Pedia Notes Compiled.pdf

HANDY PEDIATRIC NOTES

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TABLE OF CONTENTS I. ADMITTING ORDERS NEONATOLOGY NICU....................................................................................... NEUROLOGY FEBRILE SEIZURES.................................................................... LUMBAR TAP........................................................................... PULMONOLOGY BRONCHIAL ASTHMA.............................................................. BPN......................................................................................... GASTROENTEROLOGY AGE......................................................................................... IMMUNOLOGY HYPERSENSITIVITY REACTION................................................. INFECTIOUS DISEASES DENGUE FEVER....................................................................... II. MEDICATIONS ANTIBACTERIAL CELL WALL ACTIVE ANTIBIOTICS PENICILLIN....................................................................... Amoxicillin........................................................... Cloxacillin............................................................ Flucloxacillin........................................................

11 12 13 14 15 16 17 18

20 20 20 20

PENICILLIN COMBINATIONS

Amx + CA............................................................. CEPHALOSPORINS 1ST GEN Cefalexin.............................................................. 2ND GEN Cefaclor............................................................... Cefuroxime.......................................................... Cefrozil.............................................................. 3RD GEN Cefixime.............................................................. Cefdinir................................................................

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PROTEIN SYNTHESIS INHIBITOR MACROLIDES Erythromycin....................................................... Clarithromycin..................................................... Roxithromycin..................................................... Azithromycin....................................................... LINCOSAMIDES Clindamycin......................................................... CHLORAMPENICOL........................................................... TETRACYCLINE................................................................. Doxycycline......................................................... DNA SYNTHESIS INHIBITOR NITROFURAN Furaxolidone....................................................... Ercefuryl.............................................................. ANTIBACTERIAL COMBINATIONS TMP - SULFAMETHOXAZOLE Cotrimoxazole..................................................... TMP – SULFADIAZONE............................................................. IV ANTIBIOTICS............................................................................... ANTITUBERCULOSIS Isoniazid.............................................................. Rifampicin........................................................... Pyrazinamide....................................................... ANTIPROTOZOAN AMOEBICIDES Metronidazole..................................................... Etofamide............................................................ Diloxanide Furoate.............................................. Secnidazole.......................................................... Ercefuryl.............................................................. ANTIHELMINTHICS Oxantel + Pyrantel Pamoate................................ Mebendazole....................................................... Albendazole......................................................... ANTIVIRAL Acyclovir............................................................

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24 24 24 25 25 25

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ANTIFUNGAL Ketoconazole....................................................... Nystatin............................................................... Fluconazole......................................................... NEUROLOGY ANTICONVULSANT Diazepam............................................................ Midazolam........................................................... Phenobarbital...................................................... Phenytoin............................................................ Carbamazepine.................................................... Oxcarmazepine.................................................... Valproic Acid....................................................... Topiramate.......................................................... RESPIRATORY DRUGS NASAL NaCl..................................................................... Oxymetazoline..................................................... Xylometazoline.................................................... ORAL Phenylpropanolamine......................................... Bromphenamine Maleate + Pheylephrine............ Carbinoxamine maleate + Phenylephrine HCl...... Loratadine + PPA................................................. MUCOLYTIC Carbocisteine....................................................... Ambroxol............................................................. B2 AGONIST Salbutamol.......................................................... Terbutaline.......................................................... Doxofylline.......................................................... Procaterol........................................................... Theophylline........................................................ ANTI-TUSSIVES Butamirate Citrate............................................... Dextrometorphan................................................

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28 28 28 29 29 29 30 30

32 32 32 33 33 33 33 34 35 36 36 36 37 37 37 37

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IMMNULOGY ANTIHISTAMINE Diphenhydarmine................................................ Hydroxyzine......................................................... Ceterizine............................................................ Loratadine........................................................... Desloratadine...................................................... STEROIDS INHALED Budesonide.......................................................... ORAL Prednisone.......................................................... Prednisolone........................................................ INTRAVENOUS Hydrocortisone.................................................... IVIG INFUSION.................................................................... CARDIOVASCULAR DRUGS ANTIHYPERTENSIVE Hydralazine................................................................. Spirinolactone............................................................. GASTROINTESTINAL DRUGS ANTACIDS MgOH + AlOH.............................................................. Simethicone................................................................ ANTISPASMODIC Dicycloverine.............................................................. Domperidone.............................................................. H2-BLOCKER Ranitidine................................................................... Cimetidine.................................................................. Famotidine.................................................................. ANTI-DIARRHEAL ENKEPHALINASE INHIBITOR Racedotril............................................................

38 38 38 39 39

39 39 39 39 40

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43 43 43 43 44 44 44

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OTHER GI DRUGS PARENTERAL NUTRITIONAL PRODUCTS LYSMIX................................................................ SUPPLEMENTS & ADJUVANT THERAPY PROBIOTICS Prozinc............................................................ Erceflora......................................................... PRETOXIN............................................................ ANTIPYRETIC/ANALGESIC Paracetamol................................................................ Mefenamic Acid.......................................................... Aspirin........................................................................ Ibuprofen....................................................................

44

45 45 45

46 46 47 47

DRIPS Dengue....................................................................... Furosemide................................................................. Noradrenaline............................................................. Dopamine................................................................... Dobutamine................................................................ Terbutaline................................................................. Precedex..................................................................... Ketamine.................................................................... Morphine.................................................................... Naproxen....................................................................

48 49 49 49 49 49 50 50 50 50

ELECTROLYTES KCl.............................................................................. NaHCO3...................................................................... Ca GLUCONATE........................................................... VITAMINS

50 50 50 51

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III. CONDITIONS NEONATOLOGY Essential Newborn Care Protocol (DOH)............................. Newborn Care.................................................................... Apgar Score........................................................................ Newborn Screening............................................................ Nursery Notes Dextrosity................................................................... Electrolyte Requirements................................................... Glucose Infusion Rate......................................................... Emergency Intervention Level of Umbillical Catheterization.............................. ET Tube Determination............................................... Total Flow Rate........................................................... Extubation.................................................................. Cows Milk Allergy............................................................... Hyperbilirubinemia Bilirubin Metabolism................................................... Neonatal Jaundice....................................................... Kramer Classification................................................... Bilirubin Values........................................................... Physiologic vs Pathologic Jaundice.............................. Breastfeeding vs Breastmilk Jaundice.......................... Treatment of Hyperbilirubinemia................................ Neonatal Sepsis.................................................................. NEUROLOGY Glassgow Coma Scale......................................................... Motor Assessment............................................................. Deep Tendon Reflexes....................................................... Cranium Caput succedaneum.................................................... Cephalhematoma........................................................ Hydrocephalus................................................................... Seizure Bening Febrile Seizure................................................ Simple vs Complex......................................................

54 54 56 56 57 59 59 59 60 60 60 61 61 62 62 63 63 64 65 66 67 68 68 68 68 69 70 70

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Cerebrspinal Fluid CSF PATHWAY............................................................. LUMBAR PUNCTURE.................................................... CSF ANALYSIS.............................................................. Hydrocephalus................................................................... Bells Palsy.......................................................................... Cerebral Palsy.................................................................... Hypoxic Ischemic Enchepalopathy...................................... PULMONOLOGY PCAP Clinical Features of Pneumonia................................... Microbial Causes of CAP aacdg to Age......................... CXR In Assessing CAP etiology..................................... Therapeutic Mngt of CAP............................................ CPG............................................................................. ASTHMA Severity of Asthma Exacerbation................................. Levels of Asthma Control (GINA)................................. Management Approach Based on Control................... BRONCHIOLITIS.................................................................. VIRAL CROUP VS EPIGLOTITIS............................................. BICARBONATE DEFICIT CORRECTION.................................. CARDIOVASCULAR Transfusion Medicine Blood Products........................................................... Double Volume Exchange Therapy.............................. SHOCK............................................................................... Signs of Shock............................................................. LABORATORY MEDICINE HEMATOLOGY Complete Blood Count................................................ RBC INDICES................................................................ ANC............................................................................. CLINICAL CHEMISTRY Glucose......................................................................

71 71 71 72 73 74 75

77 77 78 78 80 82 83 83 84 85 86

87 88 89 90

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GASTROENTEROLOGY Assessment of Dehydration................................................ Caposition of ORS............................................................... Oral Rehydration Theraphy................................................ Fluid Management............................................................. Composition of IV Solution................................................. Maintenance Water........................................................... NEPHROLOGY GFR Normal Values............................................................. Computations GFR............................................................................. OFI.............................................................................. BSA............................................................................. AGN................................................................................... GABS.................................................................................. INTERPRETAtION OF BUN-CREA RATIO............................... IMMUNOLOGY Anaphylaxis........................................................................ Dermatitis.......................................................................... Atopic......................................................................... Contact....................................................................... Seborrheic.................................................................. Juvenile Rheumatoid Arthritis............................................ Systemic Lupus Erythematosus........................................... Henoch-Schonlein Purpura................................................. Immunization..................................................................... Vaccines............................................................................. Rabies Vaccine............................................................ Tetanus Toxoid........................................................... INFECTIOUS DISEASES Rheumatic Heart Disease Jones Criteria.............................................................. Infective Endocarditis Modified Duke Criteria................................................ Paramyxoviridae (Mumps)................................................. Rubella (German Measles)................................................. Rubeola (Measles)..............................................................

93 93 94 94 95 95 96 96 96 96 97 98 99 100 101 101 101 101 102 103 104 105 106 106 107

108 109 110 111 112

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Roseola (HSV 6).................................................................. Coxsackie A (Herpangina)................................................... Herpes Simplex Virus (Varicella)......................................... Parvovirus B19 (Erythema Infectiosum/Fifth Disease)........ Dengue Fever..................................................................... NUTRITION Waterloo Classification....................................................... Growth & Caloric Requirements......................................... Caloric & Protien Requirements......................................... Estimated Catch Up Growth Requirement.......................... Approximate Daily Water Requirement.............................. Osterized Feeding.............................................................. Milk Formulas.................................................................... Total Parenteral Nutrition.................................................. TPN in Pediatrics........................................................ TPN for Neonates........................................................ Sample Solving............................................................ EMERGENCY MEDICINE ET Tube Determination...................................................... Laryngoscope Sizes............................................................. Emergency Management.................................................... Epinephrine Amiodarone Cardioversion Albumin Epinephrine Drip Levophed Dopamine Anaphylaxis........................................................................ O2 Supplementation.......................................................... NORMAL VALUES Ideal Body Weight.............................................................. Head Circumference........................................................... Length................................................................................ Weight for Height .............................................................. Height for age.....................................................................

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ADMITTING ORDERS NEONATOLOGY NICU Please admit under RI, LI, PD or AP TPR q4H May breastfeed if NSD; NPO x 2hrs if CS Labs: NBS at 24 hrs old, secure consent CBC, BT (if w/ maternal illness, PROM or UTI HGT now then 1, 3, 6, 12, 24, 48 hrs old (GDM) HGT now (SGA or LGA) Medications: Erythromycin eye ointment both eyes Vit K 1 mg IM (term); 0.5 mg (PT) Hep B vaccine 0.5 ml IM, secure consent BCG 0.05 ml ID (PT); 0.1 ml (term), secure onsent SO Routine NB care Monitor VS q30 mins until stable Thermoregulate at 36.5 to 37.5°C Place under droplight (NSD); isolette (CS) Suction secretion prn Will infrom AP /AP attended delivery

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NEUROLOGY FEBRILE SEIZURE Please admit under the service of Dr. TPR q4H and record DAT once fully awake Labs: CBC U/A (MSCC) IVF: D5 0.3 NaCl 1P (50cc/kg in 8 h if <2 yo) D5 0.3 NaCl 1L (30cc/kg in 8 h if >2 yo) D5LR 1L at 30cc/kg in 8hif >40 kg Medications: Paracetamol prn q4h for T > 37.8°C SO: MIO q shift and record Monitor VS q2h and record Monitor neurovital signs q4h and record Continue TSB for fever Seizure precaution at bedside as ff: Suction machine at bedside O2 with functional gauge; if with active sz give O2 at 2lpm via NC Diazepam IVTT (0.3 mkd max of 5 mg IV) prn for seizure Will inform AP Pls inform Dr _____ of this admission Thank you.

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Pre Lumbar Tap NPO RBS by gluco prior to lumbar tap Prepare lumbar tap set 2% Lidocaine # 1 G 23 spinal needle Mannitol 250 cc 1 bottle - do not open Solvent Diazepam 1 amp 3cc syringe #2 2 manometers sterile bottles # 3 sterile gloves # 2 Sterile gauze # 1 Sterile gauze w/ Betadine #1 Sterile towel w/ hole #1 Sterile clamp #1 3-way stopcock #1 Post Lumbar Tap NPO x 4H Flat on bed Monitor NVS to include BP q 30mins x 4H, then qH CSF exams Bottle # 1 – Gm stain, AFB, India ink, KOH Bottle # 2 – Cell count, CHON, Sugar Bottle # 3 – C/S, save remaining specimen Watch out for vomiting, HA and hypotension

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PULMONOLOGY BRONCHIAL ASTHMA Please admit under the service of Dr. TPR q4H and record NPO if dyspneic Labs: CBC CXR APL* ABG* U/A (MSCC) IVF: D5 0.3 NaCl 1P (50cc/kg in 8 h if <2 yo) D5 0.3 NaCl 1L (30cc/kg in 8 h if >2 yo) D5LR 1L at 30cc/kg in 8hif >40 kg Medications: Paracetamol prn q4h for T > 37.8°C (10 – 15 mkdose) USN with Salbutamol or Salbu+Ipratropium neb; 1 neb x 3 doses Incorporate Budesonide 10 mkd LD (max 200mg IV); then 5mkd q6h IV (max of 100 mg IV) Ranitidine IVTT at 1mkdose (if on NPO) SO: MIO q shift and record Monitor VS q2h and record Refer for persistence of tachypnea, alar flaring and retractions O2 at 2 lpm via NC, refer for desaturations <95% Will inform AP Pls inform Dr _____ of this admission Thank you.

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BPN Please admit under the service of Dr. TPR q4H and record NPO if dyspneic Labs: CBC U/A (MSCC) ABG* CXR APL* IVF: D5 0.3 NaCl 1P (50cc/kg in 8 h if <2 yo) OR D5 IMB/D5 NM at MR if with NO losses D5 0.3 NaCl 1L (30cc/kg in 8 h if >2 yo) D5LR 1L at 30cc/kg in 8hif >40 kg Medications: Paracetamol prn q4h for T > 37.8°C (10 – 15 mkdose) USN with Salbutamol or Salbu+Ipratropium neb; 1 neb x 3 doses then refer NaCl (Muconase) nasal spray, 2 sprays per nostrils, then suction using bulb QID Ranitidine IVTT at 1mkdose (if on NPO) SO: MIO q shift and record Monitor VS q2h and record Continue TSB for fever Refer for persistence of tachypnea, alar flaring and retractions O2 at 2 lpm via NC, or 6 lpm via facemask Attach to pulse oximeter, refer for desaturations <95% Will inform AP Pls inform Dr _____ of this admission Thank you.

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GASTROENTEROLOGY AGE Please admit under the service of Dr. TPR q4H and record DAT once fully awake; NPO x 2hrs if with vomiting Labs: CBC U/A (MSCC) F/A (Concentration Method) IVF: D5 0.3 NaCl 1P (50cc/kg in 8 h if <2 yo) D5 0.3 NaCl 1L (30cc/kg in 8 h if >2 yo) D5LR 1L at 30cc/kg in 8hif >40 kg Medications: Paracetamol prn q4h for T > 37.8°C Zinc (E Zinc) Drops 10mg/ml 1ml OD (<6 mos) 1ml BID (6 mos – 2 yo) Syrup 20 mg/5ml (>2 yo) 5ml OD Ranitidine IVTT at 1mkdose (if with abdominal pain) SO: MIO q shift and record Monitor VS q2h and record Continue TSB for fever Chart character, frequency and amount of GI losses and replace w/ PLR 1L/1P vol/vol Will inform AP Pls inform Dr _____ of this admission Thank you.

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IMMUNOLOGY HYPERSENSITIVITY REACTION Please admit under the service of Dr. TPR q4H and record Hypoallergenic diet Labs: CBC U/A (MSCC) IVF: D5 0.3 NaCl 1P (50cc/kg in 8 h if <2 yo) D5 0.3 NaCl 1L (30cc/kg in 8 h if >2 yo) D5LR 1L at 30cc/kg in 8hif >40 kg Medications: *Epinephrine (1:1000) 0.1mg/kg/dose IM anterolateral thigh (max of 0.3 mg) *Salbutamol neb x 3 doses q 20 mins Diphenhydramine 10 mkdose LD (max of 200mg IV); thenmg IV) 5mkdose q6h IV (max of 100 Ranitidine IVTT at 1mkdose q 12h SO: MIO q shift and record Monitor VS q2h and record to include BP Continue TSB for fever O2 at 2 lpm via NC, or 6 lpm via facemask Attach to pulse oximeter, refer for desaturations <95% Will inform AP Pls inform Dr _____ of this admission Thank you.

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INFECTIOUS DISEASES DENGUE FEVER Please admit under the service of Dr. TPR q4H and record DAT ( No dark colored foods) Labs: CBC, Plt (optional APTT and PT) Blood typing U/A (MSCC) IVF: D5 0.3 NaCl 1P/1L (<40 kg) at 3 – 5 cc/kg D5LR 1L (>40 kg) at 3 – 5 cc/kg Medications: Paracetamol prn q4h for T > 37.8°C Omeprazole 1mkdose max 40 mg IVTT OD SO: MIO q shift and record Monitor VS q2h and record, to include BP Continue TSB for fever Refer for Hypotension, narrow pulse pressure (<20mmHg) Refer for signs of active bleeding like epistaxis, gum bleeding, melena, coffee ground vomitus Will inform AP Pls inform Dr _____ of this admission Thank you.

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MEDICATIONS ANTIBACTERIALS CELL WALL ACTIVE ANTIBIOTICS PENICILLINS Amoxicillin (30 – 50 mkday) TID Pediamox Susp : 250mg/5ml Drops : 100mg/ml Himox Cap : 250mg Moxicillin Susp : 125mg/5ml Harvimox Drops : 100mg/ml Novamox Amoxil Susp : 125mg/5ml Cap : 250mg Glamox Drops : 100mg/ml Globapen Cloxacillin (50 – 100 mkday) q6h Prostaphlin A Tab: 250mg Orbinin Susp: 125mg/5ml Flucloxacillin (50 – 100 mkday) q6h Staphloxin Susp: 125mg/5ml Cap : 250mg

500mg 250mg/5ml

250mg/5ml 500mg

500mg

500mg

PENICILLIN COMBINATIONS Amoxicillin + Clavulanic acid (30 – 50 mkday) Augmentin Tab: 375mg (250mg); 625 (500mg) Amoclav Susp: 156.25mg/5ml (125mg) TID 228.5mg/5ml (200mg) BID 312.5mg/5ml (250mg) TID 457mg/5ml (400mg) BID

642/5 (600mg)

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CEPHALOSPORINS 1st Generation Cefalexin (25 – 100 mkd ) q 6-8 h Lexum Cap : 250mg; 500mg Cefalin Susp : 125mg/5ml 250mg/5ml Keflex Drops : 100mg/ml Ceporex Cap : 250mg 500mg Selzef Caplet: 1 gm Granules: 125mg/5ml 250mg/5ml Drops: 125mg/1.25ml 2nd Generation Cefaclor (20 – 40 mkd ) q 8 – 12 h Ceclor Pulvule: 250mg 500mg Ceclor CD 375mg 750mg CD ext release Susp: 125mg/5ml 187mg/5ml 250mg/5ml 375mg/5ml Drops: 50mg/ml Xelent Cap : 250mg 500mg Vercef Susp : 125mg/5ml 250mg/5ml Cefuroxime (20 – 40mkd) q 12h Zinnat Cap : 250mg 500mg Sachet: 125mg/sat 250mg/sat Susp: 125mg/5ml Cefprozil (20 – 40mkd) q 12h Procef Susp : 125mg/5ml 250mg/5ml 3rd Generation Cefixime (6 – 12 mkd) q 12h Tergecef Susp : 100mg/5ml Zefral Drops: 20mg/ml Ultrazime Cefdinir (7mg/kg q 12h OR 14mg/kg OD) Omnicef Cap : 300mg Sachet/Susp: 125 mg/5ml 250mg/5ml

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PROTEIN SYNTHESIS INHIBITOR MACROLIDES Erythromycin (30 – 50 mkd) q 6h Macrocin Susp: 200mg/5ml Ethiocin Drops: 100mg/2.5ml Erycin Cap : 250mg 500mg Susp: 200mg/5ml Drops: 100mg/2.5ml Erythrocin Film tab: 250mg 500mg Granules: 200mg/5ml DS Granules: 400mg/5ml Drops: 100mg/2.5ml Ilosone/ Tab: 500mg Ilosone DS Pulvule: 250mg Liquid: 125mg/5ml DS Liquid: 200mg/5ml Drops: 100mg/ml Clarithromycin (6 – 15 mkday OR 7.5 mkdose q12h) Klaricid Susp : 125mg/5ml 50mg/5ml Klaz Tab: 250mg 500mg Roxithromycin <6 yo 5 – 8 mkd BID 6 – 12 yo 100mg/tab BID Macrol/Rulid Tab: 150mg Ped Tab: 100mg Rulid dispensable Tab: 50mg Azithromycin

Zithromax

3 day regimen: 10 mkday x 3 days 5 day regimen: 10 mkd on day 1 5 mkd on day 2 to 5 Adult: 500mg OD day 1 250mg OD day 2 to 5 Susp: 250mg/5ml Cap : 250mg Sachet: 200mg/sachet

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Clindamycin

LINCOSAMIDES PO: 20 – 30 mkday q 6 – 8h IV: 25 – 40vmkday q 6h Susp: 75mg/5ml Cap: 150mg 300mg Amp: 150mg/ml

CHLORAMPHENICOL Chloramphenicol (50 – 75 mkd) q6h Pediachlor Susp: 125mg/5ml Chloramol Tab : 250mg Kemicetine Chloromycetin

Tetracycline Doxycycline

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500mg

TETRACYCLINES 25 – 50 mkday q6h 5 mkday BID

DNA SYNTHESIS INHIBITOR NITROFURAN Furazolidone 5 – 8 mkday q6h NIFUROXAZIDE (20 mkday) Ercefuryl Cap 200mg Oral Susp 218mg/5ml >2yo: max: 660mg/day TID >6yo - Adult: max 800mg/day BID/QID All treatment duration must not exceed 7 days

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ANTIBACTERIAL COMBINATIONS TRIMETHOPRIM + SULFAMETHOXAZOLE COTRIMOXAZOLE (TM 5 – 8 mkd) q 12h Bactille – TS Susp/5ml SMZ 400mg TM 80mg Bacidal Tab 800mg 160mg Globaxole Trizole Susp/5ml SMZ 400mg TM 80mg

Triglobe

TRIMETHOPRIM + SULFADIAZONE Tab SDZ 410mg TM 90mg Forte 820mg 180mg Susp/5ml 205mg 45mg

Penicillin Amoxicillin Ampicillin Chloramphenicol Ampi + Cloxa Oxacillin Flucloxacillin Gentamicin Netromycin Amikacin Cephalexin Cefuroxime Ceftriazone Ceftazidime

IV ANTIBIOTICS 50,000 – 100,000 ukd q 6h 50 – 100 mkd q 6 – 8 h 50 – 100 mkd q 6 – 8 h 50 – 100 mkd q 4 – 6 h 50 – 100 mkd q 6 h 50 – 100 mkd q 6 – 8 h 50 – 100 mkd q 6 – 8 h 5 – 7.5 mkd OD 5mkd q 12 h 15mkd q 12 h 50 – 100 mkd q 6 h 50 – 100 mkd q 6 – 8 h 50 – 100 mkd OD 50 – 100 mkd q 12 h

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Isoniazid Comprilex Nicetal Trisofort Odinah

Rifampicin Natricin Rifadin Rimactane Rimaped

Pyrazinamide (PZA) CIBA Zcure Zinaplex

ANTI-TB MEDS (10 – 12 mkd) ODAC or 2hrs PC Suspension: 200mg/5ml 100mg/5ml 200mg/5ml 150mg/5ml Tablet 400mg (10 – 20 mkd) ODAC or 2hrs PC 100mg/5ml 200mg/5ml 100mg/5ml 100mg/5ml 200mg/5ml Tablet 300mg 450mg (16 – 30 mkd) BID/TID 250mg/5ml 500mg/5ml Tablet 500mg

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ANTIPROTOZOAN AMOEBICIDES PO: 30 – 50 mkday q 8h IV: 30 mkday q 8h Anaerobia Susp : 125mg/5ml Tab : 250mg Servizol Susp: 200mg/5ml Tab : 250mg 500mg Flagyl Susp : 125mg/5ml Tab : 250mg 500mg Etofamide (15 – 20 mkd) TID Kitnos Susp : 125mg/5ml Tab : 200mg 500mg Diloxanide furoate (20mkd) q8h x 10 days Furamide Tab : 500mg Dilfur Susp: 125mg/5ml Secnidazole Flagentyl 2 tab now then 2 tabs after 4 hrs Ercefuryl (20mkday) Metronidazole

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ANTI-HELMINTHICS Oxantel + Pyrantel pamoate (10 – 20 mkd) SD Trichiuriasis: x 2 days Hookworm: x 3 days Quantrel Susp : 125mg/5ml Tab : 125mg 250mg Mebendazole *not recommended below 2 yo Antiox Susp: 50 mg/ml 100mg/ml Tab: 125mg 250mg 100 mg BID x 3 days 500mg SD (>2 yo) Albendazole <2 yo: 200mg SD >2yo: 400mg SD *may give x 3 days if with severe infestation Zentel Susp: 200mg/5ml Tab : 400mg

ANTIVIRAL Acyclovir Zovirax Acevir

(20 mkdose) q 4 – 6 h Max 800mg/day x 5 days Susp: 200mg/5ml Tab: (Blue) 400mg (Pink) 800mg

ORAL ANTIFUNGALS Ketoconazole (6mkd) q 4 – 6h Daktarin Adult & Child: ½ tsp q 6h Infant: ¼ tsp q 6 h Nystatin Mucostatin Susp: 100,000 u/5ml Ready mix susp Tab: 500,000 u Fluconazole (3 – 6 mkd) OD x 2wks Diflucan Cap: 50mg 150mg Vial: 2mg/ml x 100 ml

200mg

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NEUROLOGY DIAZEPAM

MIDAZOLAM

PHENOBARBITAL

ANTICONVULSANT 0.2 – 0.3 mkdose Drip: 1amp in 50cc D5W 10mg/amp 0.05 - 0.2mkdose (0.15 mkdose) prn 2 – 3 mins interval IV (1, 5mg/ml) 6 mos - 5 yo 0.05 - 0.10 max of 0.6 mg/kg 6 yo - 12 yo 0.25 - 0.05 max of 0.4 mg/kg >12 yo 0.50 - 2 mg/dose over 2 mins LD: 15 – 20 mkd MD: 5 mkdose q 12h (max load 20 mkday IV) Tabs: 15, 30, 60, 90, 100 mg Caps: 16 mg ELIXIR 20mg/5ml Inj: 30, 60, 65, 130 mg/ml MD: PO/ IV Neonate: 3 - 5 mkD QID/ BID Infant/child: 5 - 6 mkD 1 - 5 yo: 6 - 8 mkD 6 - 12 yo: 4 - 6 mkD > 12 yo: 1 - 3 mkD Hyperbil < 12 yo: 3 - 8 mkD BID/TID

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PHENYTOIN

LD: 15 – 20 mg/kg/IV MD: Neonate: 5 mkD PO/ IV BID Infant/child: 5 7mkD BID/ TID 6mos – 3y: 8 – 10 mkD 4 – 6y: 7.5 – 9 mkD 7 – 9y: 7 – 8 mkD 10 – 16 y: 6 – 7 mkD Tab: 50mg 100mg TID Extended release caps 30, 100, 200, 300 mg OD, BID Inj: 50 mg/ml

Dilantin

CARBAMAZEPINE Tegretol

< 6 yo 6 - 12 yo > 12 y

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Tab 200mg, 100mg chew XR 100mg, 200mg, 400mg Susp 100mg/ 5ml (QID) Initial Increment Maintenance 10 - 20 mkD BID /TID q wkly til 35 mkD 10 mkD BID 100 mg/ 24H at 20 - 30 mkD BID/ QID 1 wk interval 200 mg BID 200 mg/ 24H at 800 - 1200 mg/24H 1 wk interval BID/ QID

OXCARBAMAZEPINE

(8 - 10 mkd BID) Initial: 8 -10 mkD PO BID then Increment: increase over 2 week pd to Maintenance doses: 20 -29 kg: 900 mg/24H PO BID 29.1 -39 kg: 1200 mg/24H PO BID >39 kg: 1800 mg/24H PO BID

Trileptal

Tab Susp

150 mg 300mg 300mg/5ml

600 mg

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VALPROIC ACID

Depakene Depacon TOPIRAMATE

Topamax

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PO: Initial : 10 - 15 mkD OD - TID Increment: 10 mkD at wkly interval BID Maintenance: 30 - 60 mkD BID/TID IV: same dose as PO q 6H Rectal : (syrup mix with water 1:1) LD: 20 mkd MD: 10 -15mkd TID Tab 250 mg Syr 250mg/5ml IV 100mg/ml 2 - 16 yo Initial: 1 - 3 mkd PO q HS x 7 days then Increment: increase by 1 - 3 mkday for 1 - 2 wks then Maintenance: 5 -9 mkD BID Cap 15 mg, 25 mg Tabs 25 50 100 200mg

P e d i a t r i c

N o t e s | 31

P e d i a t r i c

RESPIRATORY DRUGS DECONGESTANT Nasal NaCl Salinase Muconase Oxymetazoline HCl Drixine Xylometazoline HCl Otrivin

2 – 4 drps/spray per nostril TID/QID 2 sprays/nostril then suction q6h x 3 days Nasal spray Nasal drops 2 – 5 yo: 2 – 3 drops/nostril BID >5 yo: 2 – 3 sprays/nostril BID Nasal spray: 0.05% Nasal soln: 0.025% < 1 yo: 1 – 2 drps OD/BID 1 – 6 yo: 1 – 2 drps OD/BID max TID Adult: 2 – 3 drps / 1 squirt TID max QID

N o t e s | 32

P e d i a t r i c

Oral Phenylpropanolamine HCl (0.3 – 0.5 mkdose) Disudrin 1 – 3 mos: 0.25 ml 4 – 6 mos: 0.5 ml 7 – 12 mos: 0.75 ml 1 – 2 yo: 1 ml 2 – 6 yo: 2.5 ml 7 – 12 yo: 5 ml Drops: 6.25ml q6h Syr: 12.5mg/5ml q6h Brompheniramine maleate + Phenyleprine Dimetapp 1 – 6 mos: 0.5ml TID/QID 7 – 24 mos: 1ml TID/QID 2 – 4 yo: ¾ tsp 4 – 12 yo: 5ml Adult: 5 – 10 ml 1 tab BID Infant drops: (0.1mkdose) Syr/5ml: 2mg/5ml Extentab Carbinoxamine maleate + Phenylephrine HCl Rhinoport 1 – 5 yo: 5ml 6 – 12 yo: 10ml Adult & > 12yo: 1 cap / 15ml Syrup Cap Loratadine + PPA Loraped <30 kg: 2.5ml BID >30 kg: 5ml BID Syrup: 5mg/ml

N o t e s | 33

BID BID BID

P e d i a t r i c

MUCOLYTIC Carbocisteine

Infant Drops <3mos 3 – 5 mos 6 – 8 mos 9 – 12 mos Ped Syr 1 – 3 yo 4 – 7 yo 8 – 12 yo Adult Susp Adult & >12 yo

Carbocisteine (Solmux)

Solmux Chewable tab Loviscol

Salbutamol+Carbocisteine

(Solmux Broncho)

N o t e s | 34

QID 0.25ml 0.5ml 0.75ml 1ml TID 5 – 7.5ml 7.5 – 10ml 10 – 15ml

1 – 1 ½ tsp 1 ½ - 2 tsp 2 – 3 tsp

TID 10 – 15ml

2 – 3 tsp

Capsule TID Adult & >12 yo 1 cap Drops: 40mg/ml 1 – 3 mos: 0.5ml TID/QID 3 – 6 mos 0.75ml 6 – 12 mos 1ml 1 – 2 yo 1.5 ml Susp: 100mg/5ml 200mg/5ml 2 – 3 yo 5ml 2.5ml 4 – 7 yo 10ml 5 ml 8 – 12 yo 15ml 7.5ml Adult & >12 yo Forte: 500mg/5ml 5 – 10ml Cap: 500mg 1 cap Tab: 500mg 1 tab q 8h Infant drops 50mg/ml Ped Syrup 100mg/5ml Adult Susp 250mg/5ml Cap 500mg Capsule: (S)2mg/(C)500mg Susp (/5ml): (S)2mg/(C)500mg

P e d i a t r i c

Ambroxol

recommended dose- 1.2mkd

Mucosolvan

Ambrolex Zobrixol

Infant Drops

<6mo 7-12mo 13-24mo Pedia Syr <2yo 2 – 5 yo 5 – 10 yo Adult Syr >10yo & Adult Retard Cap >10yo & Adult Tab >10yo & Adult Inhalation <5 yo

6mg/ml 0.5ml 1ml 1.25ml

75mg/ml 0.5ml 0.75ml 1ml

2.5ml 2.5ml 5ml

N o t e s | 35

BID

BID TID TID 5ml

TID

1cap

OD

1tab

TID

1 – 2 inhalation of 2ml soln daily Adult & children >5 yo 1 – 2 inhalation of 2 – 3ml soln daily Infant drops 6mg/ml Ped liquid 15mg/5ml Adult liquid 30mg/5ml Retard cap 75mg Tab 30mg Inhalation Soln 15mg/2ml Ampule 15mg/2ml Infant drops 7.5mg/ml Ped liquid 15mg/5ml Adult liquid 30mg/5ml Tab 30mg

P e d i a t r i c

B2 AGONIST Salbutamol Ventolin

Ventar Hivent Syrup Salbutamol + Guaifenesin Asmalin Broncho Pulmovent

(0.1 – 0.15 mkdose) Tab 2mg Syr 2mg/5ml Nebule 2.5mg/2.5ml Tab 2mg Syr 2mg/5ml Tab: Syrup: 2 – 6 yo 7 – 12 yo

1 tab TID 5 – 10 ml BID/TID 10ml

Terbutaline sulfate ( 0.075 mkdose) Terbulin Tab 2.5mg Pulmoxel Tab 2.5mg Syr 1.5mg/5ml Nebule 2.5mg/ml Bricanyl Tab 2.5mg Syr 1.5mg/5ml Nebule 5mg/2ml Expectorant Guaifenesin + Terbutaline Sulfate Bricanyl Expectorant TID Per 5ml 66.65mg/1.5mg Doxofylline (6 – 8 mkdose) BID x 7 – 10 days Ansimar Syrup 100mg/5ml Tab 400mg

N o t e s | 36

P e d i a t r i c

Procaterol HCl Meptin

Theophylline Nuelin SR

ANTITUSSIVES Butamirate citrate

Sinecod Forte

(1.25mcg/kdose) Syrup 5mcg/ml Tab 25mcg; 50mcg Inhaler 10mcg/puff Nebuliser soln 100mcg/ml (10 – 20 mkdose) (3 – 5 mkdose) Tab: 125mg; 250mg 12-25kg: 125mg BID >25kg: 250mg BID

3 yo >6 yo >12 yo Adult

Syrup Tab Dextromethorphan + Guaifenesin Robitussin – DM 2 – 6 yo 6 – 12 yo Adult Syrup

5 ml TID 10ml TID 15ml TID 15ml QID 1 tab TID/QID 7.5mg/5ml 50mg 2.5 – 5ml q 6 – 8h 5ml q 6 – 8h 5 – 10ml q 6h

N o t e s | 37

P e d i a t r i c

IMMUNOLOGY ANTIHISTAMINE Diphenhydramine HCl (5mkd) q 6h IM/IV/PO: 1 – 2 mkdose Benadryl Syr: 12.5mg/5ml Cap: 25mg 50mg Inj: 50mg/ml Hydroxyzine (1mkd) BID Adult: 10mg BID 25mg ODHS Iterax Syr: 2mg/ml Tab: 10mg 25mg 50mg Ceterizine (0.25mkdose) 6mos - <12mos : 1ml OD 12mos - <2 yo: 1ml OD/BID 2 – 5 yo: 2ml OD / 1ml BID 6 – 12 yo: 10ml (2 tsp) OD 5ml BID 1 tab OD/ ½ tab BID Adult & >12yo: 1 tab OD Virlix Oral drops: 10mg/ml Oral soln: 1mg/ml Tab: 10mg Allerkid Drops: 2.5mg/ml Syr: 5mg/5ml Alnix Drops: 2.5mg/ml Syr: 5mg/5ml Tab: 10mg

N o t e s | 38

P e d i a t r i c

Loratadine

Claritin Allerta Loradex Desloratadine

Aerius

1 – 2 yo: 2 – 12 yo (<30 kg): (>30 kg): Adult & > 12 y : Syr: 5mg/ml Tab: 10mg

2.5 ml 5ml 10ml 1 tab

BID OD OD OD

6 – 12 mos: 2ml OD 1 – 5 yo: 2.5ml OD 6 – 12 yo: 5ml OD Syr: 2mg/5ml Tab: 5mg

STEROIDS INHALED Budesonide Budecort

Flexotide neb

ORAL Prednisone Prednisolone Liquidpred INTRAVENOUS HYDROCORTISONE

250mcg q 12h 500mcg q 12h 500mcg OD for allergic rhinitis 250mcg /ml (2ml) 500mcg /ml (2ml) 250mcg /ml (2ml) 250mcg q 12h LD: 10mkdose MD: 5mkdose 1 – 2 mkday 1 – 2 mkday Syrup 15mg/5ml

200mg

LD: 10 mkdose MD: 5 mkdose q 6, 8 or 12h *max dose: LD 200 MD 100

N o t e s | 39

P e d i a t r i c

N o t e s | 40

X

IVIG INFUSION Preparation: 2.5g/50cc 500g/10cc 25g/100cc 5g/100cc 10g/250cc Computation: Wt x 2 g /kg IVIG Ex wt: 7.2 kg 7.2 x 2 + 16 g IVIG 16g IVIG 2. 5 g = 320 cc Cc 50cc # of vials = total cc 320cc = 6.4 vials 50cc 50cc 320cc x 0.03 = 9. 6 cc/h for 30 mins  Transfuse 9 – 10cc/h IVIG for the 1st 30mins if no reaction, run the remaining volume for 12H  Refer for any infusion reactions  Close ML  Monitor v/s q 30 mins while on infusion If after IVIG if still febrile, rpt IVIG after 3 D If after 2nd IVIG still febrile – start Prednisone Aspirin 80 mkD QID 30 mg, 80, 100, 300 mg

P e d i a t r i c

CARDIOVASCULAR ANTIHYPERTENSIVES Hydralazine Apresoline Spirinolactone

PO: 0.75 – 1.0 mkday q 6 – 12 h IV: 0.1 – 0.2 mkdose 1 – 3 mkday

N o t e s | 41

P e d i a t r i c

GASTROENTEROLOGY ANTACIDS Maalox (plain, plus) Simethicone Restime

ANTISPASMODIC Dicycloverine Relestal Domperidone

Motilium Vometa

5ml/10kg Available in 180ml bottle < 2 yo 2 – 12 yo Oral drops

0.5ml 4ml 40mg/ml

qid qid

6mos – 2 yo 0.5 – 1ml TID Drops 5mg/ml Syrup 10mg/5ml 0.3 – 0.6 mkdose q6–8h 2.5 – 5ml/10kg BW TID Dyspepsia: 2.5/10kg TID Nausea: 2.5 – 5ml/kg TID 0.3 – 0.6 ml/5kg BW TID/QID Susp 1mg/ml Tab 10mg Oral drops 5mg/ml Susp 5mg/5ml Tab 10mg

N o t e s | 42

P e d i a t r i c

N o t e s | 43

H2-BLOCKER Ranitidine Zantac Cimetidine

Tagamet

Famotidine

ANTI-DIARRHEAL Enkephalinase Inhibitor

Racecadotril (Hidrasec)

1 – 2 mkdose q 12h Tab 75mg 150mg 300mg Neonates: 5 – 20 mkday q6 – 12h Infants: 10 – 20 mkday Child; 20 – 40 mkday Adult: 300mkdose QID 400mkdose BID 800mkdose QID Susp: 300mg/5ml Tab: 100mg 200mg 300mg 400mg 800mg PO: 0.5 mkdose q 12 h IV: 0.6 – 0.8 mkday q 8 – 12h

- Opiod Medication - Reduce intestinal motility - Antisecretory effect—it reduces the secretion of water and electrolytes into the intestine 1.5 mg/kg for PRN (Max: 1 wk) Cap: 100mg Sachet: 10mg 30mg < 9 kg

10 mg sachet

1 sach TID

9 – 13 kg

10 mg sachet

2 sach TID

13 – 27kg

30 mg sachet

1 sach TID

> 27 kg

30 mg sachet

2 sach TID

P e d i a t r i c

OTHER GI DRUGS MULTIVITAMINS LYSMIX 0.3 cc/k/dose TID Ceiling = 0.4

N o t e s | 44

P e d i a t r i c

N o t e s | 45

PROBIOTICS Lactobacillus acidophilus, Bifidobacterium bifidum, Lactobacillus casei, Bifidobacterium infantis, Bifidobacterium longum, Lactococcus lactis, oligosaccharide, Zn, lactose, maltodextrin, citric acid, sucralose Prozinc Drops 10 mg/ml < 6 mos 1 ml OD < 6 mos – 2 yo 1 ml BID Syrup 20 mg/5ml > 2 yo 5ml OD Sachet Bacillus clausii Erceflora Per vials: 2billion org/5ml Max for 2 wks OD/Q4H >1mos – 11yo: 1-2 vials /day Adults: 2-3 vials/day Always dilute with water, milk or juice Per 1 billion CFU/sachet Lactobacillus casei, Lactobacillus rhamnosus, Streptococcus thermophilus, Bifidobacterium breve, Lactobacillus acidophilus, Bifidobacterium infantis, Lactobacillus bulgaricus, fructooligosaccharide (FOS) Protexin 1billion CFU/sachet PRN (Max:7 days) OD Restore >7mos: 1 sachet mix with milk Lactobacillus casei, Lactobacillus rhamnosus, Streptococcus thermophilus, Bifidobacterium breve, Lactobacillus acidophilus, Bifidobacterium longum, Lactobacillus bulgaricus, allicin, fructooligosaccharide (FOS) Protexin 1-2 cap OD Balance

P e d i a t r i c

ANALGESIC/ANTIPYRETIC Paracetamol Tempra

Calpol

Defebrol Afebrin

Tylenol Naprex

Rexidol

Biogesic

Aeknil Opigesic

(10 – 20 mkdose) q 4h Drops: 60mg/0.6ml Syrup: 120mg/5ml Forte : 250mg/5ml Tablet: 325mg 500mg Drops: 100mg/ml Syrup: 120mg/5m 250mg/5ml Syrup: 120mg/5m 250mg/5ml Drops: 60mg/0.6ml Syrup: 120mg/5ml Forte : 250mg/5ml Tablet: 600mg Drops: 80mg/ml Syrup: 160mg/5ml Drops: 60mg/0.6ml Syrup: 250mg/5ml Inj: 300mg/2ml Drops: 60mg/0.6ml Syrup: 250mg/5ml Tablet: 600mg Drops: 100mg/ml Syrup: 120mg/5m 250mg/5ml Tablet: 500mg Ampule (2ml) 150mg/ml Suppository: 125mg 250mg

N o t e s | 46

P e d i a t r i c

Mefenamic Acid Ponstan

Aspirin Ibuprofen Dolan FP Dolan Forte Advil

(6 – 8mkdose) q 6h Suspension: 50mg/5ml Cap SF: 250mg Tab: 500mg (60 – 100 mkd) (5 – 10 mkday) q8h (max 20mkday) Suspension: 100mg/5ml 200mg/5ml Drops: 100mg/2.5ml 100mg/5 Tab: 200mg

N o t e s | 47

P e d i a t r i c

DRIPS Dengue Drips

N o t e s | 48

P e d i a t r i c

N o t e s | 49

Furosemide drip Dose: 0.04 - 0.5 80 mg + 32 cc Wt x dose = rate (cc/h) 2 Furo drip = 0.1 - 0.5mg/k/hr Prep: 20mg/2ml (2mg/ml) Rate: (wt x dose)/2 = cc/hr ex. 14.5kg x 0.45 = 3.2cc/hr To order: 8ml Furo + 32ml D5W +40 cc to run at 3.2cc/hr

Noradrenaline (Levophed) 1mg/ml dose :(0.5 – 1 ml/kg) Wt x dose ( each ml contains 4 mcg Noradrenaline) 4 mcg ( for acute hypotension) 2ml + 500cc D5W x 2cc/H (0.5 cc/H) Dopamine ( 5 -20 mcg/kg/min) Dobutamine

Terbutaline Bricanyl SC

Terbutaline drip

200 mg/250ml Single strength 400 mg/250ml DS (div by 2) Wt x dose x 0.075 250 mg/5ml SS 500 mg/250ml DS(div by 2) Wt x dose x 0.06

Inj: 1 mg/ml < 12y – 0.005 – 0.01 mkd x 3 doses q 15 -20 min then q2-6H > 12y – 0.25 mkd LD: 2 – 10 mcg/kg then 0.1 – 0.4 mcg/kg/min

P e d i a t r i c

N o t e s | 50

DEXMEDETOMIDINE Sedation of initially intubated and mechanically ventilated patients during treatment in an intensive care setting. Precedex drip Dose: 0.2 - 0.7 1ml + 99cc D5W to run at cc/h Wt x dose = rate (cc/h) Ketamine (Ketalar)

Morphine IV Naproxen

KCl IV 2 meq/ml Child: 0.5 – 1meq/k/dose infusion of 0.5 meq/k/h for 1-2 h Tabs: 8, 10, 15, 20 meq Oral soln 10% ( 6.7 meq/5ml) 15% (10 meq/5ml) 20% (13.3 meq/5ml) PO : 1-4 meq/kg/24H QID IV: 0.5 – 1meq/k/dose Ca Gluc = Children: 1cc/k/dose x 3doses; Max: 10cc/dose + equal amt of sterile water

10, 50, 100 mg/ml PO: 5mg/kg x 1 IV 0.25 - 0.5 mg/kg IM 1.5 - 2 mg/kg x 1 0.1 – 0.2 mkd q2-4H prn 250, 375, 500mg tab 125mg/5ml > 2yo – 5-7 mkd TID, BID PO NaHCO3 Inj premixed: 5% (0.6 meq/ml) 500ml Tabs: 325 mg (3.8 meq), 650 mg (7.6 meq)

Urine alkalinization 84 – 840 mg (1- 10 meq)/kg/D PO QID

P e d i a t r i c

N o t e s | 51

VITAMINS Stimulants Buclizine (syrup)

w/ Folic acid (Megaloblastic Anemia)

Pizotifen (drowsiness) MTV w/ Iron w/ Serotonin (for migraine + dec wt)

Mosegar Vita 0.25 mg/day prep 0.25 /5 ml Appetens Propan Appebon 2 - 8yo 5 - 10 ml OD 7 - 14yo 10 - 20 ml OD Molvite 7 - 12yo 10 - 15 ml OD 3 - 6yo 5 - 10 ml OD 1 - 2yo 2.5 - 5 ml OD Iberet Ferlin (10 mcg folic acid) Macrobee 1 - 2yo 2.5 - 5 cc OD 3 - 6yo 5 - 10 cc OD 7 - 12yo 10 - 15 cc OD Mosegor vita syr Appetens Propan w/ iron syr (Fe So4; elem fe 30mg) Appebon w/ iron syr (FeSo4; elem fe 10mg) Mosegor vita Mosegor plain Appeten Jagaplex syrup 1-2yo 5ml OD 3-6yo 10 ml OD 7-12yo 15 ml OD Clusivol Power syrup syr 100mg/5ml 2-6yo 5 ml OD 7-12yo 10 ml OD Zeeplus <2yo 2.5 ml OD 2-6yo 5 ml OD 7-12yo 5-10 ml OD

P e d i a t r i c

N o t e s | 52

Polynerv

Iron Deficiency Anemia

1-2yo 2.5 ml OD 3-6yo 5 ml OD 7-12yo 10 ml OD 0-6mo 0.5 ml-1 ml OD 7mo-1yr 1-1.5 ml OD 1-2yrs 1.5-2ml OD Supplemental Iron = Therapeutic Dose: 5 - 6 mkday for 3 mos Maintenance Dose: 3 - 4 mkday Elemental iron 20% of FeSo4 12% Fe gluconate 33% Fe fumarate Wt x Dose x Prep Ferlin drops15mg/ml Fe 75 mg Prophylactic dose Term 1 mg/k/Day, start 4 mos-1y PT 2 mkD, start 2 mos-1y Therapeutic dose 3 mkD BID, QID for 4-6mos Ferlin syrup 30mg/ml Fe 149.3 mg Supplemental dose 10-15 mg OD Therapeutic dose 3 mkD TID, QID for 4-6mos Sangobion syr (Fe gluc 250mg elem Fe 30mg) Incremin with Iron Syrup 30 mg elem Fe

P e d i a t r i c

N o t e s | 53

P e d i a t r i c

N o t e s | 54

CONDITIONS NEONATOLOGY ESSENTIAL NEWBORN CARE PROTOCOL [from DOH] 1. Immediate Drying – hypothermia can lead to several risks 2. Delayed Cord Clumping – to 3 mins after birth (or waiting until the umbilical cord has stopped pulsing)

3.

Latched on – – –

4.

Provide warmth Increase the duration of breastfeeding Allow the “good bacteria” from the mother’s skin to infiltrate the NB Breastfeeding

5.

No suctioning Washing should be delayed until after 6 hours because this exposes the NB to hypothermia and remove vernix. Washing also removes the baby’s crawling reflex.

NEWBORN CARE Umbilical Cord  Cut 8 inches above abdomen after 30 sec  In nursery, cut the umbilical cord 1 ½ inch above the abdomen  Healing should take place around 7 – 10 days Eye Prophylaxis  1% silver nitrate drops [most effective against Neisseria]  Erythromycin 0.5% [Chlamydia]  Tetracycline 1%  Povidone iodine 2.5% Vitamin K  Term: 1 mg Vit K  PreT: 0.5 mg Vaccine  BCG  Hep B

P e d i a t r i c

N o t e s | 55

Newborn Screening  Done on 16th hr of life . can be repeated after 2 weeks  Patients w/ CAH will die 7 – 14 days if not treated  Patient w/ CH will have permanent growth defect and MR if not treated before 4 weeks NEWBORN CARE Hypothermia  hypoxia  metabolic acidosis  hyperglycemia Erythromycin ointment  should be given an hour after birth  gonococcal/chlamydial conjunctivitis Gonococcal Conjunctivitis  within 7days Chemical conjunctivitis  disappears within 48H Other bacterial conjunctivitis  Chlamydial >10-14 days  Staph 48H-5th day (2-5days)  Herpes  Pseudomonas-give Gentamycin Umbilical stump - sloughed off <14 days Alcohol - drying effect

P e d i a t r i c

N o t e s | 56

APGAR SCORE Evaluates the need for resuscitation Taken 1 and 5 minutes after birth 0 1 2 Color Blue, pale Body pink, All pink extremities blue HR 0 <100 >100 Reflex irritability No response Grimace Cough Activity Limp Some flexion Active Respiration Absent Slow, irregular Good The APGAR Score 8 – 10 Good cardiopulmonary adaptation 4–7 Need for resuscitation, esp ventilatory support 0–3 Need for immediate resuscitation o o

Disorder Screened Congenital Hypothyroidism (CH) Congenital Adrenal Hyperplasia (CAH) Galactosemia (Gal) Phenylketonuria PKU G6PD Maple Syrup Urine Dse

NEWBORN SCREENING Effects Screened Severe MR

Effects if Screened & treated Normal

Death

Alive &Normal

Death of Cataract Severe MR Severe Anemia Kernicterus

Alive &Normal Normal Normal

P e d i a t r i c

NURSERY NOTES Dextrosity (to get factor:

Desired – D5 D50- D5

D 7.5 = 0.055 D10 = 0.11 D 12.5 = 0.166 D15 = 0.22 D 17.5 = 0.28 Limits of Dextrosity: Peripheral line = D12 Central line = D20 Total Fluid Intake (TFI): Preterm: start at 60 cckd Term: start at 80 cckd To check TFI = rate x 24 ÷ wt ex. Preterm: wt: 1.129 Day 1: start IVF with D10 water 60 x 1.219 ÷ 24 = 3.1 cc/hr x 24 hrs  Add Calcium gluconate at 200 mkd q8h Ca gluc = 1.129 x 200 ÷ 3 = 75mg q8hrs for 3 doses  Start antibiotics  Give ranitidine  HGT q 8/12 hrs  OGT  CBC  Na, K, Ca at 48 hrs  Blood c/s depends on AP Day 2: increase TFI by 10-20 (depends on AP) 70 x 1.129 ÷ 24 = 3.3 cc/hr x 24 hrs incorporate ca gluc 200 mkd to IV ex.

N o t e s | 57

P e d i a t r i c

D10 water 80 cc Ca gluc 2.2cc 82.2cc to run at 3.3ccx24hrs

Day 3: increase TFI by 10-20 (depends on AP) If electrolytes are N, may use D10IMB 80 x 1.129 ÷ 24 = rate 80 x 1.129 x factor to get value of D50 water (to make D10 use 0.11) Cont Ca gluc incorporation (if feeding may discontinue) D50 water 9.9cc D5 IMB 77.9cc = D10 IMB Ca gluc 2.2cc (200mkd) 90 cc to run at 3.7cc/hrx24h If feeding already: Total volume of milk ÷ wt = cc/kg/day Subtract this amount to TFI to get value for IV (if Dr. Reinoso, divide by 2 before subtracting to TFI) ex. MF 3cc q3hrs = 24 cc in 24 hrs 24 ÷ 1.129 = 21.2 cckd from milk 80 – 21.2 = 58.8cckd (use this for IVF) 58.8 x 1.129 ÷ 24 = rate D50 water 7.3cc D5 IMB 56.5cc = D10 IMB Ca gluc 2.2cc (200mkd) 66 cc to run at 2.7cc/hrx24h Subsequent days depend on infants status…..

N o t e s | 58

P e d i a t r i c

N o t e s | 59

Electrolyte requirements: Na: 2-4 mkd prep’n 2.5 mg/ml Ca: 100-200mkd prep’n 100mg/ml K: 2-4 mkd prep’n 2mg/ml Glucose Infusion Rate: Dextrosity x IVF rate x 10 ÷ 10 Wt Ex. 10 kg; IVF D10 IMB at 40cc/h GIR = 10 x 10 x 40 ÷ 10 = 6.6mkmin 60 NV: Newborn & Infants 6-8 mg/kg/min Children 4-6 mg/kg/min If HGT <40 mg/dl, give D10 water slow IV push at 2cc/kg and repeat HGT after 30 mins-1 hr (may do 3 boluses if still low, may inc dextrosity or rate) EMERGENCY INTERVENTION Level of Umbilical Cathetherization: (cm) If arterial between T6-T9 Wt x 3 x 8 If venous: (wt x 3) + 8 +1 2

P e d i a t r i c

N o t e s | 60

Determination of ET Tube Size ET tube size: age in yrs +4 4 ET level: o if >2yo: age(yrs) +12 2 o Or ET size x 3 Total Flow Rate = Tidal volume x wt x RR x I.E ratio + 2000 I.E = 2 Dead space = 2000 RR = 40-60 Tidal volume = Newborn: 6-10cck Child: 10-15cck Adult: 15cck FiO2 o o

Nasopharyngeal cathether = Flow rate x 20 + 20 Ex. 1L Fio2 = 40 Nasal catheter = Flow rate x 4 + 20 Ex. 1L FiO2 = 24

Extubation: o Give Dexamethasone at 0.1 mkdose q 6 hours for 24 hours prior to extubation o USN with epinephrine 0.5 cc + 1.5 cc PNSS q 15 mins x 3 doses then extubate then USN with Salbutamol ½ nebule + 1.5 cc PNSS q 6 hours x 24 hours o O2 at 10 lpm then decrease as necessary

P e d i a t r i c

Cows milk allergy  Onset- 3rd wk  Rashes on cheeks →

N o t e s | 61

eyebrows → cradle cap BILIRUBIN METABOLISM RBC

↓

Hemeoxygenase

Heme +Globin

↓

Bilirubin Reductase

Biliverdin

↓ Uncomjugated bilirubin

Enterohepatic Pathway

↓ Liver SER Glucoronyl Transferase

ß-Glucoronidase

↓

Conjugated bilirubin Kidney

↓

Urobilinogen Urobilin Urine

Small Intestine

↓ Stool

Stercobilinogen Stercobilin

P e d i a t r i c

N o t e s | 62

NEONATAL JAUNDICE Risk Factors o Jaundice visible on first day of life o A sibling w/ neonatal jaundice or anemia o Unrecognized hemolysis o Non-optimal feeding o Deficiency: G6PD o Infection o Cephalhemaoma or bruising / Central hct >65% o East Asian/ Mediteranean in origin

ZONE I II III IV V

KRAMER CLASSIFICATION JAUNDICE Head/neck Upper trunk Lower trunk, thigh Arms, leg, below knee Hands/feet

mg/dl 6–8 9 – 12 12 – 16 15 – 18 > 15

P e d i a t r i c

Bilirubin (Total) Cord

Preterm Term Preterm Term Preterm Term Preterm Term Preterm Term

0 – 1 days 1 – 2 days 3 – 5 days Older Infants Adult Bilirubin (Conjugated) Neonate Infants/Children

FACTORS Onset Rate of inc of TSB Persistent Total S. Bilirubn Sign/ Symptom

N o t e s | 63

<2 mg/dl <2 mg/dl <8 mg/dl <8.7 mg/dl <12 mg/dl <11.5 mg/dl <16 mg/dl <12 mg/dl <2 mg/dl <1.2 mg/dl 0.3 – 1.2 mg/dl

<34 µmol/L <34 µmol/L <137 µmol/L <149 µmol/L <205 µmol/L <197µmol/L <274 µmol/L <205µmol/L <34 µmol/L <21 µmol/L 5 – 12 µmol/L

<0.6 mg/dl <0.2 mg/dl

<10 µmol/L <3.4 µmol/L

PHYSIOLOGIC vs PATHOLOGIC PHYSIOLOGIC PATHOLOGIC > 24 hrs of life < 24 hrs of life < 0.5mg/dl/hr > 0.5mg/dl/hr < 14 days FT: > 8 days PT: > 14 days FT: < 12 mg/dl Any level requiring PT: < 14 mg/dl phototherapy Vomiting, lethargy, poor feeding, excess wt loss, apnea, inc RR, temp instability

P e d i a t r i c

Parameter Onset

Pathophysio

Mngt

N o t e s | 64

BREAST FEEDING vs BREASTMILK JAUNDICE BREASTFEEDING BREASTMILK 3rd to 5th day of Late; start to rise on day 4; may reach 20 – 30 life mg/dl on day 14 then ↓ slowly Normal by 4 – 12 weeks Decrease milk Unknown intake → Prob. due to β – glucoronidase in BM which ↑ ↑enterohepatic enterohepatic circulation circulation Normal LFT; (-) hemolysis Fluid and If breastfeeding is stopped, rapid decrease in caloricsupplement bilirubin level in 48 hrs, if resumed will rise to 2 – 4 mg/dl but no precipitating previous events

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N o t e s | 65

Treatment of Hyperbilirubinemia Phototherapy o Complications: metabolic acidosis, electrolyte abnormalities, hypoglycemia, hypocalcemia, Exchange thrombocytopenia, volume overload, arrhythmias, NEC, transfusion infection, graft versus host disease, and death o IV Ig

o o o

Metalloporphyrins o

Adjunctive treatment for hyperbilirubinemia due to isoimmune hemolytic disease (0.5–1.0 g/kg/dose; repeat in 12 hr) Reducing hemolysis Competitive enzymatic inhibition of the rate limiting conversion of heme-protein to biliverdin (an intermediate metabolite to the production of unconjugated bilirubin) by heme-oxygenase Patients with ABO incompatibility or G6PD deficiency or when blood products are discouraged as with Jehovah's Witness patients

PHOTOTHERAPY o 10 Bulbs o 20 watts o 200 hrs o 30 cms o Bilirubin in the skin absorbs light energy o Photo-isomerization reaction converting the toxic native unconjugated 4Z, 15Zbilirubin into an unconjugated configurational isomer 4Z,15E-bilirubin, which can then be excreted in bile without conjugation o major product from phototherapy is lumirubin, which is an irreversible structural isomer converted from native bilirubin and can be excreted by the kidneys in the unconjugated state o Complications o loose stools, erythematous macular rash, purpuric rash associated with transient porphyrinemia, overheating, dehydration (increased insensible water loss, diarrhea), hypothermia from exposure, and a benign condition called bronze baby syndrome dark, grayish-brown skin discoloration in infants

P e d i a t r i c

N o t e s | 66

NEONATAL SEPSIS Classification  Early: birth to 7th day of life  Late: 8th to 28th day of life Risk factors  Maternal infection during pregnancy  Prolongrupture of membranes (18 hrs)  Prematurity Common organism:  Bacteria: GBS, E. coli & Listeria (early)  Viruses: HSV, enteroviruses Signs & symptom  Non-specific Dx:  CBC, CXR, blood and urine culture, lumbar tap for CSF studies Treatment  Empiric antibiotics [Ampicillin + 3rd gen Cephalosporin or Aminoglycoside)  supportive

P e d i a t r i c

N o t e s | 67

NEUROLOGY Glasgow Coma Scale Response Activiy Eye Opening Spontaneous 4 To speech 3 To pain 2 None 1 Verbal Oriented 5 Confused 4 Inappropriate 3 words 2 Inappropriate 1 sounds None Motor Follows 6 command 5 Localizes pain 4 Withdraws to 3 pain 2 Abnormal 1 flexion Abnormal extension None

Infants Activity

Response

Spontaneous To speech To pain None

4 3 2 1

Coos, babbles Irritable Cries to pain Moans to pain None

5 4 3 2 1

Normal spontaneous movement Withdraws to touch Withdraws to pain Abnormal flexion Abnormal extension None

6 5 4 3 2 1

P e d i a t r i c

MOTOR full resistance with gravity some resistance with gravity movement with gravity movement w/o gravity flicker no movement

5/5 4/5 3/5 2/5 1/5 0/5

DTR very brisk brisker than average normal diminished no response

N o t e s | 68

+4 +3 +2 +1 0

CRANIUM Caput succedaneum  diffuse edematous swelling of soft tses of scalp  extend across midline  edema disappears w/in 1st few days of life  molding and overriding of parietal bones-frequent  disappear during 1st wks of life  no specific tx Cephalhematoma  subperiosteal hemorrhage  limited to1 cranial bone  occur 1-2 % cases  no discoloration of overlying scalp  swelling not visible for several hours after birth ( blding slow process)  firm tense mass with palpable rim localized over 1 area of skull  resorbed w/in 2wk- 3mos  calcify by end of 2nd wk  few remain for years  10-25% cases underlying linear skull fracture  No tx but photo in hyperbil

P e d i a t r i c

N o t e s | 69

HYDROCEPHALUS Result from impaired circulation & absorption of CSF or from inceased production  Obstructive or Noncommunicating o Due to obstruction w/n ventricular system o Abnormality of the aqueduct or a lesion in the 4th venticle (aqueductal stenosis)  Non-obstructive or Communicating o Obliteration of the subarachnoid cisterns or malfunction of the arachnoid villi o Follows SAH that obliterates arachnoid villi; leukemic infiltrates Clinical Manifestation  Infant: accelerated rate of enlargement of the head; wide anterior fontanel & bulging [Normal fontanel size: 2 x 2 cm]  Eyes may deviate downward: due to impingement of the dilated suprapineal recess on the tectum [setting – sun sign]  Long – tract sign: [brisk DTR, spasticity, clonus, Babinski sign]  Percussion of skull produce a “crackedpot” or Macewen sign *separation of sutures]  Foreshortened occiput [Chiari malformation]  Prominent occiput [Dandy-Walker malformation] Treatment  Depends on the cause  Extracranial shunt  Acetazolamide & Furosemide [provide temporary relief by reducing the rate of CSF production] 

P e d i a t r i c

N o t e s | 70

SEIZURE SEIZURE BENIGN FEBRILE SEIZURE CRITERIA  6 mos – 6 yrs  < 15 mins  Febrile  Family history of febrile seizure  GTC  Not > 1 episode in 1 febrile episode; EEG done after 2 wks of seizure episode  3% of general population develop epilepsy  1 – 2 % of BFS develop epilepsy  25% recurrence of seizure  Seizure – paroxysmal, time limited change in motor activity and/or behavior that results from abnormal electrical activity in the brain  Epilepsy – present when 2 or more unprovoked seizure s occur at an interval greater than 24 hrs apaet

SIMPLE

COMPLEX

GTC

Focal then gen post ictal

Duration

< 15 min

Recurrence CNS exam Sequelae

None Normal None

> 15 min or may go into status Recurrent (w/in 24H) Abnormal Neurodev abn

Type

P e d i a t r i c

N o t e s | 71

CSF PATHWAY Choroid plexus (lateral ventricle) → Foramen of Monroe → 3rd ventricle → Aqueduct of sylvius → 4th ventricle →Foramina of Luschka (2 laterals) → & Magendie (median) → SAS → Absorbed in the arachnoid villi, then in the Venous System

  

Contraindications to LP evidence of Inc ICP severe CP compromise Skin infection at site of puncture

Normal Infant (Term) Infant (Preterm) Older child Viral Mening TB/Fungal Bacterial Mening Partially tx BM

CSF ANALYSIS Wbc

Color

Rbc

Diff ct

Sugar

CHON

Xantho

0 -100

0 -32

L 100%

70 -80%

0 -100

0 -15

L 100%

70 -80%

Clear

0

0 -10

L 100%

> 50%

60 150 60 200 10-20

Clear

Clear

0

0 -20

L 100%

40- 60%

40 -60

Clear

0

L>N

< 40%

Purulent

0

20 500 > 1000

N>L

< 50%

Clear

0

100

L>N

> 50%

> 100 g% > 100 g% Dec

P e d i a t r i c

 



        

N o t e s | 72

HYDROCEPHALUS Result from impaired circulation & absorption of CSF or from inceased production Obstructive or Noncommunicating o Due to obstruction w/n ventricular system o Abnormality of the aqueduct or a lesion in the 4th venticle (aqueductal stenosis) Non-obstructive or Communicating o Obliteration of the subarachnoid cisterns or malfunction of the arachnoid villi o Follows SAH that obliterates arachnoid villi; leukemic infiltrates Clinical Manifestation Infant: accelerated rate of enlargement of the head; wide anterior fontanel & bulging [Normal fontanel size: 2 x 2 cm] Eyes may deviate downward: due to impingement of the dilated suprapineal recess on the tectum [setting – sun sign] Long – tract sign: [brisk DTR, spasticity, clonus, Babinski sign] Percussion of skull produce a “crackedpot” or Macewen sign [separation of sutures] Foreshortened occiput [Chiari malformation] Prominent occiput [Dandy-Walker malformation] Treatment Depends on the cause Extracranial shunt Acetazolamide & Furosemide [provide temporary relief by reducing the rate of CSF production]

P e d i a t r i c

      

N o t e s | 73

BELLS PALSY Acute unilateral facial nerve palsy that is not associated with other cranial neuropathies or brainstem dysfunction Usually develops abruptly about 2 wks after SVI [EBV, HSV, mumps] Upper and lower portions of the face are paretic Corner of the mouth droops Unable to close the eye on the involved side Protection of cornea with methylcellulose eye drops or an ocular lubricant Excellent prognosis

P e d i a t r i c

N o t e s | 74

CEREBRAL PALSY 

Non-progressive disorder of posture & movement often associated with epilepsy & abnormalities of speech, vision & intellect resulting from defect or lesion of the developing brain  Etiology: infections, toxins, metabolic, ischemia Classification Physiologic Topogrphic [major motor abnormality] [involved extremities] 1. Spastic 1. Monoplegia [1 side/portion] 2. Athetoid –worm like 2. Paraplegia 3. Rigid 3. Hemiplegia 4. Ataxic 4. Triplegia [3 limbs] 5. Tremor 5. Quadriplegia [all] 6. Atonic 6. Diplegia [LE/UE] 7. Mixed 7. Double hemiplegia 8. unclassified Clinical Manifestaion Spastic hemiplegia  Arms > legs  Dificulty in hand manipulation obviously by 1 yo  Delayed walking or walk on tiptoes  Spasticity apparent esp. in ankles  Seizure & cognitivr impairment Spastic diplegia  Bilateral spasticity of the legs  Commando crawl  Increased DTRs & (+) Babinski sign  Normal intellect Spastic quadriplegia  Most severe form, due to marked motor impairment of all extremities & high association with MR & seizures  Swallowing difficulties Management  Baseline EEG & cranial CT scan  Hearing & visual function tests  Multidisciplinary approach in the assessment & treatment  For tight heel cord: tenotomy of the Achilles tendon

P e d i a t r i c

N o t e s | 75

Criteria for Hypoxic Ischemic Encephalopathy  pH < 7 (profound met. Acidosis)  Apgar <3 more than 5 mins  Neurologic sequelae (coma; sz)  Multiorgan involvement  Difficult delivery Medications  Dopamine: wt x dose x 0.075 Prep’n : Single Strength: 200mg/250ml; Double Strength: 400/250ml if using double strength: wt x dose x 0.075÷2 (Dose = 5-20)  Dobutamine: wt x dose x 0.06 Prep’n: 250mg/250 ml; Dobuject 50mg/ml (Dose = 5-20) If using Dobuject: Wt x dose x 60÷ concentration Concentrations: 5mg/ml = 5000 50mg/50ml = 1000 50mg/20ml = 2500 To make 5mg/ml: Dobuject 5cc D5 water 45cc To make 50mg/50ml: Dobuject 1cc D5 water 49cc To make 50mg/20ml: Dobuject 1cc D5 water 19cc  Diflucan: 6 mkd OD prep’n 50mg/tab divide into pptabs and give 1 pptab OD x 2 weeks  Aminophylline: 5mkd (loading dose) then 1.6 mkd q 8 hrs (maintenance)  Phenobarbital 20 mkd (loading dose) then 5 mkd (maintenance)  Dexamethasone 0.1 mkdose q6hrs x 24 hours  For other meds, please see NEOFAX

P e d i a t r i c

N o t e s | 76

P e d i a t r i c

N o t e s | 77

PULMONOLOGY PCAP CLINICAL FEATURES of PNEUMONIA Bacterial o Fever >38.5C o Chest recession o Wheeze not a sign of primary bacterial URTI Viral o Wheeze o fever < 38.5 o marked recession o RR normal or increased Mycoplasma o School children o Cough o wheeze

Birth to 20 days

3 weeks to 3 months

4 months to 4 yo

5 years to 15 years

o o o o o o o o o o o o o o o o o o o

Microbial causes of CAP accrdng to Age Grp B Strep Gram (-) enterobacteria CMV L. monocytogenesis RSV Parainfluenza virus S. pneumonia B. pertussis S. aureus RSV, Parainfluenza virus Influenza virus, Adeno, Rhinovirus S. pneumonia H. influenzae M.pneumoniae M.tuberculosis M.pneumoniae C. pneumoniae S. pneumonia M.tuberculosis

P e d i a t r i c

N o t e s | 78

CXR in assessing CAP etiology Alveolar infltrates Bacterial pneumonia Interstitial infiltrates Viral pneumonia Both infiltrates Viral, Bacterial or mixed viral bacterial pneumonia Therapeutic Mgt of CAP OPD Mngt Birth to 20 days 3 weeks to 3 months

4 months to 4 yo 5 years to 15 years

IN-PATIENT Birth to 20 days 3 weeks to 3 months 4 months to 4 yo 5 years to 15 years

Admit Afebrile: Oral Erythromycin (30-40mkd) Oral Azithromycin (10 mg/kg/day) day 1 5mkday day2 to 5 Admit: febrile or toxic Oral Amoxicillin (90mkd/3doses) Alternative: Amox-Clav, AZM, Cefaclor Clarithromycin, Erythromycin Oral Erythromycin (30-40mkd) Oral AZM 10mkday day 1, 5mkday day 2-5 Clarithromycin 15mkday/2 doses Pneumococcal infxn: Amoxicillin alone Ampicillin + Gentamicin w or w/o Cefotaxime Afebrile: IV Erythromycin (30-40mkd) Febrile: add Cefotaxime 200mkd Cefuroxime 150 mkd If w/ pneumococcal infection: IV Ampicillin (200mkd) Cefotaxime 200mkd Cefuroxime 150 mkd Cefuroxime 150 mkd + Erythromycin 40mkd IV or orally for 10-14 days If pneumococcal is confirmed: Ampicillin 200mkd

P e d i a t r i c

VARIABLE

PCAP A Minimal Risk

PCAP PCAP B Low Risk

Comorbid Illness Compliant caregiver Ability to follow up Presence of DHN Ability to feed Age RR

None

2–12 mos 1 – 5 yo >5 yo

N o t e s | 79

PCAP C Moderate Risk

PCAP D High Risk

Present

Present

Present

Yes

Yes

No

No

Possible

Possible

Not

Not

None

Mild

moderate

Severe

Able

Able

Unable

Unable

>11 mos

>11 mos

<11 mos

<11 mos

>50/min >40/min >30/min

>50/min >40/min >30/min

>60/min >50/min >35/min

>70/min >50/min >35/min

Signs of Respiratory Failure Retractions

-

-

Head Bobbing Cyanosis Grunting Apnea

-

-

Sensorium

None

Awake

Subcosta/ Intercostal + + Irritable

Subcostal/ Intercostal + + + + Lethargy/ Stupor/ Coma

Complication:

Effusion Pneumothora x Action Plan

None

None

Present

Present

OPD f/u at end of tx

OPD f/u after 3 days

Admit (Ward)

Admit (ICU) Refer to specialist

P e d i a t r i c

N o t e s | 80

Clinical Practice Guidelines in the Evaluation and Management of PCAP 2004 Predictors of CAP in patients with cough  (3 mos to 5 yrs) – tachypnea &/or chest retractions  (5 – 12 yrs) – fever, tachypnea & crackles  (>12 yo) – (a) fever, tachypnea & tachycardia; (b) at least 1 AbN CXR WHO Age Specific classification for tachynea  2 – 12 mos: >50 RR  1 – 5 yrs: >40 RR  >5 yrs: >30 RR PCAP A/PCAP B  No diagnostic usually requested PCAP C/PCAP D  The ff shud b routinely requested o CXR APL (patchy – viral; consolidated – bacterial) o WBC o C/S (blood, Pleural Fluid, tracheal aspirate on initial intubation) o Blood gas/Pulse oximeter  The ff may be requested: C/S sputum  The ff shud NOT be routinely requested o ESR o CRP Antibiotic Recommendation 1. PCAP A/PCAP B and is beyond 2 yo & having fever w/o wheeze 2. PCAP C and is beyond 2 yo, having high grade fever, having alveolar consolidation on CXR, having WBC >15,000 3. PCAP D – refer to specialist Antibiotic Recommendation  PCAP A/PCAP B w/o previous antibiotic o Amoxicillin (40 – 50 mkday) TID  PCAP C o Pen G IV (100,000 IU/k/d) QID  PCAP C who had no HiB immunization o Ampicillin IV (100mkd) QID  PCAP D – refer to specialist

P e d i a t r i c

N o t e s | 81

What shud b done if px is not responding to current antibiotics 1. If PCAP A/PCAP B not responding w/n 72 hrs a. Change initial antibiotic b. Start oral Macrolide c. Reevaluate dx 2. PCAP C no responding w/n 72 hrs consult w/ specialisr a. PCN resistant S pneumonia b. Complication c. Other dx 3. PCAP D not responding w/n 72hrs, then immediate consultto a specialist is warranted Switch from IV to Oral Antibiotic done in 2 – 3 days after initiation in px who:  Respond to initial antibiotic  Is able to feed with intact GI tract  Does not have any pulmo or extra pulmo complication Ancillary Treatments  O2 and Hydration  Bronchodilators, CPT, steam inhalation and Nebulization Prevention  Vaccines  Zinc Supplementation o 10mg for infants o 20mg for children > 2 yo

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N o t e s | 82

ASTHMA SEVERITY OF ASTHMA EXACERBATION MILD

MODERATE

SEVERE

Breathless

Walking

Talking Infant –softer shorter cry Diff feeding

At rest Infant stops feeding

Talks in

Can lie Sentences

Prefers sitting Phrases

Hunched Words

Allertness

May b agitated

Usually agitated

Usually agitated

RR Normal RR <2 mo 2-12 mo 1-2 y 2-8 y Acessory ms

Inc

Inc

>30/min

<60/min <50/min <40/min <30/min Usually not

Usually

Usually

Wheeze

Moderate

Loud

Usually loud

<100

100-200

>120

Maybe present 10-25mmHg

Often present 20-40 mmHg

Pulse Normal PR 2-12 mo 1-2 y 2-8 y Pulsus paradoxus

<160/min <120/min <110/min Absent

PEF PaO2

<10mmHg >80% Normal

60-80% >60 mmHg

<60% <60mmHg

PaCO2

<45 mmHg

<45 mmHg

>45 mmHg

O2 Sat

>95%

91-95%

<90%

RESPIRATORY ARREST IMMINENT

Drowsy or confused

Paradoxical Thoracoabd movt Absence of wheeze Bradycardia

Absence suggests resp ms fatigue

P e d i a t r i c

LEVELS OF ASTHMA CONTROL [GINA GUIDELINES] CONTROLLED PARTLY Daytime symptom None More than 2x a [2x or less week /week] Limitation of None Any activities Nocturnal None Any sx/awakening Need for None More than 2x a reliever/recue tx week Lung function Normal 80% predicted (PEF OR FEV1) Exacerbation None One or more/yr

Step 1 PRN B2 agonist

C O N T R O L L E R

N o t e s | 83

UNCONTROLLED Three or more features of partly controled asthma present in any week

One in any week

MANAGEMENT APPROACH BASED ON CONTROL Step 2 Step 3 Step 4 Step 5 Asthma education and Environmental control As needed rapid acting B2 agonist Select one Select one Add one or more Add one or more Low dose ICS Low dose ICS + Med to Hi dose Oral LABA ICS + LABA steroids Leukotriene Medium or Hi Leukotriene modifier dose ICS Modifier Anti Low dose Sustained IgE ICS + Release treatment Leukotriene theophylline Modifier Low dose ICS + Salbutamol Release theophylline

P e d i a t r i c

   

N o t e s | 84

BRONCHIOLITIS Acute inflammation of the small airways in children <2 yrs Most commonly caused by RSV Related to exposure to cigarette smoke Risk factors for severe dse: o <6 mos o Prematurity o Heart or lung disease o immunodeficiency Signs /Symptoms  low grade fever, rhinorrhea, cough, wheezing  hyperresonance to percussion CXR  hyperinflation, interstitial infiltrates Treatment  Mild [at home]: o Increased fluids, trial of inhaled bronchodilators, aerosolized epinephrine  Severe: o Admit to hospital if: Marked respratory distress; Poor feeding; O2 sat <92%; hx of prematurity < 34 wks; underlying cardiopulmonary dse; unreliable caregivers o Manage with ventilatory and O2 support, hydration, inhaled bronchodilators and ribavirin

P e d i a t r i c

Age group Stridor Pathogen Onset Fever Severity Associated symptoms Respond to racemic epinephrine CXR

VIRAL CROUP vs EPIGLOTTITIS VIRAL CROUP 3 mos to 3 yrs 88% Parainfluenza virus Prodrome (1 – 7 days) Low grade Barking cough, hoarseness Stridor improves “steeple sign”

N o t e s | 85

EPIGLOTTITIS 3 – 7 yrs 8% H. influenzae type B Rapid (4 – 12 hrs) High grade Muffled voice, Droolong None “thumbprint sign”

P e d i a t r i c

N o t e s | 86

BICARB DEFICIT CORRECTION: Ex: wt 4.9kg pH = 7.10 pCO2 = 9.1 pO2 = 36.5 HCO3 = 2.8 BE = -26.8 O2 Sat = 53.6% BE x Wt x 0.3 = 26.8 x 4.9 x 0.3 = 39.39meqs Half correction: 39.39/2 = 19.69 meqs To order: Give 20 meqs NaHCO3 + equal amt of sterile water to be given slow IVTT over 30mins. Infuse another 20 meqs NaHCO3 + equal amt sterile water as drip for 1-2 hrs. EMPIRIC: NaHCO3 1-2mkdose even w/o ABG. HCO3 correction in ABG: Half correction: Base x’s x 0.3 x wt ÷ 2 (+ equal amount of sterile water) Full correction: Base x’s x 0.3 x wt ÷ 2 (1/2 via IV push, ½ via IV drip) Full correction: Base x’s x 0.3 x wt ÷ 2 (1/2 via IV push, ½ via IV drip)

P e d i a t r i c

N o t e s | 87

CARDIOVASCULAR TRANSFUSION MEDICINE FWB PRBC Plasma PRP Plt conc Cryoprecipitate

Factor 8

1 u FWB

BLOOD PRODUCTS 10 - 20 cc/kg 5 - 10 10 - 15 10 - 15 1 u/ 7 -10 kg 1 u/kg Hemophilia A 1 bag (200mg fibrinogen) VW dse 50 -100 mg/kg Fibrinogen dse 100 cc (2-5 kg) Hemophilia A 50 u/kg Hemophilia B 100 u/kg

= 200 cc PRBC = 50 cc platelet concentrate = 150 – 200cc PRP = 150 cc FFP PRBC to be transfused for correction = 40 – hct x wt

3 – 4H 3 – 4H 1–2H 1–2H FD FD

P e d i a t r i c

Double Volume Exchange Therapy (DVET) Wt x 80 x 2 = Volume/ amt of fresh whole blood (Use mother’s blood type) Volume _ = # of exchange aliquots per exchange > 3 kg 2-3 kg 1-2 kg 850g-1kg < 850 g

20 ml 15 ml 10 ml 5 ml 1-3 ml

Prepare the ff:  2 pcs 3 way stopcock  1 pc 5 cc syringe  1 pc BT set  1 pc IV tubing  1 pc empty bottle  Gloves  Calcium gluconate 100 mg every 10 exchanges

N o t e s | 88

P e d i a t r i c

SHOCK  CO = HR x SV  CO is primarily maintained by changes in HR HYPOVOLEMIC  Pump empty  Truma, hemorrhage, DHN (diarrhea/vomiting)  Metabolic dse (DM)  Excessive sweating CARDIOGENIC  Weak/sick pump  CHF, cardiomegaly, drug intoxication, hypothermia, after cardiac surgery DISTRIBUTIVE  Sepsis  Anaphylaxis  Barbiturate intox  CNS injury (SCI)

N o t e s | 89

 

MC in infant &children Normal BV of children 80ml/kg



Compromise CO



Redistribution of fluid w/n vascular space

P e d i a t r i c

N o t e s | 90

SIGNS OF SHOCK EARLY LATE  Narrowed pulse  Decrease systolic pressure pressure  Decrease diastolic pressure  Orthostatic changes  Cold, pale skin  Delayed capillary filling  Altered mental state  Tachycardia  Diaphoresis  Hyperventilation  Decrease urine output ED 1. Position MNGT 2. Oxygen 3. Assisted ventilation 4. Intravenous access 5. Fluid (isotonic crystalloid) 6. Reassess (look for improvement in VS, skin signs, mental status; insert foley cath & monitor UO) 7. Inotropes – help stabilize BP o Epinephrine - (0.1 – 1 ug/kg/min) Infusion of choice for Hypotensive pxs o Dobutamine - (5 – 20 ug/kg/min) Cardiogenic shock but not severely hypotensive o Dopamine – [(5 – 20 ug/kg/min αconstrictor effect) [(10 – 15 ug/kg/min] Distributive shock after successful fluid resuscitation 8. Cardiogenic shock o Diuretic – pxs may get worse after fluid challenge o Adenosine / synchronize cardioversion – SVT o Defibrillation – Venticular fibrillation

P e d i a t r i c

N o t e s | 91

LABORATORY MEDICINE HEMATOLOGY

Hgb Hct Wbc Plt Retic

COMPLETE BLOOD COUNT 1-3 1 mo 2mos 6 – 12y >12y days 14.5 – 9 -14 11.5 13-16 22.5 15.5 .48 .28 - .42 .35 - .45 .37 - .49 .69 9 -30 5 – 19.5 6 -17.5 4.5 birth 13.5 84 – 478 NB After 1 wk, same as adult 150 - 400 0.4 - 0.6 < 1 -1.2 0.1 -2.9

BLOOD INDICES MCV Hgb / rbc x 10 80 -94 MCH Hgb / rbc x 10 27 - 32 MCHC Hgb/ hct x 10 32 – 38 Absolute reticulocyte count = pt’s hct x retic % N hct for age Reticulocyte Index Absolute Retic Ct 2

> 2 hemorrhage < 2 rbc production abn

P e d i a t r i c

N o t e s | 92

ABSOLUTE NEUTROPHIL COUNT ANC - % of neutrophils & cells that become neutrophils – multiplied by wbc ANC = wbc x (% seg + % stabs + % meta) Other formula: wbc x (seg + meta + stabs ) x 10 Ex 2.1 x 53 (seg) x 10 = 1113 ANC > 1000 Normal ANC < 2000 Neutropenia ANC 1000 -1500 Low risk of infection ANC 500 -1000 Mod risk of infection ANC < 500 High risk of infection IT ratio > 0.25 sepsis > 0.80 higher risk of death fr sepsis Anemia < 10 g 8-9g <8 g

mild anemia mod anemia severe anemia

CLINICAL CHEMISTRY GLUCOSE PT : NB: 1 d: >1d: Child: Adult:

20-60 30-60 40-60 50-90 60-100 70-105

P e d i a t r i c

N o t e s | 93

GASTROENTEROLOGY 1. 2. 3. 4. 5.

AGE PROTOCOL Continue Feeding ORS – Electrolyte Replacement Sedacious Use of Antibiotics Zn Supplementation – Aids in reepitheliazation of GI Tract Probiotics – Aids in digestion

PARAMETER Condition

Eyes Tears Mouth/Togue Thirst Skin pinch

Glucolyte Hydrite WHO Pedialyte 30 45 90 Gatorade

ASSESSMENT OF DEHYDRATION [CDD] NO SIGN SOME SIGN Well, Alert RestlessI Irritable Normal

Sunkem

Present Moist Drinks normally Not thirsty Goes back quicly

Absent Dry Thirsty Drinks eagerly Goes back slowly

COMPOSITION OF ORS Na K 60 20 90 20 75 20 30 20 45 20 90 20 41 11

SEVERE Lethargic Unconscious Floppy Very sunken Dry Absent Very dry Drinks poorly Not able to drink Goes back very slowly

Cl 50 80 65 30 35 80

Glu 100 111 75

9/100

P e d i a t r i c

PLAN A

PLAN B PLAN C

N o t e s | 94

ORAL REHYDRATION THERAPY Amount ORS to give/loose stool 50 – 100 ml 100 – 200 ml As much as wanted Amount of ORS to give in 1st 24 hrs: Weight (kg) x 75ml/kg AGE 30ml/kg 70ml/kg Infants (<1 yo) 1 hr 5 hrs Children (>1 yo) 30 mins 2.5 hrs AGE

In fluid resuscitation: use 20cc/kg as bolus. Usually PLR

 

FLUID MANAGEMENT Severity Less than 2 yo More than 2 yo Mild 50cc/kg 30cc/kg Moderate 100cc/kg 60cc/kg Severe 150cc/kg 90cc/kg To run for 6 – 8 hrs then refer Usual fluid is D5 0.3 NaCl; if however more than 40 kg then D5 LR

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N o t e s | 95

COMPOSITION OF IV SOLUTION Fluid

Na

PNSS 154 0.45 NaCl 77 D5 0.3 NaCl 51 D5 LRS 130 D5 NM 40 D5 IMB 25 D5 NR 140 Na requirement : 2 – 4 meq/k/day K requirement: 2 – 3 meq/k/day KIR: 0.2 – 0.3 meq/k/hr

K

Cl

HCO3

Dxt

4 13 20 5

154 77 51 109 40 22 98

28 16 23 27

5 5 5 5 5

max of 40 meq

KIR = Rate x incorporation wt

MAINTENANCE WATER HOLLIDAY – SEGAR METHOD Weight [kg] Daily Requirement [ml/kg] 1 – 10 100 ml 10 – 20 1000 + 50ml/kg for each kg >10 >20 1500 + 20ml/kg for each kg >20 Maintenace water rate 0 – 10 4ml/kg/hr 10 – 20 40 mk/hr + 2ml/kg/hr x wt >20 60 mk/hr + 1ml/kg/hr x wt

P e d i a t r i c

NEPHROLOGY Age PT 2- 8 d 4 - 28 d 30 -90 d Term 2- 8 d 4 - 28 d 30 - 90 d 1- 6mo 6 - 12 mo 2 - 19mo 2 - 12y Adult males Adult females

GFR

Range

11 20 50

11 – 15 15 – 28 40 – 65

39 47 58 77 103 127 127 131 117

17 – 60 26 – 68 30 – 86 39 -114 49 – 157 62 – 191 89 – 165 88 – 174 87 – 147

GFR (based on plasma creatinine and ht) GFR = k x L = ml/min/1.73 m2 SA sCr L = body length (cm) Scr = mg/dL ; divide by 88.4 if units in mmol/L Computation for OFI (AGN & limiting OFI) 1. BSA x 400 + UO – IVF (half if w/ Furo) = OFI (then divide to 3 shifts) 2. 20cc x wt x UO – IVF BSA Weight in (kg) 0–5 6 – 10 11 – 20 20 – 40 >40

wt x 0.05 + 0.05 wt x 0.04 + 0.10 wt x 0.03 + 0.20 wt x 0.02 + 0.40 wt x 0.01 + 0.80

N o t e s | 96

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N o t e s | 97

AGN  inflam process affecting the kidney, lesions predom in the glomerulus Etiology  Infections: a. Bacterial: Grp A B hemolytic strep, S viridans, S pneumo, Staph aureus, S epidermidis, S typhi , T pallidum, Leptospira b. Viral: HBV, Mumps, Measles, CMV, Enterovirus c. Parasitic: Toxoplasm, Malaria, Schistosoma  Drugs: Toxins, Antisera, Vaccines (DPT)  Miscellaneous: Tumor Ag, Thyroglobulin

P e d i a t r i c

N o t e s | 98

GABS Nephritogenic Strains Sites: URT - pharyngitis - M1 2 4 12 18 25 Skin pyoderma - M49 55 57 60 Pathophysio – Immune complex disease Clinical & Lab -hematuria -hypocomplementenemia -proteinuria -oliguria -edema -n & v -hpn 82% -dull lumbar pain Typical course  Latent: few days – 3wks  Oliguric: 7 – 10 days  Diuretic: 7 – 10 days  Convalescent: 7 – 10 days Normalization of urine sediment Parameter Resolved by Gross hematuria 2 – 3 wks Complement level 6 – 8 wks Proteinuria 3 – 6 mos Micro hematuria 6 – 12mos Lab Dx:  U/A – spec grav,cast, hematuria, CHONuria  Serology – culture of GABS, ASO, C3 ( dec in acute phase, rises during convalescensce)  Renal fxn – bun crea- normal, hyponat  Hematology – dilutional anemia, transient hypoalbuminemia  Radiography – CXR , renal utz Management:  Bed rest  Fluid and salt restriction o Fluids: 400 – 600 ml/m2/day + UO 24H o NaCl < 2 g/day o K < 40 meq/day  Penicillin 50 – 100,000 u/kg/day TID/QID x 10 days  HPN, CHF o Furosemide 2 mg/k/dpse Prognosis – complete resolution, 5 – 10 % progress to chronic state

P e d i a t r i c

BUN/ crea ratio Normal 10 -20 > 20 suggest DHN, pre renal azotemia or GIB < 5 – liver disease, inborn error of metabolism

N o t e s | 99

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N o t e s | 100

IMMUNOLOGY    



ANAPHYLAXIS A syndrome involving a rapid & generalized immunologically mediated rxn After exposure to foreign allergens in previously sensitized individuals A true emergency when cardio and respi system are involved ED Management o O2 o Aqueous Epinephrine 1:1000 IM (0.01ml/kg with 0.5ml max) o Prepare intubation if w/ stridor & if initial therapy of epi is not effective o Continuous monitor ECG and O2 sat & establish IV access o Antihistamine to prevent progression o H1 & H2 blocker o Diphenhydramine (1mg/kg) IM o Steroids may modify late phase or recurrent reaction (Hydrocortisone 5mg/kg/dose) o Epinephrine 1:10,000 IV (0.1ml/kg; 10ml max) o Epinephrine drip (0.01ml/kg/min) Indication for Admission o Persistent bronchospasm o Hypotension requiring vasopressors o Significant hypoxia o Patient resides some distance from a hospital facility

P e d i a t r i c

ATOPIC DERMATITIS  Hereditary, AR  Hx of Asthma  Thickened, shiny, red  Exacerbated by dry skin, contact sty, & anxiety Treatment:  Hydrocortisone/ fluocinolone  Moisturizer  Cloxa/cefalexin if with infxn

CONTACT DERMATITIS    

Irritant – strong chem. Allergic E.g. Diaper rash E.g. Cosmetic, perfume

Treatment:  Remove reactant  High/mod potency steroid

N o t e s | 101

SEBORRHEIC DERMATITS  Excessive sebum accumulation on scalp, face, midchest, perineum  Greasy scalp (cradle cap)  Physiologic 1st 6mos Treatment:  Low potency steroid

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N o t e s | 102

JUVENILE RHEUMATOID ARTHRITIS [JRA] Criteria  Age of onset <16 yo  Arthritis (swelling or effusion or presence of 2 or more of: limitation of range of motion, tenderness or pain on motion, increased heat in one or more joints.  Duration: 6 wks or longer  Onset type defined in the 1st 6mos o Polyarthritis: (5 or more inflamed joints) o Oligoarthritis (<5) o Systemic arthritis w/ characteristic fever CM  Morning stiffness, ease of fatigue esp. after school in the early afternoon, joint pain later in the day, joint swelling  Pauci: LE, assoc w/ chronic uvietis  Poly: both large & small joints more severe if extensors of elbow and Achilles tendon are involved  Systemic: quotidian fever w/ daily temp spikes of 39°C for 2 wks; faint red macular rash over the trunk & proximal extremities Mngt  NSAIDS then Methotrexate  Seroid for overwhelming systemic illness

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N o t e s | 103

SYSTEMIC LUPUS ERYTHEMATOSUS [SLE]  Serositis (pleuritis, serous pericarditis,Libman sacks Criteria SOAP BRAIN MD

Dx

          

Blood - Hematologic disorder Renal disorder Arthritis, Nonerosive (2 or more joints) Immunologic disorder Neurologic disorder

  

Presence of 4 of 11 criteria [ANA not required dx] (+) ANA – screening Anti ds DNA – more specific; reflects the degree of disease activity Decrease C3, C4 in active dse Anti Sm Ab (most specific)

  Mngt

endocarditis Oral ulcers (painless) ANA abormal titer Photosensitivity

  



Malar rash Discoid rash

NSAIDS use w/ caution Prednisone (1 – 2 mkday) Severely ill: pulse IV steroid (30mkdose) max 1 gm over 60 mins OD x 3 days Severe dse: Pulse IV Cyclophosphamide to maintain renal fxn & prevent progression

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N o t e s | 104

HENOCH – SCHONLEIN PURPURA [HSP]  Most common cause of nonthrombocytopenic purpura in children  Typically follows URTI  2 – 8 years old Hallmark  Rash – palpable petechia or purpura, evolve from red to brown; last from 3 – 10 days [LE and buttocks]  Arthritis of knees and ankles  Intermittent abdominal pain due to edema & damage to the vasculatue of the GIT Mngt  Symptomatic  Steroid for severe abdominal pain

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N o t e s | 105

IMMUNIZATION Vaccine BCG DPT OPV/IPV Hep B

Measles MMR Hib Pneumococcal Rotavirus Hep A Varicella

Flu

Min age 1st dose At birth Before 1 mo 6 wks (2, 4, 6 mos) 6 wks 2, 4, 6 mos) At birth (0, 1, 6 mos) EPI (6, 10, 14) 6 – 9 mos

No of dose 1

15 mos

1

interval -

3

4 wks

3

4 wks

3

6 wks from 1st dose, 8 wks from 2nd dose

1

-

booster 18 mos 4 – 6 yo Same as DPT

2, 4, 6 mos

18 mos

6 mos (PCV7) 2 yrs (PPV) 3 and 5 mos

18 mos 2

I month

1 yr and up

2

6 – 12 mos apart

1st: 12 – 15 mos 2nd: 4 – 6 yo 6 months

2

Bet 1st and 2nd dose: at least 3 mos yearly

P e d i a t r i c

VACCINES BCG DPT OPV IPV MMR, Measles Varicella Hep B Hep A Hib Typ Pneumococcal

Influenza

Live attenuated M bovis Diptheria and TT – inactivated B pertussis Sabin trivalent live attenuated virus Salk inactivated virus Live attenuated virus Recombinant DNA, plasma derived Inactivated virus Capsular polysacc linked to carrier CHON Live typhoid vaccine – 3 doses x 2 days IMSC – Vi antigen typ vaccine Capsular polysaccharide 0.5 ml SC /IM – 23 valent purified cap Polysacc Antigen of 23 serotyp Split or whole virus IM

RABIES VACCINE VERORAB 0.5 cc/amp; 1 amp IM Day: 0 3 7 14 and 28 BERIRAB RD: 20 iu/kg 300 iu/vial 1 vial = 2ml ½ at wound site ½ deep IM Reqd amt in IU: wt x RD (20IU) Amount in ml = wt x RD (20) x 2 300 Ig (Human) 20 iu/kg Bayrab 300 iu/2ml Equine Berirab 300 iu/2ml 40 iu/kg Favirab 200 – 400 iu/5ml 1000 – 2000 iu/5ml

N o t e s | 106

P e d i a t r i c

Hx of Absorbed TT

TETANUS TOXOID Clean minor Wound

N o t e s | 107

All other Wounds

Td TIG Td Unknown or Yes No Yes <3 > No No No  < 7 yo Dtap is recommended  > 7 yo Td is recommended  If ony 3 doses of TT received, a 4th dose should be given  Give TT (clean minor wounds) if > 10 y since last dose  All other wounds (punctured wds, avulsions, burn)  Give TT (all clean wds) if > 5 yrs since last dose

TIG Yes No

P e d i a t r i c

N o t e s | 108

INFECTIOUS DISEASES RHEUMATIC HEART DISEASE JONES CRITERIA Major Manifestation (FEArP CPC Every Saturday) 1. Carditis (50%) a. Tachycardia b. Heart murmur of valvulitis c. Pericarditis d. Cardiomegaly e. Signs of CHF [gallop rhythm, distant heart sounds, cardiomegaly] 2. Polyarthritis (70%) 3. Chorea, Sydenham’s (15%) 4. Erythema marginatum (10%) 5. Subcutaneous nodules (2 – 10%) Minor manifestation 1. Fever at least 38.8°C 2. Elevated Acute Phase Reactants (CRP & ESR) 3. Arthralgia 4. Prolonged PR interval on the ECG Diagnosis 1. Highly probable : 2 major OR 1 major and 2 minor manifestation

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N o t e s | 109

INFECTIVE ENDOCARDITIS Modified DUKE CRITERIA Major Manifestation 1. Blood Culture Positive – IE organism isolated from two separate blood cultures (1hour apart) – (+) Coxiella Burnetti isolate in one culture + IgG Ab Titer for Q Fever Phase 1 Ag >1:8000 2. (+) Evidence of Endocardial Involvement (2D-ECHO) – Oscillating intracardiac mass on valve or supporting structures – Abscess – New partial dehiscence of prosthetic valve or new valvular regurgitation (worsening or changing of preexisting murmur not sufficient) Minor manifestation 1. Predisposing factor: – Known cardiac lesion, – Recreational drug injection 2. Fever >38°C 3. Embolism evidence: – Arterial Emboli, Pulmonary Infarcts, Janeway Lesions,Conjunctival Hemorrhage 4. Immunological problems: – Glomerulonephritis, Osler's Nodes, Roth's Spots, Rheumatoid Factor 5. Microbiologic evidence: – Positive blood culture (that doesn't meet a major criterion) – serologic evidence of infection with organism consistent with IE but not satisfying major criterion 6. Positive echocardiogram (that doesn't meet a major criterion) (this criterion has been removed from the modified Duke criteria)

P e d i a t r i c

N o t e s | 110

Diagnosis Definite – Histology (Vegetation) or Culture Positive – 2 Major – 1 Major and 3 Minor – 5 Minors Possible – 1 Major + 1 Minor – 3 Minors

VIRAL INFECTIONS MUMPS [Paramyxoviridae] MOT Direct contact, airborne droplets, fomites contaminated by saliva IP 16 – 18 days Prd of comm 1 – 2 days before onset of parotid swelling until 5 days after the onset of swelling Prodorme Fever, neck muscle pain, headache, malaise Parotid gland  Peak in 1 – 3 days swelling  1st in the space between posterior border of mandible & mastoid then extends being limited above zygoma Complications  Meningoenephalitis - most frequent, about 10 days; M>F  Orchitis & Epididymitis  Oophoritis  Dacryoadenitis or optic neuritis

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N o t e s | 111

GERMAN OR 3 DAY MEASLES [RUBELLA] [Togaviridae] MOT Oral Droplet; transplacentally to fetus IP 14 – 21 days Prd of comm 7 days before &7 days after onset of rash Enanthem Forchheimer spots [soft palate] just b4 onset of rash Rash Cephalocaudal Characteristic Retroauricular, posterior cervical & postoccipital LAD [24 sign hrs before rash & remains for 1 wk] Tx Vit A SD 100,000 IU orally for 6 mo –1 y 200,000 IU >1 yo Post Immunoglobulin [not routine] exposure Considered if termination of preg is not an option prophylaxis 0.55ml/kg) IM Vaccine w/n 72 hrs of exposure Congenital  Greatest during 1st trimester Rubella  IUGR  Congenital cataract, microcephaly, PDA, “blueberry muffin” skin lesions  Congenital or profound SNHL  Motor or mental retardation

P e d i a t r i c

N o t e s | 112

MEASLES (Rubeola) [Paramyxoviridae] MOT Droplet spray IP 10 – 12 days Prd of comm 4 days before & 4 days after onset of rash Enanthem Koplik spots (opposite lower molars) Prodrome High grade fever, conjunctivitis, catharr (3 – 5 days) Rash Appear during height of fever Cephalocaudal[1st along hairline, face, chest] [+] brawny desquamation – disappear w/n 7 – 10 days Complication 1. Otitis media 2. Pneumonia 3. Encephalitis 4. Diarrhea 5. Exacerbation of M tb infection Tx Vit A SD 100,000 IU orally for 6 mos – 1 yo 200,000 IU >1 yo Post Ig w/n 6 days of exposure exposure (0.25ml/kg max 15 ml) IM prophylaxis Vaccine Susceptible children >1 yo w/n 72 hrs SSPE  Chronic condition due to persistent measles infxn  Rare but found in 6 mo to >30 yrs of age  Subtle change in behavior & deterioration o schoolwork followed by bizarre behavior  Elevated titers of Ab to measles virus(IgG, IgM)  Inosiplex (100mg/kg/day) may prolong survival

P e d i a t r i c

N o t e s | 113

ROSEOLA [HSV 6] Exanthem subitum Age of onset < 3 yo with peak at 6 – 15 months High grade fever for 3 – 5 days but behave normally Rash Appears 12 – 24 hrs of fever resolution fades in 1 – 3 days

HERPANGINA [Coxsackie A]  Sudden onset of fever with vomiting  Small vesicles & ulcers w/ red ring found in anterior tonsillar pillars, may also seen on the soft palate, uvula & pharyngeal wall

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N o t e s | 114

VARICELLA [HSV] MOT Direct contact IP 14 days Prd of comm 1 – 2 days before the onset of the rash until 5 – 6 days after onset & all the lesions have crusted Rash Start from the trunk then spread to othe parts of the body All stages present; pruritic Macule/papule → vesicle →crust Complication  Secondary bacterial infection  Encephalitis or meningitis  Pneumonia  Reye syndrome  GN Congenital  6 -12 wks AOG: maximal interruption w/ limb devt Varicella with cicatrix(ski lesion w/ zigzag scarring)  16 – 20 wks: eye and brain involvement Tx Acyclovir 15 – 30 mg/kg/day IV or 200 – 400 mg tab q 4hrs minus midnight dose x 5 days: increased risk o severity Post VZIg 1 dose up to 96 hrs after exposure exposure Dose: 125 U/10 kg (max 625 U) IM prophylaxis NB whos mother develop varicella 5 days before to 2 days after delivery shud recv 1 vial Vaccine Susceptible children >1 yo w/n 72 hrs

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N o t e s | 115

ERYTHEMA INFECTIOSUM [Parvovirus B 19] FIFTH DISEASE MOT Droplet spread & blood & blood products IP 16 – 17 Days average Prodrome Low grade fever, headache, URTI Rash Erythematous facial flushing “slapped cheek” and spreads rapidly to the trunk & proximal extremities as a diffuse macular erythema Palms & soles are spared Resolves w/o desquamation but tend to wax and wane in 1 – 3 wks

DENGUE HEMORRHAGIC FEVER  Serotype 1, 2, 3, & 4  Aedes egypti  IP: 4 – 6 days (min 3 days; max 10 days) DHF SEVERITY GRADING GRADE I

II III

IV

MANIFESTATION Fever, non-specific constitutional symptoms such as anorexia, vomiting and abdominal pain (+) Torniquet test Grade I + spontaneous bleeding; mucocutaneous, GI Grade II w/ more severe bleeding + Evidence of circulatory failure: violaceous, cold & clammy skin, restless, weak to imperceptible pulses, narrowing of pulse pressure to < 20mmHg to actualHPON Grade III but shock is usually refractory or irreversible and assoc w/ massive bleeding

P e d i a t r i c

N o t e s | 116

Pathogenesis of Dengue Hemorrhagic Fever DENGUE VIRUS

↓

↓

↓

Liver

Lymphoblast /Plasma Cell

Platelet

↓

↓

↓

Liver Injury

Ag-Ab reaction

Decr Maturation (MEG) Incr Platelet Destruction

↓

↓

↓

Decreased Coagulation Factors

Increased Vascular Permeability

Thrombocytopenia

↓

↓

↓

Increased Bleeding Tendency

Hypoalbuminemia Hemoconcentration Pleural Effusion

Bleeding

↓ Hypotension

 



CRITERIA FOR CLINICAL DX (WHO) DHF DSS Fever, acute onset, high, lasting 2 – 7  Above criteria days Plus Hemorrhagic man:  Hypotension or narrow pulse o (+) Torniquet test pressure [SBP – DBP] <20mmHg o Minor & Major bleeding phenomenon Thrombocytopenia <100,000/mm3

P e d i a t r i c

NUTRITION Waterloo Classification Normal Mild Moderate Severe

Wasting (Wt for Ht) >90 81 – 90 70 – 80 <70

Growth and Caloric requirements AGE 0 – 3 mos 3 – 6 mos 6 – 9 mos 9 – 12 mos 1 – 3 yo 4 – 6 yo Regular milk: 20 cal/oz Preterm milk: 24 cal/oz

Stunting (Ht for Age) >95 90 – 95 85 – 89 <85

RDA kcal/kg/day 115 110 100 100 100 90 – 100

Total Caloric Intake: rate x 24 x caloric content of IVF ÷ wt To get factor:

Dextrosity x 0.04 = cal/cc

Caloric content of IVF D5 = 0.2 cal/cc D7.5 = 0.3 cal/cc D10 = 0.4 cal/cc D15 = 0.6 cal/cc

N o t e s | 117

P e d i a t r i c

Caloric requirement & Protein requirement Cal/kg 0-5mo 115 6-11mo 110 1-2 yo 110 3-6 yo 90 – 100 7-9 yo 80 – 90 10 – 12 yo 70 – 80 13-15 yo 55 – 65 16 – 19 yo 45 – 50

N o t e s | 118

g/kg 3.5 3 2.5 2 1.5 1.5 1.5 1.5

Estimated Catch up Growth Requirement = cal/k/day (age for wt) x IBW (wt for ht) Actual BW CHON reqt = CHON reqt for age x IBW Actual BW

Approximate Daily Water Requirement 0 – 3 do 120cc/k/d 4 – 6 yo 10 do 150cc/k/d 7 – 9 yo 1 – 5 mo 150cc/k/d 10 – 12 yo 6 – 12 mo 140cc/k/d 13 – 15 yo 1 – 3 yo 120cc/k/d 16 – 19 yo

100 cc/k/d 90 cc/k/d 80 cc/k/d 70 cc/k/d 50 cc/k/d

P e d i a t r i c

TFR

CHON

CHO

Fats

OSTERIZED FEEDING 60 - 70% = 100/feeding q 6H 10 kg x 60% TFR = 600 0.5 g/kg inc q other day by 0.5 , max of 2 g/kg Dose x wt x prep (Vamin 7%, 9%) 0.5 x 10 kg x (100 /7) = 71 g/kg CHON = 71 g/kg If no prep = dose x wt x 4 = 20 g/kg 60% (TFR – CHON) x 0.6 (600- 71) x 0.6 = 317 CHO = 317 181 (the rest are fats , divided into 6 feedings)

N o t e s | 119

P e d i a t r i c

N o t e s | 120

MILK FORMULAS 1:1 dilution 1:2 dilution Mead-Johnson, Nestle, Glaxo, Wyeth, Abbott, Unilab Dumex, Milupa 0-6 months (20cal/oz) Lactose free (0-6months) Mead-johnson: Alacta , Enfalac Mead-johnson: Enfalac lacto-free Nestle: NAN1, Nestogen Nestle: AL110 Glaxo: Frisolac Milupa: HN25 Dumex: Dulac Wyeth: S26 Lacto-free Milupa: Alaptamil Abbott: Similac advance Wyeth: S26, Bonna Unilab: Mylac 6months onwards (20cal/oz) Lactose free (6months onwards) Mead-johnson: Enfapro Mead-johnson: Enfapro lacto-free Nestle: NAN2, Nestogen 2 Glaxo: Frisomil Dumex: Dupro Abbott: Gain Wyeth: Bonnamil. Promil Unilab: Hi-nulac 1 year onwards (20 cal/oz) Premature Infant (24cal/oz) Mead-johnson: Enfagrow, Lactum Mead-johnson: Enfaprem Nestle: NAN3, Neslac Nestle: PreNAN Glaxo: Frisorow Milupa: Preaptamil Dumex: Dugrow Abbott: Similac prem Abbott: Gainplus Wyeth: Progress, Promil Unilab: Enervon bright Hypoallergenic (20cal/oz) Soy-Based (20cal/oz) Mead-johnson: Pregestimil Mead-johnson: Prosoybee Nestle: Alfare, NAN HA1, NAN Abbott: Isomil HA2 Wyeth: Nursoy

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N o t e s | 121

TPN Vamin 9% 0.67 cal/ml Start 0.5 g/k/day inc by 0.5 g until 3 -3.5g/k/day Compute = wt x dose x prep (100/9) Intralipid 10% 20% Start 0.5 g/k/day inc by 0.5 g until 3 g/k/day Compute = wt x dose x prep (100ml/ 10) = ml/24H Amino acids Start 0.5 g/k/day inc by 0.5 g until 3 g/k/day Compute = wt x dose x prep (100ml/g) = ml/24H TPN shortcut computation Wt 10 kg TFR= 100 ml/k/day Vamin 7% 7 = 2 g/kg x 10kg 100 CaGluc 2ml/kg D5IMB D50W 0.11 x 1000ml

TFI = 1000ml/day 285 ml 20 ml 485 ml 110 ml 1000ml x 37 cc/h

P e d i a t r i c

N o t e s | 122

TPN in Pediatrics A. Energy Requirment AGE/WT Caloric Rquirement Neonates 90-120 kcal/kg Infants & Older Children

10-120 kcal/kg <10 kg 1000kcal + 50 kcal foe each kg > 10 11-20 kg 1500 + 20 for each more than 20 >20 B. Fluid Requirement AGE/WT Fluid Rquirement Neonates VLBW (≤ 1500 Initiate at 40 – 60 ml/kg/day and increase by 10 gm) ml/kg/day till 120 ml/kg is reached

AGA & LBW



Initiate at 60 ml/kg/day and increase by 15 ml/kg/day till 120 ml/kg is reached on the 5th day of PN

Neonates under radiant heaters or on phototx an extra 30ml/kg/day of water

Infants & Older Children

100 – 120 ml/kg <10 kg 1000ml + 50 ml foe each kg > 10 11-20 kg 1500 + 20 for each more than 20 >20 C. Protein Requirement AGE/WT Dosage (gm/kg/day) VLBW (≤ 1500 gm) 2.25 0 – 12 months 2.50 1 – 8 yrs 1.50 – 2.0 8 yrs and above 1.00 – 1.50  With the initiation of PB|N, start w/ 0.5gm/kg/day and gradually increased by 0.5gm/kg/day till recommended protein is reached.

P e d i a t r i c

N o t e s | 123

D. Carbohydrate Requirement % dextrose = gram dextrose x 100 Vol infused (ml  Shud provide 50 – 60 % 0f total non-protein calories  Requirement ranges frm 10 to 25 gm/kg/day  Infusion shud not exceed 12.5mg/kg/min  Shud b decreased if urinary glucose ≥0.5% (2+) or blood sugar exceeds 7 mmol/L in neoanate or 9.7 mmol/L I above 1 mo of age E. Fat Requirement AGE Dosage (gm/kg/day) 0 – 12 months 2 1 – 8 yrs 4 8 yrs and above 2.5  30 – 40 % of total calories shud b provided as fats  2 – 4% as EFA  Start at 0.5 gm/kg/day and gradually increase by 0.5 gm/kg/day till recommended amt is reached F. Daily Electrolyte Requirements Electrolytes Neonates 1-6 mos 6 mo -11 Adolescents (mmol/kg) (mmol/kg) yr (mmol/kg) (mmol/kg) NaCl 3–5 3–4 3–4 60 – 100 Potassium 2–4 2–3 2–3 80 – 120 Cal gluc 0.6 – 1.0 0.25 – 1.2 0.25 – 1.2 4.7 Phosphate Magnesium  

1.0 0.1250.250

(max of 4.7)

(max of 4.7)

1–2

1–2

0.1250.250

0.1250.250

30 – 45 4–8

Calcium gluconate contains 100 mg calcium gluconate or 9 mg elemental calcium/ml 1 gm of calcium gluconate contains 4.7 mEq or 2.35 mmol of Ca.

P e d i a t r i c

G.

Trace Elemental Requirements Trace Prematures Elemental (ug/kg)

Infants & Children

N o t e s | 124

Adolescents (mg)

(ug/kg) Zinc 400 100 – 500 2.5 – 4 Copper 50 20 0.5 – 1.5 Chromium 0.3 0.14 – 0.2 0.01 – 0.04 Manganese 10 2 – 10 0.15 – 0.5 Iodine 8 8 0.2 Selenium 4 4 0.3 Flouride 57 57 0.9  In the absence of available prep of trace elements; weekly blood transfusion may be given at 20 ml/kg  Iron: 2 mg/kg, with dose increased to 6 mg/kg if Fe def is documntd; provided by adding iron dextran to amino acid soln

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TPN for NEONATES Wt 2kg 1. TFR = 100 ml/kg/day x 2 kg 200 ml 2. Intralipid 20% 1 g/kg/day x 2kg = 2g/day 10 ml 2 g = 20g x 100ml 3. Compute for TFR 1 TFR1 = TFR – Intralipid = 200 -10ml = 90 ml 4. Vamin 7% 1 g/kg/day x 2 kg = 2g = 29 ml 2 g = 7g x 100ml 5. Multivitamins Benutrex c 0.5 ml/100ml 0.5 ml = x 1 ml 100ml 190 ml 6. Ca gluc 10% 2ml/kg/day x 2 kg 4 ml 7. Dextrosity (D10) get d50w TFR 1 x dextrosity factor (0.11) 21 ml 190 x 0.11 8 . D5IMB = TFR 1 – (Vamin + MTV + Ca gluc + D50W) 190 – (29 + 1+ 4+ 21) = 135 ml 9. IV rate = TFR 1 / 24H 190 ml/ 24H 8 ml/H Order: Start TPN as ff: TFR= 100ml/kg/day D5 IMB 135 ml D50W 21 ml Vamin 7% 29 ml Ca Gluc 4 ml MTV 1 ml 190 ml to run at 8 ml/h Intralipid 20% 10 ml to run for 24H

N o t e s | 125

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N o t e s | 126

Sample Solving: Wt 15 80kcal/kg A. Energy: 15 x 80 = 1, 200 kcal/day B. TFR: 1,250 ml/day C. CHON: (1gm/day) 15 x 1 Prep: Aminosteril 6% (6gms/100ml) 6gms x 15 gms = 250 ml 100 x

D.

CHO: % = gm x 100 Vol Prep: D50W

10% x = 125 gms 1250

50 gm = 125gm 100 ml x

E.

Lipids: ( 1 gm) Prep: 10% Intralipid (10gms/100ml)

15 x 1 =15

10 gms x 15 gm = 150 100 ml x

F.

Sodium: (3 mmol/kg) Prep: 2.5 mmol/ml

15 x 3 = 45 mmol/kg

2.5 mmol x 45 = 18 ml ml x

G.

Potassium: (2 mmol/kg) Prep; 2 mmol/ml

15 x 2 = 30 mmol/kg

2.0mmol x 30 = 15 ml ml x

H.

Calcium gluc: (0.25 mmol/kg) Prep: 10% Cal gluc 0.25 mmol x ml

I.

15 x 0.25 = 3.75

3.75 = 15 ml x

Magnesium: (0.25 mmol/kg) Prep: 25% MgSO4 2 mmol x 3.75 = 1.9 ml x 2 = 4 ml ml x

15 x 0.25 = 3.75

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J.

Total Mixture: Aminostril D50W Na K Cal gluc MgSO4

24 hrs 250 250 18 15 15 4 ml

12 hrs 125 125 9 7.5 7.5 2 ml

Total

552

276

N o t e s | 127

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N o t e s | 128

EMERGENCY MEDICINE EMERGENCY ET tube Age in years + 4 4 ET diameter x 3 >10 yo cuffed Laryngoscope sizes PT Term 0-6mos 6-24 mos >24 mos

Epinephrine Amiodarone Cardioversion Albumin

Epinephrine Drip

Levophed

Miller 00 or 0 Miller 0 Miller 1 Miller 2 Miller 2 or Mac 2 EMERGENCY MEDS (bradycardia, asystole) (1:1000) 0.1 ml/kg q 3- 5 mins 5 mg/kg rapid IV push 2 J/kg then 4 J/kg then rpt 2x 1gm x wt given in 2-4hrs. Prep: 12.5g/50ml Vol expander: 20ml/kg HypoCHONemia – 1gm/k/dose x 4H 0.1 – 1mg/k/min; 1amp = 1mg/ml Rate = (wt x dose x 60)/desired Ex: (18kg x 0.1 x 60)/100 = 2cc/hr To order: 5 amps Epi + 50cc D5W to rum at 2cc/hr (0.1mg/k/min) 0.3-2mcg/k/min Prep: 4mg/amp (1mg/ml) Rate = (wt x dose x 60)/desired Ex. Dose 0.5 1mg/20 = 0.05 x 1000 = 50mcg/ml (18kg x 0.5 x 60)/50 = 10.8cc/hr To order: 1 amp levophed + 80 cc D5W to run at

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Dopamine

11cc/hr Renal dose Pressor alpha effect

3-5 >5 - <15 >15

N o t e s | 129

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ANAPHYLAXIS Epinephrine (1:1000)

0. 01ml/kg max of 0.5 mg/dose SC < 30 kg 0.15 mg > 30 kg 0.3 mg Diphen = 50mg IM (1mkdose) USN w/ Salbu x 3 doses

O2 SUPPLEMENTATION Peak Flow (6 – 7 yo) (Ht cm – 100) x 5 + 170 female + 175 male Nasopharyngeal catheter = flow rate x 20 + 20 Nasal cannula = flow rate X 4 + 21 TFR= TV x RR x IE ratio + dead space (2000) TV= 10 ml x wt TFR Short cut: wt x 10 + 40 ml divide by 0.5 16.77

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N o t e s | 131

NORMAL VALUES NORMAL VALUES AVERAGE WEIGHT (3,000 grams) 0 – 6 mos Age in months x 600 + BW 7 – 12 mos Age in months x 500 + BW Children 1 – 6 yo Age in years x 2+ 8 7 – 12 yo Age in years x 7 – 5 / 2 HEAD CIRCUMFERENCE [35 cm (+ 2cm)] 1 – 4 Mos ½ inch per month 5 – 12 mos ¼ inch per month 2 years old 1 inch per year 3 – 5 yo ½ inch per year 6 – 20 yo ½ inch per 5 years LENGTH (50 cm) 0 – 3 mos 9 cm 4–6 8 cm 7–9 5 cm 10 – 12 3cm

(inch = 2.54cm)

Weight for Height = Actual BW (kg) P50 Wt for Ht (kg) Height for Age = Actual Height (cm) P50 Ht for Age

Age mo 0 1 2 3

Ht (cm) boys 50.5 54.6 58.1 61.1

Ht (cm) girls 49.9 53.5 56.8 59.5

Wt for Ht (cm) 49 50 51 52

Boys (kg) 3.1 3.3 3.5 3.7

Girls (kg) 3.3 3.4 3.5 3.7

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4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 yo 3.5 4 yo 4.5

N o t e s | 132

63.7 65.9 67.8 69.5 71.0 72.3 73.6 74.9 76.1 77.2 78.3 79.4 80.4 81.4 82.4 83.3 84.2 85.1 86.0 86.8 87.6 88.5 89.2 90.0 90.8 91.6 92.3 93.0 93.7 94.5 95.2 95.8 96.5

62.0 64.1 65.9 67.6 69.1 70.4 71.8 73.1 74.3 75.5 76.7 77.8 78.9 79.9 80.9 81.9 82.9 83.8 84.7 85.6 86.5 87.3 88.2 89.0 89.8 90.6 91.3 92.1 92.8 93.5 94.2 94.9 95.6

53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85

3.9 4.1 4.3 4.6 4.8 5.1 5.4 5.7 5.9 6.2 6.5 6.8 7.1 7.4 7.7 8.0 8.3 8.5 8.8 9.1 9.3 9.6 9.8 10.0 10.3 10.5 10.7 10.9 11.1 11.3 11.5 11.7 11.9

3.9 4.1 4.3 4.5 4.8 5.0 5.3 5.5 5.8 6.1 6.4 6.7 7.0 7.3 7.5 7.8 8.1 8.4 8.6 8.9 9.1 9.4 9.6 9.8 10.0 10.2 10.4 10.6 10.8 11.0 11.2 11.4 11.6

98.4 102.9 106

97.3 101.6 104.5

86 87 88

12.3 12.3 12.5

11.8 11.9 12.2

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5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10 10.5 11 11.5 12 12.5 13 13.5 14 14.5 15 15.5 16 16.5 17 17.5 18

109.9 112.6 116.1 118.5 121.7 123.9 127.0 129.1 132.2 134.4 137.5 139.9 143.3 145.8 149.7 152.5 156.5 159.3 163.1 165.7 169.0 171.1 173.5 174.9 176.2 176.7 176.8

Age LBW < 1 yr FT < 1 yr 2-12 y 13-21 y (female) 13 -21 y (male)

108.4 111.0 114.6 117.1 120.6 123.0 126.4 128.8 132.2 134.7 138.3 140.9 144.8 147.6 151.5 154.1 157.1 158.8 160.4 161.1 161.8 162.1 162.4 162.7 163.1 163.3 163.7

89 90 91 92 93 94 95 96 97 98 99 100 101 102 103-105 106-108 109-111 112-114 115-117 118-120 121-123 124-126 127-129 130-132 133-135 136-140 141-145

K (mean value) 0.33 0.45 0.55 0.55 0.70

12.8 13.0 13.2 13.4 13.7 13.9 14.1 14.4 14.7 14.9 15.2 15.5 101.0 16.1 16.5-17.1 17.4-18.0 18.3-19.0 19.3-20.0 20.3-21.1 21.4-22.2 22.6-23.4 23.9-24.8 25.2-26.2 26.8-27.8 28.4-29.6 30.2-33.0 33.7-36.9

KI 29.17 39.78 48.62 48.62 61.88

N o t e s | 133

12.4 12.6 12.8 13.0 13.3 13.5 13.8 14.0 14.3 14.6 14.9 15.2 15.5 15.9 16.2-16.7 17.0-17.6 17.9-18.6 18.9-19.5 19.9-20.6 21.0-21.8 22.2-23.1 23.6-24.6 25.1-26.2 26.8-28.0 28.7-30.1 30.8-32