ALLERGY and IMMUNOLOGY

IMMUNODEFICIENCY
10 Warning signs of Immunodeficiency
8 ear infections or more within a year
2 sinus infections within a year
2 months antibiotics with little effect
2 pneumonias within 1 year
failure gain weight; grow normally
Recurrent abscessess
Thrush in mouth or skin
IV antibiotics for infections
2 deep-seated infections
family history of primary immunodeficiency
General Screening of Immunity
CBC, differential, platelets
IgG,IgA,IgM,IgE levels
Baseline Antibody Titers
Phagocytic Defect
NBT test
Rebuck skin window
Chemotaxis
Bacterial assay
Complement Defect
CH50
C3
C4 assay
HIV Screening (ELISA)
Positive- Probable AIDS
Verify diagnosis by:
repeat ELISA HIV test
Western blot analysis
CD4 T cell count
Negative- Non-AIDS T cell defect
CMI skin test (PPD, Candida antigen, etc.)
CD4, CD8 assay ratio
Lymphocyte blastogenic assay
T cell enumeration
ANAPHYLAXIS
Criteria for rapid recognition of Anaphylaxis
1. Exposure to an allergen within 1 hour & 1 systemic sign
2. Urticaria or angioedema & 1 systemic sign
Systemic signs:
hypotension
bronchospasm or dyspnea
laryngeal/pharyngeal edema, stridor or dysphonia
increased gastrointestinal tract motility

-hypotension,peripheral vasodilation, increased vasopermeability,

urticaria, angioedema
-positive inotropic & chronotropic effects, bronchodilation, increase
cAMP
Epinephrine 1:1000 0.01 ml/kg SC/ IM (ped) or 0.3 to 0.5 ml (adult)
given q 20 mins prn
Px on blockers may be resistant to epinephrine so higher does may be
required or glucagon given
insect sting or injected drug: infiltrate 0.1 - 0.2 ml locally to retard
absorption of the residual allergen
tourniquet applied proximally if injection or sting is on an extremity
Immediate Therapy
Rapid ABCs of resuscitation
Epinephrine IV (1:100,000) = 0.01 mg/kg or continuous drip 0.1-0.2
g/kg/min titrated q 0.1 g/kg/min to max of 1.5 g/kg/min
Separate IV line no HCO3 infusion
Continuous monitoring of CVS status and O2
Rapid HX of triggering event, current medications, HX of asthma,
allergies and concomitant medical conditions
Subacute
H1 blocker Diphenhydramine 1-2 mg/kg PO,IM,IV
Chlorpheniramine 10-20 mg IV,IM
Corticosteroids Hydrocortisone 4-8 mg/kg/dose or methylprednisolone
1-2 mg/kg Iv q 6 h
2 agonist nebulization q 20 mins of continuous
Secondary
H2 blocker Ranitidine IV or PO 2-4 mg/kg/day q 8 h
Glucagon 0.1 mg/kg IV if refractory to initial TX
Observe at least 4 hours for biphasic anaphylaxis
Fluids Loss of up to 50% intravascular volume may occur resulting in
profound hypotension not responsive to epinephrine
Antihistamines are not appropriate monotherapy for the Tx of acute
anaphylaxis
Corticosteroids are used to prevent the biphasic response and to control
bronchospasm
Bronchodilators are useful adjuncts in TX esp in those with asthma

CARDIOLOGY
Heart Rate
Age
Awake
Mean
NB-3mos
85-205
140
3mos-2yrs
100-190
130
2-10yrs
60-140
80
>10yrs
60-100
75
Prob SVT (nQRS) >220 infants, >180children

Sleeping
80-160
75-160
60-90
50-90

Cardioversion/ Defibrillation: 0.5-1J/kg (VT); 2-4J/kg (VF/ Pulseless VT)

ECG

Patterns
Acute explosive onset within seconds to minutes of exposure to
triggering event
Biphasic followed by a reaction 3 to 8 hours after initial reaction (5-20%
of cases)
Protracted lasts 3 to 21 days from onset of acute reaction
Laboratory findings
Elevated plasma histamine
Elevated serum tryptase - longer half-life
Treatment
EPINEPHRINE IS THE DRUG OF CHOICE!
potent cathecholamine with both and adrenergic properties
Reverses all pathophysiologic features of anaphylaxis
Pedia Notes

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Normal Axis
Newborn
0- (+)180
1- 6 m0
(+)10- (+)125
6mo- 3yr
(+)10- (+)110
>3yr
0- (+)90
PR
0.12-0.20sec
QRS
0.08-0.12sec
ST
not >1mm in limb leads; not >2mm in precordial
QTc
0.44sec 3-4days; 0.45 <6mos; 0.44 children
Q
<0.04sec; <25% of QRS
<5mm in L precordial & aVF; 8mm in LII for <3yo
T
(+) in I, II & V6
>48hrs abn if >7mm in LL or 10mm in precordial
P
<2.5mm amp; <3yo 0.03-0.09sec; >3yo 0.05-0.1sec
Chamber Enlargements:
RAE
Steeple; Peaked P >3 mm in L2 & V1
LAE
Wide, notched, biphasic P >2.5 mm in L2 & V1
RVH
RVH in Newborn
SL1 12mm
Pure RV1 >10mm,
RV1 >25
qR in V1
upright T in V1 >3day
R in avR8mm
RVH in Children
RV1 >20, SV6 >7
qR in chest leads
upright T >3yo
RV110mm
T wave inversion in avF
R/S ratio in V1 >1
RsR in V1
RAD >3mos
LVH
SV1 >20, RV6 >25
Asymmetric T wave inversion inV5 & V6
SV1 + RV6 >50mm
Qwave >30mm in II, III, aVF, V5-6
CVH
Direct signs of RVH & LVH
LVH + RAD & tall R in V1
RVH + q 2 mm in V5 & V6, tall R in V6, & inverted T in V6
Large equiphasic QRS in V2- V4, R + S >60 mm- KatzWachtel phenomenon
QTc (corrected QT) - Bazetts Formula:
____QTa______
RR interval
where RR interval = # of small squares between R-R x 0.04 sec
First Degree AV Block
There must be P waves
There must be one P wave to each QRS complex
P waves have morphology and axis usual for the subject
QRS complex must have morphology and axis usual for the subject
P-R interval is constant
P-R interval is prolonged (i.e. >0.20 sec.)

Pedia Notes

Second degree AV block

Mobitz type 1- Wenkebach phenomenon
there must be P waves
there must be QRS complexes
P waves must have morphology and axis usual for the subject
Progressive prolongation of P-R interval with each succeeding beat
until there is a dropped beat

Second degree AV block

Mobitz type 2
there must be P waves & QRS complexes
P waves have morphology and axis usual for the subject
QRS complex must have morphology axis usual for the subject
P-R interval of conducted beats may be normal or long but fixed, then
there is a dropped beat

High Grade AV Block

Some P waves are followed by QRS complexes and some are not
Atrio-ventricular conduction ratio is 3:1 or higher
P-R interval of beats in which a QRS complex follows a P wave may
be normal or long but must be constant

Third degree AV block

Any form of atrial activity may be seen or there may be no atrial
activity
no consistent or meaningful relationship between atrial and ventricular
activity. Variable PR and RP intervals.
QRS may be normal in shape, duration and axis but more often are
abnormal and are of constant morphology
QRS rate is usually constant and lies within the range of 15-70
beats/min.

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CHEST XRAY ABNORMAL PATTERN

RAE AP: >1/3 of the right
RVE
AP: apex upturned / rounded
Lateral: obliteration of the retrosternal space; filled only normally.
Displacement of LV posteriorly. Behind shadow of IVC
LAE
AP: increased distance between the right wall of the left atrium and left
main stem bronchus (double density); 3.5cm for infants, 4.5cm
for children; Prominence of left atrial appendage or so called
disappearance of cardiac waistline; elevation of left main stem
bronchus.
Lateral: elevation of left main stem bronchus; discrete bulge in the
region of the left atrium which pushes the esophagus posteriorly
LVE AP: prominent left heart border and mid-left heart concavity with
apex displaced posteriorly and meets IVC at the diaphragm level
MYOCARIDAL INFARCTION IN CHILDREN
ECG Findings
New onset wide Q waves (>0.035 sec) seen within first few hours and
persistent over several years
ST-segment elevation (>2mm) seen within the first few hours
Diphasic T waves seen within first few days (beginning sharply
inverted) then normalizing over time
Prolonged QT interval (>0.44 sec) with accompanying abnormal Q
waves
Deep wide Q waves in Leads I, avL, or V6 contrast Q waves in II, III,
avF
Other criteria
Elevated creatinine kinase / MB although this is not specific for
detection of acute MI in children
Cardiac Troponin I is a more sensitive indicator of early myocardial
damage in children elevated within hours of cardiac injury, persists
for 4-7 days, specific for cardiac injury
CARDIOVASCULAR MEDICATIONS
Inotropes: agents that improve myocardial contractility and enhance
stroke volume
Pressors: agents that increase systemic vascular resistance and
increase blood pressure
Chronotropic: Increase heart rate
Lusotropic: improve relaxation during diastole and decrease EDP in
the ventricles
ALPHA-ADRENERGIC MEDICATIONS
Alpha1-adrenergic effects: Vascular smooth muscle contraction
Alpha2-adrenergic effects: Vascular smooth muscle relaxation--this is
a very mild effect only at low doses of an alpha-adrenergic agent like
epinephrine.
BETA-ADRENERGIC MEDICATIONS
Beta1-adrenergic effects:Direct cardiac effects: (a) Inotropy (improved
cardiac contractility) (b) Chronotropy (increased heart rate)
Beta2-adrenergic effects: (a) Vasodilation (b) Bronchodilation
CARDIAC MEDS VIA CONTINUOUS INFUSION
EPINEPHRINE
Both an alpha- and beta-adrenergic agent
Indications for its use as a continuous infusion are:
o low cardiac output state

beta effects will improve cardiac function

alpha effects may increase afterload and decrease cardiac output

septic shock - useful for both inotropy and vasoconstriction
Actions are dose dependent (mcg/kg/min):
o 0.02-0.08 = mostly beta1 and beta2 stimulation.

increased cardiac output

mild vasodilation
o 0.1-2.0 = mix of beta1 and alpha1

increase cardiac output

increase SVR = vasoconstriction
o > 2.0 = mostly alpha1

increase SVR, and may decrease CO by increasing afterload
Side effects include:
Anxiety, tremors,palpitations
Pedia Notes

Tachycardia and tachyarrhythmias

Increased myocardial oxygen requirements and potential to cause
ischemia
Decreased splanchnic and hepatic circulation (elevation of AST and
ALT)
Anti-Insulin effects: lactic acidosis, hyperglycemia
NOREPINEPHRINE
Employed primarily for its alpha agonist effect - increases SVR (and
B.P.) without significantly increasing C.O.
Used in cases of low SVR and hypotension such as profound warm
shock with a normal or high C.O. state
Infusion rates titrated between 0.05 to 1 mcg/kg/min
In general, norepinephrine differs from epinephrine in that at doses
used in clinical practice, the vasoconstriction outweighs any increase
in cardiac output.
o i.e. norepinephrine usually increases blood pressure and SVR, often
without increasing cardiac output.
Side Effects:
Similar to those of Epinephrine
Can compromise perfusion in extremities and may need to be
combined with a vasodilator e.g. Dobutamine or Nipride
More profound effect on sphlancnic circulation and myocardial
oxygen consumption
DOPAMINE
Intermediate product in the enzymatic pathway leading to the
production of norepinephrine; thus, it indirectly acts by releasing
norepinephrine.
Directly has alpha, beta and dopaminergic actions which are dosedependent.
Indications are based on the adrenergic actions desired.
Improve renal perfusion 2-5 mcg/kg/min
Improve C.O. in mild to moderate Cardiogenic or Distributive Shock 510mcg/kg/min
Post-resuscitation stabilization in patients with hypotension (in
conjuction with fluid therapy) 10-20mcg/kg/min
DOBUTAMINE
Synthetic catecholamine with inotropic effect (increases stroke
volume) and peripheral vasodilation (decreases afterload)
Positive chronotropic effect (increases HR)
Some lusotropic effect
Overall, improves Cardiac Output by above beta-agonist acitivity
o Major metabolite is 3-O-methyldobutamine, a potent inhibitor of alphaadrenoceptors.Therefore, vasodilation is possible secondary to this
metabolite.
Usual starting infusion rate is: 5 mcg/kg/min, with the dose being
titrated to effect up to 20 mcg/kg/min.
Used in low C.O. states and CHF e.g. myocarditis, cardiomyopathy,
myocardial infarction
If BP adequate, can be combined with afterload reducer (Nipride or
ACE inhibitor)
In combination with Epi/Norepi in profound shock states to improve
Cardiac Output and provide some peripheral vasodilatation
MILRINONE/AMRINONE
Belong to new class of agents Bipyridines
Non-receptor mediated activity based on selective inhibition of
Phosphodiesterase Type III enzyme resulting in cAMP accumulation in
myocardium
cAMP increases force of contraction and rate and extent of relaxation
of myocardium
Inotropic, vasodilator and lusotropic effect
AMRINONE
First generation agent - limited use now
Long half-life (4.4 hours) with potential for prolonged hypotension
after loading dose
Associated with thrombocytopenia
Dosage: Load with 0.75 mg/kg with infusion rate of 5-10 mcg/kg/min
Milrinone is preferred drug from this group
MILRINONE
Increases CO by improving contractility, decreased SVR, PVR (?),
lusotropic effect; decreased preload due to vasodilatation
Unique in beneficial effects on RV function
Half-life is 1-2 hours
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 Load with 50 mcg/kg over 30 mins followed by 0.3 to 0.75

mcg/kg/min
No increase in myocardial O2 requirement
VASODILATORS
Classified by site of action
Venodilators: reduce preload - Nitroglycerin
Arteriolar dilators: reduce afterload Minoxidil and Hydralazine
Combined: act on both arterial and venous beds and reduce both
pre- and afterload Sodium Nitroprusside (Nipride)
NITROPRUSSIDE
Vasodilator that acts directly on arterial and venous vascular
smooth muscle.
Indicated in hypertension and low cardiac output states with
increased SVR.
Also used in post-operative cardiac surgery to decrease afterload
on an injured heart.
Action is immediate; half-life is short; titratable action.
Toxicity is with cyanide, one of the metabolites of the breakdown of
nipride.
Severe, unexplained metabolic acidosis might suggest cyanide
toxicity.
Dose starts at 0.5 mcg/kg/min and titrate to 5 mcg/kg/min to desired
effect. May go higher (up to 10 mcg/kg/min) for short periods of
time.
NITROGLYCERIN
Direct vasodilator as well, but the major effect is as a venodilator
with lesser effect on arterioles.
Not as effective as nitroprusside in lowering blood pressure.
Another potential benefit is relaxation of the coronary arteries, thus
improving myocardial regional blood flow and myocardial oxygen
demand.
Used to improve myocardial perfusion following cardiac surgery
Dose ranges from 0.5 to 8 mcg/kg/min. Typical dose is 2
mcg/kg/min for 24 to 48 hours post-operatively
Methemoglobinemia is potential side effect
ISOPROTERENOL
Synthetic catecholamine
Non-specific beta agonist with minimal alpha-adrenergic effects.
Causes inotropy, chronotropy, and systemic and pulmonary
vasodilatation.
Indications: bradycardia, decreased cardiac output, bronchospasm
(bronchodilator).
No longer available in some markets
Occasionally used to maintain heart rate following heart
transplantation.
Dose starts at 0.01 mcg/kg/min and is increased to 1.0 mcg/kg/min
for desired effect.
INHALED NITRIC OXIDE
Selective Pulmonary vasodilator
Dilates only pulmonary capillaries to alveoli participating in gas
exchange
Decreases intrapulmonary shunt and improves V/Q matching
Rapidly inactivated by Hgb in pulm. cap. so no systemic side effects
(eg hypotension)
Potential for use in ARDS and Pulmonary Hypertension
Currently only approved for use in neonatal Pulmonary
Hypertension
Expensive
Special monitoring equipment required
Dose: Concentration of 0.5-60 ppm in inhaled gas
CARDIAC ARREST MEDICATIONS
EPINEPHRINE
Both an alpha- and beta-adrenergic agent
During an cardiac arrest, most think it has the greatest benefit by
alpha-adrenergic actions, increasing afterload and thus diastolic blood
pressure, leading to improved coronary artery perfusion.
Indications:
o Cardiac arrest
o Severe bronchospasm
o Anaphylactic reactions
Route of Administration
Pedia Notes

o IV or IO
o SQ or IM (for bronchospasm)
o ET (cardiac arrest without IV or IO access)
Dosage:
o initial (low) dose: 0.01 mg/kg
o = 0.1 cc/kg of 1:10,000
o subsequent (high) doses: 0.1 mg/kg
o = (0.1 cc/kg of 1:1,000)
ATROPINE
Parasympathetic (not an alpha- or beta-adrenergic) agent--acts by
blocking cholinergic stimulation of the muscarinic receptors of the
heart.
Results in an increase in the sinus rate of the heart.
Little effect on systemic vascular resistance or myocardial contractility.
Indications:
o Bradycardia
o Second or third degree heart block
o Asystole
o Pulseless electrical activity (electrical mechanical dissociation)
o Route of Administration: IV, IO, ET, SQ, IM, nebulization
Dosage:
o 10 to 20 mcg/kg
o minimum dose is 0.1 mg--smaller doses may cause reflex
bradycardia (central stimulatory effect on the medullary vagal
nuclei)
o maximum (adult) dose is 2 mg
SODIUM BICARBONATE
Use during CPR remains a controversial issue due to lack of evidence
showing benefit from receiving bicarbonate.
Elevates blood pH by binding with hydrogen to form water and CO2
HCO-3 + H+ => H2CO3 => H2O + CO2
Must have adequate ventilation to remove CO2 or respiratory acidosis
will worsen
Adverse effects of acidosis:
o Cardiac

Decrease contractility

Lower threshold for ventricular fibrillation

Decrease responsiveness to catecholamines
o Vascular

Decrease systemic vascular resistance

Decrease systemic vascular responsiveness to catecholamines

Increase pulmonary vascular resistance
Indications:
o Pre-existing acidosis
o Prolonged CPR (after 10 minutes)
o Pulmonary hypertensive crisis
o Hyperkalemia
Route of administration: IV, IO
o Dosage: 1-2 meq/kg/dose (1 meq/cc or 0.5 meq/cc)
CALCIUM
Current recommendations for the use of calcium during CPR are
restricted to a few specific situations.
Intracellular calcium plays an important role in the process of cell
death, but no studies have shown that transient hypercalcemia
worsens outcome after cardiac arrest.
Adverse Effects of Hypocalcemia
o Decreased myocardial contractility
o Decreased systemic vascular resistance
o Decreased catecholamine release
o Decreased cardiovascular response to catecholamines
Indications:
o Hypocalcemia

Ionized hypocalcemia may result from severe alkalosis or after large
transfusions of citrated blood products.
o Hyperkalemia
o Hypermagnesemia
o Calcium channel blocker overdose
Route of administration:
o IV, IO only
o Calcium chloride--central venous line
o Calcium gluconate--peripheral venous line
Dosage:
o Calcium chloride = 10-20 mg/kg
o Calcium gluconate = 100-200 mg/kg
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LIDOCAINE
Class 1B antiarrhythmic
Decreases automaticity threshold and ventricular fibrillation threshold.
Effective in terminating PVCs.
Rarely used in pediatric arrests as ventricular tachycardia and
ventricular fibrillation are not commonplace.
Indications:
o Ventricular Tachycardia
o Ventricular Fibrillation
o Frequent PVCs
Route of Administration: IV, IO, ET
o Dosage: 1 mg/kg/dose (may need up to 2.5 mg/kg ET)
ENDOTRACHEAL MEDICATIONS (LEAN)
o Lidocaine
o Epinephrine
o Atropine
o Naloxone (Narcan)
RHEUMATIC FEVER
Guidelines for the Diagnosis of Initial Attack of Rheumatic Fever
(Jones Criteria, Updated 1992)
SUPPORTING
EVIDENCE OF
ANTECEDENT
GROUP A
MAJOR
MINOR
STREPTOCOCCAL
MANIFESTATIONS
MANIFESTATIONS
INFECTION
Clinical features:
Carditis
Positive throat culture
or rapid streptococcal
antigen test
Polyarthritis
Arthralgia
Fever
Elevated or increasing
streptococcal
antibody titer
Erythema marginatum Laboratory features:
Subcutaneous
Elevated acute phase
nodules
reactants:
Erythrocyte
sedimentation rate
C-reactive protein
Prolonged PR interval
Chorea
intended only for the diagnosis of the initial attack of acute rheumatic
fever and not for recurrences
5 major and 4 minor criteria and an absolute requirement for evidence
(microbiologic or serologic) of recent GAS infection.
Diagnosis of acute rheumatic fever: 2 major criteria or 1 major and 2
minor criteria and meets the absolute requirement.
Chorea may occur as the only manifestation of acute rheumatic fever.
Indolent carditis may be the only manifestation in patients who 1st
come to medical attention months after the onset of acute rheumatic
fever
Criteria for determining activity:
joint symptoms
new significant murmur
increasing heart size
congestive heart failure in the absence of old valvular disease
subcutaneous nodules
rectal temperature >100.4 F for at least 3 consecutive days
sleeping pulse of >100/min
positive C-reactive protein
*considered active if any one of the following findings is present
RHEUMATIC HEART DISEASE
MR/MS is appreciated on PE
LVH/RVH on ECG
irregular cardiac borders on CXR
*In RF there is also cardiomegaly but with normal ECG findings

Pedia Notes

INFECTIVE ENDOCARDITIS (Duke criteria)

Major criteria
(1) positive blood cultures (two separate cultures for a usual pathogen,
two or more for less typical pathogens) and
(2) evidence of endocarditis on echocardiography (intracardiac mass on
a valve or other site, regurgitant flow near a prosthesis, abscess, partial
dehiscence of prosthetic valves, or new valve regurgitant flow)
Minor criteria
(1) predisposing conditions
(2) fever
(3) embolic-vascular signs
(4) immune complex phenomena (glomerulonephritis, arthritis,
rheumatoid factor, Osler nodes, Roth spots)
(5) a single positive blood culture or serologic evidence of infection
(6) echocardiographic signs not meeting the major criteria.
Definite Endocarditis: Two major criteria, one major and three minor, or
five minor criteria
KAWASAKI DISEASE
Clinical and Laboratory Features
EPIDEMIOLOGIC CASE DEFINITION (CLASSIC CLINICAL CRITERIA)
Fever persisting at least 5 days
Presence of at least 4 principal features:
Changes in extremities
Acute: Erythema of palms, soles; edema of hands, feet
Subacute: Periungual peeling of fingers, toes in weeks 2 and 3
Polymorphous exanthema
Bilateral bulbar conjunctival injection without exudates
Changes in lips and oral cavity: Erythema, lips cracking, strawberry
tongue, diffuse injection of oral and pharyngeal mucosae
Cervical lymphadenopathy (>1.5 cm diameter), usually unilateral
Exclusion of other diseases with similar findings
3 Clinical phases:
Acute Febrile Phase ( 1-2 weeks )
fever, conjuctivitis, erythema, rash
Subacute Phase ( 2-4 weeks )
begins when the fever stops
desquamation, thrombocytosis, coronary aneurysms
Convalescent Phase ( 4-6 Weeks )
resolution of all sign & symptoms
labs return to normal
coronary aneurysms persists
Coronary Aneurysms
Classification of CAA
Small - <5mm internal diameter
Medim - 5-8 mm internal diameter
Large - >8 mm internal diameter
Treatment
Acute Stage
Intravenous Immunoglobulin: 2g/kg over 10-12 hours
With Aspirin (80-100 mkd) q6, until day 14 of illness and afebrile for 48 to
72 hrs
This therapy should be instituted within the 1st 10 days of illness and if
possible within 7 days of illness.
Convalescent Stage
Aspirin (3-5 mkd) OD, until the patient shows no evidence of CA changes
by 6-8 weeks after the onset of illness.
IVIG also should be administered to children presenting after the 10th
day of illness
Long Term: Coronary Abnormalities
Aspirin (3-5 mkd) divided dosed, continued indefinitely
High dose intravenous gammaglobulin (IVIG)
effective in preventing the occurrence of coronary artery
abnormalities in KD.
Patients treated with IVGG have a significant increase in T suppressor
cells, a decrease in circulating activated T helper cells, and a
decrease in spontaneous IgG and IgM synthesis.
suggest that IVGG reduces the vasculitis in KD by suppressing the
marked immune activation associated with this disease.

Page 5 /epcapul

 Measles and Varicella immunization should be deferred for 11 months

after child receives high-dose of IVIG
Even when treated with high-dose of IVIG within the 1st 10 days of
illness, 5% of children develop at the least transient coronary artery
dilation and 1% develop giant aneurysms.
Careful monitoring is necessary during the administration of gamma
globulin because it rarely can cause an allergic-like reaction.

DEVELOPMENT
Anterior fontanelles closed at 7-19 months
Posterior fontanelle closed at 3 months
ANTHROPOMETRICS
Length/Height
Average Birth Length: 50cm
Length: 9-8-5-3cm
Height: agex5+80

Sexual Maturity Rating

Girls
Stage
Breast
1
Preadolescent
2
Breast and papilla elevated as
small mound, diameter of areola
is increased
3
Breast and areola enlarged, no
contour separation
4
Areola
and
papilla
form
secondary mound
5
Mature nipple projects, areola
part of general breast contour

Pubic Hair
Preadolescent
Sparse, lightly pigmented,
straight, medial border of
labia
Darker, beginning to curl,
increased amount
Coarse, curly, abundant but
less than in adult
Adult feminine triangle,
spread to medial surface of
thighs

Head Circumference
Average 13-14in
0-4 mos 2in
5-12mos 2in
1-2 yrs 2 in
Weight
2-5 yrs 2 in
5-20 yrs 2 in
Average BW: 3000
1-6mos= age in mos x 600 + BW
OR
7-12mos= age in mos x 500 + BW
Average: 35cm
1-6yrs=agex2+8
0-3mos 2cm/mo
3-6 1cm/mo
7-12yrs=agex7-5/2
6-9 0.5cm/mo
9-12 0.5cm/mo
BSA: square root of (wt x ht / 3600)
1-3yrs 0.25cm/mo
4-6yrs 1cm/yr
Height age age points on the growth curve where the childs height
falls on the 50th percentile
Weight age age point on the weight curve where the childs weight falls
on the 50th percentile

Boys
Stage
1
2

Midparental height 7 (for girls) 10

Midparental height + 7 (for boys) 10
OR
For Males:
(mothers height + 13cm + fathers height) 5
2
For Females:
(Fathers height - 13cm + mothers height) 5
2
Growth Velocity (cm/yr)
Ht (cm) measured at Time 2 - Ht (cm) measured at Time 1 X 12 (mos/yr)
Number of months between time 2 and time 1
Age
Rate (cm/yr)
1-2 month
38
4 months
28
1 year
12
2 years
10
3-4 years
7
5-6 years
6
7-puberty
5

RED FLAGS
Motor Delay
poor head control by 3 months
hands still fisted by 4 months
unable to hold objects by 7 months
does not sit independently by 10 months
cannot stand on one leg by 3 years
Language Delay
does not turn to sound by 6 months
does not babble or use gestures by 12 months
no single word utterances by 16 months
No 2-word phrases by 2 years
No 3-word sentences by 3 years
Psychosocial Delay
No social smile by 3 months
Not laughing in playful situation by 6 months
Hard to console, stiffens when approached by 1 year
In constant motion, resists discipline
Does not play with other children at 3 years
Cognitive delay
- 2 months
Not alert to mother
-6 months
Not searching for dropped objects
- 12 months
No object permanence
- 18 months
No interest in cause-and-effect games
- 2 years
Does not categorize similarities
- 3 years
Does not know full name
-4 years
Cannot count sequentially
- 5 years
Does not know letters or colors
-5 years
Does not know birthday or address

Arm Span
Age
Boys: <10-11 years
Girls: <11-14 years
Adult Male
Adult Female

Arm Span
<height
<height
>Height by 5.3cm
>Height by 1.2cm

Body Mass Index (BMI)

Wt (kg) / ht2 (m2)
Overweight: >85th percentile
Obesity: >95th percentile

Penis
Preadolescent
Minimal change
/ Enlargement

Testes
Preadolescent
Enlarged
scrotum, pink
texture altered
Larger

Lengthens

Larger; Glans
and
breadth
increase in size

Larger, scrotum
dark

Adult size

Adult size

Pubic Hair
None
Scanty,
long,
slightly
pigmented
Darker,
beginning
to
curl,
small
amount
Resembles
adult type, but
less
quantity;
coarse, curly
Adult
distribution,
spread
to
medial surface
of thighs

Body proportions
Upper segment sitting height (measure using Harpenden sitting table)
Lower segment measure from upper border of symphysis pubis to floor
in standing position
US/LS: Birth = 1,7; 10 years 1
Pedia Notes

Page 6 /epcapul

ENDOCRINOLOGY
IDF definition of Metabolic Syndrome in children and adolescents
Age 6 to <10 years
Obesity 90th percentile as assed by WC. MS cannot be diagnosed but
further measurements should be made if family history of MS, T2DM,
dyslipidemia, CVD, hypertension, or obesity
Age 10 to <16 years
Obesity 90th percentile as assessed by WC
Triglyceride 1.7mmol/L (150mg/dL)
HDL Cholesterol < 1.03 mmol/L (40mg/dL)
BP 130mmHg systolic or 85mmHg diastolic
Glucose 5.6 mmol/L = 100mg/dL (OGTT recommended) or known
T2DM
Age >!6 yo
Use existing IDF criteria for MS
DIABETES MELLITUS
Positive findings from any two of the ff. tests on different days:
Symptoms of DM plus casual plasma glucose 200 mg/dl (11.1 mmol/l)
or
Fasting plasma glucose 126 mg/dl (7 mmol/l)
or
2hrsPPG 200 mg/dl (11.1 mmol/l) after a 75g glucose load
Clinical manifestation
HYPERGLYCEMIA
Osmotic diuresis
Dehydration
Electrolyte losses
Na, K, PO4
Volume contraction
Azotemia
KETOSISACIDOSIS
Hyperventilation
Hypocapnia
Dec. cerebral blood flow
Circulatory depression
Ileus
Gastric dilatation
DIABETIC KETOACIDOSIS
hyperglycemia (BG >200 mg/dl (11.1 mmol/l)
heavy glycosuria (>55 mmol/l)
ketonuria
acidosis (pH < 7.3)
( HCO3 < 15 mmol/l)
5% or more dehydrated
vomiting / drowsy
Principle 1:Restoration of vascular volume
In shock with poor peripheral perfusion or coma: give 10 cc/kg x 10-30
min
Repeat if poor pulses remain
Fluid of choice: 0.9 NSS
Fluid input > 4li/m2 : incrd risk for cerebral edema
IV therapy
MODEL 1
Reqts = Deficit + Maintenance
Maintenance:
3 9 kg 80 cc/kg/d
10-19 kg 70 cc/kg/d
20-30 kg 60 cc/kg/d
30-50 kg 50 cc/kg/d
>50kg
35 cc/kg/d
Add deficit to 48 hr MTN; Replace for 48 hrs w/ PNSS
MODEL 2
Covers maintenance + 10% deficit, give evenly for 48 hrs.
3 9 kg
6 cc/kg/hr
Pedia Notes

10 19 kg
20 kg
(max 250 cc/hr)

5 cc/kg/hr
4 cc/kg/hr

Compute for the fluid requirement of VJ ( BW=35 kg)

Deficit: 35 x 60cc= 2100 ml
(assume mod dehydration unless shocky)
Maintenance:
(35 x 50) x 2=35000
Total fluid for 48h: 5600 ml
Monitor urine output especially during the first 4-6 hours of therapy
Replace urine losses volume per volume
Entails frequent changing rate of infusion
Potassium supplementation
Start as early as the 3rd hour or even earlier as long as the patient is
voiding
Shift to a glucose containing solution when the blood glucose is down to
200 mgs%
Principle 2:Inhibition of lipolysis and correction of hyperglycemia
Insulin therapy
Only short-acting insulin is used ( Humulin R, Actrapid )
Should not be started until shock has been reversed
IV route only
Target fall in blood glucose: 50-100 mg per hour
Low dose continuous Insulin Infusion 0.1 u/kg/hr
(consider 0.05 u/kg/hr for a young child)

Hourly blood glucose, fluid input and output

Neurological status at least hourly
Electrolyte 2 hrs after start of IV therapy
Monitor ECG for T wave changes
How to prepare insulin infusion?
Mix 10 U SA insulin in 100 cc plain NSS 0.1 u/ml
Flush tubings with solution
For VJ: 35 kg x .1u/kg/hr= 3.5 u
35 ml/hr
So, always prepare a solution as above so that infusion rate is equal to
the weight of the patient
When do you stop insulin infusion?
acidosis is resolved
patient is awake
How to shift to subcutaneous route?
Compute at .15-.25 u/kg/dose q6h to be given 30 min pre-meals and
at MN
D/C infusion 30 min after 1st SQ dose
Principle 3:Correction of acidosis
Sodium Bicarbonate therapy
pH < 7.0
HCO3 < 5meq/li
Half-correction over 30 minutes - 1 hour
THYROID STORM
Precipitating factors for thyroid storm
Infection
Surgery (thyroidal and nonthyroidal)
Therapy with radioactive iodine
Administration of iodinated contrast dyes or ingestion of large, stable
iodine loads
Withdrawal of antithyroid medication
Amiodarone therapy
Ingestion of excessive amounts of exogenous thyroid hormone
Diabetic ketoacidosis
Congestive cardiac failure
Hypoglycemia
Toxemia of pregnancy
Parturition and the immediate postpartum state
Severe emotional stress
Acute manic crisis
Page 7 /epcapul

Pulmonary embolism
Cerebral vascular accident
Bowel infarction
Acute trauma
Tooth extraction
Vigorous palpation of thyroid gland
The predictive clinical scale for thyroid storm (Burch and
Wartofsky)
Scoring
Parameter taken into consideration
points
Thermoregulatory dysfunction, Temperature (oral)
99-99.9F
37.2-37.7C
5
100-100.9F
37.8-38.2C
10
101-101.9F
38.3-38.8C
15
102-102.9F
38.939.3C
20
103-103.9F
39.4-39.9C
25
>104F
>40C
30
CNS effects
Absent
0
Mild (agitation)
10
Moderate (delirium, psychosis, extreme
20
lethargy)
Severe (seizures, coma)
30
GI-hepatic dysfunction
Absent
0
Moderate (diarrhea, nausea/vomiting,
10
abdominal pain)
Severe (unexplained jaundice)
20
Tachycardia (beats/min)
99-109
5
110-119
10
120-129
15
130-139
20
>40
25
Congestive cardiac failure
Absent
0
Mild (pedal edema)
5
Moderate (bibasal rales)
10
Severe (pulmonary edema)
15
Atrial fibrillation
Absent
0
Present
10
Precipitating event
Absent
0
Present
10
A cumulative score of >45 is highly suggestive of thyroid storm, 25-44 is
suggestive of impeding storm, and <25 is unlikely to represent thyroid
storm.
From Sarlis NJ, Gourgiotis L. Thyroid emergencies. Rev Endocr Metab Disord 2003;4:129-36.

Treatment
1.Phenobarbital - may be used for sedation because it stimulates
metabolic clearance of thyroid hormone by the liver
2. PTU - 600-1000 mg (12-20 mg/kg) loading dose, followed by 200-300
mg (4-6 mg/kg) every 4-6 hrs orally. The drug of choice because of its
inhibition of peripheral conversion of T4 to T3 in addition to its inhibition of
synthesis of thyroid hormone
3. Methimazole (alternative) - given as a loading dose of 60-100 mg (1.22 mg/kg), followed by 20-30 mg (0.4-0.7 mg/kg) every 6-8 hrs orally
4. Inorganic iodine -Ideally, iodine therapy should be administered 2 hrs
after initial thiourea dosing, to allow for initial blockade of iodine
organification. Saturated solution of potassium iodide (children, 5 drops,
250 mg, 2-4 times/day, infants 2 drops 4 times/day) and Lugol solution
(4-8 drops 3 times/day)
5. Lithium therapy - (300 mg or 6 mg/kg every 6 hrs) may be used in
addition to iodine to block thyroid hormone release
6.High-dose corticosteroids - Hydrocortisone 50-100 mg, IV, every 6-8
hrs or 25-50 mg/m2 body surface
- effective in blocking peripheral conversion of T4 to T3
7.-adrenergic blocking agent - -blockers (e.g., propranolol, 40-80 mg,
0.5 mg/kg, orally, or 1-3 mg/dose IV, every 4-8 hrs; Given in the absence
of cardiac failure, effective in reducing tachycardia, hypertension, and
adrenergic symptoms associated with thyrotoxicosis
Pedia Notes

* medical therapy should be used for weeks to months before definitive

treatment with radioactive iodine or thyroidectomy
Indications for thyroidectomy
Thyroid cancer
Prophylactic thyroidectomy in children with MEN-2
A large multinodular goiter
Graves disease (including young children, not responding to antithyroid
drugs, in whom radioactive iodine is contraindicated)

FLUIDS & ELECTROLYTES

Daily Water Loss
Area

ml/100 cal expended

obligatory urine volume

stool water
skin
lungs

50-55
0-5
30
15

Holliday-Segar Method
Weight
Daily Requirements
3-10 kg
100 ml/kg
11-20 kg
1000 ml + 50 ml/kg for each kg > 10 kg
> 20 kg
1500 ml + 20 ml/kg for each kg > 20 kg
Body Surface Method
Water
Na+
K+

Requirements
1500 ml/m2/day
30-50 meq/m2/day
20-40 meq/m2/day

Factors Modifying Fluid Requirements

Additional Fluids Needed
fever
12% for each C > 37.5C
sustained hyperventilation or excessive 25-50%
muscular activity
hypermetabolic states
25-75%
for burns: 2% increase per 1%
BSA with burns
diarrhea and vomiting
volume per volume
sweating
10-25%
room temperature > 31C
30% per C rise > 31C
newborn under radiant warmer or 25%
phototherapy
Less Fluids needed
hypothermia
12% per C fall below 37.5C
very high humidity
30%
humidified inspired air
25%
oliguria or anuria
Individualized
sedated or paralyzed
40%
Electrolyte
Na+
K+

Daily Requirement (meq/kg/day)

2.5-3.0
2.0-2.5

Determine the fluid deficit

Severity of Dehydration
Infant
Child (>10 kg)
mild
50 cc/kg
30 cc/kg
moderate
100 cc/kg
60 cc/kg
severe
150 cc/kg
90 cc/kg
determine the maintenance fluid requirement
give the of the fluid deficit over the 1st 8 hours then over the next 16
hours
re-assess hydration status periodically
for moderate to severe dehydration, check serum electrolytes
ELECTROLYTES
Na 135-145; K 3.5-5; Ca 2.1-2.6; HCO3 22-26
Page 8 /epcapul

IVF
IVF

Na+
(meq/L)
130

K+
(meq/L)
4

Cl(meq/L)
109

pNSS
D5
0.3NaCl
D5IMB
D5NR

154
51

154
51

25
140

20
5

22
98

D5NM

40

13

40

pLR

HCO3(meq/L)
28
(lactate)
-

Mg++
(mg/dL)
-

Ca++
(mg/dL)
3

27
(acetate)
16
(acetate)

3
-

HYPONATREMIA
Fast correction:
-4mL/kg/dose of 3% NaCl
-3% NaCl= 1mL (2meqs/mL NaCl + 4mL sterile water)
-Total Na required= (M+D) bolus
M= 3meqs/kg/day
D= (desired Na actual Na) x o.6 x wt
HYPERNATREMIA
Total water required for 2 days
= (M for 2 days +D) bolus
Ideal TBW (in liters)= wtx 0.6; ideal serum Na 140
Water deficit= ideal TBW actual TBW
Actual TBW= ideal TBW x ideal serum Na/actual serum Na
CORRECTED SODIUM
Glucose in mg/dL
Na+ + Glucose -100 x 1.6
100
Glucose in mmol/L
Na+ + Glucose -5.6 x 1.6
5.6
HYPOKALEMIA
Fast correction
0.5meqs/kg/dose in PNSS diluent x 1hour x 3-5 doses (max 40meqs/L)
Example: Wt 20kg: (0.5meg/kg/dose K? x 20kg =10meq/hr
Compute how much diluent is required.
Central line (200meq/L concentration)
200meq = 10meq
1000mL
x
X=50mL
Order: Give 10meq K in 50mL NSS x 1hr
Peripheral line (60meq/L concebtration)
60meq = 10meq
1000mL
x
X=170mL
Order: Give 10meq K in 170mL NSS x 1hr
Bedside Pediatric Nephrology
PO correction is potassium chloride of 4-6meg/kg/day given in divided
doses.
Parenteral correction
Intermittent Dosing: (for symptomatic hypokalemia)
0.5 to 1.0meq/kg/hr (maximum 30meq/hr) with maximum infusion rate of
0.5meg/kg/hr and given Q2-4hours until symptoms resolve.
Continuous Dosing: (for non-symptomatic hypokalemia)
0.2-0.3meg/kg/hr for 24hours
*always consider the possibility of Magnesium deficiency especially
among patients with refractory hypokalemia. Magnesium is a important
co-factor for the activity of the Na-K-ATPase pump which is necessary
for potassium homeostasis.
Hariett Lane:
Oral:
Child: 1-4meg/kg/24hrBID-QID
Adult: 40-100meq/24hrBID-QID
Pedia Notes

IV:
Child: 0.5-1meq/kg/dose given as an infusion of 0.5meq/kg/hr x 1-2hr
Max: 1meq/kg/hr. This may be used in critical situations(i.e. hypokalemia
with arrhythmia)
Adult:
Serum K >2.5meq/L:
Replete at rates up to 10meq/hr. Total dosage not to exceed
200meq/24hr
Serum K <2meq/L:
Replete at rates 40meq/hr. Total dosage not to exceed 400meq/24hr
Maximum peripheral IV solution concentration: 40meq/L
Maximum concentration for central line administration : 150-200meq/L
Kalium durule 10meq/durule
10% Oral KCl=1.34meq/mL
HYPERKALEMIA
10% Calcium Gluconate (100mg/kg/dose) + equal diluent x1 hour
- aims to stabilize cell membrane and opposes the negative inotropic
effect of hyperkalemia
Glucose-insulin drip: 5mL/kg D10 or 1mL/kg of D50 + 0.1unit/kg Humulin
R over 30-60minutes
Beta2 adrenergic agonist- Salbutamol administration at 1-5mcg/kg/min
IV or nebulized at 10-20mg over 15 minutes
- drive potassium into the cells just like insulin
sodium bicarbonate- 2meq/kg IV over 30minutes (except for ERD
patients)
Polystyrene sulphonate resins-0.5-1gm/kg PO or PR Q4-6hours
Sodium Bicardonate
Base deficit Wt (kg)x distribution of NaHCO3(0.3)
HYPOCALCEMIA
-100mg/kg/dose Calciumgluconate/IV + equal diluent to run for 1 hour x
4-6doses, Q6hours (Max 2g)
-Corrected Calcium:
= (40-albumin) x 0.002+ actual serum calcium
INFUSIONS / DRIPS
Dopamine
amount (cc) = dose (mcg/kg/min) x BW (kg) x 480
40,000
Dobutamine
amount (cc) = dose (mcg/kg/min) x BW (kg) x 480
12,500
Epinephrine
amount (cc) = 0.6(BW) + sterile water to make 100 cc
0.1
mcg/kg/min = 1 cc/hr
general formula
drip rate (cc/hr) = dose x BW x 60 x total volume___
preparation
Preparation
Dose (mcg/kg/min)
Albumin 20%
10mg/50mL
Abumin 25%
12.5mg/50mL
Aminosteryl 6%
6g/100mL
Dobutamine
250mg/20mL
5-20
(250,000 mcg/20mL)
Dopamine
200mg/5mL
5-10
(200,000mcg/5mL)
Epinephrine
1mg/mL
0.1-0.5
(1000mcg/mL)
Furosemide
20mg/2mL
2
Midazolam
15mg/3mL
1
(15,000mcg/3mL)
Milrinone
10mg/10mL
0.25-1
Nitroglycerine(NTG)
10mg/mL
1-5
(10,000mcg/mL)
Norepinephrine
2mg/mL
Max: 2mcg/kg/min
Thiopental
20mg/mL
(20,000mcg/mL)
Voluven 6%
Max 50cc/kg/day
DEXTROSITY
Dextrosity of Fluids
D5W contains 5 g of glucose per 100 ml
changing dextrosities of fluids
Page 9 /epcapul

factor = desired dextrosity lower dextrosity

higher dextrosity lower dextrosity
amount of D50 to be added to actual IVF =
(factor)(actual IVF being given)
peripheral line D12
central line D20
Glucose Infusion Rate
determines adequacy of infused glucose
(dextrosity)(drip rate in cc/hr)(0.167)
body weight (kg)
nv: infants 6-8; children 4-6
GIR normal = 5-8
GIR = rate (gtts/min) x dextrosity x 1,000
Weight x 60
BURN
Parkland
D1: 4ml/ k/ %BSA burned
x hrs, x 16hrs + maintenance
D2: 50-75% of above
Maintenance fluids should be estimated for children who weigh <40kg
For adults and children who weigh >40kg, maintenance fluids are not
included in the estimate of fluid requirements
Half of this volume is given in the first 8 hours after injury and the other
half is given in the following 16 hours

GASTROENTEROLOGY
NUTRITIONAL STATUS ASSESSMENT
WATERLOWE CLASSIFICATION
S: 90-95 (Mi); 80-90 (Mod); <80 (S)
W: 80-90 (Mi); 70-80 (Mod); <70 (S)
Stunting
Actual height
x 100
Ideal ht for age
> 95%
normal
90-95
mild
85-90
mod
<85
severe
Wasting
Actual weight
x 100
Ideal wt for ht
>/= 90% normal
80-90
mild
70-80
mod
< 70
severe
DIARRHEA
Plan A
<2k 50-100ml
2-10k 100-200ml
>10k as much

Plan B
75ml/kg x 4hrs
Plan C
Infants 30ml/k x 1hrs, 70ml/k x 5hrs
Older 30ml/k x 30mins, 70ml/k x 2hrs

ReSoMal:
1Lpack Oresol, 1L water; 45mL 10% KCl, 50gm sucrose
1st 2hrs 5ml/k q30mins; 4-10hrs 5-10ml/k/hr
VOMITING
WARNING SIGNALS in the vomiting infant
Bilious vomiting
GI bleeding (hematemesis, hematochezia)
Forceful vomiting
Onset at 6 mos of life
Failure to thrive
Diarrhea
Constipation
Fever
Lethargy
Hepatosplenomegaly
Bulging fontanelle
Macro/microcephaly
Seizures
Ab tenderness/distention
Pedia Notes

Genetic disorders (trisomy 21)

Other chronic d/o (eg HIV)
GER passage of gastric contents to esophagus
GERD gastric contents to esoph/oropharynx and produce symptoms
such as:
Recurrent vomiting hematemesis
Wt loss/FTT
dysphagia
Irritability
feeding refusal
Regurgitation
cough
apnea/ALTE
anemia
recurrent pneum
Hoarseness
Heartburn/chestpain wheezing/stridor Esophagitis
Barrets esoph
OMEPRAZOLE
- duodenal ulcer : 20-40 mg OD x 2-4 wks
- benign gastric ulcer, reflux esophagitis 20-40 mg OD x 4-8 wks
- children >2yrs serious reflux esophagitis 1 mkd for 4-8 wks
> 20 kg 20 mg OD
10-20kg 10 mg OD
- NSAID induced gastric and duodenal ulcer : 20 mg OD x 4-8 wks
- GERD 10-20 mg OD x 2-4 wks
- symptomatic GERD w/ esophageal lesions 20 mg OD x 4 wks
-maintenance of healing of erosive esophagitis 20 mg OD up to 12 mos
Eradication of H. pylori
BID x 1 wk: Omeprazole 20 mg + Amox 1000 mg + clarithromycin 500
mg
BID x 1 wk: Omeprazole 20 mg + Metro 500 mg + clarithromycin 250 mg
CALORIC COMPUTATION
Protein: gm/k/d x wt x 4; requirement 0.5-3gm/k/d
Lipid: gm/k/d x wt x 9; requirement 0.5-4gm/k/d
CHO: gm/100cc x vol x 4 (eg. D5=5gm/100cc)
CALORIC DISTRIBUTION OF CHO, COOH, CHON OF TOTAL
CALORIES GIVEN
CHO
60-70%
CHON
10-15%
Fats
20-30%
Breastmilk: 20cal/oz; VCO: 7.7cal/cc; Cereal 12.4cal/scoop
1gm Nitrogen = 6.25gm protein
Supplements for Severe Malnutrition:
50% MgSO4 2ml (2mmol/mL) IM x 1 dose; Zn 1mkd until diarrhea stops;
Cu 0.1mkd; Folic acid 5mcg/k/d; Fe 3mkd; Vit A (if not given w/in 6mos)
<6mos 50,000iu, 6-12mos 100,000iu, >1yr 200,000iu
Age
REE
Multiplication factor
0-1
55
Maintenance
0.2
1-3
57
Acitivity
0.1-0.25
4-6
48
Fever
0.13/deg >38C
7-10
40
Simple Trauma
0.2
11-14
32M/ 28F
Multiple Injuries
0.4
15-18
27M/ 25F
Burns/ GI surgery
0.5-1
Total Daily Energy Req: Sepsis
0.4
REE + REE x Total factors
Growth
0.5
FORMULA FOR CALORIC REQUIREMENT FOR CATCH-UP GROWTH
Get the height, weight
get ideal weight for actual height
kcal/kg=RDA for age (kcal/kg) x ideal wt/ht
actual wt
CHON=CHON recommended for age x ideal wt/ht
Actual wt
* start by 50-70% of caloric requirement
* increase calories by 20 kcal/kg/k every 2 days until caloric requirement
is reached
* increase protein by 0.5 g/kg every 2 days until catch up is reached
RDA for CHON (g/kg/day)
0-6 mos
2.2
7-12 mos 1.5
1-2 yrs
1.1
3-8 yrs
0.95
9-13 yrs 0.95
14-18 yrs 0.85
RECOMMENDED ENERGY INTAKE (kcal/kg)
per kg
per day
Infants
0-6mos
108
650
Page 10 /epcapul

6-12 mo
Children
1-3 yr
4-6 yr
7-10 yr
Males
11-14 yr
15-18
19-24
25-50
> 50
Females
11-14 yr
15-18
19-24
25-50
> 50
Pregnant
Lactating

98

852

102
90
70

1,300
1,800
2,000

55
45
40
30
30

2,500
3,000
2,900
2,900
2,300

47
40
38
36
30

2,200
2,200
2,200
2,200
1,900
+300
+500

CALORIC REQUIREMENT FOR PARENTERAL NUTRITION

Neonate
90-120 cal/kg
</= 10 kg
100-170 cal/kg
11-20 kg
1000 cal + 50 cal/kg in xces of 10kg
> 20 kg
1500 + 20 cal/kg in excess of 20 kg
FAT requirement in parenteral nutrition
0-12 mos
2 g/kg/day
1-8 yr
4 g/kg/day
> 8 yr
2.5 g/kg/day
CARBOHYDRATE reqt
VLBW (<1.5 kg)
2.25
0-12 mo
2.5
1-8 yr
1.5-2
> 8 yr
1-1.5
NORMAL ELECTROLYTE REQT
Na
2-4 meq/kg/day
K
2-3
Cl
2-3
Mg
0.25-0.5
Ca
Infants
300-400 mg/kg/day
Children
100-200
Adolescent
50-100
Phosphorous
Infants
1-1.5 mmol/kg/day
Children
1
Adolescent
0.5-1
F75 DIET: 75 cal/100 cc
Skimmed milk powder
25g
Veg. oil
20g
Sugar
60g
Rice (cereal) powder
60g
Water to make 1,000 ml
*give 100-130 cc/kg/day
F100 DIET: 100 cal/100 cc
Skimmed milk powder
80g
Veg. oil
60g
Sugar
50g
Water to make 1,000 ml
* minimum daily intake of 120-200 ml/kg
RESOMAL (ORS for malnourished patients)
Dilute 1 L of ORS with 1 L water
Add 45 ml of 10% KCl
Add 50 g sucrose
Composition:
Na 45 mmol/L
K 40 mmol/L
Sugar 25 g/L
FEEDING REGIMEN (ENTERAL NUTRITION)
1. Intermittent/bolus more physiologic
- should only be used for gastric feed
- start at 1-5 ml/kg/bolus
- every 3-6 hrs
- deliver over 30-120 min (2 hrs)
Pedia Notes

2. Continuous better tolerated in px w/ feeding intolerance & significant

GER
- for critically ill px
- start 1-2 ml/kg/hr in child/adol
- can be increased by 1-2 ml/hr
- concentration shld be inc before volume

NUTRITIONAL GUIDELINE
Energy caloric goal = 125% RDA based on wt/ht at 50th percentile
* glucose polymer to in to 24-27 cal/mg formula
* MCT infant formula
* MCT oil supplement 1-2 ml/k/d 2-4 doses
* supplemental nighttime NGT feeding
Essential Fatty acids corn oil
Protein intake
(infants) 2-3 g/k/d
(child) 0.5-1 g/k/d
Children Hospital Formulary
- started at 10-20 cc/kg/d as bolus or cont.
- advance by </= 20-25 ml/kg/d
PERSISTENT DIARRHEA
First Diet: Reduced Lactose
70 cal/100g
Full fat dried milk
11g
(or whole liquid milk 85-295)
Rice
15g
Vegetable oil
3-5g
Cane sugar
3g
Water to make
200 ml
* 130 ml/kg provides 110 cal/kg
2nd Diet: Lactose free w/ reduced starch 75cal/100g
Whole egg
64g
Rice
3g
Vegetable oil
4g
Glucose
3g
Water to make
200 ml
* if finely ground cooked chicken meat is used instead of egg.
Provides 70 cal/100
* 145 ml/kg provides 110 cal/kg
MILK FORMULAS
Alfare:
72 cal/100
65 cal/100

Fats
Linolento
CHON
CHO

1:1 dilution
15g:100 ml

65cal/100ml
3.3g
0.38g
22g
7g

D1: 1 scoop +100 ml

D2: 2 scoops + 100 ml
D3: 3 scoops + 100 ml
D4: 3 scoops + 90 ml

72cal/100ml
3.6 g
0.42 g
2.5g
7.8 g
Cal/100 ml
22
44
65
72

PEPTAMEN JUNIOR (1cal/ml)

7 scoops in 210 ml to make 250 ml
14 scoops in 425 ml to make 500 ml
28 scoops in 850 ml to make 1000 ml
Per 1L preparation
Fat
38.5g
CHON
30.1 g
CHO
138.4 g
* 60% MCT
* 100% hydrolyzed when CHON 30 g /L
NUTREN JUNIOR (same prep as peptamen)
1 cal/ml
12% CHON
35% COOH
53% CHO
MCT 25%
Lactose free/ gluten free
Page 11 /epcapul

CHON
CHO
COOH

Per 100 ml
3g
13.3g
3.9 g

PEDIASURE

standard dilute
Per 100 ml
Caloric content
100cal
CHON
3g
COOH
4.78g
CHO
43.8g
* 190 ml of water + 5 scoops to make 225 ml
MICRONUTRIENTS
Vitamin A single dose
< 6mos 50,000 IU
6-12 mos 100,000 IU
> 12 mos 200,000 IU
Zinc 1mg/kg/d
Copper (infants) 0.2-0.6 mg/day
(child/adol) 1-2 mg/day
MgSO4 50% - 2ml IM/SQ
Folic acid 5 ucg/kg/d
Iron to start only in the 2nd week of illness when infection is better
controlled at a dose of 3mg/kg/d
MICRONUTRIENTS FOR UPBUILDING
Vitamin A
Folic Acid 800 ucg/prep
(5 ucg/kg/d) D1-LD 5 mg or 5 tabs
D2 1 mg or 1 tab
Zinc 1-2 mg/kg/d
Copper
0.2-0.6 mg/d (infant)
1-2 mg/d (children)
FOR ACUTE DIARRHEA
Zinc
<6mo : 10 mg/d for 10-14 days
>6mo : 20 mg/d for 10-14 days
Test dose for Intralipid
< 5kg : 0.1 g/kg x 1 hr
> 5kg 0.01 g/min x 10-15 min
TOTAL PARENTERAL NUTRITION (TPN)
amino acids
make fluid D7.5/D10
NaCl (2.5 meq/ml) 3 meq/kg
KCl (2 meq/ml) 2 meq/kg
Ca gluconate 10% - wt x 3, or wt x 300/100
MgSO4 (25% 1meq/ml, 50% 2meq/ml) -0.2 meq/kg
NEONATAL CHOLESTASIS
CHOLERETIC DRUGS
UDCA 250mg/tab, 15-45 mkd
Rifampicin 5mkd
Cholestyramine 4-16 g/d
Phenobarital 3-10 mkd
Vitamin A 2,500-25,000 IU/day
Clusivol drops /0.6ml = 4,000 IU
Clusivol syrup /5ml = 2,500 IU
Nutrilin drops /ml = 5,000 IU
Nutrilin syrup /5ml = 1,500 IU
Enervon C drops /ml = 3,500 IU
Enervon C syrup /5ml = 100 IU
Vitamin D 400-1,200 IU/day as D3
Clusivol drops /0.6ml = 400 IU
Clusivol syrup /5ml = 500 IU
Nutrilin drops /ml = 333.33 IU
Nutrilin syrup /5ml = 100 IU
Enervon C drops /ml = 200 IU
Enervon C syrup /5ml = 200 IU
Rocaltrol (Calcitriol) 0.25ucg/cap = 0.05-0.2 ucg/kg/d
Vitamin E 15mg/d -200 mg/kg/d or alpha tocopherol acetate (squibb)
[100 or 200 or 400 IU/cap] 25-200 IU/kg/d, 1 cap at least q5 days in
infants 100 IU = 65 mg
Pedia Notes

Vitamin K 1-5 mg/d

Ca (elemental)
50-200 mg/kg/d
25-100 mg/kg/d
Up to 800-200 mg/d
Ca Sandoz /5ml =110mg elemental
Ca Sandoz /tab =500mg elemental
*Corrected Ca = (40-actual)x.02 + actual
Phosphorous (elemental)
25-50 mg/kg/d up to 500 mg/d
Mg Mg oxide 1-2 meq/kg/d PO
deficiency: serum Mg <1.4 mg/L
50% solution of MgSO4 0.3-0.5 meq/kg IV over 3 hrs (max 3-6 meqs)
Zinc - 1mg/kg/day PO x 2-3 mos elemental
Gluconate 7 mg/kg/d
Sulfate 5mg/kg/d
MEDICATIONS:
Midazolam 5mg/ml 0.1 mkdose
Nalbuphine 10 mg/ml - 0.1 mkdose
Propranolol (10 mg, 40 mg) - 0.6- 8 mkd
Somatostatin 3.5 ucg/kg/hr (250 ucg +50 cc or 3mg + 250 cc D5W or
pNSS)
Adult 3mg in 500cc D5W x 12 hr
Octreotide 30 mg/m2/hr
Spironolactone (25 mg, 50 mg) 3-5 mkd
furosemide (20 mg, 40mg) 1-4 mkd
Atenolol (25, 50mg) 1.2 mkd
MOTILITY DRUGS
Domperidone (Motilium) 1mg/ml -0.3 mkdose, 3-4 doses, max 0.6
mkdose.
Erythromycin estolate 3mkdose or 20 mgd 2-4 doses
Metoclopramide 0.1mkdose up to 4x, max dose 0.5mkd. Adult: 10mg
before meals & at bedtime
Loperamide 0.5-1.5mkd, 3-4 doses
*Prophylaxis for cholangitis
Sultamicillin (Unasyn) 10mkd
Cotrimoxazole 4mkd
Somatostatin dec splanchnic blood flow in normal subjects, in cirrhotic
pts not uniformly; used to control acute variceal hemrhge
Propranolol beta blocker studied in use for recurrent variceal hmrhge;
dec splanchnic blood flow and portal HPN by splanchnic vasoconstriction
and cardiac output
LIVER FUNCTION
LIVER SPAN (Nelson)
12 wk
4.5-5 cm
12 yr (female)
6-6.5 cm
12 yr (male)
7-8 cm
After 12 yr
(female) 0.27 x wt (lbs)+ 0.22 x ht (in.) -10.75
(male) .032 x wt (lbs)+0.18 x ht (in.) -7.86
PTT measures generation of thrombin through Intrinsic pathway (uses
all coag factors including factor IX vit K dependent, andVIII, EXCEPT
for factor VII)
PT measures time for prothrombin (factor II) to be converted into
thrombin factors 1,2,5,7,10
- prolongation of >2sec is pathologic
- >3 sec indicate risk for bleeding
- evaluates extrinsic pathway
- prolonged when facter 1,2,5,7,10 deficient
- if prolonged in chronic liver dse suggest poor prognosis
NORMAL PT/PTT IN HEALTHY PRETERM
PT
PTT
Day1
13(10.6-16.2)
53(27.5-79.4)
5
12.5(10-15.3)
50.5(26.9-74)
30
11.8(10-13.6)
44.7(26.9-62.5)
90
12.3(10-14.6)
37.5(28.3-50.7)
180
12.5(10-15)
37.5(21.7-53.3)
Adult
12.4(10.8-13.9)
33.5(26.6-40.3)
Factor VIII- non-hepatic
Page 12 /epcapul

- only factor not made in liver

- can be used to differentiate liver dse fr DIC (may be N or inc
in liver dse)
Vit K deficiencies
Give Vit K 1mg/kg IM/IV, min: 1mg in FT
Measure PT 4-6 hrs after
ROLE OF LIVER IN COAGULATION
produce coag factors except von willebrand
produce & brkdown factors integral to fibrinolysis eg plasminogen &
plasminogen activator
clears activated clotting factors fr circ
Albumin principal serum protein
- synthesized only in rough endoplasmic reticulum of
hepatocytes at 150 mg/k/d
- half life: 20 d
- maintains colloid osmotic pressure
- bind/carrier of bilirubin, Ca, other drugs
- in pts w/ ascites: may be dec due to inc in the distribution vol
rather than dec synthesis
- often sign of chronic rather than acute liver dse (since long
half life)
Other nonhepatic causes of low albumin
poor nutrition, nephrotic (urine loss), protein losing enteropathies (fr gut),
inc degradation rate (poorly understood)
SERUM ALBUMIN LEVELS
g/dL
1-3mos
3.4
4-6mos
3.46
7-12 mo
3.62
13-24 mo
3.63
25-36mo
4.11
3-8yr
4
9-16 yr
4.25

+1 SD
0.72
0.36
0.6
0.8
0.78
0.65
0.7

serum albumin and PT are most impt parameters need liver transplant
HEPATOPULMONARY SYNDROME
1. Hypoxemia
2. Intrapulmonic right to left shunting of blood
3. Liver disease
Patient with chronic liver disease with history of shortness of breath or
exercise inteolerance and clinical examination findings of cyanosis
(particularly of the lips & fingers), digital clubbing, and O2 sats <96%,
particularly in the upright position
Tx: Liver transplantation
ENDOSCOPIC ESOPHAGEAL VARICEAL LIGATION
- mucosal and submucosal tissue are ensnared  strangulation 
sloughing  fibrosis  obliteration of sub/mucosal vascular channels
- < complication then sclero eg esophageal stricture, pneumonia,
bact.peritonitis
- fever treatment sessions
IRON
- absorption in prox small intestine
- ferrous>ferric absorbed
- Increases absorption: Gastric acid, some sugars, aa, Bile
- Decreased absorption: Oxalate, phosphates
- Stimulate inc absorption: 1. iron def, 2. hypoxia, 3. erythropoiesis
HEMORRHOIDS
Daflon micronized purified flavonoid fraction
chronic conditions & venous insufficiency: 2 tabs/day
acute hemorrhoidal attacks: 3tabs BID x 4 d, 2 tabs BID x 3 days
Antibiotics in Gut Obstruction (rationale)
Blood flow to the obstructed bowl decreases as the bowel dilates
Blood flow is shifted away from the mucosa with loss of mucosal
integrity
Bacteria proliferates in the stagnant bowel with a predominance of
coliforms and anaerobes

Pedia Notes

Rapid proliferation of bacteria coupled with loss of mucosal integrity

allows bacterial translocation across the bowel wall potentially
resulting in endotoxinemia, bacteremia and sepsis
Bowel gas
Air is usually demonstrable radiographically in the stomach of a
normal infant immediately after birth
Within 1 hour, air may reach the proximal portion of the small intestine
and segments of the colon
Air may become visible in the distal parts of the colon as early as the
3rd hour or as late as 18 hours

HEMATOLOGY and ONCOLOGY

ANEMIA
Measured Hgb > 2 SD below the mean for age
Age
Mean
1 mo
14
2 mo
3-6 mo
.5-2 y
2-6 y
6-12 y
12-18
M
F
18-49
M
F

-2SD
10

11.5
11.5
12
12.5
13.5

9
9.5
10.5
11.5
11.5

14.5
14

13
12

15.5
14

13.5
12

MCV
measures the average volume of a red blood cell
categorizes red blood cells by size.
Formula (2-10 yrs old)
Lower limit: 70 fL + age in years
Upper limit: 84 fL + ( age in yrs x 0.6 ), until upper limit of 96 is reached
Whats the MCV range?
Give LL and UL of a 7 years old.
Answer: LL: 77 fL; UL: 88.2 fL
RETICULOCYTE COUNT
Measures erythrocyte production
Expressed as % of circulating rbcs
Take up reticulin stain (supravital):
bec of inc RNA
N = 0.5 % to 1.5 % or = .005 to .015
Reticulocyte index
Anemic patient --> increased retic
so have to correct: retic observed x px Hct / 0.45
Example:
Hb 50
Hct 0.15
Retic count=.045= 4.5 %
Corrected retic =
4.5% x .15/.45 = 1.5 %
( N = 0.5-1.5%)
Absolute Retic Count
More accurate
Compute as ff:
RBC (in n x 1012 ) x # retic/1000 rbc x 1000
Normal = 40,000 100,000/uL
Example:
Compute for absolute retic count :
Hb 90
RBC 3 x 1012 /L Retic .015
Answer: 45,000 retics / uL
IRON DEFICIENCY ANEMIA
- microcytic, hypochromic, increased RDW
Therapy: daily total dose of 4-6mg/kg of elemental iron in 3 divided
doses
Page 13 /epcapul

Response to therapy
Time after Iron administration
12-24hr

24-48 hrs
48-72 hrs
4-30 days
1-3 months

Response
Replacement of intracellular iron
enzyme; subjective improvement,
decreased irritability, increased
appetite
Initial bone marrow response;
erythroid heperplasia
Reticulocytosis, peaking at 5-7
days
Increase in hemoglobin levels
Repletion of stores

NEUTROPENIA
Neutropenia- decrease in the absolute neutrophil count (ANC)
ANC= WBC x (neutrophils and bands)
Neutropenia
< 1000/mm3 infants between 2 weeks and 1 year
< 1500/mm3 beyond 1 year of age
Severe Neutropenia: ANC less than 500/mm3
Moderate Neutropenia: ANC 500-1000/mm3
Mild Neutropenia:ANC 1000-15000/mm3
Transient- < 8weeks
Chronic->8 weeks
Clinical Features
high fever, chills, severe prostration, and irritability
extensive necrotic and ulcerative lesions: oropharyngeal and nasal
tissues , skin, gastrointestinal tract , vagina and uterus
Gram-negative septicemia
ANC <1000/m3: stomatitis, gingivitis and cellulites
ANC < 500/M3: perirectal abscess, pneumonia and sepsis
Granulocyte colony-stimulating factor (G-CSF)
-produces sustained neutrophil recovery in patients with severe chronic
neutropenia
-reduces the incidence and severity of infection and improves the quality
of life
-dose: 5ug/kg/day
-response in 7 to 10 days
HYPERLEUKOCYTOSIS
- a total white cell count greater than 100,000/mm3
- 9-13% Acute Lymphocyte Leukemia and 5-22% Acute myeloid
LEUKEMIA
- occurs in almost all children with chronic myeloid leukemia
- leads to increased blood viscosity and emboli
- Hemorrhage and leukostasis leading to intracranial hemorrhage or
thrombosis, pulmonary hemorrhage and leukostasis are more prevalent
in AML than ALL
- myeloblasts are larger than lymphoblasts and are more easily trapped
in the microcirculation
- Tumor lysis syndrome and metabolic abnormalities occur almost
exclusively in ALL
- lymphoblasts are more sensitive than myeloblasts to chemotherapy
Clinical Features:
CNS- blurred vision, confusion, delirium, and papilledema, CT scan
hemorrhage or leukemic plaques
Pulmonary- tachypnea, dypnea, hypoxia, CXR pneumonitis or leukemic
emboli
Genitourinary- oliguria, anuria, priapism
TUMOR LYSIS SYNDROME
-results from extremely rapid proliferation, accompanied by significant
cell death and release of intracellular release of ions.
>Hyperuricemia
>Hyperkalemia
>Hyperphosphatemia
>Hypocalcemia
>Hypercalcemia
>Renal failure

Pedia Notes

Hydration
-Should be given at the rate of 3000mL/m2/day to maintain urine output
of >100mL/m2/hr or >5mL/kg/hr
Alkalinization of urine
-Increase solubility of urates
-maintain urine pH 6.5 to 7.5
-maintain urine specific gravity <1.010, monitor Q12
Uric acid reduction
300mg/m2/day TID or 200mg/m2/day IV
Preparation: 100mg/tab, 300mg/tab
Monitor electrolytes
-monitor serum Na, K, Cl, Ca, uric acid , phosphorus, BUN, Crea every
6 hours
Hyperphosphatemia
-Aluminum hydroxide 150mg/kg/day every 4-6hours
-Preparation: Alutab 600mg/tab

INFECTIOUS DISEASES
SIRS (Systemic Inflammatory Response Syndrome)
The presence of at least 2 of the following 4 criteria, 1 of which must be
abnormal temperature or leukocyte count;
-core temperature of >38.5C or <36C
-Tachycardia, defined as a mean heart rate >2 SD above normal for age
in the absence of external stimulus, long-term drug or painful stimulus, or
otherwise unexplained persistent elevations over 0.5-4 hours period OR
for children <1 year old: bradycardia, defined as a mean heart rate <10th
percentile for age in the absence of external vagal stimulus, betablockers, or congenital heart disease; or otherwise unexplained
persistent depression over 0.5hr period
- Mean respiratory rate >2 SD above normal for age or mechanical
ventilation for an acute process not related to underlying neuromuscular
disease or the receipt of general anesthesia
- Leukocyte count elevated or depressed for age ( not secondary to
chemotherapy induced leukopenia) or 10% immature neutrophils
INFECTION
Suspected or proven (by positive culture; tissue stain or PCR test)
caused bu any pathogen OR a clinical syndrome associated with a high
probability of infection. Evidence of infection include positive findings on
clinical exam, imaging or laboratory tests (e.g. white blood cells in a
normally sterile body fluid, perforated viscus, chest radiograph consistent
with pneumonia, petechial, purpuric rash or purpura fulminans
SEPSIS
- SIRS in the presence of suspected or proven infection
SEVERE SEPSIS
- Sepsis plus 1 of the following: cardiovascular organ dysfunction OR 2
or more other organ dysfunctions
TETANUS
Etiology: Clostridium tetani
Clinical Criteria for diagnosis of Tetanus
1. An illness characterized by the acute onset of hypertonia andor
painful muscle contractions (usually of the jaw and neck) and
generalized muscle spasms;
2. No history of contact with strychnine
3. Subsequent disease course consistent with tetanus
Wound classification for tetanus prophylaxis
Clinical features
Tetanus prone
Nontetanus prone
Age of wound
>6 hours
6 hours
Configuration
Stellate, avulsion
Linear
Depth
>1cm
1 cm
Mechanism of injury
Missile, crush, burn, Sharp surface (glass,
frostbite
knife)
Dentalized
Present
Absent
conataminants (dirt)
Present
Absent
Neonatal tetanus suggested system of scoring to assess prognosis at
time of admission and subsequently
The severity of the disease is inversely proportionate to the score:
0 recovery improbable; 15 recovery
Reassessment of score should be done 24 hourly
An unchanged or lower score at subsequent assessment signified
ineffective management or complications and calls for modification of
treatment
Page 14 /epcapul

Score
0
1
2
3
Age of onset 1-4
5-8
9-12
>12
of sx in days
(incubation
period)
Interval
<24
24-48
>48
No
between first
spontaneous
symptom
spasms
and
fisrt
spasm
in
hours (onset
interval)
Spasms:
Persistent
>2
<2
Transient or
duration in prolonged
on
minutes
stimulation
Temperature >3
>2-<3
>1-<2
Normal 1
C variation
from normal
Pneumonia
Definite
Definite
Suspected
Nil
and/or
widespread
limited
milk
atelectasis
Abletts Criteria for Classification of Severity of Tetanus
Grade I Mild or no respiratory involvement and dysphagia
Grade II Moderate respiratory involvement and trismus
Grade IIIA Severe respiratory involvement, generalized rigidity and major
spasms with no autonomic involvement
Grade IIIB Severe manifestations as above with autonomic dysfunction
Immunization Schedule
History
of Non-tetanus prone wound Tetanus prone wound (all
tetanus
(clean minor wound)
other wounds)
immunization Td1
TIG
Td
TIG
Unknown or Yes
No
Yes
Yes
< 3 doses
3 or more No2
No
No3
No
doses
Td Tetanus and diphtheria toxoid absorbed (adult)
TIG Tetanus immune globulin
1
Yes if wound >24 hours old
For children <7 years, DPT (DT if pertussis vaccine contraindicated)
For persons >7 years Td preferred to tetanus toxoid alone
2
Yes if >10 years since last booster
3
Yes if > 5 years since last booster
Treatment of Tetanus
1. Immunization
Passive immunization (TIG) preferably 3,000-6,000 u IM although
experts claim 500 u is just as effective
Alternate drug:Tetanus antitoxin 500u/kg body weight or 5,000 u
newborn, 10,000 u children, 20,000 u adults; intravenously and the
next intramuscularly
Active immunization
Tetanus toxoid. First dose admission; second dose discharge; third
dose 6 months later
2. Antibiotics
Metronidazole 30mkd Q6 X 10-14 days oral or iv
Pen G:
Neonate 100,000 u/kg/day Q8
Children 200,000 u/kg/day 4-6 doses
Adults 1Mu IV Q6 X 15 days
3. Control of muscular spasms
Prognosis:
Serious case fatality rate: 44-55%; Neonatal tetanus 60%

NEONATOLOGY
NEONATAL RESUSCITATION PROGRAM
Tube size (mm) inside
Weight (kg)
diameter
2.5
<1,000
3.0
1,000-2,000
3.5
2,000-3,000
3.5-4.0
> 3,000
Pedia Notes

Gestational age
(weeks)
<28
28-34
34-38
>38

Laryngoscope:
Size 0 preterm
Size 1 term
Weight (kg)

Depth of insertion (cm from upper

lip)
<1
6
1
7
2
8
3
9
4
10
Adding 6 to the babys weight in kg will give you rough estimate of depth
of ET
Positve Pressure Ventilation
breath two three: 40 to 60 breaths / minute
PPV + Chest compressions
one and two and three and breathe: 30 breaths: 90
compressions or 120 events
Proper location of compression (thumb or two-finger techniques):
between the xyphoid and line drawn between the nipples or lower third of
the sternum
Recommended dosage for Neonates
Epinephrine: 0.1 to 0.3mL/kg of 1:10,000 (equal to 0.01 to 0.03 mg/kg)
Sodium bicarbonate: 2mcg/kg (4mL/kg of 2.4% solution (slowly, no faster
than a rate of 1 meq/kg/min)
Naloxone hydrochloride: concentration 1mg/mL solution. Dose 0.1mg/kg
Magnesium sulfate drip
Loading dose: 200mg/kg/dose
Maintainance dose: 30-50mg/kg/hr
MgSO4 250mg/mL
Example: Wt 3.1kg, prepare for 8 hours
Order: Start MgSO4 drip as follows:
1. Loading dose of 620mg or 2.5mL + D5W to make 5cc to run for 30 min
immediately followed by
2. Maintenance dose of 745mg or 3mL + D5W to make 8 cc to run at
1cc/hr
NaHCO3: 75-154meqs.L
D10NaHCO3K2
D10W
293cc
NaHCO3 54cc
KCl
3cc
350cc @ 14.5cc/hr
TFI: 112; Wt 3.1
FiO2 CA Computations for O2 hood or CPC setup
Formula for Hood:
Compressed air = 100 desired FiO2 X 10
79
Oxygen = 10 Compressed air
Formula for CPAP
Compressed air = 100 desired FiO2 X desired PEEP
79
Oxygen = Desired PEEP Compressed Air
Umbilical Artery Catheterization
High thoracic vertebrae 6 and 9
Low should be below the 3rd lumbar vertebra
Low UA: BW + 7; High UA: 3 x BW + 9
Umbilical Vein Catheterization
Catherter tip should be at the junction of the inferior vena cava and right
atrium projecting just above the diaphragm
UV: High UA/2 + 1
Corrected age: actual in wks + 40-AOG
JAUNDICE
Physiologic Jaundice: >24hrs, <14d, B2 < 1, <0.5mg/dl/hr inc
Exchange level: wt x 10
Photo level: 75% of exchange
Apt Test
Mix equal parts of the bloody material with master and centrifuge it. Add
1 part of 0.25 mol sodium hydroxide to 5 parts of the pink supernatant. If
the fluid remains pink: fetal in origin, hemoglobin F. Turn from pink to
yellow brown: maternal blood is hydrolyzed, hemoglobin A.
Page 15 /epcapul

a.

Breastfeeding Jaundice
- exaggeration of physiologic jaundice of the newborn as a result of
inadequate breastmilk intake or insufficient breastfeeding frequency
starvation jaundice - free fatty acids inhibition of glucuronyl
transferase activity unconjugated bilirubin
Management: increase breastfeeding frequency; breastfeeding should
not be discontinued
Breastmilk Jaundice
- results from the presence of a yet unidentified factor which further
increases absorption of unconjugated bilirubin in newborn
Management: discontinue breastfeeding for 24-48 hours
Jaundice disappears: breastmilk induced
Jaundice persists: pathologic jaundice further diagnosis
PHOTOTHERAPY
Not for treatment of hyperbilirubinemia
It only decreases the need for exchange transfusion
Criteria to rule out physiologic jaundice
Clinical jaundice <24 hours old
TSB increases >5 mg/dl/day (85 mmol/L/day)
TSB >12 mg/dl in FT, >15mg/dl in PT
Jaundice >1week in FT, >2 weeks in PT
DB >2 mg/dl or >20% of TSB
To establish etiology of hyperbilirubinemia
Baseline TB, DB, IB
CBC with PC
PBS, Coombs test,Reticulocyte count
Mothers and babys blood type
Skin color is not reliable
Policy on Improvised Bilirubin Lights
10 fluorescent bulbs at 20 watts each
Distance of 20 inches or 50cm from the patient
Duration of use should not be more than 2000 hours
Stop photo when: 130.7 (FT); 10.71.2 (PT)
Prophylactic phototherapy
Extensive bruisingin VLBW
Diagnosis of hemolytic disease
Reminders:
Determine bilirubin levels every 8-12 hours
Follow fluid balance carefully. Increase TFI if on phototherapy.
Avoid if with liver disease or obstructive jaundice (DB >2mg/dl) because
of risk of bronze baby syndrome
Anticipate revound of 25% after phototherapy is discontinued
Cover eyes & genitals with black cloth to protect from radiation
Discontinue if patient becomes hyperthermic
Potential Complications
Impaired maternal-fetal bonding
Retinal damage
Diarrhea / ileus
Dehydration
Hyperthermia
Skin rashes
Bronze baby syndrome
EXCHANGE TRANSFUSION
Indications
Correction of anemia
Removal of sensitized RBCs
Reduction of TSB
Immune thrombocytopenia
Equivocal efficacy: Treatment of sepsis, RDS, DIC
Consider for the following conditions:
Rh incompatibility
ABO incompatibility with eigher bilirubin >20 mg/dl or lesser if clinical
condition warrants or evidence of kernicterus at any level
Hyperbilirubinemia due to other causes: VLBW infants, BW in kg X 10 
exchange necessary
Metabolic-toxic conditions: hyperammonemia in UCDs and drug
overdose
Techniques for exchange transfusion:

Pedia Notes

Prepare fresh whole blood (mothers blood type if ABO

incompatibility): should be cross-mathced with maternal blood
if ABO/Rh incompatibility
b. Place a UVC after aspirating gastric contents
c. A two-volume exchange (DVET): 80-85% turnover. A onevolume exchange only 60%.
d. Allow 1-2 minute per cycle; hour per volume, so 1 hour for
DVET
e. Pre exchange studies: CBC with PC< bilirubin
f.
Post exchange studies: CBC with PC, bilirubin, RBS, K, Ca
taken 6-12 hours post exchange, blood CS is controversial
g. A CVP of 5-8 cm H2O be maintained at all times
h. Keep thermoregulated during procedure
i.
Resume feeds 4 hours after exchange
Calculations
Total blood volume (TBV)
Term or >1kg: 80cc/kg
Preterm or <1kg: 100cc/kg
Volume for DVET = TBV X 2
Volume per aliquot: 5% of TBV
cc per aliquot = TBV X 0.05
Number of exchange/cycles = Volume per aliquot / Volume for DVET
Duration per cycle: 1-2 minutes
Duration for DVET: max of 1 hour
Total exchange vol=80 x wt x 2
Vol per exchange=80 x wt x 0.05
# of exchanges=total vol/ vol per exchange
OXYGENATION INDEX (OI)
OI = (MAP X FiO2 X 100) / Postductal PaO2
MAP mean airway pressure
OI > 15 signifies severe respiratory compromise
30-35 failure to respond to the existing mode of ventilator support
>40 80% risk of death, ECMO
Screening
ROP 4-6 weeks chronologic age, 31-33 wks PCA
1500, AOG 28 weeks, unstable course
Hearing wt>1.5, off vent/meds
<1500, furosemide, low APGAR, craniofacial malformation, CNS
infection, gentamycin, vancomycin, TORCH
Wt increase: 30gm/d (1mo); 20gm/d (3-4mos)
Breastfeeding
Contraindications
1. Maternal infections
a. HIV
b. HTLV I, II (Human T Lymphotrophic virus)
c. Active tuberculosis
d. active herpes simplex
2. Very low birth weight infants (<1500g)
3. Maternal medications contraindicated in lactation
a. antithyroid medications
b. lithium
c. cancer meds
d. isoniazid
e. recreational drugs
f. phemindione
4. Consider alternatives to treatment. Consider timing of doses;
temporarily expresses and discard milk if necessary.
Residuals / Gastric aspirate
A volume of >30% of the total formula given at the last feeding may be
abnormal and requires extensive evaluation. A gastric aspirate of >1015mL is considered extensive.
NECROTiZING ENTEROCOLITIS
Risk Factors 5 Is
Ischemia
Immaturity
Immunologic
Infection
Intake
Page 16 /epcapul

Stage
Stage I NEC
suspect

Stage IIA Mild

NEC

Systemic
Nonspecific:
apnea,
decreased HR,
lethargy,
temperature
instability
Same

Stage
IIB
Moderate NEC

Mild acidosis,
APC

Stage
IIIA
Advanced NEC

Respiratory
/
Metabolic
acidosis, assis
vent for apnea,
decreased BP,
decreased UP,
neutropenia,
DIC
Deteriorating
VS
and
laboratory
indices

Stage IIIB

Intestinal
Gastric
residuals; guiac
+ stools

Prominent
abdominal
distention

tenderness, (-)
bowel sounds,
gross blood in
stools
Abdominal wall
edema,
tenderness

palpable mass
Spreading
edema,
erythema,
abdominal
induration

Radiographic
Nonspecific

Ileus,
dilated
bowel
loops,
focal areas of
pneumatosis
intestinalis

Extensive
pneumatosis
intestinalis
Prominent
ascites,
persistent
sentinel loops
with
no
perforation

Pentoxyfylline
Preparation: 300mg/15mL
Therapeutic dose 6mg/mL
Example 1.2 kg
X = 6mg/kg X 1.2kg X 6 = 43.2 or ~ 44
X = 44mg (15mg/300mg) = 2.2 mL
Order: Give 3.8 mL pNSS + 2.2 mL Pentoxifylline to make 6mL to run at
1cc/hr X 6 hrs OD for 6 days
RESPIRATORY DISTRESS SYNDROME I / HYALINE
DISEASE
Bonsel Grading (Radiographic)
Severity
Grade
Reticulogram Cardiothymic
shadow
Mild
1
Mild,
hazy Clearly
generalized
defined
2
Moderate

Severe

Moderate /
generalized
Heavier and
more
confluent
White
out
lung fields

Still
discernible
Hazy, barely
discernible
Up to lung
periphery

MEMBRANE

Air
Bronchogram
Perihilar
within
CT
shadow
Just past CT
borders
Past 2/3 lung

Cardiac
borders no
longer visible

NEPHROLOGY
OSMOLALITY
Osmolality = 2(Na) + BUN/18 + Glucose/2.8
nv: 220-320
nCVP: 5-10cm
ARTERIAL BLOOD GAS
Compute for the pH
Compute for the expected bicarbonate when it is abnormal
Primary
Expected Change
Disorder
HCO3
pCO2
SBE
Metabolic
<22
(1.5
xHCO3) 5
acidosis
+ (82)
Pedia Notes

Metabolic
alkalosis
Acute
Respi
Acidosis

>26

Chronic
Acid

[(pCO2-40) 3]
+24

Respi

[(pCO2-40)
10] + 24

Acute Respi
Alkalosis

[(40-pCO2) 5]
+24

Chronic
Alk

[(40-pCO2)
10] +24

Respi

(0.7xHCO3) +
(212)
>45 or pH =
0.008 x (pCO240)
>45 or pH =
0.003 x (pCO240)
<35 or pH =
0.008 x (40pCO2)
<35 or pH =
0.017 x (40pCO2)

5
=0

0.4 x (pCO240)
=0

0.4 x (pCO240)

pH <7.35
ACIDOSIS
HCO3 <22
METABOLIC ACIDOSIS
COMPENSATION
Respiratory changes in paCO2
If actual paCO2 = expected paCO2
COMPENSATED METAB ACIDOSIS
If actual paCO2 < expected paCO2
METAB ACIDOSIS WITH RESP ALKALOSIS
If actual paCO2 > expected paCO2
METAB ACIDOSIS WITH RESP ACIDOSIS
Metabolic Acidosis

pH <7.35

HCO3 <22

Respiratory compensation? Calculate for expected paCO2

Compute anion gap

([Na+] + [K+]) ([Cl-] + [HCO3])
Normal = 16 2-4 mEq/L (if K+ included)
= 12 2-4 mEq/L (without K+)
Anion Gap = (Na+K) (Cl+HCO3) nv 8-16 (w/o K), 12-20 (w/ K)
Ratio = actual AG nAG or 12/ nHCO3 or 24 actual HCO3
Ratio: <0.4 hyperchloremic acidosis; <1 loss of base (combined high
and N AG); 1-2 simple high AG; >2 gain of base (concurrent metabolic
alkalosis)
Metabolic Alkalosis

pH >7.45

HCO3 >26

Respiratory compensation? Calculate for expected paCO2

pH <7.35

ACIDOSIS

paCO2 >45

RESPIRATORY ACIDOSIS

Acute or Chronic?

COMPENSATION

pH

RENAL changes in HCO3

Remember that this TAKES TIME

First, Compute for expected pH

If actual pH = 0.008 X PCO2 (expected pH in

acute resp acidosis)

UNCOMPENSATED
ACUTE
RESPIRATORY ACIDOSIS

If actual pH = 0.003 X PCO2 (expected pH in

chronic resp acidosis)

COMPENSATED
CHRONIC
RESPIRATORY ACIDOSIS

If actual pH >0.003 but <0.008 X pCO2

PARTIAL
RENAL
COMPENSATION
(Partially
compensated
respiratory
acidosis)

If actual pH >0.008 X pCO2

Overlapping
Metabolic
derangement:
RESP ACIDOSIS WITH METABOLIC
ACIDOSIS OR RESP ACIDOSIS WITH
METABOLIC ALKALOSIS
If actual pH >0.008 X pCO2 - Overlapping Metab acidosis or
alkalosis?
So, Compute for expected HCO3

If actual HCO3 < expected HCO3

Page 17 /epcapul

RESP ACIDOSIS WITH METABOLIC

ACIDOSIS

If actual HCO3 > expected HCO3

RESP ACIDOSIS WITH METABOLIC

ALKALOSIS
Respiratory Acidosis

pH <7.35, pCO2 > 45

NOTE: pH and paCO2 move in opposite direction

Compute for expected pH

Acute resp acidosis, uncompensated

Compensated chronic respiratory acidosis

Partially compensated respiratory acidosis

If actual pH > 0.008 X pCO2, then compute for expected

HCO3 concomittant metab acidosis or metab alkalosis

pH >7.45

ALKALOSIS

paCO2 <35

RESPIRATORY ALKALOSIS

Acute or Chronic?

COMPENSATION

RENAL changes in HCO3

Remember that this TAKES TIME

First, Compute for expected pH

If actual pH = 0.008 X PCO2 (expected pH in

acute resp alkalosis)

UNCOMPENSATED
ACUTE
RESPIRATORY ALKALOSIS

If actual pH = 0.017 X PCO2 (expected pH in

chronic resp alkalosis)

COMPENSATED
CHRONIC
RESPIRATORY ACIDOSIS

If actual pH >0.008 but <0.017 X pCO2

PARTIAL
RENAL
COMPENSATION
(Partially
compensated
respiratory
alkalosis)

If actual pH >0.017 X pCO2

Overlapping
Metabolic
derangement:
RESP ACIDOSIS WITH METABOLIC
ACIDOSIS OR RESP ACIDOSIS WITH
METABOLIC ALKALOSIS
If actual pH >0.017 X pCO2 - Overlapping Metab acidosis or
alkalosis?
So, Compute for expected HCO3

If actual HCO3 < expected HCO3

RESP ACIDOSIS WITH METABOLIC

ACIDOSIS

If actual HCO3 > expected HCO3

RESP ACIDOSIS WITH METABOLIC

ALKALOSIS
Respiratory Alkalosis

pH >7.46, pCO2 <35

NOTE: pH and paCO2 move in opposite direction

Compute for expected pH

Acute resp alkalosis, uncompensated

Compensated chronic respiratory alkalosis

Partially compensated respiratory acidosis

If actual pH > 0.017 X pCO2, then compute for expected

HCO3 concomittant metab acidosis or metab alkalosis

Estimated GFR
= Ht (cm)x 0.5(children/adol girls) or 0.7 (Adol boys)
Serum creatinine mg/dL
Estimated GFR (mL/min/1.73m2)=kL/Pcr
L (length/height, cm)
Pcr- plasma creatinine
k- constant
k
LBW during first year of life
0.33
Term AGA during first year of life
0.45
Children and Adolescent girls
0.55
Adolescent boys
0.70
Creatinine Clearance (mL/min/1.73m2)
=Urine cr x Urine vol x 1.73
Plasma cr
1440
BSA
Pedia Notes

Normal Values of GFR

Age
Neonates <34wk
age
2-8 days
4-28 days
30-90 days
Neonates >34wk
age
2-8 days
4-28 days
30-90 days
1-6 mo
6-12 mo
12-19 mo
2 yr-adult

GFR (mean)
mL/min/1.73m2

Range
mL/min/1.73m2

11
20
50

11-15
15-28
40-65

39
47
58
7
103
127
127

17-60
26-68
30-86
39-114
49-157
62-191
89-165

gestational

gestational

Laboratory Indices for Prerenal vs Intrinsic Acute Renal Failure

Index
Prerenal
Intrinsic Renal
Specific gravity
>1.020
<1.010
Urine osmolality (mOsm) >500
<350
Urine Sodium(meq/L)
<20
>40
FENa (%)
<1
>2
Blood urea nitrogen
>20
<20
/ Creatinine
FENa (%)= UNa x PCr x 100
PNa x Ucr
RFI (Renal Failure Index) = urine Na/ (urine Cr/plasma Cr)
Mean values of serum creatinine during the first weeks of life of term and
very low weight neonates
Serum creatinine (umol/L)
Birthweight
Postnatal period(day)
(g)
1-2
8-9 15-16 22-23
1001-1500
95
64
49
35
1501-2000
90
58
50
30
2001-2500
83
47
38
30
Term
66
40
30
27
Serum Creatinine in Children
Age
Serum Creatinine
(yr)
Umol/L
mg/dL
<2
35-40
0.4-0.5
2-8
40-60
0.5-0.7
9-18
50-80
0.6-0.9
MAP=1/3SBP+2/3 DBP; dec BP by 20=30% of MAP
Age
Systolic
Diastolic
Birth (12h, <1000gm)
35-59
16-36
Birth (12h, 3kg)
50-70
25-45
Neonate (96hrs)
60-90
20-60
Infant (6mos)
87-105
53-66
Toddler (2yrs)
95-105
53-66
School age (7yrs)
97-112
57-71
Adolescent (15yrs)
112-128
66-80
CHON Spillage=TP x 1000/ 24 x BSA; nUprot: 100mg/m2/d
BUN/Crea x 247
uAG= (uNa + uK) uCl
postive uAG: dec uNH4Cl excretion (dRTA); negative uAG: intact
uNH4Cl excretion (diarrhea, non-distal nephron defect or high AG
acidosis)

Serum Na
Urine output
Urine Na
Intravascular
volume status
Serum uric acid
Vasopressin
level

SIADH
Low
N or
High
N or

CSW
Low
High
Very high
Low

Central DI
High
High
Low
Low

Low
High

N or
Low

High
Low

Page 18 /epcapul

Acute Glomerulonephritis
Ssx: edema (facial or bipedal), hypertension, hematuria, oliguria
Labs:
urinalysis with RBC morphology (mild hematuria RBC 1-2 with
dysmorphic RBC)
C3
ASO
CBC
BUN, Crea
NO ultrasound nonspecidifc
Treatment:
Furosemide (3) Q6
Continuous Furosemide drip 0.5 mg/kg/hr
Rate = WT X 0.5
Preparation: 100mg Furosemide + 100cc D5W to make 1mg/mL
Nephrotic Syndrome
Ssx: Generalized edema, heavy proteinuria, hypoalbuminemia
Diagnostics:
Urinalysis
Albumin
24 hour urine collection with urine protein and urine creatinine
NO ultrasound
Protein spillage:
Significant proteinuria: 4-40mg/m2/hr
Nephrotic range or heavy proteinuria: >40
Total protein spillage
Management
Diuretics
Bumeanide 1mg/tab 1 tab BID to Q6
HCTX 25 or 50mg tab BID
Antibiotics
Penicillin G if with infection
Target Group A beta-hemolytic Streptococcus
Steroids
Prednisone:
Initiation: 60mg/m2/day Max of 60mg/day
20mg tabs 3 tabs max
Check response in 7-10 dyas (half life of prednisone)
May be given for 2-4 weeks; Maximum of 10 weeks
If (-)n protein or repeat UA with decreased protein, may shift
to maintenance
Maintenance phase
40mg/m2 every other day after breakfast to counteract
cortisol surge producing less side efects
Given for 6-0 months
Taper slowly every 2 weeks until with (-) protein
Hydrocortisone IV
Urinary Tract Infection
Inquire regarding manner of collection of urine sample for urinalysis
Wee bag increased sensitivity: if urinalysis is negative then we
are sure it is not UTI
Midstream catch
Clean catch
Diagnostics:
Ultrasound
Dimercaptosuccinic acid scan (DMSA) check renal scarring. If
there is no scarring, then it is not reflux.
Voiding cystourethreogram (VCUG)
Urodynamic studies
Medications: Cefuroxime, Co-amoxiclav
Duration: if culture (-), treat for 7 days; if culture (+) treat for 14 days
Renal Support Medications
CaCO3 50-100mkd TID (Prep 500mg, 650mg)
NaHCO3 1-3 meqs/kg/day (BID-QID) (Prep 325mg/tab, 450mg/tab = 7.7
meqs)
FeSO4 3-6 mkd
Erythropoietin 500mkdose (prep 2000 u, 4000 u)
Pedia Notes

Cyclphosphamide
Prehydration D5 0.3 NaCL : BSA X 3000mL to run in 1 hours
Cyclophosphamide (500mg/BSA + 40-60% Mesna dilute in D5W to make
100mL to run in 1 hour
Posthydration: FM X 6 hours (D5 0.3NaCl)
Peritocat / Stiff Cath Insertion
1. Strict asepsis
2. Instill Lidocaine in 2 fingerbreaths midline below the umbilicus
3. Using IV needle gauge 16 (large bore), insert perpendicular/vertical
once give is felt, withdraw needle slowly and continue insertion of IV
cannula into peritoneum
4. Induce ascites using Eruopersol 1.5% until boardlike rigidity of
abdomen is felt
5. Withdraw IV cannula and insert stiff cathe in a screwing motion into
the peritoneum. Once with give withdraw needle and insert eigher to R or
L of abdomen (measure depth of peritoneum catheter from umbilicus to
symphysis pubis)
6. Once in place, connect extension tube and draw fluid.
7. Stabilize peritoneal catheter by suturing continuously at the 3, 6, 9, 12
oclock position and approximately below pericath marker and tie.
8. Clean with betadine

NEUROLOGY
GCS
Eye opening
Spont
Speech
Pain
None

Verbal
Motor
Oriented/Smiles
5
Obeys
Confused/
4
Localizes
Consolable
Withdraws
Words/
3
Flexion
Inconsolable
Extension
Sounds/ Grunts
2
None
None
1
nICP: Infants 5mmHg; Children 6-13; Adults 5-15mmHg
upper limit: 20mmHg
CPP=MAP-ICP; >50-70mmHg
4
3
2
1

6
5
4
3
2
1

Cerebral Dominance
Dominant Hemisphere handedness; perception of language and
speech, writing
Nondominant Hemisphere spatial perception; recognition of faces and
music
Lentiform nucleus glovus pallidus + putamen
Corpus striatum caudate nucleus + lentiform nucleus
Neostriatum caudate nucleus + putamen
Aphasia
Expressive aphasia- Brocas area; destructive lesions in the left inferior
frontal gyrus; loss of ability to produce speech
Receptive aphasia Wernickes area; destructive lesions restricted to
Wernickes speech area; loss of ability to understand the spoken and
written word
Abnormal Respiratory Patterns
Cheyne-Stokes breathing- forebrain damage
Central neurogenic hyperventilation- hypothalamic-midbrain damage
Apnea; cluster breathing- lower pons
Ataxic breathing- medulla
Pupillary size and reaction
Anisocoria- uncal herniation
Small, reactive- metabolic, diencephalic compression
Pinpoint- pons
Midposition, fixed- midbrain
Large, fixed- tectal
Posturing
Decorticate rigidity- flexor response in the arms with extension of the
legs
Localization: cerebral hemisphere
Decerebrate rigidity- abnormal extensor response in the arms and legs
Page 19 /epcapul

Localization: bilateral diencephalic and hemisphere damage; upper

brainstem injury
Can be seen in the ff. conditions:
Massive head trauma and cerebral hemorrhage
Rostro-caudal deterioration
Posterior fossa or cerebellar lesions
Severe metabolic disorders- hepatic coma
Holoprosencephaly
Failure to form the paired cerebral hemispheres
Lateral ventricles are represented by a single midline cavity
Lissencephaly
Defect in migration of the cerebral neurons
Cortical gyri fail to develop
Surface of the cerebral hemispheres is smooth with absence of normal
cortical layers microscopically.
Severe mental retardation
Pachygyria
Defect in the migration of the cerebral neurons
Few and broad gyri
Associated with a four-layer cortex that underlies thickened gyri
Polymicrogyria
Neuronal migration defect
Excess of small and poorly developed cerebral gyri
Most commonly sporadic, may be associated with Zellweger cerebrohepato-renal syndrome
Severe mental retardation, seizures
Schizencephaly
Unilateral or bilateral gray matter lined cleft of the lateral cerebral wall,
extending from the periventricular zone to the meninges
Hydranencephaly
Congenital absences of cerebral hemispheres which are replaced by
large CSF filled cavities
Brainstem and basal ganglia are present and there may be rudiments of
frontal and occipital cortex
Chiari Malformations
Chiari I
Elongated peglike cerebellar tonsils displaced in the upper cervical canal
20-40% with associated syrinx
Chiari II (Arnold-Chiari)
Vermis, pons, medulla and an elongated fourth ventricle are displaced
inferiorly into the cervical canal
Myelomeningocoele in nearly 100%
Chiari III
Hindbrain herniation into a low occipital or high cervical encephalocoele
in combination with features of chiari II
Chiari IV
Associated with cerebellar hypoplasias and dysplasias
Dandy Walker Malformation
Large posterior fossa
Fourth ventricle floor present, ventricle open dorsally to large posterior
fossa cyst
Hydrocephalus in 80%
Vermian, cerebellar hemispheric hypoplasia
Brainstem may be hypoplastic, compressed
Porencephaly
Defect in the cerebral mantle resulting in a cyst-like expansion of the
lateral ventricle
Usually unilateral
Usually secondary to local damage to the cerebrum, either during late
fetal life or early infantile life

Refractory Status Epilepticus

status epilepticus of more than 60 minutes, where adequate dosages of
benzodiazepines, Phenobarbital and Phenytoin fail to terminate the
seizure
Intractable Epilepsy
at least 1 seizure per month for at least 12 months, refractory to
maximal, tolerable doses of at least 2 first line anticonvulsants, with
compromised quality of life.
Simple Febrile Seizure
seizure characterized as generalized (usually tonic-clonic), lasting for
less that 15 minutes and which does not recur within the same febrile
illness.
Complex Febrile Seizure
seizure with partial onset, prolonged duration (lasting >10 or >15
minutes, both have been used) and recurrent (more than 1 seizure in a
single illness episode, generally in 24=hr period).
Myaesthenia Gravis
Grade I weakness restricted to extraocular muscles
Grade IIa Generalized mild weakness
Grade IIb Generalized moderate weakness
Grade III Generalized severe weakness
Grade IV Life threatening weakness of respiratory muscles
Hepatic Encephalopathy
I Changes in behavior, minimal change in level of consciousness,
altered sleep (hypersomnia, insomnia), inversed sleep cycle in the
newborn
II Spatiotemporal disorientation, drowsiness, inappropriate behavior,
obvious asterixis
III Marked confusion, stuporous, repond or not to auditory stimuli,
decerebrate posturing to pain, asterixis usually absent
IV comatose, unresponsive to pain, decorticate posturing
Subacute Sclerosing Panencephalitis (SSPE)
Stage IA Behavioral, cognitive and personality change (decreased
school performance, attention / hyperactivity, inappropriate socially,
sleep disturbance. Walking
Stage IB Myoclonic spasm a periodic, focal, independent ambulation.
Same mental / behavioral symptoms as IA.
Stage IIA Further mental-behavioral deterioration. Myoclonic spasms
periodic, generalized and synchronous, frequent. Can walk
independently but doesnt because of drop spells.
Stage IIB Apraxia, agnosias, language difficulties. Motor signs
spasticity, ataxia. Ambulatory with assistance.
Stage IIIA Speaking less, visual difficulties, no ADLs. Sits up
independently, may stand, no independent ambulation. Myolonic spasms
frequent, multifocal, short inter-spasm intervals (3-5seconds); long
duration (3-4seconds). May have seizures.
Stage IIIB No spontaneous speech, poor verbal comprehension, may
be blind. Myoclonic spasms same as in IIIA. Bedridden, dysphagia, may
have to be fed by NG tube. No EEG delta background activity. PSWC
(periodic slow wave complexes) often obscured in background.
Movement disorder may appear (chorea-ballismus-athetosis).
Stage IV No myoclonic spasms. EEG very low voltage background
activity. No PSWC. Patient in neurovegetative state.
Acetazolamide cerebral vasodilator; transiently worsen intracranial
hypertension. Contraindicated in closed head injury

Status Epilepticus
a neurologic emergency wherein the patient develops generalized or
partial seizures lasting for 30 minutes or longer, or a series of seizures
wherein the patient does not regain consciousness in between seizures
Pedia Notes

Page 20 /epcapul

PULMONOLOGY
RR
Lights Criteria (exudates)
<2mos <60
PF LDH (>2/3 or 200)
2mos-1yr <50
PF Prot (>3g/dl)
1-5yrs <40
PF:Serum LDH (>0.6)
6-8yrs <30
PF:Serum Prot (>0.5)
Expected PEFR
Male=(ht in cm-100)x5+175
Female=(ht in cm-100)x5+170
PEFR var= actual/ exp x 100
FiO2 Estimates
Nasal cannula = flow rate (lpm) x 4 +21
Funnel = 6lpm 80FiO2
Face mask = flow rate -1 x 10
Hood = 8lpm60FiO2; 10lpm70FiO2
PiO2=FiO2 in decimal x (760mmHg 47mmHg)
PAO2=PiO2 (PACO2/0.8)
A-a gradient=PAO2-PaO2
nv: 20-65mmHg on 100%O2; 5-20 on RA; >65 respiratory compromise
MAP=PIP-PEEP x IT x RR/60 + PEEP; nv <8
OI= MAP x FiO2 x 100/ PaO2
OI>35 for 5-6hrs 1 criterion for ECMO
O2 content (CAO2) in ml/dL= Hgb in g/dL x 1.34 x O2 Sat in decimal +
PO2 x 0.003; nv 18-20
AV difference (AVDO2) = CAO2 CVO2; nv 5mL/ 100dL
O2 extraction = CAO2 CVO2/ CAO2; nv 0.25
Shunt fraction = pAO2 CAO2/ pAO2 CVO2; nv <5%
ET size: age/4+4; <1kg 2.5, 1-2kg 3, 2-3kg 3.5, 3-4kg 4
ET lt: size x 3 or wt + 6 or age/2+12
Drugs for RSI
Adjunctive
Sedative
Paralytic
Head injury/ Inc Lidocaine
Thiopental/
Vecuronium
ICP/ Status Ep
Propofol/
+ Normal BP
Etomidate/
Midazolam
Head injury/ Inc Lidocaine
Etomidate/
low Vecuronium
ICP/ Status Ep
dose Thiopental/
+ Hypotension
Midazolam
Normotensive
Midaz/Etom/
Vecuronium
Euvolemic
Prop/Thiopental
MILD Shock
Atropine
Ketamine/
low Vecuronium
Hypotensive
dose
Midaz/
Hypovolemic
Etomidate
SEVERE
Atropine
Etom/ Ket/ None
Vecuronium
Shock
Status
Atropine
Ketamine/ Midaz
Vecuronium
Asthmaticus
MECHANICAL VENTILATION
Initial Ventilator Settings
Volume Control Ventilator
o Tidal volume - around 10 cc/kg; Assess for chest rise & oxygenation
o PEEP - depends on lung status; start around 5 cm H2O; Assess for
oxygenation & hemodynamic parameters
o FiO2 maintain adequate oxygenation
o RR normal for age
Pressure Limited Time Cycled Ventilator
o PIP assess chest rise and oxygenation
o PEEP assess oxygenation and hemodynamics
o It maintain normal for age
o FiO2 maintain adequate oxygenation
o RR normal for age
Revision of Ventilator Settings
Oxygenation - Assessed via pO2
pO2 mean airway pressure
Mean airway pressure
PIP x It + PEEP x Et
It + Et
Area under pressure-time curve
Increase pO2
Decrease pO2
Increase PIP or tidal volume
Decrease PIP or tidal volume
Increase PEEP
Decrease PEEP
Increase It
Decrease It
Increase FiO2
Decrease FiO2
Pedia Notes

Ventilation - Assessed via pCO2

pCO2 1/minute ventilation
Minute ventilation = Frequency x tidal volume
Volume control ventilator: Tidal volume is set
Pressure control ventilator: Tidal volume is PIP PEEP
Increase pCO2
Decrease pCO2
Decrease frequency
Increase frequency
Decrease tidal volume
Increase tidal volume
Decrease PIP
Increase PIP
Increase PEEP
Decrease PEEP

CONGENITAL CYSTIC ADENOMATOID MALFORMATION (CCAM)

Type I Macrocystic; single or several large (>2cm), ciliated
pseudostratified epithelium; good survival
Type II Micrycystic; multiple small cysts, associated with other
congenital anomalies; poor prognosis
Type III Solid with bronchiole-like structures lined with cuboidal ciliated
epithelium
ACUTE RESPIRATORY DISTRESS SYNDROME
American European Consensus Conference
Acute onset
Bilateral infiltrates on chest radiograph
PCWP < 18 mmHg or absence of clinical evidence of left atrial
hypertension
PaO2:FiO2 < 200 (ALI if PaO2:FiO2 < 300)
Phases of ARDS
Exudative
FibrosingResolution
Phase
Alveolitis Phase
Phase
Histologic
Diffuse alveolar Fibrosis
Degree
of
features
damage
Acute
and histologic
Neutrophils,
chronic
resolution
of
macrophages
inflammatory
fibrosis not well
and erythrocytes
cells
characterized
Hyaline
Partial resolution
membranes
of
pulmonary
Protein-rich
edema
edema fluid in
alveolar spaces
Capillary injury
Disruption
of
alveolar
epithelium
Clinical
3-7 days from Observed
Gradual
features
onset
histologically as resolution
of
Accounts
for early as 5-7 days hypoxemia and
33% to 50% of of onset
improved
lung
deaths
Persistent
compliance
Arterial
hypoxemia
hypoxemia
Increased
refractory
to alveolar
dead
supplemental
space
oxygen
Further decrease
in
pulmonary
compliance
Pulmonary
hypertension
Radiologic
Bilateral
Linear opacities Radiographic
features
infiltrates
consistent
with abnormalities
Maybe patchy or evolving fibrosis
resolve
asymmetric
Pneumothorax
completely
May
include
pleural effusions
CT
Alveolar filling
Diffuse interstitial
findings
Consolidation
opacities
Atelectasis
Bullae
Predominantly in
dependent lung
zones
Etiology
Direct Lung Injury
o Pneumonia
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o Aspiration of gastric contents

o Pulmonary contusion
o Fat emboli
o Near-drowning
o Inhalational injury
o Reperfusion pulmonary edema
Indirect Lung Injury
o Sepsis
o Severe trauma with shock and multiple transfusions
o Cardiopulmonary bypass
o Drug overdose
o Acute pancreatitis
o Transfusions with blood products (TRALI)
General Measures
Careful search for underlying cause
Prevention or early treatment of nosocomial infection
Adequate nutrition preferably enteral
Prevention of GI bleeding
Prevention of thromboembolism
Specific Measures
o To decrease ventilator-induced lung injury: Mechanical ventilation
o To address surfactant deficiency and dysfunction: Surfactant therapy
o To improve V/Q mismatch: Prone positioning
o Inhaled nitric oxide and other vasodilators
o To decrease pulmonary edema: Fluid and hemodynamic
management; b-agonist (?)
o To decrease inflammation: Glucocorticoids and other antiinflammatory
agents

Antinuclear
antibody

based on (1) an abnormal serum level of lgG or lgM

anticardiolipin antibodies;(2) a positive test result for
lupus anticoagulant using a standard method, or (3) a
false-positive serologic test for syphilis known to be
positive for at least 6 mo and confirmed by
Treponema pallidum immobilization or fluorescent
treponemal antibody absorption test (FTA-ABS),
Standard methods should be used in testing for the
presence of antiphospholipid.
An abnormal titer of antinuclear antibody by
immunofluorescence or an equivalent assay at any
time and in the absence of drugs known to be
associated with drug-induced lupus syndrome

(From Hochberg MC: Updating the American College of Rheumatology revised criteria for the classification of
systemic lupus erythematosus. Arthritis Rheum 1997;40:1725. Reprinted with permission of Wiley-Liss, Inc., a
subsidiary of John Wiley & Sons, Inc.)

Criteria for the Classification of Juvenile Rheumatoid Arthritis

Age at onset: <16 yr
Arthritis (swelling or effusion, or the presence of 2 or more of the
following signs: limitation of range of motion, tenderness or pain on
motion, increased heat) in 1 joints
Duration of disease: 6 wk
Onset type defined by type of articular involvement in the 1st 6 mo after
onset:
Polyarthritis: 5 inflamed joints
Oligoarthritis: 4 inflamed joints
Systemic disease: arthritis with a characteristic intermittent fever
Exclusion of other forms of juvenile arthritis
Modified from Cassidy JT, Levison JE, Bass JC, et al: A study of classification criteria for a diagnosis of juvenile
rheumatoid arthritis. Arthritis Rheum 1986;29;174181.

RHEUMATOLOGY
SYSTEMIC LUPUS ERYTHEMATOSUS
1997 Revised Classification Criteria
CRITERION
DEFINITION
Malar rash
Fixed erythema, flat or raised, over the malar
eminences, tending to spare the nasolabial folds
Discoid rash
Erythematous raised patches with adherent keratotic
scaling and follicular plugging; atrophic scarring may
occur in older lesions
Photosensitivity
Rash as a result of unusual reaction to sunlight
(elicited by patient history or physician observation)
Oral ulcers
Oral or nasopharyngeal ulceration, usually painless,
observed by a physician
Arthritis
Non-erosive arthritis involving two or more peripheral
joints, characterized by tenderness, swelling, or
effusion
Serositis
Pleuritis:convincing history of pleuritic pain or rub
heard by a physician or evidence of pleural effusion
OR
Pericarditis:documented by ECG or rub or evidence
of pericardial effusion
Renal disorder
Persistent proteinuria >0.5 g/day or >3-plus (+ + +) if
quantitation not performed
OR
Cellular casts: may be red blood cell, hemoglobin,
granular, tubular, or mixed
Neurologic
Seizures:in the absence of offending drugs or known
disorder
metabolic derangements (e.g., uremia, ketoacidosis,
or electrolyte imbalance)
OR Psychosis:in the absence of offending drugs or
known metabolic derangements (e.g., uremia,
ketoacidosis, or electrolyte imbalance)
Hematologic
Hemolytic anemia, with reticulocytosis
disorder
OR Leukopenia: <4,000/mm3 total on two or more
occasions
OR Lymphopenia: <1,500/mm3 on two or more
occasions
OR Thrombocytopenia: <100,000/mm
Immunologic
Anti-DNA antibody to native DNA in abnormal titer
disorder
OR Anti-Smith:presence of antibody to Smith nuclear
antigen
OR Positive finding of antiphospholipid antibodies
Pedia Notes

TOXICOLOGY
Yellow phosphorus most toxic ingredient in fire crackers like Watusi;
classic syndrome of hepatotoxicity
Mechanism of toxicity
Liver steatosis, necrosis
Renal tubules & myocardium are not spared. Vascular collapse and
hepatorenal failure. Calcium is excreted as a result of phosphorus
absorption explaining cardiac abnormalities.
Toxicokinetics peak plasma level 2-3 hours. Fatal dose 1mg/kg,
minimal toxic dose 0.3 mg.kg
Manifestation of toxicity
First stage 8-24 hours
Nausea, vomiting, abdominal pain, diarrhea
Hematemesis
Extreme tirst
Shock, seizure, coma
Strong odor or garlic on breath, vomitus, & feces (smoking stool
syndrome)
Second stage 1-3 days, symptom-free, latent stage
Third stage - Hepatic failure, jaundice, renal insufficiency, restlessness,
delirium, toxic psychosis, coma; Mortality > 50%
Laboratory:
CBC, BT, LFT, Urinalysis, BUN, Crea, serum e, ABG, FOBT
Therapeutics
Calcium gluconate 10%
Dextrose 50%
NAD
Phytomenadione
Vitamin C

Page 22 /epcapul

MEDICATIONS
Amphotericin B
Amphotericin B (1mkd) 50mg/vial + 10mL sterile water to make a
5m/mL stock solution.
Give 3mg or 0.6mL (5mg/mL stock solution) + 30mL D5W to make a
0.1 mg/mL solution. Infuse over 6 hours OD.
st
nd
Adenosine for SVT 0.1mg/kg (max 1 dose 6mg, 2 12mg)
Albumin 0.5-1gm/k/dose x 30-120mins (max 6gm/k/day)
Aminophylline 6mkLD x 20mins; MD 1-2mkdose q6-8
Amiodarone 5mkdose x 20-60min (VT), bolus
(VF/Pulseless VT)
Atropine 0.01-0.02mg/k (min0.1; max0.5mg); may rpt once
Bumetanide 0.015mg-0.1mkdose (max: 10mg/day)
Calcium gluc 100mkdose x 1hr (max 3gm); 200-500mkd/q6
Chloral hydrate 25-100mkdose
Dexamethasone 1-2mkLD, MD 1-1.5mkd/q4-q6 (max 16mg/day) for
cerebral edema; 0.5-2mkd/q6 for airway edema
Dobutamine 2.5-20mcg/kg/min; rate= wt x dose/16.6
Dopamine 2-20mcg/kg/min; rate= wt x dose/13.3
Epinephrine 0.01ml/k SC (allergy/asthma); drip 0.1-1mcg/k/min; racemic
0.5ml/kg in 3mlNSS (max 2.5ml<4yo; 5ml>4yo)
Etomidate -.2-0.4mg/kg
Fentanyl 1-2mcg/kg (for BP&head injury)
Furosemide 0.5-2mkdose (max: 6mkdose)
Granisetron 10-20mcg/k/dose
Hydralazine 0.1-0.2mkdose q4-6 (max 20mg/dose)
Hydrocortisone 4-8mk LD (max 250mg); MD 8mkd/q6 (asthma), 15mkd/q12-OD (allergy)
Ipratropium bromide 0.25-0.5mg/dose TID-QID
Ketamine 1-4mg/kg
Ketorolac 0.5mkdose IV q6 (max 30mg/dose)
Labetalol 0.3-3mg/kg/hr infusion
Lidocaine for wide complex tach 1-2mg/kg
Mannitol 0.5gm/k or 2.5cc/k; 1gm/k or 5cc/k
MgSO4 25-75mkdose x 20mins q4-6 (max 2gm)
Midazolam 0.05-0.1mkdose; 1-5mcg/k/min
Milrinone 50mcg/k bolus x 15mins; 0.5-1mcg/k/min infusion
Morphine 0.1-0.2mkdose q2-4 (max 15mg/dose)
Nicardipine 1-3mcg/k/min infusion
Nifedipine 0.25-0.5mkdose q4-6 (max 10mkdose or 3mkd)
Nitroglycerin 1-5mcg/k/min (max 20mcg/kg/min)
Omeprazole 0.6-0.7mkdose OD-BID
Phenobarbital 20mkLD, 5mkdose q30min (max 30mkLD)
Phenytoin 20mkLD; MD: 5mkd/q12-q8
Prednisone 2mkd/OD-BID (max 80mg); taper if >5-7days
Procainamide for VTach 15mg/kg (do not give w/ amiodarone)
Propofol 2mg/kg
Propranolol for Tet 0.15-0.25mkdose SIV; may rpt in15mins
Prostaglandin E1 LD 0.05-0.1mcg/k/min; MD 0.005-0.04mcg/k/min
Sodium bicarbonate 0.3 x wt x base deficit; max concentration for
infusion 0.5meqs/mL; max rate 1meq/k/hr
Spironolactone 1-3mkd/OD-QID
Terbutaline 2-10mcg/k LD; 0.1-0.4mcg/k/min infusion
Thiamine for Wernickes enceph 100mg IV x 1 then OD
Thiopental 2-4mg/kg
Tramadol 1-2mkdose q4 (max 500mg/dose)
Tranexamic acid 25mkdose TID
Vecuronium 0.1mkdose q1 or 0.05-0.07 mg/kg/hr infusion
Vancomycin
Example 3kg
Vancomycin (15mkdose or 60mkd) 500mg/vial + 10mL sterile water to
make 50mg/mL stock solution, give 45mg or 0.9mL (50mg/mL stock
solution) + 9mL NSS to make 5mg/mL solution. Infuse over 1 hour Q6.
Monitor for increased/decreased BP, tachycardia.
If these appear, stop infusion and give Diphenhydramine 1mg/kg/dose
IV.

REFERENCES:
Bambo Notes
Nelson Textbook of Pediatrics
Pedia Lectures
PICU Lectures

Pedia Notes EPCapul 4.0

/phil4:13
Pedia Notes

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