PEDIATRIC

STANDARD
TREATMENT
PROTOCOLS
For new interns and non pediatric
residents in low resource settings
 OUTLINE
Respiratory Illnesses
Diarrhea
Lymphadenopathy
Headache
Pain Abdomen
Fever
Neonatal Jaundice
Scabies
Pediatric Tuberculosis
Drug Formulary

Pediatric STP
RESPIRATORY
ILLNESSES

1 | Pediatric STP
 URTIs

Rhinopharyngitis
Adenoiditis
Usually Viral
Rhinitis
Tonsillopharyngitis
Rhinosinusitis Usually Bacterial
ASOM

2 | Pediatric STP
 Cough
Coryza

Viral Bacterial

• Well Child • Sick Looking

• No pus points • Pus points
• No/non tender • Tender Lymph
lymph nodes Nodes
• Mild congestion • Deep Red
• Runny Nose Mucosa
• Family history
of running nose

Antibiotic
Treatment
Symptomatic
Treatment

Throat C/S
No Improvement Rapid Ag Test

3 | Pediatric STP
 Persistent Cough/
Rhinorrhoea/
Recurrent Rhinorrhoea

Ask for
1. h/o Mouth breathing
2. h/o Snoring
3. h/o Foreign body sensation in throat

ONLY 1 2 and/or 3

Ask for Examine Adenoids

• PND
• Sinus Tenderness

YES
X-RAY
STN

X-RAY Clinical
PNS Suspicion
Dietary
YES treatment
consult SR

NO
Treat
Sinusitis

Look for
other
causes

4 | Pediatric STP
 ASOM
Earache

Does the child have

Fever or Rhinorrhea?

YES NO

Is the tympanic Look for Wax

membrane impaction
bulging?
Treat with
solvent drops

NO YES

Otitis Otitis
Externa Media

Is there a
Age
Furuncle?

NO YES

Topical Topical
<2 yrs ≥ 2 yrs
Antibiotics Antibiotics
+
?Steroids
• Wait and
Systemic
watch
Antibiotics if
• Antipyretics
child sick
• Nasal drops

If doesn’t resolve
in 48 hrs

5 | Pediatric STP
 Influlenza

Category A Category B Category C

Category A and B
Mild fever, Cough, symptoms
Sore throat, with +
or without body Breathlesness,
aches, Headache, Ches pain,
Diarrhea & B1 B2
Drowsiness, Low
Vomiting BP, Sputum with
Category A
Category A symptoms blood, Bluish
symptoms + nails, Irritable
+ High risk groups child, worsening
High grade fever (women, Age>65y, of existing chronic
and sever sore pts. with lung, disease
No Oseltamivir
throat heart, kidney
Symptomatic
No testing disease, cancer,
Home isolation HIV)
Immediate
testing,
hospitalization and
treatment

± Oseltamivir
Symptomatic
No testing
Home isolation

6 | Pediatric STP
 LRTIs
Epiglottitis
Laryngotracheobronchitis
WALRI/Bronchiolitis
Pneumonia
Asthma Exacerbation

7 | Pediatric STP
 Fast Breathing
Coryza Always check
< 2mo -> 60
vitals first!!
2-12mo -> 50
Cough 12mo-5y -> 40
+
Noisy/Difficult Auscultate Look for cyanosis
Breathing and CRT

Stridor Wheeze Crepts

Croup Pneumonia

Asthma WALRI
exacerbation Bronchiolitis
Sick Well
Sick Well
or <3months

Oral
Refer to Admission antibiotics
Symptomatic Rx
SR ABC for 5 days

8 | Pediatric STP
 Wheeze

Asthma WALRI
exacerbation Bronchiolitis

• h/o recurrent
cough
• family hx of
atopy
• exercise cough Sick Well
• episodic cough

Admit Symptomatic Rx
• Rx with MDI
• General Measures for Rx
• Maintenance with
• Analgesics
budesonide ±
• Antipyretics
formeterol
• Citerizine
• Control with
salbutamol
• If <3yrs, teach to use
spacer wih mask

9 | Pediatric STP
DIARRHEA

10 | Pediatric STP
 RULE OUT
Diarrhoea
• Physiological stool pattern
• Incontinence/constipation
• >3episodes or >10ml/kg (Encoperesis)
of stools • Gastrocolic reflex
• consistency-watery+/- (Inadequate breast feeding)
mucus

Acute Watery Acute Bloody

Diarrhoea with SAM Persistent Diarrhoea
Diarrhoea Diarrhoea

Assess for • Antibiotics • Admit Refer to

Dehydration Cefexime or Ciproflox • Antibiotics SR
• Stool microscopy

No dehydration Some dehydration Severe Dehydration

• Active • Irritable • Lethargy

• Tears present • Tears ± • Tears abscent
• Mucosa moist • Mucosa not moist • Mucosa dry
• skin turgor normal • Skin turgor reduced • Skin turgor low
• Eyes Normal • Sunken Eyes • Sunken eyes ++

11 | Pediatric STP
 No dehydration
• ORS at 10ml/kg per stool
• Zinc supplementation
• 10mg for <6 month baby
• 20mg for >6 month baby
• Continue feeding
Severe Dehydration
• IV fluids-RL at 100ml/kg
30%
<1 year 1 hour 5 hours
>1 year 1/2 hour 2 1/2 hours
• Give ORS slowly
• Ondansetron if child is vomits
• Admit
• No role of antibiotics
Some dehydration
• ORS at 75ml/kg every 4 hours +
10ml/kg per loose stool
• Zinc supplementation
• 10mg for <6 month baby
• 20mg for >6 month baby
• Sontinue feeding
• Start IV fluids if vomiting present
• Give a trial of ondansetron in
70%
vomiting as stomach may also be
involved
• Could be viral gastritis
• Probiotics optional
• No role of antibiotics in any diarrhea
except bloody stools (dysentry)
12 | Pediatric STP
LYMPHADENOPATHY

13 | Pediatric STP
 Lymphadenopathy

>2cm Pathological

Acute Subacute Chronic

<2 weeks 2-6 weeks >6weeks

Viral Bacterial EBV TB Malignancy

• Bilateral • Unilateral
• Non Tender • Tender Fever, Anorexia Generalized
If spleen enlarged
• Recent URTI • Recent Weight loss lymphadenopathy
• Spontaneous Tonsilitis, Hx of contact and assosciated
Resolution ASOM, Dental with
• Delayed in EBV caries
• HSM
• Pan Bicytopenia
Investigate • Fever, Night
sweats, Weight
Reassure Investigate • CBC loss
• Mantoux
• CXR
• CBC • Sputum AFB
• ESR • Plan FNAC/
• Culture Biopsy

14 | Pediatric STP
HEADACHE

15 | Pediatric STP
 Headache

Runny nose + fever Sinusitis

Sick look +
Meningitis
Meningeal signs

CNS abnormality/
Intracranial SOL
Seizures

Fever+Vomiting/
Tropical Febrile Illness
abdominal pain

Check
No other correlation
Refraction

Tension Type
Migraine Headache

• <2 hour duration

• >2 hour duration
• severe frontal/
• Aura present
diffuse
• Family history +
• photophobia+
• photophobia++
• phonophobia+
• phonophobia++

• Lifestyle Modification
• NSAIDS • Analgesics
(Ibuprofen>PCM) • Fluids
• Headache diary • Triptans
• Avoid triggers -
nuts, chocolates,
coffee, pickles
• Metoclopromide Second line and
• Triptans Prophylaxis

16 | Pediatric STP
 PAIN
ABDOMEN

17 | Pediatric STP
 Pain Abdomen

Acute Chronic or Recurrent

>3 episodes in 3 months

• Rule out ACUTE ABDOMEN

• Ask for DANGER SIGNS
<2 month baby
• local tenderness
congenital causes
• weightloss
>2month-5 year old
• loss of appetite
Intususseption
• fever
Appendicitis
• night awakening
• bleeding

YES NO
• Acute Gastroenteritis/Dysentry
• Other common causes
• Constipation
• Functional abdo pain
• Dysmenorrhea (girls) USG
Likely
• Infantile coli (<4 month) Endoscopy
functional
REFER

• PPI for 4 weeks Epigastric pain

• Stress Functional
Management dyspepsia

Irritable Altered bowel habit

Bowel Sx
Cognitive
Behavioral Lactifibre or
Therapy placebo
Functional No signs
can be
used in Abd Pain Sx
any/all of
these
Abdominal h/o Migraine
NSAIDS/PCM
Migraine

hard/loose stool
Functional
Peglac/Lactulose Constipation strainy, poor pattern
recurrent fecolith

18 | Pediatric STP
FEVER

19 | Pediatric STP
 Fever Dehydration Fever

Temp >100°F M/C diagnosis in neonates

Reduce clothing and breastfeed

No localized focus Localized focus present

Tropical Febrile Illness

Running nose
See Vitals, Symptomatic Rx URTI

Cough LRTI, TB,

Bronchitis
• CBC
• LFT/KFT
• ESR
Splenomegaly
• Widal (>7days) Likely Malaria
• PS for MP
• Urine Routine
• Dengue (NS1 if <5d else
IgM ELISA) Fast breathing LRTI, WALRI,
Pneumonia

Loose stools
Antibiotics only AGE
after Ix except

Jaundice Acute
• Sick child with pending Hepatitis
reports
• Presumptive enteric fever in
high grade fever and abd.
Throat Pain/Earache
complaints* Tonsilitis

As a usual say, Amoxy-clav for Rash Viral Fever,

skin and above diaphragm Dengue
Cefixime below diaphragm
IV antibiotics in pertinent cases
Altered sensorium
Meningitis
* Due to non availability of typhidot and blood cultures

20 | Pediatric STP
NEONATAL
JAUNDICE

21 | Pediatric STP
 Neonatal Jaundice

Pathological if

• Jaundice Else
<24hrs • Jaundice with pale
• Jaundice on stools (Neonatal
palms and cholestasis)
• Jaundice in case of Physiological
soles Jaundice
Rh isoimmunization
• Any c/o kernicterus Reassure patient
(abnormal tone and
high pitched cry)
• Jauncice >14th day

Assess TSB levels

and use
AAP charts Refer to SR

Below
Phototherapy
phototherapy Exchange
range
range

Follow up SOS Phototherapy Refer to SR

22 | Pediatric STP
Indication for phototherapy

23 | Pediatric STP
Indication for exchange transfusion

24 | Pediatric STP
SCABIES

25 | Pediatric STP
 Scabies

• Prutitic Rash
• Inspect for burrows at
• Interdigits
• Genitalia
• Axilla
• Night worsening
• Similar Family history

Treatment

• 5% Permethrin cream
• Family therapy
• Overnight application
• Repeat application on
Day7-10
• Use over Head and scalp
as well in Infants
• Cetirizine/Calamine for
symptomatic relief

Suspect family miss in case of

Recurrence or no response

26 | Pediatric STP
 PEDIATRIC
TUBERCULOSIS

27 | Pediatric STP
 Pediatric TB

• Persistent fever ≥2 wks without a known

cause and/or
• Unremmiting cough for ≥2 wks and/or
• Wt loss of 5% in 3m or no wt gain in 3m

Sputum
microscopy
Sputum CBNAAT
if CBNAAT
unavailable

No MTB or
Sputum unavailable
MTB detected

Microbiologically
confirmed TB
case CXR and TST

28 | Pediatric STP
 CXR highly CXR NS shadows CXR normal CXR normal
suggestive TST - TST + TST -

Gastric aspirate or Give course of EPTB? Look for

induced sputum antibiotics Refer to SR alternate cause

Persistent shadows Gastric aspirate or

Positive Negative and symptoms induced sputum

Microbiology Clinically
confirmed diagnosed
TB case TB case
Positive Negative

Persistent
pneumonia

Refer to SR

29 | Pediatric STP
 PEDIATRIC
DRUG FORMULARY

30 | Pediatric STP
 Drugs Doses Indications

≥2 years: 400mg - On day 1 and 14

Albendazole
<2 years: 200mg Worm infestation
(Syp- 200mg/5ml)
(For NCC 15mg/kg/day BD for 7 days) NCC

URTI: 10 days, 20mg/kg Bacterial URTI

Amoxicillin
Sinusitis: 14 days, 20mg/kg Sinusitis, ASOM
(Tab- 250mg, 500mg
Acute Tonsillitis
Syp- 250mg/5ml)
LRTI: 30mg/kg TDS for 5 days Pneumonia, Pyoderma

Amoxiclav (Tab-
Same as Amoxicillin Same as Amoxicillin
250+125mg)

Azithromycin Pertussis/Enteric fever: Pertussis

(Tab- 250mg, 500mg 10mg/kg ODAC for 5 days Enteric Fever
Syp- 250mg/5ml) Other illness: 10mg/kg ODAC at day 1 fol- Third line drug for
lowed by 5mg/kg for 4 days Tonsillitis, RTI

Budesonide
2-4 puff BD in Asthma
(MDI 200 mcg/puff
(Minimum Nebulization dose 2.5 mg) Asthma, WALRI
Nebulzn: 2.5mg/ml)

Bromhex +Salbut

Syp- 2mg Salbutamol Mild to moderate wheeze

0.1 ml /kg of salbutamol TDS
/ 5ml) (WALRI)

Calcium

(Tab- 500mg Syp-

250mg/5ml) 80 mg/kg/day Calcipenic Rickets
(Syp Shelcal)

Bacterial URTI
Cefadroxil
Sinusitis, ASOM
(Syp-250 mg/5ml) 15 mg/kg/BD
Pneumonia, Pyoderma
6m -2years = 2.5 ml OD
Ceterizine
2-6 years= 2.5ml BD
(Syp- 5mg/5ml) All URTI
>6 years= 10ml HS / 5ml BD

Cefexime
UTI/Dysentery:10 mg/kg BD 7 days UTI/Desentri
(Tab- 200mg Syp-
Enteric fever: 20mg/kg BD 10-14 days Enteric fever
50mg/5ml)

31 | Pediatric STP
 Drugs Doses Indications

Chlorpheniramine URTI with wet cough

(Syp- 2mg/5ml) (All Cough Syrup Doses

0.1mg/kg TDS for 5-7 days Acc To Antihistaminic
(Mextra / Grilinctus) Content)

Ciprofloxacin Bacterial Conjunctivitis

(Eye drops) 2drops 6 hourly Ophthalmia neonatoram

Domperidone

(Syp- 1mg/ml) 0.1mg/kg/dose 8 hourly GERD Only

Diclofenac Inflammatory Arthritis

(Tab- 50mg) 0.25-1.5 mg/kg/dose to be give Abscess

Dicyclomine
Colicaid drops- 5 drops < 6months
Tab- 10mg, Drps-
6-12 months- 10 drops Infantile Colic or any colicky
10,50 mg/5ml
>12 months- 15 drops SOS pain
(Buscopan, Colicaid)

Fluconazole 3-5mg/kg/day for 7 days for disseminated disseminated fungal (skin)

(Tab- 50mg,150mg) fungal infection infection

Foracort

(MDI- Formeterol 200 Maintenance dose for Asth-

+ Budesonide 400/ 1-2 puff BD ma
puff)

Ibuprofen 5-10 mg/kg/dose

Inflammatory Arthritis
(Tab- 200mg) 6-8 hourly

Ivermectine 0.2 mg/kg single dose Drug resistant Scabies,

(Tab- 3mg/6mg) Can repeat after 2 weeks Lice, Filariasis

IFA
3mg/kg (prophylaxis for preterm baby) Don’t prescribe during acute
(Tab- 100+0.5,
Anaemia- 6mg/kg illness
Syp- 100mg/5ml)

Omeprazole
0.7mg/kg ODAC for 2 weeks Functional Dyspepsia
(Cap- 20mg)

Metronidazole Amebiasis
Amebiasis:35-50 mg/kg/day TDS 10 D
(Tab- 400mg, Anerobic Infection
Anerobic Infection: 20 mg/kg/day QDS
Syp- 200mg/5ml) Antibiotic asso diarrhea

32 | Pediatric STP
 Drugs Doses Indications

Paracetamol

(Tab- 250, 500mg, 15mg/kg/dose SOS or QDS Any type of fever or pain
Syp- 125mg/ 5ml)

Phenytoin Initial: 5 mg/kg/day BD/TDS

Seizure disorder
(Tab 100mg) Maintenance: 5-8mg/kg/day OD/BD

Ranitidine
2-4mg/kg/day BD
(Tab- 50mg, 150mg, Use is limited
For GERD 4-8mg/kg
Syp- 75mg/5 ml)

Salbutamol Syp: 0.1-0.4 mg/kg/dose TDS oral Acute asthma or WALRI

(MDI- 200 mcg/puff MDI: 1-2 puffs QDS (with SPACER for all chil-
Syp- 2mg/5ml) dren)

Sodium Valproate GTCS, Absence attack

(Tab- 200, 400mg Syp- Myoclonic

20mg/kg/day BD/TDS
200mg/5ml) Frequent febrile seizure

Tab Vit-B complex OD Malnutrition

Vit-D Normal baby: 400 IU/day for

All children < 1 year
(Cap- 60k IU SAM/Preterm: 800 IU/day
SAM, Preterm, Rickets
Syp- 400 IU/ml) Rickets 60k/week for 6 months

Prophylaxis: At risk or with

Vit-A measles, malaria, HIV,
diarrhoea
(Cap- 25k IU/16 drops) 3000 -4000 IU/day
Rx: Xerophthalmic state

Prevention of anemia of
Vit-E 1 IU/kg/day
prematurity
(Cap Evion 100IU/ Sickle cell Anemia- 450 IU/day
Sickle cell anemia
200IU/400IU) Beta-thal- 750 IU/day
Beta-thalassemia
<6 months: 25-35 mcg/day

6m-3yrs: 50 mcg/day Anemia

Folic Acid 4-6 yrs: 75 mcg/day During Phenytoin Tx

7-10: 100 mcg/day

11-14 yrs: 150 mcg/day

1-2 ml/kg/day BD/TDS for at least 3 days

Lactulose Constipation
(can be extended up to 1 year)

Prophylactic: 10mg OD
Pyridoxin INH Neuropathy
Treatment: 50mg TDS

33 | Pediatric STP
 REFERECES
Ansong-Assoku, Betty, and Pratibha A. Ankola. “Neonatal Jaundice.” In StatPearls. Treasure Island (FL): StatPearls Publishing, 2018.
http://www.ncbi.nlm.nih.gov/books/NBK532930/.

Brett, Tom, Marion Rowland, and Brendan Drumm. “An Approach to Functional Abdominal Pain in Children and Adolescents.” The
British Journal of General Practice 62, no. 600 (July 2012): 386–87. https://doi.org/10.3399/bjgp12X652562.

Gunning, Karen, Karly Pippitt, Bernadette Kiraly, and Morgan Sayler. “Pediculosis and Scabies: A Treatment Update.” American
Family Physician 86, no. 6 (September 15, 2012): 535–41.

Hyperbilirubinemia, Subcommittee on. “Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation.”
Pediatrics 114, no. 1 (July 1, 2004): 297–316. https://doi.org/10.1542/peds.114.1.297.
Indian Academy of Pediatrics. “The Respiratory Tract Infections - Group Education Module, RTI - GEM,” 2006. https://www.iapindia.
org/retrain.php.

Kelly, Meaghan, Jeffrey Strelzik, Raquel Langdon, and Marc DiSabella. “Pediatric Headache: Overview.” Current Opinion in Pediatrics
30, no. 6 (December 2018): 748–54. https://doi.org/10.1097/MOP.0000000000000688.

Mahajan, Prashant, Prerna Batra, Neha Thakur, Reena Patel, Narendra Rai, Nitin Trivedi, Bernhard Fassl, et al. “Consensus Guidelines
on Evaluation and Management of the Febrile Child Presenting to the Emergency Department in India.” Indian Pediatrics 54, no. 8
(August 1, 2017): 652–60. https://doi.org/10.1007/s13312-017-1129-8.

Poddar, Ujjal. “Approach to Constipation in Children.” Indian Pediatrics 53, no. 4 (April 2016): 319–27.
Singhi, Sunit, Dhruva Chaudhary, George M. Varghese, Ashish Bhalla, N. Karthi, S. Kalantri, J. V. Peter, et al. “Tropical Fevers:
Management Guidelines.” Indian Journal of Critical Care Medicine 18, no. 2 (February 1, 2014): 62. https://doi.org/10.4103/0972-
5229.126074.

Revised National Tuberculosis Control Program, RNtCP Guidelines, 2017

34 | Pediatric STP
 DISCLAIMER
These guidelines have been prepared based on the evidence from the references above as well as on the
locally practiced and expert opinion. They are meant to be used for educational purposes of interns, MBBS
doctors, and non-pediatric junior residents. These protocols are designed for resource-limited settings where
specialized investigations are scarcely available. Practical application of this protocol may be suitable only
for such areas and those predominantly having an outpatient practice. Hence, many algorithms have been
oversimplified to improve applicability and usage.

This document does not mean that the above content stands perfect and is subject to change as per the
regional guidelines, norms, practice as well as the clinical expertise of the personnel using the algorithms; as
well as a possibility of subjective error due to creation via single person only. This document is not meant for
practicing pediatricians/nursing staff/midwives/ASHA workers.

The guidelines used in this document largely include expert knowledge, clinical practice guidelines, and
available evidence. The content of this document is subject to change with availability of fresh evidence
and shall be modified periodically. Any errors if present is not subjectable to any medicolegal suits or legal
jurisprudence. Proofreading and editorial review is subject to identification of errors and misinterpretations
along the course of the project and sustenance cycles.

35 | Pediatric STP
 Made by -

Dr. Ayush (Pediatric Senior resident)

Dr. Vasishta Polisetty and Dr. Nabi Darya Wali
(Batch of 2014, MBBS Interns)
All India Institute of Medical Sciences, New Delhi

36 | Pediatric STP