Paediatric Protocols 3rd Edition 2012.

PAEDIATRIC
PROTOCOLS
For Malaysian Hospitals
3rd Edition
Hussain Imam Hj Muhammad Ismail

Ng Hoong Phak
Terrence Thomas
Kementerian Kesihatan Malaysia
PAEDIATRIC
PROTOCOLS
For Malaysian Hospitals
3rd Edition
Hussain Imam Hj Muhammad Ismail

Ng Hoong Phak
Terrence Thomas
Scan this QR code to

download the electronic
Paediatric Protocol 3rd Edition
Kementerian Kesihatan Malaysia
ii
FOREWORD BY THE DIRECTOR GENERAL OF HEALTH

Malaysia like the rest of the world has 3 more years to achieve the Millennium
Developmental Goals (MDG). MDG 4 is concerned with under 5 mortality. Although
we have done very well since lndependence to reduce our infant and toddler
mortality rates, we are now faced with some last lap issues in achieving this goal.
Despite urbanization there are still many children in the rural areas. This constitutes
a vulnerable group in many ways. Among the factors contributing to this vulnerability is the distance from specialist care.
There is a need to ensure that doctors in the frontline are well equipped to handle
common paediatric emergencies so that proper care can be instituted from the
very beginning.
Although all doctors are now required to do 4 months of pre-registration training in
Paediatrics, this is insufficient to prepare them for all the conditions they are likely
to meet as Medical Officers in district hospitals and health clinics. Hence the effort
made by the paediatricians to prepare a protocol book covering all the common
paediatric problems is laudable. I would also like to congratulate them for
bringing out a third edition within 4 years of the previous edition.
l am confident that this third edition will contribute to improving the care of
children attending the Ministrys facilities throughout the country.
DatoSri Dr Hasan Bin Abdul Rahman

Director General of Health, Malavsia
iii
FOREWORD TO THE THIRD EDITION
It has been 7 years since we produced the first edition of a national protocol
book for Paediatrics. This effort was of course inspired by the Sarawak Paediatric
Protocols initiated by Dr Tan Poh Tin. The 2nd edition in 2008 has proven to be
very popular and we have had to recruit the services of the Malaysian Paediatric
Association (MPA) to produce extra copies for sale. It is now the standard
reference for House officers in Paediatrics.
In producing a third edition we have retained the size and style of the current version, essentially only updating the contents. Again it is targeted at young doctors
in the service many of whom seem to have had a suboptimal exposure to
paediatrics in their undergraduate years. It is hoped that the protocol book will
help them fill in the gaps as they prepare to serve in district hospitals and health
clinics.
The Ministry of Health has once again agreed to sponsor the printing of 1000
books and 500 CDs for distribution to MOH facilities. We shall be soliciting the
help of the MPA in producing extra books to be sold to those who wish to have a
personal copy. As a result of the full PDF version being available on the MPA
website, we have had requests from as far away as Kenya and Egypt to download
and print the material for local distribution. We have gladly allowed this in the
hope that it will contribute to better care of ill children in those and other neighbouring countries.
As previously this new edition is only possible because of the willingness of busy
clinicians to chip in and update the content for purely altruistic reasons and we
hope this spirit will persist in our fraternity. Prof Frank Shann has gracefully agreed
for the latest edition of his drug dosages handbook to be incorporated into the
new edition. The Director General of Health has also kindly provided a foreword
to this edition.
We wish to thank all who have made this new edition possible and hope this
combined effort will help in improving the wellbeing of the children entrusted to
our care.
Hussain Imam B. Hj Muhammad Ismail
Ng Hoong Phak
Terrence Thomas
iv
LIST OF CONTRIBUTORS
Dr Airena Mohamad Nor,
Paediatrician
Hospital Tuanku Jaafar, Seremban.
Dr. Fazila Mohamed Kutty

Neonatologist
Hospital Serdang
Dr. Alex Khoo Peng Chuan

Paediatric Neurologist
Hospital Raja Permaisuri Bainun, Ipoh.
Dr. Fong Siew Moy

Paediatric Infectious Disease Consultant
Sabah Women &Childrens Hospital, Kota
Kinabalu
Dr. Amar-Singh HSS

Consultant Community Paediatrician &
Head, Dept. of Paediatrics
Hospital Raja Permaisuri Bainun, Ipoh
Dr. Fuziah Md. Zain

Consultant Paediatric Endocrinologist
& Head, Dept. of Paediatrics
Hospital Putrajaya
Dr. Angeline Wan

Consultant Neonatologist
Hospital Pakar Sultanah Fatimah, Muar
Dr. Hasmawati Hassan

Consultant Neonatologist,
Hospital Raja Perempuan Zainab II,
Kota Bharu
Ms. Anne John

Consultant Paediatric Surgeon
Hospital Umum Sarawak, Kuching
Dr. Hishamshah b. Mohd Ibrahim

Consultant Paediatric Haemato-Oncologist
Hospital Kuala Lumpur
Dr. Bina Menon

Consultant Paediatric Haemato-Oncologist Dr. Hung Liang Choo
Hospital Kuala Lumpur (Sessional)
Consultant Paediatric Cardiologist
Dr. Chan Lee Gaik
Dato Dr. Hussain Imam B. Hj Muhammad
Ismail
Consultant Paediatric Neurologist &
Dr. Chee Seok Chiong
Hospital Selayang
Dr. Heng Hock Sin
Dr. Chin Choy Nyok
Dr. Irene Cheah Guat Sim
Hospital Tengku Ampuan Afzan, Kuantan
Dr. Chong Sze Yee
Paediatric Gastroenterology & Hepatology Dr. Janet Hong Yeow Hua
Fellow
Consultant Paediatric Endocrinologist
Hospital Selayang
Hospital Putra Jaya
Dr. Eni Juraida
Dr. Jeyaseelan Nachiappan
Consultant Paediatric Haemato-Oncologist Pediatric Infectious Disease Consultant
Hospital Raja Perempuan Bainun, Ipoh.
Dr. Farah Inaz Syed Abdullah
Dato Dr. Jimmy Lee Kok Foo

Consultant Paediatrician &
Hospital Sultanah Nur Zahirah,
Kuala Terengganu
v
Dr. Kamarul Razali

Dr. Nazrul Neezam Nordin

Paediatric Gastroenterologist & Hepatologist
Dr. Kew Seih Teck

Dr. Neoh Siew Hong
Paediatric Gastroenterology & Hepatology Consultant Neonatologist
Fellow
Hospital Selayang
Dr. Ng Hoong Phak
Dr. Khoo Teik Beng
Consultant in General Paediatrics and Child
Consultant Paediatric Neurologist
Health,
Datuk Dr. Kuan Geok Lan
Consultant General Paediatrician
Hospital Melaka.
Dr. Ngu Lock Hock

Consultant in Paediatric Metabolic Diseases
Dr. Lee Ming Lee

Consultant Paediatric Nephrologist
Hospital Tuanku Jafar, Seremban
Dr. Nik Khairulddin

Paediatric Infectious Disease Consultant &
Hospital Raja Perempuan Zainab II, Kota Bharu
Dr. Leow Poy Lee

Hospital Melaka.
Dr. Lim Chooi Bee
Consultant Paediatric Gastroenterologist
Hospital Selayang
Dr. Lim Yam Ngo
Dr. Lynster Liaw
Hospital Pulau Pinang
Dr Noor Khatijah Nurani

Health,
Dr. Nor Azni bin Yahya
Consultant Paediatric Neurologist,
Hospital Raja Perempuan Zainab II, Kota Bharu.
Dr. Norzila Bt. Mohd Zainudin
Consultant, Paediatric Respiratory Disease
Dr. Ong Gek Bee
Dr Mahfuzah Mohamed
Dr. Pauline Choo
Neonatologist
Dr. Maznisah Bt Mahmood
Hospital Tuanku Jaafar, Seremban
Pediatric Intensivist
Dr Raja Aimee Raja Abdullah
Paediatric Endocrinologist
Dr. Martin Wong
Hospital Putrajaya
Dr. Revathy Nallusamy
Paediatric Infectious Disease Consultant &
Dr. Mohd Nizam Mat Bah
Hospital Sultanah Aminah, Johor Bharu
Dr. Rozitah Razman
Paediatrician
vi
Dr. Sabeera Begum Bt Kader Ibrahim

Consultant Paediatric Dermatologist
Dr Thahira Jamal Mohamed

Dr. See Kwee Ching

Neonatologist
Hospital Sungai Buloh
Dr. N. Thiyagar
Consultant, Adolescent Medicine &
Hospital Sultanah Bahiyah, Alor Setar
Dr. Sharifah Ainon Bt Ismail Mokhtar

Consultant Paediatric Cardiologist,
Dr. Sheila Gopal Krishnan
Specialist in General Paediatrics and
Child Health
Hospital Kulim
Dr. Siti Aishah Bt Saidin
Adolescent Medicine Specialist
Dr. Soo Thian Lian
Consultant Neonatologist & Head,
Dept. of Pediatrics
Sabah Women &Childrens Hospital,
Kota Kinabalu
Dr. Susan Pee
Consultant Paediatric Nephrologist &
Head, Dept. of Paediatrics,
Hosp Sultan Ismail, Pandan
Dr. Tan Kah Kee
Paediatric Infectious Disease
Consultant & Head, Dept. of Paediatrics
Hospital Tuanku Jafar, Seremban
Assoc. Prof. Dr. Tang Swee Fong
Consultant Paediatric Intensivist
Hospital University Kebangsaan Malaysia
Dr. Tang Swee Ping
Consultant Paediatric Rheumatologist
Hospital Selayang
Dr. Teh Chee Ming
Dato Dr. Teh Keng Hwang
Consultant Paediatric Intensivist
Hospital Sultanah Bahiyah, Alor Star
Dr. Terrence Thomas

KK Womens & Childrens Hospital, Singapore
Dr. Vidya Natthondan
Neonatologist
Hospital Putrajaya
Dr. Vigneswari Ganesan
Dr. Wan Jazilah Wan Ismail
Consultant Paediatric Nephrologist &
Hospital Selayang
Dr. Wong Ann Cheng
Paediatrician
Dr Wong Ke Juin
Pediatrician
Sabah Women & Childrens Hospital,
Kota Kinabalu
Dr. Yap Yok Chin
Dr. Yogeswery Sithamparanathan
Hospital Tuanku Ampuan Rahimah, Klang
Dr Zainah Sheikh Hendra,
Health, Hospital Batu Pahat
Dr. Zuraidah Bt Abd Latif
Consultant Neonatologist & Head,
Dept. of Paediatrics, Hospital Ampang
Dr. Zurina Zainudin
Consultant Paediatrician
Universiti Putra Malaysia
vii
TABLE OF CONTENTS
Section 1 General Paediatrics
Chapter 1: Normal Values in Children
Chapter 2: Immunisations
Chapter 3: Paediatric Fluid and Electrolyte Guidelines
Chapter 4: Developmental Milestones in Normal Children
Chapter 5: Developmental Assessment
Chapter 6: Developmental Dyslexia
Chapter 7: The H.E.A.D.S.S. Assessment
Chapter 8: End of Life Care in Children
1
5
19
27
31
37
45
49
Section 2 Neonatalogy
Chapter 9: Principles of Transport of the Sick Newborn
55
Chapter 10: The Premature Infant
63
Chapter 11: Enteral Feeding in Neonates
67
Chapter 12: Total Parenteral Nutrition for Neonates
71
Chapter 13: NICU - General Pointers for Care and Review of Newborn Infants 77
Chapter 14: Vascular Spasm and Thrombosis
85
Chapter 15: Guidelines for the Use of Surfactant
91
Chapter 16: The Newborn and Acid Base Balance
93
Chapter 17: Neonatal Encephalopathy
97
Chapter 18: Neonatal Seizures
101
Chapter 19: Neonatal Hypoglycemia
107
Chapter 20: Neonatal Jaundice
111
Chapter 21: Exchange Transfusion
117
Chapter 22: Prolonged Jaundice in Newborn Infants
121
Chapter 23: Apnoea in the Newborn
125
Chapter 24: Neonatal Sepsis
127
Chapter 25: Congenital Syphilis
129
Chapter 26: Ophthalmia Neonatorum
131
Chapter 27: Patent Ductus Arteriosus in the Preterm
133
Chapter 28: Persistent Pulmonary Hypertension of the Newborn
135
Chapter 29: Perinatally Acquired Varicella
139
Section 3 Respiratory Medicine
Chapter 30: Asthma
Chapter 31: Viral Bronchiolitis
Chapter 32: Viral Croup
Chapter 33: Pneumonia
149
161
163
165
viii
TABLE OF CONTENTS
Section 4 Cardiology
Chapter 34: Paediatric Electrocardiography
Chapter 35: Congenital Heart Disease in the Newborn
Chapter 36: Hypercyanotic Spell
Chapter 37: Heart Failure
Chapter 38: Acute Rheumatic Failure
Chapter 39: Infective Endocarditis
Chapter 40: Kawasaki Disease
Chapter 41: Viral Myocarditis
Chapter 42: Paediatric Arrhythmias
171
173
181
183
185
187
191
195
197
Section 5 Neurology
Chapter 43: Status Epilepticus
Chapter 44: Epilepsy
Chapter 45: Febrile Seizures
Chapter 46: Meningitis
Chapter 47: Acute CNS Demyelination
Chapter 48: Acute Flaccid Paralysis
Chapter 49: Guillain Barr Syndrome
Chapter 50: Approach to The Child With Altered Consciousness
Chapter 51: Childhood Stroke
Chapter 52: Brain Death
205
207
213
215
219
221
223
225
227
231
Section 6 Endocrinology
Chapter 53: Approach to A Child with Short Stature
Chapter 54: Congenital Hypothyroidism
Chapter 55: Diabetes Mellitus
Chapter 56: Diabetic Ketoacidosis
Chapter 57: Disorders of Sexual Development
237
241
245
255
263
Section 7 Nephrology
Chapter 58: Post-Infectious Glomerulonephritis
Chapter 59: Nephrotic Syndrome
Chapter 60: Acute Kidney Injury
Chapter 61: Acute Peritoneal Dialysis
Chapter 62: Neurogenic Bladder
Chapter 63: Urinary Tract Infection
Chapter 64: Antenatal Hydronephrosis
275
279
285
293
299
305
313
ix
TABLE OF CONTENTS
Section 8 Haematology and Oncology
Chapter 65: Approach to a Child with Anaemia
Chapter 66: Thalassaemia
Chapter 67: Immune Thrombocytopenic Purpura
Chapter 68: Haemophilia
Chapter 69: Oncology Emergencies
Chapter 70: Acute Lymphoblastic Leukaemia
321
325
331
337
343
353
Section 9 Gastroenterology
Chapter 71: Acute Gastroenteritis
Chapter 72: Chronic Diarrhoea
Chapter 73: Approach to Severely Malnourished Children
Chapter 74: Gastro-oesophageal Reflux
Chapter 75: Acute Hepatic Failure in Children
Chapter 76: Approach to Gastrointestinal Bleeding
359
365
373
377
383
387
Section 10 Infectious Disease

Chapter 77: Sepsis and Septic Shock
Chapter 78: Pediatric HIV
Chapter 79: Malaria
Chapter 80: Tuberculosis
Chapter 81: BCG Lymphadenitis
Chapter 82: Dengue and Dengue Haemorrhagic Fever with Shock
Chapter 83: Diphteria
391
397
413
419
425
427
439
Section 11 Dermatology
Chapter 84: Atopic Dermatitis
Chapter 85: Infantile Hemangioma
Chapter 86: Scabies
Chapter 87: Steven Johnson Syndrome
445
451
455
457
Section 12 Metabolic Disorders

Chapter 88: Inborn errors metabolism (IEM): Approach to
Diagnosis and Early Management in a Sick Child
Chapter 89: Investigating Inborn errors metabolism (IEM)
in a Child with Chronic Symptoms
Chapter 90: Approach to Recurrent Hypoglycemia
Chapter 91: Down Syndrome
461
471
483
489
TABLE OF CONTENTS
Section 13 Paediatric Surgery
Chapter 92: Appendicitis
Chapter 93: Vomiting in the Neonate and Child
Chapter 94: Intussusception
Chapter 95: Inguinal hernias, Hydrocoele
Chapter 96: Undescended Testis
Chapter 97: The Acute Scrotum
Chapter 98: Penile Conditions
Chapter 99: Neonatal Surgery
495
497
507
511
513
515
519
521
Section 14 Rheumatology
Chapter 100: Juvenile Idiopathic Arthritis (JIA)
535
Section 15 Poisons and Toxins

Chapter 101: Snake Bite
Chapter 102: Common Poisons
Chapter 103: Anaphylaxis
543
549
559
Section 16 Sedation and Procedures

Chapter 104: Recognition and Assessment of Pain
Chapter 105: Sedation and Analgesia for Diagnostic
and Therapeutic Procedures
Chapter 108: Practical Procedures
xi
565
567
571
Acknowledgements
Again, to Dr Koh Chong Tuan, Consultant Paediatrician at Island Hospital, Penang
for his excellent work in proof reading the manuscript.
xii
GENERAL PAEDIATRICS
Chapter 1: Normal Values in Children

VITAL SIGNS
Respiratory (Breath) Rate
Normal, Breath rate at rest
Age (years)
Rate/min
<1
30-40
1-2
2-5
5-12
Abnormal
These values define Tachypnoea
Age
Rate/min
25-35
< 2 months
> 60
25-30
2 mths - 1 year
> 50
20-25
1-5 years
> 40
Abnormal
Normal
Abnormal
Heart (Pulse) Rate

Age (years)
Low (Bradycardia)
Average
High (Tachycardia)
Newborn
< 70/min
125/min
> 190/min
1-11 months
< 80/min
120/min
> 160/min
2 years
< 80/min
110/min
> 130/min
4 years
< 80/min
100/min
> 120/min
6 years
< 75/min
100/min
> 115/min
8 years
< 70/min
90/min
> 110/min
10 years
< 70/min
90/min
> 110/min
Ref: Nelson Textbook of Pediatrics, 18th Edition
Blood Pressure
Hypotension if below
Normal (average)
Age (years)
5th centile for age
50th centile for age
< 1 year
65 - 75 mmHg
80 - 90 mmHg
1-2 years
70 - 75 mmHg
85 - 95 mmHg
2-5 years
70 - 80 mmHg
85 - 100 mmHg
5-12 years
80 - 90 mmHg
90 - 110 mmHg
> 12 years
90 - 105 mmHg
100-120 mmHg
Calculation for Expected Systolic Blood Pressure

= 85 + (2 x age in years) mmHg for 50th centile - Median Blood Pressure
= 65 + (2 x age in years) mmHg for 5th centile - Hypotension if below this value
Ref: Advanced Paediatric Life Support:The Practical Approach, Fifth Edition 2011
GENERAL PAEDIATRICS
Blood Pressure in Hypertension

Age
Significant Hypertension
Severe Hypertension
1 week
Systolic
96 mmHg
Systolic
106 mmHg
1 wk - 1 mth
Systolic
104 mHg
Systolic
110 mmHg
Infant
Systolic
112 mmHg
Systolic
118 mmHg
Diastolic
74 mmHg
Diastolic
82 mmHg
Systolic
116 mmHg
Systolic
124 mmHg
Diastolic
76 mmHg
Diastolic
86 mmHg
Systolic
122 mmHg
Systolic
130 mmHg
Diastolic
78 mmHg
Diastolic
86 mmHg
Systolic
126 mmHg
Systolic
134 mmHg
Diastolic
82 mmHg
Diastolic
90 mmHg
Systolic
136 mmHg
Systolic
144 mmHg
Diastolic
86 mmHg
Diastolic
92 mmHg
Systolic
142 mmHg
Systolic
150 mmHg
Diastolic
92 mmHg
Diastolic
98 mmHg
3-5 years
6-9 years
10-12 years
13-15 years
16-18 years
Age
Weight
Height
Head size
birth
3.5 kg
50 cm
35 cm
6 months
7 kg
68 cm
42 cm
1 year
10 kg
75 cm
47 cm
2 years
12 kg
85 cm
49 cm
3 years
14 kg
95 cm
49.5 cm
4 years
100 cm
50 cm
5-12 years
5 cm/year
0.33 cm/year
Points to Note
Weight
In the first 7 - 10 days of life, babies lose 10 - 15% of their birth weight.
In the first 3 months of life, the rate of weight gain is 25 gm/day
Babies regain their birth weight by the 2nd week, double this by 5 months
age, and triple the birth weight by 1 year of age
Weight estimation for children (in Kg):

Infants: (Age in months X 0.5) + 4
Children 1 10 years: (Age in yrs + 4) X 2
Head circumference
Rate of growth in preterm infants is 1 cm/week, but reduces with age.
Head growth follows that of term infants when chronological age reaches term
Head circumference increases by 12 cm in the 1st year of life (6 cm in first 3
months, then 3 cm in second 3 months, and 3 cm in last 6 months)
Other normal values are found in the relevant chapters of the book.
References:
1. Advanced Paediatric Life Support: The Practical Approach Textbook,
5th Edition 2011
2. Nelson Textbook of Pediatrics, 18th Edition.
GENERAL PAEDIATRICS
ANTHROPOMETRIC MEASUREMENTS
5-10
5-10
55
55
35
35
38
38
neutrophils > lymphocytes
26-34
27-32
55
45
neutrophils = lymphocytes
80
80
6-15
4.5-13.5
48
63
> 7 years
1.6
1.6
26-32
25-31
30
31
4 - 7 years
37-47
42-52
76-80
70-74
6-18
40
61
Differential WBC: eosinophils: 2-3%; monocytes: 6-9 %

Platelets counts are lower in first months of age;
but normal range by 6 months
Erythrocyte sedimentation rate (ESR) is < 16 mm/hr in
children, provided PCV is at least 35%.
12.0-16.0
Adult female
1.0
1.0
27
5-21
9-30
Mean
Lymphocyte
lymphocytes > neutrophils
14.0-18.0
Adult male
34-40
33-42
29
Mean
Neutrophil
1 wk - 4 years
11.0-16.0
7 - 12 years
1.0
110
x1000
TWBC
Points to note
10.5-14.0
6 mths - 6 yrs
31-41
1.0
5.0
Lowest
Lowest
neutrophils > lymphocytes
9.5-14.5
3 months
42-66
45-65
MCH pg
MCV fl
< 7 days age
13.0-20.0
Retics
Differential counts
13-7-20.1
g/dL
2 weeks
PCV
Hb
Cord Blood
Age
HAEMATOLOGICAL PARAMETERS
GENERAL PAEDIATRICS
Hib
Sabah
Age (months)
10
12
B*
B+
B
+
DT B+
18
if no scar
7 yrs
3 doses
13 yrs
School years
T B+
15 yrs
MMR, Measles, Mumps, Rubella; JE, Japanese Encephalitis, HPV, Human Papilloma Virus;
DT, Diphtheria, Tetanus; T, Tetanus IPV, Inactivated Polio Vaccine; Hib, Haemophilus influenzae type B;
Legend: B+, Booster doses; B*, Booster at 4 years age; BCG, Bacille Calmette-Guerin; DTaP, Diphhteria, Tetanus, acellular Pertussis;
HPV
JE (Sarawak)
MMR
Measles
IPV
Hepatitis B
BCG
DTaP
birth
Vaccine
National Immunisation Schedule for Malaysia (Ministry of Health, Malaysia)
GENERAL PAEDIATRICS
Chapter 2: Immunisations
GENERAL PAEDIATRICS
General Notes
Many vaccines (inactivated or live) can be given together simultaneously (does
not impair antibody response or increase adverse effect). But they are to be
given at different sites unless given in combined preparations. Vaccines are now
packaged in combinations to avoid multiple injections to the child.
sites of administration
- oral rotavirus, live typhoid vaccines
- intradermal (ID) - BCG. Left deltoid area (proximal to insertion deltoid muscle)
- deep SC, IM injections. (ALL vaccines except the above)
anterolateral aspect of thigh preferred site in children
upper arm preferred site in adults
upper outer quadrant of buttock - associated with lower antibody level production
Immunisation : General contraindications
Absolute contraindication for any vaccine: severe anaphylaxis reactions to
previous dose of the vaccine or to a component of the vaccine.
Postponement during acute febrile illness: Minor infection without fever or
systemic upset is NOT a contraindication.
A relative contraindication: avoid a vaccine within 2 weeks of elective surgery.
Live vaccine: Absolute contraindications
- Immunosuppressed children -malignancy; irradiation, leukaemia, lymphoma,
primary immunodeficiency syndromes (but NOT asymptomatic HIV).
- On chemotherapy or < 6 months after last dose.
- On High dose steroids, i.e. Prednisolone 2 mg/kg/day for > 7 days or low
dose systemic > 2 weeks: delay vaccination for 3 months.
- If topical or inhaled steroids OR low dose systemic < 2 weeks or EOD for > 2
weeks, can administer live vaccine.
- If given another LIVE vaccine including BCG < 4 weeks ago.
(Give live vaccines simultaneously. If unable to then give separately with
a 4 week interval).
- Within 3 months following IV Immunoglobulin (11 months if given high
dose IV Immunoglobulins, e.g. in Kawasaki disease).
3 weeks
Live Vaccine
3 months
HNIG
(Human Normal Immunoglobulin)
Live vaccine
- Pregnancy (live vaccine - theoretical risk to foetus) UNLESS there is

significant exposure to serious conditions like polio or yellow fever in
which case the importance of vaccination outweighs the risk to the foetus.
Killed vaccines are generally safe. The only absolute contraindications are
SEVERE local (induration involving > 2/3 of the limbs) or severe generalised
reactions in the previous dose.
6
Vaccination: Special Circumstances

Measures to protect inpatients exposed to another inpatient with measles:
- Protect all immunocompromised children with Immunoglobulin (HNIG)
0.25-0.5 mls/kg. (Measles may be fatal in children in remission from
leukaemia)
- Check status of measles immunisation in the other children. Give measles
monocomponent vaccine to unimmunised children within 24 hrs of exposure.
Vaccination within 72 hours aborts clinical measles in 75% of contacts
- Discharge the inpatient child with uncomplicated measles.
- Do not forget to notify the Health Office.
Immunisation in children with HIV (Please refer to Paediatric HIV section)
In patients with past history or family history of febrile seizures, neurological
or developmental abnormalities that would predispose to febrile seizures:- Febrile seizures may occur 5 10 days after measles (or MMR) vaccination
or within the first 72 hours following pertussis immunisation.
- Give Paracetamol (120 mg or tablet) prophylaxis after immunisation
(esp. DPT) 4-6 hourly for 48 hours regardless of whether the child is febrile.
This reduces the incidence of high fever, fretfulness, crying, anorexia and
local inflammation.
Maternal Chicken Pox during perinatal period. (Please refer to Perinatally
acquired varicella section)
Close contacts of immunodeficient children and adults must be immunized,
particularly against measles and polio (use IPV).
In contacts of a patient with invasive Haemophilus influenzae B disease:
- Immunise all household, nursery or kindergarden contacts < 4 years of age.
- Household contacts should receive Rifampicin prophylaxis at 20 mg/kg
once daily (Maximum 600 mg) for 4 days (except pregnant women
- give one IM dose of ceftriaxone )
- Index case should be immunised irrespective of age.
7
GENERAL PAEDIATRICS
The following are not contraindications to vaccination

Mild illness without fever e.g. mild diarrhoea, cough, runny nose.
Asthma, eczema, hay fever, impetigo, heat rash (avoid injection in affected area).
Treatment with antibiotics or locally acting steroids.
Childs mother is pregnant.
Breastfed child (does not affect polio uptake).
Neonatal jaundice.
Underweight or malnourished.
Over the recommended age.
Past history of pertussis, measles or rubella (unless confirmed medically)
Non progressive, stable neurological conditions like cerebral palsy, Down
syndrome, simple febrile convulsions, controlled epilepsy, mental retardation.
Family history of convulsions.
History of heart disease, acquired or congenital.
Prematurity (immunise according to schedule irrespective of gestational age)
GENERAL PAEDIATRICS
Children with Asplenia (Elective or emergency splenectomy; asplenic

syndromes; sickle cell anaemia) are susceptible to encapsulated bacteria
and malaria.
- Pneumococcal, Meningococcal A, C, Y & W-135, Haemophilus influenza b
vaccines should be given.
- For elective splenectomy (and also chemotherapy or radiotherapy): give
the vaccines preferably 2 or more weeks before the procedure. However,
they can be given even after the procedure.
- Penicillin prophylaxis should continue ideally for life. If not until 16 years
old for children or 5 years post splenectomy in adults.
Babies born to mothers who are HbeAg OR HbsAg positive should be given
Hepatitis B immunoglobulin (200 IU) and vaccinated with the Hepatitis B
vaccine within 12 hours and not later than 48 hours. Given in different
syringes and at different sites.
Premature infants may be immunised at the same chronological age as term
infants. (Please refer section on The premature infants for more discussion)
All infants,
including those born
to HBsAg positive
mothers
All health care
personnel.
All infants should

receive 5 doses
including booster
doses at 18 months
and Standard 1
Diphtheria,
Tetanus
(DT)
To be given at birth
and to be repeated
if no scar is present
BCG
Hepatitis B
Indication/Dose
Vaccine
Severe hypersensitivity to
aluminium and thiomersal
aluminium. The vaccine is
also not indicated for HBV
carrier or immuned patient
( i.e. HBsAg or Ab positive)
Not to be given to symptomatic HIV infected children.

Can be given to newborns
of HIV infected mother as
the infant is usually asymptomatic at birth.
Contraindication
Swelling, redness and pain

A small painless nodule may
develop at injection site
harmless.
Transient fever, headaches,
malaise, rarely anaphylaxis.
Neurological reactions rare.
Local reactions. Fever and

flu-like symptoms in first
48 hours. Rarely, erythema
multiforme or urticaria.
BCG adenitis may occur.
Possible Side Effects
Vaccines, indications, contraindications, doses and side effects
Intramuscular
Intramuscular.
Give with Hep B immunoglobulin for infants of HBsAg
positive mothers.
Intradermal.
Local reaction: a papule at
vaccination site may occur
in 2 - 6 weeks. This grows
and flattens with scaling
and crusting. Occasionally a
discharging ulcer may occur.
This heals leaving a scar of
at least 4 mm in successful
vaccination.
Notes
GENERAL PAEDIATRICS
10
All infants to be
given 4 doses
including booster at
18 months.
All infants should

receive 4 doses
18 months.
Patients with splenic
dysfunction, and
post splenectomy.
Haemophilus
Influenzae
type B (Hib)
Confirmed anaphylaxis to
previous Hib and allergies
to neomycin, polymyxin and
streptomycin
Allergies to neomycin, polymyxin and streptomycin

Previous severe anaphylactic
reaction
Precautions: severe reaction

to previous dose (systemic
or local) and progressive
neurological diseases.
It is recommended
that booster doses
be given at Std 1
and at Form 3 due
to increased cases
of Pertussis amongst
adolescents in
recent years
Inactivated
Polio Vaccine
(IPV)
Anaphylaxis to previous
dose; encephalopathy
develops within 7 days of
vaccination
All infants should

receive 4 doses
18 months
Pertussis
Contraindication
Indication/Dose
Vaccine
Local swelling, redness and

pain soon after vaccination
and last up to 24 hours in
10% of vaccinees
Malaise, headaches, fever, irritability, inconsolable crying.
Very rarely seizures.
Local reactions.
Acellular Pertussis vaccine

associated with less side
effects
Local reaction. Severe if

involve 2/3 limbs
Severe systemic reaction:
Anaphylaxis (2 per 100 000
doses), encephalopathy (0
10.5 per million doses), high
fever (fever>40.5), fits within
72 hours, persistent inconsolable crying (0.1 to 6%),
hyporesponsive state.
Intramuscular
Intramuscular.
Static neurological diseases,

developmental delay, personal
or family history of fits are
NOT contraindications.
Intramuscular.
Notes
GENERAL PAEDIATRICS
Mumps
All children from

12 to 15 months.
Booster at 4-6yrs
(or at Std 1).
Sabah, Orang Asli

population at 6 mths.
Not usually given to
children <12mth. If
there is a measles
outbreak, can be
given to children 6
-11 mths age. This
is later followed by
MMR at 12 mths
and 4-6 years age.
Measles
Measles,
Mumps, Rubella (MMR)
Indication/Dose
Vaccine
Severe reaction to hens

eggs and neomycin.
Pregnancy
Avoid in patients with

hypersensitivity to eggs,
neomycin and polymyxin.
Pregnancy.
Children with untreated
leukemia, TB and other
cancers.
Immunodeficiency.
Contraindication
Rarely transient rash, pruritis and purpura.

Parotitis in 1% of vaccinees,
> 3 weeks after vaccination.
Orchitis and retro bulbar
neuritis very rare.
Meningoencephalitis is mild
and rare. (1:800,000 doses).
(natural infection 1:400).
Measles: As above
Transient rash in 5%.

May have fever between D5D12 post vaccination.
URTI symptoms.
Febrile convulsions (D6-D14)
in 1:1000 9000 doses of vaccine. (Natural infection 1:200)
Encephalopathy within 30 days
in 1:1,000,000 doses. (Natural
infection 1:1000 - 5000)
Intramuscular
Intramuscular.
Can be given irrespective of
previous history of measles,
mumps or rubella infection.
Intramuscular.
** Long term prospective studies have found no association
between measles or MMR vaccine and inflammatory bowel
diseases, autism or SSPE.
Notes
GENERAL PAEDIATRICS
11
12
Headache, myalgia, injection site reactions, fatigue,

nausea, vomiting, diarrhoea,
abdominal pain, pruritus,
rash, urticaria, myalgia,
arthralgia, fever.
Indicated for
females aged 9-45
years.
Human Papilloma Virus

(HPV)
Not recommended in
pregnant patients.
Local redness, swelling,

pain, fever, chills, headache,
lassitude..
Immunodeficiency and
malignancy, diabetes , acute
exacerbation of cardiac,
hepatic and renal conditions
Given in Sarawak at
9, 10 and 18 months
Booster at 4 years.
Japanese
Encephalitis
(JE)
Contraindication
Rash, fever, lymphadenopathy, thrombocytopenia,
transient peripheral neuritis.
Arthritis and arthralgia occurs in up to 3% of children
and 20% of adults.
Indication/Dose
Rubella
Vaccine
2 vaccines available:
Cervarix (GSK): bivalent.
Gardasil (MSD): quadrivalent.
- 3 dose schedule IM (0,
1-2month, 6 month).
Recombinant vaccine.
Protective efficacy almost
100% in preventing vaccine
type cervical cancer in first
5 years.
Inactivated vaccine.
Subcutaneous.
Protective efficacy > 95%.
Given as MMR
Notes
GENERAL PAEDIATRICS
Dosage:
Infants 2-6 mth age.
3-dose primary
series at least 1 mth
apart from 6 wks
of age.
Booster: 1 dose
between 12-15 mths
of age.
Unvaccinated:
infants 7-11 mths
2 doses 1 month
apart, followed by a
3rd dose at 12- 15
months; children 1223 months 2 doses
at least 2 months
apart; healthy
children 2 - 5 years:
Single dose
Pneumococcal
(conjugate)
vaccine: PCV
13/ PCV 7
Unvaccinated high
risk children 2-5 yrs
age may be given
2 doses (6-8 wks
apart)
Indication/Dose
Vaccine
Healthy children under 6

weeks and more than 59
months of age
Children who have severe

allergic reaction to previous
pneumococcal vaccine
Contraindication
Decreased appetite,
irritability, drowsiness,
restless sleep, fever, inj site
erythema, induration or
pain, rash.
High risk children:

immunosuppression (including asymptomatic HIV),
asplenia, nephrotic syndrome
and chronic lung or heart
disease.
Intramuscular
Not in Blue Book

Immunogenic in children
< 2 years
Notes
GENERAL PAEDIATRICS
13
14
First dose given to

infants 6 wks old.
Rotateq (3 doses)
Subsequent doses
given at 4-10 wks interval. 3rd dose given
32 weeks age.
Rotarix (2 doses). 2nd
dose to be given by
24 weeks age. Interval between doses
should be > 4 wks.
Recommended for
children at high risk.
> 2 years old.
Single dose.
Booster at 3-5 years
only for high risk
patients.
Pneumococcal (polysaccharide
vaccine)
Rotavirus
Indication/Dose
Vaccine
Severe combined immunodeficiency disease (reported

prolonged shedding of vaccine virus reported in infants
who had live Rotavirus
vaccine)
Prior hypersensitivity to any

vaccine component.
Uncorrected congenital GIT
malformation, e.g. Meckels
diverticulum
Age < 2 years old.

Revaccination within 3 years
has high risk of adverse
reaction;
Avoid during chemotherapy
or radiotherapy and less
than 10 days prior to commencement of such therapy
antibody response is poor.
Pregnancy.
Contraindication
Loss of appetite, irritability,

fever, fatigue, diarrhoea,
vomiting, flatulence, abdominal pain, regurgitation
of food.
Hypersensitivity reactions.
Oral live-attenuated vaccine.

Protective efficacy 88-91%
for any rotavirus gastroenteritis episode; 63-79% for all
causes of gastroenteritis.
Listed in Blue Book.

Intramuscular, Subcutaneous
Immunogenic in children 2
yrs. Against 23 serotypes.
High risk: immunosuppression,
asymptomatic HIV, asplenia,
nephrotic syndrome, chronic
lung disease. If these children
are <2 yrs old, they should
first receive pneumococcal
conjugate vaccine; when > 2
yrs, then the polysaccharide
vaccine is used.
Notes
GENERAL PAEDIATRICS
Hepatitis A
12 mths to 12 yrs:
Single dose
> 12 yrs:
2 doses 4 wks apart.
Varicella
Zoster
For children >1 yr.

2 doses., given 6-12
months apart.
Non immune susceptible health care

workers who regularly come in contact
with VZV infection
Asymptomatic/mildly
symptomatic children
with HIV (with CD4%
> 15%); 2 doses at 3
mths interval.
Children in remission
from leukemia for 1
yr, have >700/ml circulating lymphocytes
may receive vaccine
under paediatrician
supervision (2doses).
Indication/Dose
Vaccine
aluminium hydroxide, phenoxyethanol, neomycin
Pregnant patients.
Patients receiving high dose
systemic immunosuppression therapy.
Patients with malignancy
especially haematological malignancies or blood
dyscrasias.
Hypersensitivity to neomycin.
Contraindication
Local reactions. Flu-like

symptoms lasting 2 days in
10% of recipients
Occasionally, papulovesicular eruptions, injection site

reactions, headache, fever,
paresthesia, fatigue
Intramuscular.
Protective efficacy 94%.
Live attenuated vaccine.

Subcutaneous.
70 90% effectiveness.
Notes
GENERAL PAEDIATRICS
15
16
Indication/Dose
Children 2-6 yrs:

3 doses at 1-6 wk
interval.
Children > 6 yrs:
2 doses at 1-6 wks
interval.
Booster dose >2 yrs.
Single dose.
Min age 6 mths.
Unprimed individuals
require 2nd dose 4 6 wks after 1st dose.
Recommended for
children with:
chronic decompensated respiratory or
cardiac disorders,
e.g. cyanotic heart
diseases chronic lung
disease, HIV infection.
In advanced disease,
vaccination may not
induce protective
antibody levels.
Vaccine
Cholera
Influenza
Hypersensitivity to egg or
chicken protein, neomycin,
formaldehyde.
Febrile illness, acute infection.
Contraindication
Transient swelling, redness,

pain and induration locally.
Myalgia, malaise and
fever for 1 2 days starting
within a few hours post
vaccination. Very rarely,
neurological (Guillain-Barre),
glomerulonephritis, ITP or
anaphylactic reaction occurs.
Gastroenteritis
Intramuscular.
Require yearly revaccination
for continuing protection.
Oral inactivated vaccine.

after 6 mths waning to 60%
after 3 yrs.
Notes
GENERAL PAEDIATRICS
Indication/Dose
Pre-exposure: 3 doses at Day 0,

7, 28. Booster every 2-3 yrs.
Post-exposure treatment:
Fully immunised: 2 doses at
Day 0, Day 3. Rabies Immune
Globulin (RIG) unnecessary.
Unimmunised: 5 doses at Day
0, 3, 7, 14 and 28. RIG (20 IU/
kg given half around the wound
and the rest IM.
Single dose.
Immunity up to 3 yrs.
Single dose. Seroconversion in

85-95% of recipients; confers
60-80% protection beginning
2 wks after vaccination.
Boosters every 3 yrs.
Three doses two days apart.

Effective 7 days after last
dose. Booster every 3 years.
Vaccine
Rabies
Meningococcus A, C,Y &

W-135
Typhoid
(Typhim Vi)
Typhoid
(Ty21a vaccine)
Infant <6 mth.

Congenital or acquired
immunodeficiency. Acute
febrile illness & acute intestinal infection.
Children < 2yrs.

(Immunogenicity < 2 yrs of
age has not been established)
Contraindication
Very rarely: mild GIT

disturbances or a transitory
exanthema.
Local reactions. Myalgia,

malaise, nausea, headaches
and fever in 3% of recipients.
Local reactions. Irritability,

fever and rigors for 1-2 days.
Very rarely, anaphylaxis.
Headache, dizziness, malaise,

abdominal pain, nausea, myalgia. Injection site reactions
such as itching, swelling, pain.
Oral. Live attenuated vaccine.
Intramuscular.
Polysaccharide
vaccine
Intramuscular.
(Available in Malaysia as Purified Vero
Cell Rabies Vaccine
(PVRV).
Intramuscular.
Notes
GENERAL PAEDIATRICS
17
GENERAL PAEDIATRICS
Recommended Immunisation Schedule for Infants and Children

Not Immunised at the Recommended Time
Time of Immunisation
Age at first visit

Between 6 wks -12 mths
1st visit
BCG, DPT/DTaP, Hib1,

IPV1, HBV1
2nd visit (1 mth later)
12 months and older

BCG, DPT/DTaP1, Hib1,
IPV1, HBV1, measles
(footnote 2) at 6 or 9
mths,
MMR at 12 mths of age
DPT/DTaP2, IPV2, HBV2,
Hib2
3rd visit (1 mth later)
DPT/DTaP2,Hib2, IPV2,
HBV2
DPT/DTaP3, IPV3,
4th visit (4 mths after

3rd visit)
DPT/DTaP3,Hib3, IPV3,
HBV3, DPT/DTaP4, IPV4,
2-8 mths later
HBV3, DTaP4, Hib4 &

IPV4 (booster), measles
in Sabah at 9 mths age,
MMR at 12 mths age
Polio, DT/DTaP, MMR (at

school entry)
Footnotes:
1. For infants < 6 wks age, use Recommended Immunisation Schedule for
Infants & Children.
2. Measles vaccine should be given only after 9 mths. (exception - given at 6
months in Sabah)
3. For special groups of children with no regular contact with Health Services
and with no immunisation records, BCG, HBV, DTaP- Hib-IPV and MMR can
be given simultaneously at different sites at first contact.
4. It is not necessary to restart a primary course of immunisation
regardless of the period that has elapsed since the last dose was given.
Only the subsequent course that has been missed need be given. (Example.
An infant who has been given IPV1 and then 9 months later comes for
follow-up, the IPV1 need not be repeated. Go on to IPV2.). Only exception
is Hepatitis A vaccine.
18
Well children with Normal hydration

Very few well children require intravenous fluids (IV). Whenever possible use
an enteral (oral) route for fluids.
These guidelines apply to children who are unable to tolerate enteral fluids.
The safe use of IV fluid therapy in children requires accurate prescribing of
fluids and careful monitoring because incorrectly prescribed or administered
fluids are hazardous.
If IV fluid therapy is required then maintenance fluid requirements should be
calculated using the Holliday and Segar formula based on weight.
However this should be only be used as a starting point and the individuals
response to fluid therapy should be monitored closely by clinical observation,
fluid balance, weight and a minimum daily electrolyte profile.
Prescribing Intravenous fluids
Fluids are given intravenously for the following reasons:
Circulatory support in resuscitating vascular collapse.
Replacement of previous fluid and electrolyte deficit.
Maintenance of daily fluid requirement.
Replacement of ongoing losses.
Severe dehydration with failed nasogastric tube fluid replacement
(e.g. on-going profuse losses, diarrhoea or abdominal pain).
Certain co-morbidities, particularly GIT conditions (e.g. short gut or
previous gut surgery)
Resuscitation
Fluids appropriate for bolus administration are:
Crystalloids
0.9% Normal Saline

Ringers Lactate @ Hartmanns solution
Colloids
Gelafundin,Voluven
4.5% albumin solution
Blood products
Whole blood, blood components
Fluid deficit sufficient cause impaired tissue oxygenation (i.e. clinical shock)
should be corrected with a fluid bolus of 10-20mls/kg.
Always reassess circulation - give repeat boluses as necessary.
Look for the cause of circulatory collapse - blood loss, sepsis, etc.
This helps decide on the appropriate alternative resuscitation fluid.
Fluid boluses of 10mls/kg in selected situations - e.g. diabetic ketoacidosis,
intracranial pathology or trauma.
Avoid low sodium-containing (hypotonic) solutions for resuscitation as this
may cause hyponatremia.
Check blood glucose: treat hypoglycemia with 2mls/kg of 10% Dextrose
solution.
19
GENERAL PAEDIATRICS
Chapter 3: Paediatric Fluid and Electrolyte Guidelines
GENERAL PAEDIATRICS
Measure Na, K and glucose at the outset and at least 24hourly from then on.
More frequent testing is indicated in ill patients or those with co-morbidities.
Rapid results of electrolytes can be done with blood gases measurements.
Consider septic work-up or surgical consult in severely unwell patients with
abdominal symptoms (i.e. gastroenteritis).
Maintenance
Maintenance fluid is the volume of daily fluid intake. It includes insensible
losses (from breathing, perspiration, and in the stool), and allows for
excretion of the daily production of excess solute load (urea, creatinine,
electrolytes) in the urine.
Most children can safely be managed with solution of 0.45% saline with
added glucose (i.e. 0.45% saline in 5% glucose or 0.45% saline in
10% glucose) depending on glucose requirement.
Sodium chloride 0.18 saline with glucose 5% should not be used as a
maintenance fluid and is restricted to specialist area to replace ongoing
loses of hypotonic fluids. These areas include high dependency, renal, liver
and intensive care.
Most children will tolerate standard fluid requirements. However some
acutely ill children with inappropriately increased anti-diuretic hormone
secretion (SIADH) may benefit from their maintenance fluid requirement
being restricted to two-thirds of the normal recommended volume.
Children who are at high risk of hyponatremia should be given isotonic
solutions (i.e. 0.9% saline glucose) with careful monitoring to avoid
iatrogenic hyponatremia in hospital.
These include children with the following conditions:
Peri-or post-operative
Require replacement of ongoing losses
A plasma Na at lower normal range of normal (definitely if < 135mmol/L)
Intravascular volume depletion
Hypotension
Central nervous system (CNS) infection
Head injury
Bronchiolitis
Sepsis
Excessive gastric or diarrhoeal losses
Salt-wasting syndromes
Chronic conditions such as diabetes, cystic fibrosis and pituitary deficits.
20
Weight
Total fluids
Infusion rate
First 10 Kgs
100 ml/kg
4 mls/kg/hour
Subsequent 10 Kgs
50 ml/kg
2 mls/kg/hour
All additional Kg
20 ml/kg
1 mls/kg/hour
Example: A Child of 29 kg will require:

100mls/kg for first 10kg of weight
10 x 100
= 1000 mls
50mls/kg for second 10kg of weight
10 x 50
= 500 mls
9 x 20
= 180 mls
20mls/kg for all additional weight
Total
= 1680 mls
Rate
= 1680/24
= 70mls/hour
Composition of commonly used intravenous solution

Fluid
Osmolality
Na content
Osmolality
Tonicity
(mOsm/l)
(mmol/l)
compared to
plasma
with ref to cell

membrane
Na chloride 0.9%
308
Na chloride 0.45%
154
Na chloride 0.9%
+ Glucose 5%
586
Na chloride 0.45%
+ Glucose 5%
432
Na chloride 0.18%
+ Glucose 5%
154
IsoOsmolar
Isotonic
77
HypoOsmolar
Hypotonic
150
HyperOsmolar
Isotonic
75
HyperOsmolar
Hypotonic
284
31
IsoOsmolar
Hypotonic
Dextrose 5%
278
Nil
IsoOsmolar
Hypotonic
Dextrose 10%
555
Nil
HyperOsmolar
Hypotonic
Hartmanns
278
131
IsoOsmolar
Isotonic
21
GENERAL PAEDIATRICS
Calculation of Maintanence Fluid Requirements

The following calculations approximate the maintenance fluid requirement of
well children according to weight in kg. (Holliday-Segar calculator)
GENERAL PAEDIATRICS
Deficit
A childs water deficit in mls can be calculated following an estimation of the
degree of dehydration expressed as % of body weight.
Example: A 10kg child who is 5% dehydration has a water deficit of 500mls.
Maintenance
100mls/kg for first 10 kg
= 10 100
= 1000mls
Infusion rate/hour
= 1000mls/24 hr
= 42mls/hr
Deficit (give over 24hours)

5% dehydration (5% of body water): 5/100 10kg 1000mls = 500mls
Infusion rate/hour (given over 24 hrs)
= 500mls/24 hr
= 21mls/hr
The deficit is replaced over a time period that varies according to the
childs condition. Precise calculations (e.g. 4.5%) are not necessary.
The rate of rehydration should be adjusted with ongoing clinical assessment.
Use an isotonic solution for replacement of the deficit, e.g. 0.9% saline.
Reassess clinical status and weight at 4-6hours, and if satisfactory continue.
If child is losing weight, increase the fluid and if weight gain is excessive
decrease the fluid rate.
Replacement may be rapid in most cases of gastroenteritis (best achieved
by oral or nasogastric fluids), but should be slower in diabetic ketoacidosis
and meningitis, and much slower in hypernatremic states (aim to rehydrate
over 48-72 hours, the serum Na should not fall by >0.5mmol/l/hr).
Ongoing losses (e.g. from drains, ileostomy, profuse diarrhoea)
These are best measured and replaced. Any fluid losses > 0.5ml/kg/hr needs
to be replaced.
Calculation may be based on each previous hour, or each 4 hour period
depending on the situation. For example; a 200mls loss over the previous 4
hours will be replaced with a rate of 50mls/hr for the next 4 hours).
Ongoing losses can be replaced with 0.9% Normal Saline or Hartmanns
solution. Fluid loss with high protein content leading to low serum albumin
(e.g. burns) can be replaced with 5% Human Albumin.
22
The daily sodium requirement is 2-3mmol/kg/day.

Normal serum sodium is between 135-145mmol/l.
Hypernatremia
Hypernatremia is defined as serum Na+ > 150mmol/l,
moderate hypernatremia is when serum Na+ is 150-160mmol/l, and
severe hypernatremia is when serum Na+ > 160mmol/l.
It can be due to:
Clinical signs of Hypernatremic dehydration
water loss in excess of sodium
Irritability
(e.g. diarrhoea)
water deficit
Skin feels doughy
(e.g. diabetes insipidus)
Ataxia, tremor, hyperreflexia
sodium gain
(e.g. large amount of NaHCO3 Seizure
infusion or salt poisoning).
Reduced awareness, coma
If the cause of the hypernatremia is central diabetes insipidus, it is advisable
to consult Endocrinology team regarding management.
In hypernatremia the child appears sicker than expected for the degree of
dehydration.
Shock occurs late because intravascular volume is relatively preserved.
Signs of hypernatremic dehydration tend to be predominantly that of
intracellular dehydration and neurological dysfunction.
Management
This will depend on the cause of hypernatremia.
For hypernatremic dehydration with Na+> 150mmol/l
If the patient is in shock, give volume resuscitation with 0.9% Normal saline
as required with bolus/es.
Avoid rapid correction as this may cause cerebral oedema, convulsion and
death.
Aim for correction of deficit over 48-72 hours and a fall of serum sodium
concentration not more than 0.5mmol/l/hour.
Give 0.9% saline to ensure the drop in sodium is not too rapid.
Remember to also give maintenance and replace ongoing losses following
the recommendation above.
Repeat blood urea and electrolytes every 6 hours until stable.
Special considerations
A slower rate will be required for children with chronic hypernatremia
(present for more than 5 days).
Calcium and glucose need to be checked as hypernatremia can be
associated with hypocalcaemia and hyperglycemia, these conditions need to
be corrected concurrently.
23
GENERAL PAEDIATRICS
SODIUM DISORDERS
GENERAL PAEDIATRICS
Hyponatremia
Hyponatremia is defined when serum Na+ < 135mmol/l.
Hyponatremic encephalopathy is a medical emergency that requires rapid
recognition and treatment to prevent poor outcome.
As part of the general resuscitative measures, bolus of 4ml/kg of 3% sodium
chloride should be administered over 30 minutes. This will raised the serum
sodium by 3mmol/l and will usually help stop hyponatremic seizures.
Gradual serum sodium correction should not be more than 8mmol/day to
prevent osmotic demyelination syndrome.
Calculating sodium correction in acute hyponatremia
mmol of sodium required
= (135-present Na level) 0.6 weight(kg)
The calculated requirements can then be given from the following available
solutions dependent on the availability and hydration status:
0.9% sodium chloride contains 154 mmol/l
3% sodium chloride contains 513mmol/l
Children with asymptomatic hyponatremia do not require 3% sodium
chloride treatment and if dehydrated may be managed with oral fluids or
intravenous rehydration with 0.9% sodium chloride.
Children who are hyponatremic and have a normal or raised volume status
should be managed with fluid restriction.
For Hyponatremia secondary to diabetic ketoacidosis; refer DKA protocol.
POTASSIUM DISORDERS
The daily potassium requirement is 1-2mmol/kg/day.
Normal values of potassium are:
Birth - 2 weeks: 3.7 - 6.0mmol/l
2 weeks 3 months: 3.7 - 5.7mmol/l
3 months and above: 3.5 - 5.0mmol/l
Hyperkalemia
Causes are:
Dehydration
Acute renal failure
Diabetic ketoacidosis
Adrenal insufficiency
Tumour lysis syndrome
Drugs e.g. oral potassium supplement, K+ sparing diuretics, ACE inhibitors.
Treatment: see algorithm on next page
24
Hyperkalemia K+ > 5.5 mmol/l

ECG changes in Hyperkalemia
Stop all K supplementation
Tall, tented T waves
Stop medication causing hyperK+
Prolonged PR interval
Cardiac monitoring
Prolonged QRS complex
Exclude pseudo hyperkalemia
Loss of P wave,
wide biphasic QRS
Recheck with venous sample

Child unstable
or symptomatic
Child stable,
asymptomatic
Child stable,
asymptomatic
Abnormal ECG
Normal ECG
Normal ECG
K+ > 7.0 mmol/l
K+ >6, 7 mmol/L
K+ 5.5, 6.0 mmol/L
Discuss for dialysis
Neb Salbutamol
Consider treatment ?
IV Calcium
IV Insulin
with glucose
Neb Salbutamol
Transfer to
tertiary centre?
Neb Salbutamol
IV Insulin
with glucose
IV Bicarbonate
IV Bicarbonate
if acidosis
PR/PO Resonium
IV Bicarbonate
if acidosis
PR/PO Resonium
PR/PO Resonium
Drug doses:
IV Calcium 0.1 mmol/kg.
Nebulised Salbutamol:
Age 2.5 yrs: 2.5 mg; Age 2.5-7.5 yrs: 5 mg; >7.5 yrs: 10 mg
IV Insulin with Glucose:
Start with IV Glucose 10% 5ml/kg/hr (or 20% at 2.5 ml/kg/hr).
Once Blood sugar level >10mmol/l and the K+ level is not falling,
add IV Insulin 0.05 units/kg/hr and titrate according to glucose level.
IV Sodium Bicarbonate: 1-2 mmol/kg.
PO or Rectal Resonium : 1Gm/kg.
25
GENERAL PAEDIATRICS
Hyperkalemia Treatment Algorithm
GENERAL PAEDIATRICS
Hypokalemia
Hypokalemia is defined as serum Na+ > 3.4 mmol/l
(Treat if < 3.0mmol/l or Clinically Symptomatic < 3.4 mmol/l)
Causes are:
ECG changes of Hypokalemia
Sepsis
+
GIT losses - diarrhoea, vomiting These occur when K < 2.5mmol/l
Iatrogenic- e.g. diuretic therapy,
salbutamol, amphotericin B.
Renal tubular acidosis
Hypokalaemia is often seen
with chloride depletion
and metabolic alkalosis.
Prominent U wave
ST segment depression
Flat, low or diphasic T waves
Prolonged PR interval (severe hypoK+)
Sinoatrial block (severe hypoK+)
Refractory hypokalaemia may occur with hypomagnesaemia.

Treatment
Identify and treat the underlying condition.
Unless symptomatic, a potassium level of 3.0 and 3.4 mmol/l is generally
not supplemented but rather monitored in the first instance.
The treatment of hypokalaemia does not lend itself to be incorporated into a
protocol and as a result each patient will need to be treated individually.
Oral Supplementation
Oral Potassium Chloride (KCL), to a maximum of 2 mmol/kg/day in divided
doses is common but more may be required in practice.
Intravenous Supplementation (1gram KCL = 13.3 mmol KCL)
Potassium chloride is always given by IV infusion, NEVER by bolus injection.
Maximum concentration via a peripheral vein is 40 mmol/l (concentrations
of up to 60 mmol/l can be used after discussion with senior medical staff).
Maximum infusion rate is 0.2mmol/kg/hr (in non-intensive care setting).
Intravenous Correction (1gram KCL = 13.3 mmol KCL)
K+ < 2.5 mmol/L may be associated with significant cardiovascular
compromise. In the emergency situation, an IV infusion KCL may be given
Dose: initially 0.4 mmol/kg/hr into a central vein, until K+ level is restored.
Ideally this should occur in an intensive care setting.
26
Gross Motor
Pull to sit: Head lag, rounded

back
Ventral Suspension: Head
briefly in same plane as body.
Prone: Pelvis high, knees no
longer under abdomen. Chin
raised occasionally.
Pull to sit: Slight head lag. Head

occasionally bobs forward.
Ventral Suspension: Head above
plane of body.
Prone: Pelvis flat. Lifts head up
45- 90.
Pull to sit: No head lag and sits

with straight back.
Lying supine: Feet to mouth.
Pulls to sit: Lifts head in anticipation. Sits with support.

Bears weight on legs. Prone:
Supports weight on hands;
chest, upper abdomen off
couch. Rolls prone to supine.
Age
6 wks
3 mths
5 mths
6 mths
Palmar grasp of cube, ulnar

approach. Moves head, eyes in
all directions. No squint (after
4 months).
Reaches for objects.

Plays with toes.
Hand regard. Follows object

from side to side (180). Hands
held loosely. Grasps object
placed in hand.
Not reaching out.
Fixates and follows to 90

degrees
Fine Motor
Squeals with delight.

Turns head to sound.
Vocalising by 8 weeks. Quiets

to sound. Startles to sound.
Speech/Language
Chapter 4: Developmental Milestones in Normal Children
Mouthing.
Laughs.
Smiles responsively.
Social
GENERAL PAEDIATRICS
27
28
Gross Motor
Gets up and down stairs

holding on to rail or with
one hand held. Pulls toy
or carries doll. Throws ball
without falling.
Sits on a chair.
Goes up and down stairs

alone, 2 feet per step. Walks
backwards (21 months)
Runs. Picks up toy without
falling.
Throws, kick ball without
falling.
Jumps on both feet.

Walks on tip toes.
Goes up stairs one foot per

step.
Down stairs 2 feet per step.
Jumps off bottom step.
Stands on 1 foot for
seconds.
Rides tricycle.
Age
18 mths
2 yrs
2.5 yrs
3 yrs
Copies
Imitates
Draw a man test. (3 - 10y)
Tower of 9.
Imitates bridge with cubes:
Tower of 8.
Imitates train with
chimney.
Holds pencil well.
Imitates
and
Imitates straight line.

Visual test: Snellens chart.
Tower of 6 cubes.
Imitates cubes of train with
no chimney.
Tower of 3 cubes.
Scribbles spontaneously.
Visual test: Picture charts.
Handedness
Fine Motor
Can count to 10. Names 2

colours. Nursery rhymes.
Understands on, in,
under.
Knows full name and gender.

Names one colour.
2-3 word sentences. Uses

you me I. names 3
objects. Obeys 4 simple
commands. Points to 4 body
parts.
Points to 2 - 3 body parts.

Picture Cards - identify one.
Speech/Language
Dresses, undresses with

help. Dry by night.
Plays with others.
Puts on shoes, socks, pants.

Dry by day.
Play near other children but
not with them.
Imitates housework.
Toilet trained. Uses spoon
well. Casting stops.
Social
GENERAL PAEDIATRICS
Walks heel to toe

Kicking, throwing, climbing.
Goodenough test 12.

Imitates or copies steps with 10
cubes
Copies:
Goodenough test 8.
Copies X (5 years)
Copies (5 years) triangle.
Copies gate with cubes.

Copies square.
Draws recognisable man and
house.
Copies
Goodenough test 4.
Imitates gate with cubes.
Fine Motor
Knows AGE. Names 4

colours.
Triple order preposition.
Tells the time.
Names 3 colours. Fluent

conversation. Understands
in front of, between,
behind.
Speech/Language
Note: Goodenough test: 3 + a/4 years (a = each feature recorded in his picture).
6 yrs
5 yrs
Skips on both feet.

Runs on toes.
Goes up and down stairs

one foot per step.
Skips on one foot.
Hops on one foot.
4 yrs
4.5 yrs
Gross Motor
Age
Ties shoelaces.
Dresses and undresses
alone.
Buttons clothes fully. Attends

to own toilet needs.
Social
GENERAL PAEDIATRICS
29
30
Gets from lying to sitting to

crawling to standing.
Walks like a bear.Walks with
one hand held.
Walks well (13 months).
Stands alone
Creeps upstairs.
Stoops for toy and stands up
without support. (best at 18
months)
13 mths
Crawls on abdomen.
Pull self to stand.
10 mths
1 year
Sits steadily. Leans forward

but cannot pivot.
Stands holding on.
Pulls self to sit.
9 mths
Creeping on all fours.

Pivoting. Cruising.Walks with
both hands held.
Sits with hands on couch for

support.
Rolls from supine to prone.
7 mths
11 mths
Gross Motor
Age
Tower of 2 cubes.
Scribbles spontaneously (1518 months)
Neat pincer grasp. Bangs 2

cubes.
Sees and picks up hundreds
and thousands.
Index approach. Uses index

finger to poke at pea.
Lets go of cube in hand.
Inferior pincer grasp

(Scissors grasp)
Feeds self with biscuits.

Transfers objects - hand to
hand.
Rakes at pea.
Fine Motor
More words.
Points to objects he wants.
Continual jabber and jargon.
Understands phases; 2 - 3
words with meaning. Localising sound above head.
One word with meaning.
Localises sound at 3 feet,

above and below the ear
level.
Babbling in single syllables.

(combined syllables at 8
months). Distraction Test.
Speech/Language
Takes off shoe.

Feeds self with cup and spoon
(but spills). Mouthing stops
Casting (13 months)

Less mouthing.
Shy.
Plays peek-a-boo
Waves Bye bye

Plays Pat-a-Cake
Feeds with spoon occasionally.

Looks for fallen toys.
Understands NO!
Stranger anxiety.
Social
GENERAL PAEDIATRICS
Development is the progressive, orderly, acquisition of skills and abilities as a

child grows. It is influenced by genetic, neurological, physical, environmental
and emotional factors.
Important points to note:
child must be co-operative, not tired, fretful, hungry nor sick.
Remember that a child may behave differently in an unfamiliar environment
allowance must be made for prematurity up to two years.
take note of parental account of what child can or cannot do.
Note parental comments on abnormal gait, speech defects, etc.
normal development is dependent on integrity of childs hearing and vision.
normal pattern of speech and language development is essential for a
normal social, intellectual and emotional development.
delay in development may be global i.e. affecting all areas equally, or specific
areas only e.g. oro-motor dysfunction causing speech delay.
Key Developmental Warning Signs
1
Discrepant head size or crossing centile lines (too large or too small).
Persistence of primitive reflexes > 6 months of age
No response to environment or parent by 12 months
Not walking by 18 months
No clear spoken words by 18 months
No two word sentences by 2 years
Problems with social interaction at 3 years
Congenital anomalies, odd facies
Any delay or failure to reach normal milestones
Note: Parental concerns must always be taken seriously

Assessment of children with suspected developmental delay
History
consanguinity
family history of developmental delay
maternal drugs, alcohol, illness and infection in pregnancy
prematurity, perinatal asphyxia
severe neonatal jaundice, hypoglycaemia or seizures
serious childhood infections, hospital admissions or trauma
home environment conditions (environmental deprivation)
Physical examination
head circumference, dysmorphic features
neurocutaneous markers
neurological abnormalities
full developmental assessment
31
GENERAL PAEDIATRICS
Chapter 5: Developmental Assessment
GENERAL PAEDIATRICS
Investigations
(individualised according to
history and physical findings)
Visual and auditory testing
T4, TSH
Chromosomal Analysis
Consider
- Creatine kinase in boys
- MRI Brain
- Metabolic screen
- Specific genetic studies
(Fragile X, Prader Willi
or Angelman syndrome)
- Refer to a geneticist
- EEG if history of seizures
Consider
Hypothyroidism
Chromosomal anomaly
Cerebral palsy
Congenital intrauterine infection
Congenital brain malformations
Inborn errors of metabolism
Autistic spectrum disorder
Attention deficit hyperactivity disorder
Prior brain injury, brain infections
Neuroctaneous disorders
Duchennes muscular dystrophy
Assessment of Children with Suspected Hearing Impairment

or Speech Delay
History
Congenital infection
Perinatal medications
Severe neonatal jaundice
Family history of deafness
or speech delay
Chronic ear infections
Quality, quantity of speech
Examine ears
Dysmorphic features
Distraction Test
Assess expressive, receptive
speech
Neurological / development
assessment
Warning Signs for Hearing Impairment

1
Child appears not to hear
Child makes no attempt to listen.
Does not respond to name, No or

clue words e.g. Shoe, by 1 yr age
Any speech/language milestone delay
Consider
Congenital sensorineural deafness
Familial, genetic deafness
Congenital rubella infection
Oro-motor dysfunction
Management
Formal hearing assessment
Speech-language assessment and interventions
32
Age
Test
Comments
Newborn
screening
Automated Otoacoustic
Emission (OAE) test
Determines cochlear function.

Negative test in conductive
hearing loss, middle ear
infections, or in moderate to
severe sensorineural hearing
loss.
Any age
Brainstem Auditory
Evoked Responses
(BAER)
Measures brainstem responses

to sound.
Negative test in sensorineural
hearing loss
7-9 months
Infant Distraction Test

(IDT)
Determines response to
sound whilst presented during
a visual distraction.
Infants
Behavioural Observation
Assessment (BOA) test
Audiologist identifies bodily reactions to sound, i.e.

cessation of activity, body
movement, eye widening and
opening suckling rate.
> 2.5 years
Conditioned Play
Audiometry
Earphones placed on child and

various games are done when
test tone is heard.
Older Children
Pure Tone Audiometry
Patient presses a response

button or raises a hand when
the test tone is heard
Assessment of Children with Suspected Visual Impairment

Children at risk
Prematurity.
Intrauterine Infection (TORCHES)
Family history of cataracts,
Warning Signs for Visual Impairment
retinoblastoma or squint.
Previous meningitis, asphyxia 1 Does not fix on mothers face by 6 wks
Dysmorphic babies
2 Wandering or roving eyes after 6 wks
3
Abnormal head postures
Leukocoria (white eye reflex)
Holds objects very close to eye.
Squint after 6 months of age.

33
GENERAL PAEDIATRICS
Hearing Tests at different ages
GENERAL PAEDIATRICS
Assessment of Children with Suspected Learning Difficulties

It is sometimes a challenge to identify the primary cause of the learning
difficulty as conditions like dyslexia , ADHD and intellectual impairment share
common symptoms.
A. History (A thorough history is important)
Antenatal perinatal and postnatal complications
High risk behaviour like substance abuse in mother
Family history of development delay, learning difficulties etc.
Detailed developmental milestones
When learning problems were first noted (preschool achievement, etc. as
children with dyslexia or ADHD will have symptoms in early childhood)
Past and current education performance
Areas of learning difficulties
Specific: e.g. reading difficulties (dyslexia) , writing difficulties (dysgraphia)
but extremely good in tasks that require visual stimulation, e.g. art, music
General : more commonly seen in children with some degree of intellectual
impairment or from an extremely understimulated environment
Strength of the child perceived by parents and teachers
Who is the main caregiver at home ?
Social background of the family
B1. Review School concerns with the patient, parents & teachers
(always ask for teachers report). Common symptoms
Apathy towards school
Avoidance or poor performance in specific subject areas
Disruptive or negative behaviour in certain classes
B2. Review all school workbooks (not only report card)
C. Basic Cognitive (intellectual functioning) screening tool in a Pediatric Clinic:
Ask child to tell about a recent event : birthday, visit to grandparents etc.
(note whether language is fluent, coherent, organized)
Ask parents whether child has difficulty taking retaining classroom
instructions or instructions at home (short term memory)
Observe the child using a pencil to copy symbols and words
(visual perceptual motor disorder characterized by confusing symbol,
easy distractibility , inability to copy information)
Ask the child to perform a 3-step command
(sequencing ability to communicate and understand information in a orderly
and meaningful manner)
Ask the child to repeat four words , remember them and repeat them again
when asked in 5 -10 minutes (memory , attention)
Ask the child to repeat three, then four digits forward then repeat three,
then four digits backward (concentration)
34
Block and Pencil test (From Parry TS: Modern Medicine, 1998)
Age
Block Test
Pencil Test
3 - 3.5 yrs
Build a bridge
Draw a circle
3.5 - 4 yrs
Draw a cross
3 - 4.5 yrs
Build a gate
Draw a square
5 - 6 yrs
Build steps
Draw a triangle
This test screens cognitive and perceptual development for age.

Block test: build the structure without child observing then ask the
child to copy the structure.
Pencil test: Draw the object without child observing then ask the
child to copy it.
E. Differential Diagnosis that need to be ruled out:
Common causes
Autism
ADHD or combination of both
Specific learning difficulty like Dyslexia
Limited environmental stimulation
Genetic or a chromosomal disorder
Fragile X
Hypothyroidism
Intellectual impairment
Tourette
Neurofibromatosis
Neurological
Seizures
Neurodegenerative condition
35
GENERAL PAEDIATRICS
D. Physical Examination
Anthropometric measurement
General alertness and response to surrounding
(Children with dyslexia will be very alert and usually very enterprising)
Dysmorphism
Look for neurocutaneous stigmata
Complete CNS examination including hand eye coordination
as children may have a associated motor difficulties like dyspraxia
Complete developmental assessment.
Ask child to draw something he or she likes (this can help to get a clearer
picture about intellect of the child)
GENERAL PAEDIATRICS
Miscellanous causes
Anaemia
Auditory or visual impairment
Toxins (fetal alcohol syndrome, prenatal cocaine exposure, lead poisoning)
F. Plan of Management
Dependent on the primary cause for learning difficulties
Dyslexia screening test if available
DSM 1V for ADHD or Autistic Spectrum Disorder
(Refer CPG for management of children and adolescents with ADHD :2008)
Refer Occupational therapist for school preparedness (pencil grip, attention
span etc) or for associated problems like dyspraxia
Refer speech therapist if indicated
Assess vision and hearing as indicated by history and clinical examination
Targeted and realistic goals set with child and parents
One-to-one learning may be beneficial
Registration as a Child with Special Needs as per clinical indication and after
discussion with parents
G. Investigations
Clinical impressions guides choice. Consider:
DNA analysis for Fragile X syndrome for males with Intellectual impairment
Genetic tests, e.g. Prader Willi, Angelman, DiGeorge, Williams syndromes
TSH if clinically indicated
Creatine Kinase if clinically indicated
MRI brain study abnormal neurological examination
EEG only if clinically indicated
When is IQ Testing Indicated?
When diagnosis is unclear and there is a need to determine options for school
placement.
If unsure of diagnosis refer patient to a Pediatrician, Developmental Pediatrician, Pediatric Neurologist, Child Psychiatrist and Child Psychologist depending
on availability of services in your area.
36
Some first signs suggestibe of dyslexia

Preschool and Kindergarten
Language
May have difficulty pronouncing words and

slow to add new vocabulary words
May be unable to recall the right word
Trouble learning nursery rhymes or playing rhyming
Trouble learning to recognize letters of the alphabet
(important predictor of later reading skills: recognition
of letters of alphabets starts before decoding )
Memory
Difficulty remembering rote information (name,

phone number, address)
Fine motor skills
Fine motor skills may develop more slowly than in

other children
Lower Grades in School

Language
Delayed decoding abilities for reading

Trouble following directions
Poor spelling and using of pronouns, verbs
Memory
Slow recall of facts

Organizational problems
Slow acquisition of new skills
Attention
Impulsive, easily distractible and careless errors
Fine motor skills
Unstable pencil grip

Trouble with letter formation
Visual skills
Confuses words, e.g. at to, does goes, etc

Consistent reading and spelling errors
Transposes number sequence, maths signs (+,- X/=)
Middle Grades of School

Language
Poor reading comprehension

Trouble with word problems
Lack of verbal participation in class
Memory
Slow or poor recall of math facts and failure of

automatic recall
Attention
Inconsistency and poor ability to discern relevant

details
Fine motor skills
Fist-like or tight pencil grip

illegible, slow or inconsistent writing
Visual skills
May reverse sequences (e.g.: soiled for solid )
37
GENERAL PAEDIATRICS
Chapter 6: Developmental Dyslexia
GENERAL PAEDIATRICS
Higher Grades in School

Language
Weak grasp of explanation

Poor written expressions
Trouble summarizing
Memory
Trouble studying for test

Slow work pace
Attention
Memory problems due to poor attention

Mental fatigue
Fine motor skills
Less significant
Visual skills
Misreads information
Trouble taking multiple choice questions
Difficulty with sequencing (maths, music and
science: physics)
Essentials in making a diagnosis of dyslexia

History (A thorough history is important)
When reading problems was first noted
What were the problems?
What is the current reading problem faced by the child at school
Neurodevelopment (esp speech delay)
Family history (esp. speech delay and learning disability)
Significant birth and medical history
Assessment of school work (esp. exam papers and teachers report) .
Strength of the child
Any educational interventions or others attempted before
Physical Examination
Look for this, as some of these findings may be associated with features of
dyslexia:
Microcephaly
Vision and Hearing problems
Syndromic facies
Neurocutaneous stigmata
Neurodevelopmental examination
Neurodevelopmental assessment
Look specifically for problems in the following areas:
Gross motor
Coordination (some can be clumsy)
Motor planning
Visual motor & spatial functioning.
38
Visual motor integration

Spatial relationship
Patterns in written material
Meaning of maths symbols
Temporal sequential organization
Auditory sequencing
Understanding time
Organization & planning
Language
Receptive and Expressive language.
Comprehension.
Grammar
Spoken and written instructions
Behavior
Attention
Adaptation
Self monitoring
Investigations
Tailored to patients needs.
IQ testing for those where diagnosis or underlying cause is unclear
e.g. Borderline intellectual impairment with dyslexic features.
Differential Diagnosis
Hearing and visual problems.
Attention deficit hyperactivity disorder (ADHD)
Global developmental delay
Intellectual impairment
Minimum Interventions that can be done:
Advocate for the educational needs of the child
Network for services that child may need out of the school,
e.g. one-to-one tuition
Discuss with parents how to tackle childs difficulties, best school
placements, registration as a child with special needs, etc.
Refer to other disciplines e.g. Dyspraxia and Pencil grip: Occupational
therapist
May need referral to speech therapist
39
GENERAL PAEDIATRICS
Fine motor
Small muscle manipulation (dyspraxia)
GENERAL PAEDIATRICS
Suggestions for School Based Interventions

A phonics-based reading program that teaches the link between spoken and
written sounds
A multi-sensory approach to learning, which means using as many different
senses as possible such as seeing, listening, doing and speaking
Arrangements with the childs school - for example, for them to take oral
instead of written tests
Learning via audiotape or videotape
Arrange for extra time for exams
Arrange for readers for UPSR students (need to write to JPN one year ahead
of the UPSR exams)
Features of Dyslexia that can be elicited in the General Pediatric Clinic Setting
(tables in following pages)
Assessment needs to be done in accordance to the childs cooperativeness
level (may require 2-3 visits for a thorough assessment)
This is not a validated assessment checklist, when in doubt refer to a
Pediatrician, Developmental Pediatrician or an Educational Psychologist,
depending on services available at your hospital.
At the end of the assessment, please answer these 2 questions below, and tick
the appropriate column.
Question
Yes
No
1. Does the limitation in reading, spelling and writing cause

significant learning difficulty in school?
2. From your clinical assessment do you agree that the IQ of
the child is appropriate for age?

If the answer to the both the above questions is yes then the probable
diagnosis is Dyslexia.
If unsure about diagnosis please refer to Pediatrician, Developmental Pediatrician or Educational Psychologist depending on services available in your area.
References
1.Shaywitz, NEJM 1998
2.Kenneth L.Grizzle Pedia N Am 54; 2007
3. Center for community child health
4. Dyslexia screening Test
5. Dr Khoo Teik Bengs Dyslexia Clinic
40
Unable to read appropriately for age
Reading
Difficulty in differentiating words that

sounds alike
Difficulty to name letters of the

alphabet
Letter
Indentification
A, B, C, D, E . . .
Mana
Nama
Mama
Dapat
Padat
Pilau = Pulau
Karusi = Kerusi
Maja = Meja
Unable to read unfamiliar words or

pseudo words and usually will try to
guess or make up words because of
some familiarity.
Phonological
processing /
awareness
Single Word Reading

Boy
Chair
Kite
Hope

Give age appropriate passage or books
Examples
Reading will be slow, labored, inaccurate reading of even single words

( ensure that there is no visual cues
while doing this)
Child may appear visibly tired after

reading for only a short time
Features
Skill
Prepare a table of alphabets and ask

child to read out (ensure you point to
the alphabets that you want the child
to read). Take note that child maybe
able to recite from memory
Consider the educational background

of the child
Show single words as suggested and

ask child to read.
Listen to the child read aloud from his

or her own grade level reader. (Keep
a set of graded readers available in
your clinic)
How to Test in Clinic
GENERAL PAEDIATRICS
41
42
Difficulty in identifying word that

would remain if a particular sound
were removed
Segmentation
Difficulty recalling a sentence or a

story that was just told
Difficulty identifying words beginning

with the same letter
Letter-Sound
Association
Short term
Verbal memory
(eg, recalling a
sentence or a
story that was
just told)
Features
Skill
Narrate story to the child

then ask questions like:
Apa nama kuching Ali?
Tompok suka makan apa?
Di mana Ali pergi
memancing?
What remains if the /k/

sound was taken away
from cat = at
What remains if the /Ta/
sound taken away from
table= ble
What remains if the /p/
sound was taken away
from paku = aku
What remains if the sound
/ma/ sound taken away
from mata = mata
Doll, Dog, etc

Buku, buka, etc
Examples
Have a short story which goes like

this: Ali ada seekor kuching bernama
Tompok. Tompok suka makan ikan. Ali
pergi memancing ikan di sungai dan
memberikan ikan itu kepada Tompok.
GENERAL PAEDIATRICS
Difficulty in performing task that needs

sequencing
Sequencing
steps in a task
Difficulty in listing out name of animals

or objects
Expressive
vocabulary or
word retrieval
Difficulty in memorizing non-meaningful facts (facts that are not personally

interesting and personally relevant)
Difficulty in rapidly naming a continuous series of familiar objects, digits,

letters, or colors
Rapid Naming
Rote memory
Features
Skill
Tying shoelaces
Printing letters: cant
remember the sequence
of pencil strokes
necessary to form that
letter. May write a in an
odd way
Multiplication tables
Days of the week or
months of the year in
order
Use flash cards with

pictures only, colours or
numbers
Examples
Ask child to recite simple multiplication table or to say out days of the
week or months of the year in order.
Give me the names of animals you

know
Ask child to name colours. If child not

be able to do so ask child to point to a
particular colour in a book. Usually the
child will not have difficulty in doing so.
Can use numbers for rapid naming or

to test ability of remembering numbers
in a reverse order.
GENERAL PAEDIATRICS
43
44
Features
Difficulty in spelling even simple words

that is age appropriate
Left-Right confusion
Up-Down confusion
Poor, nearly illegible handwriting or

difficulty in writing on a straight line.
Difficulty in differentiating small or big
letters.
Unusual spatial organization of the
page.
Difficulty in copying from blackboard

Takes a long time to copy and copied
work will have a lot of mistakes
Skill
Spelling
Directionality
Dysgraphia
Copying
Tying shoelaces
Printing letters: cant
remember the sequence
of pencil strokes
necessary to form that
letter. May write a in an
odd way
Words may be widely

spaced or tightly pushed
together.
Margins are often
ignored.
Substitution : b-p or d-q,

n-u, and m-w
Confusion about
directionality words:
First-last, before-after,
next-previous, over-under
Buku, meja, mata,

sekolah, etc
Examples
Observe school workbook which

needs copying
Observe school workbook for writing

problems.
Ask child to do simple spelling with 2

syllables first if able to do then
proceed to multisyllable words
GENERAL PAEDIATRICS
A Psychosocial Interview for Adolescents

Introduction
Adolescence is the developmental phase between childhood and adulthood and
is marked by rapid changes in physical, psychosocial, sexual, moral and cognitive
growth.
Dr. Cohen refined a system for organizing the developmentally-appropriate
psychosocial history that was developed in 1972 by Dr. Harvey Berman.
The approach is known by the acronym HEADSS (Home, Education /employment, peer group Activities, Drugs, Sexuality, and Suicide/depression). It was
subsequently expanded to HEEADSSS by adding Eating and Safety.
Preparing for the Interview
Parents, family members, or other adults should not be present during the
HEADSS assessment unless the adolescent specifically gives permission, or asks
for it.
Starting the interview
1. Introduction
Set the stage by introducing yourself to the adolescent and parents. If the
parents are present before the interview, always introduce yourself to the
adolescent first.
2. Understanding of Confidentiality
Ask the adolescent to explain their understanding of confidentiality.
3. Confidentiality Statement
After the adolescent has given you his/her views, acknowledge his/her
response and add your views accordingly (confidentiality statement),
based on the particular situation.
The HEADSS assessment Items are in listed in the following pages
Suggestions for ending interviews with adolescents
give them an opportunity to express any concerns you have not covered,
and ask for feedback about the interview.
ask if there is any information you can provide on any of the topics you have
discussed. Try to provide whatever educational materials young people are
interested in.
45
GENERAL PAEDIATRICS
Chapter 7: The H.E.A.D.S.S. Assessment
46
Examples of Questions
Who lives at home with you? Where do you live? Do you have your own room?
How many brothers and sisters do you have and what are their ages?
Are your brothers and sisters healthy?
Are your parents healthy? What do your parents do for a living?
How do you get along with your parents, your siblings?
Is there anything you would like to change about your family?
Which school do you go to? What grade are you in? Any recent changes in schools?
What do you like best and least about school? Favourite subjects? Worst subjects?
What were your most recent grades? Are these the same or different from the past?
How much school did you miss last/this year? Do you skip classes? Have you ever
been suspended?
What do you want to do when you finish school?
How do you get along with teachers? How do you get along with your peers?
Inquire about bullying.
Are you in any full time or part time job?
What do you like and not like about your body?

Has there been any recent change in your weight?
Have you dieted in the last one year? How? How often?
How much exercise do you get on an average day ?Week?
Do you worry about your weight? How often?
Does it ever seem as though your eating is out of control?
Have you ever made yourself throw-up on purpose to control your weight?
Item
Home
Education
Employment
Eating
GENERAL PAEDIATRICS
Are most of your friends from school or somewhere else? Are they the same age as you?
Do you hang out with mainly people of your same sex or a mixed crowd?
Do you have a lot of friends?
Do you see your friends at school and on weekends, too?
Do you do any regular sport or exercise? Hobbies or interests?
How much TV do you watch? What are your favourite shows?
Dave you ever been involved with the police? Do you belong to a group or gang?
When you go out with your friends, do most of the people that you hang out with drink or smoke?
Do you? How much and how often?
Have you or your friends ever tried any other drugs? Specifically, what?
Do you regularly use other drugs? How much and how often?
Have you ever been in a relationship? When?

Have you had sex? Number of partners? Using contraception?
Have you ever been pregnant or had an abortion?
Have you ever been checked for a sexually transmitted infection (STI)?
Knowledge about STIs and prevention?
For females: Ask about menarche, last menstrual period (LMP), and menstrual
cycles. Also inquire about breast self examination (BSE) practices.
For males: Ask about testicular self-examination (TSE) practices.
Item
Activities
Drugs
Sexuality
GENERAL PAEDIATRICS
47
48
Do you have difficulties to sleep? Has there been any change in your appetite recently?
Do you mix around well others? Do you have hopeless or helpless feelings?
Have you ever attempted suicide?
Have you ever been seriously injured? Do you always wear a seatbelt in the car?
Do you use safety equipment for sports and or other physical activities (for example, helmets for biking)?
Is there any violence in your home? Does the violence ever get physical?
Have you ever been physically or sexually abused?
Have you ever been bullied? Is that still a problem?
Have you gotten into physical fights in school or your neighborhood? Are you still getting into fights?
Item
Suicide,
Depression
Safety
GENERAL PAEDIATRICS
Introduction
Paediatric palliative care has been defined as an active and total approach to
care embracing physical, emotional and spiritual elements. It focuses on quality of life for the child and support for the family and includes management
of distressing symptoms, provision of respite and care through death and
bereavement. 1
Causes of Paediatric Mortality (Malaysian Public Hospitals)
In paediatric departments at Malaysian public hospitals, 70% of deaths occur
in neonates and 30% are in older children. 2
Under Five Mortality Study data shows that 76% are hospital deaths; 24%
are non hospital deaths.
A third (33%) of hospital deaths were congenital malformations,
deformations and chromosomal abnormalities; 5% had oncology disorders.
It is difficult to ascertain the exact percentage who require palliative care in
the latter group.
The data suggests that there is plenty of work to be done in paediatric palliative medicine and end of life care. Why is this important?
Impact of the lost of a child
The care of dying children is different from adults as the dying process of a
child affects many individuals with grief over the loss that is more intense,
long lasting and complicated.3 This is because children are generally expected
to outlive their parents.
Parental grief is the most severe form of grief 4; with an associated increase
in morbidity and mortality.5 It often intensifies in 2nd or 3rd year (when
friends and relatives expect them to be over it).
For parents who have lost a child , there is an increased risk of psychiatric
hospitalisation. 6 This risk is higher in bereaved mothers than bereaved
fathers, the risk is highest in the 1st year following their childs death, and
remains elevated for 5 years.7
Care-related factors may influence parents psychological outcomes.8
Among factors that continued to affect parents 4-9 years following their
childs death was the memory of the child having had unrelieved pain and
experienced a difficult moment of death. Interviews with 449 bereaved
parents suggest that the childs physical pain and circumstances at the
moment of death contributed to parents long term distress.9
Quality of End of Life Care
Parents associated quality end of life care with physicians.10
Giving clear information about what to expect in the End of Life period
Communicating with care and sensitivity
Communicating directly with child where appropriate
Preparing the parent for circumstances surrounding the childs death
As healthcare providers we have the unique opportunity to contribute towards
quality end of life care. A bereavement clinic follow up, or home visit, can be
arranged in 6-12 weeks after death.
49
GENERAL PAEDIATRICS
Chapter 8: End of Life Care in Children
GENERAL PAEDIATRICS
End of life Care for Paediatric Patients

When the disease trajectory of a patient has reached the final days, and the
family or caregivers understand the situation, the following steps can be taken
to help the patient and family. Existing medical orders and management strategies should be reviewed with the goal of enhancing comfort and decreasing
noxious and invasive interventions.
Aspects of care that should be addressed are
Discontinue parenteral nutrition. Enteral feeding reduced, discontinued or
offered as a comfort measure; breastfeeding may be offered if desired by
mother and baby; a lactation referral for breastfeeding mothers to stop milk
production.
Discontinue tests and treatments to minimize noxious or painful procedures.
Intravenous access maintained for medications to decrease pain, anxiety or
seizures. Alternatives to IV access are oral, sublingual or rectal medications.
Discontinue antibiotics.
Discontinue cardiac sustaining medications e.g. dopamine, adrenaline.
Ventilator support: parents must be included in the decision to disconitnue
mechanical ventilation support and should be provided with information
about the expected sequence of events surrounding disconnection from the
ventilator as well as the infants physical response, including the possibility
that the infant may not die immediately. 12
Moral and ethical issues e.g. do not resuscitate status; Do not resuscitate
(DNR) orders should be explicit and developed collaboratively with the family.
Pain management; comfort measures e.g. discontinue non essential
investigations, observations for pain, agitation, nausea and vomiting;
appropriate management to improve the quality of life; give additional
morphine for breakthrough pain.
Communication with care givers; their understanding of what to expect,
choice of place where they prefer the child to die; how the rest of the family
is coping or understands; patients desire or wish list ; organ donation.
Religious and spiritual needs of the parents and family.
For the child dying in hospital, whether the family wants to take the body
home, how will the body be transported; are there any specific religious
requirements, and does the family want symbolic memorials (e.g. hand
prints, hair lock).
Transitional care, family support, sibling support, staff support, organ
donation, follow up support for family.
50
The following is a list of lethal congenital anomalies:

Genetic
Trisomy 13 or 18, triploidy, thanatophoric dwarfism or lethal forms of
osteogenesis imperfecta; inborn errors of metabolism that are lethal even
with available therapy.
Renal (with oligo/anhydramnios and pulmonary hypoplasia)
Potters syndrome, renal agenesis, multicystic or dysplastic kidneys,
polycystic kidney disease, renal failure that requires dialysis.
Central nervous system
Anencephaly, holoprosencephaly, complex, severe meningomyelocele, large
encephaloceles, hydranencephaly, congenital severe hydrocephalus with
absent or minimal brain growth; neurodegenerative diseases, e.g. spinal
muscular atrophy type 1.
Cardiac
Acardia, Inoperable heart anomalies, hypoplastic left heart syndrome,
pentalogy of Cantrell (ectopia cordis).
Other structural anomalies
Certain cases of giant omphalocoele, severe congenital diaphragmatic hernia
with hypoplastic lungs; inoperable conjoined twins.
Some of these conditions may be prenatally diagnosed thus allowing the
paediatric palliative care team to be activated early.
Others may need further evaluation to ensure certainty in these cases it is
advisable to do what is medically necessary to support the baby. The life
sustaining medical support can be withdrawn once a definitive diagnosis or
prognosis is established.
51
GENERAL PAEDIATRICS
Neonatal Palliative Care Plan for the Infant with Lethal Anomalies
The goal of palliative care is the best quality of life for patients and their
families
GENERAL PAEDIATRICS
Neonatal Palliative Care Plan for the Infant with Lethal Anomalies
Comfort measures for babies:
dry and warm baby, provide warm blankets.
provide a hat.
allow mothers to room-in.
minimize disruptions within medically safe practice for mother
lower lights if desired.
allow presence of parents and extended family as much as possible
without disruption to work flow in the unit.
make siblings comfortable; they may wish to write letters or draw for the
baby.
begin bereavement preparation and memory building, if indicated, to
include hand and footprints, pictures, videos, locks of hair.
encourage parent/child bonding and interaction: bathe, dress baby; feeds,
diaper change.
Selected medical interventions
Humidified oxygen ( _____________ % )
Nasal cannula oxygen ( _____________ L/min)
Suctioning of airway and secretions.
Morphine sublingual 0.15 mg/kg or IV 0.05 mg/kg, as needed.
Buccal midazolam or oral clonazepam as needed.
Artificial hydration or nutrition : ________________________________
natural hydration or nutrition : _________________________________
Note: Avoid distressing delays in treating symptoms by making medications
available in all available concentrations and doses.
Spiritual care
religious preference:
__________________________________
identified religious leader:
__________________________________
religious ritual desired at or near time of death:

__________________________________
In the event of childs death in hospital
Diagnostic procedures:
__________________________________
Autopsy preference:
__________________________________
Tissue/organ procurement preferences:

__________________________________
Funeral home chosen by family:__________________________________
Rituals required for body care: __________________________________
Please notify:__________________________________________________
52
53
GENERAL PAEDIATRICS
References
Section 1 General Paediatrics
Chapter 1 Normal Values
1.Advanced Paediatric Life Support: The Practical Approach Textbook, Fifth
Edition 2011.
2.Nelson Textbook of Pediatrics, 18th Edition
Chapter 2 Immunisations
1.Ministry Of Health Malaysia.
2.Health Technology Assessment Expert Committee report on immunisation
(MOH Malaysia).
3.Malaysian Immunisation Manual 2nd Edition. College of Paediatrics,
Academy of Medicine of Malaysia. 2008.
4.AAP Red Book 2009.
5.Advisory Committee on Immunisation Practices (ACIP).
Chapter 3 Fluid and Electrolytes
1.Mohammed A et al. Normal saline is a safe rehydration fluid in children
with diarrhea-related hypernatremia. Eur J Pediatric 2012 171; 383-388
2.Advanced Paediatric Life Support: The practical approach 5th Edition 2011
Wiley- Blackwell; 279-289
3.Manish Kori, Nameet Jerath. Choosing the right maintenance intravenous
fluid in children, Apollo Medicine 2011 December Volume 8, Number 4;
pp. 294-296
4.Corsino Rey, Marta Los-Arcos, Arturo Hernandez, Amelia Sanchez, Juan
Jse Diaz, Jesus Lopez Herce. Hypotonic versus isotonic maintenance fluids
in critically ill children: a multicenter prospective randomized study, Acta
Paediatrica 2011, 100; pp.1138-1143
5.Mark Terris, Peter Crean. Fluid and electrolyte balance in children, Anaesthesia and intensive care medicine 13.1 2011 Elsevier; pp. 15-19
6.Michael L. Moritz, Juan C Ayus. Intravenous fluid management for the
acutely ill child, Current opinion in Pediatrics 2011, 23; pp.186-193
7.Davinia EW. Perioperative Fluid Management.Basics. Anaesthesia, Intensive
Care and Pain in Neonates and Children Springer-Verlag Italia 2009; 135147
8.Michael Y, Steve K. Randomised controlled trial of intravenous maintenance
fluid. Journal of Paediatric and Child Health 2009 45; 9-14
9.Malcolm A Holliday, Patricio E ray, Aaron L Friedman. Fluid therapy for children: facts, fashion and questions, Arch Dis Child 2007, 92; pp.546-550
10.B Wilkins. Fluid therapy in acute paediatric: a physiological approach. Current Paediatrics 1999 9; 51-56
11.Anthony L. Paediatric fluid and electrolytes therapy guidelines. Surgery
2010 28. 8 369-372
12.Clinical practice guideline RCH. Intravenous fluid therapy.
GENERAL PAEDIATRICS
Chapters 4 and 5 Developmental Milestones and Assessment

1.RS. Illingworth. The Development of the Infant and Young Child.
2.First L, Palfrey J. The infant or young child with developmental delay. NEJM
1994;330:478-483
3.Shevell M, et al. Practice parameter: Evaluation of the child with global developmental delay. Neurology 2003;60:367-380
4.Joint Committee on Infant Hearing Year 2000 Position Statement: Principles
and Guidelines for Early Hearing Detection and Intervention Programs. Pediatrics. 2000; 106:798-817. http://www.infanthearing.org/jcih/
5.R.R. Anand: Neuropsychiatry of Learning Disabilities, 2007
6.Trevor S Parry Assessment of developmental learning and behavioural problems in children and young people. MJA 2005
7.Assessment and investigation of the child with disordered development .
Arch Dis Child Edu Practice 2011.
Chapter 6 Developmental Dyslexia
1.Shaywitz SE. Dyslexia. N Engl J Med. 1998;338:307-12.
2.Dyslexia screening Test
Chapter 7 HEADSS Assessment
1.Goldenring J, Cohen, E. Getting into adolescents heads. Contemporary Pediatrics 1988: 75-80.
2.Goldenring JM, Rosen DS. Getting into Adolescent Heads: An essential update. Contemporary Paediatrics 2004 21:64.
Chapter 8 End of Life Care
1.A Guide to the Development of Chidrens Palliative Care Services, Update
of a Report by THE ASSOCIATION FOR CHILDREN WITH LIFE THREATENING
OR TERMINAL CONDITIONS AND THEIR FAMILIES. THE ROYAL COLLEGE OF
PAEDIATRICS AND CHILD HEALTH. 2nd edition Sept 2003. ACT Promoting
Palliative Care for Children.
2.A study on the Under Five Mortality in Malaysia in the Year 2006 , Ministry of
Health Malaysia. Dr Wong Swee Lan et al p37/8
3.Papadatou D (1997) Training health professionals in caring for dying children
and grieving families. Death studies.21;6,575-600.
4.Li J, Laursen TM Precht DH et al Hospitalisation for mental illness among
parents after the death of a child. N E J Med 2005;352:1190-6
5.Li J, Precht DH, Mortenson PB et al Mortality in parents after death of a child
in Denmark: a nationwide follow up study. Lancet 2003; 361:363-7
6.Mack JW, Hilden JM, Watterson J et al. Parent and Physician perspective
on quality of life at the end of life care in children with cancer J Clin Oncol
2005;23:9155-61
7.Gay Gale, Alison Brooks Implementing a palliative care program in a newborn intensive care unit. Advances in Neonatal Care; 2006;6(1):37.e1-37.e21
8.Malaysian CPG on withdrawal and withholding care in children.
9.Steven R Leuthner. Palliative Care of the infant with lethal anomalies. Pediatric Clinics of North America 51(2004)749-759.
54
Chapter 9: Principles of Transport of the Sick Newborn
Special Considerations in Neonates

Apnoea
Premature and septic babies are especially prone to apnoea
Bradycardia
Hypoxia causes bradycardia followed by heart block and asystole
Oxygen toxicity to the lungs and retina
especially important in the premature infant
Reversal to fetal circulation (Persistent pulmonary hypertension of the neonate, PPHN)
Precipitating factors: hypoxia, hypercarbia, acidosis and sepsis
Hypothermia
Thermoregulation is less developed, infant has a larger body surface area
to mass ratio. If bowels are exposed, heat and fluid loss are compounded
by evaporation. The effects of hypothermia are acidosis and subsequent
PPHN, impaired immune function and delayed wound healing.
Hypoglycemia
The neonate lacks glycogen stores in liver and fat deposits.
Mode of transport
Careful consideration must be made as to the mode of transport.
The best mode of transfer is in utero, e.g. a mother in premature labour
should be managed in a centre with NICU facilities or for an antenatally
detected surgical, the mother should be advised to deliver at a centre with
paediatric surgical facilities.
The advantages and disadvantages of road, air (helicopter / commercial
airlines) and riverine transport must be considered in each child
Transport incubators with monitors, ventilators, oxygen and suction
equipment are ideal.
55
NEONATOLOGY
Introduction
Transport of neonates involves pre-transport intensive care level
resuscitation and stabilisation and continuing intra-transport care to ensure
that the infant arrives in a stable state.
Organized neonatal transport teams bring the intensive care environment to
critically ill infant before and during transport.
Good communication and coordination between the referring and receiving
hospital is essential.
There is rarely a need for haste.
However, there must be a balance between the benefits of further
stabilization versus anticipated clinical complications that may arise due to
delay in the transport.
NEONATALOGY
Air Transport
Patients can be transported by either commercial airlines with pressurised
cabins or by helicopters flying without pressurised cabins at lower altitudes.
There are special problems associated with air transport:
Changes in altitude Reduced atmospheric pressure causes decreased
oxygen concentration and expansion of gases. This may be important in
infants with pneumothorax, pneumoperitoneum, volvulus and intestinal
obstruction. These must be drained before setting off as the gases will
expand and cause respiratory distress. Infants requiring oxygen may have
increased requirements and become more tachypnoeic at the higher altitude
in non-pressurised cabins.
Poor lighting - Can make assessment of child difficult .
Noise and Vibration May stress the infant and transport team; May also
cause interference with the monitors, e.g. pulse oximeters. Use ear muffs if
available. It is also impossible to perform any procedures during transport.
Limited cabin space Limits access to the infant especially in helicopters.
Commercial aircraft and helicopters are unable to accommodate transport
incubators. The infant is thus held in the arms of a team member.
Weather conditions and availability of aircraft Speed of transfer may be
compromised by unavailability of aircraft/flight or weather conditions.
Stress and safety to the infant and team during poor weather conditions
needs to be considered.
Take off and landing areas special areas are required and there will be
multiple transfers: hospital ambulance helicopter ambulance - hospital.
Finances Air transport is costly but essential where time is of essence.
Pre-transport Stabilisation
Transport is a significant stress and the infant may easily deteriorate during the
journey. Hypothermia, hypotension and metabolic acidosis has a significant
negative impact on the eventual outcome. Procedures are difficult to do during
the actual transport. Therefore, pre-transport stabilization is critical.
The principles of initial stabilisation of the neonate
(see tables on following pages)
Airway
Breathing
Circulation, Communication
Drugs, Documentation
Environment, Equipment
Fluids electrolytes, glucose
Gastric decompression
56
Airway
Establish a patent airway
Evaluate the need for oxygen, frequent suction (Oesophageal atresia) or
an artificial airway (potential splinting of diaphragm).
Security of the airway The endotracheal tubes (ETT) must be secure to
prevent intra-transport dislodgement
Chest X-ray to check position of the ETT
Breathing
Assess the need for intra-transport ventilation. Does the infant have:
Requirement of FiO2 60% to maintain adequate oxygenation.
ABG PaCO2 > 60mmHg.
Tachypnoea and expected respiratory fatigue.
Recurrent apnoeic episodes.
Expected increased abdominal/bowel distension during air transport.
If there is a possibility that the infant needs mechanical ventilation
during the transfer, it is safer to electively intubate and ventilate before
transport. Check the position of the Endotracheal tube before setting off.
In certain conditions it may be preferable not to ventilate, e.g. tracheooesophageal fistula with distal obstruction. If in doubt, the receiving
surgeon/paediatrician should be consulted. If manual ventilation is to be
performed throughout the journey, possible fatigue and the erratic nature
of ventilation must be considered.
Circulation
Assess:
Heart rate, Urine output, Current weight compared to birth weight - are
good indicators of hydration status of the newborn infant.
Also note that:
Blood pressure in infants drops just before the infant decompensates.
Minimum urine output should be 1-2 mls/kg /hr.
The infant can be catheterised or the nappies weighed (1g = 1 ml urine)
Ensure reliable intravenous access (at least 2 cannulae) before transport.
If the infant is dehydrated, the infant must be rehydrated before leaving.
57
NEONATOLOGY
NEONATALOGY

Communication
Good communication between referring doctor, transport team and
neonatologist / paediatric surgeon aids proper pre-transfer stabilization,
coordination, timing of transfer, and preparedness of receiving hospital.
Inform receiving specialist, emergency department of receiving hospital.
Provide Name and telephone contact of referring doctor and hospital
Provide patient details
Give a clear history, physical findings, provisional diagnosis, investigations
Detail current management and status of the infant
Discuss mode of transport, expected departure time, arrival at referral centre
Decide on destination of the patient (e.g. A&E, NICU, Ward)
Drugs as required
Antibiotics needed in most sick neonates
Analgesia or Sedation if infant has peritonitis or is intubated
Inotropes
Vitamin K
Sodium bicarbonate
Documentation
History including antenatal and birth history, physical findings, diagnosis
Previous and current management
Previous operative and histopathology notes, if any
Input/output charts
Investigation results, X-rays
Consent informed and signed by parents for high risk infants and
especially if parents are not accompanying child.
Parents contact address, telephone numbers, if not accompanying infant.
10 mls of Mothers blood for cross match, if she is not accompanying infant.
Environment
Maintain a Neutral Thermal Environment
Optimal temperature for the neonate (axilla) 36.5 0C 37.0 0C.
Prevention of heat loss involves maintaining an optimal ambient
temperature as well as covering the exposed surfaces.
Transport Incubator would be ideal.
Wrap limbs of the infant with cotton, metal foil or plastic.
Do not forget a cotton-lined cap for the head.
Remove all wet linen as soon as possible.
Care of exposed membranes. (See section on Abdominal Wall Defects)
Warm intravenous fluids.
ELBW placed in polyethylene bags for newborn infants to prevent heat
loss by evaporation.
58
Environment (continued)
Special Consideration.
In Hypoxic Ischaemic Encephalopathy, therapeutic hypothermia may be
indicated. Please discuss with receiving neonatal team prior to transfer.
Equipment (see Table at end of chapter)
Check all equipment: completeness and function before leaving hospital.
Monitors- Cardiorespiratory monitor/ Pulse oximeter for transport.
If unavailable or affected by vibration, a praecordial stethoscope and a
finger on the pulse and perfusion will be adequate.
Syringe and/or infusion pumps with adequately charged batteries.
If unavailable, intravenous fluids prepared into 20 or 50ml syringes can
be administered manually during the journey via a long extension tubing
connected to the intravenous cannulae.
Intubation and ventilation equipment; Endotracheal tubes of varying sizes.
Oxygen tanks ensure adequacy for the whole journey.
Suction apparatus , catheters and tubings.
Anticipated medication and water for dilution and injection.
Intravenous fluids and tubings. Pre-draw fluids, medication into syringes
if required during the journey.
Fluid therapy
Resuscitation Fluid
Give boluses of 10 - 20 mls/kg over up to 2 hours as per clinical status
Use Normal Saline or Hartmanns solution.
If blood loss then use whole blood or pack red cells.
This fluid is also used to correct ongoing measured (e.g. orogastric) or
third space losses as required. The perfusion and heart rates are reliable
indicators of the hydration.
If ongoing or anticipated losses in surgical neonates, e.g. gastroschisis,
intestinal obstruction, , then use 0.45% Saline + 10% Dextrose
Watch out for hyponatraemia and hypoglycemia.
Gastric decompression
An orogastric tube is required in most surgical neonates, especially in
intestinal obstruction, congenital diaphragmatic hernia or abdominal
wall defects.
The oral route is preferred as a larger bore tube can be used without
compromising nasal passages (neonates are obligatory nasal breathers).
As an orogastric tube is easily dislodged, check the position regularly.
4 hourly aspiration and free flow of gastric contents is recommended.
59
NEONATOLOGY
NEONATALOGY
Immediately before Departure

Check vital signs and condition of the infant.
Check and secure all tubes.
Check the equipment.
Re-communicate with receiving doctor about current status
and expected time of arrival.
Intra-transport Care
Transport Team. Ideally, there should be a specialised neonatal transport
team. Otherwise, a neonatal-trained doctor with/without a neonatal-trained
staff nurse should escort the infant. A minimum of 2 escorts will be required
for a ventilated/critically ill infant. The team should be familiar with
resuscitation and care of a neonate.
Safety of the team must be a priority.
Insurance, life jackets and survival equipment should be available.
Monitoring. Regular monitoring of vital signs, oxygenation and perfusion of
the infant should be performed.
Fluids. Intravenous fluids must be given to the ill infant to prevent
dehydration and acidosis during the transport. Boluses need to be given as
necessary depending on the haemodynamic assessment . If catheterised, the
urine output can be monitored. The orogastric tube should be aspirated and
kept on free drainage. Losses are replaced as required.
Temperature Regulation. Check temperature intermittently. Wet clothes
should be changed especially in the infant with abdominal wall defects.
Disposable diapers and one way nappy liners are useful.
Arrival at the Receiving Hospital
Reassessment of the infant
Handover to the resident team
Intrahospital Transport
Use transport incubator if available.
Ensure all parties concerned are ready before transfer.
Send team member ahead to commandeer lifts, clear corridors.
Ensure patient is stable before transport.
Skilled medical and nursing staff should accompany patient.
Ensure adequate supply of oxygen.
Prepare essential equipment and monitors for transport.
Ensure venous lines are patent, well secured.
Infusion pumps should have charged batteries. To decrease bulk of
equipment, consider cessation of non-essential infusions.
60
Equipment
Transport incubator (if available)
Airway and intubation equipment are all available and working
(ET tubes of appropriate size, laryngoscope, Magill forceps)
Batteries with spares
Manual resuscitation (Ambu) bags, masks of appropriate size
Suction apparatus
Oxygen cylinders-full and with a spare
Oxygen tubing
Nasal oxygen catheters and masks, including high-flow masks
Infusion pumps
Intravenous cannulae of various sizes
Needles of different sizes
Syringes and extension tubings
Suture material
Adhesive tape, scissors
Gloves, gauze, swabs (alcohol and dry)
Stethoscope, thermometer
Nasogastric tube of different sizes
Pulse oximeter
Cardiac monitor if indicated
Portable Ventilator if indicated
Patient Status
Airway is secured and patent (do a post-intubation chest X-ray before
departure to make sure ET tube is at correct position.)
Venous access is adequate and patent (at least 2 IV lines ) and fluid is
flowing well.
Patient is safely secured in transport incubator or trolley.
Vital signs are charted.
Tubes - all drains (if present) are functioning and secured .
61
NEONATOLOGY
Pre-Departure Checklist
NEONATALOGY
Pre-Departure Checklist (continued)

Medications
Intravenous fluids
0.9% Normal Saline
Hartmanns solution
5% Albumin in Normal Saline
0.18% Saline with 10% Dextrose
0.45% Saline with10% Dextrose
10% Dextrose water
Inotropes
Dopamine
Dobutamine
Adrenaline
Sedative/ Analgesia
Morphine
Midazolam
Blood product if indicated
Others
Atropine
Sodium bicarbonate
Sterile water for injection
Normal saline for injection
Antibiotics if indicated
Documentation
Patient notes, referral letter
X-rays
Consent form
Vital signs chart
Input, Output charts
Maternal blood (for infant less than 6 months)
62
Chapter 10: The Premature Infant

Introduction
The Premature infant: < 37 weeks gestation
Low Birth Weight (LBW): < 2500 g
Very Low Birth Weight (VLBW): < 1500 g
Extremely Low Birth Weight (ELBW): < 1000 g
Small for Gestational Age: < 10th centile of birth weight for age.
Early and Late Complications in premature infants
Hypothermia
Respiratory distress syndrome, Apnoea
Hypotension, Patent ductus arteriosus
Intraventricular haemorrhage, Periventricular leukomalacia
Gastrointestinal: Paralytic ileus, Necrotizing enterocolitis
Hypoglycaemia, Hyperglycaemia
Neonatal Jaundice
Hypoprothrombinaemia
Fluid and Electrolyte disorders:
hyponatraemia, hyperkalemia, metabolic acidosis
Septicaemia
Anaemia
Osteopaenia of prematurity
Retinopathy of prematurity
Chronic lung disease
Neuro-developmental disability
Psychosocial problems
Management
Before and During Labour
Prewarmed incubator and appropriate equipment for neonatal intensive
care should always be kept ready in the labour room or operating theatre.
Adequate Resuscitation
Transfer from Labour Room (LR) to NNU (Neonatal Unit)
Use prewarmed transport incubator if available. If not the baby must be
wiped dry and wrapped in dry linen before transfer. For extremely low
birth weight infant, from birth, the infant should be wrapped up to the
neck with polyethylene plastic wrap or food plastic bag to prevent
evaporative heat loss.
63
If infants respiration is inadequate, keep the infant intubated with

manual bag ventilation with oxygen during the transfer.
For those with mild respiratory distress, preferably initiate CPAP in labour
room, and if tolerated CPAP during transport. Use a pulse oxymeter where
available.
Admission Routine
Ensure thermoneutral temperature for infant. An incubator or radiant
warmer is necessary for more premature and ill infants.
Ventilation in NICU is often necessary if ventilated during transfer.
However, some infants take longer to adapt to extrauterine life and may
not require ventilation especially those with no risk factors and given a full
course of antenatal steroids. For the larger preterm infants above 1250
grams, review the required ventilation to maintain a satisfactory blood gas
and consider extubation if the ventilator requirements are low, patient has
good tone and good spontaneous respiration.
Maintain SaO between 89-92% for ELBW; 90-94% for the larger preterm
Head circumference (OFC), length measurements, bathing can be omitted.
Quickly and accurately examine and weigh the infant.
Assess the gestational age with Dubowitz or Ballard score when stable
(see end of this section for score).
Monitor temp, HR, RR, BP and SaO.
Immediate Care for Symptomatic infants
Investigations are necessary as indicated and include:
Blood gases.
Blood glucose (dextrostix)
Full blood count with differential WBC and IT ratio (if possible)
Blood culture.
CXR (if respiratory signs and symptoms are present)
Start on 10% dextrose drip.
Correct anaemia.
Correct hypotension (keep mean arterial pressure (MAP) > gestational age
(GA) in wks). Ensure hyperventilation is not present (a cause of hypotension).
If the baby has good tone and is active, observe first as the BP may rise after
first few hours of life towards a MAP approximating GA in weeks.
Correct hypovolaemia: Give 10 ml/kg of Normal Saline over 20-30 mins, or
packed cells if anaemic. Avoid repeat fluid boluses unless there is volume loss.
Start inotrope infusion if hypotension persists after volume correction.
Start antibiotics after taking cultures e.g. Penicillin and Gentamycin
Start IV Aminophylline or caffeine in premature infants <32-34 weeks.
Maintain SaO at 89-92% and PaO at 50 70 mmHg.
64
ICU care and Criteria for Replacement Transfusion in Neonates

See relevant chapter.
Discharge
Cranial Ultrasound for premature infants 32 weeks is recommended at:
Within first week of life to look for intraventricular haemorrhage (IVH).
Around day 28 to look for periventricular leucomalacia (PVL).
As clinically indicated.
Screening for Retinopathy of Prematurity (ROP) at 4-6 weeks of age
is recommended for
All infants 32 weeks gestation at birth or birth weight <1500 g.
All preterms < 36 weeks who received oxygen therapy depending on
individual risk as assessed by the clinician.
The infants are discharged once they are well, showing good weight gain,
established oral feeding and gestational age of at least 35 weeks.
65
NEONATOLOGY
General Measures for Premature infants

Monitor vitals signs (colour, temperature, apex beat, respiratory rate).
Look for signs of respiratory distress (cyanosis, grunting, tachypnoea, nasal
flaring, chest recessions, apnoea). In VLBL and ill infants pulse oximetry
and blood pressure monitoring are necessary.
Check Blood Sugar (see Hypoglycaemia protocol).
Keep warm in incubator at thermoneutral temperature for age and birth
weight. ELBW should preferably have humidified environment at least for
the first 3 days.
Ensure adequate nutrition.
Provide parental counselling and allow free parental access.
Infection control: observe strict hand washing practices.
Immunisation:
Hep B vaccine at birth if infant stable and BW is >1.8 kg.
Otherwise give before discharge.
Ensure BCG vaccine is given on discharge.
For long stayers other immunisation should generally follow the schedule
according to chronological rather than corrected age.
Defer immunisation in the presence of acute illnesses.
Supplements:
At birth: IM Vitamin K (0.5 mg for BW<2.5 kg; 1 mg for BW 2.5 kg)
Once on full feeding, give Infant Multivitamin drops 1 mls OD (continue
till fully established weaning diet). For preterm infants, use a
formulation with Vit D 400 IU, and Folic acid 1 mg OD.
Starting at about 4 weeks of life: Elemental Iron 2-3 mg/kg/day to be
continued for 3-4 months.
Prognosis
Mortality and morbidity are inversely related to gestation and birth weight.
Complications include retinopathy of prematurity, chronic lung disease,
neurodevelopmental delay, growth failure, cerebral palsy, mental
retardation, epilepsy, blindness and deafness.
66
Chapter 11: Enteral Feeding in Neonates
Types of milk for Newborn feeding

There are three choices:
expressed breast milk
normal infant formula
preterm infant formula
Breast Milk
Breast milk is preferred as studies have shown that breast fed babies had
low risk for necrotising enterocolitis and had better development quotients.
However, expressed breast milk (EBM) alone is not adequate for the
nutritional needs of the very preterm infant as it:
Has insufficient calories and protein to for optimal early growth at
20 kcal/30mls.
Has insufficient sodium to compensate for high renal sodium losses.
Has insufficient calcium or phosphate - predisposes to osteopenia of
prematurity.
Is low in vitamins and iron relative to the needs of a preterm infant.
Human Milk Fortifier (HMF)
It is recommended to add HMF to EBM in babies < 32 wks or < 1500 grams.
HMF will give extra calories, vitamins, calcium and phosphate.
HMF should be added to EBM when the baby is feeding at 75 mls/kg/day.
VLBW infants on exclusive breastmilk may require sodium
supplementation until 32-34 weeks corrected age.
Infant Formula
Infant formula should only be given if there is no supply of EBM. There are 2
types of infant formula: Preterm formula and Normal Term Formula.
Preterm formula : for babies born < 32 weeks or < 1500 grams.
Normal infant formula : for babies born 32 weeks or > 1500 grams.
67
NEONATOLOGY
Introduction
The goal of nutrition is to achieve as near to normal weight gain and
growth as possible.
Enteral feeding should be introduced as soon as possible. This means
starting in the labour room itself for the well infant.
Breast milk is the milk of choice. All mothers should be encouraged to give
breast milk to their newborn babies.
Normal caloric requirements in: Term infants: 110 kcal/kg/day
Preterm infants : 120 140 kcal/kg/day
Babies who have had a more eventful course need up to 180kcal/kg/day
to have adequate weight gain.
NEONATALOGY
Strategies of administering enteral feeding

Orogastric Route
Neonates are obligate nose breathers thus nasogastric tubes can obstruct
the nasal passage and compromise breathing. Thus the orogastric route is
preferable.
Continuous vs. intermittent bolus feeding
Bolus fed babies tolerate feeds better and gained weight faster. Babies on
continuous feeding have been shown to take longer to reach full feeding
but there is no difference in days to discharge, somatic growth and
incidence of necrotising enterocolitis (NEC).
Cup feeding
If the baby is able to suckle and mother is not with the baby, cup feeding is
preferable to bottle feeding to prevent nipple confusion.
When to start milk?
As soon as possible for the well term babies
However, in very preterm infants there may be an increased risk for NEC if
feeding is advanced too rapidly, although early feeds with EBM is to be
encouraged. Studies suggest that rapid increments in feeds has a higher
risk for NEC than the time at which feeding was started.
Minimal enteral feeding (MEF) is recommended in very preterm infants.
The principle is to commence very low volume enteral feeds on day 1 - 3 of
life (i.e. 5 - 25 mls/kg/day) for both EBM and formula milk. MEF enhances
gut DNA synthesis hence promotes gastrointestinal growth. This approach
allows earlier establishment of full enteral feeds and shorter hospital
stays, without any concomitant increase in NEC.
How much to increase?
Generally the rate of increment is about 20 to 30 mls/kg/day.
Well term babies should be given breastfeeding on demand.
Milk requirements for babies on full enteral feed from birth:
Day 1
60 mls/kg/day
Day 2 3
90 mls/kg/day
Day 4 6
120 mls/kg/day
Day 7 onwards 150 mls/kg/day
Add 15% if the babies is under phototherapy
In babies requiring IV fluids at birth: The rate of increment need to be
individualized to that baby. Babies should be observed for feeding
intolerance (vomit or large aspirate) and observe for any abdominal
distention before increasing the feed.
68
When to stop HMF or Preterm Formula?

Consider changing preterm to standard formula and stop adding HMF
to EBM when babies are breastfeeding on demand or have reached their
expected growth curve.
Preterm with poor weight gain can be given specially formulated post
discharge formula for preterm infants. Preterm formula meant for
newborn preterm infants should not be given to infants > 2 months
post conceptual age in view of potential Vitamin A and D toxicity.
Vitamin and mineral supplementation
Vitamins: a premature infants daily breast milk/ breast milk substitute
intake will not supply the daily vitamin requirement. Multivitamins can be
given after day 14 of life when on feeding of 150 ml/s kg/day.
Vitamin supplements at 0.5 mls daily to be continued for 3-4 months post
discharge.
Iron: Premature infants have reduced intra uterine iron accumulation and
can become rapidly depleted of iron when active erythropoiesis resumes.
Therefore babies of birth weight < 2000g should receive iron supplements.
Iron is given at a dose of 3 mg/kg elemental iron per day.
Ferric Ammonium Citrate (400mg/5mls) contains 86 mg/5 mls of
elemental iron.
Start on day 42, continue until 3-4 months post discharge or until review.
Babies who have received multiple blood transfusions may not require as
much iron supplementation.
Special Cases
IUGR babies with reversed end-diastolic flow on antenatal Doppler: Studies
have show that these babies are at risk of NEC. Thus feeds should be
introduced slowly and initially use only EBM.
69
NEONATOLOGY
What is the maximum volume?

Target weight gain should be around 15g/kg/day (range 10-25g/kg/day).
Less weight gain than this suggests a need to increase calories especially
protein calories.. More weight gain than 30g/kg/day should raise the
possibility of fluid overload particularly in babies with chronic lung disease.
Preterm infants
Increase feed accordingly to 180 to 200 mls/kg/day. (This should only be
achieved by Day 10 to Day 14 respectively if baby had tolerated feeds
well from Day 1)
If on EBM, when volume reaches 75 mls/kg/day: add HMF.
Term infants: allow feeding on demand.
70
mmol/l
mmol/l
mg%
mg%
mg%
Sodium
Potassium
Calcium
Phosphate
Iron
0.05
98
124
40
23
67
KCal/100ml
3.4
Calories
g/100ml
Protein
3.9
4.6
4:1
g/100ml
Fat
Cows milk
Casein : Lactalbumin ratio
g/100ml
Carbohydrate
Component
0.8
33
46
14
6.4
67
2:3
1.5
3.6
7.5
Standard formula
0.08
15
35
15
6.4
70
2:3
1.1
4.2
7.4
Mature breastmilk
Composition of Various Milk
0.67
41
77
19
14
80
2:3
2.0
4.4
8.6
Preterm formula
13
29
17
17
74
2.3
2.7
3.1
6.4
Preterm breastmilk
NEONATALOGY
Chapter 12: Total Parenteral Nutrition for Neonates
The goal of TPN is to

Provide sufficient nutrients to prevent negative energy and nitrogen
balance and essential fatty acid deficiency.
Support normal growth rates without increased significant morbidity.
Indication for TPN
Birth weight < 1000 gm
Birth weight 1000-1500 gm and anticipated to be not on significant feeds
for 3 or more days.
Birth weight > 1500 gm and anticipated to be not on significant feeds for
5 or more days.
Surgical conditions in neonates: necrotizing enterocolitis, gastroschisis,
omphalocoele, tracheo-esophageal fistula, intestinal atresia, malrotation,
short bowel syndrome, meconium ileus and diaphragmatic hernia.
Components of TPN
The essential components of parenteral nutrition are:
Fluids
Carbohydrate
Protein
Lipids
Electrolytes
Vitamins
Trace minerals
Goal is to provide 120-130 KCal/kg/day.
10% dextrose solution provides 0.34 KCal/ml.
10% lipid solution gives 0.9 KCal/ml; 20% lipid solution gives 1.1 KCal/ml.
Protein/Energy ratio: 3-4 gm/100 KCal is needed to promote protein
accretion. A baby given only glucose will lose 1.5 grams body protein/day.
Thus it is important to start TPN within the first 24 hours of life in the smaller
preterm infants <1250 grams birth weight.
Fluid
Fluid is an essential component.
Usually started at 60-80 ml/kg/day (if newborn), or at whatever stable
fluid intake the baby is already receiving.
Postnatal weight loss of 5 - 15 % per day in the ELBW is acceptable.
Volumes are increased over the first 7 days in line with the fluids and
electrolytes protocol with the aim to deliver 120-150 ml/kg/day by day 7.
71
NEONATOLOGY
Introduction
Total parenteral nutrition (TPN) is the intravenous infusion of all nutrients
necessary for metabolic requirements and growth.
Earlier introduction and more aggressive advancement of TPN is safe
and effective, even in the smallest and most immature infants.
Premature infants tolerate TPN from day 1 of post-natal life.
NEONATALOGY
Amino acids
Amino acids prevents catabolism; prompt introduction via TPN achieves an
early positive nitrogen balance.
Decreases frequency and severity of neonatal hyperglycaemia by stimulating
endogenous insulin secretion and stimulates growth by enhancing the
secretion of insulin and insulin-like growth factors.
Protein is usually started at 2g/kg/day of crystalline amino acids and
subsequently advanced, by 3rd to 4th postnatal day, to 3.0 g/kg/day of
protein in term and by 5th day 3.7 to 4.0 g/kg/day in the extremely low
birthweight (ELBW) infants.
Reduction in dosage may be needed in critically ill, significant hypoxaemia,
suspected or proven infection and high dose steroids.
Adverse effects of excess protein include a rise in urea and ammonia and
high levels of potentially toxic amino acids such as phenylalanine.
Glucose
There is a relatively high energy requirement in the ELBW and continuous
source of glucose is required for energy metabolism.
In the ELBW minimum supply rate is 6 mg/kg/min to maintain adequate
energy for cerebral function; additional 2-3 mg/kg/min (25 cal/kg) of
glucose per gram of protein intake is needed to support protein deposition.
Maximum rate: 12 - 13 mg/kg/min (lower if lipid also administered) but in
practice often limited by hyperglycaemia.
Hyperglycaemia occurs in 20-80% of ELBW as a result of decreased insulin
secretion and insulin resistance, presumably due to to glucagon,
catecholamine and cortisol release.
Hyperglycaemia in the ELBW managed by decreasing glucose administration,
administering intravenous amino acids and/or infusing exogenous insulin.
Glucose administration is started at 6 mg/kg/min, advancing to
12-14 mg/kg/min and adjusted to maintain euglycaemia.
If hyperglycaemia develops glucose infusion is decreased. Insulin infusion is
generally not required if sufficient proteins are given and less glucose is
administered during the often transient hyperglycaemia. Insulin infusion,
if used for persistent hyperglycaemia with glycosuria, should be titrated to
reduce risk of hypoglycaemia.
Lipid
Lipids prevent essential fatty acid deficiency, provide energy substrates and
improve delivery of fat soluble vitamins.
LBW infants may have immature mechanisms for fat metabolism. Some
conditions inhibit lipid clearance e.g. infection, stress, malnutrition.
Start lipids at 1g/kg/day, at the same time as amino acids are started, to
prevent essential fatty acid deficiency; gradually increase dose up to
3 g/kg/day (3.5g/kg/day in ELBW infants). Use smaller doses in sepsis,
compromised pulmonary function, hyperbilirubinaemia.
It is infused continuously over as much of the 24 hour period as practical.
Avoid concentrations >2g/kg/day if infant has jaundice requiring
phototherapy.
72
Electrolytes
The usual sodium need of the newborn infant is 2-3 mEq /kg/day in
term and 3-5 mEq/kg/day in preterm infants after the initial diuretic
phase(first 3-5 days). Sodium supplementation should be started after
initial diuresis(usually after the 48 hours), when serum sodium starts to
drop or at least at 5-6% weight loss. Failure to provide sufficient sodium
may be associated with poor weight gain.
Potassium needs are 2-3 mEq/kg/day in both term and preterm infants.
Start when urine output improves after the first 2-3 days of life.
Minerals, Calcium (Ca), Phosphorus (P) And Magnesium
In extrauterine conditions, intrauterine calcium accretion rates is difficult
to attain. Considering long-term appropriate mineralization and the fact
that calcium retention between 60 to 90 mg/kg/d suppresses the risk of
fracture and clinical symptoms of osteopenia, a mineral intake between
100 to 160 mg/kg/d of highly-absorbed calcium and 60 to 75 mg/kg/d of
phosphorus could be recommended.
Monitoring for osteopaenia of prematurity is important especially if
prolonged PN.
A normal magnesium level is a prerequisite for a normal calcaemia. In well
balanced formulations, however, magnesium level does not give rise to
major problems.
Trace Elements
Indicated if PN is administered for 1 week. Commercial preparations are
available.
Vitamins
Both fat and water soluble vitamins are essential. It should be added to
the fat infusion instead of amino-acid glucose mixture to reduce loss
during administration.
73
NEONATOLOGY
Preparation of 20% emulsion is better than 10% as 20% solutions require

less fluid volume and provide a lower phospholipid-to-triglyceride ratio.
10% solution interferes with triglyceride (TG) clearance leading to higher
TG and cholesterol values. Use of preparations containing lipids from fish
oil and olive oil may reduce the risk of cholestasis with prolonged TPN.
Heparin at 0.5 to 1 units/mL of TPN solutions (max 137 units/day) can
facilitate lipoprotein lipase activity to stabilize serum triglyceride values.
Lipid clearance monitored by plasma triglyceride (TG) levels.
(Max TG concentration ranges from 150 mg/dl to 200 mg/dl).
Exogenous lipid may interfere with respiratory function. Suggested
mechanisms include impaired gas exchange from pulmonary intravascular
accumulation or impaired lymph drainage resulting in oedema. Lipid may
also aggravate pulmonary hypertension in susceptible individuals.
The syringe and infusion line should be shielded from ambient light.
NEONATALOGY
Administration
TPN should be delivered where possible through central lines.
Peripheral lines are only suitable for TPN 3 days duration and dextrose
concentration 12.5%.
Peripheral lines are also limited by osmolality (<600 mOsm/L) to prevent
phlebitis.
Percutaneous central line: confirm catheter tip position on X-ray prior to use.
Ensure strict aseptic technique in preparation and administration of TPN.
Avoid breakage of the central line through which the TPN is infused,
though compatible drugs may be administered if necessary.
Caution
Hyperkalaemia. Potassium is rarely required in first 3 days unless serum
potassium < 4 mmol/l. Caution in renal impairment.
Hypocalcaemia. May result from inadvertent use of excess phosphate.
Corrects with reduction of phosphate.
Never add bicarbonate, as it precipitates calcium carbonate
Never add extra calcium to the burette, as it will precipitate phosphates.
Complications
Delivery
The line delivering the TPN may be compromised by;
Sepsis - minimized by maintaining strict sterility during and after insertion
Malposition. X-ray mandatory before infusion commences
Thrombophlebitis - with peripheral lines; requires close observation of
infusion sites.
Extravasation into the soft tissue, with resulting tissue necrosis.
Metabolic complications
Hyperglycaemia
Hyperlipidaemia
Cholestasis
Monitoring
Before starting an infant on parenteral nutrition, investigation required:
Full blood count, haematocrit
Renal profile
Random blood sugar/dextrostix
Liver function test, serum bilirubin

74
Prevention of hospital acquired infection

Aseptic precautions during preparation of PN.
Use of laminar air flow.
No compromise on disposables.
Trained staff.
No reuse of the PN solutions.
No interruption of the venous line carrying PN.
Use of bacterial filter in AA-glucose line.
75
NEONATOLOGY
While on TPN, monitoring required :

Laboratory
Full blood count, plasma sodium, potassium and creatinine.
Daily for 1 week then 2-3 times a week until stable.
Plasma calcium, magnesium, phosphate. Twice/wk until stable then weekly.
Triglyceride levels. After dose changes then weekly.
Liver function test: If long term TPN (> 2 weeks duration).
Clinical
Blood sugar / dextrostix, 4-6 hrly first 3 days, twice a day once stable.
Daily weight
Meticulous care of the catheter site and monitoring for infection.
76
NEONATALOGY
Chapter 13: NICU - General Pointers for Care and Review

of Newborn Infants
77
NEONATOLOGY
Checklist for Review of an infant in Intensive Care

Age of infant
If <72 hours state in exact hours of age. Beyond this, state in completed days.
Weight
Note birth weight and current weight. Initial drop in weight is expected for
newborn infants, term up to 10% BW in first 3-5 days, preterms up to 15% in
first 1 week. Less weight loss is expected with use of humidified incubators.
Abnormal weight gain/loss in the first days implies suboptimal fluid therapy.
General condition.
Note: ill, unstable, handles poorly e.g. desaturates on handling, stable,
active, responsive to handling, improving, or good tone.
Cardiopulmonary system
Check for:
(i) Adequacy of the blood pressure an estimate of normal BP for preterm
infant is that of the gestational age at birth. However, there is no
necessity to treat immediately if the baby is stable, responsive and of
good tone. Review after one hour to check for improvement in the BP.
(ii) Signs of poor perfusion (with poor peripheral pulses, rapid pulse, poor
capillary refilling and cold peripheries) but these signs have not been
found to be very reliable for hypotension. Hypothermia can also be a
cause of poor perfusion.
(iii) Examine for presence of a patent ductus arteriosus (PDA) in preterm
infants.
If BP is low and there has been a history of volume loss at birth or risk of
sepsis, infuse a fluid bolus of 10 ml/kg of Normal Saline. This may be
repeated if there is no improvement. After the 2nd dose of normal saline
5% albumin can be considered for volume expansion in severely
hypotensive infants. Caution: Risk of IVH in repeat doses especially in ELBW
or ill preterm infants check first for volume loss or reduced vascular
volume due to extravascular fluid losses such as in sepsis or intestinal
obstruction. Albumin is required only in severe sepsis such as in NEC.
Inotropic agents like adrenaline, dobutamine or dopamine may be needed.
Consider hydrocortisone in ill preterm infant at birth if no response to
volume or inotropes. Check that there is no iatrogenic hyperventilation as
a cause of hypotension.
Fluids and Electrolytes
Is the volume and type of fluid given to the child appropriate?
Empiric fluid therapy for newborns:
0-24 hours :
60 ml/kg/day
24-48 hours : 90 ml/kg/day
48-72 hours : 120 ml/kg/day
> 72 hours :
150 ml/kg/day
Slower rates of increment for preterm infants, i.e. of 20 mls/kg/day.
More increments may be needed if evidence of dehydration,
i.e. excessive weight loss and hypernatraemia >145 mmol/l.
NEONATALOGY
Generally, 10% Dextrose fluid is given on the 1st day; and

Sodium and Potassium added on the second/third day.
Total parenteral nutrition should be started as soon as possible for the
infant below 1000 -1250 grams, preferably within the first day of life.
Larger preterm infants may be started on parenteral nutrition if expected
to not able to be fed enterally for 5 or more days ( for eg congenital
diaphragmatic hernia, omphalocele/gastrochiasis) .
Empirically:
- A preterm infant need 4-5 mmol/kg/day of sodium and 2-3 mmol/kg/day
of potassium, after the first few days of life.
- ELBW infants are prone for hyperkalaemia and adjustments should be
made based on serum electrolytes.
- Term infants need 2-3 mmol/kg/day of both sodium and potassium.
Fluid and electrolyte therapy are influenced by underlying illness,
complications: make neccesary adjustments based on these conditions,
intake/output, weight, blood urea and electrolytes (BUSE).
- Monitor BUSE; correct any imbalances after considering underlying cause.
- Ensure the urine output is > 1 ml/kg/hr after the first day of life.5
Infection
Is there a possibility of infection? Is the child on antibiotics?
Fungal infection should be considered if the infant is a preterm infant
who has been on several courses of broad spectrum antibiotics and on
total parenteral nutrition. Consider discontinuing antibiotics if the blood
culture is negative and the patient improved too quickly after starting
antibiotics, probably responding to other measures to improve dehydration
or inadequate ventilatory support.
Feeding
Enteral feeds can be given via oro or nasogastric tube. Orogastric tube is
preferred in small infants as it prevents blockage of airway.
Encourage expressed breast milk to be started within the first 2 days of life.
Temperature Control
Use of cling wrap/plastic wrap with cap for preterm infants soon after
delivery will help maintain normothermia.
Under the radiant warmer, covering the open area of open hoods with
cling wrap and increasing water content with a humidifier will help in
temperature control and fluid regulation of the ELBW infant. Transfer
to a closed humidified incubator as soon as possible. Ensure thermoneutral
environment. Humidity is essential to maintain temperature in the
extremely preterm infants and reduce excessive weight loss in the first few
weeks of life. Below is a humidification guide for preterm infants.
78
27-30 weeks gestation
80% Humidity for at least 4 wks

(may require higher % to cope with
increased sodium)
80% Humidity for at least 2 wks
The infants skin should have keratinised fully at the end of this period,
therefore the humidity can be gradually reduced, as tolerated, to maintain
a satisfactory axillary temperature
Reduce the humidity gradually according to the infants temperature (70%
- 60% - 50%) until 20-30% is reached before discontinuing.
Skin care
A vital component of care especially for the premature infants.
Avoid direct plastering onto skin and excessive punctures for blood taking
and setting up of infusion lines.
Meticulous attention must be given to avoid extravasation of infusion fluid
and medication which can lead to phlebitis, ulceration and septicaemia.
Group your blood taking together to minimise skin breaks/ breakage of
indwelling arterial lines.
Observe limbs and buttocks prior to insertion of umbilical lines and at
regular intervals afterwards to look for areas of pallor or poor perfusion
due to vascular spasm.
Check fontanelle tension and size, condition of sutures i.e. overriding or
separated, half-hourly to hourly head circumference monitoring (when
indicated e.g. infants with subaponeurotic haemorrhage).
Sensorium, tone, movement, responses to procedures e.g. oral suctioning,
and presence or absence of seizure should be noted.
Ventilation
Check if ventilation is adequate. Is the child maintaining the optimum
blood gases? Can we start weaning the child off the ventilator?
Overventilation is to be avoided as it may worsen the infants condition.
79
NEONATOLOGY
26 weeks gestation and below
NEONATALOGY
Endotracheal tube (ETT) Care

Infant weight
ETT size
ETT position (oral)1,2,3
<1000g
2.5
1000g-2000g
3.0
7 cm
2000g-3000g
3.5
8 cm
>3000g
3.5-4.0
9 cm
Footnotes:
1. oral ETT tip-to-lip distance; 2. or weight in kg + 6
3. for nasal ETT: add 2 cm respectively; For 1 kg and below - add 1.5 cm
Note:
The length of ETT beyond the lips should be checked as to be just sufficient for
comfortable anchoring and not excessively long so as to reduce dead space.
Suction of ETT
Performed only when needed, as it may be associated with desaturation and
bradycardia.
During suctioning, the FiO2 may need to be increased as guided by the SaO
monitor during suctioning.
Remember to reduce to the level needed to keep SaO 89-95%.
Umbilical Arterial Catheter (UAC) and Umbilical Venous Catheter (UVC) care
Do not use iodine to prepare the skin for UAC or UVC placement .
Do not allow the solution to pool under the infant as it may burn the skin
particularly in the very low birthweight infant.
Change any damp or wet linen under the infant immediately following the
procedure.
Sterile procedure is required for inserting the lines.
For other than the time of insertion, wash hands or use alcohol rub before
taking blood from the UAC.
Ensure aseptic procedure when handling the hub or 3 way tap of the line to
withdraw blood.
UAC position
Length to be inserted measured from the abdominal wall is:

3 X BW(kg) + 9 cm.
Confirm with X-ray to ensure that the tip of the UAC is between T6 to T9 or
between L3-L4.
Reposition promptly if the tip is not in the appropriate position. The high
positioning of the UAC is associated with less thrombotic events than the
low position.
The UAC is kept patent with a heparin infusion (1U/ml) at 1 ml/hr and can
be attached to the intra-arterial blood pressure monitor.
80
Remember to add on the length of the umbilical stump for calculating the
length of both UAC and UVC.
Ventilation
Initial ventilator setting (in most situations):
Total Flow:
8 - 10 litres/min
Peak Inspiratory Pressure (PIP):
20-25 mmHg (lower in ELBW infants
and those ventilated for
non-pulmonary cause,
i. e normal lungs)
Positive End Expiratory Pressure (PEEP): 4 - 5 mmHg
Inspiration Time:
0.3- 0.35 sec
Ventilation rate:
40- 60 / min
FiO:
60 to 70% or based on initial oxygen
requirement on manual positive
pressure ventilation.
When Volume Guarantee is used:
VG = 4 6 ml/kg
The ventilator setting is then adjusted according to the clinical picture, pulse
oximetry reading and ABG which is usually done within the 1st hour.
Note:
The I:E ratio should not be inverted (i.e. > 1) unless requested specifically
by a specialist.
Tailor the ventilation settings to the babys ABG.

Keep:
pH
7.25 - 7.40

PaO
50 - 70 mmHg for premature infants

60 - 80 mm Hg for term infants

PaCO 40 - 60 (NB. the trend is not to chase the
PaCO by increasing ventilator settings
unless there is respiratory acidosis).

SaO
89 - 92% for preterm infants.
81
NEONATOLOGY
UVC position
Length to be inserted measured from the abdominal wall is:

UAC length as calculated above +1 cm.
This usually put the tip above the diaphragm. However, this formula is
not as accurate as using catheter length based on shoulder umbilical
length. (Check available graph) . The shoulder umbilical length is taken as a
perpendicular line dropped from the shoulder to the level of the umbilicus.
Placement of the catheter tip in the portal circulation or liver is not
acceptable and catheter should be removed and a new catheter inserted
under sterile technique. In an emergency situation, it can be withdrawn to
the level of the umbilical vein to be used for a short period until an
alternative venous access is available.
NEONATALOGY
Changing of ventilator settings:

To produce an increase in PaO either: - Increase FiO2 concentration.
- Increase PEEP.
- Increase PIP (increases minute volume).
- rarely, increase I/E ratio (prolong inspiration).
To produce a decrease in PaCO either: - Increase Rate (increases minute volume).
- Decrease I/E ratio (prolong expiration).
- Increase PEEP in worsening lung disease.
- Decrease PEEP in recovery phase.
- Increase Targeted Volume in Ventilation
Do the opposite to decrease PaO or to increase PaCO.
Minute volume = tidal volume (volume per breath) x rate per minute.
Minute volume should be about 0.1 0.3L/kg/min
With volume-limited settings, minute volume can be calculated
(use tidal volume = 4-6 ml/kg).
With pressure-limited mode - increasing peak inspiratory pressure
results in increased minute volume.
Sedation and Ventilation
Avoid the use of paralysing agents as far as possible. Paralysis has been shown
to result in poorer lung function, more dependent oedema and longer duration
of ventilation.
Use morphine infusion as an analgesia and sedative, if required.
82
Worsening of primary condition, e.g. RDS or congenital pneumonia

Mechanical problems :
ETT Dislodged or Obstructed
ETT displaced/ too deep
Pneumothorax
Ventilator tubes disconnected
Ventilator malfunction
Overventilation of the lung
Pneumonia such as nosocomial pneumonia
PDA or heart failure
Persistent pulmonary hypertension
High Frequency Oscillatory Ventilation (HFOV)
Indications
When conventional ventilation fails HFOV should be considered. This is to be
discussed with the specialist.
Care should be taken not to overinflate the lungs as this can lead to further
deterioration of childs condition i.e. worsening saturation, hypotension.
Practical management
Switching from conventional ventilation to HFOV :
- Initial setting
Leave FiO level at the same level as that on conventional ventilation.
MAP - For RDS, start at 2 cmH2O above the MAP of conventional
ventilation. In cases of air trapping, start MAP at same level as
conventional ventilation and adjust according to CXR and blood gas.
Amplitude - 50-100% (Draeger Babylog 8000), Amplitude in Sensor Medic
(start with twice MAP value); adjust until chest and upper abdomen
vibrates but not whole abdomen.
Frequency - 10Hz.
Tidal volume - about 2 to 2.5ml/kg. (VThf on Draeger Babylog 8000)
- Continuation of HFOV
Chest X-ray after 30-60 minutes, aim for lung expansion to 8-9th rib level
Hypoxia - increase MAP or FiO if not already on FiO of 1.0
Hyperoxia - reduce FiO or decrease MAP (MAP to be reduced first if CXR
shows diaphragm to be below T9 or flattened or hyperinflated lung fields)
Hypercapnia
- Increase amplitude
- Decrease frequency
- Increase MAP (if persistent or lung volume still poor)
83
NEONATOLOGY
Consider the following if the child deteriorates on ventilation:
NEONATALOGY
Hypocapnia
- Decrease amplitude.
- Increase frequency.
- Decrease MAP.
Overinflation
- Reduce MAP.
- Consider discontinuing HFOV.
- Weaning
Reduce FiO2 to 0.3-0.5.
Reduce MAP by 1 to 2 mbar per hour until 8 to 9 mbar.
Reduce amplitude.
Extubate to head box/CPAP or change to conventional ventilation.
Guidelines for packed red blood cells (PRBCs) transfusion thresholds for
preterm neonates.
< 28 days age, and
Assisted ventilation with FiO2 > 0.3: Hb 12.0 gm/dL

or PCV < 40%
Assisted ventilation with FiO2 < 0.3: Hb 11.0 g/dL
or PCV < 35%
CPAP: Hb < 10 gm/dL or PCV <30%
> 28 days age, and
Assisted ventilation: Hb < 10 gm/dL or PCV < 30%

CPAP: Hb < 8 gm/dL or PCV < 25%
Any age, breathing

spontaneously,
and
On FiO2 > 0.21: Hb < 8 gm/dL or PCV < 25%*

On Room Air: Hb < 7 gm/dL or PCV < 20%*
*Consider transfusion if there is poor weight gain or
metabolic acidosis as an indication of tissue hypoxia.
Guidelines for platelet transfusions in non-immune thrombocytopaenic

neonates
Platelet count
< 30,000/mm3
Transfuse all neonates, even if asymptomatic
Platelet count
30,000/mm3 50,000/mm3
Consider transfusion in
Sick or bleeding newborns
Newborns <1000 gm or < 1 week of age
Previous major bleeding tendency (IVH grade 3-4)
Newborns with concurrent coagulopathy
Requiring surgery or exchange transfusion
Platelet count
30,000/mm3 99,000/mm3
Transfuse only if actively bleeding.
84
Chapter 14: Vascular Spasm and Thrombosis
Definitions
Vascular spasm transient, reversible arterial constriction, triggered by
intravascular catheterisation or arterial blood sampling. The clinical effects of
vascular spasm usually last < 4 hours from onset, but the condition may be
difficult to differentiate from the more serious TE. The diagnosis of vascular
spasm may thus only be made retrospectively on documenting the transient
nature of the ischaemic changes and complete recovery of the circulation.
Thrombosis complete or partial occlusion of arteries or veins by blood
clot(s).
Assessment
Clinical diagnosis
Peripheral arterial thrombosis/ vasospasm pallor or cyanosis of the
involved extremity with diminished pulses or perfusion.
Central venous line (CVL) associated venous thrombosis CVL malfunction,
superior vena cava (SVC) syndrome, chylothorax, swelling and livid
discolouration of extremity.
Aortic or renal artery thrombosis systemic hypertension, haematuria,
oliguria.
Diagnostic imaging
Contrast angiography is the gold standard, but difficult to perform in
critically ill neonates and requires infusion of radiocontrast material that may
be hypertonic or cause undesired increase in vascular volume.
Doppler ultrasonagraphy portable, non-invasive, useful to monitor
progress over time. False positive and false negative results may occur, as
compared to contrast angiography.
Additional diagnostic tests
Obtain detailed family history in all cases of unusual or extensive TE.
In the absence of predisposing risk factors for TE, consider investigations for
thrombophilic disorders: anticardiolipin, antithrombin III, protein C, protein
S deficiency.
Management of vascular spasm
Immediate measures to be taken:
- Lie the affected limb in horizontal position
- If only one limb is affected, warm (using towel) opposite unaffected leg to
induce reflex vasodilatation of the affected leg.
- Maintain neutral thermal environment for the affected extremity, i.e. keep
heat lamps away from the area.
85
NEONATOLOGY
Thromboembolism (TE) is being increasingly recognised as a significant

complication of intravascular catheters in sick newborn infants. Many factors
contribute to neonatal catheter-related thrombosis, including the small caliber
of the vessel, endothelial damage, abnormal blood flow, design and site,
duration of catheterisation and composition of the infusate, in addition to the
increased risk of thrombus formation in sick infants. Sepsis and catheters are
the most common correlates of thrombosis in the NICU.
NEONATALOGY
Inform the paediatrician immediately.

Consider removing the catheter. If mild cyanosis of the fingers or toes is
noted after insertion of an arterial catheter, but peripheral pulses are still
palpable, a trial of reflex vasodilatation with close observation is reasonable
check continuously to see that the cyanosis is improving within a few
minutes. A white or blanched appearing extremity is an indication for
immediate removal of the catheter.
Other risk factors contributing to thrombosis includes dehydration, sepsis,
and polycythaemia. These factors may need to be corrected immediately.
Maintain good circulatory volume. If there is no immediate improvement
with removal of catheter, try volume expansion 10 mls/kg of normal saline.
Topical nitroglycerine using patch or topical 2% ointment at a dose of
4 mm/kg body weight, applied as a thin film over the affected body area;
may be repeated after 8 hours. Monitor for hypotension and be prepared to
treat immediately.
If the limb ischaemia persists for > 1 hour without any improvement, refer
urgently to the radiologist if available. An urgent doppler ultrasound scan is
needed to ascertain whether the limb ischaemia is caused by vasospasm or
thrombosis.
Management of catheter-related thromboembolism
Management of vascular TE may involve one or more of the following:
supportive care, anticoagulation, fibrinolytic therapy, surgical intervention.
Treatment for neonates is highly individualised and is determined by the
extent of thrombosis and the degree to which diminished perfusion to the
affected extremity or organ affects function.
Consultation with a paediatric haematologist, orthopaedic or vascular
surgeon may be required.
Initial management
As for vascular spasm for peripheral arterial ischaemia
Removal of catheter as soon as blanching is seen.
Supportive care correct volume depletion, electrolyte abnormalities,
anaemia and thrombocytopaenia; treat sepsis.
Anticoagulant/ thrombolytic therapy
The risk of serious bleeding associated with antithrombotic therapy in
neonates must be balanced against the possibility of organ or limb loss or
death without appropriate treatment. Adequate randomised trials to guide
therapy in neonates are not available.
Contraindications:
- Major surgery within the preceding 10 days.
- Major bleeding: intracranial, pulmonary, gastrointestinal.
- Pre-existing cerebral ischaemic lesions.
- Known history of heparin induced thrombocytopaenia or allergy to
heparin.
86
Stage
Description
aPTT
(s)
Bolus
Hold % Rate Repeat
(U/kg)
(min) change aPTT
I
Loading dose
75 IV over 10 mins
II
Initial maintainence dose
28/h
III
Adjustment
<50
50
0
+10
4 hrs
50-59
0
0
+10
4 hrs
60-85
0
0
0
next day
85-95
0
0
-10
4 hrs
96-120 0
30
-10
4 hrs
>120
0
60
-15
4 hrs
A loading dose of 75 U/kg over 10 min followed by a maintainence dose of
28 units/kg (infants < 1 year) is recommended.
An aPTT should be checked 4h after the heparin loading dose and 4h after
every change in infusion rate. Once aPTT is in therapeutic range, a complete
blood count and aPTT should be checked daily or as clinically indicated.
For preterm infants, loading dose is 50U/kg.
Initial maintenance dose for newborn < 28 weeks: 15U/kg/hr, newborn
28-36 weeks : 20U/kg/hr
Abbreviations: aPTT, activated partial thromboplastin time.
87
NEONATOLOGY
Relative contraindications
- Platelet count < 50,000 x 10 /L.
- Fibrinogen levels < 100mg/dL.
- Severe coagulation factor deficiency.
- Hypertension.
Note: anticoagulation/thrombolytic therapy can be given after correcting
these abnormalities.
Precautions:
- no arterial punctures
- no subcutaneous or IM injections
- no urinary catheterisations
- avoid aspirin or other antiplatelet drugs
- monitor serial ultrasound scans for intracranial haemorrhage
Anticoagulants
Standard or unfractionated heparin (UFH)
- Anticoagulant, antithrombotic effect limited by low plasma levels of
antithrombin in neonates. For dosage see Table below.
- Optimal duration is unknown but therapy is usually given for 5-14 days
- Monitor thrombus closely during and following treatment.
- Anti- Factor X activity (if available) aimed at 0.3-0.7 U/mL.
- Baseline aPTT is prolonged at birth and aPTT prolongation is not linear
with heparin anticoagulant effect. Therefore Anti factor X activity more
effectively monitors UFH use in newborn infants.
NEONATALOGY
- Complications: bleeding, heparin-induced thrombocytopaenia.

- Antidote: Protamine sulphate see Table below for dosage.
Heparin: Time since last dosing
Protamine dose
< 30 min
1 mg/100 u heparin received
30-60 min
0.5 - 0.75 mg/100 u heparin received
60-120 min
>120 min
Maximum dose
50 mg
Infusion rate
10 mg/ml solution; rate < 5 mg/min
Low molecular weight heparin (LMWH)

- Advantages: Subcutaneous administration. Heparin induced
thrombocytopaenia is rarely associated with LMWH.
- Antidote: Omit 2 doses if an invasive procedure is required. Protamine is
partially effective, dosage 1mg/100U heparin given within the last 3-4 hrs.
Age
Initial treatment dose
Prophylactic dose
< 2 months
1.5 mg/kg q12h
0.75 mg/kg q12h
> 2 months
1 mg/kg q12h
0.5 mg/kg q12h
Therapeutic dose range may vary from 0.95-3.5mg/kg/q12h.

Note :
- LMWH has specific anti-factor Xa activity.
- Therapy is monitored using anti-Factor Xa and not APTT
(aim for anti-Factor Xa levels of 0.5-1U/mL), monitoring 4 hours after
dosage adjustment; weekly once therapeutic level attained.
- Monitoring of anti-FXa levels may not be available in some laboratories.
Thrombolytic agents
Consider thrombolytic agents (r-tPA: recombinant tissue plasminogen
activator, streptokinase) if there is major vessel occlusion causing critical
compromise of organs or limbs.
Supplemental plasminogen (in the form of FFP) enhances thrombolytic effect.
Thrombi already present for several days may be resistant to thrombolysis
(failure rates 50%).
Monitoring
- Monitor fibrinogen levels, thrombin time, plasminogen levels before
starting, 3-4 hrs after starting and 3-4 times daily thereafter. Stop if
fibrinogen < 100 mg/dL.
- Imaging studies q4-12 hr to allow discontinuing treatment as soon as clot
lysis achieved.
- Complications: bleeding, embolisation.
88
Drug
Streptokinase
IV bolus dose
IV Maintenance dose
1000 units/kg
1000 units/kg/hr
Urokinase
4,400 U/kg over 20 mins
4,400 units/kg/hr for 6-12 hrs
Tissue plasminogen
activator
(dose for direct infusion into thrombus)
0.5 mg/kg over 10 mins
0.015-0.2 mg/kg/hr
Recommendations for management of thrombolytic therapy

Before initiating therapy:
Exclude contraindications.
Monitor full blood count, including platelets, fibrinogen.
Obtain blood type, cross match.
Ensure adequate supply of blood products, cryoprecipitate,
aminocaproic acid.
Obtain cranial ultrasound.
Ensure adequate venous access for infusion and monitoring.
Have compresses and topical thrombin available in case of localised bleeding.
During therapy:
Post sign on bed that patient is receiving thrombolytic therapy.
Monitor PT, PTT, fibrinogen level every 4 h during infusion and 4h and 12h
after infusion.
Daily cranial ultrasound.
Maintain fibrinogen > 150 mg/dlL with cryoprecipitate (1 unit/5 kg);
expect 20-50% decrease.
Maintain platelet count > 100,000/ml.
No IM injections.
No urinary catheterisation, rectal temperatures or arterial puncture.
Minimal manipulation of patient.
Avoid warfarin, antiplatelet agents.
89
NEONATOLOGY
Thrombolytic regimen in neonates
90
NEONATALOGY
Chapter 15: Guidelines for the Use of Surfactant
Who to give surfactant to?

Depressed preterm infants who have no spontaneous respiration after 30
seconds of ventilation with T-piece resuscitator or resuscitation bag with
CPAP attachment and pressure manometers, and thus require positive
pressure ventilation (PPV).
Preterm infants below 28 weeks gestation who are given only CPAP from
birth in delivery room, i.e. the infant has spontaneous respiration and good
tone at birth. Surfactant to be given within 30 minutes after birth. Decision
as to whether to leave the patient intubated after surfactant depends on the
lung compliance, severity of RDS and degree of prematurity
Preterm infants between 28-32 weeks to have CPAP from birth in delivery
room. To assess requirement for surfactant in NICU based on oxygen
requirement of FiO2 > 30% and respiratory distress.
To consider INSURE technique INtubate, SURfactant, Extubate to CPAP
More mature or larger infants should also be given surfactant if the RDS
is severe i.e. arterial alveolar (a/A) PO2 ratio of <0.22 or Fraction of inspired
(FiO2) > 0.5
PaO2 (mmHg)
Calculation for a/A PO2 ratio :
(760-47)FiO2 PaCO2 (mmHg)
To be considered in severe meconium aspiration syndrome with type II

respiratory failure to be used prior to high frequency oscillatory ventilation
and nitric oxide to allow the lungs to open optimally.
Timing of therapy
Attempts to treat with surfactant before the infant can breathe resulted in
more bronchopulmonary dysplasia than early treatment in delivery room
because it interferes with initial stabilisation of the infant. Therefore
surfactant delivery within the first minute of life is not indicated.
91
NEONATOLOGY
Surfactant therapy for respiratory distress syndrome (RDS) is standard care

for preterm infants, based on numerous randomised controlled trials
demonstrating decreased mortality.
Surfactant therapy reduces mortality rates most effectively in infants < 30
weeks and those of birthweight < 1250 gm.
The guideline below is to address how to optimally use surfactant and in
which subpopulation of preterm infants.
The approach should be an individualised one based on clinical appraisal as
given in the guideline below.
Not all preterm infants have RDS and many of them initially have sufficient
surfactant to establish relatively normal ventilation before other factors such
as hypothermia, atelectasis or ventilation trauma inactivates the surfactant.
The use of antenatal steroids has also reduced the incidence of RDS.
NEONATALOGY
The first dose has to be given as early as possible to the preterm infants
requiring mechanical ventilation for RDS. The repeat dose is given 4-6 hours
later if FiO2 is still > 0.30 with optimal tidal volume settings forthose below
32 weeks and if FiO2 > 0.40 and CXR still shows moderate to severe RDS
(white CXR) for those infants > 32 weeks gestational age.
Types of surfactant and dosage
There are two types of surfactant currently available in Malaysia
Survanta , a natural surfactant, bovine derived
Dose : 4 ml/kg per dose.
Curosurf , a natural surfactant, porcine derived (not in Blue Book)
Dose: 1.25 mls/kg per dose.
Method of administration
Insert a 5 Fr feeding tube that has been cut to a suitable length so as not
to protrude beyond the tip of the ETT on insertion, through the ETT. If the
surfactant is given soon after birth, it will mix with foetal lung fluid and
gravity will not be a factor. Therefore no positional changes are required for
surfactant given in delivery room.
Surfactant is delivered as a bolus as fast as it can be easily be pushed through
the catheter. Usually this takes 2 aliquots over a total of a few minutes.
Continue PPV in between doses and wait for recovery before the next
aliquot, with adjustments to settings if there is bradycardia or
desaturation. Administration over 15 minutes has been shown to have poor
surfactant distribution in the lung fields.
Alternatively the surfactant can be delivered through the side port on ETT
adaptor without disconnecting the infant from the ventilator. There will be
more reflux of surfactant with this method.
Monitoring
Infants should be monitored closely with a pulse oximeter and regular blood
gas measurements. An indwelling intra-arterial line wiould be useful.
Ventilator settings must be promptly wound down to reduce the risk of
pneumothorax and ventilator induced lung injury. Consider extubation to
CPAP if the oxygen requirement is less than 30% and there are minimal
pressure requirements.
92
Chapter 16: The Newborn and Acid Base Balance
Causes of Acidosis
Metabolic acidosis
Respiratory acidosis
Renal failure
Asphyxia
(injury to respiratory centre)
Septicaemia
Hypoxia
Hypothermia
Obstruction to respiratory tract e.g.

secretions, blocked endotracheal tube
Hypotension
Respiratory distress syndrome (RDS)
Cardiac failure
Pneumonia
Dehydration
Pulmonary oedema
Hyperkalaemia
Apnoea
Hyperglycaemia
Anaemia
Intraventricular haemorrhage
Drugs (e.g. acetazolamide)
Metabolic disorders
Causes of Alkalosis
Metabolic alkalosis
Respiratory alkalosis
Sodium bicarbonate
Asphyxia
(overstimulation of respiratory centre)
Pyloric stenosis
Hypokalaemia
Drugs (e.g.thiazides and frusemide)
Over-ventilation while on mechanical

ventilation
Effects of acidosis and alkalosis in the body

Acidosis
- Depression of central nervous system (CNS)
- Disorientation and coma.
- Increased depth and rate of respiration in metabolic acidosis and depressed
respiration in respiratory acidosis.
- High PaCO in respiratory acidosis increases cerebral blood flow and risk of
intraventricular haemorrhage.
93
NEONATOLOGY
The rate of metabolism in infants is twice as great in relation to body mass as

in adults, which means twice as much acid is formed which leads to a tendency
toward acidosis. Functional development of kidneys is not complete till the end
of the first month and hence renal regulation of acid base may not be optimal.
NEONATALOGY
Alkalosis
- Over-excitability of the central nervous system.
- Decreased cerebral blood flow - causing cerebral ischaemia, convulsions
Measurement of Acid Base Status
Done by analyzing following parameters in an arterial blood gas sample:

Normal values:
pH 7.34-7.45

PaCO2
5.3-6.0 kpa (40-45 mmHg)

HCO3 -
20-25 mmol/L
PaO2
8-10 kpa (60-75 mmHg)

BE
5 mmol/L
Interpretation of Blood Gases
pH < 7.34 : acidosis
- If PaCO and HCO are low and base deficit is high: metabolic acidosis.
- If PaCO and HCO are high and base excess is high: respiratory acidosis.
- If both PaCO and base deficit are high: mixed metabolic and
repiratory acidosis.
pH > 7.45: alkalosis
- If PaCO is low: respiratory alkalosis
- If HCO and base excess are high: metabolic alkalosis
Acidosis and alkalosis may be partially or fully compensated by the opposite
mechanism.
Low PaCO: hypocarbia; high PaCO: hypercarbia
Permissive hypercapnia (PCO2 45-55 mmHg) is an important ventilation
technique to reduce the risk of volume trauma and chronic lung disease.
Low PaO: hypoxaemia; high PaO: hyperoxaemia
Management of Metabolic Acidosis and Alkalosis
Treat underlying cause when possible.
Do not treat acute metabolic acidosis by hyperventilation or by giving
bicarbonate. This may correct pH but has deleterious effects on cardiac
output and pulmonary blood flow. The use of sodium bicarbonate in acute
resuscitative conditions is not advocated by the current body of evidence.
Volume expansion (i.e., bolus 10 mL/kg of 0.9% Normal Saline) should not
be used to treat acidosis unless there are signs of hypovolemia. A volume
load is poorly tolerated in severe acidosis because of decreased myocardial
contractility.
NaHCO should be used only in the bicarbonate-losing metabolic acidoses
such as diarrhea or renal tubular acidosis.
Dose of NaHCO for treatment of metabolic acidosis can be calculated by:
Dose in mmol of NaHCO3 = Base deficit (mEq) x Body weight (kg) x 0.3
Do not give NaHCO unless infant is receiving assisted ventilation that is
adequate. With inadequate ventilation, NaHCO will worsen acidosis from
liberation of CO.
94
Treatment of respiratory acidosis and alkalosis

A steadily rising PaCO at any stage in the disease is an indication that
ventilatory assistance is likely to be needed.
A sudden rise may be an indication of acute changes in the infants condition
e.g. pneumothorax, collapsed lobes, misplaced endotracheal tube. .
(DOPE mnemonic: Displacement, Obstruction, Pneumothorax and
Equipment Failure)
A swift rise in PaCO often accompanied by hypoxia following weaning is
often an indication that the infant is not ready for weaning.
A gradual rise in PaCO at the end of the first week in a LBW infant on
ventilator may be an indicator of the presence of a patent ductus arteriosus.
Low PaCO in a infant on a ventilator means overventilation, hence
treatment is to wean down the ventilation settings.
Interpretation of Blood Gases
Examples of Arterial Blood Gas (ABG) Interpretation
1. A 29 weeks gestation and 1.1 kg BW infant has RDS. He is 20 hours old and
is being nursed on nasal CPAP.
His ABG shows:

Question (Q): What does the ABG show?
pH
7.21

Answer (A): Mild respiratory acidosis due to
PaCO 6.6 kPa
worsening Respiratory Distress Syndrome.
Q:
What
is the next appropriate mode of therapy?
PaO
7.5 kPa
A: Mechanical ventilation
20 mmol/L
HCO
BE
-4 mmol/L
2. Below is the ABG of a 10 hour old 28 weeks gestation infant :
7.22
pH
Q: What does the ABG show?
A:
Mixed respiratory and metabolic acidosis
PaCO 7.0 kPa
PaO
10.0 kPa
Q:
Name a likely diagnosis
A:
Respiratory distress syndrome
HCO
17 mmol/L
BE
-8 mmol/L
95
NEONATOLOGY
For chronic mild metabolic acidosis in small premature infants on

hyperalimentation, maximize acetate and minimize chloride in the solution.
Metabolic alkalosis: usually iatrogenic in premature infants - diuretic use,
gastrointestinal losses, and occurs in combination with contracted
intravascular and ECF volumes.
NEONATALOGY
3. The following is the ABG of a 40 day old 26 weeks gestation baby:

pH
7.38

A:
Compensated respiratory acidosis
PaCO 8.0 kPa
PaO
8.0 kPa
Q: What is a likely diagnosis?
HCO
35 mmol/L
A:
Chronic lung disease.
BE
+10 mmol/L
4. An infant of 30 weeks gestation and BW 1.3 kg is on a ventilator.

ABG shows:

Q: Interpret the ABG
pH
7.35
A:
Compensated metabolic acidosis by

respiratory alkalosis and hyperoxaemia
PaCO 3.0 kPa
PaO
15.0 kPa
Q: What is your next course of action?
HCO
12 mmol/L
A:
Reduce FiO, treat any contributory cause of

acidosis and wean down ventilation settings.
BE
-12 mmol/L
5. A term infant is being ventilated for meconium aspiration.
His ABG is as follows :
pH
7.16

Q: What is likely to have happened?
A:
Pneumothorax
PaCO 10.0 kPa
PaO
6.0 kPa
Q:
What is your interpretation of the ABG
A:
Mixed respiratory and metabolic acidosis
HCO
16 mmol/L

with hypoxaemia.
BE
-10 mmol/L
6. A 6 day old infant is being ventilated for a cyanotic heart disease.
ABG shows :

pH
7.2
A:
Metabolic acidosis with severe hypoxaemia.
PaCO 4.5 kPa
Q: What is your next course of action ?
PaO
3.0 kPa
A: Consider prostaglandin infusion, confirm heart
HCO
8 mmol/L

defect by Echocardiography, consider reducing

ventilation.
BE
-15 mmol/L
Pearls
Conversion of kPa to mmHg is a factor of 7.5.
96
Chapter 17: Neonatal Encephalopathy
HIE in newborn requires the presence of all 3 of the following criteria:

1. Presence of a clinically recognized encephalopathy within 72 hrs of birth.
AND
2. Three or more supporting findings from the following list:
Arterial cord pH < 7.00
Apgar score at 5 minutes of 3 or less
Evidence of multiorgan system dysfunction within 72 hours of birth
Evidence of foetal distress on antepartum monitoring: persistent late
decelerations, reversal of end-diastolic flow on Doppler flow studies of
the umbilical artery or a biophysical profile of 2 or less
Evidence of CT, MRI, technetium or ultrasound brain scan performed
within 7 days of birth of diffuse or multifocal ischaemia or of cerebral
oedema.
Abnormal EEG: low amplitude and frequency, periodic, paroxysmal or
isoelectric.
AND
3. The absence of an infectious cause, a congenital malformation of the
brain, an inborn error of metabolism or other condition, which could
explain the encephalopathy.
In HIE, the brain injury is caused by a deficit in oxygen supply.
This can occur by
Hypoxemia - a decrease in oxygen saturation in the blood supply, or
Ischaemia - a decrease in the amount of blood perfusing the brain
or both processes.
97
NEONATOLOGY
Neonatal Encephalopathy (NE) is a clinical syndrome of disturbed

neurological function, caused by failure to make a successful transition to
extrauterine gas exchange
Manifests in a difficulty in initiating and maintaining spontaneous
respiration, depression of muscle tone and reflexes, depressed
consciousness and often seizures.
Occurs in 3.5 - 6/1000 live births; usually affects full term infants.
The terminology NE is preferred to Hypoxic Ischemic Encephalopathy (HIE)
as it is not always possible to document a significant hypoxic-ischemic insult
and there are other aetiologies such as CNS malformation, infection, multiple
gestation, IUGR, maternal autoimmune disorders, metabolic disorders, drug
exposure, and neonatal stroke as possible causes of the encephalopathy.
Risk factors for neonatal encephalopathy were mainly seen in the antenatal
period (69%) as compared to the intrapartum period (25%) in a large
Western Australian study. Only 4% were due to intrapartum hypoxia.
NEONATALOGY
Staging of Neonatal Hypoxic Ischaemic Encephalopathy (HIE)

This done using the Sarnat and Sarnat Staging system (facing page). This is
mainly used in term infants or infants > 35 weeks gestation. It is not useful in
premature infants.
Management
Adequate and effective resuscitation.
Commence cooling therapy within 6 hours of life for moderate to severe
HIE in those more than or equal to 35 weeks gestation.
Vital sign monitoring. Monitoring of blood gases, urine output, blood sugar
and electrolytes.
Management is supportive.
Avoid hyperthermia that may be associated with adverse outcome
Maintain normoglycaemia, both hypo- and hyperglycemia can be harmful.
Review infection risk and cover with antibiotics if necessary
Maintain adequate hydration (do not dehydrate or over hydrate).
Cerebral protection measures
Maintain normal Blood Pressure. If necessary, consider use of inotrope
infusion rather volume expander unless there is hypovolaemia.
Treat seizures (see chapter on Neonatal Seizures)
Mechanical ventilation to maintain normocarbia.
Treat other systemic complications that arise:
Renal. Acute tubular necrosis.
If oliguria with urine output < 1ml/kg/hr, check for prerenal cause and
treat accordingly. If in established renal failure, restrict fluid and maintain
normal electrolyte levels.
Cardiac. Hypoxic damage to myocardium with cardiogenic shock and failure.
Use of inotropes and careful fluid balance.
Lungs. Persistent Pulmonary Hypertension (PPHN).
See relevant chapter on PPHN
Gastrointestinal. Stress ulcers, feed intolerance, necrotizing enterocolitis.
Enteral feeding is preferable to parenteral but avoid rapid increase in
volume of feeds to decrease risk of necrotizing enterocolitis.
Haematology. Disseminated Intravascular Coagulation.
Correct coagulopathy as indicated.
Others. SIADH, hypoglycaemia, hypocalcaemia, and hypomagnesaemia
Restrict fluids in SIADH. Correct hypoglycaemia and electrolyte
imbalances.
98
Only for term infants or > 35 weeks gestation. Not for use in premature infants.
Variable
Stage I
Stage II
Stage III
Level of consciousness
Alert
Lethargy
Coma
Muscle tone
Normal or
hypertonia
Hypotonia
Flaccidity
Tendon reflexes
Increased
Increased
Depressed or
absent
Myoclonus
Present
Present
Absent
Seizures
Absent
Frequent
Frequent,
then subsides
Poor
Exaggerated
Normal or
exaggerated
Normal
Weak
Incomplete
Exaggerated
Absent
Absent
Absent
Overactive
Reduced
or absent
Constrictive,
reactive
Variation in rate,
depth; Periodic
Bradycardia
Variable or
fixed
Ataxic, apneic
Complex reflexes
Suck
Moro
Grasp
Dolls eyes
Autonomic function
Pupils

Dilated, reactive
Respirations
Regular
Heart rate
Normal
or tachycardia
Sparse
Bradycardia
Profuse
Variable
Electroencephalogram
Normal
Early
Low voltagecontinuous,
Later
Periodic,
paroxysmal
Early
Periodic, Burst
suppression
Later
Isoelectric
Outcome
No impairment
25% Impaired
92% Impaired
Salivation
99
NEONATOLOGY
Staging of Hypoxic Ischaemic Encephalopathy (HIE)
NEONATALOGY
Investigations
Investigation
Indication
Cranial Ultrasound
To exclude haemorrhage and other intracerebral

abnormalities.
Doppler studies (done after 24 hours of life)
suggest that a resistive index of less than 0.5-0.6 is
consistent with the diagnosis of HIE.
Brain CT scan
To exclude haemorrhage, cerebral oedema and

other intracerebral abnormalities. May assist with
prognosis. Extensive areas of low attenuation with
apparent brightness of basal ganglia are associated
with very poor prognosis (done after 1st week of
life).
Brain MRI
MRI may provide prognostic information.

Thalamic, basal ganglia abnormalities are
associated with a risk of abnormal
neuro-developmental outcome. Superior to CT
scans.
Amplitude intergrated
Electroencephalogram
(aEEG)
Overall risks for death or disability were 95% for

a severely abnormal aEEG, 64% for a moderately
abnormal aEEG and 3 % for a normal or mildly
abnormal aEEG.
Follow up
All infants with NE should be followed up to look for development and
neurological problems.
Manage epilepsy (see Ch 44: Epilepsy), developmental delay, cerebral palsy,
learning difficulty as appropriate.
To evaluate hearing and vision on follow-up and manage appropriately.
100
Chapter 18: Neonatal Seizures
Etiology
Determination of etiology is critical because it gives the opportunity to treat
specifically and also to make a meaningful prognosis.
Onset1
Etiology
0-3 days
Frequency2
Preterm
Term
+++
+++
++
++
++
++
Hypoxic - ischemic encephalopathy
Intracranial hemorrhage
Intracranial infections
Brain malformations
Hypoglycaemia
Hypocalcaemia
Metabolic disturbances, inborn errors
Epileptic Syndromes
>3 days
+
+
Footnote: 1, Postnatal age; 2, Relative frequency of seizures among all etiologies:

+++ most common, ++ less common, + least common.
From JJ Volpe: Neurology of the Newborn 4th edition. Page 190
Notes:
Hypoxic ischaemic encephalopathy
Usually secondary to perinatal asphyxia.
Most common cause of neonatal seizures (preterm and term)
Seizures occur in the first day of life (DOL)
Presents with subtle seizures; multifocal clonic or focal clonic seizures
If focal clonic seizures may indicate associated focal cerebral infarction
Intracranial haemorrhage (ICH)
Principally germinal matrix-intraventricular (GM-IVH), often with
periventricular haemorrhagic (PVH) infarction in the premature infant
Severe GM-IVH: onset of seizures in first 3 DOL (usually generalized tonic
type with subtle seizures).
With associated PVH usually develop seizures after 3 DOL.
In term infants ICH are principally subarachnoid (may occur with HIE) and
subdural (often associated with a traumatic event, usually presenting with
focal seizures in the first 2 DOL).
101
NEONATOLOGY
Seizures are the most frequent manifestation of neonatal neurological diseases.

It is important to recognize seizures, determine aetiology and treat them as:
1. The seizures may be related to diseases that require specific treatment.
2. The seizures may interfere with supportive measures e.g. feeding and
assisted respiration for associated disorders.
3. The seizures per se may lead to brain injury.
102
Common
Common
Common
Uncommon
Uncommon
Common
Tonic
Focal
Generalized
Myoclonic
Focal, Multifocal
Generalized
Common
Subtle
Clonic
Focal
Multifocal
EEG seizure
Clinical Seizure
Classification of Neonatal Seizures
Well localized, single or multiple, migrating jerks usually of limbs

Single/several bilateral synchronous jerks or flexion movement more in upper than lower limbs.
Sustained posturing of a limb, asymmetrical posturing of trunk or neck

Tonic extension of upper and lower limbs (mimic decerebrate posturing)
Tonic flexion of upper limbs and extension of lower limbs (mimic decorticate posturing)
Those with EEG correlates; autonomic phenomena, e.g. increased BP are prominent features.
Well localized clonic jerking, infant usually not unconscious

Multifocal clonic movements; simultaneous, in sequence or non-ordered (non-Jacksonian) migration
Ocular phenomena
Tonic horizontal deviation of eyes common in term infants.
Sustained eye opening with fixation common in preterm infants.
Blinking.
Oral-buccal-lingual movements
Chewing common in preterm infants.
Lip smacking, cry-grimace.
Limb movements
Pedaling, stepping, rotary arm movements
Apnoeic spells common in term infants
Manifestation
NEONATALOGY
Seizures versus Jitteriness and Other Non-epileptic Movements

Jitteriness and other normal movement during sleep (Myoclonic jerks as infant
wakes from sleep) or when awake/ drowsy (roving sometimes dysconjugate
eye movements, sucking not accompanied by ocular fixation or deviation) in
newborns may be mistaken for seizures.
Clinical Manifestation
Jitteriness
Abnormality of gaze or eye movement

Movements exquisitely stimulus sensitive
Predominant movement
Seizure
+
Tremors1
Clonic,
jerking2
Movements stop with passive flexion of affected limb
Autonomic changes (tachycardia, high BP, apnoea,

salivation, cutaneous vasomotor phenomena)
Footnote: 1,Tremors alternating movements are rhythmical and of equal rate and
amplitude; 2, Clonic, jerking movements with a fast and slow component
Adapted from JJ Volpe: Neurology in the Newborn 4th Edition. Page 188
103
NEONATOLOGY
Intracranial Infection
Common organisms are group B streptococci, E. coli., toxoplasmosis, herpes
simplex, coxsackie B, rubella and cytomegalovirus.
Malformations of cortical development
Neuronal migration disorder resulting in cerebral cortical dysgenesis
Metabolic disorder
Hypoglycemia. It may be difficult to establish hypoglycemia as the cause of
seizures because of associated hypoxic-ischemic encephalopathy,
hypocalcaemia or hemorrhage.
Hypocalcaemia has 2 major peaks of incidences:
- First 2 - 3 days of life, in low birth weight infants, infant of a diabetic
mother or history of hypoxic-ischemic encephalopathy. A therapeutic
response to IV calcium will help in determe if low serum calcium is the
cause of the seizures. Early hypocalcaemia is more commonly an
associated factor rather than the cause of seizures.
- Later-onset hypocalcaemia is associated with endocrinopathy (maternal
hypoparathyroidism, neonatal hypoparathyroidism) and heart disease
(+/- Di George Syndrome); rarely with nutritional disorders (cows milk, high
phosphorus synthetic milk). Hypomagnesemia is a frequent accompaniment.
Other metabolic disorders, e.g. intoxication with lidocaine, hypo- and
hyper-natraemia, hyperammonemia amino acidopathy, organic acidopathy,
non-ketotic hyperglycinemia, mitochondrial diosrders, pyridoxine
dependency (recalcitrant seizures cease with IV pyridoxine) and glucose
transporter defect (GLUT1 deficiency: low CSF glucose but normal blood
glucose - treated with a ketogenic diet).
NEONATALOGY
Management
Ensure adequate respiratory effort and perfusion.
Correct metabolic and electrolyte disorders.
No consensus on the treatment of minimal or absent clinical manifestations.
Anticonvulsant treatment prevents potential adverse effects on ventilatory
function, circulation and cerebral metabolism (threat of brain injury).
Little evidence for use of any anticonvulsant drugs currently prescribed in
the neonatal period. Also lack of consensus on optimal treatment protocol.
Controversy regarding identification of adequacy of treatment, elimination
of clinical seizures or electrophysiology seizures. Generally majority attempt
to eliminate all or nearly all clinical seizures.
Anticonvulsant drugs may not treat electroencephalographic seizures even if
they are effective in reducing or eliminating the clinical manifestations
(electro-clinical dissociation).
Uncertainty exists over when to commence anticonvulsant drugs.
Consider anticonvulsant drugs to treat seizures when seizures:
Are prolonged greater than 2-3 minutes.
Are frequent greater than 2-3 per hour.
Disrupt of ventilation and/or blood pressure homeostasis.
Administer anti convulsant drugs:
Intravenously to achieve rapid onset of action and predictable blood levels.
To achieve serum levels in the high therapeutic range.
To maximum dosage before introducing a second drug.
Requirement for maintenance and duration of therapy is not well defined.
Keep duration of anti convulsant drug treatment as short as possible.
However, this depends on diagnosis and likelihood of seizure recurrence.
Maintenance therapy may not be required if loading doses of anticonvulsant
drugs control clinical seizures.
Babies with prolonged or difficult to treat seizures and those with
abnormality on EEG may benefit from continuing anticonvulsant treatment.
Duration of Anticonvulsant Therapy- Guidelines
Duration of therapy depends on the probability of recurrence of seizures if
the drugs are discontinued and the risk of subsequent epilepsy. This can be
determined by considering the neonatal neurological examination, cause of the
seizure and the EEG.
Neonatal Period
If neonatal neurological examination becomes normal, discontinue therapy
If neonatal neurological examination is persistently abnormal,
Consider etiology and obtain electroencephalogram (EEG).
In most cases continue phenobarbitone, discontinue phenytoin.
And re-evaluate in one month.
104
Prognosis
Prognosis according to aetiology of neonatal seizures
Neurological disorder
Normal Development (%)1
Hypoxic Ischemic Encephalopathy
50
Severe Intraventricular Haemorrhage with

periventricular hemorrhagic infarction
10
Hypocalcaemia
Early onset
(depends on prognosis of complicating
illness, if no neurological illness present
prognosis approaches that of later onset )
Later onset (nutritional type)
100
Hypoglycemia
50
Bacterial meningitis
50
Malformation of Cortical Development
50
Footnote:1, Prognosis based cases with the stated neurological disease when
seizures are a manifestation.This will differ from overall prognosis of the disease.
From JJ Volpe: Neurology in the Newborn:4th edition. Page 202
105
NEONATOLOGY
One Month after Discharge

If neurological examination has become normal, discontinue
phenobarbitone over 2 weeks.
If neurological examination is persistently abnormal, obtain EEG.
If no seizure activity or not overtly paroxysmal on EEG, discontinue
phenobarbitone over 2 weeks.
If seizure activity is overtly paroxysmal continue phenobarbitone until
3 months of age and reassess in the same manner.
NEONATALOGY
Management of Neonatal Seizures

Investigations to consider:
Infant with Clinical Seizures
Blood sugar, Ca, Mg, electrolytes

Septic screen: FBC, Blood C&S,
LP, TORCHES
Assess ABCs.
Ensure adequate
ventilation, perfusion
Metabolic screen: ABG, ammonia,

amino acids, organic acids
Neuroimaging: US, CT, MRI Brain
Electroencephalography (EEG)
Capillary Blood Sugar STAT

No hypoglycemia
IV Phenobarbitone 20mg/kg
slow infusion over 30 mins
If seizures continue,
Give another 5-10mg/kg until
either seizures stop or a total
dose of 40mg/kg
Seizures still !
IV Phenytoin 10mg/kg slow
infusion (max rate 0.5mg/kg/min)
Repeat a 2nd loading dose if
fits recur.
Monitor Cardiac rate and
rhythm during infusion
Seizures still !
Hypoglycemia !
IV 10% Dextrose at 2 ml/kg
(200mg/kg)
Then IV Glucose infusion at
8 mg/kg/min infusion
Maintenance therapy:
IV or PO 3-5mg/kg/d q12h,
Given 12-24 h after loading
AE : Respiratory depression,
hypotension
Maintenance therapy:
4-8mg/kg/d q12h, IV
Given 12-24 h after loading
AE: Heart block, hypotension
Note: oral absorption erratic
IV Diazepam 0.3mg/kg/h
infusion, OR
Alert:
IV Midazolam 0.15mg/kg over

minimum of 5 minutes or as
an infusion 1-4mcg/kg/min
AE: Respiratory depression,

hypotension (if injected rapidly or
concomitant narcotic treatment),
myoclonus in preterm, urinary
retention
Seizures still !
Consider:
IV Calcium Gluconate,10% solution: 0.5 ml/kg

IV Magnesium sulfate, 50% solution: 0.2 ml/kg
IV Pyridoxine 50-100mg
106
Chapter 19: Neonatal Hypoglycemia
High Risk Infants

Infants of Diabetic Mothers.
Small for Gestational Age infants.
Preterm infants including late preterm infants.
Macrosomic infants / Large for gestational age infants > 4.0kg.
Ill infants including those with:
Hypoxic-ischemic encephalopathy.
Rhesus disease.
Polycythaemia.
Sepsis.
Hypothermia.
Clinical Features
Symptoms of hypoglycaemia include:
Jitteriness and irritability.
Apnoea and cyanosis.
Hypotonia and poor feeding.
Convulsions.
Note: Hypoglycaemia may be asymptomatic therefore monitoring is important
for high risk cases.
Management
Prevention and Early Detection at birth.
Identify at risk infants.
Well infants who are at risk:
Immediate feeding first feed can be given in Labour Room.
Supplement feeding until breastfeeding established.
Unwell infants:
Set up dextrose 10% drip.
Regular glucometer monitoring:
On admission and at 1, 2 and 4 hours after admission.
3 -6 hourly just prior to feeding once stable for 24-48 hours.
107
NEONATOLOGY
Introduction
The authors of several literature reviews have concluded that there is not a
specific plasma glucose concentration or duration of hypoglycemia that can
predict permanent neurologic injury in high-risk infants.
Neonatal glucose concentrations decrease after birth, to as low as
30 mg/dL (1.7 mmol/dL) during the first 1 to 2 hours after birth, and then
increase to higher and relatively more stable concentrations, generally above
45 mg/dL (2.5 mmol/L) by 12 hours after birth.
From birth to 4 hours, glucose level of above 25 mg/dL (1.5 mmol/L) is
acceptable if the infant is asymptomatic.
Hypoglycaemia is defined as < 2.6 mmol/L after first 4 hours of life.
There is no specific plasma glucose concentration or duration of
hypoglycemia that predicts permanent neurologic injury in high-risk infants.
NEONATALOGY
Hypoglycaemia
Repeat the capillary blood sugar sampling and send RBS stat.
Examine and document any symptoms.
Note when the last feeding was given.
If on IV drip, check that IV infusion of glucose is adequate and running well.
Blood Sugar Level <1.5mmol/l or if the baby is symptomatic:
GIve IV bolus Dextrose 10% at 2-3 ml/kg.
Followed by dextrose 10% drip at 60-90ml/kg/day (for day 1 of life) to
maintain normal blood glucose.
If baby is already on dextrose 10% drip, consider increasing the rate or the
glucose concentration (usually require 6-8 mg/kg/min of glucose delivery).
If blood sugar level (BSL) 1.5 2.5 mmol/l and asymptomatic:
Give supplementary feed (EBM or formula) as soon as possible.
If BSL remains < 2.6 mmol/l and baby refuses feeds, give dextrose 10% drip.
If baby is on dextrose 10% drip, consider stepwise increment of glucose
infusion rate by 2 mg/kg/min until blood sugar is > 2.6 mmol/L.
Glucose monitoring (capillary blood sugar - dextrostix, glucometer):
If blood sugar is < 2.6 mmol/l, re-check glucometer 1/2 hourly.
If blood sugar > 2.6 mmol/l for 2 readings: Monitor hourly x 2,
Then 2 hourly X 2, Then to 4-6 hourly if blood sugar remains normal.
Start feeding when capillary blood sugar remains stable and increase as
tolerated. Reduce the IV infusion rate one hour after feeding increment.
Persistent Hypoglycaemia
If hypoglycaemia persists despite intravenous dextrose, consult MO/ specialist
and for district hospitals, consider early referral.
Re-evaluate the infant
Confirm hypoglycaemia with RBS but treat as such while awaiting RBS result.
Increase volume by 30ml/kg/day and/or increase dextrose concentration to
12.5% or 15% . Concentrations >12.5% must be infused through a central line.
If hypoglycaemia still persists despite glucose delivery >8-10 mg/kg/min,
consider glucagon 40 mcg/kg stat then 10-50mcg/kg/h. Glucagon is only
useful where there is sufficient liver stores, thus should not be used for SGA
babies or in adrenal insufficiency.
In others especially SGA, give IV Hydrocortisone 2.5 -5 mg/kg /dose bd.
There may be hyperinsulinaemia in growth retarded babies as well.
Prescription to make up a 50mL solution of various dextrose infusions :
Infusion concentration
Volume of 10% Dextrose
Volume of 50% Dextrose
12.5 %
46.5 ml
3.5 ml
15 %
44.0 ml
Glucose requirement (mg/kg/min) =
6.0 ml
% of dextrose x rate (ml/hr)
weight (kg) x 6
108
Differential diagnoses include:

Hyperinsulinaemic states (e.g.Beckwith-Wiedemann syndr, Nesidioblastosis)
Adrenal insufficiency.
Galactosaemia.
Metabolic (e.g. fatty acid oxidation disorders) and mitochondrial disorders.
Investigations
Insulin , cortisol, growth hormone levels
Serum ketones
Urine for organic acids
Take blood investigations before an increase in rate of glucose infusion when
hypoglycaemia persists despite glucose infusion. Further investigation is
directed by the results of these tests and the differential diagnosis above.
Medical treatment
As per protocol for Management of Persistent Hypoglycaemia.
PO Diazoxide 10-25mg/kg/day in three divided doses
- Reduces insulin secretion, therefore useful in hyperinsulinaemia.
- Not to be used in SGA infants.
SC Octreotide (synthetic somatostatin) 2-10 g/kg/day bd/tds or as infusion.
Pearls and Pitfalls in Management
Depending on severity of hypoglycaemia, maintain some oral feeds as milk
has more calories than 10% dextrose. Breastfeeding should be encouraged
as it is more ketogenic.
Feed baby with as much milk as tolerated and infuse glucose at a sufficient
rate to prevent hypoglycaemia. The glucose infusion is then reduced slowly
while milk feeds is maintained or increased.
Avoid giving multiple boluses as they can cause a rapid rise in blood glucose
concentration which may be harmful to neurological function and may be
followed by rebound hypoglycaemia.
Any bolus given must be followed by a continuous infusion of glucose,
initially providing 4-8 mg/kg/ min. There is no place for treatment with
intermittent glucose boluses alone.
Ensure volume of IV fluid is appropriate for patient, taking into consideration
concomitant problems like cardiac failure, cerebral oedema and renal failure.
If unable to increase volume further, increase dextrose concentration.
RBS should be taken to correlate with low capillary blood sugar level as some
glucose monitors are not as accurate for neonatal blood which has a higher
haematocrit. Management can be instituted first whilst waiting for RBS
results to be available.
109
NEONATOLOGY
Recurrent or resistant hypoglycaemia

Consider this if failure to maintain normal blood sugar levels despite a
glucose infusion of 15 mg/kg/min, or
When stabilization is not achieved by 7 days of life. High levels of glucose
infusion may be needed in the infants to achieve euglycemia.
NEONATALOGY
Management of Persistent Hypoglycaemia

Hypoglycaemia
Blood Glucose (BG) < 2.6 mmol/L
BG 1.5 < 2.6mmol/L

and asymptomatic
(0-4 hours of life)
BG < 1.5 mmol/L

or symptomatic
IV 10% Dextrose 2-3 ml/kg bolus
Give supplement feeding ASAP
IV Dextrose10% drip at 60 to
90 ml/kg/day
If refuses to feed,
IV Dextrose10% drip 60ml/kg/day
Repeat BG in 30 minutes
if still Hypoglycaemia:
Re-evaluate *
Increase Volume by 30ml/kg/day
if still Hypoglycaemia:
* If BG < 1.5mmol/L
or symptomatic :
Give IV D10% 2-3ml/kg bolus,
then proceed with flowchart.
Re-evaluate *
Give via a
Central Line
#
Increase Concentration to D12.5%-D15%#

If glucose delivery > 8 -10mg/kg/min and Persistent Hypoglycaemia:

IV Glucagon 40 mcg/kg stat then 10-50mcg/kg/h.
Not to be used in SGA or adrenal insufficiency.
IV Hydrocortisone 2.5 - 5 mg/kg/dose bd in others, esp. SGA.
PO Diazoxide 10 25 mg/kg/day in 3 divided doses
Useful in hyperinsulinaemia, not to be used in SGA.
SC Octreotide 2 10 mcg/kg/day 2 - 3 times/day or as infusion.
Consider further workup in Recurrent or Persistent Hypoglycaemia if:
Failure to maintain normal BG despite Glucose infusion rate of
15mg/kg/min, or
When stabilization is not achieved in 7 days of life.
Note: Once Blood Glucose level > 2.6mmol/L for 2 readings,
monitor hourly x 2, then 2 hourly x 2, then 4 6 hourly.
110
Chapter 20: Neonatal Jaundice
Approach to an infant with jaundice

History
Age of onset.
Previous infants with NNJ, kernicterus, neonatal death, G6PD deficiency.
Mothers blood group (from antenatal history).
Gestation: the incidence of hyperbilirubinaemia increases with prematurity.
Presence of abnormal symptoms such as apnoea, difficulty in feeding, feed
intolerance and temperature instability.
General condition, gestation and weight, signs of sepsis, hydration status.
Signs of kernicterus: lethargy, hypotonia, seizure, opisthotonus, high pitch cry.
Pallor, plethora, cephalhaematoma, subaponeurotic haemorrhage.
Signs of intrauterine infection e.g. petechiae, hepatosplenomegaly.
Cephalo-caudal progression of severity of jaundice.
Management
Indications for referral to hospital:
Jaundice within 24 hours of life.
Jaundice below umbilicus (corresponds to serum bilirubin 200-250 mol/L).
Jaundice extending to soles of feet:
Urgent referral, may need exchange transfusion !
Family history of significant haemolytic disease or kernicterus.
Any unwell infant with jaundice.
Prolonged Jaundice of >14 days.
- Refer infants with conjugated hyperbilirubinaemia urgently to a hospital.
- Infants with unconjugated hyperbilirubinaemia can be investigated and
referred only if the jaundice does not resolve or a definitive cause found.
(ref Ch 22: Prolonged Jaundice in the Newborn).
111
NEONATOLOGY
Introduction
Jaundice can be detected clinically when the level of bilirubin in the serum rises
above 85 mol/l (5mg/dl).
Risk factors for Bilirubin Encephalopathy
Causes of neonatal jaundice
Preterm infants
Haemolysis due to ABO or
Rh-isoimmunisation, G6PD deficiency,
Small for gestational age
microspherocytosis, drugs.
Sepsis
Physiological jaundice.
Acidosis
Cephalhaematoma, subaponeurotic
haemorrhage.
Hypoxic-ischemic encephalopathy
Polycythaemia.
Sepsis septicaemia, meningitis, urinary Hypoalbuminaemia
tract infection, intra-uterine infection.
Jaundice < 24 hours of age
Breastfeeding and breastmilk jaundice.
Gastrointestinal tract obstruction: increase in enterohepatic circulation.
NEONATALOGY
Investigations
Total serum bilirubin
G6PD status
Others as indicated:
Infants blood group, maternal blood group, Direct Coombs test (indicated
in Day 1 jaundice and severe jaundice).
Full blood count, reticulocyte count, peripheral blood film
Blood culture, urine microscopy and culture (if infection is suspected)
Clinical Assessment of Neonatal Jaundice
Zone
Jaundice
(detected by blanching the skin with finger pressure)
Estimated Serum
Bilirubin (mol/L)
Head and neck
68 -135
Over upper trunk above umbilicus
85 - 204
Lower trunk and thighs
136 - 272
Over arms, legs and below knee
187 - 306
Hands, feet
> 306
Note: This may be difficult in dark skinned infants
DO NOT rely on Visual Assessment of Skin alone to Estimate the Bilirubin Level
Treatment
Avoid sunlight exposure due to risk of dehydration and sunburn.
Phototherapy
Phototherapy lights should have a minimum irradiance of 15 W/cm2/nm.
Measure intensity of phototherapy light periodically using irradiance meters.
Intensive phototherapy implies irradiance in the blue-green spectrum of
at least 30 W/cm2/nm measured at the infants skin directly below the
center of the phototherapy unit.
Position light source 35-50 cm from top surface of the infant
(when conventional fluorescent photolights are used).
Expose infant adequately; Cover infants eyes.
Monitor serum bilirubin levels as indicated.
Monitor infants temperature 4 hourly to avoid chilling or overheating.
Ensure adequate hydration and good urine output. Monitor for weight loss.
Adjust fluid intake (preferably oral feeds) accordingly. Routine fluid
supplementation is not required with good temperature homeostasis.
Allow parental-infant interaction.
Discontinue phototherapy when serum bilirubin is below phototherapy level.
Turn off photolights and remove eyepads during feeding and blood taking.
Once the baby is on phototherapy, visual observation as a means of
monitoring is unreliable. Serum bilirubin levels must guide the management.
112
Intensive phototherapy (KIV Exchange transfusion) indications:

Total bilirubin >300 umol/L
Early onset jaundice (First 24 hours)
Rapidly rising jaundice (more than 8.5mol/L/hr)
If the total serum bilirubin does not decrease or continues to rise in an infant
receiving intensive phototherapy, this strongly suggests hemolysis.
Guidelines for Phototherapy and Exchange Transfusion (ET) in hospitalized

infants of 35 weeks gestation (derived from fig 1, next page)
Total Serum Bilirubin levels mg/dL (mol/L)
Hours
of Life
Low risk
38 wk and well
Medium risk
38 wk + risk factors or
35 to <38 wk and well
Intensive
phototherapy
ET
Intensive
phototherapy
ET
24
12 (200)
19 (325)
10 (170)
48
15 (255)
22 (375)
13 (220)
72
18 (305)
24 (410)
96
20 (340)
25 (425)
> 96
21 (360)
25 (425)
High risk
35 to <38 wk
+ risk factors
Intensive
phototherapy
ET
17 (290)
8 (135)
15 (255)
19 (325)
11 (185)
17 (290)
15 (255)
21 (360)
13 (220)
18.5 (315)
17 (290)
22.5 (380)
14 (240)
19 (325)
18 (305)
22.5 (380)
15 (255)
19 (325)
< 24 *
Note:
Start conventional phototherapy at TSB 3 mg/dL (50 mol/L) below the
levels for intensive phototherapy.
Risk factors isoimmune hemolytic disease; G6PD deficiency, hypoxicischemic encephalopathy, significant lethargy, temperature instability,
sepsis, acidosis or albumin < 3.0 g/dL
* Infants jaundiced at < 24 hours of life are not considered healthy and
require further evaluation.
113
NEONATOLOGY
In infants without haemolytic disease, the average increase of bilirubin

level in rebound jaundice after phototherapy is < 1 mg/dl (17 mol/L).
Hospital discharge need not be delayed to observe for rebound jaundice, and
in most cases, no further measurement of bilirubin is necessary.
NEONATALOGY
Fig 1: Guidelines for Intensive Phototherapy in infants 35 wks gestation
Fig 2: Guidelines for Exchange Transfusion in infants 35 wks gestation

infants at lower risk ( 38 week and well)
infants at medium risk ( 38 week + risk factors or 35-37 completed weeks)
infants at higher risk ( 35-37 completed weeks)
513 mol/L
428 mol/L
342 mol/L
257 mol/L
171 mol/L
birth
24 hr
48 hr
72 hr
96 hr
5 days
6 days
7 days
Age
Notes:
1. The dashed lines for the first 24 hours indicate uncertainty due to a wide range
of clinical circumstances and a range of responses to phototherapy.
2. Do an Immediate exchange transfusion if infant shows signs of acute bilirubin
encephalopathy (hypertonia, retrocollis, ophisthotonus, fever, high pitched cry)
or if total serum bilirubin is 5 mg/dL (85 mol/L) above these lines
3. For infants < 35 weeks gestational age- refer NICE (National Institute for Clinical
Excellence) Guidelines 2010 for recommended levels of phototherapy and ET.
Figures 1 & 2 adapted from American Academy of Paediatrics. Pediatrics, 2004. 114:297-316
114
Intravenous Immunoglobulins (IVIG)

High dose intravenous immunoglobulin (IVIG) (0.5 - 1 gm/kg over 2 hours)
reduces the need for exchange transfusions in Rh and ABO hemolytic disease.
Give as early as possible in hemolytic disease with positive Coombs test or
where the serum total bilirubin is increasing despite intensive phototherapy.
Dose can be repeated in 12 hours if necessary. If exchange transfusion is
already indicated, IVIG should be given after ET.
Measures to prevent severe neonatal jaundice
Inadequate breast milk flow in the first week may aggravate jaundice.
Supportive measures should be there to promote successful breastfeeding.
Supplementary feeds may be given to ensure adequate hydration, especially
if there is more than 10% weight loss from birth weight.
Interruption of breastfeeding in healthy term newborns is discouraged and
frequent breast-feeding (at least 8-10 times/24 hours) should be continued.
Supplementing with water or dextrose water does not lower bilirubin level.
G6PD status should be known before discharge. Observe infants with G6PD
deficiency, for 5 days if not jaundiced and longer with moderate jaundice.
Infants of mothers with blood group O and with a sibling who had severe
neonatal jaundice should be observed for at least the first 24 hours of life.
If phototherapy in infants with hemolytic diseases is initiated early and
discontinued before the infant is 3 - 4 days old, monitor for rebound jaundice
and adequacy of breast feeding within the next 24-48 hours.
Follow-up
All infants discharged < 48 hours after birth should be seen by a healthcare
professional in an ambulatory setting, or at home within 2-3 days of discharge.
For infants with risk factors for severe neonatal jaundice, early follow up to
be arranged to detect rebound jaundice after discharge.
Infants with serum bilirubin > 20 mg/dl (340 mol/L) and those who require
exchange transfusion should be followed for neurodevelopmental outcome.
Do a Hearing assessment (using BAER, not OAE) at 0-3 months of corrected age.
Infants with hemolytic diseases not requiring ET should be closely followed
up for anaemia until the risk of ongoing hemolysis is minimal.
115
NEONATOLOGY
Additional Notes
Failure of phototherapy has been defined as an inability to observe a decline
in bilirubin of 1-2 mg/dl (17-34 mol/L) after 4-6 hours and/or to keep the
bilirubin below the exchange transfusion level.
Do an immediate exchange transfusion if infant shows signs of acute
bilirubin encephalopathy (hypertonia, retrocollis, opisthotonus, fever, high
pitch cry) or if TSB is 5 mg/dL (85 umol/L) above exchange levels stated above.
Use total bilirubin level. Do not subtract direct or conjugated bilirubin.
During birth hospitalisation, ET is recommended if the TSB rises to these
levels despite intensive phototherapy.
Infants who are of lower gestation will require phototherapy and ET at lower
levels, (please check with your specialist).
NEONATALOGY
Agents to be avoided in Infants with G6PD Deficiency

Foods and Herbs to be avoided
Fava Beans (Kacang Parang)
Chinese herbs/medicine: Chuen Lin, San Chi, 13 herbs, 12 herbs
Avoid Other traditional herbs/medications unless with medical advice
Other Chemicals to be avoided
Naphthalene (moth balls)
Mosquito coils and insect repellants which contains pyrethium
Drugs to be avoided or contraindicated
Acetanilide
Doxorubicin
Furazolidene
Methylene Blue
Nalidixic acid
Niridazole
Nitrofurantoin
Phenozopyridine
Promaquine
Sulfamethoxazole
Bactrim
Drugs that can be safely given in therapeutic doses
Paracetamol
Ascorbic Acid
Aspirin
Chloramphenicol
Chloroquine
Colchicine
Diphendramine
Isoniazid
Phenacetin
Phenylbutazone
Phenytoin
Probenecid
Procainamide
Pyrimethamine
Quinidine
Streptomycin
Sulfisoxazole
Trimethoprim
Tripelennamine
Vitamin K
Mefloquine
116
Chapter 21: Exchange Transfusion
Indications
Double volume exchange
Blood exchange transfusion to lower serum bilirubin level and reduce the
risk of brain damage associated with kernicterus.
Hyperammonimia
To remove bacterial toxins in septicaemia.
To correct life-threatening electrolyte and fluid disorders in acute renal failure.
Partial exchange transfusion
To correct polycythaemia with hyperviscosity.
To correct severe anaemia without hypovolaemia.
Preparation of infant
Signed Informed Consent from parent.
Ensure resuscitation equipment is ready and available.
Stabilise and maintain temperature, pulse and respiration.
Obtain peripheral venous access for maintenance IV fluids.
Proper gentle restraint.
Continue feeding the child; Omit only the LAST feed before ET.
If < 4 hours from last feed, empty gastric contents by NG aspiration before ET.
Type of Blood to be used
Rh isoimmunisation: ABO compatible, Rh negative blood.
Other conditions: Cross-match with baby and mothers blood.
In Emergencies if Blood type unkown (rarely): O Rh negative blood.
Procedure (Exchange Transfusion)
Volume to be exchanged is 2x the infants total blood volume (2x80mls/kg).
Use (preferably irradiated) Fresh Whole Blood preferably < 5 days old or
reconstituted Packed Red Blood Cells and FFP in a ratio of 3:1.
Connect baby to a cardiac monitor.
Take baseline observations (either via monitor or manually) and record down
on the Neonatal Exchange Blood Transfusion Sheet.
The following observations are recorded every 15 minutes:
apex beat, respiration, oxygen saturation.
Doctor performs the ET under aseptic technique using a gown and mask.
117
NEONATOLOGY
Introduction
Exchange transfusion (ET) is indicated for severe hyperbilirubinaemia.
Kernicterus has a 10% mortality and 70% long term morbidity.
Neonates with significant neonatal jaundice should be monitored closely and
treated with intensive phototherapy.
Mortality within 6 hours of ET ranged from zero death to 3 - 4 per 1000
exchanged term infants. Causes of death includes kernicterus itself,
necrotising enterocolitis, infection and procedure related events.
NEONATALOGY
Cannulate the umbilical vein to a depth of NOT > 5-7cm in a term infant
for catheter tip to be proximal to the portal sinus (for push-pull technique ET
through UVC). Refer to section on procedure for umbilical vein cannulation.
Aliquot for removal and replacement 5-6 mls/ kg (Not more than 5-8%
of blood volume) Maximum volume per cycle - 20 mls for term infants, not
to exceed 5 ml/kg for ill or preterm infants.
At the same time the nurse keeps a record of the amount of blood given or
withdrawn, and medications given (see below).
Isovolumetric or continuous technique
Indication: where UVC cannulation is not possible e.g. umbilical sepsis,
failed cannulation.
Blood is replaced as a continuous infusion into a large peripheral vein while
simlutaneously removing small amount blood from an arterial catheter at
regular intervals, matching the rate of the infusion closely
- e.g. in a 1.5 kg baby, total volume to be exchanged is 240 mls.
Delivering 120mls an hour allowing 10 ml of blood to be removed
every 5 mins for 2 hours.
Care and observation for good perfusion of the limb distal to the arterial
catheter should be performed as per arterial line care
Points to note
Pre-warm blood to body temperature using a water bath.
Avoid other methods, e.g. placing under radiant warmer, massaging between
hands or placing under running hot water, to minimise preprocedure
hemolysis of donor blood. Shake blood bag gently every 5-10 cycles to
prevent settling of red blood cells.
Rate of exchange: 3 -4 minutes per cycle (1 minute out, 1 minute in, 1-2
minute pause excluding time to discard blood and draw from blood bag).
Syringe should be held vertical during infusion in to prevent air embolism.
Total exchange duration should be 90-120 minutes utilising 30-35 cycles.
Begin the Exchange with an initial removal of blood, so that there is always a
deficit to avoid cardiac overload.
Routine administration of calcium gluconate is not recommended.
Remove the UVC after procedure unless a second ET is anticipated and there
was difficulty inserting the UVC.
Continue intensive phototherapy after the procedure.
Repeat ET may be required in 6 hours for infants with high rebound SB.
Feed after 4 hours if patient is well and a repeat ET not required.
If child is anemic (pre-exchange Hb <12 g/dL) give an extra aliquot volume of
blood (10 mls/kg) at the end of exchange at a rate of 5 mls/kg/hr after the ET.
If the infant is on any IV medication , to readminister the medication after ET.
118
Post ET Management
Maintain intensive phototherapy.
Monitor vital signs:
Hourly for 4 - 6 hours, and
4 hourly subsequently.
Monitor capillary blood sugar:
Hourly for 2 hours following ET.
Check serum Bilirubin:
4 - 6 hours after ET.
Portal, Splenic vein thrombosis (late)
Follow-up
Long term follow-up to monitor
hearing and neurodevelopmental
assessment.
Hyperkalemia
Haemodynamic problems
Overload cardiac failure
Hypovolaemic shock
Arrhythmia (catheter tip near sinus
node in right atrium)
Electrolyte/Metabolic disorders
Hypocalcemia
Hypoglycaemia or Hyperglycaemia
Partial Exchange Transfusion

To correct hyperviscosity due to polycythaemia.
Assuming whole blood volume is approximately 80 ml/kg
Volume exchanged (mL) = Blood volume x
(Initial PCV Desired PCV)

Initial PCV
To correct severe anemia without hypovolaemia

Packed Cell vol (ml)
required
= 80 ml x Bwt(kg) x
[Desired Hb Initial Hb]

22g/dL Hbw
Where Hbw is reflection of the Hb removed during partial exchange transfusion:

Hbw = [Hb desired + Hb initial]/2
119
NEONATOLOGY
Investigations
Pre-exchange (1st volume of blood removed)
Serum Bilirubin.
FBC.
Blood C&S (via peripheral venous blood; UVC to reduce contamination).
HIV, Hepatitis B (baseline).
Complications of ET
Others as indicated.
Catheter related
Post-exchange
(Discard initial blood remaining in
Infection
UVC before sampling)
Haemorrhage
Serum Bilirubin.
FBC.
Necrotising enterocolitis
Capillary blood sugar.
Air embolism
Serum electrolytes and Calcium.
Others as indicated.
Vascular events
120
NEONATALOGY
Chapter 22: Prolonged Jaundice in Newborn Infants
Causes of Prolonged Jaundice

Unconjugated Hyperbilirubinaemia
Conjugated Hyperbilirubinaemia
Septicaemia
Biliary tree abnormalities:
Urinary tract infection
Biliary atresia - extra, intra-hepatic
Breast milk jaundice
Choledochal cyst
Hypothyroidism
Paucity of bile ducts
Hemolysis:
Alagille syndrome, non-syndromic
G6PD deficiency
Idiopathic neonatal hepatitis syndrome
Congenital spherocytosis
Septicaemia
Galactosaemia
Gilbert syndrome
Congenital infection (TORCHES)

Metabolic disorders
Citrin deficiency
Galactosaemia
Progressive familial intrahepatic
cholestasis (PFIC)
Alpha-1 antitrypsin deficiency
Total Parenteral Nutrition
The early diagnosis and treatment of biliary atresia and hypothyroidism is important for favourable long-term outcome of the patient.
Unconjugated hyperbilirubinaemia
Admit if infant is unwell. Otherwise follow-up until jaundice resolves.
Important investigations: Thyroid function, urine FEME and C&S, urine for
reducing sugar, FBC, reticulocyte count, peripheral blood film, G6PD screening.
Exclude urinary tract infection and hypothyroidism.
Congenital hypothyroidism is a Neonatal Emergency. (Check Screening TSH
result if done at birth). See Ch 54 Congenital Hypothyroidism.
Where indicated, investigate for galactosaemia
Breast milk Jaundice is a diagnosis of exclusion. Infant must be well, gaining
weight appropriately, breast-feeds well and stool is yellow. Management is
to continue breast-feeding.
121
NEONATOLOGY
Definition
Visible jaundice (or serum bilirubin SB >85 mol/L) that persists beyond 14
days of life in a term infant or 21 days in a preterm infant.
NEONATALOGY
Conjugated hyperbilirubinaemia
Defined as conjugated bilirubin > 25 mol/dL.
Investigate for biliary atresia and neonatal hepatitis syndrome.
Other tests : LFT, coagulation profile, lipid profile, Hepatitis B and C virus
status, TORCHES, VDRL tests, alpha-1 antitrypsin level.
Admit and observe stool colour, for 3 consecutive days. If pale, biliary atresia
is a high possibility: consider an urgent referral to Paediatric Surgery.
Other helpful investigations are:
Serum gamma glutamyl transpeptidase (GGT) Good discriminating test
between non obstructive and obstructive causes of neonatal hepatitis.
A significantly elevated GGT (few hundreds) with a pale stool strongly
favours biliary obstruction whereas, a low/normal GGT with significant
cholestasis suggests non obstructive causes of neonatal hepatitis.
Ultrasound of liver Must be done after at least 4 hours of fasting.
Dilated intrahepatic bile ducts (poor sensitivity for biliary atresia) and an
absent, small or contracted gall bladder even without dilated intrahepatic
ducts is highly suspicious of extra hepatic biliary atresia in combination
with elevated GGT and pale stool. A normal gall bladder usually excludes
biliary atresia BUT if in the presence of elevated GGT and pale stool, biliary
atresia is still a possibility. An experience sonographer would be able to
pick up Choledochal Cyst, another important cause of cholestasis.
Biliary atresia
Biliary atresia can be treated successfully by the Kasai Procedure.
This procedure must be performed within the first 2 months of life.
With early diagnosis and biliary drainage through a Kasai procedure by
4-6 weeks of age, successful long-term biliary drainage is achieved in >80%
of children. In later surgery good bile flow is achieved only in 20-30%.
Liver transplantation is indicated if there is failure to achieve or maintain bile
drainage.
Further investigations
Aim to exclude other (especially treatable) causes of a Neonatal Hepatitis
Syndrome early which include:
Metabolic causes (see also Ch 88 Inborn Errors of Metabolism)
Classical Galactosaemia
Dried blood spots for total blood galactose and galactose-1-uridyl
transferase level (GALT). Usually sent in combination with acylcarnitine
profile in a single filter paper to IMR biochemistry.
Urine reducing sugar may be positive in infants who are on lactose
containing formula or breastfeeding.
A recent blood transfusion will affect GALT assay accuracy (false negative)
but not so much on the total blood galactose and urine reducing sugar.
Treatable with lactose free formula.
122
123
NEONATOLOGY
Citrin deficiency
An important treatable cause of neonatal hepatitis among Asians.
Investigations MAY yield elevated total blood galactose but normal
galactose-1-uridyl transferase (GALT) (i.e. secondary Galactosemia).
Elevated plasma citrulline (in plasma amino acids & acylcarnitine profile).
Treatable with lactose free formula with medium chain triglyceride (MCT)
supplementation.
Note: Use lithium heparin container to send plasma amino acids.
Tyrosinaemia type I
Treatable with NTBC (2-(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexanedione).
Urine organic acids specifically looking for presence of succinylacetone is
highly specific. Take particular attention of sending urine organic acids
frozen and protected from light (i.e. covered plain urine container) to
maintain the accuracy of the test.
Neonatal Haemochromatosis
This needs to be excluded in infants presenting with liver failure within
first weeks of life.
Significantly elevated serum ferritin (few thousands) is characteristic.
Diagnosis is confirmed by presence of iron deposits in extra hepatic tissue,
e.g. lip tissue (iron deposits in minor salivary glands). Lip biopsy can be
safely performed even in severely coagulopathic infants where liver biopsy
is contraindicated.
Treatment with combination of immunoglobulins, desferral and antioxidant cocktails is potentially life saving (avoid liver transplant which at
present not an option for neonatal onset liver failure).
Antenatal intravenous immunoglobulin prevents recurrence in subsequent
children.
Primary bile acid synthesis disorder
Suspect if cholestasis, low GGT and low cholesterol.
Serum bile acids is a good screening tool (ensure patient is not on
ursodeoxycholic acid < 1 week prior to sampling).
Definite diagnosis requires urine bile acids analysis (available at specialized
laboratory in UK).
Treatment with cholic acid (not ursodeoxycholic acid) confers excellent
outcome on all subtypes.
Peroxisomal biogenesis disorders
Cholestasis may be part of the manifestation.
Plasma very long chain fatty acids (VLCFA) is elevated.
Mitochondrial depletion syndrome
Suspect in presence of other neurological signs e.g. rotatory nystagmus,
hypotonia and elevated blood lactate. Metabolic/genetic consult for
further diagnostic evaluation.
NEONATALOGY
Infective causes
Septicaemia
Herpes simplex virus infection
Consider in infants with liver failure within first few weeks of life.
IV Acyclovir therapy while waiting for Herpes IgM results in affected
infants may be justified.
Hepatitis B virus infection
Can potentially present as early infantile liver failure but incidence is rare.
Presence of positive Hepatitis B surface antigen, positive Hepatitis B virus
envelope antigen and high viral load confirms the diagnosis.
Alagille syndrome
Consider in infants who have cardiac murmurs or dysmorphism.
One of the parents is usually affected (AD inheritance, variable penetrance)
Affected infants might not have typical dysmorphic features at birth due to
evolving nature of the syndrome.
Important screening tests include :
Slit eye lamp examination: look for posterior embryotoxon.
May also help to rule out other aetiologies in neonatal hepatitis syndrome,
e.g. retinitis in congenital infection, cataract in galactosaemia.
Vertebral x ray: To look for butterfly vertebrae.
Echocardiography: look for branched pulmonary artery stenosis.
Other known abnormalities - ASD, valvular pulmonary stenosis.
Gene test: JAG1 gene mutation which can be done at IMR (EDTA container)
(Consult Geneticist Prior to Testing)
Idiopathic Neonatal Hepatitis Syndrome
Follow up with LFT fortnightly.
Watch out for liver failure and bleeding tendency (vitamin K deficiency).
Repeat Hepatitis B and C virus screening at 6 weeks.
Most infants with idiopathic neonatal hepatitis in the absence of physical
signs of chronic liver disease usually make a complete recovery.
124
Chapter 23: Apnoea in the Newborn
Classification
Types:
Central: absence of respiratory effort with no gas flow and no evidence of
obstruction.
Obstructive: continued ineffective respiratory effort with no gas flow
Mixed central and obstructive: most common type
Aetiology
Symptomatic of underlying problems, commoner ones of which are:
Respiratory conditions (RDS, pulmonary haemorrhage, pneumothorax,
upper airway obstruction, respiratory depression due to drugs).
Sepsis
Hypoxaemia
Hypothermia
CNS abnormality (e.g. IVH, asphyxia, increased ICP, seizures)
Metabolic disturbances (hypoglycaemia, hyponatraemia, hypocalcaemia)
Cardiac failure, congenital heart disease, anaemia
Aspiration/ Gastro-oesophageal reflux
Necrotising ennterocolitis, Abdominal distension
Vagal reflex: Nasogastric tube insertion, suctioning, feeding
Differentiate from Periodic breathing
Regular sequence of respiratory pauses of 10-20 sec interspersed with
periods of hyperventilation (4-15 sec) and occurring at least 3x/ minute,
not associated with cyanosis or bradycardia.
Benign respiratory pattern for which no treatment is required.
Respiratory pauses appear self-limited, and ventilation continues cyclically.
Periodic breathing typically does not occur in neonates in the first 2 days of life
125
NEONATOLOGY
Definition
Apnea of prematurity is defined as sudden cessation of breathing that lasts
for at least 20 seconds or is accompanied by bradycardia or oxygen
desaturation (cyanosis) in an infant younger than 37 weeks gestational age.
It usually ceases by 43 weeks postmenstrual age but may persist for several
weeks beyond term, especially in infants born before 28 weeks gestation
with this risk decreasing with time.
NEONATALOGY
Management
Immediate resuscitation.
Surface stimulation
(Flick soles, touch baby)
Gentle nasopharyngeal suction
(Be careful: may prolong apnoea)
Ventilate with bag and mask on previous FiO2.
Be careful not to use supplementary oxygen if infant has been in air
as childs lungs are likely normal and a high PaO2 may result in ROP
Intubate, IPPV if child cyanosed or apnoea is recurrent/persistent
Try CPAP in the milder cases
Review possible causes (as above) and institute specific therapy,
e.g. septic workup if sepsis suspected and commence antibiotics
Remember to check blood glucose via glucometer.
Management to prevent recurrence.
Nurse baby in thermoneutral environment.
Nursing prone can improve thoraco-abdominal wall synchrony and reduce
apnoea.
Variable flow NCPAP or synchronised NIPPV can reduce work of breathing
and reduce risk of apnoea.
Monitoring:
- Pulse Oximeter
- Cardio-respiratory monitor
Drug therapy
- Methylxanthine compounds:
- Caffeine citrate (preferred if available)
- IV Aminophylline or Theophylline.
Start methylxanthines prophylactically for babies < 32 weeks gestation.
For those > 32 weeks of gestation, give methylxanthines if babies have apnoea.
To stop methylxanthines if :
gestation > 34 weeks
Apnoea free for 1 week when the patient is no longer on NCPAP
Monitor for at least 1 week once the methylxanthines are stopped.
After discharge , parents should be given advice for prevention of SIDS:
Supine sleep position.
Safe sleeping environments.
Elimination of prenatal and postnatal exposure to tobacco smoke.
126
Chapter 24: Neonatal Sepsis
Clinical Features
Risk Factors of Infants and Mother
Any stage
Prematurity, low birth weight.
Male gender.
Neutropenia due to other causes.
Early Onset Sepsis
Maternal GBS (Group B Streptococcus) carrier (high vaginal swab [HVS],
urine culture, previous pregnancy of baby with GBS sepsis).
Prolonged rupture of membranes (PROM) (>18 hours).
Preterm labour/PPROM.
Maternal pyrexia > 38 C, maternal peripartum infection, clinical
chorioamnionitis, discoloured or foul-smelling liquor, maternal urinary
tract infection.
Septic or traumatic delivery, fetal hypoxia.
Infant with galactosaemia (increased susceptibility to E. coli).
Late Onset Sepsis
Hospital acquired (nosocomial) sepsis.
- Overcrowded nursery.
- Poor hand hygiene.
- Central lines, peripheral venous catheters, umbilical catheters.
- Mechanical ventilation.
- Association with indomethacin for closure of PDA, IV lipid administration
with coagulase-negative Staphylococcal (CoNS) bacteriemia.
Colonization of patients by certain organisms.
Infection from family members or contacts.
Cultural practices, housing and socioeconomic status.
Signs and symptoms of Sepsis
Temperature instability: hypo or hyperthermia
Change in behaviour : lethargy, irritability or change in tone
(baby just doesnt seem right or doesnt look well)
Skin: poor perfusion, mottling, pallor, jaundice, scleraema, petechiae
Feeding problems: poor feeding, vomiting, diarrhea, abdominal distension
Cardiovascular: tachycardia, hypotension,
Respiratory: apnoea, tachypnoea,cyanosis, respiratory distress,
Metabolic: hypo or hyperglycaemia, metabolic acidosis
Evaluate neonate (late onset sepsis) carefully for primary or secondary foci,
e.g. meningitis, pneumonia, urinary tract infection, septic arthritis,
osteomyelitis, peritonitis, omphalitis or soft tissue infection.
127
NEONATOLOGY
Definition
Neonatal sepsis generally falls into two main categories:
Early onset: usually acquired from mother with 1 obstetric complications.
Late onset: sepsis occurring > 72hours after birth.
Usually acquired from the ward environment or from the community.
NEONATALOGY
Investigations
FBC: Hb, TWBC with differential, platelets, Blood culture (>1ml of blood).
Where available :
Serial CRP 24 hours apart
Ratio of immature forms over total of neutrophils + immature forms:
IT ratio > 0.2 is an early predictor of infection during first 2 weeks of life.
Where indicated:
Lumbar puncture, CXR, AXR, Urine Culture.
Culture of ETT aspirate (Cultures of the trachea do not predict the
causative organism in the blood of the neonate with clinical sepsis.)
Management
Empirical antibiotics
Start immediately when diagnosis is suspected and after all appropriate
specimens taken. Do not wait for culture results.
Trace culture results after 48 - 72 hours. Adjust antibiotics according to
results. Stop antibiotics if cultures are sterile, infection is clinically unlikely.
Empirical antibiotic treatment (Early Onset)
IV C.Penicillin/Ampicillin and Gentamicin
Specific choice when specific organisms suspected/confirmed.
Change antibiotics according to culture and sensitivity results
Empirical antibiotic treatment (Late Onset)
For community acquired infection, start on
- Cloxacillin/Ampicillin and Gentamicin for non-CNS infection, and
- C.Penicillin and Cefotaxime for CNS infection
For hospital acquired (nosocomial) sepsis
- Choice depends on prevalent organisms in the nursery and its sensitivity.
- For nursery where MRCoNS/ MRSA are common, consider Vancomycin;
for non-ESBL gram negative rods, consider cephalosporin; for ESBLs
consider carbapenams; for Pseudomonas consider Ceftazidime.
- Anaerobic infections (e.g. Intraabdominal sepsis), consider Metronidazole.
- Consider fungal sepsis if patient not responding to antibiotics
especially if preterm/ VLBW or with indwelling long lines.
Duration of Antibiotics
7-10 days for pneumonia or proven neonatal sepsis
14 days for GBS meningitis
At least 21 days for Gram-negative meningitis
Consider removing central lines
Complications and Supportive Therapy
Respiratory: ensure adequate oxygenation (give oxygen, ventilator support)
Cardiovascular: support BP and perfusion to prevent shock.
Hematological: monitor for DIVC
CNS: seizure control and monitor for SIADH
Metabolic: look for hypo/hyperglycaemia, electrolyte, acid-base disorder
Therapy with IV immune globulin had no effect on the outcomes of
suspected or proven neonatal sepsis.
128
129
30 days prior delivery and no

possibility of reinfection, and
High likelihood of reinfection
Treated but no documented 4

fold decrease in VDRL/RPR titre
Treatment not completed 30 days

before delivery
YES
Treatment with non-penicillin

regime
No or inadequate treatment
Presence of any one risk below:
NO
Baby has normal physical examination

regardless of non treponemal test result
*Consider LP after discussion with specialist.
Other tests, as clinically indicated

(long-bone x-ray, CXR, LFT, cranial ultrasound, ophthalmologic examination and
auditory brainstem response)
Do FBC and CSF analysis for VDRL, cell

count and protein
Baby has evidence of congenital syphilis3
Do FBC and CSF analysis2 for VDRL,

cell count and protein
VDRL/RPR 4-fold maternal titre
With adequate penicillin regime
With documented 4-fold drop in

VDRL/RPR titre
< 4-fold maternal titre
Mother completed treatment:
YES
Not infected
NOT
DETECTED
VDRL/RPR1 titre negative, or
DETECTED
Maternal TPHA
Note: If > 1 day of treatment is missed,

the entire course shoudl be restarted.
VDRL/TPHA at follow up at
3 and 6 months old
Refer parents to STD Clinic
Notification
IM Procaine Penicillin G 50,000u/kg/dose

daily for 10 14 days
IV C Penicillin G 50,000u/kg/dose BD
for first 7 days then TDS
- for 10 days if CSF normal
- 14 days if CSF abnormal, OR
If risk of defaulting follow-up:

Option to give single dose of
IM Benzathine Penicillin G 50,000 units/kg
Do VDRL/RPR titre monthly:

treat if increasing trend.
No treatment
Guidelines for Management of Infants with Congenital Syphilis
NEONATOLOGY
Maternal VDRL/RPR Reactive
Chapter 25: Congenital Syphilis
NEONATALOGY
Footnotes to algorithm on previous page:

1. VDRL/RPR test on venous blood sample as umbilical cord may be
contaminated with maternal blood and could yield a false-positive result.
2. Clinical features of congenital syphilis: non-immune hydrops, IUGR, jaundice,
hepatosplenomegaly, rhinitis, skin rash, pseudoparalysis of extremity.
3. Recommended value of 5 WBCs/mm3 and protein of 40mg/dL as the upper
limits of normal for non traumatic tap.
Follow up of patients
All sero-reactive infants should receive careful follow up examination and
serologic testing (VDRL/RPR) every 2-3 month until the test becomes nonreactive or the titre has decreased 4-fold.
VDRL/RPR titre should decline by age of 3 month and should be
non-reactive by age of 6 month if the infants was not infected or was
infected but adequately treated.
If the VDRL/RPR titre are stable or increase after 6-12 month, the child
should be evaluated and treated with a 10-day course of parenteral
Penicillin G.
For infants whose initial CSF evaluations are abnormal should undergo a
repeat lumbar puncture in 6 months. A reactive CSF VDRL test or abnormal
CSF indices that cannot be attributed to other ongoing illness required
re-treatment for possible neurosyphilis. If CSF is improving, monitor with
follow-up serology.
Additional Notes:
Tetracycline, doxycycline or erythromycin does not have an established and
well-evaluated high rate of success as injection penicillin in the treatment of
syphilis.
Penetration of tetracycline, doxycycline and erythromycin into CSF is poor.
130
Chapter 26: Ophthalmia Neonatorum
Diagnosis
Essentially a clinical diagnosis
Laboratory diagnosis to determine aetiology
Eye swab for Gram stain (fresh specimen to reach laboratory in 30 mins)
Gram stain of intracellular gram negative diplococci - high sensitivity and
specificity for Neisseria gonorrhoea.
Eye swab for culture and sensitivity.
Conjunctival scrapping for indirect fluorescent antibody identification for
Chlamydia.
Aetiology
Bacterial
Gonococcal
Most important bacteria by its potential to damage vision.
Bilateral purulent conjunctival discharge within first few days of life.
Treatment:
Systemic:
- Ceftriaxone 25-50mg/kg (max. 125mg) IV or IM single dose. or
- Cefotaxime 100 mg/kg IV or IM single dose.
(preferred if premature or hyperbilirubinaemia present)
Disseminated infections :
- Ceftriaxone 25-50mg/kg/day IV or IM in single daily dose for 7days, or
- Cefotaxime 25mg/kg/dose every 12 hours for 7 days.
Documented meningitis : 10-14 days
Local: Irrigate eyes with sterile normal saline initially every 15 mins and
then at least hourly as long as necessary to eliminate discharge. Frequency
can be reduced as discharge decreases. Topical antibiotics optional.
Non- Gonococcal
Includes Coagulase negative staphylococci, Staphylococcus aureus,
Streptococcus viridans, Haemophilus, E.coli, Klebsiella species and
Pseudomonas. Most are hospital acquired conjuctivitis.
Treatment:
Local: Chloramphenicol, gentamicin eye ointment 0.5%, both eyes
(Change according to sensitivity ,duration according to response), or
In non- responsive cases refer to ophthalmologist and consider
Fucithalmic, Ceftazidime 5% ointment bd to qid for a week.
Eye toilet (refer as above).
131
NEONATOLOGY
Definition
Conjunctivitis occurring in newborn during 1st 4 weeks of life with clinical signs
of erythema and oedema of the eyelids and palpebral conjunctivae, purulent
eye discharge with one or more polymorph nuclear per oil immersion field on a
Gram stained conjunctival smear.
NEONATALOGY
Chlamydial
Replaced N. gonorrhoea as most common aetiology associated with sexually
transmitted infections (STI).
Unilateral or bilateral conjunctivitis with peak incidence at 2 weeks of life
Treatment:
Erythromycin 50mg/kg/d in 4 divided doses for 2 weeks
Caution - association with hypertrophic pyloric stenosis
May need to repeat course of erythromycin for further 2 weeks if poor
response as elimination after first course ranges from 80-100%
If subsequent failure of treatment, use Trimethoprim-sulfamethazole
0.5ml/kg/d in 2 doses for 2 wks (Dilution 200mg SMZ /40mg TM in 5 mls).
Systemic treatment is essential. Local treatment may be unnecessary if
systemic treatment is given.
Herpes simplex virus
Herpes simplex keratoconjunctivitis usually presents with generalized
infection with skin, eyes and mucosal involvement.
May have vesicles around the eye and corneal involvement
Systemic treatment
IV acyclovir 30mg/kg/d divided tds for 2 weeks.
Important Notes
Refer patients to an ophthalmologist for assessment.
Ophthalmia neonatorum (all forms) is a notifiable disease
Check VDRL of the infant to exclude associated congenital syphilis and screen
for C. trachomatis and HIV.
Screen both parents for Gonococcal infections, syphilis and HIV.
Parents should be referred to STD clinic for further management.
On discharge, infants should be seen in 2 weeks with a repeat eye swab gram
stain and C&S.
132
Chapter 27: Patent Ductus Arteriosus in the Preterm
Clinical Features
Wide pulse pressure/ bounding pulses
Systolic or continuous murmur
Tachycardia
Lifting of xiphisternum with heart beat
Hyperactive precordium
Apnoea
Increase in ventilatory requirements
Complications
Congestive cardiac failure
Intraventricular haemorrhage (IVH)
Pulmonary haemorrhage
Renal impairment
Necrotising enterocolitis
Management
Confirm PDA with cardiac ECHO if available
Medical
Fluid restriction. Care with fluid balance to avoid dehydration
No role for diuretics
IV or oral Indomethacin 0.2mg/kg/day daily dose for 3 days
or
IV or oral Ibuprofen 10mg/kg first dose, 5mg/kg second and third doses,
administered by syringe pump over 15 minutes at 24 hour intervals.
Indomethacin or ibuprofen is contraindicated if
- Infant is proven or suspected to have infection that is untreated.
- Bleeding, especially active gastrointestinal or intracranial.
- Platelet count < 60 x 109/L
- NEC or suspected NEC
- Duct dependant congenital heart disease
- Impaired renal function: creatinine > 140 mol/L, blood urea >14 mmol/L.
Monitor urine output and renal function. If urine output < 0.6 ml/kg/hr
after a dose given, withhold next dose until output back to normal.
Monitor for GIT complications e.g. gastric bleeding, perforation.
Surgical ligation
Persistence of a symptomatic PDA and failed 2 courses of Indomethacin
If medical treatment fails or contraindicated
133
NEONATOLOGY
Introduction
Gestational age is the most important determinant of the incidence of patent
ductus arteriosus (PDA). The other risk factors for PDA are lack of antenatal
steroids, respiratory distress syndrome (RDS) and need for ventilation.
NEONATALOGY
In older preterm infant who is asymptomatic, i.e. only cardiac murmur

present in an otherwise well baby no treatment required. Follow-up as
necessary. Most PDA in this group will close spontaneously.
Pearls and Pitfalls in Management
There is a higher success rate in closure of PDA if indomethacin is given in
the first two weeks of life.
When using oral indomethacin, ensure that suspension is freshly prepared
and well mixed before serving.
IV indomethacin is unstable once the vial is opened.
134
Chapter 28: Persistent Pulmonary Hypertension of the Newborn
PPHN can be:

Idiopathic - 20%
Associated with a variety of lung diseases:
Meconium aspiration syndrome (50%)
Pneumonia/sepsis (20%)
RDS (5%)
Congenital diaphragmatic hernia (CDH)
Others: Asphyxia, Maternal diabetes, Polycythemia
Diagnosis
History
- Precipitating factors during antenatal, intrapartum, postnatal periods
Respiratory signs
- Signs of respiratory distress (tachypnoea, grunting, nasal flaring, chest
retractions)
- Onset at birth or within the first 4 to 8 hours of life
- Marked lability in pulse oximetry
Cardiac signs
- Central cyanosis (differential cyanosis between the upper and lower body
may be noted clinically, by pulse oximetry and blood gasses)
- Prominent praecordial impulse
- Low parasternal murmur of tricuspid incompetence
Radiography
- Lung fields
Normal, parenchymal lesions if lung disease is present, or oligaemia
- Cardiac shadow
Normal sized-heart, or cardiomegaly (usually right atrial or ventricular
enlargement).
Echocardiography - important to:
- Exclude congenital heart disease.
- Define pulmonary artery pressure using tricuspid incompetence, ductal
shunt velocities.
- Define the presence, degree, direction of shunt through the duct / foramen
ovale.
- Define the ventricular output.
The Hyperoxic test may play a role in diagnosis if 2D echocardiography is not
available. However, severe PPHN is likely to produce a similar result to
cyanotic CHD.
135
NEONATOLOGY
Definition
Persistent pulmonary hypertension (PPHN) of the newborn is defined as a
failure of normal pulmonary vasculature relaxation at or shortly after birth,
resulting in impedance to pulmonary blood flow which exceeds systemic
vascular resistance, such that unoxygenated blood is shunted to the systemic
circulation.
NEONATALOGY
In centres where there is a lack of readily available echocardiography and/or
Paediatric Cardiology services, the challenge is to differentiate PPHN from
Congenital Cyanotic Cardiac diseases.
Differentiating points between the two are:
Babies with congenital cyanotic heart diseases are seldom critically ill at
delivery.
Bradycardia is almost always due to hypoxia, not a primary cardiac problem
Infants with cyanotic lesions usually do not have respiratory distress.
Infants with PPHN usually had some perinatal hypoxia and handles poorly.
The cyanosed cardiac baby is usually pretty happy, but blue.
Management
General measures:
Preventing and treating
- Hypothermia
- Hypoglycaemia
- Hypocalcaemia
- Hypovolaemia
- Anaemia
Avoid excessive noise, discomfort and agitation.
Minimal handling
Sedation
Morphine given as an infusion at 10-20 mcg/kg/hr. Morphine is a safe
sedative and analgesic even in the preterm infants.
Midazolam not recommended for preterms < 34 weeks gestational age,
assocated with adverse long term neurodevelopmental outcomes.
Ventilation
Conventional ventilation adopt gentle ventilatory approach by
- Avoidance of hyperventilation (i.e. hypocarbia and hyperoxia).
Hypocarbia is associated with periventricular leukomalacia. Aim for a
PCO2 of 45-55mmHg.
Hyperoxia leads to chronic oxygen dependency and bronchopulmonary
dysplasia. Keep PO2 within normal limits of 60 -80 mmHg.
- Ventilating to achieve a tidal volume of 3 to 5mls/kg.
- Short inspiratory time (0.2-0.3 sec) to prevent alveolar overdistension
- Inadvertently increasing ventilatory settings may lead to overdistention
of the lungs and high mean airway pressures compromising venous
return to the heart which further aggravates systemic hypotension as
cardiac output is compromised.
High Frequency Oscillatory ventilation / High Frequency Jet Ventilation
Effective in newborns with PPHN secondary to a pulmonary pathology.
136
However, inotropes are still recommended in institutions without facilities

for iNO:

Dopamine 5 20 mcg/kg/min

Dobutamine 5 20 mcg/kg/min

Adrenaline 0.1 1.0 mcg/kg/min
Vasodilators
Inhaled nitric oxide (iNO)- selective pulmonary vasodilator.
- In term and near term infants (>34 weeks gestational age) reduces need
for Extra Corporeal Membrane Oxygenation (ECMO)(Dose: 5-20 ppm).
- insufficient evidence to support use in preterm infants < 34 weeks age.
Prostacycline and Sildenafil. These are not recommended for routine use
as their safety and efficacy had not been tested in large randomized trials.
Sildenafil in the treatment of PPHN has significant potential especially in
resource limited settings.
Extracorporeal membrane oxygenation (ECMO)
ECMO is effective in PPHN. It is expensive as it requires trained personnel,
specialized equipment and a good nursing-cot ratio.
Practices not recommended for routine use:
Sodium bicarbonate.
There is lack of sufficient evidence to recommend its routine use
Magnesium sulphate
Anecdotal efficacy in PPHN but not yet been tested in large randomized
trials to justify its use routinely.
Muscle relaxant agents
No evidence for use in PPHN. Use had been known to increase mortality
rates.
137
NEONATOLOGY
Circulatory support
Inotropes for circulatory support improve cardiac output and enhances
systemic oxygenation. Its use is poorly substantiated in PPHN, especially with
the use of inhaled nitric oxide (iNO), which through its pulmonary
vasodilating effect helps to improve cardiac output and the systemic blood
pressure. Aim to keep the mean arterial pressure > 50 mmHg in term infants.
138
NEONATALOGY
Chapter 29: Perinatally Acquired Varicella
139
NEONATOLOGY
Introduction
In maternal infection (onset of rash) within 5 days before and 2 days after
delivery 17-30% infants develop neonatal varicella with lesions appearing at
5-10 days of life.
Mortality is high (20%-50%), as these infants have not acquired maternal
protecting antibodies. Cause of death is due to severe pulmonary
disease or widespread necrotic lesions of viscera.
When maternal varicella occurs 5-21 days before delivery, lesions typically
appear in the first 4 days of life and prognosis is good with no associated
mortality. The mild course is probably due to the production and
transplacental passage of maternal antibodies that modify the course of
illness in new-borns.
Infants born to mothers who develop varicella between 7 days antenatally
and 14 days postnatally should receive as prophylaxis:
Varicella Zoster immunoglobulin (VZIG) as soon as possible within 96
hours of initial exposure (to reduce the occurrence of complications and
fatal outcomes). Attenuation of disease might still be achieved with
administration of VZIG up to 10 days.
If Zoster immunoglobulin is not available give IV Immunoglobulin
400 mg/kg ( this is less effective), AND
IV Acyclovir 15 mg/kg/dose over 1 hour every 8hrly (total 45 mg /kg/day)
for 5 days.
On sending home, warn parents to look out for new vesicles or baby being
unwell for 28 days after exposure. If so, parents to bring the infant to the
nearest hospital as soon as possible (62% of healthy such neonates given
VZIG after birth)
If vesicles develop to give IV Acyclovir 10-15 mg/kg/dose over 1 hour every
8hrly (total 30-45 mg /kg/day) for 7-10 days.
Women with varicella at time of delivery should be isolated from their
newborns, breast-feeding is contraindicated. Mother should express breast
milk in the mean time and commence breast-feeding when all the lesions
have crusted.
Neonates with varicella lesions should be isolated from other infants but
not from their mothers.
It has been generally accepted that passive immunization of the neonate
can modify the clinical course of neonatal varicella but it does not prevent
the disease and, although decreased, the risk of death is not completely
eliminated.
Infants whose mothers develop Zoster before or after delivery have
maternal antibodies and they will not need ZIG.
Recommend immunisation of family members who are not immune.
NEONATALOGY
Postnatal exposure to varicella in the hospital

Give VZIG within 96 hours to those who have been exposed if they fit the
following criteria:
All babies born at < 28 weeks gestation or who weighed < 1000g at birth
irrespective of maternal history of chickenpox.
All preterm babies born at 28 weeks gestation whose mothers have not
had chickenpox or whose status is unknown.
All immunocompromised patients, e.g. immunosuppressive therapy,
have malignant disease or are immunodeficient.
Isolate patient who has varicella infection and susceptible patients who have
been exposed to the virus. Treatment of symptomatic patients with acyclovir
as above.
Screen exposed, susceptible hospital staff for skin lesions, fever, headache
and systemic symptoms. They are potentially infective 10-21 days after
exposure and should be placed on sick leave immediately should any
symptoms or skin lesion arise. If possible they can also be reassigned during
the incubation period to areas where the patients are not as susceptible or
non-patient care areas.
Other notes
In hospitals, airborne transmission of VZV has been demonstrated when
varicella has occurred in susceptible persons who have had no direct contact
with the index case-patient.
Incubators are not positive pressure air flow & therefore do not provide
isolation. Neonates may not be protected given that they are frequently
open for nursing purposes.
All staff should preferably be screened and susceptible staff vaccinated for
varicella before commencing work in neonatal, oncology and ICU wards.
If not,they should receive post exposure vaccination as soon as possible
unless contraindications exist such as pregnancy. VZIG is an option for
exposed susceptible pregnant staff to prevent complications in the mother
rather than to protect the foetus.
The use of VZIG following exposure does not necessarily prevent varicella
and may prolong the incubation period by > 1 week and hence signs or
symptoms should be observed for 28 days post exposure.
VZIG is not presently recommended for healthy full term infants who are
exposed postnatally, even if their mothers have no history of varicella
infection. To emphasise to parents to bring back early for treatment with
acyclovir if any skin lesion appear within the next 3 weeks.
140
141
NEONATOLOGY
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minibolus and intravenous glucose infusion. J Pediatr. 1980;97:295-98
6. McGowan J.E. Neonatal hypoglycemia. Pediatrics in Review 1999;20;e6
7. Miralles R.E., Lodha A, Perlman M, Moore A.m., Experience with IV
Glucagon infusions as a treatment for resistant neonatal hypoglycaemia.
Arch Pediatr Adolesc Med. 2002;156:999-1004
8. Collins JE, Leonard JV, Teale D, Marks V, Williams DM, Kennedy CR, Hall
MA. Hyperinsulinaemic hypoglycaemia in small for dates babies. Arch Dis
Child 1990; 65: 1118-20
144
Chapter 21 Exchange Transfusion

1.Ip S, Chung M, Kulig J et al. An evidence-based review of important issues
concerning neonatal hyperbilirubinemia. Pediatrics:113(6) www.pediatrics.
org/cgi/content/full/113/6/e644.
2.AAP Subcommittee on hyperbilirubinemia. Clinical Practice Guideline:
Management of hyperbilirubinemia in the newborn infant 35 or more
weeks of gestation. Pediatrics 2004; 114 (1): 297-316.
3.Murki S, Kumar P. Blood exchange transfusion for infants with severe neonatal hyperbilurubinaemia. Seminars in Perinatology. 2011. 35:175-184
4.Steiner LA, Bizzaro MJ, Ehrenkranz RA, Gallagher PG. A decline in the
frequency of neonatal exchange transfusions and its effect on exchangerelated morbidity and mortality. Pediatrics 2007; 120 (1): 27-32.
5.Narang A, Gathwala G, Kumar P. Neonatal jaundice: an analysis of 551
cases. Indian Pediatr 1997: 34: 429 432.
6.Madan A, Mac Mohan JR, Stevenson DK.Neonatal Hyperbilrubinemia. In
Averys Diseases of the Newborn. Eds: Taeush HW, Ballard RA, Gleason CA.
8th edn; WB Saunders., Philadelphia, 2005: pp 1226-56.
Chapter 22 Prolonged Jaundice
2.Winfield CR, MacFaul R. Clinical study of prolonged jaundice in breast and
bottle-fed babies. Arch Dis Child 1978;53:506-7.
3.NICE clinical guidelines for neonatal jaundice. RCOG, UK. May 2010.
145
NEONATOLOGY
Chapter 20 Neonatal Jaundice

1.Integrated Plan for Detection and Management of Neonatal Jaundice,
Ministry of Health, 2009
2.Guideline on Screening and Management of NNJ with Special Emphasis on
G6PD Deficiency, MOH 1998
3.American Academy of Paediatrics . Provisonal Committee for Quality Improvement and Subcommittee on Hyperbilrubinemia. Practice Parameter:
management of hyperbilirubinemia in the healthy term newborn. Pediatrics, 2004. 114:297-316
4.Gartner LM, Herschel M. Jaundice and breast-feeding. Pediatr Clin North
Am 2001;48:389-99.
5.Maisels MJ, Baltz RD, Bhutani V, et al. AAP Guidelines -Management of
hyperbilirubinemia in the newborn infant 35 or more weeks of gestation.
Pediatrics. 2004;114 :297 316.
7.NICE clinical guidelines on Neonatal jaundice. RCOG, UK. May 2010
NEONATALOGY
Chapter 23 Apnoea in the Newborn

1.Apnea, Sudden Infant Death Syndrome, and Home Monitoring Committee
on Fetus and Newborn; Pediatrics Vol. 111 No. 4 April 2003, pp. 914-917
2.William J. R. et al , Apnes in Premature Infants: Monitoring, Incidence,
Heart Rate changes, and an Effects of Environmental Temperature;. Pediatrics Vol. 43 No. 4 April 1, 1969 pp. 510 -518
3.Eric C. et al, Apnea Frequently Persists Beyond Term Gestation in Infants
Delivered at 24 to 28 Weeks; Pediatrics Vol. 100 No. 3 September 1, 1997
pp. 354 -359
4.Hoffman HJ, Damus K, Hillman L, Krongrad E. Risk factors for SIDS.Results
of the National Institute of Child Health and Human Development SIDS
Cooperative Epidemiological Study. Ann N Y Acad Sci.1988;533:1330
5.Bhat RY, Hannam S, Pressler R et al (2006) Effect of prone and supine
position on sleep, apneas, and arousal in preterm infants. Pediatrics
118(1):101107
6.Pantalitschka T, Sievers J, Urschitz MS et al (2009) Randomized crossover
trial of four nasal respiratory support systems on apnoea of prematurity in
very low birth weight infants. Arch Dis Child Fetal Neonatal Ed 94(4):245
248
7.American Academy of Pediatrics: Committee on Fetus and Newborn: Apnea, Sudden Infant Death Syndrome, and Home Monitoring. Pediatrics,Vol.
111 No. 4 April 2003.
Chapter 24 Neonatal Sepsis
1. R.C. Roberton. Textbook of Neonatology. Churchill Livingstone
2.Ohlsson A, Lacy JB. Intravenous immunoglobulin for suspected or subsequently proven infection in neonates. The Cochrane Library 2007; Issue 4
3.D Isaacs. Unnatural selection: reducing antibiotic resistance in neonatal
units Arch. Dis. Child. Fetal Neonatal Ed., January 1, 2006; 91(1): F72 - F74.
4.U K Mishra, S E Jacobs, L W Doyle, and S M Garland. Newer approaches to
the diagnosis of early onset neonatal sepsis. Arch. Dis. Child. Fetal Neonatal Ed., May 1, 2006; 91(3): F208 - F212.
5. S Vergnano, M Sharland, P Kazembe, C Mwansambo, and P T Heath
Neonatal sepsis: an international perspective. Arch. Dis. Child. Fetal
Neonatal Ed., May 1, 2005; 90(3): F220 - f224.
6. Remington and KleinTextbook of Infectious Diseases of the Fetus and
Newborn Infant. 6th Edition
7. Treatment of of Neonatal Sepsis with Intravenous Immune Globulin. The
INIS Collaborative Group N Engl J Med 2011: 365:1201-1211.
146
Chapter 27 Patent Ductus Arteriosus in the Preterm

1.Raval M, Laughon M, Bose C, Phillips J. Patent ductus arteriosus ligation in
premature infants: who really benefits, and at what cost? J Pediatr Surg
2007; 42:69-75
2.Patent ductus arteriosus. Royal Prince Alfred Hospital Department of Neonatal Medicine Protocol Book, 2001
3.Knight D. The treatment of patent ductus arteriosus in preterm infants. A
review and overview ofrandomized trials. Sem Neonatol 2000;6:63-74
4.Cooke L, Steer P, Woodgate P. Indomethacin for asymptomatic patent ductus
arteriosus in preterm infants. Cochrane databse of systematic reviews 2003
5.Brion LP, Campbell, DE. Furosemide for prevention of morbidity in indomethacin-treated infants with patent ductus arteriosus. Cochrane database of
systematic reviews 2001.
6.Herrera CM, Holberton JR, Davis PG. Prolonged versus short course of indomethacin for the treatment of patent ductus arteriosus in preterm infants.
Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD003480.
DOI: 10.1002/14651858.CD003480.pub3. Most recent review 2009.
7.Shannon E.G. Hamrick and Georg Hansmann. Patent Ductus Arteriosus of the
Preterm Infant. Pediatrics 2010;125;1020-1030
147
NEONATOLOGY
Chapter 25 Congenital Syphilis

1.Centers for Disease Control. Sexually transmitted diseases treatment guidelines, 2010. MMWR 2010;59(No. RR-12).
2.Centers for Disease Control Northern Territory. Guidelines for the investigation and treatment of infants at risk of congenital syphilis in the Northern
Territory, 2005.
Chapter 26 Ophthalmia Neonatorum
1.Fransen L, Klauss V. Neonatal ophthalmia in the developing world. Epidemiology, etiology, management and control. Int Ophthalmol. 1988;11(3):189-96
2.PS Mallika et al. Neonatal Conjunctivitis- A Review. Malaysian Family Physician 2008; Volume 3, Number 2
3.MMWR Recomm Rep 2010; 59 (RR12): 53-55. Sexually Transmitted Diseases
Treatment Guidelines, 2010.
4.Palafox et al. Ophthalmia Neonatorum. J Clinic Exp Ophthalmol 2011, 2:1
5.Input from Dr Joseph Alagaratnam, Consultant Opthalmologist HKL , is
acknowledged.
NEONATALOGY
Ch 28 Persistent pulmonary hypertension of the newborn

1.Abman SH. Neonatal pulmonary hypertension: a physiologic approach to
treatment. Pediatr Pulmonol 2004;37 (suppl 26):127-8
2.Ng E, Taddio A, Ohlsson A. Intravenous midazolam infusion for sedation of
infants in the neonatal intensive care unit. Cochrane Database of Systematic
Reviews 2003, Issue 1. Art. No.: CD002052.
3.Keszler M, Abubakar K. Volume Guarantee: Stability of Tidal Volume and
Incidence of Hypocarbia. Pediatr Pulmonol 2004;38:240-245
4.Finer NN, Barrington KJ. Nitric oxide for respiratory failure in infants born at
or near term. Cochrane Database of Systematic Reviews 2006, Issue 4. Art.
No.: CD000399.
5.Shah PS, Ohlsson A. Sildenafil for pulmonary hypertension in neonates.
Cochrane Database Syst Rev. August 10, 2011
6.Walsh-Sukys MC, Tyson JE, Wright LL et al. Persistent pulmonary hypertension of the newborn in the era before nitric oxide: practice variation and
outcomes. Pediatrics 2000;105(1):14-21.
Ch 29 Perinatally acquired varicella
1.CDC Morbidity and Mortality Weekly Report (MMWR) Vol 61/No.12 March
30, 2012
2.Prevention of Varicella. Recommendations of National Advisory committee
on Immunization practise (ACIP). MMWR 2007
3.Hayakawa M et al. Varicella exposure in a neonatal medical centre: successful
prophylaxis with oral acyclovir . Journal of Hospital Infection. 2003; (54):212215
4.Sauerbrei A. Review of varizella-zoster virus infections in pregnany women
and neonates. Health. 2010; 2(2): 143-152
148
Chapter 30: Asthma

The International Studies on Asthma And Allergy (ISAAC) has shown that the
prevalence of asthma among school age children is 10%.
Important Points to Note in:

Clinical History
Current symptoms
Signs of chronic illness
Pattern of symptoms
Harrisons sulci
Precipitating factors
Hyperinflated chest
Present treatment
Eczema / dry skin
Previous hospital admission
Hypertrophied turbinates
Typical exacerbations
Signs in acute exacerbation
Home/ school environment
Tachypnoea
Impact on life style
Wheeze, rhonchi
History of atopy
Hyperinflated chest
Response to prior treatment
Accessory muscles
Prolonged URTI symptoms
Cyanosis
Family history
Drowsiness
Tachycardia
Note: Absence of Physical Signs Does Not Exclude Asthma!

In pre-school children, epidemiological studies have delineated children with
wheezing into 3 different phenotypes:
Transient wheezers, Persistent wheezers and Late-onset wheezers.
These phenotypes are only useful when applied retrospectively.
149
RESPIRATORY
Definition
Chronic airway inflammation leading to increase airway responsiveness that
leads to recurrent episodes of wheezing, breathlessness, chest tightness and
coughing particularly at night or early morning.
Often associated with widespread but variable airflow obstruction that is
often reversible either spontaneously or with treatment.
Reversible and variable airflow limitation as evidenced by >15% improvement
in PEFR (Peak Expiratory Flow Rate), in response to administration of a
bronchodilator.
RESPIRATORY
Hence, there are recommendations to define pre-school wheezing into two

main categories:
Episodic (viral) wheeze. Children who only wheeze with viral infections and
are well between episodes.
Multiple trigger wheezers are children who have discrete exacerbations
and symptoms in between these episodes. Triggers are smoke, allergens,
crying, laughing and exercise.
The presence of atopy (eczema, allergic rhinitis and conjunctivitis) in the
child or family supports the diagnosis of asthma . However, the absence of
these conditions does not exclude the diagnosis.
Thus, because of the difficulty to diagnose asthma in young children, an
asthmatic predictive index can be helpful in predicting children who were
going to be asthmatics. The possibility of those with negative index not
becoming asthmatic by 6 years old was 95% whereas those with a positive
index have a 65% chance of becoming asthmatic by 6 years old.
A Clinical Index to define Risk of Asthma in young children with Recurrent Wheeze:
Positive index (> 3 wheezing episodes / year during first 3 years)
plus 1 Major criterion or 2 Minor criteria.
Major criteria
Eczema1
Parental asthma1
Positive aeroallergen skin test1
Minor criteria
Positive skin test1

Wheezing without upper respiratory tract infection
Eosinophilia (> 4%)
Footnote: 1, Doctor Diagnosed

The child who presents with chronic cough alone (daily cough for > 4 weeks)
and has never wheezed is unlikely to have asthma. These children require
further evaluation for other illnesses that can cause chronic cough.
150
MANAGEMENT OF CHRONIC ASTHMA

Patients with a new diagnosis of asthma should be properly evaluated as to
their degree of asthma severity:
Category
Clinical Parameters
Intermittent
Daytime symptoms less than once a week

Nocturnal symptoms less than once a month
No exercise induced symptoms
Brief exacerbations not affecting sleep and activity
Normal lung function
Persistent (Threshold for preventive treatment)

Mild Persistent
Daytime symptoms more than once a week

Nocturnal symptoms more than twice a month
Exercise induced symptoms
Exacerbations > 1x/month affecting sleep, activity
PEFR / FEV1 > 80%
Moderate Persistent Daytime symptoms daily

Nocturnal symptoms more than once a week
Exercise induced symptoms
Exacerbations > 2x/month affecting sleep, activity
PEFR / FEV1 60 - 80%
Severe Persistent
Daytime symptoms daily

Daily nocturnal symptoms
Daily exercise induced symptoms
Frequent exacerbations > 2x/month affecting sleep,
activity
PEFR / FEV1 < 60%
Note
This division is arbitrary and the groupings may merge. An individual patients
classification may change from time to time.
There are a few patients who have very infrequent but severe or life threatening
attacks with completely normal lung function and no symptoms between
episodes. This type of patient remains very difficult to manage.
PEFR = Peak Expiratory Flow Rate; FEV1 = Forced Expiratory Volume in One Second.
151
RESPIRATORY
Evaluation of the background of newly diagnosed asthma
RESPIRATORY
In 2006, the Global Initiatives on Asthma (GINA) has proposed the management
of asthma from severity based to control based. The change is due to the fact
that asthma management based on severity is on expert opinion rather than
evidence based, with limitation in deciding treatment and it does not predict
treatment response.
Asthma assessment based on levels of control is based on symptoms and
the three levels of control are well controlled, partly control and
uncontrolled.
Patients who are already on treatment should be assessed at every clinic
visit on their control of asthma
Levels of Asthma Control (GINA 2006)
Characteristics
Controlled
Partly Controlled Uncontrolled
All of the following: Any measure present in any week:
Daytime symptoms
None
> 2 per week
Limitation of
activities
None
Any
Nocturnal symptoms None

or Awakenings
Any
Need for Reliever
None
> 2 per week
Lung function test
Normal
< 80% predicted or

personal best
Exacerbations
None
1 per year
3 features of
partly controlled
asthma present
in any week
One in any week
Prevention
Identifying and avoiding the following common triggers may be useful
Environmental allergens
These include house dust mites, animal dander, insects like cockroach,
mould and pollen.
Useful measures include damp dusting, frequent laundering of bedding
with hot water, encasing pillow and mattresses with plastic/vinyl covers,
removal of carpets from bedrooms, frequent vacuuming and removal of
pets from the household.
Cigarette smoke
Respiratory tract infections - commonest trigger in children.
Food allergy - uncommon trigger, occurring in 1-2% of children
Exercise
Although it is a recognised trigger, activity should not be limited. Taking a
-agonist prior to strenuous exercise, as well as optimizing treatment, are
usually helpful.
152
Drug Therapy
Drug Therapy: Delivery systems available & recommendation for different ages.
Oral
MDI +
Spacer
MDI + Mask
+ Spacer
Dry Powder
Inhaler
<5
58
>8
Note:
MDI = Meter dose inhaler
Mask used should be applied firmly to the face of the child
Treatment of Chronic Asthma
Asthma management based on levels of control is a step up and step down
approach as shown in the table below:
Management Based On Control
Reduce
STEP 1
STEP 2
Intermittent Mild
Persistent
Increase
STEP 3
Moderate
Persistent
STEP 4
Severe
Persistent
STEP 5
Severe
Persistent
Select one
Select One
Add one / more Add one / both
Low dose
inhaled
steroids
Low dose ICS

+ long acting
-agonist
Medium / High Oral

dose ICS
Glucocorticoids
+ long acting
lowest dose
-agonist
As needed As needed
rapid acting rapid acting
-agonist
-agonist
Controller
Options
Leukotriene Medium / High Leukotriene

modifier
dose ICS
modifier
Low dose ICS
+ Leukotriene
modifier
SR Theophylline
Low dose ICS +

SR Theophylline
Footnote: ICS, Inhaled Corticosteroids; SR, Sustained Release.
153
Anti-IgE
RESPIRATORY
Age (years)
Drug Dosages for Medications used in Chronic Asthma

Drug
Formulation
Dosage
Salbutamol
Oral
Metered dose inhaler
Dry powder inhaler
0.15 mg/kg/dose TDS-QID/PRN

100-200 mcg/dose QID/PRN
Terbutaline
Oral
0.075 mg/kg/dose TDS-QID/PRN

(maximum 4000 mcg/daily)
Fenoterol
200 mcg/dose QID/PRN
RESPIRATORY
Relieving Drugs
-agonists
Ipratropium Bromide Metered dose inhaler
40-60mcg /dose TDS/QID/PRN
Preventive Drugs
Corticosteroids
Prednisolone
Oral
1-2 mg/kg/day in divided doses
Beclomethasone
Diproprionate
Budesonide

Dry powder inhaler
<400 mcg/day
: low dose
400-800 mcg/day : Moderate 8001200 mcg/day: High
Fluticasone
Propionate

Dry powder inhaler
<200 mcg/day
: Low
200-400 mcg/day : Moderate
400-600 mcg/day : High
Ciclesonide
160 microgram daily

320 microgram daily
Sodium
Cromoglycate
Dry powder inhaler

20mg QID
1-2mg QID or 5-10mg BID-QID
Theophylline
Oral Syrup
Slow Release
5 mg/kg/dose TDS/QID
10 mg/kg/dose BD
Long acting -agonists

Dry powder inhaler
50-100 mcg/dose BD
50-100 mcg/dose BD
Salmeterol /
Fluticasone

Dry powder inhaler
25/50mcg, 25/125mcg, 25/250mcg

50/100mcg,50/250mcg, 50/500mcg
Budesonide /Formoterol
Dry powder inhaler
160/4.5mcg, 80/4.5mcg
Salmeterol
Combination
Antileukotrienes (Leukotriene modifier)

Montelukast
Oral
4 mg granules
5mg/tablet on night chewable
10mg/tablet ON
154
Monitoring
During each follow up visit, three issues need to be assessed. They are:
Assessment of asthma control based on:
Interval symptoms.
Frequency and severity of acute exacerbation.
Morbidity secondary to asthma.
Quality of life.
Peak Expiratory Flow Rate (PEFR) or FEV1 monitoring.
Compliance to asthma therapy:
Frequency.
Technique.
Asthma education:
Understanding asthma in childhood.
Reemphasize compliance to therapy.
Written asthma action plan.
Patients with High Risk Asthma are at risk of developing near fatal asthma
(NFA) or fatal asthma (FA) . This group of patients need to be identified and
closely monitored which includes frequent medical review (at least 3 monthly),
objective assessment of asthma control with lung function on each visit,
review of asthma action plan and medication supply, identification of
psychosocial issues and referral to a paediatrician or respiratory specialist.
155
RESPIRATORY
Note:
Patients should commence treatment at the step most appropriate to the
initial severity. A short rescue course of Prednisolone may help establish
control promptly.
Explain to parents and patient about asthma and all therapy
Ensure both compliance and inhaler technique optimal before progression
to next step.
Step-up; assess patient after 1 month of initiation of treatment and if control
is not adequate, consider step-up after looking into factors as above.
Step-down; review treatment every 3 months and if control sustained for at
least 4-6 months, consider gradual treatment reduction.
RESPIRATORY
MANAGEMENT OF ACUTE ASTHMA

Assessment of Severity
Initial (Acute assessment)
Diagnosis
- symptoms e.g. cough, wheezing. breathlessness , pneumonia
Triggering factors
- food, weather, exercise, infection, emotion, drugs, aeroallergens
Severity
- respiratory rate, colour, respiratory effort, conscious level
Chest X Ray is rarely helpful in the initial assessment unless complications like
pneumothorax, pneumonia or lung collapse are suspected.
Initial ABG is indicated only in acute severe asthma.
Management of acute asthma exacerbations
Mild attacks can be usually treated at home if the patient is prepared and
has a personal asthma action plan.
Moderate and severe attacks require clinic or hospital attendance.
Asthma attacks require prompt treatment.
A patient who has brittle asthma, previous ICU admissions for asthma or
with parents who are either uncomfortable or judged unable to care for the
child with an acute exacerbation should be admitted to hospital.
Criteria for admission
Failure to respond to standard home treatment.
Failure of those with mild or moderate acute asthma to respond to nebulised
-agonists.
Relapse within 4 hours of nebulised - agonists.
Severe acute asthma.
156
The Initial Assessment is the First Step in the Management of Acute Asthma
Severity of Acute Asthma Exacerbations
Mild
Breathless
When walk- When talking At rest

ing
Infant: Feeding Infant: Stops
difficulties
feeding
Talks in
Sentences
Phrases
Words
Unable to speak
Alertness
Maybe
agitated
Usually
agitated
Usually
agitated
Drowsy/ confused/ coma
Respiratory
rate
Normal to
Mildly Increased
Increased
Markedly
Increased
Poor Respiratory
Effort
Present Moderate
Present
Severe
Paradoxical
thoraco-abdominal
movement
Accessory
Absent
Muscle usage /
retractions
Moderate
Severe
Life Threatening
Wheeze
Moderate,
often only
end expiratory
Loud
Usually loud Silent chest
SpO2 (on air)
>95%
92-95%
<92%
Pulse /min
< 100
100-120
>120(>5yrs) Bradycardia
>160 (infants)
PEFR1
>80%
60-80%
<60%
Cyanosis & <92%
Unable to perform
Footnote:
1, PEFR after initial bronchodilator, % predicted or of personal best
157
RESPIRATORY
Parameters
Management of Acute Exarcerbation of Bronchial Asthma in Children
MILD
Treatment
Nebulised Salbutamol or
MDI Salbutamol + spacer
4-6 puffs (<6 yrs),
8-12 puffs (>6 yrs)
Observation
Observe
for 60 min
after
Last Dose
Oral Prednisolone
1 mg/kg/day (max 60 mg)
x 3 - 5 days
Discharged with
Improved Long Term
Treatment and
Asthma Action Plan
MODERATE
Review after 20 min,

if No Improvement
then treat as Moderate
Nebulised Salbutamol
Ipratopium Bromide
(3 @ 20 min intervals)
Short course of Oral

Steroid (3-5 days)
Observe
for 60 min
after
Last Dose
Regular Bronchodilators
4-6Hly for a few days then
given PRN.
Early Review in 2-4 weeks
+ Oral Prednisolone
1 mg/kg/day x 3-5 days
+ Oxygen 8L/min by face mask
Admission if No
Improvement
SEVERE/LIFE THREATENING
RESPIRATORY
Severity
Nebulised Salbutamol
+ Ipratopium Bromide
(3x @ 20 mins intervals/
continuously)
+ Oxygen 8L/min by face mask
+ IV Corticosteroid
+ IV Salbutamol continuous
infusion 1- 5 mcg/kg/min
Loading 15 mcg/kg over
10 minutes
Continous
Obervation
SC Terbutaline/Adrenaline
IV Magnesium sulphate 50%
bolus 0.1 mL/kg (50 mg/kg)
over 20 mins
Consider HDU/ICU admission
IV Aminophylline
Mechanical Ventilation
158
Review
159
RESPIRATORY
Footnotes on Management of Acute Exacerbation of Asthma:

1. Monitor pulse, colour, PEFR, ABG and O2 Saturation.
Close monitoring for at least 4 hours.
2. Hydration - give maintenance fluids.
3. Role of Aminophylline debated due to its potential toxicity.
To be used with caution, in a controlled environment like ICU.
4. IV Magnesium Sulphate : Consider as an adjunct treatment in severe
exacerbations unresponsive to the initial treatment. It is safe and beneficial
in severe acute asthma.
5. Avoid Chest physiotherapy as it may increase patient discomfort.
6. Antibiotics indicated only if bacterial infection suspected.
7. Avoid sedatives and mucolytics.
8. Efficacy of prednisolone in the first year of life is poor.
9. On discharge, patients must be provided with an Action Plan to assist
parents or patients to prevent/terminate asthma attacks.
The plan must include:
a. How to recognize worsening asthma.
b. How to treat worsening asthma.
c. How and when to seek medical attention.
Salbutamol MDI vs nebulizer
< 6 year old: 6 x 100 mcg puff = 2.5 mg Salbutamol nebules.
> 6 year old: 12 x 100 mcg puff = 5.0 mg Salbutamol nebules.
Drug Dosages for Medications used in Acute Asthma

Drug
Formulation
Dosage
Nebuliser solution
5 mg/ml or 2.5 mg/ml
nebule
0.15 mg/kg/dose (max 5 mg) or

< 2 years old : 2.5 mg/dose
> 2 years old : 5.0 mg/dose
Continuous : 500 mcg/kg/hr
Bolus:
5-10 mcg/kg over 10 min
Infusion:
Start 0.5-1.0 mcg/kg/min,
increase by 1.0 mcg/kg/min every
15 min to a max of 20 mcg/kg/min
RESPIRATORY
-agonists
Salbutamol
Intravenous
Terbutaline
Nebuliser solution
0.2-0.3 mg/kg/dose, or
10 mg/ml, 2.5 mg/ml or < 20 kg: 2.5 mg/dose
5 mg/ml respule
> 20 kg: 5.0 mg/dose
Parenteral
5-10 mcg/kg/dose
Fenoterol
Nebuliser solution
0.25-1.5 mg/dose
Prednisolone
Oral
1-2 mg/kg/day in divided doses

(for 3-7 days)
Hydrocortisone
Intravenous
4-5 mg/kg/dose 6 hourly
Corticosteroids
Methylprednisolone Intravenous
1-2 mg/kg/dose 6-12 hourly
Other agents
Ipratropium bromide Nebuliser solution
(250 mcg/ml)
< 5 years old : 250 mcg 4-6 hourly

> 5 years old : 500 mcg 4-6 hourly
Aminophylline
Intravenous
6 mg/kg slow bolus (if not previously

on theophylline) followed by infusion
0.5-1.0 mg/kg/hr
Montelukast
Oral
4 mg granules
5mg/tablet on night chewable
10mg/tablet ON
160
Chapter 31: Viral Bronchiolitis
Guidelines for Hospital Admission in Viral Bronchiolitis

Home Management
Hospital management
Age < than 3 months
No
Yes
Toxic looking
No
Yes
Chest recession
Mild
Moderate/Severe
Central cyanosis
No
Yes
Wheeze
Yes
Yes
Crepitations on auscultation Yes
Yes
Feeding
Well
Difficult
Apnoea
No
Yes
Oxygen saturation
> 95%
< 93 %
High risk group
No
Yes
Chest X-ray
A wide range of radiological changes are seen in viral bronchiolitis:
- Hyperinflation (most common).
- Segmental collapse/consolidation.
- Lobar collapse/consolidation.
A chest X-ray is not routinely required, but recommended for children with:
- Severe respiratory distress.
- Unusual clinical features.
- An underlying cardiac or chronic respiratory disorder.
- Admission to intensive care.
161
RESPIRATORY
Aetiology and Epidemiology

A common respiratory illness especially in infants aged 1 to 6 months old
Respiratory Syncytial Virus (RSV) remains the commonest cause of acute
bronchiolitis in Malaysia.
Although it is endemic throughout the year, cyclical periodicity with annual
peaks occur, in the months of November, December and January.
Clinical Features
Typically presents with a mild coryza, low grade fever and cough.
Tachypnoea, chest wall recession, wheeze and respiratory distress
subsequently develop. The chest may be hyperinflated and auscultation
usually reveals fine crepitations and sometimes rhonchi.
A majority of children with viral bronchiolitis has mild illness and about 1% of
these children require hospital admission.
RESPIRATORY
Management
General measures
Careful assessment of the respiratory status and oxygenation is critical.
Arterial oxygenation by pulse oximetry (SpO) should be performed at
presentation and maintained above 93%.
- Administer supplemental humidified oxygen if necessary.
Monitor for signs of impending respiratory failure:
- Inability to maintain satisfactory SpO on inspired oxygen > 40%,
or a rising pCO.
Very young infants who are at risk of apnoea require greater vigilance.
Blood gas analysis may have a role in the assessments of infants with severe
respiratory distress or who are tiring and may be entering respiratory failure.
Routine full blood count and bacteriological testing (of blood and urine) is
not indicated in the assessment and management of infants with typical
acute bronchiolitis .
Nutrition and Fluid therapy
Feeding. Infants admitted with viral bronchiolitis frequently have poor
feeding, are at risk of aspiration and may be dehydrated. Small frequent
feeds as tolerated can be allowed in children with moderate respiratory
distress. Nasogastric feeding, although not universally practiced, may be
useful in these children who refuse feeds and to empty the dilated stomach.
Intravenous fluids for children with severe respiratory distress, cyanosis and
apnoea. Fluid therapy should be restricted to maintenance requirement of
100 ml/kg/day for infants, in the absence of dehydration.
Pharmacotherapy
The use of 3% saline solution via nebulizer has been shown to increase
mucus clearance and significantly reduce hospital stay among non-severe
acute bronchiolits. It improves clinical severity score in both outpatients and
inpatients populations.
Inhaled -agonists. Pooled data have indicated a modest clinical
improvement with the use of -agonist. A trial of nebulised -agonist, given
in oxygen, may be considered in infants with viral bronchiolitis. Vigilant and
regular assessment of the child should be carried out.
Inhaled steroids. Randomised controlled trials of the use of inhaled or oral
steroids for treatment of viral bronchiolitis show no meaningful benefit.
Antibiotics are recommended for all infants with
- Recurrent apnoea and circulatory impairment.
- Possibility of septicaemia.
- Acute clinical deterioration.
- High white cell count.
- Progressive infiltrative changes on chest radiograph.
Chest physiotherapy using vibration and percussion is not recommended in
infants hospitalized with acute bronchiolitis who are not admitted into
intensive care unit.
162
Chapter 32: Viral Croup
163
RESPIRATORY
Aetiology and epidemiology

A clinical syndrome characterised by barking cough, inspiratory stridor, hoarse
voice and respiratory distress of varying severity.
A result of viral inflammation of the larynx, trachea and bronchi, hence the
term laryngotracheobronchitis.
The most common pathogen is parainfluenza virus (74%), (types 1, 2 and 3).
The others are Respiratory Syncytial Virus, Influenza virus types A and B,
Adenovirus, Enterovirus, Measles, Mumps and Rhinoviruses and rarely
Mycoplasma pneumoniae and Corynebacterium Diptheriae.
Clinical Features
Low grade fever, cough and coryza for 12-72 hours, followed by:
Increasingly bark-like cough and hoarseness.
Stridor that may occur when excited, at rest or both.
Respiratory distress of varying degree.
Diagnosis
Croup is a clinical diagnosis. Studies show that it is safe to visualise the
pharynx to exclude acute epiglotitis, retropharyngeal abscess etc.
In severe croup, it is advisable to examine the pharynx under controlled
conditions, i.e. in the ICU or Operation Theatre.
A neck Radiograph is not necessary, unless the diagnosis is in doubt, such as
in the exclusion of a foreign body.
Assessment of severity
Clinical Assessment of Croup (Wagener)
Severity
Mild:
Stridor with excitement or at rest, with no respiratory distress.
Moderate: Stridor at rest with intercostal, subcostal or sternal recession.
Severe:
Stridor at rest with marked recession, decreased air entry and
altered level of consciousness.
Pulse oximetry is helpful but not essential
Arterial blood gas is not helpful because the blood parameters may remain
normal to the late stage. The process of blood taking may distress the child.
Management
Indications for Hospital admission
Moderate and severe viral croup.
Age less than 6 months.
Poor oral intake.
Toxic, sick appearance.
Family lives a long distance from hospital; lacks reliable transport.
Treatment (ref Algorithm on next page)
The sustained action of steroids combined with the quick action of
adrenaline may reduce the rate of intubation from 3% to nil.
Antibiotics are not recommended unless bacterial super-infection is
strongly suspected or the patient is very ill.
IV fluids are not usually necessary except for those unable to drink.
164
Nebulised Adrenaline
0.5 mls/kg 1:1000 (Max dose 5 mls)
Home
Intubate and Ventilate
No Improvement
or Deterioration
Nebulised Adrenaline
0.5 mls/kg 1:1000 (Max dose 5 mls)
AND
Dexamethasone
Parenteral 0.3-0.6 mg/kg
AND
Nebulised Budesonide
2 mg stat, 1 mg 12 hrly
AND
Oxygen
Inpatient
Severe
Footnote:
The decision to intubate under controlled conditions (in Operation Theatre or Intensive Care Unit, with standby for tracheostomy)
is based on clinical criteria, often from increasing respiratory distress.
Indications for oxygen therapy include: 1. severe viral croup; 2. percutaneous SpO2 < 93%
With oxygen therapy, SpO2 may be normal despite progressive respiratory failure and a high PaCO2. Hence clinical assessment is important.
No Improvement
or Deterioration
Dexamethasone
Oral/Parenteral 0.3-0.6 mg/kg,
AND single dose
/OR
Nebulised Budesonide
2 mg stat and 1 mg 12 hrly
Inpatient
Moderate
Improvement
Dexamethasone (Preferred)
Oral/Parenteral 0.15 kg/single dose
May repeat at 12 and 24 hours
OR
Prednisolone
1-2 mg/kg/stat
OR
Nebulised Budesonide (if vomiting)
2 mg single dose only
Outpatient
Mild
Algorithm for the Management of Viral Croup
RESPIRATORY
Chapter 33: Pneumonia
Pathogens for Pneumonia

Age
Bacterial Pathogens
Newborns
Group B streptococcus, Escherichia coli, Klebsiella species,

Enterobacteriaceae
Infants 1- 3 months Chlamydia trachomatis

Preschool age
Streptococcus pneumoniae, Haemophilus influenzae type b,

Staphylococcal aureus
Less common: Group A Streptococcus,
Moraxella catarrhalis, Pseudomonas aeruginosa
School age
Mycoplasma pneumoniae, Chlamydia pneumoniae
Assessment of Severity in Pneumonia

Age < 2 months
Age 2 months - 5 years
Severe Pneumonia
Mild Pneumonia
Severe chest indrawing
Tachypnoea
Tachypnoea
Severe Pneumonia
Chest indrawing
Very Severe Pneumonia
Very Severe Pneumonia
Not feeding
Not able to drink
Convulsions
Convulsions
Abnormally sleepy, difficult to wake
Drowsiness
Fever, or Hypothermia
Malnutrition
165
RESPIRATORY
Definition
There are two clinical definitions of pneumonia:
Bronchopneumonia: a febrile illness with cough, respiratory distress with
evidence of localised or generalised patchy infiltrates.
Lobar pneumonia: similar to bronchopneumonia except that the physical
findings and radiographs indicate lobar consolidation.
Aetiology
Specific aetiological agents are not identified in 40% to 60% of cases.
It is often difficult to distinguish viral from bacterial disease.
The majority of lower respiratory tract infections are viral in origin,
e.g. Respiratory syncytial virus, Influenza A or B, Adenovirus, Parainfluenza virus.
A helpful indicator in predicting aetiological agents is the age group.
The predominant bacterial pathogens are shown in the table below:
RESPIRATORY
Assessment of severity of pneumonia

The predictive value of respiratory rate for the diagnosis of pneumonia may be
improved by making it age specific. Tachypnoea is defined as follows :
< 2 months age: > 60 /min
2- 12 months age: > 50 /min
12 months 5 years age: > 40 /min
Investigations and assessment
Children with bacterial pneumonia cannot be reliably distinguished from those
with viral disease on the basis of any single parameter: Clinical, laboratory or
chest X-ray findings.
Chest radiograph
Indicated when clinical criteria suggest pneumonia.
Does not differentiate aetiological agents.
Not always necessary if facilities are not available or if pneumonia is mild.
White blood cell count
Increased counts with predominance of polymorphonuclear cells suggests
bacterial cause.
Leucopenia suggests either a viral cause or severe overwhelming infection.
Blood culture
Non-invasive gold standard for determining the precise aetiology.
Sensitivity is low: Positive blood cultures only in 10%-30% of patients.
Do cultures in severe pneumonia or if poor response to first line antibiotics.
Pleural fluid analysis
If there is significant pleural effusion, a diagnostic pleural tap will be helpful.
Serological tests
Serology is performed in patients with suspected atypical pneumonia,
i.e. Mycoplasma pneumoniae, Chlamydia, Legionella, Moraxella catarrhalis
Acute phase serum titre > 1:160 or paired samples taken 2-4 weeks apart
with a 4 fold rise is a good indicator of Mycoplasma pneumoniae infection.
This test should be considered for children aged five years or older.
Assessment of oxygenation
Objective measurement of hypoxia by pulse oximetry avoids the need for
arterial blood gases. It is a good indicator of the severity of pneumonia.
Criteria for hospitalization
Community acquired pneumonia can be treated at home
Identify indicators of severity in children who need admission, as pneumonia
can be fatal. The following indicators can be used as a guide for admission:
Children aged 3 months and below, whatever the severity of pneumonia.
Fever ( more than 38.5 C ), refusal to feed and vomiting
Fast breathing with or without cyanosis
Associated systemic manifestation
Failure of previous antibiotic therapy
Recurrent pneumonia
Severe underlying disorder, e.g. Immunodeficiency
166
Bacterial pathogens and Recommended antimicrobial agents.

Pathogen
Antimicrobial agent
Beta-lactam susceptible
Streptococcus pneumonia
Penicillin, cephalosporins
Haemophilus influenzae type b
Ampicillin, chloramphenicol, cephalosporins
Staphylococcus aureus
Cloxacillin
Group A Streptococcus
Penicillin, cephalosporin
Mycoplasma pneumoniae
Macrolides, e.g. erythromycin, azithromycin
Chlamydia pneumoniae
Bordetella pertussis
INPATIENT MANAGEMENT
Antibiotics
For children with severe pneumonia, the following antibiotics are recommended:
Suggested antimicrobial agents for inpatient treatment of pneumonia
First line
Beta-lactams: Benzylpenicillin, moxycillin, ampicillin,

amoxycillin-clavulanate
Second line
Cephalosporins: Cefotaxime, cefuroxime, ceftazidime
Third line
Carbapenem: Imipenam
Other agents
Aminoglycosides: Gentamicin, amikacin
Second line antibiotics need to be considered when :

There are no signs of recovery
Patients remain toxic and ill with spiking temperature for 48 - 72 hours
A macrolide antibiotic is used in pneumonia from Mycoplasma or Chlamydia.
A child admitted to hospital with severe community acquired pneumonia
must receive parenteral antibiotics. As a rule, in severe cases of pneumonia,
combination therapy using a second or third generation cephalosporins and
macrolide should be given.
Staphylococcal infections and infections caused by Gram negative organisms
such as Klebsiella have been frequently reported in malnourished children.
167
RESPIRATORY
Antibiotics
When treating pneumonia, consider clinical, laboratory, radiographic findings,
as well as age of the child, and the local epidemiology of respiratory pathogens
and resistance/sensitivity patterns to microbial agents.
Severity of the pneumonia and drug costs also impact on selection of therapy.
Majority of infections are caused by viruses and do not require antibiotics.
RESPIRATORY
Staphylococcal infection
Staphylococcus aureus is responsible for a small proportion of cases.
A high index of suspicion is required because of the potential for rapid
deterioration. It chiefly occurs in infants with a significant risk of mortality.
Radiological features include multilobar consolidation, cavitation,
pneumatocoeles, spontaneous pneumothorax, empyema, pleural effusion.
Treat with high dose Cloxacillin (200 mg/kg/day) for a longer duration
Drainage of empyema often results in a good outcome.
Necrotising pneumonia and pneumatocoeles
It is a result of localized bronchiolar and alveolar necrosis.
Aetiological agents are bacteria, e.g. Staphylococcal aureus, S. Pneumonia,
H. Influenza, Klebsiella pneumonia and E. coli.
Give IV antibiotics until child shows signs of improvement.
Total antibiotics course duration of 3 to 4 weeks.
Most pneumatocoeles disappear, with radiological evidence resolving
within the first two months but may take as long as 6 months.
Supportive treatment
Fluids
Withhold oral intake when a child is in severe respiratory distress.
In severe pneumonia, secretion of anti-diuretic hormone is increased and
as such dehydration is uncommon. Avoid overhydrating the child.
Oxygen
Oxygen reduces mortality associated with severe pneumonia.
It should be given especially to children who are restless, and tachypnoeic
with severe chest indrawing, cyanosis, or is not tolerating feeds.
Maintain the SpO > 95%.
Cough medication
Not recommended as it causes suppression of cough and may interfere
with airway clearance. Adverse effects and overdosage have been reported.
Temperature control
Reduces discomfort from symptoms, as paracetamol will not abolish fever.
Chest physiotherapy
This assists in the removal of tracheobronchial secretions: removes airway
obstruction, increase gas exchange and reduce the work of breathing.
No evidence that chest physiotherapy should be routinely done.
OUTPATIENT MANAGEMENT
In children with mild pneumonia, their breathing is fast but there is no chest
indrawing.
Oral antibiotics can be prescribed.
Educate parents/caregivers about management of fever, preventing
dehydration and identifying signs of deterioration.
The child should return in two days for reassessment, or earlier if the condition
is getting worse.
168
169
RESPIRATORY
References
Section 3 Respiratory Medicine
Chapter 30 Asthma
1.Guidelines for the Management of Childhood Asthma - Ministry of Health,
Malaysia and Academy of Medicine, Malaysia
2.Pocket Guide for Asthma Management and Prevention 2007 Global Initiative for Asthma (GINA)
3.British Thoracic Society Guidelines on Asthma Management 1995. Thorax
1997; 52 (Suppl 1)
4.Paediatric Montelukast Study Group. Montelukast for Chronic Asthma in 6
-14 year old children. JAMA April 1998.
5.Pauwels et al. FACET International Study Group 1997. NEJM 1997; 337:
1405-1411.
6.Jenkins et al. Salmeterol/Fluticasone propionate combination therapy
50/250ug bd is more effective than budesonide 800ug bd in treating moderate to severe asthma. Resp Medicine 2000; 94: 715-723.
Chapter 31 Viral Bronchiolitis
1.Chan PWK, Goh AYT, Chua KB, Khairullah NS, Hooi PS. Viral aetiology of
lower respiratory tract infection in young Malaysian children. J Paediatric
Child Health 1999 ; 35 :287-90.
2.Chan PWK, Goh AYT, Lum LCS. Severe bronchiolitis in Malaysian children. J
Trop Pediatr 2000; 46: 234 6
3.Bronciholitis in children: Scottish Intercollegiate Guidelines Network.
4.Nebulised hypertonic saline solution for acute bronchiolitis in infants Zhang
L,Mendoza Sassi RA, Wainwright C, Klassen TP- Cochrane Summary 2011.
Chapter 32 Viral Croup
1.AG Kaditis, E R Wald : Viral croup; current diagnosis and treatment. Pediatric Infectious Disease Journal 1998:7:827-34.
Chapter 33 Pneumonia
1.World Health Organisation. Classification of acute respiratory infections in
WHO/ARI/91.20 Geneva. World Health Organisation 991, p.11-20
2.Schttze GE, Jacobs RF. Management of community-acquired pneumonia in
hospitalised children. Pediatric Infectious Dis J 1992 11:160-164
3.Harris M, ClarkJ, Coote N, Fletcher P et al: British Thoracic Society guidelines for the management of community acquired pneumonia in children:
update 2011.
170
RESPIRATORY
Chapter 34: Paediatric Electrocardiography

Age related changes in the anatomy and physiology of infants and children
produce normal ranges for electrocardiographic features that differ from
adults and vary with age. Awareness of these differences is the key to correct
interpretation of paediatric ECG.
The ECG cycle
CARDIOLOGY
ECG should be interpreted systematically

Heart rate, Rhythm
P wave axis, amplitude, duration
PR interval
QRS axis, amplitude, duration
ST segment and T waves
QT interval and QTc
(QTc = measured QT interval /
square root of R-R interval)
Normal values for Heart rate in children
Heart Rate (bpm)
Age
Mean
Range
< 1 day
119
94 145
1 7 days
133
100 175
3 30 days
163
115 190
1 3 months
154
124 190
3 6 months
140
111 179
6 12 months
140
112 177
1 3 years
126
98 163
3 5 years
98
65 132
5 8 years
96
70 115
8 12 years
79
55 107
12 16 years
75
55 102
Normal values in Paediatric ECG

Age
Birth
PR interval
(ms)
QRS duration
(ms)
R wave (S wave) amplitude (mm)

Lead V1
Lead V6
80 160
< 75
5 - 26 (1 - 23) 0 - 12 (0 - 10)
6 months 70 150
< 75
3 - 20 (1 - 17) 6 - 22 (0 - 10)
1 year
70 150
< 75
2 - 20 (1 - 20) 6 - 23 (0 - 7)
5 years
80 160
< 80
1 - 16 (2 - 22) 8 - 25 (0 - 5)
10 years
90 170
< 85
1 - 12 (3 - 25) 9 - 26 (0 - 4)
171
Age Group
ECG Characteristics
CARDIOLOGY
Premature infants
Left & posterior QRS axis.
(< 35 weeks gestation) Relative LV dominant; smaller R in V1, taller R in V6.
Full term infant
Right axis deviation (30 to 180) RV dominant.

Tall R in V1, Deep S in V6, R/S ratio > 1 in V1.
T wave in V1 may be upright for 48 hours.
1 to 6 months
Less right axis deviation (10 to 120).

RV remains dominant.
Negative T waves across right praecordial leads.
6 months to 3 years
QRS axis < 90.

R wave dominant in V6.
R/S ratio 1 in V1.
3 to 8 years
Adult QRS progression in praecordial leads.

LV dominant, Dominant S in V1, R in V6.
Q wave in V5-6 (amplitude < 5 mm).
Important normal variants

T wave inversion of right praecordial leads (V1 V3): normal findings from
day 2 of life until late teens. An upright T wave in V1 before 8 years old is
indicative of RVH.
Q wave may be seen in leads I, aVL, V5 and V6 provided amplitude < 5 mm.
RSR pattern of right praecordial leads: normal in children provided QRS
duration < 10 msec and R amplitude < 15 mm (infants) or 10 mm (children.)
Elevated J point: normal in some adolescents
Criteria for Right Ventricular Hypertrophy
R > 20 mm in V1 at all ages
S > 14 mm (0 to 7 days); > 10mm (1 week - 6 mths); > 7mm (6 mths - 1
year); > 5mm (> 1 year) in V6.
R/S ratio > 6.5 (0 - 3 mths); 4.0 (3 - 6 mths); 2.4 (6 mths - 3 years);
1.6 (3 to 5 years); 0.8 (6 to 15 years) in V1
T wave upright in V4R or V1 after 72 hrs of life
Presence of Q wave in V1
Criteria for Left Ventricular Hypertrophy
S > 20 mm in V1
R > 20mm in V6
S (V1) + R (V6) > 40mm over 1 year of age; > 30mm if < 1year
Q wave > 4 mm in V5-6
T wave inversion in V5-6
172
Chapter 35: Congenital Heart Disease in the Newborn

Introduction
Congenital heart disease (CHD) encompass a spectrum of structural
abnormalities of the heart or intrathoracic vessels.
Commonly presents in the newborn with central cyanosis, heart failure,
sudden collapse or heart murmur.
Causes of Cyanosis in the Newborn

Cyanotic Heart Disease
Obstructed pulmonary flow
Pulmonary atresia, Critical pulmonary stenosis, Tetralogy of Fallot
Discordant ventriculo-arterial connection
Transposition of great arteries.
Common mixing
Single ventricle, Truncus arteriosus, Tricuspid atresia, Total anomalous
pulmonary venous drainage
Primary Pulmonary Disorders
Parenchymal disease
Meconium aspiration syndrome, Respiratory distress syndrome, Congenital
pneumonia
Extraparenchymal disease
Pneumothorax, Congenital diaphragmatic hernia
Persistent pulmonary hypertension of newborn
Primary
Secondary
Meconium aspiration, Perinatal asphyxia, Congenital diaphragmatic hernia
Severe polycythaemia
Methaemoglobinuria
173
CARDIOLOGY
Central Cyanosis
Bluish discoloration of lips and mucous membranes.
Caused by excess deoxygenated haemoglobin (> 5 Gm/dL), confirmed by
pulse oxymetry (SpO2 < 85%) or ABG.
CARDIOLOGY
Heart Failure
Clinical presentation may mimic pulmonary disease or sepsis:
Tachypnoea
Tachycardia
Hepatomegaly
Weak pulses
Causes of Heart Faliure in the Newborn
Structural Heart Lesions
Obstructive Left Heart lesions
Hypoplastic left heart syndrome, critical aortic stenosis, severe
coarctation of aorta
Severe Valvular Regurgitation
Truncal arteriosus with truncal valve regurgitation
Large Left to Right Shunts
Patent ductus arteriosus, ventricular septal defects, truncus arteriosus,
aortopulmonary collaterals
Obstructed Pulmonary Venous Drainage
Total anomalous pulmonary venous drainage
Myocardial Diseases
Cardiomyopathy
Infant of diabetic mother, familial, idiopathic
Ischaemic
Anomalous origin of left coronary artery from pulmonary artery,
perinatal asphyxia
Myocarditis
Arrhythmia
Atrial flutter, SVT, congenital heart block
Extracardiac
Severe anaemia
Neonatal thyrotoxicosis
Fulminant sepsis
174
Sudden Collapse
Can be difficult to be distinguished from sepsis or metabolic disorders:
Hypotension
Extreme cyanosis
Metabolic acidosis
Oliguria
Congenital heart lesions that may present with sudden collapse

Duct-dependent systemic circulation
Coarctation of aorta, Critical aortic stenosis, Hypoplastic left heart
syndrome, Interrupted aortic arch
Duct-dependent pulmonary circulation
Pulmonary atresia with intact ventricular septum, Tricuspid atresia with
pulmonary atresia, Single ventricle with pulmonary atresia,
Critical pulmonary stenosis
Transposition of great arteries without septal defect
Obstructed total anomalous pulmonary drainage
175
CARDIOLOGY
Challenges and Pitfalls

Cyanosis is easily missed in the presence of anaemia.
Difficulty to differentiate cyanotic heart disease from non-cardiac causes
Indistinguishable clinical presentations between left heart obstructive
lesions and severe sepsis or metabolic disorders.
Possibility of congenital heart disease not considered in management of
sick infant.
CARDIOLOGY
Clinical Approach to Infants with Congenital Heart Disease

History
Antenatal scans (cardiac malformation, fetal arrhythmias, hydrops).
Family history of congenital heart disease.
Maternal illness: diabetes, rubella, teratogenic medications.
Perinatal problems: prematurity, meconium aspiration, perinatal asphyxia.
Dysmorphism: Trisomy 21, 18, 13; Turner syndrome, DiGeorge syndrome.
Central cyanosis.
Differential cyanosis (SpO lower limbs < upper limbs).
Tachypnoea.
Weak or unequal pulses.
Heart murmur.
Hepatomegaly.
Investigations
Chest X-ray
Hyperoxia test:
Administer 100% oxygen via headbox at 15 L/min for 15 mins.
ABG taken from right radial artery.
Cyanotic heart diseases: pO < 100 mmHg; rise in pO is < 20 mmHg.
(note: in severe lung diseases & PPHN, pO can be < 100 mmHg).
Echocardiography.
General principles of management
Initial stabilization: secure airway, adequate ventilation, circulatory support
Correct metabolic acidosis, electrolyte derangements, hypoglycaemia;
prevent hypothermia.
Empirical treatment with IV antibiotics.
Early cardiology consultation.
IV Prostaglandin E infusion if duct-dependent lesions suspected:
Starting dose: 10 40 ng/kg/min; maintenance: 2 10 ng/kg/min.
Adverse effects: apnoea, fever, hypotension.
If unresponsive to IV prostaglandin E, consider:
Transposition of great arteries, obstructed total anomalous pulmonary.
venous drainage.
Blocked IV line.
Non-cardiac diagnosis.
Arrangement to transfer to regional cardiac center once stabilized.
176
No/mild Respiratory
distress.
Heart murmur.
Respiratory distress
Suggestive history
(MAS, asphyxia, sepsis)
Normal
Cyanotic Heart
Disease
Primary Lung Disease
Persistent Pulmonary
Hypertension
Methemoglbinemia
ABG
Low PO2
Hgh PCO2
Normal
Normal
Maybe abnormal (lungs) Differential

cyanosis
Abnormal lungs
Abnormal heart size

Low PCO2
and
pulmonary vasculature
Chest X-ray
MAS, meconium aspiration syndrome; PFO, patent foramen ovale; PDA, patent ductus arteriosus
History, Signs
Cause
Summary of The Clinical Approach to Cyanotic Newborns

Usually diagnostic
Echocardiography
Right to left shunt

across PFO or PDA
PO2 >100mmHg Normal
Inconclusive
PO2 >100mmHg Normal
No rise in PO2
Hyperoxia test
CARDIOLOGY
177
SPECIFIC MANAGEMENT STRATEGIES FOR COMMON LESIONS
CARDIOLOGY
LEFT TO RIGHT SHUNTS

Atrial septal defects (ASD)
Small defects:
No treatment.
Large defects:
Elective closure at 4-5 years age.
Ventricular septal defects (VSD)
Small defects:
No treatment; high rate of spontaneous closure.
SBE prophylaxis.
Yearly follow up for aortic valve prolapse, regurgitation.
Surgical closure indicated if prolapsed aortic valve.
Moderate defects:
Anti-failure therapy if heart failure.
Surgical closure if:
Heart failure not controlled by medical therapy.
Persistent cardiomegaly on chest X-ray.
Elevated pulmonary arterial pressure.
Aortic valve prolapse or regurgitation.
One episode of infective endocarditis.
Large defects:
Early primary surgical closure.
Pulmonary artery banding followed by VSD closure in multiple VSDs.
Persistent ductus arteriosus (PDA)
Small PDA:
No treatment if there is no murmur
If murmur present: elective closure as risk of endarteritis.
Moderate to large PDA:
Anti-failure therapy if heart failure
Timing, method of closure (surgical vs transcatheter) depends on symptom
severity, size of PDA and body weight.
Atrioventricular septal defects (AVSD)
Partial AVSD (ASD primum):
Elective surgical repair at 4 to 5 years old; earlier if symptomatic or severe
AV valve regurgitation.
Complete AVSD:
Primary surgical repair < 6 mths age to prevent pulmonary vascular disease.
In selected patients - e.g. with severe AV valve regurgitation and older
patients, conservative treatment is an option as surgical outcomes are
poor.
178
OBSTRUCTIVE LESIONS
Coarctation of the aorta (CoA)

Neonatal severe CoA:
Frequently associated with large malaligned VSD, intractable heart failure.
Sick infants require temporary stabilization:
Mechanical ventilation.
Correction of metabolic acidosis, hypoglycaemia, electrolyte disorders.
IV Prostaglandin E infusion.
Early surgical repair (single-stage CoA repair + VSD closure or 2 stage CoA
repair followed by VSD closure at later date).
Asymptomatic / older children with discrete CoA:
Presents with incidental hypertension or heart murmur.
Choice of treatment (primary transcatheter balloon angioplasty, stent
implantation or surgical repair) depends on morphology of CoA and age of
presentation.
CYANOTIC HEART LESIONS
Tetralogy of Fallot (TOF)
Most TOFs suitable for single stage surgical repair at 1 to 2 years age
Indications for modified Blalock Taussig shunt:
Hypercyanotic spells or severe cyanosis < 6 months age when child is too
young for total repair.
Small pulmonary arteries; to promote growth before definitive repair
Anomalous coronary artery crossing in front of right ventricular outflow tract precludes transannular incision; repair with conduit required at later age.
Following surgical repair, patients need life-long follow up for late right
ventricular dysfunction; some may require pulmonary valve replacement.
Tetralogy of Fallot with pulmonary atresia
IV prostaglandin E infusion is often required during early neonatal period
Further management strategy depends on the anatomy of the pulmonary
arteries and presence of aortopulmonary collaterals.
179
CARDIOLOGY
Pulmonary stenosis (PS)

Mild (peak systolic gradient < 50 mmHg)
No treatment.
Moderate-severe (gradient > 50 mmHg)
Transcatheter balloon valvuloplasty is treatment of choice.
Neonatal critical PS:
Characterized with cyanosis and RV dysfunction.
Temporary stabilization with IV Prostaglandin E infusion.
Early transcatheter balloon valvuloplasty.
Note: SBE prophylaxis is indicated in all cases
CARDIOLOGY
Pulmonary atresia with intact ventricular septum

IV prostaglandin E infusion to maintain ductal patency in early neonatal period
Further management strategy depends on the degree of right ventricular
hypoplasia.
Transposition of the great arteries (TGA)
Simple TGA (intact ventricular septum)
IV Prostaglandin E infusion promotes intercirculatory mixing at PDA.
Early balloon atrial septostomy (BAS) if restrictive interatrial communication.
Surgical repair of choice: arterial switch operation at 2 to 4 weeks age
Left ventricular regression may occur if repair not performed within 4
weeks of life.
TGA with VSD:
Does not usually require intervention during early neonatal period; may
develop heart failure at 1 to 2 months age.
Elective one-stage arterial switch operation + VSD closure < 3 months age.
TGA with VSD and PS:
Blalock Taussig shunt during infancy followed by Rastelli repair at
4 to 6 years age.
Truncus arteriosus
Surgical repair (VSD closure and RV-to-PA conduit) before 3 months of age.
Single ventricle
Includes 3 main categories of lesions:
Double inlet ventricles:
double inlet left ventricle, double inlet right ventricle.
Atretic or stenosed atrioventricular connections:
Tricuspid atresia, mitral atresia, hypoplastic left heart syndrome.
Miscellaneous lesions which preclude biventricular circulation:
Unbalanced AV septal defect, Double outlet right ventricle with remote VSD,
Congenital corrected transposition of great arteries, Heterotaxy syndromes.
Requires staged management approach for eventual Fontan procedure.
Total anomalous pulmonary venous drainage
4 major anatomic types: supracardiac, cardiac, infracardiac and mixed.
Management strategy depends on presence of pulmonary venous
obstruction:
Obstructed pulmonary venous drainage (frequent in infracardiac type)
- Presents with respiratory distress and heart failure.
- Initial stabilization: oxygen, diuretics, positive pressure ventilation.
- Surgical repair immediately after initial stabilization.
Unobstructed pulmonary venous drainage
- Early surgical repair is required.
180
Chapter 36: Hypercyanotic Spell

Introduction
Sudden severe episodes of intense cyanosis caused by reduction of
pulmonary flow in patients with underlying Tetralogy of Fallot or other
cyanotic heart lesions. This is due to spasm of the right ventricular outflow
tract or reduction in systemic vascular resistance (e.g. hypovolaemia) with
resulting increased in right to left shunt across the VSD.
Management
Treat this as a medical emergency.
Knee-chest/squatting position:
Place the baby on the mothers shoulder with the knees tucked up
underneath.
This provides a calming effect, reduces systemic venous return and
increases systemic vascular resistance.
Administer 100% oxygen
Give IV/IM/SC morphine 0.1 0.2 mg/kg to reduce distress and hyperpnoea.
If the above measures fail:
Give IV Propranolol 0.05 0.1 mg/kg slow bolus over 10 mins.
Alternatively, IV Esmolol 0.5 mg/kg slow bolus over 1 min, followed
by 0.05 mg/kg/min for 4 mins.
Can be given as continuous IV infusion at 0.01 0.02 mg/kg/min.
Esmolol is an ultra short acting beta blocker
Volume expander (crystalloid or colloid) 20 ml/kg rapid IV push to increase
preload.
Give IV sodium bicarbonate 1 mEq/kg to correct metabolic acidosis.
Heavy sedation, intubation and mechanical ventilation.
In resistant cases, consider
IV Phenylephrine / Noradrenaline infusion to increase systemic vascular
resistance and reduce right to left shunt.
emergency Blalock Taussig shunt.
Other notes:
A single episode of hypercyanotic spell is an indication for early surgical
referral (either total repair or Blalock Taussig shunt).
Oral propranolol 0.2 1 mg/kg/dose 8 to 12 hourly should be started soon
after stabilization while waiting for surgical intervention.
181
CARDIOLOGY
Clinical Presentation
Peak incidence age: 3 to 6 months.
Often in the morning, can be precipitated by crying, feeding, defaecation.
Severe cyanosis, hyperpnoea, metabolic acidosis.
In severe cases, may lead to syncope, seizure, stroke or death.
There is a reduced intensity of systolic murmur during spell.
182
CARDIOLOGY
Chapter 37: Heart Failure

Definition
Defined as the inability to provide adequate cardiac output to meet the
metabolic demand of the body.
Causes of heart failure
Congenital structural heart lesions: more common during infancy.
Primary myocardial, acquired valvular diseases: more likely in older children.
Congenital heart disease
Acquired valvular disease
Left to right shunt lesions
Chronic rheumatic valvular diseases
VSD, PDA, AVSD, ASD
Post infective endocarditis
Obstructive left heart lesions
Myocardial disease
Hypoplastic left heart syndrome,
Primary cardiomyopathy
Coarctation of aorta, aortic stenosis Idiopathic, familial

Common mixing unrestricted pulmonary Secondary cardiomyopathy
flow
Truncus arteriosus, TAPVD, tricuspid Arrhythmia-induced: congenital
atresia with
heart block, atrial ectopic tachycardia
TGA, single ventricle, pulmonary
atresia with VSD,
Infection: post viral myocarditis,

Chagas disease
Large aortopulmonary collateral
Ischaemic: Kawasaki disease
Valvular regurgitation
Myopathic: muscular dystrophy,
AV valve regurgitation, Ebstein anomaly Pompe disease, mitochondrial dis.

Semilunar valve regurgitation
Metabolic: hypothyroidism
Myocardial ischaemia
Drug-induced: anthracycline
Anomalous origin of left coronary

artery from pulmonary artery.
Others: iron overload (thalassaemia)

Acute myocarditis
Viral, rheumatic, Kawasaki disease
Clinical presentation
Varies with age of presentation.
Symptoms of heart failure in infancy:
Feeding difficulty: poor suck, prolonged time to feed, sweating during feed.
Recurrent chest infections.
Failure to thrive.
183
CARDIOLOGY
Causes of Heart Failure
CARDIOLOGY
Signs of heart failure in infancy:

Resting tachypnoea, subcostal recession.
Tachycardia, Poor peripheral pulses, poor peripheral perfusion.
Hyperactive praecordium, praecordial bulge.
Hepatomegaly.
Wheezing.
Common signs of heart failure in adults, i.e. increased jugular venous
pressure, leg oedema and basal lung crackles are not usually found in
children.
Treatment
General measures
Oxygen supplementation, propped up position
Keep warm, gentle handling.
Fluid restriction to normal maintenance if not dehydrated or in shock
Optimize caloric intake; low threshold for nasogastric feeding;
- consider overnight continuous infusion feeds.
Correct anaemia, electrolyte imbalance, treat concomitant chest infections
Antifailure medications
Frusemide (loop diuretic)
Dose: 1 mg/kg/dose OD to QID, oral or IV
Continuous IV infusion at 0.1 0.5 mg/kg/hour if severe fluid overload
Use with potassium supplements (1 - 2 mmol/kg/day) or add potassium
sparing diuretics.
Spironolactone (potassium sparing diuretic, modest diuretic effect)
Dose: 1 mg/kg/dose BD
Captopril
Angiotensin converting enzyme inhibitor, afterload reduction agent
Dose: 0.1 mg/kg/dose TDS, gradual increase up to 1 mg/kg/dose TDS
Monitor potassium level (risk of hyperkalaemia)
Digoxin
Role controversial
Useful in heart failure with excessive tachycardia, supraventricular
tachyarrhythmias.
IV inotropic agents - i.e. Dopamine, Dobutamine, Adrenaline, Milrinone
Use in acute heart failure, cardiogenic shock, post-op low output syndrome.
Specific management
Establishment of definitive aetiology is of crucial importance
Specific treatment targeted to underlying aetiology. Examples:
Surgical/transcatheter treatment of congenital heart lesion.
Pacemaker implantation for heart block.
Control of blood pressure in post-infectious glomerulonephritis.
High dose aspirin steroid in acute rheumatic carditis.
184
Chapter 38: Acute Rheumatic Failure

Introduction
An inflammatory disease of childhood resulting from untreated
Streptococcus pyogenes (group A streptococcus) pharyngeal infections.
Peak incidence 5 to 15 years; more common in females.
Diagnostic criteria for Acute Rheumatic Fever
Minor Criteria
Investigations
o
Carditis
Fever (Temp > 38 C)
FBC: anaemia, leucocytosis
Polyarthritis, aseptic
monoarthritis or
polyarthralgia
ESR > 30 mm/h or

CRP > 30 mg/L
Elevated ESR and CRP
Chorea
Throat swab, ASOT

Blood culture
Erythema marginatum
CXR, ECG.
Echocardiogram
Subcutaneous nodules
Making the Diagnosis:
Initial episode of ARF:
2 major criteria or 1 major + 2 minor criteria,
+ evidence of a preceding group A streptococcal infection
Recurrent attack of ARF: (known past ARF or RHD)
2 major criteria or 1 major + 2 minor criteria or 3 minor criteria,
+ evidence of a preceding group A streptococcal infection
Note:
1. Evidence of carditis: cardiomegaly, cardiac failure, pericarditis, tachycardia out of
proportion to fever, pathological or changing murmurs.
2. Abbrevations: ARF, Acute Rheumatic Fever; RHD, Rheumatic Heart Disease
Treatment
Aim to suppress inflammatory response so as to minimize cardiac damage,
provide symptomatic relief and eradicate pharyngeal streptococcal infection
Bed rest. Restrict activity until acute phase reactants return to normal.
Anti-streptococcal therapy:
IV C. Penicillin 50 000U/kg/dose 6H
or Oral Penicillin V 250 mg 6H (<30kg), 500 mg 6H (>30kg) for 10 days
Oral Erythromycin for 10 days if allergic to penicillin.
Anti-inflammatory therapy
mild / no carditis:
Oral Aspirin 80-100 mg/kg/day in 4 doses for 2-4 weeks, tapering over
4 weeks.
pericarditis, or moderate to severe carditis:
Oral Prednisolone 2 mg/kg/day in 2 divided doses for 2 - 4 weeks,
taper with addition of aspirin as above.
185
CARDIOLOGY
Major Criteria
anti-failure medications
Diuretics, ACE inhibitors, digoxin (to be used with caution).
CARDIOLOGY
Important:
Consider early referral to a Paediatric cardiologist if heart failure persists or
worsens during the acute phase despite aggressive medical therapy.
Surgery may be indicated.
Secondary Prophylaxis of Rheumatic Fever
IM Benzathine Penicillin 0.6 mega units (<30 kg)
or 1.2 mega units (>30 kg) every 3 to 4 weeks.
Oral Penicillin V 250 mg twice daily.
Oral Erythromycin 250 mg twice daily if allergic to Penicillin.
Duration of prophylaxis
Until age 21 years or 5 years after last attack of ARF whichever was longer
Lifelong for patients with carditis and valvular involvement.
186
Chapter 39: Infective Endocarditis
Modified Duke Criteria for the Diagnosis of Infective Endocarditis

Major Criteria
Minor Criteria
Blood culture positive:

Typical microorganisms from two
separate blood cultures:
Predisposing heart condition, prior

heart surgery, indwelling catheter
Viridans streptococci
Fever, temperature > 38C

Vascular phenomena:
Streptococcus bovis
Major arterial emboli
HACEK group
Septic pulmonary infarcts
Staphylococcus aureus
Mycotic aneurysm
Community-acquired enterococci
Intracranial hemorrhage,
Conjunctival hemorrhages
Evidence of endocardial
involvement on echocardiogram
Janeways lesions
Immunologic phenomena:
Gomerulonephritis
Footnote:
1, Fastidious gram negative bacteria from
Haemophilus spp,
Actinobacillus actinomycetemcomitans,
Cardiobacterium hominis,
Eikenella corrodens and
Kingella kingae
Oslers nodes
Roths spots
Positive Rheumatoid factor
Microbiological evidence:
Positive blood culture not
meeting major criterion
187
CARDIOLOGY
Introduction
An uncommon condition but has a high morbidity and mortality if untreated.
Underlying risk factors include:
Congenital heart disease
Repaired congenital heart defects
Congenital or acquired valvular heart diseases
Immunocompromised patients with indwelling central catheters
Common symptoms are unexplained remitting fever > 1 week, loss of weight,
loss of appetite and myalgia.
Definition of Infective Endocarditis According to the Modified Duke Criteria
CARDIOLOGY
Definite IE
Possible IE
Pathological criteria
1 major +
1 minor criteria
Microorganisms by
OR
Culture
Histological examination 3 minor
of vegetation or intracardiac abscess specimen.
pathological lesions with
active endocarditis.
Clinical criteria
2 major or
1 major + 3 minor or
5 minor
Rejected IE
Firm alternative
diagnosis
Resolution of
symptoms with
antibiotic therapy
< 4 days.
No pathological
evidence of IE at
surgery or autopsy.
Not meet criteria for
possible IE.
Footnote: IE, Infective Endocarditis

Investigations
Blood culture
C- Reactive protein/ESR
Full blood count
Urine FEME
Chest X-ray
Echocardiography
Management
Ensure 3 blood cultures taken before antibiotic therapy.
Do not wait for echocardiography.
Use empirical antibiotics, until culture results available (see Table on facing page).
188
IV Vancomycin 40 mg/kg/day in 2 div doses x 46wks

AND
IV/IM Gentamicin 3 mg/kg/day in 3 div doses x 4-6wks
AND
IV Ciprofloxacin 20-30 mg/kg/day in 2 div doses x4-6wks
Penicillin allergy
IV Cefazolin 100mg/kg/day in 3 div doses x 6 wks
Methicillin Resistance IV Vancomycin 40 mg/kg/day in 2-4 div doses x 6wks
IV Ampicillin-Sulbactam 300mg/kg/day in 4-6 div doses

x 4-6 wks
AND
IV Gentamicin 3mg/kg/day in 3 div doses x 4-6 wks
IV Amphotericin B > 6 weeks

AND Valve replacement surgery
AND Long-term (lifelong) therapy with Oral azole
Culture- Negative
Endocarditis
Fungal Endocarditis
Candida spp or
Aspergillosis
IV Cloxacillin 200mg/kg/day in 4-6 div doses x 6wks

+/IV/IM Gentamicin 3mg/kg/day in 3 div doses x 3-5 days
IV Penicillin G 300,000 U/kg/day in 4-6 div doses x

4 - 6wks AND
IV Gentamicin 3 mg/kg/day in 3 div doses x 4 - 6 wks
Enterococcus
endocarditis
Methicillin sensitive
Staphylococcus
endocarditis
IV Vancomycin 30 mg/kg/day in 2 div doses x 46 wks

AND
IV/IM Gentamicin 3 mg/kg/day in 3 div doses x 2wks
Streptococcus
viridans
endocarditis

AND
IV/IM Gentamicin 3 mg/kg/day in 3 div doses x 2wks
IV Penicillin G 200,000 U/kg/day in 4-6 div doses x 4wks IV Vancomycin 30 mg/kg/day in 2 div doses x 46wks
AND
AND
IV/IM Gentamicin 3 mg/kg/day in 3 div doses x 2wks IV/IM Gentamicin 3 mg/kg/day in 3 div doses x 2wks
Empirical Therapy
For Infective
Endocarditis
Alternative Regime
Preferred Regime
Antibiotic choices for Infective endocarditis in Children (Adapted from Malaysian CPG on antibiotic usage)
Indication
CARDIOLOGY
189
CARDIOLOGY
Guidelines on Infective Endocarditis (IE) prophylaxis

IE prophylaxis Recommended
IE prophylaxis Not Recommended
High-risk category
Prosthetic cardiac valves.
Previous bacterial endocarditis.
Complex cyanotic congenital heart
disease.
Surgical systemic pulmonary shunts
or conduits.
Negligible-risk category
Isolated secundum ASD.
Repaired ASD,VSD, PDA (> 6 mths)
Mitral valve prolapse without
regurgitation.
Functional, or innocent heart
murmurs.
Previous Kawasaki disease without
valvar dysfunction.
Previous rheumatic fever without
valvar dysfunction.
Cardiac pacemakers and implanted
defibrillators.
Moderate-risk category
Other congenital cardiac defects
(other than high/low risk category)
Acquired valvar dysfunction.
(e.g. rheumatic heart disease)
Hypertrophic cardiomyopathy.
Mitral valve prolapse with regurgitation.
Common procedures that require IE Prophylaxis

Oral, dental procedures
Extractions, periodontal procedures.
Placement of orthodontic bands
(but not brackets).
Intraligamentary local anaesthetic
injections.
Prophylactic cleaning of teeth.
Respiratory procedures
Tonsillectomy or adenoidectomy.
Surgical operations involving
respiratory mucosa.
Rigid bronchoscopy.
Flexible bronchoscopy with biopsy.
Gastrointestinal procedures
Sclerotherapy for esophageal varices.
Oesophageal stricture dilatation.
Endoscopic retrograde
cholangiography biliary tract surgery.
Surgical operations involving
intestinal mucosa.
Genitourinary procedures
Cystoscopy.
Urethral dilation.
Antibiotic guidelines for IE prophylaxis

Endocarditis Prophylactic Regimens for Dental, Oral, Respiratory Tract and
Esophageal Procedures
Standard general prophylaxis
Penicillin allergy (Either one of below):
Oral Amoxicillin 50 mg/kg (max 2

Gm), one hour before procedure
OR
IV/IM Ampicillin 50 mg/kg
(max 2 Gm)
Oral Clindamycin 20 mg/kg (max 600 mg)

Oral Cephalexin 50 mg/kg (max 2 Gm)
Oral Azithromycin/clarithromycin 50 mg/kg
(max 500 mg)
Oral Erythromycin 20 mg/kg (max 3 Gm)
IV Clindamycin 20 mg/kg (max 600 mg)
Note: Give oral therapy 1 hour before procedure; IV therapy 30 mins before procedure.
190
Chapter 40: Kawasaki Disease

Introduction
A systemic febrile condition affecting children usually < 5 years old.
Aetiology remains unknown, possible bacterial toxins or viral agents with
genetic predisposition.
Also known as mucocutaneous lymph node syndrome.
Fever lasting at least 5 days.

At least 4 out of 5 of the following:
Bilateral non-purulent conjunctivitis.
Mucosal changes of the oropharynx (injected pharynx, red lips, dry
fissured lips, strawberry tongue).
Changes in extremities (oedema and/or erythema of the hands or feet,
desquamation, beginning periungually).
Rash (usually truncal), polymorphous but non vesicular.
Cervical lymphadenopathy.
Illness not explained by other disease process.
Clinical Pearls
Diagnosis is via table above. Other helpful signs in making the diagnosis:
Indurated BCG scar, Perianal excoriation
Irritability, Altered mental state, Aseptic meningitis.
Transient arthritis.
Diarrhoea, vomiting, abdominal pain.
Hepatosplenomegaly.
Hydrops of gallbladder.
Sterile pyuria.
Investigations
Full blood count - anaemia, leucocytosis, thrombocytosis.
ESR and CRP are usually elevated.
Serum albumin < 3g / dl; Raised alanine aminotransaminase
Urine > 10 wbc / hpf
Chest X-ray, ECG.
Echocardiogram in the acute phase; Repeat at 6-8 wks/earlier if indicated.
Note:
Most important complication is coronary vasculitis, usually within 2 weeks
of illness, affecting up to 25% of untreated children.
Usually asymptomatic, it may manifest as myocardial ischaemia, infarction,
pericarditis, myocarditis, endocarditis, heart failure or arrhythmia.
191
CARDIOLOGY
Diagnostic Criteria for Kawasaki Disease
CARDIOLOGY
Incomplete Kawasaki Disease

Patients who do not fulfill the classic diagnostic criteria outlined above. Tends
to occur in infants and the youngest patients. High index of suspicion should
be maintained for the diagnosis of incomplete KD. Higher risk of coronary
artery dilatation or aneurysm occurring.
Echocardiography is indicated in patients who have prolonged fever with:
two other criteria,
subsequent unexplained periungual desquamation,
two criteria + thrombocytosis
rash without any other explanation.
Atypical Kawasaki Disease
For patients who have atypical presentation, such as renal impairment, that
generally is not seen in Kawasaki Disease.
Treatment
Primary treatment
IV Immunoglobulins 2 Gm/kg infusion over 10 - 12 hours.
Therapy < 10 days of onset effective in preventing coronary vascular damage.
Oral Aspirin 30 mg/kg/day for 2 wks or until patient is afebrile for 2-3 days.
Maintainence:
Oral Aspirin 3-5 mg/kg daily (anti-platelet dose) for 6 - 8 weeks or until ESR
and platelet count normalise.
If coronary aneurysm present, then continue aspirin until resolves.
Alternative: Oral Dipyridamole 3 - 5 mg/kg daily.
Kawasaki Disease not responding to Primary Treatment
Defined as persistent or recrudescent fever 36hrs after completion of initial
dose of IV Immunoglobulins.
Treatment
Repeat IV Immunoglobulins 2 Gm/kg infusion over 10 - 12 hours
Vaccinations
The use of Immunoglobulins may impair efficacy of live-attenuated virus
vaccines. Delay these vaccinations for at least 11 months.
Prognosis
Complete recovery in children without coronary artery involvement.
Most (80%) 3-5 mm aneursyms resolve; 30% of 5-8 mm aneurysms resolve.
Prognosis worst for aneurysms > 8 mm in diameter.
Mortality in 1 - 2 %, usually from cardiac complications within 1 - 2 months
of onset.
192
No restrictions beyond
6-8 weeks
Avoid contact sports
Long term aspirin and

warfarin
(target INR 2.0-2.5)
or LMWH in giant
aneurysms
Long term aspirin;

Avoid contact sports
Warfarin or LMWH if
giant aneurysm persists.
Also consider betablockers
Level IV
> 1 large or giant coronary
artery aneurysm, or multiple
or complex aneurysms in
same coronary artery,
without destruction.
Level V
Coronary artery
obstruction.
LMWH, low molecular weight heparin
Age <11 yr old:

No restriction beyond
6-8 weeks .
Avoid contact sports if
on aspirin
Level III
Low dose aspirin until
One small-medium coronary aneurysm regression
artery aneurysm, major
documented
coronary artery.
None beyond 6-8

weeks
Level II
Transient coronary artery
ectasia; none after 6-8 wks
Physical Activity
No restrictions beyond
6-8 weeks
Treatment
Level I
None beyond 6-8
No coronary artery changes weeks
Risk Level
Risk stratification and long term follow up after Kawasaki Disease

Follow up
Invasive Testing
Biannual
echocardiogram and
ECG;
Annual stress test
Biannual
echocardiogram and
ECG;
Annual stress test
Angiography to address
therapeutic options
Angiography at 6-12 mo or
sooner if indicated;
Repeated study if non-invasive test, clinical or laboratory
findings suggest ischemia
Annual echocarAngiography if non-invasive

diogram and ECG, and test suggests ischemia
cardiovascular risk assessment counselling
Cardiovascular risk
None
assessment, counselling
at 3 - 5yr intervals
Cardiovascular risk
None
assessment, counselling
at 5yr intervals
CARDIOLOGY
193
194
CARDIOLOGY
Chapter 41: Viral Myocarditis

Introduction
Defined as inflammation of the myocardium with myocellular necrosis.
Viruses are found to be most important cause of acute myocarditis.
Other causes include Mycoplasma, typhoid fever, diphtheria toxins etc.
Useful Investigations for Myocarditis

Electrocardiogram (ECG)
Sinus tachycardia, Non-specific ST segment , Pathological Q wave,
low QRS voltages (<5mm in any precordial lead), T wave inversion.
Arrhythmia
Heart block, ventricular ectopics
Chest x-ray
Cardiomegaly (normal heart size doesnt exclude myocarditis)
Pleural effusion
Echocardiography
Findings often varied and non-specific, although rarely entirely normal
Global left ventricular dilatation and Hypocontractility
Pericardial effusion
Functional mitral regurgitation
Need to exclude other structural abnormalities, especially coronary artery anomalies.
Cardiac biomarkers
Troponin T , Troponin I, Creatinine kinase (CK) and CK-MB
Microbiological studies, including polymerase chain reaction (PCR)
Enterovirus 71, coxsackie B virus, adenovirus, parvovirus B19,
cytomegalovirus, echovirus, Mycoplasma, Salmonella typhi
Contrast enhanced MRI
Myocardial oedema, focal enhancement, regional wall motion abnormalities.
Endomyocardial biopsy
195
CARDIOLOGY
Vary from asymptomatic ECG abnormalities to acute cardiovascular
collapse, even sudden death.
There may be prodromol symptoms of viremia, including fever, myalgia,
coryzal symptoms or gastroenteritis.
The diagnosis is made clinically, with a high index of suspicion, with the
following presentation that cannot be explained in a healthy child:
- Tachycardia, Respiratory distress, Other signs of heart failure, Arrhythmia.
CARDIOLOGY
Management
Depends on the severity of the illness. Patients with heart failure require
intensive monitoring and haemodynamic support.
Treatment of heart failure: see Ch 37: Heart Failure.
Consider early respiratory support, mechanical ventilation in severe cases.
Specific treatment
Treatment with IV immunoglobulins and immunosuppressive drugs have
been studied but the effectiveness remains controversial and routine
treatment with these agents cannot be recommended at this moment.
Prognosis
One third of patients recover.
One third improve clinically with residual myocardial dysfunction.
The other third does poorly and develops chronic heart failure, which may
cause mortality or require heart transplantation.
196
Chapter 42: Paediatric Arrhythmias

BRADYARRHYTHMIA
Sinus node dysfunction
Criteria for sinus bradycardia (Table below):
ECG criteria
Age Group
Heart Rate
<100 bpm
Children 3 9 years
< 60 bpm
Children 9 16 years
< 50 bpm
Adolescents > 16 years
< 40 bpm
24 hours Ambulatory ECG criteria

Age Group
Infants to 1 year of age
Heart Rate
< 60 bpm sleeping, < 80 bpm awake
Children 1 6 years
< 60 bpm
Children 7 11 years
< 45 bpm
Adolescents, young adults
< 40 bpm
Highly trained athletes
< 30 bpm
Systemic causes of sinus bradycardia:

Hypoxia
Sepsis
Intracranial lesions Acidosis
Hypothyroidism Anorexia nervosa
Electrolytes abnormalities i.e. hypokalaemia, hypocalcaemia
Causes of sinus node dysfunction
Right atrial dilatation due to volume loading
Cardiomyopathies
Inflammatory conditions: myocarditis, pericarditis, rheumatic fever
Post atrial surgery: Mustard, Senning, Fontan, ASD closure, cannulation for
cardiopulmonary bypass
197
CARDIOLOGY
Infants to < 3 years
CARDIOLOGY
Atrioventricular block
Classification
1st degree - prolonged PR interval
2nd degree
Mobitz type 1 (Wenckebach): progressive PR prolongation before
dropped AV conduction.
Mobitz type 2: abrupt failure of AV conduction without prior PR
prolongation.
High grade 3:1 or more AV conduction.
3rd degree (complete heart block): AV dissociation with no atrial impulses
conducted to ventricles.
Note: 2nd degree (Type 2 and above) and 3rd degree heart block are always
pathological
Aetiology
Congenital in association with positive maternal antibody (anti-Ro and
anti-La); mother frequently asymptomatic
Congenital heart diseases: atrioventricular septal defect (AVSD), congenital
corrected transposition of great arteries (L-TGA), left atrial isomerism
Congenital long QT syndrome
Surgical trauma: especially in VSD closure, TOF repair, AVSD repair,
Konno procedure, LV myomectomy, radiofrequency catheter ablation
Myopathy: muscular dystrophies, myotonic dystrophy, Kearns-Sayre
syndrome.
Infection: diphtheria, rheumatic fever, endocarditis, viral myocarditis
Acute Management: Symptomatic Bradycardia with Haemodynamic Instability
Treat the underlying systemic causes of bradycardia
Drugs:
IV Atropine
IV Isoprenaline infusion
IV Adrenaline infusion
Transcutaneous pacing if available.
Patients who are not responding to initial acute management should be
referred to cardiologist for further management.
Emergency transvenous pacing or permanent pacing may be required.
198
Atrial flutter (AF)

Saw tooth flutter waves
Variable AV conduction
Ectopic Atrial Tachycardia (EAT)
Multifocal atrial tachycardia
Abnormal P wave axis.
P wave precedes QRS.
Variable rate.
Warm up and cool down
phenomenon.
Multifocal Atrial Tachycardia
Atrioventricular Re-entry Tachycardia
(MAT)
Irregularly irregular
Multiple different P wave
morphologies, bizarre, chaotic.
No two RR intervals the same
Atrioventricular Nodal Re-entry Tachycardia
Atrioventricular Re-entry
Tachycardia (AVRT)
P wave follows QRS.
Atrioventricular Nodal Re-entry
Tachycardia (AVNRT)
Permanent Junctional Reciprocating Tachycardia
P wave not visible,
superimposed on QRS.
Permanent Junctional
Reciprocating Tachycardia (PJRT)
Inverted P waves in II, III, aVF
appear to precede QRS
Ventricular Tachycardia
complex.
Long RP interval.
Ventricular tachycardia (VT)
Wide QRS complex.
P wave may be dissociated
Ventricular Fibrillation
from the QRS complex.
Ventricular fibrillation (VF)
chaotic, irregular rhythm.
199
CARDIOLOGY
TACHYARRHYTHMIA
Classification
Atrial tachycardia: AF, EAT, MAT Atrial Flutter
Conduction system tachycardia or
supraventricular tachycardia:
AVRT, AVNRT, PJRT
Ventricular tachycardia: VT, VF
Ectopic Atrial Tachycardia
Description
ALGORITHM FOR IDENTIFYING TACHYARRHYTHMIA

QRS WIDTH
CARDIOLOGY
Narrow QRS
Wide QRS
P/QRS ratio
P/QRS ratio
< 1:1
> 1:1
1:1
< 1:1
QRS-P interval
P wave
not visible
AVNRT
Short,
follows QRS
Orthodromic
AVRT
JET
Very long
1:1
VT
VT
SVT + BBB
Antidromic AVRT
PJRT/EAT
Regular
Variable
Chaotic
Atrial Flutter
EAT
MAT/Fib
Abbrevations. VT, ventricular tachycardia; JET, junctional ectopic tachycardia;

SVT, supraventricular tachycardia; BBB, bundle branch block; Fib, fibrillation.
AVRT, atrioventricular re-entry tachycardia; AVNRT, atrioventricular nodal
re-entry tachycardia; PJRT, permanent junctional reciprocating tachycardia;
EAT, ectopic atrial tachycardia; MAT, multifocal atrical tachycardia;
200
ALGORITHM FOR MANAGEMENT OF ACUTE TACHYARRHYTHMIA

TACHYARRHYTHMIA
Narrow QRS
Vagal
manoeuvers
Adenosine
Propranolol
Atenolol
Amiodarone
Unstable
Synchronised
Cardioversion
Stable
Amiodarone
Lignocaine
in Ventricular
Tachycardia
Unstable
Synchronised
Cardioversion
OR
Defribillation
Narrow QRS complex tachycardia

Haemodynamically stable
Vagal manoeuvers:
Icepack/iced water for infants: apply to face for a max of 30 seconds .
Valsalva manoeuvers if child is old enough (blow into a pinched straw).
IV Adenosine: 0.1mg/kg (max 6mg) rapid push. Increase by 0.1mg/kg every
2 mins until tachycardia terminated or up to a maximum of 0.5mg/kg
(maximum: 18 mg).
IV Propranolol 0.02mg/kg test dose, then 0.1mg/kg over 10 minutes.
IV Amiodarone: 25mcg/kg/min for 4 hours then 5 -15mcg/kg/min until
conversion.
Haemodynamically unstable
Synchronized DC conversion at 0.5 to 1 joule/kg.
Wide QRS complex tachycardia
Haemodynamically stable
IV Amiodarone (same as above).
IV Procainamide.
IV Lignocaine.
Synchronized cardioversion at 0.5 to 1.0 joule/kg.
In pulseless patients, defibrillate at 2 to 4 joules/kg.
201
CARDIOLOGY
Stable
Wide QRS
CARDIOLOGY
Pitfalls in management
Consult a cardiologist if these acute measures fail to revert the tachycardia.
In Wolff-Parkinson-White syndrome, digoxin is contraindicated because
paroxysms of atrial flutter or fibrillation can be conducted directly into the
ventricle.
Adenosine unmasks the atrial flutter by causing AV block and revealing
more atrial beats per QRS complex.
In wide QRS complex tachycardia with 1:1 ventriculoatrial conduction, it is
reasonable to see if adenosine will cause cardioversion, thereby making a
diagnosis of a conduction system dependent SVT.
A follow up plan should be made in consultation with cardiologist.
202
References
Section 4 Cardiology
Chapter 34 Paediatric Electrocardiography
1.Goodacre S, et al. ABC of clinical electrocardiography: Paediatric electrocardiography. BMJ 2002;324: 1382 1385.
Chapter 39 Infective Endocarditis

1.AHA Statement. Infective endocarditis. Circulation. 2005;111:31673184
2.AHA Statement. Unique Features of Infective Endocarditis in Childhood.
Circulation 2002;105:2115-2127
3.Crawford M , Durack D. Clinical Presentation of Infective endocarditis.
Cardiol Clin 2003;21: 159166
4.Role of echocardiography in the diagnosis and management of infective
endocarditis. Curr Opin Cardiol 2002, 17:478485
5.National Guideline on antibiotic usage.
Chapter 40 Kawasaki Disease
1.Shinahara M, Sone K, Tomomasa T: Corticosteroid in the treatment of the
acute phase of Kawasaki disease. J Pediatr 1999; 135: 465-9
2.Newburger J, Sleeper L, McCrindle B, et al. Randomised Trial of Pulsed
Corticosteroid Therapy for Primary Treatment of Kawasaki Disease. NEJM
2007; 356: 663-675.
3.Diagnosis, treatment, and long term management of Kawasaki Disease.
A statement for health professionals from the committee on rheumatic
fever, endocarditis, and Kawasaki disease, Council on cardiovascular
disease in the young, American Heart Association. Circulation. 2004; 110:
2747-2771.
Chapter 41 Viral Myocarditis
1.Batra A, Lewis A. Acute Myocarditis. Curr Opin Pediatr 2001; 13: 234-239.
2.Kaski J, Burch M. Viral Myocarditis in Childhood. J Paed and Child Health
2007,17:1; 11-18.
3.Haas G. Etiology, Evaluation, and Management of Acute Myocarditis. Cardiol Rev 2001, 9: 88-95.
4. Jared W. Magnani J, G. William G. Myocarditis. Current Trends in Diagnosis
and Treatment. Circulation 2006.
203
CARDIOLOGY
Chapter 38 Acute Rheumatic Fever

1.Patrick J, Bongani M. Acute Rheumatic Fever. Medicine 2006; 34:239-243
2.Jonathan R, Malcolm M, Nigel J. Acute rheumatic fever. Lancet 2005;
366:155-168
3.Judith A, Preet J, Standford T. Acute rheumatic fever: Clinical aspects and
insights into pathogenesis and revention. Clinical and Applied Immunology
Reviews 2004; 263-276
4.Ismail E. Rheumatic fever/ Baillieres Clinical Rheumatology 1995; 9:111-120
CARDIOLOGY
Chapter 42 Paediatric arrhythmia

1.Kothari D, et al. Neonatal tachycardias: an update. Arch Dis Child Fetal
Neonatal Ed 2006; 91: F136 F144.
2.Hanisch D, et al. Pediatric arrhythmias. Journal of Pediatric Nursing 2001;
Vol 16 (5): 351 362.
3.Neonatal cardiac arrhythmias. Intensive care nursery house staff manual of
UCSF Childrens Hospital 2004.
4.Batra Aet al. Arrhythmias: medical and surgical management. Paediatrics
and child health;17:1: 1 5.
5.Paediatric arrhythmias. Handbook of Paediatrics, UMMC 2nd Edition.
204
Chapter 43: Status Epilepticus

ALGORITHM FOR MANAGEMENT OF STATUS EPILEPTICUS
Child with SEIZURE
Seizure > 5 mins

Impending
Status epilepticus
At Home, In Ambulance
PR Diazepam
0.2- 0.5 mg/kg (Max 10mg)
0.5mg/kg (2-5yrs); 0.3mg/kg
(6-11yrs); 0.2mg/kg (12yrs +)
Seizure 5-30 mins

Established
Status epilepticus
Consider:
IV Diazepam 0.2mg/kg slow bolus
(if not already given)
IV Phenytoin 20 mg/kg
(Max Loading dose 1.25 Gm)
Dilute in 0.9% saline; Max. conc. at
10 mg/ml; Infuse over 20-30 mins,
with cardiac monitoring.
If on maintainence
Phenytoin, then give
IV Phenobarbitone
Monitor blood sugar,
electrolytes, blood
counts, liver function,
blood gases.
Consider blood culture,
toxicology,
neuroimaging,
antiepileptic drug levels.
If <2 yrs old, consider
IV Pyridoxine 100 mg.
CONSULT PAEDIATRICIAN !
Early Refractory
Status epilepticus
Seizures continue
> 10 mins
after Phenytoin
Consider One of the following:

IV Midazolam 0.2 mg/kg bolus
(at 2 mg/min; Max 10 mg),
then infusion 3-5 mcg/kg/min
up to a max of 15 mcg/kg/min)
IV Phenobarbitone 20 mg/kg
(Max Loading dose 1 Gm)
Infusion at 25- 50 mg/min),
IV Levetiracetam 40 mg/kg
infused over 10 minutes,
then 20 mg/kg 12 hourly
Seizure > 60 mins

Established Refractory
Status epilepticus
IV Sodium Valproate 20 mg/kg

(Max Loading 1.25 Gm, given
over 1-5 mins, at 20-50 mg/min),
then infusion 1- 5 mg/kg/hour
for 6 - 12 hours)
Discuss with Paediatric Neurologist
and Intensivist about inducing coma
205
Monitor BP, respiration

Start inotropic support,
esp. if given
Midazolam or
Phenobarbitone
Arrange for ICU.
Secure airway, prepare
to use mechanical
ventilation.
Titrate Phenobarbitone
to achieve burstsuppression pattern
on EEG.
Avoid Sodium Valproate
in metabolic
encephalopathy.
NEUROLOGY
In Hospital
Obtain IV access
IV Diazepam 0.2mg/kg slow bolus
(at 2 mg/min; maximum 10mg)
Ensure
Ventilation
Adequate Perfusion
(ABCs)
Bedside Blood Sugar
NEUROLOGY
Definition
Any seizure lasting > 30 minutes or
Intermittent seizures, without regaining full consciousness in between,
for > 30 minutes.
However, any seizure > 5 minutes is unlikely to abort spontaneously, and
should be treated aggressively. Furthermore, there is evidence of progressive, time-dependent development of pharmaco-resistance if seizures
continue to perpetuate.
Refractory status epilepticus:
Seizures lasting for >60 minutes or not responding to adequate doses of
benzodiazepine and second line medications.
Salient Points
Optimize vital functions throughout control of Status Epilepticus.
Apart from terminating seizures, management of Status Epilepticus
should include, identifying and treating underling cause.
Presence of Status Epilepticus may mask usual signs and symptoms of
meningitis or encephalitis, resulting in a danger of overlooking
life-threatening infections.
Common mistakes in failing to treat Status Epilepticus are underdosing of
anticonvulsants, excessive time lag between doses/steps of treatment and
neglecting maintenance therapy after the initial bolus of anticonvulsants
have been given. See Drug Doses for maintenance doses of
anticonvulsants.
206
Chapter 44: Epilepsy
APPROACH TO A CHILD WITH A FIRST SEIZURE

Definition
One or multiple unprovoked afebrile seizures within 24 hours with recovery
of consciousness between seizures.
Notes:
30-50% of first unprovoked seizures in children will recur.
70-80% of second seizure will recur.
Detailed history to determine if event is a seizure or a paroxysmal
non-epileptic event, e.g. syncope, breath-holding spell, gastroesophageal
reflux.
A thorough clinical examination is important to look for any possible
underlying aetiology.
There is a need to exclude acute provoking factors.
What Investigations Need To Be Done?
Routine investigations such as FBC, BUSE, Ca, Mg, RBS if
Child unwell (vomiting, diarrhoea etc).
Child not alert, lethargic or failure to return to baseline alertness.
Lumbar puncture indicated if there is suspicion of brain infection.
Toxicology screening considered if there is suspicion of drug exposure.
EEG is recommended after all first afebrile unprovoked seizures.
EEG helps classify seizure type, epilepsy syndrome and predict recurrence.
Neuroimaging (MRI preferred) indicated for:
Persisting postictal focal deficit (Todds paresis).
Condition of child not returned to baseline within several hours after the
seizure.
Is Treatment Required?
Treatment with anticonvulsant NOT indicated in all first afebrile seizure as it
does not prevent development of epilepsy or influence long term remission
207
NEUROLOGY
Definition
A neurological condition characterised by recurrent unprovoked epileptic
seizures.
An epileptic seizure is the clinical manifestation of an abnormal and
excessive discharge of a set of neurons in the brain.
An epileptic syndrome is a complex of signs and symptoms that define a
unique epilepsy condition. Syndromes are classified on the basis of seizure
type(s), clinical context, EEG features and neuroimaging.
It is important to differentiate epileptic seizures from paroxysmal
non-epileptic events such as neonatal sleep myoclonus, breath-holding
spells, vasovagal syncope, long Q-T syndrome.
NEUROLOGY
APPROACH TO A CHILD WITH EPILEPSY

Detailed history of the seizures. Video of the actual event is helpful.
Also note birth history, developmental milestones and family history.
Look for dysmorphism, neurocutaneous signs; do thorough CNS,
developmental examination.
Investigations are recommended ILAE Classification of seizure types
when a second afebrile seizure
Generalised
occurs:
Routine biochemical tests only Tonic-clonic
if clinical features suggest a
Absence (typical, atypical)
biochemical disorder, e.g.
hypoglycaemia, hypocalcaemia. Myoclonic
Do an ECG if suspicion of a
Tonic
cardiac dysrhythmia.
Clonic
EEG is important to support
the clinical diagnosis of
Atonic
epileptic seizures, classify the
Focal seizures
epileptic syndrome, selection
of anti-epileptic drug and
Epileptic spasms
prognosis. It also helps in
ILAE, International League Against Epilepsy
localization of seizure foci in
intractable epilepsy.
Neuroimaging (preferably MRI) is indicated for any child with:
Epilepsy occurring in the first year of life, except febrile seizures.
Focal epilepsy except benign rolandic epilepsy.
Developmental delay or regression.
Intractable epilepsy.
Principles of antiepileptic drug therapy for Epilepsy
Treatment recommended if 2 episodes (recurrence risk up to 80%)
Attempt to classify the seizure type(s) and epileptic syndrome. Monotherapy
as far as possible. Choose most appropriate drug, increase dose gradually until
epilepsy controlled or maximum dose reached or side effects occur.
Add on the second drug if first drug failed. Optimise second drug, then try
to withdraw first drug. (alternative monotherapy).
Rational combination therapy (usually 2 or maximum 3 drugs) i.e.
combines drugs with different mechanism of action and consider their
spectrum of efficacy, drug interactions and adverse effects.
Drug level monitoring is not routinely done (except phenytoin), unless noncompliance, toxicity or drug interaction is suspected.
When withdrawal of medication is planned (generally after being seizure
free for 2 years) , consideration should be given to epilepsy syndrome, likely
prognosis and individual circumstances before attempting slow withdrawal
of medication over 3-6 months (maybe longer if clonazepam or
phenobarbitone). If seizures recur, the last dose reduction is reversed and
medical advice sought.
208
* Epilepsies (generalized or focal), due to: (If unable to classify into the above)
- Structural / metabolic causes
- Genetic causes
- Unknown cause.
Reflex epilepsies
Hemiconvulsion-hemiplegia-epilepsy
Gelastic seizures with hypothalamic hamartoma

Rasmussen syndrome
Epilepsy with continuous spike-wave

during sleep (CSWS)
Benign familial infantile epilepsy
Mesial TLE with hippocampal sclerosis
Others
Childhood absence epilepsy (CAE)
Lennox-Gastaut syndrome
Benign infantile epilepsy
Familial focal epilepsies
Juvenile myoclonic epilepsy (JME)
Landau-Kleffner syndrome (LKS)
Epilepsy with myoclonic absences
Myoclonic epilepsy in infancy
Dravet syndrome
Late onset childhood occipital epilepsy
West syndrome
Progressive myoclonic epilepsies (PME)
Benign rolandic epilepsy (BECTS)
Autosomal-dominant nocturnal FLE
Panayiotopoulos syndrome
Ohtahara syndrome
Infancy
Epilepsy with GTC seizures alone
Epilepsy with myoclonic-atonic seizures
Early myoclonic encephalopathy
Juvenile absence epilepsy (JAE)
Febrile seizure plus (FS+)
Benign familial neonatal epilepsy
Adolescent - Adult
Childhood
Neonatal period
Classification of epilepsies and epileptic syndromes (adapted from ILAE 2010)
NEUROLOGY
209
Selecting antiepileptic drugs according to seizure types

Seizure type
First line
Second line
Carbamazepine
Valproate
Lamotrigine, Topiramate,
Levetiracetam, Clobazam,
Phenytoin, Phenobarbitone
Tonic-clonic / clonic
Valproate
Clonazepam, Carbamazepine1,
Phenytoin1, Phenobarbitone
Absence
Valproate
Lamotrigine, Levetiracetam
Atypical absences,
Atonic, tonic
Valproate
Clonazepam, Phenytoin
Myoclonic
Valproate
Clonazepam
Topiramate, Levetiracetam
Clobazam, Lamotrigine2,
Phenobarbitone
Infantile Spasm
ACTH, Prednisolone, Nitrazepam, Clonazepam,

Vigabatrin3
Valproate, Topiramate
Focal Seizures
NEUROLOGY
Generalized Seizures
Footnote:
1, May aggravate myoclonus/absence seizure in Idiopathic Generalised Epilepsy.
2, May cause seizure aggravation in Dravet syndrome and JME.
3, Especially for patients with Tuberous Sclerosis.
Antiepileptic drugs that aggravate selected seizure types
Phenobarbitone
Absence seizures
Clonazepam
Causes Tonic status in Lennox-Gastaut syndrome
Carbamazepine
Absence, Myoclonic, Generalised tonic-clonic seizures
Lamotrigine
Dravet syndrome,
Myoclonic seizures in Juvenile Myoclonic Epilepsy
Phenytoin
Absence, Myoclonic seizures
Vigabatrin
Myoclonic, Absence seizures
210
When to refer to a Paediatric Neurologist?

Refer immediately (to contact paediatric neurologist)
Behavioural or developmental regression.
Infantile spasms.
Refer
Poor seizure control despite monotherapy with 2 different antiepileptic
medications.
Difficult to control epilepsies beginning in the first two years of life.
Structural lesion on neuroimaging.
Advice for Parents
Educate and counsel on epilepsy.
Emphasize compliance if on an antiepileptic drug.
Dont stop the medication by themselves. This may precipitate
breakthrough seizures.
In photosensitive seizures: watch TV in brightly lit room. Avoid sleep
deprivation.
Use a shower with bathroom door unlocked.
No cycling in traffic, climbing sports or swimming alone.
Know emergency treatment for seizure.
Inform teachers and school about the condition.
First Aid Measures during a Seizure (Advise for Parents/Teachers)
Do not panic, remain calm. Note time of onset of the seizure.
Loosen the childs clothing especially around the neck.
Place the child in a left lateral position with the head lower than the body.
Wipe any vomitus or secretion from the mouth.
Do not insert any object into the mouth even if the teeth are clenched.
Do not give any fluids or drugs orally.
Stay near the child until the seizure is over and comfort the child as
he/she is recovering.
211
NEUROLOGY
The patients with Intractable Epilepsy

Please re-evaluate for the following possibilities: Is it a seizure or a non-epileptic event?
Antiepileptic drug dose not optimised.
Poor compliance to antiepileptic drug.
Wrong classification of epilepsy syndrome, thus wrong choice of
antiepileptic drug.
Antiepileptic drug aggravating seizures.
Lesional epilepsy, hence a potential epilepsy surgery candidate.
Progressive epilepsy or neurodegenerative disorder.
212
Drowsiness, dizziness, ataxia, diplopia, rashes
Drowsiness, hypotonia, salivary and bronchial hypersecretion,

hyperactivity and aggression
Dizziness, somnolence, insomnia, rash
Somnolence, asthenia, dizziness, irritability, behavioural change
Behavioural disturbance, cognitive dysfunction, drowsiness,

ataxia, rash
Ataxia, diplopia, dizziness, sedation, hirsutism, gum hypertrophy

megaloblastic anemia
Nausea, epigastric pain, tremor, alopecia, weight gain, hair loss,

thrombocytopaenia
weight loss, somnolence, mental slowing, word finding difficulty,

hypohidrosis, renal calculi
drowsiness, dizziness, mood changes, weight gain
Carbamazepine
Clobazam2
Clonazepam
Lamotrigine
Levetiracetam
Phenobarbitone
Phenytoin
Sodium valproate
Topiramate
Vigabatrin
Peripheral visual field constriction

(tunnel vision)
Hepatic toxicity (< 2 yrs age),

pancreatitis, encephalopathy
Steven-Johnson syndrome
Steven-Johnson syndrome1,
agranulocytosis
Serious toxicity
Footnote: 1, Steven-Johnson syndrome occurs more frequently in Chinese and Malay children who carry the HLA-B*1502 allele.
2, Clobazam is less sedative than clonazepam
Common side effects
Antiepileptic Drug
Side effects and serious toxicity of Antiepileptic Drugs
NEUROLOGY
Chapter 45: Febrile Seizures

Definition
Seizures occurring in association with fever in children between 3 months
and 6 years of age, in whom there is no evidence of intracranial pathology
or metabolic derangement.
No comprehensive local epidemiological data. Studies in Western Europe
quote a figure of 3-4% of children < 5 years experiencing febrile seizures.
Classification of Febrile Seizures
Complex Febrile Seizures
Duration < 15 minutes
Duration > 15 minutes
Generalised seizure.
Focal features
Does not recur during the febrile

episode
> 1 seizure during the febrile

episode
Residual neurological deficit
post-ictally, such as Todds paralysis
Management
Not all children need hospital admission. The main reasons are: To exclude intracranial pathology especially infection.
Fear of recurrent seizures.
To investigate and treat the cause of fever besides meningitis/encephalitis.
To allay parental anxiety, especially if they are staying far from hospital.
Investigations
The need for blood counts, blood sugar, lumbar puncture, urinalysis,
chest X-ray, blood culture etc, will depend on clinical assessment of the
individual case.
lumbar puncture
Must be done if: (unless contraindicated see Ch 46: Meningitis)
- Any signs of intracranial infection.
- Prior antibiotic therapy.
- Persistent lethargy and not fully interactive 6 hours after the seizure.
Strongly recommended if
- Age < 12 months old.
- First complex febrile seizures.
- In district hospital without paediatrician.
- Parents have difficulty bringing in child again if deteriorates at home.
Serum calcium and electrolytes are rarely necessary.
EEG is not indicated even if multiple recurrences or complex febrile
seizures.
Parents should be counselled on the benign nature of the condition
213
NEUROLOGY
Simple Febrile Seizures
NEUROLOGY
Control fever
Avoid excessive clothing
Use antipyretic e.g. syrup or rectal Paracetamol 15 mg/kg 6 hourly for
patients comfort, though this may not reduce the recurrence of seizures.
Parents should also be advised on First Aid Measures during a Seizure.
Rectal Diazepam
Parents of children with high risk of recurrent febrile seizures should be
supplied with Rectal Diazepam (dose : 0.5 mg/kg).
They should be advised on how to administer it if the seizures lasts
more than 5 minutes.
Prevention of recurrent febrile seizures.
- Anticonvulsants are not recommended for prevention of recurrent febrile
seizures because:
The risks and potential side effects of medications outweigh the benefits
No medication has been shown to prevent the future onset of epilepsy.
Febrile seizures have an excellent outcome with no neurological
deficit nor any effect on intelligence.
Risk factors for Recurrent Febrile Seizures
Family history of Febrile seizures
Age < 18 months
Low degree of fever (< 40 oC) during first Febrile seizure.
Brief duration (< 1 hr) between onset of fever and seizure.
* No risk factor < 15 % recurrence
2 risk factors > 30 % recurrence
3 risk factors > 60 % recurrence
Risk factors for subsequent Epilepsy
Neurodevelopmental abnormality
Complex febrile seizures
Family history of epilepsy
Prognosis in Febrile Seizures
Febrile seizures are benign events with excellent prognosis
3 - 4 % of population have Febrile seizures.
30 % recurrence after 1st attack.
48 % recurrence after 2nd attack.
2 - 7 % develop subsequent afebrile seizure or epilepsy.
No evidence of permanent neurological deficits following Febrile
seizures or even Febrile status epilepticus.
214
Chapter 46: Meningitis

Introduction
Meningitis is still a major and sometimes fatal problem in Paediatrics.
Morbidity is also high. A third of survivors have sequelae of their disease.
However, these complications can be reduced if meningitis is treated early.
APPROACH TO A CHIILD WITH FEVER AND SIGNS/SYMPTOMS OF MENINGITIS
When NOT to do a Lumbar Puncture

Lumbar Puncture (LP)

Contraindicated?
No
Glasgow coma scale 8

Yes
Do LP
Abnormal dolls eye reflex or

unequal pupils
Withhold LP
Lateralized signs or abnormal posturing

Immediately after a recent seizure
Do Blood, urine C&S

Start Antibiotics
Dexamethasone
Papilloedema
Normal CSF, wait for

CSF culture and Latex agglutination
Abnormal CSF
Continue antibiotics
Positive
Improvement
No improvement
Complete Treatment
(See Next Page)
Persistent Fever > 72 hrs

and Neurological deficit
(rule out various causes)
Negative
Re-evaluate, Consider
discontinue Antibiotics
Consider Ultrasound / CT Brain

Repeat LP if no evidence of raised ICP
Change antibiotics
No response
Response
Consider TB, Fungus

or Encephalitis
Complete course of
antibiotics
215
NEUROLOGY
Fever & Symptoms/Signs

of Bacterial Meningitis
Cerebrospinal fluid values in neurological disorders with fever

Condition
Leukocytes
(mm)
NEUROLOGY
Acute Bacterial
Meningitis
Protein (g/l)
Glucose
(mmol/l)
Comments
100 - >50,000 Usually 1- 5 <0.5 - 1.5 Gram stain may be

positive
Partially-treated
1 - 10,000
Bacterial
Usually high PMN,
Meningitis
but may have
lymphocytes
>1
Low
CSF may be sterile

in Pneumococcal,
Meningococcal
meningitis
Tuberculous
Meningitis
10 - 500
Early PMN, later
high lymphocytes
1- 5
0 - 2.0
Smear for AFB, TB

PCR + in CSF;
High ESR
50 500
Lymphocytes
0.5 - 2
10 - 1,000
Normal /
0.5-1
Fungal
Meningitis
Encephalitis
Normal or CSF for

low
Cryptococcal Ag
Normal CSF virology and
HSV DNA PCR
Recommended antibiotic therapy according to likely pathogen

Age Group
< 1 month
Initial
Antibiotic
C Penicillin +
Cefotaxime
Likely Organism
Grp B Streptococcus
E. coli
Duration
(if uncomplicated)
21 days
1 - 3 months C Penicillin +
Cefotaxime
Group B Streptococcus
E. coli
H. influenzae
Strep. pneumoniae
10 21 days
> 3 months C Penicillin +

Cefotaxime, OR
Ceftriaxone
H. influenzae
Strep. pneumoniae
N. meningitides
7 10 days
10 14 days
7 days
Note:
Review antibiotic choice when infective organism has been identified.
Ceftriaxone gives more rapid CSF sterilisation as compared to Cefotaxime
or Cefuroxime.
If Streptococcal meningitis, request for MIC values of antibiotics.
MIC level
Drug of choice:
MIC < 0.1 mg/L (sensitive strain)
C Penicillin
MIC 0.1-< 2 mg/L (relatively resistant) Ceftriaxone or Cefotaxime
MIC > 2 mg/L (resistant strain)
Vancomycin + Ceftriaxone or Cefotaxime
4. Extend duration of treatment if complications e.g. subdural empyema,
brain abscess.
216
Use of Steroids to decrease the sequelae of bacterial meningitis

Best effect achieved if given before or with the first antibiotic dose.
Dose:
Dexamethasone 0.15 mg/kg 6 hly for 4 days or 0.4 mg/kg 12 hly for 2 days
Give steroids if CSF is turbid and patient has not received prior antibiotics.
If persistent fever in a patient on treatment for meningitis, consider:

Thrombophlebitis and injection sites e.g. intramuscular abscess.
Intercurrent infection e.g. pneumonia, UTI or nosocomial infection.
Resistant organisms. Inappropriate antibiotics or inadequate dosage.
Subdural effusion, empyema or brain abscess.
Antibiotic fever.
Follow up (Long term follow up is important)
Note development of child at home and in school.
Note head circumference.
Ask for any occurrence of fits or any behavioural abnormalities.
Assess vision, hearing and speech.
Request for early formal hearing assessment in cases of proven meningitis.
Until child shown to have normal development (usually until 4 years old).
Prognosis depends on
Age: worse in younger patients.
Duration of illness prior to effective antibiotics treatment.
Causative organism: more complications with H. influenzae, S. pneumoniae.
Presence of focal signs.
217
NEUROLOGY
Supportive measures
Monitor temperature, pulse, BP and respiration 4 hourly and input/output.
Nil by month if unconscious.
Careful fluid balance required. Often, maintenance IV fluids is sufficient.
However, if SIADH occurs, reduce to 2/3 maintenance for initial 24 hours.
Patient may need more fluid if dehydrated.
If fontanel is still open, note the head circumference daily. Consider cranial
ultrasound or CT scan if effusion or hydrocephalus is suspected.
Seizure chart.
Daily Neurological assessment is essential.
Observe for 24 hours after stopping therapy and if there is no
complication, patient can be discharged.
Indications for Head CT Scan

Useful to detect complications
Prolonged depression of consciousness
Prolonged focal or late seizures
Focal neurological abnormalities
NEUROLOGY
Enlarging head circumference

Suspected subdural effusion or empyema
Indications for Subdural drainage

Rapid increase in head circumference
with no hydrocephalus
Focal neurological signs
Increased intracranial pressure
Suspected subdural empyema
218
Chapter 47: Acute CNS Demyelination

Introduction
These disorders consist of monophasic and polyphasic (recurrent) diseases
with acquired immune injury to the white matter in the central nervous
system.
Optic neuritis
Acute loss of vision (decreased visual acuity) of one or both eyes
Often associated with pain on eye movements and colour desaturation
A relative afferent pupillary defect is present
MRI may show swelling and abnormal signal of the optic nerves.
Acute Disseminated Encephalomyelitis (ADEM)

Acute encephalopathy (behavioural change or alteration of consciousness)
with multifocal neurological deficits/signs,
e.g. limb weakness, numbness, cerebellar ataxia, cranial nerve palsy,
speech impairment, visual loss, seizures and spinal cord involvement.
MRI shows multiple areas of abnormal signal in the white matter.
No other aetiologies can explain the event.
ADEM: Common Differential Diagnoses
CNS infection
Bacterial, tuberculous meningitis, Herpes simplex encephalitis
Clinically isolated syndrome (1st episode of Multiple sclerosis)
Guillain Barr syndrome
Acute stroke
Mitochondrial disorders
Other Investigations (as needed)
Cerebrospinal fluid - FEME, cultures, oligoclonal banding, Herpes virus PCR
(optional: lactate, viral studies)
Infection screen - virology, mycoplasma, etc.
Vasculitis screen (ESR, C3,C4, antinuclear factor).
Evoked potentials - visual, auditory and somatosensory.
219
NEUROLOGY
Acute transverse myelitis

Spinal cord dysfunction, with motor weakness, numbness of both legs
and/or arms, often associated with urinary retention
Maximal deficits occurring between 4 hours - 21 days after symptom onset
MRI may demonstrate swelling +/or abnormal signal in the spinal cord
NEUROLOGY
Treatment
Supportive measures
Vital sign monitoring, maintain blood pressure
Assisted ventilation for cerebral / airway protection
Anticonvulsants for seizures
Antibiotics / Acyclovir for CNS infections if febrile, awaiting cultures, PCR
result.
Definitive immunotherapy
IV Methylprednisolone 20 - 30 mg/kg/day (max 1 gm) daily, divided into
8 hourly dosing, for 3 to 5 days
Then oral Prednisolone 1 mg/kg/day (max 60 mg) daily to complete 2 wks.
Give longer course of oral prednisolone, 4-8 weeks for ADEM and
transverse myelitis with residual deficit.
If no response, consider: IV Immunoglobulins 2 gm/kg over 2 - 5 days
(or referral to a paediatric neurologist)
If Demyelinating episodes recur in the same patient, refer to a Paediatric
Neurologist.
220
Chapter 48: Acute Flaccid Paralysis

Introduction
Acute Flaccid Paralysis (AFP) occurs when there is rapid evolution of motor
weakness (< than 4 days), with a loss of tone in the paralysed limb. This excludes
weakness due to trauma and spastic paralysis.
AFP is a medical emergency as unnecessary delays can result in death and disability. Children with AFP need to be assessed and managed carefully. A simple
algorithm is provided on the next page.
Protocol for AFP surveillance in Malaysia

Step
Timing
Description
Case Detection At diagnosis
Follow case definition for AFP
Case Reporting Within 24 hours
Fax forms to 03-2693 8094

(Virology Unit, IMR; Tel no: 03-2616 2677)
Timing of stool Within 2 weeks of 2 stool specimens collected no less than

specimens
onset of paralysis 24 hours apart
Collection of
specimens
Fresh stool. Avoid rectal swabs.

(at least 8g size of an adult thumb).
Place in a sterile glass bottle.
Transport of
stools
As soon as able
Maintain a cold chain of 2 - 8 oC.

Transport in frozen ice packs or dry ice.
Ensure stool specimens arrive at IMR
within 72 hours of stool collection.
Caution: avoid desiccation, leakage;
Ensure adequate documentation and use
AFP Case Laboratory Request Form
Follow up of
patients
60 days from
paralysis
To determine whether there is residual

paralysis on follow up
221
NEUROLOGY
AFP surveillance in children

Collecting stools for enterovirus in children with AFP is an important part of
the Global Polio Eradication Initiative (GPEI).
For Malaysia to remain a polio-free country we need to prove that none of
our cases of AFP are caused by poliovirus infection. To do this we have to
report all cases of AFP aged < 15 years, send stools for enterovirus isolation
using a standardised protocol, and follow up children with AFP to determine
the outcome.
CLINICAL APPROACH TO A CHIILD WITH ACUTE FLACCID PARALYSIS

NEW ONSET
Difficulty in Walking
CNS Symptomatology
CNS Disorder
No demonstrable CNS
signs or motor weakness
Musculoskeletal
disorder
Demonstrable
Lower limb Motor Weakness
NEUROLOGY
Clinical Questions
Sphincters ?
Preserved
Sensory Loss ? None

Reflexes ?
Reduced
or normal
Clinical
Localisation
MUSCLE
Preserved
Preserved
Glove & Stocking
Differential
Diagnosis
Post viral myositis
Periodic paralysis
Toxic myositis
Dermatomal
Absent
Dermatomal
Absent, reduced or normal
PERIPHERAL NERVE
unilateral
bilateral
Enteroviral
infection
Local trauma
Guillain Barr
syndrome
Toxic neuropathy
Investigations
Required
AFP workup
Creatine kinase
Serum electrolytes
Urine myoglobin
Affected
Required
AFP workup
Nerve conduction
study
Optional
MRI Lumbosacral
plexus, sciatic nerve
Required
AFP workup
CSF cells, protein
Nerve conduction
study
SPINAL CORD
Acute transverse
myelitis
Spinal cord /
extraspinal tumour
Arteriovenous
malformation
Spinal cord stroke
Extradural abscess
Spinal tuberculosis
Spinal arachnoiditis
Required
AFP workup
URGENT Spinal
Cord MRI
Optional
(as per MRI result)
TB workup
CSF cells, protein,
sugar, culture,
TB PCR,
Cryptococcal Ag,
Oligoclonal bands
ESR, C3,C4,
antinuclear factor
Notes: 1. Headache, vomiting, seizures, encephalopathy, cranial nerve deficits,

ataxia, brisk tendon reflexes, upgoing plantar response.
2. Soft tissue, joint or bony causes of walking difficulty.
222
Chapter 49: Guillain Barr Syndrome

Introduction
Guillain Barr syndrome (GBS) is a post-infectious inflammatory disorder
affecting the peripheral nerves.
Clinical Pearls on GBS in Children
Rapidly progressive, bilateral and relatively symmetric weakness of the
limbs with decrease or absent reflexes. In atypical cases, weakness may
begin in the face or upper limbs, or asymmetrical at onset.
Sensory symptoms, e.g. limb pain and hyperesthesia, are common.
CSF protein level and nerve conduction studies may be normal in the
first week of illness.
GBS variants and overlapping syndrome:
Miller Fisher syndrome - cranial nerve variant characterised by
opthalmoplegia, ataxia and areflexia.
Bickerstaffs brainstem encephalitis - acute encephalopathy with cranial
and peripheral nerve involvement.
Management
The principle of management is to establish the diagnosis and anticipate /
pre-empt major complications.
a Clinical diagnosis can be made by a history of progressive, ascending
weakness (< 4 wks) with areflexia, and an elevated CSF protein level and
normal cell count (protein-cellular dissociation).
Nerve conduction study is Confirmatory.
Initial measures
Give oxygen, keep NBM if breathless. Monitor PEFR regularly
Admit for PICU / PHDU care, if having:
Respiratory compromise (deteriorating PERF).
Rapidly progressive tetraparesis with loss of head control.
Bulbar palsy.
Autonomic and cardiovascular instability.
Provide respiratory support early with BiPAP or mechanical ventilation
223
NEUROLOGY
Bladder and bowel involvement may occasionally be seen, but is never

present at onset and never persistent
(if so, think of spinal cord disorder)
NEUROLOGY
Hughes Functional Scale for GBS

0
Normal
Minor symptoms, capable of running
Able to walk up to 10 meters without assistance but unable to run
Able to walk 10 meters with assistance of one person, or a walker
Unable to walk
Requires assisted ventilation
Specific measures
IV Immunoglobulins (IVIG) 2 gm /kg total over 2 - 5 days in the first 2 wks
of illness, with Hughes functional scale 3 and above or rapidly deteriorating.
IVIG is as efficacious as Plasma exchange in both children and adults, and is
safer and technically simpler.
10 % of children with GBS may suffer a relapse of symptoms in the first
weeks after improvement from IVIG. These children, may benefit from a
second dose of IVIG.
General measures
Prophylaxis for deep vein thrombosis should be considered for patients
ventilated for GBS, especially if recovery is slow.
Liberal pain relief, with either paracetamol, NSAIDs, gabapentin or opiates.
224
Chapter 50: Approach to The Child With Altered Consciousness

consider:
Airway . . . . . secure airway, endotracheal intubation
Breathing . . . oxygen, artificial ventilation if required
Circulation . . IV bolus, ionotropes, chest compressions
Dextrostix . . correct hypoglycemia promptly
Once stable, monitor HR, BP, Resp rate, SpO, urine output
WHAT IS
THE GCS?
If GCS 12 . . monitor GCS hourly

If GCS < 12 . . monitor GCS hourly till improves
CONSIDER
Airway obstructs if not supported.

Airway compromised by vomiting.
Respiratory rate too low for adequate ventilation.
SpO remains < 92 % despite high flow O
and airway opening manouevres.
Signs of shock even after 40 ml/kg of fluid resuscitation.
Signs of exhaustion.
GCS < 8 and deteriorating.
3 ENDOTRACHEAL
INTUBATION IF:
Look for & treat:
RAISED
INTACRANIAL
PRESSURE
CONSIDER
AETIOLOGY
6 INVESTIGATIONS
SEPSIS
SHOCK
SEIZURES
If Clinically has Papilloedema, or if 2 of the following:
GCS < 8
Unreactive, unequal pupils
Abnormal dolls eye reflex
Decorticate, decerebrate posturing
Abnormal breathing (Cheyne-Stokes, apneustic)
CNS Infection
Bacterial meningitis
Viral encephalitis
TB meningitis
Brain abscess
Cerebral malaria
Trauma
Vasculitis
Acute Poisoning
Metabolic disease
Hypoglycaemia
Hyperammonemia
Non-accidental injury
Post convulsive state
Hypertensive crisis
Acute Disseminated Encephalomyelitis
Cerebral venous sinus thrombosis
Recommended
Sample when ILL:
FBC, urea & electrolytes, glucose 1-2 ml plasma/serum: separated, frozen & saved
Liver function tests
10-20 ml urine: frozen & saved
Serum ammonia, blood gas
Blood cultures
Optional:
Urinalysis
EEG, Vasculitis screen, Toxicology, IEM Screen,
Blood film for malaria parasite
Delay Lumbar Puncture
Neuroimaging: Consider CT Brain for all children with ICP, or if cause of coma is
uncertain; MRI is more useful if a brain tumour or ADEM is suspected
225
NEUROLOGY
INITIAL
ASSESSMENT
MANAGEMENT
NEUROLOGY
Management of Raised ICP

Nursing
Elevate head up to 30
Avoid unnecessary suction, procedures
Fluid balance
Keep patient well hydrated
Avoid hypo-osmolar fluid, plain dextrose solutions
Care with sodium homeostasis:
action
consider
urine
SIADH
Fluid restriction
output
serum
sodium
Replace renal
Cerebral
urine
salt wasting sodium losses
sodium
Maintain cerebral blood flow
Keep CPP > 50 mmHg
If BP: do not lower unless hypertensive crisis,
e.g. acute glomerulonephritis
Intracranial
Cerebral (CPP)
Mean (MAP)
= Arterial
- Pressure (ICP)
Perfusion
Pressure
Pressure
Use of IV Mannitol
Regular doses at 0.25 - 0.5 g/kg q.i.d. if required.
A CT scan to exclude intracranial bleeding is recommended.
PaO , PaCO level
Maintain good oxygenation, normocapnia.
i.e. PaCO 4.0 - 4.6 kPa / 35 - 40 mmHg
Surgical decompression
If medical measures fail, surgical decompression may
be indicated (ie. external ventricular drainage,
decompressive hemicraniectomy)
Treatment of Infection
Antibiotics: In all children, unless alternative cause of
coma is evident
Acyclovir: In children with encephalitis, until CSF PCR
results known
Others:
Anti-tuberculous therapy, anti-malarials
Treatment of Metabolic Encephalopathy
. . . . refer section on Metabolic disease in children
OUTCOME
General rules
Outcome depends on the underlying cause:
1/3 die, 1/3 recover with deficits, 1/3 recover completely
Acute complications improve with time.
e.g. cortical blindness, motor deficits
Metabolic causes may require long term dietary
management.
226
Chapter 51: Childhood Stroke

Introduction
The overall incidence of neonatal stroke is 1 in 4,000 live births, while for
childhood stroke is 2.5-13 per 100,000 children / year.
Ischaemic stroke, including arterial ischaemic stroke (AIS) and cerebral
sinovenous thrombosis (CSVT) is increasingly diagnosed in children.
Arterial Ischaemic Stroke
Incidence: 2-8 per 100,000 children / year.
Recurrence occurs in 10-30% of childhood AIS.
Clinical features
Typically sudden, maximal at onset (but may be evolving, waxing & waning).
Focal deficits : commonest - motor deficits (hemiparesis), sensory deficits,
speech / bulbar disturbance, visual disturbance, unsteadiness.
Diffuse neurological disturbance : altered consciouness, headache
Seizures.
Other non-specific features in neonatal stroke including apnoea, feeding
difficulty, abnormal tone.
Potential Risk Factors for Arterial Ischaemic Stroke
Cardiogenic
Congenital, acquired heart diseases;
Cardiac procedure, Arrhythmia
Vasculopathy
Non-vasculitis
Dissection, Moyamoya,
Post-varicella angiopathy
Vasculitis
Primary CNS vasculitis;
Secondary vasculitis
(Infective vasculitis, SLE, Takayasu)
Prothrombotic disorders
Inherited thrombophilia
Acquired thrombophilia:
Nephrotic syndrome, malignancy,
L-Asparaginase, anti-phospholipid
syndrome
Acute disorders
Head and neck disorder:
Trauma, Infection - Meningitis,
otitis media, mastoiditis, sinusitis.
Systemic disorders:
Sepsis, dehydration, asphyxia
Chronic disorders
Iron deficiency anaemia
Metabolic disorders
Homocystinuria, Dyslipidaemia,
Organic acidemia
MELAS (Mitochondrial
encephalomyopathy, lactic acidosis
with stroke-like episodes)
227
NEUROLOGY
Definition
1. Acute onset (may be evolving) of focal diffuse neurological disturbance
and persistent for 24 hours or more, AND
2. Neuro-imaging showing focal ischaemic infarct in an arterial territory and
of maturity consistent with the clinical features.
NEUROLOGY
Investigations
Blood workup :
Basic tests: FBC / FBP, renal profile, LFT, RBS, lipid profile, iron assay
(as indicated).
Thrombophilia screen: PT/PTT/INR, protein C, protein S, anti-thrombin III,
factor V Leiden, lupus anti-coagulant, anti-cardiolipin, serum
homocysteine level.
If perinatal / neonatal stroke: to do mothers lupus anti-coagulant and
anti-cardiolipin level.
Further tests may include MTHFR (methylenetetrahydrofolate reductase),
lipoprotein A, Prothrombin gene mutations.
Vasculitis workup (if indicated) : C3, C4, CRP, ESR, ANA
Further tests may include dsDNA, p-ANCA, c-ANCA
Others: Suspected metabolic aetiologies lactate & VBG for MELAS.
Cardiac assessment : ECG & Echocardiogram (ideally with bubble study)
Neuro-imaging (consult radiologist)
Goals to ascertain any infarction, haemorrhages, evidence of clots /
vasculopathy and to exclude stroke-mimics.
If stroke is suspected, both brain parenchymal and cervico-cephalic
vascular imaging should be considered.
Brain imaging
Cervico-cephalic Vascular Imaging
Cranial Ultrasound
If fontanel is open.
Carotid artery Ultrasound / Doppler

If suspected carotid dissection or
stenosis.
CT scan
Quick, sensitive for haemorrhages
but may miss early, small and
posterior fossa infarcts.
MR Angiogram (MRA)
Intracranial vessels (with MRI) & to
include neck vessels if suspected
cervical vasculopathy.
MRI scan (with DWI+ADC)

Better parenchymal details and
sensitive for early infarct
CT Angiogram / Formal cerebral

angiogram
May be considered in certain cases.
228
Contraindications of Anti-thrombotic therapy

Infarct associated with significant hemorrhage
Large infarct with the worry of secondary haemorrhagic transformation;
Uncontrolled hypertension
Other risks for bleeding
Caution with Aspirin
Reyes syndrome has been linked to use of aspirin during febrile illness.
Reduce aspirin by 50% during fever > 38C.
Withhold for 3-5 days if suspected/confirmed varicella / influenza infection.
229
NEUROLOGY
Management
General care
Resuscitation: A, B, Cs.
Admit to ICU if indicated for close vital signs and GCS monitoring.
(post-infarction cerebral oedema may worsen 2-4 days after acute stroke)
Workup for the possible underlying risk factor(s) and treat accordingly.
If cervical dissection is the likely aetiology ( eg : history of head & neck
trauma, Marfan syndrome, carotid bruit), apply soft cervical collar.
Acute neuro-protective care :
General measures for cerebral protection.
Maintain normothermia, normoglycemia, normovolemia
Monitor fluid balance, acceptable BP, adequate oxygenation, treat
seizures aggressively.
Acute Anti-thrombotic therapy :
Consult paediatric neurologist (and haematology team if available) for
the necessity, choice and monitoring of anti-thrombotic therapy.
If stroke due to cardiac disease/procedure, should also consult
cardiologist/cardio-thoracic team.
If anti-thrombotic is needed, consider anti-coagulation therapy
(unfractionated heparin / LMWH) or aspirin. Ensure no contraindications.
Secondary preventive therapy:
If needed, consider Aspirin (3-5mg/kg/day, may be reduced to 1-3mg/kg/
day if has side effects.)
Duration: generally for 3-5 years but may be indefinitely.
Caution with long-term aspirin. (See below)
Alternatively, LMWH or warfarin may be used in extra-cranial dissection,
intracardiac clots, major cardiac disease or severe prothrombotic disorders.
Childhood Cerebral Sino-venous Thrombosis (CSVT):
NEUROLOGY
Introduction
20-30% of childhood stroke due to CSVT; 30-40 % of CSVT will lead to
venous infarcts or stroke.
More than 50% of venous infarcts are associated with haemorrhages.
Consider CSVT if infarct corresponds to venous drainage territories or
infarct with haemorrhage not due to vascular abnormality.
Clinical features (Typically sub-acute)
Diffuse neurological disturbance:
Headache, seizures, altered sensorium, features of increased intracranial
pressure (papilloedema, 6th cranial nerves palsy).
Focal deficits if venous infarct.
Risk factors
Prothrombotic conditions (Inherited, L-asparaginase, nephrotic syndrome)
Acute disorders (Head & neck trauma / infection, dehydration, sepsis)
Chronic disorders (SLE, thyrotoxicosis, iron deficiency anaemia, malignancy)
Blood workup
Thrombophilia screen and others depending on possible risk factor(s)
Neuro-imaging
Brain imaging - as in Childhood AIS guidelines.
Cerebral Venogram
MRV-TOF (time-of-flight) flow dropout artefact may be a problem
CTV better than MRV-TOF, but radiation exposure is an issue.
Management
General care and acute neuro-protective care as in AIS.
Consult Paediatric neurologist for anti-coagulation therapy (ensure no
contraindications).
Consult neuro-surgery if infarct associated with haemorrhage.
230
Chapter 52: Brain Death

Definition
Brain death is a state when the function of the brain as a whole, including the
brain stem is irreversibly lost. A person certified to be brain dead is dead.
Test
(All conditions and exclusions fulfilled before proceeding to examine and test
for brain death)
1. Pupillary light reflex.
No response to bright light in both eyes.
2. Oculocephalic reflex. (Dolls eye response)
Testing is done only when no fracture or instability of the cervical spine
is apparent.
The oculocephalic response is elicited by fast, vigorous turning of the
head from middle position to 90o on both sides.
3. Corneal reflex.
No blinking response seen when tested with a cotton swab.
4. Motor response in cranial nerve distribution.
No grimacing seen when pressure stimulus applied to the supraorbital
nerve, deep pressure on both condyles at level of the temporo-mandibular
joint or on nail bed.
231
NEUROLOGY
Diagnosis of brain death (All to be fulfilled)

Preconditions:
Patient is in deep coma, apnoeic and on ventilator
Cause of coma fully established and sufficient to explain the status of patient.
There is irremediable structural brain damage.
Exclusions:
Coma due to metabolic or endocrine disturbance, drug intoxication and
primary hypothermia (defined as a core temperature of 32 C or lower).
Certain neurological disorders, e.g. Guillain Barre Syndrome, Miller Fisher
syndrome and Locked-in Syndrome.
Coma of undetermined cause.
Preterm neonates.
Diagnostic Criteria ( All to be fulfilled )
Deep coma, unresponsive and unreceptive, Glasgow scale 3 / 15
Apnoeic, confirmed by apnoea test
Absent brain stem reflexes confirmed by the following tests:1. Pupillary light reflex.
2. Oculocephalic reflex.
3. Motor response in cranial nerve distribution
4. Corneal reflex
5. Vestibulo-ocular reflex (caloric test)
6. Oro-pharygeal reflex
7. Tracheo-bronchial reflex
NEUROLOGY
5. Vestibulo-ocular reflex (Caloric test).

The test should not be performed if the tympanic membrane is perforated.
The head is elevated to 30o during irrigation of the tympanum on each
side with 50 ml of ice water.
Allow 1 minute after injection and at least 5 minutes between testing
on each side.
Tonic deviation of the eyes in the direction of cold stimulus is absent.
6. Oropharyngeal reflex.
Absent gag response when the posterior pharynx is stimulated.
7. Tracheo-bronchial reflex.
A suction catheter is passed down through the endotracheal tube to the level
of the carina or beyond. Lack of cough response to bronchial suctioning
should be demonstrated.
8. Apnoea test.
Prerequisites: the patient must be in a stable cardiovascular and
respiratory state.
Adjust ventilator to maintain PaCO at or around 40 mmHg.
Pre-oxygenate with 100% O for 10 minutes.
Disconnect from ventilator.
Deliver 100% O via tracheal catheter at 6 L/min
Monitor O saturation with pulse oximetry
Measure PaCO after 5 minutes and again after 8 minutes if PaCO has
not exceeded 60 mmHg.
Re-connect to ventilator after the test.
Disconnection of the ventilator shall not exceed 10 mins at any one time
The apnoea test is positive when there is no respiratory effort with a
PaCO of 60 mmHg.
If during apnoea testing, there is significant hypotension, marked
desaturation or cardiac arrhythmias immediately draw an arterial blood
sample, re-connect to ventilator and analyse ABG.
Should the PaCO < 60 mmHg, the result is indeterminate.
It is left to the discretion of the paediatrician to decide whether to repeat
the test or to depend on an ancillary test to finalise the clinical diagnosis
of brain death.
Note: For patients with chronic lung disease, the baseline PaCO may already
be above 40 mmHg. The apnoea test is then considered positive if there is no
respiratory effort at a PaCO of 20 mmHg above the baseline PaCO
232
Assessment and Certification

Two specialists who are competent (at least 3 years of postgraduate clinical
experience and trained in brain death assessment) in diagnosing brain death
are qualified to certify brain death.
They should preferably be paediatricians, anaesthesiologists, neurologists
and neurosurgeons. Doctors involved in organ transplantation are not
allowed to certify brain death.
A repeat assessment and certification must be carried out after the first
(with interval between the 2 examinations depending on the age of the
child), not necessarily by the same pair of specialists.
The Brain Death Certification form is filled up by the first set of doctors
(Doctor A and B) and completed by the 2nd set of doctors (Doctor C and D)
or Doctor A and B if the same doctors are performing the repeat test. The
time of death will then be declared by the doctors performing the repeat test.
The time of death is at the time of the 2nd testing. Should the patients heart
stop before the repeat test, that will be taken as the time of death.
Brain death certification must only be done in areas of the hospital with full
facilities for intensive cardiopulmonary care of the comatose patients.
Time criteria and ancillary testing in children
Age
Interval between assessments
Recommended no. of EEGs
7 days 2 mths
48 hours
2 mths 1 year
24 hours
> 1 year
12 hours
Not needed
Footnote:
1. If hypoxic ischaemic encephalopathy is present, observation for at least 24 hr is
recommended.This interval may be reduced if an EEG shows electrocerebral silence.
233
NEUROLOGY
Additional criteria for children

It is generally assumed that the young childs brain may be more resilient
to certain forms of injury, although this issue is controversial.
The newborn is difficult to evaluate after perinatal insults. This relates to
many factors including difficulties of clinical examination, determination of
the cause of coma, and certainty of the validity of laboratory tests.
Hence no recommendation can be made for preterm infants and newborn
less than 7 days old.
Beyond this period, the brain death criteria apply but the interval between
two examinations is lengthened depending on the age of the child, and an
ancillary test (EEG) is recommended for those less than one year old.
NEUROLOGY
Pitfalls in Assessment / Certification

Assessment may be difficult in patients with
Severe facial trauma.
Pre-existing pupillary abnormalities.
Sleep apnoea or severe pulmonary disease with chronic retention of CO
Toxic levels of sedative drugs, aminoglycosides, tricyclic antidepressants,
anticonvulsants, chemotherapeutic drugs, neuromuscular blocking agents.
Drug levels are useful if they can be quantified. If the drug level is below the
therapeutic range, brain death can be declared.
When the drug or poison cannot be quantified, observe the patients for at
least 4 times the elimination half-life, provided the elimination of the drug or
toxin is not interfered with, by other drugs or organ dysfunction.
When the drug unknown but suspicion of its presence is high, observe the
patients for 48 hours for a change in brainstem reflexes and motor response; if
none are observed, perform an ancillary test (EEG) for brain death.
Determination of brain death should be deferred in the presence of severe
acidosis or alkalosis as this may point to certain intoxication and potentially
reversible medical illness or endocrine crisis.
Spontaneous and reflex movements have been observed in patients with
brain death. The most common are finger jerks, toe flexion sign and
persistent Babinski response. These movements are spinal in origin and do
not occur spontaneously. They do not preclude the diagnosis of brain death.
Common CNS depressants and pharmacodynamics
Drugs
Midazolam
Elimination T
Therapeutic Range
2 5 hours
50 150 ng/ml
40 hours
0.2 0.8 ug/ml
Carbamazepine
10 60 hours
2 10 ug/ml
Phenobarbitone
100 hours
20 40 ug/ml
Pentobarbitone
10 hours
1 5 ug/ml
Diazepam
Thiopentone
Morphine
Amitriptyline
10 hours
6 35 ug/ml
2 3 hours
70-450 ng/ml
10 - 24 hours
75 200 ng/ml
234
Chapter 44 Epilepsy
1.Hirtz D, et al. Practice parameter: Evaluating a first nonfebrile seizure in
children. Report of the Quality Standards Subcommittee of the AAN, the
CNS and the AES. Neurol 2000; 55: 616-623
2.Sullivan J, et al. Antiepileptic Drug Monotherapy: Pediatric Concerns. Sem
Pediatr Neurol 2005;12:88-96
3. Sankar R. Initial treatment of epilepsy with antiepileptic drugs - Pediatric
Issues. Neurology 2004;63 (Suppl 4)S30S39
4.Wilner, R et. al. Efficacy and tolerability of the new antiepileptic drugs I:
Treatment of new onset epilepsy:
5. Report of the Therapeutics and Technology Assessment Subcommittee
and Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2004; 62;1252-1260.
Chapter 45 Febrile Seizures
1.Neurodiagnostic evaluation of the child with a simple febrile seizure. Subcommittee of febrile seizure; American Academy of Pediatrics. Pediatrics
2011;127(2):389-94
2.Shinnar S. Glauser T. Febrile seizures. J Child Neurol 2002; 17: S44-S52
3.Febrile Seizures: Clinical practice guideline for the long-term management
of the child with simple febrile seizures. Pediatrics 2008;121:12811286
Chapter 46 Meningitis
1.Hussain IH, Sofiah A, Ong LC et al. Haemophilus influenzae meningitis in
Malaysia. Pediatr Infect Dis J. 1998; 17 (Suppl 9):S189-90
2.Sez-Llorens X, McCracken G. Bacterial meningitis in children. Lancet 2003;
361: 213948.
3.McIntyre PB, Berkey CS, King SM, et al. Dexamethasone as adjunctive
therapy in bacterial meningitis: a meta-analysis of randomized clinical trials since 1988. JAMA 1997; 278: 92531.
4.Chaudhuri A. Adjunctive dexamethasone treatment in acute bacterial meningitis. Lancet Neurol. 2004; 3:54-62.
5.National Antibiotic Guidelines 2008. Ministry of Health, Malaysia.
235
NEUROLOGY
References
Section 5 Neurology
Chapter 43 Status Epilepticus
1.Abend N, Dlugos D. Treatment of Refractory Status Epilepticus: Literature
Review and a Proposed Protocol. Pediatr Neurol 2008; 38:377-390.
2.Walker D, Teach S. Update on the acute management of status epilepticus
in children. Curr Opin Pediatr 2006; 18:239244.
3.Goldstein J. Status Epilepticus in the Pediatric Emergency Department. Clin
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4.Riviello J, et al. Practice Parameter: Diagnostic Assessment of the Child with
Status Epilepticus. Neurology 2006;67:15421550.
NEUROLOGY
Chapter 47 Acute CNS Demyelination

1.Demyelinating Diseases Protocol. The Hospital for Sick Children, Toronto,
Ontario. 2007
2.Krupp L, Banwell B, Tenenbaum S. Consensus definitions proposed for
pediatric multiple sclerosis and related disorders. Neurology 2007; 68
(suppl 2): S7-12.
Chapter 48 Acute Flaccid Paralysis
1.Global Polio Eradication Initiative . http://www.polioeradication.org/, Unit
Virologi, Institute for Medical Research, Malaysia
Chapter 49 Guillain Barre Syndrome
1.van Doorn PA, Ruts L, Jacobs BC. Clinical features, pathogenesis, and treatment of Guillain-Barr syndrome. Lancet Neurol. 2008;7(10):939-50
Chapter 50 The Child with Altered Consciousness
1.Bowker R, Stephenson T. The management of children presenting with
decreased conscious level. Curr Paediatr 2006; 16: 328-335
2.Shetty R, Singhi S, Singhi P, Jayashree M. Cerebral perfusion pressuretargeted approach in children with central nervous system infections and
raised intracranial pressure: is it feasible? J Child Neurol. 2008;23(2):192-8.
Chapter 52 Brain Death
1.Consensus Statement on Brain Death 2003. Ministry of Health, Academy of
Medicine of Malaysia and Malaysian Society of Neurosciences.
2. Guidelines for the determination of brain death in children. American
Academy of Paediatric Task Force on Brain Death in Children. Paediatrics
2011:128:e720-e740.
236
Chapter 53: Approach to A Child with Short Stature

Short stature can be a sign of disease, disability and social stigma causing
psychological stress. It is important to have early diagnosis and treatment.
Definition
Definitions of growth failure:
Height below 3rd percentile (-2SD for age and gender).
Height significantly below genetic potentials (-2SD below mid-parental
target).
Abnormally slow growth velocity.
Downwardly crossing percentile channels on growth chart (> 18 mths age).
Measure serial heights to assess the growth pattern and height velocity.
Initial screening evaluation of growth failure
General tests:
FBC with differentials, renal profile, liver function test, ESR, Urinalysis.
Chromosomal analysis in every short girl.
Endocrine tests
Thyroid function tests.
Growth factors: IGF-1, IGFBP-3.
Growth hormone stimulation tests if growth hormone deficiency is
strongly suspected. (Refer to a Paediatric Endocrine Centre)
Imaging studies
Bone age : anteroposterior radiograph of left hand and wrist.
CT / MRI brain (if hypopituitarism is suspected).
Other investigations depends on clinical suspicion.
Blood gas analysis.
Radiograph of the spine.
237
ENDOCRINOLOGY
Average height velocity at different phases:

Prenatal growth : 1.2 -1.5 cm / week
Infancy :23 - 28 cm / year
Childhood : 5 - 6.5 cm / year
Puberty : 8.3 cm / year (girls), 9.5 cm / year (boys)
ENDOCRINOLOGY
Differential diagnosis of short stature and growth failure

Healthy but short children
Endocrinopathies
Familial short stature
Hypothyroidism
Constitutional growth delay
Hypopituitarism
Intrinsic short stature
Heredity, sporadic, idiopathic
Isolated GH deficiency
Genetic syndromes
Birth injury
Down syndrome,Turner syndrome
Craniopharyngioma
Prader-Willi syndrome
Cranial irradiation
Skeletal dysplasia
Brain tumours
Achondroplasia, hypochondroplasia
Midline defects
Systemic diseases
Haemosiderosis
Infectious: HIV, tuberculosis
GH insensitivity (Laron syndrome)
Cardiac disease
Cushing syndrome, exogenous steroids
Renal disease
Poorly controlled diabetes mellitus
Renal tubular acidosis
Precocious puberty
Chronic renal insufficiency
Pseudohypoparathyroidism
Gastrointestinal
Pseudopseudohypoparathyroidism
Cystic fibrosis
Non-organic aetiology
Inflammatory bowel disease
Psychosocial deprivation
Central nervous system disease
Nutritional dwarfing

Malignancy
Abbreviation: GH, Growth Hormone
238
Clinical Approach to children with Short Stature

History
Nutrition
Complications of pregnancy
General well being
Pre-eclampsia, hypertension
Appetite, energy, sleep, bowel habits
Maternal smoking, alcohol
Pattern of growth from birth
Infections
Maternal and child relationship
Birth
Medical history
Gestational age
Underlying illness, medications,

irradiation
Birth weight and length
Family History
Mode of delivery (breech, forceps)
Short stature (3 generations).
Apgar score
Neonatal complications
Age of onset of puberty in family

members of the same sex
Developmental milestones
Diseases in the family.
Anthropometry
General appearance and behaviour
Height, weight, head circumference
Dysmorphism
Height velocity
Pubertal staging
Arm span
Upper: lower segment Ratio:
1.7 in neonates to slightly <1.0 in adults
Family Measurements
Measure height of parents for mid-parental heights (MPH)
Boys :
Fathers height + (Mothers height +13)
Girls:
Mothers height + (Fathers height -13)
2
2
239
ENDOCRINOLOGY
Antenatal
ENDOCRINOLOGY
Management
Treat underlying cause (hypothyroidism, uncontrolled diabetes mellitus,
chronic illnesses).
For children suspected to be GH deficient, refer to Paediatric Endocrinologist
for initiation of GH.
Psychological support for non-treatable causes (genetic / familial short
stature; constitutional delay of growth and puberty)
FDA approved indications for GH treatment in Children:
Paediatric GH deficiency
Turner syndrome
Chronic renal insufficiency
Idiopathic short stature
PraderWilli syndrome
AIDS cachexia
GH Treatment
GH should be initiated by a Paediatric Endocrinologist.
GH dose: 0.025 - 0.05 mg/kg/day (0.5 - 1.0 units/kg/wk) SC daily at night.
GH treatment should start with low doses and be titrated according to clinical
response, side effects, and growth factor levels.
During GH treatment, patients should be monitored at 3-monthly intervals
(may be more frequent at initiation and during dose titration) with a clinical
assessment (growth parameters, compliance) and an evaluation for adverse
effects (e.g. impaired glucose tolerance, carpal tunnel syndrome), IGF-1 level,
and other parameters of GH response.
Other biochemical evaluations:
Thyroid function
HbA1c
Lipid profile
Fasting blood glucose
Continue treatment till child reaches near final height, defined as a height
velocity of < 2cm / year over at least 9 months (or bone age >13 years in girls
and >14 years in boys).
Treat other pituitary hormone deficiencies such as hypothyroidism,
hypogonadism, hypocortisolism and diabetes insipidus.
240
Chapter 54: Congenital Hypothyroidism
synthesis (1:30,000)
Clinical diagnosis
Most infants are asymptomatic at birth. Hypothalamo-pituitary defect
Subtle clinical features include :
(1:100,000)
Prolonged neonatal jaundice
Peripheral resistance to thyroid
Constipation
hormone (very rare)
A quiet baby
Transient
neonatal hypothyroidism
Enlarged fontanelle
(1:100 - 50,000)
Respiratory distress with feeding
Endemic cretinism
Absence of one or both epiphyses
on X-ray of left knee (lateral view).
If left untreated, overt clinical signs will appear by 3 - 6 months: coarse
facies, dry skin, macroglossia, hoarse cry, umbilical hernia, lethargy, slow
movement, hypotonia and delayed developmental milestones.
Most infants with the disease have no obvious clinical manifestations at
birth, therefore neonatal screening of thyroid function should be performed
on all newborns.
Treatment
Timing
Should begin immediately after diagnosis is established. If features of
hypothyroidism are present, treatment is started urgently.
Duration
Treatment is life long except in children suspected of having transient
hypothyroidism where re-evaluation is done at 3 years of age.
Preparation
There are currently no approved liquid preparations.
Only L-thyroxine tablets should be used. The L-thyroxine tablet should
be crushed, mixed with breast milk, formula, or water and fed to the infant.
Tablets should not be mixed with soy formulas or any preparation containing
iron (formulas or vitamins), both of which reduce the absorption of T4.
241
ENDOCRINOLOGY
Introduction
Incidence of congenital hypothyroidism worldwide is 1:2500 - 4000 live births.
In Malaysia, it is reported as 1:3666.
Causes of Congenital Hypothyroidism
It is the commonest preventable
cause of mental retardation in children. Thyroid dysgenesis (85%)
Thyroid hormones are crucial for: Athyreosis (30%)
Normal growth and development
Hypoplasia (10%)
of brain and intellectual function,
during the prenatal and early
Ectopic thyroid (60%)
postnatal period.
Other causes (15%)
Maturation of the foetal lungs
and bones.
Inborn error of thyroid hormone
Doses of L- Thyroxine by age

Age
0 3 months
10 15
3 6 months
8 10
6 12 months
68
15
ENDOCRINOLOGY
mcg/kg/dose, daily
yr
56
6 12 yr
45
> 12
23
yr
Note:
Average adult dose is 1.6 mcg /kg/day in a 70-kg adult (wide range of dose
from 50 - 200 mcg/day).
L-thyroxine can be given at different doses on alternate days, e.g. 50 mcg
given on even days and 75 mcg on odd days will give an average dose of
62.5 mcg/day.
Average dose in older children is 100 mcg/m2/day.
Goals of therapy
To restore the euthyroid state by maintaining a normal serum FT4 level at
the upper half of the normal age-related reference range. Ideally, serum
TSH levels should be between 0.5-2.0 mU/L.
Serum FT4 level usually normalise within 1-2 weeks, and then TSH usually
become normal after 1 month of treatment.
Some infants continue to have high serum TSH concentration (10 - 20 mU/L)
despite normal serum FT4 values due to resetting of the pituitary-thyroid
feedback threshold. However, compliance to medication has to be
reassessed and emphasised.
Goals of Therapy in the First Year of Life
Adequate treatment
Inadequate treatment
FT4 1.4 2.3 ng/dL (18 - 30 pmol/L)
FT4 < 18 pmol/L
TSH < 5 mU/L
TSH >15 mU/L > once in first year
242
Re-evaluation of patients likely having transient hypothyroidism

This is best done at age 3 years when thyroid dependent brain growth is
completed at this age.
Stop L-thyroxine for 4 weeks then repeat thyroid function test: FT4, TSH.
Imaging studies: Thyroid scan, Ultrasound of the thyroid.
If the FT4 is low and the TSH value is elevated, permanent hypothyroidism
is confirmed and life-long L-thyroxine therapy is needed.
Babies born to mothers with thyroid disorders
All newborns of mothers with thyroid diseases should be evaluated for
thyroid dysfunction, followed up and treated if necessary.
243
ENDOCRINOLOGY
Follow-up
Monitor growth parameters and developmental assessment.
The recommended measurements of serum FT4 and TSH by American
Academy of Pediatrics are according to the following schedules: At 2 and 4 weeks after initiation of T4 treatment.
Every 1 to 2 months during the first 6 months of life.
Every 3 to 4 months between 6 months and 3 years of age.
Every 6 to 12 months thereafter until growth is completed.
After 4 weeks if medication is adjusted.
At more frequent interval when compliance is questioned or abnormal
values are obtained.
Ongoing counseling of parents is important because of the serious
consequences of poor compliance.
SCREENING FOR CONGENITAL HYPOTHYROIDISM

CORD BLOOD SAMPLE
Collected at Birth
TSH < 21 mU/L

(Normal)
TSH 21 - 60 mU/L
(Borderline)
TSH > 60 mU/L

(High)
Free T4 (FT4) analysis

(on cord blood)
FT4 15 pmol/L
(Low)
ENDOCRINOLOGY
FT4 > 15 pmol/L

(Normal)
CLINICAL EVALUATION
Venous FT4 & TSH
TSH High
FT4 Low
PRIMARY
HYPOTHYROIDISM
TSH High
FT4 Normal
TSH Normal
FT4 Low
Subclinical
PRIMARY
HYPOTHYROIDISM
TSH Normal
FT4 Normal
NORMAL
Primary hypothyroidism, delayed TSH rise
Hypothalamic immaturity
TBG (Thyroxine-Binding Globulin) deficiency
Prematurity
Sick neonate
Footnotes:
Interpretation of the results should take into account the physiological
variations of the hormone levels during the neonatal period.
Free thyroxine (FT4) level is preferable to total thyroxine level (T4).
244
Chapter 55: Diabetes Mellitus

Introduction
Diabetes in children is almost invariably type I diabetes mellitus.
The incidence of type II diabetes mellitus is on the increasing trend among
young people due to obesity.
Symptoms and Signs of Diabetes Mellitus
Late
Polydipsia
Vomiting
Polyuria
Dehydration
Weight loss
Abdominal pain
Enuresis (secondary)
Hyperventilation due to acidosis

Drowsiness, coma
Criteria for Diagnosis of Diabetes Mellitus

Symptoms of diabetes
Plus
Casual plasma glucose concentration 11.1 mmol/L ( 200 mg/dL).
Casual is defined as any time of day without regard to time since the last meal.
OR
Fasting plasma glucose 7.0 mmol/L ( 126 mg/dL).
Fasting is defined as no caloric intake for at least 8 hours.
OR
A 2-hour Postload Glucose 11.1 mmol/L ( 200 mg/dL)
during an oral glucose tolerance test (OGTT).
Using a glucose load containing the equivalent of 75 g anhydrous glucose
dissolved in water or 1.75 g/kg of body weight to a maximum of 75 g.
(WHO).
245
ENDOCRINOLOGY
Early
ENDOCRINOLOGY
Management
Principles of insulin therapy
Daily insulin dosage
Daily insulin dosage varies between individuals and changes over time.
The correct dose of insulin for any individual is the dose that achieves the
best glycemic control without causing obvious hypoglycemia problems,
and achieving normal growth (height and weight).
Dosage depends on many factors such as: age, weight, stage of puberty,
duration and phase of diabetes, state of injection sites, nutritional intake
and distribution, exercise patterns, daily routine, results of blood glucose
monitoring (BGM), glycated hemoglobin (HbA1c) and intercurrent illness.
Guidelines on dosage:
During the partial remission phase, total daily insulin dose is usually
0.5 IU/kg/day.
Prepubertal children (outside the partial remission phase) usually require
insulin of 0.71.0 IU/kg/day.
During puberty, requirements may rise to 1 - 2 IU/kg/day.
The total daily dose of insulin is distributed across the day depending on
the daily pattern of blood glucose and the regimens that are used.
Types of Insulin
Type
Peak
Duration
5-15 mins
30-60 mins
3-5 hours
Short-acting
Actrapid,
insulin (regular) Humilin R
30 mins
2-3 hours
3-6 hours
Intermediateacting insulin
2-4 hours
4-12 hours 12-18

hours
Rapid-acting
insulin
Long-acting
insulin
Examples
NovoRapid,
Humalog
Insulatard (NPH),
Humulin N
Levemir
(Detemir),
Lantus
(Glargine)
Onset of Action
Determir
1-2 hours
Glargine
1 hour
246
Determir
6-8 hours
Glargine
No peak
Determir
6-23 hours
Glargine
24 hours
Choice of insulin regimen

At least two injections of insulin per day are advisable in most children.
The basal-bolus concept has the best possibility of imitating the
physiological insulin profile.
Some notes on converting from intermediate acting insulin to long acting
insulin analogues:
Insulin Glargine
Usually given once a day. However if needed, it can be given twice a day.
When converting from NPH to Glargine, the total dose of basal insulin
needs to be reduced by approximately 20% to avoid hypoglycemia. After
that, the dose should be individually tailored.
Insulin Detemir
Is most commonly given twice daily in children
When changing to Detemir from NPH, the same doses can be used to
start with.
247
ENDOCRINOLOGY
Frequently used regimens:

Twice Daily Regimens
2 daily injections of a mixture of a short or rapid acting insulin with and
intermediate-acting insulins (before breakfast and the main evening meal)
Approximately 1/3 of the total daily insulin dose is short acting insulin
and 2/3 intermediate-acting insulin
2/3 of the total daily dose is given in the morning and 1/3 in the evening
Three injections daily
A mixture of short, rapid and intermediate-acting insulins before breakfast;
A rapid-acting analogue or regular insulin alone before afternoon snack
or the main evening meal.
And an intermediate- acting insulin before bed.
Basal-bolus Regimen
Of the total daily insulin requirements, 40 - 60% should be basal insulin,
the rest pre-prandial rapid-acting or regular insulin.
If using regular insulin, inject 20 - 30 min before each main meal
(breakfast, lunch; and the main evening meal); if using rapid-acting insulin
analogue inject immediately before or after each main meal
(e.g. breakfast, lunch; and the main evening meal).
Basal cover is given once daily at bedtime. However sometimes twice daily
injections may be needed (the other dose usually before breakfast).
Insulin pump regimens are regaining popularity with a fixed or a variable
basal dose and bolus doses with meals.
Patient should learn about carbohydrate counting to adjust dose of
pre-prandial insulin.
ENDOCRINOLOGY
Monitoring of glycemic control

Self-Monitoring of blood glucose (SMBG)
The frequency of SMBG is associated with improved HbA1c in patients with
type 1 diabetes.
Timing of SMBG.
At different times in the day to show levels of BG.
To confirm hypoglycemia and to monitor recovery; and
During intercurrent illness to prevent hyperglycemic crises.
The number and regularity of SMBG should be individualized depending on:
Availability of equipment;
Type of insulin regimen; and
Ability of the child to identify hypoglycemia.
Note:
Successful application of intensified diabetes management with multiple
injection therapy or insulin infusion therapy requires frequent SMBG
(four to six times a day) and regular, frequent review of the results to
identify patterns requiring adjustment to the diabetes treatment plan.
However, each child should have their targets individually determined
with the goal of achieving a value as close to normal as possible while
avoiding severe hypoglycemia as well as frequent mild to moderate
hypoglycemia.
Target Indicators of Glycaemic control
Level of control
Ideal (non-diabetic)
Optimal (diabetic)
Raised Blood Glucose (BG)
Not raised
No symptoms
Low BG
Not low
Few mild, no severe

hypoglycaemias
Clinical assessment
Biochemical assessment
SBGM values, mmol/L
AM fasting or preprandial
3.6 - 5.6
5.0 - 8.0
Postprandial PG
4.5 7.0
5.0 10.0
Bedtime PG
4.0 5.6
6.7 10.0
Nocturnal PG
3.6 5.6
4.5 9.0
< 6.05
< 7.5
Plasma Glucose (PG), mmol/L
HbA1c (%)
248
Monitoring of ketones should be done during:

Illness with fever and/or vomiting.
Persistent blood glucose levels > 14 mmol/L (250 mg/dL), in an unwell
child, in a young child, an insulin pump user, or patient with a history of
prior episodes of Diabetic Ketoacidosis (DKA).
Persistent polyuria with elevated blood or urine glucose.
Episodes of drowsiness.
Abdominal pain or rapid breathing.
Interpretation of urine ketone testing

Moderate or large urinary ketone levels in the presence of hyperglycemia
indicate insulin deficiency and risk for metabolic decompensation leading
to ketoacidosis.
The presence of vomiting with hyperglycemia and large urinary ketones
must be assumed to be because of systemic acidosis and requires further
evaluation.
Urine, in contrast to blood ketone testing, is not helpful in ruling out or
diagnosing DKA.
Blood ketone determination.
Because of cost many centres limit the determination of blood ketone to
Young children (difficult to obtain a urine specimen)
For any individual if urine ketone measurement is large, i.e. 48 mmol/L.
Blood ketone testing is especially important for patients on pumps as they
have a much smaller subcutaneous (SC) insulin depot.
Recommendations for HbA1c measurement
Ideally, in younger children, 4 - 6 times per year. In older children, 3 - 4
times per year.
Adolescents with stable type 2 diabetes should have 2 - 4 measurements per
year because they can rapidly become insulin requiring (compared to adults).
HbA1c target range for all age-groups of: < 7.5% .
If hypoglycemia unawareness is present, glycemic targets must be increased
until hypoglycemia awareness is restored, especially in children < 6 years.
249
ENDOCRINOLOGY
Urine ketone testing

Tablets or urine testing strips (detect increased levels of urinary acetoacetate)
Reading (in mmol/L)
Corresponding
0.5
Trace amounts
1.5
Small amounts
4
Moderate amounts
>8
Large amounts
ENDOCRINOLOGY
Diet
A balance and healthy diet for age is required with dietician involvement.
Carbohydrate counting should be taught to patients. Insulin dosage should
match the carbohydrate intake.
Exercise
Regular exercise and participation in sport should be encouraged.
Plan the injection sites according to the activity e.g. inject insulin in the
arm if one plans to go cycling.
Approximately 1.0-1.5g carbohydrates /kg body weight/hour should be
consumed during strenuous exercise if a reduction in insulin is not instituted.
If pre-exercise blood glucose levels are high (>14 mmol/L) with ketonuria or
ketonemia, exercise should be avoided. Give approximately 0.05 IU/kg or 5%
of total daily dose and postpone exercise until ketones have cleared.
Hypoglycemia may be anticipated during or shortly after exercise, but also
possible up to 24 hours afterwards, due to increased insulin sensitivity.
Risk of post exercise nocturnal hypoglycemia is high and particular care
should be taken if bedtime blood glucose < 7.0 mmol/L.
Diabetic Education
At diagnosis - Survival skills:
Explanation of how the diagnosis has been made and reasons for symptoms.
Simple explanation of the uncertain cause of diabetes. No cause for blame.
The need for immediate insulin and how it will work.
What is glucose? Normal blood glucose (BG) levels and glucose targets
Practical skills: insulin injections; blood and/or urine testing, reasons for
monitoring.
Basic dietetic advice.
Simple explanation of hypoglycemia.
Diabetes during illnesses. Advice not to omit insulin - prevent DKA.
Diabetes at home or at school including the effects of exercise.
Psychological adjustment to the diagnosis.
Details of emergency telephone contacts.
Medic alert
Wear the medic alert at all times as this may be life saving in an emergency.
Obtain request forms for a medic alert from the local diabetes educator.
Diabetes support group
Persatuan Diabetes Malaysia (PDM) or Malaysian Diabetes Association,
Diabetes Resource Centre at the regional centre or the respective hospital.
Encourage patient and family members to enroll as members of diabetes
associations and participate in their activities.
250
Evaluation for complications

Microalbuminuria: 2 of 3 urine collections should be used as evidence of
microalbuminuria defined as :
Albumin excretion rate (AER) 20-200 mcg/min or AER 30-300 mg/day.
Albumin/creatinine ratio (ACR) 3.5-35 mg/mmol (males) and
4.0 -35 mg/mmol (females) on first morning urine specimen;
Random ACR is higher.
Albumin concentration (AC) 30-300 mg/L (on early morning urine sample).
251
ENDOCRINOLOGY
School
The school teachers should be informed about children having diabetes so
that some flexibility can be allowed for insulin injections and mealtimes.
Symptoms and treatment of hypoglycaemia should be informed so that
some emergency measures can be commenced at school.
Other complications and associated conditions
Monitoring of growth and physical development.
Blood pressure should be monitored at least annually. Blood pressure
value should be maintained at the <95th percentile for age or
130/80 mmHg for young adults.
Screening for fasting blood lipids should be performed when diabetes
is stabilized in children over 12 years of age. If normal results are obtained,
screening should be repeated every 5 years.
Screening of thyroid function at diagnosis of diabetes. Then every second
year if asymptomatic, no goitre or thyroid autoantibodies negative. More
frequent assessment is indicated otherwise.
In areas of high prevalence for coeliac disease, screening for coeliac
disease should be carried out at the time of diagnosis and every second
year thereafter. More frequent assessment if there is clinical suspicion of
coeliac disease or celiac disease in first-degree relative.
Routine clinical examination for skin and joint changes. Regular laboratory
or radiological screening is not recommended. There is no established
therapeutic intervention for lipodystrophy, necrobiosis lipoidica or limited
joint movement.
252
Neuropathy
After age 12 yrs (E)
Macrovascular disease
Improved glycemic control (A)

ACEI and AIIRA (A)
Blood pressure lowering (B)
High blood pressure (B)

Lipid abnormalities (B)
Smoking (B
Improved
glycemic
control (A)

Blood pressure control (B)
Statins (A)
Hyperglycaemia (A) Hyperglycaemia (A)

Higher BMI (C)
High blood pressure (A)
Smoking (B)
Higher BMI (B)
Urine albumin:creatinine ratio or first History and

Lipid profile every 5 yr
morning albumin concentration (E)
Physical examination Blood pressure annually (E)
Annually from age 11 yr

Unclear
if 2 yrs diabetes duration, and
from age 9 yrs with 5 yr of duration (E)
Nephropathy
Abbreviations. BMI, Body mass index; ACEI, Angiotensin converting enzyme inhibitor; AIIRA, angiotensin II receptor antagonists

Laser therapy (A)
Potential intervention
Hyperglycaemia (A)
High blood pressure (B)
Higher BMI (C)
Risk factors
Fundal microphotograph or
Mydriatic ophthalmoscopy
(less sensitive) (E)
Screening methods
Annually from age 11 yr

if 2 yrs diabetes duration, and
from age 9 yrs with 5 yr of duration (E)
When to commence screening?
Retinopathy
Screening, risk factors, and interventions for vascular complications: the levels of evidence for risk factors
and interventions pertaining to adult studies, except for improved glycemic control.
ENDOCRINOLOGY
Target levels for different parameters to reduce the risk of microvascular

and cardiovascular diseases in children and adolescents with type 1 diabetes;
the level of evidence are from adult studies.
Parameter
Target Level
Evidence Grade
7.5 % without severe

hypoglycaemia
Low density lipoprotein

cholesterol
< 2.6 mmol/l
High density lipoprotein

cholesterol
1.1 mmol/l
Triglycerides
< 1.7 mmol/l
Blood pressure
< 90th percentile by age,

sex, height
Body mass index
< 95th percentile (non

obese)
Smoking
None
Physical activity
>1 h of moderate physical

activity daily
Sedentary activities
<2 h daily
Abbreviation: DCCT, Diabetes Control and Complication Trials Standard
253
C/B
ENDOCRINOLOGY
Haemoglobin A1c
(DCCT)
254
ENDOCRINOLOGY
Chapter 56: Diabetic Ketoacidosis

Diabetic Ketoacidosis (DKA)
The biochemical criteria for the diagnosis of DKA are :
Hyperglycaemia: blood glucose > 11 mmol/L (> 200 mg/dL).
Venous pH < 7.3 or bicarbonate <15 mmol/L.
Ketonaemia and ketonuria.
Goals of therapy
Correct dehydration.
Correct acidosis and reverse ketosis.
Restore blood glucose to near normal.
Avoid complications of therapy.
Identify and treat any precipitating event.
Supportive measures
Secure the airway and give oxygen.
Empty the stomach via a nasogastric tube.
A peripheral intravenous catheter or an arterial catherter (in ICU) for
painless repetitive blood sampling.
Continuous cardiac monitoring to assess T waves for evidence of
hyper- or hypokalaemia.
Antibiotics for febrile patients after cultures.
Catheterization if the child is unconscious or unable to void on demand.
(e.g. in infants and very ill young children)
255
ENDOCRINOLOGY
Emergency management
Bedside confirmation of the diagnosis and determine its cause.
Look for evidence of infection.
Weigh the patient. This weight should be used for calculations and not the
weight from a previous hospital record.
Assess clinical severity of dehydration
Assess level of consciousness [Glasgow coma scale (GCS) ]
Obtain a blood sample for laboratory measurement of:
Serum or plasma glucose
Electrolytes, blood urea nitrogen, creatinine, osmolality
Venous blood gas (or arterial in critically ill patient)
Full blood count
Calcium, phosphorus and magnesium concentrations (if possible)
HbA1c
Blood ketone (useful to confirm ketoacidosis; monitor response to treatment)
Urine for ketones.
Appropriate cultures (blood, urine, throat), if there is evidence of infection.
If laboratory measurement of serum potassium is delayed, perform an
electrocardiogram (ECG) for baseline evaluation of potassium status.
Algorithm for Assessment and Management of Diabetic Ketoacidosis
ENDOCRINOLOGY
Clinical History
Polyuria
Polydipsia
Weight loss (weigh)
Abdominal pain
Tiredness
Vomiting
Confusion
Clinical Signs
Assess dehydration
Deep sighing
respiration(Kussmaul)
Smell of ketones
Lethargy or
drowsiness
Vomiting
Biochemical features
Ketones in urine
Elevated blood sugar
Acidemia
Do blood gases, urea,
electrolytes, other
investigations as
indicated
Diagnosis Confirmed:
DIABETIC KETOACIDOSIS
Contact Senior Staff
Shock
(reduced peripheral
pulses)
Reduced conscious
level or Coma
Dehydration > 5%
Not in shock
Acidosis
(hyperventilation)
Vomiting
Minimal
dehydration
Tolerating oral
hydration
Resuscitation
Airway
+/- NG tube
Breathing
100 % Oxygen
Circulation
0.9 % Saline
10-20 ml/kg over 1-2 hr,
Rpt until circulation
restored, but do not
exceed 30 ml/kg)
IV Therapy
Calculate fluid
requirements
Correct over 48 hrs
Saline 0.9 %
ECG for abnormal
T waves
Add KCl 40 mmol
per litre fluid
Therapy
Start SC Insulin
Continue Oral
Hydration
NO IMPROVEMENT
Continuous Insulin
infusion 0.1 unit/kg/h
Start 1-2 hrs after fluid
treatment initiated
Adapted from Dunger et al. Karger Pub. 1999

256
Algorithm for Assessment and Management of Diabetic Ketoacidosis (cont)
Critical Observations
Hourly blood glucose
Hourly fluid input and output
Neurological status at least hourly
Electrolytes 2 Hly after start of IV therapy
Monitor ECG for T wave changes
Re-evaluate
IV fluid calculations
Insulin delivery
system and dose
Need for additional
resuscitation
Consider sepsis
IV Therapy
Change to 0.45 % Saline
+ 5 % Dextrose
Adjust sodium infusion
to promote an increase
in measured serum
sodium
IMPROVING
Clinically well
Tolerating oral fluids
WARNING SIGNS !
Neurological deterioration
Headache
Slowing heart rate
Irritability, decreased
conscious level
Incontinence
Specific neurological
signs
Exclude hypoglycaemia
is it cerebral oedema ?
Management
Transition to SC Insulin
Give Mannitol 0.5 - 1 G/kg
Start SC insulin then stop IV insulin Restrict IV fluids by /
after an appropriate interval
Call senior staff
Move to ICU
Consider cranial imaging
only after patient stable
Adapted from Dunger et al. Karger Pub. 1999

257
ENDOCRINOLOGY
Blood glucose < 17 mmol/l

or
Blood glucose falls
> 5 mmol/hr
Acidosis
not improving
ENDOCRINOLOGY
Clinical and biochemical monitoring

Monitoring should include the following:
Hourly (or more frequently as indicated) vital signs (heart rate,
respiratory rate, blood pressure), head chart, accurate fluid I/O (including
all oral fluid).
Amount of administered insulin.
Hourly capillary blood glucose (must be cross checked against laboratory
venous glucose).
2-4 hourly (or more frequent in more severe cases): BUSE, glucose,
calcium, magnesium, phosphorus, hematocrit and blood gases.
2 hourly urine ketones until cleared or blood b-hydroxybutyrate (BOHB)
concentrations (if available).
Calculations
Anion gap = ( Na + K ) - (Cl + HCO)
Normal value: 12 +/- 2 mmol/L
In DKA the anion gap is typically 2030 mmol/L
An anion gap > 35 mmol/L suggests concomitant lactic acidosis
Corrected sodium ( mmol/L ) = measured Na + 2 x (plasma glucose - 5.6 )
5.6
Effective osmolality (mOsm/kg ) = 2 x (Na + K) + plasma glucose + urea
Fluids and Salt
Principles of water and salt replacement
Begin with fluid replacement before insulin therapy.
Fluid bolus (resuscitation) required ONLY if needed to restore peripheral
circulation.
Subsequent fluid administration (including oral fluids) should rehydrate
evenly over 48 hrs at a rate rarely in excess of 1.5 - 2 times the usual daily
maintenance.
Acute Resuscitation
If child is in shock, fluid resuscitation is needed to restore peripheral
circulation, fluid boluses 1020 mL/kg over 12 hrs of 0.9% saline is used.
Boluses may be repeated, if necessary.
There is no evidence that the use of colloids is better.
Replacement of water and salt deficits
Patients with DKA have a deficit in extracellular fluid (ECF) volume. Clinical
estimates of the volume deficit are subjective and inaccurate; therefore in
Moderate DKA use 57% deficit.
Severe DKA use 710% dehydration.
258
259
ENDOCRINOLOGY
Rehydrate the patient evenly over 48 hours:

As a guide fluid infused each day usually < 1.5 - 2 times daily maintenance.
IV or oral fluids given in another facility before assessment should be
factored into calculation of deficit and repair.
Replacement should begin with 0.9% saline or Ringers lactate for at least
4 - 6 h. Thereafter, use a solution that has a tonicity equal to or greater
than 0.45% saline with added potassium chloride.
Urinary losses should not routinely be added to the calculation of
replacement fluid, but may be necessary in rare circumstances.
Calculate the corrected sodium (formula as above) and monitor changes:
As plasma glucose decreases after IV fluids and insulin, the serum sodium
should increase: this does not indicate a worsening of the hypertonic state.
A failure of sodium levels to rise or a further decline in sodium levels with
therapy may signal impending cerebral oedema.
The sodium content of the fluid may need to be increased if measured
serum sodium is low and does not rise appropriately as the plasma glucose
concentration falls.
The use of large amounts of 0.9% saline has been associated with the
development of hyperchloraemic metabolic acidosis.
Insulin therapy
DKA is caused by either relative or absolute insulin deficiency.
Start insulin infusion 12 h AFTER starting fluid replacement therapy
Correction of insulin deficiency
Dose: 0.1 unit/kg/h IV infusion. (one method is to dilute 50 units regular
insulin in 50 ml normal saline, 1 unit = 1 ml).
An initial IV bolus of insulin is not necessary, and may increase the risk of
cerebral oedema and should not be given.
The dose of insulin should usually remain at 0.1 unit/kg/h at least until
resolution of DKA (evidenced by pH > 7.30, HCO > 15 mmol/L and/or
closure of the anion gap), which takes longer than normalization of blood
glucose concentrations.
If patient has a marked sensitivity to insulin (e.g. young children with DKA,
patients with Hyperglycemic Hyperosmolar State (HHS), and older children
with established diabetes), the dose may be decreased to 0.05 unit/kg/h, or
less, provided that metabolic acidosis continues to resolve.
During initial volume expansion the plasma glucose concentration falls
steeply. After commencing insulin therapy, the plasma glucose concentration
typically decreases at a rate of 25 mmol/L/h.
To prevent an unduly rapid decrease in plasma glucose concentration and
hypoglycemia, add 5% glucose to IV fluid (e.g., 5% glucose in 0.45% saline)
when plasma glucose falls to 1417 mmol/L, or sooner if rate of fall is rapid.
It may be necessary to use 10% - 12.5% dextrose to prevent hypoglycemia
while continuing to infuse insulin to correct the metabolic acidosis.
If blood glucose falls very rapidly (> 5 mmol/L/h) after initial fluid expansion
add glucose even before plasma glucose has decreased to 17 mmol/L.
ENDOCRINOLOGY
If biochemical parameters of DKA (pH, anion gap) do not improve, reassess

the patient, review insulin therapy, and consider other possible causes of
impaired response to insulin; e.g. infection, errors in insulin preparation.
If continuous IV insulin is not possible, hourly / 2-hourly subcutaneous (SC) or
IM administration of a short or rapid-acting insulin analog (insulin Lispro or
insulin Aspart) is safe / effective. (do not use in patients with impaired
peripheral circulation)
Initial dose SC: 0.3 unit/kg, followed 1 h later at SC 0.1 unit/kg every hour,
or 0.150.20 units/kg every 2 hours.
If blood glucose falls to <14 mmol/L before DKA has resolved (pH still
< 7.30), add 5% glucose and continue with insulin as above.
When DKA has resolved and blood glucose is < 14 mmol/L , reduce
SC insulin to 0.05 unit/kg/h to keep blood glucose around 11 mmol/L.
Important
If the blood glucose concentration decreases too quickly or too low before
DKA has resolved:
Increase the amount of glucose administered.
Do not decrease the insulin infusion.
Potassium replacement
There is always a deficit of total body of potassium (3-6 mmol/kg) even
with normal or high levels of serum potassium at presentation.
Replacement therapy is therefore required.
If immediate serum potassium measurements are unavailable, an ECG may
help to determine whether the child has hyper- or hypokalemia.
Subsequent potassium replacement therapy should be based on serum
potassium measurements.
Potassium replacement should continue throughout IV fluid therapy
Maximum recommended rate of IV potassium replacement is 0.5 mmol/kg/h.
If hypokalemia persists despite maximum rate of potassium replacement,
then the rate of insulin infusion can be reduced.
Serum potassium level
Action
Hypokalemic at presentation
Start potassium replacement at the time of

initial volume expansion and before starting insulin therapy, at a concentration of 20
mmol/ L (0.75 g KCl per pint).
Normokalemia
Start replacing potassium after initial

volume expansion and concurrent with
starting insulin therapy. The starting potassium concentration in the infusate should
be 40 mmol/L (1.5 g KCl/pint)
Hyperkalaemia
(K+ > 5.5 mmol/L)
Defer potassium replacement therapy until

urine output is documented.
260
Morbidity and mortality

In national population studies, mortality rate from DKA in children is
0.150.30%.
Cerebral oedema accounts for 6090% of all DKA deaths
10% - 25% of survivors of cerebral edema have significant residual morbidity.
Other rare causes of morbidity and mortality include: sepsis; hypokalemia,
hyperkalemia, severe hypophosphataemia; hypoglycaemia; aspiration
pneumonia; pulmonary oedema; adult respiratory distress syndrome
(ARDS); rhabdomyolysis; acute renal failure and acute pancreatitis.
261
ENDOCRINOLOGY
Phosphate
Depletion of intracellular phosphate occurs in DKA
Severe hypophosphatemia, with unexplained weakness, should be treated
Potassium phosphate salts may be safely used as an alternative to or
combined with potassium chloride or acetate, provided that careful
monitoring of serum calcium is performed as administration of phosphate
may induce hypocalcaemia.
Acidosis
Severe acidosis is reversible by fluid and insulin replacement.
There is no evidence that bicarbonate is either necessary or safe in DKA.
Bicarbonate therapy may cause paradoxical CNS acidosis, hypokalaemia
and increasing osmolality.
Used only in selected patients:
Severe acidaemia (arterial pH <6.9) in whom decreased cardiac contractility
and peripheral vasodilatation can further impair tissue perfusion.
Life-threatening hyperkalaemia.
Cautiously give 1 - 2 mmol/kg over 60 min.
Introduction of oral fluids and transition to SC insulin injections
Oral fluids should be introduced only with substantial clinical improvement
(mild acidosis/ketosis may still be present).
When oral fluid is tolerated, IV fluid should be reduced.
When ketoacidosis has resolved (pH > 7.3; HCO3- > 15mmmol/L), oral
intake is tolerated, and the change to SC insulin is planned, the most
convenient time to change to SC insulin is just before a mealtime.
e.g. SC regular insulin 0.25 u/kg given before meals (pre-breakfast, prelunch, pre-dinner), SC intermediate insulin 0.25 u/kg before bedtime.
Total insulin dose is about 1u/kg/day.
To prevent rebound hyperglycemia, the first SC injection is given 30 min
(with rapid acting insulin) or 12 h (with regular insulin) before stopping
the insulin infusion to allow sufficient time for the insulin to be absorbed.
The dose of soluble insulin is titrated against capillary blood glucose.
Convert to long-term insulin regime when stabilized. Multiple dose
injections 4 times per day are preferable to conventional (twice daily)
injections.
Cerebral oedema
Clinically significant cerebral oedema usually develops 4 -12 h after
treatment has started, but may occur before treatment or rarely, as late as
24 - 48 h later.
Diagnostic Criteria for Cerebral Oedema
Abnormal motor or verbal response to pain
Decorticate or decerebrate posture
ENDOCRINOLOGY
Cranial nerve palsy (especially III, IV, and VI)

Abnormal neurogenic respiratory pattern
(e.g., grunting, tachypnea, Cheyne-Stokes respiration, apneusis)
Major Criteria
Minor Criteria
Altered mentation / fluctuating level of

consciousness.
Vomiting
Sustained HR deceleration (decrease

> 20 bpm), not attributable to improved
intravascular volume or sleep state.
Lethargy, not easily arousable
Age-inappropriate incontinence
Age < 5 years
Headache
Diastolic blood pressure
> 90 mmHg
Treatment of cerebral oedema

Initiate treatment as soon as the condition is suspected. (Mannitol and
hypertonic saline should be available at the bedside)
Give mannitol 0.5 - 1 g/kg IV over 20 min and repeat if there is no initial
response in 30 minutes to 2 hours.
Reduce the rate of fluid administration by one-third.
Hypertonic saline (3%), 5 - 10 ml/kg over 30 min, may be an alternative to
mannitol, especially if there is no initial response to mannitol.
Elevate the head of the bed.
Intubation may be necessary for the patient with impending respiratory
failure. Maintain normocapnia. (PaCO within normal range).
After treatment for cerebral oedema has been started, a cranial CT scan
should be done to rule out other possible intracerebral causes of neurologic
deterioration.
262
Chapter 57: Disorders of Sexual Development

Definition
Individuals who have a genital appearance that does not permit gender
declaration are said to have disorders of sexual development (DSD),
formerly known as ambiguous genitalia.
Defined as a congenital condition in which development of chromosomal,
gonadal, or anatomical sex is atypical. Below is a summary of the
components of the revised nomenclature.
DSD is a Neonatal Emergency!
The commonest cause of AG is congenital adrenal hyperplasia (CAH).
General concepts of care

Gender assignment must be avoided before expert evaluation in newborns.
Evaluation and long-term management must be performed at a center with
an experienced multidisciplinary team (Paediatric subspecialists in
endocrinology, surgery, and/or urology, psychology/ psychiatry, gynaecology,
genetics, neonatology, and social work, nursing and medical ethics.)
All individuals should receive a gender assignment.
Open communication with patients and family is essential, and participation
in decision making is encouraged.
Patients and family concerns (eg, social and culture) should be respected and
addressed.
263
ENDOCRINOLOGY
Major concerns are : Underlying medical issues:

Dehydration, salt loss (adrenal crisis).
Urinary tract infection.
Bowel obstruction.
Decision on sex of rearing:
Avoid wrong sex assignment.
Prevent gender confusion.
Psychosocial issues
264
Ovotesticular DSD
Gonadal Regession
Iatrogenic
Endocrine disrupters
Cloacal exstrophy
Luteoma
Timing Defect
POR Gene Defect
Aromatase Deficiency
Non-CAH
Maternal
Gonadal Dysgenesis
11-OH Deficiency
21-OH Deficiency
CAH
Fetal Androgen Excess
Disorders of AMH
5 -reductase
Deficiency
Androgen Insensitivity
Testicular DSD
(SRY+, dup SOX9)
Ovotesticular DSD
Disorders of Ovarian
Development
46, XX DSD
Abbreviations: MGD, Mixed gonadal dysgenesis; AMH, Anti-Mullerian hormone; CAH, Congenital adrenal hyperplasia; 21-OH,
21-Hydroxlylase; 11-OH, 11 Hydroxylase.
Chromosomal
Ovotesticular DSD
45, X/46, XY MGD

LH-Receptor Defect
Androgen Synthesis
Defect
Complete Gonadal
Dysgenesis
Partial Gonadal
Dysgenesis
Disorders of Androgen
Synthesis/Action
Disorders of Testicular
Development
45, X Turner
47, XXY Klinefelter and

variants
46, XY DSD
Sex Chromosome DSD
Disorders of Sexual Development (DSD) - New Nomenclature
ENDOCRINOLOGY
EVALUATION
Ideally, the baby or child and parents should be assessed by a competent multidisciplinary team.
Dysmorphism (Turner phenotype, congenital abnormalities)
Cloacal anomaly
Signs of systemic illness
Hyperpigmentation
Blood pressure
Psychosocial behaviour (older children)
Appearance of external genitalia
Size of phallus, erectile tissue
Position of urethral opening (degree of virilisation)
Labial fusion or appearance of scrotum
Presence or absence of palpable gonads
Presence or absence of cervix (per rectal examination)
Position and patency of anus
Criteria that suggests DSD include
Overt genital ambiguity.
Apparent female genitalia with enlarged clitoris, posterior labial fusion, or an
inguinal labial mass.
Apparent male genitalia with bilateral undescended testes, micropenis,
isolated perineal hypospadias.
Mild hypospadias with undescended testes.
Family history of DSD, e.g. Complete androgen insensitivity syndrome (CAIS).
Discordance between genital appearance and a prenatal karyotype.
Most of DSDs are recognized in the neonatal period. Others present as
pubertal delay.
265
ENDOCRINOLOGY
History - exclude CAH in all neonates

Parental consanguinity.
Obstetric : previous abortions, stillbirths, neonatal deaths.
Antenatal : drugs taken, exogenous androgens, endocrine disturbances.
Family History: Unexplained neonatal deaths in siblings and close relatives
Infertility, genital anomalies in the family
Abnormal pubertal development
Infertile aunts
Symptoms of salt wasting in the first few days to weeks of life.
Increasing pigmentation
Progressive virilisation
APPROACH TO DISORDERS OF SEXUAL DEVELOPMENT

Ambiguous Genitalia
Karyotype
Palpable Gonads
ENDOCRINOLOGY
Absent
Present
CAH Screen
Positive
Negative
Ultrasound scan
Genitogram
Endocrine profile
Ultrasound scan
Genitogram
Gonadal inspection,
Biopsy
Investigations
Chromosome study, karyotyping with X- and Y-specific probe detection
Abdominopelvic ultrasound
Genitogram
Exclude salt losing CAH
Serial BUSE in the neonatal period
Serum 17-hydroxyprogesterone (taken after the first day of life)
Cortisol, testosterone, renin
Testosterone, LH, FSH
Anti mullerian hormone (depending on indication and availability)
Additional investigations as indicated:
LHRH stimulation test
hCG stimulation tests (testosterone, dihydrotestosterone (DHT) at Day 1 & 4)
Urinary steroid analysis
Androgen receptor study (may not be available)
DNA analysis for SRY gene (sex-determining region on the Y chromosome)
Imaging studies
Biopsy of gonadal material in selected cases.
Molecular diagnosis is limited by cost, accessibility and quality control.
Trial of testosterone enanthate 25 mg IM monthly 3x doses
This can be done to demonstrate adequate growth of the phallus and is
essential before a final decision is made to raise an DSD child as a male.
266
Uterus +/-
Ovotesticular DSD
Agonadism
Ovotestes
Uterus +/-
Absent
Partial Gonadal
Dysgenesis
Uterus +/-
Dysgenetic Testes
GONADS
KARYOTYPE 46,XY
Androgen Disorder
Synthesis or Action
Testosterone
Biosynthesis Defect
LH-Receptor Mutation
Androgen Resistant
syndrome
5 -reductase
Deficiency
POR Gene Defect
Timing Defect
Complete Gonadal
Dysgenesis
Testes Testes
Uterus -
Streak
Uterus +
Ambiguous Genitalia / Pubertal Delay
DIAGNOSTIC ALGORITHM OF 46, XY DSD
ENDOCRINOLOGY
267
268
CAH
Non-CAH
Normal
Ovotesticular DSD
Virilized Female
17-OH Progesterone
High
Uterus +
Uterus +
Uterus +
Gonadal Dysgenesis
Streak
Ovotestes
Ovary
GONADS
KARYOTYPE 46,XX
Ambiguous Genitalia / Pubertal Delay
DIAGNOSTIC ALGORITHM OF 46, XX DSD
Uterus -
Testes
XX Testicular DSD
ENDOCRINOLOGY
Gender reinforcement
Appropriate name.
Upbringing, dressing.
Treatment and control of underlying disease e.g. CAH.
Surgical correction of the external genitalia as soon as possible.
Assigned female
Remove all testicular tissue.
Vaginoplasty after puberty.
No place for vaginal dilatation in childhood.
Assigned male
Orchidopexy.
Remove all Mullerian structures.
Surgical repair of hypospadias.
Gonadectomy to be considered if dysgenetic gonads.
269
ENDOCRINOLOGY
Management
Goals
Preserve fertility.
Ensure normal sexual function.
Phenotype and psychosocial outcome concordant with the assigned sex.
General considerations
Admit to hospital. Salt losing CAH which is life threatening must be excluded.
Urgent diagnosis.
Do not register the child until final decision is reached.
Protect privacy of parents and child pending diagnosis.
Counseling of parents that DSD conditions are biologically understandable.
Encourage bonding.
Gender Assignment
Gender assignment and sex of rearing should be based upon the most
probable adult gender identity and potential for adult function. Factors to be
considered in this decision include : Diagnosis .
Fertility potential.
Adequacy of the external genitalia for normal sexual function. Adequate
phallic size when considering male sex of rearing.
Endocrine function of gonads. Capacity to respond to exogenous androgen.
Parents socio-cultural background, expectations and acceptance.
Psychosocial development in older children.
Decision about sex of rearing should only be made by an informed family
after careful evaluation, documentation, and consultation.
ENDOCRINOLOGY
Surgical management
The goals of surgery are:
Genital appearance compatible with gender
Unobstructed urinary emptying without incontinence or infections
Good adult sexual and reproductive function
The surgeon has the responsibility to outline the surgical sequence and
subsequent consequences from infancy to adulthood. Only surgeons with
the expertise in the care of children and specific training in the surgery of
DSD should perform these procedures.
Early genitoplasty is feasible only if the precise cause of DSD has been
established and gender assignment has been based on certain knowledge of
post-pubertal sexual outcome. Otherwise surgery should be postponed, as
genitoplasty involves irreversible procedures such as castration and phallic
reduction in individuals raised females and resection of utero-vaginal tissue
in those raised male.
The procedure should be anatomically based to preserve erectile function
and the innervations of the clitoris.
Emphasis in functional outcome rather than a strictly cosmetic appearance.
Timing of surgery: it is felt that surgery that is performed for cosmetic
reasons in the first year of life relieves parental distress and improves
attachment between the child and the parents; the systematic evidence for
this is lacking.
270
Diagnosis of salt-wasting CAH

May not be apparent in the first days/weeks after birth by electrolyte
measurements.
Salt wasters may be differentiated from simple virilizers by :
Serial serum/plasma and/or urine electrolytes.
Plasma renin activity (PRA) or direct renin.
Results of CYP21 molecular analysis.
Management of salt losing crisis
For patient in shock: normal saline (0.9%) bolus : 10-20 ml/kg
Correct hypoglycemia if present : 2-4 ml/kg of 10% glucose
Correct hyperkalaemia with administration of glucose and insulin if necessary.
Rehydrate using / NS 5% dextrose
Monitor hydration status, BP, HR, glucose.
Note: Hypotonic saline or 5% dextrose should not be used because it can
worsen hyponatraemia.
271
ENDOCRINOLOGY
CONGENITAL ADRENAL HYPERPLASIA (CAH)

Neonatal diagnosis and treatment
The newborn female with CAH and ambiguous external genitalia requires
urgent expert medical attention.
The ambiguity is highly distressing to the family; therefore, immediate
comprehensive evaluation is needed by a Paediatric Endocrinologist.
Ensure parents develop a positive relationship with their child
Clinical evaluation in term and premature neonates
Every newborn with ambiguous genitalia, a suspected diagnosis of CAH, or
an abnormal result in a newborn screen for 17-hydroxyprogesterone
(17-OHP) should be evaluated by a Pediatric Endocrinologist.
The evaluation of an infant with DSD has been discussed above.
Newborn screening for CAH
Neonatal mass screening for 21-hydroxylase deficiency identifies both male
and female affected infants, prevents incorrect sex assignment, and decreases
mortality and morbidity. However, it has not been started in Malaysia.
Neonatal period
Ambiguous genitalia.
Salt loss (75%).
Family history of previous unexplained neonatal death.
Hyperpigmentation (90%) - both sexes.
Virilisation of a girl.
Hypertension.
Beyond the neonatal period
Boy with gonadotrophin independent precocious puberty
(prepubertal testicular size).
ENDOCRINOLOGY
Treatment considerations in patients with CAH

Optimal glucocorticoid dosing
Aim to replace deficient steroids, minimize adrenal sex hormone and
glucocorticoid excess: thus preventing virilization, optimizing growth, and
protecting potential fertility.
During infancy, initial reduction of markedly elevated adrenal sex hormones
may require hydrocortisone (HC) up to 25 mg/m/d, but typical dosing is
1015 mg/m/d in 3 divided doses. Divided or crushed tablets of HC should
be used in growing children.
Excessive doses, especially in infancy, may cause persistent growth
suppression, obesity, and other Cushingoid features. Therefore, avoid
complete adrenal suppression.
Whereas HC is preferred in infancy and childhood, long-acting
glucocorticoids may be used at or near the completion of linear growth.
Prednisolone needs to be given twice daily. (at 24 mg/m/d).
Dexamethasone dose is 0.250.375 mg/m/d, given once daily.
In children with advanced bone age and central precocious puberty,
treatment with a GnRH agonist may be required.
Therapy will reduce vasopressin, ACTH levels and lower dosage of
glucocorticoid required.
Assess the need for continuing mineralocorticoids based on PRA and BP.
Sodium chloride supplements are often needed in infancy, at 1-3 g/day
(17-51 mEq/day), distributed in several feedings.
Monitoring treatment for classic CAH
Monitoring may be accomplished based on physical and hormonal findings
suggestive of excessive or inadequate steroid therapy.
Laboratory measurements may include serum/plasma electrolytes, serum
17-OHP, cortisol, and/or testosterone, and PRA or direct renin, every
3 months during infancy and every 412 months thereafter.
Time from the last glucocorticoid dose should be noted; the diurnal rhythm
of the adrenal axis should be taken into account. Patients receiving adequate
replacement therapy may have cortisol levels above the normal range.
Ideally, laboratory data will indicate a need for dose adjustments before
physical changes, growth, and skeletal maturation indicates inadequate or
excessive dosing.
Patients should carry medical identification and information concerning their
medical condition and therapy.
272
Genital surgery
The decision for surgery and the timing should be made by the parents,
together with the endocrinologist and the paediatric surgical team, after
complete disclosure of all relevant clinical information and all available
options have been discussed and after informed consent has been obtained.
General principals of surgery for DSD has been outlined in the preceding
section on DSD.
It is recognized that 46, XX children with significant virilization may present
at a later age. Consideration for sex reassignment must be undertaken only
after thorough psychological evaluation of patient and family.
Surgery appropriate to gender assignment should be undertaken after a
period of endocrine treatment.
Psychological issues
Females with CAH show behavioral masculinization, most pronounced in
gender role behavior, less so in sexual orientation, and rarely in gender
identity.
Even in females with psychosexual problems, general psychological
adjustment seems to be similar to that of females without CAH.
Currently, there is insufficient evidence to support rearing a 46, XX infant at
Prader stage 5 as male.
Decisions concerning sex assignment and associated genital surgery must
consider the culture in which a child and her/his family are embedded.
273
ENDOCRINOLOGY
Treatment with glucocorticoids during stress

Parents must be given clear instruction on stress dosing.
Because circulating levels of cortisol increase during stress, patients should
be given increased doses of glucocorticoids during febrile illness (> 38.5C),
when vomiting or poor oral intake, after trauma and before surgery.
Participation in endurance sports may also require additional steroid dosing
Mental and emotional stress, such as school examinations, does not require
increased dosing.
Stress dosing should be 23 times the maintenance glucocorticoid dose for
patients able to take oral medications.
Surgical and trauma patients and those unable to take oral steroids require
parenteral hydrocortisone. A bolus dose is given as shown below followed by
the same dose in four divided doses:
Below 3 years old: to give 25mg.
3-12 years old: to give 50mg.
> 12 years old: to give 100mg.
Glucose concentrations should be monitored, and intravenous sodium and
glucose replacement may be required.
ENDOCRINOLOGY
References
Section 6 Endocrinology
Chapter 53 Short Stature
1. Grimberg A, De Leon DD. Chapter 8: Disorders of growth. In: Pediatric
Endocrinology, the Requisites in Pediatrics 2005, pp127-167.
2. Cutfield WS, et al. Growth hormone treatment to final height in idiopathic
GH deficiency: The KIGS Experience, in GH therapy in Pediatrics, 20 years
of KIGS, Basel, Karger, 2007. pp 145-62.
3. Molitch ME, et al. Evaluation and treatment of adult GH deficiency: An Endocrine Society Clinical Practice Guideline. JCEM 1991; 19: 1621-1634, 2006.
4. Malaysian Clinical Practice Guidelines on usage of growth hormone in
children and adults 2011)
Chapter 54 Congenital Hypothyroidism
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2.Smith L. Updated AAP Guidelines on Newborn Screening and Therapy for
Congenital hypothyridism. Am Fam Phys 2007; 76
3.Update of newborn screening for congenital hypothyroidism. Pediatrics
2006; 117
4.Styne, DM. Disorders of the thyroid glands, in Pediatr Endocrinology: p. 83-109.
5.LaFranchi S. Clinical features and detection of congenital hypothyroidism.
2004 UpToDate (www.uptodate.com)
6.Ross DS. Treatment of hypothyroidism. 2004 UpToDate. (www.uptodate.com)
7.LaFranchi S. Treatment and prognosis of congenital hypothyroidism. 2004
UpToDate (www.uptodate.com)
8.Ogilvy-Stuart AL. Neonatal Thyroid Disorders. Arch Dis Child 2002
9.The Endocrine Societys Clinical Guidelines. JCEM 1992 : S1-47, 2007
10.Mafauzy M, Choo KE et al. Neonatal screening for congenital hypothyroid
in N-E Pen. Malaysia. Journal of AFES , Vol 13. 35-37.
Chapter 55 & 60 Diabetes Mellitus and Diabetic Ketoacidosis
1.ISPAD Clinical Practice Concensus Guidelines 2009. Diabetic ketoacidosis.
Wolfsdorf J, et al, Pediatric Diabetes 2009: 10 (Suppl. 12): 118133.
2.Global IDF/ISPAD Guideline for Type 1 Diabetes in Childhood and Adolescents, 2010.
Chapter 57 Disorders of Sexual Development
1.Nieman LK, Orth DN, Kirkland JL. Treatment of congenital adrenal hyperplasia due to CYP21A2 (21-hydroxylase) deficiency in infants and children.
2004 Uptodate online 12.1 (www.uptodate.com)
2.Consensus Statement on 21-Hydroxylase Deficiency from the Lawson
Wilkins Pediatric Endocrine Society and the European Society for Paediatric Endocrinology; J Clin Endocrinol Metab 2002; 87:40484053.
3.Ocal Gonul. Current Concepts in Disorders of Sexual Development. J Clin
Res Ped Endo 2011; 3:105-114
4.Ieuan A. Hughes. Disorders of Sex Development: a new definition and classification. Best Pract Res Clin Endocrinol and Metab. 2008; 22: 119-134.
5., 6. Houk CP, Levitsky LL. Evaluation and Management of the infant with
ambiguous genitalia. 2004 Uptodate online 12.1 (www.uptodate.com)
274
Chapter 58: Post-Infectious Glomerulonephritis

Introduction
Acute glomerulonephritis (AGN) is an abrupt onset of one or more features
of an Acute Nephritic Syndrome:
Causes of Acute Nephritis
Oedema e.g. facial puffiness.
Post streptococcal AGN
Post-infectious acute glomerulonephritis
(other than Grp A -Haemolytic Streptococci )
Subacute bacterial endocarditis
Henoch-Schoenlein purpura
IgA nephropathy
Hereditary nephritis
Systemic lupus erythematosus
Systemic vasculitidis
Presenting features of AGN

Acute nephritic syndrome (most common)
Nephrotic syndrome
Rapidly progressive glomerulonephritis
Hypertensive encephalopathy
Pulmonary oedema
Subclinical (detected on routine examination)
Investigation findings in Post-Streptococcal AGN
Urinalysis and culture
Haematuria present in all patients.
Proteinuria (trace to 2+, but may be in the nephrotic range; usually
associated with more severe disease.)
Red blood cell casts (pathognomonic of acute glomerulonephritis).
Other cellular casts.
Pyuria may also be present.
Bacteriological and serological evidence of antecedent streptococcal infection:
Raised ASOT ( > 200 IU/ml ).
Increased anti-DNAse B (if available) a better serological marker of
preceding streptococcal skin infection.
Throat swab or skin swab.
Renal function test
Blood urea, electrolytes and serum creatinine.
275
NEPHROLOGY
Microscopic /macroscopic
haematuria.
(urine: tea-coloured or smoky)
Decreased urine output (oliguria).
Hypertension.
Azotemia.
In children, the commonest cause
of an acute nephritic syndrome is
post-infectious AGN, mainly due
to post-streptococcal infection
of the pharynx or skin.
Post streptococcal AGN is
commonest at 6 10 years age.
NEPHROLOGY
Full blood count

Anaemia (mainly dilutional).
Leucocytosis may be present.
Complement levels
C3 level low at onset of symptoms, normalises by 6 weeks.
C4 is usually within normal limits in post-streptococcal AGN.
Ultrasound of the kidneys
Not necessary if patient has clear cut acute nephritic syndrome.
Management
Strict monitoring - fluid intake, urine output, daily weight, BP (Nephrotic chart)
Penicillin V for 10 days to eliminate - haemolytic streptococcal infection
(give erythromycin if penicillin is contraindicated)
Fluid restriction to control oedema and circulatory overload during oliguric
phase until child diureses and blood pressure is controlled
Day 1 : up to 400 mls/m/day. Do not administer intravenous or oral fluids
if child has pulmonary oedema.
Day 2 : till patient diureses 400 mls/m/day
(as long as patient remains in circulatory overload)
When child is in diuresis free fluid is allowed
Diuretic (e.g. Frusemide) should be given in children with pulmonary oedema.
It is also usually needed for treatment of hypertension.
Diet no added salt to diet. Protein restriction is unnecessary
Look out for complications of post-streptococcal AGN:
Hypertensive encephalopathy usually presenting with seizures
Pulmonary oedema (acute left ventricular failure)
Acute renal failure
Management of severe complications of post-streptococcal AGN
Hypertension
Significant hypertension but asymptomatic
Bed rest and recheck BP hour later
If BP still high, give oral Nifedipine 0.25 - 0.5 mg/kg. Recheck BP hour later.
Monitor BP hourly x 4 hours then 4 hourly if stable.
Oral Nifedipine can be repeated if necessary on 4 hourly basis.
May consider regular oral Nifedipine (6 8 hourly) if BP persistently high.
Add Frusemide 1 mg/kg/dose if BP still not well controlled.
Other anti-hypertensives if BP still not under control:
Captopril (0.1-0.5 mg/kg q8 hourly), Metoprolol 1-4 mg/kg 12 hourly
Symptomatic, severe hypertension or hypertensive emergency/encephalopathy
Symptom/signs: Headache, vomiting, loss of vision, convulsions,
papilloedema.
Emergency management indicated to reduce BP sufficiently to avoid
hypertensive complications and yet maintain it at a level that permits
autoregulatory mechanism of vital organs to function.
276
Target of BP control:
- Reduce BP to <90th percentile of BP for age, gender and height percentile .
- Total BP to be reduced = Observed mean BP Desired mean BP
- Reduce BP by 25% of target BP over 3 12 hours.
- The next 75% reduction is achieved over 48 hours.
Pulmonary oedema
Give oxygen, prop patient up; ventilatory support if necessary.
IV Frusemide 2 mg/kg/dose stat; double this dose 4 hours later if poor response
Fluid restriction withhold fluids for 24 hours if possible.
Consider dialysis if no response to diuretics.
Acute kidney injury
Mild renal impairment is common.
Severe persistent oliguria or anuria with azotaemia is uncommon.
Management of severe acute renal failure, see Ch 60 Acute Kidney Injury.
Weight, urea and hypertension

Streptococcal
infection
2 wks
ASOT
Haematuria
2 wks
4 wks
6 wks
complement
277
1 yr
NEPHROLOGY
Natural History of Acute Post-Streptococcal Glomerulonephritis
Indications for Renal Biopsy

Severe acute renal failure requiring dialysis.
Features suggesting non post-infectious AGN
as the cause of acute nephritis.
Delayed resolution
Oliguria > 2 weeks
Azotaemia > 3 weeks
Gross haematuria > 3 weeks
NEPHROLOGY
Persistent proteinuria > 6 months

Follow-up
For at least 1 year.
Monitor BP at every visit
Do urinalysis and renal function to evaluate recovery.
Repeat C3 levels 6 weeks later if not already normalised by the time of
discharge.
Outcome
Short term outcome: Excellent, mortality <0.5%.
Long term outcome: 1.8% of children develop chronic kidney disease
following post streptococcal AGN. These children should be referred to the
paediatric nephrologists for further evaluation and management.
278
Chapter 59: Nephrotic Syndrome

Diagnosis
Nephrotic syndrome is a clinical syndrome of massive proteinuria defined by
Oedema
Hypoalbuminaemia of < 25g/l
Proteinuria > 40 mg/m/hour (> 1g/m/day) Hypercholesterolaemia
or an early morning urine protein creatinine
index of >200 mg/mmol (> 3.5 mg/mg).
Aetiology
Primary or idiopathic (of unknown cause) nephrotic syndrome is the
commonest type of nephrotic syndrome in children.
Secondary causes of nephrotic syndrome include post-streptococcal
glomerulonephritis and systemic lupus erythematosus (SLE). This chapter
outlines the management of idiopathic nephrotic syndrome. Management
of secondary forms of nephrotic syndrome follows the management of the
primary condition.
Renal biopsy
A renal biopsy is not needed prior to corticosteroid or cyclophosphamide
therapy. This is because 80% of children with idiopathic nephrotic
syndrome have minimal change steroid responsive disease.
Main indication for renal biopsy is steroid resistant nephrotic syndrome,
defined as failure to achieve remission despite 4 weeks of adequate
corticosteroid therapy.
Other indications are features that suggest non-minimal change nephrotic
syndrome:
Persistent hypertension, renal impairment, and/or gross haematuria.
279
NEPHROLOGY
Investigations at initial presentation

Full blood count
Renal profile
Urea, electrolyte, creatinine
Serum cholesterol
Liver function tests
Particularly serum albumin
Urinalysis, urine culture
Quantitative urinary protein excretion
(spot urine protein: creatinine ratio or 24 hour urine protein)
Other investigations would depend on the age of the patient, associated renal
impairment, hematuria, hypertension or features to suggest an underlying
secondary cause for the nephrotic syndrome.
These tests include:
Antinuclear factor / anti-dsDNA to exclude SLE.
Serum complement (C3, C4) levels to exclude SLE, post-infectious
glomerulonephritis.
ASOT titres to exclude Post-streptococcal glomerulonephritis.
Other tests as indicated.
NEPHROLOGY
Management
Confirm that patient has nephrotic syndrome by ensuring that the patient
fulfills the criteria above
Exclude other causes of nephrotic syndrome. If none, then the child
probably has idiopathic nephrotic syndrome
General management
A normal protein diet with adequate calories is recommended.
No added salt to the diet when child has oedema.
Penicillin V 125 mg BD (1-5 years age), 250 mg BD (6-12 years), 500 mg BD
(> 12 years) is recommended at diagnosis and during relapses, particularly
in the presence of gross oedema.
Careful assessment of the haemodynamic status.
Check for signs and symptoms which may indicate
- Hypovolaemia: Abdominal pain, cold peripheries, poor capillary refill,
poor pulse volume with or without low blood pressure; OR
- Hypervolaemia: Basal lung crepitations, rhonchi, hepatomegaly,
hypertension.
Fluid restriction - not recommended except in chronic oedematous states.
Diuretics (e.g. frusemide) is not necessary in steroid responsive nephrotic
syndrome but if required, use with caution as may precipitate hypovolaemia.
Human albumin (20-25%) at 0.5 - 1.0 g/kg can be used in symptomatic
grossly oedematous states together with IV frusemide at 1-2 mg/kg to
produce a diuresis.
Caution: fluid overload and pulmonary oedema can occur with albumin
infusion especially in those with impaired renal function. Urine output and
blood pressure should be closely monitored.
General advice
Counsel patient and parents about the disease particularly with regards to
the high probability (85-95%) of relapse.
Home urine albumin monitoring: once daily dipstix testing of the first
morning urine specimen. The patient is advised to consult the doctor if
albuminuria 2+ for 3 consecutive days, or 3 out of 7 days.
The child is also advised to consult the doctor should he/she become
oedematous regardless of the urine dipstix result.
Children on systemic corticosteroids or other immunosuppressive agents
should be advised and cautioned about contact with chickenpox and
measles, and if exposed should be treated like any immunocompromised
child who has come into contact with these diseases.
Immunisation:
While the child is on corticosteroid treatment and within 6 weeks after its
cessation, only killed vaccines may safely be administered to the child.
Give live vaccines 6 weeks after cessation of corticosteroid therapy.
Pneumococcal vaccine should be administered to all children with
nephrotic syndrome. If possible, give when the child is in remission.
280
Acute adrenal crisis

May be seen in children who have been on long term corticosteroid
therapy (equivalent to 18 mg/m of cortisone daily) when they undergo
situations of stress.
Give Hydrocortisone 2-4 mg/kg/dose TDS or Prednisolone 1 mg/kg/day.
Corticosteroid therapy
Corticosteroids are effective in inducing remission of idiopathic nephrotic
syndrome.
Initial treatment
Once a diagnosis of idiopathic nephrotic syndrome has been established,
oral Prednisolone should be started at:
60 mg/ m/day ( maximum 80 mg / day ) for 4 weeks followed by
40 mg/m/every alternate morning (EOD) (maximum 60 mg) for 4 weeks.
then reduce Prednisolone dose by 25% monthly over next 4 months.
With this corticosteroid regime, 80% of children will achieve remission
(defined as urine dipstix trace or nil for 3 consecutive days) within 28 days.
Children with Steroid resistant nephrotic syndrome, defined by failure to
achieve response to an initial 4 weeks treatment with prednisolone at
60 mg/m/ day, should be referred to a Paediatric Nephrologist for further
management, which usually includes a renal biopsy.
Treatment of relapses
The majority of children with nephrotic syndrome will relapse.
A relapse is defined by urine albumin excretion > 40 mg/m/hour or urine
dipstix of 2+ for 3 consecutive days.
These children do not need admission unless they are grossly oedematous
or have any of the complications of nephrotic syndrome.
281
NEPHROLOGY
Management of the complications of nephrotic syndrome

Hypovolaemia.
Clinical features: abdominal pain, cold peripheries, poor pulse volume,
hypotension, and haemoconcentration.
Treatment: infuse Human Albumin at 0.5 to 1.0 g/kg/dose fast.
If human albumin is not available, other volume expanders like human
plasma can be used. Do not give Frusemide.
Primary Peritonitis
Clinical features: fever, abdominal pain and tenderness in children with
newly diagnosed or relapse nephrotic syndrome.
Investigations: Blood culture, peritoneal fluid culture (not usually done)
Treatment: parenteral penicillin and a third generation cephalosporin
Thrombosis
Thorough investigation and adequate treatment with anticoagulation is
usually needed. Please consult a Paediatric Nephrologist.
NEPHROLOGY
Induction of relapse is with oral Prednisolone as follows:

60 mg/m/day ( maximum 80 mg / day ) until remission followed by
40 mg/m/EOD (maximum 60 mg) for 4 weeks only.
Breakthrough proteinuria may occur with intercurrent infection and usually
does not require corticosteroid induction if the child has no oedema,
remains well and the proteinuria remits with resolution of the infection.
However, if proteinuria persists, treat as a relapse.
Treatment of frequent relapses
Defined as 2 relapses within 6 months of initial diagnosis or
4 relapses within any 12 month period.
Treatment
Induction of relapse is with oral Prednisolone as follows:
60 mg/m/day ( maximum 80 mg/day ) until remission followed by
40 mg/m/EOD (maximum 60 mg) for 4 weeks only.
Taper Prednisolone dose every 2 weeks and keep on as low an alternate
day dose as possible for 6 months. Should a child relapse while on low
dose alternate day Prednisolone, the child should be re-induced with
Prednisolone as for relapse.
Treatment of steroid dependent nephrotic syndrome
Defined as 2 consecutive relapses occurring during steroid taper or
within 14 days of the cessation of steroids.
Treatment
If the child is not steroid toxic, re-induce with steroids and maintain on
as low a dose of alternate day prednisolone as possible. If the child is
steroid toxic (short stature, striae, cataracts, glaucoma, severe cushingoid
features) consider cyclophosphamide therapy.
Cyclophosphamide therapy
Indicated for the treatment of steroid dependent nephrotic syndrome with
signs of steroid toxicity; begin therapy when in remission after induction
with corticosteroids.
Parents should be counseled about the effectiveness and side effects of
Cyclophosphamide therapy (leucopenia, alopecia, haemorrhagic cystitis,
gonadal toxicity).
Dose: 2-3 mg/kg/day for 8-12 weeks (cumulative dose 168 mg/kg).
Monitor full blood count and urinalysis 2 weekly.
Relapses post Cyclophosphamide
Relapses after a course of cyclophosphamide are treated as for relapses
following the initial diagnosis of nephrotic syndrome, if the child does not
have signs of steroid toxicity
Should the relapse occur soon after a course of Cyclophosphamide when
the child is still steroid toxic, or if the child again becomes steroid toxic after
multiple relapses, then a Paediatric Nephrology opinion should be sought.
The treatment options available include cyclosporine and levamisole.
282
Algorithm for the Management of Nephrotic Syndrome

1
INITIAL EPISODE OF NEPHROTIC SYNDROME

Prednisolone 60 mg/m/day for 4 weeks
Response
No Response
Prednisolone 40 mg/m/alternate day for 4 weeks.

then taper at 25% monthly over 4 months
RELAPSE
Prednisolone 60 mg/m/day till remission
40 mg/m/alternate day for 4 weeks then stop
FREQUENT RELAPSES
Reinduce as (2), then taper and keep low dose alternate

day Prednisolone 0.1 - 0.5 mg/kg/dose for 6 months
4
RELAPSES WHILE ON PREDNISOLONE
Treat as for (3) if not steroid toxic
Consider cyclophosphamide if steroid toxic.
ORAL CYCLOPHOSPHAMIDE
2-3 mg/kg/day for 8-12 weeks

Cumulative dose 168 mg/kg
6
RELAPSES POST CYCLOPHOSPHAMIDE
As for (2) and (3) if not steroid toxic
If steroid toxic, refer paediatric nephrologist to

consider therapy with cyclosporin or levamisole
283
NEPHROLOGY
RENAL BIOPSY
NEPHROLOGY
Steroid resistant nephrotic syndrome

Refer for renal biopsy. Specific treatment will depend on the histopathology.
General management of the Nephrotic state:
Control of edema:
Restriction of dietary sodium.
Diuretics e.g. Frusemide, Spironolactone.
ACE inhibitor e.g. Captopril or Angiotensin II receptor blocker (AIIRB).
e.g. Losartan, Irbesartan, to reduce proteinuria.
Monitor BP and renal profile 1-2 weeks after initiation of ACE inhibitor
or AIIRB.
Control of hypertension: antihypertensive of choice - ACE inhibitor/AIIRB.
Penicillin prophylaxis.
Monitor renal function.
Nutrition: normal dietary protein content, salt-restricted diet.
Evaluate calcium and phosphate metabolism.
284
Chapter 60: Acute Kidney Injury

Definition
Acute kidney injury (AKI) was previously called acute renal failure.
Abrupt rise in serum creatinine level and decreased glomerular filtration
rate resulting in inability of the kidneys to regulate fluid and electrolyte
balance.
Clinical features
Of underlying cause.
Oliguria (< 300 ml/m/day in children; < 1 ml/kg/hour in neonates)
Non-oliguria.
Clinical features arising from complications of AKI
e.g. seizures, acute pulmonary oedema
Common causes of Acute Kidney Injury
Renal, or intrinsic
Hypovolaemia
Glomerular
Dehydration, bleeding
Infection related
Third space loss
Systemic lupus erythematosus
Nephrotic syndrome, burns
Acute glomerulonephritis
Distributive shock
Tubulointerstitial
Dengue shock, sepsis syndrome
Acute tubular necrosis
Cardiac
Hypoxic-ischaemic injury
Congestive heart failure
Aminoglycosides, chemotherapy
Cardiac tamponade
Toxins, e.g.
Post-renal
Myoglobin, haemoglobin
Posterior urethral valves
Venom
Acute bilateral ureteric obstruction
Bee sting
Acute obstruction in solitary kidney
Tumour lysis, Uric acid nephropathy

Infection, pyelonephritis
Vascular
ACE-inhibitors
Vascular lesions
Haemolytic uremic syndrome
Renal vein thrombosis
285
NEPHROLOGY
Pre-renal
Important to consider pre-renal failure as a cause of oliguria.

In pre-renal failure, the kidney is intrinsically normal and the tubules are
working to conserve water and sodium appropriately.
In acute tubular necrosis (ATN) the damaged tubules are unable to
conserve sodium appropriately.
NEPHROLOGY
Investigations
Blood:
Full blood count.
Blood urea, electrolytes, creatinine.
Blood gas.
Serum albumin, calcium, phosphate.
Urine: biochemistry and microscopy.
Imaging: renal ultrasound scan (urgent if cause unknown).
Other investigations as determined by cause.
MANAGEMENT
Prevention
Identify patients at risk of AKI. They include patients with the following:
Prematurity, asphyxia, trauma, burns, post-surgical states, other organ
failures (eg heart, liver), pre-existing renal disease, malignancy
(leukaemia, B-cell lymphoma).
Monitor patients-at-risk actively with regards to renal function and urine
output.
Try to ensure effective non-dialytic measures, which include:
Restoring adequate renal blood flow.
Avoiding nephrotoxic agents if possible.
Maximizing renal perfusion before exposure to nephrotoxic agents.
Fluid balance
In Hypovolaemia
Fluid resuscitation regardless of oliguric / anuric state
Give crystalloids e.g. isotonic 0.9% saline / Ringers lactate 20 ml/kg fast
(in < 20 minutes) after obtaining vascular access.
Transfuse blood if haemorrhage is the cause of shock.
Hydrate to normal volume status.
If urine output increases, continue fluid replacement.
If there is no urine output after 4 hours (confirm with urinary catheterization),
monitor central venous pressure to assess fluid status.
See Chapter on shock for details of management.
286
In Hypervolaemia / Fluid overload

Features of volume overload include hypertension, raised JVP, displaced apex
beat, basal crepitations, hepatomegaly and increasing ventilatory requirements.
If necessary to give fluid, restrict to insensible loss (400 ml/m/day or
30ml/kg in neonates depending on ambient conditions)
IV Frusemide 2 mg/kg/dose (over 10-15 minutes),
maximum of 5 mg/kg/dose or IV Frusemide infusion 0.5 mg/kg/hour.
Dialysis if no response or if volume overload is life-threatening.
Euvolaemia
Once normal volume status is achieved, give insensible loss plus obvious
losses (urine / extrarenal).
Monitor fluid status: weight, BP, heart rate, nutritional needs, intake/output.
Metabolic acidosis
Treat if pH < 7.2 or symptomatic or contributing to hyperkalaemia
Bicarbonate deficit = 0.3 x body weight (kg) x base excess (BE)
Ensure that patients serum calcium is > 1.8 mmol/L to prevent
hypocalcaemic seizures with Sodium bicarbonate therapy.
Replace half the deficit with IV 8.4% Sodium bicarbonate (1:1 dilution) if
indicated.
Monitor blood gases
Electrolyte abnormalities
Hyperkalaemia
Definition: serum K > 6.0 mmol/l (neonates) and > 5.5 mmol/l (children).
Cardiac toxicity generally develops when plasma potassium > 7 mmol/l
Regardless of degree of hyperkalaemia, treatment should be initiated in
patients with ECG abnormalities from hyperkalaemia.
ECG changes in Hypokalemia
Tall, tented T waves
Widened QRS complex
Flattened P wave,
Sine wave (QRS complex
merges with peaked T waves)
VF or asystole
287
NEPHROLOGY
Hypertension
Usually related to fluid overload and/or alteration in vascular tone
Choice of anti-hypertensive drugs depends on degree of BP elevation, presence
of CNS symptoms of hypertension and cause of renal failure. A diuretic is usually
needed.
Treatment of Hyperkalemia in AKI patients

Do 12-lead ECG and look for hyperkalaemic changes
NEPHROLOGY
If ECG is abnormal or plasma K+ > 7 mmol/l, connect patient to a cardiac

monitor and give the following in sequence:
1
IV 10% Calcium gluconate 0.5 - 1.0 ml/kg (1:1 dilution) over 5 -15 mins
(Immediate onset of action)
IV Dextrose 0.5 g/kg (2 ml/kg of 25%) over 15 30 mins.
IV Insulin 0.1 unit/kg (onset of action 30 mins).
IV 8.4% sodium bicarbonate 1 ml/kg (1:1 dilution) over 10 - 30 mins

(Onset of action 15 - 30 mins)
Nebulized 0.5% salbutamol 2.5 - 5 mg (0.5 - 1 ml : 3 ml 0.9% Saline)

(Onset of action 30 mins)
Calcium polystyrene sulphonate 0.25g/kg oral or rectally 4 times/day

(Max 10g/dose) (Calcium Resonium / Kalimate)
[Give rectally (NOT orally) in neonates 0.125 0.25g/kg 4 times/day]
OR
6
Sodium polystyrene sulphonate 1g/kg oral or rectally 4 times/day

(Max15g/dose) (Resonium)
In patients with serum potassium between 5.5 - 7 mmol/L without ECG

changes, give calcium or sodium polystyrene sulphonate
If insulin is given after dextrose, monitor RBS / Dextrostix for
hypoglycaemia.
Dialyse if poor or no response to the above measures
Hyponatraemia
Usually dilutional from fluid overload
If asymptomatic, fluid restrict
Dialyse if symptomatic or the above measures fail
Hypocalcaemia
Treat if symptomatic (usually serum Ca < 1.8 mmol/L), and if Sodium
bicarbonate is required for hyperkalaemia, with IV 10% Calcium gluconate
0.5 ml/kg, given over 10 20 minutes, with ECG monitoring.
Hyperphosphataemia
Phosphate binders e.g. calcium carbonate or aluminium hydroxide orally
with main meals.
288
Nutrition
Optimal intake in AKI is influenced by nature of disease causing it, extent of
catabolism, modality and frequency of renal replacement therapy.
Generally, the principles of nutritional requirement apply except for:
Avoiding excessive protein intake
Minimizing phosphorus and potassium intake
Avoiding excessive fluid intake (if applicable)
If the gastro-intestinal tract is intact and functional, start enteral feeds as
soon as possible
Total parenteral nutrition via central line if enteral feeding is not possible;
use concentrated dextrose (25%), lipids (10-20%), protein (1.0-2.0g/kg/day)
If oliguric and caloric intake is insufficient because of fluid restriction,
start dialysis earlier
Medications
Avoid nephrotoxic drugs if possible; if still needed, monitor drug levels and
potential adverse effects.
Check dosage adjustment for all drugs used.
Concentrate drugs to the lowest volume of dilution if patient is oliguric.
289
NEPHROLOGY
Dialysis
Dialysis is indicated if there are life-threatening complications like:
Fluid overload manifesting as
Pulmonary oedema.
Congestive cardiac failure, or
Refractory hypertension.
Electrolyte / acid-base imbalances:
Hyperkalaemia (K+ > 7.0).
Symptomatic hypo- or hypernatraemia, or
Refractory metabolic acidosis.
Symptomatic uraemia.
Oliguria preventing adequate nutrition.
Oliguria following recent cardiac surgery.
The choice of dialysis modality depends on:
Experience with the modality
Patients haemodynamic stability
Contraindications to peritoneal dialysis e.g. recent abdominal surgery
NEPHROLOGY
Dosage adjustment in renal failure for some common antimicrobials

Drug
Cr Clearance1 Dose
Dose Interval
Crystalline/
Benzylpenicillin
10 - 50
Nil
8 12
< 10
Nil
12
Cloxacillin
< 10
Nil
Amoxicillin/clavulanic 10 - 30
acid (Augmentin)
< 10
Normal dose initially then half-dose 12-hly
Ampicillin/sulbactam 15 - 29
(Unasyn)
5 - 14
Nil
12
Nil
24
Cefotaxime
<5
Normal dose initially, then1/2 dose, same

frequency
Cefuroxime
> 20
Nil
10 - 20
Nil
12
24
Normal dose initially then half-dose 24-hly
< 10
Nil
Ceftriaxone
< 10
Dose not > 40mg/kg (maximum 2g)/day
Ceftazidime
30 - 50
50-100%
12
15 - 30
50-100%
24
5 -15
25-50%
24
<5
2550%
48
30 - 50
50mg/kg
12
11 - 29
50mg/kg
24
< 10
25mg/kg
24
40
75%
10
25%
12
Anuric
15%
24
25 - 50
100%
12
10 - 25
50%
12
< 10
50%
24
40
Nil
12
10
50%
24
anuric
33%
24
Cefepime
Imipenem
Meropenem
Ciprofloxacin
290
Dosage adjustment in renal failure for some common antimicrobials (cont).

Cr Clearance1 Dose
Dose Interval
Metronidazole
< 10
Nil
12
Acyclovir
(IV infusion)
25 - 50
Nil
12
10 - 25
Nil
24
Acyclovir (oral)
10 - 25
Nil
< 10
Nil
12
Erythromycin
< 10
60%
Nil
Gentamicin
Avoid if possible. If needed, give 5mg/kg, check trough level

24 hours later, and peak 1 hour post-dose.
Amikacin
Avoid if possible, If needed, give initial dose, take trough

sample immediately before next dose, and peak 1 hour
post-dose.
Vancomycin
Give initial / loading dose, take trough sample immediately

before next dose and peak, 1 hour after completion of
infusion.
Footnote:
1, Creatinine Clearance:
It is difficult to estimate GFR from the serum creatinine levels in ARF. A rough estimate
can be calculated using the formula below once the serum creatinine level remains
constant for at least 2 days.
Calculated creatinine clearance =
(ml/min/1.73m)
Height (cm) x 40
Serum creatinine (micromol/l)
Assume creatinine clearance of < 10ml/min/1.73m if patient is on dialysis or

anuric.
291
NEPHROLOGY
Drug
292
NEPHROLOGY
Chapter 61: Acute Peritoneal Dialysis

Introduction
The purpose of dialysis is
To remove endogenous and exogenous toxins and
To maintain fluid, electrolyte and acid-base equilibrium until renal function
returns.
Peritoneal dialysis (PD) is the simpler modality in infants and children as it is
technically simpler and easily accessible even in centers without paediatric
nephrologists.
Contraindications to Acute PD
Abdominal wall defects or infection.
Bowel distension, perforation, adhesion or resection.
Communication between the chest and abdominal cavities.
Indications for Dialysis

Acute renal failure
Pulmonary oedema
Refractory hypertension
Oliguria following recent heart surgery
Symptomatic electrolyte or acid-base imbalance
Hyperkalaemia (K+ > 7.0)
Hypo- or hypernatraemia
Acidosis (pH<7.2, or <7.3 with hyperkalaemia)
Uraemia
Encephalopathy
Hyperammonaemia
Severe metabolic acidosis
293
NEPHROLOGY
Types of Catheter Access

A soft PD catheter implanted percutaneously or surgically (preferred).
A straight rigid catheter if a soft PD catheter is not available.
NEPHROLOGY
Site of Insertion and Direction

Site of insertion
of Catheter Introduction
Commonest site is at the midline infraumbilical position 1 inch below the umbilicus.
In small children, where the space below the
umbilicus is limited, alternative sites include
insertion lateral to the inferior epigastric
artery as shown in the dotted lines in the
diagram, two-thirds of the distance from the
umbilicus to the left last rib (just lateral to
the border of rectus muscle).
Ensure that the catheter is inserted way
below any enlarged spleen or liver.
Procedure of PD catheter insertion
1. Consent for first peritoneal dialysis
2. Bladder must be emptied; catheterise the bladder in unconscious,
ill patients.
3. The procedure must be done under aseptic technique
4. Prepare the set of PD lines and spike the PD fluids
5. Clean the area with povidone iodine and drape the patient
6. Infiltrate insertion site with lignocaine; additional IV sedation may be
needed.
7. For small infants or patients with very scaphoid abdomen, infiltrating the
abdominal cavity with 10 - 15 ml/kg PD fluid using 20G or larger branula
prior to catheter insertion will help prevent traumatic puncture of
underlying viscus.
8. For technique of catheter insertion - see tables below.
9. Connect the catheter to the PD line via the connector provided in the set.
10. Bleeding from the insertion site can be stopped by a purse-string suture.
cover the site with dry gauze and secure with plaster.
Monitoring while on PD
Oversee the first 3 cycles of dialysis to ensure good flow.
Check for turbidity, leakage and ultrafiltration every two hours.
Input / output chart, vital signs and PD chart should be kept up-to-date.
Turbid effluent must be noted to the doctor.
Send PD fluid for cell count and culture and sensitivity at start and end of PD
and when the effluent is turbid.
Blood urea, serum electrolytes and creatinine should be requested according
to patients needs. In stable patients, once daily should be more than sufficient.
Blood urea and electrolyte results to be reviewed by the doctor and
Potassium chloride to be added into dialysate if necessary.
(1 Gm of Potassium chloride in 10 ml ampoule is equivalent to 13.3 mmol of
potassium. Hence adding 3 ml to 1 litre would result in dialysate with
4.0 mmol/l of potassium).
294
Technique of insertion of different PD catheters

Acute stiff PD catheter
1
Check catheter for any breakages (by withdrawing the stilette) before
insertion.
Make a small skin incision (slightly smaller than the diameter of the
catheter) using a sharp pointed blade. Do not cut the muscle layer.
Introduce the cather with the stillete perpendicular to the abdominal

wall while controlling the length with the dominant hand, until the
peritoneum is pierced.
The stilette is then withdrawn and the catheter gently pushed in,
directing it towards either iliac fossa until all the perforations are well
within the peritoneal cavity.
Soft PD catheter (Seldinger technique)

Cookes set 15F.
Advance the needle provided in the set connected to a syringe

perpendicularly until peritoneum is breached (a give is felt).
Thread and advance the guide wire through the needle aiming for
either iliac fossa.
Remove the needle. Using the guide wire, introduce the dilator and
sheath through a skin nick into the abdominal cavity.
Remove the dilator and guide wire while retaining the sheath in the
abdomen.
Introduce the soft PD catheter through the sheath into the abdominal
cavity directing it to either iliac fossa until the external cuff fits snugly
at the skin.
Peel off the sheath and secure the catheter via taping or a skin stitch.
295
NEPHROLOGY
The PD Prescription
NEPHROLOGY
Exchange volume
Start at 20 ml/kg and observe for discomfort, cardiorespiratory changes
or leakage at catheter site.
The volume can be increased to a maximum of 50ml/kg or
1000 -1200ml/m body surface area.
Cycle Duration
First 6 cycles are rapid cycles i.e. no dwell time. The cycle duration
depends on needs of the patient. However, the standard prescription
usually last an hour:
5-10 minutes to instill (depending on exchange volume)
30-40 minutes dwell
10-15 minutes to drain (depending on exchange volume)
The cycles can be done manually or with an automated cycler machine
if available.
PD Fluids
Type of PD fluids:
1.5%, and 4.25% dextrose (standard commercially availabe)
Bicarbonate dialysate, useful if lactic acidosis is a significant problem
PD is usually initiated with 1.5% - if more rapid ultrafiltration is required
higher glucose concentration by mixing various combinations of 1.5 and
4.25% solutions can be used.
Watch for hyperglycaemia.
Duration of PD
The duration of PD depends on the needs of the patient
The usual practice is 60 cycles but at times more cycles may be needed
based on biochemical markers or clinical needs. Peritonitis is frequent
when dialysis is prolonged or when acute catheters are used for more
than 3 to 4 days.
Note:
In centers with continuous renal replacement therapy, the bicarbonate solution
used for CRRT (Continuous Renal Replacement Therapy) can be used.
In centers where this is not available, the assistance of the pharmacist is
required to constitute a physiological dialysis solution.
The contents and concentrations are listed in the next page.
296
Pharmacy constituted PD-Bicarbonate solution 1.5% dextrose 3000ml / bag

Content
Quantitiy (ml)
NaCl 0.9%
1374.00
NaCl 20%
13.23
Sodium Bicarbonate 8.4%
120.00
Magnesium Sulphate 49.3%
1.11
Dextrose 50%
90.00
Water for injection
1401.66
297
NEPHROLOGY
Common Complications
Poor drainage (omental obstruction, kinking)
For temporary PD cannulas
Re-position.
Reinsert catheter if above unsuccessful.
For surgically implanted catheters
Irrigation.
Add Heparin (500 units/ litre) into PD fluids.
Peritonitis
Diagnostic criteria :
Abdominal pain, fever, cloudy PD effluent, PD effluent cell count
> 100 WBC/mm.
Treatment:
Intraperitoneal antibiotics (empirical Cloxacillin + Ceftazidime) for
7 - 14 days.
Adjust antibiotics once culture results known (dosage as given below).
Exit site infection
Send swab for culture.
Remove PD catheter that is not surgically implanted.
Systemic antibiotics may be considered.
Leaking dialysate
At exit site resuture immediately.
Leakage from tubings change dialysis set, empiric intraperitoneal
antibiotics for one to two days may be needed.
Blood stained effluent
If mild observe. It should clear with successive cycles.
If heavy, but vital signs stable, run rapid cycles.
Transfuse cryoprecipitate. consider blood transfusion and DDAVP.
If bleeding does not stop after the first few cycles, stop the dialysis.
If heavy, patient in shock, resuscitate as for patient with hypovolaemic
shock. Stop dialysis and refer surgeon immediately.
Paediatric Antibiotic Dosing Recommendations

Administration should be via intraperitoneal route unless specified otherwise
Continuous therapy
Intermittent therapy
Loading dose Maintenance dose

Glycopeptides
Vancomycin
500 mg/L
30 mg/L
30 mg/kg q 5-7 days
NEPHROLOGY
Cephalosporins
Cephazolin/
Cephalothin
250 mg/L
125 mg/L
15 mg/kg q 24 hrs
Cefuroxime
200 mg/L
125 mg/L
15 mg/kg q 24 hrs
Cefotaxime
500 mg/L
250 mg/L
30 mg/kg q 24 hrs
Ceftazidime
250 mg/L
125 mg/L
15 mg/kg q 24 hrs
1 mg/kg IV
1 mg/kg/day IV
Antifungals
Amphotericin B
Fluconazole
---
---
Amikacin
25 mg/L
12 mg/L
Gentamicin
8 mg/L
4 mg/L
Netilmycin
8 mg/L
4 mg/L
250-500
mg/L
50 mg/L
Ampicillin/
Sulbactam
1000 mg/L
100 mg/L
Imipenem/
Cilastin
500 mg/L
200 mg/L
Aminoglycosides
Penicillins
Amoxicillin
Combinations
298
--3-6 mg/kg IP, IV, or PO

q24-48 hrs (max 200 mg)
Chapter 62: Neurogenic Bladder

Introduction
Neurogenic bladder can develop as a result of a lesion at any level in
the nervous system, i.e. cerebral cortex, spinal cord, or peripheral nervous
system.
However, the commonest cause of neurogenic bladder is spinal cord
abnormalities.
Causes of Neurogenic Bladder

Open spinal dysraphism
Meningocele, myelomeningocele and lipomyelomeningocele
Occult spinal dysraphism
spinal bifida occulta
Anorectal agenesis, sacral agenesis
Spinal trauma
Spinal cord tumors
Transverse myelitis
The commonest cause of neurogenic bladder is a lumbosacral
myelomeningocoele.
At birth, the majority of patients with lumbosacral myelomeningocoele
have normal upper urinary tracts, but 60% of them develop upper tract
deterioration due to infections, bladder changes and reflux by 3 years of age.
Progressive renal damage is due to high detrusor pressures both
throughout the filling phase (poor compliance bladder) as well as
superimposed detrusor contractions against a closed sphincter (detrusor
sphincter dyssynergia).
Aims of management:
Preserve upper renal tracts and renal function
Achieve urinary continence
Develop sense of autonomy and better self esteem
299
NEPHROLOGY
Multi-disciplinary approach
Children with spinal dysraphism require care from a multidisciplinary team
consisting of neurosurgeon, neurologist, orthopedic surgeon, rehabilitation
specialist, neonatologist, nephrologists, urologist and other allied medical
specialists.
Long-term follow-up is necessary since renal or bladder function can still
deteriorate after childhood.
Children with the conditions listed below can present with various
patterns of detrusor sphincter dysfunction within a wide range of severity,
not predicted by the level of the spinal cord defect.
NEPHROLOGY
Open spinal dysraphism

Early management with clean intermittent catheterization (CIC):
Aim is to create a low-pressure reservoir and ensuring complete and safe
bladder emptying with clean intermittent catheterization.
CIC should be started once the myelomeningocoele is repaired starting CIC
in early infancy has led to easier acceptance by parents and children and
reduced upper tract deterioration and improvement in continence.
Timing of urodynamic study
Urodynamic study is indicated in all children with neurogenic bladder. However due to limited availability, urodynamic study should be carried out in
children with neurogenic bladder with the following:
Recurrent UTI.
Hydronephrosis.
Incontinence despite CIC.
Thickened bladder wall.
Raised serum creatinine. In infants with lumbosacral myelomeningocoele
with any of the above conditions and who have been started on CIC,
anti-cholinergic e.g. Oxybutinin (0.3-0.6 mg/kg/day in 2 to 3 divided dose)
should be started even if urodynamic study is not available.
Clean intermittent catheterisation
Children, as young as 5 years of age, have learnt to do self-catheterization.
Patients are taught catheterisation in hospital by trained nurse/doctor.
The rationale and benefits of intermittent catheterisation are explained,
and the patient is reassured that it should be neither painful nor dangerous
Patients are taught to catheterise themselves lying down, standing up,
or sitting on a lavatory, chair, or wheelchair.
Complications of CIC
Urethral trauma with creation of false passages, urethral strictures and
bacteriuria.
Notes on CIC:
In infants with myelomeningocoele, management is directed at creating a
low-pressure reservoir and ensuring complete and safe bladder emptying
with clean intermittent catheterization.
CIC should be started once the myelomeningocoele is repaired.
Starting CIC in early infancy has led to easier acceptance by parents and
children and reduced upper tract deterioration and improvement in
continence.
300
Technique of Clean Intermittent Catheterisation (CIC)

Procedure
1
Assemble all equipment: catheter, lubricant, drainage receptacle,

adjustable mirror.
Wash hands with soap and water.
Clean the urethral orifice with clean water.
In boys:
Lift penis with one hand to straighten out urethra.
Lubricate the catheter, with local anaesthetic gel (lignocaine)/K-Y jelly.
Use the other hand to insert the catheter into the urethra. There may
be some resistance as the catheter tip reaches the bladder neck.
Continue to advance the catheter slowly using gentle, firm pressure until
the sphincter relaxes.
In girls:
1
The labia are separated and the catheter inserted through the urethral
meatus into the bladder.
For both males and females

1
The catheter is inserted gently until the urine flows.
The urine is collected in a jug or bottle or is directed into the lavatory.
Once the urine has stopped flowing the catheter should be rotated
and then, if no urine drains, slowly withdrawn.
Wash hands on completion of catheterization.
Catheterise at the prescribed time with the best available measures.
Size of Catheters
Small babies: 6F
Children: 8-10F
Adolescents: 12-14F
How Often to Catheterise
Infants: 6 times a day
Children: 4-5 times a day, more frequently in patients with a high fluid
intake, and in patients with a small capacity bladder.
Reuse of catheters
1
Catheters can be re-used for 2 to 4 weeks
After using the catheter, wash in soapy water, rinse well under running
tap water, hang to air dry and store in clean container.
301
NEPHROLOGY
Algorithm for the Management of Neurogenic Bladder

Newborn with Open Spinal Dysraphism
Surgical Closure of Defect
NEPHROLOGY
Baseline evaluation and assessment of

risk for upper urinary tract damage
Clinical examination
Urine analysis and culture
Renal profile
Ultrasound kidneys, ureter and bladder
Start CIC before Discharge
Urodynamic Studies, if indicated:
Hydronephrosis
Recurrent urinary tract infection
Refer to Combined Urology/Nephrology Care

Deteriorating upper tract
Abnormal serum creatinine
Recurrent urinary tract infection
Urinary Incontinence
302
Occult spinal dysraphism

May present with cutaneous stigmata (hairy tufts, skin tags, lumbosacral
subcutaneous masses and haemangiomas)
Spinal ultrasound can be used in neonates and infants, optimally before 6
months of age, when ossification of posterior elements prevents an
acoustic window.
After 6 months of age, the imaging modality is MRI of spine.
Other conditions that lead to neurogenic bladder
Start CIC in patients with acquired neurogenic bladder with urinary
retention, recurrent urinary tract infection and/or hydronephrosis.
303
NEPHROLOGY
Recurrent urinary tract infection (UTI) and antibiotics

Prophylactic antibacterial therapy is not recommended as therapy does not
decrease the incidence of clinical infections.
Asymptomatic bacteriuria are common but does not require treatment.
All febrile UTIs should be treated with antibiotics as soon as possible.
Children with recurrent symptomatic UTI should be given prophylactic
antibiotics and may benefit from circumcision.
Management of bowel incontinence
Laxatives: mineral oil, lactulose, enema.
Aim to achieve regular and efficient bowel emptying regimen.
Follow up assessment
Voiding chart: timing of daytime and night-time voiding, volume of each
void, and incontinence and urge episodes.
Constipation and fecal incontinence.
Monitoring of blood pressure, urinalysis, renal profile.
Urine culture in suspected febrile UTI or symptomatic UTI.
Serial ultrasound imaging at regular intervals depending on the age and
baseline ultrasound findings. Infants and younger children require more
frequent ultrasound scans up to 3 to 6 monthly.
304
NEPHROLOGY
Chapter 63: Urinary Tract Infection
Symptoms depend on the age of the child and the site of infection.
In infants and toddlers: signs and symptoms are non-specific e.g. fever,
irritability, jaundice and failure to thrive.
The presence of UTI should be considered in children with unexplained
fever.
Symptoms of lower UTI such as pain with micturition and frequency are
often not recognized before the age of two.
General examination, growth, blood pressure.
Abdominal examination for distended bladder, ballotable kidneys, other
masses, genitalia, and anal tone.
Examine the back for any spinal lesion.
Look for lower limb deformities or wasting (suggests a neurogenic bladder).
Diagnosis
Accurate diagnosis is extremely important as false diagnosis of UTI would
lead to unnecessary interventions that are costly and potentially harmful.
The diagnosis is best made with a combination of culture and urinalysis
The quality of the urine sample is of crucial importance.
Urine specimen transport
If collected urine cannot be cultured within 4 hours; the specimen should be
refrigerated at 4 oC or a bacteriostatic agent e.g. boric acid (1.8%) added.
Fill the specimen container pre-filled with boric acid with urine to the
required level.
305
NEPHROLOGY
Introduction
Urinary tract infection (UTI) comprises 5% of febrile illnesses in early
childhood. 2.1% of girls and 2.2% of boys will have had a UTI before the
age of 2 years.
UTI is an important risk factor for the development of hypertension, renal
failure and end stage renal disease.
Definition
Urinary tract infection is growth of bacteria in the urinary tract or
combination of clinical features and presence of bacteria in the urine
Significant bacteriuria is defined as the presence of > 105 colony forming
units (cfu) of a single organism per ml of freshly voided urine (Kass).
Acute pyelonephritis is bacteriuria presenting clinically with fever > 38C
and/or loin pain and tenderness. It carries a higher risk of renal scarring
Acute cystitis is infection limited to the lower urinary tract presenting
clinically with acute voiding symptoms: dysuria, urgency, frequency,
suprapubic pain or incontinence.
Asymptomatic bacteriuria is presence of bacteriuria in the urine in an
otherwise asymptomatic child.
Collection of Urine
Bag urine specimen
High contamination rate of up to 70%.
Negative culture excludes UTI in untreated children.
Positive culture should be confirmed with a clean catch or suprapubic aspiration specimen (SPA).
Clean catch specimen
Recommended in a child who is bladder trained.
Catheterisation
Sensitivity 95%, specificity 99%, as compared to SPA.
NEPHROLOGY
Low risk of introducing infection but have higher success rates and the
procedure is less painful compared to SPA.
Suprapubic aspiration (SPA)
Best technique (gold standard) of obtaining an uncontaminated urine
sample.
Any gram negative growth is significant.
Technique:
Lie the child in a supine position.
Thin needle with syringe is inserted vertically in the midline, 1 - 2 cm
above symphysis pubis.
Urine is obtained at a depth of 2 to 3 cm.
Usually done in infants < 1 year; also applicable in children aged 4 - 5 years
if bladder is palpable above the symphysis pubis.
Success rate is 98% with ultrasound guidance.
Note: When it is not possible to collect urine by non-invasive methods,
catheterization or SPA should be used.
Urine testing
Rapid diagnosis of UTI can be made by examining the fresh urine with
urinary dipstick and microscopy. However, where possible, a fresh
specimen of urine should be sent for culture and sensitivity.
306
Sensitivity and specificity of various tests for UTI

Test
Sensitivity % (range)
Specificity % (range)
Leucocyte esterase (LE)
78 (64-92)
Nitrite
98 (90-100)
83 (67-94)
53(15-82)
LE or nitrite positive
72 (58-91)
93 (90-100)
Pyuria
81 (45-98)
73 (32-100)
Bacteria
83 (11-100)
81(16-99)
Any positive test
70 (60-90)
99.8 (99-100)
Antibiotic prophylaxis
Antibiotic prophylaxis should not be routinely recommended in infants and
children following first time UTI as antimicrobial prophylaxis does not
seem to reduce significantly the rates of recurrence of pyelonephritis,
regardless of age or degree of reflux.
However, antibiotic prophylaxis may be considered in the following:
Infants and children with recurrent symptomatic UTI.
Infants and children with vesico-ureteric reflux grades of at least grade III.
Measures to reduce risk of further infections
Dysfunctional elimination syndrome (DES) or dysfunctional voiding is
defined as an abnormal pattern of voiding of unknown aetiology
characterised by faecal and/or urinary incontinence and withholding of
both urine and faeces.
Treatment of DES includes high fibre diet, use of laxatives, timed frequent
voiding, and regular bowel movement.
If condition persists, referral to a paediatric urologist/nephrologist is
needed.
307
NEPHROLOGY
Management
All infants with febrile UTI should be admitted and intravenous antibiotics
started as for acute pyelonephritis.
In patients with high risk of serious illness, it is preferable that urine sample
should be obtained first; however treatment should be started if urine
sample is unobtainable.
Antibiotic Treatment for UTI

Type of Infection Preferred Treatment
Alternative Treatment
UTI (Acute cystitis)

E.coli.
Proteus spp.
PO Trimethoprim
PO Trimethoprim/
4mg/kg/dose bd
Sulphamethazole
(max 300mg daily)
4mg/kg/dose (TMP) bd
for 1 week
for1 week
Cephalexin, cefuroxime can also be used especially in children who had

prior antibiotics.
Single dose of antibiotic therapy not recommended.
Upper Tract UTI (Acute pyelonephritis)
NEPHROLOGY
E.coli.
Proteus spp.
IV Cefotaxime 100mg/kg/day IV Cefuroxime 100mg/kg/day

q8h
q8h
for 10-14 days OR
IV Gentamicin 5-7mg/kg/day
daily
Repeat culture within 48hours if poor response.

Antibiotic may need to be changed according to sensitivity.
Suggest to continue intravenous antibiotic until child is afebrile for 2-3 days
and then switch to appropriate oral therapy after culture results
e.g. Cefuroxime, for total of 10-14 days.
Asymptomatic bacteriuria
No treatment recommended
Antibiotic Prophylaxis for UTI
Indication
Preferred Treatment
UTI
Prophylaxis
PO Trimethoprim
1-2mg/kg ON
PO Nitrofurantoin
1-2mg/kg ON
or
PO Cephalexin 5mg/kg ON
Antibiotic prophylaxis is not be routinely recommended in children with UTI.

Prophylactic antibiotics should be given for 3 days with MCUG done on
the second day.
A child develops an infection while on prophylactic medication, treatment
should be with a different antibiotic and not a higher dose of the same
prophylactic antibiotic.
308
309
NEPHROLOGY
Recommendations for imaging

Previous guidelines have recommended routine radiological imaging for all
children with UTI. Current evidence has narrowed the indications for imaging
as summarized below:
Ultrasound
Recommended in
All children less than 3 years of age
Children above 3 years of age with poor urinary stream, seriously ill with
UTI, palpable abdominal masses, raised serum creatinine, non E coli UTI,
febrile after 48 hours of antibiotic treatment, or recurrent UTI.
DMSA scan
Recommended in infants and children with UTI with any of the following
features:
Seriously ill with UTI.
Poor urine flow.
Abdominal or bladder mass.
Raised creatinine.
Septicaemia.
Failure to respond to treatment with suitable antibiotics within 48 hours.
Infection with non E. coli organisms.
Micturating cystourethogram (MCUG)
Since meta-analyses of data from recent, randomized controlled trials do not
support antimicrobial prophylaxis to prevent febrile UTI; routine MCUG after
the first UTI should not be routinely recommended after the first UTI.
MCUG may be considered in:
Infants with recurrent UTI.
Infants with UTI and the following features: poor urinary stream, seriously
ill with UTI, palpable abdominal masses, raised serum creatinine,
non E. coli UTI, febrile after 48 hours of antibiotic treatment.
Children less than 3 years old with the following features:
Dilatation on ultrasound.
Poor urine flow.
Non E. coli infection.
Family history of VUR.
Other radiological investigations e.g. DTPA scan, MCUG in older children
would depend on the ultrasound findings.
Further Management
This depends upon the results of investigation.
NORMAL RENAL TRACTS
Prophylactic antibiotic not required.
Urine culture during any febrile illness or if the child is unwell.
NEPHROLOGY
NO VESICOURETERIC REFLUX BUT RENAL SCARRING PRESENT.

Repeat urine culture only if symptomatic.
Assessment includes height, weight, blood pressure and routine tests for
proteinuria.
Children with a minor, unilateral renal scarring do not need long-term
follow-up unless recurrent UTI or family history or lifestyle risk factors for
hypertension.
Children with bilateral renal abnormalities, impaired renal function, raised
blood pressure and or proteinuria should be managed by a nephrologist.
Close follow up during pregnancy.
VESICOURETEIC REFLUX
Definition
Vesicoureteral reflux (VUR) is defined as the retrograde flow of urine from
the bladder into the ureter and collecting system.
In most individuals VUR results from a congenital anomaly of ureterovesical
junction (primary VUR), whereas in others it results from high pressure
voiding secondary to posterior urethral valve, neuropathic bladder or
voiding dysfunction (secondary VUR).
Significance of VUR
Commonest radiological abnormality in children with UTI (30 40%).
Children with VUR thought to be at risk for further episodes of
pyelonephritis with potential for increasing renal scarring and renal
impairment (reflux nephropathy).
NATURAL HISTORY OF VESICOURETERIC REFLUX
Vesicoureteric
Reflux
Recurrent
UTI
Progressive
Renal Scarring
310
End Stage
Renal Disease
Hypertension
CLASSIFICATION OF VESICOURETERIC REFLUX ACCORDING TO

THE INTERNATIONAL REFLUX STUDY COMMITTEE.
Kidney
Ureter
Bladder
Grade I
Grade II
Grade III
Grade IV
Grade V
Management
Antibiotic prophylaxis refer to antibiotic prophylaxis section above
Surgical management or endoscopic treatment is considered if the child
has recurrent breakthrough febrile UTI.
POSTERIOR URETHRAL VALVE
Refer to a Paediatric urologist/surgeon/nephrologist.
RENAL DYSPLASIA, HYPOPLASIA OR MODERATE TO SEVERE
HYDRONEPHROSIS
May need further imaging to evaluate function or drainage in the case of
hydronephrosis
Refer surgeon if obstruction is confirmed.
Monitor renal function, BP and growth parameters
Summary
All children less than 2 years of age with unexplained fever should have
urine tested for UTI.
Greater emphasis on earlier diagnosis & prompt treatment of UTI
Diagnosis of UTI should be unequivocally established before a child is
subjected to invasive and expensive radiological studies
Antibiotic prophylaxis should not be routinely recommended following
first-time UTI.
311
312
NEPHROLOGY
Chapter 64: Antenatal Hydronephrosis

Definition
No consensus statement to date.
Most studied parameter is the measurement of antero -posterior diameter
(APD) of renal pelvis as visualized on transverse plane.
Most agree that APD of renal pelvis of at least 5 mm on antenatal
ultrasound of the fetus is abnormal.
APD > 15mm represents severe or significant hydronephrosis.
Fetal Hydronephrosis Index(HI): APD of renal pelvis divided by urinary
bladder volume has been proposed as studied parameter but not
uniformly accepted yet.
Goals in evaluation of patients with antenatal hydronephrosis

Prevent potential complications.
Preserve renal function.
Distinguish children who require follow up and intervention from those
who do not.
Timing of detection
90% after eighteen weeks of gestation.
95% by 22 weeks.
Grading
The Society of Fetal Urology (SFU) Hydronephronephrosis Grading System
Grades
Pattern of renal sinus splitting
SFU Grade 0
No splitting (renal pelvis)
SFU Grade I
Urine in pelvis barely splits sinus
SFU Grade II
Urine fills intrarenal pelvis
SFU Grade II
Urine fills extrarenal pelvis. Major calyces dilated
SFU Grade III
SFU Grade 2 and minor calyces uniformly dilated but

renal parenchyma preserved.
SFU Grade IV
SFU Grade 3 and renal parenchyma thin
Marked hydronephrosis is frequently seen in pelvic ureteric junction

obstruction whereas the mild hydronephrosis is associated with
vesicouretric reflux.
313
NEPHROLOGY
Advantages of prenatal detection

May potentially be used for prenatal counseling and has allowed
identification of conditions that require immediate treatment and which
otherwise would go unrecognized until symptoms arose postnatally.
Meta-analysis of 17 studies revealed that calculated risk of any postnatal
pathology per degree of antenatal hydronephrosis was 11.9% for mild ,
45.1% for moderate and 88.3% for severe.
Epidemiology
1-5% of all pregnancies
Increased frequency of up to 8% with positive family history of renal
agenesis, multicystic kidney, reflux nephropathy and polycystic kidneys.
Male to female ratio is 2:1.
Bilateral in 20 to 40 %.
Aetiology in Antenatal Hydronephrosis
NEPHROLOGY
Abnormality
Frequency (%)
Transient
48
Physiologic
15
Pelvic ureteric junction obstruction
11
Vesicoureteric reflux
Megaureter,obstructed or non-obstructed
Multicystic kidneys
Ureterocoeles
Posterior urethral valves
Transient and physiologic hydronephrosis

60% of antenatal hydronephrosis is physiological. This will resolve before
end of pregnancy or within first year of life.
Fetal urine flow is four to six times greater than neonatal urine production.
This is due to differences in renovascular resistances, GFR and concentrating
ability before and after birth. These differences may contribute to ureteric
dilatation in-utero in the absence of functionally significant obstruction.
Antenatal management
In general antenatal interventions are not required except for watchful
monitoring.
Pregnancy should be allowed to proceed to term and normal delivery can
be allowed in the absence of other complications like severe
oligohydramnios or other fetal abnormalities.
Timing of postnatal evaluation
Within first week of life: Neonates with unilateral hydronephrosis and
normal contralateral kidney.
Immediate evaluation before discharge: Bilateral hydronephrosis,
hydronephrosis in solitary kidneys and bladder outlet obstruction.
314
Postnatal management
Certain clinical features may suggest specific underlying causes:
Abdominal mass: Enlarged kidney due to pelvic-ureteric junction obstruction
or multicystic dysplastic kidneys.
Palpable bladder and/or poor stream and dribbling: Posterior urethral
valves in a male infant.
Deficient abdominal wall with undescended testes: Prune Belly syndrome.
Abnormalities in the spine and lower limb with patulous anus: Neurogenic
bladder.
Examination for other anomalies should also be carried out.
Other radiological investigations

99mDTPA/Mag 3 SCAN
DTPA or Mag 3 scans are required when there is moderate or gross
hydronephrosis on postnatal ultrasound. These scans detect differential
function of both kidneys as well as the presence of significant obstruction in the
urinary tract. In Malaysia, only DTPA scan is available in most radionuclear
centers. It is best done after one month of life.
Intravenous Urogram (IVU)
With the availability of DTPA /Mag3 scan, IVU is no more indicated.
315
NEPHROLOGY
Unilateral hydronephrosis
In babies who are normal on physical examination, a repeat ultrasound
should be done after birth; subsequent management will depend on the
ultrasound findings.
The ultrasound should be repeated one month later if initial postnatal US is
normal or show only mild hydronephrosis. The patient can be discharged
if the repeat ultrasound is also normal.
Bilateral Hydronephrosis
These babies need a full examination and investigation after birth.
Ultrasound of the kidneys and urinary tracts should be repeated.
Urine output should be monitored.
Renal profile should be done on day 2 of life.
The child should be monitored closely for UTI and a second-generation
cephalosporin started if there is any suggestion of UTI.
In boys, detailed ultrasound scan should be done by an experienced radiologist to detect thickened bladder wall and dilated posterior urethra suggestive
of posterior urethral valves. Any suggestion of posterior urethral valve or
renal failure warrants an urgent MCU.
Urgent referral to a Paediatric nephrologist and/or Urologist is needed if the
newborn has renal failure, or confirmed or suspected posterior urethral
valves.
Antibiotics
Efficacy of antibiotic prophylaxis has not been proven. Consider antibiotic
prophylaxis in high risk population such as those with gross hydronephrosis
and hydroureters.
Commonly used Antibiotic Prophylaxis
Trimethoprim
1-2mg/kg at night
Cephalexin
5mg/kg at night
NEPHROLOGY
Follow up Care
All children with significant hydronephrosis should be referred to paediatric
nephrologists / urologist after relevant radiological investigations have been
completed.
316
ALGORITHM FOR MANAGEMENT OF ANTENATALLY DIAGNOSED HYDRONEPHROSIS
Antenatal Hydronephrosis
UNILATERAL
Hydronephrosis
BILATERAL
Hydronephrosis
Postnatal
Ultrasound Kidneys
Investigations
Renal profile, VBG, FBC,
UFEME, urine C&S
Moderate/Gross
Hydronephrosis
Postnatal
Ultrasound Kidneys
Females
Incr Sr Creatinine
Repeat
Ultrasound
Kidneys
Micturating
CystoUrethrogram
(MCU)
If No VUR or
VUR Grade 1 & 2 only
Proceed to DTPA scan
Normal
Ultrasound findings
Discharge
Nephrologist / Urologist
Consultation
317
Males
Dilated post urethra
Thickened bladder wall
Posterior Urethral Valve
Micturating
CystoUrethrogram (MCU)
Urgent Referral to
Nephrologist / Urologist
NEPHROLOGY
Normal/Mild
Hydronephrosis
NEPHROLOGY
References
Section 7 Nephrology
Chapter 58 Postinfectious Acute Glomerulonephritis
1.Travis L, Kalia A. Acute nephritic syndrome. Clinical Paediatric Nephrology.
2nd ed. Postlethwaite RJ. Butterworth Heinemann 1994. pp 201 209.
2.Malaysian Hypertension Consensus Guidelines 2007. Ministry of Health &
Academy of Medicine of Malaysia
3.Simokes A, Spitzer A. Post streptococcal acute glomerulonephritis. Paediatric Rev. 16: 278 279. 1995.
4.Rodriguez-Iturbe B. Epidemic post streptococcal glomerulonephritis. Kidney
Int 1984; 25:129-136.
Chapter 59 Nephrotic Syndrome
1.Consensus statement - Management of idiopathic nephrotic syndrome in
childhood. Ministry of Health, Academy of Medicine Malaysia. 1999.
2.Hodson EM, Knight JF, Willis NS, Craig JC. Corticosteroid therapy for nephrotic syndrome in children (Cochrane Review). In: The Cochrane Library,
Issue 1, 2003. Oxford: Update Software.
3.McIntyre P, Craig JC. Prevention of serious bacterial infection in children
with nephrotic syndrome. J Paediatr Child Health 1998; 34: 314 - 317.
4.Consensus statement on management and audit potential for steroid
responsive nephrotic syndrome. Arch Dis Child 1994; 70: 151 - 157.
5.Durkan A, Hodson E, Willis N, Craig J. Non-corticosteroid treatment for nephrotic syndrome in children (Cochrane Review). In: The Cochrane Library,
Issue 1, 2003. Oxford: Update Software.
Chapter 60 Acute Kidney Injury
1.Pediatric Nephrology 5th edition, editors Ellis D Avner, William E Harmon,
Patrick Niaudet, Lippincott Williams & Wilkins, 2004
2.Paediatric Formulary 7th edition, Guys, St Thomas and Lewisham Hospitals, 2005
3.Takemoto CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook 9th edition, 2002-2003
4.Daschner M. Drug dosage in children with reduced renal function. Pediatr
Nephrol 2005; 20: 1675-1686.
Chapter 60 Acute Peritoneal Dialysis
1.Pediatric Nephrology 5th edition, editors Ellis D Avner, William E Harmon,
Patrick Niaudet, Lippincott Williams & Wilkins, 2004
2.Renal Replacement Therapy Clinical Practice Guidelines (2nd Edition) Ministry of Health, Malaysia
3.International Society for Peritoneal Dialysis (ISPD) Guidelines / Recommendations Consensus Guidelines for the Treatment of Peritonitis in Paediatric
Patients Receiving Peritoneal Dialysis. Perit Dial Int 2000; 6:610-624.
318
Chapter 62 Neurogenic Bladder

1.European Association of Urology. Guidelines on Neurogenic Lower Urinary
Tract Dysfunction.2008.
2.Sutherland R, Mevorach R, Baskin L, et al. Spinal dysraphism in children:
An overview and an approach to prevent complication. Urology 1995; 46:
294-304
3.Beattie J, Scottish Renal Paediatrics. Guideline on Management of Neuropathic Bladder 2005.
4.Verpoorten C, Buyse G. The neurogenic bladder: medical treatment. Pediatr
Nephrol; 2008; 23: 717725
5.Basic procedure for clean intermittent catheterization.
319
NEPHROLOGY
Chapter 63 Urinary Tract Infection

1.National Institute for Health and Clinical Excellence Urinary tract infection
in children: diagnosis, treatment and long-term management. http//www.
nice.org.uk/nicermedia/pdf/CG54fullguidelines.pdf (November 2007)
2.American Academy of Pediatrics. Practice parameters; the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants
and young children. Pediatrics 1999;103:843-52
3.Garin EH, Olavarria F, Nieto VG, Valenciano B, Campos A and Young L.
Clinical significance of primary VUR and urinary antibiotic prophylaxis
after acute pyelonephritis: a multicenter randomized controlled study.
Pediatrics 2006;117;626-632
4.Williams GJ, Wei L, Lee A and Craig JC. Long term antibiotics for preventing recurrent urinary tract infection in children. Cochrane Database of
Systematic Review 2006, Issue 3
5.Michael M, Hodson EM, Craig JC, Martin S, Moyer VA. Short versus standard duration oral antibiotic therapy for acute UTI in children. Cochrane
Database of Systematic Reviews 2006 Issue 3.
6.Bloomfield P, Hodson EM and Craig JC. Antibiotics for acute pyelonephritis
in children. The Cochrane Database of Systematic Reviews 2007 Issue 1.
7.Royal College of Physicians Research Unit Working Group. Guidelines for
the management of acute urinary tract infection in childhood. JR Coll
Physicians Lon 1991;25:36-42
8.Jodal U, Smellie JM, Lax H and Hoyer PF. Ten-year results of randomized
treatment of children with severe vesicoureteric reflux. Final report of the
International Reflux Study in Children. Pediatr Nephrol (2006) 21: 785-792
9.Hodson EM, Wheeler DM, Nimalchandra, Smith GH and Craig JC. Interventions for primary vesicoureteric reflux (VUR). Cochrane Database of
Systematic Reviews 2007 Issue 3.
10.U Jodal and U Lindberg. Guidelines for management of children with
urinary tract infection and vesico-ureteric reflux. Recommendations from
a Swedish state-of-the-art conference. Acta Paediatr Suppl 431:87-9,1999
NEPHROLOGY
Chapter 63 Urinary Tract Infection (cont.)

11.American Academy of Pediatrics. Technical report- Diagnosis and
Management of an Initial UTI in Febrile Infants and Young Children.
Pediatrics Volume 128, Number 3, September 2011
12.Brandstrom P, Esbjorner E, Herthelius M, Swerkersson S, Jodal U, Hansson S.
The Swedish Reflux Trial in Children, part III: urinary tract infection pattern.
J Urol. 2010;184(1):286-291.
Chapter 64 Antenatal Hydronephrosis
1.Heip T Nguyen, CD Anthony Herndon, Christopher Cooper, John Gatti et al
The Society For Fetal Urology consensus statement on the evaluation and
management of antenatal hydronephrosis J of Ped Urol(2010) 6,212-231
2.Vivian YF Leung, Winnie CW Chu, Constatntine Metrewell Hydronephrosis
index: a better physiological reference in antenatal ultrasound for assessment of fetal hydronephrosis J Pediatr ( 2009);154:116-20
3.Richard S Lee, Marc Cendron, Daniel D Kinnamon, Hiep T. Nguyen Antenatal
hydronephrosis as a predictor of postnatal outcome: A Meta-analysis
Pediatrics (2006);118:586-594
4.Baskin L Tulin Ozca Overview of antenatal hydronpehrosis www.uptodate.
com 2011.
5.Madarikan BA, Hayward C, Roberts GM et al. Clinical outcome of fetal
uropathy. Arch Dis Child 1988; 63:961.
6.ReussA, Wladimiroff JW, Niermeijer MF. Antenatal diagnosis of renal tract
anomalies by ultrasound. Pediatr Nephrol 1987; 1:546.
7.Gonzales R, Schimke CM. Uteropelvic junction obstruction in infants and
children. Pediatr Clin North Am 2001; 48:1505.
8.Woodward M, Frank D. Postnatal management of antenatal hydronephrosis. BJU Int 2002; 89:149.
9.Keating MA, Escala J, Snyder HM et al. Changing concepts in management
of primary obstructive megaureter. J Urol 1989; 142:636
10.Paediatric Formulary Guys, St. Thomas and Lewisham Hospital 7th edition.2010.
11.U, Hansson S. The Swedish Reflux Trial in Children, part III: urinary tract
infection pattern. J Urol. 2010;184(1):286-291.
320
Chapter 65: Approach to a Child with Anaemia

APPROACH TO CHILDREN WITH ANAEMIA
Child with Anaemia

History
Preliminary Investigations:
Hb, Haematocrit,
Red cell indices, Blood film
Reticulocyte count,
Presence of Generalized
Lymphadenopathy
and/or Hepatosplenomegaly?
Acute / Chronic leukaemias
Acute blood loss
Chronic haemolytic anaemia:
Iron deficiency
Thalassaemia
Folate deficiency
Hereditary Spherocytosis
B12 deficiency
Hereditary Elliptocytosis
Acute haemolytic anaemia:
G6PD deficiency
G6PD deficiency with oxidant stress
Malignancies e.g. lymphoma
Autoimmune
Chronic infection e.g. Tuberculosis
ABO incompatibility
Infection e.g. malaria
Drug induced
Bone marrow failure
Aplastic anaemia
Fanconis anaemia
Diamond-Blackfan
Others
Hypothyroidism
Chronic renal failure
321
HAEMATO-ONCOLOGY
NO
YES
Variation in Full Blood Count Indices with Age

Age
Hb (g/dl)
RBC (x10 /l)
MCV (fl)
Birth
14.9 23.7
3.7-6.5
100-135
2 months
9.4-13.0
3.1-4.3
84-105
12 months
11.3-14.1
4.1-5.3
71-85
2-6 year
11.5-13.5
3.9-5.3
75-87
6-12 year
11.5-15.5
4.0-5.2
77-95
12-18 yr girls
12.0-16.0
4.1-5.1
78-95
12-18 yr boys
13.0-16.0
4.5-5.3
78-95
HAEMATO-ONCOLOGY
Hb, haemoglobin; RBC, red blood cell count; MCV, mean corpuscular volume;
MCH, mean corpuscular haemoglobin
IRON DEFICIENCY ANAEMIA
Laboratory findings
Red cell indices : Low MCV,
Low MCH values
Low serum ferritin
Causes of Iron Deficiency Anemia

Chronic blood loss
Increase demand
Prematurity
Growth
Treatment
Malabsorption
Nutritional counseling
Worm infestation
Maintain breastfeeding.
Use iron fortified cereals.
Poor diet
Oral iron medication
Give 6 mg/kg/day of elemental iron in 3 divided doses, continue for
6-8 weeks after haemoglobin level is restored to normal.
Syr FAC (Ferrous ammonium citrate): the content of elemental iron per ml
depends on the preparation available.
Tab. Ferrous fumarate 200 mg has 66 mg of elemental iron per tablet.
Consider the following if failure to response to oral iron:
Non-compliance.
Inadequate iron dosage.
Unrecognized blood loss.
Impaired GI absorption.
Incorrect diagnosis.
Blood transfusion
No transfusion required in chronic anemia unless signs of decompensation
(e.g. cardiac dysfunction) and the patient is otherwise debilitated.
In severe anaemia (Hb < 4 g/dL) give low volume packed red cells (< 5mls/kg).
If necessary over 4-6 hours with IV Frusemide (1mg/kg) midway.
322
HEREDITARY SPHEROCYTOSIS
Pathogenesis
A defective structural protein (spectrin) in the RBC membrane
producing spheroidal shaped and osmotically fragile RBCs that are trapped
and destroyed in the spleen, resulting in shortened RBC life span.
The degree of clinical severity is proportional to the severity of RBC
membrane defect.
Inheritance is autosomal dominant in 2/3; recessive or de novo in 1/3 of
children.
Investigations in children with Suspected Spherocytosis

Reticulocytosis
Microspherocytes in peripheral blood film
Osmotic fragility is increased
Elevated MCHC
Normal direct antiglobulin test
Autohaemolysis is increased and corrected by glucose

Treatment
Splenectomy to be delayed as long as possible.
In mild cases, avoid splenectomy unless gallstones developed.
Folic acid supplements: 1 mg day.
Splenectomy is avoided for patients < 5 years because of the increased risk
of postsplenectomy sepsis.
Give pneumococcal, haemophilus and meningococcal vaccination 4-6
weeks prior to splenectomy and prophylactic oral penicillin to be given
post splenectomy.
323
HAEMATO-ONCOLOGY
Clinical features Mild, moderate and severe

Anaemia
Intermittent jaundice plenomegaly
Splenomegaly
Haemolytic crises
Pigmented gallstones in adolescents and young adults
Aplastic crises with Parvovirus B19 infections
Megaloblastic crises
All patients should receive folate supplement
Rare manifestations
Leg ulcers, spinocerebellar ataxia, myopathy
Extramedullary haematopoietic tumours,
324
HAEMATO-ONCOLOGY
Chapter 66: Thalassaemia

Introduction
-Thalassaemia major is an inherited blood disorder presenting with
anaemia at 4 - 6 months of age.
Common presenting symptoms are pallor lethargy, failure to thrive and
hepatosplenomegaly.
In Malaysia, the -thalassaemia carrier rate is estimated at 3-5%, most of
whom are unaware of their carrier / thalassaemia minor status.
The carrier rates of -thalassaemia and Haemoglobin E (HbE) are 1.8-7.5%
and 5-46% respectively. HbE are found more in the northern peninsular
states.
Interaction between a -thalassaemia carrier with a HbE carrier may result
in the birth of a patient with HbE-thalassaemia or thalassaemia
intermedia with variable clinical severity.
The moderate to severe forms behave like -thalassaemia major patients
while the milder forms are asymptomatic.
325
HAEMATO-ONCOLOGY
Baseline investigations to be done for all new patients: Full blood count, Peripheral blood film (In typical cases, the Hb is about 7g/dl)
Haemoglobin analysis by electrophoresis / HPLC:
Typical findings for -thalassaemia major: HbA decreased or absent,
HbF increased, HbA2 variable.
Serum ferritin.
Red cell phenotyping (ideal) before first transfusion.
DNA analysis (ideal)
For the detection of -carrier and confirmation of difficult cases.
Mandatory in prenatal diagnosis.
Available upon request at tertiary centre laboratories in IMR, HKL, HUKM,
UMMC and USM.
Liver function test.
Infection screen: HIV, Hepatitis B & C, VDRL screen (before first transfusion).
HLA typing (for all patient with unaffected siblings)
All nuclear family members must be investigated by Hb Analysis for genetic
counselling.
1st degree and 2nd degree relatives should also be encouraged to be
screened & counselled (cascade screening).
HAEMATO-ONCOLOGY
Management
Regular maintenance blood transfusion and iron chelation therapy is the
mainstay of treatment in patients with transfusion dependent thalassaemia.
Maintenance Blood Transfusion
Beta thalassaemia major
When to start blood transfusion?
After completing blood investigations for confirmation of diagnosis.
Hb < 7g/dl on 2 occasions > 2 weeks apart (in absence other factors
e.g. infection).
Hb > 7g/dl in +-thalassaemia major/severe forms of HbE--thalassaemia
if impaired growth, para-spinal masses, severe bone changes, enlarging
liver and spleen.
Transfusion targets?
Maintain pre transfusion Hb level at 9 -10 g/dl.
Keep mean post-transfusion Hb at 13.5-15.5g/dl.
Keep mean Hb 12 - 12.5 g/dl.
The above targets allow for normal physical activity and growth,
abolishes chronic hypoxaemia, reduce compensatory marrow hyperplasia
which causes irreversible facial bone changes and para-spinal masses.
Transfusion interval?
Usually 4 weekly interval (usual rate of Hb decline is at 1g/dl/week).
Interval varies from individual patients (range: 2 - 6 weekly).
Transfusion volume?
Volume: 15 - 20mls/kg (maximum) packed red cells (PRBC).
Round-up to the nearest pint of cross-matched blood provided.
i.e. if calculated volume is just > 1 pint of blood, give 1 pint,
or if calculated volume is just < 2 pints, give 2 pints.
This strategy minimizes the number of exposure to immunologically
different units of blood product and avoid wastage of donated blood.
Note:
In the presence of cardiac failure or Hb < 5g/dl, use lower volume PRBC (<
5ml/kg) at slow infusion rate over > 4 hours with IV Frusemide 1 mg/kg
(20 mg maximum dose).
It is recommended for patients to use leucodepleted (pre-storage, post
storage or bedside leucocyte filters) PRBC < 2 weeks old.
Leucodepletion would minimize non-haemolytic febrile reactions and
alloimmunization by removing white cells contaminating PRBC.
Thalassaemia intermedia
A clinical diagnosis where patients present later with less severe anaemia
at > 2 years of age usually with Hb 8g/dl or more.
Severity varies from being symptomatic at presentation to being
asymptomatic until later adult life.
Assessment and decision to start regular transfusion is best left to the
specialist.
326
Alpha Thalassaemia (Hb H disease)

Transfuse only if Hb persistently < 7g/dl and/or symptomatic.
Iron Chelation Therapy
This is essential to prevent iron overload in transfusion dependent
thalassaemia.
Compliance to optimal treatment is directly related to superior survival
outcome, now possible beyond the 6th decade.
Currently 3 approved iron chelators are available: Desferrioxamine (DFO),
Deferiprone (DFP) and Deferasirox (DFX).
Complications of Desferal
Local skin reactions usually due to inadequately diluted Desferal or infection
Yersinia infection: presents with fever, abdominal pain & diarrhoea.
Stop Desferal and treat with cotrimoxazole, aminoglycoside or
3rd generation cephalosporin.
Desferal toxicity (if using high doses > 50mg/kg/day in the presence of
low serum ferritin in children):
Ocular toxicity: reduced vision, visual fields, night blindness; reversible
Auditory toxicity: high tone deafness. Not usually reversible
Skeletal lesions: pseudo rickets, metaphyseal changes, vertebral growth
retardation.
Complications of chronic iron overload in Thalassaemics over 10 years
Endocrine: growth retardation, impaired glucose tolerance, pubertal delay,
hypothyroidism, hypoparathyroidism and diabetes mellitus.
Cardiac: arrhythmias, pericarditis, cardiac failure.
Hepatic: liver cirrhosis (especially if with Hepatitis B/C infection).
327
HAEMATO-ONCOLOGY
Desferrioxamine (Desferal)
When to start?
Usually when the child is > 2 - 3 years old.
When serum ferritin reaches 1000 g/L.
Usually after 10 20 blood transfusions.
Dosage and route
Average daily dose is 20 40mg/kg/day.
by subcutaneous (s.c.) continuous infusion using a portable pump over
8-10 hours daily, 5 - 7 nights a week.
Aim to maintain serum ferritin level below 1000 g/L.
Vitamin C augments iron excretion with Desferal.
Severely iron loaded patients require longer or continuous SC or IV infusion
(via Portacath) of Desferal.
HAEMATO-ONCOLOGY
Oral iron chelator

Deferiprone / L1 (Ferriprox/Kelfer) is an alternative if iron chelation is
ineffective or inadequate despite optimal Desferal use, or if Desferal use
is contraindicated. However, there is no formal evaluation in children < 10
years of age.
Deferiprone is given 75 100 mg/kg/day in 3 divided doses.
It can also be used in combination with Desferal, using a lower dose of
50mg/kg/day.
There are risks of GI disturbance, arthritis and rare occurrence of idiopathic
agranulocytosis.
Weekly full blood count monitoring is recommended. Stop if neutropaenic
(<1,500/mm).
Deferasirox (Exjade) can also be used for transfusional iron overload in
patients 2 years or older but is expensive.
The dose is 20-30 mg/kg/day in liquid dispersible tablet, taken once daily.
There are risks of transient skin rash, GI disturbance and a reversible rise in
serum creatinine.
Monthly monitoring of renal function is required.
Monitoring of patients
During each admission for blood transfusion,
the following should be done:
Clinical assessment: height, weight, liver & spleen size, any adverse side
effects of chelation therapy.
Pre-transfusion Hb, platelet count and WBC (if on Deferiprone).
Post transfusion Hb hour post transfusion.
Calculate the volume of pure RBC transfused based on the haematocrit
(HCT) of packed red blood cells (PRBC) given (usually HCT of PRBC from
blood bank is > 50 - 55%).
Volume of pure RBC transfused = volume of blood given x HCT of PRBC
given (e.g. 600 mls x 0.55 = 330 mls).
Annual volume of pure RBC transfused per kg body weight.
Iron balance assessment.
Review of current medications.
Every 3- 6 months
Evaluate growth and development.
Serum ferritin.
Liver function test.
328
Splenectomy
Indications
Blood consumption volume of pure RBC > 1.5X normal or
>200-220 mls/kg/year in those > 5 years of age to maintain average
haemoglobin levels.
Evidence of hypersplenism.
Note:
Give pneumococcal and HIB vaccinations 4-6 weeks prior to splenectomy.
Meningococcal vaccine required in endemic areas.
Penicillin prophylaxis for life after splenectomy.
Low dose aspirin (75 mg daily) if thrombocytosis > 800,000/mm after
splenectomy.
329
HAEMATO-ONCOLOGY
Every year or more frequent if indicated

Evaluate growth and development
Endocrine assessment modified GTT, T4/TSH, Ca, PO4
(If Ca low - check PTH & Vit. D).
Pubertal and sexual development from 10 years onwards.
Tanner stage of breast and genitalia.
Follicle stimulating hormone (FSH), luteinizing hormone (LH) levels,
oestradiol or testosterone hormone levels.
Infection screen (6 monthly) Hepatitis B and C, HIV, VDRL.
Annual volume of pure red blood cell transfused/median body weight.
Evaluate iron balance and overload status.
Bone: osteoporosis & skeletal abnormalities.
Cardiac assessment at variable intervals and especially after 10 years of age
Yearly ECG or Holter monitoring for arrhythmias.
Annual cardiac echocardiography.
Cardiac T2* MRI.
Liver iron assessment
Liver T2* MRI for non-invasive assessment of liver iron.
Liver biopsy for liver iron concentration and the assessment of hepatitis,
fibrosis or cirrhosis in selected cases and prior to bone marrow
transplantation.
HAEMATO-ONCOLOGY
Diet and supplements

Oral folate at minimum 1 mg daily may benefit most patients.
Low dose Vitamin C at 3 mg/kg augments iron excretion for those on
Desferral only.
Dose: <10 yrs, 50mg daily; >10yrs, 100mg daily given only on deferral days
Avoid iron rich food such as red meat and iron fortified cereals or milk.
Tea may help decrease intestinal iron absorption.
Dairy products are recommended as they are rich in calcium.
Vitamin E as antioxidant.
Calcium and zinc.
Bone marrow transplantation (BMT)
Potential curative option when there is an HLA-compatible sibling donor.
Results from matched unrelated donor or unrelated cord blood transplant
are still inferior with higher morbidity, mortality and rejection rates.
Classification of patients into Pesaro risk groups based on the presence of
3 risk factors: hepatomegaly > 2cm, irregular iron chelation and presence
of liver fibrosis.
Best results if performed at the earliest age possible in Class 1 patients.
Pesaro Risk Groups and Outcome following BMT
Class
No. of risk
factors
Event Free
Survival %
Mortality %
Rejection %
1-2
91
83
13
3
Adults
58
21
28
62
34
Note: In newly diagnosed transfusion dependent thalassaemics, the family

should be informed of this option and referred early to a Paediatrician for
counselling and HLA typing of patient and unaffected siblings to identify a
potential donor.
Antenatal diagnosis
Can be done by chorionic villous sampling at 9-11 weeks period of gestation.
Patient and parents support groups
Various states and local Thalassaemia Societies are available nationwide.
Provide support and education for families.
Organises fund raising activities and awareness campaigns.
Health professionals are welcomed to participate.
More information in www.moh.gov.my or www.mytalasemia.net.my.
330
Chapter 67: Immune Thrombocytopenic Purpura

Definition
Isolated thrombocytopenia with otherwise normal blood counts in a
patient with no clinically apparent alternate cause of thrombocytopenia
(e.g. HIV infection, systemic lupus erythematosus, lymphoproliferative
disorders, alloimmune thrombocytopenia, and congenital or hereditary
thrombocytopenia).
Pathogenesis
Increased platelet destruction, likely due to autoantibodies to platelet
membrane antigens.
In children, ITP is an acute, self-limiting disorder that resolves spontaneously.
Clinical Manifestations
Onset is usually acute.
Majority will give a history of a viral infection in the preceding 2-4 weeks
Spectrum of bleeding severity ranges from cutaneous bleeding
i.e. petechiae, to mucosal bleeds i.e. gum bleeds and epistaxis, to life
threatening bleeds i.e. intracranial haemorrhage.
331
HAEMATO-ONCOLOGY
Diagnosis and Investigations

Diagnosis is based on history, physical examination, blood counts, and
examination of the peripheral blood smear.
Physical examination: absence of hepatosplenomegaly or lymphadenopathy.
Blood counts: isolated thrombocytopenia, with normal haemoglobin and
white cell count.
Peripheral blood picture: normal apart from reduced, larger platelets, no
abnormal cells.
Threshold for performing a bone marrow aspiration is low and is indicated:
Before starting steroid therapy (to avoid partially inducing an undiagnosed
acute leukaemia).
If there is failure to respond to Immunoglobulin therapy.
When there is persistent thrombocytopenia > 6 months.
Thrombocytopenia recurs after initial response to treatment.
Other tests that may be indicated when there is atypical presentation are:
Antinuclear factor and DNA antibodies.
Coombs test.
CMV serology for those less than a year old.
Coagulation profile for those suspected non-accidental injury and inherited
bleeding disorder.
HIV testing for those at risk i.e. parents who are HIV positive or intravenous
drug users.
Immunoglobulin levels for those with recurrent infections.
Other causes of Thrombocytopenia

Neonatal alloimmune/ isoimmune
Thrombocytopenia if < 6 months old
Sepsis and infections including HIV infection
Drug-induced thrombocytopenia
Haematological malignancy
e.g. Acute leukaemias
Congenital marrow failure syndromes
e.g. Fanconi anaemia, thrombocytopenia with absent radius
Autoimmune disorders
e.g. Systemic lupus erythematosus, Evan syndrome
HAEMATO-ONCOLOGY
Primary immunodeficiency syndromes

e.g. Wiskott-Aldrich syndrome
Management
Not all children with diagnosis of acute ITP need hospitalization.
Hospitalization is indicated if:
There is severe life-threatening bleeding (e.g. ICH) regardless of platelet
count.
Platelet count < 20 x 109/L with evidence of bleeding.
Platelet count < 20 x 109/L without bleeding but inaccessible to health care.
Parents request due to lack of confidence in homecare.
Most children remit spontaneously: 70% achieve a platelet count
> 50 x 109/L by the end of the 3rd week. Treatment should be individualised.
Precautions with physical activities, avoidance of contact sports and
seeking immediate medical attention if bleeding occurs should be advised.
Careful observation and monitoring of platelet count, without specific
treatment, is appropriate for patients with:
Platelet count > 20 x 109/L without bleeding.
Platelet count > 30 x 109/L with only cutaneous purpura.
A repeat blood count should be performed within the first 7-10 days to
ensure that there is no evidence of serious evolving marrow condition.
Treatment is indicated if there is:
Life threatening bleeding episode ( e.g. ICH) regardless of platelet count.
Platelet count < 20 x 109/L with mucosal bleeding.
Platelet count < 10 x 109/L with any bleeding.
332
Choice of treatment includes:

Oral Prednisolone 2 mg/kg/day for 14 days then taper off.
Oral Prednisolone 4 mg/kg/day for 4 days.
IV Immunoglobulin (IVIG) 0.8 g/kg/dose for a single dose.
Intracranial Haemorrhage (ICH)

The most feared complication of ITP.
Incidence of ICH in a child with ITP is very low between 0.1 - 0.5%.
The risk of ICH highest with platelet count < 20 x 109/L, history of head
trauma, aspirin use and presence of cerebral arteriovenous malformation.
50% of all ICH occurs after 1 month of presentation, 30% after 6 months.
Early treatment with steroid or IVIG may not prevent late onset ICH.
Emergency treatment
Emergency treatment of ITP with severe bleeding i.e. severe epistaxis or GIT
bleed causing drop in Hb or ICH (alone or in combination) includes:
High dose IV Methylprednisolone 30 mg/kg/day for 3 days.
IVIG 0.8g - 1g/kg as a single dose.
Combination of IVIG and methylprednisolone in life threatening conditions.
Platelet transfusion in life threatening haemorrhage: 8 - 12 units/m2 body
surface area (2 to 3 folds larger than usual units) as the platelets will be
consumed by the haemorrhage to form blood clots and will reduce further
circulating platelets.
Consider emergency splenectomy if other modalities fail.
Neurosurgical intervention in ICH, if indicated and to perform with
splenectomy if necessary.
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HAEMATO-ONCOLOGY
Notes regarding treatment:

All above are effective in raising platelet count much quicker compared to
no treatment. However there is no evidence that these treatment
regimens reduce bleeding complications or mortality or influence
progression to chronic ITP.
Side effects of IVIG are common (15 - 75%): fever, flushing, headache,
nausea, aseptic meningitis and transmission of Hepatitis C (older
preparations).
Steroids should not be continued if there is no response or if there is a
rapid relapse after withdrawal. The long-term side-effects in a growing
child outweigh the benefits of either frequent high-dose pulses or titration
of platelet count against a regular lower steroid dose.
Treatment should not be directed at increasing the platelet count above a
preset level but rather on the clinical status of the patient (treat the child
and not the platelet count).
HAEMATO-ONCOLOGY
CHRONIC ITP
Definition
Persistent thrombocytopenia after 6 months of onset (occurs in 20%)
Wide spectrum of manifestations: mild asymptomatic low platelet counts
to intermittent relapsing symptomatic thrombocytopenia to the rare
stubborn and persistent symptomatic and haemorrhagic disease.
Management
Counselling and education of patient and caretakers regarding natural history
of disease and how to detect problems and possible complications early are
important. Parents should be comfortable of taking care of patients with
persistent low platelet counts at home. At the same time they must be made
aware of when and how to seek early medical attention when the need arises.
Every opportunity should be given for disease to remit spontaneously as
the majority will do so if given enough time.
Revisit diagnosis to exclude other causes of thrombocytopenia
(Immunodeficiency, lymphoproliferative, collagen disorders, HIV infection).
Asymptomatic children can be left without therapy and kept under
observation with continued precautions during physical activity.
Symptomatic children may need short course of treatments as for acute
ITP to tide them over the relapse period or during surgical procedures.
For those with Persistent bleeding, Second line therapies includes:
Pulses of steroids: oral Dexamethasone 1 mg/kg given on 4 consecutive
days every 4 weeks for 4 months.
Intermittent anti-Rh(D) Immunoglobulin treatment for those who are
Rhesus D positive: 45 - 50 ug/kg. May cause drop in Hb levels.
Second line therapy should only be started after discussion with a
Paediatric haematologist.
Note:
Care must be taken with any pulse steroid strategy to avoid treatmentrelated steroid side effects.
Family and patient must be aware of immunosuppressive complications
e.g. risk of severe varicella.
There is no justification for long-term continuous steroids.
If first and second-line therapies fail, the patient should be managed by a
paediatric haematologist.
Other useful agents are Rituximab and Cyclosporine.
334
Splenectomy
Rarely indicated in children as spontaneous remissions continue to occur
up to 15 years from diagnosis.
The risk of dying from ITP is very low - 0.002% whilst the mortality
associated with post-splenectomy sepsis is higher at 1.4 - 2.7 %.
Justified when there is:
Life-threatening bleeding event
Severe life-style restriction with no or transient success with intermittent
IVIG, pulsed steroids or anti-D immunoglobulin.
Laparoscopic method preferred if expertise is available.
Pre-splenectomy preparation of the child with immunization against
pneumococcus, haemophilus and meningocccus must be done and postsplenectomy life-long penicillin prophylaxis must be ensured.
Pneumococcal booster should be given every 5 years.
Up to 70% of patients achieve complete remission post-splenectomy.
HAEMATO-ONCOLOGY
335
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HAEMATO-ONCOLOGY
Chapter 68: Haemophilia

Definition
A group of blood disorders in which there is a defect in the clotting mechanism.
Of X-linked recessive inheritance, but in 30% there is no family history as it
is a spontaneous new mutation.
The most common haemophilias are:
Haemophilia A Deficiency of factor VIII (85% cases)
Haemophilia B Deficiency of factor IX (15% cases)
Diagnostic Investigations
Full blood count
Coagulation screen: PT, APTT
Specific factor assay: FVIII level (low in Haemophilia A).
Specific factor assay: FIX level (low in Haemophilia B).
Bleeding time if applicable.
Von Willebrand screen even if APTT normal.
In haemophilia, the activated partial thromboplastin time (APTT) is prolonged
in moderate and severe haemophilia but may not show prolongation in mild
haemophilia. The platelet count and prothrombin time (PT) are normal.
When the APTT is prolonged, then the lab will proceed to do the factor VIII
antigen level. If this is normal, only then will they proceed to assay the Factor
IX level. Once the level has been measured, then the haemophilia can be
classified as below.
Classification of haemophilia and clinical presentation
Factor level
Classification Clinical presentation
<1%
Severe
Spontaneous bleeding, risk of intracranial
haemorrhage
1-5 %
Moderate
Bleeding may only occur with
trauma, surgery or dental procedures
5-25 %
Mild
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HAEMATO-ONCOLOGY
Clinical Manifestation
Bleeding in the neonatal period is unusual.
Usually presents with easy bruising when crawling and walking
(9-12 months age).
Haemarthrosis is characteristic of haemophilia. Large joints are usually
affected (knee, ankle, elbow); swollen, painful joints are common.
Epistaxis, gum bleeding, haematuria also occur.
Intracranial haemorrhages can be life threatening.
Bleeding may also occur spontaneously or after trauma, operation or
dental procedures.
HAEMATO-ONCOLOGY
Further Investigations
Hepatitis B surface antigen, anti HBS antibody
Hepatitis C antibody
HIV serology
Renal profile and Liver function test.
Platelet aggregation if high suspicion of platelet defect.
Diagnosis of carrier status for genetic counseling.
Mother of a newly diagnosed son with haemophilia.
Female siblings of boys with haemophilia.
Daughter of a man with haemophilia.
Once a child is diagnosed to have haemophilia, check the viral status at
diagnosis and then yearly. This is because treatment carries the risk of acquiring viruses. All haemophiliacs should be immunized against Hepatitis B.
Treatment
Ideally, treatment of severe haemophilia should be prophylactic to
prevent arthropathy and ensure the best quality of life possible.The dosage
of prophylaxis is usually 25-35 U/kg of Factor VIII concentrate, given every
other day or 3 times a week. For Factor IX, the dosage is 40-60 U/kg, given
every 2-3 days. However, this form of management is costly and requires
central venous access.
On demand treatment is another treatment option when clotting factors
are inadequate. It consists of replacing the missing factor: Factor VIII concentrates are used in haemophilia A, Factor IX concentrates in Haemophilia
B. Fresh frozen plasma and cryoprecipitate ideally SHOULD NOT be used as
there is a high risk of viral transmission.
The dose of factor replacement depends on the type and severity of bleed.
Suggested Replacement Doses of Factor VIII and XI Concentrate
Type of bleed
Factor VIII dose
Haemarthrosis
Soft tissue or muscle bleeds
Intracranial haemorrhage or surgery
Factor XI dose
20 U/kg
40 U/kg
30-40 U /kg
60-80 U/kg
50 U/kg
100 U/kg
Dose of factor required can also be calculated using the formulas below
Units of Factor VIII: (% rise required) x (weight in kg) x 0.5.
Units of Factor IX: (% rise required) x (weight in kg) x 1.4.
The percentage of factor aimed for depends on the type of bleed.
For haemarthroses, 30-40 % is adequate.
For soft tissue or muscle bleed aim for 40- 50 % level.
(there is potential to track and cause compression/compartment syndrome)
For intracranial bleeds or patients going for surgery, aim for 100%.
Infuse Factor VIII by slow IV push at a rate not exceeding 100 units per
minute in young children.
338
Factor VIII is given every 8 - 12 hours. Factor IX is given every 12 - 24 hours.

Duration of treatment depends on type of bleed:
Haemarthroses 2-3 days.
Soft tissue bleeds 4-5 days.
Intracranial bleeds or surgery 7-10 days.
Veins must be handled with care. Never perform cut-down unless in an
emergency as it destroys the vein.
Supportive Treatment
Analgesia
There is rapid pain relief in haemarthroses once missing factor
concentrate is infused.
If analgesia is required, avoid intramuscular injections.
Do not use aspirin or the non-steroidal anti-inflammatory drugs (NSAIDS)
as they will affect platelet function.
Acetaminophen with or without opioids can provide adequate pain control.
Dental care
Good dental hygiene is important as dental caries are a regular source
of bleeding.
Dental clearance with factor replacement will be required in severe cases.
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HAEMATO-ONCOLOGY
Complications
Joint destruction:
Recurrent haemarthroses into the same joint will
eventually destroy the joint causing osteoarthritis and deformity.
This can be prevented by prompt and adequate factor replacement.
Acquisition of viruses
Hepatitis B, C or HIV: immunisation and regular screening recommended.
Inhibitors:
These are antibodies directed against the exogenous factor VIII
or IX neutralizing the clotting activity.
Overall incidence is 15-25% in haemophilia A and 1-3% in haemophilia B.
Can develop at any age but usually after 10 20 exposure days. It is
suspected when there is lack of response to replacement therapy despite
high doses.
Treatment requires bypassing the deficient clotting factor. Currently 2
agents are available - Recombinant activated Factor VII (rfVIIa or
Novoseven) and FEIBA. Immune tolerance induction is also another
option.
Management of inhibitors are difficult and requires consultation with the
haematologist in specialized centres.
Immunisations
This is important and must be given: The subcutaneous route is preferred.
Give under factor cover if haematomas are a problem.
Haemophilia Society
All haemophiliacs should be registered with a patient support group
e.g. Haemophilia Society.
They should have a medic-alert bracelet/chain which identifies them as
haemophiliacs and carry a book in which the diagnosis, classification of
severity, types of bleeds and admissions can be recorded
HAEMATO-ONCOLOGY
SPECIFIC GUIDELINES FOR MANAGEMENT

Intracranial haemorrhage (ICH)
Give factor replacement before suspected bleed is confirmed by CT scan
Aim to increase Factor VIII level to 100%.
For haemophilia B if monoclonal factor IX is used a level of 80% is
adequate and if prothrombin complex concentrate (PCC) is used 50% level
is recommended.
Urgent CT scan:
If CT scan confirms ICH : maintain factor level 80%100% for 17 days
and 50% for 821 days.
If CT scan show no evidence of ICH, admit 1 day for observation.
Follow up for long term sequelae.
Lab investigations:
Pre-treatment factor assay level and inhibitor level before starting
treatment and to repeat after 3 days of treatment to ensure adequate
levels have been achieved and no inhibitor has developed.
Post treatment factor assay level ( hour after infusion ) to ensure
required factor level is achieved ( if the level is not achieved , consider
development of inhibitors ) and should be repeated after 3 5 days.
follow up CT scan after 2 weeks
Surgery
Pre-op investigations
Full coagulation profile PT, PTT
Pre-factor assay level and inhibitor level
Blood grouping, full antibody screening and full cross matching if required.
Calculate dose
hour before operation, infuse patient with appropriate factors.
Preferable level :
- 80-100% for factor VIII
- 70% for monoclonal factor IX
- 50% if prothrombin complex concentrate (PCC) used
Check post transfusion specific factor level hour later if necessary or after
surgery to ensure correct factor level is achieved.
340
Clotting factor level should be maintained above 50% during the operation
and 24 hours after surgery.
Maintain adequate factor levels Days 1-3
60-80%
4-7
40-60%
8-14
30-50%
Repeat factor assay and check inhibitor level on day 3 to ensure adequate.
levels. Post operatively a minimum of 10 to 14 days replacement therapy
is recommended.
Haematuria
Management
Bed rest.
Hydration (1.5 x maintenance).
Monitor for first 24 hours: UFEME & Urine C&S.
If bleeding persists for > 24 hours, start factor concentrate infusion.
Perform KUB & Ultrasound of the kidneys.
DO NOT give anti-fibrinolytic drugs (tranexamic acid) because this may
cause formation of clots in the tubules which may not recanalize.
Haemarthroses (Joint haemorrhages)
Most spontaneous haemarthroses respond to a single infusion of factor
concentrate. Aim for a level of 30 % to 40%.
If swelling or spasm is present, treatment to level of 50% is required and
infusion may have to be repeated at 12-24 hours interval until pain subsides.
Minor haemarthroses may not require immobilization, elastic bandage or
slings and ice may help in pain relief.
Severe haemarthroses
Splint in position of comfort.
Rest.
Early physiotherapy.
341
HAEMATO-ONCOLOGY
Illiopsoas bleed
Symptoms: Pain/discomfort in the lower abdomen/upper thighs
Signs: Hip flexed, internally-rotated, unable to extend
Danger: Hypovolaemia, large volumes of blood may be lost in the
retroperitoneum.
Management:
Factor replacement: 50U/kg stat, followed by 25U/kg bd till asymptomatic,
then 20U /kg every other day for 10-14 days.
Ultrasound / CTscan to diagnose.
Physiotherapy - when pain subsides.
Repeat U/S to assess progress.
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HAEMATO-ONCOLOGY
Chapter 69: Oncology Emergencies
Risk factors for Tumour lysis syndrome

Bulky disease
Rapid cellular turnover
Tumour which is exquisitely sensitive to chemotherapy
Elevated LDH / serum uric acid
Depleted volume
Concentrated urine or acidic urine
Poor urine output
Renal failure
Multifactorial:
Uric acid, phosphorus and potassium are excreted by kidneys
The environ of the collecting ducts of the kidney is acidic coupled with
lactic acidosis due to high leucocyte associated poor perfusion will cause
uric acid crystallization and then uric acid obstructive nephropathy. Usually
occur when levels > 20 mg/dl.
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HAEMATO-ONCOLOGY
I. METABOLIC EMERGENCIES
Tumour lysis syndrome
Tumour Lysis Syndrome
Characterised by:
Introduction
Hyperuricemia
Massive tumour cell death with rapid release
Hyperkalemia
of intracellular metabolites, which exceeds
the excretory capacity of the kidneys leading
Hyperphosphatemia with
to acute renal failure. Can occur before
associated Hypocalcemia
chemotherapy is started.
More common in Iymphoproliferative tumours with abdominal involvement
(e.g. B cell/ T cell Iymphoma, leukaemias and Burkitts Iymphoma)
Hyperuricaemia
Release of intracellular purines increase uric acid
Hyperkalaemia
Occurs secondary to tumour cell Iysis itself or secondary to renal failure
from uric acid nephropathy or hyperphosphataemia.
Hyperphosphataemia with associated hypocalcaemia
Most commonly occurs in Iymphoproliferative disorders because
Iymphoblast phosphate content is 4 times higher than normal lymphocytes.
Causes:
Tissue damage from CaPO precipitation. Occurs when Ca X PO > 60 mg/dl.
Results in renal failure, pruritis with gangrene, eye and joint inflammation
Hypocalcaemia leading to altered sensorium, photophobia, neuromuscular
irritability, seizures, carpopedal spasm and gastrointestinal symptoms
HAEMATO-ONCOLOGY
Increased phosphorus excretion causing calcium phosphate precipitation

(in vivo solubility dependant on Ca X P = 58) in microvasculature and
tubules.
Risk increases if renal parenchymal is infiltrated by tumour e.g. lymphoma
or ureteral/venous obstruction from tumour compression (lymph nodes).
Management (Prevention):
To be instituted in every case of acute leukaemia or Iymphoma prior to
induction chemotherapy.
Hydration: Double hydration - 125ml/m/hr or 3000ml/m/day.
No added potassium.
Alkalization of urine: Adding NaHCO at 150 - 200 mmol/m/day
(3 mls/kg/day NaHCO 8.4%) into IV fluids to keep urine pH 7.0 - 7.5.
Avoid over alkalinization as this may aggravate hypocalcemia and cause
hypoxanthine and xanthine precipitation. It can also cause precipitation of
calcium phosphate if pH >8. Monitor urine pH and VBG 8 hourly. If urine
pH < 7.0 , consider increasing NaHCO infusion. This can only be done if
HCO in the blood is below normal range. Otherwise, have to accept that
some patients just cannot alkalinise their urine.
Allopurinol 10mg/kg/day, max 300mg/day.
May have to delay chemotherapy until metabolic status stabilizes.
Close electrolyte monitoring: BUSE, Ca, PO, uric acid, creatinine,
bicarbonate.
Strict I/O charting. Ensure adequate urine flow once hydrated.
Use diuretics with caution.
Management (Treatment)
Treat hyperkalaemia resonium, dextrose-insulin, Consider dialysis.
Diuretics.
Hypocalcaemia management depends on the phosphate level:
If phosphate is raised, then management is directed to correct the high
phosphate.
If phosphate is normal or if child is symptomatic, then give replacement
IV calcium.
If hypocalcaemia is refractory to treatment, exclude associated
hypomagnesaemia.
Dialysis if indicated. Haemodialysis most efficient at correcting electrolyte
abnormalities. Peritoneal dialysis is not effective in removing phosphates.
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II. HAEMATOLOGICAL EMERGENCIES

Hyperleucocytosis
Occurs in acute leukaemia. Defined as TWBC > 100 000 / mm.
Associated
In acute lymphoblastic leukaemia (ALL) with high risk of tumour Iysis.
In AML with leucostasis (esp monocytic).
Affects the lungs due to pulmonary infiltrates. May cause dyspnoea,
hypoxaemia and right ventricular failure.
Affects the central nervous system causing headaches, papilloedema,
seizures, haemorrhage or infarct.
Other complications: renal failure, priapism, dactylitis
Mechanism:
Excessive leukocytes form aggregates and thrombi in small veins causing
obstruction; worsens when blood is viscous.
Excessive leukocytes competes for oxygen; damages vessel wall causing
bleeding.
Management
Hydration
To facilitate excretion of toxic metabolites.
To reduce blood viscosity.
Avoid increasing blood viscosity.
Cautious in use of packed cell transfusion and diuretics.
During induction in hyperleukocytosis, keep platelet >20 000/mm and
coagulation profile near normal.
345
HAEMATO-ONCOLOGY
Other Metabolic Emergencies:

Hyponatraemia
Usually occurs in acute myeloid leukaemia (AML).
Treat as for hyponatraemia.
Hypokalaemia
Common in AML
Rapid cellular generation leads to uptake of potassium into cells.
(Intracellular potassium 30 - 40 X times higher than extracellular
potassium). Therefore may hyperkalaemia may develop after chemotherapy.
Hypercalcaemia
Associated with Non Hodgkin lymphoma, Hodgkin lymphoma, alveolar
rhabdomyosarcoma, rhabdoid tumours and others.
Management
Hydration.
Oral phosphate.
IV Frusemide (which increases calcium excretion).
Mithramycin.
Exchange transfusions and leukopheresis should not be used alone as rapid

rebound usually occurs. Concurrent drug treatment should therefore be
initiated soonest possible.
Coagulopathy
AML especially M3 is associated with an initial bleeding diathesis from consumptive coagulopathy due to release of a tissue factor with procoagulant activity
from cells. However the use of all-trans retinoic acid (Atra) has circumvented this
complication.
Management
Platelet transfusions: 6 units / m should increase platelets by 50,000 / mm.
Fresh frozen plasma (FFP) or cryoprecipitate.
Vitamin K.
+/- Heparin therapy (10u/kg/hr) - controversial
HAEMATO-ONCOLOGY
Other haematological energencies

Thrombocytopenia
Severe anaemia
III. SUPERIOR VENA CAVA OBSTRUCTION
Superior Vena Cava (SVC) Obstruction
Common in Non Hodgkin Lymphoma / Hodgkin Lymphoma / ALL .
Rarely: malignant teratoma, thymoma, neuroblastoma, rhabdomyosarcoma or
Ewings may present with anterior or middle mediastinal mass and obstruction.
50% associated with thrombosis.
Presentation: shortness of breath, facial swelling, syncope.
Management
Recognition of symptoms and signs of SVC obstruction and avoidance of
sedation and general anaesthesia.
Tissue diagnosis is important but should be established by the least invasive
measure available. Risk of circulatory collapse or respiratory failure may
occur with general anesthesia or sedation.
BMA.
Biopsy of superficial lymph node under local anaesthesia.
Measurement of serum markers e.g. alpha-fetoprotein.
If tissue diagnosis is not obtainable, empiric treatment may be necessary
based on the most likely diagnosis. Both chemotherapy and DXT may render
histology uninterpretable within 48 hours, therefore biopsy as soon as possible.
Avoid upper limb venepunctures
Bleeding due to increased intravascular pressure
Aggravate SVC obstruction.
Primary mode of treatment is with steroids and chemotherapy if pathology
due to Non-Hodkin Lymphoma
+/- DXT.
346
Typhilitis
A necrotizing colitis localised to the caecum occuring in neutropenic
patients.
Bacterial invasion of mucosa causing inflammation - can lead on to full
thickness infarction and perforation.
Usual organisms are Clostridium and Pseudomonas.
X-ray shows non specific thickening of gut wall. At the other end of the
spectrum, there can be presence of pneumatosis intestinalis +/- evidence
of free gas.
Management
Usually conservative with broad spectrum antibiotics covering gram
negative organisms and anaerobes (metronidazole). Mortality 20-100%.
Criteria for surgical intervention:
Persistent gastrointestinal bleeding despite resolution of neutropenia and
thrombocytopenia and correction of coagulation abnormalities.
Evidence of perforation.
Clinical deterioration suggesting uncontrolled sepsis (controversial).
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HAEMATO-ONCOLOGY
IV. INFECTION
Febrile neutropaenia
Febrile episodes in oncology patients must be treated with urgency especially
if associated with neutropenia. Nearly all episodes of bacteraemia or
disseminated fungal infections occur when the absolute neutorphil count
(ANC) <500 /mm. Risk increases maximally if ANC < 100 /mm and greatly
reduced if the ANC > 1000 /mm.
Management (Follow Algorithm on next page)
other considerations:
If central line is present, culture from central line (both lumens);
add anti-Staph cover e.g. Cloxacillin.
Repeated physical examination to look for new clues, signs and symptoms
of possible sources.
Close monitoring of patients well-being vital signs, perfusion, BP, I/O.
Repeat cultures if indicated
Investigative parameters, FBC, CRP, BUSE as per necessary.
In presence of oral thrush or other evidence of candidal infection, start
antifungals.
Try to omit aminoglycoside and vancomycin if on cisplatinum - nephrotoxic
and ototoxic. If required, monitor renal function closely.
APPROACH TO CHILD WITH FEBRILE NEUTROPENIA

Febrile Neutropenia
History and Examination to identify
possible source(s) of infection
HAEMATO-ONCOLOGY
Septic Workup
FBC, CRP
CXR
Bacterial and fungal cultures
- blood, urine, stool, wound
Site unknown
Site identified
Broad spectrum antibiotics

(e.g. Cephalosporins,
Aminoglycoside and Nystatin)
Specific antibiotics
Proper specimen collected
Temperature settles in 3 days
Remains febrile after 2 days
Continue Treatment
Reculture, Change antibiotics

May add systemic antifungal
Stop Treatment after 1

week Observe
Still febrile after 4 days

Look for possible sites of infection
Repeat X-ray
Repeat cultures
Echo, ultrasound
Consider add antifungals
Consider changing antibiotics
Abbrevations. FBC, full blood count; CRP, C-reactive protein; CXR, chest X-ray;
CVL, central venous line.
348
Hypercalcaemia
Diabetes insipidus
Diabetes mellitus
Intractable vomiting
Management
Ascertain cause and treat accordingly
Veno occlusive disease
Addisonian crisis
Pancreatitis
Haemorrhage
Haemorrhagic cystitis
Gastrointestinal bleeding
- Ulcers
- Typhilitis
Massive haemoptysis
Sepsis
Anaphylaxis
Etoposide
L-asparaginase
Anti-thymocyte globulin
Cytosine
Carboplatin
Blood products
Amphotericin B
Hypovolaemic
Distributive
Common causes of Shock in Children with Cancer
HAEMATO-ONCOLOGY
349
Myocarditis
Viral, bacterial, fungal
Metabolic
Hyperkalaemia, hypokalaemia
Hypocalcaemia
Cardiac tamponade
Intracardiac tumour
Intracardiac thrombus
Pericardial effusion
Constrictive pericarditis
Myopathy
Anthracycline
High dose cyclophosphamide
Radiation therapy
Cardiogenic
HAEMATO-ONCOLOGY
V. NEUROLOGICAL COMPLICATIONS
Spinal Cord Compression
Prolonged compression leads to permanent neurologic sequelae.
Epidural extension: Lymphoma, neuroblastoma and soft tissue sarcoma.
Intradural: Spinal cord tumour.
Presentation
Back pain: localized or radicular, aggravated by movement, straight leg
raising, neck flexion.
Later: weakness, sensory loss, loss of bladder and bowel continence
Diagnosed by CT myelogram/MRI
Management
Laminectomy urgent (if deterioration within 72 hours).
If paralysis present > 72 hours, chemotherapy is the better option if
tumour is chemosensitive, e.g. lymphoma, neuroblastoma and Ewings
tumour. This avoids vertebral damage. Onset of action of chemotherapy is
similar to radiotherapy.
Prior IV Dexamethasone 0.5mg/kg 6 hourly to reduce oedema.
+/- Radiotherapy.
Increased Intracranial Pressure (ICP) and brain herniation
Cause: Infratentorial tumours causing blockage of the 3rd or 4th ventricles
such as medulloblastomas, astrocytomas and ependymomas.
Signs and symptoms vary according to age/site.
Infant - vomiting, lethargy, regression of milestones, seizures, symptoms of
obstructive hydrocephalus and increased OFC.
Older - early morning recurrent headaches +/- vomiting, poor school
performance.
Cerebellar: ipsilateral hypotonia and ataxia.
Herniation of cerebellar tonsil: head tilt and neck stiffness.
Tumours near 3rd ventricle: craniopharyngima , germinoma, optic glioma,
hypothalamic and pituitary tumours.
Visual loss, increased ICP and hydrocephalus.
Aqueduct of Sylvius obstruction due to pineal tumour: raised ICP,
Parinauds syndrome (impaired upward gaze, convergence nystagmus,
altered pupillary response).
Management
Assessment of vital signs, look for focal neurological deficit.
Look for evidence of raised ICP (bradycardia, hypertension and apnea).
Look for evidence of herniation (respiratory pattern, pupil size and reactivity).
Dexamethasone 0.5 mg/kg QID.
Urgent CT to determine cause.
Prophylactic antiepileptic agents.
Lumbar puncture is contraindicated.
Decompression i.e. shunting +/- surgery.
350
Cerebrovascular accident (CVA)

Can result from direct or metastatic spread of tumour, antineoplastic agent
or haematological abnormality.
L-Asparaginase associated with venous or lateral and sagittal sinus
thrombosis caused by rebound hypercoagulable state.
AML especially APML is associated with DIVC and CVA, due to the release of
procoagulants.
Management
Supportive.
Use of anticoagulant potentially detrimental.
In L-Asparaginase induced, recommended FFP bd.
VI. MISCELLANOUS EMERGENCIES
Pancreatitis
Should be considered in patients on L-Asparaginase and steroids and complaining of abdominal pain. Careful examination plus measurement of serum
amylase and ultrasound abdomen.
351
HAEMATO-ONCOLOGY
ATRA (all-trans retinoic acid) syndrome

Characterised by: fever, respiratory distress, respiratory failure, oedema,
pleural/pericardial effusion, hypotension.
Pathophysiology: respiratory distress due to leukocytosis associated with
ATRA induced multiplication and differentiation of leukaemic promyelocytes/
Treatment: Dexamethasone 0.5 - 1mg/kg/dose bd, maximum dose 20mg bd.
352
HAEMATO-ONCOLOGY
Chapter 70: Acute Lymphoblastic Leukaemia

Definition
Acute lymphoblastic leukemia (ALL) is the most common childhood
malignancy, representing nearly one third of all paediatric cancers.
Peak age
2 5 years old. Male: Female ratio of 1.2:1.
Pathophysiology
Genetically altered lymphoid progenitor cells which undergo dysregulated
proliferation and clonal expansion.
Initial investigations
Diagnosis
Full Blood Count (FBC) and Peripheral Blood Film (PBF).
Anaemia and thrombocytopenia.
Total White Count (TWC) can be normal, low or high.
Occasionally PBF may not show presence of blast cells.
Bone marrow aspirate (BMA) and trephine biopsy.
Bone marrow for flowcytometry analysis (immunophenotyping).
Bone marrow cytogenetics.
Bone marrow/Blood for molecular studies wherever possible.
Option to send to Hospital Kuala Lumpur (HKL) Pathology Laboratory
(Haematology unit)/Haematology Laboratory in IMR (3mls in EDTA bottle)
or other University/Private laboratories for molecular characterisation
(Prior appointments must be made before sending samples).
Cerebral Spinal Fluid (CSF) examination for blast cells.
CXR to evaluate for mediastinal masses.
353
HAEMATO-ONCOLOGY
Presentation
Signs and symptoms which reflect bone marrow infiltration causing
anaemia, neutropenia, thrombocytopenia and extra-medullary disease.
Pallor and easy bleeding common
Non remitting fever.
Lymphadenopathy.
Hepatosplenomegaly.
Bone pains - not to be misdiagnosed as Juvenile Idiopathic Arthritis (JIA).
Uncommon at presentation:
CNS involvement e.g. headache, nausea and vomiting, lethargy,
irritability, seizures or spinal mass causing signs and symptoms of
spinal cord compression.
Testicular involvement, usually as a unilateral painless testicular
enlargement.
Skin manifestations e.g. skin nodules.
HAEMATO-ONCOLOGY
For assessment and monitoring:

Blood Urea and Serum Electrolytes (BUSE) especially serum Potassium.
Serum Creatinine, Uric Acid, Phosphate, Calcium, Bicarbonate levels.
Lactate dehydrogenase (LDH) to assess degree of leukaemic cell burden
and risk of tumour lysis.
Coagulation studies in APML (acute promyelocytic leukemia) or if the child
is toxic or bleeding.
Blood cultures and septic workup if febrile.
Hepatitis B/C, HIV and VZ IgG screen pre transfusion and pre treatment.
Repeat BMA and CSF examinations.
Prognosis
Overall cure rates for childhood ALL are now over 80% but it depends among
others on the prognostic groups, clinical and laboratory features, treatment
in centres with paediatric oncologist and special diagnostics, use of standard
treatment protocols and also the level of supportive care available.
Unfavourable if:
Clinical features indicating high risk
Age > 10 years old and infants.
WBC count at diagnosis > 50000/mL.
Molecular characteristics of the leukaemic blasts, e.g. Presence of
abnormal cytogenetics with oncogenes producing abnormal fusion
proteins e.g. Philadelphia chromosome t(9;22)(q34;q11);
BCR-ABL;P185BCR-ABL tyrosine kinase.
Poor response to the induction chemotherapy
Day 8 peripheral blast cell count > 1000 x 109/L.
Day 33 BMA not in remission
Treatment
The regimes or treatment protocols used varies according to originator
groups/institutions from the various countries (BFM Germany, MRC UK,
CCG/COG USA) but generally consists of induction, central nervous system
treatment/prophylaxis, consolidation/intensification and maintenance
therapy.
Complications considered as oncologic emergencies can be seen before, during and after treatment (see Ch 69 Oncologic Emergencies). These include:
Hyperleucocytosis at presentation.
Superior vena caval obstruction.
Tumor lysis syndrome leading on to renal failure.
Sepsis.
Bleeding.
Thrombosis.
Typhylitis.
CNS manifestations: Cord compression, neuropathy, encephalopathy
and seizures.
354
Once discharged, care givers must be able to recognise signs and symptoms
that require urgent medical attention, especially infections as they can be life
threatening. Even on maintenance therapy, infections must be taken seriously
as patients are still immunocompromised up to 3 months after discontinuing
chemotherapy.
If there is evidence of interstitial pneumonitis, send nasopharyngeal secretions for PCP Antigen detection e.g. Immunoflorescent test (IFT) or PCP
PCR detection and treat empirically with high dose Cotrimoxazole 20 mg/
kg/day in divided doses for a total of 2 weeks.
Different institutions and protocols will have different regimes for
maintenance chemotherapy.
Check the TWC and Absolute Neutrophil Count (ANC) threshold levels
of the various protocols:
As a general rule, chemotherapy is adjusted to maintain TWC at
2 - 3 X109/L and ANC at or more than 0.75 X 109/L.
If TWC drop to levels of 1-2 X109/L and ANC to levels of 0.5 -0.75 x 109 /L
or platelet level at 50-100 x 109/L, reduce tablet 6-Mercaptopurine (6MP)
and oral methotrexate (MTX) normal dose by 50%.
Once counts are above those levels, increase 6MP and MTX back to 75%
of normal dose.
Review the patient in 1 week and if counts can be maintained, increase
back to 100% of normal dose.
If TWC is < 1 X 109/L and ANC < 0.5 x 109/L or platelets < 50 x 109/L, stop
both drugs.
Restart drugs at 50% dose once neutrophil count have recovered
> 0.75 x 109/L and then increase back to 75% and 100% as above.
355
HAEMATO-ONCOLOGY
General guidelines for children with Acute Lymphoblastic Leukaemia on

maintenance chemotherapy for a total of 2 - 2.5 years:
Check height, weight and calculate surface area (m2) every 3 months and
adjust drug dosages accordingly.
To calculate body surface area = [Height (cm) x Weight (kg) / 3600]
Check full blood count every 2 weeks for the first 1- 2 months after starting
maintenance chemotherapy and monthly thereafter if stable.
Bone marrow aspiration should be considered if counts are repeatedly low
or if there is clinical suspicion of relapse. Majority of relapse (>2/3) would
occur within the first year of stopping treatment.
CNS disease would present itself usually with headache, vomiting,
abnormal sensorium or hypothalamic symptoms (e.g. Hyperphagia and
abnormal weight gain).
Testicular relapse present as a painless unilateral swelling
Cotrimoxazole is routinely used as prophylaxis against Pneumocystis carinii
pneumonia (PCP) and continued until the end of therapy. In the event of
chronic cough or unexplained tachypnoea, CXR is required.
HAEMATO-ONCOLOGY
Normally Haemoglobin would remain stable but repeated falls in

haemoglobin alone may be due to 6MP intolerance.
Transfuse if anaemia occurs early in the course of maintenance therapy
and the standard doses of 6MP and MTX are to be maintained as much
as possible.
If there is persistent anaemia (i.e. Hb< 8 gm/dl), reduce 6MP dose first
and maintain the MTX dose.
If anaemia persists despite reducing the dose of 6MP, reduce the MTX
dose appropriately.
If counts are persistently low and doses of 6MP/MTX are already
suboptimal, consider withholding Cotrimoxazole.
Re-introduce Cotrimoxazole once 6MP or MTX are at > 75% of standard
protocol dosage.
If neutropaenia recurs or if child cannot tolerate at least 75% drug of
dosages, Cotrimoxazole should be stopped
Maintenance of adequate drug dose should take priority over
continuing Cotrimoxazole.
If Cotrimoxazole is stopped, keep in mind that the child is at increased
risk of Pneumocystis pneumonia and there should be a relatively low
threshold for treatment of any suspected interstitial pneumonitis.
If counts take longer to recover, consider performing bone marrow
aspiration after 2-3 weeks to rule out sub-clinical relapse.
If the diagnostic test is available, consider to also send blood for
Thiopurine Methyltransferase (TPMT) enzyme deficiency screening.
Children who are homozygous TPMT deficient can become profoundly
myelosuppressed with 6MP administration.
In severe diarrhoea and vomiting, stop both drugs. Restart at 50% dose
when better and return to full dose when tolerated.
Severe MTX mucositis; withhold MTX until improvement and restart at
full dose. Initiate supportive treatment with mouthwash and antifungal
treatment.
In clinically significant liver dysfunction; oral MTX should be stopped until
improvement occurs. Restart at reduced dose and increase as tolerated.
Investigate for causes of liver dysfunction. Monitor LFT.
356
GIVE
Measles
Human broad-spectrum immune globulin IM 0.5ml/kg divided into
2 separate injection sites on the same day.
Chickenpox
For exposed patients:
(VZ IgG ve at diagnosis, on treatment or within 6 months \ of stopping
treatment); give:
VZIG if available (should be given within 7 days of contact)
< 5yrs: 250mg, 5 7 yrs: 500mg, 7 12 yrs: 750mg.
If VZIG not available - Oral acyclovir 200mg 5x/day if < 6 years old;
400 mg 5x/day if > 6 years old for 5 days.
Monitor for signs of infections.
357
HAEMATO-ONCOLOGY
Infections:
If there is significant fever (To 38.5 oC x 1 or 38 oC x 2 one hour apart)
and neutropenia, stop all chemotherapy drugs and admit for IV antibiotics.
Take appropriate cultures and CXR if indicated and give bolus IV antibiotics
immediately without waiting for specific bacteriological confirmation.
Use a combination of aminoglycoside and cephalosporins to cover both
gram negative and gram positive organisms. If nosocomial infection is
suspected, use the appropriate antibiotics according to your hospitals
cultures sensitivity pattern.
Any fever developing within 24 hours of central venous line access
should be treated as catheter related blood stream infection. Common
organisms are the gram positive cocci. Consider adding cloxacillin to
the antibiotic regime.
Assume multiresistant bacterial sepsis when dealing with patients
presenting with septic shock especially if recently discharged from hospital.
Vancomycin may be indicated if there is a long line (Hickman) or
chemoport in situ or if MRSA or coagulase negative Staphylococcus
infections are suspected.
Antifungal therapy may be indicated in prolonged neutropenia or if there
is no response to antibiotics or if fungal infection is suspected.
Early and aggressive empirical therapy without waiting for blood culture
results will save lives.
Chicken Pox/Measles
These are life-threatening infections in ill immunocompromised children.
Always reinforce this information on parents when they come for follow-up.
If a patient is significantly/directly exposed (in the same room > 1 hour),
including the 3 days prior to clinical presentation, to sibling, classroom
contact, enclosed playmate contact or other significant contact, they are
at increased risk of developing these infections.
Patient with chickenpox

Admit, isolate and treat immediately with IV acyclovir 500 mg/m2/dose
8 hourly or 10mg/kg 8 hourly until no new lesions are noted.
Switch to oral acyclovir 400mg 5x daily if <6 years old; 800mg 5x daily
if >6 years until the lesions are healed, usually in about 10 days.
Chemotherapy must be stopped on suspicion of exposure. If infected
and treated, it should only be recommenced 2 weeks after the last
vesicle has dried up.
HAEMATO-ONCOLOGY
Vaccinations
Children on chemotherapy should not receive any vaccinations until
6 months after cessation of chemotherapy.
Recommence their immunisation programme continuing from where
they left off.
References
Section 8 Haematology-Oncology
Chapter 65 Approach to a Child with Anaemia
1.Lieyman JS, Hann IM. Paediatric Haematology.London, Churchill Livingston,
1992.
Chapter 67 Immune Thrombocytopenic Purpura
1.George J, et al. (1996) Idiopathic thrombocytopenic purpura: a practice
guideline developed by explicit methods for the American Society of
Hematology. Blood 1996; 88: 3-40.
2.Lilleyman J. Management of Childhood Idiopathic Thrombocytopenic Purpura. Brit J Haematol 1997; 105: 871-875
3.James J. Treatment Dilemma in Childhood Idiopathic Thrombocytopenic
Purpura. Lancet 305: 602
4.Nathan D, Orkin S, Ginsburg D, Look A. Nathan and Oskis Hematology of
Infancy and Childhood. 6th ed 2003. W.B. Saunders Company.
Chapter 68 Haemophilia
1.Malaysian CPG for Management of Haemophilia.
2.Guidelines for the Management of Hemophilia - World Federation of
Hemophilia 2005
3.Nathan and Oski, Hematology of Infancy and Childhood, 7th Ed, 2009.
Chapter 69 Oncology Emergencies
1.Pizzo, Poplack: Principles and Practice of Paediatric Oncology. 4th Ed, 2002
2.Pinkerton, Plowman: Paediatric Oncology. 2nd Ed. 1997
3.Paediatric clinics of North America, Aug 1997.
358
Chapter 71: Acute Gastroenteritis

Introduction
The following is based on Integrated Management of Childhood Illness (IMCI)
and the College of Paediatrics, Academy of Medicine of Malaysia guidelines
on the management of Acute Diarrhoea in Children 2011 and modifications
have been made to Treatment Plan C in keeping with Advanced Paediatric
Life Support (APLS) principles.
Acute gastroenteritis is a leading cause of childhood morbidity and
mortality and an important cause of malnutrition.
Many diarrhoeal deaths are caused by dehydration and electrolytes loss.
Mild and moderate dehydration is safely and effectively treated with
ORS solution but severe dehydration requires intravenous fluid therapy.
Assess
Look at childs
general condition
Look for sunken
eyes
Offer the child
fluid
Pinch skin of
abdomen
Well, alert
No sunken eyes
Drinks normally
Skin goes back
immediately
Restless or
irritable
Sunken eyes
Lethargic or
unconscious
Sunken eyes
Drinks eagerly,
thirsty
Skin goes back
slowly
Not able to drink or

drinks poorly
Skin goes back very
slowly
(> 2 seconds)
2 above signs
present:
Severe Dehydration
> 10% Dehydrated
Classify
Mild dehydrated 2 above signs

<5% Dehydrated* present:
IMCI: No signs
Moderate
of Dehydration
Dehydration
5-10% Dehydrated
IMCI: Some signs
of Dehydration
Treat
Plan A
Plan B
Plan A
Give fluid and food Give fluid and food Give fluid for severe
to treat diarrhoea for some
dehydration
at home
dehydration
*% of body weight (in g) loss in fluid (Fluid Deficit) e.g. a 10 kg child with 5%
dehydration has loss 5/100 x 10000g = 500 mls of fluid deficit.
359
GASTROENTEROLOGY
If you have gone through the PALS or APLS course, First assess the state of
perfusion of the child.
Is the child in shock?
Signs of shock include tachycardia, weak peripheral pulses, delayed
capillary refill time > 2 seconds, cold peripheries, depressed mental state
with or without hypotension.
Any child with shock go straight to treatment Plan C.
OR you can also use the WHO chart below to assess the degree of dehydration and then choose the treatment plan A, B or C, as needed.
GASTROENTEROLOGY
PLAN C: TREAT SEVERE DEHYDRATION QUICKLY

Start intravenous (IV) or intraosseous (IO) fluid immediately.
If patient can drink, give ORS by mouth while the drip is being set up.
Initial fluids for resuscitation of shock: 20 ml/kg of NaCl 0.9% or
Hartmann solution as a rapid IV bolus.
Repeated if necessary until patient is out of shock or if fluid overload
is suspected. Review patient after each bolus.
Calculate the fluid needed over the next 24 hours:
Fluid for Rehydration (also called fluid deficit)
+ Maintenance (minus the fluids given for resuscitation).
Fluid for Rehydration: percentage dehydration X body weight in grams
Maintenance fluid (NaCl 0.45 / D5%)
(See Ch 3 Fluid And Electrolyte Guidelines)
1st 10 kg = 100 ml/kg;
10-20 kg = 1000 ml/day + 50 ml/kg for each kg above 10 kg
>20 kg = 1500 ml/day + 20 ml/kg for each kg above 20 kg.
Example:
A 6-kg child is clinically shocked and 10% dehydrated as a result of gastroenteritis.
Initial therapy:
20 ml/kg for shock = 6 20 = 120 ml of 0.9% saline given as a rapid
intravenous bolus.
Estimated fluid therapy over next 24 hours:
Fluid for Rehydration: 10/100 x 6000 = 600 ml
100ml/kg for daily maintenance fluid = 100 6 = 600 ml
Rehydration + maintenance = 600 + 600 =1200 ml
Start with infusion of 1200/24 = 50 ml/h
The cornerstone of management is to reassess the hydration status
frequently (e.g. at 1-2 hourly), and adjust the infusion as necessary.
Start giving more of the maintenance fluid as oral feeds
e.g. ORS (about 5 ml/kg/hour) as soon as the child can drink, usually after 3
to 4 hours for infants, and 1 to 2 hours for older children. This fluid should
be administered frequently in small volumes (cup and spoon works very
well for this process).
Generally normal feeds should be administered in addition to the
rehydration fluid, particularly if the infant is breastfed.
Once a child is able to feed and not vomiting, oral rehydration according
to Plan A or B can be used and the IV drip reduced gradually and taken
off.
360
If you cannot or fail to set up IV or IO line, arrange for the child to be

sent to the nearest centre that can do so immediately. Meanwhile as
arrangements are made to send the child (or as you make further
attempts to establish IV or IO access),
Try to rehydrate the child with ORS orally (if the child can drink) or by
nasogastric or orogastric tube. Give ORS 20 ml/kg/hour over 6 hours.
Continue to give the ORS along the journey.
Reassess the child every 1-2 hours
If there is repeated vomiting or increasing abdominal distension, give
the fluid more slowly.
Reassess the child after six hours, classify dehydration
Then choose the most appropriate plan (A, B or C) to continue treatment.
If there is an outbreak of cholera in your area, give an appropriate oral
antibiotic after the patient is alert.
Indications for admission to Hospital

Moderate to severe dehydration.
Need for intravenous therapy (as above).
Concern for other possible illness or uncertainty of diagnosis.
Patient factors, e.g. young age, unusual irritability/drowsiness,
worsening symptoms.
Caregivers not able to provide adequate care at home.
Social or logistical concerns that may prevent return evaluation if necessary.
* Lower threshold for children with obesity due to possibility of
underestimating degree of dehydration.
361
GASTROENTEROLOGY
Other indications for intravenous therapy

Unconscious child.
Continuing rapid stool loss ( > 15-20ml/kg/hour).
Frequent, severe vomiting, drinking poorly.
Abdominal distension with paralytic ileus, usually caused by some
antidiarrhoeal drugs ( e.g. codeine, loperamide ) and hypokalaemia.
Glucose malabsorption, indicated by marked increase in stool output
and large amount of glucose in the stool when ORS solution is given
(uncommon).
IV regime as for Plan C but the replacement fluid volume is calculated
according to the degree of dehydration. (5% for mild, 5-10% for moderate
dehydration).
GASTROENTEROLOGY
Other problems associated with diarrhoea

Fever
May be due to another infection or dehydration.
Always search for the source of infection if there is fever, especially if it
persists after the child is rehydrated.
Seizures
Consider:
- Febrile convulsion (assess for possible meningitis)
- Hypoglycaemia
- Hyper/hyponatraemia
Lactose intolerance
Usually in formula-fed babies less than 6 months old with infectious
diarrhoea.
Clinical features:
- Persistent loose/watery stool
- Abdominal distension
- Increased flatus
- Perianal excoriation
Making the diagnosis: compatible history; check stool for reducing
sugar (sensitivity of the test can be greatly increased by sending the
liquid portion of the stool for analysis simply by inverting the diaper).
Treatment: If diarrhoea is persistent and watery (over 7-10 days) and
there is evidence of lactose intolerance, a lactose free formula may
be given.
Normal formula can usually be reintroduced after 23 weeks.
Cows Milk Protein Allergy
A known potentially serious complication following acute gastroenteritis.
To be suspected when trial of lactose free formula fails in patients with
protracted course of diarrhoea.
Children suspected with this condition should be referred to a paediatric
gastroenterologist for further assessment.

362
Non pharmacological / Nutritional strategies

Undiluted vs diluted formula
No dilution of formula is needed for children taking milk formula.
Soy based or cow milk-based lactose free formuls
Not recommended routinely. Indicated only in children with suspected
lactose intolerance.
363
GASTROENTEROLOGY
Pharmacological agents
Antimicrobials
Antibiotics should not be used routinely.
They are reliably helpful only in children with bloody diarrhoea, probable
shigellosis, and suspected cholera with severe dehydration.
Antidiarrhoeal medications
The locally available diosmectite (Smecta) has been shown to be safe
and effective in reducing stool output and duration of diarrhoea. It acts
by restoring integrity of damaged intestinal epithelium, also capable to
bind to selected bacterial pathogens and rotavirus.
Other anti diarrhoeal agents like kaolin (silicates), loperamide (antimotility) and diphenoxylate (anti motility) are not recommended.
Antiemetic medication
Not recommended, potentially harmful.
Probiotics
Probiotics has been shown to reduce duration of diarrhoea in several
randomized controlled trials. However, the effectiveness is very strain
and dose specific. Therefore, only probiotic strain or strains with
proven efficacy in appropriate doses can be used as an adjunct to
standard therapy.
Zinc supplements
It has been shown that zinc supplements during an episode of
diarrhoea reduce the duration and severity of the episode and lower
the incidence of diarrhoea in the following 2-3 months.
WHO recommends zinc supplements as soon as possible after
diarrhoea has started. Dose up to 6 months of age is 10 mg/day,
and age 6 months and above 20mg/day, for 10-14 days.
364
GASTROENTEROLOGY
Chapter 72: Chronic Diarrhoea

Introduction
WHO defines persistent or chronic diarrhea as an episode of diarrhea that
begins acutely and lasts for 14 days or more. It is a complex condition with
multitude etiologies. Locally, commonest aetiology is believed to be infection related where as autoimmune enteropathy is an important aetiology in
developed countries.
Mechanisms of diarrhea
Osmotic e.g. Lactose intolerance
Secretory e.g. Cholera
Mixed secretory-osmotic e.g. Rotavirus
Mucosal inflammation e.g. Invasive bacteria, Inflammatory Bowel Disease
Motility disturbance
Differentiation of Osmotic from Secretory Diarrhoea
Osmotic diarrhoea
Secretory diarrhoea
Stool volume
Small (generally
<200ml/24 hours)
Large (>200ml/24
hours)
Response to fasting
Diarrhoea stops
Diarrhoea continues
Stool Osmolality
> (Stool Na + K) x 2
= (Stool Na + K) x 2
Osmotic Gap
> 135 mOsm/l
< 50 mOsm/l
Stool Sodium
< 70 mmol/l
> 70 mmol/l
Stool Potassium
< 30 mmol/l
> 40 mmol/l
Stool Chloride
< 35 mmol/l
> 40 mmol/l
Stool pH
<5.5
> 6.0
Stool reducing substance
Positive (>0.5%)
Negative
Adapted from M Ravikumara. Investigation of chronic diarrhea. Paediatrics

and Child Health 2008; 18: 441-47
365
GASTROENTEROLOGY
Parameter
Causes of chronic diarrhea in children

Functional diarrhea (chronic nonspecific diarrhea)
Excessive intake of juice/osmotically active carbohydrates
Inadequate dietary fat
Idiopathic
Enteric infection
Postenteritis syndrome
Parasites
Giardia lamblia; Cryptosporidia parvum; Cyclospora cayetanensis; Isospora
belli; Microsporidia; Entamoeba histolytica; Strongyloides, Ascaris, Tricuris
spesies
GASTROENTEROLOGY
Bacteria
Enteroaggregative E. coli (EAggEC); Enteropathogenic E. coli (EPEC);
Enterotoxigenic E. coli (ETEC); Enteroadherent E. coli (EAEC); Mycobacterium avium complex; Mycobacterium tuberculosis; Salmonella, Shigella,
Yersinia, Campylobacter
Viruses
Cytomegalovirus; Rotavirus; Enteric adenovirus; Astrovirus; Torovirus; Human Immunodeficiency Virus (HIV)
Syndromic persistent diarrhea (common in developing countries)
Associated with malnutrition
Immune deficiency
Primary immune deficiencies
Secondary immune deficiencies (HIV)
Abnormal immune response
Celiac disease
Food allergic enteropathy (dietary protein-induced enteropathy)
Autoimmune disorders
Autoimmune enteropathy (including IPEX)
Graft vs Host disease
Inflammatory bowel disease (more common in developed countries)
Ulcerative Colitis
Crohn's disease
Protein losing gastroenteropathy
Lymphangiectasia (primary or secondary)
Other diseases affecting the gastrointestinal mucosa
366
Causes of chronic diarrhea in children (continued)

Congenital persistent diarrhea (rare)
Microvillus inclusion disease (Microvillus atrophy)
Intestinal epithelial dysplasia (Tufting enteropathy)
Congenital chloride diarrhea
Congenital sodium diarrhea
Congenital disaccharidase (sucrase-isomaltase, etc.) deficiencies
Congenital bile acid malabsorption
Neuroendocrine tumors
Gastrinoma (Zollinger-Ellison syndrome)
VIPoma (Verner-Morrison syndrome)
Mastocytosis
Factitious diarrhea
Laxative abuse
Manipulation of stool samples
GASTROENTEROLOGY
367
Common causes of chronic diarrhea classified by typical stool

characteristics, irrespective of age
Watery diarrhea
Osmotic diarrhea
Functional diarrhea (sometimes)
Magnesium, phosphate, sulfate ingestion
Carbohydrate malabsorption (lactose intolerance, mucosal disease,
congenital disaccharidase deficiencies)
Secretory diarrhea
Laxative abuse (nonosmotic laxatives)
Bacterial toxins
Bile acid malabsorption (post cholecystecomy ileal)
Autoimmune enteropathy (isolated or IPEX syndrome)
Vasculitis
GASTROENTEROLOGY
Drugs and poisons

Disordered motility (Hirshsprung's disease, pseudoobstruction)
Neuroendocrine tumors (gastrin,VIP, carcinoid, mastocytosis)
Neoplasia
Addison's disease
Epidemic secretory diarrhea (brainerd diarrhea)
Idiopathic secretory diarrhea
Congenital secretory diarrheas
Inflammatory diarrhea
Inflammatory bowel disease (ulcerative colitis, Crohn's disease,
microscopic [lymphocytic and collagenous] colitis, diverticulitis)
Infectious diseases (ulcerating viral infections, enteric bacterial
pathogens, parasites)
Ischemic colitis
Radiation colitis
Neoplasia (colon cancer, Lymphoma)
Fatty diarrhea
Malabsorption syndromes (mucosal diseases [eg, celiac], short-bowel
syndrome, post-resection diarrhea, mesenteric ischemia)
Maldigestion (pancreatic insufficiency [eg, cystic fibrosis], bile acid
deficiency)
368
369
GASTROENTEROLOGY
Implications of some aspects of the medical history in children with chronic

diarrhea
Line of Questioning
Clinical Implication
Onset
Congenital
Chloridorrhea, Na+ malabsorption
Abrupt
Infections
Gradual
Everything else
With introduction of
Celiac disease
wheat cereals
Stool Characteristics
Daytime only
Functional diarrhea (chronic nonspecific
diarrhea of childhood)
Nocturnal
Organic etiology
Blood
Dietary protein intolerance (eg, milk),
inflammatory bowel disease
White/light tan color
Absence of bile; Celiac disease
Family history
Congenital absorptive defects, inflammatory
bowel disease, celiac disease, multiple
endocrine neoplasia
Dietary History
"Sugar-free" foods
Fructose, sorbitol, or mannitol ingestion
Excessive juice
Osmotic diarrhea/chronic nonspecific diarrhea
Raw milk
Brainerd diarrhea
Exposure to potentially
Chronic bacterial infections (eg, aeromonas),
impure water source
giardiasis, cryptosporidiosis, Brainerd diarrhea
Travel history
Infectious diarrhea, chronic idiopathic
secretory diarrhea
Failure to thrive/weight
Malabsorption, pancreatic exocrine
loss
insufficiency, anorexia nervosa
Previous therapeutic inDrug side effects, radiation enteritis,
terventions (drugs, radia- postsurgical status, pseudomembranous colitis
tion, surgery, antibiotics)
(C. difficile), post-cholecystectomy diarrhea
Secondary gain from
Laxative abuse
illness
Systemic illness symptoms Hyperthyroidism, diabetes, inflammatory bowel
disease, tuberculosis, mastocytosis
Intravenous drug abuse,
HIV disease
sexual promiscuity (in
adolescent/child's parent)
Immune problems
HIV disease, immunoglobulin deficiencies
Abdominal pain
Obstruction, irritable bowel syndrome
Excessive flatus
Carbohydrate malabsorption
Leakage of stool
Fecal incontinence (consider occult
constipation)
Investigations in Chronic Diarrhoea

Baseline investigations
Stool microscopy ova, cysts, parasites, fat globules
Stool microbiology
Stool pH, reducing substances, electrolytes
Full blood count and differential
Urea and electrolytes, CRP and ESR
Liver function tests including albumin
Coeliac serology
Subsequent investigations
Stool elastase-I
Stool alfa-1-antitrypsin
GASTROENTEROLOGY
Vitamins A, D, E, coagulation, B12, folate levels, Ca, Mg, phosphate, ferritin

Endoscopy, colonoscopy and biopsies for histology, disaccharidases,
bacterial culture, Electron microscopy
Imaging studies x-ray, ultrasound, barium, MRI
Sweat test
Immunoglobulins, subclass, lymphocyte and neutrophil function test,
complements
Zinc level
Cholesterol, triglycerides, low-density lipoproteins
Autoantibodies including anti-enterocyte antibodies
Isoelectric focussing of transferrin
Gastrin, secretin, calcitonin,VIP
Manometric studies
Urinary laxatives
Breath hydrogen tests
Plasma and urinary bile acids and salts
Response to dietary modifications
370
Specific diagnostic consideration on routine blood examination results

Parameter
Diagnostic considerations
Anaemia
Iron, folate and B12 deficiency due to

malabsorption
Neutropenia
ShwachmanDiamond syndrome
Lymphopenia
Intestinal lymphangiectasia, immunodeficiency
Eosinophilia
Food allergies, eosinophilic gastroenteritis
Elevated platelets
Acute infections, IBD (especially Crohns

disease)
Acanthocytes in blood film
Abetalipoproteinemia
Elevated ESR, CRP
IBD, infections
Low albumin
Protein losing enteropathies
Positive coeliac serology
Coeliac disease
Metabolic alkalosis
Congenital chloride diarrhoea
Collection of stool with the help of a bag placed around the anus, using
an inverted diaper or insertion of a rectal tube to collect stool sample are
practical ways to confirm the watery nature of stool and also to obtain
samples for investigations.
Collecting the liquid portion of the stool increases the sensitivity of stool
for reducing sugar testing.
Conclusion
Despite being a complex condition which frequently requires tertiary
gastroenterology unit input, a complete history, physical examination
and logical stepwise investigations would usually yield significant clues
on the diagnosis.
The type of diarrhea ie. secretory vs osmotic type should be determined
early in the course of investigations.
It helps to narrow down the differential diagnosis and assists in planning
the therapeutic strategies.
The nutritional status should not be ignored. It should be ascertained
on initial assessment and appropriate nutritional rehabilitation strategies
(parenteral or enteral nutrition) should be employed whilst investigating
the aetiology.
371
GASTROENTEROLOGY

372
consider
CMPI
Cystic Fibrosis
Immunodeficiency states
Osmotic
Diarrhoea
Congenital Glu-Gal
malabsorption
Congenital lactase deficiency
Congenital enterokinase
deficiency
Fat malabsorption
Reassurance
Gut hormones
Secretory
Diarrhoea
Osmotic
Diarrhoea
Failure to thrive
Features of Malabsorption
Hormone secreting tumours
Chronic non-specific diarrhoea

Irritable bowel syndrome
Well Child
Normal growth, nutrition
Normal baseline Investigations
Older Age Group
ADAPTED FROM RAVIKUMARA,

PAEDIATR CHILD HEALTH 2008; 18: 441-47
Carbohydrate malabsorption
Combined malabsorption
Protein loss
Coeliac disease
Cystic Fibrosis
Lymphangiectasia
IBD
Shwachman-Diamond
Post enteritis
Secondary lactose intolerance
Abetalipoproteinemia
Tufting enteropathy
Food intolerances
Sucrose-Isomaltose
deficiency
Bile acid malabsorption
IPEX/autoimmune
Short gut
Phenotypic diarrhoea Note: CMPI, Cows milk protein intolerance; IBD, Inflammatory
Motility disorder
CMPI
bowel disease; IPEX, Immune dysregulation, polyendocrinopathy,
Bacteria overgrowth
enteropathy, X-linked.
Congenital chloride
diarrhoea
Congenital sodium
Intestinal Biopsy
diarrhoea
Microvillous
Normal
inclusion disease
Abnormal
Secretory
Diarrhoea
Stool electrolytes and

Response to Fasting
Neonatal Onset
Chronic Diarrhoea
ALGORITHM FOR APPROACH TO CHRONIC DIARRHOEA
GASTROENTEROLOGY
Chapter 73: Approach to Severely Malnourished Children

RESUSCITATION PROTOCOL FOR CHILDREN WITH SEVERE MALNUTRITION
This guideline is intended for Orang asli and indigenous children who present
to District Hospitals and Health Centres with a history of being unwell with
fever, diarrhoea, vomiting and poor feeding.
This protocol is not to be used for a child who does not have malnutrition.
This guideline is only recommended for those who fulfill the following criteria:
Orang asli or other indigenous ethnic group
Severe malnutrition
Lethargic or has lost consciousness
Ill
Shock
Initial assessment
Weigh the child (or estimate)
Measure temperature, pulse rate, BP and respiratory rate
Give oxygen
Insert intravenous or intraosseouos line
Draw blood for investigations where possible
(Blood sugar, FBC, BUSE, Blood culture, BFMP, ABG)
Monitor and stabilise

Measure pulse and breathing rate every 5-10 minutes
Start antibiotic IV Cefotaxime or Ceftriaxone
(if not available Ampicillin+ Chloramphenicol)
Monitor blood sugar and prevent hypothermia
IV Quinine only after discussion with Paediatrician
If there are signs of improvements
If the child deteriorates
(pulse and breathing rates are falling)

Repeat IV/IO bolus 15ml/kg
over 1 hour
Initiate ORS (or ReSoMal) PO
at10 ml/kg/h
(breathing up by 5 breaths/min
or pulse up by 25 beats/min
or fails to improve with IV/IO fluid)
Stop infusion as this can
worsen
childs condition
Discuss case with Paediatrician

and refer
Discuss case with Paediatrician

immediately and refer
Reference
1. Management of the child with a serious infection or severe malnutrition (IMCI). Unicef WHO 2000
373
GASTROENTEROLOGY
Resuscitation for shock

Give IV/IO fluid 15ml/kg over 1 hour
Solutions used -1/2NS, Hartmans if 1/2NS not available
Use 1/2NSD5% if hypoglycaemic
RE-FEEDING SEVERELY MALNOURISHED CHILDREN

This protocol is based on the protocol for Management of the child with a
serious infection or severe malnutrition (IMCI), Unicef WHO 2000.
Algorithm for Re-Feeding Plan
GASTROENTEROLOGY
Severely dehydrated,
ill, malnourished child
(Z Score < -3SD)
Correct
dehydration
Completed
Start F75 *
immediately
Ongoing at
6hrs-10hrs
Wean from
ReSoMal to F75 *
(same volume)
Starter feed with F75 based on IMCI protocol

Feeds at 75-100kcal/kg/day (< 100kcal/kg/day in the initial phase).
Protein at 1-1.5 g/kg/day.
Total volume 130mls/kg/day (if severe oedema, reduce to 100mls/kg/day).
How to increase feeds?
Increase F75 gradually in volume, e.g. 10 ml/kg/day in first 3-4 days
Gradual decrease in feeding frequency: 2, then 3 and 4 hourly when
improves.
Calculate calorie and protein content daily
Consider F100 catch up formula when
- Calories 130/kCal-kg/day-140kCal/kg/day.
- Child can tolerate orally well, gains weight, without signs of heart failure.
Note:
1. In a severely oedematous child this process might take about a week.
2. If you do not increase calories and proteins the child is not going to gain
weight and ward stay will be prolonged.
Monitoring
Avoid causing heart failure
- Suspect if: sustained increase (> 2 hrs) of respiratory rate (increases by
5/min), and / or heart rate by 25/min from baseline.
- If present: reduce feed to 100ml/kg/day for 24 hr then slowly increase
as follows:
115ml/kg/day for next 24 hrs; then 130ml/kg/day for next 48 hrs.
Then increase each day by 10 mls.
Ensure adequate weight gain
- Weigh child every morning before feeds; ideal weight gain is > 10g/kg/day
If poor weight gain < 5g/kg/day do a full reassessment
If moderate weight gain (5-10g/kg/day) check intake or check for infection
Watch for secondary infection
374
Introducing Catch up Growth formula (F100)

Gradual transition from F75 to F100 (usually over 48-72 hrs).
Increase successive feed by 10mls till some feeds remains uneaten.
Modified porridge or complementary food can be used, provided they have
comparable energy and protein levels.
Gradually wean to normal diet, unlimited frequent feeds, 150-220 kCal/kg/day.
Offer protein at 4-6 g/kg/day.
Continue breast feeding if child is breastfed.
Note: If child refuses F75/F100 and is too vigorous for forced RT feeding,
then give normal diet. However must calculate calories and protein (as above).
Discharge criteria
Not oedematous.
Gaining weight well.
Afebrile.
Has completed antibiotics.
Aged 12 mths (caution < 12 mths: A Specialist opinion is required
before discharge).
WHO electrolyte/mineral solution recipe

Item
Quantity (gm)
Molar content
(in 20 ml)
Potassium chloride, KCl
224
20 mmol
Tripotassium citrate: C6H5K3O7.H2O
81
2 mmol
Magnesium chloride: MgCl2.6H2O
76
3 mmol
Zinc acetate: Zn(CH3COO)2.2H20
8.2
300 mol
Copper sulphate: CuSO4.5H2O
1.4
45 mol
Water
to make up 2500 ml
Note: if available, add Selenium (Sodium Selenate 0.028 g), and Iodine
(Potassium Iodide 0.012g) per 2500ml
375
GASTROENTEROLOGY
In situation where patient need to be transferred to district facilities,

make sure:
Provide a clear plan on how to feed and how to monitor progress.
Provide a dietary plan with adequate calorie and protein requirements.
A follow up appointment with a Paediatrician.
GASTROENTEROLOGY
Recipes for starter and catch-up formulas

F-75
F-100
F-135
(starter)
(catch-up)
(catch-up)
Dried skimmed milk (g)*
25
80
90
Sugar (g)
100
50
65
Vegetable oil (g)
30 (or 35 ml) 60 (or 70 ml) 85 (or 95 ml)
Electrolyte/mineral solution (ml)
20
20
20
Water: make up to
1000 ml
1000 ml
1000 ml
Contents per 100ml
Energy (kcal)
75
100
135
Protein (g)
0.9
2.9
3.3
Lactose (g)
1.3
4.2
4.8
Potassium (mmol)
4.0
6.3
7.7
Sodium (mmol)
0.6
1.9
2.2
Magnesium (mmol)
0.43
0.73
0.8
Zinc (mg)
2.0
2.3
3.0
Copper (mg)
0.25
0.25
0.34
% energy from protein
5
12
10
% energy from fat
36
53
57
Osmolarity (mOsmol/L)
413
419
508
Preparation
Using an electric blender: place some of the warm boiled water in the
blender, add the milk powder, sugar, oil and electrolyte/mineral solution.
Make up to 1000 ml, and blend at high speed.
If no blender is available, mix milk, sugar, oil and electrolyte/ mineral
solution to a paste, and then slowly add the rest of the warm boiled water
and whisk vigorously with a manual whisk.
Store made-up formula in refrigerator.
*Alternative recipes: (other milk sources)
F-75 starter formulas (make up to 100 ml)
Full-cream dried milk 35 g, 100 g sugar, 20 g (or ml) oil, 20 ml electrolyte/
mineral solution.
Full-cream milk (fresh/ long life) 300 ml, 100 g sugar, 20 g (or ml) oil,
20 ml electrolyte/mineral solution.
F-100 catch-up formulas (make up to 100 ml)
Full-cream dried milk 110 g, 50 g sugar, 30 g (or ml) oil, 20 ml electrolyte/
mineral solution.
Full-cream milk (fresh / long life) 880 ml, 75 g sugar, 20 g (or ml) oil, 20 ml
electrolyte/mineral solution.
376
Chapter 74: Gastro-oesophageal Reflux

Introduction
Gastroesophageal reflux (GER) is the passage of gastric contents into the
esophageal with/without regurgitation and vomiting. This is a normal
physiological process occurring several times per day in healthy children.
Gastroesophageal reflux disease (GERD) in pediatric patients is present
when reflux of gastric contents is the cause of troublesome symptoms
and/or complications.
Symptoms and Signs:
Symptoms and signs associated with reflux vary by age and are nonspecific.
377
GASTROENTEROLOGY
Warning signals requiring investigation in infants with recurrent

regurgitation or vomiting:
Symptoms of gastrointestinal obstruction or disease
Bilious vomiting.
GI bleeding: hematemesis, hematochezia.
Consistently forceful vomiting.
Onset of vomiting after six months of life.
Constipation.
Diarrhea.
Abdominal tenderness, distension.
Symptoms suggesting systemic or neurologic disease
Hepatosplenomegaly.
Bulging fontanelle.
Macro/microcephaly.
Seizures.
Genetic disorders (e.g., Trisomy 21).
Other chronic disorders (e.g., HIV).
Nonspecific symptoms
Fever.
Lethargy.
Failure to thrive.
GLOBAL DEFINITION OF GERD IN THE PAEDIATRIC POPULATION

GERD in paediatric patients is present when reflux of gastric contents
is the cause of troublesome symptoms and/or complications
Extraoesophageal
Oesophageal
GASTROENTEROLOGY
Symptoms
purported to
be due to GERD
Infant/younger
child (0-8 yrs) or
older without
cognitive ability
to reliably report
symptoms
Definite
associations
Syndromes
with
Oesophageal
injury
Possible
associations
Sandifers syndrome
Dental erosion
Bronchopulmonary
Asthma
Symptomatic
Syndromes
Older child/adolescent
with cognitive ability
to reliably report
symptoms
Pulmonary fibrosis
Bronchopulmonary dysplasia
Laryngotracheal and Pharyngeal
Chronic cough
Chronic laryngitis
Typical Reflux
Syndrome
Hoarseness
Pharyngitis
Excessive regurgitation
Rhinological and Otological
Feeding refusal/anorexia
Sinusitis
Unexplained crying
Serous Otitis Media
Choking/gagging/
coughing
Sleep disturbance
Infants
Pathological Apnoea
Bradycardia
Abdomial pain
Reflux oesophagitis
Apparent life threatening

events
Reflux stricture
Barrets oesophagus
Adenocarcinoma
378
From Sherman, et al.

Am J Gastroenterology
2009; 104: 1278-1295
379
GASTROENTEROLOGY
Investigations
GERD is often diagnosed clinically and does not require investigations
Indicated:
If its information is helpful to define difficult or unusual cases.
If of value in making treatment decisions.
When secondary causes of GORD need to be excluded especially in
severely affected patients.
Esophageal pH Monitoring
The severity of pathologic acid reflux does not correlate consistently
with symptom severity or demonstrable complications
For evaluation of the efficacy of antisecretory therapy
To correlate symptoms (e.g., cough, chest pain) with acid reflux
episodes, and to select those infants and children with wheezing or
respiratory symptoms in whom GER is an aggravating factor.
Sensitivity, specificity, and clinical utility of pH monitoring for diagnosis
and management of extraesophageal complications of GER is uncertain.
Barium Contrast Radiography
Not useful for the diagnosis of GERD as it has poor sensitivity and
specificity but is useful to confirm or rule out anatomic abnormalities
of the upper gastrointestinal (GI) tract.
Nuclear Scintigraphy
May have a role in the diagnosis of pulmonary aspiration in patients
with chronic and refractory respiratory symptoms. A negative test does
not rule out possible pulmonary aspiration of refluxed material.
Not recommended for the routine evaluation of GERD in children.
Esophageal manometry
Not sufficiently sensitive or specific to diagnose GERD.
To diagnose motility disorder e.g. achalasia or other motor disorders of
the esophagus that may mimic GERD.
Endoscopy and Biopsy
Endoscopically visible breaks in the distal esophageal mucosa are the
most reliable evidence of reflux esophagitis.
To identify or rule out other causes of esophagitis including eosinophilic
esophagitis which do not respond to conventional anti reflux therapy.
To diagnose and monitor Barrett esophagus (BE) and its complications.
Empiric Trial of Acid Suppression as a Diagnostic Test
Expert opinion suggests that in an older child or adolescent with typical
symptoms of GERD, an empiric trial of PPI is justified for up to 4 weeks.
However, improvement of heartburn, following treatment, does not
confirm a diagnosis of GERD because symptoms may improve
spontaneously or respond by a placebo effect
No evidence to support an empiric trial of acid suppression as a diagnostic
test in infants/young children where symptoms of GERD are less specific.
Exposing them to the potential adverse events of PPI is not the best
practice. Look for causes other than GERD before making such a move.
GASTROENTEROLOGY
Treatment
Physiologic GER does not need medical treatment.
Symptoms are often non specific esp. during infancy; many are exposed
to anti-reflux treatment without any sufficient evidence.
Should always be balance between intended improvement of symptoms
with risk of side-effects.
Suggested Schematic Therapeutic Approach
Parental reassurance & observe. Avoid overeating
Lifestyle changes.
Dietary treatment
- Use of a thickened formula (or commercial anti regurgitation formulae)
may decrease visible regurgitation but does not reduce in the frequency
of esophageal reflux episodes.
- There may be association between cows milk protein allergy and GERD.
- Therefore infants with GERD that are refractory to conventional anti
reflux therapy may benefit from a 2- to 4-week trial of elimination of
cows milk in diet with an extensively hydrolyzed protein formula that
has been evaluated in controlled trials. Locally available formulas are
Alimentum, Pepti and Pregestimil. Usually there will be strong family
history of atopy in these patients.
- No evidence to support the routine elimination of any specific food in
older children with GERD.
Position during sleep
- Prone positioning decreases the amount of acid esophageal exposure
measured by pH probe compared with that measured in the supine
position. However, prone and lateral positions are associated with an
increased incidence of sudden infant death syndrome (SIDS).
Therefore, in most infants from birth to 12months of age, supine
positioning during sleep is recommended.
- Prone or left-side sleeping position and/or elevation of the head of the
bed for adolescents with GERD may be of benefit in select cases.
Buffering agents (some efficacy in moderate GERD, relatively safe).
Antacids only in older children.
Buffering agents e.g. alginate and sucralfate are useful on demand for
occasional heartburn.
Chronic use of buffering agents is not recommended for GERD because
some have absorbable components that may have adverse effects with
long-term use.
Prokinetics .
Treat pathophysiologic mechanism of GERD.
There is insufficient evidence of clinical efficacy to justify the routine
use of metoclopramide, erythromycin, or domperidone for GERD.
380
381
GASTROENTEROLOGY
Proton Pump Inhibitors (PPI) (drug of choice in severe GERD).

Histamine-2 receptor antagonists less effective than PPI.
Histamine-2 Receptor Antagonists (H2RAs).
- Exhibit tachyphylaxis or tolerance (but PPIs do not)
- Useful for on-demand treatment
Proton Pump Inhibitors
- Administration of long-term acid suppression without a diagnosis is
inadvisable.
- When acid suppression is required, the smallest effective dose should
be used.
- Most patients require only once-daily PPI; routine use of twice-daily
dose is not indicated.
- No PPI has been officially approved for use in infants <1 year of age.
- The potential adverse effects of acid suppression, including increased
risk of community-acquired pneumonias and GI infections, need to be
balanced against the benefits of therapy.
Antireflux surgery (either open or laparoscopic surgery).
- May be of benefit in selected children with chronic-relapsing GERD.
- Indications include: failure of optimized medical therapy, dependence
on long-term medical therapy, significant non adherence with medical
therapy, or pulmonary aspiration of refluxate.
- Children with underlying disorders predisposing to the most severe GERD
e.g. neurological impairment are at the highest risk for operative
morbidity and postoperative failure.
- It is essential therefore to rule out all non-GERD causes of the
childs symptoms, confirm the diagnosis of chronic relapsing GERD,
discuss with the parents the pros and cons of surgery and to
assure that the caregivers understand the potential complications,
symptom recurrence and sometimes the need to be back on medical
therapy.
382
GASTROENTEROLOGY
Chapter 75: Acute Hepatic Failure in Children

Definitions
Fulminant hepatic failure (HF) - hepatic dysfunction (hepatic encephalopathy and coagulopathy) within 8 weeks of evidence of symptoms of liver
disease and absence of pre-existing liver disease in any form.
Hyperacute/ Fulminant HF - encephalopathy within 2 weeks of onset of
jaundice
Subfulminant HF - encephalopathy within 2-12 weeks of onset of jaundice
Subacute/ Late-onset HF- encephalopathy later than 8 weeks to 6 months
of onset of symptoms.
Salient features
jaundice with impalpable liver or a liver of reducing size
encephalopathy - may worsen rapidly (needs frequent review)
bruising, petechiae or bleeding from deranged clotting unresponsive to
vitamin K.
failure to maintain normoglycaemia (which aggravates encephalopathy)
or presence of hyperammonaemia
increased intracranial pressure (fixed dilated pupils, bradycardia,
hypertension and papilloedema)
Grade 1
Irritable, lethargic
Grade 2
Mood swings, aggression, photophobia,
Not recognising parents, presence of flap
Grade 3
Sleepy but rousable, incoherent, sluggish
Pupils, hypertonia clonus, extensor spasm
Grade 4
Comatose; decerebrate, decorticate
or no response to pain
383
GASTROENTEROLOGY
Grading of Hepatic Encephalopathy - Coma Level
GASTROENTEROLOGY
Causes of Hepatic Failure

Infection
Hepatitis A, B, non A- non B, CMV
Leptospirosis, Dengue
Herpes simplex virus (particularly in small infants)
Drugs
Carbamazepine, valproate
Paracetamol, halothane
Ingested toxins
Mushrooms, Amanita phalloides
Metabolic
Fructosaemia, galactosaemia, tyrosaemia,
Wilsons disease
Neonatal haemochromatosis
Ischaemic shock
Gram negative septicaemia,
Budd Chiari syndrome
Autoimmune
Autoimmune Hepatitis
Tumour
Histiocytosis, lymphoproliferative disorder
Principles of management
Supportive Treatment
Nurse in quiet darkened room with head-end elevated at 20o with
no neck flexion (to decrease ICP and minimise cerebral irritability).
DO NOT SEDATE unless already ventilated
This may precipitate respiratory failure and death.
Maintain blood glucose between 6-9 mmol/l using minimal fluid volume
(40-60 ml/kg/day crystalloid) with high dextrose concentrations
e.g. 10-20%. Add Potassium as necessary.
Check capillary blood sugar every 2 - 4 hourly.
Strict monitoring of urine output and fluid balance. Catheterise if necessary.
Check urinary electrolytes, serum urea, creatinine, electrolytes, osmolarity.
Frequent neurological observations (1-4 hourly).
Maintain oxygenation with facial oxygen.
Give Vitamin K to correct prolonged PT. If frank bleeding (GIT/oral)
occurs, consider prudent use of FFP or IV Cryoprecipitate at 10 ml/kg.
Prophylactic Ranitidine + oral Antacid to prevent gastric/duodenal ulceration.
Full septic screen (excluding LP) on admission, CXR. Treat sepsis
aggressively, monitoring levels of aminoglycosides frequently.
384
Indication for Liver Transplantation

Paracetamol-induced disease
Arterial pH < 7.3 (independent of the grade of encephalopathy)
OR
Grade III or IV encephalopathy and
Prothrombin time > 100 s and
Serum creatinine > 3.4 mg/dL (301 mol/l)
All other causes of fulminant hepatic failure
Prothrombin time > 100 s (independent of grade of encephalopathy)
OR
Any 3 of the following variables (independent of grade of encephalopathy)
Age < 10 years or > 40 years
Etiology: non-A, non-B hepatitis, halothane hepatitis, idiosyncratic drug
reactions
Duration of jaundice before onset of encephalopathy > 7 days
Prothrombin time > 50 s
Serum bilirubin > 18 mg/dl (308 mol/l)
Adapted from the Kings College Hospital Criteria
385
GASTROENTEROLOGY
Stop oral protein initially. Gradually reintroduce 0.5-1g/kg/day.

Lactulose to produce 3-4 loose stools per day.
*Strict fluid balance is essential - aim for urine output > 0.5 ml/kg/hour.
Consider N-Acetylcysteine. (discuss with hepatologist). The dose is a
continuous infusion at 10mg/kg/hr for at least 48-72 hours with regular
serial monitoring of liver biochemical and synthetic function parameters.
Small risk of anaphylaxis is present.
Antibiotics : Combination that provides a good cover against gram
negative organisms and anaerobes eg. cefotaxime and metronidazole if
no specific infective agent suspected (eg. leptospira, mycoplasma)
Antiviral : Acyclovir is recommended in neonates and small infants with
Acute Liver Failure due to possibility of Herpes simplex virus infection
Renal dysfunction
Possible causes : Hepato-renal syndrome, Dehydration and Low CVP/
low cardiac output. Consider haemofiltration (to discuss with
Paediatric nephrologist) if supportive measures like fluid challenge,
renal dose dopamine and frusemide infusion fail.
Clinical Pearls In a comatose patient:
In the presence of sudden coma, consider intracranial bleed: request a
CT Brain.
Patients in Grade 3 or 4 coma require mechanical ventilation to maintain
normal cerebral perfusion pressure.
Fluid management in liver failure

Normal Liver Function
Liver Failure
Volume given if no dehydration and losses are not abnormal
GASTROENTEROLOGY
Body Weight
< 10 kg
120-150 ml/kg/day
60-80 ml/kg/day
10-20 kg
90-120 ml/kg/day
40-60 ml/kg/day
> 20 kg
50-90 ml/kg/day
30-50 ml/kg/day
Fluid type
Dextrose 4 5 %
Dextrose 10%
(adjust according to
Destrostix readings)
Potassium
1 - 3.5 mmol/kg/day
NIL WHILE ANURIC
Sodium
1.5 - 3.5 mmol/kg/day
No added sodium to
existing maintenance
fluid (Adjust to keep
serum Na normal)
Other Fluids
Albumin 20% 5 ml/kg
Albumin 20% 5 ml/kg
For transfusion
FFP 10-20 ml/kg
FFP 10-20 ml/kg
Blood volume (ml) = No. of grams to raise Hb by x body weight in kg x F

Where F = 6 for whole blood, F = 4 for packed cells
386
Chapter 76: Approach to Gastrointestinal Bleeding

Definitions
Haemetemesis - vomiting out blood whether fresh or stale
Malaena - passing out tarry black stools per rectum
Both are medical emergencies that carry significant mortality.
Salient features
Duration and severity of haemetemesis and/or malaena.
Evidence of hypovolaemic shock.
Rule out bleeding diathesis.
ACUTE RESUSCITATION IN A CHILD WITH GASTROINTESTINAL BLEEDING
Acute Gastrointestinal Bleeding
Quick assessment of cardiovascular status
(Pulse, BP, Respiration)
Largest possible bore IV cannula inserted immediately
(CVP line may be required)
Take blood for GXM
At least 1-2 units of packed cells
kept available at all times
during acute period
Investigations
Hb/Platelet counts/haematocrit
Renal profile
Coagulation profile
Other investigations relevant
to cause of bleeding
Large bore NG tube passed

to aspirate fresh/ clotted blood,
then tube removed
Transfuse blood to maintain
BP/HR, urine output and Hb.
Look for complications of massive
transfusion: acidosis, hypoglycemia,
hypothermia
If required give
IV Calcium Gluconate 10%
and Sodium Bicarbonate
Monitor BP/HR/Pulse volume/

temperature/ urine output/
CVP hourly until stable
Continue to observe for
ongoing bleeding.
FFP, Cryoprecipitate and Platelet concentrates may be

needed to correct coagulation disorders, DIVC, etc
387
GASTROENTEROLOGY
Resuscitate with IV volume expander

Use 0.45 %/ 0.9 % Saline,
plasmatein, FFP
or 5% albumin to stabilise BP/HR
while waiting for blood
to be available
Decision making after acute resuscitation

Reassessment of patients
When patients condition is stable and resuscitative measures have been
instituted,
Assess patient for cause of bleeding and the need for surgery.
History is reviewed.
Ask for history of chronic liver disease, dyspepsia, chronic or intermittent
gastrointestinal bleeding (e.g. polyps), drug ingestion (anticoagulants,
aspirin), or acute fever (dengue haemorrhagic fever), easy bleeding
tendencies, antibiotics treatment (pseudomembranous colitis).
Physical examination should be directed towards looking for signs of
chronic liver disease (spider angiomata, palmar erythema, portal
hypertension or splenomegaly) or telengiectasia / angiomata in mouth,
trunk, etc.)
Diagnostic measures to localise source of bleeding
GASTROENTEROLOGY
Oesophagogastro-duodenoscopy (OGDS) or colonoscopy can be

performed when patients condition is stable.
Double contrast barium study less useful than endoscopy but may be
indicated in patients when endoscopy cannot precisely locate the
source of bleeding (e.g. in intussusception).
Visceral angiography can precisely locate the source of bleeding. But
is only reserved for patients with a difficult bleeding problem.
388
Definitive measures to management of gastrointestinal bleeding

Medical Cause
Bleeding peptic ulcer
Start H2 receptor antagonist (e.g. cimetidine or ranitidine).
Proton pump inhibitor (omeprazole) should be considered when
available as it has higher acid suppressant activity.
Pantoprazole infusion has been increasingly used off label (discuss with
Paediatric Gastroenterologist).
If biopsy shows presence of Helicobacter pylori infection, treat accordingly.
Stop all incriminating drugs e.g. aspirin, steroids and anticoagulant
drugs if possible.
Bleeding oesophageal varies ulcer
Do not transfuse blood too rapidly as this will lead to increase in CVP
and a rapid increase in portal pressure will precipitate further bleeding.
Aim to maintain Hb at 10 g/dL.
Refer Paediatric Surgeon and Paediatric Gastroenterologist to
consider use of octreotide.
Surgical Cause
When surgical cause is suspected, early referral to the surgeon is important so that a team approach to the problem can be adopted.
Intussusception requires immediate surgical referral and intervention.
Meckels diverticulum
Malrotation
389
GASTROENTEROLOGY
Pseudomembranous colitis
Stop all antibiotics
Start oral metronidazole or oral vancomycin immediately.
GASTROENTEROLOGY
References
Section 9 Gastroenterology
Chapter 72 Chronic Diarrhoea
1.Schmitz J. Maldigestion and malabsorption. In: Walker Goulet, Kleinman
Sherman, Shneider, Sanderson, eds. Pediatric gastrointestinal disease. New
York: B C Decker, 2004, p. 820.
2.Binder HJ. Causes of chronic diarrhea. N Engl J Med 2006; 355:236.
3.Bhutta ZA, Ghishan F, Lindley K, et al. Persistent and chronic diarrhea and
malabsorption: Working Group report of the second World Congress of
Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 2004; 39 Suppl 2:S711.
4.Schiller, LR. Chronic diarrhea. Gastroenterology 2004; 127:287.
5.Fine, KD, Schiller, LR. AGA technical review on the evaluation and management of chronic diarrhea. Gastroenterology 1999; 116:1464.
6.M Ravikumara. Investigation of chronic diarrhea. Paediatrics and child
health 2008; 18: 441-47.
Chapter 74 Gastroesophageal reflux
1.Yvan Vandenplas, and Colin D. Rudolph et al. Pediatric Gastroesophageal
Reflux Clinical Practice Guidelines: Joint Recommendations of the North
American Society of Pediatric Gastroenterology, Hepatology, and Nutrition
and the European Society of Pediatric Gastroenterology, Hepatology and
Nutrition. J Pediatric Gastroenterology and Nutrition. 49:498547 2009.
2.Robert Wyllie, Jeffrey S. Hyams, Marsha Kay et al.Pediatric Gastrointestinal
And Liver Disease, Fourth Edition. 2011.
390
Chapter 77: Sepsis and Septic Shock

Definitions of Sepsis and Shock
SIRS
(Systemic
Inflammatory
Response
Syndrome)
Incidence
Non hospitalized immunocompetent children may develop community acquired sepsis. More commonly, hospitalized immunocompromised patients are
at higher risk of developing serious healthcare associated sepsis.
Pathophysiology
Infection
Activation of immunological system

Release of inflammatory chemical mediators
Systemic vasodilation
Capillary leakage
Intravascular volume depletion
Maldistribution of intravascular volume
Impaired myocardial function
391
INFECTIOUS DISEASE
Non-specific systemic inflammatory response to

infection, trauma, burns, surgery etc.
Characterized by abnormalities in 2 of the
following (one of which must be abnormal temperature or leukocyte count):
Body temperature.
Heart rate.
Respiratory function.
Peripheral leucocyte count.
Sepsis
SIRS in the presence of or as a result of suspected
or proven infection.
Severe sepsis
Sepsis plus one of the following:
Cardiovascular organ dysfunction.
Acute respiratory distress syndrome.
Two or more other organ dysfunction.
Septic shock
Severe sepsis with cardiovascular organ dysfunction
i.e. Hypotension (systolic Blood Pressure < 5th
centile for age).
Early septic shock Compensated warm phase of shock.
(WARM shock)
Prompt response to fluids, pharmacologic treatment.
Refractory septic Late decompensated phase.
shock
Shock lasting >1 hour despite vigorous therapy
(COLD shock)
necessitating vasopressor support.
Based on the International Pediatric Sepsis Consensus Conference
Clinical features
Sepsis, severe sepsis and septic shock are a clinical continuum.
SEPSIS is present when 2 or more of the following features are present
Fever ( > 38.5C) or hypothermia, often in neonate (< 36C)
Hyperventilation
Tachycardia
White blood count abnormalities: leukocytosis or leucopenia
AND there is clinical evidence of infection.
Other constitutional symptoms such as poor feeding, diarrhea, vomiting,
lethargy may be present.
With progression to SEVERE SEPSIS, there are features of compromised end
organ perfusion such as:
INFECTIOUS DISEASE
Features of compromised end organ perfusion

Neurology
Altered sensorium, irritability, agitation, confusion,

unresponsiveness or coma
Respiratory
Tachypnoea, increase breathing effort,

apnoea / respiratory arrest, cyanosis (late sign)
Renal
Oliguria: urine output < 0.5ml/kg per hour
When SEPTIC SHOCK sets in, look for features of Warm or Cold shock:
Features of Warm and Cold shock
Peripheries
Capillary refill
Pulse
Heart rate
WARM shock
COLD shock
Warm, flushed
Cold, clammy, cyanotic
< 2 sec
> 2 sec
Bounding
Weak, feeble
Tachycardia
Tachycardia or bradycardia
Blood pressure
Relatively maintained
Hypotension
Pulse pressure
Widened
Narrowed
392
Look out for localizing signs - most useful but not always present:
Localising Signs
meningism , encephalopathy
Respiratory
localized crepitations, evidence of consolidation
Cardiovascular
changing murmurs
Gastrointestinal
focal or rebound tenderness, guarding
Bone and soft tissue
focal erythema, tenderness and oedema
Head and neck
cervical lymphadenopathy, sinus tenderness,
inflamed tympanic membrane, stridor,
exudative pharyngotonsillitis
Skin
pustular lesions
Complications
Multiorgan Failure:
Acute respiratory distress syndrome.
Acute renal failure.
Disseminated intravascular coagulopathy.
Central nervous system dysfunction.
Hepatic failure.
393
Investigations
Septic work - up
Monitoring severity and progress
Blood C&S
Full blood count
Urine C&S
Renal profile
Where appropriate
Electrolytes, calcium, magnesium
CSF C&S
Blood sugar
Tracheal aspirate C&S
Blood gases
Pus / exudate C&S
+/- lactate levels
Fungal cultures
Coagulation profile
Serology, viral studies
Liver function test
Imaging studies
- Chest X-ray, ultrasound, CT scan
Supporting evidence of infection:
Full blood count
Leukocytosis or leukopenia
INFECTIOUS DISEASE
Peripheral blood film

Increase in immature neutrophil count
C-reactive protein
Elevated c-reactive protein levels
Abbreviation. C&S, Culture and Sensitivity
394
Management
Initial resuscitation - ABC
Secure airway, Support breathing, Restore circulation
Caution: the use of sedation in septic or hypotensive children may result in
crash of blood pressure. If sedation is required, use low dose IV Midazolam
or Ketamine, volume infusion should be continued and inotropes should be
initiated, if time permits.
Fluid therapy
Aggressive fluid resuscitation with crystalloids or colloids at 20 mls/kg
as rapid IV push over 5-10 mins. Can be repeated up to 60 mls/kg or more.
Correct hypoglycaemia and hypocalcaemia.
Inotropic Support
If fluid refractory shock*, establish central venous access
- Start inotropes: IV Dopamine 5 - 15 g/kg min or
- IV Dobutamine 5 - 15 g/kg/min
For fluid refractory and dopamine/dobutamine refractory shock with
- Warm shock : titrate IV Noradrenaline 0.05 2.0 g/kg /min
- Cold shock : titrate IV Adrenaline 0.05 2.0 g/kg /min
The aim of titration of inotropes include normal clinical endpoints
and where available, SpO >70%.
Inotropes should be infused via a central line (whenever possible)
or a large bore peripheral canula.
Use dedicated line or lumen. Avoid concurrent use for other IV fluids,
medication.
Fluids and inotropes to be titrated to optimal vital signs, urine output
and conscious level.
*hypotension, abnormal capillary refill or extremity coolness
Antimicrobial therapy
IV antibiotics should be administered immediately after appropriate
cultures are taken. Start empirical, broad spectrum to cover all likely
pathogens, considering:
- Risk factors of patient and underlying illness.
- Local organism prevalence and sensitivity patterns.
- Protocols of the institution.
Antibiotic regime to be modified accordingly once C&S results are back.
Source control:
- Evaluate patient to identify focus of infection.
- Drainage, debridement or removal of infected devices to help
control infection.
395
Respiratory Support
Use PEEP and FIO2 to keep SaO2 > 90%, PaO2 > 80 mmHg
Caution: use sufficient PEEP to ensure alveolar recruitment in cases of sepsis
with acute lung injury. Too high PEEP can result in raised intrathoracic pressure which can compromise venous return and worsen hypotension.
Supportive Therapy
Packed cells transfusion if Hb <10g/L.
Platelet concentrate transfusion if platelet count < 20 000/mm3.
If overt clinical bleeding, correct coagulopathy or DIVC.
Bicarbonate therapy: give bicarbonate only in refractory metabolic
acidosis, if pH < 7.1 (ensure adequate tissue perfusion and ventilation
to clear by-product CO).
Aim to maintain normal electrolytes and blood sugar.
Monitoring
Frequent serial re-evaluation is essential to guide therapy and gauge
response, as below:
Monitoring in Children with Sepsis
Clinical
Vital signs
INFECTIOUS DISEASE
Heart rate via cardiac monitor

Capillary return
Skin temperature
Pulse volume
Blood pressure
Non invasive
Invasive - ideal if available
SpO2 via pulse oximeter
Central venous pressure (CVP)
Urine output via continuous bladder drainage
Head chart (GCS)
Laboratory
See previous Table on Investigations
396
Chapter 78: Pediatric HIV

Screening of children for HIV status
In newborns and in children, the following groups need to be tested:
Babies of HIV positive mothers.
Abandoned babies / street children.
Babies of mothers with high risk behaviour (e.g. drug addicts /
prostitutes / multiple sex partners / single-teenage /underage).
Sexually abused children and children with sexually transmitted disease.
Children receiving regular blood transfusions or blood products
e.g. Thalassemics.
Immunisation
Vaccines protect HIV-infected children from getting severe vaccine
preventable diseases, and generally well tolerated.
All routine vaccinations can be given according to schedule, with special
precautions for live vaccines i.e. BCG, OPV and MMR:
BCG: safe in child is asymptomatic and not immunosuppressed
(e.g. at birth); omit if symptomatic or immunosuppressed
Give IPV (killed polio vaccine) as recommended in current schedule.
MMR: safe; omit in children with severe immunosuppression (CD4<15%).
Other recommended vaccines:
Pneumococcal polysaccharide vaccine when > 2 years of age; booster
3-5 years later. Where available, use Pneumococcal conjugate vaccine
(more immunogenic).
Varicella-zoster vaccine, where available. 2 doses with 2 months interval.
Omit in those with severe immunosuppression (CD4 < 15%)
Despite vaccination, remember that long term protection may not be
achieved in severe immune suppression i.e. they may still be at risk of
acquiring the infections!
397
INFECTIOUS DISEASE
Deliveries and infant nursing

Standard precautions must be observed at all times. It is vital to use
protective barriers such as arm length gloves, mask, goggles and gown
with waterproof sleeves. Boots are to be used for institutional deliveries:
During deliveries.
During handling of placenta tissue.
During handling of babies such as wiping liquor off babies.
All equipment, including resuscitation equipment should be cleaned
and sterilised.
For home deliveries, battery operated suction device should be used.
Standard precautions are to be observed in caring for the babies.
For parents or relatives, gloves are given for use when handling the
placenta after discharge, or during burial of stillbirth or dead babies at
home. The placenta from HIV positive mothers should be soaked in
formalin solution before disposal. Alternatively, the placenta can be
sealed in a plastic bag or other leak proof container with clear
instructions to parents not to remove it from the container.
Interventions to limit perinatal transmission

Vertical transmission of HIV may occur while in utero, during the birth
process or through breast-feeding. The rates vary from 25 - 30%.
Breastfeeding confers an additional 14% risk of transmission, and is
therefore contraindicated.
Blood and blood products should be used judiciously even though the
risk of transmission of HIV infection from blood transfusion is very small.
Several interventions have proven effective in reducing vertical transmission:
Total substitution of breastfeeding with infant formula.
Elective Caesarean section.
Antiretroviral (ARV) prophylaxis.
Factors associated with higher transmission rate
Maternal
Low CD 4 counts
High viral load
Advanced disease
Seroconversion during pregnancy
INFECTIOUS DISEASE
Foetal
Premature delivery of the baby
Delivery and procedures
Invasive procedures such as episiotomy
Foetal scalp electrodes
Foetal blood sampling and amniocentesis
Vaginal delivery
Rupture of membranes > 4 hours
Chorioamnionitis
Management of Babies Born to HIV Infected Mothers
Children born to HIV positive mothers are usually asymptomatic at birth.
However, all will have acquired maternal antibodies. In uninfected children,
antibody testing becomes negative by 10 - 18 months age.
398
During pregnancy
Counsel mother regarding:
Transmission rate (without intervention) 25 to 30%.
ARV prophylaxis + elective LSCS reduces transmission to ~3%.
Feed with infant formula as breast feeding doubles the risk of transmission.
Difficulty in making early diagnosis because of presence of maternal
antibody in babies. Stress importance of regular blood tests and follow-up.
Neonatal period
Admit to ward or early review by paediatric team (if not admitted).
Examine baby for
Evidence of other congenital infections.
Symptoms of drug withdrawal (reviewing maternal history is helpful).
Most babies are asymptomatic and only require routine perinatal care
Start on prophylaxis ARV as soon as possible.
Sample blood for:
HIV DNA PCR (done in IMR, do not use cord blood; sensitivity 90%
by 1 month age).
FBC.
Other tests as indicated:
LFT, RFT, HbsAg, Hepatitis C, Toxoplasmosis, CMV, VDRL serology.
INFECTIOUS DISEASE
399
MANAGEMENT OF HIV EXPOSED INFANTS

HIV Positive Mother
1. Initiate HIV prophylaxis in newborn immediately after delivery:
Scenario 1
4mg/kg/dose bd for 6 weeks
Zidovudine
Scenario 2 + 3:
Zidovudine 4mg/kg/dose bd for 6 weeks
+ Nevirapine
8mg/dose (BW <2kg), 12mg/dose (BW >2kg)
for 3 doses: at birth, 48hrs later and 96hrs after 2nd dose
2. Investigations:
HIV DNA PCR (together with mothers blood ) at 0-2 weeks
FBC at birth and at 6 weeks
3. Start PCP prophylaxis at 6 weeks age, till HIV status determined
Co-trimoxazole 4mg TMP/20mg SMX/kg daily
or 150 mg TMP/ 750 SMX mg/m/day bd for 3 days per week
Positive
INFECTIOUS DISEASE
Repeat HIV DNA PCR

as soon as possible
HIV DNA PCR Testing

Positive
Negative
Repeat HIV DNA PCR
at 6 weeks age
Negative
Repeat HIV DNA PCR
at 4 - 6 months age
Negative
Positive
INFECTED
NOT INFECTED
PCP Prophylaxis up to 12 mths

Later evaluate for continued need
Anti-retroviral therapy,
if indicated
Follow up
Stop Co-trimoxazole
Follow 3 mthly till 18 mths age
Ensure that babys antibody
status is negative by 18 mths
Footnote:
Scenario 1: HIV infected pregnant mother who is on HAART
Scenario 2: HIV infected mother at delivery who has not received adequate ARV
Scenario 3: Infant born to HIV infected mother who has not received any ARV
ARV should be served as soon as possible (preferably within 6-12 hrs of life)
and certainly no later than 48 hours.
Dose of Syr ZDV for premature baby >30 wks: 2mg/kg 12hrly for 2 wks, then
2mg/kg 8hrly). If oral feeding is contraindicated, use IV ZDV 1.5mg/kg/dose.
Abbreviations:
ARV, Antiretroviral prophylaxis; HAART, Highly active antiretroviral therapy;
PCP, Pneumocystis carinii pneumonia.
400
Management of HIV in Children

Clinical Features
Common presenting features are:
Persistent lymphadenopathy
Hepatosplenomegaly
Failure to thrive
Developmental delay, regression
Recurrent infections (respiratory, skin, gastrointestinal)
Diagnosis of HIV infection
In children > 18 months age: 2 consecutive positive HIV antibody tests.
In children 18 months age: 2 positive HIV DNA PCR tests.
Monitoring
Monitor disease progression through clinical, immunological (CD4+ count
or %) and viral load status.
CD4+ count and viral load assay are done at diagnosis, 2-3 months after
initiation or change of ART and every 3-4 months thereafter (more
frequently if change of therapy is made or progression of disease occurs).
Antiretroviral Therapy
Clinical outcome following the use of highly active antiretroviral therapy
(HAART) in children is excellent, with reduced mortality (67 - 80%) reported
from various cohorts. However, this needs to be balanced with: failure of
current drugs to eradicate infection, medication side effects and
compliance-adherence issues.
Decrease Viral Replication

Preservation of Immune System
Diminish Viral Replication
Improved Quality of Life and Survival
Optimising Growth and Development
Reduced Opportunistic Infections
401
INFECTIOUS DISEASE
Goals of therapy
When to start?
Starting ART is very rarely an emergency. Before starting ART, intensive
education to parents, care-givers and older children-patients need to be
stressed. Do not start in haste as we may repent at leisure!
Assess familys capacity to comply with often difficult and rigid regimens.
Stress that non-adherence to medications allows continuous viral
replication and encourages the emergence of drug resistance and
subsequent treatment failure.
Young infants have a much higher risk of disease progression to clinical
AIDS or death when compared to older children or adults and hence the
treatment recommendations are more aggressive. Recommendation for
when to start ARV is shown in Table.
Please consult a specialist/consultant before starting treatment.
INFECTIOUS DISEASE
WHO classification of HIV-associated immunodeficiency using CD4 count

Age related CD4 values
Classification of
HIV-associated
Immunodeficiency
< 11 mths
(CD4 %)
Not significant
Mild
Advanced
Severe
>35
3035
2529
<25
5 years
12-35 mths 36-59 mths
(cells/mm or
(CD4 %)
(CD4 %)
CD4 %)
>30
>25
>500
2530
2025
350499
2024
1519
200349
<20
<15
<200 or <15%
Clinical categories
There are 2 widely used clinical classification systems i.e CDCs 1994
Revised Paediatric Classification and the more recently updated WHO Clinical Classification system. Both classification systems are quite similar with
only minor differences.
402
WHO Clinical Staging Of HIV for Infants and Children With Established HIV
infection (Adapted from WHO 2007)
Clinical stage 1 (Asymptomatic)
Asymptomatic
Persistent generalized lymphadenopathy
Clinical stage 2 (Mild) *
Unexplained persistent hepatosplenomegaly
Papular pruritic eruptions
Extensive wart virus infection
Extensive molluscum contagiosum
Recurrent oral ulcerations
Unexplained persistent parotid enlargement
Lineal gingival erythema
Herpes zoster
Recurrent or chronic upper respiratory tract infections (otitis media, otorrhoea, sinusitis, tonsillitis )
Fungal nail infections
Unexplained moderate malnutrition not adequately responding to standard therapy
Unexplained persistent diarrhoea (14 days or more )
Unexplained persistent fever (above 37.5 C, intermittent or constant, for
longer than one month)
Persistent oral candidiasis (after first 6 weeks of life)
Oral hairy leukoplakia
Acute necrotizing ulcerative gingivitis/periodontitis
Lymph node TB
Pulmonary TB
Severe recurrent bacterial pneumonia
Symptomatic lymphoid interstitial pneumonitis
Chronic HIV-associated lung disease including bronchiectasis
Unexplained anaemia (<8.0 g/dl ), neutropenia (<0.5 x 109/L) or chronic
thrombocytopenia (<50 x 109/ L)
403
INFECTIOUS DISEASE
Clinical stage 3 (Advanced) *
WHO Clinical Staging Of HIV for Infants and Children With Established HIV
infection (Adapted from WHO 2007) (continued)
Clinical stage 4 (Severe) *
Unexplained severe wasting, stunting or severe malnutrition not responding to standard therapy
Pneumocystis pneumonia
Recurrent severe bacterial infections (e.g. empyema, pyomyositis, bone
or joint
infection, meningitis, but excluding pneumonia)
Chronic herpes simplex infection; (orolabial or cutaneous of more than
one monthsduration, or visceral at any site)
Extrapulmonary TB
Kaposi sarcoma
Oesophageal candidiasis (or Candida of trachea, bronchi or lungs)
Central nervous system toxoplasmosis (after the neonatal period)
HIV encephalopathy
INFECTIOUS DISEASE
Cytomegalovirus (CMV) infection; retinitis or CMV infection affecting

another organ, with onset at age over 1 month
Extrapulmonary cryptococcosis (including meningitis)
Disseminated endemic mycosis (extrapulmonary histoplasmosis, coccidiomycosis)
Chronic cryptosporidiosis (with diarrhoea )
Chronic isosporiasis
Disseminated non-tuberculous mycobacteria infection
Cerebral or B cell non-Hodgkin lymphoma
Progressive multifocal leukoencephalopathy
HIV-associated cardiomyopathy or nephropathy
(*) Unexplained refers to where the condition is not explained by other
causes.
404
Which drugs to use?

Always use combination of at least 3 drugs (see Table next page)
Either
2 NRTI + 1 NNRTI [Efavirenz (age 3 years) or Nevirapine (age < 3 years)]
OR
2 NRTI + 1 PI (Lopinavir/r)
Recommended 2 NRTI combinations: ZDV + 3TC; ZDV + ddI; ABC + 3TC;
Alternative 2 NRTI combinations : d4T + 3TC ; ddI + 3TC
For infants exposed to maternal or infant NVP or other NNRTIs used for
maternal treatment or PMTCT, start ART with PI (Lopinavir/r) + 2 NRTIs.
Not Recommended
Mono or dual therapy (except mother-to-child transmission prophylaxis
during neonatal period):
d4T + ZDV - pharmacologic and antiviral antagonism.
d4T + ddI - higher risk of lipodystrophy, peripheral neuropathy.
3TC + FTC - similar resistance patterns and no additive benefit.
405
INFECTIOUS DISEASE
When to change?
Treatment failure based on clinical, virologic and immunological parameters
e.g. deterioration of condition, unsuppressed/rebound viral load or
dropping of CD4 count/%.
Toxicity or intolerance of the current regimen
If due to toxicity or intolerance:
Choose drugs with toxicity profiles different from the current regimen.
Changing a single drug is permissible.
Avoid reducing dose below lower end of therapeutic range for drug.
If due to treatment failure:
Assess and review adherence
Preferable to change all ARV (or at least 2) to drugs that the patient has
not been exposed to before.
Choices are very limited! Do not add a drug to a failing regime.
Consider potential drug interactions with other medications
When changing therapy because of disease progression in a patient
with advanced disease, the patients quality of life must be considered.
Doing genotypic resistant testing will help to choose the appropriate
ARV, however, the test is not widely available in Malaysia
Consult an infectious diseases specialist before switching.
406
Nevirapine (NVP)
Efavirenz (EFZ)
Etravirine
Zidovudine (ZDV)
Stavudine(d4T)
Lamivudine (3TC)
Nelfinavir
Darunavir
Tenofovir (TDF)
Emtricitabine (FTC)
Fixed-dose combination tablets FDC)

ZDV + 3TC combined tablet (Combivir / Duovir)
d4T + 3TC +NVP combined tablet (SLN 30)
TDF + FTC combined tablet (Tenvir-EM)
Footnote:
Not all ARVs are suitable for use in children
Atazanavir (ATV)
Saquinavir
Lopinavir/Ritonavir
(Kaletra)
Indinavir (IDV)
Ritonavir
Protease inhibitors
(PI)
Abacavir (ABC)
Didanosine (ddI)
Non nucleoside reverse transcriptase

inhibitor (NNRTI)
Nucleoside /
Nucleotide reverse
transcriptase
inhibitors (NRTI)
Categories of antiretroviral drugs available in Malaysia
INFECTIOUS DISEASE
Raltegravir
Integrase inhibitors
Maraviroc
CCR5 antagonists
Enfurvitide
Fusion inhibitors
All infants regardless of clinical

symptoms,immune status and viral load
AIDS or significant HIV-related symptoms

(WHO Stage 3** or 4**)
OR
Asymptomatic or mild symptoms (WHO Stage
1 & 2) and CD4 < 25%
AIDS or significant HIV-related symptoms

(WHO Stage 3** or 4**)
OR
Asymptomatic or mild symptoms
(WHO Stage 1 & 2) and CD4 350 cells /mm3
<12 months
1-<5 years
5 years
Asymptomatic or mild
symptoms and
CD4 > 350cells/mm3
or
VL 100,000 copies /ml
Asymptomatic or mild
symptoms and
CD4 > 25 %
or
VL 100,000 copies /ml
Consider
Asymptomatic and
CD4 >350 cells/mm3
and
VL <100,000 copies /ml
Asymptomatic and
CD4 25 %
and
VL <100,000 copies /ml
Defer
* Before making the decision to initiate therapy, the provider should fully assess, discuss, and address issues associated with
adherence with the child and the caregiver
** Stabilize any opportunistic infection (OI) before initiating ART.
Initiate Treatment*
Age
When to start ARV ?
INFECTIOUS DISEASE
407
INFECTIOUS DISEASE
Antiretroviral drugs dosages and common side effects

Drug
Dosage
Side effects
Comments
Zidovudine
(ZDV)
180-240mg/m /dose,
bd
Neonate: 4mg/kg bd
(max. dose 300mg bd)
Anaemia,
neutropenia,
headache
Large volume
of syrup not
well tolerated in
older children
Didanosine
(ddI)
90-120mg/m2/dose,
bd
Diarrhoea, abdo
pain, peripheral
neuropathy
Ideally taken on
empty stomach
(1hr before or
2h after food)
Lamivudine 4mg/kg/dose, bd
(3TC)
Diarrhoea, abdo
pain;
pancreatitis
(rare)
Well tolerated
Use oral solution
within 1 month
of opening
Stavudine
(d4T)
1mg/kg/dose, bd
(max. dose 40mg bd)
Headache,
peripheral
neuropathy,
pancreatitis
(rare)
Capsule may
be opened and
sprinkle on food
or drinks
Abacavir
(ABC)
8 mg/kg/dose bd
(max. dose 300 mg bd)
Diarrhoea,
nausea , rash,
headache;
Hypersensitivity,
Steven-Johnson
(rare)
NEVER restart
ABC after
hypersensitivity
reaction (may
cause death)
Efavirenz
(EFZ)
350mg/m2 od
13-15kg 200mg
15-20kg 250mg
20-25kg 300mg
25-32kg 350mg
33 40kg 400mg
> 40kg 600mg od
Rash, headache,
insomnia
Inducer of
CYP3A4 hepatic
enzyme; so has
many drug
interactions
Capsules may
be opened and
added to food
Nevirapine
(NVP)
150-200mg/m2/day od
for 14 days,
then increase to
300-400mg/m2/day,
bd
Severe skin rash,

headache, diarrhea, nausea
Take with food

to increase
absorption and
reduce GI side
effects
Solution
contains 43%
alcohol and is
very bitter!
408
Antiretroviral drugs dosages and common side effects (continued)

Drug
Dosage
Side effects
Comments
350-450mg/m2/dose,
bd
Vomiting, nausea, headache,

diarrhoea;
hepatitis (rare)
Take with food

to increase
absorption and
reduce GI side
effects
Solution
contains 43%
alcohol and is
very bitter!
Kaletra
(Lopinavir/
ritonavir)
230/57.5mg/m2/
dose, bd
7 -14kg
12/3 mg/kg, bd
15-40kg
10/2.5mg/kg, bd
> 40kg
400/100mg, bd
Diarrhea,
asthenia
Low volume, but

a bitter taste.
Higher dose
used with NNRTI
Indinavir
(IDV)
500mg/m2/dose, tds
(max. dose 800mg tds)
Headache,
nausea,
abdominal pain,
hyperbilirubinemia,
renal stone
Use in older
children that can
swallow tablet;
Take on an
empty stomach
Advise to drink
more fluid
409
INFECTIOUS DISEASE
Ritonavir
(RTV)
INFECTIOUS DISEASE
Follow up
Usually every 3 - 4 months, if just commencing/switching HAART,
then every 2 weeks
Ask about medication:
Adherence (who, what, how and when of taking medications)
Side effects e.g. vomiting, abdominal pain, jaundice
Examine: Growth, head circumference, pallor, jaundice, oral thrush,
lipodystrophy syndrome (if on Stavudine &/or PI)
FBC, CD4 count, viral load 3-4 monthly, RFT, LFT, Ca/Po (amylase if on ddI)
6 monthly;
If on PI also do fasting lipid profiles and blood sugar yearly
Explore social, psychological, financial issues e.g. school, home
environment. Many children are orphans, live with relatives, adopted or
under NGOs care. Referral to social welfare often required.
Compliance - adherence to therapy strongly linked to these issues.
Other issues
HIV / AIDS is a notifiable disease. Notify health office within 1 week of
diagnosis.
Screen other family members for HIV.
Refer parents to Physician Clinic if they have HIV and are not on follow up.
Disclosure of diagnosis to the child (would-be teenager, sexual rights)
Be aware of Immune Reconstitution Inflammatory Syndrome (IRIS)
In this condition there is a paradoxical worsening of a known condition
(e.g. pulmonary TB or lymphadenitis) or the appearance of a new
condition after initiating ARV.
This is due to restored immunity to specific infectious or non-infectious
antigens.
410
Horizontal transmission within families

Despite sharing of household utensils, linen, clothes, personal hygiene
products; and daily interactions e.g. biting, kissing and other close contact,
repeated studies have failed to show transmission through contact with saliva, sweat, tears and urine (except with exposure to well defined body fluids
i.e. blood, semen, vaginal fluids).
It is important to stress that the following has not transmitted infection:
Casual contact with an infected person
Swimming pools
Droplets coughed or sneezed into the air
Toilet seats
Sharing of utensils such as cups and plates
Insects
Note: It is difficult to isolate the virus from urine and saliva of seropositive
children. So day care settings are not a risk. However, due to a theoretical
risk of direct inoculation by biting, aggressive children should not be sent to
day care. Teachers should be taught to handle cuts/grazes with care.
Treatment of an Exposure Site

Wash wounds, skin exposure sites with soap, water; flush mucous
membranes with water.
Notify supervisor; refer HCW to designated doctor as in hospital
needlestick injury protocol.
411
INFECTIOUS DISEASE
Guidelines for post exposure prophylaxis

Goal is to prevent HIV infection among those sustaining exposure, and provide information and support during the follow up until infection is
diagnosed or excluded with certainty.
Risk for occupational transmission of HIV to Health Care Workers (HCW)
Risk for HIV transmission after a percutaneous exposure to HIV infected
blood is 0.3%; risk after mucous membrane exposure is 0.1%.
Risk is dependent on :
Type, volume of body fluid involved
Type of exposure that has occurred
Viral load of the source patient
Disease stage
412
INFECTIOUS DISEASE
Chapter 79: Malaria

Uncomplicated Malaria
Symptomatic infection with malaria parasitaemia without signs of severity
or evidence (clinical or laboratory) of vital organ dysfunction.
Treatment
UNCOMPLICATED PLASMODIUM FALCIPARUM
First Line Treatment
Preferred Treatment
Artesunate/Mefloquine (Artequine)# Artemether/Lumefantrine (Riamet)+

Dosage according to body wt
10-20kg:*
Artesunate 50mg OD x 3d
Mefloquine 125mg OD x 3d
(Artequine pellets)
5 -14 kg:
D1: 1 tab stat then 1 tab again after
8 hours
D2-3: 1 tab BD
20-40kg:
Artesunate: 100mg OD x 3d
(Artequine 300/750)
15 24kg:
D1: 2 tabs stat then 2 tabs again
after 8 hours
D2-3: 2 tablets BD
>40kg:
Artesunate 200mg OD x 3d
(Artequine 600/1500)
25 35kg:
D1: 3 tabs stat then 3 tabs again
after 8 hours
D2-3: 3 tablets BD
>35kg:
D1: 4 tabs stat then again 4 tabs
after 8 hours
D2-3: 4 tabs BD
Add primaquine 0.75mg/kg single dose OD if gametocyte is present at any

time during treatment. Check G6PD before giving primaquine.
#. Avoid in children with epilepsy as well.
*Use Riamet for children below 10 kg as there is no artequine
formulations for this group of children.
+ Riamet should be administered with high fat diet preferably to be taken
with milk to enhance absorption.
Both Artequine and Riamet are Artemisinin-based Combination Treatment
(ACT)
413
INFECTIOUS DISEASE
Dosage according to body wt
Second-line treatment for treatment failure

(in uncomplicated Plasmodium Falciparum):
Recommended second-line treatment:
An alternative ACT is used (if Riamet was used in the first regimen,
use Artequine for treatment failure and vice-versa).
Artesunate 4mg/kg OD plus Clindamycin 10mg/kg/dose bd for a total
of 7 days.
Quinine 10mg salt/kg 8 hourly plus Clindamycin 10mg/kg/dose bd for
a total of 7 days.
Add primaquine 0.75mg base/kg single dose OD if gametocyte is present
at any time during treatment. Check G6PD before giving Primaquine.
Treatment for Plasmodium vivax, knowlesi or malariae.
Treatment for P. vivax
Treatment for P. knowlesi or malariae
Total Chloroquine 25mg base/kg

divided over 3 days
D1: 10 mg base/kg stat then 5 mg
base/kg 6 hours later
D2: 5 mg base/kg OD
D3: 5 mg base/kg OD
Total Chloroquine 25mg base/kg

divided over 3 days
D1: 10 mg base/kg stat then 5 mg
base/kg 6 hours later
D2: 5 mg base/kg OD
D3: 5 mg base/kg OD
INFECTIOUS DISEASE
PLUS
Primaquine* 0.5 mg base/kg daily
for 14 days
Note:
Chloroquine should be prescribed as mg base in the drug chart.
P. malariae and P. knowlesi do not form hypnozoites, hence do not require
radical cure with primaquine.
Treatment of chloroquine-resistant P. vivax, knowlesi or malariae.
ACT (Riamet or Artequine) should be used for relapse or chloroquine
resistant P. vivax. For radical cure in P. vivax, ACT must be combined
with supervised 14-day primaquine therapy.
Quinine 10mg salt/kg three times a day for 7 days is also effective for
chloroquine resistant P. vivax and this must be combined with
primaquine for antihypnozoite activity.
Mefloquine 15mg/kg single dose combined with primaquine have
been found to be effective.
Primaquine may cause life threatening haemolysis in individuals with G6PD
deficiency. G6PD testing is required before administration of Primaquine. For
mild to moderate G6PD deficiency, an intermittent Primaquine regimen of
0.75mg base/kg weekly for 8 weeks can be given under medical supervision.
In severe G6PD deficiency Primaquine is contraindicated.
Severe and complicated P. vivax, knowlesi or malariae should be managed as
for severe falciparum malaria (see next page).
414
TREATMENT OF SEVERE PLASMODIUM FALCIPARUM MALARIA.

Severe P. falciparum malaria
All Plasmodium species can potentially cause severe malaria, the
commonest being P falciparum.
Young children especially those aged below 5 years old are more prone
to develop severe or complicated malaria.
Recognising Severe P. falciparum malaria
Clinical features
Impaired consciousness or unarousable coma
Prostration
Failure to feed
Multiple convulsions (more than two episodes in 24 h)
Deep breathing, respiratory distress (acidotic breathing)
Circulatory collapse or shock
Clinical jaundice plus evidence of other vital organ dysfunction
Haemoglobinuria
Abnormal spontaneous bleeding
Laboratory findings
Hypoglycaemia (blood glucose < 2.2 mmol/l or < 40 mg/dl)
Metabolic acidosis (plasma bicarbonate < 15 mmol/l)
Severe anaemia (Hb < 5 g/dL, packed cell volume < 15%)
Haemoglobinuria
Hyperparasitaemia (> 2%/100 000/l in low intensity transmission areas or
> 5% or 250 000/l in areas of high stable malaria transmission intensity)
Hyperlactataemia (lactate > 5 mmol/l)
Renal impairment (serum creatinine > 265 mol/l).
415
INFECTIOUS DISEASE
Pulmonary oedema (radiological)
First-line Treatment
D1: IV Artesunate 2.4 mg/kg on admission, then rpt again at 12H & 24H
D2-7: IV Artesunate 2.4 mg/kg OD or switch to oral ACT
Parenteral Artesunate should be given for a minimum of 24h or until patient
is able to tolerate orally and thereafter to complete treatment with a complete course of oral ACT (Artequine or Riamet). Avoid using Artequine (Artesunate + Mefloquine) if patient presented initially with impaired consciousness as increased incidence of neuropsychiatric complications associated
with mefloquine following cerebral malaria have been reported.
IM Artesunate (same dose as IV) can be used in patients with difficult intravenous access.
Second-line Treatment
D1:IV Quinine loading 7mg salt/kg over 1 hour followed by
Infusion Quinine 10mg salt/kg over 4 hours then 10mg salt/kg q8hourly
OR
Loading 20mg salt/kg over 4 hours then IV 10mg salt/kg q8 hourly
(Dilute quinine in 250ml of D5% over 4 hours)
INFECTIOUS DISEASE
D2-7: IV Quinine 10mg salt/kg q8h

AND
Doxycycline (>8yrs) (3.5 mg/kg OD) OR Clindamycin (<8yrs)
(10 mg/kg/dose bd) given for 7 days
Quinine infusion rate should not exceed 5 mg salt/kg body weight per hour.
Change to Oral Quinine if able to tolerate orally.
(Maximum Quinine per dose = 600mg.) Reduce IV Quinine dose by one third
of total dose if unable to change to Oral Quinine after 48hours or in renal
failure or liver impairment.
416
Congenital malaria
Congenital malaria is rare. It is acquired from the mother prenatally or
perinatally, usually occurring in the newborn of a non-immune mother with
P. vivax or P. malariae infection, although it can be observed with any of the
human malarial species.. The first sign or symptom most commonly occur
between 10 and 30 days of age (range: 14hr to several months of age).
Signs and symptoms include fever, restlessness, drowsiness, pallor, jaundice, poor feeding, vomiting, diarrhea, cyanosis and hepatosplenomegaly.
It can mimic a sepsis like illness. Parasitemia in neonates within 7 days of
birth implies transplacental transmission. Vertical transmission may be as
high as 40% and is associated with anemia in the baby. Baby should been
screened for malaria and be treated if parasitemia is present.
Treatment:
Chloroquine, total dose of 25mg base/kg orally divided over 3 days
D1: 10 mg base/kg stat then 5 mg base/kg 6 hours later
D2: 5 mg base/kg OD
D3: 5 mg base/kg OD
Primaquine is not required for treatment as the tissue/ exo-erythrocytic
phase is absent in congenital malaria.
417
INFECTIOUS DISEASE
Mixed Malaria infections

Mixed malaria infections are not uncommon. ACTs are effective against all
malaria species and are the treatment of choice. Treatment with
Primaquine should be given to patients with confirmed P. vivax infection.
Malaria Chemoprophylaxis
Duration of Prophylaxis
Dosage
Atovaquone/
Proguanil
(Malarone)
Start 2 days before,

continue daily during
exposure and for 7 days
thereafter
Pediatric tablet of 62.5 mg

Atovaquone and 25 mg
Proguanil:
5-8 kg: 1/2 tablet daily
>8-10 kg: 3/4 tablet daily
>10-20 kg: 1 tablet daily
>20-30 kg: 2 tablets daily
>30-40 kg: 3 tablets daily
>40 kg: 1 adult tablet daily
Mefloquine
(Tablet with
250mg base,
274mg salt)
Start 2-3 weeks before,

continue weekly during
exposure and for 4 weeks
thereafter
<15 kg: 5mg of salt/kg;

15-19 kg: tab/wk;
20-30 kg: tab/wk;
31-45 kg: tab/wk;
>45 kg: 1 tab/wk
Doxycycline
(tab 100mg)
Start 2 days before,

continue daily during
exposure and for 4 weeks
thereafter
1.5mg base/kg once daily

(max. 100 mg)
<25kg or <8 yr: Do Not Use
25-35kg or 8-10 yr: 50mg
36-50kg or 11-13 yr: 75mg
>50kg or >14 yr: 100mg
INFECTIOUS DISEASE
Prophylaxis
418
Chapter 80: Tuberculosis

Definition
The presence of symptoms, signs and /or radiographic findings caused by
MTB complex (M. tuberculosis or M. bovis).
Disease may be pulmonary or extrapulmonary, (i.e. central nervous system
(CNS), disseminated (miliary), lymph node, bone & joint) or both.
Clinical features
Pulmonary disease is commonest. Symptoms include fever, cough,
weight loss, night sweats, respiratory distress.
Extrapulmonary disease may manifest as prolonged fever, apathy, weight
loss, enlarged lymph nodes (cervical, supraclavicular, axillary), headache,
vomiting, increasing drowsiness, infants may stop vocalising. Swellings and
loss of function may suggest bone, joint or spinal TB.
Phlyctenular conjuctivitis, erythema nodosum and pleural effusions are
considered hypersensitivity reactions of TB disease.
Diagnostic Work-up
Efforts should be made to collect clinical specimens for AFB smear,
cytopathology or histopathology, special stains and AFB culture to assure
confirmation of diagnosis and drug susceptibility.
If the source case is known, it is important to utilize information from the
source such as culture and susceptibility results to help guide therapy.
the diagnostic work-up for TB disease is tailored to the organ system most
likely affected.
419
INFECTIOUS DISEASE
Diagnosis of TB disease
Diagnosis in children is usually difficult. Features suggestive of tuberculosis are:
Recent contact with a person (usually adult) with active tuberculosis.
This constitutes one of the strongest evidence of TB in a child who has
symptoms and x ray abnormalities suggestive of TB.
Symptoms and signs suggestive of TB are as listed above. Infants are
more likely to have non specific symptoms like low-grade fever, cough,
weight loss, failure to thrive, and signs like wheezing, reduced breath
sounds, tachypnoea and occasionally frank respiratory distress.
Positive Mantoux test (>10 mm induration at 72 hours; tuberculin
strength of 10 IU PPD).
Suggestive chest X-ray:
Enlarged hilar Iymph nodes +/- localised obstructive emphysema
Persistent segmental collapse consolidation not responding to
conventional antibiotics.
Pleural effusion.
Calcification in Iymph nodes - usually develops > 6 mths after infection.
Laboratory tests
Presence of AFB on smears of clinical specimens and positive
histopathology or cytopathology on tissue specimens are highly
suggestive of TB. Isolation of M. tuberculosis by culture from
appropriate specimens is confirmatory.
The diagnostic work-up for TB disease is tailored to the organ system most
likely affected. The tests to consider include but are not limited to the
following:
Pulmonary TB
Chest radiograph
Early morning gastric aspirates
Sputum (if >12 years, able to expectorate sputum)
Pleural fluid or biopsy
Central Nervous System (CNS) TB
CSF for FEME , AFB smear and TB culture
CT head with contrast
TB adenitis
Excisional biopsy or fine needle aspirate
Abdominal TB
CT abdomen with contrast
Biopsy of mass / mesenteric lymph node
INFECTIOUS DISEASE
TB osteomyelitis
CT/MRI of affected limb
Biopsy of affected site
Miliary / Disseminated TB
As for pulmonary TB
Early morning urine
CSF
Note: These specimens should be sent for AFB smear and TB culture and
susceptibility testing.
Cytopathology or histopathology should be carried out on appropriate
specimens.
In addition, all children evaluated for TB disease require a chest x-ray to
rule out pulmonary
Abbreviations: AFB, acid fast bacilli; CT, computed tomography scan; CSF,
cerebrospinal fluid
420
Treatment of TB disease
Antimicrobial therapy for TB disease requires a multidrug treatment regimen.
Drug selection is dependent on drug susceptibility seen in the area the
TB is acquired, disease burden and exposure to previous TB medications,
as well as HIV prevalence.
Therapeutic choices are best made according to drug susceptibility of
the organism cultured from the patient.
Almost all recommended treatment regimens have 2 phases, an initial
intensive phase and a second continuation phase.
For any one patient, the treatment regimen would depend on the diagnosis
(pulmonary or extrapulmonary), severity and history of previous treatment.
Directly observed therapy is recommended for treatment of active disease.
Tuberculosis Chemotherapy in Children
Drug
Daily Dose
Intermittent Dose
(Thrice Weekly)
mg/kg/day Max dose (mg) mg/kg/day Max dose (mg)

Isoniazid
10-15
300
10
900
Rifampicin
Pyrazinamide
10-20
600
10
600
30-40
2000
Ethambutol
15-25
1000
30-50
2500
421
INFECTIOUS DISEASE
Short course therapy

This consists of a 6 month regimen, an initial 2 month intensive and
subsequent 4 month continuation phase. Short course therapy is suitable
for pulmonary tuberculosis and non-severe extrapulmonary tuberculosis.
Children with tuberculous meningitis , miliary and osteoarticular tuberculosis should be treated for 12 months. It is not recommended for drug
resistant TB.
The short course consists of:
Intensive Phase (2 months)
Daily Isoniazid, Rifampicin and Pyrazinamide
A 4th drug (Ethambutol) is added when initial drug resistance may be
present or for extensive disease eg. miliary TB or where prevalence of
HIV is high.
Maintenance Phase (4 months)
Isoniazid and rifampicin for the remaining 4 months.
This should be given daily (preferred).
WHO does not recommend intermittent regimens but a thrice weekly
regimen can be given in certain cases.
All intermittent dose regimens must be directly supervised.
INFECTIOUS DISEASE
Pulmonary TB and Less Severe Extrapulmonary TB

Recommended regimen is short course therapy as above.
Less severe extrapulmonary TB include lymph node disease, unilateral
pleural effusion, bone / joint (single site) excluding spine, and skin.
WHO Recommendations
Children living in settings where the prevalence of HIV is high or where
resistance to isoniazid is high, or both, with suspected or confirmed
pulmonary tuberculosis or peripheral lymphadenitis; or children with
extensive pulmonary disease living in settings of low HIV prevalence or
low isoniazid resistance, should be treated with a four-drug regimen
(HRZE) for 2 months followed by a two-drug regimen (HR) for 4 months.
Children with suspected or confirmed pulmonary tuberculosis or
tuberculous peripheral lymphadenitis who live in settings with low HIV
prevalence or low resistance to isoniazid and children who are
HIV-negative can be treated with a three-drug regimen (HRZ) for 2
months followed by a two-drug (HR) regimen for 4 months
Children with suspected or confirmed pulmonary tuberculosis or
tuberculous peripheral lymphadenitis living in settings with a high HIV
prevalence (or with confirmed HIV infection) should not be treated with
intermittent regimens.
Thrice-weekly regimens can be considered during the continuation
phase of treatment, for children known to be HIV-uninfected and living
in settings with well-established directly-observed therapy (DOT).
Streptomycin should not be used as part of first-line treatment regimens
for children with pulmonary tuberculosis or tuberculous peripheral
lymphadenitis.
Children with suspected or confirmed tuberculous meningitis as well as
those with suspected or confirmed osteoarticular tuberculosis should be
treated with a four-drug regimen (HRZE) for 2 months, followed by a
two-drug regimen (HR) for 10 months; the total duration of treatment
being 12 months.
422
Corticosteroids
Indicated for children with TB meningitis.
May be considered for children with pleural and pericardial effusion (to
hasten reabsorption of fluid), severe miliary disease (if hypoxic) and
endobronchial disease.
Steroids should be given only when accompanied by appropriate
antituberculous therapy.
Dosage: prednisolone 1-2mg/kg per day (max. 40 mg daily)
for first 3-4 week, then taper over 3-4 weeks.
Monitoring of Drug Toxicity
Indications for baseline and routine monitoring of serum transaminases
and bilirubin are recommended for:
Severe TB disease.
Clinical symptoms of hepatotoxicity.
Underlying hepatic disease.
Use of other hepatotoxic drugs (especially anticonvulsants).
HIV infection.
Routine testing of serum transaminases in healthy children with none of
the above risk factors is not necessary.
Children on Ethambutol should be monitored for visual acuity and colour
discrimination.
423
INFECTIOUS DISEASE
Breast-feeding and the Mother with Pulmonary Tuberculosis

Tuberculosis treatment in lactating mothers is safe as the amount of
drug ingested by the baby is minimal. Hence if the mother is already on
treatment and is non-infective, the baby can be breastfed.
Women who are receiving isoniazid and are breastfeeding should
receive pyridoxine.
If the mother is diagnosed to have active pulmonary TB and is still infective:
The newborn should be separated from the mother for at least one
week while the mother is being treated. Mother should wear a surgical
mask subsequently while breast feeding until she is asymptomatic and
her sputum is AFB-smear negative .
Breast feeding is best avoided during this period, however, expressed
breast milk can be given .
The infant should be evaluated for congenital TB. If this is excluded,
BCG is deferred and the baby should receive isoniazid for 3 months
and then tuberculin tested. If tuberculin negative and mother has been
adherent to treatment and non-infectious, isoniazid can be
discontinued and BCG given. If tuberculin positive, the infant should be
reassessed for TB disease and if disease is not present, isoniazid is
continued for total of 6 months and BCG given at the end of treatment.
Other close household contacts should be evaluated for TB.
Congenital TB is rare but should be suspected if the infant born to a
tuberculous mother fails to thrive or is symptomatic.
424
Abnormal
< 5 yrs age
INH
Chemoprophylaxis
Follow up
Treat as TB
Symptoms
suggestive of TB
5 yrs age
Asymptomatic
Normal
Chest X-ray
10 mm
Investigate
Further
Normal
Mantoux Test
Child (Contact)
Treat as
High Risk
BCG
No Scar
Check BCG
Chest X-ray
Abnormal
Asymptomatic
Symptomatic
< 10 mm
MANAGEMENT OF CHILDREN WITH A POSITIVE HISTORY OF CONTACT WITH TUBERCULOSIS
INFECTIOUS DISEASE
Follow up
Scar +
Chapter 81: BCG Lymphadenitis
Correct Technique to give BCG Vaccination

Needle:
Short (10mm) 26-27 gauge needle with a short bevel

using a BCG or insulin syringe
Site:
Left arm at Deltoid insertion
Dose:
0.05 mls for infants (< 1 year of age)

0.1 ml for children > 1 year.
Route:
Intradermal
Do not give BCG at other sites where the lymphatic drainage makes
subsequent lymphadenitis difficult to diagnose and dangerous (especially
on buttock where lymphatic drains to inguinal and deep aortic nodes).
425
INFECTIOUS DISEASE
Regional lymphadenopathy is one of the more common complications

of BCG vaccination and arises as a result of enlargement of ipsilateral
lymph nodes, principally involving the axillary node.
Differential diagnoses to consider are:
Pyogenic lymphadenitis.
Tuberculous lymphadenitis.
Non-tuberculous lymphadenitis.
The following are features suggestive of BCG lymphadenitis
History of BCG vaccination on the ipsilateral arm.
Onset usually 2 to 4 months after BCG vaccination, although it may
range from 2 weeks to 6 months. Almost all cases occur
within 24 months.
There is absence of fever or other constitutional symptoms.
Absent or minimal local tenderness over the lesion(s).
>95% of cases involve ipsilateral axillary lymph nodes, but supraclavicular
or cervical glands may be involved in isolation or in association with
axillary lymphadenopathy.
Only 1 to 2 discrete lymph nodes are enlarged (clinically palpable) in
the majority of cases. Involved lymph nodes are rarely matted together.
Two forms of lymphadenitis can be recognized, non-suppurative or simple
which may resolve spontaneously within a few weeks, or suppurative
which is marked by the appearance of fluctuation with erythema and
oedema of the overlying skin and increased pigmentation.
Once suppuration has occurred, the subsequent course is usually one of
spontaneous perforation, discharge and sinus formation. Healing
eventually takes place through cicatrization and closure of the sinus, the
process taking several months with possible scarring.
MANAGEMENT
Assessment
Careful history and examination are important to diagnose BCG adenitis
BCG lymphadenitis without suppuration (no fluctuation)
Drugs are not required.
Reassurance and follow-up Is advised.
Several controlled trials and a recent metaanalysis (Cochrane database)
have suggested that drugs such as antibiotics (e.g. erythromycin) or
antituberculous drugs neither hasten resolution nor prevent its
progression into suppuration.
BCG lymphadenitis with suppuration (fluctuation)
Needle aspiration is recommended. Usually one aspiration is effective,
but repeated aspirations may be needed for some patients.
Surgical excision may be needed when needle aspiration has failed (as
in the case of matted and multiloculated nodes) or when suppurative
nodes have already drained with sinus formation.
Surgical incision is not recommended.
INFECTIOUS DISEASE
Needle aspiration
Prevents spontaneous perforation and associated complications.
Shortens the duration of healing.
Is safe.
Persistent Lymphadenitis/ disseminated disease
In patients with large and persistent or recurrent lymphadenopathy,
constitutional symptoms, or failure to thrive, possibility of underlying
immunodeficency should be considered and investigated. Thus all infants
presenting with BCG lymphadenitis should be followed up till resolution.
426
Chapter 82: Dengue and Dengue Haemorrhagic Fever with Shock

Introduction
Dengue virus infections affect all age groups and produce a spectrum of
illness that ranges from asymptomatic to a mild or nonspecific viral illness
to severe and occasionally fatal disease.
The traditional 1997 World Health Organization classification of dengue
was recently reviewed and changed. The new classification encompass
various categories of dengue since dengue exists in continuum.
The term DHF used in previous classification put too much emphasis on
hemorrhage; However, the hallmark of severe dengue (and the
manifestation that should be addressed early) IS NOT HEMORRHAGE but
increased vascular permeability that lead to shock.
NEW SIMPLIFIED CLASSIFICATION OF DENGUE VIRAL INFECTIONS, WHO 2009
DENGUE VIRAL ILLNESS
DENGUE
SEVERE DENGUE
With Warning Signs
This new system divides dengue into TWO major categories of severity:
Dengue: with or without warning signs, and
Severe dengue.
Probable Dengue
Warning Signs
Lives in/travel to dengue endemic area
Intense abdominal pain

or tenderness
Persistent vomiting
Clinical fluid
accumulation.
Mucosal bleed
Lethargy, restlessness
Liver enlargement > 2cm
Laboratory:
Increase in hematocrit
with concurrent rapid
decrease in platelet
count.
Fever and 2 of the following:

Nausea, vomiting
Rash
Aches and pains
Positive Tourniquet test
Leucopenia
Any warning sign
Laboratory-confirmed dengue
(important when no sign of plasma leakage)
427
INFECTIOUS DISEASE
Severe Shock +/Respiratory Distress

Severe Haemorrhage
Organ Failure
(CNS/Liver)
No Warning Signs
Criteria for Severe Dengue

Severe plasma leakage with rising hematocrit leading to:
Shock
Fluid accumulation (pleural,ascitic)
Respiratory distress
Severe bleeding
Severe organ involvement
Liver: Elevated transaminases (AST or ALT1000)
CNS: Impaired consciousness, seizures.
INFECTIOUS DISEASE
Heart and other organ involvement

Management of Patients with Dengue
Dengue is a complex and unpredictable disease but success can be
achieved with mortality rates of 1% when care is given in simple and
inexpensive interventions provided they are given appropriately at the
right time.
The timing of intervention starts at frontline healthcare personnel
whether they are in A&E or OPD or even health clinics.
Early recognition of disease and careful monitoring of IV fluid is
important right from beginning.
The healthcare personnel involved in managing dengue cases day to day
need to familiarize themselves with the THREE main well demarcated
phases of dengue: febrile, critical; and recovery. (see next page)
In early phase of disease, it is difficult to differentiate dengue with other
childhood illness; therefore performing a tourniquet test with FBC at first
encounter would be useful to differentiate dengue from other illness.
Temporal relationship of fever cessation (defervescence) is important as
in DENGUE (unlike other viral illness) manifest its severity (leakage/
shock) when temperature seems to have declined.
428
PHASES OF DENGUE IN RELATION TO SYMPTOMS AND LABORATORY CHANGES
Days of Illness
Temperature
Potential Clinical
Issues
10
40
Dehydration,
febrile seizures
Shock and
Bleeding
Reabsorption,
fluid overload
pulmonary oedema
Organ Impairment
Laboratory
Changes
Serology and
Virology
Haematocrit
IgM/IgG
Viraemia
FEBRILE
CRITICAL
RECOVERY
Adapted from World Health Organization: Dengue Hemorrhagic Fever: Diagnosis,

Treatment, Prevention and Control. Third Edition. Geneva, WHO/TDR, 2009.
429
INFECTIOUS DISEASE
Phase of Illness
Platelets
Priorities during first encounter are:

1 - Establish whether patient has dengue
2 - Determine phase of illness
3 - Recognise warning signs and/or the presence of severe dengue if present.
Most patients with DF and DHF can be managed without hospitalization
provided they are alert, there are no warning signs or evidence of
abnormal bleeding, their oral intake and urine output are satisfactory,
and the caregiver is educated regarding fever control and avoiding non
steroidal anti-inflammatory agents and is familiar with the course of
illness.
A dengue information/home care card that emphasizes danger/warning
signs is important.
These patients need daily clinical and/or laboratory assessment by
trained doctors or nurses until the danger period has passed.
If dengue is suspected or confirmed, disease notification is mandatory.
INFECTIOUS DISEASE
Indication for Hospitalisation

Presence of warning signs.
Infants.
Children with co-morbid factors (diabetes, renal failure, immune
compromised state, hemoglobinopathies and obesity).
Social factors - living far from health facilities, transport issues.
The THREE major priorities of managing hospitalized patient with dengue in
the critical phase are:
A - Replacement of plasma losses.
B - Early recognition and treatment of hemorrhage.
C - Prevention of fluid overload.
Fluid therapy in a patient with dengue shock has two parts: initial, rapid
fluid boluses to reverse shock followed by titrated fluid volumes to
match ongoing losses.
However, for a patient who has warning signs of plasma leakage but is
not yet in shock, the initial fluid boluses may not be necessary.
430
VOLUME REPLACEMENT FLOWCHART FOR PATIENTS

WITH SEVERE DENGUE AND COMPENSATED SHOCK
Assess airway, breathing, obtain baseline hematocrit (HCT),
insert urinary catheter.
Commence fluid resuscitation with Normal Saline or Ringers lactate
at 5-10ml/kg over 1 hour for compensated shock.
Vitals stable,
HCT falls
Yes
IMPROVEMENT
HCT still high

Signs of shock
unresolved
Check HCT
HCT low
Consider occult
/overt bleeding
Administer 2nd bolus

of crystalloid/colloid,
10-20ml/kg over 1-2hrs
depending on SBP
Yes
Emergent transfusion
with whole blood/
packed red cells
IMPROVEMENT
No
Reduce fluids to 7-10ml/kg/hr

Yes
No
IMPROVEMENT
Vitals and urine output good
Stable hemodynamics, HCT

and general well being
DISCHARGE
Note:
Recurrence of clinical instability may be due to increased plasma leak
or new onset hemorrhage:
Review HCT
431
INFECTIOUS DISEASE
If hemodynamics and HCT are

stable, plan a gradually reducing
IV fluid (IVF) regimen with serial
monitoring of vitals, urine output
and 6-8 hourly HCT
IVF 5-7ml/kg/hr for 1-2 hours,
then
Reduce IVF to 3-5ml/kg/hr for
2-4hours.
Reduce IVF to 2-3ml/kg/hr for
2-4hours.
Continue to reduce if patient
improves.
Oral rehydration solutions may
suffice when vomiting subsides
and hemodynamic stable
A monitoring fluid regimen may
be required for 24-48 hrs,until
danger subsides.
If oral intake tolerated, can
reduce IVF more rapidly.
No
APPROACH TO CHILD WITH SEVERE DENGUE AND HYPOTENSION

Stabilize airway, breathing, high flow oxygen
Normal Saline / Ringers Lactate OR 6% Hetastarch / Gelatin
10-20ml/kg as 1-2 boluses over 15-30 min.
Obtain baseline hematocrit prior to fluids
Monitor vitals and hourly urine output with an indwelling catheter.
Correct hypoglycemia, hypocalcaemia, acidosis
Yes
INFECTIOUS DISEASE
If hemodynamics and hematocrit are

stable, plan a gradually
reducing IV fluid regimen.
IV Crystalloid 5-7ml/kg/hr for
1-2 hrs, then
Reduce to 3-5ml/kg/hr for 2-4 hrs
Reduce to 2-3ml/kg/hr for 2-4 hrs
Continue serial close clinical
monitoring and 2-4 hourly HCT
IMPROVEMENT
No
Review Baseline HCT
High Baseline HCT

Low Baseline HCT
Recurrence of clinical instability

may be due to increase plasma leak
or new onset hemorrhage:
Review HCT
If HCT decreases consider
transfusion with fresh whole
blood/packed red cells
If HCT increases consider repeat
fluid bolus or increase fluid
administration
Administer 2nd bolus

of Colloid,
10-20ml/kg over 1-2hrs
depending on SBP
Urgent fresh whole
blood/packed red
cells transfusion.
Evaluate for source
of blood loss.
Extra fluid may be required

for 36-48 hours
If oral intake tolerated,
can reduce IVF more rapidly
Yes
IMPROVEMENT
No
Check HCT
Stable hemodynamics, HCT

and general well being
Depending on HCT, repeat

colloid or blood (whole blood/
packed red cells) x 2-3 aliquots
as above until better
DISCHARGE
Remember!
The commonest causes of uncorrected shock/recurrence of shock are:
Inadequate replacement of plasma losses
Occult hemorrhage (Beware of procedure related bleeds)
432
APPROACH TO A CHILD WITH SEVERE DENGUE AND REFRACTORY SHOCK

(LATE PRESENTERS).
Stabilize airway, breathing, high flow oxygen
Normal Saline / Ringers Lactate OR 6% Hetastarch / Gelatin
10-20ml/kg as 1-2 boluses over 15-30 min.
Correct hypoglycemia, hypocalcaemia, acidosis
Monitor hemodynamics: Vitals, clinical indices of perfusion,
hourly urine output, 2nd-4th hourly Haematocrit (HCT)
Transfuse fresh whole blood/PRBC early if hypotension persists.
Remember!! The commonest
causes of uncorrected shock/
recurrence of shock are:
Inadequate replacement of
plasma losses
Occult hemorrhage (Beware
of procedure related bleeds)
Shock persist despite

40-60ml/kg of colloid/blood
HCT normal
Evaluate for unrecognized
morbidities: See Box A (next page)
Consider inotrope/pressor depending on SBP (see below),

consider Echocardiogram
CVP Low / HCT High
Respiratory Distress
Consider ventilation/nasal CPAP
Infuse fluids till CVP/HCT target
Consider inotrope/vasopressor
depending on SBP, serial ECHO
and clinical response.
Hemodynamics unstable
Hemodynamics improved
CVP normal or high with

continuing shock,
HCT normal.
Consider inotrope/
vasopressor depending on SBP
Dopamine/adrenaline
(SBP low)
Dobutamine
(SBP normal/high)
Check IAP.
Controlled Ascitic Fluid drainage
with great caution if IAP elevated
and shock refractory
Wean ventilation and inotrope/pressor.

Taper fluids gradually.
Beware of over-hydration during recovery.
SBP: Systolic blood pressure, PRBC: Packed red blood cell, CVP: Central venous
pressure, ECHO: Echocardiogram, IAP: Intra-abdominal pressure
433
INFECTIOUS DISEASE
Titrate crystalloids/colloids
with care till CVP/HCT target
Consider CVP with great care

if expertise available
BOX A: Unrecognized morbidities that may contribute to refractory

dengue shock.
Occult bleeds
Rx: Whole blood/PRBC transfusion
Co-Existing bacterial septic shock/Malaria/leptospira, etc
Rx: antibiotics/antimalarials, cardiovascular support, blood transfusion
Myocardial Dysfunction (systolic or diastolic)
Rx: Cardiovascular support, evaluate with ECHO if available
Positive pressure ventilation contributing to poor cardiac output
Rx: Titrated fluid and cardiovascular support
Elevated intra-abdominal pressure (IAP)
Rx: Cautious drainage
Wide-Spread Hypoxic-ischemic injury with terminal vasoplegic shock
No treatment effective
ECHO: Echocardiogram; IAP: Intra-abdominal pressure; Rx: Treatment
Volume replacement flowchart for patient with dengue with warning signs
INFECTIOUS DISEASE
Assess airway and breathing and obtain baseline HCT level.

Commence fluid resuscitation with normal saline/Ringers lactate
at 5-7ml/kg over 1-2 hours.
If hemodynamic and HCT are stable, plan a gradually reducing
IVF regime.
Titrate fluid on the basis of vital signs, clinical examination, urine
output (aim for 0.5ml-1ml/kg/hr),and serial HCT level.
IVF:5-7ml/kg/hr for 1-2 hours, then:
Reduce IVFs to 3-5ml/kg/hr for 2-4hours;
Reduce IVFs to 2-3ml/kg/hr for 2-4 hours;
Continue serial close monitoring and every 6-8hourly HCT level.
Oral rehydration solutions may suffice when vomiting subsides and
hemodynamic stabilize.
A monitored fluid regimen may be required for 24-48hours until
danger period subsides
HCT-hematocrit; IVF, intravenous fluid
434
Guidelines for reversing dengue shock while minimizing fluid overload

Severe dengue with compensated shock:
Stabilize airway and breathing, obtain baseline Hct level, initiate fluid
resuscitation with NS/RL at 5-10 mL/kg over 1 hr, and insert urine
catheter early.
Severe dengue with hypotension:
Stabilize airway and breathing, obtain baseline Hct level, initiate fluid
resuscitation with 1-2 boluses of 20 mL/kg NS/RL or synthetic colloid
over 15-20 mins until pulse is palpable, slow down fluid rates when
hemodynamics improve, and repeat second bolus of 10 mL/kg colloid
if shock persists and Hct level is still high.
Synthetic colloids may limit the severity of fluid overload in severe shock.
End points/goals for rapid fluid boluses:
Improvement in systolic BP, widening of pulse pressure, extremity
perfusion and the appearance of urine, and normalization of elevated
Hct level.
If baseline Hct level is low or normal in presence of shock,
hemorrhage likely to have worsened shock, transfuse fresh WB or
fresh PRBCs early.
Check Hct level 2-4 hourly for first 6 hrs and decrease frequency
as patient improves.
Goals for ongoing fluid titration:
Stable vital signs, serial Hct measurement showing gradual
normalization (if not bleeding), and low normal hourly urine output
are the most objective goals indicating adequate circulating volume;
adjust fluid rate downward when this is achieved.
Plasma leakage is intermittent even during the first 24 hrs after
the onset of shock; hence, fluid requirements are dynamic.
Targeting a minimally acceptable hourly urine output (0.5-1 mL/kg/hr)
is an effective and inexpensive monitoring modality that can signal
shock correction and minimize fluid overload.
A urine output of 1.52 mL/kg/hr should prompt reduction in fluid
infusion rates, provided hyperglycemia has been ruled out.
Separate maintenance fluids are not usually required; glucose and
potassium may be administered separately only if low.
435
INFECTIOUS DISEASE
After rapid fluid boluses, continue isotonic fluid titration to match

ongoing plasma leakage for 2448 hrs; if patient not vomiting and is
alert then aftershock correction with oral rehydration fluids may
suffice to match ongoing losses.
Guidelines for reversing dengue shock while minimizing fluid overload

(cont)
Hypotonic fluids can cause fluid overload; also, avoid glucosecontaining fluids, such as 1/2Glucose Normal Saline (GNS or I/2 GNS):
the resultant hyperglycemia can cause osmotic diuresis and delay
correction of hypovolemia. Tight glucose monitoring is recommended
to avoid hyper/hypoglycemia.
Commence early enteral feeds when vital signs are stable, usually
48 hrs after admission.
All invasive procedures (intubation, central lines, and arterial
cannulation) must be avoided; if essential, they must be performed by
the most experienced person. Orogastric tubes are preferred to
nasogastric tubes.
Significant hemorrhage mandates early fresh WB or fresh PRBC
transfusion; minimize/avoid transfusions of other blood products,
such as platelets and fresh-frozen plasma unless bleeding is
uncontrolled despite 23 aliquots of fresh WB or PRBCs.
INFECTIOUS DISEASE
NS/RL, normal saline/Ringers lactate; Hct, hematocrit; BP, blood pressure;

WB, whole; HCT-hematocrit; IVF, intravenous fluid GNS-glucose/normal
saline
** It is recommended that baseline hematocrit is obtained for all cases and
repeat hematocrit done following each fluid resuscitation to look at child s
response and to plan subsequent fluid administration. In PICU/HDW settings,
ABG machine can be used to look at HCT and in general wards, either, SPIN
PCV or FBC (sent to lab).
436
Discharge of Children with Dengue

Patients who are resuscitated from shock rapidly recover. Patients with
dengue hemorrhagic fever or dengue shock syndrome may be
discharged from the hospital when they meet the following criteria:
Afebrile for 24 hours without antipyretics.
Good appetite, clinically improved condition.
Adequate urine output.
Stable hematocrit level.
At least 48 hours since recovery from shock.
No respiratory distress.
Platelet count greater than 50,000 cells/L.
INFECTIOUS DISEASE
437
HOME CARE CARD FOR DENGUE PATIENTS

(Please take this card to your health facility for each visit)
What should be done?
Adequate bed rest.
Adequate fluid intake:
(>5 glasses for average-sized adults or accordingly in children)
Milk, fruit juice (caution with diabetes patient) and
isotonic electrolyte solution (ORS) and barley/rice water.
Plain water alone may cause electrolyte imbalance.
Take Paracetamol (not more than 4 grams per day for adults and
accordingly in children).
Tepid sponging.
Look for mosquito breeding places in and around the home and
eliminate them.
INFECTIOUS DISEASE
What should be avoided?

Do not take acetylsalicylic acid (Aspirin), mefenamic acid (Ponstan),
ibuprofen or other non-steroidal anti-inflammatory agents (NSAIDs),
or steroids.
If you are already taking these medications please consult your doctor.
Antibiotics are not necessary.
If any of following is observed, take the patient immediately to the nearest
hospital. These are warning signs for danger:
Bleeding:
Red spots or patches on the skin; bleeding from nose or gum,
vomiting blood; black-colored stools;
heavy menstruation/vaginal bleeding.
Frequent vomiting.
Severe abdominal pain.
Drowsiness, mental confusion or seizures.
Pale, cold or clammy hands and feet.
Difficulty in breathing.
Laboratory Monitoring
Visit (date)
White blood cells
Hematocrit
Platelets
438
Chapter 83: Diphteria

Introduction
Diphtheria is a clinical syndrome caused by Corynebacterium diphtheria.
Diphtheria can be classified based on site of disease: nasal diphtheria,
pharyngeal and tonsillar diphtheria, laryngeal or laryngotracheal
diphtheria, and cutaneous diphteria.
Diphtheria may cause systemic complication such as myocarditis
(mortality 50%), neuritis presenting as paralysis of soft palate and rarely
non-oliguric acute kidney injury.
Management of an Acute Case
All suspected and confirmed patients must be placed under strict
isolation until bacteriological clearance has been demonstrated after
completing treatment. Strict droplet precautions and hand hygiene must
be observed by healthcare workers.
Obtain specimens for culture from nose, throat, or any mucosal
membrane (tissue). Obtain specimen before the commencement of
antibiotic and specimen must be transported to the laboratory promptly.
Notify laboratory personnel as special tellurite enriched culture media
(Lofflers or Tindales) are needed.
Form of diphtheria
Dose ( units)
Route
Pharyngeal/Laryngeal disease of 48
hours or less
20,000 to 40,000
IM OR IV
Nasopharyngeal lesions
40,000 to 60,000
IM OR IV
Extensive disease of 3 or more days

durations or diffuse swelling of the neck
(bull-neck diphtheria)
80,000 to 120,000
IM OR IV
Cutaneous lesions
(not routinely given)
20,000 to 40,000
IM
439
INFECTIOUS DISEASE
Diphtheria Antitoxin (derived from horse serum)

Definitive treatment :
Early, single dose of IV infusion (over 60minutes) diphtheria antitoxin
should be administered on the basis of clinical diagnosis, even before
culture results are available.
Tests for hypersensitivity is recommended for IV administration.
Begin antibiotic therapy

Antibiotic is indicated to stop toxin production, treat localised infection, and
to prevent transmission of the organism to contacts. It is not a substitute for
antitoxin treatment.
REGIME
Penicillin
IV aqueous crystalline Penicillin 100,000 to 150,000 U/kg/day
in 4 divided doses, maximum 1.2 million U.
Or
IM procaine Penicillin 25,000 to 50,000 U/kg/day
(maximum 1.2million U, in 2 divided doses.
Change to oral Penicillin V 125-250mg QID once patient can take orally.
Total antibiotic duration for 14 days.
OR
Erythromycin
IV OR Oral 40-50 mg/kg/day, maximum 2g/day.
Total antibiotic duration for 14 days.
INFECTIOUS DISEASE
Immunization
Before discharge, to catch up diphtheria toxoid immunization as
diptheria infection does not necessary confer immunity
Management of close contacts and asymptomatic carriers
Refer to diphtheria protocol.
440
FLOW CHART FOR THE CASE MANAGEMENT AND INVESTIGATION

OF CLOSE CONTACTS IN DIPHTHERIA
Suspected or
Proven Diphtheria
Notify Health Department
Identify Close
Contacts
Institute strict isolation

Obtain nasal & pharyngeal swab culture
for C. dipththeria
Notify laboratory
Treatment with Diphtheria antitoxin
Begin antibiotic therapy (Penicillin)
Provide active immunization
None
Stop
Ensure daily surveillance of all contacts

The following 4 issues must be addressed:
Assess for signs

/symptoms for
at least 7 days
Negative
Stop
Antibiotic prophylaxis
Immunization status
<3 doses or
unknown
Avoid close contact with

inadequately vaccinated
persons.
Identify close contacts and
proceed with preventive
measures described for close
contacts of a case.
Repeat cultures a minimum
of 2 weeks after completion
of antibiotic to assure
eradication of the organism.
3 doses, last
dose > 5 yrs ago
3 doses, last
dose < 5 yrs ago
Administer immediate
booster dose of
diphtheria toxoid
Administer immediate
dose of diphtheria toxoid
and complete primary
series according to
schedule
441
Children who need

their 4th primary dose
or booster dose should
be vaccinated;
otherwise, vaccination
INFECTIOUS DISEASE
Positive
Obtain Cultures
nose, pharynx,
wounds
INFECTIOUS DISEASE
References
Section 10 Infectious Disease
Chapter 77 Sepsis and Septic Shock
1.Goldstein B, Giroir B, Randolph A, et al. International pediatric sepsis
consensus conference: Definitions for sepsis and organ dysfunction in
pediatrics. Pediatr Crit Care Med 2005;6:2-8
2.Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock. Crit
Care Med 2008;36:296-327
3.Warrick Butt. Septic Shock. Ped Clinics North Am 2001;48(3)
4.Surviving Sepsis Campaign: International guidelines for management of
severe sepsis and septic shock: 2008. Intensive Care Med (2008) 34:1760
5.APLS 5th edition.
Chapter 78 Pediatric HIV
1.Clinical Practice Guidelines: Management of HIV infection in children
(Malaysia, 2008).
2.World Health Organization. Antiretroviral therapy of HIV infection in infants
and children in resource-limited settings: towards universal access: recommendations for a public health approach (2006).
3.Sharland M, et al. PENTA guidelines for the use of antiretroviral therapy,
2004. HIV Medicine 2004; 5 (Suppl 2) :61-86.
4.The Working Group on Antiretroviral Therapy. Guidelines for the use of
antiretroviral agents in Paediatric HIV infection. Oct 26, 2006 http://www.
aidsinfo.nih.gov/guidelines/ (accessed on 9th December 2007)
Chapter 79 Malaria
1.Dondorp A, et al. Artesunate versus quinine in the treatment of severe
falciparum malaria in African children (AQUAMAT): on open-label, randomized trial; Lancet 2010 Nov 13:376: 1647-1657.
2.WHO Malaria treatment Guidelines 2010.
3.Metha PN. UK Malaria guidelines 2007.
4.Red Book 2009.
Chapter 80 Tuberculosis
1.RAPID ADVICE. Treatment of tuberculosis in Children WHO/HTM/
TB/2010.13.
Chapter 81 BCG Lymphadenitis
1.Singha A, Surjit S, Goraya S, Radhika S et al. The natural course of nonsuppurative Calmette-Guerin bacillus lymphadenitis. Pediatr Infect Dis J
2002:21:446-448
2.Goraya JS, Virdi VS. Treatment of Calmette-Guerin bacillus adenitis, a
metaanalysis. Pediatr Infect Dis J 2001;20:632-4 (also in Cochrane Database of Systematic Reviews 2004; Vol 2.)
3.Banani SA, Alborzi A. Needle aspiration for suppurative post-BCG adenitis.
Arch Dis Child 1994;71:446-7.
442
Chapter 82 Dengue
1.World Health Organization: Dengue Hemorrhagic Fever: Diagnosis, Treatment, Prevention and Control. Second Edition. Geneva. World Health
Organization, 1997.
2.Dengue Hemorrhagic Fever: Diagnosis, Treatment, Prevention and control.
Third Edition. A joint publication of the World Health organization (WHO)
and the Special programme for Research and Training in Tropical Diseases
(TDR), Geneva, 2009.
3.TDR: World Health Organization issues new dengue guidelines. Available
at http://apps.who.int/tdr/svc/publications/tdrnews/issue-85/tdr-briefly.
Accessed July 1,2010
4.Suchitra R, Niranjan K; Dengue hemorrhagic fever and shock syndromes.
Pediatr Crit Care Med 2011 Vol.12, No.1; 90-100.
INFECTIOUS DISEASE
443
444
INFECTIOUS DISEASE
Chapter 84: Atopic Dermatitis

Introduction
A chronic inflammatory itchy skin condition that usually develops
in early childhood and follows a remitting and relapsing course. It often
has a genetic component.
Leads to the breakdown of the skin barrier making the skin susceptible
to trigger factors, including irritants and allergens, which can make the
eczema worse.
Although not often thought of as a serious medical condition, it can have
a significant impact on quality of life.
Diagnostic criteria
Major features (must have 3) Hanifin and Rajka criteria
Pruritus
Typical morphology and distribution
Facial and extensor involvement in infancy, early childhood
Flexural lichenification and linearity by adolescence
Chronic or chronically relapsing dermatitis
Personal or family history of atopy
(asthma, allergic rhinoconjuctivitis, atopic dermatitis)
Minor / less specific features
Xerosis
Preauricular fissures
Icthyosis / palmar hyperlinearity / keratosis pilaris
DERMATOLOGY
Ig E reactivity
Hand/foot dermatitis
Cheilitis
Scalp dermatitis (cradle cap)
Susceptibility to cutaneous infection
(e.g. Staph. aureus and Herpes simplex virus)
Perifollicular accentuation (especially in pigmented races)
445
Triggering factors
Infection: Bacterial, viral or fungal
Emotional stress
Sweating and itching
Irritants: Hand washing soap, detergents
Extremes of weathers
Allergens
Food : egg, peanuts, milk, fish, soy, wheat.
Aeroallergens : house dust mite, pollen, animal dander and molds.
DERMATOLOGY
Management
Tailor the treatment of atopic dermatitis individually depending on:
The severity.
Patients understanding and expectation of the disease and the
treatment process.
Patients social circumstances.
Comprehensive patient education is paramount, and a good doctor-patient
relationship is essential for long-term successful management.
In an acute flare-up of atopic dermatitis, evaluate for the following factors:
Poor patient compliance
Secondary infection: bacterial (e.g. Staphylococcus aureus), viral
(e.g. herpes simplex virus)
Persistent contact irritant/allergen.
Physical trauma, scratching, friction, sweating and adverse
environmental factors.
Bath & Emollients
Baths soothe itching and removes crusting. They should be lukewarm
and limited to 10 minutes duration. Avoid soaps. Use soap substitute e.g.
aqueous cream or emulsifying ointment.
Moisturizers work to reduce dryness in the skin by trapping moisture.
Apply to normal and abnormal skin at least twice a day and more
frequently in severe cases.
Emollients are best applied after bath. Offer a choice of unperfumed
emollients and suitable to the childs needs and preferences,
e.g. Aqueous cream, Ung. Emulsificans, and vaseline.
N.B. Different classes of moisturizer are based on their mechanism of action,
including occlusives, humectants, emollients and protein rejuvenators. In
acute exudation form KMNO4 1:10,000 solutions or normal saline daps or
soaks are useful as mild disinfectant and desiccant.
446
USE STEPPED CARE PLAN APPROACH FOR TREATMENT MEASURES
Diagnosis (Follow
Diagnostic Criteria table)
Physical assessment
including psychological impact
Clear
Normal skin
No active
eczema
Emollients
Moderate
Areas of dry
skin
Frequent
itching
Areas of
redness
Areas of
excoriation
Emollients +
Mild potency
corticosteroids
for 7-14 days
Emollients +
Moderate
potency
corticosteroids
for 7-14 days
Wet wraps
Tacrolimus
Systemic
therapy
Phototherapy
Step treatment up or down according

to physical severity
447
Severe
Widespread
areas of dry skin
Intense itching
Widespread
areas of
redness
Areas of
excoriation,
bleeding, oozing
& lichenification
Emollients +
Moderate
potency
corticosteroids
for 7-14 days
Wet wraps
Tacrolimus
DERMATOLOGY
Mild
Areas of dry
skin
In-frequent
itching
Small areas of
redness
Topical Corticosteroids
Topical corticosteroid is an anti-inflammatory agent and the mainstay
of treatment for atopic eczema.
Topical steroid are often prescribed intermittently for short term reactive
treatment of acute flares and supplemented by emollients.
Choice depends on a balance between efficacy and side-effects.
The more potent the steroid, the more the side-effect.
Apply steroid cream once or twice daily.
Avoid sudden discontinuation to prevent rebound phenomenon.
Use milder steroids for face, flexures and scalp.
Amount of topical steroid to be used the finger tip (FTU) is convenient
way of indicating to patients how much of a topical steroid should be
applied to skin at any one site. 1 FTU is the amount of steroid expressed
from the tube to cover the length of the flexor aspect of the terminal
phalanx of the patients index finger.
Number of FTU required for the different body areas.
1 hand/foot/face
1 FTU
1 arm
3 FTU
1 leg
6 FTU
Front and back of trunk 14 FTU
Adverse effect results from prolonged use of potent topical steroids.
Local effects include skin atrophy, telangiectasia, purpura, striae, acne,
hirsutism and secondary infections. Systemic effects are adrenal axis
suppression, Cushing syndrome.
DERMATOLOGY
Steroid Potency
Potency of topical steroid
Topical steroid
Mild
Hydrocortisone cream/ointment 1%
Moderate
Bethametasone 0.025% (1:4dilution)

Eumovate (clobetasone butyrate)
Potent
Bethametasona 0.050%
Elomet (mometasone furoate)
Super potent
Dermovate (clobetasone propionate)
448
Systemic Therapy
Consist of:
Relief of pruritus
Treatment of secondary infection, and
Treatment of refractory cases
Relief of Pruritus
Do not routinely use oral antihistamines.
Offer a 1-month trial of a non-sedating antihistamine to:
Children with severe atopic eczema
Children with mild or moderate atopic eczema where there is severe
itching or urticaria.
If successful, treatment can be continued while symptoms persist.
Review every 3 months.
Offer a 714 day trial of a sedating antihistamine to children over 6
months during acute flares if sleep disturbance has a significant impact.
This can be repeated for subsequent flares if successful.
Refractory cases
Refractory cases do not response to conventional topical therapy and
have extensive eczema. Refer to a Dermatologist (who may use systemic
steroids, interferon, Cyclosporine A, Azathioprine or/and phototherapy).
Other Measures
Avoid woolen toys, clothes, bedding.
Reduce use of detergent (esp. biological).
BCG contraindicated till skin improves.
Swimming is useful (MUST apply moisturizer immediately upon
exiting pool).
Avoid Aggravating Factors.
449
DERMATOLOGY
Treatment of secondary infection

Secondary bacterial skin infection is common and may cause acute
exacerbation of eczema. Systemic antibiotics are necessary when there
is evidence of extensive infection.
Commonly Staphyloccus aureus.
Useful in exudation form where superinfection occurs.
Choice:
Oral cloxacillin 15mg/kg/day 6 hourly for 7-14 days, or
Oral Erythromycin / cephalosporin
Secondary infection can arise from Herpes simplex virus causing Eczema
Herpeticum. Treatment using antiviral e.g. Acyclovir may be necessary.
For Relapse
Check compliance.
Suspect secondary infection send for skin swab; start antibiotics.
Exclude scabies
For severe eczema, emollient and topical steroid can be applied under
occlusion with wet wrap. This involves the use of a layer of wet,
followed by a layer of dry Tubifast to the affected areas i.e. limbs and
trunk. The benefits are probably due to cooling by evaporation, relieving
pruritus, enhanced absorption of the topical steroid and physical
protection of the excoriation.
DERMATOLOGY
Prognosis
Tendency towards improvement throughout childhood.
Two third will clear by adolescence.
450
Chapter 85: Infantile Hemangioma

Infantile haemangiomas
Are the most common benign vascular tumour of infancy.
Clinical course is marked by rapid growth during early infancy followed
by slower growth, then gradual involution.
A minority cause functional impairment and even more cause
psychosocial distress.
Once resolved, a significant minority (20-40%) leave residual scarring,
fibrofatty tissue, telangiectases, and other skin changes which can have
a lasting psychological effect.
Rate of
haemangioma
growth
Static
growth
Slow
growth
Slow involution
Rapid
growth
12
18
24
36
48 60
Age in months
Clinical subtypes of haemangiomas:

Superficial haemangiomas are most common (50%-60%).
Deep haemangiomas (15%): bluish soft-tissue swellings without an
overlying superficial component.
Mixed haemangiomas (both a superficial and deep component)
(25%-35%).Multiple neonatal haemangiomatosis (15%-30%), consists
of multiple small lesions ranging from a few millimeters to 1 to 2 cm.
451
DERMATOLOGY
By 5 years of age, 50% of hemangiomas involute, 70% by age 7,

and 90% by age 9. 20-40% leave residual changes in the skin.
Approximately 10% require treatment, and < 1% are life threatening.
In 95% of cases, diagnosis can be established on the basis of history
and physical examination alone.
Typical-appearing vascular tumors.
History of the lesion seen at birth or shortly thereafter, with
characteristic proliferation in early infancy.
Management
Most hemangiomas require no treatment.
Active nonintervention is recommended in order to recognize those
that may require treatment quickly.
When treatment is undertaken, it is important that it be customized to
the individual patient, and that the possible physical, and psychological
complications be discussed in advance. Often, a multidisciplinary
approach is recommended.
Individualized depending on: size of the lesion(s), location, presence of
complications, age of the patient, and rate of growth or involution at
the time of evaluation. The potential risk(s) of treatment is carefully
weighed against the potential benefits.
DERMATOLOGY
No risk or low-risk haemangiomas

(Small, causing no functional impairment and unlikely to leave permanent
disfigurement)
Wait and watch policy (active non-intervention)
Patient education: Parent education may include the following:
The expected natural history without treatment
Demonstration whenever possible serial clinical photographs of
natural involution.
High-risk haemangiomas
(Large, prognostically poor location, likely to leave permanent disfigurement,
causing functional impairment, or involving extracutaneous structures)
Large cutaneous or visceral haemangiomas (particularly liver) can result
in high-output cardiac failure.
Haemangiomas on the special sites with associated complications are
given on the table below.
Special site
Complications
Beard
Airway compromise
Eye
Amblyopia, strabismus, astigmatism
Lumbar
Tethered cord, imperforate anus, renal anomalies, sacral

anomalies.
Facial
PHACES
452
Segmental haemangiomas, which cover a particular section or area of

skin, may be markers for underlying malformations or developmental
anomalies of the heart, blood vessels, or nervous system (PHACE and
PELVIS syndromes and lumbosacral haemangiomas) and, depending on
the severity of the associated anomaly, can result in increased morbidity
or mortality.
PHACE syndrome is posterior fossa structural brain abnormalities
(Dandy-Walker malformation and various forms of hypoplasia);
haemangiomas of the face, head, and neck (segmental, >5 cm in
diameter); arterial lesions (especially carotid, cerebral, and vertebral);
cardiac anomalies (coarctation of the aorta in addition to many other
structural anomalies); eye abnormalities; and, rarely, associated midline
ventral defects such as sternal cleft or supraumbilical raphe).
PELVIS syndrome is perineal haemangioma with any of the following:
external genital malformations, lipomyelomeningocele, vesicorenal
abnormalities, imperforate anus, and/or skin tags.
453
DERMATOLOGY
Treatment
The listed treatments may be used singly, in combination with each
other, or with a surgical modality.
MEDICAL
Propranolol is the first-line therapy; Patients are admitted to ward for
propranolol therapy for close monitoring of any adverse effects.
Dose: Start at 0.5 mg/kg/d in 2 to 3 divided doses orally and then
increased if tolerated. An increase in dose by 0.5 mg/kg/d is given until
the optimal therapeutic dose of 1.5 to 2 mg/kg/day.
Duration: Ranges from 2 - 15 months but it is proposed that propranolol
should be continued for 1 year or until the lesion involutes completely,
as rebound growth has been noted if treatment is withdrawn too early.
Propranolol is withdrawn by halving the dose for 2 weeks, then halving
again for 2 weeks, before stopping.
Adverse effects: hypotension, bradycardia, hypoglycemia,
bronchospasm, sleep disturbance, diarrhea, and hyperkalemia.
Systemic corticosteroids (indicated mainly during the growth period of
haemangiomas):
Prednisolone 2 to 4 mg/kg/ day in a single morning dose or divided
doses. Watch out for growth retardation, blood pressure elevation,
insulin resistance, and immunosuppression.
Intralesional corticosteroid therapy for small, bossed, facial hemangioma.
Triamcinolone, 20mg/ml, should be injected at low pressure, using a
3 ml syringe and 25-gauge needle. Do not exceed 3-5mg/kg per
procedure.
Periocular regions must be done only by an experienced ophthalmologist
as there is a risk of embolic occlusion of the retinal artery or oculomotor
nerve palsy.
Other systemic therapy:

Interferon alfa. Very effective but is used mainly as a second-line
therapy for lesions not responsive to corticosteroids because of the
possible severe neurotoxicity, including spastic diplegia.
Vincristine. Some consider this as second-line treatment for
corticosteroid resistant hemangiomas.
DERMATOLOGY
SURGERY
The benefits and risks of surgery must be weighed carefully, since
the scar may be worse than the results of spontaneous regression.
Surgery is especially good for small, pedunculated hemangiomas and
occasionally, in cases where there may be functional impairment. It is
usually used to repair residual cosmetic deformities.
Generally, it is recommended that a re-evaluation be done when the
child is 4 years old, in order to assess the potential benefit of excision.
454
Chapter 86: Scabies

Definition
Infestation caused by the mite Sarcoptes scabei. Any part of the body may be
affected, and transmission is by skin to skin contact.
Clinical features
Symptoms
Mites burrow into the skin where they lay eggs. The resulting offspring
crawl out onto the skin and makes new burrows.
Absorption of mite excrement into skin capillaries generates a
hypersensitivity reaction.
The main symptom, which takes 4-6 wks to develop, is generalised itch
especially at night.
Signs
Characteristic silvery lines may be seen in the skin where mites have
burrowed.
Classic sites: interdigital folds, wrists, elbows, umbilical area, genital area
and feet.
Nodular Scabies- papules or nodules seen at the site of mite infestation
often affect the scrotum, axillae, back, or feet of children.
Crusted or Norwegian Scabies- seen in young infants or
immunosuppressed patients. Widespread mite infestation causing a
hyperkeratotic and/or crusted generalized rash.
Management
General advice
Educate the parents about the condition and give clear written
information on applying the treatment.
Treat everyone in the household and close contacts.
Only allow the patient to go to school 24 hours after the start of
treatment.
Wash clothing and bedding in hot water or by dry cleaning. Clothing that
cannot be washed may be stored in a sealed plastic bag for three days.
The pruritis of scabies may be treated with diphenhydramine or other
anti-pruritic medication if necessary. The pruritis can persist up to three
weeks post treatment even if all mites are dead, and therefore it is not
an indication to retreat unless live mites are identified.
Any superimposed bacterial skin infection should be treated at the same
time as the scabies treatment.
455
DERMATOLOGY
Diagnosis
The clinical appearance is usually typical, but there is often diagnostic
confusion with other itching conditions such as eczema.
Scrapings taken from burrows examined under light microscopy may
reveal mites.
DERMATOLOGY
Treatment
Permetrin 5% lotion
Use for infants as young as 2 months and onwards. Children should be
supervised by an adult when applying lotion.
Massage the lotion into the skin from the head to the soles of the feet,
paying particular attention to the areas between the fingers and toes,
wrists, axillae, external genitalia and buttocks. Scabies rarely infects the
scalp of adults, although the hairline, neck, temple and forehead may
be involved in geriatric patients.
Reapply to the hands if washed off with soap and water within eight
hours of application.
Remove the lotion after 12 to 14 hours by washing (shower or bath).
Usually the infestation is cleared with a single application. However a
second application may be given seven to 10 days after the first if live
mites are demonstrated or new lesions appear.
Benzyl Benzoate (EBB)
Use 12.5% emulsion in children age 7-12 years; 25% emulsion if above
12 years and adults.
Apply nightly or every other night for a total of three applications.
It can irritate the skin and eyes, and has caused seizures when ingested.
Crotamiton (Eurax)
Apply 10% crotamiton cream to the entire body from the neck down,
nightly, for two nights. Wash it off 24 hours after the second application.
Sulfur (3-6% in calamine lotion)
Apply from the neck down, nightly, for three nights. Bathe before
reapplying and 24 hours after the last application. No controlled
studies of efficacy or safety are available.
Lindane (1% gamma benzene hexachloride) Lotion.
Apply to cool, dry skin. Apply the lotion sparingly from the chin to the
toes, with special attention to the hands, feet, web spaces, beneath
the fingernails and skin creases. Wash off after eight to 12 hours.
95% of patients require only one treatment. Re-treat only if
i. Infestations with live mites is confirmed after one week.
ii. Itching persist three weeks after the first treatment.
456
Chapter 87: Steven Johnson Syndrome

Definitions
STEVEN JOHNSON SYNDROME (SJS)
Severe erosions of at least two mucosal surfaces with extensive necrosis
of lips and mouth, and a purulent conjunctivitis.
Epidermal detachment may occur in SJS, but less than 10% of the body
surface area is involved.
Morbidity with this disease is high, and can include photophobia,
burning eyes, visual impairment and blindness.
TOXIC EPIDERMAL NECROLYSIS (TEN)
Severe exfoliative disease associated with systemic reaction characterized
by rapid onset of widespread erythema and epidermal necrolysis.
Involves more than 30% loss of epidermis.
Aim of treatment: To remove the cause and prevent complications
Aetiology in Steven Johnson Syndrome / TEN

Drugs
Antibiotics: Sulphonamides, amoxycillin, ampicillin, ethambutol, isoniazid
Anticonvulsants: Phenobarbitone, carbamazepine, phenytoin
Non-Steroidal Anti-Inflammatory Drugs: Phenylbutazone, salicylates
Infection
Virus: herpes simplex, enteroviruses, adenoviruses, measles, mumps
Bacteria: Streptococcus, Salmonella typhi, Mycoplasma pneumoniae
457
DERMATOLOGY
Salient features
Acute prodromal flu-like symptoms, fever, conjunctivitis and malaise.
Skin tenderness, morbilliform to diffuse or macular erythema target
lesions, vesicles progressing to bullae. Blisters on the face, and upper
trunk, then exfoliation with wrinkled skin which peels off by light stroking
(Nikolksy sign).
Buccal mucosa involvement may precede skin lesion by up to 3 days
in 30% of cases.
Less commonly the genital areas, perianal area, nasal and conjuctival
mucosa.
In the gastrointestinal tract, esophageal sloughing is very common,
and can cause bleeding and diarrhoea.
In the respiratory tract, tracheobronchial erosions can lead to
hyperventilation, interstitial oedema, and acute respiratory disease
syndrome.
Skin biopsy of TEN - Extensive eosinophilic necrosis of epidermis with
surabasal cleavage plane.
Renal profile raised blood urea, hyperkalaemia and creatinine.
Glucose - hypoglycaemia.
DERMATOLOGY
Management
Supportive Care
Admit to isolation room where possible.
May need IV fluid resuscitation for shock.
Good nursing care (Barrier Nursing and hand washing).
Use of air fluidized bed, avoid bed sores.
Adequate nutrition nasogastric tubes, IV lines, parenteral nutrition if
severe mucosal involvement.
Specific treatment
Eliminate suspected offending drugs
IV Immunoglobulins at a dose of 0.4 Gm/kg/per day for 5 days. IVIG is a safe
and effective in treatment for SJS/TEN in children. It arrests the progression of
the disease and helps complete re-epithelialization of lesions.
Monitoring
Maintenance of body temperature. Avoid excessive cooling or overheating.
Careful monitoring of fluids and electrolytes BP/PR.
Intake / output charts, daily weighing and renal profile.
Prevent Complications
Skin care
Cultures of skin, mucocutaneous erosions, tips of Foleys catheter.
Treat infections with appropriate antibiotics.
Topical antiseptic preparations: saline wash followed by topical bacitracin or
10% Chlorhexidine wash.
Dressing of denuded areas with paraffin gauze / soffra-tulle.
Surgery may be needed to remove necrotic epidermis.
Eye care
Frequent eye assessment.
Antibiotic or antiseptic eye drops 2 hourly.
Synechiea should be disrupted.
Oral care
Good oral hygiene aimed at early restoration of normal feeds.
458
References
Section 11 Dermatology
Chapter 84 Atopic Dermatitis
1.NICE guideline for treatment of Atopic Dermatitis in children from birth to
12 years old. 2007
2.Topical Treatment with Glucocorticoids. M. Kerscher, S. Williams, P.
Lehmann. J Am Acad Dermatol 2006
3.Atopic Dermatitis. Thomas Bieber, M.D., Ph.D. Ann Dermatol 2010
4.Atopic dermatitis. Eric L. Simpson, MD, and Jon M. Hanifin, MD. J Am Acad
Dermatol 2005.
Chapter 85 Infantile Hemangioma
1.Guidelines of care for hemangiomas of infancy. Ilona J. Frieden, MD, Chairman, Lawrence E Eichenfield, MD, Nancy B.Esterly, MD, Roy Geronemus,
MD, Susan B. Mallory, MD. J Am Acad Dermatol 1997
2.Infantile hemangiomas. Anna L. Bruckner, MD, & Ilona J. Frieden, MD. J Am
Acad Dermatol 2006.
3.Novel Strategies for Managing Infantile Hemangiomas: A Review Silvan
Azzopardi, & Thomas Christian Wright. Ann Plast Surg 2011.
4.A Randomized Controlled Trial of Propranolol for Infantile Hemangiomas.
Marcia Hogeling, Susan Adams and Orli Wargon Pediatrics 2011.
Chapter 86 Scabies
1.Communicable Disease Management Protocol Scabies November 2001
2.United Kingdom National Guideline on the Management of Scabies infestation (2007).
DERMATOLOGY
459
460
DERMATOLOGY
Chapter 88: Inborn errors metabolism (IEM): Approach to

Diagnosis and Early Management in a Sick Child
Introduction
Over 500 human diseases due to IEM are now recognized and a
significant number of them are amenable to treatment.
IEMs may present as
An acute metabolic emergency in a sick child.
Chronic problems involving either single or multiple organs, either
recurrent or progressive, or permanent.
It will become ever more important to initiate a simple method of clinical
screening by first-line paediatric doctors with the goal Do not miss a
treatable disorder.
461
METABOLIC
Classification
From a therapeutic perspective, IEMs can be divided into 5 useful groups:
Group
Diseases
Diagnosis and Treatment
Disorders that give Aminoacidopathies
Readily diagnosed
rise to acute or
(MSUD, tyrosinaemia,
through basic IEM
chronic intoxication PKU, homocystinuria),
investigations: blood
most organic acidurias
gases, glucose, lactate,
(methylmalonic, proammonia, plasma
pionic, isovaleric, etc.),
amino acids, urinary
urea cycle defects, sugar
organic acids and
intolerances (galactosaeacylcarnitine profile
mia, hereditary fructose
Specific emergency
intolerance), defects
and long term treatin long-chain fatty acid
ment available for most
oxidation
diseases.
Disorders with
Glycogen storage
Persistent/recurrent
reduced fasting
diseases, disorders of
hypoglycemia is the first
tolerance
gluconeogenesis, fatty
clue to diagnosis.
acid oxidation disorders, Specific emergency
disorders of ketogenesis/
and long term
ketolysis
treatment available for
most diseases.
Neurotransmitter
Nonketotic hyperglycine- Diagnosis requires
defects and related mia, serine deficiency,
specialized CSF
disorders
disorders of biogenic
analysis.
amine metabolism, disor- Some are treatable.
ders of GABA metabolism, antiquitin deficiency
(pyridoxine dependent
epilepsy), pyridoxal phosphate deficiency, GLUT1
deficiency
METABOLIC
Classification (continued)
Group
Diseases
Disorders of the
Lysosomal storage disorbiosynthesis and
ders, peroxisomal disorbreakdown of
ders, congenital disorders
complex molecules of glycosylation, sterol
biosynthesis disorders,
purine and pyrimidine
disorders
Mitochondrial
Respiratory chain endisorders
zymes deficiencies,
PDHc deficiency, pyruvate
carboxylase deficiency
Diagnosis and Treatment

Specialized diagnostic
tests required.
Very few are
treatable.
Persistent lactate
acidemia is often the
first clue to diagnosis.
Mostly supportive
care.
Screening for treatable IEM in a sick child

In an acutely ill child, IEM should be considered a differential diagnosis
along with other diagnoses:
In all neonates with unexplained, overwhelming, or progressive disease
particularly after a normal pregnancy or birth, but deteriorates after
feeding.
In all children with acute encephalopathy, particularly preceded by
vomiting, fever or fasting.
In all children with unexplained symptoms and signs of metabolic
acidosis, hypoglycaemia, acute liver failure or Reye-like syndrome.
The aim is targeted to pick up treatable diseases in Group 1 and 2 as
early as possible.
Many clues may be gained from a detailed history and physical examination
Unexplained death among sibling(s) due to sepsis or SIDS.
Unexplained disorders in other family members (HELLP syndrome,
progressive neurological disease).
Consanguinity.
Deterioration after a symptom-free interval in a newborn.
Unusual smell - burn sugar (MSUD), sweaty feet (isovaleric acidemia).
Actively investigate for IEM in any acutely ill child of unknown aetiology,
as early as possible during the course of illness. According to the clinical
situation, basic and special metabolic investigations must be initiated in
parallel.
462
Basic metabolic investigations 1
Special metabolic investigations 1
Ammonia2
Acylcarnitines (Dried blood spot on

Guthrie card )
Glucose
Lactate2
Blood gases
Must be
included in
work-up of an
acutely ill child
of unknown
aetiology 4
Ketostix (urine)
Blood count, electrolytes, ALT,
AST, CK, creatinine, urea, uric acid,
coagulation
Amino acids (plasma or serum)3

Organic acids (urine)
Orotate (urine): if suspected urea
cycle defects
[Send to the metabolic lab immediately ( eg by courier) especially when
the basic metabolic investigations
are abnormal, particularly if there
is hyperammonemia or persistent
ketoacidosis]
1, Will pick up most diseases from Group 1 and 2, and some diseases in
other groups (which often require more specialized tests)
2, Send immediately (within 15 minutes) to lab with ice
3, Urinary amino acids are the least useful as they reflect urinary thresh
old. Their true value is only in the diagnosis of specific renal tubular
transport disorders (eg cystinuria ).
4, Routine analysis of pyruvate is not indicated.
Lactate
Blood: < 2.4mmol/L

CSF: < 2.0mmol/L
463
Note
1. False elevations are
common if blood sample
is not analyzed
immediately.
2. Secondary elevated
may occur in severe liver
failure.
1. Normal: renal / intestinal
loss of bicarbonate.
2. Increased: organic acids,
lactate, ketones.
False elevations are common due to poor collection
or handling techniques
METABOLIC
Useful normal/abnormal values

Basic tests
Values
Ammonia
Neonates
Healthy: <110mol/L
Sick: up to 180mol/L
Suspect IEM: >200mol/L
After the Neonatal period
Normal: 50-80 mol/L
Suspect IEM: >100mol/L
Anion Gap
Calculation
[Na+] + [K+] [Cl-] [HCO3-]
Normal :- 15-20mmol/L
464
Organic acidemias
MSUD
GSD
FAOD
Mitochondrial
disorders
Urea cycle defects
Tyrosinemia I
Ammonia
Disorders
N-
, N,
Glucose
Lactate
DisordersTypical basic laboratory constellations
METABOLIC
N-
pH
N,
Ketonuria
Liver failure, -fetoprotein,

Renal fanconi
alanine
CK
triglyceride, uric acid, ALT
anion gap, neutropenia,

thrombocytopenia
Others
Early contact to the metabolic laboratory will help target investigations, avoid
unnecessary tests, and speed up processing of samples and reporting of
results.
Emergency management of a sick child suspected IEM
In the critically ill and highly suspicious patient, treatment must be
started immediately, in parallel with laboratory investigations.
This is especially important for Group 1 diseases
465
METABOLIC
STEP 1
If the basic metabolic test results and the clinical findings indicate a disorder
causing acute endogenous intoxication due to disorder of protein
metabolism (Group 1 diseases - UCD, organic acidurias or MSUD), therapy
must be intensified even without knowledge of the definitive diagnosis.
Anabolism must be promoted and detoxification measures must be initiated.
Immediately stops protein intake. However, the maximum duration
without protein is 48 hours.
Correct hypoglycaemia and metabolic acidosis.
Reduce catabolism by providing adequate calories.
Aim 120kcal/kg/day, achieved by
IV Glucose infusion (D10%, 15% or 20% with appropriate electrolytes).
Intralipid 20% at 2-3g/kg/day (Except when a Fatty Acid Oxidation
Disorder is suspected).
Protein-free formula for oral feeding [eg Pro-phree (Ross), Calo-Lipid
(ComidaMed), basic-p (milupa)].
Anticipate complications
Hyperglycemia/glucosuria - Add IV Insulin 0.05U/kg/hr if blood glucose
> 15mmol/L to prevent calories loss.
Fluid overload: IV Frusemide 0.5-1mg stat doses.
Electrolytes imbalances: titrate serum Na+ and K+.
Protein malnutrition add IV Vamin or oral natural protein (eg milk)
after 48 hours, starts at 0.5g/kg/day.
Carry out detoxifying measures depending on the clinical and laboratory
findings.
Continue all conventional supportive/intensive care
Respiratory insufficiency: artificial ventilation.
Septicaemia: antibiotics.
Cerebral convulsions: anticonvulsants.
Cerebral edema: avoid hypotonic fluid overload, hyperventilation,
Mannitol, Frusemide.
Early central line.
Consult metabolic specialist.
Specific detoxification measures for hyperammonemia

Hyperammonemia due to Urea cycle defects
Anti-hyperammonemic drugs cocktail
Loading dose
IV Sodium benzoate 250mg/kg
IV Sodium phenylbutyrate 250mg/kg
IV L-Arginine 250mg/kg
(mix together in D10% to a total volume of 50mls, infuse over 90 min)
Maintanence dose
Same dilution as above but infuse over 24 hours
Indication:
1. NH3 > 200mol/L
2. Symptomatic (encephalopathic)
Dialysis
Hemodialysis or hemofiltration if available.
If not, peritoneal dialysis is the alternative.
Exchange transfusion is not effective.
(Method of choice depends on local availability, experience of medical staff)
Indication:
1. NH3 > 400mol/L
2. Symptomatic (encephalopathic)
3.Inadequate reduction/raising NH3 despite drugs cocktail
Hyperammonemia due to Organic aciduria
METABOLIC
Give oral Carglumic acid, 100 - 250mg/kg/day in divided doses

Other specific Detoxification measures
Disorder
Pharmacological
MSUD
nil
Organic acidurias
Carnitine
100mg/kg/day
Tyrosinemia type 1 NTBC 1-2mg/kg/day

Cobalamin
IM Hydroxocobalamin
disorders
1mg daily
466
Non-pharmacological
Dialysis. Indication:
1. Leucine >1,500mol/L
2. Symptomatic
(encephalopathic)
Dialysis. Indication:
1. intractable metabolic
acidosis
2. Symptomatic
(encephalopathic)
Nil
Nil
STEP 2
Adaptation and specification of therapy according to the results of the
special metabolic investigations/definitive diagnosis.
For protein metabolism disorders, the long term diet is consists of
Specific precursor free formula
Natural protein (breast milk or infant formula). This is gradually added
when child is improving to meet the daily requirement of protein and
calories for optimal growth.
Other long term treatment includes
Oral anti-hyperammonemic drugs cocktail (for urea cycle defects)
Carnitine (for organic acidemias)
Vitamin therapy in vitamin-dependent disorders (eg Vit B12-responsive
methylmalonic acidemia and cobalamine disorders).
Transfer the child to a metabolic centre for optimisation of therapy is
often necessary at this stage in order to plan for the long term nutritional
management according to childs protein tolerance
467
METABOLIC
STEP 3
Be prepared for future decompensation
Clear instruction to parents.
Phone support for parents.
Provide a letter that includes the emergency management protocol to
be kept by parents.
Role of first-line paediatric doctors
1. Help in early diagnosis
2. Help in initial management and stabilization of patient
3. Help in long term care (shared-care with metabolic specialist)
Rapid action when child is in catabolic stress (febrile illness, surgery, etc)
Adequate hydration and temporary adjustment in nutrition
management and pharmacotherapy according to emergency protocol
will prevent catastrophic metabolic decompensation.
Key points in managing acute metabolic decompensation in children with

known disorders of protein metabolism ( UCD, MSUD, Organic acidurias)
Consult metabolic specialist if you are uncertain.
Perform clinical and biochemical assessment to determine the severity.
Stop the natural protein but continue the special formula as tolerated
(PO or per NG tube/perfusor).
IV Glucose and Intralipid to achieve total calories 120kcal/kg/day.
IV antiemetic (e.g. Kytril) for nausea or vomiting.
Management of hypoglycemia, hyperammonemia and metabolic
acidosis as above.
Gradually re-introduce natural protein after 24-48 hours.
Acute intoxication due to classical galactossemia (Group 1)
Clinical presentation: progressive liver dysfunction after start of milk
feeds, cataract.
Diagnosis: dry blood spots (Guthrie card) for galatose and
galactose-1-P uridyltransferase (GALT) measurement
Treatment: lactose-free infant formula
Neonatal intrahepatic cholestasis caused by Citrin Deficiency (NICCD)
may mimic classical Galactosemia.
METABOLIC
Disorders with reduced fasting tolerance (Group 2)

Clinical presentation: recurrent hypoglycemia hepatomegaly.
Treatment: - 10% glucose infusion, 120- 150ml/kg/day.
This therapy is usually sufficient in acute phase.
Long term: avoid fasting, frequent meals, nocturnal continuous feeding,
uncooked cornstarch (older children).
(refer Chapter on Hypoglycaemia)
Neurotransmitter defects and related disorders (Group 3)
This group should be considered in children with neurological problems
when basic metabolic investigations are normal.
Diagnosis usually requires investigations of the CSF. Considers this in
Severe epileptic encephalopathy starting before birth or soon thereafter,
especially if there is myoclonic component.
Symptoms of dopamine deficiency: oculogyric crises, hypokinesia,
dystonia, truncal hypotonia/limb hypertonia.
Presence of vanillactate and 4(OH) Butyrate in urine.
Unexplained hyperprolactinemia.
468
Disorders of the biosynthesis and breakdown of

complex molecules (Group 4)
Disorders in this group
Typically show slowly progressive clinical symptoms and are less likely to
cause acute metabolic crises.
Are not usually recognised by basic metabolic analyses but require
specific investigations for their diagnosis.
Lysosomal disorders:
(1) screening tests: urine glycoaminoglycans (mucopolysacchardioses),
urine oligosaccharides (oligosaccharidoses).
(2) definitive diagnosis: enzyme assay, DNA tests.
Peroxisomal disorders: plasma very long chain fatty acids (VLCFA).
Congenital disorders of glycosylation: serum transferrin isoform analysis.
Mitochondrial disorders (Group 5)
Clinical: suspect in unexplained multi-systemic disorders especially if
involve neuromuscular system.
Inheritance:
(1) mtDNA defects sporadic, maternal.
(2) nuclear gene defects mostly autosomal recessive.
Laboratory markers: persistently elevated blood/CSF lactate and
plasma alanine.
Diagnosis: respiratory enzyme assay in muscle biopsy/skin fibroblast,
targeted mtDNA mutation study etc (discuss with metabolic specialist).
Treatment: ensure adequate nutrition, treat fever/seizure/epilepsy
efficiently, avoid drugs that may inhibit the respiratory chain
(e.g. valproate, tetracycline, chloramphenicol and barbiturates).
Use of vitamins and cofactors is controversial/insufficient evidence.
Useful websites: http://www.mitosoc.org/, www.umdf.org/
METABOLIC
469
METABOLIC
Management of a asymptomatic newborn but at risk of having potentially

treatable IEM
Ideally the diagnosis of treatable IEM should be made before a child
becomes symptomatic and this may be possible through newborn
screening for high risk newborns.
A previous child in the family has had an IEM.
Multiple unexplained early neonatal death.
Mother has HELLP/fatty liver disease during pregnancy
(HELLP Haemolytic Anaemia, Elevated Liver Enzymes, Low Platelets).
Affected babies may need to be transferred in utero or soon after delivery
to a centre with facilities to diagnose and manage IEM.
Admit to nursery for observation.
If potential diagnosis is known: screens for the specific condition,
e.g. urea cycle disorders monitor NH3 and plasma amino acid, MSUD
monitor plasma leucine (amino acids).
If potential diagnosis is unknown: Guthrie cards, collect on 2nd or 3rd
day after feeding, mails it immediately and get result as soon as possible.
Other essential laboratory monitoring: NH3, VBG, blood glucose. Please
discuss with metabolic specialist.
To prevent decompensation before babys status is known: provide
enough calories (oral/IV), may need to restrict protein especially if index
case presented very early (before 1 week). Protein-free formula should
be given initially and small amount of protein (eg breast milk) is gradually
introduced after 48 hours depending on babys clinical status.
If the index patient presented after the first week, the new baby should
be given the minimum safe level of protein intake from birth
(approximately 1.5 g/kg/day). Breast feeding should be allowed under
these circumstances with top-up feeds of a low protein formula to minimise catabolism.
Get the metabolic tests result as soon as possible to decide weather
the baby is affected or not.
470
Chapter 89: Investigating Inborn errors metabolism (IEM)

in a Child with Chronic Symptoms
Introduction
IEMs may cause variable and chronic disease or organ dysfunction in a child
resulting in global developmental delay, epileptic encephalopathy, movement
disorders, (cardio)-myopathy or liver disease. Thus it should be considered as
an important differential diagnosis in these disorders.
The first priority is to diagnose treatable conditions. However, making
diagnosis of non-treatable conditions is also important for prognostication, to
help the child find support and services, genetic counselling and prevention,
and to provide an end to the diagnostic quest.
PROBLEM 1: GLOBAL DEVELOPMENTAL DELAY (GDD)
Defined as significant delay in two or more developmental domains.
Investigation done only after a thorough history and physical examination.
If diagnosis is not apparent after the above, then investigations may be
considered as listed below.
Even in the absence of abnormalities on history or physical examination,
basic screening investigations may identify aetiology in 10-20%.
In the absence of any other clinical findings or abnormalities in the
baseline investigations then further investigations are not indicated.
Basic screening Investigations
Karyotyping
Serum creatine kinase
Thyroid function test
Serum uric acid
Blood Lactate
Blood ammonia
Metabolic screening using Guthrie card1
Plasma Amino acids2
Neuroimaging3
Fragile X screening (boy)
1, This minimal metabolic screen should be done in all even in the absence
of risk factors.
2, This is particularly important if one or more of following risk factors:
Consanguinity, family history of developmental delay, unexplained sib
death, unexplained episodic illness
3, MRI is more sensitive than CT, with increased yield. It is not a
mandatory study and has a higher diagnostic yield when indications exist
(eg. macro/microcephaly; seizure; focal motor findings on neurologic
examination such as hemiplegia, nystagmus, optic atrophy; and unusual
facial features eg. hypo/hypertelorism)
471
METABOLIC
Urine organic acid2
If history and physical examination reveals specific clinical signs and

symptoms, a large number of potential further investigations for possible
IEM may be available. Many of these are highly specialised investigations
and are expensive it is not suggested they are all undertaken but
considered. Referral to a clinical geneticist or metabolic specialist is useful
at this stage to help with test selection based on pattern recognition.
Interpretation of basic screening investigations
Possible causes of abnormal results
Creatine kinase
Muscle injury
Muscular dystrophy
Fatty acid oxidation disorders
Lactate
Excessive screaming, tourniquet pressure

Glycogen storage disorders
Gluconeogenesis disorders
Disorders of pyruvate metabolism
Is plasma alanine increased? If yes, suggest true
elevation of lactate
Ammonia
Sample contamination
Sample delayed in transport/processing
Specimen hemolysed
Urea cycle disorders
Liver dysfunction
Uric acids
An abnormality high or low result is significant:

Glycogen storage disorders
Purine disorders
Molybdenum cofactor deficiency
METABOLIC
Test abnormality
472
Metabolic/Genetic tests for specific clinical features

Developmental delay and ...
Disorders and Tests
Severe hypotonia
Peroxisomal disorders
Very long chain fatty acids (B)
Purine/pyrimidine disorders
Purine/pyrimidine analysis (U)
Neurotransmitters deficiencies
Neurotransmitters analysis (C)
Neuropathic organic acidemia
Organic acid analysis (U)
Pompe disease
Lysosomal enzyme (G)
Prader Willi syndrome
Methylation PCR (B)
Neurological regression +
organomegaly + skeletal
abnormalities
Mucopolysaccharidoses
Urine MPS (U)
Neurological regression
abnormal neuroimaging
e.g. leukodystrophy
Other lysosomal disorders

Lysosomal enzyme (B)
Oligosaccharidoses
Oligosaccharides (U)
Respiratory chain enzymes (M/S)
Biotinidase deficiency
Biotinidase assay (G)
Rett syndrome (girl)

MECP2 mutation study (B)
Abnormal hair
Menkes disease
Copper (B), coeruloplasmin (B)
Argininosuccinic aciduria
Amino acid (U/B)
Trichothiodystrophy
Hair microscopy
B=blood, C=cerebrospinal fluid, U=urine, G=Guthrie card
473
METABOLIC
Metabolic/Genetic tests for specific clinical features (continued)

Disorders and Tests
Macrocephaly
Glutaric aciduria type I

Organic acids (U)
Canavan disease
Organic acid (U)
Vanishing white matter disease
DNA test (B)
Megalencephalic leukodystrophy with
subcortical cysts (MLC)
DNA test (B)
Dysmorphism
Microdeletion syndromes
FISH, aCGH (B)
Smith Lemli Opitz syndrome
Sterol analysis (B)
Congenital disorders of glycosylation
Transferrin isoform (B)
Dystonia
Wilson disease
Copper (B), coeruloplasmin (B)
METABOLIC
Neurotransmitters deficiencies
Phenylalanine loading test,
Neurotransmitters analysis (C)
Neuroacanthocytosis
Peripheral blood film, DNA test (B)
B=blood, C=cerebrospinal fluid, U=urine, G=Guthrie card, aCGH=array
comparative genomic hybridization
474
Metabolic/Genetic tests for specific clinical features (continued)

Disorders and Tests
Epileptic encephalopathy
Nonketotic hyperglycinemia
Glycine measurement (B and C)
Molybdenum cofactor deficiency/
sulphite oxidase deficiency
Sulphite (fresh urine)
Glucose transporter defect
Glucose (blood and CSF)
Pyridoxine dependency
Pyridoxine challenge, alpha aminoadipic
semiadehyde (U)
PNPO deficiency
Amino acid (C), Organic acid (U)
Congenital serine deficiency
Amino acid (B and C)
Cerebral folate deficiency
CSF folate
Ring chromosome syndromes
Karyotype
Neuronal ceroid lipofuscinosis
Peripheral blood film, lysosomal enzyme (B)
Creatine biosynthesis disorders
MR spectroscopy
Cerebral dysgenesis e.g. lissencephaly

MRI brain
Angelman syndrome
Methylation PCR
Spastic paraparesis
Arginase deficiency
Amino acid (B)
Neuropathic organic academia
Organic acid (U)
Sjogren Larsson syndrome
Detailed eye examination
B=blood, C=cerebrospinal fluid, U=urine, G=Guthrie card, aCGH=array

comparative genomic hybridization
475
METABOLIC
Adenylosuccinate lyase deficiency

Purine analysis (U)
METABOLIC
PROBLEM 2: LIVER DISEASE

A considerable number of IEM cause liver injury in infants and children,
either as isolated liver disease or part of a multisystemic disease.
Hepatic clinical response to IEM or acquired causes such as infection is
indistinguishable.
While IEM should be considered in any child with liver disease, it is
essential to understand many pitfalls in interpreting the results.
Liver failure can produce a variety of non-specific results: hypoglycaemia,
ammonia, lactate, plasma amino acids (tyrosine, phenylalanine,
methionine), positive urine reducing substances (including galactose), an
abnormal urine organic acid/blood acylcarnitine profiles.
Citrin deficiency
Recognized clinical phenotypes:
Neonatal intrahepatic cholestasis caused by citrin deficiency (NICCD)
Characterized by transient neonatal cholestasis and variable hepatic
dysfunction.
Diagnosis: elevated plasma citrulline, galactossemia (secondary).
Treatment: lactose-free and/or MCT-enriched formula.
Failure to thrive and dyslipidemia caused by citrin deficiency (FTTDCD)
Characterized by post-NICCD growth retardation and abnormalities of
serum lipid concentrations.
A strong preference for protein-rich and lipid-rich foods and an
aversion to carbohydrate-rich foods.
Diagnosis: mutation testing (plasma citrulline is normal at this stage)
Treatment: diet rich in protein and lipids and low in carbohydrates,
sodium pyruvate.
Citrullinemia type II (CTLN2)
Characterized by childhood- to adult-onset, recurring episodes of hyper
ammonemia and associated neuropsychiatric symptoms.
Treatment: liver transplant.
476
ferritin
Positive urine reducing sugar, cataract
Associated (cardio)myopathy
Muscular hypotonia, multi-systemic disease,
encephalopathy, nystagmus, lactate (blood
and CSF)
Severe coagulopathy, mild AST/ALT, renal
tubulopathy, PO4,AFP
Multi-system disease, protein-losing enteropathy
Aetiology: TORCHES, parvovirus B19, echovirus,
enteroviruses, HIV,EBV, HepB, Hep C
*Galactosemia
*Long-chain fatty acid

oxidation disorders
*mtDNA depletion
syndrome
*tyrosinemia type I
*Congenital disorders of
glycosylation
Must rule out infections
Neonatal/ early infantile
Acute/subacute
hepatocellular
necrosis
(AST, ALT jaundice, hypoglycaemia,
NH3, bleeding
tendency, albumin,
ascitis)
Clues
*Neonatal
haemochromatosis
Metabolic/genetic causes
to be considered
Leading manifestation
patterns
IEM presenting mainly with Liver disease
METABOLIC
477
Serology, urine/stool
viral culture
Transferrin isoform
analysis
Urine succinylacetone
Liver biopsy for mtDNA

depletion study
Blood acylcarnitine
GALT assay
Buccal mucosa biopsy
Diagnostic tests
478
Late infancy to childhood
Acute/subacute
hepatocellular
necrosis
(AST, ALT jaundice, hypoglycaemia,
NH3, bleeding
tendency, albumin,
ascitis)
Symptoms after fructose intake, renal tubulopathy
KF ring, neurological symptoms, haemolysis
*Fructosemia
*Wilson disease
Must rule out chronic viral hepatitis and autoimmune diseases
Commonly presents as cholestatic jaundice,

gradually subsides before 6 months. Some
develop cirrhosis later. Less commonly may
present as liver failure in early infancy
Clues
*-1-antitrypsin deficiency
* above causes
to be considered
patterns
IEM presenting mainly with Liver disease (continued)
METABOLIC
Serum/urine copper,
coeruloplasmin
-1-antitrypsin
Diagnostic tests
or normal GGT
or normal GGT except PFIC type III
plasma citrulline, galactose, +ve urine
reducing sugar
Hypotonia, opthalmoplegia, hepatosplenomegaly
Severe hypotonia, cataract, dysmorphic, knee
calcification
see above
*Progressive familial intrahepatic cholestasis (PFIC)
* Citrin deficiency
* Niemann Pick C
* Peroxisomal disorders
*-1-antitrypsin deficiency
Must exclude extrahepatic

biliary disease
Eye/cardiac/vertebral anomalies
*Inborn error bile acid

synthesis
Neonatal
Cholestastic liver
disease
(conjugated bilirubin
>15%, acholic stool,
yellow brown urine,
pruritus, ALP )
GGT may be low,
normal or high useful to differentiate
various causes
Clues
*Alagille syndrome
to be considered
patterns
METABOLIC
479
-1-antitrypsin
Plasma VLCFA
Bone marrow
examination
Plasma Amino acids,

DNA study
Liver biopsy,DNA study
Liver biopsy,DNA study
DNA study
Diagnostic tests
480
Late infancy to childhood
Cholestastic liver
disease
(conjugated bilirubin
>15%, acholic stool,
yellow brown urine,
pruritus, ALP )
GGT may be low,
normal or high useful to differentiate
various causes
-1-antitrypsin
Liver biopsy
Cirrhosis around 1 year, splenomegaly, muscular hypotonia/atrophy, cardiomyopathy, fatal <

4year
See above
Liver biopsy, DNA

study
ferritin, Cardiomyopathy, hyperpigmentation
Must rule out: chronic viral hepatitis, autoimmune diseases, vascular diseases, biliary malformation etc
* -1-antitrypsin
Serum/urine copper,
coeruloplasmin
Diagnosis by exclusion
Diagnosis by exclusion
Diagnostic tests
KF ring, neurological symptoms, haemolysis
Normal liver function
* Dublin-Johnson
Cirrhosis
*Wilson disease
(end stage of chronic
hepato-cellular
*Haemochromatosis
disease)
chronic jaundice,
clubbing, spider
*GSD IV
angiomatoma, ascites,
portal HPT
Normal liver function
Clues
* Rotor syndrome
* above causes
to be considered
patterns
METABOLIC
PROBLEM 3: CARDIOMYOPATHY
Cardiomyopathy can be part of multi-systemic manifestation of many
IEMs.
In a child with an apparently isolated cardiomyopathy, must actively
screen for subtle/additional extra-cardiac involvement included
studying renal and liver function as well as ophthalmological and
neurological examinations.
Cardiomyopathy may be part of clinical features of some genetic
syndromes especially Noonan syndrome, Costello syndrome,
Cardiofaciocutaneous syndrome.
Sarcomeric protein mutations are responsible for a significant cases of
familial cardiomyopathy.
IEM that may present predominatly as Cardiomyopathy (CMP)
Cardiac finding
Clues
Primary carnitine
deficiency
Dilated CMP
Low serum free carnitine
Long chain fatty acid

oxidation disorders
Hypertrophic/
Dilated CMP
Myopathy, retinopathy, hypoketotic hypoglycaemia, abnormal

acylcarnitne profile
Hypertrophic/
Dilated CMP
Associated with multi-system

abnormalities, lactate
Kearns Sayre syndrome: Chronic
progressive external ophthalmoplegia ,complete heart block
Barth syndrome
Dilated CMP
Neutropenia, myopathy, abnormal urine organic acid

(3 methylglutaconic aciduria)
Infantile pompe
disease
Hypertrophic
CMP
Short PR, very large QRS, CK,

AST, ALT, deficient alpha
acid glucosidase enzyme activity
(could be done using dried blood
spots)
Glycogen Storage
Disease type III
Hypertrophic
CMP
Hepatomegaly, CK, AST,

ALT, postprandial lactate,
uric acid, TG
481
METABOLIC
Disorder
PROBLEM 4: HAEMATOLOGICAL DISORDERS

IEMs presenting as mainly a Haematological disorder
Clinical problem
Metabolic/Genetic causes and Clues/tests
Megaloblastic anemia
Defective transportation or metabolism of B12

Methylmalonic aciduria, homocysteine, low/
normal serum B12.
Orotic aciduria
urinary orotate.
Disorders of folate metabolism
serum folate.
Global marrow failure
Pearson syndrome
Exocrine Pancreatic dysfunction, lactate, renal
tubulopathy.
Fanconi anemia
Cafe au lait spots, hypoplastic thumbs, neurological abnormalities, increased chromosomal
breakage.
METABOLIC
Dyskeratosis congenita
Abnormal skin pigmentation, leucoplakia and
nail dystrophy; premature hair loss and/or
greying.
482
Chapter 90: Approach to Recurrent Hypoglycemia

Introduction
Definition of hypoglycemia:
Consensus for thresholds at which intervention should be considered:
<2.2 mmol/L (40 mg/dl) on first day of life.
2.22.8 mmol/L (40-50 mg/dl) after 24 hours of age.
I
II
Insulin Glucagon
Cathecolamines
III
Growth hormone
Glucagon
Cathecolamines
Cortisol
Glucose used (g/hr)
40
IV
30
Exogenous
20
Glycogen
10
0
MEAL
Gluconeogenesis
12 16
Hours
20
24
28 32 2
16
24
Days
I: Post
Prandial
II: Short to
III: Long Fast
Middle Fast
IV: Very Long

Fast
Glucose
source
Exogenous
Glycogen
Gluconeogenesis
Gluconeogenesis
(hepatic)
Glycogen
Gluconeogenesis
(hepatic and
renal)
Counsuming All
tissues
All but liver,

muscle
Brain, blood cell,

medullary kidney
Greatest
brain
nutrient
Glucose
Glucose
Ketone bodies
Glucose
Glucose
483
METABOLIC
Phase
Clinical classification of hypoglycemia

According to its timing:
Only postprandial.
Only at fast.
Permanent/hectic.
According to liver findings:
With prominent hepatomegaly.
Without prominent hepatomegaly.
According to lactic acid:
With lactic acidosis (lactate > 6mmol/l).
With hyperlactatemia (lactate 2.56mmol/l).
With normal lactate (lactate < 2.5 mmol/l).
According to ketosis:
Hyper/normoketotic.
Hypoketotic/nonketotic.
Laboratory tests during symptomatic hypoglycemia
Adequate laboratory tests must be done to identify the cause, or else
the diagnosis may be missed.
Ensure samples are taken before correcting the hypoglycemia.
METABOLIC
Laboratory tests during symptomatic hypoglycemia

Essential Tests
Other tests
Ketone (serum or urine)
Serum cholesterol/triglyceride
Acylcarnitine (dry blood spots

on Guthrie card)
Serum uric acid
Blood lactate
Liver function
VBG
Creatine kinase
Blood ammonia
Urine reducing sugar
Urine organic acids
Urine tetraglucoside
Free fatty acids (if available)
Plasma amino acid
Serum insulin
Consider toxicology tests (C-peptide)
Serum cortisol
Fasting tolerance test (only by metabolic

specialist/ endocrinologist)
Serum growth hormone
Other special tests e.g. fatty oxidation

study in cultured fibroblasts
484
DETERMINE THE CAUSE

This can be approached using the following algorithm which is based first on
2 major clinical findings :
(1) Timing of hypoglycemia and
(2) Permanent hepatomegaly.
Then looking carefully at the metabolic profile over the course of the day,
checking plasma glucose, lactate, and ketones before and after meals and
ketones in urines will allow one to reach a diagnosis in almost all cases..
HYPOGLYCEMIA
Hectic / Permanent
Post Prandial
Hyperinsulinism
Hyperinsulinism
HFI, GAL
At Fast
At Fast
Hepatomegaly
No Hepatomegaly
High Lactate
Ketosis
Post Prandial
Ketotic
hypoglycemia,
Glycogen
synthetase
deficiency
MCAD, SCAD,
Ketolytic defect
(Ketoacidosis)
No
FAOD (High CK),
Ketogenesis
defect,
Hyperinsulinism
Abbreviations:
HFI, Hereditary fructose intolerance; GAL, Galactosemia; GSD, Glycogen
storage disease; FBP, Fructose-1,6-bisphosphatase deficiency; FAOD, Fatty
acid oxidation disorders; MCAD, Medium chain acyl dehydrogenase
deficiency; SCAD, Short chain acyl dehydrogenase deficiency.
485
METABOLIC
Short:
GSD III (High CK)
GSD1a, GSD1b
GSD VI, IX
(neutropenia)
(No acidosis)
Long:
FBP, FAOD
(all with acidosis)
Yes
GLYCOGEN STORAGE DISEASE

Hepatic type: Type Ia, Ib, III, IV, VI, IX.
Clinical presentation: Recurrent hypoglycemia, hepatomegaly, failure to
thrive, doll face, bleeding tendency (GSD I), hypertrophic
cardiomyopathy (GSD III).
Laboratory findings: lactate, uric acid, triglycerides,
() transaminases, CK (GSD III), urine tetraglucosides.
Glucose challenge test: Type Ia, Ib: in lactate; Type III, VI, IX: in lactate.
Diagnosis: enzyme studies (liver), mutation analysis.
Treatment:
Avoid hypoglycemia by means of continuous carbohydrate intake.
Frequent meals (every 2-3 hours): Slowly resorbed carbohydrates
(glucose polymer/maltodextrin, starch), avoid lactose.
Nights: Continous intake of glycose polymer/maltodextrin via
nasogastric tube, uncooked cornstarch in children > 1 year age.
Complications: liver tumours, osteoporosis, cardiomyopathy (GSD III).
HYPERINSULINAEMIC HYPOGLYCAEMIA
METABOLIC
Diagnostic criteria
Glucose infusion rate > 8mg/kg/min to maintain normoglycaemia.
Detectable serum insulin (+/- C-peptide) when blood glucose < 3mmol/l.
Low or undetectable serum fatty acids.
Low or undetectable serum ketone bodies.
Serum ammonia may be high (Hyperinsulinism/hyperammonaemia
syndrome).
Glycaemic response to glucagon at time of hypoglycaemia.
Absence of ketonuria.
Causes
Congenital Hyperinsulinism (Mode of inheritance)
ABCC8 (AR, AD)); KCNJ11 (AR, AD); GLUD1 (AD); GCK (AD); HADH (AR);
HNF4A (AD); SLC16A1 (Exercise induced)(AD).
Secondary to (usually transient)
Maternal diabetes mellitus (gestational and insulin dependent).
IUGR.
Perinatal asphyxia.
Rhesus isoimmunisation.
Metabolic conditions
Congenital disorders of glycosylation (CDG), Tyrosinaemia type I.
Associated with Syndromes
Beckwith-Wiedemann, Soto, Kabuki, Usher, Timothy, Costello,
Trisomy 13, Mosaic Turner, Central Hypoventilation Syndrome.
Other causes: Dumping syndrome, Insulinoma (sporadic or associated
with MEN Type 1), Insulin gene receptor mutations, Factitious HH
(Munchausen-by-proxy).
486
Treatment for Recurrent Hypoglycaemia

Medication
Route / Dose
Diazoxide
Oral, 520mg/kg/day divided into 3 doses
Side Effects
Common: fluid retention, hypertrichosis.

Others: hyperuricaemia, eosinophilia, leukopenia.
Practical
Management
Use in conjunction with cholorothiazide especially in

newborns.
Restrict fluid intake, especially on the higher doses.
Carefully monitor fluid balance.
Chlorothiazide
Oral, 710mg/kg/day divided into 2 doses
(used in conjunction with diazoxide)

Hyponatraemia, hypokalaemia
Practical
Management
Monitor serum electrolytes
Nifedipine
Oral, 0.25-2.5mg/kg/day divided into three doses
Side Effects
Hypotension
Practical
Management
Monitor blood pressure.

Not effective in patients with CHI due to defective
KATP channels.
Glucagon
( Octreotide)
SC/IV infusion, 120g/kg/hour
Side Effects
Nausea, vomiting, skin rashes.

Paradoxical hypoglycaemia in high doses.
Practical
Management
Avoid high doses.

Watch for rebound hypoglycaemia when used as an
emergency treatment for hypoglycaemia.
Octreotide
( Glucagon)
SC/IV continuous infusion or 68-hourly SC injections;

525g/kg/day
Side Effects
Common- tachyphylaxis
Others- Suppression of GH, TSH, ACTH, glucagon;
diarrhoea, steatorrhoea, cholelithiasis, abdominal
distension, growth suppression.
Practical
Management
Use with caution in infants at risk of necrotising

enterocolitis, (reduces blood flow to the splanchnic
circulation).
Follow-up with serial ultrasound scans of the biliary
tree, if on long-term treatment with Octreotide.
Monitor long-term growth.
487
METABOLIC
Side Effects
488
METABOLIC
Chapter 91: Down Syndrome

Incidence of Down syndrome
Maternal Age-Specific Risk for Trisomy 21 at Livebirth
Overall Incidence: 1 in 800-1000 newborns
Age (years)
Incidence
20
1 in1500
30
1 in 900
35
1 in 350
40
1 in 100
41
1 in 70
42
1 in 55
43
1 in 40
44
1 in 30
45
1 in 25
Source Hecht and Hook 94
489
METABOLIC
Medical problems
Newborn

Cardiac defects (50% ): AVSD [most common], VSD, ASD, TOF or PDA
Gastrointestinal (12%): duodenal atresia [commonest], pyloric stenosis,
anorectal malformation, tracheo-oesophageal fistula, and Hirshsprung
disease.
Vision: congenital cataracts (3%), glaucoma.
Hypotonia and joint laxity
Feeding problems. Usually resolves after a few weeks.
Congenital hypothyroidism (1%)
Congenital dislocation of the hips
Infancy and Childhood
Delayed developmental milestones.
Mild to moderate intellectual impairment (IQ 25 to 50).
Seizure disorder (6%).
Recurrent respiratory infections.
Hearing loss (>60%) due to secretory otitis media, sensorineural
deafness, or both.
Visual Impairment squint (50%), cataract (3%), nystagmus (35%), glau
coma, refractive errors (70%) .
Sleep related upper airway obstruction. Often multifactorial.
Leukaemia (relative risk:15 to 20 times). Incidence 1%.
Atlantoaxial instability. Symptoms of spinal cord compression include

neck pain, change in gait, unusual posturing of the head and neck
(torticollis), loss of upper body strength, abnormal neurological reflexes,
and change in bowel/bladder functioning. (see below)
Hypothyroidism (10%). Prevalence increases with age.
Short stature congenital heart disease, sleep related upper airway
obstruction, coeliac disease, nutritional inadequacy due to feeding
problems and thyroid. Hormone deficiency may contribute to this.
Over/underweight.
Adolescence and Adulthood
Puberty:
In Girls menarche is only slightly delayed. Fertility presumed.
Boys are usually infertile due to low testosterone levels.
Increased risk of dementia /Alzheimer disease in adult life.
Shorter life expectancy.
METABOLIC
Management
Communicating the diagnosis is preferably handled in private by a senior
medical officer or specialist who is familiar with the natural history, genetic
aspect and management of Down syndrome.
Careful examination to look for associated complications.
Investigations:
Echocardiogram by 2 weeks (if clinical examination or ECG were
abnormal) or 6 weeks.
Chromosomal analysis.
T4 /TSH at birth or by 1-2 weeks of life.
Early intervention programme should begin at diagnosis if health
conditions permit.
Assess strength & needs of family. Contact with local parent support
group should be provided (Refer list of websites below).
Health surveillance & monitoring: see table below
Atlantoaxial instability
Seen in X rays in 14% of patients; symptomatic in 1-2%.
Small risk for major neurological damage but cervical spine X rays in
children have no predictive validity for subsequent acute dislocation/
subluxation at the atlantoaxial joint.
Children with Down syndrome should not be barred from taking part in
sporting activities.
Appropriate care of the neck while under general anaesthesia or after
road traffic accident is advisable.
490
Karyotyping in Down syndrome

Non-disjunction trisomy 21
95%
Robertsonian Translocation
3%
Mosaicism
2%
Recurrence Risk by Karyotype

Nondisjunction Trisomy
47(XX or XY) + 21
1%
Translocation
Both parents normal
low; <1%
Carrier Mother
10%
Carrier Father
2.5%
Either parent t(21q;21q)
100%
Mosaics
< 1%
491
METABOLIC
Useful web resources

The Down Syndrome Medical Interest Group (UK)
www.dsmig.org.uk
Down Syndrome: Health Issues
www.ds-health.com
Growth charts for children with Down Syndrome
www.growthcharts.com
Educational issues
www.downsed.org
Kiwanis Down Syndrome Foundation
www.kdsf.netmyne.com
Educational & support centre.
http://www.disabilitymalaysia.com/
Parents support group.
http://groups.yahoo.com/group/DownSyndromeMalaysia
Jabatan Pendidikan Khas
http://www.moe.gov.my/jpkhas/
Jabatan Kebajikan Malaysia.
http://www.jkm.gov.my/
492
Recommendations for Medical Surveillance for children with Down Syndrome

Birth - 6 weeks
6 - 10 months
12 months
18 mths - 2 yrs
3 - 3 years
4 - 4 years
Thyroid tests
T4, TSH
T4, TSH, antibodies
T4, TSH, antibodies
Growth
Length, weight and head circumference checked
Length and weight should be checked at least annually
monitoring
regularly and plotted on Downs syndrome growth charts. and plotted on Downs syndrome growth charts.
Eye examination Visual behaviour. Visual behaviour. Visual behaviour. Orthoptic, refracVisual acuity, reCheck for
Check for
Check for
tion, ophthalmic
fraction, ophthalcongenital cataract congenital cataract congenital cataract
examination
mic examination
Hearing check
Neonatal screening Full audiological review (hearing, impedance, otoscopy) by 6-10 months and then annually.
Cardiology,
Echocardiogram
Dental
Other advice
0-6 weeks
assessment
Age 5 to 19 years
Footnote:
1, Asymptomatic patients with mildly raised TSH
Paediatric review
Annually
(<10mu/l) but normal T4 does not need treatment but
Hearing
2 yearly audiological review (as above)
test more frequently for uncompensated hypothyroidism.
Vision / Orthoptic check
2 yearly
2, Down syndrome centile charts at www.growthcharts.
com. Consider weight for length charts of typically
Thyroid blood tests
At age 5 years, then 2 yearly
developing children for weight assessment. If BMI > 98th
School performance
Check performance and placement
centile or underweigh, refer for nutritional assessment
Sexuality and employment To discuss when appropriate, in adolescence. and guidance. Re-check thyroid function if accelerated
weight gain.
Note: The above table are suggested ages. Check at any other time if
3, Performed by optometrist/ophthalmologist.
parental or other concerns. Perform developmental assessment
during each visit.
Adapted from Down Syndrome Medical Interest Group (DSMIG) guidelines
METABOLIC
References
Section 11 Metabolic Disease
Ch 88 Inborn errors metabolism (IEM): Approach to Diagnosis and Early
Management in a Sick Child
1.Saudubray JM, van den Berghe G, Walter J, eds. Inborn Metabolic Diseases:
Diagnosis and Treatment. Berlin: Springer-Verlag, 5th edition, 2011
2.A Clinical Guide to Inherited Metabolic Diseases. Joe TR Clarke (editor). Cambridge University Press, 3rd edition, 2006
3. JM Saudubray, F Sedel, JH Walter. Clinical approach to treatable inborn
metabolic diseases: An introduction. J Inherit Metab Dis (2006) 29:261274.
Ch 89 Investigating Inborn errors metabolism (IEM) in a Child with Chronic
Symptoms
1.Georg F. Hoffmann, Johannes Zschocke, William L Nyhan, eds. Inherited
Metabolic Diseases: A Clinical Approach. Berlin: Springer-Verlag, 2010
2.Helen V. Firth, Judith G. Hall, eds. Oxford Desk Reference Clinical Genetics.
1st edition, 2005
3.M A Cleary and A Green. Developmental delay: when to suspect and
how to investigate for an inborn error of metabolism. Arch Dis Child
2005;90:11281132.
4.P. T. Clayton. Diagnosis of inherited disorders of liver metabolism. J. Inherit.
Metab.Dis. 26 (2003) 135-146
5.T. Ohura, et al. Clinical pictures of 75 patients with neonatal intrahepatic
cholestasis caused by citrin deficiency (NICCD). J Inherit Metab Dis 2007.
Ch 90 Recurrent Hypoglycemia
1.Blasetti et al. Practical approach to hypoglycemia in children. Ital J Pediatr
2006; 32: 229-240
2.Saudubray JM, et al. Genetic hypoglycaemia in infancy and childhood :
Pathophysiology and diagnosis J. Inherit. Metab. Dis. 23 (2000) 197-214
3.Khalid Hussain et al. Hyperinsulinaemic hypoglycaemia. Arch. Dis. Child
(2009).
493
METABOLIC
Ch 91 Down Syndrome
1.Clinical Practice Guideline. Down Syndrome, Assessment and Intervention
for Young Children. New York State Department of Health.
2.Health Supervision for Children with Down Syndrome. American Academy
of Paediatrics. Committee on Genetics. 2000 2001
3.The Down Syndrome Medical Interest Group (UK). Guidelines for Essential
Medical Surveillance for Children with Down Syndrome.
494
METABOLIC
Chapter 92: Appendicitis
495
PAEDIATRIC SURGERY
Appendicitis is the most common surgical condition of the abdomen in

children over the age of 4 years and yet can be a challenge to diagnose and
manage. Although diagnosis and treatment have improved over the years, it
continues to cause considerable morbidity and even mortality in Malaysia.
The deaths appear to be due to delay and difficulty in diagnosis, inadequate
perioperative fluid replacement and sepsis.
Clinical Features
Abdominal pain Lower abdominal pain is an early and almost invariable
feature. Usually the pain starts in the epigastrium or periumbilical region
before localising to the lower abdomen or the right iliac fossa. However
the younger child may not be able to localise the pain. If there is free pus,
the pain is generalised.
Nausea and vomiting occurs in about 90% of children and is an early
symptom. Most children have a loss of appetite. A hungry child rarely has
appendicitis.
Diarrhoea is more common in the younger age group causing confusion
with gastroenteritis. It can be due to pelvic appendicitis or collection of pus
within the pelvis.
Dysuria and frequency are also commonly present in the child with pelvic
appendicitis or perforated appendicitis.
Physical Findings
General the child is usually quiet and may be dehydrated.
Dehydration must be actively sought for especially in the obese child and
the child with perforated appendicitis. A history of vomiting and diarrhoea,
tachycardia, poor urine output and poor perfusion of the peripheries are
indicators of dehydration.
Tenderness on palpation or percussion is essential for the diagnosis. It may
be localised to the right iliac fossa or be generalised. The tenderness may
also be mild initially and difficult to elicit in the obese child or if the appendix is retrocaecal. Eliciting rebound tenderness is usually not required
to make the diagnosis and can cause unnecessary discomfort.
Guarding signifies peritonitis but may be subtle especially if the child is
toxic, obese and very dehydrated.
Rectal examination is only required if other diagnosis are suspected e.g.
ovarian or adnexal pathology.
Investigations
Full blood count The total white blood cell count may be elevated but a
normal count does not exclude appendicitis.
Blood Urea and Serum Electrolytes The sodium level may be apparently
normal if the child is dehydrated
Serum Amylase If pancreatitis cannot be ruled out as the cause of the
abdominal pain.
Ultrasound and CT scan have been suggested to improve the diagnostic
accuracy in doubtful cases. So in our setting the recommendation is that
the children need to be assessed by a specialist preoperatively.
If unsure of the diagnosis, the child is very ill or there are no facilities or
personnel for intensive care, the child must be referred to the nearest
paediatric surgical unit.
Complications
Perforation can occur within 36 hours of the onset of symptoms.
Perforation rate increases with the duration of symptoms and delayed
presentation is an important factor in determining perforation rate.
Perforation rate: Adolescent age group - 30-40%
Younger child - up to about 70%.
PAEDIATRIC SURGERY
However, active observation with adequate fluid resuscitation and

preoperative antibiotics before embarking upon surgery has not shown an
increase in morbidity or mortality. Delaying surgery for both perforated
and non perforated appendicitis till the daytime did not significantly affect
the perforation rate, complications or operating time.
Appendicular abscess, mass and perforation may be treated with
IV antibiotics to settle the inflammatory and infectious process. If the child
settles, this can then be followed by an interval appendicectomy which needs
to be done within 14 weeks of the original disease process as recurrent appendicitis has been reported between 10-46 %.
Management
Children with appendicitis (suspected or confirmed) should be reviewed
by a specialist.
Dehydration should be actively looked for. The heart rate, blood
pressure, perfusion and the urine output should be closely monitored.
The blood pressure is usually maintained in the children until they have
decompensated.
Rehydration must be aggressive, using 20 mls/kg aliquots of normal
saline or Hartmanns solution (Ringers lactate) given fast over - 2 hours.
The child should be reviewed after each bolus and the rehydration continued until the childs heart rate, perfusion and urine output and electrolytes
are within normal limits. Maintenance fluid saline + 5% D/W + KCl.
Antibiotics must be started early, soon after the diagnosis is made.
Inotropes may need to be started early if the child is in severe sepsis.
Operation - There is no rush to take the child to the operating theatre.
It is recommended that appendicectomies not be performed after 11 pm,
especially in the sick child. However, the time should be utilised to
continue the resuscitation and antibiotics with close monitoring of the
child.
At surgery, a thorough peritoneal washout with copious amount of
normal saline is done after the appendicectomy. No drains are required
and the skin can be closed with a subcuticular suture.
496
Chapter 93: Vomiting in the Neonate and Child

Vomiting in the child is NOT normal.
Bilious vomiting is ALWAYS significant until otherwise proven
Causes of Persistent Vomiting
Neonates
General
Sepsis
Meningitis
Hydrocephalus/ neurological disorder
Motility disorder
Congential adrenal hyperplasia
Poor feeding techniques
Oesophageal
Atresia
Webs
Swallowing disorders
Stomach
Gastro-oesophageal reflux
Duodenal atresia/ stenosis
Small intestines
Malrotation
PAEDIATRIC SURGERY
Stenosis/ atresia
Adhesions/ Bands
Meconium peritonitis/ ileus
Enterocolitis
Large intestine/ rectum
Stenosis/ atresia
Hirschprungs disease
Anorectal malformation
497
Causes of Persistent Vomiting (continued)

Infants
General
Sepsis
Meningitis
Hydrocephalus/ neurological disorder
Tumours eg neuroblastoma
Metabolic disorders
Oesophageal stricture
Stomach
Gastro-oesophageal reflux
Pyloric stenosis
Small intestines
Malrotation/ volvulus
Adhesions
Hernias
Appendix- rare
Large intestines
Intussusception
PAEDIATRIC SURGERY
Hirschprungs disease
Enterocolitis/gastroenteritis
498
Causes of Persistent Vomiting (continued)

Older Child
General
Sepsis
Neurological disorder
Tumours
Metabolic disease
Oesophageal stricture
Stomach
Gastro-oesophageal stricture/ reflux
Peptic ulcer disease
Gastric volvulus
Small intestines
Malrotation/ volvulus
Adhesions
Appendicitis/ peritonitis
Large intestines
Intussusception
Foreign body
Worm infestation
Constipation: habitual
PAEDIATRIC SURGERY
499
When is the vomiting significant?

Vomiting from Day 1 of life.
Vomit contains blood (red/black).
Bilious vomiting: green, not yellow. Bowel obstruction must be ruled out.
Faeculent vomiting.
Projectile vomiting.
Baby is unwell - dehydrated/septic.
Associated failure to thrive.
Associated diarrhoea/constipation.
Associated abdominal distension.
GASTRO-OESOPHAGEAL REFLUX
More common in infancy than generally recognized.
Majority (>90%) resolve spontaneously within the first year of life.
Small percentage develop complications.
Please refer Ch 74 Gastroesophageal Reflux Disease (GERD)
PYLORIC STENOSIS
Cause- unknown.
Usually first born baby boy; usual presentation at 2nd to 8th week of life.
Strong familial pattern.
PAEDIATRIC SURGERY
Clinical Features
Vomiting -Frequent, forceful, non-bilious with/without haematemesis.
The child is keen to feed but unable to keep the feed down.
Failure to thrive.
Dehydration.
Constipation.
Seizures.
Dehydrated
A test feed can be given with the child in the mothers left arm and
visible gastric peristalsis (left to right) observed for. The doctors left hand
then palpates beneath the liver feeling for a palpable olive sized pyloric
tumour against the vertebra.
500
Investigations
Investigation to confirm diagnosis are usually unnecessary.
Ultrasound.
Barium meal.
However, pre-operative assessment is very important
Metabolic alkalosis is the first abnormality
Hypochloraemia < 100 mmol/l
Hyponatraemia < 130 mmol/l
Hypokalaemia < 3.5 mmol/l
Hypocalcaemia < 2.0 mmol/l
Jaundice.
Hypoglycemia.
Paradoxical aciduria - a late sign.
Therapy
Rehydration
Slow (rapid will cause cerebral oedema) unless the child is in shock
Fluid
saline + 10%D/W (+ 5-10 mmol KCL/kg/day) .
Rate (mls/hr) = [Maintenance (150 ml/kg body weight) + 5-10 %
dehydration {% dehydration x body weight (kg) x 10}] /24 hours.
Replace gastric losses with normal saline.
Do NOT give Hartmanns solution (the lactate will be converted to
bicarbonate which worsens the alkalosis)
Insert a nasogastric tube 4 hourly aspiration with free flow.
Comfort glucose feeds maybe given during the rehydration period but
the nasogastric tube needs to be left on free drainage.
Pyloromyotomy after the electrolytes have been corrected.
PAEDIATRIC SURGERY
501
MALROTATION
A term that embraces a number of different types of abnormal rotation
that takes place when the bowel returns into the intra-abdominal cavity in
utero. This is Important because of the propensity for volvulus of the midgut around the superior mesenteric artery causing vascular compromise of
most of the small bowel and colon.
Types of Clinical Presentation
Acute Volvulus
Sudden onset of bilious/ non-bilious vomiting.
Abdominal distention with/without a mass (late sign).
Bleeding per rectum (late sign).
Ill baby with distended tender abdomen.
Chronic Volvulus
Caused by intermittent or partial volvulus resulting in lymphatic and
venous obstruction.
Recurrent colicky abdominal pain.
Vomiting (usually bilious).
Malabsorption.
Failure to thrive.
Internal Herniation
Due to lack of fixation of the colon.
Results in entrapment of bowel by the mesentery of colon.
Recurrent intermittent intestinal obstruction.
PAEDIATRIC SURGERY
Investigations
Plain Abdominal X-ray
All the small bowel is to the right side.
Dilated stomach +/- duodenum with rest of abdomen being gasless.
502
Upper Gastrointestinal contrast study with follow through

Duodeno-jejunal flexure to the right of the vertebra.
Duodenal obstruction, often with spiral or corkscrew appearance of
barium flow.
Presence of small bowel mainly on the right side.
503
PAEDIATRIC SURGERY
Treatment
Pre-operative Management
Rapid rehydration and correction of electrolytes
Fluids
Maintenance saline + 5% (or 10% if neonate) Dextrose Water with
added KCl.
Rehydration Normal saline or Hartmanns Solution (Ringers Lactate)
Orogastric or nasogastric tube with 4 hourly aspiration and free drainage
Antibiotics ( + inotropes) if septic.
Operative
De-rotation of volvulus.
Resection with an aim to preserve maximum bowel length (consider a
second look operation if most of the bowel appears of doubtful viability).
Division of Ladds bands to widen the base of the mesentery to prevent
further volvulus.
Appendicectomy.
ATRESIAS
Duodenal Stenosis/ Atresia
Usually at the second part of the duodenum
Presents with bilious/non-bilious vomiting
Can be associated with Downs Syndrome and gastro-oesophageal reflux.
Abdominal X-Ray double bubble with or without gas distally
PAEDIATRIC SURGERY
Management
Slow rehydration with correction of electrolytes and nutritional
deficiencies.
Duodeno-duodenostomy as soon as stabilized.
Postoperatively, the bowel motility may be slow to recover.
Ileal /Jejunal Atresia
Atresia anywhere along the small bowel. Can be multiple.
Presents usually with abdominal distension and vomiting (non-bilious
initially and then bilious)
Usually pass white or pale green stools, not normal meconium.
Differential diagnoses Long segment Hirschsprungs disease,
Meconium ileus.
Management
Evaluation for associated anormalities.
Insertion of an orogastric tube 4 hourly aspiration and free drainage.
Replace losses with Hartmanns solution (Ringers lactate).
Rehydration of the baby with correction of the electrolytes and acidosis.
Laparotomy and resection of the dilated bowels with primary
anastomosis, preserving as much bowel length as possible.
Parenteral nutrition as the motility of the bowel can be abnormal and
take a long time to recover.
504
AXR dilated loops of small bowel.
Contrast enema microcolon
PAEDIATRIC SURGERY
505
506
PAEDIATRIC SURGERY
Chapter 94: Intussusception

Intussusception is the invagination of one portion of intestine into another
with 80% involving the ileocaecal junction. The mortality and morbidity from
intussusception in Malaysia is still high due to delay in diagnosis, inadequate
IV fluid therapy and surgical complications.
It is the most common form of intestinal obstruction in infancy and early
childhood with the peak age group being 2 months to 4 years. Majority of the
children in this age group have no pathological lead point. Lymphoid hyperplasia has been implicated. Children may also have a preceding viral illness.
Common lead points (usually in the age group outside the above):
Structural Meckels diverticulum, duplication cysts.
Neoplastic Lymphoma, polyps, vascular malformations.
Vascular Henoch-Schonlein purpura, leukaemia.
Miscellaneous Foreign body.
Clinical Features
Previously healthy or preceding viral illness.
Pain - Sudden onset, severe intermittent cramping pain lasting seconds
to minutes.
During the time in-between attacks lasting between 5 to 30 minutes,
the child may be well or quiet.
Vomiting Early reflex vomiting consists of undigested food but if the
child presents late, the vomiting is bilious due to obstruction.
Stools- Initially normal, then become dark red and mucoid (redcurrant
jelly).
Note that small bowel intussusception may have an atypical
presentation.
Physical Findings
Well- looking/drowsy/dehydrated/fitting (due to hyponatremia)
depending on the stage of presentation.
Abdominal mass (sausage shaped but may be difficult to palpate in a
distended abdomen).
Abdominal distension is a late sign.
PAEDIATRIC SURGERY
507
Investigations
Plain abdominal X-ray Absence of caecal gas, paucity of bowel gas on
the right side with loss of visualization of the lower border of the liver,
dilated small bowel loops (see figure below).
Ultrasound Useful diagnostic tool. Target sign (see figure below) on

transverse section and pseudo-kidney sign on longitudinal section. May
also help to identify lead points if present.
PAEDIATRIC SURGERY
Barium enema for diagnosis and reduction if required.

Management
Resuscitation
Aggressive rapid rehydration with boluses of 20 mls/kg of Normal
saline/Hartmanns solution (Ringers lactate) till parameters are normal.
Do NOT proceed to hydrostatic reduction or surgery till fully resuscitated.
Close monitoring of vital signs and urine output.
Antibiotics and inotropes as required.
508
Non-operative reduction
Should be attempted in most patients, if there are trained radiologists
and surgeons available, successful reduction rate is about 80-90%.
Types
Barium enema reduction. (see figure below: claw sign of
intussusceptum is evident).
Air/Oxygen reduction.
Ultrasound guided saline reduction.
The younger child who has been sick for a longer duration of more than
36 hours and has complete bowel obstruction is at risk of colonic
perforation during attempted enema reduction.
Delayed repeat enemas done after 30 minutes or more after the initial
unsuccessful reduction enema may improve the outcome of a select group
of patients. These patients are clinically stable and the initial attempt had
managed to move the intussusceptum.
Indications for surgery

Failed non-operative reduction.
Bowel Perforation.
Suspected lead point.
Small bowel intussusception.
509
PAEDIATRIC SURGERY
Contraindications to enema reduction

Peritonitis.
Bowel Perforation.
Severe Shock.
Neonates or children more than 4 years old (relative contraindication).
History more than 48 hours.
Recurrence of intussusception
Rate: 5-10% with lower rates after surgery.
Success rate for non-operative reduction in recurrent intussusception is
about 30-60%.
PAEDIATRIC SURGERY
Successful management of intussusception depends on high index of suspicion, early diagnosis, adequate resuscitation and prompt reduction.
510
Chapter 95: Inguinal hernias, Hydrocoele

Both are due to a patent processus vaginalis peritonei. The patent communication in the hydrocoele is smaller, so the sac contains only fluid. The hernial
sac can contain bowel, omentum or ovaries.
INGUINAL HERNIA
Incidence: 0.8%-4.4% in children, but 16-25% in premature babies.
Boy:girl ratio = 6 : 1.
Site: 60% right side but 10% may be bilateral.
Presentation
Reducible bulge in groin extends into scrotum when crying/straining.
With complications.
Lump in groin (girls) sliding hernia containing ovary (rule out testicular
feminization syndrome if bilateral)
Complications
Incarceration/Irreducibility Highest incidence (2/3) before age of 1 year.
Testicular atrophy.
Torsion of ovary.
Management
Reducible hernia:
To operate (herniotomy) as soon as possible.
Premature: before discharge (if possible at corrected age-44 to 60 week)
Infant: as soon as possible.
Older child: on waiting list.
HYDROCOELE
Usually present since birth. May be communicating or encysted
Is typically a soft bluish swelling which is not reducible but may
fluctuate in size.
Management
The patent processus closes spontaneously within the first year of life,
in most children.
If the hydrocoele does not resolve after the age of 2 years, herniotomy
with drainage of hydrocoele is done.
511
PAEDIATRIC SURGERY
Incarcerated hernia
Attempt manual reduction as soon as possible to relieve compression on
the testicular vessels. The child is rehydrated and then given intravenous
analgesic with sedation. Constant gentle manual pressure is applied in the
direction of the inguinal canal to reduce the hernia. The sedated child can
also be placed in a Trendelenburg position for an hour to see if the hernia
will reduce spontaneously.
If the manual reduction is successful, herniotomy is performed 24-48
hours later when the oedema subsides. If the reduction is not successful,
the operation is performed immediately.
512
PAEDIATRIC SURGERY
Chapter 96: Undescended Testis

An empty scrotum may be due to the testis being undescended, ectopic,
retractile or absent. Familial predisposition present in 15%. 10 - 25% are
bilateral.
Incidence
At birth: Full term 3.4%

Premature 30.3%
At 1 year:Full term 0.8%

Premature 0.8%
Adult
0.7-1%
Spontaneous descent may occur within the 1st year of life after which
descent is rare.
Complications
Trauma (especially if in inguinal canal).
Torsion - extravaginal type.
Decreased spermatogenesis. Damage occurs in the first 6-12 months of
life. 90% of patients with orchidopexy before 2 years have satisfactory
spermatogenesis. If done after >15 years old, fertility is 15%.
Testicular tumour: Risk is 22 times higher than the normal population
(Intra-abdominal 6 times more than inguinal). Surgery makes the testis
more accessible to palpation and thus an earlier diagnosis.
Associated with hernias (up to 65%), urinary tract anomaly (3%, e.g.
duplex and horseshoe), anomalies of epididymis or vas deferens and
problems of intersex.
Psychological problems.
513
PAEDIATRIC SURGERY
Management
Ask mother whether she has ever felt the testis in the scrotum, more
easily felt during a warm bath and when squatting.
Examine patient (older children can be asked to squat). A normal sized
scrotum suggests retractile testis. The scrotum tends to be hypoplastic in
undescended testis.
If bilateral need to rule out dysmorphic syndromes, hypopituitarism,
and chromosomal abnormalities (e.g. Klinefelter). Exclude virilized female
(Congenital Adrenal Hyperplasia).
Observe the child for the 1st year of life. If the testis remains
undescended after 1 year of life surgery is indicated. Surgery should be
done between 6-18 months of age. Results of hormonal therapy (HCG,
LH-RH) have not been good.
For bilateral impalpable testis: Management of choice is Laparoscopy
open surgery. Ultrasound, CT scan or MRI to locate the testes have not
been shown to be useful. Check chromosomes and 17 OH progesterone
levels if genitalia are ambiguous.
514
PAEDIATRIC SURGERY
Chapter 97: The Acute Scrotum

Causes of Acute Scrotum
Acute testicular torsion.
Torsion of epididymal and testicular appendages.
Epididymo-orchitis.
Incarcerated inguinal hernia.
Idiopathic scrotal oedema.
Acute hydrocele.
Henoch-Schonlein purpura.
Tumours.
Trauma.
Scrotal (Fourniers) gangrene.
Symptomatic varicocele.
TORSION OF THE TESTIS
Torsion of the testis is an emergency as failure to detort testis within 6 hours
will lead to testicular necrosis.
Symptoms
Sudden severe pain (scrotum and referred to lower abdomen)
Nausea and vomiting
No fever or urinary tract infection symptoms until later
There are 2 types of torsion:

Extravaginal
The torsion usually occurs in the perinatal period or during infancy and is
thought to be probably due to an undescended testis.
Intravaginal
This is due to a high investment of tunica vaginalis causing a bell-clapper
deformity. It usually occurs in boys between 10-14 years old. The deformity
is usually bilateral.
515
PAEDIATRIC SURGERY
Physical Findings
Early
Involved testis - high, tender, swollen.
Spermatic cord swollen, shortened and tender.
Contralateral testis - abnormal lie, usually transverse.
Late
Reactive hydrocele.
Scrotal oedema.
Investigation
Doppler /Radioisotope scan. It may be normal initially
Management
Exploration: salvage rate: 83% if explored within 5 hours.
20% if explored after 10 hours.
If viable testis, fix bilaterally.
If non-viable, orchidectomy to prevent infection and sympathetic orchitis
(due to antibodies to sperm) and fix the opposite testis.
TORSION OF APPENDAGES OF TESTIS AND EPIDIDYMIS
Appendages are Mullerian and mesonephric duct remnants.
Importance: in a late presentation, may be confused with torsion of testis.
Symptoms
Age 8-10 years old.
Sudden onset of pain, mild initially but gradually increases in intensity.
Early
Minimal redness of scrotum with a normal non-tender testis
Tender nodule blue spot (upper pole of testis) is pathognomonic.
Late
Reactive hydrocele with scrotal oedema makes palpation of testis difficult.
PAEDIATRIC SURGERY
Treatment
If sure of diagnosis of torsion appendages of testis, the child can be given
the option of non-operative management with analgesia and bed rest
If unsure of diagnosis, explore and remove the twisted appendage (this
ensures a faster recovery of pain too!)
516
EPIDIDYMO-ORCHITIS
Can occur at any age.
Route of infection
Reflux of infected urine.
Blood borne secondary to other sites.
Mumps.
Sexual abuse.
Symptoms
Gradual onset of pain with fever.
May have a history of mumps.
Dysuria/ frequency.
Testis may be normal with a reactive hydrocoele.
Epididymal structures are tender and swollen.
Treatment
If unsure of diagnosis, explore.
Investigate underlying abnormality (renal ultra sound, MCU and IVU if
a urinary tract infection is also present)
Treat infection with antibiotics.
IDIOPATHIC SCROTAL OEDEMA
The cause is unknown but has been postulated to be due to an allergy.
Symptoms
Sudden acute oedema and redness of scrotum.
Painless.
Starts as erythema of perineum and extending to lower abdomen.
Well child, no fever.
Testes: normal.
517
PAEDIATRIC SURGERY
Treatment
This condition is self limiting but the child may benefit from antibiotics
and antihistamines.
518
PAEDIATRIC SURGERY
Chapter 98: Penile Conditions

Phimosis
Definition - True preputial stenosis
(In a normal child the foreskin is non-retractile till age of 5 years)
Causes
Congenital - rare
Infection- balanoposthitis
Recurrent forceful retraction of foreskin
*Balanoxerotica obliterans (BXO)
Symptoms
Ballooning of foreskin on micturition.
Recurrent balanoposthitis.
Urinary retention.
Urinary tract infection.
Management
Treat infection if present.
Elective circumcision.
*BXO:
Chronic inflammation with fibrosis of foreskin and glans causing a whitish
appearance with narrowing of prepuce and meatus.
Treatment: careful circumcision meatotomy.
(Will require long term follow-up to observe for meatal stenosis)
Paraphimosis
Cause: forceful retraction of foreskin (usually associated with phimosis)
Treatment
Immediate reduction of the foreskin under sedation/analgesia (Use an
anaesthetic gel or a penile block, apply a warm compress to reduce
oedema and then gentle constant traction on foreskin distally).
If reduction is still unsuccessful under a general anaesthetic then a
dorsal slit is performed.
The child will usually need a circumcision later.
519
PAEDIATRIC SURGERY
Balanoposthitis
(Balanitis - inflamed glans, Posthitis - inflamed foreskin)
Cause effect: phimosis with or without a urinary tract infection
Treatment
Check urine cultures.
Sitz bath.
Analgesia.
Antibiotics.
Circumcision later if there is associated phimosis or recurrent infection.
520
PAEDIATRIC SURGERY
Chapter 99: Neonatal Surgery

OESOPHAGEAL ATRESIA WITH OR WITHOUT A
TRACHEO-OESOPHAGEAL FISTULA
Presentation
Antenatal: polyhydramnios, diagnosed on ultrasound.
Mucousy baby with copious amount of secretions.
Unable to insert orogastric tube.
Respiratory distress syndrome.
Aspiration pneumonia and sepsis.
Problems
Oesophageal Atresia: Inability to swallow saliva with
a risk of aspiration pneumonia.
Tracheo-oesophageal fistula: Reflux of
gastric contents, difficult to ventilate.
Distal obstruction: If present and the baby is ventilated, prone to
perforation of bowel.
Prematurity: If present, associated problems.
Management
Evaluation for other anomalies/problems e.g. cardiac, intestinal atresias,
pneumonia.
Suction of the upper oesophageal pouch: A Replogle (sump suction)
tube should be inserted and continuous suction done if possible. Otherwise, frequent intermittent suction (every 10-15 minutes) of oropharynx is
done including throughout the journey to prevent aspiration pneumonia.
Ventilation if absolutely necessary.
Fluids - Maintenance and resuscitation fluids as required.
Position - Lie the baby horizontal and lateral or prone to minimise
aspiration of the saliva and reflux.
Monitoring Pulse oximetry and cardiorespiratory monitoring.
Keep baby warm.
Refer to nearest centre with neonatal and paediatric surgical facilities
PAEDIATRIC SURGERY
521
CONGENITAL DIAPHRAGMATIC HERNIA

Types
Bochdalek: Posterolateral, commonest, more common on left side.
Eventration of the diaphragm.
Morgagni anterior, retrosternal.
Problems
Associated pulmonary hypoplasia.
Herniation of the abdominal viscera into thoracic cavity causing
mechanical compression and mediastinal shift.
Reduced and abnormal pulmonary arterial vasculature resulting in
persistent pulmonary hypertension of the newborn (PPHN) and reversal to
foetal circulation.
High mortality rate (40-60%) associated with early presentation.
Presentation
Antenatal: Fluid filled stomach or bowel with/without liver in the left
chest cavity.
Mediastinal shift.
Birth: Respiratory distress with cyanosis.
Absent breath sounds on left side, scaphoid abdomen.
Chest X-Ray: bowel loops within the chest and minimal bowel in abdomen.
Late presentation
Left side: Gastrointestinal symptoms- bowel obstruction.
Right side: Respiratory symptoms including recurrent respiratory
infections.
Asymptomatic: Abnormal incidental chest x-ray
PAEDIATRIC SURGERY
Mediastinal shift
Bowel in
Left chest cavity
Differential Diagnoses
Congenital cystic adenomatoid malformation.
Pulmonary sequestration.
Mediastinal cystic lesions e.g. teratoma.
522
Management
Evaluation for associated anomalies and persistent pulmonary
hypertension of the newborn (PPHN).
Ventilation - Intubation and ventilation may be required soon after
delivery and pre-transport. Ventilation with a face-mask should be avoided.
Low ventilatory pressures are to be used. A contralateral pneumothorax
or PPHN need to be considered if the child deteriorates. If the baby is
unstable or high ventilatory settings are required, the baby should not be
transported.
Frequent consultation with a paediatrician or paediatric surgeon to
decide when to transport the baby.
Chest tube - If inserted, it should not be clamped during the journey.
Orogastric Tube: Gastric decompression is essential here. A Size 6 or
8 Fr tube is inserted, aspirated 4 hourly and placed on free drainage.
Fluids Caution required as both dehydration and overload can
precipitate PPHN.
May need inotropic support and other modalities to optimize outcome.
Monitoring: Pre-ductal and post-ductal pulse oximetry to detect PPHN.
Position: Lie baby lateral with the affected side down to optimise
ventilation.
Warmth.
Consent: High risk.
Air transport considerations.
Referral to the paediatric surgeon for surgery when stabilised.
523
PAEDIATRIC SURGERY
Factors most affecting the outcome

Birth weight 2kg: Good outcome.
Apgar score at 5 minutes of 7-10: Good outcome.
Size of defect: If primary repair is achieved, 95% survival vs 57% survival
in agenesis.
Willford Hall/Santa Rosa predictive formula (WHSRpf) = Highest PaO2
Highest PaCo2 (using arterial blood sample within 24 hours of life). If WHSRpf > 0, survival was 83 94%. If WHSRpf < 0, survival was only 32-34%.
Cardiac anomalies- Survival was low for patients with haemodynamically
significant cardiac defects (41.1%), compared to patients without cardiac
lesions (70.2%)
Late presentation more than 30 days of life: 100% survival.
ABDOMINAL WALL DEFECTS

Exomphalos and Gastroschisis are commoner abdominal wall defects.
Gastroschisis: Defect in the anterior abdominal wall of 2-3 cm diameter
to the right of the umbilicus with loops of small and large bowel prolapsing
freely without a covering membrane.
Exomphalos: Defect of anterior abdominal wall of variable size (diameter
of base). It has a membranous covering (Amnion, Whartons jelly,
peritoneum) and the umbilical cord is usually attached to the apex of the
defect. The content of the large defect is usually liver and bowel but in the
small defect the content may just be bowel loops.
PAEDIATRIC SURGERY
Problems
Fluid loss: Significant in gastroschisis due to the exposed loops of bowel.
Hypothermia: Due to the larger exposed surface area.
High incidence of associated syndromes and anomalies especially in
exomphalos.
Hypoglycemia can occur in 50% of babies with Beckwith-Wiedermanns
Syndrome (exomphalos, macroglossia, gigantism).
Management
Evaluation: for hydration and associated syndromes and anomalies.
Fluids: IV fluids are essential as losses are tremendous especially from
the exposed bowel. Boluses (10-20 mls/kg) of normal saline/ Hartmanns
solution must be given frequently to keep up with the ongoing losses. A
maintenance drip of Saline + 10% D/W at 60 90 mls/kg (Day 1 of life)
should also be given.
Orogastric tube: Gastric decompression is essential here and a Size 6 or
8 Fr tube is inserted, aspirated 4 hourly and placed on free drainage.
Warmth: Pay particular attention to temperature control because of the
increased exposed surface area and fluid exudation causing evaporation
and the baby to be wet and cold. Wrapping the babys limbs with cotton
and plastic will help.
Care of the exposed membranes: The bowel/membranes should be
wrapped with a clean plastic film without compressing, twisting and kinking the bowel. Please do NOT use warm, saline soaked gauze directly on
the bowel as the gauze will get cold and stick to the bowel/membranes.
Disposable diapers or cloth nappies changed frequently will help to
keep the child dry.
Monitoring: Heart rate, Capillary refill time, Urine output (the baby may
need to be catheterised to monitor urine output or have the nappies
weighed).
Position: The baby should be placed in a lateral position to prevent
tension and kinking of the bowel.
Referral to the surgeon as soon as possible.
524
INTESTINAL OBSTRUCTION
Cause -May be functional e.g. Hirschsprungs disease or mechanical e.g.
atresias, midgut malrotation with volvulus.
Problems
Fluid loss due to the vomiting, bowel dilatation and third space losses.
Dehydration.
Diaphragmatic splinting.
Aspiration secondary to the vomiting.
Nutritional deficiencies.
Presentation
Antenatal diagnosis dilated fluid-filled bowels.
Delay in passage of meconium (Hirschsprungs disease, atresias).
Vomiting bilious/non-bilious (Bilious vomiting is due to mechanical
obstruction until proven otherwise).
Abdominal distension.
Abdominal X-ray dilated loops of bowel.
Management
Evaluation for onset of obstruction and associated anomalies
(including anorectal anomalies).
Fluids Intravenous fluids are essential.
Boluses - 10-20 mls/kg Hartmanns solution/Normal Saline to correct
dehydration and replace the measured orogastric losses.
Maintenance - Saline + 10% D/W + KCl as required.
Orogastric tube Gastric decompression is essential, a Size 6 or 8 Fr tube
is inserted, aspirated 4 hourly and placed on free drainage.
If Hirschsprungs disease is suspected, rectal washout can be performed
after consultation with a paediatrician or a paediatric surgeon.
Warmth.
Monitoring vital signs and urine output.
Air transport considerations during transfer to the referral centre.
PAEDIATRIC SURGERY
525
ANORECTAL MALFORMATIONS
Incidence 1: 4,000-5,000 live births
Cause- unknown
Newborn check important to clean off the meconium to check if a
normal anus is present.
Classification (Pena)
Type
Clinical Features
Management
Low type.
Midline snail-track.
Bucket handle.
No colostomy
required
Boys
Perineal
(cutaneous) fistula
Rectourethral fistula Most common.

Bulbar
Pass meconium in urine.
Prostatic
Colostomy
Rectovesical fistula
High type.
Associated sacral anomalies.
Colostomy
Imperforate anus
without fistula
Usually Down syndrome.

Sacrum/sphincter - normal.
Colostomy
Rectal atresia
Normal anal opening.

Atresia-2cm from anal verge.
Rare.
Colostomy
Perineal
(cutaneous) fistula
Rectum and vagina well

separated.
No colostomy
required
Vestibular fistula
Common
Fistula opening just posterior to
hymen.
Common wall; rectum and vagina.
Colostomy
Persistent cloaca
Rectum, Urethra, Vagina:

Single common channel of
variable length.
Single external opening.
Associated urogenital anomalies.
Colostomy +
vesicostomy
+ vaginostomy
Imperforate anus
without fistula
Usually Down syndrome

Sacrum/sphincter - normal
Colostomy
Rectal atresia
Rare.
Normal anal opening.
Atresia 2cm from anal verge.
Colostomy
PAEDIATRIC SURGERY
Girls
526
Associated Anomalies
Sacrum and Spine
Anomalies and spinal dysraphism is common.
Good correlation between degree of sacral development and final
prognosis. Absence of more than 3 sacrum: poor prognosis.
Urogenital
Common anomalies vesicoureteric reflux, renal agenesis.
Incidence low in low types and high in cloaca (90%).
Vaginal anomalies about 30%.
Others
Cardiac anomalies.
Gastrointestinal anomalies e.g. duodenal atresia.
Syndromes e.g. Trisomy 21.
Investigations
Chest and Abdominal X-ray.
Lateral Pronogram. (see Figure)
Echocardiogram.
Renal and Sacral Ultrasound.
Micturating cystourethrogram.
Distal loopogram.
Management
Boys and Girls
Observe for 12-24 hours.
Keep nil by mouth.
If abdomen is distended, to insert an orogastric tube for 4 hourly
aspiration and free drainage.
IV fluids saline with 10% Dextrose Water with KCl. May need
rehydration fluid boluses if child has been referred late and dehydrated.
Start IV antibiotics.
Assess for urogenital, sacral and cardiac anomalies.
527
PAEDIATRIC SURGERY
Boys
Inspect the perineum and the urine if there is clinical evidence of a low
type, the child needs to be referred for an anoplasty. If there is evidence
of meconium in the urine, the child requires a colostomy followed by the
anorectoplasty a few months later.
If there is no clinical evidence, a lateral pronogram should be done to
check the distance of the rectal gas from the skin to decide if a primary
anoplasty or a colostomy should be done.
Girls
Inspect the perineum.
If there is a rectovestibular fistula or a cutaneous fistula, then a primary
anoplasty or a colostomy is done.
If it is a cloacal anomaly, the child needs to be investigated for associated
genitourinary anomalies. The baby then requires a colostomy with drainage of the bladder and hydrocolpos if they are not draining well. The
anorectovaginourethroplasty will be done many months later.
If there is no clinical evidence, a lateral pronogram should be done to
check the distance of the rectal gas from the skin to decide if a primary
anoplasty or a colostomy should be done.
HIRSCHSPRUNGS DISEASE
Common cause of intestinal obstruction of the newborn.
Aetiology
Aganglionosis of the variable length of the bowel causing inability of the
colon to empty due to functional obstruction of the distal bowel.
The primary aetiology has been thought to be due to cellular and
molecular abnormalities during the development of the enteric
nervous system and migration of the neural crest cells into the developing
intestine.
Genetic factors play a role with an increased incidence in siblings, Down
Syndrome, congenital central hypoventilation syndrome and other
syndromes.
PAEDIATRIC SURGERY
Types
Rectosigmoid aganglionosis: commonest, more common in boys.
Long segment aganglionosis.
Total colonic aganglionosis: extending into the ileum or jejunum,
almost equal male: female ratio.
May present as a neonate or later in life.
Neonate.
Delay in passage of meconium (94-98% of normal term babies pass
meconium in the first 24 hours).
Vomiting bilious/non-bilious.
Hirschsprung-associated enterocolitis (HAEC) fever, foul smelling,
explosive diarrhoea, abdominal distension, septic shock. Has a high risk
of mortality and can occur even after the definitive procedure.
Older child.
History of constipation since infancy.
Failure to thrive.
Recurrent enterocolitis.
528
Other causes of delay in passage of meconium

Prematurity.
Sepsis, including urinary tract infection.
Intestinal atresias.
Meconium ileus.
Hypothyroidism.
Investigation
Plain Abdominal X-ray dilated loops of bowel with absence of gas in the
rectum, sometimes a megacolon is demonstrated. (Figure below)
Contrast enema presence of a transition zone with an abnormal

rectosigmoid index.
Rectal Biopsy: Absence of ganglion cells and presence of acetylcholinesterase
positive hypertrophic nerve bundles confirms the diagnosis
PAEDIATRIC SURGERY
529
Management
Enterocolitis (HAEC) high risk of mortality. Can occur even after the
definitive procedure.
Aggressive fluid resuscitation.
IV broad-spectrum antibiotics.
Rectal washouts-Using a large bore soft catheter inserted into the colon
past the transition zone, the colon is washed out with copious volumes of
warm normal saline (in aliqouts of 10-20mls/kg) till toxins are cleared.
(Figure below)
PAEDIATRIC SURGERY
If the decompression is difficult with rectal washouts, a colostomy or

ileostomy is required.
Definitive surgery, with frozen section to confirm the level of
aganglionosis, is planned once the diagnosis is confirmed.
Postoperatively, the child needs close follow-up for bowel management
and the development of enterocolitis.
530
PERFORATED VISCUS
Causes
Perforated stomach.
Necrotising enterocolitis.
Spontaneous intestinal perforations.
Intestinal Atresias.
Anorectal malformation.
Hirschsprungs disease.
Management
Evaluation: These babies are usually septic with severe metabolic acidosis,
coagulopathy and thrombocytopenia.
Diagnosis: A meticulous history of the antenatal, birth and postnatal
details may elicit the cause of the perforation. Sudden onset of increased
abdominal distension and deteriorating general condition suggests perforation.
Supine abdominal x-ray showing free intraperitoneal gas. (Figure below)
Falciform ligament
visible
Loss of liver
shadow
Riglers sign
531
PAEDIATRIC SURGERY
Ventilation: Most of the babies may require intubation and ventilation if

they are acidotic and the diaphragm is splinted.
Fluids: Aggressive correction of the dehydration, acidosis and
coagulopathy should be done.
Orogastric tube: It should be aspirated 4 hourly and left on free drainage.
Urinary Catheter: Monitor hourly urine output
Drugs: Will require antibiotics and possibly inotropic support
Consultation with the paediatrician or paediatric surgeon of the regional
referral centre before transfer of the baby.
Peritoneal Drain: If there is a perforation of the bowel, insertion of a
peritoneal drain (using a size 12-14 Fr chest tube or a peritoneal dialysis
drain into the right iliac fossa) with/without lavage with normal saline or an
isotonic peritoneal dialysate solution should be considered as a temporising measure while stabilising the baby prior to surgery. This can help to
improve the ventilation as well as the acidosis.
PAEDIATRIC SURGERY
References
Section 13 Paediatric Surgery
Ch 92 Appendicitis
1.Fyfe, AHB (1994) Acute Appendicitis, Surgical Emergencies in Children ,
Butterworth- Heinemann.
2.Anderson KD, Parry RL (1998) Appendicitis, Paediatric Surgery Vol 2, 5th
Edition Mosby
3.Lelli JL, Drongowski RA et al: Historical changes in the postoperative treatment of appendicitis in children: Impact on medical outcome. J Pediatr.
Surg Feb 2000; 35:239-245.
4.Meier DE, Guzzetta PC, et al: Perforated Appendicitis in Children: Is there a
best treatment? J Pediatr. Surg Oct 2003; 38:1520-4.
5.Surana R, Feargal Q, Puri P: Is it necessary to perform appendicectomy in
the middle of the night in children? BMJ 1993;306:1168.
6.Yardeni D, Coran AG et al: Delayed versus immediate surgery in acute appendicitis: Do we need to operate during the night? J Pediatr. Surg March
2004; 39:464-9.
7.Chung CH, Ng CP, Lai KK: Delays by patients, emergency physicians and
surgeons in the management of acute appendicitis: retrospective study
HKMJ Sept 2000; 6:254-9.
8.Mazziotti MV, et al: Histopathologic analysis of interval appendectomy
specimens: support for the role of interval appendectomy. J Pediatr. Surg
June 1997; 32:806-809.
Ch 94 Intussusception
1.POMR Bulletin Vol 22 (Paediatric Surgery) 2004.
2.Navarro OM et al: Intussusception: Use of delayed, repeated reduction
attempts and the management of pathologic lead points in paediatric
patients. AJR 182(5): 1169-76, 2004.
3.Lui KW et al: Air enema for the diagnosis and reduction of intussusception
in children: Clinical experience and fluoroscopy time correlation. J Pediatr
Surg 36:479-481, 2001.
4.Calder FR et al: Patterns of management of intussusception outside tertiary
centres. J Pediatr Surg 36:312-315, 2001.
5.DiFiore JW: Intussusception.Seminars in Paediatric Surgery Vol 6, No 4:214220, 1999.
6.Hadidi AT, Shal N El: Childhood intussusception: A comparative study of
nonsurgical management. J Pediatr Surg 34: 304-7, 1999.
7.Fecteau et al: Recurrent intussusception: Safe use of hydrostatic enema. J
Pediatr Surg 31:859-61, 1996.
532
Ch 96 Undescended Testis
1.Bhagwant Gill, Stanley Kogan 1997 Cryptorchidism (current concept). The
Paediatric Clinics of North America 44: 1211-1228.
2.ONeill JA, Rowe MI, et al: Paediatric Surgery, Fifth Edition 1998
Ch 99 Neonatal Surgery
1.Congenital Diaphragmatic Hernia Registry (CDHR) Report, Seminars in
Pediatric Surgery (2008) 17: 90-97
2.The Congenital Diaphragmatic Hernia Study Group. Defect size determines
survival in CDH. Paediatrics (2007) 121:e651-7
3.Graziano JN:Cardiac anomalies in patients with CDH and prognosis: a report
from the Congenital Diaphragmatic Hernia Study Group. J Pediatr Surg
(2005) 40:1045-50
4.Hatch D, Sumner E and Hellmann J: The Surgical Neonate: Anaesthesia and
Intensive Care, Edward Arnold, 1995
5.Vilela PC, et al: Risk Factors for Adverse Outcome of Newborns with Gastroschisis in a Brazilian hospital. J Pediatr Surg 36: 559-564, 2001
6.Pierro A: Metabolism and Nutritional Support in the Surgical neonate. J
Pediatr Surg 37: 811-822, 2002
7.Haricharan RN, Georgeson KE: Hirschsprung Disease. Seminars in Paediatric
Surgery 17(4): 266-275, 2008
8.Waag KL et al: Congenital Diaphragmatic Hernia: A Modern Day Approach.
Seminars in Paediatric Surgery 17(4): 244-254, 2008
PAEDIATRIC SURGERY
533
534
PAEDIATRIC SURGERY
Chapter 100: Juvenile Idiopathic Arthritis (JIA)

Definition
Definite arthritis of
Unknown aetiology.
Onset before the age 16 yrs.
Persists for at least 6 wks.
Symptoms and Signs in JIA
Articular
Extra-articular
Joint swelling
General
Fever, pallor, anorexia, loss of weight
Joint pain
Joint stiffness / gelling after
periods of inactivity
Joint warmth
Restricted joint movements
Limping gait
Growth disturbance
General: growth failure, delayed puberty
Local: limb length / size discrepancy,
micronagthia
Skin
subcutaneous nodules
rash systemic, psoriasis, vasculitis
Others
Hepatomegaly, splenomegaly,
lymphadenopathy,
Serositis, muscle atrophy / weakness
Uveitis: chronic (silent), acute in Enthesitis
related arthritis (ERA)
Enthesitis*
* inflammation of the entheses (the sites of insertion of tendon, ligament

or joint capsule into bone)
Helpful pointers in assessing articular symptoms
Mechanical
Psychosomatic
Pain
+/-
+++
Stiffness
++
Swelling
+++
+/-
+/-
Instability
+/-
++
+/-
Sleep disturbance
+/-
++
Physical signs
++
+/-
535
RHEUMATOLOGY
Inflammatory
Diagnosis and Differential diagnosis

JIA is a diagnosis of exclusion.
Differential diagnosis of JIA
Monoarthritis
Polyarthritis
Acute
JIA polyarthritis (RF positive or

negative), ERA, psoriatic arthritis
Acute rheumatic fever

Reactive arthritis: Post viral/ post
enteric /post streptococcal infection
Reactive arthritis
Septic arthritis / osteomyelitis
SLE
Early JIA
Other connective tissue diseases
Malignancy: leukaemia,
neuroblastoma
Haemophilia
Sarcoidosis
Trauma
Familial hypertrophic synovitis

syndromes
Chronic
Immunodeficiency syndromes
JIA: oligoarthritis, ERA, psoriatic
Mucopolysaccharidoses
Lyme disease
Chronic infections: TB, fungal,

brucellosis
Pigmented villonodular synovitis
Sarcoidosis
Synovial haemangioma
RHEUMATOLOGY
Bone malignancy
Helpful pointers in diagnosis:
avoid diagnosing arthritis in peripheral joints if no observed joint swelling.
consider other causes, particularly if only one joint involved.
active arthritis can be present with the only signs being decreased range of
movement and loss of function.
in axial skeleton (including hips), swelling may not be seen. Diagnosis is
dependent on inflammatory symptoms (morning stiffness, pain relieved
by activity, pain on active and passive movement, limitation of movement).
Investigations to exclude other diagnosis are important.
in an ill child with fever, loss of weight or anorexia, consider infection,
malignancy and other connective tissue diseases.
536
Investigations
The diagnosis is essentially clinical; laboratory investigations are only
supportive.
No laboratory test or combination of tests can confirm the diagnosis of JIA.
FBC and Peripheral blood film exclude leukaemia. BMA may be required if there are any atypical symptoms/signs even if PBF is normal
ESR or CRP markers of inflammation.
X-ray/s of affected joint/s: esp. if single joint involved to look for malignancy.
Antinuclear antibody identifies a risk factors for uveitis
Rheumatoid factor assess prognosis in polyarthritis and need for
more aggressive therapy.
*Antinuclear antibody and Rheumatoid factor are NOT required to make a
diagnosis.
* Other Ix done as neccesary : complement levels, ASOT, Ferritin,
immunoglobulins (IgG, IgA and IgM), HLA B27, synovial fluid aspiration for
microscopy and culture, echocardiography, MRI/CT scan of joint, bone scan .
Management
Medical treatment
Refer management algorithm (see following pages)
Dosages of drugs commonly used in JIA
Dose
Frequency
Ibuprofen
5 - 10 mg/kg/dose
3-4/day
Naproxen
5 - 10 mg/kg/dose
2/day
Indomethacin
0.5 - 1 mg/kg/dose
2-3/day
Diclofenac
0.5 - 1 mg/kg/dose
3/day
Methotrexate
10 - 15 mg/m /dose
(max 25 mg/dose)
1/week
Folic acid
2.5 - 5.0 mg per dose
1/week
Sulphasalazine
15 - 25 mg/kg/dose
(start 2.5 mg/kg/dose and double
weekly; max 2 Gm/day
2/day
Hydroxychloroquine 5 mg/kg/dose
1/day
Methylprednisolone 30 mg/kg/dose (max 1 Gm / dose)
1/day x 3 days
Prednisolone
1-3/day
0.1 - 2 mg/kg/dose
Note:
Patients on DMARDS (e.g. Methotrexate, Sulphasalazine) and long term
NSAIDs (e.g. Ibuprofen, Naproxen) require regular blood and urine
monitoring for signs of toxicity.
537
RHEUMATOLOGY
Name
RHEUMATOLOGY
Physiotherapy
Avoid prolonged immobilisation
Strengthens muscles, improves and maintains range of movement
Improves balance and cardiovascular fitness
Occupational Therapy
Splinting when neccesary to reduce pain and preserve joint alignment.
To improve daily quality of life by adaptive aids and modifying the
environment.
Ophthalmologist
All patients must be referred to the ophthalmologist for uveitis
screening (as uveitis can be asymptomatic) and have regular follow-up
even if initial screening normal.
Others
Ensure well balanced diet, high calcium intake.
Encourage regular exercise and participation in sports and physical
education.
Family support and counselling when required.
Referral to other disciplines as required: Orthopaedic surgeons,
Dentist.
538
TREATMENT FOR CHILDREN WITH CHRONIC ARTHRITIS
Oligoarthritis (1-4 joints)

Oligoarthritis *
Start NSAIDs
Start IACI, if can

be done quickly
Review 4-6 wks
Review 4-6 wks

No/inadequate improvement *
Improving
IACI of target joints

Or/and optimize /
change NSAIDs
Continue NSAIDs
Review 3 mths
Review 2 mths
Inactive
Disease
Persistent or
Recurrent disease
Inflammation improved, but

persistent or no improvement *
cont NSAIDs x further 4-6 mths ,

then to taper off if well
Start DMARD : MTX, SZ

or HCQ if mild disease
Repeat IACI
Or/and increase dose of NSAIDs
Remember to Screen for Uveitis
Footnote:
*, Consider referral to Paeds Rheumatologist / reconsider diagnosis;
Abbreviations:
IACI, Intra-articular corticosteroid injection; MTX , Methotrexate;
SZ, Sulphasalazine; HCQ, Hydroxychloroquine; DMARD, Disease modifying
anti-rheumatic drugs.
539
RHEUMATOLOGY
All patients with persistent inflammation should be on DMARDs within 6

months of diagnosis even if only having oligoarthritis.
Polyarthritis (> 5 joints)

Polyarthritis *
Start NSAIDs
Once diagnosis certain: *
Start DMARD: oral MTX
Consider SZ in ERA; HCQ in very mild disease
Start steroids: pulsed IV Methylprednisolone (MTP) x 3/7
or short pulse of oral Prednisolone x 4-8 wks
or IACI of target joints
Review 1-2 mths
Improving
No/inadequate improvement *
Review 3 mths
Optimise dose of DMARD
IACI of target joints
or low dose Prednisolone
Remission
Review 2-3 mths
Cont NSAIDs further 6 mths,

then stop
Cont DMARDs at least 1 year
after onset of remission
& stopping steroids & NSAID
Persistent
Inflammation *
RHEUMATOLOGY
Change to s/c MTX

Consider combination DMARD:
MTX + SZ +/- HCQ
Consider alternative DMARDS
Consider biologics
Best opportunity to achieve remission in first two years of disease
Avoid accepting low grade inflammation until all avenues explored
Footnote:
Abbreviations:
IACI, Intra-articular corticosteroid injection; MTX , Methotrexate;
SZ, Sulphasalazine; HCQ, Hydroxychloroquine; ERA, enthesitis related arthritis;
DMARD, Disease modifying anti-rheumatic drugs.
540
Systemic onset JIA

Ensure diagnostic certainty of systemic JIA *
Do not misdiagnose infection, malignancy,
Kawasaki or connective tissue disease
Start NSAIDs (consider indomethacin)
Start steroids: IV MTP pulse x 3/7
or high dose oral Prednisolone
Review Frequently
Yes
Is Disease Inactive?
No
Able to Taper
Steroids?
Yes
No
Persistently
Active Disease *
Start Oral MTX

Consider IV MTP Pulse
Continue tapering and

discontinue steroids after
6 mths without inflammation
Still Persistently
Active Disease *
No
Yes
Are systemic or articular

features active, or both ? *
Refer patient *
Consider IV MTP Pulse
Consider Cyclosporin
Systemic symptoms only:

Consider pulsed IV MTP
Consider combination Rx
(Cyclosporin, IVIG,
HCQ, CYP)
Consider biologics
Arthritis and
Systemic symptoms:
Combination treatment
as per arthritis and
systemic symptoms

Avoid gold, penicillamine, SZ and caution with new drugs as risk of developing Macrophage Activation Syndrome (MAS)
Footnote:
Abbreviations: as previous page; CYP, cyclophosphamide; IVIG, IV immunoglobulins.
541
RHEUMATOLOGY
Arthritis only:
Change to SC MTX,
optimize dose
+/- IACI
Consider biologics
Is there MAS?
RHEUMATOLOGY
References
Section 14 Rheumatology
Chapter 100 Juvenile Idiopathic Arthritis
1. Cassidy JT, Petty RE. Juvenile Rheumatoid Arthritis. In: Cassidy JT, Petty RE,
eds. Textbook of Pediatric Rheumatology. 4th Edition. Philadelphia: W.B.
Saunders Company, 2001.
2. Hull, RG. Management Guidelines for arthritis in children. Rheumatology
2001; 40:1308-1312
3. Petty RE, Southwood TR, Manners P, et al. International League of Associations for Rheumatology. International League of Associations for Rheumatology classification of juvenile idiopathic arthritis: second revision,
Edmonton, 2001. J Rheumatol. 2004;31:390-392.
4. Khubchandani RP, DSouza S. Initial Evaluation of a child with Arthritis An
Algorithmic Approach. Indian J of Pediatrics 2002 69: 875-880.
5. Ansell, B. Rheumatic disease mimics in childhood. Curr Opin Rheumatol
2000; 12: 445-447
6. Woo P, Southwood TR, Prieur AM, et al. Randomised, placebo controlled
crossover trial of low-dose oral Methotrexate in children with extended
oligoarticular or systemic arthritis. Arthritis Rheum 2000; 43: 1849-57.
7. Alsufyani K, Ortiz-Alvarez O, Cabral DA, et al. The role of subcutaneous
administration of methotrexate in children with JIA who have failed oral
methotrexate. J Rheumatol 2004; 31 : 179-82
8. Ramanan AV, Whitworth P, Baildam EM. Use of methotrexate in juvenile
idiopathic arthritis. Arch Dis Child 2003; 88: 197-200.
9. Szer I, Kimura Y, Malleson P, Southwood T. In: The Textbook of Arthritis in
Children and Adolescents: Juvenile Idiopathic Arthritis. 1st Edition. Oxford
University Press, 2006
10. Wallace, CA. Current management in JIA. Best Pract Res Clin Rheumatol
2006; 20: 279-300.
542
Chapter 101: Snake Bite

Introduction
In Malaysia there are approximately 40 species of venomous snakes
(18 land snakes and all 22 of sea snakes) belonging to two families
elapidae and viperidae.
Elapidae have short, fixed front fangs. The family includes cobras,
kraits, coral snakes and sea snakes.
Viperidae have a triangular shaped head and long, retractable fangs.
The most important species in Malaysia are Calloselasma rhodostoma
(Malayan pit viper) and Trimeresurus genus (green viper). The Malayan pit
vipers are common especially in the northern part of Peninsular Malaysia
and are not found in Sabah and Sarawak.
Cobra and Malayan pit vipers cause most of the cases of snakebites in
Malaysia. Bites by sea snakes, coral snakes and kraits are uncommon.
The snake venom are complex substances proteins with enzymatic
activity. Although enzymes play an important role the lethal properties are
caused by certain smaller polypeptides. Components such as procoagulant
enzymes activate the coagulation cascade, phospholipase A2 (myotoxic,
neurotoxic, cardiotoxic causes haemolysis and increased vascular permeability), proteases (tissue necrosis), polypeptide toxins (disrupt neuromuscular transmissions) and other components.
Clinical features
Cobra usually cause pain and swelling of the bite site but more worrying
is the neurological dysfunctions: ptosis, ophthalmoplegia, dysphagia,
aphasia and respiratory paralysis.
Kraits cause minimal local effects but may cause central nervous system
manifestations. Sea snakes cause minimal local effects and mainly musculoskeletal findings: myalgia, stiffness and paresis leading to myoglobinuria
and renal failure. Paralysis can also occur.
Pit vipers cause extensive local effects: immediate pain, swelling,
blisters and necrosis, vascular effects and hemolysis and systemic effects
such as coagulopathies. Bleeding occurs at bite site, gingival sulci and
venepuncture sites. Venom alters capillary permeability causing extravasation of electrolytes, albumin and rbcs through the vessel wall into
envomated site.
Note: There may be overlap of clinical features caused by venoms of
different species of snake. For example, some cobras can cause severe local
envenoming (formerly thought to be due to only vipers).
POISONS & TOXINS
543
POISONS & TOXINS
Management
First aid
The aims are to retard absorption of venom, provide basic life support
and prevent further complications.
Reassure the victim anxiety state increases venom absorption.
Immobilise bitten limb with splint or sling (retard venom absorption).
Apply a firm bandage for elapid bites (delay absorption of neurotoxic
venom) but not for viper bites whose venom cause local necrosis.
Leave the wound alone - DO NOT incise, apply ice or other remedies.
Tight (arterial) tourniquets are not recommended.
Do not attempt to kill the snake. However, if it is killed bring the snake to
the hospital for identification. Do not handle the snake with bare hands as
even a severed head can bite!
Transfer the victim quickly to the nearest health facility.
Treatment at the Hospital
Do rapid clinical assessment and resuscitation including Airway, Breathing,
Circulation and level of consciousness. Monitor vital signs (blood pressure,
respiratory rate, pulse rate).
Establish IV access; give oxygen and other resuscitations as indicated.
History: Inquire part of body bitten, timing, type of snake, history of atopy.
Examine
Bitten part for fang marks (sometimes invisible), swelling, tenderness,
necrosis.
Distal pulses (reduced or absent in compartment syndrome)
Patient for bleeding tendencies tooth sockets, conjunctiva, puncture
sites.
Patient for neurotoxicity ptosis, ophthalmoplegia, bulbar and
respiratory paralysis.
Patient for muscle tenderness, rigidity (sea snakes).
Urine for myoglobinuria.
Send blood investigations (full blood count, renal function tests,
prothrombin time /partial thromboplastin time, group and cross matching).
Perform a 20-min Whole Blood Clotting Test. Put a few mls of blood in a
clean, dry glass test tube, leave for 20 min, and then tipped once to see if it
has clotted. Unclotted blood suggests hypofibrinogenaemia due to pit viper
bite and rules out an elapid bite.
Review immunisation history: give booster antitetanus toxoid injection
if indicated.
Venom detection kit is used in some countries to identify species of
snake. However, it is not available in Malaysia.
Admit to ward for at least 24 hours (unless snake is definitely
non-venomous).
544
Antivenom treatment
Antivenom is the only specific treatment for envenomation.
Give as early as indicated for best result. Effectiveness is time and dose
related. It is most effective within 4 hrs after envenomation and less effective after 12 hrs although it may reverse coagulopathies after 24 hrs.
Indications for antivenom
Should be given only in the presence of envenomation as evidenced by:
Coagulopathy.
Neurotoxicity.
Hypotension or shock, arrhythmias.
Generalised rhabdomyolysis (muscle aches and pains).
Acute renal failure.
Local envenomation e.g. local swelling more than half of bitten limb,
extensive blistering/bruising, bites on digit, rapid progression of swelling.
Helpful laboratory investigations suggesting envenomation include
anaemia, thrombocytopenia, leucocytosis, raised serum enzymes
(creatine kinase, aspartate aminotransferase, alanine aminotransferase),
hyperkalaemia, and myoglobinuria.
Choice of antivenom
If biting species is known, give monospecific (monovalent) antivenom
(more effective and less adverse reactions).
If it is not known, clinical manifestations may suggest the species:
Local swelling with neurological signs = cobra bites
Extensive local swelling + bleeding tendency = Malayan Pit vipers
If still uncertain, give polyvalent antivenom.
No antivenom is available for Malayan kraits, coral snakes and some
species of green pit vipers. Fortunately, bites by these species are rare
and usually cause only trivial envenoming.
Dosage and route of administration
Amount given is usually empirical. Recommendations from manufacturers
are usually very conservative as they are mainly based on animal studies.
545
Initial dose
100 mls
50 mls (local)
100 mls (systemic)
50 mls (local)
100 - 150 mls (systemic)
50 100 mls
1 000 units (1 vial)
POISONS & TOXINS
Guide to initial dosages of important Antivenoms

Species
Antivenom manufacturer
Malayan pit viper Thai Red Cross (Monovalent)
Cobra
Twyford Pharmaceuticals
(monovalent)
Serum Institute of India;
Biological E. Limited, India
(Polyvalent)
King Cobra
Thai Red Cross (Monovalent)
Common sea
CSL, Australia (polyvalent)
snake
POISONS & TOXINS
Repeat antivenom administration until signs of envenomation resolved.

Give through IV route only. Dilute antivenom in any isotonic solution
(5-10ml/kg, bigger children dilute in 500mls of IV solution) and infuse the
whole amount in one hour.
Infusion may be discontinued when satisfactory clinical improvement
occurs even if recommended dose has not been completed
Do not perform sensitivity test as it poorly predicts anaphylactic
reactions.
Do not inject locally at the bite site.
Prepare adrenaline, hydrocortisone, antihistamine and resuscitative
equipment and be ready if allergic reactions occur.
Pretreatment with adrenaline SC remains controversial. Small controlled
studies in adults have shown it to be effective in reducing risk of reactions. However, its effectiveness and appropriate dosing in children have
not been evaluated. There is no strong evidence to support the use of
hydrocortisone/antihistamine as premedications. Consider their use in the
patient with history of atopy.
Antivenom reactions occurs in 20% of patients
3 types of reactions may occur:
Early anaphylactic reactions
Occur 10-180 minutes after starting antivenom. Symptoms range from
itching, urticaria, nausea, vomiting, and palpitation to severe systemic
anaphylaxis: hypotension, bronchospasm and laryngeal oedema.
Treatment of anaphylactic reactions:
Stop antivenom infusion.
Give adrenaline IM (0.01ml/kg of 1 in 1000) and repeat every 5-10mins
till symptoms subside. In case of persistent hypotension, life threatening
anaphylaxis, adrenaline can be given IV 0.1mg of 1:10,000 dilution
bolus over 5 mins. If hypotension is refractory to bolus dose start
IV infusion at 1 microgm/kg/min. Close monitoring of heart rate is
required.
Give antihistamine, e.g. chlorpheniramine 0.2mg/kg, hydrocortisone
4mg/kg/dose and IV fluid resuscitation (if hypotensive).
Nebulised adrenaline in the presence of stridor or partial obstruction
Nebulised salbutamol in the presence of bronchospasm or wheeze
If only mild reactions, restart infusion at a slower rate.
Pyrogenic reactions develop 1-2 hours after treatment and are due to
pyrogenic contamination during the manufacturing process. Symptoms include fever, rigors, vomiting, tachycardia and hypotension. Give treatment
as above. Treat fever with paracetamol and tepid sponging.
Late reactions occur about a week later. It is a serum sickness-like
illness (fever, arthralgia, lymphadenopathy, etc).
Treat with Chlorpheniramine 0.2mg/kg/day in divided doses for 5 days.
If severe, give Oral prednisolone (0.7 1mg/kg/day) for 5-7 days.
546
When to restart the antivenom after a reaction:

Once the patient has stabilized, BP under control, manifestations of the
reaction has subsided.
In severe reactions restart antivenom under cover of adrenaline infusion.
Rate of antivenom infusion is decreased initially and done under close
monitoring in the ICU. Weigh the need for antivenom versus the potential
risk of a severe anaphylactic reaction.
Anticholinesterases
They should always be tried in severe neurotoxic envenoming, especially
when no specific antivenom is available, e.g. bites by Malayan krait and
coral snakes. The drugs have a variable but potentially useful effect.
Give test dose of Edrophonium chloride (Tensilon) IV (0.25mg/kg,
adult 10mg) with Atropine sulphate IV (50g/kg, adult 0.6mg). If patients
respond convincingly, maintain with Neostigmine methylsulphate IV
(50-100g/kg) and Atropine, four hourly by continuous infusion.
Supportive/ancillary treatment
Clean wound with antiseptics.
Give analgesia to relief pain (avoid aspirin). In severe pain, morphine
may be administered with care. Watch closely for respiratory depression.
Give antibiotics if the wound looks contaminated or necrosed
e.g. IV Crystalline Penicillin +/- Gentamicin, Amoxicillin/clavulanic acid,
Erythromycin or a third generation Cephalosporin.
Respiratory support respiratory failure may require assisted ventilation.
Watch for compartment syndrome pain, swelling, cold distal limbs and
muscle paresis. Get early orthopaedic/surgical opinion.Patient may require
urgent fasciotomy but consider only after sufficient antivenom has been
given and correction of coagulation abnormalities with fresh frozen plasma
and platelets before any surgical intervention as bleeding may be uncontrollable.
Desloughing of necrotic tissues should be carried out as required.
For oliguria and renal failure, e.g. due to sea snake envenomation,
measure daily urine output, serum creatinine, urea and electrolytes. If
urine output fails to increase after rehydration and diuretics (e.g. frusemide), start renal dose of dopamine (2.5g/kg/minute IV infusion) and place
on strict fluid balance. Dialysis is rarely required.
POISONS & TOXINS
547
POISONS & TOXINS
Pitfalls in management
Giving antivenom prophylactically to all snakebite victims. Not all
snakebites by venomous snakes will result in envenoming. On average,
30% bites by cobra, 50% by Malayan pit vipers and 75% by sea snakes DO
NOT result in envenoming. Antivenom is expensive and carries the risk of
causing severe anaphylactic reactions (as it is derived from horse or sheep
serum). Hence, it should be used only in patients in whom the benefits of
antivenom are considered to exceed the risks.
Delaying in giving antivenom in district hospitals until victims are
transferred to referral hospitals. Antivenom should be given as soon as it
is indicated to prevent morbidity and mortality. District hospitals should
stock important antivenoms and must be equipped with facilities and staff
to provide safe monitoring and care during the antivenom infusion.
Giving polyvalent antivenom for envenoming by all type of snakes.
Polyvalent antivenom does not cover all types of snakes, e.g. Sii polyvalent
(imported from India) is effective in cobra and some kraits envenoming but
is not effective against Malayan pit viper. Refer to manufacturer drug insert
for details.
Giving smaller doses of antivenom for children. The dose should be the
same as for adults. Amount given depends on the amount of venom
injected rather than the size of victim.
Giving pretreatment with hydrocortisone / antihistamine for snakebite
victims. Snakebites do not cause allergic or anaphylactic reactions. These
medications may be considered in those who are given ANTIVENOM.
548
Chapter 102: Common Poisons

Principles in approach to poisoning
There is no role for the use of emetics in the treatment of poisoning.
The use of activated charcoal for reducing drug absorption should be
considered if patient presents within 1 hour of ingestion. A single dose of
1g/kg body wt can be given by mouth or nasogastric tube within 1 hour of
ingestion of a well charcoal absorbed poison and perhaps > 1 hour in the
case of a slow release drug preparation.
Gastric lavage is not recommended unless the patient has ingested a
potentially life threatening amount of a poison and the procedure can be
undertaken within 1 hour of ingestion.
When in doubt about the nature of poison, contact the poison centre for
help:
National Poison Centre (Pusat Racun Negara)
Tel: 1800-888099 OR 04-6570099
Mon Fri: 8.10 am 4.40 pm; Sat: 8.10 am 1 pm
Tel: 012-4309499
After Office Hours
549
POISONS & TOXINS
Laboratory investigations
A careful history may obviate the need for blood tests.
Blood glucose should be taken in all cases with altered sensorium
Blood gas analysis in any patient with respiratory insufficiency,
hyperventilation or metabolic acid base disturbance is suspected.
Electrolyte estimation may be useful as hypokalaemia has been seen in
acute poisoning.
A wide anion gap is seen in methanol, paraldehyde, iron, ethanol,
salicylate poisoning.
Routine measurement of paracetamol level should be performed in
deliberate poisoning in the older child.
Radiology may be used to confirm ingestion of metallic objects, iron
salts.
ECG is an invaluable tool in detection of dysrhythmia and conduction
abnormalities such as widened QRS or prolonged QT interval. Tricyclic Antidepressant poisoning.may manifest as myocardial depression, ventricular
fibrillation or ventricular tachycardia.
PARACETAMOL
Paracetamol is also called acetaminophen. Poisoning occurs when >
150mg/kg ingested. Fatality is unlikely if < 225mg/kg is ingested.

Clinical Manifestations of Paracetamol poisoning
Stage 1
Nausea vomiting within 12 -24 hours, some asymptomatic.
Stage 2
Liver enzymes elevated by 24 hours after ingestion. Symptoms

often abate.
Stage 3
Liver enzymes abnormalities peak at 48 -72 hours and symptoms of nausea, vomiting and anorexia return. The clinical
course may result in recovery or hepatic failure. There may be
renal impairment.
Stage 4
Recovery phase lasts 7-8 days.
Most serious effect is liver damage which may not be apparent in the first
2 days.
POISONS & TOXINS
NORMOGRAM FOR ACUTE PARACETAMOL POISONING.

Adapted from Rumack BH, Matthew H. Acetaminophen
poisoning and toxicity. Pediatrics1975;55(6):871876
550
The most efficacius therapy involves the administration of N-acetylcysteine

which serves as a precursor to facilitate the synthesis of glutathione.
Management
Measure the plasma paracetamol level at 4 hours after ingestion and then
4 hourly. Other investigations: RBS/LFT/PT/PTT/RFT daily for 3 days.
Initiation of N-Acetylcysteine (NAC) within 10 hours of ingestion but it is still
beneficial up to 24 hours of ingestion.
IV NAC if the 4 hour plasma paracetamol level exceeds 150g/ml.
Dose: 150mg/kg in 3mls/kg 5%Dextrose over 15 min, followed by 50mg/kg
in 7mls/kg 5% Dextrose over 4 hours,
then 100mg/kg in 14mls/kg 5% Dextrose over 16 hours.
It is much less effective if given later than 15 hours after ingestion.
Decision is based on the Rumack- Matthew normogram. Plot the serum
level of paracetamol drawn at least 4 hrs following ingestion.
If patients are on enzyme-inducing drugs, they should be given NAC if the
levels are 50% or more of the standard reference line.
If no blood levels are available, start treatment based on clinical history.
Therapy can be stopped once level obtained is confirmed in the non toxic
range.
It may be necessary to continue the NAC beyond 24 hrs in massive overdose.
The paracetamol level should be checked before disontinuing and if still
high rebolus and continue at 6-5 mg/kg till level is < 10g/ml. Advisable to
contact the poison centre.
Ensure the NAC is appropriately diluted and patient does not become
fluid overloaded.
Adverse reactions to NAC.
Flushing, aching, rashes, angioedema, bronchospasm and hypertension.
NAC should be stopped and if necessary, IV antihistamine given.
Once adverse reactions resolved, NAC restarted at 50mg/kg over 4 hrs
If PT ratio exceeds 3.0, give Vitamin K 1 10mg IM.
FFP or clotting factor concentrate may be necessary.
Treat complications of acute hepatorenal failure.
Management of a single overdose is straightforward and is guided by the above.
However when cases are associated with staggered overdoses or repeated
supratherapeutic doses, patients with high risk factors or late presentations, management decisions become more complex.
POISONS & TOXINS
551
HIGH RISK TREATMENT LINE

At Risk Patients
Regular use of enzyme inducing drugs
e.g. Carbamazepines, phenytoin, phenobarbitone, rifampicin
Conditions causing glutathione depletion
Malnutrition, HIV, eating disorders, cystic fibrosis
Repeated supratherapeutic ingestion or when timing of ingestion is
uncertain:
Children under 6 years of age who have ingested
200mg/kg or more over a single 24 hr period
150 mg/kg or more per 24 hr period for the preceding 48 hrs
100 mg/kg or more per 24 hr period for the preceding 72 hrs or longer
Children over 6 years of age who have ingested
At least 10g or 200mg/kg (whichever is less) over a single 24 hr period
At least 6g or 150mg/kg (whichever is less) over a single 24 hr period
for the preceding 48hrs or longer.
Levels are difficult to interpret, advice should be sought from the
Poison Centre. If in doubt treat first.
Prognosis
Younger children who accidentally ingest a single dose were less at risk
for hepatotoxicity and have a good prognosis.
Older children who self harm with overdoses and young children who
ingest repeated overdosings may suffer severe morbidity and mortality.
POISONS & TOXINS
Indicators of severe paracetamol poisoning and when to refer to a

specialist centre:
Progressive coagulopathy:
INR >2 at 24hrs, INR > 4 at 48hrs or INR >6 at 72 hrs.
Renal impairment creatinine > 200 mol/l.
Hypoglycemia.
Metabolic acidosis despite rehydration.
Hypotension despite fluid resuscitation.
Encephalopathy.
552
SALICYLATE
Ingestion of > 0.15 mg/kg will cause symptoms.
The fatal dose is estimated to be 0.2 0.5g/kg.
Its main effects are as a metabolic poison causing metabolic acidosis
and hyperglycaemia.

Clinical Manifestations of Salicylate poisoning
General
Hyperpyrexia, profuse sweating and dehydration
CNS
Delirium, seizures, cerebral oedema, coma, Reyes

syndrome
Respiratory
Hyperventilation
GIT
Epigastric pain, nausea, vomiting, UGIH, acute hepatitis
Renal
Acute renal failure
Metabolic
Hyper/hypoglycaemia, anion gap metabolic acidosis,

hypokalaemia
Cardiovascular
Non-cardiogenic pulmonary oedema
Investigation : FBC, PCV, BUSE/Serum creatinine

LFT/PT/PTT, RBS; ABG
Serum salicylate level at least 6 hours after ingestion

553
POISONS & TOXINS
Management
Use activated charcoal to reduce absorption and alkalinisation to
enhance elimination. Activated charcoal 1-2g/kg/dose 4-8 hourly. Meticulous monitoring of urine pH to avoid significant alkalemia
Correct dehydration, hypoglycaemia, hypokalaemia, hypothermia and
metabolic acidosis.
Give vitamin K if there is hypoprothrombinaemia.
Plot the salicylate level on the normogram.
Forced alkaline diuresis (* Needs close monitoring as it is potentially
dangerous) for moderate to severe cases.
(For salicylate level > 35 mg/dl 6 hrs after ingestion )
Give 30mls/kg in 1st hour (1/5 DS + 1ml/kg 8.4% NaHCO3).
Give IV Frusemide (1mg/kg/dose) after 1st hr and then 8hrly.
Continue at 10mls/kg/hr till salicylate level is at a therapeutic range.
Add 1g KCl to each 500mls of 1/5 DS to the above regime
(discontinue KCl if Se K+ > 5mmol/L).
Aim for plasma pH of >7.5 and urine output of > 3-6ml/kg/h.
BUSE/RBS/ABG every 6 hrs.
Treatment of Hypoglycaemia (5ml/kg of 10% dextrose).
DONE NORMOGRAM FOR ACUTE SALICYLATE POISONING.

Adapted from Done AK. Salicylate intoxication: Significance
of measurements of salicylate in blood in cases of
acute ingestion. Pediatrics 1960;26:800-7.
Haemodialysis in
Severe cases, blood level > 100mg/dl.
Refractory acidosis.
Renal failure.
Non-cardiogenic pulmonary oedema.
Severe CNS symptoms e.g. seizures.
POISONS & TOXINS
Prognosis
The presence of coma, severe metabolic acidosis together with plasma
salicylate concentrate > 900mg/L indicate a poor prognosis even with
intensive treatment.
554
IRON
Dangerous dose of iron can be as small as 30mg/kg. The toxic effect of iron is
due to unbound iron in the serum.

Stage 1
(6 - 12hrs)
Stage 2
(8 - 16hrs)
Stage 3
(16-24hrs)
Stage 4
(2 - 5wks)
Clinical Manifestations in Iron poisoning

Gastrointestinal bleeding, vomiting, abdominal pain,
diarrhoea, hypotension, dehydration, acidosis and coma.
Symptom free period but has nonspecific malaise.
Profound hemodynamic instability and shock.
Liver failure and gastrointestinal scarring with pyloric
obstruction.
Prognosis
Gastrointestinal bleeding, hypotension, metabolic acidosis, coma and
shock are poor prognostic features.
555
POISONS & TOXINS
Management
Emphasis is on supportive care with an individualised approach to
gastrointestinal decontamination and selective use of antidotes.
Ingestion < 30mg/kg - patients are unlikely to require treatment.
Ingestion of > 30mg/kg - perform an abdominal XRay. If pellets are seen
then use gastric lavage with wide bore tube or whole bowel irrigation with
polyethylene glycol if pellets are seen in small bowel.
(500ml/h in children < 6 yrs, 1000ml/h in children 6-12 yrs and 1500
2000ml/h in children >12 yrs old.
Contraindications: Paralytic ileus, significant haematemesis, hypotension)
Blood should be taken at 4 hrs after ingestion.
If level < 55mol/l , unlikely to develop toxicity.
If level 55-90mol/l, observe for 24 48 hrs. Chelate if symptomatic
i.e. hemetemesis or malaena.
If level > 90mol/l or significant symptoms, chelation with
IV Desferrioxamine 15 mg/kg till max of 80 mg/kg in 24 hours.
If serum Iron is not available, severe poisoning is indicated by nausea,
vomiting, leucocytosis >15 X 109 and hyperglycaemia > 8.3 mol/l
Administer Desferrioxamine with caution because of hypotension and
pulmonary fibrosis. Continue chelation therapy till serum Iron is normal,
metabolic acidosis resolved and urine colour returns to normal.
If symptoms are refractory to treatment following 24 hrs of chelation, reduce
rate of infusion because of its association with acute respiratory distress
syndrome.
Critical care management includes management of cardiopulmonary
failure, hypotension, severe metabolic acidosis, hypoglycaemia or hyperglycaemia, anaemia, GIT bleed, liver and renal failure.
KEROSENE INGESTION AND HYDROCARBONS

Strict contraindication to doing gastric lavage and emesis: it increases
risk of chemical pneumonitis.
Admit the child for observation for respiratory distress and treat
symptomatically.
Cerebral effects may occur from hypoxia secondary to massive
inhalation.
Antibiotics and steroids may be useful in lipoid pneumonia
(esp. liquid paraffin).
Chest X ray.
TRICYCLIC ANTIDEPRESSANTS
POISONS & TOXINS
Clinical Manifestations of Tricyclic Antidepressant poisoning
Anticholinergic
effects
Fever, dry mouth, mydriasis, urinary retention, ileus.
CNS
Agitation, confusion, convulsion,drowsiness, coma
Respiratory
Respiratory depression
Cardiovascular
Sinus tachycardia, hypotension, complex arrhythmias
Management
There is no specific antidote.
Give activated charcoal 1-2 g/kg/dose 4-8hourly.
Place patient on continuous ECG monitoring. Meticulous monitoring is
required. In the absence of QRS widening, cardiac conduction abnormality,
hypotension, altered sensorium or seizures within the 6 hours; it is unlikely
the patient will deteriorate.
Treatment should be instituted for prolonged QRS and wide complex
arrythmias. QRS > 100ms (seizures) and QRS >160ms (arrhythymia).
Correct the metabolic acidosis. Give bicarbonate (1-2mmol/kg) to keep
pH 7.45 7.55 when QRS is widened or in the face of ventricular arrhthymias. Administration of NaHCO3 is targeted at narrowing the QRS and is
titrated accordingly by bolus or by infusion. Watch out for hypokalemia and
treat accordingly.
Convulsions should be treated with benzodiazepines.
Use propranolol to treat life-threatening arrhythmias.
If torsades de pointes occurs treat with MgSO4.
Treat hypotension with Norepinephrine and epinephrine.
Dopamine is not effective.
Haemodiaysis/PD is not effective as tricyclics are protein bound.
Important to avoid the use of flumazenil for reversal of co-ingestion of
benzodiazepines as this can precipitate tricyclic induced seizure activity.
556
ORGANOPHOSPHATES

Clinical Manifestations in Organophosphate poisoning
Cholinergic effects
Miosis, sweating, lacrimation, muscle twitching,

urination, excessive salivation, vomiting, diarrhoea
CNS
Convulsions, coma
Respiratory
Bronchospasm, pulmonary oedema, respiratory

arrest
Cardiovascular
Bradycardia, hypotension
Management
Remove contaminated clothing and wash exposed areas with soap
and water.
Gastric lavage and give activated charcoal.
Resuscitate the patient. Protect the airway by early intubation.
Use only non depolarising neuromuscular agents
Give IV atropine 0.05mg/kg every 15 minutes till fully atropinized.
Atropine administration is guided by the drying of secretions rather than
the heart rate and the pupil size.
Keep patient well atropinized for the next 2-3 days.
A continuous infusion of atropine can be started at 0.05mg/kg/hr
and titrated.
Give IV Pralidoxime 25-50mg/kg over 30 min, repeated in 1-2 hrs and
at 10-12 hr intervals as needed for symptom control (max 12g/day) till
nicotinic signs resolves.
Treat convulsions with Diazepam.
IV Frusemide for pulmonary congestion after full atropinisation.
A rapid sequence intubation involves the potential for prolonged paralysis.
PARAQUAT
Clinical features
Ulcers in the mouth and oesophagus.
Diarrhoea and vomiting.
Jaundice and liver failure.
Renal failure.
557
POISONS & TOXINS
Management
Remove contaminated cloth and wash with soap and water.
Gastric lavage till clear.
To give Fullers earth in large amounts.
General supportive care.
558
POISONS & TOXINS
Chapter 103: Anaphylaxis

Introduction
Anaphylaxis is a severe, life threatening, generalised or systemic
hypersensitivity reaction. It is characterized by rapidly (minutes to hours)
developing life threatening airway and/or breathing and /or circulation
problems usually associated with skin and/ or mucosa changes.
Life threatening features
Airway problems:
Airway swelling e.g. throat and tongue swelling.
Hoarse voice.
Stridor.
Breathing problems:
Shortness of breath (bronchospasm, pulmonary oedema).
Wheeze.
Confusion cause by hypoxia.
Cyanosis is usually a late sign.
Respiratory arrest.
Circulation problems
Shock.
Cardiovascular collapse with faintness, palpitations,
loss of consciousness.
Cardiac arrest
Key points to severe reaction
Previous severe reaction.
History of increasingly severe reaction.
History of asthma.
Treatment with blocker.
Approach to treatment (see following pages)
The clinical signs of critical illness are generally similar because they
reflect failing respiratory, cardiovascular and neurological system.
Use ABCDE approach to recognise and treat anaphylaxis.
559
POISONS & TOXINS
Discharge Planning
Prevention of further episodes.
Education of patients and caregivers in the early recognition and
treatment of allergic reaction.
Management of co-morbidities that increase the risk associated with
anaphylaxis.
An adrenaline auto injector should be prescribed for those with history
of severe reaction to food, latex, insect sting, exercise and idiopathic
anaphylaxis and with risk factor like asthma.
GENERAL MANAGEMENT AND ASSESSMENT:
Anaphylaxis reaction
Diagnosis- looks for:
Acute onset illness
Life threatening airway and/or
Breathing and/or
Circulation problems
And usually skin changes
Airway
Breathing
Circulation
Disability
Exposure
Call for help
Remove allergens
Adrenaline
POISONS & TOXINS
When skill and equipment available:

Establish airway
High flow oxygen
IV fluid challenge
Anti-histamine (H1, H2 blockers)
Hydrocortisone
Monitor:
Pulse oximetry
ECG
Blood pressure
560
6 mths to 6 years
300micrograms
(0.3ml of 1:1000)
6 years-12 years
500microgram
(0.5ml of 1:1000)
> 12 years
25mg
50mg
20 mls/kg
100mg
200mg
Start with 0.1microgram/kg/min and titrate up to 5microgram/kg/min*
10 micrograms/kg
0.1ml/kg of 1:10000 (infants/young children) OR 0.01ml/kg of 1:1000 (older children)
150 micrograms
(0.15ml of 1000)
< 6 months
Dosage by age
*If hypotensive persist despite adequate fluid (CVP>10), obtain echocardiogram and consider infusing noradrenaline
as well as adrenaline.
** Dose of intravenous corticosteroid should be equivalent to 1-2mg/kg/dose of methylprednisolone every 6 hours
(prevent biphasic reaction).
Oral prednisolone 1m/kg can be used in milder case.
Antihistamine are effective in relieving cutaneous symptoms but may cause drowsiness and hypotension.
If the patient is on -blocker, the effect of adrenaline may be blocked; Glucagon administration at 20-30g/kg, max 1mg over
5 minutes followed by infusion at 5-15g/min is useful.
Continue observation for 6-24 hours depending on severity of reaction because of the risk of biphasic reaction and the
wearing off of adrenaline dose.
Hydrocortisone **
IM or Slow IV)
Crystalloid
Adrenaline IV
Adrenaline IM- in hospital practitioners

(rpt after 5 mins if no improvement)
Adrenaline IM- pre hospital practitioners
Drugs in anaphylaxis
Emergency treatment in anaphylaxis
POISONS & TOXINS
561
SPECIFIC TREATMENT AND INTERVENTION

Call for help
Remove allergens
Administer O2 via face mask
Administer IM adrenaline
Complete
Obstruction
Intubation or
Surgical airway
Apnoea
Assess AIRWAY
Repeat adrenaline IM
if no response.
Nebulised adrenaline,
rpt every 10 min as
required.
Hydrocortisone
No Problem
Assess BREATHING
Bag ventilation via mask

or ET tube
if no response
Hydrocortisone
Wheeze
if no response.
Nebulised salbutamol,
repeat if required
Hydrocortisone
Consider Salbutamol IV
or aminophylline
No Problem
No Pulse
Partial Obstruction/
Stridor
Assess CIRCULATION
Basic and advanced

life support
Shock
if no response.
Crystalloid
Adrenaline infusion
No Problem
POISONS & TOXINS
ReAssess ABC
562
References
Section 15 Poisons And Toxins
Ch 101 Snake Bite
1.Warrell DA. WHO/SEARO guidelines for the clinical management of snake
bites in the Southeast Asia region. Southeast Asian J Trop Med Public
Health 1999;30 Supplement 1.
2.Gopalakrishnakone P, Chou LM (eds). Snakes of medical importance (Asia
- Pacific region). Venom and Toxin Research Group, Nat Univ Singapore 1990.
3.Soh SY, Rutherford G. Evidence behind the WHO Guidelines: hospital care
for children: should s/c adrenaline, hydrocortisone or antihistamines be
used as premedication for snake antivenom? J Trop Pediatr 2006;52:155-7.
4.Theakston RDG, Warrell DA, Griffiths E. Report of a WHO workshop on the
standardization and control of antivenoms. Toxicon 2003;41:541-57.
5.Ministry of Health Malaysia. Clinical protocol: Management of snake bite.
MOH/P/PAK/140.07 (GU), June 2008.
6.APLS manual 5th edition: approach to child with anaphylaxis.
Ch 102 Common Poisons
1.AL Jones, PI Dargon, What is new in toxicology? Current Pediatrics( 2001)
11, 409 413
2.Fiona Jepsen, Mary Ryan, Poisoning in children. Current Pediatrics 2005, 15
563 568
3.Rogers textbook of Pediatric Intensive Care 4th edition Chapter 31
4.Paracetamol overdose: an evidence based flowchart to guide management.
CI Wallace et al Emerg Med J 2002; 19:202-205
5.The management of paracetamol poisoning; Khairun et al Paediatrics and
Child Health 19:11 492-497
563
POISONS & TOXINS
Ch 103 Anaphylaxis
1.Sheikh A,Ten Brock VM, Brown SGA, Simons FER H1- antihistamines for the
treatment of anaphylaxis with and without shock (Review) The Cochrane
Library 2012 Issue 4
2.Advanced Paediatric Life Support: The practical approach 5th Edition 2011
Wiley- Blackwell; 279-289
3.J.K.Lee, P.Vadas Anaphylaxis: mechanism and management Clinical & Experimental Allergy Blackwell Publishing Ltd 2011 41, 923-938
4.F.Estelle, R. Simons Anaphylaxis and treatment. Allergy 2011 66 (Suppl 99)
31-34
5.K.J.L. Choo, E. Simons, A. Sheikh . Glucocorticoid for treatment of anaphyaxis: Cochrane systematic review. Allergy 2010 65 1205-1211
6.Graham R N, Neil HY. Anaphylaxis Medicine Elsevier 2008 37.2 57-60
7.Mimi LK Tang, Liew Woei Kang Prevention and treatment of anaphylaxis.
Paediatrics and Child Health Elsevier 2008 309-316
8.Sunday Clark, Carlos A, Camargo Jr Emergency treatment and prevention
of insect-sting anaphylaxis. Current Opin Allergy Clin Immunol 2006 6:
279-283
564
POISONS & TOXINS
Chapter 104: Recognition and Assessment of Pain

The health care provider should decide on an appropriate level of pain
relief for a child in pain and also before a diagnostic or therapeutic
procedure.
We can assess a child in pain using an observational-based pain score or
a self-assessment pain score. Repeated assessment needs to be done to
guide further analgesia.
Observational-based Pain Score: The Alder Hey Triage Pain Score
No. Response
Score 0
Score 1
Score 2
Cry or voice
No complaint
or cry
Normal
conversation
Consolable
Not talking
negative
Inconsolable
Complaining of
pain
Facial expresNormal
sion grimace*
Short grimace
<50% time
Long grimace
>50% time
Posture
Normal
Touching /
rubbing / sparing / limping
Defensive /
tense
Movement
Normal
Reduced or
restless
Immobile or
thrashing
Colour
Normal
pale
Very pale /
green
*grimace open mouth, lips pulled back at corners, furrowed forehead and
/or between eye-brows, eyes closed, wrinkled at corners.
From Appendix F, APLS 5th Edition; Score range from 0 to 10
SEDATION
565
Verbal Pain Assessment Scale

A child who is more than 8 years old is asked to rate his or her pain by circling on any number on the scale of 0 to 10.
FACES Pain Scale - The child is more than 3 years old and he or she is asked to choose a face on the scale which best describes his / her
level of pain. Score is 2, 4, 6, 8, or 10.
Self Assessment Pain Score:

The two examples are FACES Pain Scale (Wong & Baker) and Verbal Pain Assessment Scale (Likert Scale).
SEDATION
566
Chapter 105: Sedation and Analgesia for Diagnostic

and Therapeutic Procedures
Definitions
Sedation reduces state of awareness but does not relieve pain.
Analgesia reduces the perception of pain.
Levels of sedation
Procedural sedation means minimal or moderate sedation / analgesia.
Minimal sedation (anxiolysis) drug-induced state during which patients
respond normally to verbal commands. Although cognitive function and
coordination may be impaired, ventilatory and cardiovascular functions are
unaffected.
Moderate sedation / analgesia drug-induced depression during which
patient respond to verbal commands either alone or accompanied by light
tactile stimulation. The airway is patent and spontaneous ventilation is
adequate. Cardiovascular function is adequate.
Note:
Avoid deep sedation and general anesthesia in which the protective
airway reflexes are lost and patients need ventilatory support.
Some children require general anesthesia even for brief procedures
whether painful or painless because of their level of distress.
Indications
Patients undergoing diagnostic or therapeutic procedures.
Contra-indications
Blocked airway including large tonsils or adenoids.
Increase intracranial pressure.
Reduce level of consciousness prior to sedation.
Respiratory or cardiovascular failure.
Neuromuscular disease.
Child too distressed.
Patient selection
The patients should be in Class I and II of the ASA classification of sedation risk.
Class I a healthy patient
Class II a patient with mild systemic disease, no functional limitation
Preparation
Consent
Light restraint to prevent self injury
Personnel
At least a senior medical officer, preferably PALS or APLS trained.
A nurse familiar with monitoring and resuscitation.
SEDATION
567
Facilities
Oxygen source.
Suction.
Resuscitation equipment.
Pulse oximeter.
ECG monitor.
Non-invasive BP monitoring.
Defibrillator.
Fasting
Recommended for all major procedures:

Nil orally: no solid food for 6 hours

no milk feeds for 4 hours
May allow clear fluids up to 2 hours before, for infants
Venous access
Vein cannulated after applying local anaesthesia for 60 minutes.
Sedation for Painless Procedures
Non-pharmacologic measures to reduce anxiety
Behavioural management, child friendly environment
Medication
Oral Chloral hydrate (drug 1 in table) may be used.
Note:
Opioids should not be used.
Sedatives such as benzodiazepine and dissociative anaesthesia
ketamine should be used with caution and only by experienced senior
medical officers.
A few children may need general anaesthesia and ventilation even for
painless procedure such as MRI brain if the above fails.
SEDATION
Sedation for Painful Procedures

Non-pharmacologic measures to reduce anxiety
Behavioural management, child friendly environment.
Local anaesthesia
Topical : Lignocaine EMLA 5% applied with occlusive plaster for
60 minutes to needle puncture sites, e.g. venous access, lumbar
puncture, bone marrow aspiration.
Subcutaneous Lignocaine infiltrated to the anaesthesised area prior to
prolonged needling procedure, e.g. insertion of chest drainage.
568
Medications (see table next page)

Many sedative and analgesic drugs are available; however, it is advisable
to use the following frequently used medications:
1. Narcotics (analgesia) also have sedative effects
Fentanyl
Naloxone (narcotic reversal)
- For respiratory depression* caused by narcotics.
Morphine - general dissociative anaesthesia
2. Benzodiazepines (sedatives) have no analgesia effects
Diazepam
Flumazenil (benzodiazepine reversal)
- Can reverse respiratory depression* and paradoxical excitatory reactions
Midazolam.
3. Ketamine (to be used by senior doctors preferably in the presence of an
anaesthesia doctor).
Adverse effects include
Increased systemic, intracranial and intraocular pressures.
Hallucinogenic emergence reactions (usually in older children).
Laryngospasm.
Excessive airway secretions.
*provide bag-mask positive pressure ventilation whilst waiting for reversal
agent to take effect.
Post sedation monitoring and discharge
Patient can be discharged when:
Vital signs and SaO normal.
And
Arousable.
Baseline level of verbal ability and able to follow age-appropriate
commands.
Sit unassisted (if appropriate for age).
SEDATION
569
Drug dosages used for sedation and analgesia in children

Drug
Dose
Onset of
action
Duration of
action
Chloral
Hydrate
Oral 25 - 50 mg/kg; Max 2g.

For higher doses,
i.e. 50 -100 mg/kg, please
consult paediatrician or anaesthesiologist.
15 30 mins
2 -3 hours
Morphine
IV
>1 year: 200-500 mcg/kg
<1 year: 80 mcg/kg
5 10 mins
2 4 hours
Fentanyl
IV 1 2 mcg/kg
2 3 mins
20 -60 mins
1 -2 mins
30 60 mins
Narcotics
Benzodiazepines
Midazolam IV 0.05 0.1 mg/kg, max single
dose 5 mg; may repeat up to
max total dose 0.4 mg/kg (10
mg)
Diazepam
IV 0.1 - 0.2 mg/kg
2 - 3 mins
30 90 mins
Ketamine
IV 0.5 - 2.0 mg/kg
1 2 mins
15 60 mins
Reversal agents
Naloxone
Repeated small doses

IV 1 - 10 mcg/kg every 1-2 mins
SEDATION
Flumazenil IV 0.01 0.02 mg / kg every

1 -2 minutes
up to a maximum dose of 1 mg
570
Chapter 108: Practical Procedures

Headings
1. Airway Access Endotracheal Intubation
2. Blood Sampling & Vascular Access
2.1 Venepuncture & Peripheral Venous Cannulation
2.2 Arterial Blood Sampling & Peripheral Arterial Cannulation
2.3 Intra-Osseous Access
2.4 Neonates
2.4.1 Capillary Blood Sampling
2.4.2 Umbilical Arterial Catheterisation UAC
2.4.3 Umbilical Venous Catheterisation UVC
2.4 Central venous access - Femoral vein cannulation in children.
3. Body Fluid Sampling
3.1. CSF - Lumbar puncture
3.2. Chest tube insertion (open method)
3.3. Heart - Pericardiocentesis
3.4. Abdomen
3.4.1. Gastric lavage
3.4.2. Abdominal paracentesis
3.4.3. Peritoneal dialysis
3.4.4. Suprapubic bladder tap
3.4.5. Bladder catheterisation
3.5 Bone marrow aspiration & trephine biopsy
Selected sedation and pain relief is important before the procedures.
(see Ch 105: Sedation and Analgesia for Diagnostic and Therapeutic Procedures)
PROCEDURES
571
1. AIRWAY ACCESS - ENDOTRACHEAL INTUBATION

(Please request for assistance from the Doctor from Anaesthesiology Department if necessary).
Introduction:
APLS courses have been conducted locally since October 2010.
Kindly refer to APLS 5th Ed:Chapter 20: Practical procedures: airway and breathing
Chapter 21: Practical procedures: circulation
The control of airway and breathing is very important in a patient with
respiratory or cardiopulmonary failure or collapse.
Indications
When bag and mask ventilation or continuous positive airway pressure
(CPAP) is insufficient.
For prolonged positive pressure ventilation.
Direct suctioning of the trachea.
To maintain and protect airway.
Diaphragmatic hernia (newborn).
Contra-indications
If the operator is inexperienced in intubation, perform bag and mask
ventilation till help arrives.
Equipment
Bag and mask with high oxygen flow.
Laryngoscope.
Blades:
Straight blade for infants, curved blades for an older child.
Size 0 for neonates, 1 for infants, 2 for children.
Endotracheal tube appropriate size as shown.
Stylet (optional).
Suction catheter and device.
Scissors and adhesive tape.
Size of ETT (mm):
Pulse oximeter.
2.5 for < 1kg
Sedation (Midazolam or
Morphine).
3.0 for 1-2kg
Muscle relaxant
3.5 for 2-3kg
(Succinylcholine).
3.5 - 4.0 for > 3kg
PROCEDURES
Oral ETT length in cm for neonates:

6 + (weight in kg) cm
For Children > 1 year:
ETT size (mm) = 4 plus (age in years /4)
Oral ETT length (cm) = 12 plus (age in years /2)
572
Procedure
1. Position infant with head in midline and slightly extended.
2. Continue bag and mask ventilation with 100% oxygen till well saturated. In
newborns adjust FiO2 accordingly until oxygen saturation is satisfactory.
(Refer NRP Program 6th edition).
3. Sedate the child with
IV Midazolam (0.1-0.2 mg/kg) or IV Morphine (0.1-0.2 mg/kg).
Give muscle relaxant if still struggling IV Succinylcholine (1-2 mg/kg).
Caution: must be able to bag the patient well or have good intubation
skills before giving muscle relaxant.
4. Monitor the childs vital signs throughout the procedure.
5. Introduce the blade between the tongue and the palate with left hand
and advance to the back of the tongue while assistant secures the head.
6. When epiglottis is seen, lift blade upward and outward to visualize the
vocal cords.
7. Suction secretions if necessary.
8. Using the right hand, insert the ETT from the right side of the infants
mouth; a stylet may be required.
9. Keep the glottis in view and insert the ETT when the vocal cords are opened
till the desired ETT length while assistant applies cricoid pressure.
10. If intubation is not done within 20 seconds, the attempt should be aborted
and re-ventilate with bag and mask.
11. Once intubated, remove laryngoscope and hold the ETT firmly with left
hand. Connect to the self-inflating bag and positive pressure ventilation.
12. Confirm the ETT position by looking at the chest expansion, listen to lungs
air entry and also the stomach.
13. Secure the ETT with adhesive tape.
14. Connect the ETT to the ventilator or resuscitation bag.
15. Insert orogastric tube to decompress the stomach.
16. Check chest radiograph.
Complications and Pitfalls
Oesophageal intubation.
Right lung intubation.
Trauma to the upper airway.
Pneumothorax.
Subglottic stenosis (late).
Relative contra-indications for Succinylcholine are increased intra-cranial
pressure, neuromuscular disorders, malignant hyperthermia, hyperkalaemia
and renal failure.
Note: The drugs used in Rapid Sequence Intubation are listed in the PALS
Provider Manual.
PROCEDURES
573
2. BLOOD SAMPLING & VASCULAR ACCESS

2.1. VENEPUNCTURE & PERIPHERAL VENOUS LINE
Indications
Blood sampling.
Intravenous fluid, medications and blood components.
Equipment
Alcohol swab.
Tourniquet.
Topical anaesthetic (TA), e.g lignocaine EMLA 5%.
Catheter or needle; sizes 25, 23, 21 G.
Heparinised saline, T-connector, rubber bung for setting an IV line.
Technique
1. Identify the vein for venepuncture. Secure the identified limb and apply
tourniquet or equivalent.
2. TA may be applied with occlusive plaster an hour earlier.
3. Clean the skin with alcohol swab.
4. Puncture the skin and advance the needle or catheter in the same direction
as the vein at 15-30 degrees angle.
5. In venepuncture, blood is collected once blood flows out from the needle.
The needle is then removed and pressure applied once sufficient blood is
obtained.
6. In setting an intravenous line, the catheter is advanced a few millimetres
further. Once blood appears at the hub, then withdraw the needle while
advancing the catheter.
7. Remove the tourniquet and flush the catheter with heparinised saline.
8. Secure the catheter and connect it to either rubber bung or IV drip.
9. Immobilise the joint above and below the site of catheter insertion with
restraining board and tape.
PROCEDURES
Complications
Haematoma or bleeding.
Thrombophlebitis.
Extravasation can lead to soft tissue injury resulting in limb or digital loss
and loss of function.
This complication is of concern in neonates, where digital ischaemia,
partial limb loss, nerve damage, contractures of skin and across joints can
occur.
574
Extravasation injury
Signs include:
Pain, tenderness at insertion site especially during infusion or giving
slow bolus drugs.
Redness.
Swelling.
Reduced movement of affected site.
(Note the inflammatory response can be reduced in neonates especially
preterm babies)
Observation
The insertion site should be observed for signs of extravasation:
At least every 4 hours for ill patients.
Sick preterm in NICU observation should be done more often, that is,
every hour.
Each time before, during and after slow bolus or infusion.
(Consider re-siting the intravenous catheter every 48 to 72 hours)
If moderate or serious extravasation occurs, especially in the following
situation:
Preterm babies.
Delay in detection of extravasation.
Hyperosmolar solutions or irritant drugs (glucose concentration >10g%,
sodium bicarbonate, calcium solution, dopamine, cloxacillin, fusidic acid)
Consider:
Refer to plastic surgeon / orthopaedics surgeon.
Performing subcutaneous saline irrigation especially in neonates
(ref Davies, ADC, Fetal and Neonatal edition 1994).
Give IV analgesia morphine, then perform numerous subcutaneous
punctures around the extravasated tissue and flush slowly with generous
amount of normal saline to remove the irritant. Ensure that the
flushed fluid flows out through the multiple punctured sites.
575
PROCEDURES
Pitfalls
If the patient is in shock, the venous flow back and the arterial flow
(in event of accidental cannulation of an artery) is sluggish.
BEWARE! An artery can be accidentally cannulated, e.g. brachial artery
at the cubital fossa and the temporal artery at the side of the head of a
neonate and be mistaken as a venous access. Check for resistance to flow
during slow bolus or infusion (e.g. frequent alarming of the perfusor pump)
or watch for pulsation in the backflow or a rapid backflow. Rapid bolus or
infusion of drugs can cause ischaemia of the limb. Where in doubt, gently
remove the IV cannula.
Ensure prescribed drug is given by the proper mode of administration.
Some drugs can only be given by slow infusion (e.g.fusidic acid) instead of
slow bolus in order to reduce tissue damage from extravasation.
Avoid medication error (correct patient, correct drug, correct DOSE,
correct route).
Avoid nosocomial infection.
2.2. ARTERIAL BLOOD SAMPLING &

PERIPHERAL ARTERIAL LINE CANNULATION
Indications
Arterial blood gases.
Invasive blood pressure monitoring.
Frequent blood taking.
PROCEDURES
Contra-indications
Presence or potential of limb
ischaemia.
Do not set arterial line if close
monitoring cannot be done.
Equipment
Topical anaesthetic (TA) like
lignocaine EMLA 5%.
Alcohol swab.
Needle size 27.
Catheter size 25.
Heparinised saline in 5cc syringe (1 ml for neonate), T-connector.
Heparinised saline (1u/ml) for infusion.
Procedure
1. Check the ulnar collateral circulation by modified Allen test.
2. The radial pulse is identified. Other sites that can be used are posterior
tibial and dorsalis pedis artery.
3. TA may be applied with occlusive plaster an hour before procedure.
4. Clean the skin with alcohol swab.
5. Dorsiflex the wrist slightly. Puncture the skin and advance the catheter in
the same direction as the radial artery at a 30-40 degrees angle.
6. The catheter is advanced a few millimetres further when blood appears at
the hub, then withdraw the needle while advancing the catheter.
7. Aspirate to ensure good flow, then flush gently with a small amount of
heparinised saline.
8. Peripheral artery successfully cannulated.
Ensure that the arterial line is functioning. The arterial pulsation is
usually obvious in the tubing.
Connect to T-connector and 3-way stop-cock (red colour) to a syringe
pump.
Label the arterial line and the time of the setting.
9. Run the heparinised saline at an appropriate rate:
0.5 to 1.0 mL per hour for neonates.
1.0 mL (preferred) or even up till 3.0 mL per hour for invasive BP line
(to avoid backflow in bigger paediatrics patients).
10. Immobilize the joint above and below the site of catheter insertion with
restraining board and tape, taking care not to make the tape too tight.
576
Complications and Pitfalls

Arteriospasm which may lead to ischaemia and gangrene.
Neonates especially digital and distal limb ischaemia.
Precautions
Prevention of digital, distal limb ischaemia and gangrene
AVOID end arteries e.g. brachial (in cubital fossa) and temporal artery
(side of head) in babies (BEWARE - both these arteries can be accidentally
cannulated and mistaken as veins especially in ill patients with shock).
Test for collateral circulation
If a radial artery is chosen, please perform Allens test (to confirm the
ulnar artery collateral is intact) before cannulation.
If either the posterior tibial or dorsalispedis artery on one foot is chosen,
ensure that these 2 arteries are palpable before cannulation.
Circulation chart
Perform observation and record circulation of distal limb every hour in
the NICU/PICU, and whenever necessary to detect for signs of ischaemia,
namely:
Colour - pale, blue, mottled.
Cold, clammy skin.
Capillary refill > 2 seconds.
Treatment of digital or limb ischaemia
This is difficult as the artery involved is of small calibre.
Remove IV cannula.
Confirm thrombosis with ultrasound doppler.
May consider warming the contralateral unaffected limb to induce
reflex vasodilatation if part of one limbis affected
(see Ch 14 Vascular spasm and Thrombosis).
Ensure good peripheral circulation and blood pressure
Anticoagulant drugs and thrombolytic agents should be considered.
Refer orthopaedic surgeon if gangrene is inevitable
Reminders:
PREVENTION of limb ischaemia is of utmost importance.
Early detection of ischaemia is very important in order to avoid
irreversible ischaemia.
If the patient is in shock, the risk of limb ischaemia is greater.
Small and preterm babies are at greater risk for ischaemia.
No fluid or medication other than heparinized saline can be given
through arterial line. This mistake can occur if the line is not properly
labelled, or even wrongly labelled and presumed to be a venous line.
PROCEDURES
577
2.3. INTRAOSSEOUS ACCESS

Notes:
Intraosseous infusion can be used for all age groups.
The most common site for IO cannulation is the anterior tibia
(all age groups). Alternate sites include:
Infant distal femur
Child anterior superior iliac spine, distal tibia.
Adolescent/adult - distal tibia, medial malleolus, anterior superior iliac
spine, distal radius, distal ulna.
All the fluids and medications can be given intraosseously.
IO infusion is not recommended for use longer than a 24 hour period.
Indications
Emergency access for IV fluids and medications when other methods of
vascular access failed.
In certain circumstances, e.g. severe shock with severe vasoconstriction
or cardiac arrest, IO access may be the INITIAL means of vascular access
attempted.
PROCEDURES
Contra-indications
Fractures, crush injuries near the access site.
Conditions in which the bone is fragile e.g. osteogenesis imperfecta.
Previous attempts to establish access inthe same bone.
Infection over the overlying tissues.
Equipment
Sterile dressing set.
EZ-IO drill set if available.
Intraosseous needle.
Syringes for aspiration.
Local anaesthesia.
Procedure
1. Immobilize the lower limb.
2. Support the limb with linen
3. Clean and draped the area
4. Administer LA at the site of insertion
5. Insert the IO needle 1-3 cm below and medial to the tibial tuberosity
caudally.
6. Advance needle at a 60-90o angle away from the growth plate until a
give is felt.
7. Remove the needle trocar stylet while stabilizing the needle cannula
8. Withdraw bone marrow with a 5cc syringe to confirm access
9. Infuse a small amount of saline and observe for swelling at the insertion
site or posteriorly in the extremity opposite the insertion site. Fluid
should flow in freely and NO swelling must be seen. (Swelling indicates
that the needle has penetrated into and through the posterior cortical
bone. If this happens remove the needle.)
578
10. Connect the cannula to tubing and IV fluids. Fluid should flow in freely
11. Monitor for any extravasation of fluids.
Complications
Cellulitis.
Osteomyelitis.
Extravasation of fluids/compartment syndrome.
Damage to growth plate.
2.4. NEONATES
2.4.1. CAPILLARY BLOOD SAMPLING
Indications
Capillary blood gases
Capillary blood glucose
Serum bilirubin
Equipment
Lancet or heel prick device.
Alcohol swab.
Procedure
1. Either prick the medial or lateral aspect of the heel
2. For the poorly perfused heel, warm with gauze soaked in warm water.
3. Clean the skin with alcohol swab
4. Stab the sterile lancet to a depth of 2.5mm, then withdraw it.
Intermittently squeeze the heel gently when the heel is re-perfused until
sufficient blood is obtained.
Complications
Cellulitis.
Osteomyelitis.
PROCEDURES
579
2.4.2. UMBILICAL ARTERY CATHETERISATION (UAC)

Indications
Repeated blood sampling in ill newborn especially those on ventilator.
Occasionally it is used for continuous BP monitoring and infusion.
Contra-indications
Local vascular compromise in lower extremities.
Peritonitis, necrotising enterocolitis.
Omphalitis.
PROCEDURES
Prior to setting
Examine the infants lower extremities and buttocks for any signs of
vascular insufficiency.
Palpate femoral pulses for their presence and equality.
Evaluate the infants legs, feet, and toes for any asymmetry in colour,
visible bruising, or vascular insufficiency.
Document the findings for later comparison. Do not set if there is any
sign of vascular insufficiency.
Equipment
UAC/UVC set.
Size of UAC in mm:
Umbilical artery catheter, appropriate size.
3.5 for < 1.25 kg
5 cc syringes filled with heparinized saline.
Three-way tap.
5.0 for 1.25 - 3.5 kg
Heparinized saline (1u/ml) for infusion.
Procedure
1. Clean the umbilicus and the surrounding area using standard aseptic
technique. In order to observe for limb ischaemia during umbilical arterial
insertion, consider exposing the feet in term babies if the field of sterility is
adequate.
2. Catheterise the umbilical artery to the desired position.
The formula for UAC is:
(Body weight in kg x 3) + 9 + stump length in cm
(high position - recommended)
Height in kg + 7 cm (low position)
3. Cut the umbilicus horizontally
leaving behind a 1cm stump.
There are usually 2 arteries and
1 vein. The artery is smaller, white
and harder in consistency.
Use the curved artery forceps to
hold the umbilicus stump upright
and taut.
Use the probe to dilate the vessel.
Insert the catheter to the desired distance.
580
4. Ensure the successful and correct cannulation of one umbilical artery.

Tips for successful catheterisation of the umbilical artery:
- In a fresh and untwisted umbilical stump, the two arteries can be
clearly distinguished from the vein.
- The blood withdrawn is bright red.
- Visible arterial pulsations can be seen in the column of blood
withdrawn into the catheter. This pulsation in may not be seen in very
preterm babies and babies in shock, using the closed system.
In accidental cannulation of the umbilical vein, the catheter tip can be in
the left atrium (via the foramen ovale from the right to left atrium) or
in the left ventricle.
Stick the label of the catheter onto patients folder for future reference
(brand and material of catheter) in the event of limb ischaemia or
thrombosis of femoral artery occurring later.
5. Observe for signs of arterial occlusion to the lower limbs and buttocks
(colour, cold skin, capillary refill delayed, poor dorsalis pedis and posterior
tibial pulses) during and after the proceduredue to arterial vasospasm.
Lift the edge of the drape by an assistant to observe the lower limbs
circulation without compromising the sterility field.
6. If there are no complications (limb ischaemia see pitfalls), secure the UAC
to avoid accidental dislodgement.
7. Perform a chest and abdominal X-ray to ascertain the placement of UAC tip
Between T 6-9 vertebra (high position) - preferred
At the L 3-4 vertebra (low position)
Withdraw the catheter to the correct position, as soon as position is
ascertained, if necessary.
8. Monitor the lower limbs and buttock area for ischaemic changes 2-4 hourly
9. Infuse heparinised saline continuously through the UAC at 0.5 to 1 U/hr to
reduce the risk of catheter occlusion and thrombotic events.
10. Note the catheter length markings every day and compare with the
procedure note at the time of insertion ( to check for catheter migration).
11. Remove the UAC as soon as no longer required to reduce the incidence of
thrombus formation and long line sepsis.
581
PROCEDURES
Complications
Bleeding from accidental disconnection and open connection.
Embolisation of blood clot or air in the infusion system.
Vasospasm or thrombosis of aorta, iliac, femoral or obturator artery
leading to limb or buttock ischaemia.
(see Ch 14 Vascular spasm and Thrombosis)
Thrombosis of renal artery (hypertension, haematuria, renal failure),
mesenteric artery (gut ischaemia, necrotising enterocolitis).
Vascular perforation of umbilical arteries, haematoma and retrograde
arterial bleeding.
Infection.
2.4.3. UMBILICAL VEIN CATHETERISATION (UVC)

Indications
UVC is used for venous access in neonatal resuscitation.
As a venous access in preterm babies especially ELBW babies (<1000g)
and also in sick babies in shock with peripheral vasoconstriction.
For doing exchange transfusion for severe neonatal jaundice.
Contra-indications
Omphalitis, omphalocoele.
Necrotising enterocolitis.
Peritonitis.
Size of UVC mm:

5.0 for <2kg
PROCEDURES
Equipment
UVC set.
Umbilical venous catheter, appropriate size.
5 cc syringes filled with heparinized saline.
Three-way tap.
Heparinized saline (1u/ml) for infusion.
8.0 for 2-3.5kg

10.0 for>3.5kg
Procedure
1. Clean umbilicus and its surroundings using standard procedures. In order to
observe for limb ischaemia during insertion (in the event of accidental arterial
catheterisation), consider exposing the feet in term babies if field of sterility is
adequate.
2. Formula for insertion length of UVC:
[0.5 x UAC cm (high position)] + 1 cm.
(Refer to information on use of Shoulder - umbilical length ,
in Ch 13 NICU guidelines)
Or
2 x weight in kg + 5 + stump length in cm.
3. Perform the umbilical venous cannulation
Tips for successful UV catheterisation:
- In a fresh (first few hours of life) and untwisted umbilical stump, the
umbilical vein has a thin wall, is patulous and is usually sited at the
12 oclock position.
The two umbilical arteries which have a thicker wall and in spasm,
and sited at the 4 and 8 oclock positions.
However, in a partially dried umbilical cord, the distinction between
the vein and arteries may not be obvious.
- The venous flow back is sluggish and without pulsation (in contrast to
the arterial pulsation of UAC).
- The blood is dark red in colour.
- Stand to the right of the baby (if you are right handed). Tilt the umbilical
stump inferiorly at an angle of 45 degrees from the abdomen. Advance
the catheter superiorly and posteriorly towards the direction of the
right atrium.
582
Central venous pressure

- The UVC tip is sited in the upper IVC (inferior vena cava).
The right atrial pressure in a term relaxed baby normally ranges from
-2 to + 6 mmHg (i.e. - 3 cm to + 9 cm water).
Negative intrathoracic pressure and air embolism
- In a crying baby, the negative intrathoracic pressure can be significant
during deep inspiration.
- Ensure that no air embolism occurs during the procedure especially in
the presence of negative pressure when the catheter tip is in the right
atrium.
Air embolism can occur if the baby takes a deep inspiration when the
closed UVC circuit is broken.
Stick the label of the catheter onto the patients folder for future
reference (brand and material of catheter) in the event of thrombosis
occurring in the cannulated vessel.
4. If there are no complications, secure the UVC to avoid accidental migration
of the catheter.
5. If the UVC is for longer term usage such as for intravenous access / TPN,
perform chest and abdominal radiograph to ascertain the tip of the catheter is
in the inferior vena cava above the diaphragm.
6. Consider removing the UVC after 5 - 7 days to reduce incidence of line sepsis or
thrombus forming around the catheter.
Complications
Infections.
Thrombo-embolic lungs, liver, even systemic circulation.
Pericardial tamponade, arrhythmias, hydrothorax.
Portal vein thrombosis and portal hypertension (manifested later in life).
Pifalls
The umbilical artery can be mistakenly cannulated during umbilical venous
catheterisation.
If you suspect that the umbilical artery was wrongly cannulated resulting
in limb ischaemia, please refer Ch 14 Vascular spasm and Thrombosis.
PROCEDURES
583
2.5 CENTRAL VENOUS ACCESS: FEMORAL VEIN CANNULATION IN

CHILDREN
The routes of central venous access includes peripherally inserted central
catheter - PICC (eg through cubital fossa vein into SVC) and femoral,
external / internal jugular and subclavian veins.
These lines must be inserted by trained senior doctors in selected seriously
ill paediatrics patients requiring resuscitation and emergency treatment.
The benefits of a successfully inserted central venous access must be
weighed against the numerous potential complications arising from the
procedure.
This includes pneumothorax and life-threatening injuries of the airway,
lungs, great vessels and heart.
The basic principle of Seldinger central line insertion applies to all sites
and the femoral vein cannulation is described.
For insertion of central lines by experts in other sites, please refer to
Chapter 21, APLS 5th Ed 2011 and PALS 6 PALS 2002.
Indications
Seriously ill ventilated paediatrics patients.
To obtain central venous pressure.
Longer term intravenous infusion (compared to IO access).
Haemodialysis.
Contra-indications
Absence of trained doctors for this procedure.
Bleeding and clotting disorders.
Risk of contamination of the cannulation site by urine and faeces.
PROCEDURES
Equipment
Sterile set.
Lidocaine (Lignocaine) 1% for local anaesthetic, 2 mL syringe, 23 G needle.
5 mL syringe and normal saline, t-connector and 3-way tap.
Seldinger cannulation set syringe, needle, guide wire, catheter.
Sterile dressing.
584
Procedure
1. In a ventilated child, give a dose of analgesia (eg Morphine, Fentanyl) and
sedation (e.g. Midazolam).
2. In the supine position, expose the chosen leg and groin in a slightly
abducted position.
3. Clean the inguinal region thoroughly using iodine and 70% alcohol.
4. Infiltrate local lidocaine if necessary.
5. Identify the landmark by palpating the femoral artery pulse in the
mid-inguinal region. The femoral vein is medial to the femoral artery.
6. Insert the saline filled syringe and needle at 45 degrees angle to the skin
and 1 cm medial (depends on the age of child) and parallel to the femoral
artery pulsation. Pull the plunger gently and advance superiorly in-line
with the leg.
7. When there is a backflow of blood into the syringe, stop suction, and
disconnect the syringe from the needle. The guide wire is then promptly
and gently inserted into the needle.
8. Withdraw the needle gently without risking damage to the guide wire
9. Insert the cannula over the wire without risking displacement of the wire
into the patient.
10. Once the cannula has been inserted, remove the guide wire and attach
the infusion line securely onto the hub of the cannula. Check for easy
backflow by gentle suction on the syringe.
11. Secure the line using sterile dressing and ensure the insertion site is
clearly visible at all times.
Pitfalls
Do not lose the guide wire (inserted too deep into patient)
Do not fracture the guide wire accidentally with the needle
Do not accidentally cannulate the femoral artery (blood pressure could
be low in a patient with shock)
Beware of local haematoma at injection site.
Always check the distal perfusion of the leg and toes before and after
procedure.
PROCEDURES
585
3. BODY FLUID SAMPLING

3.1. LUMBAR PUNCTURE
Indications
Suspected meningitis / encephalitis.
Intrathecal chemotherapy for oncology patients.
In selected patients being investigated for neurometabolic disorders.
Contraindications
Increased intracranial pressure (signs and symptoms, raised blood
pressure, fundoscopic signs).
Bleeding tendency - platelet count <50,000/mm3, prolonged PT or APTT.
Skin infection over the site of lumbar puncture
Patient with hypertensive encephalopathy
Equipment
Sterile set.
Sterile bottles for CSF, bottle for RBS (random blood sugar).
Spinal needle 20-22G, length 1.5 inch with stylet; length 3.5 inches
for children > 12 years old.
Procedure
1. Give sedation (midazolam), apply local anaesthetic.
2. Take a random blood sugar sample (RBS).
3. Place child in lateral recumbent position with neck, body, hips and knees
flexed. Monitor oxygen saturation continuously.
4. Visualise a vertical line between the highest point of both iliac crests and its
transection with the midline of the spine (at level between vertebrae L 3-4).
5. Clean area using standard aseptic techniques: povidone-iodine and 70%
alcohol.
6. Gently puncture skin with spinal needle at the identified mark and point
towards the umbilicus. The entry point is distal to the palpated spinous
process L4.
7. Gently advance a few millimetres at a time until there is a backflow of CSF
(there may be a give on entering the dura mater before the CSF backflow).
Collect the CSF in the designated bottles.
8. Gently withdraw needle, spray with op-site, cover with gauze and bandage.
9. Ensure that the child lies supine for the next 4 to 6 hours, continue
monitoring child till he or she recovers from the sedation.
PROCEDURES
Complications
Headache or back pain following the procedure (from arachnoiditis).
Brain herniation associated with raised ICP.
Bleeding into CSF, or around the cord (extraspinal haematoma).
586
3.2. CHEST TUBE INSERTION

Indications
Pneumothorax with respiratory distress.
Significant pleural effusion.
Empyema.
587
PROCEDURES
Size of chest tube (mm)

Equipment
Suturing set.
8 for < 2kg
Local anaesthetic +/- sedation.
10 for > 2kg
Chest tube, appropriate size.
Underwater seal with sterile water.
Older children
Suction pump optional.
12-18 depending on size
Procedure
1. Sedate the child.
2. Position the child with ipsilateral arm fully abducted.
3. Clean and drape the skin.
4. Infiltrate LA into the skin at 4th ICS, AAL or mid axillary line.
5. Check approximate length of the chest tube to be inserted.
For Open Method
i. The open method (without the metal introducer) of chest tube cannulation
is the preferred method except in neonates
ii. Make a small incision in the skin just above the rib. Bluntly dissect through
the subcutaneous tissue and puncture the parietal pleura with the tip of the
clamp. Put a gloved finger into the incision and clear the path into the
pleura. This will not be possible in a small child. Advance the chest tube into
the pleural space during expiration.
iii. For drainage of air, roll the child slightly to the opposite side for easier
manoeuvring and advancement of the chest tube. Place the tip of the chest
tube at the incision. Point the catheter tip anteriorly and slowly advance
the chest tube. However, for drainage of empyema, roll the child slightly
towards same side and point the catheter tip posteriorly and proceed with
the rest of the procedure.
iv. Connect the chest tube to underwater seal.
For Closed Method
i. Make a small incision just above the rib down to the subcutaneous tissue.
ii. Place the tip of the chest tube at the incision, point the tip anteriorly for
drainage of air and posteriorly for drainage of empyema. Slowly advance
the chest tube with introducer by exerting a firm continuous pressure
until a give is felt.
iii. Withdraw the introducer partially and advance the chest tube till the
desired length.
iv. Remove introducer fully and clamp the chest tube.over a gauze. May not
be necessary if patient receiving positive pressure ventilation.
v. Connect the chest tube to underwater seal.
Then continue with the following for both methods:

6. The water should bubble ( if pneumothorax) and the fluid moves with
respiration if chest tube is in the pleural space.
7. Secure the chest tube with pulse string sutures or sterile tape strips in
neonates.
8. Connect the underwater seal to suction pump if necessary.
9. Confirm the position with a chest X-ray.
NEEDLE THORACOTOMY
1. Indicated in tension pneumothorax as an emergency measure to
decompress the chest until a chest tube is inserted.
2. Done under strict aseptic technique. Attach a 5ml syringe to a 16 to 20
gauge angiocatheter. Gently insert catheter perpendicularly through the
second intercostal space, over the top of the third rib, at the midclavicular
line while applying a small negative pressure as the needle is advanced. Air
will be aspirated on successful needle thoracotomy. When this happens,
remove the needle while leaving the branula in situ to allow the tension
pneumothorax to decompress.
Insert a chest tube as described above as soon as feasible.
PROCEDURES
SITE FOR CHEST TUBE INSERTION
588
3.3. PERICARDIOCENTESIS
Indications
Symptomatic collection of air.
Blood or other fluids / empyema in pericardial sac.
Equipment
Suturing set.
Angiocatheter size 20G for newborn,18G for older children.
T connector.
3-way stopcock.
Procedure
1. Place patient in supine position and on continuous ECG monitoring.
2. Clean and drape the subxiphoid area.
3. Prepare the angiocatheter by attaching the T connector to the needle hub
and connect the other end of the T-connector to a 3-way stopcock which is
connected to a syringe.
4. Insert the angiocatheter at about 1cm below the xiphoid process at angle of
20-30o to the skin and advance slowly, aiming at the tip of the left shoulder
while applying light negative pressure with the syringe. Stop advancing the
catheter if there is cardiac arrhythmia
5. Once air or fluid returns in the T connector stop advancing the catheter and
aspirate a small amount to confirm positioning.
6. Remove the T connector from the angiocatheter and rapidly hold your
finger over the needle hub.
7. Advance the catheter further while removing the needle.
8. Reattach the T connector and resume aspiration of the air or fluid required.
9. Send any aspirated fluid for cell count, biochemistry and culture.
10. Suture the angiocatheter in place. Perform CXR to confirm positioning and
look for any complication.
11. The catheter should be removed within 72 hours. If further aspiration is
required, placement of a pericardial tube is an option.
Do not hesitate to consult cardiothoracic surgeon.
Complications
Perforation of heart muscle leading to cardiac tamponade.
Haemo / pneumo pericardium
Cardiac arrhythmias.
Pneumothorax
PROCEDURES
589
3.4. ABDOMEN
3.4.1. GASTRIC LAVAGE
Indications
Removal of toxins.
Removal of meconium from stomach for newborn.
Equipment
Nasogastric tube size 8-12.
Syringes- 5cc for neonate, 25-50cc for older children.
Sterile water.
Procedure
1. Put the child in left semiprone position.
2. Estimate the length of nasogastric tube inserted by measuring the tube
from the nostril and extending it over and around the ear and down to the
epigastrium.
For orogastric tube insertion, the length of tube inserted equal to the
bridge of the nose to the ear lobe and to appoint halfway between the
lower tip of sternum and the umbilicus.
3. Lubricate the tip of the tube with KY jelly. Insert the tube gently.
4. Confirm position by aspirating stomach contents. Re-check by plunging air
into stomach whilst listening with a stethoscope, or check acidity of
stomach contents.
5. Perform gastric lavage until the aspirate is clear.
6. If indicated, leave activated charcoal or specific antidote in the stomach.
decompress. Insert a chest tube as described above as soon as feasible.
PROCEDURES
Complications
Discomfort.
Trauma to upper GIT.
Aspiration of stomach contents.
590
3.4.2. ABDOMINAL PARACENTESIS

Indications
Diagnostic procedure.
Drain ascites.
Equipment
Dressing set.
Cannula size 21,23.
Syringes 10cc.
Procedure
1. Supine position. Catheterize to empty the bladder.
Clean and drape abdomen.
2. Site of puncture is at a point in the outer 1/3 of a line drawn from the
umbilicus to the anterior superior illiac spine.
3. Insert the catheter, connected to a syringe, into the peritoneal cavity
in a Z track fashion.
4. Aspirate while advancing the catheter until fluid is seen in the syringe.
Remove the needle and reconnect the catheter to the syringe and aspirate
the amount required. Use a three-way tap if large amounts need to be
removed.
5. Once complete, remove the catheter. Cover puncture site with sterile
dry gauze.
Complications
Infection.
Perforation of viscus.
Leakage of peritoneal fluid.
Hypotension if excessive amount is removed quickly.
PROCEDURES
591
3.4.3. PERITONEAL DIALYSIS

(See Ch 61 Acute Peritoneal Dialysis)
3.4.4. SUPRAPUBIC BLADDER TAP
Indication
Urine culture in a young infant.
Equipment
Dressing set.
Needle size 21, 23.
Syringe 5cc.
Urine culture bottle.
Procedure
1. Make sure bladder is palpable. If needed,encourage patient to drink half
to 1 hour before procedure.
2. Position the child in supine position. Clean and drape the lower abdomen.
3. Insert the needle attached to a 5cc syringe perpendicular or slightly caudally
to the skin, 0.5 cm above the suprapubic bone.
4. Aspirate while advancing the needle till urine is obtained.
5. Withdraw the needle and syringe.
6. Pressure dressing over the puncture site.
7. Send urine for culture.
PROCEDURES
Complications
Microscopic hematuria.
Infection.
Viscus perforation.
592
3.4.5. BLADDER CATHETERIZATION

Indications
Monitor urine output.
Urinary retention.
MCUG - Patient for MCU needs to given stat dose of IV Gentamicin or TMP
2mg/kg bd for 48 hours.
Size of Catheter:
Urine culture.
Size 4 for <3kg
Equipment
Dressing Set.
Size 6 for >3kg
Urinary catheter.
Older children:
LA / K-Y jelly.
Syringe and water for injection.
Foleys catheter 6-10
Procedure
1. Position the child in a frog-leg position. Clean and drape the perineum.
2. In girls, separate the labia majora with fingers to expose the urethra opening.
3. In boys, hold the penis perpendicular to the body.
4. Pass catheter in gently till urine is seen then advance a few centimetres further.
5. Secure the catheter with adhesive tape to the body.
6. Connect the catheter to the urine bag.
Complications
Infection.
Trauma which lead to urethral stricture.
PROCEDURES
593
3.5. BONE MARROW ASPIRATION AND TREPHINE BIOPSY

Indications
Examination of bone marrow in a patient with haematologic or oncologic
disorder.
Contra-indications
Bleeding tendency, platelet count < 50,000/mm3.
Consider transfusion of platelet concentrates prior to procedure.
Equipment
Bone marrow set (Islam) 16 18G
Procedure
1. Sedate child, monitor continuously with pulse oximeter.
2. Position child - either as for lumbar puncture or in a prone position.
3. Identify site for aspiration - posterior iliac crest preferred, upper
anterior-medial tibia for child < 3 months old.
4. Clean skin using standard aseptic technique with povidone-iodine and 70%
alcohol.
5. Make a small skin nick over the PSIS (posterior superior iliac spine). Hold
the trocar firmly and gently enter the cortex by a twisting action.
A give is felt as the needle enters the bone marrow.
6. Trephine biopsy is usually done before marrow aspiration.
7. Withdraw needle, spray with op-site, cover with gauze and crepe bandage.
8. Lie child supine for the next 4 to 6 hours and observe for blood soaking
the gauze in a child with bleeding diasthesis.
PROCEDURES
Complications
Bleeding, haematoma.
Infection.
594
References
Section 16 Sedation, Procedures
Ch 104 & 105 Recognition and assessment of pain, Sedation and Analgesia
1.Management of pain in children, Appendix F. Advanced Paediatric Life Support 5th Edition 2011.
2.Safe sedation of children undergoing diagnostic and therapeutic procedures. Scottish Intercolleagiate Guidelines Network SIGN, May 2004.
3.Guideline statement 2005: Management of procedure-related pain in
children and adolescents.
4. Paediatrics & Child Health Division, The Royal Australian College of Physicians.
Chapter 106 Practical Procedures
1.Advanced Paediatric Life Support The Practical Approach. BMJ Books,
APLS 5th Edition 2011, Chapters 20 & 21.
2.American Heart Association Textbook for Neonatal Resuscitation NRP 5th
Edition 2006.
3.American Heart Association Textbook of Paediatric Advanced Life Support
2002
4.APLS - The Pediatric Emergency Medicine Resource. Gausche-Hill M, Fuchs
S, Yamamoto L. 4th Edition 2004, Jones and Bartlett Publishers.
5.Chester M. Edelmann. Jr., Jay Berstein, S. Roy Meadow, Adrian Spitzer, and
Luther B. Travis 1992. Paediatric Kidney Diseases 2nd edition.
6.Forfar&Arneils Textbook of Paediatrics 5th edition:1829-1847
7.Ian A. Laing, Edward Dolye 1998. Practical Procedures.
8.Michele C. Walsh-Sukys, Steven E. Krug 1997. Procedures in infants and
children.
9.Newborn Resuscitation - Handbook of Emergency Protocols, algorithms
and Procedures by Kuala Lumpur General Hospital.
10.NRC Roberton 3rd Edition 1999. Iatrogenic disorders Chapter 37, pp 917938. Procedures Chapter 51, pp 1369-1384.
11.R.J. Postlethwaite 1994 Clinical Paediatric Nephrology 2nd edition.
12.The Harriet Lane Handbook 15th Edition 2000, Procedures Chapter 3, pp
43-72.
PROCEDURES
595
PROCEDURES
596
The drug doses in the following pages are provided courtesy of

Professor Frank Shann, from the Intensive Care Unit, Royal Childrens Hospital,
Parkville, Victoria 3052, Australia, and is current as of 12 March 2012.
DRUGS ARE LISTED BY GENERIC NAME
1/100=1%=10mg/ml, 1/1000=1mg/ml, 1/10000=0.1mg/ml.
Abacavir (ABC). 8mg/kg (adult
300mg) 12H oral.
Abacavir 600mg + lamivudine
300mg (Epzicom). >16yr: 1 tab
daily oral.
Abacavir 300mg + lamivudine
150mg + zidovudine 300mg
(Trizivir). >40kg: 1 tab 12H oral.
Abarelix. Adult (NOT/kg): 1 vial (delivers 100mg) IM on day 1, 15 and
29, and then every 28 days.
Abatacept. NOT/kg: 500mg (4060kg) 750mg (60-100 kg) 1g
(>100kg) IV over 30min day 1,
2wk, 4wk, then every 4wk.
Abciximab. 0.25mg/kg IV stat 10min
before angioplasty, then 0.2mcg/
kg/min (max 10mcg/min) IV for
12hr.
Acamprosate. Adult (NOT/kg).
<60kg: 666mg mane, 333mg noon
and nocte oral. >60kg: 666mg 8H.
Acarbose. 1-4mg/kg (adult 50200mg) 8H oral.
Acebutolol. 4-8mg/kg (adult 200400mg) 8-24H oral.
Aceclofenac. 2mg/kg (adult 100mg)
12H oral.
Acemetacin. 1.2mg/kg (adult 60mg)
8-12H oral.
Acenocoumarol. See nicoumalone.
Acetaminophen. See paracetamol.
Acetazolamide. 5-10mg/kg (adult
100-250mg) 6-8H (daily for
epilepsy) oral. TB hydrocephalus:
25-50mg/kg 6-8H plus frusemide
0.25mg/kg 6H; may cause severe
alkalosis.
Acetic acid. 1% 3 drops/ear 8H. Box
jellyfish: apply vinegar.
Acetohydroxamic acid. 5mg/kg
(adult 250mg) 6-8H oral.
Acetylcholine chloride. Adult (NOT/

kg): 1% instil 0.5-2ml into anterior
chamber of the eye.
Acetylcysteine. Paracetamol
poisoning (regardless of delay):
150mg/kg in 5%D IV over 1hr;
then 10mg/kg/hr for 20hr (delay
<10hr), 32hr (delay 10-16hr),
72hr (delay >16hr) and longer
if still encephalopathic; oral
140mg/kg stat, then 70 mg/kg
4H for 72hr. Monitor serum K+.
Give if paracetamol >1000umol/L
(150mg/L) at 4hr, >500umol/L
8hr, >250umol/L 12hr. Lung disease: 20% soltn 0.1ml/kg (adult
5ml) 6-12H nebulised or intratracheal. Meconium ileus equivalent: 5ml (NOT/kg) of 20% soltn
8H oral; 60-100ml of 50mg/ml for
45 min PR. CF: 4-8mg/kg 8H oral.
Eye drop 5% + hypromellose
0.35%: 1 drop/eye 6-8H.
Acetylsalicylic acid. See aspirin.
Acetyl sulfisoxazole. 1.16g = 1.0g
sulphafurazole (qv).
Aciclovir. EBV, herpes enceph, immunodef, varicella: 500 mg/m2
IV over 1hr every 18H (<30wk),
12H (30-32wk), 8H (birth-12yr);
>12yr 10mg/kg 8H IV over 1hr.
Cutaneous herpes 250mg/m2
(birth-12yr) 5mg/kg (>12yr) 8H IV
over 1hr. Genital herpes (>12yr
NOT/kg): 200mg oral x5/day for
10 days, then 200mg x2-3/day
for 6mo if reqd. Zoster (>12yr
NOT/kg): 400 mg (<2yr) or 800mg
(>=2yr) oral x5/day for 7 days.
Cold sores: 5% cream x5/day. Eye:
3% oint x5/day.
Acipimox. 5mg/kg (adult 250mg)
8-12H oral.
597
Drug Doses
DRUG DOSES
Drug Doses
Acriflavine hydrochloride. 0.1%

soltn: apply 12-24H.
Acrivastine. 0.15mg/kg (adult 8mg)
8H oral.
Actinomycin D. See dactinomycin.
Acitretin. 0.5mg/kg (adult 25-50mg)
daily oral; occasionally up to
1mg/kg (adult 75mg) daily oral.
Activated charcoal. See charcoal,
activated.
Acyclovir. See aciclovir.
Adalimumab. Adult (NOT/kg): 40mg
every 1-2wk SC.
Adapalene. 0.1% gel: apply once a
day before bedtime.
Adapalene 0.1% + benzoyl peroxide
2.5% gel. Apply daily.
Adefovir. Adult (NOT/kg): 10mg daily
oral.
Adenosine. Arrhythmia: 0.1mg/kg
(adult 3mg) stat by rapid IV push,
incr by 0.1mg/kg (adult 3mg)
every 2min to max 0.5 mg/kg
(adult 18mg). Pul hypertension:
50mcg/kg/min (3 mg/ml at 1ml/
kg/hr) into central vein.
Adrenaline. Asthma, bronchiolitis,
croup by inhaltn (<2yr use 10 l/
min gas flow): 1% 0.05ml/kg diluted to 6ml, or 1/1000 0.5ml/kg
(max 6ml) diluted to 6ml. Cardiac
arrest (repeat if reqd): 0.1ml/kg
of 1/10,000 IV or intracardiac;
via ETT 0.1 ml/kg of 1/1000.
Anaphylaxis: IV 0.05-0.1ml/kg of
1/10,000, repeat if reqd; IM into
thigh: 0.01 mg/kg (0.01ml/kg of
1/1000) up to 0.1mg/kg, x3 doses
20 min apart if reqd. IV infsn
0.15mg/kg in 50ml 5%dex-hep at
1-10ml/hr (0.05-0.5 mcg/kg/min).
Adrenaline 0.1% + fluorouracil
3.33%. Gel: inject into each wart
x1/wk for up to 6wk.
Adrenocorticotrophic hormone
(ACTH). See corticotrophin.
Agalsidase alpha. 0.2mg/kg IV over
40min every 2wk.
Agalsidase beta. 0.2-1mg/kg IV over
40 min every 2wk.
Agar + paraffin 65%. NOT/kg: 6mo2yr 5ml, 3-5yr 5-10ml, >5yr 10ml
8-24H oral.
Agar + paraffin + phenolphthalein
(Agarol). NOT/kg: 6mo-2yr 2.5ml,
3-5yr 2.5-5ml, >5yr 5ml 8-24H
oral.
Agomelatine. Adult (NOT/kg): 25mg
(max 50mg) daily oral.
Alatrofloxacin. 4mg/kg (adult
200mg) daily IV over 60min. Severe inftn: 6mg/kg (adult 300mg)
daily IV over 90min.
Albendazole. Pinworm, threadworm, roundworm, hookworm,
whipworm: 20mg/kg (adult
400mg) oral once (may repeat
after 2wk). Strongyloides,
cutaneous larva migrans, Taenia,
H.nana, O.viverrini, C.sinesis:
20mg/kg (adult 400mg) daily for
3 days, repeated in 3wk. 7.5mg/
kg (adult 400mg) 12H for 8-30
days (neurocysticercosis); 12H
for three 28 day courses 14 days
apart (hydatid).
Albumin. 20%: 2-5ml/kg IV. 4%: 1020ml/kg. If no loss from plasma:
dose (ml/kg) = 5 x (increase g/L) /
(% albumin).
Albuterol. See salbutamol.
Alclometasone. 0.05% cream or
ointment: apply 8-12H.
Alcohol. See chlorhexidine, ethanol.
Aldesleukin (synthetic IL-2). Malignancy: constant IV infsn less
toxic than bolus injtn: 3,000,0005,000,000u/m2/day for 5 days, if
tolerated repeat x1-2 with 5 day
interval.
Alefacept. Adult (NOT/kg): 7.5mg IV,
15mg IM wkly 12wk.
Alemtuzumab. Adult (NOT/kg).
BCLL: 3mg daily IV over 2hr for
2-3 days, 10mg daily 2-3 days,
then 30mg x3/wk for up to 12wk.
MS: 12mg daily for 5days, then 3
days anually.
598
Alpha1 proteinase inhibitor. See

alpha1 antitrypsin.
Alpha1 antitrypsin. 60mg/kg once
wkly IV over 30min.
Alpha tocopheryl acetate. One
alpha-tocopheryl (at) equivalent
= 1mg d-at = 1.1mg d-at acetate
= 1.5mg dl-at acetate = 1.5u vit E.
Abetalipoproteinaemia: 100mg/
kg (max 4g) daily oral. Cystic
fibrosis: 45-200mg (NOT/kg) daily
oral. Newborn (high dose, toxicity
reported): 10-25mg/kg daily IM
or IV, 10-100mg/kg daily oral.
Alprazolam. 0.005-0.02mg/kg (adult
0.25-1mg) 8H oral. Slow rel:
0.5-1mg daily, incr to 3-6mg (max
10mg) daily oral.
Alprenolol. 1-4mg/kg (max 200mg)
6-12H oral.
Alprostadil (prostaglandin E1,
PGE1). Maintain PDA: 60 mcg/
kg in 50ml 0.9% saline 0.5-3ml/
hr (10-60ng/kg/min). Erectile dysfunction (adult NOT/kg): 2.5mcg
intracavernous inj, incr by 2.5mcg
if reqd to max 60mcg (max 3
doses/wk).
Alteplase (tissue plasminogen
activator). 0.1-0.6mg/kg/hr IV for
6-12hr (longer if no response);
keep fibrinogen >100mg/dL (give
cryoprecipitate 1bag/5kg), give
heparin 10u/kg/hr IV, give fresh
frozen plasma (FFP) 10ml/kg IV
daily in infants. Local IA infsn:
0.05mg/kg/hr, give FFP 10ml/
kg IV daily. Blocked central line:
0.5mg/2ml (<10kg) 2mg/2ml
(>10kg) per lumen left for 2-4hr,
withdraw drug, flush with saline;
repeat once in 24hr if reqd.
Altretamine. 150-300mg/m2 daily
oral.
Aluminium acetate. 13% soltn (Burrows lotion): for wet compresses,
or daily to molluscum contagiosum.
599
Drug Doses
Alendronate. 0.5mg/kg (adult 40mg)

daily oral. Postmenopausal osteoporosis (adult, NOT/kg): 10mg
daily, or 70mg slow-release wkly.
Alendronate 70mg + vitamin D3
2800u. 1 tab each wk oral.
Alfacalcidol. 0.05mcg/kg (max
1mcg) daily oral or IV, adjusted
according to response.
Alfentanil. 10mcg/kg IV or IM stat,
then 5mcg/kg prn. Theatre
(ventilated): 30-50mcg/kg IV over
5min, then 15mcg/kg prn or 0.51mcg/kg/min. ICU: 50-100mcg/
kg IV over 10min, then 0.5-4mcg/
kg/min.
Alfuzosin. Adult (NOT/kg): 10mg
daily oral.
Alginic acid (Gaviscon single
strength). <1yr: liquid 2ml with
feed 4H. 1-12yr: liquid 5-10ml, or
1 tab after meals. >12yr: liquid
10-20ml, or 1-2 tab after meals.
Alglucerase. Usual initial dose is
60u/kg every 2wk IV over 2hr,
adjusted according to response;
reduce every 3-6mo.
Alglucosidase alfa. 20mg/kg by IV
infusion every 2wk.
Alimemazine. See trimeprazine.
Aliskiren. Adult (NOT/kg): 150mg
(max 300mg) daily oral. Aliskiren/
hydrochlorothiazide 150/12.5,
150/25, 300/12.5, 300/25 (adult
NOT/kg): 1 tab daily oral.
Aliskiren + valsarten 150/160mg,
300/320mg tabs. Adult (NOT/kg):
1 tab daily oral.
Alitretinoin. 0.1% gel: apply 6-12H.
Allopurinol. 10mg/kg (adult 300mg)
12-24H oral. Chemotherapy: 50100mg/m2 6H IV, oral.
Almotriptan. Adult (NOT/kg): 6.2512.5mg oral, repeat in 2hr if reqd
(max 2 doses in 24hr).
Alosetron. Adult (NOT/kg): 1mg
daily oral, incr if reqd after 4wk
to 1mg 12H (stop if no response
after 4wk).
Drug Doses
Aluminium chloride hexahydrate.

20% lotion: x1-2/wk.
Aluminium hydroxide. 25mg/
kg (adult 0.5-1g) 4-6H oral. Gel
(64mg/ml) 0.1ml/kg 6H oral.
Aluminium hydroxide 40mg/ml, Mg
hydroxide 40mg/ml, simethicone
4mg/ml (Mylanta, Gelusil). 0.51ml/kg (adult 10-20ml) 6-8H oral.
ICU: 0.5ml/kg 3H oral if gastric
pH <5.
Aluminium sulphate. 20% soltn:
apply promptly to sting.
Alverine. 1-2mg/kg (adult 60120mg) 8-12H oral.
Alvimopan. Adult (NOT/kg): 12mg
cap 1-5hr pre-op, then 12H starting the day after surgery for up
to 7 days oral.
Amantadine hydrochloride. 2mg/
kg (adult 100mg) 12-24H oral. Flu
A prophylaxis (NOT/kg): 100mg
daily (5-9yr), 100mg 12H (>9yr).
Ambenoium. Adult (NOT/kg): 5mg
x3-4/day incr slowly to 5-25mg
(max 75mg) 6-8H oral.
Ambrisentan. Adult (NOT/kg): 5mg
Amcinonide. 0.1% lotion, cream,
ointment: apply 8-12H.
Amethocaine. Gel 4% in methylcellulose (RCH AnGel): 0.5g to skin,
apply occlusive dressing, wait
30-60min, remove gel. 0.5%, 1%:
1 drop/eye.
Amifampridine. Adult (NOT/kg): 15
mg daily oral, incr every 5 days if
reqd to max 20mg 8H.
Amifostine. 910mg/m2 IV over
15min daily 30min before chemotherapy; reduce to 740mg/m2 if
severe side effects.
Amikacin. Daily dose IV or IM. Neonate: 15mg/kg stat, then 7.5mg/
kg (<30wk) 10mg/kg (30-35wk)
15mg/kg (term <1wk) daily. 1wk10yr: 25mg/kg day 1, then 18mg/
kg daily. >10yr: 20mg/kg day 1,
then 15mg/kg (max 1.5g) daily.
Trough level <5.0mg/L.
Amiloride. 0.2mg/kg (adult 5mg)

12-24H oral.
Aminoacridine hydrochloride. See
aminacrine.
Aminacrine hydrochloride. 0.02% 1
drop/eye 2-4H.
Aminobenzoic acid. 60mg/kg (max
3g) 6H oral.
Aminocaproic acid. 3g/m2 (adult
5g) over 1hr IV, then 1g/m2/hr
(adult 1-1.25g/hr). Prophylax:
70mg/kg 6H IV, oral.
Aminoglutethimide. Adult (NOT/kg):
250mg daily oral, incr over 4wk to
250mg 6H.
Aminohippuric acid (PAHA).
6-10mg/kg stat, then 0.2-0.5 mg/
kg/min IV gives 2mg/100ml in
plasma.
Aminolevulinic acid. 20% soltn:
apply to lesions, expose to 400450nm blue light for 1000sec (10
J/cm2) next day; repeat after 8wk
if reqd.
Aminophylline (100mg = 80mg
theophylline). Load: 10 mg/
kg (max 500mg) IV over 1hr.
Maintenance: 1st wk life 2.5mg/
kg IV over 1hr 12H; 2nd wk life
3mg/kg 12H; 3wk-12 mo ((0.12 x
age in wk) + 3) mg/kg 8H; >12mo
and <35kg, 55 mg/kg in 50ml
5%dex-hep at 1ml/hr (1.1mg/
kg/hr) or 6mg/kg IV over 1hr 6H;
>35kg and <17yr, or >17yr and
smoker, 25 mg/ml at 0.028ml/
kg/hr (0.7mg/kg/hr) or 4mg/
kg IV over 1hr 6H; >17yr nonsmoke 25mg/ml at 0.02ml/kg/
hr (0.5mg/kg/hr) or 3mg/kg IV
over 1hr 6H; elderly 25mg/ml at
0.014 ml/kg/hr (0.35mg/kg/hr)
or 2mg/kg IV over 1hr 6H. Level
60-80umol/L (neonate), 60-110
(asthma) (x0.18=mcg/ml).
Aminosalicylic acid (4-Aminosalicylic acid, ASA, 4-ASA, para-ASA,
PAS). 50-100mg/kg (adult 4g)
8H oral.
5-Aminosalicylic acid. See mesalazine.
600
Amoxycillin + clavulanic acid. Dose

as amoxicillin, oral. 4:1 (non-Duo
products) 15-25mg/kg (adult
500/125mg) 8H; 7:1 (Duo) 2030mg/kg (adult 875/125mg) 12H;
or 16:1 (XR) 30-50mg/kg (adult
2000/125mg) 12H.
Amphetamine. See dexamphetamine.
Amphotericin B (Fungizone). Usually 1.5mg/kg/day (up to 2mg/
kg/day) by continuous infsn IV.
Central line: 1.5mg/kg in 50ml
5%dex-hep at 2ml/hr (up to
46kg); 1.5 mg/kg in 1.2 ml/
kg 5%dex-hep (1.25mg/ml) at
0.05ml/kg/hr (over 46kg). Peripheral IV: usually 1.5mg/kg in 12ml/
kg 5% dex-hep at 0.5ml/kg/hr
(higher concentrations may cause
thrombophlebitis). Oral (NOT/kg):
100mg 6H, 50mg 6H prophylaxis.
Bladder washout: 25 mcg/ml.
Cream, oint 3%: apply 6-12H.
Amphotericin, colloidal dispersion
(Amphocil, Amphotec). Usually
3-4mg/kg (up to 6mg/kg for aspergillus) daily IV at 2.5mg/kg/hr.
Amphotericin, lipid complex (Abelcet). 2.5-5mg/kg daily over 2hr IV,
typically for 2-4wk.
Amphotericin, liposomal (AmBisome). 3-6mg/kg (up to 15 mg/kg
if severe inftn) daily over 1-2hr IV,
typically for 2-4wk.
Ampicillin. 15-25mg/kg (adult
0.25-1g) 6H IV, IM or oral. Severe
inftn: 50mg/kg (max 2g) IV 12H
(1st wk life), 6H (2-4 wk), 3-6H or
constant infsn (4+ wk).
Ampicillin + flucloxacillin. NOT/
kg. 125mg/125mg or 250/ 250
(child), 250/250 or 500/500
(adult) 6H oral, IM or IV.
Ampicillin 1g + sulbactam 0.5g. 2550mg/kg (adult 1-2g) of ampicillin
6H IM or IV over 30min.
601
Drug Doses
Amiodarone. IV: 15mg/kg in 50ml

5%dex (no heparin) at 5ml/hr
(25mcg/kg/min) for 4hr, then
1-3ml/hr (5-15mcg/kg /min, max
1.2g/24hr). Oral: 4mg/kg (adult
200mg) 8H 1 wk, 12H 1 wk, then
12-24H. After starting tablets,
taper IV infsn over 5 days. Reduce
dose of digoxin and warfarin.
Pulseless VF or VT: 5mg/kg IV
over 3-5 min.
Amisulpride. 1-6mg/kg (adult 50300mg) daily oral; acute psychosis
5-15mg/kg (adult 300-800mg)
12H.
Amitriptyline. Usually 0.5-1mg/kg
(adult 25-50mg) 8H oral. Enuresis:
1-1.5mg/kg nocte.
Amlexanox. 5% oral paste: apply to
ulcers x4/day.
Amlodipine. 0.05-0.2mg/kg (adult
2.5-10mg) daily oral.
Amlodipine + olmesartan
(5mg/20mg, 5/40, 10/20, 10/40).
Adult (NOT/kg): 1 tablet daily
oral.
Amoldipine + telmisartan
(5mg/40mg, 5/80, 10/40, 10/80).
Adult (NOT/kg): 1 tab daily oral.
Amlodipine + valsartan
(5mg/160mg, 5/320, 10/160,
10/320). Adult (NOT/kg): 1 tablet
daily oral.
Amobarbital. See amylobarbitone.
Amodiaquine. Treatment: 10mg/kg
daily for 3 days oral. Prophylaxis:
5mg/kg once a wk.
Amorolfine. Nail lacquer 5%: apply
x1-2/wk.
Amoxapine. 0.5-2mg/kg (adult 25100mg) 8H oral.
Amoxicillin. See amoxycillin.
Amoxycillin. 15-25mg/kg (adult
0.25-1g) 8H IV, IM, oral; or
25-40mg/kg 12H. Slow release:
12yr 775mg tab daily oral.
Severe inftn: 50mg/kg (adult 2g)
IV 12H (1st wk life), 6H (2-3wk),
4-6H or constant infsn (4wk).
H.pylori: omeprazole.
Drug Doses
Amprenavir. Age 4yr or more. Soltn

(max 2.8g/day): 22.5 mg/kg 12H,
or 17mg/kg 8H oral. Caps (max
2.4g/day): 20mg/kg 12H, or
15mg/kg 8H oral.
Amrinone. <4wk old: 4mg/kg IV
over 1hr, then 3-5mcg/kg /min.
>4wk: 1-3mg/kg IV over 1hr, then
5-15mcg/kg/min.
Amsacrine. 450-600mg/m2 IV over
2hr daily for 3-5days.
Amylase. See pancreatic enzymes.
Amylmetacresol. 0.6mg lozenge as
reqd (max 8/day).
Amylobarbitone. 0.3-1mg/kg (adult
15-50mg) 8-12H, or 2-4mg/kg
(adult 200-400mg) at night, oral.
Anagrelide. Adult (NOT/kg): 0.5mg
12H, incr slowly if reqd to max
2.5mg 6H oral.
Anakinra. Adult (NOT/kg): 100mg
daily SC.
Anastrozole. Adult (NOT/kg): 1mg
daily oral.
Ancestim (human stem cell factor).
20mcg/kg/day SC.
Aneurine. See thiamine.
Anidulafungin. 2-4mg/kg (adult 100200mg) IV day 1, then 1-2mg/kg
(adult 50-100mg) daily.
Anisindione. 6mg/kg (adult 300mg)
oral day 1, 4mg/kg (adult 200mg)
day 2, 2mg/kg (adult 100mg)
day 3, then 0.5-5 mg/kg/day
(adult 25-250mg) according to
prothrombin time.
Anistreplase. Adult (NOT/kg): 30u IV
over 5min.
Anthraquinone. See sennoside.
Anthrax vaccine (BioThrax). Inanimate. 0.5ml IM stat, 4wk, 6mo,
12mo, 18mo (5 doses). Boost
annually.
Antihaemophilic factor. See factor 8.
Anti-inhibitor coagulant complex.
See factor 8 inhibitor bypassing
fraction.
Antilymphocyte globulin. See immunoglobulin, antilymte.
Antithrombin, antithrombin alfa,

antithrombin III, recombinant
human antithrombin (rhAT).
Adult: units = (100% - actual%)
x Wt / 2.2 load, then 23% of this
hrly; double dose in pregnancy.
Child: either 1000u in 20ml water
diluted to 50ml with saline: 2.5
ml/kg/hr (50u/kg/hr) for 3hr,
then 0.3 ml/kg/hr (6u/kg/hr) or
1750u in 10ml water diluted to
50ml with saline: 1.4ml/kg/hr
(49u/kg/hr) for 3hr, then 0.17ml
/kg/hr (6u/kg/hr). Monitor antithrombin activity after 6hr, then
8-12H: if <80%, incr dose 30%; if
>120%, reduce dose 30%.
Antithymocyte globulin. See immunoglobulin, antilymphte.
Antivenom to Australian box jellyfish, snakes (black, brown, death
adder, sea, taipan, tiger), spiders
(funnel-web) and ticks. Dose
depends on amount of venom injected, not size of patient. Higher
doses needed for multiple bites,
severe symptoms or delayed
administration. Give adrenaline
0.005mg/kg (0.005ml/kg of 1 in
1000) SC. Initial dose usually 1-2
amp diluted 1/10 in Hartmanns
soltn IV over 30min. Monitor PT,
PTT, fibrinogen, platelets; give
repeatedly if symptoms or coagulopathy persist.
Antivenom to black widow spider
(USA), red back spider (Australia). 1amp IM, may repeat in
2hr. Severe envenomation: 2amp
diluted 1/10 in Hartmann soltn IV
over 30min.
Antivenom to coral snake (USA).
3-6 vials IV over 1-2hr, repeat
if signs progress. Premedicate
with diphenhydramine 5mg/kg
(adult 300mg) IV, have adrenaline
available.
602
Aripiprazole. 0.1mg/kg (adult 5mg)

incr if reqd by 0.1mg/kg (adult
5mg) each wk to max 0.6mg/kg
(adult 30mg) daily.
Armodafinil. Adult (NOT/kg): 150mg
Arsenic trioxide. 0.15mg/kg daily IV
until remission (max 60 doses),
wait 6wk, then 0.15mg/kg daily
for 25 days.
Artemether, oily soltn. 3.2mg/kg
IM stat, then 1.6mg/kg daily unitl
oral therapy possible.
Artemether 20mg + lumefantrine
120mg. NOT/kg: 1 tab (10-14kg),
2 tab (15-24kg), 3 tab (25-34kg),
4 tab (>34kg) with fatty food (e.g.
milk) at 0hr, 8hr, 24hr, 36hr, 48hr
and 60hr. Repeat dose if vomit
within 1hr of ingestion.
Artemisinin. 25mg/kg oral day 1;
then 12.5mg/kg daily for 2 days
(with mefloquine 15-25mg/kg on
day 2), or for 4-6 days if mefloquine resistance.
Artesunate + mefloquine. Oral:
2.5mg/kg at 0, 12, 24 and 48
hours (with mefloquine 1525mg/kg on day 2), and daily for
another 2-4 days if mefloquine
resistance. IM, or IV over 1-2min:
2mg/kg stat, then 1mg/kg in 6hr
if hyperparasitic, then 2mg/kg
daily until oral therapy possible.
Artesunate + pyrimethamine +
sulphadoxine. Artesunate 4mg/
kg daily x3 days oral + pyrimethamine 1.25 mg/kg (max 75mg)
and sulphadoxine 25 mg/kg (max
1.5g) on 1st day.
Articane 40mg/ml + adrenaline
1:100,000. Adult (NOT/kg) avge
dose 1.7ml (max 7mg/kg =
0.175ml/kg) by injection.
Ascorbic acid. Burn (NOT/kg):
200-500mg daily IV, IM, SC, oral.
Metabolic dis (NOT/kg): 250mg
(<7yr) 500mg (>7yr) daily oral.
Scurvy (NOT/kg): 100mg 8H oral
for 10 days. Urine acidification:
10-30mg/kg 6H.
603
Drug Doses
Antivenom to Crotalidae (pit vipers,

rattlesnakes - USA). 4-6 vials,
with higher dose for more severe
envenomation, diluted 1/10 in
saline IV over 1hr, repeated 1hr
later if reqd; then 2 vials 6H for
3 doses.
Antivenom, stonefish. 1000u (2ml)
per puncture IM. Severe: 1000u/
puncture dilutd 1/10 in Hartmann
soltn IV over 30min.
Apomorphine. Adult (NOT/kg): usually 2.4-3.6mg/dose (max 6mg)
prn to max 50mg/day SC. Infsn:
0.02-0.08 mg/kg/hr (max 200mg/
day) SC.
Apraclonidine. 1 drop/eye 8H
(0.5%), 12H (1%).
Aprepitant. Adult (NOT/kg): 125mg
oral 1hr before chemo, then
80mg on days 2 and 3.
Aprostadil. See alprostadil.
Aprotinin (1kiu = 140ng =
0.00056epu, 1mg = 7143kiu).
1,200,000 kiu/m2 IV over 1hr
(plus 1,200,000 kiu/m2 in prime),
then 300,000 kiu/m2/hr; half
for low dose. Adult (NOT/kg):
2,000,000 kiu IV over 1hr (plus
2,000,000 kiu in prime), then
500,000 kiu/hr; half for low
dose. Prophylaxis: 4000 kiu/kg,
then 2000 kiu/kg 6H IV.
Arachis oil. 130ml enema as
required.
Arachis oil 57% + chlorbutol 5% +
dichlorobenzene 16% (Cerumol).
5 drops to ear 15-30min before
syringing.
Arformoterol. NOT/kg: 15mcg in 2ml
12H by nebulisation.
Argatroban. 2mcg/kg/min; adjust to
maintain APTT x1.5-3.
Arginine hydrochloride. Dose (mg) =
BE x Wt(kg) x 70; give half this IV
over 1hr, then repeat if reqd.
Arginine vasopressin, argipressin.
See vasopressin.
Drug Doses
Asenapine. Adult (NOT/kg): 5-10mg

Atovaquone 250mg + proguanil
daily sublingual.
100mg (Malarone). Malaria treat:
Asparaginase. See colaspase.
20mg/kg of atovaquone (adult
Aspirin. 10-15mg/kg (adult 3001g) daily for 3 days oral; proph:
600mg) 4-6H oral. Antiplatelet:
5mg/kg of atovaquone (adult
5mg/kg (max 100mg) daily. Kawa250mg) daily.
saki: 10mg/kg 6H (low dose) or
Atovaquone 62.5mg + proguanil
25mg/kg 6H (high dose) for 2wk,
25mg (Malarone paediatric).
then 3-5 mg/kg daily. Arthritis:
Malaria prophylaxis: 5mg/kg
25mg/kg (max 2g) 6H for 3 days,
(adult 250mg) daily oral.
then 15-20mg/kg 6H. Salicylate
Atracurium besylate. 0.3-0.6mg/
level (arthritis) midway between
kg stat, then 0.1-0.2mg/kg when
doses 0.7-2.0 mmol/L (x13.81 =
reqd or 5-10mcg/kg/min IV.
mg/100ml).
Atropine. 0.02mg/kg (max 0.6mg)
Aspirin 25mg + dipyridamole
IV or IM, then 0.01mg/kg 4-6H.
200mg. Adult (NOT/kg) 1 susOrganophosphate poisoning:
tained rel cap 12H oral.
0.05-1mg/kg (adult 2mg) IV, then
Atazanavir (ATV). >16yr: 400mg/dai0.02-0.05mg/kg (adult 2mg)
ly with food. Trough 150ng/ml.
every 15-60min until atropinAtazinavir 400mg + efavirenz 600mg
ised, then 0.02-0.08mg/kg/hr
+ ritonavir 100mg. >16yr: all daily
for several days. Auto-injector
oral, at different times (EFV not
(adult, NOT/kg): 2mg + obidoxime
with food).
110mg IM.
Atazinavir + ritonavir. 15-24kg:
Atropine 25mcg + diphenoxylate
150/80mg daily with food oral;
2.5mg tab (Lomotil). Adult (NOT/
25-31kg: 200/100mg daily; 32kg): 1-2 tab 6-8H oral.
38kg: 250/100mg daily; 39kg:
Attapulgite. Adult (NOT/kg): 0.6-1.2g
300/100mg daily with food. ATV
3-6H oral.
trough 150ng/ml.
Auranofin. 0.1mg/kg (adult 6mg)
Atenolol. Oral: 1-2mg/kg (adult 50daily oral, incr if reqd to max
100mg) 12-24H. IV: 0.05 mg/kg
0.05mg/kg (adult 3mg) 8H.
(adult 2.5mg) every 5min if reqd
Aurothioglucose. 0.25mg/kg weekly
(max 4 doses), then 0.1-0.2mg/
IM, incr to 1mg/kg (max 40mg)
kg (adult 5-10mg) over 10min
weekly for 20wk, then every
12-24H.
1-4wk.
Atomoxetine. 0.5mg/kg (>70kg
Azacitidine. 75mg/m2 SC daily for
40mg) daily oral, incr after at least
7 days, repeated every 4wk; incr
3 days to max 1.2mg/kg (>70kg
if reqd after 2 cycles to 100mg/
100mg) as single daily dose or
m2 daily.
divided 12H.
Azapropazone. 10mg/kg (max
Atorvastatin. 0.2mg/kg (adult 10mg)
600mg) 12H oral. Acute gout: 6H
daily, incr if reqd every 4wk to
(day 1), 8H (day 2), then 12H.
max 1.6mg/kg (adult 80mg) daily.
Azatadine. NOT/kg: 0.5-1mg (>6y),
Atosiban. Adult (NOT/kg): 6.75mg
1-2mg (>12y) 12-24H po.
IV over 1min, then 300 mcg/min
Azathioprine. 25-75mg/m2 (approx
for 3hr, then 100mcg/min for
1-3mg/kg) daily oral, IV.
max 45hr.
Azelaic acid. 20% cream, 15% gel:
Atovaquone, micronised. Pneumoapply 12H.
cystis: 3-24mo 45mg/kg, >24mo
Azelastine. 0.1% spray, >5yr: 0.15ml
30mg/kg (max 1500mg) daily
to each nostril 12H.
oral.
604
Baclofen. 0.2mg/kg (adult 5mg) 8H

oral, incr every 3 days to 1mg/
kg (adult 25mg, max 50mg) 8H.
Intrathecal infsn: 2-20mcg/kg
(max 1000mcg) per 24hr.
Balsalazide. Adult (NOT/kg): 2.25g
8H oral (= 2.34g mesalazine
daily).
Bambuterol. 0.2-0.4mg/kg (adult
10-20mg) nocte oral.
Basiliximab. 12mg/m2 (max 20mg)
IV 2hr preop and day 4.
BCG vaccine. See Bacillus CalmetteGuerin vaccine.
Becaplermin. 0.01% gel: apply daily
for 10-20wk.
Beclomethasone dipropionate.
Rotacap or aerosol (NOT /kg):
100-200mcg (<8yr), 150-400mcg
(>8yr) x2/day (rarely x4/day).
Nasal (NOT/kg): aerosol or pump
(50mcg /spray): 1spray 12H
(<12yr), 2spray 12H (>12yr).
Bemiparin. Surgery (adult, NOT/kg):
2500u (orthopaedics 3500u) SC
2hr pre-op or 6hr post-op, then
daily for 7-10 days. DVT: 115u/
kg daily 5-9 days (or until oral
anticoag).
Benazepril. 0.2-0.4mg/kg (adult 1020mg) 12-24H oral.
Bendamustine. CLL: 100mg/m2 IV
on days 1 and 2 of 28-day cycle
for up to 6 cycles; 70mg/m2 with
rituximab. NHL: 120mg/m2 on
days 1 and 2 of 21-day cycle for
up to 8 cycles; 90mg/m2 with
rituximab.
Bendroflumethiazide. See bendrofluazide.
Bendrofluazide. 0.1-0.2mg/kg (adult
5-10mg) daily oral.
Benflumetol (lumefantrine). See
artemether.
Benorylate. 30mg/kg (adult 1.5g)
8H oral.
Benperidol. 5-15mcg/kg (adult 0.251.5mg) 12-24H oral.
Benserazide. See levodopa + benserazide.
605
Drug Doses
Azidothymidine (AZT). See zidovudine.

Azithromycin. Oral (only 40%
bioavailable): 15mg/kg (adult
500mg) on day 1 then 7.5mg/kg
(adult 250mg) days 2-5, or 15mg/
kg (adult 500mg) daily for 3 days;
trachoma 20 mg/kg (adult 1g)
wkly x3; MAC prophylaxis (adult)
1.2g wkly; Gp A strep 20mg/
kg daily x3. IV: 15mg/kg (adult
500mg) day 1, then 5mg/kg (adult
200mg) daily. 1% eye drops: 1
drop 12H for 2 days, then daily
for 5 days.
Aztreonam. 30mg/kg (adult 1g) 8H
IV. Severe inftn: 50mg/kg (adult
2g) 12H (1st wk life), 8H (2-4 wk),
6H or infsn (4+ wk). Nebulised
(adult, NOT/kg): 75mg 8H.
Bacampicillin. 15-25mg/kg (adult
400-800mg) 12H oral.
Becaplermin. Length 0.01% gel in
cm: ulcer length x width / 4 (15g
tube), or L x W / 2 (2g tube) daily;
wash off after 12hr.
Bacillus Calmette-Guerin (BCG)
vaccine (CSL). Live. Intradermal
(1mg/ml): 0.075ml (<3mo) or
0.1ml (>3mo) once. Percutaneous
(60mg/ml suspension): 1 drop
on skin, inoculated with Heaf apparatus, once.
Bacillus Calmette-Guerin (BCG)
suspension, about 5 x 10^8 cfu/
vial. Adult: 1 vial (OncoTICE) or 3
vials (ImmuCyst) left in bladder
for 2hr each wk for 6wks, then at
3, 6, 12, 18 and 24mo.
Bacitracin 500u/g + polymyxin B
10,000u/g. Eye ointment: apply
x2-5/day.
Bacitracin 400u/g + polymyxin B
5000u/g + neomycin 5mg/g (Neosporin). Ointment or eye ointment: apply x2-5/day. Powder:
apply 6-12H (skin inftn), every
few days (burns). Eye drops: see
gramicidin.
Drug Doses
Benzathine penicillin. See penicillin,

benzathine.
Benzatropine. See benztropine.
Benzbromarone. Adult (NOT/kg):
50-300mg daily oral, or 20-25mg
with allopurinol.
Benzhexol. >3yr: 0.02mg/kg (adult
1mg) 8H, incr to 0.1-0.3 mg/kg
(adult 1.5-5mg) 8H oral.
Benzocaine. 1%-20% topical: usually
applied 4-6H.
Benzoczine + cetylpyridinium.
Mouth wash (Cepacaine): apply
3H prn, do not swallow.
Benzocane + phenazone 5.4% (Auralgin). 3 drops per ear 3 times a
day for 2-3 days.
Benzoic acid 6% + salicylic acid 3%.
Whitfields ointment: apply 12H.
Benzonatate. 2-4mg/kg (adult 100200mg) 8H oral.
Benzoyl peroxide. Liquid, gel 2.5%10%: apply x1-3/day. See also
adapalene + benzoyl peroxide.
Benzphetamine. 25-50mg daily oral,
incr if reqd to 8H.
Benzquinamide. IM: 0.5-1mg/kg
(adult 50mg) stat and repeat in
1hr if needed, then 3-4H prn. IV
over 1-5min: 0.2-0.4mg/kg (adult
25mg) once.
Benzthiazide 25mg + triamterene
50mg. Adult (NOT/kg): 1-2 tab on
alternate days, oral.
Benztropine. >3yr: 0.02mg/kg (adult
1mg) stat IM or IV, may repeat
in 15min. 0.02-0.06mg/kg (adult
1-3mg) 12-24H oral.
Benzydamine. 3% cream: apply 8H.
Benzyl benzoate. 25% lotion. Scabies: apply neck down after hot
bath, wash off after 24hr; repeat
in 5days. Lice: apply to infected
region, wash off after 24hr; repeat in 7days.
Benzylpenicillin. See penicillin G.
Bevacizumab. 10mg/kg oral on days
1 and 15 every month.
Bepotastine. 1.5% ophthalmic soltn:
1 drop 12H.
Bepridil. 4-8mg/kg (adult 200400mg) daily oral.

Beractant (bovine surfactant,
Survanta). 25mg/ml soltn. 4ml/
kg intratracheal 2-4 doses in
48hr, each dose in 4 parts: body
inclined down with head to right,
body down head left, body up
head right, body up head left.
Besifloxacin. 0.6% eye ointment:
apply 8H.
Beta carotene. Porphyria: 1-5mg/kg
Betahistine. 0.15-0.3mg/kg (adult
8-16mg) 8H oral.
Betaine hydrochloride. Usually
60mg/kg (adult 3g) 12H oral, max
100mg/kg (adult 5g) 12H.
Betamethasone. 0.01-0.2mg/kg
daily oral. Betamethasone has
no mineralocorticoid action,
1mg = 25mg hydrocortisone in
glucocorticoid action. Gel 0.05%;
cream, lotion or ointment,
0.02%, 0.05%, 0.1%: apply
sparingly 8-24H. Eye 0.1%: initially 1drop/eye 1-2H, then 6H; or
0.6cm oint 8-12H.
Betamethasone acetate 3mg/
ml + betamethasone sodium
phosphate 3.9mg/ml (Celestone
Chronodose). Adult: 0.252ml (NOT/kg) intramuscular,
intra-articular, or intralesional
injection.
Betamethasone dipropionate.
0.064% + calcipotriol 0.005%
(Dovonex). Ointment: apply daily
to no more than 30% of body
for up to 4wk (max 100g/wk in
adult).
Betamethasone 0.1% + neomycin
0.5%. 1drop/eye 4-8H.
Betaxolol. 0.4-0.8mg/kg (adult
20-40mg) daily oral. Eye drops
0.25%-0.5%: 1 drop/eye 12H.
Bethanecol. Oral: 0.2-1mg/kg (adult
10-50mg) 6-8H. SC: 0.05-0.1mg/
kg (adult 2.5-5mg) 6-8H.
Bevacizumab. 5mg/kg IV every 14
days.
606
Bivalirudin. 0.75-1mg/kg IV stat,

then 1.75-2.5mg/kg/hr for 4hr,
then stop or give 1.75-2mg/kg/hr
for 14-20hr.
Bleomycin sulfate. 10-20u/m2 IM,
SC or IV over 15min x1-2/wk. Max
total dose 250u/m2.
Bortezomib. 1.3mg/m2 on days 1,
4, 8, 11; then 10 day rest (21 day
cycle, average 6 cycles). Stop if
toxicity, then use 1 mg/m2/dose;
stop if toxicity recurs, then use
0.7mg/m2/dose.
Bosentan. 1mg/kg (adult 62.5mg)
12H oral for 1-4wk, then 2mg/kg
(adult 125mg) 12H. IV: half oral
dose.
Botulinum toxin type A. NOT/kg:
1.25-2.5u/site (max 5u/site) IM,
max total 200u in 30 days. Oesoph achalasia: 100u per session
divided between 4-6 sites. Hyperhidrosis: 50u/2ml intradermal per
axilla (given in 10-15 sites).
Botulinum toxin type B. NOT/kg:
usual total dose 2,500-10,000u,
repeated every 3-4mo if reqd.
Bowel washout. See colonic lavage
soltn.
Bretylium tosylate. 5mg/kg IV in
1hr, then 5-30 mcg/kg/min.
Brimonidine. 0.2%: 1 drop/eye 12H.
Brimonidine 0.2% + timolol 0.5%. 1
drop/eye 12H.
Brinzolamide. 1%: 1 drop/eye
8-12H.
Bromazepam. 0.02-0.1mg/kg (adult
1-3mg) 8H oral.
Bromhexine. 0.3mg/kg (adult 16mg)
8H oral for 7 days, then 0.15mg/
kg (adult 8mg) 8H.
Bromocriptine. 0.025mg/kg (adult
1.25mg) 8-12H, incr wkly to 0.050.2mg/kg (adult 2.5-10mg) 6-12H
oral. Inhibit lactn, NOT/kg: 2.5mg
12H for 2wk.
Brompheniramine. 0.1-0.2mg/kg
(adult 5-10mg) 6-8H oral, SC, IM
or slow IV.
Buclizine. 0.25-1mg/kg (adult 12.550mg) 8-24H oral.
607
Drug Doses
Bexarotene. 300mg/m2 (range 100400mg/m2) daily oral.

Bezafibrate. 4mg/kg (adult 200mg)
8H oral with food.
Bicalutamide. Adult (NOT/kg): 50150mg daily oral.
Bicalutamide + goserelin. Adult
(NOT/kg): 50mcg daily oral, +
goserelin 10.8mg implant 4wkly
or 10.8mg SC every 3mo.
Bicarbonate. Slow IV: dose (mmol)
= BE x Wt/4 (<5kg), BE x Wt/6
(child), BE x Wt/10 (adult). These
doses correct half the base deficit. Alkalinise urine: 0.25mmol/kg
6-12H oral.
Bifonazole. 1% cream: apply daily
for 2-4wk.
Bimatoprost. 0.03% drops: 1 drop/
eye each evening.
Bimatoprost 0.3mg/ml + timolol
5mg/ml. 1drop/eye daily.
Biotin (coenzyme R, vitamin H).
NOT/kg: 5-20mg daily IV, IM, SC
or oral.
Biperiden. 0.02-0.04mg/kg (adult
1-2mg) 8-12H oral. IM or slow IV:
0.05-0.1mg/kg (adult 2.5-5mg),
max x4/day.
Bisacodyl. NOT/kg: <12mo 2.5mg
PR, 1-5yr 5mg PR or 5-10mg oral,
>5yr 10mg PR or 10-20mg oral.
Enema: half daily (6mo-3yr), 1
enema daily (>3yr).
Bisacodyl 10mg + docusate sodium
100mg. <2yr half suppos, 1-11yr
half to 1 suppos, >11yr 1 suppos
daily.
Bismuth subgallate. See bismuth
subcitrate.
Bismuth subsalicylte. 5mg/kg (adult
240mg) 12H oral 30min before
meal. H.pylori, see omeprazole.
Bisoprolol. 0.2-0.4mg/kg (adult 1020mg) daily oral.
Bitolterol. Resp soltn (0.2%): 1ml diluted to 4ml 3-6H (mild), 2ml diltd
to 4ml 1-2H (moderate), undiltd
constant (severe, in ICU). Aerosol
370mcg/puff: 1-2 puff 4-6H.
Drug Doses
Budesonide. Metered dose inhaler

(NOT/kg): <12yr 50-200 mcg
6-12H, reducing to 100-200mcg
12H; >12yr 100-600 mcg 6-12H,
reducing to 100-400mcg 12H.
Nebuliser (NOT/kg): <12yr 0.51mg 12H, reducing to 0.25-0.5mg
12H; >12yr 1-2mg 12H, reducing
to 0.5-1mg 12H. Croup: 2mg
(NOT/kg) nebulised. Nasal spray,
aerosol (NOT/kg): 64-128 mcg/
nostril 12-24H. Crohns dis, adult
(NOT/kg): 9mg daily for 8wk, then
reduce over 4wk.
Budesonide + formoterol.
NOT/kg: 80mcg/4.5mcg or
160mcg/4.5mcg, two inhalations
12H.
Bumetanide. 25mcg/kg (adult
1mg) daily oral, may incr to max
50mcg/kg (adult 3mg) 8-12H.
Bupivacaine. Max dose: 2-3mg/kg
(0.4-0.6ml/kg of 0.5%). Intrathecal: 1mgkg (0.2ml/kg of 0.5%).
Epidural: 2mg/kg (0.4ml/kg of
0.5%) stat intraop, then 0.25mg/
kg/hr (0.2 ml/kg/hr of 0.125%)
postop. Intrapleural: 0.5% 0.5ml/
kg (max 20ml) 8-12H, or 0.5ml/kg
(max 10ml) stat then 0.1-0.25ml/
kg/hr (max 10ml/hr). Epidural in
ICU: 25ml 0.5% + 1mg (20ml) fentanyl + saline to 100ml at 2-8ml/
hr in adult.
Buprenorphine. Adult (NOT/kg):
200-800mcg 6-8H sublingual, IM
or slow IV.
Bupropion. 2-3mg/kg (adult
75-150mg) 8-12H oral. NOT/
kg: sustained 100-200mg 12H;
extended: 150-300mg daily.
Burrows solution. See aluminium
acetate soltn.
Buserelin. Adult, NOT/kg. Intranasal:
100mcg 4H, or 150 mcg each
nostril 8H. Prostate carcinoma:
0.5mg 8H SC for 7 days, then
100mcg dose of spray to each
nostril x6/day.
Buspirone. 0.1mg/kg (adult 5mg)

8-12H oral, incr to max 0.3mg/kg
(adult 15mg) 8-12H.
Busulfan. Induction: 0.06mg/kg
(max 4mg) daily oral if leucocytes >20,000/mm3 and platelets
>100,000/mm3. Maintenance:
0.01-0.03mg/kg (max 2mg) daily.
Butabarbital. See secbutobarbitone.
Butalbital. 1-2mg/kg (adult 50100mg) 8-24H oral.
Butenafine. 1% cream: apply 12-24H
for 1-4wk.
Butobarbitone. 2-4mg/kg (adult
100-200mg) nocte oral.
Butoconazole. 2% vaginal cream: 5g
(NOT/kg) nocte.
Butorphanol. IM: 0.02-0.1mg/kg
(adult 1-4mg) 3-4H. IV: 0.010.05mg/kg (adult 0.5-2mg) 3-4H.
C1 esterase inhibitor. 1u = activity
1ml plasma. Prophylaxis (Cinryze):
10-50u/kg (adult 1000u) IV over
1hr every 3-4 days. Treatment:
20u/kg IV (Berinert).
Cabazitaxel. 25mg/m2 IV over 1hr
every 3wk.
Cabergoline. 10mcg/kg/wk (adult
0.5mg) in 1-2 doses, incr if reqd
monthly by 10mcg/kg/wk to
usually 20mcg/kg/wk (adult 1mg)
in 1-4 doses, max 90mcg/kg/wk
(adult 4.5mg). Inhibit lactation:
1mg oral stat.
Caffeine citrate. 2mg citrate = 1mg
base. 1-5mg/kg (adult 50-250mg)
of citrate 4-8H oral, PR. Neonate:
20mg/kg stat of citrate, then
5mg/kg daily oral or IV over
30min; weekly level 5-30mg/L
midway between doses.
Caffeine 100mg + ergotamine tartrate 1mg tabs. Adult (NOT/kg): 2
stat, then 1 hrly if reqd (max 6/
attack,10/wk).
608
Calcium folinate. NOT/kg: 5-15mg

oral, or 1mg IM or IV daily. Rescue
starting up to 24hr after methotrexate: 10-15 mg/m2 6H for
36-48hr IV. Methotrexate toxicity:
100-1000mg/m2 6H IV. Before a
fluorouracil dose of 370 mg/m2:
200mg/m2 IV daily x5, repeat
every 3-4wk.
Calcium gluconate. 10% soltn
(0.22mmol/ml Ca): 0.5ml/kg (max
20ml) slow IV stat. Requirement
<16yr 5ml/kg/day IV. Inotrope:
0.5-2mmol/kg/day (0.1-0.4ml/kg/
hr) via CVC.
Calcium heparin. See heparin.
Calcium levofolinate. Half the dose
of calcium folinate.
Calcium leucovorin. See calcium
folinate.
Calcium polystyrene sulfonate
(Calcium Resonium). 0.3-0.6g/
kg (adult 15-30g) 6H NG (+ lactulose), PR.
Calfactant. 35mg/ml phosphlipids,
0.65mg/ml proteins: 1.5 ml/kg
intratracheal gradually over 20-30
breaths during inspiration with
infant lying on one side, then another 1.5 ml/kg with infant lying
on other side.
Canakinumab. 2mg/kg (15-40kg)
150mg (>40kg) SC every 8wk; if
poor response after 1wk repeat
initial dose, then give 4mg/
kg (15-40kg) 300mg (>40kg) SC
every 8wk.
Candesartan. 0.1-0.3mg/kg (adult
4-16mg) daily oral.
Cannabidiol 25mg + delta-9-tetrahydrocannabinol 27mg per 100L
spray. Titrate over 2wk to max
12 sprays/day. to different parts
of oral mucosa; review response
after 4wk.
609
Drug Doses
Cake, diablo. Fan oven 180oC. Melt

180g dark cooking chocolate +
170g unsalted butter in double
boiler. Off heat, mix in 4 wellwhisked egg yolks, 170g sugar,
40g almond meal; sift in 80g selfraising flour, mix. Fold in of egg
whites (beaten stiff with pinch of
salt); fold back into rest of beaten
whites. Put in buttered + floured
20cm tin, tap out air, bake 30min.
Calcifediol (25-OH D3). Deficiency:
1-2mcg/kg daily oral.
Calciferol (Vitamin D2). See ergocalciferol.
Calcipotriene. See calcipotriol.
Calcipotriol. 50mcg/g (0.005%)
ointment: apply 12-24H. See also
betamethasone + calcipotriol
ointment.
Calcitonin. Hypercalcaemia: 4u/kg
12-24H IM or SC, may incr up to
8u/kg 6-12H. Pagets: 1.5-3u/kg
(max 160u) x3/wk IM or SC. Nasal
spray: 200u daily.
Calcitriol (1,25-OH vitamin D3).
Renal failure, vit D resistant
rickets: 0.02mcg/kg daily oral,
incr by 0.02mcg/kg every 4-8wk
according to serum Ca (adult usually 0.25mcg 12H).
Calcium (as carbonate, lactate or
phosphate). NOT/kg. Neonate:
50mg x4-6/day; 1mo-3yr: 100mg
x2-5/day oral; 4-12yr: 300mg
x2-3/day; >12yr: 1000mg x1-2/
day.
Calcium carbimide. 1-2mg/kg (adult
50-100mg) 12H oral.
Calcium carbonate. Adult NOT/
kg: 1250-1500mg (500-600 mg
calcium) 8H oral with meals for
hyperphosphataemia.
Calcium chloride. 10% soltn
(0.7mmol/ml Ca): 0.2ml/kg (max
10ml) slow IV stat. Requirement
<16yr 2ml/kg/day IV. Inotrope:
0.03-0.12ml/kg/hr (0.5-2mmol/
kg/day) via CVC.
Calcium edetate (EDTA). See sodium
calciumedetate.
Drug Doses
Cannabis. See cannabidiol.

Carboprost (15-Me-PGF2-alpha).
Canrenoate. 3-8mg/kg (adult 150Termination (NOT/kg): 250400mg) daily IV.
500mcg 1-4H (max total 12mg)
Capecitabine. 1250mg/m2 12H oral
IM. Postpartum hge (NOT/kg):
for 2wk then 1wk off, in 3wk
250mcg every 15-120min IM
cycles.
(max total 12mg).
Capreomycin sulphate. 20mg/kg
Carglumic acid. 50mg/kg 12H oral,
(adult 1g) IM daily, decr after
incr to 6H if reqd; titrate dose to
2-4mo to 2-3 times per wk.
plasma ammonia concentration.
Capsaicin. Cream 0.025%, 0.075%.
Carisoprodol. 7mg/kg (adult 350mg)
Apply 6-8H.
6H oral.
Captopril. Beware hypotension.
Carmustine (BCNU). 200mg/m2 IV
0.1mg/kg (adult 2.5-5mg) 8H
over 2hr every 6wk (reduce if
oral, incr if reqd to max 2mg/kg
leucocytes <3000/mm3 or plate(adult 50mg) 8H. Less hypotenlets <75,000). Wafers: implant 8
sion if mixed with NG feeds given
x 7.7mg wafers (total 61.6mg) at
continuously (or 1-2H).
surgery.
Carbachol. 0.01%: max 0.5ml in
Carnitine, L form. IV: 5-15mg/kg
anterior chamber of eye.
(max 1g) 6H. Oral: 25mg/kg 6-12H
Carbamazepine. 2mg/kg (adult
(max 400mg/kg/day).
100mg) 8H oral, may incr over
Carob bean gum (Carobel Instant).
2-4wk to 5-10mg/kg (adult
NOT/kg: 1 scoop (1.8g) in 100ml
250-500mg) 8H. Bipolar disorder
water, give 10-20ml by spoon; or
(adult, NOT/kg): 200mg as
add half a scoop to every 100slow-rel cap 12H oral, incr if
200ml of milk.
reqd to max 800mg 12H. Level
Carteolol. 0.05-0.2mg/kg (adult 2.520-40umol/L (x0.24=mg/l).
10mg) daily oral. 1%, 2%: 1drop/
Carbaryl. 0.5% lotion: rub into hair,
eye 12H.
leave 12hr, shampoo.
Carvedilol. 0.1mg/kg (adult
Carbenicillin. 382mg tab, adult
3.125mg) 12H oral; if tolerated
(NOT/kg): 1-2 tab 4H oral.
incr by 0.1mg/kg (adult 3.125mg)
Carbenoxolone sodium. Adult (NOT/
every 1-2wk to max 0.5-0.8mg/kg
kg): 20-50mg 6H oral. Mouth gel
(adult 25mg) 12H.
2%, or 2g granules in 40ml water,
Casanthranol + docusate sodium.
apply 6H.
Cap 30mg/100mg (NOT/kg):
Carbetocin. Adult (NOT/kg): 100mcg
adult 1-2cap 12-24H oral. Syrup
IV over 1min, or IM.
2mg/4mg per ml (NOT/kg): child
Carbidopa. See levodopa + carbi5-15ml bedtime, adult 15-30ml
dopa.
12-24H.
Carbimazole. 0.4mg/kg (adult 20mg)
Caspofungin. 70mg/m2 (max 70mg)
8-12H oral for 2wk, then 0.1mg/
day 1, then neonate 25 mg/
kg (adult 5-10mg) 8-24H.
m2, child 50mg/m2, adult 50mg
Carbinoxamine. NOT/kg: 2mg (1(>80kg 70mg) daily IV over 1hr.
3yr), 2-4mg (3-6yr), 4-8mg (>6yr)
Cefaclor. 10-15mg/kg (adult 2506-8H oral.
500mg) 8H oral; 12H used in
Carbocisteine. 10-15mg/kg (adult
some mild infectns. Slow release
500-750mg) 8H oral.
tab 375mg (adult, NOT/kg): 1-2
Carbomer. 0.2% gel: 1 drop per eye
tab 12H oral.
x3-4/day.
Cefadroxil. 15-25mg/kg (adult 0.5Carboplatin. 300-400mg/m2 IV over
1g) 12H oral.
60min every 4wk.
Cefalexin. See cephalexin.
610
Ceftriaxone sodium. 25mg/kg

(adult 1g) 12-24H IV, or IM (in 1%
lignocaine). Severe inftn: 50mg/
kg (max 2g) daily (1st wk life), 12H
(2+ wk). Epiglottitis: 100mg/kg
(max 2g) stat, then 50mg/kg (max
2g) after 24hr. Meningococ proph
(NOT /kg): child 125mg, >12yr
250mg IM in 1% lignocaine once.
Cefuroxime. Oral (as cefuroxime
axetil): 10-15mg/kg (adult 250500mg) 12H. IV: 25mg/kg (adult
1g) 8H. Severe inftn: 50mg/kg
(max 2g) IV 12H (1st wk life), 8H
(2nd wk), 6H or constant infsn
(>2wk).
Celecoxib. Usually 2mg/kg (adult
100mg) 12H, or 4mg/kg (adult
200mg) daily oral. Familial adenomatous polyposis (adult, NOT/kg):
400mg 12H oral.
Celiprolol. 5-10mg/kg (adult 200400mg) daily oral.
Cephalexin. Skin or UTI: 12.5mg/
kg (adult 250mg) 6H, or 25mg/
kg (adult 500mg) 12H oral. Otitis:
25mg/kg 6H.
Cephalothin. 15-25mg/kg (adult
0.5-1g) 6H IV or IM. Severe inftn:
50mg/kg (max 2g) IV 4H or constant infsn. Irrigation fluid: 2g/L
(2mg/ml).
Cephamandole. 15-25mg/kg (adult
0.5-1g) 6-8H IV over 10min or IM.
Severe inftn: 40mg/kg (adult 2g)
IV over 20min 4-6H or constant
infsn.
Cephazolin. 10-15mg/kg (adult 0.5g)
6H IV or IM. Severe inftn: 50mg/
kg (adult 2g) IV 4-6H or constant
infsn. Surgical proph: 50mg/kg IV
at induction.
Cephradine. Oral: 10-25mg/kg
(adult 0.25-1g) 6H. IM or IV: 2550mg/kg (adult 1-2g) 6H.
Certolizumab. Adult (NOT/kg):
400mg SC every 2wk for 3 doses,
then every 4wk if response.
Certoparin. Prophylaxis: 60u/kg
(adult 3000u) 1-2hr preop, then
daily SC.
611
Drug Doses
Cefamandole. See cephamandole.

Cefazolin. See cephazolin.
Cefdinir. 14mg/kg (adult 600mg)
daily (or 2 div doses) oral .
Cefditoren. 4-8mg/kg (adult 200400mg) 12H oral.
Cefepime hydrochloride. 25mg/kg
(adult 1g) 12H IM or IV. Severe inftn: 50mg/kg (adult 2g) IV 8-12H
or constant infsn.
Cefixime. 5mg/kg (adult 200mg)
12-24H oral.
Cefodizime. 25mg/kg (max 1g) 12H
IV or IM.
Cefonicid. 15-50mg/kg (adult 0.52g) IV or IM daily.
Cefoperazone. 25-60mg/kg (max
1-3g) 6-12H IV in 1hr or IM.
Cefotaxime. 25mg/kg (adult 1g)
12H (<4wk), 8H (4+wk) IV. Severe
inftn: 50mg/kg (adult 2-3g) IV
12H (preterm), 8H (1st wk life),
6H (2-4 wk), 4-6H or constant
infsn (4+ wk).
Cefotetan. 25mg/kg (adult 1g) 12H
IM, IV. Severe inftn: 50mg/kg
(max 2-3g) 12H or constant infsn.
Cefoxitin. 25-60mg/kg (adult 1-3g)
12H (1st wk life), 8H (1-4wk),
6-8H (>4wk) IV.
Cefpirome. 25-50mg/kg (adult 1-2g)
12H IV.
Cefpodoxime. 5mg/kg (adult 100200mg) 12H oral.
Cefradine. See cephradine.
Cefprozil. 15mg/kg (adult 500mg)
12-24H oral.
Ceftazidime. 15-25mg/kg (adult
0.5-1g) 8H IV or IM. Severe inftn,
cystic fibrosis: 50mg/kg (max 2g)
12H (1st wk life), 8H (2-4 wk), 6H
or constant infsn (4+ wk).
Ceftibuten. 10mg/kg (adult 400mg)
daily oral.
Ceftizoxime. 25-60mg/kg (adult
1-3g) 6-8H IV.
Drug Doses
Cerumol. See arachis oil + chlorbutol

+ dichlorobenzene otic.
Cetirizine. NOT/kg: 2.5mg (6mo2yr), 2.5-5mg (2-5yr), 5-10mg
(>5yr) daily oral.
Cetrimide. See chlorhexidine.
Cetrorelix (GnRH antagonist). Adult
(NOT/kg): 0.25mg SC on stimulation day 5, then daily until hCG
given.
Cetuximab. 400mg/m2 IV over 2hr,
then 250mg/m2 wkly.
Cetylpyridinium. See benzocaine +
cetylpyridinium.
Cevimeline. 0.6mg/kg (adult 30mg)
8H oral.
Charcoal, activated. Check bowel
sounds present. 1-2g/kg (adult
50-100g) NG; then 0.25g/kg hrly
if redq. Laxative: sorbitol 1g/kg
(1.4ml/kg of 70%) once NG, may
repeat x1.
Chenodeoxycholic acid. 5-10mg/kg
12H oral.
Chickenpox vaccine. See varicella
vaccine.
Chlomethiazole. See clomethiazole.
Chloral betaine. 1.7mg = 1mg chloral hydrate.
Chloral hydrate. Hypnotic: 50mg/kg
(max 2g) stat (ICU up to 100mg/
kg, max 5g). Sedative: 10mg/kg
6-8H oral or PR.
Chlorambucil. Typically 0.1-0.2mg/
kg daily oral.
Chloramphenicol. Severe inftn:
40mg/kg (max 2g) stat IV, IM
or oral; then 25mg/kg (max 1g)
daily (1st wk life) 12H (2-4 wk)
8H (>4wk) x5 days, then 6H. Eye
drop, oint: apply 2-6H. Ear: 4drop
6H. Serum level 20-30mg/L 2hr,
<15mg/L trough.
Chlorbutol. See arachis oil + chlorbutol + dichlorobenzene.
Chlordiazepoxide. 0.1mg/kg (adult
5mg) 12H oral, may incr to max
0.5mg/kg (adult 30mg) 6-8H.
Chlorhexidine. 0.1%: catheterisation

prep, impetigo. 0.2%: mouthwash. 1%: skin disinfection. 2-4%:
hand wash.
Chlorhexidine 0.5% + alcohol 70%.
Skin disinfection.
Chlorhexidine 1.5% + cetrimide
15%. 1/30 in water: cleaning
tissues, wounds or equipment.
140ml in 1L water: disinfecting
skin, equipment (soak 2min, rinse
in sterile water).
Chlorhexidine + cetrimide.
0.05%/0.5%, 0.1%/1%,
0.15%/0.15% soltn: wound
cleaning.
Chlorhexidine 1% + hexamidine
0.15%. Powder: wounds.
Chlormethiazole. See clomethiazole.
Chlormezanone. 5mg/kg (adult
200mg) 6-8H, or 10mg/kg (adult
400mg) at night oral.
Chlorophyllin copper complex.
2mg/kg 8-24H oral.
Chloroprocaine. Max 11mg/kg
(max 800mg). With adrenaline
(1/200,000) max 14mg/kg (max
1000mg).
Chloroquine, base. Oral: 10mg/kg
(max 600mg) daily x3 days. IM:
4mg/kg (max 300mg) 12H for 3
days. Prophylaxis: 5mg/kg (adult
300mg) oral x1/wk. Lupus, rheu
arth: 12mg/kg (max 600mg) daily,
reduce to 4-8mg/kg (max 400mg)
daily.
Chloroquine + pyrimethamine +
sulphadoxine. Chloroquine base
10mg/kg (max 600mg) daily for
3 days oral, plus pyrimethamine
1.25mg/kg (max 75mg) and sulphadoxine 25 mg/kg (max 1.5g)
on first day.
Chlorothiazide. 5-20mg/kg (adult
0.25-1g) 12-24H oral, IV.
Chlorphenamine. See chlorpheniramine.
Chlorphenasin. 1% ointment: apply
12H.
Chlorpheniramine. 0.1mg/kg (adult
4mg) 6-8H oral.
612
Choriogonadotropin alfa. Adult

(NOT/kg): 250mcg SC.
Chorionic gonadotrophin. NOT/
kg. Cryptorchidism all ages: 5001000u x1-2/wk for 5wk. After
FSH: 10,000iu IM once. Men:
7000iu IM x2/wk, with 75iu FSH
and 75iu LH IM x3/wk.
Chymopapain. Adult (NOT/kg):
2000-4000 picokatal units per
disc, max 10,000 picokatal units
per patient.
Ciclesonide. Inhaltn (>12yr): 80320mcg 12-24H. Nasal: 100 mcg/
nostril once daily.
Ciclopirox. 1% cream or lotion: apply
12H.
Cidofovir. 5mg/kg over 1hr IV on
day 0, day 7, then every 14 days
(given with probenecid). Papilloma: inject 6.25 mg/ml soltn
(max total 0.6mg/kg) at interval
of >= 2wk.
Ciclosporin. See cyclosporin.
Cilazapril. Usually 0.02-0.1mg/kg
(adult 1-5mg) daily oral. Renal
hypertension: 0.005-0.01mg/kg
daily oral.
Cilostazol. Adult (NOT/kg): 100mg
12H oral.
Cimetidine. Oral: 5-10mg/kg
(adult 300-400mg) 6H, or 20
mg/kg (adult 800mg) nocte. IV:
10-15mg/kg (adult 200mg) 12H
(newborn), 6H (>4wk).
Cinacalcet. Adult (NOT/kg) 30mg
daily oral, incr every 2-4wk (to
max 180mg) to control parathyroid hormone level. Parathyroid
carcinoma: 30mg 12H, incr every
2-4wk if reqd to control serum Ca
to max 90mg 6H oral.
Cinchocaine. Max dose 2mg/kg
(0.4ml/kg of 0.5%) by injection.
Oint 0.5% with hydrocortisone
0.5%: apply 8-24H.
Cinnarizine. 0.3-0.6mg/kg (adult
15-30mg) 8H oral. Periph vasc dis:
1.5mg/kg (adult 75mg) 8H oral.
Cinoxacin. 10mg/kg (adult 500mg)
12H oral.
613
Drug Doses
Chlorpheniramine. 1.25mg + phenylephrine 2.5mg in 5ml. Syrup

(NOT/kg): 1.25-2.5ml (0-1yr),
2.5-5ml (2-5yr), 5-10ml (6-12yr),
10-15ml (>12yr) 6-8H oral.
Chlorpromazine. Oral or PR: 0.52mg/kg (max 100mg) 6-8H; up
to 20mg/kg 8H for psychosis.
IM (painful) or slow IV (beware
hypotension): 0.25-1mg/kg (usual
max 50mg) 6-8H.
Chlorpropamide. Adult (NOT/kg):
initially 125-250mg oral, max
500mg daily.
Chlorquinaldol. 5% paste: apply
12H.
Chlortalidone. See chlorthalidone.
Chlortetracycline. 3% cream or ointment: apply 8-24H.
Chlortetracycline 115.4mg + demeclocycline 69.2mg + tetracycline
115.4mg. NOT/kg. >12yr: 1 tab
12H oral.
Chlorthalidone. 2mg/kg (max
100mg) 3 times a wk oral.
Chlorzoxazone. 5-15mg/kg (adult
250-750mg) 6-8H oral.
Cholecalciferol (Vitamin D3). 1
mcg = 40u = 1mcg ergocalciferol
(qv). Osteodystrophy: 0.2mcg/
kg (hepatic) 15-40mcg/kg (renal)
daily oral.
Cholera, whole cell plus toxin b
subunit recombinant vaccine
(Dukoral). Inanimate. Dissolve
granules in 150ml water. 2-6yr:
give 75ml x3 doses 1wk apart
oral, boost after 6mo. >6yr: give
150ml x2 doses 1wk apart, boost
after 2yr .
Cholestyramine. NOT/kg. 1g (<6yr)
2-4g (6-12yr) 4g (>12yr) daily oral,
incr over 4wk to max 1-2x initial
dose 8H.
Choline magnesium trisalicylate.
See aspirin.
Choline salicylate, mouth gel (Bonjela). Apply 3H prn.
Choline theophyllinate (200mg =
theophylline 127mg). See theophylline.
Drug Doses
Ciprofibrate. 2-4mg/kg (adult 100200mg) daily oral.

Ciprofloxacin. 5-10mg/kg (adult
250-500mg) 12H oral, 4-7mg/kg
(adult 200-300mg) 12H IV. Severe
inftn, or cystic fibrosis: 20mg/kg
(max 750mg) 12H oral, 10mg/kg
(max 400mg) 8H IV; higher doses
used occasionally. Meningococcus proph: 15mg/kg (max 500mg)
once oral.
Ciprofloxacin, eye drops. 0.3%. Corneal ulcer: 1drop /15min for 6hr
then 1drop/30min for 18hr (day
1), 1drop 1H (day 2), 1drop 4H
(day 3-14). Conjunctivitis: 1 drop
4H; if severe 1 drop 2H when
awake for 2 days, then 6H.
Ciprofloxacin, eye ointment. 0.3%.
Apply 1.25cm 8H for 3 days, then
12H for 3 or more days.
Cisatracurium. 0.1mg/kg (child) or
0.15mg/kg (adult) IV stat, then
0.03mg/kg if reqd or 1-3mcg/kg/
min. ICU: 0.15 mg/kg stat, then
(1-10mcg/kg/min) IV.
Cisplatin. 60-100mg/m2 IV over 6hr
every 3-4wk x6 cycles.
Citalopram. 0.4mg/kg (adult 20mg)
daily, incr if reqd over 4wk to max
0.4mg/kg (adult 60mg) daily oral.
Citric acid 0.25g + potassium citrate
1.5g. Urine alkalinisation >6yr
(NOT/kg): 2 tab 8-12H oral.
Cladribine. Hairy cell leuk: usually
0.09mg/kg/day for 7 days by
continuous IV infsn. Ch lymph
leuk: 0.12mg/kg/day over 2hr IV
on days 1-5 of 28 day cycle, max
6 cycles.
Clarithromycin. 7.5-15mg/kg (adult
250-500mg) 12H oral. Slow release tab, adult (NOT/kg): 0.5g or
1g daily. H.pylori, see omeprazole.
Clavulanic acid. See amoxycillin,
ticarcillin.
Clemastine. 0.02-0.06mg/kg (adult
1-3mg) 12H oral.
Clenbuterol. Adult (NOT/kg): 20mcg
(up to 40mcg) 12H oral.
Clevidipine. Adult (NOT/kg): 1mg/hr

incr every 5min to 4-6mg/hr (max
16mg/hr) IV.
Clidinium. 0.05-0.1mg/kg (adult 2.55mg) 6-8H oral.
Clindamycin. 6mg/kg (adult 150450mg) 6H oral. IV over 30 min,
or IM: 5mg/kg 12H (preterm
<1wk old), 5mg/kg 8H (preterm
>1wk, term <1wk), 7.5mg/kg 8H
(term >1wk), >28 days 10mg/kg
(adult 600mg) 8H. Severe inftn
(>28 days): 15-20 mg/kg (adult
900mg) 8H IV over 1hr. Acne soltn
1%: 12H.
Clioquinol. 10mg/g cream, 100%
powder: apply 6-12H.
Clioquinol 1% + flumetasone 0.02%.
2-3 drops/ear 8-12H.
Clobazam. 0.1mg/kg (adult 10mg)
daily oral, incr if reqd to max
0.4mg/kg (adult 20mg) 8-12H
oral.
Clobetasol. 0.05% spray, cream,
ointment, gel, solution, foam,
lotion, shampoo: apply 12H.
Clobetasone. 0.1% soltn: 1drop/
eye 1-6H.
Clocortolone. Cream 0.1%: apply 8H.
Clodronate. 10-30mg/kg (adult 0.61.8g) IV over 2hr every 2mo; or
6mg/kg (adult 300mg) IV over 2hr
daily x7 days, then 15-30/mg/kg
(adult 0.8-1.6g) 12H oral.
Clofarabine. 52mg/m2 IV over 2hr
for 5 days every 2-6wk.
Clofazimine. 2mg/kg (adult 100mg)
daily oral. Lepra reaction: up to
max 3mo.
Clofibrate. 10mg/kg 8-12H oral.
Clomethiazole. Cap (192mg base)
equivalent action to 5ml syrup
(250mg edisilate). Adult (NOT/
kg): 1-2 cap, or 5-10ml syrup, at
bedtime oral.
Clomiphene. Adult (NOT/kg):
50mg daily for 5 days oral, incr
to 100mg daily for 5 days if no
ovulation.
614
Clozapine. 0.5mg/kg (adult 25mg)

12H oral, incr over 7-14 days to
8-12H; later reducing to 2mg/kg
(adult 100mg) 8-12H.
Coal tar, topical. 0.5% incr to max
10%, applied 6-8H.
Cocaine. Topical: 1-3mg/kg.
Codeine phosphate. Inactive in
10% of adults, poor activity in
children <5yrs. Analgesic: 0.51mg/kg (adult 15-60mg) 4H oral,
IM, SC. Cough: 0.25-0.5mg/kg
(adult 15-30mg) 6H.
Codeine + guaiacol. 7mg/75mg per
5ml. Adult (NOT/kg): 10ml 8H
oral.
Co-danthramer, co-danthrusate.
See dantron.
Co-dergocrine mesylate. Adult
(NOT/kg): 3-4.5mg daily before
meal oral or subling; 300mcg
daily IM, SC or IV infsn.
Coenzyme Q10. See ubidecarenone.
Colaspase. Test 2-50u intradermal.
Typical dose 6000u/m2 every
3rd day x9 doses IV over 4hr, IM
or SC.
Colchicine. Acute gout: 0.02mg/kg
(adult 1mg) 2H oral (max 3 doses/
day). Chronic use (gout, FMF):
0.01-0.04mg/kg (adult 0.5-2mg)
daily oral.
Colesevelam. 625mg tab. Adult
(NOT/kg): 3 tab 12H oral, or 6 tab
daily. With statin: 4-6 tab/day (in
1-2 doses).
Colestipol hydrochloride. 0.1-0.2g/
kg (adult 5-10g) 8H oral.
Colestyramine. See cholestyramine.
Colfosceril palmitate (Exosurf
Neonatal). Soltn 13.5 mg/ml.
Prophylaxis: 5ml/kg intratracheal
over 5min straight after birth, and
at 12hr and 24hr if still ventilated.
Rescue: 5ml/kg intratracheal
over 5min, repeat in 12hr if still
ventilated.
Colistimethate. See colistin sulfomethate sodium.
615
Drug Doses
Clomipramine. 0.5-1mg/kg (adult

25-50mg) 12H oral, incr if reqd to
max 2mg/kg (adult 100mg) 8H.
Clonazepam. 1 drop = 0.1mg.
0.01mg/kg (max 0.5mg) 12H oral,
slowly incr to 0.05mg/kg (max
2mg) 6-12H oral. Status (may
be repeated if ventilated), NOT/
kg: neonate 0.25mg, child 0.5mg,
adult 1mg IV.
Clonidine. Hypertension: 1-5mcg/
kg slow IV, 1-6mcg/kg (adult
50-300mcg) 8-12H oral. Migraine:
start with 0.5 mcg/kg (adult
50-75mcg) 12H oral. Analgesia:
2.5mcg/kg premed oral, 0.3 mcg/
kg/hr IV, 1-2mcg/kg local block;
ventld 0.5-2 mcg/kg/hr (<12kg
1mcg/kg/hr is 50mcg/kg in 50ml
at 1ml/hr, >12kg 25 mcg/kg in
50ml at 2ml/hr) + midazolam
1mcg/kg/min (3 mg/kg in 50ml
at 1ml/hr).
Clopamide 5mg + pindolol 10mg.
Adult: 1-2 tab (max 3 tab) daily
oral.
Clopidogrel. Child 0.2mg/kg daily,
adult 75mg daily oral (note higher
dose in adults). Poor converters
to active form (15-30% CYP2C19
variant) need higher doses, or
pasugrel.
Clorazepate. 0.3-2mg/kg (adult
15-90mg) daily at night oral, or
0.1-0.5mg/kg (adult 5-30mg) 8H.
Clostridia antitoxin. See gas gangrene antitoxin.
Clotrimazole. Topical: 1% cream or
solution 8-12H. Vaginal (NOT/kg):
1% cream or 100mg tab daily for
6 days, or 2% cream or 500mg tab
daily for 3 days.
Cloxacillin. 15mg/kg (adult 500mg)
6H oral, IM or IV. Severe inftn: 2550mg/kg (adult 1-2g) IV 12H (1st
wk life), 8H (2-4wk), 4-6 H (>4wk)
or constant infsn (>4wk).
Drug Doses
Colistin 3mg/ml + neomycin 3.3mg/

ml. Otic: 4 drops 8H.
Colistin sulphomethate sodium.
2.6mg = 1mg colistin base =
30,000u. IM, or IV over 5min:
40,000u/kg (adult 2 million u) 8H,
or 1.25-2.5mg/kg of colistin base
12H. Oral or inhaled: 30,00060,000 u/kg (adult 1.5-3 million
u) 8H.
Collagenase. Ointment 250u/g:
apply daily.
Colonic lavage, macrogol-3350 and
macrogol-4000 (polyethylene
glyol) 105g/L. Poisoning, severe
constipation: if bowel sounds present, 25ml/kg/hr (adult 1.5L/hr)
oral or NG for 2-4hr (until rectal
effluent clear). Before colonoscopy: clear fluids only to noon,
1 whole 5mg bisacodyl tab per
10kg (adult 4 tab) at noon, wait
for bowel motion (max 6hr), then
macrogol 4g/kg (adult 200g) in
40ml/kg fluid (adult 2L) over 2hr
oral or NG.
Colony stimulating factors. See
ancestrim, epoetin, filgrastim,
lenograstim, molgramostim,
sargramostim.
Coloxyl. See docusate sodium.
Conivaptan. Adult (NOT/kg): 20mg
over 30min IV, then 20mg (max
40mg) over 24hr by IV infusion.
Conjugated oestrogens (CO) +
medroxyprogesterone (MP).
NOT/kg. CO (NOT/kg): 0.625mg
(0.3-1.25mg) daily continuously,
with MP 10mg (up to 20mg) daily
oral for last 10-14 days of 28 day
cycle.
Co-cyprindiol. See cyproterone
acetate + ethinyloestradiol.
Corifollitropin alfa. Adult (NOT/kg):
100mcg (60kg) 150mcg (>60kg)
SC, GnRH day 5-6, FSH for 6-18
days from day 8.
Corticorelin. 1-2mcg/kg (max
100mcg) IV.
Corticotrophin releasing factor,
hormone. See corticorelin.
Cortisone acetate. 1-2.5mg/kg 6-8H

oral. Physiological: 7.5 mg/m2 8H.
Cortisone acetate 1mg = hydrocortisone 1.25mg in mineraloand gluco-corticoid action.
Cosyntropin (ACTH subunit). NOT/
kg: <2yr 0.125mg, >2yr 0.250.75mg IM, IV, or infused over
4-8hr.
Cotrimoxazole (trimethoprim 1mg
+ sulphamethoxazole 5mg).
TMP 4mg/kg (adult 80-160mg)
12H IV over 1hr or oral. Renal
proph: TMP 2mg/kg (max 80mg)
daily oral. Pneumocystis: proph
TMP 5mg/kg daily on 3 days/wk;
treatment TMP 250mg/m2 stat,
then 150mg/m2 8H (<11yr) or
12H (> 10yr) IV over 1hr; in renal
failure dose interval (hr) = serum
creatinine (mmol/l) x 135 (max
48hr); 1hr post-infsn serum TMP
5-10mcg/ml, SMX 100-200mcg/
ml. IV infsn: TMP max 1.6mg/ml
in 5% dext.
Coumarin. Oral: 1-8mg/kg (adult
50-400mg) daily. Cream 100mg/g:
apply 8-12H.
Coxiella burnetti vaccine. Inanimate.
0.5ml SC once.
Crisantaspase. See colaspase.
Cromoglycate. See sodium cromoglycate.
Cromolyn, sodium. See sodium
cromoglycate.
Crotamiton. 10% cream or lotion:
apply x2-3/day.
Cryoprecipitate. Low factor 8: 1u/
kg incr activity 2% (half life 12hr);
usual dose 5ml/kg or 1bag/4kg
12H IV for 1-2 infns (muscle,
joint), 3-6 infns (hip, forearm,
retroperitoneal, oropharynx),
7-14 infns (intracranial). Low
fibrinogen: usually 5ml/kg or
1bag/4kg IV. Bag usually 20-30ml:
factor 8 about 5u/ml (100u/
bag), fibrinogen about 10mg/ml
(200mg/bag).
616
Cyproheptadine. 0.1mg/kg (adult

4mg) 6-8H oral. Migraine 0.1mg/
kg (adult 4mg), repeated in 30min
if reqd.
Cyproterone acetate. 1mg/kg (adult
50mg) 8-12H oral. Prec puberty:
25-50mg/m2 8-12H oral. Hyperandrogenism: 50-100mg daily days
5-14, with oestradiol valerate
1mg daily days 5-25. Prostate
carcinoma (NOT/kg): 100mg
8-12H oral. See also oestradiol +
cyproterone.
Cyproterone acetate + ethinyloestradiol (2mg/35mcg) x 21
tab, + 7 inert tab. In females for
acne, contraception, or hirsutism:
1 tab daily, starting 1st day of
mensturation.
Cysteamine bitartrate. 0.05mg/m2
6H oral, incr over 6wk to 0.33mg/
m2/dose (<50kg) or 0.5mg/kg/
dose (>50kg) 6H.
Cytarabine. Usually 100mg/m2 daily
for 10 days by IV injn or constant
infsn. Intrathecal: 30mg/m2 every
4 days until CSF normal (dissolve
in saline not diluent).
Cytomegalovirus immunoglobn. See
immunoglobn, CMV.
Dabigatran. Adult (NOT/kg): 220mg
daily oral.
Dacarbazine. 250mg/m2 IV daily for
5 days every 3wk.
Daclizumab. 1mg/kg IV over 15min
every 2wk for 5 doses.
Dactinomycin. Usually 400-600mcg/
m2 IV daily for 5 days, repeat after
3-4wk.
Dalfampridine. Slow release (adult,
NOT/kg): 10mg 12H oral.
Dalfopristin 350mg + quinupristin
150mg (Synercid IV 500mg vial).
7.5mg/kg (combined) 8H IV over
1hr.
617
Drug Doses
Cyanocobalamin (Vit B12). 20mcg/

kg (adult 1000mcg) IM daily for
7 days then wkly (treatment),
monthly (prophylaxis). IV dangerous in megaloblastic anaemia.
Maintenance treatment (adult
NOT/kg): 2mg daily oral; 50mcg
(incr if reqd to 100mcg) daily, or
500mcg wkly nasal.
Cyclizine. 1mg/kg (adult 50mg) 8H
oral, IM or IV.
Cyclizine 30mg + dipipanone 10mg.
Adult (NOT/kg): 1 tab 6H oral, incr
dose by half tab if reqd to max 3
tab 6H.
Cyclobenzaprine. 0.2-0.4mg/kg
(adult 5-15mg) 8H oral. Extendedrelease (adult, NOT/kg): 15mg or
30mg daily oral.
Cyclopenthiazide. 5-10mcg/kg
(adult 250-500mcg) 12-24H .
Cyclopentolate. 0.5%, 1%: 1 drop/
eye, repeat after 5min. Pilocarpine 1% speeds recovery.
Cyclophosphamide. A typical regimen is 600mg/m2 IV over 30min
daily for 3 days, then 600mg/m2
IV wkly or 10mg/kg twice wkly (if
leucocytes >3000/mm3).
Cycloserine. 5-10mg/kg (adult 250500mg) 12H oral. Keep plasma
conc <30mcg/ml.
Cyclosporin. 1-3mcg/kg/min IV for
24-48hr, then 5-8mg/kg 12H
reducing by 1mg/kg/dose each
mo to 3-4 mg/kg/dose 12H
oral. Eczema, juvenile arthritis,
nephrotic, syndrome, psoriasis:
1.5-2.5mg/kg 12H. Usual target
trough levels by Abbott TDx
monoclonal specific assay (x 2.5 =
non-specific assay level) on whole
blood: 100-250 ng/ml (marrow),
300-400 ng/ml first 3mo then
100-300 ng/ml (kidney), 200-250
first 3mo then 100-125 (liver),
100-400ng/ml (heart, lung).
Cyclosporin ophthalmic. 0.05% 1
drop in each eye 12H.
Drug Doses
Dalteparin sodium. Proph (adult):

2500-5000u SC 1-2hr preop, then
daily. Venous thrombosis: 100u/
kg 12H SC, or infuse 200u/kg/
day IV (anti-Xa 0.5-1u/ml 4hr post
dose). Haemodialysis: 5-10u/kg
stat, then 4-5u/kg/hr IV (acute
renal failure, anti-Xa 0.2-0.4u/ml);
30-40u/kg stat, then 10-15u/kg/
hr (chronic renal failure, anti-Xa
0.5-1u/ml).
Danaparoid. Prevention: 15u/kg
(adult 750u) 12H SC. Heparin
induced thrombocytopenia: 30u/
kg stat IV, then 1.2-2u/kg/hr to
maintain anti-Xa 0.4-0.8u/ml.
Danazol. 2-4mg/kg (adult 100200mg) 6-12H oral.
Dantrolene. Hyperpyrexia: 1mg/kg/
min until improves (max 10mg/
kg), then 1-2mg/kg 6H for 1-3day
IV or oral. Spasticity: 0.5mg/kg
(adult 25mg) 6H, incr over 2wk if
reqd to 3mg/kg (adult 50-100mg)
6H oral.
Dantron + docusate (co-danthrusate). NOT/kg. 50/60mg cap:
7-12yr 1cap, adult 1-3cap at
night. 50/60mg in 5ml: 1-6yr
2.5ml, 7-12yr 5ml, adult 5-15ml
at night.
Dantron + poloxamer 188 (codanthramer). NOT/kg. 25/ 200mg
cap: 7-12yr 1cap, adult 1-3cap
at night. 25/200mg in 5ml: 1-6yr
2.5ml, 7-12yr 5ml, adult 5-15ml
at night.
Dapsone. 1-2mg/kg (adult 50100mg) daily oral. Derm herpet:
1-6mg/kg (adult 50-300mg) daily
oral.
Dapsone 100mg + pyrimethamine
12.5mg (Maloprim). 1-4yr quarter
tab wkly, 5-10yr half tab, >10yr
1tab.
Daptomycin. 4mg/kg IV over 30min
daily.
Darbepoetin alfa. Incr or reduce

dose if reqd by 25% every 4wk.
Renal failure: 0.45mcg/kg wkly
(0.75mcg/kg wkly if not on dialysis) SC or IV. Cancer: 6.75mcg/kg
every 3wk, or 2.25mcg/kg every
wk, SC or IV.
Darifenacin. Adult (NOT/kg): 7.515mg daily oral.
Darunavir (DRV). Adult (NOT/kg):
600mg 12H with food oral.
Darunavir + ritonavir. 20-29kg:
375/50mg 12H with food;
30-39kg: 450/60mg 12H;
40kg: 600/100mg 12H. 18yr:
800/100mg (nave) 600/100mg
(past Rx) daily with food.
Dasatinib. Adult (NOT/kg): 70mg (up
to 100mg) 12H oral.
Daunorubicin. 30mg/m2 wkly slow
IV, or 60-90mg/m2 every 3wk.
Max total dose 500mg/m2.
DDAVP. See desmopressin.
Decitabine. 15mg/m2 IV over 3hr
8H for 3 days, repeated every 6wk
(minimum of 4 cycles).
Deferasirox. 20mg/kg (15-30mg/kg)
daily oral.
Deferiprone. 25mg/kg 8H (max
100mg/kg/day) oral.
Deferoxamine. See desferrioxamine.
Deflazacort. Usually 0.1-1.5mg/kg
(adult 5-90mg) 24-48H oral. 1.2
mg = 1mg prednisolone in glucocorticoid activity.
Degarelix. Adult (NOT/kg): 240mg in
two SC injections, then 80mg SC
every 4wk.
Delavirdine. Adult (NOT/kg): 400mg
8H, or 600mg 12H oral.
Delta-9-tetrahydrocannabinol. See
cannabidiol.
Demecarium bromide. 0.125%,
0.25% ophthalmic soltn. Glaucoma: 1 drop x2/day to x2/wk.
Strabismus: 1 drop daily for 2wk,
then 1 drop alternate days for
2-3wk.
618
Desogestrel + ethinyloestradiol
(150mcg/30mcg, 150/20) x21
tab, + 7 inert tab. Contraception:
menstruation.
Desonide. 0.05% cream, ointment,
lotion: apply 8-12H.
Desoximetasone. See desoxymethasone.
Desoxymethasone. 0.05% or 0.25%
cream, oint, gel: apply 12H.
Desoxyribonuclease. See fibrinolysin.
Desvenlafaxine. Adult (NOT/kg): 50100mg daily oral.
Dexamethasone. Biological half life
2-3 days. 0.1-1mg/kg daily oral,
IM or IV. Antiemetic: 0.5mg/kg
(adult 16mg) daily IM, IV, oral.
BPD: 0.4mg/kg daily for 3 days,
then 0.3mg/kg 3 days, 0.2mg/kg
3 days, 0.1mg/kg 3 days, 0.05mg/
kg 7 days. Cerebral oedema: 0.251mg/kg (adult 10-50mg) stat,
then 0.6-1mg/kg (adult 4-8mg)
daily IV reducing over 3-5 days
to 0.1mg/kg (adult 2mg) daily.
Congenital adrenal hypoplasia:
0.27 mg/m2 daily oral. Severe
croup, extubtn stridor, bronchiolitis: 0.6 mg/kg (max 20mg) IV or
IM stat, then prednisolone 1mg/
kg 8-12H oral. Eye drops 0.1%: 1
drop/eye 3-8H. Dexamethasone
has no mineralocorticoid action;
glucocorticoid action.
Dexamethasone 0.5mg/ml (0.05%)
+ framycetin 5mg/ml (0.5%) +
gramicidin 0.05mg/ml (0.005%)
(Sofradex). Eye 1 drop 1-3H, ear
2-3 drops 6-8H, ointment 8-12H.
Dexamethasone 0.1% + neomycin
0.35% + polymyxin 6000u/g.
1drop/eye 6-8H.
Dexamethasone 0.1% + tobramycin
0.3%. Usually 1drop/ eye 4-6H;
up to 2H for 2 days after surgery
if reqd.
619
Drug Doses
Demeclocycline. >8yr: 3mg/kg

(adult 150mg) 6H, or 6mg/kg
(adult 300mg) 12H oral. See also
chlortetracycline.
Denileukin diftitox. 9-18mcg/kg
daily IV over 15min for 5 consecutive days every 21 days.
Denosumab. Adult (NOT/kg): 60mg
every 6mo SC, with calcium
1000mg daily and at least 400iu
vitamin D daily.
Dequalinium. NOT/kg: one 0.25mg
pastile 4H oral.
Deserpidine. 0.005-0.02mg/kg
(adult 0.25-1mg) daily oral.
Desflurane. Usually child 5-10%,
adult 3-8% by inhalation.
Desferrioxamine. Antidote: 1015mg/kg/hr IV for 12-24hr (max
6g/24hr) if Fe >60-90umol/l at
4hr or 8hr; some also give 5-10g
(NOT/kg) once oral. Thalassaemia
(NOT/kg): 500mg per unit blood;
and 5-6 nights/wk 1-3g in 5ml
water SC over 10hr, 0.5-1.5g in
10ml water SC over 5min.
Desipramine. 2-4mg/kg (adult 100200), occasionally incr up to 6mg/
kg (adult 300mg), daily oral.
Desirudin. 0.3mg/kg (adult 15mg)
12H SC.
Desloratadine. 0.1mg/kg (adult
5mg) daily oral.
Desmopressin (DDAVP). 1u = 1mcg.
Nasal (NOT/kg): 5-10mcg (0.050.1ml) per dose 12-24H; enuresis
10-40mcg nocte. IV: 0.5-2mcg in
1L fluid, and replace urine output
+ 10% hrly (but much better to
use vasopressin). Haemophilia,
von Willebrand: 0.3mcg/kg (adult
20mcg) IV over 1hr 12-24H. More
potent and longer acting than
vasopressin.
Desogestrel. Contraception: 75mcg
daily oral, starting 1st day of
menstruation.
Drug Doses
Dexamethasone 20mcg + tramazoline 120mcg per dose. Aerosol: 1

puff in each nostril 4-8H.
Dexamphetamine. 0.2mg/kg (max
10mg) daily oral, incr if reqd to
max 0.6mg/kg (max 40mg) 12H.
Dexchlorpheniramine maleate.
0.05mg/kg (adult 2mg) 6-8H oral.
Repetab (adult NOT/kg): 6mg
12H oral.
Dexibuprofen. Adult (NOT/kg):
400mg 12H (max 8H) oral.
Dexketoprofen. Adult (NOT/kg):
12.5mg 4-6H, or 25mg 8H (max
75mg/day) oral.
Dexlansoprazole. 1-2mg/kg (adult
30-60mg) daily oral.
Dexmedetomidine. ICU: 1mcg/kg IV
over 15min, then 0.2-0.7mcg/kg/
hr for max 24hr.
Dexmethylphenidate. NOT/kg,
given as two doses/day 4hr apart:
2.5mg/dose oral, incr if reqd to
10mg/dose. Long-acting (NOT/
kg): child 5-10mg (adult 5-20mg)
daily oral.
Dexpanthenol. 5-10mg/kg (adult
250-500mg) IM. 5% cream: apply
12-24H
Dexrazoxane. 10mg for each 1mg
doxorubicin IV. Extravasation
of anthracyclines: within 6hr
give 1g/m2 (max 2g) IV over 2hr,
repeated after 24hr; then 0.5g/m2
48hr after first dose.
Dextran 1 (Promit). 15% soltn.
0.3ml/kg IV 1-2min before giving
dextran 40 or dextran 70.
Dextran 40. 10% soltn: 10ml/kg x1-2
on day 1, then 10 ml/kg/day IV.
Half life about 3hr.
Dextran 70. 6% soltn: 10ml/kg x1-2
on day 1, then 10 ml/kg/day IV.
Half life about 12hr.
Dextroamphetamine. See dexamphetamine.
Dextromethorphan hydrobromide.
0.2-0.4mg/kg (adult 10-20mg)
6-8H oral.
Dextromoramide. 0.1mg/kg (adult

5mg) 8H, may incr to 0.5mg/kg
(adult 20mg) 8H oral or PR.
Dextropropoxyphene. Hydrochloride 1.3mg/kg (adult 65mg) or
napsylate 2mg/kg (adult 100mg)
6H oral.
Dextrose. Infant sedation (NOT/kg):
1ml 50%D oral. Hypoglycaemia:
0.5ml/kg 50%D or 2.5ml/kg 10%D
slow IV, then incr maintenance
mg/kg/min. Hyperkalaemia:
0.1u/kg insulin + 2ml/kg 50%D
IV. Neonates: 6g/kg/day (about
4mg/kg/min) day 1, incr to 12 g/
kg/day (up to 18g/kg/day with
hypoglycaemia). Infsn rate (ml/hr)
= (4.17 x Wt x g/kg/day) / %D =
(6 x Wt x mg/kg/min) / %D. Dose
(g/kg/day) = (ml/hr x %D) / (4.17
x Wt). Dose (mg/kg/min) = (ml/hr
x %D) / (6 x Wt). mg/kg/min = g/
kg/day / 1.44. 0.5ml/kg/hr of 50%
=6g/kg/day.
Dextrothyroxine. Adult (NOT/kg):
1-2mg daily oral, incr monthly if
reqd to max 4-8mg daily.
Dezocine. IM: 0.1-0.4mg/kg (adult
5-20mg) 3-6H. IV: 0.05-0.2mg/kg
(adult 2.5-10mg) 2-4H.
3,4-Diaminopyridine. Adult (NOT/
kg): 10mg 6-8H oral, incr if reqd
to max 20mg x5/day.
Diamorphine. Adult (NOT/kg):
5-10mg 4H IV, IM, SC, oral.
Diazepam. 0.1-0.4mg/kg (adult 1020mg) IV or PR. 0.04-0.2 mg/kg
(adult 2-10mg) 8-12H oral. Do not
give by IV infsn (binds to PVC);
emulsion can be infused. Premed:
0.2-0.4mg/kg oral, PR. 2-3mg =
1mg midazolam.
Diazoxide. Hypertension: 1-3mg/
kg (max 150mg) stat by rapid IV
injection (severe hypotension
may occur) repeat once if reqd,
then 2-5mg/kg IV 6H. Hyperinsulinism: <12mo 5mg/kg 8-12H oral;
>12mo 30-100mg/m2 per dose
8H oral.
620
Drug Doses
Dibotermin alfa. 8ml of 1.5mg/ml

Dienoestrol. 0.01% vaginal cream:
spread evenly on matrix.
1 applicatorful (5g) 12-24H for
Dibromopropamidine. 0.15% cream
1-2wk, reducing gradually to
on dressing prn.
x1-3/wk.
Dibucaine. See cinchocaine.
Dienogest (Di) + oestradiol valerate
Dichloralphenazone 100mg +
OV). Contraception, daily: day
isometheptene mucate 65mg +
1-2 OV 3mg; day 3-7 Di 2mg + OV
paracetamol 325mg (Midrin).
2mg; day 8-24 Di 3mg + OV 2mg;
Adult (NOT/kg): 2 capsules stat,
day 27-28 OV 1mg; (day 25-26)
then 1/hr if reqd (max 5cap in
placebo.
12hr).
Diethylcarbamazine. 6mg/kg daily
Dichlorobenzene. See arachis oil +
for 12 days oral, or a single dose
chlorbutol.
of 6mg/kg repeated every 6-12
Dichlorphenamide. 2-4mg/kg (adult
months.
100-200mg) stat, then 2mg/kg
Diethylpropion. 6-12yr: 25mg (NOT/
(adult 100mg) 12H until response,
kg) 12H oral. >12yr: 25mg (NOT/
then 0.5-1mg/kg (adult 50mg)
kg) 6-8H oral.
8-24H oral.
Diethylstilboestrol. See stilboestrol.
Diclofenac. 1mg/kg (adult 50mg)
Difenoxin. See atropine + diphe8-12H oral, PR. Eye drops 0.1%:
noxylate.
preop 1-5 drops over 3hr, postop
Diflorasone. 0.05% cream, oint1 drop stat, then 1 drop 4-8H.
ment: apply 6-24H.
Topical gel 1% (arthritis) 3%
Diflunisal. 5-10mg/kg (adult 250(keratoses): apply 2-4g 6-8H.
500mg) 12H oral.
Patch 1.3% (180mg) 10x14cm:
Digitoxin. 4mcg/kg (max 0.2mg)
apply 12H.
12H oral for 4 days, then 1-6mcg/
Diclofenac + misoprostal. Adult,
kg (adult usually 0.15mg, max
NOT/kg. 50mg/200mcg tab 8-12H
0.3mg) daily.
oral; 75mg/200mcg tab 12H oral.
Digoxin. 15mcg/kg stat and 5mcg/kg
Dicloxacillin. 15-25mg/kg (adult
after 6H, then 3-5 mcg/kg (usual
250-500mg) 6H oral, IM or IV. Semax 200mcg IV, 250mcg oral)
vere inftn: 25-50mg/kg (max 2g)
12H slow IV or oral. Level 6hr or
IV 12H (1st wk life), 8H (2-4 wk),
more after dose: 1.0-2.5 nmol/L
4-6H or constant infsn (>4 wk).
(x0.78=ng/ml).
Dicobalt edetate. 10mg/kg (adult
Digoxin immmune FAB (antibodies).
300mg) IV over 1-5min, repeat x2
IV over 30min. Dose (to nearest
if no response.
40mg) = serum digoxin (nmol/L)
Dicyclomine. 0.5mg/kg (adult 10x Wt (kg) x 0.3, or mg ingested x
20mg) 6-8H oral.
55. Give if >0.3mg/kg ingested, or
Dicycloverine. See dicyclomine.
level >6.4 nmol/L or 5.0ng/ml.
Didanosine (ddI). <3mo: 50mg/m2
Dihydrazaline. IV infusion: 0.1mg/
12H oral; 3-8mo: 100 mg/m2 (max
kg/hr titrated to effect (max 3.5
200mg) 12H; 9mo-12yr: 120mg/
mg/kg/day). Oral: 0.25-1mg/kg
m2 (90-150 mg/m2) 12H; >12yr:
12H.
250mg (<60kg) 400mg (60kg)
Dihydroartemisinin 40mg + pipedaily oral. Adult with tenofovir:
raquine 320mg. Oral daily for 3
200mg (<60kg) 250mg (60kg).
days: dihydroartemisinin 2.5mg/
CNS disease: 150mg/m2 12H.
kg (adult 1.6mg/kg) + piperaquine
Dideoxycytidine (ddC). See zalcit20mg/kg (adult 12.8mg/kg).
abine.
Dihydrocodeine. 0.5-1mg/kg 4-6H
Dienestrol. See dienoestrol.
oral.
621
Drug Doses
Dihydroergotamine mesylate.
Adult (NOT/kg): 1mg IM, SC or
IV, repeat hrly x2 if needed. Max
6mg/wk.
Dihydromorphinone. See hydromorphone.
Dihydrotachysterol (1-OH vitamin
D2). Renal failure, vit D resistant
rickets: 20mcg/kg daily oral, incr
by 20mcg/kg every 4-8wk according to serum calcium.
Dihydrotestosterone. See stanolone.
Dihydroxyacetone. 5% soltn: apply
1-3 coats 1hr apart, every 1-3
days.
Diiodohydroxyquin. See di-iodohydroxyquinoline.
Di-iodohydroxyquinoline. 1013.3mg/kg (adult 650mg) 8H oral
for 20 days.
Diloxanide furoate. 10mg/kg (adult
500mg) 8H oral.
Diltiazem. 1mg/kg (adult 60mg) 8H,
incr if reqd to max 3mg/kg (adult
180mg) 8H oral. Slow release
(adult, NOT/kg): 120-240mg daily,
or 90-180mg 8-12H oral.
Dimenhydrinate. 1-1.5mg/kg (adult
50-75mg) 4-6H oral, IM or IV.
Dimercaprol (BAL). 3mg/kg (max
150mg) IM 4H for 2 days, then 6H
for 1 day, then 12H for 10 days.
Dimeticone. Infant colic (NOT/kg):
42mg/5ml, 2.5ml with feeds (max
x6/day). 10%, 15% barrier cream:
apply prn.
Dimethindene. 0.02-0.04mg/kg
(adult 1-2mg) 8H oral.
Dimethyl sulfoxide (DMSO). 50%
soltn: 50ml in bladder for 15 min
every 2wk.
Dinoprost (Prostaglandin F2 alpha).
Extra-amniotic: 1ml of 250mcg/
ml stat, then 3ml 2H. Intra-amniotic: 40mg stat, then 10-40mg after
24hr if required.
Dinoprostone (Prostaglandin E2).

Labour induction: 1mg into
posterior vagina, may repeat dose
1-2mg after 6hr (max 60mcg/kg
over 6hr). Maintain PDA: 25mcg/
kg 1H (less often after 1wk) oral;
or 0.003-0.01mcg/kg/min IV.
Dioctyl sodium sulphosuccinate.
See docusate sodium.
Diphemanil methylsulphate.
20mg/g powder: apply 8-12H.
Diphenhydramine hydrochloride.
1-2mg/kg (adult 50-100mg) 6-8H
oral.
Diphenoxylate. See atropine +
diphenoxylate (Lomotil).
Diphtheria antitoxin (horse). IM
or IV (NOT/kg): 2500u (nasal),
10,000u (unilateral tonsillar),
20,000u (bilateral tonsillar),
30,000u (laryngeal), 50,000u
(beyond tonsillar fossa), 150,000u
(bullneck). Repeat dose may be
needed. See also immunoglobulin, diphtheria.
Diphtheria vaccine, adult (CSL). Inanimate. 0.5ml IM stat, 6wk later,
and 6mo later (3 doses). Boost
every 10yr.
Diphtheria vaccine, child <8yr (CSL).
Inanimate. 0.5ml IM stat, in 6wk,
then 6mo (3 doses). Boost with
adult vaccine.
Diphtheria + hepatitis B + pertussis (acellular) + polio + tetanus
[DaPT-HepB-IPV] (Pediarix).
Inanimate. 0.5ml IM at 2mo, 4mo,
6mo (3 doses), and (DaPT) 18mo.
Diphtheria + hepatitis B + pertussis
(acellular) + tetanus vaccine
[DaPT-hepB] (Infanrix Hep B).
6mo (3 doses), and (without hep
B) 18mo.
Diphtheria + hepatitis B + Hib +
pertussis (acellular) + tetanus
vaccine [DaPT-hepB-Hib] (Infanrix Hexa). Inanimate. 0.5ml IM at
2mo, 4mo, 6mo (3 doses).
622
Dipivefrin. 0.1% soltn: 1 drop per

eye 12H.
Diprophylline. Usually 15mg/kg 6H
oral or IM.
Dipyridamole. 1-2mg/kg (adult 50100mg) 6-8H oral. See also aspirin
+ dipyridamole.
Dirithromycin. 10mg/kg (adult
500mg) daily oral.
Disodium clodronate. See sodium
clodronate.
Disodium edetate. See trisodium
edetate.
Disodium etidronate. See etidonrate.
Disodium levofolinate. Half the
dose of calcium folinate.
Disodium pamidronate. See pamidronate.
Disodium tiludronate. See tiludronate.
Disopyramide. Oral: 1.5-4mg/kg
(adult 75-200mg) 6H. IV: 2mg/
kg (max 150mg) over 5min, then
0.4mg/kg/hr (max 800mg/day).
Level 9-15umol/L (x0.3395 =
mcg/ml).
Distigmine. Neurogenic bladder,
megacolon: 0.01mg/kg (adult
0.5mg) IM daily, 0.1mg/kg (adult
5mg) oral daily. Myasth gravis:
0.1-0.2mg/kg 12-24H (max 20mg/
day) oral.
Disulfiram. Adult (NOT/kg): 500mg
oral daily for 1-2wk, then 125500mg daily.
Dithranol. 0.1%-2% cream, ointment: start with lowest strength,
apply daily, wash off after 10min
incr to 30min.
Divalproex. see Sodium valproate.
Dl-alpha-tocopheryl acetate. See
vitamin E.
DMSA. See succimer.
Dobutamine. <30kg: 15mg/kg in
50ml 0.9% saline with heparin
1u/ml at 1-4ml/hr (5-20mcg/kg/
min) via CVC or periph IV; >30kg:
6mg/kg made up to 100ml with
0.9% saline with heparin 1u/ml at
5-20ml/hr (5-20mcg/kg/min).
623
Drug Doses
Diphtheria + Hib + pertussis (acellular) + polio + tetanus [DaPT-HibIPV] (Infanrix Penta, Pediacel).
6mo (3 doses), and (DaPT) 18mo.
Diphtheria + pertussis (whole cell)
+ tetanus vaccine [DPT] (Triple
Antigen). Inanimate. 0.5ml IM at
2mo, 4mo, 6mo, 18mo and 4-5yr
of age (5 doses).
Diphtheria + pertussis (acellular) +
tetanus vaccine [DaPT] (Tripacel).
6mo, 18mo and 4-5yr of age (5
doses).
Diphtheria + pertussis (acellular)
+ tetanus vaccine, adult [daPt]
(Adacel, Boostrix). Inanimate.
10yr: 0.5ml IM.
polio + tetanus vaccine [DaPTIPV] (Quadracel). Inanimate.
0.5ml IM at 2, 4 and 6mo (3
doses).
polio + tetanus vaccine [DaPTIPV] (Infanrix-IPV). Inanimate.
16mo-13yr: 0.5ml IM once as
booster.
Diphtheria + pertussis (acellular)
+ polio + tetanus vaccine [daPTIPV] (Repevax). Inanimate. >3yr:
0.5ml IM once as booster.
Diphtheria + pertussis (acellular) + polio + tetanus vaccine,
adult [daPt-IPV] (Adacel Polio,
Boostrix-IPV). Inanimate. 10yr:
0.5ml IM once as booster.
Diphtheria + polio + tetanus vaccine
[dT-IPV] (Revaxis). Inanimate.
>6yr: 0.5ml IM once as booster.
Diphtheria + tetanus vaccine, adult
[dt] (ADT Booster). Inanimate.
0.5ml IM for revaccination after
primary course.
Diphtheria + tetanus vaccine, child
<8yr [DT] (CDT). Inanimate. 0.5ml
IM, in 6wk, 6mo later (3 dose).
Boost with ADT.
Dipipanone. See cyclizine.
Drug Doses
Docetaxel. Initially 75-100mg/m2

Doxacurium. 50-80mcg/kg stat, then
over 1hr IV every 3wk.
5-10mcg/kg/dose IV.
Docosanol. 10% cream: apply 5
Doxapram. 5mg/kg IV over 1hr, then
times a day.
0.5-1mg/kg/hr for 1hr (max total
Docusate sodium. NOT/kg: 100mg
dose 400mg).
(3-10yr), 120-240mg (>10yr) daily
Doxazosin. Usually 0.02-0.1mg/kg
oral. Enema (5ml 18% + 155ml
(adult 1-4mg) daily oral.
water): 30ml (newborn), 60ml (1Doxepin. 0.2-2mg/kg (adult 1012mo), 60-120ml (>12mo) PR.
100mg) 8H oral. 5% cream: apply
Docusate sodium 50mg + sennoside
x3-4/day.
8mg, tab. >12yr: 1-4 tab at night
Doxercalciferol (1,25-OH D2 anaoral. See also bisacodyl; casanlogue). Initially 0.2mcg/kg (adult
thranol; dantron.
10mcg) oral, or 0.08mcg/kg (adult
Dofetilide. 10mcg/kg (adult 500mcg)
4mcg) IV, x3/wk at end of dialysis.
12H oral, less if renal impairment
Aim for blood iPTH 150-300pg/ml.
or increased QTc interval.
Doxorubicin. 30mg/m2 IV over
Dolasetron. Cancer: 1.8mg/kg (adult
15min wkly, or 30mg/m2 daily for
100mg) IV 30min before chemo,
2-3days every 3-4wk. Max total
or 4mg/kg (adult 200mg) oral 1hr
dose 480mg/m2 (300mg/m2 if
before chemo. Surgery: 1mg/kg
mediastinal irradiation).
(adult 50mg) oral at induction,
Doxorubicin, liposomal. Carcinoma:
or 0.25mg/kg (adult 12.5mg) IV
50mg/m2 IV every 3wk. Kaposi:
postop.
20mg/m2 IV every 2wk.
Domperidone. Oral: 0.2-0.4mg/
Doxycycline. Over 8yr: 2mg/kg
kg (adult 10-20mg) 4-8H. Rectal
(adult 100mg) 12H for 2 doses,
suppos: adult (NOT/kg) 30-60mg
then daily oral. Severe: 2mg/
4-8H.
kg 12H. Malaria proph: 2mg/kg
Donepezil. Adult (NOT/kg): 5mg at
night oral, incr to 10mg after 1mo
Doxycycline 30mg + 10mg slow reif reqd.
lease (Oracea). Rosacea in adults
Dopamine. <30kg: 15mg/kg in 50ml
(NOT/kg): 1 tab daily oral.
5%dex-hep at 1-4ml/hr (5-20mcg/
Doxylamine succinate. 0.25-0.5mg/
kg/min) via CVC; >30kg: 6mg/kg
kg (adult 12.5-25mg) 8H oral.
made up to 100ml in 5%dex-hep
Hypnotic: 0.5-1mg/kg (adult
at 5-20ml/hr (5-20mcg/kg/min).
25-50mg).
Dopexamine. IV infsn 0.5-6mcg/
D-penicillamine. See penicillamine.
kg/min.
Dronabinol. Initially 5mg/m2 2-4H
Doripenem. 10mg/kg (adult 500mg)
(max 4-6 doses per day) oral, slow
8H IV.
incr by 2.5mg/m2/dose to max
Dornase alpha (deoxyribonuclease
15mg/m2 4H.
I). NOT/kg: usually 2.5mg (max
Dronedarone. 8mg/kg (adult
10mg) inhaled daily (5-21yr), 12400mg) 12H oral.
24H (>21yr).
Droperidol. Antiemetic: postop
Dorzolamide. 2% drops: 1 drop/eye
0.02-0.05mg/kg (adult 1.25mg)
8-12H.
4-6H IM or slow IV, chemother
Dorzolamide 2% + timolol 0.5%. 1
0.02-0.1 (adult 1-5mg) 1-6H.
drop/eye 12H.
Psychiatry, neuroleptanalg, IM or
Dosulepin hydrochloride. See
slow IV: 0.1 mg/kg (adult 2.5mg)
dothiepin.
stat, incr to max 0.3mg/kg (adult
Dothiepin. 0.5-1mg/kg (adult 2515 mg) 4-6H. Psychiatry, oral: 0.150mg) 8-12H oral.
0.4mg/kg (adult 5-20mg) 4-8H.
624
Efavirenz (EFV). Daily oral 10-14kg

200mg, 15-19mg 250mg, 20-24
kg 300mg, 25-32kg 350mg,
33-39kg 400mg, 40kg 600mg
(minimum trough 1000 ng/ml).
Efavirenz 600mg + emtricitabine
200mg + tenofovir disoproxil
fumarate 300mg (Atripla). 40kg:
1 tab daily.
Efavirenz + fosamprenavir + ritonavir. >18yr: EFV 600mg daily
+ FPV 700mg 12H + RTV 100mg
12H oral. If Rx nave, can use
EFV 600mg + FPV 1400mg + RTV
300mg daily.
Eflornithine. 13.9% cream: apply
12H.
Eformoterol. Caps 12mg (NOT/kg):
1cap (5-12yr) or 1-2 caps (adult)
inhaled 12H.
Electrolyte solution. See glucose
electrolyte solution.
Eletriptan. Adult (NOT/kg): 2040mg, repeat after 2hr if reqd
(max 80mg/day).
Eltrombopag. Adult (NOT/kg): 2575mg daily oral.
EMLA cream. See lignocaine +
prilocaine.
Emedastine. 0.5mg/ml soltn: 1
drop/eye 12H.
Emtricitabine (FTC). 0-3mo: soltn
3mg/kg daily oral; >3mo: soltn
6mg/kg (adult 240mg) cap
(>33kg) 200mg daily oral.
Emtricitabine 200mg + tenofovir
300mg (Truvada). 18yr: 1tab
daily oral. See also efavirenz.
Enalapril. 0.1mg/kg (adult 2.5mg)
daily oral, incr over 2wk if reqd
to max 0.5mg/kg (adult 5-20mg)
12H.
Enalaprilat. Usually 0.025mg/kg
(max 1.25mg) 6H IV, max 0.1mg/
kg (max 5mg) 6H.
Enflurane. 2-4.5% induction, then
0.5-3% by inhalation.
Enfuvirtide (ENF). 6yr: 2mg/kg
(max 90mg) 12H SC.
Enoxacin. 4-8mg/kg (adult 200400mg) 12H oral.
625
Drug Doses
Drospirenone + ethinyloestradiol
(3mg/30mcg) x 21 tab + 7 inert
tab. Contraceptn: 1 daily starting
1st day menstruation.
Drospirenone + ethinyloestradiol
(3mg/20mcg, 3mg/ 30mcg) x
24 tab, + 4 inert tab. Contraception: 1 daily starting 1st day of
menstruation.
Drotrecogin alfa (protein C), activated. 24mcg/kg/hr for 96hr IV.
Minor surgery: stop 2hr before,
restart straight after. Major
surgery: stop 2hr before, restart
12hr after.
Duloxetine. Adult, NOT/kg: 20-30mg
12H, or 60mg daily oral.
Dutasteride. Adult (NOT/kg): 0.5mg
daily oral.
Dutasteride 0.5mg + tamsulosin
0.4mg. Adult (NOT/kg): 1 cap
daily oral.
Dyclonine hydrochloride. See dyclocaine hydrochloride.
Dydrogesterone. 0.2mg/kg (adult
10mg) 12-24H oral.
Dyphylline. See diprophylline.
Ecallantide. 0.6 mg/kg (adult 30mg/
kg) SC, repeat if reqd.
Econazole nitrate. Topical: 1%
cream, powder or lotion 8-12H.
Vaginal: 75mg cream or 150mg
ovule twice daily.
Ecothiopate iodide. 0.03%, 0.06%,
0.125%, 0.25% soltn: usually
0.125% 1 drop/eye every 1-2 days
at bedtime.
Eculizumab. 600mg IV over 35min
wkly for 4wk, 900mg the next wk,
then 900mg every 2wk.
Edrophonium. Test dose 20mcg/
kg (adult 2mg), then 1min later
80mcg/kg (adult 8mg) IV. SVT:
0.15mg/kg (max 2mg) incr to max
0.75mg/kg (max 10mg) IV, with
atropine if reqd.
EDTA. See sodium calciumedetate.
Efalizumab. 0.7mg/kg stat, then
1mg/kg wkly SC.
Drug Doses
Enoxaparin (1mg=100u). 1.5mg/

kg (<2mo), 1mg/kg (2mo-18yr),
40mg (adult) 12H SC (anti-Xa 0.51u/ml 4hr post dose). Prophylaxis: 0.75mg/kg 12H (<2mo), 0.5
mg/kg 12H (2mo-18yr), 20-40mg
2-12hr preop, then daily (adult)
SC. Haemodialysis: 1mg/kg into
arterial line at start 4hr session.
Enoximone. IV: 5-20mcg/kg/min.
Oral: 1-3mg/kg (adult 50-150mg)
8H.
Entacapone. Adult (NOT/kg): 200mg
with each l-dopa/DDC inhibitor
dose (av 800-1400mg/day, max
2000mg) oral.
Entecavir. Hepatitis B (adult, NOT/
kg): 0.5mg daily oral; 1mg daily if
refractory to lamivudine.
Entravirine. See etravirine.
Enzymes, pancreatic. See pancreatic
enzymes.
Ephedrine. 0.25-1mg/kg (adult 12.560mg) 4-8H oral, IM, SC, IV. Nasal
(0.25%-1%): 1drop each nostril
6-8H, max 4 days.
Epinastine. 0.05% ophthalmic: 1
drop/eye 12H.
Epinephrine. See adrenaline.
Epirubicin. Adult: 75-90mg/m2 IV
over 10min every 3wk.
Eplerenone. 0.5-1mg/kg (adult 2550mg) 12-24H oral.
Epoetin alfa, beta, delta, theta,
zeta. 20-50u/kg x3/wk, incr to
75-300u/kg/wk divided into 1-3
doses/wk SC, IV. If Hb >10g%: 20100u/kg x2-3/wk.
Epoprostenol (prostacyclin, PGI2).
Dilute in pharmacy, new syringe
every 8hr. <8kg: 12mcg/kg in
10ml diluent at 0.25-0.75ml/hr
(5-15ng/kg/min); >8kg: 500 mcg
in 50ml diluent at 0.03-0.09ml/
kg/hr (5-15ng/kg/ min). ECMO:
5ng/kg/min IV.Chronic pul ht:
2ng/kg/min IV, incr to 20-40ng/
kg/min.
Eprosartan. 12mg/kg (adult 600mg)
daily, incr if reqd to 6-8mg/kg
Epsilon aminocaproic acid. See

aminocaproic acid.
Eptacog alfa (recombinant factor
7a). See factor 7a.
Eptifibatide. Adult (NOT/kg):
180mcg/kg stat IV, then 2 mcg/
kg/min for up to 72hr.
Erdosteine. Adult (NOT/kg): 300mg
12H oral.
Ergocalciferol (Vitamin D2). 40u
= 1mcg = 1mcg cholecalciferol
(D3). Cystic fib, cholestasis:
10-20mcg daily oral. Cirrhosis:
adult 40-120mcg daily oral.
Deficiency: 50-100mcg daily for
2wk oral, then 10-625mcg daily
(more if severe malabs); or 2.55mg (100,000-200,000u) every
6-8wk. Monitor serum calcium;
measure alk phos and parathyroid
hormone after 6-8wk. See also
doxercalciferol.
Ergoloid mesylates. See co-dergocrine mesylate.
Ergometrine maleate. Adult (NOT/
kg): 250-500mcg IM or IV;
500mcg 8H oral, sublingual or PR.
Ergometrine maleate 0.5mg +
oxytocin 5u in 1ml. 1ml IM; may
repeat after 2hr, max 3 doses in
24hr.
Ergonovine maleate. See ergometrine maleate.
Ergotamine tartrate. >10yr (NOT/
kg): 2mg sublingual stat, then
1mg/hr (max 6mg/episode,
10mg/wk). Suppos (1-2mg): 1
stat, may repeat once after 1hr.
See also caffeine + ergot.
Erlotinib. Adult (NOT/kg): 150 mg
daily oral; reduce to 100mg then
50mg daily if reqd.
Ertapenem. 20-40mg/kg (adult 1g)
daily IM, IV over 30min.
Erythromycin. Oral or slow IV (max
5mg/kg/hr): usually 10 mg/kg
(adult 250-500mg) 6H; severe
inftn 15-25mg/kg (adult 0.75-1g)
6H. Gut prokinetic: 2mg/kg 8H.
2% gel: apply 12H.
626
Ethambutol hydrochloride. 25mg/

kg once daily for 8wk, then 15mg/
kg daily oral. Intermittent: 35mg/
kg x3/wk. IV: 80% oral dose.
Ethamsylate. 12.5mg/kg (max
500mg) 6H oral,IM,IV.
Ethanol. 10% ethanol 8ml/kg IV
over 1hr, then 0.8ml/kg/hr
(child) 1.4ml/kg/hr (adult) 2ml/
kg/hr (drinker) so blood ethanol
1-1.5mg/ml (22-33mmol/L)
until ethylene glycol <0.2g/L
(3.2mmol/L) or methanol <0.2g/L
(6.2mmol/L).
Ethanol, dehydrated (100%). Vessel
sclerosis: inject max of 1ml/kg.
Ethanolamine oleate. 5% soltn,
adult (NOT/kg): 1.5-5ml per varix
(max 20ml per treatment).
Ethchlorvynol. 10-20mg/kg (adult
0.5-1g) at night oral.
Ethinyloestradiol. 10-50mcg daily
for 21 days per month. See also
cyproterone; desogestrel.
Ethinyloestradiol + ethynodiol diacetate (50mcg/0.5mg or
50mcg/1mg) x 21 tab, + 7 inert
tab. Contraception: 1 tab daily,
starting 1st day of menstruation.
Ethinyloestradiol + gestodene
(30mcg/75mcg, 20/75) x 21 tab
+ 7 inert tab. 1 daily, starting 1st
day of menstruation.
Ethinyloestradiol + gestodene
(30mcg/50mcg x 6 tab + 40/70
x5 + 30/100 x10 + inert x7).
menstruation.
Ethinyloestradiol + levonorgestrel
(100mcg/0.5mg). Post-coital: first
dose within 72hr, rpt after 12hr.
(20mcg/90mcg). Contraception:
1 tab daily (with no hormone-free
interval).
Ethinyloestradiol + levonorgestrel (30mcg/150mcg or
50mcg/125mcg) x 21 tab, + 7
inert tab. Contraception: 1 tab
daily, starting 1st day of menstruation.
627
Drug Doses
Erythropoietin. See epoetin.

Escitalopram. Adult (NOT/kg): 5mg
20mg daily.
Esketamine. See ketamine.
Eslicarbazepine. 8mg/kg (adult
400mg) daily oral, incr to 15 mg/
kg (adult 800mg) after 2wk; max
30mg/kg (adult 1800 mg) daily.
Esmolol. 0.5mg/kg (500mcg/kg)
IV over 1min, repeated if reqd.
Infsn (undiluted 10mg/ml soltn):
0.15-1.8ml/kg/hr (25-300mcg/kg/
min); rarely given for >48hr.
Esomeprazole. 0.4-0.8mg/kg (adult
20-40mg) daily oral. H.pylori, see
omeprazole.
Esomeprazole + naproxen (375/20,
500mg/20mg). Adult (NOT/kg): 1
tab 12H before meal oral.
Estazolam. 0.02-0.1mg/kg (adult
1-4mg) at night oral.
Estradiol. See oestradiol.
Estramustine. 200mg/m2 8H oral
(avoid milk).
Estriol. See oestriol, and oestradiol
+ oestriol.
Estrogens. See oestrogens.
Estrone. See oestrone.
Estropipate. 1mg = 0.83mg piperazine oestrone sulphate. Not/kg:
induction puberty 0.19mg daily
oral, incr over 2-3yr to 1.5mg
(add progestogen for 12 days per
cycle); vasomotor symptoms or
vaginal atrophy 0.75-6mg daily;
hypogonadism 1.5-9mg daily for
21 days of 31-day cycle; osteoporosis 0.75mg daily for 25 days of
31-day cycle.
Eszopiclone. Adult (NOT/kg): 2mg
(1-3mg) at night oral.
Etamsylate. 12.5mg/kg (adult
500mg) 6H oral.
Etanercept. Adult (NOT/kg): 50mg
weekly SC.
Ethacrynic acid. IV: 0.5-1mg/kg
(adult 25-50mg) 12-24H. Oral:
12-24H.
Drug Doses
(30mcg/50mcg x6tab + 40/75
x5 + 30/125 x10 + inert x7).
menstruation.
(30mcg/150mcg) x 84 tab,
then either 7 inert tab or 7 tab
ethinyloestradol 10 mcg. Contraception: 1 daily, starting 1st day
menstruation.
Ethinyloestradiol + norelgestromin
(20mcg/150mcg, 0.75mg/6mg)
patches. Contraception: apply 1
patch wkly x3, wk 4 patch-free.
Ethinyloestradiol + norethisterone
(35mcg/0.25mg, 30/0.5, 35/0.5,
35/0.75, 20/1, 35/1, 30/1.5) x 21
tab, + 7 inert tab. Contraception:
menstruation.
(20mcg/1mg) x 24 tab, + 4 inert
tab. Contraception: 1 tab daily,
(35mcg/0.5mg x7tab + 35/1 x14
+ inert x7). Contraception: 1 daily,
(35mcg/0.5mg x7tab + 35/1 x9 +
35/0.5 x5 + inert x7). Contraception: 1 tab daily, starting 1st day
of menstruation.
(35mcg/0.5mg x7tab + 35/0.75 x7
+ 35/1 x7+ inert x7). Contraception: 1 tab daily, starting 1st day
of menstruation.
Ethionamide. TB: 15-20mg/kg
(max 1g) at night oral. Leprosy:
5-8mg/kg (max 375mg) daily.
Ethoheptazine. 3mg/kg (adult
150mg) 6-8H oral.
Ethosuximide. 10mg/kg (adult
500mg) daily oral, incr by
50% each wk to max 40mg/
kg (adult 2g) daily. Trough level
0.3-0.7mmol/L.
Ethotoin. 5mg/kg (adult 250mg) 6H

oral, incr to max 15mg/kg (adult
750mg) 6H.
Ethyl chloride. Spray on affected
area from a distance of 10-20cm
for 3-7sec (bottle) or 4-10sec
(aerosol can).
Ethynodiol. See ethinyloestradiol +
ethynodiol diacetate.
Etidocaine. 0.5%-1.5% soltn: max
6mg/kg (0.6ml/kg of 1%) parenteral, or 8mg/kg (0.8ml/kg of 1%)
with adrenaline.
Etidronate. 5-20mg/kg daily oral
(no food for 2hr before and after
dose) for max 6mo. IV: 7.5mg/kg
daily for 3-7 days.
Etidonate and calcium citrate.
Etidronate 400mg tab daily 14
days, then calcium citrate 500mg
daily for 76 days oral.
Etodolac. 4-8mg/kg (adult 200400mg) 6-8H oral.
Etomidate. 0.3mg/kg slow IV.
Etonogestrel. 68mg sub-dermal
implant lasts 3yr.
Etoposide. 50-60mg/m2 IV over
1hr daily for 5 days, repeat after
2-4wk. Oral dose 2-3 times IV
dose.
Etoricoxib. Adult (NOT/kg). 60-90mg
daily oral. Gout: 120 mg daily,
max 8 days.
Etravirine (ETR). 4mg/kg (adult
200mg) 12H oral after meal.
Etretinate. 0.25mg/kg 8-12H oral for
2-4wk, then 6H (max 75mg daily)
if reqd for 6-8wk, then 12-24H.
Etynodiol diacetate. Contraception:
500mcg daily oral, starting 1st day
of menstruation.
Everolimus. Adult (NOT/kg):10mg
(5mg if toxicity) daily oral.
Exemestane. Adult (NOT/kg): 25mg
daily oral.
Exenatide. Adult, NOT/kg: 5mcg
SC before morning and evening
meals, incr if reqd to 10mcg/dose
after 1mo.
Ezetimibe. Adult (NOT/kg): 10mg
daily oral.
628
Famciclovir. Severe infection:

320mg/m2 (adult 500mg) 8H
oral. Zoster, varicella: 160mg/m2
(adult 250mg) 8H oral for 7 days;
immunocompromised 320mg/
m2 (adult 500mg) 8H for 10 days.
Genital herpes (adult, NOT/kg):
125mg 12H oral for 5 days (treat),
250mg (suppress) 12H; immunocompromised 500mg 12H
for 7 days (treat), 500mg daily
(suppress).
Famotidine. 0.5-1mg/kg (adult
20-40mg) 12-24H oral. 0.5mg/kg
(max 20mg) 12H slow IV.
Fat emulsion 20%. See lipid emulsion.
Febuxostat. Adult (NOT/kg): 80mg
Felbamate. 5mg/kg 6-8H (max
1200mg/day) oral, incr over
2-3wk to 15mg/kg 6-8H (max
3600mg/day).
Felbinac. 3% gel, foam: apply x2-4/
day.
Felodipine. 0.1mg/kg (adult 2.5mg)
daily, incr if reqd to 0.5 mg/kg
Fenbufen. 10mg/kg (adult 450mg)
12H oral.
Fenofibrate, fenofibric acid. Adult
(NOT/kg): 135-200mg daily oral
(better absorption with micronised caps).
Fenoglide. Adult (NOT/kg): 40120mg daily oral.
Fenoldopam. 0.1mcg/kg/min IV
infsn incr gradually if reqd every
15-30min to max 1.6mcg/kg/min.
Fenoprofen. 4mg/kg (adult 200mg)
6-8H oral, may incr gradually to
12mg/kg/dose (max 800mg).
Fenoterol. Oral: 0.1mg/kg 6H. Resp
soltn 1mg/ml: 0.5ml diluted to
2ml 3-6H (mild), 1ml diluted to
2ml 1-2H (moderate), undiluted
continuous (severe, in ICU). Aerosol (200mcg/puff): 1-2 puffs 4-8H.
629
Drug Doses
Ezetimibe + simvastatin (10/20,

10/40, 10mg/80mg). Adult (NOT/
kg): 10/20mg tab daily oral, incr
strength 4wkly if reqd.
Factor 2. See factor 9 complex.
Factor 7a, recombinant (rFVIIa).
Usually 90mcg/kg IV 2H until
haemostasis, then 3-6H. See also
factor 9 complex.
Factor 8 concentrate (vial 200250u), recombinant antihaemophilic factor (rAHF). Joint 20u/kg,
psoas 30u/kg, cerebral 50u/kg. 2
x dose(u/kg) = % normal activity,
eg 35u/kg gives peak level of 70%
normal. See also Von Willebrand
factor / Factor VII concentrate.
Factor 8 inhibitor bypassing fraction. IV max 2u/kg/min: joint
50u/kg 12H, mucous membranes
50u/kg 6H, soft tissue 100u/kg
12H, cerebral 100u/kg 6-12H.
Factor 9. IV infsn (max 2u/kg/min):
minor hemorrhage 25u/kg daily,
joint 40u/kg 12-24H, surgery
50u/kg stat then 30u/kg 12-24H,
major surgery 85u/kg stat then
50u/kg 12-24H. Proph: 25-40u/kg
x2/wk (trough >1u/dl). See also
factor 9 complex.
Factor 9 complex (Beriplex, Ocatplex). Factors 2, 7, 9, 10, protein
C, protein S: approx 25u/ml. 1ml/
kg (INR 2-3.9) 1.4ml/kg (INR 4-6)
2 ml/kg (INR >6) + phytomenadione (if reversing warfarin).
Factor 9 complex (ProthrombinexVF). Factors 2, 9, 10 500u per
20ml vial, antithrombin III 25u/
vial, low levels factor 5 and 7.
1ml/kg slow IV daily. Risk of
thrombosis in acute liver failure.
Reverse warfarin: 1-2ml/kg +
phytomenadione (Vit K1) + FFP
5ml/kg.
Factor 10. See factor 9 complex.
Factor 13. Vial 250u. Prophylaxis:
10u/kg IV every 4wk. Pre-op: up
to 3u/kg just before surgery, then
10u/kg daily x5. Severe hemorrhage: 10-20u/kg daily.
Drug Doses
Fentanyl. Not ventilated: 1-2 mcg/kg

(adult 50-100mcg) IM or IV; infsn
2-4mcg/kg/hr (<10kg 100mcg/
kg in 50ml 5%dex-hep at 1-2ml/
hr; >10kg amp 50mcg/ml at
0.04-0.08ml/kg/hr). Ventilated:
5-10mcg/kg stat or 50mcg/kg IV
over 1hr; infuse amp 50mcg/ml
at 0.1-0.2ml/kg/hr (5-10 mcg/
kg/hr). Patch (lasts 72hr) in adult
(NOT/kg): 25 mcg/hr, incr if
reqd by 25 mcg/hr every 3 days.
Transmucosal tabs (adult, NOT/
kg): 100mcg between cheek and
upper gum until disolved (15-30
min) 4-8H, incr if reqd to max
800mg 4H. Buccal film: 200 mcg
incr to max 1200mcg x4/day.
Nasal spray (adult, NOT/kg): 50,
100 or 200mcg doses titrated to
response. Epidural: 0.5 mcg/kg
stat, or 0.4mcg/kg/hr.
Fenticonazole vaginal pessaries.
600mg nocte once, or 200mg
nocte for 3 nights.
Ferric carboxymaltose. Total Fe
dose (mg): <35kg = wt(kg) x (13
actual Hb in g/dl) + 13mg/kg;
35kg = wt(kg) x (15 actual Hb
in g/dl) + 500mg. IV bolus: max
200mg Fe x3/wk. IV over 15min:
max 1000mg wkly.
Ferrous salts. Prophylaxis 2mg/kg/
day elemental iron oral, treatment 6mg/kg/day elemental
iron oral. Fumarate 1mg =
0.33mg iron. Gluconate 1mg =
0.12mg iron; so Fergon (60 mg/
ml gluconate) prophylaxis 0.3ml/
kg daily, treatment 1ml/kg daily
oral. Sulphate (dry) 1mg = 0.3mg
iron; so Ferro-Gradumet (350mg
dry sulphate) prophylaxis 7mg/
kg (adult 350mg) daily, treatment
20mg/kg (adult 1050mg) daily
oral.
Ferumoxides. Fe 11.2mg/ml.
0.05ml/kg (Fe 0.56mg/kg) in 2ml/
kg (adult 100ml) 5% dextrose IV
over 30min.
Ferumoxytol. 510mg in 17ml, total

dose (ml) = 0.08 x Wt in kg x (15
Hb in g/dl) IV over 1min; adult
510mg IV stat and in 3-8 days.
Fesoterodine. Adult (NOT/kg):
4-8mg daily oral.
Fexofenadine. NOT/kg: 30mg 12H
(6-11yr), 60mg 12H or 180mg
daily (>11yr) oral.
Fibrin glue. See thrombin glue.
Fibrinogen concentrate. 70mg/kg IV;
or mg/kg = (1 measured level
g/L) / 0.17 = (100 measured
mg/dL) / 1.7.
Fibrinolysin 8-10u/ml + desoxyribonuclease 500-667 u/ml. Ointment
or soltn: apply topically 6-24H.
Filgrastim (granulocyte CSF). Idiopathic or cyclic neutropaenia:
5mcg/kg daily SC or IV over
30min. Cong neutropaenia:
12mcg/kg daily SC or IV over 1hr.
Marrow transplant: 20-30mcg/
kg daily IV over 4-24hr, reduce if
neutrophil >1x109/L.
Finasteride. Adult (NOT/kg). Prostatic hyperplasia: 5mg daily oral.
Alopecia: 1mg daily oral.
Flavocoxid. Adult (NOT/kg): 250500mg 12H oral.
Flavoxate. 2-4mg/kg (adult 100200mg) 6-8H, or single dose at
bedtime oral.
Flecainide. 2-3mg/kg (max 100mg)
12H oral, may incr over 2wk to
7mg/kg (max 200mg) 8-12H. IV
over 30min: 0.5-2mg/kg (max
150mg) 12H.
Floxuridine (FUDR). 100-300mcg/
kg/day by constant intra-arterial
infsn (400-600mcg/kg/day in hepatic artery). Stop if WCC <3500/
mm3 or platelets <100,000/mm3.
Flucloxacillin. Oral: 12.5-25mg/kg
(adult 250-500mg) 6H. IM or IV:
25mg/kg (adult 1g) 6H. Severe
inftn: 50mg/kg (adult 2g) IV 12H
(1st wk life), 8H (2-4 wk), 6H or
constant infsn (>4 wk). See also
ampicillin + flucloxacillin.
630
Fluorometholone. 0.1% soltn: 1

drop/eye 6-12H.
Fluorouracil. 15mg/kg (max 1g) IV
over 4hr daily until side effects,
then 5-10mg/kg wkly. See also
adrenaline + fluorouracil; and
folinic acid.
Fluothane. Induction 0.5-4%, then
0.5-1.5% inhalation.
Fluoxetine. 0.5mg/kg (max 20mg)
daily, incr to max 1mg/kg (max
40mg) 12H oral. Weekly 90mg
cap: 1 per wk.
Fluoxetine + olanzapine
(25mg/6mg, 25mg/12mg,
50mg/6mg, 50mg/12mg). Adult
(NOT/kg): 1cap daily oral.
Fluoxymesterone. 0.1-0.2mg/kg
(adult 5-10mg) daily oral.
Flupenthixol. Oral: 0.05-0.2mg/kg
(adult 3-9mg) 12H. Depot IM:
usually 0.4-0.8mg/kg (up to 5mg/
kg, max 300 mg) every 2-4wk
(1mg flupenthixol deconate =
0.625mg fluphenazine decanoate
= 1.25mg haloperidol).
Flupentixol. See flupenthixol.
Fluphenazine. 0.02-0.2mg/kg (adult
1-10mg) 8-12H oral.
Flurandrenolide. See flurandrenolone.
Flurandrenolone. 0.025%, 0.05%
cream, ointment or lotion: apply
6-24H. 4mcg/m2 tape: apply 12H.
Flurazepam. Adult (NOT/kg): 1530mg at night, oral.
Flurbiprofen. 1-2mg/kg (adult
50-100mg) 8H oral or PR. 0.03%
drops: 1 drop/eye every 30min
x4 doses.
Flutamide. Adult (NOT/kg): 250mg
8H oral.
Fluticasone. Inhaled (NOT/kg):
50-100mcg (child), 100-500mcg
(adult) 12H. 0.05% soltn: 1-4
sprays /nostril daily. 0.05% cream:
apply sparingly daily.
631
Drug Doses
Fluconazole. 12mg/kg (adult 200400mg) daily IV, higher doses if

very severe infection; if haemofiltered 12mg/kg (adult 600mg)
12H; neonate 12mg/kg 72H (<14
days) 48H (15-28 days). Superficial inftn: 6mg/kg (adult 200mg)
stat, then 3mg/kg (adult 100mg)
daily oral or IV.
Flucytosine (5-fluorocytosine). 4001200mg/m2 (max 2g) 6H IV over
30 min, or oral. Peak level 50100mcg/ml, trough 25-50mcg/ml
(x7.75=umol/L).
Fludarabine. 25mg/m2 daily x5 IV
over 30min, every 28 days.
Fludrocortisone acetate. 150mcg/
m2 daily oral. Fludrocortisone
1mg = hydrocortisone 125mg in
mineralocorticoid activity, 10mg
in glucocorticoid.
Flumetasone. See clioquinol +
flumetasone.
Flumazenil. 5mcg/kg every 60sec to
max total 40mcg/kg (adult 2mg),
then 2-10mcg/kg/hr IV.
Flunarizine. Adult (NOT/kg): 10mg
daily oral, reducing to 5 days/wk
with two successive days off.
Flunisolide. Asthma (250mcg/puff):
1-2 puffs 12H. Nasal (25mcg/
puff): 1-2 puffs/nostril 8-24H.
Flunitrazepam. Adult (NOT/kg): 0.52mg at night, oral.
Fluocinolone. See fluocinonide.
Fluocinonide. 0.025%, 0.05% cream
or oint: apply 6-12H.
Fluocortolone. 0.25% cream, ointment: apply 8-12H.
Fluorescein. 1%, 2% drops: 1 drop/
eye. 10% (100 mg/ml), 25%
(250mg/ml): 8mg/kg (max
500mg) IV.
Fluorescein 0.25% + oxybuprocaine
0.4%. 1 drop/eye.
Fluoride. 0.25mg (<3yr) 0.5mg
(3-6yr) 1mg (>6yr) daily oral. See
also sodium fluoride.
5-Fluorocytosine. See 5-flucytosine.
9-alpha-fluorohydrocortisone. See
fludrocortisone.
Drug Doses
Fluticasone + salmeterol. NOT/

kg. Accuhaler: 100mcg/ 50mcg
(child), 250/50 or 500/50 (adult)
x1-2 inhltn 12H. MDI: 50/25
(child), 125/25 or 250/25 x1-2
inhltn 12H.
Fluvastatin. 0.4mg/kg (adult 20mg)
nocte oral, incr to 0.8 mg/kg
(adult 40mg) 12H if reqd. Slow
relse: 80mg nocte.
Fluvoxamine. 2mg/kg (adult 100mg)
8-24H oral. Slow-release (adult,
NOT/kg): 100-300mg at night oral.
Folic acid. NOT/kg. Deficiency:
50mcg (neonate), 0.1-0.25mg
(<4yr), 0.5-1mg (>4yr) daily IV, IM,
SC or oral. Metabolic dis: 5mg/
day oral. Pregnancy: 0.5mg (high
risk 4mg) daily oral.
Folinate or folinic acid. See calcium
folinate.
Follicle stimufating hormone (FSH).
Adult (NOT/kg), monitor urinary
oestrogen. Anovulation: usually
50-150iu SC daily for 9-12 days.
Superovulation (2wk after starting
GnRH agonist): 100-225iu/kg daily
starting day 3 of cycle.
Follitropin alpha, beta. See follicle
stimulating hormone.
Fomepizole. 15mg/kg load, then
10mg/kg 12H for 48hr, then
15mg/kg 12H IV until ethylene
glycol <0.2g/L (3.2mmol/L) or
methanol <0.2g/L (6.2mmol/L).
Fomivirsen. Intravitreal injection,
adult (NOT/kg). New disease:
165mcg/eye wkly x3, then every
2wk. Previously treated: 330mcg/
eye stat, in 2wk, then every 4wk.
Fondaparinux. See fondaparin.
Fondaparin. Adult (NOT/kg): 2.5mg
SC 6hr postop, then daily for 5-9
days.
Formestane. Adult (NOT/kg): 250mg
2wkly deep IM.
Formoterol. >4yr (NOT/kg). Powder:
12mcg inhalation 12H. Solutn:
20mcg in 2ml nebulised 12H. See
also budesonide.
Fosamprenavir (FPV). 2yr: 30mg/

kg (max 1400mg) 12H oral. Amprenavir trough 400ng/ml. See
also efavirenz.
Fosamprenavir + ritonavir. 6yr:
FPV 18mg/kg (max 700 mg) + RTV
3mg/kg (max 100mg) 12H oral.
If >18yr can use FPV 1400mg +
RTV 200mg (nave) 100mg (past
Rx) daily.
Fosaprepitant. Adult (NOT/kg):
125mg oral or IV over 15min on
day 1, then 80mg on day 2 and
day 3.
Foscarnet. 20mg/kg IV over 30min,
then 200mg/kg/day by constant IV infsn (less if creatinine
>0.11mmol/l) or 60 mg/kg 8H IV
over 2hr. Chronic use: 90-120mg/
kg IV over 2hr daily.
Fosfestrol. Adult (NOT/kg). Initial:
0.5g IV over 1hr day 1, then 1g x5
days. Maintenance: 120-240mg
8H oral, later reducing to 120240mg daily.
Fosfomycin. 5.63g (3g base) sachet
mixed with water oral.
Fosinopril. 0.2-0.8mg/kg (adult 1040mg) daily oral.
Fosphenytoin. 75mg = 50mg phenytoin (qv). Prescribed and dispensed as phenytoin equivalents.
Fospropofol. Usually 6.5mg/
kg IV, then 1.6mg/kg no more
frequently than every 4min (0.30.4mg/kg/min).
Fotemustine. IV over 1hr, or IA over
4hr: 100mg/m2 weekly x3, rest
4-5wk, then every 3wk.
Framycetin sulfate (Soframycin).
Subconjunctival: 500mg in 1ml
water daily x3 days. Bladder:
500mg in 50ml saline 8H x10
days. 0.5%: eye 1drop 8H, ear
3drops 8H, ointment 8H.
Framycetin sulfate 15mg/g + gramicidin 0.05mg/g. Cream or ointment (Soframycin topical): apply
8-12H. See also dexamethasone +
framycetin + gramicidin.
632
Gadoxetic acid. 0.25mmol

(181.43mg) per ml: 0.1ml/kg IV.
Galantamine. Adult (NOT/kg): 4mg
12H for 4wk, then 8mg 12H, incr
after 4wk if reqd to 8-12mg 12H
oral.
Gallamine. 1-2mg/kg (adult 50100mg) IV.
Gallium nitrate. 100-200mg/m2/day
x5days constant IV infsn.
Galsulfase. 1mg/kg (to nearest 5mg)
weekly IV over 4-20hr.
Gamma benzene hexachloride. See
lindane.
Gamma globulin. See immunoglobulin.
Gamma hydroxybutyrate See
sodium oxybate.
Gamolenic acid. 2-5mg/kg (adult
120-240mg) 12H oral.
Ganciclovir. 5mg/kg 12H IV over
1hr for 2-3wk; then 5mg/kg IV
daily, or 6mg/kg IV on 6 days/wk,
or 20 mg/kg (adult 1g) 8H oral.
Congenital CMV: 7.5mg/kg 12H
IV over 2hr.
Ganirelix. Adult (NOT/kg): 0.25mg
daily SC from day 6 of FSH to day
of ovulation induction.
Gas gangrene (Clostridia) antitoxin.
Prophylaxis: 25,000u IM or IV.
Treatment: 75,000-150,000u IV
over 1hr, repeat x1-2 after 8-12hr;
if severe also give 100,000u IM.
Gatifloxacin. 8mg/kg (adult 400mg)
daily IV over 1hr. Gonorrh: 8mg/
kg (adult 400mg) once. 0.3%
ophthalmic: 1 drop/eye 2H when
awake days 1-2, then x4/day on
days 3-7.
Gaviscon. See alginic acid.
Gefitinib. Adult (NOT/kg): 250mg
daily oral.
Gelatin, succinylated. 10-20ml/kg
(may be repeated). Volume effect
lasts 3-4hr.
Gemcitabine. 1g/m2 IV over 30min
wkly for 3wk, rest for 1wk, then
repeat 4wk cycle.
633
Drug Doses
Frangula 8% + sterculia 62%. NOT/

kg: 1-2 sachets (or 1-2 5ml
spoonfuls) 12-24H oral.
Fresh frozen plasma. Contains all
clotting factors. 10-20 ml/kg IV. 1
bag is about 230ml.
Frovatriptan. Adult (NOT/kg): 2.5mg
oral (max 7.5mg/day).
Frusemide. Usually 0.5-1mg/kg
(adult 20-40mg) 6-24H (daily
if preterm) oral, IM, or IV over
20min (max 0.05 mg/kg/min IV).
IV infsn: 0.1-1mg/kg/hr (<20kg
25 mg/kg in 50ml 0.9% saline
with heparin 1u/ml at 0.2-2 ml/
hr; >20kg amp 10mg/ml at 0.010.1ml/kg/hr); protect from light.
Fulvestrant. Adult (NOT/kg): 250mg
IM once a month.
Furazolidone. 2mg/kg (adult 100mg)
6H oral 7-10day.
Furosemide. See frusemide.
Fusafungine. 125mcg spray: oral
1spray/10kg (adult 5 sprays) x5/
day, nasal 1spray/20kg (adult
3sprays) x5/day.
Fusidate, sodium. See sodium
fusidate.
Fusidic acid. Fusidic acid (susp) absorption only 70% that of sodium
fusidate (tabs). Suspension: 1520mg/kg (adult 750mg) 8H oral.
Eye %: 1drop/eye 12H. For tablets
and IV, see sodium fusidate.
Gabapentin. Anticonvulsant: 10mg/
kg (adult 300mg) once day 1
oral, 12H day 2, 8H day 3 then
adjusted to 10-20 mg/kg (adult
300-1200mg) 8H. Premed: 25mg/
kg (adult 1200mg) 1hr preop.
Analgesia: 2mg/kg (adult 100mg)
8H, incr if reqd to 15mg/kg (adult
800mg) or higher if tolerated.
Gadobutrol. 0.1mmol/kg IV.
Gadopentetic acid. Adult (NOT/kg).
2mmol/l inj: finger 1-2ml, wrist
4ml, ankle-elbow-hip-shoulder
10-20ml, knee 25-50ml.
Gadoteridol. 0.1 (max 0.3) mmol/
kg IV.
Drug Doses
Gemeprost (PGE1 analogue). Cervical dilatation: 1 pessary (1mg)

into posterior vagina 3hr before
surgery. Termination: 1 pessary
(1mg) into posterior vagina 3H
(max 5 pessaries).
Gemfibrozil. 10mg/kg (max 600mg)
12H oral.
Gemifloxacin. Adult (NOT/kg):
320mg daily oral.
Gemtuzumab ozogamicin. 9mg/m2
IV over 2hr, rpt after 14 days.
Gentamicin. IV or IM. 1wk-10yr:
8mg/kg day 1, then 6 mg/kg daily.
>10yr: 7mg/kg day 1, then 5mg/
kg (max 240-360mg) daily. Neonate, 5mg/kg dose: <1200g 48H
(0-7 days of life), 36H (8-30 days),
24H (>30 days); 1200-2500g 36H
(0-7 days of life), 24H (>7 days);
term 24H (0-7 days of life), then
as for 1wk-10yr. Trough level
<1.0mg/L.
Gentamicin, eye drops. 0.3% 1drop/
eye every 15min if severe, reducing to 1drop 4-6H.
Gestodene. See ethinyloestradiol +
gestodene.
Gestrinone. Adult (NOT/kg): 2.5mg
x2/wk on day 1 and 4 of menstrual cycle, then on same days
each wk.
Gestronol. Adult (NOT/kg): 200400mg every 5-7 days IM.
Getfitinib. Adult (NOT/kg): 250mg
daily oral.
Ginkgo biloba. Adult (NOT/kg):
1200mg 12H oral.
Glatiramer. Adult (NOT/kg): 20mg
daily SC.
Glibenclamide. Adult (NOT/kg):
initially 2.5mg daily oral, max
20mg daily.
Glibenclamide + metformin. Adult
(NOT/kg): 1.25mg/ 250mg
12-24H oral, incr if reqd to
2.5mg/500mg or 5mg/ 500mg
(max 10mg/1000mg) 12H.
Gliclazide. Adult (NOT/kg): initially
40mg daily oral, max 160mg 12H.
Glimepiride. Adult (NOT/kg): 2-4mg

Glimepiride + pioglitazone
(2mg/30mg, 4mg/30mg). Adult
(NOT/kg): 1 tab daily oral.
Glimepiride + rosiglitazone
(1mg/4mg, 2mg/4mg, 4mg/
4mg). Adult (NOT/kg): 1-2 tab
daily (max 4mg/8mg) oral.
Glipizide. Adult (NOT/kg): 5mg daily
oral, max 20mg 12H.
Gliquidone. 0.25-1mg/kg (adult 1560mg) 8-12H oral.
Globulin. See immunoglobulin.
Glucagon. 1u=1mg. 0.04mg/kg
(adult 1-2mg) IV or IM stat, then
10-50mcg/kg/hr (0.5mg/kg in
50ml at 1-5ml/hr) IV. Beta-blocker
overdose: 0.1mg/kg IV stat, then
0.3-2 mcg/kg/min.
Glucosamine. Adult (NOT/kg):
1500mg daily oral.
Glucose. See dextrose.
Glucose electrolyte solution. Not
dehydrated: 1 heaped teaspoon
sucrose in large cup of water (4%
sucrose = 2% glucose); do NOT
add salt. Dehydrated: 1 sachet of
Gastrolyte in 200ml water; give
freqnt sips, or infuse by NG tube.
Glutamic acid. 10-20mg/kg (adult
0.5-1g) oral with meals.
Glutaraldehyde. 10% soltn: apply to
wart 12H.
Glyburide. See glibenclamide.
Glycerin. See sorbolene + glycerin
cream.
Glycerol. Suppos: 0.7-1g infant, 1.42g child, 2.8-4g adult.
Glyceryl trinitrate. Adult (NOT/kg):
sublingual tab 0.3-0.9 mg/dose
(lasts 30-60min); sublingual aerosol 0.4-0.8 mg/dose; slow-release
buccal tab 1-10mg 8-12H; transdermal 0.5-5cm of 2% ointment,
or 5-15mg patch 8-12H. IV infsn
0.5-5mcg/kg/min (<30kg 3mg/kg
in 50ml 5%dex-hep at 0.5-5ml/hr;
>30kg 3mg/kg made up to 100ml
in 5%dex-hep at 1-10ml/hr); use
special non-PVC tubing.
634
Griseofulvin, ultramicrosize (Griseostatin). 5.5-7mg/kg (adult

Growth hormone. See somatropin.
Guaiacol. See codeine + guaiacol.
Guaifenesin. See guaiphenesin.
Guaiphenesin. 4-8mg/kg (adult 200400mg) 4H oral.
Guanabenz. 0.1mg/kg (max 4mg)
12H oral, incr to max 0.6mg/kg
(max 32mg) 12H.
Guanadrel. 0.1mg/kg (max 5mg)
12H oral, incr to max 0.5mg/kg
(max 25mg) 8-12H.
Guanethidine. 0.2mg/kg (max
10mg) daily oral, incr to 0.5-6mg/
kg (max 300mg) daily. Regnl symp
block (adult): cuff 55mmHg >syst
BP, 10-20mg in 10-25ml saline
(arm) or 15-30mg in 15-50ml (leg)
IV, wait 10-20min, release cuff
over 5min; >=7 days between
injctns (max 12/yr).
Guanfacine. 0.02mg/kg (max 1mg)
daily oral, incr over several wks to
max 0.06mg/kg (max 3mg) daily.
Guar gum. 1g/10kg (adult 5g) 8H
oral in fluid 40ml/g gum.
Haem arginate. 3-4mg/kg daily IV
over 30-60min.
Haemaccel. See polygeline.
Haemophilus influenzae type b,
vaccines. Inanimate. <12mo:
give diphtheria protein conjugate
(HibTITER, ProHIBiT), or tetanus
conjugate (Act-HIB, Hiberix) 0.5ml
IM at 2mo, 4mo, 6mo and 15mo;
or meningococcal conjugate
(Pedvax HIB) 0.5ml IM at 2mo,
4mo and 15mo. If 1st dose
>18mo: give 1 dose of HibTITER
or Pedvax HIB.
Haemophilus influenzae type b +
hepatitis B vaccine (Comvax).
Inanimate. 0.5ml IM 2mo, 4mo,
12-15mo (3 doses).
Haemophilus influenzae type b +
meningococcus type c vaccine
(Menitorix). Inanimate. 0.5ml IM
2mo, 3mo, 4mo (3 doses); boost
from 12mo.
635
Drug Doses
Glycopyrrolate. To reduce secretions

or treat bradycardia: 5-10mcg/
kg (adult 0.2-0.4mg) 6-8H IV or
IM. With 0.05mg/kg neostigmine:
10-15mcg/kg IV. Anticholinergic:
0.02-0.04mg/kg (max 2mg) 8H
oral.
Glycopyrronium bromide. Dose as
for glycopyrrolate.
GM-CSF. See sargramostim.
Gold sodium thiomalate. See sodium aurothiomalate.
Golimumab. Adult (NOT/kg): 50mg
weekly (or monthly with methotrexate) SC.
Gonadorelin (GnRH or LHRH). Pituitary function test, child or adult:
100mcg IV. See also leuprorelin.
Gonadotrophin. See chorionic
gonadtrn, and menotrophin.
Goserelin. Adult (NOT/kg): 3.6mg SC
every 28 days; implant 10.8mg SC
every 12wk. See also bicalutamide.
Gramicidin 0.025% + neomycin
0.25% + nystatin 100,000 u/g
+ triamcinolone 0.1%. Kenacomb ointment: apply 8-12H.
Kenacomb otic oint, drops: apply
8-12H (2-3 drops).
Gramicidin 25mcg/ml + neomycin
2.5mg/ml + polymyxin B 5000u/
ml (Neosporin). Eye drops: 1
drop/eye every 15-30min, reducing to 6-12H. See also dexamethasone.
Granisetron. 0.04mg/kg (adult 1mg)
IV over 5min daily. Chemotherapy: 0.05mg/kg (adult max 1-3mg)
IV over 5min; up to 3 doses/
day, at least 10min apart; adult 1
patch daily for up to 7 days starting 1-2 days before chemo.
Granulocyte-macrophage colony
stimulating factor (GM-CSF). See
lenograstim, sargramostim.
Grepafloxacin. 8-12mg/kg (adult
Griseofulvin (Grisovin, Fulcin). 1020mg/kg (adult 0.5-1g) daily oral.
Drug Doses
Halcinonide. 0.1% cream: apply

sparingly 8-12H.
Halobetasol. 0.05% cream, ointment: apply 12-24H.
Halofantrine. 10mg/kg (max 500mg)
6H for 3 doses oral, repeat after
1wk if nonimmune.
Haloperidol. 0.01mg/kg (max
0.5mg) daily, incr up to 0.1 mg/
kg 12H IV or oral; up to 2mg/kg
(max 100mg) 12H used rarely.
Acutely disturbed: 0.1-0.2mg/kg
(adult 5-10mg) IM. Long-acting
decanoate ester: 1-6mg/kg IM
every 4wk.
Halothane. 0.5-4% induction, then
0.5-2% inhalation.
Hemin. 1-3mg/kg 12-24H IV over
30min.
Heparin. 1mg=100u. Low dose:
75u/kg IV stat, then 500u/kg in
50ml 0.9% saline at 1-1.5ml/hr
(10-15u/kg/hr) IV. Full dose: 75u/
kg (adult 5000u) IV stat, then
500u/kg in 50ml saline at 2-4ml/
hr (20-40u/kg/hr)<12mo, 2-3ml/
hr (20-30 u/kg/hr) child, 1.5-2ml/
hr (15-20u/kg/hr) adult; adjust to
give APTT 60-85 sec, or anti-Xa
0.3-0.7u/ml. Hep lock: 100u/ml.
Heparin calcium. Low dose: 75u/kg
SC 12H.
Heparin, low molecular weight. See
certoparin, dalteparin, danaparoid, enoxaparin, nadroparin.
Heparinoid 0.2% + lauromacrogol
5%. Oint: apply x1-4/day.
Hepatitis A vaccine (Havrix). Inanimate. 0.5ml (child) or 1ml (adult)
IM stat, and in 6-12mo (2doses).
Boost every 5yr.
Hepatitis A vaccine (VAQTA).
Inanimate. 0.5ml (child) or 1ml
(>17yr) IM stat, and after 6-18mo
(2 doses).
Hepatitis A + hepatitis B vaccine
(Twinrix). Inanimate. 1-15yr
0.5ml, >15yr 1ml IM stat, after
1mo, and after 6mo (3 doses).
Boost every 5yr.
Hepatitis B immune globulin. See

immunoglobulin, hep B.
Hepatitis B vaccine (Engerix-B,
HB Vax II). Inanimate. EngerixB 10mcg/dose (<10yr), 20mcg
(>9yr); HB Vax II 2.5mcg/dose
(<10yr), 5mcg (10-19yr), 10mcg
(>19yr), 40mcg (dialysis) IM stat,
after 1mo, and after 6mo (3
doses). Boost every 5yr. See diphtheria and haemophilus vaccines.
Herpes zoster vaccine (Zostavax).
Live. Age 50yr or more: 0.65ml SC
once. See also Immunoglobulin,
zoster.
Hetastarch. 6% 10-20ml/kg IV.
Hexachlorophane. 3% emulsion.
>12mo: apply 5ml, scrub for
3min.
Hexamethylmelamine. 150-260mg/
m2 daily oral for 14-21 consecutive days of a 28 day cycle.
Hexamidine. See chlorhexidine.
Hexamine. 20mg/kg (adult 1g) 6H
oral.
Hexaminolevulinate. Adult (NOT/
kg): instill 100mg in 50ml.
Hexetidine. 0.1% soln: rinse/gargle
15ml (NOT/kg) 8-12H.
Histamine phosphate. 1mg/ml base:
prick, puncture or scratch testing.
0.1mg/ml base: intradermal
testing.
Histrelin. Usually 10mcg/kg daily SC.
Homatropine. 2%, 5% soltn: 1 drop/
eye 4H.
Hormone replacement therapy.
With uterus: sequential combined
oestrogen (eg.oestradiol) and
progestogen (eg. norethisterone)
if perimenopausal; continuous
combined therapy if postmenopausal. Without uterus:
oestrogen.
Human chorionic gonadotrophin.
Chorionic gonadotrophin.
Human papillomavirus vaccine
(Cervarix, Gardasil). Inanimate.
Females 10-46yr, males 9-15yr:
0.5ml IM, in 1-2mo, and 6mo
later (3 doses).
636
Hydroflumethiazide. 0.5-2mg/kg
(adult 25-100mg) 12-48H.
Hydrogen peroxide. 10 volume (3%).
Mouthwash 1:2 parts water. Skin
or ear disinfectant 1:1 part water.
Hydromorphone. Oral: 0.05-0.1mg/
kg (adult 2-4mg) 4H. IM, SC:
0.02-0.05mg/kg (adult 1-2mg)
4-6H. Slow IV: 0.01-0.02mg/kg
(adult 0.5-1mg) 4-6H. Palliative
care: incr to 40-50mg/day (up to
500mg/day) oral in divided doses.
Hydroquinone. 3-4% cream: apply
12H.
Hydrotalcite. 20mg/kg (adult 1g)
6H oral.
Hydroxocobalamin (Vit B12).
20mcg/kg (adult 1000mcg) IM
daily for 7 days then wkly (treatment), then every 2-3mo (prophyl); IV dangerous in megaloblastic anaemia. Homocystinuria,
methylmalonic acidur: 1mg daily
IM; after response, some patients
maintained on 1-10mg daily oral.
Hydroxyapatite. 20-40mg/kg (adult
1-2g) 8H oral.
Hydroxycarbamide. See hydroxyurea.
Hydroxychloroquine sulphate.
Doses as sulphate. Malaria:
3 days; prophylaxis 5mg/kg (max
300mg) once a wk oral. Arthritis,
SLE: 3-6.5mg/kg (adult 200600mg) daily oral.
Hydroxyethylcellulose. 0.44% 1
drop per eye 6-8H.
Hydroxypropyl (methyl)cellulose.
See hypromellose.
Hydroxyethylrutosides. 5mg/kg
(adult 250mg) 6-8H for 3-4wk,
then 12-24H; or 10mg/kg (adult
500mg) 12H for 3-4wk, then daily
oral.
Hydroxyprogesterone. Adult (NOT/
kg): 250-500mg/wk IM.
Hydroxypropylcellulose. 5mg insert:
1 in each eye daily.
Hydroxyquinone. 4% cream: apply
12H.
637
Drug Doses
Hyaluronic acid. Gel 20mg/ml: 0.71.4ml injctd in wrinkles.

Hyaluronidase. Hypodermoclysis:
add 1-1.5u/ml fluid. Local anaesthesia: add 50u/ml soltn.
Hydralazine. 0.1-0.2mg/kg (adult
5-10mg) stat IV or IM, then
4-6mcg/kg/min (adult 200300mcg/min) IV. Oral: 0.4 mg/
kg (adult 20mg) 12H, slow incr to
1.5mg/kg (max 50mg) 6-8H.
Hydrochloric acid. Use soltn of
100mmol/L (0.1M = 0.1N =
100mEq/L); give IV by central line
only. Alkalosis: dose(ml) = BE x Wt
x 3 (give half this); maximum rate
2ml/kg/hr. Blocked central line:
1.5ml/lumen over 2-4hr.
Hydrochlorothiazide. 1-1.5mg/kg
(adult 25-50mg) 12-24H.
Hydrochlorothiazide + quinapril.
10/12.5, 20/12.5. Adult (NOT/kg):
10/12.5 tab daily oral, incr if reqd
to 20/12.5 tab, max two 10/12.5
tab daily.
Hydrochlorothiazide + telmisartan.
(12.5mg/40mg, 12.5/80, 25/80).
Adult (NOT/kg): 1 tab daily oral.
Hydrochlorothiazide + valsartan (12.5mg/80mg, 12.5/160,
25/160). Adult (NOT/kg): 1 tab
daily oral.
Hydrocodone. 0.1-0.2mg/kg (max
10-15mg) 4-6H oral.
Hydrocortisone. Usually 0.5-2mg/kg
(adult 25-50mg) 6-8H oral, reducing as tolerated. 0.5%, 1% cream,
ointment: apply 6-12H. 1% cream
+ clioquinol: apply 8-24H. 10%
rectal foam: 125mg/dose. 2.5%
eye ointment: apply 6H.
Hydrocortisone sodium succinate.
2-4mg/kg 3-6H IM, IV reducing
as tolerated. Physiological: 5mg/
m2 6-8H oral; 0.2mg/kg 8H IM,
IV. Physiological, stress: 1mg/kg
6H IM, IV.
Hydrocortisone 1% + pramocaine
1%. Cream, foam: apply 8-12H
after defaecation.
Drug Doses
Hydroxyurea. 80mg/kg oral every

3rd day, or 20-30mg/kg daily.
CNS tumors: 1.5-3g/m2 oral stat,
in 2wk, then every 4-6wk. Sickle
cell: 15mg/kg daily, incr by 5mg/kg
every 12wk to max 35mg/kg daily.
Hydroxyzine. 0.5-2mg/kg (adult
25-100mg) 6-8H oral. 0.5-1mg/kg
(adult 25-100mg) 4-6H if reqd IM.
Hylan. 8mg inj into knee wkly x3;
max 6 doses in 6mo.
Hyoscine hydrobromide (scopolamine hydrobromide). 6-8mcg/kg
(adult 400-600mcg) 6-8H IV, IM,
SC. Motion sickness 300mcg tab
(NOT/kg): 0.25 tab (2-7yr), 0.5 tab
(7-12yr), 1-2 tab (>12yr) 6-24H
oral 30 min before, may repeat in
4hr. Transdermal (1.5mg patch):
>10yr 1 every 72hr.
Hyoscine hydrobromide (0.4mg/
ml) + papaveretum (20mg /ml).
0.008 mg/kg (H) + 0.4 mg/kg (P) =
0.02ml/kg/dose IM.
Hyoscine methobromide (methscopolamine). 0.2mg/kg (adult
2.5-5mg) 6H oral.
Hyoscine butylbromide. 0.5 mg/
kg (adult 20-40mg) 6-8H IV, IM
or oral.
Hyoscyamine (L-atropine). 2-5mcg/
kg (adult 100-300 mcg) 4-6H oral,
sublingual, IM or IV.
Hypromellose. 0.5% soltn: 1 drop/
eye prn.
Hypromellose 0.3% + dextran 70
0.1%. 1 drop/eye prn.
Ibandronate (ibandronic acid).
Adult, NOT/kg. Hypercalcaemia:
2-4mg IV over 2hr once. Osteoporosis: 2.5mg daily, or 150mg
each month oral; or 3mg IV bolus
evey 3mo.
Ibopamine. 1.5-3mg/kg 8H oral.
Ibritumomab. Adult (NOT/kg). Dosimetric dose (after rituximab): 5.5
mCi of In-111 labelled ibritumomab IV over 10min. Therapeutic
dose of Y-90 ibritumomab based
on response to dosimetric dose
and platelet count.
Ibuprofen. 5-10mg/kg (adult 200400mg) 4-8H oral, IV. Arthritis:

10mg/kg (adult 400-800mg) 6-8H.
Cystic fibrosis: 20-30mg/kg 12H.
PDA: 10mg/kg stat, then 5mg/kg
after 24 and 48 hr IV over 15min.
Ibutilide. 0.017mg/kg (max 1mg) IV
over 10min, then wait 10min and
repeat once if reqd.
Ichthammol. 1-10% cream, ointment. Apply 6-8H.
Icodextrin 7.5% in electrolyte soltn.
Adults: 1.5-2.5 litres as once daily
replacemnt for a 6-12hr glucose
dialysis.
Icatibant. Adult (NOT/kg): 30mg SC.
Idarubicin. 12mg/m2 IV over 15min
daily for 3 days.
Idebenone. Adult (NOT/kg): 30mg
8H oral.
Idinavir. 500mg/m2 (adult 800mg)
8H oral (minimum trough 100ng/
ml).
Idoxuridine. 0.1% eye drops: 1 drop
every 15min for 2hr, then hourly
by day and 2H at night. 0.1% soltn
or 0.5% ointment: apply hourly
first 24hr, then 4H.
Idursulfase. 0.5mg/kg weekly IV
over 1-3hr.
Ifosfamide. Usually 1.2-2.0g/m2
IV over 4hr daily x5, or 5-6 g/
m2 (max 10g) IV over 24hr once.
Repeat every 2-4wk.
Iloperidone. Adult (NOT/kg): 1mg
12H, incr to 6-12mg 12H oral.
Iloprost. IV: 0.2ng/kg/min incr every
4-6hr to 2ng/kg/min (up to 10ng/
kg/min rarely). Inhaltn (NOT/kg):
2.5-5mcg x6-9/day.
Imatinib. Adult (NOT/kg): 400mg
daily (chronic CML), 600mg daily
(blast crisis) or 400mg 12H (unresponsive blast) oral.
Imidapril. 0.1mg/kg (adult 5mg) daily oral, incr if reqd to 0.2-0.3mg/
kg (adult 10-20mg) daily.
Imiglucerase. Usual initial dose
60u/kg every 2wk IV over 2hr,
adjusted according to response;
reduce every 3-6mo.
638
Immunoglobulin, rabies (Hyperab,

Imogam). 20iu (0.133 ml)/kg IM
once (half SC around wound),
with rabies vaccine.
Immunoglobulin, Rh (anti-D). 1ml
(625iu, 125mcg) IM within 72hr
of exposure. Large transfusion:
0.16ml (100iu, 20mcg) per ml RH
positive red cells (maternal serum
should be anti-D positive 24-48hr
after injection).
Immunoglobulin, respiratory syncytial virus. 750mg/kg every month
IV (50mg/ml: 1.5ml/kg/hr for
15min, 3ml/kg/hr for 15min, then
6ml/kg/hr).
Immunoglobulin, subcutanoeus
(SCIG). Multiply previous IV immunoglobulin dose by 1.37, and
divide this into weekly doses.
Usually 100-200mg/kg by SC infusion weekly.
Immunoglobulin, tetanus (TIG). IM
preparation, prophylaxis: 250500iu (1-2amp). IV preparation,
treatment: 4000iu (100ml) at
0.04ml/kg/min for 30min, then
0.075 ml/kg/min IV; intrathecal
usually 250iu.
Immunoglobulin, zoster. 1iu
1.5mg. Within 96hr of exposure:
0-10kg 300mg, 11-30kg 600mg,
>30kg 900mg IM.
Indacaterol. Adult (NOT/kg): 120mcg
(max 300mcg) cap daily using
special inhaler.
Indapamide. 0.03-0.05mg/kg (adult
1.5-2.5mg) daily oral.
Indapamide 1.25mg + perindopril
5mg. Adult (NOT/kg): 1 tab daily
oral.
Indinavir (IDV). >28 days: 500mg/
m2 (adult 800mg) 8H oral.
Indinavir + ritonavir (LPVr). >18yr:
IDV 800mg + RTV 100-200mg
12H oral.
Indocyanine green. IV. Dye dilutn:
0.1mg/kg (adult 5mg). Pulsion
monitor: 0.25-0.5mg/kg. Liver
functn: 0.5mg/kg.
639
Drug Doses
Imipenem (+ cilastatin). 15mg/kg

(adult 500mg) 6H IV over 30min.
Severe inftn: 25mg/kg IV over 1hr
(adult 1g) 12H (1st wk life), 8H
(2-4 wk), 6-8H or constant infsn
(4+ wk).
Imipramine. 0.5-1.5mg/kg (adult
25-75mg) 8H oral. Enuresis:
5-6yr 25mg, 7-10yr 50mg, >10yr
50-75mg nocte.
Imiquimod. 5% cream: apply x2-3/
wk (max 16wk) before bed; wash
off after 6-10hr. Molluscum: 0.2%
cream x3/wk.
Immunoglobulin. See also antivenoms.
Immunoglobulin, CMV. 100-200mg/
kg IV over 2hr. Transplant: daily
for first 3 days, wkly x6, monthly
x6.
Immunoglobulin, diphtheria. 250u
IM once.
Immunoglobulin, hepatitis B.
400u IM within 5 days of needle
stick, repeat in 30 days; 100u IM
within 24hr birth to baby of Hep
B carrier.
Immunoglobulin, antilymphocyte
(thymocyte). Horse (Atgam): 1015mg/kg daily for 3-5 days IV over
4hr; occasionally up to 30mg/kg
daily. Rabbit (ATG-Fresenius): 2.55mg/kg daily over 4-6hr IV.
Immunoglobulin, normal, human.
Hypogammaglobulinaemia: 1015ml/kg of 6% soltn (600-900mg/
kg) IV over 5-8hr, then 5-7.5 ml/
kg (300-450mg/kg) over 3-4hr
monthly; or 0.6ml/kg of 16% soltn
(100mg/kg) every 2-4wk IM. Sepsis: 0.5g/kg IV over 4hr. Kawasaki,
Guillain-Barre, ITP, myasth gravis,
Stills dis: 35ml/kg of 6% soltn
(2g/kg) IV over 16hr stat, then if
required 15 ml/kg (900mg/kg) IV
over 8hr each month. Prevention
hep A: 0.1ml/kg (16mg/kg) IM.
Prevention measles: 0.2ml/kg
(32mg/kg) IM (repeat next day if
immunocompromised).
Drug Doses
Indomethacin. 0.5-1mg/kg (adult

Interferon alfa-2a, recombinant.
25-50mg) 8H (max 6H) oral or PR.
Haemangioma: 1 million u/m2
PDA: 0.1mg/kg (<1kg) or 0.2mg/
daily SC or IM incr over 4wk to
kg (>=1kg) day 1, then 0.1mg/kg
2-3 million u/m2 daily for 16daily days 2-7 oral or IV over 1hr.
24wk, then x3/wk. Hep B, C: 3-6
Indoramin. 0.5-1.5mg/kg (adult 25million u/m2 x3/wk SC or IM for
75mg) 8-12H oral.
4-6mo; higher doses may be reqd
Infliximab. 3mg/kg (arthritis, with
in hep B.
methotrexate) 5mg/kg (Crohns)
Interferon alfa-2b, recombinant.
IV over 2hr, then (if response)
Condylomata: 1 million unit into
after 2wk, 6wk, and then 5-10mg/
each lesion (max 5) x3/wk for
kg every 8wk.
5wk. Haemangioma: as for interInfluenza A and B vaccine (Fluvax,
feron alfa-2a. Hep B: monotherVaxigrip). Inanimate. 0.125ml
apy as for interferon alfa-2a. Hep
(3mo-2yr), 0.25ml (2-6yr), 0.5ml
C (adult, NOT/kg) 3 million unit
(>6yr) SC stat and 4wk later (2
x3/wk SC, plus ribavirin 1000mg
doses). Boost annually (1 dose).
(1200mg if >75kg) daily oral, for
Influenza A and B live nasal vaccine
24-48wk.
(Flumist). >5yr: 0.25 ml/nostril;
Interferon alfa-2a / alfa-2b, perepeat after 6wk if aged 5-8yr and
gylated. See peginterferon.
previously unimmunised. Boost
Interferon alfa-n3. Warts (NOT/kg):
annually (1 dose).
250,000u injected into base of
Inosine acedoben dimepranol.
wart (max 10 doses/session) x2/
Herpes, genital warts: 20 mg/
wk for max 8wk.
kg (adult 1g) 6-8H oral. SSPE: 10Interferon alfacon-1. Hepatitis C
15mg/kg 4H oral.
(adult, NOT/kg): usually 9mcg
Inositol nicotinate. 20mg/kg (adult
(7.5mcg if not tolerated) x3/wk SC
1g) 6-8H oral.
for 24wk; if relapse 15mcg x3/wk
Insulin. Regular insulin IV: 0.025SC for 6mo.
0.1u/kg prn, or 0.025-0.1 u/kg/
Interferon beta-1a. Mult scler
hr (2.5u/kg in 50ml 4% albumin
(adult, NOT/kg): Avonex 30mcg
at 0.5-2ml/hr); later 1u/10g dex(6 million IU) once a wk IM, Rebif
trose. For hyperkalaemia: 0.1u/kg
44mcg x3/wk SC.
insulin and 2ml/kg 50% dextrose
Interferon beta-1b. Mult scler
IV. In TPN: 5-25u/250g dextrose.
(adult, NOT/kg): 250mcg (8 milSC insulin (onset/peak/duration):
lion IU) SC alternate days.
glulisine, lispro 10-15min/1hr/
Interferon gamma-1b. Chronic
2-5hr; aspart 15-20min/1hr/3gran dis: 1.5mcg/kg (body area
5hr; inhaled 10-15min/1hr/6hr;
<=0.5m2) or 50mcg/m2 (area
regular -1hr/2hr/6-8hr; detemir
>0.5m2) x3/wk SC.
1-2hr/flat/24hr; glargine 1-2hr/
Interleukin-2. See aldesleukin.
flat/24hr; isophane (NPH)
Iobenguane (iodine 123). 5.8 mCi
2-4hr/4-12 hr/18-20hr; zinc
per m2 IV over 2min.
(lente) 2-3hr/7-15hr/24hr; crysIodoquinol. See di-iodohydroxyquitalline zinc (ultralente) 4-6hr/10noline.
30hr/24-36hr; protamine zinc 4-8
Ipecacuanha syrup (total alkaloids
hr/ 15-20hr/24-36hr.
1.4mg/ml). 1-2ml/kg (adult 30ml)
Insulin (Exubera). Initially 30-39kg
stat oral, NG. May repeat once in
1mg, 40-59kg 2mg, 60-79kg 3mg,
30min.
80-99kg 4mg, inhaled 10min
before meal.
640
Isoprenaline. IV infsn: <33kg

0.3mg/kg in 50ml 5%dex-hep
at 0.5-10ml/hr (0.05-1mcg/kg/
min); >33kg give 1/5000 (0.2 mg/
ml) soltn at 0.015-0.15ml/kg/hr
(0.05-0.5mcg/kg/min).
Isoproterenol. See isoprenaline.
Isosorbide dinitrate. Sublingual:
0.1-0.2mg/kg (max 10mg) 2H
or as needed. Oral: 0.5-1mg/
kg (max 40mg) 6H or as needed.
Slow release tab, adult (NOT/kg):
20-80mg 12H. IV infsn 0.6-2mcg/
kg/min.
Isosorbide mononitrate. Slow
release tab, adult (NOT/kg): 60120mg daily oral.
Isotretinoin. Adult: 0.5-1mg/kg
daily oral for 2-4wk, reducing if
possible to 0.1-0.2mg/kg daily for
15-20wk. 0.05% gel: apply sparingly at night.
Isoxsuprine. 0.2-0.5mg/kg (adult
10-20mg) 6-12H oral.
Ispaghula husk. Adult (NOT/kg): 1-2
x5ml teaspoonfuls 6-12H oral.
Half this dose 6-12yr.
Isradipine. 0.05mg/kg 12H oral, may
incr after 2-4wk gradually to 0.10.2mg/kg (max 10mg) 12H.
Itraconazole. 2-5mg/kg (adult
100-200mg) 12-24H oral after
food. Trough level >0.5 mcg/ml at
10-14 days.
Ivabradine. 0.1mg/kg (adult 5mg)
12H oral, range 0.05-0.15 mg/kg
(adult 2.5-7.5mg) 12H.
Ivermectin. 0.2-0.4mg/kg (adult 1224mg) oral; for head lice, repeat
after 7-10 days.
Ixabepilone. 40mg/m2 IV over 3hr
every 21 days for median of 4
cycles. Vary dose with CYP3A4
inhibitors or inducers.
Japanese encephalitis vaccine.
Inanimate. Ixiaro: adult 0.5ml
IM stat and 28 days later. JE-Vax:
0.5ml (1-3yr), 1ml (>3yr) SC stat,
7-14 days later, and (optionally)
1mo later. Boost after 1yr.
641
Drug Doses
Ipratropium bromide. Resp soltn

(250mcg/ml): 0.25-1ml diluted
to 4ml 4-8H; severe attack every
20min for 3 doses, then 4-6H.
Aerosol 20mcg/puff: 2-4 puffs
6-8H. Nasal: 84mcg/nostril 6-12H.
Irbesartan. 3mg/kg (adult 150mg)
daily oral, incr to 6mg/kg (adult
300mg) daily if reqd.
Irinotecan. 350mg/m2 IV over 90min
every 3wk; reduce to 250-300mg/
m2 every 3wk if toxicity.
Iron. See ferric salts, ferrous salts.
Iron dextran, iron polymaltose, iron
sucrose. Fe 50mg/ml: dose (ml)
= 0.05 x Wt in kg x (15 - Hb in g%)
IM (often in divided doses). IV
infsn possible (but dangerous).
Isocarboxazid. Adult (NOT/kg): 10mg
12H oral, incr over 1wk to 20mg
12H; then incr if reqd over 2wk to
max 30mg 12H.
Isoconazole. 1% cream 12H. Vaginal:
600mg (2 tab) once.
Isoetharine. Inhaltn soltn (1%):
0.5ml diltd to 4ml 3-6H (mild),
1ml diltd to 4ml 1-2H (moderate),
undiltd constant (severe, in ICU).
Aerosol 340mcg/puff: 1-2 puffs
4-6H.
Isoflurane. 1.5-3% for induction,
then 1-2.5% inhalation.
Isometheptene. 2.5mg/kg (max
130mg) stat, then 1.5mg/kg (max
65mg) 1H to max 7mg/kg (max
325mg) in 12hr oral. See also
dichloralphenazone.
Isoniazid (INAH). 10mg/kg (max
300mg) daily oral, IM or IV. TB
meningitis: 15-20mg/kg (max
500mg) daily.
Isoniazid 50mg + pyrazinamide
300mg + rifampicin 120mg tab.
30-39kg x3, 40-49kg x4, 50-64kg
x5, 65kg x6tab daily.
Isoniazid + rifampicin. 30-49kg
150mg/100mg tabs x3 daily,
50kg 300mg/150mg tabs x2
daily oral.
Drug Doses
Kanamycin. Single daily dose IV

or IM. Neonate: 15mg/kg stat,
then 7.5mg/kg (<30wk) 10mg/
kg (30-35wk) 15mg/kg (term
<1wk) daily. 1wk-10yr: 25mg/kg
day 1, then 18mg/kg daily. >10yr:
20mg/kg day 1, then 15mg/kg
(max 1.5g) daily. Trough level
<5.0mg/L.
Ketamine. Sedation, analgesia:
2-4mg/kg IM, 4mcg/kg/min IV.
Premed: 5mg/kg oral. Anaesthesia: 5-10mg/kg IM, 1-2mg/kg IV,
infsn 30mg/kg in 50ml 5%dex-hep
at 1-4ml/hr (10-40mcg/kg/min).
Incompatible with aminophylline,
magnesium and salbutamol.
Ketanserin. IV: 0.5-5mcg/kg/min
(max 150mg/day). Oral 0.5 mg/kg
(max 20mg), incr to max 1mg/kg
(max 40mg) 12H.
Ketoconazole. Oral: 5mg/kg (adult
200mg) 12-24H. 2% cream: apply
12-24H. 2% shampoo: wash hair,
apply liquid for 5min, wash off.
Ketoprofen. 1-2mg/kg (adult 50100mg) 6-12H (max 4mg/kg or
200mg in 24hr) oral, IM, PR. Slow
release, adults (NOT/kg): 200mg
daily.
Ketoprofen + omeprazole (100/20,
200mg/20mg). Adult (NOT/kg) 1
modified-release cap daily oral.
Ketorolac. Oral: 0.2mg/kg (adult
10mg) 4-6H (max 0.8mg/kg/day
or 40mg/day). IV or IM: usually
0.2mg/kg (adult 10mg) 6H; but
may use 0.6mg/kg (max 30mg)
stat, then 0.2-0.4mg/kg (max
20mg) 4-6H for 5 days, then
0.2mg/kg (max 10mg) 6H. Eye
drops 0.5%: 1 drop 8H.
Ketotifen. Child >2yr (NOT/kg): 1mg
12H oral with food. Adult (NOT/
kg): 1-2mg 12H oral with food.
Labetalol. Oral: 1-2mg/kg (adult
50-100mg) 12H, may incr wkly to
max 10mg/kg (max 600mg) 6H.
IV: 0.25-0.5mg/kg (adult 20mg)
over 2min repeated every 10min
if reqd, then 0.25-3mg/kg/hr.
Lacidipine. 0.04-0.12mg/kg (adult

2-6mg) daily oral.
Lacosamide. 1mg/kg (adult 50mg)
12H, incr weekly if reqd to
2-4mg/kg (adult 100-200mg) 12H
IV over 1hr or oral.
Lactase. See tilactase.
Lactitol. 0.1-0.3g/kg (adult 10-20g)
1-3 times a day oral.
Lactulose. 3.3g/5ml soltn. Laxative:
0.5ml/kg 12-24H oral. Hepatic
coma: 1ml/kg hrly until bowel
cleared, then 6-8H.
Lamivudine (3TC). Neonate <30
days: 2mg/kg 12H oral. Child >30
days: 4mg/kg 12H oral. Adult
<50kg: 2mg/kg 12H oral. Adult
>50kg: 150mg 12H or 300mg
daily oral. Hepatitis B: 3-4 mg/kg
(max 100mg) daily oral. See also
abacavir.
Lamivudine 150mg + zidovudine
300mg (Combivir). 30kg 1 tab
12H oral.
Lamotrigine. 0.2mg/kg (adult 25mg)
oral daily, double dose every 2wk
if reqd to max 1-4mg/kg (adult
50-200mg) 12H. Double dose if
taking carbamazepine, phenobarbitone, phenytoin or primidone;
halve dose if taking valproate.
Lanreotide. 0.5-1.0mg/kg (adult
30mg) IM every 2wk (adjust dose,
frequency according to response).
Lansoprazole. 1.5mg/kg (max 30mg)
12-24H oral.
Lanthanum carbonate. Adult (NOT/
kg) 0.5-1g 8H with meal.
Lapatinib. Adult, NOT/kg: 1.25g
every day oral (plus capecitabine
2g/m2/day on days 1-14 of a
repeating 21 day cycle).
Laronidase. 0.58mg/kg IV once /wk.
Laropiprant + nicotinic acid. Adult
(NOT/kg). 20mg/1g tabs:1 tab
daily oral, incr to 2 tab daily after
4wk.
L-asparaginase. See colaspase.
Latanoprost. 50mcg/ml: 1drop/eye
daily.
642
Levobunolol. 0.25%-0.5% soltn:

1drop/eye 12-24H.
Levobupivacaine. See bupivacaine.
Levocabastine. 0.5mg/ml: 1drop/
eye 6-12H max 8wk, 2 sprays/
nostril 6-12H max 8wk.
Levocarnitine. See carnitine.
Levocetirizine. NOT/kg: 2.5mg (611yr) 5mg (adult) daily.
Levodopa + benserazide (4:1).
Adult (NOT/kg): initially levodopa
100mg 8H oral; if not controlled,
incr wkly by 100mg/day to max
250mg 6H.
Levodopa + carbidopa.
250mg/25mg and 100mg/10mg
tabs. Adult (NOT/kg): initially
one 100/10 tab 8H oral; if not
controlled, substitute one 250/25
tab for one 100/25 tab every 2nd
day; if not controlled on 250/25
8H, incr by one 250/25 tab every
2nd day to max 6-8 tab/day.
Levofloxacin. 5-10mg/kg (adult 250500mg) 12-24H oral or IV over
1hr. Eye 5mg/ml: 1drop x8/day
for 2 days, then 6H.
Levofolinate, levofolinic acid,
levoleucovorin. Half the dose of
calcium folinate.
Levomepromazine. See methotrimeprazine.
Levomethadyl acetate. Adult (NOT/
kg): usual starting dose 20-40mg
every 2-3 days oral.
Levonorgestrel. Contraception:
30mcg daily oral, starting 1st day
menstruation. Intrauterine Tsystem 52mg: insert within 7 days
of start of menstruation, replace
after 3yr. Post-coital: 1.5mg oral
within 72hr; or 0.75mg within
72hr, repeated after 12hr; or
0.5mg + ethinyloestradiol
100mcg oral within 72hr, repeat
in 12hr. See also ethinyloestradiol
+ levonorgestrel, oestradiol +
levonorgestrel.
Levorphanol. 0.03-0.1mg/kg 12-24H
oral or SC.
643
Drug Doses
Latanoprost 0.005% + timolol 0.5%.

1drop per eye daily.
Laureth-9. Spider veins: inject
0.1-0.2ml of 0.5% (10mg /2ml).
Small varices: 0.1-0.3ml of 1%
(20mg/2ml). Medium varices:
0.5-1ml of 3% (60mg/2ml). Max
2mg/kg/day.
Lauromacrogol. See heparinoid +
lauromacrogol ointment.
L-carnitine. See carnitine, L form.
Leflunomide. Adult (NOT/kg):
100mg daily x3, then 20mg daily
oral.
Lenalidomide. Adult (NOT/kg): 10mg
daily oral; or 25mg daily on days
1-21 of 28 day cycles.
Lenograstim (rHuG-CSF, Granocyte).
150mcg/m2 daily SC or IV over
30min. Keep WCC 5,000-10,000/
mm3.
Lepirudin. 0.4mg/kg IV stat, then
0.15mg/kg/hr (adjusted by APTT)
for 2-10 days.
Lercanidipine. 0.2mg/kg (adult
10mg) daily oral, incr to 0.4mg/kg
(adult 20mg) daily if reqd.
Letrozole. Adult (NOT/kg): 2.5mg
daily oral.
Leucovorin. See folinic acid.
Leuprolide. See leuprorelin.
Leuprorelin (GnRH or LHRH). Adult
(NOT/kg): 7.5mg depot injn
monthly IM; or microspheres
11.25mg SC every 3mo.
Levalbuterol (levosalbutamol). See
salbutamol.
Levamisole. Anthelmintic: 3mg/kg
(adult 150mg) oral once (ascaris),
repeat in 1wk (hookworm).
Adenocarcinoma colon (with
5-fluorouracil 450mg/m2 IV wkly):
1mg/kg (adult 50mg) 8H oral for 3
days every 2wk.
Levetiracetam. 10mg/kg (adult
500mg) 12H oral, incr every
2-4wk to max 30mg/kg (adult
1500mg) 12H if reqd.
Levobetaxolol. 0.5% soltn: 1drop/
eye 12H.
Drug Doses
Levosimendan. 0.3mg/kg (adult

0.15-0.3mg/kg) in 6ml/kg 5%dex
(no heparin) and give 1.5ml/kg/
hr for 10min (12.5mcg/kg), then
0.24ml/kg/hr (0.2mcg/kg/min;
adult 0.1-0.2mcg/kg/min) for
24hr IV. Via CVC or peripheral IV;
compatible only with frusemide
or GTN.
Levothyroxine sodium. See thyroxine.
Lidocaine. See lignocaine.
Lignocaine. IV: 1% soltn 0.1ml/kg
(1mg/kg) over 2min, then 0.090.3ml/kg/hr (15-50mcg/kg/min);
or 30mg/kg in 50ml 5%dex-hep at
50ml/hr for 2min, then 1.5-15ml/
hr (15-50mcg/kg/min). Nerve
block: without adrenaline max
4mg/kg (0.4ml/kg of 1%), with
adrenaline 7mg/kg (0.7ml/kg of
1%). Topical spray: max 3-4mg/
kg (Xylocaine 10% spray pack:
about 10mg/puff). Topical 2% gel,
2.5% compound mouth paint/
gel (SM-33), 2% and 4% soltn, 5%
ointment, 10% dental ointment:
apply 3H prn.
Lignocaine 2.5% + prilocaine 2.5%.
Cream (EMLA): 1.5g/10cm2 under occlusive dressing for 1-3hr.
Lincomycin. 10mg/kg (adult 600mg)
8H oral, IM or IV over 1hr. Severe
inftn: 15-20mg/kg (adult 1.2g) IV
over 2hr 6H.
Lindane. 1% cream, lotion. Scabies:
apply from neck down, wash off
after 8-12hr. Lice: rub into hair for
4min, then wash off; repeat after
24hr (max x2/wk).
Linezolid. 10mg/kg 8-12H (child) or
400-600mg 12H (adult), IV over
1-2hr or oral.
Linoleic acid. See fatty acids.
Liothyronine sodium (T3). Oral:
0.2mcg/kg (adult 10mcg) 8H, may
incr to 0.4mcg/kg (adult 20mcg)
8H. IV: 0.1-0.4mcg/kg (adult
5-20mcg) 8-12H. Septic shock:
0.1-0.2mcg/kg/hr (adult 100200mcg/day) IV infsn.
Liotrix. Liothyronine (T3) plus thyroxine (T4) mixture.

Lipase, lipolytic enzymes. See pancreatic enzymes.
Lipid. 20%: 1-3g/kg/day IV (ml/hr =
g/kg/day x Wt x 0.21).
Liraglutide. Adult (NOT/kg): 0.6mg
daily SC for 1wk, then 1.2-1.8mg
daily.
Lisdexamphetamine dimesylate.
NOT/kg. 6-12yr: 30mg daily oral,
incr over 2-3wk to max 70mg
daily.
Lisinopril. 0.1mg/kg (adult 5mg)
daily oral, may incr over 4-6wk to
0.2-1mg/kg (adult 10-20mg) daily.
Lithium (salts). 5-20mg/kg
8-24H oral. Slow release tab
450mg (adult, NOT/kg): 1-2
tab 12H. Maintain trough level
0.8-1.6mmol/L (>2mmol/L toxic).
L-methylfolate. Adult (NOT/kg): 7.515mg daily oral.
Lodoxamide. 0.1% soltn: 1 drop/
eye 6H.
Lofepramide. Adult (NOT/kg): 70mg
morning, 70-140mg night oral.
Lofexidine. 2-8mcg/kg (adult 100400mcg) 6-12H oral.
Lomefloxacin. 8mg/kg (adult
400mg) daily oral.
Lomustine (CCNU). 100-130mg/m2
oral every 6 wk.
Loperamide. 0.05-0.1mg/kg (adult
2-4mg) 8-12H oral, incr if reqd to
max 0.4mg/kg (max 4mg) 8H.
Lopinavir + ritonavir (LPV/r). 2wk:
230/57.5 mg/m2 (max 400/100
mg) 12H oral. With efavirenz,
fosamprenavir, nelfinavir or
nevirapine (if 6mo): 300/75 mg/
m2 (max 600/150mg) 12H. Trough
lopinavir 1000ng/ml.
Lopinavir + ritonavir + saquinavir.
7-15yr: LPV 400mg/m2 + RTV
100mg/m2 + SQV 750mg/m2 12H
oral.
Loprazolam. Adult (NOT/kg): 1mg
(max 2mg) bedtime oral.
Loracarbef. 4-8mg/kg (adult 200400mg) 12H oral.
644
Lysuride. Migraine: 0.5mcg/kg (adult

25mcg) 8H oral. Parkinsons,
adults (NOT/kg): 0.2mg daily, incr
by 0.2mg daily each wk to max
1.6mg 8H oral.
Macrogol 3350, 105g/L. 2-11yr
6.563g in 60ml water, >11yr
13.125g in 125ml water: 1 sachet
daily oral, incr to 2-3/day if
reqd. Faecal impactn >2yr: one
13.125g sachet in 125ml water
per 5kg body wt (adult 8 sachet)
consumed in <6hr (max 3 days
therapy). See also colonic lavage.
Macrogol 400 (polyethylene glycol)
1% + tetrahydrozoline 0.05%. 1
drop/eye 8-12H.
Macrogol 4000. 8yr (NOT/kg): 1020g daily oral.
Mafenide acetate. 8.5% cream: apply 2mm layer 12-24H. 5% soltn:
apply 4-8H to keep dressings wet.
Maggots of Lucilia sericata, sterile.
Packs: standard (for standard
wound), boot (toe, amputation
stump), boot (foot), sleeve (limb
wound). Change maggots after 3
days; sooner if reqd. See www.
ZooBiotic.co.uk/products-LarvE.
htm
Magnesium alginate. See alginic
acid.
Magnesium aspartate (Magmin).
500mg tab = 1.5mmol Mg. Low
Mg: 5 tabs per m2 per day in
divided doses.
Magnesium chloride 10%.
0.48g/5ml = Mg 1mmol/ml. Low
Mg: 0.4ml/kg slow IV, then 0.3ml/
m2/hr. My infarct (NOT/kg): 5ml/
hr IV for 6hr, then 1ml/hr for 2448hr. VF: 0.06ml/kg IV.
Magnesium hydroxide. 58mg = Mg
1mmol. Low Mg: 7.5 mmol/m2/
day oral (1.4 ml/m2 6H of 78mg/
ml soltn). Antacid: 10-40mg/
kg (max 2g) 6H oral. Laxative:
50-100mg/kg (max 5g). See also
Al hydroxide + Mg hydroxide +
simethicone.
645
Drug Doses
Loratadine. NOT/kg: 5mg (2-5yr),

10mg (>5yr) daily oral.
Lorazepam. 0.02-0.06mg/kg (adult
1-3mg) 8-24H oral. IV: 0.050.2mg/kg IV over 2min, then
0.01-0.1mg/kg/hr.
Lormetazepam. Adult (NOT/kg):
0.5mg (max 1.5mg) at bedtime
oral.
Losartan. 0.5-2mg/kg (adult 25100mg) daily oral.
Loteprednol. NOT/kg. 0.5% 1-2
drops/eye 6H.
Lovastatin. 0.4-0.8mg/kg (adult
20-40mg) 12-24H oral. Slow
release (adult, NOT/kg): 10-60mg
at bedtime.
Lovastatin + slow-release
niacin (20/500mg, 20/750mg,
20/1000mg). 20mg/500mg at
bedtime oral, incr if reqd every
4wk by 500mg niacin to max
40mg/2000mg.
Loxapine. 0.2-1mg/kg (adult 1060mg) 6-12H oral, IM.
L-tryptophan. Adult (NOT/kg): 1-2g
8H oral.
Lubiprostone. Adult (NOT/kg):
8-24mcg 12H oral with food.
Lumefantrine (benflumetol). See
artemether.
Lumiracoxib. Adult, NOT/kg: 100mg
daily oral.
Lutropin alfa (luteinising hormone.
Adult (NOT/kg): 75iu daily SC,
with 75-150iu follicle stimulating
hormone.
Lymecycline. 408mg = 300mg
tetracycline base. Adult (NOT/kg):
408mg 12H oral.
Lymphocyte immune globulin. See
immunoglobulin, lymphocyte
immune.
Lynestrenol. Mentrual disorders
(NOT/kg): 5mg (max 15mg) daily
oral. Contraception: 0.5-2.5mg
daily.
Lypressin (lysine-8-vasopressin). 1
spray (2.5iu) into 1 nostril 4-8H,
may incr to 1 spray both nostrils
4-8H.
Drug Doses
Magnesium oxide. 40mg = Mg

1mmol. Low Mg:7.5 mmol/m2/
day oral (1.4 ml/m2 6H of 55mg/
ml soltn).
Magnesium sulphate 50% (2mmol/
ml). Low Mg: 0.2ml/kg IM or slow
IV, then 0.16ml/m2/hr. Asthma,
digoxin tachycardia, eclampsia,
prem labour, pul ht: 0.1ml/kg (50
mg/kg) IV over 20min, then 0.06
ml/kg/hr (30 mg/kg/hr); keep
serum Mg 1.5-2.5mmol/l (pul ht
3-4mmol/l). Myoc infarct (NOT/
kg): 2.5 ml/hr (5mmol/hr) IV for
6hr, then 0.5 ml/hr (1mmol/hr)
for 24-48hr. VF: 0.05-0.1ml/kg
(0.1-0.2 mmol/kg) IV. Incompatible with aminophylline, ketamine,
salbutamol. Laxative: 1ml/kg =
0.5g/kg (max 15g) as 10% soltn
8H for 2 days oral.
Malathion. See maldison.
Maldison. 0.5% liquid: 20ml to hair,
wash off after 12hr.
Mannitol. 0.25-0.5g/kg IV (2-4ml/
kg of 12.5%, 1.25-2.5ml/kg of
20%, 1-2ml/kg of 25%) 2H prn,
provided serum osmolality
<320-330mmol/L.
Maprotiline. 0.15-1mg/kg (adult
10-50mg) 8-24H oral.
Maraviroc (MVC). 16yr: 150mg
(with strong CYP3A inhibitors, incl
protease inhibitors), 300mg (with
tipranavir or ritonavir), 600mg
(with CYP3A inducers, incl efavirenz) 12H oral. Resistant HIV-1
trough >50 ng/ml.
Marimastat. Adult (NOT/kg): 5-25mg
(usual 10mg) 12H oral.
Mazindol. Adult (NOT/kg): 0.5mg
daily oral, up to 3mg daily.
Measles vaccine (Attenuvax). Live.
>12mo: 0.5ml SC once.
Measles + mumps vaccine (Rimparix). Live. >12mo: 0.5ml SC once.
Measles + mumps + rubella vaccine
(MMRII, Priorix). Live. >12mo:
0.5ml SC.
Mebendazole. NOT/kg: 100mg 12H

x3 days. Enterobiasis (NOT/kg):
100mg once, may repeat after
2-4wks.
Mebeverine. 135mg tab: adult
(NOT/kg) 1-3 tab daily oral.
Mebhydrolin. 1-2mg/kg (adult 50100mg) 8-12H oral.
Mecamylamine. 0.05mg/kg (adult
2.5mg) 12H oral; may incr to max
0.5mg/kg (adult 25mg) 6H oral.
Mecasermin. 40-80mcg/kg (max
120mcg/kg) 12H SC.
Mechlorethamine. See mustine HCl.
Meclizine. See meclozine.
Meclofenamate. 1-2mg/kg (adult
50-100mg) 6-8H oral.
Meclozine. 0.5-1mg/kg (adult 2550mg) 12-24H oral.
Mecysteine. Adult (NOT/kg): 200mg
8-12H oral.
Medroxyprogesterone. Adult (NOT/
kg): 5mg daily for 5-10 days per
month oral; precocious puberty
5-10mg daily; to achieve amenorrhoea 10-20mg daily; uterine
hge 60mg daily reducing over 10
days to 10mg; malignancy 0.5g
daily IM or oral for 4wk, then 1g
wkly. Depot contraceptive: 150
mg deep IM during 1st 5 days of
cycle, then repeat every 12wk.
See also conjugated oestrogens.
Medroxyprogesterone 10mg tab +
oestradiol 4mg patch. NOT/kg:
10mg tab daily oral for first 10-14
days of each 28 day cycle, and
4mg patch x2/wk continuously.
Medrysone. 1% soltn: 1 drop/eye
6-12H.
Mefenamic acid. 10mg/kg (adult
500mg) 8H oral.
Mefloquine. 15mg/kg (adult 750mg)
after 6-8hr. Prophylaxis: 5mg/kg
(adult 250mg) wkly.
Mefruside. 0.5-1mg/kg (up to 2mg/
kg for 3 days) daily 10-14 days,
then 0.5-1mg/kg (adult 25-50mg)
every 2-3 days.
646
Mequitazine. 0.1mg/kg (adult 5mg)

12H oral.
Mercaptamine. See cysteamine.
Mercaptopurine (6MP). 75-100mg/
m2 daily oral.
Meropenem. 10-20mg/kg (adult
0.5-1g) 8H IV over 5-30min.
Severe inftn: 20-40mg/kg (adult
1-2g) 12H (1st wk life) 8H (>1wk)
or constant infsn.
Mesalamine. See mesalazine.
Mesalazine. Usually high initial
dose, lower maintenance.
Mesasal, Salofalk: 15-20mg/kg
(adult 500mg) 8H, decr to 10mg/
kg (adult 250mg) 8H oral. Adult,
NOT/kg: 0.4-1.6g 8H (Asacol, Coltec); 0.5-1g 6H (Pentasa); slowrelease 1.5g (Apriso) 2.4-4.8g
(Lialda) daily oral. Suppos: 0.5-1g
8H. Enema: 1-4g nocte.
Mesna. IV over 30min: 20% of
cyclophosphamide or ifosfamide
dose at 0, 4 and 6 hr. Oral: 40% of
dose of cytotoxic at -2, 2 and 6hr.
Nebulisr: 0.6-1.2g (NOT/kg) 4-6H.
Mesoridazine. Oral: 0.25-3mg/kg
(adult 25-150mg) 8H. IM: 0.5mg/
kg (adult 25mg, max 200mg/day).
Mesterolone. 0.5mg/kg (adult
25mg) 6-12H oral.
Mestranol 50mcg + norethisterone
1mg. Contraception: 1 tab daily
from 5th to 25th day of menstrual
cycle.
Metaproterenol. See orciprenaline.
Metaraminol. IV: 0.01mg/kg stat
(repeat prn), then 0.15 mg/kg in
50ml 5% dextrose (no heparin) at
1-10ml/hr (0.05-0.5 mcg/kg/min)
and titrate dose against BP. SC:
0.1mg/kg.
Metaxalone. 15mg/kg (max 800mg)
6-8H oral.
Metformin. Adult (NOT/kg): initially
500mg 8-24H oral, max 1g per
dose 8H. See also glibenclamide.
Metformin + rosiglitazone (500/2,
1000/2, 1000mg/4mg). Adult:
1000/2 (1000/4 after 8wk if reqd)
1 tab 12H oral.
647
Drug Doses
Megestrol acetate. NOT/kg: 80mg

per dose 12H oral.
Meglumine antimonate. Soltn
85mg/ml of pentavalent antimony. Same dose as sodium
stibogluconate, deep IM.
Melatonin. Usually 0.1mg/kg (adult
6mg) at night oral.
Meloxicam. 0.15-0.3mg/kg (adult
7.5-15mg) daily oral, PR.
Melphalan. Usually 6mg/m2 daily
x5, repeat every 6wk.
Memantine. Adult (NOT/kg): 5mg
daily oral, incr by 5mg wkly to
max 10mg 12H.
Menadiol, menadione. See menaphthone sod bisulphate.
Menapthone sodium bisulphite (vitamin K3). NOT/kg: 5-10mg x1-2/
wk (infant) 10mg daily (child)
10mg 8H (adult) oral. Mitochondrial dis (all ages, not/kg): 10mg
6H oral.
Meningococcus gp A, C, W135, Y
vaccine (Mencevax ACWY).
Inanimate. >2yr: 0.5ml SC. Boost
1-3yrly.
Meningococcus gp A, C, W135 , Y
conjugate vaccines. Inanimate.
Menactra 2-55yr 0.5ml IM.
Menveo 11-55yr 0.5ml IM. Menomune 2yr 0.5ml SC..
Meningococcus gp C, conjugate
vaccine (Meningitec, Menjugate,
NeisVac-C). Inanimate. 0.5ml
IM: 3 doses 1-2mo apart (6wk6mo), 2 doses (6-12mo), 1 dose
(>12mo).
Mepenzolate. Adult (NOT/kg): 2550mg 6H oral.
Meperidine. See pethidine.
Mephenytoin. See methoin.
Mephobarbital. See methylphenobarbitone.
Mepivacaine. Max dose 5-7mg/kg.
Meprobamate. 5-10mg/kg (max
800mg) 8-12H oral.
Meptazinol. 4mg/kg (adult 200mg)
3-6H oral.
Mepyramine. 2-4mg/kg (adult 100200mg) 8H oral.
Drug Doses
Metformin + sitagliptin (500/50,

Methotrimeprazine. 0.25-1mg/
1000mg/50mg). 1-2 cap 12H
kg (adult 12.5-50mg) 6-8H oral,
(max 2000mg/100mg a day) oral.
IM or IV. Up to 1g/day in severe
Metformin + vildagliptin.
psychosis.
50mg/850mg or (if tolerated)
Methoxamine. 0.1-0.4mg/kg (adult
50mg/1000mg 12H oral.
5-20mg) IM, or 0.1-0.2 mg/kg
Methacycline. NOT/kg: 150mg (>8y)
(adult 5-10mg) IV over 5-10min
300mg (>12y) 12H oral.
(at least 15min between doses).
Methadone. 0.1-0.2mg/kg (adult
Nose drop 0.25%: 1-3drop/nostril
5-10mg) 6-12H oral, SC, IM.
6-12H.
Methamphetamine. See methylamMethoxsalen. Adult (NOT/kg): 20mg
phetamine.
2hr before UV exposure. 1%
Methazolamide. 1-2mg/kg (adult
lotion: wkly before 1min of UV
50-100mg) 8-12H oral.
light.
Methdilazine. 0.1-0.3mg/kg (adult
Methoxy polyethylene glycol-epoet4-16mg) 12-24H oral.
in beta. See epoetin.
Methenamine hippurate or mandeMethoxypsoralen. See methoxsalen.
late. See hexamine.
Methscopolamine. See hyoscine
Methenolone. Adult (NOT/kg). Oral:
methobromide.
5-10mg 12H. IM: 100mg every
Methsuximide. 5mg/kg (adult
1-2wk or 200mg every 2-3wk (car300mg) daily, may incr to max
cinoma); 50-100mg every 2wk,
10mg/kg (adult 400mg) 8-12H
then every 3-4wk (osteopor).
oral.
Methimazole. 0.3-1mg/kg (adult 20Methyl aminolevulinate. See ami60mg) daily oral, reducing to 0.1nolevulinic acid.
0.5mg/kg (adult 5-30mg) daily.
Methyclothiazide. 0.05-0.2mg/kg
Methionine. 50mg/kg (max 2.5g)
(adult 2.5-10mg) daily oral.
oral 4H for 4 doses. Prophylaxis:
Methylcellulose. Constipation: 301mg to paracetamol 5mg.
60mg/kg (adult 1.5-3g) with at
Methocarbamol. Oral: 30mg/kg
least 10ml/kg (adult 300ml) fluid
(adult 1.5g) 6H for 3 days, then
12H oral. Obesity: 30mg/kg (adult
15-20mg/kg (adult 0.75-1g) 6-8H.
1.5g) with 5ml/kg water hr
IV over 5-10 min or IM: 15mg/kg
before a meal.
(adult 750mg) 6H.
Methylcysteine. 4mg/kg (adult
Methohexital. See methohexitone.
200mg) 6-12H oral.
Methohexitone. 1-2mg/kg (adult
Methyldopa. 3mg/kg (adult 150mg)
50-120mg) slow IV.
8H oral, may incr to max 15mg/
Methoin. 1mg/kg (adult 50mg) daily
kg/dose (adult 750mg).
oral, may incr by 1mg/kg each wk
Methyldopate. 5-20mg/kg (adult
to max 10mg/kg (adult 600mg)
0.25-1g) 6H IV over 1hr.
daily.
Methylene blue. 1-2mg/kg (G6PD
Methotrexate. Leukaemia: typically
deficiency 0.4mg/kg) IV prn.
3.3mg/m2 IV daily for 4-6wk; then
Septic shock: 2mg/kg stat IV, then
2.5mg/kg IV every 2wk, or 30mg/
0.25-2mg/kg/hr.
m2 oral or IM x2/wk; higher doses
Methylergometrine. Adult (NOT/kg):
with folinic acid rescue. Intrathe200mcg IM, IV over 5min, or oral;
cal: 12mg/m2 wkly for 2wk, then
may repeat in 2hr, then 4-6H.
monthly. Arthritis: 10-20mg/m2
Methylergonovine. See methylergowkly oral, IV, IM or SC. Adult psometrine.
riasis: 0.2- 0.5mg/kg wkly oral, IV
Methylnatrexone. 0.15mg/kg (adult
or IM until response, then reduce.
12mg) every 2nd day SC.
648
Drug Doses
Methylphenidate. 0.1mg/kg oral

Metolazone. 0.1-0.2mg/kg (adult
8am, noon and (occasionally)
5-10mg) daily oral. Up to 0.5mg/
4pm; incr if reqd to max 0.5mg/
kg (adult 30mg) daily short term.
kg/dose (adult 20mg). Long acting Metoprolol. IV: 0.1mg/kg (adult
(NOT/kg): child 10-60mg (adult
5mg) over 5 min, repeat
10-80mg) in morning. Transderevery 5 min to max 3 doses, then
mal patch: apply for up to 9hr;
1-5mcg/kg/min. Oral: 1-2mg/kg
start with 12.5cm2, and incr to
(adult 50-100mg) 6-12H.
18.75cm2, 25cm2, and 37.5cm2
Metronidazole. 15mg/kg (max 1g)
if rqd.
stat, then 7.5mg/kg (max 1g) 12H
Methylphenobarbitone. 4-12mg/kg
in neonate (1st maintenance dose
48hr after load if <2kg, 24hr in
Methylprednisolone. Asthma:
term baby), 8H (4+ wk) IV, PR or
0.5-1mg/kg 6H oral, IV or IM day
oral. Giardiasis: 30mg/kg (adult
1, 12H day 2, then 1mg/kg daily,
2g) daily x3 oral. Amoebiasis:
reducing to minimum effective
15mg/kg (adult 750-800mg) 8H
dose. Severe croup: 4mg/kg IV
oral for 10 days, usually followed
stat, then 1mg/kg 8H. Severe
by diloxanide furoate 10mg/
sepsis before antibiotics (or
kg (adult 500mg) 8H oral for 10
within 4hr of 1st dose): 30mg/kg
days. C.difficile: 10mg/kg (adult
IV once. Spinal cord injury (within
500mg) 8H oral. Topical gel 0.5%:
8hr): 30mg/kg stat, then 5mg/
apply daily. Level 60-300umol/ml
kg/hr 2 days. Lotion 0.25%: apply
(x0.17mcg/ml).
sparingly 12-24H. Methylpred
Metyrapone. Diagnosis: 15mg/kg
1mg = hydrocortisone 5mg in
(minimum 250mg) 4H x6 dose
glucocorticoid activity, 0.5mg in
oral. Cushing: 1-20mg/kg (max
mineralocorticoid.
1g) 4H.
Methylprednisolone aceponate.
Metyrosine. See metirosine.
0.1% cream, ointment: apply
Mexiletine. IV infsn: 2-5mg/kg
12-24H.
(max 250mg) over 15 min, then
Methyltestosterone. NOT/kg: 2.55-20mcg/kg/min (max 250mg/
12.5mg/day buccal.
hr). Oral: 8mg/kg (max 400mg)
Methysergide. 0.02mg/kg (adult
stat, then 4-8mg/kg (max 400mg)
1mg) 12H oral, incr if reqd to max
8H starting 2hr after loading dose.
0.04mg/kg (adult 2mg) 8H for
Mezlocillin. 50mg/kg 6-8H (1st wk
3-6mo.
life), 4-6H (2+ wk) IM or IV. SeriMetipranolol. 0.1%, 0.3%, adult: 1
ous inftn: 60mg/kg (max 3g) 4H.
drop/eye 12H.
Mianserin. 0.2-0.5mg/kg (adult 10Metirosine. 5-20mg/kg (adult 0.2540mg) 8H oral.
1g) 6H oral.
Micafungin. Infant 10mg/kg, child
Metoclopramide. 0.15-0.3mg/kg
8mg/kg, adult 50-150mg daily
(adult 10-15mg) 6H IV, IM, oral;
IV over 1hr. Prophylaxis: 1mg/kg
0.2-0.4mg/kg (adult 10-20mg)
(adult 50mg) daily IV over 1hr.
8H PR. Periop: 0.5 mg/kg (adult
Miconazole. 7.5-15mg/kg (adult 0.615-20mg) IV stat, then 0.2mg/kg
1.2g) 8H IV over 1hr. Topical: 2%
(adult 10mg) 4-6H if reqd. With
cream, powder, lotion, tincture or
chemotherapy: up to 1-2mg/kg
gel 12-24H. Vaginal: 2% cream or
4H IV.
100mg ovule daily x7.
Metocurine iodide. ICU: 0.4mg/kg
Microlax enema. <12mo 1.25ml,
IV prn. Theatre: 0.1-0.4 mg/kg
1-2yr 2.5ml, >2yr 5ml.
stat, then 0.01-0.02mg/kg/dose.
649
Drug Doses
Midazolam. Sedation: usually 0.10.2mg/kg (adult 5mg) IV or IM,

up to 0.5mg/kg used in children;
0.2mg/kg (repeated in 10min
if reqd) nasal; 0.5 mg/kg (max
20mg) oral. Infusion (ventltd):
3mg/kg in 50ml 5%dex-hep at
1-4ml/hr (1-4mcg/kg /min); fitting
usually 2-4 ml/hr (range 1-24ml/
hr); sedatn 1ml/hr + clonidine
0.5-2 mcg/kg/hr. 1mg = 2-3mg
diazepam.
Midodrine. 0.06mg/kg (adult 3mg)
morning and 4-6pm oral, incr
slowly if reqd to max 0.2-0.4mg/
kg (adult 10-20mg) morning,
noon and 4-6pm. Beware supine
hypertension.
Mifamurtide. 2mg/m2 IV x2/wk for
12wk, then wkly for 24wk.
Mifepristone. Termination (NOT/
kg): 200-600mg oral once, then if
abortion incomplete gemeprost
1mg PV or misoprostol 400mcg
oral or misoprostol 800mcg PV
in 48hr.
Miglitol. Adult (NOT/kg): 25mg
8-24H incr over 3-6mo to usual
maintenance dose of 50mg (max
100mg) 8H oral.
Miglustat. dose wk1, dose wk2,
then 110mg/m2 (adult 200mg)
8H oral if tolerated.
Milnacipran. 0.25mg/kg (adult
12.5mg) daily oral incr over 7 days
to 1mg/kg (adult 50mg) 12H.
Milrinone. <30kg: 1.5mg/kg in
50ml 5%dex-hep, 2.5ml over
1hr (75mcg/kg), then 1-1.5 ml/
hr (0.5-0.75mcg/kg/min). >30kg:
1.5mg/kg made up to 100ml in
5%dex-hep, 5ml over 1hr (75mcg/
kg), then 2-3ml/hr (0.5-0.75mcg/
kg/min).
Mineral mixture (Aminogram).
<5.5kg: 1.5g/kg daily oral, mixed
with feed. >5.5kg: 8g daily (NOT/
kg).
Mineral oil. See paraffin liquid.
Minocycline. Over 8yr: 4mg/kg (max

200mg) stat, then 2mg/kg (max
100mg) 12H oral or IV over 1hr.
Sustained release tabs (NOT/kg):
45mg (45-59kg), 90mg (60-89kg),
135mg (90kg or more) daily oral.
Minoxidil. 0.1mg/kg (max 5mg)
daily, incr to max 0.5mg/kg (max
25mg) 12-24H oral. Baldness: 2%
soltn (male and female) 5% soltn
(males only) 1ml 12H to dry scalp.
Mirtazapine. 0.3-1mg/kg (adult 1560mg) daily oral.
Misoprostol (PGE1 analogue).
5mcg/kg (max 200mcg) 4-6H oral.
See also mifepristone.
Mitomycin-C. 2mg/m2 IV daily x10
days, repeat only if leucocytes
>3000/mm3 + platelets >75,000.
Mitotane. 10-80mg/kg (adult 0.54g) 6H oral.
Mitoxantrone. See mitozantrone.
Mitozantrone. Breast cancer or
lymphoma: 10-14mg/m2 IV over
10min every 3wk. Leukaemia:
10-12mg/m2 IV over 10min daily
for 3-5 days. MS: 12mg/m2 IV
every 3mo.
Mivacurium. 0.15mg/kg stat,
then 0.1mg/kg/dose IV. Infsn:
5-15mcg/kg/min.
Mizolastine. Adult (NOT/kg): slow
rel tab, 10mg daily oral.
Moclobemide. 2-3mg/kg (adult 50150mg) 6-12H oral.
Modafinil. 2-4mg/kg (adult 100200mg) 12H oral. Adult (NOT/
kg): 200mg morning (obs sleep
apnoea), 1hr before shift (night
work sleep disorder) oral.
Moexipril. 0.15-0.2mg/kg (adult 7.510mg) 8-24H oral.
Molindone. 0.1-1.5mg/kg (adult 5075mg) 8H oral.
Molgramostim. 5-10mcg/kg daily SC
or IV over 6hr.
Mometasone. 0.1% cream or oint:
apply daily. 50mcg spray: adult 2
sprays/nostril daily.
650
Mycophenolate mofetil. 600mg/m2

(max 1g) 12H oral or IV over 2hr.
Mycophenolic acid. 400mg/m2 (max
720mg) 12H oral.
Nabilone. Adult (NOT/kg): 1mg 12H,
up to 2mg 8H oral.
Nabumetone. 10-20mg/kg (adult
0.5-1g) 12-24H oral.
Nadolol. 1-5mg/kg (adult 40-240mg)
daily oral.
Nadroparin. Venous thrombosis:
90anti-XaU/kg 12H SC. Prophylaxis: genrl surgery 2850antiXaU (adult, NOT/kg) daily SC;
orthopaedics 40anti-XaU/kg 24H
(start 12hr pre-surgery) SC, then
55anti-XaU/kg daily. Haemodialysis: 65anti-XaU/kg into arterial
line at start 4hr session.
Nafarelin. Adult (NOT/kg): 200mcg
spray to 1 nostril 12H.
Nafcillin. Oral: 15-30mg/kg 6H.
Severe inftn (slow IV, IM): 40mg/
kg (max 2g) 12H (1st wk life), 8H
(2nd wk), 6H or constant infsn
(>2wk).
Naftifine. 1% cream, gel: apply daily.
Naftidrofuryl. 2-4mg/kg (adult 100200mg) 8H (oral) or 12H (IM, or
IV or IA infsn over 2hr).
Nalbuphine. 0.2-0.5mg/kg (adult
20-30mg) 3-6H SC, IM or IV.
Anaesthesia: 0.3-1mg/kg IV over
15min, then 0.2-0.5mg/kg every
30min.
Nalidixic acid. 15mg/kg (adult 1g)
6H oral, reducing to 7.5mg/kg
(adult 500mg) 6H after 2wk.
Nalmefene. Opiate intoxication:
0.007mg/kg IV, and 0.0014 mg/
kg after 2-5min (15min if IM, SC)
if reqd. Postop sedtn: 0.25mcg/kg
every 2-5min (max 4 doses). Half
life 10hr.
651
Drug Doses
Montelukast. NOT/kg: 4mg (2-5yr)

5mg (6-14yr) 10mg (>14yr) daily
at bedtime, oral.
Moracizine. 4-6mg/kg (adult 200300mg) 8H oral.
Moricizine. See moracizine.
Moroctogog alfa. Recombinant human factor 8; see factor 8.
Morphine. Half life 2-4 hr. IM:
neonate 0.1mg/kg, child 0.1-0.2
mg/kg, adult 10-20mg; half this
IV over 10 min. IV (ventltd): 0.10.2mg/kg/dose (adult 5-10mg).
Infsn of 1mg/kg in 50ml 5%dexhep: ventilated neonate 0.5-1.5
ml/hr (10-30mcg/kg/hr), child or
adult 1-4ml/hr (20-80mcg/kg/
hr). Patient controlled: 20mcg/
kg boluses (1ml of 1mg/kg in
50ml) with 5min lockout time +
(in child) 5mcg/kg/hr. Oral double
IM dose; slow release: start with
0.6mg/kg 12H and incr every 48hr
if reqd.
Morphine + naltrexone
(20mg/0.8mg, 30/1.2, 50/2,
60/2.4, 80/3.2, 100/4). 1 capsule
12-24H oral.
Morrhuate sodium. Adult (NOT/kg):
50-250mg per injtn.
Moxifloxacin. 10mg/kg (adult
400mg) daily oral or IV. 0.5%
ophthalmic: 1 drop/eye 8H for
7 days.
Moxisylyte. Adult (NOT/kg): 4080mg 6H oral.
Moxonidine. 4mg/kg (adult 200mg)
8-24H oral.
Mumps vaccine (Mumpsvax). Live.
>12mo: 0.5ml SC once. See also
measles + mumps + rubella vaccine.
Mupirocin. 2% ointment: apply
8-12H.
Muromonab-CD3 (Orthoclone
OKT3). 0.1mg/kg (adult 5mg)
daily for 10-14 days IV over 1min.
Mustine HCl (nitrogen mustard).
0.1mg/kg IV daily for 3-4 days.
Hodgkins: 6mg/m2 IV.
Drug Doses
Naloxone. Postop sedatn: 0.002mg/

kg/dose (0.4mg diluted to 20ml,
give 0.1ml/kg/dose) repeat every
2min x4 if reqd, then 0.3mg/kg in
30ml 5%dex-hep at 1ml/hr (0.01
mg/kg/hr) IV. Opiate overdose
(including newborn): 0.01 mg/
kg (max 0.4mg) (0.4mg diluted
to 10ml, give 0.25 ml/kg/dose),
repeated every 2min (15min if
IM or SC) x4 if reqd, then 0.3mg/
kg in 30ml 5%dex-hep at 1ml/hr
(0.01mg/kg/hr) IV.
Naltrexone. 0.5mg/kg (adult 25mg)
daily oral. Adult (NOT/kg): 380mg
every 4wk IM.
Nandrolone decanoate. Anaemia:
1-4mg/kg (adult 50-200mg) wkly
deep IM. Osteoporsis: adult
(NOT/kg) 50mg deep IM every
3wk.
Naphazoline. 0.012-0.1%: 1-2drop/
nostril, 1drop/eye 3-4H.
Naproxen. 1mg = 1.1mg naproxen
sodium. >2yr: 5-10mg/kg (adult
250-500mg) 8-12H oral. Adult:
500mg 12H PR.
Naproxen + esomeprazole. See
esomeprazole + naproxen.
Naproxen 500mg+ sumatriptan
85mg. Adult (NOT/kg):1 tab oral,
may repeat after 2 hours (max 2
tab per day).
Naratriptan. 0.05mg/kg (adult
2.5mg), repeat after 4hr if reqd.
Natalizumab. Adult (NOT/kg):
300mg IV over 1hr every 4wk.
Natamycin. 5%: 1 drop in eye x6-8/
day for 14-21 days.
Nateglinide. Adult (NOT/kg): 60120mg 8H oral.
Nebivolol. 0.1mg/kg (adult 5mg)
daily oral, incr to max 1mg/kg
(adult 40mg) daily.
Nedocromil. Inhltn: 4mg (2 puffs)
6H, reducing to 12H when imporoved. 2% eye drops: 1 drop/
eye 6-24H.
Nefazodone. 1mg/kg (adult 50 mg)

12H oral, incr by 1mg/kg/dose
(adult 50mg) each wk to 4-6mg/
kg (adult 200-300mg) 12H. Slow
release: daily dose.
Nefopam hydrochloride. Oral:
0.5-2mg/kg (adult 30-90mg) 8H.
IM: 0.4mg/kg (adult 20mg), may
repeat in 6hr.
Neisseria meningitidis vaccine. See
meningococcal vacc.
Nelarabine. Child: 650mg/m2 IV over
1hr daily for 5 days; rpt every 21
days. Adult: 1500mg/m2 IV over
2hr on days 1, 3 and 5; rpt every
21 days.
Nelfinavir (NFV). 45-55mg/kg (adult
1250mg) 12H oral, or 25-35mg/kg
(adult 750mg) 8H. M8 metabolite
trough 800ng/ml.
Neomycin. 1g/m2 4-6H oral (max
12g/day). Bladder washout:
40-2000mg/L. See also colistin;
dexamethasone; gramicidin.
Neomycin 0.5% + prednisolone
sodium phosphate 0.5%. 1drop/
eye 4-6H.
Neostigmine. Reverse relaxants:
0.05-0.07mg/kg (adult 0.5-2.5mg)
IV; suggested dilution: neostigmine (2.5mg/ml) 0.5ml + atropine
(0.6mg/ml) 0.5ml + saline 0.5ml,
give 0.1ml/kg IV. Myasth gravis
(NOT/kg): neonate 0.05-0.25mg,
child 0.2-0.5mg, adult 1-2.5mg
2-4H IM, SC.
Nepafenac. 1mg/ml (NOT/kg): 1
drop/eye 8H.
Nesiritide. 2mcg/kg IV, then
0.01mcg/kg/min (range 0.0050.03mcg/kg/min).
Netilmicin. IV or IM. 1wk-10yr:
8mg/kg day 1, then 6mg/kg daily.
>10yr: 7mg/kg day 1, then 5mg/
kg (max 240-360mg) daily. Neonate, 5mg/kg dose: <1200g 48H
(0-7 days of life), 36H (8-30 days),
24H (>30 days); 1200-2500g 36H
(0-7 days of life), 24H (>7 days);
term 24H (0-7 days of life), then
as for 1wk-10yr. Trough <1.0mg/L.
652
Nicoumalone. 0.2mg/kg (adult

10mg) day 1, 0.12m/kg (adult
6mg) day 2, then 0.02-0.25mg/
kg (adult 1-12mg) daily oral. INR
2-2.5 for prophylaxis, 2-3 for
treatment.
Nifedipine. Caps 0.25-0.5mg/kg
(adult 10-20mg) 6-8H, tabs 0.51mg/kg (adult 20-40mg) 12H oral
or sublingual.
Nilotinib. Adult (NOT/kg): 400mg
12H oral.
Nilutamide. Adult (NOT/kg): 300mg
daily oral for 4wk, then 150mg
daily.
Nimodipine. 10-15mcg/kg/hr
(adult 1mg/hr) IV for 2hr, then
10-45mcg/kg/hr (adult 2 mg/hr).
Adult: 60mg 4H oral.
Nisoldipine. Slow release: 0.2 mg/
kg (adult 10mg) daily oral, incr
to 0.4-0.8mg/kg (adult 20-40mg)
daily.
Nitazoxanide. 100mg (12-47mo)
200mg (4-11yr) 500mg (>11yr)
12H for 3 days oral.
Nitisinone. 0.5-0.75mg/kg 12H oral.
Nitrazepam. Child epilepsy: 0.1250.5mg/kg 12H oral. Hypnotic
(NOT/kg): 2.5-5mg (child) 5-10mg
(adult) nocte.
Nitric oxide. 1-40ppm (up to 80ppm
used occasionally). 0.1 l/min of
1000ppm added to 10 l/min gas
gives 10ppm. [NO] = Cylinder
[NO] x (1 - (Patient FiO2 / Supply
FiO2)). [NO] = Cylinder [NO] x NO
flow / Total flow.
Nitrofurantoin. 1.5mg/kg (adult
50-100mg) 6H oral. Prophylaxis:
1-2mg/kg (adult 50-100mg) at
night.
Nitrofurazone. 0.2% cream, soltn:
apply every 1-3 days.
Nitrogen mustard. See mustine HCl.
Nitroglycerine. See glyceryl trinitrate.
Nitroprusside. See sodium nitroprusside.
653
Drug Doses
Nevirapine (NVP). <8yr: 200mg/m2

(max 200mg) daily oral for 2wk,
then 12H if no rash; 8yr: 120150mg/m2 (max 200mg) daily
for 2wk, then 12H if no rash. Min
trough 3000 ng/ml.
Niacin + lovastatin. See lovastatin
+ niacin.
Niacin + simvastatin (500mg/20mg,
750/20, 1000/20). Adult (NOT/
kg): 500mg/20mg at bedtime
oral, incr by 500mg every 4wk to
max 2000/40mg.
Nicardipine. 0.4-0.8mg/kg (adult 2040mg) 8H oral. 1-3mcg/kg/min
(max 20mg/hr) IV.
Niclosamide. 50mg/kg (adult 2g)
oral.
Nicotinamide. 4% gel: apply sparingly 12-24H
Nicorandil. 0.1-0.6mg/kg (adult
5-30mg) 12H oral.
Nicotine inhaler. 10mg cartridges.
Adult: usually inhale 6-12 cartridges/day for 3mo, then reduce
over 6-8wk.
Nicotine resin chewing gum. NOT/
kg: 2-4mg chewed over 30min
when inclined to smoke; usually
need 16-24mg/day, max 60mg/
day.
Nicotine transdermal patches. Usually 21mg, 14mg, and 7mg per
24hr. Adult: if smoked >20cig/day
apply strongest patch daily 3-4wk,
medium patch daily 3-4wk (initial
dose if smoked <=20cig/day),
then weakest patch daily 3-4wk.
Nicotinic acid. Hypercholesterolaemia and hypertriglyceridaemia: 5mg/kg (adult 200mg) 8H,
gradually incr to 20-30mg/kg
(adult 1-2g) 8H oral. See also
laropiprant.
Nicotinyl alcohol tartrate. Adult
(NOT/kg): 25-50mg 6H, slow
release tab 150-300mg 12H oral.
Drug Doses
Nizatidine. 3-5mg/kg (adult 150mg)

12H oral for max 8wk, then daily.
H pylori (adult): 300mg 12-24H.
Nonacog alfa. Recombinant human
factor 9, see factor 9.
Nonoxynol-9. 2% (Ortho), 5%
(Delfen) cream: 1 applicatorful
just before intercourse. 12.5%
(Delfen) foam: 1 applicatorful
<60min before intercourse.
Noradrenaline. 0.15mg/kg in 50ml
5%dex-hep at 1-10ml/hr (0.050.5mcg/kg/min); flow <2ml/
hr may cause swings in blood
pressure. Low dose: 0.06mg/kg in
50ml at 1-10ml/hr (0.02-0.2mcg/
kg/min).
Norelgestromin. See ethinyloestradiol + norelgestromin.
Norepinephrine. See noradrenaline.
Norethindrone. See norethisterone.
Norethisterone. Contraception:
350mcg daily, starting 1st day of
menstruation; or 200mg oily soltn
IM in 1st 5 days of cycle, repeated
once after 8wk. Menorrhagia:
10mg 3H until hge stops, then
5mg 6H for 1wk, then 5mg 8H for
2wk; or 5mg 8-12H on days 19-26
of cycle.
Norfloxacin. 10mg/kg (adult 400mg)
12H oral.
Norgestimate. See ethinyloestradiol
+ norgestimate.
Norgestrel. See levonorgestrel.
Normacol granules. 6mo-5yr half
teasp 12H, 6-10yr 1 teasp 12H,
>10yr 1 teasp 8H.
Nortriptyline. 0.5-1.5mg/kg (adult
25-75mg) 8H oral.
Noscapine. NOT/kg: 7.5mg (1-6yr)
15mg (6-12yr) 15-30mg (adult)
6-8H oral.
Noxythiolin. 1-2.5% soltn into body
cavity 12-24H, left at least 30min.
Max daily dose 200mg/kg (max
10g).
NTBC (nitro-trifluoromethylbenzoyl
cyclohexanedione). 0.5mg/kg
12H oral.
Nystatin. 100,000u <12mo,

500,000u (1 tab) >12mo 6H NG
or oral. Prophylaxis 50,000u
<12mo, 250,000u >12mo 8H.
Topical: 100,000u/g gel, cream or
ointment 12H. Vaginal: 100,000u
12-24H.
Obidoxime. 4mg/kg (adult 250mg)
slow IV, then 0.6mg/kg/hr (adult
30mg/hr). See also atropine.
Octocog alfa (recombinant factor
8). See factor 8.
Octoxinol (octoxynol). 1% jelly
(Ortho-Gynol): 1 teaspoonful on
diaphragm before intercourse.
Octreotide. Diarrhoea: 1mcg/kg
(adult 50mcg) 12-24H SC, may
incr to 10mcg/kg (adult 250mcg)
8H. IV: 1mcg/kg stat, then
1-5mcg/kg/hr. Chyle: 5mcg/kg/
hr IV. Acromegaly (NOT /kg): 0.050.1mg 8-12H SC incr if reqd to
max 0.5mg 8H for 4wk, then slow
release 20mg (10-30mg) every
4wk deep IM.
Oestradiol. NOT/kg. Oesteoporosis:
every wk apply a patch releasing
12.5mcg/day. Induction puberty:
0.5mg alternate days oral, incr
over 2-3yr to 2mg/day (add progestogen for 14 days/mo when
dose 1.5mg/day or when bleeding occurs). Tall stature: 12mg/
day oral until bone age >16yr
(add progestogen for 14 days/
cycle). Gonadal failure: 2mg/
day oral (add progestogen for 14
days/cycle).
Oestriol. Induction puberty: 0.25
mg/day incr to 2mg/day (+
progestogen 12days/cycle) oral.
Epiphyseal maturation: 10mg/
day (+ progestogen 12days/cycle).
Vaginal: 0.5mg daily, reducing
to x2/wk. Patch (Menorest)
37.5 (3.28mg), 50 (4.33mg), 75
(6.57mg), 100 (8.66mg): apply
1 patch x2/wk (adjust dose
monthly), with medroxyprogesterone acetate (if uterus intact)
10mg x10 days/mo.
654
Ondansetron. IV: prophylaxis

0.15mg/kg (adult 4mg); treatment 0.2mg/kg (adult 8mg) over
5 min, or 0.2-0.5mcg /kg/min.
Oral: 0.1-0.2mg/kg (usual max
8mg) 6-12H.
Oprelvekin (IL-11). 2mg/m2 (adult
50mcg/kg) SC daily.
Oral rehydration solution (ORS). See
glucose electrolyte solution.
Orciprenaline. Oral: 0.25-0.5mg/kg
(adult 20mg) 6H. Resp soltn (2%):
0.5ml diltd to 4ml 3-6H (mild),
1ml diltd to 4ml (moderate),
undiluted continuously (severe,
in ICU). Aerosol 750mcg/dose: 2
puffs 4-6H.
Orlistat. 1.5-3mg/kg (adult 60120mg) with each main meal
containing fat (max 3 doses/day).
Ornipressin (POR 8). IV: 0.1u/kg/
hr (max 6u/hr) for max 4hr, then
0.03u/kg/hr (max 1.5u/hr). SC:
5u in 30ml saline, max total dose
0.1u/kg.
Orphenadrine. 1-2mg/kg (adult 50100mg) 8H oral.
Osalazine. Adult (NOT/kg): 500mg
6H oral.
Oseltamivir. 2mg/kg (adult 75mg)
12H for 5 days oral. Prophylaxis:
2mg/kg (adult 75mg) daily.
Oxacillin. 15-30mg/kg 6H oral, IV,
IM. Severe inftn: 40 mg/kg (max
2g) 12H (1st wk life), 8H (2nd wk),
6H or infsn (>2wk).
Oxaliplatin. 85mg/m2 every 2wk
over 2-6hr IV before 5-FU.
Oxandrolone. 0.1-0.2mg/kg (adult
2.5-20mg) daily oral. Turners
synd: 0.05-0.1mg/kg daily.
Oxaprozin. Usually 20mg/kg (max
1200mg), range 10-26mg/kg (max
1800mg), daily oral.
Oxazepam. 0.2-0.5mg/kg (adult 1030mg) 6-8H oral.
Oxcarbazepine. 4-5mg/kg (adult
300mg) 12H oral; incr wkly by max
5mg/kg/dose (adult 300mg) to
15mg/kg/dose (adult 750mg), max
25mg/kg/dose (adult 1200mg).
655
Drug Doses
17-beta-Oestradiol. 2mg vaginal

ring, replace every 3mo.
Oestrogen. See ethinyloestradiol.
Oestrone. Adult (NOT/kg). Hypogonadism: 1.25-7.5mg daily oral.
Oestropipate. Adult (NOT/kg):
0.625-7.5mg daily starting 1st day
menstruation, for 3 of every 4wk
oral. Intravaginal: 2-4g cream daily.
Ofatumumab. Adult (NOT/kg):
300mg IV, then 2g wkly for 7wk,
then 2g every 4wk for 4wk.
Ofloxacin. 5mg/kg (adult 200mg)
8-12H, or 10mg/kg (adult 400mg)
12H oral or IV over 1hr. 0.3%:
1 drop/eye hrly for 2 days (4H
overnight), reducing to 3-6H.
OKT3. See muromonab-CD3.
Olanzapine. 0.1-0.2mg/kg (adult
5-10mg) daily oral; slow incr to
0.4mg/kg (adult 20mg) daily if
reqd.
Olmesartan. 0.4-0.8mg/kg (adult
Olopatadine. 0.1-0.2% soltn: 1 drop/
eye twice a day. 0.6% soltn: 1-2
sprays/nostril 12H.
Olpadronate. 0.5mg/kg daily oral.
Olsalazine. NOT/kg: 250mg 12H, incr
to max 500mg 6H oral. Maintenance: 500mg 12H.
Omalizumab. NOT/kg: 150-375mg
SC every 2-4wk depending on
body weight and serum IgE level.
Omeprazole. Usually 0.4-0.8mg/
kg (adult 20-40mg) 12-24H oral.
ZE synd: 1mg/kg (adult 60mg)
12-24H oral, incr up to 3mg/
kg (adult 120mg) 8H if reqd. IV:
2mg/kg (adult 80mg) stat, then
1mg/kg (adult 40mg) 8-12H.
H.pylori quadruple therapy (adult
NOT/kg): 20mg 12H + bismuth
subcitrate potassium 420mg 6H +
metronidazole 375mg 6H + tetracycline hydrochloride 375mg 6H
oral for 10-14 days. H.pylori triple
therapy (adult, NOT/kg): 20mg +
amoxycillin 500mg + clarithromycin 500mg 12H oral for 7 days.
Drug Doses
Oxerutin. 10mg/kg (adult 500mg)

12H oral.
Oxethazaine. 10mg/5ml (with Al
hydrox + Mg hydrox): adult (NOT/
kg) 5-10ml 6-8H oral.
Oxiconazole. 1% cream, lotion: apply 12-24H.
Oxitropium. Inhaltn: 200mcg (NOT/
kg) 8-12H.
Oxpentifylline. Adult (NOT/kg): slow
release tab 400mg 8-12H oral.
Oxprenolol. 0.5-2mg/kg (adult 30120mg) 8-12H oral.
Oxtriphylline. See choline theophyllinate.
Oxybuprocaine. 4mg/ml (0.4%): 1
drop/eye 8-12H. Deep anaes: 1
drop/eye every 90sec x3 doses.
See fluorescein + oxybuprocaine.
Oxybutynin. <5yr: 0.2mg/kg 8-12H
oral. >5yr (NOT/ kg): 2.5-5mg
8-12H oral. Slow rel: adult 5-30mg
daily oral. Adult (NOT/kg): apply
39cm2 patch (3.9mg/day) x2/wk;
apply 100mg gel sachet daily.
Oxycodone. 0.1-0.2mg/kg (adult
5-10mg) 4-6H oral, SC or IV
(beware hypoventilation); incr
if reqd. IV infsn: 0.05mg/kg/hr
(adult 2mg/hr) adjusted. Slow release: 0.6-0.9mg/kg (adult 10mg)
12H oral, incr if reqd. Suppos:
adult 30mg 6-8H PR.
Oxymetazoline. 0.25mg/ml =
0.025% (<6yr), 0.5mg/ml = 0.05%
(>6yr): 2-3 drops or sprays in each
nostril 8-12H.
Oxymetholone. 1-2mg/kg (up to
5mg/kg) daily oral.
Oxymorphone. Usually 0.020.03mg/kg (adult 1-1.5mg) 4-6H
IM or SC. Slow IV: 0.01mg/kg
(adult 0.5mg) 4-6H. Oral: 0.10.4mg/kg (adult 5-20mg) 4-6H;
slow-release adult 5mg 12H. PR:
0.1mg/kg (adult 5mg) 4-6H.
Oxytetracycline. >8yr (NOT/kg): 250500mg 6H oral, or 250-500mg
6-12H slow IV.
Oxytocin. Lactation: 1 spray (4iu)

into each nostril 5min before
infant feeds.
Paclitaxel. 175mg/m2 IV every 3wk,
x3-6 doses. Albumin-bound:
260mg/m2 IV every 3wk.
Palifermin. 60mcg/kg IV daily for
3 days before chemo, and for 3
days after.
Palivizumab. 15mg/kg IM once a
month.
Paliperidone (3mg, 6mg, 9mg slow
release). Adult (NOT/ kg): usually
6mg daily oral; may incr by 3mg
every 5-7 days; Injection 234mg
IM, 156mg after 1wk, then 117mg
monthly.
Palonosetron. Adult: 0.25mg IV
30min before chemo.
Pamidronate. Osteoporosis, OI:
3-7mg/kg daily oral, 1mg/kg
(adult 15-90mg) IV over 4hr
daily x3 every 4mo, or once every
3-4wk. Hypercalcaemia 20-50mg/
m2 (depending on Ca level) IV
over 4hr every 4wk.
Pancreatic enzymes. Cotazyme,
Creon, Nutrizym, Pancrease,
Pancrex, Ultrase, Viokase. NOT/
kg: usually 1-5 caps with meals.
Max lipase 10,000u/kg/day.
Pancuronium. ICU: 0.1-0.15mg/
kg IV prn. Theatre: 0.1mg /kg IV,
then 0.02mg/kg prn. Infsn: 0.250.75mcg/kg/min.
Panitumumab. 6mg/kg IV over
1-2hr every 14 days.
Pantoprazole. 1.0mg/kg (adult
40mg) 12-24H oral, IV. GI hge,
adult: 80mg stat, then 8mg/hr.
ZE: 80mg 8-12H adjusted to
achieve acid <10mmol/l.
Papaveretum (Omnopon). 0.2mg/kg
IV, 0.4mg/kg IM (half life 2-4hr).
ICU: 0.3mg/kg IV, 0.6mg/kg IM.
See also hyoscine + papaveretum.
Papaveretum (Omnopon). 0.2mg/kg
IV, 0.4mg/kg IM (half life 2-4hr).
ICU: 0.3mg/kg IV, 0.6mg/kg IM.
See also hyoscine + papaveretum.
656
Pegaptanib sodium. Adult: 1.65mg

(0.3mg of free acid form) by
intravitreous inj every 6wk.
Pegaspargase. 82.5iu/kg (<0.6m2) or
2500iu/m2 (>0.6m2) IM, or IV over
2hr, every 14 days.
Pegfilgrastim. >44kg: 6mg SC 24hr
after chemo.
Peginterferon alfa-2a. Hep C, adult
(NOT/kg): 180mcg wkly SC, plus
ribavirin 1g (1.2g if >75kg) daily
oral, for 48wk.
Peginterferon alfa-2b. Hep C:
1.5mcg/kg wkly SC, plus ribavirin
15mg/kg (adult 800mg) daily oral,
for 48wk.
Pegvisomant. 40mg SC stat, then
10mg daily adjusted up or down
by 5mg (max 30mg/day) every
4-6wk based on serum IGF-1
concentration.
Pemetrexed. 500mg/m2 IV over
10min every 3wk.
Pemoline. >6yr (NOT/kg): 20-120mg
daily oral.
Penbutolol. 0.4-1.5mg/kg (adult 2080mg) daily oral.
Penciclovir. 1% cream (10mg/g):
apply x6/day for 4 days.
Penicillamine (d-penicillamine).
Arthritis: 1.5mg/kg (adult 125mg)
12H oral, incr over 3mo to max
3mg/kg (adult 375 mg) 6-8H.
Wilsons dis, lead poisoning: 5-7.5
mg/kg (adult 250-500mg) 6H
oral. Cystinuria: 7.5mg/kg (adult
250-1000 mg) 6H oral, titrated to
urine cystine <100-200mg/day.
Penicillin, benzathine. 1mg = 1250u.
Usually 25mg/kg (max 900mg) IM
once. Venereal disease: 40mg/
kg (max 1.8g) IM once. Strep
proph: 25mg/kg (max 900mg) IM
3-4wkly, or 10mg/kg IM 2wkly.
Penicillin, benzathine + procaine.
900mg/300mg in 2ml: 0-2yr half
vial, 3yr or more 1 vial IM once.
657
Drug Doses
Papaverine. Adult (NOT/kg): 150300mg 12H oral, 12-40 mg x1-2/

wk intracavernosal. IA lines:
0.12mg/ml.
Para-aminobenzoic acid. See aminobenzoate.
Para-aminohippuric acid. See aminohippuric acid.
Paracetamol. Oral, IV: 20mg/kg stat,
then 15mg/kg 4-6H (max 4g/day);
child usual daily max 60mg/kg (up
to 90mg/kg for 48hr). Neonate:
7.5mg/kg (<10 days) 15mg/kg
(>10 day) 6H. Rectal: 40mg/kg
stat, then 30mg/kg 6H (max 5g/
day).
Paraffin. Liquid: 1ml/kg (adult
30-45ml) daily oral. Liquid 50%
+ white soft 50%, ointmnt: apply
6-12H. See also agar.
Paraldehyde. IM: 0.2ml/kg (adult
10ml) stat, then 0.1 ml/kg 4-6H.
IV: 0.2ml/kg (adult 10ml) over
15 min, then 0.02ml/kg/hr (max
1.5ml/hr). Rectal, NG: 0.3ml/kg
(adult 10ml) dilute1:10.
Parathyroid hormone. Adult (NOT/
kg): 100mcg daily SC. See also
teriparatide.
Parecoxib. Adult (NOT/kg): 40mg
stat IM or IV, then 20-40mg
6-12H; max 80mg/day.
Paricalcitol. 0.04-0.1mcg/kg x2-3/wk
IV during dialysis, incr every 2-4wk
if reqd to max 0.24mcg/kg. Or
dose in mcg = [iPTH picomol/L] / 7.
Paromomycin. Amoebiasis: 10mg/
kg 8H oral for 5-10 days. Hepatic
coma: 20mg/kg (adult 1g) 6H oral.
Paroxetine. 0.4mg/kg (adult 10mg)
daily oral, incr if rqd over 4wk to
1mg/kg (adult 20-60mg) daily.
Pasugrel. Adult (NOT/kg): 60mg stat,
then 5mg (<60kg) 10mg (60kg)
daily oral.
Pazopanib. Adult (NOT/kg): 800mg
(400mg if toxicity) daily oral.
Pegademase. 10u/kg IM wkly, incr
to 20u/kg wkly.
Drug Doses
Penicillin, benzyl (penicillin G, crystalline). 1mg = 1667u. 30mg/kg

6H. Severe inftn: 50mg/kg (max
2g) IV 12H (1st wk life), 6H (2-4
wk), 4H or constnt infsn (>4 wk).
Penicillin, benzathine + procaine.
900mg/300mg in 2ml: 0-2yr half
vial, 3yr or more 1 vial IM once.
Penicillin, benzyl (penicillin G, crystalline). 1mg = 1667u. 30mg/kg
6H. Severe inftn: 50mg/kg (max
2g) IV 12H (1st wk life), 6H (2-4
wk), 4H or constnt infsn (>4 wk).
Penicillin, procaine. 1mg = 1000u.
25-50mg/kg (max 1.2-2.4g ) 1224H IM. Single dose: 100mg/kg
(max 4.8g).
Penicillin V. See phenoxymethylpenicillin.
Penicilloyl polylysine (Prepen).
0.00006 molar. Scratch: 1 drop.
Intradermal: 0.01-0.02ml (NOT/
kg).
Pentaerythritol tetranitrate. 0.21mg/kg (adult 10-60mg) 6-8H
oral.
Pentagastrin. 6mcg/kg SC, or
0.6mcg/kg/hr IV.
Pentamidine isethionate. 3-4mg/kg
(1.7-2.3mg/kg base) IV over 2hr
or IM daily for 10-14 days (1mg
base = 1.5mg mesylate = 1.74mg
isethionate). Neb: 600mg/6ml
daily for 3wk (treatment),
300mg/3ml every 4wk (prophylaxis).
Pentastarch. 10% soltn: 10-40mg/
kg IV.
Pentazocine. Oral: 0.5-2.0mg/kg
(adult 25-100mg) 3-4H. SC, IM
or slow IV: 0.5-1mg/kg (adult 3060mg) 3-4H. PR: 1mg/kg (adult
50mg) 6-12H.
Pentetate calcium trisodium. 14mg/
kg (adult 1g) IV.
Pentetate zinc disodium. 14mg/kg
(adult 1g) IV.
Pentobarbitone. 0.5-1mg/kg (adult
30-60mg) 6-8H oral, IM, slow IV.
Hypnotic: 2-4mg/kg (adult 100200mg).
Pentosan. 2mg/kg (adult 100mg)

8H oral.
Pentostatin. 4mg/m2 IV wkly.
Pentoxifylline. See oxpentifylline.
Pentoxyverine. 0.3mg/kg (adult
15mg) 3-6H oral.
Peppermint oil. Adult (NOT/kg).
0.2ml cap: 1-2 8H oral.
Pergolide. Parkinsons: 1mcg/kg
(max 50mcg) daily, incr to max
25mcg/kg (max 2mg) 8H oral.
Hyperprolactinaemia: 0.5-3mcg/
kg daily. Perhexiline. 2mg/kg
(adult 100mg) daily oral; adjust
every 2-4wk to max 6-8mg/kg
(adult 300-400mg) daily. Maintain
plasma level 150-600mcg/l.
Pericyazine. 0.5mg/yr of age (110yr) 10mg (>10yr) daily oral, incr
if reqd to max 1mg/yr (1-10yr)
25mg (>10yr) 8H.
Perindopril. 0.05-0.15mg/kg (adult
2-8mg) daily oral. See also indanapamide + perindopril.
Permethrin. 1% creme rinse (head
lice): wash hair, apply creme for
10min, wash off; may repeat in
2wk. 5% cream (scabies): wash
body, apply to whole body except
face, wash off after 12-24hr.
Perphenazine. 0.1-0.3mg/kg (adult
5-20mg) 8-12H oral.
Pertussis. See diphtheria + tetanus +
pertussis vaccine.
Pethidine. 0.5-1mg/kg (adult
25-50mg) IV, 0.5-2mg/kg (adult
25-100mg) IM (half life 2-4hr).
Infsn: 5mg/kg in 50ml at 1-4ml/hr
(0.1-0.4mg/kg/hr). PCA 5mg/kg
in 50ml: usually bolus 2ml with
lockout 5min, optional background 0.5ml/hr.
Phenacemide. 10-20mg/kg (adult
0.5-1g) 8H oral.
Phenazone. See benzocaine +
phenazone.
Phenazocine. 0.1-0.4mg/kg (adult
5-20mg) 4-6H oral or sublingual.
Phenazopyridine. 4mg/kg (adult
200mg) 6H oral for 2 days.
658
Phentolamine. 15mg/kg in 50ml

5%dex-hep at 1-10ml/hr
(5-50mcg/kg/min) IV. May accumulate (half-life 19min, longer
if renal impairment).
Phenylbutazone. Initially 2mg/kg
(adult 100mg) 4H, reducing to
1-2mg/kg (adult 50-100mg) 6-8H
oral.
Phenylephrine. IV: 2-10mcg/kg stat
(adult 500mcg), then 1-5mcg/
kg/min. SC or IM: 0.1-0.2mg/
kg (max 10mg). Oral: 0.2mg/kg
(max 10mg) 6-8H. 0.15%, 10% eye
drops: 1 drop/eye 6-8H. 0.25%,
0.5% nose drops: 1-3 drops/
sprays per nostril 6-8H. See also
chlorpheniramine.
Phenylephrine 0.12% + prednisolone acetate 1%. 1 drop per eye
6-12H.
Phenyltoloxamine. 1mg/kg (adult
50mg) 8H oral.
Phenytoin. Loading dose in emergency: 15-20mg/kg (max 1.5g)
IV over 1 hr. Initial maintenance,
oral or IV: 2mg /kg 12H (preterm);
3mg/kg 12H (1st wk life), 8H
(2wk-4yr), 12H (5-12yr); 2mg/kg
(max 100mg) 8H >12 yr. Level 4080 umol/L (x0.25 = mcg/ml).
Pholcodine. 0.1-0.2mg/kg (adult
5-15mg) 6-12H oral.
Phosphate, potassium (1mmol/
ml). 0.1-1.5mmol/kg/day (max
70mmol/day) IV infsn.
Phosphate, sodium. Laxative,
diluted, NOT/kg: 250mg (2-4yr)
250-500mg (>4yr) 6H oral.
Phosphate, sodium (Fleet enema).
Na 1.61mEq/l + PO4 4.15 mEq/l +
P 1.38mEq/l: 33ml (2-5yr), 66ml
(5-11yr), 133ml (adult) rectal.
Phosphatidylcholine. Usually 60mg/
kg (max 3g) daily oral.
Phosphocol P32. Adult (NOT/kg).
Peritoneum: 370-740 MBq (10-20
mCi). Peritoneal: 222-444 MBq
(6-12 mCi). Interstitial: 3.7-18.5
MBq (0.1-0.5 mCi) per gram of
tumor.
659
Drug Doses
Phendimetrazine. 0.4-1.4mg/kg
Phenelzine. 0.3-2mg/kg (adult 1590mg) 8H oral.
Phenindamine. 0.5-1mg/kg (adult
25-50mg) 8-12H oral.
Phenindione. 2mg/kg (adult 100mg)
12H day 1, 1mg/kg (adult 50mg)
12H day 2, then 0.25-1mg/kg
(adult 12.5-50mg) 12H oral. INR
for prophylaxis 2-2.5, treatment
2-3.
Pheniramine. 0.5-1mg/kg (adult 2550mg) 6-8H oral. Slow release tab
75mg at night.
Phenobarbital. See phenobarbitone.
Phenobarbitone. Loading dose in
emergency: 20-30mg/kg IM or
IV over 30min stat. Ventilated:
repeat doses of 10-15mg/kg up
to 100mg/kg per day (beware hypotension). Usual maintenance:
5mg/kg (adult 300mg) daily IV,
IM or oral. Infant colic: 1mg/kg
4-8H oral. Level 60-172 umol/L
(x0.23=mcg/ml).
Phenolphthalein. 0.5-5mg/kg (adult
30-270mg) at night oral. See also
agar + paraffin + phenolphthalein.
Phenoperidine. 0.03-0.05mg/kg
(adult 1mg) every 40-60min.
Ventilated: 0.1-0.15mg/kg (adult
2-5mg) every 40-60min.
Phenothrin. Apply; shampoo after
30min (0.5% mousse) 2hr (0.2%
lotion), 12hr (0.5% emulsion);
comb hair when wet.
Phenoxybenzamine. 0.2-0.5mg/
kg (adult 10-40mg) 8-12H oral.
Cardiac surgery: 1mg/kg IV over
1-4hr stat, then 0.5 mg/kg 8-12H
IV over 1hr or oral.
Phenoxymethylpenicillin (penicillin
V). 7.5-15mg/kg (adult 250500mg) 6H oral. Proph: 12.5mg/
kg (adult 250mg) 12H.
Phentermine. Adult (NOT/kg):
30-40mg daily oral, reducing to
15-40mg daily.
Phentermine resin. Adult (NOT/kg):
15-30mg daily oral.
Drug Doses
Phosphocysteamine. 10mg/kg 6H
oral, incr by 2.5 mg/kg/dose
every 2wk to 10-20mg/kg 6H so
leukocyte half-cysteine <2nmol /
mg protein 6hr after dose.
Physostigmine. 0.02mg/kg (max
1mg) IV every 5 min until
response (max 0.1mg/kg), then
0.5-2.0mcg/kg/min.
Phytomenadione (vitamin K1).
Deficiency with hge: FFP 10ml/kg,
then 0.3mg/kg (max 10mg), IM
or IV over 1hr. Prophylaxis in neonates (NOT/kg): 1mg (0.1ml) IM at
birth. Warfarin reversal: 0.1mg/
kg (max 5mg) SC or oral (repeat
if reqd); if severe hge 0.3mg/kg
(max 10mg) with FFP 10ml/kg.
Mitochondrial disease (NOT/kg):
10mg 6H oral.
Phytonadione. See phytomenadione.
Picibanil (OK-432). 1 Klinishe Einheit
= 0.1mg. 1mg into tumour 1-2wk
preop, then 0.5mg/2wk ID for 1yr
postop.
Pilocarpine. 0.1mg/kg (adult 5mg)
4-8H oral. 0.5%, 1%, 2%, 3%, 4%
eye drops: 1 drop/eye 6-12H.
Pimecrolimus. 1% cream: apply 12H.
Pimozide. 0.04mg/kg (adult 20mg)
0.4mg/kg (adult 20mg) daily.
Pindolol. 0.3mg/kg (adult 15mg)
8-24H oral.
Pine tar. Gel, solution: 5ml to baby
bath, 15-30ml to adult bath; soak
for 10min.
Pioglitazone. Adult (NOT/kg):
15-45mg daily oral. See also
glimepiride + pioglitazone.
Pipamperone. Adult (NOT/kg): 40mg
(max 120mg) 8H oral.
Pipecuronium. 20-85mcg/kg IV stat,
then 5-25mcg/kg prn.
Piperacillin. 50mg/kg (adult 2-3g)
6-8H IV. Severe inftn: 75mg/
kg (adult 4g) 8H (1st wk life) 6H
(2-4wk) 4-6H (>4wk) or constant
infsn.
Piperacillin 1g + tazobactam 125mg.

As for piperacillin.
Piperaquine. See dihydroartemisinin
+ piperaquine.
Piperazine. 75mg/kg (max 4g) oral
daily for 2 days (ascaris), 7 days
(pinworm).
Piperazine oestrone sulphate. See
estropipate.
Piperonyl butoxide bioallethrin. Apply enough to wet scalp or body,
leave 30min, wash off.
Pipotiazine. Oily injtn: initially
0.5mg/kg (adult 25mg), then
gradual incr to 1-4mg/kg (adult
50-200mg) every 4wk IM.
Piracetam. 15mg/kg (max 800mg)
8H oral, IM or IV.
Pirbuterol. Oral: 0.2-0.3mg/kg (adult
10-15mg) 6-8H. Inhaltn (NOT/
kg): 0.2-0.4mg 4-6H.
Piroxicam. 0.2-0.4mg/kg (adult 1020mg) daily oral. Gel 5mg/g: apply 1g (3cm) 6-8H for up to 2wk.
Pitavastatin. Adult (NOT/kg): 2mg
Pivampicillin. 15mg/kg (adult
500mg) 8-12H oral.
Pivampicillin 1.25mg + pivmecillinam 1mg. 10mg/kg per dose
(adult 250mg) of pivampicillin
12H oral.
Pivmecillinam. 5-10mg/kg (adult
200-400mg) 6-8H oral.
Pizotifen. NOT/kg: 0.5mg daily oral,
incr if reqd to max 0.5mg morning
and 1mg at night.
Plague vaccine (CSL). Inanimate.
Adult (>11yr): 0.5ml SC stat, and
1-4wk later (2 doses); boost every
6mo. Child: 0.1ml (6mo-2yr),
0.2ml (3-6yr), 0.3ml (7-11yr) SC
stat, 1-4wk later, and 1-4wk later
(3 doses); boost every 6mo.
Plerixafor. 0.24mg/kg (max 40mg)
daily SC for up to 4 days.
Plicamycin. Testicular tumours: 2530mcg/kg daily for 8-10 days IV
over 6hr, rpt monthly if response.
Hypercalcaemia: 25mcg/kg daily
for 3-4 days, then x1-3/wk.
660
POR 8. See ornipressin.

Porfimer. 2mg/kg IV, then 630nm
laser light after 40-50hr and 96120hr; max 3 courses at least 30
days apart.
Posaconazole. Invasive inftn:
150mg/m2 (max 200mg) 6H, or
300mg/m2 (max 400mg) 12H
oral with fatty meal. Oral candida
(adult NOT/kg): 200mg stat, then
100mg daily. Prophylaxis: 230mg/
m2 (max 300mg) 12H with fatty
meal .
Potassium. Deficiency: usually
0.3mmol/kg/hr (max 0.4 mmol/
kg/hr) for 4-6 hr IV, then 4mmol/
kg/day. Max oral dose 1mmol/
kg (<5yr), 0.5mmol/kg (>5yr).
Maintenance 2-4mmol/kg/day. If
peripheral IV, max 0.05 mmol/ml.
1g KCl = 13.3mmol K, 7.5% KCl =
1mmol/ml.
Potassium citrate. See citric acid +
potassium citrate.
Potassium guaiacolsulfonate.
1-3mg/kg (adult 50-160 mg) 4-6H
oral.
Potatoes, roast. Oven 2300C (2100C
fan-forced), pan with 5mm peanut oil in oven; peel potatoes, boil
20-30min until friable on outside,
drain, put in hot oil, cook on top
shelf of oven for 60-100min until
crisp (baste every 20min).
Povidone-iodine. Cream, oint,
paint, soltn: apply 6-12H.
Pralatrexate. 30mg/m2 IV wkly
for 6wk, then one wk rest (7wk
cycles).
Pralidoxime. 50mg/kg (adult 2g)
over 30min, then 20 mg/kg/
hr (adult 1g/hr) for 48hr, then
20mg/kg (adult 1g) 4H.
Pramipexole. Adult (NOT/kg):
0.125mg 8H incr by 0.125-0.25mg
every 5-7 days to 0.5-1.5mg 8H
oral. Restless legs: 0.125mg (max
0.5mg) 2-3 hours before bedtime.
Sustained release: 0.26mg daily
oral, incr if reqd to max 3.15mg
daily.
661
Drug Doses
Pneumococcal vaccine, polysaccharide (Pneumovax 23). Inanimate.

>2yr: 0.5ml SC or IM once. Boost
every 5yr.
Pneumococcal vaccine, CRM conjugate (Prevenar) or H influenzae
conjugate (Synflorix). Inanimate.
0.5ml IM. 6mo: 2mo, 3mo, 4mo,
12-15mo (4 doses). 7-11mo:
6mo, 7mo, 12-15mo (3 doses).
12-23mo: 2 doses 2mo apart.
>23mo: 1 dose.
Podofilox. See podophyllotoxin.
Podophyllotoxin. 0.5% paint: apply
12H for 3 days, then none for 4
days; 4wk course.
Podophyllum. 15%-25% soltn, oint:
apply to wart x2/day.
Polidocanol. 0.5%, 1%: 0.1-0.3ml/
dose IV, max 10ml/day.
Polifeprosan. See carmustine
wafers.
Poliomyelitis vaccine, oral (Sabin).
Live. 2 drops oral at 2mo, 4mo
and 6mo (3 doses). Boost at 5yr,
and if going to epidemic area.
Poliomyelitis vaccine, SC (IPOL). Inanimate. 0.5ml SC stat, 8wk later,
and 8wk later (3 doses). Boost
12mo later, and at school entry.
Poloxalkol. See poloxamer.
Poloxamer. 10% soltn: <6mo
10drops, 6-18mo 15drops, 18mo3yr 25drops 8H oral.
Polyethylene glycol. See colonic lavage, macrogol.
Polymyxin B. See bacitracin; dexamethasone.
Polynoxylin. 10% gel: apply 12H.
Polygeline. 10-20ml/kg (may be
repeated). Half life 2hr.
Polystyrene sulphonate. See sodium
polystyrene sulph.
Polythiazide. 0.02-0.1mg/kg (adult
1-4mg) daily oral.
Polyvinyl alcohol. 1.4%, 3% soltn: 1
drop/eye prn.
Poractant alfa (porcine surfactant,
Curosurf). Intratracheal: 200mg/
kg stat, then up to 4 doses of
100mg/kg 12H if reqd.
Drug Doses
Pramlintide. Reduce insulin dose

by 50% initially. Adult, NOT/kg.
Type 1 diabetes: 15mcg SC before
meals (x4/day), incr if tolerated to
30-60mcg/dose. Type 2: 60mcg
SC before meals (x4/day), incr if
tolerated to 90-120mcg/dose.
Pramocaine. See hydrocortisone +
pramocaine cream.
Pramoxine. 1% cream, lotion: apply
6-8H.
Prasugrel. Adult (NOT/kg): 60mg
load, then 5mg (<60kg) 10mg
(60kg) daily oral.
Pravastatin. Adult (NOT/kg): 2080mg at bedtime oral.
Praziquantel. 20mg/kg oral once
(tapeworm), 4H x3 doses (schistosomiasis), 8H x6 doses (other
flukes), 8H 14 days (cysticercosis).
Prazosin. 5mcg/kg (max 0.25mg)
test dose, then 0.025-0.1 mg/kg
(adult 1-5mg) 6-12H oral.
Prednisolone. Oral. Alopecia,
autoimm liver, Crohns, epilepsy,
SLE, ulcerative col: 2mg/kg daily,
gradually reducing. Asthma: 0.51mg/kg 6H for 24hr, 12H x2, then
1mg/kg daily. Croup: 1mg/kg stat
and in 12hr; severe 4 mg/kg stat,
then 1mg/kg 8H. ITP: 4mg/kg
daily. Nephrotic: 60mg/m2 (max
80mg) daily, reducing over several
months. Physiological: 4-5mg/m2
daily. Eye 0.5%: initially 1drop/eye
2H, then 6-12H. 1mg = hydrocortisone 4mg in glucocorticoid
activity, 0.8mg in mineralocorticoid. See also methylprednisolone, neomycin + prednisolone,
phenylephrine + prednisolone.
Prednisolone sodium phosphate.
0.5%: ear 2-3 drops/ear, eye 1
drop/eye 2-6H.
Prednisone. Action equivalent to
prednisolone.
Pregabalin. Adult (NOT/kg): 50mg
8H oral, incr gradually if reqd to
max 200mg 8H.
Pridopidine. Adult (NOT/kg): 45mg
12H oral.
Prilocaine. Max dose 6mg/kg

(0.6ml/kg of 1%). With adrenaline
max dose 9mg/kg (0.9ml/kg of
1%).
Primaquine. Usually 0.3mg/kg (adult
15mg) daily for 14-21 days oral.
Gameteocyte: 0.7mg/kg (adult
45mg) once.
Primidone. Initially 2.5mg/kg (adult
125mg) nocte, incr to max 15mg/
kg (adult 750mg) 12H oral. Trough
(phenobarbitone) 60-120umol/L.
Probenicid. 25mg/kg (adult 1g) stat,
then 10mg/kg (adult 500mg) 6H
oral.
Probucol. 10mg/kg (adult 500mg)
12H oral.
Procainamide. IV: 0.4mg/kg/min
(adult 20mg/min) for max 25min,
then 20-80mcg/kg/min (max 2g/
day). Oral: 5-8mg/kg 4H. Level
3-10mcg/ml.
Procaine. Max dose 20mg/kg (1ml/
kg of 2%).
Procarbazine. 1mg/kg (adult 50mg)
daily oral, incr over 4-6 days to
daily until remission, then 1-2mg/
kg (adult 50-100mg) daily. Suspend if leucocytes <3000/mm3 or
platelets <80,000/mm3.
Prochlorperazine. 1mg base = approx 1.5mg edisylate, maleate
or mesylate. Only use if >10kg.
Oral (salt): 0.2mg/kg (adult
5-10mg) 6-8H, slow incr if reqd
to max 0.6mg/kg (max 35mg) 6H
in psychosis. IM, slow IV (salt):
0.2mg/kg (adult 12.5mg) 8-12H.
Buccal (salt): 0.05-0.1mg/kg (max
6mg) 12-24H. PR (base): 0.2mg/
kg (adult 25mg) 8-12H.
Procyclidine. 0.05-0.2mg/kg (adult
2.5-10mg) 6-8H oral.
Progesterone. Adult (NOT/kg).
Premenst syn: 200-400mg PV or
PR 12-24H (last half of cycle). Dysfunctional uterine hemorrhage:
5-10mg/day IM for 5-10 days
before menses. Prevent abortion:
25-100mg IM every 2-4 days.
662
Prostaglandin. See alprostadil

(PGE1), carboprost (15-Me-PGF2alpha), dinoprost (PGF2-alpha),
dinoprostone (PGE2), epoprostenol (PGI2, prostacyclin),
gemeprost (PGE1 analogue), and
misoprostol (PGE1 analogue.
Protamine. IV 1mg/100u heparin
(0.5mg/100u if >1hr since heparin
dose) slow IV stat; subsequent
doses of protamine 1mg/kg (max
50mg). 1mg per 25ml pump
blood. Heparin 1mg=100u (half
life 1-2hr).
Protein C, activated. See drotrecogin
alfa.
Protein C and S. See factor 9 complex (Beriplex, Octaplex).
Prothionamide. TB: 15-20mg/
kg (adult 0.75-1g) at night oral.
Leprosy: 5-8mg/kg (adult 250375mg) daily.
Prothrombin complex. See factor 9
complex.
Protionamide. See prothionamide.
Protirelin. NOT/kg: 200mcg IV stat.
Protriptyline. 0.1-0.4mg/kg (adult
5-20mg) 6-8H oral.
Proxymetacaine. 0.5% soltn: 1 drop/
eye stat, then 1 drop every 10min
for 5-7 doses.
Prucalopride. Adult (NOT/kg): 1-2mg
daily oral.
Pseudoephedrine. 1mg/kg (adult
60mg) 6-8H oral. Slow release:
adult (NOT/kg) 120mg 12H.
Pseudoephedrine 60mg + triprolidine 2.5mg (Actifed). 10ml
elixir=1tab. NOT/kg: 2.5ml (<2yr),
2.5-5ml (2-5yr), 0.5tab (6-12yr),
1tab (>12yr) 6-8H oral.
Psyllium. Usually 0.1-0.2g/kg (adult
5-10g) 8-24H oral.
Pumactant (ALEC). Preterm babies
(NOT/kg): disconnect ETT, rapidly
inject 100mg in 1ml saline via
catheter at lower end ETT, flush
with 2ml air; repeat after 1hr and
24hr. Prophylaxis if unintubated:
100mg into pharynx.
663
Drug Doses
Proguanil. 3.5mg/kg (adult 200mg)

daily oral after food. See also
atovaquone + proguanil.
Promazine. Oral: 2-4mg/kg (adult
100-200mg) 6H. IM 0.7mg/kg
(max 50mg) 6-8H.
Promethazine. Antihist, antiemetic:
0.2-0.5mg/kg (adult 10-25mg)
6-8H IV, IM or oral. Sedative,
hypnotic: 0.5-1.5mg/kg (adult
25-100mg).
Propacetamol IV preparation: 1g =
0.5g paracetamol.
Propafenone. Oral: 70mg/m2 (adult
150mg) 8H, incr if reqd to max
165mg/m2 (adult 300mg) 8H.
IV: 2mg/kg over 2hr, then 4mcg/
kg/min incr if reqd to max 8mcg/
kg/min.
Propamidine. 0.1%: 1 drop/eye 6H
for up to 2 days.
Propantheline. 0.3-0.6mg/kg (adult
15-30mg) 6H oral.
Propiverine. 0.3mg/kg (adult 15mg)
6-12H oral.
Propofol. Sedation in ICU: 1-3mg/
kg/hr (max 4mg/kg/hr) IV, for
no longer than 48 hr. Short-term
anaesthesia: child 2.5-3.5mg/
kg stat, then 7.5-15mg/kg/hr IV;
adult 1-2.5mg/kg stat, then 3-12
mg/kg/hr IV.
Propoxyphene. See dextropropoxyphene.
Propranolol. 0.2-0.5mg/kg (adult
10-25mg) 6-12H oral, incr to max
1.5mg/kg (max 80mg) 6-12H if
reqd. IV: 0.02mg/kg (adult 1mg)
test dose then 0.1mg/kg (adult
5mg) over 10min (repeat x1-3
prn), then 0.1-0.3mg/kg (adult
5-15mg) 3H.
Propylthiouracil. 50mg/m2 8H oral,
reduce with response.
Proscillaridin. 10-15mcg/kg (adult
500-750mcg) 8-12H oral.
Prostacyclin. See epoprostenol.
Drug Doses
Pyrantel. Threadworm: 10mg/kg

Quinapril. 0.2-0.8mg/kg (adult
(adult 750mg) once oral, may
10-40mg) daily oral. See also
repeat 2wkly x3 doses. Roundhydrochlorothiazide.
worm, hookworm: 20mg/kg
Quinidine, base. 10mg/kg stat, then
(adult 1g) once, may repeat in 7
5mg/kg (max 333mg) 4-6H oral.
days. Necator: 20mg/kg (adult 1g)
IV: 6.3mg/kg (10mg/kg of glucodaily x2-3 doses.
nate) over 2hr, then 0.0125mg/
Pyrazinamide. 30-35mg/kg (max
kg/min. IM: 15mg/kg stat, then
1.5g) daily oral, or 75 mg/kg (max
7.5mg/kg (max 400mg) 8H. NOTE:
3g) x2/wk.
1mg base = 1.2mg sulphate
Pyrethrins + piperonyl butoxide.
= 1.3mg bisulphate = 1.6mg
Lice: apply enough shampoo
gluconate.
to wet hair, wash off in 15min;
Quinine, base. Oral: 8.3mg/kg
repeat in 10 days.
(max 500mg) 8H for 7-10 days.
Pyridostigmine. Myas gravis: 1mg/
Parenteral: 16.7mg/kg (20mg/kg
kg (adult 60mg) 4-6H oral, incr to
of dihydrochloride) IV over 4hr or
max 2-3mg/kg (adult 120-180mg)
IM, then 8.3mg/kg 8H IV over 2hr
4-6H if reqd. 180mg slow rel tab
or IM for 2-3 days, then 8.3mg/
(Timespan), adult (NOT/kg): 1-3
kg 8H oral for 5 days. NOTE: 1mg
tab 12-24H oral. 1mg IV, IM or SC
base = 1.7mg bisulphate = 1.2mg
= 30mg oral.
dihydrochloride = 1.2mg ethyl
Pyridoxine. With isoniazid or penicilcarbonate = 1.3mg hydrobromide
lamine (NOT/kg): 5-10mg daily
= 1.2mg hydrochloride = 1.2mg
IV or oral. Fitting: 10-15mg/kg
sulphate.
daily IV or oral. Siderobl anaemia:
Quinupristin. See dalfopristin +
2-8mg/kg (max 400mg) daily IV
quinupristin.
or oral.
Rabeprazole. Adult (NOT/kg): 20mg
Pyrilamine. See mepyramine.
daily oral 4-8wk (DU), 6-12wk
Pyrimethamine. Adult (NOT/kg):
(GU), 4wk then 10-20mg daily (re25mg tab weekly oral.
flux). ZE: 60mg daily, incr if reqd
Pyrimethamine 25mg + sulphadto 12H. H.pylori, see omeprazole.
oxine 500mg (Fansidar). <4yr
Rabies vaccine. Inanimate. 1ml IM
tab once, 4-8yr 1 tab, 9-14yr 2
days 0, 7 and 21 or 28 (3 doses).
tab, >14yr 3 tab. Prophylaxis: <4yr
Boost every 2yr, or if antibody
tab wkly, 4-8yr tab, 9-14yr
low. Postexposure: immune 1ml
tab, >14yr 1 tab. See also artesuIM days 0, 3 (2 doses); non-imnate, chloroquine, dapsone.
mune 1ml IM days 0, 3, 7, 14, 30,
Q fever vaccine (Q-Vax). See Coxiella
90 (6 doses), with immunoglobln.
burnetti vaccine.
Raloxifene. 1mg/kg (adult 60mg)
Quazepam. 0.15-0.6mg/kg (adult
daily oral.
15-30mg) at night oral.
Raltegravir (RAL). 8mg/kg (adult
Quetiapine. Adult (NOT/kg) 12H
400mg, max 600mg) 12H oral.
oral per dose: 25mg day 1, 50mg
Raltitrexed. Initially 3mg/m2 IV over
day 2, 100mg day 3, 150mg day
15min every 3wk.
4, then 150-250mg (range 75Ramelteon. Adult (NOT/kg): 8mg at
400mg) 12H.
bedtime oral.
Quinagolide. 0.5mcg/kg (adult
Ramipril. 0.05mg/kg (adult 2.5mg)
25mcg) nocte, incr to 1.5-3 mcg/
oral daily, may incr over 4-6wk
kg (adult 75-150mcg) nocte oral.
to 0.1-0.2mg/kg (adult 5-10mg)
Quinalbarbitone. Sedative 5mg/kg.
daily.
Premed 10mg/kg.
664
Drug Doses
Ranibizumab. 0.5mg by intravitreReteplase. Adult (NOT/kg) for myoous injection every month.
card infarct: give heparin 5000u
Ranitidine. IV: 1mg/kg (adult 50mg)
IV + aspirin 250-350mg oral; then
slowly 6-8H, or 2mcg/kg/min.
reteplase 10u IV over 2min + 2nd
Oral: 2-4mg/kg (adult 150mg)
dose 30min later; then heparin
8-12H, or 300mg (adult) at night.
1000u/hr for 24-72hr and aspirin
Ranitidine bismuth citrate. 8mg/kg
75-150mg/day until discharge.
(adult 400mg) 12H oral. H.pylori,
Retigabine. Adult (NOT/kg): 200see omeprazole.
400mg 8H oral.
Ranolazine. 10mg/kg (adult 500mg)
Retinol A. See vitamin A.
12H incr if reqd to 20mg/kg (adult
Reviparin. Child >2mo: 100u/kg 12H
1g) 12H oral.
SC. Adult (NOT/kg): 1432u 2hr
Rapacuronium. Initially 2mg/kg
before surgery, then daily SC.
(child), 1.5mg/kg (adult), 2.5mg/
Ribavirin. Inhltn (Viratek nebulizer):
kg Caesar); maintenance 33-50%
20mg/ml at 25ml/hr (190mcg/l of
initial.
gas) for 12-18hr/day for 3-7 days.
Rasagiline. Adult (NOT/kg): 0.5-1mg
Oral: 5-15mg/kg 8-12H. Hepatitis
daily oral.
C: see interferon alfa-2b..
Rasburicase. 0.15-0.2mg/kg IV daily
Riboflavine. NOT/kg: 5-10mg daily
for 5-7 days.
oral. Organic acidosis (NOT/kg):
Razoxane. 2mg/kg (max 125mg)
50-200mg daily oral, IM or IV.
8-24H oral; or 7.5-15mg/kg (max
Rifabutin. Pulmonary TB: 3-5 mg/
750mg) daily for 2-3 days every
kg (adult 150-300mg) daily oral.
1-4wk. Kaposi sarc, leukaemia:
Resistant pul TB: 5-7.5 mg/kg
max 0.33g/m2 8H oral.
(adult 300-450mg) daily. MycoReboxetine. Adult (NOT/kg): 2-4mg
bact avium complex: 7.5-12mg/kg
12H oral, incr gradually if reqd to
(adult 450-600mg) daily; prophymax 10mg 12H.
laxis 5mg/kg (adult 300mg) daily.
Recombinant antihaemophilic facRifampicin. 10-15mg/kg (max
tor. See factor 8.
600mg) daily oral fasting, or
Recombinant human antithrombin.
IV over 3hr (monitor AST).
See antithrombin.
Prophylaxis: N.meningitidis 10
Remifentanil. 0.05-0.2mcg/kg/min.
mg/kg daily (neonate), 10 mg/
Ventilated: usually 0.5-1 mcg/kg/
kg (max 600mg) 12H for 2 days;
min; occasionally up to 8mcg/kg/
H.influenzae 10mg/kg daily
min if reqd.
(neonate), 20mg/kg (max 600mg)
Repaglinide. Adult (NOT/kg) before
daily for 4 days.
main meals, oral: initially 0.5mg,
Rifampin. See rifampicin.
incr every 1-2wk to 4mg (max
Rifapentine. Usually 10-15 mg/kg
16mg/day).
(adult 600mg) x2/wk for 2mo,
Reproterol. Aerosol 0.5mg/puff: 1-2
then wkly for 4 months.
puffs 3-8H.
Rifaximin. Adult (NOT/kg): 200mg
Reserpine. 0.005-0.01mg/kg (adult
8H for 3 days.
0.25-0.5mg) 12-24H oral.
Rilonacept. Adult (NOT/kg): 320mg,
Residonrate. Adult (NOT/kg): 5mg
then 160mg wkly SC.
daily oral; slow release 35mg
Riluzole. 1mg/kg (adult 50mg) 12H
once a week.
oral.
Resonium. See sodium polystyrene
Rimantadine. 2.5mg/kg (adult
sulphonate.
100mg) 12H oral.
Retapamulin. 1% ointment: apply
12H for 5 days.
665
Drug Doses
Rimexolone. 1%. 1drop/eye 6H.

Uveitis: 1drop 1H in daytime for
1wk, 2H for 1wk, 6H for 1wk,
daily 1wk.
Rimonabant. Adult (NOT/kg): 20mg
oral before breakfast.
Risedronate. Osteoporosis: 0.1mg/
kg (adult 5mg) daily oral; slow release (adult): 35mg weekly, 75mg
twice a month, 150mg monthly.
Pagets: 0.5mg/kg (adult 30mg)
daily oral.
Risperidone. 0.02mg/kg (adult 1mg)
12H, incr if reqd to 0.15mg/kg
(adult 2-4mg, max 8mg) 12H oral.
Ritodrine. Prem labour (NOT/kg):
50mcg/min, incr to 150-350mcg/
min IV; then oral 10mg 2H for
24hr, 10-20mg 4-6H.
Ritonavir (RTV). See atazinavir, darunavir, efavirenz, fosamprenavir,
indinavir, lopinavir, maraviroc.
Ritonavir + saquinavir. 5-14kg: RTV
3mg/kg + SQV 50 mg/kg 12H oral
with food; 15-39kg: RTV 2.5mg/
kg + SQV 50mg/kg 12H; 40kg:
RTV 100mg + SQV 50mg/kg (adult
1000mg) 12H.
Ritonavir + tipranavir. 2yr: RTV
150mg/m2 (max 200mg) + TPV
375 mg/m2 (max 500mg) 12H
oral with food.
Rituximab. Leukaemia: 260-370mg/
m2 by IV infsn wkly x4. Rheumatoid arthritis (adult, NOT/kg): 1g
IV twice, 2wk apart.
Rivaroxaban. Adult (NOT/kg): 10mg
daily oral.
Rivastigmine. Adult (NOT/kg):
initially 1.5mg 12H, incr every
2wk to max 6mg 12H oral. Patch:
apply 4.6mg (5cm2) daily for 4wk,
then 9.5mg (10cm2) daily.
Rizatriptan. Adult (NOT/kg): 10mg
oral, may repeat x1 in 2hr.
Rocuronium. 0.6-1.2mg/kg IV stat,
then 0.1-0.2mg/kg boluses or
5-15mcg/kg/min.
Roflumilast. Adult (NOT/kg): 500mcg
daily oral.
Romidepsin. 14mg/m2 IV over 4hr

on days 1, 8 and 15 of a 28-day
cycle.
Romiplostim. 1-10mcg/kg weekly
SC.
Ropinirole. Adult (NOT/kg): 0.25mg
daily for 2 days, 0.5mg for 5 days,
then 1mg daily; incr wkly to max
4mg daily oral. Restless legs:
0.25mg (max 4mg) 2hr before
bedtime.
Ropivacaine. 2-3mg/kg (adult max
200-250mg). Intrathecal: 1mg/kg
(0.1ml/kg of 1%). Postop infusion
0.2-0.4mg/kg/hr (0.1-0.2ml/kg/
hr of 0.2%).
Rosiglitazone. Adult (NOT/kg):
4mg daily oral, incr after 6-8
wk to 4mg 12H if reqd. See also
glimepiride + rosiglitazone and
metformain + rosiglitazone.
Rosuvastatin. 10mg daily oral, incr if
reqd to 20mg then 40mg at 4wk
intervals.
Rotavirus vaccine (Rotarix). Live,
monovalent. 1.5ml oral at
6-14wk, and at least 4wk later at
14-24wk (total 2 doses).
Roatvirus vaccine (Rotateq). Live,
pentavalent. 2ml oral at 6-12wk,
then at 4-10wk intervals (total 3
doses).
Rotavirus vaccine, human-bovine
(RotaTeq). Live, penta-valent.
2ml oral at age 2mo, 4mo, 6mo
(3 doses).
Rotigotine. Adult, NOT/kg: 2mg
patch daily for 1wk, then 4mg
daily; incr if reqd to 6mg daily.
Roxithromycin. 2.5-4mg/kg (adult
150mg) 12H oral.
Rubella vaccine (Ervevax, Meruvax
II) Live. >12mo: 0.5ml SC once.
See also measles + mumps +
rubella vaccine.
Rufinamide. 10mg/kg (adult 400mg)
daily oral, incr over 1-2wk to
45mg/kg (adult 3200mg). Lower
dose if on valproate.
Rupatadine. Adult (NOT/kg): 10mg
daily oral.
666
Saquinavir (SQV). See lopinavir, ritonavir. Trough 100-250ng/ml.

Saracenia purpurea (Sarapin). Adult
(NOT/kg): 2-10ml nerve block,
5-10ml local infiltration.
Sargramostim (GM-CSF, Leucomax).
3-5mcg/kg daily SC, or IV over
6hr. Keep WCC 5,000-10,000/
mm3.
Saxagliptin. Adult (NOT/kg): 5mg
daily oral.
Scopolamine. See hyoscine hydrobromide.
Secbutobarbitone. 0.3-0.6mg/kg
(adult 15-30mg) 6-8H, or 1-4mg/
kg (adult 50-200mg) nocte oral.
Secobarbital sodium. See quinalbarbitone.
Secretin. 1cu = 4chr units. 1-2cu/kg
slow IV.
Selegiline. Adult (NOT/kg): 10mg
daily, oral. Transdermal patch:
6mg daily; incr to max 9-12mg
daily if reqd.
Selenium sulphide. 2.5% shampoo
x2/wk for 2wk.
Senna, Sennoside. Tab 7.5mg, granules 15mg/5ml. Daily (NOT/kg):
6mo-2yr 7.5mg, 3-10yr 7.5-15mg,
>10yr 1-30mg.
Sermorelin (GHRH). 1mcg/kg fasting
in morning IV.
Sertaconazole. 2% cream: apply 12H
for 4wk.
Sertindole. Adult 4mg daily, incr to
12-24mg daily oral.
Sertraline. 0.5mg/kg (adult 25mg)
daily oral, incr if reqd to 1-2mg/
kg (adult 50-100mg) daily; may
give 3-4mg/kg (adult 150-200mg)
daily for up to 8wk.
Sevelamer. 20-40mg/kg (adult
800-1600mg) 8H oral, titrated to
serum phosphorus.
Sevoflurane. 7% (child) 5% (adult)
induction, then 0.5-3%.
Sibutramine. Adult (NOT/kg): usually
10mg (range 5-15mg) daily oral.
667
Drug Doses
Sacrosidase. 15kg 1ml or 1 full

scoop (8500-u), >15kg 2ml or 2
full scoops (17000u) oral with
each meal or snack.
Salbutamol (and levalbuterol). 0.10.15mg/kg (adult 2-4mg) 6H oral.
Inhaltn: mild resp soltn (5mg/
ml, 0.5%) 0.5ml diluted to 4ml, or
nebule 2.5mg/2.5ml (0.1%) 3-6H;
moderate 0.5% soltn 1ml diluted
to 4ml, or nebule 5mg/2.5ml
(0.2%) 1-2H; severe (in ICU)
0.5% soltn undiluted continuous.
Aerosol 100mcg/puff: 1-2 puff
4-6H. Rotahaler: 200-400mcg
6-8H. IM or SC: 10-20 mcg/kg
(adult 500mcg) 3-6H. IV in child:
amp 1mg/ml at 0.3-0.6ml/kg/hr
(5-10mcg/kg/min) for 1hr, then
0.06-0.12ml/kg/hr (1-2mcg/kg/
min). Preterm labour: (adult,
NOT/kg): 200 mcg/ml in 5%D at
3ml/hr (10mcg/min), incr until
contractions cease (usually at
3-15ml/hr), then halve dose
every 6hr; max duration usually
48hr. IV infsn incompatible with
aminophylline, ketamine and
magnesium.
Salcatonin. Hypercalcaemia: 5u/kg
12-24H IM, SC or IV over 6-12hr.
Pagets: adult 50-100u daily. Cancer bone pain: 4u/kg (adult 200u)
up to x4/day.
Salicylic acid. Cradle cap: 6% soltn
(Egocappol) 12H 3-5 days. Plantar
warts: 15% soltn x1-2/day, 40%
medicated disc 24-48H. See also
benzoic acid + salicylic acid.
Salicylsalicylic acid. See salsalate.
Salmeterol. Aerosol, diskhaler (NOT/
kg): 50-100mcg 12H. See also
fluticasone + salmeterol.
Salmonella typhi vaccine. See
typhoid vaccine.
Salsalate. 10-20mg/kg (adult 0.5-1g)
6H oral.
Samarium-153. Adult: 1.0mCi/kg IV
over 1min.
Sapropterin. 10mg/kg (max 20mg/
kg) daily oral.
Drug Doses
Sildenafil. Adult sexual dysfunction: 25-100mg (NOT/kg) oral 1hr

before sexual activity (max once/
day). Pul hypertension: 0.3mg/
kg 3-6H incr until effective or systemic hypotension occurs (usual
max 2-3 mg/kg/dose); adult
(NOT/kg) usually 20mg 8H oral.
1hr before stopping NO: 0.4mg/
kg oral once.
Silodosin. Adult (NOT/kg): 8mg daily
oral.
Silver nitrate, stick. Apply daily to
affected area only.
Silver sulfadiazine 1% + chlorhexidine 0.2%. Cream: apply in
3-5mm layer.
Simethicone. See aluminium hydroxide compound.
Simvastatin. Adult (NOT/kg): 10mg
daily oral, incr 4wkly if reqd to
max 80mg daily. See also simvastatin + ezetimibe.
Sincalide. Contract gallbladder:
0.02mcg/kg IV over 1min, then
0.04mcg/kg after 15min if reqd;
or 0.1 mcg/kg IM; or 0.12mcg/
kg in 100ml saline at 2ml/min.
Pancreas test: 0.25 u/kg secretin
IV over 60min, plus sincalide
0.02mcg/kg IV infsn during 2nd
30min of secretin infsn.
Sinecatechins. 15% ointment: apply
8H for up to 16wk.
Sipuleucel-T. Adult (NOT/kg): 50
million treated autologous CD54+
cells IV over 60min on 3 occasions
2wk apart.
Sirolimus. 3mg/m2 (adult 6mg) stat,
then 1mg/m2 (adult 2mg) daily
oral.
Sitagliptin. 2mg/kg (adult 100mg)
daily oral. See also metformin +
sitagliptin..
Sitaxentan. 2mg/kg (adult 100mg)
daily oral.
Sodium. Deficit (ml saline) = Wt(kg)

x 4 x (140 - [Na]) / % saline. To
incr serum Na by 0.5mmol/L/
hr (max safe rate), infusn rate
(ml/hr) = 2 x Wt(kg) / (% saline
infused); hours of infusion = 2
x (140 - serum Na). 4ml/kg of
X% saline raises serum Na by
Xmmol/L. Need 2-6 mmol/kg/
day. NaCl MW = 58.45, 1g NaCl
= 17.1mmol Na, NaCl 20% =
3.4mmol/ml.
Sodium alginate. See alginic acid.
Sodium aurothiomalate. 0.25mg/
kg wkly IM, incr to 1 mg/kg (max
50mg) wkly for 10wk, then every
2-6wk.
Sodium benzoate. Neonate: 250mg/
kg over 2hr stat, then 10-20mg/
kg/hr IV.
Sodium bicarbonate. See bicarbonate.
Sodium calcium edetate (EDTA). 2540mg/kg 12H IM or IV over 1hr
for 5 days; rpt after 3 days if reqd.
With dimercaprol: 12.5mg/kg 4H
for 3-7 days.
Sodium cellulose phosphate (Calcisorb). Adult: 5g (NOT/kg) 8H oral.
Sodium chloride. See sodium.
Sodium citrate. Constipation (adult,
NOT/kg): usually 450mg in 5ml as
enema, often with sodium lauryl
sulphoacetate, glycerol, sorbitol
or sorbic acid.
Sodium citrotartrate. 40-80mg/kg
(adult 2-4g) in 50ml water 8-12H
oral.
Sodium clodronate. See clodronate.
Sodium cromoglycate. Inhalation (Intal): 1 cap (20mg) 6-8H,
2ml soltn (20mg) 6-8H, aerosol
1-10mg 6-8H. Eye drops 2%: 1
drop/eye 4-6H. Oral: 5-10mg/kg
(max 200mg) 6H oral. Nasal 2% or
4%: 1 dose to each nostril 3-12H.
Sodium feredetate. See ferrous salts.
Sodium ferric gluconate. Fe 12.5mg/
ml. 0.05ml/kg (adult 2ml) test
dose IV over 1hr, then 0.25ml/kg
(adult 10ml) IV over 1hr with each
dialysis (usually for 8 doses).
668
Drug Doses
Sodium fluoride. NOT/kg: <2yr

Sodium salicylate. 1g = 1.1g aspirin.
0.55mg oral daily, 2-4yr 1.1
Sodium stibogluconate. Soltn
mg, >4yr 2.2mg. Osteoporosis,
100mg/ml of pentavalent
Pagets, bone secondaries in adult
antimony. 20mg/kg (usual max
(NOT/kg): 20-40mg 8-12H.
850mg) daily IV over 5-10min for
Sodium fusidate. Tablets: 10-15mg/
20 days (visceral) or at least 4wk
kg (adult 250-500mg) 8H oral.
(mucocutaneous); 10-15mg/kg
IV over 2-8hr: 10mg/kg (adult
12H if toxicity or poor response.
500mg) 8H; severe inftn 15mg/
Early cutaneous: infiltrate lesions
kg (adult 750mg). Peak level
with 1-3ml, repeat x1-2 if reqd
30-200umol/L (x0.52 = mcg/ml).
after 1-2 days. Severe cutaneous:
For suspension, see fusidic acid.
20mg/kg daily IV over 5-10min
Sodium hyaluronate. Adult (NOT/
until 3 days after cure (usually),
kg). Cystitis 800mcg/ml: 50ml into
for 4wk (L.braziliensis), or 3mo
bladder wkly x4, then 4wkly. Ophafter cure (L.amazonensis).
thalmic: 10-15 mg/ml (1-1.5%)
Sodium tetradecyl sulphate. NOT/
0.2-0.6ml into anterior chamber;
kg: 0.25-1ml per vein as 1% (max
0.18% drops 1/eye as reqd. Os10 small veins) or 3% (max 4 large
teoarthritis 10-15mg/ml: 2-2.5ml
veins).
intra-articular wkly x3-5.
Sodium thiosulphate. 1ml/kg (adult
Sodium nitrite. 3%: 0.2ml/kg (max
50ml) 25% soltn IV over 10min.
10ml) IV over 5 min.
Sodium valproate. 5mg/kg (adult
Sodium nitroprusside. <30kg: 3mg/
200mg) 8-12H oral, incr if reqd to
kg in 50ml 5%dex-hep at 0.5-4ml/
max 20mg/kg (adult 1g) 8-12H.
hr (0.5-4mcg/kg/min) IV. >30kg:
Slow-rel 15-60 mg/kg (adult 10003mg/kg made to 100ml in 5%dex3000mg) daily. Level 2hr after dose
hep at 1-8ml/hr (0.5-4mcg/kg/
350-900umol/l (x0.14=mg/l).
min). If used for >24hr, max rate
Solifenacin. Adult (NOT/kg): 5-10mg
4mcg/kg/min. Max total 70mg/
daily oral.
kg with normal renal function
Somatorelin. Diagnostic: 1mcg/kg
(or sodium thiocyanate <1725
IV. Therapy: 30mcg/kg daily at
umol/L, x0.058=mg/L). Protect
bedtime SC.
from light.
Somatostatin. See octreotide.
Sodium oxybate. Narcolepsy (NOT/
Somatrem. 4u/m2 3 days a wk IM.
kg): 2.25g at bedtime, repeated
Somatropin. 1mg = 3iu. Usually
2-4hr later; incr if reqd by 0.75g
2-3iu/m2 on 5-7 days a wk SC, or
every 2wk to max 4.5g + 4.5g (9g
4-6iu/m2 on 3 days a wk IM.
per night).
Sorafenib. Adult (NOT/kg): 400mg
Sodium phenylbutyrate. 10-13g/m2/
12H (or 24-48H) oral.
day divided into equal amounts
Sorbitol 70%. 0.2-0.5ml/kg (adult
with each feed or meal, oral.
20-30ml) 8-24H oral. With actiSodium phosphate. See phosphate,
vated charcoal: 1g/kg (1.4ml/kg)
sodium.
NG, x1-2.
Sodium picosulphate. 2.5mg (1-4yr),
Sorbolene cream; pure, with 10%
2.5-5mg (4-10yr), 5-10mg (>10yr)
glycerin, or with 5% or 10% olive
at night oral.
oil or peanut oil. Skin moisturSodium polystyrene sulphonate
iser: apply prn.
(Resonium). 0.3-1 g/kg (adult 15Sotalol. IV: 0.5-2mg/kg (adult
30g) 6H NG (give lactulose) or PR.
25-120mg) over 10min 6H. Oral:
Sodium pyrrolidone carboxylate.
2.5% cream: apply prn.
8-12H.
669
Drug Doses
Sparfloxacin. 10mg/kg (adult

400mg) stat, then 5mg/kg (adult
200mg) daily oral.
Spectinomycin. 40-80mg/kg (adult
2-4g) IM once.
Spironolactone. Oral (NOT/kg):
0-10kg 6.25mg 12H, 11-20kg
12.5mg 12H, 21-40kg 25mg 12H,
over 40kg 25mg 8H. Female
hirsutism 50mg 8H. IV: see potassium canrenoate.
Stanolone. 2.5% gel. Male: apply
5-10g daily to a large area of skin
and allow 5 min to dry. Female
(lichen sclerosus): apply 2.5g to
vulva on alternate days.
Stanozolol. 0.05-0.2mg/kg oral
(adult 2.5-10mg) daily at first,
then every 2-3 days.
Stavudine (d4T). 0.5mg/kg
(<14days) 1mg/kg (<30kg), 30mg
(30-59kg), 40mg (60kg) 12H oral.
Slow rel (adult, NOT/kg): 75mg
(<60kg), 100mg (60kg) daily oral.
Sterculia. NOT/kg: 3.5-7g 12-24H
oral. See also frangula.
Stibogluconate. See sodium stibogluconate.
Stilboestrol. Ca breast (NOT/kg):
10-20mg daily oral. Ca prostate:
1-3mg daily oral or IV.
Streptokinase (SK). Short term
(myoc infarct): 30,000u/kg (max
1,500,000u) IV over 1hr, repeat
if occlusion recurs <5 days. Long
term (DVT, pul emb, art thrombosis): 2,000 u/kg (max 100,000u)
IV over 10min, then 1000u/kg/hr
(max 100,000u/hr); stop heparin
and aspirin, if PTT <x2 normal at
4hr give extra 10,000u/kg (max
500,000u) IV over 30min, stop
SK if PTT >x5 normal then give
1000u/kg/hr. Local infsn: 50 u/kg/
hr (continue heparin 10-15u/kg/
hr). Blocked IV cannula: 5000u/
kg in 2ml in cannula for 2hr then
remove, may repeat x2.
Streptomycin. 20-30mg/kg (max 1g)
IM daily.
Streptozocin. 1-1.5g/m2 wkly IV.
Strontium-89. 1.5-2.2 MBq/kg (4060Ci/kg) IV over 2min.

Strontium ranelate. Adult, NOT/kg:
2g daily at bedtime.
Succimer. 350mg/m2 8H for 5 days,
then 12H x14 days oral.
Succinylcholine. See suxamethonium.
Sucralfate. 1g tab (NOT/kg): 0-2yr
quarter tab 6H, 3-12 yr half tab
6H, >12yr 1 tab 6H oral.
Sucrose. Analgesia in infants: 0.17g/
kg (0.5ml/kg of 33% soltn) 2min
before procedure.
Sufentanil. 2-50mcg/kg slow IV; may
then infuse so that total dose is
1mcg/kg/hr of expected surgical
time.
Sugammadex. 2mg/kg (after spontaneous recovery), 4mg/kg (if 1-2
post-tetanic counts), 16mg/kg for
immediate reversal of rocouronium (but not vecuronium).
Sulbactam. See ampicillin + sulbactam.
Sulconazole. 1% cream: apply 12H
for 3wk after cure.
Sulfacetamide. See sulphacetamide.
Sulfadiazine. 50mg/kg (max 2g) 6H
slow IV.
Sulfadoxine. See pyrimethamine +
sulphadoxine.
Sulfamethizole. See sulphamethizole.
Sulfamethoxazole + trimethoprim.
See cotrimoxazole.
Sulfametopyrazine. 40mg/kg (adult
2g) wkly oral.
Sulfasalazine. See sulphasalazine.
Sulfinpyrazone. See sulphinpyrazone.
Sulfisoxazole. See sulphafurazole.
Sulindac. 4mg/kg (adult 200mg)
12H oral.
Sulphacetamide. 100mg/ml 1 drop/
eye 2-3H during the day.
Sulphadoxine. See pyrimethamine +
sulphadoxine.
Sulphafurazole. 75mg/kg (adult 4g)
stat, then 35mg/kg (adult 1.5g)
4-6H oral.
670
Tadalafil. Adult (NOT/kg): 10mg

(range 5-20mg) oral 30min before
sex (max x1/day), or 2.5mg (max
5mg) every day. Pulmonary
hypertension: 40mg daily.
Tafluprost. 15mcg/ml: 1 drop/eye at
bedtime.
Tamoxifen. Adult (NOT/kg): 20mg
daily, incr to 40mg daily if no
response after 1mo.
Tamsulosin. Adult 400mcg daily
after breakfast oral. See also dutasteride + tamsulosin.
Tapentadol. 1-2mg/kg (adult 50100mg) 4-6H oral.
Tar. See coal tar.
Tasonermin. Isolated limb perfusion:
arm 3mg, leg 4mg.
Tazarotene. 0.05%, 0.1% gel, cream:
apply a thin layer to affected area
daily (or on alternate days) in the
evening.
Tazobactam. See piperacillin +
tazobactam.
Tegafur 100mg + uracil 224mg.
100mg/m2 tegafur + 224 mg/
m2 uracil (with 30mg calcium
folinate) 8H oral for 28 days, 7
days off, then repeat cycle.
Tegaserod. Adult (NOT/kg): 6mg 12H
oral before a meal.
Teicoplanin. 250mg/m2 IV over
30min stat, then 125mg/m2 IV or
IM daily. Severe inftn: 250mg/m2
12H x3 doses, then 250mg/m2 IV
or IM daily.
Telavancin. 10mg/kg IV over 1hr
daily.
Telbivudine. Adult (NOT/kg): 600mg
daily oal.
Telithromycin. Adult (NOT/kg):
800mg oral daily.
Telmisartan. 1mg/kg (adult 40mg)
daily, incr if reqd to 2 mg/kg (adult
80mg) daily oral. See also hydrochlorothiazide + telmisartan.
Temazepam. 0.3mg/kg (adult 2040mg) oral.
Temocillin. 25-50mg/kg (adult 1-2g)
12H IV or IM.
671
Drug Doses
Sulphamethizole. 10mg/kg (adult

0.5-1g) 6H oral.
Sulphamethoxazole + trimethoprim. See cotrimoxazole.
Sulphasalazine. Active colitis: 20mg/
kg 6-12H (max 4g/day) oral;
remission 7.5mg/kg (max 0.5g)
6-8H, suppos (NOT/kg) adult 0.51g 12H. Arthritis: 5mg/kg 12H,
incr if reqd to 10mg/kg 8-12H
(max 2g/day).
Sulphinpyrazone. 2-3mg/kg (max
200mg) 6-12H oral.
Sulpiride. 4mg/kg (adult 200mg)
12H, slow incr if reqd to 4-24mg/
kg (adult 0.2-1.2g) 12H oral.
Sulthiame. 1mg/kg (adult 50mg)
8-12H oral, may incr to 5mg/kg
(adult 200mg) 8H.
Sumatriptan. Oral: 1-2mg/kg (adult
50-100mg) stat, may repeat
twice. SC or needle-free: 0.12mg/
kg (max 6mg) stat, may repeat
once after 1hr. Nasal: 10-20mg,
may repeat x1 after 2hr.
Sunitinib. Adult (NOT/kg): 50mg
(37.5-87.5mg) daily oral for 4wk,
then 2wk off.
Surfactant. See beractant (Survanta), calfactant (Infasurf), colfosceril palmitate (Exosurf), poractant alfa (Curosurf), pumactant
(ALEC).
Suxamethonium. IV: neonate 3mg/
kg, child 2mg/kg , adult 1mg/kg.
IM: double IV dose.
Tacalcitol. 4mcg/g oint, lotion: apply
sparingly at bedtime (max 10g
oint or lotion per day).
Tacrine. Adult (NOT/kg): 10mg 6H
oral for 6wk, then incr if reqd by
10mg every 6wk to max 40mg 6H.
Tacrolimus. IV infusion: 2mg/m2/
day. Oral: 3mg/m2 12H. Trough
level: whole blood 10-15ng/ml.
Tacrolimus ointment. 2-16yr: apply
0.03% sparingly 12H for max 3wk,
then daily. >16yr: apply 0.1%
sparingly 12H for max 3wk, then
0.03% 12H.
Drug Doses
Temoporfin. 150mcg/kg IV over

10min; 96hr later give 652 nm
laser for about 200 sec to give
20J/cm2; repeat once after 4wk
if reqd.
Temozolomide. 200mg/m2 daily
oral for 5 days per 28 day cycle
(150mg/m2 for first cycle if previous chemotherapy).
Temsirolimus. Adult (NOT/kg): 25mg
IV over 1hr wkly.
Tenecteplase. 1mg = 200u. Myocar
infarct (adult): 100u/kg (max
10,000u) IV over 10sec once;
also give aspirin 150-325mg/day,
and heparin to maintain APTT
50-75sec.
Teniposide. 100-150mg/m2 IV over
1hr wkly.
Tenofovir (TDF). 300mg of tenofovir
DF = 245mg tenofovir D. <35kg:
8-10mg/kg daily oral; 35kg:
300mg daily oral. See also efavirenz and emtricitabine.
Tenoxicam. 0.2-0.4mg/kg (adult 1020mg) daily oral.
Terazosin. 0.02mg/kg test, then
0.04-0.4mg/kg (adult 2-20 mg)
daily oral.
Terbinafine. 62.5mg (<20kg), 125mg
(20-40kg), 250mg (adult) daily
oral. 1% cream, gel: apply 12-24H
to dry skin.
Terbutaline. Oral: 0.05-0.1mg/kg
(adult 2.5-5mg) 6H. SC: 5-10mcg/
kg (adult 0.25-0.5mg). IV: child
3-6mcg/kg/min for 1hr, then 0.41mcg/kg/min; adult 0.25mg stat
over 10min, then 1-10mcg/kg/
hr. Inhaltn: mild resp soltn (1%,
10mg/ml) 0.25ml diluted to 4ml
3-6H; moderate 0.5ml of 1% diluted to 4ml, or respule 5mg/2ml
1-2H; severe (in ICU) undiluted
continuous. Aerosol 250mcg /
puff: 1-2 puffs 4-6H.
Terfenadine. 30mg (6-12yr), 60mg
(adult) 12H oral.
Teriparatide. Adult (NOT/kg): 20mcg
SC daily.
Terlipressin. 0.04mg/kg (adult 2mg)

IV, then 0.02-0.04mg/kg (adult
1-2mg) 4-6H for max 72hr. Slow
onset, long action: continuous
infsn may cause necrosis.
Testolactone. 5-10mg/kg (max
250mg) 6H oral. Testosterone.
Esters (NOT/kg): 100-500mg IM
every 2-4wk. Implant: 8mg/kg (to
nearest 100mg) every 16-24wk.
Undecanoate (NOT/kg): 40mg
daily oral, incr to 80-120mg
daily. 1% gel: 5g tube (50mg
testosterone) to skin daily. 30mg
buccal tab: applied just above
incisor 12H. Postmenopausal
breast cancer (NOT/kg): 100mg
x2-3/wk IV or IM. Testosterone
level: <16yr 5-10nmol/L, >16yr
10-30nmol/L.
Tetanus toxoid (Tet-Tox). 0.5ml IM
stat, 6wk later, and 6mo later.
Boost every 10yr, or if contaminated wound. See also diphtheria
(+ pertussis) + tetanus vaccines.
Tetrabenazine. Adult (NOT/kg):
12.5 daily oral; slow increase if
required to max 37.5mg 8H oral.
Tetracaine. See amethocaine.
Tetracosactrin zinc injection (Synacthen Depot). 600 mcg/m2 (max
1mg) IM every 1-7 days.
Tetracycline. >8yr (NOT/kg): 250500mg 6H oral. Acne (NOT/kg):
500mg 12H, reducing to 250mg
12H. Eye: apply 2-8H. See also
rolitetracycline.
Tetrahydrobiopterin. Defective
synthesis: 20mg/kg daily oral.
Defective regeneration: 5mg/kg
6H oral. Loading test: 20mg/kg
oral, 2mg/kg IV.
Tetrahydrozoline. 0.05%: 1 drop/
eye 8-12H. See also macrogol +
tetrahydrozoline.
Thalidomide. 4mg/kg (adult 200mg)
12H oral, reducing over 2-4wk to
0.5-1mg/kg (adult 25-50mg) 12H.
THAM. See trometamol.
672
Thrombin, topical. 100-2000u/ml

onto bleeding surface.
Thymidine. 75g/m2 every 4-6wk IV
over 24hr.
Thymoxamine. Adult (NOT/kg): 4080mg 6H oral.
Thyrotropin alfa. Adult (NOT/kg):
0.9mg IM 24H x2 doses, or 72H
x3 doses.
Thyroxine. 50mcg tab. 100mcg/m2
rounded to nearest quarter tab
(adult 100-200mcg) daily oral.
Tiagabine. 0.1mg/kg (adult 5mg)
12H oral, incr wkly to 0.1-0.2mg/
kg (adult 5-10mg) 8H; 0.2-0.3mg/
kg (adult 10-15mg) 8H if on
carbamazepine, phenobarb,
phenytoin, primidone.
Tiaprofenic acid. 2-4mg/kg (adult
100-200mg) 8H oral.
Tibolone. Adult (NOT/kg): 2.5mg
daily oral.
Ticarcillin. 50mg/kg (adult 3g)
IV 6-8H (1st wk life), 4-6H or
constant infsn (2+ wk). Cystic fib:
100mg/kg (max 6g) 8H IV.
Ticarcillin + clavulanic acid. Dose as
for ticarcillin.
Tick-borne encephalitis vaccine.
Inanimate. 0.5ml IM stat, after
4-12wk, and after 9-12mo. Boost
every 3-6yr.
Ticlopidine. 5mg/kg (adult 250mg)
12H oral.
Tigecycline. 2mg/kg (adult 100mg)
IV over 1hr stat, then 1mg/kg
(adult 50mg) IV over 30min 12H.
Tilactase. 200u/drop: 5-15 drops/L
added to milk 24hr before use.
3300u/tab: 1-3tabs with meals
oral.
Tiludronate. Adult 400mg daily for
12 wk oral.
Tiludronic acid. See tiludronate
disodium.
Timolol. 0.1mg/kg (adult 5mg)
8-12H, incr to max 0.3mg/
kg (adult 15mg) 8H. Eye drops
(0.25%, 0.5%): 1 drop/eye
12-24H; see also bimatoprost +
timolol, latanoprost + timolol.
673
Drug Doses
Theophylline. 80mg theophylline =

100mg aminophylline). Loading
dose: 8mg/kg (max 500mg) oral.
Maintenance: 1st wk life 2mg/
kg 12H; 2nd wk 3mg/kg 12H;
3wk-12mo ((0.1 x age in wk) +
2.7) mg/kg 8H; 1-9yr 4mg/kg
4-6H, or 10mg/kg slow rel 12H;
10-16yr or adult smoker 3mg/kg
4-6H, or 7mg/kg 12H slow rel;
adult non-smoker 3mg/kg 6-8H;
elderly 2mg/kg 6-8H. Serum level:
neonate 60-80umol/L, asthma
60-110 (x0.18 =mcg/ml).
Thiabendazole. 25mg/kg (max 1.5g)
12H oral 3 days.
Thiamazole. See methimazole.
Thiamine. Beriberi: 1-2mg/kg IV, IM
or oral daily. Metabolic dis (NOT/
kg): 100mg 8H IV, IM, SC, oral.
Thiethylperazine. >10kg: 0.2mg/
kg (adult 10mg) 8-24H oral, IM,
or PR.
Thioguanine. 100mg/m2 daily oral;
or 100mg/m2 12H for 5-7 days.
Thiopental. See thiopentone.
Thiopentone. 2-5mg/kg slowly stat
(beware hypotension). IV infsn:
amp 25mg/ml at 0.04-0.2ml/
kg/hr (1-5mg/kg/hr). Level
150-200umol/L (x0.24 = mcg/ml).
Thioridazine. 0.5-3mg/kg (adult 25150mg) 6-8H oral or IM.
Thiosulphate. See sodium thiosulphate.
Thiotepa. 10-14mg/m2 IV every
1-4wk.
Thiotepa. 1 in 2000: 1 drop/eye
4-6H for 6wk.
Thiothixene. >12yr (NOT/kg):
initially 2mg 8H oral, slow incr to
2-20mg per dose.
Threonine. 15-30mg/kg (adult 0.751.5g) 8H oral.
Thrombin glue. 10,000u thrombin in
9ml mixed with 1ml 10% calcium
chloride in syringe 1, 10ml cryoprecipitate in syringe 2: apply to
bleeding sites together. Do not
inject.
Drug Doses
Timolol 5mg/ml + travoprost

Tocainide. 5-10mg/kg (max 40040mcg/ml. 1drop/eye daily.
800mg) 8-12H IV over 30min or
Tinidazole. Giardia, trichomonas:
oral.
50mg/kg (adult 2g) daily for 2
Tocilizumab. 4mg/kg (up to 8mg/kg)
days oral, or 25mg/kg (adult 1g)
IV over 1hr every 4wk.
daily x5 days. Amoebiasis: 50mg/
Tocopherol. See alpha-tocopheryl
kg (adult 2g) daily for 3-5 days,
acetate, and vitamin E. Tolazausually followed by diloxanide
mide. 2-5mg/kg (adult 100furoate 10mg/kg (adult 500mg)
250mg) 6-24H oral.
8H x10 days.
Tolazoline. Newborn: 1-2mg/kg
Tinzaparin. 1mg = 75 anti-Xa IU.
slowly stat (beware hypotenProphylaxis: 50u/kg SC 2hr before
sion), then 2-6mcg/kg/min
surgery, then daily for 7-10 days.
(0.12-0.36mg/kg/hr) IV. Note:
Treatment: 175u/kg SC daily for
1-2mg/kg/hr too much (Pediatrics
at least 6 days.
1986;77:307).
Tioconazole. 280mg/ml: apply to
Tolbutamide. Adult (NOT/kg): ininails 12H for 6-12mo.
tially 1g 12H oral, often reducing
Tioguanine. Usually 200mg/m2 daily
to 0.5-1g daily.
oral for 5-20 days.
Tolcapone. Adult (NOT/kg): 100mg
Tiopronin. 3-10mg/kg (adult 1508H oral; if no response, try maxi500mg) 6-8H oral.
mum dose of 200mg 8H. Monitor
Tiotropium. NOT/kg: 18mcg cap
ALT and AST.
daily by inhaler.
Tolfenamic acid. 4mg/kg (adult
Tipranavir (TPV). Resistant HIV-1
200mg) oral, may repeat once
trough 20,500 ng/ml.
after 2hr.
Tirilazad. 1.5mg/kg 6H IV over
Tolmetin. 5-10mg/kg (adult 40030min.
600mg) 8H oral.
Tirofiban. 0.4mcg/kg/min for 30min,
Tolnaftate. 1% cream, ointmnt,
then 0.1mcg/kg/min for 2-5 days;
powdr, soltn: apply 8-12H.
also give heparin to APTT x2
Tolterodine. 0.05mg/kg (adult 2mg)
normal.
12H oral. Slow rel: adult 2-4mg
Tissue plasminogen activator. See
daily oral.
alteplase.
Tolvaptan. Adult (NOT/kg): 15mg
Tizanidine. 0.01mg/kg (adult 0.5mg)
8H, incr gradually to 0.1-0.25mg/
Topiramate. 1mg/kg (adult 50mg)
kg (adult 6-12mg) 8H oral.
12-24H oral, incr slowly if reqd
Tobramycin. IV or IM. 1wk-10yr:
to 4-10mg/kg (adult 100-500mg)
8mg/kg day 1, then 6 mg/kg
12H.
daily. >10yr: 7mg/kg day 1, then
Topotecan. 1.5mg/m2 daily x5 IV
5mg/kg (max 240-360mg) daily.
over 30min, repeat every 3wk for
Neonate, 5mg/kg dose: <1.2kg
at least 4 courses.
48H (0-7 days of life), 36H (8-30
Torasemide. 0.1-1mg/kg (adult
days), 24H (>30 days); 1.2-2.5kg
5-50mg) daily oral or IV. Rarely up
36H (0-7 days of life), 24H (>7
to 4mg/kg (adult 200mg) daily in
days); term 24H (0-7 days of life),
renal failure.
then as for 1wk-10yr. Trough level
Toremifene. Adult (NOT/kg): 60mg
<1.0mg/L. Inhaltn: 80mg diluted
daily oral.
to 4ml 12H; or TOBI 300mg 12H
Torsemide. See torasemide.
alternate months. Eye: 1 drop or
1cm cream 4H. See also dexamethasone.
674
Treosulfan. Adjust dose according to

response. 3-8g/m2 IV over 30min
every 1-3wk. Adult (NOT/kg): 4wk
cycles of 250mg 6H oral for 2wk,
then 2wk off.
Treprostinil. 1.25ng/kg/min SC infsn,
incr each wk by 1.25-2.5ng/kg/
min to max 20-60ng/kg/min.
Tretinoin. 22.5mg/m2 12H oral.
Cream or lotion 0.05%, gel 0.01%:
apply daily for 3-4 months, then
x1-3/wk.
Triamcinolone. Joint, tendon (NOT/
kg): 2.5-15mg stat. IM: 0.050.2mg/kg every 1-7 days. Cream
or ointment 0.02%, 0.05%: apply
sparingly 6-8H. Triamcinolone
has no mineralcorticoid action,
glucocorticoid action. See also
gramicidin + neomycin + nystatin
+ triamcinolone cream and ointment.
Triamterene. 2mg/kg (adult 100mg)
8-24H oral. See also benzthiazide
+ triamterene.
Triazolam. 0.005-0.01mg/kg (adult
0.125-0.5mg) at night oral. 30 min
preop: 0.01-0.03 mg/kg (adult
0.5mg) oral.
Tribavirin. See ribavirin.
Triclofos. 25-30mg/kg (adult 0.5-1g)
at bedtime oral.
Triclosan. 0.5%-5% lotion: 2ml to
wet skin for 30sec, rinse and repeat. Bath oil: 20ml in 20cm bath,
soak 15min.
Trientine. 10mg/kg (adult 500mg)
6-12H oral.
Triethylenethiophosphoramide. See
thiotepa.
Trifluoperazine. 0.02-0.4mg/kg
(adult 1-10mg, occasionally
20mg) 12H oral. Capsule: adult
15mg daily.
Trifluridine. 1% soltn: 1 drop/eye 2H
(max 9 drops/day) until epithelialised, then 4H (max 5 drops/day)
for 7 days.
Trihexyphenidyl. See benzhexol.
675
Drug Doses
Tositumomab. Dosimetric dose

(adult, NOT/kg): 450mg in 50ml
saline IV over 60min, then I131
(5mCi) tositumomab (35mg) in
30ml saline IV over 20min. Therapeutic dose based on response
to dosimetric dose and platelet
count.
Trabectedin. Premed with dexamethasone 0.4mg/kg (max 20mg)
IV. Sarcoma 1.5mg/m2 IV over
24hr every 3wk; ovarian cancer
1.1mg/m2 IV over 3hr every 3wk
(given after pegylated liposomal
doxorubicin 30mg/m2 IV over
15min).
Tramadol. 2-3mg/kg (adult 50100mg) stat, then 1-2mg/kg
(adult 50-100mg) 4-6H (usual
max 400mg/day, up to 600 mg/
day) oral or IV over 3min.
Slow-release (adult, NOT/kg):
100-300mg daily oral. IV infusion
2-8mcg/kg/min.
Tramazoline. Nasal: 82mcg each
nostril x3-6/day. See also dexamethasone + tramazoline.
Trandolapril. 0.01-0.1mg/kg (adult
0.5-4mg) daily oral.
Tranexamic acid. Oral: 15-25mg/kg
(adult 1-1.5g) 8H for 5 days. IV:
10-15mg/kg (adult 0.5-1g) 8H;
surgery for cyanotic congenital
heart disease 100mg/kg load,
then 10mg/kg/hr.
Tranylcypromine. 0.2mg/kg (adult
10mg) 8-12H oral.
Trastuzumab. 4mg/kg IV over 90min
load, then 2mg/kg IV over 30min
wkly. Early cancer after chemo: 8
mg/kg IV over 90min, then 6mg/
kg IV over 90min every 3wk.
Travoprost. 40mcg/ml (0.004%):
1drop/eye in evening. See also
timolol + travoprost.
Trazodone. 1-4mg/kg (adult 50200mg) 8H oral.
Drug Doses
Triiodothyronine (T3). See liothyronine.

Trilostane. 0.5-4mg/kg (adult 30240mg) 6H oral.
Trimeprazine. Antihist: 0.1-0.5mg/kg
(adult 2.5-25mg) 6H oral. Sedatn:
0.5-1mg/kg IM, 2-4mg/kg oral.
Trimethobenzamide. 5mg/kg (adult
250mg) 6-8H oral,IM,PR.
Trimethoprim. 4mg/kg (adult 75150mg) 12H, or 6-8mg/kg (usual
max 300mg) daily oral or IV.
Urine prophylaxis: 2 mg/kg (adult
150mg) at night oral.
Trimethoprim + sulphamethoxazole. See cotrimoxazole.
Trimethylglycine. See betaine hydrochloride.
Trimetrexate. 45mg/m2 IV over
90min daily for 21 days, with folinic acid 20mg/m2 IV over 10min
6H for 24 days (ie for 3 days
longer than the trimetrexate).
Trimipramine. 1-2mg/kg (adult 50100mg) 8-24H oral.
Trioxsalen. See trioxysalen.
Trioxysalen. Adult: 5-10mg daily 2hr
before UV exposure.
Tripelennamine. 1.25mg/kg (adult
75mg) 6H oral.
Tripotassium dicitratobismuthate.
See bismuth subcitrate.
Triprolidine. See pseudoephedrine +
triprolidene.
Triptorelin. Adult (NOT/kg). Depot:
3.75-4.2mg IM every 28 days. Long
acting: 11.25mg IM every 12wk.
Trisodium edetate. 40-70mg/kg
(max 3g) IV over 6hr daily for 5
days; max 3 courses each 2 days
apart.
Trometamol (THAM). ml of 0.3 molar (18g/500ml) soltn = (Wt in kg)
x BE; give half this IV over 30min,
then repeat if reqd.
Tropicamide. 0.5%, 1%: 1 drop/eye,
repeat after 5min.
Tropisetron. 0.1mg/kg (adult 5mg)
slow IV just before chemotherapy,
then oral 12-24H.
Trospium. 0.4mg/kg (adult 20mg)

12H oral.
Trovafloxacin. 4mg/kg (adult
200mg) daily oral. Severe inftn:
6mg/kg (adult 300mg) daily oral.
Tryptophan, L isomer. Adult (NOT/
kg) 1-2g 8H oral.
Tyloxapol. See colfosceril palmitate.
Tulobuterol. 0.04mg/kg (adult 2mg)
8-12H oral.
Typhoid vaccine, oral (Vivotif). Live.
1 cap oral days 1, 3, 5 and (for better immunity) 7. Boost yearly.
Typhoid vaccine, parenteral, polysaccharide (Typherix, Typhim Vi).
Inanimate. >5yr: 0.5ml IM once.
Boost 3yrly.
Ubidecarenone. 1-3mg/kg (adult
50-150mg) 12H oral.
Ulipristal. NOT/kg: 30mg oral within
120hr of intercourse.
Undecenoic acid, undecylenic acid.
2-5% cream, oint, powder: apply
12H.
Uracil. See tegafur + uracil.
Urea. 10% cream: apply 8-12H.
Urofollitrophin. See follicle stimulating hormone.
Urokinase. 4000u/kg IV over 10min,
then 4000u/kg/hr for 12hr (start
heparin 3-4hr later). Blocked
cannula: instill 5000-25000u
(NOT/kg) in 2-3ml saline for 2-4hr.
Empyema: 2ml/kg of 1500u/ml
in saline, position head up/down
and right side up/down 30min
each, then drain. Pericard eff:
10,000u/ml, 1ml/kg (max 20ml),
clamp 1hr, drain.
Ursodeoxycholic acid. 5-10mg/kg
Ursodiol. See ursodeoxycholic acid.
Ustekinumab. Adult (NOT/kg) 45mg
(90mg if >100kg) stat, 4wk later,
then every 12wk SC.
Valaciclovir. 20mg/kg (adult 1g) 8H
oral. Genital herpes (NOT/kg):
treatment 500mg 12H, prevention 500mg daily (<10 episodes/
yr) 1g daily (>9 episodes/yr).
Orolabial: 40mg/kg (adult 2g) 12H
676 for 2 doses.
Vasopressin, oily. 2.5-5u (NOT/kg)

IM every 2-4 days.
Vecuronium. ICU: 0.1mg/kg prn IV.
Theatre: 0.1mg/kg stat, then 0.52mcg/kg/min; up to 10mcg/kg/
min occasionally.
Velaglucerase alpha. 60u/kg infused
IV erery 2wk.
Venlafaxine. Adult (NOT/kg): 37.5mg
12H oral, incr if reqd to max
150mg 12H. Slow rel: 75mg daily
oral, incr if reqd to max 225mg
daily.
Verapamil. IV: 0.1-0.2mg/kg (adult
5-10mg) over 10min, then 5mcg/
kg/min. Oral: 1-3 mg/kg (adult
80-120mg) 8-12H.
Veregen. 15% ointment: apply 8H
for up to 16wk.
Versenate. See sodium calciumedetate.
Verteporfin. 6mg/m2 over 10min
IV; 15min after start of infsn give
diode laser of 689nm at 600mW/
cm2 for 83sec.
Vidarabine. Eye ointment: x5/day
until epithelialised, then 12H 7
days. IV infsn: 10mg/kg/day 5-10
days (varicella-zoster), 15mg/kg/
day 10 days (herpes encephalitis).
Vigabatrin. 25mg/kg (adult 500mg)
12H oral, incr if reqd to max 75
mg/kg (adult 1.5g) 12H.
Vildagliptin. See metformin +
vildagliptin.
Viloxazine. 2-5mg/kg (adult 100250mg) morning, and 2-3mg/
kg (adult 100-150mg) noon oral.
Elderly: 100mg daily.
Vinblastine. 6.5mg/m2 IV over 1 min
every 1-4wk.
Vincristine. 1.5mg/m2 wkly IV over
1 min.
Vindesine. 3-4mg/m2 IV every
7-10day if WCC>2500/mm3.
Vinflunine. 320mg/m2 IV over 20min
every 3wk; 200-280 mg/m2 if
neutropenia, renal impairment or
liver toxicity.
Vinorelbine. 30mg/m2 IV over
10min weekly.
677
Drug Doses
Valcyte. Adult (NOT/kg): 900mg 12H

oral for 3wk, then 900mg daily.
Valdecoxib. Adult(NOT/kg): 10mg
daily (arthritis), 20mg 12H (dysmenorrhoea) oral.
Valganciclovir. Adult (NOT/kg):
900mg 12H oral with food for 21
days, then 900mg daily.
Valproic acid, valproate. See sodium
valproate.
Valrubicin. Adult (NOT/kg): 800mg
wkly x6 intravesical.
Valsartan. 0.8-3mg/kg (adult
40-160mg) daily oral. See also
amlodipine + valsartan, hydrochlorothiazide + valsartan.
Vancomycin. Infuse IV over 90min.
Usually 25mg/kg IV, then 1520mg/kg 8H; trough 10-15 mg/L.
Severe inftn: 30mg/kg IV, then 1520 mg/kg 8H; trough 15-20mg/L,
MIC <1mg/L, AUC/MIC 400. C.
difficile: 10mg/kg (adult 500mg)
6H oral. Intraventric (NOT/kg):
10mg 48H.
Vardenafil. Erectile dysfunction
(NOT/kg): 10mg (range 5-20mg)
oral 1hr before sexual activity
(max once/day).
Varenicline. Adult (NOT/kg): 0.5mg
oral daily for 3 days, 12H days 4-7;
then 1mg 12H for 11wk (23wk if
stopped smoking).
Varicella vaccine (Varilix, Varivax).
Live. 0.5ml SC at 18mo and 12yr
(Year 7). >12yr: 0.5ml SC stat, and
4-8wk later. See herpes zoster
vaccine, and immunolobulin
zoster.
Vasopressin, aqueous. IM, SC:
2.5-10u 6-12H. IV: put 2-5u in 1L
fluid, and replace urine output
+ 10% each hour. Hypotension
(brain death, sepsis, post-bypass):
1u/kg in 50ml 5%dex-hep at
1-3ml/hr (0.02-0.06units/kg/hr) +
adrenaline 0.1-0.2mcg/kg/min. GI
hge: 6u/kg in 50ml at 1-5ml/hr IV,
1ml/hr local IA. See desmopressin, lypressin.
Drug Doses
Vitamin A. High risk (NOT/kg):

100,000iu (<8kg), 200,000iu
(>8kg) oral or IM every 4-6mo.
Severe measles: 400,000iu
(NOT/kg) once. Cystic fib: 1500u
daily (<3yr) 5000u daily (3-10yr)
10000u daily (>10yr) oral.
>10,000iu daily or >25000u per
wk may be teratogenic.
Vitamin A, B, C, D compound (Pentavite, infant). <3yr (NOT/kg):
0.15ml daily, incr by 0.15ml/day
to 0.45ml/day.
Vitamin A, B, C, D compound
(Pentavite, child). <3yr (NOT/
kg): 2.5ml daily. >3yr (NOT/kg):
5ml daily.
Vitamin B group. Amp: IV over 30
min. Tab: 1-2/day.
Vitamin B1. See thiamine.
Vitamin B2. Metabolic disease: 50150mg 12-24H oral.
Vitamin B6. See pyridoxine.
Vitamin B12. See hydroxocobalamin.
Vitamin C. See ascorbic acid.
Vitamin D2. See ergocalciferol.
Vitamin D3. See cholecalciferol.
Vitamin E. 1u = 1mg. Preterm
babies, Coperol E (NOT/kg): 40u
(2 drops) daily oral. CF, malabs:
50-100u (<3yr) 200-400u (>3yr)
daily oral. Cholestasis: 50u/kg
daily oral, incr if reqd in 50u/kg
increments. A-beta-lipoproteinaemia: 35-70 u/kg 8H oral. HUS:
0.25g/m2 6H oral. See alphatocopheryl.
Vitamin K1. See phytomenadione.
Vitamin K3. See menapthone sodium bisulphite.
Vitamins, parenteral. MVI-12 (for
adult): 5ml in 1 litre IV fluid. MVI
Paediatric, added to IV fluid:
65% of a vial (<3kg), 1 vial (3kg
to 11yr).
Vitaprem (RCH: Pentavite, folate,
B12, C). 1ml daily oral.
Von Willebrand factor / Factor VII

concentrate (Wilate). Minor hge:
20-40 IU/kg then 20-30 IU/kg 1214H. Surgery: 35-50 IU/kg, then
30-40 IU/kg 12-24H.
Voriconazole. Oral, IV over 2hr:
child 7mg/kg 12H, adult 6mg/kg
repeated after 12hr, then 4mg/
kg 12H. Increase maintenance by
50% if required.
Vorinostat. Adult (NOT/kg): 400mg
daily oral; may need to decrease
to 300mg daily, or 300mg on 5
days a week.
Warfarin. Usually 0.2mg/kg (adult
5mg) stat, 0.2mg/kg (adult 5mg)
next day if INR <1.3, then 0.050.2mg/kg (adult 2-5mg) daily oral.
Usual INR 2-2.5 for prophylaxis,
2-3 for treatment, 3-4 mechanical
valve. Beware drug interactions.
Severe hge: reverse with either
coagulation factor (Prothrombinex) 25 u/kg (adult 500u) or
factor 7a (rFVIIa) 20mcg/kg, and
phytomenadione 0.3mg/kg
(adult 10mg), and fresh frozen
plasma 10ml/kg; repeat according
to INR.
Whole blood. 6ml/kg raises Hb 1g%.
1bag = 400ml approx.
Xamoterol. 4mg/kg (adult 200mg)
12-24H oral.
Xipamide. 0.5-1.5mg/kg (adult 2080mg) daily oral.
Xylometazoline. <6yr: 0.05% 1 drop
or spray 8-12H. 6-12yr: 0.05%
2-3 drops or sprays 8-12H. >12yr:
0.1% 2-3 drops or sprays 6-12H.
Yellow fever vaccine (Stamaril).
Live. >12mo: 0.5ml SC once.
Boost every 10yr.
Yohimbine. 0.05-0.1mg/kg (adult
2.7-5.4mg) 8H oral.
Zafirlukast. NOT/kg: 10mg (>7yr)
20-40mg (adult) 12H oral.
Zalcitabine. Usually 0.015mg/kg
(adult 1mg) 12H oral.
Zaleplon. Adult (NOT/kg): 10mg (520mg) at night oral.
678
Zolpidem. 0.1-0.4mg/kg (adult

5-20mg) nocte oral. Sublingual:
5-10mg nocte.
Zonisamide. 2mg/kg (adult 100mg)
daily oral, incr if reqd after 2wk to
12H, then 3mg/kg (adult 150mg)
12h, then 4mg/kg (adult 200mg)
12H; rarely up to 6mg/kg (adult
300mg) 12H. Level 10-20mg/l.
Zopiclone. 0.1-0.3mg/kg (adult
5-15mg) at bedtime oral.
Zotepine. 0.5mg/kg (adult 25mg)
8H oral, adjusted every 4 days to
0.5-2mg/kg 8H.
Zuclopenthixol. 0.4-3.0mg/kg (adult
679
Drug Doses
Zanamivir. Adult (NOT/kg): 10mg

12H for 5 days inhaled. Prophylaxis: 10mg daily inhaled.
Ziconotide. Adult (NOT/kg): 2.4mcg/
day by intrathecal infusion, incr
every 24-48hr to max 21.6mcg/
day.
Zidovudine (AZT, ZDV). Preterm:
1.5mg/kg 12H IV, or 2 mg/kg 12H
oral to 2wk (30wk gest) or 4wk
(<30wk gest), then 8H. Term newborn: 1.5mg/kg 6H IV, 2mg/kg
6H oral. Child: usually 180mg/m2
(up to 240mg/m2) 12H oral; 120
mg/m2 6H IV, or 20mg/m2/hr IV
(range 90-180 mg/m2 6-8H IV).
18yr: usually 200mg 8H oral, or
300mg 12H oral, or 150mg 8H IV.
See also abacavir and lamivudine.
Zileuton. Adult (NOT/kg): 600mg
6H oral.
Zinc chloride. 5.3mg/ml = 2.5mg/ml
Zn = 38umol/ml Zn. 2-4umol/kg/
day (<1yr), 1umol/kg/day (child),
40-60umol/day (adult). Serum
zinc 11-22 umol/l.
Zinc sulphate. (220mg cap = 50mg
Zn = 765umol Zn). Deficiency,
acroderm enteropath: initially
3mg/kg (adult 220mg) 8-12H oral,
adjusted to achieve serum zinc
11-22umol/L (0.7-1.4mg/L). Diarrhoea child (NOT/kg): 10-20mg
daily oral.
Ziprasidone. Adult (NOT/kg): 20mg
12H, incr if reqd to max 80mg
12H oral.
Zoledronate. 0.025-0.05mg/
kg (adult 4mg) IV over 15min;
usually repeated every 4wk.
Postmenopausal osteoporosis
(adult, NOT/kg): 5mg IV every 1-2
years.
Zoledronic acid. See zoledronate.
Zolmitriptan. Adult (NOT/kg): 2.55mg oral, repeat in 2hr if reqd;
max 15mg in 24hr. Nasal: 5mg
spray in each nostril, repeat in 2hr
if reqd; max twice in 24hr.
680
Drug Doses

Paediatric Protocols 3rd Edition 2012.

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What is the purpose of developing paediatric protocols?

What is the purpose of developing paediatric protocols?

What challenges are faced in achieving MDG 4?

What challenges are faced in achieving MDG 4?

PAEDIATRIC

Hussain Imam Hj Muhammad Ismail

Kementerian Kesihatan Malaysia

Hussain Imam Hj Muhammad Ismail

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Kementerian Kesihatan Malaysia

FOREWORD BY THE DIRECTOR GENERAL OF HEALTH

DatoSri Dr Hasan Bin Abdul Rahman

FOREWORD TO THE THIRD EDITION

Dr. Fazila Mohamed Kutty

Dr. Alex Khoo Peng Chuan

Dr. Fong Siew Moy

Dr. Amar-Singh HSS

Dr. Fuziah Md. Zain

Dr. Angeline Wan

Dr. Hasmawati Hassan

Ms. Anne John

Dr. Hishamshah b. Mohd Ibrahim

Dr. Bina Menon

Dato Dr. Jimmy Lee Kok Foo

Dr. Kamarul Razali

Dr. Nazrul Neezam Nordin

Dr. Kew Seih Teck

Dr. Ngu Lock Hock

Dr. Lee Ming Lee

Dr. Nik Khairulddin

Dr. Leow Poy Lee

Dr Noor Khatijah Nurani

Dr. Sabeera Begum Bt Kader Ibrahim

Dr Thahira Jamal Mohamed

Dr. See Kwee Ching

Dr. Sharifah Ainon Bt Ismail Mokhtar

Dr. Terrence Thomas

Section 10 Infectious Disease

Section 12 Metabolic Disorders

Section 15 Poisons and Toxins

Section 16 Sedation and Procedures

Chapter 1: Normal Values in Children

Heart (Pulse) Rate

Ref: Nelson Textbook of Pediatrics, 18th Edition

5th centile for age

50th centile for age

Calculation for Expected Systolic Blood Pressure

Blood Pressure in Hypertension

neutrophils > lymphocytes

Differential WBC: eosinophils: 2-3%; monocytes: 6-9 %

lymphocytes > neutrophils

neutrophils > lymphocytes

< 7 days age

National Immunisation Schedule for Malaysia (Ministry of Health, Malaysia)

- Pregnancy (live vaccine - theoretical risk to foetus) UNLESS there is

Vaccination: Special Circumstances

The following are not contraindications to vaccination

Children with Asplenia (Elective or emergency splenectomy; asplenic

All infants should