Paediatric Fluids Prescribing, PEWS and Growth Charts

Question 1

Broadly there are three indications for IV fluids in infants and children:

Answer 1

routine maintenance, replacement and resuscitation.

Question 2

Replacement fluid therapy is required if there is an existing fluid deficit and the oral route is not possible or impractical.

For example:

Answer 2

Prolonged poor oral intake
Vomiting
Diarrhoea
Increased insensible losses (e.g. fever, excessive sweating)
Diabetic ketoacidosis
Burn injuries

Question 3

Resuscitation is required if the patient is shocked. Types of shock and their underlying causes include:

Answer 3

Hypovolaemic: gastroenteritis, burns, diabetic ketoacidosis, heatstroke, haemorrhage

Distributive: sepsis, anaphylaxis, neurological injury (neurogenic)

Cardiogenic: congenital heart disease, arrhythmia

Obstructive: cardiac tamponade, tension pneumothorax, congenital heart disease

Question 4

Clinical shock is defined by the presence of one or more of:

Answer 4

Decreased level of consciousness
Pale or mottled skin
Cold extremities
Pronounced tachycardia/ tachypnoea
Weak peripheral pulses
Prolonged capillary refill time
Hypotension - sign of decompensated shock and indicates that the child is critically unwell.

Children have a large physiological reserve. They will compensate until they become very unwell and then deteriorate rapidly

Question 5

What fluids are given for resucictation purposes in children?

Answer 5

0.9% sodium chloride (write out in full) as a bolus
10ml/kg dose given over 10 minutes

Question 6

What fluids are given for maintenance purposes in children?

Answer 6

always 0.9% sodium chloride + 5% glucose

100 ml/kg/day for the first 10kg of weight
50 ml/kg/day for the next 10kg of weight
20 ml/kg/day for weight over 20kg

Question 7

What maintenance fluids are given for neonates?

Answer 7

Day 1 - 50ml/kg/day
Day 2 - 75 ml/kg/day
Day 3 - 100ml/kg/day
Day 4 - 120 ml/kg/day
Day 5 - 150 ml/kg/day

Question 8

What should you write in the volume section of a child’s fluid prescription chart?

Answer 8

always 500mls (bag size) NOT the overall volume for their weight - remember the chart serves as an instruction to the nurses about what to give

The amount given to each child will be shown by the rate :
volume of fluid needed for child’s weight / 24
= rate in mls/hour

Question 9

What should you write in the time/date to reassess box for a child’s fluid prescription?

Answer 9

review daily

Question 10

What should you be sure to write in the indication section of a prescription chart for a child with an infection?

Answer 10

whether the infection is suspected or confirmed

Question 11

What should you put for course length on the prescription chart if you are treating a suspected infection?

Answer 11

review pending results (e.g. of blood culture, LP)

Question 12

What is the calculation for a child’s percentage dehydration?

Answer 12

(well weight (kg) - current weight (kg) / well weight) x 100

Question 13

How can you clinically estimate a child’s percentage dehydration?

Answer 13

Clinical signs of dehydration are only detectable when the patient is 2.5 – 5% dehydrated. Therefore, a child that has symptoms/signs of dehydration, but no red flag features will be approximately 5% dehydrated.

If any red flag features of dehydration are present, or the child is clinically shocked, then it is common practice to assume 10% dehydration.

Question 14

How do you calculate the replacement fluids that a child requires?

Answer 14

1% dehydration is additional 10ml/kg
2% dehydration is additional 20ml/kg
3% dehydration is additional 30ml/kg … etc etc

Question 15

How do you know what a child’s surface area is in m2?

Answer 15

Use the BNFC
Search Body surface area in children
Use the conversion chart of weight to m2

Question 16

The PEWS chart is used to identify acutely unwell children as quickly as possible. The chart itself will advise you on what to do for each score.

When should you become more concerned?

Answer 16

PEWS score of 4 and above = immediately escalated to senior member of staff

In reality, most ill children will be tachycardic and pyrexial so will start to score quite quickly

If they remain tachycardic in spite of anti-pyrexials, then start to be concerned

Question 17

What questions should you ask parents of an acutely unwell baby with a temperature?

Answer 17

have they been feeding? gaining weight appropriately?
wet nappies? opening their bowels?
vomiting?
any runny nose or sounding sniffly?
any rashes?
laboured breathing?
behaving normally?
any eye rolling? - encephalitis

Question 18

What should you be aware of when plotting a child’s centile on a growth chart?

Answer 18

If the point is within 1/4 of a space of the line, they are on the centile (i.e. 91st).

If not, they should be described as being between the two centiles (i.e. 75th-91st).

A centile space may be considered the equivalent distance if midway between centiles.
A centile space may also be considered the distance between two of the centile lines.

Plotting for PRE-TERM INFANTS: Draw a line back the number of weeks preterm and mark with an arrow (Dot = actual age / Arrow = gestational age).

Question 19

What findings on a growth chart are concerning?

Answer 19

A sustained drop through two or more weight centiles is unusual and should be investigated.

After 6 weeks a head circumference below the 2nd centile should be investigated.

A head circumference above the 99.6th centile, or crossing upwards through 2 centile spaces should be cause for concern if there is continued rise after 6 months, or other signs and symptoms (i.e. irritability, vomiting, full or bulging fontanelle, persistent downwards gaze).

Question 20

Between 2-18 years – Further assessment is required with any of the following findings on a growth chart:

Answer 20

Weight or height or BMI is below the 0.4th centile (unless already fully investigated at an earlier age).

The height centile is more than 3 centile spaces below the mid-parental centile.

A drop in the height centile position of more than 2 centile spaces.

Any other concerns about the child’s growth.

Question 21

What is the mid-parental centile?

Answer 21

the average adult height centile to be expected for all children of these particular parents.

The scale is located on the right-hand side of the chart

Question 22

What BMI is concerning in a child?

Answer 22

A BMI above the 91st centile suggests the child is overweight.

A BMI above the 98th centile is very overweight (clinically obese).

A BMI below the 2nd centile is unusual and may reflect undernutrition requiring further investigation. In older children, this may simply reflect a small build.

Question 23

What weight should you use when prescribing for a neonate?

Answer 23

Weight used for drug calculation is the birth weight until current weight exceeds birth weight

Question 24

How would you calculate replacement fluids to add on top of a child’s maintenance?

Answer 24

percentage dehydration x weight x 10 (add that on top of maintenance and replace over 48 hours)