Paediatrics - Queensland Health - Queensland Government

Section 6 

Paediatrics

Paediatric presentation 

Section 6. 

Paediatrics 

Contents 

• History and physical examination - child 

• Child with fever 

• Child with cough 

• Child with stridor 

• Child with vomiting 

• Child with abdominal pain 

• Child with chronic diarrhoea 

• Meningitis 

• Respiratory problems 

• Immune complications 

• Ear problems 

• Gastrointestinal problems 

• Urinary tract problems 

• Bone and joint problems 

• Abuse and neglect - child 

544 

Examples of positioning of children 

for examination of throat and ears 

Controlled copy V1.0 

Primary Clinical Care Manual 2011


History and physical examination 

child 

Recommend 

Use of Children’s Early Warning Tools (CEWT) appropriate to age for rural and remote 

facilities ordered through: qheps.health.qld.gov.au/psq/rmdp/html/rmdp_homepage. 

htm or by email at: RMDP@health.qld.gov.au 

Consult MO immediately about any baby under 3 months of age who is at risk 

or febrile 

Always check the immunisation status of children at every opportunity 

Believe the child or parent / carer: no matter the time of day or night or the circumstance, 

make sure the patient and their parent / carer feels he or she has been listened to 

and done the right thing in bringing the child regardless of the concern 

Background 

Small children, especially young babies, get sick very quickly 

Risk signs in children are: 

-- temperature > 38°C or < 35.5°C 

-- irritability 

-- high pitched cry or weak cry 

-- drowsiness 

-- decreased activity 

-- reduced feeding 

-- breathing fast / noisy, respiratory distress, apnoea 

-- persistent vomiting 

-- dehydration (< 4 wet nappies in 24 hours) 

-- sunken eyes 

-- cold extremities 

-- capillary refill > 2 seconds 

-- uses eyes (rather than head) to follow you 

-- abdominal distension 

Other high risk children include those with: 

-- lots of diarrhoea (> 8 watery stools in 24 hours) 

-- congenital or chronic disease e.g. cardiac, gastrointestinal, neurological 

-- where social conditions are concerning and / or where parents may have difficulty 

managing at home 

-- a history of repeated or prolonged separations from their primary caregiver(s) 

-- psychosocial risk factors including family violence, poverty, homelessness, 

parents with intellectual disability or mental health problems 

Related topics 

Immunisation program 

Patient presentation and assessment 

DRS ABCD resuscitation / the collapsed patient 

Assessment and physical examination of skin, 

hair and nails 

Assessment of the eye 

Assessment of ear 

Abuse and neglect - child 

Mental health assessment 

Medication reconciliation 

Medication history checklist 

Glasgow Coma Scale / AVPU 

Primary Clinical Care Manual 2011 Controlled copy V 1.0 545


Standard clinical observations and other vital signs - child 

Approximate normal physiological ranges for a child 

Parameter 

Normal range 

12 years 

HR 

(beats per min) 

110 - 160 100 - 150 95 - 140 80 - 120 60 - 100 

Respiration rate 

Standard clinical (breaths / min) 

30 - 40 25 - 35 25 - 30 20 - 25 15 - 20 

observations 

Axilla - clinically significant fever > 37.8°C (37.2°C *) 

Temperature 

Sublingual - clinically significant fever > 38.0°C (37.5°C *) 

Rectal - clinically significant fever > 38.5°C (38.0°C *) 

* clinically significant fever lower in infants < 3 months of age 

Blood pressure Systolic > Systolic > Systolic > Systolic > Systolic > 

(mmHg) 

60 70 75 80 90 

Respiratory 

distress 

Nil 

Other vital signs 

if indicated 

546 

O 2 saturation (%) > 95% 

Capillary refill time Less than or equal to 2 secs 

Level of 

consciousness 

Blood glucose 

level 

Glasgow coma scale 15 

AVPU tool - alert 

4 - 8 mmol (random capillary) 


[1] [8] 

Pain assessment in a child 

Rate pain level in children using faces, numbers and behavioural observations. Physiological 

changes e.g. altered HR, RR, BP are not good indicators to use in isolation [2]. Non - verbal 

children are very vulnerable to having their pain under estimated [2] 

• Refer to Children’s Early Warning tools (CEWT) for pain assessment tools 

Pain rating scale for children 



Presentation 

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

collection of information to identify the patient’s health status. The following is essential 

to achieve this: 

-- taking a patient history 

-- performing standard clinical observations and other vital signs 

-- perform physical examination 

-- using diagnostic and pathology services, and 

-- collaboration with other members of the team 

-- note: not all children are at the same stage of development in areas of physical, 

cognitive and psychosocial development 

• It is a requirement that all clinicians document their findings in a clear and concise way. 

This section is set out to assist. It is recommended the page number of HMP / CCG is 

referred to in the documentation 

Types of history 

There are four types of history taking [3] See History and physical examination - adult 

History taking 

• The purpose of a full history is to ascertain the cause of the child's illness. A careful 

history will make the cause clear in the vast majority of cases. 

• The first priority is to assess whether the child is: 

-- seriously ill and needs immediate management or, 

-- is a non urgent presentation, and there is time for a complete patient history and 

health education 

• Obtaining a full history is done in conjunction with examining the patient 

-- In a sick child this entails a full assessment of all systems 

-- In a child who has a localised problem it is reasonable to examine the relevant 

system only. However, always be guided by the history and be prepared to examine 

other systems as necessary. This is particularly important for children who often 

present with generalised symptoms and signs 

-- Ask open ended questions 

-- Believe the carer 

Presenting concern 

• Ask the child or carer what the problem is 

• Ask about length of illness and exact details of symptoms and signs. For each symptom 

the following details are important [4] 

Site - where is the pain / symptom? does it go anywhere else? 

Onset - when did it start, gradual or sudden onset? 

Character e.g. sharp, dull or burning 

Radiation - does the pain radiate anywhere else? 

Alleviating factors - what makes it better e.g. sitting up, medicines? 

Timing - how long did it last, have they had it before? 

Exacerbating factors - what makes it worse? 

Severity - mild, moderate or severe pain. Pain score 0 - no discomfort to 10 - unbearable 

pain or use facial diagrams 

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

-- always ask specifically about fever, pain, shortness of breath / rapid breathing, 

diarrhoea and / or weight loss, rash 

• Behaviour and activity during this illness 

-- is the child active / alert, sleepy or irritable? easy / difficult to wake? 



• Appetite and fluid intake / output during this illness 

-- try to be as precise as possible with quantities 

-- how many drinks / breastfeeds? 

-- how alert during feeds? 

-- how long between intake and vomit? / diarrhoea? 

-- how many wet nappies or times passed urine in preceding 24 hours? 

-- amount / type bowel movements 

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

-- what, how much, when, how often, how effective? 

Past history 

Past medical and 

surgical history 

Family and social 

history 

548 

• Was delivery normal and were there any immediate neonatal problems? 

• Any problems with growth and development? 

• Significant illnesses in the past? What and when? 

• Hospital admissions? Why and when? 

• Operations or injuries? What and when? 

• Mothers alcohol history during pregnancy? 

• Health problems in the family - especially siblings and parents 

• Who looks after the child, what is the social situation? 

• Mental health problems in carers / child? 

• Household smokers? 

• Recent contacts or trips away 

• If medicines are given, will they be taken? 

Medications • Regular medicines (prescribed, herbal, bush medicines, over the counter) 

generic name(s), dose, frequency? 

• Are they taken correctly? 

• May need to ask about other medicine(s) in the home the child may have 

taken 

• See Medication reconciliation / Medication history checklist for more details 

Allergies • Adverse drug reactions: 

-- adverse reactions / allergies to medicines? 

-- attach “adverse drug reaction” sticker to medication chart if required 

• Allergens e.g. bee stings, tapes, sticking plaster, nuts: 

-- specific reaction e.g. skin reaction, bronchospasm 

-- is an Epi-pen® / medication used to treat the allergy? 

Immunisations • Check if up to date 

• Documented evidence of immunisation status should be obtained, follow 

up with opportunistic immunisation See Immunisation program 




Standard clinical observations 

All children • Temperature, HR, respiratory rate 

presenting for • If indicated: 

acute care 

-- -- O saturation 

2 

BP 

○ is not usually needed 

○ ensure correct sized cuff - must be wider than 2/3 the length of upper arm 

-- blood glucose level (BGL) 

○ indications include altered level of consciousness / seriously ill children 

-- conscious level - GCS / AVPU 

-- capillary refill 

-- weight 

See Standard clinical obervations and vital signs - child, Glasgow Coma Scale / AVPU 

Physical examination 

• May be best done with the child on the carer’s knee. If the child is irritable perform 

the examination opportunistically i.e. do what you can when you can. Leave the most 

disruptive parts (ears and throat) until last 

• In general, examination of a child is not a good screening test. Use the history 

to guide you to areas where you think you will find an abnormality 

• In any sick child a thorough and complete examination is required. All clothing will 

need to be removed at some stage during the complete examination 

• In a child who is not sick, examine the relevant system first and proceed to further 

examination as guided by the history and your findings 

Physical examination - child 

General 

appearance 

• Does the child look well or sick? 

• Alert or drowsy? Altered conscious state? See Glasgow coma scale / AVPU 

• Muscle tone - normal or is the child floppy? 

• Look / gaze - does the child fix the gaze on the face or is there a glassy eyed stare? 

• Interactive or disinterested in interacting / playing? 

• Increased work of breathing? e.g. retractions, nasal flaring, grunting, gasping, fast 

breathing, wheeze 

• Observe speech / cry - strong and vigorous or weak or hoarse? 

• Look at the conjunctiva and the nail beds - are they pale? 

• Look at the lips, tongue and fingers - are they blue? 

• Is the child well nourished? 

• Is there any neck stiffness - feel gently. Ask the older child to put their chin on their 

chest - if they can they do not have neck stiffness 

• Is the child able to be consoled by the care giver? 

Hydration • Any weight loss? 

• Eyes - normal or sunken? Tears absent or present? 

• Mouth and tongue - wet or dry? 

• Skin turgor - pinch a loose piece of skin. Does it return to normal immediately or 

stay saggy? 

• Fontanelle - normal or depressed? (if bulging consider meningitis) 

• See Clinical assessment of hydration of children for detailed assessment 



Physical examination - child (continued) 

Skin • Always check the whole body, particularly in a sick child 

• Rash ? non blanching, petechiae, purpura 

• Colour - unusually pale, mottled or cyanotic? 

• Bruising, unexplained or unusual marks? 

• Signs of infection: redness, swelling or tenderness? 

• Inspect / palpate lymph nodes in the neck, axillae or groins for tenderness 

• See Assessment and physical examination of skin, hair and nails for detailed 

assessment 

Growth • Height 

• Weight - if child < 2 years weigh naked 

• Head circumference if < 2 years 

• Plot on growth charts appropriate for age and gender 

Cardiovascular 

system 

Respiratory 

system 

Gastrointestinal 

and 

reproductive 

systems 

550 

• Skin colour - pink, white, grey mottling? Compare the trunk with the limbs 

• Skin temperature - hot, warm, cool, cold, sweating? Compare the trunk with the 

limbs 

• Palpate peripheral pulses - is rate fast, slow or normal - is the pulse volume weak 

or strong? 

• Central perfusion - blanch the skin over the sternum with your thumb for 5 seconds. 

Time how long it takes for the mark to disappear 

• Peripheral perfusion - ‘blanch’ the skin on a finger or toe for 5 seconds. Time how 

long it takes for the mark to disappear 

• Any evidence of oedema - particularly hands, feet and face? 

• If skilled, listen to heart sounds 

• Most information is gained through inspection 

• Inspect anterior / posterior chest: 

-- equal chest movement 

-- use of accessory muscles of respiration? Look for retraction, recession - mild, 

moderate or severe? Nasal flaring? 

• Can they talk continuously, or only in words or sentences, or unable to talk at all? 

• Measure respiratory rate over one minute, observe rhythm, depth and effort breathing 

• Listen for extra noises - cough, ± sputum, wheeze, stridor, grunt, snore, hoarse 

speech / cry 

• Auscultate air entry in both lung fields - equal? Adequate, decreased or absent? Are 

there wheezes or crackles? Do they occur on inspiration or expiration? (Note that 

transmitted sounds from the upper respiratory tract are very common in children and 

may mask other signs) 

• Will the child lie flat? 

• O saturation 

2 

• Look - are there any scars or abdominal distension / hernias 

• Auscultate bowel sounds - present or absent? 

• Palpate abdomen 

-- soft or firm? 

-- any obvious masses? 

-- tender to touch? Identify which abdominal quadrant and exact area 

-- any guarding / rigidity - even when the child is relaxed? 

-- any rebound tenderness - press down and take your hand away very quickly - is 

the pain greater when you do this? 

• Question about change in bowel habits 

• Feel for a palpable bladder 

• Check the testes in boys - are they both in the scrotum? 

-- any redness, swelling or tenderness? 




Physical examination - child (continued) 

Nervous • A detailed assessment of the nervous system in a child is both technically difficult 

system 

and time consuming. A brief assessment is all that is needed. Assess: 

-- conscious state. See Glasgow Coma Scale / AVPU 

-- orientation to time, place and person if appropriate for the child’s age. Ask the 

child their name, age, location. Ask them to tell you the time, date and year 

-- pupils: size, equality, shape, reactivity to light 

• Look for inequality between one side of the body and the other. Compare the tone 

and power of each side of the face and the limbs 

• Test touch sensation using cotton wool 

• Test finger nose coordination. If possible, observe child walking, looking around and 

using hands 

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

skeletal system • Pain in limbs, joints or muscles? 

• Any redness, pain, swelling, heat over joint(s)? Observe gait 

• See Acute rheumatic fever / Bone or joint infections - child 

Ears, nose and • Ears 

throat 

-- look at the pinna - redness, swelling? 

-- any obvious swelling or redness of the ear canal, if there is, looking with an 

otoscope will be painful 

-- looking inside with an otoscope - look at the ear canal - redness, swelling, 

discharge? 

-- inspect eardrum - normal? or redness, dullness, bulging or retraction, fluid or air 

bubbles, perforations or discharge? 

-- See Assessment of ear for detailed assessment 

• Nose 

-- feel for facial swelling / inflammation 

-- is there any discharge or obvious foreign body? 

• Throat 

-- look at the lips, buccal mucosa, gums, palate, tongue, throat 

-- redness / swelling? 

-- condition of teeth 

-- inspect tonsils - redness, enlargement or pus? 

Eyes • Always test the visual acuity of each eye. Use age appropriate Snellen chart at 6 

metres in good light 

• Look at the eyes and surrounding structures - any redness, discharge or swelling? 

• Look at the pupils - are they equal in size and regular in shape? Check pupillary 

reflex to light 

• Check eye movements - ask the child to follow the movement of your finger 

• See Assessment of the eye for detailed assessment 

Urinalysis • Examine the urine of all sick children, all children with abdominal pain or urinary 

symptoms and all children with unexplained symptoms or signs 

• Look at the colour - is it normal, dark, blood stained? 

• Does it smell normal? 

• Perform urinalysis 

[4] [5] [6] [7] 

• See decision making flowcharts to assist with clinical impression 

-- child with fever / cough / stridor / vomiting / abdominal pain and / or chronic 

diarrhoea 



Diagnostic and pathology services 

• Point of care testing is available in some facilities for example iSTAT® blood gases 

• Pathology request forms 

-- all pathology requests made by SM R&IP must be compliant with the specific Health 

Management Protocol 

-- if in the clinician’s opinion other pathology is required this must be ordered by a MO 

• Pathology results / follow up: 

-- if a SM R&IP has initiated pathology testing according to the Health Management 

Protocol they are responsible for the follow up of pathology results 

552 

-- MO should be consulted if results are abnormal 

• Refer to the Pathology Queensland Specimen Collection Manual available at: 

qis.health.qld.gov.au/DocumentManagement/Default.aspx?DocumentID=10021&Doc 

umentInstanceID=45973 

Consulting the MO 

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

• It is often easier if you write your findings down first (time permitting) 

• It is helpful to advise the MO early that you have a child about whom you want some 

advice or alternately who you think may need evacuation 

• Always begin with the name and age of the child, then start with the presenting concern 

and proceed through to the examination. Say what you think is wrong - your assessment 

is important; after all, you are actually with the child 

• Always consult with the MO if you are not sure. Discuss difficulties and problems with 

the MO during routine visits. Take the opportunity to discuss general or specific cases 

or issues with the MO at the next clinic visit 

• See Royal Flying Doctor Service (Queensland Section) and Queensland Emergency 

Medical System - consulting the MO / ISOBAR 

References 

1. Pemsoft®. Normal vital signs. 2008-2011 [cited 2011 August]. 

2. The Royal Children’s Hospital. Acute Pain Management 2010 [cited 2011 April]. 

3. Estes M. and Schaefer K.P., Health assessment & physical examination. 2nd ed. 2002, Albany, NY 

Delmar. 

4. Talley N. and O’Connor S., A systematic guide to physical diagnosis: clinical examination. 6th ed. 2010, 

Australia: Churchill Livingstone: Elsevier. 

5. Murtagh J. and Rosenblatt J., John Murtagh’s general practice 5th ed. 2011, Australia: McGaw Hill. 

6. Corrales A.Y. and Starr M., Assessment of the unwell child. Australian Family Physician, 2010. 39(5): p. 

270-275. 

7. Douglas G., Nicole F., and Robertson C., Macleod’s clinical examination 12th ed, ed. Douglas G., Nicole 

F., and Robertson C. 2009: Churchill Livingstone: Elsevier. 

8. Advanced Paediatric Life Support Group, Advanced Paediatric Life Support The Practical Approach. 

5th ed, ed. Samuels M. and Wieteska S. 2011: Wiley-Blackwell. 



Child with fever 

Fever is usually an indicator of infection. Two or more infections may co-exist, e.g. URTI plus meningitis 

Babies less than 3 months of age contact MO immediately 

Consult MO for the child with a fever with no obvious source of infection or a fever that is persistent despite measures taken 

Clinical assessment performed 

Consult MO 

Yes 

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

No 

Basically 

well child 

Basically 

well child 

Basically 

well child 

Basically 

well child 

Child unwell 

Child 

unwell 

Child unwell 

Child unwell 

Sore throat, ears, 

nasal discharge, 

cough, 

cervical 

lymphadenopathy, 

red inflamed 

throat, 

tonsillar 

enlargement 

No other 

significant 

features 

URTI type 

symptoms may 

be present 

Vomiting and 

diarrhoea 

Obvious 

abscess or 

cellulitis 

Cough 

Dysuria, 

frequency, 

smelly 

urine 

Rapid onset 

high fever 

May have 

history of URTI 

like illness 

Bulging ear 

drum on 

examination 

No other 

significant 

features 

No other 

significant 

features 

Rapid 

breathing, 

chest 

recession 

Positive 

urinalysis 

Stridor, 

drooling, 

unable to 

eat, 

drink or talk, 

reluctant to 

move neck 

Neck stiffness 

or bulging 

fontanelle 

No other 

significant 

features 

Headache, 

photophobia 

+/- 

Rash 


See 

URTI 

See 

Acute 

otitis media 

See Acute 

gastroenteritis 

See 

Bacterial 

skin infections 

See 

Pneumonia 

See 

UTI 

See 

Epiglottitis 

See 

Meningitis 

Primary Clinical Care Manual 2011 Controlled copy V 1.0 553 

Tachycardia 

Child with fever 

No other 

significant 

features 

No other 

significant 

features


Child with cough 

554 


Consult MO 

Yes 


No 

Paroxysmal 

cough 

whoop 

Nocturnal 

or exercise 

induced 

cough 

Child unwell 

Basically well child 

Child unwell 

Basically 

well child 

Fever 

Sudden onset 

in previously 

well child 

Sore throat, ears, 

nasal discharge 

Rapid onset 

high fever 

Barking cough 

Apnoea 

Wheeze, rapid 

breathing 

Rapid breathing 

with chest 

recession 

Cervical 

lymphadenopathy 

Cough +/- 

Stridor +/- 

Wheeze +/- 

Stridor, 

drooling 

Mild URTI 

symptoms 

No other 

significant 

features 

No other 

significant 

features 

Tachycardia 

Fever, red 

inflamed throat 

Airway 

compromised 

Unable to eat, 

drink or talk 

Mild fever 


No other 

significant 

features 

Mild / moderate 

stridor 

Tonsillar 

enlargement 

Reluctant to 

move neck 

No other 

significant features 

Usually there 

is a history of 

ingesting or 

choking on 

something 

Cough may be 

absent 

No other 

significant 

features 

Child with cough 

See 

Whooping 

cough / 

pertussis 

See 

Asthma 

See 

Pneumonia 

See 

URTI 

See 

Acute upper 

airway 

obstruction / 

choking 

See 

Epiglottitis 

See 

Croup 


Child with stridor 

Stridor is a harsh vibrating sound originating from the large upper airways and occurring on inspiration. It occurs due to upper airway 

obstruction. Consider the following causes: croup – common, inhaled foreign body, epiglottitis – rare but important, trauma, angioneurotic 

oedema, mass (tumour or abscess) 

Obtain full history, including Hib immunisation status. Limit examination. Do not examine mouth or throat 

Consult MO 

In the meantime, consider epiglottitis 

Yes 


No 

Gradual swelling of face, 

neck and throat 

Sudden onset in previously 

well child 

Slow onset 

Rapid onset 

Usually there is a history 

of exposure to allergen: an 

injection of a drug or blood 

product, ingestion of oral drug 

/ food or bites / stings 

Cough or wheeze may be 

present 

Usually there is a history 

of ingesting or choking on 

something e.g. peanut 

Croupy (barking) cough 

Temp < 38.5°C 

No systemic disturbance 

Severe stridor less common 

Able to swallow 

Will usually drink 

Normal voice 

< 4 years 

More prominent at night 

Weak or no cough 

Temp >38.5°C 

Septicaemia 

Drooling saliva 

Unable to eat or drink 

Doesn’t talk 

Any age 

Reluctant to move neck 

As the condition 

deteriorates the stridor 

may decrease 


Child with stridor 

See 

Anaphylaxis 

See 

Acute upper airway 

obstruction / choking 

See 

Croup / epiglottitis 

See 




Child with vomiting 

556 

Vomiting is a common and important symptom, which may indicate serious illness especially in a very young child. 

Consider the following causes: infection (pneumonia, UTI, meningitis, otitis media), obstruction (pyloric stenosis, intussusception, appendicitis, 

hernia), reflux oesophagitis, raised intracranial pressure (trauma, abscess or tumour), metabolic (diabetic ketoacidosis, poisoning) 

Perform clinical assessment 

Consult MO 

Yes 


No 

Child unwell 

Well baby 

3 mths - 3 yrs 

2-6 weeks old 

Basically well 

child 

Moderate or 

severe 

dehydration 

Unweaned 

Dysuria 

frequency 

smelly urine 

Child unwell 

Child unwell 

Abdominal 

pain 

intermittently 

Diarrhoea 

Vomiting and 

irritable after 

feeds 

Fever 

High 

capillary BGL 

Red currant 

jelly stool 

Projectile 

vomits, 

hungry 

following 

feed 

Cough 

Fever 

Positive 

urinalysis 

Rapid 

breathing 

May have 

history of URTI 

like illness 


No other 

significant 

features 

Ketones on 

urinalysis 

No other 

significant 

features 

No other 

significant 

features 

Weight loss or 

poor gain 

No other 

significant 

features 

Chest 

recession 

Tachycardia 

Headache, 

photophobia 

+/- 

Child with vomiting 

No other 

significant 

features 

No other 

significant 

features 

Neck stiffness 

+/- 

Rash 

See 

Diabetes 

See Gastroesophageal 

reflux 

See 

Intussusception 

See 

Pyloric 

stenosis 

See 

UTI 

See 

Acute 

gastroenteritis 

See 

Pneumonia 

See 

Meningitis 


Any history of significant trauma? 

No 

Bile-stained vomiting? 

Bloody stool? 

Localised tenderness? 

Distension? 

Guarding? 

Rebound tenderness? 

Palpable mass? 

Inguinal-scrotal pain or swelling? 

No 

Positive urine dipstick for 

leukocytes, nitrates or blood; 

or bacteria on microscopy 

No 

Fever +/- 

Tachypnoea 

Recession 

Cough 

Chest pains 

No 

Diarrhoea +/- vomiting / fever 

No 

Firm stool palpable in lower abdomen? 

No 

Consult MO 


Child with abdominal pain 

See Criteria for Early Notification of 

Trauma for Interfacility Transfer 

Consult MO 

Consider UTI 

See Urinary tract infection - child 

Consider pneumonia 

See Pneumonia - child 

Consider gastroenteritis 

See Child with vomiting / fever / 

chronic diarrhoea 

Consider constipation 

See Constipation 


Yes 

Yes 

Yes 

Yes 

Yes 

Yes


558 


Child with chronic diarrhoea 

Diarrhoea every day for at least 10 days or recurrent episodes of loose stools over longer 

periods requires investigation. Consider the following causes: parasites (strongyloides, 

cryptosporidium, giardiasis), malabsorption (lactose intolerance, coeliac disease), 

inflammatory conditions (crohns disease, ulcerative colitis), other infections e.g. UTI, 

pneumonia 

Perianal itch 

Sighting of worms 

in faeces 

See 

Intestinal worms 


Significant features of assessment 

unclear or you are unsure of cause 

No 

Well hydrated, normal growth and 

development, adequate diet 

Obtain faeces sample for MC/S and OCP 

Is test positive? 

No 

Test for lactose intolerance 

See Lactose intolerance 

Is test positive? 

No 

Consider significant features 

of asssessment 

Foul smelling, 

watery diarrhoea 

Flatulence 

Nausea 

See 

Giardiasis 

Yes 

Yes 

Yes 

Consult MO 

Treat if positive 

for giardia or 

intestinal 

worms. 

Consult MO if 

other +ve result 

See Lactose 

intolerance 

Bloody diarrhoea 

Mucus in diarrhoea 

Abdominal pain 

Consult 

MO 


Meningitis 

Meningitis 

Recommend 

Consult MO immediately: 

- - if a sick looking child has no obvious source of infection, which would explain 

their symptoms - the diagnosis is meningitis until proven otherwise 

- - if the child has been treated with antibiotics but is still not well (they may have 

partly treated meningitis with masking of signs) 

-- if the child is unwell with prolonged URTI symptoms 

Restrict fluids to 50% of maintenance (10mg / kg) unless there are signs of shock - 

MO to discuss as soon as possible with a Paediatrician 

Parents or carers may notice early, subtle changes in the child’s conscious state. 

Their concerns should not be ignored 

Perform hearing test 3 months after discharge from hospital 

Background 

Mortality is probably 5 - 10% in bacterial meningitis. Most children will make 

a full recovery, if appropriately treated. Deafness is the most common long term 

complication 

Hyponatraemic solutions e.g. 4 % dextrose and one-fifth normal saline or one-quarter 

normal saline, have no place in the management of meningitis as they may worsen 

hyponatraemia and increase the risk of cerebral oedema [1] 


Fits / convulsions / seizures 

Upper respiratory tract infection - 

child 


DRS ABCD resuscitation / the collapsed 

patient 

O 2 delivery systems 

1. May present with 

• URTI type symptoms, fever, lethargy, poor feeding 

• In young children - non specific signs and symptoms including fever, irritability, 

refusing feeds, pallor and a high pitched moaning cry may be present 

• In older children - headache, photophobia, neck stiffness [2] 

• Leg pain, cold hands and feet 

• Abnormal skin colour - pallor or sweating 

• Rash in meningococcal disease: usually non blanching petechiae (fine dark red 

spots) but may be purpura (like bruises), or less commonly, a ‘flea bitten’ pink / red 

maculopapular rash. The rash often develops rapidly, however meningococcal 

disease can occur without a rash 

• Muscle / joint pains, vomiting, diarrhoea 

• Confusion, drowsiness, loss of consciousness 

• Bulging fontanelle, fitting 

2. Immediate management 

• Consult MO immediately 

• If altered level of consciousness See DRS ABCD resuscitation / the collapsed 

patient 

• If fitting see Fits / convulsions / seizures 

• Give O 2 to maintain O 2 saturation >95%. If >95% not maintained consult MO. 

See O 2 delivery systems 

• Insert IV / IO cannula and take FBC, U/E, blood cultures, PCR for Neisseria 

meningitis (meningococcal bacteria) 


Meningitis 

• In the critically ill, shocked or septic child with suspected meningitis e.g. 

unresponsive, poorly perfused, purpuric rash, it is appropriate to first give a bolus 

of intravenous or intraosseous fluids (initially 10 - 20 mL / kg of normal saline [1]) 

before giving antibiotics. Otherwise restrict total fluids to 10 mL / kg. 

• MO to consult as soon as possible with Paediatrician 

3. Clinical assessment 

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

of the presentation. Of particular importance in a sick looking child is: 

-- -headache, irritability, fever, ask about any rash, neck stiffness 

• Perform standard clinical observations + 

-- weight (if able) 

-- GCS 

-- O saturation 

2 

• Perform physical examination: 

-- inspect all skin surfaces for any skin rash especially at pressure points and 

under nappies and clothing. Note: petechiae and purpura do not fade on 

pressure 

-- assess hydration status 

-- -inspect and palpate the ears, nose and throat 

-- palpate the fontanelle in young baby - feeling for fullness 

-- check for neck stiffness - with patient lying down, put hand behind head and 

gently raise 

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

• Check vaccination status, especially Hib / meningococcal / conjugate 

pneumococcal 

4. Management 

• Consult MO who will arrange / order: 

-- evacuation / hospitalisation 

-- monitor clinical observations closely 

-- continue IV / IO fluids at 50% of maintenance fluids (10 mL / kg). If the child is 

drinking ensure total fluids do not exceed 10 mL / kg (or 50 % of maintenance 

fluids) 

-- if meningitis is suspected, stat dose of parenteral antibiotics must be given 

before transfer to hospital. Blood samples for culture and PCR should be 

taken where possible but should not delay initial treatment 

-- give IV ceftriaxone (can be given by IM route if unable to obtain IV access) 

100 mg / kg / dose to a total of 4 grams daily (or 50 mg / kg / dose bd to a total 

of 2 grams bd) [3] 

• Give paracetamol for fever, pain or distress 

See Simple analgesia back cover 

5. Follow up 

All children with suspected meningitis should be managed in an appropriately 

equipped hospital 

Notify the Public Health Unit of any suspected case of bacterial meningitis as 

soon as possible 

Chemoprophylaxis will be required for close contacts of a patient with either 

meningococcal or Hib meningitis. Unvaccinated contacts of Hib meningitis

6. Referral / consultation 

Consult MO immediately on all occasions if meningitis is suspected 

Most will require urgent treatment and evacuation / hospitalisation 

Respiratory problems 

References 

1. The Royal Children’s Hospital. Fluid management in meningitis. 2005 [cited 2011 March ]. 

2. The Royal Children’s Hospital. Meningitis guideline. 2009 [cited 2011 March ]. 

3. Therapeutic Guidelines. Meningitis: empirical therapy (organism or susceptibility not yet known). 2010 

[cited 2011 March]. 

Upper respiratory tract infection - child 

Common cold, sore throat, tonsillitis 

Recommend 

Remember the symptoms and signs of an upper respiratory tract infection (URTI) 

may be a precursor to more serious illnesses such as meningitis 

Always be alert to the relationship between group A streptococcal sore throat and ARF 

/ APSGN. These complications are common and serious but potentially avoidable in 

Aboriginal and Torres Strait Islander children 

Ten (10) days of oral antibiotics, or one dose of benzathine penicillin IM, is required 

to eradicate group A streptococcus 

Background 

The vast majority of URTI are caused by viruses and do not require antibiotics. 

However a viral URTI can be complicated by secondary bacterial infection such as 

otitis media or pneumonia, requiring antibiotics 

Other complications include exacerbation of asthma 


Meningitis 


Pneumonia 

Acute otitis media 

Pertussis (whooping cough) 


Bronchiolitis 


• Watery or purulent nasal discharge and / or sneezing 

• Sore / red throat and / or tonsils with or without pus 

• Difficulty swallowing, cough, chest wheeze, earache 

• Enlarged tender cervical (neck) lymph nodes 

• Fever, headache, general malaise 

2. Immediate management Not applicable 


• Take patient history including: 

- - past episodes, history of asthma, complications such as ARF / APSGN 

- - otitis media, measures taken to treat including medications taken 


-- collect urine for MC/S and test for nitrates 

• Perform physical examination including: 

-- overall appearance e.g. smiling? agitated? lethargic? 

-- respiratory effort e.g. chest recession, nasal flaring, grunting (noisy breathing), 

abdominal breathing 

-- inspect the ears, nose and throat 



562 

- - palpate the head and neck for enlarged lymph glands 

- - auscultate the chest for air entry and any added sounds - crackles or wheezes 

- - inspect all skin surfaces for any skin rash especially at pressure points and 

under nappies and clothing Note: petechiae and purpura do not fade on 

pressure 

• Check vaccination status. See Immunisation program 

4. Management 

• Consult MO if 

- - < 3 months of age 

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

○ 1 - 2 years more than 35 rpm 



○ 12 years and older more than 20 rpm 

○ respiratory distress or apnoea 

-- if child looks sick, not alert or interactive and has temperature over 38°C 

-- if child still looks sick when temperature reduced 

- - if child has any rash 

- - if child has a cough productive of mucopurulent sputum, may need further 

investigations for possibility of chronic respiratory disease 

- - if child has tonsillitis and is sick 

• If child has cough as the main feature; consider other diagnoses. See Pertussis 

(whooping cough), croup, acute asthma 

• If child has an increased respiratory rate, or any chest findings consider other 

diagnoses. See Bronchitis / pneumonia 

• If child has evidence of secondary ear infection. See Acute otitis media 

• For the child with URTI, indications for antibiotic treatment are: 

-- sore throat and red swollen tonsils, with or without pus, with fever (>38°C) 

and local lymphadenitis 

-- sore throat with red swollen tonsils in a child with existing rheumatic heart 

disease 

-- Scarlet fever - has a characteristic and striking red blanching rash and 

strawberry tongue due to streptococcal infection; rash usually starts after the 

sore throat and lasts a week 

-- Quinsy (severe infection of the tonsils causing massive enlargement). If 

quinsy is present, consult MO (may need evacuation / hospitalisation for IV 

penicillin and / or surgical drainage of pus) 

• For the child with uncomplicated URTI, treatment is symptomatic [1]: 

- - encourage rest and increase fluid intake 

- - paracetamol for analgesia if uncomfortable (do not use aspirin in children) 

- - topical nasal decongestants can be helpful for sleeping and eating particularly 

in young infants; however their use should be limited to short periods of time 

(5 days max.). Nose drops of normal saline or cool boiled water can also be 

helpful and are safe 

- - other symptomatic treatments, nebulised saline, and lemon and honey drinks 

may have some subjective benefit in some children 





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

with oral penicillin: 

Schedule 4 Phenoxymethylpenicillin 

DTP 

IHW / SM R&IP / IPAP 

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

Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed 

Form Strength 

Route of 

administration 

Capsule 

250 mg 

500 mg Oral 

Suspension 150 mg / 5 mL 

Recommended 

dosage 

Child 

15 mg / kg / dose bd 

to a max. of 500 mg bd 

Duration 

10 days 

Provide Consumer Medicine Information: should be taken on an empty stomach; ½ to 1 hour before meals. 

Ensure full course is completed 

Management of associated emergency: as for severe allergic reactions See Anaphylaxis 

[1] 

• If a lack of observance with oral medication is anticipated or those intolerant of 

oral therapy treat with IM penicillin: 

Schedule 4 

Benzathine penicillin 

(Bicillin LA) 

DTP 




Form Strength 

Route of 


Recommended 

dosage 

3 kg - < 6 kg 225 mg 

Duration 

Disposable 

syringe 

900 mg IM 

6 kg - < 10 kg 337.5 mg 

10 kg - < 15 kg 450 mg 

15 kg - < 20 kg 675 mg 

>20 kg 900 mg 

Stat 

Use a concentration of 442 mg / mL when measuring part doses. Refer to product information 

Provide Consumer Medicine Information 


Administration tips - as per patient preference: 

-- apply EMLA cream to the injection site 30 - 60 minutes prior to injection and allow medication to warm 

up to room temperature or 

-- allow medication to warm up to room temperature, apply pressure with thumb (to the exact injection 

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

[1] 

• If allergic to penicillin, treat with roxithromycin: 



Schedule 4 Roxithromycin 

DTP 




564 

Form Strength 

Tablet for 

suspension 

Tablet 

50 mg 

150 mg 

300 mg 

Route of 


Oral 


Recommended 

dosage 

Child 



Duration 

10 days 

Provide Consumer Medicine Information: should be taken on an empty stomach, 15 minutes before food; 

ensure course is completed 

Management of associated emergency: consult MO 

[1] 

5. Follow up 

Review next day, if not improving consult MO 

If antibiotics have been given for sore throat: 

- - review in 2 weeks 

- - ask about sore joints, chest pain, breathlessness and check urinalysis 

- - consult MO if symptoms persist see Rheumatic fever or if abnormal urinalysis 

see Acute post streptococcal glomerulonephritis 


Consult MO as above or if symptoms persist despite symptomatic treatment 

If recurrent tonsillitis (>6 episodes per year) MO may consider prolonged course 

of prophylactic penicillin or referral to ENT specialist for consideration for 

tonsillectomy / adenoidectomy 

Pertussis (whooping cough) 

Recommend 

If adults and teenagers present with pertussis ask about young babies at home as 

pertussis is a particularly severe disease in infants < 12 months of age 

It is important to explain that coughing may continue for 6 - 8 weeks after treatment 

and may recur with the next URTI. The recurrence will not last long 

In Queensland free pertussis vaccine is now available for birth parents, foster parents, 

adoptive parents, grandparents of babies < 6 months of age and other adults in a 

household with a baby < 6 months of age [2] 

Background 

Pertussis (whooping cough) is still common 

Incubation period is on average 7 - 10 days 

Pertussis is a prolonged illness and can be complicated by apnoea in infants, 

pneumonia, hypoxic brain injury, seizures or lead to chronic lung disease 



URTI 




• URTI symptoms 

• Cough (typically paroxysmal i.e. intermittent episodes of prolonged coughing 

followed by the characteristic inspiratory ‘whoop’ as the child catches his / her 

breath) 

• Vomiting, typically after an episode of coughing 

• Cyanosis, typically during an episode of coughing 

• Young babies usually do not have the characteristic whoop but are likely to be very 

distressed by coughing and vomiting. They can develop apnoea (stop breathing) 

and become cyanosed during a coughing bout 

• Adults usually have a persistent troublesome cough only, without a whoop. A 

cough of several weeks duration, that is worse at night, in an adult, is pertussis 

until proven otherwise 


• If severe consult MO immediately 


• See Upper respiratory tract infection 

• The ‘whoop’ can be characteristic but may not always be present. The child may 

not be distressed in periods between paroxysms of coughing, with few clinical 

signs, however the overall impression is of a sick child 

• Check vaccination status. See Immunisation program 

4. Management 

• Consult MO who may advise: 

-- evacuation / hospitalisation if young child (< 6 months) or if symptoms are 

significant, appropriate tests to confirm diagnosis - serum for IgA and / or 

nasopharyngeal aspirate / swab for PCR testing and / or MC/S 

-- antibiotics may shorten the length of the illness if given early and will also 

reduce infectivity to others. Person can be considered not infective after 5 

days of treatment. It is important to explain that coughing will continue for 6 - 8 

weeks, and may recur with the next URTI. The recurrence will not last long 

-- household and child care contacts may require prophylactic antibiotics to 

prevent further clinical cases of pertussis 

-- advise to avoid contact with other individuals, especially young children and 

infants until at least 5 days of antibiotics have been received [3] 

-- consult Public Health Unit for advice 

5. Follow up 

If not evacuated / hospitalised review daily, at least initially 


Consult MO on all occasions whooping cough is suspected 



566 



Recommend 

Keep the child as calm as possible 

Do not examine the mouth or throat and do not lie the child flat 

Background 

Croup usually follows 3 or 4 days of a mild URTI when the infection spreads to affect 

the upper airways; it is usually mild and self limiting 

Epiglottitis (cellulitis of the epiglottis) is caused by Haemophilus influenza type B 

infection and is fatal if untreated. It is rare since Hib vaccination was introduced 


Acute upper airway obstruction and choking 


• Acute epiglottitis 

- - weak or no cough 

- - temperaure >38.5°C 

-- septicaemia 

-- looks sick 

- - drooling saliva 

-- unable to eat or drink 

- - doesn’t talk 

- - any age 

- - reluctant to move neck 

• Croup 

- - croupy (barking) cough 

- - temperature 95% and consult MO immediately. If >95% not maintained consult 

MO. See O 2 delivery systems 

• If not tolerated, it is best to interfere with the child as little as possible. Try holding 

the O 2 tubing / mask close to face 


• Obtain patient history including onset and preceding URTI 

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

respiratory rate (when the child is quiet) 

• Inspect for signs of respiratory distress - grunting (stridor), rib or sternal recession, 

nasal flaring 

• Inspect for drooling in a sick looking child. This along with high fever is suggestive 

of epiglottitis 



4. Management 

• Consult MO 

• If epiglottitis: 

-- have the parents / carer stay with child to comfort 

-- handle the child as little as possible 

-- MO will organise evacuation by skilled MO with paediatric airway management 

and IV insertion for IV ceftriaxone [4] 

• If croup: 

- - symptomatic treatment as per URTI 

-- for mild to moderate cases MO may advise: 

○ prednisolone 1 mg / kg / dose stat with a second dose for the next 

evening or 

○ a single dose of oral dexamethasone 0.15 mg / kg / dose 

-- for severe cases MO may advise: 

○ 0.6 mg / kg / dose (max. 12 mg) IM / IV dexamethasone 

○ 5 mL of adrenaline 1:1,000 solution via nebuliser [5] 

○ evacuation / hospitalisation 

5. Follow up 

If child with croup is not evacuated / hospitalised, review next day and consult MO 

if not improving 


Consult MO on all presentations of stridor 

Bronchiolitis 

Recommend 

Consult MO immediately if severe 

Background 

In bronchiolitis, generally the child is distressed without looking sick or toxic 

A viral infection of the chest affecting infants 95%. If >95% not maintained consult 

MO. See O 2 delivery systems 




• Obtain complete patient history of particular importance is: 

- - a history of URTI symptoms in a child that is basically well 

- - history of chest conditions such as asthma, pneumonia 

- - if wheeze is present 

- - if child has stopped breathing (apnoea) for short periods of time 

-- how well is the child / infant feeding 

• 

• 

Perform standard clinical observations + O saturation 

2 

Perform physical examination: 

- - inspect for signs of respiratory distress (grunting, nasal flaring, sternal and / 

or intercostal / subcostal recession) 

- - inspect middle ear 

- - inspect for cyanosis (lips, tongue, extremities) present in severe cases 

- - auscultate chest for presence of wheezes / crackles 

4. Management 

• Consult MO who will consider treating similar to: 

-- acute asthma, if wheeze is prominent, however in infants bronchodilators are 

unlikely to be effective 

-- pneumonia, if fever and rapid breathing is prominent 

-- O if SpO < 95% 

2 2 

• If child / infant is not feeding well, fluids may be required NG or IV 

5. Follow up 

Patients who are not evacuated / hospitalised should be reviewed daily 

Consult MO if the patient is not improving 


Consult MO on all occasions bronchiolitis is suspected 

568 


Pneumonia - child 

Recommend 

If baby < 3 months of age contact MO immediately 

Severe dehydration is unusual in pneumonia unless there are abnormal fluid losses 

from frequent diarrhoea or vomiting 

Background 

Children with co-existent illnesses are more at risk. Examples are bronchiolitis and 

chronic lung disease e.g. due to prematurity 




Bronchiolitis 


• Cough dry or with sputum, fever, tachycardia 

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

cyanosis, apnoea in infants 


Child 

< 3 months 

Contact MO 

immediately 

Resps 

≥40 / min 

and / or 

recession 

grunting 

apnoea 

cyanosis 

Resps 


570 

Mild pneumonia 

• MO may advise: 

-- chest x-ray if available 

-- oral or IM antibiotics 

-- antibiotics may not be indicated if typical of viral infection or bronchiolitis 

• Encourage rest and increase oral fluids 

• Treat fever with regular paracetamol to make more comfortable 

Moderate / severe pneumonia 

• Give O to maintain O saturation >95% (if not already in place). If > 95 % not 

2 2 

maintained consult MO. See O delivery systems 

2 

• Give oral fluids as tolerated 

• MO may advise: 

-- insert IV cannula - if possible take blood cultures prior to commencing 

antibiotics 

-- IV fluids - it is usual to start with normal saline or Hartmann’s solution; MO will 

advise quantities and rate 

-- to commence IV antibiotics 

• Evacuation / hospitalisation 

• Give analgesia 


5. Follow up 

Patients with mild pneumonia who are not evacuated / hospitalised should be 

reviewed daily 

Consult MO if the patient is not improving 

See next MO clinic 


Consult MO on all occasions pneumonia is suspected 

Some children with pneumonia will require a paediatric referral 

References 

1. Therapeutic Guidelines. Pharyngitis and/or tonsillitis. 2010 [cited 2011 January]. 

2. Queensland Health, Expansion of Free Pertussis Vaccine Program, in Immunisation Program. 2011: 

Brisbane. 

3. Therapeutic Guidelines. Pertussis. 2010 [cited 2011 March]. 

4. Therapeutic Guidelines. Acute epiglottitis (supraglottitis). 2010 [cited 2011 March]. 

5. The Royal Children’s Hospital. Croup (Laryngotracheobronchitis). 2009 [cited 2011 March ]. 



Immune complications 

Acute post streptococcal glomerulonephritis (APSGN) 

Recommend 

Early treatment of skin infections is essential for prevention of acute post-streptococcal 

glomerulonephritis (APSGN) 

Background 

APSGN is common among Aboriginal and Torres Strait Islander children in northern 

Australia 

Inflammation of the kidneys results from immune complexes forming after a group A 

streptococcal infection causing blood to not filter properly and blood cells and protein 

leaking into urine 


Bacterial skin infections 


• Fever, headache, malaise 

• Oedema (swelling) of face, feet and hands or excessive weight gain 

• Haematuria - urine may be dark coloured 

• Incidental finding on urinalysis (blood and protein in urine) 

• Rarely may present fitting secondary to acute hypertensive crisis 


• If fitting see Fitting / convulsions / seizures 


• Take complete patient history in particular: 

- - any history of sore throat and length of time since present 

- - any skin infections present and length of time since occurred 

- - past history of APSGN, close contacts who may have similar signs or 

symptoms, any measures taken to treat presenting concern 


-- BP ensuring correct cuff size (APSGN is one of the few conditions where it is 

important to monitor BP in a child) 

-- urinalysis (for blood and protein) 

• Check weight 


- - inspect face, hands and feet for oedema, throat looking for signs of recent 

infection and palpate skin looking for signs of recent infection 

- - inspect and palpate abdomen for tenderness or guarding 

- - listen to chest for crackles or wheezes (fluid retention can cause heart failure) 

year 1 

Upper limits of normal BP for boys at 

50th percentile for height and weight 

[1] 

BP upper level systolic 103 106 111 114 116 119 123 128 134 136 

of normal diastolic 56 61 69 74 78 80 81 82 84 87 

2 years 


4 years 

6 years 

8 years 

10 years 

12 years 

14 years 

16 years 

> 17years


Upper limits of normal BP levels 

for girls at 50th percentile for 

height and weight [1] 

BP 

upper level 

systolic 104 105 108 111 115 119 123 126 128 129 

of normal 

diastolic 58 63 70 74 76 78 80 82 84 84 

572 

1 years 

2 years 

4 years 

Diagnostic features of APSGN [2] 

This illness usually features oedema and / or hypertension (BP greater than levels in tables 

for age and gender). Other features include: 

1. Haematuria - often macroscopic but can be microscopic 

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

• Microscopic haematuria is defined as >10 x 106 red blood cells on microscopy 

of fresh urine; red cells casts should also be seen. If microscopy is not readily 

available 

2. Reduced serum complement: C 200 international units or, 

• anti-DNase B >300 U / mL 

• These serological titres are often high at baseline in Aboriginal and Torres Strait 

Islander community children because of repeated skin infections with GAS. So 

acceptable evidence for recent GAS infection is either: 

-- titres of > 2 x reference e.g. ASOT > 400 international units / mL or 

-- anti-DNase B > 600 units / mL or 

-- a rising titre when repeated after 10 - 14 days 

4. Management 

• Consult MO who: 

- - will advise to treat streptococcal infection with IM benzathine penicillin 

[3] regardless of whether skin sores / sore throat are present at the time 

of presentation or not; or if allergic to penicillin a full 10 day course of oral 

roxithromycin [3] 

-- may advise to treat hypertension and / or heart failure (initial treatment is 

usually frusemide) 

• All cases with hypertension should be evacuated / hospitalised 

• Restrict fluids and salt intake (usually patient is fluid overloaded) 

• Notify all cases of APSGN to the Public Health Unit 

6 years 


8 years 

10 years 

12 years 

14 years 

16 years 

> 17years 



Schedule 4 


(Bicillin LA) 

DTP 




Form Strength 

Route of 


Recommended 

dosage 

3 kg - < 6 kg 225 mg 

Duration 

Disposable 

syringe 

900 mg IM 

6 kg - < 10 kg 337.5 mg 

10 kg - < 15 kg 450 mg 

15 kg - < 20 kg 675 mg 

20 kg > 900 mg 

Stat 









[1] 

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


DTP 




Form Strength 

Tablet for 

suspension 

Tablet 

50 mg 

150 mg 

300 mg 

Route of 


Oral 

Recommended 

dosage 

Child 



Duration 

10 days 

Provide Consumer Medicine Information: should be taken on an empty stomach, 15 minutes before food. 

Ensure full course is completed 


[1] 

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

immediately 



5. Follow up 

Most children will require evacuation / hospitalisation 

If not evacuated / hospitalised the child requires close follow up with daily review 

including weight, BP and urinalysis. If there is any deterioration, consult MO 

Refer to next MO clinic 

Following discharge, most children will require at least monthly weight, BP and 

urinalysis (it takes a considerable time for haematuria to resolve) following 

glomerulonephritis but persisting proteinuria is of more concern. Some children 

will be on antihypertensives for a period of time after the illness and will require 

more frequent monitoring of BP 

If urinalysis shows protein on follow up, collect urine for urine protein / creatinine 

ratio 

If persistent proteinuria refer to Paediatrician for follow up 

Blood should be tested to check the immune system complement factor serum 

complement (C 3 ) level has returned to normal after three months; an MSU should 

also be sent 

Review at 3, 6, 9 and 12 months 


Consult MO on all occasions of suspected glomerulonephritis 

Most will need paediatric referral and follow up 

If C 3 does not return to normal refer to Paediatrician 

References 

1. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children 

and Adolescents, The Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure 

in Children and Adolescents. Pediatrics, 2004. 114 (2): p. 555. 

2. Queensland Government. Acute Post-streptococcal Glomerulonephritis Control of Communicable 

Diseases Protocol Manual 2009 [cited 2011 May]; Available from: qheps.health.qld.gov.au/cdpm/index/ 

apsgn.htm. 

3. Therapeutic Guidelines. Impetigo. 2009 [cited 2010 December]. 

574 




Acute rheumatic fever 

Recommend 

In Aboriginal and Torres Strait Islander communities where there are high rates of 

acute rheumatic fever (ARF) and rheumatic heart disease (RHD) treat streptococcal 

throat and skin infections early 

Any case of arthritis with fever in a child should be considered as possible ARF 

or septic arthritis and transferred to hospital for investigation and confirmation of 

diagnosis 

Regular penicillin prophylaxis is critical to prevent recurrences of ARF, which can 

lead to the development or worsening of RHD 

Background 

ARF is an auto-immune response to bacterial infection with group A Streptococcus 

(GAS) [1] in the throat (and possibly the skin); it affects the heart, joints, nervous 

system and skin 

Aboriginal and Torres Strait Islander Australians living in rural or remote settings are 

known to be at high risk. Those living in urban settings, Maori and Pacific Islander 

people and, potentially immigrants from developing countries also may be at high 

risk [2] 

ARF is predominantly a disease of children aged between 5 and 14 years although 

recurrent episodes may continue well into the fourth decade of life [1] 

Patients with recurring ARF have a higher risk of developing RHD 

RHD is a chronic condition resulting from scarring and deformity of the heart valves 

following ARF 



Upper respiratory tract infection - adult 


Bone and joint infections - child 

Acute rheumatic fever and rheumatic heart disease prophylaxis 


• Fever and malaise 

• Painful tender swollen joints. Symptoms classically seen to progress from one 

joint to another (migratory polyarthritis) however only one joint may be affected 

(aseptic monoarthritis). Any joint can be involved but most commonly affects the 

large joints of the limbs - knees, ankles, elbows 

• Abdominal pain 

• Inability to weight-bear or walk unaided 

• Uncontrollable jerky movements of the trunk, face and / or limbs (Sydenham’s 

chorea), that disappear when asleep 

• Skin rash. This is rare, but highly suggestive of ARF (can be difficult to see in 

dark skinned people) 

• Small nodules over bony areas such as elbows and knees; again rare 

• History of a sore throat or skin infection within the previous 2 - 3 weeks 

• Breathlessness (if cardiac involvement), chest pain 

• Abnormal heart sounds 





• Obtain complete patient history including: 

-- past episodes of ARF / RHD or previous symptoms suggesting history - ask 

whether benzathine penicillin injections have been ordered previously / have 

they been received regularly? 

-- recent history of sore throat, painful joint or skin infections and whether treated 

-- measures taken to treat presenting symptoms 

-- current medications 


-- O saturations 

2 


-- inspect throat for signs of infection 

-- inspect and palpate all skin surfaces for signs of skin infection and pink skin 

rash with definite rounded borders, occurring mainly on the trunk, never on 

the face; blanches under pressure (erythema marginatum) 

-- inspect and palpate joints for swelling and tenderness and presence of small 

nodules (pea sized), painless, overlying bony prominences 

-- auscultate the heart to determine whether there is an audible murmur 

-- look for indications of heart failure - increased HR or irregular (heart block), 

increased respiratory rate, basal crackles in chest, liver enlargement, ankle 

oedema 

Diagnostic criteria ARF [1] 

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

laboratory evidence of a recent group A streptococcal (GAS) infection 

• An experienced Medical Specialist should review the clinical presentation with 

pathology results to confirm the diagnosis and determine ongoing management. 

All suspected cases of ARF should be referred to a tertiary facility to have the 

diagnosis confirmed and to ensure adequate workup for appropriate long-term 

management 

• ARF is a notifiable condition in Queensland - contact the ARF / RHD Register 

in the area and the Public Health Unit 

• Note: Unlike most other notifiable diseases, ARF is not based solely upon a 

laboratory diagnosis, and therefore notification has to be done by the clinician / 

Health Care Worker 

Diagnostic criteria RHD 

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

• This is confirmed through the use of echocardiogram by an experienced clinician 

• Serial echocardiography plays a critical role in diagnosis and management 

576 




Australian guidelines for the diagnosis of Acute rheumatic fever in high risk groups [1] 

For an initial episode of ARF to be confirmed there must be 2 major manifestations or 1 major and 2 

minor manifestations, plus evidence of a recent group A streptococcal infection. 

Since Sydenham’s chorea can occur after all other signs and symptoms have resolved, it can be used 

alone to confirm the diagnosis 

A recurrent episode of ARF (known past ARF or chronic RHD) requires 2 major or 1 major and 2 minor 

or 3 minor manifestations plus evidence of a recent GAS infection 

Major manifestations 

• Polyarthritis or aseptic monoarthritis or 

polyarthralgia. Usually migratory i.e. finishes 

in one joint, begins in another 

• Chorea - strange jerky movements of the 

trunk and / or limbs which the patient cannot 

control 

• Carditis - (including subclinical evidence of 

rheumatic valve disease on echocardiogram) 

• Erythema marginatum - pink skin rash with 

definite rounded borders, occurring mainly 

on the trunk, never on the face, and blanches 

under pressure 

• Subcutaneous nodules - small painless pea 

sized nodules over bony prominences (e.g. 

elbows) 

• Carditis identified on echocardiogram may 

be included as a major manifestation [1] 

Minor manifestations 

• History of fever or presenting fever >38ºC 

• Laboratory / other clinical findings: 

-- elevated acute phase reactants - ESR 

≥ 30 mm/hr or CRP ≥ 30 mg / L 

-- prolonged PR interval on ECG 

Supporting evidence of group A streptococcal infection 

• Group A streptococcus isolated on throat culture 

• Elevated or rising streptococcal antibody titre. See link for age related levels www.heartfoundation. 

org.au/Professional Information/Clinical Practice/ARF RHD/Pages/default.aspx 

These serological titres are often high at baseline in Aboriginal and Torres Strait Islander community 

children because of repeated infections with GAS. So acceptable evidence for recent GAS infection are 

either: 

-- titres of > 2 x reference e.g. ASOT > 400 IU / mL or Anti-DNase B > 600 U / mL or 

-- a rising titre when repeated after 10 - 14 days 

4. Management 

• Consult MO who will likely advise: 

-- evacuation / hospitalisation - confirmation and management of ARF should 

occur in hospital (a wrong diagnosis either positive or negative will have 

serious consequences) 

-- blood for FBC, ESR, C-reactive protein (CRP), ASOT, anti-DNase B and 

streptococcal serology 

-- swab throat and any skin sores 

• Take blood cultures if temperature ≥ 38°C 

• Record ECG 

• Consider chest x-ray and echocardiogram 

• Provide pain relief as required. Use paracetamol for pain and fever. Do not give 

aspirin or non-steroidal anti-inflammatory drugs (NSAID) until the diagnosis is 

confirmed - these may cause joint symptoms to disappear and complicate the 

diagnosis 



578 

• Treatment of ARF is based on the eradication of GAS infection and management 

of symptoms: 

-- IM benzathine penicillin to eliminate streptococci (even if group A streptococci 

not isolated on culture) 

-- oral penicillin should not normally be used, as completion of 10 days of 

treatment cannot be guaranteed 


Schedule 4 


(Bicillin LA) 


DTP 

IHW / IPAP 


Form Strength 

Disposable 

syringe 

Route of 


900 mg IM 

Recommended 

dosage 

Child < 20 kg 

450 mg 

Adult / child ≥ 20 kg 

900 mg 

Duration 



Management of associated emergency: as for severe allergic reactions. See Anaphylaxis 






[1] [2] 

• If reliably documented allergy to penicillin treat with erythromycin [1] 

• If penicillin allergy not reliably documented arrange for testing in hospital 

Schedule 4 Erythromycin 

DTP 

IHW / IPAP 


Form Strength 

Capsule 250 mg 


Route of 


Oral 

Recommended 

dosage 

500 mg bd 



Provide Consumer Medicine Information: take with food 


Stat 

Duration 

10 days 

5. Follow up 

Assign an individualised management plan based on ARF and absence or 

[1] 


presence of RHD 

Place person on Recall Register and monitor closely 


Recommended duration of secondary prophylaxis. 

-- the most effective regime for continuous prophylaxis is a 4 weekly injection 

of benzathine penicillin - may be increased to 3 weekly, see current edition 

of NHFA guideline www.heartfoundation.org.au 

-- consult MO for antibiotic prophylaxis for procedures expected to produce 

bacteraemia 

Provide education and support to patient and family. Resources available include; 

Strong Heart, Strong Body books, DVD and reminder cards (from Tropical Public 

Health) 

Contact the ARF / RHD Control Program (arfregister@health.qld.gov.au) in your 

district or Public Health Unit for help, even if ARF only suspected 

Antenatal patients with RHD may deteriorate because of the increased cardiac 

workload during pregnancy. Pregnant women known to have RHD need to be 

assessed early in pregnancy and monitored closely with 2 weekly follow up. 

The woman will also need antibiotic cover if prolonged labour and / or ruptured 

membranes [1] 

Primary prevention: 

-- have a low threshold for treating throat infections with penicillin in Aboriginal 

and Torres Strait Islander and Pacific Islander children. See URTI - child / 

URTI - adult 

-- reduce the prevalence of scabies and impetigo 

Give influenza and pneumococcal vaccines according to the current edition of the 

NHMRC Australian Immunisation Handbook. See Immunisation program 


Consult MO on all occasions of suspected ARF 

Consult MO for anticoagulation therapy / INR range 

Refer to Paediatrician within 3 months of diagnosis 

References 

1. National Heart Foundation, RF/RHD Guideline Development Working Group, and Cardiac Society of 

Australia and New Zealand, Diagnosis and management of acute rheumatic fever and rheumatic heart 

disease in Australia: An evidence based review. 2006, National Heart Foundation Australia. 

2. Therapeutic Guidelines. Rheumatic fever in children. 2010 [cited 2011 January]. 


Ear problems 

580 


Assessment of the ear 

History 

• Obtain a complete patient history 

• Of particular note is environmental history e.g. dusty, passive smoking or smoker 

• Social history 

• Surgical history, medical history 

• Has the patient been swimming? 

• Of particular importance are problems with hearing, speech and language 

• Does the patient have any pain? Is there pain on movement of the pinna? Describe 

pain, how long has the patient had the symptoms? Young children may not be able to 

localise their pain but parent may notice they are unsettled or pulling at an ear 

• Is the ear itchy? 

• Is this the first episode? Note the number of past episodes 

• Is there a history of URTI? How many? 

• Is the person under the care of ENT physician? Audiologist? 

• Is there a history of AOM with perforation? 

• Have any measures been used to treat the ear? 

Examination 

• Examine ear at eye level 

• Position infant / toddlers on parent / carer’s knee. Older child can stand and adult sit 

• Often very painful - approach gently 

Outer ear 

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

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

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

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

• Is there auricular tenderness? pain? tenderness on palpation of mastoid? 

Ear canal 

• Inspect the ear canal for discharge, redness / swelling, fungal membrane or debris, 

lumps or bony growths, foreign body, extruding grommets, wax, fluid 

• If pain levels allow, inspect the ear canal for inflammation, exudates, lesions or foreign 

bodies 

Tympanic membrane (ear drum) 

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

• Cone of light - right ear at 5 o’clock, left ear at 7 o’clock 

• Handle of malleus - right ear 1 o’clock, left ear 11 o’clock 

• Is the ear drum intact? bulging? retracted? 

• Is there fluid or air / fluid or bubbles behind the ear drum? 

Right 

Left 


Ear problems 

• Clean the ear using tissue spears until all pus has been removed and the drum and 

perforation can be seen. Document the size and position of perforation on a diagram 

in the case notes. If an unsafe perforation (in the attic region) of the ear drum is 

found consult MO immediately 

Attic perforation - unsafe perforation 

Safe perforation 

Related systems 

• Nose and throat 

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

Chest 

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

• Note other injuries if present e.g. cause of traumatic rupture of the ear drum 

Hearing screening and assessment commences from birth across the life span. Refer to 

current edition of Chronic Disease Guidelines available at www.health.qld.gov.au/cdg for 

procedures in performing: 

• Otoscopy 

• Audiometry to assess hearing level 

• Tympanometry to test middle ear function 

If a person is under the care of an Ear Nose and Throat Specialist or Audiologist ensure 

they are up to date with appointments / care 


Ear problems 

582 


Ear infections 

Recommend 

Language and speech develop in the 0 - 5 year age group. Assessment for possible 

middle ear disease, hearing impairment and speech and language problems should 

be a routine part of the primary care of children aged 0 - 5 years 

Prevention of otitis media through [1]: 

- - encouraging family or care giver to present child for treatment early if there are 

features of otitis media. Informing family of risk if child is in a high risk group 

(includes Aboriginal and Torres Strait Islander children) 

- - informing family and carers that onset of otitis media can occur within the first 

months of life. Baby may have pain, irritability, fever or ear discharge 

- - there is an increased risk of acute otitis media during respiratory infections 

- - the family or care giver should be advised that ear pain may be absent and that 

regular clinic attendance for ear examinations is recommended 

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

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

- - breastfeeding for at least three months reduces the risk of otitis media and should 

be encouraged 

- - smoke exposure is a risk for otitis media in children. Adults should be encouraged 

to quit smoking or smoke outside away from children 

- - swimming should not be discouraged unless it is known to be associated with 

new infections in that person 

- - full immunisation; 23 valent pneumococcal vaccine (Pneumovax 23®) for children 

4 - 5 years of age who are at risk of pneumococcal infections 

Definitions [1] 

• Acute otitis media (AOM) - presence of fluid behind the ear drum plus at least one of 

the following: bulging ear drum, red ear drum, recent discharge of pus, fever, ear pain 

or irritability 

• Recurrent acute otitis media (rAOM) - the occurrence of three or more episodes of 

acute otitis media in a six month period 

• Otitis media with effusion (OME, glue ear) - presence of fluid behind the ear drum 

without any symptoms or signs of acute otitis media 

• Acute otitis media with acute perforation (AOM with perforation less than 6 weeks) - 

discharge of pus through a perforation (hole) in the ear drum within the last six weeks 

• Chronic suppurative otitis media (CSOM discharging more than 6 weeks) - persistent 

discharge of pus through a perforation (hole) in the ear drum for at least six weeks 

despite appropriate treatment for acute otitis media with perforation 


Ear problems 

Acute otitis media (AOM) 

Non-discharging painful ear 

Recommend 

Consult MO immediately if child is < 3 months of age, who is sick or hot, or meets 

any of the other criteria outlined at beginning of paediatric section 

All children with AOM should be reviewed after four to seven days of treatment or 

earlier if deterioration [1]. A second review should take place after completion of 

therapy [1] 

Health clinics have targeted hearing health programs to focus on day care and pre 

school children where intervention may prevent ear damage and hearing loss 

Personal hygiene in children - washing hands and face is important 

Background 

In some rural and remote Aboriginal communitites complications of otitis media 

are much more common. They include tympanic membrane perforations, CSOM, 

OME and mastoiditis. This is the reason that antibiotics are recommended in these 

children, while in low risk populations the advantage of antibiotics is small 



Pneumonia 

Acute asthma 

Bronchiolitis 



• A history of acute onset of signs and symptoms 

• Young child may present with irritability, disturbed sleep, pulling at ears, sometimes 

vomiting and diarrhoea 

• Fever or upper respiratory symptoms 

• Pain clearly originating from the ear 

• Some children will not have pain but a red bulging drum is found on routine exam 



• Obtain a complete patient history. See Assessment of the ear 

• Perform standard clinical observations 

• Perform physical examination. See Assessment of the ear Look for inflammation 

with a red bulging tympanic membrane and loss of light reflex 

4. Management 

• Provide adequate and regular analgesia 


• Consult MO if child: 

- - < 3 months of age, who is sick or hot 

-- temperature over 38° C or below 36°C 

-- has any rash, increased respiratory rate or respiratory distress or meets any 

of the other criteria as outlined at beginning of paediatric section - this child 

needs to be managed as a septic infant 

• Spontaneous resolution of AOM is unlikely in high risk populations therefore if not 

allergic to penicillin treat with amoxycillin [1] 


Ear problems 

584 

• Talk to the family about the need to complete the full course of antibiotics and to 

return at 4 - 7 days for the ear to be checked 

• Give or help to give the first dose in the clinic and ensure the family know the right 

dose to give. If family do not have a fridge at home they may have to return to the 

health service for medicine each day 

Schedule 4 Amoxycillin 

DTP 




Form Strength 

Route of 


Recommended 

dosage 

250 mg 

Capsule 

Adult and child 

500 mg 

Oral 25 mg / kg / dose bd 

125 mg / 5 mL 

Suspension to a max. of 1 g bd 

250 mg / 5 mL 




Duration 

7 days 

[4] [6] 

• If parent or Health Care Worker think it will be difficult to comply with oral antibiotics 

or if the child has significant diarrhoea or vomiting, treat with IM procaine penicillin 

with the option to return to oral antibiotic once vomiting settles 

Schedule 4 Procaine penicillin 

DTP 




Form Strength 

Route of 


Recommended 

dosage 

Adult 

Duration 

Disposable 

syringe 

1.5 g IM 

1.5 g daily 

Child 

50 mg / kg / dose daily 

to a max. of 1.5 g daily 

5 days 








[3] [4] 

• If allergic to penicillin, treat with roxithromycin 


Ear problems 


DTP 




Form Strength 

Route of 


Recommended 

dosage 

Duration 

Tablet 

150 mg 

300 mg 

Adult 

300 mg daily 

Tablet for 

suspension 

50 mg 

Oral 

Child 



10 days 


Ensure course is completed 


[5] 

5. Follow up 

Review the patient in 4 - 7 days 

If not improving consult MO who may consider alternative or increased dose of 

antibiotic 

At next MO visit. If child not improved needs weekly review. Child < 2 years of 

age may need many weeks of antibiotics [6] 

Review after completion of treatment at the 1 week mark 

Ask family about child’s hearing, speech development, behaviour, school progress. 

If there are concerns about any of these refer for formal hearing assessment if not 

done recently 

To prevent recurrent otitis media and transmission of bacteria to other children 

encourage personal hygiene in children - washing hands and face 

Breathe, blow and cough (BBC) program is targeted at school aged children 

Review at 3 months to identify those with chronic disease [1] 


Consult MO as above 

If otitis media is recurrent (more than 3 episodes in 6 months or more than 4 in 12 

months) the MO may consider antibiotics for prophylaxis [1] 

ENT specialist for those with frequent painful AOM 


Ear problems 

586 

Otitis media with effusion (OME) 

Painless non discharging ears, glue ear 

Recommend 

Review children with bilateral OME at 3 monthly intervals and refer if required 

Health clinics have targeted hearing health programs to focus on day care and 

pre school children where intervention may prevent ear damage and hearing loss. 

Personal hygiene in children - washing hands and face and keeping face clear of 

nasal discharge is most effective 

Provide full immunisation 

Background 

OME is diagnosed if thick fluid persists in the middle ear usually after AOM 

OME results in thick glue like material filling the middle ear which may take many 

months to resolve. It is important because children with OME will have impaired 

hearing. If hearing is impaired for a significant length of time especially at the critical 

age of language learning in the first 5 years it may result in significant long term 

disability 

Decongestants and antihistamines are not recommended [7] 

Steroids are not recommended [1] but inhaled steroids may be trialed in children 

where significant nasal obstruction, sneezing etc. suggests allergic rhinitis 







• Usually is asymptomatic 

• Parents may be concerned about the child’s hearing 

• Diagnosis may also be suspected at routine ear examination, in a child being 

followed up after AOM, or in a child referred for medical assessment because of 

hearing impairment on testing 

• Child may have: 

-- past history of recurrent otitis media 

-- concerns about speech or language development 

• Reported decrease in hearing 

• Reported poor hearing leading to learning difficulties 





• Perform physical examination. See Assessment of the ear 

-- the following may be noted on examination 

○ air / fluid level, bubbles behind the ear drum 

○ retraction of ear drum 

○ limited or absent movement of the ear drum with pneumatic otoscopy. 

This is the best way to diagnose - refer to audiology / MO to perform. 

Diagnosis is confirmed by tympanometry which shows a type B (stiff ear 

drum) pattern 


Ear problems 

4. Management 

• Give amoxycillin 

• Arrange for audiology if there are concerns about hearing or speech or OME is 

persistent for > 3 months 

• Refer to ENT specialist: 

- - if hearing test shows moderate impairment in both ears for more than 3 

months 

-- if there is speech delay and effusion persists more than 3 months or 

-- if there is more severe hearing impairment or concerns about the appearance 

of the drum 

• Encourage personal hygiene in children - washing hands and face and keeping 

face clear of nasal discharge 

• Breathe, blow, cough (BBC) program is for school aged children 

• Check immunisation status particularly Pneumovax and perform catch up 

immunisation if required 


DTP 




Form Strength 

Route of 


Recommended 

dosage 

250 mg 

Capsule 


500 mg 


125 mg / 5 mL 


250 mg / 5 mL 



Duration 

14 days 

[4] [6] 

• If not resolved may need a further 14 days to a total of 28 days. If allergic to 

amoxycillin see Antibiotics for acute otitis media 

5. Follow up 

3 monthly 

If OME persists for > 3 months arrange - audiometry and tympanometry 

See the current edition of the Chronic Disease Guidelines available at: 

www.health.qld.gov.au/cdg 


Next MO visit 

Refer to ENT specialist if: 

-- any concerns about hearing or speech 

-- problem remains longer than 3 months 

-- antibiotic therapy has failed 

-- has severe retracted ear drum 

If there is speech delay refer to Speech Pathologist 

If hearing is impaired in school children make sure the school is informed, with 

parental consent, as the teacher can use measures to assist child 


Ear problems 

588 

Acute otitis media with acute perforation 

Discharging ear for less than 6 weeks - may be painful 

Recommend 

If seen in the first days treat see Acute otitis media 

Always follow up to ensure perforation has healed 

If discharge does not resolve by 14 days add ciprofloxacin drops and increase the 

dose of oral amoxicillin 

If discharge continues through an established perforation after 6 weeks of treatment 

treat See Chronic suppurative otitis media (CSOM) 

You may need to clean the discharge from the ear before you can see the drum, you 

can usually do this by gently cleaning with a tissue spear 

Background 

Infection behind the eardrum may cause the drum to rupture 

AOM with perforation occurs mainly in the first 18 months of life and effective 

treatment will dramatically reduce the incidence of chronic suppurative otitis media 

(CSOM) [1] 

Ciprofloxacin drops are restricted on the Pharmaceutical Benefits Scheme to 

treatment of chronic suppurative otitis media: 

-- in an Aboriginal or a Torres Strait Islander person aged 1 month or older 

-- in a patient less than 18 years of age with perforation of the tympanic membrane 

-- in a patient less than 18 years of age with a grommet in situ 

If not in an S100 community MO will need to obtain authority script 



Chronic suppurative otitis media (CSOM) 


Cleaning technique for ears with 

discharge 



• Presents with onset of ear discharge for < 6 weeks 

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




• Document length of time perforation has been present 


• Perform physical examination. See Assessment of the ear: 

-- for otoscopic examination - you may need to clean the discharge from the ear 

before you can see the drum, you can usually do this by gently cleaning with 

a tissue spear 

-- document the size and position of perforation on a diagram in the case notes 

4. Management 

• Give analgesia if required 

• If not allergic to penicillin treat with amoxycillin 

• If the discharge has been present for > 14 days the MO may increase the dose of 

amoxycillin and order use of ciprofloxacin drops 

• If the discharge has been present for >6 weeks the condition is chronic suppurative 

otitis media (CSOM). Treatment is as for CSOM. Oral antibiotics are not indicated 



Ear problems 


DTP 




Form Strength 

Route of 


Recommended 

dosage 

250 mg 

Capsule 


500 mg 


125 mg / 5 mL 


250 mg / 5 mL 



Duration 

7 days 

• If parent or Health Care Worker thinks it will be very difficult to comply with oral 

antibiotic treatment or if the child has significant diarrhoea or vomiting, treat with 

IM procaine penicillin with the option to return to oral antibiotic once vomiting 

settles 

Schedule 4 Procaine penicillin 

DTP 




Form Strength 

Route of 


Recommended 

dosage 

Adult 

Duration 

Disposable 

syringe 

1.5 g IM 

1.5 g daily 

Child 

50 mg / kg / dose 

to a max. of 1.5 g daily 

5 days 








[4] 


[4]

Ear problems 

590 

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

roxithromycin 


DTP 




Form Strength 

Route of 


Recommended 

dosage 

Duration 

Tablet 

150 mg 

300 mg 

Adult 

300 mg daily 

Tablet for 

suspension 

50 mg 

Oral 

Child 



10 days 


Ensure course is completed 


[5] 

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

Schedule 4 

Ciprofloxacin hydrochloride 

ear drops 

DTP 

IHW 

Ciprofloxacin hydrochloride ear drops must be ordered by MO / NP. MO / NP note restrictions 

Authorised Indigenous Health Workers can only administer on MO / NP order 

Form Strength 

Route of 


Recommended 

dosage 

Duration 

Ear drops 

Ear drops 

(0.3%) 

Topical 

Instil 5 drops in 

affected ear bd 

Until the ear is dry 

or 9 days 

Provide Consumer Medicine Information: if not drying in 2 weeks check with family on ability to clean and 

instil drops 


Administration tip 

-- The patient should be sitting or lying down with the affected ear upwards 

-- Once the drops have been instilled maintain position for 30 - 60 sec. 

-- Apply tragal pressure (pressing several times on the flap of skin in front of ear canal) after the drops 

have been instilled to assist the drops through the perforation 

[8] 

5. Follow up 

Review the patient in 2 days 

If not improving consult MO 

Weekly review until the signs of AOM with perforation have resolved 

If failing to resolve discuss with parents / carer - explore if the child is being 

given antibiotics. Is the child spitting it out or vomiting afterwards? Consider daily 

treatment in the clinic or use IM procaine penicillin 

If the discharge continues after 6 weeks of treatment manage See Chronic 

suppurative otitis media (CSOM) 

If perforation heals review in 6 weeks: 

- - inspect ear drum 

-- perform hearing assessment - audiometry and tympanometry 

- - advise to prevent recurrent otitis media with good personal hygiene in children 

- - Breathe, blow, cough (BBC) program is targeted at school aged children 



Ear problems 



If concerns about hearing, speech, language development or the child has had 

recurrent AOM refer for audiology 

Chronic otitis media 

Discharging and non-discharging 

Chronic suppurative otitis media (CSOM) 

Ear has been discharging for more than 6 weeks 

Recommend 

Consult MO immediately if unsafe perforation of the eardrum found (in the attic 

region). See Assessment of the ear 

Use antibiotic ear drops with tissue spears (dry mopping) to reduce the production 

of pus [1] 

Document the duration of ear discharge and size and position of perforation [1] 

Treat discharging ears actively 

Background 

CSOM is diagnosed in children who have discharging ears for more than 6 weeks [1] 


Acute otitis media with perforation 

Chronic suppurative otitis media 

(CSOM) 

Cholesteatoma 

Cleaning technique for ears with chronic 

discharge 



• Intermittent and continuous ear discharge often associated with poor hearing 

leading to learning difficulties 


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

drum See Assessment of the ear 



• Document length of time discharge has been present 


• Perform physical examination See Assessment of the ear: 

-- -clean the ear using tissue spears until all pus has been removed and the 

drum and perforation can be seen 


4. Management 

• Dry mopping twice daily until tissue is dry, followed by ciprofloxacin ear drops 

twice per day 

1. Ciprofloxacin ear drops 

2. Use Sofradex ear drops only if ciprofloxacin drops not available 

• Consult MO for ciprofloxacin order 

• For removal of pus and debris from ear canal See Cleaning techniques for ears 

with chronic discharge 


Ear problems 

592 

• In young children it may be difficult for family members to adequately clean the 

ears and instil the drops - clinic staff are advised to do this daily for 7 days 

• Encourage personal hygiene in children - washing hands and face 

• Avoid swimming or immersing head under water 

• Consult MO if perforation found in attic region (unsafe perforation) of the ear drum 

Schedule 4 

Ciprofloxacin hydrochloride 

ear drops 

DTP 

IHW 

Ciprofloxacin hydrochloride ear drops must be ordered by MO / NP. MO / NP note restrictions 

Authorised Indigenous Health Workers can only administer on MO / NP order 

Form Strength 

Route of 


Recommended 

dosage 

Duration 

Ear drops 0.3 % Topical 

Instil 5 drops in 

affected ear bd 

Until the ear is dry or 

9 days 




• The patient should be sitting or lying down with the affected ear upwards 

• Once the drops have been instilled maintain position for 30 - 60 secs 

• Apply tragal pressure (pressing several times on the flap of skin in front of ear canal) after the drops 


[8] 

• or 

Schedule 4 

Sofradex ® ear drops 

(Dexamethasone 0.5 mg / Framycetin Sulphate 

5 mg / Gramicidin 0.05 mg / mL) 


DTP 




Form Strength 

Route of 


Recommended 

dosage 

Duration 

Until the middle ear has 

Ear drops 

See 

above 

Topical 3 drops qid 

been free of discharge 

for at least 3 days 

Do not administer longer 

than 7 days 

Provide Consumer Medicine Information: evidence of ototoxicity - limit treatment to no longer than 7 

days 



• The patient should lie with their head on a pillow for several minutes after administration to allow the 

drops to gravitate to the bottom of the ear canal 



[2] 


Ear problems 

5. Follow up 

Children < 5 years of age, review and treat daily for 7 days. If not drying in older 

children consider daily treatment in the clinic. Suction under direct vision is very 

useful to clear the ear if clinics have the equipment and staff have experience and 

training 

If not improving consult MO 

Teach patient / carer cleaning technique and instillation of drops 


Review weekly thereafter until ear is dry 

If the ear is still discharging, consult MO 

When the ear dries review at 3 months 

To prevent recurrent otitis media encourage personal hygiene in children - washing 

hands and face 

Breathe Blow Cough (BBC) program is targeted at school aged children 


For hearing assessment - audiometry and tympanometry when ear dry 

With education staff 

Consult MO as above including a presentation with perforation in the upper drum 

(attic). Note unsafe perforation attic retraction or suspicion of cholestoma will 

need urgent referral to ENT 

Refer to ENT specialist: 

-- if ear continues to discharge for 4 months 

-- unsafe perforation 


Ear problems 

Cleaning techniques for ears with chronic discharge 

Suction 

• Suction under direct vision is the most effective technique but this requires special 

equipment and training 

Dropper method 

• The ear canal can be cleaned by irrigating with clean water using an eye dropper 

• An eye dropper uses a small volume of wash solution at low pressure and is therefore 

relatively safe in unskilled hands 

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

Equipment 

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

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

contaminated) 

• Clean container for the dirty water from the ear 

Technique 

1. The patient should be sitting or lying down with the affected ear upwards 

2. Using a clean dropper filled with clean water, squirt water into the discharging ear. 

Only the tip of the dropper needs to be in the canal. Without withdrawing the dropper 

and just by releasing the bulb, suck the water and pus back into the dropper 

3. Discard the contents of the dropper into the container for dirty water. Do not squirt the 

water in and out of the ear. When all the pus has been washed out of the ear, the water 

sucked back into the dropper is clear 

4. Repeat the above steps until there is clean return from the ear 

5. Dry the ear canal using tissue spears (see details) 

Tissue spear method (dry mopping) 

• This can safely be done by a child on their own or by the parent. It should be done 

whenever the ear discharges. The tissue paper actively absorbs the moisture 

• In the management of chronic suppurative otitis media, the tissue spear method should 

be used in conjunction with regular eye dropper irrigation by the Health Care Worker 

Technique 

1. Make a spear by twisting corner of tissue paper 

2. Insert into ear gently, twisting slowly 

3. Stop when child blinks 

4. Leave in place for 30 seconds then remove and repeat until tissue tip is dry 

5. Perform at least twice per day until the ear is dry 

Topical antibiotics and other ear drops with dry mopping 

• The patient should be sitting or lying down with the affected ear upwards 

• Clean and dry the ear canal as per dropper method and tissue spears 

• Instil the ear drops 

• Apply tragal pressure (pressing several times on the flap of skin in front of ear canal) 

after the drops have been instilled to assist the drops through the perforation [1] 

• Keep the patient in position for several minutes 

• Use of cotton wool as a ‘plug’ just soaks up the medication. Let excess run out 

594 



Ear problems 

Ear discharge in the presence of grommets 


• History of insertion of grommet in one or both ears 

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





• Perform physical examination. See Assessment of the ear plus: 

-- clean the ear using tissue spears until all pus has been removed and the 

drum and perforation can be seen 


4. Management 

• Consult MO for antibiotic order 

• Treat as per Acute otitis media with perforation 

5. Follow up 

As per MO instructions 

Advise no swimming. If this is not possible in a hot tropical climate, ear plugs with 

a swimming cap for swimming are recommended for children with grommets. 

Effective ear plugs can be custom built or made from silicon putty, cotton wool 

with Vaseline, or “Blu-Tack®” 


As above 

Cholesteatoma 

Recommend 

Be aware of cholesteatoma when performing all otoscopic examinations 

Cholesteatoma is treated surgically and success is highly dependent on early 

recognition and the extent of the lesion 

Background 

Most patients who acquire cholesteatomas have a history of recurrent acute otitis 

media and / or chronic middle-ear perforation 

Patients with a family history of chronic middle ear disease and / or cholesteatoma 

are at increased risk [9] 


Acute otitis media with perforation Assessment of the ear 


If diagnosed early may have no symptoms. Otherwise may present with: 

• Dizziness, ache behind the ear especially at night 

• Muscle weakness of the face, foul odour from the ear 

• White mass behind intact ear drum on otoscopic examination 

• New onset of hearing loss in a previously operated ear 

• History of chronic perforation of the ear drum 


Ear problems 


• Consult MO for referral to Paediatrician or ENT Specialist 





596 

-- on otoscopic examination - white mass behind an intact ear drum: 

○ a deep retraction pocket with or without granulation and skin debris 

○ focal granulation on the surface of the drum, especially at the periphery 

○ perforation in the attic region (unsafe perforation) 

4. Management 

• If suspected refer ENT Specialist 

5. Follow up 

If confirmed, surgical treatment is required 


Refer to Paediatrician and / or ENT Specialist 


Acute mastoiditis 

Recommend 

Urgent referral to hospital with paediatric and ENT Specialist for management 

Background 

Mastoiditis is inflammation in the mastoid air cells and typically occurs after acute 

otitis media 


Acute otitis media Ear wick technique for otitis externa 



• As per Acute otitis media; in addition: 

-- may have systemic features - with fever and rigors 

-- pain swelling and tenderness above and behind the ear over the mastoid 

(bony prominence behind the ear) 

-- the ear may be pushed away from the head by swelling of the mastoid area 

-- dizziness or tinnitus (ringing in the ears) may be present 


• Consult MO immediately 




• Perform physical examination. See Assessment of the ear plus: 

- - palpate behind the ear. Palpate the mastoid tip noting any tenderness 

- - is the mastoid bone swollen and / or hot - describe 

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


Ear problems 

4. Management 

• Consult MO who will arrange: 

-- urgent referral to hospital with Paediatric and ENT Specialist for management 

-- discuss antibiotic regime with Infectious Disease Specialist 

• Staff may be required to give first dose of antibiotics prior to evacuation 

5. Follow up 

As per post discharge orders 


Urgent referral to Paediatrician and ENT Specialist 

Otitis externa 

Swimmer’s ear or tropical ear 

Recommend 

In the acute phase with inflammation the canal should not be syringed. However in 

established otitis externa aural toilet may be indicated to remove debris. Consult MO 


Earwick techique for otitis externa 



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

• Varying degrees of canal redness and peeling, debris collects in the canal, ear 

pain (sometimes severe) or itch 

• Tender, swollen outer ear and ear canal; very painful if outer ear manipulated, 

discharge not always present 

• Ear blockage, deafness or fullness, a foreign body may be present 






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

4. Management 

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

• Give analgesia 


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

of drops or in severe cases, a wick soaked with sofradex or cortocosteriod + 

antibiotic ointment to remove pus and debris. The ear should be kept dry for at 

least two weeks after treatment [10]. Advise not to swim until healed 


Ear problems 

Ear wick technique for otitis externa 

Materials 

• Flumethasone 0.02% + clioquinol 1% or Sofradex ® drops or triamcinolone compound 

(Kenacomb®) ointment 

• Ribbon gauze approximately 10 cm in length for an adult 

• Non-toothed forceps e.g. nasal packing forceps 

Technique 

1. The ribbon gauze is laid along a wooden tongue depressor and is impregnated with 

drops or ointment along its length 

2. The end of the impregnated strip is grasped with the forceps and is gently fed into 

the ear canal, 1 cm at a time. The ear canal is straightened by gently pulling the ear 

backwards and upwards in an adult or backwards in a child. The ear canal is 2.5 cm 

long in an adult 

3. If there is too much ribbon, the excess is trimmed with scissors. Once in place, the 

patient should be comfortable. If the patient has increased pain, the wick should be 

removed 

Schedule 4 

598 


(Dexamethasone 0.5 mg / framycetin 

sulphate 5 mg / gramicidin 0.05 mg / mL) 


DTP 




Route of 

Recommended 

Form Strength 

Duration 


dosage 

Ear drops See above 

Topical - drops 3 drops tds 7 days 

Topical - earwick Soaked gauze 

Wick left in canal for 2 days 

then review 



Administration tip - drops 





Administration tip - earwick 

• Remove the wick using forceps. Inspect and clean the ear. Reinsert if required 

[10] 

• or 


Ear problems 

Schedule 4 

Flumethasone 0.02% + clioquinol 

1% 

DTP 




Form Strength 

Route of 


Recommended 

dosage 

Duration 

Ear drops As above Topical - ear wick Soaked gauze 





• or 

The wick is left in the canal 

for 2 days then review 

Schedule 4 

Triamcinolone compound 

(Kenacomb®) 

DTP 




Form Strength 

Triamcinolone 0.1 % 

Route of 


Recommended 

dosage 

Duration 

Ointment 

Neomycin 0.25 % 

Gramicidino 0.025 % 

Nystatin 100,000 

units / g 

Topical - ear wick 

Ointment 

soaked gauze 

The wick is left in the canal 

for 2 days then review 





[4] 

5. Follow up 

Review in 2 days and in 1 week 

Advise not to swim and keep ears dry until healed 

Next MO visit if ear canal not back to normal at 1 week, or if recurrent 


Otitis externa can become chronic or recurrent, especially in hot humid climates 

General prevention involves keeping the ear canal dry and protected by a lining 

of wax. Use drying ear drops e.g. Aqua-ear® / Vosol®, after swimming and 

showering will help prevent recurrence 

Advise patient to keep foreign objects such as cotton buds out of their ears; 

remove built-up wax, if necessary with e.g. Waxsol® 

Patients with recurrent infections often have a chronic fungal infection present. 

This infection may be seen with fungal hyphae looking like wet blotting paper or 

dry like cotton wool or the infection may be suspected even if the canal looks 

clean and normal but is itchy 

Suction ear toilet followed by Sofradex ® or flumethasone 0.02% + clioquinol 

1% or triamcinolone compound (Kenacomb®) ointment to prevent further acute 

bacterial infection 


[10]

Ear problems 

600 

Traumatic rupture of the ear drum 


Trauma to teeth Head injuries 

Eye injuries 

Fractured mandible / jaw 


• A history of the injury e.g.: 

- - a blow to the side of the head or an explosion, i.e. a pressure wave 

- - penetrating injury e.g. a sharp stick 

- - water forced into ear e.g. a fall from a height into water 

• Pain in the ear, reduced hearing and / or bleeding from the ear 

• Dizziness and nausea 


• Management of life threatening injuries 


• Obtain a complete patient history: 

-- ask about the circumstances and mechanism of injury 

-- time, date of occurrence and when first noticed 

-- does the patient have decreased hearing? 


-- conscious state if applicable 


-- note other injuries if present 

4. Management 

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

e.g. fall into water. The ear should be kept dry until healed. Antibiotic eardrops are 

not necessary if hole was caused by dry trauma (blow to head) 

5. Follow up 

Review in 2 days and then weekly 

If perforation not healed in 2 weeks, consult MO 


Consult MO on presentation and if perforation not healed in 2 weeks 



Ear problems 

Foreign body / insect 

Recommend 

The main danger of a foreign body in the ear lies in its careless removal [11] 


Otitis externa 


• Foreign body or insect in ear canal 



• Obtain a full history including circumstances (accidental, purposeful, incidental 

finding) 


• Examine the ears. See Assessment of the ear 

4. Management 

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

easily removable using e.g. nasal packing forceps 

• Larger foreign bodies and those further down the canal require special equipment 

and training for removal and may even require a general anaesthetic (send to 

hospital with ENT facilities) 

• A live insect in the ear canal should be drowned using Sofradex® eardrops or 

cooking oil or 2 mL of 1% lignocaine introduced by the blunt end of a syringe or 

via a cut-off ‘butterfly’ needle (or other plastic tubing is also effective) [11]. Do not 

syringe with water as can cause insect to swell 

• After removal of foreign body or insect, instil Sofradex® ear drops to prevent 

infection secondary to the trauma caused to the skin of the ear canal 

Schedule 4 


(Dexamethasone 0.5 mg / Framycetin 

Sulphate 5 mg / Gramicidin 0.05 mg / mL) 

DTP 




Form Strength 

Route of 


Recommended 

dosage 

Duration 

Ear drops See above Topical - drops 

3 drops 

tds - qid 

7 days 









[10]

Ear problems 

5. Follow up 

If foreign body or insect easily removed, review in 2 days 

Review as per Otitis externa if secondary infection occurs after removal 


Consult MO as per Otitis externa if secondary infection occurs after removal 

References 

1. Office for Aboriginal and Torres Strait Health. Recommendations for Clinical Care Guidelines on the 

Management of Otitis Media (middle ear infection) in Aboriginal and Torres Strait Islander Populations. 

2001 [cited 2011 March]. 

2. Therapeutic Guidelines. Otitis media. 2010 [cited 2011 March]. 

3. Australian Medicine Handbook. Procaine penicillin. 2011 [cited 2011 May]. 

4. Dr A White, Paediatrician. 2011. 

5. Dr E. Binotto, Infectious Diseases & Clinical Microbiology. 2011. 

6. CRANA plus, Clinical Procedure Manual for remote and rural practice. 2nd ed. 2009, Alice Springs. 

7. Griffin, G., Flynn C A., and Bailey R E. Antihistamines and / or decongestants for otitis media with 

effusion (OME) in children. Cochrane Database of Systemic Reviews 2006 [cited 2011 March]. 

8. Australian Medicine Handbook. Ciprofloxacin (ear). 2011 [cited 2011 March]. 

9. Isaacson G., Diagnosis of pediatric cholesteatoma. Pediatrics 2007. (3): p. 603-608. 

10. Therapeutic Guidelines. Otitis externa. 2010 [cited 2011 March]. 

11. Murtagh J., Practice Tips. 4th ed. 2004: The McGraw-Hill Inc. 

602 



Gastrointestinal problems 

Acute gastroenteritis and dehydration 

Vomiting and diarrhoea 

Recommend 

Always contact MO immediately if baby is < 3 months or the child has any of the 

following: 

- - is sick or febrile with temperature over 38°C or under 35.5°C 

- - irritable 

- - high pitched or weak cry 

- - sleepy 

- - not feeding well 

-- increased respiratory rate: 

○ 40 rpm 

○ 1 - 2 years >35 rpm 

○ 2 - 5 years > 30 bpm 

○ 5 - 12 years >25 rpm 

○ 12 years and older >20 rpm 

-- respiratory distress 

- - apnoea 

- - dehydration 

- - abdominal distension 

-- persistent / bilious vomiting and no diarrhoea (consider other diagnoses) 

Other high risk children include: 

-- excessive diarrhoea (> 8 watery stools in 24 hours) 

- - those with congenital or chronic disease e.g. cardiac, gastrointestinal or 

neurological 

- - where social conditions are concerning and / or where the parents may have 

difficulty managing at home 

Always consider other infections. Any infection can cause diarrhoea or vomiting 


Intraosseous cannulation DRS ABCD resuscitation / the collapsed patient 

Shock 


• Vomiting 

• Diarrhoea 

• Cramping abdominal pain 

• Irritability in the young child 

• Fever 

• Dehydration 

• Lethargy, floppy, unresponsive 



-- O saturations 

2 

-- level of consciousness 

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

dehydration 

• Commence rehydration according to MO advice 




• Obtain a complete history including: 

-- diarrhoea - how much and for how long? Is it watery or semiformed, is there 

blood or mucous? 

-- vomiting - how much and for how long? Is there bile? 

-- fluid intake - how much and what type? 

-- diet - how much food has the child eaten and what? 

-- urine output if known, number of wet nappies? 

-- has any home treatment / medicine been given? 

-- past history of diarrhoea or other illnesses or infections? 

• Did the child receive rotavirus vaccine? 


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

recorded weight [1] and 

-- level of consciousness if not previously done 

• Collect a faeces specimen for MC/S and OCP (ova, cysts and parasites) and 

viral studies if: 

-- -history of blood in the stool, severe diarrhoea or prolonged (> 7 days) 

-- -history suggestive of food poisoning i.e. cluster presentation 

-- -recent travel overseas 


-- degree of dehydration 

Clinical assessment of hydration in children 

To assess the child 

for dehydration 

604 

No signs 

Mild < 5% 


Some signs 

Moderate 5 - 10% 

Definite signs 

Severe > 10% 

Eyes normal sunken very sunken and dry 

Mouth and tongue moist dry very dry 

Condition alert 

Thirst 

drinks normally, 

may be thirsty 

restless, irritable, 

lethargic 

thirsty, drinks eagerly 

extreme lethargy 

“ragdoll appearance” 

drinks poorly or 

not able to drink 

Respiratory rate normal increased fast 

Pulse normal fast fast, weak, thready 

Capillary return normal (≤ 2 seconds) sluggish (> 2 seconds) slow (> 3 seconds) 

Management 

Can usually be treated 

at home or with close 

monitoring by 

PHC / rural facility 

Consult MO 

Require urgent 

rehydration usually 

nasogastric / IV 

Consult MO 

Requires resuscitation 



4. Management 

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

dehydration 

• Children and babies with watery diarrhoea lasting 2 - 3 days should have bloods 

taken for electrolytes. Take bloods earlier if indicated 

• Do not use: 

- - anti-diarrhoeal agents 

- - metoclopramide or prochlorperazine in young children. MO may order 

ondansetron if vomiting is preventing oral intake [2]. Ondansetron not 

recommended for children


606 

Management of dehydration in children flow chart [1] 

Mild 

Assist carers to give 

child small amounts 

of oral fluids 

frequently 

Continue 

breastfeeding / bottle 

feeding 

Rehydration 

Diagnosis of 

Gastroenteritis in 

doubt? 

No 

Significant 

co-morbidities or risk 

factors such as age 

< 3 months, febrile 

No 

Vomiting 

prominent? 

No 

Assess dehydration 

Moderate 

Consult MO 

Requires urgent 

rehydration 

nasogastric / IV. 

MO may organise 

evacuation / 

hospitalisation 

• Approximate volumes [3] 

-- less than 6 months as per MO order 

-- 6 - 23 months 40 - 60 mL each hour 

-- 2 - 5 years 60 - 100 mL each hour 




Yes 

Yes 

Yes 

Consult MO 

for input on 

management 

MO may 

consider 

ondansetron 

wafer 

Trial of oral 

fluids 10 - 20 mL 

/ kg for 1 hour 

unless severe 

dehydration 

Severe 

Consult MO urgently 

who will organise 

evacuation / 


IV / IO insertion 

Commence bolus of 

20 mL / kg 

normal saline 

• Breastfed infant [3] 

-- continue breastfeeding on demand or at least every 2 hours 

-- in between breastfeeds, water or oral rehydration solution may be offered 

-- do not give solids if the child is vomiting 

-- give solids when the vomiting has stopped or after 24 hours 

-- if the baby is on solids introduce simple foods such as rice cereal, potato or 

pumpkin - even if the diarrhoea is still present 



• Bottle fed infant and older child [3] 

-- while the infant or child is still vomiting replace formula or usual drinks with 

oral rehydration fluid or other clear fluid (volume on previous page) 

-- aim to be back to usual formula / diet within 24 hours - do not dilute 

-- offer age appropriate foods at meal times even if diarrhoea still present 

-- occasionally children will develop lactose intolerance and the diarrhoea will 

continue. See Nutrition after gastroenteritis and lactose intolerance 

4.2 Moderate dehydration (5 to 10% loss of body weight) 


• Commence rehydration therapy according to MO instructions, usually oral / 

nasogastric. Examples of rehydration volumes given below 

-- must be managed in appropriately equipped and staffed facility 

-- MO will arrange evacuation if required 

• Commence a fluid balance sheet immediately 

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

mild dehydration 

• Monitor child’s observations closely 

• Discuss with MO for further decision making after 4 hours 

Oral / NGT fluid replacement regime example for moderate dehydration 5 - 10 % [1] 

Weight kg 

0 - 6 hours 

Give oral / NGT fluid replacement 

(mL / hr) 

7 - 24 hours 

(following previous column doses) 

Give oral / NGT fluid replacement 

(mL / hr) 

3 30 20 

4 40 30 

5 50 35 

6 60 40 

7 70 45 

8 80 50 

9 90 55 

10 100 60 

12 120 65 

15 150 70 

20 200 85 

30 300 90 

4.3 Severe dehydration (>10% loss of body weight) 

If severe hypovolaemic shock. See Shock 


-- commence rehydration therapy according to MO instructions 

- - must be managed in appropriately equipped and staffed facility 

- - MO will arrange evacuation 

• Monitor conscious state closely and consult MO immediately if altered 

• Commence a fluid balance sheet immediately 

• Insert IV cannula. If this is unsuccessful after 2 attempts insert intraosseous 

cannula and commence infusion using the regime below. MO may take / 

request bloods whilst inserting IV / IO for electrolytes, glucose, acid base. See 

Intraosseous insertion 



Fluid resuscitation regime for severe dehydration 

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

Initial treatment 

• 20 mL / kg 

• Reassess 

• Give second bolus of 20 mL / kg if still shocked 

• Ongoing fluids as discussed with MO 

• Re-hydrate / resuscitate severely dehydrated child with normal saline or IV Hartmann’s 

solution only [1] 

• Contact MO for ongoing fluid orders 

• Common IV fluids used in children for ongoing maintenance or replacement include 

normal saline or normal saline + 5% glucose [1] 

Arrangements should be made to transfer child to a paediatric centre. Ongoing fluid input 

should be managed in consultation with a Paediatrician 

5. Follow up 

Evacuation / hospitalisation of children with moderate (if indicated) or severe 

dehydration 

Children with mild dehydration i.e. < 5% and no clinical signs review in 24 hours 

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

Inform the carer that bowel actions may not return to normal for 2 weeks but a 

child with continuing watery diarrhoea should be reviewed by a MO 

Children with watery diarrhoea lasting longer than 2 - 3 days should have bloods 

taken for electrolytes, babies may require this earlier 

Reassurance, education and advice concerning hand washing, personal hygiene, 

avoiding food preparation, and public swimming pools until diarrhoea has settled 

Place child on care plan with individualised review and weighs according to 

severity and family situation 

If diarrhoea continues beyond 10 days. See Child with chronic diarrhoea flow 

chart 

Alert other parents of young children in the community of current gastrointestinal 

illness and the need to present early to clinic if their child displays any gastro- 

intestinal symptoms 

Advise parent / carer(s) [1] 

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

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

be harmful 

• Your baby or child is infectious so wash your hands well with soap and warm water, 

particularly before feeding and after changing nappies 

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

has stopped 

• Return to clinic if: 

-- child is not drinking and still has vomiting and diarrhoea 

-- child is vomiting frequently and seems unable to keep any fluids down 

-- child is dehydrated e.g. not passing urine (< 3 wet nappies), is pale and has lost 

weight, sunken eyes, cold hands and feet, or is hard to wake up 

-- if your child has a bad stomach pain 

-- if there is any blood in the faeces 

-- if there is any green vomit, or you are worried for any other reason 

608 




Nutrition during gastroenteritis 

• Poor appetite is normal during the acute phase of the illness - during this time, ensure 

fluid intake is sufficient as described above 

• Babies and young children who are breastfeeding will want to feed more often when 

they are sick - this is normal. Support mum to breastfeed more frequently 

• Acute gastroenteritis can result in transient lactose intolerance. Formula fed babies 

may need lactose free formulas until the baby’s gut recovers sufficiently to digest 

and absorb lactose 

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

• Breastfeeding should be maintained during the acute phase and through any 

subsequent lactose intolerance. Breastfed babies are fed more frequently than 

formula fed babies and are usually able to tolerate the lactose in the breast milk 

• If the child has an appetite, eating should be encouraged but avoid fatty food or high 

sugar foods and drinks 

Nutrition after gastroenteritis 

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

or older 

• If the child is under one year of age and not breastfed, he / she will need infant 

formula, not cows milk. The type of formula will depend on whether the child can 

tolerate lactose 

• An episode of acute gastroenteritis may result in weight loss 

• For children > 6 months of age, once the child’s appetite returns, encourage carer to 

provide healthy food with one extra meal each day until lost weight is regained 

• Healthy food is important for replacing lean body tissue lost during the illness - 

encourage lean meat, fish, eggs, fruit and vegetables, peanut paste, baked beans, 

cheese and yoghurt, and wholegrain cereals like Weet-Bix ® 

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

intolerance 

• Monitor weekly to ensure healthy growth is resumed 

• Refer to MO if healthy growth is not resumed within four weeks - repeated or chronic 

infections can result in poor appetite and growth failure 


Consult MO immediately as above 

Children with chronic diarrhoea. See Child with chronic diarrhoea flow chart 

Children with weight loss or poor weight gain who are not acutely unwell - refer to 

Child Health Nurse or next MO clinic 

See Poor growth in children in the latest edition of the Chronic Disease Guidelines 

www.health.qld.gov.au/cdg/default.asp 



610 


Lactose intolerance 

Recommend 

Continue breastfeeding (lactase can be tried). For formula fed infants use low lactose 

formula 

Consider other causes of chronic diarrhoea 

Background 

Lactose intolerance commonly follows acute diarrhoea in Aboriginal and Torres Strait 

Islander children 



Failure to thrive 

Nappy rash 

Child with chronic diarrhoea flow chart 


• Chronic diarrhoea, bloating, vomiting, irritability 

• Stool may be “frothy” 

• Perianal area may be scalded 



• Obtain a complete patient history 


-- weigh - use naked weight in young children - record against last recorded 

weight 

• Collect a faeces specimen for MC/S, OCP (ova, cysts and parasites) and reducing 

substances 

• Perform physical examination: See Clinical assessment of hydration in children 

-- palpate abdomen for tenderness or guarding 

-- inspect the perianal area for irritation of area 

4. Management 

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

• Never restrict breastfeeding 

• Encourage extra fluids while the child continues to have diarrhoea 

• Avoid lactose based formulas and cows milk products: 

-- -lactase (Tilactase® [Lacteeze®]) can be used in breastfed infants before, 

during and after a breastfeed, but is not very effective because the enzyme 

takes about 30 minutes to breakdown the breast milk lactose, so there may 

not be enough contact time in the stomach 

-- an infant usually fed on lactose based formula or cows milk should be 

prescribed a low lactose formula as an alternative: De-Lact® or O-Lac® 

-- don’t use soy formulas 

• Reintroduce normal formula after 2 - 4 weeks starting with 1/3 normal to 2/3 

lactose free and increasing the proportion of normal formula over 3 - 4 days 

• If symptoms recur, revert to lactose free formula and try again in 2 - 4 weeks 


5. Follow up 

Review 1 - 2 days after starting on low lactose formula 

Consult MO if diarrhoea persists 

See next Child Health Nurse or MO clinic 


Consult MO on all occasions lactose intolerance suspected 

Dietitian if available 


Giardiasis 

Recommend 

If treatment with tinidazole or metronidazole fails a longer course may be required or 

reconsider the diagnosis 


Anaemia - child Acute gastroenteritis and dehydration 



• Foul smelling watery diarrhoea 

• Chronic diarrhoea, frequent loose and pale greasy stool 

• Abdominal cramps 

• Abdominal distension, flatulence 

• Nausea, poor appetite 

• Anaemia 

• Weight loss / failure to thrive 

• May be asymptomatic 




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

weight 

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


- - assess for dehydration. See Clinical assessment of hydration in children 

-- palpate the abdomen for tenderness or guarding 

-- inspect the perianal area for signs of irritation 

4. Management 

• Encourage oral fluids 

• Treatment of people with asymptomatic passage of cysts is unwarranted unless 

they are a contact of pregnant women or immunocompromised patient 

• Treat with tinidazole or metronidazole if symptomatic, or failure to thrive (it is not 

necessary to wait for laboratory confirmation). If thriving and not unwell treat after 

laboratory confirmation 



Schedule 4 Tinidazole 

DTP 




Form Strength 

Route of 


Recommended 

dosage 

Adult 

2 g 

Duration 

Tablet 500 mg Oral 

Child 


to a max. of 2 g 

Stat 

Provide Consumer Medicine Information: take dose after food. When possible, the tablets should be dosed 

whole as the drug’s taste is very bitter. However, when a part tablet is required, tablets can be crushed. 

The tablets are film coated, so must be peeled then crushed. The appropriate dose can then be weighed 

and mixed with flavouring 


[4] 

612 

• or 

Schedule 4 Metronidazole 

DTP 




Form Strength 

Route of 


Recommended 

dosage 

Duration 

Tablet 

200 mg 

400 mg 

Adult 

2 g daily 

Oral 

Child 

3 days 


30 mg / kg / dose daily 

to a max. of 2 g daily 

Provide Consumer Medicine Information: avoid alcohol while and for 48 hours after taking this drug. Take 

with food or immediately after food 


[4] 

• If the above treatment fails a longer course of metronidazole is sometimes 

required or diagnosis should be reconsidered 

5. Follow up 

Review next day 

Consult MO if diarrhoea not settling 

Provide education and advice concerning handwashing before handling food, 

eating and after toilet; avoiding food preparation and public swimming pools until 

diarrhoea has settled 







Recommend 

Use only pyrantel (Combantrin®) in children under 6 months and in pregnant women 

[7] 

Perform de-worming in three situations: 

-- as part of a community eradication program 

-- symptomatic children 

-- on the basis of faeces specimen result, sent as part of investigation for anaemia 

or weight loss / failure to thrive 


Anaemia - child Failure to thrive 


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

seen (doesn’t cause diarrhoea or failure to thrive) 

• Anaemia - hookworm 

• Acute diarrhoea - strongyloides 

• Failure to thrive - strongyloides can contribute 




-- -past episodes 

-- -previous weights 

-- -length of time signs and symptoms have been present 

-- -do any other members of the family or close contact have signs or symptoms? 

-- -is the child on medication? 

-- -have they been treated for worms? If so when and with what? 


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

recorded weight 

- - check Hb on haemoglobinometer (HemoCue®) 

- - collect a faeces specimen for MC/S and OCP (ova, cysts and parasites). This 

will be repeated as part of follow up 


-- inspect the abdomen for signs of mobility 

-- palpate the abdomen for tenderness or guarding 

-- inspect the perianal / perineal area for signs of irritation (if indicated) 

4. Management 

• Consult MO if abdominal pain present See Abdominal pain 



Treatments for common worms [5] 

Drug Worm 

Pyrantel (Combantrin®) 

Mebendazole (Vermox®) 

Albendazole 

614 

Threadworm (pinworm) 

Hookworm 

Roundworm 


Hookworm 

Roundworm 

Whipworm 


Hookworm 

Roundworm 

Strongyloidiasis 

Whipworm 

Praziquantel 

Beef tapeworm and pork tapeworm 

Dwarf tapeworm 

Ivermectin Strongyloidiasis 

Schedule 2 

Pyrantel embonate 

(Combantrin®) 

DTP 

IHW / IPAP 

Authorised Indigenous Health Workers and Isolated Practice Area Paramedic may proceed 

Form Strength 

Route of 


Recommended 

dosage 

Duration 

Tablet 

Suspension 

125 mg 

250 mg 

50 mg / mL 

Oral 


to a max. of 1 g 

Stat 

Repeat after 7 days if 

heavy infestation 

Provide Consumer Medicine Information: for use in children < 6 months of age and pregnant women 


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

hygiene 

• If treating worms without laboratory confirmation use albendazole or mebendazole 

• If treating after laboratory confirmation of the worm, see table for the preferred 

treatment: pyrantel (Combantrin®), albendazole or mebendazole (Vermox®) 

• If part of a worm eradication program, use albendazole as a single dose every 4 

to 6 months 

• Only pyrantel (Combantrin®) can be used in children < 6 months and in pregnant 

women [5] 

• Albendazole and mebendazole should not be used in children < 6 months or in 

pregnant women [5] 


[5] 



Schedule 4 Albendazole 

DTP 




Form Strength 

Tablet 

200 mg 

400 mg 

Route of 


Oral 

Recommended 

dosage 

Threadworm (pinworm), 

hookworm, roundworm 

Adult 

400 mg 

Child 

≤10 kg give 200 mg 

Strongyloidiasis, whipworm 

Adult 

400 mg daily 

Child 

≤10 kg give 200 mg daily 

Duration 


Stat 

3 days 

Provide Consumer Medicine Information: women should use effective contraception during and one month 

after treatment. To increase absorption for systemic indications i.e. strongyloides, take medication with 

fatty meal. For other indications take on an empty stomach 


[5] 

• or 

Schedule 2 

Mebendazole 

(Vermox®) 

DTP 

IHW / IPAP 

Authorised Indigenous Health Workers and Isolated Practice Area Paramedic may proceed 

Form Strength 

Route of 


Recommended 

dosage 

Theadworm (pinworm) 

Adult 

Duration 

Tablet 100 mg 

100 mg 

Child 

Stat 

Oral 

≤10 kg give 50 mg 

Whipworm, hookworm, 

roundworm 


Adult 

100 mg bd 

Child 

≤10 kg give 50 mg bd 

3 days 



5. Follow up 

See at next MO clinic if anaemia or weight loss / failure to thrive 



[5]


616 


Constipation 

Recommend 

Maintenance programs consisting of medication, toileting program, dietary advice 

and follow up to prevent recurrence 

Background 

Constipation is the difficult passage of infrequent dry, hard stools that often cause 

pain and discomfort. The most common cause is functional - no underlying cause [8] 

Constipation starts a vicious cycle - passing hard stool is painful, so the child avoids 

straining at stool, the constipation gets worse and so on. Part of the battle is forming 

a habit for the child to go to the toilet each day 

Straining is normal in babies 


• Hard stool - often small pellets 

• Excessive straining at stool 

• Soiling (also known as encopresis) 



• Obtain a complete patient history including: 

- - medical history 

- - past episodes 

- - current diet including food allergies [6] 

- - fluid intake - are they breastfeeding or on formula? how is the formula made 

up? (Over concentrated formula can lead to constipation.) Are they given 

water as well? 

- - what / how much is their physical activity? 

- - family routine (the constipated child usually has poor nutrition, poor fluid 

intake and is inactive) 

- - parental expectations of ‘normal’ stool pattern 

- - length of time since last passed a stool / defecated? 

- - describe stool, colour, consistency, frequency of defecation 

- - ask carer if any change in child’s behaviour? 

- - what is there urinary output history? are they bedwetting? daytime wetting? 

- - is the child on medication? 



- - plot growth and height / length 


- - inspect mouth, look for mouth ulcer(s) and state of teeth / gums 

- - inspect and palpate abdomen - for masses 

- - ankle knee reflexes (to assess sacral nerve roots and gait) 

- - inspect the anus and perianal area - position of the anus, pressure of stool 

around anus, perineal sensation, skin tags, anal fissures 

• Consider possible organic problem (and refer for further work up) if: 

-- child has constipation from birth 

-- child has vomiting, and abdominal distension 

-- there is any bile vomiting 

-- the child is not growing well 

-- there is more than just a streak of blood on the stool 

-- constipation does not improve with simple measures 



4. Management 

• Dietary interventions: 

- - encourage a healthy diet with fruit and vegetables and wholegrain cereals 

- - encourage drinking plenty of water 

- - pears (fresh or pureed) or prunes will stimulate the gut gently and soften 

stools 

- - excessive dietary intake can cause constipation in children 

• Encourage physical activity 

• Toileting programs: 

-- -take advantage of the gastrocolic reflex. Most people, especially children 

have the urge to pass a motion after eating a meal, especially breakfast 

-- -advise that the child should sit on the toilet after each meal and attempt to 

pass a motion without straining 

-- -positively reinforce good behaviour. A reward for sitting on the toilet and 

passing a motion is often beneficial 

• Disimpaction: 

-- -oral laxatives 

○ liquid paraffin, chocolate flavoured liquid paraffin i.e. Parachoc. Avoid 

in infants under 12 months of age 

○ lactulose, senna, Movicol Half ® 

-- enemas 

○ micro-enemas such as Microlax® 

• Most constipation in children will resolve with these measures. If it persists, refer 

to the next Child Health Nurse or MO clinic or Continence Advisor 

5. Follow up 

Children with constipation should be reviewed regularly to assess progress. 

Once the problem settles remember to continue with dietary improvement and 

increased water intake to prevent recurrence 

Advise parent / carer to use appropriate gentle fibre or laxative (prune / pear juice 

/ psyllium) for at least 3 months to regulate peristalsis 


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

Child Health Nurse 

Continence Advisor (if available) 

MO may consider referral to a Paediatrician 

Children with chronic constipation require long term management with multiple 

laxatives to keep their stool soft and prevent recurrence of painful anal fissures. 

It is important to ensure observance with laxative regimes 



618 


Pyloric stenosis 

Recommend 

Consult MO immediately 

May need rehydration 

Evacuate for investigation. Will need surgical treatment if diagnosis confirmed 

Background 

Most common in babies between 2 and 6 weeks of age. Rarely occurs after 12 

weeks of age 




• Vomiting which progressively gets worse, projectile, after feeds 

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

• Dehydration 


• Consult MO if child dehydrated 



- - of particular importance progressive increase of projectile vomiting after feeds 

in a baby that is usually well and eager to feed following the vomiting episode 





-- -inspect and palpate abdomen 

• Visible peristalsis over the abdomen or an olive-sized and shaped mass may be 

felt in the right upper quadrant 

• Assess degree of dehydration. See Acute gastroenteritis and dehydration 

4. Management 

• Consult MO who may advise 

-- checking electrolytes (U/E) 


-- IV fluids 

-- abdominal ultrasound examination 

5. Follow up 

All babies with suspected pyloric stenosis must be managed in hospital. Diagnosis 

is usually confirmed by ultrasound. If confirmed the baby will require surgery, 

which is very successful 


Consult MO on all occasions of suspected pyloric stenosis. These infants may 

present with severe acid base imbalance such as hypokalaemia 



Intussusception 

Background 

Suspect in a young child who looks unwell and has intermittent severe abdominal 

pain 

In 15 % of cases the classic triad of abdominal pain, palpable sausage shaped 

abdominal masses and red currant jelly stool is present. The small bowel telescopes 

into itself (as if it were swallowing itself) 

Most common cause of obstruction in children 6 - 36 months of age (60%


620 



Recommend 

Refer to Poor growth in children care plan in the latest edition of the Chronic Disease 

Guidelines www.health.qld.gov.au/cdg 

MO / Dietitian to perform complete examination and calculate the degree of failure to 

thrive - mild, moderate or severe, using weight for age, and weight for height, for Z 

score 

Provide nutritional supplements for management of failure to thrive depending on 

severity 

It is important in an underweight child to differentiate wasting (thin child) of acute 

failure to thrive from stunting (short child) due to chronic failure to thrive. Often both 

are present, and can be assessed on anthropometric measurements of weight and 

height for age and sex 

Background 

Suite of Growing Strong resources available at: 

www.health.qld.gov.au/ph/documents/hpu/growingstrong.asp 

Failure to thrive (FTT) refers to child whose weight is less than normal for gestational 

corrected age / gender and past medical history. Children with genetic short stature, 

intrauterine growth retardation or prematurity, who have appropriate proportional 

weight for length and normal growth velocity, are not regarded as FTT 


Anaemia 

Giardia 


Lactose intolerance 

Urinary tract infection - child 


• Any condition 

• A child whose weight has crossed down 2 or more major centile lines on standard 

growth charts (and who is not overweight or obese) [7] 




- - family and social history - spend time assessing the social situation: 

○ who is the main carer? which other family members contribute to looking 

after the child, household and buying food? 

○ amount of support the carer has? extended family? friends? 

○ have other children in the family had problems with growth faltering? 

○ ask about food security, financial security? 

- - cultural history 

- - medical history - past or current illnesses 

- - birth history - low birth weight (preterm or IUGR) 

- - mother’s antenatal history - particularly alcohol and smoking intake 

-- nutrition intake - if breastfed, frequency of feeding during night and day, if 

formula fed when did the formula start? how is it prepared? other milks or 

drinks? 

- - solids, type - when were solids introduced? frequency of feeding? 

- - eating pattern 

- - urine output and number of stools per day 




- - urinalysis 

-- check haemoglobin on haemoglobinometer (HemoCue®) 

- - collect stool specimen for lactose intolerance testing 

• Perform a complete physical examination: 

-- head to toe assessment of current state of health, looking for evidence of 

undetected illness 

- - do naked weigh, check length and head circumference - plot growth chart 

It is important in an underweight child to differentiate wasting of acute FTT from stunting 

due to chronic FTT - often both are present 

A child with stunting may look healthy. It is important to measure and assess the child's 

growth on a growth chart to identify stunting 

4. Management 

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

• Depending on severity of FTT commencement of: 

-- nutritional supplements such as Pediasure® 

-- food prescription 

• Multivitamins are only required


622 

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

Food prescription 

Drinks 

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

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

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

Food 

• Meals - breakfast, lunch, dinner, snacks containing fruit, vegetables 

5. Follow up 

Place child on individualised care plan, setting out actions, targets and who is 

responsible to closely provide: 

- - social support 

-- set actions / targets for weight gain. See Chronic Disease Guidelines at: 


- - regular monitoring of growth with child’s carer 

Appropriate nutritional needs for child as recommended by Dietitian, MO or Child 

Health Nurse / Child Health - Health Worker. Often children with FTT lose their 

appetite and are unable to meet their nutritional requirements without additional 

strategies in place. Advice needs to be given to carer’s beyond just what healthy 

foods are. Carers need to know which foods are appropriate for FTT and also 

how often, the amount of food and how to fortify breast milk / foods / drinks 


Consult MO. Child may need hospitalisation 

Child development unit for developmental screening of gross and fine motor, 

language and social milestones 

Dietitian to conduct thorough diet history, feeding history and nutrition advice 

May need referral to a community based specialised nutrition program e.g. Mum’s 

and bubs 

See current edition of Chronic Disease Guidelines at: 


Recommend 

Aim to achieve haemoglobin level above 110 g / L [8] 

Treat with iron 

- - babies aged 6 -12 months with haemoglobin < 105 g / L 

- - children over 1 year of age with haemoglobin < 110 g / L 

Consult MO immediately 

- - if any child has haemoglobin < 80 g / L 


- - if child has haemoglobin 80 -100 g / L 

Suite of Growing Strong resources, especially iron rich food available at: 

www.health.qld.gov.au/ph/documents/hpu/growing_strong.asp 

Regular calibration of haemoglobinometer (HemoCue®) 


Anaemia - child 



Background 

Nutrient requirements are very high in young children, especially for iron between 

the ages of 6 months and 24 months 

Anaemia is common in Aboriginal and Torres Strait Islander children particularly in 

the 6 to 30 months age group 

Childhood anaemia is more likely if mother had low iron status or was anaemic in 

pregnancy and/or if baby was premature or low birth weight 

Anaemia is largely due to dietary deficiency in iron and / or folate and the inhibitory 

effects of infestations and infections 

There are higher rates of iron deficiency and anaemia in infants and toddlers where 

high cows’ milk intake is encouraged or allowed [11] 

Failure to thrive may or may not co-exist 

Overweight and obesity may or may not co-exist 

Iron deficiency of any degree affects child development 


Giardia 




• Almost always asymptomatic 

• Low haemoglobin detected on haemoglobinometer. Re-check if any doubt 

• Tiredness, lethargy 

• Recurrent infections 

• Occasionally pica (eating substances not fit as food) 

• Loss of appetite 




- - family and ethnic history (different types of anaemia caused by production 

and life of red blood cells) 

-- social history. Spend time assessing the social situation 

○ who is the main carer? 

○ which other family members contribute to looking after the child, 

household and buying food? 

○ amount of support the carer has? extended family? friends? 

○ have other children in the family had problems with anaemia? 

- - cultural history 

- - medical history - past or current illnesses 

- - current medications - Pentavite® or iron liquid? 

- - birth history - low birth weight (preterm or IUGR) 

- - mother’s antenatal history 

- - nutrition intake, breast or formula fed or both - when did formula start? what 

type of milk is child drinking? cows milk? 

- - solids, type - when were solids introduced? 

- - eating pattern 

- - urine output / number of stools per day 


-- urinalysis 





624 

-- check length and do head circumference and plot against growth chart 

- - check haemoglobin on haemoglobinometer (HemoCue®) (if not already 

done) 

- - collect stool for lactose intolerance testing 

• Perform a complete physical examination: 

-- -from head to toe assessing current state of health and looking for evidence of 

undetected illness 

4. Management 

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

problematic as child is often asymptomatic. Do not give during diarrhoeal illness. 

Parents to be advised about the risk of iron ingestion by children and to store 

safely out of reach) 

• Treat with IM ferrum H if family unable to give oral iron or child will not take oral 

iron: 

- - babies aged 6 - 12 months with haemoglobin

Schedule 2 Folic Acid 


DTP 

IHW / IPAP 


Form Strength 

Tablet 

500 

microgram 

5 mg 

Route of 


Oral 



Recommended 

dosage 

Child 

0.5 mg / kg / dose daily 

to a max. of 5 mg daily 

Duration 

Long term according 

to response on MO / NP 

order 

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

foods, healthy food and drinks and many more available at: 

www.health.qld.gov.au/ph/documents/hpu/growingstrong.asp 

• Recommend breastfeed exclusively for first 6 months 

• Appropriate iron rich first foods at around 6 months 

-- -foods rich in iron and or folate: 

○ red meat, beef / lamb liver or kidneys, bush meat 

○ chicken, fish 

○ egg yolks 

○ iron fortified baby cereal 

○ green vegetables 

○ fruit and vegetables (to help iron absorption) 

○ breast milk or infant formula (NOT normal cow or goat milk unless over 

1 year of age) 

○ No turtle or dugong liver or kidneys or intestines - as concern about 

cadmium content 

○ No cows milk or Sunshine® milk before 1 year old 

○ No tea or coffee 

○ No soft drink, juice or cordial 

5. Follow up 

Place child on individualised care plan, setting out actions, targets and who is 

responsible to closely provide ongoing support and monitoring 


Consult MO or see next MO clinic as above 

Refer to Dietitian for diet history, feeding history and nutrition advice 

Refer to Child Health Nurse / Child Health - Health Worker 

Repeat FBC after 1 month of iron and / or folate to confirm response to treatment 

If a response is demonstrated with iron and / or folate supplements, continue for 

several months 

Check haemoglobin monthly until it is >110 g/L 


[10]


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

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

Ventrogluteal injection according to Hochstetter is recommended in the top outer quadrant of the 

2. 

gluteus maximus muscle 

The site of injection is determined as follows. First point A is found, corresponding to the ventral iliac 

spine. If the patient lies on the right side, for instance, the middle finger of the left hand is placed on 

3. point A. The index finger is extended away from the middle finger, so that it comes to lie below the iliac 

crest, at point B. The triangle lying between the proximal phalanges of the middle and index fingers 

represents the site of injection. This is disinfected in the usual way 

Before the needle is inserted, the skin over the site of injection is pulled down, about 2 cm, to give 

4. an S-shaped puncture channel. This prevents the injected solution from running back into the 

subcutaneous tissues and discolouring the skin 

The needle is introduced more or less vertically to the skin surface, angled to point towards the iliac 

5. 

crest rather than the hip joint 

After the injection, the needle is slowly withdrawn and pressure from a finger applied beside the 

6. 

puncture site. This pressure is maintained for about one minute 

7. The patient should move about after the injection 

[11] 

Schedule 4 

626 

Form Strength 

Ampoule 

100 mg / 2 mL 

50 mg / mL 

Route of 


IM 

Iron polymaltose 

(Ferrum H®, Ferrosig®) 


Recommended 

dosage 

< 5.0 kg 0.5 mL / day 

5 - 10 kg 1.0 mL / day 

>10 kg - 45 kg 2.0 mL / day 

Formula for calculating iron injection dose 

Weight x (125 - Hb in g/L) x 0.3 = mL required (50 mg / mL) 

Total dose (may be over several days) 

Non DTP 

Must consult MO / NP 

Duration 

Stat 

or alternate days 

Weight (kg) Hb 75 g / L Hb 90 g / L Hb 105 g / L 

5 3 mL 3 mL 2 mL 

10 6 mL 5 mL 4 mL 

15 9 mL 7 mL 6 mL 

20 11 mL 10 mL 8 mL 

25 14 mL 12 mL 11 mL 

30 17 mL 15 mL 13 mL 

35 23 mL 20 mL 18 mL 

40 24 mL 22 mL 19 mL 

45 26 mL 23 mL 20 mL 

Provide Consumer Medicine Information: the wrong injection technique may result in pain and persistent 

discolouration of the skin. Iron polymaltose should never be injected into the arm or other exposed areas 


[9] 


Urinary tract problems 

References 

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

au/clinicalguide/cpg.cfm?docid=12364#degree 

2. Dunia A., Al-Hakima H., and Fedorowicz Z. Antiemetics for reducing vomiting related to acute 

gastroenteritis in children and adolescents. Cochrane Database of Systemic Reviews 2009 [cited 2011 

February]. 

3. The Children’s Hospital at Westmead Sydney Children’s Hospital Randwick & Kaleidoscope * Hunter 

Children’s Health Network, Fact Sheet Gastroenteritis. 2010. 

4. Therapeutic Guidelines. Giardia lamblia (intestinalis) (acute giardiasis). 2006 [cited 2011 February]. 

5. Therapeutic Guidelines. Worms (helminths). 2006 [cited 2011 March]. 

6. IMPACT Paediatric Bowel Care Pathway, A Guide to the Management of Constipation and Faecal 

Impaction in Children 2006: Australia. 

7. American Academy of Pediatrics Committee on Child Abuse and Neglect and the Committee on Nutrition, 

Robert W Block., and Nancy F Krebs., Failure to Thrive as a Manifestation of Child Neglect. Pediatrics, 

2005. 116 

8. The World Health Organization, Iron deficiency anaemia, assessment, prevention and control. A guide 

for program managers. 2001, WHO: Geneva. 

9. Therapeutic Guidelines. Iron deficiency. 2006 [cited 2011 March]. 

10. Australian Medicine Handbook. Folic acid. 2011 [cited 2011 March]. 

11. MIMS Online. Ferrum H Injection. 2008 [cited 2011 March]. 

Urinary tract infection - child 

Recommend 

Definitive diagnosis of urinary tract infection (UTI) by urine culture collected in a sterile 

fashion - mid stream urine (clean catch), supra pubic aspiration, catheter specimen 

[1] 

Finding a UTI in a sick child does not rule out other sources of infection so keep 

looking e.g. meningitis [1] 

Some children require further imaging of renal tract depending on age 

Background 

Collection of urine in a paediatric bag can only be used for dipstix testing. It has poor 

sensitivity and specificity [1] 

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

Children with UTI commonly have acute pyelonephritis and particularly in infants, it is 

difficult to distinguish between cystitis and pyelonephritis [2] 

1. May present with [3] 

Infant younger than 3 months 

• Most common 

- - fever 

- - vomiting 

- - failure to thrive 

- - diarrhoea 

- - poor feeding 

• Least common 

-- abdominal pain 

- - jaundice 

- - haematuria 

- - offensive urine 



628 

Infants and children 3 months or older (preverbal) 


-- -fever 

-- -abdominal pain 

- - loin tenderness 

-- vomiting 

- - poor feeding 


-- irritability 

-- -haematuria 


-- failure to thrive 

Infants and children 3 months or older (verbal) 


-- frequency 

- - dysuria 

- - dysfunctional voiding e.g. bed wetting 

- - changes to continence patterns 

- - loin tenderness 


-- fever 

- - malaise 

- - haematuria 


- - cloudy urine 




- - medical history 

- - is this the first UTI? have there been past episodes? 

- - does the child look unwell / septic? 

- - is there vomiting present? diarrhoea? 

- - how is the child’s appetite? what and how much are they eating and drinking? 

- - has the carer noticed anything such as strong urine odour, colour of urine, 

child passing urine frequently? or child crying when passes urine? 


-- assess growth and plot against chart for age and sex 


-- inspect and palpate head to toe looking for other signs of infection 

- - palpate the abdomen, supra-pubic area and loin - is there tenderness? 

• Collect urine - always write the method of collection on the pathology form 

- - clean catch midstream urine 

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

Method 

○ wash genitalia with water and dry 

○ have the child pass the first few mL in the toilet 

○ catch the rest of the specimen in a sterile container 

- - catheter specimens 

○ for children too young to obtain clean catch and with a high probability 

of UTI 




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


- - supra-pubic aspiration 

○ supra-pubic aspirates are the gold standard for obtaining urine specimens 

for culture - age limit (best) to 6 months but can try up to 12 months of age 

(contraindications include bleeding tendencies, abdominal distension 

and enlarged organs) [1] 

- - bag urine 

○ can never prove a UTI on a bag sample 

○ can use specimen for dipstick urinalysis - nitrates are the most sensitive 

for UTI 

○ can be used to rule out a UTI (if correctly applied urine bag specimen is 

negative on dipstick urinalysis) see below 

• Assessment of dipstick urinalysis 

- - If urinalysis is positive for nitrites UTI is likely - it would be reasonable to 

commence treatment 

- - If urinalysis is positive for leucocytes but negative for nitrates, UTI is possible 

- wait for culture result before starting treatment 

- - If blood and / or protein are positive but leucocytes and nitrates negative then 

UTI is unlikely 

4. Management 

• Consult MO who will arrange / refer / discuss: 

-- infants < 3 months of age with Paediatric Unit. UTI and

Bone and joint problems 

630 


Routine prophylaxis is no longer recommended [1] 


Consult MO on all occasions of suspected UTI in children 

All children with confirmed UTI require referral to Paediatrician 

All children < 6 months of age should have a renal ultrasound 

Consider renal ultrasound for older children with first UTI [1] 

Micturating cysto-urethrogram (MCU) or nuclear medicine scan may be necessary 

but the decision to perform this needs to be individualised in consultation with 

Paediatrician [1] 

References 

1. The Royal Children’s Hospital Melbourne. Urinary Tract Infection Guideline. 2008 [cited 2011 January]; 

8th edition: Available from: www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5241. 

2. Therapeutic Guidelines. Urinary tract infections: children 2010 [cited 2011 January]. 

3. NHS choices. Urinary tract infection, children. 2010 [cited 2011]; April]. Available from: www.nhs.uk/ 

Conditions/Urinary-tract-infection-children/Pages/Symptoms.aspx. 

4. Royal Children’s Hospital, AntibioCard. 2011: Brisbane. 

Bone or joint infections - child 

Osteomyelitis and septic arthritis 

Recommend 

Referral to Orthopaedic Specialist if suspected osteomyelitis / septic arthritis [1] 

An important consideration if a skin infection is taking a long time to resolve, or 

occurs over a joint 

Background 

Osteomyelitis and septic arthritis can affect any joint or bone, but most commonly 

involve the lower limbs [1] 

Polyarthritis or aseptic monoarthritis or polyarthralgia, usually migratory (finishes in 

one joint and then begins in another) is a major manifestation of acute rheumatic 

fever (ARF) [2] 



Acute rheumatic fever (ARF) 


Osteomyelitis 

• Subacute onset of limp / nonweight 

bearing / refusal to use limb 

• Localised pain and pain on 

movement 

• Tenderness 

• Soft tissue redness / swelling may 

not be present and may appear 

late 

• + / - fever 




Septic arthritis 

• Acute onset of limp / non-weight 

bearing / refusal to use limb 

• Pain on movement and at rest 

• Limited range / loss of movement 

• Soft tissue redness / swelling often 

present 

• Fever 


Bone and joint problems 


• Obtain complete patient history including: 

-- past episodes 

-- does the patient have pain? ask them to rate? 

-- when does it hurt? at rest? on movement? 

-- has there been any recent trauma? 

-- has the patient any skin infections currently or recently? 

-- history of acute rheumatic fever 

-- current medications taken 



-- note patient on presentation - do they walk in? limp? hop? lean on another 

person? hold their arm to chest? 

-- inspect joints - is there any swelling, redness? 

-- allowing for pain levels check the range of movement in affected joint 

-- palpate the joint - is the joint warm to touch? is there tenderness? 

4. Management 

• Consult MO who will arrange: 


-- referral to Orthopaedic Specialist 

-- FBC, ESR, blood cultures 

-- may order x-ray 

-- IV antibiotics 

• Rest and immobilise limb [1] 

• Treat pain and fever with paracetamol 


5. Follow up 

All children with suspected osteomyelitis or septic arthritis should be managed in 

hospital 


Consult MO on all occasions of suspected osteomyelitis and septic arthritis 

Refer to Orthopaedic Specialist if osteomyelitis / septic arthritis is suspected or 

confirmed [1] 

References 

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

Available from: www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5234. 

2. National Heart Foundation, RF / RHD Guideline Development Working Group, and Cardiac Society of Australia and 

New Zealand, Diagnosis and management of acute rheumatic fever and rheumatic heart disease in Australia: An 

evidence based review. 2006, National Heart Foundation Australia. 


Abuse and neglect 

632 


Abuse and neglect - child 

Recommend 

Do not ask child leading questions - this may taint evidence. If the child volunteers 

information, write it down 

Document injuries well using a body chart 

In some circumstances e.g. child sexual assault (CSA), examination is best done 

once. The best person to perform examination following CSA is usually a Paediatrician 

or MO specialising in child sexual abuse or Forensic MO. Assessment of CSA is 

complex and requires multi-agency investigation. A Child Protection Advisor (CPA) 

should be consulted 

Queensland legislation stipulates that all MO and RN (both public and private 

sector) are mandated to report concerns to the Department of Communities Child 

Safety Services, regarding children about whom they hold a reasonable suspicion of 

significant harm or risk of significant harm 

In addition it is Queensland Health policy that all health professionals have a duty of 

care to report reasonable suspicion of child abuse and neglect to the Department of 

Communities Child Safety Services [1] 

Do not request STI tests in an asymptomatic child as the initial response to a suspicion 

of sexual abuse 

If there is a suspicion of sexual abuse, please report as indicated above 

There is no screening test for child abuse - informed vigilance is required 

Background 

Under legislation staff do not breach professional ethics and are not liable under civil 

or criminal processes if the report is made in good faith and on reasonable grounds 

[1] 

Relevant provision is made under legislation for information sharing to prevent 

serious risk to life, health or safety [1]. 


Rape / sexual assault 


When considering if there is a reasonable suspicion of abuse or neglect, it is important 

to identify significant harm or risk of significant harm and how that is linked to actions 

or inactions of the parent 


• Physical abuse - injuries which don’t fit child’s developmental level or description 

provided by parent, punching, slapping, kicking, shaking, biting, applying physical 

‘discipline’ or ‘punishment’ causing harm or injury. Patterned injuries including 

burns and bruises 

• Emotional or psychological abuse - constant criticism, scapegoating, namecalling, 

belittling, excessive teasing, ignoring, punishing normal behaviour, 

exposure to domestic and family violence, withholding praise and affection 

• Neglect - failing to meet the child’s basic needs for adequate supervision, food, 

clothing, shelter, safety, hygiene, medical care, education, love and affection and 

failure to use available resources to meet those needs 

• Sexual abuse or exploitation - pregnancy, STI, disclosure of abuse, behaviour 

change, sexualised behaviour, any sexual act or sexual threat imposed upon a 

child including exposure, indecent phone calls, voyeurism, persistent intrusion of 

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

prostitution 




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

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

3. Assessment 

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

- - signs - injuries 

-- symptoms 

-- behaviours 

-- and occasionally disclosures 

4. Management 

• Treat all physical injuries appropriately 

• Thoroughly document any injuries using body charts 

• Document any disclosures using exact quotes as well as recording what question 

was asked before the disclosure. Be careful not to ask leading questions 

• If you have concerns regarding the injuries and the cause of the injury, or any 

other factor as outlined, it is recommended that you obtain advice / consult with 

line manager, Senior Health Worker, Director of Nursing, CPA / CPLO / MO 

• Consult MO who may need to arrange evacuation 

• If there is reasonable suspicion of child abuse or neglect, RN and MO are 

mandated to make a report immediately to Regional Intake Services and complete 

the process as per Queensland Health policy. See qheps.health.qld.gov.au/csu/ 

reportingforms.htm 

• How to make a report to Child Safety Services 

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

(RIS) to make a verbal report 

2. After hours - telephone Child Safety After Hours Service Centre 1300 681 

513 Fax: 3235 9898 

3. Complete the ‘Report of Reasonable Suspicion of Child Abuse and Neglect’ 

Form (SW010) 

4. Fax a copy of the Report Form to the RIS that received your verbal report 

within 7 days 

5. File the original copy of the Report Form in the correspondence section of 

the child’s hospital record 

6. Forward the yellow copy of the Report Form to your District CPLO, contact 

details are available on the QHEPS site qheps.health.qld.gov.au/csu/ 

districtcpacplo.htm 

Regional Intake Service Phone number Fax number 

South East 1300 678 801 3884 8802 

South West 1300 683 259 4616 1796 

Far North Queensland 1300 683 596 4039 8320 

North Queensland 1300 704 514 4799 7273 

North Coast 1300 705 201 5420 9049 

Brisbane 1300 705 339 3259 8771 

Central Queensland 1300 683 042 4938 4697 



5. Follow up 

Staff may be requested to provide relevant information to the Department 

of Communities Child Safety Services or other prescribed entities. If staff are 

unsure regarding information sharing request consultation with district medicolegal 

services is recommended 

Document in the client record accurate, considered, objective and up to date 

account of concerns, consultations, contacts, actions and plans related to 

presentation as these may be requested 

Ensure all information relating to the child, including immunisation status, is 

current 


Consult MO. Child may need evacuation 

Refer parent / carer to Social Worker, non government agencies or other support 

services depending on availability or Parentline 1300 301300 

When considering management of children who have been abused or at risk of abuse, it 

can be helpful to consider the following factors. Note: it is not the role of the MO to make a 

full assessment of risk and protective factors. If abuse is suspected it must be reported to 

Department of Communities - Child Safety Services, to investigate further 

Risk factors and protective factors associated with child abuse and neglect 

• Protective indicators are safety factors that may reduce the likelihood of harm or risk 

of harm to a child. They are characteristics that prevent or balance risk-producing 

conditions [1] 

• The presence of risk factors does not confirm abuse or neglect. They are common 

features of families, parents or caregivers, children and environments that research and 

clinical experience have shown to increase the likelihood of child abuse and neglect [1] 

It is important to remember factors need to be considered in the context of a child’s personal 

history. For more detail See Protecting Queensland Children: Policy Statement and 

Guidelines on the management of child abuse and neglect in children and young people 

0 - 18 years www.health.qld.gov.au/csu/policy.htm [1] 

Resources 

• Queensland Health, Child Health and Safety Unit 

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

• Department of Communities Child Safety Services 

www.childsafety.qld.gov.au 

• Commission for Children, Young People and Child Guardian 

www.ccypcg.qld.gov.au/index.aspx 

• NSW Department of Community Services 

www.community.nsw.gov.au/preventingchildabuseandneglect/ 

reportingsuspectedabuseorneglect.html 

132 111 (24 hours) 

• Victorial Office For Children 

www.education.vic.gov.au/officeforchildren 

131 278 (24 hrs) 

References 

1. Queensland Health. Protecting Queensland Children: Policy Statement and Guidelines on the 

management of child abuse and neglect in children and young people (0-18 years). 2008 [cited 2011 

January]; Available from: www.health.qld.gov.au/csu/policy.htm. 

2. Queensland Government. What is child abuse? 2008 [cited 2011 January ]; Available from: www. 

childsafety.qld.gov.au/child-abuse/index.html 

634

Paediatrics - Queensland Health - Queensland Government

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