movement can result in joint contractures. Referrals
should be made to Physiotherapy, Occupational Therapy and Orthotics within 1-2 days of
admission:
Physiotherapy: for range of movement exercises & positioning patient in good

alignment
Orthotics: splints for ankles
Occupational Therapy: splints for hands
Autonomic hyperreflexia (Dysreflexia)
Autonomic Dysreflexia is a MEDICAL EMERGENCY that needs immediate recognition and

action
Usually it affects those with injuries T6 or higher and generally won’t occur until a few
weeks post injury (After spinal shock has subsided)
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PAEDIATRIC MANUAL
Autonomic dysreflexia is a condition where the autonomic nervous system has an abnormal
excessive response to noxious stimuli below the level of the injury
Common causes of stimuli include full bladder or bowel (ineffective emptying or

constipation), pressure sores, tight clothing, fractures, surgery, pain
Signs & symptoms include:
Hypertension
o Sudden and severe nature which requires immediate recognition and treatment
o Hypertension may be the only manifestation of dysreflexia
o Note: BP for children with a SCI is normally low, so a BP that is in the high end
of normal range for age is actually elevated for them
o Bradycardia
Severe pounding headache
Skin rash (flushed, blotchy, transient)
Vasodilation above the level of the injury or sweating
Vasoconstriction below level of injury: pale, cool skin with, goosebumps and/or
piloerection
Blurred vision/ pupillary dilation
Anxiety
Nasal congestion
Nausea
Note: for very young children symptoms may be vague & hard to recognise due to
verbal & developmental stages
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PAEDIATRIC MANUAL
Manage by:
Remove noxious stimuli where possible
o Loosen clothing, remove compression stockings, abdominal binder
o Perform urinary catheterisation using lignocaine gel, ensure catheter not

blocked
o Bowel disimpaction using lignocaine gel
o Look for pressure areas, ingrown toenails, evidence of fracture
Position child sitting upright or with head of bed elevated
Monitor BP & HR 5 minutely
Antihypertensive agents may be prescribed if not responding to above measures

within a few minutes, or cause cannot be found
Sexual function
Sexual function can be of great concern to families even in very young children
Important topic for adolescents with SCI
Topic needs to be discussed with family & child in age appropriate manner so that they
understand implications for the child’s lifetime
Puberty will occur as for other children; for females pregnancy is possible, and for males
treatment may be required for erection, ejaculation & fertility
Psychological
A diagnosis of spinal cord injury is often devastating for children and their families. There
are frequently preconceptions about spinal cord injury that need addressing and there may
also be pre-existing issues for the child or family
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PAEDIATRIC MANUAL
Make appropriate referrals
Social work
Clinical psychology
 Link to support groups or other children with similar injury
Potential complications and management
The following are the most common complications seen for these children
Pressure sores
Autonomic Hyperreflexia (Dysreflexia)
Pneumonia and retained secretions
Urinary tract infections
Constipation
Deep venous thrombosis
Bone demineralisation/ hypercalcaemia
Latex allergy
Spasticity – deformities/pain
Family centred care
Incorporate child’s developmental level when planning care
The child who is unable to perform care may be able to direct it enabling a sense of control
Enable family to work with the multi disciplinary care team to develop culturally sensitive
care
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PAEDIATRIC MANUAL
Provide as much information as possible regarding the child’s plan of care for the next few
days/weeks
Involve Nursing Care Coordinator early
Special considerations
Referral must be made to the rehabilitation team in the first 24 hours
If long term mechanical ventilation is required, phrenic nerve/diaphragm pacing may be

considered
Companion documents
Medical management of spinal cord injury
Acute traumatic spinal cord injury admission process
~ 106 ~
PAEDIATRIC MANUAL
Acute Upper Airway Obstruction
Key points
Allow children with acute upper airway obstruction to adopt a position of their choice and
avoid causing distress
Decompensation of acute upper airway obstruction can be rapid and requires emergency
airway management
In any child with severe acute upper airway obstruction, nebulised adrenaline may provide
temporary relief while awaiting other definitive measures
Background
Due to their size, infants are most at risk of severe upper airway obstruction
Children with pre-existing narrowing of the upper airway may fully obstruct with otherwise
minor acute upper airway swelling
Although croup is the most common cause of acute upper airway obstruction, other
diagnoses must always be considered
Assessment
Allow the child to settle quietly on parent’s lap in a position of their choice, and observe
closely with minimal examination
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PAEDIATRIC MANUAL
Rapidly assess airway patency and respiratory status:
Mild obstruction Moderate obstruction Severe to complete

obstruction
Able to speak or cry, may be Tachypnoea Hypoxia (late sign)

hoarse Stridor Slow respiratory rate or marked
Intermittent stridor or Prolonged inspiratory time tachypnoea
occasional stertor Moderate work of breathing, Sniffing or tripod position
Minimal or no work of breathing nasal flaring, grunting, Agitated or drowsy conscious
Good air entry paradoxical chest movement state
Decreased air entry Severe work of breathing
Markedly reduced or no air
movement
Silent gagging or coughing
Total obstruction will rapidly

progress to unconsciousness
and cardiorespiratory arrest
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PAEDIATRIC MANUAL
Differential diagnoses: (the table below is not an exhaustive list)

Presentations, particularly the bacterial causes, often overlap
Possible diagnosis Features
Young child (rare <3 months)

Rapid onset harsh barking cough
Croup Hoarse voice/cry
Stridor
May be febrile and miserable but systemically well
Swelling of the face and tongue

Wheeze
Anaphylaxis Urticarial rash
Allergen exposure
Haemodynamic compromise
Young child (or developmentally similar)

Very sudden onset
Inhaled foreign body
Coughing, choking, vomiting episode (may not be witnessed)
May have unilateral chest findings, wheeze
Reduced conscious state e.g. after drug or alcohol ingestion, recent

Reduced pharyngeal
seizure, head injury (including NAI)
tone or size
Pre-existing narrow or floppy upper airway
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PAEDIATRIC MANUAL
Sore throat
Fever
Retropharyngeal Neck pain and stiffness or torticollis
abscess Fullness and redness of posterior pharyngeal wall; may be midline but
can be laterally behind tonsil
Dysphagia and drooling
Severe sore throat (often unilateral)

Hot potato/muffled voice
Peritonsillar abscess
Trismus
(quinsy)
Swollen posterior palate and tonsil, with medial displacement of
tonsil and deviation of the uvula
Inadequate Hib immunisation or immunocompromised

High fever and systemically unwell
Epiglottitis Muffled voice

Hyperextension of neck
Dysphagia
Pooling of secretions, drooling
Absent cough
Low pitched expiratory stridor or stertor
Systemically unwell
More severe and rapidly progressive symptoms
Bacterial tracheitis Recent URTI
Markedly tender trachea
Cough may be productive with thick secretions
Ludwig angina Swollen, tender floor of mouth and under tongue

(infection of the Facial laceration or dental abscess
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PAEDIATRIC MANUAL
sublingual and Submandibular swelling

submandibular spaces)
Burns elsewhere, especially facial

Airway burns Singed nasal hairs
Sooty sputum
Bruising and swelling of the neck

Trauma Subcutaneous emphysema
May progress to pneumothorax / pneumomediastinum
Management
Investigations
Children with moderate to severe upper airway obstruction are at high risk of
deterioration and complete obstruction if they are upset, sedated or repositioned.
Investigations should be deferred until the airway is secure
If IV access is required use appropriate analgesia and distraction techniques to minimise

distress
Children with croup do not require any investigations
X-ray (chest and/or soft tissue neck) or CT may be helpful in identifying the location and
nature of upper airway obstruction
Treatment
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PAEDIATRIC MANUAL
If emergency airway management is required, it will be a “difficult airway”. Involve the

most senior clinician available ± anaesthetic or ENT support
If awaiting other definitive measures
Oxygen can be given. It may improve saturations but does not relieve obstruction
Consider nebulised adrenaline to provide temporary relief in any life-threatening

upper airway obstruction
Consider dexamethasone 0.6 mg/kg IM/IV/oral to reduce swelling if present
For intubation, use an endotracheal tube ½ to 1 size smaller than usual for age. Cuffed
tubes allow for cuff inflation if leak develops when obstruction begins to resolve. Gaseous
induction methods are preferred
Treat the specific cause. For bacterial infections refer to local antimicrobial
guidelines
Child has moderate acute upper airway obstruction
Consider consultation with anaesthetics and/or ENT:
Child with severe acute upper airway obstruction
Child is at risk of deteriorating due to known difficult airway
Child is at risk of deteriorating and requires airway management beyond the capability of
available local services
The cause for the acute upper airway obstruction has been identified and symptoms and
signs of acute upper airway obstruction have resolved, or are mild and improving
Appropriate management undertaken and an adequate follow up plan is in place
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PAEDIATRIC MANUAL
Tonsillectomy and Adenoidectomy Post Operative Nursing Management
Introduction
Tonsillectomy is a surgical procedure commonly performed at The Royal Children’s Hospital,

often with an adenoidectomy
Surgery is performed most commonly for children who have Obstructive Sleep Apnoea, Sleep
Disordered Breathing and recurrent tonsillitis
Aim
To provide nursing staff with a guideline for the postoperative management of children who
undergo tonsillectomy +/- adenoidectomy so that care can be standardised across all
inpatient units
Definition of Terms
Tonsillectomy: The surgical removal of the tonsils
Adenoidectomy: The surgical removal of the adenoids
Obstructive Sleep Apnoea: Complete or partial obstruction of the upper airway which
presents as snoring with pauses in breathing while asleep. For most young children this is
often from large tonsils and adenoids but can also be due to the relaxation of the tongue
and airway muscles
T and A: Tonsillectomy and Adenoidectomy
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PAEDIATRIC MANUAL
Assessment
Routine Post Anaesthetic Observations are required for all patients post tonsillectomy
All children should have continuous oximetry when they are asleep
All children who stay overnight should be placed on a Nellcor™ downloadable oximeter
overnight, an order should be placed in EMR for overnight oximetry. This report is
downloaded and printed in the morning if the child has had desaturations or if the nurse was
concerned about the patient’s breathing
Regular pain assessments
All patients should continue on 4 hourly observations until discharge
Management
Early management
The greatest risk of primary bleeding is within the first 6 hours; patients going home via day
surgery should be observed for 6 hours prior to discharge
Diet should be introduced as soon as possible, there are no restrictions on what children can
eat however they may prefer a soft and cool diet
Analgesia should be given strictly, including waking children overnight
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PAEDIATRIC MANUAL
Analgesia Regimen – RCH Specific
Medication Type of Medication Frequency/ Special Instructions

Name
Parecoxib An intravenous selective STAT dose given intraoperatively

COX-2 inhibitor
Celecoxib An oral COX-2 inhibitor The recommended dose at RCH for patient’s post T
& A is 4mg/kg up to a maximum of 200mg BD,
given regularly for 7 days. To be commenced day 1
post operatively
Paracetamol Simple Analgesic Given strictly every 6 hours including overnight for
the first few post-operative nights, and regularly
for 7 days
Tramadol Synthetic opioid like Given only for breakthrough pain relief and is the
analgesic for moderate to preferred opioid
severe pain
Oxycodone Narcotic analgesic for Caution should be taken with children who have
severe pain OSA
Please note that Tramadol is the preferred opioid

in this patient group
RCH does not recommend the prescription of tramadol drops, instead tramadol capsules are
ordered and nursing staff are to disperse in water and give the recommended dosage
At RCH our surgeons recommend that in order to reduce the risks from post-tonsillectomy
bleeding, ibuprofen should not be administered
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PAEDIATRIC MANUAL
Ongoing management
Children with OSA who are yet to pass a night on overnight oximetry should be placed on
continuous monitoring while they sleep (A child who has passed overnight oximetry will have
been monitored overnight and not had any oxygen desaturations)
Overnight downloadable oximetry should be repeated if the patient failed to pass the first
night
Maintain IV access until the day of discharge
All patients should be given the Tonsils and adenoids removed – discharge care Kids health
info factsheet along with the Tramadol Pharmacy factsheet and the Celecoxib Kids health
info factsheet. In depth discussion regarding analgesia, diet and oral intake, activity at home
and risk of secondary bleeding should take place with the family prior to discharge from RCH
Discharge Criteria / Follow Up
Most children can be placed on a Criteria Led Discharge for the next morning post-
operatively
Patient must be tolerating diet and fluids
Pain controlled
Tonsil bed inspection by competent nurses or ENT staff
Downloadable oximetry reviewed by ENT Registrar if applicable
Afebrile and other observations within age appropriate limits
Family state that they understand the care at home
Follow up is usually with the GP in 2 weeks, unless stated otherwise.
Ensure discharge scripts are filled at the RCH pharmacy. Celecoxib suspension is not usually
available at external pharmacies
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PAEDIATRIC MANUAL
Special Considerations
Managing Oxygen Desaturations
Children with chronic obstructive sleep apnoea may have hypoxia and hypercarbia. The
administration of oxygen in this patient group may cause apnoea or mask the obstruction
and hypercarbia
Oxygen should not be applied to this patient group without consultation with ENT staff or
the Medical Lead after hours unless in a life threatening situation
If a patient’s oxygen saturations begin to drop, rouse and reposition them. If this happens
more than 3 times in one hour the patient requires a medical review
If oxygen saturations do not spontaneously resolve with repositioning a rapid review or MET
should be called
Report any difficulty breathing to ENT or the after-hours medical team
Managing Post-Operative Bleeding
Post tonsillectomy bleeding is uncommon (5% of patients), but is a potentially life

threatening event
The main difficulties arise from aspiration of blood and hypovolaemic shock
Primary (not common) – within 24 hours of surgery
Will likely need to return to theatre
Secondary – most commonly at day 5 to 10 post surgery
Usually self-limiting and do not require return to theatre
Usually require observation in hospital as there may be a second bleed
Report any bleeding to the ENT Registrar on call and the Nurse in Charge.
Keep the patient nil by mouth. Consider antiemetic if patient nauseated.
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PAEDIATRIC MANUAL
Record estimated amount of blood loss (note that bleeding may be haemoptysis or
haematemesis as children often swallow blood).
Allow patient to sit upright, leaning forward to assist in keeping blood out of airway.
Monitor for signs and symptoms of hypovolemic shock. Consider the need for continuous
cardiac monitoring.
If no active bleeding, keep patient nil by mouth for 6 hours or until review in the morning.
If airway, breathing or circulation is compromised call a MET or Resus Team
If active bleeding continues or concern of hypovolemic shock
Set up for insertion of 2 IV Cannulas (large bore) and prepare for FBE, Coagulation Screen,
Group and Hold, Cross Match
Consider the need for
Blood Box
Or activating the Massive Transfusion Procedure (MTP)
Manage child’s fluid status as per signs of hypovolemic shock
Additional agents to consider include Tranexamic Acid (IV), Adrenaline 1:10000 for topical
use
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PAEDIATRIC MANUAL
Adolescent Gynaecology - Heavy Menstrual Bleeding
Key Points
The most common cause of Heavy Menstrual Bleeding (HMB) in adolescents is anovulatory
cycles
Mild bleeding with a normal haemoglobin can be managed with reassurance, non-hormonal
treatments and observation
Pregnancy related bleeding and bleeding disorders are important differentials to consider
Hormonal therapy aims to stabilise the endometrium
Background
Normal menstrual blood loss: pads/tampon changes at ≥3 hour intervals, seldom overnight
and fewer than 21 pads/tampons per cycle
Excessive menstrual flow is defined as any of the following:
>7 days duration or >80 mL
Necessitating changing a super pad/tampon more than every 2 hours
Causing symptomatic anaemia
Causing lifestyle disturbance
Menstrual cycles are often irregular and anovulatory in the first few years after menarche.
The time to establish regular ovulatory cycles increases with increasing age of menarche
Anovulatory uterine bleeding is excessive noncyclic uterine bleeding related to immaturity

of the hypothalamic-pituitary-ovarian axis (in the absence of structural uterine lesions or
systemic disease)
Causes
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PAEDIATRIC MANUAL
Pregnancy: miscarriage, ectopic pregnancy, gestational trophoblastic disease
Endocrine: anovulatory, thyroid dysfunction, polycystic ovarian syndrome (PCOS)
Haematological: von Willebrand Disease, platelet function disorder, thrombocytopenia,

other bleeding disorder
Medication: hormonal contraception, anticoagulants
Other: trauma, infection, malignancy, structural causes (uncommon in adolescence),

gastrointestinal bleeding
Assessment
Red flags in red
History
Menstrual history (menarche, last menstrual period, frequency, duration, flow, pain,
flooding, large clots (>2cm in diameter), and frequency of pad/tampon changes)
Impact on daily life: missing school, sports, social activities
Sexual history and contraception
Symptoms of
Anaemia: dizziness, shortness of breath, fatigue
Bleeding disorders: epistaxis, bleeding gums, easy bruising
Past medical history including: coagulopathy, platelet function disorders, recurrent

haemorrhagic cysts, chronic medical conditions
HEADSS screen
Examination
Vital signs: hypotension, tachycardia
Skin: pallor, petechiae, bruising
Abdominal examination: tenderness or pelvic mass
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PAEDIATRIC MANUAL
Secondary signs of PCOS: acne, excess facial or body hair, weight gain
Vaginal examination is rarely indicated in an adolescent. It should be discussed with a

senior clinician, and if needed should only be performed once
Assessment of severity
Mild Slightly or moderately increased menstrual flow with normal haemoglobin.
Moderate Moderately prolonged or frequent menses (every 1–3 weeks), with moderate to
heavy flow and reduced haemoglobin (≥100 g/L)
Severe Heavy bleeding with haemoglobin <100 g/L and/or haemodynamic instability
Management
Investigations
FBE
Blood group and antibody screen for severe bleeding
Ferritin
Coagulation screen
TSH
Urine or blood ßhCG (with consent)
Consider pelvic ultrasound if bleeding accompanied by pain or palpable mass
If a bleeding disorder is suspected, consider Platelet function assay (PFA) 100 and von
Willebrand screen. These tests should not be done during acute bleeding or with recent
NSAID use
Treatment
Treatment is targeted to the underlying cause; for anovulatory bleeding, the objective is to
stabilise the endometrium (oestrogen for initial haemostasis and progestins for extended
endometrial stability)
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PAEDIATRIC MANUAL
Severity Treatment
Mild Mild bleeding with a normal haemoglobin and no desire for contraception,
provide reassurance and observation
Consider non-hormonal management such as regular NSAIDs and tranexamic

acid during menses
Moderate Tranexamic acid during menses
Hormonal Therapy
Combination estrogen-progesterone oral contraceptive pills ***
or
Oral progesterone-only hormone therapy
Severe IV Access
Fluid bolus and Resuscitation
Tranexamic acid
Hormonal Therapy
High dose norethisterone
Iron infusion as required or PRBC if haemodynamic instability despite fluid

resuscitation
Specialist review (Gynaecology) and consider inpatient observation
*** Contraindications include (consider progesterone only): uncontrolled hypertension,

cardiovascular disease, migraine with focal neurological signs, thrombosis risk
All patients may benefit from iron supplements
Consider a menstrual calendar or app (for example Clue, Flo)
~ 122 ~
PAEDIATRIC MANUAL
Non-hormonal
Tranexamic acid taken day 1–5 of menses can decrease flow by 25–50%. The usual dose in
adolescents is 1 gram TDS (Dosing by weight 15–25 mg/kg 2–3 times a day, maximum 1
gram). Antifibrinolytics do not regulate the menstrual cycle, but reduce bleeding by
inhibiting clot-dissolving enzymes in the endometrium
All NSAIDs (eg Mefenamic acid 500 mg TDS, Naproxen 500 mg BD) can decrease flow if taken
regularly during menstruation. These can be used in conjunction with tranexamic acid.
NSAIDs reduce the effects of prostaglandins, which are elevated in those with excessive
menstrual bleeding, and may aid dysmenorrhoea symptoms
Hormonal
Progestins (eg norethisterone 5 mg, medroxy-progesterone acetate 10 mg) generates a

secretory endometrium and are good for anovulation (infrequent periods) due to the lack of
progesterone
Active bleeding acute treatment:
Norethisterone 5–10 mg can be taken 3 times daily for 10 days then weaned slowly (eg
by 5 mg/week)
Alternatively, medroxy-progesterone acetate 10–20 mg 3 times per day for 10 days

then weaned
Notes
o If progesterone-only treatment is stopped abruptly this will precipitate

bleeding
o Seek specialist advice for higher doses or patients not responding to initial
treatment
Prophylactic treatment
Norethisterone 5–10 mg or medroxyprogesterone acetate 10 mg daily taken

continuously
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PAEDIATRIC MANUAL
Depot medroxyprogesterone-acetate 150 mg IM every 12 weeks
Mirena (levonorgestrel intrauterine device)
Combined estrogen and progestin oral contraceptive pill: can decrease flow by 50% and is
effective for anovulation or irregular menses. Often started with a low dose estrogen and
moderate progestin (eg ethinylestradiol 30 microg + levonorgestrel 150 microg)
Active bleeding acute treatment
o One pill every eight hours until the bleeding stops (usually within 48 hours),
then
o One pill every 12 hours for 3 days, then
o One pill daily continuously until outpatient review with GP or gynaecology
Prophylactic Treatment
o One oral contraceptive pill daily
o Transition to continuous use after the first month’s withdrawal bleed
Contraindications include (consider progesterone only): smoking, uncontrolled hypertension,

cardiovascular disease, migraine with focal neurological signs, thrombosis risk
Consultation with local paediatric team when
Consider admission for hemodynamically unstable patients with a low haemoglobin

concentration or who have symptomatic anaemia
Advice regarding escalation of care if beyond the local centre capabilities or unable to
control bleeding
Patients can be discharged when stable and a review is scheduled:
Within a month for mild bleeding
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PAEDIATRIC MANUAL
within 48 hours for ongoing mild to moderate bleeding (with confirmatory

haemoglobin)
If there are concerning or symptoms persist refer to paediatrician or local gynaecologist
Adolescent Gynaecology - Lower Abdominal Pain
Key points
Pregnancy related causes of acute pelvic pain (ectopic pregnancy, miscarriage, placental
abruption and uterine rupture) should always be considered
Other surgical and medical causes for acute abdominal pain must be considered
Gynaecological causes for abdominal pain increase after puberty
Background
Abdominal pain is one of the most common symptoms reported in childhood and adolescence
This guideline focuses on gynaecological causes of abdominal and pelvic pain
The pain characteristics and associated symptoms may help differentiate between the
various gynaecologic causes of lower abdominal pain
For non-specific, episodic abdominal pain, consider chronic conditions such as constipation,
abdominal migraine and functional abdominal pain
Assessment
Red flag features in red
History
Menstrual history (menarche, last menstrual period, frequency, duration, flow)
Pain characteristics and associated symptoms (bowel, bladder, fever, nausea, vomiting)
Sexual history and contraception. If sexually active discuss safe sex and contraception
Systemic features: fever, weight loss, vomiting, headache
Adolescent assessment
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PAEDIATRIC MANUAL
Examination
Pallor, hypotension, tachycardia
Palpation of the abdomen for uterine or ovarian mass
Vaginal examination is rarely indicated in a child. Perineal inspection and vaginal

examination should be discussed with a senior clinician, and if needed should only be
performed once
Gynaecological causes of acute abdominal pain
Cause Clinical features
Critical
Ectopic pregnancy Abdominal pain, missed period with subsequent vaginal bleeding
Ovarian torsion Acute, sharp pelvic pain (moderate to severe), adnexal mass, often
with nausea and vomiting
Acute placental abruption Vaginal bleeding, abdominal and/or back pain, and uterine
contractions, in severe cases with disseminated intravascular
coagulation (DIC). Any gestation (peak between 24–26 week)
Uterine rupture Uterine tenderness, peritoneal irritation, vaginal bleeding and

abnormal foetal heart rate
Molar Pregnancy Vaginal bleeding, pelvic pain, an enlarged uterus and severe vomiting
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PAEDIATRIC MANUAL
Infection
Pelvic inflammatory Unprotected sex, post coital bleeding, mucopurulent discharge, lower
disease (PID) abdominal or pelvic pain, fever
Other
Pregnancy Early signs & symptoms can include: breast tenderness, vomiting,
bleeding, pelvic discomfort
Dysmenorrhoea Crampy and intermittent lower abdominal, suprapubic or back pain,

can have associated nausea, vomiting, headache, dizziness or fainting
Mittelschmerz Mild unilateral recurrent midcycle pain, caused by normal follicular

enlargement
Ruptured ovarian cyst Sudden, severe, unilateral pelvic pain, can be precipitated by
strenuous physical activity
Spontaneous miscarriage Early pregnancy crampy pelvic pain, vaginal bleeding, and passage of
some or all of the products of conception
Endometriosis Crampy pelvic pain associated with menses. Depending on its location
can be associated with pain on passing stool, urine or during sexual
intercourse
Functional abdominal pain Periumbilical or diffuse, variable location, exacerbated by stress,

functional impairment out of proportion, chronic duration
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PAEDIATRIC MANUAL
Management
Investigations
Many non-gynaecological causes of acute abdominal pain do not require investigation
If there is any concern for pregnancy perform (with consent) a ßhCG (urine and/or blood if
need a quantitative result)
For significant bleeding: FBE, blood group and antibody screen ± coagulation screen
Transabdominal (with full bladder) or transvaginal (in sexually active adolescents with
consent) pelvic ultrasound
For infective causes
Urine MCS to exclude UTI
Perform first pass urine (nucleic acid amplification tests) for Chlamydia trachomatis,
Neisseria gonorrhoeae and Trichomonas or an endocervical swab for gonorrhoea,
chlamydia and MCS
If high degree of concern for pelvic inflammatory disease perform FBE, CRP ± blood
culture if septic
Education about contraception and STI prevention, as well as STI screening, should be
offered opportunistically to all sexually active adolescents. This may include serology for
blood borne viruses depending on their sexual history and risk behaviour
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PAEDIATRIC MANUAL
Treatment
Treatment is targeted to the underlying cause
Consultation with local paediatric team when
Managing patients with hemodynamically instability, marked pain or unclear underlying

cause
Needing advice regarding escalation of care, if beyond the local centre capabilities
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PAEDIATRIC MANUAL
Stable and a review is scheduled with the GP
If there are concerning or persistent symptoms refer to paediatrician or local gynaecologist
Sexually Transmitted Infections (STIs)
Background
STIs are a major cause of female reproductive morbidity and have been associated with
spontaneous abortion, preterm labour, and pelvic inflammatory disease (PID), ectopic
pregnancy, chronic pelvic pain, and tubal-factor infertility
STIs are among the most common infectious diagnoses in adolescents. Any adolescent
diagnosed with any STI should undergo through STI screening including: gonorrhea,
Chlamydia, trichomoniasis, syphilis and HIV and proper referral to Infectious Disease
Specialist
50% of adolescents will be sexually active by age 18 (end of Year 12 completion)
Sexually transmitted infections are increasing in incidence in Australian Adolescents
Consider screening of any young person who has been previously or is currently sexually
active. Screening involved testing young females and males who are asymptomatic. In
general young men are more likely to be symptomatic of infection
Assessment
Provide a confidentiality statement, including the 3 exclusions
Risk of self harm/suicide
Risk of homicide
Suspicion of abuse
Risk assessment including: age of onset of sexual activity, gender of partner (increased risk
associated with male to male intercourse), contraceptive use, associated risk factors (in
both your patient and their partners) for transmission including intravenous drug use, sex
work, body piercing, tattoos and type of intercourse (anal, vaginal or oral)
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PAEDIATRIC MANUAL
Remember to consider the risk of pregnancy and test where appropriate
Assess the need for emergency contraception. Please discuss with the Gynaecologist on call
or gynae fellow for advice
Consider referral for ongoing contraceptive needs
Chlamydia trachomatis
60-70% of chlamydial endocervical infections in women are asymptomatic
In men, urethritis is the most common clinical presentation, representing 30-50% of all cases
of nongonococcal urethritis (NGU)
History
Urethral discharge is usually in the morning with mild dysuria (less copious and
purulent than gonococcal)
Women may have vaginal discharge, mid-cycle and/or post coital bleeding
Investigations
First pass urine sample for screening for Chlamydia (PCR)
Culture, direct inmunoflourescense and nucleic acid amplification tests (NAATs) for
endocervical specimen
Treatment
Uncomplicated infection of cervix, urethra and rectum (adult doses)
o Azithromycin 1 gr orally in a single dose or
o Doxycycline 100 mg twice a day for 7 days (not for children <8 yrs)
Neisseria gonorrhoeae
19-50% of asymptomatic infections in women
Co-infection with Chlamydia is twice as common in women with gonorrhea
History
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PAEDIATRIC MANUAL
Vaginal discharge, mid-cycle or post coital bleeding and dysuria
Investigations
Urine sample for screening of Neisseria Gonorrhoeae
Culture and NAATs on endocervical specimen
Treatment:
Ceftriaxone 125 mg IM in a single dose OR
Cefixime 400 mg orally in a single dose OR
PLUS treatment for Chlamydia
Trichomoniasis:
Adolescents may be asymptomatic
History
Presence of diffuse, malodorous, yellow-green vaginal discharge and vaginal itching.
Investigations
Microscopy of vaginal secretions
Culture of vaginal secretions
Treatment
Metronidazole 2 gr orally single dose OR
Metronidazole 500 mg orally twice a day for 7 days (extended course)
Topical therapy is not advice due to inadequate level of drug concentration found in
urethral and paracervical glands
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PAEDIATRIC MANUAL
Pelvic inflammatory disease
Polymicrobial inflammatory condition
Most commonly sequelae of undiagnosed or improperly treated C.trachomatis or

N.gonorrhoeae infections, although non-STI related PID is an established and recognize
entity
History
Presentation can range from asymptomatic to severe peritonitis and tubo-ovarian

abscess formation
Classic PID: dull abdominal pain, fever, vaginal discharge, abnormal vaginal bleeding
and symptom duration typically of 3 weeks
50% can present: Gastrointestinal symptoms, nausea and vomiting
Diagnostic criteria (CDC)
1. Uterine or adnexal or cervical motion tenderness on pelvic exam
2. Fever >38.5C
3. Cervical or vaginal mucopurulent discharge
4. Vaginal secretions with presence of White blood cells on microscopy
5. Elevated CRP and ESR
6. Lab documented: N. gonorrhoeae or C. trachomatis
Investigations
Endocervical swabs
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Treatment
Patients with the following criteria should be considered for admission and parenteral
therapy
1. Surgical emergencies, such as appendicitis, cannot be excluded
2. Pregnancy
3. The patient does not respond clinically to oral antimicrobial therapy
4. The patient is unable to follow or tolerate an outpatient oral regimen
5. The patient has severe illness, nausea, vomiting, or high fever
6. The patient has a tubo-ovarian abscess
7. The patient is immunodeficient (eg HIV infection with low CD4 counts,
immunosuppressive therapy) or has another disease
Parenteral Regimen
o Clindamycin 900 mg every 8 hrs PLUS
o Gentamicin loading dose (2 mg/kg) followed by maintenance dose of 7.5 mg

once day
Outpatient Oral Regimen
o Ceftriaxone 250 mg IM in a single dose PLUS
o Doxycycline 100 mg orally twice a day for 14 days (with or without

Metronidazole 500 mg orally twice a day for 14 days)
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All patients should be referred to Gynaecology
Syphilis
Primary infection: ulcer or chancre at the infection site
Secondary infection: manifestations that include, but are not limited to, skin rash,
mucocutaneous lesions, and lymphadenopathy
Tertiary infection: cardiac or ophthalmic manifestations, auditory abnormalities, or

gummatous lesions
Latent infections: lacking clinical manifestations are detected by serologic testing.
Investigations
Darkfield examinations and direct fluorescent antibody (DFA) tests of lesion exudate
Nontreponemal tests: VDRL and RPR
Treponemal tests: FTA-ABS and TP-PA]
Treatment
Primary and secondary syphilis
o Benzathine penicillin G50,000 units/kg IM, up to the adult dose of 2.4 million
units in a single dose
Early Latent Syphilis
o Benzathine penicillin G50,000 units/kg IM, up to the adult dose of 2.4 m in a

single dose
Late Latent Syphilis or Latent Syphilis of Unknown Duration
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o Benzathine penicillin G50,000 units/kg IM, up to the adult dose of 2.4 million
units, administered as 3 doses at 1-week intervals (total 150,000 units/kg up to
the adult total dose of 7.2 million units)
Tertiary syphilis
o Benzathine penicillin G7.2 million units total, administered as 3 doses of 2.4

million units IM each at 1-week intervals
All patients should be referred to Infectious Diseases
Prevention of STIs
Tailored patient education and counselling addressing specific risk factors and effective
changes in sexual behaviour
Identification of adolescents unlikely to seek health care services
Effective diagnosis and treatment
Appropriate evaluation and treatment of sex partners
Pre-exposure vaccination of persons at risk for vaccine-preventable STIs
Referral for follow up
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Vulval Ulcers
Background
Vulvar ulcers are rare in girls and young women, especially when they are not sexually
active.Most lesions are exquisitely painful and result in considerable anxiety and emotional
distress for both the patient and family, not to mention the physician's frustration in trying
to expediently diagnose and treat a lesion which is rarely seen in general practice.Parents
and physicians may also suspect sexual abuse, which can be very disconcerting. Most ulcers
in the paediatric population however are NOT sexually transmitted infections
The differential diagnosis of non-sexually transmitted vulvar ulcers is as follows (most

common in bold)
Aphthous ulcers(synonyms include aphthosis, canker sores, Lipschutz ulcers, ulcus

vulvae acutum)
Infectious
o HSV via autoinoculation
o EBV (self limited genital ulcers)
o CMV
o VZV (varicella or herpes zoster)
o Group A Strep
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o Mycoplasma
o Molluscum contagiosum
Autoimmune
o Crohn's disease (ulcers + GI symptoms)
o Behçet's disease (Aphtous genital ulcers that last for weeks and heal with
scarring)
o Vaculitis (LUPUS)
o Pemphigus and Pemphigoid (lesions may mimic lichen sclerosus with extensive
scarring)
Drug reactions
o Fixed drug eruptions(NAIDs, metronidazole, Acetaminophen, Sulfonamides,

Tetracycline, Phenitoyn, oral contraceptives, Barbiturates, Phenolphthaten)
o Stevens Johnson's syndrome/ toxic epidermal necrolysis
Other
o Erosive Lichen Sclerosus
o Hair removal folliculitis
o Epidermolysis bullosa
o Allergic contact dermatitis
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In sexually active young women, or in cases of sexual abuse, the differential diagnosis also
includes:
HSV (most common, multiple vesicles progressing to pustules over 10-14 days)
Syphilis (painless ulcer)
Rarely- Lymphogranuloma venereum and Chancroid (Ulcer is exquisitely painful and is

associated with suppurative inguinal adenopathy)
Assessment
History
The history should determine whether these are primary or recurrent lesions and the
evolution of it. A review of systems should include:
Systemic symptoms (fever, malaise, headache, GI symptoms, respiratory symptoms,

myalgia)
Oral ulcers, skin lesions, ocular symptoms
A family history of autoimmune disorders should be determined. Behçet's disease is more

common in families from Mediterranean countries, Turkey and the Middle East, and South
East Asia
Social history should be obtained confidentially, especially if there is a possibility of sexual

activity.
Examination
Assess for the following:
General appearance
Oral ulcers
Uveitis (Behçet's)
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Skin inspection (eczema, rash, other ulcers or bullae)
Lymphadenopathy (cervical, inguinal/femoral)
Size, shape, location of vulvar ulcer(s): Physical examination of the external genitalia
can be accomplished in the frog leg or knee chest position
Investigations: (send results to GP)
Non-sexually active:
Swabs
HSV 1 and 2, VZV
o PCR
OR
o Immunofluorescence
OR
o Culture
Gram stain and bacterial culture
Yeast Culture
Consider the following
Serology
o Herpes simplex (HSV-1/HSV-2)
o EBV (IgM and IgG) and/ or monotest
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o CMV and Mycoplasma
CRP and ESR
FBE
ANA and Consider HLA-B51 if Behçet's disease is a possibility
Sexually active
All of the above plus
Urine
Pregnancy test
PCR for Chlamydia (First pass urine test)
PCR for Gonorrhea (First pass urine test)
Serology
RPR (Rapid Plasma Reagin)
HIV
If non healing refer the patient for biopsy of lesion
Management
Because of the delay in results from most of the investigations, treatment is often
supportive, directed to pain relief, prevention of scarring and specific treatment based on
diagnosis. In severe cases where micturition is impossible secondary to pain, an in-dwelling
catheter may be required
Provide reassurance to parents and the patient that ulcers in young girls and women are
often not sexually transmitted, and that recurrence rates are low
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1. Remove all irritants
2. No pads, underwear, tight clothes
3. Pain relief
Salt baths and general vulvar hygiene are recommended
Spray bottles or voiding in the bath to reduce external dysuria
Petrolatum or zinc oxide barrier after soak
Topical anaesthetics (ie. Viscous Xylocaine, Lignocaine gel 2%)
Oral Analgesics ( NSAIDs)
4. Antiviral
Consider Aciclovir if primary HSV likely diagnosis
5. Steroids
Consider topical corticosteroids (Advantan fatty ointment) if aphthous ulcers or

Behçhet's disease most likely
6. Antibiotics: if bacterial infection suspected
7. Treatment of Sexually Transmited Infections (Refer to CPGs on STIs)
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8. Immunosuppressants: (Discuss with Reumathology Consultant if Behchet's disease and

aphtous ulcers is likely the diagnosis)
Referral
Most ulcers are self-limiting and can be followed up by the GP. If the ulcers are recurrent or
there are associated abnormalities to the underlying skin, then a referral to Gynaecology for
follow-up should be organized. If Behçet's disease is suspected, a referral to Rheumatology
may be useful. Dermatology or Infectious Diseases could also be consulted
Engaging With and Assessing the Adolescent Patient
Key points
Adolescence is a transitional phase of growth and development between childhood and

adulthood
Adolescents have the legal right to confidential health care
Adolescents less than 18 years old may be considered ‘mature minors’, capable of giving
informed consent
The HEEADSSS interview for psychosocial screening is an important component of adolescent

assessments
Background
What is adolescence?
Historically spanning from ages 12–18 years, approximating the phase between pubertal
onset and legal ‘independence’, and generally corresponding with attendance at high school
More recently the term has expanded to include young adulthood, up to 25 years of age
Adolescent health care considerations
Increased risk-taking behaviours and psychosocial issues, contributing to morbidity and

mortality
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Rarely access routine health care, so any contact should be an opportunity for preventative
health care
Some health services manage those aged >16 years through adult services or on adult
inpatient wards
Planning for transition to appropriate adult services should start well before age 18
Assessment
An adolescent consultation should include time with the adolescent and guardian/s together,
as well as dedicated time with the adolescent alone
Confidentiality and consent
Be explicit about confidentiality requirements and obtain permission prior to contacting

other relevant professionals, such as school or youth agencies
Adolescents have the legal right to confidential health care unless:
They cannot be considered a mature minor and/or
There is significant concern regarding risk (ie harm to self or others, physical or
sexual abuse)
Mature minors can give informed consent if they have sufficient understanding and
intelligence to enable full comprehension of what is proposed
Most adolescents aged 16–18 are presumed to be mature minors (legislation differs by
State)
Younger adolescents may sometimes be considered mature minors and be capable of

providing informed consent depending on the nature of the proposed intervention.
Interventions include history, physical examination, procedures and treatments
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Adolescents involved with child protection services require special consideration with
respect to confidentially and consent. The relevant State-based service may be able to assist
when consent cannot be obtained in the usual way
Psychosocial interview
The HEEADSSS interview is a useful screening tool, that can also aide engagement. It is best
completed with the adolescent alone
Parents should be asked if they have any concerns prior to leaving the room and again
at the close of the interview
Preface the interview by discussing confidentiality and explaining that you are about
to ask lots of personal questions about the adolescent’s life, interests and behaviours,
as these may be affecting their health and wellbeing
Try to use open-ended, non-judgmental questions that avoid assumptions
General statements instead of personalising questions can be less intrusive (eg "some
young people experiment with cigarettes, alcohol or drugs. In your year, do people
smoke/drink/use illicit drugs? What about your friends? And you?")
The HEEADSS framework is designed to progress from important but less threatening
questions to those considered highly personal
It is often not possible to cover every aspect of the interview in a single encounter.
You may focus on the most relevant areas for your patient or population
You may choose to end the psychosocial interview by asking the adolescent who they
can trust and confide in if they have problems
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The HEEADSSS psychosocial interview for adolescents
Who, where, recent changes (moves or new people), relationships, stress

Home
or violence, smartphone or computer use (in home vs room)
Education and Where, year, attendance, performance, relationships and bullying,

Employment supports, recent moves, disciplinary actions, future plans, work details
Weight and body shape (and relationship to these), recent changes, eating
Eating and Exercise
habits and dieting, exercise and menstrual history
Extra-curricular activities for fun: sport, organised groups, clubs, parties,

Activities
TV/computer use (how much screen time and what for)
Cigarettes, alcohol and illicit drug use by friends, family and patient.
Drugs and Alcohol Frequency, intensity, patterns of use, payment for, regrets and negative
consequences
Gender identity, romantic relationships, sexuality and sexual experiences,

Sexuality and Gender uncomfortable situations/sexual abuse, previous pregnancies and risk of
pregnancy, contraception and STIs
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Presence and frequency of feeling stressed, sad, down, ‘bored’, trouble

Suicide, Depression sleeping, online bullying, current feelings (eg on scale of 1 to 10). thoughts
and Self-harm or actions of self-harm/ hurting others, suicide risk: thoughts, attempts,
plans, means and hopes for future
Serious injuries, online safety (eg meeting people from online), riding with
Safety intoxicated driver, exposure to violence (school and community), if high
risk - carrying weapons, criminal behaviours, justice system
** HEEADSSS screen may be adapted for local use
Examination
General considerations for physical examination of an adolescent patient:
Use of a chaperone is recommended
Ensure privacy
For pubertal assessment (Tanner staging) consider asking the adolescent to make a
self-assessment
Management
General considerations
Depends on the issues identified during psychosocial interview
Adolescent health concerns can generally be viewed in terms of risk and protective factors
If there are significant health risk behaviours, devise an immediate management plan
which may include formal mental health assessment and admission (eg intentional
overdose)
Remember to document the adolescent’s contact details if follow-up is required
Consider opportunistic vaccination
Medicare cards
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Anyone over the age of 15 years should be encouraged to obtain their own Medicare card
Transition to adult services
Transition to adult services should be considered from mid-adolescence and include formal
support and education
Most health services will aim to transition an adolescent to adult services by their
18th birthday or once their final year of high school is completed
For complex cases, a period of overlap between paediatric and adult services may be
required to permit adequate communication between specialists and safe transition
Assessing any adolescent deemed to be at significant risk
Note: Depending on local resources and the adolescent’s presentation, mental health,
adolescent medicine or social work may be the most appropriate team to consult
An assessment by mental health staff including a risk assessment has been completed, if
indicated
A clear discharge destination has been established, with follow-up and referrals to necessary
services made
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Substance Use (Abuse)
Background
The assessment and management of patients presenting with acute intoxication, withdrawal
or toxicity can be demanding and potentially dangerous. Patients rapidly deteriorate or may
become extremely agitated, aggressive and violent. Young people may conceal or deny
substance use because of potential parent/guardian responses
It is important to note that a person's physiological, psychological and behavioural reaction

to a drug depends on:
Characteristics of the individual (eg age, size, gender, health state, mood etc.)
Pharmacology of the drug/s used
Pharmacokinetics of drug/s used
Dosage of the drug/s taken
Side effects or unwanted effects of the drug/s used
The setting in which the drug/s were used
Drug/s used in combination with other substances (inc. medicines, inhalants, herbal
preparations)
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Previous experience with the drug/s used
Assessment
Common symptoms and signs of intoxication include:
Slurred speech
Poor concentration
Altered perception
Agitation
Confusion
Disorientation
Unstable mood
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Vomiting, diarrhoea, incontinence
Exclude possible medical or biological reasons for the presentation (eg head injury, acute
infection, electrolyte imbalance, CVA, hypoglycemia, psychosis, severe liver disease etc.)
Take an Alcohol & other Drug (AOD) use history. Enquire about AOD use on the day of
presentation and the time and quantity of recently consumed substances. If the patient is
unwilling or unable to provide an AOD use history, attempt to identify collateral sources for
obtaining information i.e. companions, parents, family, guardians etc.
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Examine for physical signs of drug use such as puncture marks, cellulitis, phlebitis, skin
abscesses, nasal erosion, irritation or rash around nostrils, septum or mouth, evidence of
rectal damage, dehydration, rapid weight loss
Review the patient's general functioning and psychosocial circumstances. Consult with the
mental health service if background mental health issues are suspected. Small or infrequent
use of any substance in a young person with underlying psychological or psychiatric issues
may cause a dramatic and significant response
Management
General
Create a simple, quiet, and uncluttered environment - remove unnecessary equipment
Minimise the number of staff attending the patient
Treat the patient with respect
Approach in a quiet, calm and confident manner
Speak clearly and slowly
Use the patient's proper name when speaking to them
Always explain who you are and what you are doing
Acknowledge the patient's feelings and concerns
Provide frequent reassurance. Brief and frequent attendances will assist with this
and may avoid unnecessary agitation
Protect the patient from accidental harm (eg do not leave them unattended on a bed
without safety guards. Lower the bed as close to the floor as possible)
Provide regular reality orientation
For the confused/disoriented patient, keep an object familiar to them in view (eg a
bag or an item of clothing)
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Correct perceptual errors and tell the patient what is real (eg that the curtain does
not have snakes on it)
Accompany the person to and from places (eg toilet)
In the case of aggressive patients - use space for self-protection (eg ensure you have
easy access to the open door, do not 'crowd' them, keep furniture between yourself
and the person etc). Work in pairs or request security if you feel at risk
Be flexible when dealing an aggressive patient - try to identify the cause of their
anger and if possible, remove it
If a patient is refusing treatment and wishes to leave the hospital when it is unsafe to
do so, you may need to exercise your duty of care to ensure their safety and
wellbeing. Refer to Code response procedures. Consult senior staff
Stabilisation
Patients presenting as intoxicated or in withdrawal should be observed and monitored

closely as they are at risk of medical complication
Note that alcohol withdrawal can occur before a zero blood alcohol reading
Seizures may be an indication of alcohol withdrawal, benzodiazepine withdrawal or

stimulant intoxication
Disposition
Patients who appear to have stabilised after being intoxicated should be further assessed for
any possibility of withdrawal - early identification and treatment for withdrawal can prevent
potentially life-threatening complications
Following assessment and acute management of the intoxicated presentation, a referral to

the patient's primary health practitioner should be made. In appropriate circumstances a
referral to a specialist AOD or mental health service should be considered
If there are concerns about the young person's future care or safety due to AOD use please
consult with the RCH ED social worker or duty social worker about making a DHS notification
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Adrenal Crisis and Acute Adrenal Insufficiency
Key Points
Adrenal crisis most commonly presents in children with known adrenal insufficiency who
develop an intercurrent illness or injury
Consider a new presentation of adrenal insufficiency in a child presenting with unexplained

severe dehydration or shock
The classic triad for primary adrenal crisis is ↓ serum sodium, ↑ serum potassium, and ↓
serum glucose
The key elements of treatment include fluid resuscitation, steroid replacement and
management of glucose and potassium levels
Background
An adrenal crisis is a physiological event caused by an acute relative insufficiency of adrenal

hormones. It may be precipitated by physiological stress in a susceptible patient. It should
be considered in patients who have a history of:
Known primary adrenal insufficiency
Hypopituitarism (any known pituitary hormone deficit or clinical features indicating

increased risk), or
Previous or current prolonged course (2-4 weeks) of steroid therapy
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Adrenal crisis may also be the first presentation of underlying adrenal insufficiency or there
may be a history suggestive of chronic hypoadrenalism
Assessment
Red flag features in Red
History
Weakness
Fatigue
Anorexia
Dizziness/ Syncope
Nausea / vomiting
Weight loss
Confusion
Seizure
Screen for infective symptoms or injury as a trigger for presentation
Examination
Assess degree of dehydration
Hypotension, tachycardia
Pigmentation in skin creases, nail bed or scars (may be present in primary adrenal failure)
CNS signs (in Adrenoleukodystrophy)
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Confusion → coma
Management
Investigations
All children
Blood glucose (both bedside and formal): low in cortisol deficiency
UEC: hyperkalaemia and hyponatraemia indicates mineralocorticoid deficiency
Blood gas: Acidosis indicates mineralocorticoid deficiency
Additional investigations if first presentation (prior to steroid administration if possible)
Cortisol
ACTH
17 hydroxyprogesterone
Plasma renin activity
Urine: urinary steroid profile and urinary sodium
Treatment
Severely unwell – Unstable / in crisis or unwell (vomiting/diarrhoea, drowsy)
1. Steroid replacement
Give IV bolus of 50-100 mg/m2 hydrocortisone (Solu-CortefTM) immediately (dose for

age shown below). If IV access is not immediately available, give IM while
establishing intravenous access
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Consider repeating the IV/IM hydrocortisone dose if there is a poor response to initial
steroid and fluid treatment
Follow with hydrocortisone 6 hourly IV
When the child is stable, reduce the IV dose, or if tolerating oral medications, switch
to triple dose oral hydrocortisone replacement (~30-50 mg/m 2/day). This can then be
gradually reduced to maintenance levels following the advice of the local
Paediatric/Endocrinology team
Mineralocorticoid replacement: when the patent can tolerate oral fluids, start
fludrocortisone (FlorinefTM) at maintenance doses (usually 0.05 - 0.1 mg daily). Initial
correction is achieved with fluids and the mineralocorticoid activity of stress dose
hydrocortisone
Recommended doses of 'Stress' Hydrocortisone (given IM or IV) by age:
Age Initial dose of IM/IV hydrocortisone THEN hydrocortisone every 6 hours*
Neonate – 6 weeks 25 mg 5 – 10 mg
6 weeks – 3 yrs 25 mg 10 mg
3 yrs – 12 yrs 12.5 mg ages 3-6 yo 25 mg ages 6-12

50 mg
yo
≥12 years 100 mg 25 mg
*Note: some centres use continuous hydrocortisone infusions instead of intermittent dosing.
This should be done under the guidance of the local endocrinology team
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2. Intravenous fluids
Shock or moderate to severe dehydration
Give 0.9% sodium chloride (normal saline) 10-20 mL/kg during the first hour of
treatment. Repeat until circulation is restored
Replace remaining deficit + maintenance fluid requirements evenly over 24 hours with
0.9% sodium chloride and 5% glucose
Check pH, electrolytes and glucose frequently
o Blood gas and blood glucose hourly for 2 hours; then 2-4 hourly once
normoglycaemic and acidosis correcting
o U&E: 2 hourly initially
o Interval can then be extended once glucose stable and electrolytes normalising
o Avoid rapid rise in serum sodium
Mild or no dehydration
No bolus
1-1.5 x maintenance fluid volume as 0.9% sodium chloride and 5% glucose

administered evenly over 24 hours
Check electrolytes and glucose frequently as above / clinically indicated
3. Treat hypoglycaemia
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Hypoglycaemia is common in infants and small children with adrenal insufficiency
Give an IV bolus of 10% dextrose 2-5 mL/kg and recheck blood glucose level after 30
minutes to ensure recovery to >4.0 mmol/L
Continue to monitor as described above
Maintenance fluids may require up to 10% dextrose in 0.9% sodium chloride to

maintain normoglycaemia
4. Hyperkalaemia
This usually normalises with fluid, electrolyte and steroid replacement
Children with potassium >6.0 mmol/L should have ECG and be on cardiac monitoring
If potassium is >7.0 mmol/L and ECG changes of hyperkalaemia are present (eg.
peaked T waves ± wide QRS complex ± flattened P waves), treat with either calcium
gluconate or insulin infusion as per hyperkalaemia
5. Precipitating illness/injury
Identify and treat the illness or injury that precipitated the adrenal crisis
Management to prevent an adrenal crisis
Children with known adrenal insufficiency will have an individualised sick day management
plan. This should be followed in the first instance. The following guidance is for when there
is no sick day plan available
Moderately unwell
Moderate illness or injury and/or fever >38oC and tolerating oral intake and medicines
Give glucocorticoids 30 mg/m2/day and increase fluids and carbohydrates
Vomiting and diarrhoea
If one or two vomits give glucocorticoids 30 mg/m2/day
Increase fluids and carbohydrates
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If ongoing vomiting, consider child to have an imminent adrenal crisis, even if they
are otherwise well. This is because oral medications are not reliably absorbed in this
scenario
o Where there is an obvious cause eg. other family members with gastro, etc,
give an initial 'stress' dose of IV / IM hydrocortisone as above and observe for 4-
6 hours
o If there is any doubt as to the clinical status or ability to tolerate oral

hydrocortisone, admit for ongoing parenteral hydrocortisone
Mildly unwell
For example, respiratory or ear infection with no more than low grade fever <38 0C, looks
well, able to tolerate oral intake and no need for antibiotics
Increase dose of glucocorticoids to 20 mg/m2/day
In all cases of adrenal insufficiency
Severe electrolyte or glucose abnormalities
Children not responding to stress dose steroids
Haemodynamic instability
Children requiring care above the level of comfort of the local hospital
Consider discharge when:
Recovering from illness and
Back on usual dose of glucocorticoid
OR
Have a clear plan for weaning steroids
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Additional notes
Patients on corticosteroids should wear an identification disc or bracelet carrying the words
"Adrenal insufficiency: In emergency give hydrocortisone at 2 mg/kg IM / IV"
Patients with known adrenal insufficiency should have an adrenal action plan for managing
sick days
Adrenal Insufficiency Steroid Replacement Before and After Surgery Or

Procedure Requiring GA
Background
Children with known or suspected adrenal insufficiency require increased doses of

hydrocortisone in the peri-operative period. This is required to replace the body's usual
'stress' cortisol response in such a scenario; if adequate replacement is not given, an adrenal
crisis may be precipitated.
Recommended doses of 'Stress' Hydrocortisone (given IM or IV) at different ages*:
Neonate - 6 weeks: 25 mg stat initial dose, and then 5-10mg, 6 hourly
6 weeks up to 3 years: 25 mg stat initial dose, then 10mg, 6 hourly
Children aged between 3-12 50 mg stat initial dose, then 12.5 -25mg, 6 hourly
years: (use 12.5 mg as 6 hourly dose if aged 3-6 yrs or 25 mg 6
hourly if aged >7yrs)
Adolescents (13years+): 100 mg stat initial dose, then 25 mg, 6 hourly
For elective surgery, the 'initial' dose can be given at induction of anaesthesia (when an IV
line can be more easily sited), with 6 hourly parenteral dosing continuing thereafter
If the child requires emergency surgery, the initial dose should be administered without
delay and ongoing doses continued 6 hourly thereafter. Doses can be given IM if IV
access is not readily available
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Children having a short GA for an elective non-invasive procedure (eg MRI) should have an
initial 'stress' dose at induction. If clinically well and tolerating oral intake after the
procedure, they can then recommence their usual replacement therapy
*The doses outlined equate to approximately 50-75mg/m2 as a stat dose initially, followed by
50-75 mg per m2/day divided in 4 doses (6 hourly). These doses will also cover the patient's
mineralocorticoid replacement over this dosing period
Transition to oral steroid replacement therapy:
Please discuss with the endocrinology team who will advise on individual dosing schedules.
1. Hydrocortisone replacement:
Once the child is stable and tolerating oral intake post-op,
hydrocortisone cover can be changed to oral route. Initial dosing can be
given by tripling the child's usual hydrocortisone dose (where applicable)
for ~48 hours, followed by double the usual dose for ~48 hours, followed by a
return to maintenance therapy
If a child with suspected adrenal insufficiency has not previously been on replacement
therapy, the initial 'stress' oral hydrocortisone replacement should be at a dose of
between ~30-50 mg/m2/day. This can then be gradually reduced to maintenance
levels over ~4-5 days. Usual replacement requirements are ~10-15 mg/m 2/day for
patients with primary adrenal insufficiency, or ~5-8 mg/m 2/day in secondary adrenal
insufficiency
2. Mineralocorticoid replacement:
Patients with primary adrenal insufficiency require
mineralocorticoid as well as glucocorticoid replacement. The
mineralocorticoid activity of 'stress' parenteral doses of hydrocortisone
will cover this requirement in the initial period. Fludrocortisone (Florinef)
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replacement should be recommenced at usual maintenance doses once the

patient transitions to oral therapy. In a patient newly diagnosed with
primary adrenal insufficiency, the endocrine team will advise on dosing
(usually ~50-100mcg/day; higher doses required in neonates)
Adrenaline and Fluid Bolus Administration in Resuscitation
Introduction
The Australian Resuscitation Council recommends the administration of Adrenaline and 0.9%
Sodium Chloride bolus as treatment in the event of a cardiac arrest for Basic Life Support
(BLS) or Advanced Life Support (ALS).
NB-this guideline does not include BLS associated within neonatal inpatients cared for within
the Butterfly unit within the Royal Children’s Hospital
Aim
The purpose of this clinical guideline is to describe how to draw up and administer
intravenous (IV) or intraosseous (IO) adrenaline and fluid in a resuscitation situation.
Definition of terms
IV - Intravenous
IO - Intraosseous
Endorsed Clinicians - appropriately endorsed Registered Nurses, Doctors or Pharmacists.
Cardiac arrest – the sudden stoppage of effective heart action
Drawing up adrenaline
Adrenaline
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1:10 000 IV/IO for use in emergency resuscitation
0.1mL/kg of 1:10 000 Adrenaline = 10mcg/kg, (Maximum single dose of 1mg)
OR
0.01mL/kg of 1:1000 Adrenaline =10mcg/kg (Recommend drawing up the whole 1mL in

1:1000 adrenaline concentration vial and dilute with 9mL 0.9% Sodium Chloride for injection
so 0.1mL/kg dosage (10mcg/kg) is always administered
Equipment
1 x Vial 1:10 000 Adrenaline undiluted (May need further vials depending on patient size and
if repeated doses are required)
1 x 10mL luer lock syringe
1 x blunt drawing up needle
1 x 3 way tap
2 x drug labels
2 x 1, 3 & 5ml syringe depending on size of patient and dosage required
Red caps
Alcohol wipes
Procedure
Draw up the entire 10mL ampoule of 1:10,000 Adrenaline into a 10mL luer lock syringe with
a blunt needle. (Double check with another endorsed clinician and label clearly as per RCH
drug labelling guidelines)
Attach a 3 way tap to the10mL syringe
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Attach the appropriate size syringe for the required adrenaline dose to the 3 way tap to
draw up adrenaline (1mL, 3mL or 5mL). Label syringes clearly and place in silver drug tray
on Resuscitation trolley ready for use as required
Document any administered drug doses as given on resuscitation chart and MAR as ordered
by Doctor and signed by 2 Registered Clinicians
(NB:if the above process is leading to any delay in immediate access to adrenaline dose then
an initial dose can be drawn from the vial and then the remainder of the vial drawn up as
described above)
Example of how to draw up adrenaline
Check patency of IV cannula/ IO with 0.9% Sodium Chloride
Ensure the The Six Rights of Drug Administration as described in the medication
Management Procedure are adhered to
Following the protocol, administer prescribed dose of adrenaline once via IV/IO route
followed by 3-5mLl 0.9% Sodium Chloride. If adrenaline is not required urgently place red
bung on the end of the syringe and leave in silver drug tray on emergency trolley.
Drawing up 0.9% Sodium Chloride
Sodium Chloride Dosage
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If hypovolaemia is suspected as the cause of cardiorespiratory arrest, intravenous or

intraosseous crystalloid may be used initially for resuscitation] as a bolus of 20mL/kg.
Additional boluses of crystalloid or colloid solution should be titrated against the response
The recommended standard fluid resuscitation dose is 20mL/kg of 0.9% Sodium Chloride
followed by an additional dose if required
Drawing up 0.9% Sodium Chloride (Patients <20kg)
Equipment
500mL bag 0.9% Sodium Chloride (0.9% saline)
Green burette (Dosifix 150mL burette macro dropper)
2 x 3-way-taps
30 mL syringe
Alcohol wipes
Procedure
Connect both 3-way-taps to patient end of Dosifix green burette line
Attach 30mL syringe to 3 way tap furthest away from the patient for fluid
administration
Ensure rolling clamps are on
Endorsed clinician double check the 500mL 0.9% Sodium Chloride bag with second
endorsed clinician
Spike 0.9% sodium chloride bag, open clamps on burette line and prime line (including
3 way taps)
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Attach to patient using non-touch technique after cleansing IV/IO access with alcohol
wipe and administer as ordered. Bolus can be administered via gravity (not IO), or by
using the 30mL syringe attached to the 3-way-tap - the fluid is drawn from the
burette then manually infused into the patient’s access site
Drawing up 0.9% Sodium Chloride (Patients >20kg)
Equipment
500 mL bag 0.9% Sodium Chloride (0.9% saline)
Tuta hand pump set
2 x 3-way-taps
30mLsyringe
Alcohol wipes
Procedure
Connect both 3-way-taps to patient end of Tuta line
Attach 30mLsyringe to 3 way tap furthest away from the patient for fluid
administration
Ensure Tuta line clamps are on
Endorsed clinician double check the 500mL 0.9% Sodium Chloride bag with second
endorsed clinician
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Spike bag 0.9% Sodium Chloride bag, invert fluid chamber on line, open clamp and
prime line including 3 way taps
o Attach to patient using a non-touch technique after cleansing IV/IO access

with alcohol wipe and administer as ordered. Fluid can be rapidly infused by
squeezing fluid chamber on Tuta line with hand. Volume of fluid delivered is
assessed by observing the volume lines on the 500mL Sodium Chloride 0.9%
bag. Bolus can be also be administered by using the 30mL syringe attached to
the 3-way-tap-fluid is drawn from the burette into the syringe then manually
infused into patient’s access site
Acute management
Administration/application of intervention
Responsibilities of administration for Endorsed Clinicians:
Ensure patency of IV cannula before administering fluid bolus. Ensure the cannula site
can be visualised during fluid bolus
Ensure fluid bolus has been ordered by Medical staff (can be verbally in an
emergency)
During administration of fluid monitor IV cannula
Continue to monitor fluid bolus administration until completed
Once completed confirm the volume has been delivered to the Medical staff member
or Team Leader and Scribe
Document fluid bolus as per RCH documentation policy
Document Patient observations
Special Considerations
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Infection control
Patient safety alerts
Potential adverse events
Afebrile Seizures
Key Points
Aim to identify reversible cause and manage accordingly
Seizures lasting more than 5 minutes should be treated
EEG should not be routinely performed after a first afebrile seizure
Ensure parental education regarding safety and future seizures
Background
Unprovoked seizures are common in children with around 8% having a seizure by 15 years of
age. Most seizures are brief and self-limiting, generally ceasing within 5 minutes
Seizures should be treated immediately in the following situations:
Child actively seizing with duration unknown, or seizure for >5 minutes
Known pathology
o Meningitis
o Hypoxic injury
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o Trauma
Cardio-respiratory compromise
Assessment
Assessment and management should occur concurrently if the child is actively seizing
Key considerations in acute assessment
Duration of seizure including pre-hospital period
Past history: previous seizures and anti-seizure medication (management plan if in place),
neurological comorbidity (eg VP shunt, structural brain abnormality) renal failure
(hypertensive encephalopathy), endocrinopathy (electrolyte disturbance)
Focal features
Evidence of underlying cause that may require additional specific emergency management.
Underlying causes include:
Hypoglycaemia
Electrolyte disturbances
Meningitis
Drug/toxin overdose
Trauma
Stroke and intracranial haemorrhage
Age: treatable cause is more likely in children <6 months
History
Detailed chronological history of events and behaviours before, during and after the seizure
History should be taken from the child if possible and obtain bystander account
Ask about:
Aura, focal features
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Level of awareness
Recent trauma, consider non-accidental injury
Focality of limb or eye movement
Post-ictal phase/hemiparesis
Relevant past history
Family history of seizures or cardiac disorders/sudden death
History suggestive of absence seizures or myoclonic jerks, nocturnal events
Developmental history
Examination
Full neurological examination looking for any abnormal neurological findings, signs of
meningitis or raised intracranial pressure
Cardiovascular examination including BP and look for any signs that suggest an underlying
cause eg neurocutaneous stigmata, microcephaly
Red Flags
Head injury with delayed seizure
Developmental delay or regression
Headache prior to the seizure
Bleeding disorder, anticoagulation therapy
Drug/alcohol use
Focal signs
Differential diagnosis of seizure
Arrhythmia
Breath holding spell (episode occurs when the child is crying)
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Vasovagal syncope with anoxic seizure (postural change, preceded by dizziness and nausea)
Non-epileptic paroxysmal disorder
Management
Initial support
In most situations, observation for 5 minutes is appropriate whilst waiting for seizure to stop
spontaneously
Treat the child the way the parents will at home – keep safe and observe
At this stage there is no need to check oximetry or apply oxygen
Active seizure flowchart
Account for benzodiazepine doses given pre-hospital (eg by parents or paramedics)
If available, refer to patient specific seizure management plan in children with a known
seizure disorder
Do not give a medication if the child is allergic, has previously been unresponsive, or if
he/she already taking it
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Medications used in acute seizures
Medication Dose Comments
1st line
Midazolam 0.15 mg/kg IV/IM (max 10

mg)
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0.3 mg/kg buccal/IN (max 10

mg)
0.3 mg/kg IV/IO (max 10 mg)

IV dose preferable
Diazepam
Do not give IM
0.5 mg/kg PR (max 10 mg)
2nd line
Infuse undiluted into a large vein over 20

Loading dose: min (max rate 50 mg/min) in a monitored
Phenytoin
patient
20 mg/kg IV/IO
Do not give in age <1 month
Levetiracetam 40 mg/kg IV/IO (max 3g) Dilute to 50 mg/mL and infuse over 5 mins
Dilute to 20 mg/mL or weaker and infuse

over 20 mins (max rate 30 mg/min) in a
monitored patient.
Phenobarbitone 20 mg/kg IV/IO (Max 1g)
Stop infusion when seizure ceases
Commonly used in neonatal seizures
3rd line
2.5 mg/kg IV/IO stat

Propofol followed by infusion at 1-3 For refractory seizures requiring rapid
mg/kg/hr sequence induction and ventilation. Use only
with involvement of senior staff confident
Thiopentone 2-5 mg/kg IV/IO slowly stat
with airway management. Beware
followed by infusion at 1-4
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PAEDIATRIC MANUAL
mg/kg/hr
hypotension.
Midazolam
1 mcg/kg/min
infusion
Ketamine 1-2 mg/kg
Consider in children up to 6 months with

Pyridoxine 100 mg IV seizures refractory to standard
anticonvulsants
Post seizure care
Position child in recovery position, maintain airway
Monitor for further seizure activity
Consider investigations as appropriate
Investigations
Bloods
Blood glucose should be performed as soon as possible
Consider electrolytes, calcium and venous gas in the following circumstances:
Any seizure needing a second line agent
Children <6 months
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Medical comorbidity such as metabolic disorder, diabetes, dehydration
Child has not returned to baseline once the post-ictal phase and the effect of any
medication has passed
Imaging
Consider in the following circumstances:
Focal seizure
Patients requiring 3rd line agent
Children <6 months
Signs of elevated ICP
Bleeding disorder/anticoagulation
Child has not returned to baseline once the post-ictal phase and the effect of any
medication has passed
EEG
Rarely required in the acute setting
Not indicated as a routine test following all first seizures
Benign focal epilepsy of childhood (BFEC) (also known as benign childhood epilepsy with
centrotemporal spikes or benign rolandic epilepsy) and idiopathic generalised epilepsy (IGE)
are the most common causes of afebrile seizures in children. Diagnosis of either cannot be
confirmed without EEG. BFEC and IGE may not require treatment, so EEG confirmation is
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PAEDIATRIC MANUAL
usually not urgent. An EEG should generally be performed if a child has a second seizure. A
positive diagnosis can avoid the need for neuroimaging
Children <6 months
Prolonged seizures
Incomplete recovery
Focal seizures or post-ictal findings
Recurrent seizures without a diagnosis of epilepsy
Frequent/uncontrolled seizures in a child with known epilepsy
Developmental delay
Existing comorbidities
Consider admission for observation in children <6 months
Consider transfer to tertiary centre when
Children anticipated to require ICU level care (cardiorespiratory compromise)
In older children, when the child is back to baseline function with no red flags on history,
examination or presumed cause
All families should receive education prior to discharge which includes:
Explanation of risk of recurrence
Seizure first aid and management plan
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Advise parents to video events if safe to do so and keep a record
Provide written information
Consider need for emergency medication (buccal midazolam)
Follow-up after a first afebrile seizure
All children who have a first afebrile seizure should have medical follow up
EEG should not be routinely performed after a first afebrile seizure
Emergency Airway Management
Key points
Specific measures to optimise physiology should be undertaken prior to every emergency

intubation
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PAEDIATRIC MANUAL
Every emergency intubation should include early consideration of the need for help, clear
team member role allocation, a clear plan for unsuccessful intubation, and strategies to help
maintain situational awareness
An emergency intubation checklist and other cognitive aids should be used during emergency
airway management
Continuous wave-form end-tidal CO2 (ETCO2) should be used to confirm correct endotracheal
tube (ETT) position
If ETCO2 waveform is lost or child goes into cardiac arrest, reassess the child, commence
resuscitation measures and check ETT position (including direct visualisation)
Background
In emergencies, problems with airway management are rarely due to anatomically difficult
airways, and commonly due to physiologically or situationally difficult airways (operator
experience or staffing numbers)
The strongest predictors of adverse events are multiple intubation attempts, and respiratory
or cardiovascular failure as the indication for intubation
Preparation
Optimisation of the physiology
In a child with cardiac and respiratory compromise, optimise positioning, oxygenation,

breathing, circulation and perfusion prior to the induction of anaesthesia
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Strategies to optimise physiology
Hypoxia Elevate head of bed to up to 40 degrees
Pre-oxygenate with positive airway pressure / PEEP (BVM with PEEP valve, T-
piece, CPAP, BiPAP or HFNC)
Consider providing apnoeic oxygenation with nasal cannula oxygen 2 L/kg/min (15
L/min maximum)
Abort intubation attempt if saturations <93% or drop by 10% from baseline
Hypotension Fluid resuscitation 10–20 mL/kg
Consider push dose adrenaline 1 microg/kg (max 50 microg)* in non-arrested child

- can be repeated as required
Titrate induction agent dose (See Medication dosing section below)
Consider push dose adrenaline following induction
* Push dose adrenaline in the non-arrested child is NOT the same as the adrenaline dose
given in cardiac arrest
Assess the airway
Consult anaesthetics for assistance if difficult airway anticipated
Anticipate difficulty in oxygenation by bag mask ventilation, laryngoscopy, ETT, supraglottic

airway or rescue techniques
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Congenital syndromes involving micrognathia, macroglossia or midface hypoplasia and some

acquired conditions are often associated with difficult airways
There is an increased risk of airway obstruction in the setting of:
Head injury or intoxication (loss of pharyngeal tone)
Trauma (injury to the airway or compression due to neck haematoma)
Airway debris (teeth, vomitus, blood etc)
Facial or neck burns
Inhaled smoke or liquids even in the absence of burns to the face
Acquired conditions
Pre-surgical Airway burns / trauma / infections / tumours
Tonsillar hypertrophy
Tracheal anomalies (subglottic stenosis)
Sleep apnoea
Foreign body aspiration
Post-surgical Cervical spine fixation
Maxillofacial surgery
ENT surgery
Assess the situation
Do you need help? If your assessment of the child's airway, physiological condition, or the
skillset of your team raises concerns, maintain oxygenation and call for help before
administering any medications
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PAEDIATRIC MANUAL
Equipment preparation / monitoring / medications
An airway equipment template should be used to minimise errors during the procedure, see
an example template below. Individual centres may choose to use their own site-specific
templates
Equipment should be laid out on the airway equipment template prior to emergency
intubation. Equipment not on the template should be at the bedside and confirmed as
functioning (T-piece, suction, video laryngoscope)
Optimise positioning for intubation as shown in figure below by
Maintaining head in neutral position
Open and clear the airway
Consider using adjuncts such as nasopharyngeal and oropharyngeal airways
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PAEDIATRIC MANUAL
Example Emergency Airway Template
Monitoring should include: saturations, heart rate, respiratory rate, blood pressure (2-
minute cycle) and ETCO2
Induction agent and muscle relaxant should be chosen and drawn up (the dose administered
may be titrated according to the child's condition). Post-intubation sedation should be
prepared
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Medication dosing
Induction agent All induction agents can precipitate acute hypotension if used at
"normal" doses in unwell children; significant dose reduction is required
Ketamine (0.5–2 mg/kg) is the preferred default induction agent for

most emergency intubation scenarios
Muscle relaxant Higher doses may be required in unwell children to achieve normal
onset of action
Rocuronium (1.2–1.6 mg/kg) is the preferred default muscle relaxant

for emergency intubation
Pre-intubation checklist
The emergency intubation checklist should be read aloud in a challenge-response format by

the Team Leader prior to every emergency intubation, reassessing after any single failed
attempt
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PAEDIATRIC MANUAL
Management
Cricoid force (pressure)
Cricoid force is not routinely used for emergency intubation Cricoid force (application of
pressure to the cricoid cartilage to compress the oesophagus and prevent passive regurgitation of
gastric contents) is different from external laryngeal manipulation (movement of the trachea to
help glottic exposure)
Cricoid force in children compresses the trachea, making oxygenation and intubation more
difficult, results in oesophageal displacement and not compression, and decreases lower
oesophageal sphincter tone, making regurgitation more likely
Confirmation of tube position
Verification of correct endotracheal tube (ETT) placement is of vital importance as an

unrecognised oesophageal intubation can prove rapidly fatal. There is no single method
that is 100% reliable for the detection of correct placement of an ETT
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PAEDIATRIC MANUAL
The best indicators to confirm successful placement of the ETT:
1. Visualisation of ETT passing through the cords: direct visualisation may not always
be possible, especially in an anatomically difficult airway or an airway that is
obscured by blood, secretions or vomitus. Additional objective techniques should still
be used to confirm correct ETT position
If you cannot see the cords, do not try to pass the ETT. Remove laryngoscope,
reoxygenate, plan and perform subsequent attempts with a different intubator,
position of the child, or intubation technique
2. Continuous waveform capnography (ETCO2) is the best objective method of

confirmation of correct ETT placement. If the ETCO 2 reads zero, the tube could be in
the oesophagus or there is no cardiac output. Note that for children in cardiac arrest,
or those with markedly reduced perfusion, ETCO 2 determination may be less accurate.
In these situations, if the ETCO2 determination is inconclusive, other methods of
confirmation should be used
If ETCO2 waveform is lost or child goes into cardiac arrest, reassess the child,
commence resuscitation measures and check ETT position (including direct
visualisation)
If correct placement of the ETT is uncertain despite these measures, it should be removed
and reoxygenation commenced
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PAEDIATRIC MANUAL
Less reliable indicators
Auscultation: equal breath sounds should be heard on auscultation of both apices and high
in each axilla. Also listen over epigastrium during ventilation (for ETT in oesophagus)
Chest rise: equal rise and fall of chest during each ventilation
Misting of ETT: observe escape of air / moisture clouding on ETT
Pulse Oximetry: hypoxia is a relatively late (and ominous) sign with regard to determining
correct ETT position. There is a lag for a few seconds until saturations start coming up after
correct ETT insertion
CXR: only useful to assess the depth of insertion of the ETT
Ultrasound: point of care ultrasound by experienced clinician can also help confirm the
correct position of ETT
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PAEDIATRIC MANUAL
Example Emergency Airway Plan
~ 187 ~
PAEDIATRIC MANUAL
Plan D: If you Cannot Intubate, Cannot Oxygenate (CICO) Emergency
Post Intubation Care
Secure ETT with tape / fastener (eg HollisterTM)
Reconfirm ETT position as above
Commence ongoing sedation
Post Intubation Debriefing
Post intubation debriefing for team members should routinely occur. This can be a "hot" (as
soon as possible after the event) or "cold" (delayed) debrief
This should be short (5–10 mins)
This identifies technical and human factors that can be addressed to improve the safety of
future intubations
The attached debrief form may be used as a cognitive aid
No facility to manage intubated children is available at local hospital
~ 188 ~
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~ 189 ~
PAEDIATRIC MANUAL
Acute Upper Airway Obstruction
Key points
Allow children with acute upper airway obstruction to adopt a position of their choice and
avoid causing distress
Decompensation of acute upper airway obstruction can be rapid and requires emergency
airway management
In any child with severe acute upper airway obstruction, nebulised adrenaline may provide
temporary relief while awaiting other definitive measures
Background
Due to their size, infants are most at risk of severe upper airway obstruction
Children with pre-existing narrowing of the upper airway may fully obstruct with otherwise
minor acute upper airway swelling
Although croup is the most common cause of acute upper airway obstruction, other
diagnoses must always be considered
Assessment
Allow the child to settle quietly on parent’s lap in a position of their choice, and observe
closely with minimal examination
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PAEDIATRIC MANUAL
Rapidly assess airway patency and respiratory status:
Severe to complete
Moderate obstruction
Mild obstruction obstruction
Hypoxia (late sign)

Slow respiratory rate or marked
tachypnoea
Tachypnoea
Able to speak or cry, may be Sniffing or tripod position
Stridor
hoarse Agitated or drowsy conscious
Prolonged inspiratory time
Intermittent stridor or state
Moderate work of breathing,
occasional stertor Severe work of breathing
nasal flaring, grunting,
Minimal or no work of Markedly reduced or no air
paradoxical chest movement
breathing movement
Decreased air entry
Good air entry Silent gagging or coughing
Total obstruction will rapidly

progress to unconsciousness
and cardiorespiratory arrest
Differential diagnoses (the table below is not an exhaustive list)

Presentations, particularly the bacterial causes, often overlap
~ 191 ~
PAEDIATRIC MANUAL
Possible diagnosis Features
Young child (rare <3 months)

Rapid onset harsh barking cough
Croup Hoarse voice/cry
Stridor
May be febrile and miserable but systemically well
Swelling of the face and tongue

Wheeze
Anaphylaxis Urticarial rash
Allergen exposure
Haemodynamic compromise
Young child (or developmentally similar)

Very sudden onset
Inhaled foreign body Coughing, choking, vomiting episode (may not be
witnessed)
May have unilateral chest findings, wheeze
Reduced conscious state eg after drug or alcohol ingestion,

Reduced pharyngeal tone or size recent seizure, head injury (including NAI)
Pre-existing narrow or floppy upper airway
Retropharyngeal abscess Sore throat

Fever
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PAEDIATRIC MANUAL
Neck pain and stiffness or torticollis

Fullness and redness of posterior pharyngeal wall; may be
midline but can be laterally behind tonsil
Dysphagia and drooling
Severe sore throat (often unilateral)

Hot potato/muffled voice
Peritonsillar abscess (quinsy) Trismus
Swollen posterior palate and tonsil, with medial
displacement of tonsil and deviation of the uvula
Inadequate Hib immunisation or immunocompromised

High fever and systemically unwell
Epiglottitis Muffled voice

Hyperextension of neck
Dysphagia
Pooling of secretions, drooling
Absent cough
Low pitched expiratory stridor or stertor
Systemically unwell
More severe and rapidly progressive symptoms
Bacterial tracheitis Recent URTI
Markedly tender trachea
Cough may be productive with thick secretions
Ludwig angina (infection of the Swollen, tender floor of mouth and under tongue
sublingual and submandibular Facial laceration or dental abscess
spaces) Submandibular swelling
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PAEDIATRIC MANUAL
Burns elsewhere, especially facial

Airway burns Singed nasal hairs
Sooty sputum
Bruising and swelling of the neck

Trauma Subcutaneous emphysema
May progress to pneumothorax / pneumomediastinum
Management
Investigations
Children with moderate to severe upper airway obstruction are at high risk of deterioration
and complete obstruction if they are upset, sedated or repositioned. Investigations should be
deferred until the airway is secure
If IV access is required use appropriate analgesia and distraction techniques to minimise

distress
Children with croup do not require any investigations
X-ray (chest and/or soft tissue neck) or CT may be helpful in identifying the location and
nature of upper airway obstruction
Treatment
If emergency airway management is required, it will be a “difficult airway”. Involve the

most senior clinician available ± anaesthetic or ENT support
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PAEDIATRIC MANUAL
If awaiting other definitive measures:
Oxygen can be given. It may improve saturations but does not relieve obstruction
Consider nebulised adrenaline to provide temporary relief in any life-threatening

upper airway obstruction
Consider dexamethasone 0.6 mg/kg IM/IV/oral to reduce swelling if present
For intubation, use an endotracheal tube ½ to 1 size smaller than usual for age. Cuffed
tubes allow for cuff inflation if leak develops when obstruction begins to resolve. Gaseous
induction methods are preferred
See croup for specific management
Treat the specific cause. For bacterial infections refer to local antimicrobial guidelines
Child has moderate acute upper airway obstruction
Consider consultation with anaesthetics and/or ENT:
Child with severe acute upper airway obstruction
Child is at risk of deteriorating due to known difficult airway
Child is at risk of deteriorating and requires airway management beyond the capability of
available local services
The cause for the acute upper airway obstruction has been identified and symptoms and
signs of acute upper airway obstruction have resolved, or are mild and improving
Appropriate management undertaken and an adequate follow up plan is in place
Alkalis Poisoning
Alkalis include Drain cleaners, Oven cleaners
~ 195 ~
PAEDIATRIC MANUAL
Automatic dish washing liquids and powders
Laundry detergents, Ammonia
Portland cement
pH of >11.5 is likely to cause significant GI ulceration
Attempt to obtain container to check contents and strength of substance
Corrosive potential varies with concentration of specific ingredients and preparations, i.e.
liquid preparations are more likely to cause oesophageal burns than powders
Check preparations with Poisons Information Centre to determine whether ingested

substance is weak, strong, irritant or corrosive in nature
Assessment
Toxicity
Exposure may lead to severe burns of GIT, especially oesophagus
Absence of mouth or pharyngeal ulcers does not preclude gastro-oesophageal lesions
Symptoms (may be Pain

minimal) Nausea and vomiting, drooling or refusing to eat and drink
Stridor, respiratory distress
Management
Activated charcoal is contraindicated
If asymptomatic treat with fluid dilution: 10 ml/kg of water (max 250 ml)
If asymptomatic after 4 hours and able to eat and drink the patient can be safely discharged
If any symptoms, contact surgical registrar, and admit for oesophagoscopy
Brief Resolved Unexplained Event BRUE
Key Points
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PAEDIATRIC MANUAL
A BRUE (Brief Resolved Unexplained Event) is an event in an infant that is characterised by a

marked change in breathing, tone, colour or level of responsiveness, followed by a complete
return to a baseline state, and that cannot be explained by a medical cause
A BRUE is a diagnosis of exclusion. There are many diagnosable conditions that cause
symptoms similar to that of a BRUE
Infants who have had a BRUE can be stratified into groups of low and high risk of having a
repeat event or a serious underlying disorder
A low risk BRUE may be safely managed in an outpatient setting
Background
The term Apparent Life Threatening Event (ALTE) has been replaced by BRUE
A BRUE refers to an episode in an infant less than 12 months old which is:
Duration <1 minute (typically 20-30 seconds)
Sudden onset, accompanied by a return to a baseline state
Characterised by ≥1 of the following:
o Cyanosis or pallor
o Absent, decreased or irregular breathing
o Marked change in tone (hypertonia or hypotonia)
o Altered level of responsiveness
Not explained by identifiable medical conditions
Assessment
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The assessment of the event should be directed at determining if there is a cause for the
event and to assess for risk factors for recurrence. The differential diagnoses of these events
are broad
Differential diagnoses
Airway: obstruction, inhaled foreign body, laryngospasm, congenital abnormalities, infection
Cardiac: congenital heart disease, vascular ring, arrhythmias, prolonged QT
Abdominal: intussusception, strangulated hernia, testicular torsion
Infection: pertussis, sepsis, pneumonia, meningitis
Metabolic: hypoglycaemia, hypocalcaemia, hypokalaemia, other inborn errors of metabolism
Toxins/Drugs/Ingestions: accidental or non-accidental
Inflicted injury
History
History should be taken, ideally first-hand, from someone who observed the infant during or
immediately after the event. Key features of history should include:
Description of event
Choking, gagging
Breathing: struggling to breathe, pause, apnoea
Colour and colour distribution: normal, cyanosis, pallor, plethora
Distress
Conscious state: responsive to voice, touch, or visual stimulus
Tone: stiff, floppy, or normal
Movement (including eyes): purposeful, repetitive
Circumstances and environment prior to event
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PAEDIATRIC MANUAL
Awake or asleep
Relationship of the event to feeding and history of vomiting
Position (prone/supine/side)
Environment: sleeping arrangement, co-sleeping, temperature, bedding
Objects nearby that could be swallowed, cause choking or suffocation
Illness in preceding days
End of event
Duration of event
Circumstances of cessation: self-resolved, repositioned, stimulation, mouth to mouth

and/or chest compressions
Recovery phase: rapid or gradual
Other history
Past medical history including previous similar events
Preceding/intercurrent illness
Sick contacts
Family history of sudden death or significant childhood illness
Patient medications, medications or other drugs within the home
Social history – parental supports, psychosocial assessment
Examination
A detailed general physical examination is required, bearing in mind the differential

diagnoses
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Risk Stratification
It is common for no specific diagnosis to be made after evaluation and a period of

observation. The most common cause of these events is thought to be exaggerated airway
reflexes in the setting of feeding, reflux, or increased upper airway secretions
If the infant has fully recovered, has benign examination findings and the event meets the
criteria for a BRUE, the event can be risk stratified
A low risk BRUE occurs when there are no concerning features on history or examination AND
all of the following:
Age >60 days
Born ≥32 weeks gestation and corrected gestational age ≥45 weeks
No CPR by trained healthcare professional
First event
Event lasted <1 minute
A low risk BRUE is unlikely to represent a presentation of a severe underlying disorder and is
unlikely to recur
Management
Investigations
A low risk BRUE does not require any investigations
For similar events that fall outside the low risk BRUE criteria, consider performing the
following investigations
ECG (measure QT interval)
Nasopharyngeal sample for viruses and pertussis
Blood glucose
FBE and UEC if clinically indicated
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PAEDIATRIC MANUAL
Treatment
If the infant requires ongoing acute treatment, the event is not considered to be a BRUE
It should be acknowledged with the family that these events are highly anxiety provoking
and parents often feel that their child has nearly died
Infants who have had a low risk BRUE may be discharged safely if their parents feel
reassured and capable of caring for their infant at home
If discharged, it is recommended that these infants have early medical follow up. In
practice, many infants with a low risk BRUE are admitted to hospital for observation for
parental reassurance
Infants with a high-risk BRUE may still have a benign cause for their symptoms but should be
admitted for observation, pulse oximetry (or cardiac telemetry if clinical suspicion of
arrhythmia) and paediatric review
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The event does not meet low risk BRUE criteria
There is a concern of a serious underlying disorder
There is low clinical suspicion of a serious underlying disorder and the parents are reassured
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Anaemia
Key Points
In Australia, the prevalence of anaemia in children under the age of 5 years is about 8%,
corresponding to over 100,000 preschool children
Iron deficiency is the most common cause of anaemia in children
Background
This guideline is adapted from the National Blood Authority (NBA) Patient Blood Management
Guidelines: Module 6 Neonatal and Paediatrics (2016)
Definition
Anaemia is defined as Haemoglobin (Hb) less than the lower limit of the reference range for
age
Age Lower limit of normal range Hb (g/L)
2 months 90
2 – 6 months 95
6 – 24 months 105
2 – 11 years 115
Female – 120
>12 years
Male - 130
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PAEDIATRIC MANUAL
Assessment
History
Ethnic background can be helpful in guiding workup for haemoglobinopathies and G6PD
deficiency
Medication history: past and current, particularly those that may cause haemolysis in the
instance of G6PD deficiency
Dietary history: iron intake (with particular attention to iron-rich foods, breast feeding and
cow’s milk intake), vitamin B12 intake, recent fava/broad bean ingestion (may precipitate
haemolysis in the case of G6PD deficiency)
Family history: anaemia, jaundice, gallstones or splenomegaly
Examination
Clinical features suggestive of anaemia:
Pallor
Pale conjunctivae
Tachycardia
Cardiac murmur
Lethargy
Listlessness
Poor growth
Poor concentration
Weakness
Shortness of breath
Signs of cardiac failure
Signs of haemolysis include jaundice, scleral icterus, splenomegaly and dark urine
Management
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Investigations
If anaemia is suspected begin with a full blood examination including blood film (FBC),
ferritin and reticulocyte count
Iron studies or serum iron should not be requested to diagnose iron deficiency. Serum iron
reflects recent iron intake and does not provide a measure of the iron stores
The initial classification is based on the Mean Corpuscular Volume (MCV):
Red flags
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PAEDIATRIC MANUAL
Hb <60 g/L (including iron deficiency)
Tachycardia, cardiac murmur or signs of cardiac failure
Features of haemolysis (dark urine, jaundice, scleral icterus)
Associated reticulocytopenia
Presence of nucleated red blood cells on blood film
Associated thrombocytopenia or neutropenia may indicate malignancy or an infiltrative

disorder
Severe vitamin B12 or folate deficiency
Need for red cell transfusion: Where possible defer transfusion until a definitive diagnosis is
made
Microcytic Hypochromic Anaemia
Beta Thalassaemia minor/trait
Carrier of beta thalassaemia
Frequently seen in South East Asian, Mediterranean, Arabic families
Usually asymptomatic
There may be a positive family history
Microcytic hypochromic red cells with normal or borderline low Hb
Diagnosed on HPLC or Hb electrophoresis - HbA2 > 3.5%, often elevated Hb F
Red cell distribution width (RDW) is often normal
Pre-pregnancy carrier testing of partner is important (Ensure parents have been tested if
likely to have more children)
Note: HbA2 may not be elevated in the presence of concomitant iron deficiency, therefore
give iron treatment (if ferritin low) before ordering test
Alpha Thalassaemia minor/trait
Carrier of alpha thalassaemia

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Commonly seen in South East Asian, African, Mediterranean, Arabic families
Microcytic hypochromic red cells with normal or borderline low Hb
Cannot be diagnosed on HPLC or Hb electrophoresis - DNA testing required for formal

diagnosis (not a first-line investigation - exclude other causes first)
Pre-pregnancy carrier testing of partner is important
Rare causes of Microcytic Anaemia
Chronic inflammation
Lead poisoning (high blood lead level)
Sideroblastic anaemia
Normocytic Normochromic Anaemia
Haemolytic anaemia
Acute haemolysis in childhood can be a life threatening illness and all cases should be
discussed with a Haematologist
Children with haemolytic anaemia should be admitted for observation, they need frequent
heart rate assessment and monitoring looking for tachycardia which may indicate a further
drop in Hb
The FBC should be repeated within 6-12 hours to detect ongoing haemolysis
In addition, reticulocyte count and bilirubin should be monitored
Additional investigations will be guided by red blood film findings e.g. Coombs (DAT) Blood
group and antibody screening (BGAB), G6PD assay and Eosin-5 maleimide red cell staining
(diagnosis of hereditary spherocytosis)
Sickle cell anaemia
Hypoplastic/Aplastic Anaemia
(eg acute leukaemia, aplastic anaemia, infiltrative disorders)
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PAEDIATRIC MANUAL
May be due to drugs eg cytotoxics, chloramphenicol, sulfonamides or viral infection
May be seen in severe nutritional deficiencies (vitamin B12 or folate deficiency) but usually
children present with macrocytic red cells
Reticulocyte count is usually low
Consider bone marrow infiltration if neutrophils and/or platelets also decreased
If isolated anaemia with low reticulocyte count with normal platelet and neutrophil counts
consider transient erythroblastopenia of childhood (TEC) or congenital forms (eg Diamond-
Blackfan anaemia)
Bone marrow aspirate is usually required for diagnosis
Chronic disease
Normochromic normocytic anaemia can be seen with chronic inflammation and chronic
disease such as renal disease
Reticulocyte may be low
Platelet count may be elevated
Further investigation with UEC, LFT and ESR may be indicated depending on clinical history
Blood loss
Normochromic normocytic anaemia can be seen with acute blood loss
Reticulocyte count may be normal or elevated
Suggest correlation with any bleeding symptoms
Macrocytic Anaemia
Vitamin B12 and folate deficiency
~ 208 ~
PAEDIATRIC MANUAL
Can be associated with failure to thrive or neurodevelopmental problems. (regression,

seizures, irritability, poor feeding)
Vitamin B12 deficiency may be seen in exclusively breast-fed infants of mothers with vitamin
B12 deficiency, children with a vegan or vegetarian diet, pernicious anaemia and metabolic
disorders
Characteristic blood film findings include teardrop red cells and hypersegmented neutrophils
and often neutropenia or thrombocytopenia
Needs urgent investigation with red cell folate and active vitamin B12
If low active vitamin B12 suggest serum homocysteine and urine methylmalonic acid
Treatment must be commenced urgently, particularly if neurological symptoms or regression
Other causes of red cell macrocytosis with or without anaemia
Myelodysplasia
Medications
Secondary to medications such as anticonvulsants, immunosuppressives and

zidovudine
Liver disease
Hypothyroidism
When red flags identified (see list above)
Consider transfer when:
Children requiring care beyond the level of comfort of the local hospital
Additional Notes
Other features on the blood film appearance that prompt further investigation
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PAEDIATRIC MANUAL
Film features Cause Investigation
Ferritin
Iron deficiency anaemia
Target cells Haemoglobinopathy testing
Haemoglobinopathies
(HPLC/Hb Electrophoresis)
Ferritin
Elliptocytes or pencil Iron deficiency anaemia
Haemoglobinopathy testing
cells Haemoglobinopathies
DAT
Hereditary spherocytosis
Spherocytes BGAB (Blood group)
Autoimmune haemolysis
Eosin 5 maleimide (E5M)
Platelet count
Bilirubin, Reticulocyte count

Fragmented red cells Haemolysis
Urea + Creatinine
Coagulation profile
Bite and blister cells G6PD deficiency G6PD assay
Consider bone marrow examination

Nucleated red blood Bone marrow infiltration
Thalassaemia testing (HPLC/Hb
cells Haemolysis
Electrophoresis)
Haemoglobinopathy testing
Sickle cells Sickle cell anaemia
~ 210 ~
PAEDIATRIC MANUAL
May need bone marrow

Bone marrow infiltration
Tear drop cells examination
Vitamin B12 deficiency
Active vitamin B12
Anaphylaxis
Key points
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PAEDIATRIC MANUAL
Anaphylaxis is a multi-system severe allergic reaction characterised by an acute onset

of cardiovascular (eg hypotension) or respiratory (eg bronchospasm) symptoms. It is usually
associated with typical skin features (urticarial rash or erythema/flushing and/or
angioedema) and/or persistent severe gastrointestinal symptoms
Treatment of anaphylaxis is intra-muscular adrenaline 10 microgram/kg or 0.01 mL/kg

of 1:1000 (maximum 0.5 mL), into lateral thigh which should be repeated after 5 minutes if
the child is not improving
In children with possible anaphylaxis and known asthma, always give adrenaline first, then
asthma medicines
Do not allow children with anaphylaxis to stand or walk
Background
Most reactions occur within 30 minutes of exposure to a trigger but can occur up to 4 hours
later
Causes of anaphylaxis in children include:
Foods: Peanut, tree nuts, cow milk, eggs, soy, shellfish, fish, wheat
Bites/stings: Bee, wasp, jack jumper ants, ticks
Medications: Beta-lactams, NSAIDs
Other: Exercise, idiopathic, rubber latex (bottle nipples, pacifiers, toys)
Newer monoclonal antibody therapies may produce delayed anaphylactic reactions and
rebound symptoms that occur more than 12 hours after the initial reaction
NB: a cause is not identified in 20% of cases
Assessment
Identify risk factors for fatal anaphylaxis
Delay to administration of adrenaline or emergency response services
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PAEDIATRIC MANUAL
Poorly controlled asthma
Allergy to nuts, shellfish, drugs and insect stings
Adolescence
Pre-existing cardiac and respiratory conditions
Anaphylaxis is a clinical diagnosis made in the setting of the acute onset of either:
1. Typical skin features (urticaria, flushing and/or angioedema) plus features of

anaphylaxis involving one or more system
OR
2. Hypotension, bronchospasm or upper airway obstruction where anaphylaxis is

possible
A detailed history of pre-hospital events is vital to confirm anaphylaxis and its associated
trigger(s)
Clinical features
System Features of anaphylaxis
~ 213 ~
PAEDIATRIC MANUAL
Persistent cough
Wheeze, stridor, hoarse voice, difficulty talking or change in
character of cry
Respiratory (most common in
Tongue swelling
children)
Chest pain or dyspnoea
Subjective feeling of swelling, tightness or tingling the throat or
mouth
Pale and floppy (infant)

Palpitations, tachycardia, bradycardia
Cardiovascular Hypotension, pallor
Collapse with or without unconsciousness
Cardiac arrest
Headache (usually throbbing)

Neurological Dizziness
Altered consciousness, confusion, sudden behaviour change
Nausea, vomiting, dysphagia

Gastrointestinal Diarrhoea
Abdominal or pelvic pain
Urticarial rash
Erythema, flushing, tearing
Dermatological
Angioedema
Pruritus (skin, eyes, nose, throat, mouth)
Management
Investigations
~ 214 ~
PAEDIATRIC MANUAL
Anaphylaxis is a clinical diagnosis. A serum tryptase has no role in acute management of

anaphylaxis. It should only be ordered after consultation with a paediatric allergy specialist
in special circumstances
Treatment
Remove allergen if still present (eg insect stinger, food debris in mouth)
Lay patient flat. Do not allow the child to stand or walk. Fatality can occur within seconds
if the child stands or sits suddenly. Treat the child in the supine position or lying on their
side. If a vomiting child is sat upright, monitor for hypotension
Intramuscular adrenaline 10 microgram/kg or 0.01 mL/kg of 1:1000 (maximum 0.5 mL) ,

into lateral thigh which should be repeated after 5 minutes if the child is not improving
Do not use SC adrenaline, as absorption is less reliable than the IM route
Do not use IV bolus adrenaline unless cardiac arrest is imminent
Use an adrenaline autoinjector if unable to calculate exact dose or to avoid delay, including
in children <1 year old
The following doses of adrenaline may be used
~ 215 ~
PAEDIATRIC MANUAL
Adrenaline doses
Volume of 1:1000
Age (years) Weight (kg) Adrenaline autoinjectors
adrenaline (mL)
<1 <7.5 kg 0.1 mL Not available
<1 - 2 7.5 – 10 0.1 mL
0.15 mg device
2–3 15 0.15 mL
4–5 18 0.18 mL
5–6 20 0.2 mL 0.3 mg device
7 – 10 30 0.3 mL
10 – 12 40 0.4 mL
>12 and adults >50 0.5 mL 0.3 mg or 0.5 mg device
Give oxygen
If not improving, give a second dose of adrenaline, consult senior staff and consider
adrenaline infusion (0.05 - 0.5 microgram/kg/min)
Continue giving IM adrenaline every 5 minutes until IV access is obtained
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PAEDIATRIC MANUAL
Other treatments to consider
Repeated doses of IM adrenaline together with
Nebulised or MDI salbutamol is recommended if the child has respiratory distress with
wheezing. Also consider other anti-asthma medications
Antihistamines may be given for symptomatic relief of pruritus. Second generation

antihistamines are preferred (eg cetirizine). Avoid promethazine as it can cause
hypotension
Corticosteroids and leukotriene antagonists have no proven benefit in anaphylaxis
Avoid NSAIDs
~ 217 ~
PAEDIATRIC MANUAL
Observation and admission
All children with anaphylaxis should be observed for at least 4 hours in a supervised setting
with facilities to manage deterioration
Admission for a minimum 12-hour period of observation is recommended if:
Further treatment is required within 4 hours of last adrenaline administration

(biphasic or prolonged reaction)
Previous history of biphasic reaction
Poorly controlled asthma
The child lives in an isolated location with delay to emergency services
Anaphylaxis to monoclonal antibody
The acute care setting should provide resources, education and follow up options to the
family including:
1. Update the medical record highlighting suspected allergen to avoid, and health
department notification if applicable
2. Anaphylaxis action plans for home, school and/or other care settings if applicable
3. Two EpiPens®/ EpiPens Jnr®/ Anapens® and training in correct use with an
Epipen/Anapen trainer. Current dose recommendations are:
7.5 - 20 kg = EpiPen Jnr® or Anapen® (150 microgram)
>20 kg = EpiPen® or Anapen® (300 microgram)
>50 kg = Anapen® (500 microgram)
4. Consider provision of a Medicalert bracelet
5. All children with anaphylaxis should be referred to a paedatrician or paediatric allergy

specialist. Review is ideal as soon as possible after the episode
~ 218 ~
PAEDIATRIC MANUAL
6. Ensure that asthma control is addressed including diagnosis, action plan, and
preventers, as asthma is an independent risk factor for fatal anaphylaxis
Peripheral IV adrenaline infusion
This should only be done in consultation with a senior staff member. Avoid high infusion
rates for more than two hours as it may cause fluid overload
Check local health service adrenaline infusion guidelines. Below is an example guideline:
Mix 1 mL of 1:1000 adrenaline in 1000 mL of fluid
Suitable fluids are glucose 5%, glucose 10%, sodium chloride 0.9% saline and glucose
with sodium chloride combinations
Start infusion at 5 mL/kg/hr (this is equal to 0.1 microgram/kg/minute)
A dedicated line, infusion pump and anti-reflux valves should be used when possible
Titrate dose according to response and side-effects
Monitor continuously (all vitals, 12-lead ECG and conscious state)
If possible, insert a second IV as fluid boluses may be needed
If hypotensive, resuscitate with fluid; use boluses of 20 mL/kg of sodium chloride 0.9%
for shock
Nebulised adrenaline is not recommended as first-line therapy, but may be a useful

adjunct after IM adrenaline if upper airway obstruction or bronchospasm is present
If airway oedema is not responding to parenteral (IM, IV) and nebulised

adrenaline, early intubation is indicated
~ 219 ~
PAEDIATRIC MANUAL
High risk of fatal anaphylaxis
More than one dose of adrenaline required
First diagnosis of anaphylaxis
Anaphylaxis to monoclonal antibody
Inadequate adrenaline response
Multiple doses of adrenaline
Adrenaline infusion
Immediate life-threatening situation
A child requiring care beyond the comfort level of the hospital
NB: Also consider consultation with paediatric allergy/immunology team
See Observation and Admission section above
Additional notes
In Victoria it is a requirement to notify all cases of anaphylaxis presenting to hospital, to the

Department of Health and Human Services (this does not include cases arising in hospital)
Where the suspected cause is the consumption of a packaged food, notifications are
required to be made immediately (within 24 hours of diagnosis) by telephone (1300 651 160,
which is staffed 24 hours a day, seven days a week)
Where the suspected cause is anything other than packaged food, notifications are required
to be made within five days of initial diagnosis of anaphylaxis and electronically via
the online form through the department's web
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PAEDIATRIC MANUAL
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PAEDIATRIC MANUAL
~ 222 ~

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PAEDIATRIC

Abdominal Pain - Acute

Symptoms in neonates may be attributed by parents as abdominal pain. A thorough

Common and time critical causes of abdominal pain by age

Neonates Infants and Children Adolescents

Hirschprung enterocolitis Appendicitis

Important non-abdominal causes of abdominal pain to consider:

Sexually transmitted infection

Toxin exposure or overdose

Underlying condition Potential complications causing abdominal pain

Hirschprung disease Enterocolitis

Liver disease and/or ascites Primary bacterial peritonitis

Inflammatory bowel disease Toxic megacolon

Observe the child's movements, gait, position and level of comfort

Examine the abdomen for:

Focal vs generalised tenderness

Assess for non-abdominal causes (list above)

Most children need no investigations

Investigations to consider, depending on differential diagnosis, may include:

Urine analysis (+/- culture +/- pregnancy test if indicated)

Electrolytes +/- LFTs

lipase for pancreatitis

venous blood gas

blood sugar for DKA

LFTs, lipase and UEC in abdominal injury

o AXR if obstruction suspected. It is not helpful in diagnosing constipation

o CXR if pneumonia is suspected

 May be appropriate in suspected ovarian torsion

 Useful if the history is suggestive of intussusception, even if examination

Treatment will be guided by the likely aetiology

Fluid resuscitation may be required

Provide adequate analgesia. IV morphine or intranasal fentanyl may be required as

Keep children fasting. Consider enteral or intravenous fluids if assessment or diagnosis

Early referral of children with possible diagnoses requiring surgical or gynaecological

Consider a nasogastric tube if bowel obstruction is suspected

Consider consultation with local paediatric / surgical team when

Surgical cause suspected

Severe pain not responding to analgesia

Child requiring admission

Consider transfer when

Consider discharge when

There are no concerning clinical features

A clear follow-up plan has been arranged, often with a local GP

Appendicitis in young children

Often a late diagnosis

May not present with classical symptoms

Often presents as perforation or sepsis

Requires careful attention to fluid and antibiotic management

Non-specific abdominal pain

Occurs in 10-15% of children (usually primary school aged)

Investigations are usually not indicated

Non-pharmacological measures (reassurance, relaxation, rubbing and heat packs) can be

Follow-up is important. Consider outpatient general paediatric / adolescent referral

Acceptable Ranges for Physiological Variables

Repeated observations are essential

Consider measurements in the clinical context of the child

Acceptable ranges for physiological variables

Approximate Systolic Heart Respiratory

Term 3.5 60-95 120-185 25-60

3 months 6 60-105 115-180 25-60