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Toaz - Info Pedia Notes Compiledpdf PR
Toaz - Info Pedia Notes Compiledpdf PR
Toaz - Info Pedia Notes Compiledpdf PR
NOTES
P e d i a t r i c N o t e s |2
TABLE OF CONTENTS
I. ADMITTING ORDERS
NEONATOLOGY
NICU....................................................................................... 11
NEUROLOGY
FEBRILE SEIZURES.................................................................... 12
LUMBAR TAP........................................................................... 13
PULMONOLOGY
BRONCHIAL ASTHMA.............................................................. 14
BPN......................................................................................... 15
GASTROENTEROLOGY
AGE......................................................................................... 16
IMMUNOLOGY
HYPERSENSITIVITY REACTION................................................. 17
INFECTIOUS DISEASES
DENGUE FEVER....................................................................... 18
II. MEDICATIONS
ANTIBACTERIAL
CELL WALL ACTIVE ANTIBIOTICS
PENICILLIN....................................................................... 20
Amoxicillin........................................................... 20
Cloxacillin............................................................ 20
Flucloxacillin........................................................ 20
PENICILLIN COMBINATIONS
Amx + CA............................................................. 20
CEPHALOSPORINS
1ST GEN
Cefalexin.............................................................. 21
2ND GEN
Cefaclor............................................................... 21
Cefuroxime.......................................................... 21
Cefrozil.............................................................. 21
3RD GEN
Cefixime.............................................................. 21
Cefdinir................................................................ 21
P e d i a t r i c N o t e s |3
ANTIFUNGAL
Ketoconazole....................................................... 27
Nystatin............................................................... 27
Fluconazole......................................................... 27
NEUROLOGY
ANTICONVULSANT
Diazepam............................................................ 28
Midazolam........................................................... 28
Phenobarbital...................................................... 28
Phenytoin............................................................ 29
Carbamazepine.................................................... 29
Oxcarmazepine.................................................... 29
Valproic Acid....................................................... 30
Topiramate.......................................................... 30
RESPIRATORY DRUGS
NASAL
NaCl..................................................................... 32
Oxymetazoline..................................................... 32
Xylometazoline.................................................... 32
ORAL
Phenylpropanolamine......................................... 33
Bromphenamine Maleate + Pheylephrine............ 33
Carbinoxamine maleate + Phenylephrine HCl...... 33
Loratadine + PPA................................................. 33
MUCOLYTIC
Carbocisteine....................................................... 34
Ambroxol............................................................. 35
B2 AGONIST
Salbutamol.......................................................... 36
Terbutaline.......................................................... 36
Doxofylline.......................................................... 36
Procaterol........................................................... 37
Theophylline........................................................ 37
ANTI-TUSSIVES
Butamirate Citrate............................................... 37
Dextrometorphan................................................ 37
P e d i a t r i c N o t e s |5
IMMNULOGY
ANTIHISTAMINE
Diphenhydarmine................................................ 38
Hydroxyzine......................................................... 38
Ceterizine............................................................ 38
Loratadine........................................................... 39
Desloratadine...................................................... 39
STEROIDS
INHALED
Budesonide.......................................................... 39
ORAL
Prednisone.......................................................... 39
Prednisolone........................................................ 39
INTRAVENOUS
Hydrocortisone.................................................... 39
IVIG INFUSION.................................................................... 40
CARDIOVASCULAR DRUGS
ANTIHYPERTENSIVE
Hydralazine................................................................. 41
Spirinolactone............................................................. 41
GASTROINTESTINAL DRUGS
ANTACIDS
MgOH + AlOH.............................................................. 43
Simethicone................................................................ 43
ANTISPASMODIC
Dicycloverine.............................................................. 43
Domperidone.............................................................. 43
H2-BLOCKER
Ranitidine................................................................... 44
Cimetidine.................................................................. 44
Famotidine.................................................................. 44
ANTI-DIARRHEAL
ENKEPHALINASE INHIBITOR
Racedotril............................................................ 44
P e d i a t r i c N o t e s |6
OTHER GI DRUGS
PARENTERAL NUTRITIONAL PRODUCTS
LYSMIX................................................................ 44
SUPPLEMENTS & ADJUVANT THERAPY
PROBIOTICS
Prozinc............................................................ 45
Erceflora......................................................... 45
PRETOXIN............................................................ 45
ANTIPYRETIC/ANALGESIC
Paracetamol................................................................ 46
Mefenamic Acid.......................................................... 46
Aspirin........................................................................ 47
Ibuprofen.................................................................... 47
DRIPS
Dengue....................................................................... 48
Furosemide................................................................. 49
Noradrenaline............................................................. 49
Dopamine................................................................... 49
Dobutamine................................................................ 49
Terbutaline................................................................. 49
Precedex..................................................................... 50
Ketamine.................................................................... 50
Morphine.................................................................... 50
Naproxen.................................................................... 50
ELECTROLYTES
KCl.............................................................................. 50
NaHCO3...................................................................... 50
Ca GLUCONATE........................................................... 50
VITAMINS 51
P e d i a t r i c N o t e s |7
III. CONDITIONS
NEONATOLOGY
Essential Newborn Care Protocol (DOH)............................. 54
Newborn Care.................................................................... 54
Apgar Score........................................................................ 56
Newborn Screening............................................................ 56
Nursery Notes
Dextrosity................................................................... 57
Electrolyte Requirements................................................... 59
Glucose Infusion Rate......................................................... 59
Emergency Intervention
Level of Umbillical Catheterization.............................. 59
ET Tube Determination............................................... 60
Total Flow Rate........................................................... 60
Extubation.................................................................. 60
Cows Milk Allergy............................................................... 61
Hyperbilirubinemia
Bilirubin Metabolism................................................... 61
Neonatal Jaundice....................................................... 62
Kramer Classification................................................... 62
Bilirubin Values........................................................... 63
Physiologic vs Pathologic Jaundice.............................. 63
Breastfeeding vs Breastmilk Jaundice.......................... 64
Treatment of Hyperbilirubinemia................................ 65
Neonatal Sepsis.................................................................. 66
NEUROLOGY
Glassgow Coma Scale......................................................... 67
Motor Assessment............................................................. 68
Deep Tendon Reflexes....................................................... 68
Cranium
Caput succedaneum.................................................... 68
Cephalhematoma........................................................ 68
Hydrocephalus................................................................... 69
Seizure
Bening Febrile Seizure................................................ 70
Simple vs Complex...................................................... 70
P e d i a t r i c N o t e s |8
Cerebrspinal Fluid
CSF PATHWAY............................................................. 71
LUMBAR PUNCTURE.................................................... 71
CSF ANALYSIS.............................................................. 71
Hydrocephalus................................................................... 72
Bells Palsy.......................................................................... 73
Cerebral Palsy.................................................................... 74
Hypoxic Ischemic Enchepalopathy...................................... 75
PULMONOLOGY
PCAP
Clinical Features of Pneumonia................................... 77
Microbial Causes of CAP aacdg to Age......................... 77
CXR In Assessing CAP etiology..................................... 78
Therapeutic Mngt of CAP............................................ 78
CPG............................................................................. 80
ASTHMA
Severity of Asthma Exacerbation................................. 82
Levels of Asthma Control (GINA)................................. 83
Management Approach Based on Control................... 83
BRONCHIOLITIS.................................................................. 84
VIRAL CROUP VS EPIGLOTITIS............................................. 85
BICARBONATE DEFICIT CORRECTION.................................. 86
CARDIOVASCULAR
Transfusion Medicine
Blood Products........................................................... 87
Double Volume Exchange Therapy.............................. 88
SHOCK............................................................................... 89
Signs of Shock............................................................. 90
LABORATORY MEDICINE
HEMATOLOGY
Complete Blood Count................................................ 91
RBC INDICES................................................................ 91
ANC............................................................................. 92
CLINICAL CHEMISTRY
Glucose...................................................................... 92
P e d i a t r i c N o t e s |9
GASTROENTEROLOGY
Assessment of Dehydration................................................ 93
Caposition of ORS............................................................... 93
Oral Rehydration Theraphy................................................ 94
Fluid Management............................................................. 94
Composition of IV Solution................................................. 95
Maintenance Water........................................................... 95
NEPHROLOGY
GFR Normal Values............................................................. 96
Computations
GFR............................................................................. 96
OFI.............................................................................. 96
BSA............................................................................. 96
AGN................................................................................... 97
GABS.................................................................................. 98
INTERPRETAtION OF BUN-CREA RATIO............................... 99
IMMUNOLOGY
Anaphylaxis........................................................................ 100
Dermatitis.......................................................................... 101
Atopic......................................................................... 101
Contact....................................................................... 101
Seborrheic.................................................................. 101
Juvenile Rheumatoid Arthritis............................................ 102
Systemic Lupus Erythematosus........................................... 103
Henoch-Schonlein Purpura................................................. 104
Immunization..................................................................... 105
Vaccines............................................................................. 106
Rabies Vaccine............................................................ 106
Tetanus Toxoid........................................................... 107
INFECTIOUS DISEASES
Rheumatic Heart Disease
Jones Criteria.............................................................. 108
Infective Endocarditis
Modified Duke Criteria................................................ 109
Paramyxoviridae (Mumps)................................................. 110
Rubella (German Measles)................................................. 111
Rubeola (Measles).............................................................. 112
P e d i a t r i c N o t e s | 10
NUTRITION
Waterloo Classification....................................................... 117
Growth & Caloric Requirements......................................... 117
Caloric & Protien Requirements......................................... 118
Estimated Catch Up Growth Requirement.......................... 118
Approximate Daily Water Requirement.............................. 118
Osterized Feeding.............................................................. 119
Milk Formulas.................................................................... 120
Total Parenteral Nutrition.................................................. 121
TPN in Pediatrics........................................................ 122
TPN for Neonates........................................................ 125
Sample Solving............................................................ 126
EMERGENCY MEDICINE
ET Tube Determination...................................................... 128
Laryngoscope Sizes............................................................. 128
Emergency Management.................................................... 128
Epinephrine
Amiodarone
Cardioversion
Albumin
Epinephrine Drip
Levophed
Dopamine
Anaphylaxis........................................................................ 130
O2 Supplementation.......................................................... 130
NORMAL VALUES
Ideal Body Weight.............................................................. 131
Head Circumference........................................................... 131
Length................................................................................ 131
Weight for Height .............................................................. 131
Height for age..................................................................... 131
P e d i a t r i c N o t e s | 11
ADMITTING ORDERS
NEONATOLOGY
NICU
Please admit under RI, LI, PD or AP
TPR q4H
May breastfeed if NSD; NPO x 2hrs if CS
Labs:
NBS at 24 hrs old, secure consent
CBC, BT (if w/ maternal illness, PROM or UTI
HGT now then 1, 3, 6, 12, 24, 48 hrs old (GDM)
HGT now (SGA or LGA)
Medications:
Erythromycin eye ointment both eyes
Vit K 1 mg IM (term); 0.5 mg (PT)
Hep B vaccine 0.5 ml IM, secure consent
BCG 0.05 ml ID (PT); 0.1 ml (term), secure onsent
SO
Routine NB care
Monitor VS q30 mins until stable
Thermoregulate at 36.5 to 37.5°C
Place under droplight (NSD); isolette (CS)
Suction secretion prn
Will infrom AP /AP attended delivery
P e d i a t r i c N o t e s | 12
NEUROLOGY
FEBRILE SEIZURE
Please admit under the service of Dr.
TPR q4H and record
DAT once fully awake
Labs:
CBC
U/A (MSCC)
IVF:
D5 0.3 NaCl 1P (50cc/kg in 8 h if <2 yo)
D5 0.3 NaCl 1L (30cc/kg in 8 h if >2 yo)
D5LR 1L at 30cc/kg in 8hif >40 kg
Medications:
Paracetamol prn q4h for T > 37.8°C
SO:
MIO q shift and record
Monitor VS q2h and record
Monitor neurovital signs q4h and record
Continue TSB for fever
Seizure precaution at bedside as ff:
Suction machine at bedside
O2 with functional gauge; if with active sz give O2 at 2lpm via NC
Diazepam IVTT (0.3 mkd max of 5 mg IV) prn for seizure
Will inform AP
Pls inform Dr _____ of this admission
Thank you.
P e d i a t r i c N o t e s | 13
PULMONOLOGY
BRONCHIAL ASTHMA
Please admit under the service of Dr.
TPR q4H and record
NPO if dyspneic
Labs:
CBC CXR APL*
ABG* U/A (MSCC)
IVF:
D5 0.3 NaCl 1P (50cc/kg in 8 h if <2 yo)
D5 0.3 NaCl 1L (30cc/kg in 8 h if >2 yo)
D5LR 1L at 30cc/kg in 8hif >40 kg
Medications:
Paracetamol prn q4h for T > 37.8°C (10 – 15 mkdose)
USN with Salbutamol or Salbu+Ipratropium neb; 1 neb x 3 doses
Incorporate Budesonide 10 mkd LD (max 200mg IV); then 5mkd
q6h IV (max of 100 mg IV)
Ranitidine IVTT at 1mkdose (if on NPO)
SO:
MIO q shift and record
Monitor VS q2h and record
Refer for persistence of tachypnea, alar flaring and retractions
O2 at 2 lpm via NC, refer for desaturations <95%
Will inform AP
Pls inform Dr _____ of this admission
Thank you.
P e d i a t r i c N o t e s | 15
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.
P e d i a t r i c N o t e s | 16
GASTROENTEROLOGY
AGE
Please admit under the service of Dr.
TPR q4H and record
DAT once fully awake; NPO x 2hrs if with vomiting
Labs:
CBC
U/A (MSCC)
F/A (Concentration Method)
IVF:
D5 0.3 NaCl 1P (50cc/kg in 8 h if <2 yo)
D5 0.3 NaCl 1L (30cc/kg in 8 h if >2 yo)
D5LR 1L at 30cc/kg in 8hif >40 kg
Medications:
Paracetamol prn q4h for T > 37.8°C
Zinc (E Zinc)
Drops 10mg/ml 1ml OD (<6 mos)
1ml BID (6 mos – 2 yo)
Syrup 20 mg/5ml (>2 yo) 5ml OD
Ranitidine IVTT at 1mkdose (if with abdominal pain)
SO:
MIO q shift and record
Monitor VS q2h and record
Continue TSB for fever
Chart character, frequency and amount of GI losses and replace w/
PLR 1L/1P vol/vol
Will inform AP
Pls inform Dr _____ of this admission
Thank you.
P e d i a t r i c N o t e s | 17
IMMUNOLOGY
HYPERSENSITIVITY REACTION
Please admit under the service of Dr.
TPR q4H and record
Hypoallergenic diet
Labs:
CBC
U/A (MSCC)
IVF:
D5 0.3 NaCl 1P (50cc/kg in 8 h if <2 yo)
D5 0.3 NaCl 1L (30cc/kg in 8 h if >2 yo)
D5LR 1L at 30cc/kg in 8hif >40 kg
Medications:
*Epinephrine (1:1000) 0.1mg/kg/dose IM anterolateral thigh
(max of 0.3 mg)
*Salbutamol neb x 3 doses q 20 mins
Diphenhydramine 10 mkdose LD (max of 200mg IV); thenmg IV)
5mkdose q6h IV (max of 100
Ranitidine IVTT at 1mkdose q 12h
SO:
MIO q shift and record
Monitor VS q2h and record to include BP
Continue TSB for fever
O2 at 2 lpm via NC, or 6 lpm via facemask
Attach to pulse oximeter, refer for desaturations <95%
Will inform AP
Pls inform Dr _____ of this admission
Thank you.
P e d i a t r i c N o t e s | 18
INFECTIOUS DISEASES
DENGUE FEVER
Please admit under the service of Dr.
TPR q4H and record
DAT ( No dark colored foods)
Labs:
CBC, Plt (optional APTT and PT)
Blood typing
U/A (MSCC)
IVF:
D5 0.3 NaCl 1P/1L (<40 kg) at 3 – 5 cc/kg
D5LR 1L (>40 kg) at 3 – 5 cc/kg
Medications:
Paracetamol prn q4h for T > 37.8°C
Omeprazole 1mkdose max 40 mg IVTT OD
SO:
MIO q shift and record
Monitor VS q2h and record, to include BP
Continue TSB for fever
Refer for Hypotension, narrow pulse
pressure (<20mmHg)
Refer for signs of active bleeding like
epistaxis, gum bleeding, melena,
coffee ground vomitus
Will inform AP
Pls inform Dr _____ of this admission
Thank you.
P e d i a t r i c N o t e s | 19
P e d i a t r i c N o t e s | 20
MEDICATIONS
ANTIBACTERIALS
CELL WALL ACTIVE ANTIBIOTICS
PENICILLINS
Amoxicillin (30 – 50 mkday) TID
Pediamox Susp : 250mg/5ml
Drops : 100mg/ml
Himox Cap : 250mg 500mg
Moxicillin Susp : 125mg/5ml 250mg/5ml
Harvimox Drops : 100mg/ml
Novamox
Amoxil Susp : 125mg/5ml 250mg/5ml
Cap : 250mg 500mg
Glamox Drops : 100mg/ml
Globapen
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
PENICILLIN COMBINATIONS
Amoxicillin + Clavulanic acid (30 – 50 mkday)
Augmentin Tab: 375mg (250mg); 625 (500mg)
Amoclav Susp: 156.25mg/5ml (125mg) TID
228.5mg/5ml (200mg) BID
312.5mg/5ml (250mg) TID
457mg/5ml (400mg) BID
642/5 (600mg)
P e d i a t r i c N o t e s | 21
CEPHALOSPORINS
1st Generation
Cefalexin (25 – 100 mkd ) q 6-8 h
Lexum Cap : 250mg; 500mg
Cefalin Susp : 125mg/5ml
250mg/5ml
Keflex Drops : 100mg/ml
Ceporex Cap : 250mg 500mg
Selzef Caplet: 1 gm
Granules: 125mg/5ml 250mg/5ml
Drops: 125mg/1.25ml
2nd Generation
Cefaclor (20 – 40 mkd ) q 8 – 12 h
Ceclor Pulvule: 250mg 500mg
Ceclor CD 375mg 750mg
CD ext release Susp: 125mg/5ml 187mg/5ml
250mg/5ml 375mg/5ml
Drops: 50mg/ml
Xelent Cap : 250mg 500mg
Vercef Susp : 125mg/5ml 250mg/5ml
Cefuroxime (20 – 40mkd) q 12h
Zinnat Cap : 250mg 500mg
Sachet: 125mg/sat 250mg/sat
Susp: 125mg/5ml
Cefprozil (20 – 40mkd) q 12h
Procef Susp : 125mg/5ml 250mg/5ml
3rd Generation
Cefixime (6 – 12 mkd) q 12h
Tergecef Susp : 100mg/5ml
Zefral Drops: 20mg/ml
Ultrazime
Cefdinir (7mg/kg q 12h OR 14mg/kg OD)
Omnicef Cap : 300mg
Sachet/Susp: 125 mg/5ml 250mg/5ml
P e d i a t r i c N o t e s | 22
LINCOSAMIDES
Clindamycin PO: 20 – 30 mkday q 6 – 8h
IV: 25 – 40vmkday q 6h
Susp: 75mg/5ml
Cap: 150mg 300mg
Amp: 150mg/ml
CHLORAMPHENICOL
Chloramphenicol (50 – 75 mkd) q6h
Pediachlor Susp: 125mg/5ml
Chloramol Tab : 250mg 500mg
Kemicetine
Chloromycetin
TETRACYCLINES
Tetracycline 25 – 50 mkday q6h
Doxycycline 5 mkday BID
ANTIBACTERIAL COMBINATIONS
TRIMETHOPRIM + SULFAMETHOXAZOLE
COTRIMOXAZOLE (TM 5 – 8 mkd) q 12h
Bactille – TS Susp/5ml SMZ 400mg TM 80mg
Bacidal Tab 800mg 160mg
Globaxole
Trizole Susp/5ml SMZ 400mg TM 80mg
TRIMETHOPRIM + SULFADIAZONE
Triglobe Tab SDZ 410mg TM 90mg
Forte 820mg 180mg
Susp/5ml 205mg 45mg
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
P e d i a t r i c N o t e s | 25
ANTI-TB MEDS
Isoniazid (10 – 12 mkd) ODAC or 2hrs PC
Comprilex Suspension:
Nicetal 200mg/5ml
Trisofort 100mg/5ml
Odinah 200mg/5ml
150mg/5ml
Tablet 400mg
Rifampicin (10 – 20 mkd) ODAC or 2hrs PC
Natricin 100mg/5ml
Rifadin 200mg/5ml
100mg/5ml
Rimactane 100mg/5ml
Rimaped 200mg/5ml
Tablet 300mg
450mg
Pyrazinamide (16 – 30 mkd) BID/TID
(PZA)
CIBA 250mg/5ml
Zcure
Zinaplex 500mg/5ml
Tablet 500mg
P e d i a t r i c N o t e s | 26
ANTIPROTOZOAN
AMOEBICIDES
Metronidazole PO: 30 – 50 mkday q 8h
IV: 30 mkday q 8h
Anaerobia Susp : 125mg/5ml
Tab : 250mg
Servizol Susp: 200mg/5ml
Tab : 250mg 500mg
Flagyl Susp : 125mg/5ml
Tab : 250mg 500mg
Etofamide (15 – 20 mkd) TID
Kitnos Susp : 125mg/5ml
Tab : 200mg 500mg
Diloxanide furoate (20mkd) q8h x 10 days
Furamide Tab : 500mg
Dilfur Susp: 125mg/5ml
Secnidazole
Flagentyl 2 tab now then 2 tabs after 4 hrs
Ercefuryl (20mkday)
P e d i a t r i c N o t e s | 27
ANTI-HELMINTHICS
Oxantel + Pyrantel pamoate (10 – 20 mkd) SD
Trichiuriasis: x 2 days Hookworm: x 3 days
Quantrel Susp : 125mg/5ml
Tab : 125mg 250mg
Mebendazole *not recommended
below 2 yo
Antiox Susp: 50 mg/ml 100mg/ml
Tab: 125mg 250mg
100 mg BID x 3 days
500mg SD (>2 yo)
Albendazole <2 yo: 200mg SD
>2yo: 400mg SD
*may give x 3 days if with severe
infestation
Zentel Susp: 200mg/5ml
Tab : 400mg
ANTIVIRAL
Acyclovir (20 mkdose) q 4 – 6 h
Max 800mg/day x 5 days
Zovirax Susp: 200mg/5ml
Acevir Tab: (Blue) 400mg (Pink) 800mg
ORAL ANTIFUNGALS
Ketoconazole (6mkd) q 4 – 6h
Daktarin Adult & Child: ½ tsp q 6h
Infant: ¼ tsp q 6 h
Nystatin
Mucostatin Susp: 100,000 u/5ml
Ready mix susp Tab: 500,000 u
Fluconazole (3 – 6 mkd) OD x 2wks
Diflucan Cap: 50mg 150mg 200mg
Vial: 2mg/ml x 100 ml
P e d i a t r i c N o t e s | 28
NEUROLOGY
ANTICONVULSANT
DIAZEPAM 0.2 – 0.3 mkdose
Drip: 1amp in 50cc D5W
10mg/amp
MIDAZOLAM 0.05 - 0.2mkdose (0.15 mkdose) prn 2 – 3 mins interval
IV (1, 5mg/ml)
6 mos - 5 yo 0.05 - 0.10 max of 0.6 mg/kg
6 yo - 12 yo 0.25 - 0.05 max of 0.4 mg/kg
>12 yo 0.50 - 2 mg/dose over 2 mins
PHENOBARBITAL LD: 15 – 20 mkd MD: 5 mkdose q 12h
(max load 20 mkday IV)
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
P e d i a t r i c N o t e s | 29
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 BID/ QID
1 wk interval
> 12 y 200 mg BID 200 mg/ 24H at 800 - 1200 mg/24H
1 wk interval BID/ QID
TOPIRAMATE 2 - 16 yo
Initial: 1 - 3 mkd PO q HS x 7 days then Increment:
increase by 1 - 3 mkday for 1 - 2 wks then
Maintenance: 5 -9 mkD BID
Topamax Cap 15 mg, 25 mg
Tabs 25 50 100 200mg
P e d i a t r i c N o t e s | 31
P e d i a t r i c N o t e s | 32
RESPIRATORY DRUGS
DECONGESTANT
Nasal
NaCl 2 – 4 drps/spray per nostril TID/QID
2 sprays/nostril then suction q6h x 3 days
Salinase Nasal spray
Muconase 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 < 1 yo: 1 – 2 drps OD/BID
HCl 1 – 6 yo: 1 – 2 drps OD/BID max TID
Adult: 2 – 3 drps / 1 squirt TID max QID
Otrivin
P e d i a t r i c N o t e s | 33
Oral
Phenylpropanolamine HCl (0.3 – 0.5 mkdose)
Disudrin 1 – 3 mos: 0.25 ml
4 – 6 mos: 0.5 ml
7 – 12 mos: 0.75 ml
1 – 2 yo: 1 ml
2 – 6 yo: 2.5 ml
7 – 12 yo: 5 ml
Drops: 6.25ml q6h
Syr: 12.5mg/5ml q6h
Brompheniramine maleate + Phenyleprine
Dimetapp 1 – 6 mos: 0.5ml TID/QID
7 – 24 mos: 1ml TID/QID
2 – 4 yo: ¾ tsp
4 – 12 yo: 5ml
Adult: 5 – 10 ml
1 tab BID
Infant drops: (0.1mkdose)
Syr/5ml: 2mg/5ml
Extentab
Carbinoxamine maleate + Phenylephrine HCl
Rhinoport 1 – 5 yo: 5ml BID
6 – 12 yo: 10ml BID
Adult & > 12yo: 1 cap / 15ml BID
Syrup
Cap
Loratadine + PPA
Loraped <30 kg: 2.5ml BID
>30 kg: 5ml BID
Syrup: 5mg/ml
P e d i a t r i c N o t e s | 34
MUCOLYTIC
Carbocisteine Infant Drops QID
<3mos 0.25ml
3 – 5 mos 0.5ml
6 – 8 mos 0.75ml
9 – 12 mos 1ml
Capsule TID
Adult & >12 yo 1 cap
Carbocisteine Drops: 40mg/ml
(Solmux) 1 – 3 mos: 0.5ml TID/QID
3 – 6 mos 0.75ml
6 – 12 mos 1ml
1 – 2 yo 1.5 ml
Susp: 100mg/5ml 200mg/5ml
2 – 3 yo 5ml 2.5ml
4 – 7 yo 10ml 5 ml
8 – 12 yo 15ml 7.5ml
B2 AGONIST
Salbutamol (0.1 – 0.15 mkdose)
Ventolin Tab 2mg
Syr 2mg/5ml
Nebule 2.5mg/2.5ml
Ventar Tab 2mg
Hivent Syrup Syr 2mg/5ml
Salbutamol + Guaifenesin
Asmalin Tab: 1 tab TID
Broncho Syrup:
2 – 6 yo 5 – 10 ml BID/TID
Pulmovent 7 – 12 yo 10ml
Terbutaline sulfate ( 0.075 mkdose)
Terbulin Tab 2.5mg
Pulmoxel Tab 2.5mg
Syr 1.5mg/5ml
Nebule 2.5mg/ml
Bricanyl Tab 2.5mg
Syr 1.5mg/5ml
Nebule 5mg/2ml
Expectorant
Guaifenesin + Terbutaline Sulfate
Bricanyl Expectorant TID
Per 5ml 66.65mg/1.5mg
Doxofylline (6 – 8 mkdose) BID x 7 – 10 days
Ansimar Syrup 100mg/5ml
Tab 400mg
P e d i a t r i c N o t e s | 37
ANTITUSSIVES
Butamirate citrate 3 yo 5 ml TID
>6 yo 10ml TID
>12 yo 15ml TID
Adult 15ml 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
P e d i a t r i c N o t e s | 38
IMMUNOLOGY
ANTIHISTAMINE
Diphenhydramine HCl (5mkd) q 6h
IM/IV/PO: 1 – 2 mkdose
Benadryl Syr: 12.5mg/5ml
Cap: 25mg 50mg
Inj: 50mg/ml
Hydroxyzine (1mkd) BID
Adult: 10mg BID 25mg ODHS
Iterax Syr: 2mg/ml
Tab: 10mg 25mg 50mg
Ceterizine (0.25mkdose)
6mos - <12mos : 1ml OD
12mos - <2 yo: 1ml OD/BID
2 – 5 yo: 2ml OD / 1ml BID
6 – 12 yo: 10ml (2 tsp) OD
5ml BID
1 tab OD/ ½ tab BID
Adult & >12yo: 1 tab OD
Virlix Oral drops: 10mg/ml
Oral soln: 1mg/ml
Tab: 10mg
Allerkid Drops: 2.5mg/ml
Syr: 5mg/5ml
Alnix Drops: 2.5mg/ml
Syr: 5mg/5ml
Tab: 10mg
P e d i a t r i c N o t e s | 39
STEROIDS
INHALED
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
IVIG INFUSION
Preparation:
2.5g/50cc 500g/10cc 25g/100cc
5g/100cc 10g/250cc
Computation:
Wt x 2 g /kg IVIG
Ex wt: 7.2 kg
7.2 x 2 + 16 g IVIG
16g IVIG 2. 5 g = 320 cc
X
Cc 50cc
# of vials = total cc 320cc = 6.4 vials
50cc 50cc
320cc x 0.03 = 9. 6 cc/h for 30 mins
Transfuse 9 – 10cc/h IVIG for the 1st 30mins if no reaction, run the
remaining volume for 12H
Refer for any infusion reactions
Close ML
Monitor v/s q 30 mins while on infusion
If after IVIG if still febrile, rpt IVIG after 3 D
If after 2nd IVIG still febrile – start Prednisone
Aspirin 80 mkD QID
30 mg, 80, 100, 300 mg
P e d i a t r i c N o t e s | 41
CARDIOVASCULAR
ANTIHYPERTENSIVES
Hydralazine PO: 0.75 – 1.0 mkday q 6 – 12 h
Apresoline IV: 0.1 – 0.2 mkdose
Spirinolactone 1 – 3 mkday
P e d i a t r i c N o t e s | 42
GASTROENTEROLOGY
ANTACIDS
Maalox 5ml/10kg
(plain, plus) 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 q6–8h
2.5 – 5ml/10kg BW TID
Dyspepsia: 2.5/10kg TID
Nausea: 2.5 – 5ml/kg TID
0.3 – 0.6 ml/5kg BW TID/QID
Motilium Susp 1mg/ml
Tab 10mg
Vometa Oral drops 5mg/ml
Susp 5mg/5ml
Tab 10mg
P e d i a t r i c N o t e s | 43
H2-BLOCKER
Ranitidine 1 – 2 mkdose q 12h
Zantac Tab 75mg 150mg 300mg
Cimetidine Neonates: 5 – 20 mkday q6 – 12h
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
ANTI-DIARRHEAL
Enkephalinase - Opiod Medication
Inhibitor - Reduce intestinal motility
- Antisecretory effect—it reduces the
secretion of water and electrolytes into the
intestine
Racecadotril 1.5 mg/kg for PRN (Max: 1 wk)
(Hidrasec) Cap: 100mg
Sachet: 10mg 30mg
OTHER GI DRUGS
MULTIVITAMINS
LYSMIX 0.3 cc/k/dose TID Ceiling = 0.4
P e d i a t r i c N o t e s | 45
PROBIOTICS
Lactobacillus acidophilus, Bifidobacterium bifidum, Lactobacillus
casei, Bifidobacterium infantis, Bifidobacterium longum,
Lactococcus lactis, oligosaccharide, Zn, lactose, maltodextrin,
citric acid, sucralose
Prozinc Drops 10 mg/ml
< 6 mos 1 ml OD
< 6 mos – 2 yo 1 ml BID
Syrup 20 mg/5ml
> 2 yo 5ml OD
Sachet
Bacillus clausii
Erceflora Per vials: 2billion org/5ml
Max for 2 wks OD/Q4H
>1mos – 11yo: 1-2 vials /day
Adults: 2-3 vials/day
ANALGESIC/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
P e d i a t r i c N o t e s | 47
DRIPS
Dengue Drips
P e d i a t r i c N o t e s | 49
Furosemide drip
Dose: 0.04 - 0.5
80 mg + 32 cc
Wt x dose = rate (cc/h)
2
Furo drip = 0.1 - 0.5mg/k/hr
Prep: 20mg/2ml (2mg/ml)
Rate: (wt x dose)/2 = cc/hr ex. 14.5kg x 0.45 =
3.2cc/hr
To order: 8ml Furo + 32ml D5W +40 cc to run at
3.2cc/hr
DEXMEDETOMIDINE
Sedation of initially intubated and mechanically ventilated
patients during treatment in an intensive care setting.
Precedex drip Dose: 0.2 - 0.7
1ml + 99cc D5W to run at cc/h
Wt x dose = rate (cc/h)
KCl NaHCO3
IV 2 meq/ml Inj premixed: 5% (0.6
Child: 0.5 – 1meq/k/dose meq/ml)
infusion of 500ml
0.5 meq/k/h for 1-2 h Tabs: 325 mg (3.8 meq), 650
Tabs: 8, 10, 15, 20 meq mg (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: 84 – 840 mg (1- 10
1cc/k/dose x 3doses; meq)/kg/D PO QID
Max: 10cc/dose + equal amt
of sterile water
P e d i a t r i c N o t e s | 51
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 7 - 12yo 10 - 15 ml OD
Anemia) 3 - 6yo 5 - 10 ml OD
1 - 2yo 2.5 - 5 ml OD
Iberet
Ferlin (10 mcg folic acid)
Macrobee
1 - 2yo 2.5 - 5 cc OD
3 - 6yo 5 - 10 cc OD
7 - 12yo 10 - 15 cc OD
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
<2yo 2.5 ml OD
2-6yo 5 ml OD
7-12yo 5-10 ml OD
P e d i a t r i c N o t e s | 52
Polynerv
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
CONDITIONS
NEONATOLOGY
Washing should be delayed until after 6 hours because this exposes the NB to
hypothermia and remove vernix. Washing also removes the baby’s crawling reflex.
NEWBORN CARE
Umbilical Cord
Cut 8 inches above abdomen after 30 sec
In nursery, cut the umbilical cord 1 ½ inch above the abdomen
Healing should take place around 7 – 10 days
Eye Prophylaxis
1% silver nitrate drops [most effective against Neisseria]
Erythromycin 0.5% [Chlamydia]
Tetracycline 1%
Povidone iodine 2.5%
Vitamin K
Term: 1 mg Vit K
PreT: 0.5 mg
Vaccine
BCG
Hep B
P e d i a t r i c N o t e s | 55
Newborn Screening
Done on 16th hr of life . can be repeated after 2 weeks
Patients w/ CAH will die 7 – 14 days if not treated
Patient w/ CH will have permanent growth defect and MR if not treated
before 4 weeks
NEWBORN CARE
Hypothermia
hypoxia
metabolic acidosis
hyperglycemia
Erythromycin ointment
should be given an hour after birth
gonococcal/chlamydial conjunctivitis
Gonococcal Conjunctivitis
within 7days
Chemical conjunctivitis
disappears within 48H
Other bacterial conjunctivitis
Chlamydial >10-14 days
Staph 48H-5th day (2-5days)
Herpes
Pseudomonas-give Gentamycin
Umbilical stump - sloughed off <14 days
Alcohol - drying effect
P e d i a t r i c N o t e s | 56
APGAR SCORE
o Evaluates the need for resuscitation
o Taken 1 and 5 minutes after birth
0 1 2
Color Blue, pale Body pink, All pink
extremities blue
HR 0 <100 >100
Reflex irritability No response Grimace Cough
Activity Limp Some flexion Active
Respiration Absent Slow, irregular Good
The APGAR Score
8 – 10 Good cardiopulmonary adaptation
4–7 Need for resuscitation, esp ventilatory support
0–3 Need for immediate resuscitation
NEWBORN SCREENING
Disorder Screened Effects Screened Effects if Screened &
treated
Congenital Severe MR Normal
Hypothyroidism (CH)
Congenital Adrenal Death Alive &Normal
Hyperplasia (CAH)
Galactosemia (Gal) Death of Cataract Alive &Normal
Phenylketonuria PKU Severe MR Normal
G6PD Severe Anemia Normal
Kernicterus
Maple Syrup Urine Dse
P e d i a t r i c N o t e s | 57
NURSERY NOTES
Dextrosity
Limits of Dextrosity:
Peripheral line = D12
Central line = D20
Total Fluid Intake (TFI):
Preterm: start at 60 cckd
Term: start at 80 cckd
D10 water 80 cc
Ca gluc 2.2cc
82.2cc to run at 3.3ccx24hrs
Electrolyte requirements:
Na: 2-4 mkd prep’n 2.5 mg/ml
Ca: 100-200mkd prep’n 100mg/ml
K: 2-4 mkd prep’n 2mg/ml
Glucose Infusion Rate:
Dextrosity x IVF rate x 10 ÷ 10
Wt
Ex. 10 kg; IVF D10 IMB at 40cc/h
GIR = 10 x 10 x 40 ÷ 10 = 6.6mkmin
60
NV: Newborn & Infants 6-8 mg/kg/min
Children 4-6 mg/kg/min
If HGT <40 mg/dl, give D10 water slow IV push at 2cc/kg and
repeat HGT after 30 mins-1 hr (may do 3 boluses if still low, may inc dextrosity
or rate)
EMERGENCY INTERVENTION
Level of Umbilical Cathetherization: (cm)
If arterial between T6-T9
Wt x 3 x 8
If venous: (wt x 3) + 8 +1
2
P e d i a t r i c N o t e s | 60
FiO2
o Nasopharyngeal cathether = Flow rate x 20 + 20
Ex. 1L Fio2 = 40
o Nasal catheter = Flow rate x 4 + 20
Ex. 1L FiO2 = 24
Extubation:
o Give Dexamethasone at 0.1 mkdose q 6 hours for 24 hours prior to
extubation
o USN with epinephrine 0.5 cc + 1.5 cc PNSS q 15 mins x 3 doses
then extubate then USN with Salbutamol ½ nebule + 1.5 cc PNSS q
6 hours x 24 hours
o O2 at 10 lpm then decrease as necessary
P e d i a t r i c N o t e s | 61
BILIRUBIN METABOLISM
RBC
↓ Hemeoxygenase
Heme +Globin
↓ Bilirubin Reductase
Biliverdin
↓
Uncomjugated bilirubin Enterohepatic Pathway
↓
Liver SER ß-Glucoronidase
Glucoronyl Transferase ↓
Conjugated bilirubin
↓ Urobilinogen
Urobilin ↓ Stercobilinogen
Stercobilin
Urine Stool
P e d i a t r i c N o t e s | 62
NEONATAL JAUNDICE
Risk Factors
o Jaundice visible on first day of life
o A sibling w/ neonatal jaundice or anemia
o Unrecognized hemolysis
o Non-optimal feeding
o Deficiency: G6PD
o Infection
o Cephalhemaoma or bruising / Central hct >65%
o East Asian/ Mediteranean in origin
KRAMER CLASSIFICATION
ZONE JAUNDICE mg/dl
I Head/neck 6–8
II Upper trunk 9 – 12
III Lower trunk, thigh 12 – 16
IV Arms, leg, below knee 15 – 18
V Hands/feet > 15
P e d i a t r i c N o t e s | 63
Bilirubin (Total)
Cord Preterm <2 mg/dl <34 µmol/L
Term <2 mg/dl <34 µmol/L
0 – 1 days Preterm <8 mg/dl <137 µmol/L
Term <8.7 mg/dl <149 µmol/L
1 – 2 days Preterm <12 mg/dl <205 µmol/L
Term <11.5 mg/dl <197µmol/L
3 – 5 days Preterm <16 mg/dl <274 µmol/L
Term <12 mg/dl <205µmol/L
Older Infants Preterm <2 mg/dl <34 µmol/L
Term <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
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
P e d i a t r i c N o t e s | 64
Treatment of Hyperbilirubinemia
Phototherapy
o Complications: metabolic acidosis, electrolyte
Exchange abnormalities, hypoglycemia, hypocalcemia,
transfusion thrombocytopenia, volume overload, arrhythmias, NEC,
infection, graft versus host disease, and death
PHOTOTHERAPY
o 10 Bulbs
o 20 watts
o 200 hrs
o 30 cms
o Bilirubin in the skin absorbs light energy
o Photo-isomerization reaction converting the toxic native unconjugated 4Z, 15Z-
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
o loose stools, erythematous macular rash, purpuric rash associated with transient
porphyrinemia, overheating, dehydration (increased insensible water loss,
diarrhea), hypothermia from exposure, and a benign condition called bronze baby
syndrome dark, grayish-brown skin discoloration in infants
P e d i a t r i c N o t e s | 66
NEONATAL SEPSIS
Classification
Early: birth to 7th day of life
Late: 8th to 28th day of life
Risk factors
Maternal infection during pregnancy
Prolongrupture of membranes (18 hrs)
Prematurity
Common organism:
Bacteria: GBS, E. coli & Listeria (early)
Viruses: HSV, enteroviruses
Signs & symptom
Non-specific
Dx:
CBC, CXR, blood and urine culture, lumbar tap for CSF studies
Treatment
Empiric antibiotics [Ampicillin + 3rd gen Cephalosporin or Aminoglycoside)
supportive
P e d i a t r i c N o t e s | 67
NEUROLOGY
MOTOR DTR
full resistance with gravity 5/5 very brisk +4
some resistance with 4/5 brisker than average +3
gravity normal +2
movement with gravity 3/5 diminished +1
movement w/o gravity 2/5 no response 0
flicker 1/5
no movement 0/5
CRANIUM
Caput succedaneum
diffuse edematous swelling of soft tses of scalp
extend across midline
edema disappears w/in 1st few days of life
molding and overriding of parietal bones-frequent
disappear during 1st wks of life
no specific tx
Cephalhematoma
subperiosteal hemorrhage
limited to1 cranial bone
occur 1-2 % cases
no discoloration of overlying scalp
swelling not visible for several hours after birth ( blding slow
process)
firm tense mass with palpable rim localized over 1 area of skull
resorbed w/in 2wk- 3mos
calcify by end of 2nd wk
few remain for years
10-25% cases underlying linear skull fracture
No tx but photo in hyperbil
P e d i a t r i c N o t e s | 69
HYDROCEPHALUS
Result from impaired circulation & absorption of CSF or from inceased
production
Obstructive or Noncommunicating
o Due to obstruction w/n ventricular system
o Abnormality of the aqueduct or a lesion in the 4th venticle
(aqueductal stenosis)
Non-obstructive or Communicating
o Obliteration of the subarachnoid cisterns or malfunction of
the arachnoid villi
o Follows SAH that obliterates arachnoid villi; leukemic
infiltrates
Clinical Manifestation
Infant: accelerated rate of enlargement of the head; wide anterior
fontanel & bulging [Normal fontanel size: 2 x 2 cm]
Eyes may deviate downward: due to impingement of the dilated
suprapineal recess on the tectum [setting – sun sign]
Long – tract sign: [brisk DTR, spasticity, clonus, Babinski sign]
Percussion of skull produce a “crackedpot” or Macewen sign *separation
of sutures]
Foreshortened occiput [Chiari malformation]
Prominent occiput [Dandy-Walker malformation]
Treatment
Depends on the cause
Extracranial shunt
Acetazolamide & Furosemide [provide temporary relief by reducing the
rate of CSF production]
P e d i a t r i c N o t e s | 70
SEIZURE
SEIZURE
BENIGN FEBRILE SEIZURE CRITERIA
6 mos – 6 yrs
< 15 mins
Febrile
Family history of febrile seizure
GTC
Not > 1 episode in 1 febrile episode; EEG done after 2 wks of seizure
episode
3% of general population develop epilepsy
1 – 2 % of BFS develop epilepsy
25% recurrence of seizure
Seizure – paroxysmal, time limited change in motor activity and/or
behavior that results from abnormal electrical activity in the brain
Epilepsy – present when 2 or more unprovoked seizure s occur at an
interval greater than 24 hrs apaet
SIMPLE COMPLEX
Type GTC Focal then gen post ictal
CSF PATHWAY
Choroid plexus (lateral ventricle) → Foramen of Monroe → 3rd ventricle
→ Aqueduct of sylvius → 4th ventricle →Foramina of Luschka (2 laterals)
→ & Magendie (median) → SAS → Absorbed in the arachnoid villi,
then in the Venous System
Contraindications to LP
evidence of Inc ICP
severe CP compromise
Skin infection at site of puncture
CSF ANALYSIS
Color Rbc Wbc Diff ct Sugar CHON
Normal
Infant Xantho 0 -100 0 -32 L 100% 70 -80% 60 -
(Term) 150
Infant Clear 0 -100 0 -15 L 100% 70 -80% 60 -
(Preterm) 200
Older Clear 0 0 -10 L 100% > 50% 10-20
child
Viral Clear 0 0 -20 L 100% 40- 60% 40 -60
Mening
TB/Fungal Clear 0 20 - L>N < 40% > 100
500 g%
Bacterial Purulent 0 > 1000 N>L < 50% > 100
Mening g%
Partially Clear 0 100 L>N > 50% Dec
tx BM
P e d i a t r i c N o t e s | 72
HYDROCEPHALUS
Result from impaired circulation & absorption of CSF or from inceased
production
Obstructive or Noncommunicating
o Due to obstruction w/n ventricular system
o Abnormality of the aqueduct or a lesion in the 4th venticle
(aqueductal stenosis)
Non-obstructive or Communicating
o Obliteration of the subarachnoid cisterns or malfunction of
the arachnoid villi
o Follows SAH that obliterates arachnoid villi; leukemic
infiltrates
Clinical Manifestation
Infant: accelerated rate of enlargement of the head; wide anterior
fontanel & bulging [Normal fontanel size: 2 x 2 cm]
Eyes may deviate downward: due to impingement of the dilated
suprapineal recess on the tectum [setting – sun sign]
Long – tract sign: [brisk DTR, spasticity, clonus, Babinski sign]
Percussion of skull produce a “crackedpot” or Macewen sign
[separation of sutures]
Foreshortened occiput [Chiari malformation]
Prominent occiput [Dandy-Walker malformation]
Treatment
Depends on the cause
Extracranial shunt
Acetazolamide & Furosemide [provide temporary relief by reducing the
rate of CSF production]
P e d i a t r i c N o t e s | 73
BELLS PALSY
Acute unilateral facial nerve palsy that is not associated with other cranial
neuropathies or brainstem dysfunction
Usually develops abruptly about 2 wks after SVI [EBV, HSV, mumps]
Upper and lower portions of the face are paretic
Corner of the mouth droops
Unable to close the eye on the involved side
Protection of cornea with methylcellulose eye drops or an ocular
lubricant
Excellent prognosis
P e d i a t r i c N o t e s | 74
CEREBRAL PALSY
Non-progressive disorder of posture & movement often associated with
epilepsy & abnormalities of speech, vision & intellect resulting from defect or
lesion of the developing brain
Etiology: infections, toxins, metabolic, ischemia
Classification
Physiologic Topogrphic
[major motor abnormality] [involved extremities]
1. Spastic 1. Monoplegia [1 side/portion]
2. Athetoid –worm like 2. Paraplegia
3. Rigid 3. Hemiplegia
4. Ataxic 4. Triplegia [3 limbs]
5. Tremor 5. Quadriplegia [all]
6. Atonic 6. Diplegia [LE/UE]
7. Mixed 7. Double hemiplegia
8. unclassified
Clinical Manifestaion
Spastic hemiplegia Arms > legs
Dificulty in hand manipulation obviously by 1 yo
Delayed walking or walk on tiptoes
Spasticity apparent esp. in ankles
Seizure & cognitivr impairment
Spastic diplegia Bilateral spasticity of the legs
Commando crawl
Increased DTRs & (+) Babinski sign
Normal intellect
Spastic quadriplegia Most severe form, due to marked motor
impairment of all extremities & high association
with MR & seizures
Swallowing difficulties
Management
Baseline EEG & cranial CT scan
Hearing & visual function tests
Multidisciplinary approach in the assessment & treatment
For tight heel cord: tenotomy of the Achilles tendon
P e d i a t r i c N o t e s | 75
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)
PULMONOLOGY
PCAP
CLINICAL FEATURES of PNEUMONIA
Bacterial o Fever >38.5C
o Chest recession
o Wheeze not a sign of primary bacterial URTI
Viral o Wheeze
o fever < 38.5
o marked recession
o RR normal or increased
Mycoplasma o School children
o Cough
o wheeze
PCAP
VARIABLE PCAP A PCAP B PCAP C PCAP D
Minimal Risk Low Risk Moderate High Risk
Risk
Comorbid None Present Present Present
Illness
Compliant Yes Yes No No
caregiver
Ability to Possible Possible Not Not
follow up
Presence of None Mild moderate Severe
DHN
Ability to feed Able Able Unable Unable
Age >11 mos >11 mos <11 mos <11 mos
RR
2–12 mos >50/min >50/min >60/min >70/min
1 – 5 yo >40/min >40/min >50/min >50/min
>5 yo >30/min >30/min >35/min >35/min
Signs of Respiratory Failure
Subcosta/ Subcostal/
Retractions - - Intercostal Intercostal
Head Bobbing - - + +
Cyanosis - - + +
Grunting - - - +
Apnea - - - +
Lethargy/
Sensorium None Awake Irritable Stupor/
Coma
Complication:
Effusion None None Present Present
Pneumothora
x
Action Plan OPD OPD Admit (Ward) Admit (ICU)
f/u at end of f/u after 3 Refer to
tx days specialist
P e d i a t r i c N o t e s | 80
ASTHMA
SEVERITY OF ASTHMA EXACERBATION
MILD MODERATE SEVERE RESPIRATORY
ARREST
IMMINENT
Breathless Walking Talking At rest
Infant –softer Infant stops
shorter cry feeding
Diff feeding
BRONCHIOLITIS
Acute inflammation of the small airways in children <2 yrs
Most commonly caused by RSV
Related to exposure to cigarette smoke
Risk factors for severe dse:
o <6 mos
o Prematurity
o Heart or lung disease
o immunodeficiency
Signs /Symptoms
low grade fever, rhinorrhea, cough, wheezing
hyperresonance to percussion
CXR
hyperinflation, interstitial infiltrates
Treatment
Mild [at home]:
o Increased fluids, trial of inhaled bronchodilators, aerosolized
epinephrine
Severe:
o Admit to hospital if: Marked respratory distress; Poor
feeding; O2 sat <92%; hx of prematurity < 34 wks; underlying
cardiopulmonary dse; unreliable caregivers
o Manage with ventilatory and O2 support, hydration, inhaled
bronchodilators and ribavirin
P e d i a t r i c N o t e s | 85
CARDIOVASCULAR
TRANSFUSION MEDICINE
BLOOD PRODUCTS
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
Volume _ = # of exchange
aliquots per exchange
> 3 kg 20 ml
2-3 kg 15 ml
1-2 kg 10 ml
850g-1kg 5 ml
< 850 g 1-3 ml
SHOCK
CO = HR x SV
CO is primarily maintained by changes in HR
HYPOVOLEMIC Pump empty MC in infant &children
Truma, hemorrhage, DHN Normal BV of children
(diarrhea/vomiting) 80ml/kg
Metabolic dse (DM)
Excessive sweating
CARDIOGENIC Weak/sick pump Compromise CO
CHF, cardiomegaly, drug
intoxication, hypothermia,
after cardiac surgery
DISTRIBUTIVE Sepsis Redistribution of fluid w/n
Anaphylaxis vascular space
Barbiturate intox
CNS injury (SCI)
P e d i a t r i c N o t e s | 90
SIGNS OF SHOCK
EARLY LATE
Narrowed pulse Decrease systolic pressure
pressure Decrease diastolic pressure
Orthostatic changes Cold, pale skin
Delayed capillary filling Altered mental state
Tachycardia Diaphoresis
Hyperventilation Decrease urine output
ED 1. Position
MNGT 2. Oxygen
3. Assisted ventilation
4. Intravenous access
5. Fluid (isotonic crystalloid)
6. Reassess (look for improvement in VS, skin signs, mental status;
insert foley cath & monitor UO)
7. Inotropes – help stabilize BP
o Epinephrine - (0.1 – 1 ug/kg/min)
Infusion of choice for Hypotensive pxs
o Dobutamine - (5 – 20 ug/kg/min)
Cardiogenic shock but not severely hypotensive
o Dopamine – [(5 – 20 ug/kg/min αconstrictor effect)
[(10 – 15 ug/kg/min]
Distributive shock after successful fluid resuscitation
8. Cardiogenic shock
o Diuretic – pxs may get worse after fluid challenge
o Adenosine / synchronize cardioversion – SVT
o Defibrillation – Venticular fibrillation
P e d i a t r i c N o t e s | 91
LABORATORY MEDICINE
HEMATOLOGY
COMPLETE BLOOD COUNT
1-3 1 mo 2mos 6 – 12y >12y
days
Hgb 14.5 – 9 -14 11.5 - 13-16
22.5 15.5
Hct .48 - .28 - .42 .35 - .45 .37 - .49
.69
Wbc 9 -30 5 – 19.5 6 -17.5 4.5 -
birth 13.5
Plt 84 – 478 NB After 1 wk, same as adult
150 - 400
Retic 0.4 - 0.6 < 1 -1.2 0.1 -2.9
BLOOD INDICES
MCV Hgb / rbc x 10 80 -94
MCH Hgb / rbc x 10 27 - 32
MCHC Hgb/ hct x 10 32 – 38
Absolute reticulocyte count = pt’s hct x retic %
N hct for age
Reticulocyte Index
Absolute Retic Ct > 2 hemorrhage
2 < 2 rbc production abn
P e d i a t r i c N o t e s | 92
Anemia
< 10 g mild anemia
8-9g mod anemia
<8 g severe anemia
CLINICAL CHEMISTRY
GLUCOSE
PT : 20-60
NB: 30-60
1 d: 40-60
>1d: 50-90
Child: 60-100
Adult: 70-105
P e d i a t r i c N o t e s | 93
GASTROENTEROLOGY
AGE PROTOCOL
1. Continue Feeding
2. ORS – Electrolyte Replacement
3. Sedacious Use of Antibiotics -
4. Zn Supplementation – Aids in reepitheliazation of GI Tract
5. Probiotics – Aids in digestion
COMPOSITION OF ORS
Na K Cl Glu
Glucolyte 60 20 50 100
Hydrite 90 20 80 111
WHO 75 20 65 75
Pedialyte 30 30 20 30
45 45 20 35
90 90 20 80
Gatorade 41 11 9/100
P e d i a t r i c N o t e s | 94
FLUID MANAGEMENT
Severity Less than 2 yo More than 2 yo
Mild 50cc/kg 30cc/kg
Moderate 100cc/kg 60cc/kg
Severe 150cc/kg 90cc/kg
To run for 6 – 8 hrs then refer
Usual fluid is D5 0.3 NaCl; if however more than 40 kg then D5 LR
P e d i a t r i c N o t e s | 95
COMPOSITION OF IV SOLUTION
Fluid Na K Cl HCO3 Dxt
PNSS 154 - 154 - -
0.45 NaCl 77 - 77 - -
D5 0.3 NaCl 51 - 51 - 5
D5 LRS 130 4 109 28 5
D5 NM 40 13 40 16 5
D5 IMB 25 20 22 23 5
D5 NR 140 5 98 27 5
Na requirement : 2 – 4 meq/k/day
K requirement: 2 – 3 meq/k/day
KIR: 0.2 – 0.3 meq/k/hr max of 40 meq
MAINTENANCE WATER
HOLLIDAY – SEGAR METHOD
Weight [kg] Daily Requirement [ml/kg]
1 – 10 100 ml
10 – 20 1000 + 50ml/kg for each kg >10
>20 1500 + 20ml/kg for each kg >20
Maintenace water rate
0 – 10 4ml/kg/hr
10 – 20 40 mk/hr + 2ml/kg/hr x wt
>20 60 mk/hr + 1ml/kg/hr x wt
P e d i a t r i c N o t e s | 96
NEPHROLOGY
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
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
P e d i a t r i c N o t e s | 97
AGN
inflam process affecting the kidney, lesions predom in the glomerulus
Etiology
Infections:
a. Bacterial: Grp A B hemolytic strep, S viridans, S pneumo, Staph
aureus, S epidermidis, S typhi , T pallidum, Leptospira
b. Viral: HBV, Mumps, Measles, CMV, Enterovirus
c. Parasitic: Toxoplasm, Malaria, Schistosoma
Drugs: Toxins, Antisera, Vaccines (DPT)
Miscellaneous: Tumor Ag, Thyroglobulin
P e d i a t r i c N o t e s | 98
IMMUNOLOGY
ANAPHYLAXIS
A syndrome involving a rapid & generalized immunologically mediated
rxn
After exposure to foreign allergens in previously sensitized individuals
A true emergency when cardio and respi system are involved
ED Management
o O2
o Aqueous Epinephrine 1:1000 IM (0.01ml/kg with 0.5ml max)
o Prepare intubation if w/ stridor & if initial therapy of epi is
not effective
o Continuous monitor ECG and O2 sat & establish IV access
o Antihistamine to prevent progression
o H1 & H2 blocker
o Diphenhydramine (1mg/kg) IM
o Steroids may modify late phase or recurrent reaction
(Hydrocortisone 5mg/kg/dose)
o Epinephrine 1:10,000 IV (0.1ml/kg; 10ml max)
o Epinephrine drip (0.01ml/kg/min)
Indication for Admission
o Persistent bronchospasm
o Hypotension requiring vasopressors
o Significant hypoxia
o Patient resides some distance from a hospital facility
P e d i a t r i c N o t e s | 101
IMMUNIZATION
Vaccine Min age 1st No of interval booster
dose dose
BCG At birth 1 - -
Before 1 mo
DPT 6 wks 3 4 wks 18 mos
(2, 4, 6 mos) 4 – 6 yo
OPV/IPV 6 wks 3 4 wks Same as
2, 4, 6 mos) DPT
Hep B At birth 3 6 wks from 1st dose,
(0, 1, 6 mos) 8 wks from 2nd dose
EPI (6, 10, 14)
Measles 6 – 9 mos 1 -
MMR 15 mos 1
Hib 2, 4, 6 mos 18 mos
Pneumococcal 6 mos (PCV7) 18 mos
2 yrs (PPV)
Rotavirus 3 and 5 mos 2 I month
Hep A 1 yr and up 2 6 – 12 mos apart
Varicella 1st: 12 – 15 2 Bet 1st and 2nd dose:
mos at least 3 mos
2nd: 4 – 6 yo
Flu 6 months yearly
P e d i a t r i c N o t e s | 106
VACCINES
BCG Live attenuated M bovis
DPT Diptheria and TT – inactivated B pertussis
OPV Sabin trivalent live attenuated virus
IPV Salk inactivated virus
MMR, Measles Live attenuated virus
Varicella
Hep B Recombinant DNA, plasma derived
Hep A Inactivated virus
Hib Capsular polysacc linked to carrier CHON
Typ Live typhoid vaccine – 3 doses x 2 days
IMSC – Vi antigen typ vaccine
Pneumococcal Capsular polysaccharide 0.5 ml
SC /IM – 23 valent purified cap
Polysacc Antigen of 23 serotyp
Influenza 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
P e d i a t r i c N o t e s | 107
TETANUS TOXOID
Hx of Clean minor Wound All other Wounds
Absorbed TT
Td TIG Td TIG
Unknown or 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
P e d i a t r i c N o t e s | 108
INFECTIOUS DISEASES
INFECTIVE ENDOCARDITIS
Modified DUKE CRITERIA
Major Manifestation
1. Blood Culture Positive
– IE organism isolated from two separate blood cultures (1hour
apart)
– (+) Coxiella Burnetti isolate in one culture + IgG Ab Titer for Q
Fever Phase 1 Ag >1:8000
2. (+) Evidence of Endocardial Involvement (2D-ECHO)
– Oscillating intracardiac mass on valve or supporting structures
– Abscess
– New partial dehiscence of prosthetic valve or new valvular
regurgitation (worsening or changing of preexisting murmur not
sufficient)
Minor manifestation
1. Predisposing factor:
– Known cardiac lesion,
– Recreational drug injection
2. Fever >38°C
3. Embolism evidence:
– Arterial Emboli, Pulmonary Infarcts, Janeway
Lesions,Conjunctival Hemorrhage
4. Immunological problems:
– Glomerulonephritis, Osler's Nodes, Roth's Spots, Rheumatoid
Factor
5. Microbiologic evidence:
– Positive blood culture (that doesn't meet a major criterion)
– serologic evidence of infection with organism consistent with IE
but not satisfying major criterion
6. Positive echocardiogram (that doesn't meet a major criterion) (this
criterion has been removed from the modified Duke criteria)
P e d i a t r i c N o t e s | 110
Diagnosis
Definite
– Histology (Vegetation) or Culture Positive
– 2 Major
– 1 Major and 3 Minor
– 5 Minors
Possible
– 1 Major + 1 Minor
– 3 Minors
VIRAL INFECTIONS
MUMPS [Paramyxoviridae]
MOT Direct contact, airborne droplets, fomites contaminated by
saliva
IP 16 – 18 days
Prd of comm 1 – 2 days before onset of parotid swelling until 5 days
after the onset of swelling
Prodorme Fever, neck muscle pain, headache, malaise
Parotid gland Peak in 1 – 3 days
swelling 1st in the space between posterior border of
mandible & mastoid then extends being limited
above zygoma
Complications Meningoenephalitis - most frequent, about 10 days;
M>F
Orchitis & Epididymitis
Oophoritis
Dacryoadenitis or optic neuritis
P e d i a t r i c N o t e s | 111
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
P e d i a t r i c N o t e s | 114
VARICELLA [HSV]
MOT Direct contact
IP 14 days
Prd of comm 1 – 2 days before the onset of the rash until 5 – 6 days
after onset & all the lesions have crusted
Rash Start from the trunk then spread to othe parts of the body
All stages present; pruritic
Macule/papule → vesicle →crust
Complication Secondary bacterial infection
Encephalitis or meningitis
Pneumonia
Reye syndrome
GN
Congenital 6 -12 wks AOG: maximal interruption w/ limb devt
Varicella with cicatrix(ski lesion w/ zigzag scarring)
16 – 20 wks: eye and brain involvement
Tx Acyclovir 15 – 30 mg/kg/day IV or 200 – 400 mg tab q 4hrs
minus midnight dose x 5 days: increased risk o severity
Post VZIg 1 dose up to 96 hrs after exposure
exposure Dose: 125 U/10 kg (max 625 U) IM
prophylaxis NB whos mother develop varicella 5 days before to 2 days
after delivery shud recv 1 vial
Vaccine Susceptible children >1 yo w/n 72 hrs
P e d i a t r i c N o t e s | 115
GRADE MANIFESTATION
I Fever, non-specific constitutional
symptoms such as anorexia, vomiting
and abdominal pain (+) Torniquet test
II Grade I + spontaneous bleeding;
mucocutaneous, GI
III Grade II w/ more severe bleeding +
Evidence of circulatory failure:
violaceous, cold & clammy skin, restless,
weak to imperceptible pulses, narrowing
of pulse pressure to < 20mmHg to
actualHPON
IV Grade III but shock is usually refractory
or irreversible and assoc w/ massive
bleeding
P e d i a t r i c N o t e s | 116
DENGUE VIRUS
↓ ↓ ↓
Liver Lymphoblast Platelet
/Plasma Cell
↓ ↓ ↓
Liver Injury Ag-Ab reaction Decr Maturation (MEG)
Incr Platelet Destruction
↓ ↓ ↓
Decreased Coagulation Increased Vascular
Factors Permeability Thrombocytopenia
↓ ↓ ↓
Increased Bleeding Hypoalbuminemia Bleeding
Tendency Hemoconcentration
Pleural Effusion
↓
Hypotension
NUTRITION
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)
P e d i a t r i c N o t e s | 120
MILK FORMULAS
1:1 dilution 1:2 dilution
Mead-Johnson, Nestle, Glaxo, Wyeth, Abbott, Unilab
Dumex, Milupa
0-6 months (20cal/oz) Lactose free (0-6months)
Mead-johnson: Alacta , Enfalac Mead-johnson: Enfalac lacto-free
Nestle: NAN1, Nestogen Nestle: AL110
Glaxo: Frisolac Milupa: HN25
Dumex: Dulac Wyeth: S26 Lacto-free
Milupa: Alaptamil
Abbott: Similac advance
Wyeth: S26, Bonna
Unilab: Mylac
6months onwards (20cal/oz) Lactose free (6months onwards)
Mead-johnson: Enfapro Mead-johnson: Enfapro lacto-free
Nestle: NAN2, Nestogen 2
Glaxo: Frisomil
Dumex: Dupro
Abbott: Gain
Wyeth: Bonnamil. Promil
Unilab: Hi-nulac
1 year onwards (20 cal/oz) Premature Infant (24cal/oz)
Mead-johnson: Enfagrow, Lactum Mead-johnson: Enfaprem
Nestle: NAN3, Neslac Nestle: PreNAN
Glaxo: Frisorow Milupa: Preaptamil
Dumex: Dugrow Abbott: Similac prem
Abbott: Gainplus
Wyeth: Progress, Promil
Unilab: Enervon bright
Hypoallergenic (20cal/oz) Soy-Based (20cal/oz)
Mead-johnson: Pregestimil Mead-johnson: Prosoybee
Nestle: Alfare, NAN HA1, NAN Abbott: Isomil
HA2 Wyeth: Nursoy
P e d i a t r i c N o t e s | 121
TPN
Vamin 9% 0.67 cal/ml
Start 0.5 g/k/day inc by 0.5 g until 3 -3.5g/k/day
Compute = wt x dose x prep (100/9)
TPN in Pediatrics
A. Energy Requirment
AGE/WT Caloric Rquirement
Neonates 90-120 kcal/kg
Infants & Older
Children 10-120 kcal/kg
<10 kg 1000kcal + 50 kcal foe each kg > 10
11-20 kg 1500 + 20 for each more than 20
>20
B. Fluid Requirement
AGE/WT Fluid Rquirement
Neonates
VLBW (≤ 1500 Initiate at 40 – 60 ml/kg/day and increase by 10
gm) ml/kg/day till 120 ml/kg is reached
D. Carbohydrate Requirement
% dextrose = gram dextrose x 100
Vol infused (ml
Shud provide 50 – 60 % 0f total non-protein calories
Requirement ranges frm 10 to 25 gm/kg/day
Infusion shud not exceed 12.5mg/kg/min
Shud b decreased if urinary glucose ≥0.5% (2+) or blood sugar
exceeds 7 mmol/L in neoanate or 9.7 mmol/L I above 1 mo of age
E. Fat Requirement
AGE Dosage (gm/kg/day)
0 – 12 months 2
1 – 8 yrs 4
8 yrs and above 2.5
30 – 40 % of total calories shud b provided as fats
2 – 4% as EFA
Start at 0.5 gm/kg/day and gradually increase by 0.5 gm/kg/day till
recommended amt is reached
F. Daily Electrolyte Requirements
Electrolytes Neonates 1-6 mos 6 mo -11 Adolescents
(mmol/kg) (mmol/kg) yr (mmol/kg)
(mmol/kg)
NaCl 3–5 3–4 3–4 60 – 100
Potassium 2–4 2–3 2–3 80 – 120
Cal gluc 0.6 – 1.0 0.25 – 1.2 0.25 – 1.2 4.7
(max of (max of
Phosphate 1.0 4.7) 4.7) 30 – 45
Magnesium 0.125- 1–2 1–2 4–8
0.250 0.125- 0.125-
0.250 0.250
Calcium gluconate contains 100 mg calcium gluconate or 9 mg
elemental calcium/ml
1 gm of calcium gluconate contains 4.7 mEq or 2.35 mmol of Ca.
P e d i a t r i c N o t e s | 124
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
P e d i a t r i c N o t e s | 126
Sample Solving:
Wt 15 80kcal/kg
A. Energy: 15 x 80 = 1, 200 kcal/day
B. TFR: 1,250 ml/day
C. CHON: (1gm/day) 15 x 1
Prep: Aminosteril 6% (6gms/100ml)
6gms x 15 gms = 250 ml
100 x
D. CHO: % = gm x 100 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 x
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
P e d i a t r i c N o t e s | 127
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
EMERGENCY MEDICINE
EMERGENCY
ET tube Age in years + 4
4
ET diameter x 3
>10 yo cuffed
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 0.1 – 1mg/k/min; 1amp = 1mg/ml
Drip 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
P e d i a t r i c N o t e s | 129
11cc/hr
Dopamine Renal dose 3-5
Pressor >5 - <15
alpha effect >15
P e d i a t r i c N o t e s | 130
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
O2 SUPPLEMENTATION
Peak Flow (6 – 7 yo)
(Ht cm – 100) x 5 + 170 female
+ 175 male
Nasopharyngeal catheter = flow rate x 20 + 20
Nasal cannula = flow rate X 4 + 21
NORMAL VALUES
NORMAL VALUES
AVERAGE WEIGHT (3,000 grams)
0 – 6 mos Age in months x 600 + BW
7 – 12 mos Age in months x 500 + BW
Children
1 – 6 yo Age in years x 2+ 8
7 – 12 yo
Age in years x 7 – 5 / 2
HEAD CIRCUMFERENCE [35 cm (+ 2cm)] (inch = 2.54cm)
1 – 4 Mos ½ inch per month
5 – 12 mos ¼ inch per month
2 years old 1 inch per year
3 – 5 yo ½ inch per year
6 – 20 yo ½ inch per 5 years
LENGTH (50 cm)
0 – 3 mos 9 cm
4–6 8 cm
7–9 5 cm
10 – 12 3cm