primary care manual of paediatrics

Section 6

Paediatrics

Primary Clinical Care Manual 2011 Controlled copy V1.0544

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 childrenfor examination of throat and ears

Primary Clinical Care Manual 2011 Controlled copy V 1.0 545


History and physical examinationchild

Recommend � Use of Children’s 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: [email protected]

� 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 > 38°C or < 35.5°C-- 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 nailsAssessment of the eyeAssessment of ear Abuse and neglect - childMental health assessmentMedication reconciliationMedication history checklistGlasgow Coma Scale / AVPU



Standard clinical observations and other vital signs - child Approximate normal physiological ranges for a child

Parameter Normal range <1 year 1 - 2 years 2 - 5 years 5 - 12 years > 12 years

Standard clinical observations

HR(beats per min) 110 - 160 100 - 150 95 - 140 80 - 120 60 - 100

Respiration rate (breaths / min) 30 - 40 25 - 35 25 - 30 20 - 25 15 - 20

Temperature

Axilla - clinically significant fever > 37.8°C (37.2°C *)Sublingual - clinically significant fever > 38.0°C (37.5°C *)Rectal - clinically significant fever > 38.5°C (38.0°C *)* clinically significant fever lower in infants < 3 months of age

Other vital signs if indicated

Blood pressure (mmHg)

Systolic > 60

Systolic > 70

Systolic > 75

Systolic > 80

Systolic > 90

Respiratory distress Nil

O2 saturation (%) > 95%

Capillary refill time Less than or equal to 2 secs

Level of consciousness

Glasgow coma scale 15 AVPU tool - alert

Blood glucose level 4 - 8 mmol (random capillary)

[1] [8]

Pain assessment in a childRate 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 Children’s Early Warning tools (CEWT) for pain assessment tools

Pain rating scale for children



Presentation• When a child presents for health care the clinician is required to gather an orderly

collection of information to identify the patient’s 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 historyThere 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 burningRadiation - 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?



• 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 historyPast medical and surgical history

• 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?

Family and social history

• 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?

Medications • 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

Allergies • 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?

Immunisations • Check if up to date • Documented evidence of immunisation status should be obtained, follow

up with opportunistic immunisation See Immunisation program



Standard clinical observationsAll children presenting for acute care

• Temperature, HR, respiratory rate• If indicated:

-- 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 carer’s 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 - childGeneral appearance

• Does the child look well or sick?• Alert or drowsy? Altered conscious state? See Glasgow coma scale / AVPU• 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



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 system

• Skin colour - pink, white, grey mottling? Compare the trunk with the limbs • Skin temperature - hot, warm, cool, cold, sweating? Compare the trunk with the

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 system

• Most information is gained through inspection • Inspect anterior / posterior chest:

-- 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

Gastro-intestinal and reproductive systems

• 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 system

• A detailed assessment of the nervous system in a child is both technically difficult 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 child’s 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 handsMusculo-skeletal system

• Full range of movement in limbs, joints and muscles?• 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 throat

• Ears-- 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



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 clinician’s 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&DocumentInstanceID=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

References1. Pemsoft®. Normal vital signs. 2008-2011 [cited 2011 August].2. The Royal Children’s 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 O’Connor S., A systematic guide to physical diagnosis: clinical examination. 6th ed. 2010,

Australia: Churchill Livingstone: Elsevier.5. Murtagh J. and Rosenblatt J., John Murtagh’s 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., Macleod’s 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.



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Child with stridor


Paediatric presentationC

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with

vom

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Child with vomiting



Child with abdominal pain

See Criteria for Early Notification of Trauma for Interfacility Transfer

Consult MO

Consider UTISee Urinary tract infection - child

Consider pneumoniaSee Pneumonia - child

Consider gastroenteritisSee Child with vomiting / fever / chronic diarrhoea

Consider constipationSee Constipation

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

Any history of significant trauma?

Bile-stained vomiting?Bloody stool?

Localised tenderness?Distension?Guarding?

Rebound tenderness?Palpable mass?

Inguinal-scrotal pain or swelling?

Positive urine dipstick for leukocytes, nitrates or blood;

or bacteria on microscopy

Fever +/- TachypnoeaRecession

CoughChest pains

Diarrhoea +/- vomiting / fever

Firm stool palpable in lower abdomen?

Consult MO



Child with chronic diarrhoea

Consult MO

Treat if positive for giardia or intestinal worms. Consult MO if other +ve result

See Lactose intolerance

No

No

No

Yes

Yes

Yes

Clinical assessment performed

Is test positive?

Well hydrated, normal growth and development, adequate diet

Test for lactose intolerance See Lactose intolerance

Consider significant features of asssessment

Consult MO

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

Obtain faeces sample for MC/S and OCP

Is test positive?

Bloody diarrhoea Mucus in diarrhoea

Abdominal pain

Perianal itch Sighting of worms

in faeces

Foul smelling, watery diarrhoea

Flatulence Nausea

See Giardiasis

See Intestinal worms


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 child’s conscious state. Their concerns should not be ignored

� Perform hearing test 3 months after discharge from hospitalBackground

� 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 Immunisation program

DRS ABCD resuscitation / the collapsed patientO2 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• Consult MO immediately• 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)


Meningitis

• In 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• Obtain as complete a patient history as possible according to the circumstances

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• Consult MO who will arrange / order:

-- 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

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


Respiratory problems

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 Children’s Hospital. Fluid management in meningitis. 2005 [cited 2011 March ].2. The Royal Children’s 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 - childCommon 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 Immunisation program Pneumonia Acute otitis media

Pertussis (whooping cough)Croup / epiglottitisBronchiolitis

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

3. Clinical assessment• Take patient history including:

-- past episodes, history of asthma, complications such as ARF / APSGN-- otitis media, measures taken to treat including medications taken

• Perform standard clinical observations + -- 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



-- palpate 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• Consult MO if

-- < 3 months of age -- < 1 year with respiratory rate more than 40 respirations per minute (rpm)

○ 1 - 2 years more than 35 rpm ○ 2 - 5 years more than 30 rpm ○ 5 - 12 years more than 25 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 38°C-- 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 (>38°C) 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




• For the child with indicators for antibiotic treatment present and if not allergic treat with oral penicillin:

Schedule 4 Phenoxymethylpenicillin DTPIHW / SM R&IP / IPAP

Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NPScheduled Medicines Rural & Isolated Practice Registered Nurses may proceed

Form Strength Route of administration

Recommended dosage Duration

Capsule 250 mg500 mg Oral

Child15 mg / kg / dose bd

to a max. of 500 mg bd10 days

Suspension 150 mg / 5 mLProvide Consumer Medicine Information: should be taken on an empty stomach; ½ to 1 hour before meals. Ensure full course is completedManagement of associated emergency: as for severe allergic reactions See Anaphylaxis

[1]

• If a lack of observance with oral medication is anticipated or those intolerant of oral therapy treat with IM penicillin:

Schedule 4 Benzathine penicillin(Bicillin LA)

DTPIHW / SM R&IP / IPAP




Disposable syringe 900 mg IM

3 kg - < 6 kg 225 mg 6 kg - < 10 kg 337.5 mg10 kg - < 15 kg 450 mg 15 kg - < 20 kg 675 mg

>20 kg 900 mg

Stat

Use a concentration of 442 mg / mL when measuring part doses. Refer to product information Provide Consumer Medicine InformationManagement of associated emergency: as for severe allergic reactions See AnaphylaxisAdministration 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 needle and deliver injection very slowly (2 minutes)[1]

• If allergic to penicillin, treat with roxithromycin:



Schedule 4 Roxithromycin DTPIHW / SM R&IP / IPAP




Tablet for suspension 50 mg

OralChild

4 mg / kg / dose bdto a max. of 150 mg bd

10 daysTablet 150 mg

300 mgProvide Consumer Medicine Information: should be taken on an empty stomach, 15 minutes before food; ensure course is completedManagement of associated emergency: consult MO

[1]

5. Follow up Review next day, if not improving consult MO If antibiotics have been given for sore throat:

-- review 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 Consult 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 Immunisation program URTI



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

2. Immediate management • If severe consult MO immediately

3. Clinical assessment• See Upper respiratory tract infection • 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• Consult MO who may advise:

-- 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

6. Referral / consultation Consult MO on all occasions whooping cough is suspected



Croup / epiglottitis

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 >38.5°C-- septicaemia-- looks sick-- drooling saliva-- unable to eat or drink-- doesn’t talk-- any age-- reluctant to move neck

• Croup-- croupy (barking) cough-- temperature <38.5°C (however viral croup

often has a high temperature)-- no systemic disturbance-- able to swallow-- will usually drink-- normal or hoarse voice

2. Immediate management• Consult MO as soon as circumstances allow• 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

3. Clinical assessment• Obtain patient history including onset and preceding URTI• 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

• 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



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

6. Referral / consultation 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 Upper respiratory tract infection - child 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

2. Immediate management • Consult MO• If severe give O2 to maintain O2 saturation >95%. If >95% not maintained consult

MO. See O2 delivery systems



3. Clinical assessment• Obtain complete patient history of particular importance is:

-- 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• Perform physical examination:

-- 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• Consult MO who will consider treating similar to:

-- 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 Patients who are not evacuated / hospitalised should be reviewed daily Consult MO if the patient is not improving

6. Referral / consultation 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 vomitingBackground� Children with co-existent illnesses are more at risk. Examples are bronchiolitis and

chronic lung disease e.g. due to prematurity

Related topics Upper respiratory tract infection - child Immunisation program

Bronchiolitis

1. May present with• Cough dry or with sputum, fever, tachycardia • Rapid breathing, nasal flaring, grunting respirations and chest recession in infants,

cyanosis, apnoea in infants



Child < 3 monthsContact MO immediately

Child3 months - 1 yr

Child1 - 4 yrs

Child over 4 yrs

Resps≥40 / minand / or

recessiongruntingapnoeacyanosis

Resps<40 / min

Resps ≥40 / minand / or


Resps<40 / min

Resps ≥30 / minand / or


Resps<30 / min

Resps≥25 / minand / or


Resps<25 / min

Mild pneumonia or consider other diagnosis

2. Immediate management • If severe administer O2 to maintain O2 saturation >95%. If >95% not maintained

consult MO. See O2 delivery systems• Consult MO

3. Clinical assessment• Obtain patient history including:

-- 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

• Perform standard clinical observations +-- O2 saturations. Note in particular respiratory rate and temperature

• Perform physical examination including:-- 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• Consult MO using the following flow chart as a guide only, to be used in conjunction

with CEWT for rural and remote facilities

Moderate or severe

pneumonia



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 Hartmann’s 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 Consult MO if the patient is not improving See next MO clinic

6. Referral / consultation Consult MO on all occasions pneumonia is suspected Some children with pneumonia will require a paediatric referral

References1. 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 Children’s Hospital. Croup (Laryngotracheobronchitis). 2009 [cited 2011 March ].


Immune complications

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

2. Immediate management • If fitting see Fitting / convulsions / seizures

3. Clinical assessment• 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• Perform standard clinical observations +

-- 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 • Perform physical examination including:

-- 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)

Upper limits of normal BP for boys at 50th percentile for height and weight [1] 1

year

2 ye

ars

4 ye

ars

6 ye

ars

8 ye

ars

10 ye

ars

12 ye

ars

14 ye

ars

16 ye

ars

> 17

year

s

BP upper level of normal

systolic 103 106 111 114 116 119 123 128 134 136diastolic 56 61 69 74 78 80 81 82 84 87



Upper limits of normal BP levels for girls at 50th percentile for height and weight [1] 1

year

s

2 ye

ars

4 ye

ars

6 ye

ars

8 ye

ars

10 ye

ars

12 ye

ars

14 ye

ars

16 ye

ars

> 17

year

s

BPupper level of normal

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• 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



Schedule 4 Benzathine penicillin(Bicillin LA)






3 kg - < 6 kg 225 mg6 kg - < 10 kg 337.5 mg10 kg - < 15 kg 450 mg 15 kg - < 20 kg 675 mg

20 kg > 900 mg

Stat

Use a concentration of 442 mg / mL when measuring part doses. Refer to product information Provide Consumer Medicine InformationManagement of associated emergency: as for severe allergic reactions See AnaphylaxisAdministration tips - as per patient preference:-- apply EMLA cream to the injection site 30 - 60 minutes prior to injection and allow medication to warm


site) 30 seconds prior to the injection, use 21 gauge needle and deliver injection very slowly (2 minutes)[1]

• if allergic to penicillin, give oral roxithromycin [3]





Tablet for suspension 50 mg

OralChild

4 mg / kg / dose bdto a max. of 150 mg bd

10 daysTablet 150 mg

300 mg Provide Consumer Medicine Information: should be taken on an empty stomach, 15 minutes before food. Ensure full course is completedManagement of associated emergency: consult MO

[1]

• If treatment for hypertension and / or heart failure required, contact MO immediately



5. Follow up Most 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 Refer 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

6. Referral / consultation Consult 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

References1. 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].



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 - child Upper respiratory tract infection - adult Bacterial skin infections 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 (Sydenham’s

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




3. Clinical assessment• 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

• Perform standard clinical observations +-- O2 saturations

• Perform physical examination: -- 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• 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 Sydenham’s chorea can occur after all other signs and symptoms have resolved, it can be used alone to confirm the diagnosisA 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 infectionMajor manifestations• Polyarthritis or aseptic monoarthritis or

polyarthralgia. Usually migratory i.e. finishes in one joint, begins in another

• Chorea - strange jerky movements of the trunk and / or limbs which the patient cannot 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]

Minor manifestations• History of fever or presenting fever >38ºC• Laboratory / other clinical findings:

-- elevated acute phase reactants - ESR ≥ 30 mm/hr or CRP ≥ 30 mg / L

-- prolonged PR interval on ECG

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 ≥ 38°C• 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



• 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 See Simple analgesia back cover

Schedule 4 Benzathine penicillin (Bicillin LA)

DTP IHW / IPAP

Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NP




Child < 20 kg450 mg

Adult / child ≥ 20 kg 900 mg

Stat

Use a concentration of 442 mg / mL when measuring part doses. Refer to product information Provide Consumer Medicine Information Management of associated emergency: as for severe allergic reactions. See Anaphylaxis Administration tips - as per patient preference:-- apply EMLA cream to the injection site 30 - 60 minutes prior to injection and allow medication to warm


site) 30 seconds prior to the injection, use 21 gauge needle and deliver injection very slowly (2 minutes) [1] [2]

• If reliably documented allergy to penicillin treat with erythromycin [1]• If penicillin allergy not reliably documented arrange for testing in hospital

Schedule 4 Erythromycin DTP IHW / IPAP




Capsule 250 mg

Oral

500 mg bd

10 daysSuspension 200 mg / 5 mL 20 mg / kg / dose bd

to a max. of 500 mg bd

Provide Consumer Medicine Information: take with foodManagement of associated emergency: as for severe allergic reactions. See Anaphylaxis

[1]

5. Follow up Assign an individualised management plan based on ARF and absence or



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 ([email protected]) 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

6. Referral / consultation Consult MO on all occasions of suspected ARF Consult MO for anticoagulation therapy / INR range Refer to Paediatrician within 3 months of diagnosis

References1. 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].


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 / carer’s 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 o’clock, left ear at 7 o’clock • Handle of malleus - right ear 1 o’clock, left ear 11 o’clock• Is the ear drum intact? bulging? retracted?• Is there fluid or air / fluid or bubbles behind the ear drum?

LeftRight


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

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

Attic perforation - unsafe perforation

Safe perforation


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 - children’s hands and faces should be washed. Transmission

of bacteria causing otitis media is often from other children’s 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


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 Upper respiratory tract infection - child Pneumonia Acute asthma

BronchiolitisAssessment of the ear

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


3. Clinical assessment• 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


• Consult MO if child:-- < 3 months of age, who is sick or hot-- temperature over 38° C or below 36°C-- 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]


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

Schedule 4 Amoxycillin DTPIHW / 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



Capsule 250 mg 500 mg Oral

Adult and child25 mg / kg / dose bdto a max. of 1 g bd

7 daysSuspension 125 mg / 5 mL

250 mg / 5 mLProvide Consumer Medicine Information Management of associated emergency: as for severe allergic reactions. See Anaphylaxis

[4] [6]

• If 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

Schedule 4 Procaine penicillin DTPIHW / SM R&IP / IPAP



Recommendeddosage Duration

Disposable syringe 1.5 g IM

Adult1.5 g daily

Child 50 mg / kg / dose dailyto a max. of 1.5 g daily

5 days

Provide Consumer Medicine Information Management of associated emergency: as for severe allergic reactions. See Anaphylaxis 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 needle and deliver injection very slowly (2 minutes)[3] [4]

• If allergic to penicillin, treat with roxithromycin


Ear problems





Tablet 150 mg300 mg

Oral

Adult 300 mg daily

10 daysTablet for suspension 50 mg


to a max. of 150 mg bdProvide Consumer Medicine Information: should be taken on an empty stomach, 15 minutes before food. Ensure course is completedManagement of associated emergency: consult MO

[5]

5. Follow up Review 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 child’s 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]

6. Referral / consultation Consult 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


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 Immunisation program


1. May present with• Usually is asymptomatic • Parents may be concerned about the child’s 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


3. Clinical assessment• Obtain a complete patient history. See Assessment of the ear• Perform standard clinical observations • 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









[4] [6]

• 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

6. Referral / consultation Next 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


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 spearBackground

� 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 Chronic suppurative otitis media (CSOM)

Cleaning technique for ears with dischargeAssessment of the ear

1. May present with• Presents with onset of ear discharge for < 6 weeks• Child may often have symptoms of acute otitis media - pain, fever


3. Clinical assessment• Obtain a complete patient history. See Assessment of the ear • Document length of time perforation has been present • Perform standard clinical observations • 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• 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










[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

Schedule 4 Procaine penicillin DTPIHW / SM R&IP / IPAP




Disposable syringe 1.5 g IM

Adult1.5 g daily

Child 50 mg / kg / dose

to a max. of 1.5 g daily

5 days

Provide Consumer Medicine Information Management of associated emergency: as for severe allergic reactions. See Anaphylaxis 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 needle and deliver injection very slowly (2 minutes) [4]


Ear problems

• If allergic to penicillin and has perforation for less than 6 weeks treat with roxithromycin





Tablet 150 mg300 mg

Oral

Adult 300 mg daily

10 daysTablet for suspension 50 mg


to a max. of 150 mg bdProvide Consumer Medicine Information: should be taken on an empty stomach, 15 minutes before food. Ensure course is completedManagement of associated emergency: consult MO

[5]

• If discharge present for longer than 14 days MO may add ciprofloxacin drops

Schedule 4 Ciprofloxacin hydrochlorideear drops

DTP IHW

Ciprofloxacin hydrochloride ear drops must be ordered by MO / NP. MO / NP note restrictionsAuthorised Indigenous Health Workers can only administer on MO / NP order



Ear drops Ear drops (0.3%) Topical Instil 5 drops in

affected ear bd Until the ear is dry

or 9 days Provide Consumer Medicine Information: if not drying in 2 weeks check with family on ability to clean and instil dropsManagement of associated emergency: as for severe allergic reactions. See Anaphylaxis 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]

5. Follow up Review the patient in 2 days 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


Ear problems

6. Referral / consultation Consult 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)

CholesteatomaCleaning technique for ears with chronic dischargeAssessment of the ear

1. May present with• Intermittent and continuous ear discharge often associated with poor hearing

leading to learning difficulties

2. Immediate management• Consult MO if perforation found in attic region (unsafe perforation) of the ear

drum See Assessment of the ear

3. Clinical assessment • Obtain a complete patient history. See Assessment of the ear • Document length of time discharge has been present• Perform standard clinical observations • 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 day1. Ciprofloxacin ear drops2. 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


Ear problems

• In 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

Schedule 4 Ciprofloxacin hydrochlorideear drops

DTP IHW

Ciprofloxacin hydrochloride ear drops must be ordered by MO / NP. MO / NP note restrictionsAuthorised Indigenous Health Workers can only administer on MO / NP order



Ear drops 0.3 % Topical Instil 5 drops in affected ear bd

Until the ear is dry or 9 days

Provide Consumer Medicine Information Management of associated emergency: as for severe allergic reactions. See Anaphylaxis 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


• or

Schedule 4Sofradex ® ear drops

(Dexamethasone 0.5 mg / Framycetin Sulphate5 mg / Gramicidin 0.05 mg / mL)





Ear drops See above Topical 3 drops qid

Until the middle ear has been free of discharge

for at least 3 daysDo not administer longer

than 7 daysProvide Consumer Medicine Information: evidence of ototoxicity - limit treatment to no longer than 7 daysManagement of associated emergency: consult MOAdministration 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 • Apply tragal pressure (pressing several times on the flap of skin in front of ear canal) after the drops



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

6. Referral / consultation For 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


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 • 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 homeEquipment• 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 earTechnique1. 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 ear5. Dry the ear canal using tissue spears (see details)

Tissue spear method (dry mopping)• 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 WorkerTechnique1. Make a spear by twisting corner of tissue paper 2. Insert into ear gently, twisting slowly3. Stop when child blinks4. Leave in place for 30 seconds then remove and repeat until tissue tip is dry5. Perform at least twice per day until the ear is dry

Topical antibiotics and other ear drops with dry mopping• The patient should be sitting or lying down with the affected ear upwards • 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


3. Clinical assessment• Obtain a complete patient history. See Assessment of the ear• Perform standard clinical observations • 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 • Consult MO for antibiotic order • 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®”

6. Referral / consultation 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 lesionBackground

� 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 Assessment of the ear

1. May present withIf 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


Ear problems

2. Immediate management• Consult MO for referral to Paediatrician or ENT Specialist

3. Clinical assessment • Obtain a complete patient history. See Assessment of the ear• Perform standard clinical observations • Perform physical examination. See Assessment of the ear

-- 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

6. Referral / consultation 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

2. Immediate management• Consult MO immediately

3. Clinical assessment• Obtain a complete patient history. See Assessment of the ear• Perform standard clinical observations • 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• Consult MO who will arrange:

-- 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

6. Referral / consultation Urgent referral to Paediatrician and ENT Specialist

Otitis externaSwimmer’s 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 topicsEarwick techique for otitis externaAssessment of the ear

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


3. Clinical assessment• Obtain a complete patient history. See Assessment of the ear• Perform standard clinical observations • Perform physical examination. See Assessment of the ear

-- often very painful on movement of the pinna - approach gently

4. Management • Consult MO if fever, cellulitis or enlarged pre / post auricular lymph nodes • Give analgesia


• Gentle cleaning with dry mopping to keep the ear canal dry, then installation 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


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 length2. 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


(Dexamethasone 0.5 mg / framycetin sulphate 5 mg / gramicidin 0.05 mg / mL)





Ear drops See above

Topical - drops 3 drops tds 7 days

Topical - earwick Soaked gauzeWick left in canal for 2 days

then review

Provide Consumer Medicine Information Management of associated emergency: consult MOAdministration tip - drops• 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 • 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 Administration tip - earwick• Remove the wick using forceps. Inspect and clean the ear. Reinsert if required

[10]

• or


Ear problems

Schedule 4 Flumethasone 0.02% + clioquinol 1%





Ear drops As above Topical - ear wick Soaked gauze The wick is left in the canal for 2 days then review

Provide Consumer Medicine Information Management of associated emergency: consult MOAdministration tip - earwick• Remove the wick using forceps. Inspect and clean the ear. Reinsert if required

[10]

• or

Schedule 4 Triamcinolone compound (Kenacomb®)





Ointment

Triamcinolone 0.1 %Neomycin 0.25 %

Gramicidino 0.025 %Nystatin 100,000

units / g

Topical - ear wick Ointment soaked gauze

The wick is left in the canal for 2 days then review

Provide Consumer Medicine Information Management of associated emergency: consult MOAdministration tip - earwick• Remove the wick using forceps. Inspect and clean the ear. Reinsert if required

[4]

5. Follow up Review 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

6. Referral / consultation Otitis 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


Ear problems

Traumatic rupture of the ear drum

Related topics Trauma to teeth Head injuries

Eye injuriesFractured 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

2. Immediate management• Management of life threatening injuries

3. Clinical assessment• 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?

• Perform standard clinical observations + -- conscious state if applicable

• Perform physical examination. See Assessment of the ear-- note other injuries if present

4. Management• Consult MO who will advise antibiotic ear drops if water penetrated the perforation

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 Review in 2 days and then weekly If perforation not healed in 2 weeks, consult MO

6. Referral / consultation Consult MO on presentation and if perforation not healed in 2 weeks


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


3. Clinical assessment• Obtain a full history including circumstances (accidental, purposeful, incidental

finding)• Perform standard clinical observations • Examine the ears. See Assessment of the ear

4. Management• Consult MO unless small object and seen to be near external ear opening and

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


(Dexamethasone 0.5 mg / Framycetin Sulphate 5 mg / Gramicidin 0.05 mg / mL)





Ear drops See above Topical - drops 3 drops tds - qid 7 days

Provide Consumer Medicine Information Management of associated emergency: consult MOAdministration 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• Apply tragal pressure (pressing several times on the flap of skin in front of ear canal) after the drops



Ear problems

5. Follow up If foreign body or insect easily removed, review in 2 days Review as per Otitis externa if secondary infection occurs after removal

6. Referral / consultation Consult MO as per Otitis externa if secondary infection occurs after removal

References1. 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.


Gastrointestinal problems

Acute gastroenteritis and dehydrationVomiting 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 38°C or under 35.5°C -- 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

2. Immediate management• Perform standard clinical observations +

-- O2 saturations-- level of consciousness

• Consult MO immediately if any risk factors present or moderate / severe dehydration

• Commence rehydration according to MO advice



3. Clinical assessment• Obtain a complete history including:

-- 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?• Perform standard clinical observations +

-- 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

• Perform physical examination: -- degree of dehydration

Clinical assessment of hydration in children

To assess the child for dehydration

No signs Mild < 5%

Some signsModerate 5 - 10%

Definite signsSevere > 10%

Eyes normal sunken very sunken and dryMouth and tongue moist dry very dry

Condition alert restless, irritable, lethargic

extreme lethargy “ragdoll appearance”

Thirst drinks normally, may be thirsty thirsty, drinks eagerly drinks poorly or

not able to drinkRespiratory rate normal increased fastPulse normal fast fast, weak, threadyCapillary 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 MORequires resuscitation



4. Management• Consult MO immediately - for those children with risk factors or moderate / severe

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 ExampleOral 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

waterSoft 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



No

No

NoYes

Yes

Yes

Rehydration

Diagnosis of Gastroenteritis in

doubt?Consult MO for input on

managementSignificant co-morbidities or risk factors such as age < 3 months, febrile

MO may consider

ondansetron wafer

Trial of oral fluids 10 - 20 mL

/ kg for 1 hour unless severe dehydration

Vomiting prominent?

Assess dehydration

Assist carers to give child small amounts

of oral fluids frequently Continue

breastfeeding / bottle feeding

Mild

Consult MO Requires urgent

rehydration nasogastric / IV.

MO may organise evacuation /

hospitalisation

Moderate

Consult MO urgently who will organise

evacuation / hospitalisation IV / IO insertion

Commence bolus of 20 mL / kg

normal saline

Severe

• 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-- 6 - 10 years 100 - 120 mL each hour-- 11 - 16 years 120 - 160 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

Management of dehydration in children flow chart [1]



• 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 child’s 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 kg0 - 6 hours

Give oral / NGT fluid replacement (mL / hr)

7 - 24 hours (following previous column doses) Give oral / NGT fluid replacement

(mL / hr)3 30 204 40 305 50 356 60 407 70 458 80 509 90 55

10 100 6012 120 6515 150 7020 200 8530 300 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



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 Hartmann’s

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



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 baby’s 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 child’s 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

6. Referral / consultation 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



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 topicsAcute gastroenteritis and dehydrationFailure to thriveNappy rashChild with chronic diarrhoea flow chart

1. May present with• Chronic diarrhoea, bloating, vomiting, irritability• Stool may be “frothy” • Perianal area may be scalded


3. Clinical assessment• Obtain a complete patient history• Perform standard clinical observations +

-- 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• Consult MO if suspect lactose intolerance and refer to next MO clinic• 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®

-- don’t 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

6. Referral / consultation Consult 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 Acute gastroenteritis and dehydration

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


3. Clinical assessment• Perform standard clinical observations +

-- weigh - use naked weight in young children and record against most recent weight

• Collect a faeces specimen for MC/S and OCP (ova, cysts and parasites) x 2• Perform physical examination:

-- 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• Encourage oral fluids• 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



Schedule 4 Tinidazole DTPIHW / SM R&IP / IPAP




Tablet 500 mg Oral

Adult2 g

StatChild 50 mg / kg / doseto a max. of 2 g

Provide Consumer Medicine Information: take dose after food. When possible, the tablets should be dosed whole as the drug’s 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 flavouringManagement of associated emergency: consult MO

[4]

• or

Schedule 4 Metronidazole DTPIHW / SM R&IP / IPAP




Tablet 200 mg400 mg

Oral

Adult2 g daily


Child 30 mg / kg / dose dailyto 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 foodManagement of associated emergency: consult MO

[4]

• If the above treatment fails a longer course of metronidazole is sometimes required or diagnosis should be reconsidered

5. Follow up Review 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

6. Referral / consultation Consult MO as above



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• Perianal / perineal itch - pinworm (thread worm), small threadlike worm may be

seen (doesn’t cause diarrhoea or failure to thrive)• Anaemia - hookworm• Acute diarrhoea - strongyloides• Failure to thrive - strongyloides can contribute



-- -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?

• Perform standard clinical observations +-- weigh - use naked weight in young children and record against most recent

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• Perform physical examination:

-- 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



Treatments for common worms [5] Drug Worm

Pyrantel (Combantrin®)Threadworm (pinworm) HookwormRoundworm

Mebendazole (Vermox®)

Threadworm (pinworm)HookwormRoundworm Whipworm

Albendazole

Threadworm (pinworm)HookwormRoundwormStrongyloidiasisWhipworm

Praziquantel Beef tapeworm and pork tapeworm Dwarf tapeworm

Ivermectin Strongyloidiasis

Schedule 2 Pyrantel embonate (Combantrin®)

DTPIHW / IPAP

Authorised Indigenous Health Workers and Isolated Practice Area Paramedic may proceed



Tablet 125 mg250 mg Oral 10 mg / kg / dose

to a max. of 1 g

StatRepeat after 7 days if

heavy infestationSuspension 50 mg / mL

Provide Consumer Medicine Information: for use in children < 6 months of age and pregnant womenManagement of associated emergency: consult MO

[5]

• Reassurance, education and advice regarding hand-washing and personal 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]



Schedule 4 Albendazole DTPIHW / SM R&IP / IPAP




Tablet 200 mg400 mg Oral

Threadworm (pinworm), hookworm, roundworm

Adult 400 mg

Child ≤10 kg give 200 mg

Stat

Strongyloidiasis, whipwormAdult

400 mg dailyChild

≤10 kg give 200 mg daily

3 days

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 stomachManagement of associated emergency: consult MO

[5]

• or

Schedule 2 Mebendazole (Vermox®)

DTPIHW / IPAP

Authorised Indigenous Health Workers and Isolated Practice Area Paramedic may proceed



Tablet 100 mg

Oral

Theadworm (pinworm)Adult

100 mg Child

≤10 kg give 50 mg

Stat

Suspension 100 mg / 5 mL

Whipworm, hookworm, roundworm

Adult 100 mg bd

Child ≤10 kg give 50 mg bd

3 days

Provide Consumer Medicine Information Management of associated emergency: consult MO

[5]

5. Follow up See at next MO clinic if anaemia or weight loss / failure to thrive

6. Referral / consultation Consult MO as above



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)


3. Clinical assessment• 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 child’s behaviour?-- what is there urinary output history? are they bedwetting? daytime wetting?-- is the child on medication?

• Perform standard clinical observations + -- weigh - use naked weight in young children and record against most recent-- plot growth and height / length

• Perform physical examination: -- 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

6. Referral / consultation Consult MO if constipation is severe, or the child is unwell in any other way 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



Pyloric stenosis

Recommend� Consult MO immediately � 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 topicsAcute gastroenteritis and dehydration

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

2. Immediate management• Consult MO if child dehydrated


-- 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

• Perform standard clinical observations +-- weigh - use naked weight in young children and record against most recent

recorded weight • Perform physical examination:

-- -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) -- evacuation / hospitalisation-- 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

6. Referral / consultation Consult MO on all occasions of suspected pyloric stenosis. These infants may

present with severe acid base imbalance such as hypokalaemia



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

2. Immediate management• Consult MO


-- 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) + -- weigh - use naked weight in young children and record against most recent

recorded weight • Perform physical examination:

-- -inspect and palpate abdomen ○ palpable sausage shape mass? (but absence does not exclude

intussusception) ○ guarding and tenderness ○ inspect stool

4. Management• Consult MO who will advise evacuation / hospitalisation• 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

6. Referral / consultation Consult MO on all occasions of suspected intussusception



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 intoleranceUrinary 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]



-- 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)-- mother’s 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



• Perform standard clinical observations + -- 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 presentA 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• MO perform examination and calculate degree of FTT - mild, moderate or severe• 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 child’s 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 Immunisation program

• 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



• Children need small frequent meals (5 times a day if possible)

Food prescriptionDrinks• 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:

www.health.qld.gov.au/cdg-- regular monitoring of growth with child’s 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 carer’s 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

6. Referral / consultation

Consult 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. Mum’s

and bubs See current edition of Chronic Disease Guidelines at:

www.health.qld.gov.au/cdg

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

� Consult MO immediately -- 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®)



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



-- 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)-- mother’s 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

• Perform standard clinical observations + -- urinalysis-- weigh - use naked weight in young children and record against most recent

recorded weight



-- 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• Treat with oral iron supplement for 1 month under supervision (taking iron daily is

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

• Consult MO immediately -- 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

Schedule 2 Ferrous Sulphate(Ferro-Liquid®)

DTPIHW / IPAP




Liquid

30 mg (equiv. to 6 mg of elemental iron) per mL

150 mg / 5 mL

Oral

Child under 2 years only on MO advice

Child 2 - 6 yearsup to 5 mL daily

Child 7 - 12 years5 - 20 mL daily

Continue for 3 months after Hb has returned to

normal to replenish stores

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 CManagement of associated emergency: consult MO - overdose of iron is very toxic.

[9]

• Give folic acid supplement if:-- low serum and / or RBC folate-- severe iron deficiency (haemoglobin < 80 g/L) even if normal folate levels



Schedule 2 Folic Acid DTPIHW / IPAP




Tablet 500microgram

5 mgOral

Child0.5 mg / kg / dose daily to a max. of 5 mg daily

Long term accordingto response on MO / NP

orderProvide Consumer Medicine Information Management of associated emergency: consult MO

[10]

• Give nutrition advice. Use Growing Strong resources - breastfeeding, iron rich 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

6. Referral / consultation Consult MO or see next MO clinic as above 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



Iron injection procedure See manufacturer's product information for accompanying diagrams

1. The length of the needle should be at least 5 to 6 cm. The lumen of the needle should not be too wide

2. Ventrogluteal injection according to Hochstetter is recommended in the top outer quadrant of the gluteus maximus muscle

3.

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

4.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

5. The needle is introduced more or less vertically to the skin surface, angled to point towards the iliac crest rather than the hip joint

6. 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

7. The patient should move about after the injection[11]

Schedule 4 Iron polymaltose (Ferrum H®, Ferrosig®)

Non DTPMust consult MO / NP



Ampoule 100 mg / 2 mL50 mg / mL

IM < 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 doseWeight 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 / L5 3 mL 3 mL 2 mL10 6 mL 5 mL 4 mL15 9 mL 7 mL 6 mL20 11 mL 10 mL 8 mL25 14 mL 12 mL 11 mL30 17 mL 15 mL 13 mL35 23 mL 20 mL 18 mL40 24 mL 22 mL 19 mL45 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 areasManagement of associated emergency: consult MO

[9]


Urinary tract problems

References1. The Royal Children’s Hospital. Gastroenteritis 2009 [cited 2011 February]; Available from: www.rch.org.

au/clinicalguide/cpg.cfm?docid=12364#degree2. 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 Children’s Hospital at Westmead Sydney Children’s Hospital Randwick & Kaleidoscope * Hunter Children’s 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 ageBackground� 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



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



-- 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 child’s 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? • Perform standard clinical observations +

-- assess growth and plot against chart for age and sex• Perform physical examination:

-- 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 requestMethod

○ 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



○ where no MO in residence these children will need evacuation / 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

• Assessment of dipstick urinalysis-- 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• Consult MO who will arrange / refer / discuss:

-- 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

If 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


Bone and joint problems

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 jointBackground

� 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 Bacterial skin infections Acute rheumatic fever (ARF)

1. May present with [1]Osteomyelitis • Subacute onset of limp / non-

weight 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

2. Immediate management• Consult MO

See next MO clinic Routine prophylaxis is no longer recommended [1]

6. Referral / consultation Consult MO on all occasions of suspected UTI in children 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]

References1. The Royal Children’s 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 Children’s Hospital, AntibioCard. 2011: Brisbane.


Bone and joint problems

3. Clinical assessment• 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

• Perform standard clinical observations • Perform physical examination including:

-- 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:

-- evacuation / hospitalisation -- 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

6. Referral / consultation Consult MO on all occasions of suspected osteomyelitis and septic arthritis Refer to Orthopaedic Specialist if osteomyelitis / septic arthritis is suspected or

confirmed [1]

References1. The Royal Children’s Hospital Melbourne. Osteomyelitis and Septic Arthritis. 2008 [cited 2011 January]; 8th edition:

Available from: www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5234.2. 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.


Abuse and neglect

Abuse and neglect - child

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 topicsRape / 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

1. May present with [2]• Physical abuse - injuries which don’t fit child’s developmental level or description

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 child’s 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 child’s privacy, penetration, rape, incest, involvement with pornography, child prostitution


Abuse and neglect

2. Immediate management• If you suspect abuse always obtain advice. Consider discussing the case with

your line manager, Paediatrician, CPLO (Child Protection Liaison Officer) or CPA

3. Assessment• Forming a concern or well founded suspicion is based on the presence of:

-- 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 Services1. During office hours - telephone your Child Safety Regional Intake Service

(RIS) to make a verbal report2. After hours - telephone Child Safety After Hours Service Centre 1300 681

513 Fax: 3235 98983. 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 child’s hospital record6. 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 Phone number Fax numberSouth East 1300 678 801 3884 8802South West 1300 683 259 4616 1796Far North Queensland 1300 683 596 4039 8320North Queensland 1300 704 514 4799 7273North Coast 1300 705 201 5420 9049Brisbane 1300 705 339 3259 8771Central Queensland 1300 683 042 4938 4697


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 medico-legal 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

6. Referral / consultation

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 child’s 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)

References1. 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

primary care manual of paediatrics

Documents