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infants discharged before 24 hours from hospitals or free \ - standing birthing centres, or for home births, would require special arrangements. despite the risk for higher fp rates, screening before 24 hours is preferable to not screening at all. centres having a care system sufficiently robust to ensure that early discharge newborns either return or are assessed by public health nurses at 24 hours to 36 hours postbirth could be an effective alternative. similarly, midwives could screen during the routine home visit, at around 24 hours postbirth. whatever the local practice may be, consistency and effective communication are critical, as well as having a tracking system in place so that newborns are not lost to screening. while protocols testing only one foot detect most cchds, additional sensitivity is gained by testing the right hand and one foot. using the left hand is not recommended because of proximity to the ductus arteriosus. local expertise should guide the use of pulse oximetry equipment and practices the 90 % oxygen saturation ( sao2 ) threshold for failed screens is supported by data from one study where the cchd group showed a median postductal sao2 of 90 %. a borderline screening result, with an sao2 reading in any limb of 90 % to 94 % or \ > 3 % difference between limbs, has greater potential to be an fp than an sao2 reading \ < 90 %. studies usually repeated testing after 1 hour to allow transitional circulation to adapt and decrease the risk for an fp result. a third borderline result is considered a ‘ fail ’ because continuing to retest prolongs the screening process unnecessarily and clinical decompensation may occur. # what to do with a failed pos screen? newborns with a failed screen require thorough assessment by the most responsible health care provider, who may be a midwife, nurse, nurse practitioner or physician. an assessment that includes four limb blood pressures, an electrocardiogram and a chest x \ - ray may be helpful. if not already initiated, consult with a paediatrician, and when the most likely cause for a failed screening result appears to have a cardiac origin or remains unclear, a consult with paediatric cardiology followed by an echocardiogram is required to rule out cchd. for many centres in canada, the need for ground or air transport to access cardiac services, including an echocardiogram, underlines the importance of minimizing
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fp results. # what are the limitations of pos screening? while pos can help detect the cardiac anomalies listed in, it cannot identify all patients with chd. the frequency of false negatives is low, reported in only 33 / 229, 421 ( 0 \. 014 % ) neonates screened in one meta \ - analysis. because coarctation of the aorta is a challenge to diagnose by any detection method, a confident assessment of femoral pulses in the newborn period can be critical. it is difficult to generalize the cost benefit of pos across all regions of canada because prenatal ultrasound detection rates and access to echocardiography vary widely, but regions with high prenatal detection rates would probably benefit less from pos. # summary of recommendations for practice - pulse oximetry screening improves detection rates for critical congenital heart disease and is recommended for all newborns in canada, especially when used in conjunction with prenatal ultrasound and physical examination. - recognizing that delivery and time of discharge practices vary across canada, the timing of testing should be individualized for each centre and ( ideally ) occur after 24 hours postbirth to lower fp results. and because the intent is to screen newborns before they develop symptoms, the goal should be to perform screening before they reach 36 hours of age. - testing using the right hand and one foot minimizes false \ - negative rates. - a rigorous care system should ensure that all newborns are screened and tracked for follow \ - up, as needed. - newborns who fail screening should undergo a complete clinical evaluation by the most responsible health care provider, which could include consultation with a paediatrician if the initial assessment did not involve one. if a cardiac diagnosis cannot be excluded, referral to a paediatric cardiologist for consultation and echocardiogram is advised.
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sexually transmitted infections ( stis ) are a growing public health concern in canada, with rates of * chlamydia trachomatis * infection, gonorrhea, and syphilis increasing among adolescents and young adults. this practice point outlines epidemiology, risk factors, laboratory testing, and management for the more common stis in adolescents, including * chlamydia trachomatis *, * neisseria * * gonorrhoeae, * * treponema * * pallidum - ( syphilis ), * trichomonas vaginalis *, and herpes simplex virus, with a lesser focus on hiv and human papillomavirus. the need for test \ - of \ - cure and indications for further investigations is also discussed. the importance of maximizing opportunities to screen for and treat stis in this age group is highlighted. sexually transmitted infections ( stis ) are a growing public health concern in canada, where detection rates for * chlamydia trachomatis - infection, syphilis, and gonorrhea in adolescents and young adults have increased over the past decade. \ ] * c trachomatis * ( non \ - lymphogranuloma venereum serological variants ), is the most frequently reported sti in canada, predominantly affecting women 15 to 24 years of age and men 20 to 29 years of age. \ ] * n * * gonorrhoeae - is more prevalent in men 20 to 29 years of age, particularly among men who have sex with men ( msm ). recent data show declining rates among adolescents \ < 20 years of age, but increasing rates in older age groups. \ ] the number of female cases is likely to be underestimated because, unlike males, females are often asymptomatic. concurrent infection with * c trachomatis * is common. \ ] gonococcal antimicrobial resistance has been growing both in canada and globally, which makes management with combination antimicrobial therapy and repeat testing post \ - treatment increasingly necessary. \ ] * t * * pallidum * infection ( syphilis ) most commonly affects msm 25 to 29 years of age, sex workers and their clients, and individuals who have acquired infection in endemic regions of the world. \ ] the incidence of syphilis is rising across canada among msm as well as in
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women with histories of heterosexual contact, and outbreaks have been reported in many canadian cities. rates of positive hiv tests vary across canada. a downward trend in hiv rates in some regions, starting in 2008, was followed by a subsequent rise in new diagnoses from 2014 to 2016 \. \ ] the groups affected most commonly are msm, individuals who have acquired infection via heterosexual contact, and people who inject drugs ( pwid ). the largest increases in hiv rates were seen in males, especially 30 to 39 years of age, and among individuals of first nations ethnicity. \ ] * t vaginalis, - herpes simplex virus ( hsv ), and human papillomavirus ( hpv ) infections are not reportable and the true incidence of these diseases in canada is not known. studies have suggested that * t vaginalis - is the most common sti causing vaginitis, affecting an estimated 2 % of sexually active females 14 to 19 years of age in the united states. * t vaginalis - infections are asymptomatic in greater than 70 % of patients. \ ] hsv is the most common cause of genital ulcer disease. data from the united states ( 2015 \ - 16 \ ) estimate the prevalence of hsv \ - 1 at 48 % and hsv \ - 2 at 12 %. the prevalence of both hsv types is higher among women and increases with age. \ ] at present, hsv \ - 1 accounts for more genital infections than hsv \ - 2 \. hpv is the most common sti among males and females, with a 75 % lifetime risk of infection. infection with high \ - risk hpv types ( e. g., 16, 18 \ ) can lead to cervical and other genital cancers, while low \ - risk hpv types ( e. g., 6, 11 \ ) cause anogenital warts ( agws ). the prevalence of high \ - risk hpv types is higher among females younger than 25 years of age, those of lower socioeconomic status, and among indigenous women. \ ] the introduction of hpv immunization programs for girls has lowered rates of hpv infection, precancerous cervical abnormalities, and agws. \ ] sti risk factors and opportunities for assessment during routine and incidental medical visits, health care professionals should be asking young patients open \ - ended questions to elicit information about
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sexual history, stis, and associated risks. because youth are not frequent users of the health care system, * any * visit is an opportunity for sti assessment. shows a list of behavioural and other factors associated with increasing risk for stis. \ ] \ ] \ ] when exploring risk factors, clinicians should take a simple, confidential, nonjudgmental approach and use language that patients can easily understand. screening for stis comprehensive canadian guidelines for sti screening are available on the public health agency of canada website and via a mobile application. \ ] the decision to screen is based on risk factors and symptoms, both genital and systemic, always recognizing that rectal and pharyngeal gonococcal infections are often asymptomatic. test types and specimen requirements should be discussed with the local laboratory before collection ( tables and ). ideally, all of a patient ’ s sexual contacts should be identified, tested, and treated appropriately, although ensuring full disclosure and follow \ - up in individuals with multiple sexual partners is challenging. local public health units can assist in this process. chlamydia : all sexually active youth younger than 25 years of age should be offered screening at least annually, with more frequent screening offered to individuals with additional sti risk factors ( ). after treatment, screening should be repeated every six months if the risk of reinfection persists. \ ] \ ] the nucleic acid amplification test ( naat ) is the most sensitive and specific test for * c trachomatis *. first \ - catch void urine, vaginal ( including self \ - collected ), endocervical or urethral specimens are all suitable for naat testing. \ ] \ ] evidence suggests that a midstream urine specimen would be adequate, but first catch is preferred. \ ] serological testing should not be used for diagnostic purposes due to cross \ - reactivity and the associated difficulty of interpreting test results. a noninvasive screening specimen ( e. g., urine or a self \ - collected vaginal swab ) can be obtained if the patient is asymptomatic and has no risk factors or indications for a pelvic examination. a culture using cervical or urethral specimens remains the test of choice for medico \ - legal purposes but is a less sensitive test than naat. \ ] confirmation of a positive naat by another naat using different primers may
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also be acceptable. consultation with your local laboratory is advised. \ ] \ ] \ ] test \ - of \ - cure ( toc ) using naat three to four weeks after completion of therapy is recommended in adolescents when compliance is uncertain, an alternative treatment was used, re \ - exposure is likely, or the adolescent is pregnant. \ ] gonorrhea : screening should occur in the same groups as for chlamydial disease. a first \ - catch urine sample or self \ - collected vaginal swab is recommended for screening asymptomatic individuals, particularly when urethral and cervical samples are not practical. pharyngeal specimens should be obtained when there is a history of oral sex, and rectal samples if there is a history of receptive anal intercourse. cultures provide the best opportunity for determining the resistance pattern of an isolate. culture with susceptibility testing is particularly important given the emerging antimicrobial resistance of * n gonorrhoeae *, and should always be performed in the following circumstances, if possible : in sexual assault cases ; when treatment failure is presumed ; in evaluating pelvic inflammatory disease ; in symptomatic msm ; and when infection is believed to have been acquired overseas or in an area of recognized antimicrobial resistance. \ ] as the most sensitive testing method, natt is often used in place of culture to detect gonorrhea although it does not provide antibiotic susceptibility information. naat is validated for urine, vaginal, urethral and cervical samples. naats validated for these sites can also detect rectal and oropharyngeal infections, but are currently not licensed in canada for this purpose. however, clinicians should consult regularly with their regional laboratories because recommendations change over time. in light of the rising rates of gonococcal resistance to cephalosporins and azithromycin and resulting treatment failures, combination therapy for gonorrhea is recommended. toc is recommended when the following contexts apply : \ ] \ ] a second \ - line or alternative treatment is used ; antimicrobial resistance is suspected ; high re \ - exposure risk exists ; an adolescent is pregnant ; a previous treatment has failed ; in cases of pharyngeal or disseminated infection ; or if signs or symptoms persist following treatment. toc by culture performed three to seven days post \ - treatment is preferred. if a
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culture cannot be obtained, naat testing may be performed two to three weeks post \ - treatment because naat remains positive for longer than a culture following adequate therapy. \ ] repeat screening using naat six months after completing therapy is recommended for individuals at risk for reinfection. \ ] \ ] co \ - treatment for chlamydia is indicated for all patients with proven gonorrhea, even if chlamydia is not detected. syphilis : all sexually active adolescents should be offered screening for syphilis. screening in pregnancy should be performed at the first prenatal visit and, ideally, again at delivery. individuals at high risk for syphilis may also be screened at 28 to 32 weeks ’ gestation or at more regular intervals ( e. g., monthly ) when they are at very high risk ( e. g., engaged in sex trade work in an area experiencing an outbreak of infectious syphilis ). \ ] non \ - treponemal tests ( such as rapid plasma reagin ( rpr ) ) may yield false \ - negative results in early cases of primary syphilis. some laboratories use a “ reverse sequence algorithm ”, in which a treponemal test is used for screening ( e. g., treponemal \ - specific eia ) with positives confirmed by a nontreponemal test. \ ] \ ] clinicians should contact their local laboratory for more information. follow \ - up rpr testing is recommended after the treatment of all stages of syphilis with a reactive rpr. \ ] patients diagnosed with syphilis should be referred to an sti or infectious diseases clinic for treatment and follow \ - up. hiv : education about hiv prevention and testing is an essential component of routine health care for adolescents. all sexually active adolescents should be offered screening for hiv. all pregnant adolescents should be screened for hiv at the first prenatal visit. those considered to be at ongoing risk for hiv should be retested during pregnancy and at the point of delivery. \ ] in addition to testing, appropriate counselling should be arranged. adolescents who are newly diagnosed with hiv require urgent referral to an hiv specialist for initiation of treatment. \ ] \ ] this level of care should continue through the transition into adult care. \ ] \ ] routine screening is not recommended for trichomonas or hsv. screening for hpv or cervical cancer is not recommended before 21 years of age.
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screening for hepatitis a, b, and c may be considered for adolescents with specific risk factors as described in. key issues in managing stis # choosing antimicrobial agents the canadian paediatric society supports treatment protocols set out in the public health agency of canada ’ s canadian guidelines on sexually transmitted infections. \ ] clinicians should always consult this resource and any local public health guidelines for emerging trends and related treatment strategies. treatment regimens for chlamydia, gonorrhea, hsv, and trichomonas are summarized in. patients diagnosed with syphilis and hiv require urgent specialist referral as described above. the increase in cases of quinolone \ - resistant gonorrhea \ ] and, more recently, a rising number of isolates with reduced susceptibility to cefixime and ceftriaxone, with associated treatment failures, are cause for concern. \ ] if recommended treatments are not tolerated, or pathogens are resistant, consultation with infectious disease specialists is recommended. * im intramuscular ; po by mouth ; stis sexually transmitted infections ; * specific primary and secondary prevention strategies are known to decrease the risk for stis. clinicians should be mindful of, and counsel on, contextual issues that can impact treatment : - primary prevention measures include vaccination against hepatitis b virus and hpv, condom use, and behavioural change. - for youth at high risk for acquiring hiv, referral to an infectious dieseases or hiv specialist may be considered for discussion of pre \ - exposure prophylaxis ( prep ), when available. - effective secondary preventive strategies include partner notification, and treatment and screening for stis in asymptomatic young adults. - providing education and management strategies for the partners of individuals with stis is essential for infection control and patient well \ - being. - several of the stis discussed above are reportable diseases, and clinicians should be familiar with the reporting process for their area and comply in a timely fashion. public health authorities can assist with contact tracing when indicated. - directly observing therapy is important to improve compliance in adolescents receiving antimicrobial treatment for stis. - check for the presence of multiple stis, including hiv, because risk factors are similar for different stis. - retesting at six months is indicated for adolescents and adults with * n gonorrhoeae * and / or chlamydia because the risk for
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reinfection is a major concern in this age group. - youth with a newly diagnosed hiv infection should be referred urgently to a specialized clinic for treatment. - public health agency of canada. canadian guidelines on sexually transmitted infections. 2016 : \ - health / services / infectious \ - diseases / sexual \ - health \ - sexually \ - transmitted \ - infections / canadian \ - guidelines / sexually \ - transmitted \ - infections. html. - toronto public health sti treatment reference guide :.
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health care providers who see homeless or street \ - involved youth can help to reduce the impact of many risk factors – physical, mental, emotional and social – pertaining to street culture. the present statement describes the types and scale of homelessness in canada, and reviews reasons why youth turn to the street, risks of the ‘ street economy ’ and barriers to health care. common physical and mental health problems are considered, along with legal and ethical issues that may affect care. principles of care, including accessibility, confidentiality and harm reduction, and strategies to target and engage this population lead to recommendations for improving services, outcomes, advocacy and increased governmental support. key words : health problems ; homelessness ; siy ; street ; youth inadequate health care, education and advocacy for homeless and street \ - involved youth ( siy ) who present in various health care settings every day in canada is one of this country ’ s great unmet needs. the intention of the present statement is to help paediatricians, family physicians and other health care providers recognize and reduce the multiple risks – physical, mental, emotional and social – of being homeless or street \ - involved. recommendations are made toward diminishing the negative impact of risk factors on youth heath, safety and well \ - being. a medline search was conducted for the period between 1950 and november 2012, using the terms “ street youth ” and “ homeless youth ” combined with “ health care, health behaviour or health ”, “ health resources / health services ”, “ oral health ”, “ delivery of health care ”, “ adolescent health services ” and “ preventive health services ”. the literature was limited to english \ - language articles, with the majority originating in canada and the united states. the term ‘ street \ - involved youth ’ is quite broad, accounting for both varying degrees of homelessness and a wide range of at \ - risk behaviours. the youth who is not necessarily ‘ homeless ’ but who is exposed to and experiencing the physical, mental, emotional and social risks of street culture is the focus of this statement. while elevated risk profiles are associated with street involvement, street youth studies have revealed a diverse spectrum of characteristics and lifestyles. researchers have developed different categories for study and classification purposes. \ - some terms describe how youth make their way to the street ; others describe current housing status. many siy fit within multiple categories. examples of common and often overlapping terms are : ‘ situational runaway ’, ‘ runaway ’,
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‘ throwaway ’, ‘ systems youth crasher ’, ‘ curbsider ’, ‘ missing child ’ and ‘ homeless ’ youth. the two classifications used by the united nations compare the “ absolutely homeless ” with the “ relatively homeless ”. absolutely homeless youth live outdoors, in abandoned buildings or use emergency shelters or hostels. relatively homeless youth live in unsafe, inadequate or insecure housing, including a hotel or motel room rented by the month, or stay temporarily with friends or relatives ( called ‘ couch surfing ’ ). this group are also known as the “ invisible homeless ”. siy face adverse physical, mental, emotional and social consequences of street culture. health care providers need to identify children and youth at risk, be aware of specific health and social issues in this population, and be able to link their siy patients with community resources that can help with support. a study from 2007 explained the difficulties of estimating the number of siy in canada and the implications this has for policy \ - makers, service providers and researchers. however, the authors confirmed an urgent need for “ concern with homeless youth in every large canadian city ” as well as “ to reduce the numbers of youth on the street and to meet the needs of those youth who find themselves there ”. a 1999 study pegged the number of street youth in canada at approximately 150, 000, which is the same ( although admittedly conservative ) estimate cited in another 2007 study. recurring themes for turning to a life on the street are : poverty, dysfunctional family life, violence, sexual and physical abuse, underlying mental illness, parental drug use and curiosity. \ - a community \ - based study published in 2005 showed that women who report a history of being sexually abused were over 2 \. 5 times more likely to resort to runaway behaviours. women reporting both physical and sexual abuse were almost four times more likely to run away compared with their unabused peers. youth involved with the child welfare system become homeless when they run away from group homes or foster care. basic requirements for money, food, shelter and other necessities of life combine with early initiation of sexual activity to place siy at high risk of becoming involved in the sex trade or of practicing ‘ survival sex ’ in exchange for food, shelter, money or drugs. dependency on aspects of the ‘ street economy ’ ( eg, the sex trade, selling drugs or panhandling ) not only puts youths at risk for psychological harm but also for behaviours
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with serious medical consequences such as substance use, sexually transmitted infections ( stis ), violence, and physical and sexual abuse. canadian research has shown that the longer youth are living away from home, the greater the likelihood of involvement in the sex trade. # barriers to health care several individual and systems \ - level barriers to health care exist for this population. individually, siy often lack the money, transportation and knowledge to access appropriate health care. they also have issues with trusting adults or authority figures and worries about confidentiality that prevent them from seeking health care services. often, youth with child welfare status who have run away from their last placement and individuals with legal problems avoid health care facilities for fear of ‘ getting caught ’. concern about confidentiality is compounded by fear of being reported to authorities. more formal health care barriers include : the need to present a health card or supply a permanent address ; the perceived need for an adult ’ s consent or involvement ; lack of knowledge regarding mature minor protocols ; and services that are poorly coordinated or difficult to access. siy presenting in traditional health care settings may not always reveal that they are homeless, leaving health care practitioners under \ - aware of risk factors. for example, a prescription to treat streptococcal pharyngitis may never be purchased by a youth who has no money. however, this problem could be avoided by administering one dose of intramuscular benzathine penicillin, which is equivalent to 10 days of oral penicillin and may be provided at no cost in certain health care settings. this treatment choice illustrates how essential it is for health care practitioners to determine the housing and economic status of each youth they see as part of history \ - taking. earlier identification of youth at risk can reduce barriers to care and create opportunities for targeted support through suitable treatment options and connecting individuals with appropriate community resources. when siy making initial contact with health care personnel meet with criticism or any of the barriers described above, significant difficulties with follow \ - up usually ensue. a complete and comprehensive check \ - up at first visit and prompt treatment of suspected stis without laboratory confirmation are two effective approaches with the most vulnerable youth. there is an ongoing, urgent need for street \ - accessible medical clinics and youth agencies targeting this population, along with focused intervention programs for regular medical follow \ - up and on \ - the \ - spot testing for stis and pregnancy. health care practitioners need to provide anticipatory guidance to
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reduce harm, prescribe medications at no or low cost, choose simple treatment regimens, and ease follow \ - up by offering walk \ - in appointments and care during evening hours. removing systemic barriers to health care is crucial, but what concepts about their own health do siy hold that influence their desire, willingness or ability to access services? # physical and mental health concerns siy have both physical and mental health concerns associated with homelessness and high \ - risk behaviours. # # general physical health siy are at risk for many common, acute health problems. the street environment places homeless youths at increased risk of respiratory problems, including tuberculosis \ - and asthma. many youths present in acute care settings because they are unable to manage their asthma on the street. most have had medications in the past which have been used up, lost or stolen, and do not have the resources to replace them. dental disease is common due to lack of oral care, poor hygiene, smoking and alcohol use. dermatological problems that are seen regularly include lice, scabies, acne, atopic dermatitis, impetigo and infections due to community \ - acquired methicillin \ - resistant * staphylococcus aureus *. foot problems are a major concern because homeless youth endure wet, cold and exposed extremities, with limited access to clean socks or appropriate footwear. malnutrition often occurs secondary to food insecurity ( ie, poor intake and lack of resources ), inadequate knowledge and drug use. one toronto \ - based study published in 2002 showed that the day \ - to \ - day lives of street youth were characterized by constant struggle to find safe, secure shelter, generate income and obtain sufficient food. injuries also occur due to intoxication, burns from crack pipes or violence ( eg, sustained by being ‘ jumped ’, stabbed or shot ). disruptions in healthy development can lower sense of self, while lack of schooling often leaves vulnerable youth without the basic life skills needed to navigate the adult world. all immunizations currently recommended in the schedule for children and youth ( accessible at ) by the public health agency of canada should be provided to street youth. immunization programs are province \ - or territory \ - specific, and health care professionals need to be aware of programs in their own and neighbouring jurisdictions. if a vaccine is not covered, the health care provider should advocate for siy to receive it through alternative funding
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sources, if available. regarding immunization against sti \ - related illnesses, the enhanced surveillance of canadian street youth study ( 1999 \ - 2003 \ ) suggested that up to 40 % of siy were susceptible to hepatitis b infection. this population would greatly benefit from an enhanced hepatitis b vaccine program. be sure to ask siy patients about their immunization status and counsel them on access and ‘ catching up ’ on vaccines. street youth of both sexes are an important target group for the human papillomma virus vaccine because the majority will not have been immunized in school programs and are at high risk for cervical cancer and genital warts. funded immunization programs should be fully supported by governmental policies. siy experience much higher rates of hiv infection \ - and other stis. inconsistent condom use and multiple partners increase the risk of * chlamydia trachomatis - ( ct ), * neisseria gonorrheae - and herpes \ - simplex virus 2 ( hsv2 \ ) infections, and injection drug use increases transmission of hepatitis b and c. youth between 15 and 24 years of age account for more than two \ - thirds of reported cases of ct in canada, with risk among street youth approximately nine times higher as a result of risky sexual practices and substance use. other correlates of ct in canadian street youth were aboriginal status, self \ - perceived risk, having no permanent home and having lived in foster care. # # mental health disorders siy show a wide range of mental health problems, which often coexist with addictions and related physical health problems. research shows that adolescents with mental health disorders are not only at a higher risk of running away but that runaways are also at high risk of developing mental health disorders. \ - siy are at greater risk of developing mood disorders, bipolar disorder, conduct disorder and post \ - traumatic stress disorder, and of attempted suicide. these conditions increase with history of sexual abuse and sometimes precede homelessness. \ - siy show a higher rate of substance use. alcohol and illicit drugs are sometimes used as a means of coping or as part of risk \ - taking behaviour but inevitably lead to morbidity and increased mortality. the striking mortality rates in one prospective cohort study conducted in montreal, quebec, highlighted mental health and substance abuse as major issues that must be addressed by health care providers seeing this population. given the high rates of mental health diagnosis – including
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addictions – in siy, at least an initial mental health screening should be integrated into various health care settings, focusing on suicide risk, self \ - harm and whether an individual is a risk to others. many siy with psychiatric diagnoses need psychotropic medications. precarious living conditions often lead to inability to pay for a prescription, losing medications or having them stolen. this population needs extra support for managing medication issues. approaches to history \ - taking and the physical examination are provided in table 1 \. # legal and ethical considerations health care providers often worry about issues of consent to treatment when dealing with youth. siy pose a particular dilemma because they usually present in acute care facilities and clinics on their own. decision \ - making should be consistent with provincial / territorial health care consent legislation, which may state ( as in ontario, for example ) that consent to medical treatment depends on the mental capacity rather than the chronological age of a patient. engagement in the street economy places siy at high risk of victimization. some governments have legislation in place to protect youth. it is important to be aware of legislation in your own and neighbouring jurisdictions. alberta, for example, has two acts in place, one for the drug trade ( the protection of children abusing drugs act \ ) and comparable legislation for the sex trade ( protection of sexually exploited children act \ ). # principles of care this population ’ s specific health needs should be addressed by providing accessible medical services oriented to the context in which these youth live. services should offer comprehensive, confidential health care, including but not limited to : general health care, sexual health ( ie, contraception, stis, options counselling ), substance use assessment and mental health evaluation and referral. because they will be dealing with sensitive and serious issues, staff should be specially trained in harm reduction best practices and motivational interviewing techniques. for more information, read ‘ ’, a canadian paediatric society position statement published in 2008 \. referrals could come from acute care facilities, family physicians, public health nurses, social workers and other services that work closely with at \ - risk youth. any referral should have a self \ - referral or walk \ - in component. this option provides youth who have had typically limited or inconsistent medical care with unique access to medical assessment, treatment and planning for longer term medical care and follow \ - up. why are clinical models for adult homeless individuals insufficient for treating siy? youth tend
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to avoid these establishments because they do not believe they are “ that bad off ” or feel that particular adolescent issues are not being addressed. we need street \ - accessible medical clinics and youth agencies to target this population with focused intervention programs for regular medical follow \ - up. also, evidence \ - based programs, such as the foyer model of transitional housing for siy, need to be expanded and funded. collaboration and coordination among youth services are essential. an example of such a clinic in alberta is the calgary adolescent treatment services ( cats ) clinic :. # recommendations for improving services and outcomes some of the following recommendations were developed by other organizations ( acknowledged in footnotes ). # # health care providers should : - recognize siy as a heterogeneous population with different degrees of street \ - involvement. because these youth present in a variety of health care settings, care providers generally need to be more aware of specific issues and risk factors. - be aware of the mature minor protocols and inform youth of their right to confidentiality. confidentiality issues should always be reviewed before the formal health encounter. - integrate an initial mental health screening should be integrated into various health care settings, focusing on suicide, self \ - harm and whether the individual is a risk to others. - determine housing and economic status during history \ - taking. many youth are reluctant to reveal this information for fear of stigmatization. - ask whether medications can be purchased and used securely. - ask youth whether they can follow through with referrals. recognize that siy live unpredictable lives and follow \ - up may not occur. try to prioritize : - address the youth ’ s most immediate concerns at first visit, then explore others at the next visit. - certain examinations, investigations and treatments can be recommended at first visit if follow \ - up is not assured ( ie, with informed consent, diagnose with either a pelvic examination or a urine \ - based specimen collection for pregnancy, ct and * n gonorrheae * ). diagnose and treat ct, gonorrhea and other stis based on public health agency of canada guidelines :. - if hiv, hbv or hcv risk is identified or suspected ( eg, due to sexual exposures, abuse or intravenous drug use ), screen for hiv * at a minimum - at initial visit. early diagnosis can help prevent spread. also, be sure to discuss transmission of these pathogens at first visit
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– there may not be another chance. - health care workers should administer applicable vaccines at any available opportunity. ask all youth about their immunization status. advise how to access ‘ catch \ - up ’ or new vaccines. better yet, be prepared to provide them ‘ on \ - the \ - spot ’ in any office setting. - advocate for siy to receive vaccines that are not covered, through alternative funding sources if available. - keep treatment regimens as simple and straightforward as possible. make follow \ - up procedures easier by having some walk \ - in appointments and evening hours. - learn about youth services in your community so that you can make prompt referrals and initiate collaborative care and support. - advocate for better postgraduate interdisciplinary health care training on issues specific to this population. # # governments should : - provide universal coverage of vaccines such as the human papillomma virus vaccine, and fund outreach services and mobile medical vans. - respond to the urgent need for integrated adolescent mental health services throughout the continuum of care for siy. - prioritize societal issues that place youth at risk of running away ( ie, through poverty reduction, improved mental health services and family support ). - fund specific interventions ( ie, evidence \ - based programs such as the foyer model of transitional housing for siy ). - support networking and partnership development within communities, notably among social services, justice and educational organizations, and housing initiatives to work together locally to prevent homelessness by improving social conditions, strengthening communities, and developing age \ - specific, targeted interventions and care models that work.
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goals of care discussions and advance care planning aim to align the values and wishes of patients and their families with the care received. all paediatric health care practitioners who care for fetuses, infants, children, or adolescents with serious illnesses have an ethical responsibility to educate themselves about these aspects of care. this statement assists care providers with important conversations. effective communication is essential to clarify the goals of care and establish agreement on appropriate treatments for achieving those goals, including resuscitative and palliative measures. keywords : * advance care planning ; goals of care ; palliative care ; serious illness ; shared decision \ - making * medical advances have led to higher rates of survival of children with chronic and sometimes complex health conditions, many of whom would not have survived previously \ ] \ ]. children living with medical complexity often require multiple interventions to maintain their health, including surgical procedures, hospitalizations, and home technological support. their families frequently face difficult decisions about which interventions are in their child ’ s best interests. the potential for burden and other harms mandates health care providers ( hcps ) to carefully counsel families ( and legal guardians ), always acknowledging the delicate balance between promoting survival and compromising quality of life. the aim of any paediatric hcp involved with complex care cases should be “ to add life to the child ’ s years, not simply years to the child ’ s life ” \ ]. there continues to be a relative dearth of information regarding advance care planning in paediatric compared to adult populations. the emphasis on beneficence in paediatric substitute decision \ - making may lead to a bias toward curative or life \ - prolonging options. the concept is also consistent with parental obligations to protect children and society ’ s predisposition to favour life for its own sake. in general, children are expected to outlive their parents. furthermore, the overriding instinct to protect children from harm can lead to avoidance of difficult topics, even to the extent that some children, despite having adequate capacity to understand and cope with their condition, are excluded from discussions about the gravity of their illness. lastly, concerns about the legal status of advance care plans for minors may contribute to the lack of evidence and guidance on this issue. what is advance care planning? advance care planning is an extension of usual discussions about the future, typically for patients with a serious illness, that focus on possible medical needs as things change. advance care planning
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is rarely a single event. rather, it is a process that should occur over time as more becomes known about an individual ’ s condition and prognosis. the purpose of advance care planning is to give patients and families an opportunity to identify what matters most concerning medical care, based on their personal beliefs, values, and wishes in the context of their medical situation. planning can encompass both short and longer term health goals and treatments. while plans may include drafting formal advance directives specifying what treatments should ( or should not ) be provided under specific circumstances, the benefits of advance care planning are as much procedural as they are substantive. engaging patients and families in open dialogue helps ensure that the treatment provided aligns with shared goals of care, whether life \ - prolonging or palliative. advance care planning should start with discussions about ‘ goals of care ’, to capture what is hoped for from medical interventions. goals of care should be identified using a shared decision \ - making framework \ ] \ ]. the patient and / or the legal guardians, together with members of the health care team, should work collaboratively to determine realistic goals within the context of the illness \ ]. goals of care represent the culmination of three sequential activities (. while goals can be readily identified in most clinical situations, a physician ’ s ability to confidently recommend the best treatment to achieve them is sometimes hampered by degree of uncertainty. when uncertainty is high, it can be tempting to describe options in ‘ black and white ’ terms, with the hope of helping families navigate the ‘ shades of gray ’. however, humility and the acknowledgement of uncertainty are often more appreciated by family and other caregivers \ ] \ ]. when possible, time \ - limited trials to assess an uncertain treatment ’ s effectiveness in meeting goals of care can be useful \ ]. generally, goals of care for children and youth living with serious illness fit into 1 of 3 categories ( ). while treatment objectives may be shared by the family and health care team, not all are achievable. goals of care are limited, ultimately, by the limits of medicine. when goals are focused on prolonging life but the clinical situation leaves no reasonable chance to do so, it can be useful to acknowledge this : “ i know it ’ s important that we do everything possible to prolong life, but i ’ m worried more chemotherapy / additional procedures / cpr won ’ t help us accomplish that goal ” ( if appropriate
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add : “ and may in fact shorten life ” ). goals of care direct current treatment in the present, while advance care planning involves thinking about or applying goals of care to potential future states. both align the values, goals, and wishes of a patient and family with the care being received. while clarity regarding goals of care should guide current treatment, some patients and caregivers are reluctant to think too far ahead, preferring instead to “ cross that bridge when we get there ” \ ]. if the patient and family do not appear ready to engage in advance care planning, particularly when death is not believed to be imminent, respect for autonomy and parental authority includes supporting them as they defer decision \ - making. why should care planning discussions happen? parents may be more optimistic than health care team members about a child ’ s prognosis \ ]. the reverse can also occur \ ]. health care professionals may also underestimate parental understanding and receptiveness to discussions about foregoing life \ - sustaining interventions \ ]. a retrospective survey of parents whose children died in paediatric intensive care units showed that although the discussion was initiated by physicians 90 % of the time, almost one \ - half of parents thus engaged reported they had considered withdrawal of life \ - prolonging treatment before this option was raised by staff \ ]. although the possibility of premature death is widely known for many conditions ( e. g., congenital anomalies, paediatric cancers, neuromuscular conditions ), preferences regarding treatment may not be solicited if members of the health care team assume that the patient and / or family are in favour of life \ - prolonging treatment. one international survey showed that 45 % of paediatric oncologists do not initiate this discussion \ ]. and despite recent increased attention to the benefits of early integration of palliative care, the evidence suggests that the rapid emergence of novel treatments and technologies may be compounding clinician hesitancy to talk about situations where cure is not possible \ ]. these discussions may occur even less commonly for paediatric patients with chronic conditions, for whom the timing of death cannot be easily predicted ( e. g., severe cerebral palsy, neurodegenerative disorders, complex congenital heart disease, and short gut syndrome ). because children with these conditions and their parents may have varied understanding of the potential for dying until discussion is initiated, the health care practitioner should share
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valuable information and provide the opportunity for reflection. while honest discussions about ‘ what if? ’ scenarios, including the possibility of a shortened life, are often emotionally laden, they are still generally appreciated. in a small exploratory study involving adolescents and young adults with metastatic cancer and hiv, there was an overwhelming endorsement of the use of an advance care planning document ( ‘ five wishes ’ ) \ ]. respondents believed that completing the document would be helpful both in their own situation ( 19 / 20 ; 95 % ) and for others living with serious illness ( 18 / 20 ; 90 % ). none of the participants described the experience as stressful. in another study of adolescents followed in a tertiary hospital outpatient cardiac clinic, 92 % wanted a physician to inform them if their condition was terminal and 91 % wished to be involved in discussions about their end \ - of \ - life care \ ]. by comparison, 71 % of their parents endorsed open discussions with the adolescent, despite hesitancy expressed by some. indeed, parents of children with cancer \ ] \ ], serious neurologic impairment \ ], and a variety of other serious illnesses \ ] value the opportunity to discuss their children ’ s prognosis and engage in advance care planning. in one study involving parents of children with cancer, 87 % desired as much prognostic information as possible \ ]. moreover, while 36 % found the prognostic details shared “ very ” or “ extremely ” upsetting, these parents were just as likely to report that receiving the information was important and helped with decision \ - making. beyond the value placed on open communication about serious illness, prognosis, and goals of care by paediatric patients and their families, available evidence suggests additional important benefits. in a recent multicentre study \ ], adolescents with cancer and their families were randomized to receive three weekly sessions of an advance care planning intervention versus routine care. family members engaged in the advance care planning intervention reported increased positive appraisals of themselves as caregivers at 3 months compared with those in the control group. the researchers hypothesized that advance care planning helped participants become more informed about their child ’ s medical condition, putting them in a better position to advocate for their child. in a retrospective survey completed by bereaved parents of children who died from a variety of chronic complex conditions, the 61 % who reported advance care planning discussions prior to their child ’ s death reported feeling more
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prepared at end of life, perceived their child to have had ‘ good ’ to ‘ excellent ’ quality of life, and planned for the location of death \ ]. ensuring that patients and families have accurate information about prognosis and opportunities to identify goals of care can also result in meaningful alterations in care at the end of life. adjustments might include integrating palliative and home care services, reduced attention on unhelpful or potentially harmful treatments, earlier formulation of ‘ do not resuscitate ’ orders, and increased attention to reducing suffering \ ]. when should these discussions take place and who should participate? goals of care and advance care planning discussions for children and youth are most frequently triggered by admission to intensive care \ ], where the stimulus for discussion is often the anticipation of impending death. the transition to a palliative focus of care may be abrupt, with the intents to avoid prolonging the time to death and limiting nonbeneficial or even harmful interventions. while it is understandable that the need for critical care might prompt these discussions, evidence suggests that they should start earlier, sometimes even shortly after diagnosis and, occasionally, even before a child is born \ ] \ ]. medicine has always sought to help patients live well for as long as possible, and it is most often reasonable to assume that children and parents desire both quantity and quality of life. but for young people living with a serious illness, there may be a point where preference for quantity or quality becomes relevant to treatment decisions. when discussions regarding goals of care occur amid a life \ - threatening event, the objective is often to set limits or review the merits of potentially life \ - sustaining treatments. while such conversations are necessary, capable paediatric patients and substitute decision \ - makers may be reluctant to engage. some may dismiss concerns expressed by the medical team, calling attention to the fact that they have persevered through similar situations before \ ]. others may take offence because clinicians guiding these decisions are personally unfamiliar with their child and are basing recommendations on the very sick patient in front of them ( e. g., when a child is ‘ at their worst ’ ), rather than the child at baseline ( e. g., ‘ at their best ’ ) \ ] \ ]. even parents who acknowledge the limits of what medical interventions can accomplish may still be inclined to ‘ keep fighting ’ as an expression of faith or belief that a ‘ good ’ parent never gives up \ ]
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. by initiating conversations with patients and their families about values, beliefs, and wishes early in the disease course, health care providers introduce the notion that treatment decisions should be based on more than just what will result in the longest possible lifespan. while earlier conversations will frequently elicit the goal of cure ( or prolonging life ), their outcome may be less important than a physician and family deliberating together. earlier conversations have the added benefit of inviting patients and families to reflect on difficult subjects from a safe distance – when the prospect of death feels remote or unlikely – rather than mid \ - crisis. goals of care should be periodically revisited, especially following significant changes in health status or other major life events. as varying degrees of health and quality of life are experienced over time, it is not uncommon for goals to change. nothing has more influence on goals of care than the life experiences of the child and family. even individuals who previously held firm to prolonging life at all costs often reconsider goals of care in the face of persistent suffering without meaningful chance of recovery. families must be given the opportunity to reflect on how their child ’ s condition and quality of life have changed over time and what matters most to them moving forward. never assume that goals expressed strongly early in the course of a serious illness will stay the same. when reviewing goals of care, explain that the purpose of discussion is to ensure that optimal care is being provided in a changing situation. this starting point is likely to be supported by everyone involved. if requests to review goals of care are perceived by families as attempts to change their minds about care, they will be less receptive to engaging in conversation or sharing perspectives. there is emerging consensus that the responsibility for initiating these discussions rests with health care providers, not the patient or family \ ] \ ] \ ] \ ] \ ]. parents describe the need to be ‘ ready ’ for advance care planning discussions ( ), but many acknowledge that there is never a ‘ good ’ time to have them. some prefer to have these emotionally difficult conversations when a child is stable ; others during or immediately after acute deterioration \ ]. most parents of children with a serious medical condition acknowledge thinking about ‘ life and death ’ issues, but sometimes their attempts to initiate conversations with their child ’ s health care provider are unheeded \ ]. clinicians seeking additional guidance on how to start these conversations are encouraged to explore the \ ]. expressions of hope or faith are often misinterpreted
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as signs of not being ready to engage in advance care planning or to an assumption that goals of care are firmly in the ‘ prolong life ’ category. however, families facing critical situations can maintain hope while simultaneously grasping the reality of their child ’ s prognosis \ ]. the ‘ wish, worry, wonder framework ’ described in the is an effective way to continue conversations while acknowledging and validating expressions of hope \ ]. instead of trying to destroy hope, the framework recommends aligning with it ( “ i wish … ” ), then acknowledging persistent concerns ( “ i worry … ” ). these steps can then be followed by a request to discuss the best way to care for a child should those undesired concerns come to fruition ( “ i wonder … ” ). families prefer to engage in advance care planning with a trusted health care provider who is familiar with the child and their underlying illness and who will lead these conversations sensitively and compassionately \ ]. while the provider with primary responsibility for the child ’ s most significant medical issues should be involved, their leadership should not be presumed. numerous concerns and barriers have been identified by clinicians that delay or even prevent advance care planning with paediatric patients and families \ ]. when clinicians feel uncomfortable leading such conversations, consulting with colleagues or specialists who are more experienced with their facilitation ( e. g., in palliative or critical care ) can be helpful. paediatric patients should be invited to participate in serious illness discussions, even when they lack the capacity to make decisions regarding their goals of care. parents and other substitute decision \ - makers should be encouraged to watch for and listen to their child ’ s voice, behaviours, and body language, particularly in young or non \ - verbal children. along with showing respect for the child \ ], parents that describe feeling as though their child ‘ made the decision for them ’ may feel less burdened by the task \ ]. parents and capable youth can sometimes disagree on goals of care. clinicians confronted by this difficult situation are encouraged to consult the cps position statement for guidance. while a serious illness discussion often begins with one family member, it is important to involve all relevant decision \ - makers in the evolving conversation to achieve consensus. for some families, bringing extended family members, a respected spiritual leader, or other community members into the conversation is vital. language interpreters can be invaluable. barriers to implementing advance care plans
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while the main purpose of advance care planning is thinking about and discussing future health states, it is not uncommon for decisions regarding treatment to emerge from the process. such decisions should be documented in the patient ’ s chart and shared appropriately with care providers less familiar with the patient or uninvolved with discussions. accessible documentation increases the likelihood that carefully considered goals and wishes are honoured \ ] \ ]. legal documents that outline care preferences and recognize specific substitute decision \ - makers are commonly referred to as ‘ advanced directives ’ ( in canada, the more accurate term is ‘ power of attorney for personal care ’ ). however, most jurisdictions in canada do not have legislation granting legal validity to advance directives made by capable mature minors. the stipulated legal age for advance directives ( or ‘ expressed capable wishes ’ ) is 16 years in new brunswick, newfoundland and labrador, ontario, prince edward island, and saskatchewan. ( see table 1 in for a summary of canadian law regarding age of consent and advance directives. ) furthermore, advance directives as legally binding documents to guide future care can only be made by and for oneself. health care providers must honour the valid advance directives of a previously capable adult. by contrast, when substitute decision \ - makers ( e. g., parents ) create documents together with health care providers to guide an incapable patient ’ s future care, consent for the plan of care is still required in the moment. even without legal authority, the clinical value of written documents that clearly articulate wishes surrounding end \ - of \ - life care for paediatric patients cannot be understated. paediatric patients and their families are entitled to the benefits of advance care planning and specifically, the opportunities to reflect on goals of care in the context of a serious illness and how those goals might apply to future health states. decisions documented as part of this process, including not to attempt resuscitation, should not be viewed by paediatric health care providers as ‘ final ’ but rather as a prelude to necessary discussion when a health crisis occurs. the conversation might begin with : “ i understand that you ’ ve had conversations about your preferences in the event of … ”. the role of palliative care palliative care aims to provide comfort, reduce suffering, and improve quality of life \ ]. though originally conceived as a model of care at the end of life, contemporary paediatric palliative care is focused on living more than dying.
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calls for earlier discussion of goals of care and advance care planning echo advocacy to integrate palliative care early in the disease course for children with a serious or life \ - limiting condition \ ] \ - \ ]. when introduced early, palliative care is often provided as a consultative service, with involvement ebbing and flowing based on clinical need. one analogy that has been presented is that of a ‘ dimmer switch ’ instead of an ‘ on \ - off switch ’ model of palliative care, such that palliative measures are sometimes introduced alongside potentially curative treatments. paediatric palliative care teams are widely available at tertiary care centres across canada and have expertise in leading goals of care and advance care planning discussions \ ]. teams can facilitate these conversations virtually, enabling families who live far from the hospital to access palliative care expertise. referrals are welcomed from community providers practising throughout the regions they serve. paediatric palliative care providers can also help ensure that decisions arising from advance care planning are honoured, particularly when they involve a desire to focus on comfort and avoid intensive interventions as much as possible near the end of life. moreover, paediatric palliative care teams can often help access enhanced supports ( e. g., increased nursing, visiting hospice care, equipment and medications to optimize comfort at home ) and assist with documentation ( e. g., a ‘ dnr ’ or ‘ no cpr ’ order ) for different care settings. 1. health care providers should initiate conversations about goals of care and advance care planning. 2. conversations should start early in the disease course for children living with serious illnesses, especially for those who may have a shortened lifespan. 3. health care providers should assess patient and / or parent readiness to engage in advance care planning. signs of readiness may be verbal ( e. g., “ i don ’ t ever want to go back to the icu again ” ; “ something ’ s different … he ’ s lost that spark ” ) or non \ - verbal ( e. g., the patient can no longer do the things that they loved to do ). 4. unless urgent decisions are needed, health care providers should respect a family ’ s wish to delay conversations about the future, but with an agreement to check in again at a later time. 5. a health care provider who has a trusting relationship with the child and family should be continuously involved in these
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discussions, whenever possible. 6. health care providers should emphasize that the primary goal of these discussions is to engage patients and families in thoughtful conversations about what matters most to them. decisions regarding future care or the drafting of advanced directives may or may not be an outcome. 7. specialist paediatric palliative care teams are available and should be accessed to facilitate goals of care discussions and advance care planning for children within their jurisdiction, when needed. these conversations can be conducted using virtual care technologies.
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ca1cc885b067a4ddc746138d0e94ec0ef3586d39
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mental health in children with neuromotor disorders is part of a dynamic system, including medical and developmental domains, family, school and community. presentations are often complex and multifactorial, requiring a broad, individualized approach. a narrative overview of mental health symptoms in children with neuromotor disabilities is provided, along with recommendations for their assessment and management using the who ’ s international classification of functioning framework. key words : * cp ; disability ; hrqol ; icf ; mental health ; spina bifida * neuromotor disabilities are conditions of the nervous system, with motor deficits being their defining feature. mental health problems in children with neuromotor disabilities are common, incompletely understood \ - and “ likely determined by the interacting influences of multiple biological, neuropsychological, and social factors ”. their clinical presentations often reflect a dynamic or transactional relationship between the child living with a disability and the environment ( eg, the effect of caregiving needs on caregiver fatigue ). the purely medical model must give way to “ diagnosing the child \ - world interaction ”. the present statement offers a narrative overview of mental health symptoms in children with various neuromotor disabilities, followed by recommendations for their assessment and management that utilize the who ’ s international classification of functioning ( icf ) framework. the icf system has provided a new context for thought and practice in the field of childhood disability by encouraging an approach to care that puts more emphasis on a child ’ s function ( “ activity ” ) and social engagement ( “ participation ” ) than on their impairment. # health conditions # # neuromotor disorders common disorders that affect movement, posture and manual abilities include cerebral palsy ( cp ), muscular dystrophy and spina bifida. neurological impairment is attributed to lesions that are static ( as in cp ) or progressive ( as in muscular dystrophy ). children may present with combinations of weakness, hypotonia, spasticity, dystonia, contractures, sensory disorders, cognitive deficits and other medical comorbidities. there is great variability of function within the many diagnostic categories and among different classification approaches. # # mental health problems associated with neuromotor disorders children and adolescents with neuromotor disorders have more mental health symptoms than the general population, including difficulties with social skills, self \ - esteem, behaviour, anxiety, mood and attention. assessment may
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be complicated by communication problems ( eg, difficulty speaking ), atypical presentations of motor disability and neurodevelopmental disorders ( eg, attention \ - deficit hyperactivity disorder or its symptoms ), and challenges to obtaining clinical history. physicians often resort to describing ‘ features ’ without diagnosing specific categorical disorders. # body structures and functions # # musculoskeletal pain pain is associated with reduced participation in social or other activities, a lower quality of life and mental health problems. children with cp experience physical pain in direct relation to the severity of their functional disability. possible sources of chronic pain include medical procedures, neuromuscular disturbances, such as dystonia, and musculoskeletal causes such as a hip dislocation. pain in children with neuromotor disabilities has been found to be associated with feelings of isolation, frustration and sadness, as well as with caregiver observations of anxiety, increased crying ( with or without movement ), difficulty concentrating, irritability and lower activity levels. cognitive behavioural therapy may help to mitigate the effects of pain on mental health. # # medical comorbidities children with neuromotor disorders often have medical comorbidities. seizures and the medications used to control them may affect cognition, motor and emotional \ - behavioural functioning. dysphagia includes feeding difficulties caused by abnormal oral, pharyngeal and esophageal phases of deglutition, which also increase the risk for aspiration and recurrent pneumonia. gastroesophageal reflux and frequent or chronic constipation can lead to pain and nutritional problems. sleep disorders are often multifactorial and may relate to pain caused by skin ulcers, neuromuscular and musculoskeletal problems, gastroesophageal reflux disease or constipation, or to obstructive sleep apnea, the inability to change sleep position, as well as to difficulties with parent \ - child interaction ( eg, with limit \ - setting ). levels of motor impairment that are not severe have been associated with both worse and better health \ - related quality of life ( hrqol ). as these findings imply, hrqol, mental health and motor disability have a complex interrelationship. many children with cp have more positive perceptions about their situation than what may be expected by others, including
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their parents. while internalizing problems may lead to less engaged or irregular physical and social activity, which in turn is associated with lower child \ - reported hrqol, externalizing behaviours ( ie, being disruptive or aggressive ) correlate negatively with lower parent \ - reported hrqol but positively with child \ - reported hrqol. these findings highlight that behaviour problems, being subjective and perspective \ - dependent, are difficult to define in this population. # # communication, cognition and learning cognitive disability is strongly associated with mental health disorders. neuromotor disorders often involve social \ - emotional, executive and cognition dysfunction, mild to profound intellectual disability and learning disabilities. for example, spina bifida is associated with nonverbal learning disorder, attention \ - deficit hyperactivity disorder, executive dysfunction and hydrocephalus ( with possible complications from ventriculoperitoneal shunting such as increased intracranial pressure from shunt failure and central nervous system infections ). motor impairments can impede cognitive tests that are based on verbal or pencil \ - and \ - paper responses and appropriate assessment of level of function. individuals with a severe motor impairment ( eg, dyskinetic cp ) can also have trouble understanding spoken language, expressing themselves or achieving typical cognitive milestones. the importance of accurately determining a child ’ s levels of function and ability cannot be overstated in regard to shaping expectations for emotional \ - behavioural maturity, academic demands and peer interactions. when abilities and expectations are mismatched in the child \ - environment interaction, symptoms of emotional stress can result, such as internalizing or externalizing symptoms of stress. the biopsychosocial relationship of children living with neuromotor disability and their environment is especially complex because it includes family, school and community. the parents of children with a physical disability can bear a tremendous long \ - term burden of providing care. unsurprisingly, such parents are statistically less healthy, both physically and psychologically, compared with parents of children without disabilities. a child ’ s behavioural difficulties can undermine a parent ’ s sense of competence, reinforce problems with attachment, and compound parental stress, spousal relationship difficulties and caregiver depression. such stressors are associated, in turn, with difficult child behaviours. parental mental health problems increase the risk for mental health problems for any child, particularly in the developmentally critical early years. however, the strategic use of res
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##pite care may help to decrease caregiver stress and enhance family environments. positive academic and social involvement at school is a protective factor for health in the longer term. however, many children with neuromotor disabilities form fewer friendships, have fewer social skills and experience social isolation and victimization more often than their typical peers. motor disorders can increase risk for neglect in the classroom, such as when insufficient time is alloted to children to use their speaking devices. on the other hand, higher cognitive functioning is predictive of fewer social difficulties, and personalized classroom supports have been strongly associated with increased participation. research is ongoing into the social effects of environment, specifically of better access to recreational activities and opportunities for interaction, on the lives of individuals with neuromotor disabilities. it is already well known that participation in physical activities is negatively impacted by limited financial resources, by environmental factors such as a lack of open space, rough terrain or inadequate transport, and by lack of inclusiveness. one study found that exposure to other individuals with disabilities supported more favourable attitudes in children concerning their own disabilities. participation has been defined by the who ’ s icf framework as “ involvement in life situations ” and is a key determinant of mental health. in children with a neuromotor disability, participation is a “ multi \ - determined phenomenon ” associated with motor and cognitive function, family factors, accessibility within the home and community, favourable attitudes of people sharing the child ’ s household and neighbourhood, the child ’ s own ability to access and develop specific personal interests, and a more positive perception by parents concerning the extent of their child ’ s constraints. # personal factors every child has a unique temperament that affects their interaction with the world, including traits of adaptability, intensity, persistence, activity level, attention, predominant mood and sensory sensitivity. as with any child, the ability to express and act on preferences, feeling capable and experiencing companionship will affect levels of participation. children with neuromotor disabilities often experience mental health symptoms, which can involve multiple body systems and environmental factors which, in turn, can directly impact personal functioning and social participation. for the health care provider, family factors and quality of life are integral components of assessment and intervention. a careful systemic review examining body structures, functional abilities, home and school environments, participation levels and personal factors should be conducted ( table 1 \ ). appropriate physical and psychosocial examinations usually require multiple visits, at least initially. the following recommendations may
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help health care providers to assess and promote mental health in the child or adolescent living with a neuromotor disability : - mental health should be considered contextually, in the child \ - environment system, necessitating a broad assessment of icf domains. - addressing mismatches in a child ’ s multiple environments ( home, school, recreation ) compared with functional abilities ( motor, communication, social \ - emotional skills ) can improve participation levels. physicians should consider providing a medical letter to caregivers with specific information about a child ’ s functional abilities, medical diagnoses and recommended supports, such as assistive technologies and strategies. - a consistent coordinating physician is best able to identify and manage the many possible sources of physical discomfort that may be affecting a child ’ s mental health symptoms. - a coordinating physician can also be a source of information, compassionate care and referrals for parents who have difficulty meeting their child ’ s complex needs. - the child ’ s history should be compiled directly from multiple sources, including from the child and his / her family members, educators and therapists, through face \ - to \ - face meetings, written reports and telephone conversations.
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63e12085ce8254da5cadd4334e1ce44b5103fe4c
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recent studies have resulted in major changes in the management of urinary tract infections ( utis ) in children. the present statement focuses on the diagnosis and management of infants and children \ > 2 months of age with an acute uti and no known underlying urinary tract pathology or risk factors for a neurogenic bladder. uti should be ruled out in preverbal children with unexplained fever and in older children with symptoms suggestive of uti ( dysuria, urinary frequency, hematuria, abdominal pain, back pain or new daytime incontinence ). a midstream urine sample should be collected for urinalysis and culture in toilet \ - trained children ; others should have urine collected by catheter or by suprapubic aspirate. uti is unlikely if the urinalysis is completely normal. a bagged urine sample may be used for urinalysis but should not be used for urine culture. antibiotic treatment for seven to 10 days is recommended for febrile uti. oral antibiotics may be offered as initial treatment when the child is not seriously ill and is likely to receive and tolerate every dose. children \ < 2 years of age should be investigated after their first febrile uti with a renal / bladder ultrasound to identify any significant renal abnormalities. a voiding cystourethrogram is not required for children with a first uti unless the renal / bladder ultrasound reveals findings suggestive of vesicoureteral reflux, selected renal anomalies or obstructive uropathy. key words : * bacteremia ; cefixime ; cystitis ; gentamicin ; pyelonephritis ; pyuria ; sepsis ; uti ; vur * urinary tract infections ( utis ) are a common cause of acute illness in infants and children. guidelines and recommendations on management of uti were last published by the canadian paediatric society ( cps ) in 2004 \. since then, meta \ - analytic reviews investigating the utility of diagnostic tests, radiological assessment and randomized control treatment trials have been published. in 2011, the american academy of pediatrics markedly revised its clinical practice guideline for diagnosing and managing initial febrile uti in young children. the present statement focuses on the diagnosis and management of infants and children \ > 2 months of age with an acute uti and no
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known underlying urinary tract pathology or risk factors for a neurogenic bladder. many of the recommendations for children \ > 3 years of age and all recommendations for managing lower utis ( cystitis ) are based on expert opinion alone because studies are lacking. for infants \ < 2 months of age with a febrile illness, bacterial sepsis must be considered, leading to a different approach to investigation and management. children with recurrent utis, renal abnormalities or pre \ - existing major medical problems should be managed individually because these patients may require more extensive investigation, and more aggressive therapy and follow \ - up. a subsequent statement will address antibiotic prophylaxis of utis. # incidence of uti in a 2008 systematic review, approximately 7 % of children two to 24 months of age presenting with fever without a source and 8 % of children two to 19 years of age presenting with possible urinary symptoms were diagnosed with a uti. occurrence rates varied widely depending on age, sex and race. the rate in uncircumcised febrile boys \ < 3 months of age was 20 \. 7 % compared with 2 \. 4 % in circumcised boys, declining to 7 \. 3 % and 0 \. 3 %, respectively, in boys six to 12 months of age. however, contamination is very common in obtaining a urine sample from a male when the foreskin cannot be retracted and the rates in uncircumcised males are, undoubtedly, overestimates. in febrile girls, approximately 7 \. 5 % \ < 3 months of age, 5 \. 7 % three to six months of age, 8 \. 3 % six to 12 months of age and 2 \. 1 % 12 to 24 months of age had a uti as the cause of their fever. # diagnosis of uti # # clinical features as previously recommended by the cps, a urinalysis and urine culture should be obtained from children \ 39 \. 0°c rectal ) with no apparent source. a child with rhinitis, cough, wheezing, rash or diarrhea is likely to have a viral infection as the source of fever and need not be investigated for a uti. although positive urine cultures occur with bronchiolitis, it is probable that most positive urine cultures in infants \ > 2 months of age with bronchiolitis are caused by contamination or asympt
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##omatic bacteruria. the incidence of uti without fever in preverbal children is not known but positive urine cultures in afebrile young children are much more commonly due to contamination than to uti. for children ≥3 years of age, the presence of urinary symptoms ( dysuria, urinary frequency, hematuria, abdominal pain, back pain or new daytime incontinence ) can be used as a criterion for requesting a urinalysis and culture. be wary that prepubertal girls can develop dysuria and a red vulva from poor hygiene or exposure to bubble bath or other irritants ; urine cultures will be sterile but this problem is often inappropriately treated as a uti. systematic reviews of the diagnostic accuracy of clinical examination and urinalysis in diagnosing uti have been published. they show that infants with a fever \ > 39°c for \ > 48 h without another source for fever on examination are highly likely to have a uti. some studies have proposed a predictive rule for ruling out uti in girls \ 39°c, fever for \ > 2 days and absence of another source of infection. when there are * no more than one - of these features, the risk for uti is \ < 1 %. it is unusual for males to have their first uti after three years of age in the absence of instrumentation of the urinary tract. # # sampling urine obtaining urine samples from children who are not toilet trained involves urethral catheterization, suprapubic aspiration ( spa ), use of a paediatric urine collection bag or leaving the child with the diaper off and obtaining a clean \ - catch urine when the child voids. although collecting urine using a bag for urinalysis is simple and noninvasive, bag samples have a high a rate of contamination ( up to 63 % ), making culture results unreliable for diagnosis of uti. in some hospital and clinic settings, a bag specimen is used as an initial screen and a subsequent specimen is obtained by catheterization or spa if the urinalysis is abnormal. for toilet \ - trained children, a midstream urine sample should be collected. asking little girls to sit backward on the toilet seat spreads the labia and may prevent contamination. it appears that perineal cleansing may not be necessary before collection of midstream urine, presumably because the first drops
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of urine wash away contaminants. # # interpreting urinalysis rapid urine tests ( also known as dipsticks or macroscopic urinalysis ) remain useful for diagnosis of uti. the nitrite test measures the conversion of dietary nitrate to nitrite by gram \ - negative bacteria. a positive nitrite test makes uti very likely ( ), but the test may be falsely negative if the bladder is emptied frequently or if an organism that does not metabolize nitrate ( including all gram \ - positive organisms ) is the cause of infection. the leukocyte esterase test is an indirect measure of pyuria and, therefore, may be falsely negative when leukocytes are present in low concentration. a microscopic urinalysis is useful to determine whether there are white blood cells in the urine, which is a sensitive indicator of inflammation associated with infection. shows that pyuria is 73 % sensitive and 81 % specific for diagnosis of uti. however, the definition of pyuria is not uniform in the literature. the finding of 10 white blood cells per microliter in uncentrifuged urine specimen is reported to be a more sensitive indicator of uti, but most centres in canada report the number of white blood cells per high \ - power field ( with \ > 5 being abnormal ). common teaching is that absence of pyuria does not exclude a uti, especially in infants \ < 2 months of age. however, it has also been argued that febrile utis should always result in pyuria, bringing into question whether many infants with positive urine cultures but no pyuria have contamination or asymptomatic bacteruria rather than a uti. bacteria and yeast seen on microscopic urinalysis are often contaminants. debris is sometimes confused with bacteria on an unstained specimen, but the combination of pyuria and bacteruria on urinalysis should raise suspicion for a uti. according to published literature, a child with a negative urine dipstick for nitrites and leukocyte esterase and no pyuria or bacteruria on microscopic examination has a \ < 1 % chance of having a uti ( ). # # interpreting urine cultures urine collection must occur before starting antibiotics because a single dose of an effective antibiotic rapidly sterilizes the urine. for children who are not toilet trained, only urethral catheterization and spa are
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considered to be reliable methods for specimen collection for the purpose of culture. a negative bag culture rules out a uti but a positive result is not useful. see for interpretation of urine cultures. however, strict definitions of colony count criteria are operational and not absolute ; in rare circumstances, low colony counts can be indicative of a uti. in previously well children who have not been on antibiotics, utis are usually due to * escherichia - * coli *, * klebsiella - * pneumoniae *, * enterobacter - species, * citrobacter - species, * serratia - species or, in adolescent females only, * staphylococcus - * saprophyticus *. it is controversial whether enterococci commonly cause utis in previously healthy children with no history of recent antibiotic exposure. mixed growth or growth of other organisms usually indicates that the urine is contaminated. # # other investigations there is no evidence that documentation of bacteremia in children with utis should influence therapy. blood cultures need not be performed when the diagnosis of uti is clear unless the child is hemodynamically unstable. renal function should be monitored when the child has a complicated uti ( see below ) or is treated with aminoglycosides for \ > 48 h. # # reassessment when urine culture results are available when children are started on antibiotics for possible uti, the diagnosis must be reassessed once the results of all investigations are available and antibiotics stopped if uti appears to be unlikely. # treatment of uti a series of reports on the treatment of pyelonephritis and the long \ - term risk of renal scarring has shed new light on treatment strategies. the risk of permanent renal damage due to acute pyelonephritis in children with normal kidneys is believed to be very low, and the need for routine intravenous ( iv ) antibiotics has been questioned. a cochrane review of children up to 18 years of age with pyelonephritis found no difference between oral antibiotics ( 10 to 14 days ) and iv antibiotics ( three days ) followed by oral antibiotics ( 10 days ) with respect to duration of fever or subsequent renal damage. similarly, no significant differences were found comparing iv antibiotics ( three to four days ) followed by oral antibiotics, versus iv antibiotics alone for seven to 14 days. based on these studies, most experts recommend initial treatment with oral antibiotics for febril
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##e utis in nontoxic children with no known structural urological abnormality, assuming that they are likely to receive and tolerate every dose. data on oral therapy is limited for infants two to three months of age, so close follow \ - up is warranted for this age group. some experts recommend initial iv antibiotics for this age group. while waiting for antibiotic susceptibility results for the likely bacterial pathogen, clincians should make an empirical choice of antibiotics based on local susceptibility patterns. annually updated susceptibility patterns for community \ - acquired * e coli - infections should be sought from valid internet or local microbiology laboratories. the least broad \ - spectrum antibiotic option should be used. currently, cefixime is a good choice in most areas. for patients requiring hospitalization, a common iv choice is gentamicin, with or without ampicillin. clinicians sometimes favour using cefotaxime or ceftriaxone because they are less nephrotoxic than gentamicin, but these cephalosporins are broader spectrum ( see for dose recommendations ). therapy should be modified to the narrowest spectrum antimicrobial when susceptibility results become available, but it is not necessary to switch outpatients to a different oral antibiotic if the isolate is susceptible to the one that they are on. aminoglycoside levels and renal function need to be monitored when the aminoglycoside is continued for \ > 48 h. uti without fever is usually a lower tract infection ( cystitis ). cystitis occurs mainly in postpubertal girls and presents as dysuria and urinary frequency. there are a paucity of studies, but a two \ - to four \ - day course of oral antibiotics based on local community \ - acquired * e coli - susceptiblities is likely to be effective. # when to be concerned that a child has a complicated uti children should receive more extensive assessment when they are hemodynamically unstable, have an elevated serum creatinine level at any time, have a bladder or abdominal mass, have poor urine flow, or are not improving clinically within 24 h or fever is not trending downward within 48 h of starting appropriate antibiotics. a clinician would usually start with a renal and bladder ultrasound ( rbus ) to look for obstruction or an abscess. iv rather
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than oral antibiotics are indicated for complicated utis until the child is clearly improving. # what should one do if a multiresistant organism is isolated in urine? it is increasingly common to isolate an organism that is resistant to the empirical antibiotics that were chosen, even when the child has not previously been on antibiotics. often the susceptibility pattern of the isolate is limited to antibiotics that cannot be given orally or to quinolones, which are not licensed for use in prepubertal children. quinilone antibiotics should not be used routinely but may be appropriate if the organism is resistant to other oral antibiotics. commonly, too, the child has shown marked clinical improvement on treatment by the time susceptibilities become available. it is not clear whether clinical improvement is because the organism is susceptible to the high concentration of antibiotic that is achieved in the urine or because the urine was contaminated initially. if the child is now asymptomatic, one approach would be to repeat the urinalysis and urine culture and change therapy only if results are suggestive of a persistent uti, keeping in mind that even a repeat positive urine culture may be contaminated. if the child remains symptomatic, urinalysis and urine culture should be repeated and the antimicrobial modified pending results. # imaging : what imaging studies should be performed, and when? children with suspected cystitis do not require imaging. major objectives for conducting diagnostic imaging studies during or after a febrile uti are to confirm that the child had pyelonephritis and to identify whether severe vesicoureteral reflux ( vur ) or structural anomalies are present. imaging should only be performed when it is likely to alter management. the choice of imaging should be guided by the safety, cost and accuracy of the procedure to be done. in the past, a voiding cystourethrogram ( vcug ) was recommended routinely for children between two months and two years of age who had a febrile uti, but this is no longer recommended practice. # imaging options current common imaging options for children with uti include renal / bladder ultrasound ( rbus ), radiographic ( eg, vcug ) and radioisotope ( eg, dimercaptosuccinic acid \ ) techniques. at the time of the first acute infection, clinicians will be concerned as to whether the child is predisposed to recurrent
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urinary infection, because of kidney stones or anatomical anomalies of the kidney, ureter or bladder, which may cause vur or urinary stasis. antibiotic prophylaxis pending results of imaging is no longer advised routinely. rbus has become a standard tool for evaluating children \ < 2 years of age with a first febrile uti during or within two weeks of their acute illness ( where practical ) because it is convenient, inexpensive and less invasive than vcug. rbus reliably detects hydronephrosis, which usually occurs with high grade ( grade iv or v ) vur. in one study, 12 of 14 children ( 86 % ) with grade iv or v vur were identified by rbus alone. although rbus is less sensitive at diagnosing grades i to iii vur, many experts question the importance of vur at these grades because most low \ - grade vur resolves spontaneously. rbus has the advantage of being readily available, radiation free and noninvasive. thus, rbus alone is an attractive alternative to performing a vcug after the first episode of febrile uti. it is controversial whether there is a need to obtain a rbus if a high \ - quality ultrasound reported by an expert can be documented to have shown a normal fetal urinary tract late in pregnancy. a vcug is the optimal method for diagnosing vur and for assessing the degree of vur and the anatomy of the male urethra. there are several drawbacks to performing a vcug including expense, exposure to radiation, the risk of causing a uti and discomfort for the child. a recent change in practice is that antibiotic prophylaxis is no longer recommended for children with grade i through iii vur because the number needed to prophylax for one year to prevent one uti is probably \ > 10 \. therefore, routine imaging of infants with vcug after the first uti is no longer suggested unless rbus is suggestive of selected renal abnormalities or obstruction, or high \ - grade vur ; a child with normal kidney structure is not at significant risk of developing chronic kidney disease because of utis. a vcug is usually indicated for children \ < 2 years of age with a second well \ - documented uti. although a vcug is often postponed until the child finishes antibiotics, there is no evidence that this delay is necessary. it is controversial whether
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antibiotic prophylaxis is indicated for a vcug. where available, a nuclear cystogram ( ncg ) may be used in place of a vcug to assess for vur using radioisotopes. ncg delivers less radiation than a vcug but is less readily available and provides poor anatomical detail for the male urethra ; thus, it can miss posterior urethral valves. it is logical to use ncg in place of vcug as the initial test for vur investigation in females and in follow \ - up studies for both sexes. a dmsa scan can be used to diagnose acute pyelonephritis ( when performed during acute illness ) and to identify renal scars ( when performed months following the acute illness ). this method requires exposure to radiation and is not likely to alter management ; thus, a dmsa is primarily useful when the diagnosis of acute uti or of repeated utis is in doubt. # recommendations for physicians : - infants from two to 36 months of age with a fever of \ > 39°c and no other source for fever on history or physical examination could have a uti, and should have urine collected for urinalysis. unless this test is completely normal, they should then have urine collected by catheter or suprapubic aspirate sent for culture. the present statement does not apply to infants \ < 2 months of age. - when uti is suspected in toilet \ - trained children, a midstream urine sample rather than a catheter or spa specimen should be submitted for urinalysis and culture. - children with possible uti who require antibiotic treatment immediately for other indications, such as suspected bacteremia, should have urine collected for urinalysis, microscopy and culture. the test sample should be midstream urine if the child is toilet trained, and a catheter or spa or clean \ - catch specimen if not, and obtained before starting antibiotics. overdiagnosis of uti is a common problem, leading to overuse of antibiotics and unnecessary imaging. urines collected by bag should never be used for diagnosis of uti. urines with low colony counts, mixed growth or no pyuria are usually contaminated. - infants and children with febrile uti should be treated with antibiotics for seven to 10 days. oral antibiotics can be administered as initial treatment when the child has no other indication for admission to hospital and is considered
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likely to receive and tolerate every dose. there is no evidence that children with utis and documented bacteremia who have a rapid clinical response to antibiotics require intravenous antibiotics or a longer course of antibiotics. however, all such children need to be assessed by a physician the day that the blood culture is known to be positive. the choice of antibiotic should be guided by the resistance pattern of common urinary pathogens in the community and changed to a less broad spectrum agent, if practical, when the sensitivity of the pathogen is known. - children \ < 2 years of age should be investigated after their first febrile uti with a renal and bladder ultrasound ( rbus ) to identify significant renal abnormalities and grade iv or v vur. a voiding cystourethrogram ( vcug ) is not indicated with a first febrile uti when the rbus is normal. - antibiotic prophylaxis is no longer recommended for grades i through iii vur or pending results of the initial rbus. - children with grade iv or v vur or a significantly abnormal rbus should be discussed with a paediatric urologist or nephrologist to determine whether there is an urgent need for a consult and make the best plan for further investigation and management. - parents of all children with febrile utis, with or without vur, should be advised that their child needs to be assessed for the possibility of recurrent uti early in the course of any unexplained fever. such guidance is especially pertinent in this era, where very few children are on prophylactic antibiotics for utis. - for older children with no fever and presumed cystitis, a two \ - to four \ - day course of oral antibiotics is usually adequate. # future research needs for optimal management of uti in children : - long \ - term cohort studies to establish the relationship between uti in infants and young children and reduced renal function and hypertension in adults. - less invasive techniques for diagnosis of vur and better understanding of the contribution of vur and other risk factors to the development of renal function abnormalities. - assessment of optimal treatment strategies ( length of therapy, choice of antibiotics ) for febrile utis and for older children with cystitis. - management strategies for infants \ < 2 months of age with utis.
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head trauma leading to brain injury is an important cause of morbidity and mortality in childhood. injury severity is related to the mechanism of trauma, which itself varies with age. the vast majority of head trauma in paediatric patients is mild, requires no specific therapy and leaves no sequelae. however, it is important to identify individuals at risk of significant injury, and thus in need of specific evaluation. the purpose of this statement is to describe issues related to head trauma in infants, children and youth, including clinical manifestations, initial management priorities, guidelines for imaging, and subsequent observation and treatment. it addresses the evaluation of patients with acute trauma to the head at the time of initial assessment ; it does not describe the subsequent management of such patients in the paediatric intensive care unit. key words : * ct scan ; head trauma ; skull x \ - rays ; prevention ; traumatic brain injury * head trauma leading to brain injury is an important cause of morbidity and mortality in childhood. estimates of the incidence in paediatric patients vary according to definition and methodology ; however, the annual rate ranges from 130 to 200 cases per 100, 000 population, leading to at least 20, 000 emergency department ( ed ) visits in canadian paediatric hospitals per year. \ - in the united states, head trauma is estimated to lead to \ > 470, 000 emergency department visits and 35, 000 hospital admissions annually. head trauma is thus one of the most common reasons for consultation in the ed. only a small proportion of patients with head trauma will be found to have a traumatic brain injury ( tbi ). this term is used to describe the symptoms and signs that result from trauma to the brain itself, which may or may not be associated with findings of injury on imaging studies. in sports \ - related concussion, it is well recognized that significant symptoms and impaired functioning may persist for a considerable length of time after the traumatic event. the clinical significance of intracranial lesions may be defined in a variety of ways, such as the need for hospitalization or neurosurgical intervention. in one large series of children presenting to the ed in children ’ s hospitals in italy, the risk of fatal and nonfatal traumatic brain injury was 0 \. 5 and 5 \. 2 per 1000 children with closed head trauma, respectively. the unique anatomy of children may make them more likely to develop an intracranial lesion due to head trauma. they have a larger head \
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- to \ - body size ratio, a thinner cranial bone and less myelinated neural tissue. paediatric patients with traumatic brain injury more commonly develop a pattern of diffuse axonal injury and secondary cerebral edema compared with adults. lesions actually requiring neurosurgical intervention, such as evacuation of a hematoma, are relatively rare. the most common causes of head trauma in children and youth presenting to canadian eds are : - sports \ - related injuries - being hit on the head, by an object or by colliding with an obstacle - injuries involving the use of a bicycle - injuries involving motor vehicles, especially as a pedestrian. intracranial injury is more frequent following falls from a height above three feet ( 91 cm, or twice the length / height of the individual ), involvement in a motor vehicle accident ( either as a passenger or a pedestrian ) or impact from a high \ - velocity projectile. # clinical manifestations children with head trauma may present with a variety of symptoms, including : - impaired level of consciousness, disorientation or confusion - loss of consciousness - blurred vision younger children may present with lethargy or irritability. it is difficult to conclude from published studies which, if any, single clinical symptom or sign is a reliable predictor of intracranial injury. however, signs that have been particularly associated with intracranial injury include : - prolonged loss of consciousness or impaired level of consciousness - disorientation or confusion ; amnesia - worsening headache - repeated or persistent vomiting # classification of the severity of head trauma the glasgow coma scale ( gcs ) ( ) is a validated tool used to evaluate level of consciousness. the paediatric glasgow coma scale ( ) has been shown to be particularly useful in preverbal children. for the purposes of these guidelines, head trauma is classified according to gcs as follows : - gcs 14 to 15 : minor head trauma - gcs 9 to 13 : moderate head trauma - gcs ≤8 : severe head trauma minor head trauma accounts for the majority of paediatric patients presenting for medical assessment for possible head injury. patients with moderate or severe head trauma are more likely to exhibit intracranial pathology and require either supportive care or specific treatment in a hospital setting. # initial management priorities the first priority is to stabilize vital signs. an important goal of stabilization is to avoid secondary injury to the traumatized brain from hypoxia, hypotension
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, hyperthermia or raised intracranial pressure. a structured approach to the assessment of airway, breathing, circulation and disability ( abcd ) is described in. on occasion, early and definitive treatment of a primary intracranial injury may be required ( eg, in some cases of epidural hematomas ). a pertinent history should also be obtained. elements to include are : - the mechanism of head trauma, whether witnessed or not ; - the state in which the patient was found, including loss of consciousness or seizures ; - presenting symptoms, especially impaired level of consciousness, disorientation or confusion, amnesia, worsening headache or repeated vomiting ; and - medical history of head injury, neurological disorders, medication use and bleeding diathesis., especially in situations of altered level of consciousness without obvious cause, or when the clinical findings are not compatible with the history provided. abusive head trauma may not be recognized initially, due to variable modes of presentation and the typically young age of victims. delays in recognizing traumatic brain injury in this context may lead to relatively poor outcomes. # # indications for skull x \ - rays while the presence of a linear skull fracture appears to be an independent risk factor for intracranial lesions, skull x \ - rays need not be performed routinely in all patients. children younger than two years of age with head trauma present particular challenges. clinical assessment of their neurological status may be limited by their developmental level, particularly in the preverbal stage. the incidence of skull fracture following minor head injury may be as high as 11 % in this age group but obtaining imaging studies, especially computed tomography ( ct ) scans, may require sedation. guidelines for evaluating children younger than two years of age with apparently minor head trauma have been published. these have supported the recommendation that skull x \ - rays should be performed in the presence of a large, boggy hematoma in a child younger than two years of age. while an obvious penetrating lesion or suspected depressed skull fracture in an older patient is an indication for skull x \ - ray, a ct scan is more commonly performed. if elements of the history or physical examination raise the suspicion of child abuse, skull x \ - rays are indicated as part of the investigation. detailed discussion of abusive head trauma is beyond the scope of this statement and has been addressed well in other documents. # # indications for ct scan all patients presenting with moderate or severe head trauma should undergo a cranial ct scan.
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however, there is considerable debate about which patients with minor head trauma require a ct scan, given the potential for late deterioration resulting from delayed diagnosis of an intracranial injury and the relative unreliability of clinical signs in predicting intracranial injury. the low rate of positive findings on ct scan, the need to sedate some patients in order to perform the examination, and concern about the risk of radiation exposure have prompted the development of clinical prediction rules to guide clinicians in deciding for whom a scan should be performed. all of these rules involve some combination of variables based on the mechanism of trauma, signs and symptoms on initial assessment, or status after a period of observation. recent systematic reviews have criticized their heterogeneity and lack of prospective validation in multicentre cohorts. the largest study published to date on this issue is from the pediatric emergency care applied research network. this study included 42, 412 patients from 25 sites. this group ’ s approach differed from previous studies in identifying elements whose * absence - would obviate the need for a ct scan. while highly sensitive and relatively specific, widespread application of these algorithms may lead to greater, rather than less, use of ct scans. members of the pediatric emergency research canada head injury study group derived the canadian assessment of tomography for childhood head injury ( catch ) rule, by means of a prospective cohort study involving 3886 children presenting with symptomatic minor head trauma to 10 canadian paediatric teaching institutions. the catch rule is outlined in. the seven high \ - and medium \ - risk factors were shown in a subsequent prospective validation study to be 98 % sensitive ( 95 % ci 95 % to 99 % ) for predicting acute brain injury, and would require that 38 % of patients undergo ct. elements on history or physical examination that should motivate the clinician to order a ct scan : - focal neurological deficit on physical examination - clinically suspected open or depressed skull fracture, or a widened or diastatic skull fracture observed on x \ - ray - abnormal mental status : gcs \ < 14 at any point from time of initial assessment onward, or gcs \ < 15 at 2 h after injury - clinical deterioration over 4 h to 6 h of observing a symptomatic patient in the ed, including worsening headache or repeated vomiting - signs suggestive of a basal skull fracture - large, boggy scalp hematoma in child ≥2 years of age ; in younger children, consider
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performing a skull x \ - ray first - mechanism of trauma raising suspicion for serious injury ( eg, falling from a height, a motor vehicle collision in which speed was a factor, or impact with a projectile, such as a gunshot or a metal fragment ) - persistent irritability in a child \ < 2 years of age - seizures at the time of the event or later - known coagulation disorder # management after initial assessment # # minor head trauma ( gcs 14 or 15 \ ) asymptomatic patients may be discharged home to the care of reliable parents or guardians. written instructions describing signs to watch for ( eg, worsening headache, persistent vomiting, difficulty in awakening ), who to contact in such a case and when to return for follow \ - up, should be provided. if after initial evaluation there is headache or repeated vomiting, or there is a history of loss of consciousness at the time of trauma, a period of clinical observation, with reassessment, is indicated. if there is improvement in symptoms and the gcs is 15, the patient may be discharged home with parental instructions as above. if there is no improvement, the patient should be admitted to hospital with evaluation of vital signs and level of consciousness every 2 h to 4 h. intravenous rehydration should be provided for patients with persistent vomiting. persistent symptoms after 18 h to 24 h of hospitalization may indicate a cranial ct scan, if not already performed. a ct scan with positive findings should be discussed with a neurosurgeon, and consulting a clinician experienced in the management of head trauma may be appropriate for patients with negative ct scans but experiencing persistent symptoms. in the child younger than two years of age, and particularly in children younger than 12 months of age, greater caution is advised. the challenges of their clinical assessment and the importance of identifying abusive trauma should lead clinicians to observe these patients for a longer period, with frequent reassessments. trivial head trauma in an asymptomatic, ambulatory toddler is compatible with discharge from the ed ; this may not be the case for an infant or baby. the presence of a widened or diastatic skull fracture ( \ > 4 mm ) increases the risk of developing a leptomeningeal cyst, and follow \ - up of these patients should be arranged. in cases of suspected abusive head trauma, hospitalization may be indicated and referral to the local child protection authorities
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is always required. # # moderate head trauma ( gcs 9 to 13 \ ) all patients with moderate head trauma should undergo imaging by ct scan. skull x \ - rays may also be indicated. they should be admitted to hospital and consultation with a neurosurgeon or clinician experienced in the management of head trauma is advised. depending on the ct scan findings and the evolution of neurological status, admitting these patients to a paediatric intensive care unit may be needed to provide closer monitoring. this is particularly true for patients at the lower end of the gcs spectrum ( gcs 9 to 10 \ ). the decision to transfer a patient with a moderate head injury to a tertiary care centre must be individualized, based on clinical judgment and local resources, and should be discussed with a paediatric intensive care or trauma team, or both. # # severe head trauma ( gcs ≤8 \ ) once the patient with a severe head injury has been stabilized, including intubation, a cranial ct scan should be performed. severe traumatic brain injury is a complex and challenging emergency. patients with severe head trauma are at risk of raised intracranial pressure ( icp ). raised icp may result from the mass effect of localized bleeding, as in the case of epidural and subdural hematomas, or be produced by vasogenic edema from diffuse axonal injury. in the acute setting, measures aimed at maintaining a normal icp and cerebral perfusion pressure are appropriate. management should include : - continuous monitoring of vital signs and, if possible, end \ - tidal co2 - mechanical ventilation to maintain normal oxygenation and ventilation - maintenance of a normal core temperature - providing sedation and analgesia, particularly during procedures and transport - fluid administration as required to maintain normovolemia and avoid hypotension. patients with severe head trauma require referral to a trauma centre with neurosurgical and paediatric critical care services. during transport, continuous monitoring of neurological, respiratory and hemodynamic status is essential, and treatment modalities for emergency management of raised icp should be available. # post \ - traumatic seizures the majority of post \ - traumatic seizures in children occur within the first 24 h, and rarely beyond seven days. factors increasing the risk of post \ - traumatic seizures may include younger age, severe head trauma ( gcs ≤8 \ ), cerebral edema, subdural hem
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##atoma, and open or depressed skull fractures. the incidence of early post \ - traumatic seizures ranges from 5 % to 6 \. 5 % but may be as high as 30 % to 35 % in severe head trauma. it is possible that abnormal mental status at initial assessment following a head trauma is due to a postictal state. post \ - traumatic seizures may contribute to secondary brain injury, with the exception of those occurring immediately after the head trauma : so \ - called ‘ impact seizures ’. patients with impact seizures or an isolated post \ - traumatic seizure shortly after the event, but whose neurological examination and imaging are normal, are at low risk of further complications and may be discharged. the acute treatment of post \ - traumatic seizures is identical to that of acute seizures occurring in other contexts. the has been described in a recent statement from the canadian paediatric society. administering phenytoin to prophylax for post \ - traumatic seizures in paediatric head trauma patients is not proven effective but it is still used frequently to treat post \ - traumatic seizures and to prophylax in patients with severe head trauma. the majority of patients with minor head injury do not exhibit intracranial pathology and their symptoms will resolve quickly. nevertheless, the literature regarding clearly demonstrates that some patients will continue to experience symptoms of varying intensity for days or weeks following the concussion, with effects on global functioning and school performance. with a documented intracranial injury, indicators of poor prognosis include clinical severity at initial presentation, especially a gcs ≤5, and the presence of raised icp. research is underway to assess the validity of serum or cerebral spinal fluid ( csf ) markers of severity of injury, as well as early examinations of cerebral physiology such as cerebral oximetry and somatosensory \ - evoked potentials. other elements influencing prognosis following traumatic brain injury include the presence and severity of injuries at other body sites, pre \ - injury attention \ - deficit \ - hyperactivity disorder, and socioeconomic status. difficulties in concentration, attention and behaviour may lead to problems with social functioning long after the time of the injury. health care practitioners have numerous opportunities to provide age \ - appropriate anticipatory guidance around risk factors for head trauma in children. the cps advocates for public policy and legislation to ensure, for example, helmet use in sporting activities, child restraint use in vehicles and the ban on baby walkers in canada. such measures have
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proven successful in reducing both the incidence and severity of head trauma in paediatric patients. \ clinicians treating infants, children and youth should include injury prevention when counselling families. head trauma is a frequent occurrence in childhood and adolescence, with most injuries being minor and without sequelae. a systematic approach to the clinical assessment of the patient presenting with head trauma is recommended, with investigations being conducted according to the symptoms, signs and estimated likelihood of intracranial pathology. most patients can be either discharged or observed in hospital for a short period. severely injured children require immediate stabilization, close surveillance and continuous monitoring to prevent secondary lesions that may aggravate the consequences of the primary brain injury.
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antimicrobial stewardship is a recent concept that embodies the practical, judicious use of antimicrobials to decrease adverse outcomes from antimicrobials while optimizing the treatment of bacterial infections to reduce the emergence of resistant pathogens. the objectives of the present statement are to illustrate the principles of antimicrobial stewardship and to offer practical examples of how to make antimicrobial stewardship part of everyday hospital and outpatient practice. vital components of antimicrobial stewardship include appropriate testing to diagnose whether infections are viral or bacterial, and using clinical follow \ - up rather than antibiotics in cases in which the child is not very ill and uncertainty exists. other specific, important actions include questioning whether positive urine cultures are contaminated when there is no evidence of pyuria or inflammatory changes, and obtaining a chest radiograph to support a diagnosis of bacterial pneumonia. optimizing the choice and dosage of antimicrobials also reduces the probability of clinical failures and subsequent courses of antimicrobials. a list of common clinical scenarios to promote stewardship is included. key words : * aom ; - c difficile * ; - e coli * ; pneumonia ; superbugs ; utis * antimicrobial stewardship is defined as a collection of interventions geared toward optimizing the prescribing of antimicrobials, and includes the appropriate selection, dosing, route and duration of antimicrobial therapy with the goal of optimizing patient outcomes and decreasing adverse events related to antimicrobial therapy. few drugs aside from antimicrobials can lay claim to providing cures for diseases. the dramatic and lifesaving impacts of antimicrobial therapy in the treatment of major illnesses, such as bacterial pneumonia, typhoid fever, urinary tract infections ( utis ), sepsis and endocarditis, are still observed every day, but may be in peril in the future. the objectives of the present statement are to illustrate the principles of antimicrobial stewardship and to offer practical examples of how to make antimicrobial stewardship part of everyday hospital and outpatient practice. the need for antimicrobial stewardship stems from the knowledge that overusing antimicrobials has increased the risk of children carrying antimicrobial \ - resistant bacteria and contributing to the increasing incidence of * clostridium di
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##fficile - gastrointestinal infections. examples of the relationship between the overuse of antimicrobials and emerging resistance include macrolide use and resistance in * streptococcus pneumoniae *, and ampicillin use and resistance in * escherichia coli *. \ - furthermore, resistant bacteria and * c difficile - can be shed into the environment and, as such, be transmitted from person to person, thus representing a risk to society in general. other benefits of antimicrobial stewardship for patients and for organizations are the decrease in adverse events and superinfections related to antimicrobial use, and the cost savings associated with lowering antimicrobial use. common situations of overuse include prescribing for uncomplicated upper respiratory tract infections, chronic serous otitis media, “ bronchitis ” or the empirical use of antibiotics for pharyngitis. without changing prescribing practices and controlling access to ‘ over \ - the \ - counter ’ antimicrobials globally, we can expect increasing antimicrobial resistance and the emergence of ‘ superbugs ’ that will threaten the well \ - being of people around the world. additionally, recent long \ - term studies of the effect of antimicrobial therapy on the human microbiome have suggested a possible association between previous antimicrobial therapy and the development of obesity and allergies. \ - such findings and others could revolutionize our understanding of the long \ - term impact of antimicrobials on the human host. being better ‘ stewards ’ of antimicrobials not only helps to preserve their use in treating infections, but also decreases the unintentional harms caused by using antimicrobials unwisely. intervening and demonstrating antimicrobial stewardship will continue to be a required organizational practice for health care organizations in canada. as a prescriber, improving stewardship means deciding whether a patient truly needs antimicrobials and, if so, selecting the most appropriate antimicrobial, dose, route and duration of therapy with two related goals : optimizing therapy and minimizing the risk of adverse events. current antimicrobial stewardship programs in hospitals range from committee influence on the formulary to ‘ persuasive ’ influences on prescribing such as prospective audit and feedback from pharmacists and physicians specifically trained
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in infectious diseases. individual prescribers, however, are also responsible for applying the same principles to all patients, including those in outpatient settings. some principles of stewardship, such as watchful waiting or narrowing the antimicrobial spectrum, may not be applicable to patients who are immunosuppressed or otherwise susceptible to severe infections ( eg, asplenic patients or those with congenital immunodeficiency syndromes ), or to newborns or infants for whom empirical antimicrobials should be considered in clinical settings where localizing signs of infection are subtle. # use clinical judgement and test judiciously clinical judgment based on a patient ’ s age, history and physical examination ( including vital signs ) is critically important for deciding whether there is an infection and judging its severity. when signs or symptoms suggest bacteremia, meningitis or other serious or life \ - threatening infection, appropriate cultures should be taken and effective antimicrobials, based on potential pathogens, initiated immediately. similarly, a ‘ septic work \ - up ’ and cultures of specimens should be restricted to patients with a reasonable suspicion of a bacterial infection. determining the results of culture testing and reassessing the clinical situation to adjust or stop antimicrobial therapy are important steps in the management process. testing in an office practice may be more challenging depending on proximity to a laboratory or a diagnostic imaging centre. unless antimicrobials are required immediately, delaying antimicrobial therapy is reasonable in a stable, mildly ill child for whom a viral etiology is most probable ( eg, a wheezing, febrile but otherwise reasonably well infant during respiratory syncytial virus season ). however, prolonged or worsening symptoms in a presumed viral illness should prompt re \ - evaluation because a small proportion of patients may develop a secondary bacterial infection. in other situations, confirming a viral etiology is important for therapeutic or epidemiological purposes ( such as early in the influenza season or for patients who are hospitalized ). during the viral season, even in outpatient settings, timely testing for influenza in a moderately ill child with or without a pneumonia or with risk factors for severe disease may be important to starting treatment with antiviral agents active against influenza ( eg, oseltamivir ). in the setting of pharyngitis with nonviral symptoms, a throat swab or a rapid antigen detection test for group a streptococci
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should be used to confirm streptococcal pharyngitis. if culture based, waiting 24 h to 48 h for the result before prescribing an antibiotic is reasonable when the child is not severely ill. an excellent review on this subject is available. when considering acute otitis media ( aom ), accuracy of the diagnosis ( fluid behind an inflamed tympanic membrane in a child who has acute ear pain ) should be paramount. if the child is older than six months of age, has uncomplicated, unilateral aom with mild signs and symptoms, follow \ - up is accessible and caregivers understand the rationale, it is reasonable to treat with analgesics alone and adopt the ‘ watch and wait ’ approach for 48 h to 72 h after onset of symptoms to see if pain and fever resolve. persistent symptoms should be treated with antimicrobials because the likelihood of a bacterial etiology is higher. confirming a diagnosis of lobar pneumonia with a chest radiograph, if possible, is also recommended before starting empirical therapy. studies indicate that clinical assessment alone leads to overdiagnosis and overtreatment in many cases. if a pneumonic infiltrate is not observed or if the radiograph is consistent with bronchiolitis, careful follow \ - up without antimicrobial therapy is warranted. similarly, when a site is clinically infected and shows purulent drainage, it is equally important to take cultures. in the vast majority of circumstances, it is more prudent for patients with suspected or proven viral illnesses to have access to timely follow \ - up rather than prescribing antibiotics initially. good clinical acumen and the course of illness remain the mainstays when deciding whether a viral or a bacterial process is at work. # treat infection, not contamination the contamination of specimens is common, especially with urine and wound samples. without symptoms and signs of infection, there is a significant probability that the isolated bacteria was simply at the site when the specimen was collected or when it reached the testing laboratory and has contaminated the specimen. to prevent contamination, ensure that urine specimens are collected appropriately ( by catheter or a clean catch midstream ), even in newborns. the diagnosis of a uti requires the presence of some signs of infection ( ie, fever, or dysuria, or frequency in older ages ) and some laboratory evidence of inflammation ( e
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##g, white blood cells, leukocyte esterase or nitrites in the urine ) in addition to the presence of a significant amount of a uropathogen such as * e coli *. generally, the treatment of positive cultures when there are no signs of infection is incorrect, and avoiding this practice is an important principle of antimicrobial stewardship. taking a pharyngeal culture in an asymptomatic person or in a child with cough and rhinorrhea is not wise because the culture only demonstrates that group a streptococcus is colonizing or present at the site without causing infection ; this should not be a reason for treatment. similarly, the presence of methicillin \ - resistant * staphylococcus aureus - ( mrsa ) isolated from nasal or rectal specimens should not routinely trigger the start of antibiotic regimens for decolonization or treatment. on the other hand, antibiotic prophylaxis is indicated in specific settings, such as defined close contacts of individuals with invasive meningococcal, group a streptococcal or * haemophilus influenzae - type b ( hib ) disease. # take a careful history of potential antibiotic side effects and, if possible, confirm an antimicrobial allergy an immunoglobulin ( ig ) \ - e \ - mediated allergy usually manifests as urticaria, pruritus, bronchospasm, angioedema or hypotension within 1 h of drug administration. patients with an ige \ - mediated allergy to a penicillin should avoid penicillins in the future. however, the crossreactivity with a cephalosporin is extremely low ( 2 % ) even with a penicillin allergy. if the history is suggestive of an ige \ - mediated reaction to penicillin, penicillin skin testing should be performed by an allergist. a negative test will allow for penicillin use in the future and the ‘ label ’ of penicillin allergy can be removed. a history of ige \ - mediated allergy in a parent is not a reason to avoid that antibiotic in the child. a history of serious non \ - ige \ - mediated reactions, such as stevens \ - johnson syndrome or toxic epidermal necrolysis attributed to an antibiotic, is
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a contraindication to using related antibiotics in the future. the most common side effects of using an antibiotic are nonurticarial maculopapular rashes or gastrointestinal symptoms such as diarrhea. many of these symptoms are probably viral in etiology or idiosyncratic reactions to the drug, and not an allergy. because these are not ige \ - mediated side effects, the child can be given that antibiotic in the future, often permitting use of antimicrobials with a narrower spectrum of activity. # laboratories should produce local, age \ - specific antibiograms to guide antibiotic choices for selected infections aside from empirical therapy for meningitis and other life \ - threatening infections for which guidelines recommend broad spectrum coverage pending cultures, the local or regional antibiogram is a useful tool. the local antibiogram is a compilation of susceptibility patterns for common isolated bacteria, such as * s pneumoniae *, * s aureus - or * e coli *, in a local area and, as such, is useful for predicting susceptibility of bacteria. for example, in some areas, \ > 90 % of * e coli - in utis in children may be susceptible to a first \ - generation cephalosporin, making this antibiotic a reasonable choice for empirical outpatient treatment. using antibiotic resistance patterns from other countries or based on predominantly adult patients may overestimate resistance ( eg, the prevalence of penicillin \ - resistant * s pneumoniae - is higher in adults than in children in canada ) and encourages unnecessarily broad \ - spectrum antimicrobial use. similarly, multidrug \ - resistant pathogens in utis are uncommon in most children and the use of quinolones should be restricted to cases for which there is documented resistance of a pathogen to other agents. quinolones should not be used as empirical therapy in this scenario. regional laboratories should produce and disseminate age \ - specific antibiograms on a routine basis for use by clinicians. in turn, physicians should become familiar with the usual prevalence of resistance for common pathogens to guide empirical therapy. although cultures should still be performed, the need to ‘ de \ - escalate ’ therapy would probably occur less often. # narrow the spectrum of antimicrobials when a causative organism is identified because initial therapy is most often empirical,
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it is incumbent on the physician to de \ - escalate therapy when the pathogen is found to be susceptible to a narrower \ - spectrum agent ( eg, for utis ) if this is practical. if * s aureus - is susceptible to oxacillin, then cloxacillin or cephalexin ( rather than a second \ - or third \ - generation cephalosporin or a macrolide ) is the drug of choice. most community \ - acquired respiratory infections are due to pathogens ( * s pneumoniae - and group a streptococcus ) which have retained susceptibility to penicillins. # optimize the dosing of antimicrobials to obtain maximal benefit dose optimization for antimicrobials is often a neglected part of therapy and the choice among antibiotics should not be made solely on the basis of convenient dosing. generally, prescribers should always use the higher end of the recommended dose range for a specific infection to treat children with normal kidney and liver function. some antimicrobials ( such as aminoglycosides ) exhibit ‘ dose \ - dependent ’ killing. they typically have a maximal effect when the initial dose is high with less frequent dosing. aminoglycosides administered once every 24 h, rather than on a traditional dosing schedule of every 8 h, is recommended for all children with normal renal function beyond the neonatal period ( with some centres also using it for neonates ). by contrast, most oral penicillins and cephalosporins ( beta \ - lactams ) have a very short half \ - life of approximately 1 h. however, for maximal effectiveness ( bacterial killing ), the amount of beta \ - lactam at the site of infection should be higher than the concentration needed to inhibit the pathogen at least one \ - half of the day. otherwise, bacterial multiplication will continue during trough periods. this is known as ‘ time \ - dependent ’ killing. for a nonserious infection such as aom, using the beta \ - lactam amoxicillin in a twice \ - per \ - day regimen is reasonable if the dose is sufficiently high ( 75 mg / kg / day to 90 mg / kg / day ). however, for more serious infections, such as pneumonia, cellulitis, cervical adenitis, sinusitis or abscess, a beta \ - lactam should be given three or
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four times per day. physicians should explain to parents why a dosing schedule of three or four times per day has a higher chance of cure compared with a twice \ - per \ - day regimen in these situations. # use the shortest recommended course of therapy for uncomplicated infections the optimal duration of therapy for most infections is not known. shorter courses of antimicrobials are associated with fewer adverse events and less development of resistance compared with longer courses. the length of recommended penicillin therapy for streptococcal pharyngitis is still 10 days. for other infections, however, some data support shorter courses. in children older than two years of age, the recommended duration of therapy for uncomplicated aom that has failed a ‘ watch and wait ’ approach is five days rather than seven to 10 days. for uncomplicated pneumonia in otherwise healthy children, seven days, rather than 10 to 14 days, is reasonable. for utis, recommendations range from seven to 14 days. individualizing therapy to use the shorter recommended courses should take into consideration the extent of illness at presentation and the rapidity of clinical improvement after starting antimicrobials. # take care not to change or prolong antimicrobial therapy unnecessarily knowing that patients with infections such as lobar pneumonia, cervical adenitis or pyelonephritis, for example, can take three days or more to defervesce completely should not be regarded as evidence of treatment failure when other signs indicate some improvement in clinical condition. cellulitis also may take a day or so to improve. in most cases, escalating therapy to broader \ - spectrum coverage is not warranted when there is no microbiological reason to do so. in cases for which there is no clinical evidence of infection or when there is no response to antimicrobial therapy, it is useful to reassess the presumed diagnosis and consider noninfectious or other ( fungal or viral ) etiologies for the symptoms. other conditions associated with fever include kawasaki disease, neoplasms, juvenile inflammatory arthritis, inflammatory bowel disease and recurrent fever syndromes. # promote vaccinations to reduce the likelihood of clinical disease vaccines prevent infections and, consequently, decrease antimicrobial use. the routine use of conjugated pneumococcal vaccine has lowered the incidence of otitis media and pneumonia, helping to reduce antimic
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##robial use significantly. similarly, administering influenza vaccine to children has been shown to decrease febrile illnesses and thus, potentially, antibiotic use. publicly funded varicella vaccine has not only lowered the incidence of varicella but has also prevented associated secondary cellulitis. for other simple ways to minimize the use of antibiotics in practice, see below. antimicrobial stewardship is a complex interplay of art, science and common sense. many variables, such as when to start antibiotics, optimal dosing, reassessment of patients, determining what is and what is not a bacterial infection and when the patient can stop antibiotics, should be considered in using these valuable medications. careful consideration of our use of antimicrobials must become an integral part of practice. # ten ways to promote antimicrobial stewardship in your paediatric practice 1. always document a child ’ s vital signs, the physical examination and why you are using an antibiotic in your notes. this forces more mindful reflection on the decision and is of great practical value when others see the child in follow \ - up. schedule a clinical follow \ - up instead of starting antibiotics for patients who are not very ill but may have a bacterial infection. 2. detail a suspected drug reaction as much as possible, to determine whether the history meets criteria for a true allergy or not. consultation with an allergist may be useful for some patients. 3. ensure that the minimum diagnostic criteria for the diagnosis of a urinary tract infection are met before starting antibiotics. send a urinalysis, a urine microscopy and a urine culture ( clean catch or catheter specimen ). vaginitis from soap or bubble bath is commonly confused with urinary tract infections in preschool \ - age girls. 4. infectious syndromes that are typically due to * streptococcus pneumoniae - or group a streptococcus ( gas ) are best treated with beta \ - lactam antibiotics ( such as penicillin ), not with azithromycin or other macrolides ( eg, clarithromycin ). if you need coverage for * staphylococcus aureus - primarily, use cloxacillin ( if the child can swallow pills ) or cephalexin. if the child has a high risk for methicillin \ - resistant * s aureus - and the lesions are typical, drainage alone
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may work and / or trimethoprim \ - sulfamethoxazole orally, or vancomycin intravenously for severe infections, may be used empirically. 5. do not perform throat cultures on children with sore throat who have any features of a cold ( rhinorrhea, cough or hoarseness of voice ). a positive culture for gas in this setting almost always indicates that the child is a carrier and will not benefit from antibiotics. do not perform follow \ - up throat swabs on individuals who have completed therapy for gas pharyngitis. 6. always use the correct weight \ - based dose and optimize the frequency and duration of the antibiotic to achieve maximal benefit from therapy. most outpatient antibiotic prescriptions should be for five to seven days. many cases of mild \ - to \ - moderate acute otitis media will resolve on their own without antibiotic therapy. 7. ampicillin intravenously or oral amoxicillin ( three times per day ) are the empirical drugs of choice for community \ - acquired pneumonia. if there is poor response, consider complications of pneumonia or other diagnoses before changing antibiotics. treatment with a macrolide should be reserved for clinical presentations consistent with * mycoplasma - or * chlamydia - pneumonia. 8. a chest radiograph has high sensitivity in the diagnosis of pneumonia and, whenever practical, should be performed before starting antibiotics. 9. children who present with wheezing almost never need antibiotics because the diagnosis is usually asthma in older children or viral bronchiolitis in infants. 10. know the typical bacteria that cause common outpatient infections. most skin and soft tissue infections are due to * s aureus - or gas and will respond to narrow \ - spectrum antibiotics such as cephalexin. clinically infected sites that are visibly draining or purulent should be cultured. minor skin and wound infections may be managed with topical therapy.
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3b01a843f3c7f49479b1e106209ed85c1ca80daf
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lyme disease, the most common tick \ - borne infection in canada and much of the united states, is caused by the bacteria * borrelia burgdorferi *. peak incidence for lyme disease is among children five to nine years of age and older adults ( 55 to 59 years of age ). the bacteria are transmitted through the bite of infected black \ - legged ticks of the * ixodes * species. the primary hosts of black \ - legged ticks are mice and other rodents, small mammals, birds ( which are reservoirs for * b burgdorferi * ) and white \ - tailed deer. geographical distribution of * ixodes * ticks is expanding in canada and an increasing number of cases of lyme disease are being reported. the present practice point reviews the epidemiology, clinical presentation, diagnosis, management and prevention of lyme disease, with a focus on children. key words : * black \ - legged tick ; borrelia burgdorferi ; erythema migrans ; post \ - treatment lyme disease syndrome * lyme disease ( ld ), a serious disease, is the most common tick \ - borne infection in canada and the northeastern to midwestern united states, with cases also occurring ( with less frequency ) on the west coast. ld is caused by the bacteria spirochete, * borrelia burgdorferi *, transmitted to humans through the bite of infected black \ - legged ticks : * ixodes scapularis * in eastern and central canada and * ixodes pacificus * in british columbia. \ ] peak incidence for ld is among children five to nine years of age and older adults ( 55 to 59 years of age ), and many cases likely go unreported. \ ] no relationship between treated maternal ld and abnormal pregnancies or disease in infants has been documented. \ ] although there is a theoretical risk, no case of infection has been linked to blood transfusion. \ ] ticks cannot jump or fly. instead, they climb and wait on tall grasses or shrubs for a potential host to brush against them. they then transfer to the host and seek an attachment site. \ ] immature ticks ( nymphs ) are responsible for most human ld infections because their very small size hinders detection. \ ] how prevalent is ld in canada? black \ - legged tick populations are well established in parts of british columbia, manitoba, ontario, quebec, new brunswick
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and nova scotia, and may be expanding. migratory birds can bring infected ticks into nonendemic areas, and people may also become infected while travelling to other endemic areas in north america and europe. \ ] in 2009, ld became a nationally reportable disease. the number of reported cases has increased from 128 in 2009 to an estimated ≥500 in 2013 \. \ ] \ ] what are the clinical manifestations of ld? clinical manifestations are divided into early, localized ( cutaneous ) disease, and later ( extracutaneous ) disease. without treatment, em resolves spontaneously over a four \ - week period, on average. later ( extracutaneous ) disease : approximately 20 % of children with ld first present to a health care provider with extracutaneous signs or symptoms that are compatible with ld. these cases may also have a recent past history of em lesions ( single or multiple ) and non \ - specific low \ - grade fever, myalgia, and fatigue upon questioning further. \ ] other manifestations ( with or without rash ) include an isolated facial nerve palsy, arthritis, heart block ( or carditis ) or meningitis ( severe headache, fever ), which is usually lymphocytic predominant. \ ] \ ] \ - \ ] the most common late \ - stage symptoms are pauciarticular arthritis affecting large joints, especially the knees, which may manifest weeks to months ( mean four months ) after the tick bite. arthritis can occur without a history of earlier stages of illness. peripheral neuropathy and central nervous system manifestations can also occur, although rarely in children. \ ] how is the diagnosis of ld made? testing should be carried out at an approved provincial, territorial or national public health laboratory in canada. test results from private laboratories not approved by health canada, provincial or territorial governments cannot be relied upon for accuracy nor validity. early, localized ( cutaneous ) disease : in general, the diagnosis of ld is clinical ( see em, above ), supported by a history of potential tick bite in an area where it is known or suspected that black \ - legged ticks have been established. however, because tick populations are expanding, it is possible that ld can be acquired outside of currently identified areas. such a possibility should be considered when assessing patients. patients with em should be diagnosed and treated without laboratory confirmation, \ ] \ ] \ ] \ ] because antibodies against * b burgdorferi * are often not detectable
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by serodiagnostic testing within the first four weeks after infection ( ). \ ] \ ] \ ] supplemental tests can detect * borrelia * species that cause ld outside of north america. therefore, travel history should be documented. \ ] some individuals treated with antimicrobials for early ld never develop antibodies against * b burgdorferi *. they are cured. \ ] \ ] most individuals with extracutaneous disease have antibodies against * b * * burgdorferi *. once such antibodies develop, they persist for years. a decline in antibody levels is not useful to assess treatment response. \ ] \ ] serological test results for ld should be interpreted along with careful consideration of the clinical setting and quality of the testing laboratory. \ ] \ ] tests of joint fluid for antibody to * b * * burgdorferi * and urinary antigen detection have no role in diagnosis. \ ] in suspected lyme meningitis, testing for intrathecal immunoglobulin m or immunoglobulin g antibodies may be helpful. \ ] \ ] \ ] how is ld treated? treatment of ld should follow the clinical practice guidelines by the infectious diseases society of america \ ] \ ] \ ] and the american academy of pediatrics ( tables and ). \ ] there has been a shift to using shorter durations of antimicrobials and to more permissive use of oral drugs in select circumstances ( tables and ). additionally, data on the safety of short courses of doxycycline for children \ < 8 years old, coupled with its proven efficacy for treating ld, including meningitis, has prompted more permissive use of this antimicrobial. \ ] arthritis frequency has decreased in the united states, probably because of improved recognition and earlier treatment of patients with early ld. up to one \ - third of ld patients with arthritis experience residual synovitis and joint swelling, which almost always resolve without repeating the antibiotic course. for patients who have persistent or recurrent joint swelling after a recommended course of oral antibiotic therapy, some experts recommend retreatment with another four \ - week course of oral antibiotics or with a course of parenteral ceftriaxone. \ ] for cases with ongoing arthritis, consultation with an expert is recommended. \ ] consider hospitalization and constant monitoring for a child with heart block and syncope that may rapidly worsen enough to require a pacemaker. \
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] the jarisch \ - herxheimer reaction ( fever, headache, myalgia and an aggravated clinical picture lasting \ < 24 h ) can occur when therapy is initiated. nonsteroidal anti \ - inflammatory agents should be started and the antimicrobial agent continued. \ ] approximately 10 % to 20 % of cases experience lingering symptoms of fatigue and joint and muscle aching that last longer than six months. the clinical term for this condition is persistent ‘ post \ - treatment lyme disease syndrome ’ ( ptlds ). the exact cause of this response is not yet known. most medical experts believe that lingering symptoms are the result of residual damage to tissues and the immune system. \ ] \ ] long \ - course antibiotic treatments do not provide long \ - term improvement in ptlds cases. \ ] how to remove a tick - clean the bite area and your hands with rubbing alcohol, an iodine scrub, or soap and water. \ ] the public health agency of canada advises people to : - keep any ticks they remove themselves in a resealable plastic bag or pill vial and note the location and date of the bite. - watch for symptoms and see a health care professional immediately should symptoms appear. - take the tick with them to their medical appointment, to verify species and test as needed. \ ] how can ld be prevented? physicians should be aware of the epidemiology of tick \ - borne ld in their area, \ ] \ ] \ ] and recommend some basic precautions for families living, hiking or camping in rural or wooded areas where they may be exposed to ticks. \ ] \ ] \ ] - where play spaces adjoin wooded areas, landscaping can reduce contact with ticks. \ ] a pictogram from the centers for disease control and prevention is available at : www. cdc. gov / lyme / prev / in \ _ the \ _ yard. html - apply 20 % to 30 % deet or icaridin repellents. repellents can be applied to clothing as well as to exposed skin. always read and follow label directions. \ ] \ ] - do a ‘ full body ’ check every day for ticks. promptly remove ticks found on yourself, children and pets. shower or bathe within two hours of being outdoors to wash off unattached ticks. \ ] for more information on how to prevent tick bites, refer to a recent practice point from the canadian pa
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##ediatric society at : www. cps. ca / en / documents / position / preventing \ - mosquito \ - and \ - tick \ - bites. postexposure antibiotic therapy the risk of acquiring lyme disease from a tick bite, even in a highly endemic area, is low, at approximately 3 %. if the tick is engorged, the risk increases to 25 %. therefore, if the tick is flat when removed, risk is lower. consensus on postexposure prophylaxis for ld is that there may be some benefit when the tick is engorged. some experts recommend prescribing doxycycline 200 mg ( or 4 \. 4 mg / kg ) as a single dose for children and youth after a tick bite. prophylaxis can be started within 72 h of removing a tick, even if it has been attached for ≥36 h. as the risk of infection is extremely low if attachment is \ < 36 hours, prophylaxis is not indicated in this circumstance. \ ] \ ] \ ] \ ] data are insufficient to recommend amoxicillin prophylaxis in younger children. \ ] \ ] \ ] \ ] a vaccine to prevent ld in humans is not available at the present time. \ ] \ ] post lyme disease persistent symptoms non \ - specific post lyme disease persistent symptoms ( such as fatigue ) can occur after adequate treatment of the initial infection. this does not require retreatment with antibiotics as this has not been shown to be beneficial. furthermore, additional antibiotic therapy will promote colonization with resistant bacteria and can cause harm. instead, care should be provided to either establish another diagnosis or provide ongoing support. \ ] government of canada. lyme disease ( video ) : ( accessed july 22, 2014 \ ).
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6e2168515fadd412bad0bfecb4c25e15bf93ae6c
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- current : about cps position … about cps position statements position statements convey the opinion and recommendations of the canadian paediatric society. they provide guidance to health care practitioners and policy makers on issues relevant to the health and well \ - being of canadian children and youth. the cps also publishes practice points, which are aimed at paediatricians, family physicians and other child health care providers and discuss specific issues of clinical care. position statements are written and reviewed by expert and approved by the. they involve a review of the available medical literature, recognizing that in some cases, a position statement is required for an issue where definitive data is lacking. statements are published in our peer \ - review journal,, and. position statements that appear online are current cps policy. position statements are reviewed by the authoring committee three years after publication, and every year after that. committees either reaffirm, revise, or retire statements. retired statements are removed from the website. statement development involves a rigorous development and review process : - committees indicate their intent to develop a statement. when the board approves the intent, development can begin. - committee members write and review the document, which may go through several drafts. - the draft may be reviewed by other cps committees or an external organization. - the final statement is reviewed by the board of directors. members of cps committees and the board of directors are volunteers. they do not receive any financial compensation for writing or reviewing position statements. authors and reviewers are asked to disclose conflicts of interest.
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guidelines
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c604c8a104c9482c24ebf610d524f8ec991090d2
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anaphylaxis is a severe, acute and potentially life \ - threatening condition, often in response to an allergen. patients experiencing anaphylaxis can present with cutaneous, respiratory, cardiovascular or gastrointestinal manifestations. epinephrine given intramuscularly remains the mainstay of treatment for this condition. other second \ - line therapies, such as inhaled beta \ - 2 agonists, h1 and h2 receptor antagonists and corticosteroids, may play a role in resolving respiratory and cutaneous signs and symptoms. biphasic reactions may occur during the resolution phase of symptoms and, thus, all patients should be observed for a minimum of 4 h to 6 h before discharge from hospital. on discharge, all patients should be prescribed epinephrine autoinjectors, and referred to an allergist or immunologist for further evaluation and education. key words : * anaphylaxis ; children ; emergency ; infant ; paediatric ; treatment * revised december 2016 to remove reference to a product no longer available in canada. anaphylaxis is a severe, acute and potentially life \ - threatening medical condition caused by the systemic release of mediators from mast cells and basophils, often in response to an allergen. the incidence of patients with anaphylaxis presenting to emergency departments ( eds ) is estimated to be approximately one to four per 1000 ed visits ( 0 \. 1 % to 0 \. 4 % ) \ -. of these presentations, only one \ - third end up having an identifiable trigger for the anaphylactic reaction. food is the most common associated trigger, followed closely by hymenoptera ( bee / wasp ) stings and medications. when food is identified as the trigger, peanuts, tree nuts, fish, milk, eggs and shellfish ( eg, shrimp, lobster, crab, scallops and oysters ) are the products most often implicated in fatal or near \ - fatal reactions. although clinical symptoms and signs can involve multiple organ systems ( ), cutaneous manifestations such as urticaria, pruritus, angioedema and flushing tend to occur in the majority of children ( 80 % to 90 % ) with anaphylaxis. of the more concerning symptoms, respiratory involvement seems to predominate, with 60 % to 70 % of anaphylactic children being
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guidelines
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c604c8a104c9482c24ebf610d524f8ec991090d2
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affected. cardiovascular involvement is less frequent, with 10 % to 30 % of anaphylactic children developing signs of cardiovascular compromise including dizziness, hypotension and syncope. in july 2005, a panel of allergy and immunology experts convened at the second symposium on the definition and management of anaphylaxis. they defined anaphylaxis as, “ a serious allergic reaction that is rapid in onset and may cause death ”. this group of experts also published a set of three clinical criteria for diagnosing anaphylaxis, as outlined in. the first clinical criterion, describing acute onset of illness with involvement of cutaneous manifestations, should be applicable to the majority of anaphylaxis presentations because up to 80 % to 90 % of children experience some degree of skin involvement. although cutaneous involvement is usually the first and most common manifestation of anaphylaxis, the absence of skin signs at presentation does not rule out a diagnosis of anaphylaxis. the remaining two criteria address clinical features for patients with a known allergic history, and exposure to a likely or known allergen. first aid treatment in the community when available, self \ - injectable epinephrine should be immediately administered as an intramuscular ( im ) dose to all children with signs and symptoms suspicious of anaphylaxis before arrival to hospital. regardless of whether epinephrine is administered, parents should urgently seek medical attention at the nearest ed if they are concerned about anaphylaxis. currently, self \ - injectable epinephrine is available in only two doses : 0 \. 15 mg ( epipen jr ) and 0 \. 3 mg ( epipen ). based on the recommended epinephrine dose of 0 \. 01 mg / kg, these two doses are most applicable to children weighing 15 kg or 30 kg. the current recommendations are that patients weighing 10 kg to 25 kg should be prescribed epipen jr, while those weighing more than 25 kg should be prescribed epipen. for patients weighing less than 10 kg, physicians and families will need to weigh the benefits and risks of administering epinephrine via syringes after being drawn up by a family member from small ampules. this method has been shown to be both error and delay prone, and family members must be fully competent before choosing this method of administration. on prescription of self \ - in
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guidelines
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c604c8a104c9482c24ebf610d524f8ec991090d2
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##jectable epinephrine, parents and children must be educated to administer epinephrine when symptoms occur after known exposure to a trigger that previously caused anaphylaxis. this includes, for example, administration of epinephrine for isolated urticaria in a child who previously suffered anaphylaxis after exposure to the same allergen. prompt administration is also indicated for treatment of respiratory or cardiovascular symptoms of anaphylaxis, although determining the need for administration under these circumstances may be difficult for parents. in general, physicians should err on the side of caution by recommending that parents and patients inject epinephrine early, rather than to wait for symptoms to progress and worsen. acute management of anaphylaxis in hospital initial management of the paediatric patient with suspected anaphylaxis should include a rapid, thorough assessment of the airway, breathing and circulation, with immediate and concurrent administration of im epinephrine. in patients with signs of upper airway obstruction ( stridor, swollen tongue or uvular edema ) or severe respiratory distress, early preparation for definitive airway management is critical. because intubation may be challenging with a swollen, obstructed airway, additional support from a respiratory therapy, anesthesia, or ear, nose and throat specialist should be requested if available. careful consideration of the benefits and risks of rapid sequence intubation should be discussed among team members, and equipment for emergency surgical airway placement should ideally be at the bedside and ready for use if required. although there are several medications available for use in the treatment of anaphylaxis, epinephrine remains the first \ - line agent, and should be given immediately to any patient who meets the clinical criteria for anaphylaxis. the other medications, consisting of h1 and h2 antihistamines, corticosteroids and inhaled medications, play a less important role and are considered to be second \ - line agents for the management of anaphylaxis ( ). epinephrine is a direct \ - acting sympathomimetic agent with various properties that help to reverse the pathophysiological effects of anaphylaxis. the alpha \ - adrenergic actions of epinephrine work to increase peripheral vascular resistance and reverse peripheral vasodilation while also decreasing angioedema and urticaria. the
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guidelines
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c604c8a104c9482c24ebf610d524f8ec991090d2
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beta \ - 1 adrenergic effects have positive chronotropic and inotropic effects on the heart, while the beta \ - 2 adrenergic effects cause bronchodilation and reduction of inflammatory mediator release from mast cells and basophils. in combination, these effects help to reverse the anaphylactic process and, in turn, improve the cutaneous, respiratory and cardiovascular effects of the condition. epinephrine 1 : 1000 should be administered im into the anterolateral thigh at a dose of 0 \. 01 mg / kg ( maximum total dose 0 \. 5 mg ), and can be repeated every 5 min to 15 min depending on the patient ’ s response to previous doses. im administration of epinephrine into the thigh results in higher peak plasma concentrations compared with im or subcutaneous ( sc ) injection into the upper arm. additionally, peak plasma concentrations are achieved significantly faster after im injection into the thigh compared with sc administration into the deltoid region. the local vasoconstriction caused by sc injection may inhibit absorption from the injection site. thus, im injection of epinephrine into the anterior lateral thigh is the preferred route of delivery for anaphylaxis. some patients with persistent symptoms may require repeat doses of epinephrine. the decision to administer a repeat dose of epinephrine should be made on an individual basis, and response to therapy should be carefully monitored with frequent reassessment of vital signs and the patient ’ s clinical condition. # h1 and h2 antihistamines although oral antihistamines are considered to be the mainstay of treatment for minor allergic reactions, their slow onset of action and limited effect on symptoms makes them a second \ - line agent for anaphylaxis \ -. these agents are not appropriate for first \ - line treatment of anaphylaxis, and should never be used in place of im epinephrine. unfortunately, there are no randomized, placebo \ - controlled clinical trials of antihistamines for use in anaphylaxis. however, given their proven benefit with localized allergic reactions such as urticaria, h1 antagonists such as cetirizine or diphenhydramine can be given to relieve the cutaneous symptoms of anaphylaxis ( eg, urticaria, pruritus and angioedema ). h
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guidelines
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c604c8a104c9482c24ebf610d524f8ec991090d2
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##1 antagonists have no effect on the respiratory, gastrointestinal or cardiovascular symptoms of anaphylaxis. if the patient is not vomiting, cetirizine should be used because it is faster in onset than diphenhydramine, and much less sedating. h2 antagonists, such as raniditine, can be given in combination with h1 antagonists because their combined effect is superior in treating cutaneous manifestations compared with the use of h1 antagonists alone. cetirizine should be given orally at a weight \ - appropriate dose ( ). diphenhydramine for the vomiting child can be given as an iv or im dose of 1 mg / kg / dose, with a maximum dose of 50 mg. ranitidine should be given as an oral or iv dose of 1 mg / kg / dose, also with a maximum dose of 50 mg. corticosteroids play an integral role in the treatment of several allergy \ - related diseases including asthma and allergic rhinitis. however, no randomized controlled trials have demonstrated a proven benefit of steroids in the treatment of anaphylaxis. despite this, most experts would still recommend treatment with corticosteroids, with the knowledge that their onset of action is slow ( 4 h to 6 h ), and that there will likely be little benefit in the acute phase of management. when ordered, oral prednisone can be given at a dose of 1 mg / kg ( maximum single dose 75 mg ) or, for more severe reactions, methylprednisolone at a dose of 1 mg / kg iv ( maximum single dose 125 mg ). # inhaled medications children who present with bronchospasm and wheezing, or who have a history of asthma may benefit from inhaled salbutamol as part of their anaphylaxis treatment. salbutamol should be given at a dose of five to 10 puffs using a metered dose inhaler, and administered every 20 min or continuously until symptoms of wheezing or respiratory distress improve. infants and children unable to effectively use the metered dose inhaler may be given 2 \. 5 mg to 5 mg of salbutamol per dose via nebulization. children who present with stridor may find some relief from inhaled epinephrine, although no studies have documented the clinical efficacy of epinephrine delivered by this route for
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guidelines
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c604c8a104c9482c24ebf610d524f8ec991090d2
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the treatment of upper airway obstruction induced by anaphylaxis. certainly, im epinephrine remains the first \ - line treatment for symptoms of upper or lower airway obstruction due to anaphylaxis, with inhaled salbutamol and epinephrine playing more supportive roles. # iv epinephrine some patients who experience severe anaphylactic shock may have persistent hypotension despite aggressive fluid resuscitation and repeated doses of im epinephrine. in fact, repeated administration of im epinephrine has no demonstrated benefit for improving persistent hypotension related to anaphylaxis. instead, these patients should be started on an epinephrine infusion at a dose of 0 \. 1 µg / kg / min to 1 µg / kg / min ( maximum 10 µg / min ), with gradual titration of the infusion to produce a normal blood pressure. titrated iv infusions of epinephrine seem to produce a more sustained improvement in blood pressure, whereas intermittent iv boluses of epinephrine may have an immediate effect that is often short lived, accompanied by coexisting concerns for induced cardiac arrhythmias when administered too rapidly. patients regularly taking beta \ - blockers who present with anaphylactic shock may have persistent hypotension despite epinephrine administration. in this situation, glucagon, which activates adenylate cyclase independent of the beta \ - receptor, may be given in an attempt to reverse the cardiovascular effects of anaphylaxis. glucagon should be given at a dose of 20 µg / kg to 30 µg / kg iv over 5 min ( maximum dose 1 mg ), followed by the initiation of a glucagon infusion at a rate of 5 µg / min to 15 µg / min, which is then titrated to effect. observation period and disposition biphasic reactions, defined as a recurrence of anaphylactic symptoms after initial resolution, can occur anywhere from 1 h to 72 h after the first onset of symptoms \ -. approximately 5 % to 20 % of patients with anaphylaxis experience a biphasic reaction, with 3 % of children having a significant reaction requiring oxygen, vasopressors, intubation, repeat epinephrine administration or unsche
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guidelines
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c604c8a104c9482c24ebf610d524f8ec991090d2
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##duled bronchodilator treatments. although no validated clinical predictors of biphasic reactions have been verified, some studies suggest that biphasic reactions are more likely to occur in patients who had delayed administration of epinephrine, who needed more than one dose of epinephrine or who initially presented with more severe symptoms \ -. because most biphasic reactions occur within the first 4 h to 6 h after initial onset of symptoms, a reasonable length of time for observation of an anaphylactic patient would be 4 h to 6 h. however, the physician must be aware that symptoms may still recur up to 72 h after initial presentation, and counsel parents accordingly to monitor for such a recurrence. in rural environments, where larger distances of travel are required to reach medical care, it may be reasonable to observe patients for a longer period of time ( eg, 12 h ) or to admit them to hospital overnight. patients who require repeated doses of epinephrine, who initially presented with more severe symptoms ( eg, hypotension, severe respiratory distress ) or who experience a biphasic reaction should be admitted to hospital for observation. other patients who have high \ - risk features, such as peanut allergy, asthma or use of beta \ - blockers, should also be strongly considered for overnight observation or admission. patients presenting with severe respiratory symptoms requiring definitive airway management or those who have persistent hypotension requiring iv epinephrine or glucagon infusions should be admitted to the intensive care unit. the decision to discharge a patient should be individualized to take into account initial presentation, responsiveness to therapy, persistence of symptoms and accessibility to an urgent care facility. on discharge, patients suffering from anaphylaxis should be given a prescription for a self \ - injectable form of epinephrine ( eg, epipen, epipen jr ). if possible, patients should leave the emergency room with an epinephrine autoinjector because a biphasic reaction could occur on the way home. parents, caretakers, older children and adolescents should be carefully educated about how to administer epinephrine, and counselled to err on the side of caution and administer the drug when symptoms occur after exposure to the individual ’ s known trigger. an epinephrine autoinjector should be kept with the child at all times (
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guidelines
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c604c8a104c9482c24ebf610d524f8ec991090d2
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at school and with the parent or child ). ideally, two doses should be available for administration at each location ( eg, two epipen autoinjectors ). children who present with less severe allergic reactions and risk factors for anaphylaxis should also be prescribed self \ - injectable epinephrine ( ). the emphasis in educating parents should be placed on responding promptly to anaphylactic symptoms, rather than delaying treatment due to confusion attributed to an unknown allergen. in addition to epinephrine, a three \ - day course of oral h1 and h2 antihistamines ( cetirizine and ranitidine ) and oral corticosteroids may be prescribed on discharge. most experts recommend this additional therapy despite limited data to support its use because these drugs are unlikely to cause harm, and may have some added benefit in the resolution of symptoms. all patients suffering from anaphylaxis should be provided with strict guidelines for avoidance of the precipitating trigger, and education about prevention of allergic reactions. patient information resources available online, such as anaphylaxis canada ( www. anaphylaxis. ca ) or the allergy / asthma information association ( www. aaia. ca ), should also be passed on to the family. finally, medicalert bracelets ( canadian medicalert foundation ) should be recommended, and referral to an allergist or immunologist who can provide additional testing, information and therapy should be initiated. anaphylaxis is a serious and potentially life \ - threatening condition that requires immediate diagnosis and treatment with im epinephrine to ensure optimal outcome. adjunctive therapies for treatment of anaphylaxis are available, but epinephrine remains the most important component of the acute management phase. hypotension should be managed aggressively with repeated boluses of normal saline, with initiation of an iv epinephrine infusion in refractory cases. patients experiencing resolution of symptoms while in hospital should be observed for a minimum of 4 h to 6 h before discharge to monitor for a biphasic reaction. patients with severe symptoms at presentation, repeat doses of epinephrine, or who suffer a biphasic reaction should be admitted to hospital. on discharge, parents should be carefully counselled and educated about the signs and symptoms of anaphylaxis, the avoidance of triggers, the use of
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guidelines
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c604c8a104c9482c24ebf610d524f8ec991090d2
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self \ - injectable epinephrine, and the importance of follow \ - up with an allergy or immunology specialist.
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guidelines
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f9b63032406327654dee7b9eaacef3bb115710b3
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7T Gummy ES Chewable Tablets Dosage Guide
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7T Gummy ES Chewable Tablets Dosage Guide
1. home 2. dosage 3. 7t gummy es chewable tablets print save 7t gummy es chewable tablets dosage generic name : acetaminophen 500mg dosage form : tablet, chewable do not take more than directed ) adults and children 12 years and over : - take 2 chewable gels every 6 hours while symptoms last or as prescribed and directed by a physician - chew each chewable gel thoroughly before swallowing - do not take more than 6 chewable gels in 24 hours, unless directed by a physician - under the supervision of a physician, daily doses up to 8 chewable gels may be used - do not take for more than 10 days unless prescribed and directed by a physician
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guidelines
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94bc52e72830ea6e41c624806279cf3cb999279a
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8-MOP Dosage Guide
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8-MOP Dosage Guide
1. home 2. 8 \ - mop 3. dosage print save 8 \ - mop dosage generic name : methoxsalen 10mg dosage form : capsule, gelatin coated drug class : psoralens two capsules in one dose taken with milk or in food two to four hours before ultraviolet light exposure. the exposure time to sunlight should comply with the following guide : gradually increase exposure based on erythema and tenderness of the amelanotic skin. therapy should be on alternate days and never two consecutive days. the methoxsalen capsules should be taken 2 hours before uva exposure with some food or milk according to the following table : additional drug dosage directions are as follows : a. weight change : in the event that the weight of a patient changes during treatment such that he / she falls into an adjacent weight range / dose category, no change in the dose of methoxsalen is usually required. if, in the physician ' s opinion, however, a weight change is sufficiently great to modify the drug dose, then an adjustment in the time of exposure to uva should be made. b. dose / week : the number of doses per week of methoxsalen capsules will be determined by the patient ' s schedule of uva exposures. in no case should treatments be given more often than once every other day because the full extent of phototoxic reactions may not be evident until 48 hours after each exposure. c. dosage increase : dosage may be increased by 10 mg. after the fifteenth treatment under the conditions outlined in section xi. b. 4 \. b.
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guidelines
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9d38a54a1a42ae8ae4bbb5cc805350e249538027
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Acetaminophen Dosage Guide + Max Dose, Adjustments
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Acetaminophen Dosage Guide + Max Dose, Adjustments
1. home 2. acetaminophen 3. dosage print save acetaminophen dosage applies to the following strengths : 160 mg ; 80 mg / 0 \. 8 ml ; 160 mg / 5 ml ; 500 mg ; 650 mg ; 80 mg ; 325 mg ; 500 mg / 15 ml ; 120 mg ; 120 mg / 5 ml ; 325 mg / 10 \. 15 ml ; 650 mg / 20 \. 3 ml ; 10 mg / ml ; 80 mg / 5 ml ; 650 mg / 25 ml ; 80 mg / ml ; 500 mg / 5 ml ; 48 mg / ml usual adult dose for fever doses may be given as a single or repeated dose as follows : parenteral : weight 50 kg or greater : 1000 mg iv every 6 hours or 650 mg iv every 4 hours maximum single dose : 1000 mg minimum dosing interval : every 4 hours maximum dose : 4000 mg per 24 hours weight less than 50 kg : 15 mg / kg iv every 6 hours or 12 \. 5 mg / kg iv every 4 hours maximum single dose : 15 mg / kg minimum dosing interval : every 4 hours maximum dose : 75 mg / kg per 24 hours oral : immediate \ - release : 325 mg to 1 g orally every 4 to 6 hours minimum dosing interval : every 4 hours maximum single dose : 1000 mg maximum dose : 4000 mg per 24 hours extended \ - release : 1300 mg orally every 8 hours maximum dose : 3900 mg per 24 hours rectal : 650 mg rectally every 4 to 6 hours maximum dose : 3900 mg per 24 hours comments : - maximum daily dose is based on all routes of administration and all products containing acetaminophen. - maximum daily dose and dosing recommendations may differ by product ; some manufacturers have decreased the maximum daily dose to protect consumers from inadvertent overdoses. - for iv administration, verify the dose in mg and ml to ensure the dose is correct ; verify that infusion pumps are properly programmed uses : - for the management of mild to moderate pain and the management of moderate to severe pain with adjunctive opioid analgesics. - for the reduction of fever. usual adult dose for pain doses may be given as a single or repeated dose as follows : parenteral : weight 50 kg or greater : 1000 mg iv every 6 hours or 650 mg iv every 4 hours maximum single dose : 1000 mg minimum dosing interval : every 4 hours maximum dose : 4000 mg per
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guidelines
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9d38a54a1a42ae8ae4bbb5cc805350e249538027
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Acetaminophen Dosage Guide + Max Dose, Adjustments
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Acetaminophen Dosage Guide + Max Dose, Adjustments
24 hours weight less than 50 kg : 15 mg / kg iv every 6 hours or 12 \. 5 mg / kg iv every 4 hours maximum single dose : 15 mg / kg minimum dosing interval : every 4 hours maximum dose : 75 mg / kg per 24 hours oral : immediate \ - release : 325 mg to 1 g orally every 4 to 6 hours minimum dosing interval : every 4 hours maximum single dose : 1000 mg maximum dose : 4000 mg per 24 hours extended \ - release : 1300 mg orally every 8 hours maximum dose : 3900 mg per 24 hours rectal : 650 mg rectally every 4 to 6 hours maximum dose : 3900 mg per 24 hours comments : - maximum daily dose is based on all routes of administration and all products containing acetaminophen. - maximum daily dose and dosing recommendations may differ by product ; some manufacturers have decreased the maximum daily dose to protect consumers from inadvertent overdoses. - for iv administration, verify the dose in mg and ml to ensure the dose is correct ; verify that infusion pumps are properly programmed uses : - for the management of mild to moderate pain and the management of moderate to severe pain with adjunctive opioid analgesics. - for the reduction of fever. usual pediatric dose for pain doses may be given as a single or repeated dose as follows : parenteral : age : 2 to 12 years : - weight \ - based dosing : 12 \. 5 mg / kg iv every 4 hours or 15 mg / kg iv every 6 hours - maximum single dose : 15 mg / kg ; not to exceed 750 mg - minimum dosing interval : every 4 hours - maximum daily dose : 75 mg / kg in 24 hours ; not to exceed 3750 mg age : 13 years or older : - weight less than 50 kg : 12 \. 5 mg / kg iv every 4 hours or 15 mg / kg iv every 6 hours maximum single dose : 15 mg / kg ; not to exceed 750 mg minimum dosing interval : every 4 hours maximum daily dose : 75 mg / kg in 24 hours ; not to exceed 3750 mg - weight 50 kg or greater : 650 mg iv every 4 hours or 1000 mg iv every 6 hours maximum single dose : 1000 mg minimum dosing interval : every 4 hours maximum daily dose : 4000 mg in 24 hours oral : 10 to 15 mg / kg orally every 4 to 6 hours as needed not to exceed 5 doses in 24 hours - alternatively,
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guidelines
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9d38a54a1a42ae8ae4bbb5cc805350e249538027
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Acetaminophen Dosage Guide + Max Dose, Adjustments
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Acetaminophen Dosage Guide + Max Dose, Adjustments
use weight first, then age : weight : 2 \. 7 to 5 \. 3 kg : 40 mg orally every 4 hours as needed not to exceed 5 doses in 24 hours weight : 5 \. 4 to 8 \. 1 kg : 80 mg orally every 4 hours as needed not to exceed 5 doses in 24 hours weight : 8 \. 2 to 10 \. 8 kg : 120 mg orally every 4 hours as needed not to exceed 5 doses in 24 hours weight : 10 \. 9 to 16 \. 3 kg : 160 mg orally every 4 hours as needed not to exceed 5 doses in 24 hours weight : 16 \. 4 to 21 \. 7 kg : 240 mg orally every 4 hours as needed not to exceed 5 doses in 24 hours weight : 21 \. 8 to 27 \. 2 kg : 320 mg orally every 4 hours as needed not to exceed 5 doses in 24 hours weight : 27 \. 3 to 32 \. 6 kg : 400 mg orally every 4 hours as needed not to exceed 5 doses in 24 hours weight : 32 \. 7 to 43 \. 2 kg : 480 mg orally every 4 hours as needed not to exceed 5 doses in 24 hours age : 12 years or older : immediate \ - release : 325 mg to 1 g orally every 4 to 6 hours minimum dosing interval : every 4 hours maximum single dose : 1000 mg maximum dose : 4000 mg per 24 hours extended \ - release : 1300 mg orally every 8 hours maximum dose : 3900 mg per 24 hours rectal : age : 6 to 11 months : 80 mg rectally every 6 hours up to a maximum of 4 doses in 24 hours age : 12 to 36 months : 80 mg rectally every 4 to 6 hours up to a maximum of 5 doses in 24 hours age : 3 to 6 years : 120 mg rectally every 4 to 6 hours up to a maximum of 5 doses in 24 hours age : 6 to 12 years : 325 mg rectally every 4 to 6 hours up to a maximum of 5 doses in 24 hours age : 12 years or older : 650 mg rectally every 4 to 6 hours up to a maximum of 6 doses in 24 hours comments : - maximum daily dose is based on all routes of administration and all products containing acetaminophen. - maximum daily dose and dosing recommendations may differ by product ; some manufacturers have decreased the maximum daily dose to protect consumers from inad
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guidelines
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9d38a54a1a42ae8ae4bbb5cc805350e249538027
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Acetaminophen Dosage Guide + Max Dose, Adjustments
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Acetaminophen Dosage Guide + Max Dose, Adjustments
##vertent overdoses. - for iv administration, verify the dose in mg and ml to ensure the dose is correct ; verify that infusion pumps are properly programmed. uses : - for the management of mild to moderate pain and for the management of moderate to severe pain when used with adjunctive opioid analgesics. usual pediatric dose for fever doses may be given as a single or repeated dose as follows : parenteral : neonates : 12 \. 5 mg / kg iv every 6 hours minimum dosing interval : 6 hours maximum daily dose : 50 mg / kg / day infants : 15 mg / kg every 6 hours minimum dosing interval : 6 hours maximum daily dose : 60 mg / kg / day age : 2 to 12 years : 12 \. 5 mg / kg iv every 4 hours or 15 mg / kg iv every 6 hours maximum single dose : 15 mg / kg ; not to exceed 750 mg minimum dosing interval : every 4 hours maximum daily dose : 75 mg / kg in 24 hours ; not to exceed 3750 mg age : 13 years or older ; weight less than 50 kg : 12 \. 5 mg / kg iv every 4 hours or 15 mg / kg iv every 6 hours maximum single dose : 15 mg / kg ; not to exceed 750 mg minimum dosing interval : every 4 hours maximum daily dose : 75 mg / kg in 24 hours ; not to exceed 3750 mg age : 13 years or older ; weight 50 kg or greater : 650 mg iv every 4 hours or 1000 mg iv every 6 hours maximum single dose : 1000 mg minimum dosing interval : every 4 hours maximum daily dose : 4000 mg in 24 hours oral : 10 to 15 mg / kg orally every 4 to 6 hours as needed not to exceed 5 doses in 24 hours - alternatively, use weight first, then age : weight : 2 \. 7 to 5 \. 3 kg : 40 mg orally every 4 hours as needed not to exceed 5 doses in 24 hours weight : 5 \. 4 to 8 \. 1 kg : 80 mg orally every 4 hours as needed not to exceed 5 doses in 24 hours weight : 8 \. 2 to 10 \. 8 kg : 120 mg orally every 4 hours as needed not to exceed 5 doses in 24 hours weight : 10 \. 9 to 16 \. 3 kg : 160 mg orally every 4 hours as needed not to exceed 5 doses in 24 hours weight : 16 \. 4 to 21 \. 7 kg :
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guidelines
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9d38a54a1a42ae8ae4bbb5cc805350e249538027
|
Acetaminophen Dosage Guide + Max Dose, Adjustments
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Acetaminophen Dosage Guide + Max Dose, Adjustments
240 mg orally every 4 hours as needed not to exceed 5 doses in 24 hours weight : 21 \. 8 to 27 \. 2 kg : 320 mg orally every 4 hours as needed not to exceed 5 doses in 24 hours weight : 27 \. 3 to 32 \. 6 kg : 400 mg orally every 4 hours as needed not to exceed 5 doses in 24 hours weight : 32 \. 7 to 43 \. 2 kg : 480 mg orally every 4 hours as needed not to exceed 5 doses in 24 hours 12 years or older : immediate \ - release : 325 mg to 1 g orally every 4 to 6 hours minimum dosing interval : every 4 hours maximum single dose : 1000 mg maximum dose : 4000 mg per 24 hours rectal : age : 6 to 11 months : 80 mg rectally every 6 hours up to a maximum of 4 doses in 24 hours age : 12 to 36 months : 80 mg rectally every 4 to 6 hours up to a maximum of 5 doses in 24 hours age : 3 to 6 years : 120 mg rectally every 4 to 6 hours up to a maximum of 5 doses in 24 hours age : 6 to 12 years : 325 mg rectally every 4 to 6 hours up to a maximum of 5 doses in 24 hours age : 75012 years or older : 650 mg rectally every 4 to 6 hours up to a maximum of 6 doses in 24 hours comments : - maximum daily dose is based on all routes of administration and all products containing acetaminophen. - maximum daily dose and dosing recommendations may differ by product ; some manufacturers have decreased the maximum daily dose to protect consumers from inadvertent overdoses. - for iv administration, verify the dose in mg and ml to ensure the dose is correct ; verify that infusion pumps are properly programmed. use : for the reduction of fever. renal dose adjustments severe renal impairment : use caution ; longer dosing intervals and a reduced total daily dose may be warranted liver dose adjustments parenteral : severe hepatic impairment, severe active hepatic disease : use is contraindicated mild to moderate hepatic impairment, mild to moderate active hepatic disease : use with caution ; a reduced total daily dose may be warranted over the counter products must contain labeling that states : this product contains acetaminophen. severe liver damage may occur if : - adult takes more than maximum daily dose in 24 hours - child takes more than 5
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guidelines
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9d38a54a1a42ae8ae4bbb5cc805350e249538027
|
Acetaminophen Dosage Guide + Max Dose, Adjustments
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Acetaminophen Dosage Guide + Max Dose, Adjustments
doses in 24 hours - more than 3 alcoholic drinks are consumed per day while using this product. dose adjustments use caution in patients with alcoholism, chronic malnutrition, severe hypovolemia ; a reduced daily dose may be warranted. suspected overdose : - if an overdose is suspected, obtain a serum drug level as soon as possible, but no sooner than 4 hours after oral ingestion. - liver function studies should be obtained and repeated at 24 \ - hour intervals. - the antidote, n \ - acetylcysteine should be administered as soon as possible according to nac protocols. precautions us boxed warning : risk of medication errors take care when prescribing, preparing, and administering iv acetaminophen injection to avoid dosing errors which could result in accidental overdose and death. in particular, be careful to ensure that - the dose in milligrams and milliliters is not confused ; - the dosing is based on weight for patients under 50 kg ; - infusion pumps are properly programmed ; - the total daily dose of acetaminophen from all sources does not exceed maximum daily limits. us boxed warning : hepatotoxicity : this drug has been associated with cases of acute liver failure, at times resulting in liver transplant and death. most of the cases of liver injury are associated with the use of acetaminophen at doses that exceed the maximum daily limits, and often involve more than 1 acetaminophen \ - containing product. us over the counter labeling : adults only : this product contains acetaminophen. severe liver damage may occur if : - more than maximum daily dose is taken in 24 hours - this product is taken with other drugs containing acetaminophen - three or more alcoholic drinks are consumer every day while using this product. us over the counter labeling : adults and children under 12 years of age : this product contains acetaminophen. severe liver damage may occur if : - adult takes more than maximum daily dose in 24 hours - child takes more than 5 doses in 24 hours - this product is taken with other drugs containing acetaminophen - persons consume 3 or more alcoholic drinks per day while using this product. contraindications : - hypersensitivity to the active substance or any product excipients - severe hepatic impairment or severe active liver disease safety and efficacy for the treatment of acute pain have not been established
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guidelines
|
9d38a54a1a42ae8ae4bbb5cc805350e249538027
|
Acetaminophen Dosage Guide + Max Dose, Adjustments
|
Acetaminophen Dosage Guide + Max Dose, Adjustments
in patients younger than 2 years ; the safety and effectiveness for treatment of fever in pediatric patients, including premature neonates born at 32 weeks or later, has been demonstrated in clinical trials. consult warnings section for additional precautions. dialysis children : intermittent hemodialysis or peritoneal dialysis : administer every 8 hours crrt : no adjustments necessary adults : intermittent hemodialysis or peritoneal dialysis : no adjustment necessary crrt : administer every 8 hours other comments administration advice : - when calculating daily acetaminophen doses, be sure to account for all acetaminophen \ - containing products and all routes of administration ; do not exceed maximum doses chewable tablets : - chew tablets before swallowing extended \ - release : - swallow whole ; do not crush, chew, split, or dissolve oral disintegrating tablets : - allow to dissolve in mouth or chew before swallowing oral suspension : - shake well before using - use enclosed measuring device to accurately measure dose parenteral : - infuse iv over 15 minutes ; ensure infusion pumps are properly programmed - monitor end of infusion in order to prevent the possibility of an air embolism, especially in cases where this is the primary infusion. suppositories : - for rectal use only - remove wrapper - carefully insert suppository well up into the rectum reconstitution / preparation techniques : - for iv doses of 1000 mg : may administer without further dilution ; may administer by inserting a vented iv set through the septum of the vial. - for doses less than 1000 mg : withdraw the appropriate dose from the vial and place in a separate empty, sterile container for iv infusion - administer within 6 hours of penetrating the vacuum seal of the glass vial - do not use if particulate matter or discoloration is observed - do not add other medications to the acetaminophen solution - consult manufacturer product information for additional information iv compatibility : - diazepam and chlorpromazine hydrochloride are physically incompatible storage requirements : - iv : single use only ; store at 20c to 25c ; do not refrigerate or freeze general : - drug \ - induced hepatotoxicity is preventable ; all patients and caregivers need to be educated on how to give / take this drug safely and what to do if more than the recommended dose is consumed. - use of more than 1 ace
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guidelines
|
9d38a54a1a42ae8ae4bbb5cc805350e249538027
|
Acetaminophen Dosage Guide + Max Dose, Adjustments
|
Acetaminophen Dosage Guide + Max Dose, Adjustments
##taminophen \ - containing product at one time should be discouraged. - hypersensitivity reactions and serious rashes have been reported. - the effectiveness of iv administration for the treatment of acute pain in patients younger than 2 years has not been established. monitoring : - monitor for nausea, vomiting, loss of appetite, sweating, extreme tiredness, unusual bleeding or bruising, pain in upper right part of the stomach, yellow of the skin or eyes, and / or flu \ - like symptoms as this may be an indication of overdose. - monitor for skin reactions patient advice : - patients should be advised to follow package directions for over the counter acetaminophen products including observing the maximum single dose and maximum daily dose limits. - patients should be discouraged from using multiple acetaminophen containing products concurrently. - patients should be advised that severe liver damage may occur if more than the recommended amount of this drug is taken ; patients should seek medical help promptly if they suspect they have taken too much of this drug or if they experience nausea, vomiting, loss of appetite, or yellowing of the skin or eyes. - patients should be advised to limit alcohol use while taking this drug.
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guidelines
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cd47883daa98d813179588f50f8ee58639a9dfb8
|
Albuterol Dosage Guide + Max Dose, Adjustments
|
Albuterol Dosage Guide + Max Dose, Adjustments
1. home 2. albuterol 3. dosage print save albuterol dosage applies to the following strengths : 2 mg ; 4 mg ; 2 mg / 5 ml ; 90 mcg / inh ; 5 mg / ml ; 2 \. 5 mg / 3 ml ; with cfc 90 mcg / inh ; 200 mcg ; 8 mg ; 0 \. 63 mg / 3 ml ; 1 \. 25 mg / 3 ml ; 2 \. 5 mg / 0 \. 5 ml ; 5 mg / ml preservative \ - free ; 5 mg / ml \ - nacl 0 \. 8 % preservative \ - free usual adult dose for asthma \ - acute intravenous infusion solution : - dilute 5 ml of this drug in 500 ml of sodium chloride injection, or sodium chloride and dextrose. - infusion rates can be started at 5 mcg / min, and can be increased to 10 mcg / min and 20 mcg / min at 15 at 30 minute intervals, if necessary. nebulizer inhalation solution : - 2 \. 5 mg three or four times a day by nebulization, over approximately 5 to 15 minutes. comments : - never inject the iv infusion undiluted. do not administer in the same infusion with other medications. - check the iv infusion for clarity, particulate matter, precipitate, discoloration and leakage prior to administration. - discard unused infusion solution 24 hours after preparation. uses : - relief of severe bronchospasm associated with acute exacerbations of chronic bronchitis and bronchial asthma, and acute attack of bronchospasm - treatment of status asthmaticus usual adult dose for chronic obstructive pulmonary disease \ - acute intravenous infusion solution : - dilute 5 ml of this drug in 500 ml of sodium chloride injection, or sodium chloride and dextrose. - infusion rates can be started at 5 mcg / min, and can be increased to 10 mcg / min and 20 mcg / min at 15 at 30 minute intervals, if necessary. nebulizer inhalation solution : - 2 \. 5 mg three or four times a day by nebulization, over approximately 5 to 15 minutes. comments : - never inject the iv infusion undiluted. do not administer in the same infusion with other medications
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guidelines
|
cd47883daa98d813179588f50f8ee58639a9dfb8
|
Albuterol Dosage Guide + Max Dose, Adjustments
|
Albuterol Dosage Guide + Max Dose, Adjustments
. - check the iv infusion for clarity, particulate matter, precipitate, discoloration and leakage prior to administration. - discard unused infusion solution 24 hours after preparation. uses : - relief of severe bronchospasm associated with acute exacerbations of chronic bronchitis and bronchial asthma, and acute attack of bronchospasm - treatment of status asthmaticus usual adult dose for bronchitis intravenous infusion solution : - dilute 5 ml of this drug in 500 ml of sodium chloride injection, or sodium chloride and dextrose. - infusion rates can be started at 5 mcg / min, and can be increased to 10 mcg / min and 20 mcg / min at 15 at 30 minute intervals, if necessary. nebulizer inhalation solution : - 2 \. 5 mg three or four times a day by nebulization, over approximately 5 to 15 minutes. comments : - never inject the iv infusion undiluted. do not administer in the same infusion with other medications. - check the iv infusion for clarity, particulate matter, precipitate, discoloration and leakage prior to administration. - discard unused infusion solution 24 hours after preparation. uses : - relief of severe bronchospasm associated with acute exacerbations of chronic bronchitis and bronchial asthma, and acute attack of bronchospasm - treatment of status asthmaticus usual adult dose for bronchospasm prophylaxis inhalation powder : 2 inhalations orally 15 to 30 minutes before exercise inhalation capsule : 1 inhalation 15 minutes before exercise uses : prevention of exercise \ - induced bronchospasm usual adult dose for asthma \ - maintenance inhalation powder : - 1 or 2 inhalations orally every 4 to 6 hours inhalation capsules : - 1 inhalation orally every 4 to 6 hours - maximum dose : 4 inhalations per day nebulizer inhalation solution : - 2 \. 5 mg three or four times a day by nebulization, over approximately 5 to 15 minutes oral tablets : immediate \ - release tablets : - initial dose : 2 mg or 4 mg orally three or four times a day. dosage may be cautiously increased stepwise up to a maximum of 8 mg four times a day as tolerated. - elderly patients and
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guidelines
|
cd47883daa98d813179588f50f8ee58639a9dfb8
|
Albuterol Dosage Guide + Max Dose, Adjustments
|
Albuterol Dosage Guide + Max Dose, Adjustments
those sensitive to beta \ - adrenergic stimulators : the initial dosage should be restricted to 2 mg three or four times a day ; dosage may be gradually increased up to 8 mg three or four times a day. extended \ - release tablets : - initial dose : 4 mg or 8 mg orally every 12 hours. dosage may be cautiously increased stepwise under the control of the supervising physician to a maximum 32 mg / day in divided doses. in unusual circumstances, such as adults of low body weight, use a starting dosage of 4 mg every 12 hours and progress to 8 mg every 12 hours according to response. oral syrup : - initial dose : 2 mg or 4 mg orally three or four times a day. dosage may be cautiously increased stepwise up to a maximum of 8 mg four times a day as tolerated. - elderly patients and those sensitive to beta \ - adrenergic stimulators : the initial dosage should be restricted to 2 mg three or four times a day and individually adjusted thereafter. uses : - treatment or prevention of bronchospasm due to bronchial asthma, chronic bronchitis and other chronic bronchopulmonary disorders in which bronchospasm is a complicating factor - relief of bronchospasm in patients with reversible obstructive airway disease usual adult dose for chronic obstructive pulmonary disease \ - maintenance inhalation powder : - 1 or 2 inhalations orally every 4 to 6 hours inhalation capsules : - 1 inhalation orally every 4 to 6 hours - maximum dose : 4 inhalations per day nebulizer inhalation solution : - 2 \. 5 mg three or four times a day by nebulization, over approximately 5 to 15 minutes oral tablets : immediate \ - release tablets : - initial dose : 2 mg or 4 mg orally three or four times a day. dosage may be cautiously increased stepwise up to a maximum of 8 mg four times a day as tolerated. - elderly patients and those sensitive to beta \ - adrenergic stimulators : the initial dosage should be restricted to 2 mg three or four times a day ; dosage may be gradually increased up to 8 mg three or four times a day. extended \ - release tablets : - initial dose : 4 mg or 8 mg orally every 12 hours. dosage may
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guidelines
|
cd47883daa98d813179588f50f8ee58639a9dfb8
|
Albuterol Dosage Guide + Max Dose, Adjustments
|
Albuterol Dosage Guide + Max Dose, Adjustments
be cautiously increased stepwise under the control of the supervising physician to a maximum 32 mg / day in divided doses. in unusual circumstances, such as adults of low body weight, use a starting dosage of 4 mg every 12 hours and progress to 8 mg every 12 hours according to response. oral syrup : - initial dose : 2 mg or 4 mg orally three or four times a day. dosage may be cautiously increased stepwise up to a maximum of 8 mg four times a day as tolerated. - elderly patients and those sensitive to beta \ - adrenergic stimulators : the initial dosage should be restricted to 2 mg three or four times a day and individually adjusted thereafter. uses : - treatment or prevention of bronchospasm due to bronchial asthma, chronic bronchitis and other chronic bronchopulmonary disorders in which bronchospasm is a complicating factor - relief of bronchospasm in patients with reversible obstructive airway disease usual adult dose for reversible airways disease \ - maintenance inhalation powder : - 1 or 2 inhalations orally every 4 to 6 hours inhalation capsules : - 1 inhalation orally every 4 to 6 hours - maximum dose : 4 inhalations per day nebulizer inhalation solution : - 2 \. 5 mg three or four times a day by nebulization, over approximately 5 to 15 minutes oral tablets : immediate \ - release tablets : - initial dose : 2 mg or 4 mg orally three or four times a day. dosage may be cautiously increased stepwise up to a maximum of 8 mg four times a day as tolerated. - elderly patients and those sensitive to beta \ - adrenergic stimulators : the initial dosage should be restricted to 2 mg three or four times a day ; dosage may be gradually increased up to 8 mg three or four times a day. extended \ - release tablets : - initial dose : 4 mg or 8 mg orally every 12 hours. dosage may be cautiously increased stepwise under the control of the supervising physician to a maximum 32 mg / day in divided doses. in unusual circumstances, such as adults of low body weight, use a starting dosage of 4 mg every 12 hours and progress to 8 mg every 12 hours according to response. oral syrup : - initial dose : 2 mg or 4 mg orally three or four
|
guidelines
|
cd47883daa98d813179588f50f8ee58639a9dfb8
|
Albuterol Dosage Guide + Max Dose, Adjustments
|
Albuterol Dosage Guide + Max Dose, Adjustments
times a day. dosage may be cautiously increased stepwise up to a maximum of 8 mg four times a day as tolerated. - elderly patients and those sensitive to beta \ - adrenergic stimulators : the initial dosage should be restricted to 2 mg three or four times a day and individually adjusted thereafter. uses : - treatment or prevention of bronchospasm due to bronchial asthma, chronic bronchitis and other chronic bronchopulmonary disorders in which bronchospasm is a complicating factor - relief of bronchospasm in patients with reversible obstructive airway disease usual pediatric dose for asthma \ - acute inhalation powder and capsules : less than 4 years : not indicated 4 years or older : - inhalation powder : 1 or 2 inhalations orally every 4 to 6 hours - inhalation capsules : 1 inhalation orally every 4 to 6 hours. the total daily dose should not exceed 4 inhalations. nebulizer inhalation solution : less than 2 years : not indicated 2 to 12 years : - less than 15 kg : 0 \. 1 to 0 \. 15 mg / kg / dose by nebulization. the appropriate volume of the 0 \. 5 % inhalation solution should be diluted in sterile normal saline solution to a total of 3 ml prior administration. dosing should not exceed 2 \. 5 mg three to four times daily. - 15 kg or more : 2 \. 5 mg three or four times a day by nebulization, over approximately 5 to 15 minutes. the 0 \. 5 % inhalation solution should be diluted with 2 \. 5 ml of sterile normal saline solution 13 years or older : - inhalation solution 0 \. 5 % : 2 \. 5 mg three or four times a day by nebulization, over approximately 5 to 15 minutes use : relief of bronchospasm in patients with reversible obstructive airway disease and acute attacks of bronchospasm usual pediatric dose for chronic obstructive pulmonary disease \ - acute inhalation powder and capsules : less than 4 years : not indicated 4 years or older : - inhalation powder : 1 or 2 inhalations orally every 4 to 6 hours - inhalation capsules : 1 inhalation orally every 4 to 6 hours.
|
guidelines
|
cd47883daa98d813179588f50f8ee58639a9dfb8
|
Albuterol Dosage Guide + Max Dose, Adjustments
|
Albuterol Dosage Guide + Max Dose, Adjustments
the total daily dose should not exceed 4 inhalations. nebulizer inhalation solution : less than 2 years : not indicated 2 to 12 years : - less than 15 kg : 0 \. 1 to 0 \. 15 mg / kg / dose by nebulization. the appropriate volume of the 0 \. 5 % inhalation solution should be diluted in sterile normal saline solution to a total of 3 ml prior administration. dosing should not exceed 2 \. 5 mg three to four times daily. - 15 kg or more : 2 \. 5 mg three or four times a day by nebulization, over approximately 5 to 15 minutes. the 0 \. 5 % inhalation solution should be diluted with 2 \. 5 ml of sterile normal saline solution 13 years or older : - inhalation solution 0 \. 5 % : 2 \. 5 mg three or four times a day by nebulization, over approximately 5 to 15 minutes use : relief of bronchospasm in patients with reversible obstructive airway disease and acute attacks of bronchospasm usual pediatric dose for bronchitis inhalation powder and capsules : less than 4 years : not indicated 4 years or older : - inhalation powder : 1 or 2 inhalations orally every 4 to 6 hours - inhalation capsules : 1 inhalation orally every 4 to 6 hours. the total daily dose should not exceed 4 inhalations. nebulizer inhalation solution : less than 2 years : not indicated 2 to 12 years : - less than 15 kg : 0 \. 1 to 0 \. 15 mg / kg / dose by nebulization. the appropriate volume of the 0 \. 5 % inhalation solution should be diluted in sterile normal saline solution to a total of 3 ml prior administration. dosing should not exceed 2 \. 5 mg three to four times daily. - 15 kg or more : 2 \. 5 mg three or four times a day by nebulization, over approximately 5 to 15 minutes. the 0 \. 5 % inhalation solution should be diluted with 2 \. 5 ml of sterile normal saline solution 13 years or older : - inhalation solution 0 \. 5 % : 2 \. 5 mg three or four times a day by nebulization, over approximately 5 to 15 minutes use : relief of bronchospasm in
|
guidelines
|
cd47883daa98d813179588f50f8ee58639a9dfb8
|
Albuterol Dosage Guide + Max Dose, Adjustments
|
Albuterol Dosage Guide + Max Dose, Adjustments
patients with reversible obstructive airway disease and acute attacks of bronchospasm usual pediatric dose for bronchospasm prophylaxis less than 4 years : not indicated 4 years or older : - inhalation powder : 2 inhalations orally 15 to 30 minutes before exercise - inhalation capsule : 1 inhalation 15 minutes before exercise uses : prevention of exercise \ - induced bronchospasm usual pediatric dose for asthma \ - maintenance inhalation powder and capsules : less than 4 years : not indicated 4 years or older : - inhalation powder : 1 or 2 inhalations orally every 4 to 6 hours - inhalation capsules : 1 inhalation orally every 4 to 6 hours. the total daily dose should not exceed 4 inhalations. nebulizer inhalation solution : less than 2 years : not indicated 2 to 12 years : - less than 15 kg : 0 \. 1 to 0 \. 15 mg / kg / dose by nebulization. the appropriate volume of the 0 \. 5 % inhalation solution should be diluted in sterile normal saline solution to a total of 3 ml prior administration. dosing should not exceed 2 \. 5 mg three to four times daily. - 15 kg or more : 2 \. 5 mg three or four times a day by nebulization, over approximately 5 to 15 minutes. the 0 \. 5 % inhalation solution should be diluted with 2 \. 5 ml of sterile normal saline solution 13 years or older : - inhalation solution 0 \. 5 % : 2 \. 5 mg three or four times a day by nebulization, over approximately 5 to 15 minutes. oral tablets : less than 6 years : not indicated 6 to 12 years : - immediate \ - release tablets : initial dose : 2 mg orally three or four times a day. dosage may be cautiously increased stepwise, but not to exceed 24 mg / day. - extended \ - release tablets : initial dose : 4 mg orally every 12 hours. dosage may be cautiously increased stepwise under the control of the supervising physician to a maximum 24 mg / day in divided doses. 13 years or older : - immediate \ - release tablets : initial dose : 2 mg or 4 mg orally three or four times a day. dosage may be cautiously increased stepwise up to a maximum of 8 mg four times a
|
guidelines
|
cd47883daa98d813179588f50f8ee58639a9dfb8
|
Albuterol Dosage Guide + Max Dose, Adjustments
|
Albuterol Dosage Guide + Max Dose, Adjustments
day as tolerated. - extended \ - release tablets : initial dose : 4 mg or 8 mg orally every 12 hours. dosage may be cautiously increased stepwise under the control of the supervising physician to a maximum 32 mg / day in divided doses. oral syrup : - less than 2 years : not indicated - 2 to 5 years : initial dose : 0 \. 1 mg / kg orally three times a day. dosage may be increased stepwise to 0 \. 2 mg / kg three times a day. a maximum dose of 4 mg three times a day should not be exceeded. - 6 to 14 years : initial dose : 2 mg orally three or four times a day. dosage may be cautiously increased stepwise, but not exceed 24 mg / day. - 15 years or older : initial dose : 2 mg or 4 mg orally three or four times a day. dosage may be cautiously increased stepwise up to a maximum of 8 mg four times a day as tolerated. uses : treatment or prevention of bronchospasm due to bronchial asthma, chronic bronchitis and other chronic bronchopulmonary disorders in which bronchospasm is a complicating factor usual pediatric dose for chronic obstructive pulmonary disease \ - maintenance inhalation powder and capsules : less than 4 years : not indicated 4 years or older : - inhalation powder : 1 or 2 inhalations orally every 4 to 6 hours - inhalation capsules : 1 inhalation orally every 4 to 6 hours. the total daily dose should not exceed 4 inhalations. nebulizer inhalation solution : less than 2 years : not indicated 2 to 12 years : - less than 15 kg : 0 \. 1 to 0 \. 15 mg / kg / dose by nebulization. the appropriate volume of the 0 \. 5 % inhalation solution should be diluted in sterile normal saline solution to a total of 3 ml prior administration. dosing should not exceed 2 \. 5 mg three to four times daily. - 15 kg or more : 2 \. 5 mg three or four times a day by nebulization, over approximately 5 to 15 minutes. the 0 \. 5 % inhalation solution should be diluted with 2 \. 5 ml of sterile normal saline solution 13 years or older : - inhalation solution 0 \. 5 % : 2 \. 5 mg
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guidelines
|
cd47883daa98d813179588f50f8ee58639a9dfb8
|
Albuterol Dosage Guide + Max Dose, Adjustments
|
Albuterol Dosage Guide + Max Dose, Adjustments
three or four times a day by nebulization, over approximately 5 to 15 minutes. oral tablets : less than 6 years : not indicated 6 to 12 years : - immediate \ - release tablets : initial dose : 2 mg orally three or four times a day. dosage may be cautiously increased stepwise, but not to exceed 24 mg / day. - extended \ - release tablets : initial dose : 4 mg orally every 12 hours. dosage may be cautiously increased stepwise under the control of the supervising physician to a maximum 24 mg / day in divided doses. 13 years or older : - immediate \ - release tablets : initial dose : 2 mg or 4 mg orally three or four times a day. dosage may be cautiously increased stepwise up to a maximum of 8 mg four times a day as tolerated. - extended \ - release tablets : initial dose : 4 mg or 8 mg orally every 12 hours. dosage may be cautiously increased stepwise under the control of the supervising physician to a maximum 32 mg / day in divided doses. oral syrup : - less than 2 years : not indicated - 2 to 5 years : initial dose : 0 \. 1 mg / kg orally three times a day. dosage may be increased stepwise to 0 \. 2 mg / kg three times a day. a maximum dose of 4 mg three times a day should not be exceeded. - 6 to 14 years : initial dose : 2 mg orally three or four times a day. dosage may be cautiously increased stepwise, but not exceed 24 mg / day. - 15 years or older : initial dose : 2 mg or 4 mg orally three or four times a day. dosage may be cautiously increased stepwise up to a maximum of 8 mg four times a day as tolerated. uses : treatment or prevention of bronchospasm due to bronchial asthma, chronic bronchitis and other chronic bronchopulmonary disorders in which bronchospasm is a complicating factor usual pediatric dose for reversible airways disease \ - maintenance inhalation powder and capsules : less than 4 years : not indicated 4 years or older : - inhalation powder : 1 or 2 inhalations orally every 4 to 6 hours - inhalation capsules : 1 inhalation orally every 4 to 6 hours. the total daily dose should not exceed 4 inhalations. nebulizer inhalation solution
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guidelines
|
cd47883daa98d813179588f50f8ee58639a9dfb8
|
Albuterol Dosage Guide + Max Dose, Adjustments
|
Albuterol Dosage Guide + Max Dose, Adjustments
: less than 2 years : not indicated 2 to 12 years : - less than 15 kg : 0 \. 1 to 0 \. 15 mg / kg / dose by nebulization. the appropriate volume of the 0 \. 5 % inhalation solution should be diluted in sterile normal saline solution to a total of 3 ml prior administration. dosing should not exceed 2 \. 5 mg three to four times daily. - 15 kg or more : 2 \. 5 mg three or four times a day by nebulization, over approximately 5 to 15 minutes. the 0 \. 5 % inhalation solution should be diluted with 2 \. 5 ml of sterile normal saline solution 13 years or older : - inhalation solution 0 \. 5 % : 2 \. 5 mg three or four times a day by nebulization, over approximately 5 to 15 minutes. oral tablets : less than 6 years : not indicated 6 to 12 years : - immediate \ - release tablets : initial dose : 2 mg orally three or four times a day. dosage may be cautiously increased stepwise, but not to exceed 24 mg / day. - extended \ - release tablets : initial dose : 4 mg orally every 12 hours. dosage may be cautiously increased stepwise under the control of the supervising physician to a maximum 24 mg / day in divided doses. 13 years or older : - immediate \ - release tablets : initial dose : 2 mg or 4 mg orally three or four times a day. dosage may be cautiously increased stepwise up to a maximum of 8 mg four times a day as tolerated. - extended \ - release tablets : initial dose : 4 mg or 8 mg orally every 12 hours. dosage may be cautiously increased stepwise under the control of the supervising physician to a maximum 32 mg / day in divided doses. oral syrup : - less than 2 years : not indicated - 2 to 5 years : initial dose : 0 \. 1 mg / kg orally three times a day. dosage may be increased stepwise to 0 \. 2 mg / kg three times a day. a maximum dose of 4 mg three times a day should not be exceeded. - 6 to 14 years : initial dose : 2 mg orally three or four times a day. dosage may be cautiously increased stepwise, but not exceed 24 mg / day. - 15 years or older : initial dose : 2 mg or 4 mg orally three or four
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guidelines
|
cd47883daa98d813179588f50f8ee58639a9dfb8
|
Albuterol Dosage Guide + Max Dose, Adjustments
|
Albuterol Dosage Guide + Max Dose, Adjustments
times a day. dosage may be cautiously increased stepwise up to a maximum of 8 mg four times a day as tolerated. uses : treatment or prevention of bronchospasm due to bronchial asthma, chronic bronchitis and other chronic bronchopulmonary disorders in which bronchospasm is a complicating factor renal dose adjustments data not available liver dose adjustments data not available precautions inhalation solution and oral syrup : safety and efficacy have not been established in patients younger than 2 years. inhalation powder and inhalation capsules : safety and efficacy have not been established in patients younger than 4 years. immediate and extended release oral tablet : safety and efficacy have not been established in patients younger than 6 years. intravenous infusion : safety and efficacy have not been established in patients younger than 18 years. consult warnings section for additional precautions. dialysis data not available other comments administration advice : - inhalation solution, powder, and capsules are for oral inhalation only. - more frequent administration or a larger number of inhalations are not recommended. - oral tablets should not be chewed or crushed ; tablets should be swallowed whole with liquids. - the manufacturer product information should be consulted for instructions of use. inhalation powder hfa : - prime the inhalation device before using for the first time, when the inhaler has not been used for more than 2 weeks, or when the inhaler has been dropped. - to prime, release 4 sprays into the air away from the face, shaking well before each spray. - to ensure proper dosing and to prevent actuator orifice blockage, wash the actuator with warm water and let it air \ - dry completely at least once a week. inhalation powder respiclick : - inhaler does not require priming. - keep the inhaler clean and dry at all times. never wash or put any part of the inhaler in water. switching from oral immediate release to extended release products : - the administration of one 4 mg extended \ - release tablet every 12 hours is comparable to one 2 mg immediate tablet every 6 hours. multiples of this regimen up to the maximum recommended daily dose also apply. patient advice : - other inhaled drugs and asthma medications should be taken only as directed by the physician while taking this drug. - seek medical advice if short \ - acting relief bronchodilator
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guidelines
|
cd47883daa98d813179588f50f8ee58639a9dfb8
|
Albuterol Dosage Guide + Max Dose, Adjustments
|
Albuterol Dosage Guide + Max Dose, Adjustments
treatment becomes less effective, or more inhalations than usual is required. do not increase the dose or its frequency of administration.
|
guidelines
|
882ae87accc9afe0421e9a44ecdc938bff171c07
|
Alendronate Dosage Guide + Max Dose, Adjustments
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Alendronate Dosage Guide + Max Dose, Adjustments
1. home 2. alendronate 3. dosage print save alendronate dosage applies to the following strengths : 70 mg ; 35 mg ; 40 mg ; 5 mg ; 10 mg ; 70 mg / 75 ml usual adult dose for osteoporosis 10 mg orally once a day or 70 mg orally once a week for the treatment of glucocorticoid \ - induced osteoporosis : 5 mg orally once a day for the treatment of glucocorticoid \ - induced osteoporosis in postmenopausal women not receiving estrogen : 10 mg orally once a day comments : - in postmenopausal women, this drug increases bone mass and reduces the incidence of fractures including those of the hip and spine. - this drug increased bone mass in men with osteoporosis. - the optimal duration of use has not been determined ; data is based on clinical use of 4 years. - patients receiving therapy should have use re \ - evaluated on a periodic basis ; patients with a low risk of fracture should consider stopping therapy after 3 to 5 years of use. - once therapy is discontinued, patients should have their fracture risk re \ - evaluated periodically. uses : for the treatment of osteoporosis in postmenopausal women, men with osteoporosis, and men and women with glucocorticoid \ - induced osteoporosis receiving glucocorticoids in a daily dose equivalent to 7 \. 5 mg or greater of prednisone who have low bone mineral density. usual adult dose for prevention of osteoporosis 5 mg orally once a day or 35 mg orally once a week comments : - the optimal duration of use has not been determined ; data is based on clinical use of 4 years. - patients receiving therapy should have use re \ - evaluated on a periodic basis ; patients with a low risk of fracture should consider stopping therapy after 3 to 5 years of use. - once therapy is discontinued, patients should have their fracture risk re \ - evaluated periodically. use : prevention of osteoporosis in postmenopausal women usual adult dose for paget ' s disease 40 mg orally once a day for 6 months comments : - treatment is indicated in patients who have alkaline phosphatase at least 2 x the upper limit of normal, or those who are sy
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guidelines
|
882ae87accc9afe0421e9a44ecdc938bff171c07
|
Alendronate Dosage Guide + Max Dose, Adjustments
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Alendronate Dosage Guide + Max Dose, Adjustments
##mptomatic, or those at risk for future complications from their disease. - retreatment may be considered, following a 6 \ - month post \ - treatment evaluation period in patients who have relapsed, based on increases in serum alkaline phosphatase, which should be measured periodically. - retreatment may also be considered in patients who failed to normalize serum alkaline phosphatase. use : treatment of paget ' s disease of bone renal dose adjustments crcl 35 ml / min or more : no adjustment recommended crcl less than 35 ml / min : not recommended liver dose adjustments no adjustment recommended precautions - abnormalities of the esophagus which delay esophageal emptying such as stricture or achalasia - inability to stand or sit upright for at least 30 minutes - hypocalcemia - hypersensitivity to active substance or any of the ingredients ; hypersensitivity reactions have included urticaria and angioedema - increased risk of aspiration safety and efficacy have not been established in patients younger than 18 years. consult warnings section for additional precautions. dialysis data not available other comments administration advice : - this drug should be taken at least 30 minutes before the first food, beverage, or medication of the day - avoid lying down for at least 30 minutes after taking this drug and until after the first food of the day - take with plain water only : do not take with mineral water, coffee, tea, soda, or juice, etc. - tablets : take with a full glass of plain water - oral solution : follow with at least 2 ounces of water - effervescent tablet : dissolve effervescent tablet in 4 ounces of plain room temperature water ; after effervescence stops, wait 5 minutes, then stir solution for 10 seconds, and consume recommendations for calcium and vitamin d supplementation : - take supplemental calcium and vitamin d if dietary intake is inadequate - patients at increased risk for vitamin d insufficiency may need vitamin d supplementation - patients with gastrointestinal malabsorption syndromes may require higher doses of vitamin d. supplementation ; measurement of 25 \ - hydroxyvitamin d should be considered - patients treated with glucocorticoids should receive adequate amounts of calcium and vitamin d missed doses : - if the once \ - weekly dose is missed, take dose on the morning after remembering ; two doses should not be taken on the same
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guidelines
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882ae87accc9afe0421e9a44ecdc938bff171c07
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Alendronate Dosage Guide + Max Dose, Adjustments
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Alendronate Dosage Guide + Max Dose, Adjustments
day ; resume regular schedule general : - optimal duration of use has not been determined ; use should be reevaluated periodically. - patients at low \ - risk for fracture should consider drug discontinuation after 3 to 5 years of use. - patients who discontinue therapy should have their risk for fracture reevaluated periodically. monitoring : - metabolic : monitor serum calcium and hypocalcemia symptoms in patients with disorders affecting mineral metabolism patient advice : - patients should be instructed to read the us fda \ - approved patient labeling. - patients should be instructed to take supplemental calcium and vitamin d if their daily dietary intake is inadequate. - patients should be instructed on proper administration instructions.
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guidelines
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