609
PAEDIATRIC PROTOCOLS For Malaysian Hospitals Hussain Imam Hj Muhammad Ismail Ng Hoong Phak Terrence Thomas 3rd Edion Kementerian Kesihatan Malaysia
PAEDIATRIC PROTOCOLS
For Malaysian Hospitals
Hussain Imam Hj Muhammad IsmailNg Hoong PhakTerrence Thomas
3rd Edition
Kementerian Kesihatan Malaysia
i
PAEDIATRIC PROTOCOLS
For Malaysian Hospitals
Hussain Imam Hj Muhammad IsmailNg Hoong PhakTerrence Thomas
3rd Edition
Kementerian Kesihatan Malaysia
Scan this QR code to download the electronicPaediatric Protocol 3rd Edition
ii
iii
FOREWORD BY THE DIRECTOR GENERAL OF HEALTH
Malaysia like the rest of the world has 3 more years to achieve the Millennium Developmental Goals (MDG). MDG 4 is concerned with under 5 mortality. Although we have done very well since lndependence to reduce our infant and toddler mortality rates, we are now faced with some last lap issues in achieving this goal.
Despite urbanization there are still many children in the rural areas. This constitutes a vulnerable group in many ways. Among the factors contributing to this vulner-ability is the distance from specialist care.
There is a need to ensure that doctors in the frontline are well equipped to handle common paediatric emergencies so that proper care can be instituted from the very beginning.
Although all doctors are now required to do 4 months of pre-registration training in Paediatrics, this is insufficient to prepare them for all the conditions they are likely to meet as Medical Officers in district hospitals and health clinics. Hence the effort made by the paediatricians to prepare a protocol book covering all the common paediatric problems is laudable. I would also like to congratulate them forbringing out a third edition within 4 years of the previous edition.
l am confident that this third edition will contribute to improving the care of children attending the Ministry’s facilities throughout the country.
Dato’Sri Dr Hasan Bin Abdul RahmanDirector General of Health, Malavsia
iv
FOREWORD TO THE THIRD EDITION
It has been 7 years since we produced the first edition of a national protocol book for Paediatrics. This effort was of course inspired by the Sarawak Paediatric Protocols initiated by Dr Tan Poh Tin. The 2nd edition in 2008 has proven to be very popular and we have had to recruit the services of the Malaysian Paediatric Association (MPA) to produce extra copies for sale. It is now the standard reference for House officers in Paediatrics.
In producing a third edition we have retained the size and style of the current ver-sion, essentially only updating the contents. Again it is targeted at young doctors in the service many of whom seem to have had a suboptimal exposure to paediatrics in their undergraduate years. It is hoped that the protocol book will help them fill in the gaps as they prepare to serve in district hospitals and health clinics.
The Ministry of Health has once again agreed to sponsor the printing of 1000 books and 500 CDs for distribution to MOH facilities. We shall be soliciting the help of the MPA in producing extra books to be sold to those who wish to have a personal copy. As a result of the full PDF version being available on the MPA website, we have had requests from as far away as Kenya and Egypt to download and print the material for local distribution. We have gladly allowed this in the hope that it will contribute to better care of ill children in those and other neigh-bouring countries.
As previously this new edition is only possible because of the willingness of busy clinicians to chip in and update the content for purely altruistic reasons and we hope this spirit will persist in our fraternity. Prof Frank Shann has gracefully agreed for the latest edition of his drug dosages handbook to be incorporated into the new edition. The Director General of Health has also kindly provided a foreword to this edition.
We wish to thank all who have made this new edition possible and hope this combined effort will help in improving the wellbeing of the children entrusted to our care.
Hussain Imam B. Hj Muhammad IsmailNg Hoong PhakTerrence Thomas
v
LIST OF CONTRIBUTORS
Dr. Fazila Mohamed Kutty Neonatologist Hospital Serdang
Dr. Fong Siew MoyPaediatric Infectious Disease ConsultantSabah Women &Children’s Hospital, Kota Kinabalu
Dr. Fuziah Md. ZainConsultant Paediatric Endocrinologist& Head, Dept. of PaediatricsHospital Putrajaya
Dr. Hasmawati HassanConsultant Neonatologist,Hospital Raja Perempuan Zainab II,Kota Bharu
Dr. Hishamshah b. Mohd IbrahimConsultant Paediatric Haemato-Oncologist Hospital Kuala Lumpur
Dr. Hung Liang ChooConsultant Paediatric CardiologistHospital Kuala Lumpur
Dato’ Dr. Hussain Imam B. Hj Muhammad IsmailConsultant Paediatric Neurologist &Head, Dept. of PaediatricsHospital Kuala Lumpur
Dr. Heng Hock SinPaediatric NeurologistHospital Kuala Lumpur
Dr. Irene Cheah Guat SimConsultant NeonatologistHospital Kuala Lumpur
Dr. Janet Hong Yeow HuaConsultant Paediatric EndocrinologistHospital Putra Jaya
Dr. Jeyaseelan NachiappanPediatric Infectious Disease ConsultantHospital Raja Perempuan Bainun, Ipoh.
Dato’ Dr. Jimmy Lee Kok FooConsultant Paediatrician &Head, Dept. of PaediatricsHospital Sultanah Nur Zahirah,Kuala Terengganu
Dr Airena Mohamad Nor, PaediatricianHospital Tuanku Jaafar, Seremban.
Dr. Alex Khoo Peng ChuanPaediatric NeurologistHospital Raja Permaisuri Bainun, Ipoh.
Dr. Amar-Singh HSSConsultant Community Paediatrician &Head, Dept. of PaediatricsHospital Raja Permaisuri Bainun, Ipoh
Dr. Angeline WanConsultant Neonatologist Head, Dept. of PaediatricsHospital Pakar Sultanah Fatimah, Muar
Ms. Anne JohnConsultant Paediatric SurgeonHospital Umum Sarawak, Kuching
Dr. Bina MenonConsultant Paediatric Haemato-OncologistHospital Kuala Lumpur (Sessional)
Dr. Chan Lee GaikConsultant Neonatologist& Head, Dept. of PaediatricsHospital Umum Sarawak, Kuching
Dr. Chee Seok Chiong Consultant NeonatologistHospital Selayang
Dr. Chin Choy NyokConsultant Neonatologist& Head, Dept. of PaediatricsHospital Tengku Ampuan Afzan, Kuantan
Dr. Chong Sze YeePaediatric Gastroenterology & Hepatology FellowHospital Selayang
Dr. Eni JuraidaConsultant Paediatric Haemato-OncologistHospital Kuala Lumpur
Dr. Farah Inaz Syed Abdullah Consultant Neonatologist Hospital Kuala Lumpur
vi
Dr. Nazrul Neezam NordinPaediatric Gastroenterologist & Hepatologist Hospital Kuala Lumpur
Dr. Neoh Siew HongConsultant NeonatologistHospital Kuala Lumpur
Dr. Ng Hoong PhakConsultant in General Paediatrics and Child Health,Hospital Umum Sarawak, Kuching
Dr. Ngu Lock HockConsultant in Paediatric Metabolic DiseasesHospital Kuala Lumpur
Dr. Nik KhairulddinPaediatric Infectious Disease Consultant &Head, Dept. of PaediatricsHospital Raja Perempuan Zainab II, Kota Bharu
Dr Noor Khatijah NuraniConsultant in General Paediatrics and Child Health,Hospital Raja Permaisuri Bainun, Ipoh
Dr. Nor Azni bin YahyaConsultant Paediatric Neurologist, Hospital Raja Perempuan Zainab II, Kota Bharu.
Dr. Norzila Bt. Mohd ZainudinConsultant, Paediatric Respiratory DiseaseHospital Kuala Lumpur
Dr. Ong Gek BeeConsultant Paediatric Haemato-OncologistHospital Umum Sarawak, Kuching
Dr. Pauline Choo NeonatologistHospital Tuanku Jaafar, Seremban
Dr Raja Aimee Raja AbdullahPaediatric EndocrinologistHospital Putrajaya
Dr. Revathy NallusamyPaediatric Infectious Disease Consultant &Head, Dept. of PaediatricsHospital Pulau Pinang
Dr. Rozitah RazmanPaediatricianHospital Kuala Lumpur
Dr. Kamarul RazaliPaediatric Infectious Disease Consultant Hospital Kuala Lumpur
Dr. Kew Seih TeckPaediatric Gastroenterology & Hepatology FellowHospital Selayang
Dr. Khoo Teik BengConsultant Paediatric NeurologistHospital Kuala Lumpur
Datuk Dr. Kuan Geok LanConsultant General Paediatrician Hospital Melaka.
Dr. Lee Ming LeeConsultant Paediatric NephrologistHospital Tuanku Ja’far, Seremban
Dr. Leow Poy LeeConsultant NeonatologistHospital Melaka.
Dr. Lim Chooi BeeConsultant Paediatric GastroenterologistHospital Selayang
Dr. Lim Yam NgoConsultant Paediatric NephrologistHospital Kuala Lumpur
Dr. Lynster LiawConsultant Paediatric NephrologistHospital Pulau Pinang
Dr Mahfuzah MohamedConsultant Paediatric Haemato-OncologistHospital Kuala Lumpur
Dr. Maznisah Bt MahmoodPediatric IntensivistHospital Kuala Lumpur
Dr. Martin WongConsultant Paediatric CardiologistHospital Umum Sarawak, Kuching
Dr. Mohd Nizam Mat BahConsultant Paediatric CardiologistHead, Dept. of PaediatricsHospital Sultanah Aminah, Johor Bharu
vii
Dr Thahira Jamal MohamedPaediatric Infectious Disease ConsultantHospital Kuala Lumpur
Dr. N. ThiyagarConsultant, Adolescent Medicine &Head, Dept. of PaediatricsHospital Sultanah Bahiyah, Alor Setar
Dr. Terrence ThomasConsultant Paediatric NeurologistKK Women’s & Children’s Hospital, Singapore
Dr. Vidya NatthondanNeonatologist Hospital Putrajaya
Dr. Vigneswari GanesanConsultant Paediatric NeurologistHospital Pulau Pinang
Dr. Wan Jazilah Wan IsmailConsultant Paediatric Nephrologist &Head, Dept. of PaediatricsHospital Selayang
Dr. Wong Ann Cheng PaediatricianHospital Kuala Lumpur
Dr Wong Ke JuinPediatricianSabah Women & Children’s Hospital, Kota Kinabalu
Dr. Yap Yok ChinConsultant Paediatric NephrologistHospital Kuala Lumpur
Dr. Yogeswery SithamparanathanConsultant Neonatologist Hospital Tuanku Ampuan Rahimah, Klang
Dr Zainah Sheikh Hendra,Consultant in General Paediatrics and Child Health, Hospital Batu Pahat
Dr. Zuraidah Bt Abd LatifConsultant Neonatologist & Head, Dept. of Paediatrics, Hospital Ampang
Dr. Zurina ZainudinConsultant PaediatricianUniversiti Putra MalaysiaHospital Kuala Lumpur
Dr. Sabeera Begum Bt Kader IbrahimConsultant Paediatric DermatologistHospital Kuala Lumpur
Dr. See Kwee Ching Neonatologist Hospital Sungai Buloh
Dr. Sharifah Ainon Bt Ismail MokhtarConsultant Paediatric Cardiologist,Hospital Pulau Pinang
Dr. Sheila Gopal KrishnanSpecialist in General Paediatrics and Child Health Head, Dept. of PaediatricsHospital Kulim
Dr. Siti Aishah Bt SaidinAdolescent Medicine SpecialistHospital Raja Permaisuri Bainun, Ipoh
Dr. Soo Thian LianConsultant Neonatologist & Head, Dept. of PediatricsSabah Women &Children’s Hospital, Kota Kinabalu
Dr. Susan PeeConsultant Paediatric Nephrologist &Head, Dept. of Paediatrics,Hosp Sultan Ismail, Pandan
Dr. Tan Kah KeePaediatric Infectious Disease Consultant & Head, Dept. of PaediatricsHospital Tuanku Ja’far, Seremban
Assoc. Prof. Dr. Tang Swee FongConsultant Paediatric IntensivistHospital University Kebangsaan Malaysia
Dr. Tang Swee PingConsultant Paediatric RheumatologistHospital Selayang
Dr. Teh Chee MingPaediatric NeurologistHospital Pulau Pinang
Dato’ Dr. Teh Keng HwangConsultant Paediatric Intensivist Hospital Sultanah Bahiyah, Alor Star
viii
TABLE OF CONTENTS
Section 1 General PaediatricsChapter 1: Normal Values in Children 1Chapter 2: Immunisations 5Chapter 3: Paediatric Fluid and Electrolyte Guidelines 19Chapter 4: Developmental Milestones in Normal Children 27Chapter 5: Developmental Assessment 31Chapter 6: Developmental Dyslexia 37Chapter 7: The H.E.A.D.S.S. Assessment 45Chapter 8: End of Life Care in Children 49
Section 2 NeonatalogyChapter 9: Principles of Transport of the Sick Newborn 55Chapter 10: The Premature Infant 63Chapter 11: Enteral Feeding in Neonates 67Chapter 12: Total Parenteral Nutrition for Neonates 71Chapter 13: NICU - General Pointers for Care and Review of Newborn Infants 77Chapter 14: Vascular Spasm and Thrombosis 85Chapter 15: Guidelines for the Use of Surfactant 91Chapter 16: The Newborn and Acid Base Balance 93Chapter 17: Neonatal Encephalopathy 97Chapter 18: Neonatal Seizures 101Chapter 19: Neonatal Hypoglycemia 107Chapter 20: Neonatal Jaundice 111Chapter 21: Exchange Transfusion 117Chapter 22: Prolonged Jaundice in Newborn Infants 121Chapter 23: Apnoea in the Newborn 125Chapter 24: Neonatal Sepsis 127Chapter 25: Congenital Syphilis 129Chapter 26: Ophthalmia Neonatorum 131Chapter 27: Patent Ductus Arteriosus in the Preterm 133Chapter 28: Persistent Pulmonary Hypertension of the Newborn 135Chapter 29: Perinatally Acquired Varicella 139
Section 3 Respiratory MedicineChapter 30: Asthma 149Chapter 31: Viral Bronchiolitis 161Chapter 32: Viral Croup 163Chapter 33: Pneumonia 165
ix
TABLE OF CONTENTS
Section 4 CardiologyChapter 34: Paediatric Electrocardiography 171Chapter 35: Congenital Heart Disease in the Newborn 173Chapter 36: Hypercyanotic Spell 181Chapter 37: Heart Failure 183Chapter 38: Acute Rheumatic Failure 185Chapter 39: Infective Endocarditis 187Chapter 40: Kawasaki Disease 191Chapter 41: Viral Myocarditis 195Chapter 42: Paediatric Arrhythmias 197
Section 5 NeurologyChapter 43: Status Epilepticus 205Chapter 44: Epilepsy 207Chapter 45: Febrile Seizures 213Chapter 46: Meningitis 215Chapter 47: Acute CNS Demyelination 219Chapter 48: Acute Flaccid Paralysis 221Chapter 49: Guillain Barré Syndrome 223Chapter 50: Approach to The Child With Altered Consciousness 225Chapter 51: Childhood Stroke 227Chapter 52: Brain Death 231
Section 6 EndocrinologyChapter 53: Approach to A Child with Short Stature 237Chapter 54: Congenital Hypothyroidism 241Chapter 55: Diabetes Mellitus 245Chapter 56: Diabetic Ketoacidosis 255Chapter 57: Disorders of Sexual Development 263
Section 7 NephrologyChapter 58: Post-Infectious Glomerulonephritis 275Chapter 59: Nephrotic Syndrome 279Chapter 60: Acute Kidney Injury 285Chapter 61: Acute Peritoneal Dialysis 293Chapter 62: Neurogenic Bladder 299Chapter 63: Urinary Tract Infection 305Chapter 64: Antenatal Hydronephrosis 313
x
TABLE OF CONTENTS
Section 8 Haematology and OncologyChapter 65: Approach to a Child with Anaemia 321Chapter 66: Thalassaemia 325Chapter 67: Immune Thrombocytopenic Purpura 331Chapter 68: Haemophilia 337Chapter 69: Oncology Emergencies 343Chapter 70: Acute Lymphoblastic Leukaemia 353
Section 9 GastroenterologyChapter 71: Acute Gastroenteritis 359Chapter 72: Chronic Diarrhoea 365Chapter 73: Approach to Severely Malnourished Children 373Chapter 74: Gastro-oesophageal Reflux 377Chapter 75: Acute Hepatic Failure in Children 383Chapter 76: Approach to Gastrointestinal Bleeding 387
Section 10 Infectious DiseaseChapter 77: Sepsis and Septic Shock 391Chapter 78: Pediatric HIV 397Chapter 79: Malaria 413Chapter 80: Tuberculosis 419Chapter 81: BCG Lymphadenitis 425Chapter 82: Dengue and Dengue Haemorrhagic Fever with Shock 427Chapter 83: Diphteria 439
Section 11 DermatologyChapter 84: Atopic Dermatitis 445Chapter 85: Infantile Hemangioma 451Chapter 86: Scabies 455Chapter 87: Steven Johnson Syndrome 457
Section 12 Metabolic DisordersChapter 88: Inborn errors metabolism (IEM): Approach to Diagnosis and Early Management in a Sick Child 461Chapter 89: Investigating Inborn errors metabolism (IEM) in a Child with Chronic Symptoms 471Chapter 90: Approach to Recurrent Hypoglycemia 483Chapter 91: Down Syndrome 489
xi
TABLE OF CONTENTS
Section 13 Paediatric SurgeryChapter 92: Appendicitis 495Chapter 93: Vomiting in the Neonate and Child 497Chapter 94: Intussusception 507Chapter 95: Inguinal hernias, Hydrocoele 511Chapter 96: Undescended Testis 513Chapter 97: The Acute Scrotum 515Chapter 98: Penile Conditions 519Chapter 99: Neonatal Surgery 521
Section 14 RheumatologyChapter 100: Juvenile Idiopathic Arthritis (JIA) 535
Section 15 Poisons and ToxinsChapter 101: Snake Bite 543Chapter 102: Common Poisons 549Chapter 103: Anaphylaxis 559
Section 16 Sedation and ProceduresChapter 104: Recognition and Assessment of Pain 565Chapter 105: Sedation and Analgesia for Diagnostic and Therapeutic Procedures 567Chapter 108: Practical Procedures 571
xii
AcknowledgementsAgain, to Dr Koh Chong Tuan, Consultant Paediatrician at Island Hospital, Penang for his excellent work in proof reading the manuscript.
1
VITAL SIGNS
Respiratory (Breath) Rate
Normal, Breath rate at rest Abnormal
Age (years) Rate/min These values define Tachypnoea
60
2-5 25-30 2 mths - 1 year > 50
5-12 20-25 1-5 years > 40
Heart (Pulse) Rate
Abnormal Normal Abnormal
Age (years) Low (Bradycardia) Average High (Tachycardia)
Newborn < 70/min 125/min > 190/min
1-11 months < 80/min 120/min > 160/min
2 years < 80/min 110/min > 130/min
4 years < 80/min 100/min > 120/min
6 years < 75/min 100/min > 115/min
8 years < 70/min 90/min > 110/min
10 years < 70/min 90/min > 110/min
Ref: Nelson Textbook of Pediatrics, 18th Edition
Blood Pressure
Hypotension if below Normal (average)
Age (years) 5th centile for age 50th centile for age
< 1 year 65 - 75 mmHg 80 - 90 mmHg
1-2 years 70 - 75 mmHg 85 - 95 mmHg
2-5 years 70 - 80 mmHg 85 - 100 mmHg
5-12 years 80 - 90 mmHg 90 - 110 mmHg
> 12 years 90 - 105 mmHg 100-120 mmHg
Calculation for Expected Systolic Blood Pressure= 85 + (2 x age in years) mmHg for 50th centile - Median Blood Pressure= 65 + (2 x age in years) mmHg for 5th centile - Hypotension if below this value
Ref: Advanced Paediatric Life Support: The Practical Approach, Fifth Edition 2011
GEN
ERAL PAEDIATRICS
Chapter 1: Normal Values in Children
2
GEN
ERAL
PAE
DIA
TRIC
S
Blood Pressure in Hypertension
Age Significant Hypertension Severe Hypertension
1 week Systolic 96 mmHg Systolic 106 mmHg
1 wk - 1 mth Systolic 104 mHg Systolic 110 mmHg
Infant Systolic 112 mmHg Systolic 118 mmHg
Diastolic 74 mmHg Diastolic 82 mmHg
3-5 years Systolic 116 mmHg Systolic 124 mmHg
Diastolic 76 mmHg Diastolic 86 mmHg
6-9 years Systolic 122 mmHg Systolic 130 mmHg
Diastolic 78 mmHg Diastolic 86 mmHg
10-12 years Systolic 126 mmHg Systolic 134 mmHg
Diastolic 82 mmHg Diastolic 90 mmHg
13-15 years Systolic 136 mmHg Systolic 144 mmHg
Diastolic 86 mmHg Diastolic 92 mmHg
16-18 years Systolic 142 mmHg Systolic 150 mmHg
Diastolic 92 mmHg Diastolic 98 mmHg
3
ANTHROPOMETRIC MEASUREMENTS
Age Weight Height Head size
birth 3.5 kg 50 cm 35 cm
6 months 7 kg 68 cm 42 cm
1 year 10 kg 75 cm 47 cm
2 years 12 kg 85 cm 49 cm
3 years 14 kg 95 cm 49.5 cm
4 years 100 cm 50 cm
5-12 years 5 cm/year 0.33 cm/year
Points to NoteWeight • In the first 7 - 10 days of life, babies lose 10 - 15% of their birth weight. • In the first 3 months of life, the rate of weight gain is 25 gm/day • Babies regain their birth weight by the 2nd week, double this by 5 months age, and triple the birth weight by 1 year of age • Weight estimation for children (in Kg): Infants: (Age in months X 0.5) + 4 Children 1 – 10 years: (Age in yrs + 4) X 2
Head circumference • Rate of growth in preterm infants is 1 cm/week, but reduces with age. Head growth follows that of term infants when chronological age reaches term • Head circumference increases by 12 cm in the 1st year of life (6 cm in first 3 months, then 3 cm in second 3 months, and 3 cm in last 6 months)
Other normal values are found in the relevant chapters of the book. References:1. Advanced Paediatric Life Support: The Practical Approach Textbook, 5th Edition 20112. Nelson Textbook of Pediatrics, 18th Edition.
GEN
ERAL PAEDIATRICS
4
GEN
ERAL PAEDIATRICS
HA
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5
Nati
onal
Imm
unis
ation
Sch
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r Mal
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inis
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ealth
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aysi
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Age
(mon
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56
910
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BCG
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no sc
ar
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Chapter 2: ImmunisationsG
ENERAL PAED
IATRICS
6
General Notes • Many vaccines (inactivated or live) can be given together simultaneously (does not impair antibody response or increase adverse effect). But they are to be given at different sites unless given in combined preparations. Vaccines are now packaged in combinations to avoid multiple injections to the child. • sites of administration - oral – rotavirus, live typhoid vaccines - intradermal (ID) - BCG. Left deltoid area (proximal to insertion deltoid muscle) - deep SC, IM injections. (ALL vaccines except the above) • anterolateral aspect of thigh – preferred site in children • upper arm – preferred site in adults • upper outer quadrant of buttock - associated with lower antibody level production
Immunisation : General contraindications • Absolute contraindication for any vaccine: severe anaphylaxis reactions to previous dose of the vaccine or to a component of the vaccine. • Postponement during acute febrile illness: Minor infection without fever or systemic upset is NOT a contraindication. • A relative contraindication: avoid a vaccine within 2 weeks of elective surgery. • Live vaccine: Absolute contraindications - Immunosuppressed children -malignancy; irradiation, leukaemia, lymphoma, primary immunodeficiency syndromes (but NOT asymptomatic HIV). - On chemotherapy or < 6 months after last dose. - On High dose steroids, i.e. Prednisolone ≥ 2 mg/kg/day for > 7 days or low dose systemic > 2 weeks: delay vaccination for 3 months. - If topical or inhaled steroids OR low dose systemic < 2 weeks or EOD for > 2 weeks, can administer live vaccine. - If given another LIVE vaccine including BCG < 4 weeks ago. (Give live vaccines simultaneously. If unable to then give separately with a 4 week interval). - Within 3 months following IV Immunoglobulin (11 months if given high dose IV Immunoglobulins, e.g. in Kawasaki disease).
3 weeks 3 months
Live Vaccine HNIG Live vaccine (Human Normal Immunoglobulin)
- Pregnancy (live vaccine - theoretical risk to foetus) UNLESS there is significant exposure to serious conditions like polio or yellow fever in which case the importance of vaccination outweighs the risk to the foetus. • Killed vaccines are generally safe. The only absolute contraindications are SEVERE local (induration involving > 2/3 of the limbs) or severe generalised reactions in the previous dose.
GEN
ERAL
PAE
DIA
TRIC
S
7
The following are not contraindications to vaccination • Mild illness without fever e.g. mild diarrhoea, cough, runny nose. • Asthma, eczema, hay fever, impetigo, heat rash (avoid injection in affected area). • Treatment with antibiotics or locally acting steroids. • Child’s mother is pregnant. • Breastfed child (does not affect polio uptake). • Neonatal jaundice. • Underweight or malnourished. • Over the recommended age. • Past history of pertussis, measles or rubella (unless confirmed medically) • Non progressive, stable neurological conditions like cerebral palsy, Down syndrome, simple febrile convulsions, controlled epilepsy, mental retardation. • Family history of convulsions. • History of heart disease, acquired or congenital. • Prematurity (immunise according to schedule irrespective of gestational age)
Vaccination: Special Circumstances • Measures to protect inpatients exposed to another inpatient with measles: - Protect all immunocompromised children with Immunoglobulin (HNIG) 0.25-0.5 mls/kg. (Measles may be fatal in children in remission from leukaemia) - Check status of measles immunisation in the other children. Give measles monocomponent vaccine to unimmunised children within 24 hrs of exposure. Vaccination within 72 hours aborts clinical measles in 75% of contacts - Discharge the inpatient child with uncomplicated measles. - Do not forget to notify the Health Office. • Immunisation in children with HIV (Please refer to Paediatric HIV section) • In patients with past history or family history of febrile seizures, neurological or developmental abnormalities that would predispose to febrile seizures:- - Febrile seizures may occur 5 – 10 days after measles (or MMR) vaccination or within the first 72 hours following pertussis immunisation. - Give Paracetamol (120 mg or ¼ tablet) prophylaxis after immunisation (esp. DPT) 4-6 hourly for 48 hours regardless of whether the child is febrile. This reduces the incidence of high fever, fretfulness, crying, anorexia and local inflammation. • Maternal Chicken Pox during perinatal period. (Please refer to Perinatally acquired varicella section) • Close contacts of immunodeficient children and adults must be immunized, particularly against measles and polio (use IPV).• In contacts of a patient with invasive Haemophilus influenzae B disease: - Immunise all household, nursery or kindergarden contacts < 4 years of age. - Household contacts should receive Rifampicin prophylaxis at 20 mg/kg once daily (Maximum 600 mg) for 4 days (except pregnant women - give one IM dose of ceftriaxone ) - Index case should be immunised irrespective of age.
GEN
ERAL PAEDIATRICS
8
• Children with Asplenia (Elective or emergency splenectomy; asplenic syndromes; sickle cell anaemia) are susceptible to encapsulated bacteria and malaria. - Pneumococcal, Meningococcal A, C, Y & W-135, Haemophilus influenza b vaccines should be given. - For elective splenectomy (and also chemotherapy or radiotherapy): give the vaccines preferably 2 or more weeks before the procedure. However, they can be given even after the procedure. - Penicillin prophylaxis should continue ideally for life. If not until 16 years old for children or 5 years post splenectomy in adults. • Babies born to mothers who are HbeAg OR HbsAg positive should be given Hepatitis B immunoglobulin (200 IU) and vaccinated with the Hepatitis B vaccine within 12 hours and not later than 48 hours. Given in different syringes and at different sites. • Premature infants may be immunised at the same chronological age as term infants. (Please refer section on The premature infants for more discussion)
GEN
ERAL
PAE
DIA
TRIC
S
9
Vacc
ines
, ind
icati
ons,
con
trai
ndic
ation
s, d
oses
and
side
effe
cts
Vacc
ine
Indi
catio
n/D
ose
Con
trai
ndic
atio
nPo
ssib
le S
ide
Effe
cts
Not
es
BCG
To b
e gi
ven
at b
irth
an
d to
be
repe
ated
if
no s
car
is p
rese
nt
Not
to
be g
iven
to
sym
pto-
mat
ic H
IV in
fect
ed c
hild
ren.
Can
be
give
n to
new
born
s of
HIV
infe
cted
mot
her
as
the
infa
nt is
usu
ally
asy
mp-
tom
atic
at
birt
h.
BCG
ade
nitis
may
occ
ur.
Intr
ader
mal
.Lo
cal r
eact
ion:
a p
apul
e at
va
ccin
atio
n si
te m
ay o
ccur
in
2 -
6 w
eeks
. Thi
s gr
ows
and
flatt
ens
with
sca
ling
and
crus
ting.
Occ
asio
nally
a
disc
harg
ing
ulce
r m
ay o
ccur
. T
his
heal
s le
avin
g a
scar
of
at le
ast
4 m
m in
suc
cess
ful
vacc
inat
ion.
Hep
atiti
s B
All
infa
nts,
incl
udin
g th
ose
born
to
HBs
Ag
posi
tive
mot
hers
A
ll he
alth
car
e pe
rson
nel.
Seve
re h
yper
sens
itivi
ty t
o al
umin
ium
. The
vac
cine
is
also
not
indi
cate
d fo
r H
BV
carr
ier
or im
mun
ed p
atie
nt
( i.e
. HBs
Ag
or A
b po
sitiv
e)
Loca
l rea
ctio
ns.
Feve
r an
d flu
-like
sym
ptom
s in
firs
t 48
hou
rs.
Rar
ely,
eryt
hem
a m
ultif
orm
e or
urt
icar
ia.
Intr
amus
cula
r.G
ive
with
Hep
B im
mun
o-gl
obul
in fo
r in
fant
s of
HBs
Ag
posi
tive
mot
hers
.
Dip
hthe
ria,
Te
tanu
s (D
T)
All
infa
nts
shou
ld
rece
ive
5 do
ses
incl
udin
g bo
oste
r do
ses
at 1
8 m
onth
s an
d St
anda
rd 1
Seve
re h
yper
sens
itivi
ty t
o al
umin
ium
and
thi
omer
sal
Swel
ling,
redn
ess
and
pain
A s
mal
l pai
nles
s no
dule
may
de
velo
p at
inje
ctio
n si
te –
ha
rmle
ss.
Tran
sien
t fe
ver,
head
ache
s,
mal
aise
, rar
ely
anap
hyla
xis.
Neu
rolo
gica
l rea
ctio
ns r
are.
Intr
amus
cula
r
GEN
ERAL PAEDIATRICS
10
Vacc
ine
Indi
catio
n/D
ose
Con
trai
ndic
atio
nPo
ssib
le S
ide
Effe
cts
Not
es
Pert
ussi
sA
ll in
fant
s sh
ould
re
ceiv
e 4
dose
s in
clud
ing
boos
ter
at
18 m
onth
s
It is
rec
omm
ende
d th
at b
oost
er d
oses
be
giv
en a
t St
d 1
and
at F
orm
3 d
ue
to in
crea
sed
case
s of
Per
tuss
is a
mon
gst
adol
esce
nts
in
rece
nt y
ears
Ana
phyl
axis
to
prev
ious
do
se; e
ncep
halo
path
y de
velo
ps w
ithin
7 d
ays
of
vacc
inat
ion
Prec
autio
ns: s
ever
e re
actio
n to
pre
viou
s do
se (
syst
emic
or
loca
l) an
d pr
ogre
ssiv
e ne
urol
ogic
al d
isea
ses.
Loca
l rea
ctio
n. S
ever
e if
invo
lve
2/3
limbs
Seve
re s
yste
mic
rea
ctio
n:
Ana
phyl
axis
(2 p
er 1
00 0
00
dose
s), e
ncep
halo
path
y (0
–
10.5
per
mill
ion
dose
s), h
igh
feve
r (fe
ver>
40.5
), fit
s w
ithin
72
hou
rs, p
ersi
sten
t in
con-
sola
ble
cryi
ng (
0.1
to 6
%),
hypo
resp
onsi
ve s
tate
.
Ace
llula
r Pe
rtus
sis
vacc
ine
asso
ciat
ed w
ith le
ss s
ide
effe
cts
Intr
amus
cula
r.
Stat
ic n
euro
logi
cal d
isea
ses,
de
velo
pmen
tal d
elay
, per
sona
l or
fa
mily
his
tory
of fi
ts a
re
NO
T c
ontr
aind
icat
ions
.
Inac
tivat
ed
Polio
Vac
cine
(IP
V)
All
infa
nts
to b
e gi
ven
4 do
ses
incl
udin
g bo
oste
r at
18
mon
ths.
Alle
rgie
s to
neo
myc
in, p
oly-
myx
in a
nd s
trep
tom
ycin
Prev
ious
sev
ere
anap
hyla
ctic
re
actio
n
Loca
l rea
ctio
ns.
Intr
amus
cula
r.
Hae
mop
hilu
s In
fluen
zae
type
B (
Hib
)
All
infa
nts
shou
ld
rece
ive
4 do
ses
incl
udin
g bo
oste
r at
18
mon
ths.
Patie
nts
with
spl
enic
dy
sfun
ctio
n, a
nd
post
spl
enec
tom
y.
Con
firm
ed a
naph
ylax
is t
o pr
evio
us H
ib a
nd a
llerg
ies
to n
eom
ycin
, pol
ymyx
in a
nd
stre
ptom
ycin
Loca
l sw
ellin
g, re
dnes
s an
d pa
in s
oon
afte
r va
ccin
atio
n an
d la
st u
p to
24
hour
s in
10
% o
f vac
cine
esM
alai
se, h
eada
ches
, fev
er, i
r-ri
tabi
lity,
inco
nsol
able
cry
ing.
Ve
ry r
arel
y se
izur
es.
Intr
amus
cula
r
GEN
ERAL
PAE
DIA
TRIC
S
11
Vacc
ine
Indi
catio
n/D
ose
Con
trai
ndic
atio
nPo
ssib
le S
ide
Effe
cts
Not
es
Mea
sles
Saba
h, O
rang
Asl
i po
pula
tion
at 6
mth
s.N
ot u
sual
ly g
iven
to
child
ren
<12
mth
. If
ther
e is
a m
easl
es
outb
reak
, can
be
give
n to
chi
ldre
n 6
-11
mth
s ag
e. T
his
is la
ter
follo
wed
by
MM
R a
t 12
mth
s an
d 4-
6 ye
ars
age.
Avo
id in
pat
ient
s w
ith
hype
rsen
sitiv
ity t
o eg
gs,
neom
ycin
and
pol
ymyx
in.
Preg
nanc
y.C
hild
ren
with
unt
reat
ed
leuk
emia
, TB
and
othe
r ca
ncer
s.Im
mun
odefi
cien
cy.
Tran
sien
t ra
sh in
5%
.M
ay h
ave
feve
r be
twee
n D
5-D
12 p
ost
vacc
inat
ion.
U
RTI s
ympt
oms.
Febr
ile c
onvu
lsion
s (D
6-D
14)
in 1
:100
0 –
9000
dos
es o
f vac
-ci
ne. (
Nat
ural
infe
ctio
n 1:
200)
Ence
phal
opat
hy w
ithin
30
days
in
1:1
,000
,000
dos
es. (
Nat
ural
in
fect
ion
1:10
00 -
5000
)
Intr
amus
cula
r.**
Lon
g te
rm p
rosp
ectiv
e st
ud-
ies
have
foun
d no
ass
ocia
tion
betw
een
mea
sles
or M
MR
vac-
cine
and
infla
mm
ator
y bo
wel
di
seas
es, a
utism
or
SSPE
.
Mea
sles
, M
umps
, Ru-
bella
(M
MR
)
All
child
ren
from
12
to
15 m
onth
s.
Boos
ter
at 4
-6yr
s (o
r at
Std
1).
Seve
re r
eact
ion
to h
en’s
eggs
and
neo
myc
in.
Preg
nanc
y
Mea
sles
: As
abov
eIn
tram
uscu
lar.
Can
be
give
n ir
resp
ectiv
e of
pr
evio
us h
isto
ry o
f mea
sles
, m
umps
or
rube
lla in
fect
ion.
Mum
psR
arel
y tr
ansi
ent
rash
, pru
ri-
tis a
nd p
urpu
ra.
Paro
titis
in 1
% o
f vac
cine
es,
> 3
wee
ks a
fter
vac
cina
tion.
Orc
hitis
and
ret
ro b
ulba
r ne
uriti
s ve
ry r
are.
Men
ingo
ence
phal
itis
is m
ild
and
rare
. (1:
800,
000
dose
s).
(nat
ural
infe
ctio
n 1:
400)
.
Intr
amus
cula
r
GEN
ERAL PAEDIATRICS
12
Vacc
ine
Indi
catio
n/D
ose
Con
trai
ndic
atio
nPo
ssib
le S
ide
Effe
cts
Not
es
Rub
ella
Ras
h, fe
ver,
lym
phad
enop
a-th
y, th
rom
bocy
tope
nia,
tr
ansi
ent
peri
pher
al n
euri
tis.
Art
hriti
s an
d ar
thra
lgia
oc-
curs
in u
p to
3%
of c
hild
ren
and
20%
of a
dults
.
Giv
en a
s M
MR
Japa
nese
En
ceph
aliti
s (JE
)
Giv
en in
Sar
awak
at
9, 1
0 an
d 18
mon
ths
Boos
ter
at 4
yea
rs.
Imm
unod
efici
ency
and
m
alig
nanc
y, di
abet
es ,
acut
e ex
acer
batio
n of
car
diac
, he
patic
and
ren
al c
ondi
tions
Loca
l red
ness
, sw
ellin
g,
pain
, fev
er, c
hills
, hea
dach
e,
lass
itude
..
Inac
tivat
ed v
acci
ne.
Subc
utan
eous
.Pr
otec
tive
effic
acy
> 9
5%.
Hum
an P
ap-
illom
a Vir
us
(HPV
)
Indi
cate
d fo
r fe
mal
es a
ged
9-45
ye
ars.
Not
rec
omm
ende
d in
pr
egna
nt p
atie
nts.
Hea
dach
e, m
yalg
ia, i
njec
-tio
n si
te r
eact
ions
, fat
igue
, na
usea
, vom
iting
, dia
rrho
ea,
abdo
min
al p
ain,
pru
ritu
s,
rash
, urt
icar
ia, m
yalg
ia,
arth
ralg
ia, f
ever
.
2 va
ccin
es a
vaila
ble:
C
erva
rix
(GSK
): bi
vale
nt.
Gar
dasi
l (M
SD):
quad
riva
lent
.-
3 do
se s
ched
ule
IM (
0,
1-2m
onth
, 6 m
onth
). R
ecom
bina
nt v
acci
ne.
Prot
ectiv
e ef
ficac
y al
mos
t 10
0% in
pre
vent
ing
vacc
ine
type
cer
vica
l can
cer
in fi
rst
5 ye
ars.
GEN
ERAL
PAE
DIA
TRIC
S
13
Vacc
ine
Indi
catio
n/D
ose
Con
trai
ndic
atio
nPo
ssib
le S
ide
Effe
cts
Not
es
Pneu
mo-
cocc
al
(con
juga
te)
vacc
ine:
PC
V
13/ P
CV
7
Dos
age:
In
fant
s 2-
6 m
th a
ge.
3-do
se p
rim
ary
seri
es a
t le
ast
1 m
th
apar
t fr
om 6
wks
of
age
. Bo
oste
r: 1
dose
be
twee
n 12
-15
mth
s of
age
. U
nvac
cina
ted:
in
fant
s 7-
11 m
ths
2 do
ses
1 m
onth
ap
art,
follo
wed
by
a 3r
d do
se a
t 12
- 15
m
onth
s; ch
ildre
n 12
-23
mon
ths
2 do
ses
at le
ast
2 m
onth
s ap
art;
heal
thy
child
ren
2 -
5 ye
ars:
Si
ngle
dos
e
Unv
acci
nate
d hi
gh
risk
chi
ldre
n 2-
5 yr
s ag
e m
ay b
e gi
ven
2 do
ses
(6-8
wks
ap
art)
Chi
ldre
n w
ho h
ave
seve
re
alle
rgic
rea
ctio
n to
pre
viou
s pn
eum
ococ
cal v
acci
ne
Hea
lthy
child
ren
unde
r 6
wee
ks a
nd m
ore
than
59
mon
ths
of a
ge
Dec
reas
ed a
ppet
ite,
irri
tabi
lity,
drow
sine
ss,
rest
less
sle
ep, f
ever
, inj
site
er
ythe
ma,
indu
ratio
n or
pa
in, r
ash.
Not
in B
lue
Book
Imm
unog
enic
in c
hild
ren
< 2
yea
rs
Inac
tivat
ed v
acci
ne.
Intr
amus
cula
r
Hig
h ri
sk c
hild
ren:
im
mun
osup
pres
sion
(in
clud
-in
g as
ympt
omat
ic H
IV),
aspl
enia
, nep
hrot
ic s
yndr
ome
and
chro
nic
lung
or
hear
t di
seas
e.
GEN
ERAL PAEDIATRICS
14
Vacc
ine
Indi
catio
n/D
ose
Cont
rain
dica
tion
Poss
ible
Sid
e Eff
ects
Not
es
Pneu
moc
oc-
cal (
poly
sac-
char
ide
vacc
ine)
Reco
mm
ende
d fo
r ch
ildre
n at
hig
h ri
sk.
> 2
year
s ol
d.
Sing
le d
ose.
Bo
oste
r at
3-5
yea
rs
only
for
high
ris
k pa
tient
s.
Age
< 2
yea
rs o
ld.
Reva
ccin
ation
with
in 3
yea
rs
has
high
ris
k of
adv
erse
re
actio
n;
Avoi
d du
ring
che
mot
hera
py
or ra
diot
hera
py a
nd le
ss
than
10
days
pri
or to
com
-m
ence
men
t of s
uch
ther
apy
– an
tibod
y re
spon
se is
poo
r. Pr
egna
ncy.
Hyp
erse
nsiti
vity
reac
tions
.Li
sted
in B
lue
Book
. In
tram
uscu
lar,
Subc
utan
eous
Imm
unog
enic
in c
hild
ren
≥2
yrs.
Aga
inst
23
sero
type
s.H
igh
risk:
imm
unos
uppr
essio
n,
asym
ptom
atic
HIV
, asp
leni
a,
neph
rotic
synd
rom
e, c
hron
ic
lung
dise
ase.
If th
ese
child
ren
are
2 yr
s, th
en th
e po
lysa
ccha
ride
va
ccin
e is
use
d.
Rota
viru
sFi
rst d
ose
give
n to
in
fant
s ≥
6 w
ks o
ld.
Rota
teq
(3 d
oses
) Su
bseq
uent
dos
es
give
n at
4-1
0 w
ks in
-te
rval
. 3rd
dos
e gi
ven
≤ 32
wee
ks a
ge.
Rota
rix (2
dos
es).
2nd
dose
to b
e gi
ven
by
24 w
eeks
age
. Int
er-
val b
etw
een
dose
s sh
ould
be
> 4
wks
.
Prio
r hy
pers
ensi
tivity
to a
ny
vacc
ine
com
pone
nt.
Unc
orre
cted
con
geni
tal G
IT
mal
form
ation
, e.g
. Mec
kel’s
di
verti
culu
m
Seve
re c
ombi
ned
imm
uno-
defic
ienc
y di
seas
e (r
epor
ted
prol
onge
d sh
eddi
ng o
f vac
-ci
ne v
irus
repo
rted
in in
fant
s w
ho h
ad li
ve R
otav
irus
va
ccin
e)
Loss
of a
ppeti
te, i
rrita
bilit
y,
feve
r, fa
tigue
, dia
rrho
ea,
vom
iting
, flat
ulen
ce, a
b-do
min
al p
ain,
regu
rgita
tion
of fo
od.
Ora
l liv
e-att
enua
ted
vacc
ine.
Prot
ectiv
e effi
cacy
88-
91%
fo
r an
y ro
tavi
rus
gast
roen
-te
ritis
epi
sode
; 63-
79%
for
all
caus
es o
f gas
troe
nter
itis.
GEN
ERAL
PAE
DIA
TRIC
S
15
Vacc
ine
Indi
catio
n/D
ose
Cont
rain
dica
tion
Poss
ible
Sid
e Eff
ects
Not
es
Vari
cella
Zo
ster
12 m
ths
to 1
2 yr
s:
Sing
le d
ose
> 12
yrs
: 2
dose
s ≥4
wks
apa
rt.
Non
imm
une
sus-
cepti
ble
heal
th c
are
wor
kers
who
regu
-la
rly c
ome
in c
onta
ct
with
VZV
infe
ction
Asym
ptom
atic/
mild
ly
sym
ptom
atic
child
ren
with
HIV
(with
CD
4%
> 15
%);
2 do
ses a
t 3
mth
s int
erva
l.Ch
ildre
n in
rem
issio
n fr
om le
ukem
ia fo
r ≥1
yr, h
ave
>700
/ml c
ir-cu
latin
g ly
mph
ocyt
es
may
rece
ive
vacc
ine
unde
r pae
diat
ricia
n su
perv
ision
(2do
ses)
.
Preg
nant
pati
ents
.Pa
tient
s re
ceiv
ing
high
dos
e sy
stem
ic im
mun
osup
pres
-si
on th
erap
y.Pa
tient
s w
ith m
alig
nanc
y es
peci
ally
hae
mat
olog
i-ca
l mal
igna
ncie
s or
blo
od
dysc
rasi
as.
Hyp
erse
nsiti
vity
to n
eom
ycin
.
Occ
asio
nally
, pap
ulov
esic
u-la
r er
uptio
ns, i
njec
tion
site
re
actio
ns, h
eada
che,
feve
r, pa
rest
hesi
a, fa
tigue
Live
att
enua
ted
vacc
ine.
Su
bcut
aneo
us.
70 –
90%
effe
ctive
ness
.
Hep
atitis
AFo
r chi
ldre
n >1
yr.
2 do
ses.
, giv
en 6
-12
mon
ths a
part
.
Seve
re h
yper
sens
itivi
ty to
al
umin
ium
hyd
roxi
de, p
he-
noxy
etha
nol,
neom
ycin
Loca
l rea
ction
s. F
lu-li
ke
sym
ptom
s la
sting
2 d
ays
in
10%
of r
ecip
ient
s
Intr
amus
cula
r. In
activ
ated
vac
cine
.Pr
otec
tive
effica
cy 9
4%.
GEN
ERAL PAEDIATRICS
16
Vacc
ine
Indi
catio
n/D
ose
Con
trai
ndic
atio
nPo
ssib
le S
ide
Effe
cts
Not
es
Cho
lera
Chi
ldre
n 2-
6 yr
s:
3 do
ses
at 1
-6 w
k in
terv
al.
Chi
ldre
n >
6 y
rs:
2 do
ses
at 1
-6 w
ks
inte
rval
. Bo
oste
r do
se >
2 yr
s.
Gas
troe
nter
itis
Ora
l ina
ctiv
ated
vac
cine
. Pr
otec
tive
effic
acy
80-9
0%
afte
r 6
mth
s w
anin
g to
60%
af
ter
3 yr
s.
Influ
enza
Sing
le d
ose.
Min
age
6 m
ths.
U
nprim
ed in
divi
dual
s re
quire
2nd
dos
e 4
- 6
wks
afte
r 1s
t dos
e.
Rec
omm
ende
d fo
r ch
ildre
n w
ith:
chro
nic
deco
mpe
n-sa
ted
resp
irato
ry o
r ca
rdia
c di
sord
ers,
e.
g. cy
anot
ic h
eart
di
seas
es c
hron
ic lu
ng
dise
ase,
HIV
infe
ctio
n.
In a
dvan
ced
dise
ase,
va
ccin
atio
n m
ay n
ot
indu
ce p
rote
ctiv
e an
tibod
y le
vels.
Hyp
erse
nsiti
vity
to
egg
or
chic
ken
prot
ein,
neo
myc
in,
form
alde
hyde
. Fe
brile
illn
ess,
acut
e in
fec-
tion.
Tran
sien
t sw
ellin
g, re
dnes
s,
pain
and
indu
ratio
n lo
cally
.M
yalg
ia, m
alai
se a
nd
feve
r fo
r 1
– 2
days
sta
rtin
g w
ithin
a fe
w h
ours
pos
t va
ccin
atio
n. V
ery
rare
ly,
neur
olog
ical
(G
uilla
in-B
arre
), gl
omer
ulon
ephr
itis,
ITP
or
anap
hyla
ctic
rea
ctio
n oc
curs
.
Intr
amus
cula
r. In
activ
ated
vac
cine
.Pr
otec
tive
effic
acy
70-9
0%R
equi
re y
earl
y re
vacc
inat
ion
for
cont
inui
ng p
rote
ctio
n.
GEN
ERAL
PAE
DIA
TRIC
S
17
Vacc
ine
Indi
catio
n/D
ose
Con
trai
ndic
atio
nPo
ssib
le S
ide
Effe
cts
Not
es
Rab
ies
Pre-
expo
sure
: 3 d
oses
at D
ay 0
, 7,
28.
Boos
ter
ever
y 2-
3 yr
s.Po
st-e
xpos
ure
trea
tmen
t:Fu
lly im
mun
ised:
2 d
oses
at
Day
0, D
ay 3
. R
abie
s Im
mun
e G
lobu
lin (R
IG) u
nnec
essa
ry.
Uni
mm
unise
d: 5
dos
es a
t Day
0,
3, 7,
14 a
nd 2
8. R
IG (2
0 IU
/kg
giv
en h
alf a
roun
d th
e w
ound
an
d th
e re
st IM
.
Hea
dach
e, d
izzi
ness
, mal
aise
, ab
dom
inal
pai
n, n
ause
a, m
y-al
gia.
Inje
ctio
n si
te r
eact
ions
su
ch a
s itc
hing
, sw
ellin
g, pa
in.
Inac
tivat
ed v
acci
ne.
(Ava
ilabl
e in
Mal
ay-
sia
as P
urifi
ed V
ero
Cel
l Rab
ies V
acci
ne
(PV
RV).
Intr
amus
cula
r.
Men
ingo
coc-
cus A
, C, Y
&
W-1
35
Sing
le d
ose.
Im
mun
ity u
p to
3 y
rs.
Loca
l rea
ctio
ns.
Irri
tabi
lity,
feve
r an
d ri
gors
for
1-2
days
. Ve
ry r
arel
y, an
aphy
laxi
s.
Intr
amus
cula
r.
Typh
oid
(Typ
him
Vi)
Sing
le d
ose.
Ser
ocon
vers
ion
in
85-9
5% o
f rec
ipie
nts;
conf
ers
60-8
0% p
rote
ctio
n be
ginn
ing
2 w
ks a
fter
vac
cina
tion.
Bo
oste
rs e
very
3 y
rs.
Chi
ldre
n <
2yr
s.(Im
mun
ogen
icity
< 2
yrs
of
age
has
not
been
est
ab-
lishe
d)
Loca
l rea
ctio
ns.
Mya
lgia
, m
alai
se, n
ause
a, he
adac
hes
and
feve
r in
3%
of r
ecip
ient
s.
Intr
amus
cula
r.Po
lysa
ccha
ride
va
ccin
e
Typh
oid
(Ty2
1a v
ac-
cine
)
Thr
ee d
oses
tw
o da
ys a
part
. Ef
fect
ive
7 da
ys a
fter
last
do
se. B
oost
er e
very
3 y
ears
.
Infa
nt <
6 m
th.
Con
geni
tal o
r ac
quir
ed
imm
unod
efici
ency
. Acu
te
febr
ile il
lnes
s &
acu
te in
tes-
tinal
infe
ctio
n.
Very
rar
ely:
mild
GIT
di
stur
banc
es o
r a
tran
sito
ry
exan
them
a.
Ora
l. L
ive
atte
nu-
ated
vac
cine
.
GEN
ERAL PAEDIATRICS
18
Recommended Immunisation Schedule for Infants and Children Not Immunised at the Recommended Time
Time of Immunisation Age at first visit
Between 6 wks -12 mths 12 months and older
1st visit BCG, DPT/DTaP, Hib1, IPV1, HBV1
BCG, DPT/DTaP1, Hib1, IPV1, HBV1, measles (footnote 2) at 6 or 9 mths, MMR at 12 mths of age
2nd visit (1 mth later) DPT/DTaP2, IPV2, HBV2, Hib2
3rd visit (1 mth later) DPT/DTaP2,Hib2, IPV2, HBV2
DPT/DTaP3, IPV3,
4th visit (4 mths after 3rd visit)
DPT/DTaP3,Hib3, IPV3, HBV3, DPT/DTaP4, IPV4,
2-8 mths later HBV3, DTaP4, Hib4 & IPV4 (booster), measles in Sabah at 9 mths age, MMR at 12 mths age
Polio, DT/DTaP, MMR (at school entry)
Footnotes:1. For infants < 6 wks age, use “Recommended Immunisation Schedule for Infants & Children”. 2. Measles vaccine should be given only after 9 mths. (exception - given at 6 months in Sabah)3. For special groups of children with no regular contact with Health Services and with no immunisation records, BCG, HBV, DTaP- Hib-IPV and MMR can be given simultaneously at different sites at first contact.4. It is not necessary to restart a primary course of immunisation regardless of the period that has elapsed since the last dose was given. Only the subsequent course that has been missed need be given. (Example. An infant who has been given IPV1 and then 9 months later comes for follow-up, the IPV1 need not be repeated. Go on to IPV2.). Only exception is Hepatitis A vaccine.
GEN
ERAL
PAE
DIA
TRIC
S
19
Well children with Normal hydrationVery few well children require intravenous fluids (IV). Whenever possible use an enteral (oral) route for fluids. These guidelines apply to children who are unable to tolerate enteral fluids.The safe use of IV fluid therapy in children requires accurate prescribing of fluids and careful monitoring because incorrectly prescribed or administered fluids are hazardous. If IV fluid therapy is required then maintenance fluid requirements should be calculated using the Holliday and Segar formula based on weight. However this should be only be used as a starting point and the individuals’ response to fluid therapy should be monitored closely by clinical observation, fluid balance, weight and a minimum daily electrolyte profile.
Prescribing Intravenous fluidsFluids are given intravenously for the following reasons: • Circulatory support in resuscitating vascular collapse. • Replacement of previous fluid and electrolyte deficit. • Maintenance of daily fluid requirement. • Replacement of ongoing losses. • Severe dehydration with failed nasogastric tube fluid replacement (e.g. on-going profuse losses, diarrhoea or abdominal pain). • Certain co-morbidities, particularly GIT conditions (e.g. short gut or previous gut surgery)
Resuscitation
Fluids appropriate for bolus administration are:
Crystalloids 0.9% Normal Saline
Ringer’s Lactate @ Hartmann’s solution
Colloids Gelafundin, Voluven
4.5% albumin solution
Blood products Whole blood, blood components
• Fluid deficit sufficient cause impaired tissue oxygenation (i.e. clinical shock) should be corrected with a fluid bolus of 10-20mls/kg. • Always reassess circulation - give repeat boluses as necessary. • Look for the cause of circulatory collapse - blood loss, sepsis, etc. This helps decide on the appropriate alternative resuscitation fluid. • Fluid boluses of 10mls/kg in selected situations - e.g. diabetic ketoacidosis, intracranial pathology or trauma. • Avoid low sodium-containing (hypotonic) solutions for resuscitation as this may cause hyponatremia.• Check blood glucose: treat hypoglycemia with 2mls/kg of 10% Dextrose solution.
Chapter 3: Paediatric Fluid and Electrolyte GuidelinesG
ENERAL PAED
IATRICS
20
• Measure Na, K and glucose at the outset and at least 24hourly from then on. More frequent testing is indicated in ill patients or those with co-morbidities. Rapid results of electrolytes can be done with blood gases measurements. • Consider septic work-up or surgical consult in severely unwell patients with abdominal symptoms (i.e. gastroenteritis).
Maintenance • Maintenance fluid is the volume of daily fluid intake. It includes insensible losses (from breathing, perspiration, and in the stool), and allows for excretion of the daily production of excess solute load (urea, creatinine, electrolytes) in the urine. • Most children can safely be managed with solution of 0.45% saline with added glucose (i.e. 0.45% saline in 5% glucose or 0.45% saline in 10% glucose) depending on glucose requirement. • Sodium chloride 0.18 saline with glucose 5% should not be used as a maintenance fluid and is restricted to specialist area to replace ongoing loses of hypotonic fluids. These areas include high dependency, renal, liver and intensive care. • Most children will tolerate standard fluid requirements. However some acutely ill children with inappropriately increased anti-diuretic hormone secretion (SIADH) may benefit from their maintenance fluid requirement being restricted to two-thirds of the normal recommended volume. • Children who are at high risk of hyponatremia should be given isotonic solutions (i.e. 0.9% saline ± glucose) with careful monitoring to avoid iatrogenic hyponatremia in hospital.
These include children with the following conditions: • Peri-or post-operative • Require replacement of ongoing losses • A plasma Na at lower normal range of normal (definitely if < 135mmol/L) • Intravascular volume depletion • Hypotension • Central nervous system (CNS) infection • Head injury • Bronchiolitis • Sepsis • Excessive gastric or diarrhoeal losses • Salt-wasting syndromes • Chronic conditions such as diabetes, cystic fibrosis and pituitary deficits.
GEN
ERAL
PAE
DIA
TRIC
S
21
Calculation of Maintanence Fluid RequirementsThe following calculations approximate the maintenance fluid requirement of well children according to weight in kg. (Holliday-Segar calculator)
Weight Total fluids Infusion rate
First 10 Kgs 100 ml/kg 4 mls/kg/hour
Subsequent 10 Kgs 50 ml/kg 2 mls/kg/hour
All additional Kg 20 ml/kg 1 mls/kg/hour
Example: A Child of 29 kg will require:
100mls/kg for first 10kg of weight 10 x 100 = 1000 mls
50mls/kg for second 10kg of weight 10 x 50 = 500 mls
20mls/kg for all additional weight 9 x 20 = 180 mls
Total = 1680 mls
Rate= 1680/24 = 70mls/hour
Composition of commonly used intravenous solution
Osmolality Na content Osmolality Tonicity
Fluid (mOsm/l) (mmol/l) compared to plasma
with ref to cell membrane
Na chloride 0.9% 308 154 IsoOsmolar Isotonic
Na chloride 0.45% 154 77 HypoOsmolar Hypotonic
Na chloride 0.9% + Glucose 5%
586 150 HyperOsmolar Isotonic
Na chloride 0.45%+ Glucose 5%
432 75 HyperOsmolar Hypotonic
Na chloride 0.18% + Glucose 5%
284 31 IsoOsmolar Hypotonic
Dextrose 5% 278 Nil IsoOsmolar Hypotonic
Dextrose 10% 555 Nil HyperOsmolar Hypotonic
Hartmann’s 278 131 IsoOsmolar Isotonic
GEN
ERAL PAEDIATRICS
22
GEN
ERAL
PAE
DIA
TRIC
S
Deficit
• A child’s water deficit in mls can be calculated following an estimation of the degree of dehydration expressed as % of body weight.
Example: A 10kg child who is 5% dehydration has a water deficit of 500mls.
Maintenance
100mls/kg for first 10 kg = 10 × 100 = 1000mls
Infusion rate/hour = 1000mls/24 hr = 42mls/hr
Deficit (give over 24hours)
5% dehydration (5% of body water): 5/100 × 10kg × 1000mls = 500mls
Infusion rate/hour (given over 24 hrs) = 500mls/24 hr = 21mls/hr
• The deficit is replaced over a time period that varies according to the child’s condition. Precise calculations (e.g. 4.5%) are not necessary. The rate of rehydration should be adjusted with ongoing clinical assessment. • Use an isotonic solution for replacement of the deficit, e.g. 0.9% saline. • Reassess clinical status and weight at 4-6hours, and if satisfactory continue. If child is losing weight, increase the fluid and if weight gain is excessive decrease the fluid rate. • Replacement may be rapid in most cases of gastroenteritis (best achieved by oral or nasogastric fluids), but should be slower in diabetic ketoacidosis and meningitis, and much slower in hypernatremic states (aim to rehydrate over 48-72 hours, the serum Na should not fall by >0.5mmol/l/hr).
Ongoing losses (e.g. from drains, ileostomy, profuse diarrhoea) • These are best measured and replaced. Any fluid losses > 0.5ml/kg/hr needs to be replaced. • Calculation may be based on each previous hour, or each 4 hour period depending on the situation. For example; a 200mls loss over the previous 4 hours will be replaced with a rate of 50mls/hr for the next 4 hours). • Ongoing losses can be replaced with 0.9% Normal Saline or Hartmann’s solution. Fluid loss with high protein content leading to low serum albumin (e.g. burns) can be replaced with 5% Human Albumin.
23
SODIUM DISORDERS
• The daily sodium requirement is 2-3mmol/kg/day. • Normal serum sodium is between 135-145mmol/l.
Hypernatremia • Hypernatremia is defined as serum Na+ > 150mmol/l, moderate hypernatremia is when serum Na+ is 150-160mmol/l, and severe hypernatremia is when serum Na+ > 160mmol/l. • It can be due to: • water loss in excess of sodium (e.g. diarrhoea) • water deficit (e.g. diabetes insipidus) • sodium gain (e.g. large amount of NaHCO3 infusion or salt poisoning).
• If the cause of the hypernatremia is central diabetes insipidus, it is advisable to consult Endocrinology team regarding management. • In hypernatremia the child appears sicker than expected for the degree of dehydration. • Shock occurs late because intravascular volume is relatively preserved. Signs of hypernatremic dehydration tend to be predominantly that of intracellular dehydration and neurological dysfunction.
ManagementThis will depend on the cause of hypernatremia. For hypernatremic dehydration with Na+> 150mmol/l • If the patient is in shock, give volume resuscitation with 0.9% Normal saline as required with bolus/es. • Avoid rapid correction as this may cause cerebral oedema, convulsion and death. • Aim for correction of deficit over 48-72 hours and a fall of serum sodium concentration not more than 0.5mmol/l/hour. • Give 0.9% saline to ensure the drop in sodium is not too rapid. • Remember to also give maintenance and replace ongoing losses following the recommendation above. • Repeat blood urea and electrolytes every 6 hours until stable.
Special considerations • A slower rate will be required for children with chronic hypernatremia (present for more than 5 days). • Calcium and glucose need to be checked as hypernatremia can be associated with hypocalcaemia and hyperglycemia, these conditions need to be corrected concurrently.
Clinical signs of Hypernatremic dehydration
Irritability
Skin feels “doughy”
Ataxia, tremor, hyperreflexia
Seizure
Reduced awareness, coma
GEN
ERAL PAEDIATRICS
24
GEN
ERAL
PAE
DIA
TRIC
S
Hyponatremia • Hyponatremia is defined when serum Na+ < 135mmol/l. • Hyponatremic encephalopathy is a medical emergency that requires rapid recognition and treatment to prevent poor outcome. • As part of the general resuscitative measures, bolus of 4ml/kg of 3% sodium chloride should be administered over 30 minutes. This will raised the serum sodium by 3mmol/l and will usually help stop hyponatremic seizures. • Gradual serum sodium correction should not be more than 8mmol/day to prevent osmotic demyelination syndrome.
Calculating sodium correction in acute hyponatremia
mmol of sodium required = (135-present Na level)× 0.6 × weight(kg)
The calculated requirements can then be given from the following available solutions dependent on the availability and hydration status:
0.9% sodium chloride contains 154 mmol/l
3% sodium chloride contains 513mmol/l
• Children with asymptomatic hyponatremia do not require 3% sodium chloride treatment and if dehydrated may be managed with oral fluids or intravenous rehydration with 0.9% sodium chloride. • Children who are hyponatremic and have a normal or raised volume status should be managed with fluid restriction. • For Hyponatremia secondary to diabetic ketoacidosis; refer DKA protocol.
POTASSIUM DISORDERS
• The daily potassium requirement is 1-2mmol/kg/day. • Normal values of potassium are: • Birth - 2 weeks: 3.7 - 6.0mmol/l • 2 weeks – 3 months: 3.7 - 5.7mmol/l • 3 months and above: 3.5 - 5.0mmol/l
Hyperkalemia • Causes are: • Dehydration • Acute renal failure • Diabetic ketoacidosis • Adrenal insufficiency • Tumour lysis syndrome • Drugs e.g. oral potassium supplement, K+ sparing diuretics, ACE inhibitors.
Treatment: see algorithm on next page
25
Hyperkalemia Treatment Algorithm
Drug doses: • IV Calcium 0.1 mmol/kg. • Nebulised Salbutamol: Age ≤2.5 yrs: 2.5 mg; Age 2.5-7.5 yrs: 5 mg; >7.5 yrs: 10 mg • IV Insulin with Glucose: Start with IV Glucose 10% 5ml/kg/hr (or 20% at 2.5 ml/kg/hr). Once Blood sugar level >10mmol/l and the K+ level is not falling, add IV Insulin 0.05 units/kg/hr and titrate according to glucose level. • IV Sodium Bicarbonate: 1-2 mmol/kg. • PO or Rectal Resonium : 1Gm/kg.
ECG changes in Hyperkalemia
Tall, tented T waves
Prolonged PR interval
Prolonged QRS complex
Loss of P wave, wide biphasic QRS
Stop all K+ supplementation
Stop medication causing hyperK+
Cardiac monitoring
Hyperkalemia K+ > 5.5 mmol/l
Transfer to tertiary centre?
Exclude pseudo hyperkalemia
Recheck with venous sample
Child stable,asymptomatic
Normal ECG
K+≥ 5.5, ≤ 6.0 mmol/L
Child unstable or symptomatic
Abnormal ECG
K+ > 7.0 mmol/l
Child stable,asymptomatic
Normal ECG
K+ >6, ≤ 7 mmol/L
Discuss for dialysis
IV Calcium
Neb Salbutamol
IV Insulin with glucose
IV Bicarbonate
± PR/PO Resonium
Neb Salbutamol
IV Insulin with glucose
± IV Bicarbonate if acidosis
± PR/PO Resonium
Consider treatment ?
± Neb Salbutamol
± IV Bicarbonate if acidosis
± PR/PO Resonium
GEN
ERAL PAEDIATRICS
26
Hypokalemia
• Hypokalemia is defined as serum Na+ > 3.4 mmol/l (Treat if < 3.0mmol/l or Clinically Symptomatic < 3.4 mmol/l) • Causes are: • Sepsis • GIT losses - diarrhoea, vomiting • Iatrogenic- e.g. diuretic therapy, salbutamol, amphotericin B. • Diabetic ketoacidosis • Renal tubular acidosis • Hypokalaemia is often seen with chloride depletion and metabolic alkalosis.
• Refractory hypokalaemia may occur with hypomagnesaemia.
Treatment • Identify and treat the underlying condition. • Unless symptomatic, a potassium level of 3.0 and 3.4 mmol/l is generally not supplemented but rather monitored in the first instance. • The treatment of hypokalaemia does not lend itself to be incorporated into a protocol and as a result each patient will need to be treated individually.
Oral Supplementation • Oral Potassium Chloride (KCL), to a maximum of 2 mmol/kg/day in divided doses is common but more may be required in practice.
Intravenous Supplementation (1gram KCL = 13.3 mmol KCL) • Potassium chloride is always given by IV infusion, NEVER by bolus injection. • Maximum concentration via a peripheral vein is 40 mmol/l (concentrations of up to 60 mmol/l can be used after discussion with senior medical staff). • Maximum infusion rate is 0.2mmol/kg/hr (in non-intensive care setting). Intravenous Correction (1gram KCL = 13.3 mmol KCL) • K+ < 2.5 mmol/L may be associated with significant cardiovascular compromise. In the emergency situation, an IV infusion KCL may be given • Dose: initially 0.4 mmol/kg/hr into a central vein, until K+ level is restored. • Ideally this should occur in an intensive care setting.
ECG changes of Hypokalemia
These occur when K+ < 2.5mmol/l
Prominent U wave
ST segment depression
Flat, low or diphasic T waves
Prolonged PR interval (severe hypoK+)
Sinoatrial block (severe hypoK+)
GEN
ERAL
PAE
DIA
TRIC
S
27
Cha
pter
4: D
evel
opm
enta
l Mile
ston
es in
Nor
mal
Chi
ldre
n
Age
Gro
ss M
otor
Fine
Mot
orSp
eech
/Lan
guag
eSo
cial
6 w
ksPu
ll to
sit:
Hea
d la
g, ro
unde
d ba
ckVe
ntra
l Sus
pens
ion:
Hea
d br
iefly
in s
ame
plan
e as
bod
y. Pr
one:
Pelv
is hi
gh, k
nees
no
long
er u
nder
abd
omen
. Chi
n ra
ised
occa
siona
lly.
Fixa
tes
and
follo
ws
to 9
0 de
gree
sVo
calis
ing
by 8
wee
ks. Q
uiet
s to
sou
nd. S
tart
les
to s
ound
.Sm
iles
resp
onsiv
ely.
3 m
ths
Pull
to s
it: Sl
ight
hea
d la
g. H
ead
occa
siona
lly b
obs
forw
ard.
Ve
ntra
l Sus
pens
ion:
Hea
d ab
ove
plan
e of
bod
y.Pr
one:
Pelv
is fla
t. Li
fts h
ead
up
45°-
90°
.
Han
d re
gard
. Fol
low
s obj
ect
from
side
to si
de (1
80°)
. Han
ds
held
loos
ely.
Gra
sps o
bjec
t pl
aced
in h
and.
N
ot re
achi
ng o
ut.
Sque
als
with
del
ight
.Tu
rns
head
to s
ound
.La
ughs
.
5 m
ths
Pull
to s
it: N
o he
ad la
g an
d sit
s w
ith s
trai
ght b
ack.
Lyin
g su
pine
: Fee
t to
mou
th.
Rea
ches
for
obje
cts.
Play
s w
ith to
es.
Mou
thin
g.
6 m
ths
Pulls
to s
it: Li
fts h
ead
in a
n-tic
ipat
ion.
Sits
with
sup
port
. Be
ars
wei
ght o
n le
gs. P
rone
: Su
ppor
ts w
eigh
t on
hand
s;
ches
t, up
per
abdo
men
off
couc
h. R
olls
pron
e to
sup
ine.
Palm
ar g
rasp
of c
ube,
ulna
r ap
proa
ch. M
oves
hea
d, e
yes
in
all d
irect
ions
. No
squi
nt (a
fter
4 m
onth
s).
GEN
ERAL PAEDIATRICS
28
Age
Gro
ss M
otor
Fine
Mot
orSp
eech
/Lan
guag
eSo
cial
18 m
ths
Get
s up
and
dow
n st
airs
ho
ldin
g on
to
rail
or w
ith
one
hand
hel
d. P
ulls
toy
or
car
ries
dol
l. Thr
ows
ball
with
out
falli
ng.
Sits
on
a ch
air.
Tow
er o
f 3 c
ubes
. Sc
ribb
les
spon
tane
ously
. V
isua
l tes
t: Pi
ctur
e ch
arts
. H
ande
dnes
s
Poin
ts t
o 2
- 3
body
par
ts.
Pict
ure
Car
ds -
iden
tify
one.
Imita
tes
hous
ewor
k.To
ilet
trai
ned.
Use
s sp
oon
wel
l. C
astin
g st
ops.
2 yr
sG
oes
up a
nd d
own
stai
rs
alon
e, 2
feet
per
ste
p. W
alks
ba
ckw
ards
(21
mon
ths)
R
uns.
Pick
s up
toy
with
out
falli
ng.
Thr
ows,
kick
bal
l with
out
falli
ng.
Tow
er o
f 6 c
ubes
. Im
itate
s cu
bes
of t
rain
with
no
chi
mne
y.
Imita
tes
stra
ight
line
. V
isua
l tes
t: Sn
elle
n’s
char
t.
2-3
wor
d se
nten
ces.
Use
s ‘y
ou’ ‘
me’
‘I’.
nam
es 3
ob
ject
s. O
beys
4 s
impl
e co
mm
ands
. Poi
nts
to 4
bod
y pa
rts.
Puts
on
shoe
s, so
cks,
pant
s.
Dry
by
day.
Play
nea
r ot
her
child
ren
but
no
t w
ith t
hem
.
2.5
yrs
Jum
ps o
n bo
th fe
et.
Wal
ks o
n tip
toe
s.To
wer
of 8
. Im
itate
s tr
ain
with
ch
imne
y.
Hol
ds p
enci
l wel
l.Im
itate
s
a
nd
Kno
ws
full
nam
e an
d ge
nder
.N
ames
one
col
our.
3 yr
sG
oes
up s
tair
s on
e fo
ot p
er
step
.D
own
stai
rs 2
feet
per
ste
p.Ju
mps
off
bott
om s
tep.
Stan
ds o
n 1
foot
for
seco
nds.
Rid
es t
ricy
cle.
Tow
er o
f 9.
Imita
tes
brid
ge w
ith c
ubes
:
Cop
ies
O Im
itate
s D
raw
a m
an t
est.
(3 -
10y
)
Can
cou
nt t
o 10
. Nam
es 2
co
lour
s. N
urse
ry r
hym
es.
Und
erst
ands
“on
”, “i
n”,
“und
er”.
Dre
sses
, und
ress
es w
ith
help
. Dry
by
nigh
t. Pl
ays
with
oth
ers.GEN
ERAL
PAE
DIA
TRIC
S
29
Age
Gro
ss M
otor
Fine
Mot
orSp
eech
/Lan
guag
eSo
cial
4 yr
sG
oes
up a
nd d
own
stai
rs
one
foot
per
ste
p.Sk
ips
on o
ne fo
ot.
Hop
s on
one
foot
.
Imita
tes
gate
with
cub
es.
Cop
ies
G
oode
noug
h te
st 4
.
Nam
es 3
col
ours
. Flu
ent
conv
ersa
tion.
Und
erst
ands
“i
n fr
ont
of”,
“bet
wee
n”,
behi
nd”.
Butt
ons
clot
hes
fully
. Att
ends
to
ow
n to
ilet
need
s.
4.5
yrs
Cop
ies
gate
with
cub
es.
Cop
ies
squa
re.
Dra
ws r
ecog
nisab
le m
an an
d ho
use.
5 yr
sSk
ips
on b
oth
feet
.R
uns
on t
oes.
Cop
ies ‘
X’ (
5 ye
ars)
C
opie
s (5
½ y
ears
) tr
iang
le.
Goo
