Vital signs

Formula for weight = (Age x 2) + 8 or 9

Formula for lower limit of systolic BP = ( Age x 2 ) + 70 

Diastolic BP is 2/3 of systolic BP

BP (systolic)

<1m : 60 to 90

1m to 1yo: 71 to 90

1yo to 2yo: 81 to 102

2yo to 3yo: 81 to 105

3yo to 4yo: 81 to 108

4yo to 5yo: 81 to 110

5yo to 6yo: 81 to 111

6yo to 7yo: 82 to 113

7yo to 8yo: 84 to 114

8yo to 9yo: 86 to 115

9yo to 10yo: 91 to 117

10yo to 11yo: 91 to 118

11yo to 12yo: 91 to 120

12yo to 13yo: 91 to 122

13yo to 14yo: 91 to 125

14yo to 15yo: 91 to 127

>15yo: 101 to 130

HR

<3m: 90 to 180

3m to 6m: 80 to 160

6m to 1yo: 80 to 140

1y to 6y: 75 to 135

6yo to 10 yo: 70 to 110

10 yo to 15 yo: 60 to 90

>15 yo: 60 to 90

RR

<3m: 30 to 60

3m to 6m: 30 to 60

6m to 1 yo: 25 to 45

1yo to 6yo: 20 to 30

6yo to 10 yo: 16 to 24

10 yo to 15yo: 14 to 20

>15yo: 12 to 16

SpO2 > 95%

The vomiting child

AETIOLOGY 
Surgical vs non-surgical

Surgical

• Pyloric stenosis
• Intussusception
• Volvulus
• Appendicitis
• Adhesion bands
• Incarcerated hernia
• I/O
• Torsion of testis
• Head injury

Non-surgical

• Sepsis
• CNS 
• space occupying lesion (tumour, abscess)
•  meningitis
• benign intracranial hypertension
• encephalopathy (Reye's)
• ICH (haematoma)
• Metabolic  
• DM
• inborn errors of metabolism
• adrenal insufficiencies
• GE / viral (food poisoning, infections)
• Reflux
• Over feeding / mother craft/ aerophagy
• Drugs/toxins - leading to ileus / encephalopathy
• Vestibular 
• otitis media 
• vestibular dysfunction
• Pregnancy

HISTORY

A) NATURE OF VOMITING

• Bilious/non-bilious/bloody
• Onset - acute, acute on chronic, chronic, recurrent bouts
• Amount, frequency
• Type - projectile, forceful, regurgitation
• Relation to meal - is it soon after feeds
• Appetite
• Any overfeeding? Especially if water is given with milk
• Technique of burping
• First time parents

B) BOWEL HABITS

• Diarrhoea, constipation or stringy stools (Hirschprung)

C) ASSOCIATED SYMPTOMS

• Fever
• Abdo pain, tenderness
• Diarrhoea
• Dysuria
• Headache
• Earache
• Recent injury
• Recent ingestion
• Ataxic gait

D) HYDRATION

• Number of wet diapers
• Last passage of urine or change of diapers
• History of scanty urine

EXAMINATION

A) ASSESS SEVERITY OF VOMITING

• Degree of hydration/acidosis
• Altered mental state (?underlying encephalopathies/metabolic disturbances e.g. hypoglycaemia, acidosis)

B) ABDOMEN

• Distension, mass, bowel sounds
• Tenderness
• Groin for testes and hernias 

C) CNS

• Fontanelles
• Facial/scalp bruising (NAI)
• Cranial nerves
• Fundoscopy for stigmata of NAI and raised ICP
• Nystagmus, gait
• Ears for infection/bleed

INVESTIGATIONS

• Urilax/UFEME - TRO UTI
• FBC - If Fever
• Hypocount - If lethargic/dehydrated
• UEC - If suspecting electrolyte abnormalities or Ix dehydration before discharge. KIV admit if low HCO3 or abnormal electrolytes
• AXR - If suspecting surgical abdomen

DISCHARGE ADVICE

• Strategy for home is small frequent feeds or soft diet of choice
• 1/2 hour after vomit, can give feeds for 1-2 hours
• If <3yo, 15ml Q15min
• If >3yo, 30ml Q15min
• If tolerating can gradually increase amount
• RETURN IF
• persistent vomiting
• Bilious vomiting
• Very little urine over 8 hours
• Increasing lethargy
• Taking poor intake of oral fluids

Vomiting and diarrhoea

Workflow for GE

Cat 2

• <6/12
• SIS 8
• Mild to mod dehydration
• Abdo distension

Cat 2+

• Bilious or bloody vomiting
• Severe abdo pain (6-10)

All else Cat 3

• Can prescribe trial of feeds if has history of vomiting, no abdo pain, episode of vomiting more than 30 min ago

If unstable, Cat 1 Resus

• ABCs
• istat (glucose), FBC, UEC
• Fluid resus with NS 20ml/kg for pre-shock/shock
• Correct hypoglycaemia, hyponatraemia
• After initial resuscitation, maintenance fluid with 5%Dextrose and 0.45% NS or 5% dextrose and 0.9% NS, including fluid deficit over 48H
• Include maintenance fluid
• Admit HD/ICU

Acute gastroenteritis and viral gastritis is a diagnosis of exclusion.

Other important differential diagnoses:

1) Non-GI infections

- pneumonia, UTI, otitis media, septicaemia, meningitis

2) Surgical 

- intussusception, torsion of testis, IO, appendicitis, volvulus, post-op complications

3) CNS

- space occupying lesion, meningitis, encephalitis

4) Metabolic

- DKA, CAH, endocrine, inborn errors of metabolism

5) HUS

6) Toddler's diarrhoea

7) Food allergy/intolerance

8) Hirschprung's enterocolitis

9) IBD

10) Bact GE (dysentry)

11) Myocarditis

12) Poisoning

Rehydration
Determine if min, mild, mod dehydrated

MIN or nil (<3%loss of body weight)

• High risk, definite admission to GW
• Exisiting comorbidity (congenital heart disease, short bowel syndrome, heart failure, ileostomy)
• <6/12 old ,with vomiting >1x past 24H (excludes mild regurgitation and post tussive vomiting), or frequent and large volume stools, or feeding less than normal, or irritable
• High risk, for observation in ED
• <6/12 with criteria for admission but carer refuses (to sign AOR even if pt succeeds in trial of feeds)
• More than 6/12 old with vomiting, unable to retain >1/2 of feeds past 24H and unable to retain at least 1 normal feed past 4H
• If >1yo, start ondansetron (1st line)/supp domperidone (2nd line) before starting ORS
• If <1yo, do not give anti-emetic, start trial of feeds
• Start trial of feeds x 1 hour. Start 30 min after PO ondan/1 hour after supp domperidone
• If pt vomits more than 1x or cannot complete prescribed fluids, ADMIT
• If fulfils discharge criteria, discharge with GE advice, information pamphlet, Lacteol Forte, Hydralyte (chargeable). DO NOT DISCHARGE WITH ANTI-EMETIC
• Low-risk, DISCHARGE 
• <6/12 with no criteria for admission
• >6/12 with no vomiting, can retain >1/2 feeds past 24H and has 1 normal feed past 4H

MILD (3-5% loss of body weight) 

•  If high-risk (<1yo or no competent caregiver),
• ADMIT
• While waiting for admission, start Oral rehydration therapy (ORT) 10ml/kg/hr over 4 hours (over 15 minute aliquots) (e.g. 10kg child requires 100ml every hour, therefore prescribe 25-30ml ORT Q15m x 4H)
• For 1yo or more, with vomiting and unable to retain more than half of normal feeds in 4H, offer oral ondansetron (1st line) or supp domperidone (2nd line) if distressed, before starting ORT
• If no high risk criteria, 
• Give oral rehydration therapy 10ml/kg/hr x 2 hours (over 15 minute aliquots)
• If unable to retain more than half of feeds in past 24H and  unable to retain more than 1 normal feed for past 4H, offer anti-emetic before starting ORT
• If vomits more than 1x or unable to complete prescribed volume over the required period, ADMIT
• If succeeds in 2H of oral rehydration therapy (no vomiting), and fulfils discharge criteria, discharge with instructions to complete the remaining 2H of oral rehydration therapy 10ml/kg/hr, and advise on maintenance oral fluids and GE advice
• Document all advice related to ORT and GE management

MODERATE (6-9% loss of body weight)

a) Vomiting not significant, but fluid loss from diarrhoea > oral intake
b) Vomiting within past 3H, & unable to retain fluids x 6H
- PO ondansetron (1st line) / supp domperidone if distressed before ORT
c) Uncertain of Dx, possibly severely dehydrated , tachypnoeic, drowsiness
- FBC, I-stat, UEC, IV-plug, KIV IV fluids

For moderately dehydrated cases, ADMIT
Expedite admission (S/T shift nurse IC)
- ORT 60-90ml/kg over 6H in 15min aliquots while waiting for admission
- Counsel caregivers: Your child has mod dehydration due to vomiting/diarrhoea/gastroenteritis
- He will need admission for rehydration. Oral route will be tried, but IV will be necessary if PO fails. We will also need to monitor his vital signs, hydration status and ongoing losses through his stool or vomit
- Simple investigations may be done

TRIAL OF FEEDS (if minimally dehydrated) not the same as ORS. If child prefers other liquids, non-fizzy drinks or milk may be given instead.

• If <3yo, 15ml Q 15min x 4  (1 hour)
• If >3yo, 30ml Q 15min x 4 (1 hour)

USE OF ANTI-EMETICS

• Do not use anti-emetics unless vomiting is due to GE
• Do not use if there is 
• post tussive vomiting
• significant abdominal pain/tenderness
• Abdominal distension
• After head injury 
• Do not use if there is nausea without vomiting
• Do not prescribe on discharge

ONDANSETRON

• Risk of accentuating diarrhoea
• Oral fluids may be started 30 min after therapy

DOMPERIDONE SUPP

• Risk of extra-pyramidal symptoms (neck arching, tongue twisting) 
• Oral fluids may be started 1 hour after therapy
• May be less effective if there is ongoing diarrhoea
• Dose 0.1-0.2mg/kg/dose

REVIEW BEFORE DISCHARGE

• If patient vomits 1x, rest 30min before restarting oral fluids trial (trial of feeds 1 hour, ORS 2 hours)
• Review patient for discharge 30min after last feed
• After 2nd episode of vomiting, review for hospitalization

CRITERIA FOR DISCHARGE

• Has retained prescribed oral fluids
• Age appropriate normal mental status
• No vomiting
• No abdominal pain, abdo soft and not distended
• No tachycardia, vitals stable (document!), not toxic
• Not dehydrated
• Reliable, competent caregiver
• Advice on GE/vomiting/abdo pain and when to return 

ON DISCHARGE

• Provide patient leaflets
• Withhold solids for 8H and give small frequent clear feeds
• Explain appropriate types, frequency and volume
• For diarrhoea, calculate how much fluid for each stool
• Emphasise importance of maintaining oral hydration
• Do not give too many medications
• Lacteol forte for diarrhoea
• Paracetamol for fever
• Magnesium carbonate for abdo colic
• Barrier cream (silicon cream or zinc oxide Desitin (non-standard) for perianal excoriation
• If pt has mild dehydration and successfully completed 2 H of ORT, prescirbe another 2H of ORS in sachets for home
• If min dehydrated, advise for clear fluids / diluted milk to be given. Hydralyte is chargeable
• If <6/12, check bottle hygiene and document. Ensure adequate sterilization
• If bloody GE, and child well and >3/12 old, stool CS and Abx not indicated. Discuss with senior. If bloody GE and child <3/12, unwell, ADMIT.

Neonatal jaundice

Neonatal jaundice typically occurs on day 2- 3.

ALL JAUNDICE IN FIRST 24 H IS PATHOLOGICAL.

Risk factors

• Prematurity
• Low birth weight
• Peri-natal hypoxia / hypoxia
• Cephalhaematoma/bruising
• Sepsis
• Blood group incompatibility
• Polycythaemia
• Inadequate feeding
• Delayed passage of meconium

Aetiology of NNJ

• Physiological 
• Breakdown of fetal rbc
• Inadequate conjugation due to low levels of hepatic enzyme glucuronosyltransferase
• Inadequate conversion to urobilinogen by intestinal flora
• Prematurity
• Haemolysis - ABO, G6PD, Rh, hereditary spherocytosis, drug-induced, polycythaemia, cephalhaematoma
• Infection - intrauterine infection, UTI, sepsis
• Metabolic - hypothyroidism, inborn errors of metabolism, insulin dependent diabetic mother, hypoglycaemia
• Breastmilk jaundice

Aetiology of Prolonged NNJ (Beyond 15 to 21 days)

• Neonatal hepatitis
• Obstructive jaundice - biliary atresia, choledochal cyst, duct hypoplasia 
• UTI
• Hypothyroidism
• Breastmilk jaundice

ADMIT:

1) SB at phototherapy exchange levels

2) Babies > 14 days with any of :

• Antenatal/birth history suggestive of intrauterine infections
• History of feeding problems, vomiting
• Recurrence of jaundice after initial improvement
• Pale stools, dark urine
• Physical findings of deep jaundice, rashes, cataract, pallor, hepatosplenomegly, microcephaly, cardiac murmurs, abnormal neurological examination

There is no benefit of phototherapy for babies with jaundice > 14 days of life. 

If baby is >14 days of life, consider 

• Direct/Total SB
• check cord TSH ( aim <20 umol/L)
• no need routine UFEME

Admitting criteria for NNJ

Low-risk vs high-risk (2 different cut off SB levels, refer to table)

High- risk:

• Jaundice in first 24H
• Blood group incompatibility with DCT or antibody titre > or equal 128
• G6PD
• Gestational age 35-36 wks at birth, <7 days of age
• Significant cephalhaematoma, bruising
• Exclusive breastfeeding, if not nursing well ( Weight loss >10% from birth weight, dehydrated, less than 5 wet diapers/day)
• <72H and mother O+ with baby A/B/unknown
• Rise in SB > 85umol/L in 24H

vs

Low-risk

No known high-risk factors

Clinically well

REFER TO OPS FOR REVIEW:

1) Majority of babies with physiological jaundice < 14/7 and none of the above abnormal features

2) If SB is on downward trend or downward trend is to be expected

• physiological jaundice is maximum on D3-D5 in term infants and D5-6 in prems, and disappears by D7 in terms and D9 in prems.

REFER TO PAEDS MED FOR REVIEW:

1) Direct SB< 15% total, child well and asymptomatic, TCU 1/52

2) If direct/total SB>15% and direct SB > 35% can get early TCU, will need phenobarb priming and HIDA scan

3) KIV admit if baby > 3/52 old so Ix can be done in the ward.

BILIARY ATRESIA MUST BE RULED OUT AND OPERATED ON BY 6 WEEKS OF LIFE.

NNJ discharge advice

• Ensure hydration and good feeding and normal bowel movement
• Return if febrile, vomiting, poor feeding 
• Sunning baby is not effective and may lead to sunburn and dehydration
• No treatment is required but will need careful assessment at SOC / OPS TCU

Paediatric Fever and Management

Defined as T>38C

Admit:
1) <3months old with fever/toxicity
2) Toxic in appearance (sepsis)
- lethargic (poor/absent eye contact, failure to recognise parents)
- poor perfusion
- hypo/hyperventilation
3) Fever > 7 days with no source
4) T>41C
5) Immunocompromised (chronic/cyclical neutropaenia, malignancy on chemo, high/chronic steroid, post splenectomy, post transplant)
6) Dengue, plt <80
7) Atypical/classical Kawasaki

Fever can be A) INFECTIVE or B) NON-INFECTIVE

Serious infective fevers
1) Meningitis
2) Pneumonia
3) UTI - admit those < 6/12 old
4) Dengue  or Malaria
5) Septic arthritis
6) Myocarditis, endocarditis

Serious non-infective fevers
1) Kawasaki
- Features: FEVER for >5 days, with 4 of the following 5 criteria

• Rash - polymorphous erythematous
• Non-suppurative conjunctivitis
• Cervical lymphadenopathy (1 node > 1.5cm)
• Oral mucosa changes e.g. cracked red lips, strawberry tongue, injected tonsils
• Skin changes e.g. periungal peeling, initial pedal and palmar swelling

- may be a/w leucocytosis/thrombocytosis from 2nd wk of illness

- early dx essential to prevent coronary artery thrombosis!

- Admit even if incomplete KD if suspicion high.

2) Malignancy

3) Collagen vascular disease

FEVER WITHOUT SOURCE?
- Well child with fever but no viable source on history/examination
- Most commonly viral or UTI in pre-verbal children. If prolonged, consider occult infection or non-infective causes.

INVESTIGATIONS
1) Urinalysis
- All fevers of unknown origin in preverbal child
- Fever with abdo pain, vomiting, min or no diarrhoea (preverbal child)
- Dysuria (verbal child)
- MSU or in-and-out catheter for urine C/S before starting antibiotics!
- Admit if WBC > 100hpf if child is <6/12

2) Full blood count
- Use for dengue -look for  thrombocytopaenia
- Tonsils with exudates - possible infectious mononucleosis- look for raised atypical lymphocytes
- Consider FBC if fever >5/7 . Consider FBC if fever without source  >3/7.
- Consider admission if :

• TW >20 k, ANC > 10k in <3yo
• TW >30k in >3yo
• If TW 20-30k or ANC <10k in child < 3yo, check with senior doctor

- Check with senior doctor before admission as some children may be non-toxic and can have PO Abx empirically outpatient

3) CXR

Use if 

• Fever with prolonged cough
• Tachypnoea
• Adventitious lung sounds
• Fever without source and TW > 20k

- Use if fever and cough  >5/7

- Occult pneumonia  = 26% prevalence

4) ECG

- TRO myocarditis

- Consider if tachycardia out of proportion to fever.

VIRAL FEVER is a diagnosis of exclusion!

MANAGEMENT

1) Conservative measures

• Thin clothing
• Tepid sponging/shower if T>38.5C
• Fluids and hydration
• Rest 

2) Medications

• PARACETAMOL
• Drug of choice
• 10-15mg/kg
• Toxic dose is 150mg/kg or 15x maximum dose
• Q6H
• Can use Q4H if T>39C
• Can give on empty stomach. Monitor temperature throughout the night.
• DO NOT PRESCRIBE IF <3/12 - MAY NEED ADMISSION IF FEBRILE

• NSAIDs
• Risk of GIT bleed, renal toxicity
• PO ibuprofen 5-10mg/kg Q6-8H
• Rectal Diclofenac (12.5mg) 1/2 supp Q12H if <2yo, or 1 supp Q8 to 12H if >2yo
• Only use rectal diclofenac if Hx of febrile seizures, or if caregiver insists (to document)
• DO NOT USE BOTH NSAIDS and PARACETAMOL for children <1yo
• Do not combine ibuprofen/diclofenac
• No evidence diclofenac superior to ibuprofen
• Combined use of paracetamol and NSAID
• No benefit/toxicity
• Can add on NSAID if temp still high
• Use paracetamol 4-6H as first line as it is safer
• If fever still increasing after paracetamol/tepid sponging/cold compress, then use NSAID PRN
• Use next dose NSAID 6H later
• Dosing is independent and not related to frequency of panadol

ANTI-PYRETICS ARE NOT A CURE FOR FEVER. Will not change the natural history of fever.

FEVER DISCHARGE ADVICE

- TO RETURN IF:

- Persistent fever at high level x 3-4/7 with no nadir

- Persistent vomiting, not feeding well

- Lethargic, drowsiness, irritability, poor headache

- Pale/blue

- SOB

- Fever without source > 3/7 (?atypical pneumonia, UTI)

- Fever persists >3/7 after antibiotics prescribed

- Not to resume strenuous activity till recovery - MC 5/7, excuse from PE 14/7