’ pediatric shad ee ee 1.1.ed. 2019 & 55-75/35-45 65-85/45-55 70-90/50-65 6-12 months I 80-100/55-65 L-3yearsold =| 90-105/55-70 3-6 years old 95-110/60-75 6-12 years old | 100-120/60-75 > 12 years old I 110-135/65-85 iene cera Trice ret) Normal HR rises by 10 bpm per 1°C increase {*) Insleep, Infant’s HR may drop significantly lower. But Hf perfusion ls maintained, no intervention Is required. (#) ‘Many premature infants require mechanical ventilatory support making thelr spontaneous RR less relevant. Proper blood pressure Measurement a >» Use right arm for consistency, comparison with standard tables and avold false reading from the loft arm In the case of coarctation of the aorta. » Cuff bladder length should encircle 80 ~ 100% of the circumference of the arm, and the width should be at least 40% of the mid-arm circumference (midpoint between the acromion of the scapula and olecranon of the elbow with the shoulder in neutral position and the elbow flexed to 90°) » For further instructions and p-values, refer to “Ci BP IN CHILDREN AND ADOLESCENTS” from American Academy of Pediatrics. hypertension < 90" percentile 290% to <95!"% ‘or 120/80 to <95" % (WIL) 295% to <95!"% + 12 or 130/80—139/8 (WIL) <120/<80 mmiig 120 /<80 - 129/<80 mmHg 180 / 80-139/ 89 mmHg “Neonati aoe Narrow PP: <20 mmtig one 1-9-year-old Wide PP: >40 mmHg. || KNEE HEIGHT: [Atbieth 328 __ (flexed at 90) proximalpatella— under the heel I i a M: Ht in em = 64,19 ~ (0.04 x age) + (2.02 x knee ht cm) Geren) a172 | rise age | F:_Ht in cm = 84,88 ~ (0,24 x age) + (1.83 x kneo ht cm) ——__ | TIBIAL HEIGHT: (flexed at 90°) knee joint distal medial malleolus | BODY MASS INDEX (BMI) i For older than 2-year-old (3.26 x tiblal height In cm) + 30.8 kg/ (height in meters)” BODY SURFACE AREA (BSA) Height ae (kg) 1) Child ts very tall, tt is rarely a problem unless it Is excessive (e.g. endocrine disorder). 2) May have a growth problem, this Is better assessed from 'WEL/H or BMI. 3) Possible risk. Trend toward 22 — score shows definite risk 5; 4 = 4) Possible for stunted or severely Z zs Chee | i He stunted to become overweight. or eS Saute etn ew wie In IMCI training modules. fsaews | ete [ ern | Sct] s08 note frichmond Fluids, Feeding, Resplratory, infectlous, Cardiac, Hematology, Metabollc, Output, Neurology, Drugs.|__ Psi _ || ‘physical or metabolic disturbance ee Milid to moderate disturbance that do not Interfere with dally routine Sevore disturbance that Interfere with dally ordinary activities [Severe disturbances that are a constant threat to Ifo L_rss | rss | | PSS || Moribund condition In patient likely to succumb within 24 hours Organ donor RO Tse aa AAC ten CSSUESTSIE Children in close contact w/ known or suspicious contagious people w/ TB disease RT TenE Children suspected to have TB disease: - Findings on chest radograph consistent with active or previously TB disease Clinical evitence of tuberculosis disease -Children receiving immunosuppressive therapy or.w/ immunosuppressive conditions (¢ Immunosuppressive doses of corticostarolds or TNFa antagonists) residents of nursing homes, Incarcerated or institutlonallzed, or migrant farm workers Children at increased risk of disseminated TB disease: CRUE chisdren >4 year of age er condition Hodgkin disease, lymphoma, DM, chronic renal fallure, or malnutrition Children with Increased exposure to TB disease: ‘ Chikdren born in high-prevatence regions of the world * Children often exposed to adults who are HIV Infected, homeless, users of Milt drugs, ‘© Children who travel to high-prevalence regions of the world Children 24 year of age without any risk factors TUBERCULOSIS (NTCP MOP 2014) fous A condition In which an individual Is in close contact with an active adult TB case, CUT e en Lue ac eee To Pulmonary TB, naw (whether bacterlologieally- confirmed or clinically — | 2 HRZE/ 4HR diagnosed) Extra-pulmonary TB, new (whether bacterlologically - confirmed or Pulmonary or extra-pulmonary, previously treated drug-susceptible TB |] 2 HRZES/ (whether bacterlologically- confirmed or clinically — diagnosed) HRZE/SHRE Relapse, Treatment After Failure, Treatment After Lost to Follow-up |} ALF), Pravious Treatment Outcome Unknown. I Extra-pulmonary, previously treated drug-susceptible TB (whether || 2 HRZES/ bacteriologically- confirmed or clinically — diagnosed 1HRZE/SHRE (CNS/bones or Joints) ae ed) | MAXIMUM PNEUMONIA (PAPP 2016) RISK CLASSIFICATION PCAP Paes = es aes Severe or moderate risk Respiratory ~Retractiona None Inter/subcostal (SC) Supractavicular/IC/$C - Head bobbing None Present + Cyanosls None Present + Grunting None Present None Present 250/min to <60/min >60/min to <70/min 240/min to <50/min >80/min >30/min to <35/min ry Feil > it Inability to drink ‘CXR: (+) affuslon, abscov, alr leak or multilobar consolidation 2 sat. atroom alr usiny Ise 0management of asthma exacerbation in acute care facility GINA 2018 Are any of the following present? wc ie Poe nurd DSCs? C: Circulation PY NSE Soe eA ket RIAGE BY CLINICAL STATUS (eae EST ye kere tl eee acai ee) MILD or MODERATE SEVERE Talks In phrases Talks In words Praters sitting to tying ‘Sits hunched forwards Not agitated Aghated Respiratory rate Increased Resplratory rate >30/min Accessory muscles not used Accessory muscle being used Pulse rate 100 - 120 bpm| Pulse rate >120 bpm 02 saturation (on alr) 90-95% (02 saturation (on alr) <90% PEF > 50% predicted or best PEF < 50% predicted or best ‘Short —acting Betaragonists ‘Short acting Beteregonists Consider Ipratroplum bromide Ipratropium bromide Controlled ©2 to maintain saturation 93- 95% Controlled 02:to maintain saturation 93- (children 94-98%) 95% (children 94-98%) Oral corticosteroids Oral or IV corticosterolds ‘Consider 1V magnesium Consider high dose ICs rma ea eye CSC Me ono e) Pa: ASSESS CLINICAL PROGRESS FREQUENTLY MEASURE LUNG FUNCTION UE UMAR Me LMC Senin FEV, of PEF 60-80% of predicted or FEV, of PEF <60 of predicted or personal best or personal best and symptoms improved lack of clinical response MODERATE SEVERE Consider for discharge planning Continue treatment as above and reassess frequently hormogram of normal l children aged 5 - 18 year-old MALES: | (ht in cm= 100) x5+175_| __{ht In cm - 100) x 5 +170 SHORTCUT 1" 100m (helght) = PEFR 100 THEN EVERY 10 cm = + PEFR 50 oj height 150 cm = PEFR 350 uence ne TINS LINE; modern 2™ generation antihistamines It aymptoms persist after 2 waeks > 2° MINE: Increase dosage up to fourfold of modern 2™ generation antihistamines: if symptoms persist after 1 - 4 further weeks > 2)" LINE: add on to 2" line: Omallzumab or Ciclosporin A or Montelukast Short course (max 10 days) of corticosterold may be used at all times if exacerbation demand this. CMC AW ate) ATLEAST 1of 3 CRITERIA FULFILLED: 1) Sudden acute onset of an iliness (MINUTES TO SEVERAL HOURS) with Involvement of THE SKIN AND/OR MUCOSAL TISSUE (hives, pruritus, flushing, swollen lips/ tongue/ wvula) or both (e.g. generaltzed hives, Itching oF Nushing, swollen Iips-tongue-uvula) and at least ONE of the following: . Sudden respiratory signs and symptoms . Sudden raduced BP or symptoms of end — organ dysfunction 2)» 2 of the ff that occur suddenly after exposure to a LIKELY allergen or other trigger for that patient (minutes 10 veveral hours) . ‘Skin or mucosal tissue © Respiratory compromise . ‘Suddlon reduced BP or symptoms of end — organ dysfunction . Sudden Glsymptoms 4) Neducod bP following axposure to a KNOWN allergen for that patient (minutes to several hours) » Infants and children | SBP or greater than 30% decrease in SBP . ‘Adults: SBP < 90 mmHg or greater than 30% dropART ere a [80-00% _ | [7 to +2 | Tenants nists (acon x waal INV: 16-20 mL 02/ 100mL blood syncope DIAGNOSTIC CONSIDERATION IN EVALUATING THE PATIENT WITH A PAROXYSMAL LOSS OF CONSCIOUSNESS | yamination, orthostatic BP, ECG, basic laboratory tests to exclude a metabolic cause } v SEIZURE VERSUS SYNCOPE Idiopathic generalized Features of focal epilepsy Ebadi Acute provoked | pllepsy lke selzures ‘CARDIAC RED FLAGS: chest paln, no warning, abnormal cardiac examination, abnormal EEG, family ory of sudden death ‘Thorough evaluation depending on intial findings cardiac telemetry, Holter monitoring, RicRetNG: echocardiography, peenaey, coronary anglography peiceey, ‘Admission, observation, Monitored If strong suspicion for arrythmia but hee carotid negative monitoring, consider ‘Consider jeferral arr sinus Implantable loop recorder or EP toa neurologist massage testing j ‘Treatment: Co revascularization | eae Vasodepresor | cp: Sacondaryprovention of ventricular arythmias | measures Midodine CCF with EF <35, Recurrent unexplained syncope In i Pacemaker Fludrocortisone: advanced structural heart disease AED: anti-eplleptic drug, PNES: psychogenic non-eplleptic encephelography, HUTT: head-up tift test, EP: electrophyslology, ICD: Implantable cardiac defibrillators, CCF: congestive heart fallure, MSA: Multiple-system atrophy Dengue A Acidosis 6B Bleeding C Calcium OD _ Drugs PENSMA em auncerons ec cen kc POUR i che oy CSR CCR OM Le ce OCI 1 skin, rash AND laboratory test, at least CBC (leucopenia with or without thrombocytopenia) and/or Sources cca) Cee Aen eee PEMA mac een Monro cm LikC ny aie Os OU Oe CCIE Se Cue mc enc u ucaeee Te uCU ecu LL | bleeding, lethargy, restlessness, liver enlargement, AND laboratory test: increase in Het and/ or ac atcets eee neces aura {Dengue with/ without warning signs) PLUS ANY of the following severe plasma leakage, leading to: shock, fluid accumulation with respiratory distress, severe bleeding, severe organ impairment (liver: AST or ALT Reem ee Ae ei LM nea ec TC) coe Patients general wellbeing improves, hemodynamic status stabilizes, and dluresis ensues. CLASSIC RASH: HERMAN’S RASH — Isles of white in the sea of redBOX A. Obtain baseline HCT (a) ‘Fluid resuscttation with plain lsotonic crystallold 10 ~15 ml/kg/hour aver 2 hour. Give oxygen support. 80xD, Hf thare ore signs of occult/ overt bleeding Initiate transfusion with FW 20 mi/kg or pRBC 10 mL/kg Reassoss hemodynamic status hea en: BOX C, Administer 2™ bolus of fluid (colloid) 10-20 mI/rg/hr over to Lhour Check hemodynamic parameters | Patient Is stable patient is unstable HCT decreases: HCT Increases | 2.1 patient does: Reduce IVF rate Administer 3" bolus of to 7-10 mlfeg/he fluld (collold/crystallold) not Improve, go to for1-2hours 10-20mi/kg/hr fori hour 86xE Hpatient remains eeenrnma stable, go to Box B J sudden drop In me cose Het, FWB 20 ml/kg or pREC 10 ml/kg, 4, If patient is stable for 48 stop IVF or give maintenance fluids or ORS. ttpatient | BOXE.Ifpatient does Improves, go to not improve, consider Box B Inotropes (d) and refer to ‘tertiary centerendocrinology diabetic ketoacidosis ISPAD 2018 BIOCHEMICAL FEATURES & CLINICAL HISTORY CLINICAL SIGNS RIVETTERTTONS Polyuria, polydipsia,nocturla, Dehydration, deep sighing Hyperglycemia (>11 mmol/L = 200 enuresis, welght loss, nausea, —_resplration (KUSSMAUL), mg/dl), venous pH <7.3 or vomiting, abdominal pain, smell of ketones, lethargy HCO3 <15 mmol/L, ketonemla and Weakness, fatigue, confusion, drowsiness ketonurla, urea, electrolytes and decrease level of ‘other Investigation Indicated consclousness avin y Airway + NGT Saline 0.9%, 10 ml/kg over Start with SC Insulin Breathing (100% oxygen) ‘Lhour, may repeat Continue Oral | Circulation, 0.9% saline Calculate fluld requirements | 10-20 mt/kg over. —2 ‘Correct fluid deficit over 24 - hours & repeat until 48 hours circulation Is restored. ECG for abnormal T waves ‘Add KCL 40 mmol per L fluid infusion at 0.05 ~ 0.3 unit/kg/hour starting 2 hour after fluids initiated ee eau Hourly blood glucose, hourly fluld Input and output, hourly after starting IV fluid therapy, monitor EC ACcIDOs Pierro eer ee fe IMPROVING Eee le Eee yokes setae (90 mg/d) Bee eee Rr) Reg ee SC slowing heart rate, irritability, confusion, decreased consciousness, eee ene ce ay RE-EVALUATE IV THERAPY EXCLUDE HYPOGLYCEMIA Weld Change to 0.45% or 0.9% 1S IT CEREBRAL EDEMA? cafculation saline; add glucose to fiulds ‘CE MANAGEMENT Insulin delivery (5~ 12.5%) to prevent Give mannitol 0.5- 1 g/kg or 3% system and dose hypoglycemia, adjust hypertonic saline, adjust {VF to maintain ed for ‘sodium infusion to promote Normal 6P, but avoid overhydration, call additional ‘an Increase in measured senior staff, move to ICU te consider resuscitation serum sodium cranial imaging only after patient Is Consider sepsis stabilized Clinically wel TRANSITION TO SC INSULIN ‘Start SC Insulin then stop IV Insulin after an appropriate level a) ea1s eC} In children less than old, the dominant side is the right hence 15L ECG Is requested 1500 / R —R Interval (#t of small boxes) NV: y.0. = 0.03 — 0.09 sec, > 3y.0. = 0.05 to 0.10 sec} <2.5 mm at all , NV: neonate 0.08 ~ 0.16 sec; children and adolescents 0.09 — 0.18 seconds | ||_ Prolonged: 1* degree AV block May or may not be present Normally: Lead V1 (+) R wave (-) S wave up to 5 months, Lead V6 (+) R (-)S at any age Low vokage: sign of myocardial edema, loss of functioning of myocardium, Increased NV: ¢ 0.44 sec Prolonged QT: congenital Long QT Syndrome, abnormal ventricular depolarization, abnormalities ESTIMATED BLOOD VOLUME Pretarm infant: 90-100 mi/kg ‘Term infant - 12 months 80 mi/kg 70 mi fig HARRIET LANE AGE-SPECIFIC BLOOD CELL INDICES Hb (g/dL) Het (%) WBC Platelets ab oS x10%/mt)_|_(x10%ml) 26 - 40 wk gestation 11-134 349-415 27-44 180 - 327 145 “5 = 275 15 a7 = ~ | 290 135-165 42-51 9-30 290 145-185 45-56 94-34 192 13.4- 166 41-53 5-20 __|-2s2 10.7-13.9 33-44 4-195 : 94-112 28-35 = : 11,1-12.6 31-36 6-175 : 10.5-12.0 33-36 6-17 150-350 115-125 34-37 5-155 150-350 11,5-13.5 35-40 45-135 150-350 13-145 36-43 45-135 150 - 350 12-14 37-41 45-135 150 - 350 ; Le RDW NORMAL ROW HIGH i | Heterozygous Thallasernia | 104, Hb S Thallasemia, Hb H, RBC Fragmentation Chronic disease, transfusion, chemotherapy, | Mixed deficiency, early IDA, CML, Hereditary spherocytosis, hemorrhage | Hgbpathles, myelofibrosis, sideroblastic Aplastic anemia Folate/B12 deficiency Pre-leukemia Immune Hemolytic Anemia FWB: Massive blood loss within a day, 50% loss of blood volume within: ‘3 hours or blood loss 150 mL/minhilia for treatment with constraints DEsiReD | DESIRED ‘TYPE OF HEMORRHAGE LeveL DURATION (DAYS) oe 1/4) Ta yin kee eae response is IOPSOAS AND DEEP MUSCLE WITH NV INJURY, OR SUBSTANTIAL BLOOD LOSS hemo; x Level Desired in %x 1.4 Nephrology — syMPTOMS ASSOCIATED WITH DEHYDRATION pasorrs) BW to: ‘CRAWFORD BODY SURFACE AREA METHOD: 1500 mim? for critically il, obese, AKI CKD, malignancy & severe sepsis | MAINTENANCE (HOLLIDAY SEGAR) DEFICITS (LUDAN’S METHOD) [amr [ coneonen | ot [Sat | ee L Weert. ‘After 20 kg GUI eC replaced every 6-8 hours es ee ee |_UrineNa | eee [Urine output ory Tt ys"ALWAYS USE PRE-ILLNESS WEIGHT (WF NOT AVAILABLE) ‘MILD DEHYDRATION DEXTROSE CONTAINING CRYSTALLOIO WITH Na 51. 77 mmol/L FOR MAXIMUM OF 6 HOURS RESUSCITATION PHASE Use a dextrose-FREE crystalloid solution that contains Ne 130-154 mmol/L bolus dose of 20 mi/kg In 5 to 20 minutes via “push-pull” technique using the largest bore catheter possible (maximum of 60 ml/kg In an hour). SEEK expert advice for intensive fluld Management and stert vasoactive agents. Consider other causes of shock. Fluld related refractory shock may be due to the ff: S—Sepsis ‘T—Third specing/ tamponade A~Adrenal Crisis B-Bleeding No ‘ALGORITHM 2 Doe Nd OM conc dg Cuore cee a uae ed eo ae fluid joss and maintenance Re Coca PCy ‘ Ure Sma Pees cr nari Se eens re ALGORITHM 2 Cents If blood glucose 1s LOW, infuse 2 mL/kg of D1OW over 5 mins. Ht blood glucose is HIGH, reduce Na content of current parenteral fluid, ar Ea an ened ‘or consider giving diuretics, concentration of dextrose solution. Hf sa <135 mmol/l decrease drip rate to 50-80% of maintenance water requirement. if sNe >145 mmol/L, reduce Ne content of parenteral fluld to <77 mmol/L and infuse ot maintenance rate plus 30-50 ‘ml/kg x 48 hours or advise the Patient to drink ad bitum. INTRAVENOUS FLUIDS COMPOSITION. eae ce requirement via enteral fluids and is able to eat or has an aooettte URINALYSIS FISHBONE RS Color H_| SG Ds 0.30% Nac Clari Albumin | Sugar | RBC | WBC Ds 0.45% Nacl Ds 0.90% Nac Nana Te egy Ds IMB Luo a if Cg ae ce) Pred Ds NR ere ee CE) sisisiglsieielela GFR computation creatinine in mg/dl. ‘SCHWARTZ: k=byage MODIFIED SCHWARTZ k = 0.413 (CKD) | LBW during 1" year of life | Term during 1* year of life _ | Children & Adolescent F AdolescontM | | | 39-114 | | ar i t 62-181. i Adult (M) (a=174 [Adulte (F) | s7-147 mnie kx length/heightincm i= (mL)/ W of hours/ weight (kg) BSA: 600 — 1000 [——_auouar | wirvoimathoursBron 'Ne deficit: 0.6 x BW x (desired Na — actual Na) ‘Na maintenance: wt (kg) x 2-3 meqs Recommended target of correction: 8 - 10. d FWD use 4 mi/kg if physiologic, 3 ml/kg if Na > 195 mEq/L MAINTENANCE = Total fluld requirement x birthweight Rate: [{FWD + maintenance) ~ feeding] / 24 hours K defictt = 0.4 x body we (ke) x (4 - serum ) K maintenance = wt (kg) x 2-3 meqs Oral Therapy Preferred agent: Potassium Chioride (750 mg tablet = 10 meq) K Phosphate - treat with hypophosphatemia (DKA) K HCOs/X Citrate — treat with metabolic acidosis Can be as much as 40 ~ 160 mEq/dose every 2-4 hours for every 10 még, there will be mean increase of 0.12 mEq/L 1:20 ~ 40 meq XC! per titer MAX CONC: Peripheral 40 mEq/L, Central 200 mEq/L MAX: 1 mEq/kg/hr or 10 mEq/br for every 10 mEq, there will be an increase of 0.14 mEq ‘Salbutamol IV 4 ug/kg over 20 minutes (¥ 0.87 ~ 1.4 mmol/L) Salbutamo! nebulization 2.5 mg if <25 kg or 5 mg If >25 kg (4 0.53 — 0.98 mmol/L) + discontinue all potassium containing solution, diuresis is helpful ~ sodium polysterene sulfonate 14/kg Q6 PO + Ingule 0.1. Ufkg over 30 min + glucose 0.5 g/kg over Z hours, = NaHCOs 1 mEq/kg/IV over 10 mins = 10% Ca gluconate 1 mL/kg over 5 ~ 25 minutes ere | amare | ests imgcear sagen | C3 exceed 0.5 ~ 1 mea/kg of | ht/ho gastroenterolo CRITERIA FOR IDENTIFYING WITH SEVERE ACUTE ‘MALNUTRITION FOR TREATMENT (Leena ee |e] (© 6-59 months of age + MUAC <115 mm I ts, ~ | | | + titaterat ptting edema | * WFH/L below x score 3 | | | | CRITERIA FOR DISCHARGING CHLDREN FROM TREATMENT || “chien year |__| © WFH/L tsp -2 Z-SCORE + no edema for 2 weeks ‘© MUAC 2125 mm with no edema for 2 weeks l How to hydrate severely malnourished child: Rehydration Solution for Malnutrition (ReSoMal) [[a0-32 T2060 1980) / PREVENT DEHYDRATION FOR SEVERELY ACUTE Creer Give 5 ml/kg every 30 minutes for two hours, orally ‘or by NGT then S ~ 10 mi/kg/hour for next 4~ 10 hours (max 12 hours) Give startle 20% giucose (S mig) by IV (Give IVF at 25 ei /feg over an hour = DUR or haltetrength Darrow's solution with 5% dextresa Of M these ara ‘unavailable, 0S 0.45% saline | | | | Mwith improvement: | | | Signs the patient is rehydrated {3 or more}: Lem letharek, eyes less sunken, leas thirty, moist mouth, teary, skin pinch less slow, passing urine, Improved pulse and respiratory rate Signe the patient ls overtvydrated: lncremsing RR ond PR, increasing edema and pufl eyelids, ‘= Fapeat lV 15 mi/kg over an hour then swttch to oral or NGT nydration with [RaSoMial 10 mi /kg/br for up te 10 hours {with no Improvement: = give maintenance IVF (4 mi/kg/Ihr) while waiting for blood then transfuse FWD 10 mii slowty over 3 hours; then begin feeding with starter F-75. TREATMENT FOR DIARRHEA (IMI): GIVE RECOMMENDED AMOUNT OF ORS OVER 4 HOUR PERIOD "Une the child's age only when you do not inow the weight. The approximate amount of ORS required (in mt) can also be calculated by ‘multiplying the chile’s weight (in kz) times 75. *For Infants under 6 months who are not breastfed, you can also give 100 to 200 mi. clean water during this period of standard ORS. If the child vornits, wait 10 minutes, then continue but more slowty.ROME IV CRITERIA FOR FUNCTIONAL CONSTIPATION Parade) Erno ee) ‘Lmonth of at least 2 of the following: | Include >2 of the ff. occurring at least once per week for minimum Hf 1 ‘© Zor fewer defections per weeks | month with insufficient criterie for diagnosis of 18S: ‘© History of excessive stool © or fever defecations per week in a child of a developmental age of at retention least 4-years-old © Atleast one episode/week of incontinence History of retentive posturing in excessive volitional stool retention, History of painful or hard bowel movements History of large diameter stools which may obstruct the toilet © History of painful or hard bowel © History of lorge diameterstools Presence of lerge fecal mass in the rectum In tollet-trained following edditionsl criteria may be used: . At lnast one episcde/week of incontinence after acquisition of toileting skills : History of large diameter stools which may obstruct the toilet management of coin ingestion (naspghan 2015) COIN INGESTION: A and lateral ers, engure no button battery 4 SMALL BOWEL \ Clinical observation: Fever persisting for 5 days (4 days W treatment a ATE Madea ot) PLUS least four of the following clinkal ‘signs not explained by another disease process: 1, Bilateral conjunctival injection (80% to 90%) 2. Changes in the oropharyngeal mucous membranes, including one or more of injected and/or fissured lips, strawberry tongue, injected pharynx (80% to 90%) 3. Changes in the peripheral extremities, including erythema and/or edema of the hands and feet (acute phase) or perlungual desquemation (convalescent phase) (80%) espe hertirsedaboraki ier eater yay Aspirin — Hf pationt ls febrile 80 - 100 me/kg/day in four doses, i afebrile 3 - 5 me/ke/day in one dose + IVig— 2 g/tg administered over 8 to 12 hours with M radaquat cra respon, conader corticomtarokd (2 ma/ka/ey, or 30 mkdovs, or nftsinal 3 mt Entry criterion: ANA ate titer of > 1:80 on HEp-2 cells or an equivalent positive test (ever) + Wabsent, do not classify as SLE, If present, apply additive criteria ADDITIVE CRITERIA: De not count sertterion if there is a more likely explanation than SLE. Occurrence of a criterion on at least one some heroes Su ciesticotion request tess one clinical crerton end 2 10 pol. Crterle need not coeur ‘Arthritis in > Jlnt with or preceded by fever of et leest two weeks duration thats documented to be dally {quotidian) for at least 3 days and accompanied by >1 of the following: 1, Evanescent (nonfixed) erythematous rash 3. Hepatomegaly and/or splenomegaly |__2. Generalized lymph node enlargement ASeroitis ‘Age at onset: <16-year-old Arthritis (swelling or effusion, or the presence of 2 or mora of the ff signs: limitation ROM, tenderness or pein on motion, increased heat} in >1 joint Duration of disease >6 week neat type defined by type of articular involvement in the 1* 6 mo after onset: Polyerthritis: 25 ‘Oligoerthitie <4 Systemic-onset disease: arthritis with rash and characteristic quotidian fever Exclusion of other forms of Juvenile artheitis Purpura (palpable, in crops) or petechiae w/ lower limb predominance, not related to thrombocytopenia ‘And wt least 1 out of 4 of the following: 1, ABDOMINAL PAIN: diffuse, acute, colicky pain: may Include intussusception and Gi bleeding 2, HISTOPATHOLOGY: leukocytoclestic vasculitla with predominent igh deposits; or proliferative GN with predominant igA deposits 3. ARTHRITIS: acute joint swelling or pain with LOM, ARTHRALGIA: ecute joint pain w/o Joint swelling o LOM 4, RENAL INVOLVEMENT: Proteinuria >0.3 £/24 hr; spot urine albumin to creatinine ration >30 mmol/mg or 22+ on ipatick. Nemataras ved oll cats wine sediment “it punneurology ILAE 2017 CLASSIFICATION OF Seizure rvpes @ isk yaaa fare Motor Aedes arta arr Den Myoclanic-tonic-clonic Even Ui lclg oni Motor Onset ay Cee et cS eed Dd Dead Tonic Non-Motor Onset Eos og era Emotional ey Deere Oat tae ed Non-Motor (absence) te ere) Oe oe ‘Definitions, other seizure types end descriptors are listed in the accompanying paper and glostary of terms “Degree of awareness inually is not specified *Duie to Inadequate Information or inability to place In other ie Peller BrraU ae One 1, Diazepam at (dose) mg/ SIVP for active seizures lasting | [V: for more than 3 minutes at bedside 2. Hook to.02 via FM at 10 LPM during wctive setzures 3. Koap bed railings up at all times 4, Must ba sccomp. by 2 responatble edulte at all times 5. Place patient on left lateral decubitus during active areas) (mms) Nave Cac} ere ec nG ee PE ‘Neonate 0.3 ~ 0.75 mkdose (MAX 2 mg) Child> 1.mo:0.2~ 04 mkdose (MAX <5 ye: § mgs 25 yr: 20 ma) ‘Adult: 5 ~ 10 me/doue (MAX'30 mg) 0.5 mkdose ff by 0.25 mkdose 10 min PRN H. Skin ~to skin contact Hil, Properly timed cord clamping 1V. Non-separation of mother and baby aan ey Amin ca) Pry Ce, ry Th Py Cr food ret fa VENTILATION CORRECTIVE STEPS Ie ea Cee Suction mouth and nose Cra ony Srmost common infections (national antibiotic guidelines 2018) ETIOLOGY DRUGS Candida albicans ‘Nystatin oral suspension 100 000 U/ml, 4 mL QJD or Miconazole oral ge! 2%, apply to affected area QID DOT: 714 days Eyedropa: Levofloxacin or Tobramycin of Erythromycin or Fusidic Acid Adrop TID- QID DOT: 5-7 days Tobramycin or Levofloxacin 2 drops QID ‘henoxymethylpenicillin or Pen V 25-50 mg/kg/d PO q6 2 tine: Amox. trinydrate SOmg/ke/d PO q8~ 12h (Max: g/day) DOT: 10 days For penicillin allorgy: The primary choice Is « macrolide such as Erythromycin ethylsuccinete 40 mkday PO a6h (Max 1¢/d) OR Clarithromycin 15 mkday PO div q12h Azithromycin 12 mg/kg PO qd x5 days Altemative to the macrolides for severe penicilin atergy: Clindamycin 20-30 mkday PO qth (MAX 1.86/d) Group A 2 Une: ‘Streptococcus Phenoxymethylpeniciliin or Penicillin V 25 ~ 50 mg/kg/d PO a6 Amoxiellin trihydrate 50 mg/kg/d PO q8 ~ 12h (Max: 1 g/d) 24 Une: Cefuroxime axetil 20 mkday PO div q1zh Amoxicillin clavulanic acid based on amoxtelin content: For 3months and <40 kg: 20-40 mkday PO div 8 ot 25-45 mkday PO div Q12 For >3 months and >40 ky: 500 mg/125 mg PO ql? oTmis ~Due to secondary _ Ofloxacin ear drops (00 NOT GIVE FOR PERFORATED TM) EXTERNA seborrhea ‘<1 yrold: norecommendation Act <5. epidermidis 46% 1=J2yri Sdrops bid in the affected ear nH RenmeuN > 12yn 10 drops bid ‘Pevalemanes 118 DOT: 7-10 days or 3d after cessation of symptoms ‘Anoerobes 2% Candida #6 ‘Adult: Offonacin ear drops 10 drops 1~2x/day x 7 days {f chronic OM ( 6 wks to 3 mos) - consider debridement & application of topical antl-inflammatory agents Avold submerging head In water x 7 ~ 10 days. A 1:1 white vinegar + rubbing alcohol solution may be instilled in the ‘external ear canal after swimming to restore proper acidic pH to the ear canal & to dry residual water. UTE OTITIS) 6% virus No antiblotic use in the prior month IEDIA’ 49% 5 pneumonia a" tine: (ao 29% H influenzae Amoxicillin 80-90 mkday PO div Q12 no 28% M catarrhalis DOT: <2y: 10 days, 2~5 years: 7 days, >5 y: 5 ~7 days 24 1ine with anaphylaxls~ Clarithromycin 15 mkday PO Q12 without anaphylaxis ~ Cefuroxime axetil 30 mkday q12 DOT: <2y: 10 days, 2-5 years: 7 days, >5 y:5~7 days OR Ceftriaxone 50 mkday IM/IV x 3 days Note: For patiants >2 yo with no fever and esr pain with a negative or questionable exam, consider analgesic treatment without antimicrobials. There may be favorable results in most afebrile patiants while waiting for 48 hours before: deciding to use antibloties. Co~amox and Ceftriaxone may be used as 1" line If ut the onset, the child presents with high fever 39°C and or/ if with severe otalgla, PERSISTENT MIDDLE EAR EFFUSION for 2 ~ 3 months after therapy is EXPECTED and does not require retreatment. medications weight x dose x (mL in solution/mg) = mL to be given * Domoke necessary RENAL ADIUSTMENT If indicated, Always ask for history of ALLERGIES/FAMILY HISTORY /GPD. For other ‘references: please check NeoFax (Neonates), National Antibiotic Guidelines DOH and Nelson’s. Moreover, please take note of COMPATIBILITY of medications and CONTRAINDICATIONS. * BETA-LACTAM + AMINOGLYCOSIDE should be given 2 hours apart. PARACETAMOL | 1015 mkdose PO Qs for fever Q6 for pain '5~ 10 mkdose Q6 ~ QB PO max dose: 40 mkday JRA: 3050 mkday Q5 PO max dose 2400 mg/hr _| Syrup: 100 mg/S mt. Varicella: 80 micay PO QJDx 5 days max: 8200mg/day “Tab: 200, 400, 200 me Zoster: 4000 mg/day div Sx/day x5-7 days for 212.0. n . Standard dose: 25 — 50 mkday Q8 = 12 hr PO "Tab 750/500 me, High dose: 80-90 mkday Q8— 12 hours PO. ‘SYRUP: 100 mg/mt, Max dove: 2-3 g/24 hour 225 mg/SmL, 250 m4 mL “AMOXICILLIN Infant 1 - <3 mo: 30 mkday Q12 PO TID - TAB: 250/500 +125 mg CLAVULANIC Child >3mo et cay AciD (non-high dose amoxicitin regimen, ure edult if >40 kg) SYRUP: 125/5mt TID: 20-40 mkday Q8 PO Ee ose BID: 25-45 mkday Q12 PO ics a AOM: 80-90 mkday ‘SYRUP: 200 (20.5 1), 400 mg. ____| Adults 250-500 mg/dose Q8 PO or 875 mg/doseQi2PO | _ (574), 600mg (42.9.1) ‘AEITHRQMYCIN | “CAP 6 mo.: 10 mg/kg PO on day 2 (max. 500 mg) “TABLET: 250/ 500mg ff by 5 mkday PO QD (max dose 250 mz/24 hr) on days 2~S ‘SYRUP: 200mg/S mi Pharynattis/ Tonsilitis (2-25 yr) 12 mkday PO x 5 days (max dose 500 m/24 hr) ____|_Aauita Sinusitis: (2 6 mo) 10 mkdose (MAX 500 mg) _ Z ‘CEFACLOR ‘Child (> 4 mo}: 20-40 mkday QB, ‘TABLET: 250, 500 mg/tab — ‘max 2g/day~ on empty stomach SUSP1250¢250mg/SmL_ CCEFIXIME Infant (6 mo) and child: 8 mkday Q12~24PO ‘ORALDROPS: 20me/mi, MAXDOSE 400 mkday ‘SUSP: 1004/5 mi 3 INFANT (@8MO)/CHILD: ‘SUSP: 125 oF 250 mg/Smi. (Mild/Moderate Infection: 75 —100 mkday QB MAX:1500mg/dose i ‘Severe: 100~200 mksay Q6 ~8 MAX: 1500 me/doue ‘Adult 750-1500 me/dose Q8. MAX: 94/24 hour PO ‘Child (3 mo~22 yr) Pharyngitis 20 mkday Q12 MAX 50Ome/day ‘Otite Media 80 mkday Q12 MAXig/day ‘Child >23 yr 250 ma/rablet C2 Adult 250-500 mg BID MAX: Milld/ moderate: 25-50 mkday Q6 MAX DOSE: 2g/24 hours | CAP:250, 500mg ‘Severe: 75~ 100 miday Q6 MAX 4g/24 hr(Child: PO Mild — Mod 20 mkdlay Q12 MAX 1g/24 he ‘Severe: 30 — 40 mkday Q12 MAX 1.5 g/24 hours 1V_Severe 10 mkdose O8 — 12 MAX 400 mg/dose tnt] Chik NOM, 15 mcey Cl MAK e/done Adolescent/ Adult: CLINDAMYCIN Giiadiicadta ancora — (MAX 1.8 h/24 hour IM/IV: 25 — 40 mikday Q6-8 he MAX 2.7 ¢/24 hours mikday tn 4 doses (MAX 2g/day) co- Pneumocystc jirovect: TRIMOXAZOLE ‘Treatment > 2mo PO or [V: 15-20 mkday Q5-8 x21 days BasedonTMP | Prophylaxis >1 mo& child: 150 mkdey divide BID 3 consecutive days/wk MAX DOSE: 320 mg/24 hour Wedolescent & adult: BO-160mg QD 3 days/wk (MEBENDAZOLE | >2 yr and ADULT PINWORIM: 100 me PO x 1 dose, repeat after 2 weeks If not cured HOOKWORM, ROUNOWORM, WHIPWORM: 100 mg PO BID x cs _|_3 days, may rpt in 3 4 wha oF 300 mg x2 dove METRONIDAZOLE |” AMEBIASIS: Child 85 — 50 mkday PO TID x Adult 300 ~ 750 me/dose PO TID x 10 days ‘ANAEROBIC: Infant/Child/Adolescent 2: 20-50 mkdey Q8 MAX 2250 mg/24 hour | Ws 22.5 40 mkday Q8 MAX: 1500 me/24 hour ADULT: PO/IV 30 mkday QS MAK: 44/24 hour \deys MAGIC ‘Mix AIMgOH (Maalox) § mL.+ Sucratfate 1e/tab ¥ tab pulverized + Diphenhrydrarnine 12.5 ___MOUTHWASH | _mg/Smi, 5 ml, then paint on oral ulcers QS : TRANEXAMIC ‘Tranesamic ecld 250 mg/cap + 250 rl. water gargle TI Harriet: Child: Initia! 0.4-0.7 mkday or 15 - 20 mg/m2/dey Qa, __Maintanance: 1/3 - 2/3 of initial dose PO QB MAX DOSE: 30 me/24 hour Harriet: Child PO Dosing: 1-3 mo: 10-15 mcg/kg/dose W et risk with cardiac falure, start with lower dose 25 mca/24 hour, and If patient has very low T4 { 12 yr end Adult: intel: Lme/dose _Maintanance: 0.4 mg/24 fr OD. CUTE aurea | SYRUP: 2.5 mg/ml, Smg/S ml. TAR 10mg apy Child: 1 =: 2 mldoee OS une! dna: Smaa/26 hour ied 8. MAK: 3 ma dova ee 900 me/24 hour ‘Adult: 25 ~ 50 mg/dose Q4-8 MAX DOSE: 400 mg/24 hour Monee te Sentara ai 1:1000 dilution, <12 yr old: 0.01 mg/kg; maximum 0.5 mg 212 yr old: 0.5 mg IM dose eee meee oe eine craton reactor ree: tre ene penis ios dee }me/dose SYRUP: 2 mg/ml, TAB: 30’ 25 mq 2 ‘Oral: Chitd and adolescent: 2 mkday divided Q6-Shour PRN, 12 yr: 25 mg and >12 yr: 200mg, mg/24+-hour Q6-8 hr PRN, >6 yr: 30 100 mg/24 hr Q6-Q8 PRN | For adolescent and edult: PO 150 mg/dose BID or 300 me/dose GHS _IM/IV: 50 mg/dose Q6-C8, max dose: 400 mg/24 hour ‘SALBUTAMOL ~ [Sv 2 mg/Sml, NEB: 25 mg/25 mi, 1 mg/imi, PUFF:I00 meg/ectuation_ | Aerosol: 2 pufts (90 meg) Q4-6 br PRN NEBULZAT <1y (0.05 -0.15 midoee Q4-6he 1-5 yr: 125-25 mg/dose Q46 hour LBS mefdoweQ4-6he _>12 yr: 25-Smg/doeQt8hour [ ORAL (nL DISCOURAGED DUE TO WCREASED SIE EFFECTS AND DECREASOD GACT _ 2 6yr | 0.3 mkday TIO (MAX 12 mg/26 hour), 6-12" 6 mg/24-hour PO TID (MAX 24 mg/24 he) pazyfedut | 2-4 mg/dose PO TID- CSD (MAX 32 mg/24 be)CASTOR OIL PEG 3350 impaction: 1-15 g /kg/day (max ot 6 consecutive days) ELEMENTAL ZINC <6 mo: 10 mg QD x 14 deys {_28mer20.ng G0 x 34doye AL mg/rq/dove PO - B10 Duodenal wear cr GN: 20 me/dasa PO 4-8 wh Gastric vicer: 40 mg/ 24 be PO QD - BIO x: immunization NATIONAL IMMUNIZATION PROGRAM OMEPRAZOLE ‘The following vaccines are In the 2019 National immunization Program {WIP}: BCG, monovalent Hep B, Pentavalent (OTw?-Hib-Hep8), bivalent OPV, IPV, PCV, MMR, MR, Td, HPV, JE BCG (0.05 ml for children <12 months of age & 0.1 mi. for children > 12 months of age For heelthy infents and children > 2 months of age net given BCG, PPD prior to BCG (ID) ‘vaccination ls not necessary. However, PPO Is RECOMMENDED prior to BCG vaccination any of the ff present: -Congental TB, History of close contact to known or suspected Infectious cases, clinical findings suggesting of TB and/or CXR suggestive of TE In the presence of any of these conditions, an induration of 3 mm is (+) end BCG Is NO recommended LONGER HBV Administer the 1* dose of monovalent HBV to all newborns >2 kgs within 24 HOL A.2% dose la given 1-2 months after the birth dose (Im) Final dose: edministered not sertler then 24 weeks of age. ‘Another dove ls needed ifthe last dove was given at age <24 weeks. Hasag (#) mother: -Administer HBV and HBIG (0.8 ml) within 12 hours of birth. HBNG should be edministared not ater than 7 daysof ere, Hnot immedietely avellable. Unknown HBsAg status: -BW 22 kg, administer HBV within 12 hours of birth and determine the mother’s HBaAg as soon as possible, If HBsAg (4) administer also HBig net tater than 7 days of aze. = BW <2 kgs, administer HBIG In addition to HBV within 12 HOL For preterm Infants: ff born to HBaAg -) mothers and medically stable, the 1 dose of HBV maybe given st 30 deys of chronological age regardless of weight and thia con be counted as part of the 3-dose primary series for those <2 gs, the 1” dose received at birth is not counted es pert of the veccine series. Additional B HBV doses are needed. Hib S.doset raries with minimum age of 6 weeks and minimum interval of 4 weeks dose given between 12-15 manths of age with an interval of 6 months from the 8" (im) = DTP 2 dotes series with minimum exe of 6 weeks and minimum tnterval of 4 weeks Boomter 3 DOSE series: 12 23 months (OTP), 4 7 years (OTP), 9— 25 years (Td/Tdap) (Im) Minimum interval between booster doses should be 4 years IpV 2 doves teries with minimum age of 6 weeks and minimum interval of 4 weeks BOOSTER DOSE: IPV - containing vaccine should be given on or after the 4" birthday UN) RV 2 dotes series with miniroum ae of 6.weeks and minimum interval of 4 weeks Last dose: NOT LATER THAN 32 WEEKS OF AGE (PO) VL: 2 —dose series, RVS: 3 - dose series pcv Given a minimum age of 6 weeks for PCV10 end PCVI3 3. doses series with minimum age of 6 weeks and minimum interval of $ weeks (Im) BOOSTER: 6 months eter the 3% dose Healthy children 2 ~ 5 y.0. without previous PCV veccination may be given 1 dose of PCV 13, or 2 doses of PCV 10 at least # weeks apart, FLU Given a minimum oge of 6 months 6 monthe - 8 years receiving influenza veccina for 1% time should receive 2 doses separated (im) by 4 weeks only one dose wes given during the previousinfiventa sesson, give 2 doses of vaccine then (one dose yearly thereafter Children aged 9 - 18 years should receive one dose of the veccine yearly MEASLES ‘9 months, may be given as early as Gmonths of age incases of outbreaks IF MM ts used in lieu of monovalent messies vaccine, the recipient should receive 2 more (sc) MMR vaccines sterting at 1 year of age JAP ENCEPH Minimum age of 9 months Children 9 mo to 17 yeers of age should receive ONE primary dose followed by a booster (sc) dose 12-24 montha after the primary dose 118 years and older should receive a single dose only Minimum age of 12 months MMR 2 doses of MMR are recommended: (sc) 2% dose usuelly given at 6-6 years of age but may be piven at an sartler age with minimum of 4 weeks HepA Minimum age of 12 months 2 does recommended (IM) 2™ dose is given at least 6 months from the 1" dose Minimum age at 12 months MMRV 2 doses recommended (sc) 2™ dose: 4— 6 y.c. but may be given sariler at an interval of 3 months trom the first dose. If 2" dose given 4 weeks from the first dose, It ls VALID. 214.yo: minimum interval between doses ts 4 weeks. HPV ‘9 14 vox 2 doves sertes ls recommended Bivelent, quedrivalent or nonevalent: 0, 6 months (Im) Mf the interval between the 1* and 2“ dose is < 6 months, a 3” dose Is needed. ‘The minimum interval between the 2~! and 3” dose ls 3 months 215 years (3 doses sertes ts recommended) Rivelent, quadrivelent or nonevelent: 0.2, 6 months ‘The minimum intervel between the 1* end 2~ dose is 1 month and the minimum interval between the 2~ and 3“ dose ls 3 months. The 3% dose should be given at east 6 months from the 1 dove (MALES: 9-18 v.0. - 4vHPV & SVHPV to be given for the prevention of enogenttal warts and ‘anal concer Fully immunized: Td booster doses should ba given every 10 years Td/ Tdap —y\.or singe done of dup con be gen end eploce doe Te. (im)‘COMBINATION MINIMUM INTERVAL Two live parenteral or live intranasal influenze vaccine Aweeks vaccine given second should be repested -Exception is yellow fever vaccine given leas than 4 weeks after measles C: contraindication, P: precaution, V: vaccinate if indicated "except HPV and Tdap ** MMA and varicella - containing (except zoster veccine) and rotavirus vaccines only _ INVALID CONTRAINDICATIONS TO VACCINATION, Mild illness, antimicroblal therapy, disease exposure or convelescence, pregnant of immunosuppressed person in the housshold, breastfeeding, preterm birth, allergy to products not present In vaccine or allergy that ts not anaphylactic, femnily history of adverse events, TST, multiple vaccines Childhood Immunization Schedule 2019