Doses of Emergency Drugs

Pediatrics
by Medscape, Micromedex, & BNF
Ameer Saadallah M.B.Ch.B.
1st edition
10-1-2018
Download the latest version of this PDF through (all capital letters): WWW.GOO.GL/AHJMFK

Table of Contents
Table of Contents .........................................................................................................1
General dosing info .......................................................................................................3
Analgesics: ...................................................................................................................4
Acetaminophen: .......................................................................................................4
Ibuprofen: ................................................................................................................4
Diclofenac: ...............................................................................................................4
Tramadol:.................................................................................................................4
Pethidine:.................................................................................................................4
Morphine: ................................................................................................................5
Antiemetic & Spasmolytic: .............................................................................................6
Ondansetron (Devomit): ............................................................................................6
Hyoscine butylbromide (Buscopan): ............................................................................6
Antimicrobials: .............................................................................................................7
Amoxicillin:...............................................................................................................7
Ceftriaxon: ...............................................................................................................7
Cefotaxime (Claforan): ...............................................................................................7
Ceftazidime: .............................................................................................................7
Vancomycin: .............................................................................................................7
Meropenem: ............................................................................................................8
Acyclovir (Zovirax): ....................................................................................................8
Metronidazole: .........................................................................................................9
Diloxanide furoate, or paromomycin: ..........................................................................9
Trimethoprim/Sulfamethoxazole ................................................................................9
Azithromycin: ...........................................................................................................9
Gentamicin: .............................................................................................................9
Amikacin: .................................................................................................................9
Steroids: .................................................................................................................... 11
Hydrocortisone: ...................................................................................................... 11
Prednisone: oral solution, tablet ............................................................................... 11
 Methylprednisolone: ............................................................................................... 11
Dexamethasone: ..................................................................................................... 11
Bronchodilators: ......................................................................................................... 12
Salbutamol (Ventoline): ........................................................................................... 12
Ipratropium bromide (Atrovent) ............................................................................... 12
Epinephrine racemic ................................................................................................ 13
Manage like an expert: ................................................................................................ 14
Anaphylactic shock (Adults and Pediatrics): ................................................................ 14
Status Asthmaticus (Adults and Pediatrics): ................................................................ 16
Status Epilepticus (Adults and Pediatrics): .................................................................. 18
Pediatric Febrile Seizures: ........................................................................................ 20
Pediatric DKA: ......................................................................................................... 21
Cardiac arrest: ........................................................................................................ 22
Pediatric Urinary Tract Infection: .............................................................................. 22
Pediatric Pyelonephritis: .......................................................................................... 24
Pediatric Pneumonia: .............................................................................................. 24
Bronchiolitis: .......................................................................................................... 25
Acute Bronchitis: ..................................................................................................... 26
Tonsillitis and Pharyngitis Empiric Therapy: ................................................................ 26
Croup:.................................................................................................................... 27
Epiglottitis: ............................................................................................................. 28
Pediatric Gastroenteritis: ......................................................................................... 29
Bacterial Meningitis (adults and pediatrics): ............................................................... 31
 General dosing info BNF
Dose calculation:
 Many children’s doses are standardised by weight; occasionally, the doses have been
standardised by body surface area (in m2).
 For most drugs, the adult maximum dose should not be exceeded.
 Calculation by body-weight in the overweight child may result in much higher doses being
administered than necessary; in such cases, dose should be calculated from an ideal
weight, related to height and age.

Dose frequency:
 Antibacterials are generally given at regular intervals throughout the day. Some flexibility
should be allowed in children to avoid waking them during the night. For example, the
night-time dose may be given at the child’s bedtime.
 Where new or potentially toxic drugs are used, the manufacturers’ recommended doses
should be carefully followed.

Rote:
 Whenever possible, intramuscular injections should be avoided in children because they
are painful.
 When a prescription for a liquid oral preparation is written and the dose ordered is smaller
than 5mL an oral syringe will be supplied.
 Parents should be advised not to add any medicines to the infant’s feed, since the drug
may interact with the milk or other liquid in it; moreover the ingested dosage may be
reduced if the child does not drink all the contents.
 Analgesics:
Acetaminophen: Syrup, solution, or suspension, tablet, suppository.
General dosing: 10-15 mg/kg X 4-6
Neonates: 12.5 mg/kg IV X 4
1 month-2 years: 12.5 mg/kg IV X 4
2-12 years: 10-15 mg/kg X 4-6
60 Kg > like adults.

Dose adjustment in severe RF

Dose adjustment in any liver disease
Contraindicated in active liver disease & severe LF.

Onset: 60 minutes in oral route.

Note:
Once IV container is penetrated, use within 6 hours.
Do not administer simultaneously with diazepam (physically incompatible).
Insert suppository well into rectum.

Ibuprofen: tablet, oral suspension

Fever & Pain, 6 months to 12 years:
5-10 mg/kg X 3-4; not to exceed 40 mg/kg/day

Onset: 30-60 minutes

Severe RF: dose should be adjusted.

Severe LF: contraindicated.

Diclofenac:
Safety and efficacy has not been established in pediatrics.

Tramadol:
 Use is contraindicated for all children younger than 12
 Avoid use in 12-18 years who have other risk factors for respiratory depression.
 Use the lowest effective dose for the shortest duration.

Pethidine: PO/IM/SC
 1-1.8 mg/kg every 3-4 hours as needed, individual dose not to exceed 100 mg
 In general, it is not recommended as a first choice, if no other options, limit use in acute
pain to ≤48hr; doses should not exceed 600 mg/24hr
 Oral route is not recommended for treatment of acute or chronic pain

Renal impairment: Contraindicated.

Hepatic impairment: Consider lower initial dose initially.

Onset: rapid
Contraindicated in:
 Significant respiratory depression.
 Acute or severe bronchial asthma in an unmonitored setting or in absence of
resuscitative equipment.
 Known or suspected gastrointestinal obstruction, including paralytic ileus.
 Within 2 weeks of monoamine oxidase inhibitor (MAOI) therapy

Morphine: IV, IM, SC, PO, suppository

Analgesia/Cyanotic Tetralogy of Fallot:
 Neonates (<30 days): 0.3-1.2 mg/kg ÷ 6 IM/SC
 Infants and children (PO solution): 0.2-0.5 mg/kg PO every 4-6 hours as needed
 Infants and children (IM/SC): 0.05-0.2 mg/kg every 2-4 hours as needed, not to exceed
15 mg/dose

Pain:
 Continuous infusion: 0.025-2.6 mg/kg/hr IV; average, 0.06 mg/kg/hr
 Neonates (<30 days): 0.01-0.02 mg/kg/hr by IV infusion
 Postoperative pain: 0.01-0.04 mg/kg/hr by IV infusion
 Sickle-cell disease, cancer: 0.04-0.07 mg/kg/hr by IV infusion

Onset: oral 15-30 min; IV <5 min

Contraindications:
 GI obstruction including paralytic ileus
 Respiratory depression, acute or severe bronchial asthma, upper airway obstruction.
 Within 2 weeks of monoamine oxidase inhibitor (MAOI) therapy
 Injectable formulation: Heart failure due to chronic lung disease, head injuries, brain
tumors, deliriums tremens, seizure disorders, during labor when premature birth
anticipated
 Immediate release tablets/solution: Hypercarbia (In patients who may be susceptible to
intracranial effects of CO2 retention ‘’e.g., those with evidence of increased intracranial
pressure or brain tumors’’, therapy may reduce respiratory drive, and resultant CO2
retention can further increase intracranial pressure)
 Epidural/intrathecal: Upper airway obstruction
 Suppository formulcation: Cardiac arrhythmia, increased intracranial or cerebrospinal
pressure, acute alcoholism, use after biliary tract surgery, surgical anastomosis.

Notes:
 Consider lowest end of dosing range and monitor for side effects in elderly patients and
those with renal or hepatic impairment.
 May cause constipation; consider preventive measures (eg, stool softener, increased
fiber) to reduce potential for constipation, especially in patients with unstable angina
and patients with myocardial infarction
 Use with caution in patients with biliary tract dysfunction, including acute pancreatitis; use
may cause constriction of sphincter of Oddi diminishing biliary and pancreatic secretion
  Therapy may cause severe hypotension including orthostatic hypotension and syncope
in ambulatory patients
Antiemetic & Spasmolytic:

Ondansetron (Devomit): oral, IV, IM

IV:
0.1 mg/kg to be given over at least 30 seconds, max per dose 4 mg, max per day 32 mg.

Gastroenteritis (orally):
8-15 kg: 2 mg dissolved orally as a single dose.
15-30 kg: 4 mg dissolved orally as a single dose.
More than 30 kg: 8 mg dissolved orally as a single dose.

Severe hepatic impairment: not to exceed 8 mg/day

Hyoscine butylbromide (Buscopan): Oral, IV, IM

Smooth muscle spasm of gastro-intestinal or genito-urinary system (oral):
 Child 6–11 years: 10 mg X 3
 Child 12–17 years: 20 mg X 4

Bowel colic (in palliative care): Oral IV, IM:

 Child 1 month–4 years: 0.3-0.5 mg/kg X 3–4 (max. per dose 5 mg)
 Child 5–11 years: 5–10 mg X 3-4
 Child 12–17 years: 10–20 mg X 3-4

Contraindication: tachycardia
 Antimicrobials:
Amoxicillin:
IV:
Neonate: 30 mg/kg X 2, up to 60 mg/kg X 2
Child: 20–30 mg/kg X 3 up to 60 mg/kg X 3
Child with severe infection: 40–60 mg/kg every 8 hours, max. 1 g X 3

Oral:
Neonate: 30 mg/kg X 3 (max. per dose 125 mg).
1–11 months: 125 mg 3 X 3; up to 30 mg/kg X 3
Child 1–4 years: 250 mg X 3; up to 30 mg/kg X 3
5–11 years: 500 mg X 3; up to 30 mg/kg X 3 (max. per dose 1 g)

Dose adjustment is severe RF.

Note:
For suspension, shake well before use. Discard after 14 days.
If taste is unacceptable, mixed with milk, fruit juice & other drinks. After mixing administer
immediately & completely.
Amoxiclav should not be taken on empty stomach (reduced absorption).

Ceftriaxon: IV, IM
50-100 mg/kg divided into 1-2 doses (Maximum 2g/day)

Cefotaxime (Claforan): IV, IM

50-200 mg/kg/day IV/IM divided into 3-4 doses

Ceftazidime: IV, IM
<1 month: Safety and efficacy not established
1 month-12 years: 90-150 mg/kg IV divided into 3 doses, not to exceed 6 g/day

Vancomycin: IV
15 mg/kg X 3, maximum 2 g per day
Slow IV infusion over 1 hr.
Adjust dose in RF

Notes:
 Avoid rapid infusion because of risk of red man syndrome (flushing, pruritus,
hypotension, erythema, and urticaria).
 Avoid extravasation; necrosis may occur.
 Oral preparations are only indicated for treatment of pseudomembranous colitis; not
effective for systemic infections.
Meropenem: IV
Neonate 1-7 days: 20 mg/kg X 2, increased to 40 mg/kg X 2 in severe infections
Neonate 7- 28 days: 20 mg/kg X 3, increased to 40 mg/kg X 3 in severe infections
Child 1m–11 y (body-weight up to 50 kg): 10–20 mg/kg X 3
Infuse IV over 30 min
Adjust dose in RF

Acyclovir (Zovirax): oral suspension, tablet, capsule, IV

Neonatal Herpes Simplex Virus Infection:
 30 mg/kg/day IV into 3 doses IV for 14-21 days;
 Alternatively, 20 mg/kg X 3 IV for 14-21 days
In obese patients, use ideal body weight

Herpes Simplex Virus Encephalitis

 3 months-12 years: 20 mg/kg X 3 IV for 10 days; up to 14-21 days reported
In obese patients, use ideal body weight
 >12 years: 10-15 mg/kg X 3 IV for 14-21 days

Mucocutaneous Herpes Simplex Virus Infection

 Treatment in immunocompromised patients: <12 years: 10 mg/kg X 3 IV for 7 days
In obese patients, use IBW
 >12 years: 5-10 mg/kg/day IV divided into 3 doses for 5-7 days; up to 14 days reported

Herpes Zoster (Shingles)

 <12 years (immunocompromised): 20 mg/kg X 3 IV for 7 days
In obese patients, use IBW
 >12 years (immunocompetent): 800 mg X 5 PO while awake for 7-10 days
 >12 years (immunocompromised): 10 mg/kg X 3 IV for 7-10 days

Varicella Zoster (Chickenpox)

 ≥2 years and <40 kg: 20 mg/kg X 4 PO for 5 days; not to exceed 800 mg/dose
In obese patients, use IBW
 >40 kg: 800 mg X 4 PO for 5 days
 Immunocompromised patients
o <12 years: 20 mg/kg X 3 IV for 7 days
o >12 years: 10 mg/kg X 3 IV for 7 days

Adjust dose in RF

Notes:
 Maintain adequate hydration during PO or IV therapy
 Avoid rapid infusion because of risk of renal damage
 Use with caution in patients receiving nephrotoxic drugs
Metronidazole: Oral, IV
Anaerobic Infection:
1-2 months: Loading dose 15 mg/kg, followed by 7.5 mg/kg X 3 (after 8 hours), for a total
duration of 7 days.
2 months–17 years: 7.5 mg/kg X 3 (max. per dose 500 mg) usually treated for 7 days.

Amebiasis & amebic liver abscess:

11-17 mg/kg X 3 for 10 days.

Giardiasis:
5 mg/kg X 3 for 7-10 days.

Severe RF: No dose adjustment (although metabolites may accumulate, monitor for SE).
Severe LF: Reduce dose.

Diloxanide furoate, or paromomycin: tablet

Amebiasis: 500 mg X 3 for 10 days after treatment by metronidazole.

Trimethoprim/Sulfamethoxazole TMP/SMX: parenteral, oral suspension, tablet

<2 months: Contraindicated

Mild to Moderate Infections:

 8mg TMP/kg/day PO divided into 4 doses
Serious Infections:
 15-20 mg TMP/kg/day PO divided into 4 doses
 8-12 mg TMP/kg/day IV divided into 2-4 doses.

Contraindicated in:
 Severe RF
 Severe LF
 Megalobalstic anemia or folate deficiency.

Azithromycin: Oral solution, tablet

<6 months: Safety and efficacy not established
10 mg/kg once daily for 3 days (max. per dose 500 mg).
Renal impairment: Use with caution

Gentamicin: IV, IM
Infants: 2.5 mg/kg X 3
Children and adolescents: 2-2.5 mg/kg X 3

Renal impairment: Dose adjusted

Amikacin: IV, IM
5-7.5 mg/kg X 3
Infused over 1-2 hours in infants.
Renal impairment: Dose adjusted
Notes about aminoglycosides (Gentamicin and Amikacin):
 Narrow therapeutic index (not intended for long-term therapy)
 Patients treated with aminoglycosides should be under close clinical observation; high
risk of toxicity associated with their use
 Avoid potent diuretics (eg, ethacrynic acid, furosemide) because they increase risk of
ototoxicity.
 Risk of ototoxicity; tinnitus or vertigo may be indications of vestibular injury and
impending bilateral irreversible damage; discontinue therapy if signs of ototoxicity occur
 Risk of nephrotoxicity; other factors that increase patient risk of ototoxicity include
advanced age and dehydration
 Use caution in patients with hearing and renal impairment.
 Neuromuscular blockade and respiratory paralysis have been reported, especially when
given soon after anesthesia or muscle relaxants; if blockage occurs, calcium salts may
reverse these phenomena, but mechanical respiratory assistance may be necessary
 Steroids:
Hydrocortisone: PO, IV, IM
Inflammation:
Oral: 2.5-10 mg/kg ÷ 3-4.
IV: 1-5 mg/kg ÷ 1-2

Prednisone: oral solution, tablet

Inflammation:
0.5-2 mg/kg PO ÷ 1-2 for 3-10 days; not to exceed 80 mg/day

Acute Asthma:
<12 years: 1-2 mg/kg PO ÷ 1-2 for 3-10 days; not to exceed 80 mg/day
≥12 years: 40-60 mg PO once daily for 3-10 days

Methylprednisolone: Oral, IV, IM

Inflammation:
0.5-1.7 mg/kg ÷ 2

Status Asthmaticus:
<12 years: 1-2 mg/kg IV/IM ÷ 2 until peak expiratory flow is 70% of predicted or personal
best; not to exceed 60 mg/day
>12 years: 40-80 mg IM ÷ 1-2 until peak expiratory flow is 70% of predicted or personal best;
not to exceed 60 mg/day

Dexamethasone: PO, IV, IM

Airway Edema: 0.5-2 mg/kg ÷ 4, starting 24 hours before extubation and continued for 4-6
doses afterward

Croup: 0.6 mg/kg once only; not to exceed 16 mg

Inflammation: 0.08-0.3 mg/kg ÷ 2-4
Meningitis: >6 weeks: 0.6 mg/kg/day ÷ 4 for first 2-4 days of antibiotic therapy, starting 10-
20 minutes before or simultaneously with first antibiotic dose
Cerebral Edema Associated With Brain Tumor: 1-2 mg/kg once; maintenance: 1-1.5 mg/kg ÷
4-6; not to exceed 16 mg/day
 Bronchodilators:
Salbutamol (Ventoline):
Severe bronchospasm:
1-Nebulizer:
 Child 1 month–4 years: 2.5 mg
 Child 5–11 years: 2.5–5 mg
 Adults: 5 mg
 Repeat every 20–30 minutes or when required, give via oxygen driven nebuliser if
available (all ages)
 Calmly breathe through your mouth until no more mist is formed (~5-15 minutes).
 Preparations are either 2.5 mg/2.5 ml (used without dilution), or 0.5 ml of 0.5% solution diluted
with NS to a total of 2.5 ml)
 It can also be given continuously (10-15 mg/h)

2-Metered-dose inhaler with spacer chamber:

 All ages 2-4 puffs, repeated at 15- to 30-minute intervals as needed.
 Each puff is to be inhaled separately, give via large volume spacer (and a close-fitting face
mask in children under 3 years).

Administration:
1-Aerosol metered-dose inhaler:
 Prime inhaler (before first-time use or when inhaler has not been used for >2
weeks): Release 4 test sprays into the air, away from the face
 Shake well before each use
 Breathe out fully through the mouth; place mouthpiece fully into mouth, holding
inhaler in its upright position and close lips around it
 While breathing in deeply and slowly through the mouth, fully depress the top of the
metal canister with your index finger
 Hold your breath for ≤10 sec; before breathing out
 For additional puffs, wait 1 minute, shake inhaler again, and repeat steps listed
above; replace cap after use

2-Powder metered-dose inhaler:

 Does NOT require priming
 Do not use with a spacer or volume holding chamber

Note:
Salbutamol and ipratropium bromide solutions are compatible and can be mixed for nebulisation.

Ipratropium bromide (Atrovent): (Nebulized)

 Child 1 month–11 years: 0.25 mg
 Child 12–17 years: 0.5 mg
 Adults: 0.5 mg
* Dose can be repeated every 20 min for 3 doses, then it can be given X 4-6.
Epinephrine racemic (nebulised solution):
0.4 mg/kg (max. per dose 5 mg) dose to be repeated after 30 minutes if necessary.
Note: it is used when patient is not effectively controlled with corticosteroid treatment
The effects of nebulised adrenaline for the treatment of croup lasts for 2–3 hours.
 Manage like an expert: Medscape

Anaphylactic shock (Adults and Pediatrics): Medscape & BNF

Note: Intramuscular route is important because of peripheral vasoconstriction.
 Prevent further contact with allergen
 Place the patient in the supine position with legs elevated.
 Ensure airway patency
 Oxygen
 Adrenaline (epinephrine): 1:1000 solution SC/IM in anterolateral aspect of the thigh
(vastus lateralis)
 <30 kg: 0.01 mg/kg (0.01 mL/kg)
 ≥30 kg: 0.3-0.5 mg (0.3-0.5 mL)
 Adults: 0.3-0.5 mg (0.3-0.5 mL), not to exceed 0.5 mg (0.5 mL) per injection
*Adrenaline can be repeated every 5-10 minutes as necessary (all ages).

 H1 + H2 blockers:
Allermine (Chlorphenamine): IM/slow IV injection
 Child 1–5 months: 0.25 mg/kg (max. per dose 2.5 mg)
 Child 6 months–5 years: 2.5 mg
 Child 6–11 years: 5 mg
 Child 12–17 years: 10 mg
 Adult: 10 mg
* Allermine can be repeated if necessary; maximum 4 doses per day (all ages).

Zantac (Ranitidine): IM/IV

 Pediatrics: 1 mg/kg X 4
 Adults: 50 mg X 3-4
* Zantac can be repeated if necessary; maximum 4 doses per day (all ages).

 Hydrocortisone: IM/IV in pediatrics, IV in adults

Child 1–5 months: Initially 25 mg 3 times a day
Child 6 months–5 years: Initially 50 mg 3 times a day
Child 6–11 years: Initially 100 mg 3 times a day
Child 12–17 years: Initially 200 mg 3 times a day
*Dose can be adjusted according to response (pediatrics)
 Adults IV: 100–300 mg, to be administered as sodium succinate
*Administer corticosteriods early to prevent a potential late-phase reaction (biphasic anaphylaxis)

 Inhaled Salbutamol (Ventolin): for wheeze and stridor

1-Nebulizer:
 Child 1 month–4 years: 2.5 mg
 Child 5–11 years: 2.5–5 mg
 Child >12 years: 5 mg
 Adults: 5 mg
 Repeat every 20–30 minutes or when required, give via oxygen driven nebuliser if
available (all ages)
 Calmly breathe through your mouth until no more mist is formed (~5-15 minutes).
 Preparations are either 2.5 mg/2.5 ml (used without dilution), or 0.5 ml of 0.5% solution diluted
with NS to a total of 2.5 ml)
 It can also be given continuously (10-15 mg/h)

2-Metered-dose inhaler with spacer chamber:

 All ages 2-4 puffs, repeated at 15- to 30-minute intervals as needed.
 Each puff is to be inhaled separately, give via large volume spacer (and a close-fitting face
mask in children under 3 years).

Blood Pressure Management:

 IV fluids: If hypotension or tachycardia is present, administer a fluid bolus of 20 mg/kg for
children and 1 L for adults.
Depending on response, fluid boluses may be repeated up to a total of 80 m/kg in
pediatrics, and 5 L or more in adults.
 Vasopressors: It is indicated for patients unresponsive to fluid resuscitation:
 Epinephrine (0.1-1 mcg/kg/min IV) should be considered as the initial vasopressor in
children.
 Dopamine (2-20 mcg/kg/min IV) may be used in addition to epinephrine.
 Norepinephrine (0.1-2 mcg/kg/min IV) is a potent vasopressor. It is usually considered
in children unresponsive to epinephrine.
 Glucagon IV: It may help with refractory symptoms in patients who are taking a beta-blocker.
Children:
o Loading: 20-30 mcg/kg (not to exceed a cumulative dose of 1 mg) over 5 minutes
o Maintenance: 5-15 mcg/min.
Adults:
o Loading: 50-150 mcg/kg IV over 1 minute
o Maintenance: 3-5 mg/hr or 50-100 mcg/kg/hr IV

Monitoring:
 Patients with non–life-threatening symptoms may be observed for 4-6 hours after
successful treatment and then discharged.
 Some investigators recommend 24 hours.

Outpatient medications (for 3 days):

The oral forms of antihistamines and corticosteroids that should be continued for a short
time (3 days) following an episode:

 Steroids (e.g. Prednisone):

 Children, a dose of 0.5-1 mg/kg/day in divided doses
 Adults, a dose of 1 mg/kg/day in divided doses
 H1 -blocker antihistamine (e.g. loratadine):
 Children: 5 mg once daily
 Adults: 10 mg once daily
 H2 -blocker antihistamine (e.g. Ranitidine)
 Children: Not recommended
 Adullts: 150 mg X 2
Status Asthmaticus (Adults and Pediatrics):
 Supplemental oxygen; in severe cases mechanical ventilation.
 Inhaled Salbutamol (Ventolin) ± Ipratropium bromide (Atrovent).
Most patients respond within 1 hour of treatment.
 Oral prednisone or intravenous methylprednisolone is suggested in children with asthma
that fails to respond promptly and completely to inhaled beta2-agonists.
Corticosteroid action usually requires at least 4-6 hours to occur
 On discharge: Reduce recurrence by a short course of systemic corticosteroids.

Inhaled Salbutamol (Ventolin):

 Nebulizer:
 Child 1 month–4 years: 2.5 mg
 Child 5–11 years: 2.5–5 mg
 Child >12 years: 5 mg
 Adults: 5 mg
 Repeat every 20–30 minutes or when required, give via oxygen driven nebuliser if available (all ages)
 Calmly breathe through your mouth until no more mist is formed (~5-15 minutes).
 Preparations are either 2.5 mg/2.5 ml (used without dilution), or 0.5 ml of 0.5% solution diluted
with NS to a total of 2.5 ml)
 It can also be given continuously (10-15 mg/h)

 Metered-dose inhaler with spacer chamber:

 All ages 2-4 puffs, repeated at 15- to 30-minute intervals as needed.
 Each puff is to be inhaled separately, give via large volume spacer (and a close-fitting face
mask in children under 3 years).

 IV: Some patients with severe, refractory status asthmaticus may benefit from the
addition of beta-agonists delivered intravenously.

Note: Most patients respond within 1 hour of treatment.

Ipratropium bromide (Atrovent): (Nebulized)

 Child 1 month–11 years: 0.25 mg
 Child 12–17 years: 0.5 mg
 Adults: 0.5 mg
* Dose can be repeated every 20 min for 3 doses, then it can be given X 4-6.
 The maximal effect of inhaled ipratropium occurs 30–60 minutes after use; its duration of
action is 3 to 6 hours and bronchodilation can usually be maintained with treatment 3
times a day.
 It can be synergistic with albuterol or other beta2-agonists when treating severe acute
asthma exacerbations.
 Ipratropium may also be used as an alternative bronchodilator in patients who are unable
to tolerate inhaled beta2-agonists. Because children appear to have more cholinergic
receptors, they are more responsive to parasympathetic stimulation than adults.
Epinephrine:
 Patients whose bronchoconstriction is resistant to continuous nebulizer treatments with
beta2-agonists may be candidates for nonselective beta2-agonists (epinephrine 0.3-0.5 mg
administered subcutaneously. However, systemic therapy has no proven advantage over
aerosol therapy with selective beta2 agents.
 Caution in patients with other complicating factors (eg, congestive heart failure (CHF),
history of cardiac arrhythmia).
Note: Endotracheal adrenaline in patients who are intubated has been associated with
variable success in different studies. However, based on the current literature, no specific
advantage can be gained at this point by using endotracheal adrenaline.[22]

Steroids:
 Hydrocortisone:
Pediatrics: 4 mg/kg X 4 (max. per dose 100 mg) until conversion to oral prednisolone.
Adults: 100 mg X 4 until conversion to oral prednisolone.
 Prednisone: for 3-10 days
Pediatrics: 1-2 mg/kg ÷ 2
Adults: 40-60 mg ÷ 1-2
 Methylprednisolone 1 mg/kg X 4
 Corticosteroid treatment for acute asthma is necessary but has potential adverse effects
like hyperglycemia and hypokalemia. Thus, monitoring of glucose & potassium is essential.
 Corticosteroid onset of action usually requires at least 4-6 hours.

Theophylline or aminophylline:
-Aminophylline: The loading dose is usually 5-6 mg/kg, followed by a continuous infusion of
0.5-0.9 mg/kg/h.
-Theophylline: loading dose is 6mg/kg infused over 20-30 minutes, followed by
maintenance:
 1.5-6 months: 0.5 mg/kg/hr IV or 10 mg/kg/day PO in divided doses
 6-12 months: 0.6-0.7 mg/kg/hr IV or 12-18 mg/kg/day PO in divided doses
 1-9 years: 1 mg/kg/hr IV or 8 mg/kg X 3 PO (extended release)
 9-12 years: 0.8-0.9 mg/kg/hr IV or 6.4 mg/kg X 3 PO (extended release)
 12-16 years: 0.7 mg/kg/hr IV or 5.6 mg/kg X 3 PO (extended release)
 Adults: 1mg/kg/h IV in the emergent setting.
Starting intravenous aminophylline may be reasonable in patients who do not respond to
medical treatment with bronchodilators, oxygen, corticosteroids, and intravenous fluids
within 24 hours.
Data suggest that aminophylline may have an anti-inflammatory effect in addition to its
bronchodilator properties.

Magnesium sulfate
Adults: 1-2.5 g over 20 minutes.
Pediatrics: 25-50 mg/kg IV over 10-20 minutes
Intravenous magnesium sulfate infusion has been advocated in the past for the treatment of
acute asthma. Magnesium can relax smooth muscle and hence may cause bronchodilation
by competing with calcium at calcium-mediated smooth muscle ̶ binding sites.

Sedatives
Patients may benefit from sedatives in very small doses and under controlled, monitored
settings. Sedatives should be used judiciously, if at all. For example, lorazepam (0.5 or 1 mg
intravenously) could be used for patients who are very anxious and are undergoing
appropriate and aggressive bronchodilator therapy.

Status Epilepticus (Adults and Pediatrics):

Summary for pediatrics:

Step 1 (5 min):
 IV access & withdraw blood for analysis: glucose, electrolyes, CBC, LFT, & RFT.
 D5NS 20 mL/kg/h
 Other measures:
 Hypoglycemia: Pediatrics 2 mL/kg of 25% glucose.
Adults 50 mL of 50% glucose, along with 100 mg of thiamine
 Naloxone - 0.1 mg/kg/dose
 Pyridoxine - 50-100 mg
 Antibiotics

Step 2 (5-15 min):

 IV Diazepam: Pediatrics 0.3 mg/kg, not to exceed infusion rate of 2 mg/min.
Adult: 5-20 mg IV slowly; not to exceed infusion rate of 5 mg/min.
 Rectal diazepam at 0.5 mg/kg (not to exceed 10 mg).

Step 3 (after 15 min)

Phenobarbital 10-20 mg/kg IV (not to exceed 700 mg IV); increase infusion rate by 100
mg/min; be prepared to intubate patient; closely monitor hemodynamics and support blood
pressure as indicated.

Step 4: General anesthesia

Supportive care:
 Place patients in the lateral decubitus position to avoid aspiration of emesis and to
prevent epiglottis closure over the glottis.
 Administer supplemental 100% oxygen by facemask
 Assist ventilation and use artificial airways (eg, endotracheal intubation) as needed
 Suction secretions and decompress the stomach with a nasogastric tube.

Details for both adults and pediatrics:

Step 1: First 5 minutes of seizure activity (if witnessed):
 Establish intravenous access and to obtain samples for laboratory tests and for seizure
medication levels.
 Infuse D5NS 20 mL/kg/h
 If serum glucose is low or cannot be measured give:
o Pediatrics 2 mL/kg of 25% glucose.
o Adults 50 mL of 50% glucose, along with 100 mg of thiamine to avoid Wernicke-
Korsakoff syndrome.
 Selected agents and indications are as follows:
 Naloxone - 0.1 mg/kg/dose intravenously preferably (if needed may administer
intramuscularly/subcutaneously) for narcotic overdose
 Pyridoxine - 50-100 mg intravenously/intramuscularly for possible dependency, deficiency,
or isoniazid toxicity
  Antibiotics - If meningitis is strongly suspected, initiate treatment with antibiotics prior to
cerebrospinal fluid (CSF) analysis or CNS imaging

Most seizures stop without anticonvulsant medications.

Monitoring:
 Vital signs
 Carefully monitor the patient's temperature because hyperthermia may worsen
brain damage caused by seizures.

Step 2 (6-15 min):

 Diazepam: 0.3 mg/kg; not to exceed infusion rate 1-2 mg/min.
Adult: 5-20 mg IV slowly; not to exceed infusion rate of 2 mg/min.
 Lorazepam: 0.05-0.1 mg/kg; not to exceed infusion rate of 0.05 mg/kg over 2-5 min
Alternative: If IV line is unavailable, use rectally administered (PR) diazepam at 0.5 mg/kg
(not to exceed 10 mg) or midazolam at 0.2 mg/kg intramuscularly (IM), IV, or intranasally.

Step 3 (16-35 min)

 Phenytoin (20 mg/kg) IV or fosphenytoin (20 mg phenytoin-equivalent/kg) IV over 20
min; not to exceed infusion rate of 1 mg/kg/min or 50 mg/min in adults; do not dilute in
5% dextrose in water (D5W).
 If seizures persist, administer 5 mg/kg for additional 2 doses (if blood pressure is within
the reference range and no history of cardiac disease is present).
Alternative: If unsuccessful, administer phenobarbital 10-20 mg/kg IV (not to exceed 700 mg
IV); increase infusion rate by 100 mg/min; be prepared to intubate patient; closely monitor
hemodynamics and support blood pressure as indicated.

Step 4 (45-60 min)‡: Pentobarbital anesthesia (patient already intubated)

 Loading dose: 5-7 mg/kg IV; may repeat 1-mg/kg to 5-mg/kg boluses until EEG exhibits
burst suppression; closely monitor hemodynamics and support blood pressure as
indicated
 Maintenance dose: 0.5-3 mg/kg/h IV; monitor EEG to keep burst suppression pattern at
2-8 bursts/min
 With phenobarbital-induced anesthesia, repeated boluses of 10 mg/kg are administered
until cessation of ictal activity or appearance of hypotension; closely monitor
hemodynamics and support blood pressure as indicated.
Alternative:
-Midazolam: loading dose: 100-300 mcg/kg IV followed by IV infusion of 1-2 mcg/kg/min;
increase by 1-2 mcg/kg/min every 15 min if seizures persist (effective range 1-24
mcg/kg/min); closely monitor hemodynamics and support blood pressure as indicated; when
seizures stop, continue same dose for 48 h then wean by decrements of 1-2 mcg/kg/min
every 15 min.
Another midazolam regimen preferred by other authors is loading dose of 0.1-0.3 mg/kg
followed by infusion at a rate of 0.1-0.3 mg/kg/h.
-Propofol: initial bolus 2 mg/kg IV; repeat if seizures continue and follow by IV infusion of 5-
10 mg/kg/h, if necessary, guided by EEG monitoring; taper dose 12 h after seizure activity
stops; closely monitor hemodynamics and support blood pressure as indicated.

Notes to step 4:
 Thiopental (thiopentone) is often used rather than pentobarbital in the UK.
 High-dose phenobarbital has also been used.
Notes:
 If the seizures cease, no further drugs are immediately necessary.
 In many pediatric institutions, phenobarbital is the second-line choice, rather than
fosphenytoin or phenytoin, especially for febrile and neonatal siezures.
 Phenobarbital's major disadvantages are that it significantly depresses mental status and
causes respiratory difficulty.
 Midazolam is the only benzodiazepine that can be administered safely intramuscularly
while providing rapid onset equivalent to that of intravenous agents and a moderate
duration of action.
 Intranasal midazolam may also be an option in children with prolonged seizure without
an IV access.
 Fosphenytoin is preferable, as it provides the advantage of a potentially rapid rate of
administration with less risk of venous irritation (eg, to avoid the risk of purple-glove
syndrome with phenytoin).
 Reports have shown the efficacy of levetiracetam as an add-on therapy in adults with
refractory SE, with reported loading doses of 500-3000 mg/day and a maintenance dose
of 2000-3000 mg/d. In children, the reported loading dose is 30-40 mg/kg.

Further Inpatient Care

Any child with persistent altered mental status (despite cessation of seizure activity) or with
prolonged status epilepticus should be admitted to a pediatric critical care unit.
Treat the underlying cause.

Pediatric Febrile Seizures:

Antiepileptics:
 On the basis of risk/benefit analysis, neither long-term nor intermittent anticonvulsant
therapy is indicated for children who have experienced 1 or more simple febrile seizures.
 Continuous therapy with phenobarbital or valproate decreases the occurrence of
subsequent febrile seizures, but it is not recommended.
 Oral diazepam can reduce the risk of subsequent febrile seizures. Because it is
intermittent, this therapy probably has the fewest adverse effects. If preventing
subsequent febrile seizures is essential, this would be the treatment of choice. [4]
 Diazepam 0.33 mg/kg X 3 oral throughout the febrile illness until the child was afebrile for
24 hours (A study reported in New England Journal of Medicine). However, this dosage
was frequently associated with side effects such as imbalance, lethargy, and irritability.

Antipyretics:
 Rectal acetaminophen 10 mg/kg given every 6 hours may prevent febrile seizure
recurrence within the same febrile episode, suggested by a randomized controlled trial
published in 2018
 Although it has been felt that antipyretic therapy cannot prevent simple febrile seizures,
it is desirable for other reasons, for instance comfort.
Pediatric DKA:
Fluid Replacement:
 Resuscitate with 10-20 mL/kg of NS over 30 minutes.
 After resuscitation, calculate fluid deficit by clinical assessment to a maximum 8% of
body weight, then slowly correct the fluid deficit over 48 hours by providing normal
maintenance fluids together with the calculated deficit. Remember to subtract any
initial resuscitation fluid boluses given from the total calculated deficit
 Administer isotonic sodium chloride solution until blood glucose levels have fallen to
250-300 mg/dL, at which time change to D5NS or D5 ½ NS until the child is eating
and drinking normally.

Notes:
If cerebral edema develops, restrict fluid replacement to two thirds of normal maintenance
and replace the deficit over a period of 48 hours or longer
Although strict assessment of fluid balance is important, replacement of ongoing losses is
not normally required.

Insulin Replacement:

 Continous IV insulin infusion at a rate of 0.1 U/kg/h is given.

 Blood glucose levels not fall faster than 90 mg/dl (5 mmol/L) per hour. The infusion
rate of insulin can be reduced as blood glucose levels fall but should not drop below
0.05 U/kg/h.
 If blood glucose falls below 120 mg% (ie, 7 mmol/L), increase the concentration of
infused glucose to prevent hypoglycemia.
 Do not discontinue infusion until subcutaneous insulin has been given when the
child has recovered.

Note: Time to start insulin is one hour after starting fluid resuscitation especially in the
newly diagnosed child. The results of a prospective national study of diabetic ketoacidosis in
the United Kingdom suggested a greater risk of cerebral edema in patients who received
insulin within the first hour of treatment.

Potassium:
 After initial resuscitation and if a good renal output has been maintained add
potassium to all replacement fluids.
 Potassium chloride most commonly is administered. This theoretically could make
the acidosis worse, but no evidence indicates that administration of other potassium
salts, such as phosphate or acetate, is more effective.

Serum/Plasma K+ (mEq/L) Potassium Chloride (KCL) Dose in Infusion Fluids

< 2.5 mEq/L Carefully monitored administration of 1 mEq/kg body weight
by separate infusion over 1 h
2.5-3.5 mEq/L 40 mEq/L
3.5-5 mEq/L 20 mEq/L
5-6 mEq/L 10 mEq/L (optional)
Over 6 mEq/L Stop K+ and repeat level in 2 h
Monitoring:
 Specifically designed recording charts make the process of care much easier.
 These usually include: Insulin infusion, deficit fluid, maintenance fluid, blood glucose,
vitals, & electrolytes.
 Frequent review of neurologic status at least hourly (or any time a change in the level of
consciousness is suspected)—is essential during the first 12 hours of diabetic ketoacidosis
treatment. Promptly treat any suspected cerebral edema.

Treatment of Cerebral Edema:

Only half of children who develop cerebral edema have obvious signs of deterioration;
children may present with respiratory arrest.
If cerebral edema is suspected and hypoglycemia is excluded, prompt treatment with an
osmotic diuretic is indicated, followed by a CT scan and referral to a neurosurgeon.
 Mannitol: is 0.5-1 g/kg infused over 30 minutes, which can be repeated after 1 hour.
 Hypertonic saline (3%): 5-10 mL/kg, infused over 30 minutes, which can be repeated
after 1 hour.

Cardiac arrest:
 Compression-to-ventilation ratio is 30:2 for a single rescuer, 15:2 for multiple rescuers.
 Adrenaline (epinephrine):
 1:10,000 solution (0.1 mg/mL) IO/IV : 0.01 mg/kg; not to exceed 1 mg; repeat q3-
5min until return of spontaneous circulation
 1:1000 solution (1 mg/mL) endotracheal tube: 0.1 mg/kg (0.1 mL/kg); not to exceed
2.5 mg q3-5min until IO/IVP access established or spontaneous circulation achieved.
Flush with 5 mL of normal saline immediately after administration.
 Atropine: 0.01-0.03 mg/kg IV, IM, SC, endotracheal tube.
 Amiodarone (after 3 DC shocks):
 5 mg/kg IV bolus, may be repeated for a total 2-3 doses.
 Shock Energy
 2 J/kg first shock
 4 J/kg second shocks
 ≥4 J/kg subsequent shocks, maximum 10 J/kg or adult dose
 Lidocaine 1 mg/kg IV/IO loading dose, 20-50 mcg/kg/min maintenance infusion
 Flush medications with fluid after and elevate extremity for 10-20 seconds.
 Combining medications is not recommended and may cause harm.
 Routine use of sodium bicarbonate is not recommended and may cause harm.

Pediatric Urinary Tract Infection:

 IV fluids: 1-1.5 times the usual maintenance rate.
 Antibiotics
 Dysurea:
 Increasing fluid intake to enhance urine dilution
 Use of acetaminophen and (NSAIDs).
 Add phenazopyridine hydrochloride (Pyridium) If voiding symptoms are severe and
persistent. Do not administer phenazopyridine for longer than 48 hours, because of the
risk of methemoglobinemia, hemolytic anemia, and other adverse reactions.
 Sitting in a tub of warm water for 20-30 minutes 3-4 times daily also often affords symptomatic relief.
Antibiotics:
Antibiotics can be given for 7 or 14 days.
A 4-day course of an oral antibiotic agent is recommended for the treatment of cystitis.

Initial treatment:
 Single dose of ceftriaxone (75 mg/kg IV/IM q12-24h).
 Or gentamicin (2.5 mg/kg IV/IM as a single dose) If the patient has cephalosporin
allergy.
Patients who demonstrate a satisfactory response can be switched to an oral antibacterial
agent at therapeutic doses within the next 12-18 hours.

Parenteral Treatment:
 Ceftriaxone:
50-75 mg/kg/day IV/IM as a single dose or divided q12h
Do not use in infants < 6 wk of age; parenteral antibiotic with long half-life; may displace
bilirubin from albumin.
 Cefotaxime:
150 mg/kg/day IV/IM divided into 3-4 doses.
Safe to use in infants < 6 wk of age; used with ampicillin in infants aged 2-8 wk
 Ampicillin:
100 mg/kg/day IV/IM divided q8h
Used with gentamicin in neonates < 2 wk of age; for enterococci and patients allergic to
cephalosporins
 Gentamicin:
Term neonates < 7 days: 3.5-5 mg/kg/dose IV q24h
Infants and children < 5 years: 2.5 mg/kg/dose IV q8h
or single daily dosing of 5-7.5 mg/kg/dose IV with normal renal function
Children ≥5 y: 2-2.5 mg/kg/dose IV q8h
or single daily dosing of 5-7.5 mg/kg/dose IV q24h with normal renal function
*Monitor blood levels and kidney function if therapy

Empiric oral treatment:

 Trimethoprim/Sulfamethoxazole (TMP/SMZ): 30-60 mg/kg SMZ, 6-12 mg/kg TMP divided q12h
 Amoxicillin/clavulanic acid: 20-40 mg/kg divided q8h
 Cephalexin: 50-100 mg/kg divided q6h
 Cefixime: 8 mg/kg q24h
 Cefpodoxime: 10 mg/kg divided q12h
 Nitrofurantoin: 5-7 mg/kg divided q6h
Nitrofurantoin may be used to treat cystitis. It is not suitable for the treatment of
pyelonephritis, because of its limited tissue penetration.
Pediatric Pyelonephritis:
Antibiotic Therapy
Initial therapy with IV antibiotics for 3-4 days followed by oral therapy to complete a 10-14
day course is equivalent to 10-14 days of IV therapy.
Initial oral therapy with cefixime or amoxicillin-clavulanate is equivalent to IV ceftriaxone for
3 days followed by oral therapy.
IV gentamicin may be dosed daily, rather than 3 times a day, for children who require IV
treatment or who are infected with multiresistant organisms.

Inpatient Care
Hospitalization is necessary for pyelonephritis in any of the following situations:
 Toxicity or sepsis
 Signs of urinary obstruction or significant underlying disease
 Inability to tolerate adequate oral fluids or medications
 Infants and children younger than age 2 years with febrile UTI, presumed
pyelonephritis
 All infants younger than age 3 months

Outpatient Care:
Patients treated exclusively in the outpatient setting should be reevaluated in 48 hours to
ensure adequate hydration and an appropriate response to therapy. For a first infection,
perform renal ultrasonography. Manage constipation and voiding dysfunction.

Pediatric Pneumonia:
Investigations:
Chest radiography should be performed to identify the presence of an effusion/empyema.

Inpatient treatment:
 Younger than 2 months or premature because of the risk of apnea in this age group.
 Children younger than 5 years are hospitalized more often because of their toxic
appearance or hydration status.
 It is indicated for patients who are toxic or hypoxic enough to require supplemental
oxygen.
 Unless they are vomiting and toxic, they do not require intravenous fluids or antibiotics.

Management:
 Emergency Respiratory Management:
 Grunting, flaring, severe tachypnea, and retractions should prompt immediate
respiratory support.
 Children who are in severe respiratory distress should undergo tracheal intubation if
they are unable to maintain oxygenation or have decreasing levels of consciousness.
 Supportive care:
 Hb should be 13-16 g/dl
 Fluids
 Humidified inspired air
 Chest percussion may be used (although studies have proven it is not effective)
 Antibiotics:
 High-dose amoxicillin is the first line.
  Second- or third-generation cephalosporins
 Azithromycin useful in most school-aged children
 Children who are toxic appearing should receive antibiotic therapy that includes
vancomycin along with a second- or third-generation cephalosporin.
 Newborns and young infants: Initially ampicillin plus either gentamicin or cefotaxime.
 Steroids:
Antimicrobial agents directed at killing invasive organisms may transiently worsen
inflammatory cascades.
Steroids are of greater importance in pneumonia resulting from noninfectious causes
 Bronchodilators: for infants or children with reactive airway disease or asthma may react to
a viral infection with bronchospasm, which responds to bronchodilators.

Management of Pleural Effusions:

When a child with pneumonia develops a pleural effusion, thoracentesis should be
performed for diagnostic and therapeutic purposes.

Notes:
 Influenza pneumonia that is particularly severe or when it occurs in a high-risk patient
may be treated with zanamivir or oseltamivir.
 A second-line alternative is a combination of oseltamivir plus rimantadine rather than
oseltamivir alone.
 Herpes simplex virus pneumonia is treated with parenteral acyclovir.
 CMV pneumonitis should be treated with intravenous ganciclovir or foscarnet.
 Invasive fungal infections, such as those caused by Aspergillus or Zygomycetes species,
are treated with amphotericin B or voriconazole.

Bronchiolitis:
 Position: Held in a parent’s arms or sitting in the position of comfort
 Supportive Therapy
 Humedified oxygen: using of high-flow nasal cannulas to maintain saturation higher than 90%
 Hydration: patients are usually mildly dehydrated. Avoid excessive fluid administration
because of risk of SIADH.
 Oral therapy is preferred. Parenteral therapy may be necessary in those patients who are
unable to take fluids by mouth or who have a respiratory rate higher than 70 breaths/min.
 Bronchodilators: continue the use of bronchodilators only in patients who demonstrate
clinical improvement after initial use of these agents.
 Nebulized epinephrine
 Steroids: corticosteroids may be useful in patients with history of reactive airway disease.
Steroids used are: prednisolone, methylprednisolone, & dexamethasone.
 Hypertonic saline: nasal spray or nebulized 3% hypertonic saline, or nasal drops.
Nasal drops may be used 2-3 times a day for no more than 3 days.
 Then perform nasal and oral suctioning. Deep oral and nasal suctioning is not routinely
needed.
 Antibiotics: In patients who are febrile or who appear toxic at presentation, leukocytosis,
or positive bacterial cultures).Concomitant otitis media is common and may be treated
with oral antibiotics
Intranasal Decongestants:
Nebulized epinephrine may be primarily beneficial as a nasal decongestant.
Oxymetazoline (Afrin, 12 Hour Nasal Relief): Oxymetazoline is applied directly to mucous
membranes, where it stimulates alpha-adrenergic receptors and causes vasoconstriction.
Decongestion occurs without drastic changes in blood pressure, vascular redistribution, or
cardiac stimulation.

Acute Bronchitis:
Analgesics antipyretics.
 Acetaminophen 15 mg/kg X 4-6 orally
 Ibuprofen 10 mg/kg X 3 orally

Antibiotics:
In otherwise healthy individuals, the use of antibiotics has not demonstrated any consistent
benefit in relieving symptoms or improving the natural history of acute bronchitis.

Bronchodilators:
A trial of inhaled albuterol may be worthwhile because it may provide significant relief of
symptoms for many pediatric patients, not for adults.

Antitussives and expectorants:

They are often prescribed but have not been demonstrated to be useful.
Preliminary studies suggest a possible role for Pelargonium sidoides roots extracts, in the
treatment of pediatric patient with bronchitis.

Supportive:
Febrile patients should increase oral fluid intake.

Tonsillitis and Pharyngitis Empiric Therapy:

Analgesics antipyretics: for a limited time (≤ 2-3 days)
 Acetaminophen 15 mg/kg X 4-6 orally
 Ibuprofen 10 mg/kg X 3 orally

Antibiotics:
 Penicillin V 25-50 mg/kg/day divided q6h for 10d or
 Benzathine penicillin G 25,000 U/kg IM once (maximum 1.2 million U) or
 Amoxicillin 50 mg/kg/day PO in 2 or 3 divided doses for 10d or
 Amoxicillin-clavulanate 500-875 mg PO q12h for 10d
 Cefdinir 14 mg/kg PO once daily for 10d or
 Cefuroxime axetil 10 mg/kg PO BID for 4-10d

If penicillin allergic:
 Azithromycin 12 mg/kg PO once daily for 5d or
 Clarithromycin 250 mg PO q12h for 10d or
 Erythromycin succinate 20 mg/kg PO BID for 10d or
 Clindamycin 7 mg/kg/day PO in 3 divided doses (maximum 1.8 g/d) for 10d
Steroids:
Steroid use, dexamethasone in particular, may reduce pain and decrease symptom duration
for both viral pharyngitis and streptococcal pharyngitis.
This has been primarily shown in the adult population.
In children, a single dose of oral dexamethasone (0.6 mg/kg) only marginally hastened the
onset of pain relief.
Infectoius mononucleosis: Corticosteroids may shorten the duration of fever and
pharyngitis.

Note: Airway obstruction due to tonsillitis may require management by placing a nasal
airway device, using intravenous corticosteroids, and administering humidified oxygen.

Croup:
Outpatient treatment:
 Treat fever with an antipyretic such as acetaminophen or ibuprofen.
 Encourage oral intake.
 Cool mist from a humidifier and/or sitting with the child in a bathroom (not in the shower)
filled with steam generated by running hot water from the shower, help minimize
symptoms.
 Engaging the child in a calming activity, such as reading a favorite book, can help decrease
the child's anxiety and minimize crying, which can worsen stridor.
 Persistent crying increases oxygen demands
 Coughing can be treated with warm, clear fluids to loosen mucus in the oropharynx
 Frozen juice popsicles also can be given to ease throat soreness
 Avoid smoking in the home; smoke can worsen a child's cough.
 Keep the child's head elevated:
o An infant can be placed in a car seat.
o A child may be propped up in bed with an extra pillow.
o Pillows should not be used with infants younger than 12 months of age.
 At nighttime, parents/caregivers should stay in close proximity to the ill child so that they
can immediately assist the child, if he or she begins to have difficulty breathing.

 Monitoring for respiratory distress:

Tachypnea, tachycardia, chest wall retractions, and hypoxia.

Inpatient treatment:
Steroids:
 Dexamethasone 0.15-0.6 mg/kg have proven beneficial in severe, moderate, and even
mild croup.
 The long half-life of dexamethasone (36-54 h) often allows for a single injection or dose to
cover the usual symptom duration of croup.
 Dexamethasone has shown the same efficacy if administered intravenously,
intramuscularly, or orally.

Nebulized epinephrine:
 Its effectiveness is immediate with evidence of therapeutic benefit within the first 30
minutes and then, a lasting effect from 90-120 minutes (1.5-2 h).
 Patients who receive nebulized racemic epinephrine in the emergency department should
be observed for at least 3 hours post last treatment because of concerns for a return of
bronchospasm, worsening respiratory distress, and/or persistent tachycardia.
Antibiotics:
 Lack of improvement or worsening of symptoms can be due to a secondary bacterial
process, which requires the use of antimicrobials for treatment.
 Typically, patients with a bacterial component would have had moderate-to-severe croup
assessment scores, requiring inpatient care and observation.

Oxygen:
 Severe respiratory distress may require oxygenation with ventilation support, initially with
a bag-valve-mask device.
 If the airway and breathing require further stabilization due to increasing respiratory
fatigue and hence, worsening hypercarbia (as evident by ABG), the patient should be
intubated with an endotracheal tube. Intubation should be accomplished with an
endotracheal tube that is 0.5-1 mm smaller than predicted.

Epiglottitis:
Antibiotics:
 Ceftriaxone is the antibiotic of choice.
 Amoxicillin/clavulanic acid
 Chloramphenicol is used if patients are allergic to penicillin and cephalosporins.
 Clindamycin
Therapy should begin after blood and epiglottic cultures have been obtained.

Analgesic Antipyretic

Supportive:
 Avoid agitating the patient with acute epiglottitis. Let the patient take a position in which
he or she feels comfortable.
 Orotracheal intubation may be required with little warning. Equipment for intubation,
cricothyroidotomy, or percutaneous transtracheal jet ventilation should be made available
at the bedside.
 Avoid therapy such as sedation, inhalers, or racemic epinephrine.
 Administer supplemental humidified oxygen if possible, but do not force the patient, as
the resultant agitation could worsen the condition.
 Clinical pitfalls include the following:
o Underestimating the potential for sudden deterioration (most common error)
o Inadequate monitoring in which deterioration goes unnoticed (second most
common error)
o Rushing intubation without proper support (ensure the availability of an
anesthesiologist or other individual experienced in difficult intubation)
o Performing unnecessary medical procedures that result in agitation and respiratory
collapse

Indications for intubation:

 Respiratory distress
 Stridor
 Sitting erect
 Inability to swallow
 Drooling
 Airway compromise on examination
 Deterioration within 8-12 hours.
 -Enlarged epiglottis on radiographs is associated with airway obstruction. When in doubt,
securing the airway is likely the safest approach.
-Obstruction in acute epiglottitis can be reduced by using dexamethasone therapy or
budesonide aerosols to treat pharyngeal edema.

Treatment of contacts:
 Close contacts of patients in whom Haemophilus influenzae type b is isolated should
receive rifampin prophylaxis (20 mg/kg; not to exceed 600 mg/d for 4 d).

Note: Racemic epinephrine, corticosteroids, and beta-agonists have not been proven to be
helpful in epiglottitis.

Pediatric Gastroenteritis:
Minimal or no dehydration:
 If the child is breastfed: breastfeed more frequently.
 If the child is not exclusively breastfed: then oral maintenance fluids (including clean water,
soup, rice water, yogurt drink, or other culturally appropriate fluid) should be given at a
rate of approximately:
 <2 years: 500 mL/day
 2-10 years: 1000 mL/day
 >10 years: 2000 mL/day

Mild-to-moderate dehydration
Children should be given 50-100 mL/kg of ORS over a 2- to 4-hour period to replace their
estimated fluid deficit.

Severe dehydration
 Bolus of 20-30 mL/kg lactated Ringer (LR) or normal saline (NS) solution over 60 minutes.
 If pulse, perfusion, and/or mental status do not improve, a second bolus should be
administered.
 After this, the patient should be given an infusion of 70 mL/kg LR or NS over:
 Infants: 5 hours
 Older children: 2.5 hours
 Once resuscitation is complete and mental status returns to normal, rehydration should
continue with ORS as described above, as it has been shown to decrease the rate of
hyponatremia and hypernatremia when compared with IV rehydration.
 Serum electrolytes, bicarbonate, urea/creatinine, and glucose levels should be tested.

Ongoing fluid losses should be replaced with:

 10 mL/kg body weight of additional ORS for each loose stool
 2 mL/kg body weight of additional ORS for each episode of emesis

ORS:
ORS should be given slowly at the rate of 5 mL every 1-2 minutes using a teaspoon, syringe,
or medicine dropper. If tolerated by the patient, the rate of ORS delivery can be increased
slowly over time
For patients who do not tolerate ORS by mouth, nasogastric (NG) feeding is a safe and
effective alternative. Multiple clinical trials have found NG rehydration to be as efficacious as
IV rehydration, but more cost effective and with fewer adverse events.
 A large Cochrane meta-analysis confirmed several earlier studies showing that reduced-
osmolarity ORS is better.
In developing countries, homemade solution of 1 tsp salt and 6 tsp sugar added to 1 liter of
clean water can be used.

Feeding and nutrition

In general, children with gastroenteritis should be returned to a normal diet as rapidly as
possible.
Formula-fed infants should restart feeding at full strength as soon as the rehydration phase
is complete (ideally in 2-4 hours).
Fatty foods and foods high in simple sugars should be avoided.

Medications:
Antiemetics: oral ondansetron reduced vomiting and the need for intravenous (IV)
rehydration and hospital admission, IV ondansetron and metoclopramide reduced the
number of episodes of vomiting and hospital admission, and dimenhydrinate suppository
reduced the duration of vomiting.
Antidiarrheal (ie, kaolin-pectin) and antimotility agents (ie, loperamide) are contraindicated.
Probiotics are (especially Lactobacillus GG) effective in reducing the duration of diarrhea in
children presenting with acute gastroenteritis.
Zinc supplementation (10-20 mg/day for 10-14 days) for all children younger than 5 years
with acute gastroenteritis may be effective in reducing the duration of diarrhea.

Antibiotics:
 They are not indicated. even in cases of dysentery may prolong the carrier state
(Salmonella infection) or may increase the risk of developing hemolytic-uremic syndrome
(enterohemorrhagic Escherichia coli infection).
 In patients with positive stool assays or high clinical suspicion for C difficile infection, the
offending antibiotic should be stopped immediately. Metronidazole (30 mg/kg/day divided
qid for 7 days) can be used as a first-line agent, with oral vancomycin reserved for resistant
infections.
 Cholera: tetracycline (50 mg/kg/day PO divided qid for 3 days) and doxycycline (6 mg/kg PO
as a single dose). Although generally not recommended for children younger than 8 years.
Alternative treatments with good efficacy include erythromycin and ciprofloxacin.
 Giardia: metronidazole (35-50 mg/kg/day PO divided q8h) remains the drug of choice.

Further Outpatient Care

Parents should seek medical attention if dehydration returns, oral intake is inadequate, or if
their child develops worsening abdominal pain, fever greater than 101°F, or prolonged
diarrhea lasting longer than 14 days.

Further Inpatient Care

Inpatient admission should be considered for all children with acute gastroenteritis in the
following situations:
 Signs of severe dehydration are present
 Caregivers are unable to manage oral rehydration or provide adequate care at home
 Substantial difficulties exist in administering oral rehydration solution (ORS), such as
intractable vomiting or inadequate ORS intake
  Treatment failure, such as worsening diarrhea or dehydration despite adequate ORS
intake, occurs
 Factors are present necessitating closer observation, such as young age, decreased
mental status, or uncertainty of diagnosis
Children with mild-to-moderate dehydration, children younger than 6 months, or children
with a high frequency of stools/vomits should be monitored in the emergency department
for a minimum of 4-6 hours before discharge.

Bacterial Meningitis (adults and pediatrics):

Dexamethasone:
0.15 mg/kg X 4 for 2-4 days, initiated 10-20 minutes before (or at least concomitant with)
the first antimicrobial dose.

Antibiotics:
-Neonate:
 Ampicillin 100 mg/kg plus either:
o Cefotaxime 50 mg/kg q6h
o Aminoglycoside (gentamicin 2.5 mg/kg or tobramycin 2.5 mg/kg) X 3

-Pediatrics (1 month – 18 years):

 Vancomycin 15 mg/kg X 4 plus a third-generation cephalosporin
(ceftriaxone 75-100 mg/kg X 1-2 or cefotaxime 75-100 mg/kg X 3-4)

-Adults:
 Vancomycin 15 mg/kg X 3 plus a third-generation cephalosporin
(ceftriaxone 2 g X 2 or cefotaxime 2 g X 6)

Older than 50 years:

 Same adult regimen plus ampicillin 2 g X 6 (if Listeria is suspected)

Treatment according to predisposing conditions

 Pregnancy: commonly due to Listeria. Ampicillin 2 g X 6 or penicillin G 4 mU X 6
 Basilar skull fracture: same as adults regimen
 Penetrating trauma or post neurosurgery or CSF shunt:
 Vancomycin 15 mg/kg q8h plus cefepime 2 g X 3 or ceftazidime 2 g X 3 or meropenem 2 g X 3
 Immunecompromized (chemotherapy, steroids): same as elderly regimen.

 Duration of therapy:
o Neisseria meningitidis - 7 days
o Haemophilus influenzae - 7 days
o Streptococcus pneumoniae - 10-14 days
o S agalactiae (GBS) - 14-21 days
o Aerobic gram-negative bacilli - 21 days or 2 weeks beyond the first sterile culture
(whichever is longer)
o Listeria monocytogenes - 21 days or longer
Prevention
Preventive therapy has been shown to reduce mortality and morbidity and consists of the
following:
Causative Organism Drug Name Age of Contact Dosage
Adults >600 mg PO qd for 4 days
Haemophilus 20 mg/kg PO qd for 4 days;
Rifampin =1 month
influenzae not to exceed 600 mg/dose
< 1 month >10 mg/kg PO qd for 4 days
Adults 600 mg PO q12h for 2 days
10 mg/kg PO q12h for 2 days;
Rifampin >1 month
not to exceed 600 mg/dose
Neisseria meningitidis =1 month >5 mg/kg PO q12h for 2 days
>15 years 250 mg IM once
Ceftriaxone
=15 years >125 mg IM once
Ciprofloxacin =18 years >500 mg PO once