Age-Appropriate Consent & Legal Framework
Gillick CompetenceUnder 16
- Child can consent if they have sufficient understanding to comprehend the nature, purpose and consequences of proposed treatment
- Assessed individually — not age-based automatically
- Parent can override refusal in child's best interest
- Document capacity assessment clearly in notes
Parental ConsentStandard process
- Both parents with Parental Responsibility should ideally consent
- In GCC — cultural considerations: father's signature often primary
- Emergency: treat in child's best interest if parent unavailable
- Interpreter services mandatory for non-English/Arabic speakers
- Site marking must be co-signed by operating surgeon before theatre
Paediatric Fasting Guidelines (RCPCH 2020)
⚠NBM anxiety is a major source of distress in children. Play specialists and clear parental communication are essential to minimise suffering.
| Intake Type | Minimum Fasting Time | Notes |
|---|
| Clear fluids (water, diluted juice) | 1 hour | Encourage right up to 1h pre-op — reduces distress |
| Breast milk | 3 hours | Empties faster than formula |
| Formula milk / non-human milk | 4 hours | Treat as per solids if mixed with solids |
| Solids / formula feeds with cereal | 6 hours | Standard solid food rule |
Psychological Preparation & Play Specialist Role
Play SpecialistCore team member
- Age-appropriate explanation using dolls, picture books, theatre tours
- Therapeutic play to process anxiety pre- and post-operatively
- Distraction techniques during procedures (cannulation, dressing changes)
- Support for siblings and family members
- Preparation packs: surgical gown teddy, countdown calendars
EMLA CreamTopical anaesthesia
- Apply 1 hour before planned cannulation site
- Cover with occlusive dressing (Tegaderm/OpSite)
- Document time of application in nursing notes
- Do not use on broken skin or mucous membranes
- Ametop (tetracaine) — faster onset 30–45 min, slightly more effective
- Avoid fingers in infants — vasoconstriction risk
Parental Presence in Anaesthetic Room
✓Benefits: Reduces child's separation anxiety, speeds induction, parents feel involved and less anxious about the unknown
- Particularly beneficial for children aged 1–8 years
- One parent only — clearly briefed on what to expect
- Prepare parent: child may go limp quickly — normal
- Parent leaves immediately after loss of consciousness
!Cautions: Highly anxious parents can increase child's distress — assess parent anxiety first
- Parent should not be present if: previous fainting, needle phobia, extreme distress
- Anaesthetist has final decision on suitability
- Always have a nurse available to escort parent out
Temperature Management — Neonates & Infants
Neonatal RiskHypothermia prevention
- Neonates cannot shiver — rely entirely on brown fat thermogenesis
- Theatre temperature: 26–28°C for neonates, 22–24°C for older children
- Warming blanket (Bair Hugger) before, during and after surgery
- Warm IV fluids — use fluid warmer for all IV infusions in neonates
- Hat on head in theatre — large surface area heat loss
- Wrap exposed bowel in warm saline-soaked gauze immediately
- Target temperature: 36.5–37.5°C
Drug DosingWeight-based calculation
- Use APLS formula: Weight (kg) = (age + 4) × 2 for ages 1–10 years
- Neonates: use actual birth weight or corrected gestational age weight
- Always double-check with second nurse for opioids and high-alert drugs
- Document actual weight on drug chart — never estimate without recording
- Use oral syringes for oral medications in infants
Pre-operative Investigations
| Investigation | Indication | Notes |
|---|
| FBC | Major surgery, suspected anaemia, neonates | Neonatal Hb >130 g/L acceptable pre-op |
| U&E / Electrolytes | Major surgery, pyloric stenosis, renal conditions | Critical in pyloric stenosis — correct before surgery |
| Coagulation (PT/APTT) | Liver disease, bleeding history, major surgery | Not routine for minor elective surgery |
| Group & Save | Any surgery with significant blood loss risk | Crossmatch if >20% EBV loss anticipated |
| Blood glucose | Neonates, diabetics, prolonged fasting | Neonatal hypoglycaemia <2.6 mmol/L — treat urgently |
| CXR / AXR | OA/TEF, duodenal atresia, malrotation | Double bubble sign — duodenal atresia |
| ECG / ECHO | Cardiac history, Down syndrome, major surgery | Down syndrome — 40% have congenital heart defects |
🚨Neonatal Surgical Emergencies: Time-critical conditions requiring immediate senior escalation, IV access, and stabilisation before transfer to specialist surgical centre if not available on site.
Oesophageal Atresia + Tracheo-Oesophageal Fistula (OA+TEF)
RecognitionClassic presentation
- Excessive bubbling/frothing at mouth and nose
- Choking, coughing, cyanosis with feeds
- Inability to pass NG tube — tube coils at blind pouch (~10 cm)
- Respiratory distress — aspiration pneumonitis
- CXR: coiled NG tube in mediastinum; gastric gas if TEF present
- Antenatal: polyhydramnios on USS
Nursing ManagementImmediate actions
- Insert Replogle tube (double-lumen) into upper pouch — continuous low suction to prevent aspiration
- Position upright at 30° head-up to reduce acid reflux into lungs
- IV access — maintenance fluids (nil by mouth)
- Oxygen therapy / ventilatory support as required
- Keep warm — incubator / warming blanket
- Urgent surgical referral — thoracoscopic or open repair
- Document Replogle suction output (colour/volume/frequency)
Duodenal Atresia
AssociationDown syndrome (Trisomy 21)
- Present in ~30% of Down syndrome neonates
- Screen all Down syndrome neonates for duodenal obstruction
- Double bubble sign on AXR/prenatal USS — gastric + duodenal gas
- Bilious vomiting from birth (vomiting is bilious as obstruction is post-ampulla of Vater)
- Check for associated cardiac defects (ECHO mandatory)
ManagementPre-op stabilisation
- IV fluid resuscitation and maintenance (no oral feeds)
- NG tube insertion and free drainage — decompress stomach
- Electrolyte correction
- Surgical repair: duodeno-duodenostomy (diamond anastomosis)
- Post-op: gradual enteral feeds — often slow gut motility initially
Pyloric Stenosis
⚠Key exam point: Always correct metabolic alkalosis (hypokalaemic, hypochloraemic) BEFORE surgery. Ramstedt pyloromyotomy is never an emergency — stabilise first.
Presentation2–8 weeks of age
- Projectile, non-bilious vomiting — forceful, after every feed
- Hungry after vomiting — "hungry vomiter"
- Visible gastric peristalsis (left to right) after feed
- Olive-shaped mass in epigastrium / right upper quadrant
- USS — pyloric muscle thickness >4 mm, channel length >16 mm
- Metabolic alkalosis: ↑pH, ↑HCO₃, ↓Cl⁻, ↓K⁺
- Progressive dehydration and weight loss
Pre-op CorrectionBEFORE Ramstedt
- IV 0.9% NaCl with KCl — correct chloride and potassium deficit
- Target: serum Cl⁻ >100 mmol/L, K⁺ >3.5 mmol/L, pH <7.45
- Monitor urine output — catheter or weigh nappies
- NGT for gastric decompression
- Do NOT give NaHCO₃ — worsens alkalosis
- Correct over 24–48 hours — not rapidly
- Laparoscopic Ramstedt pyloromyotomy once stable
Malrotation & Volvulus
🚨Surgical emergency: Bilious vomiting in a neonate = malrotation/volvulus until proven otherwise. Every minute of delay risks irreversible midgut ischaemia.
Recognition
- Sudden onset bilious (green) vomiting in neonate/infant
- Abdominal distension, bloody stools (late sign — ischaemia)
- Rapid deterioration: shock, haemodynamic instability
- Upper GI contrast study — corkscrew sign of twisted bowel
- USS: whirlpool sign of superior mesenteric vessels
- AXR may appear normal in early volvulus
ManagementLadd's Procedure
- Immediate IV access — bolus 10 mL/kg 0.9% NaCl for shock
- NGT insertion and free drainage
- Urgent surgical consultation — do NOT delay for imaging if shocked
- Ladd's procedure: untwist volvulus, divide Ladd's bands, appendicectomy, caecum to left fossa
- Post-op: TPN if significant bowel resection needed
- Short bowel syndrome risk if extensive resection
Gastroschisis vs Exomphalos (Omphalocele)
GastroschisisPara-umbilical defect
- Bowel herniates through defect to RIGHT of umbilicus — no sac
- Bowel directly exposed: risk of hypothermia, fluid loss, infection
- Immediate: cover bowel in warm saline-soaked gauze, then cling film / bowel bag
- NG tube — decompress gut, reduce vomiting
- IV access — high fluid losses from exposed bowel surface
- Staged silo reduction or primary closure
- Not associated with chromosomal abnormalities
ExomphalosCentral defect with sac
- Bowel (and liver) herniates through umbilicus — covered by sac
- Associated with chromosomal anomalies (Down, Edwards, Beckwith-Wiedemann)
- Cardiac defects in ~30% — ECHO mandatory pre-op
- If sac intact: less urgent, wrap in warm saline gauze + film
- If sac ruptured: treat as gastroschisis — emergency
- Conservative management with silver sulfadiazine (giant exomphalos)
- Staged surgical repair
Hirschsprung Disease
Presentation
- Failure to pass meconium within 48 hours of birth
- Chronic constipation / abdominal distension from birth
- Explosive decompression of stool on rectal examination
- Risk of enterocolitis — fever, explosive diarrhoea, shock
- AXR: dilated proximal bowel, collapsed distal bowel
- Rectal biopsy: absent ganglion cells (aganglionosis)
- Contrast enema: transition zone
Nursing Management
- Rectal washouts (saline) to decompress — nurse competency required
- Defunctioning colostomy if unstable or enterocolitis
- Stoma care teaching for parents — critical discharge skill
- Definitive pull-through surgery (Swenson / Soave / Duhamel)
- Post pull-through: monitor for constipation recurrence, soiling
- Long-term bowel management programme
Appendicitis in Children
!Perforation risk: Children under 5 years cannot localise pain well — present late. Perforation rates up to 80% in under-5s. High index of suspicion needed.
ALVARADO ScoreDiagnostic aid
Migration of pain to RIF1 point
Anorexia1 point
Nausea / vomiting1 point
RIF tenderness on palpation2 points
Rebound tenderness1 point
Elevated temperature (>37.3°C)1 point
Leucocytosis (>10×10⁹/L)2 points
≤4 — unlikely | 5–6 — possible | ≥7 — probable appendicitis
Post-op NursingLaparoscopic appendicectomy
- Vital signs monitoring Q1–2h until stable
- Wound site assessment — 3 laparoscopic port sites
- Diet: clear fluids when bowel sounds return, progress to normal diet
- Mobilisation: sitting up day 1, mobilise day 1–2
- Analgesia: paracetamol + ibuprofen regularly, opioid PRN
- Perforated appendix: IV antibiotics (co-amoxiclav / metronidazole) 48–72h then oral
- Longer hospital stay if perforated: monitor temperature, CRP
- School return: 1–2 weeks (non-perforated), 3–4 weeks (perforated)
Intussusception
PresentationPeak 3–12 months
- Episodic colicky abdominal pain — child draws up legs, screams
- Pain every 15–20 minutes, child well between episodes initially
- Red currant jelly stool — blood-stained mucus (late sign, bowel ischaemia)
- Sausage-shaped mass in RUQ
- Lethargy, pallor — "collapsed" child in advanced cases
- USS: target/doughnut sign — diagnostic
Management
- Air enema reduction — first-line if no peritonitis/perforation
- Success rate 80–90% — perform under fluoroscopy/USS guidance
- IV access before procedure — resuscitation ready
- Surgery if: peritonitis, perforation, haemodynamic instability, failed air enema
- Laparoscopic or open reduction ± bowel resection
- Recurrence rate ~10% — warn parents
- Lead point (Meckel's/polyp) more common in older children
Inguinal Hernia Repair
OverviewMost common elective paediatric surgery
- Indirect inguinal hernia — patent processus vaginalis
- More common in males, premature infants, right side
- Incarceration risk highest in infants <6 months — early repair recommended
- Day-case surgery for most children >3 months corrected age
- Laparoscopic or open herniotomy
Post-op Care
- Oral analgesia: paracetamol + ibuprofen regularly for 48h
- Wound: small incision, steri-strips or tissue glue — keep dry 48h
- Scrotal swelling/bruising — expected, reassure parents
- Feeding: breast/bottle feed as soon as awake and alert
- Return to school: 48–72 hours for uncomplicated repair
- Avoid strenuous activity / swimming for 2 weeks
Circumcision Nursing Care
Indications
- Medical: phimosis, recurrent balanitis, paraphimosis, VUR management
- Religious/cultural: common in GCC — Muslim and Jewish communities
- Day-case procedure under general anaesthesia in children
Post-op Nursing
- Monitor for haemostasis — primary haemorrhage in first 6 hours
- Vaseline gauze dressing — prevents adhesion to nappy/clothing
- Parent education: expected swelling, bruising, white exudate at day 3–5 is normal healing
- Urine output check before discharge — first void post-op documented
- Return if: no urine in 8h, significant bleeding, fever, foul smell
- Analgesia: regular paracetamol + ibuprofen 48h
Developmental Dysplasia of the Hip (DDH)
Screening TestsNeonatal examination
- Ortolani test — reduces a dislocated hip (clunk = positive)
- Barlow test — dislocates an unstable hip (clunk = positive)
- Risk factors: female sex, breech presentation, family history, oligohydramnios
- USS <6 months — imaging of choice (acetabular cartilage not ossified)
- X-ray >6 months — when femoral head ossifies
Pavlik Harness Nursing0–6 months conservative treatment
- Harness worn 23h/day — hips in flexion and abduction
- Skin checks: axilla, groin, behind knee — pressure areas q8h
- Nappy changes with harness on — guide parents carefully
- Sponge bath only — harness must not get wet
- Document hip position in harness at each nursing assessment
- USS at 6 weeks in harness to assess reduction
- If failed: closed/open reduction under GA + spica cast
Talipes Equinovarus (Club Foot / CTEV)
Ponseti MethodSerial casting
- Manipulation and casting from first week of life
- Cast changes weekly — 5–7 casts typically required
- Sequence of correction: Cavus → Adductus → Varus → Equinus
- Achilles tenotomy — minor procedure, local anaesthetic, corrects equinus
- Final long leg cast 3 weeks post-tenotomy
Boots & Bar NursingMaintenance phase
- Dennis-Brown bar worn 23h/day until walking age, then nights
- Skin checks: heels, ankles, pressure points under bar straps
- Parent teaching: how to apply/remove boots, skin checks
- Monitor cast circulation: capillary refill, sensation, movement of toes
- Red flag: toe discolouration, swelling above cast, odour — cast removal needed
- Relapse common — compliance with brace is critical
Hypospadias
Overview
- Urethral meatus opens on ventral (under) surface of penis
- Types: glanular, penile, penoscrotal, perineal
- Chordee (penile curvature) may be associated
- Ideal repair age: 6–18 months
- Do NOT circumcise — prepucial skin needed for repair
- Urethroplasty under GA — day surgery or overnight
Post-op Nursing
- Urethral stent/catheter in situ — keep drain patent, document hourly output
- Double nappy technique to minimise stent displacement
- Loose clothing only — no tight nappies over repair
- Analgesia: paracetamol + ibuprofen + penile block (local)
- Monitor for urinary retention if stent blocked
- Stent removal day 5–7 by surgeon or advanced practitioner
- Parent education: observe urinary stream post-removal
Vesicoureteric Reflux (VUR) & Orchidopexy
VUR Management
- Diagnosed following UTI in children — NICE guidelines investigation pathway
- DMSA scan — renal cortical scarring assessment
- MCUG (micturating cystourethrogram) — grades reflux I–V
- Antibiotic prophylaxis: trimethoprim or nitrofurantoin daily
- Endoscopic submucosal injection: STING procedure (dextranomer/hyaluronic acid)
- Open ureteric reimplantation for high-grade/failed conservative
OrchidopexyUndescended testis
- Unilateral undescended testis in 2–4% term males; higher in premature
- Await spontaneous descent until 6 months of age
- hCG or GnRH hormone therapy (limited evidence, rarely used in GCC)
- Surgical orchidopexy: 6–18 months recommended timing
- Bilateral: higher fertility risk, malignancy risk — surveillance post-puberty
- Post-op: scrotal support, monitor testicular position at follow-up
Post-operative Monitoring — PICU/NICU
ABC MonitoringImmediate post-op
- Airway: Position, secretions, stridor — airway adjunct if needed
- Breathing: RR, SpO₂ target 94–98%, work of breathing, chest symmetry
- Circulation: HR, BP, CRT <2s, urine output >1 mL/kg/h
- Disability: GCS/AVPU, pain score, glucose, pupils
- Exposure: Temperature 36.5–37.5°C, wound inspection, drain output
- Frequency: Q15min for 1h → Q30min for 2h → Q1h when stable
Pain Assessment Tools
FLACC Score
Non-verbal / pre-verbal children (0–10)
| Category | 0 | 1 | 2 |
|---|
| Face | No expression | Occasional grimace | Frequent grimace |
| Legs | Normal | Uneasy, restless | Kicking |
| Activity | Lying quietly | Squirming | Arched/rigid |
| Cry | No cry | Moans/whimpers | Screaming |
| Consolability | Content | Reassurable | Inconsolable |
FACES scale ≥3 years
NRS ≥8 years
NIPS for neonates
Multi-Modal Analgesia — Weight-Based Paediatric Dosing
| Drug | Route | Dose | Frequency | Max dose | Notes |
|---|
| Paracetamol | PO/PR | 15 mg/kg | Q4–6h | 75 mg/kg/day (max 4g/day) | Reduce in hepatic impairment |
| Paracetamol | IV | 15 mg/kg | Q6h | 60 mg/kg/day or 4g/day | <10 kg: 7.5 mg/kg IV |
| Ibuprofen | PO | 5–10 mg/kg | Q6–8h | 40 mg/kg/day (max 2.4g) | Avoid <3 months, renal impairment |
| Morphine | IV (NCA) | 10–20 mcg/kg/h | Continuous | Titrate to pain | NCA for pre-verbal/younger, PCA ≥5y |
| Morphine | IV bolus | 50–100 mcg/kg | Q2–4h PRN | Monitor sedation score | Naloxone available at bedside |
| Ondansetron | IV/PO | 0.1 mg/kg | Q8h PRN | 4 mg per dose | Antiemetic — max 4 mg in children |
⚠NCA vs PCA: Nurse-Controlled Analgesia (NCA) is used for children under 5 years or those unable to self-administer. PCA (Patient-Controlled Analgesia) appropriate from age 5 years with adequate cognitive ability. Both require dedicated opioid chart and hourly sedation scoring.
Fluid Management Post-operatively
Maintenance FluidsHolliday-Segar formula
- First 10 kg: 100 mL/kg/24h (4 mL/kg/h)
- 11–20 kg: 50 mL/kg/24h for each kg above 10
- Over 20 kg: 20 mL/kg/24h for each kg above 20
- Add deficit replacement for pre-op fluid losses
- Add ongoing losses: drain output, stoma, NG aspirates
Fluid Safety
!Hypotonic fluids (0.18% NaCl, 0.45% NaCl) risk hyponatraemia and cerebral oedema in children — now largely avoided
- Use 0.9% NaCl + 5% dextrose as standard post-op fluid in children
- Monitor Na⁺ 6–12 hourly if on IV fluids
- Neonates: consider glucose needs — 10% dextrose maintenance
- Document fluid balance every shift — include all losses
Wound Care, Feeding & Discharge
Wound Care
- Waterproof dressings for groin/abdominal wounds near nappy
- Barrier cream around wound if nappy rash risk
- Inspect wound Q shift — redness, swelling, discharge, dehiscence
- Tissue glue / steri-strips — do not scrub
- Dressings in situ for 5–7 days unless soiled
Early Feeding (ERAS)
- Early enteral feeding reduces infection, improves healing
- Most paediatric surgery: feeds within 4–6h post-op
- Start with clear fluids/breast milk, progress to normal diet
- Bowel surgery: early NG/nasojejunal feeds or TPN if not tolerating
- Document feed volumes and tolerance Q shift
Discharge Planning
- Pain managed on oral analgesia before discharge
- Tolerating adequate oral intake (≥75% feeds)
- No fever, wound clean and dry
- Parent education: wound care, red flags, medication doses
- Follow-up appointment booked
- GP/community nursing referral if complex wound or stoma
Parent Anxiety Management
- Acknowledge parental anxiety — normalise their concerns
- Clear, jargon-free explanations at each stage of care
- Involve parents in care: nappy changes, feeding, comfort holding
- Kangaroo care for neonates on NICU — reduces parent-infant separation anxiety
- Family-centred care model: parents as partners, not visitors
- Chaplaincy / social work referral for families with additional needs
- Bilingual staff or interpreter services in GCC hospitals for non-Arabic/English speakers
- WhatsApp communication group with ward team (where policy allows) — improves parent satisfaction in GCC context
GCC-Specific Clinical Context
Consanguinity & Congenital Anomalies
- GCC has among the world's highest rates of consanguineous marriage (20–50%)
- Increased risk of autosomal recessive conditions: metabolic disorders, structural anomalies
- Higher prevalence of Hirschsprung disease, congenital heart defects, tracheo-oesophageal anomalies
- Genetic counselling pre-pregnancy and post-diagnosis essential
- Expanded newborn screening programs in Saudi, UAE, Qatar
High Caesarean Section Rates
- GCC Caesarean rates among highest globally (>40% in some centres)
- Associated with increased gastroschisis incidence (gut microbiome disruption)
- Delayed gut function post-CS: meconium passage, feeding difficulties
- Higher rates of respiratory morbidity affecting post-op recovery
- Increased neonatal surgical referrals for gut dysmotility
Key Paediatric Surgical Centres — GCC
Saudi Arabia
- King Abdullah Specialist Children's Hospital (KASCH) — Riyadh, tertiary centre
- National Guard Health Affairs — paediatric surgery programme
- King Faisal Specialist Hospital — complex neonatal surgical cases
- SCFHS (Saudi Commission for Health Specialties) — nursing licensing body
- Air ambulance transport for neonatal surgical emergencies from rural regions
UAE / Qatar
- Sick Kids Dubai (DHCC) — joint venture with Toronto SickKids
- Al Jalila Children's Speciality Hospital — Abu Dhabi
- Zayed Military Hospital — paediatric surgery unit, Abu Dhabi
- Sidra Medicine — Doha, Qatar — quaternary paediatric centre
- DHA (Dubai Health Authority) and DOH (Dept of Health Abu Dhabi) — standards and licensing
✦Neonatal emergency transport: Limited paediatric surgical expertise outside major GCC cities means neonatal surgical emergencies (OA/TEF, gastroschisis, volvulus) may require air transport. Stabilise thoroughly before transfer — Replogle tube, IV access, warmth, parental consent documented.
Islamic Bioethics in Paediatric Surgery
- Life is a divine trust (amanah) — treatment of illness is both permitted and encouraged in Islam
- Periviable neonates (<24 weeks): surgery thresholds debated — Islamic scholars vary; family and religious consultation mandatory
- Do Not Resuscitate (DNR) orders require family agreement and often religious scholar consultation in GCC
- Transfusion of blood products: Islam permits in life-threatening situations (darura — necessity principle)
- Gender-concordant care: families may request female nurses for female patients — accommodate where possible
- Prayer times: accommodate family prayer during ward rounds and procedures where safe
- Ramadan: fluid and medication schedules may require adjustment — liaise with parents
DHA / DOH / SCFHS Exam Prep — Key Topics
High-Yield MCQ Topics
★Ramstedt pyloromyotomy: pre-op correction of hypokalaemic hypochloraemic metabolic alkalosis is the MOST commonly tested point
- Pyloric stenosis: correct electrolytes BEFORE surgery — not an emergency operation
- OA/TEF: Replogle tube + upright 30° positioning
- Intussusception: red currant jelly stool + air enema first-line
- Bilious vomiting in neonate = malrotation until proven otherwise
- FLACC score for non-verbal children; FACES for ≥3 years
- Hirschsprung: absent ganglion cells on rectal biopsy
- EMLA cream must be applied 1 hour before cannulation
- Fasting: clear fluids 1h, breast milk 3h, solids 6h
Nursing Management SBAs
- Gastroschisis: bowel in warm saline-soaked gauze immediately at delivery
- Hypospadias: never circumcise before repair — skin needed for urethroplasty
- DDH: Pavlik harness — skin checks Q8h, worn 23h/day
- Post-op fluid: use 0.9% NaCl + glucose — avoid hypotonic fluids
- NCA vs PCA: NCA for under 5 years / pre-verbal
- Paracetamol IV dose <10 kg: 7.5 mg/kg (not 15 mg/kg)
- Circumcision post-op: first void must be documented before discharge
- Talipes (CTEV): Ponseti casting — cast changes weekly
Quick Reference Summary
Neonatal Emergencies
- OA/TEF → Replogle tube
- Pyloric stenosis → correct alkalosis first
- Volvulus → urgent Ladd's procedure
- Gastroschisis → cover bowel now
- Hirschsprung → rectal biopsy
Post-op Priorities
- FLACC pain score (non-verbal)
- 0.9% NaCl + dextrose (not hypotonic)
- Urine output >1 mL/kg/h
- Early enteral feeding (ERAS)
- Temperature 36.5–37.5°C
GCC Context
- Consanguinity → congenital anomalies
- Air transport for neonatal emergencies
- Islamic bioethics for life-limiting decisions
- DHA/DOH/SCFHS licensing standards
- Sidra / Al Jalila / KASCH specialist centres
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