VITAL SIGNS OF FILIPINO INFANTS AND CHILDREN

Average Respiratory Rate and Cardiac Rate

Respiratory Rate Cardiac Rate

Age Males Females Males Females

Mean ± 2 SD Mean ± 2 SD Mean ± 2 SD Mean ± 2 SD

0-1 mo 59 18.2 56 22.0 147 30.5 145 26.2

2-6 mo 52 22.5 52 21.6 139 31.4 141 33.5

7-12 mo 45 24.6 48 22.8 133 32.4 134 31.9

13-24mo 38 14.9 36 22.5 128 34.1 129 34.3

2-4 yo 30 12.1 29 12.0 109 32.6 110 29.5

5-9 yo 25 6.1 25 6.1 93 23.7 92 23.2

10-14 yo 22 3.5 22 3.6 86 20.4 86 20.7

Weight for Height = Actual BW (kg) Height for Age = Actual Height (cm)
P50 Wt for Ht (kg) P50 Ht for Age
 Mean Blood Pressure and Upper Limits
Mean Upper Limit
Age Mean Systolic ± 2 SD ± 2 SD
Diastolic (95th percentile)
NB – 7 days: 95
0-1 mo 72 0.6
8 – 30 days: 105
2-11 mo 81.66 0.6 <2 yrs: 115
1y 87.30 0.8 56.40 0.6 75
2y 88.20 1.2 63.15 0.6
2-5 yrs:
3y 87.47 1.8 55.50 1.2
4y 87.37 1.2 56.45 1.4 130
80
5y 93.90 1.2 59.80 0.8
6y 93.84 1.2 60.05 1.0
6-11 yrs:
7y 96.56 1.0 61.55 1.0
8y 98.50 1.2 60.06 1.0 135
85
9y 97.00 1.2 57.30 0.4
Note:
10 y 98.95 2.2 61.50 0.8 SBP=90mmHg +
11 y 98.80 2.6 74.40 2.8 (2 x age in years)
12 y 101.55 1.8 67.55 1.8
>12 yrs:
13 y 106.95 3.0 65.70 1.0
14 y 108.00 1.2 71.50 0.6 140
90
15 y 104.15 1.8 86.85 1.6
 GROWTH & DEVELOPMENT
I. BODY WEIGHT
Ideal Body Weight
Age Kilograms Pounds
3 (Filipino)
At Birth 7
3.25 (Caucasian)
3 – 12 mo (age in months + 9)/2 Age in months + 10 (Filipino)
1–6y (age in years x 2 ) + 8 (Age in yrs x 5) + 17
(age in yrs x 7) – 5
7 – 12 y (Age in yrs x 7) + 5
2
Ideal Body Weight given Birth Weight
Age Using Weight in Grams
< 6 mo (Age in months x 600) + birth weight in gm
6 – 12 mo (Age in months x 500) + birth weight in gm
Expected Body Wieght (good up to 1 month of age)
Term [(age in days – 10) x 20] + birth weight in gm
Pre-term [(age in days – 14) x 15 ]+ birth weight in gm
Where: 10 = # of days to recover over physiologic weight loss; and 20 = g/day gained
Usual Changes in Weight at Different Ages
4 – 5 mo 2x birth weight 5y 6x birth weight
1y 3x birth weight 7y 7x birth weight
2y 4x birth weight 10 y 10x birth weight
3y 5x birth weight 5y 6x birth weight
II. LENGTH / HEIGHT Gain in 1st yr or 25cm distributed as follows

Age Cenitmeters Inches 0 – 3 mo 9 cm

At birth 50 20 3 – mo 8 cm
1y 75 30 6 – 9 mo 5 cm
2 – 12 y (age in years x 5) + 80 (age in years x 2) + 32 9 – 12 mo 3 cm

III. HEAD CIRCUMFERENCE

Age Monthly or Yearly Total
At birth 35 cm (13.8 in)
< 4 mo ½ inch per month 2 inches
5 – 12 mo ¼ inch per month 2 inches
2 yr 1 inch
3–5y ½ inch per year 1.5 inches
5 – 20 y ½ per 5 years 1.5 inches

Correction Factors for the Determination of Head Circumference

Boys Girls Amount to be
Age Inch Cm Inch Cm added or
subtracted for
Birth 1/4 0.6 1/3 0.8 each pound
6 wks 1/4 0.6 1/4 0.6 above or
below the
6 mo 1/8 0.3 1/8 0.3
average
10 mo 1/10 0.3 1/10 0.3 weight
 IV. MINIMUM GROWTH REQUIREMENTS

Age Daily Weight Monthly Weight Growth in Length Growth in HC

Gain (g) Gain (cm/mo)

0 – 3 mo 30 2 lb 3,5 2.00

3 – 6 mo 20 1 ¼ lb 2.0 1.00

6 – 9 mo 15 1 lb 1.5 0.50

9 – 12 mo 12 13 oz 1.2 0.50

1–3y 8 8 oz 1.0 0.25

4–6y 6 6 oz 3 cm/yr 1 cm/yr

V. ANTERIOR VS POSTERIOR FONTANELS

Midline at junction of Midline between intersection - Normally slightly depressed and

coronal and sagittal of occipital and parietal bones pulsatile
sutures - Evaluated when infant is held
upright, asleep or feeding
Diamond Triangular

2 x 2 cm Very small or appears as

closed

Closure @ 9 – 18 mos Closure @ 6 – 8 wks

 VI. EXPECTED LIVER SPAN OF INFANTS & CHILDREN
Males Females
Mean Mean
Age/yr SEM Age/yr SEM
estimated estimated
0.5 (6 mo) 2.4 2.5 0.5 (6 mo) 2.6 2.6
1 2.8 2.0 1 3.1 2.1
2 3.5 1.6 2 3.6 1.7
3 4.0 1.6 3 4.0 1.7
4 4.4 1.6 4 4.3 1.6
5 4.8 1.5 5 4.5 1.6
6 5.1 1.5 6 4.8 1.6
8 5.6 1.5 8 5.1 1.6
10 6.1 1.6 10 5.4 1.7
12 6.5 1.8 12 5.6 1.8
14 6.8 2.0 14 5.8 2.1
16 7.1 2.2 16 6.0 2.3
18 7.4 2.5 18 6.1 2.6
20 7.7 2.8 20 6.3 2.9
VII. TEETH ERUPTION
VIII. TANNER STAGING
 IX. DEVELOPMENTAL MILESTONES
Age Gross Motor Adaptive Fine Language Personal Social
Motor
Newborn Tonic neck reflex Crying
Startles (Moro Reflex)
1 mo Raise head slightly Eye follows Throaty, gurgling sound Regard face
from prone (<45°) object to
Hands fisted midline
2 mo Head control 45° Eye follows Social smile (smiles after Responsive, Diminishes
Holds head in midline object past being talked to) activity when failed to
Hands no longer midline Laughs, Vocalizes Recognizes parents
fisted
3 mo Head control 90° Hands Coos (long musical vowel Regards hand
Pull to sit, no head lag together in sounds) Anticipates feeding
midline
4 mo Rools over Reaches & Orients to voice Play with rattle in hand
grasps
5 mo Good head control Transfer Orients to bell (localizes Enjoys looking around
object hand to laterally) the environment
hand
6 mo Sits without support Chews Monosyllabic babble Indicates likes, dislikes
Orients to bell (localized
Bounces, Crawls
Rakes at small indirectly)
7 mo Bears some weight on Feeds self with crackers
objects Follows one step
legs
command w/ gesture
8 Leans forwards, “Dada, Mama” Object permanence
Bangs to cubes
mo back rounded indiscriminately “Close-open” hands
Pivots when sitting Imitates sounds
9 Shy w/ strangers
Creeps Thumb finger grasp/ Orients to bell (directly)
mo Waves bye, bye
Stands holding on Pincer grasp (assisted) “Dada, Mama”
Holds bottle discriminately
10 Cruises Pokes with forefinger Follows one step Plays peek-a-boo,
mo Pulls self to stand command w/o gesture pat-a-cake

11 Walks holding on Pincer grasp One-word other than Helps dress, holding arm
mo (unassisted) “dada, mama” or-foot out
12 Stand alone Throws objects 2-3 words other than Egocentric pretend play
mo Walks with one Lets go of toys, hand “dada, mama” Comes when called
hand held release Obeys commands or Attempts to use a spoon
requests
15 Walks well alone Builds tower 2-3 cubes 4-6 words other than Indicates desires/needs
mo Walks backward Makes line with crayon “dada, mama” Pats picture
Crawls upstairs Inserts pellet in bottle Irritates housework
sweeping, washing
18 Runs stiffly; Seats Builds tower 4 cubes 10 words Feeds self
mo self in child’s chair Imitates a vertical Names pictures Complains when wet
Walks upstairs stroke/scribbling Identifies one or more Turns 2 or 3 pages at a
with one hand held Dumps pellet fr bottle body parts time

2y Runs well Builds tower 7 cubes Combines two or three Removes garment
Walks up, down Imitates a circular words in sentences Toilet trained by day
stairs one step at a stroke 2-step commands Turns pages 1 at a time
time
2½y Walks upstairs Builds tower 9 cubes Knows full name Helps put things away
alternating steps Imitates circular Uses pronouns Gets self drink w/o help
Jumps stroke forming closed appropriately
figure
3y Rides tricycle Builds tower 10 cubes Knows age and sex Unbuttons, puts on
Stands Imitates cross Counts 3 objects shoes
momentarily on Copies circle Uses plurals, past tense Dry by night
one foot Tells little stories about Washes & dries hands
experiences Plays interactive games
4y Hops on one food Copies square, bridge Knows color Buttons up
Climbs well Draws man w/ 3-5 Counts 4 pennies Tells “tall tales”
Walks parts Says song and poem Goes to toilet alone
downstairs Names longer of 2 from memory
alternating feet lines
5y Skips, both feet Copies triangle Counts 10 pennies Plays competitive games
Heel to toe walk Writes alphabet Prints first name Abide by rules
Jumps over low Ties shoes Asks what a word Domestic role-playing
obstacles Spread with knife means
6y Backward heel to Draws a complete Adds and subtracts Dresses self completely
toe walk person with clothing Distinguishes between
Can write fairly well left and right

8y Complex pattern Awkward and self Tells time Sense of humor

movements conscious Reads for pleasure Accepts rules
(dancing, piano) Concrete operations Conventional morality
 STAGE THEORIES OF SOCIOEMOTIONAL DEVELOPMENT
Birth – 18 mo 18 mo – 3 yrs 3 – 6 yrs 6 – 12 yrs Adult
Erikson (Psychosocial development)
Trust vs Autonomy vs Initiative vs Guilt Industry vs Identity vs Role
Mistrust Shame & Doubt Inferiority Confusion
Infants learn Children learn to Children learn to initiate Children develop Adolescents come to
to trust, or exercise will, to activities & enjoy a sense of see themselves as
mistrust, that control accomplishments, industry & unique & integrated
their needs themselves, or acquiring curiosity & are persons with an
will be met by they become directions/purpose, if eager to learn , or ideology, or they
the world, uncertain & not allowed initiative, they feel inferior become confused
especially by doubt that they they feel guilty for & lose interest in about what they
the mother can do things by attempts at the tasks before want out of life
themselves independence them
Freud (Psychosexual development)
Oral Stage Anal Stage Phallic Stage Latency Stage Genital Stage
(Oedipal)
Infants obtain Children obtain Children develop sexual Children’s sexual Adolescents have
gratification gratification curiosity & obtain urges are adult heterosexual
through through exercise gratification through submerged, they desires and seek to
stimulation of of the anal masturbation. They have put their energies satisfy them
the mouth, as musculature sexual fantasies of into acquiring
they suck and during opposite sex parent & cultural skills
bite elimination or guilt about their
retention fantasies.
 STAGE THEORIES OF SOCIOEMOTIONAL DEVELOPMENT
Birth – 2 yrs 2 – 6 yrs 7 – 11 yrs > 12 yrs
Piaget (Cognitive)

Sensorimotor Preoperational Concrete operations Formal operations

Learning occurs Child capable of Child becomes capable of Can reason logically
through activity, symbolic limited logical thought & abstractly. Can
exploration, & representation of processes, as in seeing formulate & test
manipulation of the world, as in use of relationships & classifying, as hypotheses. Thought
environment. Motor & language, play & long as manipulable, concrete no longer depends on
sensory impressions deferred imitation. materials are available concrete reality. Can
form the foundation Still not capable of • Conservation: things play with
of later learning sustained, systemic remain the same despite possibilities
• Self-identity: thought. change in appearance • Can manipulate
learns to • Engages in • Reversibility variables in
differentiate self symbolic play • Decentration: can focus on scientific
from world • Decline in > 1 aspect of a situation at situation
• Formation and egocentricity a time • Can deal with
integration of • Develops language • Transitivity: can deduce analogies &
schemes & drawing as new relationships from metaphors
• Achieves object modes of earlier ones • Can work out
permanence: representing • Seriation: order things in combinations &
things can exist experience sequence permutations
even when not • Classification: groups
visible objects
 PEDIATRIC DIAGNOSIS
PEDIATIC PHYSICAL EXAMINATION
• No hard and fast rules; must be opportunistic
• Most bothersome procedures last (e.g. ear and throat)
Suggested Order of Examination
1. Take weight and measurements (HC, Length, etc.)
2. Inspect patient: ill-looking, skin changes dehydration, breathing, deformities, nutrition, etc.
3. Palpate fontanels. Note neck.
4. Inspect, palpate and percuss chest. Auscultate heart and lungs.
5. Inspect, auscultate, palpate and percuss abdomen.
6. Check lymph nodes.
7. Examine back and spine. Test hips & other joints.
8. Inspect external genitalia. Use Tanner staging.
9. Neurologic exam: motor, reflexes, coordination sensory
10. Examine ears: use otoscope
11. Inspect nose & mouth
12. Take BP
13. Assess development, behavior & intelligence
14. Observe gait
15. Rectal exam if needed.
TECHNIQUE IN MAKING DIAGOSIS
A. A symptoms, sign or group of signs pathognomonic / strongly indicative of a probable diagnosis
B. A symptoms, sign or group of signs pointing to a definite organ or system
C. A symptoms, sign or group of symptoms or signs pointing to a definite group of disease
D. A symptom or sign whose mechanisms is well understood
E. A symptom, sign or group of symptoms or signs found in the least number of diseases
 NUTRITION
COMPUTATION FOR TOTAL CALORIC REQUIREMENT (TCR)
Required Daily Allowance (RDA)
Age Weigth (kg) Calories (kcal/kg) CHON (g/kg)
0 – 5 mo 3–6 115 3.5
6 – 11 mo 7–9 110 3.0
1–2y 10 – 12 110 2.5
3–6y 14 – 18 90 – 100 2.0
7–9y 22 – 24 80 – 90 1.5
10 – 12 y 28 – 32 70 – 80 1.5
13 – 15 y 36 – 44 55 – 65 1.5
18 – 19 y 48 – 55 45 – 50 1.2
A. Solve for TCR
TCR = Actual body weight (kg) x Calories (kcal/kg)
e.g. 1 yo baby weighing 10kg
10 kg x 110 kcal/kg = 1100 kcal

B. Determine TCRCHON in grams then convert to calories

TCRCHON = CHON (g/kg) x ABW (kg)
e.g. 2.5g CHON/kg x 10 kg = 25g CHON
Conversion factor to calories (kcal/g): CHON 4, CHO 4, fat 9
e.g. 25g CHON/kg x 4 kcal/g CHON = 100 kcal CHON
C. Subtract TCRCHON from TCRTotal then get fraction of CHO & fats (usual ratio 60:40)
e.g. 1100 kcal – 100 kcal CHON = 1000 kcal
60% of 1000 = 600kcal CHON; 40% of 1000 = 400kcal fats

D. Convert back to grams; write final prescription

e.g. 1100 kcal = 25 g 150 g 4g
TCR CHON CHO fats

RDA ADJUSTMENT FOR MALNOURISHED CHILDREN

(CATCH-UP CALORIES)

Adjust RDA = RDA for chronological age x desired wt at p50

actual wt
e.g. Adjusted RDA = 110kcal/kg x 6.4 kg = 220 kcal/kg
3.2 kg
Adjusted TCR = 220 kcal/kg x actual wt (3.2kg) = 704 kcal

Total Caloric Intake = calories x amount of intake (oz)

Gastric Capacity: age in months + 2
Gastric Emptying time: 2 – 3 hrs
Other Caloric Values
Cane / table sugar 20 kcal / 5 cc or 120 kcal / oz
D5W 20 kcal / 100 cc
D10W 40 kcal / 100 cc
Karo syrup 4 kcal / cc
* 1 ounce = 30 cc * 1 tbs = 15 cc * 1 tsp = 5 cc
 BREASTMILK
Colostrum
• 1st 2 – 4 days postpartum
• High CHON (globulin), vitamins, salt, & Ig; low fat & sugar
Foremilk
• Clear, thin, and bluish; low fat; high water content
Hindmilk
• Thick, creamy-white; high fat (peaks early in the day

BREAST MILK VS COW’S MILK

Human Milk, Mature Cow’s Milk
Protein
• Whey: casein ratio 60 : 40 20 : 80
• Cystine Increased
• Methionine Decreased
• Digestion More efficient
Fatty acids PUFA & long chain Saturated
• Linoliec acid Increased
• Lipase (+) (-)
• Digestion No loss in stools Stool losses
Carbohydrates
• Lactose 7% (sweeter) 4.8%
• Bifidus factor (+) (-)
Minerals Less (to increase free water)
 COMPOSITION OF NATURAL MILK & MILK SUBSTITUTES
Gram / 100 mL mEq / L Mg / L
Kcal/oz CHON CHO Fat Na K Cl Ca P Fe

Human milk, mature, average 22 1.1 7.0 3.8 6.5 14 12 340 150 1.5
Cow’s milk, market, average 20 3.3 4.8 3.7 25 35 29 1.17 920 1.0
Cow’s milk, evaporated 40 3.8 5.4 4.0 28 39 32 1.3 1.1 1.0
Prepared formula, cow’s milk 20 2.0 7.3 3.2 8.5 15.0 13.0 594 396 7.9
Soy based e.g. isomil 20 1.7 7.0 3.7 13.0 18.0 15.0 710 510 12.0
COMERCIALLY AVAILABLE MILK FORMULAS
1 scoop : 1 oz dilution 1 scoop : 2 oz dilution
Prepared formula, cow’s milk based
A. Infant formulas Alactamil, Aptamil, Dulac, Enfalac w/ DHA, Bonna, S – 26, S – 26 Gold, Similac
Frisolac, Nestogen 1 Advance
B. Follow – on formulas Dupro, Enfapro, Frisomel, Milumil, NAN – 2 Bonamil, Gain w/ TPAN, Hi-Nulac,
w/ Bifidus, Nestogen 2 Promil, Promil Gold
Special formulas
A. Soy based ProSobee Isomil, Nursoy
B. Casein based Al 110, Enfagrow, Lactofree, Enfapro S – 26 Lactofree
Lactofree
C. Hypoallergenic NANA H.A. 1
D. Nutritional Products Enfalac A+, Pediasure (5 scoops / 190 mL)
E. Premature Enfalac Premature, PreNAN w/ LCPUFA S – 26 LBW, Similac PM 60/40
 MILK FORMULAS
1:1 dilution 1:2 dilution
Mead-Johnson, Nestle, Glaxo, Dumex, Milupa Wyeth, Abbott, Unilab
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
Abbott: Similac advance
Milupa: Alaptamil
Wyeth: S26, Bonna
Unilab: Mylac
6months onwards (20cal/oz) Lactose free (6months onwards)
Mead-johnson: Enfapro Mead-johnson: Enfapro lacto-
Nestle: NAN2, Nestogen 2 free
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 Glaxo: Frisorow Nestle: PreNAN Abbott: Similac prem
Dumex: Dugrow Abbott: Gainplus Milupa: Preaptamil
Wyeth: Progress, Promil
Unilab: Enervon bright
Hypoallergenic (20cal/oz) Soy-Based (20cal/oz)
Mead-johnson: Pregestimil Mead-johnson: Prosoybee
Nestle: Alfare, NAN HA1, NAN HA2 Abbott: Isomil
Wyeth: Nursoy
 RECOMMENDED DAILY ALLOWANCES FOR VITAMINS & MINERALS
RDA Deficiency Excess Sources
Fat Soluble Vitamins
A 1800 Eye symptoms (nyctalopia, Carotenemia, anorexia, Liver, fish, liver, oils,
retinol IU/day photobia, xerophobia, slow growth, drying of whole milk, milk fat
xeropthalmia, Bitot’s spots, skin, liver & spleen products, egg yolk,
keratomalacia), enlargement, bone green and yellow
keratinization of mucous pain / swelling vegetables
membranes, growth failure
D 400 Rickets, Infantile, tetany, Hypercalcemia Vit D fortified
chole- IU/day osteomalacia, cranial (vomiting, retardation, milk/margarine, fish
calciferol bossing, bowed legs, open bone changes, soft liver, oil, exposure to
ant. Fontanelle tissue calcification) sunlight & other UV
E 4–5 r/t steatorrhea Unknown Germ oils of various
toco- IU/day Hemolytic anemia in seeds, green leafy
pherol premature infants, loss of vegetables, legumes
neural integrity
K 1–2 Hemorraghic Hyperbilirubnemia, Green leafy vegetables,
phylo- mg/day manifestations; bone nerve palsy pork, liver
quinolone metabolism

Water Soluble Vitamins

B2 0.5 Arboflavinosis; photophobia, None Milk, cheese, liver, eggs,
Riboflavin mg/day blurred vision, itching, corneal fish, green leafy
vascularization, cheilosis vegetables, darak
 Niacin 6 mg/day Pellagra (diarrhea, dementia, Vasodilation Meat, fish, poultry, enriched
Nicotin- dermatitis), cheilosis, angular (flushing and or whole grains, green
amid stomatitis itching); veggies
hepatopathy

Folacin 50 – 100 Magaloblastic anemia, Unknown Liver and other organs, green
ug stomatitis, glossitis vegetables, nuts

Biotin Dermatits, seborrhea Unknown Yeast, animal products,

* Inactivated by avidin in raw synthesized in intestine
egg white

B6 1 -2 Irritability, convulsions, Sensory Meat, liver, kidney, whole

Pyridoxine mg/day hypochromic & macrocytic neuropathy grains, soybeans, nut, fish,
anemia; peripheral neuritis green vegetables
(w/ INH adm)

B12 0.3 Juvenile pernicious anemia; 2° Unknown Muscle or organ meats, fish,
Cyanocob ug/day gastrectomy, celiac & small eggs, cheese, milk
alamin bowel dse; neurologic
manifestations

C 1st yr: Scurvy (skin hemorrhages, Oxaluria Citrus fruits, berries,

Ascorbic 30mg irritability, leg tenderness) tomatoes, cantaloupe, green
acid >1 yr: 35- poor wound healing vegetables
75 mg * Inactivated by cooking
 Minerals
Calcium <1yr: 0.6 g Poor mineralization of Dietary: Unknown Milk, cheese, green
1-9yr: bones and teeth; Parenteral: Heart leafy vegetables,
0.5 g osteomalacia; osteoporosis; block & renal canned salmon,
>10yr: 0.7g tetany, rickets stones clams
Chloride 0.5 g/day Hypochloremic alkalosis Unknown Table salt; Brinned,
(w/ prolonged vomiting/ pickled, smoked
sweating, IV glucose w/o foods, meat, milk,
saline) eggs

Mg 150-300 Assoc. w/ Ca deficiency, Dietary: none Cereals, legumes,

mg/day malabsorption, tetany, nuts, meat and milk
decrease K+

PO4 Same as Ca Rickets; Ca and Vit D Tetany (low Ca:P Milk, egg yolk, nuts
deficiency ratio)
Potassium 1-2g or Muscle weakness, Heart block at All foods
1.5mEq/kg abdominal distention, serum levels of 10
or irritability/ drowsiness, mEq/L
40mEq/m2 arrhythmias

Sodium 1g or Nausea, diarrhea, Edema, seizures Table salt, milk,

2mEq/kg or hypotension, muscle eggs, baking soda,
50mEq/m2 cramps, dehydration spices

Sulfate Unknown Growth failure Not harmful Protein foods w/

appro 1%
Iodine 35 – 45 ug Goiter; cretinism Not harmful Iodized salt,
seafoods
Iron Infants: Hypochromic, microcytic Hemosiderosis Liver, meat, egg
1mg/kg anemia, growth failure yolk
Kids:
10-18mg
Zinc Dwarfism, decrease wound GI upsets, copper Meat, grain, nuts,
healing, hepatomegaly, deficiency, in cheese
anemia, pigmentation, deceased HDL
hypogonadism
WATERLOW CLASSIFICATION
Weight for Age (WFA) = actual wt ÷ wt at p50 x 100
>90 No PEM
75 – 90 Mild PEM
60 – 74 Moderate PEM
< 60 Severe PEM
Height for Age (HFA) = actual ht ÷ ht at p50 x 100
>95 No stunting
90 – 95 Mild stunting
85 – 89 Moderate stunting
<85 Severe stunting
Weight for Ht (WFH) = actual wt ÷ wt at p50 of ht at p50 x 100
>90 No wasting
81 – 90 Mild wasting
70 – 80 Moderate wasting
<70 Severe wasting
 PROTEIN – CALORIE MALNUTRITION
MARASMUS KWASHIORKOR
Etiology Decrease CHON & calories Decrease CHON only
Usual age 0 – 2 yrs 1 – 3 yrs
Essential features
Edema None Legs, or generalized
Wasting Gross loss of SC fat Sometimes hidden
Mental changes Apathetic, quiet Irritable, moaning
Variable features
Appetite Good Poor
Skin changes Seldom Diffuse pigmentation
Flaky-paint dermatoses
Hair changes Seldom Flag sign
Facies “old man” facies Moon facies
Others “potbelly” Hepatomegally
Winged scapulae
Albumin Usually normal Low
Anemia Uncommon Megaloblastic
Iron deficiency
 PREVENTIVE PEDIATRICS
ANTICIPATORY GUIDANCE
Newborn
• Care of the umbilical cord, circumcision, fontanels
• Breast engorgement, vaginal discharge
• Jaundice, colic, hiccups, spit-up, stools
• Jitteriness, sleeping, sneezing
• Pacifier, bathing, skin care
• Unwanted advice, postpartum adjustment, importance of close interaction, rest for mother, sibling
reaction, change in parent-family relationships, feeling of inadequacy, depression
• Breast & bottle feeding; vitamin & fluoride supplement
• When to call the doctor, fever, vomiting, diarrhea
• Injury prevention (IP): crib safety, never leave alone with pet or young siblings, be careful with hot
water during bath
• PE: gestational age, red reflex, HC, L, BW, cardiac, femoral arteries
2 – 4 weeks
• IP: never leave infant unattended
• Nutrition: breast / formula feeding
• Sleep, crying, bladder & bowel habits, urinary stream
• Emphasize baby’s abilities; hold, cuddle, talk to baby
• Parents time for themselves, avoid isolation
• Prepare for future immunization
• PE: umbilicus, heart, hearing, dacryocystitis, abdominal masses
2 months
• IP: don’t lay baby on bed or table unattended, caution with hot liquids, cigarette ash
• Advice against infant walker
• Nutrition: iron supplement in pre-term
• Sleep, play, talk, cuddle baby, spend time with siblings
• PE: WFH, muscle tone, congenital malformations
4 months
• IP: car safety, protect from falls from bed, keep powder containers, small objects out of reach; sitters /
nanny
• Talk to baby, responds to vocalization; sleep, thumb-sucking
• Nutrition: introduce solid food (mashed veggie, chicken breast)
• PE: anthrompometry (W, H, HC), WFH
6 months
• IP: home checklist for hazards, syrup of ipecac, car safety, protect from hot liquids, dangling cords,
pulling tablecloths, walker & expanding table gates, pool & bathtub safety, electrical outlets & plugs
• Play games, talk with baby, stranger anxiety, teething
• Resistance to sleep, suggest favorite toy / possession
• Nutrition: iron – fortified cereal, fruits & vegetables, fluoride & vit D (prn); discourage milk/juice as
pacifier
• Hgb & Hct screening or LBW infants
• Changing diapers; shoes; day care; family planning
• PE: anthropometry, hearing and vision
9 months
• IP: stair gates & window guards to prevent falls, choking hazards e.g. small objects, peanuts, grapes,
hotdog, syrup of Ipecac, water safety
• Good parenting practices (GPP): vocalization, imitation, communication, social games, autonomy, limit
setting, discipline; separation protest; shoes; child care
• Sleep, night awakening, favorite toy or possession
• Nutrition: table food, toast or teething biscuit for self-feeding, encourage cup, begin to wean, anticipate
decrease food intake
12 months
• IP: hot liquids, tap water (maximum flow); kitchen, car & stair safety; fences, gates, latches, moving
machinery, cars
• GPP: speech dev’t (talk to baby); hold, cuddle, love; discuss autonomy, limit setting; discipline; praise
desired behavior; prohibition few but firm; child care
• Nutrition: table foods, decrease food intake, start to phase off bottle use; advise against bottle in bed;
fluoride if indicated
• PE: anthropometry; strabismus & hearing

15 months
• IP: locked doors, safety gates, poison proof, danger of aspiration (nuts, popcorn, gum); burns/scales;
electrical injuries, water safety, danger of plastic bags
• Play, talk, read & sing with baby; discipline; remove from temptation; praise good behavior, consistency
b/w parents
• Review indicators of toilet training; day care
• Nutrition: self-feeding, eats meals with family

18 months
• IP: car restraints, protect from falls, supervise play near street, never leave unattended in car or house,
water safety
• GPP: read simple stories regularly, play games, praise/show affection; short ritual before regular
bedtime, night fears, night awakening; may show toilet training readiness at 8 – 24 months
• Discipline: need for autonomy & independence, self-comforting behavior, thumb-sucking, masturbation,
favorite toy or possession
• Nutrition: wean from bottle, fluoride if needed
24 months
• IP: burn, falls, restraints, care safety, toxic substances, old batteries, electrical injuries, drowning,
unsafe toys; plastic bags/balloons, supervise play near street
• GPP: read regularly, talk at meals, play & peer contacts, watch kid’s TV shows with child; curiosity
about body parts
• Sleep: move to regular bed, reassure that day napping varies; toilet training; show interest/ readiness
• Nutrition: avoid struggles about eating, discourage non-nutritious snacks
• Mild speech dysfluency may be normal
3 years
• IP: danger of running in street, stray dogs, water safety
• GPP: talk about activities w/ child, reserve time alone with child, allow to explore, showing initiative,
communicate, encourage out-of home experiences, limit TV viewing, tolerate transient speech
dysfluency, satisfy curiosity about babies, sex, differences; toilet training discipline; dental appointment
• Nutrition: balanced diet, avoid junk foods, fluoride if needed
• School: nursery, day care, baby sitters; school readiness
4 years
• IP: electrical tools, firearms, matches, poisons, bike riding in street, car seats, uninterrupted supervision
near water, refuse food from strangers, stray dogs, street proofing
• GPP: provide interaction w/ other kids; assign chore eg. Set table, take exploratory walks/trips, play
marbles, card/board games, answer questions about sex at child’s level
• Discipline; toilet training; nursery school / day care
5 years
• IP: electrical tools, firearms, matches & poisons, bicycle, safety, water safety, seatbelts, home fire
safety, know phone no. & address; never go w/ accept anything from strangers
• GPP: promote interaction w/ other kids, assign chores (ex. Tidy room, set table), demonstrates
interest in kindergarten
• School readiness, plays well w/ other kids, normal dev’t, endures ½ day separation from home, sex education
• PE: visual acuity, strabismus, BP
6 years
• Good health habits (GHH): avoid junk food, maintain appropriate weight, exercise regularly, learn to swim, brush
teeth at least once daily, bicycle safety, seatbelts, adequate sleep, limit TV viewing
• Social interaction w/ family & peers
• GPP: establish rules, act as models, provide allowance, spend time w/ child, show interest in school, adult
supervision when away, praise, hobbies, exercise

8 years
• GHH: balanced diet, avoid junk food, maintain weight, regular exercise, bicycle & car safety, enough sleep
• Social & family interactions
• GPP: establish fair rules, communicate w/ child, interest in school, allowance, be a role model, praise & encourage
child, promote outside activities, obtain library card for child
10 years
• GHH: balanced diet, maintain weight, dental care, bicycle, water & skateboard safety, drugs, alcohol & tobacco,
sex education at home / school, TV & videogame limits
• Academic activities, social interaction / skills, peers, hobbies
• GPP: supervise potentially hazardous activities, contribute to self-esteem, encourage activities prepare girls for
menarche
• PE: Tanner stage, scoliosis screening
12 years
• GHH: diet, weight, physical activity, sports, hobbies, dental care, tampon use, rapid physical growth & sexual dev’t,
breast & testes self-examination, seatbelts, hitch-hiking
• Sex education; school
• Social interaction w/ family & peers; sports; weekend jobs
• GPP: establish rules, supervise hazardous activities, spend time w/ child, respect privacy, allow decision making
• PE: Tanner stage, external genetalia, skin gold, BP, scoliosis
 PREVENTIVE EVALUATION AT SPECIFIC AGES
Activity 1 1 2 4 6 9 12 18 2 3 4 5 8 10 11- 15-
wk mo yr 14 17
I. History
• Developmental evaluation ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕
• Anticipatory guidance ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕
• Hearing/vision ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕
• GI / feeding ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕
• Dental care ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕
II. Physical Exam
• Height & Weight ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕
• Head circumference ∕ ∕ ∕ ∕ ∕ ∕ ∕
• Blood pressure ∕ ∕ ∕ ∕ ∕ ∕ ∕
• Vision (Snellen chart) ∕ ∕ ∕
• Hearing ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕
• Sexual development ∕ ∕ ∕ ∕
III. Laboratory
• Hgb / Hct ∕ ∕ ∕ ∕ ∕ ∕
• U/A ∕ ∕ ∕
• Tuberculin ∕ ∕ ∕ ∕ ∕ ∕ ∕
IV. Immunization ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕ ∕
 19-23

13-15

16-18
2-3yo

11-12
1 mo
Birth

7-10
4-6
Vaccine

12

15

18
2
4

6
9
Hep B 1 2 3 Catch-up

RV 1 2
DPT<7 1 2 3 4 5
DPT>7 1
Hib 1 2 3 3 or 4
PCV13 1 2 3 4 High Risk
PPSV23
IPV 1 2 3 4
Influenza Annual (IV only) Annual (IV or LAIV)
MMR 1 2
VAR 1 2
Hep A 2 doses Catch-up or High Risk
HPV 3d
Men 1 B
 EXPANDED PROGAM ON IMMUNIZATION (EPI) OF DOH
Vaccine Age Dose No. Route Size Interval b/w
doses
BCG 1 Birth; any 0.05 mL for NB 1 ID R deltoid region
time after or 6 0.1 mL older
wks infants
DPT 6 wks 0.5mL 3 IM Upper outer aspect of 4 wks
thigh
OPV / IPV 6 wks 2 drops 3 PO Mouth 4 wks
Hep B 6 wks 0.5 mL 3 IM Antero-lateral aspect of 4 wks
thigh
Measles 9 mo 0.5 mL 1 SC Outer part of upper arm
BCG 2 School entry 0.1 mL 1 ID L deltoid
Tetanus Childbearing 0.5 mL 3 IM Deltoid region 1 mo then 6 –
toxoid women 12 mo
MMR 15 mo 1
Hib 2, 4, 6 mo 18 mos booster
Pneumococc 6 mo (PCV7); 18 mos booster
al 2 y (PPV)
Rotavirus 3 and 5 mo 2 1 mo
Hep A 1 y and up 2 6 – 12 mo
Varicella 1st: 12 – 15 2 At least 3 mo
mo
2n: 4 – 6 y
Flu 6 mo Yearly
 CONTRAINDICATIONS TO VACCINATION
Absolute Contraindications Relative Contraindications Not Contraindications
• Severe anaphylactic or allergic • Immunosuppressive • Mild illness ± low-grade fever
reaction to previous vaccine therapy (all live vaccines) • Current antibiotic therapy
• Moderate to severe illness ± • Egg allergy (MMR) • Recent infectious disease
fever • Seizure within 3 days of exposure
• Encephalopathy within 7 days of last dose (Pertussis) • Positive PPD
administration (Pertussis) • Shock within 48 hrs of • Prematurity, except if infant is
• Immunodeficiency in patient last dose (Pertussis) still hospitalized at 2 mo, OPV
(congenital – all live vaccines) or • Fever ≥ 40.5°C within should be delayed until
household contact (OPV) 48hrs of last dose discharge. Or, if mother is HBsAg
• Pregnancy (MMR, OPV / IPV) (Pertussis) (-), Hep B vaccine delayed until
child ≥ 2000 g
RECOMMENDED SCHEDULE FOR CHILDREN NOT IMMUNIZED IN THE 1ST YR OF LIFE
Time / Age Vaccines Comments
Less than 7 yo
First visit DTP, IPV / OPV, Hib, Must be 12 mo of age to receive MMR and Varicella. If
(4 mo of age) Hep B, MMR, >5yo, Hib is not normally indicated
Varicella
Second visit DTP, IPV / OPV, Hib, Hib schedule varies by manufacturer. The 4th dose must
(1 mo after 1st visit) Hep B be >2mo after the 3rd dose and/or after the 1st bday.
Third visit DTP, IPV / OPV, Hib If series started:
(1 mo after 2nd visit) • 7-11 mo = 3 doses w/ 3rd dose 2 mo after 2nd dose
• 12-14 mo = 2 doses, 2 mo apart
Fourth visit DTP, Hep B, Hib • ≥ 15 mo = one dose
(>6 mo after 3 visit)
rd
 • Preferably at or before school entry. DPT not necessary if
4 – 6 yo DTP, OPV, MMR
fourth dose given on or after the fourth bday

11 – 12 yo MMR, Varicella, Hep B • Repeat Td every 10 yrs throughout life

RECOMMENDED SCHEDULE FOR CHILDREN NOT IMMUNIZED IN THE 1ST YR OF LIFE

Time / Age Vaccines Comments

7 years and older

IPV / OPV, Td, Hep B, MMR,

First visit
Varicella

Second visit OPV may be given 1 mo after the first visit if

IPV / OPV, Td, Hep B
(2 mo after 1st visit) accelerated polio vaccination is necessary

Third visit
(6 – 12 mo after 2nd IPV / OPV, Td, Hep B
visit)

11 – 12 years MMR, Varicella, Hep B Repeat Td every 10 yrs throughout life

 RECOMMENDED ROUTINELY ADMINISTERED ACTIVE IMMUNIZATIONS
Vaccine Age Dose Possible Reaction Immunity
Bacille Calmette P: usually 3 – 14 mo P: 0.05 mL ID Keloid scar, suppurative 50%
Guerin (BCG) B: school entry B: 0.01 mL adenitis, BCG infection
Diphtheria, P: 2, 4, 6 mo P: 0.5 mL IM Fever, restlessness, Almost 100%
Pertussis, Tetanus B1: 1 yr after primary B: 0.5 mL IM irritability, local signs of In 10 yrs
toxoid (DPT) B2: 4-6 yrs after inflammation
TOPV / Sabin Same as DPT 0.5 mL PO Paralytic polio >90% Lifelong
IPV / Salk Same as DPT 0.5 mL SC None >95%
Measles (Live P: 9 mo or later 0.5 mL SC Fever & rash 5 – 10 days 95%
attenuated) B1: 15 mo after At least 12 yrs
B2: 5 – 12 yrs
MMR P: 12 mo or older 0.5 mL SC Fever, rash, arthralgia, >95%
B: 5 – 12 yrs after LAD, seizure Lifelong
Recombinant Hep P: 0, 1, 6 mo 0.5 mL IM Arthralgia, neurologic ≈ 100%
B B: 5 yrs after rxns In 10 yrs
Varicella 9 mo – 12 yrs: 1 dose 0.5 mL SC Fever, vesicular eruption ≈ 100%
>13 yrs: 2 doses 6 – 8 wks apart
Hemophilus P: 2 mos – 5 yrs 0.5 mL IM Pain, redness, swelling 90 – 100%
influenza < 6 mos: 3 at injection site, fever
>6 mos: 2
>1 yr: 1
* P – primary dose *B - booster *TOPV – trivalent oral poliovirus vaccine *IPV – inactivated polio vaccine
 PREPARATIONS FOR PASSIVE IMMUNIZATION (Antitoxin or Immunoglobulin)
Disease Vaccine Indications Dosage
Diptheria Diptheria Close contacts who cannot be observed closely Prevention: 5,000 U
anti-toxin Tx: 40,000 – 120,000U
Tetanus Antitoxin Inadequately immunized with serious wounds 3,000 – 5,0000 U
IG Same 250 – 500 U
Ab IGIM Substitution therapy in antibody deficiency; 0.06 mL/kg q 2 – 4 mo
immuno- ITP, Kawasaki, GBS
deficiency
IGIV 2 mL/kg of 5%
preparation
3.3 mL/kg of 3%
preparation
Measles IG Within 6 days of exposure 0.25 mL/kg BW, IM
Rabies IG Immediately after exposure 20 U/kg BW, IM
Antirabies 40 U/kg BW, IM
Rubella IG Post-exposure pregnant woman (1st trimester) 0.55 mL/kg BW, IM
Hep A IG Within 7 days exposure 0.02-0.06 mL/kg BW, IM
Hep B IG Within 12 hrs after birth if mother HbsAg+ 0.5mL, IM
After percutaneous exposure 0.06 – 0.12 mL/kg IM
(max: 5 mL)
Varicella IG Within 48 hrs post-exposure 625 U or 125 U/kg BW IM
VACCINES
BCG DPT OPV IPV Live attenuated M bovis
MMR, Measles Varicella Diptheria and TT – inactivated B pertussis Sabin trivalent live attenuated
Hep B virus
Hep A Hib Typ Salk inactivated virus Live attenuated virus

Pneumococcal Recombinant DNA, plasma derived Inactivated virus

Capsular polysacc linked to carrier CHON Live typhoid vaccine – 3 doses
x 2 days
Influenza 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
 Hx of Absorbed TT Clean minor Wound All other Wounds
Td TIG Td TIG
Unknown or <3 Yes No Yes Yes
>3 No 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

NEONATOLOGY

ROUTINE DELIVERY ROOM CARE

1. Position: place infant head downward immediately, to clear mouth, pharynx & nose of secretions

2. Suction: Gently suction nose and pharynx with bulb syringe or soft catheter, while stimulating to cry
• Non-high risk infant: head down
• High risk (eg. CS deliver): crib level
3. Asssess APGAR SCORE
Sign 1 2 3
Color Pale blue Pink body, blue extremities Completely pink
Reflex irritability None Grimace Vigorous cry
Heart rate Absent Slow (<100) >100
Respiratory effort Absent Slow (irregular) Crying
Muscle tone Flaccid Some flexion of extremites Active motion
7 – 10 Vigorous infant
Interpretation 4–6 Mild-moderate asphysia – 100% O2 by face mask
0–3 Severe asphyxia – intubation
One-minute score: gives index of necessity for resuscitation
Five-minute score: more valuable in predicting mortality, success of resuscitation and neurologic deficit at
1 yr of age
Resuscitation of the depressed infant
Score: 4 – 6
• Vigorous stimulation and suctioning of secretions
• Assisted ventilation for the depressed baby may produce spontaneous respiration
• If still unresponsive, tracheal intubation and positive pressure
Score: 0 – 3
• Vigorous stimulation and suctioning of secretions
• Immediate intubation and O2 inhalation
• Correction of acidosis
4. Maintain body heat
• Body surface of NB 3x that of adult
• Rate of heat loss 4x that of adult occurring by:
a. Convection to cooler air
b. Conduction to cooler materials
c. Radiation from infant
d. Evaporation from moist skin
• Initial rectal temperature (NV: 36.6 – 37.2°C), then q 4 hrs until stable. Following readings taken per
axilla q 8 hrs

5. Normal physical exam and maturity testing

Skin: vernix caseosa, lanugo, jaundice >24 hrs, harlequin color, mottling (thermoregulation instability),
Mongolian spots, milia, erythema toxicum (harmless small erythematous papules)
Head / Neck: HC, fontanels (tense, bulging or depressed)
• Caput succedaneum: edema w/ w/o ecchymoses, ill-defined borders, disappearing in a few days
• Cephalhematoma: subperiosteal bleed limited by periosteal attachments, NOT crossing suture lines,
absorbed slower than a caput
• Craniotabes: soft areas of bone, which give a “pingpong” ball sensation when depressed
• Epstein pearls: whitish shiny crystals on palate and gums

Chest:
• Normal RR: 30 – 60 / min, diaphragmatic
• Periodic breathing (apnea < 10 sec): normal in pre-term
• Normal CR: 120 – 160 bpm; auscultate for murmurs
• Brachial = femoral pulse intensity; BP (term): 50 – 70 / 25 – 50 mmHg
Abdomen / Back:
• globular but not distended
• diastasis recti (separation of recti muscle common in newborns)
• liver edge palpable 2 – 3 com subcostal margin
• back without dimpling or tuft of hair
Hip dislocation:
• Barlow’s test: dislocates unstable hip; flex ad adduct hip
• Ortolani’s test: relocates unstable hip; abduct ------- “clunk”

Neurologic:
Reflex Appears Disappears
Moro Birth 8 mo
Stepping Birth 6 wks
Placing birth 6 wks
Sucking and rooting Birth 4 mo, awake
7 mo, asleep
Palmar; plantar grasp Birth 6 mo; 10 mo
Adductor spread of knee jerk Birth 7 mo
Tonic neck 2 mo 6 mo
Neck righting 4 – 6 mo 24 mo
Landau 3 mo 24 mo
Parachute reaction 9 mo persists
6. Measurements: weight, length, HC, CC, AC
Low birth weight (LBW) infant BW < 2,275 grams
Very low birth weight (VLBW) BW < 1,500 grams
Extremely low birth weight (ELBW) BW < 1,000 grams
• Small for gestational age (SGA): BW < 10th percentile for gestation or below 2 standard deviations from
mean
• Large for gestational age (LGA): BW > 90th percentile
Ponderal index = (Wt in g ÷ L in cm) x 100
• If > 2: symmetrical SGA
• If < 2: asymetrical SGA
7. Antiseptic skin and cord care
• Cord: 2 arteries, 1 vein (AVA)
• Initially use triple dye / betadine to prevent staph infection, then 70% alcohol q 4hrs till it falls off
8. Apply 1cm strip Erythromycin ointment to both eyes to prevent Opthalmia neonatorum.
• Covers for both N. gonorrhea and chlamydia
9. Inject 1mg vit K IM to prevent hypoprothombinemia
• 1 mg for full-term; 0.5 mg for pre-term
• Given IM to prevent hyperbilirubinemia / hemolysis
10. Infant feeding
• Term, healthy infants: feed 4-6 hrs after birth; start with 15-20 cc, increasing by 5 mL/feeding
• Pre-term, SGA, LGA: early feeding (2-3hrs after) to prevent hypoglycemia; increasing 3-4 mL/feeding
• < 1,250 gms: parenteral feeding 5-10% glucose solution w/o saline initially
eg. IVF D10W @ 65mL/kg/d for D1 then D10IMB @ 80mL/kg/d for succeeding days
 PHYSIOLOGIC CHANGES IN THE NEWBORN

1. Physiologic weight loss: not more than 10% of BW, occurring on the 2nd day, recovered by the 10th day of
life

2. Physiologic jaundice (unconjugated hyperbilirubinemia)

• Predisposing factors:
a. Surpion (surplus of RBC, increased cell mass
b. Decreased red cell survival
c. Immature hepatic function (slow bilirubin metabolism)
d. Breast feeding
• Occurs on 2nd-3rd day, peaks @ 4-5th day, disappears on the 7th day (term); 14th day (pre-term)

3. Vasomotor instability

4. Genital crisis: pseudomenses (d/t maternal estrogen)

5. Witch milk (d/t maternal estrogen)

6. Transitional stools

7. Inanition fever: during 1st wk d/t dehydration

8. Physiologic desquamation or the skin for not more than 1 wk

9. Falling off of the cord

10. Physiologic anemia: @ 2-3 mo, permissible level 8 mg%

ESSENTIAL NEWBORN CARE PROTOCOL [from DOH]
o What should be done immediately after birth is to dry the baby because hypothermia can lead
to several risks
o Delaying the cord clamping to 3 mins after birth (or waiting until the umbilical cord has
o stopped pulsing)
Instead of immediately washing the NB, the baby should be placed on the mother’s chest or
abdomen to provide warmth, increase the duration of breastfeeding, and allow the “good
bacteria” from the mother’s skin to infiltrate the NB
o 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% [Clamydia]
✓ Tetracycline 1%
✓ Povidone iodine 2.5%
Vitamin K
✓ 1 mg Vit K1
✓ PT: 0.5 mg
Vaccine
✓ BCG
✓ Hep B
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
Disorder Screened Effects Screened Effects if Screened & treated
Congenital Hypothyroidism (CH) Severe MR Normal
Congenital Adrenal Hyperplasia (CAH) Death Alive &Normal
Galactosemia (Gal) Death of Cataract Alive &Normal
Phenylketonuria PKU Severe MR Normal
G6PD Severe Anemia Normal
Kernicterus
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
Cows milk allergy
• Onset- 3rd wk
• Rashes on cheeks → eyebrows → cradle cap

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
 DISEASES OF THE NEWBORN
NEONATAL SEPSIS
Features Early Onset Late Onset
Onset Birth – 7 days 8 – 28 days
Intrapartum Often present (amonionitis, prematurity) Unusual
complications
Presentation Fulminant, multisystem, resp. distress, Insidious, fever, CNS, focal signs
pneumonia
Meningitis 30% Common, 75%
Pathogens Grp B strep I, II, III; E. coli, Listeria, Grp B strep III, E. coli, Staph, fungal,
Klebsiella, S. pneumoniae, enterococci Herpes simplex
Treatment Ampicillin & gentamycin or cefotaxime
Clinical signs:
1. Resp distress: tachypnea, retractions, grunting, 5. Abn heart rate and BP
nasal flaring and apnea
2. Abn skin color: mottling, jaundice, cyanosis 6. Abn neurologic status: lethargy, seizures
3. Temp instability: hypothermia, rarely 7. Opthalmia neonatorum
hyperthermia
4. Feeding intolerance: vomiting, poor suck, abd 8. Omphalitis
distention
 Sepsis Screen (Possible if 2 or more are abn) Neutrophil indices of Sepsis
1. Culture: blood, urine 1. Neutropenia – most specific
2. Immature to total neutrophil (I:T) ratio > 0.2 2. I:T ration – most sensitive
I:T = % bands + metas (immature)
% segs + bands + metas (total)
3. Leukocyte cout: WBC < 5,0000 3. Band count = bands x WBC x 1,000
Neutropenia if ANC < 1,750 / mm3 NV: < 1,0000 / mm3
ANC = WBC x % (segs + bands + metas)
4. CRP
RESPIRATORY DISTRESS SYNDROME
• Pathology: diffuse lung atelectasis, congestion & edema w/ hyaline membranes containing
fibrin & cellular products d/t surfactant deficiency
• Signs: retractions, tachypnea, cyanosis, grunting
• Fine reticulogranular densities on CXR; L/S ratio < 2
• Course: gets worse before improving in 3 – 5 days
• Prevention: antenatal glucocorticoids @ 26 – 34 wks AOG if at risk for pre-term delivery
(Betamethasone 12mg IM 24 hrs apart or 6mg IM q 12 x 4 doses)
TRANSIENT TACHYPNEA OF THE NEWBORN
• Transient pulmonary edema resulting from delayed clearance of fetal lung fluid
• Signs: tachypnea, retractions w/o cyanosis, hypotension
• CXR: hyperaeratio, increases vascular markings (sunburst pattern)
• Course: benign, self-limited
 NEONATAL PNEUMONIAS
• Predisposed by premature labor, PROM, ↑ • Etiology and Treatment
digital exam a. GBS – penicillin
• Signs: tachypnea, retractions, cyanosis, b. Chlamydia – erythromycin
grunting c. E. coli – 3rd gen Cephalosporins
• CXR: diffuse homogenous & linear radiating d. Staph – oxacillin, vancomycin
densities *Refer to section on pulmonology tx algorithm

EMERGENCY MEDICINE
BASIC CPR IN INFANTS AND CHILDREN
Infant (< 1 yo) Older Child (< 8 yo)
AIRWAY
Determine unresponsive ness
Shout for help
Position patient supine; support head and neck
Head-tilt / chin lift or jaw thrust; no blind finger sweeps

BREATHING
Give 2 initial breaths (seal mouth & nose in infants)
If airway obstructed: 5 back blows / chest thrust
Then: 20 breaths / min Then: 15 breaths /min
CIRCULATION
Check branchial pulse Check carotid pulse
 Infant (< 1 yo) Older Child (< 8 yo)

Chest Compression

Compression location: 1 finger breadth below

Compression location: lower 1/3 of sternum
inter-mammary line on sternum

Compression method: hands encircle or 2

Compression method: 1 or 2 hands on sternum
fingers on sternum

Compression depth: 0.5 to 1” Compression depth: 1 – 1.5”

Compression rate: 100 / min Compression rate: 80 – 100 / min

Compression : ventilation ratio = 5:1

Reassessment: palpate pulse q 10 cycles

ACTIVATE EMS SYSTEMS – Call 911 (After 1 min of CPR)

Infants & children ≤ 8yo: phone fast; Adult and children > 8yo: phone first
 ASYSTOLE AND PULSELESS ARREST DECISION TREE

• Determine pulselessness and begin CPR

• Confirm cardiac rhythm in more than one lead

V-fib / pulseless V-tach Asystole Eletromechanical dissociation

Pulseless electrical activity
• Defibrillate 3x (2, 2-4, 4 J/kg Identify and teat cause
• Severe hypoxemia, acidosis, hypovolemia,
• Continue CPR, Secure airway tension pneumothorax, cardiac
• Hyperventillate w/ 100% O2 tamponade, profound hypothermia
• Obtain IV or IO access but do
not delay defibrillation
• Continue CPR, Secure airway
• Hyperventillate w/ 100% O2
• Epinephrine, first dose • Obtain IV or IO access
IV / IO: 0.01 mg/kg (1:10,000) • HCO3 1mg/kg if ↑K, acidosis
ET: 0.1 mg/kg (1:1,000)
• Lidocaine 1 mg/kg IV or IO
• Epinephrine, first dose
IV / IO: 0.01 mg/kg (1:10,000)
• Epinephrine, next dose
ET: 0.1 mg/kg (1:1,000)
IV / IO: 0.1-0.2 mg/kg (1:10,000) q 3-5min
• Lidocaine 1 mg/kg • Epinephrine, 2nd & subsequent
• Consider bretylium 5 mg/kg 1st dose, 10mg/kg 2nd dose doses
IV / IO / ET: 0.1-0.2 mg
• Defibrillate 4 J/kg, 30 – 60s after meds (1:1,000) q 3 – 5 min
Remember:
• Heart rate is the most sensitive measure of volume status
• Capillary refill time: most sensitive measure of adequate circulation -NV < 2s in ambient temp
• Urine output: should be 1 – 2 cc/kg/hr
• Easy rise and fall of chest: best indication of adequate ventillation
ENDOTRACHEAL TUBE SIZE BY AGE
Age Tube Size (mm) • < 8 yo use uncuffed tube to ↓
Premature 2.5 subglottic edema & stenosis
0 – 3 mo 3.0 • ET level: size of tube x 3
3 – 7 mo 3.5 • Laryngoscope Blade Size:
7 – 15 mo 4.0 Term, Newborn Size 1
15 – 24 mo 4.5
2 – 11 yrs Size 2
2 – 10 yrs Age (yrs) + 16 or
4 > 12 yrs Size 3
Age (yrs) + 4
4 • < 8yo use straight blade
10 – 20 yrs 6-8
VASCULAR ACCESS MANAGEMENT DURING CPR

Percutaneous peripheral IV

Yes No (after 90s)

• LR or NSS 10 – 20 mL/kg then • Intraosseous needle (1st choice for < 5yo)
titrate (max: 60 – 80 mL/kg) • Saphenous vein cutdown
• Resuscitation drugs • Central venous access
 MEDICATIONS THAT CAN BE GIVEN BY ENDOTRECHEAL TUBE
L – Lidocaine, E – Epinephrine, A – Atropine, N – Naloxone
RAPID SEQUENCE INTUBATION FOR INFANTS / CHILDREN
1. Pre treatment with Defasciculating drugs:
• Lidocaine – dose: 1 – 1.5 mg/kg IV; for high ICP
• Atropine – dose: 0.01 mg/kg IV; best for pediatric patients
• Vecuronium – defasciculating dose: 0.01 mg/kg IV ET tube age in years + 4
2. Prime with induction agents: 4
ET diameter x 3
• Midazolam (0.05 – 0.1 mg/kg) or
>10 yo cuffed
• Thiopental (4 – 7 mg/kg) or
• Fentanyl (1 – 2 mcg/kg)
3. Paralyzed with:
• Succinylcholine (1.5 mg/kg IV) or
• Vecuronium (0.1 – 0.2 mg/kg IV)
Laryngoscope sizes

PT Miller 00 or 0

Term Miller 0

0-6mos Miller 1

6-24 mos Miller 2

>24 mos Miller 2 or Mac 2

 EMERGENCY MEDS
Epinephrine (bradycardia, asystole)
(1:1000) 0.1 ml/kg q 3- 5 mins
Amiodarone 5 mg/kg rapid IV push
Cardioversion 2 J/kg then 4 J/kg then rpt 2x
Albumin 1gm x wt given in 2-4hrs.
Prep: 12.5g/50ml
Vol expander: 20ml/kg HypoCHONemia – 1gm/k/dose x 4H
Epinephrine Drip 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)
Levophed 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 11cc/hr
Dopamine Renal dose 3-5
Pressor >5 - <15
alpha effect >15
ANAPHYLAXIS
Epinephrine 0. 01ml/kg max of 0.5 mg/dose SC
(1:1000) < 30 kg 0.15 mg
> 30 kg 0.3 mg
Diphen = 50mg IM (1mkdose)
USN w/ Salbu x 3 doses
 RESUSCITATION DRUGS
Drug Dose Preparation Remarks

Adenosine 0.1 – 0.2 mg/kg Max single dose: 12 Rapid IV bolus for paroxysmal SVT
mg

Atropine 0.02 mg/kg/dose IV, ET Dilute w/ NSS to 1 – Min: 0.1 mg

0.04 mg/kg/dspe SC 2 mL total vol if per Max/single dose: 0.5mg (child)
ET 1.0 mg (adolescent)

CaCl 20 mg/kg/dose, SIVP 100 mg/mL (10% ↓ Ca, ↑ K & Mg

soln)

Dopamine Begin @ 5 – 10 200 mg in 250 mL Refer to rule of 6 for computation

ug/kg/min titrate to D5W or Dose related effects:
desired effect to max of 20 400 mg in 250 mL • 5 – 10 ug: dopaminergic
ug/kg/min D5W • 10 – 20 ug: B adrenergic
• > 20 ug: a adrenergic

Dobutamine 5 – 20 ug/kg/min Same as dopamine Refer to rule of 6

Epinephrine Infusion: 0.1 ug/kg/min ET: Dilute in 3 – 5 mL Refer to rule of 6

titrate to max of 1.0 ug NSS & follow w/ (+) Neonate: IV = ET = IO dose
ET: 0.1 mg/kg (1: 1,000) pressure, ET = 10 Higher doses not acceptable
times IV dose

Fentanyl 0.5 – 5 ug/kg/dose q 1 – 5 ug/kg/hr as For severe pain

1-4hr infusion
 Drug Dose Preparation Remarks
Furosemide 1-2 mg/kg (0.1-0.2 ml/kg) 10 mg/ml Maximum: 4 mg/kg
Glucose 0.5–1.0 g/kg or 2–4 ml/kg Refer to Glucose Infusion
Rate below
Hydralazine 0.15 mg/kg/dose IV bolus q30 Daily dose: 1.7 – 3.6
– 90 min prn mg/kg/24 hr
Insulin Bolus: 0.05 – 0.1 g/kg Use regular insulin Rate of blood glucose ↓ ≈
Infusion: 0.1 – 0.2 g/kg/hr 150 mg/hr
If < 150: ↑ to 0.2 g
If > 150: ↓ to 0.05

Lidocaine Bolus: 1 mg/kg/dose 10 mg/mL (1%) Bolus doses may be given at

Infussion: 20 – 50 ug/kg/min 20 mg/mL (2%) 5 min intervals 3x, then use
infusion

Mannitol 0.25 – 1 g/kg/dose 15 – 25% soln Given over 30 – 60 min

Midazolam Loading dose: 0.05 – 0.2 mg/kg followd by 0.1 – 0.2 For conscious sedation
mg/kg/hr dose tritrated to effect
Naloxone 0.01 – 0.1 mg/kg dose q 2 – 3 mins pm up to 3x then q 1 For respirator depression 2°
– 2 hr opioids
NaHCO3 1 – 2 mEq/kg/dose or 1 mEq/mL (8.4% Infuse slowly & only if
0.3 x kg x base deficit soln); use 0.5 mEq/mL ventilation is adequate
in newborn
Rule of 6 (for dopamine & dobutamine)

6 x kg BW = _ mg to be added to 100cc D5W

or Eg. 10 kg child to be given 8 ug/kg/min:
15 x kg BW = __ mg to be added to 250cc 6 x 10 kg BW = 60 mg dopamine to be added
D5W to 100 cc D5W to run @ 8cc/hr to deliver 8
* Above formula yields: cc/hr = 1 ug/kg/min ug/kg/min

Modified Rule for 6 (for epinephrine)

0.6 x kg BW = _ mg to be added to 100cc D5W or 1.5 x kg BW = _ mg to be added to 250 cc

D5W
* Above formula yields: cc/hr = 1 ug/kg/min

Glucose infusion rate (NV: 6-8 mg/kg/min; if not w/in N, ↑/↓ dextrosity)

GIR (mg/kg/min) = total vol (cc) x dextrosity (glucose/cc) x 1,000 mg/g x 1 hr or

hrs to infuse x wt (kg) 60 min
GIR = rate (cc/hr) x dextrosity (g/cc) x 0.167
kg BW
 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)
 FLUIDS & ELECTROLYTES

FLUID VOLUME

I. MAINTENANCE

A. Based on caloric expenditure (Holliday-Segar Method)

First 10 kg 100 mL/kg/24hrs

Second 10kg 50 mL/kg/24hrs

Further 1kg 20 mL/kg/24hrs

Ex: 24hr requirement for child weighing 25kg

Soln: 10 kg x 100 mL/kg/24hrs = 1000 mL

10 kg x 50 mL/kg/24hrs = 500 mL
+ 1 kg x 20 mL/kg/24hrs = 100 mL
1600 mL for 24 hrs

For those below 5k full maintenance is 150 mL/kg/day

Full maintenance fluid over 24hrs should not exceed 2000mL for girls 0r 2500mL for boys

In emergency situations where weight is unknown:

>1 yo (age +4) x 2 = estimated wt
< 1yo (months + 9) = estimated wt
 B. Based on BSA
TFR = Insensible water loss + Urine output
where: Approximate BSA
IWL: 400 – 600 mL/m2/day x BSA Age / Wt BSA (m2)
Urine: 600 – 1000 mL/m2/day x BSA NB / 3 kg 0.3
1 yr / 10 kg 0.5
10 yr / 30 kg 1
13 – 14 yr / 60 kg 1.5
Adult / 70 kg 1.73

C. Conditions that alter maintenance fluid

Condition Adjustment needed Condition Adjustment needed
Extra needed Less required
Fever 12% for each °C > 37.5°C or Hypothermia 12% for each °C >
7 mL/kg for each 0.5°C > 37.5°C 37.5°C

Room temp > 31°C 30% per °C rise Hight humidity 30%
Hypermetabolism Oliguria / edema Case-to-case / 30%
• Major surgery 20 – 30%
• Burns 2% increase per 1% area burnt

Diarrhea / vomiting Volume per volume Sedated / paralyzed 40%

Phototherapy 25%
II. CORRECTION OF DEFICIT

• First assess degree, then type of dehydration

A. Degree of Dehydration

S/S Mild Moderate Severe

< 2 yo 50mL/kg 100 mL/kg 150 mL/kg

(5% body weight) (10% body weight) (15% body weight)
> 2 yo 30mL/kg 60mL/kg 90mL/kg
(3% body weight) (6% body weight) (9% body weight)
General Thirsty; alert; restless Thirsty; maybe restless or Drowsy; limp, cold,
appearance: lethargic but irritable to sweaty, cyanotic
Infants/young touch extremities; may be
child comatose

Older child Thirsty; usually alert; ± ↓ LOC; apprehensive:

postural hypotension cold, sweaty, cyanotic
ext, cramps

Tachycardia Absent present Present

Palpable pulses Present Present (weak) Decreased

BP Normal Orthostatic hypotension Hypotension

Cutaneous Normal Normal Reduced/ mottled

perfusion
 S/S Mild Moderate Severe

Capillary refill Normal ± 2 sec > 3 sec

Skin turgor Normal Slight reduction Reduced; wrinkled skin

on fingers / toes

Fontanel Normal Slightly depressed Sunken

Mucous membrane Moist Dry Very dry

Eyes Normal Sunken Grossly sunken

Tears Present Present / absent Absent

Respirations Normal Deep; may be rapid Deep and rapid

Urine output Normal Oliguria Anuria / severe oliguria

Note: Bolus = 20mL/kg for 20min

Mild dehydration: Full maintenance fluid + Deficit for 24 hrs
Moderate dehydration: ¼ of Deficit for the first 1 hr
¾ of Deficit for the next 7 hrs
Full maintenance fluid for next 16hrs
Sever dehydration: 1/3 of Deficit for first 1 hr
2/3 of Deficit for the next 5 hrs
Full maintenance fluid for the next 18hrs
 B. Type of Dehydration

Sign Hyponatremic Isonatremic Hypernatremic

Skin Color Gray Gray Gray

Temp cold Cold Cold

Turgor Very poor Poor Fair

Feel Clammy Dry Thick, doughy

Mucous mem Sl. Moist Dry Parched

Eyeballs Sunken, soft Sunken, soft Sunken, firm

Fontanel sunken Sunken Sunken

Consciousness Very lethargic Lethargic Hyperirritable

Pulse rapid Rapid Moderately rapid

BP Very low Low Moderately low

Serum Na Low Normal High

IVF Tx 0.45% NaCl 0.30% NaCl 0.2% NaCl

77 mEq /L Na 51.3 mEq /L Na 34 mEq /L Na
Oral Rehydration Therapy
Mild Moderate
Initial dose 50 mL/kg over 4 hrs 100 mL/kg over 6 hrs
Subsequent 100 mL/kg/ 24 hr 100 mL/kg/ 24 hr
Oral hydrating solution
Preparation Contents (mEq/L)
Formulated ORS 1/3 tsp NaCl, baking soda, KCl; 1L Na+ to, K+ 20, Cl- 50, HCO3 20, glucose 20g
water
Glucolyte 60 1 sachet / 250 mL Na+ 60, K+ 20, Cl- 50, Mg2+ 5, Gluconate 5,
citrate 10, Gluc 100
Hydrite 2 tabs / 200mL Na+ 90, K+ 20, Cl- 80, HCO3 30, Glucose 111
(ORS 45: 1 tab/200mL)
Oresol (DOH) 1 sachet / 1L Na+ 90, K+20, Cl- 80, HCO3 30
Orhydrate 60 mL in 940 mL water or Na+ 45, K+ 20, Cl- 35, Mg2+ 2.5, gluconate
concentrate syrup 5 mL in 78 mL water 2.5, Citrate 30, glucose 10g, sucrose 20g
Pedialyte 45 Premixed Na+ 45, K+ 20, Cl- 35, Citrate 30, Dextrose
25g, Calories 100
Pedialyte 90 Premixed Na+ 90, K+ 20, Citrate 30, Dextrose 25g,
Calories 100
Gatorade Na+ 41, K 11, Gluc 9/100
 ORAL REHYDRA TION THERAPY
PLAN A AGE Amount ORS to give/loose stool
50 – 100 ml
100 – 200 ml
As much as wanted

PLAN B Amount of ORS to give in 1st 24 hrs:

Weight (kg) x 75ml/kg
PLAN C AGE 30ml/kg 70ml/kg
Infants (<1 yo) 1 hr 5 hrs
Children (>1 yo) 30 mins 2.5 hrs
In fluid resuscitation: use 20cc/kg as bolus. Usually PLR
IV Hydration Therapy (Ludan’s Method)
 Some commonly used IVF for Infants and Children
IVF Dextrose Na+ Cl- K+ Lactate Others
g/L mEq/L mEq/L mEq/L mEq/L mEq/L

LRS 130 109 4 28 Ca2+: 3

NSS 154 154
D5 0.15% NaCl 50 25 25
D5 0.3% NaCl 50 51 51
D5 0.45% NaCl 50 77 77
D5 0.9% NaCl 50 154 154
D5 IMB 50 25 22 20 23 Mg: 3; PO4: 3
D5LRS 50 130 109 4 28 Ca2+: 3
D5NM 50 40 40 13 Mg: 3; Acetate: 26
D5NR 50 140 98 5 Mg: 3; Acetate: 27;
Gluconate: 23

Na requirement: 2 – 4 mEq/kg/day
K requirement: 2 – 3 mEq/k/day
KIR: 0.2 – 0.3 mEq/k/hr max of 40 mEq

KIR = Rate x incorporation

wt
 FLUID COMPOSITION
Sodium (NV: 135 – 150 mEq/L or 3 – 4 mEq/kg/day)
Hyponatremia
• mEq Na deficit = (desired – actual) x TBW
where: TBW (in L) = 0.6 x body weight (kg)
• Initial goal: 120 mEq/L; Subsequent: 130 in 24 – 3 hrs
• Correct only up to 15 mEq/L/day (2.5 mEq/L/hr) to avoid pontine myelinolysis

Hypernatremia
• Water deficit = plasma (Na+) – 140 x TBW
140
• Correct only 10 – 15 mmol/L/day
Potassium (NV: 3.5 – 6 mEq/L or 2 – 3 mEq/kg/day
Hypokalemia
• Mmol K deficit = (desired – actual) x 0.3 x wt (kg) or,
deficit = wt (kg) x 50 x estimated % deficit

K Serum level Estimated deficit

3 – 3.5 mEq/L 5% deficit (approx. 200 – 400 mmol)
2 – 2.5 mEq/L 10% deficit
1 – 2.0 mEq/L 20% deficit (approx. 600 mmol and up)
Hypokalemia

• If asymptomatic: oral replacement 2 – 3 mEq/kg/d

• IV replacement guidelines:
1. rate: 0.2 – 0.3 mmol/kg/hr NOT to exceed 1 mmol/kg/hr
2. if via peripheral vein, not > 40 mmol/L
3. if via central vein, not > 80 mmol/L; continuous ECG

Hyperkalemia

• ECG changes: peaked/tented T waves,

@ > 7.0 mEq/L: prolonged PR, ↓ST, wide QRS
@ > 8.0 mEq/L: P wave disappears, QRS merges with T
• Treatment:
1. reverse membrane effects:
Ca gluconate 10% @ 0.5 – 1.0 mL/kg IV over 2 – 10 mins
2. transfer K into cells (redistribute): B2 agonists; or
regular insulin 10 – 20 ‘u’ + glucose 25 – 50 g; or NaHCO3 3 amp/L D5W
3. Enhance renal excretion of K:
Kayexalate 1 gm/kg PO diluted with 2 – 4 mL sorbitol

Calcium
Hypocalcemia

• Ca gluconate 10% (8.9 mg/mL elemental Ca): 0.5 – 1.0 mL/kg IV bolus over 20 – 30 min w/ cardia
monitoring x 3 doses
• Maintenance: 500 mg/kg/24hr PO
 Magnesium

Hypomagnesemia

• For symptomatic children:

4 – 7 kg: 0.5 mL of 50% MgSO4 (1 mmol Mg)
> 7kg: 1 mL of 50% MgSO4 (2 mmol Mg)

ANION GAP = (Na + K) – (Cl + HCO3) = 8.16 mEq/L

• Represents unmeasured anions eg. PO4, SO4, AA’s, Lactate

Increased Normal Decreased

Methanol poisoning Hypernatremic dehydration ↑ K, Ca, Mg

Uremia / renal failure Renal tubular acidosis Hypoalbuminemia /
DKA Hyperalimentation Nephrotic Syndrome
Paraldehyde / Penicillin Diarrhea Lithium poisoning
Iron tablets / Isoniazid
Lactic acidosis
Ethanol / Ethylene glycol
Salicylates
↓ K, Ca, Mg, ↑ PO4
 TOTAL PARENTERAL NUTRITION COMPUTATIONS

A Total Fluid Requirement (TFR)

Term Preterm

Start @ 60 mL/kg/day Start @ 80 – 90 mL/kg/day

Increments of 10 mL/kg/day Maximum: 150 mL/kg/day
Maximum 150 mL/kg/day

B Electrolytes / AA Preparations Normal Values

NaCl 2.5 mEq/mL 2 – 4 mEq/kg/day

KCl 2 mEq/mL 1 – 3 mEq/kg/day
10% Ca Gluconate 100 g/mL 100 – 400 g/kg/day
7% AA 7 g/ 100 mL 2 – 3 g/kg/day

* Correction factor for tubings: multiply all values by 1.1

Example: 2 kg Preterm; start TFR @ 80 cc/kg/day

1. Compute TFR (subtract vol of meds from computed TFR, if any):

TFR = 80 mL/kg/day = 160 mL/day (- meds) x 1.1 = 176 mL/day
2. Compute Electrolytes and amino acids, then total:
NaCl: 3 mEq/kg/day x 2 kg ÷ 2.5 mEg/mL = 2.4 mL/day x 1.1 = 2.64
KCl: 2 mEq/kg/day x 2 kg ÷ 2 mEq/mL = 2 mL/day x 1.1 = 2.2
Ca: 200 g/kg/day x 2 kg ÷ 100 g/mL = 4 mL/day x 1.1 = 4.4
AA: 3 g/kg/day x 2 kg ÷ 7 g/100mL = 85.7 mL/day x 1.1 = 94.2
total = 103.4 mL/day
3. Compute to desired Dextrosity (D10): First get volume of D50W (X):
TFR x dextrosity = 50 x 5 (TFR – [electrolytes + AA] – X) or
D50W = {(A x dextrosity) – [5 (A-b)]} ÷ 45
176 x D10 = 50 X x 5 (176 – [103.4]) – X)
X = [1760 – 5 (176 – 103.4)] ÷ 45 = 31.04mL D50W
Then get volume of D5W:
D5W = TFR – D5W – (Electrolytes + AA)
D5W = 176 – 31.04 – 103.4 = 41.6 mL D5W

4. To Check Dextrosity:

D50W = 31.04 x 50 = 1552

D5W = 41.6 x 5 = 208 Total ÷ TFR = Desired dextrosity which is 10
total = 1760

5. TPN to be prepared by pharmacy under laminar flow:

D50W 31.04 mL; D5W 41.6 mL; NaCl 2.64 mL; KCl 2.2 mL;
10% Ca Gluconate 4.4 mL; 7% Aminosol 94.2 mL
To infuse only 160 mL at 6.6 cc/hr for 24 hrs
 FLUID MANAGEMENT IN NEPHROTIC PATIENTS
Estimated Creatinine Clearance = Ht (cm) x K ÷ Creatinine (mg/dL)
NV: 120 ± 20 mL/min/1.73m2
40 – 65 mL/min/1.73m2 (newborn)
where: K values
LBW during first year of life 0.33
Term AGA during first year of life 0.45
Girl child/ adolescent 0.55
Boy child/ adolescent 0.70

Fluid Limit = BSA x IWL x Urine output in 24hrs

Na Limit = (Wt x 23 x 2) ÷ 1,000
CHON Limit = 0.5 g/day x Wt

FLUID RESUSCITATION IN BURN PATIENTS

Parkland Formula = 4 mL LRS/kg/% burn
1st half in 8 hours; Next half in 16 hrs
Oral supplementation given 48 hrs after
PRBC if: Hgb < 8 FFP if: PT level > 1.5x control
Hct < 0.24 PTT level > 1.2 x control
Albumin: Maintain @ 2 g/dL
30 – 50% BSA burn: 0.3 mL albumin/kg/BSA burn/day
50 -70%: 0.4 mL
70 – 100%: 0.5 mL
Galveston:
1st 24 h 5,000 cc (PLRS) / % burned BSA / day (burn related losses)
+ 2,000 cc (D5LRS)/BSA/day (maintenance mainline)
50% in 1st 8hrs
50% in next 16 hrs
2nd 24 h 3,750 cc / % burned BSA /day (burned related losses)
+ 1,500 cc / BSA / day (maintenance fluid)

CONVERSION FACTORS
Element or mEq/L to mg/dL to Laboratory Tests
Radical mg/dL mEq/L mg/dL to umol/L
Na+ 2.30 0.4348 Creatinine 88.4
K+ 3.91 0.2558 Total Bilirubin 17.10

Ca2+ 2.005 0.4988 mg/dL to mmol/L

BUN 0.357
Mg2+ 1.215 0.8230
Cholesterol 0.0259
Cl- 3.55 0.2817
Glucose 0.0555
HCO3- 6.1 0.1639

Celsius to Fahrenheit: (°C x 1.8) ÷ 32

Fahrenheit to Celsius: (°F – 32) / 1.8
 GASTROENTEROLOGY

DIARRHEA

4 Major Mechanisms of Action:

1. Poorly absorbable osmotically active substances in lumen

2. Intestinal ion secretion
3. Outpouring into the lumen of blood, mucus
4. Derangement of intestinal motility

Management: rehydration therapy depending on degree and type of dehydration

WHO Tx PLAN A for Mild or No Dehydration:

• Treat at home; educate mother

• Give more fluids and food than usual
- may dilute mild formula for children < 6 months
- may add 1 – 2 tsp oil to solid food for older children
• Replace losses w/ ORS according o the ff table:

Age Amt of ORS after each loose Amt of ORS to provide for
stool use @ home
<24 mo 50 – 100 mL 500 mL/day
2 – 10 yrs 100 – 200 mL 1,000 mL/day
10 yrs or more As much as wanted 2,000 mL/day
Tx PLAN B for Moderate or Some Dehydration:

Approximate amt of ORS to give in the 1st 4 hrs

Age <4 mo 1 – 11 mo 12 – 23 mo 2–4y 5 – 14 y

Wt (kg) <5 5 – 7.9 8 – 10 11 – 15.9 16 – 29.9

Amt (mL) 200 – 400 400 – 600 600 – 800 800 – 1,200 1,200 – 2,200

• Alternative formula: 75 mL ORS / kg BW

• Reassess after 4 hrs to change plan or continue treatment

Tx PLAN C for Severe Dehydration

• Start IVF. Give 100 mL/kg LRS/ NSS divided as follows:

Age First, Give 30 Then give 70

mL/kg mL/kg
Infants (< 12 mo) In 1 hr In 5 hrs
Older 30 min 2 ½ hrs

• Reassess q 1 – 2 hrs. May repeat once if radial pulse is still weak.

• As soon as they can drink, give ORS @ 5 mL/kg/hr
• If IV therapy not available, give ORS PO/NGT @ mL/kg/hr for 6 hrs

Dysentery: bloody and mucoid diarrhea, w/ tenesmus / cramping

 Antimicrobial Agents for Specific Causes of Diarrhea

Antibiotic of choice Alternative

Tetracyclin* 12.5 mg/kg Furazolidone 1.25 mg/kg QID x 3d,

Cholera
QID x3 d or TMP/SMX 8/40 mg/kg BID x 5 d

Shigella TMP/SMX 8/40 mg/kg BID Nalidixic acid 15 mg/kg QID x 5d, or
dysentery x 5d Ampicillin 25 mg/kg QID for 5d

Very severe cases: Dehydroemetine

Metronidazole 35 mg/kg
Amoebiasis hydrochloride/IM 1 – 1.5 mg/kg OD
TID x 5d (10d for severe)
x 5d; max: 90 mg

Metronidazole 15 mg/kg
Giardiasis Quinacrine: 2.5 mg/kg TID x 5d
TID x 5d

• Limited indication in childhood d/t interference w/ growth

 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.
 JAUNDICE
• Yellow discoloration of skin w/ serum bilirubin levels > 5 mg/dL in neonates; > 2 mg/dL in older
children
• Physiologi jaundice (Refer to Changes in the newborn)
Criteria for Pathologic Jaundice
1. Clinical jaundice in 1st 24 hrs or after 1st wk
2. Total serum bilirubin > 12 mg/dL (Term); > 15 mg/dL (Pre-term)
3. ↑ in total serum bilirubin > 5 mg/dL/day (85 umol/L/d)
4. Direct bilirubin > 2 mg/dL (34 umol/L) or 15% of TB
5. Lasting for more than 1 wk (Term), 2 wks (Pre-term)
Breastfeeding Jaundice
• D/t 5B-Pregnane-3a, 20B-diol or Non-esterified long chain fatty acid which competitively inhibits
glucoronyl transferase
• Onset: 4 – 7 days; Peak: 2nd – 3rd wk; Wane: 3 – 10 wks
• Tx: Discontinue breastfeeding for 1 -2 days

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
 PHYSIOLOGIC vs PATHOLOGIC
FACTORS PHYSIOLOGIC PATHOLOGIC
Onset > 24 hrs of life < 24 hrs of life
Rate of inc of TSB < 0.5mg/dl/hr > 0.5mg/dl/hr
Persistent < 14 days FT: > 8 days
PT: > 14 days
Total S. Bilirubn FT: < 12 mg/dl Any level requiring
PT: < 14 mg/dl phototherapy
Sign/ Symptom Vomiting, lethargy, poor feeding, excess wt loss, apnea,
inc RR, temp instability
BREAST FEEDING vs BREASTMILK JAUNDICE
Parameter BREASTFEEDING BREASTMILK
Onset 3rd to 5th day of life Late; start to rise on day 4; may reach 20 – 30 mg/dl on
day 14 then ↓ slowly Normal by 4 – 12 weeks
Pathophysio Decrease milk intake → Unknown
↑enterohepatic Prob. due to β – glucoronidase in BM which ↑
circulation enterohepatic circulation
Normal LFT; (-) hemolysis
Mngt Fluid and If breastfeeding is stopped, rapid decrease in bilirubin
caloricsupplement level in 48 hrs, if resumed will rise to 2 – 4 mg/dl but no
precipitating previous events
Bilirubin (Total)
Cord
Preterm Term <2 mg/dl <34 µmol/L
<2 mg/dl <34 µmol/L
0 – 1 days
Preterm Term <8 mg/dl <137 µmol/L
<8.7 mg/dl <149 µmol/L
1 – 2 days
Preterm Term <12 mg/dl <205 µmol/L
<11.5 mg/dl <197µmol/L
3 – 5 days
Preterm Term <16 mg/dl <274 µmol/L
<12 mg/dl <205µmol/L
Older Infants
Preterm Term <2 mg/dl <34 µmol/L
<1.2 mg/dl <21 µmol/L
Adult 0.3 – 1.2 mg/dl 5 – 12 µmol/L
Bilirubin (Conjugated)
Neonate <0.6 mg/dl <10 µmol/L
Infants/Children <0.2 mg/dl <3.4 µmol/L
 JAUNDICE
Total bilirubin > 12 mg/dL and infant < 24 hrs old

Coomb’s Test Positive Coomb’s Test Negative

• Immune – mediated hemolysis
• ABO/Rh Incompatibility

Direct Bilirubin > 2 mg/dL Direct Bilirubin < 2 mg/dL

Conjugated Hyperbilirubinemia Unconjugated
• Intrahepatic: Viral (hepa, Hyperbilirubinemia
TORCH); Genetic/Metab (Dubin,
Rotor)
Hct Normal Hct High
• Exttrahepatic: Biliary atresia,
or low • polycythemia
Choledocal cyst, etc.

Abnormal RBC morphology & High Normal RBC morphology & High
reticulocyte count reticulocyte count
• Hemolytic process: red cell • Swallowed blood; ↑
defects (Spherocytosis, etc); drug enterohepatic circulation; breast
rxn (Pen, sulfonamides); DIC milk; DO of bilirubin metab
(Gilbert, Crigler); Endocrine;
bacterial sepsis
 Kramer’s Classification (Cephaolpedal Progression)
Zone Jaundice Areas Serum bilirubin (mg/dL)
I Head / neck 6–8
II Upper trunk 9 – 12
III Lower trunk / thigh 12 – 14
IV Arms / legs / elbows / knees 15 – 18
V Hands / Feet > 18
Kernicterus
• Sequelae d/t non – albumin bound unconjugated bilirubin depositing on the basal ganglia starting
@ 15 – 20 mg/dL
• Increased by ↓albumin binding and ↑ free bilirubin diffusion
• Manifested by poor suck, hypotonia, ↓ sensorium

Treatment of Jaundice in Healthy Term Infats w/o Hemolysis

Tx Strategies
Age (hr) Phototherapy* Photo tx & Prepare ET Exchange Transfusion
24 – 48 ≥ 15 – 18 ≥ 25 ≥ 20
49 – 72 ≥ 18 – 20 ≥ 30 ≥ 25
> 72 ≥ 20 ≥ 30 ≥ 25
* ↓ bilirubin by 1 – 2 mg/dL in 4 – 6 hrs; give IVF @ 1.5x maintenance
Treatment of Hyper bilirubinemia
Phototherapy
Exchange o Complications: metabolic acidosis, electrolyte abnormalities, hypoglycemia,
transfusion hypocalcemia, thrombocytopenia, volume overload, arrhythmias, NEC, infection,
graft versus host disease, and death
IV Ig o Adjunctive treatment for hyperbilirubinemia due to isoimmune hemolytic
disease
o (0.5–1.0 g/kg/dose; repeat in 12 hr)
o Reducing hemolysis
Metalloporphyrins o 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
o 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
Photo-isomerization reaction converting the toxic native unconjugated 4Z, 15Z-
o
bilirubin 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
• 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

PULMONOLOGY
ASTHMA
Symptom pattern: cough, recurrent wheeze/ dyspnea/ chest tightness occurring or worsening @ night/
early am
Risk factors: male, atopy, smoke exposure, maternal history
Objective measure: • Confirmatory test:
• Peak expiratory flow rate: NV: > 80% for age and 1. Chest X-ray: air trapping, ↑ lung
height markings
• PEF reversibility = post – prebronchodilator x 100% 2. Pulmonary function test (spirometry,
prebronchodilaor peak flow meter)
* definitive dx of asthma: PEF (FEV1) ↑ of 15% or 3. Bronchoprovocation test:
greater, 15 – 20 min after inhaled B2 agonist methacholine, exercise, cold air
• PEF variability = PM, postdilator – AM, predilator x 4. Diurnal variation determination
100 5. Therapeutic trial of steroids and
½ (PM, postdilator + AM, predilator) bronchodilators (x 5d)
* NV: should be less than 20%
Treatment:
• Relievers (“rescue agents”): for symptomatic tx of bronchospasm w/ rapid onset (15 – 30 mins); 4 –
6 hr relief
- short – acting B2 agonist; salbutamol, terbutaline, albuterol
- ipratropium bromide (cholinergic antagonist)
- short – acting Theophylline
- Prednisone, prednisolone, methylprednisolone
• Controllers: longer duration of action (12 – 24 hrs) but slow onset; not a substitute for anti –
inflammatory therapy
- long – acting B2 agonist: Salmeterol, Bambuterol
- long – acting Theophylline
- Cromolyn Na (prophylactic anti – inflammatory)
- Inhaled corticosteroids
- Anti - leukotrienes

LEVELS OF ASTHMA CONT ROL [GINA GUID ELINES]

CONTROLLED PARTLY UNCONTROLLED
Daytime symptom None [2x or less/week] More than 2x a week Three or more
Limitation of activities None Any features of partly
Nocturnal sx/awakening None Any controled asthma
Need for reliever/recue tx None More than 2x a week present in any week
Lung function (PEF OR Normal 80%
FEV1) predicted
Exacerbation None One or more/yr One in any week
 CLASSIFICATION AND TX OF ASTHMA (Children over 5 yrs and adults)

Intermittent Persistent

Step 1 Mild (Step 2) Moderate (Step 3) Severe (Step 4)

Brief Affects activity & Affects activity & Limits activity &
Exacerbation sleep sleep sleep

< 1x / wk ≥ 1x / wk but not Daily Continuous

Daytime sx daily

≤ 2x / wk >2x / mo >1x / wk Frequent

Nighttime sx
≥ 80% ≥ 80% 61 – 79% ≤ 60%
PEFR predicted
< 20% 20 – 30% >30% >30%
PEF variability
Oral / inhaled short – Inhaled short – acting B2 – agonist, prn, not Inhaled short –
Quick relief acting B2 – agonist, to exceed 3 – 4x/d acting B2 – agonist,
prn prn
(relievers)
Inhaled steroids 200 Inhaled steroids ≥ Inhaled steroids >
– 500 ug/day or 500 ug + long – 800 ug + long =
Long – term / Cromolyn, acting; B2 – agonist, acting: B2 – agonist,
daily meds Nedocromil or theophylline ± anti or theophylline + oral
Theophyllin – leukotriene steroids
(controllers)
 For children 5 yrs and younger
Quick relief: same as above w/ option for inhaled or oral ipratropium bromide
Step 1 Mild (Step 2) Moderate (Step 3) Severe (Step 4)
Inhaled steroids* 200 Inhaled steroids ≥ Inhaled steroids >
– 400 ug/day or 400 ug or nebulized 1 mg or Nebulized
Long – term /
Cromolyn Na budesonide ≤ 1 mg budesonide > 1 mg
daily meds BID BID ± oral steroids
(low dose)
* Inhaled steroids: use MDI w/ spacer and face mask or nebulizer
CLINICAL FEATURES OF ASTHMA EXACERBATION
Mild Moderate Severe Arrest imminent
Breathless Walking Talking At rest
while… Infant: difficult Infant: stops
feeding feeding
Position Can lie down Prefers sitting Hunched forward
Talks in… Sentence Phrases Words
Alertness May be agitated Usually agitated Usually agitated Drowsy / confused
RR ↑ ↑ Often > 30 min
Guide to normal RR:
Age Normal rate Age Normal rate
< 2 mo < 80 / min 1 – 5 yo < 40 / min
2 – 12 mo < 50 / min 6 – 8 yo < 30 / min
 Mild Moderate Severe Arrest imminent

Accessory M. & Usually none Usually present Usually present Paradoxical thoracoabdominal
retractions movement

Wheeze Mod, end – Loud Usually loud None

expiratory

PR / min < 100 100 – 120 >120 Bradycardia

normal PR: infant (2 – 12 mo) < 160/min pre-school (1-2yr) < 120 / min school age (2 – 8 yr) < 110 / min

Pulsus paradoxus Absent Present Present Absence suggests respiratory

< 10 mmHg 10 – 20 mmHg 20 – 40 mmHg fatigue

PEFR % predicted >70% 60 – 70% 50%

PaO2 Normal 60 – 80 mmHg < 60 mmHg possible cyanosis

PaCO2 ≤ 45 mmHg ≤ 45 mmHg 45 mmHg possible respiratory failure

SaO2 >95% 90 – 95% < 90%

 BRONCHIAL ASTHMA
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) 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.
 MANAGEMENT APPROACH BASED ON CONTROL
Step 1 Step 2 Step 3 Step 4 Step 5
PRN B2 Asthma education and Environmental control
agonist As needed rapid acting B2 agonist
Select one Select one Add one or Add one
more or more
C O N T R Low dose Low dose Med to Hi Oral
O L L E R ICS ICS + LABA dose ICS + LABA steroids
Leukotriene Medium or Leukotriene
modifier Hi dose ICS Low dose Modifier Sustained Anti IgE
ICS + Release treatment
Leukotriene theophylline
Modifier Low dose
ICS +
Salbutamol
Release theophylline

PULMONARY TUBERCULOSIS a S/S: cough / wheezing / fever > 2 wks

failure to return to normal health after an
Classification
infection
Exposure S/Sa CXR PPD Labs painless cervical & / or other
I: Exposure + - - - - lymphadenopathy
poor wt gain
II: Infection +/- - + - - failure to respond to appropriate antibiotic
III: Diseaseb + + + + +c therapy
b Active TB must have 3 or more out of the 5 criteria
IV: Inactive +/- - +d + - c Positive culture w/ or w/o a smear is the gold

standard
d Radiographic of healed or calcified TB
 Diagnosis & Prevention
Tuberculin skin test (Manteux tech, purified protein derivative):
1. 0.1 mL or 5 TU intradermally on volar surface of forearm to form a 6 – 10 mm wheal, read after 48 –
72 hrs
2. Induration, not erythema, read crosswise to forearm axis
3. Positive if > 5 mm (HIV+, contact to active TB, healed)
> 10 mm (all others)
Bacille Calmette-Guerin (BCG) Vaccination Reaction
Accelerated BCG Normal BCG
Induration 2 – 3 days 2 – 3 wks
Pustule formation 5 – 7 days 4 -8 wks
Scar formation 2 – 3 wks 8 – 12 wks
Treatment
Drug / Preparation Dosage (mg/kg) Side effects
≤ 12 yo ≥ 12 yo
Isoniazid (H)a 5 – 10 5 Hepatotoxicityd
100 & 200 mg/5mL) (max 300 mg) (max 300 mg)

Rifampicin (R)b 10 – 15 10 Hepatotoxicity

100 & 200 mg/5mL (max 600 mg) (max 600 mg)

Pyrazinamide (P)c 15 – 30 15 – 30 Arthralgia d/t ↑ uric acid

250 mg/5mL (max 2 g) (max 2 g)
Ethambutol (E) 15 – 25 1st 2 mo 15 – 25 Retrobulbar neuritise
200 & 400 mg tab then 15 (max 2.5 g)
Streptomycin (S) 20 – 30 15 Nephrotoxicity
1 g vial (max 1 g) (max 1 g) Ototoxicity
a Best on an empty stomach (30 min before or 2 hrs after meals); given w/ Pyridoxine / Vit B6; storage temp < 37°C
b Best on an empty stomach; at the same time as H
c Best absorbed on a full stomach
d Requires monitoring of liver function tests in severe TB;

if elevated 2 – 3x the normal: Do not discontinue drug

if > 3x normal: Discontinue drug
e Do visual acuity & red – green color discrimination tests

UPPER AIRWAY INFECTIONS

CROUP EPIGLOTTITIS* TRACHEITIS
Age 3 mo – 5 yrs 2 – 7 yrs 2 mo – 6 yrs
Etiology Viral, usually parainfluenza H. Influenzae Gradual; 2 – 3 days
Fever Low grade High grade High grade
Resp. Distress Mild – moderate Severe Severe
Position Prefers sitting up perched, neck extended May have preference
Improves with aerosolized No response to racemic No response to racemic
Stridor racemic epi epinephrine epinephrine
“steeple sign” on AP view “thumbprint sign” on lateral Subglottic narrowing
CXR view

Tx Epinephrine, steroids Intubate, IV antibiotics Antibiotics

* May cause life – threatening obstruction. Do not examine throat!
 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
 ETIOLOGY OF PNEUMONIA ACCORDING TO AGE
Age Common Pathogen
0 – 48 hrs Group B – Streptococcus
1 – 14 days E. coli, Klebsiella, Enterobacteriaceae, Listeria, S. aureus, Anaerobes, Group
B – Streptococcus
2 wks – 2 mo Enterobacteriaceae, Group B – Streptococcus, S. aureus, C. albicans, H.
influenza, Strep. pneumoniae
2 mo – 5 yrs H. influenza, Strep. Pneumoniae
5 – 21 yrs Strep. Pneumoniae, M. pneumoniae

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
CXR in assessing CAP etiology
Alveolar infltrates Bacterial pneumonia
Interstitial infiltrates Viral pneumonia
Both infiltrates Viral, Bacterial or mixed viral bacterial pneumonia
 PNEUMONIA IN INFANTS LESS THAN 2 MO

Clinical signs Classify as Summary of tx

No fast breathing: < 60 min ADVISE HOME CARE

No chest indrawing
NO PNEUMONIA
Cough / Cold

Fast breathing*: > 60 / min ADMIT

Severe chest indrawing Give antibiotic: Benzyl Penicillin + Gentamicin IM,
IV
SEVERE PNEUMONIA

Central cyanosis, poor feeding, ADMIT

wheezing, stridor in a calm child, Give antibiotic: Benzyl Penicillin + Gentamicin IM,
convulsions, abnormally sleepy IV
VERY SEVERE
PNEUMONIA

• Tachypnea: most predictive sign of Pneumonia

 PNEUMONIA IN INFANTS & CHILDREN (2 MO – 5 YO)
Clinical signs Classify as Summary of tx
No fast breathing: If coughing > 30 days, assess for causes of chronic
< 50 / min if 2 mo – 1 yr NO cough
< 40 / min if 1 – 5 yrs PNEUMONIA Assess or treat ear problem or sore throat, if present
No chest indrawing Cough / Cold ADVISE HOME CARE
Treat fever and wheezing, if present
No fast breathing: ADVISE HOME CARE
< 50 / min if 2 mo – 1 yr Give antibiotic: Cotrimoxazole PO, Amoxicillin,
< 40 / min if 1 – 5 yrs Ampicillin or Procaine Penicillin
PNEUMONIA
No chest indrawing Treat fever and wheezing, if present
Advise to return in 2 days for reassessment or earlier if
child gets worse
Chest indrawing ADMIT
No central cyanosis Give antibiotic: Benzyl Penicillin IM, IV
SEVERE
Able to drink Treat fever and wheezing, if present; give supportive
PNEUMONIA
care
Reassess daily to upgrage or downgrade dx & tx
Central cyanosis, inability to ADMIT, Give oxygen
feed or drink, stridor in a Give antibiotic: Chloramphenicol IM, IV
calm child, convulsions, Treat fever; supportive care
VERY SEVERE
abnormally sleepy, severe Reassess twice daily
PNEUMONIA
undernutrition If getting worse after 48 hrs on chloramphenicol shift
to Cloxacillin + Gentamicin for suspected Staph.
Pneumonia
 PCAP
VARIABLE PCAP A PCAP B PCAP C PCAP D
Minimal Risk Moderate Risk
Low Risk High Risk
Comorbid Illness None Present Present Present
Compliant caregiver Yes Yes No No
Ability to follow up Possible Possible Not Not
Presence of dehydration None Mild moderate Severe
Ability to feed Able Able Unable Unable
Age >11 mos >11 mos <11 mos <11 mos
RR >50/min >50/min >60/min >70/min
2 – 12 mos >40/min >40/min >50/min >50/min
1 – 5 yo >30/min >30/min >35/min >35/min
>5 yo
Signs of Respiratory Failure
Retractions - - Subcostal/ Subcostal/
Intercostal Intercostal
Head babbing - - + +
Cyanosis - - + +
Grunting - - - +
Apnea - - - +
Sensorium None Awake Irritable Lethargy /
Stupor
Coma/
Complication: Effusion None None Present Present
Pneumothorax
Action Plan OPD OPD Admit to regulat Admit to CCU
f/u at end of tx f/u after 3 days Refer to specialist
ward
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
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

Therapeutic Mgt of CAP

OPD Mngt
Birth to 20 days Admit
3 weeks to 3 months Afebrile: Oral Erythromycin (30-40mkd) Oral Azithromycin (10
mg/kg/day) day 1
5mkday day2 to 5 Admit: febrile or toxic
4 months to 4 yo Oral Amoxicillin (90mkd/3doses) Alternative: Amox-Clav, AZM, Cefaclor
Clarithromycin, Erythromycin
5 years to Oral Erythromycin (30-40mkd)
15 years Oral AZM 10mkday day 1, 5mkday day 2-5
Clarithromycin 15mkday/2 doses Pneumococcal infxn: Amoxicillin alone
IN-PATIENT
Birth to 20 days Ampicillin + Gentamicin w or w/o Cefotaxime
3 weeks to 3 months Afebrile: IV Erythromycin (30-40mkd) Febrile: add Cefotaxime 200mkd
Cefuroxime 150 mkd
4 months to 4 yo If w/ pneumococcal infection:
IV Ampicillin (200mkd) Cefotaxime 200mkd Cefuroxime 150 mkd
5 years to Cefuroxime 150 mkd + Erythromycin 40mkd IV or orally for 10-14 days
15 years If pneumococcal is confirmed: Ampicillin 200mkd
 NEUROLOGY
NEUROLOGICAL EXAMINATION

Mental status, cognitive function, level of aletness

Examine the head

• Size, circumference, shape, tension of fontanels

• Palpate, auscultate and transilluminate cranium

Examine 12 cranial nerves

Motor examination

• Muscle strength, tone & bulk

• Locomotion and motility
• Deep tendon, abnormal and primitive reflexes

Sensory examination

Gait and Station

Soft neurologic signs:

• Form of deviant performance on motor or sensory tests, abnormal for a particular age
• Repetitive and successive finger mov’ts, arm pronation – supination movements, hopping tandem
walking, hand pats and foot taps
 PEDIATRIC GLASGOW COMA SCALE (PGCS)
>1yr < 1yr Score
Spontaneous Spontaneous 4
To voice To voice 3
Eye opening
To pain To pain 2
None None 1
Obeys commands Normal, spontaneous 6
Localizes pain Withdraws to touch 5
Withdraws Withdraws to pain 4
Motor response
Abn. Flexion Abn. Flexion 3
Abn. Extension Abn. Extension 2
None None 1
>5yr 2-5yr 0-23mos Score
Appropriate words Smiles/coos appropriately
Oriented 5

Confused Inappropriate words Irritable 4

Verbal Persistent cries and Cries to pain
Inappropriate words screams 3

Incomprehensible words Grunts Moans to pain 2

None None None 1
 BRAINSTEM AND CORTICAL FXN IN INTUBATED PATIENTS
Brainstem function Score Cortical function Score
Normal pupillary, corneal, oculovestibular 3 Spontaneous movement 6
and oculocephalic reflex Move to command 5
Some absent Localizes pain 4
All absent 2 Withdraws 3
All absent and apneic 1 Decorticate 2
0 Decerebrate 1
Flaccid 0

LUMBAR PUNCURE
• Done at L3 – L4 or L4 – L5 using a G18 – 22 beveled spinal needle, in a flexed lateral
position

• Contraindications:
1. Raised ICP d/t mass lesion ---- herniation
2. S/S of pending cerebral herniation: gen. seizure, abN pupil size & rxn, (-) oculocephalic
response, apnea
3. Critically ill, moribund patient at risk of CR arrest
4. Skin infection at the site of LP
5. Thrombocytopenia (< 20 x 109/L)
 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
 CSF ANALYSIS
Color Rbc Wbc Diff sugar CHON
ct
Normal
Infant Xantho 0- 0 -32 L 70 - 60 -
(Term) 100 100% 80% 150
Infant Clear 0- 0 -15 L 70 - 60 -
(Preterm) 100 100% 80% 200
Older Clear 0 0 -10 L > 10-20
child 100% 50%
Viral Clear 0 0 -20 L 40- 40 -60
Mening 100% 60%
TB/Fungal Clear 0 20 - L >N < > 100
500 40% g%
Bacterial Purulent 0 > N >L < > 100
Mening 1000 50% g%
Partially Clear 0 100 L >N > Dec
tx BM 50%
 CSF FINDINGS IN VARIOUS CNS DISORDERS ASSOCIATED WITH FEVER
Condition Pressure Leukocytes per Protein Glucose Comments
(mmH2O) mm3 (mg/dL) (mg/dL)
Normal 75% lympho CSF / Bld glucose Ratio
0.74 – 0.98
Neonate 10 – 40 0 – 32 20 – 150 34 – 119 >0.75
Infant 85 – 110 0 – 10 15 – 45 40 – 80 >0.75
Children 60 – 150 0–5 15 – 45 40 – 80
Acute Usually 100 – 60,000 100 – 500 ↓ to < 40 ± on gram stain and culture
bacterial elevated PMNs predominate mg/dL; ↓
meningitis CSF:RBS ratio
Partially Normal or 1 – 10,000 PMNS 100+ Depressed or CSF sterile if pre-treated in patients
treated elevated usual but if treated, normal with pneumococcal and
bacterial mononuclear cells meningococcal disease, but not with
meningitis predominate H. influenza
Tuberculous Usually 10 – 500; PMNa 100 – 500; <50 mg/dL; ↓ ± on acid – fast smear & culture;
meningitis elevated early but higher if w/ time if tx india ink preparation may be
lymphocytes blocked is not positive in cryptococcal disease
predominate provided
Fungal Usually 25 – 500; PMNs 25 – 600 <50 mg/dL; ↓ ± budding yeast cells & culture;
Meningitis elevated early but w/ time if tx india ink preparation may be
mononuclear cells is not positive in cryptococcal disease
predominate provided
Viral Normal or Rarely > 1000 cells; 50 – 200 Usually Enteroviruses may be recovered
Meningitis slightly PMNs early but normal; may from CSF by appropriate viral
or meningo- elevated mononuclear cells be ↓ to < 40 cultures
encephalitis predominate mg/dL in
mumps
Condition Pressure Leukocytes per mm3 Protein Glucose Comment
(mmH2O) (mg/dL) (mg/dL)
Chemical Usually 100 – 1,000; PMNs 50 – 100 20 – 40 Dermoids; ± Epithial cells seen with
(dye, drugs, elevated predominate mg/dL use of polarized light
dermoids)
Brain abscess Usually 10 – 200; 75 – 500 Normal unless No organism on smear or culture
elevated lymphocytes abscess unless abscess ruptures into
predominate; if ruptures into ventricular system
ruptured, count ↑ to ventricular
> 100,000; ↑ PMNs systems
Collagen – Slightly 0 – 500; PMNs may 100 Normal or No organism on smear or culture; LE
vascular elevated predominate; ± slightly preparation may be positive
disease lymphocytes depressed
EMPIRIC THERAPY FOR BACTERIAL MENINGITIS

Age Etiology Primary Alternative Dosage (mg/kg/day)

0 – 2 mo E. coli, GBS, Listeria, Ampicillin or Ampicillin + Ampicillin: 300 – 400 q 8 hrs

Gram (-) enteric bacilli penicillin + cefotaxime or Cefotaxime: 200 q 6 hrs
aminoglycoside ceftriaxone Ceftriaxone: 100 q 12 hrs
Ceftazidime: 150 q 8 hrs
2 mo – 5 yrs H. influenza, S. Ampicillin + cefotaxime or
Chloramphenicol: 50 – 100 q 6
pneumoniae, N. chloramphenicol ceftriaxone
hrs
meningitides
Cotrimoxazole: 20 q 6 hrs
6 – 18 yrs S. pneumoniae, N. Penicillin Chloramphenicol Gentamycin: 4 q 8 hrs
meningitides or ceftriaxone
Immunodeficient S. aureus, S. epidermidis, ampicillin + Cotrimoxazole + Pen G: 300,000 U/kg/day q 4 – 6
S. pneumoniae, ceftazidime ± ceftazidime ± hrs
Salmonella, P. aminoglycoside aminoglycoside
aeruginosa, Listeria
 TREATMENT APPROACH TO BACTERIAL MENINGITIS

Intracranial Pressure Measurement

Scan
results NORMAL INCREASED

None Hyperventilate to decrease cerebral blood

Normal volume

Restrict fluids Don’t hyperventilate;

Edema Use furosemide or mannitol

None; resolves Ventricular tap or drain CSF; Acetazolamide;

spontaneously ↓ CSF production; Steroids: ↑ CSF
Hydrocephalus reabsorption

Subdural None; resolves Subdural drainage

spontaneously
effusion
Improve perfusion by Steroids: ↓ peri – infarct edema;
increasing BP; Steroids: ↓ Barbiturates: to ↓ brain metabolism activity
Infarct vasculitis
 DURATION OF TREATMENT OF BACTERIAL MENINGITIS
Pathogen Duration (days)
H. Influenzae 7 – 10
S. Pneumoniae 10 – 14
N. Meningitidis 5–7
Grp B streptococci 14 – 21
Gram negative bacilli 21 days – 3 wks
SEIZURE
Algorithm For Determining Seizure Cause

SEIZURE
Afebrile
Febrile

History:
BFC / CFC CNS Infection • Drug intake
• Trauma

Meningitis: Encephalitis Brain Abscess PE:

• Aseptic • Jap B • Anaerobes • Neurocutaneous
• Purulent • Enterovirus • Staph. infxn
• TB • Varicella Labs:
• Fungal • Hgt, Electrolyte
• Screen for toxic
substances
 International Classification of epileptic seizures
1. Partial (focal/local) seizures
A. Simple partial – consciousness not impaired
B. Complex partial – consciousness impaired
C. Partial seizures evolving to secondarily generalized seizures

2. Generalized Seizures (convulsive or non-convulsive)

A. Absence seizures
B. Myoclonic seizures
C. Clonic seizures
D. Tonic seizures
E. Tonic – Clonic seizures
F. Atonic seizures

3. Unclassified Epileptic Seizures

Simple Complex

Type GTC Focal then gen post ictal

Duration < 15 min > 15 min or may go into

 status

Recurrence None Recurrent (w/in 24H)

CNS exam Normal Abnormal
Sequelae None Neurodev abn

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
 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 O 2 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.
 COMMON ANTICONVULSANT DRUGS
Drug Seizure Type Side Effects and Toxicity
Sedating
Carbamazepine (tegretol) Generalized tonic – clonic Dizziness, nausea and vomiting, liver dysfunction,
10 mg/kg/d q 8 – 12 h partial anemia, ↓ WBC & Platelet
Clonazepam (Rivotril) Absence; partial; Irritability, behavioral abN, depression, excessive
0.05 mg/kg/d q 8 h myoclonic; infantile spasm salivation
Ethosuximide (Zarontin) Absence Abd dc, skin rash, liver dysfxn, leukopenia, aplastic
20 mg/kg/d q 12 – 24 h anemia
Gabapentin (Neurontin) Complex partial; Somnolence, dizziness, ataxia, headache, tremor,
secondarily generalized vomiting, nystagmus, fatigue
Phenobarbital (Luminal) Tonic – clonic; partial Hyperactivity, sedation, nystagmus, ataxia
3- 5 mg/kg/d q 8 – 12
Nonsedating
Phenytoin (Dilantin) 5 Tonic – clonic; partial Rash, nystagmus, ataxia, drug-induced lupus,
mg/kg/d q 8 – 12 h anemia, leukopenia, polyneuropathy
Valproate (depakene) 10 Tonic – clonic; absence, Hepatotoxicity, n/v, abd pain, anemia, ↓ WBC &
mg/kg/d q 8 – 12 h partial Platelet
STATUS EPILEPTICUS
• Continuous clinical or EEG seizures lasting for at least 30 mins or recurrent seizures without return of
consciousness during interictal period, lasting for more than 30 mins
 ANTICONVULSANT
DIAZEPAM 0.2 – 0.3 mkdose
Drip: 1amp in 50cc D5W 10mg/amp
MIDAZOLAM 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
PHENOBARBITAL 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
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
Dilantin Tab: 50mg 100mg TID
Extended release caps 30, 100, 200, 300 mg OD, BID ; Inj: 50 mg/ml
CARBAMAZEPINE
Tegretol Tab 200mg, 100mg chew
XR 100mg, 200mg, 400mg Susp 100mg/ 5ml (QID)
Initial Increment Maintenance
< 6 yo 10 - 20 mkD BID /TID q wkly til 35 mkD
6 - 12 yo 10 mkD BID 100 mg/ 24H at 20 - 30 mkD
1 wk interval BID/ QID
> 12 y 200 mg BID 200 mg/ 24H at 800 - 1200 mg/24
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 150 mg 300mg 600 mg
Susp 300mg/5ml
VALPROIC ACID 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
Depakene Tab 250 mg
Syr 250mg/5ml
Depacon IV 100mg/ml

TOPIRAMATE 2 - 16 yo
Initial: 1 - 3 mkd PO q HS x 7 days increase
then Increment: for 1 - by 1 - 3 mkday
2 wks then
Maintenance: 5 -9 mkD BID
Topamax Cap 15 mg, 25 mg
Tabs 25 200mg 50 100
 Treatment Algorithm For Status Epilepticus
Time Action Medications
0–5 Ensure airway and cardiovascular Diazepam
mins fxn Dose: 0.2 – 0.4 mg/kg, SIVP
Oxygen, v/s 0.3 – 0.5 mg/kg, rectal
IV line: D5NSS / D50.5 @ 75% Rate: 1 – 2 mg/min
maintenance Max: 10 mg
CBC, Na, K, ABG, Hgt Repeat 1x q 15 - 20 min

6–9 If hypoglycemia, give Lorazepam

mins • Glucose bolus @ 2 – 4 mL/kg, Dose: 0.05 – 0.1 mg/kg SIVP; SL
25% glucose solution, or Rate: 1 – 2 mg/min
• Rapid infusion @ 5 mL/kg, 10% Max: 4 mg single dose ; 8 mg total
gluc soln Repeat 2x q 15 - 20 min

10 – 20 Monitor Phenytoin
mins Loading: 15 – 20 mg/kg SVP
Rate: 1 – 3 mg/min
Max: 1 gm
Maintenance: 5 – 8 mg/kg/day divided q 12h
Fosphenytoin (Water-soluble)
Dose: 20 mg/kg IV or IM
Rate: 50 – 100 mg/min

Diazepam should not be given IM or diluted with any fluid

Phyenytoin and Phenobarbital crystallize in dextrose solution
Paraldehyde not compatible with plastic containers
21 – 60 Support respiration and/or Phenobarbital b
mins intubate Loading: 10 – 20 mg/kg IV
Rate: 1 mg/kg/min
Refer to anesthesiologist Max: 800 mg
Admit @ ICU Maintenance: 3 – 5 mg/kg/day divided q 12 – 14 hrs
5% Paraldehyde c
Loading: 150 – 200 mg/kg IV over 15- - 20 min
Maintenance: 20 mg/kg/hr
ACUTE SUBDURAL vs EPIDURAL BLEEDS
SUBDURAL EPIDURAL
Location Between dura and arachnoid Between the skull and the dura
layers
Symmetry Usually bilateral Usually unilateral
Etiology Rupture of cortical bridging Rupture of dural veins or middle meningeal
veins artery
Typical injury Direct trauma or shaking Direct trauma in the temporal area
Consciousness Intact but altered Impaired – lucid – impaired
Common assoc. findings Seizures; retinal hemorrhages Ipsilateral papillary dilatation, papilledema,
contralateral hemiparesis
CT (contrast) Crescenteric Biconcave
Prognosis High morbidity; low mortality Low morbidity; high mortality
Complications Herniation Skull fracture; uncal herniation
 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.
 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]
 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
✓

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
2. Athetoid –worm like side/portion]
3. Rigid 2. Paraplegia
4. Ataxic 3. Hemiplegia
5. Tremor 4. Triplegia [3 limbs]
6. Atonic 5. Quadriplegia [all]
7. Mixed 6. Diplegia [LE/UE]
8. unclassified 7. Double hemiplegia
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
 INFECTIOUS
DENGUE HEMORRHAGIC FEVER
Clinical Criteria:
1. fever: 2 – 7 days, regardless of character
2. Hemorrhagic manifestations:
a. (+) tourniquet test: Wintrobe’s mtd (> 20 petechiae / inch2) Serotype 1, 2, 3, & 4
b. Mucocutaneous bleeding Aedes egypti
c. GI bleeding d. thrombocytopenia (<100,000/mm3) IP: 4 – 6 d (min 3 d; max 10 d)
Laboratory Criteria:
1. Evidence of consumptive coagulopathy
a. Decreased platelet count (<150,000 cumm)
b. Prolonged BT (Ivy mtd: N = 2 – 5 min)
c. Prolonged PT (F II, V, VII, X, fibrinogen)
d. Prolonged PTT (F II, V, VIII, IX, XI, XII, fibrinogen)
2. Steadily increasing hematocrit (20% or more) in spite of proper hydration or increased vascular
permeability.
Dengue Shock Syndrome
DHF Criteria + Evidence of Circulatory Failure:
• Violaceous, cold, clammy skin
• Restlessness, weak to imperceptible pulses
• Narrowing of pulse pressure to ≤ 20 mmHg
• Hypotension
 Grading of Severity of DHF Age – related Hypotension w/ > 25 % blood loss
I Fever <4 yrs <65 mmHg systolic BP
Non – specific constitutional symptoms
(anorexia, vomiting, abdominal pain)
(+) Tourniquet test
II Grade I + spontaneous bleeding 5 – 8 yrs <75 mmHg
III Grade II + severe bleeding + circulatory 9 – 12 yrs <85 mmHg
failure
IV Grade III + Irreversible shock + massive Adolescents <95 mmHg
bleeding
Indications for Hospitalization:
1. When diagnostic criteria have been met
2. Dengue suspects;
a. Fever > 2 days w/ ↑ Hct or ↓ platelet count and/or prolonged BT
b. Altered sensorium
c. Marked anorexia, vomiting and thirsting
Treatment: rehydration therapy (refer to fluids / electrolytes)
Blood component therapy in DIC
• Whole bood: 20 mL/kg, if loss • Cryoprecipitate: 50 – 100 mg/kg fibrinogen (1
• Packed RBC: 1 mL/kg, raises Hct by 1% bag ≈ 200 mg fibrinogen)
• FFP: 10 – 15 mL/kg initially, mayneed 5 mL/kg • Platelet concentrate: 1 “U”/10 kg BW
q 6 hrs 1 “U” plt conc./m2 raises count by
10,000/mm3
 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.
Dengue Drips
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

Precedex drip
Dose: 0.2 - 0.7
1ml + 99cc D5W to run at cc/h Wt x dose = rate (cc/h)
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) 200 mg/250ml Single strength

400 mg/250ml DS (div by 2) Wt x dose x
0.075
Dobutamine 250 mg/5ml SS
500 mg/250ml DS(div by 2) Wt x dose x 0.06
Terbutaline Bricanyl SC Inj: 1 mg/ml
< 12y – 0.005 – 0.01 mkd x 3 doses q 15
-20 min then q2-6H
> 12y – 0.25 mkd
Terbutaline drip LD: 2 – 10 mcg/kg then
0.1 – 0.4 mcg/kg/min
Ketamine (Ketalar) 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
Morphine IV 0.1 – 0.2 mkd q2-4H prn
Naproxen 250, 375, 500mg tab
125mg/5ml
> 2yo – 5-7 mkd TID, BID PO

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
16 gIVIG x 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
KCl NaHCO3
IV 2 meq/ml Inj premixed: 5% (0.6 meq/ml)
Child: 0.5 – 1meq/k/dose infusion of 500ml
0.5 meq/k/h for 1-2 h Tabs: 8, 10, 15, 20 Tabs: 325 mg (3.8 meq), 650 mg
meq (7.6 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
Urine alkalinization
Ca Gluc = Children: 1cc/k/dose x 84 – 840 mg (1- 10 meq)/kg/D PO
3doses; QID

Max: 10cc/dose + equal amt of sterile water

LYSMIX 0.3 cc/k/dose TID Ceiling = 0.4
Prozinc drops 10 mg/ml
< 6 mos1 ml OD
< 6 mos – 2 yo 1 ml BID
syrup 20 mg/5ml
> 2 yo 5ml OD
Ercefuryl 20 mkday
Erceflora 1-2 vials/day OD for 2 wks
mix with water, milk or juice
Protexin Restore 1 sachet mix with milk OD
Racecadotril 1.5 mg/kg for 1 wk
(Hidrasec)
< 9 kg 10 mg sachet 1 sachet TID
9 – 13 kg 10 mg sachet 2 sachets TID
13 – 27kg 30 mg sachet 1 sachet TID
> 27 kg 30 mg sachet 2 sachets TID
FWB 10 - 20 cc/kg 3 – 4H
PRBC 5 - 10 3 – 4H
Plasma 10 - 15 1 – 2H
PRP 10 - 15 1 – 2H
Plt conc 1 u/ 7 -10 kg FD
Cryoprecipitate 1 u/kg FD
Hemophilia A 1 bag (200mg fibrinogen)
VW dse 50 -100 mg/kg
Fibrinogen dse 100 cc (2-5 kg)
Factor 8 Hemophilia A 50 u/kg
Hemophilia B 100 u/kg
 PRESENTATIONS AND COMPLICATIONS OF CHILDHOOD VIRAL ILLNESS
Virus Examthem Presenting features Complications
Confluent, erythematous Coryza, cough, Pneumonia, myocarditis /
maculopapular rash that conjunctivitis, Koplik’s pericarditis,
Measles
starts on the head and spot (small red spots with thrombocytopenic
(paramyxovirus)
progresses caudally bluish centers on the purpura, encephalitis; rare:
buccal mucosa only) SSPE, death
Typically none Swollen salivary glands, Orchitis (in puberty),
Mumps
especially parotid glands hearing loss; rare:
(paramyxovirus)
meningitis, encephalitis
Similar to measles but does Cervical, suboccipital, Rare: arthritis, aplastic
Rubella
not coalesce posterior auricular crisis (in G6PD),
(togavirus) lymphadenopathy encephalitis, hydrops
Similar to measles but Acute – onset high fever in Febrile seizures (no more
Roseola
starts on trunk and a well – appearing child common than with other
(Human Herpes
spreads to extremities before the development of febrile illness)
Virus 6)
rash
“slapped cheeks,” then Virtually asymptomatic Rare: arthritis in older
Erythema
reticular erythematous patients, hemolytic anemia,
infectiosum
maculopapular rash encephalopathy
(fifth disease;
beginning on arms then to
parvovirus)
the trunk and legs
Pruritic “teardrop” – Scattered crops of lesions Rare: pneumonia,
Chicken pox shaped vesicles that break appear over several days, secondary bacterial
(varicella; herpes and crust over, beginning so lesions in diff. stages of infection,
virus) on face or trunk and dev’t & resolution are meningoencephalitis,
spreading to extremities observed simultaneously hepatitis; Reye syndrome
 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 swelling ✓ Peak in 1 – 3 days
✓ 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

VIRAL INFECTIONS
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 exposure prophylaxis Ig w/n 6 days of exposure (0.25ml/kg max 15 ml) IM
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
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
sign LAD [24 hrs before rash & remains for 1 wk]
Tx Vit A SD 100,000 IU orally for 6 mos – 1 yo 200,000 IU >1 yo
Post exposure Immunoglobulin [not routine]
prophylaxis Considered if termination of preg is not an option 0.55ml/kg) IM
Vaccine w/n 72 hrs of exposure
Congenital Rubella ✓ Greatest during 1st trimester
✓ IUGR
✓ Congenital cataract, microcephaly, PDA,
͞ďlueďeƌƌLJ ŵuffiŶ͟ skiŶ lesioŶs
✓ Congenital or profound SNHL
✓ Motor or mental retardation
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
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 Varicella ✓ 6 -12 wks AOG: maximal interruption w/ limb devt 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 exposure VZIg 1 dose up to 96 hrs after exposure Dose: 125 U/10 kg (max
prophylaxis 625 U) IM
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
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 cheek͟ 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
 HEMATOLOGY
BLOOD COMPONENT THERAPY

Whole Blood

Cellular components Fluid component

Red cells Platelets Granulocytes FFP

Packed, Washed, Cryoprecipitate Liquid plasma

Leukocyte - poor

Whole Blood (1 unit ≈ 500 mL)

• High reaction rates, so given only when ↑ in both O2 & volume are required i.e. massive bleed,
exchange transfusion, bypass surgery
• Dose: 10 – 20 mL/kg in 24 hrs; Rate: 5 – 10 cc/kg/hr

Packed RBC (1 unit ≈ 250 – 300 mL)

• Dose: 10 – 15 mL/kg in 4 – 6 hrs; Rate: 2 – 3 cc/kg/hr (may give Furosemide if given @ a rate
>3cc/kg/hr
• 10 mL PRBC/kg ↑ Hct by ≈ 10%; 3 mL PRBC/kg ↑ Hgb by ≈ 1 g/dL
 Indications For Transfusion
< 4 mo >4 mo
1. Hgb < 13 g/dL in NB < 24 hrs 1. Significant pre – op anemia
2. Acute blood loss > 10% 2. Blood loss w/ hypovolemia
3. TBV Hgb < 13 g/dL, severe cardiopulmonary 3. Hgb < 13 g/dL, severe pulmonary disease
disease 4. Chronic / congenital anemia
4. Phlebotomy losses > 5 – 10%
5. Hgb level < 8 g/dL in stable NB
• Dose corrected to Deficit
(Desired Hct – Actual Hct) x 100 = mL PRBC
• Dose corrected to Donor Hct
(Desired Hct – Actual Hct) x kg x est. blood vol = mL PRBC
(Hct of PRBC to be transfused, usually 0.65)
Age Estimated blood Desired Hct Platelet
volume (EBV)
Preterm 90 – 105 cc/kg 0.45 • Dose: 3 – 4 U/m2 or 1 unit / 10 kg BW
• Normally, 1 U/m2 ↑ platelet count by 10,000 –
Term 78 – 86 0.45
12,000 / uL
1 mo 70 0.40 • When sick, 1 U/m2 ↑ platelet count by 6,300 –
1 yr 73 – 78 0.40 8,900 / uL
• 1 U/10 kg BW ↑ platelet count by 40,000 / uL
>1 yr 74 – 90 0.40 • Term NB = 5 – 10 mL/kg ↑ platelet count by
Adult 68 – 88 0.40 50,000 – 100,000 uL

Corrected count increment (CCI)

CCI = PCPOST – PCPRE x BSA CCI = PCPOST – PCPRE x BSA
# of units transfused # of plt in units x 1011

Adequate if: 4,000 – 5,000 / uL Adequate if: 10,000 / uL

 Plasma Transfusion
Fresh Frozen plasma Cryprecipitate
• Has all coagulation factors, albumin, Ig, • Has FVIII = 80 – 100 U/bag; vWFs = 100 U
complement fibrinogen = 150 – 250 mg/dL; FXIII = 75 U
• Volume: 200 – 250 mL • Volume: 30 mL
• Dose: 10 – 15 mL/kg ↑ 30% plasma clotting • Dose: 4 U/10 kg BW
factors 1 bag/ 10 kg ↑ fibrinogen 50 mg/mL
• Rate: 4 – 6 hrs • Rate: fast drip
Clotting Factor Concentrates

• 1 U Factor 8 / kg BW raises Factor 8 by 2% (1/2 life: 12 hrs)

• 1 U Factor 9 / kg BW raises Factor 9 by 2% (1/2 life: 24 hrs)
Desired Factor 8 replacement

Minor replacement (20 – 40%) i.e. simple hematoma 10 U/kg

Moderate replacement (> 50%) i.e. mucosal bleed 20 – 25 U/kg

Major replacement (80 - 100%) i.e. GI bleed, surgery 50 U/kg

Absolute Reticulocyte count (ARC)

Actual hematocrit x estimated blood volume
Hematocrit for age
Reticulocyte index = ARC ÷ 2 (NV: 2)
if < 2: suppressed marrow; if > 2: compensatory marrow
Phlebotomy (Volume to be extracted)
Volume (mL) = EBV x KgBW x Actual Hct – Desired Hct
Actual Hct
 CARDIOLOGY
CONGENITAL HEART DISEASE

Right – to – Left Shunts (early cyanosis / “Blue Babies”)

PE / Auscultation ECG CXR

Tetralogy of fallot SEM; single S2 (not loud) RVH Boot – shaped heart

Transposition of Great No murmur; Single S2 RVH Egg – shaped heart; ↑ PVM

vessels (loud)
TAPVR SEM; Wide, fixed Split S2 RVH Snowman / Figure of eight; ↑ PVM

Truncus arteriosus Holosystolic murmur LVH + RVH Right aortic arch cardiomegaly

SEM: Systolic Ejection Murmur; PVM: Pulmonary Vascular Markings

Left – to – Right Shunts (Late cyanosis/ “Blue kids”)

PE / Auscultation ECG CXR

Ventricular septal defect Pansystolic mumur LVH, RVH ↑ PVM

Atrial septal defect Fixed split S2 Mild RVH ↑ PVM

Patent ductus arteriosus Continuous machine – LVH, ± RVH ↑ PVM

like mumur
Coarctation of the aorta Hypertension, ↓ femoral LVH Enlarged aortic knob
pulses
Eisenmenger syndrome: Uncorrected L – to – R shunt leads to progressive pulmonary hypertension. This
changes shunt direction from L → R to R→ L and causes late cyanosis
 RHEUMATIC HEART DISEASE
JONES CRITERIA
Major Manifestation
1. Arthritis (70%)
2. Carditis (50%)
a. Tachycardia
b. Heart murmur of valvulitis
c. Pericarditis
d. Cardiomegaly
e. Signs of CHF [gallop rhythm, distant heart sounds, cardiomegaly]
3. Erythema marginatum (10%)
4. Subcutaneous nodules (2 – 10%)
5. Sydenham’s chorea (15%)
Minor manifestation
1. Arthralgia
2. Fever at least 38.8°C
3. Elevated Acute Phase Reactants (CRP & ESR)
4. Prolonged PR interval on the ECG
Diagnosis
1. Highly probable : 2 major OR 1 major and 2 minor manifestation
INFECTIVE ENDOCARDITIS
DUKE CRITERIA
Major Manifestation
1.
Minor manifestation
Diagnosis
2. Highly probable : 2 major OR 1 major and 2 minor manifestation
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
SYSTEMIC LUPU S ERYTHEMATOSUS [SLE]
Criteria ✓ Malar rash
✓ Discoid rash
✓ Photosensitivity
✓ Oral ulcers (painless)
✓ Nonerosive arthritis (2 or more joints)
✓ Serositis (pleuritis, serous pericarditis,Libman sacks endocarditis
✓ Renal disorder
✓ Neurologic disorder
✓ Hematologic disorder
✓ Immunologic disorder

✓ ANA abormal titer

Dx ✓ 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 ✓ 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
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

ATOPIC DERMATITIS CONTACT DERMATITIS SEBORRHEIC DERMATITS

Hereditary, AR Irritant – strong chem. excessive sebum
hx of Asthma e.g. diaper rash accumulation on scalp,
thickened, shiny, red remove reactant face, midchest, perineum
exacerbated by dry skin, contact Allergic greasy scalp (cradle cap)
sty, & anxiety e.g. cosmetic, perfume physiologic 1st 6mos
tx: hydrocortisone/ fluocinolone tx: high/mod petency tx: low potency steroid
moisturizer steroid
cloxa/cefalexin if with infxn
 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
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
 EARLY LATE
Narrowed pulse pressure Decrease systolic pressure
Orthostatic changes Decrease diastolic pressure
Delayed capillary filling Cold, pale skin
Tachycardia Altered mental state
Hyperventilation Diaphoresis
Decrease urine output
ED MNG

1. Position
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)
Inotropes – help stabilize BP
7.
o

o
Epinephrine - (0.1 – 1 ug/kg/min) Infusion of choice for
o Hypotensive pxs Dobutamine - (5 – 20 ug/kg/min)
Cardiogenic shock but not severely hypotensive
8. Dopamine
Cardiogenic shock – [(5 – ϮϬ ug/kg/ŵiŶ αcoŶstrictor effectͿ Ϳ;ϭϬ – 15 ug/kg/min]
Distributive shock after successful fluid resuscitation
o
o Diuretic – pxs may get worse after fluid challenge
o Adenosine / synchronize cardioversion – SVT
Defibrillation – Venticular fibrillation
 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.
 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
 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
 COMMONLY USED OPD DRUGS
Drug Dose (Infant & Children) Preparation
AMOXICILLIN 40 mg/kg/d q 8 h 100mg/mL; 125mg/5mL; 250mg/5mL
CEFALEXIN 25 – 50 mg/kg/d q 6 h 100mg/mL; 125mg/5mL; 250mg/5mL
CHLORAMPHENICOL 50 – 100 mg/kg/d q 6 h 125mg/5mL
CLOXACILLIN 50 – 100 mg/kg/d q 6 h 125mg/5mL
CO – AMOXICLAV 40 mg/kg/d q 8 h 156.25 mg/5mL
COTRIMOXAZOLE 40 mg SMX & 8 mg TMP/kg/d q 12 h 200 mg SMX & 40 mg TMP/ 5mL
DIPHENHYDRAMINE 5 mg/kg/d q 6 h 12.5mg/5mL
ERYTHROMYCIN 40 mg/kg/d q 6 h 100mg/2.5mL; 200mg/5mL; 400mg/5mL
FERROUS SALTS Prophylaxis: 1 mg elemental Fe/kg/d 75mg (15mg elemental Fe) / 0.6mL
(as sulfate) Tx: 3 – 6 mg elemental Fe/kg/d ÷ 3 doses 131mg (26.25mg elemental Fe) / 5mL
HYDROXYZINE 2 – 5 mg/kg/d q 6 - 8 h 2 mg/mL
MEBENDAZOLE 100 mg BID x 3 d 50 mg/mL
(children > 2yo) 500 mg single dose 100 mg/ 5 mL
METOCLOPRAMIDE 0.1 mg/kg/dose q 6 h 5 mg / 5 mL
10 -15 mg/kg/dose q 6 h 80mg/0.6mL drops; 120mg/5mL susp
PARACETAMOL 125mg/5mL; 250mg/5mL
PREDNISONE 1 – 2 mg/kg/d BID – QID 5 mg/ta
PYRANTEL PALMOATE 11 mg/kg (max 1g) single dose 125 mg/5mL
0.1 mg/kg/dose (max: 2mg/dose) q6–8h 2mg/5mL
SALBUTAMOL 1 – 2 puffs/inhalation q 4 – 6 h or prn 100 mcg/actuation x 400 doses (MDI)
 ANTIBIOTICS
Amoxicillin (30 – 50 mkday) TID
Pediamox Susp : 250mg/5ml Drops : 100mg/ml
Himox Cap : 250mg, 500mg
Moxicillin Susp : 125mg/5ml 250mg/5ml
Harvimox Novamox Drops : 100mg/ml
Amoxil Susp : 125mg/5ml 250mg/5ml Cap : 250mg
500mg
Glamox Globapen Drops : 100mg/ml
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
Cloxacillin (50 – 100 mkday) q6h
Prostaphlin A Tab: 250mg 500mg
Orbinin Susp: 125mg/5ml
Flucloxacillin (50 – 100 mkday) q6h
Staphloxin Susp: 125mg/5ml
Cap : 250mg 500mg
Chloramphenicol (50 – 75 mkd) q6h
Pediachlor Chloramol Susp: 125mg/5ml
Kemicetine Chloromycetin Tab : 250mg 500mg
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 Ceclor CD Pulvule: 250mg 500mg 375mg 750mg
CD ext release Susp: 125mg/5ml 187mg/5ml
250mg/5ml 375mg/5ml Drops: 50mg/ml
Xelent Vercef Cap : 250mg 500mg 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 Zefral Ultrazime Susp : 100mg/5ml Drops: 20mg/ml
Cefdinir (7mg/kg q 12h OR 14mg/kg OD)
Omnicef Cap : 100mg
Sachet/ Susp: mg/5ml
COTRIMOXAZOLE (TM 5 – 8 mkd) q 12h
Bactille – TS Susp/5ml SMZ 400mg TM 80mg Tab
800mg
Bacidal 160mg
Susp/5ml 400mg 80mg
Trizole Susp/5ml 400mg 80mg
Globaxole Tab 800mg
160mg
Susp/5ml 400mg 80mg
Trimethoprim + Sulfadiazone (TM 5 – 8 mkd)
Triglobe Tab Sdz 410mg TM 90mg Forte 820mg
180mg
Susp/5ml 205mg 45mg
AMINOGLYCOSIDES
Tetracycline 25 – 50 mkday q6h
Doxycycline 5 mkday BID
Furaxolidone 5 – 8 mkday q6h
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/ Ilosone DS Tab: 500mg Pulvule: 250mg Liquid: 125mg/5ml
DS Liquid: 200mg/5ml Drops: 100mg/ml
Clarithromycin (6 – 15 mkday OR 7.5 mkdose q12h)
Klaricid Klaz Susp : 125mg/5ml 50mg/5ml Tab:
250mg 500mg
Roxithromycin <6 yo 5 – 8 mkd BID
6 – 12 yo 100mg/tab BID
Macrol/Rulid Tab: 150mg Ped Tab: 100mg Tab: 50mg

Rulid dispensable
Azithromycin 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
 ORAL ANTIFUNGALS
Ketoconazole (6mkd) q 4 – 6h
Daktarin Adult & Child: ½ tsp q 6h Infant: ¼ tsp q 6 h
Nystatin
Mucostatin Ready mix susp Susp: 100,000 u/5ml
Tab: 500,000 u
Fluoconazole (3 – 6 mkd) OD x 2wks
Diflucan Cap: 50mg 150mg 200mg Vial: 2mg/ml x 100
ml

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
 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
Loratadine 1 – 2 yo: 2.5 ml BID
2 – 12 yo (<30 kg): 5ml OD
(>30 kg): 10ml OD
Adult & > 12 y : 1 tab OD
Claritin Allerta Loradex Syr: 5mg/ml Tab: 10mg
Desloratadine 6 – 12 mos: 2ml OD
1 – 5 yo: 2.5ml OD
6 – 12 yo: 5ml OD
Aerius Syr: 2mg/5ml Tab: 5mg
 DECONGESTANT
Nasal 2 – 4 drps/spray per nostril TID/QID
NaCl 2 sprays/nostril then suction q6h x 3 days
Salinase Muconase Nasal spray Nasal drops
Oxymetazoline HCl 2 – 5 yo: 2 – 3 drops/nostril BID
>5 yo: 2 – 3 sprays/nostril BID
Drixine Nasal spray: 0.05%
Nasal soln: 0.025%
Xylometazoline HCl < 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
Otrivin
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
Brompheniramine maleate + PPA Drops: 6.25ml q6h Syr: 12.5mg/5ml q6h
Dimetapp 1 – 6 mos:
7 – 24 mos:
2 – 4 yo:
4 – 12 yo:
Adult:
Infant drops: (0.1mkdose) Syr
Extentab
Carbinoxamine maleate + Phenylephrine HCl
Rhinoport 1 – 5 yo: 5ml 10ml BID BID BID
6 – 12 yo: 1 cap / 15ml
Adult & > 12yo:
Syrup Cap
Loratadine + PPA
Loraped <30 kg: 2.5ml 5ml BID BID
>30 kg:
Syrup: 5mg/ml
MUCOLYTIC
Solmux Drops: 40mg/ml TID/QID
1 – 3 mos: 0.5ml
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
5ml
8 – 12 yo 15ml 7.5ml

Forte: 500mg/5ml Cap: 500mg

Adult & >12 yo: 5 – 10ml
1 cap
Solmux Broncho Capsule Suspension
Solmux Chewable tab Tab: 500mg 1 tab q 8h
Carbocisteine Infant Drops QID 1 – 1 ½ tsp
MUCOLYTIC <3mos 0.25ml 1½ - 2 tsp
3 – 5 mos 0.5ml 2– 3 tsp
6 – 8 mos 0.75ml
9 – 12 mos 1ml
2 – 3 tsp
Ped Syr TID
1 – 3 yo 5 – 7.5ml
4 – 7 yo 7.5 – 10ml
8 – 12 yo 10 – 15ml

Adult Susp TID

Adult & >12 yo 10 – 15ml

Capsule TID
Adult & >12 yo 1 cap
Lovsicol Infant drops 50mg/ml
Ped Syrup 100mg/5ml
Adult Susp 250mg/5ml
Cap 500mg
Ambroxol Infant drops 6mg/ml 75mg/ml BID
< 6 mo 0.5ml
0.5ml
7 – 12 mo1 ml 0.75ml
13 – 24 mo 1.25ml 1ml

Pedia Syrup
<2 yo 2.5ml BID
2 – 5 yo 2.5ml TID
5 – 10 yo 5ml TID

Adult Syrup
Adult & >10 yo 5ml TID

Retard cap
Adult & >10 yo 1 cao OD

Tab
Adult & >10 yo 1 tab TID

Inhalation
<5 yo 1 – 2 inhalation of 2ml soln daily Adult & children >5 yo
1 – 2 inhalation of 2
– 3ml soln daily
Mucosolvan Infant drops 6mg/ml Ped liquid 15mg/5ml
Adult liquid 30mg/5ml Retard cap
75mg
Tab 30mg
 Inhalation Soln 15mg/2ml Ampule 15mg/2ml
Ambrolex Zobrixol Infant drops 7.5mg/ml Ped liquid 15mg/5ml
Adult liquid 30mg/5ml Tab 30mg
B2 AGONIST
Salbutamol (0.1 – 0.15 mkdose)
Ventolin Tab 2mg
Syr 2mg/5ml
Nebule 2.5mg/2.5ml
Ventar Hivent Syrup Tab 2mg
Syr 2mg/5ml
Salbutamol + Guaifenesin
Asmalin Broncho Tab
1tab TID Syrup
Pulmovent 2– 6 yo 5 – 10 ml BID/TID
7 – 12 yo10ml
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
Doxophelline (6 – 8 mkdose) BID x 7 – 10 days
Ansimar Syrup 100mg/5ml
Tab400mg
Procaterol HCl (0.25ml/kg)
Meptin Syrup 5mcg/ml
Tab 25mcg
Nebuliser soln 100mcg/ml

Theophylline 10 – 20 mkdose
3 – 5 mkdose

ANTITUSSIVES
Butamirate citrate 3 yo 5 ml TID
>6 yo10ml TID
>12 yo 15ml TID
Adult15ml QID
1 tab TID/QID
Sinecod Forte Syrup 7.5mg/5ml
Tab 50mg

Dextromethorphan + Guaifenesin
Robitussin – DM 2 – 6 yo 2.5 – 5ml q 6 – 8h
6 – 12 yo 5ml q 6 – 8h
Adult 5 – 10ml q 6h
Syrup
INHALED STEROIDS
Budesonide
Budecort 250mcg q 12h 500mcg q 12h
500mcg OD for allergic rhinitis
250mcg /ml (2ml) 500mcg /ml (2ml)
Flexotide neb 250mcg /ml (2ml)
250mcg q 12h
 ANTACIDS
Maalox (plain, plus) 5ml/10kg
Available in 180ml bottle
Simethicone
Restime < 2 yo 0.5ml qid
2 – 12 yo 4ml qid
Oral drops 40mg/ml
ANTISPASMODIC
Dicycloverine 6mos – 2 yo 0.5 – 1ml TID
Relestal Drops 5mg/ml
Syrup 10mg/5ml
Domperidone 0.3 – 0.6 mkdose q 6 – 8 h
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
Motilium Susp 1mg/ml Tab 10mg
Vometa Oral drops 5mg/ml Susp 5mg/5ml
Tab 10mg
H2-BLOCKER
Ranitidine 1 – 2 mkdose q 12h
Zantac Tab 75mg 150mg 300mg
Cimetidine Neonates: 5 – 20 mkday q6 – 12 h
Infants: 10 – 20 mkday
Child; 20 – 40 mkday
Adult: 300mkdose QID
400mkdose BID 800mkdose QID
Tagamet Susp: 300mg/5ml
Tab: 100mg 200mg 300mg 400mg 800mg
Famotidine PO: 0.5 mkdose q 12 h
IV: 0.6 – 0.8 mkday q 8 – 12h
ANTIPYRETIC
Paracetamol (10 – 20 mkdose) q 4h
Tempra Drops: 60mg/0.6ml Syrup: 120mg/5ml Forte : 250mg/5ml
Tablet: 325mg 500mg
Calpol Drops: 100mg/ml Syrup: 120mg/5m
250mg/5ml
Defebrol Syrup: 120mg/5m
250mg/5ml
Afebrin Drops: 60mg/0.6ml Syrup: 120mg/5ml Forte : 250mg/5ml
Tablet: 600mg
Tylenol Drops: 80mg/ml Syrup: 160mg/5ml
Naprex Drops: 60mg/0.6ml Syrup: 250mg/5ml Inj: 300mg/2ml
Rexidol Drops: 60mg/0.6ml Syrup: 250mg/5ml Tablet: 600mg
Biogesic Drops: 100mg/ml Syrup: 120mg/5m
250mg/5ml Tablet: 500mg
Aeknil Ampule (2ml) 150mg/ml
Opigesic Suppository: 125mg 250mg
Mefenamic Acid (6 – 8mkdose) q 6h
Ponstan Suspension: 50mg/5ml Cap SF: 250mg
Tab: 500mg
Aspirin (60 – 100 mkd)
Ibuprofen (5 – 10 mkday) q8h (max 20mkday)
Dolan FP Dolan Suspension: 100mg/5ml
Forte 200mg/5ml
Drops: 100mg/2.5ml 100mg/5
Tab:200mg
Advil
 IV ANTIBIOTICS
Penicillin 50,000 – 100,000 ukd q 6h
Amoxicillin 50 – 100 mkd q 6 – 8 h
Ampicillin 50 – 100 mkd q 6 – 8 h
Chloramphenicol 50 – 100 mkd q 4 – 6 h
Ampi + Cloxa 50 – 100 mkd q 6 h
Oxacillin 50 – 100 mkd q 6 – 8 h
Flucloxacillin 50 – 100 mkd q 6 – 8 h
Gentamicin 5 – 7.5 mkd OD
Netromycin 5mkd q 12 h
Amikacin 15mkd q 12 h
Cephalexin 50 – 100 mkd q 6 h
Cefuroxime 50 – 100 mkd q 6 – 8 h
Ceftriazone 50 – 100 mkd OD
Ceftazidime 50 – 100 mkd q 12 h
HYDROCORTISONE LD: 10 mkdose
MD: 5 mkdose q 6, 8 or 12h
*max dose: LD 200 MD 100
 ANTICONVULSANT
Diazepam 0.2 – 0.3 mkdose
Drip: 1amp in 50cc D5W 10mg/amp
Midazolam 0.15 mkdose OR
0.05 – 0.2 mkdose
Phenobarbital LD: 10 mkdose q 12h MD: 5 mkdose q 12h
ANTIHYPERTENSIVES
Hydralazine Apresoline PO: 0.75 – 1.0 mkday q 6 – 12 h
IV: 0.1 – 0.2 mkdose
Spirinolactone 1 – 3 mkday
ANTI-TB MEDS
Isoniazid (10 – 12 mkd) ODAC or 2hrs PC
Comprilex Nicetal Trisofort Suspension:
Odinah 200mg/5ml 100mg/5ml 200mg/5ml
150mg/5ml
Tablet 400mg
Rifampicin (10 – 20 mkd) ODAC or 2hrs PC
Natricin Rifadin 100mg/5ml 200mg/5ml 100mg/5ml
100mg/5ml 200mg/5ml
Rimactane Rimaped Tablet 300mg 450mg
Pyrazinamide (PZA) (16 – 30 mkd) BID/TID
CIBA 250mg/5ml 500mg/5ml Tablet 500mg
Zcure Zinaplex
 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.
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…..

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)

Level of Umbilical Cathetherization: (cm)

If arterial between T6-T9
Wt x 3 x 8

If venous: (wt x 3) + 8 +1 2

ET tube size: age in yrs +4

4
ET level:
 if >2yo: age(yrs) +12 2
 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
 Nasopharyngeal cathether = Flow rate x 20 + 20 Ex. 1L Fio2 = 40
 Nasal catheter = Flow rate x 4 + 20 Ex. 1L FiO2 = 24
Extubation:
 Give Dexamethasone at 0.1 mkdose q 6 hours for 24 hours prior to extubation
 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
 O2 at 10 lpm then decrease as necessary
Regular milk: 20 cal/oz Preterm milk: 24 cal/oz

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

Caloric requirement & Protein requirement

Cal/kg g/kg
0-5mo 115 3.5
6-11mo 1-2 yo 110 3
3-6 yo 110 2.5
7-9 yo 90 – 100 2
10 – 12 yo 80 – 90 1.5
13-15 yo 70 – 80 1.5
16 – 19 yo 55 – 65 1.5
45 – 50 1.5
Approximate Daily Water Requirement
1– 3 do 120cc/k/d 4 – 6 yo 100 cc/k/d
10 do 150cc/k/d 7 – 9 yo 90 cc/k/d
2– 5 mo 150cc/k/d 140cc/k/d 10 – 12 yo 80 cc/k/d
6 – 12 mo 120cc/k/d 13 – 15 yo 70 cc/k/d
1 – 3 yo 16 – 19 yo 50 cc/k/d
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
Growth and Caloric requirements
AGE RDA kcal/kg/day
0 – 3 mos 115
3 – 6 mos 110
6 – 9 mos 100
9 – 12 mos 100
1 – 3 yo 100
4 – 6 yo 90 – 100
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 kg20 ml
2-3 kg 15 ml
1-2 kg 10 ml
850g-1kg 5 ml
< 850 g 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 Criteria for Hypoxic Ischemic Encephalopathy
 Gloves  pH < 7 (profound met. Acidosis)
 Calcium gluconate 100 mg every 10 exchanges  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
 REFERENCE RANGES FOR LABORATORY TEST
Test Sp Age Reference range SI
APTT P 25 – 35 sec Infant: < 90
P Preterm 1 d 1.8 – 3.0 g/dL
Term < 6 d 2.5 – 3.4
Albumin <5y
5 – 19 y
3.9 – 5.0
4.0 – 5.3
U 4 – 16 y 3.35 – 15.3 mg/24 hr / 1.73 m2
S, P Arterial 21 – 28 mmol/L
Bicarbonate Venous 22 - 29
W Normal: 2 – 7 min
Bleeding time, Ivy
Borderline: 7 – 11 min
S Cord blood 52 – 1,330 ng/mL 52 – 1,330 ug/mL
C – reactive protein
2 – 12 y 67 – 1,800 ng/mL 67 – 1,800 ug/mL
S, P Cord blood 5.0 – 6.0 mg/dL 1.25 – 1.50 mmol/L
Calcium, W NB: 3 – 24 h 4.3 – 5.1 mg/dL 1.07 – 1.27 mmol/L
ionized 24 – 48 h
Thereafter
4.0 – 4.7
4.8 – 4.92 or 2.24 – 2.46 mEq/L
1.00 – 1.17
1.12 – 1.23
W Newborn 27 – 40 mmHg 3.6 – 5.3 kPa
CO2, Infant 27 – 41 3.6 – 5.5
Then: Male 35 – 48 4.7 – 6.4
PCO2 Female 32 – 45 4.3 – 6.0
Clotting time W Glass tubes 5 – 6 min (5 – 15 @ RT)
S, P Cord blood 96 – 104 mmol/L
Chloride Newborn
Thereafter
97 – 110
98 - 106
 U Infant 2 – 10 mmol/d
Child 15 – 40
Thereafter 110 – 250
S Cord blood 57 – 116 mg/dL

C3
1 – 3 mo 53 – 131
3 mo – 1 yr 62 – 180
1 – 10 yr 77 – 195
Adult 83 – 177
S, P Newborn 1 – 24 ug/dL 26 – 662 nmol/L
Adults: 5 – 23 136 – 635
Cortisol 0800 h
1600 h
3 – 15
≤ 50% of 0800h
82 – 413
≤ 0.50 of 0800h
2000 h
S, P Cord blood 0.6 – 1.2 mg/dL 53 – 106 umol/L
Creatinine plasma, Newborn 0.3 – 1.0 27 – 88
Jaffe, kinetic or Infant 0.2 – 0.4 18 – 35
enzymatic Child 0.3 – 0.7 27 – 62
Adolescent 0.5 – 1.0 44 – 88
Factor: 88.4 Adult: Male 0.6 – 1.2 53 – 106
Female 0.5 – 1.1 44 – 97
U Premature 8.1 – 15 mg/kg/d 72 – 133 umol/kg/d
Creatinine, urinary
Full – term 10.4 – 19.7 92 – 174
1.5 – 7 y 10 – 15 88 – 133
Factor: 8.84
7 – 15 y 5.2 – 41 46 – 362
W Millions/mm3 X 1012 cells/L
Erythrocyte Cord blood 3.9 – 5.5 3.9 – 5.5
count 1–3d 4.0 – 6.6 4.0 – 6.6
1 wk 3.9 – 6.3 3.9 – 6.3
2 wk 3.6 – 6.2 3.6 – 6.2
 W 1 mo 3.0 – 5.4 3.0 – 5.4
2 mo 2.7 – 4.9 2.7 – 4.9
3 – 6 mo 3.1 – 4.5 3.1 – 4.5
0.5 – 2 y 3.7 – 5.3 3.7 – 5.3
Erythrocyte 2–6y 3.9 – 5.3 3.9 – 5.3
count 6 – 12 y 4.0 – 5.2 4.0 – 5.2
12 – 18 y M 4.5 – 5.3 4.5 – 5.3
F 4.1 – 5.1 4.1 – 5.1
18 – 49 y M 4.5 – 5.9 4.5 – 5.9
F 4.0 – 5.2 4.0 – 5.2

Erythrocyte W Westergren Wintrobe

Child 0 – 10 mm/hr 0 – 13
Sedimentation Adult: M 0 – 15 0–9
Rate F 0 – 20 0 – 20
W Adult 65 – 95 3.6 – 5.3
Glucose S Cord blood 45 – 96 mg/dL 2.5 – 5.3 mmol/L
NB: 1 d 40 – 60 2.2 – 3.3
>1d 50 – 90 2.8 – 5.0
Factor: 0.0555 Child 60 – 100 3.3 – 5.5
Adult 70 – 105 3.9 – 5.8
S Normal Diabetic
Glucose Tolerance
Fasting 70 – 105 mg/dL >115 mg/dL
Test (GTT), oral
60 min 120 – 170 ≥ 200
Child: 1.75 g.kg of
90 100 – 140 ≥ 200
ideal wt
120 70 – 120 ≥ 140
W Volume fraction
Hematocrit 1d 0.48 – 0.69
2d 0.48 – 0.75
3d 0.44 – 0.72
 W 2 mo 0.28 – 0.42
6 – 12 y 0.35 – 0.45

Hematocrit
12 – 18 y: M 0.37 – 0.49
F 0.36 – 0.46
18 – 49 y: M 0.41 – 0.53
F 0.46 – 0.46
W 1–3d 14.5 – 22.5 g/dL 2.25 – 3.49 mmol/L
2 mo 9.0 – 14.0 1.40 – 2.17
6 – 12 y 11.5 – 15.5 1.78 – 2.40
Hemoglobin 12 – 18 y: M
F
13.0 – 16.0
12.0 – 16.0
2.02 – 2.48
1.86 – 2.48
18 – 49 y: M 13.5 – 17.5 2.09 – 2.27
F 12.0 – 16.0 1.86 – 2.48

Lecithin/ Sphingomyelin ratio AF 2.0 – 5.0 indicates probable fetal lung maturity (>3.0 IDM)
W X 109 cells/L
Birth 9.0 – 30.0
24 h 9.4 – 34.0
Leukocyte count 1 mo 5.0 – 19.5
1–3y 6.0 – 17.5
(WBC) 4–7y 5.5 – 15.5
8 – 13 y 4.5 – 13.5
Adult 4.5 – 11.0

W Myelocytes 0
Neutrophils – “bands” 3 – 5%
“segs” 54 – 62%
Leukocyte differential Lymphocytes 25 - 33%
Monocytes 3 – 7%
Eosinophils 1 – 3%
Basophils 0 – 0.75%
 W Birth 31 – 37 pg/cell 0.48 – 0.57 mmol/cell
1–3d 31 – 37 0.48 – 0.57
Mean 1 wk – 1 mo 28 – 40 0.43 – 0.62
corpuscular 2 mo 26 – 34 0.40 – 0.53
3 – 6 mo 25 – 35 0.39 – 0.54
hemoglobin 0.5 – 2 y 23 – 31 0.36 – 0.48
concentration 2–6y 24 – 30 0.37 – 0.47
(MCHC) 6 – 12 y 25 – 33 0.39 – 0.51
12 – 18 y 25 – 35 0.39 – 0.54
18 – 49 y 26 – 34 0.40 – 0.53
W 1–3d 95 – 121 um3 95 – 121 fl
0.5 – 2 y 70 – 86 70 – 86
Mean 6 – 12 y 77 – 95 77 – 95
corpuscular 12 – 18 y: M 78 – 98 78 – 98
F 78 – 102 78 – 102
volume (MCV)
18 – 49 y: M 80 – 100 80 – 100
F 80 – 100 80 – 100
S Child / Adult 275 – 295 mOsm / kg H2O
Osmolality
U Random: 50 – 1,400 24 hr: 300 – 900
W, a Birth 6 – 24 mmHg 1.1 – 3.2 kPa
Oxygen Partial 5 – 10 min 33 – 75 4.4 – 10.0
Pressure (PO2) 30 min 31 – 85 4.1 – 11.3
>1 hr 55 – 80 7.3 – 10.6
1d 54 – 95 7.2 – 12.6
* ↓ w/ age Thereafter 83 – 108 11 – 14.4
O2 saturation W Newborn: 85 – 90% Thereafter: 95 – 99%
PTT W Nonactivated: 60 – 85 sec activated: 25 – 35
pH, arterial W Preterm 48 h 7.35 – 7.50
 Brth, Term 7.11 – 7.36
5 – 10 min 7.09 – 7.30
S 30 min 7.21 – 7.38
>1 h 7.26 – 7.49
1d 7.29 – 7.45
Thereafter 7.35 – 7.45
pH U Newborn: 5 – 7 Thereafter: 4.5 – 8 (ave 6)
S 1 – 9y 145 – 420 U/L
10 – 11 y 130 – 560
Phosphatase, 12 – 13 y M: 200 – 495 F: 105 - 420
alkaline 14 – 15 y 130 – 525 70 - 230
16 – 19 y 65 – 260 50 – 130

Platelet count W Newborn: 84 – 478 x 109 / L Adult: 150 – 400

S < 2 mo 3.0 – 7.0 mmol/L

Potassium 2 – 12 mo 3.5 – 6.0
>12 mo 3.5 – 5.0
S Premature 4.3 – 7.6 g/dL
Newborn 4.6 – 7.4
Protein, 1–7y
8 – 12 y
6.1 – 7.9
6.4 – 8.1

total U
13 – 19 y 6.6 – 8.2
1 – 14 mg/dL; 50 – 80 mg/24 hr (@ rest)
< 250 mg/24 h after intense exercise
Prothrombin time W In general, 11 – 15 s
(1 – Stage) Newborn: Prolonged by 2 – 3 s
W Adults 0.5 – 1.5% of RBC or 25T – 75T / mm3
Reticulocyte count
1d 0.4 – 6.0 %
 7d < 0.1 – 1.3%
1 – 4 wk < 1.0 – 1.2%
5 – 6 wk <0.1 – 2.4%
7 – 8 wk 0.1 – 2.9
9 – 10 wk < 0.1 – 2.6%
11 – 12 wk 0.1 – 1.3%

U Adult: 1.002 – 1.030

After 12 h fluid restriction: > 1.025
Specific gravity 24 h urine: 1.015 – 1.025

S NB: 3 d 2.0 – 4.9 ng/dL 26 – 631 pmo; / L

1 – 12 mo 0.9 – 2.6 12 – 33
Thyroxine, free Prepuberty 0.8 – 2.2 10 – 28

S Cord blood 20 – 240 pg/dL 0.3 – 3.7 pmol/L

1–3d 200 – 610 3.1 – 9.4
Triiodothyronine 6 wk 240 – 560 3.7 – 8.6
free Adult 230 – 660 3.5 – 10.0

S, P Cord blood 21 – 40 mg/dL 7.5 – 14.4 mmol/L

Preterm 1 wk 3 – 25 1.1 – 9
Urean nitrogen Newborn 3 – 12 1.1 – 4.3
Infant / child 5 – 18 1.6 – 6.4
Factor: 0.357 Thereafter 7 – 18 2.5 – 6.4
1 u FWB = 200 cc PRBC
= 50 cc platelet concentrate
= 150 – 200cc PRP
= 150 cc FFP
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 hemorrhage
2 < 2 rbc production abn

PRBC to be transfused for correction = 40 – hct x wt

1 - 3 days 1 mo 2mos 6 – 12y >12y

Hgb 14.5 – 22.5 9 -14 11.5 - 13-16
15.5
Hct .48 - .69 .28 - .42 .35 - .45 .37 - .49
Wbc 9 -30 birth 5 – 19.5 6 -17.5 4.5 -
13.5
Plt 84 – 478 After 1 wk, same as adult
NB 150 - 400
Retic 0.4 - 0.6 < 1 -1.2 0.1 -2.9
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 mild anemia
8- 9 g mod anemia
<8 g severe anemia

Glucose PT 20 -60 Child Adult

NB 30 – 60 60 -100 70 -105
1 d 40 -60
> 1d 50 -90
BUN/ crea ratio
Normal 10 -20
> 20 suggest DHN, pre renal azotemia or GIB
< 5 – liver disease, inborn error of metabolism
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

Age GFR Range

PT
2- 8 d 11 11 – 15
4 - 28 d 20 15 – 28
30 -90 d 50 40 – 65
Term
2- 8 d 39 17 – 60
4 - 28 d 47 26 – 68
30 - 90 d 58 30 – 86
1- 6mo 77 39 -114

6 - 12 mo 103 49 – 157
2 - 19mo 127 62 – 191
2 - 12y 127 89 – 165
Adult males 131 88 – 174
Adult females 117 87 – 147
 Age K (mean value) KI
LBW < 1 yr 0.33 29.17
FT < 1 yr 0.45 39.78
2-12 y 0.55 48.62
13-21 y (female) 0.55 48.62
13 -21 y (male) 0.70 61.88

BSA
Weight in (kg)
0 –5 wt x 0.05 + 0.05
6 – 10 wt x 0.04 + 0.10
11 – 20 wt x 0.03 + 0.20
20 – 40 wt x 0.02 + 0.40
>40 wt x 0.01 + 0.80

Computation for OFI (AGN & limiting OFI)

1. BSA x 400 + UO – IVF (half if w/ Furo) = OFI (then divide to 3 shifts) 20cc x wt x UO
2. – IVF
 OSTERIZED FEEDING
TFR 60 - 70% = 100/feeding q 6H
10 kg x 60%
TFR = 600
CHON 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
CHO 60%
(TFR – CHON) x 0.6
(600- 71) x 0.6 = 317
CHO = 317
Fats 181 (the rest are fats , divided into 6 feedings)

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 TFI = 1000ml/day

Vamin 7% 7 = 2 g/kg x 10kg 285 ml

100
CaGluc 2ml/kg 20 ml
D5IMB 485 ml
D50W 0.11 x 1000ml 110 ml
1000ml x 37 cc/h
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

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
VITAMINS
Stimulants Mosegar Vita 0.25 mg/day prep 0.25 /5 ml
Buclizine (syrup) Appetens
Propan Appebon
2 - 8yo 5 - 10 ml OD
7 - 14yo 10 - 20 ml OD
w/ Folic acid Molvite
(Megaloblastic Anemia) 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 - 12yo10 - 15 cc OD
Pizotifen Mosegor vita syr
(drowsiness) Appetens
MTV w/ Iron Propan w/ iron syr (Fe So4; elem fe 30mg)
Appebon w/ iron syr (FeSo4; elem fe 10mg)
w/ Serotonin (for Mosegor vita
migraine + dec wt) 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
<2yo2.5 ml OD
2-6yo 5 ml OD
7-12yo 5-10 ml OD
Polynerv
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

Iron Deficiency Supplemental Iron =

Anemia 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
TPN in Pediatrics
A. Energy Requirment
AGE/WT Caloric Rquirement
Neonates 90-120 kcal/kg
Infants & Older
Children
<10 kg 10-120 kcal/kg
11-20 kg 1000kcal + 50 kcal foe each kg > 10 1500 + 20 for each
>20 more than 20
B. Fluid Requirement
AGE/WT Fluid Rquirement
Neonates
VLBW (≤ 1500 gm) Initiate at 40 – 60 ml/kg/day and increase by 10 ml/kg/day
till 120 ml/kg is reached

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
AGA & LBW
✓ Neonates under radiant heaters or on phototx an extra
30ml/kg/day of water
Infants & Older
Children
<10 kg 100 – 120 ml/kg
11-20 kg 1000ml + 50 ml foe each kg > 10 1500 + 20 for each
>20 more than 20
 C. Protein Requirement
AGE/WT Dosage (gm/kg/day)
VLBW (≤ 1500 gm) 2.25
1– 12 months 2.50
2– 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.
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 yr Adolescents
mmol/kg mmol/kg mmol/kg mmol/kg
NaCl 3 –5 3 –4 3 –4 60 – 100
K 2 –4 2 –3 2 –3 80 – 120
Ca 0.6 – 1.0 0.25 – 1.2 0.25 – 1.2 4.7
(max of (max of
4.7) 4.7)
Glucos 1.0 1 –2 1 –2 30 – 45
PO4 0.125- 0.125- 0.125- 4 –8
0.250 0.250 0.250
Ma

✓ 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.
G. Trace Elemental Requirements
Trace Elemental Prematures Infants & Adolescents
Children
(ug/kg) (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

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
100x
 D. CHO: % = gm x 100 10% x = 125 gms
Vol 1250
Prep: D50W
50 gm = 125gm
100 ml x
E. Lipids: ( 1 gm) 15 x 1 =15
Prep: 10% Intralipid (10gms/100ml)

10 gms x 15 gm = 150
100 ml
F. Sodium: (3 mmol/kg) 15 x 3 = 45 mmol/kg
Prep: 2.5 mmol/ml
2.5 mmol x 45 = 18 ml ml x
G. Potassium: (2 mmol/kg) 15 x 2 = 30 mmol/kg
Prep; 2 mmol/ml
2.0mmol x 30 = 15 ml ml x
H. Calcium gluc: (0.25 mmol/kg) 15 x 0.25 = 3.75
Prep: 10% Cal gluc
0.25 mmol x 3.75 = 15 ml ml x
I. Magnesium: (0.25 mmol/kg) 15 x 0.25 = 3.75
Prep: 25% MgSO4
2 mmol x 3.75 = 1.9 ml x 2 = 4 ml ml x
J. Total Mixture:
24 hrs 12 hrs
Aminostril 250 125
D50W 250 125
Na 18 9
K 15 7.5
Cal gluc 15 7.5
MgSO4 4 ml 2 ml
Total 552 276