Paediatrics - Queensland Health - Queensland Government
Paediatrics - Queensland Health - Queensland Government
Paediatrics - Queensland Health - Queensland Government
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Section 6<br />
<strong>Paediatrics</strong>
Paediatric presentation<br />
Section 6.<br />
<strong>Paediatrics</strong><br />
Contents<br />
• History and physical examination - child<br />
• Child with fever<br />
• Child with cough<br />
• Child with stridor<br />
• Child with vomiting<br />
• Child with abdominal pain<br />
• Child with chronic diarrhoea<br />
• Meningitis<br />
• Respiratory problems<br />
• Immune complications<br />
• Ear problems<br />
• Gastrointestinal problems<br />
• Urinary tract problems<br />
• Bone and joint problems<br />
• Abuse and neglect - child<br />
544<br />
Examples of positioning of children<br />
for examination of throat and ears<br />
Controlled copy V1.0<br />
Primary Clinical Care Manual 2011
Paediatric presentation<br />
History and physical examination<br />
child<br />
Recommend<br />
Use of Children’s Early Warning Tools (CEWT) appropriate to age for rural and remote<br />
facilities ordered through: qheps.health.qld.gov.au/psq/rmdp/html/rmdp_homepage.<br />
htm or by email at: RMDP@health.qld.gov.au<br />
Consult MO immediately about any baby under 3 months of age who is at risk<br />
or febrile<br />
Always check the immunisation status of children at every opportunity<br />
Believe the child or parent / carer: no matter the time of day or night or the circumstance,<br />
make sure the patient and their parent / carer feels he or she has been listened to<br />
and done the right thing in bringing the child regardless of the concern<br />
Background<br />
Small children, especially young babies, get sick very quickly<br />
Risk signs in children are:<br />
-- temperature > 38°C or < 35.5°C<br />
-- irritability<br />
-- high pitched cry or weak cry<br />
-- drowsiness<br />
-- decreased activity<br />
-- reduced feeding<br />
-- breathing fast / noisy, respiratory distress, apnoea<br />
-- persistent vomiting<br />
-- dehydration (< 4 wet nappies in 24 hours)<br />
-- sunken eyes<br />
-- cold extremities<br />
-- capillary refill > 2 seconds<br />
-- uses eyes (rather than head) to follow you<br />
-- abdominal distension<br />
Other high risk children include those with:<br />
-- lots of diarrhoea (> 8 watery stools in 24 hours)<br />
-- congenital or chronic disease e.g. cardiac, gastrointestinal, neurological<br />
-- where social conditions are concerning and / or where parents may have difficulty<br />
managing at home<br />
-- a history of repeated or prolonged separations from their primary caregiver(s)<br />
-- psychosocial risk factors including family violence, poverty, homelessness,<br />
parents with intellectual disability or mental health problems<br />
Related topics<br />
Immunisation program<br />
Patient presentation and assessment<br />
DRS ABCD resuscitation / the collapsed patient<br />
Assessment and physical examination of skin,<br />
hair and nails<br />
Assessment of the eye<br />
Assessment of ear<br />
Abuse and neglect - child<br />
Mental health assessment<br />
Medication reconciliation<br />
Medication history checklist<br />
Glasgow Coma Scale / AVPU<br />
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Paediatric presentation<br />
Standard clinical observations and other vital signs - child<br />
Approximate normal physiological ranges for a child<br />
Parameter<br />
Normal range<br />
12 years<br />
HR<br />
(beats per min)<br />
110 - 160 100 - 150 95 - 140 80 - 120 60 - 100<br />
Respiration rate<br />
Standard clinical (breaths / min)<br />
30 - 40 25 - 35 25 - 30 20 - 25 15 - 20<br />
observations<br />
Axilla - clinically significant fever > 37.8°C (37.2°C *)<br />
Temperature<br />
Sublingual - clinically significant fever > 38.0°C (37.5°C *)<br />
Rectal - clinically significant fever > 38.5°C (38.0°C *)<br />
* clinically significant fever lower in infants < 3 months of age<br />
Blood pressure Systolic > Systolic > Systolic > Systolic > Systolic ><br />
(mmHg)<br />
60 70 75 80 90<br />
Respiratory<br />
distress<br />
Nil<br />
Other vital signs<br />
if indicated<br />
546<br />
O 2 saturation (%) > 95%<br />
Capillary refill time Less than or equal to 2 secs<br />
Level of<br />
consciousness<br />
Blood glucose<br />
level<br />
Glasgow coma scale 15<br />
AVPU tool - alert<br />
4 - 8 mmol (random capillary)<br />
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[1] [8]<br />
Pain assessment in a child<br />
Rate pain level in children using faces, numbers and behavioural observations. Physiological<br />
changes e.g. altered HR, RR, BP are not good indicators to use in isolation [2]. Non - verbal<br />
children are very vulnerable to having their pain under estimated [2]<br />
• Refer to Children’s Early Warning tools (CEWT) for pain assessment tools<br />
Pain rating scale for children<br />
Primary Clinical Care Manual 2011
Paediatric presentation<br />
Presentation<br />
• When a child presents for health care the clinician is required to gather an orderly<br />
collection of information to identify the patient’s health status. The following is essential<br />
to achieve this:<br />
-- taking a patient history<br />
-- performing standard clinical observations and other vital signs<br />
-- perform physical examination<br />
-- using diagnostic and pathology services, and<br />
-- collaboration with other members of the team<br />
-- note: not all children are at the same stage of development in areas of physical,<br />
cognitive and psychosocial development<br />
• It is a requirement that all clinicians document their findings in a clear and concise way.<br />
This section is set out to assist. It is recommended the page number of HMP / CCG is<br />
referred to in the documentation<br />
Types of history<br />
There are four types of history taking [3] See History and physical examination - adult<br />
History taking<br />
• The purpose of a full history is to ascertain the cause of the child's illness. A careful<br />
history will make the cause clear in the vast majority of cases.<br />
• The first priority is to assess whether the child is:<br />
-- seriously ill and needs immediate management or,<br />
-- is a non urgent presentation, and there is time for a complete patient history and<br />
health education<br />
• Obtaining a full history is done in conjunction with examining the patient<br />
-- In a sick child this entails a full assessment of all systems<br />
-- In a child who has a localised problem it is reasonable to examine the relevant<br />
system only. However, always be guided by the history and be prepared to examine<br />
other systems as necessary. This is particularly important for children who often<br />
present with generalised symptoms and signs<br />
-- Ask open ended questions<br />
-- Believe the carer<br />
Presenting concern<br />
• Ask the child or carer what the problem is<br />
• Ask about length of illness and exact details of symptoms and signs. For each symptom<br />
the following details are important [4]<br />
Site - where is the pain / symptom? does it go anywhere else?<br />
Onset - when did it start, gradual or sudden onset?<br />
Character e.g. sharp, dull or burning<br />
Radiation - does the pain radiate anywhere else?<br />
Alleviating factors - what makes it better e.g. sitting up, medicines?<br />
Timing - how long did it last, have they had it before?<br />
Exacerbating factors - what makes it worse?<br />
Severity - mild, moderate or severe pain. Pain score 0 - no discomfort to 10 - unbearable<br />
pain or use facial diagrams<br />
• Any associated symptoms e.g. nausea, vomiting, photophobia, headache<br />
-- always ask specifically about fever, pain, shortness of breath / rapid breathing,<br />
diarrhoea and / or weight loss, rash<br />
• Behaviour and activity during this illness<br />
-- is the child active / alert, sleepy or irritable? easy / difficult to wake?<br />
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Paediatric presentation<br />
• Appetite and fluid intake / output during this illness<br />
-- try to be as precise as possible with quantities<br />
-- how many drinks / breastfeeds?<br />
-- how alert during feeds?<br />
-- how long between intake and vomit? / diarrhoea?<br />
-- how many wet nappies or times passed urine in preceding 24 hours?<br />
-- amount / type bowel movements<br />
• Treatment and / or medication given by carer during this illness?<br />
-- what, how much, when, how often, how effective?<br />
Past history<br />
Past medical and<br />
surgical history<br />
Family and social<br />
history<br />
548<br />
• Was delivery normal and were there any immediate neonatal problems?<br />
• Any problems with growth and development?<br />
• Significant illnesses in the past? What and when?<br />
• Hospital admissions? Why and when?<br />
• Operations or injuries? What and when?<br />
• Mothers alcohol history during pregnancy?<br />
• <strong>Health</strong> problems in the family - especially siblings and parents<br />
• Who looks after the child, what is the social situation?<br />
• Mental health problems in carers / child?<br />
• Household smokers?<br />
• Recent contacts or trips away<br />
• If medicines are given, will they be taken?<br />
Medications • Regular medicines (prescribed, herbal, bush medicines, over the counter)<br />
generic name(s), dose, frequency?<br />
• Are they taken correctly?<br />
• May need to ask about other medicine(s) in the home the child may have<br />
taken<br />
• See Medication reconciliation / Medication history checklist for more details<br />
Allergies • Adverse drug reactions:<br />
-- adverse reactions / allergies to medicines?<br />
-- attach “adverse drug reaction” sticker to medication chart if required<br />
• Allergens e.g. bee stings, tapes, sticking plaster, nuts:<br />
-- specific reaction e.g. skin reaction, bronchospasm<br />
-- is an Epi-pen® / medication used to treat the allergy?<br />
Immunisations • Check if up to date<br />
• Documented evidence of immunisation status should be obtained, follow<br />
up with opportunistic immunisation See Immunisation program<br />
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Primary Clinical Care Manual 2011
Paediatric presentation<br />
Standard clinical observations<br />
All children • Temperature, HR, respiratory rate<br />
presenting for • If indicated:<br />
acute care<br />
-- -- O saturation<br />
2<br />
BP<br />
○ is not usually needed<br />
○ ensure correct sized cuff - must be wider than 2/3 the length of upper arm<br />
-- blood glucose level (BGL)<br />
○ indications include altered level of consciousness / seriously ill children<br />
-- conscious level - GCS / AVPU<br />
-- capillary refill<br />
-- weight<br />
See Standard clinical obervations and vital signs - child, Glasgow Coma Scale / AVPU<br />
Physical examination<br />
• May be best done with the child on the carer’s knee. If the child is irritable perform<br />
the examination opportunistically i.e. do what you can when you can. Leave the most<br />
disruptive parts (ears and throat) until last<br />
• In general, examination of a child is not a good screening test. Use the history<br />
to guide you to areas where you think you will find an abnormality<br />
• In any sick child a thorough and complete examination is required. All clothing will<br />
need to be removed at some stage during the complete examination<br />
• In a child who is not sick, examine the relevant system first and proceed to further<br />
examination as guided by the history and your findings<br />
Physical examination - child<br />
General<br />
appearance<br />
• Does the child look well or sick?<br />
• Alert or drowsy? Altered conscious state? See Glasgow coma scale / AVPU<br />
• Muscle tone - normal or is the child floppy?<br />
• Look / gaze - does the child fix the gaze on the face or is there a glassy eyed stare?<br />
• Interactive or disinterested in interacting / playing?<br />
• Increased work of breathing? e.g. retractions, nasal flaring, grunting, gasping, fast<br />
breathing, wheeze<br />
• Observe speech / cry - strong and vigorous or weak or hoarse?<br />
• Look at the conjunctiva and the nail beds - are they pale?<br />
• Look at the lips, tongue and fingers - are they blue?<br />
• Is the child well nourished?<br />
• Is there any neck stiffness - feel gently. Ask the older child to put their chin on their<br />
chest - if they can they do not have neck stiffness<br />
• Is the child able to be consoled by the care giver?<br />
Hydration • Any weight loss?<br />
• Eyes - normal or sunken? Tears absent or present?<br />
• Mouth and tongue - wet or dry?<br />
• Skin turgor - pinch a loose piece of skin. Does it return to normal immediately or<br />
stay saggy?<br />
• Fontanelle - normal or depressed? (if bulging consider meningitis)<br />
• See Clinical assessment of hydration of children for detailed assessment<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 549
Paediatric presentation<br />
Physical examination - child (continued)<br />
Skin • Always check the whole body, particularly in a sick child<br />
• Rash ? non blanching, petechiae, purpura<br />
• Colour - unusually pale, mottled or cyanotic?<br />
• Bruising, unexplained or unusual marks?<br />
• Signs of infection: redness, swelling or tenderness?<br />
• Inspect / palpate lymph nodes in the neck, axillae or groins for tenderness<br />
• See Assessment and physical examination of skin, hair and nails for detailed<br />
assessment<br />
Growth • Height<br />
• Weight - if child < 2 years weigh naked<br />
• Head circumference if < 2 years<br />
• Plot on growth charts appropriate for age and gender<br />
Cardiovascular<br />
system<br />
Respiratory<br />
system<br />
Gastrointestinal<br />
and<br />
reproductive<br />
systems<br />
550<br />
• Skin colour - pink, white, grey mottling? Compare the trunk with the limbs<br />
• Skin temperature - hot, warm, cool, cold, sweating? Compare the trunk with the<br />
limbs<br />
• Palpate peripheral pulses - is rate fast, slow or normal - is the pulse volume weak<br />
or strong?<br />
• Central perfusion - blanch the skin over the sternum with your thumb for 5 seconds.<br />
Time how long it takes for the mark to disappear<br />
• Peripheral perfusion - ‘blanch’ the skin on a finger or toe for 5 seconds. Time how<br />
long it takes for the mark to disappear<br />
• Any evidence of oedema - particularly hands, feet and face?<br />
• If skilled, listen to heart sounds<br />
• Most information is gained through inspection<br />
• Inspect anterior / posterior chest:<br />
-- equal chest movement<br />
-- use of accessory muscles of respiration? Look for retraction, recession - mild,<br />
moderate or severe? Nasal flaring?<br />
• Can they talk continuously, or only in words or sentences, or unable to talk at all?<br />
• Measure respiratory rate over one minute, observe rhythm, depth and effort breathing<br />
• Listen for extra noises - cough, ± sputum, wheeze, stridor, grunt, snore, hoarse<br />
speech / cry<br />
• Auscultate air entry in both lung fields - equal? Adequate, decreased or absent? Are<br />
there wheezes or crackles? Do they occur on inspiration or expiration? (Note that<br />
transmitted sounds from the upper respiratory tract are very common in children and<br />
may mask other signs)<br />
• Will the child lie flat?<br />
• O saturation<br />
2<br />
• Look - are there any scars or abdominal distension / hernias<br />
• Auscultate bowel sounds - present or absent?<br />
• Palpate abdomen<br />
-- soft or firm?<br />
-- any obvious masses?<br />
-- tender to touch? Identify which abdominal quadrant and exact area<br />
-- any guarding / rigidity - even when the child is relaxed?<br />
-- any rebound tenderness - press down and take your hand away very quickly - is<br />
the pain greater when you do this?<br />
• Question about change in bowel habits<br />
• Feel for a palpable bladder<br />
• Check the testes in boys - are they both in the scrotum?<br />
-- any redness, swelling or tenderness?<br />
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Primary Clinical Care Manual 2011
Paediatric presentation<br />
Physical examination - child (continued)<br />
Nervous • A detailed assessment of the nervous system in a child is both technically difficult<br />
system<br />
and time consuming. A brief assessment is all that is needed. Assess:<br />
-- conscious state. See Glasgow Coma Scale / AVPU<br />
-- orientation to time, place and person if appropriate for the child’s age. Ask the<br />
child their name, age, location. Ask them to tell you the time, date and year<br />
-- pupils: size, equality, shape, reactivity to light<br />
• Look for inequality between one side of the body and the other. Compare the tone<br />
and power of each side of the face and the limbs<br />
• Test touch sensation using cotton wool<br />
• Test finger nose coordination. If possible, observe child walking, looking around and<br />
using hands<br />
Musculo- • Full range of movement in limbs, joints and muscles?<br />
skeletal system • Pain in limbs, joints or muscles?<br />
• Any redness, pain, swelling, heat over joint(s)? Observe gait<br />
• See Acute rheumatic fever / Bone or joint infections - child<br />
Ears, nose and • Ears<br />
throat<br />
-- look at the pinna - redness, swelling?<br />
-- any obvious swelling or redness of the ear canal, if there is, looking with an<br />
otoscope will be painful<br />
-- looking inside with an otoscope - look at the ear canal - redness, swelling,<br />
discharge?<br />
-- inspect eardrum - normal? or redness, dullness, bulging or retraction, fluid or air<br />
bubbles, perforations or discharge?<br />
-- See Assessment of ear for detailed assessment<br />
• Nose<br />
-- feel for facial swelling / inflammation<br />
-- is there any discharge or obvious foreign body?<br />
• Throat<br />
-- look at the lips, buccal mucosa, gums, palate, tongue, throat<br />
-- redness / swelling?<br />
-- condition of teeth<br />
-- inspect tonsils - redness, enlargement or pus?<br />
Eyes • Always test the visual acuity of each eye. Use age appropriate Snellen chart at 6<br />
metres in good light<br />
• Look at the eyes and surrounding structures - any redness, discharge or swelling?<br />
• Look at the pupils - are they equal in size and regular in shape? Check pupillary<br />
reflex to light<br />
• Check eye movements - ask the child to follow the movement of your finger<br />
• See Assessment of the eye for detailed assessment<br />
Urinalysis • Examine the urine of all sick children, all children with abdominal pain or urinary<br />
symptoms and all children with unexplained symptoms or signs<br />
• Look at the colour - is it normal, dark, blood stained?<br />
• Does it smell normal?<br />
• Perform urinalysis<br />
[4] [5] [6] [7]<br />
• See decision making flowcharts to assist with clinical impression<br />
-- child with fever / cough / stridor / vomiting / abdominal pain and / or chronic<br />
diarrhoea<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 551
Paediatric presentation<br />
Diagnostic and pathology services<br />
• Point of care testing is available in some facilities for example iSTAT® blood gases<br />
• Pathology request forms<br />
-- all pathology requests made by SM R&IP must be compliant with the specific <strong>Health</strong><br />
Management Protocol<br />
-- if in the clinician’s opinion other pathology is required this must be ordered by a MO<br />
• Pathology results / follow up:<br />
-- if a SM R&IP has initiated pathology testing according to the <strong>Health</strong> Management<br />
Protocol they are responsible for the follow up of pathology results<br />
552<br />
-- MO should be consulted if results are abnormal<br />
• Refer to the Pathology <strong>Queensland</strong> Specimen Collection Manual available at:<br />
qis.health.qld.gov.au/DocumentManagement/Default.aspx?DocumentID=10021&Doc<br />
umentInstanceID=45973<br />
Consulting the MO<br />
• If it is necessary to consult with a MO present your findings clearly and methodically<br />
• It is often easier if you write your findings down first (time permitting)<br />
• It is helpful to advise the MO early that you have a child about whom you want some<br />
advice or alternately who you think may need evacuation<br />
• Always begin with the name and age of the child, then start with the presenting concern<br />
and proceed through to the examination. Say what you think is wrong - your assessment<br />
is important; after all, you are actually with the child<br />
• Always consult with the MO if you are not sure. Discuss difficulties and problems with<br />
the MO during routine visits. Take the opportunity to discuss general or specific cases<br />
or issues with the MO at the next clinic visit<br />
• See Royal Flying Doctor Service (<strong>Queensland</strong> Section) and <strong>Queensland</strong> Emergency<br />
Medical System - consulting the MO / ISOBAR<br />
References<br />
1. Pemsoft®. Normal vital signs. 2008-2011 [cited 2011 August].<br />
2. The Royal Children’s Hospital. Acute Pain Management 2010 [cited 2011 April].<br />
3. Estes M. and Schaefer K.P., <strong>Health</strong> assessment & physical examination. 2nd ed. 2002, Albany, NY<br />
Delmar.<br />
4. Talley N. and O’Connor S., A systematic guide to physical diagnosis: clinical examination. 6th ed. 2010,<br />
Australia: Churchill Livingstone: Elsevier.<br />
5. Murtagh J. and Rosenblatt J., John Murtagh’s general practice 5th ed. 2011, Australia: McGaw Hill.<br />
6. Corrales A.Y. and Starr M., Assessment of the unwell child. Australian Family Physician, 2010. 39(5): p.<br />
270-275.<br />
7. Douglas G., Nicole F., and Robertson C., Macleod’s clinical examination 12th ed, ed. Douglas G., Nicole<br />
F., and Robertson C. 2009: Churchill Livingstone: Elsevier.<br />
8. Advanced Paediatric Life Support Group, Advanced Paediatric Life Support The Practical Approach.<br />
5th ed, ed. Samuels M. and Wieteska S. 2011: Wiley-Blackwell.<br />
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Primary Clinical Care Manual 2011
Child with fever<br />
Fever is usually an indicator of infection. Two or more infections may co-exist, e.g. URTI plus meningitis<br />
Babies less than 3 months of age contact MO immediately<br />
Consult MO for the child with a fever with no obvious source of infection or a fever that is persistent despite measures taken<br />
Clinical assessment performed<br />
Consult MO<br />
Yes<br />
Significant features of assessment unclear or you are unsure of cause?<br />
No<br />
Basically<br />
well child<br />
Basically<br />
well child<br />
Basically<br />
well child<br />
Basically<br />
well child<br />
Child unwell<br />
Child<br />
unwell<br />
Child unwell<br />
Child unwell<br />
Sore throat, ears,<br />
nasal discharge,<br />
cough,<br />
cervical<br />
lymphadenopathy,<br />
red inflamed<br />
throat,<br />
tonsillar<br />
enlargement<br />
No other<br />
significant<br />
features<br />
URTI type<br />
symptoms may<br />
be present<br />
Vomiting and<br />
diarrhoea<br />
Obvious<br />
abscess or<br />
cellulitis<br />
Cough<br />
Dysuria,<br />
frequency,<br />
smelly<br />
urine<br />
Rapid onset<br />
high fever<br />
May have<br />
history of URTI<br />
like illness<br />
Bulging ear<br />
drum on<br />
examination<br />
No other<br />
significant<br />
features<br />
No other<br />
significant<br />
features<br />
Rapid<br />
breathing,<br />
chest<br />
recession<br />
Positive<br />
urinalysis<br />
Stridor,<br />
drooling,<br />
unable to<br />
eat,<br />
drink or talk,<br />
reluctant to<br />
move neck<br />
Neck stiffness<br />
or bulging<br />
fontanelle<br />
No other<br />
significant<br />
features<br />
Headache,<br />
photophobia<br />
+/-<br />
Rash<br />
Paediatric presentation<br />
See<br />
URTI<br />
See<br />
Acute<br />
otitis media<br />
See Acute<br />
gastroenteritis<br />
See<br />
Bacterial<br />
skin infections<br />
See<br />
Pneumonia<br />
See<br />
UTI<br />
See<br />
Epiglottitis<br />
See<br />
Meningitis<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 553<br />
Tachycardia<br />
Child with fever<br />
No other<br />
significant<br />
features<br />
No other<br />
significant<br />
features
Paediatric presentation<br />
Child with cough<br />
554<br />
Clinical assessment performed<br />
Consult MO<br />
Yes<br />
Significant features of assessment unclear or you are unsure of cause?<br />
No<br />
Paroxysmal<br />
cough<br />
whoop<br />
Nocturnal<br />
or exercise<br />
induced<br />
cough<br />
Child unwell<br />
Basically well child<br />
Child unwell<br />
Basically<br />
well child<br />
Fever<br />
Sudden onset<br />
in previously<br />
well child<br />
Sore throat, ears,<br />
nasal discharge<br />
Rapid onset<br />
high fever<br />
Barking cough<br />
Apnoea<br />
Wheeze, rapid<br />
breathing<br />
Rapid breathing<br />
with chest<br />
recession<br />
Cervical<br />
lymphadenopathy<br />
Cough +/-<br />
Stridor +/-<br />
Wheeze +/-<br />
Stridor,<br />
drooling<br />
Mild URTI<br />
symptoms<br />
No other<br />
significant<br />
features<br />
No other<br />
significant<br />
features<br />
Tachycardia<br />
Fever, red<br />
inflamed throat<br />
Airway<br />
compromised<br />
Unable to eat,<br />
drink or talk<br />
Mild fever<br />
Controlled copy V1.0<br />
No other<br />
significant<br />
features<br />
Mild / moderate<br />
stridor<br />
Tonsillar<br />
enlargement<br />
Reluctant to<br />
move neck<br />
No other<br />
significant features<br />
Usually there<br />
is a history of<br />
ingesting or<br />
choking on<br />
something<br />
Cough may be<br />
absent<br />
No other<br />
significant<br />
features<br />
Child with cough<br />
See<br />
Whooping<br />
cough /<br />
pertussis<br />
See<br />
Asthma<br />
See<br />
Pneumonia<br />
See<br />
URTI<br />
See<br />
Acute upper<br />
airway<br />
obstruction /<br />
choking<br />
See<br />
Epiglottitis<br />
See<br />
Croup<br />
Primary Clinical Care Manual 2011
Child with stridor<br />
Stridor is a harsh vibrating sound originating from the large upper airways and occurring on inspiration. It occurs due to upper airway<br />
obstruction. Consider the following causes: croup – common, inhaled foreign body, epiglottitis – rare but important, trauma, angioneurotic<br />
oedema, mass (tumour or abscess)<br />
Obtain full history, including Hib immunisation status. Limit examination. Do not examine mouth or throat<br />
Consult MO<br />
In the meantime, consider epiglottitis<br />
Yes<br />
Significant features of assessment unclear or you are unsure of cause?<br />
No<br />
Gradual swelling of face,<br />
neck and throat<br />
Sudden onset in previously<br />
well child<br />
Slow onset<br />
Rapid onset<br />
Usually there is a history<br />
of exposure to allergen: an<br />
injection of a drug or blood<br />
product, ingestion of oral drug<br />
/ food or bites / stings<br />
Cough or wheeze may be<br />
present<br />
Usually there is a history<br />
of ingesting or choking on<br />
something e.g. peanut<br />
Croupy (barking) cough<br />
Temp < 38.5°C<br />
No systemic disturbance<br />
Severe stridor less common<br />
Able to swallow<br />
Will usually drink<br />
Normal voice<br />
< 4 years<br />
More prominent at night<br />
Weak or no cough<br />
Temp >38.5°C<br />
Septicaemia<br />
Drooling saliva<br />
Unable to eat or drink<br />
Doesn’t talk<br />
Any age<br />
Reluctant to move neck<br />
As the condition<br />
deteriorates the stridor<br />
may decrease<br />
Paediatric presentation<br />
Child with stridor<br />
See<br />
Anaphylaxis<br />
See<br />
Acute upper airway<br />
obstruction / choking<br />
See<br />
Croup / epiglottitis<br />
See<br />
Croup / epiglottitis<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 555
Paediatric presentation<br />
Child with vomiting<br />
556<br />
Vomiting is a common and important symptom, which may indicate serious illness especially in a very young child.<br />
Consider the following causes: infection (pneumonia, UTI, meningitis, otitis media), obstruction (pyloric stenosis, intussusception, appendicitis,<br />
hernia), reflux oesophagitis, raised intracranial pressure (trauma, abscess or tumour), metabolic (diabetic ketoacidosis, poisoning)<br />
Perform clinical assessment<br />
Consult MO<br />
Yes<br />
Significant features of assessment unclear or you are unsure of cause?<br />
No<br />
Child unwell<br />
Well baby<br />
3 mths - 3 yrs<br />
2-6 weeks old<br />
Basically well<br />
child<br />
Moderate or<br />
severe<br />
dehydration<br />
Unweaned<br />
Dysuria<br />
frequency<br />
smelly urine<br />
Child unwell<br />
Child unwell<br />
Abdominal<br />
pain<br />
intermittently<br />
Diarrhoea<br />
Vomiting and<br />
irritable after<br />
feeds<br />
Fever<br />
High<br />
capillary BGL<br />
Red currant<br />
jelly stool<br />
Projectile<br />
vomits,<br />
hungry<br />
following<br />
feed<br />
Cough<br />
Fever<br />
Positive<br />
urinalysis<br />
Rapid<br />
breathing<br />
May have<br />
history of URTI<br />
like illness<br />
Controlled copy V1.0<br />
No other<br />
significant<br />
features<br />
Ketones on<br />
urinalysis<br />
No other<br />
significant<br />
features<br />
No other<br />
significant<br />
features<br />
Weight loss or<br />
poor gain<br />
No other<br />
significant<br />
features<br />
Chest<br />
recession<br />
Tachycardia<br />
Headache,<br />
photophobia<br />
+/-<br />
Child with vomiting<br />
No other<br />
significant<br />
features<br />
No other<br />
significant<br />
features<br />
Neck stiffness<br />
+/-<br />
Rash<br />
See<br />
Diabetes<br />
See Gastroesophageal<br />
reflux<br />
See<br />
Intussusception<br />
See<br />
Pyloric<br />
stenosis<br />
See<br />
UTI<br />
See<br />
Acute<br />
gastroenteritis<br />
See<br />
Pneumonia<br />
See<br />
Meningitis<br />
Primary Clinical Care Manual 2011
Any history of significant trauma?<br />
No<br />
Bile-stained vomiting?<br />
Bloody stool?<br />
Localised tenderness?<br />
Distension?<br />
Guarding?<br />
Rebound tenderness?<br />
Palpable mass?<br />
Inguinal-scrotal pain or swelling?<br />
No<br />
Positive urine dipstick for<br />
leukocytes, nitrates or blood;<br />
or bacteria on microscopy<br />
No<br />
Fever +/-<br />
Tachypnoea<br />
Recession<br />
Cough<br />
Chest pains<br />
No<br />
Diarrhoea +/- vomiting / fever<br />
No<br />
Firm stool palpable in lower abdomen?<br />
No<br />
Consult MO<br />
Paediatric presentation<br />
Child with abdominal pain<br />
See Criteria for Early Notification of<br />
Trauma for Interfacility Transfer<br />
Consult MO<br />
Consider UTI<br />
See Urinary tract infection - child<br />
Consider pneumonia<br />
See Pneumonia - child<br />
Consider gastroenteritis<br />
See Child with vomiting / fever /<br />
chronic diarrhoea<br />
Consider constipation<br />
See Constipation<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 557<br />
Yes<br />
Yes<br />
Yes<br />
Yes<br />
Yes<br />
Yes
Paediatric presentation<br />
558<br />
Controlled copy V1.0<br />
Child with chronic diarrhoea<br />
Diarrhoea every day for at least 10 days or recurrent episodes of loose stools over longer<br />
periods requires investigation. Consider the following causes: parasites (strongyloides,<br />
cryptosporidium, giardiasis), malabsorption (lactose intolerance, coeliac disease),<br />
inflammatory conditions (crohns disease, ulcerative colitis), other infections e.g. UTI,<br />
pneumonia<br />
Perianal itch<br />
Sighting of worms<br />
in faeces<br />
See<br />
Intestinal worms<br />
Clinical assessment performed<br />
Significant features of assessment<br />
unclear or you are unsure of cause<br />
No<br />
Well hydrated, normal growth and<br />
development, adequate diet<br />
Obtain faeces sample for MC/S and OCP<br />
Is test positive?<br />
No<br />
Test for lactose intolerance<br />
See Lactose intolerance<br />
Is test positive?<br />
No<br />
Consider significant features<br />
of asssessment<br />
Foul smelling,<br />
watery diarrhoea<br />
Flatulence<br />
Nausea<br />
See<br />
Giardiasis<br />
Yes<br />
Yes<br />
Yes<br />
Consult MO<br />
Treat if positive<br />
for giardia or<br />
intestinal<br />
worms.<br />
Consult MO if<br />
other +ve result<br />
See Lactose<br />
intolerance<br />
Bloody diarrhoea<br />
Mucus in diarrhoea<br />
Abdominal pain<br />
Consult<br />
MO<br />
Primary Clinical Care Manual 2011
Meningitis<br />
Meningitis<br />
Recommend<br />
Consult MO immediately:<br />
- - if a sick looking child has no obvious source of infection, which would explain<br />
their symptoms - the diagnosis is meningitis until proven otherwise<br />
- - if the child has been treated with antibiotics but is still not well (they may have<br />
partly treated meningitis with masking of signs)<br />
-- if the child is unwell with prolonged URTI symptoms<br />
Restrict fluids to 50% of maintenance (10mg / kg) unless there are signs of shock -<br />
MO to discuss as soon as possible with a Paediatrician<br />
Parents or carers may notice early, subtle changes in the child’s conscious state.<br />
Their concerns should not be ignored<br />
Perform hearing test 3 months after discharge from hospital<br />
Background<br />
Mortality is probably 5 - 10% in bacterial meningitis. Most children will make<br />
a full recovery, if appropriately treated. Deafness is the most common long term<br />
complication<br />
Hyponatraemic solutions e.g. 4 % dextrose and one-fifth normal saline or one-quarter<br />
normal saline, have no place in the management of meningitis as they may worsen<br />
hyponatraemia and increase the risk of cerebral oedema [1]<br />
Related topics<br />
Fits / convulsions / seizures<br />
Upper respiratory tract infection -<br />
child<br />
Immunisation program<br />
DRS ABCD resuscitation / the collapsed<br />
patient<br />
O 2 delivery systems<br />
1. May present with<br />
• URTI type symptoms, fever, lethargy, poor feeding<br />
• In young children - non specific signs and symptoms including fever, irritability,<br />
refusing feeds, pallor and a high pitched moaning cry may be present<br />
• In older children - headache, photophobia, neck stiffness [2]<br />
• Leg pain, cold hands and feet<br />
• Abnormal skin colour - pallor or sweating<br />
• Rash in meningococcal disease: usually non blanching petechiae (fine dark red<br />
spots) but may be purpura (like bruises), or less commonly, a ‘flea bitten’ pink / red<br />
maculopapular rash. The rash often develops rapidly, however meningococcal<br />
disease can occur without a rash<br />
• Muscle / joint pains, vomiting, diarrhoea<br />
• Confusion, drowsiness, loss of consciousness<br />
• Bulging fontanelle, fitting<br />
2. Immediate management<br />
• Consult MO immediately<br />
• If altered level of consciousness See DRS ABCD resuscitation / the collapsed<br />
patient<br />
• If fitting see Fits / convulsions / seizures<br />
• Give O 2 to maintain O 2 saturation >95%. If >95% not maintained consult MO.<br />
See O 2 delivery systems<br />
• Insert IV / IO cannula and take FBC, U/E, blood cultures, PCR for Neisseria<br />
meningitis (meningococcal bacteria)<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 559
Meningitis<br />
• In the critically ill, shocked or septic child with suspected meningitis e.g.<br />
unresponsive, poorly perfused, purpuric rash, it is appropriate to first give a bolus<br />
of intravenous or intraosseous fluids (initially 10 - 20 mL / kg of normal saline [1])<br />
before giving antibiotics. Otherwise restrict total fluids to 10 mL / kg.<br />
• MO to consult as soon as possible with Paediatrician<br />
3. Clinical assessment<br />
• Obtain as complete a patient history as possible according to the circumstances<br />
of the presentation. Of particular importance in a sick looking child is:<br />
-- -headache, irritability, fever, ask about any rash, neck stiffness<br />
• Perform standard clinical observations +<br />
-- weight (if able)<br />
-- GCS<br />
-- O saturation<br />
2<br />
• Perform physical examination:<br />
-- inspect all skin surfaces for any skin rash especially at pressure points and<br />
under nappies and clothing. Note: petechiae and purpura do not fade on<br />
pressure<br />
-- assess hydration status<br />
-- -inspect and palpate the ears, nose and throat<br />
-- palpate the fontanelle in young baby - feeling for fullness<br />
-- check for neck stiffness - with patient lying down, put hand behind head and<br />
gently raise<br />
-- auscultate the chest for air entry and any added sounds (crackles or wheezes)<br />
• Check vaccination status, especially Hib / meningococcal / conjugate<br />
pneumococcal<br />
4. Management<br />
• Consult MO who will arrange / order:<br />
-- evacuation / hospitalisation<br />
-- monitor clinical observations closely<br />
-- continue IV / IO fluids at 50% of maintenance fluids (10 mL / kg). If the child is<br />
drinking ensure total fluids do not exceed 10 mL / kg (or 50 % of maintenance<br />
fluids)<br />
-- if meningitis is suspected, stat dose of parenteral antibiotics must be given<br />
before transfer to hospital. Blood samples for culture and PCR should be<br />
taken where possible but should not delay initial treatment<br />
-- give IV ceftriaxone (can be given by IM route if unable to obtain IV access)<br />
100 mg / kg / dose to a total of 4 grams daily (or 50 mg / kg / dose bd to a total<br />
of 2 grams bd) [3]<br />
• Give paracetamol for fever, pain or distress<br />
See Simple analgesia back cover<br />
5. Follow up<br />
All children with suspected meningitis should be managed in an appropriately<br />
equipped hospital<br />
Notify the Public <strong>Health</strong> Unit of any suspected case of bacterial meningitis as<br />
soon as possible<br />
Chemoprophylaxis will be required for close contacts of a patient with either<br />
meningococcal or Hib meningitis. Unvaccinated contacts of Hib meningitis
6. Referral / consultation<br />
Consult MO immediately on all occasions if meningitis is suspected<br />
Most will require urgent treatment and evacuation / hospitalisation<br />
Respiratory problems<br />
References<br />
1. The Royal Children’s Hospital. Fluid management in meningitis. 2005 [cited 2011 March ].<br />
2. The Royal Children’s Hospital. Meningitis guideline. 2009 [cited 2011 March ].<br />
3. Therapeutic Guidelines. Meningitis: empirical therapy (organism or susceptibility not yet known). 2010<br />
[cited 2011 March].<br />
Upper respiratory tract infection - child<br />
Common cold, sore throat, tonsillitis<br />
Recommend<br />
Remember the symptoms and signs of an upper respiratory tract infection (URTI)<br />
may be a precursor to more serious illnesses such as meningitis<br />
Always be alert to the relationship between group A streptococcal sore throat and ARF<br />
/ APSGN. These complications are common and serious but potentially avoidable in<br />
Aboriginal and Torres Strait Islander children<br />
Ten (10) days of oral antibiotics, or one dose of benzathine penicillin IM, is required<br />
to eradicate group A streptococcus<br />
Background<br />
The vast majority of URTI are caused by viruses and do not require antibiotics.<br />
However a viral URTI can be complicated by secondary bacterial infection such as<br />
otitis media or pneumonia, requiring antibiotics<br />
Other complications include exacerbation of asthma<br />
Related topics<br />
Meningitis<br />
Immunisation program<br />
Pneumonia<br />
Acute otitis media<br />
Pertussis (whooping cough)<br />
Croup / epiglottitis<br />
Bronchiolitis<br />
1. May present with<br />
• Watery or purulent nasal discharge and / or sneezing<br />
• Sore / red throat and / or tonsils with or without pus<br />
• Difficulty swallowing, cough, chest wheeze, earache<br />
• Enlarged tender cervical (neck) lymph nodes<br />
• Fever, headache, general malaise<br />
2. Immediate management Not applicable<br />
3. Clinical assessment<br />
• Take patient history including:<br />
- - past episodes, history of asthma, complications such as ARF / APSGN<br />
- - otitis media, measures taken to treat including medications taken<br />
• Perform standard clinical observations +<br />
-- collect urine for MC/S and test for nitrates<br />
• Perform physical examination including:<br />
-- overall appearance e.g. smiling? agitated? lethargic?<br />
-- respiratory effort e.g. chest recession, nasal flaring, grunting (noisy breathing),<br />
abdominal breathing<br />
-- inspect the ears, nose and throat<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 561
Respiratory problems<br />
562<br />
- - palpate the head and neck for enlarged lymph glands<br />
- - auscultate the chest for air entry and any added sounds - crackles or wheezes<br />
- - inspect all skin surfaces for any skin rash especially at pressure points and<br />
under nappies and clothing Note: petechiae and purpura do not fade on<br />
pressure<br />
• Check vaccination status. See Immunisation program<br />
4. Management<br />
• Consult MO if<br />
- - < 3 months of age<br />
- - < 1 year with respiratory rate more than 40 respirations per minute (rpm)<br />
○ 1 - 2 years more than 35 rpm<br />
○ 2 - 5 years more than 30 rpm<br />
○ 5 - 12 years more than 25 rpm<br />
○ 12 years and older more than 20 rpm<br />
○ respiratory distress or apnoea<br />
-- if child looks sick, not alert or interactive and has temperature over 38°C<br />
-- if child still looks sick when temperature reduced<br />
- - if child has any rash<br />
- - if child has a cough productive of mucopurulent sputum, may need further<br />
investigations for possibility of chronic respiratory disease<br />
- - if child has tonsillitis and is sick<br />
• If child has cough as the main feature; consider other diagnoses. See Pertussis<br />
(whooping cough), croup, acute asthma<br />
• If child has an increased respiratory rate, or any chest findings consider other<br />
diagnoses. See Bronchitis / pneumonia<br />
• If child has evidence of secondary ear infection. See Acute otitis media<br />
• For the child with URTI, indications for antibiotic treatment are:<br />
-- sore throat and red swollen tonsils, with or without pus, with fever (>38°C)<br />
and local lymphadenitis<br />
-- sore throat with red swollen tonsils in a child with existing rheumatic heart<br />
disease<br />
-- Scarlet fever - has a characteristic and striking red blanching rash and<br />
strawberry tongue due to streptococcal infection; rash usually starts after the<br />
sore throat and lasts a week<br />
-- Quinsy (severe infection of the tonsils causing massive enlargement). If<br />
quinsy is present, consult MO (may need evacuation / hospitalisation for IV<br />
penicillin and / or surgical drainage of pus)<br />
• For the child with uncomplicated URTI, treatment is symptomatic [1]:<br />
- - encourage rest and increase fluid intake<br />
- - paracetamol for analgesia if uncomfortable (do not use aspirin in children)<br />
- - topical nasal decongestants can be helpful for sleeping and eating particularly<br />
in young infants; however their use should be limited to short periods of time<br />
(5 days max.). Nose drops of normal saline or cool boiled water can also be<br />
helpful and are safe<br />
- - other symptomatic treatments, nebulised saline, and lemon and honey drinks<br />
may have some subjective benefit in some children<br />
See Simple analgesia back cover<br />
Controlled copy V1.0<br />
Primary Clinical Care Manual 2011
Respiratory problems<br />
• For the child with indicators for antibiotic treatment present and if not allergic treat<br />
with oral penicillin:<br />
Schedule 4 Phenoxymethylpenicillin<br />
DTP<br />
IHW / SM R&IP / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic must consult MO / NP<br />
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed<br />
Form Strength<br />
Route of<br />
administration<br />
Capsule<br />
250 mg<br />
500 mg Oral<br />
Suspension 150 mg / 5 mL<br />
Recommended<br />
dosage<br />
Child<br />
15 mg / kg / dose bd<br />
to a max. of 500 mg bd<br />
Duration<br />
10 days<br />
Provide Consumer Medicine Information: should be taken on an empty stomach; ½ to 1 hour before meals.<br />
Ensure full course is completed<br />
Management of associated emergency: as for severe allergic reactions See Anaphylaxis<br />
[1]<br />
• If a lack of observance with oral medication is anticipated or those intolerant of<br />
oral therapy treat with IM penicillin:<br />
Schedule 4<br />
Benzathine penicillin<br />
(Bicillin LA)<br />
DTP<br />
IHW / SM R&IP / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic must consult MO / NP<br />
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed<br />
Form Strength<br />
Route of<br />
administration<br />
Recommended<br />
dosage<br />
3 kg - < 6 kg 225 mg<br />
Duration<br />
Disposable<br />
syringe<br />
900 mg IM<br />
6 kg - < 10 kg 337.5 mg<br />
10 kg - < 15 kg 450 mg<br />
15 kg - < 20 kg 675 mg<br />
>20 kg 900 mg<br />
Stat<br />
Use a concentration of 442 mg / mL when measuring part doses. Refer to product information<br />
Provide Consumer Medicine Information<br />
Management of associated emergency: as for severe allergic reactions See Anaphylaxis<br />
Administration tips - as per patient preference:<br />
-- apply EMLA cream to the injection site 30 - 60 minutes prior to injection and allow medication to warm<br />
up to room temperature or<br />
-- allow medication to warm up to room temperature, apply pressure with thumb (to the exact injection<br />
site) 30 seconds prior to the injection, use 21 gauge needle and deliver injection very slowly (2 minutes)<br />
[1]<br />
• If allergic to penicillin, treat with roxithromycin:<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 563
Respiratory problems<br />
Schedule 4 Roxithromycin<br />
DTP<br />
IHW / SM R&IP / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic must consult MO / NP<br />
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed<br />
564<br />
Form Strength<br />
Tablet for<br />
suspension<br />
Tablet<br />
50 mg<br />
150 mg<br />
300 mg<br />
Route of<br />
administration<br />
Oral<br />
Controlled copy V1.0<br />
Recommended<br />
dosage<br />
Child<br />
4 mg / kg / dose bd<br />
to a max. of 150 mg bd<br />
Duration<br />
10 days<br />
Provide Consumer Medicine Information: should be taken on an empty stomach, 15 minutes before food;<br />
ensure course is completed<br />
Management of associated emergency: consult MO<br />
[1]<br />
5. Follow up<br />
Review next day, if not improving consult MO<br />
If antibiotics have been given for sore throat:<br />
- - review in 2 weeks<br />
- - ask about sore joints, chest pain, breathlessness and check urinalysis<br />
- - consult MO if symptoms persist see Rheumatic fever or if abnormal urinalysis<br />
see Acute post streptococcal glomerulonephritis<br />
6. Referral / consultation<br />
Consult MO as above or if symptoms persist despite symptomatic treatment<br />
If recurrent tonsillitis (>6 episodes per year) MO may consider prolonged course<br />
of prophylactic penicillin or referral to ENT specialist for consideration for<br />
tonsillectomy / adenoidectomy<br />
Pertussis (whooping cough)<br />
Recommend<br />
If adults and teenagers present with pertussis ask about young babies at home as<br />
pertussis is a particularly severe disease in infants < 12 months of age<br />
It is important to explain that coughing may continue for 6 - 8 weeks after treatment<br />
and may recur with the next URTI. The recurrence will not last long<br />
In <strong>Queensland</strong> free pertussis vaccine is now available for birth parents, foster parents,<br />
adoptive parents, grandparents of babies < 6 months of age and other adults in a<br />
household with a baby < 6 months of age [2]<br />
Background<br />
Pertussis (whooping cough) is still common<br />
Incubation period is on average 7 - 10 days<br />
Pertussis is a prolonged illness and can be complicated by apnoea in infants,<br />
pneumonia, hypoxic brain injury, seizures or lead to chronic lung disease<br />
Related topics<br />
Immunisation program<br />
URTI<br />
Primary Clinical Care Manual 2011
Respiratory problems<br />
1. May present with<br />
• URTI symptoms<br />
• Cough (typically paroxysmal i.e. intermittent episodes of prolonged coughing<br />
followed by the characteristic inspiratory ‘whoop’ as the child catches his / her<br />
breath)<br />
• Vomiting, typically after an episode of coughing<br />
• Cyanosis, typically during an episode of coughing<br />
• Young babies usually do not have the characteristic whoop but are likely to be very<br />
distressed by coughing and vomiting. They can develop apnoea (stop breathing)<br />
and become cyanosed during a coughing bout<br />
• Adults usually have a persistent troublesome cough only, without a whoop. A<br />
cough of several weeks duration, that is worse at night, in an adult, is pertussis<br />
until proven otherwise<br />
2. Immediate management<br />
• If severe consult MO immediately<br />
3. Clinical assessment<br />
• See Upper respiratory tract infection<br />
• The ‘whoop’ can be characteristic but may not always be present. The child may<br />
not be distressed in periods between paroxysms of coughing, with few clinical<br />
signs, however the overall impression is of a sick child<br />
• Check vaccination status. See Immunisation program<br />
4. Management<br />
• Consult MO who may advise:<br />
-- evacuation / hospitalisation if young child (< 6 months) or if symptoms are<br />
significant, appropriate tests to confirm diagnosis - serum for IgA and / or<br />
nasopharyngeal aspirate / swab for PCR testing and / or MC/S<br />
-- antibiotics may shorten the length of the illness if given early and will also<br />
reduce infectivity to others. Person can be considered not infective after 5<br />
days of treatment. It is important to explain that coughing will continue for 6 - 8<br />
weeks, and may recur with the next URTI. The recurrence will not last long<br />
-- household and child care contacts may require prophylactic antibiotics to<br />
prevent further clinical cases of pertussis<br />
-- advise to avoid contact with other individuals, especially young children and<br />
infants until at least 5 days of antibiotics have been received [3]<br />
-- consult Public <strong>Health</strong> Unit for advice<br />
5. Follow up<br />
If not evacuated / hospitalised review daily, at least initially<br />
6. Referral / consultation<br />
Consult MO on all occasions whooping cough is suspected<br />
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Respiratory problems<br />
566<br />
Controlled copy V1.0<br />
Croup / epiglottitis<br />
Recommend<br />
Keep the child as calm as possible<br />
Do not examine the mouth or throat and do not lie the child flat<br />
Background<br />
Croup usually follows 3 or 4 days of a mild URTI when the infection spreads to affect<br />
the upper airways; it is usually mild and self limiting<br />
Epiglottitis (cellulitis of the epiglottis) is caused by Haemophilus influenza type B<br />
infection and is fatal if untreated. It is rare since Hib vaccination was introduced<br />
Related topics<br />
Acute upper airway obstruction and choking<br />
1. May present with<br />
• Acute epiglottitis<br />
- - weak or no cough<br />
- - temperaure >38.5°C<br />
-- septicaemia<br />
-- looks sick<br />
- - drooling saliva<br />
-- unable to eat or drink<br />
- - doesn’t talk<br />
- - any age<br />
- - reluctant to move neck<br />
• Croup<br />
- - croupy (barking) cough<br />
- - temperature 95% and consult MO immediately. If >95% not maintained consult<br />
MO. See O 2 delivery systems<br />
• If not tolerated, it is best to interfere with the child as little as possible. Try holding<br />
the O 2 tubing / mask close to face<br />
3. Clinical assessment<br />
• Obtain patient history including onset and preceding URTI<br />
• Perform standard clinical observations. Note in particular, temperature and<br />
respiratory rate (when the child is quiet)<br />
• Inspect for signs of respiratory distress - grunting (stridor), rib or sternal recession,<br />
nasal flaring<br />
• Inspect for drooling in a sick looking child. This along with high fever is suggestive<br />
of epiglottitis<br />
Primary Clinical Care Manual 2011
Respiratory problems<br />
4. Management<br />
• Consult MO<br />
• If epiglottitis:<br />
-- have the parents / carer stay with child to comfort<br />
-- handle the child as little as possible<br />
-- MO will organise evacuation by skilled MO with paediatric airway management<br />
and IV insertion for IV ceftriaxone [4]<br />
• If croup:<br />
- - symptomatic treatment as per URTI<br />
-- for mild to moderate cases MO may advise:<br />
○ prednisolone 1 mg / kg / dose stat with a second dose for the next<br />
evening or<br />
○ a single dose of oral dexamethasone 0.15 mg / kg / dose<br />
-- for severe cases MO may advise:<br />
○ 0.6 mg / kg / dose (max. 12 mg) IM / IV dexamethasone<br />
○ 5 mL of adrenaline 1:1,000 solution via nebuliser [5]<br />
○ evacuation / hospitalisation<br />
5. Follow up<br />
If child with croup is not evacuated / hospitalised, review next day and consult MO<br />
if not improving<br />
6. Referral / consultation<br />
Consult MO on all presentations of stridor<br />
Bronchiolitis<br />
Recommend<br />
Consult MO immediately if severe<br />
Background<br />
In bronchiolitis, generally the child is distressed without looking sick or toxic<br />
A viral infection of the chest affecting infants 95%. If >95% not maintained consult<br />
MO. See O 2 delivery systems<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 567
Respiratory problems<br />
3. Clinical assessment<br />
• Obtain complete patient history of particular importance is:<br />
- - a history of URTI symptoms in a child that is basically well<br />
- - history of chest conditions such as asthma, pneumonia<br />
- - if wheeze is present<br />
- - if child has stopped breathing (apnoea) for short periods of time<br />
-- how well is the child / infant feeding<br />
•<br />
•<br />
Perform standard clinical observations + O saturation<br />
2<br />
Perform physical examination:<br />
- - inspect for signs of respiratory distress (grunting, nasal flaring, sternal and /<br />
or intercostal / subcostal recession)<br />
- - inspect middle ear<br />
- - inspect for cyanosis (lips, tongue, extremities) present in severe cases<br />
- - auscultate chest for presence of wheezes / crackles<br />
4. Management<br />
• Consult MO who will consider treating similar to:<br />
-- acute asthma, if wheeze is prominent, however in infants bronchodilators are<br />
unlikely to be effective<br />
-- pneumonia, if fever and rapid breathing is prominent<br />
-- O if SpO < 95%<br />
2 2<br />
• If child / infant is not feeding well, fluids may be required NG or IV<br />
5. Follow up<br />
Patients who are not evacuated / hospitalised should be reviewed daily<br />
Consult MO if the patient is not improving<br />
6. Referral / consultation<br />
Consult MO on all occasions bronchiolitis is suspected<br />
568<br />
Controlled copy V1.0<br />
Pneumonia - child<br />
Recommend<br />
If baby < 3 months of age contact MO immediately<br />
Severe dehydration is unusual in pneumonia unless there are abnormal fluid losses<br />
from frequent diarrhoea or vomiting<br />
Background<br />
Children with co-existent illnesses are more at risk. Examples are bronchiolitis and<br />
chronic lung disease e.g. due to prematurity<br />
Related topics<br />
Upper respiratory tract infection - child<br />
Immunisation program<br />
Bronchiolitis<br />
1. May present with<br />
• Cough dry or with sputum, fever, tachycardia<br />
• Rapid breathing, nasal flaring, grunting respirations and chest recession in infants,<br />
cyanosis, apnoea in infants<br />
Primary Clinical Care Manual 2011
Child<br />
< 3 months<br />
Contact MO<br />
immediately<br />
Resps<br />
≥40 / min<br />
and / or<br />
recession<br />
grunting<br />
apnoea<br />
cyanosis<br />
Resps<br />
Respiratory problems<br />
570<br />
Mild pneumonia<br />
• MO may advise:<br />
-- chest x-ray if available<br />
-- oral or IM antibiotics<br />
-- antibiotics may not be indicated if typical of viral infection or bronchiolitis<br />
• Encourage rest and increase oral fluids<br />
• Treat fever with regular paracetamol to make more comfortable<br />
Moderate / severe pneumonia<br />
• Give O to maintain O saturation >95% (if not already in place). If > 95 % not<br />
2 2<br />
maintained consult MO. See O delivery systems<br />
2<br />
• Give oral fluids as tolerated<br />
• MO may advise:<br />
-- insert IV cannula - if possible take blood cultures prior to commencing<br />
antibiotics<br />
-- IV fluids - it is usual to start with normal saline or Hartmann’s solution; MO will<br />
advise quantities and rate<br />
-- to commence IV antibiotics<br />
• Evacuation / hospitalisation<br />
• Give analgesia<br />
See Simple analgesia back cover<br />
5. Follow up<br />
Patients with mild pneumonia who are not evacuated / hospitalised should be<br />
reviewed daily<br />
Consult MO if the patient is not improving<br />
See next MO clinic<br />
6. Referral / consultation<br />
Consult MO on all occasions pneumonia is suspected<br />
Some children with pneumonia will require a paediatric referral<br />
References<br />
1. Therapeutic Guidelines. Pharyngitis and/or tonsillitis. 2010 [cited 2011 January].<br />
2. <strong>Queensland</strong> <strong>Health</strong>, Expansion of Free Pertussis Vaccine Program, in Immunisation Program. 2011:<br />
Brisbane.<br />
3. Therapeutic Guidelines. Pertussis. 2010 [cited 2011 March].<br />
4. Therapeutic Guidelines. Acute epiglottitis (supraglottitis). 2010 [cited 2011 March].<br />
5. The Royal Children’s Hospital. Croup (Laryngotracheobronchitis). 2009 [cited 2011 March ].<br />
Controlled copy V1.0<br />
Primary Clinical Care Manual 2011
Immune complications<br />
Acute post streptococcal glomerulonephritis (APSGN)<br />
Recommend<br />
Early treatment of skin infections is essential for prevention of acute post-streptococcal<br />
glomerulonephritis (APSGN)<br />
Background<br />
APSGN is common among Aboriginal and Torres Strait Islander children in northern<br />
Australia<br />
Inflammation of the kidneys results from immune complexes forming after a group A<br />
streptococcal infection causing blood to not filter properly and blood cells and protein<br />
leaking into urine<br />
Related topics<br />
Bacterial skin infections<br />
1. May present with<br />
• Fever, headache, malaise<br />
• Oedema (swelling) of face, feet and hands or excessive weight gain<br />
• Haematuria - urine may be dark coloured<br />
• Incidental finding on urinalysis (blood and protein in urine)<br />
• Rarely may present fitting secondary to acute hypertensive crisis<br />
2. Immediate management<br />
• If fitting see Fitting / convulsions / seizures<br />
3. Clinical assessment<br />
• Take complete patient history in particular:<br />
- - any history of sore throat and length of time since present<br />
- - any skin infections present and length of time since occurred<br />
- - past history of APSGN, close contacts who may have similar signs or<br />
symptoms, any measures taken to treat presenting concern<br />
• Perform standard clinical observations +<br />
-- BP ensuring correct cuff size (APSGN is one of the few conditions where it is<br />
important to monitor BP in a child)<br />
-- urinalysis (for blood and protein)<br />
• Check weight<br />
• Perform physical examination including:<br />
- - inspect face, hands and feet for oedema, throat looking for signs of recent<br />
infection and palpate skin looking for signs of recent infection<br />
- - inspect and palpate abdomen for tenderness or guarding<br />
- - listen to chest for crackles or wheezes (fluid retention can cause heart failure)<br />
year 1<br />
Upper limits of normal BP for boys at<br />
50th percentile for height and weight<br />
[1]<br />
BP upper level systolic 103 106 111 114 116 119 123 128 134 136<br />
of normal diastolic 56 61 69 74 78 80 81 82 84 87<br />
2 years<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 571<br />
4 years<br />
6 years<br />
8 years<br />
10 years<br />
12 years<br />
14 years<br />
16 years<br />
> 17years
Immune complications<br />
Upper limits of normal BP levels<br />
for girls at 50th percentile for<br />
height and weight [1]<br />
BP<br />
upper level<br />
systolic 104 105 108 111 115 119 123 126 128 129<br />
of normal<br />
diastolic 58 63 70 74 76 78 80 82 84 84<br />
572<br />
1 years<br />
2 years<br />
4 years<br />
Diagnostic features of APSGN [2]<br />
This illness usually features oedema and / or hypertension (BP greater than levels in tables<br />
for age and gender). Other features include:<br />
1. Haematuria - often macroscopic but can be microscopic<br />
• A urine dipstick reading of ≥ 2+ red blood cells is adequate to define haematuria<br />
• Microscopic haematuria is defined as >10 x 106 red blood cells on microscopy<br />
of fresh urine; red cells casts should also be seen. If microscopy is not readily<br />
available<br />
2. Reduced serum complement: C 200 international units or,<br />
• anti-DNase B >300 U / mL<br />
• These serological titres are often high at baseline in Aboriginal and Torres Strait<br />
Islander community children because of repeated skin infections with GAS. So<br />
acceptable evidence for recent GAS infection is either:<br />
-- titres of > 2 x reference e.g. ASOT > 400 international units / mL or<br />
-- anti-DNase B > 600 units / mL or<br />
-- a rising titre when repeated after 10 - 14 days<br />
4. Management<br />
• Consult MO who:<br />
- - will advise to treat streptococcal infection with IM benzathine penicillin<br />
[3] regardless of whether skin sores / sore throat are present at the time<br />
of presentation or not; or if allergic to penicillin a full 10 day course of oral<br />
roxithromycin [3]<br />
-- may advise to treat hypertension and / or heart failure (initial treatment is<br />
usually frusemide)<br />
• All cases with hypertension should be evacuated / hospitalised<br />
• Restrict fluids and salt intake (usually patient is fluid overloaded)<br />
• Notify all cases of APSGN to the Public <strong>Health</strong> Unit<br />
6 years<br />
Controlled copy V1.0<br />
8 years<br />
10 years<br />
12 years<br />
14 years<br />
16 years<br />
> 17years<br />
Primary Clinical Care Manual 2011
Immune complications<br />
Schedule 4<br />
Benzathine penicillin<br />
(Bicillin LA)<br />
DTP<br />
IHW / SM R&IP / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic must consult MO / NP<br />
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed<br />
Form Strength<br />
Route of<br />
administration<br />
Recommended<br />
dosage<br />
3 kg - < 6 kg 225 mg<br />
Duration<br />
Disposable<br />
syringe<br />
900 mg IM<br />
6 kg - < 10 kg 337.5 mg<br />
10 kg - < 15 kg 450 mg<br />
15 kg - < 20 kg 675 mg<br />
20 kg > 900 mg<br />
Stat<br />
Use a concentration of 442 mg / mL when measuring part doses. Refer to product information<br />
Provide Consumer Medicine Information<br />
Management of associated emergency: as for severe allergic reactions See Anaphylaxis<br />
Administration tips - as per patient preference:<br />
-- apply EMLA cream to the injection site 30 - 60 minutes prior to injection and allow medication to warm<br />
up to room temperature or<br />
-- allow medication to warm up to room temperature, apply pressure with thumb (to the exact injection<br />
site) 30 seconds prior to the injection, use 21 gauge needle and deliver injection very slowly (2 minutes)<br />
[1]<br />
• if allergic to penicillin, give oral roxithromycin [3]<br />
Schedule 4 Roxithromycin<br />
DTP<br />
IHW / SM R&IP / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic must consult MO / NP<br />
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed<br />
Form Strength<br />
Tablet for<br />
suspension<br />
Tablet<br />
50 mg<br />
150 mg<br />
300 mg<br />
Route of<br />
administration<br />
Oral<br />
Recommended<br />
dosage<br />
Child<br />
4 mg / kg / dose bd<br />
to a max. of 150 mg bd<br />
Duration<br />
10 days<br />
Provide Consumer Medicine Information: should be taken on an empty stomach, 15 minutes before food.<br />
Ensure full course is completed<br />
Management of associated emergency: consult MO<br />
[1]<br />
• If treatment for hypertension and / or heart failure required, contact MO<br />
immediately<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 573
Immune complications<br />
5. Follow up<br />
Most children will require evacuation / hospitalisation<br />
If not evacuated / hospitalised the child requires close follow up with daily review<br />
including weight, BP and urinalysis. If there is any deterioration, consult MO<br />
Refer to next MO clinic<br />
Following discharge, most children will require at least monthly weight, BP and<br />
urinalysis (it takes a considerable time for haematuria to resolve) following<br />
glomerulonephritis but persisting proteinuria is of more concern. Some children<br />
will be on antihypertensives for a period of time after the illness and will require<br />
more frequent monitoring of BP<br />
If urinalysis shows protein on follow up, collect urine for urine protein / creatinine<br />
ratio<br />
If persistent proteinuria refer to Paediatrician for follow up<br />
Blood should be tested to check the immune system complement factor serum<br />
complement (C 3 ) level has returned to normal after three months; an MSU should<br />
also be sent<br />
Review at 3, 6, 9 and 12 months<br />
6. Referral / consultation<br />
Consult MO on all occasions of suspected glomerulonephritis<br />
Most will need paediatric referral and follow up<br />
If C 3 does not return to normal refer to Paediatrician<br />
References<br />
1. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children<br />
and Adolescents, The Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure<br />
in Children and Adolescents. Pediatrics, 2004. 114 (2): p. 555.<br />
2. <strong>Queensland</strong> <strong>Government</strong>. Acute Post-streptococcal Glomerulonephritis Control of Communicable<br />
Diseases Protocol Manual 2009 [cited 2011 May]; Available from: qheps.health.qld.gov.au/cdpm/index/<br />
apsgn.htm.<br />
3. Therapeutic Guidelines. Impetigo. 2009 [cited 2010 December].<br />
574<br />
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Primary Clinical Care Manual 2011
Immune complications<br />
Acute rheumatic fever<br />
Recommend<br />
In Aboriginal and Torres Strait Islander communities where there are high rates of<br />
acute rheumatic fever (ARF) and rheumatic heart disease (RHD) treat streptococcal<br />
throat and skin infections early<br />
Any case of arthritis with fever in a child should be considered as possible ARF<br />
or septic arthritis and transferred to hospital for investigation and confirmation of<br />
diagnosis<br />
Regular penicillin prophylaxis is critical to prevent recurrences of ARF, which can<br />
lead to the development or worsening of RHD<br />
Background<br />
ARF is an auto-immune response to bacterial infection with group A Streptococcus<br />
(GAS) [1] in the throat (and possibly the skin); it affects the heart, joints, nervous<br />
system and skin<br />
Aboriginal and Torres Strait Islander Australians living in rural or remote settings are<br />
known to be at high risk. Those living in urban settings, Maori and Pacific Islander<br />
people and, potentially immigrants from developing countries also may be at high<br />
risk [2]<br />
ARF is predominantly a disease of children aged between 5 and 14 years although<br />
recurrent episodes may continue well into the fourth decade of life [1]<br />
Patients with recurring ARF have a higher risk of developing RHD<br />
RHD is a chronic condition resulting from scarring and deformity of the heart valves<br />
following ARF<br />
Related topics<br />
Upper respiratory tract infection - child<br />
Upper respiratory tract infection - adult<br />
Bacterial skin infections<br />
Bone and joint infections - child<br />
Acute rheumatic fever and rheumatic heart disease prophylaxis<br />
1. May present with<br />
• Fever and malaise<br />
• Painful tender swollen joints. Symptoms classically seen to progress from one<br />
joint to another (migratory polyarthritis) however only one joint may be affected<br />
(aseptic monoarthritis). Any joint can be involved but most commonly affects the<br />
large joints of the limbs - knees, ankles, elbows<br />
• Abdominal pain<br />
• Inability to weight-bear or walk unaided<br />
• Uncontrollable jerky movements of the trunk, face and / or limbs (Sydenham’s<br />
chorea), that disappear when asleep<br />
• Skin rash. This is rare, but highly suggestive of ARF (can be difficult to see in<br />
dark skinned people)<br />
• Small nodules over bony areas such as elbows and knees; again rare<br />
• History of a sore throat or skin infection within the previous 2 - 3 weeks<br />
• Breathlessness (if cardiac involvement), chest pain<br />
• Abnormal heart sounds<br />
2. Immediate management Not applicable<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 575
Immune complications<br />
3. Clinical assessment<br />
• Obtain complete patient history including:<br />
-- past episodes of ARF / RHD or previous symptoms suggesting history - ask<br />
whether benzathine penicillin injections have been ordered previously / have<br />
they been received regularly?<br />
-- recent history of sore throat, painful joint or skin infections and whether treated<br />
-- measures taken to treat presenting symptoms<br />
-- current medications<br />
• Perform standard clinical observations +<br />
-- O saturations<br />
2<br />
• Perform physical examination:<br />
-- inspect throat for signs of infection<br />
-- inspect and palpate all skin surfaces for signs of skin infection and pink skin<br />
rash with definite rounded borders, occurring mainly on the trunk, never on<br />
the face; blanches under pressure (erythema marginatum)<br />
-- inspect and palpate joints for swelling and tenderness and presence of small<br />
nodules (pea sized), painless, overlying bony prominences<br />
-- auscultate the heart to determine whether there is an audible murmur<br />
-- look for indications of heart failure - increased HR or irregular (heart block),<br />
increased respiratory rate, basal crackles in chest, liver enlargement, ankle<br />
oedema<br />
Diagnostic criteria ARF [1]<br />
• Diagnosis of ARF requires a combination of clinical and laboratory indicators and<br />
laboratory evidence of a recent group A streptococcal (GAS) infection<br />
• An experienced Medical Specialist should review the clinical presentation with<br />
pathology results to confirm the diagnosis and determine ongoing management.<br />
All suspected cases of ARF should be referred to a tertiary facility to have the<br />
diagnosis confirmed and to ensure adequate workup for appropriate long-term<br />
management<br />
• ARF is a notifiable condition in <strong>Queensland</strong> - contact the ARF / RHD Register<br />
in the area and the Public <strong>Health</strong> Unit<br />
• Note: Unlike most other notifiable diseases, ARF is not based solely upon a<br />
laboratory diagnosis, and therefore notification has to be done by the clinician /<br />
<strong>Health</strong> Care Worker<br />
Diagnostic criteria RHD<br />
• Diagnosis of RHD is based on the degree of damage to the heart<br />
• This is confirmed through the use of echocardiogram by an experienced clinician<br />
• Serial echocardiography plays a critical role in diagnosis and management<br />
576<br />
Controlled copy V1.0<br />
Primary Clinical Care Manual 2011
Immune complications<br />
Australian guidelines for the diagnosis of Acute rheumatic fever in high risk groups [1]<br />
For an initial episode of ARF to be confirmed there must be 2 major manifestations or 1 major and 2<br />
minor manifestations, plus evidence of a recent group A streptococcal infection.<br />
Since Sydenham’s chorea can occur after all other signs and symptoms have resolved, it can be used<br />
alone to confirm the diagnosis<br />
A recurrent episode of ARF (known past ARF or chronic RHD) requires 2 major or 1 major and 2 minor<br />
or 3 minor manifestations plus evidence of a recent GAS infection<br />
Major manifestations<br />
• Polyarthritis or aseptic monoarthritis or<br />
polyarthralgia. Usually migratory i.e. finishes<br />
in one joint, begins in another<br />
• Chorea - strange jerky movements of the<br />
trunk and / or limbs which the patient cannot<br />
control<br />
• Carditis - (including subclinical evidence of<br />
rheumatic valve disease on echocardiogram)<br />
• Erythema marginatum - pink skin rash with<br />
definite rounded borders, occurring mainly<br />
on the trunk, never on the face, and blanches<br />
under pressure<br />
• Subcutaneous nodules - small painless pea<br />
sized nodules over bony prominences (e.g.<br />
elbows)<br />
• Carditis identified on echocardiogram may<br />
be included as a major manifestation [1]<br />
Minor manifestations<br />
• History of fever or presenting fever >38ºC<br />
• Laboratory / other clinical findings:<br />
-- elevated acute phase reactants - ESR<br />
≥ 30 mm/hr or CRP ≥ 30 mg / L<br />
-- prolonged PR interval on ECG<br />
Supporting evidence of group A streptococcal infection<br />
• Group A streptococcus isolated on throat culture<br />
• Elevated or rising streptococcal antibody titre. See link for age related levels www.heartfoundation.<br />
org.au/Professional Information/Clinical Practice/ARF RHD/Pages/default.aspx<br />
These serological titres are often high at baseline in Aboriginal and Torres Strait Islander community<br />
children because of repeated infections with GAS. So acceptable evidence for recent GAS infection are<br />
either:<br />
-- titres of > 2 x reference e.g. ASOT > 400 IU / mL or Anti-DNase B > 600 U / mL or<br />
-- a rising titre when repeated after 10 - 14 days<br />
4. Management<br />
• Consult MO who will likely advise:<br />
-- evacuation / hospitalisation - confirmation and management of ARF should<br />
occur in hospital (a wrong diagnosis either positive or negative will have<br />
serious consequences)<br />
-- blood for FBC, ESR, C-reactive protein (CRP), ASOT, anti-DNase B and<br />
streptococcal serology<br />
-- swab throat and any skin sores<br />
• Take blood cultures if temperature ≥ 38°C<br />
• Record ECG<br />
• Consider chest x-ray and echocardiogram<br />
• Provide pain relief as required. Use paracetamol for pain and fever. Do not give<br />
aspirin or non-steroidal anti-inflammatory drugs (NSAID) until the diagnosis is<br />
confirmed - these may cause joint symptoms to disappear and complicate the<br />
diagnosis<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 577
Immune complications<br />
578<br />
• Treatment of ARF is based on the eradication of GAS infection and management<br />
of symptoms:<br />
-- IM benzathine penicillin to eliminate streptococci (even if group A streptococci<br />
not isolated on culture)<br />
-- oral penicillin should not normally be used, as completion of 10 days of<br />
treatment cannot be guaranteed<br />
See Simple analgesia back cover<br />
Schedule 4<br />
Benzathine penicillin<br />
(Bicillin LA)<br />
Controlled copy V1.0<br />
DTP<br />
IHW / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic must consult MO / NP<br />
Form Strength<br />
Disposable<br />
syringe<br />
Route of<br />
administration<br />
900 mg IM<br />
Recommended<br />
dosage<br />
Child < 20 kg<br />
450 mg<br />
Adult / child ≥ 20 kg<br />
900 mg<br />
Duration<br />
Use a concentration of 442 mg / mL when measuring part doses. Refer to product information<br />
Provide Consumer Medicine Information<br />
Management of associated emergency: as for severe allergic reactions. See Anaphylaxis<br />
Administration tips - as per patient preference:<br />
-- apply EMLA cream to the injection site 30 - 60 minutes prior to injection and allow medication to warm<br />
up to room temperature or<br />
-- allow medication to warm up to room temperature, apply pressure with thumb (to the exact injection<br />
site) 30 seconds prior to the injection, use 21 gauge needle and deliver injection very slowly (2 minutes)<br />
[1] [2]<br />
• If reliably documented allergy to penicillin treat with erythromycin [1]<br />
• If penicillin allergy not reliably documented arrange for testing in hospital<br />
Schedule 4 Erythromycin<br />
DTP<br />
IHW / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic must consult MO / NP<br />
Form Strength<br />
Capsule 250 mg<br />
Suspension 200 mg / 5 mL<br />
Route of<br />
administration<br />
Oral<br />
Recommended<br />
dosage<br />
500 mg bd<br />
20 mg / kg / dose bd<br />
to a max. of 500 mg bd<br />
Provide Consumer Medicine Information: take with food<br />
Management of associated emergency: as for severe allergic reactions. See Anaphylaxis<br />
Stat<br />
Duration<br />
10 days<br />
5. Follow up<br />
Assign an individualised management plan based on ARF and absence or<br />
[1]<br />
Primary Clinical Care Manual 2011
presence of RHD<br />
Place person on Recall Register and monitor closely<br />
Immune complications<br />
Recommended duration of secondary prophylaxis.<br />
-- the most effective regime for continuous prophylaxis is a 4 weekly injection<br />
of benzathine penicillin - may be increased to 3 weekly, see current edition<br />
of NHFA guideline www.heartfoundation.org.au<br />
-- consult MO for antibiotic prophylaxis for procedures expected to produce<br />
bacteraemia<br />
Provide education and support to patient and family. Resources available include;<br />
Strong Heart, Strong Body books, DVD and reminder cards (from Tropical Public<br />
<strong>Health</strong>)<br />
Contact the ARF / RHD Control Program (arfregister@health.qld.gov.au) in your<br />
district or Public <strong>Health</strong> Unit for help, even if ARF only suspected<br />
Antenatal patients with RHD may deteriorate because of the increased cardiac<br />
workload during pregnancy. Pregnant women known to have RHD need to be<br />
assessed early in pregnancy and monitored closely with 2 weekly follow up.<br />
The woman will also need antibiotic cover if prolonged labour and / or ruptured<br />
membranes [1]<br />
Primary prevention:<br />
-- have a low threshold for treating throat infections with penicillin in Aboriginal<br />
and Torres Strait Islander and Pacific Islander children. See URTI - child /<br />
URTI - adult<br />
-- reduce the prevalence of scabies and impetigo<br />
Give influenza and pneumococcal vaccines according to the current edition of the<br />
NHMRC Australian Immunisation Handbook. See Immunisation program<br />
6. Referral / consultation<br />
Consult MO on all occasions of suspected ARF<br />
Consult MO for anticoagulation therapy / INR range<br />
Refer to Paediatrician within 3 months of diagnosis<br />
References<br />
1. National Heart Foundation, RF/RHD Guideline Development Working Group, and Cardiac Society of<br />
Australia and New Zealand, Diagnosis and management of acute rheumatic fever and rheumatic heart<br />
disease in Australia: An evidence based review. 2006, National Heart Foundation Australia.<br />
2. Therapeutic Guidelines. Rheumatic fever in children. 2010 [cited 2011 January].<br />
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Controlled copy V1.0<br />
Assessment of the ear<br />
History<br />
• Obtain a complete patient history<br />
• Of particular note is environmental history e.g. dusty, passive smoking or smoker<br />
• Social history<br />
• Surgical history, medical history<br />
• Has the patient been swimming?<br />
• Of particular importance are problems with hearing, speech and language<br />
• Does the patient have any pain? Is there pain on movement of the pinna? Describe<br />
pain, how long has the patient had the symptoms? Young children may not be able to<br />
localise their pain but parent may notice they are unsettled or pulling at an ear<br />
• Is the ear itchy?<br />
• Is this the first episode? Note the number of past episodes<br />
• Is there a history of URTI? How many?<br />
• Is the person under the care of ENT physician? Audiologist?<br />
• Is there a history of AOM with perforation?<br />
• Have any measures been used to treat the ear?<br />
Examination<br />
• Examine ear at eye level<br />
• Position infant / toddlers on parent / carer’s knee. Older child can stand and adult sit<br />
• Often very painful - approach gently<br />
Outer ear<br />
• Inspect the external ear - is there any sign of inflammation?<br />
• Palpate the ear - is it warm to touch? Is there pain on moving the pinna?<br />
• Palpate behind the ear? Is the mastoid bone swollen? hot?<br />
• Palpate the occiput, around the ears, both sides of the neck for lymph glands<br />
• Is there auricular tenderness? pain? tenderness on palpation of mastoid?<br />
Ear canal<br />
• Inspect the ear canal for discharge, redness / swelling, fungal membrane or debris,<br />
lumps or bony growths, foreign body, extruding grommets, wax, fluid<br />
• If pain levels allow, inspect the ear canal for inflammation, exudates, lesions or foreign<br />
bodies<br />
Tympanic membrane (ear drum)<br />
• Colour of drum - is it normal - transparent and shiny, or dull?<br />
• Cone of light - right ear at 5 o’clock, left ear at 7 o’clock<br />
• Handle of malleus - right ear 1 o’clock, left ear 11 o’clock<br />
• Is the ear drum intact? bulging? retracted?<br />
• Is there fluid or air / fluid or bubbles behind the ear drum?<br />
Right<br />
Left<br />
Primary Clinical Care Manual 2011
Ear problems<br />
• Clean the ear using tissue spears until all pus has been removed and the drum and<br />
perforation can be seen. Document the size and position of perforation on a diagram<br />
in the case notes. If an unsafe perforation (in the attic region) of the ear drum is<br />
found consult MO immediately<br />
Attic perforation - unsafe perforation<br />
Safe perforation<br />
Related systems<br />
• Nose and throat<br />
• Examine the nose and throat - is there any discharge from nose? describe<br />
Chest<br />
• Auscultate the chest for air entry and any added sounds (crackles or wheezes)<br />
• Note other injuries if present e.g. cause of traumatic rupture of the ear drum<br />
Hearing screening and assessment commences from birth across the life span. Refer to<br />
current edition of Chronic Disease Guidelines available at www.health.qld.gov.au/cdg for<br />
procedures in performing:<br />
• Otoscopy<br />
• Audiometry to assess hearing level<br />
• Tympanometry to test middle ear function<br />
If a person is under the care of an Ear Nose and Throat Specialist or Audiologist ensure<br />
they are up to date with appointments / care<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 581
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Controlled copy V1.0<br />
Ear infections<br />
Recommend<br />
Language and speech develop in the 0 - 5 year age group. Assessment for possible<br />
middle ear disease, hearing impairment and speech and language problems should<br />
be a routine part of the primary care of children aged 0 - 5 years<br />
Prevention of otitis media through [1]:<br />
- - encouraging family or care giver to present child for treatment early if there are<br />
features of otitis media. Informing family of risk if child is in a high risk group<br />
(includes Aboriginal and Torres Strait Islander children)<br />
- - informing family and carers that onset of otitis media can occur within the first<br />
months of life. Baby may have pain, irritability, fever or ear discharge<br />
- - there is an increased risk of acute otitis media during respiratory infections<br />
- - the family or care giver should be advised that ear pain may be absent and that<br />
regular clinic attendance for ear examinations is recommended<br />
- - personal hygiene - children’s hands and faces should be washed. Transmission<br />
of bacteria causing otitis media is often from other children’s hands<br />
- - breastfeeding for at least three months reduces the risk of otitis media and should<br />
be encouraged<br />
- - smoke exposure is a risk for otitis media in children. Adults should be encouraged<br />
to quit smoking or smoke outside away from children<br />
- - swimming should not be discouraged unless it is known to be associated with<br />
new infections in that person<br />
- - full immunisation; 23 valent pneumococcal vaccine (Pneumovax 23®) for children<br />
4 - 5 years of age who are at risk of pneumococcal infections<br />
Definitions [1]<br />
• Acute otitis media (AOM) - presence of fluid behind the ear drum plus at least one of<br />
the following: bulging ear drum, red ear drum, recent discharge of pus, fever, ear pain<br />
or irritability<br />
• Recurrent acute otitis media (rAOM) - the occurrence of three or more episodes of<br />
acute otitis media in a six month period<br />
• Otitis media with effusion (OME, glue ear) - presence of fluid behind the ear drum<br />
without any symptoms or signs of acute otitis media<br />
• Acute otitis media with acute perforation (AOM with perforation less than 6 weeks) -<br />
discharge of pus through a perforation (hole) in the ear drum within the last six weeks<br />
• Chronic suppurative otitis media (CSOM discharging more than 6 weeks) - persistent<br />
discharge of pus through a perforation (hole) in the ear drum for at least six weeks<br />
despite appropriate treatment for acute otitis media with perforation<br />
Primary Clinical Care Manual 2011
Ear problems<br />
Acute otitis media (AOM)<br />
Non-discharging painful ear<br />
Recommend<br />
Consult MO immediately if child is < 3 months of age, who is sick or hot, or meets<br />
any of the other criteria outlined at beginning of paediatric section<br />
All children with AOM should be reviewed after four to seven days of treatment or<br />
earlier if deterioration [1]. A second review should take place after completion of<br />
therapy [1]<br />
<strong>Health</strong> clinics have targeted hearing health programs to focus on day care and pre<br />
school children where intervention may prevent ear damage and hearing loss<br />
Personal hygiene in children - washing hands and face is important<br />
Background<br />
In some rural and remote Aboriginal communitites complications of otitis media<br />
are much more common. They include tympanic membrane perforations, CSOM,<br />
OME and mastoiditis. This is the reason that antibiotics are recommended in these<br />
children, while in low risk populations the advantage of antibiotics is small<br />
Related topics<br />
Upper respiratory tract infection - child<br />
Pneumonia<br />
Acute asthma<br />
Bronchiolitis<br />
Assessment of the ear<br />
1. May present with<br />
• A history of acute onset of signs and symptoms<br />
• Young child may present with irritability, disturbed sleep, pulling at ears, sometimes<br />
vomiting and diarrhoea<br />
• Fever or upper respiratory symptoms<br />
• Pain clearly originating from the ear<br />
• Some children will not have pain but a red bulging drum is found on routine exam<br />
2. Immediate management Not applicable<br />
3. Clinical assessment<br />
• Obtain a complete patient history. See Assessment of the ear<br />
• Perform standard clinical observations<br />
• Perform physical examination. See Assessment of the ear Look for inflammation<br />
with a red bulging tympanic membrane and loss of light reflex<br />
4. Management<br />
• Provide adequate and regular analgesia<br />
See Simple analgesia back cover<br />
• Consult MO if child:<br />
- - < 3 months of age, who is sick or hot<br />
-- temperature over 38° C or below 36°C<br />
-- has any rash, increased respiratory rate or respiratory distress or meets any<br />
of the other criteria as outlined at beginning of paediatric section - this child<br />
needs to be managed as a septic infant<br />
• Spontaneous resolution of AOM is unlikely in high risk populations therefore if not<br />
allergic to penicillin treat with amoxycillin [1]<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 583
Ear problems<br />
584<br />
• Talk to the family about the need to complete the full course of antibiotics and to<br />
return at 4 - 7 days for the ear to be checked<br />
• Give or help to give the first dose in the clinic and ensure the family know the right<br />
dose to give. If family do not have a fridge at home they may have to return to the<br />
health service for medicine each day<br />
Schedule 4 Amoxycillin<br />
DTP<br />
IHW / SM R&IP / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic must consult MO / NP<br />
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed<br />
Form Strength<br />
Route of<br />
administration<br />
Recommended<br />
dosage<br />
250 mg<br />
Capsule<br />
Adult and child<br />
500 mg<br />
Oral 25 mg / kg / dose bd<br />
125 mg / 5 mL<br />
Suspension to a max. of 1 g bd<br />
250 mg / 5 mL<br />
Provide Consumer Medicine Information<br />
Management of associated emergency: as for severe allergic reactions. See Anaphylaxis<br />
Controlled copy V1.0<br />
Duration<br />
7 days<br />
[4] [6]<br />
• If parent or <strong>Health</strong> Care Worker think it will be difficult to comply with oral antibiotics<br />
or if the child has significant diarrhoea or vomiting, treat with IM procaine penicillin<br />
with the option to return to oral antibiotic once vomiting settles<br />
Schedule 4 Procaine penicillin<br />
DTP<br />
IHW / SM R&IP / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic must consult MO / NP<br />
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed<br />
Form Strength<br />
Route of<br />
administration<br />
Recommended<br />
dosage<br />
Adult<br />
Duration<br />
Disposable<br />
syringe<br />
1.5 g IM<br />
1.5 g daily<br />
Child<br />
50 mg / kg / dose daily<br />
to a max. of 1.5 g daily<br />
5 days<br />
Provide Consumer Medicine Information<br />
Management of associated emergency: as for severe allergic reactions. See Anaphylaxis<br />
Administration tips - as per patient preference:<br />
-- apply EMLA cream to the injection site 30 - 60 minutes prior to injection and allow medication to warm<br />
up to room temperature or<br />
-- allow medication to warm up to room temperature, apply pressure with thumb (to the exact injection<br />
site) 30 seconds prior to the injection, use 21 gauge needle and deliver injection very slowly (2 minutes)<br />
[3] [4]<br />
• If allergic to penicillin, treat with roxithromycin<br />
Primary Clinical Care Manual 2011
Ear problems<br />
Schedule 4 Roxithromycin<br />
DTP<br />
IHW / SM R&IP / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic must consult MO / NP<br />
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed<br />
Form Strength<br />
Route of<br />
administration<br />
Recommended<br />
dosage<br />
Duration<br />
Tablet<br />
150 mg<br />
300 mg<br />
Adult<br />
300 mg daily<br />
Tablet for<br />
suspension<br />
50 mg<br />
Oral<br />
Child<br />
4 mg / kg / dose bd<br />
to a max. of 150 mg bd<br />
10 days<br />
Provide Consumer Medicine Information: should be taken on an empty stomach, 15 minutes before food.<br />
Ensure course is completed<br />
Management of associated emergency: consult MO<br />
[5]<br />
5. Follow up<br />
Review the patient in 4 - 7 days<br />
If not improving consult MO who may consider alternative or increased dose of<br />
antibiotic<br />
At next MO visit. If child not improved needs weekly review. Child < 2 years of<br />
age may need many weeks of antibiotics [6]<br />
Review after completion of treatment at the 1 week mark<br />
Ask family about child’s hearing, speech development, behaviour, school progress.<br />
If there are concerns about any of these refer for formal hearing assessment if not<br />
done recently<br />
To prevent recurrent otitis media and transmission of bacteria to other children<br />
encourage personal hygiene in children - washing hands and face<br />
Breathe, blow and cough (BBC) program is targeted at school aged children<br />
Review at 3 months to identify those with chronic disease [1]<br />
6. Referral / consultation<br />
Consult MO as above<br />
If otitis media is recurrent (more than 3 episodes in 6 months or more than 4 in 12<br />
months) the MO may consider antibiotics for prophylaxis [1]<br />
ENT specialist for those with frequent painful AOM<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 585
Ear problems<br />
586<br />
Otitis media with effusion (OME)<br />
Painless non discharging ears, glue ear<br />
Recommend<br />
Review children with bilateral OME at 3 monthly intervals and refer if required<br />
<strong>Health</strong> clinics have targeted hearing health programs to focus on day care and<br />
pre school children where intervention may prevent ear damage and hearing loss.<br />
Personal hygiene in children - washing hands and face and keeping face clear of<br />
nasal discharge is most effective<br />
Provide full immunisation<br />
Background<br />
OME is diagnosed if thick fluid persists in the middle ear usually after AOM<br />
OME results in thick glue like material filling the middle ear which may take many<br />
months to resolve. It is important because children with OME will have impaired<br />
hearing. If hearing is impaired for a significant length of time especially at the critical<br />
age of language learning in the first 5 years it may result in significant long term<br />
disability<br />
Decongestants and antihistamines are not recommended [7]<br />
Steroids are not recommended [1] but inhaled steroids may be trialed in children<br />
where significant nasal obstruction, sneezing etc. suggests allergic rhinitis<br />
Related topics<br />
Acute otitis media<br />
Immunisation program<br />
Controlled copy V1.0<br />
Assessment of the ear<br />
1. May present with<br />
• Usually is asymptomatic<br />
• Parents may be concerned about the child’s hearing<br />
• Diagnosis may also be suspected at routine ear examination, in a child being<br />
followed up after AOM, or in a child referred for medical assessment because of<br />
hearing impairment on testing<br />
• Child may have:<br />
-- past history of recurrent otitis media<br />
-- concerns about speech or language development<br />
• Reported decrease in hearing<br />
• Reported poor hearing leading to learning difficulties<br />
2. Immediate management Not applicable<br />
3. Clinical assessment<br />
• Obtain a complete patient history. See Assessment of the ear<br />
• Perform standard clinical observations<br />
• Perform physical examination. See Assessment of the ear<br />
-- the following may be noted on examination<br />
○ air / fluid level, bubbles behind the ear drum<br />
○ retraction of ear drum<br />
○ limited or absent movement of the ear drum with pneumatic otoscopy.<br />
This is the best way to diagnose - refer to audiology / MO to perform.<br />
Diagnosis is confirmed by tympanometry which shows a type B (stiff ear<br />
drum) pattern<br />
Primary Clinical Care Manual 2011
Ear problems<br />
4. Management<br />
• Give amoxycillin<br />
• Arrange for audiology if there are concerns about hearing or speech or OME is<br />
persistent for > 3 months<br />
• Refer to ENT specialist:<br />
- - if hearing test shows moderate impairment in both ears for more than 3<br />
months<br />
-- if there is speech delay and effusion persists more than 3 months or<br />
-- if there is more severe hearing impairment or concerns about the appearance<br />
of the drum<br />
• Encourage personal hygiene in children - washing hands and face and keeping<br />
face clear of nasal discharge<br />
• Breathe, blow, cough (BBC) program is for school aged children<br />
• Check immunisation status particularly Pneumovax and perform catch up<br />
immunisation if required<br />
Schedule 4 Amoxycillin<br />
DTP<br />
IHW / SM R&IP / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic must consult MO / NP<br />
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed<br />
Form Strength<br />
Route of<br />
administration<br />
Recommended<br />
dosage<br />
250 mg<br />
Capsule<br />
Adult and child<br />
500 mg<br />
Oral 25 mg / kg / dose bd<br />
125 mg / 5 mL<br />
Suspension to a max. of 1 g bd<br />
250 mg / 5 mL<br />
Provide Consumer Medicine Information<br />
Management of associated emergency: as for severe allergic reactions. See Anaphylaxis<br />
Duration<br />
14 days<br />
[4] [6]<br />
• If not resolved may need a further 14 days to a total of 28 days. If allergic to<br />
amoxycillin see Antibiotics for acute otitis media<br />
5. Follow up<br />
3 monthly<br />
If OME persists for > 3 months arrange - audiometry and tympanometry<br />
See the current edition of the Chronic Disease Guidelines available at:<br />
www.health.qld.gov.au/cdg<br />
6. Referral / consultation<br />
Next MO visit<br />
Refer to ENT specialist if:<br />
-- any concerns about hearing or speech<br />
-- problem remains longer than 3 months<br />
-- antibiotic therapy has failed<br />
-- has severe retracted ear drum<br />
If there is speech delay refer to Speech Pathologist<br />
If hearing is impaired in school children make sure the school is informed, with<br />
parental consent, as the teacher can use measures to assist child<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 587
Ear problems<br />
588<br />
Acute otitis media with acute perforation<br />
Discharging ear for less than 6 weeks - may be painful<br />
Recommend<br />
If seen in the first days treat see Acute otitis media<br />
Always follow up to ensure perforation has healed<br />
If discharge does not resolve by 14 days add ciprofloxacin drops and increase the<br />
dose of oral amoxicillin<br />
If discharge continues through an established perforation after 6 weeks of treatment<br />
treat See Chronic suppurative otitis media (CSOM)<br />
You may need to clean the discharge from the ear before you can see the drum, you<br />
can usually do this by gently cleaning with a tissue spear<br />
Background<br />
Infection behind the eardrum may cause the drum to rupture<br />
AOM with perforation occurs mainly in the first 18 months of life and effective<br />
treatment will dramatically reduce the incidence of chronic suppurative otitis media<br />
(CSOM) [1]<br />
Ciprofloxacin drops are restricted on the Pharmaceutical Benefits Scheme to<br />
treatment of chronic suppurative otitis media:<br />
-- in an Aboriginal or a Torres Strait Islander person aged 1 month or older<br />
-- in a patient less than 18 years of age with perforation of the tympanic membrane<br />
-- in a patient less than 18 years of age with a grommet in situ<br />
If not in an S100 community MO will need to obtain authority script<br />
Related topics<br />
Acute otitis media<br />
Chronic suppurative otitis media (CSOM)<br />
Controlled copy V1.0<br />
Cleaning technique for ears with<br />
discharge<br />
Assessment of the ear<br />
1. May present with<br />
• Presents with onset of ear discharge for < 6 weeks<br />
• Child may often have symptoms of acute otitis media - pain, fever<br />
2. Immediate management Not applicable<br />
3. Clinical assessment<br />
• Obtain a complete patient history. See Assessment of the ear<br />
• Document length of time perforation has been present<br />
• Perform standard clinical observations<br />
• Perform physical examination. See Assessment of the ear:<br />
-- for otoscopic examination - you may need to clean the discharge from the ear<br />
before you can see the drum, you can usually do this by gently cleaning with<br />
a tissue spear<br />
-- document the size and position of perforation on a diagram in the case notes<br />
4. Management<br />
• Give analgesia if required<br />
• If not allergic to penicillin treat with amoxycillin<br />
• If the discharge has been present for > 14 days the MO may increase the dose of<br />
amoxycillin and order use of ciprofloxacin drops<br />
• If the discharge has been present for >6 weeks the condition is chronic suppurative<br />
otitis media (CSOM). Treatment is as for CSOM. Oral antibiotics are not indicated<br />
Primary Clinical Care Manual 2011
See Simple analgesia back cover<br />
Ear problems<br />
Schedule 4 Amoxycillin<br />
DTP<br />
IHW / SM R&IP / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic must consult MO / NP<br />
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed<br />
Form Strength<br />
Route of<br />
administration<br />
Recommended<br />
dosage<br />
250 mg<br />
Capsule<br />
Adult and child<br />
500 mg<br />
Oral 25 mg / kg / dose bd<br />
125 mg / 5 mL<br />
Suspension to a max. of 1 g bd<br />
250 mg / 5 mL<br />
Provide Consumer Medicine Information<br />
Management of associated emergency: as for severe allergic reactions. See Anaphylaxis<br />
Duration<br />
7 days<br />
• If parent or <strong>Health</strong> Care Worker thinks it will be very difficult to comply with oral<br />
antibiotic treatment or if the child has significant diarrhoea or vomiting, treat with<br />
IM procaine penicillin with the option to return to oral antibiotic once vomiting<br />
settles<br />
Schedule 4 Procaine penicillin<br />
DTP<br />
IHW / SM R&IP / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic must consult MO / NP<br />
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed<br />
Form Strength<br />
Route of<br />
administration<br />
Recommended<br />
dosage<br />
Adult<br />
Duration<br />
Disposable<br />
syringe<br />
1.5 g IM<br />
1.5 g daily<br />
Child<br />
50 mg / kg / dose<br />
to a max. of 1.5 g daily<br />
5 days<br />
Provide Consumer Medicine Information<br />
Management of associated emergency: as for severe allergic reactions. See Anaphylaxis<br />
Administration tips - as per patient preference:<br />
-- apply EMLA cream to the injection site 30 - 60 minutes prior to injection and allow medication to warm<br />
up to room temperature or<br />
-- allow medication to warm up to room temperature, apply pressure with thumb (to the exact injection<br />
site) 30 seconds prior to the injection, use 21 gauge needle and deliver injection very slowly (2 minutes)<br />
[4]<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 589<br />
[4]
Ear problems<br />
590<br />
• If allergic to penicillin and has perforation for less than 6 weeks treat with<br />
roxithromycin<br />
Schedule 4 Roxithromycin<br />
DTP<br />
IHW / SM R&IP / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic must consult MO / NP<br />
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed<br />
Form Strength<br />
Route of<br />
administration<br />
Recommended<br />
dosage<br />
Duration<br />
Tablet<br />
150 mg<br />
300 mg<br />
Adult<br />
300 mg daily<br />
Tablet for<br />
suspension<br />
50 mg<br />
Oral<br />
Child<br />
4 mg / kg / dose bd<br />
to a max. of 150 mg bd<br />
10 days<br />
Provide Consumer Medicine Information: should be taken on an empty stomach, 15 minutes before food.<br />
Ensure course is completed<br />
Management of associated emergency: consult MO<br />
[5]<br />
• If discharge present for longer than 14 days MO may add ciprofloxacin drops<br />
Schedule 4<br />
Ciprofloxacin hydrochloride<br />
ear drops<br />
DTP<br />
IHW<br />
Ciprofloxacin hydrochloride ear drops must be ordered by MO / NP. MO / NP note restrictions<br />
Authorised Indigenous <strong>Health</strong> Workers can only administer on MO / NP order<br />
Form Strength<br />
Route of<br />
administration<br />
Recommended<br />
dosage<br />
Duration<br />
Ear drops<br />
Ear drops<br />
(0.3%)<br />
Topical<br />
Instil 5 drops in<br />
affected ear bd<br />
Until the ear is dry<br />
or 9 days<br />
Provide Consumer Medicine Information: if not drying in 2 weeks check with family on ability to clean and<br />
instil drops<br />
Management of associated emergency: as for severe allergic reactions. See Anaphylaxis<br />
Administration tip<br />
-- The patient should be sitting or lying down with the affected ear upwards<br />
-- Once the drops have been instilled maintain position for 30 - 60 sec.<br />
-- Apply tragal pressure (pressing several times on the flap of skin in front of ear canal) after the drops<br />
have been instilled to assist the drops through the perforation<br />
[8]<br />
5. Follow up<br />
Review the patient in 2 days<br />
If not improving consult MO<br />
Weekly review until the signs of AOM with perforation have resolved<br />
If failing to resolve discuss with parents / carer - explore if the child is being<br />
given antibiotics. Is the child spitting it out or vomiting afterwards? Consider daily<br />
treatment in the clinic or use IM procaine penicillin<br />
If the discharge continues after 6 weeks of treatment manage See Chronic<br />
suppurative otitis media (CSOM)<br />
If perforation heals review in 6 weeks:<br />
- - inspect ear drum<br />
-- perform hearing assessment - audiometry and tympanometry<br />
- - advise to prevent recurrent otitis media with good personal hygiene in children<br />
- - Breathe, blow, cough (BBC) program is targeted at school aged children<br />
Controlled copy V1.0<br />
Primary Clinical Care Manual 2011
Ear problems<br />
6. Referral / consultation<br />
Consult MO as above<br />
If concerns about hearing, speech, language development or the child has had<br />
recurrent AOM refer for audiology<br />
Chronic otitis media<br />
Discharging and non-discharging<br />
Chronic suppurative otitis media (CSOM)<br />
Ear has been discharging for more than 6 weeks<br />
Recommend<br />
Consult MO immediately if unsafe perforation of the eardrum found (in the attic<br />
region). See Assessment of the ear<br />
Use antibiotic ear drops with tissue spears (dry mopping) to reduce the production<br />
of pus [1]<br />
Document the duration of ear discharge and size and position of perforation [1]<br />
Treat discharging ears actively<br />
Background<br />
CSOM is diagnosed in children who have discharging ears for more than 6 weeks [1]<br />
Related topics<br />
Acute otitis media with perforation<br />
Chronic suppurative otitis media<br />
(CSOM)<br />
Cholesteatoma<br />
Cleaning technique for ears with chronic<br />
discharge<br />
Assessment of the ear<br />
1. May present with<br />
• Intermittent and continuous ear discharge often associated with poor hearing<br />
leading to learning difficulties<br />
2. Immediate management<br />
• Consult MO if perforation found in attic region (unsafe perforation) of the ear<br />
drum See Assessment of the ear<br />
3. Clinical assessment<br />
• Obtain a complete patient history. See Assessment of the ear<br />
• Document length of time discharge has been present<br />
• Perform standard clinical observations<br />
• Perform physical examination See Assessment of the ear:<br />
-- -clean the ear using tissue spears until all pus has been removed and the<br />
drum and perforation can be seen<br />
-- document the size and position of perforation on a diagram in the case notes<br />
4. Management<br />
• Dry mopping twice daily until tissue is dry, followed by ciprofloxacin ear drops<br />
twice per day<br />
1. Ciprofloxacin ear drops<br />
2. Use Sofradex ear drops only if ciprofloxacin drops not available<br />
• Consult MO for ciprofloxacin order<br />
• For removal of pus and debris from ear canal See Cleaning techniques for ears<br />
with chronic discharge<br />
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Ear problems<br />
592<br />
• In young children it may be difficult for family members to adequately clean the<br />
ears and instil the drops - clinic staff are advised to do this daily for 7 days<br />
• Encourage personal hygiene in children - washing hands and face<br />
• Avoid swimming or immersing head under water<br />
• Consult MO if perforation found in attic region (unsafe perforation) of the ear drum<br />
Schedule 4<br />
Ciprofloxacin hydrochloride<br />
ear drops<br />
DTP<br />
IHW<br />
Ciprofloxacin hydrochloride ear drops must be ordered by MO / NP. MO / NP note restrictions<br />
Authorised Indigenous <strong>Health</strong> Workers can only administer on MO / NP order<br />
Form Strength<br />
Route of<br />
administration<br />
Recommended<br />
dosage<br />
Duration<br />
Ear drops 0.3 % Topical<br />
Instil 5 drops in<br />
affected ear bd<br />
Until the ear is dry or<br />
9 days<br />
Provide Consumer Medicine Information<br />
Management of associated emergency: as for severe allergic reactions. See Anaphylaxis<br />
Administration tip<br />
• The patient should be sitting or lying down with the affected ear upwards<br />
• Once the drops have been instilled maintain position for 30 - 60 secs<br />
• Apply tragal pressure (pressing several times on the flap of skin in front of ear canal) after the drops<br />
have been instilled to assist the drops through the perforation<br />
[8]<br />
• or<br />
Schedule 4<br />
Sofradex ® ear drops<br />
(Dexamethasone 0.5 mg / Framycetin Sulphate<br />
5 mg / Gramicidin 0.05 mg / mL)<br />
Controlled copy V1.0<br />
DTP<br />
IHW / SM R&IP / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic must consult MO / NP<br />
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed<br />
Form Strength<br />
Route of<br />
administration<br />
Recommended<br />
dosage<br />
Duration<br />
Until the middle ear has<br />
Ear drops<br />
See<br />
above<br />
Topical 3 drops qid<br />
been free of discharge<br />
for at least 3 days<br />
Do not administer longer<br />
than 7 days<br />
Provide Consumer Medicine Information: evidence of ototoxicity - limit treatment to no longer than 7<br />
days<br />
Management of associated emergency: consult MO<br />
Administration tip<br />
• The patient should lie with their head on a pillow for several minutes after administration to allow the<br />
drops to gravitate to the bottom of the ear canal<br />
• Apply tragal pressure (pressing several times on the flap of skin in front of ear canal) after the drops<br />
have been instilled to assist the drops through the perforation<br />
[2]<br />
Primary Clinical Care Manual 2011
Ear problems<br />
5. Follow up<br />
Children < 5 years of age, review and treat daily for 7 days. If not drying in older<br />
children consider daily treatment in the clinic. Suction under direct vision is very<br />
useful to clear the ear if clinics have the equipment and staff have experience and<br />
training<br />
If not improving consult MO<br />
Teach patient / carer cleaning technique and instillation of drops<br />
See next MO clinic<br />
Review weekly thereafter until ear is dry<br />
If the ear is still discharging, consult MO<br />
When the ear dries review at 3 months<br />
To prevent recurrent otitis media encourage personal hygiene in children - washing<br />
hands and face<br />
Breathe Blow Cough (BBC) program is targeted at school aged children<br />
6. Referral / consultation<br />
For hearing assessment - audiometry and tympanometry when ear dry<br />
With education staff<br />
Consult MO as above including a presentation with perforation in the upper drum<br />
(attic). Note unsafe perforation attic retraction or suspicion of cholestoma will<br />
need urgent referral to ENT<br />
Refer to ENT specialist:<br />
-- if ear continues to discharge for 4 months<br />
-- unsafe perforation<br />
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Ear problems<br />
Cleaning techniques for ears with chronic discharge<br />
Suction<br />
• Suction under direct vision is the most effective technique but this requires special<br />
equipment and training<br />
Dropper method<br />
• The ear canal can be cleaned by irrigating with clean water using an eye dropper<br />
• An eye dropper uses a small volume of wash solution at low pressure and is therefore<br />
relatively safe in unskilled hands<br />
• Eye droppers are cheap and easy to obtain and to clean for use at home<br />
Equipment<br />
• A clean eye dropper and bulb. This can be washed with soap and water or an antiseptic<br />
• A clean container of clean water (sterile or cool boiled) (some rainwater tanks may be<br />
contaminated)<br />
• Clean container for the dirty water from the ear<br />
Technique<br />
1. The patient should be sitting or lying down with the affected ear upwards<br />
2. Using a clean dropper filled with clean water, squirt water into the discharging ear.<br />
Only the tip of the dropper needs to be in the canal. Without withdrawing the dropper<br />
and just by releasing the bulb, suck the water and pus back into the dropper<br />
3. Discard the contents of the dropper into the container for dirty water. Do not squirt the<br />
water in and out of the ear. When all the pus has been washed out of the ear, the water<br />
sucked back into the dropper is clear<br />
4. Repeat the above steps until there is clean return from the ear<br />
5. Dry the ear canal using tissue spears (see details)<br />
Tissue spear method (dry mopping)<br />
• This can safely be done by a child on their own or by the parent. It should be done<br />
whenever the ear discharges. The tissue paper actively absorbs the moisture<br />
• In the management of chronic suppurative otitis media, the tissue spear method should<br />
be used in conjunction with regular eye dropper irrigation by the <strong>Health</strong> Care Worker<br />
Technique<br />
1. Make a spear by twisting corner of tissue paper<br />
2. Insert into ear gently, twisting slowly<br />
3. Stop when child blinks<br />
4. Leave in place for 30 seconds then remove and repeat until tissue tip is dry<br />
5. Perform at least twice per day until the ear is dry<br />
Topical antibiotics and other ear drops with dry mopping<br />
• The patient should be sitting or lying down with the affected ear upwards<br />
• Clean and dry the ear canal as per dropper method and tissue spears<br />
• Instil the ear drops<br />
• Apply tragal pressure (pressing several times on the flap of skin in front of ear canal)<br />
after the drops have been instilled to assist the drops through the perforation [1]<br />
• Keep the patient in position for several minutes<br />
• Use of cotton wool as a ‘plug’ just soaks up the medication. Let excess run out<br />
594<br />
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Primary Clinical Care Manual 2011
Ear problems<br />
Ear discharge in the presence of grommets<br />
1. May present with<br />
• History of insertion of grommet in one or both ears<br />
• Discharge of pus from a grommet, fever, URTI, related to water immersion<br />
2. Immediate management Not applicable<br />
3. Clinical assessment<br />
• Obtain a complete patient history. See Assessment of the ear<br />
• Perform standard clinical observations<br />
• Perform physical examination. See Assessment of the ear plus:<br />
-- clean the ear using tissue spears until all pus has been removed and the<br />
drum and perforation can be seen<br />
-- document the size and position of perforation on a diagram in the case notes<br />
4. Management<br />
• Consult MO for antibiotic order<br />
• Treat as per Acute otitis media with perforation<br />
5. Follow up<br />
As per MO instructions<br />
Advise no swimming. If this is not possible in a hot tropical climate, ear plugs with<br />
a swimming cap for swimming are recommended for children with grommets.<br />
Effective ear plugs can be custom built or made from silicon putty, cotton wool<br />
with Vaseline, or “Blu-Tack®”<br />
6. Referral / consultation<br />
As above<br />
Cholesteatoma<br />
Recommend<br />
Be aware of cholesteatoma when performing all otoscopic examinations<br />
Cholesteatoma is treated surgically and success is highly dependent on early<br />
recognition and the extent of the lesion<br />
Background<br />
Most patients who acquire cholesteatomas have a history of recurrent acute otitis<br />
media and / or chronic middle-ear perforation<br />
Patients with a family history of chronic middle ear disease and / or cholesteatoma<br />
are at increased risk [9]<br />
Related topics<br />
Acute otitis media with perforation Assessment of the ear<br />
1. May present with<br />
If diagnosed early may have no symptoms. Otherwise may present with:<br />
• Dizziness, ache behind the ear especially at night<br />
• Muscle weakness of the face, foul odour from the ear<br />
• White mass behind intact ear drum on otoscopic examination<br />
• New onset of hearing loss in a previously operated ear<br />
• History of chronic perforation of the ear drum<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 595
Ear problems<br />
2. Immediate management<br />
• Consult MO for referral to Paediatrician or ENT Specialist<br />
3. Clinical assessment<br />
• Obtain a complete patient history. See Assessment of the ear<br />
• Perform standard clinical observations<br />
• Perform physical examination. See Assessment of the ear<br />
596<br />
-- on otoscopic examination - white mass behind an intact ear drum:<br />
○ a deep retraction pocket with or without granulation and skin debris<br />
○ focal granulation on the surface of the drum, especially at the periphery<br />
○ perforation in the attic region (unsafe perforation)<br />
4. Management<br />
• If suspected refer ENT Specialist<br />
5. Follow up<br />
If confirmed, surgical treatment is required<br />
6. Referral / consultation<br />
Refer to Paediatrician and / or ENT Specialist<br />
Controlled copy V1.0<br />
Acute mastoiditis<br />
Recommend<br />
Urgent referral to hospital with paediatric and ENT Specialist for management<br />
Background<br />
Mastoiditis is inflammation in the mastoid air cells and typically occurs after acute<br />
otitis media<br />
Related topics<br />
Acute otitis media Ear wick technique for otitis externa<br />
Assessment of the ear<br />
1. May present with<br />
• As per Acute otitis media; in addition:<br />
-- may have systemic features - with fever and rigors<br />
-- pain swelling and tenderness above and behind the ear over the mastoid<br />
(bony prominence behind the ear)<br />
-- the ear may be pushed away from the head by swelling of the mastoid area<br />
-- dizziness or tinnitus (ringing in the ears) may be present<br />
2. Immediate management<br />
• Consult MO immediately<br />
3. Clinical assessment<br />
• Obtain a complete patient history. See Assessment of the ear<br />
• Perform standard clinical observations<br />
• Perform physical examination. See Assessment of the ear plus:<br />
- - palpate behind the ear. Palpate the mastoid tip noting any tenderness<br />
- - is the mastoid bone swollen and / or hot - describe<br />
- - palpate the occiput, around the ears, both sides of the neck for lymph glands<br />
Primary Clinical Care Manual 2011
Ear problems<br />
4. Management<br />
• Consult MO who will arrange:<br />
-- urgent referral to hospital with Paediatric and ENT Specialist for management<br />
-- discuss antibiotic regime with Infectious Disease Specialist<br />
• Staff may be required to give first dose of antibiotics prior to evacuation<br />
5. Follow up<br />
As per post discharge orders<br />
6. Referral / consultation<br />
Urgent referral to Paediatrician and ENT Specialist<br />
Otitis externa<br />
Swimmer’s ear or tropical ear<br />
Recommend<br />
In the acute phase with inflammation the canal should not be syringed. However in<br />
established otitis externa aural toilet may be indicated to remove debris. Consult MO<br />
Related topics<br />
Earwick techique for otitis externa<br />
Assessment of the ear<br />
1. May present with<br />
• Infection of the skin of the ear canal; may be acute or chronic<br />
• Varying degrees of canal redness and peeling, debris collects in the canal, ear<br />
pain (sometimes severe) or itch<br />
• Tender, swollen outer ear and ear canal; very painful if outer ear manipulated,<br />
discharge not always present<br />
• Ear blockage, deafness or fullness, a foreign body may be present<br />
2. Immediate management Not applicable<br />
3. Clinical assessment<br />
• Obtain a complete patient history. See Assessment of the ear<br />
• Perform standard clinical observations<br />
• Perform physical examination. See Assessment of the ear<br />
- - often very painful on movement of the pinna - approach gently<br />
4. Management<br />
• Consult MO if fever, cellulitis or enlarged pre / post auricular lymph nodes<br />
• Give analgesia<br />
See Simple analgesia back cover<br />
• Gentle cleaning with dry mopping to keep the ear canal dry, then installation<br />
of drops or in severe cases, a wick soaked with sofradex or cortocosteriod +<br />
antibiotic ointment to remove pus and debris. The ear should be kept dry for at<br />
least two weeks after treatment [10]. Advise not to swim until healed<br />
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Ear problems<br />
Ear wick technique for otitis externa<br />
Materials<br />
• Flumethasone 0.02% + clioquinol 1% or Sofradex ® drops or triamcinolone compound<br />
(Kenacomb®) ointment<br />
• Ribbon gauze approximately 10 cm in length for an adult<br />
• Non-toothed forceps e.g. nasal packing forceps<br />
Technique<br />
1. The ribbon gauze is laid along a wooden tongue depressor and is impregnated with<br />
drops or ointment along its length<br />
2. The end of the impregnated strip is grasped with the forceps and is gently fed into<br />
the ear canal, 1 cm at a time. The ear canal is straightened by gently pulling the ear<br />
backwards and upwards in an adult or backwards in a child. The ear canal is 2.5 cm<br />
long in an adult<br />
3. If there is too much ribbon, the excess is trimmed with scissors. Once in place, the<br />
patient should be comfortable. If the patient has increased pain, the wick should be<br />
removed<br />
Schedule 4<br />
598<br />
Sofradex ® ear drops<br />
(Dexamethasone 0.5 mg / framycetin<br />
sulphate 5 mg / gramicidin 0.05 mg / mL)<br />
Controlled copy V1.0<br />
DTP<br />
IHW / SM R&IP / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic must consult MO / NP<br />
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed<br />
Route of<br />
Recommended<br />
Form Strength<br />
Duration<br />
administration<br />
dosage<br />
Ear drops See above<br />
Topical - drops 3 drops tds 7 days<br />
Topical - earwick Soaked gauze<br />
Wick left in canal for 2 days<br />
then review<br />
Provide Consumer Medicine Information<br />
Management of associated emergency: consult MO<br />
Administration tip - drops<br />
• The patient should lie with their head on a pillow for several minutes after administration to allow the<br />
drops to gravitate to the bottom of the ear canal<br />
• Apply tragal pressure (pressing several times on the flap of skin in front of ear canal) after the drops<br />
have been instilled to assist the drops through the perforation<br />
Administration tip - earwick<br />
• Remove the wick using forceps. Inspect and clean the ear. Reinsert if required<br />
[10]<br />
• or<br />
Primary Clinical Care Manual 2011
Ear problems<br />
Schedule 4<br />
Flumethasone 0.02% + clioquinol<br />
1%<br />
DTP<br />
IHW / SM R&IP / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic must consult MO / NP<br />
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed<br />
Form Strength<br />
Route of<br />
administration<br />
Recommended<br />
dosage<br />
Duration<br />
Ear drops As above Topical - ear wick Soaked gauze<br />
Provide Consumer Medicine Information<br />
Management of associated emergency: consult MO<br />
Administration tip - earwick<br />
• Remove the wick using forceps. Inspect and clean the ear. Reinsert if required<br />
• or<br />
The wick is left in the canal<br />
for 2 days then review<br />
Schedule 4<br />
Triamcinolone compound<br />
(Kenacomb®)<br />
DTP<br />
IHW / SM R&IP / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic must consult MO / NP<br />
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed<br />
Form Strength<br />
Triamcinolone 0.1 %<br />
Route of<br />
administration<br />
Recommended<br />
dosage<br />
Duration<br />
Ointment<br />
Neomycin 0.25 %<br />
Gramicidino 0.025 %<br />
Nystatin 100,000<br />
units / g<br />
Topical - ear wick<br />
Ointment<br />
soaked gauze<br />
The wick is left in the canal<br />
for 2 days then review<br />
Provide Consumer Medicine Information<br />
Management of associated emergency: consult MO<br />
Administration tip - earwick<br />
• Remove the wick using forceps. Inspect and clean the ear. Reinsert if required<br />
[4]<br />
5. Follow up<br />
Review in 2 days and in 1 week<br />
Advise not to swim and keep ears dry until healed<br />
Next MO visit if ear canal not back to normal at 1 week, or if recurrent<br />
6. Referral / consultation<br />
Otitis externa can become chronic or recurrent, especially in hot humid climates<br />
General prevention involves keeping the ear canal dry and protected by a lining<br />
of wax. Use drying ear drops e.g. Aqua-ear® / Vosol®, after swimming and<br />
showering will help prevent recurrence<br />
Advise patient to keep foreign objects such as cotton buds out of their ears;<br />
remove built-up wax, if necessary with e.g. Waxsol®<br />
Patients with recurrent infections often have a chronic fungal infection present.<br />
This infection may be seen with fungal hyphae looking like wet blotting paper or<br />
dry like cotton wool or the infection may be suspected even if the canal looks<br />
clean and normal but is itchy<br />
Suction ear toilet followed by Sofradex ® or flumethasone 0.02% + clioquinol<br />
1% or triamcinolone compound (Kenacomb®) ointment to prevent further acute<br />
bacterial infection<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 599<br />
[10]
Ear problems<br />
600<br />
Traumatic rupture of the ear drum<br />
Related topics<br />
Trauma to teeth Head injuries<br />
Eye injuries<br />
Fractured mandible / jaw<br />
1. May present with<br />
• A history of the injury e.g.:<br />
- - a blow to the side of the head or an explosion, i.e. a pressure wave<br />
- - penetrating injury e.g. a sharp stick<br />
- - water forced into ear e.g. a fall from a height into water<br />
• Pain in the ear, reduced hearing and / or bleeding from the ear<br />
• Dizziness and nausea<br />
2. Immediate management<br />
• Management of life threatening injuries<br />
3. Clinical assessment<br />
• Obtain a complete patient history:<br />
-- ask about the circumstances and mechanism of injury<br />
-- time, date of occurrence and when first noticed<br />
-- does the patient have decreased hearing?<br />
• Perform standard clinical observations +<br />
-- conscious state if applicable<br />
• Perform physical examination. See Assessment of the ear<br />
-- note other injuries if present<br />
4. Management<br />
• Consult MO who will advise antibiotic ear drops if water penetrated the perforation<br />
e.g. fall into water. The ear should be kept dry until healed. Antibiotic eardrops are<br />
not necessary if hole was caused by dry trauma (blow to head)<br />
5. Follow up<br />
Review in 2 days and then weekly<br />
If perforation not healed in 2 weeks, consult MO<br />
6. Referral / consultation<br />
Consult MO on presentation and if perforation not healed in 2 weeks<br />
Controlled copy V1.0<br />
Primary Clinical Care Manual 2011
Ear problems<br />
Foreign body / insect<br />
Recommend<br />
The main danger of a foreign body in the ear lies in its careless removal [11]<br />
Related topics<br />
Otitis externa<br />
1. May present with<br />
• Foreign body or insect in ear canal<br />
2. Immediate management Not applicable<br />
3. Clinical assessment<br />
• Obtain a full history including circumstances (accidental, purposeful, incidental<br />
finding)<br />
• Perform standard clinical observations<br />
• Examine the ears. See Assessment of the ear<br />
4. Management<br />
• Consult MO unless small object and seen to be near external ear opening and<br />
easily removable using e.g. nasal packing forceps<br />
• Larger foreign bodies and those further down the canal require special equipment<br />
and training for removal and may even require a general anaesthetic (send to<br />
hospital with ENT facilities)<br />
• A live insect in the ear canal should be drowned using Sofradex® eardrops or<br />
cooking oil or 2 mL of 1% lignocaine introduced by the blunt end of a syringe or<br />
via a cut-off ‘butterfly’ needle (or other plastic tubing is also effective) [11]. Do not<br />
syringe with water as can cause insect to swell<br />
• After removal of foreign body or insect, instil Sofradex® ear drops to prevent<br />
infection secondary to the trauma caused to the skin of the ear canal<br />
Schedule 4<br />
Sofradex ® ear drops<br />
(Dexamethasone 0.5 mg / Framycetin<br />
Sulphate 5 mg / Gramicidin 0.05 mg / mL)<br />
DTP<br />
IHW / SM R&IP / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic must consult MO / NP<br />
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed<br />
Form Strength<br />
Route of<br />
administration<br />
Recommended<br />
dosage<br />
Duration<br />
Ear drops See above Topical - drops<br />
3 drops<br />
tds - qid<br />
7 days<br />
Provide Consumer Medicine Information<br />
Management of associated emergency: consult MO<br />
Administration tip<br />
• The patient should lie with their head on a pillow for several minutes after administration to allow the<br />
drops to gravitate to the bottom of the ear canal<br />
• Apply tragal pressure (pressing several times on the flap of skin in front of ear canal) after the drops<br />
have been instilled to assist the drops through the perforation<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 601<br />
[10]
Ear problems<br />
5. Follow up<br />
If foreign body or insect easily removed, review in 2 days<br />
Review as per Otitis externa if secondary infection occurs after removal<br />
6. Referral / consultation<br />
Consult MO as per Otitis externa if secondary infection occurs after removal<br />
References<br />
1. Office for Aboriginal and Torres Strait <strong>Health</strong>. Recommendations for Clinical Care Guidelines on the<br />
Management of Otitis Media (middle ear infection) in Aboriginal and Torres Strait Islander Populations.<br />
2001 [cited 2011 March].<br />
2. Therapeutic Guidelines. Otitis media. 2010 [cited 2011 March].<br />
3. Australian Medicine Handbook. Procaine penicillin. 2011 [cited 2011 May].<br />
4. Dr A White, Paediatrician. 2011.<br />
5. Dr E. Binotto, Infectious Diseases & Clinical Microbiology. 2011.<br />
6. CRANA plus, Clinical Procedure Manual for remote and rural practice. 2nd ed. 2009, Alice Springs.<br />
7. Griffin, G., Flynn C A., and Bailey R E. Antihistamines and / or decongestants for otitis media with<br />
effusion (OME) in children. Cochrane Database of Systemic Reviews 2006 [cited 2011 March].<br />
8. Australian Medicine Handbook. Ciprofloxacin (ear). 2011 [cited 2011 March].<br />
9. Isaacson G., Diagnosis of pediatric cholesteatoma. Pediatrics 2007. (3): p. 603-608.<br />
10. Therapeutic Guidelines. Otitis externa. 2010 [cited 2011 March].<br />
11. Murtagh J., Practice Tips. 4th ed. 2004: The McGraw-Hill Inc.<br />
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Primary Clinical Care Manual 2011
Gastrointestinal problems<br />
Acute gastroenteritis and dehydration<br />
Vomiting and diarrhoea<br />
Recommend<br />
Always contact MO immediately if baby is < 3 months or the child has any of the<br />
following:<br />
- - is sick or febrile with temperature over 38°C or under 35.5°C<br />
- - irritable<br />
- - high pitched or weak cry<br />
- - sleepy<br />
- - not feeding well<br />
-- increased respiratory rate:<br />
○ 40 rpm<br />
○ 1 - 2 years >35 rpm<br />
○ 2 - 5 years > 30 bpm<br />
○ 5 - 12 years >25 rpm<br />
○ 12 years and older >20 rpm<br />
-- respiratory distress<br />
- - apnoea<br />
- - dehydration<br />
- - abdominal distension<br />
-- persistent / bilious vomiting and no diarrhoea (consider other diagnoses)<br />
Other high risk children include:<br />
-- excessive diarrhoea (> 8 watery stools in 24 hours)<br />
- - those with congenital or chronic disease e.g. cardiac, gastrointestinal or<br />
neurological<br />
- - where social conditions are concerning and / or where the parents may have<br />
difficulty managing at home<br />
Always consider other infections. Any infection can cause diarrhoea or vomiting<br />
Related topics<br />
Intraosseous cannulation DRS ABCD resuscitation / the collapsed patient<br />
Shock<br />
1. May present with<br />
• Vomiting<br />
• Diarrhoea<br />
• Cramping abdominal pain<br />
• Irritability in the young child<br />
• Fever<br />
• Dehydration<br />
• Lethargy, floppy, unresponsive<br />
2. Immediate management<br />
• Perform standard clinical observations +<br />
-- O saturations<br />
2<br />
-- level of consciousness<br />
• Consult MO immediately if any risk factors present or moderate / severe<br />
dehydration<br />
• Commence rehydration according to MO advice<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 603
Gastrointestinal problems<br />
3. Clinical assessment<br />
• Obtain a complete history including:<br />
-- diarrhoea - how much and for how long? Is it watery or semiformed, is there<br />
blood or mucous?<br />
-- vomiting - how much and for how long? Is there bile?<br />
-- fluid intake - how much and what type?<br />
-- diet - how much food has the child eaten and what?<br />
-- urine output if known, number of wet nappies?<br />
-- has any home treatment / medicine been given?<br />
-- past history of diarrhoea or other illnesses or infections?<br />
• Did the child receive rotavirus vaccine?<br />
• Perform standard clinical observations +<br />
-- weigh - use naked weight in young children and record against most recent<br />
recorded weight [1] and<br />
-- level of consciousness if not previously done<br />
• Collect a faeces specimen for MC/S and OCP (ova, cysts and parasites) and<br />
viral studies if:<br />
-- -history of blood in the stool, severe diarrhoea or prolonged (> 7 days)<br />
-- -history suggestive of food poisoning i.e. cluster presentation<br />
-- -recent travel overseas<br />
• Perform physical examination:<br />
-- degree of dehydration<br />
Clinical assessment of hydration in children<br />
To assess the child<br />
for dehydration<br />
604<br />
No signs<br />
Mild < 5%<br />
Controlled copy V1.0<br />
Some signs<br />
Moderate 5 - 10%<br />
Definite signs<br />
Severe > 10%<br />
Eyes normal sunken very sunken and dry<br />
Mouth and tongue moist dry very dry<br />
Condition alert<br />
Thirst<br />
drinks normally,<br />
may be thirsty<br />
restless, irritable,<br />
lethargic<br />
thirsty, drinks eagerly<br />
extreme lethargy<br />
“ragdoll appearance”<br />
drinks poorly or<br />
not able to drink<br />
Respiratory rate normal increased fast<br />
Pulse normal fast fast, weak, thready<br />
Capillary return normal (≤ 2 seconds) sluggish (> 2 seconds) slow (> 3 seconds)<br />
Management<br />
Can usually be treated<br />
at home or with close<br />
monitoring by<br />
PHC / rural facility<br />
Consult MO<br />
Require urgent<br />
rehydration usually<br />
nasogastric / IV<br />
Consult MO<br />
Requires resuscitation<br />
Primary Clinical Care Manual 2011
Gastrointestinal problems<br />
4. Management<br />
• Consult MO immediately - for those children with risk factors or moderate / severe<br />
dehydration<br />
• Children and babies with watery diarrhoea lasting 2 - 3 days should have bloods<br />
taken for electrolytes. Take bloods earlier if indicated<br />
• Do not use:<br />
- - anti-diarrhoeal agents<br />
- - metoclopramide or prochlorperazine in young children. MO may order<br />
ondansetron if vomiting is preventing oral intake [2]. Ondansetron not<br />
recommended for children
Gastrointestinal problems<br />
606<br />
Management of dehydration in children flow chart [1]<br />
Mild<br />
Assist carers to give<br />
child small amounts<br />
of oral fluids<br />
frequently<br />
Continue<br />
breastfeeding / bottle<br />
feeding<br />
Rehydration<br />
Diagnosis of<br />
Gastroenteritis in<br />
doubt?<br />
No<br />
Significant<br />
co-morbidities or risk<br />
factors such as age<br />
< 3 months, febrile<br />
No<br />
Vomiting<br />
prominent?<br />
No<br />
Assess dehydration<br />
Moderate<br />
Consult MO<br />
Requires urgent<br />
rehydration<br />
nasogastric / IV.<br />
MO may organise<br />
evacuation /<br />
hospitalisation<br />
• Approximate volumes [3]<br />
-- less than 6 months as per MO order<br />
-- 6 - 23 months 40 - 60 mL each hour<br />
-- 2 - 5 years 60 - 100 mL each hour<br />
-- 6 - 10 years 100 - 120 mL each hour<br />
-- 11 - 16 years 120 - 160 mL each hour<br />
Controlled copy V1.0<br />
Yes<br />
Yes<br />
Yes<br />
Consult MO<br />
for input on<br />
management<br />
MO may<br />
consider<br />
ondansetron<br />
wafer<br />
Trial of oral<br />
fluids 10 - 20 mL<br />
/ kg for 1 hour<br />
unless severe<br />
dehydration<br />
Severe<br />
Consult MO urgently<br />
who will organise<br />
evacuation /<br />
hospitalisation<br />
IV / IO insertion<br />
Commence bolus of<br />
20 mL / kg<br />
normal saline<br />
• Breastfed infant [3]<br />
-- continue breastfeeding on demand or at least every 2 hours<br />
-- in between breastfeeds, water or oral rehydration solution may be offered<br />
-- do not give solids if the child is vomiting<br />
-- give solids when the vomiting has stopped or after 24 hours<br />
-- if the baby is on solids introduce simple foods such as rice cereal, potato or<br />
pumpkin - even if the diarrhoea is still present<br />
Primary Clinical Care Manual 2011
Gastrointestinal problems<br />
• Bottle fed infant and older child [3]<br />
-- while the infant or child is still vomiting replace formula or usual drinks with<br />
oral rehydration fluid or other clear fluid (volume on previous page)<br />
-- aim to be back to usual formula / diet within 24 hours - do not dilute<br />
-- offer age appropriate foods at meal times even if diarrhoea still present<br />
-- occasionally children will develop lactose intolerance and the diarrhoea will<br />
continue. See Nutrition after gastroenteritis and lactose intolerance<br />
4.2 Moderate dehydration (5 to 10% loss of body weight)<br />
• Consult MO<br />
• Commence rehydration therapy according to MO instructions, usually oral /<br />
nasogastric. Examples of rehydration volumes given below<br />
-- must be managed in appropriately equipped and staffed facility<br />
-- MO will arrange evacuation if required<br />
• Commence a fluid balance sheet immediately<br />
• As well as oral / NGT rehydration, continue breastfeeds / formula and diet as per<br />
mild dehydration<br />
• Monitor child’s observations closely<br />
• Discuss with MO for further decision making after 4 hours<br />
Oral / NGT fluid replacement regime example for moderate dehydration 5 - 10 % [1]<br />
Weight kg<br />
0 - 6 hours<br />
Give oral / NGT fluid replacement<br />
(mL / hr)<br />
7 - 24 hours<br />
(following previous column doses)<br />
Give oral / NGT fluid replacement<br />
(mL / hr)<br />
3 30 20<br />
4 40 30<br />
5 50 35<br />
6 60 40<br />
7 70 45<br />
8 80 50<br />
9 90 55<br />
10 100 60<br />
12 120 65<br />
15 150 70<br />
20 200 85<br />
30 300 90<br />
4.3 Severe dehydration (>10% loss of body weight)<br />
If severe hypovolaemic shock. See Shock<br />
• Consult MO<br />
-- commence rehydration therapy according to MO instructions<br />
- - must be managed in appropriately equipped and staffed facility<br />
- - MO will arrange evacuation<br />
• Monitor conscious state closely and consult MO immediately if altered<br />
• Commence a fluid balance sheet immediately<br />
• Insert IV cannula. If this is unsuccessful after 2 attempts insert intraosseous<br />
cannula and commence infusion using the regime below. MO may take /<br />
request bloods whilst inserting IV / IO for electrolytes, glucose, acid base. See<br />
Intraosseous insertion<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 607
Gastrointestinal problems<br />
Fluid resuscitation regime for severe dehydration<br />
is based on 10% dehydration (person weighs 10% less than their usual weight)<br />
Initial treatment<br />
• 20 mL / kg<br />
• Reassess<br />
• Give second bolus of 20 mL / kg if still shocked<br />
• Ongoing fluids as discussed with MO<br />
• Re-hydrate / resuscitate severely dehydrated child with normal saline or IV Hartmann’s<br />
solution only [1]<br />
• Contact MO for ongoing fluid orders<br />
• Common IV fluids used in children for ongoing maintenance or replacement include<br />
normal saline or normal saline + 5% glucose [1]<br />
Arrangements should be made to transfer child to a paediatric centre. Ongoing fluid input<br />
should be managed in consultation with a Paediatrician<br />
5. Follow up<br />
Evacuation / hospitalisation of children with moderate (if indicated) or severe<br />
dehydration<br />
Children with mild dehydration i.e. < 5% and no clinical signs review in 24 hours<br />
or earlier if parent / carer is concerned that child is worse<br />
Inform the carer that bowel actions may not return to normal for 2 weeks but a<br />
child with continuing watery diarrhoea should be reviewed by a MO<br />
Children with watery diarrhoea lasting longer than 2 - 3 days should have bloods<br />
taken for electrolytes, babies may require this earlier<br />
Reassurance, education and advice concerning hand washing, personal hygiene,<br />
avoiding food preparation, and public swimming pools until diarrhoea has settled<br />
Place child on care plan with individualised review and weighs according to<br />
severity and family situation<br />
If diarrhoea continues beyond 10 days. See Child with chronic diarrhoea flow<br />
chart<br />
Alert other parents of young children in the community of current gastrointestinal<br />
illness and the need to present early to clinic if their child displays any gastro-<br />
intestinal symptoms<br />
Advise parent / carer(s) [1]<br />
• Use methods to help children drink e.g. cup, iceblock, bottle, syringe<br />
• Do not give medicines to reduce vomiting and diarrhoea. They do not work and may<br />
be harmful<br />
• Your baby or child is infectious so wash your hands well with soap and warm water,<br />
particularly before feeding and after changing nappies<br />
• Keep your child away from other children as much as possible until the diarrhoea<br />
has stopped<br />
• Return to clinic if:<br />
-- child is not drinking and still has vomiting and diarrhoea<br />
-- child is vomiting frequently and seems unable to keep any fluids down<br />
-- child is dehydrated e.g. not passing urine (< 3 wet nappies), is pale and has lost<br />
weight, sunken eyes, cold hands and feet, or is hard to wake up<br />
-- if your child has a bad stomach pain<br />
-- if there is any blood in the faeces<br />
-- if there is any green vomit, or you are worried for any other reason<br />
608<br />
Controlled copy V1.0<br />
Primary Clinical Care Manual 2011
Gastrointestinal problems<br />
Nutrition during gastroenteritis<br />
• Poor appetite is normal during the acute phase of the illness - during this time, ensure<br />
fluid intake is sufficient as described above<br />
• Babies and young children who are breastfeeding will want to feed more often when<br />
they are sick - this is normal. Support mum to breastfeed more frequently<br />
• Acute gastroenteritis can result in transient lactose intolerance. Formula fed babies<br />
may need lactose free formulas until the baby’s gut recovers sufficiently to digest<br />
and absorb lactose<br />
• It is particularly important to ensure that formula fed babies get sufficient fluids<br />
• Breastfeeding should be maintained during the acute phase and through any<br />
subsequent lactose intolerance. Breastfed babies are fed more frequently than<br />
formula fed babies and are usually able to tolerate the lactose in the breast milk<br />
• If the child has an appetite, eating should be encouraged but avoid fatty food or high<br />
sugar foods and drinks<br />
Nutrition after gastroenteritis<br />
• Encourage continued breastfeeding with healthy food as well if the child is six months<br />
or older<br />
• If the child is under one year of age and not breastfed, he / she will need infant<br />
formula, not cows milk. The type of formula will depend on whether the child can<br />
tolerate lactose<br />
• An episode of acute gastroenteritis may result in weight loss<br />
• For children > 6 months of age, once the child’s appetite returns, encourage carer to<br />
provide healthy food with one extra meal each day until lost weight is regained<br />
• <strong>Health</strong>y food is important for replacing lean body tissue lost during the illness -<br />
encourage lean meat, fish, eggs, fruit and vegetables, peanut paste, baked beans,<br />
cheese and yoghurt, and wholegrain cereals like Weet-Bix ®<br />
• Children over one year of age can have cows milk provided there is no lactose<br />
intolerance<br />
• Monitor weekly to ensure healthy growth is resumed<br />
• Refer to MO if healthy growth is not resumed within four weeks - repeated or chronic<br />
infections can result in poor appetite and growth failure<br />
6. Referral / consultation<br />
Consult MO immediately as above<br />
Children with chronic diarrhoea. See Child with chronic diarrhoea flow chart<br />
Children with weight loss or poor weight gain who are not acutely unwell - refer to<br />
Child <strong>Health</strong> Nurse or next MO clinic<br />
See Poor growth in children in the latest edition of the Chronic Disease Guidelines<br />
www.health.qld.gov.au/cdg/default.asp<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 609
Gastrointestinal problems<br />
610<br />
Controlled copy V1.0<br />
Lactose intolerance<br />
Recommend<br />
Continue breastfeeding (lactase can be tried). For formula fed infants use low lactose<br />
formula<br />
Consider other causes of chronic diarrhoea<br />
Background<br />
Lactose intolerance commonly follows acute diarrhoea in Aboriginal and Torres Strait<br />
Islander children<br />
Related topics<br />
Acute gastroenteritis and dehydration<br />
Failure to thrive<br />
Nappy rash<br />
Child with chronic diarrhoea flow chart<br />
1. May present with<br />
• Chronic diarrhoea, bloating, vomiting, irritability<br />
• Stool may be “frothy”<br />
• Perianal area may be scalded<br />
2. Immediate management Not applicable<br />
3. Clinical assessment<br />
• Obtain a complete patient history<br />
• Perform standard clinical observations +<br />
-- weigh - use naked weight in young children - record against last recorded<br />
weight<br />
• Collect a faeces specimen for MC/S, OCP (ova, cysts and parasites) and reducing<br />
substances<br />
• Perform physical examination: See Clinical assessment of hydration in children<br />
-- palpate abdomen for tenderness or guarding<br />
-- inspect the perianal area for irritation of area<br />
4. Management<br />
• Consult MO if suspect lactose intolerance and refer to next MO clinic<br />
• Never restrict breastfeeding<br />
• Encourage extra fluids while the child continues to have diarrhoea<br />
• Avoid lactose based formulas and cows milk products:<br />
-- -lactase (Tilactase® [Lacteeze®]) can be used in breastfed infants before,<br />
during and after a breastfeed, but is not very effective because the enzyme<br />
takes about 30 minutes to breakdown the breast milk lactose, so there may<br />
not be enough contact time in the stomach<br />
-- an infant usually fed on lactose based formula or cows milk should be<br />
prescribed a low lactose formula as an alternative: De-Lact® or O-Lac®<br />
-- don’t use soy formulas<br />
• Reintroduce normal formula after 2 - 4 weeks starting with 1/3 normal to 2/3<br />
lactose free and increasing the proportion of normal formula over 3 - 4 days<br />
• If symptoms recur, revert to lactose free formula and try again in 2 - 4 weeks<br />
Primary Clinical Care Manual 2011
5. Follow up<br />
Review 1 - 2 days after starting on low lactose formula<br />
Consult MO if diarrhoea persists<br />
See next Child <strong>Health</strong> Nurse or MO clinic<br />
6. Referral / consultation<br />
Consult MO on all occasions lactose intolerance suspected<br />
Dietitian if available<br />
Gastrointestinal problems<br />
Giardiasis<br />
Recommend<br />
If treatment with tinidazole or metronidazole fails a longer course may be required or<br />
reconsider the diagnosis<br />
Related topics<br />
Anaemia - child Acute gastroenteritis and dehydration<br />
Failure to thrive<br />
1. May present with<br />
• Foul smelling watery diarrhoea<br />
• Chronic diarrhoea, frequent loose and pale greasy stool<br />
• Abdominal cramps<br />
• Abdominal distension, flatulence<br />
• Nausea, poor appetite<br />
• Anaemia<br />
• Weight loss / failure to thrive<br />
• May be asymptomatic<br />
2. Immediate management Not applicable<br />
3. Clinical assessment<br />
• Perform standard clinical observations +<br />
-- weigh - use naked weight in young children and record against most recent<br />
weight<br />
• Collect a faeces specimen for MC/S and OCP (ova, cysts and parasites) x 2<br />
• Perform physical examination:<br />
- - assess for dehydration. See Clinical assessment of hydration in children<br />
-- palpate the abdomen for tenderness or guarding<br />
-- inspect the perianal area for signs of irritation<br />
4. Management<br />
• Encourage oral fluids<br />
• Treatment of people with asymptomatic passage of cysts is unwarranted unless<br />
they are a contact of pregnant women or immunocompromised patient<br />
• Treat with tinidazole or metronidazole if symptomatic, or failure to thrive (it is not<br />
necessary to wait for laboratory confirmation). If thriving and not unwell treat after<br />
laboratory confirmation<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 611
Gastrointestinal problems<br />
Schedule 4 Tinidazole<br />
DTP<br />
IHW / SM R&IP / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic must consult MO / NP<br />
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed<br />
Form Strength<br />
Route of<br />
administration<br />
Recommended<br />
dosage<br />
Adult<br />
2 g<br />
Duration<br />
Tablet 500 mg Oral<br />
Child<br />
50 mg / kg / dose<br />
to a max. of 2 g<br />
Stat<br />
Provide Consumer Medicine Information: take dose after food. When possible, the tablets should be dosed<br />
whole as the drug’s taste is very bitter. However, when a part tablet is required, tablets can be crushed.<br />
The tablets are film coated, so must be peeled then crushed. The appropriate dose can then be weighed<br />
and mixed with flavouring<br />
Management of associated emergency: consult MO<br />
[4]<br />
612<br />
• or<br />
Schedule 4 Metronidazole<br />
DTP<br />
IHW / SM R&IP / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic must consult MO / NP<br />
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed<br />
Form Strength<br />
Route of<br />
administration<br />
Recommended<br />
dosage<br />
Duration<br />
Tablet<br />
200 mg<br />
400 mg<br />
Adult<br />
2 g daily<br />
Oral<br />
Child<br />
3 days<br />
Suspension 200 mg / 5 mL<br />
30 mg / kg / dose daily<br />
to a max. of 2 g daily<br />
Provide Consumer Medicine Information: avoid alcohol while and for 48 hours after taking this drug. Take<br />
with food or immediately after food<br />
Management of associated emergency: consult MO<br />
[4]<br />
• If the above treatment fails a longer course of metronidazole is sometimes<br />
required or diagnosis should be reconsidered<br />
5. Follow up<br />
Review next day<br />
Consult MO if diarrhoea not settling<br />
Provide education and advice concerning handwashing before handling food,<br />
eating and after toilet; avoiding food preparation and public swimming pools until<br />
diarrhoea has settled<br />
6. Referral / consultation<br />
Consult MO as above<br />
Controlled copy V1.0<br />
Primary Clinical Care Manual 2011
Gastrointestinal problems<br />
Intestinal worms<br />
Recommend<br />
Use only pyrantel (Combantrin®) in children under 6 months and in pregnant women<br />
[7]<br />
Perform de-worming in three situations:<br />
-- as part of a community eradication program<br />
-- symptomatic children<br />
-- on the basis of faeces specimen result, sent as part of investigation for anaemia<br />
or weight loss / failure to thrive<br />
Related topics<br />
Anaemia - child Failure to thrive<br />
1. May present with<br />
• Perianal / perineal itch - pinworm (thread worm), small threadlike worm may be<br />
seen (doesn’t cause diarrhoea or failure to thrive)<br />
• Anaemia - hookworm<br />
• Acute diarrhoea - strongyloides<br />
• Failure to thrive - strongyloides can contribute<br />
2. Immediate management Not applicable<br />
3. Clinical assessment<br />
• Obtain a complete patient history:<br />
-- -past episodes<br />
-- -previous weights<br />
-- -length of time signs and symptoms have been present<br />
-- -do any other members of the family or close contact have signs or symptoms?<br />
-- -is the child on medication?<br />
-- -have they been treated for worms? If so when and with what?<br />
• Perform standard clinical observations +<br />
- - weigh - use naked weight in young children and record against most recent<br />
recorded weight<br />
- - check Hb on haemoglobinometer (HemoCue®)<br />
- - collect a faeces specimen for MC/S and OCP (ova, cysts and parasites). This<br />
will be repeated as part of follow up<br />
• Perform physical examination:<br />
-- inspect the abdomen for signs of mobility<br />
-- palpate the abdomen for tenderness or guarding<br />
-- inspect the perianal / perineal area for signs of irritation (if indicated)<br />
4. Management<br />
• Consult MO if abdominal pain present See Abdominal pain<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 613
Gastrointestinal problems<br />
Treatments for common worms [5]<br />
Drug Worm<br />
Pyrantel (Combantrin®)<br />
Mebendazole (Vermox®)<br />
Albendazole<br />
614<br />
Threadworm (pinworm)<br />
Hookworm<br />
Roundworm<br />
Threadworm (pinworm)<br />
Hookworm<br />
Roundworm<br />
Whipworm<br />
Threadworm (pinworm)<br />
Hookworm<br />
Roundworm<br />
Strongyloidiasis<br />
Whipworm<br />
Praziquantel<br />
Beef tapeworm and pork tapeworm<br />
Dwarf tapeworm<br />
Ivermectin Strongyloidiasis<br />
Schedule 2<br />
Pyrantel embonate<br />
(Combantrin®)<br />
DTP<br />
IHW / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic may proceed<br />
Form Strength<br />
Route of<br />
administration<br />
Recommended<br />
dosage<br />
Duration<br />
Tablet<br />
Suspension<br />
125 mg<br />
250 mg<br />
50 mg / mL<br />
Oral<br />
10 mg / kg / dose<br />
to a max. of 1 g<br />
Stat<br />
Repeat after 7 days if<br />
heavy infestation<br />
Provide Consumer Medicine Information: for use in children < 6 months of age and pregnant women<br />
Management of associated emergency: consult MO<br />
• Reassurance, education and advice regarding hand-washing and personal<br />
hygiene<br />
• If treating worms without laboratory confirmation use albendazole or mebendazole<br />
• If treating after laboratory confirmation of the worm, see table for the preferred<br />
treatment: pyrantel (Combantrin®), albendazole or mebendazole (Vermox®)<br />
• If part of a worm eradication program, use albendazole as a single dose every 4<br />
to 6 months<br />
• Only pyrantel (Combantrin®) can be used in children < 6 months and in pregnant<br />
women [5]<br />
• Albendazole and mebendazole should not be used in children < 6 months or in<br />
pregnant women [5]<br />
Controlled copy V1.0<br />
[5]<br />
Primary Clinical Care Manual 2011
Gastrointestinal problems<br />
Schedule 4 Albendazole<br />
DTP<br />
IHW / SM R&IP / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic must consult MO / NP<br />
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed<br />
Form Strength<br />
Tablet<br />
200 mg<br />
400 mg<br />
Route of<br />
administration<br />
Oral<br />
Recommended<br />
dosage<br />
Threadworm (pinworm),<br />
hookworm, roundworm<br />
Adult<br />
400 mg<br />
Child<br />
≤10 kg give 200 mg<br />
Strongyloidiasis, whipworm<br />
Adult<br />
400 mg daily<br />
Child<br />
≤10 kg give 200 mg daily<br />
Duration<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 615<br />
Stat<br />
3 days<br />
Provide Consumer Medicine Information: women should use effective contraception during and one month<br />
after treatment. To increase absorption for systemic indications i.e. strongyloides, take medication with<br />
fatty meal. For other indications take on an empty stomach<br />
Management of associated emergency: consult MO<br />
[5]<br />
• or<br />
Schedule 2<br />
Mebendazole<br />
(Vermox®)<br />
DTP<br />
IHW / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic may proceed<br />
Form Strength<br />
Route of<br />
administration<br />
Recommended<br />
dosage<br />
Theadworm (pinworm)<br />
Adult<br />
Duration<br />
Tablet 100 mg<br />
100 mg<br />
Child<br />
Stat<br />
Oral<br />
≤10 kg give 50 mg<br />
Whipworm, hookworm,<br />
roundworm<br />
Suspension 100 mg / 5 mL<br />
Adult<br />
100 mg bd<br />
Child<br />
≤10 kg give 50 mg bd<br />
3 days<br />
Provide Consumer Medicine Information<br />
Management of associated emergency: consult MO<br />
5. Follow up<br />
See at next MO clinic if anaemia or weight loss / failure to thrive<br />
6. Referral / consultation<br />
Consult MO as above<br />
[5]
Gastrointestinal problems<br />
616<br />
Controlled copy V1.0<br />
Constipation<br />
Recommend<br />
Maintenance programs consisting of medication, toileting program, dietary advice<br />
and follow up to prevent recurrence<br />
Background<br />
Constipation is the difficult passage of infrequent dry, hard stools that often cause<br />
pain and discomfort. The most common cause is functional - no underlying cause [8]<br />
Constipation starts a vicious cycle - passing hard stool is painful, so the child avoids<br />
straining at stool, the constipation gets worse and so on. Part of the battle is forming<br />
a habit for the child to go to the toilet each day<br />
Straining is normal in babies<br />
1. May present with<br />
• Hard stool - often small pellets<br />
• Excessive straining at stool<br />
• Soiling (also known as encopresis)<br />
2. Immediate management Not applicable<br />
3. Clinical assessment<br />
• Obtain a complete patient history including:<br />
- - medical history<br />
- - past episodes<br />
- - current diet including food allergies [6]<br />
- - fluid intake - are they breastfeeding or on formula? how is the formula made<br />
up? (Over concentrated formula can lead to constipation.) Are they given<br />
water as well?<br />
- - what / how much is their physical activity?<br />
- - family routine (the constipated child usually has poor nutrition, poor fluid<br />
intake and is inactive)<br />
- - parental expectations of ‘normal’ stool pattern<br />
- - length of time since last passed a stool / defecated?<br />
- - describe stool, colour, consistency, frequency of defecation<br />
- - ask carer if any change in child’s behaviour?<br />
- - what is there urinary output history? are they bedwetting? daytime wetting?<br />
- - is the child on medication?<br />
• Perform standard clinical observations +<br />
- - weigh - use naked weight in young children and record against most recent<br />
- - plot growth and height / length<br />
• Perform physical examination:<br />
- - inspect mouth, look for mouth ulcer(s) and state of teeth / gums<br />
- - inspect and palpate abdomen - for masses<br />
- - ankle knee reflexes (to assess sacral nerve roots and gait)<br />
- - inspect the anus and perianal area - position of the anus, pressure of stool<br />
around anus, perineal sensation, skin tags, anal fissures<br />
• Consider possible organic problem (and refer for further work up) if:<br />
-- child has constipation from birth<br />
-- child has vomiting, and abdominal distension<br />
-- there is any bile vomiting<br />
-- the child is not growing well<br />
-- there is more than just a streak of blood on the stool<br />
-- constipation does not improve with simple measures<br />
Primary Clinical Care Manual 2011
Gastrointestinal problems<br />
4. Management<br />
• Dietary interventions:<br />
- - encourage a healthy diet with fruit and vegetables and wholegrain cereals<br />
- - encourage drinking plenty of water<br />
- - pears (fresh or pureed) or prunes will stimulate the gut gently and soften<br />
stools<br />
- - excessive dietary intake can cause constipation in children<br />
• Encourage physical activity<br />
• Toileting programs:<br />
-- -take advantage of the gastrocolic reflex. Most people, especially children<br />
have the urge to pass a motion after eating a meal, especially breakfast<br />
-- -advise that the child should sit on the toilet after each meal and attempt to<br />
pass a motion without straining<br />
-- -positively reinforce good behaviour. A reward for sitting on the toilet and<br />
passing a motion is often beneficial<br />
• Disimpaction:<br />
-- -oral laxatives<br />
○ liquid paraffin, chocolate flavoured liquid paraffin i.e. Parachoc. Avoid<br />
in infants under 12 months of age<br />
○ lactulose, senna, Movicol Half ®<br />
-- enemas<br />
○ micro-enemas such as Microlax®<br />
• Most constipation in children will resolve with these measures. If it persists, refer<br />
to the next Child <strong>Health</strong> Nurse or MO clinic or Continence Advisor<br />
5. Follow up<br />
Children with constipation should be reviewed regularly to assess progress.<br />
Once the problem settles remember to continue with dietary improvement and<br />
increased water intake to prevent recurrence<br />
Advise parent / carer to use appropriate gentle fibre or laxative (prune / pear juice<br />
/ psyllium) for at least 3 months to regulate peristalsis<br />
6. Referral / consultation<br />
Consult MO if constipation is severe, or the child is unwell in any other way<br />
Child <strong>Health</strong> Nurse<br />
Continence Advisor (if available)<br />
MO may consider referral to a Paediatrician<br />
Children with chronic constipation require long term management with multiple<br />
laxatives to keep their stool soft and prevent recurrence of painful anal fissures.<br />
It is important to ensure observance with laxative regimes<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 617
Gastrointestinal problems<br />
618<br />
Controlled copy V1.0<br />
Pyloric stenosis<br />
Recommend<br />
Consult MO immediately<br />
May need rehydration<br />
Evacuate for investigation. Will need surgical treatment if diagnosis confirmed<br />
Background<br />
Most common in babies between 2 and 6 weeks of age. Rarely occurs after 12<br />
weeks of age<br />
Related topics<br />
Acute gastroenteritis and dehydration<br />
1. May present with<br />
• Vomiting which progressively gets worse, projectile, after feeds<br />
• Baby is not putting on weight well or may be losing weight<br />
• Dehydration<br />
2. Immediate management<br />
• Consult MO if child dehydrated<br />
3. Clinical assessment<br />
• Obtain a complete patient history:<br />
- - of particular importance progressive increase of projectile vomiting after feeds<br />
in a baby that is usually well and eager to feed following the vomiting episode<br />
• Perform standard clinical observations +<br />
- - weigh - use naked weight in young children and record against most recent<br />
recorded weight<br />
• Perform physical examination:<br />
-- -inspect and palpate abdomen<br />
• Visible peristalsis over the abdomen or an olive-sized and shaped mass may be<br />
felt in the right upper quadrant<br />
• Assess degree of dehydration. See Acute gastroenteritis and dehydration<br />
4. Management<br />
• Consult MO who may advise<br />
-- checking electrolytes (U/E)<br />
-- evacuation / hospitalisation<br />
-- IV fluids<br />
-- abdominal ultrasound examination<br />
5. Follow up<br />
All babies with suspected pyloric stenosis must be managed in hospital. Diagnosis<br />
is usually confirmed by ultrasound. If confirmed the baby will require surgery,<br />
which is very successful<br />
6. Referral / consultation<br />
Consult MO on all occasions of suspected pyloric stenosis. These infants may<br />
present with severe acid base imbalance such as hypokalaemia<br />
Primary Clinical Care Manual 2011
Gastrointestinal problems<br />
Intussusception<br />
Background<br />
Suspect in a young child who looks unwell and has intermittent severe abdominal<br />
pain<br />
In 15 % of cases the classic triad of abdominal pain, palpable sausage shaped<br />
abdominal masses and red currant jelly stool is present. The small bowel telescopes<br />
into itself (as if it were swallowing itself)<br />
Most common cause of obstruction in children 6 - 36 months of age (60%
Gastrointestinal problems<br />
620<br />
Controlled copy V1.0<br />
Failure to thrive<br />
Recommend<br />
Refer to Poor growth in children care plan in the latest edition of the Chronic Disease<br />
Guidelines www.health.qld.gov.au/cdg<br />
MO / Dietitian to perform complete examination and calculate the degree of failure to<br />
thrive - mild, moderate or severe, using weight for age, and weight for height, for Z<br />
score<br />
Provide nutritional supplements for management of failure to thrive depending on<br />
severity<br />
It is important in an underweight child to differentiate wasting (thin child) of acute<br />
failure to thrive from stunting (short child) due to chronic failure to thrive. Often both<br />
are present, and can be assessed on anthropometric measurements of weight and<br />
height for age and sex<br />
Background<br />
Suite of Growing Strong resources available at:<br />
www.health.qld.gov.au/ph/documents/hpu/growingstrong.asp<br />
Failure to thrive (FTT) refers to child whose weight is less than normal for gestational<br />
corrected age / gender and past medical history. Children with genetic short stature,<br />
intrauterine growth retardation or prematurity, who have appropriate proportional<br />
weight for length and normal growth velocity, are not regarded as FTT<br />
Related topics<br />
Anaemia<br />
Giardia<br />
Intestinal worms<br />
Lactose intolerance<br />
Urinary tract infection - child<br />
1. May present with<br />
• Any condition<br />
• A child whose weight has crossed down 2 or more major centile lines on standard<br />
growth charts (and who is not overweight or obese) [7]<br />
2. Immediate management Not applicable<br />
3. Clinical assessment<br />
• Obtain a complete patient history including:<br />
- - family and social history - spend time assessing the social situation:<br />
○ who is the main carer? which other family members contribute to looking<br />
after the child, household and buying food?<br />
○ amount of support the carer has? extended family? friends?<br />
○ have other children in the family had problems with growth faltering?<br />
○ ask about food security, financial security?<br />
- - cultural history<br />
- - medical history - past or current illnesses<br />
- - birth history - low birth weight (preterm or IUGR)<br />
- - mother’s antenatal history - particularly alcohol and smoking intake<br />
-- nutrition intake - if breastfed, frequency of feeding during night and day, if<br />
formula fed when did the formula start? how is it prepared? other milks or<br />
drinks?<br />
- - solids, type - when were solids introduced? frequency of feeding?<br />
- - eating pattern<br />
- - urine output and number of stools per day<br />
Primary Clinical Care Manual 2011
Gastrointestinal problems<br />
• Perform standard clinical observations +<br />
- - urinalysis<br />
-- check haemoglobin on haemoglobinometer (HemoCue®)<br />
- - collect stool specimen for lactose intolerance testing<br />
• Perform a complete physical examination:<br />
-- head to toe assessment of current state of health, looking for evidence of<br />
undetected illness<br />
- - do naked weigh, check length and head circumference - plot growth chart<br />
It is important in an underweight child to differentiate wasting of acute FTT from stunting<br />
due to chronic FTT - often both are present<br />
A child with stunting may look healthy. It is important to measure and assess the child's<br />
growth on a growth chart to identify stunting<br />
4. Management<br />
• MO perform examination and calculate degree of FTT - mild, moderate or severe<br />
• Depending on severity of FTT commencement of:<br />
-- nutritional supplements such as Pediasure®<br />
-- food prescription<br />
• Multivitamins are only required
Gastrointestinal problems<br />
622<br />
• Children need small frequent meals (5 times a day if possible)<br />
Food prescription<br />
Drinks<br />
• Nutritional supplement - usually Pedisure® at least one 237 mL can or one cup<br />
• 250 mL of supplement every day or 5 scoops of powder in 200 mL water<br />
• Water, breast milk, infant formula, cows milk if over 12 months<br />
Food<br />
• Meals - breakfast, lunch, dinner, snacks containing fruit, vegetables<br />
5. Follow up<br />
Place child on individualised care plan, setting out actions, targets and who is<br />
responsible to closely provide:<br />
- - social support<br />
-- set actions / targets for weight gain. See Chronic Disease Guidelines at:<br />
www.health.qld.gov.au/cdg<br />
- - regular monitoring of growth with child’s carer<br />
Appropriate nutritional needs for child as recommended by Dietitian, MO or Child<br />
<strong>Health</strong> Nurse / Child <strong>Health</strong> - <strong>Health</strong> Worker. Often children with FTT lose their<br />
appetite and are unable to meet their nutritional requirements without additional<br />
strategies in place. Advice needs to be given to carer’s beyond just what healthy<br />
foods are. Carers need to know which foods are appropriate for FTT and also<br />
how often, the amount of food and how to fortify breast milk / foods / drinks<br />
6. Referral / consultation<br />
Consult MO. Child may need hospitalisation<br />
Child development unit for developmental screening of gross and fine motor,<br />
language and social milestones<br />
Dietitian to conduct thorough diet history, feeding history and nutrition advice<br />
May need referral to a community based specialised nutrition program e.g. Mum’s<br />
and bubs<br />
See current edition of Chronic Disease Guidelines at:<br />
www.health.qld.gov.au/cdg<br />
Recommend<br />
Aim to achieve haemoglobin level above 110 g / L [8]<br />
Treat with iron<br />
- - babies aged 6 -12 months with haemoglobin < 105 g / L<br />
- - children over 1 year of age with haemoglobin < 110 g / L<br />
Consult MO immediately<br />
- - if any child has haemoglobin < 80 g / L<br />
See next MO clinic<br />
- - if child has haemoglobin 80 -100 g / L<br />
Suite of Growing Strong resources, especially iron rich food available at:<br />
www.health.qld.gov.au/ph/documents/hpu/growing_strong.asp<br />
Regular calibration of haemoglobinometer (HemoCue®)<br />
Controlled copy V1.0<br />
Anaemia - child<br />
Primary Clinical Care Manual 2011
Gastrointestinal problems<br />
Background<br />
Nutrient requirements are very high in young children, especially for iron between<br />
the ages of 6 months and 24 months<br />
Anaemia is common in Aboriginal and Torres Strait Islander children particularly in<br />
the 6 to 30 months age group<br />
Childhood anaemia is more likely if mother had low iron status or was anaemic in<br />
pregnancy and/or if baby was premature or low birth weight<br />
Anaemia is largely due to dietary deficiency in iron and / or folate and the inhibitory<br />
effects of infestations and infections<br />
There are higher rates of iron deficiency and anaemia in infants and toddlers where<br />
high cows’ milk intake is encouraged or allowed [11]<br />
Failure to thrive may or may not co-exist<br />
Overweight and obesity may or may not co-exist<br />
Iron deficiency of any degree affects child development<br />
Related topics<br />
Giardia<br />
Intestinal worms<br />
Failure to thrive<br />
1. May present with<br />
• Almost always asymptomatic<br />
• Low haemoglobin detected on haemoglobinometer. Re-check if any doubt<br />
• Tiredness, lethargy<br />
• Recurrent infections<br />
• Occasionally pica (eating substances not fit as food)<br />
• Loss of appetite<br />
2. Immediate management Not applicable<br />
3. Clinical assessment<br />
• Obtain a complete patient history including:<br />
- - family and ethnic history (different types of anaemia caused by production<br />
and life of red blood cells)<br />
-- social history. Spend time assessing the social situation<br />
○ who is the main carer?<br />
○ which other family members contribute to looking after the child,<br />
household and buying food?<br />
○ amount of support the carer has? extended family? friends?<br />
○ have other children in the family had problems with anaemia?<br />
- - cultural history<br />
- - medical history - past or current illnesses<br />
- - current medications - Pentavite® or iron liquid?<br />
- - birth history - low birth weight (preterm or IUGR)<br />
- - mother’s antenatal history<br />
- - nutrition intake, breast or formula fed or both - when did formula start? what<br />
type of milk is child drinking? cows milk?<br />
- - solids, type - when were solids introduced?<br />
- - eating pattern<br />
- - urine output / number of stools per day<br />
• Perform standard clinical observations +<br />
-- urinalysis<br />
- - weigh - use naked weight in young children and record against most recent<br />
recorded weight<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 623
Gastrointestinal problems<br />
624<br />
-- check length and do head circumference and plot against growth chart<br />
- - check haemoglobin on haemoglobinometer (HemoCue®) (if not already<br />
done)<br />
- - collect stool for lactose intolerance testing<br />
• Perform a complete physical examination:<br />
-- -from head to toe assessing current state of health and looking for evidence of<br />
undetected illness<br />
4. Management<br />
• Treat with oral iron supplement for 1 month under supervision (taking iron daily is<br />
problematic as child is often asymptomatic. Do not give during diarrhoeal illness.<br />
Parents to be advised about the risk of iron ingestion by children and to store<br />
safely out of reach)<br />
• Treat with IM ferrum H if family unable to give oral iron or child will not take oral<br />
iron:<br />
- - babies aged 6 - 12 months with haemoglobin
Schedule 2 Folic Acid<br />
Gastrointestinal problems<br />
DTP<br />
IHW / IPAP<br />
Authorised Indigenous <strong>Health</strong> Workers and Isolated Practice Area Paramedic must consult MO / NP<br />
Form Strength<br />
Tablet<br />
500<br />
microgram<br />
5 mg<br />
Route of<br />
administration<br />
Oral<br />
Provide Consumer Medicine Information<br />
Management of associated emergency: consult MO<br />
Recommended<br />
dosage<br />
Child<br />
0.5 mg / kg / dose daily<br />
to a max. of 5 mg daily<br />
Duration<br />
Long term according<br />
to response on MO / NP<br />
order<br />
• Give nutrition advice. Use Growing Strong resources - breastfeeding, iron rich<br />
foods, healthy food and drinks and many more available at:<br />
www.health.qld.gov.au/ph/documents/hpu/growingstrong.asp<br />
• Recommend breastfeed exclusively for first 6 months<br />
• Appropriate iron rich first foods at around 6 months<br />
-- -foods rich in iron and or folate:<br />
○ red meat, beef / lamb liver or kidneys, bush meat<br />
○ chicken, fish<br />
○ egg yolks<br />
○ iron fortified baby cereal<br />
○ green vegetables<br />
○ fruit and vegetables (to help iron absorption)<br />
○ breast milk or infant formula (NOT normal cow or goat milk unless over<br />
1 year of age)<br />
○ No turtle or dugong liver or kidneys or intestines - as concern about<br />
cadmium content<br />
○ No cows milk or Sunshine® milk before 1 year old<br />
○ No tea or coffee<br />
○ No soft drink, juice or cordial<br />
5. Follow up<br />
Place child on individualised care plan, setting out actions, targets and who is<br />
responsible to closely provide ongoing support and monitoring<br />
6. Referral / consultation<br />
Consult MO or see next MO clinic as above<br />
Refer to Dietitian for diet history, feeding history and nutrition advice<br />
Refer to Child <strong>Health</strong> Nurse / Child <strong>Health</strong> - <strong>Health</strong> Worker<br />
Repeat FBC after 1 month of iron and / or folate to confirm response to treatment<br />
If a response is demonstrated with iron and / or folate supplements, continue for<br />
several months<br />
Check haemoglobin monthly until it is >110 g/L<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 625<br />
[10]
Gastrointestinal problems<br />
Iron injection procedure See manufacturer's product information for accompanying diagrams<br />
1. The length of the needle should be at least 5 to 6 cm. The lumen of the needle should not be too wide<br />
Ventrogluteal injection according to Hochstetter is recommended in the top outer quadrant of the<br />
2.<br />
gluteus maximus muscle<br />
The site of injection is determined as follows. First point A is found, corresponding to the ventral iliac<br />
spine. If the patient lies on the right side, for instance, the middle finger of the left hand is placed on<br />
3. point A. The index finger is extended away from the middle finger, so that it comes to lie below the iliac<br />
crest, at point B. The triangle lying between the proximal phalanges of the middle and index fingers<br />
represents the site of injection. This is disinfected in the usual way<br />
Before the needle is inserted, the skin over the site of injection is pulled down, about 2 cm, to give<br />
4. an S-shaped puncture channel. This prevents the injected solution from running back into the<br />
subcutaneous tissues and discolouring the skin<br />
The needle is introduced more or less vertically to the skin surface, angled to point towards the iliac<br />
5.<br />
crest rather than the hip joint<br />
After the injection, the needle is slowly withdrawn and pressure from a finger applied beside the<br />
6.<br />
puncture site. This pressure is maintained for about one minute<br />
7. The patient should move about after the injection<br />
[11]<br />
Schedule 4<br />
626<br />
Form Strength<br />
Ampoule<br />
100 mg / 2 mL<br />
50 mg / mL<br />
Route of<br />
administration<br />
IM<br />
Iron polymaltose<br />
(Ferrum H®, Ferrosig®)<br />
Controlled copy V1.0<br />
Recommended<br />
dosage<br />
< 5.0 kg 0.5 mL / day<br />
5 - 10 kg 1.0 mL / day<br />
>10 kg - 45 kg 2.0 mL / day<br />
Formula for calculating iron injection dose<br />
Weight x (125 - Hb in g/L) x 0.3 = mL required (50 mg / mL)<br />
Total dose (may be over several days)<br />
Non DTP<br />
Must consult MO / NP<br />
Duration<br />
Stat<br />
or alternate days<br />
Weight (kg) Hb 75 g / L Hb 90 g / L Hb 105 g / L<br />
5 3 mL 3 mL 2 mL<br />
10 6 mL 5 mL 4 mL<br />
15 9 mL 7 mL 6 mL<br />
20 11 mL 10 mL 8 mL<br />
25 14 mL 12 mL 11 mL<br />
30 17 mL 15 mL 13 mL<br />
35 23 mL 20 mL 18 mL<br />
40 24 mL 22 mL 19 mL<br />
45 26 mL 23 mL 20 mL<br />
Provide Consumer Medicine Information: the wrong injection technique may result in pain and persistent<br />
discolouration of the skin. Iron polymaltose should never be injected into the arm or other exposed areas<br />
Management of associated emergency: consult MO<br />
[9]<br />
Primary Clinical Care Manual 2011
Urinary tract problems<br />
References<br />
1. The Royal Children’s Hospital. Gastroenteritis 2009 [cited 2011 February]; Available from: www.rch.org.<br />
au/clinicalguide/cpg.cfm?docid=12364#degree<br />
2. Dunia A., Al-Hakima H., and Fedorowicz Z. Antiemetics for reducing vomiting related to acute<br />
gastroenteritis in children and adolescents. Cochrane Database of Systemic Reviews 2009 [cited 2011<br />
February].<br />
3. The Children’s Hospital at Westmead Sydney Children’s Hospital Randwick & Kaleidoscope * Hunter<br />
Children’s <strong>Health</strong> Network, Fact Sheet Gastroenteritis. 2010.<br />
4. Therapeutic Guidelines. Giardia lamblia (intestinalis) (acute giardiasis). 2006 [cited 2011 February].<br />
5. Therapeutic Guidelines. Worms (helminths). 2006 [cited 2011 March].<br />
6. IMPACT Paediatric Bowel Care Pathway, A Guide to the Management of Constipation and Faecal<br />
Impaction in Children 2006: Australia.<br />
7. American Academy of Pediatrics Committee on Child Abuse and Neglect and the Committee on Nutrition,<br />
Robert W Block., and Nancy F Krebs., Failure to Thrive as a Manifestation of Child Neglect. Pediatrics,<br />
2005. 116<br />
8. The World <strong>Health</strong> Organization, Iron deficiency anaemia, assessment, prevention and control. A guide<br />
for program managers. 2001, WHO: Geneva.<br />
9. Therapeutic Guidelines. Iron deficiency. 2006 [cited 2011 March].<br />
10. Australian Medicine Handbook. Folic acid. 2011 [cited 2011 March].<br />
11. MIMS Online. Ferrum H Injection. 2008 [cited 2011 March].<br />
Urinary tract infection - child<br />
Recommend<br />
Definitive diagnosis of urinary tract infection (UTI) by urine culture collected in a sterile<br />
fashion - mid stream urine (clean catch), supra pubic aspiration, catheter specimen<br />
[1]<br />
Finding a UTI in a sick child does not rule out other sources of infection so keep<br />
looking e.g. meningitis [1]<br />
Some children require further imaging of renal tract depending on age<br />
Background<br />
Collection of urine in a paediatric bag can only be used for dipstix testing. It has poor<br />
sensitivity and specificity [1]<br />
Some children with UTI may look quite well while others may appear very unwell [1]<br />
Children with UTI commonly have acute pyelonephritis and particularly in infants, it is<br />
difficult to distinguish between cystitis and pyelonephritis [2]<br />
1. May present with [3]<br />
Infant younger than 3 months<br />
• Most common<br />
- - fever<br />
- - vomiting<br />
- - failure to thrive<br />
- - diarrhoea<br />
- - poor feeding<br />
• Least common<br />
-- abdominal pain<br />
- - jaundice<br />
- - haematuria<br />
- - offensive urine<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 627
Urinary tract problems<br />
628<br />
Infants and children 3 months or older (preverbal)<br />
• Most common<br />
-- -fever<br />
-- -abdominal pain<br />
- - loin tenderness<br />
-- vomiting<br />
- - poor feeding<br />
• Least common<br />
-- irritability<br />
-- -haematuria<br />
- - offensive urine<br />
-- failure to thrive<br />
Infants and children 3 months or older (verbal)<br />
• Most common<br />
-- frequency<br />
- - dysuria<br />
- - dysfunctional voiding e.g. bed wetting<br />
- - changes to continence patterns<br />
- - loin tenderness<br />
• Least common<br />
-- fever<br />
- - malaise<br />
- - haematuria<br />
- - offensive urine<br />
- - cloudy urine<br />
2. Immediate management Not applicable<br />
3. Clinical assessment<br />
• Obtain a complete patient history:<br />
- - medical history<br />
- - is this the first UTI? have there been past episodes?<br />
- - does the child look unwell / septic?<br />
- - is there vomiting present? diarrhoea?<br />
- - how is the child’s appetite? what and how much are they eating and drinking?<br />
- - has the carer noticed anything such as strong urine odour, colour of urine,<br />
child passing urine frequently? or child crying when passes urine?<br />
• Perform standard clinical observations +<br />
-- assess growth and plot against chart for age and sex<br />
• Perform physical examination:<br />
-- inspect and palpate head to toe looking for other signs of infection<br />
- - palpate the abdomen, supra-pubic area and loin - is there tenderness?<br />
• Collect urine - always write the method of collection on the pathology form<br />
- - clean catch midstream urine<br />
○ can be obtained from children who can pass urine on request<br />
Method<br />
○ wash genitalia with water and dry<br />
○ have the child pass the first few mL in the toilet<br />
○ catch the rest of the specimen in a sterile container<br />
- - catheter specimens<br />
○ for children too young to obtain clean catch and with a high probability<br />
of UTI<br />
Controlled copy V1.0<br />
Primary Clinical Care Manual 2011
Urinary tract problems<br />
○ where no MO in residence these children will need evacuation /<br />
hospitalisation<br />
- - supra-pubic aspiration<br />
○ supra-pubic aspirates are the gold standard for obtaining urine specimens<br />
for culture - age limit (best) to 6 months but can try up to 12 months of age<br />
(contraindications include bleeding tendencies, abdominal distension<br />
and enlarged organs) [1]<br />
- - bag urine<br />
○ can never prove a UTI on a bag sample<br />
○ can use specimen for dipstick urinalysis - nitrates are the most sensitive<br />
for UTI<br />
○ can be used to rule out a UTI (if correctly applied urine bag specimen is<br />
negative on dipstick urinalysis) see below<br />
• Assessment of dipstick urinalysis<br />
- - If urinalysis is positive for nitrites UTI is likely - it would be reasonable to<br />
commence treatment<br />
- - If urinalysis is positive for leucocytes but negative for nitrates, UTI is possible<br />
- wait for culture result before starting treatment<br />
- - If blood and / or protein are positive but leucocytes and nitrates negative then<br />
UTI is unlikely<br />
4. Management<br />
• Consult MO who will arrange / refer / discuss:<br />
-- infants < 3 months of age with Paediatric Unit. UTI and
Bone and joint problems<br />
630<br />
See next MO clinic<br />
Routine prophylaxis is no longer recommended [1]<br />
6. Referral / consultation<br />
Consult MO on all occasions of suspected UTI in children<br />
All children with confirmed UTI require referral to Paediatrician<br />
All children < 6 months of age should have a renal ultrasound<br />
Consider renal ultrasound for older children with first UTI [1]<br />
Micturating cysto-urethrogram (MCU) or nuclear medicine scan may be necessary<br />
but the decision to perform this needs to be individualised in consultation with<br />
Paediatrician [1]<br />
References<br />
1. The Royal Children’s Hospital Melbourne. Urinary Tract Infection Guideline. 2008 [cited 2011 January];<br />
8th edition: Available from: www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5241.<br />
2. Therapeutic Guidelines. Urinary tract infections: children 2010 [cited 2011 January].<br />
3. NHS choices. Urinary tract infection, children. 2010 [cited 2011]; April]. Available from: www.nhs.uk/<br />
Conditions/Urinary-tract-infection-children/Pages/Symptoms.aspx.<br />
4. Royal Children’s Hospital, AntibioCard. 2011: Brisbane.<br />
Bone or joint infections - child<br />
Osteomyelitis and septic arthritis<br />
Recommend<br />
Referral to Orthopaedic Specialist if suspected osteomyelitis / septic arthritis [1]<br />
An important consideration if a skin infection is taking a long time to resolve, or<br />
occurs over a joint<br />
Background<br />
Osteomyelitis and septic arthritis can affect any joint or bone, but most commonly<br />
involve the lower limbs [1]<br />
Polyarthritis or aseptic monoarthritis or polyarthralgia, usually migratory (finishes in<br />
one joint and then begins in another) is a major manifestation of acute rheumatic<br />
fever (ARF) [2]<br />
Related topics<br />
Bacterial skin infections<br />
Acute rheumatic fever (ARF)<br />
1. May present with [1]<br />
Osteomyelitis<br />
• Subacute onset of limp / nonweight<br />
bearing / refusal to use limb<br />
• Localised pain and pain on<br />
movement<br />
• Tenderness<br />
• Soft tissue redness / swelling may<br />
not be present and may appear<br />
late<br />
• + / - fever<br />
2. Immediate management<br />
• Consult MO<br />
Controlled copy V1.0<br />
Septic arthritis<br />
• Acute onset of limp / non-weight<br />
bearing / refusal to use limb<br />
• Pain on movement and at rest<br />
• Limited range / loss of movement<br />
• Soft tissue redness / swelling often<br />
present<br />
• Fever<br />
Primary Clinical Care Manual 2011
Bone and joint problems<br />
3. Clinical assessment<br />
• Obtain complete patient history including:<br />
-- past episodes<br />
-- does the patient have pain? ask them to rate?<br />
-- when does it hurt? at rest? on movement?<br />
-- has there been any recent trauma?<br />
-- has the patient any skin infections currently or recently?<br />
-- history of acute rheumatic fever<br />
-- current medications taken<br />
• Perform standard clinical observations<br />
• Perform physical examination including:<br />
-- note patient on presentation - do they walk in? limp? hop? lean on another<br />
person? hold their arm to chest?<br />
-- inspect joints - is there any swelling, redness?<br />
-- allowing for pain levels check the range of movement in affected joint<br />
-- palpate the joint - is the joint warm to touch? is there tenderness?<br />
4. Management<br />
• Consult MO who will arrange:<br />
-- evacuation / hospitalisation<br />
-- referral to Orthopaedic Specialist<br />
-- FBC, ESR, blood cultures<br />
-- may order x-ray<br />
-- IV antibiotics<br />
• Rest and immobilise limb [1]<br />
• Treat pain and fever with paracetamol<br />
See Simple analgesia back cover<br />
5. Follow up<br />
All children with suspected osteomyelitis or septic arthritis should be managed in<br />
hospital<br />
6. Referral / consultation<br />
Consult MO on all occasions of suspected osteomyelitis and septic arthritis<br />
Refer to Orthopaedic Specialist if osteomyelitis / septic arthritis is suspected or<br />
confirmed [1]<br />
References<br />
1. The Royal Children’s Hospital Melbourne. Osteomyelitis and Septic Arthritis. 2008 [cited 2011 January]; 8th edition:<br />
Available from: www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5234.<br />
2. National Heart Foundation, RF / RHD Guideline Development Working Group, and Cardiac Society of Australia and<br />
New Zealand, Diagnosis and management of acute rheumatic fever and rheumatic heart disease in Australia: An<br />
evidence based review. 2006, National Heart Foundation Australia.<br />
Primary Clinical Care Manual 2011 Controlled copy V 1.0 631
Abuse and neglect<br />
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Abuse and neglect - child<br />
Recommend<br />
Do not ask child leading questions - this may taint evidence. If the child volunteers<br />
information, write it down<br />
Document injuries well using a body chart<br />
In some circumstances e.g. child sexual assault (CSA), examination is best done<br />
once. The best person to perform examination following CSA is usually a Paediatrician<br />
or MO specialising in child sexual abuse or Forensic MO. Assessment of CSA is<br />
complex and requires multi-agency investigation. A Child Protection Advisor (CPA)<br />
should be consulted<br />
<strong>Queensland</strong> legislation stipulates that all MO and RN (both public and private<br />
sector) are mandated to report concerns to the Department of Communities Child<br />
Safety Services, regarding children about whom they hold a reasonable suspicion of<br />
significant harm or risk of significant harm<br />
In addition it is <strong>Queensland</strong> <strong>Health</strong> policy that all health professionals have a duty of<br />
care to report reasonable suspicion of child abuse and neglect to the Department of<br />
Communities Child Safety Services [1]<br />
Do not request STI tests in an asymptomatic child as the initial response to a suspicion<br />
of sexual abuse<br />
If there is a suspicion of sexual abuse, please report as indicated above<br />
There is no screening test for child abuse - informed vigilance is required<br />
Background<br />
Under legislation staff do not breach professional ethics and are not liable under civil<br />
or criminal processes if the report is made in good faith and on reasonable grounds<br />
[1]<br />
Relevant provision is made under legislation for information sharing to prevent<br />
serious risk to life, health or safety [1].<br />
Related topics<br />
Rape / sexual assault<br />
Failure to thrive<br />
When considering if there is a reasonable suspicion of abuse or neglect, it is important<br />
to identify significant harm or risk of significant harm and how that is linked to actions<br />
or inactions of the parent<br />
1. May present with [2]<br />
• Physical abuse - injuries which don’t fit child’s developmental level or description<br />
provided by parent, punching, slapping, kicking, shaking, biting, applying physical<br />
‘discipline’ or ‘punishment’ causing harm or injury. Patterned injuries including<br />
burns and bruises<br />
• Emotional or psychological abuse - constant criticism, scapegoating, namecalling,<br />
belittling, excessive teasing, ignoring, punishing normal behaviour,<br />
exposure to domestic and family violence, withholding praise and affection<br />
• Neglect - failing to meet the child’s basic needs for adequate supervision, food,<br />
clothing, shelter, safety, hygiene, medical care, education, love and affection and<br />
failure to use available resources to meet those needs<br />
• Sexual abuse or exploitation - pregnancy, STI, disclosure of abuse, behaviour<br />
change, sexualised behaviour, any sexual act or sexual threat imposed upon a<br />
child including exposure, indecent phone calls, voyeurism, persistent intrusion of<br />
a child’s privacy, penetration, rape, incest, involvement with pornography, child<br />
prostitution<br />
Primary Clinical Care Manual 2011
Abuse and neglect<br />
2. Immediate management<br />
• If you suspect abuse always obtain advice. Consider discussing the case with<br />
your line manager, Paediatrician, CPLO (Child Protection Liaison Officer) or CPA<br />
3. Assessment<br />
• Forming a concern or well founded suspicion is based on the presence of:<br />
- - signs - injuries<br />
-- symptoms<br />
-- behaviours<br />
-- and occasionally disclosures<br />
4. Management<br />
• Treat all physical injuries appropriately<br />
• Thoroughly document any injuries using body charts<br />
• Document any disclosures using exact quotes as well as recording what question<br />
was asked before the disclosure. Be careful not to ask leading questions<br />
• If you have concerns regarding the injuries and the cause of the injury, or any<br />
other factor as outlined, it is recommended that you obtain advice / consult with<br />
line manager, Senior <strong>Health</strong> Worker, Director of Nursing, CPA / CPLO / MO<br />
• Consult MO who may need to arrange evacuation<br />
• If there is reasonable suspicion of child abuse or neglect, RN and MO are<br />
mandated to make a report immediately to Regional Intake Services and complete<br />
the process as per <strong>Queensland</strong> <strong>Health</strong> policy. See qheps.health.qld.gov.au/csu/<br />
reportingforms.htm<br />
• How to make a report to Child Safety Services<br />
1. During office hours - telephone your Child Safety Regional Intake Service<br />
(RIS) to make a verbal report<br />
2. After hours - telephone Child Safety After Hours Service Centre 1300 681<br />
513 Fax: 3235 9898<br />
3. Complete the ‘Report of Reasonable Suspicion of Child Abuse and Neglect’<br />
Form (SW010)<br />
4. Fax a copy of the Report Form to the RIS that received your verbal report<br />
within 7 days<br />
5. File the original copy of the Report Form in the correspondence section of<br />
the child’s hospital record<br />
6. Forward the yellow copy of the Report Form to your District CPLO, contact<br />
details are available on the QHEPS site qheps.health.qld.gov.au/csu/<br />
districtcpacplo.htm<br />
Regional Intake Service Phone number Fax number<br />
South East 1300 678 801 3884 8802<br />
South West 1300 683 259 4616 1796<br />
Far North <strong>Queensland</strong> 1300 683 596 4039 8320<br />
North <strong>Queensland</strong> 1300 704 514 4799 7273<br />
North Coast 1300 705 201 5420 9049<br />
Brisbane 1300 705 339 3259 8771<br />
Central <strong>Queensland</strong> 1300 683 042 4938 4697<br />
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Abuse and neglect<br />
5. Follow up<br />
Staff may be requested to provide relevant information to the Department<br />
of Communities Child Safety Services or other prescribed entities. If staff are<br />
unsure regarding information sharing request consultation with district medicolegal<br />
services is recommended<br />
Document in the client record accurate, considered, objective and up to date<br />
account of concerns, consultations, contacts, actions and plans related to<br />
presentation as these may be requested<br />
Ensure all information relating to the child, including immunisation status, is<br />
current<br />
6. Referral / consultation<br />
Consult MO. Child may need evacuation<br />
Refer parent / carer to Social Worker, non government agencies or other support<br />
services depending on availability or Parentline 1300 301300<br />
When considering management of children who have been abused or at risk of abuse, it<br />
can be helpful to consider the following factors. Note: it is not the role of the MO to make a<br />
full assessment of risk and protective factors. If abuse is suspected it must be reported to<br />
Department of Communities - Child Safety Services, to investigate further<br />
Risk factors and protective factors associated with child abuse and neglect<br />
• Protective indicators are safety factors that may reduce the likelihood of harm or risk<br />
of harm to a child. They are characteristics that prevent or balance risk-producing<br />
conditions [1]<br />
• The presence of risk factors does not confirm abuse or neglect. They are common<br />
features of families, parents or caregivers, children and environments that research and<br />
clinical experience have shown to increase the likelihood of child abuse and neglect [1]<br />
It is important to remember factors need to be considered in the context of a child’s personal<br />
history. For more detail See Protecting <strong>Queensland</strong> Children: Policy Statement and<br />
Guidelines on the management of child abuse and neglect in children and young people<br />
0 - 18 years www.health.qld.gov.au/csu/policy.htm [1]<br />
Resources<br />
• <strong>Queensland</strong> <strong>Health</strong>, Child <strong>Health</strong> and Safety Unit<br />
qheps.health.qld.gov.au/csu/home.htm<br />
• Department of Communities Child Safety Services<br />
www.childsafety.qld.gov.au<br />
• Commission for Children, Young People and Child Guardian<br />
www.ccypcg.qld.gov.au/index.aspx<br />
• NSW Department of Community Services<br />
www.community.nsw.gov.au/preventingchildabuseandneglect/<br />
reportingsuspectedabuseorneglect.html<br />
132 111 (24 hours)<br />
• Victorial Office For Children<br />
www.education.vic.gov.au/officeforchildren<br />
131 278 (24 hrs)<br />
References<br />
1. <strong>Queensland</strong> <strong>Health</strong>. Protecting <strong>Queensland</strong> Children: Policy Statement and Guidelines on the<br />
management of child abuse and neglect in children and young people (0-18 years). 2008 [cited 2011<br />
January]; Available from: www.health.qld.gov.au/csu/policy.htm.<br />
2. <strong>Queensland</strong> <strong>Government</strong>. What is child abuse? 2008 [cited 2011 January ]; Available from: www.<br />
childsafety.qld.gov.au/child-abuse/index.html<br />
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