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TABLE OF CONTENTSSection 1 General PaediatricsChapter 1: Normal Values in Children Chapter 2: Immunisations Chapter 3: Paediatric Fluid and Electrolyte Guidelines Chapter 4: Developmental Milestones in Normal Children Chapter 5: Developmental Assessment Chapter 6: Developmental Dyslexia Chapter 7: The H.E.A.D.S.S. Assessment Chapter 8: End of Life Care in Children 15192731374549Section 2 NeonatalogyChapter 9: Principles of Transport of the Sick Newborn 55Chapter 10: The Premature Infant 63Chapter 11: Enteral Feeding in Neonates 67Chapter 12: Total Parenteral Nutrition for Neonates 71Chapter 13: NICU - General Pointers for Care and Review of Newborn Infants 77Chapter 14: Vascular Spasm and Thrombosis 85Chapter 15: Guidelines for the Use of Surfactant 91Chapter 16: The Newborn and Acid Base Balance 93Chapter 17: Neonatal Encephalopathy 97Chapter 18: Neonatal Seizures 101Chapter 19: Neonatal Hypoglycemia 107Chapter 20: Neonatal Jaundice 111Chapter 21: Exchange Transfusion 117Chapter 22: Prolonged Jaundice in Newborn Infants 121Chapter 23: Apnoea in the Newborn 125Chapter 24: Neonatal Sepsis 127Chapter 25: Congenital Syphilis 129Chapter 26: Ophthalmia Neonatorum 131Chapter 27: Patent Ductus Arteriosus in the Preterm 133Chapter 28: Persistent Pulmonary Hypertension of the Newborn 135Chapter 29: Perinatally Acquired Varicella 139Section 3 Respiratory MedicineChapter 30: Asthma Chapter 31: Viral Bronchiolitis Chapter 32: Viral Croup Chapter 33: Pneumonia 149161163165viii

TABLE OF CONTENTSSection 4 CardiologyChapter 34: Paediatric Electrocardiography Chapter 35: Congenital Heart Disease in the Newborn Chapter 36: Hypercyanotic Spell Chapter 37: Heart Failure Chapter 38: Acute Rheumatic Failure Chapter 39: Infective Endocarditis Chapter 40: Kawasaki Disease Chapter 41: Viral Myocarditis Chapter 42: Paediatric Arrhythmias 171173181183185187191195197Section 5 NeurologyChapter 43: Status Epilepticus Chapter 44: Epilepsy Chapter 45: Febrile Seizures Chapter 46: Meningitis Chapter 47: Acute CNS Demyelination Chapter 48: Acute Flaccid Paralysis Chapter 49: Guillain Barré Syndrome Chapter 50: Approach to The Child With Altered Consciousness Chapter 51: Childhood Stroke Chapter 52: Brain Death 205207213215219221223225227231Section 6 EndocrinologyChapter 53: Approach to A Child with Short Stature Chapter 54: Congenital Hypothyroidism Chapter 55: Diabetes Mellitus Chapter 56: Diabetic Ketoacidosis Chapter 57: Disorders of Sexual Development 237241245255263Section 7 NephrologyChapter 58: Post-Infectious Glomerulonephritis Chapter 59: Nephrotic Syndrome Chapter 60: Acute Kidney Injury Chapter 61: Acute Peritoneal Dialysis Chapter 62: Neurogenic Bladder Chapter 63: Urinary Tract Infection Chapter 64: Antenatal Hydronephrosis 275279285293299305313ix

TABLE OF CONTENTSSection 8 Haematology and OncologyChapter 65: Approach to a Child with Anaemia Chapter 66: Thalassaemia Chapter 67: Immune Thrombocytopenic Purpura Chapter 68: Haemophilia Chapter 69: Oncology Emergencies Chapter 70: Acute Lymphoblastic Leukaemia 321325331337343353Section 9 GastroenterologyChapter 71: Acute Gastroenteritis Chapter 72: Chronic Diarrhoea Chapter 73: Approach to Severely Malnourished Children Chapter 74: Gastro-oesophageal Reflux Chapter 75: Acute Hepatic Failure in Children Chapter 76: Approach to Gastrointestinal Bleeding 359365373377383387Section 10 Infectious DiseaseChapter 77: Sepsis and Septic Shock Chapter 78: Pediatric HIV Chapter 79: Malaria Chapter 80: Tuberculosis Chapter 81: BCG Lymphadenitis Chapter 82: Dengue and Dengue Haemorrhagic Fever with Shock Chapter 83: Diphteria 391397413419425427439Section 11 DermatologyChapter 84: Atopic Dermatitis Chapter 85: Infantile Hemangioma Chapter 86: Scabies Chapter 87: Steven Johnson Syndrome 445451455457Section 12 Metabolic DisordersChapter 88: Inborn errors metabolism (IEM): Approach toDiagnosis and Early Management in a Sick Child Chapter 89: Investigating Inborn errors metabolism (IEM)in a Child with Chronic Symptoms Chapter 90: Approach to Recurrent Hypoglycemia Chapter 91: Down Syndrome x461471483489

TABLE OF CONTENTSSection 13 Paediatric SurgeryChapter 92: Appendicitis Chapter 93: Vomiting in the Neonate and Child Chapter 94: Intussusception Chapter 95: Inguinal hernias, Hydrocoele Chapter 96: Undescended Testis Chapter 97: The Acute Scrotum Chapter 98: Penile Conditions Chapter 99: Neonatal Surgery 495497507511513515519521Section 14 RheumatologyChapter 100: Juvenile Idiopathic Arthritis (JIA) 535Section 15 Poisons and ToxinsChapter 101: Snake Bite Chapter 102: Common Poisons Chapter 103: Anaphylaxis 543549559Section 16 Sedation and ProceduresChapter 104: Recognition and Assessment of Pain Chapter 105: Sedation and Analgesia for Diagnosticand Therapeutic Procedures Chapter 108: Practical Procedures xi565567571

AcknowledgementsAgain, to Dr Koh Chong Tuan, Consultant Paediatrician at Island Hospital, Penangfor his excellent work in proof reading the manuscript.xii

GENERAL PAEDIATRICSChapter 1: Normal Values in ChildrenVITAL SIGNSRespiratory (Breath) RateNormal, Breath rate at restAge (years)Rate/min 130-40AbnormalThese values define TachypnoeaAgeRate/min1-225-35 2 months 602-525-302 mths - 1 year 505-1220-251-5 years 40AbnormalNormalAbnormalHeart (Pulse) RateAge (years)Low (Bradycardia)AverageHigh (Tachycardia)Newborn 70/min125/min 190/min1-11 months 80/min120/min 160/min2 years 80/min110/min 130/min4 years 80/min100/min 120/min6 years 75/min100/min 115/min8 years 70/min90/min 110/min10 years 70/min90/min 110/minRef: Nelson Textbook of Pediatrics, 18th EditionBlood PressureHypotension if belowNormal (average)Age (years)5th centile for age50th centile for age 1 year65 - 75 mmHg80 - 90 mmHg1-2 years70 - 75 mmHg85 - 95 mmHg2-5 years70 - 80 mmHg85 - 100 mmHg5-12 years80 - 90 mmHg90 - 110 mmHg 12 years90 - 105 mmHg100-120 mmHgCalculation for Expected Systolic Blood Pressure 85 (2 x age in years) mmHg for 50th centile - Median Blood Pressure 65 (2 x age in years) mmHg for 5th centile - Hypotension if below this valueRef: Advanced Paediatric Life Support:The Practical Approach, Fifth Edition 20111

GENERAL PAEDIATRICSBlood Pressure in HypertensionAgeSignificant HypertensionSevere Hypertension1 weekSystolic96 mmHgSystolic106 mmHg1 wk - 1 mthSystolic104 mHgSystolic110 mmHgInfantSystolic112 mmHgSystolic118 mmHgDiastolic74 mmHgDiastolic82 mmHgSystolic116 mmHgSystolic124 mmHgDiastolic76 mmHgDiastolic86 mmHgSystolic122 mmHgSystolic130 mmHgDiastolic78 mmHgDiastolic86 mmHgSystolic126 mmHgSystolic134 mmHgDiastolic82 mmHgDiastolic90 mmHgSystolic136 mmHgSystolic144 mmHgDiastolic86 mmHgDiastolic92 mmHgSystolic142 mmHgSystolic150 mmHgDiastolic92 mmHgDiastolic98 mmHg3-5 years6-9 years10-12 years13-15 years16-18 years2

AgeWeightHeightHead sizebirth3.5 kg50 cm35 cm6 months7 kg68 cm42 cm1 year10 kg75 cm47 cm2 years12 kg85 cm49 cm3 years14 kg95 cm49.5 cm4 years100 cm50 cm5-12 years5 cm/year0.33 cm/yearPoints to NoteWeight In the first 7 - 10 days of life, babies lose 10 - 15% of their birth weight. In the first 3 months of life, the rate of weight gain is 25 gm/day Babies regain their birth weight by the 2nd week, double this by 5 monthsage, and triple the birth weight by 1 year of age Weight estimation for children (in Kg):Infants: (Age in months X 0.5) 4Children 1 – 10 years: (Age in yrs 4) X 2Head circumference Rate of growth in preterm infants is 1 cm/week, but reduces with age.Head growth follows that of term infants when chronological age reaches term Head circumference increases by 12 cm in the 1st year of life (6 cm in first 3months, then 3 cm in second 3 months, and 3 cm in last 6 months)Other normal values are found in the relevant chapters of the book.References:1. Advanced Paediatric Life Support: The Practical Approach Textbook,5th Edition 20112. Nelson Textbook of Pediatrics, 18th Edition.3GENERAL PAEDIATRICSANTHROPOMETRIC MEASUREMENTS

42-521.68027-325-105535neutrophils lymphocytesneutrophils lymphocytes35 7 years553838484 - 7 years5-105545303163 Differential WBC: eosinophils: 2-3%; monocytes: 6-9 % Platelets counts are lower in first months of age;but normal range by 6 months Erythrocyte sedimentation rate (ESR) is 16 mm/hr inchildren, provided PCV is at least 35%.26-344.5-13.56-156-186140lymphocytes neutrophils8026-3225-31279-305-21MeanLymphocyte1 wk - 4 years1.676-8070-74-29MeanNeutrophilPoints to note37-471.01.01.0-110TWBCx1000neutrophils lymphocytes12.0-16.034-4033-4231-415.01.0MCH pgLowestMCV flLowest 7 days age14.0-18.0Adult maleAdult female45-6542-66Retics%Differential counts10.5-14.011.0-16.09.5-14.53 months6 mths - 6 yrs13.0-20.07 - 12 years13-7-20.1Cord BloodPCV%Hbg/dL2 weeksAgeHAEMATOLOGICAL PARAMETERSGENERAL PAEDIATRICS4

51Hib222233335Sabah36Age (months)19210112B*B B DT B 18if no scar7 yrs3 doses13 yrsSchool yearsT B 15 yrsMMR, Measles, Mumps, Rubella; JE, Japanese Encephalitis, HPV, Human Papilloma Virus;DT, Diphtheria, Tetanus; T, Tetanus IPV, Inactivated Polio Vaccine; Hib, Haemophilus influenzae type B;Legend: B , Booster doses; B*, Booster at 4 years age; BCG, Bacille Calmette-Guerin; DTaP, Diphhteria, Tetanus, acellular Pertussis;HPVJE (Sarawak)MMRMeasles12IPV1Hepatitis B11BCG1DTaPbirthVaccineNational Immunisation Schedule for Malaysia (Ministry of Health, Malaysia)GENERAL PAEDIATRICSChapter 2: Immunisations

GENERAL PAEDIATRICSGeneral Notes Many vaccines (inactivated or live) can be given together simultaneously (doesnot impair antibody response or increase adverse effect). But they are to begiven at different sites unless given in combined preparations. Vaccines are nowpackaged in combinations to avoid multiple injections to the child. sites of administration- oral – rotavirus, live typhoid vaccines- intradermal (ID) - BCG. Left deltoid area (proximal to insertion deltoid muscle)- deep SC, IM injections. (ALL vaccines except the above) anterolateral aspect of thigh – preferred site in children upper arm – preferred site in adults upper outer quadrant of buttock - associated with lower antibody level productionImmunisation : General contraindications Absolute contraindication for any vaccine: severe anaphylaxis reactions toprevious dose of the vaccine or to a component of the vaccine. Postponement during acute febrile illness: Minor infection without fever orsystemic upset is NOT a contraindication. A relative contraindication: avoid a vaccine within 2 weeks of elective surgery. Live vaccine: Absolute contraindications- Immunosuppressed children -malignancy; irradiation, leukaemia, lymphoma,primary immunodeficiency syndromes (but NOT asymptomatic HIV).- On chemotherapy or 6 months after last dose.- On High dose steroids, i.e. Prednisolone 2 mg/kg/day for 7 days or lowdose systemic 2 weeks: delay vaccination for 3 months.- If topical or inhaled steroids OR low dose systemic 2 weeks or EOD for 2weeks, can administer live vaccine.- If given another LIVE vaccine including BCG 4 weeks ago.(Give live vaccines simultaneously. If unable to then give separately witha 4 week interval).- Within 3 months following IV Immunoglobulin (11 months if given highdose IV Immunoglobulins, e.g. in Kawasaki disease).3 weeksLive Vaccine3 monthsHNIG(Human Normal Immunoglobulin)Live vaccine- Pregnancy (live vaccine - theoretical risk to foetus) UNLESS there issignificant exposure to serious conditions like polio or yellow fever inwhich case the importance of vaccination outweighs the risk to the foetus. Killed vaccines are generally safe. The only absolute contraindications areSEVERE local (induration involving 2/3 of the limbs) or severe generalisedreactions in the previous dose.6

Vaccination: Special Circumstances Measures to protect inpatients exposed to another inpatient with measles:- Protect all immunocompromised children with Immunoglobulin (HNIG)0.25-0.5 mls/kg. (Measles may be fatal in children in remission fromleukaemia)- Check status of measles immunisation in the other children. Give measlesmonocomponent vaccine to unimmunised children within 24 hrs of exposure.Vaccination within 72 hours aborts clinical measles in 75% of contacts- Discharge the inpatient child with uncomplicated measles.- Do not forget to notify the Health Office. Immunisation in children with HIV (Please refer to Paediatric HIV section) In patients with past history or family history of febrile seizures, neurologicalor developmental abnormalities that would predispose to febrile seizures:- Febrile seizures may occur 5 – 10 days after measles (or MMR) vaccinationor within the first 72 hours following pertussis immunisation.- Give Paracetamol (120 mg or ¼ tablet) prophylaxis after immunisation(esp. DPT) 4-6 hourly for 48 hours regardless of whether the child is febrile.This reduces the incidence of high fever, fretfulness, crying, anorexia andlocal inflammation. Maternal Chicken Pox during perinatal period. (Please refer to Perinatallyacquired varicella section) Close contacts of immunodeficient children and adults must be immunized,particularly against measles and polio (use IPV). In contacts of a patient with invasive Haemophilus influenzae B disease:- Immunise all household, nursery or kindergarden contacts 4 years of age.- Household contacts should receive Rifampicin prophylaxis at 20 mg/kgonce daily (Maximum 600 mg) for 4 days (except pregnant women- give one IM dose of ceftriaxone )- Index case should be immunised irrespective of age.7GENERAL PAEDIATRICSThe following are not contraindications to vaccination Mild illness without fever e.g. mild diarrhoea, cough, runny nose. Asthma, eczema, hay fever, impetigo, heat rash (avoid injection in affected area). Treatment with antibiotics or locally acting steroids. Child’s mother is pregnant. Breastfed child (does not affect polio uptake). Neonatal jaundice. Underweight or malnourished. Over the recommended age. Past history of pertussis, measles or rubella (unless confirmed medically) Non progressive, stable neurological conditions like cerebral palsy, Downsyndrome, simple febrile convulsions, controlled epilepsy, mental retardation. Family history of convulsions. History of heart disease, acquired or congenital. Prematurity (immunise according to schedule irrespective of gestational age)

GENERAL PAEDIATRICS Children with Asplenia (Elective or emergency splenectomy; asplenicsyndromes; sickle cell anaemia) are susceptible to encapsulated bacteriaand malaria.- Pneumococcal, Meningococcal A, C, Y & W-135, Haemophilus influenza bvaccines should be given.- For elective splenectomy (and also chemotherapy or radiotherapy): givethe vaccines preferably 2 or more weeks before the procedure. However,they can be given even after the procedure.- Penicillin prophylaxis should continue ideally for life. If not until 16 yearsold for children or 5 years post splenectomy in adults. Babies born to mothers who are HbeAg OR HbsAg positive should be givenHepatitis B immunoglobulin (200 IU) and vaccinated with the Hepatitis Bvaccine within 12 hours and not later than 48 hours. Given in differentsyringes and at different sites. Premature infants may be immunised at the same chronological age as terminfants. (Please refer section on The premature infants for more discussion)8

All infants,including those bornto HBsAg positivemothersAll health carepersonnel.All infants shouldreceive 5 dosesincluding boosterdoses at 18 monthsand Standard 1Diphtheria,Tetanus(DT)To be given at birthand to be repeatedif no scar is presentBCGHepatitis BIndication/DoseVaccineSevere hypersensitivity toaluminium and thiomersalSwelling, redness and painA small painless nodule maydevelop at injection site –harmless.Transient fever, headaches,malaise, rarely anaphylaxis.Neurological reactions rare.Local reactions. Fever andflu-like symptoms in first48 hours. Rarely, erythemamultiforme or urticaria.BCG adenitis may occur.Not to be given to symptomatic HIV infected children.Can be given to newbornsof HIV infected mother asthe infant is usually asymptomatic at birth.Severe hypersensitivity toaluminium. The vaccine isalso not indicated for HBVcarrier or immuned patient( i.e. HBsAg or Ab positive)Possible Side EffectsContraindicationVaccines, indications, contraindications, doses and side effectsIntramuscularIntramuscular.Give with Hep B immunoglobulin for infants of HBsAgpositive mothers.Intradermal.Local reaction: a papule atvaccination site may occurin 2 - 6 weeks. This growsand flattens with scalingand crusting. Occasionally adischarging ulcer may occur.This heals leaving a scar ofat least 4 mm in successfulvaccination.NotesGENERAL PAEDIATRICS9

10All infants to begiven 4 dosesincluding booster at18 months.All infants shouldreceive 4 dosesincluding booster at18 months.Patients with splenicdysfunction, andpost splenectomy.HaemophilusInfluenzaetype B (Hib)Confirmed anaphylaxis toprevious Hib and allergiesto neomycin, polymyxin andstreptomycinAllergies to neomycin, polymyxin and streptomycinPrevious severe anaphylacticreactionPrecautions: severe reactionto previous dose (systemicor local) and progressiveneurological diseases.It is recommendedthat booster dosesbe given at Std 1and at Form 3 dueto increased casesof Pertussis amongstadolescents inrecent yearsInactivatedPolio Vaccine(IPV)Local reaction. Severe ifinvolve 2/3 limbsSevere systemic reaction:Anaphylaxis (2 per 100 000doses), encephalopathy (0 –10.5 per million doses), highfever (fever 40.5), fits within72 hours, persistent inconsolable crying (0.1 to 6%),hyporesponsive state.Anaphylaxis to previousdose; encephalopathydevelops within 7 days ofvaccinationAll infants shouldreceive 4 dosesincluding booster at18 monthsPertussisLocal swelling, redness andpain soon after vaccinationand last up to 24 hours in10% of vaccineesMalaise, headaches, fever, irritability, inconsolable crying.Very rarely seizures.Local reactions.Acellular Pertussis vaccineassociated with less sideeffectsPossible Side IntramuscularIntramuscular.Static neurological diseases,developmental delay, personalor family history of fits areNOT contraindications.Intramuscular.GENERAL PAEDIATRICS

MumpsAll children from12 to 15 months.Booster at 4-6yrs(or at Std 1).Sabah, Orang Aslipopulation at 6 mths.Not usually given tochildren 12mth. Ifthere is a measlesoutbreak, can begiven to children 6-11 mths age. Thisis later followed byMMR at 12 mthsand 4-6 years age.MeaslesMeasles,Mumps, Rubella (MMR)Indication/DoseVaccineRarely transient rash, pruritis and purpura.Parotitis in 1% of vaccinees, 3 weeks after vaccination.Orchitis and retro bulbarneuritis very rare.Meningoencephalitis is mildand rare. (1:800,000 doses).(natural infection 1:400).Measles: As aboveTransient rash in 5%.May have fever between D5D12 post vaccination.URTI symptoms.Febrile convulsions (D6-D14)in 1:1000 – 9000 doses of vaccine. (Natural infection 1:200)Encephalopathy within 30 daysin 1:1,000,000 doses. (Naturalinfection 1:1000 - 5000)Avoid in patients withhypersensitivity to eggs,neomycin and polymyxin.Pregnancy.Children with untreatedleukemia, TB and othercancers.Immunodeficiency.Severe reaction to hen’seggs and neomycin.PregnancyPossible Side ular.Can be given irrespective ofprevious history of measles,mumps or rubella infection.Intramuscular.** Long term prospective studies have found no associationbetween measles or MMR vaccine and inflammatory boweldiseases, autism or SSPE.GENERAL PAEDIATRICS11 page

Chapter 44: Epilepsy 207 Chapter 45: Febrile Seizures 213 Chapter 46: Meningitis 215 Chapter 47: Acute CNS Demyelination 219 Chapter 48: Acute Flaccid Paralysis 221 Chapter 49: Guillain Barré Syndrome 223 Chapter 50: Approach to The Child With Altered Consciousness 225 Chapter 51: Childhood Stroke 227 Chapter 52: Brain Death 231