RCH and PIC

Intranet for hospital staff and Internet for all

Abdominal pain acute (PIC)

Abdominal pain chronic ( PIC)

Acceptable ranges for physiological variables (PIC)- vital signs range for age groups

Acquired Torticollis ( PIC)  a "wry neck" or neck spasm, sometimes with head tilt

Acute asthma (PIC)

Acute behavioural disturbance : acute management (PIC) summary of managing a child in  an acutely agitated state (verbal, oral medication , parenteral medication  )

Acute behavioural disturbance: code response (PIC) team approach to restraining and sedating an acutely agitated child

Acute severe behavioural disturbance ( SCHN)

Acute eye injury (RCH)

Acute Rheumatic Fever ( SCHN)

Acute meningococcal disease (PIC)

Acute otitis media (RCH)

Acute management of variceal bleed (RCH)

Acute pain management (PIC)

Acute red eye (RCH) 

Acute rhabdomyolysis (SCHN)

Acute rheumatic fever ( SCHN) 

Acute scrotal pain or swelling   (PIC)

Acute spinal cord injury (RCH)

Acute upper airway obstruction (RCH)

Adenoidectomy post operative management (RCH)

Adolescent gynaecology - heavy menstrual bleeding (PIC)

Adolescent gynaecology- lower abdominal pain (PIC)

Adrenal crisis and acute adrenal insufficiency (PIC)

Adrenal insufficiency - emergency treatment (SCHN) and  Adrenal crisis and adrenal insufficiency (RCH)

Adrenal insufficiency pre-operative treatment (RCH)

Adrenaline and fluid bolus during resuscitation (RCH)

Adverse drug reaction (SCHN) this is mainly on documenting in the EMR and logistics

Afebrile seizures (PIC) 

Airway obstruction- Acute upper airway obstruction (PIC)

Airway managment- see emergency airway management (PIC)

Alkali poisoning RCH)

Altered conscious state (PIC)

Aminoglycoside dosing and monitoring (SCHN) 

Anaemia (PIC)

Anaesthetic- see Post anaesthetic observations (RCH) nursing observations

Anaphylaxis (PIC)

Angioedema (RCH)

Animal and human bites (PIC)

Antibiotic guidelines - for a variety of common conditions (Victorian)

Antibiotic prescribing in children with reported penicillin or cephalosporin allergy (PIC)

Anticholinergic syndrome (RCH)

Anticoagulant therapy of venous thromboembolism (SCH)

Anticoagulation therapy (RCH) IV heparin and TPA regimes

Anticonvulsant poisoning (RCH)

Antifungal treatment (empiric): in oncology, haematology and stem cell transplant patients

Antihistamine poisoning (RCH)

Anti-malarial therapy (SCHN)

Apnoea , neonatal (RCH)

Arthitis - the acutely swollen joint (RCH)

Arterial line management in PICU (SCHN)

Asthma acute treatment (SCHN)  a thorough PDF document to scroll through

Acute asthma treatment (RCH) - take care with discharging home children with O2 saturations < 95% (speak to senior or paediatrician)

Asthma management- stretching inhaled salbutamol (SCHN) focuses on stretching salbutamol on wards

Asthma when to start preventers (Australian Asthma Handbook)

Asthma discharge plan (RCH)

Ataxia (PIC)

Atopic dermatitis (see Eczema PIC)

Autism and developmental disability - managing distress (RCH)

Anaphylaxis (SCHN) summary document which contrasts anaphylaxis versus generalised reactions; indicates when EpiPen appropriate

Anaphylaxis (Victorian)

Anaphylaxis action plan (ASCIA)  scroll down to Red Plan. if your specialist or GP has recommend your child have an Epipen for severe allergy,  this sheet documents the plan for home and school

Action plan for allergic reactions (ASCIA) - Scroll down to Green Plan. This is for milder reactions, i.e not anaphylaxis. This is a plan for home and school

FOOD ALLERGY TIPS  

WHICH FOOD AND WHAT ARE THE SYMPTOMS?

• Note the type of food, how much was eaten, if this has happened before ,  and the timing and order of onset of clinical features 

• Typically the story will be eating the food and then within 10-60 minutes the child will have:  tingling mouth, rash around mouth, eyes and face, abdominal cramps, vomiting

• Then as the allergic reaction progresses  a more generalised rash may be seen on the  chest, tummy and legs (if so monitor closely in hospital for imminent anaphylaxis) , and then to anaphylaxis.

•  A small amount of coughing/ throat clearing is not unusual but persistent coughing is concerning 

• Food allergy may present with wheeze and no rash (etc) but this is uncommon.

• If egg or milk was eaten, was  it extensively heated? (baked in oven > 180c, > 40 mins, or just partially cooked)

GRADE THE SEVERITY OF THE ALLERCIC REACTION

• Note all symptoms on the "mild, moderate and severe allergy reactions" of anaphylaxis sheet  and try to work out if your child has local/ generalised reaction to food or if it had ANAPHYLAXIS  (i.e how far did the child progress on the sheet?- you should have your child examined by a doctor, as they may be wheezing , but you can't hear it)

DIAGNOSIS  OF FOOD ALLERGY, GOING HOME AND FOLLOWUP

A diagnosis food allergy is made with a combination of :

a) a typical story of exposure with symptoms (history of one of more ingestions; two very similar events, with typical symptoms is very suggestive of  food allergy )

and 

b) evidence of allergy (raised IgE to the food) on blood tests or skin prick testing

• If the diagnosis of food allergy is made you should receive an action plan; for milder reactions Action plan for allergic reactions  or for anaphylaxis  (Anaphylaxis action plan )

Blood tests: If going home, discuss with seniors on serum specific testing blood test eg for peanut allergy you would order "Serum specific IgE peanut" or milk "serum specific IgE milk".   Copy result to the family doctor.  

• Total total value of the serum specific IgE does not necessarily correlate with severity of anaphylaxis.  The history of anaphylaxis, in particular needing intramuscular adrenaline, from clinicians, is of paramount concern.

• That being said serum specific IgE > 30 could be considered or referral to a specialist. And if the serum  specific food IgE > 100 IU we recommend your GP speak to a specialist paediatrician promptly on an urgent outpatient appointment for severe allergy assessment.

•  Do not order total IgE , this does not assist with diagnosis

• Skin prick testing can be performed options: Sydney allergist, ? visiting allergy specialist to Dubbo, Dubbo Paediatric Outpatients skin prick testing (referral from GP to Dr Dominic FitzGerald  ph 6809 7082)

• All anaphylaxis cases should be referred to a specialist for assessment . Dubbo Paediatric Outpatients

Food allergy Home page (ASCIA)  to explore information on food allergy from the foremost Australian site for reliable information on allergy

Food allergy (ASCIA) general information about the types of food allergy reactions

Dietary guide for food allergens (ASCIA)

Cow's milk allergic reactions (ASCIA) note with milk whether it was extensively heated (e.g. baked in oven for over 40 minute at over 180c or not)

Egg allergy-  note with egg whether it was extensively heated (e.g. baked in oven for over 40 minute at over 180c or not; or just lightly cooked eg fried or boiled)

Peanut allergy- fast facts (ASCIA)  and Peanut, tree nuts and legumes information (ASCIA)

Food adverse reactions  - not all reactions to food are allergic (IgE associated)

NOTE: Dubbo Paediatric Department recommends in pubertal adolescents, in whom the cause of the abdominal pain is not known, that  cases are discussed with both General Surgery and Gynaecology on call, prior to Paediatric Department.

Please see the paediatric guidelines below which outline the surgical, gynaecological and medical causes of abdominal pain.

Acute abdominal pain (PIC)

Adolescent gynaecology- lower abdominal pain (PIC)

DUBBO HEALTH SERVICE ACUTE ABDOMINAL PAIN TEMPLATE FOR JUNIOR STAFF:

This template is a simple approach to taking the history, performing a physical examination, and assisting with interpretation of investigations. We will attempt to support junior clinicians in these areas providing some clinical commentary in italics, for education purposes. For background information on likely differential at various age groups , please refer to the abdominal pain guideline on the Paediatric Improvement Collaborative, the link is above

HISTORY

When did the abdominal pain begin?

Is the abdominal pain mild or severe?

Is the abdominal pain coming and going in spasms (intermittent severe, colicky, spasms of inconsolable abdominal pain, associated with pallor of the child's face and vomiting is a good story for intussusception)

Has the pain changed in position from around the belly button (periumbilical) to down lower in the abdomen, example right or left lower abdomen?

Has the pain changed from coming and going to a constant pain?

Or is the abdominal pain constant and localised to a particular spot? 

Where is the abdominal pain the worst?, periumbilical (the belly button)?  right iliac fossa (right lower abdomen)? 

Has there been vomiting with the abdominal pain? 

How many vomits have been noted?

Is the vomiting noted to have coffee-ground (black content), or does it have blood (hematemesis)?

Does the vomiting have yellow or green pigmentation (bile is green) ? Is it dark green? How many green vomits have been noted? (Green vomiting is a surgical abdomen until proven otherwise and discuss with senior clinicians (and/or surgical team and paediatrics, but children with repeated vomiting, may have ileus and then biliary reflux with viral gastroenteritis)

Does your child have a blown up stomach, i.e.  "abdominal distension?"

Is your child passing regular bowel motions and does your child have a history of constipation (hard stools which are not usually passed daily, straining and painful passing of stools?

(Note : constipation usually presents with abdominal pain, a past history of constipation, and abdominal distension. Less commonly will it present with vomiting (but if severe it may) , and a fever would be unexplained by constipation)

When was your child's last bowel motion passed?

Has your had watery stools , i.e. diarrhoea, if so how many? 

(Note1: somewhat unkindly appendicitis may present with vomiting, diarrhoea and fever, perhaps in part due to irritation of the appendix on the large bowel- so do not be confident that, if diarrhoea is present, that appendicitis is much less likely)

(Note 2: diarrhoea presenting with more than 10 episodes per day may be consistent with bacterial colitis or dystentery

Was your child noted to have black stools (malaena) or did it have blood-stained stools (hematochezia).

Has your child had a fever noted? 

How many days has the fever been noted? What was the maximum height of the fever e.g. 38.5c,  > 39c?

GYNAECOLOGY HISTORY , EXAM AND INVESTIGATIONS IN PUBERTAL FEMALES
Please read PIC guideline on lower abdominal pain in adolescent females (PIC)

GENERAL SYSTEMS HISTORY

Has your child been noted to have a cough or chest pain or have you noticed your child to have shortness of breath?

Has your child had reduced urine output? 

How many times has he passed urine in the last 24-48 hours? (If those were nappies, how many wet nappies have been noted).

Has your child had pain in its back or pain when passing urine?

HISTORY of PRESENT ILLNESS

Has your child ever had a bowel operation ? (considering the possibility of adhesions as cause of abdominal pain)

Has your child ever had their appendix out?

Is your child taking any medication, in particular has taken Panadol or Nurofen, if so how much has been taken over the past few days.

Is your child taking antibiotics? (may partially treat acute abdomen)

Is your child taking any other medication?

Is your child fully immunised?

Does your child have any drug or food allergies?

Has your child been hospitalised for any other reason?

EXAMINATION

Vital signs:

• Pulse rate - note whether the pulse rate is inceased ,ie tachycardic and if so is it mild or severe tachycardia. (A red zone Between the Flags chart , which persists is concerning ; an elevated pulse rate may indicate a surgical problem, shock,  dehydration, pain, or anxiety)

• Respiratory rate - note whether the child has rapid panting breathing , i.e. tachypnoea; not if the child has heavy breathing or grunting  (this may point to pneumonia, which somewhat unkindly may present with vomiting and fever due to ileus).

• Fever - note height of fever (for example early appendicitis , viral gastroenteritis typically have low-grade temperatures example 37.9-38.2c. Peritonitis, pneumonia, pyelonephritis, dysentery, typically have spikes of  high-grade temperatures > 38.5c-39c).

• Oxygen saturations - (If O2 saturation are <95%, this is consistent with hypoxaemia and  may be due to pneumonia - consider a chest x-ray)

• Central capillary return- push on chest and if capillary return is >> 2 seconds (outside of neonates in whom > 3 seconds is abnormal), consider causes of sepsis or hypovolaemia

• Blood pressure - note if child is hypertensive or hypotensive. Hypotension in children is a late sign of sepsis check capillary return and pulse

EXAMINATION 

• Beware children under 5 years as the abdominal findings are often unreliable to rule out appendicitis clinically. The perforation rate is over 80% in some studies- so the author recommends early paediatric review.

• The acute abdominal pain (+/- vomiting and fever) presentation in children requires a top-to-tail examination as children may localise pain poorly, and the abdominal pain may represent referred pain from other areas (e.g. back, spine, chest, testes)

• ENT is done last as it annoys everyone, but tonsillitis can present with vomiting, fever and abdominal pain.

• First begin examination by observing child's behaviour and abdomen lying on its back/side in the bed, or on parent's lap

• If you are uncertain whether there is abdominal distension or not ask the parents (is your child's abdomen distended?)

• Typically children with peritonitis will sit still in the bed and are reluctant to move freely in the bed or roll around in the bed. Watch the child closely to see how much spontaneous movement is noted. Children under 8 years of age, usually fidget a lot. Almost all children with peritonitis will lie still, and grimace when the try to roll over.

• Walking/jumping/hopping the child is useful and you may notice a right antalgic gait with appendicitis and a collection of fluid in the right iliac fossa.

Abdominal examination:

• Note whether there is pain in one area of the abdomen with focal pain or whether there is generalised tenderness.

• Note whether there is rebound tenderness (pain which is worse when the hand is released from the abdomen and causes rebound pain.

• Guarding or rigidity (this is pain noted where the child stiffens the abdomen and holds the abdominal muscles tight, which tends to minimise pain).

• Percussion tenderness and rotating the right hip may elicit pain in appendicitis

• Abdominal masses - there may be a fullness due to mass, fluid collection, bowel obstruction etc - this may be present anywhere in the abdomen but most likely right iliac fossa.

• Distension - again asking the family. Palpable faeces (abdominal pain and distension is commonly constipation, but fever points to perhaps alternative diagnosis)

• Rectal and vaginal examination is really indicated though inspection of the rectum and vagina may be indicated.

• It is important to examine both the umbilicus (belly button) and for inguinal hernia in boys and examination of the testes for epididymo-orchitis. (Boys with testicular pathology may present with abdominal pain due to referred pain.

General systems examination:

• Note in particular whether there is tachypnoea and recession. Pneumonia may present with non-specific signs in the right upper lobe, left upper lobe. 

• Fever, vomiting, abdominal pain with tachypnoea and recession should have a chest x-ray performed.

• Heart murmurs

• Back is checked for pain- loin pain and spine is palpated (renal angle pain with pyelonephritis)

INVESTIGATIONS for sicker child with abdominal pain (+/-vomiting & +/- fever)

• It is difficult to make "hard and fast rules around investigations" on children with abdominal pain. Consideration of the child's case, how acutely unwell they are and try to formulate which is the most likely diagnosis , and align investigations accordingly:

• e.g.: a) mild colicky pain, non bilious vomiting and watery non-bloody diarrhoea (probably viral gastroenteritis - may just NG rehydration) 

versus

• b) a 2 year old with severe pain, bilious vomiting, very tachycardic in red zone on BTF, high fever , rigid abdomen (the "works" see all of the below recommendations)

• A useful clinical "rule" is:  in a child in whom the acute abdomen is strongly suspected (that is fever, abdominal pain and vomiting) , and who the surgical team wish to take to theatres, a chest x-ray should be taken looking for right & left lower lobe and retrocardiac pneumonia BEFORE THEY GO TO THEATRE. The reason for this is that referred pain to the abdomen is not uncommon with lower lobe pneumonia, which may cause ileus (closely mimicking appendicitis and the acute abdomen)

• Urinalysis - typically urinary tract infection will have a combination of white cells (leukocytosis), red cells (haematuria) and/or nitrates. All may be present alone (eg just raised red cells) or raised together.

• Nitrates are relatively specific for UTI diagnosis on a midstream urine (assuming there is no contamination by faeces) and suggests a urinary tract infection with a gram-negative organism.

• If the urinalysis are no white cells, red cells or nitrates it is probably not a UTI (>95% probability); but if there is no clear focus, still send the urine culture.

• Electrolytes - with a child who is dehydrated they may have a combination of hyponatraemia, and/or hypokalaemia or hyperkalaemia. 

• As they progress to 5% dehydration typically they will also have high urea (>7) and/or high creatinine. This reflects a reduced GFR.

• Lipase and amylase may be run for pancreatitis (this is relatively uncommon in children but certainly on the differential of abdominal pain and vomiting.

• Venous blood gas - looking for acidosis and high lactate.

• Blood glucose for diabetic ketoacidosis - diabetic ketoacidosis may present with abdominal pain which is related to ketosis and vomiting.

• Liver function tests - acute hepatitis can present with abdominal pain and fever. (In particular note the nephrotic syndrome can present with peritonitis if the albumin is less than 25 

If fever is >38.5c , and the child has vomiting with significant abdominal pain, and so appendicitis / peritonitis is suspected then also consider doing:

• procalcitonin (PCT)- most of Dubbo's cases of peritonitis, who have had PCT checked have had a significant elevation in PCT. And note, in particular, this applies also to the group of patients who may pose the greatest clinical challenge diagnostically , i.e the < 5 year old group, in whom even experienced clinicians can make clinical errors in their assessment.

So, for example, if a child has vomiting , fever and abdominal pain, and the PCT > 2, it is unlikely the patient has viral gastroenteritis or mesenteric adenitis. Look hard for a bacterial cause. Pneumonia, urosepsis (pyelonephritis), sepsis, and/or peritonitis (rather than just uncomplicated appendicitis) are likely underlying differential diagnoses, in this scenario.

• C-reactive protein - if the CRP > 100 consider bacterial infections carefully

• blood culture

IMAGING

• An abdominal supine film and an erect chest x-ray are recommended where possible. The abdominal x-ray may show distension of abdominal loops which is defined as a bowel lumen greater than half the width of L2.

• Chest x-ray - be wary of missing lower lobe pneumonia; in particular check for retrocardiac consolidation.

• Ultrasound - this is a fairly reliable investigation which if it shows an appendix greater than 10 mm is consistent with appendicitis. An appendix that is not visualised on ultrasound does not exclude appendicitis. Also an ultrasound is useful looking for signs of intussusception.

TREATMENT AND REFERRING on to SPECIALIST TEAMS IN DUBBO

In children under 5 years of age it is recommended consultations be held with the paediatrician, in particular if there are: abnormal vital signs, green vomiting, abdominal distension, peritonism and there is concern about the possibility of a surgical abdomen. The paediatrician will assist the ED team "put it all together" and formulate a clinical likelihood of a surgical abdomen being present. 

Providing adequate analgesia, intravenous morphine or intranasal fentanyl can be directed by the person in-charge in the emergency department - see acute pain management.

In particular with abdominal distension, bilious vomiting keep the child fasted and hydrate the child with intravenous and/or enteral fluids.

In children over 5 years of age refer to Surgical Team

Pubertal females presenting with abdominal pain - the Paediatric Department in Dubbo recommends 

a) general surgical review

b) consider gynaecological review and pregnancy testing  if no general surgical pathology found, 

and then

c) and if no surgical or gynaecological causes found to explain the pain, then refer on to paediatrics (who may request some of the above investigations

If there is bilious vomiting and bowel obstruction is suspected clinically and radiologically, consider nasogastric tube placement.

Asthma acute treatment (SCHN)  a thorough PDF document to scroll through

Acute asthma treatment (RCH) -  easier to read, but take care with discharging home children with O2 saturations < 95% (speak to senior or paediatrician)

Asthma management- stretching inhaled salbutamol (SCHN) focuses on stretching salbutamol on wards

Asthma when to start preventers (Australian Asthma Handbook)

Asthma discharge plan (RCH)

Asthma Action Plan ( National document )

Balanitis - infected foreskin (RCH)

Bell's palsy - facial weakness (RCH)
Benzodiazepine poisoning (RCH)

Bier block (RCH)

BiPAP (RCH nursing)

Bleeding dental socket - Dental conditions non-traumatic (RCH)

Blood cultures in oncology patients with central lines (RCH)

Blood pressure charts (RCH)

Blood pressure monitoring in the ED (SCHN) includes BP centile chart, which is a little hard to read.

Blood product prescription (RCH) indications for blood, platelets, FFP etc

Blood transfusions (SCHN) and Massive transfusion protocol - paediatric (SCHN)

Blood transfusions and blood management in surgical patient (RCH) Patient blood management and blood transfusion in surgical setting (RCH)

( includes iron infusion and oral iron replacement if anaemic)

Blunt abdominal solid organ injury management (SCHN)

Bowel management - post operative (RCH)

Bowel washouts and enemas (SCHN)

Bowel washout (RCH)

Bradycardia during sleep (PIC)

Breast feeding promotion and support (RCH)
Brief Resolved Unexplained Event (" BRUE" )  (PIC)

Bronchiolitis (PIC)

Bronchiolitis in retrieval ( NETS)

Bronchiolitis: acute management in ED (SCHN) has link to Humidified High Flow Nasal Cannula Therapy 

Bronchiolitis ward management (RCH)

Bronchiolitis in retrieval (NETS)

Buck's traction - skin traction for orthopaedic fractures (RCH)

Burns (PIC) interstate  clinical practice guidelines- well presented and user friendly

Burns : practice guideline (SCHN)

Burns: ED management (SCHN)

Burns: nursing management of burns (RCH)

Burns- post acute care and dressings (PIC)

Button battery : suspected ingestion (SCHN)

Button battery ingestions - see foreign body ingestion (PIC)

Camphor poisoning (RCH)

Carbamazepine poisoning (PIC)

Cardiac telemetry (RCH)

Cardiopulmonary resuscitation (SCHN)

Catheters , urinary ( SCHN)

Catheter - indwelling urinary catheter (RCH)

Cellulitis (PIC)

Central venous access device- neonates (SCHN- Grace)

Central venous access device- older children (SCHN)  Facts sheet from SCHN containing wide range of resources on types of CVL and weblinks

Tips for central lines in children in Dubbo for the Paediartric Registrar: 

1) Confirm we have an appropriate size central line prior to ringing Anaesthetic Department

2) Give facts sheet to family and discuss risks and benefits with family prior to discussing with Anaesthetics and obtain a consent from care givers (note Anaesthetic Department may wish to elaborate on risks of procedure)

3) Discuss clearly with Anaesthetics Department  why Dubbo Paediatrics Department needs a central line for its patient

4) Central line placement is checked both by anaesthetics and Paediatric Department

Radiological confirmation of the position of the tip must be performed. 

This may be done during the procedure using image intensifier (II) or in the interventional suite or afterwards with conventional X-ray. 

The CVAD tip should sit in the SVC or at the SVC-RA junction. The tip should be WITHIN 2 vertebral body heights below carina. Some exceptions do apply e.g. cardiac surgical patients 

5) The occasional may rise that no other access if possible, other than subclavian vein placement. Under those circumstances, a risk benefit analysis by your paediatrician will need to be undertaken for treatment goals versus risks of thrombosis. Note: under these circumstances consider thromboembolic prophylaxis.

Cerebral palsy (RCH) an overview of outpatient problems

Cerebral palsy -chest infection (RCH)

Cerebral palsy -increased seizures (RCH)

Cerebral palsy - pain and irritability (RCH)

Cervical lymphadenopathy (RCH)

Cervical spine assessment (PIC)

Cervical- spine management (SCHN)

Charcoal in poisonings (RCH)- the limited use is discussed here

Chemotherapy induced nausea and vomiting (RCH)

Chest drain see Thoracocentesis and chest drain (PIC)

Chest drain management - nursing (RCH)

Chest drain (SCHN)

Chest pain  (RCH)

Chickenpox (SCHN)

Chickenpox (RCH)

Child exposed to blood or potentially blood contaminated secretions - CHW

Children's Hospital Westmead - NSW Health contacts 

Chloral hydrate poisoning (RCH)

Chroming - inhalant volatile substance use (RCH)

Circumcision - see the penis and the foreskin (RCH)

Community acquired pneumonia (PIC)

Colic see unsettled or crying babies (RCH)

Coma (RCH)

Compartment syndrome (neurovascular observations nursing- RCH)

Congenital torticollis (PIC)

Constipation (PIC)

Convulsion see Afebrile seizures (PIC) 

Convulsions see Febrile seizure (Victorian)

Contact prophylaxis for invasive meningococcal disease or haempohilus type B (RCH)

Corrosives - caustic poisonings - alkali and acid (RCH)

Cough (RCH)

COVID-19 (PIC)

COVID Swabbing (PIC)

CPAP and non-invasive ventilation (RCH)

CPR - cardiopulmonary resuscitation (RCH

Croup - laryngotracheobronchitis (PIC)

CRP and procalcitonin in the emergency department (SCHN)

CSF interpretation (PIC)

Cyanotic episodes spells (RCH) may occur in cyanotic heart disease

Cystic fibrosis manual (SCHN)

Cytotoxic drugs (SCHN)

CHILD CHILD ABUSE

For all cases of suspected child abuse Dubbo Paediatrics Department recommends that the carer for the child ring the appropriate on call person:

1) for suspected physical abuse or neglect a carer should call DCJ on...

If there is a disclosure of physical abuse, or DCJ have information of same a  physical examination will need to be done, which is called a SCAN Protocol.  

Resources in Microsoft Teams for NSW Health staff

SCAN Protocol is completed by the on call paediatrician.  

Families should note that if DCJ requests such an examination, the paediatrician is required to complete this by law, even if the family object to same.

NSW Health law on photographing such cases

2) for suspected sexual abuse a carer should call...

Dubbo Paediatrics department provides a service for both  suspected physical and sexual abuse. Physical abuse is reviewed by Dubbo Paediatrics up to, and including , adolescents aged 16 years. 

If a young adult is over 16 years and is a victim of suspected physical abuse, they may be seen in the emergency services and by Police if need be.

With suspected sexual abuse in young women over the age of 14 years, suspected sexual abuse is referred to adult sexual assault services.

Suspected sexual abuse

This falls into two broad categories: 

a) those children who have made a disclosure of sexual assault  (i.e. the child has told a carer or trusted adult figure something potentially concerning, that needs checking by health and counselling professionals with experience in this area )

b) those children who have not made a disclosure but there are clinical concerns from the carer (for example concerns around a child's private parts being sore or out of character "sexualised" behaviours).  Under these circumstances it may be desirable to have a paediatrician review the child, including the private parts, and for ease of reference we will call this a  Complete Physical Examination (see below) . 

In those children who have a made a disclosure , it is the opinion of Dubbo Paediatric Department,  that child and carer present urgently to the police and have an interview. If it is in evening, this may be scheduled the next morning, but the carer is advised not to discuss the matter further with the child, until the police have spoken with the child. The carer should also make contact with sexual assault counsellor at Dubbo Health Service and they will contact the paediatrician, ir a child specialist  who is on call. 

If the police have concern around likely sexual assault then Dubbo Paediatrics recommends the Police call the on call paediatrician to discuss what an appropriate forensic examination should be, and when that will be performed. 

Complete physical examination

In those children who have not made a disclosure, or who are too young to give a clear verbal account,  but have concerning symptoms eg sore genitalia,  Dubbo Paediatrics Department recommends that a medical review take place.  

Dubbo Paediatrics Department does not believe that the carer's involved should assume that sexual abuse has taken place, nor it is our experience that in children presenting with sore genitals (especially in girls) that sexual assault is the most likely cause of same.  

There are more common conditions in girls presenting with vulval and vaginal irritation. 

Child abuse is one uncommon possibility that needs to be considered, once others have also been considered. 

In some ways referring a young child with sore private parts, with no disclosure, to the Dubbo sexual assault worker sends the wrong message. 

However, we acknowledge that there may be considerable anxiety from the child and family in such cases, and some doctors either lack experience in examination of children, and/or are reluctant to perform such examinations. It is also our belief that such an examination needs to be done sensitively for the child's sake and done once only.

This needs to an experienced GP , emergency doctor or may be the paediatrician. Sometimes there are heightened concerns from the family around the possibility of a sexual assault, and reassurance is sought. In such cases , it is appropriate to refer to the paediatrician on call, or the outpatient department depending on the availability of the on call paediatrician.

Note, a SCAN protocol is not done with a complete physical examination, as this examination begins a health review, not a forensic medical review. It may become a forensic medical review later.

Child protection procedures in NSW

Cow’s Milk Allergy (CMA) – for clinicians

• Note: the authors recommend that clinicians, with a patient they suspect of CMA, read the ASCIA website section on CMA

• Pepti-Junior authority script

• Note: if the baby has blood stained stools confirmed on stool analysis and FPIAP is a likely diagnosis (see below), the general practitioner may consider calling a paediatrician and:

  • • a) recommending the mother breast restrict dairy in her diet (see below for maternal diet changes and reasons for this)

    • b) if formula is desired for the baby, the GP may issue a script for Rice formula and/or cow' milk formula alternatives (ASCIA)

·       CMA encompasses a heterogenous group of clinical and pathological entities

·       Terms such as cow’s milk protein intolerance/sensitivity are best avoided due to lack of specificity in definition and inconsistent application

·       In a similar vein, caution is required to avoid false attribution of common infant symptoms (eg. crying, vomiting, rashes) in isolation to a presumed CMA diagnosis, which may in turn lead to unnecessarily restrictive maternal and infant diet, and deter breastfeeding

·       Recognised phenotypes of CMA are discussed below:

o   IgE mediated (immediate hypersensitivity reaction)

Ø  Anaphylaxis

o   Mixed IgE and non-IgE mediated

Ø  Eosinophilic gastrointestinal disorders

o   Non-IgE mediated

Ø  Food protein-induced enterocolitis syndrome (FPIES)

Ø  Food protein-induced allergic proctocolitis (FPIAP)

Ø  Food protein-induced enteropathy

·       Anaphylaxis is the classical food allergy, mediated by antibodies against cow’s milk (CM) proteins, inducing mast cell activation and histamine release

·       For resources on food allergy and anaphylaxis see Dubbo Kids Health on Anaphylaxis

o   Prevalence of ~0.9-1.2%. Accounts for ~60% of all CMA. Can occur from first week of life

o   A sensitisation event is required (first exposure)

o   Subsequent exposure to antigen results in rapid onset (minutes to two hours post ingestion) signs and symptoms involving skin, respiratory, GIT and cardiovascular systems (eg. urticaria, angioedema, increased work of breathing/tachypnoea, wheeze, low SpO2, vomiting, abdominal pain, diarrhoea, shock)

o   Life-threatening event, which depending upon clinical setting may require 000 call or rapid response, and certainly resuscitation principles to be implemented

o   Investigation in an individual with a suggestive clinical history involves sensitisation testing (serum specific IgE (RAST) or skin prick test (SPT)) and on occasion oral food challenge (OFC).

o   Dubbo Kids Health on Anaphylaxis and food allergy has a typical history of what a clinician may expect in a child with IgE mediated food allergy.

Diagnosis:

o    Referral to paediatrics department is recommended to assist with confirmation of diagnosis and subsequent management when anaphylaxis is suspected

Ø  RAST: Caution is required in the interpretation of RAST, however CM is considered positive if >15 kUA/L (>5 kUA/L for children less than two years of age). This result in combination with a high pre-test probability (ie. suggestive clinical history) can be diagnostic of CMA in 95% of cases. Lower values are less helpful and do not necessarily exclude CMA (particularly if >2 kUA/L)

Ø  SPT: greater sensitivity than RAST. Performed in medically supervised setting by treating paediatrician when needed

Ø  OFC: may be required if evidence does not clearly confirm or refute diagnosis of CMA or to survey for resolution of allergy. Performed in medically supervised setting by treating paediatrician

o   Treatment involves:

Acute:

Ø  DRABC approach to resuscitation

Ø  IM adrenaline 0.01mg/kg of 1mg/mL solution. Repeat 5-15mins as needed

Ø  Supplemental oxygen

Ø  Antihistamines, beta agonists and glucocorticoids as adjuncts only

Long-term:

Ø  CM avoidance. This requires maternal dairy restriction if breast fed, switch to an amino acid formula if formula fed and avoidance of all dairy products. ASCIA’s guide to milk substitutes in CMA can be found here

Ø  Epipen and anaphylaxis management plan (0.15mg autoinjector ideal for 10-15kg, can be used down to 7.5kg. Alternative is to draw up exact dose from ampoule)

Ø  Medic alert bracelet

·   Eosinophilic gastrointestinal disorders include eosinophilic oesophagitis and eosinophilic gastroenteritis. The role of food allergy in these conditions is not clearly defined, however elimination diet may play some role in their management. These conditions are discussed in greater detail elsewhere.

FPIES 

ASCIA information on FPIES

FPIES is likely T-cell mediated intestinal inflammation, leading to increased permeability and fluid shift, resulting in profuse, protracted vomiting, sometimes with diarrhoea (+/- blood), dehydration, shock, failure to thrive

o   Incidence of ~0.012 - 0.7%, slight male preponderance (52-60%). Occurs in first months of life - within 1-4 weeks introduction of CM (eg. formula). Rare after 12 months of age.

o   CM-FPIES rare in exclusively breastfed infants

o   Two clinically distinct phases are described:

Ø  Acute: repetitive vomiting, sometimes diarrhoea, dehydration, lethargy, pallor, shock, abdominal distention. Onset 1-3 hours after ingestion, lasting hours. Typically occurs if initially breast-fed infant changes to formula, if CM is ingested intermittently, or follows chronic phase if CM is removed then reintroduced to the diet

Ø  Chronic: watery diarrhoea with intermittent vomiting, leading to weight loss, failure to thrive, dehydration and metabolic derangements (hypoproteinaemia/hypoalbuminaemia/anaemia). This is the typical infant onset CM-FPIES due to regular ongoing exposure to CM antigen

o   CM-FPIES is a clinical diagnosis on basis of typical history and constellation of symptoms with improvement following withdrawal of CM. Gold standard involves reintroduction of CM via medically supervised OFC, which may be considered by your local paediatrician. Referral to paediatrics department is recommended to assist with confirmation of diagnosis and subsequent management when FPIES is suspected.

o   Treatment involves:

Ø  CM avoidance. This requires switch to an extensively hydrolysed formula (or failing this, an amino acid formula) and avoidance of all dairy products

Ø  Division of emergency treatment plan for acute accidental exposures, which may include:

§  ED presentation

§  IV normal saline resuscitation (20mL/kg bolus)

§  IV ondansetron (0.15mg/kg) in >6mo, max 16mg

§  IV methylprednisolone (1mg/kg), max 80mg

§  IM adrenaline if severe shock or hypotension

§  Oxygen and vasopressors may be required

o   CM-FPIES spontaneously resolves in majority of children by age 3 (88-90%), with a mean resolution of ~10-24 months of age

o   Medically supervised OFC may be useful to determine resolution. This is typically performed after 12 months of age, however is determined by treating paediatrician

Food Protein-Induced Allergic Proctocolitis (FPIAP) 

ASCIA information on FPIAP

FPIAP is characterised by inflammation of distal colon via a non-IgE mediated mechanism. Ie the blood test serum specific IgE to milk and skin prick testing is not useful.

·       This results in gross flecks of blood mixed in the stools, or occult blood in stool, sometimes mucus (+/- loose stools); otherwise the child is typically asymptomatic, well and thriving.

o   Population prevalence ~1-2% (represents ~18-64% infants with rectal bleeding). Commences within first weeks (to months) of life on exposure to CM (either through breast milk or formula)

o   CM-FPIAP more common in breast-fed infants (>50%)

o   Clinical diagnosis suggested by confirmation of blood in stools (+/- white cells in stools & +/- stool eosinophils called a “Giemsa stain”. A blood test of FBC may done to look for iron deficiency anaemia , and peripheral FBC eosinophilia.

o   Referral to paediatrics department is recommended to assist with confirmation of diagnosis and subsequent management when FPIAP is suspected.

o   Treatment involves:

Ø  Maternal elimination of all dairy products (as the breast milk may contain small amounts of the cow’s milk protein lactoglobulin and cause in exclusively breastfed infants). In truth this is very hard to achieve and time consuming as the stay at home parent will be cooking much of the food from scratch. Any food in a wrapper may contain traces of dairy product, which may be enough to inflame baby’s gut.

§  If refractory, review dietary elimination with scrutiny. Stepwise soy, then egg removal

§  Consider switch from breastfeeding to hydrolysed formula

OR

§  Continue breast feeding despite ongoing symptoms (controversial, but likely low risk)

Ø  Switch to extensively hydrolysed formula (or amino-acid formula) in formula fed infants

o   Empirically reintroduce CM at 12 months of age (some reintroduce success from 6-9 months possible). Can consider baked milk products sooner. Again, management should be guided by treating paediatrician

·  CM-Food Protein-Induced Enteropathy is characterised by small bowel injury, leading to malabsorption, intermittent vomiting, diarrhoea (or steatorrhoea), failure to thrive and rarely blood in stool. Clinically and histologically similar to coeliac disease (though less severe)

o   Most common in infants fed unmodified CM prior to 9 months

o   Diagnosed on suspicion of typical clinical features, confirmed by biopsy of proximal small intestine = patchy villous atrophy with cellular infiltrate. Referral to paediatrics department is recommended to assist with confirmation of diagnosis and subsequent management when food protein-induced enteropathy is suspected.

o   Treatment includes strict dietary elimination of CM

o   Spontaneously resolves by age two in majority of cases

References

1.       Australasian Society of Clinical Immunology and Allergy (ASCIA). Cow’s Milk (Dairy) Allergy. 2019. Available: https://www.allergy.org.au/patients/food-allergy/cows-milk-dairy-allergy. Accessed December 2020.

2.       Sicherer SH. Anaphylaxis in Infants. UpToDate 2019; Accessed August 2020.

3.       Burks W. Diagnostic evaluation of food allergy. UpToDate 2019; Accessed August 2020.

4.       Sicherer SH. Oral food challenges for diagnosis and management of food allergies. UptoDate 2019; Accessed August 2020.

5.       Liacouras CA. Food protein-induced allergic proctocolitis of infancy. UpToDate 2020; Accessed August 2020.

6.       Gonsalves N. Eosinophilic gastroenteritis. UpToDate 2019; Accessed August 2020.

7.       Nowak-Wegrzyn A. Food protein-induced enterocolitis syndrome (FPIES). UpToDate 2019; Accessed August 2020.

8.       Munblit D, Perkin MR, Palmer DJ, et al. Assessment of evidence about common infant symptoms and cow’s milk allergy. JAMA Pediatr 2020; 174(6): 599-608.

Unsettled infant or crying baby (PIC)

NEED DUBBO GUIDELINE

Daytime wetting- urinary incontinence (RCH)

Death of a child (SCHN)

Death of a child with a suspected metabolic disorder (RCH)

Decannulation of tracheostomy- Tracheostomy management (RCH)

Dehydration (PIC) 

Dental conditions non-traumatic (RCH)

Dental abscess see Dental conditions non-traumatic (RCH)

Dental trauma (RCH)

Developmental disability management of distress  (RCH)

Diabetes- transitioning from intravenous to subcutaneous insulin (RCH)

Diabetic phone calls  (RCH)- problem solving (for families with a child with diabetes)

Diabetic ketoacidosis (SCHN) DKA (NETS) DKA (RCH)

Diabetes Mellitus (RCH) includes newly diagnosed diabetic short acting doses

Diabetes management and insulin administration (SCHN)     (Diabetic ketoacidosis Kussmaul respiration in young child - YouTube)

Diabetes mellitus (type 1) inpatients using insulin pumps (SCHN)

Diabetic children: surgery and fasting (SCHN)

Diabetes mellitus and endoscopy (RCH) - has fasting advice Diabetes mellitus and surgery (RCH)

Dobutamine or dopamine infusions outside of ICU (SCHN)

Drowning (PIC)

Drug dosing for overweight or obese patient (SCHN)

Drug use- see Recreational drug use (RCH)

Ear infection- Acute otitis media (RCH)

Eating disorders - a guideline for emergency department management

Eating disorders in the emergency department  (RCH)

Eczema (PIC) and Ezcema management nursing (RCH)

Electrolyte replacement (SCH)

Empyema management (SCH) 

Enteral feeding tubes and the administration of enteral nutrition (SCHN)

Enteral feeding and medication administration (RCH)

Enuresis - bed wetting monosymptomatic enuresis (PIC)

Enuresis - bed wetting (RCH)

Envenomation - snakebite (RCH)

Epididymoorchitis see acute scrotal pain (RCH)

Epiglottitis -see acute upper airway obstruction (RCH)

Epilepsy - imitators of seizures videos etc 

Epistaxis (SCH) -nose bleeding guideline

Epistaxis (RCH)

Essential oil poisoning (RCH)

Ethanol poisoning (RCH)

Eucalyptus oil poisoning (RCH)

Extended spectrum betalactamase (ESBL) producing gram negative bacteria: infection control  (SCHN)  

Extravasation injury   (RPA)  (when a drip tissues into the skin)

Extravasation injury (RCH) includes procedure for potential vesicant injury ie for drug which may cause blistering 

Eye cleaning with water and ointment (SCHN)

Eye injury see Acute eye injury (RCH)

Eye- see also Acute red eye (RCH) 

Eating Disorders in Children and Adolescents

This pathway is for patients aged under 18 years. See also Eating Disorders in Adults.

Red flags

• Ceased fluid intake

• Suicidality with active intent and plan

• Refeeding syndrome or high risk of refeeding syndrome

• Patient meets indicators for medical inpatient admission

• BMI < 5th percentile

Background

About eating disorders

About eating disorders

• Early diagnosis and treatment improves health outcomes.

• In adults, females with eating disorders outnumber males by 9:1. In younger people, males compromise at least 25% of this clinical group.

• Eating disorders may occur at any age, even in those as young as age 6 years.

• People can progress from one eating disorder to another.

• Anorexia nervosa has the highest mortality rate of any psychiatric disorder.

• The highest incidence of anorexia nervosa is in the 15 to 19 years age group but can be present at any age.

• There is a high prevalence of suicide in patients with an eating disorder.

Assessment

1. Consider an eating disorder in patients who present with any suggestive features. Patients with an eating disorder may not always disclose the extent of eating disordered behaviours, or they may deny or downplay the severity of symptoms.

2. Suggestive features

   • Rapid weight gain or loss

   • Depression or anxiety

   • Fertility issues or amenorrhoea

   • Gastrointestinal problems

   • Injuries caused by over-exercising

   • Presyncope, syncope, light-headedness

   • Fatigue, low energy, and poor sleep

   • Bilateral parotid gland swelling

   • Damage to teeth and bad breath

   • Type 1 diabetes – higher risk

   • Polycystic ovary syndrome – higher risk

   • Athletes, dancers, or models desiring a specific body shape

   • Requests for laxatives, appetite suppressants, and diuretics

3. Consider using a screening tool such as the SCOFF questionnaire.

4. SCOFF questionnaire

5. Score 1 point for every "yes" answer.

   • "Do you ever make yourself Sick because you feel uncomfortably full?"

   • "Do you worry you have lost Control over how much you eat?"

   • "Have you recently lost more than One stone (6.4 kg) in a 3‑month period?"

   • "Do you believe yourself to be Fat when others say you are too thin?"

   • "Would you say that Food dominates your life?"

6. Two or more positive answers should raise the index of suspicion and indicates the need for a comprehensive assessment for an eating disorder.

7. Source: Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ 1999 Dec 4;319(7223):1467-8.

8. Take a history. Ask about:

   • weight, including weight changes over time, highest and lowest past weight, and goal weight.

   • Weight

     • Since I saw you last, you’ve lost/gained weight, what’s been happening?

     • How do you feel about your current weight?

     • Many people have concerns about weight. Do you have any concerns or worries about this?

     • Are there things you do to control your weight?

   • eating and past history of eating disorder.

   • Eating

     • Many people have concerns about food. Do you have any concerns or worries about these?

     • Meal patterns e.g., dietary restrictions, skipping meals, ritualistic eating.

     • Do you ever use food as a way to cope with your emotions e.g., not eat or overeat?

     • Do you ever eat to the point of feeling uncomfortable even when you are not hungry?

     • Do you ever eat much more than you intended?

     • Many people have trouble with eating too much, has this ever been a problem for you?

   • compensatory behaviours.

   • Compensatory behaviours

     • Self-induced vomiting

     • Misuse of medications e.g., laxatives, diuretics, diet pills

     • Increased gum chewing or smoking

     • Excessive exercise

     • Insulin misuse

   • physiological signs.

   • Physiological signs

     • Amenorrhoea or irregular menstrual cycle – this may be masked if on oral contraceptives

     • Presyncope or syncope

     • Cold intolerance

   • cognitive changes.

   • Cognitive changes

     • Impaired concentration and alertness

     • Easily distracted and lethargic

     • Intrusive thoughts of food

   • fluid intake.

9. Perform a psychosocial assessment.

10. Psychosocial assessment

11. Consider history and current circumstances:

    • Living arrangements

    • Substance use

    • Relationships, social supports, and activities

    • Mental health history

    • Family history of mental illness, or weight- or eating-related issues

    • Recent stressors

    • Increased social isolation and/or withdrawal from social activities previously enjoyed

12. Assess mental health, including mood, anxiety, and suicide risk. See also HEEADSSS psychosocial interview for adolescents.

13. HEEADSSS psychosocial interview for adolescents

14. Ask about:

15.  

Home

who, where, recent changes (moves or new people), relationships, stress or violence, smartphone or computer use (in home vs room)

Education & Employment

where, year, attendance, performance, relationships and bullying, supports, recent moves, disciplinary actions, future plans, work details

Eating and Exercise

weight and body shape (and relationship to these), recent changes, eating habits and dieting, exercise, and menstrual history

Activities

extra‑curricular activities for fun: sport, organised groups, clubs, parties, TV or computer use (how much screen time and what for)

Drugs and Alcohol

cigarettes, alcohol and illicit drug use by friends, family, and patient. Frequency, intensity, patterns of use, payment for, regrets and negative consequences

Sexuality and Gender

gender identity, romantic relationships, sexuality and sexual experiences, uncomfortable situations or sexual abuse, previous pregnancies and risk of pregnancy, contraception, and STIs

Suicide, Depression & Self‑harm

presence and frequency of feeling stressed, sad, down, ‘bored’, trouble sleeping, online bullying, current feelings (e.g. on scale of 1 to 10). thoughts or actions of self-harm or hurting others, suicide risk: thoughts, attempts, plans, means, and hopes for future

Safety

serious injuries, online safety (e.g. meeting people from online), riding with intoxicated driver, exposure to violence (school and community), if high risk – carrying weapons, criminal behaviours, justice system

16. See also – The Royal Children's Hospital Melbourne (RCH) – Engaging With and Assessing the Adolescent Patient

17. Conduct a physical examination.

18. Physical examination

    • Check:

      • temperature.

      • blood pressure and postural drop.

      • pulse rate and postural change.

      • height and weight

      • Body Mass Index (BMI) = kg/m2 (weight divided by height squared):

        • If aged < 18, calculate using the Child and Teen BMI Calculator.

        • Healthy range = 25th to 85th centile, < 5th centile indicator for hospital treatment.

        • BMI Centile Chart – Girls.

        • BMI Centile Chart – Boys.

    • Assess hydration.

    • Perform oral examination looking for complications of acid damage from vomiting e.g., enamel erosion, inflamed throat.

    • Look for:

      • enlarged parotid glands from purging.

      • dorsal hand calluses from inducing purging.

      • hair loss, lanugo, skin dryness, skin colour, sores.

    • See also Centre for Eating Disorders – The Medical Examination recommendations.

19. Assess for risk of refeeding syndrome.

20. Refeeding syndrome

21. Refeeding syndrome is a severe fluid and electrolyte imbalance in starved patients who undergo refeeding, which can lead to arrhythmias, organ failure, and death.

    • Patients at risk have 1 or more of:

      • BMI less than 16 kg/m2

      • Unintentional weight loss of more than 15% within the last 3 to 6 months

      • Little or no nutritional intake for 7 to 10 days

      • Low levels of potassium, phosphate, or magnesium prior to feeding

      • Prolonged QTc interval on ECG

    • Or 2 or more of:

      • BMI less than 18.5 kg/m2

      • Unintentional weight loss of more than 10% within the last 3 to 6 months

      • Little or no nutritional intake for more than 5 days

      • A history of alcohol abuse or drugs including insulin, chemotherapy, antacids, or diuretics

22. Conduct initial investigations as appropriate.

23. Initial investigations

    • Phosphate

    • Phosphate

    • Low phosphate can be an indicator of refeeding syndrome or a patient at high risk of developing refeeding syndrome.

    • Abnormal result: Alert < 0.8 mmol/L

    • Potassium

    • Potassium

    • Low potassium can indicate vomiting, laxative use, diuretic use or a refeeding problem. Elevated levels can indicate kidney dysfunction or dehydration. Repeat regularly if purging. Chronic deficiency at whole normal body level may not be reflected by serum values.

    • Abnormal result:

      • Concern < 3.5 mmol/L

      • Alert < 3 mmol/L

    • Magnesium

    • Magnesium

    • Low serum magnesium always indicates magnesium deficiency. Normal serum magnesium does not exclude deficiency. Low levels may indicate poor nutrition, laxative use, or refeeding problems.

    • Abnormal result:

      • Concern 0.7 to 1.0 mmol/L

      • Alert < 0.7 mmol/L

    • Sodium

    • Sodium

    • Low sodium may mean fluid overload or laxative use. May require fluid restriction or sodium supplementation.

    • Abnormal result:

      • Concern < 130 mmol/L

      • Alert < 125 mmol/L

    • Calcium – Low calcium can solely reflect a low blood albumin. Low corrected calcium may also be associated with magnesium deficiency.

    • Urea

    • Urea

    • Elevated urea levels can be a sign of dehydration or catabolism of muscle.

    • Abnormal result:

      • Concern > 7 mmol/L

      • Alert > 10 mmol/L

    • Other electrolytes and enzymes

    • Other electrolytes and enzymes

    • Potential indications:

      • Chloride (low – vomiting, high – laxative use)

      • Blood bicarbonate (low – laxative use, high – vomiting)

      • Creatinine (low – poor muscle mass, high – dehydration, renal dysfunction)

      • Amylase (high – vomiting, pancreatitis)

      • Lipase (high – pancreatitis)

    • Glucose

    • Glucose

    • Hypoglycaemia may occur in severe caloric restriction. If the patient has diabetes, increased glucose may indicate insulin omission.

    • Abnormal result:

      • Concern < 3.5 mmol/L

      • Alert < 2.5 mmol/L

    • Iron, ferritin, B12, RBC folate – Ferritin may be high at presentation due to blood volume contraction but may fall following treatment.

    • FBC – Mild leukopenia is common, and pancytopenia can occur.

    • Cholesterol – Not usually performed, though high levels may reflect response to malnutrition, and resolve with weight gain in anorexia nervosa.

    • Liver function tests

    • Liver function tests

    • Abnormalities may occur due to fatty infiltration of the liver in starvation.

    • Abnormal result:

      • AST and ALD:

        • Concern > mildly elevated

        • Alert – markedly elevated e.g., > 500 units/L

      • Bilirubin:

        • Concern > 20 units/L

        • Alert > 40 units/L

    • Creatinine kinase (elevated in excessive exercise), lactate dehydrogenase (only if co-morbid alcohol abuse or dependence)

    • Oestradiol, follicle-stimulating hormone, luteinising hormone

    • Bone mineral densitometry, particularly if restrictive eating with amenorrhoea > 6 months

    • ECG QTc interval – especially if BMI ≤ 16 or hypokalaemia

    • ECG QTc interval

    • A prolonged QTc is an indication of cardiac compromise and increases risks associated with electrolyte abnormalities, refeeding, and medication use.

    • Abnormal result:

      • Alert > 450 milliseconds

      • Alert: Arrhythmias

24. Whenever possible and with patient consent, obtain corroborative information from family.

25. Consider the specific diagnosis based on this comparison of eating disorders table, or for more detailed information, the DSM‑5 Diagnostic Criteria for Eating Disorders.

Management

Practice point

Ensure early intervention

Early intervention with a multidisciplinary team achieves the best outcomes.

1. Arrange emergency assessment if:1

   • immediate risk to self or others.

   • risk of refeeding syndrome.

   • indicators for medical inpatient admission.

   • Indicators for medical inpatient admission1

     1. Weight loss:

        • Weight – BMI less than 14 kg/m2

        • Weight loss – rapid weight loss (i.e.,1 kg/week for 6 weeks or more)

        • Inadequate nutritional intake (less than 1000 kCal daily)

     2. Physiological instability:

        • Hypotension – systolic blood pressure less than 80 mmHg

        • Postural blood pressure drop – more than 20 mmHg with standing

        • Heart rate less than 50 bpm or more than 110 bpm or significant postural tachycardia (increase in more than 20 bpm on standing)

        • Hypothermia – temperature less than 35.5°C or extremities are cold and blue

     3. Abnormal ECG:

        • Any arrhythmia

        • QTc prolongation (more than 450 milliseconds)

        • Non-specific ST or T wave changes including inversion or bi-phasic waves

     4. Electrolyte imbalance:

        • Blood sugar – less than 3 mmol/L

        • Sodium – less than 125 mmol/L

        • Potassium – less than 3.0 mmol/L

        • Magnesium – less than 0.7 mmol/L

        • Phosphate – less than 0.8 mmol/L

        • Albumin – less than 30 g /L

        • Liver enzymes – AST or ALT more than 500 units/L

     5. Haematological conditions:

        • Neutrophils – less than 1.0 x 109 L

        • Symptomatic anaemia

     6. Other – significant medical complications, special considerations such as diabetes or pregnancy

2. Obtain parental consent for all treatment for patients aged < 14 years. Follow the mandatory reporting process in situations where the parents of a child aged < 16 years are refusing treatment, which places the child at risk.

3. If the patient is medically unstable and refusing treatment:

   • schedule the patient under the NSW Mental Health Act.

   • phone 000 and arrange for the ambulance to transfer them to the emergency department.

   • and the patient has anorexia, check if they meet the criteria for compulsory inpatient treatment.

   • Criteria for compulsory inpatient treatment

   • Under the Mental Health Act2, a person with anorexia can be involuntarily treated if their circumstances meet all 3 of the statutory criteria:

     1. The person is a "mentally ill person", i.e.:

        • They have a condition which seriously impairs their mental functioning, either temporarily or permanently.

        • They must also either experience particular symptoms or behave in a sustained or repeatedly irrational way which indicates the presence of these symptoms, including refusing to eat, sabotaging treatment, or exercising obsessively.

        • Symptoms

          • Delusions e.g., a fixed idea that they are grossly overweight

          • Serious disorders of thought form, including concrete or illogical thoughts

          • Severe disturbance of mood as a result of malnourishment or depression or anxiety

     2. The person is at risk of serious harm.

     3. There is no other form of safe and effective care. This criterion can be satisfied if voluntary care or treatment under a guardianship order is not adequate.

   • See also Mental Health Review Tribunal – Information Sheet: Coercive Treatment Options for Anorexia Under the Mental Health and Guardianship Acts.

4. For more information on managing patients who refuse care, see Centre for Eating and Dieting Disorders – Patient Refusal of Care (page 18).

5. Refer all patients who fulfil the DSM-5 criteria for an eating disorder to a healthcare provider with experience in this area. Consider referral:

   • for inpatient or community management.

   • to a dietitian with a self-identified interest in or expertise in eating disorders.

   • to a psychologist with a self-identified interest in or expertise in eating disorders.

   • for eating disorders support programs.

6. For the management of co-morbid psychiatric conditions, consider:

   • psychiatry referral.

   • psychology referral.

   • private hospital referral.

   • child and adolescent mental health assessment.

7. Seek eating disorders advice for:

   • urgent clinical advice.

   • advice about management in general practice.

8. If medically stable, arrange regular follow-up to monitor medical and psychological safety. Consider weekly appointments initially and manage according to likely condition:

   • Anorexia nervosa

   • Patients with anorexia have a high mortality rate and require multidisciplinary care.

     1. If the patient is medically stable but deteriorating, consider whether hospital admission would be of benefit.

     2. If the patient fulfils the DSM-5 criteria for an eating disorder and is medically stable, request eating disorders specialised assessment. The first-line treatment is enhanced cognitive therapy (CBT-E), although other models may be used depending on clinical presentation. CBT-E involves:

        • collaborative therapy involving the development of an individual formulation with the patient that outlines the factors that maintain their eating disorder.

        • patients being weighed as part of their therapy, and asked to monitor their dietary intake as well as associated thoughts and feelings.

     3. Develop a care plan and treatment agreement, in consultation with the patient, family (unless contraindicated), and other members of the treating team:

        • Incorporate family-based therapy, which is the recommended first-line therapy for children and adolescents with anorexia nervosa.

        • Complete an Eating Disorder Treatment Plan (EDTP) to access increased psychological and dietitian services.

        • Eating Disorder Treatment Plan (EDTP)

          • Complete the GP EDTP template:

          • GP EDTP template

            • Inside Out – Online Form

            • Best Practice Forms:

              • Initial consultation (rtf)

              • Review (rtf)

            • For information about how to import rtf forms, see Best Practice Templates.

            • Medical Director Forms:

              • Initial consultation (rtf)

              • Review (rtf)

            • For information about how to import rtf forms, see Medical Director Templates.

            • This replaces a mental health care plan (items 2715 and 2717) and a chronic disease management plan (CDMP) (items 721 and 723).

            • It gives access for up to 40 (4 courses of 10) psychological, and 20 dietetic services in a 12‑month period.

            • The patient may still have a CDMP for an unrelated chronic condition with clear documentation in the patient’s file that the conditions are unrelated.

          • Document the EDTP in the patient’s file.

          • Use new MBS items for eating disorders.

          • New MBS items for eating disorders

            • General practitioner eating disorders treatment plan without mental health skills training:

              • 90250: 20‑to‑39‑minute consultation

              • 90251: a ≥ 40‑minute consultation

            • General practitioner eating disorders treatment plan with mental health skills training:

              • 90252: 20‑to‑39‑minute consultation

              • 90253: a ≥ 40‑minute consultation

            • General practitioner review of eating disorders treatment and management plan – 90264:

              • Review eating disorder treatment and management plan after every 10 psychological sessions by a general practitioner for:

                • treatment efficacy, and evaluate with the patient whether it meets their needs.

                • modifications to continue with treatment options in the plan or alter treatment options in the plan with new arrangements.

              • Initiate referral to psychiatrist as appropriate.

              • Offer the patient a copy of plan and eating disorder education.

            • Specialist review by 20th psychological session:

              • A psychiatrist must review the patient by the 20th psychological session before they can access the final 20 sessions.

              • No review for dietitian services are required to complete the course of 20.

          • See National Eating Disorders Collaboration – New MBS Items for Eating Disorders: Cheat Sheet for GPs.

     4. Prescribe a multivitamin and mineral supplement until diet is adequate.

     5. Consider psychotropic medication if co-morbid depressive illness or extreme agitation. Do not use as the sole or primary treatment for anorexia nervosa.

     6. Psychotropic medication3

        • Antidepressants:

          • Consider antidepressant if persistently depressed mood, neurovegetative features (e.g., late insomnia, diurnal mood variation, and anhedonia), and depressive ideation such as guilt, hopelessness, and worthlessness.

          • Where possible, avoid SSRIs until renourished with normal electrolytes and heart rate.

          • Monitor any increase in agitation and suicidal thoughts and behaviours when initiating antidepressant medication in adolescents.

          • Use antidepressants with low risk of cardiovascular side-effects, starting at half the usual dose due to increased risk of cardiovascular complications associated with anorexia. Avoid:

            • tricyclic antidepressants (TCAs).

            • citalopram and escitalopram in patients with known prolonged QT interval or current electrolyte disturbance.

          • Use:

            • fluoxetine: initiate at 10 mg daily dose in adolescents, increasing to 20 mg daily dose after 1 to 2 weeks and continuing the same dose for 4 to 8 weeks before further review.

            • sertraline: initiate at 25 mg daily dose in adolescents, increasing to 50 mg daily dose in 1 to 2 weeks and continue the same for 4 to 8 weeks before further review.

          • When there is co-morbid anxiety (especially panic attacks), initiate at lower dose: 5 mg fluoxetine or 12.5 mg sertraline and slowly build up to optimum dose, as initiating SSRIs can worsen anxiety and agitation initially.

        • If normal weight, consider psychotropic medication to treat depression or obsessive-compulsive problems.

     7. Arrange regular follow-up to monitor:

        • for refeeding syndrome and features suggesting acute medical collapse. If urgent medical assessment is required, request emergency assessment.

        • compensatory behaviours.

        • Compensatory behaviours

          • Self-induced vomiting

          • Misuse of medications e.g., laxatives, diuretics, diet pills

          • Increased gum chewing or smoking

          • Excessive exercise

        • cognitive changes.

        • mental health, including for depression, anxiety, substance abuse, and suicidal ideation and intent.

        • physical health – review weight gain goals (generally accepted outpatient weekly gain up to 0.5 kg)

        • Physical health

          • Temperature

          • Blood pressure and postural drop

          • Pulse rate and rhythm

          • Weight and body mass index (BMI) = kg/m2 (weight divided by height squared)

            • Identify target weight or BMI

            • Ensure agreement as to which clinician involved in care will weigh the patient, and that this is consistently communicated amongst the care team

          • Assess hydration

          • Monitor dental care and examine for possible dental erosion

          • Menstrual irregularities

        • investigations, as required.

        • Investigations

          • ECG QTc interval

          • Phosphate – consider hospitalisation if at risk and monitor regularly during early treatment.

          • Potassium

          • Magnesium

          • Sodium

          • Calcium – Low calcium can solely reflect a low blood albumin. Low corrected calcium may also be associated with magnesium deficiency.

          • Urea – If elevated, promote adequate fluid intake or use intravenous saline drip. Do not use intravenous dextrose.

          • Other electrolytes and enzymes

          • Glucose

          • Iron, ferritin, B12, RBC folate – Ferritin may be high at presentation due to blood volume contraction but may fall following treatment. Correct deficiencies.

          • FBC – Mild leukopenia is common and pancytopenia can occur.

          • Cholesterol – Not usually performed, though high levels may reflect response to malnutrition, and resolve with weight gain in anorexia nervosa.

          • Liver function tests

        • Also consider thyroid function test, oestradiol, luteinizing hormone (LH) and follicle-stimulating hormone (FSH), 25-OH-vitamin D.

     8. If BMI < 16 or if rapid weight loss over a short period of time, reassess weekly. Weight gain of ≤ 0.5 kg per week is accepted.

     9. As the patient is stabilising, engage in relapse prevention planning.

   • Bulimia nervosa

     1. Develop a care plan and treatment agreement, in consultation with the patient, family (unless contraindicated), and other members of the treating team. Consider whether the patient is eligible for an eating disorder plan.

     2. Eligible for an eating disorder plan

     3. The patient is eligible for an eating disorder plan if they have either:

        • anorexia nervosa, or

        • binge eating disorder, bulimia, or other specified eating disorder (OSFED) and meet all of the following criteria:

          • Eating Disorder Examination Questionnaire (EDE-Q) score of ≥ 3.

          • rapid weight loss or ≥ 3 binge eating or compensatory episodes in a week.

          • ≥ 2 of the following:

            • weighing < 85% of their expected weight due to an eating disorder.

            • high risk of medical complications.

            • serious co-morbid psychological or medical conditions affecting health and functioning.

            • admission to a hospital for an eating disorder in the previous 12 months.

            • inadequate treatment response to evidence based eating disorder treatment over the past 6 months despite active and consistent participation.

     4. See also National Eating Disorders Collaboration – New MBS Items for Eating Disorders – Cheat Sheet for GPs.

        • If the patient qualifies, complete an Eating Disorder Treatment Plan (EDTP) to access increased psychological and dietitian services.

        • If the patient does not qualify for an EDTP, consider developing a GP Mental Health Care Plan and/or a Chronic Disease Management Plan.

     5. Discuss and give patient information. Consider:

        • directing to online cognitive behavioural modules. Consider free 12‑week trial of online CBT program for bulimia nervosa for patients aged 16 years and over – see website or PDF for further information.

        • advising about minimising harm from vomiting.

        • Minimising harm from vomiting

          • Give oral hygiene advice:

            • Avoid brushing immediately after vomiting.

            • Rinse with a non-acid mouthwash after vomiting.

            • Limit acidic foods like citrus.

          • Screen for symptoms of a peptic ulcer or Mallory-Weiss tear and manage appropriately. See the Assessment section of the Gastro-oesophageal Reflux Disease (GORD) / Heartburn pathway.

          • Advise regular dental check-ups.

        • See also Australian Dental Association (ADA) – Eating Disorders: Talking to Your Dentist.

     6. If identified risk of suicide or self‑harm, see Suicide Ideation and Intent pathway.

     7. Consider medication to reduce binge frequency and purging behaviours. Advise to separate medications from meals (an hour before meals or 2 hours after) if the patient is purging meals.

     8. Medication4,3

     9. Consider SSRI to reduce binge eating:

        • Where possible, avoid SSRIs until renourished with normal electrolytes and heart rate.

        • Use antidepressants with low risk of cardiovascular side-effects, starting at half the usual dose due to increased risk of cardiovascular complications associated with bulimia.

        • Monitor any increase in agitation and suicidal thoughts and behaviours when initiating antidepressant medication in adolescents.

        • A 50 to 75% reduction in bingeing and purging is considered a clinical response.

        • Use:

          • First-line, fluoxetine: initiate at 10 mg daily dose in adolescents, and increase as tolerated to a maximum of 60 mg daily, or

          • Second-line, sertraline: initiate at 25 mg daily dose in adolescents, increasing to 50 mg daily dose in 1 to 2 weeks and continue the same for 4 to 8 weeks before further review.
            When there is co-morbid anxiety (especially panic attacks), initiate at lower dose: 5 mg fluoxetine or 12.5 mg sertraline and slowly build up to optimum dose as initiating SSRIs can worsen anxiety and agitation initially.

          • Third-line, topiramate initiate 25 mg once daily, increase dose gradually in progressively larger increments of 25 to 100 mg at intervals ≥ 1 week based on response and tolerability, up to 400 mg/day.

            • Note topiramate can worsen co-morbid depression – monitor if present.

            • Evidence for use in the adolescent population is limited.

     10. Arrange regular follow-up to monitor medical and psychological safety. Consider weekly appointments initially. Monitor:

         • for evidence of purging, giving special attention to features suggesting acute medical collapse.

         • Evidence of purging

           • BMI can be normal or high.

           • Hypokalaemia

           • Mallory-Weiss syndrome (oesophageal tears)

           • Erosion of dental enamel

           • Parotid and salivary gland hypertrophy

           • Scarring or calluses on dorsum of hand

           • Gastro-oesophageal reflux disease (GORD)

           • Constipation

           • Diarrhoea and malabsorption

           • ECG changes – QTc > 450 milliseconds, and presence of U waves (indicates hypokalaemia)

         • compensatory behaviours.

         • cognitive changes.

         • mental health, including for depression, anxiety, substance abuse, and suicidal ideation and intent.

         • physical health.

         • blood test results:

           • If initial blood tests are normal, repeat as needed. Patients who are purging require monitoring more frequently.

           • If abnormal, frequency of repeating depends on the degree and type of electrolyte disturbance.

     11. As the patient is stabilising, engage in relapse prevention planning.

   • Binge eating disorder

     1. Develop a care plan and treatment agreement, in consultation with the patient, family (unless contraindicated), and other members of the treating team. Consider whether the patient is eligible for an eating disorder plan.

        • If the patient qualifies, complete an Eating Disorder Treatment Plan (EDTP) to access increased psychological and dietitian services.

        • If the patient does not qualify for an EDTP, consider developing a GP Mental Health Care Plan and/or a Chronic Disease Management Plan.

     2. Coordinate treatment for any coexisting mental health issues.

     3. Give patient information, and offer self-help. Consider directing to Centre for Clinical Interventions – Disordered Eating CBT modules.

     4. If overweight, monitor cardiovascular risk.

     5. Consider SSRI therapy as an adjunct to psychotherapy if co-morbid depression.

     6. Arrange regular follow-up to monitor medical and psychological safety. Consider weekly appointments initially. Monitor:

        • compensatory behaviours.

        • cognitive changes.

        • mental health, including for depression, anxiety, substance abuse, and suicidal ideation and intent.

        • physical health.

     7. As the patient is stabilising, engage in relapse prevention planning.

   • Other specified feeding and eating disorders (OSFED)

     1. Develop a care plan and treatment agreement, in consultation with the patient, family (unless contraindicated), and other members of the treating team. Consider whether the patient is eligible for an eating disorder plan.

        • If the patient qualifies, complete an Eating Disorder Treatment Plan (EDTP) to access increased psychological and dietitian services.

        • If the patient does not qualify for an EDTP, consider developing a GP Mental Health Care Plan and/or a Chronic Disease Management Plan.

     2. Coordinate treatment for any coexisting mental health issues.

     3. Give patient information, and offer self-help. Consider directing to Centre for Clinical Interventions – Disordered Eating CBT modules.

     4. Arrange regular follow-up to monitor for features suggesting acute medical collapse, and for psychological safety. Reassess weekly, if BMI is approaching 16 or if rapid weight loss over a short period of time. Monitor:

        • compensatory behaviours.

        • cognitive changes.

        • mental health, including for depression, anxiety, substance abuse, and suicidal ideation and intent.

        • physical health.

     5. As the patient is stabilising, engage in relapse prevention planning.

   • Disordered eating

     1. Develop a care plan and treatment agreement, in consultation with the patient, family (unless contraindicated), and other members of the treating team. Patients with a clinical diagnosis of avoidant-restrictive food intake disorder (ARFID) or unspecified feeding or eating disorder (UFED) do not qualify for an Eating Disorder Treatment Plan – consider developing a GP Mental Health Care Plan and/or a Chronic Disease Management Plan.

     2. Coordinate treatment for any coexisting mental health issues.

     3. Give patient information, and offer self-help. Consider directing to Centre for Clinical Interventions – Disordered Eating CBT modules.

     4. Consider providing nutritional information e.g., REAL food guide.

     5. Arrange regular follow-up to monitor medical and psychological safety. Consider weekly appointments initially. Monitor:

        • for significant weight loss or gain, or symptoms of an eating disorder.

        • compensatory behaviours.

        • cognitive changes.

        • mental health, including for depression, anxiety, substance abuse, and suicidal ideation and intent.

        • physical health.

     6. As the patient is stabilising, engage in relapse prevention planning.

Referral

• Arrange emergency assessment if:

  • immediate risk to self or others.

  • indicators for medical inpatient admission.

  • ceased fluid intake.

  • suicidality with active intent and plan.

  • refeeding syndrome or high risk of refeeding syndrome.

• If the patient is medically unstable and refusing treatment:

  • schedule the patient under the NSW Mental Health Act.

  • phone 000 and arrange for the ambulance to transfer them to the emergency department.

• Follow the mandatory reporting process in situations where the parents of a child aged < 16 years are refusing treatment, which places the child at risk.

• Seek eating disorders advice for:

  • urgent clinical advice.

  • advice about management in general practice.

• For all patients, consider referral:

  • for inpatient or community management.

  • to a dietitian with a self-identified interest in or expertise in eating disorders.

  • to a psychologist with a self-identified interest in or expertise in eating disorders.

  • for eating disorders support programs.

• For the management of co-morbid psychiatric conditions, consider referral to a:

  • psychiatry referral.

  • psychology referral.

  • private hospital referral.

  • child and adolescent mental health assessment.

• Consider free 12-week trial of online CBT program for bulimia nervosa for patients aged 16 years and over – see the website or PDF for further information.

Information

Acute otitis media (RCH)

Secondary haemmorhage post tonsillectomy and adenoid surgery - ED management

Post tonsillectomy bleed  (note this is a Perth  guideline and focuses on: getting IV access, considering coagulopathies as a root cause of the bleeding, giving IV fluids, considering tranexamic acid, and getting blood cross matched +/- urgent  transfusion of O negative blood) 

Note: in Dubbo if a child has an unexpected  post tonsillectomy bleed, the  emergency staff have three options on whom to call, if the surgeon involved is not contactable, and general surgeon on call expresses reservations around providing ENT cover: 

1) Dr Hayder Ridha (ENT)

2) Dr Ranga Sirigiri  (ENT)

Adenoidectomy post operative management (RCH)

Facial weakness - Bell's palsy (RCH)

Failure to thrive - see poor growth (RCH)

Fainting-see  Syncope - (RCH)

Febrile and suspected or confirmed neutropaenia (RCH)

Febrile seizure (RCH)

Femoral fractures in ED (SCHN)

Febrile child (RCH)

Fever:  assessment and management in the emergency (SCH) (note for children under 3 months of age , there is a separate guideline and the authors recommend consulting senior clinicians in ED +/- paediatrics early for consideration of full septic workup)

Fever and petechial rash (SCH) Note: 1) Dubbo Paediatric does not yet recommend home observations and treatment 2) get prompt IV access and blood tests recommended: a) sterile blood culture (1ml minimum aseptic technique) b) CRP and c) procalcitonin

Fever and petechiae (RCH)

Fever and sickle cell disease (RCH) see Sickle cell disease and fever (RCH)

Fever in recently returned traveller (RCH)

Femoral nerve block (RCH)

Fever and suspected or confirmed neutropaenia (RCH) see Febrile and suspected or confirmed neutropaenia (RCH)

Fluid management (IV fluids - RCH)and Intravenous fluid- quick link to types of fluid per age group (ACI)

Food allergy  IgE mediated(PIC)

Food allergy ( Non- IgE medited) (PIC)

Foreign body (PIC)

Foreign body inhaled (RCH)

Foreskin - see the Penis and foreskin (RCH)

Food allergy- high alert meal service (SCHN)

Foreskin concerns see - see the penis and the foreskin (RCH)

Fracture management (SCHN)

Fracture casting videos (RCH)

Fractured femur - see skin traction (RCH)

Fracture reduction in the ED (SCHN)

Fractures (RCH) a comprehensive list of fractures for the Emergency department. Edited by Victorian Paediatric Orthopaedic Network

Febrile child: The PIC guideline on RCH site is a concise approach

Recognition of the seriously unwell neonate ( RCH- this includes infections in neonates)

Sepsis pathway- Clinical excellence commission - this is a 2 page document which is like a flow chart for how to assess vitals signs, do tests , and resuscitate a child with sepsis.

Fever:  assessment and management in the emergency in children under 5 years  (SCH) (note for children under 3 months of age , there is a separate guideline and the authors recommend consulting senior clinicians in ED +/- paediatrics early for consideration of full septic workup)

Petechiae and purpura (RCH)

Fever in neonate (Nepean and has links to CEC) 

Dr FITZGERALD's TIPS for assessing and managing the febrile child in the emergency

1) If the child represents to the emergency with a fever for a 2nd opinion- the author recommends after ED has completed its assessment to discuss with Paediatrics prior sending home.

2) Be particularly careful with :

a)  Infants less than 6 months (and the author recommends that  in a child under 3 months with a fever >38.5c , with no focus should be  treated as a medical emergency. 

b) be careful with children who are taking oral antibiotics while you assess the patient- this may interfere with how an underlying disease presents ( e.g. a partially treated meningitis)

3) In the post vaccination era, UTI is the commonest cause of serious bacterial infection in children presenting to ED with fever and no focus

Overall, we don't do urine collections well in the non-toilet trained child- so ask for help early on how to best obtain it.

A bag urine can be used as screening tool to look at the urinalysis results - see below. Bag urines are not sent for culture, the exception being if the child is well and you are not starting antibiotics. If the urine culture on bag is positive, you will need to a do a clean catch/catheter prior to starting antibiotics for UTI.

So put a urine bag on early, or attempt a clean catch early, and get on with examining the child.

If it is fever with no focus in a sick child, who is not toilet trained, proceed to in/out urine catheter.  The exception is a boy less than 3 months of age, in whom it is hard to push a 5 French feeding tube.

If a UA is completely "clear" for UTI screen ie no leucocytes, no red cells and no nitrates it rules out UTI in over 95% of cases. Nevertheless if there is no cause for fever a urine culture is still indicated

If ketone are > +1 or Specific gravity > 1.030 then the child may be dehydrated

Urinalysis , if it shows nitrates positive on clean catch or catheter urine (not on a bag), this indicates a >95 probability of gram negative urinary tract infection eg E. Coli. Catch sterile urine as you are able, and start treatment for UTI

Fever itself can cause  leucocytes and red cells in the urine ; but rarely would be be UA > 2+ white cells or UA > 3 +. (or on microscopy > 100 WCC)

If a clean catch is done- chase the microscopy for bacteruria. If bacteria are noted on wet preparation there is a > 95 % chance of UTI- start treatment

4) Top to tail examination is done with variable levels of expertise and accuracy, areas for considering and watching are :

Calm the child down, place on parents lap, or get them to give the parent a front hug to hear the lower lobes. 

Before laying hands on the child , stand back and note levels of activity and communication. Is the child normal/ tired/lethargic?

Remember an anxious child may well have tachycardia and tachypnoea caused by anxiety; be ready to re-examine when child is calmer.

a) persistent tachypnoea for clue for underlying pneumonia. Many children with fever are tachypnoeic so reassess the patient after antipyretics, if the breathing rate remains high consider pneumonia/bronchiolitis etc

b) pulse rate- note if the PR is HIGH (e.g. into the BTF  red zone tachycardia) and if it remains high,  treat on sepsis pathway  (PIC)with urgent consultation with senior ED staff +/- paediatrics

c) O2 saturations < 95% are not normal- find out why. If the O2 saturations are 94% or less and you cant hear anything abnormal in the chest- you are probably missing something- ask someone with more experience to double check your findings

c) check glucose- we often to do not check this , which is sloppy, and it may be low from sepsis or fasting. If less than 3.5mmol check hypoglycaemia guideline and think about 0.5ml/oral dextrose child , oral sugary drinks etc

d) chest auscultation: Calm the child down, place on parents lap, or get them to give the parent a front hug to hear the lower lobes. 

Get the child to open its mouth , which  may amplify chances of successful hearing faint crepitations, wheeze , reduce air entry or bronchial breath sounds.

If child has persistent tachypnoea, respiratory distress , grunting +/- O2 saturations < 95% , consider a chest x-ray for pneumonia

e) heart murmurs- remember Aboriginal children in Dubbo and surroundings have a risk  of rheumatic heart disease, new onset murmur could be a flow murmur with fever (re-examine later).

f) examine for lymph nodes, abdomen for hepatomegaly (more than 3cm below the costal margin is enlarged of ptosed), splenomegaly (spleen is not usually palpable

g) skin rashes

h) joint pains- are there any swollen joints or limping/refusal to weight bear , does the child have focal bone or joint pain?

i) ear examination: looking for acute otitis media (AOM) and mastoiditis (RCH  AOM guide with images)

j) mouth , tonsils and pharynx (see Tonsillitis or sore throat- below on this page under T)

5) Blood tests

a) Blood culture- take in a sterile manner, so as to not obtain a contaminant on culture

b) FBC - looking for high neutrophil count > 20 in bacterial infection

c) CRP- if > 100 consider bacterial infections to be more likely (but some severe viral infections , such as enterovirus& VZV may be this high)

CRP may take 24-36 hours to become elevated- consider what stage in the febrile illness the child is up to

d) procalcitonin (PCT)  if > 1.0, and in particular if > 2.0 consider serious bacterial infection. If PCT > 10 serious bacterial infection is very likely (>90% odds). Only very rarely will a viral infection elevated PCT.

6) Prolonged fever > 5 days.

Most viral infections will have a febrile period of less than 5 days, but occasionally may go on for 14 days.

A fever for > 5 days raises questions around alternative diagnoses, thought above approach is still valid.

A prolonged fever generally is a paediatric referral, where alternative diagnoses will be considered.

Kawasaki disease (RCH) is always worth thinking about, as it both problematic if clinicians fail to diagnose it and it is treatable.

For city slicker doctors don't forget Q fever, zoonoses in general (in addition to the usual suspects below)

a) Fever without a source in children 3 to 36 months of age: Evaluation and management  (Up To Date)

b) Fever of unknown origin ( Up to Date)

FOOD ALLERGY TIPS  

WHICH FOOD AND WHAT ARE THE SYMPTOMS?

• Note the type of food, how much was eaten, if this has happened before ,  and the timing and order of onset of clinical features 

• Typically the story will be eating the food and then within 10-60 minutes the child will have:  tingling mouth, rash around mouth, eyes and face, abdominal cramps, vomiting

• Then as the allergic reaction progresses  a more generalised rash may be seen on the  chest, tummy and legs (if so monitor closely in hospital for imminent anaphylaxis) , and then to anaphylaxis.  

•  A small amount of coughing/ throat clearing is not unusual but persistent coughing is concerning 

• Food allergy may present with wheeze and no rash (etc) but this is uncommon.

• If egg or milk was eaten, was  it extensively heated? (baked in oven > 180c, > 40 mins, or just partially cooked)

GRADE THE SEVERITY OF THE ALLERCIC REACTION

• Note all symptoms on the "mild, moderate and severe allergy reactions" of anaphylaxis sheet  and try to work out if your child has local/ generalised reaction to food or if it had ANAPHYLAXIS  (i.e how far did the child progress on the sheet?- you should have your child examined by a doctor, as they may be wheezing , but you can't hear it)

DIAGNOSIS  OF FOOD ALLERGY, GOING HOME AND FOLLOWUP

• A diagnosis food allergy is made with a combination of :

a) a typical story of exposure with symptoms (history of one of more ingestions; two very similar events, with typical symptoms is very suggestive of  food allergy)

and 

b) evidence of allergy (raised IgE to the food) on blood tests or skin prick testing

• If the diagnosis is made you should receive an action plan; for milder reactions Action plan for allergic reactions  or for anaphylaxis  (Anaphylaxis action plan )

• Blood tests: If going home, discuss with seniors on serum specific testing blood test eg for peanut allergy you would order "Serum specific IgE peanut" or milk "serum specific IgE milk".   Copy result to the family doctor.  We recommend a result >30 IU be referred to an allergy specialist or paediatrician. 

• If the serum  specific food IgE > 100 IU we recommend your GP speak to a specialist paediatrician promptly on an urgent outpatient appointment for severe allergy assessment.

•  Do not order total IgE , this does not assist with diagnosis

• Skin prick testing can be performed options: Sydney allergist, ? visiting allergy specialist to Dubbo, Dubbo Paediatric Outpatients skin prick testing (referral from GP to Dr Dominic FitzGerald  ph 6809 7083)

• All anaphylaxis cases should be referred to a specialist for assessment . Dubbo Paediatric Outpatients

Food allergy Home page (ASCIA)  to explore information on food allergy from the foremost Australian site for reliable information on allergy

Food allergy (ASCIA) general information about the types of food allergy reactions

Dietary guide for food allergens (ASCIA)

Cow's milk allergic reactions (ASCIA) note with milk whether it was extensively heated (e.g. baked in oven for over 40 minute at over 180c or not)

Egg allergy-  note with egg whether it was extensively heated (e.g. baked in oven for over 40 minute at over 180c or not; or just lightly cooked eg fried or boiled)

Peanut allergy- fast facts (ASCIA)  and Peanut, tree nuts and legumes information (ASCIA)

Food adverse reactions  - not all reactions to food are allergic (IgE associated)

Food Allergy in Children

Red flags

§  Rapidly progressing respiratory or circulatory symptoms, i.e. signs and symptoms of anaphylaxis

Background

About food allergy in children

About food allergy in children

Food allergy occurs in around 1 in 10 children.

The most common triggers are egg, cow's milk, peanut, tree nuts, seafood, sesame, soy, fish, and wheat. The majority of food allergies in children are not severe, and may be outgrown with time. However, peanut, tree nut, seed, and seafood allergies are less likely to be outgrown and tend to be lifelong allergies. Some food allergies can be severe and in rare instances, cause anaphylaxis.

Adverse reactions to foods that are not allergy include food intolerances, toxic reactions, food poisoning, enzyme deficiencies, food aversion, or irritation from skin contact with certain foods. These adverse reactions are often mistaken for food allergy.

Assessment

Practice point

Test only if indicated by history

Food specific IgE testing should not be performed without a clinical history suggestive of IgE-mediated food allergy. Allergy testing of patients where there is no evidence that food allergy plays a role in their clinical symptoms increases the likelihood of false positive results and potential harm.

1.     If a reaction to food progresses rapidly and causes respiratory or circulatory symptoms, treat as anaphylaxis – follow the Anaphylaxis pathway.

2.     Take a careful history. Consider features to help distinguish between food allergy (immune mediated) and food intolerance (non-immune food allergy).

Food allergy (immune mediated) and food intolerance (non-immune food allergy)

A true food allergy:

·   causes an immune system reaction that affects numerous systems in the body.

·   can cause a range of symptoms due to inflammatory response e.g. skin (hives/eczema), gastrointestinal tract (enteropathy, proctolitis), and respiratory system (wheeze).

·   can be severe or life-threatening in some cases.

Food intolerance:

·   can be confused with food allergy as symptoms may be similar. However these are generally less serious and often limited to digestive problems.

·   does not involve the immune system. The mechanism by which food intolerances occur is not always clear. Examples include:

·   enzyme deficiency in lactose intolerance.

·   histamine toxicity from scromboid fish poisoning.

·       will not show on allergy testing.

Careful history

·   History of the reaction:

·   What was eaten

·   Amount eaten

·   Symptoms and their duration

·   Time between eating and symptoms occurring

·   Reproducibility:

o   Number of times this food has been eaten in the past

o   Whether it has been eaten without any adverse reaction

·   Medications used

·   Whether the patient exercised before the reaction

·   Family history – Allergic conditions, including food allergy

·   Patient history:

·   Eczema, asthma, or allergic rhinitis

·       Infant growth and feeding history. Allergic reactions in exclusively breastfed babies is extremely rare and manipulation of maternal diet is often unnecessary. See ASCIA – Infant Feeding and Allergy Prevention Guidelines.

3.     Distinguish between immediate reactions (within 2 hours) and delayed reactions (after 2 hours, but within 24 hours) to food ingestion:

·   Immediate reactions are mostly IgE-mediated food allergies (immediate hypersensitivity), which usually occur within 30 minutes (always within 2 hours) of ingesting the food allergen. Clinical presentations include:

o   severe allergic reaction (anaphylaxis).

Severe allergic reaction (anaphylaxis)

Severe IgE mediated allergic systemic reaction with respiratory and/or cardiovascular involvement in addition to involvement of other systems, such as skin or gut, in isolation or combination.

·   Respiratory symptoms:

·   Difficulty breathing or noisy breathing

·   Swelling of tongue

·   Swelling or tightness in throat

·   Difficulty talking and/or hoarse voice

·   Wheeze or persistent cough

·   Cardiovascular symptoms:

·   Loss of consciousness

·   Collapse

·   Pale and floppy (in young children)

·       Hypotension

o   mild-to-moderate allergic reaction also known as generalised allergic reaction.

Mild-to-moderate allergic reaction

·   May involve:

·   skin – urticaria, erythema, pruritus, angioedema.

·   gut – oral itch, vomiting, abdominal cramps, diarrhoea.

·   upper respiratory tract – sneezing, rhinorrhoea.

·   Does not involve the larynx, lower respiratory tract, or cardiovascular system

·       Urticaria lasting days to weeks is not due to food allergy.

o   oral allergy syndrome.

Oral allergy syndrome

·   An allergy to certain fruits and vegetables, especially when eaten raw

·   Usually causes redness, itching, burning, and swelling of the lips, inside of the mouth, tongue, and soft palate

·   Anaphylaxis is rare

·   Often seen in children who are sensitised to birch tree and other pollens, and have allergic rhinitis

·       See Oral Allergy Syndrome.

o   contact urticaria without ingestion.

Contact urticaria

·   A trial of food contact on skin to check for allergy is not recommended. If urticaria develops immediately on accidental skin contact, it is not necessarily an indication of an allergy. Encourage the parent or carer to continue to offer small amounts of the food orally.

·       Further skin contact with this food is very unlikely to progress to a severe reaction.

·   Delayed reactions (non‑IgE reactions). These reactions are generally delayed several hours to days after the food is ingested. Clinical presentations include:

Delayed reactions (non-IgE reactions)

Symptoms are predominantly gastrointestinal and must occur reproducibly on exposure.

The disorders of infancy characterized by non-IgE-mediated gastrointestinal inflammatory responses to food are:

·   food protein-induced enterocolitis syndrome (FPIES), in which a large portion of the gastrointestinal tract is affected, with severe clinical manifestations.

·   food protein induced allergic proctolitis (FPIAP).

·   food protein-induced enteropathy, in which the small bowel is affected.

See NZMJ – Summary of Non-IgE Mediated Food Allergies in Children (Table 1).

o   food protein induced enterocolitis syndrome (FPIES).

Food protein induced enterocolitis syndrome (FPIES)

·   Occurs exclusively in infants and young children. FPIES is rare in exclusively breast-fed infants.

·   It is a non-IgE mediated allergic reaction to one or more ingested foods which results in inflammation of the small and large intestine.

·   Symptoms of profuse vomiting and sometimes diarrhoea occur 2 to 4 hours after eating a food recently introduced in the diet.

·   Children may become pale, floppy, and have reduced body temperature and/or blood pressure during a reaction.

·   Avoidance of trigger food is currently the only effective treatment option, though most children outgrow their FPIES in the preschool years.

·       Common triggers are rice, cow's milk and soy, though any food can cause a FPIES reaction.

o   food protein induced allergic proctocolitis (FPIAP).

Food protein induced allergic proctocolitis (FPIAP)

·   Benign condition and infant usually appears well.

·   Visible specks of blood, with or without mucus in the stool due to distal colon inflammation.

·   Typically presents between age 2 and 8 weeks.

·   Occurs in breast and formula-fed infants.

·       If the child is thriving, no intervention is required. Occasionally, a short (maximum 2 weeks) elimination of cow’s milk can be considered.

o   food protein‑induced enteropathy.

Food protein-induced enteropathy

·   Occurs mainly in infants.

·   Chronic symptoms, e.g. vomiting, diarrhoea, and failure to thrive. May develop anaemia (iron deficiency), oedema (due to protein loss via gut), secondary lactose intolerance.

·       Major triggers are cow's milk and soy.

o   coeliac disease.

o   eosinophilic oesophagitis (EoE).

Eosinophilic oesophagitis (EoE)

·   Localised eosinophilic inflammation of the oesophagus.

·   Diagnosed on endoscopy with biopsy.

·   In infants or young children, presents with feeding difficulties (refusal), failure to thrive, vomiting, and reflux symptoms.

·       In adolescents or older children, most often presents with dysphagia and oesophageal food impaction.

4.     Perform examination:

·   Usually normal, unless acute presentation.

·   Check growth.

·   If eczema or asthma, check skin and respiratory system.

5.     Keep in mind the limits of allergy testing. For most patients, management and referral can be initiated without investigation.

Limits of allergy testing

·   Tests are only indicated when the history suggests an IgE mediated food allergy. Skin prick testing (SPT) is preferred (only accessible locally after consultation with an immunologist).

·   While radioallergosorbent (RAST) testing is accessible through pathology companies, the Australian Society of Clinical Immunology and Allergy (ASCIA) recommends these are only undertaken and interpreted by a specialist.

·   RAST is only used in children for whom a SPT would be unreadable e.g. severe eczema, and are most useful if directed by history.

·   Testing for a large panel of allergens is not useful and not recommended.

·   There are no validated tests specifically for non-IgE mediated reactions.

·   There is no role for measuring total serum IgE.

·   Tests alone are not diagnostic of food allergy.

Do not remove a food from a child’s diet on the basis of a test result (SPT or RAST), especially if the child is eating and tolerating that food.

Only test for suspect foods or triggers rather than doing a full panel as this could give false positive results. Tests only indicate sensitisation and need to be interpreted in the context of the clinical history.

See ASCIA – Allergy Testing.

Management

Acute

Refer acutely to the local emergency department if:

·   anaphylaxis. See also the anaphylaxis pathway.

·   child is acutely unwell and has:

·   rectal bleeding which is not suggestive of food protein induced allergic proctocolitis (FPIAP).

·   possible food protein induced enterocolitis syndrome (FPIES).

Non-acute

1.     Assess the need for an adrenaline auto-injector and provide education on adrenaline autoinjector use if the child meets the criteria. 

Education

·   SCHN – EpiPen Use Fact Sheet

·       Allergy and Anaphylaxis Australia – Videos from A&AA

Adrenaline auto-injector

Specialist approval is required for initial scripts – refer to a general paediatrician or paediatric immunologist. Timely review is not always possible – phone and discuss if long delays are anticipated. An authority script can be written by the general practitioner if the name of the specialist consulted is given at the time of application for initial supply.

·   EpiPen Jnr can be used in children 10 to 20 kg and EpiPen in children and adults over 20 kg.

·   Adrenaline autoinjectors are not usually recommended for children less than 10 kg. Discuss with paediatric immunologist before prescribing.

·   When providing an adrenaline autoinjector:

·   ensure the patient receives the appropriate action plan.

Action plan

The Australasian Society for Clinical Immunology and Allergy (ASCIA) provides the following action plans:

·   Action Plan for Allergic Reactions

·   Action Plan for Anaphylaxis

Ensure the action plan original goes to school, nursery, kindergarten, pre-school, and a copy stays in the home. Public Health Nurses provide education in schools and early childhood education settings.

·   provide resources about avoidance of food and keeping the child safe at preschool and school.

Provide resources

·   See Allergy and Anaphylaxis Australia.

·   Periodically check Allergy and Anaphylaxis Australia's Food Alerts.

·   Discuss use of a medical alert band.

·       See ASCIA General Information Sheet.

·   advise patients and parents to use the ASCIA – Travel Plan and Checklist for People at Risk of Anaphylaxis for any trips away from home. SelectWisely has a range of cards in different languages to communicate food allergy. 

·   refer for specialist assessment to the Paediatric Allergy Clinic, fax (02) 4922-3904.

·   If the child has an IgE mediated allergy but does not meet the criteria for an adrenaline autoinjector:

·   provide resources about avoidance of food.

·       consider referral to a general paediatrician or paediatric immunologist.

2.     Provide education on the avoidance of trigger. For children with IgE-mediated food allergy, instruct carer to eliminate food allergen from diet.

Eliminate food allergen from diet

·   Provide information on elimination of food from diet:

·   Strict elimination means careful reading of labels and looking for hidden sources of the food allergen.

·   Inform others of the food allergy when eating away from home

·   Do not share or swap food or utensils

·   Question food offered by others

·   Wash hands and surfaces to prevent cross contamination

·   Provide resources about avoidance of food and keeping the child safe at preschool and school. See HNE Kids Health fact sheets.

The Sydney Children's Hospitals Network health fact sheets

·   Egg free diet

·   Milk free diet

·   Peanut free diet

·   Peanut and tree nut free diet

·   Sesame free diet

·   Soy free diet

·       Seafood allergy

·   Some allergies will be outgrown after a period of time:

·   Children with peanut, tree nut, sesame, fish, and shellfish allergies usually do not outgrow these.

·   Cow’s milk, egg, soy, and wheat allergies commonly resolve, with 85% of young children in population-based studies outgrowing their allergy to cow’s milk or egg by age 3 to 5 years.

·   Consider a supervised food challenge:

·   In IgE mediated allergies, i.e. when there has been anaphylaxis or an acute allergic reaction, refer for a supervised food challenge under medical supervision. Refer to paediatric immunologist.

·   In non-IgE mediated food allergies, food reintroduction plans vary and are usually discussed with the parents at the time of initial consultation with the specialist. However if advice is required, discuss with paediatric immunologist.

·   Provide advice about reporting a food product that caused a reaction.

Reporting a food product suspected of causing anaphylaxis

Encourage patients with known anaphylaxis to make a report if an episode happens:

·   in a restaurant or café, despite disclosing their allergy.

·   in response to a packaged food that does not list the suspected allergen in its ingredients.

This may prevent further instances of serious reactions to the same food or at the same food service facility. Patients or general practitioners can contact Allergy & Anaphylaxis Australia by phone 1300-728-000 or email: coordinator@allergyfacts.org.au.

3.     Manage any cow’s milk protein (CMP) allergy.

Cow’s milk protein (CMP) allergy

Ensure referral to general paediatrician or paediatric immunologist to confirm diagnosis if criteria met.

Criteria

·   Food allergy with failure to thrive

·   Allergic reaction to a food in a child aged 1 year or younger

·   Multiple food allergies

·   Suspected severe non-IgE mediated food allergy e.g. FPIES

·       Food allergy and co-existent allergic disease e.g. eczema and asthma

·   If an allergy to CMP is suspected, only remove CMP from the infant's diet while awaiting review if the child is failing to thrive.

·   If the child is breast fed, complete maternal exclusion of food allergens is not usually required and should only be implemented under specialist guidance. Dietary elimination must be advised judiciously, due to the risks of dietary restriction.

Risks of dietary restriction

·   Nutritional deficiency

·   Feeding disorders

·   Loss of tolerance

·   Severe allergic reaction on re-introduction of food1

·       Cost

·   If the child is formula fed and failing to thrive, they may require an alternative form of milk.

·   Choice of formula is dependent on the type of allergy to CMP. If uncertain about the type of CMP allergy, or if advice about prescribing alternative milk replacement formula is required, phone and discuss with a paediatrician or paediatric immunologist while awaiting review.

·   Extensively hydrolysed formulas (EHF) and amino acid formulas (AAF) require authority prescriptions in consultation with a specialist general paediatrician, paediatric immunologist, or paediatric gastroenterologist. If delay in review is anticipated, phone and discuss before prescribing.

·   Do not give a child with CMP allergy the following:

o   Goat's milk and other mammalian milks

o   Rice, oat, and nut drinks until after age 1 year

o   Soy infant formula if infant aged less than 6 months, and soy drink if infant aged less than 1 year

o   A2 milk

o   Lactose-free milk

o   Partially hydrolysed formulae such as NAN-HA

·   Once a child with CMP allergy is aged 1 year, refer to dietitian for advice on milk options.

·   If the infant is suspected to have CMP FPIAP and the parents have trialled CMP elimination, consider a rechallenge:

·   Rechallenge is recommended after 2 to 4 weeks to confirm the diagnosis, although parents may be reluctant.2

·   In patients with FPIAP from CMP, reintroduction of CMP is usually successful by age 12 to 18 months.2

·   Children with IgE and more severe non-IgE allergic reactions (e.g. FPIES) should only have a rechallenge under specialist supervision. Refer to paediatric immunologist.

·       See NZMJ – Algorithm for Formula Use in Cows’ Milk Protein Allergy.

4.     If mild to moderate allergic reactions, use less-sedating antihistamine.

Less-sedating antihistamine

Recommended antihistamines include:

·   Cetirizine (e.g., Alzene™, Little Allergies for Children™, Zyrtec™) – preparations: Tablets 10 mg, oral Liquid 1 mg/mL, oral drops 10 mg/mL

·   1 to 2 years: oral drops 2.5 mg (5 drops) twice a day

·   3 to 6 years: 5 mg orally, once a day or 2.5 mg orally, twice a day

·   7 years or older: 10 mg orally, once a day or 5 mg orally, twice a day

Do not use oral drops in children aged 2 years or older as the amount of sorbitol (0.32 g/mL) in the oral liquid may cause diarrhoea.

·   Loratadine (e.g., Allereze™, Claratyne™, Lorapaed™) – preparations: Tablets 10 mg, dispersible tablets 10 mg, oral liquid 1 mg/mL

·   1 to 2 years: 2.5 mg orally, once a day

·   3 to 12 years (less than 30 kg): 5 mg orally, once a day

·   Children over 30 kg: 10 mg orally, once a day

·   Desloratadine (e.g., Aerius™) – preparations: Tablets 5 mg, oral liquid 0.5 mg/mL

·   6 months to 12 months (for chronic idiopathic urticaria only): 1 mg orally, once a day

·   1 to 6 years: 1.25 mg orally, once a day

·   7 to 12 years: 2.5 mg orally, once a day

·   13 to 18 years: 5 mg orally, once a day

Fexofenadine (e.g., Fexotabs™, Telfast™, Xergic™) – preparations: Tablets 30 mg, oral liquid 6 mg/mL

·   6 months to 2 years: 15 mg orally, twice a day

·   3 to 12 years: 30 mg orally, twice a day

·   13 to 18 years: 180 mg orally, once a day

Dosage information is available on the packaging for these preparations upon purchase from a pharmacy.

5.     Manage any food intolerance.

Food intolerance

Provide information – ASCIA – Food Intolerance.

It is important to emphasise that dietary elimination must only be undertaken in the short term under strict medical supervision, due to the risks of dietary restriction.

6.     If egg allergy:

·   For management of isolated mild egg allergy, see Royal Children's Hospital Melbourne – Allergy and Immunology: Egg Allergy, and consider referral to a general paediatrician. Most children will tolerate egg baked into cake or muffin. Consider introducing baked egg – see example recipe.

·   Consider immunisations:

o   MMR vaccination – safe for children who have egg allergy, even for those with a history of severe reactions, and can be given safely in general practice.

o   Influenza vaccination – check recommended for administration of influenza vaccine in people with egg allergy. See also Australian Immunisation Handbook – Influenza (Flu): Contraindications and Precautions.

7.     Advise about prognosis.

Prognosis

·   IgE mediated:

·   Depends upon the food in question.

·   Most children with food allergy eventually tolerate milk, egg, soy, wheat, e.g. clinical tolerance develops in approximately 80% of children with cow's milk allergy by age 8 to 9 years.

·   Allergies to peanut, tree nuts, fish, and shellfish are generally prolonged.

·       Non-IgE mediated reactions will generally resolve with time (1 to 3 years), depending on clinical presentation.

8.     Arrange routine referral to a paediatric immunologist if:

·   food allergy with failure to thrive.

·   allergic reaction to a food in a child aged 1 year or younger.

·   multiple food allergies.

·   suspected severe non-IgE mediated food allergy (e.g. FPIES).

·   food allergy and co-existent allergic disease e.g., eczema and asthma.

·   ambiguity between history and test results.

·   for follow-up after first episode of anaphylaxis.

·   suspected oesinophilic oesophagitis.

Follow‑up

Continue focus on asthma control in patients with IgE mediated food allergy.

Referral

·   Refer acutely to the local emergency department if:

·   anaphylaxis.

·   child is acutely unwell and has:

o  rectal bleeding which is not suggestive of food protein induced allergic proctocolitis (FPIAP).

o  possible food protein induced enterocolitis syndrome (FPIES).

·   Refer to a paediatric immunologist if:

·   food allergy with failure to thrive.

·   allergic reaction to a food in a child aged 1 year or younger.

·   multiple food allergies.

·   suspected severe non-IgE mediated food allergy (e.g. FPIES).

·   food allergy and co-existent allergic disease e.g. eczema and asthma.

·   follow-up after first episode of anaphylaxis.

·   ambiguity between history and test results.

·   suspected oesenophilic oesophagitis.

·   supervised food challenge required for IgE mediated allergy.

·   For children who need an initial script for an adrenaline autoinjector, refer to, or if a delay in review is anticipated, discuss with a paediatric immunologist or general paediatrician.

·   Consider referral to a paediatric immunologist or general paediatrician if the child has an IgE mediated allergy but does not meet the criteria for an adrenaline autoinjector.

·   If considering a food challenge for a patient with non-IgE mediated food allergy or FPIES, refer to or discuss with a paediatric immunologist.

·   If suspected CMP allergy:

·   ensure referral to general paediatrician or paediatric immunologist to confirm diagnosis.

·   and uncertain about the type of CMP allergy, or if advice about prescribing alternative milk replacement formula is required, phone and discuss with a paediatrician or paediatric immunologist while awaiting review.

·   once a child with CMP allergy is aged 1 year, refer to dietitian for advice on milk options.

·   For children with a mild isolated egg allergy, consider referral to a general paediatrician.

Note that the John Hunter Paediatric Respiratory lab is currently unable to accept referrals from general practitioners for food allergen skin prick tests. Skin prick testing at John Hunter Children's Hospital is only performed in conjunction with a paediatric allergy and immunology clinic appointment.

 eReferral is the recommended referral method. Read more...

Information

For health professionals

Education

·   ASCIA Health Professionals e-training Anaphylaxis Course

·   Epi Pen Education Video

Further information

·   Australasian Society for Clinical Immunology and Allergy (ASCIA):

·   Action Plan for FPIES (Food Protein Induced Enterocolitis Syndrome)

·   Adrenaline for Severe Allergies

·   Anaphylaxis Action Plan

·   Food Allergy Clinical Update

·   Generalised Allergic Reaction Action Plan

·       HNE Kids Health – Allergy and Immunology

For patients 

·   Australasian Society of Clinical Immunology and Allergy (ASCIA):

·   Anaphylaxis Action Plan

·   Generalised Allergic Reaction Action Plan

·   Introducing Foods and Allergy Prevention Fast Facts

·   Information for Patients, Consumers and Carers: Food Allergy

·   Cow’s Milk Allergy Information for Parents

·   Dietary Avoidance for Food Allergy

·   Patient Factsheets – NSW Multicultural Health Communication Service 

·   Allergy Information Sheets – HNE Kids Health

·       What Foods Should I Feed my Baby? – National Allergy Strategy

Gallows traction for fracture (SCHN) Orthopaedic traction (SCHN)

Gastrointestinal bleeding (SCHN)  see also Acute management of variceal bleeding (RCH)

Gastro-oesophageal reflux in infants (PIC)

Gastrostomy homecare (SCHN)

Gastrostomy management (SCHN) includes advise on dislodged buttons

Gynaecology - prepubescent gynaecology (RCH)

Gynaecology - lower abdominal pain (RCH)

Gastroenteritis is very common in childhood, and it can pose management challenges for families and clinicians.

Oral rehydration solution (this has a sheet for parents keeping and eye on intake and output- may work in Dubbo)

Facts sheet

ADJUNCT TIPS for child with:  diarrhoea +/- vomiting , +/- fever

• Check the history and examination are typical for gastroenteritis. 

• Check the types of fluids being given at home. The child who is "only taking" water may be vulnerable to low sodium (hyponatraemia) and low blood sugar (hypoglycaemia). Education is needed for parents on oral rehydration solution ( GastrolyteTM, HYDRAlyteTM, PedialyteTM )  or apple juice diluted (1/4 apple juice into 3/4 water- note this does not have much salt, which may be problematic)

• A guide on oral rehydration Oral rehydration solution (SCH)

• Give them a facts sheet on gastroenteritis 

• If there is concern around accuracy of diagnosis of gastroenteritis access an appropriate resource which considers other diagnoses (such as on abdominal pain) , review this, and discuss with a senior clinician.

• Assess for dehydration  , which is surprisingly hard to assess accurately, though the following (in addition to the RCH summary) may assist clinicians assessing levels of dehydration

(a) get an accurate bare weight, or in undies/nappies (this is very helpful if done on consecutive days with same scales and clothes to ascertain changes 

(b) pulse with child NOT crying (is the child tachycardic on the BTF)

(c) blood pressure 

(d) urine checked (bag or clean catch) high SG > 1.030 and high ketones suggests dehydration (also look for glycosuria in DM)

(e) sighing respirations

• Check for hypoglycaemia with capillary blood glucose. If hypoglycaemic and no access and vomiting consider oral dextrose gel 0.5ml/kg rubbed into the inside of the cheeks, and sips of sugary fluids.

• Insert a nasogastric tube for rehydration,  if the child presents with typical vomiting and diarrhoea, and the clinical examination does not suggest a surgical abdomen or alternative diagnosis better treated with IV fluids  (eg septic shock) . 

• Nasogastric (NG)  rehydration is the preferred method (compared to IV fluids which is less safe), and the rate is on the RCH guideline. The author generally prefers the slower rehydration protocol , but notes ED may like to get patients home more quickly , and the rapid rehydration may facilitate this.

• If there is repeated vomiting on NG rehydration, not corrected by slowing the rate and ondansetron, and in particular with a child who has non- surgical bilious vomiting from ileus (rotavirus may induce this), the NG route is probably not going to work- consider going to IV fluids

Haematological emergencies in the ED (SCHN)

Haematuria (RCH)

Haemophilia (PIC)

Hand hygiene (SCHN)

Handover - nursing (RCH)

Hazardous and cytotoxic drugs (CHW)

Headache (PIC)

Head lice and scabies (SCHN)

Head injury- see also Traumatic brain injury (NETS) severe head injury

Head injury (RCH)

Head injury (Predict research with guideline, summary and algorithm)

Heavy menstrual bleeding - Adolescent gynaecology - heavy menstrual bleeding (PIC)

Henoch-Schonlein Purprua (RCH) purpuric rash usually on lower limbs

Heparin infusion (SCHN)

Heparin infusion (RCH) see anticoagulation 

Hereditary angioedema  (RCH)

Herpes simplex virus gingivostomatitis (RCH)

High flow nasal prong therapy (RCH)

High risk -low dose paediatric ingestions  (RCH)

High risk anaesthesia - perioperative management (RCH)

Hip spica care on the ward(SCHN)

Hip spica care at home (SCHN)

Hirschprung's disease pre and postoperative care in Grace Nursery  (SCHN)

Humidified High Flow Nasal Prong Oxygen (SCHN) and High flow nasal prong therapy (RCH)

Hydrocarbon poisoning (RCH)

Hydrofluoric acid (RCH)

Hyperkalaemia (NETS) and Hyperkalaemia RCH see also Potassium administration (SCHN) excellent summary with ECGs

Hypernatraemia (PIC)

Hypertension (RCH) charts, causes treatments

Hypertrophic pyloric stenosis - see pyloric stenosis (PIC)

Hypoglycaemia in the ED (SCHN) and Hypoglycaemia (RCH)  

Hypoglycaemia poisoning - see oral hypoglycaemic poisoning (RCH)

Hypokalaemia (RCH) see also Potassium administration (SCHN)

Hyponatraemia (RCH)

Overview

-          Hypoglycaemia in children is a medical emergency

-          Children with prolonged or recurrent hypoglycaemia are at risk of acute and long-term neurological sequaelae if prompt treatment is not administered

-          Defined as a BSL < 2.6mmol/L (or <3 mmol/L if symptomatic)

o   Symptoms and signs include:

§  CNS: Lethargy, headache, irritability, confusion, reduced tone, visual disturbance

§  Adrenergic: Tremor, sweaty, pallor, weakness, tachycardia, hunger

Investigations

-          First presentation or severe hypoglycaemia should be investigated

-          Accelerated starvation (previously known as ‘ketotic hypoglycaemia’):

o   Requires a history of a prolonged fast (usually precipitated by illness) with a low BSL, elevated ketones and normalisation of BSL upon feeding

o   It is a diagnosis of exclusion and children presenting with their first episode / severe hypoglycaemia may have an underlying metabolic condition (although rare)

-          Perform critical bloods immediately in these children prior to glucose administration

-          This shouldn’t delay treatment in symptomatic patients or if attempts at IV access are prolonged

Procedure

-          Blood collection

o   Whilst obtaining critical bloods, ask 1 staff member to prepare glucose solution (see over)

o   Also ask additional staff member to call lab and obtain any additional tubes needed: (2 x Purple, 2 x Red, 3 x Light Green, 2 x Dark Green Paediatric Tubes, 1 x VBG)

o   Total blood needed: 6mL

o   Distribute:

§  0.5mL each into 2 purple tubes (FBC, Free Fatty Acids)

§  0.6mL each into 3 light green tubes (UEC, LFT, Plasma Glucose, Ammonia, Growth Hormone)

§  0.6mL each into 2 red tubes (Insulin, C-Peptide, Cortisol)

§  0.6mL each into 2 dark green tubes (Carnitine / Acylcarnitine, Amino Acids)

§  0.8mL for VBG (Lactate) and blood ketones (Beta hydroxybutyrate)

o   Send urgently to lab:

§  ON ICE: 1 x Purple, 1 x Dark Green, 1 x Light Green

§  Remainder NOT ON ICE (unless delay sending to lab, then send BOTH dark green on ice)

§  Call ahead to lab and notify urgent bloods coming for immediate processing

o   If difficulty obtaining enough blood:

§  Send 1 x Purple 0.5mL for Free Fatty Acids and 1 x Dark Green 0.6mL for Acylcarnitine profile BOTH ON ICE, indicating these tests are the priority

-          Urine Collection

o   Place urine bag on patient to ensure first urine passed after episode is collected for urine metabolic screen (a urine bag is OK in this instance as it doesn’t matter if it is contaminated)

o   Also perform urine dipstick for ketones / glucose / reducing substances

See SCHN Management Flowchart of Paediatric Hypoglycaemia on opposite side

Idiopathic nephrotic syndrome (RCH)  see Nephrotic syndrome

Illness in the returned traveller (RCH)

Immigrant health (PIC)

Immigrant health resources (RCH

Immunisation (SCHN ) has the schedule

Immunisation and anaesthesia (RCH)

Immunoglobulin infusions for replacement and immunomodulation (SCHN)

Immunoglobulin infusion- see intravenous immunoglobulin (RCH)

Immune thrombocytopaenic purpura ITP (PIC)

Inborn errors of metabolism -  see Metabolic disorders Metabolic disorders (RCH)   Metabolic diseases:  Vademecum Metabolicum  

Metabolic disorders- see Death of a child with a suspected metabolic disorder  (RCH)

Incontinence - see urinary incontinence (RCH)

Infant feeding -0 to 12 months including breast feeding (SCHN)

Infant feeding  0 to 12 months - formula feeding and introduction of solids (SCHN)

Infantile spasms: high dose oral prednisolone (SCHN)

Infective endocarditis: lesions for which prophylaxis is required (SCHN)

Infliximab infusion  (SCHN)

Influenza (PIC)

Inguinal hernia (PIC)

Inhalants substance use see "Chroming "- inhalant volatile substance use (RCH)

Insertion of feeding tube(nasogastric tube) at home (SCHN)

Insuflon- see subcutaneous catheter device

Intranasal fentanyl for pain relief in the ED or ward (SCHN)

Intranasal fentanyl (RCH)

Intraosseous access (RCH)

Intravenous access (RCH)

Intravenous fluids (PIC)

Intravenous fluids:  converting 5% glucose to 10% glucose and normal saline to normal saline and 5% or N/S with 10% glucose

Worked calculation to convert 5% glucose to 10% glucose (down the bottom of the page)

• IV fluid bags contain a significant overfill volume; a 1 L Baxter brand bag of 5% glucose contains an average volume of 1035 mL (51.75 grams of glucose). To prepare a 10% solution, withdraw 120 mL from the 1 L bag of 5% glucose and discard. Add 110 mL of 50% glucose. The final solution will contain 100 grams in 1025 mL (approximately 10% glucose)   

• For Normal saline to be made up to 5% glucose , withdraw 110ml from 1L of normal saline bag , then add 110ml of 50% glucose in 1L Bag.

The final solution will be normal saline + 5% glucose

• For normal saline to be made up to 10% glucose , withdraw 220ml from bag and add 220ml of 50% glucose in 1L bag (gives Normal saline and 10% dextrose. The final solution will be normal saline + 10% dextrose.

• Note for 500ml bags of fluid, which are commonly used in paediatric wards, half the above amounts withdrawn, and half the 50% dextrose in.

Intravenous extravasation (SCHN)

Intravenous fluid management (CHW) a big document

Intravenous fluid- quick link to types of fluid per age group (ACI)

Intubation (RCH)

Intussusception (PIC)

Invasive group A streptococus household contacts (RCH)

Iron deficiency (RCH)

Iron deficiency parents facts sheet (RCH)

Iron poisoning (RCH) see Xray images

Jaundice in early infancy (see also "Babies" section on jaundice)

Jejenul feeding guideline (RCH)

Joint pain- see the Acutely Swollen Joint (RCH)

Kawasaki disease  (RCH)

Ketamine use in procedural sedation (PIC)

Kidney transplant (CHW)

Laceraine® topical wound anaesthetic : application - ED (SCHN)

Lacerations (RCH)

Lactation promotion using galactagogues to increase supply of breast milk and sustain breast feeding (SCHN)

Laryngotracheobronchitis (PIC) see croup

Latex allergy indentification and management in hospital (SCHN)

Latex allergy (RCH)

Limping or non-weight bearing child (PIC)  If a child is unable ,or refusing to walk, and the diagnosis is not clear, Dubbo Paediatrics recommends admission and observation.

If limping and fever see Osteomyelitis section

Liver transplantation (CHW)

Local anaesthetic poisoning (RCH)

Log rolling in patient with suspected/confirmed  spinal cord injury (SCH)

Lumbar puncture (CHW)

Lumbar puncture (RCH)

Lymphadenitis (RCH) see cervical lymphadenopathy 

Malaria (PIC)

Mandatory alcohol and drug sampling after accident -in  ED (SCH)

Massive transfusion protocol - paediatric (SCHN)

Measles: infection control (SCHN)