DISEASES OF NEWBORN
Apnoea in the Newborn
Apnoea is defined as cessation of breathing for > 20 seconds, which is common in preterm neonates and/or accompanied by bradycardia with heart rate < 100/min or cyanosis.
- General measures
- Clear respiratory airway with a mucus catheter or a suction machine (negative pressure not more than 5 mmHg).
- Keep the baby dry and warm under a warmer.
- Administer oxygen with nasal catheter or face mask.
- Gentle cutaneous stimulation.
- Bag and mask ventilation if tactile stimulation ineffective.
- Avoid oral feeds.
- Treat underlying causes, e.g. sepsis, anemia, polycythemia, hypoglycemia, hypocalcemia, respiratory distress, respiratory distress sydnrome.
- Trasfusion of packed cells if hematocrit <30%.
- Specific measures
- Continuous positive airway pressure (CPAP).
- Mechanical ventilator.
- IV Aminophylline 5–6 mg/kg followed by 1.5–3 mg q8–12 h.
- If patient does not respond to aminophylline and CPAP:Intubate—mechanical ventilatorPressure control
- ℞ Inj. Doxepram infusion 0.5 mg/kg/h, gradually increased to 2 to 2.5 mg/kg/h.
- ℞ Inj. Midazolam 0.2 mg/kg stat followed by 0.06 mg to 0.9 mg/kg/h.
- ℞ IV glucose 25% 2–4 mL/kg.
- ℞ IV calcium gluconate 10% 1–2 mL/kg.
- ℞ Phenobarbital 20 mg/kg IV. Maintain withIV/oral 5–10 mg/kg daily in divided doses.
- ℞ Inj. Phenytoin sodium 10–15 mg/kg IV slowly.Later 5–7 mg/kg orally.
If convulsions persist :
- ℞ Inj. Diazepam drug of choice0.25–0.5 mg/kg IV or IM.
- ℞ Inj. Pyridoxine 50–100 mg IM as therapeutic test of pyridoxine deficiency or dependency if suspected.
- Symptomatic hypocalcemia in neonate
- ℞ Calcium gluconate IV 100–200 mg/kg, 9–18 mg of elemental Ca/kg, repeated q6–8 h until Ca level stabilises.
- Late neonatal hypocalcemia is usually partially secondary to hyperphosphatemia.
- ℞ Calcium gluconate syrup700–1000 mg/kg/24 h divided into 4–6 doses
- Beyond neonatal period
Starting dose of elemental calcium is 50 mg/kg/24 h in 3–4 divided doses.
- ℞ 100–200 mg/kg IV calcium gluconate over 5–10 minutes is effective. Once calcium level is normal, start oral syrup—calcium carbonate or calcium gluconate.
- ℞ Inj. Magnesium sulphate 25–50 mg/kg (0.05–0.1 mL/kg of 50% solution by slow IV infusion or by IM inj.
Hemorrhagic Disease of Newborn
- ℞ Inj. Kenadim 1 mg IM stat. Repeat dose of 1 mg if bleeding does not stop. If bleeding persists after 2 mg.
- ℞ Transfusion of fresh whole blood or Plasma 10–15 mL/kg.
Send cord blood for determination of blood group, Coomb's test, Hb level and bilirubin. Send mother's blood for Rh and ABO antibody titre and blood for grouping and crossmatching.
If baby has anaemia or CHF, give Lanoxin (refer CHF)
In all other cases –
Start phototherapy :
Put the baby under a light, fitted with about 8 tubes of cool daylight or blue fluorescent tubes.
The light should be kept about 45 cm above the surface of the child's body.
- ℞ Repeat serum bilirubin every 6 hours.
- ℞ Exchange transfusion with 170 mL/kg of Rh–ve blood in case of Rh disease and O group of same Rh as mother in case of ABO incompatibility.
- Cord bilirubin more than 3.5 mg%.
- Cord Hb less than 12 g.
- Direct Coomb's test positive.
- Rapid rate of bilirubin rise (> 0.5 mg/h).
- Indirect bilirubin level > 10 mg% at 12 hours or> 15 mg% at 24 hours or > 20 mg% at any time.
Preterm and low birth weight babies are prone.
Acyclovir 10 mg/kg/day IV given as infusion over 1 hour used in neonatal herpes simplex, herpes encephalitis.
Small babies who cannot tolerate gavage feeding and have gastric stasis require parenteral fluids:
- ℞ Isolyte P 100–150 mL/kg/day.Babies under infant warmer or phototherapy require 20% more fluids.
- ℞ Calcium gluconate 2 mL/kg 8–hourly, diluted with twice the amount of fluid—to be given by slow push.
Note: Ampicillin can be given if meconium aspiration or prolonged labour for prophylaxis.
Preterm or Low Birth Weight Babies
- Proper resuscitation at birth.
- Thermoregulation (a) Keep the body temperature at 37°C (nurse in incubator). (b) Kangaroo mother care: Soon after delivery, the naked bady with the head and neck covered should be placed inbetween the breast of the mother in skin–to–skin contact position. It not only maintains the temperature of the body but also helps in the prompt initiation of breastfeeding. The bady should be covered with at least 3 layers of clothes, socks, mittens and cap.
- Give gavage feeding to small babies:For normal babies start after 2 hours.First feed 5% glucose.Milk: Calculate amount as follows :1st day40–60 mL/kg/day2nd day60–80 mL/kg/day3rd day80–100 mL/kg/day4th day100–120 mL/kg/day7th day and above150 mL/kg/day
Use breast milk as far as possible or modified milk formula: Prelactogen or Dexolac. Special care or Lactodex LBW.
Increase the quantity gradually.
Milk to be given 2–3 hourly round the clock.
- ℞ Vitamin K 0.5–1 mg at birth to all.Vitamin supplements after 7 days.
Use all aseptic measures.
In very small babies, start parenteral fluids.
Isolyte–P (quantity as above).
Vomiting in Newborn
- Stomach wash with normal saline to relieve meconium or blood gastritis.
- Keep infant in upright position after feeds or as long as needed.
- Treat the cause.
- Maintain hydration with IV fluids.
- Domstal liquid 0.5 mg/kg body weight in divided doses, before feeds.
- X–ray abdomen in vertical position to rule out obstruction.If vomiting persists consider surgical causes.
- Pass stomach tube and take X–ray chest.
- Maintain body temperature.
- Estimate blood gases, give oxygen.
- If pH < 7.2 and child has metabolic acidosis :
- ℞ Soda bicarb after calculating the deficit as follows –Weight in kg × 0.3 × (20– observed bicarbonate reading).Give ½ the deficit by slow push after diluting with Isolyte P or 10% glucose. Add remaining to a 24 hours drip.
- If respiratory acidosis, then the child should be given ventilatory support.
- ℞ Glucose 10% IV at rate of 70 mL/kg/day. After 24 hours:℞ Isolyte P or suitable glucose electrolyte solution.
If any signs of infection :
- ℞ Inj. Ampicillin 100 mg/kg/day.
- ℞ Inj. Gentamicin 5 mg/kg/day.Depending on blood culture and antibiotic sensitivity, changes in the antibiotic can be made.Apnoea monitor should be used.
Polycythemia in Newborn
Venous hematocrit > 65% or venous Hb >22 g/dL.
Mangement (a) Conservative with hydration. (b) Partial exchange transfusion (PET).
As a rough guide volume of exchange is usually 20 mL/kg.
Hypoglycemia in Newborn
Blood sugar <40 mg/dL. It can occur in prematurity, growth retardation and maternal diabetes. It may be asymptomatic or symptomatic.
Mangement (a) Asymptomatic hypoglycemia: Breastfeeds promote ketogenesis. If breastfeeds not possible, give formula feed or fortified feed by adding sugar 5 g in 200 mL water or 5% dextrose. If blood sugar <20 mg/dL, IV fluid with dextrose 6 mg/kg/mt. (b) Symptomatic hypoglycemia (including seizure) 2 mL/kg 10% dextrose bolus.
Total serum calcium concentration < 5 mg/dL. More in preterm newborn.
Treatment of hypocalcemic crisis with seizures, apnoea or tetany (serum calcium <5 mg/dL).
- ℞ Inj. Calcium gluconate 1–2 mL/kg(8 mg of elemental calcium IV over 5 minutes under heart rate monitoring).
Note : Peripheral smear for microcytic hypochromic anaemia.
Reticulocyte count is a must before starting iron therapy to rule out hemolytic anemia.
- ℞ Iron syrup Vitcofol com. 5 mL od.
- ℞ Tonoferon dropsProphylactic dailyUpto 3 months 3 drops3–6 months 5 drops6–12 months 6–12 drops bdTherapeutic : Double the prophylactic dose.
- Diet : Green leafy vegetables and cereals.Blood transfusion if severe anaemia: 20 mL/kg body weight of packed cells.Parenteral iron therapy. Formula for dose : mg iron = (Blood volume) × (12.5 – Observed Hb) × (3.4) × (1.2) ÷ 100.Where blood vol = 75 mL/kgImferon contains 50 mg elemental iron/mL.Total dose over 2–3 weeks. Not to exceed 0.1 mL/kg/dose, maximum 2 mL/dose.
Autoimmune hemolytic anaemia :
Autoimmune with warm antibodies
Transfusion gives transient benefit and the blood should be one where red cells give least positive in vitro reaction by Coomb's technique.
- ℞ Prednisolone 4–6 mg/kg/day to induce response, then reduced to 2–4 mg/kg/day within 48 hours when possible.
If relapse: Start with full dose of prednisolone.
If large doses of steroids are required to maintain reasonable Hb level—splenectomy.
- ℞ If steroids fail to control hemolysis : Course of plasmapheresis.
- ℞ Inj. Gammaglobulin (Isiven) IV 1 g/kg/day × 5 days.
Autoimmune with cold antibodies
Exchange transfusion in neonatal period for hyperbilirubinemia.
If severe anaemia : Packed cell transfusion
10–15 mL/kg. Avoid exposure to low temperature.
Hemoglobinopathies (No specific cure)
- Sickle cell crisis
- ℞ Paracetamol 10 mg/kg 6 hourly for pain.
- ℞ Oxygen in severe crisis.
If infection :
- ℞ Ampicillin + Gentamicin.Blood transfusion 10–15 mL/kg to dilute patient's red cells with normal ones.
Maintain Hb >12 g%. If it falls blood transfusion 10–15 mL/kg.
Splenectomy if spleen is very large or evidence of hypersplenism.
- ℞ Desferal 30–50 mg/kg/day subcut.Give 5 days/week or
- ℞ Deferiprone (Kelfer) 75 mg/kg by mouth.
Congestive Heart Failure
Rest in bed.
Diet : Salt free not necessary (in children) generally.
However, in florid failure and older children restriction of salt.
- ℞ Lanoxin tablet 0.25 mg/tab.Elixir lanoxin 0.05 mg/mL.Digitalising dose : By mouth/24 h.Premature : 0.02 mg/kg.Full term : 0.02 mg/kg.<2 years : 0.04 mg/kg.>2 years : 0.03–0.04 mg/kg.Maximum : 1 mg PO.Maintenance dose : 1/4th–1/6th total digitalising dose.
Note : Be careful if digitalis has been given in previous 2 weeks.
- ℞ Frusemide (Lasix) 1–2 mg/kg/dose 2–4 times/day
- ℞ Hydrochlorthiazide 2 mg/kg/day in 2 divided doses PO
- ℞ Metolazone 0.2 mg/kg bd.
- ℞ Captopril (Aceten) 0.5 mg/kg/day
- ℞ Enalapril 2.5–5 mg/day.
In severe cases:
- ℞ Dobutamine 5–25 mg/kg/min or
- ℞ Dopamine 5–25 mg/kg/min IV.
- ℞ Inj. Morphine 0.1 mg/kg IM stat.
- ℞ IV Sodabicarb 1 mg/kg (monitor arterial pH)
- ℞ Inj. Propranolol0.1 mg/kg IM or IV to terminate an attack.
- ℞ Tab. Inderal or ciplar 10 mg.1 mg/kg 6 hourly by mouth as maintenance dose.
- ℞ If hemoglobin is less than 15 g/mL, transfusion (5 mL/kg) to be given.
Acute Rheumatic Fever with Arthritis
Rest in bed till all signs of rheumatic activity disappear (About 3–6 weeks in case of arthritis and 6–12 weeks in case of carditis).
Suppressive therapy :
- ℞ Disprin tablets
- ℞ AntacidOne teaspoon with each dose of aspirin.
If no relief after 8–10 days of aspirin :
- ℞ Prednisolone 2 mg/kg/day for 3–6 weeks.
- ℞ Inj. Benzathine penicillin600,000 units if wt. <27 kg1200,000 units if wt. >27 kgIf allergy to Penicillin :
- ℞ Oral penicillin (e.g. Pentids) 200–400 mg bd.
- ℞ Erythromycin 50 mg/kg/day in 4 divided doses.
- ℞ Multivitamin syrup once daily.Nutritious diet.
- ℞ Tab. Aspirin (dosage as above).If no response to aspirin, or aspirin allergy or fulminating carditis :
- ℞ Prednisolone 2 mg/kg/day. To be continued for 3–6 weeks and tapered over 6 weeks period.Start aspirin when prednisolone is tapered and continue for 1–2 weeks.
- ℞ Antibiotics as above.Treatment of CHF (Refer).
- ℞ Phenobarb 6 mg/kg/day and/or
- ℞ Valproate 5 mg/kg/day.Taper as symptoms improve.
- 0.01–0.03 mg/kg/day in 2 divided doses.
- ℞ Diazepam 2 mg thrice daily.
Prophylaxis of rheumatic fever :
Treat every attack of sore throat vigorously.
- ℞ Inj. Benzathine penicillin (Penidure LA 12) 12 lac units once in 3 weeks at least up to age of 20, or 5 years after the last attack whichever period is longer, or for life if valve involvement.
- ℞ Penicillin G (pentids) 400 mg bd for lifetime. If penicillin allergy :
- ℞ Erythrocin 250 mg twice daily.
- ℞ Multivitamin syrup one teaspoon daily.
- ℞ Cap. Aquasol or
- ℞ Tab. Vit. A 50,000 units
- ℞ Inj. Aquasol (100,000 IU per vial) daily for 6 doses and after 15 days 1 dose.Aqueous solution can be given IM particularly if there is diarrhoea.
- ℞ Tab. Vit A 1 od
Care of the eyes
- ℞ Soframycin eye ointment.
- ℞ Atropine eye drops.Cover with pad and bandage.
- ℞ Tab. B complex forte—one daily or syrup with therapeutic concentration.Plenty of green leafy vegetables.
Vitamin B1 Deficiency
Mother and child both to be treated if mother lactating.
Mother – Berin 50 mg daily.
Child – Berin 10 mg daily.
If carditis and gastroenteritis :
- ℞ Inj. Berin (100 mg/mL) 0.5 mL daily.
- ℞ Tab. Benurone forte—one daily.
- ℞ Tab. Riboflavin 5 mg – 2 daily.If no response within a week :
- ℞ Inj. Riboflavin 0.5 mL daily (1 mL = 5 mg).
Niacin Deficiency (Pellagra)
- ℞ Tab. Peloninamide 50 mg.2–6 tablets daily.Avoid sunshine.Use soothing applications for skin lesions.
For convulsions :
- ℞ Inj. Pyridoxine 100 mg IM stat.
For Pyridoxine dependent children :
- ℞ Pyridoxine tablets 10 mg—twice daily.
- ℞ Inj. Redoxon forte 500 mg IM stat.
- ℞ Redoxone or celin tablets 100 mg.One thrice daily till complete recovery.
- ℞ Vitamin C drops—20 drops thrice daily.
Vitamin D Deficiency (Rickets)
- ℞ Inj. Massive D.
- ℞ Arachitol–6 one amp. every 4 weeks for 3 doses.½ litre of milk daily.If milk is not consumed:
- ℞ Ostocalcium or calcimax (250 mg) tablets–One bd or tds daily × 3 months.
- ℞ Oral calcirol sachets (one sachet–60,000 units) can be given orally with milk along with calcium syrup.
Management of gastroenteritis (Refer).
If severe anorexia : Gavage feeding (with nasogastric tube):
4–6 oz of milk or
Nutritional powder (several brands available) 2–3 teaspoons every 3 to 4 hours. Add one teaspoonful of sugar to every feed.
Gradually add beaten egg once or twice a day. Curd is better for veg.
(Aim is to give 200 cals/kg and 3–4 g of protein/kg).
- or Simple ready to use therapeutic foods.
- ℞ Cephalexin (sporidex) 100 mg/mL 225–250 mg bd.
- ℞ Cefpodoxime (cepodem) 50–100 mg bd.
Start feeding gradually to avoid malabsorption diarrhoea.
When child is able to take solids give rice and dal. Also bananas, fruit juices and some butter or ghee.
Gradually add green leafy vegetables to diet.
- ℞ B complex syrup—one teaspoon daily.
- ℞ Digeplex or bestozyme liquid.1–2 teaspoons after major meals.Deworm (refer).
If concurrent respiratory infection:
- ℞ Augmentin Duo 1 tsp bd
If urinary tract infection : (Refer).
If recovery slow :
Blood transfusion 10–20 mL/kg once or twice.
GASTROINTESTINAL SYSTEM AND LIVER DISEASE
- Diet: Containing roughage (green leafy vegetables) and less of carbohydrates and starches. Fruits such as bananas, figs. Dry figs, apricots and black currants to be soaked overnight and the crushed pulp sweetened and given daily.
- Water intake to be increased.
- ℞ Isopgul or Isogel 1 tsp in water or milk daily at night
- ℞ Lactulose (Duphalac) 15 mL followed by a glass of water daily.
- ℞ Laxative syrup (Senolax syrup) one tsf daily.
- ℞ Syrup of figs.
- Regular bowel habits to be encouraged.
Hypertonic saline enema
Bowel wash with normal saline till all the hard masses are removed.
Rectal examination should be done to detect fissure–in–ano, stricture of anus, or any other painful condition around rectum and anus.
Note : Habitual constipation is more common and should be treated with psychological backup.
Diarrhoea is excessive loss of fluid and electrolytes in the stool. Young infant has about 5 gm/kg of stool output per day. Disorders that interfere with absorption in the small bowel tend to produce voluminous diarrhoea whilst those disorders comprising colonic absorption produce low volume diarrhoea.
Osmotic diarrhoea is caused by presence of non–absorbable solutes in the GI tract, e.g. lactose intolerance caused by lactase enzyme deficiency.
Secretory diarrhoea is characterized by high volume stools in cholera and E. coli infection.
Viral gastroenteritis. Rotavirus, adenovirus, coronaviruses such as Norwalit agents are important pathogens. In Rotavirus these are held to moderate fever and vomiting followed by watery stool which continue for 5–7 days. Dehydration can occur rapidly.
- ℞ Electral or Prolyte powder (small sachets)Sachet/200 mg waterThis is called low–osmolarity ORS
- ℞ Sugar 8 tsfGive ad lib.
Do not stop breastfeeding.
Give rice cunjee, dal water.
If moderate to severe dehydration or oral fluids not tolerated.
- ℞ IV fluids 200–250 mL/kg in 24 hours.
If signs of hypokalemia (paralytic ileus, hypotonia) add: Potassium chloride 1 mL (2 mEq) per 100 mL glucose.
- ℞ Isolyte–M for older children.
- ℞ Isolyte–P for newborn and small infants.Start oral feeds as soon as possible.Home made chhas, chicken soup, rice–water are alternatives to ORS.
If infant is toxic, has fever or stools contain pus cells, blood and mucus :
- ℞ Norfloxacin 10 mg/kg/dose bd.
- ℞ Ampicillin 100 mg/kg 6 hourly
- ℞ Syrup ofloxacin 7.5 mg/kg/dose bd.All above drugs to be given for 5–7 days.
If above drugs fail to act :
- ℞ Inj. Amikacin 10 mg/kg in two divided doses.5 mg/kg IM in 2 divided doses daily × 5 days.
- ℞ Enuff sachets (racecadotril) 1.5 mg/kg every 8 hours or Racy capsules 100 mg bd.
- ℞ Nutrolin B syrup – ½–1 tsp. thrice daily.(To be used when antibiotics are administered for prolonged periods).
Milk allergy : Prosoyal or Zerolac 4–8 oz. 3–hourly.
Diet : Moog dal, rice with oil and sugar cooked and given as khichdi or paste, mashed potatoes. Minced chicken, mutton or dals may be used as protein substitutes.
Lactose intolerance :
- ℞ Lactodex baby food (lactose–free milk).Add Nolac drops—12 drops/litre of boiled cool milk. Stir gently. Let the milk stand for 3 hours before feeding.
Sucrose intolerance :
Avoid cane sugar. Use Dextrimaltose.
- ℞ Vitazyme or Aristozyme or Bestozyme syrup1–2 tsf thrice daily.
If stools contain blood and mucus or child has colic or leucocytosis suggesting infection as the cause of diarrhoea, get stool culture and sensitivity done and prescribe suitable antibiotic.
- ℞ Colicaid or Flatuna drop 8–10 drops 3–4 times a day
The baby should be fed in upright position and burped to promote expulsion of swallowed air. It should be placed in bed on the right side.
Loss of Appetite
Note : Look for any systemic cause such as urinary infection, tuberculosis, septic focus, or local painful condition of mouth, or nasal obstruction. Allay parental anxiety and caution against forced feeding.
Tonics should not be used.
If constipation :
Build up general nutritional status.
- ℞ Liquid paraffin—one tablespoon at night.
- ℞ Olive oil enema.
Reduction of acute prolapse:
Apply gentle pressure with hot packs. Cover finger with toilet paper and introduce it into the lumen of the mass and gently push into the rectum. Immediately withdraw the finger. Toilet paper will adhere to the rectum allowing withdrawal of the finger.
Other Common Conditions
Pass a 6F–9F nasogastric tube and give stomach wash with normal saline.
- ℞ Syrup Phenergan 0.25–1 mg/kg/dose 3–4 times/day.
- ℞ Domperidone (Domstal) 0.3 mg/kg 3–4 times a day before meals.
- ℞ Metoclopramide (Maxeron, Perinorm) liquid 0.2 mg/kg/day in divided doses before meals.
If severe vomiting :
- ℞ Perinorm 1-2 mg IM.
- ℞ IV fluid 5% glucose saline drip (to correct dehydration, acidosis and nausea).Specific treatment according to cause.
Cyanotic spells are precipitated by anger or frustration.
Pallid spells are associated with fever or minor injury.
Avoid preciptating factors
Have an understanding attitude to the child
Attack could be aborted by a physical stimulus e.g. pinch at the onset of the spell.
Reduction of body temperature :
Remove excessive clothing, blankets.
Provide a cool environmental temperature and avoidance of increased activity.
Note : In hyperpyrexia if patient does not respond, ice cold IV fluids should be given. In resistant cases ice cold enema can be given. Topical sponging advised with warm water.
- ℞ Acetaminophen 15 mg/kg qds.
- ℞ Ibuprofen 10 mg/kg qds.
Note : Aspirin is no longer recommended for children.
Mefanamic acid/nimesulide should be avoided in infant <6 months of age.
(See Tropical Infections)
Clean eyes and mouth regularly.
Keep the environment cool.
- ℞ Syrup Paracetamol.One teaspoon 3–4 times a day.
- ℞ B complex syrup—one teaspoon twice daily.
Hospitalise the child. (Give oxygen under hood. Prop up).
IV fluids 100 mL/kg
- ℞ 500 mL 5% glucose+Conc. Ringer lactate solution – One ampoule.
- ℞ Ampicillin + Cloxacillin100 mg/kg in 4 divided doses. or
- ℞ Cefazolin 100 mg/kg in 4 divided doses.
- ℞ Syrup B complex with C—one teaspoon daily.
- ℞ Syrup pedicloryl one teaspoon twice daily if child is restless.
Small milk feeds 4–6 oz. every 3 hourly during day.
Check for progression of disease, staphylococcal infection, empyema, etc. After recovery, rule out TB activation.
In abortive phase : Analgesics.
Hot fomentations to the limbs.
In paralytic phase : Limbs should be supported. Splints to prevent contractures. Passive movements to be started immediately. Once fever subsides, intensive physiotherapy.
Watch for respiratory paralysis particularly if upper limbs are involved. Shift to hospital if respiratory embarrassment.
Nurse the child in prone position with head turned to one side. Constant suction.
Tracheostomy may be required if vocal cords are paralysed (as indicated by inspiratory stridor).
If gavage feeding incites vomiting, administer parenteral fluids.
- ℞ Ampicillin syrup100 mg/kg/day in 4 divided doses.
Causes : Frequently caused by coxsackievirus A16.
Other enterovirus 71, coxsackieA5, 7,9,10, coxsackievirus B5, 2.
Symptoms : Mild illness with or without low grade fever.
Signs : a) Inflamed oropharynx. b) Vesicles over tongue, buccal mucosa, posterior pharynx, palate, gingiva, lips. c) Maculopapular vesicular/pustular lesions on hands, fingers, feet, buttocks, groin, common on dorsal surfaces, palms and soles. d) These lesions are tender varying in size from 3 mm to 7 mm.
- Vesicles resolve in 1 week.
- Buttock lesions do not progress.
- Brainstem encephalitis.
- Neurogenic pulmonary oedema.
- Pulmonary haemorrhage
- Rapid death.
Mn. : Symptomatic treatment with antihistamines for itching and soothing lotion locally. Antipyretics ± immunoglobin and corticosteroids if severe neurological manifestations.
Rest in bed till gross hematuria clears (usually about 1–3 weeks).
Diet : No restriction if uncomplicated. Fluid and salt restriction if gross oedema. Fluid restriction if oliguria.
Protein restriction if renal failure.
If any underlying infection (particularly streptococcal sore throat):
Appropriate antibiotic. If CHF (Refer).
Hypertensive crisis :
- ℞ Inj. Lasix 2 mg/kg IV.Refer hypertension.
For moderate hypertension :
- ℞ Tab. Nepresol ½–1 tab 2–3 times a day.
- ℞ Tab. Alphadopa 10–65 mg/kg/day.If hypertensive encephalopathy :(For use of hypotensive drugs refer)
- ℞ Tab. Lasix 2 mg/kg (refer renal failure).
If no renal failure :
Culture urine and use appropriate antibiotic as per sensitivity.
Diet : As a rule no restriction. High protein if gross oedema.
Restriction of fluids if gross oedema and ascites.
- ℞ Prednisolone 60 mg/m2/day in 2 divided doses (maximum 80 mg/day).
Remission usually occurs between days 7 and 14, though some children need up to 6 weeks’ therapy to achieve complete remission. After disappearance of proteinuria, or 1 week after remission is induced, prednisolone dose is reduced to 35 mg/m2/day and then tapered slowly. An attempt to stop treatment must be made after 8 weeks. Longer duration of corticosteroid therapy significantly reduces rate of relapse.
Upto 50% of patients remain corticosteroid dependent. Then:
- ℞ Cyclophosphamide 2.5 mg/kg/day.
- ℞ Prednisolone 7.5–15 mg/day for 8–12 weeks.
Note : Neutrophil count should be checked every week and cyclophosphamide stopped if it falls below 2000/mm3.
- ℞ Cyclosporin 3–5 mg/day is effective in some corticosteroid–resistant or corticosteroid–dependent patients.Low dose prednisolone (7.5–15 mg/day) is given with cyclosporin.
- ℞ Levamisole 2.5 mg/kg to maximum of 150 mg on alternate days is useful in maintenance of remission.
Immunization with polyvalent pneumococcal vaccine is recommended.
Note : All children with bedwetting should be evaluated for diabetes mellitus (sugar in urine) or renal concentrating defect (urine sp. gr. <1,016).
Recent bed wetting :
Rule out urinary tract infection and worm infestation.
Then follow the following regime:
Meal at 7 pm
No water after 7 pm
Wake the child up by putting an alarm at 12.30am– 1 am and make the child empty the bladder. If this fails or If child more than 6 years –
- ℞ Tab. Imipramine 25 mg.
One tablet 1 hour before bedtime. If response is not adequate increase to 50 mg if <12 years, or 75 mg if >12 years. (Maximum single dose 2.5 mg/kg body wt.)
Not to be used in :
- ℞ Tab. Amitryptyline 10–15 mg at bedtime(Tablet 10 mg and 25 mg).
- ℞ Desmopressin (Mintrin) produces temporary dryness for some children. Given as nasal spray 20–40 mg dose last thing at night.Psychotherapy and Reassurance are essential.
Urinary Tract Infection
Acute uncomplicated infection : Send urine routine and culture before starting antibiotics.
- ℞ Clotrimazole syrup1–2 tsp bd for 8–10 days
- ℞ Amoxycillin 25–50 mg/kg/day for 8–10 days.If condition deteriorates and culture report shows Pseudomonas aeruginosa or Klebsiella or Proteus is grown –
- ℞ Inj. Gentamicin 3–5 mg/kg/day in 2 divided doses IM.
- ℞ Ciprofloxacin 20 mg/kg/day in 2 divided doses.
- ℞ Cefuroxime or Ofloxacin.
Recurrent infections :
- ℞ Furadantin 3 mg/kg/day in 4 divided doses.
- ℞ TMP – SMX 2 mg/kg/day for 6–12 months.
- Establish airway.
- Prevent injury. Lay the child on a mat on the floor, head turned to one side.
- Keep the environment cool with fan or air-conditioner.
- ℞ Paracetamol 60–240 mg 4 times a day.
If shivering :
- ℞ Ibuprofen 10 mg/kg qds.
- ℞ Syrup Largactil pediatric (5 mg/tsf) 0.5–1 mg/kg.
- ℞ Syrup Calmpose One tsp twice a day till fever comes down.
- Treat the cause.
Major generalized seizure
- ℞ Dilantin suspension (1 mL = 25 mg).Child under 6, 5 mg/kg/day in divided doses.Child over 6, 4 mL 3–4 times a day.
- ℞ Tegrital 15–30 mg/kg in 2–3 divided doses.
- ℞ Valparin suspension (5 mL = 200 mg) 20–30 mg/kg/d in 2 divided doses. Drug of choice.
Note : Gardenal to be avoided because of side effects such as dysarthria, behaviour problems.
- ℞ Syrup Zarontin 20–30 mg/kg/day in 2 divided doses.
- ℞ Valproate (valparin) 20–60 mg/kg/day in 2–3 divided doses.
- Clobazam (Frisium): Adjunctive therapy if seizures poorly controlled.Dose : 0.25–1 mg/kg/d divided in 2 or 3 doses.Side effects: Dizziness, weight gain, fatigue, ataxia, behaviour problems.
- Clonazepam (Rivotril): Absence, myoclonic infantile spasms. Dose : Child < 30 kg, initial 0.05 mg/kg/24 h, increase by 0.05 mg/kg/wk. Maxium 0.25–1 mg/kg/24 h, not to exceed 20 mg/24 h.Side effects: Partial, akinetic depression, salivation, behavioural problems.
- Gabapentin (Neurontin): Adjuvant therapy if seizures poorly controlled. Dose: 25–50 mg/kg/24 h. Side effects: Somnolence, dizziness, ataxia, headache, tremors, nystagmus, fatigue.
- Lamotrigine (Lamictal): If seizures poorly controlled adjunctive therapy. A broad spectrum anticonvulsant useful in complex partial, absence, myoclonic, tonic clonic seizures. Dose: 25 mg bd and gradually increased to maintenance 300 mg/day. Side effects: Rash, dizziness, ataxia, somnolence, diplopia, headache, nausea, vomiting.
- Topiramate (Topimax): Adjunctive therapy for poorly controlled seizures. Refractory complex partial seizures. Dose : 1–9 mg/kg/24 h. Side effects: Aggressive behaviour, personality changes, fatigue, depression.
- Tiagabine (Gabitril): Adjunctive therapy for complex partial seizures. Dose 6 mg tds. Side effects : Asthenia, dizziness, poor attention span, nervousness, tremor.
- Vigabatrin: Infantile spasms and adjunctive therapy for poorly controlled seizures. Dose : Initial 30 mg/kg/24 h od or bd. Side effects : Hyperactivity, agitation, somnolence, weight gain. Possibly visual field defects, optic neuritis.
Continuous seizures lasting for at least 5 minutes, or two or more discrete seizures between which there is incomplete recovery of consciousness.
- Monitor pulse, respiration, BP, temperature.
- Secure airway by giving oxygen. Consider intubation if respiratory failure.
- Hypoglycemia 5 mL/kg of 10% dextrose or 2 mL/kg of 25% dextrose.
- Lorazepam 0.1 mg/kg IV (2 mg/min), or inj. diazepam (0.3 g/kg, 5 min). Lorazepam has lower risk of apnoea and prolonged duration of action. Can be used sublingually.
- Diazepam is a short acting drug because of rapid inclusion in body fat. Hence it should be followed by long acting drug like phenytoin.
- Midazolam given IV 0.2 mg/kg is a short–acting drug. It can be given buccally (0.2–0.5 g/kg/dose) in case of febrile convulsions. It can also be given by intranasal, rectal and IM route.
- Phenobarbital 15 mg/kg over 10 minutes followed by maintenance 3–5 mg/kg/day.
- Phenytoin 20 mg/kg IV can be given in case of emergency.
- Valproic acid IV 25 mg/kg (3 mg/kg/h). Per rectum dose is 20 mg/kg.
- Paraldehyde. Loading dose 150–200 mg/kg/IV slowly over 15–20 minutes, maintenance 20 mg/kg/h 5%. Kept in glass bottle. 5% sol is prepared adding 1.75 mL of paraldehyde to 5% dextrose sol. To make total volume of 35 mL per rectum dose is 0.3–0.5 mL/kg max, 5 mL diluted in 1:1 vegetable oil. Glass compatible with plastic.
- General anesthesia if drug therapy fails.
When seizures continue > 60–90 minutes in spite of adequate treatment.
- Intubate and ventilate the patient.
- CVP lines.
- ℞ IV Midazolam 0.2 mg/kg followed by continuous infusion at a rate of 0.75 to 18 mg/kg/min or protocol 1–2 mg/kg followed by 2–10 mg/kg/h or
- ℞ Pentobarbital 5–15 mg/kg IV bolus followed by 0.5–5 mg/kg or
- ℞ Thiopental infusion 2–8 mg/kg
- ℞ Dopamine to treat hypotension
- ℞ If midazolam is not available, diazepam infusion can be used in a dose of 0.02–0.04 mg/kg/min IV
- ℞ Valproic acid. Loading dose of 20–40 mg/kg diluted in 1:1 normal saline or dextrose sol over 1–5 min followed by an infusion at a rate of 5 mg/kg/h.
Coma in Paediatric Patients
Quick history taking and neurological evaluation should be done.
- Fever indicates infection.
- Elevated BP suggests ICP or hypertensive encephalopathy.
- Jaundice indicates impending hepatic failure.Splenomegaly, anaemia, fever indicate malaria.Signs of trauma—bleeding or haematoma.
Causes of coma :
- Infections: Meningitis, encephalitis, brain abscess, subdural/epidural empyema, cerebral malaria, enteric fever and Shigella encephalopathy.
- Drugs and poisons (status epilepticus), mass lesions in brain, demyelinating disorder of CNS, hypertensive encephalopathy, hyponatremia, hypomagnesemia, hypermagnesemia, hypocalcemia.
Emergency measures :
- Intubate if Glassgow coma score <8.
- 100% oxygen.
- Start normal saline or Ringer lactate drip 20 mL/kg/h to maintain BP and peripheral perfusion.
- Inotropic support and antihypertensives, if required.
- Head elevation 15–30°, manual hyperventilation, mannitol 0.25–5 g/kg IV over 20 minutes.
- 25% glucose 2 mL/kg IV.
- Specific antidotes, if necessary.
- To reduce increased intracranial pressure: a) 20% mannitol. b) Furosemide 1–2 mg/kg/dose IV 6–8 hourly. c) Dexamethasone 1–2 mg/kg IV.
- Treatment of the cause – e.g. insulin for diabetic ketoacidosis, antibiotics for meningitis, etc.
- Nifedipine 0.3–0.5 mg/kg per dose oral or sublingual. (may reduce BP suddenly.
- Diazoxide 1–3 mg/kg bolus IV rapidly. Repeat after 15–30 minutes.
- Hydralazine 0.15–3 mg/kg IV.
- Sodium nitroprusside 0.5–0.8 mg/kg/min.
- Captopril 1.0 mg/kg/day in 3 doses.
- Furosemide 1 mg/kg IV every 12 hours.
- Diazepam 0.2 mg/kg IV 12 hourly.
- Morphine 0.1–0.2 mg/kg IM.
Send CSF for culture and sensitivity. While awaiting the report:
- ℞ Inj. Crystalline penicillin 500,000–1 million units every 4 hours, with
- ℞ Chloromycetin 100 mg/kg IV in 4 divided doses.For child less than 3 months :
- ℞ Inj. Ampicillin 200 mg/kg/day IV. 4 divided doses, with
- ℞ Inj. Gentamicin 5 mg/kg/day IV in 2 divided doses.
- ℞ Inj. Cefotaxime 100 mg/kg in 3 divided doses.
- ℞ Inj. Mepropenem 40 mg/kg/dose q8h.Give above for 15 days, then reduce dose to half for next 7 days.
Note : A change of antibiotic is necessary if culture report and clinical response suggest.
- ℞ Gardenal 5–6 mg/kg/24 hours if needed.
- Pass nasogastric tube for aspiration/feeding.
- ℞ Inj. Ampicillin 50–100 mg/kg/day 6 hourly.
- Control seizures (Ref. convulsions).
- Reduce intracranial tension:
- ℞ Dexamethasone 0.4 mg/kg IV followed by 0.1 mg/kg/dose IV 4–6 hourly. Taper dose gradually.
- ℞ Mannitol 1.5–2 g/kg over 30–60 mins. May be repeated every 8–12 hours.
- ℞ Glycerol orally 0.5–1 mL/kg, dilute with twice the volume with orange juice.
For herpes simplex encephalitis :
- ℞ Acyclovir 30 mg/kg/day IV in 3 divided doses for 10 days.
Care of skin, bladder, bowels.
Laryngo–tracheo–bronchitis (Viral Croup)
A syndrome of acute stridor, barking cough, hoarseness and respiratory distress.
Recurrent (spasmodic) croup without infection is more common in atopic children. Typically, symptoms appear suddenly at night and disappear within hours.
Bacterial tracheitis (pseudomembranous croup) is uncommon and life threatening. Staphylococcus aureus infection produces pus, mucosal necrosis and obstruction. Child is toxic with high fever.
Oxygen saturation monitoring is more reliable than clinical signs in detecting hypoxemia.
- ℞ Dexamethasone 0.15–0.60 mg/kg plus nebulised budesonide 1 mg, repeated once if necessary are equally effective in reducing severity and duration of croup. Nebulised adrenaline 2–5 mL of 1:1000, in children with severe croup.
Intubation and IV antibiotics in bacetrial croup.
If inspiratory stridor : Tracheostomy.
If foreign body suspected : X–ray chest AP and Lat.
Laryngoscopy, bronchoscopy or tracheostomy.
If suspicion of laryngeal diphtheria : Laryngeal swabs for culture.
If high fever :
- ℞ Ampicillin 50–100 mg/kg/day for 7 days.
- ℞ Erythromycin 50 mg/kg/day for 7 days.
Prop the infant up.
Avoidance of trigger factors, e.g. cigarette smoke, aero–allergens, furry pets at home (if strong family history of atopy).
Note : Breastfeeding reduces risk of wheeze. There is no evidence to support use of sodium cromoglycate or theophylline in infancy.
- ℞ Salbutamol syrup 2 mg thrice daily.
- ℞ Alupent 1–2 tablet or tsf 4 times a day.(Half the dose for infant).
- ℞ Salbutamol inhalerRotacap inhaler orMetered dose inhaler(with spacer and mask).
If response to bronchodilators not satisfactory, early use of steroids advised.
- ℞ Prednisolone – 1–2 mg/kg/day. Reduce the dose gradually and stop as early as possible.
For severe wheezing :
- Humidified oxygen.
If nebuliser not available :
- ℞ Nebulization with salbutamol respirator solution (5 mg/mL). 0.02 mg/kg 4 hourly as required.
- ℞ Terbutaline 0.01 mg/ kg subcutaneous, max. 0.3 mg.
- ℞ Inj. Aminophylline IV 5–7 mg/kg bolus infused over 20 minutes. Continuous infusion 1mg/kg/hour.
- ℞ Inj. Hydrocortisone 1–3 mg/kg 6–hourly.
- ℞ Prednisolone 1–2 mg/kg/day PO 12–hourly.
If acidosis :
- ℞ Glucose 10% 500 mL + Ringer's lactate 20 mL.
- ℞ Soda bicarb 2 mEq/kg (9 mEq in 10 mL)(Do not try to overcorrect acidosis)(Regulate if possible pH, PaCO2, PaO2).
Patients with status asthmaticus require management in ICU.
Long term treatment : Try to detect the allergen which should be avoided. Dietetic allergen must be looked for.
Look for cause : Eosinophilia, post–pharyngeal drip or allergy.
For dry cough :
- ℞ Syp. Tossex 1/2 tsp 3–4 times a day. orSyp. Cherry cough
- ℞ Coscopin Linctus 10–20 drops thrice daily.Sip hot water with honey and lime mixed.
For productive cough :
- ℞ Dilosyn or Piriton1–2 teaspoon thrice a day.
- ℞ Bromhexine syrup ½–1 tsf 3 times a day.
- ℞ Septran liquid
- ℞ Ampicillin 50 mg/kg body wt. thrice daily.
- ℞ Cefadroxyl, cephalexin 30 mg/kg in 2 divided doses.
For eosinophilia :
Hetrazan or Banocide 10 mg/kg daily in 2–3 divided doses for 21 days.
All forms except miliary TB
Start with 3 drug therapy :
- ℞ Rifampicin (Rimactane syrup 100 g/5 mL) or Rimictazid disped10 mg/kg before breakfast
- ℞ Isoniazid (liquid) 100 mg/mL5 mg/kg before breakfast
- ℞ Pyrazinamide tab. 25–30 mg/kg/day for 2 months.Later continue with Rifampicin and Isoniazid for 6–9 months.
- ℞ Ethambutol 20 mg/kg/day
To be avoided in children below 7 years as they are not able to inform about loss of peripheral vision.
For 2 months :
- ℞ Tab. Prednisolone 1 mg/kg for 2 weeks and gradually tapered over next 2–4 weeks.
If drug resistance is suspected :
- ℞ Inj. Streptomycin 30–40 mg/kg/day IM
- ℞ Tab. Ethambutol 15 mg/kg for 4½ months.
Note : Refer for newer drugs. Miliary TB requires 4 drugs therapy as in TB meningitis.
Note : As a routine, HIV infection should be ruled out in any child who comes with TB meningitis.
PCR for M. tuberculosis and EILSA assays lack specificity and sensitivity.
Cornerstone of diagnosis is CSF examination and CT or MRI imaging.
Antituberculous therapy consists of :
First 2 months : Isoniazid (15 mg/kg), rifampicin (10 mg/kg), ethambutol (10–15 mg/kg) and pyrazinamide (30 mg/kg).
Next 12 months: Isoniazid and rifampicin:
- ℞ Prednisolone 1–2 mg/kg/day for 4–8 weeks, followed by gradual discontinuation over 2–4 weeks.
- ℞ Multivitamin syrup.
- ℞ IV glucose saline if necessary.Gavage feeding if child unconscious or unable to take by mouth.Indwelling catheter for retention of urine.Enema every 3rd or 4th day if constipation.
If patient deteriorates while on treatment, restart steroid and prolong the bactericidal drug, adding a second line drug if needed or refer for MDR therapy.
If raised intracranial pressure persists and patient fails to improve, shunting may be recommended at a later date.
Recommended vaccines by Indian Academy of Paediatrics
Oral polio vaccine – 2nd dose+IPV1
16 to 18 months
DTwP B1/DTaP B1
DTwP B2/DTaP B2
10 to 12 years
|* OPV alone if IPV cannot be given*# Rotavirus vaccine (2/3 doses (depending on the brand) at 4–8 weeks interval)** The third dose of Hepatitis B can be given at 6 months$ The second dose of MMR vaccine can be given at any time 4–8 weeks after the first dose.$$ Varicella (2nd dose at 4–6 years)# Typhoid revaccination every 3 years& Tdap preferred to Td, followed by repeat Td every 10 yearsΛ Only females, three doses at 0, 1–2 and 6 months|
Note : Two days for two additional pulse polio doses, to be given at 6 weeks apart for children under five years.
Meningococcal vaccines : Unconjugated polysaccharide vaccine (MPSV) is either bivalent or polyvalent. The response in children younger than 2 years is poor hence they are advised for older children but only under special circumstances in children 3 months to 2 years of age. Conjugate vaccines are preferred when available.
Newer vaccines have been added
Rotavirus vaccine : Two types –
- Human monovalent live vaccine contains one strain of live attenuated human strain rota virus. Available in powder form to be reconstituted, stored at 28°C. 1st dose (1 mL) at age of 6 weeks, 2nd dose after 4 weeks.
- Human Bovine pentavalent live vaccine developed from human and bovine rota viruses. Av Dose : 3 oral doses of liquid virus at 2, 4 and 6 months.
Japanese encephalitis vaccine given SC 0.5 mL in children 1–3 years, 1 mL in older children. Primary immunization consists of 3 doses given on 0, 7 and 30 days.
Yellow fever vaccine: Dose 0.5 mL SC, compulsory from international travel point to endemic areas.
Cholera vaccine: Oral vaccine given in 2 doses 1 week apart. Should be given to children aged 2 years and more. Efficacy 90% upto 6 months, but drops to 60% after 2 yrs. Should be used where cholera is highly endemic.
Influenza vaccine: Dose—age 6 months to 3 years 0.25 mL, after 3 years and more 0.5 mL at interval of 4 weeks.
- Quadrupel vaccine—3 doses 0.5 mL at 0, 2 and 6 months.
- Bivalent vaccine—dose 0.5 mL IM in deltoid region at age from 10–12 years till age of 45.
Recent view is that boys between ages 13 to 21 should also receive HPV vaccine for protection against oral, anal and penile cancers.
Pneumococcal vaccine : Non–conjugated polysaccharide vaccine in children above 2 years. Given as single dose 0.5 mL SC or IM. At present it is recommended in children with sickle cell disease, functional and anatomic asplenia, nephrotic syndrome. Patients with CSF leak and children with malignancy and HIV infections.
Meningococcal vaccine : For older children > 2 years and adults. Dose: Single 0.5 mL SC.
Human papilloma virus (HPV) vaccine should be given prior to sexual debut, can prevent about 7% of cervical cancer.
Dr (Mrs) Shirin N Mullan
MD, DCH, MCPS