Friday, 11 October 2013

PHILO X DTH X DBL EGL X B WAY x H WAY

//////////////////////CICERO saith, that to Philosophise is no other thing than for a man to prepare himselfe to death: which is the reason that studie and contemplation doth in some sort withdraw our soule from us,


////////////////////double eagle is a gold coin of the United States with a denomination of $20.[1] (Its gold content of 0.9675 troy oz (30.0926 grams) was worth $20 at the 1849 official price of $20.67/oz.) The coins are made from a 90% gold (0.900 fine = 21.6 kt) and 10% copper alloy and have a total weight of 1.0750 troy ounces (33.4362 grams).




//////////////////ZEN 10


///////////////////ZEN ALTISM


///////////////////////ZEN IT


////////////////////////ZEN BLEEP



//////////////////////
To philosophize is nothing else than to prepare oneself for death."

  --  Michel Eyquem de Montaigne



/////////////////////THENCE CDS



///////////////////////////PROFESSNL FBT-PEDS, GCKING DMCD



////////////////////////////
Death is more universal than life; everyone dies but not everyone lives.
A. Sachs



I want to pay tribute to the word emptiness. It’s one of the most profound words in Buddhist literature, and it lies at the very heart of the Buddha’s teachings. The sutras often refer to emptiness as the Mother Prajnaparamita —the Mother of Transcendent Wisdom. The “mother” refers to the natural womblike quality of emptiness that is pregnant with possibility


“The mind that is not baffled is not employed.”


PANGONIC- You don’t see a lot of yellow, orange, and red in the arid climate of the Rockies—except in the autumn. In the autumn, the sunlight hits the leaves and they shimmer. I felt so overwhelmed by this beauty, I was almost agitated by it. I kept saying, “How beautiful it is, how beautiful, how beautiful . . .” Rinpoche turned to me and asked: “Is it too beautiful for you?” This got me thinking . . . even beauty can cause us pain when we objectify it. 


My friend Robin lost her son as he was just moving into young adulthood. She said that after his death she joined a support group with other parents who had also experienced the loss of a child. Witnessing their grief she was able to move from “I am suffering” to “there is suffering.” She wears a mustard seed in a locket around her neck to remind her of Gotami and her search.




Tao- Zen
Laying here doing nothing
Spring comes and
coconut trees grow by themselves.
Without one knowing
where they come from
or why.
Let go and realize
that everything gets done.

The Buddha called this reflection on suffering the First Noble Truth. We must know that the Buddha only called suffering a “truth” in order to acknowledge that living beings experience it. Suffering itself 
possesses no inherent reality. Essentially, like all “things,” suffering arises and falls away due to its dependence upon causes 




/////////////////////////In a word, there is suffering, named by the Buddha as the First Noble Truth of human existence. This is not the whole of life. There are also love and joy, 




laughing with friends, and the comfort of a warm sweater on a cold day. Yet each of us must face the truth of suffering some of the time, and many of us face it all of the time. 
and conditions. Therefore, it has no identifiable boundaries. It is just another experience that cannot be objectified, captured, or pinned down. What is suffering before we objectify it? That’s a good question. 1. The first teaching the Buddha gave immediately after his enlightenment. The four truths are the truth of suffering, the truth of the causes of suffering, the truth of 
the cessation of suffering, and the truth of the path

Sanskrit, स्मृत्युपस्थान (smṛty-upasthāna). Pali, सतिपट्ठान (satipaṭṭhāna). OR MINDFULNESS








Image may contain: possible text that says 'I opened two gifts this morning. They were my eyes.'

Wednesday, 17 July 2013

THE SHY QUIET TYPE X B X MIFU

///////////////////Jerome Kagan suggested that about 10-15 per cent of infants are ‘born shy’. Being easily fearful and less socially responsive, they reacted to mildly stressful situations with a quicker heartbeat and higher blood cortisol levels.



//////////////////AEON...........Higher primates are social creatures, hard-wired to want to meet and mate; but there might also be some value in their being cautious and risk-avoiding, traits that might over-evolve into excessive timidity. Neither Kagan nor Suomi suggest that shyness is fixed at birth. They see it as a case study in the rich interplay between nature and nurture. Similarly, for Antonio Damasio, professor of neuroscience at the University of Southern California, shyness is a ‘secondary emotion’. Unlike primary emotions such as anger, fear and disgust — where there is a large biological and universally felt component — shyness is ‘tuned by experience’, leaving it open to a huge amount of cultural conditioning, historical variation and definitional ambiguity.




/////////////////////.............bodily functions and aggressive language and behaviour were rendered increasingly invisible in polite society, thanks to what the late sociologist Norbert Elias called the ‘civilising process’ that took place in the Western world from the 16th century onwards.



////////////////////////Shyness is something different: a longing for connection with other people which is foiled by fear and awkwardness


////////////////////fluctuation of feelings between a sort of misguided superiority and irrational inferiority.



/////////////////// science, technology, engineering or math (STEM)




///////////////////////////,,,,,,,,,,,Realize that triggers are handed down through generations. You can deactivate your buttons by recognizing that this strong sensitivity that you carry was really passed down to you through the generations and is not as personal as you thought it was. Often, something was your mother’s hot button because it was her mother’s hot button, and so on. As you detach from your triggers, they will become less of an issue for you and as a result, less of one for your children. You will all be able to put the issue of "sensitivity" to certain hot buttons into perspective, and your whole family will benefit.





///////////////////////anti-anginal nicorandil induced perianal ulceration




////////////////////////////////ONE FLEW OVER THE CUCKOOS NEST= Brooks retired as hospital superintendent in 1981, but remained active in mental health issues until his death. To help “decriminalise mental illness,” he founded the Dorothea Dix think tank. His work is honoured by the Oregon State Hospital Museum for Mental Health.5
Brooks’s wife of 65 years, Ulista Brooks, died in 2006. He leaves three daughters, five grandchildren, and two great grandchildren.



/////////////////////////// Infants required less time to reach the feeding volume end point if they were given ``trophic`` enteral feedings when they received indomethacin or ibuprofen treatments



///////////////////There was a small increase in the incidence of mental disorders in children born after ovulation induction/intrauterine insemination. Children born after in vitro fertilisation/intracytoplasmic sperm injection were found to have overall risk comparable with children conceived spontaneously.



///////////////////////////MWAH


/////////////////////Commercial aircraft are pressurised to –2438m (8000ft) above sea level that equates breathing 15% oxygen at sea level


/////////////////////////////////////AIRCRASH RISK MAX 3 MIN AFTER TAKEOFF AND 8 MIN BEFORE LANDING



//////////////////////////////////BACK AISLE SEAT STATS SAFEST


///////////////////////////////////// monoamine oxidase A and B (MAO A/B), which sit next to each other in our genetic code as well as on that of mice. Prior research has found an association between deficiencies of these enzymes in humans and developmental disabilities along the autism spectrum such as clinical perseverance – the inability to change or modulate actions along with social context.

MAOA, MAOB ABSENT=FEAR


////////////////////////////// three magic words in relationships are communication, communication, communication



/////////////////////B  AVOID UNSKILFUL MENTAL QLITIES 
B DTHING

DHAMMAPADA XVIII : Impurities 
You are now like a yellowed leaf. 
Already Yama ’ s minions stand near. 
You stand at the door to departure but have yet to provide for the journey. 
Make an island for yourself! 
Work quickly! Be wise! 
With impurities all blown away, unblemished, you ’ll reach the divine realm of the noble ones. 

You are now right at the end of your time. You are headed to Yama ’ s presence, with no place to rest along the way, but have yet to provide for the journey

...........Poignantly, much of our suffering is added to life. We add it when we worry needlessly, criticize ourselves to no good purpose, or replay the same conversation over and over again.


///////////As the Nobel Prize winner Eric Kandel put it: Brain cells have particular ways of processing information and communicating with one another.… …Electrical signaling represents the language of mind, the means whereby nerve cells…communicate with one another.… …All animals have some form of mental life that reflects the architecture of their nervous system.


/////////////Every sensation, every thought and desire, and every moment of awareness is being shaped by three pounds of tofu-like tissue inside your head. The stream of consciousness involves a stream of information in a stream of neural activity. The mind is a natural phenomenon that is grounded in life. Major causes of both suffering and its end are rooted in your own body



/////////////// In a saying from the work of the psychologist Donald Hebb, neurons that fire together wire together. This means that you can use your mind to change your brain to change your mind for the better.


//////////////Mental activity and neural activity thus affect each other. Causes flow both ways, from the mind into the brain…and from the brain into the mind. The mind and brain are two distinct aspects of a single, integrated system. As the interpersonal neurobiologist Dan Siegel summarizes it, the mind uses the brain to make the mind.


//////////////////MIFU After just three days of training, prefrontal regions behind the forehead exert more top-down control over the posterior (rearward) cingulate cortex (PCC). This matters because the PCC is a key part of the default mode network that is active when we’re lost in thought or caught up in “selfreferential processing” (for example, Why’d they look at me that way? What’s wrong with me? What should I say next time?). Consequently, greater control over the PCC means less habitual mind wandering and less preoccupation with oneself.


/////////Mindfulness-Based Stress Reduction (MBSR), develop greater top-down control over the amygdala.


/////////More experienced mindfulness meditators, typically with years of daily practice, have thicker layers of neural tissue in their prefrontal cortex, which supports their executive functions, such as planning and self-control. They also have more tissue in their insula, which is involved with selfawareness and empathy for the feelings of others. Their anterior (frontal) cingulate cortex is also strengthened. This is an important part of your brain that helps you pay attention and stay on track with your goals. And their corpus callosum—which connects the right and left hemispheres of the brain—also adds tissue, suggesting a greater integration of words and images, logic and intuition.



//////////////////experienced practitioners of Tibetan Buddhism— some who have already meditated for more than twenty thousand hours— demonstrate a remarkable calm before receiving a pain they know is coming, and unusually rapid recovery afterward. They also possess extraordinarily high levels of gamma-range brain-wave activity: the rapid, 25- to 100-times-a-second synchronization of large areas of cortical real estate associated with enhanced learning. Overall, there’s a gradual shift from deliberate self-regulation toward an increasingly natural sense of presence and ease during both meditation and daily life.


//////////////////Seven Steps of Awakening We’ll explore these ways of being in depth in the pages to come, but here you can get a sense of each one in a single meditation. For general information about how to approach experiential practices—including taking your time as we explore far-reaching and sometimes subtle subjects— please see this page in chapter 1, at the start of the Let Be, Let Go, Let In practice. 

For this meditation, I suggest you find a comfortable place where you’ll be undisturbed and have enough time, at least twenty minutes. If you don’t relate to the later steps, you can just come back to previous ones. 

THE MEDITATION Find a posture that is comfortable and alert. Be aware of your body, and let yourself be. As you focus on each theme in this meditation, you can let other things such as sounds or thoughts pass through awareness without pushing them away or following after them. Steadiness. Choose an object of attention such as the sensations of breathing or a word such as “peace,” and stay aware of it. For example, if it’s the breath, apply attention to the beginning of each inhalation and then sustain your attention to its full course, and do the same with each exhalation, breath after breath. Let your body relax… your heart opening…feeling more settled, calmer, and steadier…staying with the object of attention…Finding a stable sense of presence in the moment…awareness spacious and open…letting anything pass through it…as you rest in a stable centeredness. 

Lovingness. With an increasingly steadied mind, focus on warmhearted feelings as your object of attention. Be aware of people or pets you care about…Focus on feelings of compassion and kindness for them… staying simple, focusing on the feelings themselves…Be aware of beings who care about you, even if the relationship is imperfect, and focus on feelings of being cared about…feeling appreciated…liked…loved…If other thoughts and feelings arise, let them come and go as you focus on a simple sense of warmheartedness…As you breathe, there could be a sense of love flowing in and out through your chest and heart. Steadily warmhearted…resting in love…sinking into love as it sinks into you. 

Fullness. Present with an open heart, focus on the sense of enoughness in the moment as it is…enough air to breathe…simply living, even if there is also pain or worry…Let yourself feel as safe as you can…safe enough in this moment…letting go of any anxiety…any irritation… finding a growing sense of peace. Also find gratitude for what you’ve been given…focusing on simple feelings of gladness and other positive emotions…letting go of any disappointment or frustration…any sense of stress or drivenness falling away…resting in a growing sense of contentment…Then touching again some feelings of warmheartedness…lovingness flowing in and out…letting any hurts ease and release, perhaps as you exhale…letting any resentments ease and release…any clinging to others falling away…resting in a growing sense of love…Take a little longer to rest in a general sense of fullness…a sense of peace and contentment and love. 

Wholeness. Resting at ease in fullness, be aware of the sensations of breathing in the left side of your chest…the right side…and left and right together…being aware of the sensations in your chest as a whole…many sensations as a single experience…Gradually widen awareness of breathing to include your stomach and back…head and hips…arms and legs included…being aware of your whole body as a single field of experience…abiding as a whole body breathing…While remaining aware of the whole body, include sounds in awareness… hearing and breathing together. Then include seeing…feelings…and anything else in awareness…Accepting all that you’re experiencing… opening to your whole being…accepting all the parts of yourself…all the parts of you as a single whole…widening further to include awareness…all of you as a whole…abiding undivided. 

Nowness. As you abide as a whole, stay in the present…the sensations of each moment of breathing continually changing…staying present while letting go…remaining alert, experiences changing, things happening…with no need to follow them…no need to figure them out… simply being…now…finding a comfort in the present…a sense of going on being even as there is continual changing…Be aware of the continual arising of the next moment…Be at ease, you’re all right…here in the present as it changes…receiving this moment…receiving now… resting at the front edge of now…and now. 

Allness. Abiding now as a whole…breathing air flowing in and flowing out…inhaling oxygen from green growing things…exhaling carbon dioxide to them…each breath receiving and giving…what you’re receiving becoming a part of you, what you’re giving becoming part of other things…Letting these knowings become feelings of relatedness… of inter-being…with plants…and animals…and people…and with air and water…and mountains and all of this earth. All this flowing into you and you flowing out into it. Know you are connected with the moon and sun and all of space, all the stars everywhere…that what is happening now in the mind and body is related to everything else… every thought and thing is a wave in the ocean of allness. Let edges soften between you and anything else…feel a sense of the allness of everything…all experiences are passing waves in allness…allness enduring…so peaceful…only allness. 

Timelessness. Abide…present…opening to intuition of what might be always unconditioned…not yet formed…always just before this moment…As ideas about this appear, let them go…settle back into a wordless sense of what might be not yet conditioned…distinct, fundamentally, from all conditioned mind and matter. An intuition, an intimation, perhaps a sense of possibility…spaciousness…stillness… abiding at the meeting of conditioned and unconditioned…what is conditioned is continually changing, what is unconditioned is not arising and passing away, thus eternal and timeless…Let go of thinking, not trying to make anything happen…for the time being…time passing in timelessness. When it feels right, come into a grounded sense of this moment…in this body…in this place…perhaps moving your feet and hands…eyes opening…perhaps breathing more fully. Touch again some feelings of fullness…warmheartedness…living from them. You are here, breathing and all right…being at peace. 


/////////////////Flowers in springtime, moon in autumn, cool wind in summer, snow in winter. If you don’t make anything in your mind, for you it is a good season. WUMEN HUIKAI


////////////////////Problem solving and rumination usually involve inner speech that draws on regions in the temporal lobes on the left side of your brain if you’re righthanded.



//////////////////You are the sky. Everything else— It’s just the weather. PEMA CHÖDRÖN



////////////////THE FIVE HINDRANCES Sensual desire: This hindrance is the stressful pursuit of lasting pleasure in passing experiences. (It can also be approached as the stressful resisting of pain; for simplicity, I’ll focus on grasping after pleasure.) Ill will: This is the will for ill: a motivation to hurt and harm. It includes hostility, bitterness, and destructive anger. Fatigue and laziness: This is heaviness of body and dullness of mind. There could be a sense of weariness, even depression, and little motivation for practice. Restlessness, worry, remorse: This is mental and physical agitation. There’s an inability to settle down, and one preoccupation or another has invaded the mind. Doubt: This is not healthy skepticism but a corrosive mistrust of what you know or what could be reasonably believed. There could be a lack of conviction, an overthinking, a “paralysis by analysis.” This is a powerful hindrance, since anything can be doubted.



/////////////////////Tell me, what is it you plan to do with your one wild and precious life? MARY OLIVER


////////////////////What can anyone give you greater than now, starting here, right in this room, when you turn around? WILLIAM STAFFORD



///////////////////Nearly 14 billion years ago, the big bang produced a universe with four dimensions—three of space and one of time—and all of them have been expanding ever since (the emphases are his): The Big Bang is an explosion of 4D space-time. Just as space is being generated by [this] expansion, so time is being created.… Every moment, the universe gets a little bigger, and there is a little more time, and it is this leading edge of time that we refer to as now.… …By the flow of time, we mean the continual addition of new moments, moments that give us the sense that time moves forward, in the continual creation of new nows.



////////////////////////Pali Canon that “deconstructs” the flow of experience into five parts: 

1. forms: sights, sounds, tastes, touches, smells; basic sensory processes 

2. hedonic tones: the quality of pleasant, unpleasant, relational, or neutral 


3. perceptions: categorizing, labeling; identifying what something is 4. formations: a traditional term for all the other elements of experience, including thoughts, emotions, desires, images, and memories; expressions of temperament and personality; planning and choosing; and sense of self 5. awareness: a kind of field (or space) in which experiences occur


//////////////////All conditioned things are impermanent.” Seeing this with insight, one becomes disenchanted with suffering. DHAMMAPADA 277



////////////////////There is no past. There is no future. You are completely supported. ROSHI HOGEN BAYS



//////////////////////In truth we are always present. We only imagine ourselves to be in one place or another. HOWARD COHN



//////////////////////Deep insight into the nature of all experiences can free us from holding on to them, and thus free us from the suffering this clinging causes.



////////////////////In the deepest forms of insight, we see that things change so quickly that we can’t hold on to anything, and eventually the mind lets go of clinging. Letting go brings equanimity. The greater the letting go, the deeper the equanimity… In Buddhist practice, we work to expand the range of life experiences in which we are free. GIL FRONSDAL


//////////////////MDGS CRSS X DTR CRSS X NO RUMINATION X BNCABOD LINE



//////////////////////

Friday, 12 July 2013

INFANTILE COLIC CMJ

Differential diagnosis of colic symptoms in infants

Infection
Meningitis, urinary tract infection, otitis media
Gastrointestinal
Constipation, cow’s milk protein allergy, gastro-oesophageal reflux disease, inguinal hernia, intussusception, anal fissure
Metabolic
Hypoglycaemia, inborn errors of metabolism
Neurological
Hydrocephalus
Trauma
Non-accidental injury, accidental trauma




//////////////////////////////////////

Red flags signs and symptoms

Signs
  • Irritability, tachycardia, pallor, mottling, poor perfusion
  • Petechiae, bruising, tachypnoea, cyanosis, nasal flaring
  • Hypotonia, meningism, full fontanelle
  • Weight <4th centile for age (or decreasing on the centile charts)
  • Head circumference >95th centile (or increasing on the centile charts)
Symptoms
  • Bilious or projectile vomiting, bloody stool
  • Fever, lethargy, poor feeding
  • Perinatal risk factors for sepsis (premature rupture of membranes, maternal fever or infection, group B streptococcus)




    /////////////////////////////////Simethicone (Infacol), which reduces intraluminal gas and is readily available over the counter, has been studied in two randomised controlled trials. No difference in reducing colic episodes was shown compared with placebo


    /////////////////////////H DOG AS YAMA

////////////////////////////////SAT CHID ANANDA - EXISTENCE KNOWLEDGE BLISS





///////////////////////////////2020



FEVER NICE NEW 2013

//////////////////When a child has been given antipyretics, do not rely on a decrease or lack of decrease in temperature at 1–2 hours to differentiate between serious and non-serious illness. Nevertheless, in order to detect possible clinical deterioration, all children in hospital with 'amber' or 'red' features should still be reassessed after 1–2 hours. [new 2013]




////////////////////////////Consider using either paracetamol or ibuprofen in children with fever who appear distressed. [new 2013]



//////////////////////////////1.6.3.2
Do not use antipyretic agents with the sole aim of reducing body temperature in children with fever. [new 2013]




//////////////////////////////////1.6.3.3
When using paracetamol or ibuprofen in children with fever:
  • continue only as long as the child appears distressed
  • consider changing to the other agent if the child's distress is not alleviated
  • do not give both agents simultaneously
  • only consider alternating these agents if the distress persists or recurs before the next dose is due. [new 2013]












Children with 'green' features and none of the 'amber' or 'red' features can be cared for at home with appropriate advice for parents and carers, including advice on when to seek further attention from the healthcare services (seesection 1.7). [2007, amended 2013]




///////////////////////GP=Children with 'green' features and none of the 'amber' or 'red' features can be cared for at home with appropriate advice for parents and carers, including advice on when to seek further attention from the healthcare services (seesection 1.7). [2007, amended 2013]



/////////////////////////When parenteral antibiotics are indicated for infants younger than 3 months of age, a third-generation cephalosporin (for example cefotaxime or ceftriaxone) should be given plus an antibiotic active against listeria (for example, ampicillin or amoxicillin). [2007]



////////////////////////////>3MO OLDS-Perform the following investigations in children with fever without apparent source who present to paediatric specialists with 1 or more 'red' features:
  • full blood count
  • blood culture
  • C-reactive protein
  • urine testing for urinary tract infection[6][2013]






    //////////////////////////////





Give parenteral antibiotics to:
  • infants younger than 1 month with fever
  • all infants aged 1–3 months with fever who appear unwell
  • infants aged 1–3 months with WBC less than 5 × 109/litre or greater than 15 × 109/litre. [2007, amended 2013]



    ///////////////////////////////



Perform lumbar puncture in the following children with fever (unless contraindicated):
  • infants younger than 1 month
  • all infants aged 1–3 months who appear unwell
  • infants aged 1–3 months with a white blood cell count (WBC) less than 5 × 109/litre or greater than 15 × 109/litre. [2007, amended 2013]










  • Recognise that children with tachycardia are in at least an intermediate-risk group for serious illness. Use the Advanced Paediatric Life Support (APLS)[1] criteria below to define tachycardia: [new 2013]
Age
Heart rate (bpm)
<12 months
>160
12–24 months
>150
2–5 years
>140

//////////////////////////

Management by the paediatric specialist

  • Perform the following investigations in infants younger than 3 months with fever:
    • full blood count
    • blood culture
    • C-reactive protein
    • urine testing for urinary tract infection[2]
    • chest X-ray only if respiratory signs are present
    • stool culture, if diarrhoea is present. [2013]




      //////////////////////////////

Antipyretic interventions

      • Antipyretic agents do not prevent febrile convulsions and should not be used specifically for this purpose. [2007]
      • When using paracetamol or ibuprofen in children with fever;
        • continue only as long as the child appears distressed
        • consider changing to the other agent if the child's distress is not alleviated
        • do not give both agents simultaneously
        • only consider alternating these agents if the distress persists or recurs before the next dose is due. [new 2013]




          ////////////////////////////TACHY >140, CRT >3 S



          ///////////////////////////
          Kawasaki disease
          Fever for more than 5 days and at least 4 of the following:
          • bilateral conjunctival injection
          • change in mucous membranes
          • change in the extremities
          • polymorphous rash
          • cervical lymphadenopathy




        ///////////////////////When assessing children with learning disabilities, take the individual child's learning disability into account when interpreting the traffic light table. [new 2013]




        ///////////////////////////Recognise that children with any of the following symptoms or signs are in a high-risk group for serious illness:
        • pale/mottled/ashen/blue skin, lips or tongue
        • no response to social cues[3]
        • appearing ill to a healthcare professional
        • does not wake or if roused does not stay awake
        • weak, high-pitched or continuous cry
        • grunting
        • respiratory rate greater than 60 breaths per minute
        • moderate or severe chest indrawing
        • reduced skin turgor
        • bulging fontanelle. [new 2013]




          /////////////////////////////////Recognise that children with any of the following symptoms or signs are in at least an intermediate-risk group for serious illness:
          • pallor of skin, lips or tongue reported by parent or carer
          • not responding normally to social cues[3]
          • no smile
          • wakes only with prolonged stimulation
          • decreased activity
          • nasal flaring
          • dry mucous membranes
          • poor feeding in infants
          • reduced urine output
          • rigors. [new 2013]





            ////////////////////////////Recognise that children who have all of the following features, and none of the high- or intermediate-risk features, are in a low-risk group for serious illness:
            • normal colour of skin, lips and tongue
            • responds normally to social cues[3]
            • content/smiles
            • stays awake or awakens quickly
            • strong normal cry or not crying
            • normal skin and eyes
            • moist mucous membranes. [new 2013]





              ////////////////////////////Recognise that a capillary refill time of 3 seconds or longer is an intermediate-risk group marker for serious illness ('amber' sign). [2013]



              /////////////////////////In children older than 6 months do not use height of body temperature alone to identify those with serious illness. [2013]




              ////////////////////////Recognise that children younger than 3 months with a temperature of 38°C or higher are in a high-risk group for serious illness. [2013]




              /////////////////////Recognise that children aged 3–6 months with a temperature of 39°C or higher are in at least an intermediate-risk group for serious illness. [new 2013]




              ////////////////////

              Do not use duration of fever to predict the likelihood of serious illness. However, children with a fever lasting more than 5 days should be assessed for Kawasaki disease (see recommendation 1.2.3.10). [new 2013]




              ////////////////////////Consider bacterial meningitis in a child with fever and any of the following features[5]:
              • neck stiffness
              • bulging fontanelle
              • decreased level of consciousness
              • convulsive status epilepticus. [2007, amended 2013]




                ////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////Consider urinary tract infection in any child younger than 3 months with fever[6].[2007]



                ///////////////Consider urinary tract infection in a child aged 3 months or older with fever and 1 or more of the following[6]:
                • vomiting
                • poor feeding
                • lethargy
                • irritability
                • abdominal pain or tenderness
              • urinary frequency or dysuria. [new 2013]


                ////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////[new 2013]
                Children with fever and any of the symptoms or signs in the red column should be recognised as being at high risk.

              • 1.1.2.2In children aged 4 weeks to 5 years, measure body temperature by one of the following methods:
                • electronic thermometer in the axilla
                • chemical dot thermometer in the axilla
                • infra-red tympanic thermometer. [2007]
                1.1.2.3Healthcare professionals who routinely use disposable chemical dot thermometers should consider using an alternative type of thermometer when multiple temperature measurements are required. [2007]
                1.1.2.4Forehead chemical thermometers are unreliable and should not be used by healthcare professionals. [2007]

              • 1.1.3.1Reported parental perception of a fever should be considered valid and taken seriously by healthcare professionals. [2007]

1.2 Clinical assessment of children with fever

              • 1.2.1.1First, healthcare professionals should identify any immediately life-threatening features, including compromise of the airway, breathing or circulation, and decreased level of consciousness. [2007]

              • 1.2.2.1Assess children with feverish illness for the presence or absence of symptoms and signs that can be used to predict the risk of serious illness using the traffic light system (see table 1). [2013]
                1.2.2.2When assessing children with learning disabilities, take the individual child's learning disability into account when interpreting the traffic light table. [new 2013]
                1.2.2.3Recognise that children with any of the following symptoms or signs are in a high-risk group for serious illness:
                • pale/mottled/ashen/blue skin, lips or tongue
                • no response to social cues[3]
                • appearing ill to a healthcare professional
                • does not wake or if roused does not stay awake
                • weak, high-pitched or continuous cry
                • grunting
                • respiratory rate greater than 60 breaths per minute
                • moderate or severe chest indrawing
                • reduced skin turgor
                • bulging fontanelle. [new 2013]
                1.2.2.4Recognise that children with any of the following symptoms or signs are in at least an intermediate-risk group for serious illness:
                • pallor of skin, lips or tongue reported by parent or carer
                • not responding normally to social cues[3]
                • no smile
                • wakes only with prolonged stimulation
                • decreased activity
                • nasal flaring
                • dry mucous membranes
                • poor feeding in infants
                • reduced urine output
                • rigors. [new 2013]
                1.2.2.5Recognise that children who have all of the following features, and none of the high- or intermediate-risk features, are in a low-risk group for serious illness:
                • normal colour of skin, lips and tongue
                • responds normally to social cues[3]
                • content/smiles
                • stays awake or awakens quickly
                • strong normal cry or not crying
                • normal skin and eyes
                • moist mucous membranes. [new 2013]
                1.2.2.6Measure and record temperature, heart rate, respiratory rate and capillary refill time as part of the routine assessment of a child with fever. [2007]
                1.2.2.7Recognise that a capillary refill time of 3 seconds or longer is an intermediate-risk group marker for serious illness ('amber' sign). [2013]
                1.2.2.8Measure the blood pressure of children with fever if the heart rate or capillary refill time is abnormal and the facilities to measure blood pressure are available.[2007]
                1.2.2.9In children older than 6 months do not use height of body temperature alone to identify those with serious illness. [2013]
                1.2.2.10Recognise that children younger than 3 months with a temperature of 38°C or higher are in a high-risk group for serious illness. [2013]
                1.2.2.11Recognise that children aged 3–6 months with a temperature of 39°C or higher are in at least an intermediate-risk group for serious illness. [new 2013]
                1.2.2.12Do not use duration of fever to predict the likelihood of serious illness. However, children with a fever lasting more than 5 days should be assessed for Kawasaki disease (see recommendation 1.2.3.10). [new 2013]
                1.2.2.13Recognise that children with tachycardia are in at least an intermediate-risk group for serious illness. Use the Advanced Paediatric Life Support (APLS)[4] criteria below to define tachycardia: [new 2013]
                Age
                Heart rate (bpm)
                <12 months
                >160
                12–24 months
                >150
                2–5 years
                >140
                1.2.2.14Assess children with fever for signs of dehydration. Look for:
                • prolonged capillary refill time
                • abnormal skin turgor
                • abnormal respiratory pattern
                • weak pulse
                • cool extremities. [2007]

              • 1.2.3.1Look for a source of fever and check for the presence of symptoms and signs that are associated with specific diseases (see table 2). [2007]
                1.2.3.2Consider meningococcal disease in any child with fever and a non-blanching rash, particularly if any of the following features are present[5]:
                • an ill-looking child
                • lesions larger than 2 mm in diameter (purpura)
                • a capillary refill time of 3 seconds or longer
                • neck stiffness. [2007]
                1.2.3.3Consider bacterial meningitis in a child with fever and any of the following features[5]:
                • neck stiffness
                • bulging fontanelle
                • decreased level of consciousness
                • convulsive status epilepticus. [2007, amended 2013]
                1.2.3.4Be aware that classic signs of meningitis (neck stiffness, bulging fontanelle, high-pitched cry) are often absent in infants with bacterial meningitis[5][2007]
                1.2.3.5Consider herpes simplex encephalitis in children with fever and any of the following features:
                • focal neurological signs
                • focal seizures
                • decreased level of consciousness. [2007]
                1.2.3.6Consider pneumonia in children with fever and any of the following signs:
                • tachypnoea (respiratory rate greater than 60 breaths per minute, age 0–5 months; greater than 50 breaths per minute, age 6–12 months; greater than 40 breaths per minute, age older than 12 months)
                • crackles in the chest
                • nasal flaring
                • chest indrawing
                • cyanosis
                • oxygen saturation of 95% or less when breathing air. [2007]
                1.2.3.7Consider urinary tract infection in any child younger than 3 months with fever[6].[2007]
                1.2.3.8Consider urinary tract infection in a child aged 3 months or older with fever and 1 or more of the following[6]:
                • vomiting
                • poor feeding
                • lethargy
                • irritability
                • abdominal pain or tenderness
                • urinary frequency or dysuria. [new 2013]
                1.2.3.9Consider septic arthritis/osteomyelitis in children with fever and any of the following signs:
                • swelling of a limb or joint
                • not using an extremity
                • non-weight bearing. [2007]
                1.2.3.10Consider Kawasaki disease in children with fever that has lasted longer than 5 days and who have 4 of the following 5 features:
                • bilateral conjunctival injection
                • change in mucous membranes in the upper respiratory tract (for example, injected pharynx, dry cracked lips or strawberry tongue)
                • change in the extremities (for example, oedema, erythema or desquamation)
                • polymorphous rash
                • cervical lymphadenopathy

                  Be aware that, in rare cases, incomplete/atypical Kawasaki disease may be diagnosed with fewer features. [2007]

              • 1.2.4.1When assessing a child with feverish illness, enquire about recent travel abroad and consider the possibility of imported infections according to the region visited.[2007]

              • [new 2013]
                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 columns are at low risk. The management of children with fever should be directed by the level of risk.
                This traffic light table should be used in conjunction with the recommendations in this guideline on investigations and initial management in children with fever.
                A colour version of this table is available.




                Green – low risk
                Amber – intermediate risk
                Red – high risk
                Colour
                (of skin, lips or tongue)
                • Normal colour
                • Pallor reported by parent/carer
                • Pale/mottled/ashen/blue
                Activity
                • Responds normally to social cues
                • Content/smiles
                • Stays awake or awakens quickly
                • Strong normal cry/not crying
                • Not responding normally to social cues
                • No smile
                • Wakes only with prolonged stimulation
                • Decreased activity
                • No response to social cues
                • Appears ill to a healthcare professional
                • Does not wake or if roused does not stay awake
                • Weak, high-pitched or continuous cry
                Respiratory
                • Nasal flaring
                • Tachypnoea: respiratory rate
                  • >50 breaths/minute, age 6–12 months;
                  • >40 breaths/minute, age >12 months
                • Oxygen saturation ≤95% in air
                • Crackles in the chest
                • Grunting
                • Tachypnoea: respiratory rate >60 breaths/minute
                • Moderate or severe chest indrawing
                Circulation and hydration
                • Normal skin and eyes
                • Moist mucous membranes
                • Tachycardia:
                  • >160 beats/minute, age <12 months
                  • >150 beats/minute, age 12–24 months
                  • >140 beats/minute, age 2–5 years
                • Capillary refill time ≥3 seconds
                • Dry mucous membranes
                • Poor feeding in infants
                • Reduced urine output
                • Reduced skin turgor
                Other
                • None of the amber or red symptoms or signs
                • Age 3–6 months, temperature ≥39°C
                • Fever for ≥5 days
                • Rigors
                • Swelling of a limb or joint
                • Non-weight bearing limb/not using an extremity
                • Age <3 months, temperature ≥38°C
                • Non-blanching rash
                • Bulging fontanelle
                • Neck stiffness
                • Status epilepticus
                • Focal neurological signs
                • Focal seizures