foareh SOTY — MIU COM HANDY PEDIATRICS : NOTES - . Odpee S. Oobrioxn. Baby Print Copyright @ 2003 by MEDwoRx Desktop Publishing All rights reserved. No portion of this, bobk may bé reproduced, photocopied. or transmitted in any form “without written permission fram the copyright owner, Printed 2008, Uedefed. babysrintmd@[Link] = --TARLE OF CONTENTS GENERALITES / VITAL SIGNS | GROWTH AND DEVELOPMENT Weicht, Length Height Head Circumference, Fontanets. Liver Span, Teeth Enuption Tanner St Gevelopmental Miiestones Socisemetional Development PEDIATRIC DIAGNOSIS NUTRITION Computation for TCR. Catch-up Calories Breast Milk vs, Cow's Milk Natural Milk and Mik Substitutes RIDA for Vitamins and Minerals Wateriow Classification Protein-Calorie Malnutrition PREVENTIVE PEDIATRICS Anticipatory Guidance Preventive Evaluation Inenunization NEONATOLOGY Routine Delivery Room Care Nonmal Physical Examination Dubowitz & Ballard Sconng Physical Mabrity Rating Physiologic Changes. Neonetal Sepsis Respiratory Distrass Syndrome Transient Tachyprea-of the NB Neonatal Pheymonias ‘EMERGENCY MEDICINE Basic CPR Advance Cardiac Life Support Rapid Sequence intubation Resusctation Drugs FLUIDS & ELECTROLYTES Maintenance Degres & Types. of. ‘Dehydration Fluid Composition i Anion Gap Total Parenteral Nutrticn, GASTROENTEROLOGY Dlarhea SHG8 HAR RBS & BASE RS Jaundice PULMONOLOGY Asthma Pulmonary Tuberculosis Upper Ainseays infections Preumonia NEUROLOGY Netrotagic Exam ‘Glasgow Coma Scale Lurmibar Puncture, Meningitis CSF Findings. Seizure Status Epi Subdural vs, Epidural Bleeds WFECTIOUS MEDICINE Dengue Hemonhagic Fever Viral tines HEMATOLOGY Blood Component Therapy CARDIOLOGY Congenital Heat Disease COMMON OFD DRUGS REFERENCE LAB VALUES Hae. 2 58 8 a Bi & 64 66 66 m B aaaVITAL SIGNS OF FILIPINO INFANTS. AND CHILDREN = 4 Average Respiratory Rate and Cardiac Rate a “92.0 | 147 até | 139 Teas | 22.5 | 128 (85" percentile} 5 ane s ay rer te | see | te Te Pea ie ae io 96.80 | 26 pa 28 iss | 18 [tay | 10695 | 30 Tee! NB-7 days: 95 & 11 yrs: 36.56 By | sam are = 9 37.00 5730 | 04 |” aye pare oy 135 a63 (Fispina} ue Catmasian} Ape (ma ie cau Age (ye) x5 +17 where 10 = number of aa: ta recover over Physiologic eit nas 20 = piday gained Usual Changes in Weight al Different Ages — “Gain in 12! yrs 25 cm, -f lnches | distributed as follows: [20] game: Sem 3-60: Bem |_| Agex25+a0| 6-9mo; Som 9=12 mo: 3 emHEAD CIRCUMFERENCE i [moh [somites [Sid eine [Trine per month] inches} poet ee rer Correction Factors for the Determination of Head Circumference Add or subtract anit for gach pound above of below average waigh 20 f 15 see a Wy : Boz. 1.0 46 6 G oz FONTANELS : * Nonmally slightly depressed and pulsatile * Evaluated when infantis held upright, asleep or feeding . * Approximate size at birth: 2x2 em (anterior fontanal) * Gloses at) Anterior: 18 mo, as early as 9-12'mo Posterior: 6-8 weeksTHORACIC INDEX = fansverse chest diameter, 4 i AP diasneter NV: Bri - 4.0 1yeer 1.25 : Gyears = 1.35 EXPECTED LIVER SPAN AGE OF TEETH ERUPTION Betiduows Teeth _ Permal Average Ages indnonths | Avérage Ag " Maxillary | Mansdibular fi- 7% 64-1 11% 12%Hypematremic Skin Color = - a : Gre Tompariture Tugor We Di Thigk, doughy D 100 mikg aver 6 brs 10 mlkg ORS! dearrheic stool Formulated ORS Glucoiwte 60 20, Glucose 20g Nat 60, Kt 20, Cr 50, Mig’ 5, Ghitonate 6, Crate 10, Glue 100 Net 90, K+ 20, Ct 60, HOO. 3), Glucose 111 - 4 sachet (250 mi Hydrite ORS 45: ttab/ 200ml Oresol (DOH) 4 sachet HL Orhydrate — | 60 ml in 940 mi water Concentrate | Oe 5 md irs 7B mil wets Syrup Nar 45, K*20, CF 35, Mg 25, Gluconale 2.5, Citrate 30, Glucose 10g, Sucrose 20g Nar 45, K 20, Ch 35, Citrate 50, Dextrose 25g, Calories 100) Nar 90, Kr 20, Citrate 30, Dextrosa 259, Calories 100 Premixed Pouialyte 99. | PremixedTANNER SEX MATURITY RATING 5 SMR nee Preadolescert Sparse, lightly pigmented, straight, medial border of Jabra Breast and panilla elevated as small mound: areolar dameter increased Coarse aut, abundant but amoint < ach Breast & areola enlarged, 10 contour separation Areola and papilla formed secondary mound Adult, fannie inangle, spread to medial None, Scant, ong slighty pigmented Darker, starts to curl, small amount Sacer —— : Sere ce gement ‘Mature; nipple projects, areola part of general breast contour et surface of thighs 4 Resermbles adiult type bul less in ce gars and quantity, coarse, curly breadth T in size 5 Adult distribution, spread to medial Adult size b Adut sizeDEVELOPMENTAL MILESTONES Starles (Muro Reflex} Tmo Raises head slightly = |. | from prone {<:457} midline Hands fisied ot 2 tna Head contol 46° Holds head in midline Hands no longer fisted Head contd 90° Pull te siL no head lag vowel sounds} 4m Ralls over t Onents to voice “| Play with ratte in hand 5mo | Good head control Transfer object hand te pet to bell localizes | Enjoys looking around hand the environmen | 6 mo Sits without support Chews . : Ee babble Indicates likes, disikes Fira Bounces, Crawls Rakes at small objects Feeds self with crackers & mo Onents to bell (localized indrectiy| Follows one step command with gesturePivots when sitting Creeps Stands holding on Cruises Pulls self to stand | Stands alone Walks with one hand held Walks well alone ) Walks backward Crawls upstairs “Runs Siffly 4 Seats self in child's chair Walks upstairs with one hand held Runs well Walks up, down stairs one siep of time Thur finger grasp / Pincer grasp (assisted) Holds bottle Pokes with forefinger Pincer grasp (unassisted) Throws abjects Lats go of toys, hand releose Builds tower 2-3 cubes Makes fine with crayon Inserts pellet in bottle Builds tower 4 cubes: Initates a verical stroke scribbling OCumps pellet fr. bottle Builds tower 7 cubes imitates a circuwar eircka Invtates sounds Orlents to bell (directly) “Dada, Mama" discriminately Follows ene siep command wit: gesture One word other than “dada, mama [2d words other than “dada, mama" Obeys commands or requests 10 words * Names pictures _idantifias one or more body parts Combines two of three words in sentences 2-etep commands Shy with strangers 7 Waves bye, bye Pieys peek aboo, Paea--cake Heps dress, holding arm of foot out Egecentric pretend play. Gomes when caled Attempts to use @ spoon Indicaies desires! needs Pais picture irsitates housework _ Complains when wet Tums 2 of 3 pages at a time . Tolet trained by day Tums pagas 1 ata time~ Age Grogs Motor Adaptive Fine Motor Personal Social eviy | Walksupstaig = Builds tower cubes = | Kinews full mare Helps put things away’ gltemating steps « imitates circular sticke =| Usex pronouns Gets self dink wii help Jumps forming closed figure | appropriately - 3y Ridgs tricycle Builds tower 10 cubes ~ |. Knows age and sex Unbttons, puts on Stands momenianly of | lmitates-cross Counts 3 objects shoes one faut Copies circle Uses plurals, past tense) Dry by night : Tels lifile slories ehout | Washes & dries hands 2 -_experiences Plays interactive games ay Hops cn one foot © Copies square, bridge | Knows color Bulicns up i | Climbs welll Draws man wi 3-5 parts | Counts ¢ pennies Tells “tal falas" 1 Watks dowrstalrs . Names longer of 2 hes 1 Says song and poam ‘Goes tc tpfet alone i attemating feet from memary ; . Sy 7 Skips, both feet Comes tangle Counts 10 pennies - Plays competitive “= | Heel tatoe walk Viriles alphabet Prints first name games | Jumps over tow Asks whal a word Abide by res: {__ obstacles means: Domestic role-playing Backward heel'to toe “| Draws. a complete Adds and subtracts Dresses self ccmpletely wok peredn with dothing = | Distinguishes betwaan po Gan write fairly wel left and right ps ae ‘Complex patiern Aveward and self (| -Talle tiene ie Sense‘af humor movements idancing. conscicus Reads for pleasure Accapts Tes ___ playing piara} i! Cencrele operations Conventional moralitySTAGE THEORIES OF SOCIOEMOTIONAL DEVELOPMENT - 18 mo-3 ys 8-6 yrs B12 yrs, Autonomy vs. Initiative vs. industry vs. Shame, Doubt Guilt infariority infants learn to| Children team te | Chidrenleamic - | Children develop trust, or exerdse wil to | iniliate actives & asense cf fristrust, that | control enjcy accomplish- industry & their needs wil| themselves, or =| mers, acquiring curiosity & are be mei bythe | they become directions! purpose. If | eager to learn, or world, uncertain & doubt} not allowed initistive, | they feel infenor & they feel quilty for lose Interest in the attample at tasks before them in ~ Phallic stage Latency stage (Oedipal) Children's sexual “Children develop lages are sexual curiosity & submerged, they obiain gratification pul their energies through masturbation. | into acquiring They have sexual cultural skills fantasies of opposite sex parent & quilt about the fantasies Anal stage Children obiain gratification through through exercise stimulation of | cfthe anal. the meut, as | musculature they suck &- | curing elimination cr retention Genital stage | Adolescents have adult heterosexual desires & seek ioPiaget (Cages) = Sensorimotar Concrete operations | Formal operations Learning occurs. Child beuames capable.) Gan reascrvlogigaly & though activity, of Finite logical abstractly. Can exploration, & representations of + thougat proceszes, as | formulate & tesi i manipuation cf the world, as in use of in seeing relationshins | hypotheses. Thought environment. Moler & | language. play, & & classifying, as kong =| no longer depends on . Sensoryimpressiors | deferred irifation. Stil | as menipulatle, - concrete realy, Can. form the foundation of |-not capable of concrete Tateris are } play with possibilities | tater learning sustained, systamaitic | available » Can manipulate = Seif-identity -Leame | thought. * vation: things | variables in 2 scientific te differentiate’ self © Engages in remalt the same despite) siuation from world spmbaltc play | change in appearance, | 6 Can deal with « Formation & * Dacline in *Reversiiity | aneiogies & metaphors } integraton of schemes | agccentricity ¢ Decenttation— can » Cen reflect on own : e OHS an >| aspect af a = Achieves offect « Develops language & sibeatlon at tine thinking permanence — thal drawing 2s modes of / | | Transiiity can = Can work cut things can exist even representing deduce new relaionehips | oormbinations & when not visible experience om carber ones parmutaiions # + Senation - order things : in baquence « Glaentication - groups tienPEDIATRIC PHYSICALEXAMINATION st « nohard & fast rules; must be opportunistic * do most bothersome procedures last (e.g. eat & throat) Suggested Order of Examination Take weight & measurements (HC, Length, etc.) Inspect patient —illooking? skin changes? nutrition? atc. Palpate fontanels. Note neck. Auscultate heart & lungs. Palpate & Percuss. _ Palpate abdomen. Percuss & Auscultate. . Check lymph nodes. = * * / . Examine back & spine. Test hips & other jaints, . Inspect external genitalia. Use Tanner staging (p.5} Neuro'exam: motor; reflexes, coordination; séngory (p.59) 4. Examine eyes / optic fund & ears (otoseope: aa 11. Inspect nose & mouth. 12. Take blood pressure. : 13, Assess development, behavior & Pere Observe gait. 14. Rectal exam ifneeded. TECHNIQUE IN MAKING A DIAGNOSIS } * Summarize data then choose ‘presenting manifestation” ~ 4 Si Sx pathognamantc of a probable diagnosis - da trial dx % SVSK pointing to a definite organ think of diseases commonly : affecting that organ or system 4s SISK pointing fa a definite group of diseases —dotrialdx 4 SVSK whose mechanism is wedi understood — study mechanism % S/Sx found in the feast aurrber of diseases = do triat dx Test trial diagnosis. Apply it & discover unexplained data, Choose probable diagnosis then do confirmatory tests Once confirmed, make treatment & prognosis Diagnosis final when patient: 1} recovers, 2) is operated on, 3} dies, 4) disease runs its characteristic course, and 5} histapath confirms it DOW oom bw eo. fF ©COMPUTATION FOR TOTAL CALORIC REQUIREMENT (TCR) Required Daily Allowance (RDA ; 12 Weight (kg). [Calories (kcalvkg)| CHON (gikg 3-6 115 35 3.0 25 20 6-14 mo i oe a A. Solve for Total Caloric Requirement {TCR} TCR = Weight at p50 (kg) x Calories {kcal/kg} eg. 1 yt old baby weighing 10 kg: 10 kg x 110 kealfkg = 1100 keal ; B. Determine TOReeoin grams, then convert to calories TC Renan = CHON (g/kg) x ABW (kg) \ eg. 259 CHONAg x 10 kg = 25g CHON Conversion factor to calorias (kcal/g): CHON#, CHO 4, fat 9 e.g. 25 g CHON x 4 keallg CHON = 100 kcal GHON C. Subtract TCRevow from TCRiom then get traction of CHO & fats (usual ratio 60-40) eg. 1100 keal - 100 keal CHON = 1000 keal 60% of 1000 = 600kcal CHO: 40% of 1000 = 400kcal fats D. Gonvertback lo grams: write final prescription _ eg 00kca - 25q 1809 1 459 ™TCR CHON CHO fats RDA ADJUSTMENT FOR MALNOURISHED CHILDREN (CATCH-UP CALORIES) Adjusted RDA = RDA for chronological age x wt {kg} at p50 ‘, actual weighteg CUC = 1140 heats 6.4kg = 999 kealkg eo 2kg : Adjusted TCR = 220 kealhg x actual wt (3.2 kg! = 704 eal Total Caloric Intake = calories x amount of intake (oz) Gastric Capacity: Age in months +2 Gastric Emptying time: 2-3 hours Other Caloric Values (1 oz = 30ce “1 thep = 150 (tsp =5 ce} Cane! table sugar Wkeal Sco or 120 kealloz a [DW a hea 100ce [Karo syrup cae BREASTMILK Colostrum (12 2-4 days postpartum) eT CHON (globulin), vitamins, salt, & Ig, + fat & sugar Foremilk — clear, thin & bluish; low fat; high water content . Hitidmil— thick, ore amy-white; high fat (peaks early in tha day) Contraindications to Breastfeeding Absolute: Galactosernia, Tyrosinemia Relative. Psychosis, active PTB Comparison of Breast milk vs. Cow's milk « [ Human Milk, Mature I Cows mik | Pratain es PUFA & ong chain * Efficient, No loss in stools =} Stool losses_COMPOSITION OF NATURAL MILK & MILK SUBSTITUTES 14 Grand 100m E L Reals Protein] CHO | Fat Ma x a] Ca Pp Fe Humon mik, mature, average | 220 | 1.1 | 70 | 38 | 65 | 4 f2_ | 3a | 150 | 15 Cow's mik, market, average a | 33 | 48 | a7 | 2 a5 ao] it | geo] 1.0 | Cow's mak, evaporated 0 ‘38 f4 40 28 3 a2 -) 13 1A 1.0 || Prepared formula, cow's milk 2 20 ra’ Pa BG | 15.0 | 13.0 | 594 | 308 rg based e.g. [som 20 1 0 47 {| 130 | 18.0 | 15.0 | fo | S10 | 120 COMMERCIALLY AVAILABLE MILK FORMULAS 1 scoop: 1 oz dilution 1 scoop : 2 oz didution Prepared formula, cow's milk based i ars A. Infant formulas Aladami, Apiaml, Dulac, Enfalac wi DHA, Bonna, 5-26, $-26 Gold, Similac Advanee Frisolac, Nestogen 1 : : B. Follow-On formulas | Dupre, Enfapro, Frisomel, Milurnil, NAN Dw Bonaril, Gain w! TRAN, Hi-Nudac, Prom, al Bifidus, N 2 = Prom Gold Specie! fpamutas . AL Soy based Prosobee Tsomil, Nursoy B. Casein basedt Al 110, Enfagrow Laclofree, Enfanre Laciotree | 5-26 Lactofree : CH i NAN [Link] " O. Nutritional Products | Enfalac A+, Pediasure (5 scoops! 190 E. Premature Enfalac Premature, PreNAN wi LCPUFA i ee.RECOMMENDED DAILY —_—__ FOR VITAMINS & MINERALS 15 Eye symptoms aaa Carotanemia, Liver, fish, liver als, , xeropihalmia, anorexia, slow growth, | whole mitk, milk fat Biter's spots, keratomalacia); | drying of skin, liver & \ Menrbranes, failure | Vitamin D “Ot tiday | Rickets, infantile tetany, Hypercalcemia (ehole- Ostoemalacia, Cranial (vomiting, retardation, calciferol) - i bone changes, soft 4-5 [Uiday (tocopheral} Hemotytic anemia in premature: infants, loss of neural i Vitarmen K 1-2 mglday i i (phytaquinone} Water Soluble Vitaming Vitamin B O5mgday | Ber-neri, fatigue, ancrexia, i initability, constipation; Pelyneuritis, edema, cardiac failure, aphoniaB2 (Ribofiavin} ‘Nadn (nicotinamide) blurred vision, itching, comeal iebolinanosis photophobia. Peliagra (diarrhea, dermertia, | Milk, cheese, liver, @ggs, fish, green jeaky vegetables, clarak Meat, fish, poutiry, dermaiilis): Cheficsis. angular | & itching): enriched or whole (et Leeeniy: drains, green veggies Slegetoblaslic anermea, Unknean Liver & other organs, is, iti green vegetables, nuls Dermaillis: seborrhea, Unkroven Yeast, animal’ * inactivated ty avidin in raw «| producis. synthesized egg white 4. in intestine 1-2 motday ss 1 Meat, liver, kidney, BS (Pyridoxine) inttabllily, corvaulsions,- hypochrome & macrocytic whole grains. ~ahernia; peripheral neuritis epybaans, mut fish, with INH adiminisiration) | ~ ie green vegetables "| Biz (Cyano- 0.3 pyday | Juvenile pemicious anemia; Unknewa Muscle g-argan meats,‘| cobalanin) }. Secondary to gasirectamy, fish, eggs, .cheese, : cellac & small bowel dse,; amitk Neurologic manifestations : Wiamin C Istye: [Link] | Scurvy {stan herorhagas, Citrus fruits, berries, af yr: 35-75mg | iritability, leg tendemess } tomatoes, cantaloupe, (eacorbic ack} Peer wound healing ifyre: OF g 05g! day Poor mineralization of bones & teeth; osteomalacia; f osteoporosis: tetany; rickets Hypochioremic alkalosis (with Associated with Ca deficiency, malabsorption, tetany, 4 ke Muscle ‘woalkness, abdominal Heart Thiokas serum: distention, irritabalty! levels of 10 mEq/L drowsiness, arrhythmias Nausea, diathea, hypotension, | Edema, seigures: muscle cramps, dehydration (Growth fagure Goiter, Cretinism Hypochromec, microcytc anemia, growth fallure Dwarfism, + wound healing, aesereay, anemia, Protein foods. ar 1% lodized sal, seafoods~ WATERLOW CLASSIFICATION 1a Weight for Age (WFA) = actual wt+ wt at p50 x 100% > 90 no PEM : TS-O7 mad PEM 60481. moderate PEM. - <6 severe PEM Height for Age (HFA) = actual ht+ ht at p50 x 100 % > 95 no stunting 90-102 Thild afunting 85-89 moderate stunting =< BS Bevere stunting Weight for Ht (WFH) = actual wt+ wt at p50 of ht at p0 x 100 % > oO no wasting 80-90 mild wasting 70-80 moderate wasting <70 severe wasting PROTEIN - GALORIE MALNUTRITION Lo MARASMUS essential features | edema None Legs or generalized | | Wasting ~ | Gross lose of SO fa Apathetic, quiet E Variable features Uncommon Megaloblastic Iron deficiencyANTICIPATORY GUIDANCE 19 « ©Parant education to anticipate child's needs, prevent diseases & injuries, & to promote optimum health, growth & dev't Newborn & Care of the umbilical cord, clrcumeision, fontanels > Breast engorgement, vaginal discharge > Jaundice, colic, hiccups, spitup, stools < Jitleriness, sleeping, sneezing, pacifier, bathing, skin care > Unwanted advice, postpartum adiustment, importance of close interaction, rest for mother, sibling reaction, change in parent-family relations, feeling of inadequacy, depression > Breast & boltle feeding; Vitamin & fluoride supplement When to call the doctor, fever, vomiting, diarrhea & Injury prevention (1.P.)- crib safety, never leave alone with pet or young siblings, be careful with hot water during bath PE. gestational age, red reflex, HC, L, BV, aera, femoral arteries 2-4 weaks @ |.P: never leave infant unattended Nutrition breast / formula feeding ® Sleep, crying, bladder & bowel habits, urinary stream Emphasize baby's abilities; hold, cuddle, talk to baby > Parents time for themselves, avoid isolation Prepare for future immunization * PE: umbilicus, heart, heating, dacryocystitis, abd. masses 2 months & IP: don'tlay baby on bed ¢ or table unattended, caution with hot liquids, cigarette ash ® Advice against infant walker ® Nutrition: iron supplament in pre-tarm Sleep; play, talk, cuddle baby; spend time with siblings & PE: WFH, muscle tone, congenital malformations4months . 20 ® IP. car safety, protect from falls from bed, keep powder ‘ containers, small objects out of reach; sittersinanny > Talk to baby, responds to vocalization; sleep, thumb-sucking ® Nutrition: introduce solid food (mashed veggie, chix breast) © PE: Anthropometry (W, H, HC), WFH 6 months ® JP: home checklist for hazards, syrup of Ipecac, car safaly, protect fromhot liquids, dangling cords, pulling tablecloths, walker & expanding table gates, pool & bath safety, electnical cutlets & plugs > Play games, talk with baby, siranger anxiety, teething > Resistance to sleep, suggest favorite toy! possession Nutrition: iron-fortfied cereal, fruits & vegetables, fluoride & Vitamin DB (if needed); discourage milk! juice a8 pacifier Hab & Het screening for LBW infants Changing diapers; shoes; day care; farnily mare ® PE, Anthropomeiry, Hearing & Vision § months . ® IP: stair gates & window guards to prevent falls, Choking hazards e.g. small objects, peanuts, grapes, holdog, syrup of Ipecac; Water safety Good parenting practices (GPP), vocalization, imitation, communication, social games, autonomy, limit setting, ~ discipline; Separation protest; Shoes; Child care 4 Sleep, night awakening, favorite toy or possession ‘ Nutrition table food, toast or teething biscuit for self-feeding, encourage cup, begin to wean, anticipate 4 food intake 12 months & [Phot liquids, tap water (maximum flow); kitchen, car & stair safety; fences, gates, latches, moving machinery, cars ® GPP: speech dev't (talk to baby); hold, cuddle, love; discusserrs | autonomy, limit setting: discipline; praise desired behavior, prohibition few but firm: shikd-care 4 Nutrition: table foods, + food intake, start te phase aff bottle use: advise against bottle in bed; fiuoride if indicated ® PLE; Anthropometry: Strabismus & Hearing 18 months >» iP- locked doors, safety gates, poison proof, danger of- aspiration (nuts, papeam, gurn); burnaf sealds; electrical injuries, water safety: danger of plasti¢ bags _. Play, talk, read & sing with baby; Discipline: remove trom temptation, praige good behavior, consistancy b/w parents > Review indicators of toilet training, Day Care & Nuthition: sellfeeding, eats meals with eine 18 manths ms 1 ® JP: car restraints, protect from falls, supervise play near street, never feava unattended in car or house, water safety ‘4 GPP Read simple stories regularly, play games, praisef show affection; Short ritual before regular bedtime, night fgars, night awakening; May show toilet training readiness al 18-24 mo “ Discipline: need for autonomy & independence, self- _ cornfarling behavior, thumb-sucking, masturbation, fave toy “of passessian ; Nuirtion. wean from bottle > fap ifneeded” 24 months a e /P burn, falls, restraints, car safety, toxic substances, od . batteries, electrical injuries, drowning, unsafa toys: plastic bag balloons, supervise play near street GPP Read regularly, talk at meals, play & peer contacts, watch kid's TV shows with child; curiosity about bady parts; Sleem move to areguiar bed, reassure that day napping vanes; Toilet training: shew interes! readinessNutrition: avoid stuggiés about eating, discoura ge 22 nor-nutritious snacks “ Mild speech dysfluency may be normal 3 years ® IP. danger of running in street, stray dogs, water safety & GPP» Talk about activites w/ child, Reserve time alone w/ child, allow to explore, showing initiative, communicate, encourage outothome experiences, limit TV viewing, tolerate transient speech dysfuency, satisfy curiosity about babies, sex differences: toilet training; discipline; dental appointment Nutrition: balanced diet, avoid junk foods, fluoride if needed © School nursery, day cara, baby sitters; school readiness 4 years IP. electrical tools, firearms, matches, poisons, bike riding in street, car seats, uninterrupted supervision near water, refuse food from strangers, stray dogs, steetproofing i > GPP: Provide interaction w/ ather kids: assign chores eq. set table, take exploratory walks/trips, play marbles, card/ board games, answer questions about sex at child's level > Discipline; Toilet ne Nursery school / Day care 5 years “® IP. electncal tools, firearms, matches & poisons, bicycle safely, water safely, seatbelts, home fire safety, know phone no. & address; Never go wi or accept anything-fr. strangers GPP promote interaction wi other kids, assign chores (ex. tidy room, set table), demonstrates interest in kindergarten School readiness, plays well wi other kids, normal dev't, endures ‘4 day separation from home; sex education o PLE. Visual, acuity, strabismus, BP 6 years “ Good heath habits (GHH)}: avoid junk food, maintain appropriate weight, exercise regularly, learn to swim, brush. we 33 teeth at least once daily, bicycle safely, seatbelts, adequate sleep, limit TY viewing Sociat interaction w/ family 4 peers GPP: establish rules, act as modals, provide allowance. spend time wi child, show interestin school, adult supervision when away, praise, hobbies, Renee 8 years & GHH: balanced diet, ‘avdid ik food, maintain weight reguiar exercise, bicycle & car safely, enough sl mp © Social & family interactions GPP- establish'fair rules, communicate wi child, interest in school, allowance, be a tole model; praise & encourage child, promote outside activities, obtain Bake card for chitd 10 years .& GHH: balanced diet, maintain weight, defisl care, bicycle, water & skateboard safely, drugs, alcohol & tobacco, sex education at home/schodl, TY & videogame limits Academic activities, Social interattion’skills, peers, hobbies & GPP: Supervise potentially hazardous activities, contribute io self-esteem, encourage ac tivities, prepare gts for menarche > PE. Tanner stage “scoliosis screening 12 years’ > GHH Diet, weight, physical activily,sports, hobbies, dental care, tampon use, rapid physical growth & sexual dav't, breast & testes self-examination, seatbelts, hitch-hiking ® Sex educatian; School Socia interaction wi family & peers: sports: weekend jobs GPP: establish rules, supervise hazardous activities, spend time w child, respect privacy, allow decision making =~ PE: Tanner stage, external genitalia, skin fold, BP, scoliosis24 1h 14 11. Ea) a ¥ fit ¥ |? Tv [¥ # |. ¥ ty | a EP EEE ETE ET 7 f f vw Ea wk [mo PREVENTIVE EVALUATION AT SPECIFIC AGES ray Blood press Vision (Snellen chart’ Heanng Urinalysis Hgbi Het Sexull development Tuberoulln AV komunizationsEXPANDED PROGRAM ON IMMUNIZATION (EPI) OF THE DEPARTMENT OF HEALTH —25 Vaccine Age Bose tt Site Interval bw doses | | BCG4 | Birth anytime | 0.05 mi for NB R deltoid region “ | after or G wks 10.1 milclder infants |. DIF fi wks 05m Upper outer aspect of thigh Bole Gwks 2 ops Mouth is Hepatitis 8 G wks 0.5 mi Antero-lateral aspect of thigh Measles |- Simo 0.5 mi Outer part of upper arm | BCG2 | Scheol entry OAm LU dettoid | Tetanus Childbearing o5m _ Delinid region toxoid women ie _&12menths | CONTRAINDICATIONS TO VACCINATION | Absolute Contraindications Relainve Contraindcations Not Goniraindications | Severe anaphylactic or allergec Immuncsuppressive therapy (all ive | Mild illness + low-grade fever reaction to previous vaccine _ vaccines) Current antibiotic therapy | Moderata to severe ness + fever | Eng allergy (WMR} Recent infectious disease exposure | Encephalopathy within 7 days of Seizure within 3 days of last dose Positive PPO | administration (Periussis} (Pertussis) Prematurily, except ffinfantis stil | | Immuncdeficiency in patient Shock within £8 hrs of last dese hospitalized at 2mo, OPV should be | | (congenital - all lve vaccines} or | (Pertussis) delayed until dischorge. Cr. # mother household contac! (OPV . Fever >40.5 °C within 42 hrs of last is HBsAg {-]. Hep 8B vacune delayed | | Pregnancy (MMR, OPVAPY) dose (Pariusais) until chad = 2000g. : |RECOMMENDED SCHEDULE FOR CHILDREN NOT IMMUNIZED INTHE 1" YROF LIFE 26 Time FAge fnmunizations Less than 7 years ole: (é mo of age} (1 month after 1© visit) Third visit (1 month afier 2"¢ visit} DTP, IPV i OPV, Hib, Hecatiis 8, MMA, Varicella DIP, iPV7 OPV, Hepatitis 8, Hib BTP, (PV / OPV, Hib Fourth visit DTP. Hepatitis 8, Hb Comments Musi be 12 mo of agé fo receive MMR and Varicella. Ht 25 yrs of age, Hib is not normally indicated Hib schedule varies. by manufacturer, The 4" dose must be > 2mo after the 3+ dose andor affer the 1* birlhday if series started: FA mo = 3 deses wi 37 dose 2 mo affer 2%! dose iv 12-14 mo = 2 doses, 2 months apart 426 mo afier 3" visit} = 15 mo= one dose 4-6 years of age DTP, OPY, MMR Preferably af or before scheol entry. DPT not necessary if x a Toth dose given on of after the fourth birthday 11-12 years of age MMR, Varicella, Hepaitis B | Repeal Td every 10 years throughout life ~ T years and older: First visit IPV/ OPV, Td, Hepatitis 8, | MMR, Varicella 6 suf Second visit IP¥/ OPV, Td, Hepatiiis 8 =| OPV maybe given 1 month after the first visit if ; i2 month after 42 visit} accelerated polio vaccination is necessary Third visit 6-12 mo after 274 visit (7-2 year V7 OFV, Ta, Hepailis B | MMR, Varicella, Hepatitis 8 | Repeal Td every 10 years throughout Ife |RECOMMENDED ROUTINELY —— ACTIVE IMMUNIZATIONS, ae [cast te ee A |. Possble Reaction | Reaction Bacile Caimatte Guerin a a usually = ieee oe 704m ip ae ee Scar, suppurative {BCG} S school entry Baim ‘@denitis, BOG infection Dipitheria, Pertussis, PlO.6mi lit | Fevey, restlessness, Teme te B: 0.5 iM inabity, toca Sgr emma fee ; 8: 71 after then q 10 yre B: 05 rt iM Tiveant oret poliovirus: - Same as DPT , ; — Measles P12 mopths or older 6: 5-12 ygars afler Fever, rash, arthralga. lymphadenopachy. seizure| Primary: 2 mos -- 5 yrs Doses: 4 moe 9. 05 mi iM Pain, redness, swelling at ‘nlection site; fever 97-00% Indications observed closely Prevention: 5,000 units Treatment: 40,600 -- 1211000 unite 3.000 - 5,000 units Substitution Temyn antibody deficiency, #50 - 500 units Ey IAT 9.55 mi kg BV. IM 002 - G6 el kg BOTT Mt Suns OR 125 ul kg BW. WH ITP, Kawasakl, GES 2 rnlkg of 5% preparation dd mig of 3% preparaiion Within 6 days of exposure O25 ravkg BY. IM | immediately after expestire 20 unite! kg BW, IM Post-exposure pregnant woman (14 trimester) Whin 7 days of exposure Within u hrs efter bi iROUTINE DELIVERY ROOM CARE “4. Position: Place infant haad downward inmeday, to clear mouth, pharynx’ & nose of secretions. 2. Suction: Gently suction pharynx and nose with bulb syringe or soft catheter, while stimulating te cry If Normal: head down: High risk fe.g. C5): crib level 3. Assess APGAR Score Activity ‘Appearance |, Blue, pale Grimace Noresponse | Grimace Some flexion of extremities : 2 Blue jimbs Completely limbs & trunk | Pink trunk =| pink “Absent + Below 100 Above 100 “Cry, cough, aneazes Active moter Scare: Respiration | Absent Slow, Irregular 7-40 at 1 min = vigorous infant 4-6 = mild-moderate asphyxia 0.3 = severe asphyxia Good strong Gry One-minute score: gives index of necessity for resuscitation Five-minute seare: more valuable in predicting-mortality, success of resuscitation and neurologic deficit at 1 yr of age ' 4. Resuscitation of the depressed. infant a. Warmin pre-heated radiant warmer b. Position head in ‘sniffing position’, neck slightly extended” roa" eoo . Suction mouth then nose with bulb syringe or suction . Dry-wipe dry & remove wet linen Stimulate = rub back or flick soles of feet Assess HR, respiration & color — give O» as needed . Bag-Mask Ventilation (if HR < 100) at 40-60 breaths! min _ Chest Compression (if HR < 60): 2 thumb-encircling handsi, Endotracheal Intubation only if CPR not effective 30 |. Consider Epinephrine (0.01-0.03 mavkg IV [Link]}, lsotonic crystalicid (PNSS;PLRS), NaHCOs, Naloxone, ~ 5. Maintain body heat ‘ > Body surface of NB 3x that of adult > Rate ofheatloss 4x that of adult occurring by: . @, convection to cooler air i b. conduction to cooler materials ¢, faolston from infant d.° eveperaton from moist skin > Initial rectal temperature (N.V: 36.6 — 37.2°C), then q4 until stable, Following readings taken per axilla g8. §. Normal physical exam and maturity testing — Skin: vernix caseesa, lanugo, jaundice (> 24 hours), harlaquin color, motiing (thermoregulatory instability), Mongolian spots, milia, eryihema toxicum (harmless small erythematous papules), Head / Neck: HC, fontanels ftense, bulging or depressed}, Caput succedaneum— edema wi or w/a ecchymases, ill- defined borders, disappearing in a few days Cephalhematorma - subperiosteal bleed limited by periosteal attachments, NOT crossing suture lines, absorbed slower than a caput Craniotabes= soft areas of bone, which give a ‘pingpong’ bail sensation when depressed ° . Epstein pearls - whitish shiny cysts on palate & guiris Ghest Normal RR: 30-60 /min, diaphragmatic Periodic breathing {apnea <10 sec): nonmal in pre-term Normal CR: 120-160; auscultate for-murmurs Brachial = femoral pulse intensity: BP (farm): 50-7ov25-50 Abdomen Back: globular but not distended; diastasis recti (separation of recti muscles commen in newborns}:Liver edge palpable 2-3 cm subcostal margin; 31 Back without dinmpling or-tuft of hair Hip dislocation, ¢ Barlow's test - dislocatas ungtabla hip: flex & adduct He Ortetani's tast - relocates unstable hip; abduct — ‘clunk" "Neurologic, . flex Appears Disappears hora Birth am Stepaing Birth fiw Placing birth ” wks | Sucking and rooting Birth am, awake Palmar: Plantar grag to Ear Tonic neck Birth Neck righting 46m 24m Landau am 24m Parachute reaction gm Persists NEUROMUSCULAR SCORING Posture Square Window in Recoil Popliteal aso Angle go°| «90° * Beart Sian HeelPHYSICAL MATURITY RATING - 32 om ormed anc ae soit but is with aie ear ropes feady rece | instant reccil | stitf i Testes Testes down, an ° -§. Measuremente: weight, langth, HC. CC, AC ‘4 [Row birth weight (LBW) infant Ve ; Extremely tow bith weight (ELBW Small for gestational age (SGA) -BW< tO" percentile for gestation or below 2 standard deviations from mean Large for gestational age{LGA)—- BW > 90+ percentile . Ponderal Index = (Wting + Length in em) x 100 f lf> 2 symmetrical SGA; if < 2: ATEN RS SGA 7. Antiseptic skin and cord care Cord: 2 arteries, lvein > Initially use triple dye’ betadine to prevent Staph. _ infection, then 70% aleohal every-4 hours til it falls off 8. Apply tom strip Erythromycin oiniment to both eyes to prevent Ophthalmia neonatorum = Covers for both Neissena gonorhes and Chismydia . 9. Inject timg Vitis IM to prevent hypeprathrombi nemia & 40mg for full-term; 0.5 mg for pre-term ®. Given IM to prevent fvpedliubines heal a 10. Infant feeding Fern, hesitity infants: feed 446 hours after birth, start with 15-20 ca, increasing by 5 mi feading Pre-farin, SGA, LGA; earty feeding {2-3 hours after} to " prevent hypoglycemia, increasing 3-4ml! feeding- : < 1250 grams: parenteral feeding 5- sale ue solution without saline inibally eg. IVF DIOW at 65. mi/kg/d for Dt han D10IMB at 80 ‘mbkg'd for succeading days 7 PHYSIOLOGIC CHANGES IN THE NEWSORN / 1. Physislogic waight ioss — not more than 10% of BW, occurs oh 2™ day, recovered by 10!" day (147 day if premature) 2. Physiologic jaundice (uncenjugated hyperbilirubinemia)% predisposing factors: ye a. sumptus of REC, increased call mass b. decreased red celt survival i / ¢. ‘immature hepatic function (stow bilinabin metabolism} d. breast feeding © ogous on 243e day. paaks at the 45h day, di sappears on the 7" day (Term), 14b day (Pre- terra 3. Vasomotor instability 4. Genital crisis — pseudomenses due to matemal 5, Witch milk. i af estrogen 6. Transitional stools, 7. Inanition fever - during 1" week due te dehydration ~ 8. Physiologic desquamation of the skit RH not mora than 1 wk §. Falling off of tha cord 10. Physislogic anemia — at 2-3 mo, betrisibe level & mq DISEASES OF THE NEWBORN: ~ NEONATAL SEPSIS. env Onset] Pits Often present / Unusual amnionitie, pramaturity) Fulminant, multisystem Resp. distress, pneumonia 30% Group B strep f, fl, llr E coll, Usteria, Kiebsiela, S. - | prenroniae, enterococci Presentation Insidious, focal signs fever, ONS Common, 75% Group B strep Ill, E. coli, Stare, fungal, Hermes simplex ” Meningitis Treatment Ampicilin &Gentamycin | Ampiciliin & Genta- or Gefotaxime mycin or Cafotaxime Clinical signs: ; 1, Respiratory distrass— tachypnea, retractions, grunting, nasal ‘ flaring & apnea. : 2. Abnormal skin color~ motting, jaundice, cyanosis | 3. Temperature instability - hypathermia, rarely hyperthermia 4. Feeding Intolerance ~voriting, poor suck, abd distention5, Abnormal heartrate & blood pressure Fl 6, Abnormal neurotogic status — lethargy, seizures ! 7. Ophthalmia neonatorum : 8. Omphalitis » : Sepsis Sereen (Positive ff 2 or more are abnornad: 1. Culture - blood, CSF, wine ki ja Inmatare to total neutrophil (1:T} ratio > 0.2 ! pr yetlo = “Sebands + metas (immature) % segs + bands + melas ee ‘ 3. Leukacite count 7 Leukopenia if WAC < 5,000 Neutropenia if ANC < 1,750! mm? _ s ANC = WBC x % (segs + bands + nel 4. G-eactve protein Hteutrophil Indices of Sepsis : = 1. Neutropenia - inest specific 6 ey ? 1T ratio — mast sensitive 4. Band count =bands* WEG x 41,000 nv. <1,000/ mrs RESPIRATORY DISTRESS SYNDROME : Pathology: Diffuse lung atelectasis, congestion & edema with hyaline membranes containing fibtin.& eellular products due to surfactant deficiency . Signs. retractons, tachypnea, cyanosis grunting ® Fife retculogranular densities on CXR: LiS ratia <2 Course: gets worse before iiproving in 3-5 days Pievention, antenatal glucocorticoids at 26-34 wks AOG if at isk for pre-term delivery (Betamethasone 12 mg IM 24 Hours apart Or Ging iIMqi2x4doses) =~ w TRANSIENT TACHYPNEA OF THE NEWBORN Transient pulmonaty edema resulting from delayed clearance of fetal lung fiuid © Signs: tachypnea, rebactions WIC cyanosis, hypotension CXR: hyperaeration, * vascular raring (sunburst pattern ® Course: benign, selHimitedNEONATAL PNEUMONIAS ee Fe & Predisposed by premature labor, PROM, ' digital exam “42 Signs: tachypnea, ratractons, cyanosis, grunting CXR: diffuse homogenous & linear radiating densities © # Eliclogy and Treatment GES = Penicillin Chlamydia Enihvomyein * Refer to Seetion on Pumanobgy for Treats’ Agente We ' SASIC CPR IN INFANTE AND CHILDREN . Infant fe 4 yia} ’ Older Child (8 yio} , AIRWAY Unrespansive? Shout fer help Pos#ion patient Slipine on firm surface: Head-tit! Chin lift daw thnist ONLY if suspected SC injtiry;, No bind finger sweeps BREATHING Give 2 initial breaths (seal mouth & nose in Jnfants) If ainvay obstructed: 5-back blows {infant} / chest thrust Then: 20 breaths f min Then, 1S breaths / min CIRCULATION | _Gheck bractrial puilse Cheek carotid piles Chest Compression Compression location just below] Compression tacation: uit Ye stornum of sternum, betwean nipples Compression method 2 thumbs, | Compression method Heel of Hands encircling chest 1-2 hands Compression depth: 14. AP Chest diameter Compression: ventilation ratio = 30:2 (15:2 ff 2 rescuers} Push hard & fast (100/min}, Allow full chest recoil, Avoid interruptions ACTIVATE EMS SYSTEM — Call 817 (After 5-cyclos af CPR} infarits & Chilgret <8: phone fast; Adutt & Chiltrem ~ 8c phone first ' DEFIBRILLATION (see PALS next pa Baseu! an 2008 AHA Guidaires Or CPR § ECC, Afayo Foundation tor Meuisal Education & Raseaoh, & dat Linon Commitee ort Resusctaton. ASYSTOLE AND PULSELESS ARREST DECISION TREE 37 Y Quality BLS, Continue CPR, Oz therapy a \ © Confirm cardiac rhythm in more than one lead ¥— Ventricular fibrillation / Pulse: | less ventricular tachycardia “eee TPaseleas electrical activity (PEA): ¥ | « Shock tx (2 Wkg) | = Resume CPR at away sae ca 1 | * Do CPR while Te * Shock 4x (4 Wkg) | * Continue CPR « Epinepivine, q +6 min WD; 0.04-mafkg (4:10000) ET: 6.1 movkg {1:1000} Check rhythm | « De CPR while charging | * Shook tx (4 kg) + Consider Amiodarone, et dose 5 mofkg, then 2nd dese 10 magfkg | + Consider My for torsades de "pointes, 25-50 mafkyg IWAO Remember: es. an Hypoxia * Continue CPR for 5 cycles * Epinephrine, q 3-5 min "IMAC: 0.04 mgtkg (1:10000) ET: 0.4 mg/kg (1:1000} * Continue CPR * Ifshockable, proceed as VF: * Stillnot sheckable, continue — with CPR & * Check for & treat most | COMMON CAUSES | I Hypovolemia “Tablets’/ toxing Hypoglycemia Tamponade H+ ion acidosis Tension Hypol hyper K pneumothorax | Hypothermia Thrombosis Trauma © Quality BLS: Push hard & fast, Full chest recoil, Avoid interruptions of chest compression © Heart rate isthe most sensitive measure of volume status Capillary refill time - most sensitive measure of adequate : Jtirculation (MV. <2 gece in ambient temperature}ENDOTRACHEAL TUBE SIZE BY AGE : 3 ag since use uncuffed fube to + Subglattic edema & stenosis ® El Level Site of tube. 3 4 @ Lanngoscope Blade Size: MEDICATIONS THAT CAN GE GIVEN BY ENDOTRACHEAL TUBE NAVEL Naloxone Atropine Vasapressin Epinephtine Lidocaine RAPID SEQUENCE INTUBATION FOR INFANTS¥ CHILDREN 1. Pre treatment with Adjunct drugs (decrease secrefions): ~. * Lidataine - dose: 1 mgikg IV bol us, also for high ICP * Atropine - dose: 0.01 mg/kg IV: best for pediatric patients . 2. Prime with Sedatives: Midazolam (0.05-0.1 mg/kg} Or Thiopental (4-7 mg/kg) Or Fentanyl (1-2 meq/kg)- 3. Paralyze: Suceinyichodine (1.5 mgikg Iv) Or Vecuronium (0.1-0.2 mg'kg IV} + ~ 4, Pressure on cricothyroid. Place fuibe & confer placement. VASCULAR } INTRAOSSEQUS ACCESS sis « If Peripheral)lV line not accessed in 90 sec, Do Intraasseous access ( 15' choice for children < 5 y/o} via {in order}: ‘ Antcromedial surface of proximal tibia, [Link] belew 2 4-2 em modial to tibial tuberosity on fat part of bane ‘« Distal femur 3 em above lateral condyle in the midline ‘Medial surface of distal tibia 1-2cm above malleoius FLUID RESUSCITATION ; | @ 2cekg Normal Saline or Ringer's Lactate WAG folie over 20 minutes; Repeat up te 60 cofkg as needed _ ? * May give colloids-or blood if still needed after 34 bolusRESUSCITATION DRUGS 39 i Remarks Rapid IV bolus for paroxysmal Dilute with NSS Fi total vedurne if per ET mg Vian! single dose: 0.5 mg (Child) - 41.0 mg (aticlescent 100 mgimi {10% sokition) | | Ca. TK & Nig. | 200 mg in 250 mi DSW Refer to Rute of 6 for computation’ OR : ‘ 5. 10 ug: dopaminergic 400mg incom DSW a { 10-20 pag: ao > pg u adrenergic Same as Dopanine Refer to Rule of 6 ET: Ditute in 3-5 miNSS & | Refer to Rule of 6 follow with (+) pressure, | Neonate: IV = ET= lO dese ° ET = 10 times |V'dose | Higher doses not acceptable > Uprgs es raion Por sqvore, pain 40 mgimn Vangmury 4 rigikg Refer to Glucose Infusion Rete below Daly dese: 1.7 73.8 mgikgl2s hr Begin at 5- 10 ugtigrin titrate to desired effect io max of 20 wapfkamnin Epinephrine infusion: 0.1 wgrkgfmin ‘Strate to max of 1.0 pp ET: 0.1 moikg (1:7,000) Fentanyl 0: 3 Eaglkgtdese qi br Furosemida 4-2 mokg (0.1-6.2 mifkg} Glucose 0.5-1.0 gikg or 24mg Fygralazine 0.15 mayhgsdose IV bolus 30-90 rin pm tnsuén Bolus: £.05-0.1 gékg infusion: 0.1-0.2 gikgihr - Use raguiar insulin Rate of blood glucose + 2 15Qmg/hr If< 13 find? g ite 1: + to 0.05 J10 main (1553 Bolus: 1 mgrkgfdose Bolus dass may be given at 5 min Infusion: 20-50 wo?kait 20 magitel (295+ intervals 3a, then use infusion Manni 0.25-1 wkgidoss 18-25% solution Midazolam Loading dose: 0.0540.2 rapkg tolowed by [Link] | mafeg'hr dose titrated ib effect Mainwone .. ~ a G1 merka‘dese g2-3 mins pm pie He then qied br For respiratory depression 2° to opicids Ne bicarbonate. 1-2 mEqkgdose OR TmEgirt (B4% solution’: | infuse savy 8 only if ventilation ia I ‘a4 x kgx base deficit use 0.5 mEqin In newbom) adequate | [Link] 6 (for dosamine & dobutaminer: GARQEW=~ mgt be added to Occ DSW OR [eg TO kg child tobe given 2 ugkgiman: ~t ‘Bickg BWV = mg‘p be added to 258 oc DSW! ee Gi mg dopamine to be added lo 100 ce & “ O5W to nun at @ e/he to deliver 2 jag/kg/min i ~ “above fonmule yields: cow = 1 povkgimin i : i Modified Rue of & (for epineplirine) 4 - : : é fs 0.6 x by BY = mg to ba addad-f 100 ec O5W oR 15 xg BW rag lo be added te 250 cc DSW “* above formula yields: 1 boh-= dtygkeyrin Glucose Infusion Rate (MV. 8-8 mgfkgimin; if ard within nonmat, 4 daxiresity} GIR (mgkgimin} = Total vol foc) x dextfoslty’g'cc) x 1000 mq x ihour where: dextrosity = total glucose ‘g] hours to infuse x weight {kg} “een erin total wodume (cc} OR GIR = Raté (catir} x dexirnsity (a/er} «0.187 - Kg BW ee 4gFLUID VOLUME at |. Maintenance A. Based oncaloric ey Body Weight (kg) 42 10 kg of BW 100-miigiday, plus 2nd 10kg of BAY 50 milkg/day, plus Body weight 20 kg 20 mifkg! 1 ag. 28 kg child; (1000 + 500+ 100) = 1600 midday A. Basedon BSA TFR = Ingensible water loss + Urine output Approximate BSA riyitong | 05 _| 70 year 30 kg [1 | Adultf.70 kg B Conditions that ater maintenance fluid Adjustment needed (WL: 400-600 mifnPiday x BSA Urine; 600-1000 mimeiday x BSA BSA = (| ai fontd cw tke) 3600 Extra needed ; 12% far each °C > 37.5.°C or 7 milkg for each 0.5 °C > 37.5 °C 206 per °C rise Room temp > 31°C Hyperrietabolism * major surgery ? 20-30% burns 2% increase per 1%6 area bumt Diarrhea! vomiting Vahume per volume Case-to-case / 30% 40% 2 Sedated / Paralyzed ~#. Correction of Deficit : ‘i 42 First, assess degreg, then ‘ype of dehyovation : Assessment Of Degree Of Dehydration is Signs / § areas Exinsted mated fui deficit +400 llkg or more i 2 Hj Thirsty: maybe restless, or Drowsy: limp, cold, sweaty, cyanotic, lethargic but irrable fo touch | extremities: may be comatose Thirsty, alert; | Thirsty, usually alert; ~~ |" level of consciousness; apprehensive, restless + postumal ypolensicn wild, sweaty, aoe Bxlrernities: sare Ta Presend . | Preseni t i Present (week) Decreased | Blood pressure Normal Orihesiatic hypotension Hypctenson é Cutaneous pertusion Ncrmal | Normal Reduced / metied Capillary Refill” >3 sec — fe TSS nee Redunerd: Winkled shin on frgers Toon Sunken Fontane! ~[ Deep and tapd Urine output onal Oliguria __| Anuria ? Severe cliguriaNext 5-7 hr. HDs _o (+ [Lactate] Others mEgL|mEgL| mEq | meq |. [| 4 | ers | the: 44 PLRS Next 5-/ hr: 4 De 0.3% LRS -FLUID COMPOSITION Ayponarenia mEq Na deficit = [ao [as | gS eae: 28 | Magis 3, Acetate: 27 Gueonate 23 Sodium (nv. 135-150 mEq/L or 3-4 mEgk p18) ces gfday} desired — actual) x TRW where: TBIN (inL}= 0.6 x body weight (kg) 4 Initial goal: 120 mEg/L; Subsequent 130 in 24hrs > correct onty upto 12 mEqLday (2-5 mEgpLihy) lo avoid : pontine myelinolysis - Aypernatrena % Water deficit =. Plasma < comectonly 1016mmolLiday [Na']- 140 x TBW ja > °Potassium (fv. a5 Giniot oF 2-3 en 45 Hypokalennia mmol K deficit = (desired - actual) x 0.3 x wt (kg), OF, deficit = wt (kg) x50 x estimated % deficit K Serum level Estimated deficit 3- 3.5 mEgL 5% deficit (approx 200-400 mmol] > |fasymptomatic: oral replacement 2-3 mEq/ka/d ® |Vreplacement guidelines: 1, Rate: 0.2-0.3 mmolkg/hr NOT to excedd 1 mmolkgfhr 2 if via peripheral vein, not >40 mmol \ 3. Ifvia central vein, not >80 mmol/L; continuous ECG Hyperkalemia “ ECG changes: peaked / tented T waves, at> 7.0 mEq/L: protonged PR, +ST, wide ars at> 8.0 mEg':: P wave disappears, QRS: merges with T 4. Reverse membrane effects: Ca gluconate 10% at 0.6-1.0 ml/kg IV over 2-10 mins 2 Transfer K into calls (redistribute}: 2 agonists; or Regular Insulin 10-20 'W' + Glucose 25-50 9; or NaHCO: 50 mEq Vin § min 3, Enhance renal [Link] K: Kayexalate 15-50 g PO diluted with 2-4 ml sorbitol Calcium ! Hypocabemia Ca gluconate 10% (8.9 mg/ml alemantal Ca): 0.5-1.0 mikg IV bolus over 20-30 mins w/ cardiac monitoring x 3 doses & Maintenance: 500 mgkg/24 hr PO Magnesium Hypomagnesemia : % For symptomatic children / 47 kg: 0.5 ff of 50% MgSO, (1 mmol Mg) > F kg 1 ml of §0% MgSO. (2 mmol Mg}ANICN GAP = [Na’+ K4]-[Ck+HCO3]-= 846 mEgt 48 Reprosents unmeasured anions eg. POs, S0,, AAs, Lactate increased T : Decraased Methanal poisoning Hypematremic Kr Gae+, Mg Uretnia:t Renal fatlure dehydration Hypoalbuminemia i DKA Renaltubular acidosis: Naphratic + “3 Paraldehyde / Penicillin | Hyperatimentation Syndrome Tron tablets {isoniazid | Diarrhea Lithium poisoning Lactic acidosis ] Ethanol Ethene glycol Saticylates LK, Gat, Ngee, SPO TOTAL PARENTERAL NUTRITION COMPUTATIONS Tofal Find Requirement (TFR} Tew: Start af 60 mikgfday Preterin: iherements of 10 mV'kgfday =| Start at 80-90 mifkgtday. ff Maximum 150 mbkoda Méaxinurn:-150 miikg'da B | Electoytes/ 44 Preparations Normal Vaiues NaGl 2.5 mEgiml 2-4 mEatkgiday KCl ; 2 mEq/ml +-d mEq kglday 10% Ca Gluconate 410 gf 100 mi 400-400 otaat 7% AR 7g! 100ml 23 akatda » Correction factor for tubings: meitiply all values by 1 Example: 2 kg Preterm; start TFR at 80 cokgfday t Compufe TAR (subtract vo! of meds frant competed THR, if aryl TFR = HO mifkg/day x 2kg = 160 mbday {- mads)x 1.4= 176 miday Compute Electrolytes and Amino acids, fhen Total =< ae NaGk 3 mEqhkgiday x2 kg + 2.5 mEqfmi = 2.4 miday x 1.1= 2. é KCL 2 mEqko/dayx2kg +2mEqiml =2mbdayx 1 = 22 Ca: WO gkgdayx2kg + 100 gil =dmldayx 11 =44 AA: A ghkgfday x2 kg x 100ml fg = 85.7 mbiday x 1.1 = O42 Total = 103.4 mifday Compute to desired Dextrosity (40): First get wolume of Gent" (XI: TFR x Dextrosity = 50% x 5 (TFR < [Etectrolytas + 44] -X) OR, Daw = {{A x dextrasity) + (5 (A= Bi] } + 45 : can176 x O10 = 50% x5 (176,~ [103.4]) -X} 47 X= [4760-5 (176 -103.4y + 45 = 34.04 mi Da Then get volume of DSW: De = TER - Decl - (Electrolytes + AA) DEW = 176 = 31.04 - 103.4 = 416 ml Davy 4. To Check Dewirasity : DS0W = 31.04 x60 = 1552 ss DSW =416x5= 208 Total = 1760 Total + TFR = Desirad Dextrosity which is 10 5. TPN to be prepared by pharmacy under laminar flow: Da 31.04 mi DeW 41.6 mk NaCl 2.64mi; KCI 2.2 mi; 10% Ca Gluconata 4.4 ml; 7% Aminosal 94,2 mi To infuse only 160 ml at 6.6 ecvhr for 24 hours FLUID MANAGEMENT IN NEPHROTIC PATIENTS Estimated Crea Clearance = Ht (cr) x K + Creatinine (mg/dl) MM: 120+ 20 mimin! 1.79 mé 40.65 ml/min/1.73: mm? (newborn) where. K values i [LEW during fret year oflife [Oa ~ [Term AGA during st year ofife [04 | [Gitchidladolescent TS Fluid Limit = BSA‘ WL x Urine output in 24hrs Na Limit=(Wtx23x2)+ 1,000 — CHON Limit = 0.5 g/day x Wt 7 FLUID RESUSCITATION IN BURN PATIENTS Parkland Formula = 4ml LRSt-kg/ % burn'+ maintenance 1st half in & hours; Next half in 16 hours’ Next day: 50-75% of Day 1 Fluid Replacement PRBC if Hgb < 8 FFP if, PT level > 15x control Het < 0,24 PTT level > +2 control Albumin: Maintain at 2.5 gfdL [ 30-50.% BSA bum: 0.3 mb-albumin/kg/BSA burn/day 50-70 %: 04m 70-100 %: . 0.4mGalveston: ; 4 5000 ce (PLAS) / % burned BSA {day (burn related losses} + 2000 cc (DSLRS) / BSA / day (maintenance maining) 50% in 131 8 hrs: 50% in next 16 Ars ‘ 2 24h) 3780-ce f % bumed BSA / day (burned related losses) =e + 1500 e¢ | BSA f day (maintenance fluid) | CONVERSION FACTORS Element ] ‘mEq. to of Radical| mg/dl” Creatine | 864 | Total Bibi | 17.10 2.005 0.4988 1245 08230 | 3.65. 0.2817 1 Celsius to Fahrenhell. (°C x 16) +32 Fahenhet to Gelsiys. (°F ~32)718 7] — TTT, DIARRHEA , 4 Major Mechanisms of Action 1. poorly absorbable osmotically activa substances in lumen 2. intestinal ion secretion : 3. olitpouring into the lumen of blopd, mucus 4. derangement of intestinal motility Management: Rehydration therapy [Link] degree and type of dehydration (Refer to Section on Fld ane Electroivtes) WHO Treatment PLAN A far Mild or No Dehydrati on: % Treat at home: educate mother © Give. more fiuids and food than usual * may ditute milk formula for children < 6 manths * may add 1-2 tsp oil to solid food for older children@ Replace losses with ORS according te the following table Amount af ORS to give Amount of ORS to | after cach loose stool | provide for use al home c 50 = 100 m 500 mifda 2-10 ys 00 - 200 ml 1000 miday 10 ys ormore | As much as wanted 2000 milida * Refer fo Fluids and Electrolytes for ofher Hydrating Solution Treatment PLAN 8 for Moderate or Some'Dehydration: Approximate Amount of ORS to Give inthe 12:4 Hours [toe [<4mo [+11 mo [ie2smo| Zay | *Altemative formula 75 mlORS/ kg BW * Reagaess after 4 hours to change plan or continue treatment Treatment PLAN € for Severe Dehydration: ¢ Start IV fluids. Give 100 mi*kg LRS/ NSS divided as follows: First, Gwe 30 mika | Then, Give 7 milky In 1 hour ind hours 30 minutes 24 hours * Reaseass every 1-2 hrs. May repeat ance if radial pulse is still weak. * As soon as they cant drink, give ORS at 5 mifkg/hr * If IV therapy not available, Give ORS PO / NGT at 20 miékghr for 6h Dysentery: bloody & mucoid diarrhea, wi tenesmus f cramping Antimicrobial Agents for Specific Causes of Diarrhea | maka GID x3 d or, TMP/SM® B40 mg/kg BID xad Shigella Nalidixic acid 15 mgfkg QUID x 5d, dysentery | mgkg BID x5d | or, Ampicillin 25 mg/kg QID for Sd Amoebiasis| Metronidazole Very severe Gases: 35 mg/kg TID x5 d | Dehydroometine hydrechiondes IM 10d for severe, 1-1.5 mofkg OD x Sd) Max. 90 mg Giardiasss | Metronidazole Quinacrine 2.5 makg TID x Sd 15 mg/kg TID x5 d i he was CholeraJAUNDICE, 50 *~ ‘Yellow discoloration of skin with serum bilirubin levels: > Smafdl inneonates; > 2 mg/dl in older children > Physiologic jaundice (Refer to Changes in the Newbom| Criteria for Pathologie Jaundice 1. Clinical jaundice in 12! 24 hours or after 1? weak : 2. “Total Serum Bilirubin > 12 mg/dl (Term), > 15 mg/dl (Preterm 3. T In Total Serum Bilirubin of > 5 mg/dL fday (65 umolLid) 4. Direct bilitubin > 2 moval (34 umoVL} or 15% of TB (3, Lasting for more than 1 week (Term), 2 weeks (Pre-term} Breastfeeding Jaundice *® Due to §8-Pregnane-3c.,206-diol or Non-estatified long chain fatty acid which competitively inhibits glueorony| transferase “ Onset 4-7 days; Peak 2°43" week: Wane: 3-10 weeks * Treatment Discontinue breastfeeding for 1-2 days Kramer's Classification (Cephalopedal Progression’ Jaundiced Areas Serum Bilirubin { mg/dl) 68 42 Arms / Legs / Elbows / Knees Hands / Feet : Kernicterus ; ; Sequelae due to nor-albumin bound unconjugated bilirubin depositing on the basal ganglia starting at 15-20 mg/dl % Increased by | albumin binding and T free bilirubin diffusion ~ Manifested by poor suck, hypotonia, + sensoriuim Treatment in Healthy Term Infants WITHOUT Hemoiysis Treatment Strategies Hage tap Ptohrany a7 bilirubin by 1-2 mgfdk in 4-6 hrs; give IV fluids at 1.5% maintenance | 15-18 >18 Be = & nyt = an a o| Total oinubin 2 12 mofdl and Infant <24 hes okt = Bae a ens | Coomb's Test Positive “deomb's Test Negative te ‘ simmune-redatedheraysis [_“Geemb’s test Nestive 7 » ABG/Rh inctirgatiblty ——__-—__—.. ’ ; ” Dikest Bilirubin 22 mgidi a ) . etnvehepatic: Viral (hepa TORCH: ‘Genetic Metab (Dubin, Rector} | « Exirahepaile. Biliary Airesia, | cyst, atc, : | Abnormal RBC Morphology & | Normal RBC Morphology & | = High Reticulocyts Count * ~ Reticulacyte Count ~ + © Hemobtic process: Redcell | « Swallewed bod; Increased defects (Spherocytosis, sic); |__|’ enterohepatic circulation; Breast Brug reaction (Penicilin, i rik; Disorders cf bilirubin Sulfonamides}; DIC ns ! metabolism (Gilbert, Grigher}; i‘ Endocrine; Sacieral sepsiscanola ASTHMA Symptom pattern: cough, recument wheeze / dyspnea / chest tightness occurring of worsening at night / early AM Risk factors: genetics, allergens (dust mite, fur, pollen, smoke, viral infection, temp change, stress, drugs e.g aspirin’ B_blockers) Objective measure: % Peak Croiretory Flow Rete: au >BO% for Age & Height PEF Reversibility =° Post =| Prebronchodilator x 100 % : Prebronchodilator & PEF Vorighility = 7M. Postdilater— AM, Predilator EP variability = + (pl, Postilator + AM, Pradiatoi) ©" ‘ov. should be lpas than 20% Definitive diagnosis: : 1. PEF (FEV:)? of = 15%, 15-20 min after inhaled Be agonist 2. PEF varies > 20% from am waking up PEF to 12 hours later 3. PEF 1.15% after 6 min sustained exercise Treatment “ Educate patient & family: Avoid exposure to risk factors, compliance with meds, proper technique, follow-Uip care | > Treatment plan based on severity-of asthma (see next page) % Relievers (‘fescue agents"): for symptomatic treatment of bronchospasm with rapid onset (15-30 mins}; 4-6 hr relief * Short-acting P2 agonist: Salbutamel, Albuterol, Terbutalina + |pratropium bromide (cholinergic antagonist) _ * OralPradnisone, Prednisolone, Methylpredniselone: ~ @ Controllers: longer duration of action (12-24 hr) butslow onset; not a substitute for antiinflammatory therapy * Long-acting 82 agonist: Salmeterol, Bambuterol * Sustained release Theophylline , * Cromolyn Na (prophylactic antiinflammatory) + Inhaled corticosterinds + Anti-leukolrienesCLASSIFICATION AND TREATMENT OF ASTHMA (Children over 5 years and —— 8 t Persistent Affects acihity & sleep = 1W wk but nol dally > 30% Long-Ternn? Dally Meds (Controllers) inhaled Short-acting B- eet fim, not to exceed Trheled Sterakis 2500 ug + Long-acting: B2-agonist, wee Inhaled Stercids > 800 jag + Long-acting: 8: aganist, or Theophyline _+ Oral Steroids fong-Tenn | Daily Meds inheled Steroids 400 ng Or Nebulized Budesonide <1 ma bid * inhaled Stenoids, use MDI with spacer and face mask or nebulizer Inhaled Steroids =1 mg Or Nebulized Budesonide[Peco TeSys CLINICAL FEATURES OF ASTHMA EXACERBATION Ea en a [Rees [igi ops — [Teh oe — rate — Drowsy! confused increased Increased Often > 4lmin Bia fo normal RR: Age Newrnal Rate” - Age = Normal Rate <2m =< §0/ mn ys = <.40! min a SU. Ba < dui min Usually present ~ Paradoxical thoraco- : 3 «qo abdominal moverneni Usually loud None < 10 mim Hg 10-20 mm Hg 20-40 mm Hg ~ peg SS [Ree ——— fost Fe . Sas > SBPULMONARY TUBERCULOSIS 58 Classification Class |- (Exposure) Class II (infection) Class ill * (Disease) Class IW (inactive) +} aS &Sx . cough / wheezing / fever > 2 weeks failure to return to normal health after an infection painless cervical &/or other lymphadenopathy poor weight-gain failure to respond to appropriate antibiotic therapy ® Active TB must have J or more out of the 5 criteria ° Positive culture w/ or wio a smear ts the gold standard 9 Radiographic evidence of healed or aka Te Diagnosis & Prevéntion Tuberculin Skin Test (Mantoux Tech. Purified Pratein Deryative): 1. OA mior 5 TU intradermally on volar surface of forearm to form a 6-10 mm wheal, read after 48-72 hours 2. Induration, not erythema, read crosswise to forearm axis 3, Positive if > 5mm (HIV+, contact to active TB, healed) > 10 mm (all others) Bacille Calmette-Guenn (BOG) Vaccination Reaction Scar Formation 5 &l2 weeks Treatment Side Effects Drug? Proparin [zie | ste] | Isoniazid (H} # Hepatatoxicity # “570 mil | (max 300 mg} sass 100 & 200 mgamide(P] © I 200 8 400 mg tab then 15 {max 2.59) | neuritis ® tga | noe 1g vial max 1g} max 19 Ototoxicity * Beet on an empty stamach (30 min before ar 2 hours after maals}; given with Pytidoxine / Vi. BG; storage bamp < 37°C * ® Best on an empty stomach; at the same time ae H * Best absorbed on a full stomach “Requires menitoring of iver function tests in severe TB: ifelevated 2-3x the normal: Da nat discontinue drug: if> 3x normal: Discontinue drug "Do visual acuity & red-green calor discrimination tests UPPER AIRWAY INFECTIONS _ CROUP EPIGLOTTITIS * Age | dmo-5 2-7 Etialo gy Viral, usually H. influenzae Course, Rapid: over hrs Mid—-Moderate | Severe Prefers sitting up | Perched, nack extended preference Improves with - | Ne respenss to | No response to aerosolized racemic racemic racemic epl epinephrine epinephrine Subglettic narrowing Antibiatigs Chest Xray | “Steeple sign* on | “Thumbprint Epinephrine, sign’ on lateral Treatment Steroids Intubate, * Mey cause tfeiiveatening obstruction, Do not examine throat ! IV antibioticsETIOLOGY OF PNEUMONIA ACCORDING: TO AGE peer RADIOGRAPHIC DIAGNOSIS 5. one i I - Bacterial Lung Consolidation + Viral: Streaky interstitial infiltrates Pleural effusion «without aeolar compromise. PNEUMONIA IN INFANTS LESS THAN 2 MONTHS Classify As No fast breathing: 60/min SEVERE PNEUMONIA | ADAAT Severe chest indrawing Centrat cyanasis Poor feeding, Wheezing Stridor in @ calm chiles Convidsions, A _ * Fachypnes: most predictive sign of Preimonia Give antibiotic: Benzyl Penicdiin + Gentarmicn IM IV ADMIT , Give antibiotic: Benzyl Peniciin + Gentamicin IM,IV VERY SEVERE PNEUMONIA |Fest breathing >fdlimin if 2 mos—1 yr =dDimin if 1-5 yrs No chest indrawing Central cyanosis inatulify to feed or drink Sindor in caim chil Convulsions © Abnormally sleany Severe undermairition _ PNEUMONIA NO PNEUMONIA Cough or Cold ADVISE HOME CARE ADVISE HOME CARE Procaine Penicillin gels worse Treat fever and wheezing: if present Treal fever and wheezing if present Advise fo retum in 2 days for reassessment or earlier if child Hf coughing >30 days, assess for causes of chronic cough Feoesr kestiem Wet ot Sere cet if present Give an antibintig: Cotrimoxazole PO, Amoxicillin, Ampacilin on VERY SEVERE PNEUMONIA ADMIT ADMIT, Give oxygen Treat fever; Supportive care Reassass tite daily Give antibiotic: Berzy Penicillin (44, Treat fever and wheezing if present; Give supportive care porade or downgrade diagnosis and tx, Give antibiotic: Chloramphenicol IMI Ng eee ees eee ee for suspected Staph.NEUROLOGICAL EXAMINATION . 59 Mental Status, Cagnilive Function, [Link] Aleriness . Examine the Head * Size, Circumference, Shape, Tension of fartanele * Palpate, auscultate & trangilluminate cranium Examine 12 cranial nerves Motor Examination * Muscle strength, tone & bulk + Locomotion & motility, . = Deep tendon, abnormal & primitive reflexes (Refer to Section on Neonatology) “Sensory Examination Gait & Station Solf Neurologic Signs . © form of deviant performance on motor or sansory tests, abnormal for a particular age * repetitive and successive finger mov'ts, arm pronation-supination *— mavements, hopping tandem walking, hand pats and foat tans GLASCOW COMA SCALE e Child Activity Spontaneous Spontangous To speach! sound To speech To pain To pain None None Coos, babbies Oriented Irritable ory Confused Cries to pain Inappropriate werds Moans to pain Nonspecific sounds None Follows commands Localizes ta pain Withdraws to pain Abnormal flexion Abnarmal extension None Norie Normal, spontaneous Withdraws to touch Withdraws to pain Abnormal flexion Abnormal extension ‘None SN WR OB awe mon ww BEBRAINSTEM AND CORTICAL FXN IN INTUBATED PATIENTS [_ Grom Function [Sere] Cont Funsion [Ser Normal pupillary, cormeal, Spontaneous movement ocuilovestibular & H Move to command aculocephalic reflex Logalizes pain Some absent Withdraws All Absent Derorbeate Decerebrate f Flaccid Allabsent & apneic LUMBAR PUNCTURE « done at L3-L4 or L4-L5 using a G18-2? beveled spinal needle, ina flexed lateral position * Contraindications: 1. Raised ICP due ta mass ‘esion — hermiation 9. § & Sx of pending cerebral herniation: gen. seizure, abn. pupil size & rxn, (+) oculocephalic response, apnea _-@. Critically ill, moribund patientat risk of CR arrest 4. Skin infection at the [Link] LP 5. Thrombocytopenia (< 20 x 10/1) TREATMENT APPROACH TO BACTERIAL MENINGITIS Intracranial Pressure Measurement Scan Results NORMAL INCREASED Normal None ; Hyperverttilate to decroasa cerebral blood volume Restrict fluids Don't hyperventilate; s Use Furosemide or Mannital: ‘Ventricular tap or drain CSF; -Acetazolamide: |: CSF prodin; Steroids: T CSF reabsoption Subdural drainage Stervids: 4 periinfarct edema; Barbiturates: to brain metabotism activit Nang; resolves spontaneously Hydrocephalus] Subdural , None; resolves Effusion spontaneousl lerfaret Improve perfusion byi increasing BP; Steroids: 4 vasculitis+ on Aalitest smear & cute | + Eudding yeast cells & culture:Chemical isye, F Usually im 1.000; PWNS” 508 eae 62. Dertnolits: + Epitheligt cafe seen with use of polarized light Nic ofganigm on smear or culture undess abstess ruptures into. ventricular systarn Etnjogy E. coll, GBS, Listeria, Gram ()}entee baci H. influenzae, 8. pneumoniae AL mermngitidis 5: pneumoniae, AL ménngiicis ‘ | 3. aureus, 5. epidermidis 5. preumoniae, Salrionella - P aeruginosa. Listeria Iran detterent No oganismon smear or FE Arapsciin: Se Culture: LE preparation tray be | postive Cefotexime: 200 q6 hrs, Cefirlaxone: 100 q12 hrs * | Ceftazidime: 150 ge hs Chloramphenicol: 50-100 op be Cotrimenazoe: 20 qi Ws Genlanyoin: 4 # hrs Pen G; 300 008 ugh tlDURATION OF TREATMENT OF BACTERIAL MENINGITIS H. fnfhenzae T- 10 | §. praumomae 10-14 AC mreringificis §-7 Group B streptacedti: 4-71 Gram negative bacilli. 21 days ~ 3 weeks SEIZURE es a Algorithm for Determining Seizure Cause é SEIZURE | Meaney Infection) History: et : «Drug intake perm pee. e Trauti | | (Brain Abscess’ pe. | + Aseptic | |» Jap B sAnaarobes - | seurncut | oPuruient | i*Enterovirus! | Staph, ‘tae, rat . | sVaticella ; | infection 39 °C within hours of the seizure 4 Farnily history of BFC 5. Neneurologic deficit that would explain the seizure COMMON ANTICONVULSANT DRUGS Diziness, nausea and Carbamazenine (Tegretol) vomiting, liver dysfunction, 4O-mgkgid q@-12h anemia, + WEC & Platelet Clonazepam Absence: Parial | Irrtability, behavioral (Rivet) Myoclonia abnermalities, depression, Infantile spasm | excessive salivation . Ethosus mide Absence © | Abdominal discomfort, skin (Zarontin} rash iver dysfunction, 20 mafkg lastie anemia Gabapentin ‘Complex partial Sonmolenee, dizziness, | (Neurontin) Secondarily ataxia, headache, tremor, generalized vomiting, nystagmus, fatigue Phenobarbital Tonit-clonic ] Hyperactivity, sedation, {Luminal} Partial nystagmus, ataxia 3-5 mgd 8-12 Nonsedating Phenytein Tonic-¢lonic Rash, nystagmus, ataxia, (Dilantin) Partial ~ | drug-induced lupus, anemia, YS moka q&12h | > leukopenia, polyneuropathy | Valproate Tonic-clonic Hepatotoxictly, nausea and (Depakene) Absence vomiting, abdominal pain, 10 markg'd g8-12h| Partial anemia, + WEC & Platelet STATUS EPILEPTICUS * Continuous clinical or EEG seizures lasting for at least 30 mins or recurrent se@ures without ratum-of consciousness during interictal period, lasting for more than 30 minsTreatment Algorithm Fer Status Epilepticus 65 Ensure ainway and Diazepam # Cardiovascular fn =] Doge: 0.2- 0.4 mg/kg, SIVP Oxygen, Vital signs 0.3- 0.5 mpikg, rectal Miine: DeNSS/Ds0.3 | Rate: 1-2mg/min at 75% maintenance | Max: 10mg CBC, Na, K,ABG, Hot | Repeat ixg 15-20 min if hypaglycemia, give Lorazepam = Glucose bolus-at 2-4 | Dose: 0.05-0.1 mgrkg SIVP: SL mkg, 25% glucose =| Rate: 1-2 mg/min solution, Or Max: 4 mg single dose * Rapid infusion at & 8 mg total g. 10% gluc soln. | Repeat 2x q 5-15 min Phenytoin ® Loading: 15-20 movkg SIVP Rate: 1-3 mokg/min Max: 1 gm Maintanance: 5-9 mp/kg/day divided qf2 hrs Fosphenytoin (Water-soluble) Dose: 20 mg/kg, [V or IM Rate: 50-100 mg/min Support Respiration Phenobarbial & andor Intubate Loading: 10-20 mavkg IV Rate: 1 mg/kg/min Refer to Anesthesiologist | Max: 800 mg Admit at ICU Maintenance: 3-5 mg/kg/day r ’ divided q12-24 hrs f 5% Paraldehyde ¢ Loading 150 - 200 mg/kg IV A over 15-20 mins Maintenance: 20 mg‘ke * Diazepam should not be given JM or ditited with any fluid ® Phenytoin and Phenobarbital erystallize i dextrose solution * Paraetyde not compatible witht plastic containersACUTE SUBDURAL versus EPIOURAL BLEEDS 66 SUBDURAL Location Between ans ni Between the skull and the dura arachnoid la Symmetry Usually blast Usually unilateral Etiology Rupture of cortical) Rupture of dural veins or middie bridging veins meningeal artery Typical injury | Direct trauma or | Direct trauma in the temporal Shaking area Impairad-lucic-impaired Ipsilateral papitiary dilatation, papiledema, contralateral hemiparesis Consciousness} Intact but altered Carman Seizures; associated | Retinal findings hemorrhages (CT (contrast) | Crescenteric Biconcave Prognosis High morbidity; Low ee Low mortalit Complications | Herniation DENGUE HEMORRHAGIC FEVER Clinical Criteria: |, Fever: 2-7 days, regardiess of character 2. Hemorrhagic manifestations: - a. (+) Tourniquet test: Wintrobe's mtd (> 20 petechiae/ inch) b. Mucocutaneous bleeding c. Gl bleeding ¢ Laboralory Criteria: 4, Evidence of Consumptive Coagul al _ @, Decreased platelet count (< 150,000 mm?) b. Prolonged BT (Ivy method: nv... 2-5 min) c. Profanged PT (Factor Il, ¥, Vil, %, fibrinogen) d, Prolonged PTT (Factor ll, V, VIll, IM, X, XI, Xl, fibrinogen) 2. Sleadily increasing hematocrit (20% or more} in spite of proper hydration or increased vascular permeabilityDengue Shock Syndrome 67 DHF Criteria + Evidence of Circulatory Failure Violaceous, cold, clammy skin Restlessness, Weak to imperceptible pulses Narrowing of pulse pressure to < 20 mmHg Hypotension Grading of Severity of DHF Fever Non-specific constitutional symptams (anorexia, vomiting, abdominal pain) +] Tourniquet test il. | Grade |+spontaneous bleeding [li Grade IT + severe bleeding + circulatory failure | Grade III + irreversible shack +massive bleeding Age-related Hypotension with > 25% Blood Loss < 4 years < 65 mm Hg systolic BP 5-8 years < 76mm Hg i Q- 42 years < 85 mm Hg i Q Indications for Hospitalization: 1. When diagnostic criteria have been met 2, Dengue suspects: a. Fever > 2dwith T Het of + pitct &/or prolonged BT b. Altered'sensorium c. Marked anorexia, vorniting and thirsting Treatment, Rehydration therapy (Refer fo Fluids Electrolytes) Blood Component Therapy in BIC & Whole blood: 20 ml/kg, iflass > 25% t Packed RBC: 1 milkg, raises Het by 1% @ FFP 10-15 midkg initially, may need Smi/kg q hr Cryoprecipitate: 50-100 mg/kg fibrincgen ( 1 bag = 200 mg fibrinogen) . & Platelet concentrate: 1"UVI0kg BW 1‘U!" platelet concentrate/ mé raises count by 10,000/mm*Exanthem Confluent, aryharnatous Measles ([Pararnyxcnins) maculopapular rash that’ Coryza, cough, conjunctivitis, Koplik's spot fsrmadi red spots an. SSE r pericarditis, thrombocytopenic: staris on the head and with bluish centers on ihe purpura, encephalitis; Rave: buccal mucosa early) SSPE, death Swollen saitvery giands, Orchiiis (in puberty}, hearing loss; agpecially parotid giands Rare: meningitis, encephalitis Cenical, subcesipitel, posterior | Rare: arthritis. apastic cris (in > | auricular kmphadencpaihy GSPD}, encephalitis, hydrops s but Acute-onsat fagh fever ina -—.| Febrile sezures (no mone wealheppeating child before corimen than with other febrile. spreads to exirerities the development of rash liiness) Enjthema “Slenpad cheeks,” then Vitually asyriplomatic Rare: aritnitis in clder Patients, infectiosum feticular erythematous hermobis anemia, {Fifth Disease: maculopapular rash ~ encephalopathy Parvovirus} beginning on arms then 2 tothe trunk ard egs wi ae o Chicken Pox Prumiic teardrop"shaped | Scatlered crops of lesions Rare: pneumonia. secondary (Varicellay, vesicles that break and appear over several days, 20 | bacteralinfecticn, Merpes Virus) Grusi over, heginning cn | lesions in different stages of meningoencaphalitis. hepatitis, face or ink and development and résolution Reye syndrome |__sfreadingio exiremities | are observed simullaneousy =BLOGD COMPONENT THERAPY ; ee Whola Blood oe : :| Cellular compondnts | Fluid component | a [_Recote | [Paes] Ganivone] (AP [ee eal Packed Washed) Cryoprecipitate| [Liquid Plasma] |_ Leukocyte-poor Whole Blood ( 1 unit $00 mi) * -high teaction rates, so given only when f in both Oe & volume are required i.e, massive bleed, exchange transfusion, bypass surgery * Dose: 10-20 mikg in4-6 hrs; Rate +10 och Packed RBC (1 unit # 250-300 mi) * Dose 10-15 mikg in4-6 hrs, Rate 2-3 celkgthr (May give Furosemide if given at a rate >3 co/agyhr| + 40 mi PREC(kg T-Hot by 10%; 3 ml PRECIkg T Hob by &1 gid. indications for transfusion 1. Hgb < 13 g/dl in NB < 24 bre | 1. pb < 8 with chronic anemia, 2. Acute blood loss > 15% pre-op, or marrow failure 3. Hab < 13 gidi, severe 2, Blood logs wi hypovolemia cardiopulmonary disease =| 3. Hgb < 13 g/dl, severe” 4 Phlebotomy agri > 510% cardiopulmonary disease ‘ Dose Corene to Deficits {(Desited Het — Actual Het) x kg BW x 100 = mi PREC « Dose Corrected to Donor Hct {Desired Het - Actual Het) x ka x Est. blood vol = jp] PREC (Het of PRBC to be transfused, usually 0.65)Platelat ' ‘ * Dose 34 Us mr? or 1 unit! 10 kg BW or 10 mi/ kg BW * Normally, 4 Use * platelet count by 10-12,000/ pL © When sick, 1 U/m? 7 platelet count by 6,300-8,900F HL * 1 UL0 kg BW * platelet count by 40,000) pL * TermNB = 5-10 mikg t platelet count by 50-100,000 ul Corected Count Increment (CCH CCl = Prat — PCrne x BSA | CCI = PGpos1—PCpae x BSA # of units ransfused # of Pitin units x 10": Plasma Transfusion pe Fresh Frozen Plasma Cryoprecipitate { « Hae all coagulation factors, | * Has FVII = 80-100 U/ bag, albumin, Ig, complement WAFe = 100 U, fibrinogen = 150-250 mafdL, FAlll = 75 U + Volume 30m ® Bose. 10-45 mlkg T30% | + Dose 4U'10 kg BW : plasma clotting factors 1 bag/10 kg T fibrinogen 50 mg/ml” * Rate. 46 hrs + Rate: fast drip Clotting Factor Concentrates + 1 Factor & (kg BW raises Factor & by 2% (1/2 life: 12 brs} * 1 Factor 9 /kg BW raises Factor 9 by 1% (172 life: 24 hrs) Desired Factor 8 Replacement ‘Moderate replacement (> 50%) i.e. mucasal bleed Major replacement (B0-190%) (6. Gl bleed, surgeryAbsolute Reticulocyte Count (ARC) m1 Actual Hematocrit x vel Hematoerit for Age * Estiméted bleed volume Reticulocyte Index = ARC +2 (nv 2) If< 2 suppressed marrow; If> 2: compensatory marrow Phlebotomy (Value fo be extracted) Volume (mi) = EBV x kg BW x Actual Het — Desired Het f Actual Het i sete hale li CONGENITAL HEART DISEASE Righite-et Sh to-Left Shunts {Early Cyanosis /"Blue Babies") [| PE Ausoutation SEM; Single $2 | RVH Boot-shaped Foti || tan ! Greaf Vessels” 32 (oud) heart; * PYM TAPYR SEM; Wide, fixed RV Srowtna! rh Spit S2 of Eig ‘ Truncus arteriosus | Holasystolic LVH + | Right oe aa Crcemeg SEM: Systolic Ejection Murmur; PVM: ae Vascular iarkings [PE Fausaitaton | €6S [OXF Ventricular i Panaystolic murmur | LVH, RVH Septal Defect ; Mild RVH | 7 PYM Atrial Septal Defect] Fixed split 52 Patent Ductus Artoricsus Continuous machine- {ike murmur +RVH Coarctation af the Hypartension, « LVH Enlarged “Aorta femoral pulses aortic knob Elsenmenger syrdrarne: Uncorrected L-to-R shunt leads to ‘ progressive pulmonary hypertension. This changes shunt direction fromL->R to RL and causes late cyanosis._ COMMONLY USED OPD DRUGS a 7 Dose (infant & Chore : CHLORAMPHENICOL | CLOXAGILLIN | S100 mpkgid Bh CO-AMOXICLAY i mgfkgid ge hi : COTRIMOXAZOLE a mg SUB mg aT qi 7 DIPHENHYORAMINE — [ Smakgd gah _. ERYTHROMYCIN i 6 Pn Tr ‘Bri: 200 mg Sm; 4001 aime Sm | FERROUS SALTS Becher Ting elemental Felkgid 7img (18 mg demental Fe) /06m (as sulfate) Tc_3-6 mg elemental Fe fkgii = 3 doses | 131 aes Fel nl HYDROXVZINE 2-5 mokgid qéah WEBENDAZOLE 700 mg BID x 3d Children >2 yt METOCLOPRAMIDE — [GT mortgidose gi PARACETAMOL 10-15 movkgidcse g¢-6h PREONISONE “_f 2 mpkgid BG-G0 1 mglg/duse (max Zmpldese] qB-OH” | 2 may Sd 100 meq! actuation * 406 doses {MD}REFERENCE MANGES FUR LABURA TL Teor} ts Teal Sp Agé Reierence range 3 APTI. FP 25-35 sec Infant: < 90 sec a 4.35-15.e mg 24 hil 7a ne er ie Arlareal 24-28 mmol Venous 22-29 mmolfL Bleeding lime, We] Normal: 2-7 mn. “oy Borderline: 7-4141min $ | Cord bleed | 52-1,330 ng/mi | $2-1,330 a - Bily 67-4,800 ng‘mi | 67:1,800 pg/L 6,77 Cord blood | 5.0-6.0 tmgfdl 425-1 50 mmovL WY NB: 32d | 43-5.7 mpd) | 1.07-1.27 mmovl 400-4117 142-1.23 4 Bd 92 or 224246 mEq CO:, Partial |. 27-40 mm Hg |-3.6-5.3 KPa pressure(Poos)|* [ - | aa 36-55 tins : | 4a" 47-64 32-45 4346.0 96-104 mmol 97-110 98-106 2.10 mimolfd 40 110-250 5-8 min {S45 mi 57-116 medi 53134 T eo 62-180 T7195 oRiri ‘Clating Time VW | Gass tubes |‘Cortisol Creatinine =~ | 5,P| Cord blocd plasma... Newhom Jaffe, kinetic Infant ‘or enzymatic Chi Adolescent Factor 88 4 Adult Male _ Female Creatinine, Uo} Promature urinary ¢ FutHtarm 1BTy iby Card blood 1-3d dwk 2 wk dma 2m 26 me O52 y Loy" AM y 72-18 y M ca BS 18-48 y F Child - ‘| 3Rb3 35-4 | 40-52 {0-10 mo hr a a = 50% of O800h | O,6-1.2 maid, O441.0 02.0.4 OF07 03-1.0 0.64.2 05-11 1449.7 3.835 406.4 3063 3.06.2 30-54 27-49 3.145 4553 4.1-6.1 45-5.9 405.2 : Westergren 0-15 | 22-4 D i (Ta Bone 3 0.50 of 0800 A g2174 BS 139 46-362 X10 cola 3955 4.06.6 3.96.3 3.60.2 3.0-5.4— 3445 37-53 3.953 4.052 45.53 44-521 45-59 40-57 yiritrabe O-13 - G-5 0-20 i653Glutose Factor 0.0555 Glucose 5 Tolerance Test (CTT), oral Chit: 175qkg| - Haemoglobin =| W Lecithin’Sphing) AF omyein rato | Cord blood | 45-86 mgd. 4-100 70-105 Normal 70-105 mgyll 1M-170 100-140 7120 Volume fraction TSS E25 gal 5.0-14.0 115-15.5 130-16. 12.0-16.0 1BHATS . | 120-16.0 2.05.0 ndicales probable feta > 3.010 ° 0.37-0.49 | 0.46-0.46 fung maturity 2.5-6.3 mmol | 2233 2.85.0 3.3-5.5 36-56 Diabetic > 115 mgfdl = 200 = 200 = 140 0.48-0.69 048075 044-072 028-042 0.35045 0.36-0.46 044-059 2.253.459 mmalll| 140-217 1.70-2.40 2.02-2,48 186-248 200-227 186-246 9.0-90.0 9434.0» 5,049.5 BIS C- 5515.5 45135 4541.0Whelocvies ' 0 Loukooyte W differential Neutrophils"bands’ = 3-5% Neutrophile-"sege” 54-62% Lymphocytes 25-33% Monocytes a-7% - Ensinephils 13% Basophils 0.75% Mean: W |. Birth 0.4.57 tmolcel corpuscular t-dd OAS? - hamoglobin 4 wh-1 mo 043-062 concentration 2mo 0.40053 (MCHC) +6 mo 0.30-0.54 O5-2y 036-048 2GY O.97-0.47 B12y 0.90-0.54 12-18 y 6.39-0.54 140 y 0.40-0.53 Mean W | 43d 95-121 pm 95-1241 f. corpuscular Oe y 70-86 76-86 volume (MGV) B42 y 77-58 77-06 ‘Rib yM | 78-98 76-08 . F | 78-102 78-102 18-49 y: MIF] 80-100 80-100 Osmolality § | Child ‘Adut | 275-295 mOsnvkg HO: Uo | Random: 501,400 24 hour: 300-900 Oxygen, a) Birth 11-32 kPa Partial = 5-10 min 4410.0 pressure of” 30 min 4411.3 (Poo) > thr TPG * Lwith age ‘ _ 1d 72126 Thereafter : 11-14.4 W | Newborn: 85-50% Thereafter: 95-99% | PTT W | Nonactivated: 60465 sec Activaled. 25-35 PH, arterial W “Preterm 48h} 7.35-7.50 Birth, Term | 7.11-7.36 5-10 min | 7.08-7.30 4pH, arterial 30 min 72-738 Ti | ath 726-749 : td 7207 45 - Thereafter | 735-745 pH U | Newbem: &/ Thereafter: 45-6 {ave 6 Phosphatase;.) 5 | 1-3y 145420 WL . alkaline Weity . 130-560: i 12-13 y fi: 200-495 F: 105-420 14-15 y 130-525. 70-230 = 16-19 65-260 50-130 Piaielet count |W | Newbom: 64-476 x 10%" --Adult: 150-400 Potassium $ | <2mo 3.0-7.0 mmol, : 212 mo 3546.0 >12m0 3545.0 Protein, total | S$ | Premature | 437.8 g/dl Newborn 46-74 Ty 61-7.9 f Bt2y 648.1 13-18 y 668.2 U | 1-14 mardi; 50-80 mgy24 hr (at rest) = 250 mg/24 hr after intense exercise Prothrombin =| W | in general, 14-15 5 NB: Profonged by 2-3 s Reticulocyte | W | Adults 0.5-1.5% of RBC of 257-75 T/mme count - | 4d 046.0% =e i td <01-1.3% 1-4 wk <104.2% 5-6 wk 201-286 7-3 wk 0.1-2.9% 9-10 wk <0,4-2.6% . 14-12 wk 0.1-1.3% Specific gravity] U | Adult: .002-1.030 After 12h fluid restriction: = > 1.025 24h urine: 1.015-1.026 Thyroxine, free 26-031 pmol 12:33 10-28 Paty20-240 podl = | 0.3-3.7 pmol 200-610 31-9.4 240-560 | 37-86. 730-660 35-100 Urea nitrogen |5,P] Gord Blood 21-40 mofdl | 7.5-14.3 mmol |) Pretarmitwk | 325 ' 41.4-9 Newborn | 312 VAd InfaniAChild | 5-18 186.4 Thereafter | 7-18 25-5.4 ON Hama; U-arine,; Wiafiole bod, NB-reabom; Minale, F-femafe pre J- Dvolbrican REFERENCES American Heart Association. “Part 11: Pediatric Basic Life Support and Part 12: Pediatric Advanced Cardiac Life Support.” CirewJation 008: 142 (IW 156-166, Ballard: JL., et al, "New Ballard Seore, Expanded to Include Extramely Premature Infants." Journa/ of Pediatrics, 1991. 417. . Behrman, RE., Kiegman, R. Nelson's, Textbook of Pediatrics, 16" ed. Philadelphia. WB, Saunders Company, 1999, [Link] Immunization, Infectious Disease [Link] Philippine Foundation for Vaccination, “Childhood Immunization Schedute." 2002. Del Mundo, F., et al. Textbook of Pediatrics and Child Health, 4" ed, Quezon City. JMC Press, 2000, | DOH & Health Services Centers for Diseases Control & Prevention. Recommended Childhood & Adolescent Immunization Sched 2005 Marino, B., Snead, K. Beats jt Pediaifes. USA. Blackwell Science. 1998. National Consensus on Chikthood Tuberculosis, Philippines. 1997, NHLBI and WHO Recommendation. Global Initiative for Asthma. "Global Strategy for Asthma Management and Prevention.” 2005. Roberteon, J; Shilkofeki, N, The Johns Hopkins Hospital The Harriet ‘Lane Handbook, 17" ed. Philadelphia. Elsevier-Mosby. 2005, WHO Recommendation on Acute Respiratory Infections, 1990 WHO Recommendation on Diarrhea, 1990.