CNS / MetabolicAbnormal appearance, normal WOB, normal circulation
Age-Based Normal Vital Signs Interactive
Age Group
HR (bpm)
RR (/min)
Systolic BP (mmHg)
SpO2 (%)
Newborn
100–160
30–60
60–90
≥95
1–12 Months
100–150
30–60
70–100
≥95
1–3 Years
90–150
24–40
80–110
≥95
3–5 Years
80–140
22–34
80–110
≥95
6–12 Years
70–120
18–30
90–120
≥95
12–18 Years
60–100
12–20
100–130
≥95
WETFLAG Calculator Interactive
Enter child's age to calculate resuscitation parameters. Always verify with clinical judgment and actual weight.
WETFLAG Formula Reference
W = (Age + 4) × 2 kg | E = 4 J/kg | T = (Age/4) + 4 mm | F = 20 mL/kg NS | L = Blade 1 (<1yr), 2 (1–8yr), 3 (>8yr) | A = 0.1 mL/kg of 1:10,000 | G = 2 mL/kg of 10% dextrose
VentilationBVM with 100% O2 preferred in pre-hospital setting. Give each breath over 1 second — visible chest rise. Avoid over-ventilation (increases intrathoracic pressure, reduces cardiac output).
Defibrillation & Drugs in Cardiac Arrest
Defibrillation
Initial shock: 4 J/kg
Subsequent shocks: 4 J/kg (up to 8 J/kg max, not exceeding adult 360 J monophasic / 200 J biphasic)
Paediatric pads for children <8 years or <25 kg
AED acceptable if no manual defibrillator available
Resume CPR immediately after shock — do not pause to check rhythm
Adrenaline (Epinephrine)
0.01 mg/kg IV/IO (= 0.1 mL/kg of 1:10,000)
Max single dose: 1 mg
Give every 3–5 minutes after 3rd shock (shockable) or immediately (non-shockable)
Amiodarone (VF/pVT)
5 mg/kg IV/IO bolus after 3rd shock
Repeat after 5th shock if needed
Vascular Access & Fluid Resuscitation
Vascular Access PriorityIV peripheral first. If 2 failed attempts or >60 seconds — proceed to IO immediately. Do not delay resuscitation.
IO Sites (Intraosseous)
Proximal tibia — most common (2 cm below tibial tuberosity, medial aspect)
Distal femur — alternative
Proximal humerus — alternative in older children
Use EZ-IO drill; confirm placement by aspiration of marrow and easy fluid flow
Fluid Bolus (Shock)
10 mL/kg 0.9% NaCl over 5–10 min (septic shock)
Reassess after each bolus (HR, BP, cap refill, mental status)
Repeat up to 40–60 mL/kg total in first hour if no improvement
Caution: avoid aggressive fluids in cardiac causes of shock
Paediatric Airway Management
BVM Ventilation (Preferred Pre-Hospital)Size-appropriate mask; head in neutral (infant) or sniffing (child) position. Two-person BVM technique preferred for optimal seal.
ETT Size Guidelines
Uncuffed (traditional <8 years): ID = (Age/4) + 4 mm
Cuffed (now acceptable at any age if sized correctly): ID = (Age/4) + 3.5 mm; inflate cuff to <20 cmH2O
Depth at lip (cm) = ETT size × 3
Confirm placement: bilateral chest rise, CO2 detection, CXR
Temperature reduction: paracetamol / tepid sponging
Time the seizure from onset
Status Epilepticus (>5 minutes) — Treat Immediately
Midazolam 0.1–0.2 mg/kg buccal or IM (max 10 mg). IV lorazepam 0.1 mg/kg if access available. If seizure persists >10 min — second benzodiazepine dose. >20 min — phenytoin/levetiracetam IV loading dose. Intubation if refractory.
Croup (Laryngotracheobronchitis) 0–5 Years
PresentationBarky, seal-like cough; inspiratory stridor; hoarse voice; worse at night; viral cause (parainfluenza). Westley Croup Score guides management.
Mild CroupStridor at rest absent or mild; no retractions; SpO2 normal. Management: calm child, cool humidified air, upright position, oral dexamethasone 0.15 mg/kg single dose.
Moderate CroupStridor at rest, mild-moderate retractions, some distress but SpO2 normal. Management: dexamethasone 0.6 mg/kg oral/IM (single dose); consider nebulised adrenaline if not improving.
Severe CroupSignificant stridor, severe retractions, pallor/cyanosis, agitated or exhausted. Management: Nebulised adrenaline 0.5 mL/kg of 1:1000 (max 5 mL) + dexamethasone 0.6 mg/kg. Prepare for airway intervention. ICU referral. Heliox if available.
Bronchiolitis Infants <2 Years
Key Facts
RSV most common cause (autumn/winter)
Wheeze, crackles, subcostal retractions
Tachypnoea, poor feeding
Risk: prematurity, CHD, immunodeficiency
Evidence-Based Management
Supplemental O2: maintain SpO2 ≥92%
Nasal suctioning (bulb/NPA)
Feeding support (NG if needed)
HFNC (high flow nasal cannula) if severe
CPAP / intubation if respiratory failure
NOT RecommendedBronchodilators (salbutamol/epinephrine) — NOT routinely recommended (no proven benefit). Corticosteroids — NOT indicated. Antibiotics — only if secondary bacterial infection confirmed.
Anaphylaxis in Children Emergency
Immediate Action — Adrenaline FirstIM Adrenaline 0.01 mg/kg (0.1 mL/kg of 1:1000) into anterolateral mid-thigh. Max dose: 0.5 mg. Repeat every 5–15 min if no improvement. Lay flat (legs elevated) unless respiratory distress.
Secondary Treatments
IV fluid bolus 10 mL/kg if hypotensive
Chlorphenamine (antihistamine) IV/IM
Hydrocortisone 4 mg/kg IV/IM
Salbutamol nebulisation if bronchospasm
Triggers in GCC Context
Foods: nuts, eggs, fish, sesame (tahini)
Antibiotics: penicillin, cephalosporins
Insect stings
Latex (healthcare setting)
Diabetic Ketoacidosis (DKA) in Children Caution: Cerebral Oedema Risk
Resuscitation: only if shocked — 10 mL/kg 0.9% NaCl (repeat cautiously)
Rehydration: 2–3 L/m²/day (oral + IV combined) — NOT rapid rehydration
Use 0.9% NaCl initially, switch to 0.45% NaCl + 5% glucose when glucose <14 mmol/L
Add K+ to fluids after first voiding (once renal function confirmed)
InsulinStart insulin 0.1 units/kg/hr ONLY after at least 1 hour of IV fluids. Aim glucose drop of 2–5 mmol/L/hr. Reduce to 0.05 units/kg/hr when glucose <14 mmol/L.
Cerebral Oedema Warning SignsHeadache, altered consciousness, bradycardia, hypertension, papilloedema. Act immediately: mannitol 0.5–1 g/kg IV or hypertonic saline 3% 2.5–5 mL/kg IV. Head elevation 30°. Restrict fluids. CT head.
Bacterial Meningitis / Meningococcal Disease Time Critical
Purpuric Rash = Meningococcal — DO NOT WAITNon-blanching purpuric rash + fever = meningococcal septicaemia until proven otherwise. Give antibiotics BEFORE transfer.
Antibiotics
Benzylpenicillin IM/IV before hospital transfer if suspected
Ceftriaxone 100 mg/kg/day IV (BD dosing, max 4g/day)
Classic TriadIntermittent colicky abdominal pain (drawing up knees), currant jelly stool (blood + mucus), sausage-shaped mass in right upper quadrant. Vomiting. Child appears well between episodes initially.
Management
IV access, fluid resuscitation if shocked
Abdominal USS to confirm (target sign)
Air enema reduction (radiological) — first-line treatment, 80–90% success
Surgical reduction if air enema fails or perforation suspected
NPO, IV antibiotics if surgical intervention likely
Weight-Based Dosing Principles Safety Critical
Decimal Errors KillAlways calculate dose by actual weight (kg). Use WETFLAG as a cross-check. Independent double-check required for ALL paediatric high-alert medications. Never estimate weight by appearance alone.
Safe Practices
Weigh child at every admission
Document weight in kg on drug chart
Use oral syringes for oral liquids
State dose in mg AND volume
Never use trailing zeros (1 mg not 1.0 mg)
Always use leading zero (0.5 mg not .5 mg)
Concentration Confusion Prevention
Adrenaline: 1:1000 = 1 mg/mL (IM use)
Adrenaline: 1:10,000 = 0.1 mg/mL (IV/IO use)
Morphine: standard concentration 1 mg/mL
Check concentration on ampoule before drawing up
Common Paediatric Drug Doses
Paracetamol
Oral/IV/rectal: 15 mg/kg every 4–6h (max 4 doses/day, max 1g/dose >50 kg). IV 7.5–15 mg/kg 4–6 hrly.
Ibuprofen
Oral: 5–10 mg/kg every 6–8h (≥3 months only; avoid if renal impairment, dehydration, or asthma). Max 400 mg/dose.
Amoxicillin
Oral: 25–50 mg/kg/day divided TDS (max 500 mg TDS). For severe infections: 80–100 mg/kg/day.
Ceftriaxone
IV/IM: 50–100 mg/kg/day. Meningitis: 100 mg/kg/day in 1–2 divided doses, max 4 g/day. Sepsis: 50 mg/kg OD, max 2 g/day.
Benzylpenicillin
IV/IM: 50 mg/kg every 6h (meningococcal: 75 mg/kg/dose for neonates; 50–100 mg/kg/dose for older children).
Mild–Moderate Dehydration (<9%)ORS (oral rehydration solution): 50–100 mL/kg over 3–4 hours. Ongoing losses: replace 5–10 mL/kg per vomiting/diarrhoea episode. Preferred over IV where tolerated. NG-ORT acceptable if oral route limited.
Severe Dehydration (≥9% or shocked)IV 0.9% NaCl 10–20 mL/kg bolus. Reassess and repeat. Transition to oral/NG ORT as tolerated. Measure and replace ongoing losses.
WHO-ORS CompositionNa 75 mmol/L | K 20 mmol/L | Chloride 65 mmol/L | Citrate 10 mmol/L | Glucose 75 mmol/L | Osmolarity 245 mOsm/L. Available as sachets (dissolve in 1L boiled water).
Family-Centred Care Principles Core Philosophy
Core Principles
Parents as partners in care, not visitors
Open visiting — family present at all times
Family presence during resuscitation (FPR)
Shared decision-making
Information delivered in family's language
Respect for cultural & religious values
GCC Family Dynamics
Extended family often present — identify primary decision-maker
Grandparents may be highly influential
Father often expects to be the spokesperson
Gender-specific care preferences (female staff for female patients)
High parental anxiety — regular clear communication essential
Family Presence During Resuscitation (FPR)Evidence supports FPR as beneficial for families. Assign a dedicated nurse/staff member to support the family away from the resuscitation area. Explain what is happening in simple terms. Document family presence and support provided.
Paediatric Pain Assessment
FLACC Scale (Non-Verbal / <3 Years)
Face — grimacing, furrowed brow
Legs — kicking, tensed
Activity — arched, rigid, jerking
Cry — constant cry, screaming
Consolability — inconsolable
Score 0–10 (0=no pain, 10=worst)
Wong-Baker FACES Scale (3–12 Years)6 cartoon faces from smiling (0 = no hurt) to crying (10 = hurts worst). Point to the face that matches your pain. Culturally adaptable.
NRS — Numeric Rating Scale (>8 Years)Rate pain 0–10. 0 = no pain; 10 = worst imaginable. Simple, reliable in older children and adolescents.
Child Safeguarding in GCC
Mandatory ReportingAll healthcare workers are legally obligated to report suspected child abuse or neglect. Report to hospital Child Protection team or relevant authority (e.g., Ministry of Social Affairs, Child Protection Units in each GCC country).
Abuse Indicators
Inconsistent history with injury
Unexplained bruising in non-mobile child
Multiple injuries at different stages
Delayed presentation
Behavioural changes, withdrawal
Pattern burns or bite marks
Documentation (SBAR)
Record direct quotes from history
Describe injuries in objective terms (size, shape, colour, location)
Do NOT interpret — describe what you see
Time and date all entries
Body chart documentation
Cultural Considerations in GCC Paediatrics
Common Clinical Considerations
Vitamin D deficiency: high prevalence due to sun avoidance, covered clothing — supplement routinely