Paediatric
https://www.uhbristol.nhs.uk/for-clinicians/clinical-guidelines/edgeneral-paediatrics/
https://bonexray.com/
https://www.uhbristol.nhs.uk/for-clinicians/clinical-guidelines/edgeneral-paediatrics/
https://bonexray.com/
If you develop significant worsening of your symptoms, or have breathing/dehydration concerns then please seek urgent medical attention.
- Evidence of difficulty breathing include: sucking in below the ribs, between the ribs, and above the breastbone, as well as head-bobbing, nasal flaring, grunting with every breath. Breathing hard and fast is sometimes seen with fever, however if this does not resolve with paracetamol/ibuprofen or the child becomes exhausted, then please seek medical attention.
- Evidence of dehydration include: cold hands, cold feet, dry eyes, dry mouth, poor circulation to the extremities, excessive drowsiness (e.g. not recognising family), especially not passing at least 2-3 urine/day, and usually associated with less than 50% of normal fluid intake.
---
We advised all parents that smoke in the home is associated with more severe symptoms. You can look at complete abstinence, smoking outside, or anything that reduces the child’s exposure to smoke - these are all good steps to take.
Return advice given:
If any of the following concerns, please present to ED immediately:
- feeding concerns: if reduced feeds by less than half of usual, or child looking dehydrated
- urine: less than half of usual nappies/urine output
- breathing: struggling to breath, increased work of breathing: retractions in the chest, grunting, blue around lips
- parental concerns: if child looking drowsy, lethargic or any other concerns
Nga mihi nui!
We have discussed how fevers (typically >37.8) that are well tolerated are part of the body's normal reaction to fight infection, and do not immediately require treatment. However, children that are upset/distressed with fevers would benefit from paracetamol and ibuprofen. Best effect is when these are used one after another, rather than immediately together, and provides better coverage in the day.
https://dontforgetthebubbles.com/hot-garbage-mythbusting-fever-children/
The normal time-course for viral gastroenteritis is typically 1-2 days of vomiting, with 5-7 days of diarrhoea. In a few cases the diarrhoea may last up to 14 days.
We have advised you to return if you are concerned for dehydration such as
- cold hands, cold feet, dry eyes, dry mouth, poor circulation to the extremities, excessive drowsiness (e.g. not recognising family), especially not passing at least 1-2 urine/day, and usually associated with less than 50% of normal fluid intake.
Molaxole on discharge:
Child 2–6 years 1 sachet on first day, then 2 sachets daily for 2 days, then 3 sachets daily for 2 days, then 4 sachets daily, stopping after 7 days treatment or earlier if impaction resolves
Child 6–12 years 2 sachets on first day, then increase in steps of 1 sachet daily to maximum 6 sachets daily, stopping after 7 days treatment or earlier if impaction resolves
Child 12–18 years 8 sachets daily, taken over 6 hours, for up to 3 days; contents of 8 sachets to be dissolved in 1 litre of water, after reconstitution the solution should be kept in a refrigerator and discarded if unused after 6 hours
once maintaining good regular soft bowel motions - can continue with molaxole sachets 0.5-1 daily
Advice on improving your child's bowel routine:
- Increase the water your child drinks daily - give them water at each meal time and extra water when it is hot
- Increase the fibre in your child's diet
- Increase fruit and vegetables in your child's diet
- Encourage your child to sit on the toilet for 5 mins twice daily 10 mins after meals (even if they don't do a poo). Position a step under feet, elevate knees above hip level.
- Helpful video: "Poo in you" can be found on YouTube: https://www.youtube.com/watch?v=SgBj7Mc_4sc
- Whanau information leaflet on constipation and treatment of constipation on KidzHealth: https://www.kidshealth.org.nz/constipation
We have discussed a possible functional element to chronic abdominal pain, a relatively common syndrome in childhood (estimated to affect 10-15% of children in the UK, 20% in the US). We typically do not make this diagnosis in the Emergency Department but strongly advise you to follow-up with your GP. As per national Starship guidelines, a diary kept by the child with parental assistance is an easy way to confirm the frequency, duration and associations of the pain.
Useful things to record include:
- Date
- Time
- What I was doing when the pain started
- How bad my pain was (1 to 3 : 1= mild; 3= the worst pain)
- How long my pain lasted
- What made my pain better
For reference only, as per Starship guidelines:
'The non-specific abdominal pain is often most severe in the morning but rarely lasts more than an hour - it is important to take the child to school once the pain starts settling. Similarly any sick bay attendances should be as short as possible and sending the child home from school is always the last resort. It is helpful to gain the support of teachers to ensure that the child and the pain are appropriately managed. With regular follow-up and support from their GP most children with recurrent abdominal pain syndrome will improve or at least reach a stage where they can cope with daily activities. Cognitive behavioural therapy may be helpful.'
https://uhbw.mystaffapp.org/diliboards/46/diliboard_contents/12401/document_view.pdf
Febrile convulsions are typically seen between the ages of 1-6yo, and usually occur alongside fevers. They typically do not cause long-term problems, and they usually stop as children grow up. However, we have stressed to you that it is not possible to prevent seizures by controlling temperature, use of paracetamol/ibuprofen or cooling does not prevent febrile convulsions.
First aid for seizures
1. Start a timer
2. Don't panic
3. Remove immediate dangers, for example if on chair it would help to bring your child to the ground to avoid falls, or cushioning the head with blankets/clothes.
4. Turning your child onto their side and recovery position is ideal but do not restrain your child if resistant during seizure activity.
5. If lasting longer than 5 minutes, call for an ambulance on 111
Most seizures self-terminate without medication. Even if this is the case, we have advised that you are welcome to bring your child in for assessment and review. If seizure activity lasts longer than 5 minutes, call for an ambulance in case medication is needed to prevent prolonged seizures (generally considered >15 minutes).
https://media.starship.org.nz/febrile-seizure/Febrile_seizure.pdf
https://uhbw.mystaffapp.org/diliboards/86/diliboard_contents/931/document_view.pdf.
First aid for seizures
1. Start a timer
2. Don't panic
3. Remove immediate dangers, for example if on chair it would help to bring your child to the ground to avoid falls, or cushioning the head with blankets/clothes.
4. Turning your child onto their side and recovery position is ideal but do not restrain your child if resistant during seizure activity.
5. If lasting longer than 5 minutes, call for an ambulance on 111
Most seizures self-terminate without medication. Even if this is the case, we have advised that you are welcome to bring your child in for assessment and review. If seizure activity lasts longer than 5 minutes, call for an ambulance in case medication is needed to prevent prolonged seizures (generally considered >15 minutes).
https://media.starship.org.nz/your-child-has-had-a-seizure/your-child-has-had-a-seizure.pdf
https://media.starship.org.nz/seizure-plan-lasting-over-5-minutes-with-buccal-midazolam/Seizure_plan_lasting_over_5_minutes_with_Buccal_Midazolam.pdf
* You have been requested to isolate at home pending the results of your swab *
The Public Health team have been notified regarding this possible case of mumps. They will call you directly and follow-up the results of the swab and advise you on next steps. The swab is sent to Auckland for testing and the results should return early next week.
We have provided treatment as per the latest evidence including the FORCE trial for similar fractures in this age group. These fractures tend to be very stable and require minimal/no follow-up, however, we have advised you you are welcome to check in with your GP in 1-2 weeks if you are concerned.
You are welcome to remove the soft bandage cast at 2 weeks, or sooner if you feel OK to do so.
Further information on the FORCE trial can be found here https://dontforgetthebubbles.com/the-force-trial/
We have diagnosed you with likely chickenpox. This is a common childhood infection that can cause nasty itching and blistering but often heals very well without treatment in healthy adults and children. General advice is to:
- Trim children's fingernails to minimise scratching.
- Take a warm bath and apply moisturising cream.
- Paracetamol can reduce fever and pain.
- Calamine lotion and oral antihistamines may relieve itching.
Avoid NSAIDS medications like ibuprofen during this illness (outside of hospital use) due to the increased risk of severe cutaneous complications such as invasive group A streptococcal superinfections. Do not use aspirin in children as this is associated with Reye syndrome.
You are infectious from 2 days prior to the appearance of the rash, up until either (1) 5 days after the appearance of the rash, or (2) crusting of all the lesions, whichever is LONGEST. This can take 5-10 days. Children should stay away from school or childcare facilities throughout this contagious period. Adults with chickenpox who work among children should also remain home.
As chickenpox may cause complications in immunocompromised individuals and pregnant women, these people should avoid visiting friends or family when there is a known case of chickenpox. In cases of inadvertent contact, see your doctor who may prescribe special preventive treatment.
cetirizine hydrochloride 1 mg/mL oral liquid
Symptomatic relief of allergy such as hayfever, chronic idiopathic urticaria, atopic dermatitis
Child 6–11 months 2.5 mg once daily
Child 12–23 months 2.5 mg once daily, increased to a maximum of 2.5 mg twice daily as required
Child 2–5 years 2.5 mg once daily, increased to a maximum of 5 mg daily in 1 or 2 divided doses
Child 6–11 years 5–10 mg once daily depending on symptom severity
Child 12–18 years 5–10 mg once daily depending on symptom severity; usual starting dose is 10 mg
calamine 4% (40 mg/g) + zinc oxide 3% (30 mg/g) cream, 100 g
Wash and pat dry skin, apply as a thin layer to itchy skin as needed - usually every 3-4 hours.
Shake well before use.
Most tonsillitis is viral and does not require specific treatment - recovery time is typically less than a week and symptoms are managed with supportive care, good hydration, and painkillers. In a minority of cases, tonsillitis may be caused by a bacteria such as Streptococcus A - we have discussed several risk factors that may increase this chance. When bacterial tonsillitis is suspected we use antibiotics to prevent rare but significant complications where those bacteria may spread to other parts of the body such as the heart. On average, antibiotics reduce the average time of sore throat symptoms by 16 hours only.
We have taken a throat swab to look for these bacteria, this is cultured and grown in the lab and results take several days to come back. You should hear from either your GP or ED within the next 4-5 days with the results of the swab. If you do not hear back, please complete your antibiotic course (10-days in full).
www.aafp.org/pubs/afp/issues/2014/0701/p23.html
Amoxicillin Group A streptococcal pharyngitis; acute rheumatic fever
Oral
Child 50 mg/kg (maximum 1 g) once daily for 10 days OR 25 mg/kg (maximum 500 mg) twice daily for 10 days
OR
Child under 30 kg 750 mg once daily for 10 days
Child 30 kg and over 1 g once daily for 10 days
Note See New Zealand Guidelines for Rheumatic Fever Group A Streptococcal Sore Throat Management Guideline: 2019 Update Heart Foundation, June 2019 for more information.
Why treatment fails:
Parents are scared to use TCS
Parents most often do not see the bleach baths as necessary
Families do not have health education to get repeat scripts
Points to check:
Check what the family understands about which cream and where to apply it (ideally they should have their creams with them)
Check what has been dispensed on NZePS - cross reference the number of actual creams vs what you would have expected they need to keep the child under control
Check bleach bath/wash. Most often overlooked by families who are afraid it will hurt the child or do not see it as important.
Ensure they are not using Cetomacrogel + glycerol as the moisturiser - this is soap replacement
Ensure adequate volume of moisturiser is being dispensed and used
Ensure they know how to get repeat scripts
Ensure they have written instructions along with the bleach mix guide.
TEMPLATE 1:
Paeds < 12 months
Initial treatment:
Use cetomacrogol + glycerol as soap replacement product – 1000 g
Bleach wash. Use a mixture of 1.2 ml of 4.2% bleach (Value Extra Strength Bleach from Pak n Save, New World and Four Square) mix with 1000ml (larger pump bottle) of cetomacrogol + glycerol - shake well and use as a soap replacement in the shower for three months. These should be done weekly during a flare and 3 x per week as maintenance. Ask the family to use the bleach mix as soap in the first week.
Apply moisturiser on the whole body and face. We recommend liquid paraffin 50% + soft white paraffin 50% ointment. This should be applied three times daily. The patient should use at least 1000 g per month. The skin should not be allowed to dry out.
Body: Triamcinolone acetonide (Aristocort) ointment should be applied to all affected rash areas on the whole body once daily until the rash clears. This may take up to 2 weeks. Re-start as soon as the rash recurs. Use up to 50 g per month
Face: 1% Hydrocortisone cream should be applied to all affected facial rash areas once daily until the rash clears. This may take up to 2 weeks. Re-start as soon as the rash recurs. Use up to 30 g per month
Step-up:
Use cetomacrogol + glycerol as soap replacement product – 1000 g
Bleach wash. Use a mixture of 1.2 ml of 4.2% bleach (Value Extra Strength Bleach from Pak n Save, New World and Four Square) mix with 1000ml (larger pump bottle) of cetomacrogol + glycerol - shake well and use as a soap replacement in the shower for three months. These should be done weekly during a flare and 3 x per week as maintenance. Ask the family to use the bleach mix as soap in the first week.
Apply moisturiser on the whole body and face. We recommend liquid paraffin 50% + soft white paraffin 50% ointment. This should be applied three times daily. The patient should use at least 1000 g per month. The skin should not be allowed to dry out.
Body: Triamcinolone acetonide (Aristocort) ointment should be applied once daily to any active eczema spots on the body until the skin is smooth and clear. Aristocort should be applied to the whole body (neck down) as a 'moisturiser' on a Saturday and Sunday (even if no rash). Use up to 50 g per month.
Face: Calcineurin inhibitor: Please prescribe a topical calcineurin inhibitor for the face. Apply for Special Authority for pimecrolimus . Use pimecrolimus (Elidel) cream as outlined below:
Week 1: use hydrocortisone 1% cream once a day for one week
Week 2: use hydrocortisone 1% cream once a day in the morning and pimecrolimus (Elidel) cream at night
Week 3: use pimecrolimus (Elidel) cream twice daily
Week 4: reduce pimecrolimus (Elidel) cream to once daily as maintenance.
Calcineurin inhibitors are safe for long-term use and do not cause skin thinning.
Continued maintenance treatment with pimecrolimus (Elidel) cream twice weekly is recommended to reduce flares.
If the skin is acutely inflamed when you start the pimecrolimus (Elidel) cream, it can cause stinging. This can be reduced by keeping the calcineurin inhibitor in the fridge.
TEMPLATE 2
Paeds 12 months – 12 years
Initial treatment
Use cetomacrogol + glycerol as soap replacement product – 1000 g
Bleach wash. Use a mixture of 1.2 ml of 4.2% bleach (Value Extra Strength Bleach from Pak n Save, New World and Four Square) mix with 1000ml (larger pump bottle) of cetomacrogol + glycerol - shake well and use as a soap replacement in the shower for 3 months. These should be done weekly during a flare and 3 x per week as maintenance. Ask the whole family to use the blach mix as soap in the first week.
Apply moisturiser on the whole body and face. We recommend liquid paraffin 50% + soft white paraffin 50% ointment. This should be applied three times daily. The patient should use at least 1000 g per month. The skin should not be allowed to dry out.
Mometasone furoate (Elocon) ointment should be applied to all affected rash areas on the body once daily until the rash clears. This may take up to 2 weeks. Re-start as soon as the rash recurs. (See table below for the amount needed if the whole body was covered in eczema. e.g. 12 month old 160g per month for month 1, then 50g per month ongoing; 2 years - 5 years 200g in the first month, then 75 g per month ongoing, 5 years old 280 g for 1 month, the 100g per month ongoing
Triamcinolone acetonide should be applied to the whole face once daily until the rash clears. This may take up to 2 weeks. Re-start as soon as the rash recurs. 100g every 3 months
Step-up:
Use cetomacrogol + glycerol as soap replacement product – 1000 g
Bleach wash. Use a mixture of 1.2 ml of 4.2% bleach (Value Extra Strength Bleach from Pak n Save, New World and Four Square) mix with 1000ml (larger pump bottle) of cetomacrogol + glycerol - shake well and use as a soap replacement in the shower for 3 months. These should be done weekly during a flare and 3 x per week as maintenance. Ask the whole family to use the blach mix as soap in the first week.
Apply moisturiser on the whole body and face. We recommend liquid paraffin 50% + soft white paraffin 50% ointment. This should be applied three times daily. The patient should use at least 1000 g per month. The skin should not be allowed to dry out.
Body: Mometasone furoate (Elocon) ointment should be applied to all affected rash areas on the body once daily until the rash clears. This may take up to 2 weeks. Elocon ointment should be applied to the whole body (neck down) as a 'moisturiser' on a Saturday and Sunday (even if no rash). (See table below for the amount needed if the whole body was covered in eczema. e.g. 12 month old 160g per month for month 1, then 50g per month ongoing; 2 years - 5 years 200g in the first month, then 75 g per month ongoing, 5 years old 280 g for 1 month, the 100g per month ongoing
Face: Start tacrolimus (Zematop) ointment as outlined below for the whole face:
Week 1: use triamcinolone (Aristocort) ointment once a day for one week
Week 2: use triamcinolone (Aristocort) ointment once a day in the morning and tacrolimus (Zematop) ointment at night
Week 3: use tacrolimus (Zematop) ointment twice daily
Week 4: reduce tacrolimus (Zematop) ointment to once daily as maintenance.
Calcineurin inhibitors are safe for long-term use and do not cause skin thinning.
Keep the tacrolimus (Zematop) ointment in the fridge to reduce stinging.
Continued maintenance treatment with tacrolimus (Zematop) ointment twice weekly is recommended to reduce flares.
If the skin is acutely inflamed when you start the tacrolimus (Zematop) ointment, it can cause stinging. This can be reduced by keeping the calcineurin inhibitor in the fridge.
TEMPLATE 3
Seborrhoeic eczema < 12 months
Use ketoconazole shampoo once daily on the whole scalp (can use on the face, neck and body) for 1 week. Leave on for 5 minutes and rinse off. Maintain with treatment 3 x per week ongoing. 100 ml every 3 months
Apply hydrocortisone butyrate (Locoid) scalp Crelo to the whole scalp once daily for 1 week then 3 x per week as maintenance. 100 ml every 3 months
Apply miconazole + 1% hydrocortisone (Micreme H) 1 -2 x per day to the face and nappy area (affected areas) 30g per month
TEMPATE 4
Seborrhoeic eczema 12 months to 12 years
Use ketoconazole shampoo once daily on the whole scalp (can use on the face, neck and body) for 1 week. Leave on for 5 minutes and rinse off. Maintain with treatment 3 x per week ongoing. 100 ml every 3 months
Apply hydrocortisone butyrate (Locoid) scalp Crelo to the whole scalp once daily for 1 week then 3 x per week as maintenance. 100 ml every 3 months OR escalate to betamethasone valerate (Beta scalp drops) if child is > 2 years
Apply miconazole + 1% hydrocortisone (Micreme H) 1 -2 x per day to the face 30g per month
Consider oral itraconazole daily for 4 weeks then 3 x per week as maintenance (see NZ formulary for dosage)
AR
https://www.kidshealth.org.nz/eczema-action-plan
https://starship.org.nz/guidelines/eczema/