Children’s Conditions Specific Care Pathways
• Condition specific care pathways and family information leaflets- developed by
the multi- agency pathways group
• Pathways and leaflets developed
–
–
–
–
–
–
–
Asthma and wheeze pathway
Asthma and wheeze for under 2s pathway
Asthma and wheeze leaflet
Diarrhoea and vomiting pathway and leaflet
Bronchiolitis pathway and leaflet
Fever pathway and leaflet
Acute lower respiratory tract infection pathway
• Pathways and leaflets being developed
– Constipation pathway and leaflet
– Head injury pathway and leaflet
– Abdominal pain pathway and leaflet
Wheeze in Primary Care
– Clinical Assessment / Management Tool UNDER 2 years
Management – Out of Hospital Setting acute Asthma/
Wheeze
High Risk Children
·
·
·
·
·
·
Prompt recognition of respiratory failure
Alarming Signs
· SpO₂<92%, Cyanosis
· Bradycardia < 100 beats /min
· RR < 20 / Apnoea
· Marked Sternal recessions
· Worsening SOB
· Poor air entry
· Previous severe episodes
· Too breathless to feed
<3/12
Extreme low birth weight
Prolonged NICU/SCBU
CHD, pre-existing lung
condition
Reduced feeding <50%
Previous severe epidosed
Refer to hospital urgently (999)
Oxygen via face mask
Oxygen driven salbutamol nebuliser
Mild - Moderate
·
·
·
·
·
·
First Line Treatment:
Alert
Still feeding
SpO₂ > 92%
Bilateral wheeze on
Auscultation
Good air entry
Up to 10 puffs of beta 2 agonist via MDI with spacer and face mask (preferred route)
or nebulised salbutamol. O₂ driven is the recommended method of nebulisation
(compressor driven nebuliser treatment is acceptable if oxygen is not available)
Re-assess after 15 – 30 minutes
Good Response
·
·
·
·
·
·
·
·
·
Antibiotics should not be routinely given
Oral beta 2 agonist not recommended
Personalised written action plan
Check inhaler technique
Safety net and review by 48 – 72 hrs
Provide parent information leaflet
Consider oral Prednisolone 10mg once a day for 3 days
Plain 5mg tablets is the first line option
5mg/5ml unit dose oral solution is the second line option
Poor response
·
·
Bleep on call paediatrician urgently 01908 660033
Oxygen if SpO₂ < 94%
This guidance has been produced by the MK Caring for Children Closer to Home Pathway
Design Group and is written in the following context
This assessment tool was arrived at after careful consideration of the evidence available but not exclusively
NICE, SIGN, Bristol guidelines, EBM data and NHS evidence. Healthcare professionals are expected to take it
fully into account when exercising their clinical judgement. The guidance does not, however, override the
individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the
individual patient, in consultation with the patient and/or guardian or carer. Issue date June 2015.
Management of Acute Asthma/Wheeze in Primary Care
Clinical Assessment / Management Tool for 2 – 16 years
Management – Out of Hospital Setting acute Asthma/Wheeze
Immediate resuscitation
if required. Dial 999
Child presenting with acute wheeze
Table 1: High Risk Factors – Healthcare professionals
should be aware of the increased need for hospital
admission in infants with the following:
·
·
·
·
·
·
·
·
·
Table 2: Consider other diagnoses if any of the
following are present:
·
·
·
·
·
Attack in late afternoon, at night or early in the morning
Recent hospital admission
Previous severe attack
Young age
Previous cardio-respiratory illness
Significant co-morbidity
Already taking oral steroids
Concern over social circumstances or ability to cope at home
Food allergy
·
·
·
Fever (pneumonia) >38.5 C
Dysphagia (epiglottitis)
Productive cough (pneumonia)
Inspiratory stridor (croup)
Breathlessness with light headedness and peripheral tingling
(hyperventilation)
Asymmetry on auscultation (pneumonia or a foreign body etc)
Excessive vomiting (GORD)
Possibility of anaphylaxis
Table 3: Traffic Light system for identifying severity of acute wheeze/asthma
Green – Moderate
Amber – Severe
Red – Life Threatening
Talking
In sentences (active/alert)
Not able to complete a sentence in one breath
Too breathless to talk or feed
Not able to talk / Not responding
Confusion / Agitation
Auscultation of chest
Good air entry, mild – moderate wheeze
Decreased air entry with marked wheeze
Silent chest
Respiratory Rate
Within normal range
• < 40 breaths / min (2-5 yrs)
• < 30 breaths / min (> 5 yrs)
> 40 breaths p/min (2–5 yrs)
> 30 breaths p/min (> 5 yrs)
Cyanosis
Poor respiratory effort
Exhaustion
Heart Rate
< 140 beats p/min (2–5 yrs)
< 125 beats p/min (> 5 yrs)
> 140 beats p/min (2–5 yrs)
> 125 beats p/min (> 5 yrs)
Tachycardic or Bradycardic
Hypotension
Oxygen Saturation in air
Greater than or equal to 92% in air
< 92% in air
< 92% in air
PEFR (if possible)
> 50% of predicted
33 – 50% of predicted
< 33% predicted
Feeding
Still feeding / eating
Struggling
Unable to feed / eat
·
·
·
Give 2-10 puffs of salbutamol via spacer +/- facemask (given
1 puff at a time, inhaled separately using tidal breathing). If
nebulising this should be oxygen driven but if necessary
compressor driven is acceptable.
Reassess 15-30 minutes post intervention
Consider a 3 day course of prednisolone – 1st dose now. (See
Table 4: Drug Doses)
·
·
·
·
·
·
Refer to hospital A&E resus urgently via ambulance (999)
High flow oxygen via face mask if available
Give 10 puffs of salbutamol via spacer or nebuliser, oxygen driven if
available (See Table 4: Drug Doses)
If poor response add ipratropium bromide dose mixed with the
nebulised salbutamol (See Table 4: Drug Doses)
Continue with further doses of bronchodilator while awaiting transfer
Give 3 day course of prednisolone (See Table 4: Drug Doses)
Good Response
·
·
·
·
·
·
·
·
Send home with personalised written action
plan
3 days of oral prednisolone (See Table 4: Drug
Doses)
Antibiotics should not be routinely given
Check inhaler technique
Safety Net
Advise parents to contact their GP surgery the
next day to arrange a follow up within 48 – 72
hours
Remember to check they have enough inhaler
and appropriate spacer
Consider stand-by steroids for future
exacerbations
Poor Response
·
·
·
·
Consider hospital admission/999
Oxygen if Sp02 <94%
Continue with further doses of
salbutamol while awaiting transfer
Add ipratropium dose mixed with
salbutamol nebuliser
Table 4: Drug Doses:
Dose of Prednisolone (orally)
First line option: plain 5mg tablets
Second line option: 5mg/5ml unit dose oral
solution
<2yrs 10mg; 2-5yrs 20mg; 5-7yrs 30mg;
>7yrs 40mg
Dose of salbutamol nebulisers
<5yrs 2.5 mg; >5yrs 5mg
Dose of Ipratropium Bromide
250 mcg all ages (or up to 500mcg via
nebuliser for over 12 years)
Table 5: Normal Paediatric value
(Adapted from APLS+)
Respiratory Rate at rest:
Heart Rate
Systolic BP mmHg
Pre-school 2 – 5 years
25 – 30
95 – 140
85 – 100
School 5 – 11 years
20 – 25
80 – 120
90 – 110
Adolescent 12 – 16 years
15 – 20
60 – 100
100 – 120
This guidance has been produced by the MK Caring for Children Closer to Home Pathway Design Group and is written in the following context:
This assessment tool was arrived at after careful consideration of the evidence available including but not exclusively NICE. SIGN, Bristol guideline, EBM data
and NHS evidence. Healthcare professionals are expected to take it fully into account when exercising clinical judgement. The guidance does not, however,
override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation
with the patient and/or guardian or carer. Issue date: June 2015.
What do I do if my child is Wheezy / has Asthma? (traffic light advice)
If your child:
●
●
●
LIFE
THREAT
●
●
●
becomes unresponsive
becomes blue
is having severe difficulty breathing
- using tummy muscles
- ribs are sinking in
unable to complete sentences
is unable to take fluids and is
getting tired
is pale, drowsy, weak or quiet
If your child is:
having some difficulty in breathing /
noisy breathing
● Mild wheeze and has breathless ness that is not responding to
the usual reliever (blue inhaler)
treatment
● Using their blue reliever inhaler –
more than 2 puffs every 4 hours
● Breathing more quickly than normal
●
MODERATE
You need EMERGENCY help
Ring 999 - you need help immediately
If you have a blue inhaler use it now 1 puff per minute via Spacer
UNTIL AMBULANCE ARRIVES
Nearest hospital: Milton Keynes Hospital
(open 24 hours 7 days a week)
Name: ...................................................................
You need to contact a nurse
or doctor today – within 4 hours
Increase blue inhaler 10 puffs over 20
minutes and repeat every 4 hours via spacer
(1 puff every 5 breaths – tidal breathing)
Please ring your GP surgery during .the
day or when your GP surgery is closed,
please call NHS 111 by dialling 111
If your child is:
MILD
Using their reliever more than usual or
more than 3 times a week but is not
breathing quickly and is able to
continue doing day to day activities
and is able to talk in full sentences
How to Treat your
Asthma/Wheeze
Needs doctor / nurse review over the next few
days, unless deteriorating. Continue to use blue
inhaler as required. Read this leaflet about how to
help with your wheeze / Asthma symptom control.
Date: ...................................
What is asthma?
Asthma is a condition that affects your airways (the tubes that
take oxygen to and from your nose and mouth to your lungs),
and can begin at any age. With asthma, the airways are usually
inflamed and are very sensitive to allergens and ‘triggers’.
During an asthma attack the airways become narrower making it
harder for air to get in and out of the lungs. As air whistles
through the airways you can sometimes hear a wheeze.
Everyone’s triggers can be different but the most common
include: colds and flu; smoke inhalation; exercise or playing; and
allergens, like dust mite, pollen or animal fur. It is important to
recognise your triggers so that you can avoid them.
Warning signs that your asthma is not well controlled include:
●
●
●
●
Waking up regularly to cough, feeling tight / wheezy during the night
Early morning tightness wheeze or cough
Frequently needing your blue inhaler or using it more than 3 times a week
Frequent exercise induced cough or wheeze
Reassess and monitor your child regularly (symptoms may start or get worse in the evening )
- please follow traffic light advice above.
REMEMBER ALWAYS HAVE YOUR BLUE INHALER AND SPACER WITH YOU
IMPORTANT: ASTHMA/WHEEZE CAN BE LIFE THREATENING
This guidance has been produced by the MK Caring for Children Closer to Home Pathway Design Group and is
written in the following context
This assessment tool was arrived at after careful consideration of the evidence available including but not exclusively ‘NICE, SIGN, Bristol guideline,
EBM data and NHS evidence. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. The
guidance does not, however, override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of
the individual patient, in consultation with the patient and/or guardian or carer. Issue date: June 2015.
Useful Websites:
Asthma UK: www.asthma.org.uk
Teenage Health Freak:
www.teenagehealthfreak.com
Treatment Plan once you are home
YOUR
INHALER
When my asthma is back under controlGIVING
this is
what
I should do
Oral Prednisolone (Dose) .............................................................................................
Steps 1 -3 needs to be followed for
each
whole
process
twice.
puff e.g. if asked to give 2 puffs; repeat the
You may be given different coloured
Preventer Inhalers
inhalers or chambers. The process is the
(many different colours but not blue)
same for all colours.
Below
some examples
different (colour)
My are
Preventer
Inhaler is of
...................
coloured inhalers and chambers.
Reliever
Length of treatment (in days) ..............................................................................................
(Blue Inhaler)
Start date:..................................................... End date: ......................................................
Salbutamol (Blue Reliever Inhaler)
Dose.................................................. Start Date................................................................
Other Medication ................................................................................................................
This should be reduced using the Six Steps to reducing your inhaler usage guide below
Steroids (Preventer Inhaler) ......................................................................................
Dose.................................................. Start Date ................................................................
Other Medication ................................................................................................................
Rinse gargle and spit after using steroid inhalers
A follow up review should be undertaken by your GP/nurse within the next ................ days.
Spacers
Always take your inhalers via a spacer as this is a much more effective
way of getting medicines into the lungs
Volumatic
Aero Chamber
● Smaller children (generally under 3 years)
to use spacer with face mask
● Older children (generally over 3 years) to
use spacer with mouth piece
This inhaler prevents my lungs becoming
irritated and inflamed.
This is my Blue
Reliever Inhaler.
This is used to relieve the wheeze/cough and Spacer prescribed? YES
NO
can be used before exercise if necessary - it
is best used with a spacer.
Health Care Professional has checked
technique?
This helps me when I am coughing or
YES
NO
wheezing by opening up and relaxing my
lungs.
If I am using this more frequently than normal
or more than 3 times a week, I should see my
doctor or nurse to have my asthma checked.
When my asthma is well controlled I should
not need to use my blue inhaler regularly.
Top Tips
Six Steps to reducing your salbutamol (Blue Reliever Inhaler) usage
(If your child is sleeping and breathing comfortably you do not need to wake them to give them their
inhalers overnight).
One puff every five breaths using the spacer (Tidal Breathing)
6 Inhale 10 puffs every 4 hours for 24 hours
●
●
●
●
5 Then inhale 8 puffs every 4 hours for 24 hours
4 Then inhale 6 puffs every 6 hours for 24 hours
3 Then inhale 4 puffs every 6 hours for 24 hours
2 Then inhale 2 puffs every 6-8 hours for 24 hours
1 Then inhale 2 puffs as and when required
If your child gets more wheezy or breathless, go back up
a step and contact your GP as soon as possible
I must use this every day even when I am
well to keep my asthma under control.
●
●
●
●
●
Organise a review with your GP or Asthma Nurse at least once a year
Keep your blue inhaler with you at all times
Get a new inhaler when you start your last full one
Ask your Health Care Professional how to use your inhaler and spacer properly
and check your technique at every appointment
If you run out, in an emergency a pharmacist may be able to supply
a reliever inhaler (there may be a charge for this)
Avoid trigger factors for your asthma/wheeze eg. pollen/dust
Remember to rinse your mouth out after using your preventer
Wash your spacer monthly with warm soapy water, leaving it to drip dry.
Replace every 12 months
Smoking even outdoors will make asthma worse
Clinical Assessment tool for the Child
with suspected gastroenteritis 0-5 years
Management Out of Hospital Setting
Child presenting with diarrhoea and/or vomiting:
Assess for signs of dehydration, see table 1. (Consider Boxes 1 & 2 overleaf)
If all green features and no
amber or red
If any amber features
and no red
If any red features
No clinical dehydration
Clinical dehydration
Clinical shock suspected or confirmed
Depending on severity of child and
social circumstances in this category
action should be based on clinical
judgement (consider Box 2).
Preventing dehydration:
• Continue breastfeeding and
other milk feeds.
• Encourage fluid intake.
• Discourage fruit juices and
carbonated drinks (especially
those children in Box 2).
• Offer oral rehydration
solution (ORS) as supplemental
fluid to those at increased risk
of dehydration (Box 2).
• Refer to Box 4 for stool
microbiology advice.
• Home with advice to give 50ml/kg of
an oral rehydration solution over 4 hours
without delay, often and in small amounts
in addition give on-going ORS fluid
maintenance.
• Continue breastfeeding.
• Consider supplementing with usual fluids
(including milk feeds/water, but not fruit
juices or carbonated drinks.
• If after 4 hours child is not tolerating
ORS / vomiting / there is no improvement
/ cause for concern parents should be
instructed to consider a face to face
Provide parents/carers with
advice. Follow up by arranging an
appointment with the appropriate
health care professional. Direct to
local numbers overleaf.
Send child for urgent assessment in
hospital setting.
Commence relevant treatment to
stabilise baby/child for transfer if
appropriate. Consider appropriate
transport means (999).
If there is blood or mucus in the stool
or a suspicion of septicaemia or if the
child is immunocompromised, bleep
on call paediatrician 01908 660033.
• Consider admission according to
clinical and social circumstance.
re-assessment from a healthcare
professional.
• Seek further advice – bleep on call
• Refer to Box 4 for stool microbiology
advice.
• En-route parents should be
• Give advice sheet.
paediatrician 01908 660033
encouraged to give child fluids often
and in small amounts (including milk
feeds/water, but not fruit juices or
carbonated drinks).
Table 1 - Traffic light system for identifying signs and symptoms of clinical dehydration and shock
Green - low risk Amber - intermediate risk
Red - high risk
Activity
- Not responding normally to or no
response to social cues
- Appears ill to a healthcare professional
- Responds normally to social cues
- Altered response to social cues
- Content/smiles
- Decreased activity
- Stays awake / awakes quickly
- No smile
- Strong normal cry / not crying
- Unable to rouse or if roused does not stay awake
- Weak, high-pitched or continuous cry
Skin
- Normal colour skin
- Normal skin colour
- Pale/Mottled/Ashen blue
- Normal turgour
- Warm extremities
- Cold extremities
- Reduced skin turgour
Respiratory
Hydration
- Normal breathing
- Tachypnoea (ref to norm values box 3)
- Tachypnoea (ref to normal values box 3)
- CRT < 2 secs - Moist mucous membranes
(except after a drink)
- Normal urine
- CRT 2 - 3 secs - Dry mucous membranes
(except for mouth breather)
- Reduced urine output
- CRT > 3 secs
Pulses / Heart rate
- Heart rate normal - Heart rate normal - Tachycardic (ref to norm values box 3)
- Peripheral pulse normal
- Peripheral pulses normal
- Peripheral pulses weak
Blood Pressure
- Normal (ref to normal values box 3)
- Normal (ref to normal values box 3)
Eyes
- Normal eyes
- Sunken eyes
CRT: capillary refill time
RR: respiration rate
- Hypotensive (ref to normal values box 3)
Clinical Assessment tool for the Child
with suspected gastroenteritis 0-5 years
Management Out of Hospital Setting
Box 1 Consider the following that may indicate diagnoses other than gastroenteritis:
- Temperature of 38oC or higher (younger than 3 months)
- Temperature of 39oC or higher (3 months or older)
- Shortness of breath or tachypneoa
- Altered conscious state
- Neck-stiffness
- Abdominal distension or rebound tenderness
- History/Suspicion of poisoning
- Bulging fontanelle (in infants)
- Non-blanching rash
- Blood and/or mucus in stool
- Bilious (green) vomit
- Severe or localised abdominal pain
- History of head injury
Box 2 These children are at increased risk of dehydration:
- Children younger than 1 year, especially those younger than 6 months
- Infants who were of a low birth weight
- Children who have passed six or more diarrhoeal stools in the past 24 hours
- Children who have vomited three times or more in the last 24 hours
- Children who have failed to tolerate ORS
- Infants who have stopped breastfeeding during the illness
- Children with signs of malnutrition
Box 3: Normal Paediatric Values (also refer to PEWS chart)
Box 4 Stool microbiology advice:
Age
Respiratory rate/min Heart rate/min
Systolic Blood pressure mmHg Consider performing stool
microbiological investigations if:
0-3 months
30-60
110-160
> 60
3-12 months
25-50
100-150
80
1-4 years
20-40
90-120
90 + (2 x age in years)
- the child has recently been abroad
- the diarrhoea has not improved by
day 7
- suspected septicaemia
- immunocompromised child
- blood in stool
4-12 years
20-30
70-110
90 + (2 x age in years)
12 + 12-16
60-100
120
Information to give to parent/carer:
• Ensure parent/carer has name and contact number of GP/practice nurse/relevant healthcare professional
• MK Urgent Care Service – open 24/7, based at MK Hospital Campus, Standing Way, Eaglestone, Milton Keynes MK6 5NG
• NHS 111
• D&V patient information leaflet
This guidance has been produced by the MK Caring for Children Closer to Home Pathway
Design Group and is written in the following context
This assessment tool was arrived at after careful consideration of the evidence available including but not exclusively
‘NICE, SIGN, Bristol guideline, EBM data and NHS evidence. Healthcare professionals are expected to take it fully
into account when exercising their clinical judgement. The guidance does not, however, override the individual
responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual
patient, in consultation with the patient and/or guardian or carer. Issue date: June 2015.
Oral fluid challenge
Name
DOB
Date
Weight of child
Age of child
24 Hour fluid replacement
(plus NICE 50ml/kg over 4 hours if dehydrated)
For the first four hours, please give your child ……………..mls of …………………. every ……..minutes
After 4 hours please give you child ……………..mls of …………………. every ……..minutes
Please complete the chart below to show when you have given fluid, how much has been taken and whether your
child has had any vomiting and/or diarrhoea and/or has urinated. Please keep this chart to give to a healthcare
professional when/if your child is seen.
Time
1oz = 30ml
Fluid Amount Taken (ml/oz)
Vomit/Diarrhoea (tick
please)
Urine (tick please)
Clinical Assessment Tool for Babies/Children
with Suspected Bronchiolitis
Management in Primary Care
·
·
·
·
·
·
·
·
·
·
·
·
Rhinorrhoeas (Runny nose)
Cough
Poor Feeding
Vomiting
Pyrexia
Respiratory distress
Apnoea
Inspiratory crackles +/- wheeze
Cyanosis
C
Box 1 Signs and Symptoms can include:
If all green features and no amber or red
Assess clinical signs and
symptoms
Assess Risk factors
Look for life threatening
signs and symptoms
See table 1 and Boxes 1 and 2
Box 2 Risk Factors:
·
·
·
·
·
·
·
If there are amber features and no red
Oxygen support required?
Provide parents/carers with discharge advice.
Follow up by arranging an appointment with an
appropriate healthcare professional. Provide
information overleaf.
Pre existing lung disease, congenital heart
disease, neuromuscular weakness, immuneincompetence
Age <6weeks (corrected)
Prematurity (less than 35 weeks)
Family anxiety
Re-attendance
Duration of illness is less than 3 days and
Amber – may need to admit
Exposure to parental smoke
No
Yes
If any red features
Send child for urgent assessment in hospital
setting.
Commence relevant treatment to stabilise
baby/child for transfer if appropriate.
Is feeding sufficient to maintain hydration?
Yes
Consider commencing high flow oxygen
support.
No
Consider calling 999
Consider referral to hospital according to clinical and social circumstance and risk factors. If further advice is required by a paediatric professional bleep the
Paediatrician on call on 01908 660033.
Provide a safety net for the parents/carers by using one or more of the following:
·
·
·
·
Written or verbal information on warning symptoms and accessing further healthcare
Arrange appropriate follow up – refer to local services
Liaise with other professionals to ensure parent/carer has direct access to further assessment
Consider the need to follow up this child within 4 hours and see Hydration advice in box 2
Green – low risk
Amber – intermediate risk
Red – high risk
Colour (of skin, lips or tongue)
Normal colour
Pallor reported by parent/carer
Pale/mottled/ashen/blue
Activity
Responds normally to social cues
Content/smiles
Stays awake or awakens quickly
Strong normal cry/not crying
Not responding normally to social cues
No smile
Wakes only with prolonged stimulation
Decreased activity
No response to social cues
Appears ill to a healthcare
professional
Does not wake or if roused does not
stay awake
Nasal flaring
Tachypnoea:
RR >50 breaths/minute, aged 6-12 months
RR >40 breaths/minute, age > 12 months
Oxygen saturation ≤95% in air
Crackles in the chest
Grunting
Tachypnoea:
RR >60 breaths/minute
Moderate or severe chest indrawing
Respiratory
Circulation and hydration
Normal skin and eyes
Moist mucous membranes
Tachycardia:
> 160 beats/minute, age <12 months
>150 beats/minute, age 12-24 months
>140 beats beats/minute, age 2-5 years
CRT ≥3 seconds
Dry mucous membranes
Poor feeding in infants
Reduced urine output
Reduced skin turgor
Other
None of the amber or red
symptoms or signs
Age 3-6 months, temperature ≥39°C
Fever for ≥5 days
Rigours
Swelling of a limb or joint
Non-weight bearing limb/not using an
extremity
Age <3 months, temperature ≥38°C
Non-blanching rash
Bulging fontanelle
Neck stiffness
Status epilipticus
Focal neurological signs
Focal seizures
CRT: Capillary Refill Time, RR: Respiratory Rate. * This traffic light table should be used in conjunction with the recommendations in the guidelines on investigations and initial management
in children with fever. See http://guidance.nice.org.uk/CG160 (update of NICE clinical guidance 47).
Information to give to parent/carer:
Ensure patient/carer has name and contact number of GP/Practice Nurse/relevant healthcare professional
MK Urgent Care Service – Open 24/7, based at MK Hospital Campus, Standing Way, Eaglestone, Milton Keynes, MK6 5NG
NHS 111
Bronchiolitis patient information leaflet
Table 3
Normal paediatric values:
Age
Respiratory rate
Hear rate/min
Systolic Blood pressure mmHg
0-3 months
30-60
110-160
>60
3-12 months
25-50
100-150
80
1-4 years
20-40
90-120
90 + (2 x age in years)
4-12 years
20-30
70-110
90 + (2 x age in years)
12+ years
12-16
60-100
120
Box 4: These children are at increased risk of dehydration:
·
·
·
·
·
·
·
Children younger than 1 year, especially those younger than 6 months
Infants who were of a low birth weight
Children who have passed six or more diarrhoeal stools in the past 24 hours
Children who have vomited three times or more in the last 24 hours
Children who have failed to tolerate ORS
Infants who have stopped breastfeeding during the illness
Children with signs of malnutrition
This guidance has been produced by the MK Caring for Children Closer to Home Pathway Design Group and is written in the following context:
This assessment tool was arrived at after careful consideration of the evidence available including but not exclusively NICE. SIGN, Bristol guideline, EBM data
and NHS evidence. Healthcare professionals are expected to take it fully into account when exercising clinical judgement. The guidance does not, however,
override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation
with the patient and/or guardian or carer. Issue date: TBA.
What are the symptoms?
Some useful telephone numbers:
·
If you need advice please try:
·
·
·
·
·
·
Your child may have a runny nose and sometimes have a
temperature and a cough.
After a few days your child’s cough may become worse.
Your child’s breathing may be faster than normal and it
may become noisy. He or she may need to make more
effort to breathe.
Sometimes, in very young children, bronchiolitis may
cause them to have brief pauses in their breathing.
Sometimes their breathing can become more difficult,
and our child may not be able to take their usual amount
of milk by breast or bottle or may want to feed more
frequently but take a smaller amount.
You may notice fewer wet nappies than usual.
Your child may vomit after feeding and become irritable.
Your local pharmacy can be found at www.nhs.uk
Health Visitor: ……………………………………………………..
Your GP Surgery: ………………………………………………….
Please contact your GP when the surgery is open or call
NHS 111 when the GP surgery is closed.
NHS 111 provides advice for urgent care needs.
NHS 111 is available 24 hours a day, 365 days a year.
Calls from landlines and mobile phones are free.
NHS Choices: www.nhs.uk
Bronchiolitis
Advice Sheet
Advice for parents and carers of
children aged 2 years old and under
Below are some other conditions that could
affect your child’s ability to cope:
If they have or were:
·
A premature baby
·
Are less than 6 weeks old
·
A lung problem
·
A heart problem
·
A problem with their immune system
·
Or any other pre-existing medical conditions that may
affect your child’s ability to cope with this illness
If you are worried about your child, trust
your instincts.
Contact your GP or dial NHS 111
What is bronchiolitis?
Please contact your Practice Nurse or Doctor
How long does bronchiolitis last?
·
·
·
·
Most children with bronchiolitis will seem to worsen
during the first 1-3 days of the illness before beginning to
improve over the next two weeks. The cough may go on
for a few more weeks.
As a parent / carer, you may find this useful to know as it
lasts longer than the normal coughs / colds that children
get.
Your child can go back to nursery or day care as soon as
he or she is well enough (feeding normally and with no
difficulty in breathing).
There is usually no need to see your doctor if your child is
recovering well. If you are worried about your child’s
progress, discuss this with your Health Visitor, Practice
Nurse or Doctor.
This guidance has been produced by the MK Caring for Children
Closer to Home Pathway Design Group and is written in the following
context:
This assessment tool was arrived at after careful consideration of the
evidence available including but not exclusively NICE. SIGN, Bristol
guideline, EBM data and NHS evidence. Healthcare professionals are
expected to take it fully into account when exercising clinical
judgement. The guidance does not, however, override the individual
responsibility of healthcare professionals to make decisions
appropriate to the circumstances of the individual patient, in
consultation with the patient and/or guardian or carer. Issue date:
TBA.
Bronchiolitis is when the smallest air passages in a child’s
lungs become swollen. This can make it more difficult
for your child to breathe. Usually, bronchiolitis is cause
by a virus called respiratory syncytial virus (known as
RSV). Almost all children will have had an infection
caused by RSV by the time they are two years told. It is
most common in the winter months and usually only
causes mild “cold-like” symptoms.
Most children get better on their own. Some children,
especially very young ones, can have difficulty with
breathing or feeding and may need to go to hospital.
Most children with bronchiolitis get better within about
two weeks. The cough may go on for a few more weeks.
How can I help my baby?
·
·
·
·
·
·
If your child is not feeding as normal, offer
smaller feeds more frequently.
If your child is distressed or you feel they are in
discomfort you may use medicines
(Paracetamol or Ibuprofen) to help them feel
more comfortable. However, you may not need
to use these medicines.
At home, we do not recommend giving both
Paracetamol and Ibuprofen at the same time
together. If you child has not improved after 23 hours you may want to give them the other
medicine. Never exceed the dose on the bottle.
Please read and follow the instructions on the
medicine container. Over the counter (OTC)
medicines may not be available to purchase for
all age groups. Ask your pharmacist.
If your child is already taking medicines or
inhalers, you should carry on using these. If you
find it difficult to get your child to take them,
ask your Pharmacist, Health Visitor or Doctor
for advice.
Bronchiolitis is caused by a virus so antibiotics
will not help.
What do I do if my child has bronchiolitis? (traffic light advice)
Most children with bronchiolitis get better over time, but some children can get worse.
You need to regularly check your child and follow the advice below.
You need EMERGENCY help
Call 999 or go straight to the nearest Hospital
Emergency (A&E) Department
RED
If your child has any one of these below:
·
Has blue lips
·
Or is unresponsive or very irritable
·
Or is struggling to breathe
·
Or has unusually long pauses in breathing
·
Or has an irregular breathing pattern
·
·
·
·
·
·
Milton Keynes Hospital
John Radcliffe, Oxford
Luton and Dunstable Hospital
Bedford Hospital
Northampton Hospital
Stoke Mandeville Hospital, Aylesbury
Bring your child’s Red Book with you.
AMBER
If your child has any one of these below:
·
If your child’s health gets worse or you are
worried
·
Or has decreased feeding by 50% (half)
·
Or you are needing to change the nappy less
frequently than normal
·
Or has vomited on more than one occasion
·
Or temperature is above 38 degrees centigrade
·
Or is finding it difficult to breathe
·
Please see box “conditions that could affect
your child’s ability to cope” overleaf
Passive smoking affects your baby – if you would like
help to stop smoking: www.nhs.uk/smokefree
Make sure your child is never exposed to tobacco
smoke. Passive smoking can seriously damage your
child’s health. It can make breathing problems like
bronchiolitis worse. Remember smoke remains on
your clothes when you smoke anywhere including
outside.
Nearest Hospitals (open 24 hours 7 days a week):
You need to contact a
nurse or doctor today
Please ring your GP Surgery during the
day or when your GP Surgery is closed,
please call NHS 111
Bring your child’s Red Book with you.
Self Care
GREEN
If none of the features in the red or amber boxes
above are present.
Using the advice on this leaflet you can
care for you child at home.
If you feel you need advice please contact your Health
Visitor or GP Surgery or your local pharmacy
(follow the links at www.nhs.uk)
You can also call NHS 111
Fever Advice Sheet for Children 0-5 years
Most children with a fever do get better very quickly but some children can
get worse. You need to regularly check your child and follow the advice below.
If you have been given this leaflet by a doctor or nurse they will advise you about what to look out for.
If your child has any one of these below:
·
Has blue lips
·
or is unresponsive or very irritable
·
or is struggling to breathe
·
or has unusually long pauses in breathing
·
or has an irregular breathing pattern
·
or has a non-blanching rash
·
or has had a fit (having never had one in the
past)
·
or has a bulging fontanel
·
or is unresponsive
·
or has neck stiffness
If your child has any one of these below:
·
If your child’s health gets worse or you are
worried
·
or has decreased feed by 50% (half)
·
or you are needing to change the nappy less
frequently than normal
·
or has vomited on more than one occasion
·
or temperature is above 38° C
·
or is finding it difficult to breathe
·
or has had a fever for more than 5 days
·
or has had a rash that has not been seen by a
clinician
·
or has had a severe pain that doesn’t go away
with painkillers
Please see box “conditions that could affect your
child’s ability to cope” overleaf
You need EMERGENCY help
Call 999 or go straight to the nearest Hospital Emergency (A&E)
Department
Nearest Hospitals (open 24 hours 7 days a week):
·
Milton Keynes Hospital
·
John Radcliffe, Oxford
·
Luton and Dunstable Hospital
·
Bedford Hospital
·
Northampton Hospital
·
Stoke Mandeville Hospital
Bring your child’s Red Book with you.
You need to contact a nurse or doctor
today
Please ring your GP surgery during the day or when your GP
surgery is closed please call NHS 111
Bring your child’s Red Book with you.
Self care
If none of the features in the red or amber boxes
above are present.
Using the advice on this leaflet you can care for your child at
home.
If you feel you need advice please contact your local Health Visitor
or GP surgery or your local pharmacy (follow the links at
www.nhs.uk)
You can also call NHS 111
Keep a record of how your child is doing to help you remember when you gave the medicines and how your
child has been feeling.
Time and date
Temperature
Medicines given
What is your child doing?
Name of child________________________________________________________________________________
Age______________________
Date/Time advice given__________________________________
Name of professional (print)____________________________________________________________________
Signature of professional______________________________________________________________________
Further advice/Follow Up______________________________________________________________________
Some useful telephone numbers
GP/Practice Nurse____________________________________________________________________________
(Parent to complete)
Health Visitor________________________________________________________________________________
(Parent to complete)
If out of hours please call 111
Looking After Your Feverish Child
·
·
·
·
·
·
·
·
·
·
·
·
·
·
Check your child during the night to see if they are getting better
If a rash appears do the tumbler test (see guidance below)
If you are concerned that your child is not improving follow the advice on the
front of this sheet
Children with fever should not be under cover or over dressed
If your child is hot to touch remove some of their clothes
If your child is distressed or very unwell you may use medicines (paracetamol or
ibuprofen) to help them feel more comfortable however it is not always
necessary
Please read the instructions on the medicine bottle first
Don’t give both medicines (paracetamol and ibuprofen) at the same time
Use one and if your child has not improved 2-3 hours later you may want to try
giving the other medicine
Please ask your local pharmacist for more advice about medicines
Never give aspirin to a child
Offer your child regular drinks (where a baby is breastfed the most appropriate
fluid is breast milk)
If your child is due to have immunisations please consult your GP, practice nurse
or Health Visitor for advice as there may be no need to delay their appointment
If you need to keep your child away from nursery or school while they are unwell
and have a fever please notify the nursery or school – your health visitor,
community nurse of GP will be able to advise you if you are unsure
Below are some
other conditions that
could affect your
child’s ability to
cope:
IfIf they
they have
have or
or were:
were:
·· AA premature
premature baby
baby
·· Are
less
than
6
Are less than 6 weeks
weeks
old
old
·· AA lung
lung problem
problem
·· AA heart
heart problem
problem
·· AA problem
problem with
with their
their
immune
system
immune system
·· Or
Or any
any other
other prepreexisting
existing medical
medical
conditions
conditions that
that may
may
affect
affect your
your child’s
child’s
ability
ability to
to cope
cope with
with
this
this illness
illness
Please
Please contact
contact your
your
Practice
Practice Nurse
Nurse or
or
Doctor
Doctor
The Tumbler Test
Do the ‘tumbler test’ if your child has a rash. Press a glass tumbler
firmly against the rash. If you can see the spots through the glass
and they do not fade this is called a ‘non-blanching rash’. If this
rash is present seek medical advice immediately. The rash is
harder to see on dark skin so check paler areas, such as palms of
the hands, soles of the feet, tummy and inside the inside the
eyelids.
(Photo courtesy of the Meningitis Research Foundation)
Management of Feverish Illness Out of Hospital
Clinical Assessment and Management Tool for Children over 3 months
Child presents with a feverish illness
Remote assessment
Face to Face Assessment
Identifying risk of serious illness
Identifying life threatening features
Using the traffic light system; If evidence
of any amber features, undertake a face
to face assessment within 2 hours
First, healthcare professionals should identify any immediately
life-threatening features, including compromise of the airway,
breathing or circulation, and decreased level of consciousness
Immediate
resuscitation
if required.
Dial 999
Use the traffic light system to assess the risk of serious illness
Green – low risk
Amber – intermediate risk
Red – high risk
Colour (of skin, lips or tongue)
Normal colour
Pallor reported by parent/carer
Pale/mottled/ashen/blue
Activity
Responds normally to social cues
Content/smiles
Stays awake or awakens quickly
Strong normal cry/not crying
Not responding normally to social cues
No smile
Wakes only with prolonged stimulation
Decreased activity
No response to social cues
Appears ill to a healthcare
professional
Does not wake or if roused does not
stay awake
Nasal flaring
Tachypnoea:
RR >50 breaths/minute, aged 6-12 months
RR >40 breaths/minute, age > 12 months
Oxygen saturation ≤95% in air
Crackles in the chest
Grunting
Tachypnoea:
RR >60 breaths/minute
Moderate or severe chest indrawing
Respiratory
Circulation and hydration
Normal skin and eyes
Moist mucous membranes
Tachycardia:
> 160 beats/minute, age <12 months
>150 beats/minute, age 12-24 months
>140 beats beats/minute, age 2-5 years
CRT ≥3 seconds
Dry mucous membranes
Poor feeding in infants
Reduced urine output
Reduced skin turgor
Other
None of the amber or red
symptoms or signs
Age 3-6 months, temperature ≥39°C
Fever for ≥5 days
Rigours
Swelling of a limb or joint
Non-weight bearing limb/not using an
extremity
Age <3 months, temperature ≥38°C
Non-blanching rash
Bulging fontanelle
Neck stiffness
Status epilipticus
Focal neurological signs
Focal seizures
CRT: Capillary Refill Time, RR: Respiratory Rate. * This traffic light table should be used in conjunction with the recommendations in the guidelines on investigations and initial management
in children with fever. See http://guidance.nice.org.uk/CG160 (update of NICE clinical guidance 47).
If all green features and no amber or red
Children with ‘green’ features and none of the
‘amber’ or ‘red’ features can be cared for at
home with appropriate advice for parents and
carers, including advice on when to seek
further attention from the healthcare services
See advice box 3 for home care
If any amber features and no red
If any red features
If any ‘amber’ features are present and no diagnosis has been reached,
provide parents or carers with a ‘safety net’ or refer to specialist
paediatric care for further assessment. The safety net should be 1 or more
of the following:
·
providing the parent or carer with verbal and/or written information
on warning symptoms and how further healthcare can be assessed
·
arranging further follow-up at a specialist time and place
·
liaising with other healthcare professionals, including out-of-hours
providers, to ensure
·
direct access for the child if further assessment is required.
Children with any ‘red’ features but
who are not considered to have an
immediately life threatening illness
should be referred urgently to the care
of a paediatric specialist
Management by a paediatric specialist
See pathway
Assess for Symptoms and signs of a specific illness
Table 1: Symptoms and signs of specific illness
Diagnosis to
be
considered
Meningococcal
disease
Bacterial
meningitis
Herpes simplex
encephalitis
Pneumonia
Urinary tract
infection
Septic
arthritis
Kawasaki disease
Symptoms
and signs in
conjunction
with fever
Non-blanching rash,
particularly with one
or more of the
following:
- An ill-looking child
- Lesions larger
than 2mm in
diameter
(purpura)
- Capillary refill
time of ≥3
seconds
- Neck stiffness
- Bacterial
meningitis
- Bulging fontanelle
Bulging
fontanelle
Decreasing level
of consciousness
Convulsive status
epilepticus
Neck stiffness
Focal
neurological
signs
Focal seizures
Decreased level
of
consciousness
Tachypnoea:
respiratory rate:
>60 breaths/minute,
age 0-5 months
>50 breaths/minute,
age 6-12 months
>40 breaths/minute,
age >12months
Crackles in the chest
Nasal flaring
Chest indrawing
Cyanosis
Oxygen saturation
≤95%
Vomiting
Poor feeding
Lethargy
Irritability
Abdominal pain
or tenderness
Urinary
frequency or
dysuria
Swelling of
a limb or
joint
Not using
an
extremity
Non-weight
bearing
Fever for more than
5 days and at least
4 of the following:
- bilateral
conjunctival
injection
- Change in
mucus
membranes
- Change in the
extremities
- Polymorphous
rash
- Cervical
lymphadenecto
my
Bacterial
meningitis and
meningococcal
septicaemia
NHS Guidelines
Urinary tract
infection in
children NICE
Guidelines
Management of Feverish Illness Out of Hospital
Clinical Assessment and Management Tool
Table 2
Normal paediatric values:
Age
Respiratory rate
Hear rate/min
Systolic Blood pressure mmHg
0-3 months
30-60
110-160
>60
3-12 months
25-50
100-150
80
1-4 years
20-40
90-120
90 + (2 x age in years)
4-12 years
20-30
70-110
90 + (2 x age in years)
12+ years
12-16
60-100
120
Advice box 1
Advice for home care
Manage the child’s temperature as described in antipyretic interventions.
Advise patients or carers looking after a feverish child at home:
·
To offer the child regular fluids (where a baby or child is breastfed the most appropriate fluid is breast milk)
·
How to detect signs of dehydration by looking for the following features:
·
sunken fontanelle
·
dry mouth
·
sunken eyes
·
absence of tears
·
poor overall appearance
·
To encourage their child to drink more fluids and consider seeking further advice if they detect signs of dehydration
·
How to identify a non-blanching rash
·
To check their child during the night
·
To keep their child away from the nursery or school while the child’s fever persists but to notify the school or nursery of the illness.
When to seek further help
Following contact with a healthcare professional, parents and carers who are looking after their feverish child at home should seek further advice if:
·
The child has a fit
·
The child develops a non-blanching rash
·
The parent or carer feels that the child is less well that when they previously sought advice
·
The parent or carer is more worried than when they previously sought advice
·
The fever last longer than 5 days
·
The parent or carer is distressed, or concerned that they are unable to look after their child
·
Difficulty breathing
Advice box 2
Antipyretic interventions
Effects of body temperature reduction
Antipyretic agents do not prevent febrile convulsions and should not be used
specifically for this purpose.
Physical interventions to reduce body temperature
Tepid sponging is not recommended for the treatment of fever.
Children with fever should not be underdressed or over-wrapped.
Drug interventions to reduce the body temperature
Consider using either paracetamol or ibuprofen in children with fever who
appear distressed.
Do not use antipyretic agents with the sole aim of reducing body temperature
in children with fever.
When using paracetamol or ibuprofen in children with fever:
·
Continue as long as the child appears distressed
·
Consider changing to the other agent if the child’s distress is not alleviated
·
Do not give both agents simultaneously
·
Only consider alternating these agents if the distress persists or recurs
before the next dose is due.
Advice box 3
Thermometers and the detection of fever
Oral and rectal temperature measurements
Do not routinely use the oral or rectal routes to measure the
body temperature of children aged 0-5 years.
Measurement of body temperature at other sites
In infants under the age of 4 weeks, measure body temperature
with an electronic thermometer in the axilla.
In children aged 4 weeks to 5 years, measure body temperature
by one of the following methods:
·
Electronic thermometer in the axilla
·
Chemical dot thermometer in the axilla
·
Infra-red tympanic thermometer
Healthcare professionals who routinely use disposable chemical
dot thermometers should consider using an alternative type of
thermometer when multiple temperature measurements are
required.
Forehead chemical thermometers are unreliable and should not
be used by healthcare professionals.
This guidance has been produced by the MK Caring for Children Closer to Home Pathway Design Group and is
written in the following context
This assessment tool was arrived at after careful consideration o the evidence available including but not exclusively NICE Guidelines.
Healthcare professionals are expected to take it fully into account when excising their clinical judgement. The guidance does not,
however, override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the
individual/patient in consultation with the patient and/or guardian or carer.
Acute Lower Respiratory Tract Infection in Children
(> 1 Year Old) Out of Hospital
Clinical Assessment & Management
High risk factors
Clinical Diagnosis of Pneumonia
Increased need for hospital admission if children have any of the
following:
·
Recent hospital admission
·
Younger age children
·
Pre-existing cardio-respiratory condition
·
Compromised immune system
Acute illness with fever (>38.5°C) and breathlessness that is not
thought to be asthma or bronchiolitis.
Cough, tachypnoea, signs of respiratory distress, crepitations,
purrulent sputum, pleurritic chest pain or upper abdominal pain may
or may not be present.
Assess Severity (treat according to category of most severe signs and symptoms)
Green – low risk
Amber – intermediate risk
Red – high risk
Colour (of skin, lips or tongue)
Normal colour
Pallor reported by parent/carer
Pale/mottled/ashen/blue
Activity
Responds normally to social cues
Content/smiles
Stays awake or awakens quickly
Strong normal cry/not crying
Not responding normally to social cues
No smile
Wakes only with prolonged stimulation
Decreased activity
No response to social cues
Appears ill to a healthcare
professional
Does not wake or if roused does not
stay awake
Nasal flaring
Tachypnoea:
RR >50 breaths/minute, aged 6-12 months
RR >40 breaths/minute, age > 12 months
Oxygen saturation ≤95% in air
Crackles in the chest
Grunting
Tachypnoea:
RR >60 breaths/minute
Moderate or severe chest indrawing
Respiratory
Circulation and hydration
Normal skin and eyes
Moist mucous membranes
Tachycardia:
> 160 beats/minute, age <12 months
>150 beats/minute, age 12-24 months
>140 beats beats/minute, age 2-5 years
CRT ≥3 seconds
Dry mucous membranes
Poor feeding in infants
Reduced urine output
Reduced skin turgor
Other
None of the amber or red
symptoms or signs
Age 3-6 months, temperature ≥39°C
Fever for ≥5 days
Rigours
Swelling of a limb or joint
Non-weight bearing limb/not using an
extremity
Age <3 months, temperature ≥38°C
Non-blanching rash
Bulging fontanelle
Neck stiffness
Status epilipticus
Focal neurological signs
Focal seizures
CRT: Capillary Refill Time, RR: Respiratory Rate. * This traffic light table should be used in conjunction with the recommendations in the guidelines on investigations and initial management
in children with fever. See http://guidance.nice.org.uk/CG160 (update of NICE clinical guidance 47).
If all green features and no amber or red
Mild Disease
·
Can be managed in the community
·
Chest radiograph not required
·
Consider oral antibiotics
Consider 1st Line Oral Antibiotics
First choice – Amoxicillin (7 days)
Penicillin allergic – Clarithromycin (7 days)
Amoxicillin plus clarithromycin may be
required in certain situations
Safety Netting
Advice about:
·
Signs of deterioration
·
Fever management
·
Prevention of hydration
·
When to seek help
Discharge home – ask parents to return of:
·
Not tolerating fluids or oral antibiotics
·
High swinging or persistent fever
(particularly after 48hrs of treatment)
·
Increasing effort of breathing,
agitation or distress
Advise parents to seek review if cough
persists 8 weeks after the initial illness
If any amber features and no red
Moderate Disease
·
Discuss with Paediatric team
Moderate Disease
If both primary care physician and paediatric
team agree child can be managed in the
community. Follow advice for mild disease.
If any red features
Severe Disease
·
Arrange urgent transfer to hospital
·
If Sp02 <92% oxygen given by nasal
cannula, high flow density delivery
device or face mask to maintain oxygen
saturation >92%
Deterioration or
No Improvement at 48 hours
·
Re-evaluate
·
Consider possible complications (e.g. sepsis, pleural effusion, empyema, lung
abscess, metastatic infection, haemolytic uraemic syndrome, dehydration)
·
Consider whether child is having appropriate drug treatment at an adequate dosage
·
Consider adding macrolide
·
Discuss with paediatric team
Review at 48 – 72 hours or earlier
if deterioration
Improving
·
Reinforce safety advice
·
Advise parents to seek review if
cough persists 8 weeks after the
initial illness
Acute Lower Respiratory Tract Infection in Children
(> 1 Year Old) in Primary Care
Clinical Assessment & Management
Normal paediatric values
Age
Respiratory rate/min
Hear rate/min
Systolic Blood pressure mmHg
0-3 months
30-60
110-160
>60
3-12 months
25-50
100-150
80
1-4 years
4-12 years
12+ years
20-40
20-30
12-16
90-120
70-110
60-100
90 + (2 x age in years)
90 + (2 x age in years)
120
Table 2 – Oral Antibiotic Doses
Amoxicillin
Clarithromycin
Flucloxacilin
(7 day treatment duration)
(7 day treatment duration)
(7 day treatment duration)
1-5 years: 250mg tds
< 8kg: 7.5mg/kg bd
1 months – 2 years 62.5-125mg qds
5-16 years: 500mg tds
8-11kg: 62.5mg bd
2-10 years 125-250mg qds
12-19kg: 125mg bd
10-16 years 250-500mg qds
20-29kg: 187.5mg bd
>12y / >30kg: 250mg bd
Antibiotics
Antibiotics
··
··
Children
Children under
under the
the age
age of
of 22 with
with mild
mild symptoms
symptoms do
do not
not usually
usually have
have pneumonia
pneumonia and
and need
need not
not be
be treated
treated with
with oral
oral antibiotics.
antibiotics. They
They should
should be
be
reviewed
reviewed ifif symptoms
symptoms persist.
persist.
All
All children
children >> 22 years
years of
of age
age with
with aa clear
clear diagnosis
diagnosis of
of Community
Community Acquired
Acquired Pneumonia
Pneumonia (CAP)
(CAP) should
should receive
receive antibiotics
antibiotics as
as differentiating
differentiating
between
between bacterial
bacterial and
and viral
viral pneumonia,
pneumonia, clinically
clinically or
or radiologically,
radiologically, isis unreliable.
unreliable.
Oral
Oral Antibiotics
Antibiotics
·· Oral
Oral antibiotics
antibiotics are
are safe
safe and
and effective
effective for
for even
even severe
severe CAP.
CAP.
·· Amoxicillin
is
recommended
as
first
choice
oral
Amoxicillin is recommended as first choice oral antibiotic.
antibiotic. AA macrolide
macrolide can
can be
be used
used in
in penicillin
penicillin allergy.
allergy.
·· Add
Add Flucloxacillin
Flucloxacillin for
for 14-21
14-21 days
days for
for suspected
suspected infection
infection with
with staphylococci
staphylococci (in
(in influenza
influenza or
or measles)
measles)
Macrolide
Macrolide antibiotics
antibiotics can
can be
be added
added if:
if:
·· There
There isis no
no response
response to
to first
first line
line therapy
therapy after
after 48
48 hours
hours
·· Mycoplasma
Mycoplasma or
or Chlamydia
Chlamydia isis suspected
suspected (symptoms
(symptoms worse
worse than
than the
the signs
signs would
would suggest,
suggest, insidious
insidious onset,
onset, chest
chest pain,
pain, non-respiratory
non-respiratory
symptoms
symptoms [e.g.
[e.g. arthralgia,
arthralgia, headache,
headache, on-going
on-going malaise].
malaise]. Mycoplasma
Mycoplasma pneumonia
pneumonia isis responsible
responsible for
for up
up to
to 40%
40% of
of community-acquired
community-acquired
pneumonia
pneumonia in
in children
children over
over five
five years
years of
of age
age but
but should
should also
also be
be considered
considered in
in younger
younger children).
children). Treatment
Treatment should
should be
be for
for 10
10 days
days with
with both
both
agents.
agents.
Chest
Chest X-Ray
X-Ray
Should
Should not
not be
be routine
routine in
in children
children not
not admitted
admitted to
to hospital
hospital as:
as:
·· Poor
correlation
with
clinical
signs
Poor correlation with clinical signs
·· CXR
CXR isis too
too insensitive
insensitive to
to distinguish
distinguish viral
viral from
from bacterial
bacterial aetiology
aetiology
However
However as
as per
per the
the NICE
NICE Guidelines
Guidelines “Feverish
“Feverish Illness
Illness in
in Children”
Children” there
there isis aa role
role for
for CXR
CXR in
in those
those aged
aged less
less than
than three
three months
months with
with respiratory
respiratory signs
signs
and
and in
in older
older children
children with
with fever
fever and
and no
no focus.
focus.
Other
Other Investigations
Investigations
Generally
Generally investigations
investigations are
are not
not required
required in
in LRTI.
LRTI. Acute
Acute phase
phase reactants
reactants (ESR/CRP)
(ESR/CRP) are
are not
not useful
useful in
in distinguishing
distinguishing viral
viral from
from bacterial
bacterial pneumonia.
pneumonia.
Further
Further microbiological
microbiological diagnosis
diagnosis isis useful
useful only
only in
in children
children with
with severe
severe pneumonia
pneumonia (i.e.
(i.e. PICU
PICU or
or complications).
complications).
Follow
Follow Up
Up
IfIf aa child
child was
was previously
previously healthy
healthy and
and isis recovering
recovering well
well from
from CAP
CAP then
then no
no follow
follow up
up isis needed.
needed. Parents
Parents should
should be
be instructed
instructed to
to see
see the
the GP
GP after
after 33
weeks
weeks ifif the
the cough
cough has
has not
not resolved.
resolved. Hospital
Hospital out-patient
out-patient follow
follow up
up and
and radiology
radiology should
should be
be arranged
arranged in
in cases
cases of:
of:
·· Severe
•• Empyema
•• Lobar
Severe pneumonia
pneumonia
Empyema
Lobar Collapse
Collapse
·· Persisting
•• Lung
•• Effusion
Persisting symptoms
symptoms
Lung abscess
abscess
Effusion
Authors: Ralph Robertson, Craig McDonald
References:
1. Harris et. Al. (2011), British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax 2011; 66:ii1 – ii23
2. Richardson et. Al. (2007), Feverish illness in children: Assessment and initial management in children younger than 5 years. NICE Guidance.
3. Wang et. Al. (2012), Clinical symptoms and signs for the diagnosis of Mycoplasma pneumonia in children and adolescents with community acquired pneumonia,
Cochrane Database of Systematic Reviews
4. BNFc (2014), Section 5.1.2.1, Cephalosporins
This guidance has been produced by the MK Caring for Children Closer to Home Pathway Design Group and
is written in the following context
This assessment tool was arrived at after careful consideration of the evidence available including but not exclusively NICE
Guidelines. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. The
guidance does not, however, override the individual responsibility of healthcare professionals to make decisions appropriate to the
circumstances of the individual patient, in consultation with the patient and/or guardian or carer.