Management Guidelines for the

Paediatric Department,
Worcester Hospital
Keep page blank

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Protocol
The Department of Paediatrics in Worcester Hospital is the referral centre for seven Level 1 hospitals and will
always take over management of patients needing this department’s level of care.

Every child entering this facility is managed optimally to the best of the hospital personnel’s knowledge, despite
their medical history, illness and available facilities within the premises.

No care will ever be refused due to a lack of space, regardless of the circumstances. The intubation of a patient
must always be discussed with a consultant to ensure optimal management.

The paediatric team has a consultant available at all times (including after hours), in all units, to manage
emergency situations and guide in the overall management of patients.

Disclaimer
These Guidelines are intended to assist trainees in the treatment of patients in emergency conditions in
Worcester Hospital in a uniform manner.

The procedures described in this document are not intended to replace any clinical examination,
diagnosis or sound medical knowledge.

All dosages were obtained from Frank Shann and all trainees are responsible to correlate themselves and ensure
that they administer the correct dosages at all times.

NOTE
This document is in draft form, meant for internal use only
and may be changed or updated at any time without prior warning.
Any changes to this document must be signed off by Dr HM Kunneke before implementation.

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List of Resources
Coovadia HM and Wittenberg DF Paediatrics & Child Health — A manual for Health Professionals in the Third
World

Merck Manual, The

UCT Medical School – The Pediatric Handbook (Red ‘Oxford’ book)

Full referencing needed for all these resources

ii
Table of Contents Page
Terminology, Abbreviations & Acronyms iii

Introduction v

Standard Operating procedure vi

Gastroenterology 1

Gastroenteritis 1
Malnutrition/FTT 7

SAM/MAM 8

Liver failure 5

Respiratory System 9

Croup 9

Bronchiolitis 10

Pneumonia 11

Asthma 12
Neurology 14

Convulsions 14

Afebrile Seizures 15

Draw-a-Person 16

Meningitis 17

ADHD 19

Supressed Consciousness 23

Raised Intracranial pressure 24

Nephrology

Glomerulonephritis 25

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 Nephrotic syndrome 26

Urinary tract infections 27

Haematuria 31

Endocrinology

Diabetic ketoacidosis 33

Dermatology 38

Eczema 38

Vitiligo 39

Alopecia 39

Haemangioma 39

Molluscum Contagiosum 39

Ringworm/Fungal Infections 39

Larva Migrans 39

General

General Lymphadenopathy 40

Cervical Lymphadenopathy 42

Axillary Lymphadenopathy 43

Inguinal Lymphadenopathy 44

Poisoning 45

Paracetamol 45

Iron Poisoning 46

Salicylate 47

Organophosphate 47

Neonatology

Admission Criteria 49

Ballard 50

Addendum 64

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Inborn errors of metabolism

ECG: guidelines to interpretation

Ventilation: Intubation, settings, sedation, inotropes

Vela ventilator and troubleshooting

v
vi
Terminology, Abbreviations & Acronyms
C/S Caesarean Section
CPAP Continuous Positive Airway Pressure
EC Emergency Centre
HCU High Care Unit
POPD Paediatric Out patient Department
TTO To Take Out
TBM Tuberculosis meningitis
WCC White cell count
LP Lumbar puncture
CSF Cerebrospinal Fluid
A/B Antibiotic
GBS Guillain Barre Syndrome
ABG Arterial blood gas

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Introduction
The purpose of this document is to guide the user to manage patients as best as possible across the spectrum of
the region.

It is important to ensure uniformity in the referral area and allow patients equal access and care on all levels of
care.

It is useful after a diagnosis has been made, to guide the user to best optimal care of the specific disease
process.

The most common paediatric conditions that are seen in our EC have been included in the pack. It includes
various systems e.g. gastrointestinal, respiratory, cardiology, central nervous system, genito-urinary track, and
endocrinology and covers Convulsions UTI’s, LRTI, Croup, epilepsy, pneumonia, nephrotic- and nephritic
syndrome, etc.

Wat is die doel van die dokument

Waaruit bestaan die geheel en waarna word in elke onderafdeling gekyk

viii
Standard Operating Procedure (SOP)
ORGANISATION
Personnel (team members): 3 Consultants • Dr Kunneke, HCU
• Dr Engelbrecht, Senior Specialist
• Dr Camp, Senior Specialist
2 Registrars
3 Medical officers
1 Cosmo
2 Houseman
DISTRIBUTION OF WORK AND DUTIES
The whole team is responsible for and divided to work in—
• Neonates
• EC Department
• Clinics
• Intensive Care
• POPD
This is to ensure that all patients are seen and treated effectively early in the morning.
• Each team member is responsible for his/her own unit from 07H30 until hand-over is done before
16H00.
• After 12:00 each team member is equally responsible for EC.
Each of the team members will be available for C/S’ and resuscitation at all times and in all places in the
hospital.
A consultant must be available on the premises during working hours at all times.
GENERAL SCHEDULE
07H45 All team members start to see patients, check and clerk results, X-rays and reboard
medication.
08H30 Consultant ward rounds start in order to get discharges out; order milk and prescriptions
before 11h00.
11H00 Cut-off time for all orders (milk/prescriptions) and discharges
12H00–15H00 Quiet / resting time. Team members should respect this and not manage patients during
this time.
15H00 Results must be checked and acted upon; late discharges managed; drips replaced and
general check on patients for hand-over to be done.
Before 16H00 Hand-over to person on call.

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 EXCEPTIONS
Before 09H30 TTOs must be in the pharmacy — Weekend TTOs must be written and in the pharmacy at
the latest by 12H00 on a Friday.
Before 11H00 Discharges must be done and in the discharge lounge
Failure to do so will lead to patients being in the ward a day longer and congestion in
casualty. The system does not allow apathy in this regards.
Thursdays Academic rounds take place at 07H45 — general ward rounds start as usual at 08H30.
Fridays Academic meeting is held at 10H00. Therefore–
• Working rounds start at 07H30 in all units
• consultant rounds start at 08H00
GUIDELINES TO ADMISSION
Ward A1 • All children with medical and surgical problems that require admission.
• Babies with jaundice who were discharged
• All neonates ever discharged from the birthing unit.
• Gastro patients
D1 Neonates • All neonates from any obstetric unit who were never discharged.
HCU • All children requiring CPAP, ventilation and general high care.
There is a bed in the unit that can be used for ventilation when space and personnel are
available. All children in need of ventilation are preferably handled here. When there isn’t a
bed available, other alternatives need to be discussed with the consultant on duty.
Ventilation should never be refused.
Out Patients Specialist and super specialist clinics are available from Mondays to Fridays in the
morning and appointments can be made at (+2723) 348–1172.
Specialist Clinic Monday & Thursday mornings:
• Only patients referred by a GP or MO from a hospital or
DHS
• Correct referral form to be presented
• Patient is seen by paediatrician and then managed or
referred
Houseman Clinic Wednesday mornings:
• All patients for follow-ups after EC and/or ward
admissions
• Discharge letter to be presented
Cardiology Clinic Tuesday mornings:
• Cardiology consultants from RXH manages the clinic
four times per year
• Referrals can only be done through consultants
Neurology Clinic Tuesday mornings:
• Referrals only from hospital or clinic doctors
• Correct referral form to be presented
Dermatology Clinic One Friday morning per month:
• Are done by Dr Kunneke
• Referrals by doctors in the region
• No referral form necessary

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 Emergency • Only referrals of emergencies from a doctor who communicated telephonically with
Centre one of the MOs or clinical assistants, will be seen
• All other patients must first be evaluated by a doctor in GGS 40
• All patients seen after hours, are managed, admitted or discharged according to the
protocols
• No patient should wait for an opinion
• All patients are managed upon he first consultation
• Specialists continuously available to give advice
• After-hours appointments for a specific paediatric clinic must be done on Clinicom
GENERAL MANAGEMENT OF PATIENTS
• Low threshold for admissions
• Complete separate paediatric book for each patient
• Indicate date and time of consultation with specific diagnosis and plan
• Legible signature and/or stamp
• Prescriptions must be clear and legible
• All dosages for children are calculated in mg/kg and must be verified
• All fluids must be calculated in ml/kg per 24 hours and total ml/hr as well as drops/minute of 6 dropper must
be charted
• Discussions of a patient with a doctor (preferably a consultant) must be noted on the patient’s chart with
the person’s name, time and specific orders
• Discharge letters and ward statistics forms must be completed for each patient that is discharged
(including over weekends)

RVD
Opt-out policy:
• All children need to be tested if not done before–
o >18 months – Rapid. If positive, confirm with ELISA
o <18 months – Rapid HIV. If negative, no more tests
o <18 months – Rapid HIV. If positive, do PCR
PRESUMED SEPSIS (BABIES <3 MONTHS)
All babies <3 months are admitted and treated as presumed sepsis
• Do urine & blood culture as well as LP, FBC.
• Start on–
o Cefotaxime 100mg/kg/day in 3 divided dosages
o Amikacin 15mg/kg/day
PNEUMONIA
All patients with pneumonia–
• Do HIV ELISA
• Do a complete TB work-up with Mantoux, CXR and 2 x gastric washings
Gastroenteritis
All patients with gastroenteritis–
• Do Urine Dipsticks
o If >6 months and dipsticks clear: No MC&S
o If <6months or Nitrates, Leucocytes on dipsticks: DO MC&S

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Gastroenterology
GASTROENTERITIS — ACUTE MANAGEMENT

IMPORTANT
Institute fluid therapy early — the longer the wait, the worse the prognosis!

A. HISTORY
Establish a concise history:

• Is the child vomiting?

• Duration of loose stools?
• Consistency / colour / odour / blockages?

B. EXAMINATION

Decreased skin tugor

Sunken fontanelle

Dehidration Sunken eyes

Dry mucous membranes
Either or not dehydrated,
5% or 10%

Capillary filling assess

Hypotension
Tachycardia
Shock Dehydration
Late: drowsy, decreased
ALWAYS 10%

responsiveness

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C. SPECIAL INVESTIGATIONS (POST INITIAL FLUID RESUS)
• Urea & electrolytes
• Blood gas
• Always do urine dipsticks
u–MC&S always if < 6 Months / nitrate positive dipsticks / malnourished FTT

• HIV (Rapid) if not done before

If Ward Hb <10 Do FBC
If shocked BC / RVD / UKe / FBC / CMP / ALT
= Resus + maintenance + rehydration + ongoing losses

D. FLUIDS = RESUS + MAINTENANCE + REHYDRATION + ONGOING LOSSES

Route of administration:
If shocked / vomiting Give intravenous fluids
If after 2 tries unsuccessful IO only >6yrs
If < 6years or unsuccessful IO Call senior doctor
10% dehydration IV access
5% dehydration If no vomiting – oral fluids / IVI
If vomiting - IVI

FLUID CATEGORIES:

Resuscitation
Shocked / >10% dehydration / BE >-10 15ml/kg 0,9% NaCl and 5ml/kg 4,2% NaHCO3 X 2
(review)
If still shocked after 2 x boluses or Inotropes:
severe acidosis BE: ≥-10 START: • Dobutamine 3mg/kg in 50ml N/S, start at 5ml/hr.,
review 2hrly
Sodabic/Saline infusion:
• 4,2% NaHCO3: ml = 0,3 x weight x BE + N/S 20ml/kg
over 4hours (Discuss with senior colleague)
It is important to start ½ D/D BEFORE 4,2% NaCO3 containing IV bolus is given, to prevent
serious hypokalaemia

Rehydration ½ D/D (Give with maintenance over 24 hours)

5% dehydration 50ml/kg extra

10% dehydration 100ml/kg extra

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Maintenance ½ D/D
0-3months 150ml/kg/day
3-9months 120ml/kg/day
Up to 10kg 100/kg/day
10-20kg 1000ml + 50ml/kg over 10kg
Over 20kg 1500ml = 20ml/kg over 20kg

Ongoing losses: 15ml/kg for each loose stool or vomitus

If shocked / vomiting Give bolus 0,9% N/Saline as second infusion
If tolerating fluids Give SOROL per os or though NGT 10-15ml/kg

Less than 5% dehydrated

Tolerating oral fluids SOROL orally for maintenance and rehydration
Ongoing losses — replace with SOROL
Normal diet

Initial treatment
ZnSO4 <6m = 10mg/day for two weeks
≥6 = 20mg/day for two weeks
Gentamycin 8mg/kg 4hrly PO 3/7
Flagyl 7,5mg/kg TDS PO 5/7

E. ELECTROLYTE ABNORMALITIES

Hypokalaemia
IV 1,5m KCL per 200 ml of ½ D/D (1ml = 2mmol)
PO 3–6mmol/kg/d in 3–4 doses (Mist Pot Chlor contains 13mmol per 5ml)

Hyperkalaemia
Stop potassium containing fluid and give 0,45% Saline + 5% dextrose
Kayexelate 1g/kg PR/PO
0,5–1ml/kg of 10% calcium gluconate over 5 minutes IV
Bolus of 10ml/kg 0,9% NaCI
NaHCO3 3ml/kg stat IV

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Hypernatremia
Can still use 0,9% N/Saline as boluses to correct shock
Maintenance + rehydration still over 24 hours
BUT
If Na 150 – 160 Add 6ml of 8,5% Sodabic to each 200ml ½ D/D
If Na >160 Add 8ml of 8% Sodabic to each 200ml ½ D/D and run at 10ml/kg/hr for 2
HRS only, repeat U&E
If more losses Increase rate to 12–15ml/hr. and review after 2hrs, repeat U&E
If adequate rehydration Run ½ D/D at ;maintenance plus rehydration rate and introduce SOROL,
after 4 hrs. review again after 2hrs, with U&E
If well tolerated, Decrease ½ D/D–
hydration adequate, then • Maximum sodium decrease 1 mmol/hour
• Do 2-hourly U&E, UNTIL Na and K stabilised
Observe for seizures, which is indicative of cerebral oedema, cerebral
vein thrombosis

Hyponatremia
mmol Na over 12 hours = (135 – serum Na) x mass in kg x 0.6
If fitting Give 3% Saline 1–2ml/kg/h for 3 hours, then correct over 12 hours

Hypocalcaemia
0,5ml/kg Calcium Gluconate IV SLOWLY over 20 minutes

Hypomagnesaemia
0,1–0,2ml/kg 50% MgSO4IV over 10 minutes

MALNUTRITION OR ANY OTHER DISEASE,

ADMIT IN THE WARD AND TREAT ACCORDINGLY

F. OTHER PROBLEMS
Dysentery Ceftriaxone, IV, 50mg/kg as a single daily dose for 5 days
OR
Ciprofloxacin, oral, 15mg/kg/dose 12 hourly for 3 days
Entamoeba Histolytica Metronidazole, oral, 15mg/kg/dose 8 hourly for 7 days
Severe disease: treat for 10 days
Typhoid Ceftriaxone, IV, 50mg/kg once daily for 10–14 days
Chronic diarrhoea Gentamycin 50mg/kg/day, 4hrly orally for 3 days and Flagyl
Metronidazole, oral, 15mg/kg/dose 8 hourly for 5 days

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G. FEEDING
Any child with diarrhoea asking for food or taking oral fluids can be fed, especially <1yr and breastfeeding.

Small amounts are usually well tolerated.

Dysentery: Aetiology
Bacterial Shigella; Salmonella; E Coli; Campylobacter; Yersinia; Clostridium
Parasitic E Histolytica; Balantidium Coli; Malaria; Worms
Management Supportive; Hydration and Fluid
E Coli; Campylobacter; Yersinia; Salmonella } NO antibiotics, self-limiting
Shigella } usually none if mild disease
} Severe disease: Bactrim, Ampicillin
Clostridium } Vancomycin
Parasites } Mbendazole

FULMINATING LIVER FAILURE

A: ETIOLOGY
Viruses: most common Hep A
Hep B
Virus: less common Hep E,
CMV
EBV
HIV
HVH
Other agents Leptospirosis
ECHO
Medicines Salicylate
Paracetamol
Anti-epileptic drugs
Anti TB drugs
Toxins Mushrooms
Traditional remedies
Auto-Immune
Malignancies
metabolic Galactosaemia
Wilson’s
Hemochromatosis
Vascular Veno – occlusive disease

B: CLINICAL EXAMINATION
Enlarged Liver Malignancies
Infiltrations
Metabolic
Auto-Immune Joint abnormalities

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 Rashes
Spider naevi
Haematological abnormalities

C: SPECIAL INVESTIGATIONS: DO

Aetiology Viruses Hep A, B, C, E; EBV, HIV, CMV, Echo, HVH

Toxins Paracetamol, Salicylic acid

Metabolic Ferritin, Abdominal U/S, α1Anti-Trypsine, urine reducing

substances

Vascular Abdominal U/S

Auto-Immune ANA, RF,

Monitoring Admission CXR, Blood and urine culture, Abdominal U/S

Daily LFT, UKe, pH, Mg, Po4, Clotting profile

4-6hly Glucose, BP, Pulse, Sats, Neuro Obs

D: WARD MANAGEMENT
Routine Observations 6hly
Neuro observations 2hrly
Glucose 4hly If stable, 6hly
Strict Input and output Daily
NG tube free drainage First 24 hours
Isolation, barrier nursing
NPO First 24 – 48 hours If stable, start 6g/kg proteien after 48 hrs
Fluid 80% of maintenance

E: MEDICAL MANAGEMENT
Lactulose 1ml/kg 4-8hly 2-3 stools/day, monitor hydration
Gentamycin orally
Vitamin K Daily for 5 days 2x/week after 5 days
Ulsanic
Treat any infections appropriately
Parvolex See below
N-Acetylcysteiene (NAC)/ Parvolex Regime

Weight >20kg
Dose NAC mg/kg Volume 5% Dextrose Duration
1 150 100ml 15 minutes
2 50 250ml 4 Hours
3 100 500ml 16 Hours
Weight <20kg
1 150 3ml/kg body weight 15 minutes
2 50 7ml/kg body weight 4 Hours
3 100 14ml/kg body weight 16 Hours
Take care with asthmatics, if reaction: Hydrocortisone and anti-histamine and decrease rate of infusion

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 Signs of encephalopathy in advancing liver failure

Grade of encephalopathy Tone and reflexes Response to pain Pupils

Grade 1 Normal Obeys Normal
Grade 2 Brisk reflexes and Obeys Normal
increased tone
Grade 3 Extensor plantar, clonus Localizes, Flexes Hyperactive
Grade 4 Sustained clonus Extends Hippus, dilated sluggish
Brain Death Flaccid, absent reflexes None Fixed, dilated

MALNUTRITION / FTT

A. SPECIAL INVESTIGATIONS
T/B workup Mantoux, CXR, G/W
Urine MC&S
UKE
RVD
FBC Check Hb, MCV, MCH
Ca, Mg, PO4, Albumin Replace if low
Blood Culture

B. MANAGEMENT

Adequate feeding
D/W Dietician re F75, F100, Pre-Nan or Imunat to be supplied.

Drug treatment:
Zentel <1yr 20mg/kg PO
1-2yr 200mg PO
>2yr 400mg PO
ZnSO4 <6m = 10mg/day for two weeks
≥6 = 20mg/day for two weeks

MVT 0-1month Vidaylin 0,3ml/day

1-12months Vidaylin 0,6ml/day
>1yr MVT 5ml/day PO
Folic acid 2,5mg/day PO
Elemental Iron 6mg/kg/day PO if microcytic anaemia
Antibiotics Ampicillin 50-100mg/kg/day6hly AND
Gentamycin: 5mg/kg/day IVI
Vit K According to national schedule

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 SAM ± OEDEMA

For investigations and treatment see: Severe PEM inpatient management guide

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Respiratory System
RESPIRATORY DISTRESS IN CHILDREN

QUESTIONS
• Upper or lower airway
• Sudden onset or insidious
• Unwell and fever; cold or playing
• Toxic, abnormal posturing
• Previous history of intubation or distress
• Since birth, new onset
• History of asthma/croup
• Previous accidents/surgery
• Diarrhoea/ poor feeding/ decreased intake
• Prematurity
• ANY possibility of ingestion of substances
• Metabolic acidosis

These questions above are as important as diagnosis. Management depends on cause of distress. For each of
the above, the management is different.

CROUP

High upper airway obstruction • Tonsillitis, quinsy, lymph nodes, foreign object
• Noise very loud, severe tracheal tuck
Middle airway • Toxic: epiglottitis, abscess
• Non-toxic: foreign object, bleed, trauma
Lower airway • Larynchotracheobronchitis, foreign object, bacterial or candida
tracheitis, larynchomalacia, vascular ring, lymph nodes
• Sounds not very loud

GRADE: SEVERITY (STRICTLY SPEAKING ONLY APPLICABLE TO VIRAL LTB)

Grade 1: Inspiratory stridor only
Grade 2: Inspiratory and expiratory stridor
Grade 3: In- and expiratory stridor and active use of abdominal
muscles
Grade 4: Cyanosis

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MANAGEMENT
Adrenalin 1:1000: Saline nebs: 2ml: 2ml

IMPORTANT AND NON-NEGOTIABLE

Grade 3 croup can never be left alone, doctor present AT ALL TIMES.
Administer adrenalin and if grade does not improve to Grade 2 within half an hour; PATIENT MUST BE TAKEN
TO THEATRE.
Anaesthetist, paediatrician, and ENT surgeon must be present for intubation and ventilation.
If intubation fails, i.e. severe bacterial tracheiitis, a trachi must be done.
Any tube above size 2,5 is acceptable for transfer to a tertiary unit if ventilation is effective.
Grade 1 and 2 croup can be managed in the ward on adrenalin alone.

BRONCHIOLITIS

SIGNS AND SYMPTOMS

Child less than 1 year

History of runny or blocked nose

Not ill at all

Playing and happy

No fever or <37, 4ºC

Can still feed well

Soft musical sounds on auscultation, diffuse over all lung areas

MANAGEMENT
Responds well to adrenalin 1:1000 2ml: 2ml N/Saline prn hourly intake

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 PNEUMONIA

CLINICAL CLASSIFICATION OF PNEUMONIA:

Non-severe pneumonia: Cough and tachypnoea
Severe Pneumonia: Cough, recession, grunting, nasal flaring, apnoea,
altered LOC, stridor, cyanosis, hypoxemia

SPECIAL INVESTIGATIONS
Ward Hb if <10 — Do FBC
T/B W/U Mantoux, CXR, G/W x 2
If severe pneumonia Do ABG, FBC, B/C

TREATMENT:
0-6m/severe pneumonia/PEM/RVD ADMIT
Lobar pneumonia: Pen G 50000iu/kg 6hrly IVI
Bronchopneumonia: Ampicillin 50-100mg/kg/day6hly AND Gentamycin: 5mg/kg/day IVI
Suspected PCP: (RVD exposed<1yr or hypoxic on room air)
Bactrim 10mg/kg stat then 5mg/kg/6hly IVI
Methylprednisolone: 2mg/kg stat then 6hly IVI
Ganciclovir 5mg/kg stat then 12hly IVI
Suspected Staph: pneumatocoele, empyema, abscess Cloxacillin 50mg/kg 6hly IVI
>6months and non-severe Lobar pneumonia: Pen G IVI for 24 hours then Pen VK
pneumonia Bronchopneumonia: Amoxil 30mg/kg 8hrly PO

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 ACUTE SEVERE ASTHMA

DANGER SIGNS:
• Previous ICU admission
• Acute episode >12 hours
• Recent oral steroids
• Drowsy / confused
• Silent chest
• Saturation <90%

INITIAL TREATMENT:
Oxygen by mask 4-6 l/min, prongs 2l/min
Inhaled short acting ß2 agonist Via large volume spacer 1 puff / 4-5 breaths, repeat every
30 seconds to 20 puffs / 20 minutes
OR
Via nebuliser Salbutamol 2,5mg (small child), or 5 mg
(bigger child) up to 4 ml with normal saline every 1-6 hrs.
prn
Inhaled Ipratropium Bromide 0,25mg (small child) or, 5mg
(bigger child) added to Salbutamol 4hrly
Systemic corticosteroids Prednisone 1-2mg/kg/dose 12hrly max 80mg orally
OR
Hydrocortisone 2-4 mg/kg 6hrly (max 200mg) IVI
Assess after one hour
Moderate episode: Severe episode:
Moderate symptoms and retractions, PEFR Severe symptoms, retraction, PEFR <60%, accessory
60-80% muscles used
• Inhaled ß2 agonist hourly as above • Oxygen
• Inhaled Ipratropium Bromide 4hrly as • Inhaled ß2 agonist hourly / cont above
above • IVI steroid as above
• Oral corticosteroids as above • Inhaled Ipratroprium Bromide 4hrly
• ß2 agonist 15mg/kg S/C stat and 20mins later, if
necessary SLOWLY or S/C
• Adrenalin 1:1000 0,01mg/kg S/C (max 0,3ml)
Reassess after one hour

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Good response Incomplete response Poor response
Sustained 60 minutes after last Rx Tachypnoea, wheezing, Severe wheezing
No retraction minimal retraction Talks with difficulty
Talks with ease Unable to feed
No wheezing

PEFR > 70%

O2 sats >95% PEFR > 50% but <70% PEFR <30%
O2 sats <95% but >90% PCO2 >4,5kPa; PO2 <8kPa
O2 sats <90%
Discharge home Admit to ward Admit to ICO
Maintenance treatment Inhale ß2 agonist hourly Call registrar / consultant

Ipratropium 4 hourly Aminophylline 6mg/kg stat

Action plan inhaled then
Follow up Oxygen Infusion 0,5-0,8mg/kg/hr
Oral corticosteriod OR
Salbutamol (see below)
Salbutamol 1mg/ml ampule: IVI
Infusion
0,3–0,6ml/kg/hr = 5–10mcg/kg/min for
1 hour
then
0,06–0,12ml/kg/hr = 1–2mcg/kg/min
NB:
INCOMPATIBLE WITH
AMINOPHYLLINE, KETAMINE,
MAGNESIUM

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Neurological System
CONVULSIONS

A. DIFFERENTIAL DIAGNOSIS
Metabolic: Hyper/hyponatremia
Hyper/hypocalcaemia
Hyper/hypomag
HYPOGLYCEAMIA
Infective: Meningitis
Encephalitis

Structural Abnormalities
Epileptic Syndromes

B. ACUTE AIM — STOP THE CONVULSION

100% O2 by face mask or prongs Check glucose, urea, electrolytes, calcium, magnesium, Hb,
acidosis, BP

if <10kg – Diazepam 5mg P/R

if >10kg – Diazepam 10mg P/R
OR
Diazepam 0,3mg/kg IVI over 3 minutes (max 10mg)
and commence
Phenobarbitone infusion IVI, 20mg/kg over 20 minutes

Can be repeated every 20 minutes until convulsions

stop, up to 10 x in a 10mg/kg/dosage cycle
If convulsions are longer than 20 minutes Dexamethasone 15mg/kg 6 hourly IVI
Mannitol 1g/kg stat
If still no response, admit to ICU, call consultant re further management and intubation

Options in ICU with consultant

Rivotril (Clonazepam If <10kg – 0,25mg

If >10kg – 0,05mg/kg 200ml 5% Dextrose at 1ml/min
(titrate)
Dormicum (Midazolam) 0,15mg/kg IVI bolus then
3mg/kg in 50ml @ 1–4ml/hr = 1–4mcg/kg/min
If fitting @ 2-4ml/hr (can go higher)
Thiopentone 2-5mg/kg bolus SLOWLY followed by infusion:
Ampoule 25mg/ml @ 0,04-0,2ml/kg/hr = 1-5mg/kg/hr

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 AFEBRILE SEIZURES

Afebrile seizures – first onset HGT and BP always

(clinically unprovoked) RVD; U&E; CMP; FBC
TB W/U: GA x 2 if suggestive CXR
u-Dipstix and u-MCS if dipstix+ or <6m
LP
If all above normal Discharge, no follow up

Afebrile seizures second time AND Book for EEG

previous work up normal Start Epilim 20mg/kg/day/orally, 12hrly
F/U neurology Clinic
Side room and special investigations as per underlying
Febrile seizures – first onset clinical indication (always HGT and BP)
No investigations necessary if all of:
• Typical febrile convulsion (FC)
• Clear extra-cranial focus for fever that can be treated as
an outpatient
• No indication for LP (see below)
• Patient awake and clinically stable (not sick enough to
warrant admission)

LP indications in FC:
>24m all first fever-associated fits
<12m always and every time to exclude meningitis
12–18m mostly (can only omit if previous FC-associated LP was normal
AND absolutely no clinical suspicion of meningitis AND
discussed with consultant paediatrician
>18m if clinical suspicion of meningitis
First FC is atypical (>2yr)
Received prior antibiotics
(>1yr)

Omit LP if:

Focal Signs or
Focal Fit > 1yr
Any bleeding tendency or low platelets
Abnormal Consciousness

- 15 -
DRAW A PERSON TEST TO ESTABLISH MENTAL AGE

- 16 -
 MENINGITIS

MEDICAL MANAGEMENT
Bacterial Ceftriaxone: 1g/kg/day, max 2g IV q12hr for 7-14 days
<3/12: Cefotaxime 50mg/kg 6hly
Viral Acyclovir: 10-15 mg/kg IV q8hr for 10 days
TBM 4 drugs plus prednisone

- 17 -
GUIDELINE TO INTERPRETATION OF LP

- 18 -
Diagnosis Predominant cellcount Glucose Proteien Comments
(selle/mm3) (mmol/ℓ)
(g/ ℓ)
Normal (>3m) 0-6 lymphs ≥ ⅔ of s-gluc 0.15-0.45
s-gluc value up
0 polys One of the
to tot 4h pre
most sensitive
LP can be used
indicators of
2.7-5.5 CNS pathology
Aceptic/Viral 25-500 lymphs Normaal Normaal of  Crystal clear CSF
Slightly
Sometimes Usually beter after LP except Herpes
low, but ration Enkefalitis: Diagnosed with HSV type 1
>1000 cells, probably not viral
never< <0.25 PCR op CSF – 100% sensitivity
Reikwydte:
polys can predominate within
first 72 hrs 0.15-2.0
Bacterial 100-50000 polys  (1.1-1.6)  slight to Turbid CSF
meningitis moderate (±
87% >1000 <0.5: serious Gram stain can be (+) in 60-80% of
1.0)
infection untreated cases and 40-60% of partially
99% > 100
treated cases
Ngluc.Does not
Thus < 100: niot bacterial
exclude Range:
15% lymphs predominate bacterial–up to
0.5-5
50 has normal
value

TB meningitis 25-100 Max 500  moderate  moderate Clear CSF: low cellcount
Sometimes ↓ Cl- (<100 mmol/ℓ)
lymphs Range: CSF changes persist > 3w
oorwegend maar polys kan 0.5-3.0 Clinical suspicious cases: Collect 1-2ml
vroeg pre-domineer) extra SCF and ask for TB-MCS
SCF verdag: Contak lab and request
TB-MCS
In uncertain cases, continue TBM,
bacterial cover and repeat LP after 10-
14 days
Subacute 100-700 lymphs   Cryptococcus indian ink colour and
meninigitis Cryptococcus Ag is used for diagnosing
Cryptokokkus meningitis
(Cryptokkokus,
sarkoied,
leukemie,
karsinoom)
Brainabces or 0-1000 lymphs Normal 
tumor
(naburigheid
syndrome)
Traumatic tap Def.: > 1000 red blood cells / mm3
(vs. 1 poly for each 500 red blood cells(if peripheral WCC not high or low and 0.01g/ ℓ proteien for each 1000 red
Intracraniale blood cell (slegs akkuraat as dieselfde monsterbuisie gebruik word vir prot bepaling en seltelling) can be
bleeding) accepted. If polys or RBC outside these ranges, consider meningitis or ontracranial bleed.
Clots suspicious of traumatic tap.

- 19 -
 If RBC drops in three consecuttive tubes, indicative of traumatic tap versus staying constant in intracranial
bleed.
Xantochromia, is a more reliable indication of intracranial bleed, an dis seen in > 90% of patients within 12h of
a subarachnoid bleed. Other causes of xantochromia: old bleed, severe jaundice, prot >1.0)
Guillain-Barré Few Normal  (>1.0) ’n LP in suspected cases of GBS is
syndromw indicated but the sito-albuminc dissociation
(lymphs; 0-100)
(few cells, raised prot.)usually only seen 1-2
weke after onset.
Poliomyelitis 10-300 lymphs Normal Slightly

Post-ictal Should be normal

Indien ↑ cell count (in 20% of patients who had status epileptikus) behandel treat as suspected
bacterial meningitis until CSF culture negative
Partially usually: SCF but still ↑ seltelling (polys0, ↓ glucose en ↑ proteien.
treated
meningitis.
(Received any
A/B before LP
was done)

DIAGNOSIS OF BRAIN DEATH

In children and term infants older than 7 days, pre term infants >32 weeks gestation

THE CLINICAL DIAGNOSIS OF BRAIN DEATH CAN BE MADE ON THE BASIS OF THE FOLLOWING:
Coma Lack of response to pain, light or auditory stimulation
Apnoea Failure to breathe when pCO2 is 60mm Hg (tested by 3 minutes without ventilator
support while continuing 100% O2.)
Tone and movements Flaccid tone and absent spontaneous or induced movements
Brain stem reflexes Absent brain stem reflexes and bulbar movements
Fully dilated pupils with no reaction to light or pain
Absent oculocephalic,caloric,corneal,gag,cough,rooting and sucking reflexes
should all be present by 33 weeks gestation
Barbiturate level Does not exceed 25g/ml.

Ref .1. Pediatrics 80:298,1987

2. Pediatrics 84:429,1989

- 20 -
 LEARNING DISABILITIES AND ADHD

(A): EVALUATION OF POSSIBLE ADHD IN A CHILD:

Attention deficit hyperactivity disorder (ADHD)/ Attention deficit disorder (ADD)/ Hyperkinesia. Etc.

The above implies a child that struggles in school due to

Concentration problems as well as

Impulsivity,

Being easily distracted, and

Shouting answers without thinking.

This would lead to a referral.

To do a proper and objective assessment of ADHD or ADD, evaluation over a period or spectrum is
necessary.

The following documents are needed:

1. Last school rapport card of previous year, most recent rapport card of this year
2. Books from last term previous year and most recent books
3. SDQ questionnaire filled in by two people e.g. mother and teacher
4. School psychologist evaluation with IQ, learning problems, etc. stated and planning on management in
class, or alternative schooling if borderline IQ.
5. Visual and hearing screen

Clinical examination to evaluate:

Gross motor neurology; eye hand coordination; crossing of midline; balance; fine motor function and exclude petit
mal epilepsy.

With all of the above; the patient can be referred to a paediatrician or psychiatrist to evaluate re initiation of
drugs e.g. methylphenidate.

(B): FOLLOW UP 1 MONTH AFTER INITIATION ON CNS STIMULATING DRUGS, E.G.

METHYLPHENIDATE:
1. Enquire about side effects, should be resolved by now

2. Evaluate books pre and post treatment

3. SDQ mother and teacher pre and post treatment

4. Report from teacher re behaviour and work in class

5. Decide to keep dosage the same; decrease or increase.

6. If steady state follow up after one year.

- 21 -
(C): YEARLY FOLLOW UP OF CHILDREN WITH ADHD
The following should be checked and evaluated

Weight and height

Work books

Letter from teacher re behaviour and concentration in class for full day

Evaluate If methylphenidate dosage should be increased.

Dosage:
Dosage guideline 0,5 – 1mg.kg
<20kg or <Grade 3 Ritalin 5 or 10 mg
>20kg or Grade 3 Ritalin LA 20 or 30 mg
Concentration problems after 12h00 Add Ritalin 10mg, (not later than 14h00)

DSMIV- CRITERIA FOR ADHD:

A.: 6 OR MORE OF FOLLOWING PRESENT FOR MORE THAN 6 MONTHS AND INAPPROPRIATE TO
DEVELOPMENTAL LEVEL:

Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other
activities

Often has difficulty sustaining attention in tasks or play activities

Often does not seem to listen when spoken to directly

Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the
workplace (due to oppositional behaviour and failure to understand instructions)

Often has difficulty organising tasks and activities

Often avoids, dislikes, and is reluctant to engage in tasks that require sustained mental effort (such as
schoolwork or homework)

Often loses things that is necessary for tasks or activities

Is often easily distracted by external stimuli

Is often forgetful in daily activities

B: SIX OR MORE OF THE FOLLOWING SYMPTOMS OF HYPERACTIVITY- IMPULSIVITY HAVE

PERSISTED FOR AT LEAST 6 MONTHS TO A DEGREE THAT IS MALADAPTIVE OR INCONSISTENT
WITH DEVELOPMENTAL LEVEL

Hyperactivity: Often:

- 22 -
 -Fidgets with hands and feet and squirms in seat

-Leaves seat in situations in which remaining in seat is expected

-Runs and climbs excessively in situations in which it is inappropriate

-Has difficulty in playing or engaging in leisure activities quietly

-Is on the go or acts as if driven by a motor

-Talks excessively

Impulsivity: Often:

-Blurts out answers before the question has been completed

-Has difficulty awaiting turn

-Interrupts and intrudes on others (butts into conversation or games)

C: SOME HYPERACTIVE- IMPULSIVE OR INATTENTIVE SYMPTOMS THAT CAUSED IMPAIRMENT

WERE PRESENT BEFORE AGE 7 YEARS

D: SOME IMPAIRMENT FROM THE SYMPTOMS IS PRESENT IN TWO OR MORE SETTINGS, E.G. SCHOOL AND
HOME

E: THERE MUST BE CLEAR EVIDENCE OF CLINICAL SIGNIFICANT IMPAIRMENT IN SOCIAL, ACADEMIC, OR

OCCUPATIONAL FUNCTIONING

F: THE SYMPTOMS DO NOT OCCUR EXCLUSIVELY DURING THE COURSE OF A PERVASIVE

DEVELOPMENTAL DISORDER, SCHIZOPHRENIA, OR OTHER PSYCHOTIC DISORDER AND ARE NOT BETTER
ACCOUNTED FOR BY ANOTHER MENTAL DISORDER E.G.: MOOD,- ANXIETY,- DISSOCIATIVE,- OR
PERSONALITY DISORDER

DEPRESSED CONSCIOUSNESS

PNEUMONIC
D Diabetes
I Infection, Inflammation
M Metabolic Hypoglycemia
Abnormal Na, Ca
Renal, hepatic failure, Reye
T Tumor, Toxic Trauma
O Oxygen Hypoxia
P Post ictal Psychosis
Psychiatric Psychosis
Poison Organophosphate
V Vascular Stroke,
Bleed

- 23 -
 RAISED INTRACRANIAL PRESSURE

A: SIGNS
Doll’s eye abnormal
Posture Decorticate Decerebrate
Abnormal pupil reaction
Breathing pattern Cheyenne Stokes Cortical
Ataxic Brain stem
Cushing’s triade Bradycardia
HPT
Abnormal breathing

B: MANAGEMENT
O2 and support
Head in neutral position and 45 raised
IVI fluid Fluid bolus if shocked
Mannitol 0,5 – 1g/kg over 20 minutes
Dexamethasone 0,15mg/kg 6hly IVI
Drugs Rocephin 1g/kg IVI (max 2g/dose)
Acyclovir
TBM drugs (see guidelines)
IPPV Normal gases
Treat Cause

- 24 -
Nephroplogy
GLOMERULONEPHRITIS:
INTRODUCTION
The vast majority of patients are hypertensive during the phase of fluid overload. Occasionally the hypertension
persists and if the renal function deteriorates simultaneously, consider renal biopsy.

DIAGNOSIS
Heamaturia >2+; usually macroscopic
Hypertension
Facial or generalised Oedema
Oliguria/Anuria

INVESTIGATIONS
Always FBC,U&E Creatinine; U-MC&S; Cholesterol; Albumin
Occasionally Anti-DNase; ASOT

MANAGEMENT
Observations BP; Pulse 4-6hrly
Dipsticks and weight Daily
Fluid Balance monitor Input and Output Daily
Fluid Management No contraindications 1liter clear fluid/24hrs
Pulmonary oedema oliguria/anuria sips of clear fluid
Hydrated anuric patient without oral fluid to replace insensible losses Insensible losses calculated
extra renal fluid losses as:25ml/kg/day or
400ml/m2/kg)
Normal hydration plus oliguria oral fluid to replace insensible losses plus
previous 24hr urine output
Normal hydration plus normal urine give normal fluid intake
output
Bed rest is necessary in all patients with severe hypertension and pulmonary oedema

ANTI-HYPERTENSIVE MANAGEMENT IN ACUTE GLOMERULONEPHRITIS

Initially 1 litre of oral pure water per monitor BP; input and output
day
Lasix 1-4mg/kg/day 8hly ensure adequate diuresis
IF oliguria Lasix 5mg/kg/dose- slow bolus over
5mins to due to risk of ototoxicity
If hypertensive episodes Systole >135mmHg and/or Diastole Nifedipine 0, 2 – 0,5mg/kg/dose
>90mmHg; given sublingually.
Ongoing severe hypertension, Dihidralazyne 0, 1 – 0, 8
regardless of above: mg/kg/dose IM or IV
If frequent dosages above Atenolol 50 – 100 mg b/d orally
necessary for more than 48hrs, OR
treat with: Amlodipine 0,05-0,2mg/kg orally
once a day
OR
Hydralazine 0,4mg/kg/os or
0.1-0.5 mg/kg IM/IV q4-6h;
Max: 20mg/dose.

- 25 -
ANTI – HYPERTENSIVE DRUG GROUPS

Vasodilators
Diazoxide rapid IVI injection for severe HT 1-3mg/kg/dose, repeat once then infusion. Max
150mg
Sodium nitroprusside: 30 kg: 3mg/kg in 50ml 5% Dex at 0,5-4ml/hr.
(0,5-4mcg/kg/min) IVI
>30kg: 3mg/kg in 100ml 5% Dex at 1-8ml/hr.
(0,5-4mcg/kg/min ) IVI
Max rate: 4mcg/kg/min if over 24hrs.
Hydralazine 0,4mg/kg/orally or 0.1-0.5 mg/kg IM/IV q4-6h;
Max: 20 mg/dose.

ACE Inhibitors:
Captopril 100-00mcg/kg/os 3 times a day
Enalapril 0,1-0,5mg/kg/os once a day

Calcium Channel Blockers

Nifedipine Capsules: 0,25-0,5mg/kg8hly orally OR Tablets: 0,5-
1mg/kg12hly oral or S/L
Amlodipin 0.05-0.2mg/kg/day oral

NEPHROTIC SYNDROME:
Nephrotic syndrome is a clinical syndrome associated with massive proteinuria due to increased permeability of
the glomerular basement membrane

DIAGNOSIS:
Massive proteinuria >3+ proteinuria
Hypo-albuminaemia
Oedema
Hyperlipidaemia
Usually normal blood pressure
Transient microscopic haematuria and/or hypertension in 25% of cases
Usually normal renal function

INVESTIGATIONS:
Urine Dipsticks
Spot random urine sample protein: creatinine ratio >0.2g/mmol
Urine microscopy hyaline and lipid casts
Tot protein and albumin Albumin <25g/dl
Cholesterol raised
To investigate secondary causes of nephrotic syndrome ASOT, Anti-DNase
Hepatitis Screen
HIV

- 26 -
 Abdominal U/S

MANAGEMENT
Monitor fluid balance Daily input and output
Weigh daily 1kg =1L of fluid
Assess hydration status daily
Replace ongoing extra-renal losses as for dehydrated patient Sorol for GIT losses

MEDICAL
If secondary cause is identified treat
accordingly
If hypovolemic 0.9%N/S 20ml/kg bolus:, replace ongoing extra renal losses
Oedema and hypervolemia Furesomide,oral:2mg/kg/dose12hrly
Intractable oedema who fail to Hydrochlorothiazide1mg/kg daily. Do not exceed 12.5mg/kg
improve on furosemide Rx
Ascites Spironolactone oral 1.5-2.5mg/kg/dose, 12hrly
Anasarca,Hypovoleamia and 20% Human Albumin (salt free),IV,1g/kg (i.e. 5ml/kg)administered over
Oliguria 5hrs on 2 consecutive days AND furosemide IVI 2mg/kg slowly over 5hrs

Antibiotics ampicillin and gentamycin (normal renal function)

If suspected Strep – Penicillin G
Steroids 2-6yrs, trace haematuria
2mg/kg/day orally mane for 4weeks
1,5mg/kg/day orally mane for 4 weeks
1mg/kg/day orally mane for 4 weeks
1mg/kg/day orally mane for 4 weeks

URINARY TRACT INFECTION:

DEFINITIONS OF DIFFERENT UTI’S:
Simple UTI Lower tract, few symptoms, usually normal tractus
Complicated UTI/ Pyelonephritis Febrile, systemic features
Unresolved UTI No improvement after 48 hours of treatment Ask if:
Compliant
Adequate drug dosage
Resistant organism
Reinfection Recurring UTI with different organism after sterile urine
Persistent infection Same organism isolated repeatedly (nidus)
Catheter associated UTI
Recurrent UTI: 2 or more episodes of UTI with pyelonephritis OR
1 episode of pyelonephritis and 1 episode of LTI OR
3 or more LTI

ORGANISMS:
Usually E.Coli (80% of time)
Atypical K. Pneumonia, Serratia, Enterococcus, Enterobacter,
Pseudomonas

- 27 -
Virusses Tend to give haemorrhagic cystitis
Adenovirus is the most common.

DIAGNOSIS:
NEED TO TAKE SPECIMEN BEFORE ANTIBIOTIC IS STARTED

Urine MC&S: sterile sample: (BAG SPECIMEN IS UNACCEPTABLE)

Neonates and children not potty trained: use in/out catheter with sterile technique, OR
suprapubic (gold standard)
Potty trained: midstream clean catch
UK&e

How to interpret urine dispsticks (12)

Blood/protein Non-specific; many other causes.
Leukocyte esterase test Sensitive for leukocytes but not specific for UTI’s –especially in
girls
Nitrite test for bacteria: High specificity (99%) but low sensitivity50%.
pH alkaline urine - Proteus infection
+ve leucocytes and nitrites 85-90% UTI
-ve leucocytes and +ve nitrites ask yourself if your specimen is fresh, if YES – treat
+ve leucocytes and –ve nitrites most likely have UTI – treat if clinically indicated
Both negative 85-98% chance of not having UTI
Urine with any positive parameters should be sent for culture
Negative we accept as negative

How to interpret culture result:

Specimen obtained Organism significance
Suprapubic Any Gram negative
> 5 000 cfu/ml gram positives
Midstream >100 000 cfu/ml
Transurethral >10 000 cfu/ml

TREATMENT:
Start with broad spectrum antibiotic after sampling
IVI antibiotic is given if: child septic OR <3months of age OR vomiting
Oral (preferable) Cefixime or Augmentin/Amoxil short course 3-4 days
Pyelonephritis only IVI therapy – 6 days
It has been proven there is no difference in
outcome between oral and IVI treatment for LTI’s

- 28 -
 SPECIAL INVESTIGATIONS: (ACCORDING TO RSA PAEDIATRIC UTI PROTOCOL)

Confirmed UTI Abnormal U/S

Normal U/S All patients have Ultrasound (U/S) +

U/S as soon as possible

No Further Infections

Dilatation of the System* Other abnormality of system

2nd or Atypical UTI

Repeat U/S MCUG Refer and investigate

No Further investigations appropriately
Boys<3years

Girls not potty trained

DMSA # (Exclude valve/reflux)

Assess upper tract/renal

involvement
Indirect systogram (nuclear medicine)

Boys>3years

Girl’s potty trained

Normal Abnormal/Scarring
Exclude VUR, bad scar

+ Presumed reliable 3rd trimester Antenatal U/S not available in all patients
* Dilated Kidney only – PUJ (pelvi-ureteric junction) obstruction need MAG3 Nuclear study
#DMSA in our setting best early as compliance better + if bad ‘defect’ proceed with investigations
Book DMSA six months after UTI at Tygerberg Nuclear medicine – 0219384268 and follow up 1 week after scan
at WH Paediatric intern clinic for results

Book MAG3 Scan with indirect systogram ASAP at Tygerberg Nuclear medicine – 021938 4268 and follow up 1
week after scan at WH paediatric Intern clinic for results

PROPHYLAXIS: BEFORE STARTING

Treat underlying problem:

Dysfunctional voiding

Urotherapy

Constipation

- 29 -
Toileting advice

Psych

Physio –biofeedback TENS

Neurogenic bladder

PROPHYLAXIS INDICATED:
• Children less than 1 year with structural abnormality
• Grade 4-5 VUR
• Obstructive uropathy with recurrent UTI’s
• Single kidney with recurrent UTI’s
• Previous pyelonephritis with renal scarring
• Renal stones
• Neuropathic bladder and recurrent UTI’s

Referral to Nephrology:

All children with recurrent UTI’s, abnormal imaging, abnormal renal function with UTI’s should be referred.

- 30 -
 AN APPROCH TO HEMATURIA
Is the red urine really haematuria?

Red urine

U-Dipstix: test for Hb in urine

Hb(+) : blood (>1+)

Hb(-)

urine Microscopy Beetroot, sweets, drugs, serrtia marcescens

RBC + RBC (-)

True hematuria Hemoglobinuria, myoglobinuria

Three glass test

Start of micturition Throughout micturition End of micturition

Brown Red  clots

Urethral

Renal Bladder

Types of Hematuria

Acute Persistent
Gross (Macroscopic) Microscopic
Symptomatic Asymptomatic

- 31 -
CAUSES OF HEMATURIA
Systemic Nephrological Urological
Menarche Family History Trauma
Exercise Hydronephrosis
Bleeding tendency Reflux nephropathy
Sickle Cell + - Stones
Infective endocarditis Cystic/medullary sponge kidney
Septicemia Hereditary Nephroblastoma
Infective Non-
Drugs nephritis
Infective Rhabdomyosarcoma of bladder
Idiopathic Ca2+uria Renal haemangioma
Nephrocalcinosis (Alport)

UTI HUS

TB APIGN

Bilharzia Chronic GN

Benign recurrent haematuria

DIFFERENTIAL DIAGNOSIS OF HEMATURIA

Dipstick and Microscopy confirmed haematuria

RBC Morphology

Dysmorphic RBC’s Eumorphic RBC’s

Cellular casts

Urine Dipstick Hypercalciuria

Nephrocalcinosis
Prot - Nephrolithiasis
Cystitis
Prot (>1+) Trauma
Exercise
Isolated microscopic haematuria Cystic kidney disease
Tumor
Haemangioma
Nephritis
APSGN
Family history of haematuria
IgA nephropathy
Alport syndrome
HSP
SLE Yes No
HUS
Chronic GN
Sickle cell disease IgA nephropathy
Hep B associated GN Family history of hearing APSGN (late)
loss/ renal failure

No
Yes
Thin basement
membrane disease

Alport syndrome

- 32 -
 DIABETIC KETOACIDOSIS

Vomiting?

Dehydrated?

Toxic/Febrile?
Mostly yes Mostly no
Kussmaul breathing?
Changed
conciousness?
Polyuria?

Venous blood gas

pH < 7.2

Yes No
DKA Not DKA

No insulin or IV
Urine ketones and glucose
fluids
Blood glucose

U&E

Venous blood gas

Serum osmolality

FBC

Urine MCS

DKA CRITERIA:
Hyperglycaemia blood glucose >11mmol
Venous pH<7.2 or Bicarbonate <15
Ketoneamia or Ketonuria
Severe glycosuria >55mmol/l

- 33 -
ASSESS SEVERITY
Clinical sign mild moderate severe
shock no no Yes
dehydration <5% <10% >10%
LOC Alert Drowsy Depressed
Acidosis pH<7.3 pH<7.2 pH<7.1
SB<15 SB<10 SB<5

A: FLUID REGIMEN

10ml/kg 0.9% Normal Saline IV in first hour; do not give more than 20ml/kg
Assume 10% deficit and add to maintenance and give over 36 hours
Maintenance: 1st 10kg: 100ml/kg; 2nd 10kg: 50ml/kg; 3rd 10kg: 20ml/kg over 36hrs
Urine replacement: if Urine output greater than 2ml/kg the difference must be replaced with 0.45% N/S

Example: Child weighs 27kg

100ml/kg/d (first 10kg) 1000ml (10kg x 100ml)

50ml/kg/d (second 10kg) + 500ml (10kg x 50ml)

20ml/kg/d (every kg over 20) + 140ml (7kg x 20ml)____

1640ml

Corrected Na: Calculate by adding 1mmol Na for every 2 mmol glucose >5,5mmol
If S-Na+ < 150mmol/l: 0.9% Normal Saline at normal rate over 36 hours
If S-Na+ > 150mmol/l: 0.45% Normal Saline at normal rate over 36 hours
NB Hyperglycaemia may cause a false hyponatremia

Fluid and electrolyte treatment: 2-bag system.

This consists of two bags (1lt each) consisting of the same electrolyte content, BUT different glucose
concentration (0% and 10%) titrated against each other according to blood glucose concentration. The total
infusion rate and type of electrolyte as calculated above. Example:
Content Bag 1 Bag 2

1 Litre NaCl NaCl

20ml (40mmol) KCl KCl
0% Dex trose 10% Dextrose
(800ml 0.9% N/S+200ml 50%dex)

Glucose>15 100% maintenance 0% maintenance

Glucose10-15 50% maintenance 50% maintenance

- 34 -
B: POTASSUIM
Although the initial plasma concentration will be high it will fall rapidly following treatment with fluid and insulin.
Start as soon as resuscitation is complete and: Child is passing urine
The ECG does not show elevated T-waves
Serum potassium is < 4.5

Give 40mmol KCL/L IVI fluid (40mmolKCl=20ml of 15%KCL)

Increase KCL supplementation if necessary –maximum rate is 0.5mmol/kg/hr

NB 1ml 15% KCL = 2mmol K, 1gr KCL=13mmol K

Give potassium phosphate only if serum phosphate is low or the child is clinically weak.

KCL and K2PO4 are added in equal volumes to IVI fluids for 6-12 hrs. of therapy only.

NB 1ml K2PO4 =2mmolK and 1.4mmol PO4

C. INSULIN
No stat IV dosages
Reduce the glucose at a rate of 1-5mmol/hr
ALWAYS keep insulin at rate of 0,1U/kg/hr

10 Units Actrapid/Humulin R in 100ml 0.9% saline

Rate =mass in Kg/hr =ml/hr –TO administer 0.1U/kg/hr

D: SODIUM BICARBONATE (USED ONLY IN SELECTED PATIENTS)

DO NOT GIVE UNLESS DISCUSSED WITH A CONSULTANT
SEVERE acidemia pH <6.9 – in whom decreased cardiac contractility and peripheral vasodilation can further
impair tissue perfusion.
In case of life threatening hyperkalaemia.
Correct only 25% over 4 hrs. (Not a bolus)
Mmol bicarbonate = (base deficit x 0.3 x body weight) divide 4
Stop when pH >7.15 or standard bicarbonate >8 mmol

E: IF ACIDOSIS NOT RESOLVING CONSIDER:

Sepsis

Check Drip site and potency

Check if all bags running i.e. Insulin infusion, maintenance and rehydration fluid?

ARE you giving enough fluids? Is the patient adequately resuscitated?

- 35 -
Is urine loss being replaced?

Consider persistent acidosis is due to hyperchloreamic acidosis – could need Sodabic (Consultant decision)

IF all of the above is addressed consider increasing insulin infusion rate - MUST BE DISCUSSED WITH
CONSULTANT.

F: COMPLICATIONS

CEREBRAL OEDEMA
0.7%-3% of paediatric patients are complicated by cerebral oedema with a morbidity of 21-35% and mortality of
21-24%

SIGNS
Headache

Change in vital signs: decreased PR Increased BP, decreased saturation and fever

Change in CNS signs: Depressed LOC, irritability, restlessness, cranial nerve palsies

PREVENTION:
Do not administer hypotonic fluid.

Do not give IVI or subcutaneous insulin bolus.

Start IVI insulin infusion 1hr after fluid resuscitation has begun.

TREATMENT:
Exclude hypoglycaemia

Mannitol 1g|kg immediately over 20 minutes

Halve IVI fluids

Elevate head to 45 degrees

Mannitol 0.25g/kg/hour as infusion or boluses 4-6 hourly

G: SWITCHING TO S\C INSULIN

Plan to switch at a mealtime –breakfast is most convenient

Insulin requirements: start at 0.6u/kg/day/ or less

2/3 of total dose in the morning: -1/3 actrapid (humulin R)

-2/3 protophane (humulin N)

1/3 of total dose in the evening: -1/3 actrapid (humulin R) 30 minutes before supper

- 36 -
 -2/3protophane (humulin N) @ 21h00

Give the first dose 30 minutes before meal

Stop insulin infusion +/- 60 minutes after subcutaneous injection

Sliding Scale

If HGT >15 test the urine if ketones are present give 0.05-0.1u/kg/dose of actrapid extra

If HGT>15 test the urine if no ketones present do not give extra actrapid

H: SICK DAY RULES

Test HGT at least q4h
Continue on insulin
Replace meals (if necessary) with frequent sugary drinks/jelly
Drink plenty sugar free fluids
Test urine: if ≥ 3+ ketones – call doctor!
Sliding Scale:

HGT Total insulin/day<20u Total Insulin/day >20u

<13 Normal insulin Normal Insulin
13 - 22 2u extra 4u extra
>22 4u extra 6u extra

I: THE NEW DIABETIC

Remember: Had raised glucose for weeks

Will drop glucose at home because of increased activity

Sliding scale waste of time

< 4 years: 0.25 – 0.5 U/kg/day all in morning

4 – 5 years 0.5 – 0.75 U/kg/day ⅔ mane, ⅓ nocte 30:70 short/medium acting

> 6 years 0.5 – 0.75 U kg/day

Do not aim for perfect control initially. If persistent high sugars (e.g. > 28mmol/l) give extra soluble with next
scheduled dose, e.g.

HGT > 44 0.4U/kg

HGT 28 – 44 0.3U/kg

- 37 -
 Eczema
Eczema is the result of a dry skin and will only get better as soon as the skin has been moisturised.

DIET:
The intake of the wrong food or food with preservatives plays a large role in the development of eczema and
allergies.

If a child is being breastfed, do NOT change to any commercial milk, carry on breastfeeding and advise mum on
her nutrition.

For any growing child, a healthy, balanced, home cooked meal is the best nutrition available. Advise parents to
cook meat, vegetables and starches from start and not to buy ready-made meals or fast foods. Cereal is
acceptable. Be aware of allergies to pork, fish, and egg and dairy products, stop all, and reintroduce one by one
and check for reaction. For cereal, one can use maize- or rice porridge without colorants and flavours and
Cornflakes or Weet-Bix.

Stay totally away from packaged food or drinks in any form, especially fruit juices, ice tea, etc. Ensure enough fruit
is included in the diet.

The only safe drink is ice rooibos tea made at home. Boil a litre of tea and cool down, add Ceres clear Apple
juice. 2 parts tea: 1part apple juice.

The only packages crisps or chips that might be safe, is the original ‘Flings’.

MANAGEMENT OF CLOTHES
All the specific child’s clothes and bedding must be washed using the original green ‘Sunlight Soap’. No softener
can be used, rather use one tablespoon vinegar in the last rinse. All the clothes should be dried outside and
everything touching the child’s skin should be ironed, bedding included.

MEDICAL MANAGEMENT OF VARIOUS SKIN CONDITIONS

SCALP:
If there are ulcers, impetigo, or infection on the scalp, use the following:

Salicylic acid 1%: Apply to scalp for one hour for three nights in a row.

Wash immediately after one hour with Betadine Solution.

BODY:
1. Bath with Aqueous Cream once a day (500g) - If skin is very dry and scaly, use HEB to bath(500g)
2. Rub Soft white paraffin twice daily into entire body and scalp (if dry). (500g) – if skin is severely dry, use
HEB and Soft white paraffin in combination as an emollient.
3. Lenovate (200g) rub a thin layer over entire body or affected areas in the evening following 2.
4. Mylocort (50g) rub a thin layer after 2 on face, head and scalp if affected.
5. Dovate b/d on lichenified areas for ten days if necessary

Wet wraps can be used in severe eczema, Sr. Zincfontein demonstrates to the mother.

Use Allergex if indicated

- 38 -
VITILLIGO:

The best steroid for vitiligo, is Advantan cream, not available on code; use Lenovate tds on affected areas until
skin improves.

ALOPECIA.

The best steroid for alopecia, is Advantan cream, not available on code; use Lenovate tds on affected areas until
hair grows back. Do not plait or tie hair tightly and do not use braids, etc. in hair.

CONGENITAL HEMANGIOMA:

This is a bening lesion, usually starts in neonatal period, increases in size for one year and then decreases in size
and disappear naturally.

MOLLUSCUM CONTAGIOSUM
These lesions are managed on the ‘knoppieslys’. Please make an appointment to have lesions removed under
anaesthesia.

RINGWORM

LARVA MIGRANS

- 39 -
General:
Generalised Lymphadenopathy
A: DEFINITION >1 cm cervical and axilliary in more than two non-continuous node regions

>1, 5 cm inguinal

B: PATHOPHYSIOLOGY
Usually secondary to: Proliferation of normal elements e.g. during infection

Infiltration e.g. malignancy

C: CLINICAL PRESENTATION
Acutely Infected tender, red, warm, soft
Chronic Infection/infiltration Non – tender, firm

D: AETIOLOGY
Infections Viral: Common upper respiratory infections
Infectious mononucleosis
CMV
Hepatitis B
AIDS
Rubella
Varicella
Measles
Bacterial Septicemia Typhoid fever Syphilis
Protozoa Toxoplasmosis
Fyngal Coccidiomycosis
Autoimmune disorders and JRA
hypersensitivity Drug reactions
Serum sickness
Storage diseases Gaucher Nieman-pick
Neoplastic and proliferative Primary Hodgkins and non-hodgkins lymphoma
disorders
Secondary Leukemia, neuroblastoma, Rhabdomyosarcoma

E: MANAGEMENT
Viral No treatment
Bacterial Appropriate antibiotics
Abscess Incision and drainage
If node not smaller in size after 14 days, further investigation:

FBC, diff
EBV, CMV, Cat scratch,
ASO, Anti- DNAse
PPD
CXR
Biopsy indicated if the above tests are negative, the node enlarges in two weeks or no improvement in 6 weeks

- 40 -
- 41 -
- 42 -
- 43 -
- 44 -
 POISONING

BASIC MANAGEMENT OF ALL ORAL POISONS

If the poison ingested is not corrosive and the patient’s level of consciousness is normal, do a gastric lavage and
administer activated charcoal.

Activated Charcoal If <6yrs of age -10g in 50-100ml water

If >6yrs of age -20 – 50g -300ml water
Always do baseline bloods ABG, U&E and ALT, AST
Do drug levels if an unknown substance was ingested.

PARACETAMOL
Paracetamol poisoning in a child is almost always intentional. The accidental ingestion of paediatric elixir
preparations by the toddler rarely achieves toxicity.

Toxicity can be due to acute ingestion or repeated over therapeutic ingestion.

A: DIAGNOSIS
Doses in excess of 150mg/kg per24-hr period in healthy children are potentially toxic

Serum paracetamol concentration must be measured at least 4hrs after ingestion

Use nomogram to assess risk: NB Serum levels drawn before 4hrs may not represent peak levels
Use the graph only in relation to a single acute ingestion.
If patient presents >8hrs after ingestion start treatment immediately
If the time of ingestion is unknown, start treatment for any detectable
level of paracetamol or any elevation of AST or ALT.
Nomogram was not designed for use in overdose with extended release
paracetamol formulations.

REFER TO CHAPTER 18 EDL FOR NOMOGRAM

B: MANAGEMENT
If patient presents within 1hour of ingestion do gastric lavage.
Avoid activated charcoal if only oral n-acetyl cysteine is available for treatment, as it will absorb the antidote.

Acetyl cysteine:
150mg/kg in 5% dextrose, 5ml/kg over 15 minutes
Acetyl cysteine: (IVI) First 24 hours THEN
50mg/kg in 5% dextrose, 5ml/kg over next 4 hours
THEN
100mg/kg in 5% dextrose 10ml/kg over 16 hours

150mg/kg in 5% dextrose, 10ml/kg over 24 hours

Acetyl cysteine: (IVI) Second 24 hours
IF IVI not available: Oral: 140mg/kg immediately as single dose, then
70mg/kg every 4hrs for 17 doses

- 45 -
 IRON POISONING
Iron is widely available over –the-counter product and is commonly accidentally ingested by toddlers.

Clinical manifestations

Toxicity is related to the ingested dose of elemental iron.

Single dose of elemental iron >20mg/kg requires hospital management

A: 5 STAGES OCCUR
1: Haemorrhagic gastritis: occurs in 30-60 minutes after ingestion. This is due to the local effect of iron on the
gastric mucosa. Nausea, vomiting, diarrhoea, abdominal pain, hematemesis, shock and acidosis may occur. This
phase usually lasts 4-6 hours

2. Phase of improvement: this lasts 2-12 hours during which the patient looks better. During this stage iron
accumulates in the mitochondria and organs.

3. Delayed shock: This may occur 12-48 hours after ingestion, usually associated with serum iron levels
exceeding 500mcg/dl. Metabolic acidosis, fever, leucocytosis and hypoglycaemia may be present.

4. After apparent recovery: 2-4 days after ingestion, severe hepatic necrosis and liver failure may develop.
Raised transaminases and bilirubin may occur.

5. Scarring and stenosis: of the pyloric area occurs 2-4 weeks after ingestion.

B: CATEGORIES OF IRON TOXICITY

LOW RISK MEDUIM RISK HIGH RISK
No history of: abdominal pain Clinical: Minimal Clinical: Lethargic, Acidotic,
:nausea gastrointestinal symptoms Shocked, May have evidence of
:vomiting and Normal physical hematemesis or melena
:diarrhoea examination Investigations :Abdominal X-ray;
Investigations: Abdominal X- ABG; UK&E; Serum iron levels
Asymptomatic for 6hrs ray; ABG; UK&E; Serum iron within 2-6 hours after ingestion
levels within 2-6 hours after Management:
<20mg/kg of elemental iron ingestion Manage Airway
ingested Management:
Fluid resuscitation: 20ml/kg Fluid resuscitation: 20ml/kg
Management: serum iron bolus Normal Saline then bolus Normal Saline then
<500mcg/dl, patient is low maintenance maintenance
risk.
If no signs of GIT dysfunction If moderate GIT symptoms or
Can be discharged e.g. perforation altered mental state: requires
/haemorrhage – whole bowel chelation therapy.
irrigation. Urgent chelation therapy if
ingested >60mg/kg of elemental
If moderate gastrointestinal iron
symptoms or altered mental Desferrioxamine: 10-15mg/kg
state: requires chelation /hour over 24hrs(the total dose
therapy. should not exceed 6g)
Continue with infusion until urine

- 46 -
 Desferrioxamine: 10- is no longer pink.
15mg/kg /hour over Beware of hypotension.
24hrs(the total dose should
not exceed 6g)
Continue with infusion until
urine is no longer pink.

SALICYLATE POISONING
Salicylate poisoning may result from oral or topical exposure.

Doses less than 150mg/kg Will not cause toxicity in children except in a child with hepatic or renal disease.
Ingestion of 150 -300 mg /kg may result in mild to moderate toxicity
Ingestion > 500mg/kg regarded as a lethal dose.

A: CLINICAL SIGNS:
Fever

Epigastric pain

CNS depression

Hypoglycaemia

Hyperventilation

Renal Failure

Respiratory Alkalosis (initially) followed by a metabolic acidosis

B: INVESTIGATIONS:
Blood gas,

U&E

Salicylate level: toxic > 30mg/dl – serial monitoring until declining levels are documented

C: MANAGEMENT
Observe HGT and urine output
Gastric Lavage
Correct Hydration
Activated Charcoal: may be used up to 12 hours post ingestion
Urine Alkalinisation: Sodium bicarbonate IVI - 2mmol/kg/day in maintenance administered over 3 hours
Can increase if necessary, to maintain urine Ph > 7.5

ORGANOPHOSPHATE POISONING
Notifiable Condition

Organophosphates are potent inhibitors of acetylcholinesterase

- 47 -
A: DIAGNOSIS
Onset and duration dependant on various factors:

Oral and respiratory exposure Symptoms within 3 – 5 hours

Dermal exposure Symptoms delayed up to 12 hrs
Lipophilic agents Symptoms delayed to 5 days Prolonged illness up to 30 days

Muscurinic Nicotinic CNS

Diaphoresis,diarrhoea Muscle fasiculations Altered level of consciousness
Urination,Miosis
Bradycardia,Vomiting,
Lacrimation,Bronchorrhoea

Wheezing Fatigue Restlessness, Confusion

Pulmonary Oedema Paralysis Headache
Respiratory muscle Slurred Speech,Ataxia
weakness
Tachycardia Convulsions
Hypertension Coma

B: INVESTIGATION:
Psuedocholinesterase: for confirmation only.

C: MANAGEMENT
Remove patients clothing

Wash affected skin, face and hair with soap and water

Suction secretions frequently

Monitor respiratory function, heart rate pupillary size and level of consciousness.

Atropine: IVI stat: 0.02-0.05mg/kg followed by a repeat dose every 10-15 minutes.
Maintenance: 0.01mg/kg/hour.
Therapeutic endpoint is the resolution of secretions and bronchospasm.

Tachycardia and mydriasis is not a contraindication for atropine.

If any respiratory compromise transfer to ICU.

- 48 -
 Worcester Hospitaal: Toelating in Neonatale Hoësorg Eenheid

• Ondersoek neonaat volledig

• Voltooi opnamevorm, dws. verloskundige geskiedenis, algemene en sistemiese ondersoek, en skryf ’ n plan!
• Ballard gestasiebepaling moet gedoen word

1000g – 15000g
<1000g of
• MAS, TTN, HIE, Pneumonie
1500g – 2000g
<28 weke

• CPAP dadelik
• CPAP dadelik • Perifere lyn en A/B ( sien onder)
• geen lyne, geen
IV lyn + 10% dextrose • Perifere lyn en 10% dextrose ondersoeke of terapie • Stabiliseer bloeddruk en sirkulasie
Hou baba warm • KMC • begin bors-voeding met Saline, Sodabic en Inotrope
KMC verkieslik • CXR, ABG na een uur en en KMC dadelik en • CXR, FBC, BC, ABG
CPAP Curosurf as op >40% suurstof monitor observasies • Uriene kateter en Dipstix
Bloedgas,CXR, FBC, BK • EBM /koppie as kos ‘ vra’ en Hgt vir 24 uur • EBM met koppie as kos ‘ vra’
na een uur • Indien probleme, roep • Verlengde ruptuur vliese
Curosurf as met konsultant • FBC, ABG, BK
konsultant bespreek • IVI Aminofillien • A/B (sien onder),
IVI Aminofillien en • Bloedkultuur en Antibiotika • Observasies
Antibiotika( sien onder) as geindikeerd
Observasies en Hgt • Observasies en Hgt

• Aminofillien 4mg/kg IV ladingsdosering, dan

2mg/kg q12h
• Gentamisien:
• as < 36 weke
2,5mg/kg/dag<7dae; 2,5mg/kg18hrly>7dae,

• as > 36 weke
2,5mg/kg q12h<7 dae

2,5mg/kg 8hrly>7dae

- 49 -
A: BALLARD SCORE

Physical Maturity:

-1 0 1 2 3 4 5

Superficial Cracking, pale Parchment, Leathery,

Sticky, friable, Gelatinous red, Smooth pink,
Skin peeling and/or areas, rare deep cracking, cracked,
transparent translucent visible veins
rash, few veins veins no vessels wrinkled
Lanugo None Sparse Abundant Thinning Bald areas Mostly bald
Anterior
Plantar Heel-toe 40-50 Heel-toe >50 Faint red marks transverse crease Creases over Creases over
Creases mm = -1, mm, no creases only anterior 2/3 entire sole

Barely Flat areola, no Stippled areola, 1- Raised areola, Full areola, 5-10
Breast Imperceptible
perceptible bud 2 mm bud 3-4 mm bud mm bud
Lids fused, Lids open, Slightly curved Well-curved Formed and
Thick cartilage,
Eye & Ear loosely = -1, pinna flat, stays pinna, soft with pinna, soft but firm, with
ear stiff
tightly = -2 folded slow recoil ready recoil instant recoil
Testes in upper Testes Testes
Genitals, Scrotum flat, Scrotum empty, cannal, rare descending, few Testes down, pendulous, deep
male smooth faint rugae rugae rugae good rugae rugae
Prominent
Prominent Majora and Majora cover
Genitals, Clitoris prominent, clitoris, Majora large,
clitoris, small minora equally clitoris and
female labia flat enlarging minora small
labia minora prominent minora
minora
Neuromuscular Maturity

Maturity Rating:
Add up the individual Physical and Neuromuscular maturity
scores for the twelve categories, then obtain the estimated
gestational age from the table below.

Total Gestational Age,

Score Weeks
-10 20
-5 22
0 24
5 26
10 28
15 30
20 32
25 34
30 36
35 38
40 40
45 42
50 44

` Plot weight on the growth chart overleaf, then decide on:

- 50 -
 OGA AGA UGA
(overweight for gestational (appropriate for gestational (underweight for gestational
age) age) age)

- 51 -
B: GROWTH CHARTS

- 52 -
- 53 -
 C: VOLUMES OF NEONATAL FLUID ADMINISTRATION

DAY 1 2 3 4 5 6 7 8 9

<1000g 110 120 130 140 150 150 150 150 150

1-1.65kg 75 90 110 120 130 140 150 150 150

1.65-1.8kg 60 80 100 110 120 130 140 150 150

1.8-2.2kg 60 80 100 120 130 150 150 150 150

>2.2 50 75 100 125 150 150 150 150 150

Calculate fluid as follows:

Step 1:
Determine from above table the total volume of fluids for the day
Remember to add additional volumes: Overhead warmer 10%; Phototherapy 10%
Step 2:
Decide on the volume of enteral feeding
In almost all neonates enteral feeding can by initiated on the first day of life.
Discuss every neonate considered to be kept NPO with a consultant.
Strategy: < 1000g Day 1 Trophic feeds 0.5 ml every 4-6 hours
Day 2 0.5-1 ml every 2 hours
Day 3 and on Increase enteral feeds by 30ml/kg/day
1 – 1.65 kg ≥ 1.5 kg can potentially fully breastfeed
Day 1 1-2 ml every 2 hours;
Day 2 and on Increase enteral feeds by 30ml/kg/day
> 1.65 kg Day 1 Either fully breastfeed or 30ml/kg/day if not fully breastfeed (3 hrlyfeeds)
Day 2 and on Either fully breastfeed or increase by 30ml/kg/day

Step 3:
Calculate intravenous fluid volume: IV fluids = Total volume of fluids – Enteral feeds
Always use 10% Neolyte or 10% Neonatelyte; alternatively if persistent hyperglycemia use
0.2% saline + 5% dextrose

Type of enteral feeding

Always give breast milk
Potential exceptions:

- 54 -
1) RVD exposed and mom opted for EFF (exclusive formula feeding)
Always confirm that thorough antenatal counselling was done re infant feeding choice.
If baby < 1.5 kg counsel mom and discuss with consultant the use of pasteurized EBM until safe to switch to
preferred feeding method.

2) Baby for adoption

Route of enteral feeding:

Always breast or cup feeding
Discuss the potential use of oro-gastric feeding with consultant in cases of
1) uncoordinated swallowing,
2) excessive spilling of milk by baby during cup feeding,
3) poor weight gain despite adequate calorie intake and other causes excluded and
4) any contra-indications to oral feeding.

D: ANTIBIOTIC PROTOCOL

Empirical Use:
Do FBC and differential on Day 1 and 3; Blood Culture
on day1
Start on antibiotics Ampicillin 25mg/kg/6hrly
Gentamycin 5mg/kg

Re-evaluate on day 3 with FBC and B/C result if all negative/normal; stop A/

Respiratory distress and you clinically suspect group B strep PENG 100000U/kg/dose -12hr

Meningitis Cefotaxime 50mg/kg/dose 6hrly

Amikacin 15mg/kg/day
Ampicillin 25mg/kg/6hrly
2nd line Cefotaxime 50mg-100mg/kg/dose /24hrs -12hrly
Amikacin 15mg/kg/day
3rd line: Meropenem
Vancomycin (only added if suspect MRSA or the neonate has a long line associated
sepsis)
Suspected NEC Flagyl

BEFORE CHANGING TO A 2ND LINE ANTIBIOTIC THE FOLLOWING MUST BE DONE:

1. FBC ,CRP
2. Blood culture
3. LP
4. UMC&S
5. CXR if indicated

- 55 -
E: TOTAL BODY COOLING PROTOCOL FOR BABIES WITH SUSPECTED HIE AT WORCESTER
HOSPITAL

Neonates with suspected birth asphyxia should be assessed to determine whether they meet the criteria for
cooling.

Criteria for considering treatment with cooling:

• Term or late preterm baby (36 weeks and more) + weight > 1800g
• Needs no surgery in next 3 days
• No other fatal/poor prognostic features eg Anencephaly, Chromosome abnormality, Uncontrolled severe
bleeding, Unstable (severe PPHN OR refractory Hypotension)

↓YES

At least one of the following (evidence of possible peripartum hypoxia):

• Apgar score ≤5 at 10 min

• Resuscitation (ventilation) with Neopuff or ETT ≥ 10 min after birth
• pH<7 (umbilical cord bloodgas / blood gas from baby within an hour of birth)
• Base deficit ≥ 16 mmol/l in any blood sample (cord or baby) within 1 hr after birth

↓YES

Altered state of consciousness (↓response to stimulation) and at least one other Neurological Parameter from list
below (ie evidence of moderate encephalopathy at least – see Sarnat Staging table)

• Abnormal tone (hypotonic/flaccid)

• Abnormal reflexes including oculomotor or pupillary abnormalities
• Absent or weak suck or Moro reflex
• Seizures

Babies with only mild or babies with very severe HIE (ie not moderate) does not qualify for cooling (see Sarnat
Staging table below).
Also not babies that had no signs of life and no heart beat at 10 min.
Babies that made no attempt at breathing/gasping at 30min of resuscitation are also not for cooling.

Discuss with Consultant-on-call at Worcester Hospital (or Neonatologist on-call at a tertiary cooling unit)
if in doubt.
As soon as decision is made to cool baby: administer Aminophylline 6mg/kg IV over 30 minutes (renal indication)

Expected management at referring hospital

1. SET TEMPERATURE OF INCUBATOR OR RADIANT WARMER TO 36°C in the Baby control or Servo-
control mode. Monitor and document axillary temperature every 30 minutes to prevent ‘relative’
hyperthermia but also hypothermia by ensuring that the baby’s temperature is below 36°C but not lower
than 35°C (when using a traditional mercury thermometer) or 34°C (when using an electronic
thermometer that can mostly measure lower temperatures)

- 56 -
 2. Stabilize baby with specific attention to O2 saturations; Acid-base abnormalities; Blood pressure, pulse
and peripheral perfusion; Termination of any convulsions; Management of infection risk and Blood
glucose control
3. Discuss case with doctor on call for Pediatrics at Worcester Hospital regarding possible whole body
cooling and further management
4. Organize urgent transfer of baby to Worcester Hospital Neonatal High Care (D2N) only if patient is
accepted for cooling and only if transfer can be guaranteed for active cooling to begin within 6h from birth
at Worcester Hospital.
5. If baby is accepted for cooling administer Aminophylline 6mg/kg IV over 30 minutes ASAP

Start cooling within 6 hrs of life (consider up to 8hrs).

• Switch off overhead heater.
• Set up the Blanketrol machine with patient on blanket (linen saver between patient and blanket, no
nesting, no nappy) and rectal probe inserted 5 cm and taped in position with Opsite transparent adhesive
to upper thigh
• Set initial mattress temp to 33.5°C and record time cooling was started
• Fill out the observation pack booklet
• Keep rectal temperature 33-34°C
• If baby shows signs of discomfort eg shivering, consider sedation (phenobarbitone 20mg/kg IV – can be
repeated OR lorazepam (Ativan) 0.05mg-0.1mg/kg/dose OR morphine 50mcg/kg bolus over 10 min. then
50mcg/kg/dose 6 hrly)
• Cooling can be reversed after 72hrs (increase temp not > 0.5°C/hr)

Fluid management:

• a) Fluid restrict (potential ATN and SIADH) maintenance to 40ml/kg/24h with potassium-free 10%
Neolyte/Neonatelyte until diuresis or until serum sodium remains above 135mmol/l for 12hrs – then slowly
increase by 10-20ml/kg/day from Day 2 depending on clinical course, changes in weight, urine output,
and the results of serum electrolyte and renal function studies. Give potassium supplementation
(changing IV fluids back to normal 10% Neolyte/ Neonatelyte) only if urine output is normal (>1ml/kg/hr)
and serum Potassium is <5.3
b) Feeds: Keep NPO for the first 24hrs, thereafter slowly introduce EBM (only) – usually 12ml/kg on Day
2, increment by 12-24ml/kg on Day 3 and subsequently (titrate against clinical state)
c) Strict urinary output monitoring in especially first 24h – place transurethral catheter for first 24h
d) Do not give repeated boluses of fluid to treat acidosis unless infant is obviously hypovolemic – if poor
perfusion/low BP: give single 10-20ml/kg 0.9% NaCl IV bolus ± inotropes

Sarnat Staging of HIE with prognosis

Need to have 3 out of the 6 categories in Stage 2 for moderate encephalopathy.

Categories (1-6) Mild HIE (Sarnat 1) Moderate HIE (Sarnat 2) Severe HIE (Sarnat 3)

1. Level of Hyperalet Lethargic Stupor or coma

- 57 -
 consciousness

2. Spontaneous Normal activity Decreased Activity No activity

activity

3. Posture Mild distal Distal flexion or complete Decerebrate

flexion extension

4. Muscle tone Normal Hypotonia (focal or general) Flaccid

5. Primitive reflexes
Suck Weak Weak Absent
Moro Strong Incomplete Absent

6. Autonomic
function
Dilated Constricted Deviated, dilated or
Pupils non-reactive
Variable HR
Tachycardia Bradycardia
Heart rate Apnoea requiring
Spontaneous Periodic or shallow
IPPV
Respiration breathing

Seizures None Common (onset 6-24 hrs of age) Uncommon (excluding

decerebration)
Outcome Normal At least 25% abnormal with CP > 80% Abnormal /death

Ensure that the parent(s) are aware that the results from studies have shown improved outcome for many of
these babies, but that poor outcome is still possible and that this is a new therapy where long-term outcomes
beyond 2 years of age are not known.
All babies that were cooled, needs high risk clinic follow-up until 18 months of age and need a screening test for
hearing to be done at discharge or shortly thereafter.

During cooling expect:

• Decreased heart rate.
• Increased blood pressure initially due to increases in peripheral vasoconstriction.
• Increase in urine output initially due to shunting of blood to the internal organs, cold, and diuresis.
• Decrease in calcium, magnesium, phosphorus and potassium.
• Labile glucose due to relative insulin resistance decreased metabolic rate, and shivering.
• Possible anticoagulant effects (contraindicated if intracranial bleed is suspected).

Remember that the half-life of certain medications is decreased during cooling.

QT interval can be prolonged: use medication known to prolong QT time with caution.

Referring hospital IDENTIFICATION and MANAGEMENT of neonates (≥ 36w and >1800g) with suspected
moderate to severe HIE possibly qualifying for whole body cooling (therapeutic hypothermia)

- 58 -
Neonates with suspected birth asphyxia should be assessed to determine whether they meet the criteria for
cooling.

IDENTIFICATION (Criteria for considering treatment with cooling)

• Term or late preterm baby (36 weeks and more) + weight > 1800g
• Needs no surgery in next 3 days
• No other fatal/poor prognostic features eg anencephaly, chromosome abnormality

↓YES
At least one of the following (evidence of possible peripartum hypoxia):
• Apgar score ≤5 at 10 min
• Resuscitation (ventilation) with Neopuff or ETT ≥ 10 min after birth
• pH<7 (umbilical cord bloodgas / blood gas from baby within an hour of birth)
• Base deficit ≥ 16 mmol/l in any blood sample (cord or baby) within 1 hr after birth

↓YES
Altered state of consciousness (↓response to stimulation) and at least one other Neurological Parameter from list
below (ie evidence of moderate encephalopathy at least – see Sarnat Staging table)
• Abnormal tone (hypotonic/flaccid)
• Abnormal reflexes including oculomotor or pupillary abnormalities
• Absent or weak suck reflex
• Seizures

Babies with only mild or babies with very severe HIE (ie not moderate) does not qualify for cooling (see Sarnat
Staging table below).

Also not babies that had no signs of life and no heart beat at 10 min. Babies that made no attempt at
breathing/gasping at 30min of resuscitation are also not for cooling.

MANAGEMENT
1. SET TEMPERATURE OF INCUBATOR OR RADIANT WARMER TO 36°C in the Baby skin control or
Servo-control mode. Monitor and document axillary temperature every 30 minutes to prevent ‘relative’
hyperthermia but also hypothermia by ensuring that the baby’s temperature is below 36°C but not lower
than 35°C (when using a traditional mercury thermometer) or 34°C (when using an electronic
thermometer that can mostly measure lower temperatures)
2. Stabilize baby with specific attention to O2-saturations; Acid-base homeostasis; Blood pressure, pulse
and peripheral perfusion; Termination of any convulsions; Management of infection risk and Blood
glucose control (liaise with doctor on call for Pediatrics re stabilization)
3. Discuss case with doctor on call for Pediatrics at Worcester Hospital regarding possible whole body
cooling and further management
4. Organize urgent transfer of baby to Worcester Hospital Neonatal High Care (D2N) only if patient is
accepted for cooling and only if transfer can be guaranteed for active cooling to begin within 6h from birth
at Worcester Hospital.

- 59 -
 Sarnat Staging of HIE with prognosis (Please complete this table by marking the relevant blocks with a  and
send this page with the patient to Worcester Hospital)

Categories (1-6) Mild HIE (Sarnat 1) Moderate HIE (Sarnat 2) Severe HIE (Sarnat 3)

1. Level of Hyperalet Lethargic Stupor or coma

consciousness

2. Spontaneous Normal activity Decreased Activity No activity

activity

3. Posture Mild distal Distal flexion or complete Decerebrate

flexion extension

4. Muscle tone Normal Hypotonia (focal or general) Flaccid

5. Primitive reflexes
Suck Weak Weak Absent
Moro Strong Incomplete Absent

6. Autonomic function
Pupils Dilated Constricted Deviated, dilated or
non-reactive
Variable HR
Heart rate Tachycardia Bradycardia
Apnoea requiring
Respiration Spontaneous Periodic or shallow
IPPV
breathing

Need to have 3 out of the 6 categories in Stage 2 for moderate encephalopathy.

Seizures None Common (onset 6-24 hrs of Uncommon (excluding

age) decerebration)
Outcome Normal At least 25% abnormal with CP > 80% Abnormal /death
Please inform the parent(s) of babies that is accepted for transfer for possible cooling that the baby might be
cooled at the referral hospital and that the results from studies have shown improved outcome for many of these
babies, but that poor outcome is still possible and that this is a new therapy where long-term outcomes beyond 2
years of age are not known.

- 60 -
 F: HYPERBILIRUBINAEMIA

(aetiology)

Measure
bilirubin

Mainly unconjugated Repeat value and Conjugated > 25

observe

Coombs

Positive Negative Hepatitis

TORCH

Sepsis
Rh
Haematocrit
Obstruction
Antibodies
Cystic Fibrosis
High
Normal/Low Alpha-1 antitrypsin
deficiency

Syphilis
Red cell Policythaemia
morphology, Hyperalimentation
reticulocytes
Haemochromatosis
Normal
Dubin-Johnson
Abnormal
Rotor
? Haemorrhage

Increased enterohepatic circulation

ABO incompatibility
Breast milk
Thallasaemia
Hypothyroidism
Spherocytosis
Diabetic mother
Elliptocytosis
G: PROLONGED RDS
Pyknocytosis
Asphyxia

Infection

- 61 -
G: PROLONGED RUPTURE OF MEMBRANES
Babies born to mothers with a history of rupture of membranes longer than 24 hours should be investigated at
birth.

The babies can be managed in low care.

Insert Jelco and at the same time do STERILE blood culture, WCC, platelets

Commence on Gentamycin < 36 weeks gestation: <7days: 2,5mg/kg/day

antibiotics >7days: 2,5mg/kg18hrly
> 36 weeks gestation <7 days: 2,5mg/kg q12h
>7days: 2,5mg/kg 8hrly

Pen G 100 000U/kg q12h

On day three, WCC should be repeated and blood culture traced.

If all normal and negative and baby clinically normal and feeding well, baby can be discharged.

If any of the parameters are abnormal or there is any clinical concern about the baby continue with antibiotics.

The baby should be started on breast feeding if tone and clinical examination is normal.

DO NOT replace the breast with a bottle if not sucking well, REFER TO PEDS IMMEDIATELY. Babies with
neurological problems and/or sepsis usually do not feed well on the breast and should be investigated and cup
fed.

G: ANTENATAL EXPOSURE TO VARICELLA

The concern is here for women exposed within 21 days of delivery

Mother and baby should be discharged from hospital as soon as possible

If exposure was from a household contact with current disease, the VZIG should be administered to both mother
and child prior to discharge.

In mothers with active disease or in whom varicella has occurred less than 21 days prior to delivery:

• Isolate the mother and infant

• Administer VZIG (125 units IMI) to the newborn if the maternal disesase started <5 days prior to delivery
or 2 days postpartum
• If other neonates were exposed, VZIG may be administered and these infants may require isolation.

- 62 -
 H. RESUSCITATION IN THE DELIVERY ROOM

Approximate time Birth

Clear of meconium? Routine care

Breathing or Crying Yes Provide warmth

Good muscle tone Clear airway

Colour
Nopink Dry
30 sec Term gestation
Provide warmth

Position

Clear airway

Dry, stimulate

Give O2
Evaluate resp, H/R and Breathing Supportive care
colour

H/R > 100

Apnoea or H/R <100
Pink

Provide positive pressure Ventilating

30 sec Ongoing care
Ventilation
H/R > 100
H/R<60 H/R>60
Pink

Provide positive pressure

Ventilation and chest

30 sec compressions

Adrenaline 1:1000-0,01ml/kg IVI

H/R<60
Atropine 0,5ml of 100mcg/ml

Continue chest compressions

Repeat Adrenaline and Atropine

- 63 -
 I. NEONATAL RESUSCITATION
Drug: Dosage Route Comment
Adrenalin 1:1000 0.01 – 0.03 ml/kg S/C, ET tube, IV Asystoly, Bradi
Normal Saline 10 – 20 ml/kg IVI Quickly
Naloksonehydrochloride 0.1 mg/kg or 0.25 ml/kg IV, IVI, S/C, ET tube If apnoea as result of
0.4mg/ml drugs
Inotropes: Dobutamine 6 x Weight = Dose in mg In 50ml Nomal Saline IVI 1-5 ml/h = 2 – 10
Titrate agains BP:M: 40 – OR ug/kg/min
55mmHg) 3 x Weight = Dose in mg In 50ml Nomal Saline IVI 1 – 10 ml/h = 1 – 10
ug/kg/min
Sedation: Morphine 3 x Weight = Dose in mg IV 0,5 - 1 ml/h = 1 ug/kg/min

NB: MARK ALL SOLUTIONS, DRUGS AND MIXES IN RED INK.

- 64 -
 J. NEONATAL HYPOGLYCEMIA (HGT <2, 6)
KMC and Breastfeed all healthy newborn babies as soon as possible and no later than 30 min after birth.
Encourage feeding on demand and only do subsequent HGT monitoring in babies 1) at high risk for or 2)
proof of hypoglycemia or 3) if they have a clinical picture of hypoglycemia.
(Clinical picture of hypoglycemia: Sleepy/hypotonic, jittery/irritable, poor feeding, respiratory distress, convulsions, apnea

NEWBORN BABIES AT HIGH RISK FOR HYPOGLYCEMIA:

Babies first fed >1hr after birth Babies of diabetic mothers
Premature babies <37 weeks Birth asphyxia 5-min apgar <6
Low birthweight babies <2,5kg Hypothermia <36,5
Post mature babies >42 weeks Respiratory distress
Feeding problems

THESE HIGH RISK BABIES SHOULD BE MONITORED AND MANAGED AS FOLLOWS:

HGT 1, 5 - 2, 6 HGT 0 – 1, 5 While hypoglycemic, repeat HGT every

30min until >2.6;

Any of: PREFERABLY Then hourly until 3 consecutive

Weight<1,8kg Resp values>2.6
distress Temp<35C Can try 10ml/kg milk feed in well baby first –
Sick baby repeat HGT in 15min Then 3-4hrly

10% Dextrose 2ml/kg IVI stat AND

Unable to feed
Start Dextrose infusion to deliver 6-8mg/kg/min

No YES
HGT remains low?
15 min later
Give 10ml/kg milk feed

10% Dextrose 5ml/kg IVI stat

1 .Glucagon 0, 1 – 0, 3 ml/kg IM/IV stat Refer to tertiary unit if:

AND HGT remains low?
1–2mg in maintenance solution over 24 hrs 1. Refractory hypoglycaemia

2. Hydrocortisone 2, 5mg/kg 6hrly IV/IM 2. Persistent recurring hypoglycaemia

>120hrs

Take note: Remember to flush IV line with new % Dextrose solution before administration

To deliver Dextrose of 6 – 12 mg/kg/min; increase % of solution 10% - 12, 5% - 15%

Calculations: Dose (mg/kg/min) = (%Dextr solution x rate) ÷ (weight x6) OR dose (mg/kg/min) = % dextr solution x total ml/kg/dayx0.007 OR use gluciose rate
calculator (TBH neonatal handbook)

- 65 -
Addendum:
1. Inborn errors of metabolism
2. ECG guidelines to interpret
3. Ventilation: Intubation, settings, sedation, inotropes
4. Vela ventilator and troubleshooting

- 66 -
- 67 -
INTERPRETATION OF ECG
Full standard vs Half standard

1. Rate
2. Rhythm
3. QRS-axis
4. Intervals
5. P-wave
6. QRS-amplitude and ab(N) Q-waves
7. ST-segment and T-wave ab(N)

Rate (paper speed 25mm/s thus 1mm = 0.04 sec)

• fH = Number of QRS-complexes per ECG page (10sek) X 6
• fH = 300  (number of large squares between R-waves)
• Normal variation: Newborn 110-150; 2j 85-125; 4j 75-115; >6j 60-100

Rhythm
• Sinus rhythm 1. P-wave in front of every QRS-complex
2. Upright P-wave in SI, II and aVF
3. Constant PR-time
Alterations:
• Normal (variation) Sinus arrhythmia
• Slow Regular Sinus bradycardia
Grade 1 AV-block (PR-time > 4 blocks thus > 0.16 sec)
Irregular Grade 2-3 AV-block

• Fast Regular Sinus tachycardia

NARROW QRS (< 0.12 sec) SUPRAVENTRICULAR
tachycardia
Atrial, Nodal and Re-entry
WIDE QRS (> 0.12 sec) VENTRICULAR tachycardia
SVT with aberrant conduction (rare)
Irregular VF
Torsades de Pointes (long QT syndrome)

QRS-axis
• Use largest (+) or (-) deviation SI and AVF
(term neonate normally have a ®-axis vs premature neonate with a (L)-tending axis)

- 68 -
4: Intervals
• PR > 0.16 sec Grade 1 AV-block (miocarditis, digitalis toxicity, CHD)
< 0.12 sec Pre-exitasion WPW syndrome
LGL syndrome
• QRS > 0.12 sec Ventricular conduction disturbances
RBBB
LBBB
Pre-excitation
Intra-ventricular block
Ventricular rhythms
• Corrected QT interval
QTc < 0.45 sec (Normal)
QT
=
R − R int erval

P-wave
• Normal: Duration 0.08-0.12 sec / 2-3 small blocks, Amplitude < 3 small blocks
Evaluate in SII and V1
• RAH SII ≥ 3 mm high (peaked P-wave ≡ P-pulmonale)
V1 P-golf mainly positive
• LAH SII ≥ 2-2.5 small blocks wide (wide P-wave ≡ P-mitrale)
V1 P-golf mainly negative
• Bi-AH wide and peaked P-waves

QRS-amplitude and ab(N) Q-waves

Ventricular hypertrophy
• RVH Voltage criteria: Pure R-wave in V1 > 12 mm
R+S-waves in V1 > 20 mm
Indirect: RAD
Upright T-wave in V1 (1w-10y)
Incomplete RBBB pattern in V1 (rSr pattern)
Q-wave in V1
• LVH Voltage criteria: Pure R-wave in V5/V6 > 30 mm
S-wave in V1 > 20 mm
R in V5 + S in V1 > 35 mm
(>45mm in neonate)
Indirect: LAD

- 69 -
 Large amplitude T-waves in V5 and V6
• CVH Voltage criteria for RVH and LVH
LARGE equiphasic QRS-complexes in ≥ 2 of V2-V5 (R+S > 60mm)
= Katz-Wachtel phenomenon

Ab(N) Q-waves: 1. Too deep, 2. Too wide (> 0.03 sek) or 3. Appear in ab(N) leads
• Examples:
1. Too deep Q-waves (≥ 5 mm in V5 and V6): LVH (LV volume/diastolic overload)
2. Wide and deep Q-waves: MI
3. Appear in ab(N) leads: (Q-waves appear V1 and V2): Severe RVH
Ventricular inversion
(Q-waves disappear out of V5 and V6): LBBB
Ventricular inversion

ST-segment and T-wave ab(N)

• Normal - Iso-electric
1 mm elevation/depression
depression with upward slope (J-depression)
• Abnormal - Depression: horizontal > 1 mm
downward slope
Elevation: pericarditis, myocardial ischemia or MI, Digitalis effect
T-wave ab(N)
• Peaked: hyper K+
LVH (volume overload)
• Plat: Newborn – normal
Hypo-K+, -thyroid
Peri- or myocarditis
Myocardial ischemia

- 70 -
GUIDELINES TO INTUBATION OF NEONATES AND OLDER CHILDREN
Preparation – see below: Please ensure that the following equipment is available before attempting intubation:

Enough oxygen; at LEAST 2 points: one for ambubag and one for ventilator/nebs, etc. (Ambubag
must inflate!)

• Suction AND suction pipe and suction catheter

• Laryngoscope with two different size blades

• ET-tube: correct size as well as one size bigger and smaller

• Magill forceps

• Hegpleister
Do not set ventilator first, stabilize patient first then prepare ventilator.

Drugs:
STANDARD INTUBATION FOR OLDER KIDS:

Atropine 0.02mg/kg, minimum dosage 0.1mg IV

Ketamien 2mg/kg IV

Suxametonium 2mg/kg IV

HEAD INJURY - HEMODINAMICALLY STABLE (2 MINS before OTHER DRUGS)

Atropine 0, 02 mg/kg

Lignocaine 1mg/kg

Vecuronium 0,01mg/kg

THEN

Thiopentone 3-5mg/kg

Scoline 1mg/kg

HEAD INJURY - HEMODINAMICALLY UNSTABLE

Replace Thiopentone with Ethomidate 0,3mg/kg

- 71 -
HOOFBESERING EN HEMODINAMIES ONSTABIEL
 Drugs:
STANDARD INTUBATION FOR NEONATES:

Atropine 0.02mg/kg, minimum dosage 0.1mg IV

Ketamine: 2mg/kg IVI

Vecuronium 0,1mg/kg IV

TAKE NOTE:
-Intubation in children is usually a crash intubation and the stomach is usually full – Empty stomach of all
secretions prior to intubation and use cricoid pressure.

-Nasotracheal route is the preferred route of intubation in neonates and younger patients

-Make use of the tables which are laminated and displayed in neonates, Frank Shan,HCUto obtain the tube size
and depth – do NOT guess.

- The intubation must be atraumatic and smooth, use KY jelly on the side of the tube, not in the lumen!

-Do not force the tube through the nasal passage, aim anterior to ease passing.

Intubate through vocal cords under DIRECT vision – do NOT force the tube

Post-intubation care:
Ensure symmetrical movement of lungs with bagging

There is no advantage to forced bag ventilation with ambubag – it causes barotrauma and will cause
abdominal distention, which inhibits effective ventilation. Every time the ambubag has a blowing noise, 40 cmH20
has been EXCEEDED!! = BAROtrauma.

Listen in both axillae, air entry must be good and equal, use guidelines for tube depth and verify by listening to
aeration.

Sedation = urine retention = sister will phone and report child has not excreted urine.

NG tube and urine catheter must be passed post intubation

Request CXR immediately post intubation.

Ensure routine observations BP, Pulse, Hgt, Saturation, etc. is done and normal

Do blood gas post intubation and 2 HOURLY when on ventilator.

Ventilator:
Settings according to diagnoses, discuss with consultant

Children are always ventilated with warm, humidified air.

Blue circuit (to humidifier): at your RIGHT on ventilator. (VELA en Newport)

- 72 -
White circuit (From baby): at your LEFT on ventilator. (VELA en Newport)

Paediatric ventilators: Newport (in neonates and HCU)

Vela (in EC, HCU for bigger children >5kg)

Avea (in HCU – all ages – not good when in need of pressure)

Ventilation mode (Vela, Newport): Pressure SIMV

Peek pressure (PIP): 20-24 cmH2O

PEEP: 5 cmH2O

Rate: 40-60 p/minute

Insp. time: 0.3 – 0.5 seconds

FiO2: begin by 100% en speen so vinnig

moontlik, as saturasie >92%, SPEEN

Sedation (intravenous)

Neonates: use morphine usually unless contraindicated (MAS -Fentanyl)

Morphine 3mg/kg in 50mL 5% dextrose at 1ml/hr = 1mcg/kg/min

OR

Fentanyl 100mcg/kg in 50 ml@2,5 – 5ml/hr = 5 – 10mcg/kg/hr

AND / OR

Dormicum NOT routine for neonates, kids>6 months:

3mg/kg in 50 ml @ 1-4ml/hr = 1- 4mcg/kg/min

OR

Ketamine 3mg/kg in 50ml @ 2-20ml/hr = 2-20mcg/kg/min

Remember ALL opiates cause chest wall rigidity. If this happens – administer induction dosage of atropine and
suxamethonium.

Muscle relaxing: This is NOT a replacement for sedation, no paralysis without sedation!!

- 73 -
Paralysis is best avoided, but if absolutely indicated, rather use vecuronium (Norcuron) above pancuronium
(Pavulon). The latter can cause excessive vagolytic response which leads to decrease cardiac function in a baby
with a tachycardia

Vecuronium (Norcuron) 0.08-0.1mg/kg IV

Pancuronium (Pavulon) 0.08-0.1mg/kg IV

INOTROPES Inotropes should be given in a central, or the most central line and NEVER in
combination with Sodium Bicarbonate, as this leads to inactivation of inotropes.

Dobutamine (Dobutrex) 6mg/kg in 50ml@1-20ml/hr = 1-20mcg/kg/min,

start at 3 – 5 ml/hr

Available inotropes : Dobutamine , Dopamine

Dosages of medication:

Wanted (mg) Volume (ml)

X = dosage wanted in ml

Stock (mg) 1

- 74 -
GUIDELINES FOR PEDIATRIC VENTILATION WITH AVEA VENTILATOR USING (PRESSURE
SIMV + PSV) MODE

1. Terminology and definitions

SIMV = Synchronized intermittent mandatory ventilation

• Synchronization of ventilator breaths with patient’s own spontaneous inspiratory efforts.
• Thus: the ventilator will deliver a preset quantity/amount (RR = Mand Rate) of SIMV breaths but will also support
additional patient initiated breaths (Spon Rate) in a synchronized manner. (The patient initiated breaths will only be
delivered if his inspiratory effort exceeds the inspiratory flow trigger.)
Rate represent/reflects the real/exact amount of breaths that the patient is receiving and should not
exceed the Mand Rate, except if 1) the ventilator is auto-triggering and then auto-cycling (usually the case)
or if 2) the patient’s spontaneous breath rate was underestimated when setting the Mand Rate (sometimes).
• Pressure SIMV: 1. Pressure-limited (PIP and PEEP is set/preset and Vt is only being monitored)
2. Time-cycled (Ti and RR is preset with automatic determination of Te)
3. Flow-triggered

SIMV + PSV (pressure support ventilation)

• Same as SIMV but the additional patient initiated (spontaneous) breaths will be assisted with preset PS (pressure
support) above PEEP.

PIP (Ppeak) = Peak inspiratory pressure

• Peak airway pressure at the end of inspiration
• Please note: PIP = IP + PEEP (PIP is not a preset parameter but is being displayed by the ventilator on the left side
of the screen)

IP = Inspiratory pressure

PEEP = Positive end-expiratory pressure

• Positive pressure (constant distending pressure) that is being applied on the airway during the full duration of the
respiratory cycle.

RR (Mand Rate) = Respiratory rate (preset ventilator rate)

Ti = Inspiratory time

Te = Expiratory time
• Te = (60 ÷ RR) – Ti

FiO2 = fraction of inspired oxygen (0.21 = 21%; 1.0 = 100%)

Vte = Expiratory tidal volume

• Tidal volume (Vt) is the volume of air being breathed in and out with each respiration

- 75 -
MAP (Pmean) = Mean airway pressure
• Mean airway pressure that is delivered during the respiratory cycle
PIP − PEEP  Ti
• MAP = PEEP +
Ti + Te

2. Types of lung pathophysiology needing ventilation

1. Normal lungs
2. Lung Compliance
3. Airway Resistence

Tablel 1: Summary of causes and pathophysiology of respiratory diseases and an approch to

mechanical ventilation of these lung conditions
CAUSES AND PATHOPHYSIOLOGY OF RESPIRATORY DISEASES
Lung Compliance Airway Resistence
Examples ARDS, Atelectasis, Pneumonia, Pulmonary Asthma, Bronchiolitis, BPD, Cystic
oedema, Pulmonary bleed, HMD fibrosis
• Lungparenchiema affected • Airway lumen narrowed
Pathophysiology
(oedema, spasm or intra-
luminal obstruction)
• Alveoli filled with abnormal fluid and • Airway collapse happen during
collapsed due to surfactant inactivation → normal expiration thus: In
 FRC conditions with airway
resistence there will be airflow
restriction Exp > Insp.

• intrapulmonary shunt
• intrapulmonary shunt (perfusion of poorly (perfusion of poorly ventilated lung
ventilated lung units [fluid filled or collapsed]) units [ resistance →  airflow])

• Dead space ventilation: 

resistance → air trapping and
• Affected alveoli: difficult to open during hyperinflation of lung units →
breathing / ventilation (Long Compliance) compress surrounding blood
vessels → ventilation of poorly
perfused alveoli

VENTILATION STRATEGIES IN DIFFERENT LUNG CONDITIONS

Normal lungs Lung Complaince Airway Resistence

- 76 -
Ventilation parameters
• Vte monitoring 5 (4-6) 5 (6-10 sometimes 5 (6-10 sometimes
(ml/kg) necessary; remember necessary; remember
though that if high Vt is though that if high Vt is
continuously being continuously being
delivered it will often delivered it will often
result in acute secondary result in acute secondary
[ventilator-induced] lung [ventilator-induced] lung
injury) injury)

Possibly RR needed to Often  RR needed to

maintain Ve BUT as soon ensure adequate Te BUT
• RR (bpm) as being ventilated set as soon as being
the RR individually ventilated set the RR
Choose initially ≤ normal according to the flow-time individually according to
fR for age (table 2) BUT curve (see C.1-2) the flow-time curve (see
as soon as being C.1-2)
ventilated set the RR
individually according to
the flow-time curve (see 25-30 (often necessary;
C.1-2) 25-30 (often necessary; sometimes more but
sometimes more but monitor and govern Vte)
monitor and govern Vte)
• PIP (cmH2O)
20-25 (monitor chest
movement and Vte) () 4-5 often
() 6-10 depending on
recruitment response

• PEEP (cmH2O)
5 Begin with 1.0 and try to Begin with 1.0 and try to
wean ≤ 0.5-0.6 by MAP wean while ensuring
(preferably PEEP) adequate oxygenation but
• FiO2 preventing O2 toxicity
Often no need for sup-
plemental O2 (begin with
Begin with 0.5 BUT do
1.0 and rapidly wean to Begin with 0.5 BUT do individual setting
< 0.5) individual setting according to flow-time
according to flow-time curve (see C.1-2) as soon
curve (see C.1-2) as soon as patient is on ventilator
• Ti (sec) Begin with 0.5 BUT do as patient is on ventilator
individual setting
according to flow-time
curve (see C.1-2) as soon
as patient is on ventilator

3. Setting of:

The patient’s respiratory mechanics dictate the maximal respiratory

rate. In other words: the Ti and Te (and thus RR) must be set
individually for each patient.

- 77 -
Remember: RR = 60 ÷ (Ti + Te); 60 ÷ RR = Ti + Te; Te = (60 ÷ RR) – Ti

3.1 Inspiratory time (Ti)

Begin with 0.5 seconds
BUT, TAKE NOTE:
The inspiratory time must be set individually as soon as patient is connected to ventilator,
and then according to the inspiratory leg of the flow-time curve which is displayed on the
ventilator screen.
Ideally the inspiratory leg must return gradually to the baseline (zero flow).
• If the Ti is too short the flow will be terminated / interrupted too early resulting in 1) a reduced tidal
volume as well as 2) unnecessary high PIP will be delivered.

• Alternatively an unnecessary long Ti can be shortened if 1) intrinsic (auto)

PEEP (due to a too short Te) is present and a reduction in RR is not desirable and
2) hypercarbia is present in the absence of autoPEEP (Te long enough) and a
shortening of the Ti will then automatically lead to an increase in RR.
• A significant air leak past the endotracheal tube will, despite for example prolonging the Ti,
prevent the inspiratory flow to terminate on the baseline and chest movement will then need to be
assessed to determine if the Ti is adequate.

3.2 RR and Expiratory time (Te)

Initial choice of ventilator rate will depend on the underlying lung pathology and age of patient:
1. Normal lungs – choose a RR that corresponds to or are less than the physiologically
normal breath rate for patient age

Table 2: Normal breath rates in children

Age Breath rate (bpm) Proposed RR

- 78 -
 Neonate 40-50 40
1m-1y 30-40 30
1-5y 20-30 20
>5y 15-25 15
2.  Lung Compliance – a  as proposed RR will possibly be necessary
3.  Airway Resistance – a  as proposed RR will possibly be necessary

BUT, TAKE NOTE: (see next page!!)

Once the patient is connected to the ventilator and the inspiratory time set (according to the flow-time curve) the
expiratory time must be set individually according to the expiratory leg of the flow-time curve which is
displayed on the ventilator screen.
Ideally the expiratory leg must return gradually to the baseline (zero flow).
• With a too short Te the expiratory leg will plateau under the baseline and the patient will not
have enough time to fully exhale. This will result in 1) inadequate delivery of the full tidal volume
and 2) the development of autoPEEP with the risk of hypercarbia and hemodynamic instability.

Too short T

• Alternatively (in the absence of autoPEEP) the Te can be shortened if 1) premature inspiratory
flow termination (Ti too short) is taking place and a reduction in RR is not favourable (by Ti
and keeping the RR the same the Te will automatically become shorter) and 2) hypercarbia is
present along with acceptable inspiratory flow termination where  RR will automatically lead to
a shorter Te.

Changes in PIP will affect:

3.3 PIP (= IP + PEEP)
• PaO2 via MAP changes (directly proportional)

- 79 -
 → IP is set on ventilator

An educated guess is to start with a PIP of 20-25 cmH2O (normal lungs ± 20)

A higher initial PIP can be considered in the following situations:

1. If, with prior bag-and-mask or Neopuff ventilation, it becomes clear that > 20-25 cmH20 is necessary
for adequate 1) visible chest wall movement, 2) air entry on auscultation or 3) to maintain acceptable
O2-saturations.
2. Lung Compliance (often ± 30)
3. Airway Resistance (often ± 30)

As soon as patient is connected to the ventilator and during ventilation the following parameters
can be used to determine if PIP is adequate:
1. Visible chest wall movement (“steady rise and fall“) and good air entry during auscultation
2. Acceptable O2-saturations (see table 3)
3. Tidal volume is ≥ 5 ml/kg
4. Blood gas determinations of PaCO2 and PaO2 (see table 5,6)

3.4 PSV
Always set 2 cmH2O below IP

Aim: 1. Prevent derecruitment (collapse) of alveoli and thus resetting the FRC to

physiological values.

2. MAP and improving oxygenation by V-P mismatch.

3.5 PEEP
3. Protect lungs against damage occuring during phasic opening and closing of

An educated guess is to start with a PEEP of 5 cmH2O. (normal lungs 4-5)

Reasons to deviate from this initial setting is as follows:

- 80 -
PEEP (6-10 cmH2O; can be titrated up from 5 until adequate oxygenation with FiO2 < 0.6)
• Long Compliance
• Chest wall Compliance
o Oedema of chest wall
o Abdominal distention
o Pleural effusion or thickening
• With the use of high PEEP → anticipate venous return and thus CO and hypotension (patient
may need volume infusions to maintain venous return and CO;
with very high PEEP [> 10] it may be necessary to give inotropic support)
PEEP
• Airway Resistance (4-5 cmH2O)

Dangers of excessive PEEP

• Alveolar overdistention with hyperinflation and potential barotrauma and air leaks.
• Dead space ventilation: excessive alveolar pressures compress adjacent bloodvessels resulting
in ventilation of poorly perfused alveoli and work of breathing
• ICP (reason: intrathoracic pressures → venous return → pooling of venous drainage of
head and neck vessels)
• Cardiac output and hypotension: intrathoracic pressures →venous return → preload
→CO

AutoPEEP (intrinsic PEEP) = air trapped in alveoli at the end of expiration

(dynamic hyperinflasion)
• Causes: 1. Too short expiratory time (Te)
2. Expiratory air flow restriction due to peripheral airway narrowing
(bronchospasm, bronchial wall oedema or mucus plugs)
• Consequences: Increased work of breathing and eventually leads to hypercarbia
• Identification: See 3.2
• Management during mechanical ventilation: expiratory time (Te) via RR and/or Ti

3.6 Inspiratory flow trigger:

Table 3: Inspiratory flow trigger setting:

Parameter Trigger (l/min)
Remember:
< 3 kg 0.3-0.5
Red curves = ventilator breaths
1y ± 0.5
>2y 1.0 Yellow curves = patient initiated breaths

Auto-triggering (leading to auto-cycling)

• Additional ventilations that is either not patient initiated or doesn’t correspond with preset
ventilator rate
• Causes:1. Ventilator circuit leaks or ET tube leaks.
(management: inspect circuit and repair any leaks; if a leak past the
ET tube is causing auto-triggering gradually increase inspiratory flow

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 trigger until auto-triggering is just eliminated)
2. Water condensation in ventilator circuits
(management: careful positional drainage into inline reservoir or
drainage of reservoir itself if full)

3.7 FiO2
Always set FiO2 on 1.0 (100% O2) before patient is connected to ventilator.
If O2-saturations stays acceptable (for 5 minutes after connected) then start weaning FiO 2 according to the
following parameters:
1. O2-saturations of patient
2. Blood gas determination of PaO2
Always be aware that a FiO2 > 0.5 can cause O2-toxicity.

Table 4: Acceptable oxygenation values

Age O2-sats (%) PaO2 (kPa)

Neonate
• Preterm 88-92 8-10
• Term
92-95 8-12

Non-neonate 90-100 (95) 8-12 (10-12)

4. Monitor:

4.1 Tidal volume

• Use expiratory tidal volume (Vte/kg) as the measure of tidal volume
• In order to protect lungs against ventilation trauma a tidal volume of 5 ml/kg should ideally be
used.
(for a correct normalized Vte/kg reading it is paramount that the patient’s weight be entered into Setup)
• In sick lungs with  lung compliance and airway resistance it will sometimes be necessary to
use a Vte/kg ≈ 6-10 ml/kg. Always keep in mind that continuously using such big lung volumes
will often lead to acute secondary (ventilator-induced) lung damage.

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 • Vt is manipulated by changing the PIP (directly proportional at a given value of lung compliance)
[Lung parenchyma compliance = ∆ in volume / ∆ in pressure]

4.2 Minute ventilation (Ve)

minute ventilation = Vt x RR
because Vt is directly proportional to PIP a PIP will lead to Ve
Ve = Vt(or PIP) x RR

5. Setting of:

Normal blood gas values:

PaO2 = 10.5 – 13.2 kPa
PaCO2 = 4.7 – 5.8 kPa

Tabel 5: Ventilator settings based on blood gas values (PaO2 and PaCO2)
PaO2 is PaCO2 is Ventilator settings indicated
  PIP
 Acceptable FiO2 followed by MAP (rather
PEEP or Ti than PIP)
  ?over-ventilated (confirm with CXR)
PIP or RR and repeat ABG in 30min
Acceptable  RR; eliminate autoPEEP;PEEP
Acceptable  RR
 Acceptable FiO2
  PIP
NB.: If unexpected PaCO2: firstly exclude ET tube obstruction or malpositioning; as well as pneumothorax.

Tabel 6: Ventilator setting and the consequently expected changes in PaO2 and PaCO2

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Parameter PaO2 change PaCO2 change
 FiO2  None
 RR  
 PIP  
 PEEP   (in absence of dynamic hyperinflation)
Vt  
NB.: These are just expected changes. With some parameter changes the result can be paradoxical, for example if a too high
RR is set it can shorten the expiratory time and thus expiration so much that hypercarbia can develop (PaCO 2 accumilation
due to ‘stacking of breaths‘).

6. Limit ventilator-induced lung damage (O2- toxicity, barotrauma, volutrauma,

atelectrauma, biotrauma)
by practising Lung protecting ventilation:
1. Preferrably keep FiO2 < 0.5-0.6 (if acceptable oxygenation allows)
2. Ventilate with minimum PIP (monitor tidal volume [Vte] and aim for 5 ml/kg)
3. Use PEEP recruitment, i. especially in compliance lung disease, ii. to increase MAP (rather than PIP),
iii. to improve oxygenation and iv. to prevent atelectrauma,
4. Set the Ti and Te individually for each patient as dictated by his/her respiratory mechanics and reflected
on the flow-time curve.
5. Use patient’s own spontaneous respiratory efforts (trigger and PSV) to
a) reduce pressure delivery from the ventilator,
b) prevent atelectasis and
c) prevent diaphragm muscle atrophy.
6. Optimize patient-ventilator interaction by preventing asynchrony.
a) Use SIMV mode
b) Sedation not too light or too deep
c) Use muscle relaxants judiciously
(Remember: muscle relaxation ONLY if sedation already given, it is never a substitute for sedation!)
7. Mild to moderate respiratory acidosis (permissive hypercapnea) is acceptable and weaning can take
place as long as pH ≥ 7.25.
• Keep however an eye on the patient’s clinical status and O2 requirements – an acceptable PaCO2 (increased but
with pH ≥ 7.25) is not necessarily proof that he/she is tolerating weaning especially if he/she is clinically still
distressed or still have high O2 demands!
• Contra-indications for permissive hypercapnea: head injury, SVO,  ICP and cardiovascular instability.
8. Limit duration of ventilation by introducing, and frequently re-evaluating, a WEANING PLAN as soon as
patient is intubated.
• The more acute the disease process, often the quicker weaning can take place.
• Try to wean ventilation with each blood gas being done, even if just a little! (see table 5 and discuss blood gases
with consultant on call)
• Keep the patient’s baseline PaCO2 and PaO2 in mind when weaning ventilation.

7. Prerequisites for extubation (not criteria):

1. Good cough and gag reflex (child can protect own airway).
2. NPO for 4 hours before extubation (if extubation fails and re-intubation is necessary).
3. Sedation has been stopped 2-4 hours before.
4. Acceptable oxygenation on ≤ 40% FiO2 with PEEP ≤ 5.

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 5. Availibility of someone that can re-intubate patient if necessary.
6. Equipment for re-intubation of patient available if necessary.

Mechanical ventilation should be treated as

a drug and should be taken in a well-titrated,

8. Ventilation TROUBLESHOOTING
1. Low pressure alarms
Triggered by air leaks
i. Ventilator circuit leaking or disconnected from ET tube
ii. ET tube malpositioning (unplanned extubation)
iii. Deflation of ET tube cuff (in pediatrics only use cuffed tubes if tube size ≥ 5.5 mm and then only inflate
with ‘200ml 0.9% Saline bag-method’)
2. High pressure alarms
Triggered by  resistance to ventilation
i.  Lung elasticity
1. Worsening lung complaince due to expanding lung parenchymal disease
ii. Airway obstruction
1. mainstem intubation
2.  ET tube patency (plugged or bent)
3. Bronchospasm (with resultant hyperinflation)
iii. Extrinsic compression
1. Pneumothorax
2. Intra-abdominal pressure
3. Psychomotor agitation
3. Hypoxia
Causes
1. Inadequate FiO2
2. Hypoventilation due to air leaks and  resistance to ventilation (as mentioned above)
3. Pulmonary blood flow restriction (pulmonary hypertensive episodes)
4. Anemia or methemoglobenemia
Quick causes for sudden hypoxia: DOPE = Dislogement Obstruction Pneumothorax Embolism
Management:  FiO2 and ventilation settings (PEEP or RR and only then PIP) is handy first steps after malfunctioning
of equipment and mechanical causes of hypoxia have been excluded.
4. Hypercarbia
Causes

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 1. Hypoventilation due to i. resistance against ventilation (see above-mentioned causes) and/or ii.
extreme  or RR (Te too short  too little time to exhale  PaCO2 accumilation; thus: ‘stacking of
breaths‘).

5. Hypotension
Causes (related to ventilation)
1.  Intrathoracic pressures ( central venous return →  CO →  BP)
2. Vasovagal reactions due to ET tube positioning
3. Sedation (sympatolysis)
4. Tension pneumothorax

6. Tachycardia
Causes
1. Stress due to pain and/or inadequate sedation
2. Hyperthermia
3. Hypovolemia
4. Cardiac failure
5. Hypoxia (early sign)
6. Anemia
7. Inotropic support

7. Bradycardia
Causes
1. Vasovagal stimulation
2. Excessive sedation (sympatolysis)
3. Sleep
4. Hypothermia
5. Hypoxia (late sign)
6. Acidosis
7.  ICP (Cushing’s reflex and then with associated BP)

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 Notifiable Conditions
Notification should be done ON day of diagnosis

Acute flaccid paralysis

Acute rheumatic fever

Anthrax

Brucellosis

Cholera

Congenital syphilis

Diptheria

Food poisoning( outbreak of >4people)

Haemophilus Influenza Type B

Haemorrhagic fever(Africa)

Lead poisoning

Legionerae’s disease

Leprosy

Malaria

Measles

Meningococcal infection

Parataphyoid fever

Plague

Agricultural poisoning INCLUDING Organophosphates

Pertussis

Poliomyolitis

Rabies

Small pox

Tetanus

Tuberculosis

Typhoid fever

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Viral Hepatitis, A and B

Non-A, Non B hepatitis, or undifferentiated

Whooping cough

Yellow fever

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