Primary Care Manual of Paediatrics

Section 6
Paediatrics
Paediatric presentation
Section 6.
Paediatrics
Contents

History and physical examination - child

Child with fever

Child with cough

Child with stridor

Child with vomiting

Child with abdominal pain

Child with chronic diarrhoea

Meningitis

Respiratory problems

Immune complications

Ear problems

Gastrointestinal problems

Urinary tract problems

Bone and joint problems

Abuse and neglect - child
Examples of positioning of children

for examination of throat and ears
544
Controlled copy V1.0
Primary Clinical Care Manual 2011
History and physical examination

child
Recommend
Use of Childrens Early Warning Tools (CEWT) appropriate to age for rural and remote
facilities ordered through: qheps.health.qld.gov.au/psq/rmdp/html/rmdp_homepage.
htm or by email at: RMDP@health.qld.gov.au
Consult MO immediately about any baby under 3 months of age who is at risk
or febrile
Always check the immunisation status of children at every opportunity
Believe the child or parent / carer: no matter the time of day or night or the circumstance,
make sure the patient and their parent / carer feels he or she has been listened to
and done the right thing in bringing the child regardless of the concern
Background
Small children, especially young babies, get sick very quickly
Risk signs in children are:
-- temperature > 38C or < 35.5C
-- irritability
-- high pitched cry or weak cry
-- drowsiness
-- decreased activity
-- reduced feeding
-- breathing fast / noisy, respiratory distress, apnoea
-- persistent vomiting
-- dehydration (< 4 wet nappies in 24 hours)
-- sunken eyes
-- cold extremities
-- capillary refill > 2 seconds
-- uses eyes (rather than head) to follow you
-- abdominal distension
Other high risk children include those with:
-- lots of diarrhoea (> 8 watery stools in 24 hours)
-- congenital or chronic disease e.g. cardiac, gastrointestinal, neurological
-- where social conditions are concerning and / or where parents may have difficulty
managing at home
-- a history of repeated or prolonged separations from their primary caregiver(s)
-- psychosocial risk factors including family violence, poverty, homelessness,
parents with intellectual disability or mental health problems
Related topics
Immunisation program
Patient presentation and assessment

DRS ABCD resuscitation / the collapsed patient
Assessment and physical examination of skin,
hair and nails
Assessment of the eye
Assessment of ear
Mental health assessment
Medication reconciliation
Medication history checklist
Glasgow Coma Scale / AVPU
Controlled copy V 1.0
545
Standard clinical observations and other vital signs - child
Approximate normal physiological ranges for a child

Normal range
Parameter
<1 year
1 - 2 years 2 - 5 years 5 - 12 years > 12 years
HR
110 - 160
100 - 150
95 - 140
80 - 120
60 - 100
(beats per min)
Respiration rate
30 - 40
25 - 35
25 - 30
20 - 25
15 - 20
Standard clinical (breaths / min)
observations
Axilla - clinically significant fever > 37.8C (37.2C *)
Sublingual - clinically significant fever > 38.0C (37.5C *)
Temperature
Rectal - clinically significant fever > 38.5C (38.0C *)
* clinically significant fever lower in infants < 3 months of age
Blood pressure
Systolic >
Systolic >
Systolic >
Systolic >
Systolic >
(mmHg)
60
70
75
80
90
Respiratory
Nil
distress
Other vital signs
if indicated
O2 saturation (%) > 95%

Capillary refill time Less than or equal to 2 secs
Level of
consciousness
Blood glucose
level
Glasgow coma scale 15

AVPU tool - alert
4 - 8 mmol (random capillary)
[1] [8]
Pain assessment in a child
Rate pain level in children using faces, numbers and behavioural observations. Physiological
changes e.g. altered HR, RR, BP are not good indicators to use in isolation [2]. Non - verbal
children are very vulnerable to having their pain under estimated [2]

Refer to Childrens Early Warning tools (CEWT) for pain assessment tools
Pain rating scale for children
546
Presentation

When a child presents for health care the clinician is required to gather an orderly
collection of information to identify the patients health status. The following is essential
to achieve this:
-- taking a patient history
-- performing standard clinical observations and other vital signs
-- perform physical examination
-- using diagnostic and pathology services, and
-- collaboration with other members of the team
-- note: not all children are at the same stage of development in areas of physical,
cognitive and psychosocial development
It is a requirement that all clinicians document their findings in a clear and concise way.
This section is set out to assist. It is recommended the page number of HMP / CCG is
referred to in the documentation
Types of history
There are four types of history taking [3] See History and physical examination - adult
History taking

The purpose of a full history is to ascertain the cause of the child's illness. A careful
history will make the cause clear in the vast majority of cases.
The first priority is to assess whether the child is:
-- seriously ill and needs immediate management or,
-- is a non urgent presentation, and there is time for a complete patient history and
health education
Obtaining a full history is done in conjunction with examining the patient
-- In a sick child this entails a full assessment of all systems
-- In a child who has a localised problem it is reasonable to examine the relevant
system only. However, always be guided by the history and be prepared to examine
other systems as necessary. This is particularly important for children who often
present with generalised symptoms and signs
-- Ask open ended questions
-- Believe the carer
Presenting concern

Ask the child or carer what the problem is

Ask about length of illness and exact details of symptoms and signs. For each symptom
the following details are important [4]
Site - where is the pain / symptom? does it go anywhere else?
Onset - when did it start, gradual or sudden onset?
Character e.g. sharp, dull or burning
Radiation - does the pain radiate anywhere else?
Alleviating factors - what makes it better e.g. sitting up, medicines?
Timing - how long did it last, have they had it before?
Exacerbating factors - what makes it worse?
Severity - mild, moderate or severe pain. Pain score 0 - no discomfort to 10 - unbearable
pain or use facial diagrams

Any associated symptoms e.g. nausea, vomiting, photophobia, headache

-- always ask specifically about fever, pain, shortness of breath / rapid breathing,
diarrhoea and / or weight loss, rash
Behaviour and activity during this illness

-- is the child active / alert, sleepy or irritable? easy / difficult to wake?
547
Appetite and fluid intake / output during this illness

-- try to be as precise as possible with quantities
-- how many drinks / breastfeeds?
-- how alert during feeds?
-- how long between intake and vomit? / diarrhoea?
-- how many wet nappies or times passed urine in preceding 24 hours?
-- amount / type bowel movements
Treatment and / or medication given by carer during this illness?

-- what, how much, when, how often, how effective?
Past history
Past medical and
surgical history
Family and social

history
Medications
Allergies
Immunisations
548
Was delivery normal and were there any immediate neonatal problems?
Any problems with growth and development?
Significant illnesses in the past? What and when?
Hospital admissions? Why and when?
Operations or injuries? What and when?
Mothers alcohol history during pregnancy?
Health problems in the family - especially siblings and parents
Who looks after the child, what is the social situation?
Mental health problems in carers / child?
Household smokers?
Recent contacts or trips away
If medicines are given, will they be taken?
Regular medicines (prescribed, herbal, bush medicines, over the counter)
generic name(s), dose, frequency?
Are they taken correctly?
May need to ask about other medicine(s) in the home the child may have
taken
See Medication reconciliation / Medication history checklist for more details
Adverse drug reactions:
-- adverse reactions / allergies to medicines?
-- attach adverse drug reaction sticker to medication chart if required
Allergens e.g. bee stings, tapes, sticking plaster, nuts:
-- specific reaction e.g. skin reaction, bronchospasm
-- is an Epi-pen / medication used to treat the allergy?
Check if up to date
Documented evidence of immunisation status should be obtained, follow
up with opportunistic immunisation See Immunisation program
Standard clinical observations

All children
Temperature, HR, respiratory rate
presenting for
If indicated:
acute care
-- O2 saturation
-- BP
is not usually needed
ensure correct sized cuff - must be wider than 2/3 the length of upper arm
-- blood glucose level (BGL)
indications include altered level of consciousness / seriously ill children
-- conscious level - GCS / AVPU
-- capillary refill
-- weight
See Standard clinical obervations and vital signs - child, Glasgow Coma Scale / AVPU
Physical examination

May be best done with the child on the carers knee. If the child is irritable perform
the examination opportunistically i.e. do what you can when you can. Leave the most
disruptive parts (ears and throat) until last
In general, examination of a child is not a good screening test. Use the history
to guide you to areas where you think you will find an abnormality
In any sick child a thorough and complete examination is required. All clothing will
need to be removed at some stage during the complete examination
In a child who is not sick, examine the relevant system first and proceed to further
examination as guided by the history and your findings
Physical examination - child

Does the child look well or sick?
General
Alert or drowsy? Altered conscious state? See Glasgow coma scale / AVPU
appearance
Muscle tone - normal or is the child floppy?
Look / gaze - does the child fix the gaze on the face or is there a glassy eyed stare?
Interactive or disinterested in interacting / playing?
Increased work of breathing? e.g. retractions, nasal flaring, grunting, gasping, fast
breathing, wheeze
Observe speech / cry - strong and vigorous or weak or hoarse?
Look at the conjunctiva and the nail beds - are they pale?
Look at the lips, tongue and fingers - are they blue?
Is the child well nourished?
Is there any neck stiffness - feel gently. Ask the older child to put their chin on their
chest - if they can they do not have neck stiffness
Is the child able to be consoled by the care giver?
Hydration
Any weight loss?
Eyes - normal or sunken? Tears absent or present?
Mouth and tongue - wet or dry?
Skin turgor - pinch a loose piece of skin. Does it return to normal immediately or
stay saggy?
Fontanelle - normal or depressed? (if bulging consider meningitis)
See Clinical assessment of hydration of children for detailed assessment
549
Physical examination - child (continued)

Skin
Always check the whole body, particularly in a sick child
Rash ? non blanching, petechiae, purpura
Colour - unusually pale, mottled or cyanotic?
Bruising, unexplained or unusual marks?
Signs of infection: redness, swelling or tenderness?
Inspect / palpate lymph nodes in the neck, axillae or groins for tenderness
See Assessment and physical examination of skin, hair and nails for detailed
assessment
Growth
Height
Weight - if child < 2 years weigh naked
Head circumference if < 2 years
Plot on growth charts appropriate for age and gender
Cardiovascular Skin colour - pink, white, grey mottling? Compare the trunk with the limbs
Skin temperature - hot, warm, cool, cold, sweating? Compare the trunk with the
system
limbs
Palpate peripheral pulses - is rate fast, slow or normal - is the pulse volume weak
or strong?
Central perfusion - blanch the skin over the sternum with your thumb for 5 seconds.
Time how long it takes for the mark to disappear
Peripheral perfusion - blanch the skin on a finger or toe for 5 seconds. Time how
long it takes for the mark to disappear
Any evidence of oedema - particularly hands, feet and face?
If skilled, listen to heart sounds
Respiratory
Most information is gained through inspection
system
Inspect anterior / posterior chest:

Gastrointestinal and
reproductive
systems
550
-- equal chest movement

-- use of accessory muscles of respiration? Look for retraction, recession - mild,
moderate or severe? Nasal flaring?
Can they talk continuously, or only in words or sentences, or unable to talk at all?
Measure respiratory rate over one minute, observe rhythm, depth and effort breathing
Listen for extra noises - cough, sputum, wheeze, stridor, grunt, snore, hoarse
speech / cry
Auscultate air entry in both lung fields - equal? Adequate, decreased or absent? Are
there wheezes or crackles? Do they occur on inspiration or expiration? (Note that
transmitted sounds from the upper respiratory tract are very common in children and
may mask other signs)
Will the child lie flat?
O2 saturation
Look - are there any scars or abdominal distension / hernias

Auscultate bowel sounds - present or absent?
Palpate abdomen
-- soft or firm?
-- any obvious masses?
-- tender to touch? Identify which abdominal quadrant and exact area
-- any guarding / rigidity - even when the child is relaxed?
-- any rebound tenderness - press down and take your hand away very quickly - is
the pain greater when you do this?
Question about change in bowel habits
Feel for a palpable bladder
Check the testes in boys - are they both in the scrotum?
-- any redness, swelling or tenderness?
Physical examination - child (continued)

Nervous
A detailed assessment of the nervous system in a child is both technically difficult
system
and time consuming. A brief assessment is all that is needed. Assess:
-- conscious state. See Glasgow Coma Scale / AVPU
-- orientation to time, place and person if appropriate for the childs age. Ask the
child their name, age, location. Ask them to tell you the time, date and year
-- pupils: size, equality, shape, reactivity to light
Look for inequality between one side of the body and the other. Compare the tone
and power of each side of the face and the limbs
Test touch sensation using cotton wool
Test finger nose coordination. If possible, observe child walking, looking around and
using hands
Musculo Full range of movement in limbs, joints and muscles?
skeletal system Pain in limbs, joints or muscles?
Any redness, pain, swelling, heat over joint(s)? Observe gait
See Acute rheumatic fever / Bone or joint infections - child
Ears, nose and Ears
throat
-- look at the pinna - redness, swelling?
-- any obvious swelling or redness of the ear canal, if there is, looking with an
otoscope will be painful
-- looking inside with an otoscope - look at the ear canal - redness, swelling,
discharge?
-- inspect eardrum - normal? or redness, dullness, bulging or retraction, fluid or air
bubbles, perforations or discharge?
-- See Assessment of ear for detailed assessment
Nose
-- feel for facial swelling / inflammation
-- is there any discharge or obvious foreign body?
Throat
-- look at the lips, buccal mucosa, gums, palate, tongue, throat
-- redness / swelling?
-- condition of teeth
-- inspect tonsils - redness, enlargement or pus?
Eyes
Always test the visual acuity of each eye. Use age appropriate Snellen chart at 6
metres in good light
Look at the eyes and surrounding structures - any redness, discharge or swelling?
Look at the pupils - are they equal in size and regular in shape? Check pupillary
reflex to light
Check eye movements - ask the child to follow the movement of your finger
See Assessment of the eye for detailed assessment
Urinalysis
Examine the urine of all sick children, all children with abdominal pain or urinary
symptoms and all children with unexplained symptoms or signs
Look at the colour - is it normal, dark, blood stained?
Does it smell normal?
Perform urinalysis
[4] [5] [6] [7]

See decision making flowcharts to assist with clinical impression

-- child with fever / cough / stridor / vomiting / abdominal pain and / or chronic
diarrhoea
551
Diagnostic and pathology services

Point of care testing is available in some facilities for example iSTAT blood gases
Pathology request forms
-- all pathology requests made by SM R&IP must be compliant with the specific Health
Management Protocol
-- if in the clinicians opinion other pathology is required this must be ordered by a MO
Pathology results / follow up:
-- if a SM R&IP has initiated pathology testing according to the Health Management
Protocol they are responsible for the follow up of pathology results
-- MO should be consulted if results are abnormal
Refer to the Pathology Queensland Specimen Collection Manual available at:
qis.health.qld.gov.au/DocumentManagement/Default.aspx?DocumentID=10021&Doc
umentInstanceID=45973
Consulting the MO

If it is necessary to consult with a MO present your findings clearly and methodically

It is often easier if you write your findings down first (time permitting)
It is helpful to advise the MO early that you have a child about whom you want some
advice or alternately who you think may need evacuation
Always begin with the name and age of the child, then start with the presenting concern
and proceed through to the examination. Say what you think is wrong - your assessment
is important; after all, you are actually with the child
Always consult with the MO if you are not sure. Discuss difficulties and problems with
the MO during routine visits. Take the opportunity to discuss general or specific cases
or issues with the MO at the next clinic visit
See Royal Flying Doctor Service (Queensland Section) and Queensland Emergency
Medical System - consulting the MO / ISOBAR
References
1. Pemsoft. Normal vital signs. 2008-2011 [cited 2011 August].
2.
The Royal Childrens Hospital. Acute Pain Management 2010 [cited 2011 April].
3.
Estes M. and Schaefer K.P., Health assessment & physical examination. 2nd ed. 2002, Albany, NY
Delmar.
4.
Talley N. and OConnor S., A systematic guide to physical diagnosis: clinical examination. 6th ed. 2010,
Australia: Churchill Livingstone: Elsevier.
5.
Murtagh J. and Rosenblatt J., John Murtaghs general practice 5th ed. 2011, Australia: McGaw Hill.
6.
Corrales A.Y. and Starr M., Assessment of the unwell child. Australian Family Physician, 2010. 39(5): p.
270-275.
7.
Douglas G., Nicole F., and Robertson C., Macleods clinical examination 12th ed, ed. Douglas G., Nicole
F., and Robertson C. 2009: Churchill Livingstone: Elsevier.
8. Advanced Paediatric Life Support Group, Advanced Paediatric Life Support The Practical Approach.
5th ed, ed. Samuels M. and Wieteska S. 2011: Wiley-Blackwell.
552
See
Meningitis
Headache,
photophobia
+/Rash
Neck stiffness
or bulging
fontanelle
Rapid onset
high fever
May have
history of URTI
like illness
See
Epiglottitis
Stridor,
drooling,
unable to
eat,
drink or talk,
reluctant to
move neck
Child unwell
Child unwell
See
Pneumonia
No other
significant
features
No other
significant
features
See
UTI
Tachycardia
Rapid
breathing,
chest
recession
Cough
Child unwell
Positive
urinalysis
Dysuria,
frequency,
smelly
urine
Child
unwell
See
Bacterial
skin infections
No other
significant
features
Obvious
abscess or
cellulitis
Basically
well child
No
Yes
See Acute
gastroenteritis
No other
significant
features
Vomiting and
diarrhoea
Basically
well child
Significant features of assessment unclear or you are unsure of cause?
Clinical assessment performed
See
Acute
otitis media
No other
significant
features
Bulging ear
drum on
examination
URTI type
symptoms may
be present
Basically
well child
Consult MO
See
URTI
Sore throat, ears,

nasal discharge,
cough,
cervical
lymphadenopathy,
red inflamed
throat,
tonsillar
enlargement
No other
significant
features
Basically
well child
Fever is usually an indicator of infection. Two or more infections may co-exist, e.g. URTI plus meningitis
Babies less than 3 months of age contact MO immediately
Consult MO for the child with a fever with no obvious source of infection or a fever that is persistent despite measures taken
Child with fever
Child with fever
553
554
Tonsillar
enlargement
Usually there
is a history of
ingesting or
choking on
something
Unable to eat,
drink or talk
Reluctant to
move neck
Cough may be
absent
See
Epiglottitis
No other
significant
features
See
Croup
Mild / moderate
stridor
Fever, red
inflamed throat
Airway
compromised
See
Acute upper
airway
obstruction /
choking
See
URTI
No other
significant features
Cervical
lymphadenopathy
Mild fever
Cough +/Stridor +/Wheeze +/-
Stridor,
drooling
Fever
Sore throat, ears,

nasal discharge
See
Pneumonia
No other
significant
features
Tachycardia
Rapid breathing
with chest
recession
Child unwell
Yes
Basically well child
Mild URTI
symptoms
Sudden onset
in previously
well child
Rapid onset
high fever
Child unwell
Barking cough
Basically
well child
No
Child with cough
See
Asthma
No other
significant
features
Wheeze, rapid
breathing
Nocturnal
or exercise
induced
cough
Consult MO
See
Whooping
cough /
pertussis
No other
significant
features
Apnoea
Paroxysmal
cough
whoop
Child with cough
Slow onset
Croupy (barking) cough

Temp < 38.5C
No systemic disturbance
Severe stridor less common
Able to swallow
Will usually drink
Normal voice
< 4 years
More prominent at night
See
Croup / epiglottitis
Rapid onset
Weak or no cough
Temp >38.5C
Septicaemia
Drooling saliva
Unable to eat or drink
Doesnt talk
Any age
Reluctant to move neck
As the condition
deteriorates the stridor
may decrease
See
Usually there is a history

of exposure to allergen: an
injection of a drug or blood
product, ingestion of oral drug
/ food or bites / stings
See
Anaphylaxis
Cough or wheeze may be

present
Usually there is a history
of ingesting or choking on
something e.g. peanut
See
Acute upper airway
obstruction / choking
Consult MO
In the meantime, consider epiglottitis
Gradual swelling of face,

neck and throat
Yes
Sudden onset in previously

well child
No
Obtain full history, including Hib immunisation status. Limit examination. Do not examine mouth or throat
Stridor is a harsh vibrating sound originating from the large upper airways and occurring on inspiration. It occurs due to upper airway
obstruction. Consider the following causes: croup common, inhaled foreign body, epiglottitis rare but important, trauma, angioneurotic
oedema, mass (tumour or abscess)
Child with stridor
Child with stridor
555
556
Cough
Rapid
breathing
Fever
May have
history of URTI
like illness
Tachycardia
No other
significant
features
See
Pneumonia
Headache,
photophobia
+/-
Neck stiffness
+/Rash
See
Meningitis
Chest
recession
Child unwell
Child unwell
See
Acute
gastroenteritis
No other
significant
features
Fever
Diarrhoea
Basically well
child
See
UTI
No other
significant
features
Positive
urinalysis
Dysuria
frequency
smelly urine
No
See
Pyloric
stenosis
No other
significant
features
Weight loss or
poor gain
Projectile
vomits,
hungry
following
feed
2-6 weeks old
Perform clinical assessment

Consult MO
Intussusception
See
No other
significant
features
Red currant
jelly stool
Abdominal
pain
intermittently
3 mths - 3 yrs
Yes
See Gastroesophageal
reflux
No other
significant
features
Vomiting and
irritable after
feeds
Unweaned
Well baby
See
Diabetes
Ketones on
urinalysis
High
capillary BGL
Moderate or
severe
dehydration
Child unwell
Vomiting is a common and important symptom, which may indicate serious illness especially in a very young child.
Consider the following causes: infection (pneumonia, UTI, meningitis, otitis media), obstruction (pyloric stenosis, intussusception, appendicitis,
hernia), reflux oesophagitis, raised intracranial pressure (trauma, abscess or tumour), metabolic (diabetic ketoacidosis, poisoning)
Child with vomiting
Child with vomiting
Child with abdominal pain

Any history of significant trauma?
Yes
See Criteria for Early Notification of

Trauma for Interfacility Transfer
Yes
Consult MO
Yes
Consider UTI
See Urinary tract infection - child
Yes
Consider pneumonia
See Pneumonia - child
Yes
Consider gastroenteritis
See Child with vomiting / fever /
chronic diarrhoea
Yes
Consider constipation
See Constipation
No
Bile-stained vomiting?
Bloody stool?
Localised tenderness?
Distension?
Guarding?
Rebound tenderness?
Palpable mass?
Inguinal-scrotal pain or swelling?
No
Positive urine dipstick for
leukocytes, nitrates or blood;
or bacteria on microscopy
No
Fever +/Tachypnoea
Recession
Cough
Chest pains
No
Diarrhoea +/- vomiting / fever
No
Firm stool palpable in lower abdomen?
No
Consult MO
557
Child with chronic diarrhoea

Diarrhoea every day for at least 10 days or recurrent episodes of loose stools over longer
periods requires investigation. Consider the following causes: parasites (strongyloides,
cryptosporidium, giardiasis), malabsorption (lactose intolerance, coeliac disease),
inflammatory conditions (crohns disease, ulcerative colitis), other infections e.g. UTI,
pneumonia
Significant features of assessment
unclear or you are unsure of cause
Yes
Consult MO
Yes
Treat if positive
for giardia or
intestinal
worms.
Consult MO if
other +ve result
Yes
See Lactose
intolerance
No
Well hydrated, normal growth and
development, adequate diet
Obtain faeces sample for MC/S and OCP
Is test positive?
No
Test for lactose intolerance
See Lactose intolerance
Is test positive?
No
Consider significant features
of asssessment
558
Perianal itch
Sighting of worms
in faeces
Foul smelling,
watery diarrhoea
Flatulence
Nausea
Bloody diarrhoea
Mucus in diarrhoea
Abdominal pain
See
Intestinal worms
See
Giardiasis
Consult
MO
Meningitis
Meningitis

Recommend
Consult MO immediately:
-- if a sick looking child has no obvious source of infection, which would explain
their symptoms - the diagnosis is meningitis until proven otherwise
-- if the child has been treated with antibiotics but is still not well (they may have
partly treated meningitis with masking of signs)
-- if the child is unwell with prolonged URTI symptoms
Restrict fluids to 50% of maintenance (10mg / kg) unless there are signs of shock MO to discuss as soon as possible with a Paediatrician
Parents or carers may notice early, subtle changes in the childs conscious state.
Their concerns should not be ignored
Perform hearing test 3 months after discharge from hospital
Background
Mortality is probably 5 - 10% in bacterial meningitis. Most children will make
a full recovery, if appropriately treated. Deafness is the most common long term
complication
Hyponatraemic solutions e.g. 4 % dextrose and one-fifth normal saline or one-quarter
normal saline, have no place in the management of meningitis as they may worsen
hyponatraemia and increase the risk of cerebral oedema [1]
Related topics
Fits / convulsions / seizures
Upper respiratory tract infection child
DRS ABCD resuscitation / the collapsed

patient
O2 delivery systems
1. May present with

URTI type symptoms, fever, lethargy, poor feeding

In young children - non specific signs and symptoms including fever, irritability,
refusing feeds, pallor and a high pitched moaning cry may be present
In older children - headache, photophobia, neck stiffness [2]
Leg pain, cold hands and feet
Abnormal skin colour - pallor or sweating
Rash in meningococcal disease: usually non blanching petechiae (fine dark red
spots) but may be purpura (like bruises), or less commonly, a flea bitten pink / red
maculopapular rash. The rash often develops rapidly, however meningococcal
disease can occur without a rash
Muscle / joint pains, vomiting, diarrhoea
Confusion, drowsiness, loss of consciousness
Bulging fontanelle, fitting
2. Immediate management

onsult MO immediately
C
If altered level of consciousness See DRS ABCD resuscitation / the collapsed
patient
If fitting see Fits / convulsions / seizures
Give O2 to maintain O2 saturation >95%. If >95% not maintained consult MO.
See O2 delivery systems
Insert IV / IO cannula and take FBC, U/E, blood cultures, PCR for Neisseria
meningitis (meningococcal bacteria)
559
Meningitis
I n the critically ill, shocked or septic child with suspected meningitis e.g.
unresponsive, poorly perfused, purpuric rash, it is appropriate to first give a bolus
of intravenous or intraosseous fluids (initially 10 - 20 mL / kg of normal saline [1])
before giving antibiotics. Otherwise restrict total fluids to 10 mL / kg.
MO to consult as soon as possible with Paediatrician
3. Clinical assessment

btain as complete a patient history as possible according to the circumstances

O
of the presentation. Of particular importance in a sick looking child is:
-- headache, irritability, fever, ask about any rash, neck stiffness
Perform standard clinical observations +
-- weight (if able)
-- GCS
-- O2 saturation
Perform physical examination:
-- inspect all skin surfaces for any skin rash especially at pressure points and
under nappies and clothing. Note: petechiae and purpura do not fade on
pressure
-- assess hydration status
-- inspect and palpate the ears, nose and throat
-- palpate the fontanelle in young baby - feeling for fullness
-- check for neck stiffness - with patient lying down, put hand behind head and
gently raise
-- auscultate the chest for air entry and any added sounds (crackles or wheezes)
Check vaccination status, especially Hib / meningococcal / conjugate

pneumococcal
4. Management

onsult MO who will arrange / order:

C
-- evacuation / hospitalisation
-- monitor clinical observations closely
-- continue IV / IO fluids at 50% of maintenance fluids (10 mL / kg). If the child is
drinking ensure total fluids do not exceed 10 mL / kg (or 50 % of maintenance
fluids)
-- if meningitis is suspected, stat dose of parenteral antibiotics must be given
before transfer to hospital. Blood samples for culture and PCR should be
taken where possible but should not delay initial treatment
-- give IV ceftriaxone (can be given by IM route if unable to obtain IV access)
100 mg / kg / dose to a total of 4 grams daily (or 50 mg / kg / dose bd to a total
of 2 grams bd) [3]
Give paracetamol for fever, pain or distress
See Simple analgesia back cover
5. Follow up
All children with suspected meningitis should be managed in an appropriately

560
equipped hospital
Notify the Public Health Unit of any suspected case of bacterial meningitis as
soon as possible
Chemoprophylaxis will be required for close contacts of a patient with either
meningococcal or Hib meningitis. Unvaccinated contacts of Hib meningitis <5
years should be immunised as soon as possible - Public Health Unit will advise
Arrange paediatric follow up, after discharge from hospital
Perform hearing test 3 months after discharge
6.
Referral / consultation
Consult MO immediately on all occasions if meningitis is suspected

Most will require urgent treatment and evacuation / hospitalisation
References
1.
The Royal Childrens Hospital. Fluid management in meningitis. 2005 [cited 2011 March ].
2.
The Royal Childrens Hospital. Meningitis guideline. 2009 [cited 2011 March ].
3.
Therapeutic Guidelines. Meningitis: empirical therapy (organism or susceptibility not yet known). 2010
[cited 2011 March].
Upper respiratory tract infection - child
Common cold, sore throat, tonsillitis
Recommend
Remember the symptoms and signs of an upper respiratory tract infection (URTI)
may be a precursor to more serious illnesses such as meningitis
Always be alert to the relationship between group A streptococcal sore throat and ARF
/ APSGN. These complications are common and serious but potentially avoidable in
Aboriginal and Torres Strait Islander children
Ten (10) days of oral antibiotics, or one dose of benzathine penicillin IM, is required
to eradicate group A streptococcus
Background
The vast majority of URTI are caused by viruses and do not require antibiotics.
However a viral URTI can be complicated by secondary bacterial infection such as
otitis media or pneumonia, requiring antibiotics
Other complications include exacerbation of asthma
Related topics
Meningitis
Pneumonia
Acute otitis media
Pertussis (whooping cough)

Bronchiolitis
1. May present with

Watery or purulent nasal discharge and / or sneezing

Sore / red throat and / or tonsils with or without pus
Difficulty swallowing, cough, chest wheeze, earache
Enlarged tender cervical (neck) lymph nodes
Fever, headache, general malaise
2. Immediate management Not applicable


ake patient history including:

T
-- past episodes, history of asthma, complications such as ARF / APSGN
-- otitis media, measures taken to treat including medications taken
-- collect urine for MC/S and test for nitrates
Perform physical examination including:
-- overall appearance e.g. smiling? agitated? lethargic?
-- respiratory effort e.g. chest recession, nasal flaring, grunting (noisy breathing),
abdominal breathing
-- inspect the ears, nose and throat
561
-- p
alpate the head and neck for enlarged lymph glands
-- auscultate the chest for air entry and any added sounds - crackles or wheezes
-- inspect all skin surfaces for any skin rash especially at pressure points and
under nappies and clothing Note: petechiae and purpura do not fade on
pressure
Check vaccination status. See Immunisation program
4. Management

onsult MO if
C
-- < 3 months of age
-- < 1 year with respiratory rate more than 40 respirations per minute (rpm)
1 - 2 years more than 35 rpm
12 years and older more than 20 rpm
respiratory distress or apnoea
-- if child looks sick, not alert or interactive and has temperature over 38C
-- if child still looks sick when temperature reduced
-- if child has any rash
-- if child has a cough productive of mucopurulent sputum, may need further
investigations for possibility of chronic respiratory disease
-- if child has tonsillitis and is sick
If child has cough as the main feature; consider other diagnoses. See Pertussis
(whooping cough), croup, acute asthma
If child has an increased respiratory rate, or any chest findings consider other
diagnoses. See Bronchitis / pneumonia
If child has evidence of secondary ear infection. See Acute otitis media
For the child with URTI, indications for antibiotic treatment are:
-- sore throat and red swollen tonsils, with or without pus, with fever (>38C)
and local lymphadenitis
-- sore throat with red swollen tonsils in a child with existing rheumatic heart
disease
-- Scarlet fever - has a characteristic and striking red blanching rash and
strawberry tongue due to streptococcal infection; rash usually starts after the
sore throat and lasts a week
-- Quinsy (severe infection of the tonsils causing massive enlargement). If
quinsy is present, consult MO (may need evacuation / hospitalisation for IV
penicillin and / or surgical drainage of pus)
For the child with uncomplicated URTI, treatment is symptomatic [1]:
-- encourage rest and increase fluid intake
-- paracetamol for analgesia if uncomfortable (do not use aspirin in children)
-- topical nasal decongestants can be helpful for sleeping and eating particularly
in young infants; however their use should be limited to short periods of time
(5 days max.). Nose drops of normal saline or cool boiled water can also be
helpful and are safe
-- other symptomatic treatments, nebulised saline, and lemon and honey drinks
may have some subjective benefit in some children
562
For the child with indicators for antibiotic treatment present and if not allergic treat
with oral penicillin:
DTP
IHW / SM R&IP / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NP
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed
Route of
Recommended
Form
Strength
Duration
administration
dosage
250 mg
Child
Capsule
500 mg
Oral
15 mg / kg / dose bd
10 days
Suspension 150 mg / 5 mL
to a max. of 500 mg bd
Provide Consumer Medicine Information: should be taken on an empty stomach; to 1 hour before meals.
Ensure full course is completed
Management of associated emergency: as for severe allergic reactions See Anaphylaxis
[1]
Schedule
Phenoxymethylpenicillin
If a lack of observance with oral medication is anticipated or those intolerant of

oral therapy treat with IM penicillin:
Benzathine penicillin
DTP
(Bicillin LA)
Route of
Recommended
Duration
Form
Strength
administration
dosage
3 kg - < 6 kg 225 mg
6 kg - < 10 kg 337.5 mg
Disposable
10 kg - < 15 kg 450 mg
Stat
900 mg
IM
syringe
15 kg - < 20 kg 675 mg
>20 kg 900 mg
Use a concentration of 442 mg / mL when measuring part doses. Refer to product information
Provide Consumer Medicine Information
Administration tips - as per patient preference:
-- apply EMLA cream to the injection site 30 - 60 minutes prior to injection and allow medication to warm
up to room temperature or
-- allow medication to warm up to room temperature, apply pressure with thumb (to the exact injection
site) 30 seconds prior to the injection, use 21 gauge needleand deliver injection very slowly (2 minutes)
[1]
Schedule
If allergic to penicillin, treat with roxithromycin:
563
DTP
Route of
Recommended
Form
Strength
Duration
administration
dosage
Tablet for
50 mg
Child
suspension
Oral
4 mg / kg / dose bd
10 days
150 mg
Tablet
300 mg
Provide Consumer Medicine Information: should be taken on an empty stomach, 15 minutes before food;
ensure course is completed
Management of associated emergency: consult MO
[1]
Schedule
Roxithromycin
5. Follow up
R
eview next day, if not improving consult MO
If antibiotics have been given for sore throat:
-- r eview in 2 weeks
-- ask about sore joints, chest pain, breathlessness and check urinalysis
-- consult MO if symptoms persist see Rheumatic fever or if abnormal urinalysis
see Acute post streptococcal glomerulonephritis
6. Referral / consultation
C
onsult MO as above or if symptoms persist despite symptomatic treatment
If recurrent tonsillitis (>6 episodes per year) MO may consider prolonged course
of prophylactic penicillin or referral to ENT specialist for consideration for

tonsillectomy / adenoidectomy
Pertussis (whooping cough)

Recommend
If adults and teenagers present with pertussis ask about young babies at home as
pertussis is a particularly severe disease in infants < 12 months of age
It is important to explain that coughing may continue for 6 - 8 weeks after treatment
and may recur with the next URTI. The recurrence will not last long
In Queensland free pertussis vaccine is now available for birth parents, foster parents,
adoptive parents, grandparents of babies < 6 months of age and other adults in a
household with a baby < 6 months of age [2]
Background
Pertussis (whooping cough) is still common
Incubation period is on average 7 - 10 days

Pertussis is a prolonged illness and can be complicated by apnoea in infants,
pneumonia, hypoxic brain injury, seizures or lead to chronic lung disease
Related topics
URTI
564
1. May present with

URTI symptoms
Cough (typically paroxysmal i.e. intermittent episodes of prolonged coughing
followed by the characteristic inspiratory whoop as the child catches his / her
breath)
Vomiting, typically after an episode of coughing
Cyanosis, typically during an episode of coughing
Young babies usually do not have the characteristic whoop but are likely to be very
distressed by coughing and vomiting. They can develop apnoea (stop breathing)
and become cyanosed during a coughing bout
Adults usually have a persistent troublesome cough only, without a whoop. A
cough of several weeks duration, that is worse at night, in an adult, is pertussis
until proven otherwise

If severe consult MO immediately

ee Upper respiratory tract infection

S
The whoop can be characteristic but may not always be present. The child may
not be distressed in periods between paroxysms of coughing, with few clinical
signs, however the overall impression is of a sick child
4. Management

onsult MO who may advise:

C
-- evacuation / hospitalisation if young child (< 6 months) or if symptoms are
significant, appropriate tests to confirm diagnosis - serum for IgA and / or
nasopharyngeal aspirate / swab for PCR testing and / or MC/S
-- antibiotics may shorten the length of the illness if given early and will also
reduce infectivity to others. Person can be considered not infective after 5
days of treatment. It is important to explain that coughing will continue for 6 - 8
weeks, and may recur with the next URTI. The recurrence will not last long
-- household and child care contacts may require prophylactic antibiotics to
prevent further clinical cases of pertussis
-- advise to avoid contact with other individuals, especially young children and
infants until at least 5 days of antibiotics have been received [3]
-- consult Public Health Unit for advice
5. Follow up
If not evacuated / hospitalised review daily, at least initially

Consult MO on all occasions whooping cough is suspected
565
Recommend
Keep the child as calm as possible
Do not examine the mouth or throat and do not lie the child flat
Background
Croup usually follows 3 or 4 days of a mild URTI when the infection spreads to affect
the upper airways; it is usually mild and self limiting
Epiglottitis (cellulitis of the epiglottis) is caused by Haemophilus influenza type B
infection and is fatal if untreated. It is rare since Hib vaccination was introduced
Related topics
Acute upper airway obstruction and choking
1. May present with
Acute epiglottitis
-- weak or no cough
-- temperaure >38.5C
-- septicaemia
-- looks sick
-- drooling saliva
-- unable to eat or drink
-- doesnt talk
-- any age
-- reluctant to move neck
Croup
-- croupy (barking) cough
-- temperature <38.5C (however viral croup
often has a high temperature)
-- no systemic disturbance
-- able to swallow
-- will usually drink
-- normal or hoarse voice
If epiglottitis is suspected, examination of the airway can cause airway spasm

/ complete obstruction. If this occurs an emergency airway may be required
therefore:
-- do not examine mouth or throat
-- do not lie the child flat

onsult MO as soon as circumstances allow

C
A calm atmosphere is most beneficial
If severe respiratory distress, lethargic or cyanosed, give O2 to maintain O2

saturation >95% and consult MO immediately. If >95% not maintained consult
MO. See O2 delivery systems
If not tolerated, it is best to interfere with the child as little as possible. Try holding
the O2 tubing / mask close to face

566
btain patient history including onset and preceding URTI

O
Perform standard clinical observations. Note in particular, temperature and

respiratory rate (when the child is quiet)
Inspect for signs of respiratory distress - grunting (stridor), rib or sternal recession,
nasal flaring
Inspect for drooling in a sick looking child. This along with high fever is suggestive
of epiglottitis
4. Management

Consult MO
If epiglottitis:
-- have the parents / carer stay with child to comfort
-- handle the child as little as possible
-- MO will organise evacuation by skilled MO with paediatric airway management
and IV insertion for IV ceftriaxone [4]
If croup:
-- symptomatic treatment as per URTI
-- for mild to moderate cases MO may advise:
prednisolone 1 mg / kg / dose stat with a second dose for the next
evening or
a single dose of oral dexamethasone 0.15 mg / kg / dose
-- for severe cases MO may advise:
0.6 mg / kg / dose (max. 12 mg) IM / IV dexamethasone
5 mL of adrenaline 1:1,000 solution via nebuliser [5]

evacuation / hospitalisation
5. Follow up
If child with croup is not evacuated / hospitalised, review next day and consult MO
if not improving
Consult MO on all presentations of stridor
Bronchiolitis
Recommend
Consult MO immediately if severe
Background
In bronchiolitis, generally the child is distressed without looking sick or toxic
A viral infection of the chest affecting infants <12 months of age
Can occur throughout the year in north Queensland (in southern Australia more
common in winter - spring)
More significant in babies < 4 months of age and those with underlying heart or lung
problems
Related topics
Acute asthma
Pneumonia
1. May present with

Cough night and day, fever, nasal discharge is often profuse

Rapid breathing, chest wheezes and crackles
Nasal flaring, grunting respirations and sternal or intercostal recession
Low O2 saturation, cyanosis (severe), apnoea

Consult MO
If severe give O2 to maintain O2 saturation >95%. If >95% not maintained consult
MO. See O2 delivery systems
567

btain complete patient history of particular importance is:

O
-- a history of URTI symptoms in a child that is basically well
-- history of chest conditions such as asthma, pneumonia
-- if wheeze is present
-- if child has stopped breathing (apnoea) for short periods of time
-- how well is the child / infant feeding
Perform standard clinical observations + O2 saturation
-- inspect for signs of respiratory distress (grunting, nasal flaring, sternal and /
or intercostal / subcostal recession)
-- inspect middle ear
-- inspect for cyanosis (lips, tongue, extremities) present in severe cases
-- auscultate chest for presence of wheezes / crackles
4. Management

onsult MO who will consider treating similar to:

C
-- acute asthma, if wheeze is prominent, however in infants bronchodilators are
unlikely to be effective
-- pneumonia, if fever and rapid breathing is prominent
-- O2 if SpO2 < 95%
If child / infant is not feeding well, fluids may be required NG or IV
5. Follow up
P
atients who are not evacuated / hospitalised should be reviewed daily
Consult MO if the patient is not improving

Consult MO on all occasions bronchiolitis is suspected
Pneumonia - child
Recommend

If baby < 3 months of age contact MO immediately

Severe dehydration is unusual in pneumonia unless there are abnormal fluid losses
from frequent diarrhoea or vomiting
Background

Children with co-existent illnesses are more at risk. Examples are bronchiolitis and
chronic lung disease e.g. due to prematurity
Related topics
Bronchiolitis
1. May present with

568
Cough dry or with sputum, fever, tachycardia

Rapid breathing, nasal flaring, grunting respirations and chest recession in infants,
cyanosis, apnoea in infants

I f severe administer O2 to maintain O2 saturation >95%. If >95% not maintained

consult MO. See O2 delivery systems
Consult MO

btain patient history including:

O
-- past episodes or complications
-- length of time signs or symptoms have been present
-- any history of asthma, bronchiolitis, chronic lung disease
-- ask if child has stopped breathing (apnoea) for short periods of time
-- ask about feeding, fluid intake and output (wet nappies, passing urine,
diarrhoea)
-- medications taken
-- O2 saturations. Note in particular respiratory rate and temperature
-- inspect the respiratory system for respiratory distress - grunting, nasal flaring,
sternal / intercostal / subcostal recession
-- auscultate the chest for air entry and any added sounds (crackles or wheezes)
-- inspect lips, tongue, extremities for cyanosis
--
inspect for signs of dehydration - moist tongue, skin elasticity (severe
dehydration is unusual)
-- inspect skin surface for any skin rash
4. Management

onsult MO using the following flow chart as a guide only, to be used in conjunction
C
with CEWT for rural and remote facilities
Child
< 3 months
Contact MO
immediately
Child
3 months - 1 yr
Child
1 - 4 yrs
Child
over 4 yrs
Resps
Resps
Resps
Resps
40 / min
30 / min
25 / min
40 / min
and / or
and / or
and / or
and / or
Resps
Resps
Resps
Resps
recession
recession
recession
recession
<40 / min
<40 / min
<30 / min
<25 / min
grunting
grunting
grunting
grunting
apnoea
apnoea
apnoea
apnoea
cyanosis
cyanosis
cyanosis
cyanosis
Moderate
or severe
pneumonia
Mild pneumonia or consider other diagnosis

569
Mild pneumonia

MO may advise:
-- chest x-ray if available
-- oral or IM antibiotics
-- antibiotics may not be indicated if typical of viral infection or bronchiolitis

Encourage rest and increase oral fluids

Treat fever with regular paracetamol to make more comfortable
Moderate / severe pneumonia

Give O2 to maintain O2 saturation >95% (if not already in place). If > 95 % not
maintained consult MO. See O2 delivery systems

Give oral fluids as tolerated

MO may advise:
-- insert IV cannula - if possible take blood cultures prior to commencing
antibiotics
-- IV fluids - it is usual to start with normal saline or Hartmanns solution; MO will
advise quantities and rate
-- to commence IV antibiotics

Evacuation / hospitalisation

Give analgesia
5. Follow up
Patients with mild pneumonia who are not evacuated / hospitalised should be
reviewed daily
C
onsult MO if the patient is not improving
See next MO clinic
C
onsult MO on all occasions pneumonia is suspected
Some children with pneumonia will require a paediatric referral
References
1.
Therapeutic Guidelines. Pharyngitis and/or tonsillitis. 2010 [cited 2011 January].
2.
Queensland Health, Expansion of Free Pertussis Vaccine Program, in Immunisation Program. 2011:
Brisbane.
3.
Therapeutic Guidelines. Pertussis. 2010 [cited 2011 March].
4.
Therapeutic Guidelines. Acute epiglottitis (supraglottitis). 2010 [cited 2011 March].
5.
The Royal Childrens Hospital. Croup (Laryngotracheobronchitis). 2009 [cited 2011 March ].
570
Acute post streptococcal glomerulonephritis (APSGN)
Recommend
Early treatment of skin infections is essential for prevention of acute post-streptococcal
glomerulonephritis (APSGN)
Background
APSGN is common among Aboriginal and Torres Strait Islander children in northern
Australia
Inflammation of the kidneys results from immune complexes forming after a group A
streptococcal infection causing blood to not filter properly and blood cells and protein
leaking into urine
Related topics
Bacterial skin infections
1. May present with

Fever, headache, malaise

Oedema (swelling) of face, feet and hands or excessive weight gain
Haematuria - urine may be dark coloured
Incidental finding on urinalysis (blood and protein in urine)
Rarely may present fitting secondary to acute hypertensive crisis

If fitting see Fitting / convulsions / seizures
103 106
56 61
111
69
114
74
> 17years
16 years
14 years
8 years
116
78
12 years
systolic
diastolic
10 years
BP upper level
of normal
6 years
Upper limits of normal BP for boys at

50th percentile for height and weight
[1]
4 years
2 years
Take complete patient history in particular:

-- any history of sore throat and length of time since present
-- any skin infections present and length of time since occurred
--
past history of APSGN, close contacts who may have similar signs or
symptoms, any measures taken to treat presenting concern
-- BP ensuring correct cuff size (APSGN is one of the few conditions where it is
important to monitor BP in a child)
-- urinalysis (for blood and protein)
Check weight
-- inspect face, hands and feet for oedema, throat looking for signs of recent
infection and palpate skin looking for signs of recent infection
-- inspect and palpate abdomen for tenderness or guarding
-- listen to chest for crackles or wheezes (fluid retention can cause heart failure)
1 year
119
80
123 128 134 136

81 82 84 87
571
2 years
4 years
6 years
8 years
10 years
12 years
14 years
16 years
> 17years
BP
upper level
of normal
1 years
Upper limits of normal BP levels

for girls at 50th percentile for
height and weight [1]
systolic
104
105
108
111
115
119
123
126
128
129
diastolic
58
63
70
74
76
78
80
82
84
84
Diagnostic features of APSGN [2]

This illness usually features oedema and / or hypertension (BP greater than levels in tables
for age and gender). Other features include:
1. Haematuria - often macroscopic but can be microscopic

A urine dipstick reading of 2+ red blood cells is adequate to define haematuria

Microscopic haematuria is defined as >10 x 106 red blood cells on microscopy
of fresh urine; red cells casts should also be seen. If microscopy is not readily
available
2. Reduced serum complement: C3 <0.7 g / L (should return to normal within 3 months)
3. Evidence of recent group A streptococcal infection. Either:

a positive skin or throat culture or,

ASOT > 200 international units or,

anti-DNase B >300 U / mL

These serological titres are often high at baseline in Aboriginal and Torres Strait
Islander community children because of repeated skin infections with GAS. So
acceptable evidence for recent GAS infection is either:
-- titres of > 2 x reference e.g. ASOT > 400 international units / mL or
-- anti-DNase B > 600 units / mL or
-- a rising titre when repeated after 10 - 14 days
4. Management

572
Consult MO who:
--
will advise to treat streptococcal infection with IM benzathine penicillin
[3] regardless of whether skin sores / sore throat are present at the time
of presentation or not; or if allergic to penicillin a full 10 day course of oral
roxithromycin [3]
-- may advise to treat hypertension and / or heart failure (initial treatment is
usually frusemide)
All cases with hypertension should be evacuated / hospitalised
Restrict fluids and salt intake (usually patient is fluid overloaded)
Notify all cases of APSGN to the Public Health Unit
DTP
(Bicillin LA)
Route of
Recommended
Form
Strength
Duration
administration
dosage
3 kg - < 6 kg 225 mg
6 kg - < 10 kg 337.5 mg
Disposable
900 mg
IM
10 kg - < 15 kg 450 mg
Stat
syringe
15 kg - < 20 kg 675 mg
20 kg > 900 mg
[1]
Schedule
if allergic to penicillin, give oral roxithromycin [3]
DTP
Route of
Recommended
Form
Strength
Duration
administration
dosage
Tablet for
50 mg
Child
suspension
Oral
4 mg / kg / dose bd
10 days
150 mg
Tablet
300 mg
Provide Consumer Medicine Information: should be taken on an empty stomach, 15 minutes before food.
Ensure full course is completed
[1]
Schedule
Roxithromycin
If treatment for hypertension and / or heart failure required, contact MO

immediately
573
5. Follow up
M
ost children will require evacuation / hospitalisation
If not evacuated / hospitalised the child requires close follow up with daily review
including weight, BP and urinalysis. If there is any deterioration, consult MO
R
efer to next MO clinic
Following discharge, most children will require at least monthly weight, BP and
urinalysis (it takes a considerable time for haematuria to resolve) following

glomerulonephritis but persisting proteinuria is of more concern. Some children
will be on antihypertensives for a period of time after the illness and will require
more frequent monitoring of BP
If urinalysis shows protein on follow up, collect urine for urine protein / creatinine
ratio
If persistent proteinuria refer to Paediatrician for follow up
Blood should be tested to check the immune system complement factor serum
complement (C3) level has returned to normal after three months; an MSU should
also be sent
Review at 3, 6, 9 and 12 months
C
onsult MO on all occasions of suspected glomerulonephritis
Most will need paediatric referral and follow up
If C3 does not return to normal refer to Paediatrician
References
1.
National High Blood Pressure Education Program Working Group on High Blood Pressure in Children
and Adolescents, The Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure
in Children and Adolescents. Pediatrics, 2004. 114 (2): p. 555.
2. Queensland Government. Acute Post-streptococcal Glomerulonephritis Control of Communicable
Diseases Protocol Manual 2009 [cited 2011 May]; Available from: qheps.health.qld.gov.au/cdpm/index/
apsgn.htm.
3.
Therapeutic Guidelines. Impetigo. 2009 [cited 2010 December].
574
Acute rheumatic fever

Recommend
In Aboriginal and Torres Strait Islander communities where there are high rates of
acute rheumatic fever (ARF) and rheumatic heart disease (RHD) treat streptococcal
throat and skin infections early
Any case of arthritis with fever in a child should be considered as possible ARF
or septic arthritis and transferred to hospital for investigation and confirmation of
diagnosis
Regular penicillin prophylaxis is critical to prevent recurrences of ARF, which can
lead to the development or worsening of RHD
Background
ARF is an auto-immune response to bacterial infection with group A Streptococcus
(GAS) [1] in the throat (and possibly the skin); it affects the heart, joints, nervous
system and skin
Aboriginal and Torres Strait Islander Australians living in rural or remote settings are
known to be at high risk. Those living in urban settings, Maori and Pacific Islander
people and, potentially immigrants from developing countries also may be at high
risk [2]
ARF is predominantly a disease of children aged between 5 and 14 years although
recurrent episodes may continue well into the fourth decade of life [1]
Patients with recurring ARF have a higher risk of developing RHD
RHD is a chronic condition resulting from scarring and deformity of the heart valves
following ARF
Related topics
Upper respiratory tract infection - adult
Bone and joint infections - child
Acute rheumatic fever and rheumatic heart disease prophylaxis
1. May present with

Fever and malaise

Painful tender swollen joints. Symptoms classically seen to progress from one
joint to another (migratory polyarthritis) however only one joint may be affected
(aseptic monoarthritis). Any joint can be involved but most commonly affects the
large joints of the limbs - knees, ankles, elbows
Abdominal pain
Inability to weight-bear or walk unaided
Uncontrollable jerky movements of the trunk, face and / or limbs (Sydenhams
chorea), that disappear when asleep
Skin rash. This is rare, but highly suggestive of ARF (can be difficult to see in
dark skinned people)
Small nodules over bony areas such as elbows and knees; again rare
History of a sore throat or skin infection within the previous 2 - 3 weeks
Breathlessness (if cardiac involvement), chest pain
Abnormal heart sounds
575

Obtain complete patient history including:

-- past episodes of ARF / RHD or previous symptoms suggesting history - ask
whether benzathine penicillin injections have been ordered previously / have
they been received regularly?
-- recent history of sore throat, painful joint or skin infections and whether treated
-- measures taken to treat presenting symptoms
-- current medications
-- O2 saturations
-- inspect throat for signs of infection
-- inspect and palpate all skin surfaces for signs of skin infection and pink skin
rash with definite rounded borders, occurring mainly on the trunk, never on
the face; blanches under pressure (erythema marginatum)
-- inspect and palpate joints for swelling and tenderness and presence of small
nodules (pea sized), painless, overlying bony prominences
-- auscultate the heart to determine whether there is an audible murmur
-- look for indications of heart failure - increased HR or irregular (heart block),
increased respiratory rate, basal crackles in chest, liver enlargement, ankle
oedema
Diagnostic criteria ARF [1]

Diagnosis of ARF requires a combination of clinical and laboratory indicators and

laboratory evidence of a recent group A streptococcal (GAS) infection
An experienced Medical Specialist should review the clinical presentation with
pathology results to confirm the diagnosis and determine ongoing management.
All suspected cases of ARF should be referred to a tertiary facility to have the
diagnosis confirmed and to ensure adequate workup for appropriate long-term
management
ARF is a notifiable condition in Queensland - contact the ARF / RHD Register
in the area and the Public Health Unit
Note: Unlike most other notifiable diseases, ARF is not based solely upon a
laboratory diagnosis, and therefore notification has to be done by the clinician /
Health Care Worker
Diagnostic criteria RHD

576
Diagnosis of RHD is based on the degree of damage to the heart

This is confirmed through the use of echocardiogram by an experienced clinician
Serial echocardiography plays a critical role in diagnosis and management
Australian guidelines for the diagnosis of Acute rheumatic fever in high risk groups [1]
For an initial episode of ARF to be confirmed there must be 2 major manifestations or 1 major and 2
minor manifestations, plus evidence of a recent group A streptococcal infection.
Since Sydenhams chorea can occur after all other signs and symptoms have resolved, it can be used
alone to confirm the diagnosis
A recurrent episode of ARF (known past ARF or chronic RHD) requires 2 major or 1 major and 2 minor
or 3 minor manifestations plus evidence of a recent GAS infection
Major manifestations
Minor manifestations

Polyarthritis or aseptic monoarthritis or
History of fever or presenting fever >38C
polyarthralgia. Usually migratory i.e. finishes
Laboratory / other clinical findings:
in one joint, begins in another
-elevated acute phase reactants - ESR

Chorea - strange jerky movements of the
30 mm/hr or CRP 30 mg / L
trunk and / or limbs which the patient cannot
-prolonged PR interval on ECG
control

Carditis - (including subclinical evidence of
rheumatic valve disease on echocardiogram)

Erythema marginatum - pink skin rash with
definite rounded borders, occurring mainly
on the trunk, never on the face, and blanches
under pressure

Subcutaneous nodules - small painless pea
sized nodules over bony prominences (e.g.
elbows)

Carditis identified on echocardiogram may
be included as a major manifestation [1]
Supporting evidence of group A streptococcal infection

Group A streptococcus isolated on throat culture

Elevated or rising streptococcal antibody titre. See link for age related levels www.heartfoundation.
org.au/Professional Information/Clinical Practice/ARF RHD/Pages/default.aspx
These serological titres are often high at baseline in Aboriginal and Torres Strait Islander community
children because of repeated infections with GAS. So acceptable evidence for recent GAS infection are
either:
-- titres of > 2 x reference e.g. ASOT > 400 IU / mL or Anti-DNase B > 600 U / mL or
-- a rising titre when repeated after 10 - 14 days
4. Management

Consult MO who will likely advise:

-- evacuation / hospitalisation - confirmation and management of ARF should
occur in hospital (a wrong diagnosis either positive or negative will have
serious consequences)
-- blood for FBC, ESR, C-reactive protein (CRP), ASOT, anti-DNase B and
streptococcal serology
-- swab throat and any skin sores
Take blood cultures if temperature 38C
Record ECG
Consider chest x-ray and echocardiogram
Provide pain relief as required. Use paracetamol for pain and fever. Do not give
aspirin or non-steroidal anti-inflammatory drugs (NSAID) until the diagnosis is
confirmed - these may cause joint symptoms to disappear and complicate the
diagnosis
577
Treatment of ARF is based on the eradication of GAS infection and management

of symptoms:
-- IM benzathine penicillin to eliminate streptococci (even if group A streptococci
not isolated on culture)
-- oral penicillin should not normally be used, as completion of 10 days of
treatment cannot be guaranteed
(Bicillin LA)
DTP
IHW / IPAP
Route of
Recommended
Form
Strength
Duration
administration
dosage
Schedule
Disposable
syringe
Stat
Adult / child 20 kg
900 mg
Management of associated emergency: as for severe allergic reactions. See Anaphylaxis
[1] [2]

900 mg
Child < 20 kg
450 mg
IM
If reliably documented allergy to penicillin treat with erythromycin [1]

If penicillin allergy not reliably documented arrange for testing in hospital
DTP
IHW / IPAP
Schedule
Form
Strength
Capsule
250 mg
Suspension
200 mg / 5 mL
Erythromycin
Route of
administration
Recommended
dosage
Duration
500 mg bd
Oral
10 days
Provide Consumer Medicine Information: take with food

[1]
5. Follow up
Assign an individualised management plan based on ARF and absence or
578
presence of RHD
Place person on Recall Register and monitor closely
Recommended duration of secondary prophylaxis.
-- the most effective regime for continuous prophylaxis is a 4 weekly injection

of benzathine penicillin - may be increased to 3 weekly, see current edition
of NHFA guideline www.heartfoundation.org.au
-- consult MO for antibiotic prophylaxis for procedures expected to produce
bacteraemia
Provide education and support to patient and family. Resources available include;
Strong Heart, Strong Body books, DVD and reminder cards (from Tropical Public
Health)
Contact the ARF / RHD Control Program (arfregister@health.qld.gov.au) in your
district or Public Health Unit for help, even if ARF only suspected
Antenatal patients with RHD may deteriorate because of the increased cardiac
workload during pregnancy. Pregnant women known to have RHD need to be
assessed early in pregnancy and monitored closely with 2 weekly follow up.
The woman will also need antibiotic cover if prolonged labour and / or ruptured
membranes [1]
Primary prevention:
-- have a low threshold for treating throat infections with penicillin in Aboriginal
and Torres Strait Islander and Pacific Islander children. See URTI - child /
URTI - adult
-- reduce the prevalence of scabies and impetigo
Give influenza and pneumococcal vaccines according to the current edition of the
NHMRC Australian Immunisation Handbook. See Immunisation program
Consult MO on all occasions of suspected ARF

Consult MO for anticoagulation therapy / INR range
Refer to Paediatrician within 3 months of diagnosis
References
1.
National Heart Foundation, RF/RHD Guideline Development Working Group, and Cardiac Society of
Australia and New Zealand, Diagnosis and management of acute rheumatic fever and rheumatic heart
disease in Australia: An evidence based review. 2006, National Heart Foundation Australia.
2.
Therapeutic Guidelines. Rheumatic fever in children. 2010 [cited 2011 January].
579
Ear problems
Assessment of the ear

History

Obtain a complete patient history

Of particular note is environmental history e.g. dusty, passive smoking or smoker
Social history
Surgical history, medical history
Has the patient been swimming?
Of particular importance are problems with hearing, speech and language
Does the patient have any pain? Is there pain on movement of the pinna? Describe
pain, how long has the patient had the symptoms? Young children may not be able to
localise their pain but parent may notice they are unsettled or pulling at an ear
Is the ear itchy?
Is this the first episode? Note the number of past episodes
Is there a history of URTI? How many?
Is the person under the care of ENT physician? Audiologist?
Is there a history of AOM with perforation?
Have any measures been used to treat the ear?
Examination

Examine ear at eye level

Position infant / toddlers on parent / carers knee. Older child can stand and adult sit
Often very painful - approach gently
Outer ear

Inspect the external ear - is there any sign of inflammation?

Palpate the ear - is it warm to touch? Is there pain on moving the pinna?

Palpate behind the ear? Is the mastoid bone swollen? hot?

Palpate the occiput, around the ears, both sides of the neck for lymph glands

Is there auricular tenderness? pain? tenderness on palpation of mastoid?
Ear canal

Inspect the ear canal for discharge, redness / swelling, fungal membrane or debris,
lumps or bony growths, foreign body, extruding grommets, wax, fluid

If pain levels allow, inspect the ear canal for inflammation, exudates, lesions or foreign
bodies
Tympanic membrane (ear drum)

Colour of drum - is it normal - transparent and shiny, or dull?

Cone of light - right ear at 5 oclock, left ear at 7 oclock

Handle of malleus - right ear 1 oclock, left ear 11 oclock

Is the ear drum intact? bulging? retracted?

Is there fluid or air / fluid or bubbles behind the ear drum?
Right
580
Left
Ear problems
Clean the ear using tissue spears until all pus has been removed and the drum and
perforation can be seen. Document the size and position of perforation on a diagram
in the case notes. If an unsafe perforation (in the attic region) of the ear drum is
found consult MO immediately
Attic perforation - unsafe perforation
Safe perforation
Related systems

Nose and throat

Examine the nose and throat - is there any discharge from nose? describe
Chest

Auscultate the chest for air entry and any added sounds (crackles or wheezes)

Note other injuries if present e.g. cause of traumatic rupture of the ear drum
Hearing screening and assessment commences from birth across the life span. Refer to
current edition of Chronic Disease Guidelines available at www.health.qld.gov.au/cdg for
procedures in performing:

Otoscopy

Audiometry to assess hearing level

Tympanometry to test middle ear function
If a person is under the care of an Ear Nose and Throat Specialist or Audiologist ensure
they are up to date with appointments / care
581
Ear problems
Ear infections
Recommend
Language and speech develop in the 0 - 5 year age group. Assessment for possible
middle ear disease, hearing impairment and speech and language problems should
be a routine part of the primary care of children aged 0 - 5 years
Prevention of otitis media through [1]:
-- encouraging family or care giver to present child for treatment early if there are
features of otitis media. Informing family of risk if child is in a high risk group
(includes Aboriginal and Torres Strait Islander children)
-- informing family and carers that onset of otitis media can occur within the first
months of life. Baby may have pain, irritability, fever or ear discharge
-- there is an increased risk of acute otitis media during respiratory infections
-- the family or care giver should be advised that ear pain may be absent and that
regular clinic attendance for ear examinations is recommended
-- personal hygiene - childrens hands and faces should be washed. Transmission
of bacteria causing otitis media is often from other childrens hands
-- breastfeeding for at least three months reduces the risk of otitis media and should
be encouraged
-- smoke exposure is a risk for otitis media in children. Adults should be encouraged
to quit smoking or smoke outside away from children
-- swimming should not be discouraged unless it is known to be associated with
new infections in that person
-- full immunisation; 23 valent pneumococcal vaccine (Pneumovax 23) for children
4 - 5 years of age who are at risk of pneumococcal infections
Definitions [1]

Acute otitis media (AOM) - presence of fluid behind the ear drum plus at least one of
the following: bulging ear drum, red ear drum, recent discharge of pus, fever, ear pain
or irritability

Recurrent acute otitis media (rAOM) - the occurrence of three or more episodes of
acute otitis media in a six month period

Otitis media with effusion (OME, glue ear) - presence of fluid behind the ear drum
without any symptoms or signs of acute otitis media

Acute otitis media with acute perforation (AOM with perforation less than 6 weeks) discharge of pus through a perforation (hole) in the ear drum within the last six weeks

Chronic suppurative otitis media (CSOM discharging more than 6 weeks) - persistent
discharge of pus through a perforation (hole) in the ear drum for at least six weeks
despite appropriate treatment for acute otitis media with perforation
582
Ear problems
Acute otitis media (AOM)
Non-discharging painful ear
Recommend
Consult MO immediately if child is < 3 months of age, who is sick or hot, or meets
any of the other criteria outlined at beginning of paediatric section
All children with AOM should be reviewed after four to seven days of treatment or
earlier if deterioration [1]. A second review should take place after completion of
therapy [1]
Health clinics have targeted hearing health programs to focus on day care and pre
school children where intervention may prevent ear damage and hearing loss
Personal hygiene in children - washing hands and face is important
Background
In some rural and remote Aboriginal communitites complications of otitis media
are much more common. They include tympanic membrane perforations, CSOM,
OME and mastoiditis. This is the reason that antibiotics are recommended in these
children, while in low risk populations the advantage of antibiotics is small
Related topics
Pneumonia
Acute asthma
Bronchiolitis
1. May present with

A history of acute onset of signs and symptoms

Young child may present with irritability, disturbed sleep, pulling at ears, sometimes
vomiting and diarrhoea
Fever or upper respiratory symptoms
Pain clearly originating from the ear
Some children will not have pain but a red bulging drum is found on routine exam


Obtain a complete patient history. See Assessment of the ear

Perform standard clinical observations
Perform physical examination. See Assessment of the ear Look for inflammation
with a red bulging tympanic membrane and loss of light reflex
4. Management

Provide adequate and regular analgesia

onsult MO if child:
C
-- < 3 months of age, who is sick or hot
-- temperature over 38 C or below 36C
-- has any rash, increased respiratory rate or respiratory distress or meets any
of the other criteria as outlined at beginning of paediatric section - this child
needs to be managed as a septic infant
Spontaneous resolution of AOM is unlikely in high risk populations therefore if not
allergic to penicillin treat with amoxycillin [1]
583
Ear problems
Talk to the family about the need to complete the full course of antibiotics and to
return at 4 - 7 days for the ear to be checked
Give or help to give the first dose in the clinic and ensure the family know the right
dose to give. If family do not have a fridge at home they may have to return to the
health service for medicine each day
DTP
Route of
Recommended
Form
Strength
Duration
administration
dosage
250 mg
Capsule
Adult and child
500 mg
Oral
7 days
125 mg / 5 mL
Suspension
to a max. of 1 g bd
250 mg / 5 mL
[4] [6]
Schedule
Amoxycillin
I f parent or Health Care Worker think it will be difficult to comply with oral antibiotics
or if the child has significant diarrhoea or vomiting, treat with IM procaine penicillin
with the option to return to oral antibiotic once vomiting settles
DTP
Route of
Recommended
Duration
Form
Strength
administration
dosage
Adult
1.5 g daily
Disposable
5 days
1.5 g
IM
Child
syringe
50 mg / kg / dose daily
to a max. of 1.5 g daily
[3] [4]
Schedule
584
Procaine penicillin
If allergic to penicillin, treat with roxithromycin
Ear problems
DTP
Route of
Recommended
Form
Strength
Duration
administration
dosage
150 mg
Adult
Tablet
300 mg
300 mg daily
Oral
10 days
Child
Tablet for
50 mg
4 mg / kg / dose bd
suspension
Ensure course is completed
[5]
Schedule
Roxithromycin
5. Follow up
R
eview the patient in 4 - 7 days
If not improving consult MO who may consider alternative or increased dose of

antibiotic
At next MO visit. If child not improved needs weekly review. Child < 2 years of
age may need many weeks of antibiotics [6]
Review after completion of treatment at the 1 week mark
Ask family about childs hearing, speech development, behaviour, school progress.
If there are concerns about any of these refer for formal hearing assessment if not
done recently
To prevent recurrent otitis media and transmission of bacteria to other children
encourage personal hygiene in children - washing hands and face
Breathe, blow and cough (BBC) program is targeted at school aged children
Review at 3 months to identify those with chronic disease [1]
C
onsult MO as above
If otitis media is recurrent (more than 3 episodes in 6 months or more than 4 in 12
months) the MO may consider antibiotics for prophylaxis [1]
ENT specialist for those with frequent painful AOM
585
Ear problems
Otitis media with effusion (OME)

Painless non discharging ears, glue ear
Recommend
Review children with bilateral OME at 3 monthly intervals and refer if required
Health clinics have targeted hearing health programs to focus on day care and
pre school children where intervention may prevent ear damage and hearing loss.
Personal hygiene in children - washing hands and face and keeping face clear of
nasal discharge is most effective
Provide full immunisation
Background
OME is diagnosed if thick fluid persists in the middle ear usually after AOM
OME results in thick glue like material filling the middle ear which may take many
months to resolve. It is important because children with OME will have impaired
hearing. If hearing is impaired for a significant length of time especially at the critical
age of language learning in the first 5 years it may result in significant long term
disability
Decongestants and antihistamines are not recommended [7]
Steroids are not recommended [1] but inhaled steroids may be trialed in children
where significant nasal obstruction, sneezing etc. suggests allergic rhinitis
Related topics
Acute otitis media
1. May present with

Usually is asymptomatic
Parents may be concerned about the childs hearing
Diagnosis may also be suspected at routine ear examination, in a child being
followed up after AOM, or in a child referred for medical assessment because of
hearing impairment on testing
Child may have:
-- past history of recurrent otitis media
-- concerns about speech or language development
Reported decrease in hearing
Reported poor hearing leading to learning difficulties


586

Perform physical examination. See Assessment of the ear
-- the following may be noted on examination
air / fluid level, bubbles behind the ear drum
retraction of ear drum
limited or absent movement of the ear drum with pneumatic otoscopy.
This is the best way to diagnose - refer to audiology / MO to perform.
Diagnosis is confirmed by tympanometry which shows a type B (stiff ear
drum) pattern
Ear problems
4. Management

Give amoxycillin
Arrange for audiology if there are concerns about hearing or speech or OME is
persistent for > 3 months
Refer to ENT specialist:
-- if hearing test shows moderate impairment in both ears for more than 3
months
-- if there is speech delay and effusion persists more than 3 months or
-- if there is more severe hearing impairment or concerns about the appearance
of the drum
Encourage personal hygiene in children - washing hands and face and keeping
face clear of nasal discharge
Breathe, blow, cough (BBC) program is for school aged children
Check immunisation status particularly Pneumovax and perform catch up

immunisation if required
DTP
Route of
Recommended
Duration
Form
Strength
administration
dosage
250 mg
Capsule
Adult and child
500 mg
Oral
14 days
125 mg / 5 mL
Suspension
to a max. of 1 g bd
250 mg / 5 mL
[4] [6]
Schedule
Amoxycillin
If not resolved may need a further 14 days to a total of 28 days. If allergic to

amoxycillin see Antibiotics for acute otitis media
5. Follow up
3
monthly
If OME persists for > 3 months arrange - audiometry and tympanometry
See the current edition of the Chronic Disease Guidelines available at:
www.health.qld.gov.au/cdg
N
ext MO visit
Refer to ENT specialist if:
-- any concerns about hearing or speech

-- problem remains longer than 3 months
-- antibiotic therapy has failed
-- has severe retracted ear drum
If there is speech delay refer to Speech Pathologist
If hearing is impaired in school children make sure the school is informed, with
parental consent, as the teacher can use measures to assist child
587
Ear problems
Acute otitis media with acute perforation
Discharging ear for less than 6 weeks - may be painful

Recommend
If seen in the first days treat see Acute otitis media
Always follow up to ensure perforation has healed
If discharge does not resolve by 14 days add ciprofloxacin drops and increase the
dose of oral amoxicillin
If discharge continues through an established perforation after 6 weeks of treatment
treat See Chronic suppurative otitis media (CSOM)
You may need to clean the discharge from the ear before you can see the drum, you
can usually do this by gently cleaning with a tissue spear
Background
Infection behind the eardrum may cause the drum to rupture
AOM with perforation occurs mainly in the first 18 months of life and effective
treatment will dramatically reduce the incidence of chronic suppurative otitis media
(CSOM) [1]
Ciprofloxacin drops are restricted on the Pharmaceutical Benefits Scheme to
treatment of chronic suppurative otitis media:
-- in an Aboriginal or a Torres Strait Islander person aged 1 month or older
-- in a patient less than 18 years of age with perforation of the tympanic membrane
-- in a patient less than 18 years of age with a grommet in situ
If not in an S100 community MO will need to obtain authority script
Related topics
Acute otitis media
Cleaning technique for ears with
Chronic suppurative otitis media (CSOM) discharge
1. May present with

Presents with onset of ear discharge for < 6 weeks

Child may often have symptoms of acute otitis media - pain, fever



Document length of time perforation has been present
Perform physical examination. See Assessment of the ear:
-- for otoscopic examination - you may need to clean the discharge from the ear
before you can see the drum, you can usually do this by gently cleaning with
a tissue spear
-- document the size and position of perforation on a diagram in the case notes
4. Management

588
Give analgesia if required

If not allergic to penicillin treat with amoxycillin
If the discharge has been present for > 14 days the MO may increase the dose of
amoxycillin and order use of ciprofloxacin drops
If the discharge has been present for >6 weeks the condition is chronic suppurative
otitis media (CSOM). Treatment is as for CSOM. Oral antibiotics are not indicated
Ear problems

DTP
Route of
Recommended
Form
Strength
Duration
administration
dosage
250 mg
Capsule
Adult and child
500 mg
Oral
7 days
125 mg / 5 mL
Suspension
to a max. of 1 g bd
250 mg / 5 mL
Schedule
Amoxycillin
[4]
If parent or Health Care Worker thinks it will be very difficult to comply with oral
antibiotic treatment or if the child has significant diarrhoea or vomiting, treat with
IM procaine penicillin with the option to return to oral antibiotic once vomiting
settles
DTP
Route of
Recommended
Duration
Form
Strength
administration
dosage
Adult
1.5 g daily
Disposable
5 days
1.5 g
IM
Child
syringe
50 mg / kg / dose
to a max. of 1.5 g daily
[4]
Schedule
Procaine penicillin
589
Ear problems
If allergic to penicillin and has perforation for less than 6 weeks treat with
roxithromycin
DTP
Route of
Recommended
Form
Strength
Duration
administration
dosage
150 mg
Adult
Tablet
300 mg
300 mg daily
Oral
10 days
Child
Tablet for
50 mg
4 mg / kg / dose bd
suspension
Ensure course is completed
[5]
Schedule
Roxithromycin
If discharge present for longer than 14 days MO may add ciprofloxacin drops
Ciprofloxacin hydrochloride
DTP
ear drops
IHW
Ciprofloxacin hydrochloride ear drops must be ordered by MO / NP. MO / NP note restrictions
Authorised Indigenous Health Workers can only administer on MO / NP order
Route of
Recommended
Form
Strength
Duration
administration
dosage
Ear drops
Instil 5 drops in
Until the ear is dry
Ear drops
Topical
(0.3%)
affected ear bd
or 9 days
Provide Consumer Medicine Information: if not drying in 2 weeks check with family on ability to clean and
instil drops
Administration tip
-- The patient should be sitting or lying down with the affected ear upwards
-- Once the drops have been instilled maintain position for 30 - 60 sec.
-- Apply tragal pressure (pressing several times on the flap of skin in front of ear canal) after the drops
have been instilled to assist the drops through the perforation
[8]
Schedule
5. Follow up
eview the patient in 2 days

R
If not improving consult MO
Weekly review until the signs of AOM with perforation have resolved
If failing to resolve discuss with parents / carer - explore if the child is being
given antibiotics. Is the child spitting it out or vomiting afterwards? Consider daily
treatment in the clinic or use IM procaine penicillin
If the discharge continues after 6 weeks of treatment manage See Chronic
suppurative otitis media (CSOM)
If perforation heals review in 6 weeks:
-- inspect ear drum
-- perform hearing assessment - audiometry and tympanometry
-- advise to prevent recurrent otitis media with good personal hygiene in children
-- Breathe, blow, cough (BBC) program is targeted at school aged children

590
Ear problems
6.
Referral / consultation
C
onsult MO as above
If concerns about hearing, speech, language development or the child has had
recurrent AOM refer for audiology
Chronic otitis media
Discharging and non-discharging
Chronic suppurative otitis media (CSOM)

Ear has been discharging for more than 6 weeks
Recommend
Consult MO immediately if unsafe perforation of the eardrum found (in the attic
region). See Assessment of the ear
Use antibiotic ear drops with tissue spears (dry mopping) to reduce the production
of pus [1]
Document the duration of ear discharge and size and position of perforation [1]
Treat discharging ears actively
Background
CSOM is diagnosed in children who have discharging ears for more than 6 weeks [1]
Related topics
Acute otitis media with perforation
Chronic suppurative otitis media
(CSOM)
Cholesteatoma
Cleaning technique for ears with chronic
discharge
1. May present with

Intermittent and continuous ear discharge often associated with poor hearing
leading to learning difficulties

onsult MO if perforation found in attic region (unsafe perforation) of the ear

C
drum See Assessment of the ear


Document length of time discharge has been present
Perform physical examination See Assessment of the ear:
-- clean the ear using tissue spears until all pus has been removed and the
drum and perforation can be seen
4. Management

Dry mopping twice daily until tissue is dry, followed by ciprofloxacin ear drops
twice per day
1. Ciprofloxacin ear drops
2. Use Sofradex ear drops only if ciprofloxacin drops not available
Consult MO for ciprofloxacin order
For removal of pus and debris from ear canal See Cleaning techniques for ears
with chronic discharge
591
Ear problems
I n young children it may be difficult for family members to adequately clean the
ears and instil the drops - clinic staff are advised to do this daily for 7 days
Encourage personal hygiene in children - washing hands and face
Avoid swimming or immersing head under water
Consult MO if perforation found in attic region (unsafe perforation) of the ear drum
Ciprofloxacin hydrochloride
DTP
ear drops
IHW
Ciprofloxacin hydrochloride ear drops must be ordered by MO / NP. MO / NP note restrictions
Authorised Indigenous Health Workers can only administer on MO / NP order
Route of
Recommended
Form
Strength
Duration
administration
dosage
Instil 5 drops in
Until the ear is dry or
Ear drops
0.3 %
Topical
affected ear bd
9 days
Administration tip
The patient should be sitting or lying down with the affected ear upwards
Once the drops have been instilled maintain position for 30 - 60 secs
Apply tragal pressure (pressing several times on the flap of skin in front of ear canal) after the drops
[8]
Schedule
or
Sofradex ear drops

DTP
Schedule
4
(Dexamethasone 0.5 mg / Framycetin Sulphate
5 mg / Gramicidin 0.05 mg / mL)
Route of
Recommended
Form
Strength
Duration
administration
dosage
Until the middle ear has
been free of discharge
See
Ear drops
Topical
3 drops qid
for at least 3 days
above
Do not administer longer
than 7 days
Provide Consumer Medicine Information: evidence of ototoxicity - limit treatment to no longer than 7
days
Administration tip
The patient should lie with their head on a pillow for several minutes after administration to allow the
drops to gravitate to the bottom of the ear canal
[2]
592
Ear problems
5. Follow up
Children < 5 years of age, review and treat daily for 7 days. If not drying in older
children consider daily treatment in the clinic. Suction under direct vision is very
useful to clear the ear if clinics have the equipment and staff have experience and
training
If not improving consult MO
Teach patient / carer cleaning technique and instillation of drops
See next MO clinic
Review weekly thereafter until ear is dry
If the ear is still discharging, consult MO
When the ear dries review at 3 months
To prevent recurrent otitis media encourage personal hygiene in children - washing
hands and face
Breathe Blow Cough (BBC) program is targeted at school aged children
F
or hearing assessment - audiometry and tympanometry when ear dry
With education staff
Consult MO as above including a presentation with perforation in the upper drum
(attic). Note unsafe perforation attic retraction or suspicion of cholestoma will

need urgent referral to ENT
Refer to ENT specialist:
-- if ear continues to discharge for 4 months
-- unsafe perforation
593
Ear problems
Cleaning techniques for ears with chronic discharge

Suction

Suction under direct vision is the most effective technique but this requires special
equipment and training
Dropper method
Tissue spear method (dry mopping)
Topical antibiotics and other ear drops with dry mopping
The ear canal can be cleaned by irrigating with clean water using an eye dropper
An eye dropper uses a small volume of wash solution at low pressure and is therefore
relatively safe in unskilled hands

Eye droppers are cheap and easy to obtain and to clean for use at home
Equipment

A clean eye dropper and bulb. This can be washed with soap and water or an antiseptic

A clean container of clean water (sterile or cool boiled) (some rainwater tanks may be
contaminated)

Clean container for the dirty water from the ear
Technique
1. The patient should be sitting or lying down with the affected ear upwards
2. Using a clean dropper filled with clean water, squirt water into the discharging ear.
Only the tip of the dropper needs to be in the canal. Without withdrawing the dropper
and just by releasing the bulb, suck the water and pus back into the dropper
3. Discard the contents of the dropper into the container for dirty water. Do not squirt the
water in and out of the ear. When all the pus has been washed out of the ear, the water
sucked back into the dropper is clear
4. Repeat the above steps until there is clean return from the ear
5. Dry the ear canal using tissue spears (see details)

This can safely be done by a child on their own or by the parent. It should be done
whenever the ear discharges. The tissue paper actively absorbs the moisture

In the management of chronic suppurative otitis media, the tissue spear method should
be used in conjunction with regular eye dropper irrigation by the Health Care Worker
Technique
1. Make a spear by twisting corner of tissue paper
2. Insert into ear gently, twisting slowly
3. Stop when child blinks
4. Leave in place for 30 seconds then remove and repeat until tissue tip is dry
5. Perform at least twice per day until the ear is dry

594
he patient should be sitting or lying down with the affected ear upwards
T
Clean and dry the ear canal as per dropper method and tissue spears
Instil the ear drops
Apply tragal pressure (pressing several times on the flap of skin in front of ear canal)
after the drops have been instilled to assist the drops through the perforation [1]
Keep the patient in position for several minutes
Use of cotton wool as a plug just soaks up the medication. Let excess run out
Ear problems
Ear discharge in the presence of grommets

1. May present with

History of insertion of grommet in one or both ears

Discharge of pus from a grommet, fever, URTI, related to water immersion



Perform physical examination. See Assessment of the ear plus:
-- clean the ear using tissue spears until all pus has been removed and the
drum and perforation can be seen
4. Management

onsult MO for antibiotic order

C
Treat as per Acute otitis media with perforation
5. Follow up
As per MO instructions

Advise no swimming. If this is not possible in a hot tropical climate, ear plugs with
a swimming cap for swimming are recommended for children with grommets.
Effective ear plugs can be custom built or made from silicon putty, cotton wool
with Vaseline, or Blu-Tack
As above
Cholesteatoma
Recommend
Be aware of cholesteatoma when performing all otoscopic examinations

Cholesteatoma is treated surgically and success is highly dependent on early
recognition and the extent of the lesion
Background
Most patients who acquire cholesteatomas have a history of recurrent acute otitis
media and / or chronic middle-ear perforation
Patients with a family history of chronic middle ear disease and / or cholesteatoma
are at increased risk [9]
Related topics
Acute otitis media with perforation
1. May present with
If diagnosed early may have no symptoms. Otherwise may present with:

Dizziness, ache behind the ear especially at night

Muscle weakness of the face, foul odour from the ear

White mass behind intact ear drum on otoscopic examination

New onset of hearing loss in a previously operated ear

History of chronic perforation of the ear drum
595
Ear problems

Consult MO for referral to Paediatrician or ENT Specialist


-- on otoscopic examination - white mass behind an intact ear drum:
a deep retraction pocket with or without granulation and skin debris
focal granulation on the surface of the drum, especially at the periphery
perforation in the attic region (unsafe perforation)
4. Management

If suspected refer ENT Specialist
5. Follow up

If confirmed, surgical treatment is required
Refer to Paediatrician and / or ENT Specialist
Acute mastoiditis
Recommend

Urgent referral to hospital with paediatric and ENT Specialist for management
Background

Mastoiditis is inflammation in the mastoid air cells and typically occurs after acute
otitis media
Related topics
Acute otitis media
Ear wick technique for otitis externa

1. May present with

As per Acute otitis media; in addition:

-- may have systemic features - with fever and rigors
-- pain swelling and tenderness above and behind the ear over the mastoid
(bony prominence behind the ear)
-- the ear may be pushed away from the head by swelling of the mastoid area
-- dizziness or tinnitus (ringing in the ears) may be present

Consult MO immediately

596

Perform physical examination. See Assessment of the ear plus:
-- palpate behind the ear. Palpate the mastoid tip noting any tenderness
-- is the mastoid bone swollen and / or hot - describe
-- palpate the occiput, around the ears, both sides of the neck for lymph glands
Ear problems
4. Management

onsult MO who will arrange:

C
-- urgent referral to hospital with Paediatric and ENT Specialist for management
-- discuss antibiotic regime with Infectious Disease Specialist
Staff may be required to give first dose of antibiotics prior to evacuation
5. Follow up

As per post discharge orders

Urgent referral to Paediatrician and ENT Specialist
Otitis externa
Swimmers ear or tropical ear

Recommend

In the acute phase with inflammation the canal should not be syringed. However in
established otitis externa aural toilet may be indicated to remove debris. Consult MO
Related topics
Earwick techique for otitis externa
1. May present with

Infection of the skin of the ear canal; may be acute or chronic

Varying degrees of canal redness and peeling, debris collects in the canal, ear
pain (sometimes severe) or itch
Tender, swollen outer ear and ear canal; very painful if outer ear manipulated,
discharge not always present
Ear blockage, deafness or fullness, a foreign body may be present



-- often very painful on movement of the pinna - approach gently
4. Management

onsult MO if fever, cellulitis or enlarged pre / post auricular lymph nodes

C
Give analgesia
entle cleaning with dry mopping to keep the ear canal dry, then installation
G
of drops or in severe cases, a wick soaked with sofradex or cortocosteriod +
antibiotic ointment to remove pus and debris. The ear should be kept dry for at
least two weeks after treatment [10]. Advise not to swim until healed
597
Ear problems
Ear wick technique for otitis externa

Materials

Flumethasone 0.02% + clioquinol 1% or Sofradex drops or triamcinolone compound
(Kenacomb) ointment

Ribbon gauze approximately 10 cm in length for an adult

Non-toothed forceps e.g. nasal packing forceps
Technique
1. The ribbon gauze is laid along a wooden tongue depressor and is impregnated with
drops or ointment along its length
2. The end of the impregnated strip is grasped with the forceps and is gently fed into
the ear canal, 1 cm at a time. The ear canal is straightened by gently pulling the ear
backwards and upwards in an adult or backwards in a child. The ear canal is 2.5 cm
long in an adult
3. If there is too much ribbon, the excess is trimmed with scissors. Once in place, the
patient should be comfortable. If the patient has increased pain, the wick should be
removed
Sofradex ear drops
DTP
Schedule
4
(Dexamethasone 0.5 mg / framycetin
sulphate 5 mg / gramicidin 0.05 mg / mL)
Route of
Recommended
Duration
Form
Strength
administration
dosage
Ear drops See above
Topical - drops
3 drops tds
7 days
Topical - earwick
Soaked gauze
Wick left in canal for 2 days

then review

Administration tip - drops
Administration tip - earwick
Remove the wick using forceps. Inspect and clean the ear. Reinsert if required
[10]

598
or
Ear problems
Flumethasone 0.02% + clioquinol

DTP
1%
Route of
Recommended
Form
Strength
Duration
administration
dosage
Schedule
Ear drops
As above
Topical - ear wick
Soaked gauze
The wick is left in the canal

for 2 days then review


[10]
or
Triamcinolone compound
DTP
(Kenacomb)
Route of
Recommended
Duration
Form
Strength
administration
dosage
Triamcinolone 0.1 %
Neomycin 0.25 %
Ointment
The wick is left in the canal
Ointment Gramicidino 0.025 % Topical - ear wick
soaked gauze
for 2 days then review
Nystatin 100,000
units / g
[4]
Schedule
5. Follow up
R
eview in 2 days and in 1 week
Advise not to swim and keep ears dry until healed
Next MO visit if ear canal not back to normal at 1 week, or if recurrent
O
titis externa can become chronic or recurrent, especially in hot humid climates
General prevention involves keeping the ear canal dry and protected by a lining
of wax. Use drying ear drops e.g. Aqua-ear / Vosol, after swimming and
showering will help prevent recurrence
Advise patient to keep foreign objects such as cotton buds out of their ears;
remove built-up wax, if necessary with e.g. Waxsol
Patients with recurrent infections often have a chronic fungal infection present.
This infection may be seen with fungal hyphae looking like wet blotting paper or
dry like cotton wool or the infection may be suspected even if the canal looks
clean and normal but is itchy
Suction ear toilet followed by Sofradex or flumethasone 0.02% + clioquinol
1% or triamcinolone compound (Kenacomb) ointment to prevent further acute
bacterial infection
599
Ear problems
Traumatic rupture of the ear drum

Related topics
Trauma to teeth
Head injuries
Eye injuries
Fractured mandible / jaw
1. May present with

A history of the injury e.g.:

-- a blow to the side of the head or an explosion, i.e. a pressure wave
-- penetrating injury e.g. a sharp stick
-- water forced into ear e.g. a fall from a height into water
Pain in the ear, reduced hearing and / or bleeding from the ear
Dizziness and nausea

Management of life threatening injuries

Obtain a complete patient history:

-- ask about the circumstances and mechanism of injury
-- time, date of occurrence and when first noticed
-- does the patient have decreased hearing?
-- conscious state if applicable
-- note other injuries if present
4. Management

onsult MO who will advise antibiotic ear drops if water penetrated the perforation
C
e.g. fall into water. The ear should be kept dry until healed. Antibiotic eardrops are
not necessary if hole was caused by dry trauma (blow to head)
5. Follow up
R
eview in 2 days and then weekly
If perforation not healed in 2 weeks, consult MO
Consult MO on presentation and if perforation not healed in 2 weeks
600
Ear problems
Foreign body / insect

Recommend
The main danger of a foreign body in the ear lies in its careless removal [11]
Related topics
Otitis externa
1. May present with

Foreign body or insect in ear canal


btain a full history including circumstances (accidental, purposeful, incidental

O
finding)
Examine the ears. See Assessment of the ear
4. Management

onsult MO unless small object and seen to be near external ear opening and
C
easily removable using e.g. nasal packing forceps
Larger foreign bodies and those further down the canal require special equipment
and training for removal and may even require a general anaesthetic (send to
hospital with ENT facilities)
A live insect in the ear canal should be drowned using Sofradex eardrops or
cooking oil or 2 mL of 1% lignocaine introduced by the blunt end of a syringe or
via a cut-off butterfly needle (or other plastic tubing is also effective) [11]. Do not
syringe with water as can cause insect to swell
After removal of foreign body or insect, instil Sofradex ear drops to prevent
infection secondary to the trauma caused to the skin of the ear canal
Sofradex ear drops

DTP
Schedule
4
(Dexamethasone 0.5 mg / Framycetin
Sulphate 5 mg / Gramicidin 0.05 mg / mL)
Route of
Recommended
Form
Strength
Duration
administration
dosage
3 drops
Ear drops See above
Topical - drops
7 days
tds - qid
Administration tip
[10]
601
Ear problems
5. Follow up
I f foreign body or insect easily removed, review in 2 days

Review as per Otitis externa if secondary infection occurs after removal
Consult MO as per Otitis externa if secondary infection occurs after removal
References
1.
Office for Aboriginal and Torres Strait Health. Recommendations for Clinical Care Guidelines on the
Management of Otitis Media (middle ear infection) in Aboriginal and Torres Strait Islander Populations.
2001 [cited 2011 March].
2.
Therapeutic Guidelines. Otitis media. 2010 [cited 2011 March].
3.
Australian Medicine Handbook. Procaine penicillin. 2011 [cited 2011 May].
4.
Dr A White, Paediatrician. 2011.
5.
Dr E. Binotto, Infectious Diseases & Clinical Microbiology. 2011.
6.
CRANA plus, Clinical Procedure Manual for remote and rural practice. 2nd ed. 2009, Alice Springs.
7.
Griffin, G., Flynn C A., and Bailey R E. Antihistamines and / or decongestants for otitis media with
effusion (OME) in children. Cochrane Database of Systemic Reviews 2006 [cited 2011 March].
8.
Australian Medicine Handbook. Ciprofloxacin (ear). 2011 [cited 2011 March].
9.
Isaacson G., Diagnosis of pediatric cholesteatoma. Pediatrics 2007. (3): p. 603-608.
10. Therapeutic Guidelines. Otitis externa. 2010 [cited 2011 March].
11. Murtagh J., Practice Tips. 4th ed. 2004: The McGraw-Hill Inc.
602
Acute gastroenteritis and dehydration
Vomiting and diarrhoea
Recommend
Always contact MO immediately if baby is < 3 months or the child has any of the
following:
-- is sick or febrile with temperature over 38C or under 35.5C
-- irritable
-- high pitched or weak cry
-- sleepy
-- not feeding well
-- increased respiratory rate:
<1 year >40 rpm
1 - 2 years >35 rpm
2 - 5 years > 30 bpm
5 - 12 years >25 rpm
12 years and older >20 rpm
-- respiratory distress
-- apnoea
-- dehydration
-- abdominal distension
-- persistent / bilious vomiting and no diarrhoea (consider other diagnoses)
Other high risk children include:
-- excessive diarrhoea (> 8 watery stools in 24 hours)
those with congenital or chronic disease e.g. cardiac, gastrointestinal or
--
neurological
-- where social conditions are concerning and / or where the parents may have
difficulty managing at home
Always consider other infections. Any infection can cause diarrhoea or vomiting
Related topics
Intraosseous cannulation
DRS ABCD resuscitation / the collapsed patient

Shock
1. May present with

Vomiting
Diarrhoea
Cramping abdominal pain
Irritability in the young child
Fever
Dehydration
Lethargy, floppy, unresponsive

erform standard clinical observations +

P
-- O2 saturations
-- level of consciousness
Consult MO immediately if any risk factors present or moderate / severe
dehydration
Commence rehydration according to MO advice
603

btain a complete history including:

O
-- diarrhoea - how much and for how long? Is it watery or semiformed, is there
blood or mucous?
-- vomiting - how much and for how long? Is there bile?
-- fluid intake - how much and what type?
-- diet - how much food has the child eaten and what?
-- urine output if known, number of wet nappies?
-- has any home treatment / medicine been given?
-- past history of diarrhoea or other illnesses or infections?
Did the child receive rotavirus vaccine?
-- weigh - use naked weight in young children and record against most recent
recorded weight [1] and
-- level of consciousness if not previously done
Collect a faeces specimen for MC/S and OCP (ova, cysts and parasites) and
viral studies if:
-- history of blood in the stool, severe diarrhoea or prolonged (> 7 days)
-- history suggestive of food poisoning i.e. cluster presentation
-- recent travel overseas
-- degree of dehydration
Clinical assessment of hydration in children

To assess the child
for dehydration
No signs
Mild < 5%
Some signs
Moderate 5 - 10%
Definite signs
Severe > 10%
Eyes
normal
sunken
very sunken and dry
Mouth and tongue
moist
dry
very dry
Condition
alert
restless, irritable,
lethargic
extreme lethargy
ragdoll appearance
drinks normally,
may be thirsty
thirsty, drinks eagerly
drinks poorly or
not able to drink
Respiratory rate
normal
increased
fast
Pulse
normal
fast
fast, weak, thready
Capillary return
normal ( 2 seconds)
sluggish (> 2 seconds)
slow (> 3 seconds)
Management
Can usually be treated

at home or with close
monitoring by
PHC / rural facility
Consult MO
Require urgent
rehydration usually
nasogastric / IV
Consult MO
Requires resuscitation
Thirst
604
4. Management

onsult MO immediately - for those children with risk factors or moderate / severe
C
dehydration

Children and babies with watery diarrhoea lasting 2 - 3 days should have bloods
taken for electrolytes. Take bloods earlier if indicated

Do not use:
--
anti-diarrhoeal agents
metoclopramide or prochlorperazine in young children. MO may order
--
ondansetron if vomiting is preventing oral intake [2]. Ondansetron not
recommended for children <6 months of age or < 8kg [1]
-- antibiotics (rarely indicated)
4.1 Mild dehydration (<5% loss of body weight)

The main treatment is to keep child drinking small amounts of fluids often. Give
enough fluids to cover normal requirements and to replace what is lost through
vomiting and diarrhoea [3]
-- oral rehydration fluids e.g. Gastrolyte, Hydralyte, Pedialyte
-- continue breastfeeding / bottle feeding
-- diluted commercial cordials or diluted (35%) fruit juice drinks, lemonade if oral
rehydration fluids not available
-- do not use low-joule or diet carbonated beverages, sports drinks, Lucozade,
or undiluted lemonade, cordials, or fruit juices

It is important for the fluids to be taken even if the diarrhoea seems to get worse

Children with mild / no dehydration can be looked after at home or with close
monitoring by facility. However significant ongoing vomiting and / or diarrhoea
minimise the chance of success at home

Consider early nasogastric rehydration in these children [1] if oral replacement is
not successful

Maintain a record of fluid intake and output - by staff and family
How to prepare suitable fluid for rehydration [3]
Fluid
Dilution
Example
Oral rehydration fluid e.g.

Gastrolyte
As per instructions on pack
Mix with water only
Oral rehydration fluid e.g.

Hydralyte
Pre-prepared as fluid or iceblock
Do not mix with other fluids
Cordial concentrate (not low

calorie / low joule)
1 part in 20 parts
5 mL (1 teaspoon) plus 100 mL

water
Soft drink or Juice (35%)

(not low calorie / low joule)
1 part in 5 parts
20 mL (1 tablespoon) plus 80 mL
water
How much to give - fluids [3]

-- give small amounts of clear fluid often
-- aim for at least 5 mL fluid per kg body weight each hour for example:
for a 6 kg infant offer 30 mL every hour or 60 mL every 2 hours
for a 12 kg toddler offer 60 mL every hour or 120 mL every 2 hours
give older children one cup (150- 200 mL) of fluid for every big vomit or
case of diarrhoea
605
Management of dehydration in children flow chart [1]

Rehydration
Diagnosis of
Gastroenteritis in
doubt?
Yes
No
Significant
co-morbidities or risk
factors such as age
< 3 months, febrile
Yes
No
Vomiting
prominent?
No
Yes
Assess dehydration
606
Consult MO
for input on
management
MO may
consider
ondansetron
wafer
Trial of oral
fluids 10 - 20 mL
/ kg for 1 hour
unless severe
dehydration
Mild
Moderate
Severe
Assist carers to give

child small amounts
of oral fluids
frequently
Continue
breastfeeding / bottle
feeding
Consult MO
Requires urgent
rehydration
nasogastric / IV.
MO may organise
evacuation /
hospitalisation
Consult MO urgently
who will organise
evacuation /
hospitalisation
IV / IO insertion
Commence bolus of
20 mL / kg
normal saline
Approximate volumes [3]

-- less than 6 months as per MO order
-- 6 - 23 months 40 - 60 mL each hour
-- 2 - 5 years 60 - 100 mL each hour
Breastfed infant [3]

-- continue breastfeeding on demand or at least every 2 hours
-- in between breastfeeds, water or oral rehydration solution may be offered
-- do not give solids if the child is vomiting
-- give solids when the vomiting has stopped or after 24 hours
-- if the baby is on solids introduce simple foods such as rice cereal, potato or
pumpkin - even if the diarrhoea is still present
Bottle fed infant and older child [3]

-- while the infant or child is still vomiting replace formula or usual drinks with
oral rehydration fluid or other clear fluid (volume on previous page)
-- aim to be back to usual formula / diet within 24 hours - do not dilute
-- offer age appropriate foods at meal times even if diarrhoea still present
-- occasionally children will develop lactose intolerance and the diarrhoea will
continue. See Nutrition after gastroenteritis and lactose intolerance
4.2 Moderate dehydration (5 to 10% loss of body weight)

Consult MO

Commence rehydration therapy according to MO instructions, usually oral /
nasogastric. Examples of rehydration volumes given below
-- must be managed in appropriately equipped and staffed facility
-- MO will arrange evacuation if required

Commence a fluid balance sheet immediately

As well as oral / NGT rehydration, continue breastfeeds / formula and diet as per
mild dehydration

Monitor childs observations closely

Discuss with MO for further decision making after 4 hours
Oral / NGT fluid replacement regime example for moderate dehydration 5 - 10 % [1]
Weight kg
0 - 6 hours
Give oral / NGT fluid replacement
(mL / hr)
3
4
5
6
7
8
9
10
12
15
20
30
30
40
50
60
70
80
90
100
120
150
200
300
7 - 24 hours
(following previous column doses)
Give oral / NGT fluid replacement
(mL / hr)
20
30
35
40
45
50
55
60
65
70
85
90
4.3 Severe dehydration (>10% loss of body weight)

If severe hypovolaemic shock. See Shock

Consult MO
-- commence rehydration therapy according to MO instructions
-- must be managed in appropriately equipped and staffed facility
-- MO will arrange evacuation

Monitor conscious state closely and consult MO immediately if altered

Commence a fluid balance sheet immediately

Insert IV cannula. If this is unsuccessful after 2 attempts insert intraosseous
cannula and commence infusion using the regime below. MO may take /
request bloods whilst inserting IV / IO for electrolytes, glucose, acid base. See
Intraosseous insertion
607
Fluid resuscitation regime for severe dehydration

is based on 10% dehydration (person weighs 10% less than their usual weight)
Initial treatment

20 mL / kg

Reassess

Give second bolus of 20 mL / kg if still shocked

Ongoing fluids as discussed with MO

Re-hydrate / resuscitate severely dehydrated child with normal saline or IV Hartmanns
solution only [1]

Contact MO for ongoing fluid orders

Common IV fluids used in children for ongoing maintenance or replacement include
normal saline or normal saline + 5% glucose [1]
Arrangements should be made to transfer child to a paediatric centre. Ongoing fluid input
should be managed in consultation with a Paediatrician
5. Follow up
Evacuation / hospitalisation of children with moderate (if indicated) or severe
dehydration
Children with mild dehydration i.e. < 5% and no clinical signs review in 24 hours

or earlier if parent / carer is concerned that child is worse

Inform the carer that bowel actions may not return to normal for 2 weeks but a
child with continuing watery diarrhoea should be reviewed by a MO
Children with watery diarrhoea lasting longer than 2 - 3 days should have bloods
taken for electrolytes, babies may require this earlier
Reassurance, education and advice concerning hand washing, personal hygiene,
avoiding food preparation, and public swimming pools until diarrhoea has settled
Place child on care plan with individualised review and weighs according to
severity and family situation
If diarrhoea continues beyond 10 days. See Child with chronic diarrhoea flow
chart
Alert other parents of young children in the community of current gastrointestinal
illness and the need to present early to clinic if their child displays any gastrointestinal symptoms
Advise parent / carer(s) [1]

Use methods to help children drink e.g. cup, iceblock, bottle, syringe

Do not give medicines to reduce vomiting and diarrhoea. They do not work and may
be harmful

Your baby or child is infectious so wash your hands well with soap and warm water,
particularly before feeding and after changing nappies

Keep your child away from other children as much as possible until the diarrhoea
has stopped

Return to clinic if:
-- child is not drinking and still has vomiting and diarrhoea
-- child is vomiting frequently and seems unable to keep any fluids down
-- child is dehydrated e.g. not passing urine (< 3 wet nappies), is pale and has lost
weight, sunken eyes, cold hands and feet, or is hard to wake up
-- if your child has a bad stomach pain
-- if there is any blood in the faeces
-- if there is any green vomit, or you are worried for any other reason
608
Nutrition during gastroenteritis

Poor appetite is normal during the acute phase of the illness - during this time, ensure
fluid intake is sufficient as described above

Babies and young children who are breastfeeding will want to feed more often when
they are sick - this is normal. Support mum to breastfeed more frequently

Acute gastroenteritis can result in transient lactose intolerance. Formula fed babies
may need lactose free formulas until the babys gut recovers sufficiently to digest
and absorb lactose

It is particularly important to ensure that formula fed babies get sufficient fluids

Breastfeeding should be maintained during the acute phase and through any

subsequent lactose intolerance. Breastfed babies are fed more frequently than
formula fed babies and are usually able to tolerate the lactose in the breast milk

If the child has an appetite, eating should be encouraged but avoid fatty food or high
sugar foods and drinks
Nutrition after gastroenteritis

Encourage continued breastfeeding with healthy food as well if the child is six months
or older

If the child is under one year of age and not breastfed, he / she will need infant
formula, not cows milk. The type of formula will depend on whether the child can
tolerate lactose

An episode of acute gastroenteritis may result in weight loss

For children > 6 months of age, once the childs appetite returns, encourage carer to
provide healthy food with one extra meal each day until lost weight is regained

Healthy food is important for replacing lean body tissue lost during the illness encourage lean meat, fish, eggs, fruit and vegetables, peanut paste, baked beans,
cheese and yoghurt, and wholegrain cereals like Weet-Bix

Children over one year of age can have cows milk provided there is no lactose
intolerance

Monitor weekly to ensure healthy growth is resumed

Refer to MO if healthy growth is not resumed within four weeks - repeated or chronic
infections can result in poor appetite and growth failure
Consult MO immediately as above

Children with chronic diarrhoea. See Child with chronic diarrhoea flow chart
Children with weight loss or poor weight gain who are not acutely unwell - refer to
Child Health Nurse or next MO clinic

See Poor growth in children in the latest edition of the Chronic Disease Guidelines
www.health.qld.gov.au/cdg/default.asp
609
Lactose intolerance
Recommend
Continue breastfeeding (lactase can be tried). For formula fed infants use low lactose
formula
Consider other causes of chronic diarrhoea
Background
Lactose intolerance commonly follows acute diarrhoea in Aboriginal and Torres Strait
Islander children
Related topics
Failure to thrive
Nappy rash
Child with chronic diarrhoea flow chart
1. May present with

Chronic diarrhoea, bloating, vomiting, irritability

Stool may be frothy
Perianal area may be scalded


btain a complete patient history

O
-- weigh - use naked weight in young children - record against last recorded
weight
Collect a faeces specimen for MC/S, OCP (ova, cysts and parasites) and reducing
substances
Perform physical examination: See Clinical assessment of hydration in children
-- palpate abdomen for tenderness or guarding
-- inspect the perianal area for irritation of area
4. Management

610
onsult MO if suspect lactose intolerance and refer to next MO clinic

C
Never restrict breastfeeding
Encourage extra fluids while the child continues to have diarrhoea
Avoid lactose based formulas and cows milk products:
-- lactase (Tilactase [Lacteeze]) can be used in breastfed infants before,
during and after a breastfeed, but is not very effective because the enzyme
takes about 30 minutes to breakdown the breast milk lactose, so there may
not be enough contact time in the stomach
-- an infant usually fed on lactose based formula or cows milk should be
prescribed a low lactose formula as an alternative: De-Lact or O-Lac
-- dont use soy formulas
Reintroduce normal formula after 2 - 4 weeks starting with 1/3 normal to 2/3
lactose free and increasing the proportion of normal formula over 3 - 4 days
If symptoms recur, revert to lactose free formula and try again in 2 - 4 weeks
5. Follow up
Review 1 - 2 days after starting on low lactose formula

Consult MO if diarrhoea persists
See next Child Health Nurse or MO clinic
C
onsult MO on all occasions lactose intolerance suspected
Dietitian if available
Giardiasis
Recommend

If treatment with tinidazole or metronidazole fails a longer course may be required or
reconsider the diagnosis
Related topics
Anaemia - child

Failure to thrive
1. May present with

Foul smelling watery diarrhoea

Chronic diarrhoea, frequent loose and pale greasy stool
Abdominal cramps
Abdominal distension, flatulence
Nausea, poor appetite
Anaemia
Weight loss / failure to thrive
May be asymptomatic



weight
Collect a faeces specimen for MC/S and OCP (ova, cysts and parasites) x 2
-- assess for dehydration. See Clinical assessment of hydration in children
-- palpate the abdomen for tenderness or guarding
-- inspect the perianal area for signs of irritation
4. Management

ncourage oral fluids

E
Treatment of people with asymptomatic passage of cysts is unwarranted unless
they are a contact of pregnant women or immunocompromised patient
Treat with tinidazole or metronidazole if symptomatic, or failure to thrive (it is not
necessary to wait for laboratory confirmation). If thriving and not unwell treat after
laboratory confirmation
611
DTP
Route of
Recommended
Form
Strength
Duration
administration
dosage
Adult
2g
Tablet
500 mg
Oral
Child
Stat
50 mg / kg / dose
to a max. of 2 g
Provide Consumer Medicine Information: take dose after food. When possible, the tablets should be dosed
whole as the drugs taste is very bitter. However, when a part tablet is required, tablets can be crushed.
The tablets are film coated, so must be peeled then crushed.The appropriate dose can then be weighed
and mixed with flavouring
[4]
Schedule
Tinidazole
or
DTP
Route of
Recommended
Duration
Form
Strength
administration
dosage
200 mg
Adult
Tablet
400 mg
2 g daily
Oral
Child
3 days
30 mg / kg / dose daily
to a max. of 2 g daily
Provide Consumer Medicine Information: avoid alcohol while and for 48 hours after taking this drug. Take
with food or immediately after food
[4]
Schedule
Metronidazole
If the above treatment fails a longer course of metronidazole is sometimes

required or diagnosis should be reconsidered
5. Follow up
R
eview next day
Consult MO if diarrhoea not settling
Provide education and advice concerning handwashing before handling food,
eating and after toilet; avoiding food preparation and public swimming pools until
diarrhoea has settled
Consult MO as above
612
Intestinal worms
Recommend

Use only pyrantel (Combantrin) in children under 6 months and in pregnant women
[7]

Perform de-worming in three situations:
-- as part of a community eradication program
-- symptomatic children
-- on the basis of faeces specimen result, sent as part of investigation for anaemia
or weight loss / failure to thrive
Related topics
Anaemia - child
Failure to thrive
1. May present with

2.
Perianal / perineal itch - pinworm (thread worm), small threadlike worm may be
seen (doesnt cause diarrhoea or failure to thrive)
Anaemia - hookworm
Acute diarrhoea - strongyloides
Failure to thrive - strongyloides can contribute
Immediate management Not applicable

btain a complete patient history:

O
-- past episodes
-- previous weights
-- length of time signs and symptoms have been present
-- do any other members of the family or close contact have signs or symptoms?
-- is the child on medication?
-- have they been treated for worms? If so when and with what?
recorded weight
-- check Hb on haemoglobinometer (HemoCue)
-- collect a faeces specimen for MC/S and OCP (ova, cysts and parasites). This
will be repeated as part of follow up
-- inspect the abdomen for signs of mobility
-- palpate the abdomen for tenderness or guarding
-- inspect the perianal / perineal area for signs of irritation (if indicated)
4. Management

Consult MO if abdominal pain present See Abdominal pain
613
Treatments for common worms [5]

Drug
Pyrantel (Combantrin)
Mebendazole (Vermox)
Albendazole
Praziquantel
Ivermectin
Worm
Threadworm (pinworm)
Hookworm
Roundworm
Hookworm
Roundworm
Whipworm
Hookworm
Roundworm
Strongyloidiasis
Whipworm
Beef tapeworm and pork tapeworm
Dwarf tapeworm
Strongyloidiasis
Pyrantel embonate
DTP
(Combantrin)
IHW / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic may proceed
Route of
Recommended
Form
Strength
Duration
administration
dosage
125 mg
Stat
Tablet
10 mg / kg / dose
250 mg
Oral
Repeat after 7 days if
to a max. of 1 g
Suspension 50 mg / mL
heavy infestation
Schedule
Provide Consumer Medicine Information: for use in children < 6 months of age and pregnant women

614
[5]
eassurance, education and advice regarding hand-washing and personal

R
hygiene
If treating worms without laboratory confirmation use albendazole or mebendazole
If treating after laboratory confirmation of the worm, see table for the preferred
treatment: pyrantel (Combantrin), albendazole or mebendazole (Vermox)
If part of a worm eradication program, use albendazole as a single dose every 4
to 6 months
Only pyrantel (Combantrin) can be used in children < 6 months and in pregnant
women [5]
Albendazole and mebendazole should not be used in children < 6 months or in
pregnant women [5]
DTP
Route of
Recommended
Form
Strength
Duration
administration
dosage
Threadworm (pinworm),
hookworm, roundworm
Adult
Stat
400 mg
Child
200 mg
10
kg
give 200 mg
Tablet
Oral
400 mg
Strongyloidiasis, whipworm
Adult
400 mg daily
3 days
Child
10 kg give 200 mg daily
Provide Consumer Medicine Information: women should use effective contraception during and one month
after treatment. To increase absorption for systemic indications i.e. strongyloides, take medication with
fatty meal. For other indications take on an empty stomach
[5]
Schedule
Albendazole
or
Mebendazole
DTP
(Vermox)
IHW / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic may proceed
Route of
Recommended
Form
Strength
Duration
administration
dosage
Theadworm (pinworm)
Adult
Tablet
100 mg
100 mg
Stat
Child
10 kg give 50 mg
Oral
Whipworm, hookworm,
roundworm
Adult
3 days
100 mg bd
Child
10 kg give 50 mg bd
Schedule
[5]
5. Follow up
See at next MO clinic if anaemia or weight loss / failure to thrive
Consult MO as above
615
Constipation
Recommend
Maintenance programs consisting of medication, toileting program, dietary advice
and follow up to prevent recurrence
Background
Constipation is the difficult passage of infrequent dry, hard stools that often cause
pain and discomfort. The most common cause is functional - no underlying cause [8]
Constipation starts a vicious cycle - passing hard stool is painful, so the child avoids
straining at stool, the constipation gets worse and so on. Part of the battle is forming
a habit for the child to go to the toilet each day
Straining is normal in babies
1. May present with

Hard stool - often small pellets

Excessive straining at stool
Soiling (also known as encopresis)


616
Obtain a complete patient history including:

-- medical history
-- past episodes
-- current diet including food allergies [6]
-- fluid intake - are they breastfeeding or on formula? how is the formula made
up? (Over concentrated formula can lead to constipation.) Are they given
water as well?
-- what / how much is their physical activity?
-- family routine (the constipated child usually has poor nutrition, poor fluid
intake and is inactive)
-- parental expectations of normal stool pattern
-- length of time since last passed a stool / defecated?
-- describe stool, colour, consistency, frequency of defecation
-- ask carer if any change in childs behaviour?
-- what is there urinary output history? are they bedwetting? daytime wetting?
-- is the child on medication?
-- plot growth and height / length
-- inspect mouth, look for mouth ulcer(s) and state of teeth / gums
-- inspect and palpate abdomen - for masses
-- ankle knee reflexes (to assess sacral nerve roots and gait)
-- inspect the anus and perianal area - position of the anus, pressure of stool
around anus, perineal sensation, skin tags, anal fissures
Consider possible organic problem (and refer for further work up) if:
-- child has constipation from birth
-- child has vomiting, and abdominal distension
-- there is any bile vomiting
-- the child is not growing well
-- there is more than just a streak of blood on the stool
-- constipation does not improve with simple measures
4. Management

Dietary interventions:
-- encourage a healthy diet with fruit and vegetables and wholegrain cereals
-- encourage drinking plenty of water
-- pears (fresh or pureed) or prunes will stimulate the gut gently and soften
stools
-- excessive dietary intake can cause constipation in children
Encourage physical activity
Toileting programs:
-- take advantage of the gastrocolic reflex. Most people, especially children
have the urge to pass a motion after eating a meal, especially breakfast
-- advise that the child should sit on the toilet after each meal and attempt to
pass a motion without straining
-- positively reinforce good behaviour. A reward for sitting on the toilet and
passing a motion is often beneficial
Disimpaction:
-- oral laxatives
liquid paraffin, chocolate flavoured liquid paraffin i.e. Parachoc. Avoid
in infants under 12 months of age
lactulose, senna, Movicol Half
-- enemas
micro-enemas such as Microlax
Most constipation in children will resolve with these measures. If it persists, refer
to the next Child Health Nurse or MO clinic or Continence Advisor
5. Follow up

Children with constipation should be reviewed regularly to assess progress.
Once the problem settles remember to continue with dietary improvement and
increased water intake to prevent recurrence
Advise parent / carer to use appropriate gentle fibre or laxative (prune / pear juice
/ psyllium) for at least 3 months to regulate peristalsis

onsult MO if constipation is severe, or the child is unwell in any other way

C
Child Health Nurse
Continence Advisor (if available)
MO may consider referral to a Paediatrician
Children with chronic constipation require long term management with multiple
laxatives to keep their stool soft and prevent recurrence of painful anal fissures.
It is important to ensure observance with laxative regimes
617
Pyloric stenosis
Recommend

May need rehydration

Evacuate for investigation. Will need surgical treatment if diagnosis confirmed
Background
Most common in babies between 2 and 6 weeks of age. Rarely occurs after 12
weeks of age
Related topics
1. May present with

Vomiting which progressively gets worse, projectile, after feeds

Baby is not putting on weight well or may be losing weight
Dehydration

Consult MO if child dehydrated


O
-- of particular importance progressive increase of projectile vomiting after feeds
in a baby that is usually well and eager to feed following the vomiting episode
recorded weight
-- inspect and palpate abdomen
Visible peristalsis over the abdomen or an olive-sized and shaped mass may be
felt in the right upper quadrant
Assess degree of dehydration. See Acute gastroenteritis and dehydration
4. Management

Consult MO who may advise

-- checking electrolytes (U/E)
-- IV fluids
-- abdominal ultrasound examination
5. Follow up
All babies with suspected pyloric stenosis must be managed in hospital. Diagnosis
is usually confirmed by ultrasound. If confirmed the baby will require surgery,

which is very successful
Consult MO on all occasions of suspected pyloric stenosis. These infants may
present with severe acid base imbalance such as hypokalaemia
618
Intussusception
Background
Suspect in a young child who looks unwell and has intermittent severe abdominal
pain
In 15 % of cases the classic triad of abdominal pain, palpable sausage shaped
abdominal masses and red currant jelly stool is present. The small bowel telescopes
into itself (as if it were swallowing itself)
Most common cause of obstruction in children 6 - 36 months of age (60% <12 months
of age)

1. May present with

Intermittent severe abdominal pain (may settle and appear well between bouts
of pain 10 - 20 minutes apart)
Intermittent inconsolable crying
Poor feeding
Vomiting
Blood per rectum (classically red currant jelly but is often a late sign)
Child may look pale and unwell

Consult MO

Obtain a complete patient history:

-- length of time condition present
-- describe stools passed, how many? colour? formation?
-- describe vomiting - is bile present?
-- recent rotavirus vaccination?
Perform standard clinical observations (fever may be a late sign) +
recorded weight
-- inspect and palpate abdomen
palpable sausage shape mass? (but absence does not exclude
intussusception)
guarding and tenderness
inspect stool
4. Management

onsult MO who will advise evacuation / hospitalisation

C
All children with suspected intussusception should be managed in hospital
Most will be treated in radiology department with air or contrast enema which will
reduce the intussusception
5. Follow up

Monitor child on return to community
Consult MO on all occasions of suspected intussusception
619
Failure to thrive
Recommend
Refer to Poor growth in children care plan in the latest edition of the Chronic Disease
Guidelines www.health.qld.gov.au/cdg

MO / Dietitian to perform complete examination and calculate the degree of failure to
thrive - mild, moderate or severe, using weight for age, and weight for height, for Z
score
Provide nutritional supplements for management of failure to thrive depending on
severity

It is important in an underweight child to differentiate wasting (thin child) of acute
failure to thrive from stunting (short child) due to chronic failure to thrive. Often both
are present, and can be assessed on anthropometric measurements of weight and
height for age and sex
Background
Suite of Growing Strong resources available at:
www.health.qld.gov.au/ph/documents/hpu/growingstrong.asp
Failure to thrive (FTT) refers to child whose weight is less than normal for gestational
corrected age / gender and past medical history. Children with genetic short stature,
intrauterine growth retardation or prematurity, who have appropriate proportional
weight for length and normal growth velocity, are not regarded as FTT
Related topics
Anaemia
Giardia
Intestinal worms
Lactose intolerance
Urinary tract infection - child
1. May present with

Any condition
A child whose weight has crossed down 2 or more major centile lines on standard
growth charts (and who is not overweight or obese) [7]


620
btain a complete patient history including:

O
-- family and social history - spend time assessing the social situation:
who is the main carer? which other family members contribute to looking
after the child, household and buying food?
amount of support the carer has? extended family? friends?
have other children in the family had problems with growth faltering?
ask about food security, financial security?
-- cultural history
-- medical history - past or current illnesses
-- birth history - low birth weight (preterm or IUGR)
-- mothers antenatal history - particularly alcohol and smoking intake
-- nutrition intake - if breastfed, frequency of feeding during night and day, if
formula fed when did the formula start? how is it prepared? other milks or
drinks?
-- solids, type - when were solids introduced? frequency of feeding?
-- eating pattern
-- urine output and number of stools per day
erform standard clinical observations +

P
-- urinalysis
-- check haemoglobin on haemoglobinometer (HemoCue)
-- collect stool specimen for lactose intolerance testing
Perform a complete physical examination:
-- head to toe assessment of current state of health, looking for evidence of
undetected illness
-- do naked weigh, check length and head circumference - plot growth chart
It is important in an underweight child to differentiate wasting of acute FTT from stunting

due to chronic FTT - often both are present
A child with stunting may look healthy. It is important to measure and assess the child's
growth on a growth chart to identify stunting
4. Management

O perform examination and calculate degree of FTT - mild, moderate or severe

M
Depending on severity of FTT commencement of:
-- nutritional supplements such as Pediasure
-- food prescription
Multivitamins are only required <3 years (Pentavite infant vitamins 0.45 mL
daily)
MO may advise collection of :
-- blood for FBC
-- urine MC/S. See Urinary tract infection - child, for method of collection
-- faeces specimen for MC/S and OCP and lactose intolerance testing
If faeces specimen results:
-- positive for intestinal worms or giardia, treat accordingly
-- negative; treat for giardia in any case
-- other positive result, consult MO
Chest x-ray if available
Refer to Child Health Nurse / Child Health - Health Worker or next MO clinic - if no
adverse findings from clinical assessment and the child with weight loss or poor
weight gain is not acutely unwell
If no organic cause found for FTT, management will revolve around education on
nutrition, support of the carer and regular monitoring of the childs growth (use
Growing Strong brochures / resources)
Refer to Dietitian for detailed diet history, feeding history and nutrition advice
Check if immunisations are up to date. Documented evidence of immunisation
status should be obtained; follow up with opportunistic immunisation. See
Healthy food is needed for healthy weight gain and growth in all children:
-- exclusive breast milk to 6 months of age
-- breast milk or infant formula up to 12 months
-- breast milk or cows milk over 12 months
-- iron rich foods also provide zinc and other nutrients:
red meat, beef / lamb liver or kidneys, bush meat, chicken, fish
egg yolks, iron fortified baby cereal

green vegetables, fruit (not fruit juice) and vegetables (to help iron
absorption)

no turtle or dugong liver, kidneys or intestines - as concern about
cadmium content
no cows milk or Sunshine milk before 1 year old
no take away / junk food, sugary food, tea or soft drinks - these spoil
appetite for healthy food
621
Children need small frequent meals (5 times a day if possible)
Food prescription
Drinks

Nutritional supplement - usually Pedisure at least one 237 mL can or one cup

250 mL of supplement every day or 5 scoops of powder in 200 mL water

Water, breast milk, infant formula, cows milk if over 12 months
Food

Meals - breakfast, lunch, dinner, snacks containing fruit, vegetables
5. Follow up
Place child on individualised care plan, setting out actions, targets and who is
responsible to closely provide:

-- social support
-- set actions / targets for weight gain. See Chronic Disease Guidelines at:
-- regular monitoring of growth with childs carer
Appropriate nutritional needs for child as recommended by Dietitian, MO or Child
Health Nurse / Child Health - Health Worker. Often children with FTT lose their
appetite and are unable to meet their nutritional requirements without additional
strategies in place. Advice needs to be given to carers beyond just what healthy
foods are. Carers need to know which foods are appropriate for FTT and also
how often, the amount of food and how to fortify breast milk / foods / drinks
C
onsult MO. Child may need hospitalisation
Child development unit for developmental screening of gross and fine motor,
language and social milestones
Dietitian to conduct thorough diet history, feeding history and nutrition advice
May need referral to a community based specialised nutrition program e.g. Mums
and bubs
See current edition of Chronic Disease Guidelines at:
Anaemia - child
Recommend
Aim to achieve haemoglobin level above 110 g / L [8]
Treat with iron
-- babies aged 6 -12 months with haemoglobin < 105 g / L
-- children over 1 year of age with haemoglobin < 110 g / L
-- if any child has haemoglobin < 80 g / L
See next MO clinic
-- if child has haemoglobin 80 -100 g / L
Suite of Growing Strong resources, especially iron rich food available at:
www.health.qld.gov.au/ph/documents/hpu/growing_strong.asp
Regular calibration of haemoglobinometer (HemoCue)
622
Background
Nutrient requirements are very high in young children, especially for iron between
the ages of 6 months and 24 months
Anaemia is common in Aboriginal and Torres Strait Islander children particularly in
the 6 to 30 months age group
Childhood anaemia is more likely if mother had low iron status or was anaemic in
pregnancy and/or if baby was premature or low birth weight
Anaemia is largely due to dietary deficiency in iron and / or folate and the inhibitory
effects of infestations and infections
There are higher rates of iron deficiency and anaemia in infants and toddlers where
high cows milk intake is encouraged or allowed [11]
Failure to thrive may or may not co-exist
Overweight and obesity may or may not co-exist
Iron deficiency of any degree affects child development
Related topics
Giardia
Intestinal worms
Failure to thrive
1. May present with

Almost always asymptomatic

Low haemoglobin detected on haemoglobinometer. Re-check if any doubt
Tiredness, lethargy
Recurrent infections
Occasionally pica (eating substances not fit as food)
Loss of appetite


Obtain a complete patient history including:

-- family and ethnic history (different types of anaemia caused by production
and life of red blood cells)
-- social history. Spend time assessing the social situation
who is the main carer?

which other family members contribute to looking after the child,
household and buying food?
amount of support the carer has? extended family? friends?
have other children in the family had problems with anaemia?
-- cultural history
-- medical history - past or current illnesses
-- current medications - Pentavite or iron liquid?
-- birth history - low birth weight (preterm or IUGR)
-- mothers antenatal history
-- nutrition intake, breast or formula fed or both - when did formula start? what
type of milk is child drinking? cows milk?
-- solids, type - when were solids introduced?
-- eating pattern
-- urine output / number of stools per day
-- urinalysis
recorded weight
623
-- check length and do head circumference and plot against growth chart
--
check haemoglobin on haemoglobinometer (HemoCue) (if not already
done)
-- collect stool for lactose intolerance testing
Perform a complete physical examination:
-- from head to toe assessing current state of health and looking for evidence of
undetected illness
4. Management

reat with oral iron supplement for 1 month under supervision (taking iron daily is
T
problematic as child is often asymptomatic. Do not give during diarrhoeal illness.
Parents to be advised about the risk of iron ingestion by children and to store
safely out of reach)
Treat with IM ferrum H if family unable to give oral iron or child will not take oral
iron:
-- babies aged 6 - 12 months with haemoglobin <105 g / L
-- children over 1 year of age with haemoglobin <110 g / L
-- if any child has haemoglobin <80 g / L
See next MO clinic
-- if child has haemoglobin 80 -100 g / L
Collect:
-- if severe anaemia collect blood for FBC / film (look for microcytic hypochromic
picture - low MCV, serum and RBC folate)
-- mid stream urine for MC/S
-- faeces specimen for MC/S and OCP
If faeces specimen:
-- positive for intestinal worms, treat accordingly
-- other positive result, consult MO
-- if in region with high rates of hook worm - treat with 3 days of albendazole.
See Intestinal worms
Refer to Dietitian to conduct thorough diet and feeding history and nutrition advice
Ferrous Sulphate
DTP
(Ferro-Liquid)
IHW / IPAP
Route of
Recommended
Form
Strength
Duration
administration
dosage
Child under 2 years
30 mg
only on MO advice
(equiv. to 6 mg
Continue for 3 months
of elemental
Child 2 - 6 years
after Hb has returned to
Liquid
Oral
normal to
iron) per mL
up to 5 mL daily
replenish stores
Child 7 - 12 years
150 mg / 5 mL
5 - 20 mL daily
Provide Consumer Medicine Information: keep iron mixtures and tablets out of reach of children. Warn
patient / carer about dark, tarry stools and constipation. Oral absorption of iron is enhanced by Vitamin C
Management of associated emergency: consult MO - overdose of iron is very toxic.
[9]
Schedule
624
Give folic acid supplement if:

-- low serum and / or RBC folate
-- severe iron deficiency (haemoglobin < 80 g/L) even if normal folate levels
DTP
IHW / IPAP
Route of
Recommended
Form
Strength
Duration
administration
dosage
500
Child
Long term according
Tablet
microgram
Oral
0.5 mg / kg / dose daily
to response on MO / NP
5 mg
to a max. of 5 mg daily
order
[10]
Schedule
Folic Acid
ive nutrition advice. Use Growing Strong resources - breastfeeding, iron rich
G
foods, healthy food and drinks and many more available at:
www.health.qld.gov.au/ph/documents/hpu/growingstrong.asp
Recommend breastfeed exclusively for first 6 months
Appropriate iron rich first foods at around 6 months
-- foods rich in iron and or folate:
red meat, beef / lamb liver or kidneys, bush meat
chicken, fish
egg yolks
iron fortified baby cereal
green vegetables
fruit and vegetables (to help iron absorption)
breast milk or infant formula (NOT normal cow or goat milk unless over
1 year of age)
No turtle or dugong liver or kidneys or intestines - as concern about
cadmium content
No cows milk or Sunshine milk before 1 year old
No tea or coffee
No soft drink, juice or cordial
5. Follow up
Place child on individualised care plan, setting out actions, targets and who is
responsible to closely provide ongoing support and monitoring
onsult MO or see next MO clinic as above

C
Refer to Dietitian for diet history, feeding history and nutrition advice
Refer to Child Health Nurse / Child Health - Health Worker
Repeat FBC after 1 month of iron and / or folate to confirm response to treatment
If a response is demonstrated with iron and / or folate supplements, continue for
several months
Check haemoglobin monthly until it is >110 g/L

625
Iron injection procedure See manufacturer's product information for accompanying diagrams
1.
2.
3.
4.
5.
6.
7.
The length of the needle should be at least 5 to 6 cm. The lumen of the needle should not be too wide
Ventrogluteal injection according to Hochstetter is recommended in the top outer quadrant of the
gluteus maximus muscle
The site of injection is determined as follows. First point A is found, corresponding to the ventral iliac
spine. If the patient lies on the right side, for instance, the middle finger of the left hand is placed on
point A. The index finger is extended away from the middle finger, so that it comes to lie below the iliac
crest, at point B. The triangle lying between the proximal phalanges of the middle and index fingers
represents the site of injection. This is disinfected in the usual way
Before the needle is inserted, the skin over the site of injection is pulled down, about 2 cm, to give
an S-shaped puncture channel. This prevents the injected solution from running back into the
subcutaneous tissues and discolouring the skin
The needle is introduced more or less vertically to the skin surface, angled to point towards the iliac
crest rather than the hip joint
After the injection, the needle is slowly withdrawn and pressure from a finger applied beside the
puncture site. This pressure is maintained for about one minute
The patient should move about after the injection
[11]
Schedule
Form
Strength
Ampoule
100 mg / 2 mL
50 mg / mL
Iron polymaltose
(Ferrum H, Ferrosig)
Route of
administration
IM
Non DTP
Must consult MO / NP
Recommended
dosage
Duration
< 5.0 kg 0.5 mL / day

5 - 10 kg 1.0 mL / day
>10 kg - 45 kg 2.0 mL / day
Stat
or alternate days
Formula for calculating iron injection dose

Weight x (125 - Hb in g/L) x 0.3 = mL required (50 mg / mL)
Total dose (may be over several days)
Weight (kg)
Hb 75 g / L
Hb 90 g / L
Hb 105 g / L
5
3 mL
3 mL
2 mL
10
6 mL
5 mL
4 mL
15
9 mL
7 mL
6 mL
20
11 mL
10 mL
8 mL
25
14 mL
12 mL
11 mL
30
17 mL
15 mL
13 mL
35
23 mL
20 mL
18 mL
40
24 mL
22 mL
19 mL
45
26 mL
23 mL
20 mL
Provide Consumer Medicine Information: the wrong injection technique may result in pain and persistent
discolouration of the skin. Iron polymaltose should never be injected into the arm or other exposed areas
[9]
626

References
1.
The Royal Childrens Hospital. Gastroenteritis 2009 [cited 2011 February]; Available from: www.rch.org.
au/clinicalguide/cpg.cfm?docid=12364#degree
2. Dunia A., Al-Hakima H., and Fedorowicz Z. Antiemetics for reducing vomiting related to acute
gastroenteritis in children and adolescents. Cochrane Database of Systemic Reviews 2009 [cited 2011
February].
3.
The Childrens Hospital at Westmead Sydney Childrens Hospital Randwick & Kaleidoscope * Hunter
Childrens Health Network, Fact Sheet Gastroenteritis. 2010.
4.
Therapeutic Guidelines. Giardia lamblia (intestinalis) (acute giardiasis). 2006 [cited 2011 February].
5.
Therapeutic Guidelines. Worms (helminths). 2006 [cited 2011 March].
6.
IMPACT Paediatric Bowel Care Pathway, A Guide to the Management of Constipation and Faecal
Impaction in Children 2006: Australia.
7.
American Academy of Pediatrics Committee on Child Abuse and Neglect and the Committee on Nutrition,
Robert W Block., and Nancy F Krebs., Failure to Thrive as a Manifestation of Child Neglect. Pediatrics,
2005. 116
8.
The World Health Organization, Iron deficiency anaemia, assessment, prevention and control. A guide
for program managers. 2001, WHO: Geneva.
9.
Therapeutic Guidelines. Iron deficiency. 2006 [cited 2011 March].
10. Australian Medicine Handbook. Folic acid. 2011 [cited 2011 March].
11. MIMS Online. Ferrum H Injection. 2008 [cited 2011 March].
Urinary tract infection - child

Recommend

Definitive diagnosis of urinary tract infection (UTI) by urine culture collected in a sterile
fashion - mid stream urine (clean catch), supra pubic aspiration, catheter specimen
[1]
Finding a UTI in a sick child does not rule out other sources of infection so keep
looking e.g. meningitis [1]
Some children require further imaging of renal tract depending on age
Background

Collection of urine in a paediatric bag can only be used for dipstix testing. It has poor
sensitivity and specificity [1]

Some children with UTI may look quite well while others may appear very unwell [1]

Children with UTI commonly have acute pyelonephritis and particularly in infants, it is
difficult to distinguish between cystitis and pyelonephritis [2]
1. May present with [3]
Infant younger than 3 months

Most common
-- fever
-- vomiting
-- failure to thrive
-- diarrhoea
-- poor feeding

Least common
-- abdominal pain
-- jaundice
-- haematuria
-- offensive urine
627
Infants and children 3 months or older (preverbal)

Most common
-- fever
-- abdominal pain
-- loin tenderness
-- vomiting
-- poor feeding

Least common
-- irritability
-- haematuria
-- offensive urine
-- failure to thrive
Infants and children 3 months or older (verbal)

Most common
-- frequency
-- dysuria
-- dysfunctional voiding e.g. bed wetting
-- changes to continence patterns
-- loin tenderness

Least common
-- fever
-- malaise
-- haematuria
-- offensive urine
-- cloudy urine


628

O
-- medical history
-- is this the first UTI? have there been past episodes?
-- does the child look unwell / septic?
-- is there vomiting present? diarrhoea?
-- how is the childs appetite? what and how much are they eating and drinking?
-- has the carer noticed anything such as strong urine odour, colour of urine,
child passing urine frequently? or child crying when passes urine?
-- assess growth and plot against chart for age and sex
-- inspect and palpate head to toe looking for other signs of infection
-- palpate the abdomen, supra-pubic area and loin - is there tenderness?
Collect urine - always write the method of collection on the pathology form
-- clean catch midstream urine

can be obtained from children who can pass urine on request
Method

wash genitalia with water and dry

have the child pass the first few mL in the toilet

catch the rest of the specimen in a sterile container
-- catheter specimens

for children too young to obtain clean catch and with a high probability
of UTI
here no MO in residence these children will need evacuation /

w
hospitalisation
-- supra-pubic aspiration
supra-pubic aspirates are the gold standard for obtaining urine specimens
for culture - age limit (best) to 6 months but can try up to 12 months of age
(contraindications include bleeding tendencies, abdominal distension
and enlarged organs) [1]
-- bag urine
can never prove a UTI on a bag sample
can use specimen for dipstick urinalysis - nitrates are the most sensitive
for UTI
can be used to rule out a UTI (if correctly applied urine bag specimen is
negative on dipstick urinalysis) see below

ssessment of dipstick urinalysis

A
-- If urinalysis is positive for nitrites UTI is likely - it would be reasonable to
commence treatment
-- If urinalysis is positive for leucocytes but negative for nitrates, UTI is possible
- wait for culture result before starting treatment
-- If blood and / or protein are positive but leucocytes and nitrates negative then
UTI is unlikely
4. Management

onsult MO who will arrange / refer / discuss:

C
-- infants < 3 months of age with Paediatric Unit. UTI and <3 months of age treat as for pyelonephritis [4]
-- if oral antibiotics [2] MO will order:
trimethoprim + sulfamethoxazole (40 / 200 mg per 5 mL) 0.5 mL / kg /
dose bd for 5 days (equal to 4 + 20 mg / kg / dose bd) to max. of 160 +
800 mg for 5 days or
cephalexin 12.5 mg / kg up to 500 mg 6 hourly for 5 days or
amoxycillin + clavulanate 22.5 / 3.2 mg / kg up to 875 / 125 mg orally bd
for 5 days
-- for severe infection - child will require evacuation / hospitalisation
-- for all babies aged < 3 months and any child who is unwell (with high fever,
irritability, vomiting or loin pain) admission to hospital for IV antibiotics
-- MO may order commencement of IV antibiotics [2]
gentamicin 7.5 mg / kg / dose IV for one dose for children less than 10
years of age
gentamicin 6 mg / kg / dose IV for one dose for children 10 years of
age or more - then determine dosing interval for a maximum of either
1 or 2 doses based on renal function (if gentamicin is contraindicated
cefotaxime or ceftriaxone can be used IV), plus
amoxycillin / ampicillin 50 mg / kg / dose (to a maximum of 2 g) IV, 6
hourly
remember gentamicin levels [1]
-- blood cultures, electrolytes and consider a lumbar puncture [1]
5. Follow up
I f not evacuated review daily for next 2 days - if not improving, consult MO
Check results of urine MC/S (24 - 48 hours) and discuss with MO - advice on
interpreting culture results may be required

Follow up with urinalysis 1 week after treatment to indicate cure or midstream
urine for MC/S if possible
629
S
ee next MO clinic
Routine prophylaxis is no longer recommended [1]

onsult MO on all occasions of suspected UTI in children

C
All children with confirmed UTI require referral to Paediatrician
All children < 6 months of age should have a renal ultrasound
Consider renal ultrasound for older children with first UTI [1]
Micturating cysto-urethrogram (MCU) or nuclear medicine scan may be necessary
but the decision to perform this needs to be individualised in consultation with
Paediatrician [1]
References
1.
The Royal Childrens Hospital Melbourne. Urinary Tract Infection Guideline. 2008 [cited 2011 January];
8th edition: Available from: www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5241.
2.
Therapeutic Guidelines. Urinary tract infections: children 2010 [cited 2011 January].
3.
NHS choices. Urinary tract infection, children. 2010 [cited 2011]; April]. Available from: www.nhs.uk/
Conditions/Urinary-tract-infection-children/Pages/Symptoms.aspx.
4.
Royal Childrens Hospital, AntibioCard. 2011: Brisbane.
Bone or joint infections - child

Osteomyelitis and septic arthritis
Recommend
Referral to Orthopaedic Specialist if suspected osteomyelitis / septic arthritis [1]
An important consideration if a skin infection is taking a long time to resolve, or
occurs over a joint
Background
Osteomyelitis and septic arthritis can affect any joint or bone, but most commonly
involve the lower limbs [1]
Polyarthritis or aseptic monoarthritis or polyarthralgia, usually migratory (finishes in
one joint and then begins in another) is a major manifestation of acute rheumatic
fever (ARF) [2]
Related topics
Acute rheumatic fever (ARF)

Osteomyelitis

Subacute onset of limp / nonweight bearing / refusal to use limb

Localised pain and pain on
movement

Tenderness

Soft tissue redness / swelling may
not be present and may appear
late

+ / - fever
Septic arthritis

Acute onset of limp / non-weight
bearing / refusal to use limb

Pain on movement and at rest

Limited range / loss of movement

Soft tissue redness / swelling often
present

Fever

630
Consult MO

Obtain complete patient history including:

-- past episodes
-- does the patient have pain? ask them to rate?
-- when does it hurt? at rest? on movement?
-- has there been any recent trauma?
-- has the patient any skin infections currently or recently?
-- history of acute rheumatic fever
-- current medications taken
-- note patient on presentation - do they walk in? limp? hop? lean on another
person? hold their arm to chest?
-- inspect joints - is there any swelling, redness?
-- allowing for pain levels check the range of movement in affected joint
-- palpate the joint - is the joint warm to touch? is there tenderness?
4. Management

Consult MO who will arrange:

-- referral to Orthopaedic Specialist
-- FBC, ESR, blood cultures
-- may order x-ray
-- IV antibiotics
Rest and immobilise limb [1]
Treat pain and fever with paracetamol
5. Follow up
All children with suspected osteomyelitis or septic arthritis should be managed in
hospital
Consult MO on all occasions of suspected osteomyelitis and septic arthritis

Refer to Orthopaedic Specialist if osteomyelitis / septic arthritis is suspected or
confirmed [1]
References
1.
2.
The Royal Childrens Hospital Melbourne. Osteomyelitis and Septic Arthritis. 2008 [cited 2011 January]; 8th edition:
Available from: www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5234.
National Heart Foundation, RF / RHD Guideline Development Working Group, and Cardiac Society of Australia and
New Zealand, Diagnosis and management of acute rheumatic fever and rheumatic heart disease in Australia: An
evidence based review. 2006, National Heart Foundation Australia.
631
Abuse and neglect

Recommend
Do not ask child leading questions - this may taint evidence. If the child volunteers
information, write it down
Document injuries well using a body chart
In some circumstances e.g. child sexual assault (CSA), examination is best done
once. The best person to perform examination following CSA is usually a Paediatrician
or MO specialising in child sexual abuse or Forensic MO. Assessment of CSA is
complex and requires multi-agency investigation. A Child Protection Advisor (CPA)
should be consulted
Queensland legislation stipulates that all MO and RN (both public and private
sector) are mandated to report concerns to the Department of Communities Child
Safety Services, regarding children about whom they hold a reasonable suspicion of
significant harm or risk of significant harm
In addition it is Queensland Health policy that all health professionals have a duty of
care to report reasonable suspicion of child abuse and neglect to the Department of
Communities Child Safety Services [1]
Do not request STI tests in an asymptomatic child as the initial response to a suspicion
of sexual abuse
If there is a suspicion of sexual abuse, please report as indicated above
There is no screening test for child abuse - informed vigilance is required
Background
Under legislation staff do not breach professional ethics and are not liable under civil
or criminal processes if the report is made in good faith and on reasonable grounds
[1]

Relevant provision is made under legislation for information sharing to prevent
serious risk to life, health or safety [1].
Related topics
Rape / sexual assault
Failure to thrive
When considering if there is a reasonable suspicion of abuse or neglect, it is important
to identify significant harm or risk of significant harm and how that is linked to actions
or inactions of the parent

632
hysical abuse - injuries which dont fit childs developmental level or description
P
provided by parent, punching, slapping, kicking, shaking, biting, applying physical
discipline or punishment causing harm or injury. Patterned injuries including
burns and bruises
Emotional or psychological abuse - constant criticism, scapegoating, name
calling, belittling, excessive teasing, ignoring, punishing normal behaviour,
exposure to domestic and family violence, withholding praise and affection
Neglect - failing to meet the childs basic needs for adequate supervision, food,
clothing, shelter, safety, hygiene, medical care, education, love and affection and
failure to use available resources to meet those needs
Sexual abuse or exploitation - pregnancy, STI, disclosure of abuse, behaviour
change, sexualised behaviour, any sexual act or sexual threat imposed upon a
child including exposure, indecent phone calls, voyeurism, persistent intrusion of
a childs privacy, penetration, rape, incest, involvement with pornography, child
prostitution
Abuse and neglect

I f you suspect abuse always obtain advice. Consider discussing the case with
your line manager, Paediatrician, CPLO (Child Protection Liaison Officer) or CPA
3. Assessment

orming a concern or well founded suspicion is based on the presence of:

F
-- signs - injuries
-- symptoms
-- behaviours
-- and occasionally disclosures
4. Management

Treat all physical injuries appropriately

Thoroughly document any injuries using body charts
Document any disclosures using exact quotes as well as recording what question
was asked before the disclosure. Be careful not to ask leading questions

If you have concerns regarding the injuries and the cause of the injury, or any
other factor as outlined, it is recommended that you obtain advice / consult with
line manager, Senior Health Worker, Director of Nursing, CPA / CPLO / MO

Consult MO who may need to arrange evacuation

If there is reasonable suspicion of child abuse or neglect, RN and MO are
mandated to make a report immediately to Regional Intake Services and complete
the process as per Queensland Health policy. See qheps.health.qld.gov.au/csu/
reportingforms.htm

How to make a report to Child Safety Services
1. During office hours - telephone your Child Safety Regional Intake Service
(RIS) to make a verbal report
2. After hours - telephone Child Safety After Hours Service Centre 1300 681
513 Fax: 3235 9898
3. Complete the Report of Reasonable Suspicion of Child Abuse and Neglect
Form (SW010)
4. Fax a copy of the Report Form to the RIS that received your verbal report
within 7 days
5. File the original copy of the Report Form in the correspondence section of
the childs hospital record
6. Forward the yellow copy of the Report Form to your District CPLO, contact
details are available on the QHEPS site qheps.health.qld.gov.au/csu/
districtcpacplo.htm

Regional Intake Service
South East
South West
Far North Queensland
North Queensland
North Coast
Brisbane
Central Queensland
Phone number
1300 678 801
1300 683 259
1300 683 596
1300 704 514
1300 705 201
1300 705 339
1300 683 042
Fax number
3884 8802
4616 1796
4039 8320
4799 7273
5420 9049
3259 8771
4938 4697
633
Abuse and neglect
5. Follow up
Staff may be requested to provide relevant information to the Department
of Communities Child Safety Services or other prescribed entities. If staff are

unsure regarding information sharing request consultation with district medicolegal services is recommended
Document in the client record accurate, considered, objective and up to date
account of concerns, consultations, contacts, actions and plans related to
presentation as these may be requested
Ensure all information relating to the child, including immunisation status, is
current
Consult MO. Child may need evacuation

Refer parent / carer to Social Worker, non government agencies or other support
services depending on availability or Parentline 1300 301300
When considering management of children who have been abused or at risk of abuse, it
can be helpful to consider the following factors. Note: it is not the role of the MO to make a
full assessment of risk and protective factors. If abuse is suspected it must be reported to
Department of Communities - Child Safety Services, to investigate further
Risk factors and protective factors associated with child abuse and neglect

Protective indicators are safety factors that may reduce the likelihood of harm or risk
of harm to a child. They are characteristics that prevent or balance risk-producing
conditions [1]

The presence of risk factors does not confirm abuse or neglect. They are common
features of families, parents or caregivers, children and environments that research and
clinical experience have shown to increase the likelihood of child abuse and neglect [1]
It is important to remember factors need to be considered in the context of a childs personal
history. For more detail See Protecting Queensland Children: Policy Statement and
Guidelines on the management of child abuse and neglect in children and young people
0 - 18 years www.health.qld.gov.au/csu/policy.htm [1]
Resources

Queensland Health, Child Health and Safety Unit

qheps.health.qld.gov.au/csu/home.htm

Department of Communities Child Safety Services
www.childsafety.qld.gov.au

Commission for Children, Young People and Child Guardian
www.ccypcg.qld.gov.au/index.aspx

NSW Department of Community Services
w w w. c o m m u n i t y. n s w. g o v. a u / p r e v e n t i n g c h i l d a b u s e a n d n e g l e c t /
reportingsuspectedabuseorneglect.html
132 111 (24 hours)

Victorial Office For Children
www.education.vic.gov.au/officeforchildren
131 278 (24 hrs)
References
1. Queensland Health. Protecting Queensland Children: Policy Statement and Guidelines on the
management of child abuse and neglect in children and young people (0-18 years). 2008 [cited 2011
January]; Available from: www.health.qld.gov.au/csu/policy.htm.
2.
Queensland Government. What is child abuse? 2008 [cited 2011 January ]; Available from: www.
childsafety.qld.gov.au/child-abuse/index.html
634

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Section 6

Examples of positioning of children

Controlled copy V1.0

Primary Clinical Care Manual 2011

History and physical examination

Primary Clinical Care Manual 2011

Patient presentation and assessment

Controlled copy V 1.0

Standard clinical observations and other vital signs - child

Approximate normal physiological ranges for a child

O2 saturation (%) > 95%

Glasgow coma scale 15

Pain assessment in a child

Pain rating scale for children

Controlled copy V1.0

Primary Clinical Care Manual 2011

Any associated symptoms e.g. nausea, vomiting, photophobia, headache

Behaviour and activity during this illness

Primary Clinical Care Manual 2011

Controlled copy V 1.0

Appetite and fluid intake / output during this illness

Treatment and / or medication given by carer during this illness?

Family and social

Controlled copy V1.0

Primary Clinical Care Manual 2011

Standard clinical observations

Physical examination - child

Primary Clinical Care Manual 2011

Controlled copy V 1.0

Physical examination - child (continued)

-- equal chest movement

Look - are there any scars or abdominal distension / hernias

Primary Clinical Care Manual 2011

Physical examination - child (continued)

See decision making flowcharts to assist with clinical impression

Primary Clinical Care Manual 2011

Controlled copy V 1.0

Diagnostic and pathology services

If it is necessary to consult with a MO present your findings clearly and methodically

Controlled copy V1.0

Primary Clinical Care Manual 2011

Primary Clinical Care Manual 2011

Controlled copy V 1.0

Significant features of assessment unclear or you are unsure of cause?

Clinical assessment performed

Sore throat, ears,

Child with fever

Child with fever

Controlled copy V1.0

Cough +/Stridor +/Wheeze +/-

Sore throat, ears,

Basically well child

Significant features of assessment unclear or you are unsure of cause?

Clinical assessment performed

Child with cough

Child with cough

Primary Clinical Care Manual 2011

Primary Clinical Care Manual 2011

Croupy (barking) cough

Usually there is a history

Cough or wheeze may be

Gradual swelling of face,

Sudden onset in previously

Significant features of assessment unclear or you are unsure of cause?

Upper respiratory tract infection - child