Child Health Pharmacology

Question 1

How would you prescribe maintenance fluids for a child?

Answer 1

• First 10kg = 100ml/kg
• Second 10kg = 50ml/kg • Rest = 20 ml/kg
• E.g. 30 kg child will need: • 10 x 100ml = 1000ml
• 10 x 50ml = 500ml
• 10 x 20ml = 200ml
• Total 1700 ml fluid per 24 hours
• There is a maximum volume/day!! • Females – 2000ml
• Male – 2500ml

Question 2

Which maintenance fluids should be prescribed for a child?

Answer 2

• Practical guide based on current use in department
• Maintenance fluids – 0.9% normal saline+5% dextrose
• Bolus – 0.9% normal saline
• Dextrose bolus – 10% Dextrose
• Neonates – first 24 hours – 10% Dextrose with no electrolytes

Question 3

What is the equation to calculate Dehydration correction fluid?

Answer 3

Weight x % dehydration x 10 = amount of fluid required to correct dehydration over 24 hours
TOTAL FLUID CALCULATION:
Maintenance fluid amount + Dehydration correction fluid amount 24
= ml/hr to be infused for next 24 hours

Question 4

How would you calculate the amount of bolus fluid to be administered to a child?

Answer 4

• Bolus fluid:
• Generally given as 20ml/kg
• Some exceptions where 5-10ml/kg aliquots are used instead • E.g. Neonates, Cardiac pathology, Trauma
• Should be subtracted from the total fluids during calculation

Question 5

What is anaphylaxis?

Answer 5

• It is a severe, life threatening, generalised or systemic hypersensitivity reaction
• Characterised by rapidly developing, life threatening Airway and/or Breathing and /or circulatory problems
• Associated with skin/and or mucosal changes

Question 6

Management of anaphylactic reaction

Answer 6

adrenaline
establish airway
high flow oxygen
IV fluid challenge
chlorphenamine 
hydrocortisone

Monitor: pulse oximetry, ECG, BP

Question 7

IM adrenaline doses for anaphylaxis

Answer 7

IM 1:1000 adrenaline

Less than 6 months: 0.15mL (which is 150 micrograms)

Child 6 month - 6 years (0.15 ml)

Child 6-12 0.3 mL (which is 300 micrograms)

Adult or child more than 12 years 0.5 mL (which is 500 micrograms)

Question 8

Differential for Upper airway problems in children

Answer 8

• Croup
• Epiglottitis
• Bacterial tracheitis
• Foreign body inhalation
• Trauma and thermal injury

Question 9

Key Symptoms of croup

Answer 9

• Barking / seal like cough
• Hoarseness of voice
• Stridor

Question 10

Child most likely has croup. What ‘Red flag signs’ should be looking out for? M

Answer 10

• Rapidly progressive
• Underlying condition
• Toxic appearance
• Tripod position
• Altered level of consciousness

Question 11

Basic management of croup

Answer 11

• Reduce anxiety by being calm and organised
• Do not move the child from the mother
• observe carefully for signs of hypoxia or exhaustion
• Do not examine the throat with a spatula

Question 12

Role of steroids in croup (which one to use)

Answer 12

• Dexamethasone and takes 90-120 minutes to work
• Dose 150microgram/Kg (oral or IV, and can be repeated after 12 hours)
• nebulised budesonide

If severe
•Nebulised adrenaline
•Watch for rebound of symptoms
•If deteriorating call for urgent senior help

Question 13

Differentiate the presentation of croup and epiglottis

Answer 13

epiglottitis has a faster onset, with no preceding coryza, absent or slight cough, not able to drink, drooling saliva, appear toxic

croup onset is longer with preceding coryza, severe parking cough, able to drink, no drooling. Appear unwell but not toxic

Question 14

Management of epiglottitis

Answer 14

• Life threatening emergency
• Urgent admission
• Senior Anaesthetist, Paediatrician and ENT surgeon summoned
• Intubated
• Blood culture
• IV antibiotics – ceftriaxone

Question 15

Clues to foreign body in child

Answer 15

• Sudden onset of cough

* Lack of preceding viral illness

Question 16

Gastroenteritis in children: Additional history to ask

Answer 16

• recent contact with someone with acute diarrhoea and/or vomiting
• exposure to a known source of enteric infection
• recent travel abroad

Question 17

Parents seeking advice on gastroenteritis in child. How long will it last?

Answer 17

• diarrhoea usually lasts for 5–7 days (max 2 weeks)

* vomiting usually lasts for 1–2 days (max 3 days)

Question 18

Gastroenteritis in children: when should you Consider stool test?

Answer 18

Consider stool test only if
•Recent travel abroad
•Persisting more than 7 days
•Diagnosis uncertain

Perform stool test if
•Suspicion of septicaemia
•Blood/mucus in stools
•Immunocompromised child

Question 19

How can you differentiate clinical dehydration from clinical shock?

Answer 19

dehydration: altered responsiveness, normal skin colour, warm extremities

Shock: decreased level of consciousness, pale or mottled skin, cold extremities, peak pulse, prolonged CRT, hypotension

Question 20

Maximum fluid maintenance in children

Answer 20

MAXIMUM 2 litres in females and 2.5 Litres in males

Question 21

Primary prevention of dehydration in children

Answer 21

• continue breastfeeding and other milk feeds
• §encourage fluid intake
• discourage the drinking of fruit juices and carbonated drinks
• offer Oral Rehydration Solution (ORS)

Question 22

Treat dehydration (use ORS over 4 hours) in children

Answer 22

• Maintenance fluids (calculate requirement for 4 hours)
• fluid deficit = 50ml/Kg (over 4 hours)
• give frequently and in small amounts
• consider supplementation with their usual fluids
• consider nasogastric tube if they are unable to drink it

Question 23

When should Intravenous fluid therapy be used for dehydration in children?

Answer 23

Consider if
•shock is suspected or confirmed
•red flag symptoms or signs
•Deteriorates despite oral rehydration therapy

NB: Treat suspected or confirmed shock
with Rapid intravenous infusion of 20 ml/kg of 0.9% sodium chloride

Question 24

Treatment of status epilepticus: describe benzodiazepines stage

Answer 24

Midazolam 0.5 mg/kg buccally
or
Lorazepam 0.1 mg/kg if intravenous
access established

In hospital: Lorazepam 0.1 mg/kg intravenously. Start to prepare phenytoin for 4th step
Re-confirm it is an epileptic seizure

Question 25

Treatment of status epilepticus: describe phenytoin stage

Answer 25

Phenytoin 20 mg/kg by intravenous infusion over 20 mins
or (if on regular phenytoin)
Phenobarbital 20 mg/kg
intravenously over 5 mins

Paraldehyde 0.8 ml/kg of mixture may be
given after start of phenytoin infusion as
directed by senior staff
Inform intensive care unit and/or senior
Anaesthetist