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Newborn Resuscitation (NLS 2021)

NLS 2021 · Apgar score · 5 inflation breaths · 3:1 compressions · Room air start · Therapeutic hypothermia

NLS 2021 · RCUK · ILCOR 2020

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85% of newborns need only drying and stimulation. 10% need airway and inflation breaths. ~1% need chest compressions. Call for help early — better to have help and not need it.

📋 NLS Algorithm — Step by Step▾

ADRY & STIMULATE. Warm towels. Remove wet towel. Rub back and soles of feet. Note time of birth. Call for help.
BASSESS at 60 seconds: Breathing? Heart rate >100? Tone? If breathing well and HR >100 → routine care / skin-to-skin.
CAIRWAY. Neutral position (NOT hyperextended). Jaw thrust if no response. Two-person airway technique preferred for masks.
D5 INFLATION BREATHS via face mask + T-piece or self-inflating bag. Each breath 2–3 seconds. Pressure 30 cmH₂O. Start in room air (21% O₂). Watch for chest movement.
EASSESS RESPONSE. HR rising → ventilation breaths 40–60/min. No chest movement → recheck position, try 2-person jaw thrust, check for secretions, try longer inflation breaths. Consider intubation.
FHR <60 after 30 seconds of effective ventilation → Chest compressions: 3:1 ratio (90 compressions + 30 breaths = 120 events/min). 2 thumbs encircling chest. Depth 1/3 AP. Intubate. Increase O₂ to 100%.
GDRUGS if HR still <60: Adrenaline 10–30 mcg/kg IV/IO/UVC (1:10,000: 0.1–0.3 mL/kg). Repeat q3–5 min.
HREVERSIBLE CAUSES: Hypovolaemia (10 mL/kg 0.9% NaCl), Pneumothorax (needle decompression), Hypoglycaemia (2 mL/kg 10% dextrose), Hypocalcaemia.

Apgar Score (Assess at 1 & 5 min)

Each component scored 0–2: Heart rate · Respiratory effort · Muscle tone · Reflex irritability · Colour

7–10: Normal | 4–6: Moderate — stimulation, O₂, inflation breaths | 0–3: Severe — immediate resuscitation

O₂ Titration Targets (NLS 2021)

Start 21% air (term and near-term >35 weeks). Pre-ductal SpO₂ (right hand): 2 min 60%, 3 min 70%, 4 min 80%, 5 min 85%, 10 min 90%+

Preterm <32 weeks: start 30% O₂. Avoid hyperoxia — increases mortality. Titrate against SpO₂ targets.

Therapeutic Hypothermia (HIE)

Criteria: ≥36 weeks + moderate/severe HIE + within 6h of birth. Core temp 33–34°C for 72h. Reduces death/disability ~25%.

Do NOT actively warm — passive cooling. Transfer to cooling centre. If distant: cooling blanket/packs to axillae/groin.

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Newborn Cardiac Arrest

NLS · 3:1 ratio · Adrenaline via UVC · Reversible causes · Sodium bicarbonate

NLS 2021 · ILCOR

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Neonatal arrest is almost always respiratory in origin. Effective ventilation is the single most important intervention. 3:1 compression:ventilation ratio is unique to neonates. UVC is the preferred vascular access route.

💊 Drugs & Reversible Causes▾

Adrenaline (Epinephrine)

IV/IO/UVC: 10–30 mcg/kg (= 0.1–0.3 mL/kg of 1:10,000 adrenaline). Repeat every 3–5 min.

Endotracheal route NOT recommended (unreliable absorption)

Volume Replacement (if Hypovolaemia Suspected)

0.9% NaCl or O-negative blood: 10 mL/kg IV/IO over 10–20 min

Suspect if: cord prolapse, abruption, feto-maternal haemorrhage, pale despite O₂

Dextrose

10% dextrose: 2.5 mL/kg IV/IO if BM <2.6 mmol/L

Sodium Bicarbonate

4.2% NaHCO₃: 1–2 mmol/kg (= 2–4 mL/kg) only after effective ventilation is established. UVC preferred. Avoid peripheral extravasation.

4Hs and 4Ts — Reversible Causes

Hypoxia (most common — ensure effective ventilation first), Hypovolaemia, Hypoglycaemia, Hypothermia

Tension pneumothorax (needle decompression), Tamponade, Toxins (opioid → naloxone 200 mcg IM/IV — NOT if mother on methadone), Thrombosis

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Paediatric Cardiac Arrest (APLS 2023)

15:2 CPR · 4 J/kg shocks · 5 rescue breaths first · Adrenaline · Amiodarone · IO access

APLS 2023 · RCUK · ILCOR 2020

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Paediatric arrest is usually asphyxial (respiratory first). Shockable rhythms (VF/pVT) occur in only ~10%. Give 5 rescue breaths BEFORE chest compressions. Oxygenation is the priority.

📋 APLS 2023 Algorithm▾

1Unresponsive, not breathing normally? Call resus team. Start timer. Open airway.
25 RESCUE BREATHS (1–1.5 seconds each, visible chest rise). Check for signs of life / HR after breaths.
3No signs of life or HR <60 with poor perfusion → 15 compressions : 2 breaths. Rate 100–120/min. Depth: 4 cm infant / 5 cm child (1/3 AP diameter).
4Attach defibrillator pads ASAP. Assess rhythm every 2 minutes.
5SHOCKABLE (VF/pVT): 4 J/kg unsynchronised. Resume CPR immediately. After 3rd shock: give adrenaline + amiodarone.
6NON-SHOCKABLE (PEA/Asystole): Adrenaline 10 mcg/kg IV/IO immediately, then every 3–5 min. Treat reversible causes.
7IO access: tibial plateau (anterior, 1 cm below tibial tuberosity medially) or distal femur. Confirm position → flush with 5–10 mL NaCl. Intubate only if skilled operator — do not stop CPR.

Drug Doses During Arrest

Adrenaline 1:10,000: 0.1 mL/kg IV/IO (= 10 mcg/kg). Max 1 mg per dose. Every 3–5 min (shockable: from 3rd shock; non-shockable: immediately)

Amiodarone: 5 mg/kg IV/IO after 3rd shock and after 5th shock. Max 300 mg. Dilute in 5% dextrose.

Calcium chloride 10%: 0.2 mL/kg IV/IO — only for hypocalcaemia, hyperkalaemia, or Ca-channel blocker OD

Magnesium 50% (0.1 mL/kg = 25 mg/kg): Torsades de pointes / hypomagnesaemia

Post-ROSC Care

SpO₂ 94–98%. PaCO₂ 4.5–6 kPa (normocapnia — avoid hyper/hypoventilation). Glucose 4–8 mmol/L.

Temperature: normothermia 36–37°C. Avoid fever. THAPCA trial: cooling not superior to normothermia in children.

PICU referral. 12-lead ECG. Echo. Consider underlying cause.

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Paediatric Tachyarrhythmias

SVT · Adenosine weight-based · DC cardioversion · VT · Torsades

APLS 2023 · RCUK

📋 Assessment & Treatment Algorithm▾

Haemodynamically Unstable

Shock, altered consciousness, signs of low output → immediate synchronised DC cardioversion regardless of diagnosis.

Narrow Complex (SVT)

HR >220 infant / >180 child. Regular. No P waves visible. Try vagal → adenosine.

Broad Complex Tachycardia

Treat as VT. Do NOT give adenosine in broad complex — may precipitate VF in WPW+AF.

Step 1 — Vagal Manoeuvres

Ice to face (diving reflex): bag of iced water over face for 15 seconds — most effective in infants. Do NOT occlude airway.

Valsalva (older children): blow through straw or syringe against resistance for 15 seconds.

Step 2 — Adenosine (Rapid IV Bolus + Immediate Large Flush)

1st dose: 0.1 mg/kg IV (max 6 mg). Rapid bolus into large vein — antecubital or central. Follow immediately with 5–10 mL NaCl flush.

2nd dose: 0.2 mg/kg IV (max 12 mg). Wait 1–2 minutes. Warn patient: chest tightness, flushing, transient feeling of doom, asystole pause 3–10 seconds.

3rd dose: 0.3 mg/kg IV (max 18 mg). Defibrillator on and ready.

Contraindications: asthma (relative), 2nd/3rd degree AV block, known WPW + AF, sick sinus syndrome.

Step 3 — DC Cardioversion

SVT: 1 J/kg synchronised → 2 J/kg. Sedate first if conscious: ketamine 1–2 mg/kg IV or midazolam 0.1 mg/kg IV.

Adenosine refractory SVT: amiodarone 5 mg/kg over 30 min or flecainide (specialist only).

VT Management

Pulseless VT = VF protocol (4 J/kg unsynchronised). Pulse present: amiodarone 5 mg/kg IV over 30 min OR synchronised cardioversion.

Torsades de pointes: MgSO₄ 25–50 mg/kg IV (max 2g) over 2–5 min. Correct K⁺ and Mg²⁺. Overdrive pacing if recurrent.

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Hypovolaemic Shock in Children

APLS 2023 · 10 mL/kg bolus · Max 40 mL/kg crystalloid · Blood products · Vasopressors

APLS 2023 · NICE NG29 · FEAST trial

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FEAST trial: 20 mL/kg boluses in severe febrile illness increased mortality. APLS now recommends 10 mL/kg boluses with reassessment after each. Maximum 40 mL/kg total crystalloid before starting vasopressors in septic shock.

📋 Recognition & Fluid Protocol▾

Compensated Shock

Tachycardia. Normal BP. CRT >2s. Mottled/pale skin. Oliguria (<1 mL/kg/h). Children compensate until 25–30% volume lost — act before BP drops.

Decompensated Shock

SBP < 70+(age×2) mmHg. Altered consciousness. Absent peripheral pulses. IV/IO access NOW. Vasopressors if no response after 40 mL/kg.

Fluid Resuscitation Protocol

Bolus 1: 10 mL/kg Hartmann's IV/IO over 10–15 min. Reassess: HR, CRT, BP, consciousness immediately after.

Bolus 2: Not improving → repeat 10 mL/kg. Total 20 mL/kg. Reassess.

Bolus 3: Not improving → repeat 10 mL/kg. Consider blood products now. Total 30 mL/kg.

After 40 mL/kg: Start vasopressors. Give blood 1:1:1 (pRBC:FFP:platelets). No further plain crystalloid.

Blood Transfusion

Haemorrhagic shock: give O-negative blood early — do not wait for cross-match. 10 mL/kg pRBC over 30–60 min (raises Hb ~10–15 g/L).

Transfusion threshold: Hb <70 stable / Hb <100 if haemodynamically compromised or ongoing bleeding.

Vasopressors (After 40 mL/kg Crystalloid in Sepsis)

Noradrenaline: 0.05–0.5 mcg/kg/min IV infusion. Central line preferred; IO acceptable short-term.

Adrenaline: 0.05–0.5 mcg/kg/min — if cardiogenic component suspected or poor response to noradrenaline.

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Duct-Dependent Congenital Heart Disease

Alprostadil (PGE1) · Cyanotic neonate · Apnoea risk 10% · Intubation readiness

APLS · BCS · RCPCH

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Any cyanosed neonate not responding to 100% O₂, or collapsing in first 2–3 weeks, may have duct-dependent CHD. Start alprostadil IMMEDIATELY. Prepare for apnoea (10–12%) — intubation equipment at bedside at all times.

📋 Lesions, Diagnosis & Management▾

Duct-Dependent Lesions

Pulmonary blood flow dependent on duct: Pulmonary atresia, critical PS, tricuspid atresia, severe Ebstein's, severe Tetralogy of Fallot

Systemic blood flow dependent on duct: HLHS, critical aortic stenosis, severe coarctation, interrupted aortic arch

Parallel circulation (TGA): duct-dependent mixing — emergency balloon atrial septostomy (Rashkind procedure)

Hyperoxia Test (Diagnostic)

Pre-ductal (right hand) SpO₂ vs post-ductal (either foot). Difference >3% = significant right-to-left shunt.

Give 100% O₂ for 10 minutes. PaO₂ <20 kPa despite 100% O₂ = likely cardiac (not respiratory). Avoid prolonged hyperoxia — may close duct.

Alprostadil (PGE1) Infusion — Start Immediately

Starting dose: 5–10 ng/kg/min IV continuous infusion. Dilute in 5% dextrose. Dedicated IV line.

Increase to 20 ng/kg/min if no response. Max 100 ng/kg/min. Effect may take 20–30 min.

Side effects: Apnoea 10–12% (intubation must be immediately available), fever, hypotension, flushing, jitteriness, seizures (reduce dose).

Urgent paediatric cardiology/NICU discussion. Transfer to PICU/cardiac surgical centre once stabilised on alprostadil.

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Paediatric Asthma

BTS/SIGN 2023 · Salbutamol · Ipratropium · Magnesium 40 mg/kg · PICU criteria

BTS/SIGN 2023 · NICE NG80

🔬 Severity Assessment▾

Mild

SpO₂ ≥94%. Full sentences. PEFR >75%. Mild wheeze. HR <100 infant / <120 child.

Moderate

SpO₂ 92–94%. Phrases. PEFR 50–75%. Accessory muscles. HR 100–130.

Severe

SpO₂ <92%. Single words. PEFR <50%. Severe tachycardia. Cyanosis. Paradoxical breathing.

Life-Threatening

SpO₂ <92% on O₂. Silent chest. Poor respiratory effort. Confusion. Bradycardia. PICU NOW.

ℹ

Under 5s: viral-induced wheeze more common than true asthma. Ipratropium NOT routinely used under 2 years. Salbutamol via spacer/mask as effective as nebuliser in mild-moderate.

💊 Treatment by Severity▾

O₂ — All Patients With SpO₂ <94%

Target SpO₂ 94–98%. High-flow O₂ via tight-fitting mask if required. Continuous pulse oximetry.

Salbutamol (All Moderate+)

<5y: 2.5 mg neb q20 min × 3 in first hour. ≥5y: 5 mg neb q20 min × 3. Then q1–4h.

Alternatively: 6–12 puffs salbutamol MDI via spacer — equivalent efficacy to nebuliser in mild-moderate.

Ipratropium (Severe/Life-Threatening — Added to Salbutamol)

<5y: 0.125 mg q20 min × 3. ≥5y: 0.25 mg q20 min × 3. Then q4–6h.

Steroids (All Moderate+ — Give Early)

Prednisolone oral: 1–2 mg/kg/day (max 40 mg) for 3–5 days. Give in ED, do not wait.

Vomiting / unable to swallow: dexamethasone 0.15–0.3 mg/kg oral (equally effective, less vomiting).

IV: hydrocortisone 4 mg/kg q6h (max 100 mg) if oral not possible.

Magnesium Sulfate (Severe / Life-Threatening)

MgSO₄ 40 mg/kg IV (max 2g) over 20 min. Single dose. Reduces PICU admission in severe attacks (MAGNETIC trial).

Nebulised MgSO₄ 150 mg isotonic solution — additional benefit in severe acute asthma (BTS 2023).

IV Salbutamol (Imminent Arrest)

Loading dose: 5 mcg/kg IV over 5 min. Infusion: 1–5 mcg/kg/min. Monitor for hypokalaemia (correct K⁺).

Intubation (Last Resort)

Call PICU early — warn before the crisis. Ketamine 1–2 mg/kg IV preferred induction agent (bronchodilator).

Ventilate: low RR (12–16/min), long expiratory time, high tidal volume — avoid gas trapping. HELIOX if available.

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Bronchiolitis (RSV)

NICE NG9 2021 · Supportive only · HFNC · Nirsevimab · No salbutamol/steroids

NICE NG9 2021 · RCPCH

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Clinical diagnosis — no investigations routinely needed. Salbutamol, steroids, antibiotics, and physiotherapy NOT recommended (NICE NG9). Focus exclusively on: supportive care, adequate oxygenation, and maintaining hydration.

📋 Admission Criteria & Management▾

Clinical Features

Age <2 years (peak 3–6 months). RSV in 80% of cases. Autumn/winter. Upper respiratory prodrome (1–2 days) → wheeze + crepitations + tachypnoea.

Nasal flaring, intercostal recession, grunting. Feeding difficulty (most common reason to admit). Apnoeas (especially <6 weeks gestation corrected age).

Admission Criteria (NICE NG9)

SpO₂ persistently <92%. Moderate/severe respiratory distress. Feeding <50–75% of normal over 24h.

Apnoeas (witnessed or reported). Clinical exhaustion. Age <3 months (higher risk). Born <37 weeks gestation. Haemodynamically significant CHD or chronic lung disease.

Respiratory Support

Target SpO₂ ≥92%. Low-flow O₂ nasal cannula first line. Avoid painful procedures — worsens distress.

HFNC (Optiflow): start at 2 L/kg/min (max 60 L/min, 34–37°C humidified). Reduces PICU transfer in moderate bronchiolitis (PARIS RCT). Escalate to CPAP/intubation if failing.

Feeding & Hydration

NG feeds if oral intake <75% normal. Avoid oral feeding if RR >70/min (aspiration risk).

IV: 0.9% NaCl + 5% dextrose at maintenance rate if NG not tolerated. Avoid over-hydration.

Prevention

Nirsevimab (Beyfortus): single IM injection — all infants entering first RSV season (UK from autumn 2023). Replaces palivizumab for most.

NOT recommended: salbutamol, adrenaline, steroids, antibiotics (unless secondary bacterial pneumonia confirmed), chest physiotherapy.

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Croup (Laryngotracheobronchitis)

Westley Croup Score · Dexamethasone 0.15 mg/kg · Nebulised adrenaline · Parainfluenza

SIGN 2021 · RCPCH

📋 Westley Score & Management▾

Feature	0	1	2	3	5
Stridor	None	At rest with stethoscope	At rest without stethoscope	—	—
Recession	None	Mild	Moderate	Severe	—
Air entry	Normal	Decreased	Markedly decreased	—	—
Cyanosis	None	—	With agitation	—	At rest
Consciousness	Normal	—	—	Depressed	—

Score Interpretation & Treatment

≤2 Mild: Oral dexamethasone, observe 2–4h, discharge if improved. Parental education re rebound.

3–7 Moderate: Oral/IM dexamethasone + nebulised adrenaline. Observe minimum 2h post-neb. Admit if not settling.

≥8 Severe: Nebulised adrenaline + IV/IM dexamethasone + O₂. Call anaesthetics immediately. PICU. Consider intubation.

Dexamethasone

0.15 mg/kg oral/IM (max 10 mg) single dose. Severe: 0.3–0.6 mg/kg.

Alternative: prednisolone 1 mg/kg oral. Budesonide 2 mg neb (equally effective — useful if vomiting).

Nebulised Adrenaline 1:1000

0.5 mL/kg (max 5 mL) undiluted. Rapid onset (5–10 min). Duration 1–2h. Observe ≥2h after (rebound possible).

Cause: parainfluenza 1–3. Age 6 months–3 years. Barking cough. Inspiratory stridor. Worse at night.

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Epiglottitis

Do NOT examine throat · Theatre gas induction · Cefotaxime · Now common in adults too

APLS · ENT UK

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DO NOT: examine the throat, attempt IV access in awake child, lay child flat, send to X-ray. ANY disturbance can cause complete obstruction. Keep child sitting upright, blow-by O₂ only, call anaesthetics and ENT IMMEDIATELY.

📋 Recognition & Airway Management▾

Recognition

Toxic child, high fever (39–40°C), drooling (unable to swallow secretions), dysphonia ("hot potato" voice), tripod posture (leaning forward, neck extended, mouth open). Inspiratory stridor.

Rapid progression over hours (unlike gradual croup). Refuses to lie down. Child appears frightened. HiB vaccination has dramatically reduced UK incidence — now more common in adults and unvaccinated.

Team Call — All at Once

Senior ED doctor + Paediatric anaesthetist + ENT surgeon + PICU. Most experienced person stays with child at all times. Do not leave child alone.

Airway Securing — Theatre

Gas induction with sevoflurane + 100% O₂ in sitting position. Parents in theatre if helpful to keep child calm.

Intubate only once deeply anaesthetised. Use smallest ETT that passes (marked subglottic oedema). Rigid bronchoscopy + emergency surgical airway on standby.

Extubate in PICU after 24–48h when oedema resolves and child tolerates cuff deflation.

Antibiotics (After Airway Secured)

Cefotaxime 50 mg/kg IV q6–8h (max 2g/dose) for 5–7 days. Organism: H. influenzae type B (HiB) in unvaccinated; also Strep, Staph.

Dexamethasone 0.15 mg/kg IV — reduces airway oedema.

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Bacterial Tracheitis

Staphylococcal · Croup that deteriorates suddenly · Pseudomembranes · PICU

APLS · RCPCH

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Bacterial tracheitis = croup that went wrong. The child looks TOXIC. Does NOT respond to dexamethasone or nebulised adrenaline. Pseudomembranes obstruct the trachea. High mortality without early intubation in PICU.

📋 Features & Management▾

Features

Age 1–6 years. Often follows a viral URTI or croup → sudden deterioration with high fever, toxic appearance, stridor, productive cough.

No response to croup treatments (a key diagnostic clue). Barking cough may persist but signs of toxicity distinguish from viral croup.

Organisms: Staph aureus (including MRSA — increasing), Strep pneumoniae, H. influenzae, Moraxella. CXR: steeple sign + subglottic irregularity.

Management

Senior anaesthetics + ENT immediately. PICU bed required. Intubation in theatre (as per epiglottitis protocol). Frequent suction of pseudomembranes required post-intubation.

Empirical antibiotics: Flucloxacillin 50 mg/kg IV q6h (max 2g) + cefotaxime 50 mg/kg q6–8h. Duration 10–14 days.

MRSA suspected: vancomycin 15 mg/kg IV q6h (target trough 10–20 mg/L). Discuss with microbiology.

🌊

Laryngomalacia

Most common stridor in infants · Floppy epiglottis · Positional · 85% self-resolve by 18 months

ENT UK · RCPCH

📋 Features, Diagnosis & Management▾

Clinical Features

Most common cause of chronic stridor in infants. Onset in first few weeks of life. Inspiratory stridor — high-pitched, musical.

Worse: supine, feeding, crying, URTI, agitation. Better: prone, calm, neck extended. Omega-shaped epiglottis on endoscopy.

Feeding difficulties common (poor weight gain). Usually mild and self-resolving by 12–18 months (85–95%).

Red Flags — Urgent ENT Referral

Cyanosis or SpO₂ <93%. Apnoeas. Failure to thrive (weight below 2nd centile or crossing centiles). Severe distress. Cor pulmonale. Feeding requiring nasogastric tube.

ED Management

Reassurance and positional advice (prone, neck extended during feeding). ENT outpatient referral for flexible nasendoscopy (confirms diagnosis and severity).

Admit if: SpO₂ <93%, apnoeas, feeding <50% normal, or acute deterioration suggesting intercurrent illness.

Severe cases: Supraglottoplasty under GA — division of aryepiglottic folds. Effective in 80–95%.

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Paediatric Pneumonia (BTS 2022)

Amoxicillin first-line · Empyema · Urokinase · SpO₂ <92% = admission

BTS 2022 · NICE NG143

📋 Diagnosis, Admission & Treatment▾

Admission Criteria

SpO₂ <92%. Moderate/severe respiratory distress. Unable to maintain oral hydration. Complication (empyema, abscess). Age <3–6 months. Social concerns or poor follow-up possible.

Antibiotics — Community-Acquired Pneumonia

1st line oral (typical CAP — any age): Amoxicillin 40–45 mg/kg/day in 3 divided doses (max 500 mg TDS) × 5 days

Atypical (Mycoplasma — >5y or poor response to amoxicillin): Clarithromycin 7.5 mg/kg BD (max 500 mg BD) × 7 days

Hospitalised IV: Co-amoxiclav 30 mg/kg q8h IV or cefuroxime 30 mg/kg q8h IV × 5 days

Complicated/severe: Ceftriaxone 80 mg/kg OD IV (max 4g) ± clarithromycin if atypical suspected

Staphylococcal (fluffy infiltrates, pneumatocoeles): add flucloxacillin 50 mg/kg q6h IV

Empyema

Suspect if persistent fever despite 48h antibiotics. USS confirms pleural fluid. Send fluid for pH (exudate pH <7.2), LDH, protein, MC&S, AFB.

Chest drain + intrapleural urokinase 40,000 units in 40 mL 0.9% NaCl BD × 3 days (MIST1 trial — superior to drainage alone for fibrinopurulent stage).

VATS decortication if drain fails — direct debridement of loculated empyema. Discuss with paediatric surgery.

💨

Paediatric Pneumothorax

BTS 2010 · Spontaneous vs secondary · Tension · Aspiration · 100% O₂ reabsorption

BTS 2010 · APLS

📋 Management▾

Types

Spontaneous primary: tall thin adolescent males. Apical bullae. No underlying disease. Recurrence 50%.

Secondary: CF (most common in UK), asthma, staphylococcal pneumonia, Marfan's. Higher morbidity.

Tension: haemodynamic compromise, deviated trachea, absent breath sounds, distended neck veins → treat immediately, do not wait for CXR.

Management by Severity

Tension: Immediate needle decompression 2nd ICS MCL (14–16G). Finger thoracostomy 4th/5th ICS anterior axillary line → chest drain.

Large (>2 cm rim or symptomatic): Needle aspiration (16–18G, 2nd ICS MCL, up to 20 mL/kg aspirated). Failure → small-bore Seldinger chest drain.

Small/asymptomatic: 100% O₂ (increases reabsorption rate 4×). Observe 4–6h. Repeat CXR. Discharge if stable.

Recurrent: VATS pleurodesis (talc or mechanical) after 2nd ipsilateral episode.

🔩

Foreign Body Aspiration

Peak 6m–4y · Unilateral wheeze · Button battery = emergency · Rigid bronchoscopy

ENT UK · APLS · RCS

📋 Recognition & Management▾

Common FBs and Features

Peak age 6 months–4 years. Common objects: peanuts/nuts (organic — swell, cause intense reaction), grapes, toy parts, coins, button batteries.

Acute phase: sudden choking, violent coughing paroxysm, gagging, respiratory distress. May resolve spontaneously — giving false reassurance that FB has been cleared.

Subacute/chronic: unilateral wheeze not responding to bronchodilators, recurrent pneumonia in same lobe, persistent cough. Normal CXR in 30% — inspiratory/expiratory views may show air trapping.

Management

Complete obstruction / unconscious: Back blows + chest thrusts (<1y) or abdominal thrusts/Heimlich (>1y). No blind finger sweeps. CPR if pulseless.

Partial obstruction (coughing): Do NOT intervene — encourage coughing. Intervention may convert partial to complete obstruction. Monitor SpO₂ and RR.

Button battery = EMERGENCY: Immediate rigid endoscopy — liquefactive necrosis begins within 2h. Do not wait. Notify ENT/ORL immediately.

Definitive treatment: Rigid bronchoscopy under GA — simultaneous diagnostic and therapeutic. Flexible bronchoscopy only diagnostic (cannot safely retrieve).

🌡️

Febrile Convulsions

NICE NG217 2022 · Simple vs complex · LP criteria · Recurrence 30%

NICE NG217 2022 · RCPCH

📋 Classification & Management▾

Simple (85%)

Generalised. Single episode. Duration <15 min. Full recovery within 1h. Age 6m–5y. Normal development.

Complex (15%)

Focal OR duration >15 min OR recurs within 24h OR Todd's paresis OR age <6 months. Further investigation required.

LP Indications (NICE NG217)

<12 months: Consider LP in ALL first febrile seizures — meningism signs may be absent in infants

12–18 months: LP if meningitis signs, not immunised (Hib/MenC/Pneumo), or clinically concerned

>18 months: LP only if clinical signs of meningitis or encephalitis

Complex: CT head first if focal signs, raised ICP, or not fully recovered. Then LP if no contraindication.

Treatment During Active Seizure

Position safely. O₂. BM. If seizing >5 min: Buccal midazolam 0.3 mg/kg (max 10 mg) or rectal diazepam 0.5 mg/kg

IV/IO available: Lorazepam 0.1 mg/kg (max 4 mg). Treat fever with paracetamol/ibuprofen.

Parental Education & Discharge

Antipyretics: for comfort only — do NOT prevent febrile seizure recurrence. Evidence clear on this.

Recurrence risk 30%. Epilepsy risk: simple FC 1.5–3% (same as general population). Complex FC: up to 10%.

Prescribe buccal midazolam for home rescue if: complex FC, multiple recurrences, or family anxiety. Written action plan.

Admit: complex, age <18 months, uncertain diagnosis, parental concern. Discharge: simple with written advice leaflet.

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Paediatric Status Epilepticus

APLS 2023 · Lorazepam · Levetiracetam · Phenytoin · RSI at 25 min

APLS 2023 · NICE NG217

🚨

Status = seizure ≥5 minutes OR recurrent seizures without recovery. Treat at 5 min — do NOT wait 30 min. Each additional minute of seizure = progressive neuronal injury. Have anaesthetics on standby from 15 min onwards.

📋 APLS Algorithm▾

0–5 min: ABC, O₂, lateral, BM check, positioning, IV/IO access attempt

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5 min: FIRST BENZODIAZEPINE

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10 min: Still seizing → SECOND BENZODIAZEPINE (same drug, same dose)

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15 min: Secure IV/IO → Second-line AED. Call anaesthetics NOW.

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25–30 min: RSI — anaesthetics intubate. Thiopentone. PICU.

First-Line Benzodiazepines (Give at 5 min)

IV/IO available: Lorazepam 0.1 mg/kg IV/IO (max 4 mg). Onset 2–3 min. Preferred route.

No IV: Buccal midazolam 0.3–0.5 mg/kg buccal (max 10 mg). Oromucosal. Onset 5 min. (UK licensed as Epistatus/Buccolam)

Rectal diazepam 0.5 mg/kg (max 10 mg). Intranasal midazolam 0.2 mg/kg via atomiser.

Second-Line AED (Give at 15 min, IV/IO)

Levetiracetam 40–60 mg/kg IV/IO (max 3g) over 15 min — now first-line per APLS 2023 (ECLIPSE/ConSEPT RCTs show equal efficacy to phenytoin, better safety)

Phenytoin 20 mg/kg IV/IO over 20 min (max 2g). ECG monitoring. Rate <1 mg/kg/min. Avoid in cardiac arrhythmia.

Sodium valproate 40 mg/kg IV/IO (max 3g) over 5 min — avoid <3 years and girls of childbearing potential (teratogenic).

Third-Line / RSI (25–30 min)

Call anaesthetics immediately at 15 min — do not wait until 25 min to call.

Thiopentone 4–8 mg/kg IV induction (gold standard for refractory status). Propofol 1–2 mg/kg. Midazolam infusion 0.1–0.4 mg/kg/h.

EEG monitoring in PICU. Continue treating reversible causes throughout.

🧠

Raised Intracranial Pressure in Children

Cushing's triad · Mannitol 0.5 g/kg · 3% NaCl · Head 30° · Normocapnia

APLS · NICE NG176 · RCPCH

🚨

Cushing's triad (↑BP + bradycardia + irregular breathing) = impending herniation — a LATE sign. Treat raised ICP before this develops. Avoid hypoxia, hypercapnia, hypoglycaemia, hyperthermia, hyponatraemia — all worsen ICP.

💊 ICP Management▾

General Measures (All Patients)

Head 30°, midline position. Minimal stimulation. SpO₂ 94–98%. PaCO₂ 4.5–5 kPa (normocapnia only — prophylactic hyperventilation causes cerebral ischaemia).

Glucose 4–8 mmol/L. Temperature 36–37°C. Seizure control (levetiracetam prophylaxis in TBI). Avoid hypotonic fluids.

Osmotherapy — Choose One

Mannitol 20%: 0.25–0.5 g/kg IV (= 1.25–2.5 mL/kg 20% mannitol) over 15–20 min. Target serum osmolality <320 mOsm/kg. Repeat q4–6h.

3% NaCl: 2–5 mL/kg IV over 10–20 min — equally effective, maintains intravascular volume (preferred if hypotensive). Target Na⁺ 145–155 mmol/L.

Common Causes in Children

TBI (most common), bacterial meningitis, viral encephalitis, DKA cerebral oedema, brain tumour, hydrocephalus, VP shunt failure, hypertensive encephalopathy, status epilepticus.

VP shunt failure: any change in headache pattern in shunted child = shunt failure until proven otherwise. Urgent neurosurgical review. Shunt series X-rays + CT head.

💊

Meningitis & Meningococcal Disease

NICE NG51 2023 · Benzylpenicillin prehospital · Ceftriaxone 80 mg/kg · Dexamethasone · LP timing

NICE NG51 2023 · RCPCH · Meningitis Research Foundation

🚨

Non-blanching petechial/purpuric rash + fever = meningococcal disease until proven otherwise. Benzylpenicillin IMMEDIATELY prehospital. Blood cultures → antibiotics → LP (if safe). Do NOT delay antibiotics for LP.

📋 Treatment▾

Prehospital Benzylpenicillin (If Meningococcal Suspected)

<1 year: 300 mg IM/IV. 1–9 years: 600 mg IM/IV. ≥10 years: 1200 mg IM/IV.

Give if non-blanching rash present and transfer >20 min. Penicillin allergy: chloramphenicol 25 mg/kg prehospital.

ED Antibiotics

≥3 months: Ceftriaxone 80 mg/kg IV OD (max 4g). Covers N. meningitidis, Strep. pneumoniae, H. influenzae type B.

<3 months: Cefotaxime 50 mg/kg q6h + Ampicillin 50 mg/kg q6h (add Listeria cover in neonates).

Dexamethasone

0.15 mg/kg IV q6h × 4 days (max 10 mg/dose). Give before or with first antibiotic dose. Reduces deafness and neurological sequelae in bacterial meningitis.

Do NOT give: septicaemia without meningitis, neonatal meningitis, viral meningitis.

LP Timing & Contraindications

Contraindications to LP: Papilloedema, focal neurology, GCS <13 or rapidly deteriorating, haemodynamic instability, coagulopathy (INR >1.5 or PLT <100), posterior fossa signs.

CT head before LP if any contraindications. Blood cultures + antibiotics FIRST in all cases.

Meningococcal Septicaemia — Additional

10 mL/kg fluid boluses. Vasopressors early if no response. PICU. DIC: FFP 10 mL/kg + cryoprecipitate.

Notifiable disease immediately. Close contacts: ciprofloxacin single dose (adults) / rifampicin BD × 2 days — via public health team.

🔴

Headache Red Flags in Children

CT indications · Thunderclap · Raised ICP features · VP shunt failure · Migraine

NICE NG176 · RCPCH · BASH

📋 Red Flags & Management▾

Red Flags — Immediate CT Head

Thunderclap headache: sudden onset, maximal at onset ("worst ever") — SAH, CVST, pituitary apoplexy, RCVS

Positional: worse lying down (raised ICP — tumour/hydrocephalus) or worse standing (intracranial hypotension — CSF leak)

Progressive: worsening over days/weeks. Night waking due to headache. Morning headache + vomiting (raised ICP).

Focal neurology: motor/sensory deficit, visual field loss, ataxia, diplopia, dysphasia, papilloedema on fundoscopy.

VP shunt in situ: ANY headache change = shunt failure until proven otherwise. Neurosurgery urgently. Shunt series X-ray + CT.

NAI: subdural haematoma in young child with vomiting + altered consciousness + headache.

Migraine — Most Common Severe Recurrent Headache

Unilateral or bilateral throbbing. Nausea/vomiting. Photophobia/phonophobia. Duration 1–72h. Family history common.

Acute: Ibuprofen 10 mg/kg (superior to paracetamol for migraine). Sumatriptan nasal spray ≥12y. Rest in dark quiet room.

Prochlorperazine 0.1 mg/kg (max 5 mg) buccal for nausea. Prophylaxis: topiramate/amitriptyline — outpatient neurology.

🚨

Paediatric Sepsis (NICE NG51)

RCPCH Paediatric Sepsis 6 · Antibiotics within 1 hour · PEWS · Organ dysfunction

NICE NG51 2022 · RCPCH · Sepsis Trust

📋 Paediatric Sepsis 6▾

Recognition — PEWS Trigger Features

Tachycardia (HR above age-appropriate normal). Tachypnoea. Fever >38°C or hypothermia <36°C.

Altered consciousness (GCS drop ≥2 or AVPU <A). CRT >2s. Mottled/pale/cyanotic skin. Hypotension (LATE sign). Petechial or purpuric rash.

Paediatric Sepsis 6 — All Within 1 Hour

TAKE 3: Blood cultures ×2 peripheral. Lactate + ABG/VBG. FBC, U&E, CRP, coagulation, LFTs, glucose, CXR.

GIVE 3: High-flow O₂ (titrate SpO₂ 94–98%). IV/IO antibiotics. IV/IO fluid 10 mL/kg if shocked (repeat and reassess).

Empirical Antibiotics

<3 months: Benzylpenicillin 50 mg/kg q6h IV + Gentamicin 5 mg/kg OD IV (GBS, Listeria, gram-negative enteric)

3m–17y community-acquired: Ceftriaxone 80 mg/kg OD IV (max 4g). Add metronidazole 15 mg/kg BD if abdominal source.

Hospital-acquired / immunocompromised / PICU: Pip-tazo 90 mg/kg q8h IV (max 4.5g TDS) ± aminoglycoside. Review with microbiology at 48h.

❤️‍🔥

Kawasaki Disease

≥5 days fever + 4/5 criteria (CRASH) · IVIg 2 g/kg · Aspirin · Coronary aneurysm

BSR 2022 · AHA 2017 · RCPCH

⚠

Most common acquired heart disease in children in the developed world. IVIg within 10 days of fever onset reduces coronary aneurysm risk from 20–25% to 3–5%. Do NOT miss in any child with unexplained prolonged fever.

📋 Criteria, Investigations & Treatment▾

Diagnosis — Fever ≥5 Days + 4 or 5 of (CRASH mnemonic)

Conjunctival injection — bilateral, non-purulent, limbic-sparing

Rash — polymorphous, non-vesicular, truncal predominance

Adenopathy — cervical lymphadenopathy (>1.5 cm), usually unilateral

Strawberry tongue/lips — erythema, lip cracking, strawberry tongue

Hands/feet — erythema of palms/soles, indurated oedema. Periungual desquamation in convalescent phase (2–3 weeks)

Incomplete KD: Fewer features but elevated CRP/ESR + echo showing coronary changes. Treat if high suspicion.

Investigations

FBC (WCC >15, PLT rises week 2 — thrombocytosis). CRP >30 (often >100). ESR >40. ALT elevated. Low albumin. Sterile pyuria.

Echocardiogram: at diagnosis (Z-score for coronary arteries). Repeat at 2 weeks and 6–8 weeks. LAD and RCA measurements.

Treatment

IVIg 2 g/kg IV as single infusion over 10–12 hours. Best given within day 5–10 of fever. Repeat if fever persists >48h post-infusion.

Aspirin anti-inflammatory: 30–50 mg/kg/day in 4 divided doses (max 2–3g/day) until afebrile 48–72h

Aspirin antiplatelet: 3–5 mg/kg/day OD × 6–8 weeks (indefinitely if coronary aneurysm on echo)

IVIg-resistant: infliximab 5 mg/kg IV single dose or methylprednisolone 30 mg/kg OD × 3 days. Cardiology input essential.

🍓

Scarlet Fever

Group A Streptococcus · Sandpaper rash · Phenoxymethylpenicillin × 10d · Notifiable

UKHSA · NICE · PHE

📋 Features & Treatment▾

Clinical Features

Age 2–10 years. Group A Streptococcus (GAS). Highly contagious. 2022–23 UK: significant rise in invasive GAS — be alert for rapid deterioration.

Prodrome: fever, sore throat (exudative tonsillitis), vomiting, headache (24–48h before rash)

Rash: sandpaper texture (fine papular), erythematous, starts in flexures (axillae/groin) → spreads to trunk. Pastia's lines. Circumoral pallor. Desquamation 1–2 weeks later.

Tongue: White strawberry tongue → bright red strawberry tongue by day 5. Notifiable disease (UK).

Treatment

Phenoxymethylpenicillin × 10 days: <1y: 62.5 mg QDS | 1–5y: 125 mg QDS | 6–11y: 250 mg QDS | ≥12y: 500 mg QDS

Penicillin allergy: azithromycin 10 mg/kg OD (max 500 mg) × 5 days. Or clarithromycin.

Return to school/nursery: 24h after antibiotic started AND afebrile.

Complications: Rheumatic fever (rare in UK), post-strep GN, peritonsillar abscess, otitis media, invasive GAS (necrotising fasciitis, TSS) — suspect if sudden deterioration, severe pain out of proportion, skin crepitus.

🔴

Measles

3Cs prodrome · Koplik spots · Morbilliform rash · Vitamin A · Notifiable · PEP

UKHSA · WHO · PHE

📋 Features & Management▾

Clinical Features

Prodrome (days 1–4): 3Cs — Coryza, Cough, Conjunctivitis + high fever (38.5–40°C)

Koplik spots: white/grey spots on buccal mucosa opposite lower molars — pathognomonic. Appear day 2–4, fade as rash develops.

Rash (day 3–5): Maculopapular (morbilliform), begins hairline/face → spreads downwards. Confluent on face, discrete on limbs. Fades with branny desquamation.

Notifiable immediately. Confirm with salivary IgM or throat swab PCR. Airborne transmission — isolate 4 days post-rash onset.

Treatment

Supportive. Vitamin A (WHO recommendation): <6m: 50,000 IU × 2 days | 6m–1y: 100,000 IU × 2 days | >1y: 200,000 IU × 2 days

Complications: Pneumonia (most common cause of death), bacterial superinfection, otitis media, croup, febrile seizures, encephalitis (1:1000), SSPE (rare, 7–10 years later, always fatal)

Post-Exposure Prophylaxis (PEP)

MMR within 72h (3 days) of exposure — immunocompetent unvaccinated contacts

IVIG within 144h (6 days) — immunocompromised, pregnant, infants <6 months, those where MMR contraindicated

🌟

Chickenpox (Varicella-Zoster)

Aciclovir high-risk groups · VZIG · No aspirin or NSAIDs · Invasive GAS alert

NICE · UKHSA · RCPCH

📋 Features, High-Risk Groups & Treatment▾

Features

Pruritic vesicular rash — multiple stages simultaneously (macule → papule → vesicle → crust). Trunk first, then face and extremities. Oral lesions common. Infectious 1–2 days before rash until all lesions crusted (~5 days).

Treat with Aciclovir — High-Risk Groups

Immunocompromised (steroids >2 mg/kg prednisolone >1 week, chemotherapy, biological agents, primary immunodeficiency)

Neonates (<28 days or maternal VZV from 5 days before to 2 days after delivery). Adults. Pregnant. Secondary household cases (more severe).

Oral aciclovir: 20 mg/kg QDS (max 800 mg QDS) × 5 days. Start within 24h of rash onset.

IV aciclovir: 10–15 mg/kg q8h (max 500 mg/m²) — severe disease or immunocompromised × 7–14 days.

Complications & Important Warnings

Bacterial superinfection: GAS or Staph — rapidly enlarging, painful, warm lesion = invasive GAS emergency (mortality 10–15%). Urgent debridement + clindamycin + benzylpenicillin.

Cerebellar ataxia: benign, self-limiting (1–2 weeks). Reassure. Pneumonia (adults). Encephalitis (rare).

NEVER aspirin (Reye's syndrome). Avoid NSAIDs — strong evidence for increased invasive GAS risk.

VZIG: for non-immune high-risk contacts within 10 days of exposure. Check VZV IgG first if time allows.

✋

Hand, Foot & Mouth Disease

Enterovirus · Supportive · Dehydration risk · EV-A71 neurological complications

UKHSA · PHE

📋 Features & Management▾

Features

Age <10 years (peak <5y). Coxsackievirus A16 (most common), EV-A71 (more severe). Summer/autumn. Prodrome: fever + malaise 1–2 days.

Oral lesions: Painful vesicles/ulcers on tongue, buccal mucosa, soft palate — may cause refusal to eat/drink → dehydration.

Skin rash: Non-pruritic vesicular lesions on palms, soles, between digits, and buttocks. Duration 7–10 days. Nail shedding (onychomadesis) 4–8 weeks later — warn parents.

Management

Supportive. Paracetamol/ibuprofen. Cold fluids, ice cream, cold yoghurt to soothe oral lesions. Soft diet.

Admit if unable to maintain oral hydration → IV/NG fluids. Particular risk in children <2 years.

EV-A71 complications (rare but serious): Rhombencephalitis, aseptic meningitis, acute flaccid paralysis, neurogenic pulmonary oedema. Notifiable if neurological complications suspected. No antiviral treatment available.

🧫

UTI in Children (NICE NG224)

Clean catch MSU · Dipstick interpretation · Cefalexin · USS criteria · DMSA scan

NICE NG224 2022

📋 Diagnosis, Treatment & Imaging▾

Urine Collection

Clean catch MSU preferred. Suprapubic aspiration (SPA) if clean catch not possible. Catheter specimen if SPA failed. Bag urine: high false positive rate — only use for dipstick.

Dipstick Interpretation

Nitrite positive: Probable UTI — treat empirically, send MSU for culture confirmation

Nitrite negative + leucocytes positive: Possible UTI — send MSU and consider empirical treatment in unwell child

Both negative: UTI unlikely — do not treat empirically unless clinically very unwell

Empirical Antibiotic Treatment

Lower UTI (≥3 months, well, afebrile): Trimethoprim 4 mg/kg BD (max 200 mg) × 3 days OR cefalexin 12.5 mg/kg QDS × 3 days

Pyelonephritis (febrile, systemically unwell): Cefalexin 12.5 mg/kg QDS × 7–10 days oral OR cefotaxime 50 mg/kg q8h IV

<3 months: IV antibiotics always — cefotaxime 50 mg/kg q8h + amoxicillin 50 mg/kg q6h. Admit.

Imaging (NICE NG224)

Urgent USS (<6h): <6 months, atypical infection (non-E.coli, serious illness, raised creatinine), poor response to antibiotics at 48h

USS within 6 weeks: First febrile UTI ≥6 months if good response. Recurrent UTI at any age.

DMSA (static renal scan at 4–6 months post-infection): Atypical or recurrent UTI — detects renal scarring. VUR on MAG3 if recurrent/abnormal DMSA.

🦴

Septic Arthritis & Osteomyelitis

Kocher criteria · Flucloxacillin · Surgical washout · 4–6 weeks antibiotics

BOA · BOAST · RCPCH

📋 Kocher Criteria & Management▾

Kocher Criteria — Septic Arthritis vs Transient Synovitis (Hip)

1. Fever >38.5°C | 2. Non-weight-bearing | 3. ESR >40 mm/h | 4. WCC >12 × 10⁹/L | 5. CRP >20 mg/L (Caird et al.)

0 criteria: <0.2% probability septic arthritis. 1 criterion: 3%. 2 criteria: 40%. 3 criteria: 93.1%. 4–5 criteria: 99.6% → theatre for washout.

Investigation

FBC, CRP, ESR, blood cultures (before antibiotics if possible but DO NOT delay treatment). Plain X-ray (often normal early — periosteal reaction 7–14 days). USS hip: effusion.

MRI: gold standard — shows bone and soft tissue changes early. Bone scan if MRI unavailable or multi-focal disease suspected.

Antibiotic Treatment

Organism: Staph aureus (most common all ages). Strep (any age). Kingella kingae (<5y). GBS (neonates). HiB (unvaccinated).

Flucloxacillin 50 mg/kg IV q6h (max 2g/dose) × 2 weeks IV then oral × 4 weeks total

MRSA risk factors: vancomycin 15 mg/kg IV q6h (max 1g/dose) target trough 10–15 mg/L

MSSA confirmed: can step down to oral flucloxacillin 25 mg/kg QDS when clinically improving + CRP falling

Surgical Management

Septic arthritis: Arthrotomy or arthroscopic washout + irrigation. Urgent — within hours. Hip: open washout to preserve femoral head blood supply.

Osteomyelitis: Most managed medically. Surgery if: subperiosteal abscess, no response to antibiotics 48h, bone necrosis, chronic osteomyelitis (sequestrum).

🩸

Paediatric DKA (BSPED 2021)

BSPED 2021 · Cerebral oedema prevention · 48h fluid replacement · No bolus unless shocked · Insulin 0.05–0.1 u/kg/h

BSPED 2021 · ISPAD 2022

🚨

BSPED 2021 KEY CHANGES: Spread fluid replacement over 48h (not 24h). No fluid bolus unless shocked (BP severely low, GCS ≤11). Slower insulin start (0.05 u/kg/h). Goal: prevent cerebral oedema — the main cause of death in paediatric DKA.

📋 DKA Severity & Protocol▾

Mild (pH 7.2–7.29)

Alert, tolerating fluid. Oral rehydration may suffice. Insulin SC if established on pump.

Moderate (pH 7.1–7.19)

IV fluids. Insulin infusion 0.05–0.1 u/kg/h. Hourly neurological obs.

Severe (pH <7.1)

PICU consideration. Strict fluid protocol. Glasgow Coma Score monitoring. Consider intubation.

Fluid Management (BSPED 2021)

Shock resuscitation (ONLY if: BP severely low, poor perfusion, GCS ≤11): 10 mL/kg NaCl 0.9% IV over 15–30 min. Repeat once only if needed. Do NOT give fluid bolus routinely.

48h rehydration: Calculate deficit (mild 5%, moderate 7%, severe 10% body weight) + maintenance. Replace over 48h (not 24h) as 0.9% NaCl. Use BSPED calculator.

Add 5% dextrose when BG <14 mmol/L. Add KCl to bags from the start (assuming urine output confirmed).

Insulin Infusion

Start insulin 1 hour after fluids begin (not simultaneously). Rate: 0.05 units/kg/h (mild-moderate) or 0.1 units/kg/h (severe). Do not exceed 0.1 u/kg/h.

Target BG fall: 3–5 mmol/L/h. Never stop insulin while ketones positive. Reduce rate rather than stopping if BG falling fast.

Ketones must be monitored — beta-hydroxybutyrate. Target: <0.5 mmol/L before converting to SC insulin.

Cerebral Oedema — Recognition & Treatment

Risk factors: very young age, new diagnosis T1DM, severe acidosis, low PCO₂, high urea, bicarbonate treatment, rapid fluid administration, hyponatraemia.

Signs: Headache, behaviour change, GCS fall, specific neurological signs, bradycardia, papilloedema — onset typically 4–12h after treatment starts.

Treatment: Mannitol 20% 0.5–1 g/kg IV over 10–15 min OR 3% NaCl 2.5–5 mL/kg over 15 min. Reduce fluid rate. Intubate if GCS deteriorating. PICU immediately.

💧

Dehydration & Oral Rehydration Therapy

NICE NG29 · ORS · Ondansetron · Holliday-Segar · Isotonic IV fluids

NICE NG29 2009 · ESPGHAN

📋 Assessment & Management▾

Feature	No/Mild <5%	Moderate 5–10%	Severe >10%
Eyes	Normal	Sunken	Very sunken
Tears	Present	Reduced	Absent
Mucosa	Moist	Dry	Very dry
Fontanelle	Normal	Sunken	Very sunken
CRT	<2s	2–3s	>3s
HR/BP	Normal	Tachycardia	Tachycardia + hypotension

ORS (Oral Rehydration Solution) — First-Line Mild/Moderate

ORS 50 mL/kg over 4h (mild) or 100 mL/kg over 4h (moderate). Dioralyte or equivalent. Small frequent sips.

Ondansetron 0.15 mg/kg oral (max 4 mg) — single dose to reduce vomiting and facilitate ORS (NICE NG29). Evidence base good.

Breast milk/formula: continue alongside ORS. Do not restrict food — reintroduce as soon as tolerated.

IV Fluids (Moderate Failing ORS / Severe)

Shock bolus: 10 mL/kg 0.9% NaCl IV/IO over 15–30 min. Reassess. Repeat if no improvement.

Deficit replacement: 0.9% NaCl + 5% dextrose. Deficit volume (mL) = % dehydration × weight (kg) × 10. Replace over 24h.

Maintenance (Holliday-Segar): First 10 kg: 100 mL/kg/day. Next 10 kg: 50 mL/kg/day. Each kg >20 kg: 20 mL/kg/day.

Hyponatraemia risk: Always use isotonic (0.9% NaCl + 5% dextrose or Hartmann's) IV fluids in children. Hypotonic fluids cause iatrogenic hyponatraemia.

💉

Paediatric Anaphylaxis

RCUK 2021 · Adrenaline IM weight-based · EpiPen thresholds · Observe 6–12h · Allergy referral

RCUK 2021 · NICE NG212 · BSACI

🚨

Adrenaline IM is the FIRST-LINE treatment. Give IMMEDIATELY on diagnosis. Do not delay for antihistamines or steroids. These are adjuncts only and should not precede adrenaline.

💊 Adrenaline Doses & Protocol▾

Adrenaline IM 1:1000 — Anterolateral Thigh

<6 months (body weight <7.5 kg): 0.05 mg (0.05 mL) IM — seek expert advice

6 months–6 years (body weight 7.5–25 kg): 0.15 mg (0.15 mL) IM — EpiPen Jr available

6–12 years (body weight 25–50 kg): 0.3 mg (0.3 mL) IM — standard EpiPen

>12 years (body weight >50 kg): 0.5 mg (0.5 mL) IM — adult dose

Repeat after 5 min if no improvement. Anterolateral thigh preferred (faster absorption than deltoid).

Adjuncts (After Adrenaline)

Chlorphenamine IM: <6m: 250 mcg/kg | <6y: 2.5 mg | 6–12y: 5 mg | >12y: 10 mg

Hydrocortisone IV: <6m: 25 mg | 6m–6y: 50 mg | 6–12y: 100 mg | >12y: 200 mg

Fluid bolus 10 mL/kg 0.9% NaCl if hypotensive. Salbutamol neb if bronchospasm persists.

Observation & Discharge

Monophasic: Observe minimum 6h in ED. Biphasic reaction risk: observe 12h (severe initial reaction, idiopathic, asthma). Admit overnight if severe.

Discharge with: 2 × EpiPen prescribed. Allergy referral letter. Written anaphylaxis action plan. Medic-alert bracelet advice.

🍬

Paediatric Hypoglycaemia

BM <3.5 mmol/L symptomatic · 2 mL/kg 10% dextrose IV · Glucagon IM · Underlying cause

BNFc · NICE · BSPED

📋 Recognition & Treatment▾

Definition & Causes

BG <3.5 mmol/L with symptoms (or <2.6 neonates). Symptoms: sweating, pallor, irritability, tremor, altered consciousness, seizure, coma.

Causes: fasting/illness, insulin OD (T1DM — most common), hyperinsulinism, metabolic disease, Addison's/CAH, GH deficiency, sepsis.

Treatment — By Consciousness Level

Conscious and able to swallow: Oral glucose: 15–20g sugary drink or glucose tablets. Repeat BM in 10–15 min. Follow with complex carbohydrate.

Impaired consciousness or IV access: 10% dextrose 2 mL/kg IV/IO over 5–10 min. Target BG 5–8 mmol/L. Start maintenance dextrose infusion to prevent recurrence.

No IV access: Glucagon IM/SC: <25 kg: 0.5 mg | >25 kg: 1 mg. Works within 10–15 min. If no response (glycogen depleted — prolonged fasting, liver disease): IV access essential.

Neonatal: Dextrose gel 40% buccal 0.5 mL/kg massaged into buccal mucosa (before IV if birth >35 weeks, BG 1.0–2.6).

Investigate Cause

During hypoglycaemia: insulin, C-peptide, IGF-1, cortisol, GH, free fatty acids, ketones, amino acids, metabolic screen. "Critical sample" — not to be missed.

⚡

Adrenal Crisis & Congenital Adrenal Hyperplasia

Hydrocortisone IM weight-based · Saline · CAH sick day rules · Medic-alert

BSPED · RCPCH · Society for Endocrinology

📋 Recognition & Emergency Treatment▾

Features

Vomiting, abdominal pain, shock, hypoglycaemia, hyponatraemia, hyperkalaemia. In CAH: ambiguous genitalia (female virilisation), salt-wasting crisis in neonates (day 7–14).

Triggers: illness, injury, surgery, missed medication. Child may have Medic-Alert bracelet or emergency letter.

Emergency Hydrocortisone

<10 kg: Hydrocortisone 25 mg IM/IV stat | 10–25 kg: 50 mg IM/IV stat | >25 kg: 100 mg IM/IV stat

Then hydrocortisone 25–50 mg/m² IV q6h (or continuous infusion 50–100 mg/m²/24h) until stable and tolerating oral.

0.9% NaCl 10 mL/kg IV over 30 min for volume resuscitation. 10% dextrose 2 mL/kg if BM <3.5 mmol/L.

CAH Sick Day Rules (Educate Family)

Fever >38.5°C or vomiting: double/triple regular hydrocortisone dose. Vomiting/unable to take oral: IV/IM hydrocortisone immediately. Do not wait for worsening.

Medic-Alert bracelet. Emergency hydrocortisone injection at home (Solu-Cortef 100 mg kit). Emergency letter for ED.

🩺

Paediatric Hypertensive Emergency

SBP >99th centile + 5 mmHg · End-organ damage · Labetalol · Amlodipine · Secondary causes

NICE NG136 · ESH 2022 · AAP 2017

⚠

Unlike adults, hypertension in children is nearly always SECONDARY. Always look for an underlying cause. Lower BP gradually — reduce MAP by no more than 25% in first 6–8h. Rapid lowering causes ischaemia.

📋 Definition, Causes & Management▾

Definition (Age-Specific)

Hypertensive urgency: BP >99th centile + 5 mmHg for age/sex/height. No end-organ damage.

Hypertensive emergency: Same BP threshold + end-organ damage (encephalopathy, seizures, retinal changes, acute kidney injury, cardiac failure, haemorrhage).

Approximate thresholds: <1y: >100/70 | 1–5y: >110/74 | 6–12y: >120/80 | 13–17y: >130/85 mmHg

Secondary Causes (Always Investigate)

Renal (most common 70–80%): Renal artery stenosis, renal parenchymal disease (GN, reflux nephropathy, PKD, HUS)

Cardiovascular: Coarctation of aorta (check femoral pulses and 4-limb BPs)

Endocrine: Phaeochromocytoma, Cushing's, hyperaldosteronism, hyperthyroidism, CAH

Drugs: Stimulants (amphetamines, cocaine), steroids, ciclosporin, NSAIDs, OCP

Other: Raised ICP, pain, anxiety, white coat hypertension (confirm with repeat readings)

Investigations

U&E, creatinine, urine dipstick + MC&S, urine protein:creatinine ratio, FBC, calcium, TFTs, plasma renin/aldosterone. Renal USS. Echocardiogram (LVH). Fundoscopy.

Plasma/urine catecholamines if phaeochromocytoma suspected. 4-limb BPs if coarctation suspected.

Emergency Treatment (End-Organ Damage)

Target: Reduce MAP by max 25% in first 6–8h, then normalise over 24–48h. Too rapid lowering = ischaemia.

Labetalol IV: 0.2–1 mg/kg/h infusion (max 3 mg/kg/h). Bolus 0.2–0.5 mg/kg IV over 2 min. Avoid in asthma, cardiac failure, bradycardia.

Sodium nitroprusside: 0.5–8 mcg/kg/min — rapid onset/offset, PICU only, cyanide toxicity risk >72h.

Hydralazine 0.1–0.5 mg/kg IV (max 20 mg) bolus q4–6h — good for renal hypertension.

Hypertensive encephalopathy: treat seizures (lorazepam), manage ICP, urgent nephrology/PICU.

Oral Agents (Urgency Without End-Organ Damage)

Amlodipine 0.1–0.3 mg/kg OD (max 5 mg) — calcium channel blocker, well tolerated

Nifedipine modified-release 0.25–0.5 mg/kg BD (max 3 mg/kg/day). Avoid immediate-release (rapid drop).

Refer to paediatric nephrology for all children with confirmed hypertension requiring treatment.

🩸

Paediatric Hyperosmolar Hyperglycaemic State (HHS)

Adolescent T2DM · Glucose >33 mmol/L · Osmolality >320 · Very gradual fluid replacement · Thrombosis risk

BSPED 2022 · ISPAD 2022

🚨

Paediatric HHS is distinct from adult HHS and from DKA. Mortality and morbidity are HIGH. May overlap with DKA (mixed picture). Extreme dehydration (10–15 L deficit). Replace fluid VERY slowly over 48–72h. Thrombosis is a major complication.

📋 Diagnosis & Management▾

Diagnostic Criteria (BSPED 2022)

Glucose >33 mmol/L | Osmolality >320 mOsm/kg | Minimal or absent ketonaemia (beta-OH butyrate <3 mmol/L) | No or mild acidosis (pH >7.25, HCO₃ >15)

Calculated osmolality: 2(Na + K) + glucose + urea. Corrected sodium: Na + 2 × ((glucose − 5.5) / 5.5).

Context: obese adolescent, T2DM (often new diagnosis), often precipitated by infection, vomiting, reduced fluid intake over days-weeks.

Fluid Replacement — The Key Difference From DKA

Replace deficit over 48–72h (NOT 24h or 48h as in DKA). Aim to reduce osmolality by no more than 3–5 mOsm/kg/h.

0.9% NaCl throughout initial replacement — do NOT switch to hypotonic fluids early. Risk: cerebral oedema from too-rapid osmolality fall.

If shocked: 10 mL/kg 0.9% NaCl bolus (cautious — most are profoundly dehydrated but not shocked).

Maintenance + deficit. Monitor osmolality and corrected Na⁺ hourly. Aim glucose fall ≤5 mmol/L/h.

Insulin

Do NOT start insulin immediately. Fluids alone often bring glucose down safely.

Start insulin (0.05 units/kg/h) ONLY if: glucose not falling with fluids alone, or significant ketosis (mixed HHS/DKA). Add dextrose when glucose <14 mmol/L.

Thromboprophylaxis

High thrombosis risk: hyperviscous blood + immobility + dehydration + adolescent obesity. LMWH: enoxaparin 1 mg/kg SC BD (prophylactic) while in hospital.

DVT/PE: treat dose enoxaparin 1 mg/kg SC BD. Consider catheter-directed thrombolysis for major PE.

Monitoring

Hourly: BG, urine output, neurological obs. 2-hourly: VBG (osmolality, electrolytes, ketones). Cardiac monitoring.

Cerebral oedema: headache, behaviour change, GCS fall → mannitol 0.5 g/kg IV / 3% NaCl 3 mL/kg IV. Reduce fluid rate.

PICU for all severe HHS. Endocrinology/paediatric diabetes team urgent input.

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Sickle Cell Crisis in Children

Vaso-occlusive crisis · Acute chest syndrome · Splenic sequestration · Stroke · Exchange transfusion

BSH 2021 · NICE NG143 · RCPCH

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Acute chest syndrome (ACS) is the leading cause of death in sickle cell disease. Fever + respiratory symptoms + new CXR infiltrate = ACS until proven otherwise. Transfuse early — do not wait for deterioration.

📋 Vaso-Occlusive Crisis (Painful Crisis)▾

Management

Pain assessment within 30 min of arrival. Target: effective analgesia within 60 min. Use NRS or FLACC.

Mild-moderate: Ibuprofen 10 mg/kg + paracetamol 15 mg/kg regular. Oral morphine 0.3–0.5 mg/kg q4h if needed.

Severe: IV morphine 0.05–0.1 mg/kg bolus q20 min PRN until controlled, then PCA or regular dosing. Do not undertreat — these children know their pain.

IV fluids: 0.9% NaCl or Hartmann's at 1–1.5× maintenance. Incentive spirometry (prevents ACS). Warmth. Avoid triggers: cold, dehydration, infection, hypoxia.

Admit if: IV analgesia needed, fever, respiratory symptoms, neurological symptoms, splenic enlargement, Hb fall >20 g/L from baseline, priapism >4h.

🫁 Acute Chest Syndrome (ACS)▾

Diagnosis

New infiltrate on CXR + one of: fever, cough, tachypnoea, wheeze, chest pain, hypoxia (SpO₂ <95% or >3% from baseline).

Cause: fat embolism, infection (pneumonia — atypical organisms common), pulmonary infarction, hypoventilation. Often presents as pain crisis first.

Treatment

O₂ to maintain SpO₂ ≥95%. IV analgesia (avoid over-sedation). Incentive spirometry.

Antibiotics: Co-amoxiclav 30 mg/kg q8h IV + clarithromycin 7.5 mg/kg BD (atypical cover — Mycoplasma common)

Simple transfusion: Hb <90 g/L or rapidly falling → 5 mL/kg pRBC (sickle-negative, leucodepleted, extended matched). Target Hb 90–100 g/L.

Exchange transfusion: Severe ACS (SpO₂ <90% despite O₂, rapid deterioration, multi-lobar) → automated red cell exchange. Contact haematology immediately. Target HbS <30%.

PICU if: mechanical ventilation needed, SpO₂ deteriorating despite treatment.

🧠 Stroke & Splenic Sequestration▾

Stroke (Overt Ischaemic)

Sudden focal neurological deficit, seizures, altered consciousness. Do NOT give thrombolytics — ischaemia due to sickling, not clot.

Emergency exchange transfusion immediately — target HbS <30%. MRI/CT urgently but DO NOT delay exchange for imaging if diagnosis clear. Haematology NOW.

TCD (transcranial Doppler) screening programme — velocity >200 cm/s predicts stroke risk → chronic transfusion programme.

Acute Splenic Sequestration

Sudden massive splenomegaly + acute anaemia (Hb falls ≥20 g/L from baseline) + thrombocytopenia. Hypovolaemic shock. Age typically 3 months–5 years (before autosplenectomy).

10 mL/kg pRBC immediately (sickle-negative). Do not over-transfuse — sequestered blood re-enters circulation on recovery → hyperviscosity. Target Hb 70–80 g/L.

Recurrence risk 50%. Elective splenectomy after second episode. Vaccinations before splenectomy: PCV, MenACWY, HiB, influenza.

Priapism

>4 hours = emergency. Analgesia. IV fluids. Oral pseudoephedrine 1 mg/kg (unlicensed). Urology urgently — aspiration + irrigation of corpus cavernosum if no resolution by 4h.

Exchange transfusion if surgical management fails. Erectile dysfunction risk increases with duration — treat aggressively.

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Neonatal Jaundice (NICE NG98)

NICE NG98 · Phototherapy thresholds by gestation · IVIg for haemolytic · Exchange transfusion

NICE NG98 2016 · BAPM · RCPCH

📋 Recognition, Thresholds & Treatment▾

Assessment

Pathological if: jaundice within 24h of birth (always urgent), jaundice in unwell baby, rising SBR despite phototherapy, direct bilirubin >25 mmol/L (conjugated — liver disease).

Serum bilirubin (SBR) hourly if rising rapidly. Use NICE phototherapy/exchange transfusion threshold charts for gestational age.

Phototherapy

Intensive phototherapy: irradiance ≥30 µW/cm²/nm. Maximum skin exposure. Continuous (remove for feeds only).

Threshold: use NICE NG98 nomogram by postnatal age in hours and gestation. Lower threshold for haemolytic disease.

Recheck SBR 4–6h after starting. If rising despite phototherapy → IVIg.

IVIg (Haemolytic Disease — Rh/ABO)

IVIg 500 mg/kg IV over 2–4h — if SBR rising despite intensive phototherapy. Reduces haemolysis and exchange transfusion requirement.

Repeat after 12h if bilirubin still rising rapidly.

Exchange Transfusion

Indicated when SBR above exchange threshold on NICE chart, or encephalopathy developing (acute bilirubin encephalopathy: hypotonia → hypertonia, arched back, high-pitched cry).

Double-volume exchange: 160–180 mL/kg. Via UVC. Irradiated, CMV-negative, crossmatched blood. Paediatric haematologist input.

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Neonatal Sepsis (EOS & LOS)

NICE NG195 2021 · Benzylpenicillin + gentamicin · GBS early-onset · CRP 8–12h

NICE NG195 2021 · RCPCH · BAPM

📋 Classification, Features & Antibiotics▾

Classification

Early-Onset Sepsis (EOS): <72h of age. Organisms: GBS, E. coli, Listeria, other gram-negatives. Risk: maternal GBS, PPROM, maternal fever, prematurity, invasive procedure.

Late-Onset Sepsis (LOS): >72h of age. Organisms: CoNS (NICU), Staph aureus, gram-negatives, Candida. Risk: prematurity, lines, prolonged NICU stay.

Clinical Features

Temperature instability (fever OR hypothermia). Respiratory distress. Apnoeas. Poor feeding. Lethargy/hypotonia. Mottled/pale skin. Bulging fontanelle. Seizures. Shock (late).

Empirical Antibiotics — EOS

Benzylpenicillin 50 mg/kg IV q12h (term) or q6h (meningitis dose) + Gentamicin 5 mg/kg OD IV

Meningitis suspected (LP: high WCC, low glucose): add cefotaxime and increase benzylpenicillin to 50 mg/kg q6h

Empirical Antibiotics — LOS (NICU)

Line-associated / CoNS suspected: Vancomycin 15 mg/kg q6–12h IV (adjust by levels) + gentamicin 5 mg/kg OD

Gram-negative sepsis risk: pip-tazo or meropenem (local policy). Antifungal (fluconazole/amphotericin) if Candida risk.

Investigation (NICE NG195)

Blood culture. CRP at presentation and 18–24h. FBC. CXR if respiratory. LP if meningitis suspected and baby stable. Urine MC&S (catheter/SPA — not bag).

NICE NG195 2021: CRP <10 at 18–24h in well baby = low risk, review antibiotics at 36h.

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Neonatal Seizures

Phenobarbitone 20 mg/kg · Levetiracetam · Glucose · Calcium · Pyridoxine

BAPM · RCPCH · ILAE

📋 Recognition & Treatment▾

Recognition

May be subtle: eye deviation, lip smacking, cycling/pedalling limb movements, apnoea (with other subtle features), tonic stiffening, clonic jerking.

Causes: HIE (most common), hypoglycaemia, hypocalcaemia, hyponatraemia, meningitis/encephalitis, pyridoxine deficiency (rare), metabolic disease, stroke.

First-Line — Treat Metabolic Causes First

BM: 10% dextrose 2.5 mL/kg IV if BG <2.6 mmol/L

Calcium: 10% calcium gluconate 0.5 mL/kg IV slowly (over 5–10 min with ECG monitoring) if hypocalcaemia confirmed

Anticonvulsants

Phenobarbitone 20 mg/kg IV over 15–20 min — first-line antiepileptic. Repeat 10 mg/kg if no response (max 40 mg/kg).

Levetiracetam 40–60 mg/kg IV over 15 min — increasingly used as alternative to phenobarbitone or second-line.

Phenytoin 20 mg/kg IV over 20 min — second-line if phenobarb fails. ECG monitoring.

Pyridoxine 100 mg IV — if all above fail (pyridoxine-dependent epilepsy — rare but treatable). Give trial if refractory.

Midazolam infusion 0.15 mg/kg/h — for continuous electrographic seizures (EEG monitoring).

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Neonatal Hypoglycaemia

BG <2.6 mmol/L · 10% dextrose 2.5 mL/kg · Dextrose gel 40% buccal · BAPM guidelines

BAPM 2017 · NICE NG3

📋 Management▾

Threshold & Risk Groups

Definition: BG <2.0 mmol/L (first 4h) or <2.6 mmol/L (>4h of age) in at-risk neonates.

At-risk: infant of diabetic mother, macrosomia, IUGR/SGA, preterm <37 weeks, perinatal asphyxia, hypothermia, late preterm 34–36+6 weeks.

Treatment

Symptomatic (seizures, jitteriness, apnoea, poor tone): 10% dextrose 2.5 mL/kg IV/IO stat over 5 min → maintenance dextrose infusion 5–8 mg/kg/min

Asymptomatic BG 1.0–2.6: Dextrose gel 40% 0.5 mL/kg buccal (NeoKGel/40% dextrose) massaged into buccal mucosa. Breastfeed/feed within 30 min. Recheck BM 30 min post-feed. (NICE NG3, Sugar Babies trial)

Asymptomatic BG <1.0: IV glucose immediately.

Maintenance: 10% dextrose at 60 mL/kg/day via UVC or 10% peripherally. Increase rate if BG still low. Target BG >2.6 mmol/L.

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Neonatal Respiratory Distress Syndrome (NRDS)

Surfactant deficiency · CPAP · Calfactant/Poractant · Caffeine · INSURE technique

BAPM · BTS · ESPNIC

📋 Features & Management▾

Features

Preterm neonates (inversely proportional to gestational age: nearly universal <28 weeks). Surfactant deficiency → alveolar collapse → ground-glass opacification on CXR → air bronchograms.

Tachypnoea, recession, grunting (auto-PEEP), nasal flaring. Onset at birth or within 4h. Antenatal steroids (dexamethasone/betamethasone) dramatically reduce severity.

CPAP — First-Line Respiratory Support

nCPAP 5–8 cmH₂O (Infant Flow or NCPAP). Maintains lung volume. FiO₂ titrated to SpO₂ 91–95% (<34 weeks) or 93–97% (>34 weeks).

CPAP reduces need for intubation and surfactant in mild-moderate NRDS. Continue CPAP after surfactant (INSURE technique).

Surfactant Therapy

Poractant alfa (Curosurf): 100–200 mg/kg IT via ET tube. Second dose 100 mg/kg if still intubated and FiO₂ >0.3 after 6–12h.

INSURE technique: INtubate-SURfactant-Extubate — brief intubation for surfactant, then immediate extubation to CPAP. Reduces ventilator-associated lung injury.

LISA (Less Invasive Surfactant Administration): surfactant via thin catheter while baby breathes on CPAP — preferred in experienced centres.

Caffeine

Caffeine citrate loading: 20 mg/kg IV/oral → maintenance 5–10 mg/kg OD. All preterm <34 weeks. Reduces apnoea, BPD, cerebral palsy, improves survival. Continue until 34+ weeks.

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Necrotising Enterocolitis (NEC)

Bell staging · Pneumatosis intestinalis · NBM · Pip-tazo + metro · Surgery for perforation

BAPM · BAPS · ESPGHAN

📋 Bell Staging & Management▾

Bell Staging (Modified)

Stage I (Suspected): Temperature instability, apnoea, abdominal distension, blood in stool. Normal/non-specific X-ray. Treat as NEC.

Stage II (Proven): Above + absent bowel sounds, tenderness. Pneumatosis intestinalis (intramural gas — pathognomonic) or portal venous gas on X-ray.

Stage III (Advanced): Stage II + shock, DIC, peritonitis. Free air on X-ray = perforation = surgery.

Medical Management (Stages I–II)

NBM: Stop all enteral feeds immediately. NG tube free drainage. IV nutrition (TPN) via central line.

Antibiotics: Pip-tazo 90 mg/kg q8h IV + metronidazole 15 mg/kg q12h IV. Duration 7–14 days. Discuss with microbiology.

Supportive: IV fluids, vasopressors if shocked, treat DIC (FFP, platelet transfusion). Serial abdominal X-rays 6–12h. Bloods 12-hourly.

Surgical Management (Stage III / Perforation)

Absolute indications: free air (perforation), clinical deterioration despite medical management, palpable abdominal mass.

Options: laparotomy + resection of necrotic bowel + stoma formation. Or peritoneal drainage (VLBW unstable neonates) as bridge to definitive surgery.

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Haemolytic Disease of the Newborn

Rh incompatibility · Anti-D · IVIg · Phototherapy · Exchange transfusion

NICE NG25 · BCSH · RCOG

📋 Pathophysiology & Management▾

Types & Causes

Rh incompatibility (anti-D): Rh-negative mother, Rh-positive baby. Sensitisation in previous pregnancy. Increasingly prevented by anti-D prophylaxis

ABO incompatibility: O mother + A or B baby. Milder than Rh. Most common cause of significant neonatal jaundice in UK

Other red cell antibodies: anti-Kell, anti-c, anti-E — may cause severe disease

Features: early jaundice (<24h), anaemia, hydrops fetalis (severe — ascites, pleural/pericardial effusions, oedema)

Prevention

Anti-D immunoglobulin 1500 IU IM to Rh-negative mother at 28 weeks, 34 weeks, and within 72h of delivery, sensitising event (amniocentesis, antepartum haemorrhage, miscarriage)

Kleihauer test: quantifies feto-maternal haemorrhage — guides anti-D dose post-delivery

Neonatal Treatment

Intensive phototherapy for hyperbilirubinaemia (per NICE NG98 bilirubin thresholds — lower in haemolytic disease)

IVIg 500 mg/kg IV over 2–4h: reduces haemolysis and exchange transfusion requirement. Give if SBR rising despite phototherapy

Exchange transfusion: double-volume (160–180 mL/kg) via UVC. Use crossmatched blood (irradiated, CMV-negative). Removes antibodies + bilirubin + sensitised RBCs

Top-up transfusion: for progressive anaemia after acute phase. Intrauterine transfusion for severe cases (diagnosed antenatally)

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Neonatal Abstinence Syndrome (NAS)

Finnegan score · Morphine / methadone weaning · Supportive care · Non-pharmacological first

BAPM 2020 · AAP 2012 · NICE

📋 Recognition, Scoring & Management▾

Background & Timing

Occurs in neonates born to mothers dependent on opioids (prescribed or illicit), benzodiazepines, SSRIs, alcohol, stimulants.

Onset timing: Heroin/short-acting opioids: 24–48h. Methadone: 36–72h (may be up to 5 days). SSRIs: 24–48h. Benzodiazepines: up to 5–7 days.

Symptoms: high-pitched cry, irritability, poor feeding, vomiting, diarrhoea, hypertonicity, tremors, sweating, sneezing, yawning, seizures (severe).

Finnegan Neonatal Abstinence Score (Modified)

Score 21 items across: CNS (crying, sleep, Moro, tremors, tone, seizures), metabolic (fever, sweating, yawning, sneezing, nasal stuffiness), GI (poor feeding, regurgitation, loose stools), skin (excoriation).

Score every 3–4h for first 5 days. Score <8: no treatment. Score 8–12: increase non-pharmacological. Score >12 or ≥8 on 3 consecutive scores: pharmacological treatment.

Non-Pharmacological (Always First-Line)

Rooming-in with mother (reduces pharmacological treatment need by 50%). Skin-to-skin contact. Swaddling. Low stimulation environment (dim lights, minimal noise).

Breastfeeding encouraged if mother on stable methadone/buprenorphine and no other contraindication (HIV, illicit drug use). Small frequent feeds.

Pharmacological Treatment

Morphine oral solution 0.04–0.08 mg/kg per dose q3–4h — first-line for opioid NAS. Dose titrated to Finnegan score. BAPM 2020.

Increase dose by 10% if scores remain high. Wean by 10% every 24–48h once scores consistently <8 for 48h.

Methadone alternative: 0.05–0.1 mg/kg q12h — longer half-life, easier weaning schedule for methadone-exposed infants.

Adjunct (non-opioid NAS or refractory): Phenobarbitone 5–8 mg/kg/day divided BD. Clonidine 0.5–1 mcg/kg q4–8h (monitor BP/HR).

Monitoring & Discharge

Monitor minimum 5–7 days for opioid NAS (longer for methadone). NAS seizures: phenobarbitone loading 20 mg/kg IV. Hypoglycaemia monitoring (glucose every 4–6h).

Safeguarding assessment mandatory. MDT: neonatology, midwifery, social care, drug liaison team. Written weaning plan on discharge.

🌀

Intussusception

Peak 6–18 months · Redcurrant jelly stools · USS diagnosis · Air enema reduction · Surgery if failed

BAPS · RCR · RCPCH

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Classic triad (colicky pain + vomiting + redcurrant jelly stools) present in only 40%. High index of suspicion in any infant with paroxysmal screaming, pale episodes, or unexplained altered consciousness. USS is diagnostic.

📋 Features, Diagnosis & Management▾

Clinical Features

Peak age 6–18 months (80%). Ileocolic junction most common. Paroxysmal colicky abdominal pain → infant draws knees up, becomes pale and lethargic between episodes.

Vomiting (initially non-bilious, then bilious as obstruction worsens). Redcurrant jelly stool (blood + mucus) — late sign. Sausage-shaped abdominal mass (right upper quadrant → right lower quadrant).

Late: abdominal distension, peritonitis, shock. Pathological lead point (<2y rare, >5y consider — Meckel's, polyp, lymphoma).

Diagnosis

USS: "Doughnut" or "target" sign (concentric rings of bowel). Sensitivity 98%, specificity 88%. First-line investigation.

AXR: dilated small bowel loops, absent right iliac fossa gas pattern, soft tissue mass. Useful if USS unavailable or perforation suspected (free air).

Management

IV access. IV fluids. Analgesia (morphine 0.1 mg/kg IV). NBM. NG tube if vomiting/distended. Blood crossmatch.

Air enema reduction (radiological): Success rate 70–90% in uncomplicated cases. Done under fluoroscopy or USS guidance. Risks: perforation (1–3%). Sedation required. Paediatric surgeon must be available immediately.

Contraindications to air enema: Peritonitis, perforation (free air on AXR), haemodynamic instability, long symptom duration (>48h relative).

Surgery: Failed enema, perforation, peritonitis, or suspected pathological lead point. Laparoscopic or open reduction ± resection if ischaemic bowel.

🤮

Hypertrophic Pyloric Stenosis

3–6 weeks · Non-bilious projectile vomiting · Hypochloraemic alkalosis · Ramstedt's pyloromyotomy

BAPS · RCPCH

ℹ

Pyloric stenosis is NOT a surgical emergency — correct the electrolyte abnormality FIRST. Operating on an uncorrected hypochloraemic alkalosis = anaesthetic risk. Target: Na >130, K >3.0, HCO₃ <30, Cl >90 before theatre.

📋 Diagnosis & Management▾

Clinical Features

Age 3–6 weeks (range 2–8 weeks). Male:Female 4:1. First-born male. Positive family history (maternal > paternal). Increasing frequency in UK.

Non-bilious projectile vomiting after feeds — force may increase. Hungry infant who wants to feed immediately after vomiting. Progressive weight loss, dehydration.

Olive-shaped mass palpable in right upper quadrant in 50–80% (best after vomiting, in relaxed, warm infant). Visible peristaltic waves across abdomen.

Metabolic Derangement

Hypochloraemic hypokalaemic metabolic alkalosis — from repeated vomiting of HCl. Serum Cl⁻ ↓, K⁺ ↓, Na⁺ ↓, pH ↑, HCO₃ ↑.

Paradoxical aciduria: despite alkalosis, kidney excretes acid urine to conserve Na⁺ (H⁺ secreted instead of K⁺).

Diagnosis

USS: Pyloric muscle thickness >4 mm, pyloric channel length >17 mm. Sensitivity >95%. First-line.

Barium meal (historical) — "string sign" on contrast. Only if USS equivocal.

Pre-operative Resuscitation

0.9% NaCl + KCl (20–40 mmol/L) IV. Do NOT use dextrose alone. Correct electrolytes before surgery — may take 24–48h.

Target before GA: Na⁺ >130, K⁺ >3.0, HCO₃⁻ <30, Cl⁻ >90 mmol/L. NG tube free drainage.

Surgery — Ramstedt's Pyloromyotomy

Laparoscopic (preferred) or open. Longitudinal incision through pyloric muscle down to mucosa — preserving mucosa integrity. Cure rate >99%.

Feed 4–6h post-op. Minor vomiting normal for 24–48h. Discharge 24–48h post-surgery.

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Meckel's Diverticulum

Rule of 2s · Painless rectal bleeding · Tc-99m pertechnetate scan · Laparoscopic resection

BAPS · RCPCH

📋 Rule of 2s, Features & Management▾

Rule of 2s

Clinical Presentations

Painless rectal bleeding (most common in children): Bright red or dark red blood PR. Gastric mucosa in diverticulum → acid → ulceration → bleeding. May be massive.

Obstruction: Intussusception (Meckel's as lead point), volvulus around fibrous band.

Meckel's diverticulitis: Clinically identical to appendicitis. Consider if laparoscopy negative appendix.

Diagnosis

Tc-99m pertechnetate (Meckel's) scan: 85% sensitivity for gastric mucosa. False negative if no gastric mucosa. Best in children.

Capsule endoscopy / CT angiography (active bleeding). Laparoscopy (diagnostic + therapeutic). USS may show.

Management

Active bleeding: IV access, crossmatch, transfuse. Stabilise. Then Meckel's scan or laparoscopy.

Surgery: Laparoscopic diverticulectomy or small bowel resection (if wide base or palpable ectopic tissue). Symptomatic Meckel's always resected. Incidental finding: resect if ectopic mucosa suspected or in child <2y.

📍

Paediatric Appendicitis

PAS score · USS / MRI preferred · Co-amoxiclav · Laparoscopic appendicectomy

BAPS · NICE · RCPCH

📋 PAS Score & Management▾

Paediatric Appendicitis Score (PAS)

≤3: Low risk — discharge with advice. 4–6: Intermediate — observe 24h ± USS. ≥7: High risk — surgical review ± imaging.

Clinical Features

Pain: periumbilical → RIF (classical migration). Anorexia. Vomiting. Fever (usually low-grade initially).

RIF tenderness, guarding. Rovsing's sign, psoas sign. Young children: atypical presentation common — peritonitis occurs earlier (thin omentum).

Perforated appendicitis: diffuse peritonitis, high fever, very unwell. More common in children (<24h history to perforation in young children).

Investigations

FBC (WBC/neutrophilia), CRP, CXR (exclude pneumonia mimicking appendicitis). Urine dipstick (sterile pyuria in 20% appendicitis — don't be misled).

USS first-line imaging (avoids radiation): inflamed appendix >6mm, non-compressible, periappendiceal fat stranding. Sensitivity 70–94% (operator dependent).

MRI if USS non-diagnostic and high clinical suspicion (no radiation). CT if MRI unavailable and clinical urgency.

Management

IV access. Analgesia early (does NOT mask signs — evidence clear). NBM. IV fluids. Co-amoxiclav 30 mg/kg q8h IV (or single pre-op dose in uncomplicated).

Laparoscopic appendicectomy: gold standard. Safe in children. Perforated: thorough peritoneal lavage. Post-op antibiotics × 3–5 days if perforated.

Non-operative management (antibiotics alone): emerging evidence in uncomplicated appendicitis. High recurrence rate (30–40% at 5y). Surgical decision-making.

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Testicular Torsion

Surgical emergency · 6-hour viability window · Absent cremasteric reflex · Manual detorsion · Orchidopexy

BAUS · EAU · RCPCH

🚨

Testicular torsion is a surgical emergency. Viability: >95% if operated within 6h, ~50% at 12h, <10% at 24h. Do NOT wait for USS if clinical suspicion is high. Normal USS does NOT exclude torsion if clinically suspected — go directly to theatre.

📋 Recognition & Management▾

Clinical Features

Bimodal: neonates (extravaginal torsion at birth) and puberty (peak 12–18 years, intravaginal torsion — bell-clapper deformity).

Sudden onset severe unilateral scrotal pain. Nausea and vomiting. High-riding testis. Transverse lie (horizontal lie — pathognomonic).

Absent cremasteric reflex: most reliable sign (sensitivity 99%) — stroking inner thigh should elevate testis. Absent in torsion.

Differential: epididymo-orchitis (gradual, urinary symptoms, tender epididymis), torted hydatid of Morgagni (blue dot sign — tender nodule at upper pole), hernia, trauma, tumour.

Investigation

Colour Doppler USS: Absent or reduced blood flow — sensitivity 88–100%. Do NOT delay surgery if clinical diagnosis clear. Normal USS does NOT exclude torsion.

Send routine bloods + group and save. Analgesia: morphine 0.1 mg/kg IV. NBM immediately.

Management

Immediate urology/paediatric surgery referral. Mark scrotum side. NBM. IV access.

Manual detorsion ("open book"): Rotate testis outward (lateral) — as opening a book. Medial torsion is most common (twist inward). Relief of pain confirms success. Temporary only — surgery still required.

Surgical exploration: Scrotal incision. Detorsion and assess viability. Viable → orchidopexy (3-point fixation to tunica vaginalis). Infarcted → orchidectomy. Contralateral orchidopexy always performed.

🔋

Foreign Body Ingestion

Button battery = emergency (<2h) · Coin · Magnets · Oesophageal vs gastric · Endoscopy criteria

BSG · ESPGHAN · BAPS 2021

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BUTTON BATTERY in oesophagus = endoscopic emergency within 2 hours. Liquefactive necrosis begins in <2h. Honey 10 mL q10 min (if >1y, alert, no airway compromise) while arranging emergency endoscopy — reduces mucosal injury.

📋 Assessment by Object Type▾

Button Battery (Lithium 20mm disc)

Oesophagus: Emergency endoscopy within 2h regardless of symptoms. Double ring sign on X-ray (distinguishes from coin). Honey 10 mL q10 min if >1 year old, alert, no respiratory compromise.

Stomach/beyond (asymptomatic): If >20 mm AND <5 years → remove. If <20 mm or >5 years → observe, repeat AXR in 4 days if not passed. Remove if symptomatic at any point.

Post-removal: oesophageal injury common. NGT, PPI (omeprazole 1 mg/kg OD), barium swallow at 3–4 weeks.

Coins & Blunt Objects

Oesophagus: Symptoms (drooling, dysphagia, vomiting) → endoscopy within 24h. Asymptomatic → endoscopy within 24h if upper oesophagus, can await 24h if lower.

Stomach/beyond: Most pass spontaneously. Coins <23 mm usually pass within 4–6 weeks. Observe, repeat AXR in 4 weeks. No dietary restriction needed.

Endoscopy required: persistent oesophageal location >24h, sharp objects anywhere in GI tract, symptomatic at any location.

Multiple Magnets / Magnet + Metal Object

Two or more magnets, or magnet + metal: Can attract across bowel loops → pressure necrosis, perforation, fistula. Remove urgently regardless of location.

Single magnet: usually safe to observe if asymptomatic and in stomach/bowel. AXR to confirm passage.

Sharp Objects (Needles, Pins, Bones)

Oesophagus: remove immediately. Stomach: remove within 24h (perforation risk in pylorus/duodenum). Beyond pylorus: 70–75% pass safely. Daily AXR. Remove if not progressing or symptomatic.

Symptoms at any stage → endoscopy/surgery immediately: Abdominal pain, fever, haematemesis, melaena, haemodynamic compromise.

Radiology

PA + lateral CXR (oesophageal vs tracheal), AXR. Button battery: double ring/halo sign on AP, step-off sign on lateral. Urgent if symptomatic. CT if perforation suspected.

🛡️

Non-Accidental Injury (NAI) & Child Safeguarding

NICE NG76 · Recognition · Section 47 · Skeletal survey · Documentation

NICE NG76 2017 · Working Together 2023 · HM Government

🚨

Safeguarding is everyone's responsibility. Any clinician can — and must — refer to children's social care if they have concerns. You do not need parental consent to refer. If a child is in immediate danger, call police (999) immediately.

📋 Recognition & Red Flags▾

Features Raising Concern (NICE NG76)

Bruising: in non-mobile child (bruising before cruising), unusual sites (ears, neck, buttocks, back, face), shape of implement, multiple/different stages

Burns: contact burns with clear margins (cigarette, iron), immersion scalds (stockings/glove distribution), bilateral or symmetric

Fractures: in non-mobile infant, posterior rib fractures (highly specific for NAI), metaphyseal/corner fractures, multiple or different ages, spiral fractures in non-ambulant child

Head injury: subdural haematoma + retinal haemorrhages + encephalopathy = classic triad of abusive head trauma (shaken baby syndrome)

Behaviour: inconsistent history, delay in presentation, mechanism doesn't match injury, child discloses abuse, parental behaviour concerning

Action — Safeguarding Referral Process

Document everything: exact words used, body map, photography of injuries (with consent where possible), measurements. Time and date all entries

Consult designated/named safeguarding doctor immediately. Do NOT confront parents

Refer to Children's Social Care (Section 47 referral): if reasonable cause to suspect significant harm. Can be done without parental consent

Police: if immediate risk of serious harm or criminal offence. Joint agency response (MASH — Multi-Agency Safeguarding Hub)

Skeletal survey: all children <2 years with suspected physical abuse. Repeat films at 11–14 days (detects healing fractures). +CT head ± MRI

🔥

Paediatric Burns

Lund-Browder chart · Modified Parkland formula · Referral criteria · Airway

NBCN 2023 · NICE · BAPRAS

📋 Assessment & Fluid Resuscitation▾

%TBSA Assessment — Lund-Browder (Children — differs from adults)

Head/neck: much larger proportion in infants (18% at birth → 9% by age 15)

Each leg: smaller in infants. Use Lund-Browder chart (age-adjusted) NOT rule of 9s

Palmar surface of patient's hand (including fingers) = approximately 1% TBSA — useful for irregular burns

Fluid Resuscitation (if %TBSA ≥10% in children)

Modified Parkland formula: 3–4 mL × kg × %TBSA (Hartmann's) in first 24h

Half in first 8h from time of burn (not from time of arrival). Remaining half over next 16h

+ Maintenance fluid added on top (paediatric): Hartmann's or 0.9% NaCl + 5% dextrose at Holiday-Segar rate

Monitor: urine output target 1 mL/kg/h (children, cf 0.5 mL/kg/h adults). Titrate fluids accordingly

Referral Criteria to Burns Centre (NBCN 2023)

>5% TBSA full thickness. >10% TBSA partial thickness. Burns to face, hands, feet, genitalia, perineum, major joints

Chemical/electrical burns. Inhalation injury. Circumferential burns. NAI suspected. Child <1 year

Inhalation injury: carbonaceous sputum, hoarse voice, facial burns, singed eyebrows/nasal hair, stridor → intubate early before oedema develops

🧠

Paediatric Head Injury (NICE NG176)

CT criteria under 1yr vs 1–16yr · CHALICE · PECARN · GCS · NAI

NICE NG176 2023

📋 CT Criteria (NICE NG176)▾

Immediate CT Head — Children Under 1 Year

GCS <14 on ED assessment. Suspicion of NAI. Post-traumatic seizure (no prior epilepsy)

Bulging fontanelle. Suspected skull fracture. Focal neurological deficit. Bruising/swelling/laceration >5 cm on head

Immediate CT Head — Children 1–16 Years

GCS <14 on ED assessment, or GCS 14 at 2h post-injury

Suspected open, depressed or basal skull fracture (periorbital haematoma, Battle's sign, haemotympanum, CSF leak)

Focal neurological deficit. Post-traumatic seizure (no prior epilepsy). LOC >5 min

Amnesia (>5 min). Abnormal drowsiness. Three or more discrete vomiting episodes. Dangerous mechanism (pedestrian, cyclist, fall >3m)

Observe for 4 Hours if No CT Criteria

Any LOC, amnesia, confusion, abnormal drowsiness, headache, vomiting (1–2 episodes) → observe 4h → discharge if improved

No concerning features: can discharge with head injury advice leaflet if reliable carer, safe to return

Paediatric GCS (Modification for Infants)

Eye opening: same as adults (1–4). Motor: same (1–6). Verbal: modified — <2 years: 5=coos/babbles, 4=irritable/cries, 3=cries to pain, 2=moans, 1=none

Always consider NAI: inconsistent history, delayed presentation, unusual injury pattern, multiple injuries at different stages

🦴

Paediatric Fractures

Salter-Harris · Toddler's fracture · Greenstick · Physeal injuries · Torus fracture

BOAST · BOA · RCPCH

📋 Fracture Patterns & Management▾

Fracture Types Unique to Children

Greenstick: incomplete fracture — cortex broken on tension side, intact on compression side. Treat with plaster ± manipulation

Torus (buckle) fracture: cortex buckles without complete break. Stable. Soft splint/wrist splint only. No manipulation needed. WBCTF trial: same outcomes with soft bandage as rigid cast

Toddler's fracture: undisplaced spiral fracture of distal tibia in ambulant child 9 months–3 years. Normal X-ray often. Bone scan/MRI if suspected. Above-knee POP 3 weeks

Plastic deformation: bone bends without fracture. Common in forearm. May need manipulation under GA

Salter-Harris Classification (Physeal/Growth Plate Fractures)

Type I: through physis only. X-ray may appear normal. Treat symptomatically

Type II: through physis + metaphysis (most common — 75%). Conservative if undisplaced

Type III: through physis + epiphysis. Intra-articular. May need ORIF

Type IV: through metaphysis + physis + epiphysis. Intra-articular. Usually requires ORIF

Type V: crush injury of physis. May appear normal acutely. Growth disturbance risk high

Mnemonic: SALTR — Same, Above, Lower, Through, Rammed (crushed)

NAI Alert Fractures

Posterior rib fractures (highly specific for squeezing/shaking). Metaphyseal corner fractures ("bucket-handle"). Multiple fractures at different stages. Spiral fractures in non-ambulant infants. Any fracture unexplained or inconsistent history

🌊

Paediatric Drowning & Choking

RCUK 2021 · 5 rescue breaths first · Cold water neuroprotection · Age-specific choking

RCUK 2021 · ILCOR

📋 Drowning & Choking Algorithms▾

Drowning — Paediatric Specific Points

5 rescue breaths first (as all paediatric arrest) before chest compressions — hypoxic arrest priority

Cold water drowning: "not dead until warm and dead." K⁺ <12 mmol/L = resuscitation should continue. Prolonged APLS/resuscitation warranted

C-spine: immobilise only if diving, watercraft injury, or clinical concern — routine immobilisation not recommended (RCUK 2021 revision)

Rewarming: warm IV fluids 39°C, warm humidified O₂, warm environment, bladder irrigation. ECMO in severe hypothermia

Choking — Infant (<1 year)

Mild obstruction: allow coughing. Do not intervene

Severe obstruction: face-down over forearm, head lower than chest. 5 back blows (heel of hand between shoulder blades)

Turn face-up on forearm. 5 chest thrusts (2 fingers on lower sternum, 1 finger-breadth below nipple line). NOT abdominal thrusts (liver injury risk)

Unconscious infant: start CPR (15:2). Look in mouth before each breath — only remove visible object

Choking — Child (>1 year)

Mild: encourage coughing. Severe: 5 back blows (lean forward, heel of hand between shoulder blades)

5 abdominal thrusts (Heimlich): stand behind, fist above umbilicus below xiphisternum, pull inward and upward. Scale force appropriately to child's size

Alternate 5+5. Call 999/crash team. If unconscious: CPR 15:2. Look in mouth each cycle

Advanced in ED: direct laryngoscopy + Magill forceps. RSI + fibreoptic if beyond cords. Surgical airway if complete obstruction

🫂

Self-Harm in Young People

NICE NG225 2022 · CAMHS · Psychosocial assessment · Risk assessment · MHA

NICE NG225 2022 · RCPCH

ℹ

Every young person who presents with self-harm deserves a compassionate, non-judgmental psychosocial assessment. Self-harm is a signal of distress, not attention-seeking. Avoid conveying this attitude. All under-18s with self-harm must be seen by CAMHS before discharge.

📋 Assessment & Management▾

Immediate Medical Management

Treat physical injuries first. Paracetamol OD: 4-hour serum paracetamol level. N-acetylcysteine if above treatment line (Rumack-Matthew nomogram)

Lacerations: suture or steri-strip. Wound care and tetanus status

Ingestions: activated charcoal if within 1h, alert, airway protected. Identify substance(s). Toxicology advice

Psychosocial Assessment (NICE NG225)

All young people with self-harm must receive psychosocial assessment (not just psychiatric referral)

Assess: intent (was it planned? did they seek help?), method lethality, precipitating factors, mental state, support network, previous self-harm, suicidal ideation

Columbia Suicide Severity Rating Scale (C-SSRS) or equivalent — structured tool. Risk stratify: low/moderate/high

Always involve parents/carers (unless safeguarding concern). Assess family functioning

Disposition & Referral

All under-18s: CAMHS assessment before discharge. Do NOT discharge without mental health assessment

High risk / active suicidal ideation / no safe home environment: admit to paediatric ward under Section 2/3 MHA if needed

Safeguarding: always consider if young person is at risk from others as well as themselves. Refer to social care if needed

Crisis resources on discharge: written safety plan, crisis line numbers (PAPYRUS 0800 068 4141, Samaritans 116 123)

⚖️

Eating Disorders & Medical Compromise

NICE NG69 · Medical compromise criteria · Refeeding syndrome · MARSIPAN · CAMHS

NICE NG69 2017 · MARSIPAN 2022 · Royal Colleges

📋 Medical Compromise & Management▾

Junior MARSIPAN — Medical Criteria for Admission (Children)

HR <40 bpm. BP <80/50 mmHg. SpO₂ <94%. Syncopal episodes. BMI <13 or >25% weight loss

Muscle weakness: unable to stand from squat without arm support (squat test). Electrolyte imbalance: K⁺ <3, PO₄ <0.5, Na⁺ <130, Mg <0.6

ECG: prolonged QTc (>450ms), arrhythmias, bradycardia. Hypoglycaemia

Emergency Management

Cardiac monitoring. IV fluids if haemodynamically compromised (cautiously — fluid overload risk in starved heart)

Refeeding syndrome prevention: start calories slowly (5–10 kcal/kg/day). Check and supplement: phosphate, potassium, magnesium, thiamine before refeeding

Thiamine 200 mg IV before any glucose (Wernicke's risk in severe malnutrition)

Nasogastric feeding: under specialist supervision. May require Mental Health Act/Mental Capacity Act in severe cases

Urgent CAMHS + paediatric joint review. Involve family. NICE NG69: family-based therapy is first-line treatment

Refeeding Syndrome — Watch For

Falls in phosphate, potassium, magnesium within 24–72h of starting nutrition → cardiac arrhythmias, respiratory failure, seizures, cardiac failure

Monitor electrolytes BD for first week of refeeding. Replace aggressively. Slow calorie increase if electrolytes fall

⚡

Behavioural Emergency & ADHD Crisis

De-escalation · Safeguarding · CAMHS · Medication · Mental Health Act (children)

NICE NG87 · RCEM · CAMHS

📋 Management▾

De-escalation (Always First-Line)

Calm environment: reduce noise/stimulation, quiet room, one consistent staff member communicating

Neutral, non-threatening body language. Validate feelings. Offer choices where possible. Avoid confrontation

Involve parents/carers — often most effective at calming child. Sensory tools for autism spectrum

Chemical Sedation (Last Resort — After De-escalation Failed)

Oral lorazepam 0.05 mg/kg (max 2 mg) — preferred first oral option if child cooperative

Oral/IM risperidone 0.5–1 mg (≥20 kg) — for psychotic features or known psychiatric history

IM midazolam 0.1–0.15 mg/kg (max 5 mg) — rapid sedation if IV not accessible. Monitor airway

IV/IO ketamine 1–2 mg/kg — for severe, dangerous agitation not responding to above

Avoid haloperidol in young children. All sedation: continuous SpO₂ monitoring, resuscitation equipment available

ADHD Specific

Medication crisis: missed stimulant dose → rebound hyperactivity. Give regular medication if known ADHD

Assess for comorbidities: ODD, conduct disorder, ASD, anxiety, trauma history

Safeguarding: always consider — is the child safe at home? Is this presentation related to neglect or abuse?

Disposition: CAMHS urgent review. Consider emergency MHA assessment if risk to self or others

🎯

Paediatric Pain Assessment & Analgesia

FLACC · Wong-Baker · WHO ladder · Weight-based doses · Intranasal route

NICE NG108 · RCPCH · BNFc

📋 Assessment Tools & Analgesic Ladder▾

Pain Assessment Tools

FLACC scale (0–2 months and non-verbal): Face, Legs, Activity, Cry, Consolability — each 0–2. Total 0–10

Wong-Baker FACES (3–8 years): 6 face drawings from happy (0) to crying (10). Self-reported

NRS (Numeric Rating Scale 0–10): children ≥8 years who can conceptualise numbers

Always reassess 30 min after analgesia given. Document score, drug, dose, route, time

Step 1 — Mild Pain (NRS 1–3)

Paracetamol: 15 mg/kg oral/IV q4–6h (max 60 mg/kg/day, max 4g/day). IV over 15 min

Ibuprofen: 5–10 mg/kg oral q6–8h (max 40 mg/kg/day). With food. Avoid if asthma, renal impairment, dehydrated. >3 months

Step 2 — Moderate Pain (NRS 4–6)

Paracetamol + ibuprofen together (alternate or combine). Evidence supports combination over monotherapy

Codeine: NOT recommended under 12 years (ultrarapid CYP2D6 metabolisers → morphine toxicity). MHRA guidance 2013

Tramadol: avoid under 12 years. >12 years: 1–2 mg/kg oral q4–6h (max 400 mg/day)

Step 3 — Severe Pain (NRS 7–10)

Morphine IV/IO: 0.1 mg/kg (max 5 mg per dose) slowly. Repeat q4h. Titrate to effect. Max 0.4 mg/kg/day

Intranasal diamorphine/fentanyl: fentanyl 1.5 mcg/kg IN (max 100 mcg) — rapid, needleless, effective for acute severe pain. Diamorphine 0.1 mg/kg IN (use atomiser)

Ketamine (sub-dissociative): 0.3–0.5 mg/kg IV over 15 min — adjunct for opioid-refractory pain or procedures

Non-pharmacological: sucrose solution in infants <6 months (2 mL of 24% sucrose during painful procedure). Distraction, play therapy, parental presence

😴

Paediatric Procedural Sedation

RCEM · Ketamine · Midazolam · Nitrous oxide · Monitoring requirements

RCEM 2020 · SIGN · NICE

💊 Drug Options & Monitoring▾

Pre-Sedation Checklist

ASA I–II ideal. Airway assessment. Fasting — RCEM: not mandatory for urgent procedures (balance risk/benefit)

Equipment: monitoring (SpO₂, ETCO₂, ECG, BP), high-flow O₂, suction, BVM, reversal agents, resuscitation trolley

Two trained persons: one for procedure, one dedicated to sedation/monitoring/documentation

Ketamine (Preferred for Paediatric ED Procedural Sedation)

IM: 4–5 mg/kg — onset 5 min, duration 20–40 min. Preferred when IV not feasible

IV: 1–2 mg/kg over 60 seconds — onset 60 seconds, duration 15–20 min. Repeat 0.5 mg/kg boluses

Glycopyrrolate 4 mcg/kg IV — reduces secretions. Midazolam 0.05 mg/kg — reduces emergence phenomena

Advantages: analgesia + sedation, maintains airway, bronchodilator. Widely used for fracture reduction, wound care, LP

Nitrous Oxide (Entonox/Equanox)

50% N₂O/50% O₂ — ideal for brief painful procedures (cannulation, wound care, LP) in cooperative children ≥3 years

Self-administered via mouthpiece or face mask. Onset 2–3 min, offset 5 min. Excellent safety profile

Contraindications: bowel obstruction, pneumothorax, middle ear disease, B₁₂ deficiency, COPD

Midazolam (Anxiolysis)

Oral: 0.3–0.5 mg/kg (max 15 mg) 30 min before procedure — excellent for anxious children for less painful procedures

IV: 0.05–0.1 mg/kg titrated (max 5 mg). Onset 2–5 min

Intranasal: 0.2–0.3 mg/kg (max 10 mg) — useful when IV not available. Onset 5–10 min. Burns nasopharynx

Reversal: flumazenil 0.01 mg/kg IV (max 0.2 mg). Can repeat. Short duration — re-sedation possible

Post-Sedation Monitoring

Continuous until: GCS 15, SpO₂ on room air, stable vital signs. Minimum 30–60 min post-ketamine

Discharge criteria: awake and alert, eating/drinking tolerated, safe discharge to responsible adult, written instructions

Age	HR (bpm)	RR (/min)	SBP (mmHg)	Weight (kg)
Neonate (<1m)	100–160	30–60	60–90	3–4
Infant (1–12m)	100–160	25–50	70–100	4–10
Toddler (1–2y)	90–150	20–40	80–105	10–14
Pre-school (3–5y)	80–140	20–30	80–110	14–20
School (6–12y)	70–120	15–25	90–120	20–45
Adolescent (>12y)	60–100	12–20	100–135	45–70+

Paediatric Emergency Tool

Newborn Resuscitation (NLS 2021)

Newborn Cardiac Arrest

Paediatric Cardiac Arrest (APLS 2023)

Paediatric Tachyarrhythmias

Haemodynamically Unstable

Narrow Complex (SVT)

Broad Complex Tachycardia

Hypovolaemic Shock in Children

Compensated Shock

Decompensated Shock

Duct-Dependent Congenital Heart Disease

Paediatric Asthma

Mild

Moderate

Severe

Life-Threatening

Bronchiolitis (RSV)

Croup (Laryngotracheobronchitis)

Epiglottitis

Bacterial Tracheitis

Laryngomalacia

Paediatric Pneumonia (BTS 2022)

Paediatric Pneumothorax

Foreign Body Aspiration

Febrile Convulsions

Simple (85%)

Complex (15%)

Paediatric Status Epilepticus

Raised Intracranial Pressure in Children

Meningitis & Meningococcal Disease

Headache Red Flags in Children

Paediatric Sepsis (NICE NG51)

Kawasaki Disease

Scarlet Fever

Measles

Chickenpox (Varicella-Zoster)

Hand, Foot & Mouth Disease

UTI in Children (NICE NG224)

Septic Arthritis & Osteomyelitis

Paediatric DKA (BSPED 2021)

Mild (pH 7.2–7.29)

Moderate (pH 7.1–7.19)

Severe (pH <7.1)

Dehydration & Oral Rehydration Therapy

Paediatric Anaphylaxis

Paediatric Hypoglycaemia

Adrenal Crisis & Congenital Adrenal Hyperplasia

Paediatric Hypertensive Emergency

Paediatric Hyperosmolar Hyperglycaemic State (HHS)

Sickle Cell Crisis in Children

Neonatal Jaundice (NICE NG98)

Neonatal Sepsis (EOS & LOS)

Neonatal Seizures

Neonatal Hypoglycaemia

Neonatal Respiratory Distress Syndrome (NRDS)

Necrotising Enterocolitis (NEC)

Haemolytic Disease of the Newborn

Neonatal Abstinence Syndrome (NAS)

Intussusception

Hypertrophic Pyloric Stenosis

Meckel's Diverticulum

Paediatric Appendicitis

Testicular Torsion

Foreign Body Ingestion

Non-Accidental Injury (NAI) & Child Safeguarding

Paediatric Burns

Paediatric Head Injury (NICE NG176)

Paediatric Fractures

Paediatric Drowning & Choking

Self-Harm in Young People

Eating Disorders & Medical Compromise

Behavioural Emergency & ADHD Crisis

Paediatric Pain Assessment & Analgesia

Paediatric Procedural Sedation