METABOLIC ALKALOSIS

Three basic mechanisms may produce metabolic alkalosis: excessive loss of hydrogen ion, as in prolonged
gastric aspiration or persistent vomiting associated with pyloric stenosis; increased addition of bicarbonate to the
extracellular fluid, which may result from excessive administration by the parenteral route or by oral intake, as in
the milk-alkali syndrome, or from increased renal reabsorption of bicarbonate caused by profound potassium
depletion, primary hyperaldosteronism, Cushing syndrome, Bartter syndrome, or excessive intake of liquorice;
and contraction of the extracellular fluid volume, which increases bicarbonate concentration in this fluid space
and increases bicarbonate reabsorption in the proximal tubule. Low chloride and alkalosis result from loss of HCl
from the stomach. Potassium is exchanged a the distal tubule for H
+
in alkalosis, producing an alkaline urine.
Patients may have cramps or feel weak and may have the signs of tetany if ionised calcium has been reduced by
the alkalosis.
Gas in Intestine
Normally, air can be demonstrated roentgenographically in the jejunum by 10-60 min, in the ileum by 2-3 hr, and
in the colon by 3 hr after birth. Absence of rectal gas at 24 hr is abnormal.
copper metabolism
Copper is essential for the production of red blood cells; transferrin, haemoglobin formation; absorption of iron,
activities of tyrosinase, catylase, urecase, cytochrome c-oxydase, 8-aminolevulinc acid, dehydrase, lisaloxydase.
It is absorbed with sulphur rich proteins, transported bound to alpha-g globulins through the plasmin; is present in
erythrocytes in labile form and a more stable haemocuprine; has its highest concentration in the liver and central
nervous system and is excreted mainly via the intestinal wall and the bile. Deranged metabolism is found in
Wilson's Disease (hepatoventricular degeneration and Menke's Syndrome).
Deficiency may cause refractory anaemia, osteoporosis, neutropenia, depigmentation, delayed bone age, bone
infractions, pseudoparalysis and ataxia with an increase in serum cholesterol. Excess copper can result in
cirrhosis, gastritis and haemolysis. The main dietary sources are liver, oysters, meats, fish, wholegrains, nuts and
legumes. Chromium is involved in glycaemia regulation and insulin metabolism, and deficiency may cause
diabetes in animals. It is found mainly in yeasts. Flourine deficiency results in a tendency to dental caries. Copper
deficiency is a favoured defence in non-accidental injury cases.


FEATURES OF CROHN'S DISEASE:
Rectal bleeding - sometimes
Abdominal mass - common
Rectal disease - occasional
Ileal involvement - common
Perianal disease - common
Strictures - common
Fistula - common
Skip lesions - common
Transmural involvement - common
Crypt abscesses - less common
Granulomas - common
Risk of colonic cancer - slightly increased
FEATURES OF ULCERATIVE COLITIS:
Rectal bleeding - common
Abdominal mass - not present
Rectal disease - nearly universal
Ileal involvement - none (backwash ileitis)
Perianal disease - unusual
Strictures - unusual
Fistula - unusual
Skip lesions - unusual
Trasmural involvement - unusual
Crypt abscesses - common
Granulomas - unusual
Risk of colonic cancer - greatly increased.

Pancreatic function can be measured by direct and indirect methods.
Direct stimulation with a Lund meal of corn oil, skimmed milk powder and dextrose or with secretrin plus
cholecystokinin is accompanied by measurement of tripsin, chymotripsin, lipase, amylase and bicarbonate in
aspirated secretions.
Indirect methods include: a) Qualitative - microscopy for fat globules. b) Quantitative - 3 day faecal fat, stool
chymotripsin or tripsin, and carbon labelled triglyceride breath tests. Bentyramide is a synthetic tripeptide or non-
invasive testing of pancreatic enzyme function. After oral ingestion it is split by chymotripsin releasing
paraminobenzoic acid which is excreted by the kidneys. This can be measured in a serum specimen obtained at
90 minutes.
1. Learning bite - recommended treatment in patients with ADHD
Patient Psychological Intervention First line medication
Pre-school child (3-5
years)
Parent training and education programme Only by tertiary care

Only if significant
impairment persists
School age children
and young people (5-
18 years) - moderate
ADHD
Parent training and education programme

Consider adding cognitive behavioural
therapy
Only if significant
impairment persists
School age children
and young people (5-
18 years) - severe
ADHD
Parent training and education programme

Consider adding cognitive behavioural
therapy
In conjunction with
psychological
interventions
Adults Comprehensive treatment programme
including psychological, behavioural, and
In conjunction with
psychological
occupational needs. Consider adding
cognitive behavioural therapy
interventions
Diagnosis and treatment of patients with ADHD should be made and started at secondary
care level.
1. a : Patients treated with atomoxetine should be closely observed for agitation,
irritability, suicidal thinking and self harming behaviour, and unusual changes
in behaviour
Patients treated with atomoxetine should be closely observed for agitation, irritability,
suicidal thinking and self harming behaviour, and unusual changes in behaviour,
particularly during the initial months of treatment, or after a change in dose. Parents
and/or carers should be warned about the potential for suicidal thinking and self
harming behaviour with atomoxetine and asked to report these to their healthcare
professionals.
b : Methylphenidate and dexamfetamine can cause abdominal pain but
atomoxetine does not
Methylphenidate, dexamfetamine, and atomoxetine can all cause abdominal pain.
c : Methylphenidate and dexamfetamine can cause tachycardia but atomoxetine
does not
Methylphenidate, dexamfetamine, and atomoxetine can all cause tachycardia.
For people taking methylphenidate, dexamfetamine, or atomoxetine who have
sustained resting tachycardia, arrhythmia, or systolic blood pressure greater than the
95th percentile (or a clinically significant increase) measured on two occasions should
have their dose reduced and be referred to a paediatrician or adult physician.
For people taking methylphenidate, dexamfetamine, and atomoxetine, routine blood
tests and ECGs are not recommended unless there is a clinical indication.
Learning bite
Methylphenidate, dexamfetamine, and atomoxetine can all cause hypertension.
In people with ADHD, heart rate and blood pressure should be monitored and
recorded on a centile chart before and after each dose change and routinely every
three months.
In young people and adults, sexual dysfunction (that is, erectile and ejaculatory
dysfunction) and dysmenorrhoea should be monitored as potential side effects of
atomoxetine.
5. a : Increase her dose to the maximum suggested in the BNF, and then reduce the
dose if she experiences side effects
This approach is not recommended, as it is more likely to result in the patient
experiencing side effects. The dose should be gradually increased to find a dose which
provides adequate treatment with minimal side effects.
b : Change her to atomoxetine. If methylphenidate was going to benefit her, she
should have had some response to the drug after two weeks
It is premature to change drugs after only two weeks on a minimal dose. You should
only do this if the patient is suffering side effects at this dose. Otherwise you should
wait until she is on the maximum tolerated dose and if this is ineffective then you
should change drugs.
c : Book weekly appointments and consider titrating the dose over four to six
weeks, using symptom relief and any side effects to select the most effective dose.
Explain to the father that the "forms" are a standard ADHD rating scale and he
needs to fill one in before each visit and after you change her dose. Ask him to
complete one when he gets home and to drop it back to the surgery as soon as
possible so you have a clear picture of her current condition
It is useful to have a standardised measurement of symptoms to gauge the effects of
different doses of the medication. You could also ask a teacher to provide feedback,
with consent. The aim should be to titrate the dose over four to six weeks, using
symptom relief and any side effects to judge the most effective dose. When a
satisfactory response has been achieved the patient can change to a modified release
formulation which will simplify the drug regimen.
d : Book monthly reviews and increase the dose of drug gradually over four to
six months, keeping a close watch for side effects such as anorexia, weight loss, or
palpitations
This is too timid an approach. The aim should be to titrate the dose over four to six
weeks, using symptom relief and any side effects to judge the most effective dose.
Learning bite - dosages of medications
Methylphenidate
In children and adolescents, doses should start at 5 mg, once or twice a day, and can
be increased to 0.7 mg/kg per dose up to three times a day (total daily dose of 2.1
mg/kg/day). The total maximum dose should be 90 mg/day.
In adults the dose should be started at 5 mg three times daily and can be increased up
to 100 mg/day.
Atomoxetine
In children and adolescents, the dose should start at about 0.5 mg/kg and be increased
after seven days to about 1.2 mg/kg/day, in one or two doses a day.
For young people weighing more than 70 kg and adults, the initial dose over a whole
day should be 40 mg. This should be increased after seven days up to a maintenance
dose of 80 mg/day.
In patients showing a poor response, the dose may be increased to 1.8 mg/kg/day
(total maximum dose of 120 mg/day).
A single daily dose can be given; two divided doses may be prescribed to minimise
side effects.
Dexamfetamine
In children and adolescents, the dose should start at about 5-10 mg once daily.
Treatment should be given in divided doses increasing to a maximum of 20 mg/day.
Older children have received a maximum of 40 mg/day.
In adults, initial treatment should begin with low doses (5 mg twice daily) and
increased according to response up to a maximum of 60 mg per day in divided doses
(usually two to four doses per day).
o Where higher doses are used the prescriber must closely monitor the child or young
person for side effects
At the time of publication, September 2009, methylphenidate, dexamfetamine, and
atomoxetine did not have UK marketing authorisation for use in adults with ADHD.
However, atomoxetine is licensed for adults with ADHD when the drug has been
started in childhood. Informed consent should be obtained and documented.
6. Depending on a range of factors such as the presence of coexisting conditions, side
effects, and patient preference, the person may be offered methylphenidate,
atomoxetine, or dexamfetamine.
The decision regarding which product to use should be based on the following:
o The presence of comorbid conditions, for example, tic disorders, Tourette's
syndrome, or epilepsy
o The different adverse effects of the drugs
o Specific problems regarding compliance identified for the individual child or
adolescent, for example problems created by the need to administer a mid-day
treatment dose at school
o The possibility of drug diversion occurring (where the medication is
forwarded on to others for non-prescription uses) and/or misuse
o The preferences of the child/adolescent and/or his or her parent or guardian.
When a decision has been made to treat children or young people with ADHD with
drugs, you should consider:
o Methylphenidate for ADHD without significant comorbidity
o Methylphenidate for ADHD, with comorbid disorder
o Methylphenidate or atomoxetine when tics, Tourette's syndrome, anxiety
disorder, stimulant misuse, or risk of stimulant diversion are present
o Atomoxetine if methylphenidate has been tried and has been ineffective at the
maximum tolerated dose, or the child or young person is intolerant to low or
moderate doses of methylphenidate.
When prescribing methylphenidate for children or young people, modified release
preparations should be considered for the following reasons:
o Convenience
o Improving adherence
o Reducing stigma (because the child or young person does not need to take
medication at school)
o Reducing problems that schools have in storing and administering controlled
drugs.
Alternatively, immediate release preparations may be considered if more flexible
dosing regimens are required, or during initial titration to determine correct dosing
levels.
When starting drug treatment children and young people should be monitored for side
effects. In particular, those treated with atomoxetine should be closely observed for
agitation, irritability, suicidal thinking, and self harming behaviour, and unusual
changes in behaviour, particularly during the initial months of treatment or after a
change in dose. Parents and/or carers should be warned about the potential for suicidal
thinking and self harming behaviour with atomoxetine and asked to report these to
their healthcare professionals. Parents or carers should also be warned about the
potential for liver damage in rare cases with atomoxetine (usually presenting as
abdominal pain, unexplained nausea, malaise, darkening of the urine, or jaundice).
If there is a choice of more than one appropriate drug, the product with the lowest cost
(taking into account the cost per dose and number of daily doses) should be
prescribed.
Antipsychotics are not recommended for the treatment of ADHD in children and
young people.
7. Learning bite - diet and ADHD
Food additives are popularly thought to be a common cause of hyperactive behaviour
in children, but usually there is no clear link. The elimination of artificial colouring
and additives from the diet is not recommended as a generally applicable treatment
for children and young people with ADHD
8. Learning bite - ADHD rating scales
During the titration phase of medication initiation in children and young people,
symptoms and side effects should be recorded at each dose change, by parents and
teachers, on standard scales (for example, Conners 10 item scale)
These standardised questionnaires have been developed as attempts to quantify
behaviour and make diagnoses and responses to treatment more objective. Two
commonly used tools are:
o Conners scale (1) - there are several versions of this test which use the DSM-IV
diagnostic criteria for ADHD to create a score
o Strengths and Difficulties questionnaire (2) - there are also different versions of this
test. It asks questions about 25 attributes, such as conduct problems, on five scales.
It is more general than the Conners scale, and does not just focus on features of
ADHD.
These scales can be useful as adjuncts to clinical judgment for making diagnoses and
for measuring behaviour before and after treatment. But they are not reliable enough
to use on their own.
Drug treatment should be offered as the first line treatment for:
o School age children and young people with severe ADHD
o Adults with ADHD of any severity, unless they prefer a psychological approach
Drug treatment for people with ADHD should always:
o Be started by an expert
o Form part of a treatment plan that includes psychological, behavioural, and
educational or occupational interventions
Following a decision to start drug treatment in people with ADHD, methylphenidate should
normally be tried first. Atomoxetine and dexamfetamine are effective alternatives. Other
drugs, such as bupropion, clonidine, modafinil, and imipramine, which are not licensed for
the management of ADHD, should only be prescribed by tertiary services
The diagnosis of ADHD should always be made in secondary care by a specialist psychiatrist,
paediatrician, or other appropriately qualified healthcare professional with training and
expertise in the diagnosis of ADHD
Clinical tips
Children and young people with behavioural problems suggestive of ADHD can be referred
by their school or primary care practitioner for parent training and education programmes
without a formal diagnosis of ADHD
Once a patient's effective dose of methylphenidate has been titrated, consider offering a
modified release preparation
Training and education programmes typically last for eight to 12 weeks. They should have a
clear end point, and patients should be discharged after they have completed the
programme
Symptoms of ADHD can overlap with symptoms of other related disorders, and ADHD
cannot be considered a categorical diagnosis. Therefore care in differential diagnosis is
needed. Many patients with ADHD have other comorbid conditions
o The causes of ADHD are not fully understood, and so the reasons for coincidence of
conditions are not known
o Common coexisting conditions in children with ADHD are disorders of mood,
conduct, learning, motor control and communication, and anxiety disorders
o In adults, common coexisting conditions include personality disorders, bipolar
disorder, obsessive-compulsive disorder, and substance misuse
The specialist ADHD teams should jointly develop age appropriate training programmes for
children, young people, and adults for the diagnosis and management of ADHD for other
professionals, who may come into contact with people with ADHD
Review patient knowledge, understanding, and concerns about medicines, and a patient's
view of their need for medicine at intervals agreed with the patient, because these may
change over time. Offer repeat information and review to patients

Table 1. Features of commonly used intravenous fluids in the UK
Solution Osmolarity
(mOsmol/l)
Sodium
content
(mequiv/l)
Osmolality
(compared with
plasma)
Tonicity

(with reference to
cell membrane)
Sodium chloride
0.9%
308 154 Iso-osmolar Isotonic
Sodium chloride
0.45%
154 77 Hypo-osmolar Hypotonic
Sodium chloride
0.45% with glucose
5%
432 75 Hyperosmolar Hypotonic
Glucose 5% 278 - Iso-osmolar Hypotonic
Glucose 10% 555 - Hyperosmolar Hypotonic
Sodium chloride
0.9% with glucose
5%
586 150 Hyperosmolar Isotonic
Sodium chloride
0.45% with glucose
2.5%
293 75 Iso-osmolar Hypotonic
Sodium chloride
0.18% with glucose
4%
284 31 Iso-osmolar Hypotonic
Hartmann's solution 278 131 Iso-osmolar Isotonic
4.5% Human
albumin solution
275 100-160 Iso-osmolar Isotonic





Maintenance
Calculate volumes of fluid infused according to body weight up to a maximum of 2500
ml/day in males and 2000 ml/day in females (see Table 2).
Table 2. Calculating maintenance volumes of fluid
Less than 10
kg
100 ml/kg/day or 4 ml/kg/hour
10-20 kg 1000 ml plus 50 ml/kg/day for each kg over 10 kg or 40 ml/hour plus 2 ml/kg/hr
for each kg over 10 kg
Over 20 kg 1500 ml plus 20 ml/kg/day for each kg over 20 kg or 60 ml/hour plus 1
ml/kg/hour for each kg over 20 kg

Children with the following risk factors should receive isotonic solutions:
Plasma sodium at the lower normal reference range; particularly if less than 135
mmol/l
Intravascular volume depletion
Hypotension
Central nervous system infection
Head injury
Bronchiolitis
Sepsis
Peri- and postoperative patients
Excessive gastric or diarrhoeal losses
Salt wasting syndromes
Chronic conditions such as diabetes, cystic fibrosis, or pituitary deficits
Those requiring replacement of ongoing losses.
Children found to have significant hypernatraemia with a plasma sodium greater than 160
mmol/l should also receive only isotonic solutions to reduce the risk of neurological injury
associated with a rapid fall in plasma sodium concentration.
Examples of isotonic solutions are:
Sodium chloride 0.9%
Sodium chloride 0.9% with glucose 5%
Hartmann's solution.

1. a : Full blood count
Infants younger than 3 months with fever should have a full blood count.
b : Blood culture
Infants younger than 3 months with fever should have blood cultures. You should
always try to take blood cultures before giving antibiotics.
c : C reactive protein
Infants younger than 3 months with fever should have a C reactive protein.
d : Urine testing
Infants younger than 3 months with fever should have urine testing for urinary tract
infection. You should consider urinary tract infection in any child younger than 3
months with fever.
e : Chest x ray
A chest x ray is only necessary if respiratory signs are present. Similarly stool cultures
are only necessary if diarrhoea is present.
Learning bite
You should perform a lumbar puncture on the following children (unless
contraindicated):
o Infants younger than 1 month
o All infants aged 1-3 months who appear unwell
o Infants aged 1-3 months with a white blood cell count less than 5 or greater than 15
x 10
9
/litre.
When indicated, you should perform the lumbar puncture without delay and,
whenever possible, before giving antibiotics. If you suspect meningitis you should not
delay giving antibiotics.
2. You should give parenteral antibiotics to:
o Infants younger than 1 month
o All infants aged 1-3 months who appear unwell
o Infants aged 1-3 months with white cell count less than 5 or greater than 15 x
10
9
/litre.
3. Children aged 3 months or older with fever without apparent source presenting to
paediatric specialists with one or more "red" features should have the above
investigations performed. You should also consider doing
o A chest x ray
o Electrolytes
o Blood gases.
4. You should give immediate parenteral antibiotics if children are:
o Shocked
o Unrousable
o Showing signs of meningococcal disease.
When parenteral antibiotics are indicated, you should give a third generation
cephalosporin (for example, cefotaxime or ceftriaxone), until culture results are
available.
Children with fever and symptoms and signs suggestive of herpes simplex
encephalitis should receive intravenous aciclovir.
You should give oxygen to children with fever who have signs of shock or oxygen
saturation of less than 92% when breathing air. Treatment with oxygen should also be
considered for children with a saturation greater than 92% if clinically indicated.
Table 1: Traffic light system for identifying risk of serious illness
Children with fever and any of the symptoms or signs in the red column should be recognised
as being at high risk. Similarly, children with fever and any of the symptoms or signs in the
amber column and none in the red column should be recognised as being at intermediate risk.
Children with symptoms and signs in the green column and none in the amber or red column
are at low risk. The management of children with fever should be directed by the level of
risk.
Green - low risk Amber - intermediate
risk
Red - high risk
Colour Normal colour of
skin, lips and tongue
Pallor reported by
parent/carer
Pale/mottled/ashen/blue
Activity Responds normally to
social cues
Content/smiles
Stays awake or
awakens quickly
Strong normal
cry/not crying
Not responding
normally to social cues
Wakes only with
prolonged stimulation
Decreased activity
No smile
No response to social cues
Appears ill to a healthcare
professional
Unable to rouse or if roused
does not stay awake
Weak, high pitched, or
continuous cry
Respiratory Nasal flaring
Tachypnoea:
RR >50
breaths/minute
age 6-12 months
RR >40 breaths
/minute
age >12 months
Oxygen saturation 95%
in air
Crackles
Grunting
Tachypnoea:
RR >60 breaths/minute
Moderate or severe chest
indrawing
Hydration Normal skin and eyes
Moist mucous
membranes
Dry mucous membrane
Poor feeding in infants
CRT 3 seconds
Reduced urine output
Reduced skin turgor
Other None of the amber or Fever for 5 days Age 0-3 months, temperature
red symptoms or
signs
38C
Age 3-6 months, temperature
39C
Swelling of a limb or
joint
Non-weight bearing/not
using an extremity
Non-blanching rash
Bulging fontanelle
Neck stiffness
Status epilepticus
Focal neurological signs
Focal seizures
A new lump >2 cm Bile stained vomiting

1. This boy is at intermediate risk of serious illness. He has one amber sign suggesting
intermediate risk - that is, he is not feeding that well. A single amber sign is sufficient
to put the child at intermediate risk. This child does not necessarily need to be
admitted to hospital. If you decide that a child does not need admission, but have not
reached a diagnosis, you should provide a safety net for parents if any "red" or
"amber" features are present. The safety net should be one or more of the following:
o Providing the parent or carer with verbal and written information on warning
symptoms and how to access further health care
o Arranging further follow up at a specified time and place
o Liaising with other healthcare professionals, including out of hours providers, to
ensure direct access for the child if further assessment is required.
Children with "green" features and none of the "amber" or "red" features can be
managed at home with appropriate advice for parents and carers, including advice as
to when to seek further attention.
c : High risk
This boy is at intermediate risk of serious illness.
Learning bite - admission to and discharge from hospital
In addition to the child's clinical condition, you should consider the following factors
when deciding whether to admit a child with fever:
o Social and family circumstances
o Other illnesses that affect the child or other family members
o Parental anxiety and instinct
o Contacts with other people who have serious infectious diseases
o Recent travel abroad
o When the parent's concern for their child's current illness has caused them to seek
healthcare advice repeatedly
o Where the family has experienced a previous serious illness or death due to feverish
illness
o When a feverish illness has no obvious cause, but the child remains ill for longer
than expected for a self limiting illness.
Detection of fever
In children aged 4 weeks to 5 years, you should measure body temperature by one of the
following methods:
Electronic thermometer in the axilla
Chemical dot thermometer in the axilla
Infrared tympanic thermometer.
In infants under the age of 4 weeks, you should measure temperature with an electronic
thermometer in the axilla
Management
Infants younger than 3 months with fever should be observed and have the following vital
signs measured and recorded:
Temperature
Heart rate
Respiratory rate
capillary refill time
Children with fever without apparent source presenting to hospital with one or more "red"
features should have the following investigations performed:
Full blood count
Blood culture
C reactive protein
Urine testing for urinary tract infection.
The following investigations should also be considered in children with "red" features, as
guided by the clinical assessment:
Lumbar puncture in children of all ages (if not contraindicated)
Chest x ray irrespective of body temperature and white blood cell count
Electrolytes
Blood gases.
You should not prescribe oral antibiotics if there is no apparent source of infection.
Table 2: Summary table for symptoms and signs suggestive of specific diseases
Diagnosis to be
considered
Symptoms and signs in conjunction with fever
Meningococcal
disease
Non-blanching rash, particularly with one or more of the following:
An ill looking child
Lesions larger than 2 mm in diameter (purpura)
A capillary refill time of 3 seconds
Neck stiffness.
Meningitis One or more of the following:
Neck stiffness
Bulging fontanelle
Decreased level of consciousness
Convulsive status epilepticus.
Herpes simplex
encephalitis
Herpes simplex encephalitis should be considered in children with fever
and any of the following features:
Focal neurological signs
Focal seizures
Decreased level of consciousness
Pneumonia You should consider pneumonia in children with fever and any of the
following signs:
Tachypnoea
o (RR > 60 breaths per minute Age 0-5 months,
o RR > 50 breaths per minute Age 6-12 months;
o RR > 40 breaths per minute Age >12 months)
Crackles
Nasal flaring
Chest indrawing
Cyanosis
Oxygen saturation 95% on air.
Urinary tract
infection
You should think of a urinary tract infection in a child aged 3 months and
older with fever and one or more of the following:
Vomiting
Poor feeding
Lethargy
Irritability
Abdominal pain or tenderness
Urinary frequency or dysuria
Offensive urine or haematuria.
Septic arthritis Septic arthritis/osteomyelitis should be considered in children with fever
and any of the following signs:
Swelling of a limb or joint
Not using an extremity
Non-weight bearing.
Kawasaki disease Fever for more than five days and at least four of the following:
Bilateral conjunctival injection
Change in mucous membranes (for example, injected pharynx, dry
cracked lips, or strawberry tongue)
Change in the extremities (for example, oedema, erythema, or
desquamation)
Polymorphous rash
Cervical lymphadenopathy.
Healthcare professionals should be aware that, in rare cases,
incomplete/atypical Kawasaki disease may be diagnosed with fewer
features.
Learning bite
Children aged 3 months or older with fever without apparent source presenting to hospital
who have one or more "amber" features should have the following investigations performed
unless deemed unnecessary by an experienced paediatrician:
Urine should be collected and tested for urinary tract infection
Blood tests: full blood count, C reactive protein and blood cultures
Lumbar puncture should be considered for children younger than 1 year
Chest x ray in a child with a fever greater than 39C and white cell count greater than 20 x
10
9
/l.

in children in the green group, they may want to do a urine test and then assess whether any other
tests need to be done. The children in the amber group in whom theres no specific diagnosis made,
one will want to do normally a urine test, a full blood count, a CRP, and, if the white count is over
20 000 in that group and temperature over 39, one would also want to do a chest x ray. In children
in the red group in whom theres no specific diagnosis, under the age of 3 months one would want
to do a full blood count, blood culture, CRP, and a urine test. And, if a child had respiratory signs, a
chest x ray, certainly under 1 month every child should get a lumbar puncture, between 1 and 3
months then one should do a lumbar puncture if a child seems to be unwell when they present, or if
they have a low white count or high white count.