pediatric must know

EXPANDED PROGRAM ON IMMUNIZATION

VACCINE AGE DOSE # ROUTE SITE INTERVAL

BCG-1 Birth or 6 wks 0.05mL(NB) 0.1mL (older) 1 ID R-Deltoid DPT 6 wks 0.5mL 3 IM Upper Outer thigh

OPV 6 wks 2 drops 3 PO Mouth 4 wks

HEPA B 6 wks 0.5mL 3 IM

Antero-lateral thigh

4 wks

MEASLES 9 mos 0.5mL 1 SC Outer

upper arm 4 wks BCG-2 School entry 0.1mL 1 ID L-Deltoid TetToxoid Childbearing

women 0.5mL 3 IM Deltoid 1 mo then6-12 mos

ADVERSE REACTIONS FROM VACCINES

BCG 1. Wheal ► small ► abscess ► ulceration ► healing / scar formation in 12 wks

2. Deep abscess formation, indolent ulceration, glandular enlargement, suppurative lymphadenitis

DPT 1. Fever, local soreness

2. Convulsions, encephalitis / encephalopathy, permanent brain damage

OPV Paralytic Polio HEPA B Local soreness MEASLES 1. Fever & mild rash

2. Convulsions, encephalitis / encephalopathy, SSPE, death

ACTIVE PASSIVE

BCG Diphtheria

DPT Tetanus

OPV Tetanus Ig

Hep B Measles Ig

Measles Rabies (HRIg)

Hib Hep A Ig

MMR Hep B ig

Tetanus Toxoid Rubella Ig Varicella BODY TEMPERATURE Subnormal <36.6°C Normal 37.4°C Subfebrile 35.7 – 38.0°C Fever 38.0°C High fever >39.5°C Hyperpyrexia >42.0°C AGE HR (bpm) BP (mmHg) RR (cpm) Preterm 120-170 55-75/35-45 40-70 Term 120-160 65-85/45-55 30-60 0-3 mo 100-150 65-85/45-55 35-55 3-6 mo 90-120 70-90/50-65 30-45 6-12 mo 80-120 80-100/55-65 25-40 1-3 yrs 70-110 90-105/55-70 20-30 3-6 yrs 65-110 95-110/60-75 20-25 6-12 yrs 60-95 100-120/60-75 14-22 12-17 yrs 55-85 110-135/65-85 12-18 BP cuff should cover 2/3 of arm

-: SMALL cuff: falsely high BP -: LARGE cuff: falsely low BP

BMI Asian Caucasian Underweight <18.5 <18.5 Normal 18.5 – 22.9 18.5 – 24.9 Overweight ≥ 23.0 25 – 29.9 at risk 23 – 24.9 Obese I 25 – 29.9 30 – 39.9 Obese II ≥ 30 >40 ABG pH: 7.35-7.45 HCO3: 22-26mEq/L

pCO2: 35-45 B.E.: +/- 2mEq/L

pO2: 80-100 O2 sat: 97%

NORMAL LABORATORY VALUES

NB Infant Child Adole

RBC 4.8-7.1 3.8-5.5 3.8-5. M: 4.6-6.2 F: 4.2-5.4 WBC 9-30,000 6-17,500 5-10,000 6-10,000 PMNs 61% 61% 60% 60% Lymph 31% 32% 30% 30% Hgb 14-24 11-20 11-16 M: 14-18 F: 12-16 Hct 44-64% 35-49 31-46 M: 40-54 F: 37-47 Platelets 140-300 200-423 150-450 150-450 Ret 2.6-6.5 0.5-3.1 0-2 0-2 COUNT (%) BT 1-5 min 1-6 1-6 1-6 CT 5-8 min 5-8 5-8 5-8 PTT 12-20sec 12-14 12-14 12-14 ANTHROPOMETRIC MEASUREMENTS IDEAL BODY WEIGHT

Age Kilograms Pounds

At Birth 3kg (Fil)

3.35kg (Cau) 7

3-12

mo Age (mo) + 9 / 2 Age (mo) + 10 (F)Age (mo) + 11 (C) 1-6 y Age (y) x 2 + 8 Age (y) x 5 + 17 7-12 y Age (y) x 7 – 5 / 2 Age (y) x 7 + 5 Given Birth Weight:

Age Using Birth Weight in Grams < 6 mo Age (mo) x 600 + birth weight (gm) 6-12 mo Age (mo) x 500 + birth weight (gm) Expected Body Weight (EBW):

Term Age in days – 10 x 20 + Birth Weight Pre-Term Age in days – 14 x 15 + Birth Weight

Age of Infant Ideal Weight 4-5 months 2 x Birth Weight

1 year 3 x Birth Weight 2 years 4 x Birth Weight 3 years 5 x Birth Weight 5 years 6 x Birth Weight 7 years 7 x Birth Weight 10 years 10 x Birth Weight

LENGTH / HEIGHT (50 cm)

Age Centimeters Inches

At Birth 50 20

1 y 75 30

2-12 mo Age x 6 + 77 Age x 2.5 + 30

Age Gain in 1st_{Year is ~ 25cm}

0-3 mo + 9 cm 3 cm per mo 3-6 mo + 8 cm 2.67 per mo 6-9 mo + 5 cm 1.6 cm per mo 9-12 mo + 3 cm 1 cm per mo HEAD CIRCUMFERENCE (33-38 cms)

Age Inches Centimeters

At Birth 35 cm (13.8 in) < 4 mo + 2 in (1/2 inches / mo) + 5.08cm (1.27cm / mo) 5-12 mo + 2 in

(1/4 inches / mo) (0.635cm / mo)+ 5.08cm

1-2 yrs + 1 inch 2.54 cm 3-5 yrs + 1.5 in (1/2 inches / year) + 3.81cm (1.27cm / mo) 6-20 yrs + 1.5 in

(1/2 inches / year) (1.27cm / mo)+ 3.81cm

Age Transverse-AP

Diameter ratio Inches At Birth 1.0 Transverse = AP

1 y 1.25 Transverse > AP 6 y 1.35 Transverse >>> AP

FONTANELS Appropriate size at birth: 2 x 2 cm (anterior) Closes at: Anterior = 18 months, or as early

as 9-12 months Posterior = 6 – 8 weeks or

2 – 4 months

THORACIC INDEX TI = transverse chest diameter

AP diameter Birth : 1.0 1 year : 1.25 6 years : 1.35 APGAR 0 1 2

A Blue /_Pale Pink body/ Blue_extremities Completely_pink P Absent Slow (<100) > 100 G _Response(-) Grimaces Sneezes,Coughs,

Cries A _Movement(-) Some flexion /_{extension movement}Active R Absent Slow / Irregular _{strong cry}Good, 8 – 10: Normal

4 – 7: Mild / Moderate Asphyxia 0 – 3: Severe asphyxia

GCS

Function Infants/Young Older

Eye

Opening 4- Spontaneous3- To speech 2- To pain 1- None Spontaneous To speech To pain None Verbal 5- Appropriate 4- Inconsolable 3- Irritable 2- Moans 1- None Oriented Confused Inappropriate Incomprehensible None Motor 6- Spontaneous 5- Localize pain 4- Withdraw 3- Flexion 2- Extension 1- None Spontaneous Localize pain Withdraw Flexion Extension None

H.E.A.D.S.S.S. Sexual activities

◦ Sexual orientation? ◦ GF/BF? Typical date?

◦ Sexually active? When started? # of persons? Contraceptives? Pregnancies? STDs? Suicide/Depression

◦ Ever sad/tearful/unmotivated/hopeless? ◦ Thought of hurting self/others? ◦ Suicide plans?

Safety

◦ Use seatbelts/helmets? ◦ Enter into high risk situations? ◦ Member of frat/sorority/orgs? ◦ Firearm at home? F.R.I.C.H.M.O.N.D. ◦ Fluids ◦ Respiration ◦ Infection ◦ Cardiac ◦ Hematologic ◦ Metabolic

◦ Output & Input [cc/kg/h] N: 1-2 ◦ Neuro

◦ Diet

H.E.A.D.S.S.S. Home Environment

◦ With whom does the adolescent live? ◦ Any recent changes in the living situation? ◦ How are things among siblings? ◦ Are parents employed?

◦ Are there things in the family he/she wants to change?

Employment and Education

◦ Currently at school? Favorite subjects? ◦ Patient performing academically? ◦ Have been truant / expelled from school? ◦ Problems with classmates/teachers? ◦ Currently employed?

◦ Future education/employment goals? Activities

◦ What he/she does in spare time? ◦ Patient does for fun?

◦ Whom does patient spend spare time? ◦ Hobbies, interests, close friends? Drugs

◦ Used tobacco/alcohol/steroids? ◦ Illicit drugs? Frequency? Amount?

Affected daily activities? ◦ Still using? Friends using/selling?

NUTRITION

AGE WT. CAL CHON

0-5 mo 3-6 115 3.5 8-11 mo 7-9 110 3.0 1-2 y 10-12 110 2.5 3-6 y 14-18 90-100 2.0 7-9 y 22-24 80-90 1.5 10-12 y 28-32 70-80 1.5 13-15 y 36-44 55-65 1.5 16-19 y 48-55 45-50 1.2 TCR β = Wt at p50 x calories TCR = CHON X ABW

Total Caloric Intake : calories X amount of intake (oz) Gastric Capacity : age in months + 2 Gastric Emptying Time : 2-3 hours

1:1 1:2 Alacta Bonna Enfalac Nursoy Lactogen Promil Lactum S-26 Nan Similac Nestogen SMA Nutraminogen Pelargon Prosobee

THE SEVEN HABITS OF HIGHLY EFFECTIVE PEOPLE

by Stephen R. Covey Habit 1: Be Proactive

Habit 2: Begin with the end in mind Habit 3: Put First Things First Habit 4: Think Win-Win

Habit 5: Seek first to understand and then to be understood Habit 6: Synergize

Habit 7: Sharpen the saw

EXPECTED LA SALLIAN GRADUATE ATTRIBUTES

(ELGA) 1. Competent & safe physicians 2. Ethical & socially responsible

Doctors / practitioners 3. Reflective lifelong learners 4. Effective communicators 5. Efficient & innovative managers

TREATMENT PLAN B Recommended amount of ORS over 4 hour period

Age up to: 4 mo – 4 mo 12 mo – 12 mo 2 yrs – 2 yrs 5 yrs

Wt: <6kg 6-9.9kg 10-11.9kg 2-19kg

(mL) 200-400 400-700 700-900 900-1400

◦ Use child’s age only when weight is not known ◦ Approximate amount of ORS (mL) CHILDS WT (kg) x 25

◦ if the child wants more ORS than shown, give more ◦ give frequent small sips from a cup

◦ if the child vomits, wait for 10 min then resume ◦ continue breastfeeding whenever the child wants AFTER 4 HOURS

◦ reassess the child & classify dehydration status ◦ select the appropriate plan to continue treatment ◦ begin feeding the child while at the clinic DIARRHEA

◦ Chronic : >14 days, non-infectious causes ◦ Persistent : >14 days, infectious cause

◦ ORS vol. after each loose stool 1 day

<24 mo 5-100mL 500mL

2-10 y.o. 100-200mL 1000mL >10 y.o. As much as wanted 2000mL

For severe dehydration / WHO hydration (fluid: PLR 100cc/kg) Age 30mL/kg 75mL/kg <12 1H 5H >12 30 mins 2 ½ H Patient in SHOCK ◦ 20-30cc/kg IV fast drip

◦ but in infants 10cc/kg IV (repeat if not stable) ◦ If responsive & stable 75/kg x 4-6 hours

ACUTE DIARRHEA (at least 3x BM in 24 hrs) 4 Major Mechanisms

1. Poorly absorbed osmotically active substances in lumen

2. Intestinal ion secretion (increased) or decreased absorption

3. Outpouring into the lumen of blood, mucus 4. Derangement of intestinal motility

Rotaviral AGE (vomiting first then diarrhea) Ingestion of rotavirus ► rotavirus in intestinal villi

►destruction of villi

(secretory diarrhea ▼absorption ▲ secretion) ► AGE

Assessment of dehydration (Skin Pinch Test) ◦ (+) if > 2 seconds

◦ no dehydration if skin tenting goes back immediately

ETIOLOGY of AGE

Bacteria Viruses

Aeromonas Astroviruses

Bacillus cereus Caloviruses

Campylobacter jejuni Norovirus Clostridium perfringens Enteric Adenovirus Clostridium difficile Rotavirus Escherichia coli Cytomegalovirus Plesiomonas shigelbides Herpes simplex virus Salmonella

Shigella

Staphylococcus aureus Vibrio cholerae 01 & 0139 Vibrio parahaemolyticus Yersinia enterocolitica Parasites Balantidium coli Blastocyctis hominis Cryptosporidium Giardia lamblia Amoeba Metronidazole Ascariasis Al/mebendazole Cholera Tetracyline Shigella TMP/SMX (Cotri) Salmonella Chloramphenicol TREATMENT PLAN A 4 Rules of Home Treatment

1. Give extra fluid (as much as the child will take) > Breastfeed frequently & longer at each feeding

> if the child is exclusively breastfed, give one or more of the following in addition to breastmilk

◦ ORS solution

◦ food based fluid (e.g. soup, rice, water) clean water How much fluid to be given in addition to the usual fluid intake?

Up to 2 years: 50-100 mL after each loose stool 2 years or more: 140-200 mL

:- give frequent small sips from a cup :- if the child vomits, wait for 10 min then

resume

:- continue giving extra fluids until diarrhea stops

2. Give Zinc supplements

Up to 6 mo: 1 half tab per day for 10-14 days 6 months or more: 1 tab or 20mg OD x 10-14 days

3. Continue feeding 4. Know when to return

TREATMENT PLAN C Treat severe dehydration QUICKLY! 1. Start IV fluid immediately

2. If the child can drink, give ORS by mouth while the IV drip is being set up

3. Give 100mL/kg Lactated Ringer’s solution

Age First give Then give

30mL/kg in: 70mL/kg in: Infants

(<12mo) 1 hour* 5 hours Children

(12mo-5yrs) 30 min* 2 ½ hours

Repeat once if radial pulse is very weak or not detectable

◦ reassess the child every 15-30 min. if dehydration is not improving, give IV fluid more rapidly

◦ also give ORS (~5mL/kg/hr) as soon as the child can drink [usually after 3-4 hours in infants; 1-2 hours in children]

SMR GIRLS

Stage Pubic Hair Breasts

1 Preadolescent Preadolescent

2 Sparse, lightly pigmented, straight,_{medial border of labia} Breast & papilla elevated, as small_{mound, areola diameter increased} 3 Darker, beginning to curl, ▲amount Breast & areola enlarged, no contour_separation 4 Course, curly, abundant but amount <_adult Areola & papilla formed secondary_mound 5 Adult, feminine triangle, spread to_{medial surface of thigh} Mature, nipple projects, areola part of_{general breast contour}

SMR BOYS

Stage Pubic Hair Penis Testes

1 None Preadolescent Preadolescent

2 Scanty, long slightly_pigmented Slightly enlargement Enlarged scrotum, pink_{texture altered} 3 Darker, starts to curl, small_amount Longer Larger 4

Resembles adult type but less in quantity, course,

curly

Larger, glans &

breadth ▲ in size Larger, scrotum dark 5 Adult distribution, spread_{to medial surface of thigh} Adult size Adult size ORS

• Glucolyte 60

-: for acute DHN secondary to GE or other forms of diarrhea except CHOLERA. In burns, post-surgery replacement or maintenance, mild-salt loosing syndrome, heat cramps and heat exhaustion in adults.

Glucose:

100mmol/L Cl:50mmol/L Gluconate:5mmol/L Na:

60 mol/L

Mg: 5mmol/L K:

20 mmol/L Citrate:10 mmol/L

• Hydrite

-: 2 tab in 200ml water or 10sachets in 1L water Glucose:

111mmol/L Cl:80mmol/L Glucose:11mml/L Na: 90 mmol/L HCO3: 5mmol/L Na: 90 mmol/L K: 20 mmol/L K:20 mmol/L • Pedialyte 45 0r 90

-: prevention of DHN & to maintain normal fluidelectrolyte balance in mild to moderate dehydration.

Glucose 45mEq Glucose 90mEq

Na: 20mEq Na: 20mEq

K: 35mEq K: 80mEq

Citrate: 30mEq Citrate: 30mEq Dextrose: 20g Dextrose: 25g

• Pedialyte mild 30

-: to supplement fluid & electrolyte loss due to active play, prolonged exposure, hot and humid environment

Glucose: 30mEq Mg: 4mEq

Na: 20mEq lactate: 20mEq

K: 30mEq Ca: 4mEq

Energy: 20kcal/ 100ml

ETIOLOGY OF PNEUMONIA Bacterial

- Streptococcus pneumoniae

- Group B streptococci (neonates) - Group A streptococci

- Mycoplasma pnemoniae (adolescents) - Chlamydia trachomatis (infants) - Mixed anearobes (aspiration pneumonia) - Gram negative enteric (nosocomial pneumonia) Viral

- Respiratory syncitial virus

- Parainfluenza type 1-3 (Croup) - Influenza types A, B

- Adenovirus - Metapneumovirus Fungal

- Histoplasma capsulatum (bird, bat contact) - Cryptococcus neoformans (bird contact) - Aspergillus sp. (immunosuppressed) - Mucormycosis (immunosuppressed) - Coccidioides immitis

- Blastomyces dermatitides

- Pneumocystis carinii (immunosuppressed, HIV, steroids)

LUDAN’S METHOD (HYDRATION THERAPY) MILD

DEHYDRATION DEHYRATIONMODERATE DEHYDRATIONSEVERE < 15 kg, < 2 y/o 50 cc/kg 100 cc/kg 150 cc/kg > 15 kg, 2 y/o 30 cc/kg 60 cc/kg 90 cc/kg D5 0.3% in 6-8 hours 1st_{hr: ¼ Plain LR} Next 5-7 hrs: ¾ D5 0.3% in 5-7 hours 1st_{hr: ⅓ Plain LR} Next 5-7 hrs: ⅔ D5 0.3% in 5-7 hours HOLIDAY-SEGAR METHOD (MAINTENANCE)

WEIGHT TOTAL FLUID REQUIREMENT

0 - 10 kg 100 mL / kg

11- 20 kg 1000 + [ 50 for each kg in excess of 10 kg] > 20 kg 1500 + [ 20 for each kg in excess of 20 kg] NOTE: Computed Value is in mL/day

Ex. 25kg child Answer: 1500 + [100] = 1600cc/day A R I P R O T O C O L (P R O G R A M F O R T H E C O N T R O L O F A R I) C h il d A g e 2 m o n th s u p to 5 y e ar s IV -F L U ID C O M P O S IT IO N S (C o m m o n ly U s e d fo r In fa n ts a n d C h il d ): Y o u n g In fa n ts < 2 m o n th s o ld

ATYPICAL PNEUMONIA -: extrpulmonary manifestations -: low grade fever

-: patchy diffuse infiltrates -: poor response to Penicillin -: negative sputum gram stain

Etiologic Agents Grouped by Age > Neonates (<1mo)

- GBS - E. coli

- other gram (-) bacilli - Streptococcus pneumoniae - Haemophilus influenza (Type B) > 1-3 months

* Febrile pneumonia - RSV

- Other respiratory viruses - Streptococcus pneumoniae - Haemophilus influenza (Type B) * Afebrile pneumonia - Chlamydia trachomatis - Mycoplasma homilis - CMV > 3-12 mo - RSV

- Other respiratory viruses - Streptococcus pneumoniae - Haemophilus influenzae (Type B) - C. trachomatis

- M. pneumoniae - Group A Streptococcus > 2-5 yrs

- RSV

- Other respiratory viruses - Streptococcus pneumoniae - Haemophilus influenzae (Type B) - C. trachomatis - M. pneumoniae - Group A Streptococcus - Staph aureus > 2-5 yrs - Streptococcus pneumoniae - Haemophilus influenzae (Type B) - C. trachomatis

- M. pneumoniae - Group A Streptococcus - Staph aureus

Dengue Shock Syndrome Manifestations of DHF plus signs of circulatory failure 1. rapid & weak pulse

2. narrow pulse pressure (<20mmHg) 3. hypotension for age

4. cold, clammy skin & irritability / restlessness

DANGER SIGNS OF DHF 1. abdominal pain (intense & sustained) 2. persistent vomiting

3. abrupt change from fever to hypothermia with sweating

4. restlessness or somnolence

Grading of Dengue Hemorrhagic Fever DENGUE

> MOT: mosquito bite (man as reservior) > Vector: Aedes aegypti

> Factors affecting transmission:

- breeding sites, high human population density, mobile viremic human beings

> Age incidence peaks at 4-6 yrs > Incubation period: 4-6 days > Serotypes:

- Type 2 – most common - Types 1& 3

- Type 4– least common but most severe > Main pathophysiologic changes:

a. increase in vascular permeability ▼ extravasation of plasma - hemoconcentration - 3rd_{spacing of fluids} b. abnormal hemostasis - vasculopathy - thrombocytopenia - coagulopathy

Dengue Fever Syndrome (DFS) Biphasic fever (2-7 days) with 2 or more of the ff: 1. headache

2. myalgia or arthralgia 3. retroorbital pain 4. hemorrhagic manifestations

[petechiae, purpura, (+) torniquet test] 5. leukopenia

Dengue Hemorrhagic Fever (DHF) 1. fever, persistently high grade (2-7 days) 2. hemorrhagic manifestations

- (+) torniquet test

- petechiae, ecchymoses, purpura - bleeding from mucusa, GIT, puncture sites - melena, hematemesis

3. Thrombocytopenia (< 100,000/mm3₎

4. Hemoconcentration

- hematocrit >40% or rise of >20% from baseline - a drop in >20% Hct (from baseline) following

volume replacement - signs of plasma leakage

[pleural effusion, ascites, hypoproteinemia]

D E N G U E P A T H O P H Y S IO L O G Y MANAGEMENT OF DENGUE A. Vital Signs and Laboratory Monitoring

Monitor BP, Pulse Rate

We have to watch out for Shock (Hypotension)

Torniquet Test: SBP + DBP = mean BP for 5 mins. 2

if ≥20 petechial rash per sq. inch on antecubital fossa (+) test

Herman’s Rash:

- usually appears after fever lysed - initially appears on the lower extremities - not a common finding among dengue patients - “an island of white in an ocean of red”

Recommended Guidelines for Transfusion: Transfuse:

- PC < 100,000 with signs of bleeding - PC < 20,000 even if asymptomatic - use FFP if without overt bleeding - FWB in cases with overt bleeding or

signs of hypovolemia > if PT & PTT are abnormal: FFP > if PTT only: cryprecipitate

3-7cc/kg/hr depending on the Hct (1st _{no.) level}

(D5LR)

10-20cc/kg fast drip PLR - hypotension, narrow pulse pressure fair pulse

Leukopenia in dengue: probable etiology is Pseudomonas therefore: give Meropenem or Ceftazidime

URINARY TRACT INFECTION

Suggestive UTI:

- Pyuria: WBC ≥ 5/HPF or 10mm3

- Absence of pyuria doesn’t rule out UTI - Pyuria can be present w/o UTI Presumptive UTI:

- (-) urine culture

- lower colony counts may be due to: * overhydration

* recent bladder emptying * previous antibiotic intake Proven or Confirmed UTI:

- (+) urine culture ≥ 100,000 cfu/mL urine of a single organism

- multiple organisms in culture may indicate a contaminated sample ACUTE GLOMERULONEPHRITIS Complications of AGN - CHF 2° to fluid overload - HPN encephalopathy - ARF due to ê GFR STAGES of AGN

- Oliguric phase [7-10days] – complications sets in - Diuretic phase [7-10days] – recovery starts - Convalescent phase [7-10days] – patients are

usually sent home

Prognosis

- Gross hematuria 2-3 weeks

- Proteinuria 3-6 weeks

- ▼C3 8-12 weeks

- microscopic hematuria 6-12 mo or 1-2 years

- HPN 4-6 weeks

> Hyperkalemia may be seen due to Na+_retention

> Ca++_{decreases in PSAGN}

> ▲ in ASO titer - normal within 2 weeks - peaks after 2 weeks

- more pronounced in pharyngeal infection than in cutaneous RHEUMATIC FEVER JONES CRITERIA: A. Major Manifestations - Carditis (50-60%) - Polyarthritis (70%) - Chorea (15-20%) - Erythema Marginatum (3%) - Subcutaneous Nodules (1%) B. Minor Manifestations - Arthralgia - Fever

- Laboratory Findings of:

▲ Acute Phase Reactants (ESR / CRP) Prolonged PR interval

C. PLUS Supporting Evidence of Antecedent Group-A Strep Infection

- (+) Throat Culture or Rapid Strep-Ag Test - ▲Rising Strep-AB Test

TREATMENT OF RHEUMATIC FEVER A. Antibiotic Therapy

- 10 days of Oral Penicillin or Erythromycin - IM Injection of Benzethine Penicillin *** NOTE: Sumapen = Oral Penicillin! B. Anti-Inflammatory Therapy

1. Aspirin (if Arthritis, NOT Carditis) Acute: 100mg/kg/day in 4 doses x 3-5days Then, 75mg/kg/day in 4 doses x 4 weeks 2. Prednisone

2mg/kg/day in 4 doses x 2-3weeks Then, 5mg/24hrs every 2-3 days

PREVENTON A. Primary Prevention

- 10 days of Oral Penicillin or Erythromycin - IM Injection of Benzethine Penicillin

B. Secondary Prevention

C. Duration of Chemoprophylaxis

BRONCHIAL ASTHMA (GINA GUIDELINES)

Controlled Partly Controlled Uncontrolled Day

symptoms none > 2x per wk

3 or more symptoms of Partly Controlled Asthma in any week Limitation of

activities none any

Nocturnal Sx

(awakening) none any

Need for

reliever < 2x per wk > 2x per wk Lung

function normal < 80%

KAWASAKI DISEASE CDC-CRITERIA FOR DIAGNOSIS:

ADOPTED FROM KAWASAKI (ALL SHOULD BE PRESENT) A) HIGH Grade Fever (>38.5 Rectally) PRESENT

for AT LEAST 5-days without other Explanation “High Grade Fever of at least 5 days”

DOES NOT Respond to any kind of Antibiotic! B) Presence of 4 of the 5 Criteria

1. Bilateral CONGESTION of the Ocular Conjunctiva (seen in 94%)

2. Changes of the Lips and Oral Cavity (At least ONE) 3. Changes of the Extremities (At least ONE) 4. Polymorphous Exanthem (92%) 5. Cervical Adenopathy = Non-Suppurative Cervical

Adenopathy (should be >1.5cm) in 42%) HARADA Criteria

- used to determine whether IVIg should be given - assessed within 9 days from onset of illness

1. WBC > 12,000 2. PC <350,000 3. CRP > 3+ 4. Hct <35% 5. Albumin <3.5 g/dL 6. Age 12 months 7. Gender: male

• IVIg is given if ≥ 4 of 7 are fulfilled • If < 4 with continuing acute symptoms,

risk score must be reassessed daily

TREATMENT Currently Recommended Protocol: A. IV-Immunoglobulin

2g/kg Regimen Infusion EQUALLY Effective in Prevention of Aneurysms and Superior to 4-day Regimen with respect to Amelioration of Inflammation

as measured by days of

Fever, ESR, CRP, Platelet Count, Hgb, and Albumin NOTE: There is a TIME FRAME of 10 days

B. Aspirin

HIGH Dose ASA (80-100mg/kg/day divided q 6h) should be given Initially in Conjunction with IV-IG

THEN

Reduced to Low Dose Aspirin (3-5mg/kg/day) AND

Continued until Cardiac Evaluation COMPLETED (approximately 1-2 months AFTER Onset of Disease)

TYPES OF SEIZURES A. Partial Seizures (Focal / Local)

– Simple Partial

– Complex Partial (Partial Seizure + Impaired Consciousness) – Partial Seizures evolving to Tonic-Clonic

Convulsion B. Generalized Seizures

– Absence (Petit mal) – Myoclonic

– Clonic – Tonic – Tonic-Clonic – Atonic

SIMPLE FEBRILE SEIZURE vs.

COMPLEX FEBRILE SEIZURE Febrile Seizure:

“A seizure in association with a febrile illness in the absence of a CNS infection or acute electrolyte imbalance in children older than 1 month of age without prior afebrile seizures”

CLASSIFICATION BY CAUSE A. Acute Symptomatic

(shortly after an acute insult) – Infection

– Hypoglycemia, low sodium, low calcium – Head trauma

– Toxic ingestion B. Remote Symptomatic

– Pre-existing brain abnormality or insult – Brain injury (head trauma, low oxygen) – Meningitis

– Stroke – Tumor

– Developmental brain abnormality C. Idiopathic

– No history of preceding insult – Likely “genetic” component

SEIZURES

> Seizures: sudden event caused by abrupt, uncontrolled, hypersynchronous discharges of neurons

> Epilepsy: tendency for recurrent seizures that are unprovoked by an immediate cause > Status epilepticus: >30min or back-to-back

w/o return to baseline > Etiology:

- V ascular : AVM, stroke, hemorrhage - I nfections : meningitis, encephalitis - T raumatic :

- A utoimmune : SLE, vasculitis, ADEM - M etabolic : electrolyte imbalance - I diopathic : “idiopathic epilepsy” - N eoplastic : space occupying lesion - S tructural : cortical malformation,

prior stroke - S yndrome : genetic disorder

SIMPLE FEBRILE SEIZURE A. Criteria for an SFS

– < 15 minutes – Generalized-tonic-clonic

– Fever > 100.4 rectal to 101 F (38 to 38.4 C) – No recurrence in 24 hours

– No post-ictal neuro abnormalities (e.g. Todd’s paresis)

– Most common 6 months to 5 years – Normal development

– No CNS infection or prior afebrile seizures B. Risk Factors

– Febrile seizure in 1st_{/ 2}nd_{degree relative}

– Neonatal nursery stay of >30 days – Developmental delay

– Height of temperature C. Risk Factors for Epilepsy

(2 to 10% will go on to have epilepsy) – Developmental delay

– Complex FS (possibly > 1 complex feature) – 5% > 30 mins => _ of all childhood status – Family History of Epilepsy

– Duration of fever

TUBERCULOSIS A. Pulmonary TB

– fully susceptible M. tuberculosis, – no history of previous anti-TB drugs – low local persistence of primary resistance to

Isoniazid (H)

2HRZ OD then 4HR OD or 3x/wk DOT – Microbial susceptibility unknown or initial drug

resistance suspected (e.g. cavitary) – previous anti-TB use

– close contact w/ resistant source case or living in high areas w/ high pulmonary resistance to H.

–

2HRZ + E/S OD, then 4 HR + E/S OD or 3x/week DOT

B. Extrapulmonary TB

– Same in PTB

– For severe life threatening disease (e.g. miliary, meningitis, bone, etc)

2HRZ + E/S OD, then 10HR + E/S OD or 3x/wk DOT

RESPIRATORY DISTRESS SYNDROME (Hyaline Membrane Disease) o Male, preterm, low BW, maternal DM, & perinatal

asphyxia o Corticosteroids:

• most successful method to induce fetal lung maturation

• Administered 24-48 hours before delivery decrease incidence of RDS

• Most effective before 34 weeks AOG o Microscopically: diffuse atelectasis, eosinophilic

membrane

Pathophysiology:

1. Impaired/delayed surfactant synthesis & secretion 2. V/Q (ventilation/perfusion) imbalance due to

deficiency of surfactant and decreased lung compliance

3. Hypoxemia and systemic hypoperfusion 4. Respiratory and metabolic acidosis 5. Pulmonary vasoconstriction 6. Impaired endothelial &epithelial integrity 7. Proteinous exudates

8. RDS

Clinical Features:

1. Tachypnea, nasal flaring, subcostal and intercostal retractions, cyanosis, grunting 2. Pallor – from anemia,

peripheral vasoconstriction 3. Onset – within 6 hours of life

Peak severity – 2-3 days

Recovery – 72 hours

Retractions:

o Due to (-) intrapleural pressure produced by interaction b/w contraction of diaphragm & other respiratory muscles and mechanical properties of the lungs & chest wall

Nasal flaring:

o Due to contraction of alae nasi muscles leading to marked reduction in nasal resistance

Grunting:

o Expiration through partially closed vocal cords • Initial expiration: glottis closed

lungs w/ gas

inc. transpulmo P w/o airflow

• Last part of expiration: gas expelled against partially closed cords

Cyanosis:

o Central – tongue & mnucosa (imp. Indicator of impaired gas exchange); depends on total amount of desaturated Hgb

LUMBAR PUNCTURE

• the technique of using a needle to withdraw cerebrospinal fluid (CSF) from the spinal canal. SPINE

• spinal cord stops near L2

• lower lumbar spine (usually between L3-L4 or L4–5) is preferable

CSF

• clear, watery liquid that protects the central nervous system from injury

• cushions the brain from the surrounding bone. • It contains:

– glucose (sugar) – protein – white blood cells

• Rate : 500ml/day or 0.35ml/min • Range : 0.3-04 ml/min • Volume : 50ml (infants)

150ml (adults) Indication

• to diagnose some malignancies (brain cancer and leukemia)

• to assess patients with certain psychiatric symptoms and conditions.

• for injecting chemotherapy directly into the CSF (intrathecal therapy)

• To diagnose other medical conditions such as: – viral and bacterial meningitis

– syphilis, a sexually transmitted disease – bleeding around the brain and spinal cord – multiple sclerosis, (affects the myelin coating of

the nerve fibers of the brain and spinal cord) – Guillain-Barré syndrome, (inflammation of the

nerves) Complication • Local pain • Infection • Bleeding • Spinal fluid leak

• Hematoma (spinal subdural hematoma • Spinal headache

• Acquired epidermal spinal cord tumor Caution & Contraindications • Increased ICP

• Bleeding diasthesis • Traumatic Tap • Overlying skin infection • Unstable patient Empirical dose

 6 months ¼ tsp TID QID

 6 mos – 2 yrs ½ tsp

 2-6 1 tsp

 6-9 1 ½ tsp

 9-12 2 tsp

NEWBORN RESUSCITATION AIRWAY: open & clear

 Positioning  Suctioning

 Endotracheal intubation (if necessary) BREATHING is spontaneous or assisted  Tactile stimulation (drying, rubbing)  Positive-pressure ventilation

CIRCULATION of oxygenated blood is adequate  Chest compressions

 Medication and volume expansion

RESUSCITAION MEDICATIONS Atropine 0.02 ml/k IM, IV, ET

Bicarbonate 1-2 meq/k

Calcium 10 mg elem Ca/k slow IV Calcium chloride 0.33/k (27 mg Ca/cc) Calcium gluconate 1 cc/k (9 mg Ca/cc) Dextrose 1g/k = 2 cc/k D50_{4 cc/k D25} Epinephrine 0.01 cc/k IV, ET

UMBILICAL CATHERIZATION Indications

• Vascular access (UV)

• Blood Pressure (UA) and blood gas monitoring in critically ill infants

Complications • Infection • Bleeding • Hemorrhage • Perforation of vessel

• Thrombosis w/ distal embolization

• Ischemia or infarction of lower extremities, bowel or kidney • Arrhythmia • Air embolus Cautions • Never for: – Omphalitis – Peritonitis • Contraindicated in – NEC – Intestinal hypoperfusion Line Placement • Arterial line • Low line

– Tip lie above the bifurcation between L3 & L5 • High line

– Tip is above the diaphram between T6 & T9

Cathether length • Standardize Graph

– Perpedicular line from the tip of the shoulder to the umbilicus

• Measure length from Xiphoid to umbilicus and add 0.5 to 1cm.

• Birth weight regression formula

– Low line : UA catheter in cm = BW + 7 – High line : UA catheter = [3xBW] + 9 – UV catheter length = [0.5xhigh line] + 1 Procedure

• Determine the length of the catheter

• Restrain infant and prep the area using sterile technique

• Flush catheter with sterile saline solution • Place umbilical tape around the cord. Cut cord

about 1.5-2cm from the skin. • Identify the blood vessels.

(1thin=vein, 2thick=artery)

• Grasp the catheter 1cm from the tip. Insert into the vein, aiming toward the feet.

• Secure the catheter

• Observe for possible complications

MKD COMPUTATION

Wt x mkd x preparation [mg/mL] = mL per dose e.g. 12kg x 10mg x 5ml = 5mL per dose

120mg

* If per day, divide total (mL) by the # of divided doses Dose x preparation x frequency = mkd

weight

Paracetamol Drops = Wt: move 1 decimal point to the left

Age Wt 1 10 kg 2 12 3 14 4 16 5 18 6 20 1 drop = 1/20 mL 1 teaspoonful = 5 mL 1 tablespoonful = 15 mL 1 wineglassful = 60 mL = 2 ounces 1 glassful = 250 mL = 8 ounces 1 grain = 60 mg 1 pint = 500 mL 1 quart = 1000 mL 1 ounce = 30 mL 1 Kg = 2.2 lbs 1 lb = 0.45359 Kg BILIRUBIN PRETERM: mg/dl mmol/L 0-1 hr 1-6 17-100 1-2 d 6-8 100-140 3-5 d 10-12 170-200 TERM mg/dl mmol/L 0-1 hr 2-6 34-100 1-2 d 6-7 100-120 3-5 d 4-12 70-200 1 mo <1 <17

KRAMERS CLASSIFICATION OF JAUNDICE

ZONE JAUNDICE _BILIRUBINSERUM I Head & neck 6-8 II _{to umbilicus}Upper trunk 9-12 III Lower trunk_{to thigh} 12-16 IV Arms, legs,_below 15 V Hands & feet 15