hannah ivane bendanio: Silliman University Medical School

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SILLIMAN UNIVERSITY MEDICAL SCHOOL

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) L GA) Medications: Erythromycin eye ointment both eyes Vit K 1 mg IM (term); 0.5 mg (PT) Hep B vaccine 0.5 ml IM, secure consent BCG 0.05 ml ID (PT); 0.1 ml (term), secure onsent SO Routine NB care Monitor VS q30 mins until stable Thermoregulate at 36.5 to 37.5°C Place under droplight (NSD); isolette (CS) Suction secretion prn Will infrom AP /AP attended delivery

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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.

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

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.

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

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.

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.

ANTIBIOTICS 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 Amoxicillin + Clavulanic acid (30  – 50 mkday) Augmentin Tab: 375mg (250mg); 625 (500mg) Amoclav Susp: 156.25mg/5ml (125mg) TID 228.5mg/5ml (200mg) BID 312.5mg/5ml (250mg) TID 457mg/5ml (400mg) BID Cloxacillin (50  – 100 mkday) q6h Prostaphlin A Tab: 250mg 500mg Orbinin Susp: 125mg/5ml Flucloxacillin (50  – 100 mkday) q6h Staphloxin Susp: 125mg/5ml Cap : 250mg 500mg Chloramphenicol (50  – 75 mkd) q6h Pediachlor Susp: 125mg/5ml Chloramol Tab : 250mg 500mg Kemicetine Chloromycetin 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 Drops: 125mg/1.25ml

250mg/5ml

2nd Generation Cefaclor (20  – 40 mkd ) q 8  – 12 h Ceclor Pulvule: 250mg 500mg 375mg Ceclor CD 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 : 100mg Sachet/ Susp: mg/5ml COTRIMOXAZOLE (TM 5  – 8 mkd) q 12h Bactille – TS Susp/5ml SMZ 400mg TM Tab 800mg Bacidal 160mg Susp/5ml 400mg Trizole Susp/5ml 400mg Globaxole Tab 800mg 160mg Susp/5ml 400mg

80mg

80mg 80mg

80mg

Trimethoprim + Sulfadiazone (TM 5  – 8 mkd) Triglobe Tab Sdz 410mg TM 90mg Forte 820mg 180mg Susp/5ml 205mg 45mg AMINOGLYCOSIDES Tetracycline 25 – 50 mkday q6h Doxycycline 5 mkday BID Furaxolidone 5 – 8 mkday q6h MACROLIDES Erythromycin (30  – 50 mkd) q 6h Macrocin Susp: 200mg/5ml Ethiocin Drops: 100mg/2.5ml Erycin Cap : 250mg 500mg Susp: 200mg/5ml Drops: 100mg/2.5ml Erythrocin Film tab: 250mg 500mg Granules: 200mg/5ml DS Granules: 400mg/5ml Drops: 100mg/2.5ml Ilosone/ Tab: 500mg Ilosone DS Pulvule: 250mg Liquid: 125mg/5ml DS Liquid: 200mg/5ml Drops: 100mg/ml Clarithromycin (6  – 15 mkday OR 7.5 mkdose q12h) Klaricid Susp : 125mg/5ml 50mg/5ml Klaz Tab: 250mg 500mg Roxithromycin <6 yo 5  – 8 mkd BID 6 – 12 yo 100mg/tab BID Macrol/Rulid Tab: 150mg Ped Tab: 100mg Rulid dispensable Tab: 50mg Azithromycin

3 day regimen: 10 mkday x 3 days 5 day regimen: 10 mkd on day 1 5 mkd on day 2 to 5 Adult: 500mg OD day 1

250mg OD day 2 to 5 Zithromax Susp: 250mg/5ml Cap : 250mg Sachet: 200mg/sachet Clindamycin PO: 20  – 30 mkday q 6  – 8h IV: 25  – 40vmkday q 6h Susp: 75mg/5ml Cap: 150mg 300mg Amp: 150mg/ml 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)

Acyclovir Zovirax Acevir

ANTIVIRAL (20 mkdose) q 4  – 6 h Max 800mg/day x 5 days Susp: 200mg/5ml 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 Fluoconazole (3  – 6 mkd) OD x 2wks Diflucan Cap: 50mg 150mg Vial: 2mg/ml x 100 ml

200mg

ANTI-HELMINTHICS Oxantel + Pyrantel pamoate (10  – 20 mkd) SD Trichiuriasis: x 2 days Hookworm: x 3 days Quantrel Susp : 125mg/5ml Tab : 125mg 250mg Mebendazole *not recommended below 2 yo Antiox Susp: 50 mg/ml 100mg/ml Tab: 125mg 250mg 100 mg BID x 3 days 500mg SD (>2 yo) Albendazole <2 yo: 200mg SD >2yo: 400mg SD *may give x 3 days if with severe infestation Zentel Susp: 200mg/5ml Tab : 400mg ANTIHISTAMINE Diphenhydramine HCl (5mkd) q 6h IM/IV/PO: 1  – 2 mkdose Benadryl Syr: 12.5mg/5ml Cap: 25mg 50mg Inj: 50mg/ml Hydroxyzine (1mkd) BID Adult: 10mg BID 25mg ODHS Iterax Syr: 2mg/ml Tab: 10mg 25mg 50mg

Ceterizine

Virlix

Allerkid Alnix

Loratadine

Claritin Allerta Loradex Desloratadine

(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 Oral drops: 10mg/ml Oral soln: 1mg/ml Tab: 10mg Drops: 2.5mg/ml Syr: 5mg/5ml Drops: 2.5mg/ml Syr: 5mg/5ml Tab: 10mg 1 – 2 yo: 2.5 ml BID 2 – 12 yo (<30 kg): 5ml OD (>30 kg): 10ml OD Adult & > 12 y : 1 tab OD Syr: 5mg/ml Tab: 10mg

Aerius

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

DECONGESTANT Nasal NaCl Salinase Muconase Oxymetazoline HCl Drixine

2 – 4 drps/spray per nostril TID/QID 2 sprays/nostril then suction q6h x 3 days Nasal spray Nasal drops 2 – 5 yo: 2 – 3 drops/nostril BID >5 yo: 2 – 3 sprays/nostril BID Nasal spray: 0.05%

Xylometazoline HCl

Nasal soln: 0.025% < 1 yo: 1 – 2 drps OD/BID 1 – 6 yo: 1 – 2 drps OD/BID max TID Adult: 2 – 3 drps / 1 squirt TID max QID

Otrivin Oral Phenylpropanolamine HCl (0.3  – 0.5 mkdose) Disudrin 1 – 3 mos: 0.25 ml 4 – 6 mos: 0.5 ml 7 – 12 mos: 0.75 ml 1 – 2 yo: 1 ml 2 – 6 yo: 2.5 ml 7 – 12 yo: 5 ml Drops: 6.25ml q6h Syr: 12.5mg/5ml q6h

Brompheniramine maleate + PPA Dimetapp 1 – 6 mos: 7 – 24 mos: 2 – 4 yo: 4 – 12 yo: Adult:

0.5ml TID/QID 1ml TID/QID ¾ tsp 5ml 5 – 10 ml 1 tab BID Infant drops: (0.1mkdose) Syr Extentab Carbinoxamine maleate + Phenylephrine HCl Rhinoport 1 – 5 yo: 5ml 6 – 12 yo: 10ml Adult & > 12yo: 1 cap / 15ml Syrup Cap Loratadine + PPA Loraped <30 kg: 2.5ml BID >30 kg: 5ml BID Syrup: 5mg/ml

BID BID BID

MUCOLYTIC Solmux

Drops: 40mg/ml 1 – 3 mos: 0.5ml 3 – 6 mos 0.75ml 6 – 12 mos 1ml 1 – 2 yo 1.5 ml

TID/QID

Susp: 100mg/5ml 200mg/5ml  2 – 3 yo 5ml 2.5ml 4 – 7 yo 10ml 5 ml 8 – 12 yo 15ml 7.5ml

Solmux Broncho Solmux Chewable tab Carbocisteine MUCOLYTIC

Forte: 500mg/5ml Cap: 500mg Adult & >12 yo: 5 – 10ml 1 cap Capsule Suspension Tab: 500mg 1 tab q 8h Infant Drops QID <3mos 0.25ml 3 – 5 mos 0.5ml 6 – 8 mos 0.75ml 9 – 12 mos 1ml Ped Syr 1 – 3 yo 4 – 7 yo 8 – 12 yo  Adult Susp Adult & >12 yo

TID 5 – 7.5ml 7.5 – 10ml 10 – 15ml TID 10 – 15ml

1 – 1 ½ tsp 1 ½ - 2 tsp 2 – 3 tsp

2 – 3 tsp

Capsule Adult & >12 yo

Lovsicol

Ambroxol

Infant drops Ped Syrup Adult Susp Cap Infant drops 75mg/ml BID < 6 mo 0.5ml 7 – 12 mo 0.75ml 13 – 24 mo

Pedia Syrup <2 yo 2 – 5 yo 5 – 10 yo

Mucosolvan

TID 1 cap

50mg/ml 100mg/5ml 250mg/5ml 500mg 6mg/ml 0.5ml 1 ml 1.25ml

2.5ml 2.5ml 5ml

1ml

BID TID TID

 Adult Syrup Adult & >10 yo

5ml

TID

Retard cap Adult & >10 yo

1 cao

OD

Tab Adult & >10 yo

1 tab

TID

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

Ambrolex Zobrixol

Salbutamol

Ventolin

Inhalation Soln 15mg/2ml Ampule 15mg/2ml Infant drops 7.5mg/ml Ped liquid 15mg/5ml Adult liquid 30mg/5ml Tab 30mg B2 AGONIST (0.1  – 0.15 mkdose)

Tab Syr Nebule Tab Syr

Ventar Hivent Syrup Salbutamol + Guaifenesin Asmalin Tab Broncho 1 tab TID Syrup Pulmovent 2 – 6 yo 7 – 12 yo

Terbutaline sulfate Terbulin Pulmoxel

Bricanyl

Doxophelline Ansimar

Procaterol HCl

2mg 2mg/5ml 2.5mg/2.5ml 2mg 2mg/5ml

5 – 10 ml 10ml

( 0.075 mkdose) Tab 2.5mg Tab 2.5mg Syr 1.5mg/5ml Nebule 2.5mg/ml Tab 2.5mg Syr 1.5mg/5ml Nebule 5mg/2ml Expectorant (6  – 8 mkdose) BID x 7  – 10 days Syrup 100mg/5ml Tab 400mg (0.25ml/kg)

BID/TID

Meptin

Syrup Tab Nebuliser soln

Theophylline

10  – 20 mkdose 3  – 5 mkdose

Butamirate citrate

Sinecod Forte

ANTITUSSIVES 3 yo >6 yo >12 yo Adult Syrup Tab

5mcg/ml 25mcg 100mcg/ml

5 ml 10ml 15ml 15ml 1 tab 7.5mg/5ml 50mg

Dextromethorphan + Guaifenesin Robitussin – DM 2 – 6 yo 2.5 – 5ml 6 – 12 yo 5ml Adult 5 – 10ml Syrup INHALED STEROIDS Budesonide Budecort 250mcg q 12h 500mcg q 12h 500mcg OD for allergic rhinitis 250mcg /ml (2ml) 500mcg /ml (2ml) Flexotide neb 250mcg /ml (2ml) 250mcg q 12h ORAL STEROIDS Prednisone Prednisolone Liquidpred

LD: 10mkdose MD: 5mkdose 1 – 2 mkday 1 – 2 mkday Syrup 15mg/5ml

200mg

TID TID TID QID TID/QID

q 6 – 8h q 6 – 8h q 6h

Maalox (plain, plus) Simethicone Restime

Dicycloverine Relestal Domperidone

Motilium Vometa

Ranitidine Zantac Cimetidine

Tagamet

Famotidine

Paracetamol

ANTACIDS 5ml/10kg  Available in 180ml bottle < 2 yo 0.5ml qid 2 – 12 yo 4ml qid Oral drops 40mg/ml ANTISPASMODIC 6mos – 2 yo 0.5 – 1ml TID Drops 5mg/ml Syrup 10mg/5ml 0.3 – 0.6 mkdose q 6 – 8 h 2.5 – 5ml/10kg BW TID Dyspepsia: 2.5/10kg TID Nausea: 2.5 – 5ml/kg TID 0.3 – 0.6 ml/5kg BW TID/QID Susp 1mg/ml Tab 10mg Oral drops 5mg/ml Susp 5mg/5ml Tab 10mg H2-BLOCKER 1  – 2 mkdose q 12h Tab 75mg 150mg 300mg Neonates: 5 – 20 mkday q6 – 12 h Infants: 10 – 20 mkday Child; 20 – 40 mkday Adult: 300mkdose QID 400mkdose BID 800mkdose QID Susp: 300mg/5ml Tab: 100mg 200mg 300mg 400mg 800mg PO: 0.5 mkdose q 12 h IV: 0.6 – 0.8 mkday q 8 – 12h ANTIPYRETIC (10  – 20 mkdose) q 4h

Tempra

Calpol

Defebrol Afebrin

Tylenol Naprex

Rexidol

Biogesic

Aeknil Opigesic Mefenamic Acid Ponstan

Aspirin Ibuprofen Dolan FP Dolan Forte Advil

Drops: Syrup: Forte : Tablet: Drops: Syrup:

60mg/0.6ml 120mg/5ml 250mg/5ml 325mg 500mg 100mg/ml 120mg/5m 250mg/5ml Syrup: 120mg/5m 250mg/5ml Drops: 60mg/0.6ml Syrup: 120mg/5ml Forte : 250mg/5ml Tablet: 600mg Drops: 80mg/ml Syrup: 160mg/5ml Drops: 60mg/0.6ml Syrup: 250mg/5ml Inj: 300mg/2ml Drops: 60mg/0.6ml Syrup: 250mg/5ml Tablet: 600mg Drops: 100mg/ml Syrup: 120mg/5m 250mg/5ml Tablet: 500mg Ampule (2ml) 150mg/ml Suppository: 125mg 250mg (6  – 8mkdose) q 6h Suspension: 50mg/5ml Cap SF: 250mg Tab: 500mg (60  – 100 mkd) (5  – 10 mkday) q8h (max 20mkday) Suspension: 100mg/5ml 200mg/5ml Drops: 100mg/2.5ml 100mg/5 Tab: 200mg

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

IV ANTIBIOTICS 50,000 – 100,000 ukd q 6h 50 – 100 mkd q 6 – 8 h 50 – 100 mkd q 6 – 8 h 50 – 100 mkd q 4 – 6 h 50 – 100 mkd q 6 h 50 – 100 mkd q 6 – 8 h 50 – 100 mkd q 6 – 8 h 5 – 7.5 mkd OD 5mkd q 12 h 15mkd q 12 h 50 – 100 mkd q 6 h 50 – 100 mkd q 6 – 8 h 50 – 100 mkd OD 50 – 100 mkd q 12 h LD: 10 mkdose MD: 5 mkdose q 6, 8 or 12h *max dose: LD 200 MD 100

Diazepam

Midazolam Phenobarbital

Hydralazine Apresoline Spirinolactone Isoniazid Comprilex Nicetal Trisofort Odinah

Rifampicin Natricin Rifadin Rimactane Rimaped Pyrazinamide (PZA) CIBA Zcure Zinaplex

ANTICONVULSANT 0.2 – 0.3 mkdose Drip: 1amp in 50cc D 5W 10mg/amp 0.15 mkdose OR 0.05 – 0.2 mkdose LD: 10 mkdose q 12h MD: 5 mkdose q 12h ANTIHYPERTENSIVES PO: 0.75 – 1.0 mkday q 6 – 12 h IV: 0.1 – 0.2 mkdose 1 – 3 mkday ANTI-TB MEDS (10 – 12 mkd) ODAC or 2hrs PC Suspension: 200mg/5ml 100mg/5ml 200mg/5ml 150mg/5ml Tablet 400mg (10 – 20 mkd) ODAC or 2hrs PC 100mg/5ml 200mg/5ml 100mg/5ml 100mg/5ml 200mg/5ml Tablet 300mg 450mg (16 – 30 mkd) BID/TID 250mg/5ml 500mg/5ml Tablet 500mg

IMMUNIZATION Vaccine BCG

DPT

OPV/IPV

Hep B

Measles MMR

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

No of dose 1

interval

booster

-

-

3

4 wks

18 mos 4 – 6 yo

3

4 wks

Same as DPT

3

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

1

-

15 mos

1

Hib

2, 4, 6 mos

18 mos

Pneumococcal

6 mos (PCV7) 2 yrs (PPV) 3 and 5 mos 1 yr and up 1st: 12 – 15 mos 2nd: 4 – 6 yo

18 mos

Rotavirus Hep A Varicella

Flu

6 months

2

I month

2

6 – 12 mos apart Bet 1st and 2nd dose: at least 3 mos yearly

2

Fluid PNSS 0.45 NaCl D5 0.3 NaCl D5 LRS D5 NM D5 IMB D5 NR

COMPOSITION OF IV SOLUTION Na K Cl 154 154 77 77 51 51 130 40 25 140

4 13 20 5

Na requirement : 2 – 4 meq/k/day K requirement: 2 – 3 meq/k/day KIR: 0.2 – 0.3 meq/k/hr

109 40 22 98

HCO3  -

Dxt 5

28 16 23 27

5 5 5 5

max of 40 meq

KIR = Rate x incorporation wt Electrolyte correction computation

Glucolyte Hydrite WHO Pedialyte 30 45 90 Gatorade

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

Cl 50 80 65 30 35 80

Glu 100 111 75

9/100

ASSESSMENT OF DEHYDRATION [CDD] PARAMEeTER NO SIGN SOME SIGN Condition Well, Alert RestlessI Irritable Eyes Tears Mouth/Togue Thirst

Skin pinch

PLAN A

PLAN B PLAN C

Normal

Sunkem

Present Moist Drinks normally Not thirsty Goes back quicly

Absent Dry Thirsty Drinks eagerly Goes back slowly

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

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

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

 

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 D 5 LR

VARIABLE

PCAP A Minimal Risk None

Comorbid Illness Compliant Yes caregiver Ability to Possible follow up Presence of None dehydration Ability to feed Able Age >11 mos RR 2 – 12 mos >50/min 1 – 5 yo >40/min >5 yo >30/min Signs of Respiratory Failure Retractions Head babbing Cyanosis Grunting Apnea Sensorium

Complication: Effusion Pneumothorax Action Plan

PCAP PCAP B Low Risk

PCAP D High Risk

Present

PCAP C Moderate Risk Present

Yes

No

No

Possible

Not

Not

Mild

moderate

Severe

Able >11 mos

Unable <11 mos

Unable <11 mos

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

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

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

-

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

Present

None

Awake

Subcostal/ Intercostal + + Irritable

None

None

Present

Present

OPD f/u at end of tx

OPD f/u after 3 days

Admit to regulat ward

Admit to CCU Refer to specialist

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

What shud b done if px is not responding to current antibiotics 1.

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

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

II III

IV

 



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

CRITERIA FOR CLINICAL DX (WHO) DHF Fever, acute onset, high, lasting 2 –  7 days Hemorrhagic man:  o (+) Torniquet test o Minor & Major bleeding phenomenon 3 Thrombocytopenia <100,000/mm

DSS Above criteria Plus Hypotension or narrow pulse pressure [SBP – DBP] <20mmHg

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

ATOPIC DERMATITIS



Hereditary, AR



hx of Asthma







thickened, red

CONTACT DERMATITIS

shiny,

exacerbated by dry skin, contact sty, & anxiety



Irritant  –  strong chem.



e.g. diaper rash



remove reactant



tx: hydrocortisone/ fluocinolone





moisturizer





cloxa/cefalexin with infxn

if

SEBORRHEIC DERMATITS 

excessive sebum accumulation on scalp, face, midchest, perineum



greasy scalp (cradle cap)



physiologic 6mos



tx: low potency steroid

Allergic

e.g. cosmetic, perfume tx: high/mod petency steroid

1st

SIGNS OF SHOCK EARLY     

Narrowed pulse pressure Orthostatic changes Delayed capillary filling Tachycardia Hyperventilation

LATE      

Decrease systolic pressure Decrease diastolic pressure Cold, pale skin Altered mental state Diaphoresis Decrease urine output

SHOCK  

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 .    7

 .    8

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 

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 Continuous monitor ECG and O2 sat & establish IV o access Antihistamine to prevent progression o o H1 & H2 blocker Diphenhydramine (1mg/kg) IM o 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

VIRAL INFECTIONS MEASLES (Rubeola) [Paramyxoviridae] MOT Droplet spray IP 10 – 12 days Prd of comm 4 days before & 4 days after onset of rash Enanthem Koplik spots (opposite lower molars) Prodrome High grade fever, conjunctivitis, catharr (3 – 5 days) Rash Appear during height of fever Cephalocaudal[1st along hairline, face, chest] [+] brawny desquamation – disappear w/n 7 – 10 days Complication 1. Otitis media 2. Pneumonia 3. Encephalitis 4. Diarrhea 5. Exacerbation of M tb infection Tx Vit A SD 100,000 IU orally for 6 mos – 1 yo 200,000 IU >1 yo Post exposure Ig w/n 6 days of exposure prophylaxis (0.25ml/kg max 15 ml) IM Vaccine Susceptible children >1 yo w/n 72 hrs SSPE Chronic condition due to persistent measles  infxn Rare but found in 6 mo to >30 yrs of age  Subtle change in behavior & deterioration o  schoolwork followed by bizarre behavior Elevated titers of Ab to measles virus(IgG,  IgM) Inosiplex (100mg/kg/day) may prolong  survival GERMAN OR 3 DAY MEASLES [RUBELLA] [Togaviridae] MOT Oral Droplet; transplacentally to fetus IP 14 – 21 days Prd of comm 7 days before &7 days after onset of rash Enanthem Forchheimer spots [soft palate] just b4 onset of rash Rash Cephalocaudal Characteristic Retroauricular, posterior cervical & postoccipital

sig n sign Tx

LAD [24 hrs before rash & remains for 1 wk] Vit A SD 100 100,000 ,000 IU orally for 6 mos mos –  – 1  1 yo 200,000 IU >1 yo Post exposure Immunoglobulin Immunoglob ulin [not [ not routine] prophylaxis Considered if termination of preg is not an option 0.55ml/kg) IM Vaccine w/n 72 hrs of exposure Congenital Greatest during 1st trimester  Rubella IUGR  Congenital cataract, microcephaly, PDA,  “blueberry muffin” skin lesions Congenital Conge nital or profound SNHL   Motor or mental retardation ROSEOLA [HSV 6] Exanthem subitum Age of onset < 3 yo with peak at 6 –  – 15  15 months High grade fever for 3 – 3  – 5  5 days but behave normally Rash Appears Appe ars 12 12 –  – 24  24 hrs of fever resolution fades in 1  – 3 days HERPANGINA [Coxsackie A] - Sudden onset of fever with vomiting - Small vesicles & ulcers w/ red ring found in anterior tonsillar pillars, may also seen on the soft palate, uvula & pharyngeal wall

VARICELLA [HSV] MOT IP Prd of comm Rash

Complication

Direct contact 14 days 1 –  – 2  2 days before the onset of the rash until 5 – 5  – 6  6 days after onset & all the lesions have crusted Start from the trunk then spread to othe parts of the body All stages present; pruritic Macule/papule → vesicle →crust Secondary bacterial infection  Encephalitis Enceph alitis or meningitis  Pneumonia  Reye syndrome  GN 

Congenital Varicella



6 -12 wks AOG: maximal interruption w/ limb devt with cicatrix(ski lesion w/ zigzag scarring) 16 – 16  – 20  20 wks: eye and brain involvement  Tx Acyclovir 15 15 –  – 30  30 mg/kg/day IV or 200 – 200  – 400  400 mg tab q 4hrs minus midnight dose x 5 days: increased risk o severity Post exposure VZIg 1 dose up to 96 hrs after exposure prophylaxis Dose: 125 U/10 kg (max 625 U) IM NB whos mother develop varicella 5 days before to 2 days after delivery shud recv 1 vial Vaccine Vacci ne Susceptible childr children en >1 yo w/n 72 hrs ERYTHEMA INFECTIOSUM [Parvovirus B 19] FIFTH DISEAS DISEASE E MOT Droplet spread & blood & blood products IP 16 – 17 16 –  17 Days average Prodrome Low grade fever, headache, URTI Rash Erythematous Eryth ematous facial flushing “slapped cheek”  and  and spreads rapidly to the trunk & proximal extremities as a diffuse macular erythema Palms & soles are spared Resolves w/o desquamation but tend to wax and wane in 1 – 1 – 3  3 wks Dengue insert Rabies

JUVENILE RHEUMATOID ARTHRITIS [JRA] Criteria Age of onset <16 yo   Arthritis (swelling or effusion or presence of 2 or more of: limitation of range of motion, tenderness or pain on motion, increased heat in one or more  joints.  Duration: 6 wks or longer Onset type defined in the 1st 6mos  o Polyarthritis: (5 or more inflamed  joints) o Oligoarthritis (<5) o Systemic Syste mic arthritis w/ characteristi characteristicc fever CM Morning Mornin g stiffness, stif fness, ease of fatigue esp. after school  in the early afternoon, joint pain later in the day,  joint swelling Pauci: LE, assoc w/ chronic uvietis  Poly: both large & small joints more severe if  extensors of elbow and Achilles tendon are involved Systemic: quotidian fever w/ daily temp spikes of  39°C for 2 wks; faint red macular rash over the trunk & proximal extremities  Mngt NSAIDS then Methotrexate Seroid for overwhelming systemic illness  SYSTEMIC LUPUS ERYTHEMATOSUS [SLE] Criteria Malar rash  Discoid rash  Photosensitivity  Oral ulce ulcers rs (painless)  Nonerosive arthritis (2 or more joints)   Serositis (pleuritis, serous pericarditis,Libman sacks endo endocarditis carditis  Renal disorder Neurologic disorder   Hematologic disorder Immunologic Immunolo gic disorder 



ANA abormal titer Dx Presence of 4 of 11 criteria [ANA not required  dx] (+) ANA – screening   Anti ds DNA – more specific; reflects the degree of disease activity  Decrease C3, C4 in active dse Anti Sm Ab (most specific)   Mngt NSAIDS use w/ caution Prednisone (1  – 2 mkday)   Severely ill: pulse IV steroid (30mkdose) max 1 gm over 60 mins OD x 3 days Severe dse: Pulse IV Cyclophosphamide to  maintain renal fxn & prevent progression HENOCH  – SCHONLEIN PURPURA [HSP] Most common cause of nonthrombocytopenic purpura in children   Typically follows URTI 2 – 8 years old   Hallmark Rash – palpable petechia or purpura, evolve from red to brown; last from 3 – 10 days [LE and buttocks] Arthritis of knees and ankles  Intermittent abdominal pain due to edema &  damage to the vasculatue of the GIT  Mngt Symptomatic Steroid for severe abdominal pain 

MAINTENANCE WATER HOLLIDAY  – SEGAR METHOD Weight [kg] Daily Requirement [ml/kg] 3 – 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 Microbial causes of CAP accrdng to Age o Birth to 20 days Grp B Strep o Gram (-) enterobacteria o CMV o L. monocytogenesis o 3 weeks to 3 RSV months Parainfluenza virus o o S. pneumonia B. pertussis o o S. aureus o 4 months to 4 RSV, Parainfluenza virus o yo Influenza virus, Adeno, Rhinovirus S. pneumonia o o H. influenzae M.pneumoniae o o M.tuberculosis o 5 years to M.pneumoniae 15 years C. pneumoniae o o S. pneumonia M.tuberculosis o

Therapeutic Mgt of CAP OPD Mngt Birth to 20 days

Admit

3 weeks to 3 months

Afebrile: Oral Erythromycin (30-40mkd) Oral Azithromycin (10 mg/kg/day) day 1 5mkday day2 to 5 Admit: febrile or toxic

4 months to 4 yo

Oral Amoxicillin (90mkd/3doses) Alternative: Amox-Clav, AZM, Cefaclor Clarithromycin, Erythromycin

5 years to 15 years

Oral Erythromycin (30-40mkd) Oral AZM 10mkday day 1, 5mkday day 2-5 Clarithromycin 15mkday/2 doses Pneumococcal infxn: Amoxicillin alone

IN-PATIENT Birth to 20 days

Ampicillin + Gentamicin w or w/o Cefotaxime

3 weeks to 3 months

Afebrile: IV Erythromycin (30-40mkd) Febrile: add Cefotaxime 200mkd Cefuroxime 150 mkd

4 months to 4 yo

If w/ pneumococcal infection: IV Ampicillin (200mkd) Cefotaxime 200mkd Cefuroxime 150 mkd

5 years to 15 years

Cefuroxime 150 mkd + Erythromycin 40mkd IV or orally for 10-14 days If pneumococcal is confirmed: Ampicillin 200mkd

CLINICAL FEATURES of PNEUMONIA o Bacterial Fever >38.5C o Chest recession o Wheeze not a sign of primary bacterial URTI o Viral Wheeze o fever < 38.5 o marked recession o RR normal or increased o Mycoplasma School children o Cough wheeze o CXR in assessing CAP etiology Alveolar infltrates Bacterial pneumonia Interstitial infiltrates Viral pneumonia Both infiltrates Viral, Bacterial or mixed viral bacterial pneumonia 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

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

o

o o

Metalloporphyrins

o

o

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

Influenza

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

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

RABIES VACCINE VERORAB BERIRAB

Ig (Human) Equine

Hx of Absorbed TT Unknown or <3 >      

0.5 cc/amp; 1 amp IM Day: 0 3 7 14 and 28 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 20 iu/kg Bayrab 300 iu/2ml Berirab 300 iu/2ml 40 iu/kg Favirab 200 – 400 iu/5ml 1000 – 2000 iu/5ml Clean minor Wound

All other Wounds

Td Yes

TIG No

Td Yes

TIG Yes

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

BILIRUBIN METABOLISM RBC Heme +Globin Heme oxygenase Biliverdin Bilirubin reductase Unconjugated bilirubin Enterohepatic pathway Liver SER Glucoronyl transferase

B-glucoronidase

Conjugated bilirubin

Kidney Urobilinogen Urobilin Urine

Small intestine Stercobilinogen Stercobilin Stool

Pathogenesis of Dengue Hemorrhagic Fever Dengue Virus

Liver

Liver injury

Dec coagulation Factors

Inc. Bleeding Tendency

Lymphoblast/plasma Cell

Platelet

Ag-Ab reaction

Dec maturation Megakaryocyte Inc plt destruction

Inc Vascular Permeability

Thrombocytopenia

Hypoalbuminemia Hemoconc. Pleural Effusion

Hypotension

Bleeding

Step 1 PRN B2 agonist

C O N T R O L L E R

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

SEVERITY OF ASTHMA EXACERBATION MILD MODERATE SEVERE

Breathless

Walking

Can lie

Talking Infant – softer shorter cry Diff feeding

Talks in

Sentences

Prefers sitting Phrases

Words

Allertness

May b agitated

Usually agitated

Usually agitated

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

Inc

Inc

>30/min

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

Usually

Usually

Wheeze

Moderate

Loud

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

<100

100-200

Usually loud >120

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

Maybe

Often

RESPIRAT ORY ARREST IMMINEN T

At rest Infant stops feeding

Hunched

Drowsy or confused

Paradoxic al Thoracoab d movt Absence of wheeze Bradycard ia

Absence

paradoxus

<10mmH g

PEF PaO2

>80% Normal

PaCO2

<45 mmHg >95%

O2 Sat

present 1025mmHg 60-80% >60 mmHg

present 20-40 mmHg <60% <60mmHg

<45 mmHg

>45 mmHg

91-95%

<90%

suggests resp ms fatigue

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

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

      

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

CEREBRAL PALSY Non-progressive disorder of posture & movement often  associated with epilepsy & abnormalities of speech, vision & intellect resulting from defect or lesion of the developing brain  Etiology: infections, toxins, metabolic, ischemia Classification Physiologic Topogrphic [major motor abnormality] [involved extremities] 1. Spastic 1. Monoplegia [1 2. Athetoid –worm like side/portion] 3. Rigid 2. Paraplegia 4. Ataxic 3. Hemiplegia 5. Tremor 4. Triplegia [3 limbs] 6. Atonic 5. Quadriplegia [all] 7. Mixed 6. Diplegia [LE/UE] 8. unclassified 7. Double hemiplegia Clinical Manifestaion Spastic hemiplegia Arms > legs  Dificulty in hand manipulation obviously  by 1 yo Delayed walking or walk on tiptoes  Spasticity apparent esp. in ankles  Seizure & cognitivr impairment  Spastic diplegia Bilateral spasticity of the legs  Commando crawl  Increased DTRs & (+) Babinski sign 



Spastic quadriplegia





Normal intellect 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

ESSENTIAL NEWBORN CARE PROTOCOL [from DOH] o What should be done immediately after birth is to dry the baby because hypothermia can lead to several risks o Delaying the cord clamping to 3 mins after birth (or waiting until the umbilical cord has stopped pulsing) o Instead of immediately washing the NB, the baby should be placed on the mother’s chest or abdomen to provide warmth, increase the duration of breastfeeding, and allow the “good bacteria” from the mother’s skin to infiltrate the NB o Washing should be delayed until after 6 hours because this exposes the NB to hypothermia and remove vernix. Washing also removes the baby’s crawling reflex.

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 No response Grimace Cough irritability 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 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)] 2.54cm) 1 – 4 months 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 months 9 cm 4 – 6 8 cm 7 – 9 5 cm 10 – 12 3cm

(inch =

NEWBORN CARE Umbilical Cord Cut 8 inches above abdomen after 30 sec  In nursery, cut the umbilical cord 1 ½ inch above the abdomen  Healing should take place around 7 – 10 days  Eye Prophylaxis  1% silver nitrate drops [most effective against Neisseria] Erythromycin 0.5% [Clamydia]  Tetracycline 1%  Povidone iodine 2.5%  Vitamin K 1 mg Vit K1  PT: 0.5 mg  Vaccine BCG  Hep B  Newborn Screening Done on 16th hr of life . can be repeated after 2 weeks  Patients w/ CAH will die 7 – 14 days if not treated  Patient w/ CH will have permanent growth defect and MR if not  treated before 4 weeks Disorder Screened Effects Screened Effects if Screened & treated Congenital 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

NEONATAL JAUNDICE Risk Factors Jaundice visible on first day of life o A sibling w/ neonatal jaundice or anemia o Unrecognized hemolysis o Non-optimal feeding o Deficiency: G6PD o Infection o Cephalhemaoma or bruising / Central hct >65% o East Asian/ Mediteranean in origin PHYSIOLOGIC vs PATHOLOGIC FACTORS PHYSIOLOGIC PATHOLOGIC Onset > 24 hrs of life < 24 hrs of life Rate of inc of TSB < 0.5mg/dl/hr > 0.5mg/dl/hr Persistent < 14 days FT: > 8 days PT: > 14 days Total S. Bilirubn FT: < 12 mg/dl Any level requiring PT: < 14 mg/dl phototherapy Sign/ Symptom Vomiting, lethargy, poor feeding, excess wt loss, apnea, inc RR, temp instability 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 o

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

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  VIRAL CROUP vs EPIGLOTTITIS VIRAL CROUP EPIGLOTTITIS Age group 3 mos to 3 yrs 3 – 7 yrs Stridor 88% 8% Pathogen Parainfluenza virus H. influenzae type B Onset Prodrome (1 – 7 Rapid (4 – 12 hrs) days) Fever Severity Low grade High grade Associated sympto Barking cough, Muffled voice, hoarseness Droolong Respond to racemic Stridor improves None epinephrine CXR “steeple sign” “thumbprint sign”

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

Age mo

Ht (cm) boys

Ht (cm) girls

Wt for Ht (cm)

Boys (kg)

Girls (kg)

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34

50.5 54.6 58.1 61.1 63.7 65.9 67.8 69.5 71.0 72.3 73.6 74.9 76.1 77.2 78.3 79.4 80.4 81.4 82.4 83.3 84.2 85.1 86.0 86.8 87.6 88.5 89.2 90.0 90.8 91.6 92.3 93.0 93.7 94.5 95.2

49.9 53.5 56.8 59.5 62.0 64.1 65.9 67.6 69.1 70.4 71.8 73.1 74.3 75.5 76.7 77.8 78.9 79.9 80.9 81.9 82.9 83.8 84.7 85.6 86.5 87.3 88.2 89.0 89.8 90.6 91.3 92.1 92.8 93.5 94.2

49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83

3.1 3.3 3.5 3.7 3.9 4.1 4.3 4.6 4.8 5.1 5.4 5.7 5.9 6.2 6.5 6.8 7.1 7.4 7.7 8.0 8.3 8.5 8.8 9.1 9.3 9.6 9.8 10.0 10.3 10.5 10.7 10.9 11.1 11.3 11.5

3.3 3.4 3.5 3.7 3.9 4.1 4.3 4.5 4.8 5.0 5.3 5.5 5.8 6.1 6.4 6.7 7.0 7.3 7.5 7.8 8.1 8.4 8.6 8.9 9.1 9.4 9.6 9.8 10.0 10.2 10.4 10.6 10.8 11.0 11.2

35 95.8 94.9 84 36 96.5 95.6 85 3.5 98.4 97.3 86 4 yo 102.9 101.6 87 4.5 106 104.5 88 5 109.9 108.4 89 5.5 112.6 111.0 90 6 116.1 114.6 91 6.5 118.5 117.1 92 7 121.7 120.6 93 7.5 123.9 123.0 94 8 127.0 126.4 95 8.5 129.1 128.8 96 9 132.2 132.2 97 9.5 134.4 134.7 98 10 137.5 138.3 99 10.5 139.9 140.9 100 11 143.3 144.8 101 11.5 145.8 147.6 102 12 149.7 151.5 103-105 12.5 152.5 154.1 106-108 13 156.5 157.1 109-111 13.5 159.3 158.8 112-114 14 163.1 160.4 115-117 14.5 165.7 161.1 118-120 15 169.0 161.8 121-123 15.5 171.1 162.1 124-126 16 173.5 162.4 127-129 16.5 174.9 162.7 130-132 17 176.2 163.1 133-135 17.5 176.7 163.3 136-140 18 176.8 163.7 141-145 Weight for Height = Actual BW (kg) P50 Wt for Ht (kg)

Height for Age = Actual Height (cm) P50 Ht for Age

11.7 11.9 12.3 12.3 12.5 12.8 13.0 13.2 13.4 13.7 13.9 14.1 14.4 14.7 14.9 15.2 15.5 101.0 16.1 16.5-17.1 17.4-18.0 18.3-19.0 19.3-20.0 20.3-21.1 21.4-22.2 22.6-23.4 23.9-24.8 25.2-26.2 26.8-27.8 28.4-29.6 30.2-33.0 33.7-36.9

11.4 11.6 11.8 11.9 12.2 12.4 12.6 12.8 13.0 13.3 13.5 13.8 14.0 14.3 14.6 14.9 15.2 15.5 15.9 16.2-16.7 17.0-17.6 17.9-18.6 18.9-19.5 19.9-20.6 21.0-21.8 22.2-23.1 23.6-24.6 25.1-26.2 26.8-28.0 28.7-30.1 30.8-32

Waterloo Classification Normal Mild Moderate Severe

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

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

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

NURSERY NOTES Dextrosity (to get factor:

Desired – D5 D50- D5

D 7.5 = 0.055 D10 = 0.11 D 12.5 = 0.166 D15 = 0.22 D 17.5 = 0.28 Limits of Dextrosity: Peripheral line = D12 Central line = D20 Total Fluid Intake (TFI): Preterm: start at 60 cckd Term: start at 80 cckd

To check TFI = rate x 24 ÷ wt ex. Preterm: wt: 1.129

Day 1: start IVF with D10 water 60 x 1.219 ÷ 24 = 3.1 cc/hr x 24 hrs Add Calcium gluconate at 200 mkd q8h Ca gluc = 1.129 x 200 ÷ 3 = 75mg q8hrs for 3 doses Start antibiotics Give ranitidine HGT q 8/12 hrs OGT CBC Na, K, Ca at 48 hrs Blood c/s depends on AP Day 2: increase TFI by 10-20 (depends on AP) 70 x 1.129 ÷ 24 = 3.3 cc/hr x 24 hrs incorporate ca gluc 200 mkd to IV ex. D10 water 80 cc 

      

Ca gluc

2.2cc 82.2cc to run at 3.3ccx24hrs

Day 3: increase TFI by 10-20 (depends on AP) If electrolytes are N, may use D10IMB 80 x 1.129 ÷ 24 = rate 80 x 1.129 x factor to get value of D50 water (to make D10 use 0.11) Cont Ca gluc incorporation (if feeding may discontinue) D50 water 9.9cc D5 IMB 77.9cc = D10 IMB Ca gluc 2.2cc (200mkd) 90 cc to run at 3.7cc/hrx24h If feeding already: Total volume of milk ÷ wt = cc/kg/day Subtract this amount to TFI to get value for IV (if Dr. Reinoso, divide by 2 before subtracting to TFI) ex. MF 3cc q3hrs = 24 cc in 24 hrs 24 ÷ 1.129 = 21.2 cckd from milk 80 – 21.2 = 58.8cckd (use this for IVF) 58.8 x 1.129 ÷ 24 = rate D50 water 7.3cc D5 IMB 56.5cc = D10 IMB Ca gluc 2.2cc (200mkd) 66 cc to run at 2.7cc/hrx24h Subsequent days depend on infants status….. Electrolyte requirements: Na: 2-4 mkd prep’n 2.5 mg/ml Ca: 100-200mkd prep’n 100mg/ml K: 2-4 mkd prep’n 2mg/ml Glucose Infusion Rate :

Dextrosity x IVF rate x 10 ÷ 10 Wt Ex. 10 kg; IVF D10 IMB at 40cc/h GIR = 10 x 10 x 40 ÷ 10 = 6.6mkmin 60

NV: Newborn & Infants 6-8 mg/kg/min Children 4-6 mg/kg/min If HGT <40 mg/dl, give D10 water slow IV push at 2cc/kg and repeat HGT after 30 mins-1 hr (may do 3 boluses if still low, may inc dextrosity or rate)

Level of Umbilical Cathetherization : (cm) If arterial between T6-T9 Wt x 3 x 8 If venous: (wt x 3) + 8 2

+1

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



FiO2 Nasopharyngeal cathether = Flow rate x 20 + 20 Ex. 1L Fio2 = 40  Nasal catheter = Flow rate x 4 + 20 Ex. 1L FiO2 = 24 Extubation: Give Dexamethasone at 0.1 mkdose q 6 hours for 24 hours prior  to extubation  USN with epinephrine 0.5 cc + 1.5 cc PNSS q 15 mins x 3 doses then extubate then USN with Salbutamol ½ nebule + 1.5 cc PNSS q 

6 hours x 24 hours O2 at 10 lpm then decrease as necessary  Regular milk: 20 cal/oz Preterm milk: 24 cal/oz

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

Dextrosity x 0.04 = cal/cc

Caloric content of IVF D5 = 0.2 cal/cc D7.5 = 0.3 cal/cc D10 = 0.4 cal/cc D15 = 0.6 cal/cc Caloric requirement & Protein requirement Cal/kg 0-5mo 115 6-11mo 110 1-2 yo 110 3-6 yo 90 – 100 7-9 yo 80 – 90 10 – 12 yo 70 – 80 13-15 yo 55 – 65 16 – 19 yo 45 – 50 Approximate Daily Water Requirement 0 – 3 do 120cc/k/d 4 – 6 yo 10 do 150cc/k/d 7 – 9 yo 1 – 5 mo 150cc/k/d 10 – 12 yo 6 – 12 mo 140cc/k/d 13 – 15 yo 1 – 3 yo 120cc/k/d 16 – 19 yo Estimated Catch up Growth Requirement = cal/k/day (age for wt) x IBW (wt for ht) Actual BW

CHON reqt = CHON reqt for age x IBW Actual BW Growth and Caloric requirements

g/kg 3.5 3 2.5 2 1.5 1.5 1.5 1.5 100 cc/k/d 90 cc/k/d 80 cc/k/d 70 cc/k/d 50 cc/k/d

AGE RDA kcal/kg/day 0 – 3 mos 115 3 – 6 mos 110 6 – 9 mos 100 9 – 12 mos 100 1 – 3 yo 100 4 – 6 yo 90 – 100 Double Volume Exchange Therapy (DVET) Wt x 80 x 2 = Volume/ amt of fresh whole blood (Use mother’s blood type) Volume _ = # of exchange aliquots per exchange > 3 kg 2-3 kg 1-2 kg 850g-1kg < 850 g

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

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

    

pH < 7 (profound met. Acidosis) Apgar <3 more than 5 mins Neurologic sequelae (coma; sz) Multiorgan involvement Difficult delivery

Medications 

Dopamine: wt x dose x 0.075 Prep’n : Single Strength: 200mg/250ml;



Double Strength: 400/250ml if using double strength: wt x dose x 0.075÷2 (Dose = 5-20) Dobutamine: wt x dose x 0.06 Prep’n: 250mg/250 ml; Dobuject 50mg/ml (Dose = 5-20)

If using Dobuject: Wt x dose x 60÷ concentration Concentrations: 5mg/ml = 5000 50mg/50ml = 1000 50mg/20ml = 2500 To make 5mg/ml: Dobuject 5cc D5 water 45cc To make 50mg/50ml: Dobuject 1cc D5 water 49cc To make 50mg/20ml: Dobuject 1cc D5 water 19cc  Diflucan: 6 mkd OD prep’n 50mg/tab divide into pptabs and give 1 pptab OD x 2 weeks Aminophylline: 5mkd (loading dose) then 1.6 mkd q 8 hrs  (maintenance)  Phenobarbital 20 mkd (loading dose) then 5 mkd (maintenance) Dexamethasone 0.1 mkdose q6hrs x 24 hours   For other meds, please see NEOFAX 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 



t

Staph 48H-5  day (2-5days)  Herpes Pseudomonas-give Gentamycin  Umbilical stump - sloughed off <14 days Alcohol - drying effect Cows milk allergy rd  Onset- 3  wk Rashes on cheeks → eyebrows → cradle cap 

CRANIUM Caput succedaneum diffuse edematous swelling of soft tses of scalp   extend across midline st edema disappears w/in 1  few days of life   molding and overriding of parietal bones-frequent st disappear during 1  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  nd calcify by end of 2  wk   few remain for years 10-25% cases underlying linear skull fracture  No tx but photo in hyperbil  seizure

Type

Duration

Simple

Complex

GTC

Focal then gen post ictal

< 15 min

> 15 min or may go into

status Recurrence

None

Recurrent (w/in 24H)

CNS exam

Normal

Abnormal

Sequelae

None

Neurodev abn

DIAZEPAM

MIDAZOLAM

PHENOBARBITAL

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

PHENYTOIN

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 LD: 15 – 20 mg/kg/IV MD: Neonate: 5 mkD PO/ IV BID Infant/child: 5 7mkD BID/ TID 6mos – 3y: 8 – 10 mkD 4 – 6y: 7.5 – 9 mkD 7 – 9y: 7 –  8 mkD

10 – 16 y: 6 – 7 mkD Tab: 50mg 100mg TID Extended release caps 30, 100, 200, 300 mg OD, BID ; Inj: 50 mg/ml

Dilantin

CARBAMAZEPINE Tegretol

< 6 yo 6 - 12 yo > 12 y

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

OXCARBAMAZEPINE

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

Trileptal

Tab 150 mg 300mg 600 mg Susp 300mg/5ml PO: Initial : 10 - 15 mkD OD - TID Increment: 10 mkD at wkly interval BID Maintenance: 30 - 60 mkD BID/TID IV: same dose as PO q 6H Rectal : (syrup mix with water 1:1) LD: 20 mkd MD: 10 -15mkd TID Tab 250 mg Syr 250mg/5ml IV 100mg/ml

VALPROIC ACID

Depakene Depacon

TOPIRAMATE

Topamax

Glasgow Coma Scale Activiy Eye Opening Spontaneous To speech To pain None Verbal Oriented Confused Inappropriate words Inappropriate sounds None Motor Follows command Localizes pain Withdraws to pain Abnormal flexion Abnormal extension None

2 - 16 yo Initial: 1 - 3 mkd PO q HS x 7 days then Increment: increase by 1 - 3 mkday for 1 - 2 wks then Maintenance: 5 -9 mkD BID Cap 15 mg, 25 mg Tabs 25 50 100 200mg

Response

Infants Activity

Response

4 3 2 1

Spontaneous To speech To pain None

4 3 2 1

5 4 3 2 1

Coos, babbles Irritable Cries to pain Moans to pain None

5 4 3 2 1

6 5 4 3 2 1

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

6 5 4 3 2 1

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

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

DTR very brisk brisker than average normal diminished no response

+4 +3 +2 +1 0

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

<2 mg/dl <2 mg/dl

<34 µmol/L <34 µmol/L

<8 mg/dl <8.7 mg/dl

<137 µmol/L <149 µmol/L

<12 mg/dl <11.5 mg/dl

<205 µmol/L <197µmol/L

<16 mg/dl <12 mg/dl

<274 µmol/L <205µmol/L

<2 mg/dl <1.2 mg/dl 0.3 – 1.2 mg/dl

<34 µmol/L <21 µmol/L 5 – 12 µmol/L

<0.6 mg/dl <0.2 mg/dl

<10 µmol/L <3.4 µmol/L

Pre Lumbar Tap NPO RBS by gluco prior to lumbar tap Prepare lumbar tap set 2% Lidocaine # 1 G 23 spinal needle Mannitol 250 cc 1 bottle - do not open Solvent Diazepam 1 amp 3cc syringe #2 2 manometers sterile bottles # 3 sterile gloves # 2 Sterile gauze # 1 Sterile gauze w/ Betadine #1 Sterile towel w/ hole #1 Sterile clamp #1 3-way stopcock #1

Post Lumbar Tap NPO x 4H Flat on bed Monitor NVS to include BP q 30mins x 4H, then qH CSF exams Bottle # 1 – Gm stain, AFB, India ink, KOH Bottle # 2 – Cell count, CHON, Sugar Bottle # 3 – C/S, save remaining specimen Watch out for vomiting, HA and hypotension

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

CSF ANALYSIS Color

Rbc

Wbc

Diff

sugar

CHON

L

70 -

60 -

100%

80%

150

L

70 -

60 -

100%

80%

200

L

>

10-20

100%

50%

L

40-

100%

60%

L>N

<

> 100

40%

g%

<

> 100

50%

g%

>

Dec

ct Normal Infant

Xantho

(Term) Infant

0 -32

100 Clear

(Preterm) Older

00-

0 -15

100 Clear

0

0 -10

child Viral

Clear

0

0 -20

Mening TB/Fungal

Clear

0

20 500

Bacterial

Purulent

0

Mening Partially tx BM

>

N>L

1000 Clear

0

100

L>N

40 -60

50%

CSF PATHWAY r Choroid plexus (lateral ventricle) → Foramen of Monroe → 3 th ventricle → Aqueduct of sylvius → 4  ventricle →Foramina of Luschka (2 laterals) → & Magendie (median) → SAS → Absorbed in the arachnoid villi, then in the Venous System Dengue Drips Furosemide drip Dose: 0.04 - 0.5 80 mg + 32 cc Wt x dose = rate (cc/h) 2 Furo drip = 0.1 - 0.5mg/k/hr Prep: 20mg/2ml (2mg/ml) Rate: (wt x dose)/2 = cc/hr ex. 14.5kg x 0.45 = 3.2cc/ hr To order: 8ml Furo + 32ml D5W +40 cc to run at 3.2cc/hr

Precedex drip Dose: 0.2 - 0.7 1ml + 99cc D5W to run at cc/h Wt x dose = rate (cc/h) Noradrenaline (Levophed) 1mg/ml dose :(0.5  – 1 ml/kg) Wt x dose ( each ml contains 4 mcg Noradrenaline) 4 mcg ( for acute hypotension) 2ml + 500cc D5W x 2cc/H (0.5 cc/H) Dopamine ( 5 -20 mcg/kg/min)

Dobutamine

Terbutaline Bricanyl SC

Terbutaline drip Ketamine (Ketalar)

Morphine IV Naproxen

200 mg/250ml Single strength 400 mg/250ml DS (div by 2) Wt x dose x 0.075 250 mg/5ml SS 500 mg/250ml DS(div by 2) Wt x dose x 0.06 Inj: 1 mg/ml < 12y – 0.005 – 0.01 mkd x 3 doses q 15 -20 min then q2-6H > 12y – 0.25 mkd LD: 2 – 10 mcg/kg then 0.1 – 0.4 mcg/kg/min 10, 50, 100 mg/ml PO: 5mg/kg x 1 IV 0.25 - 0.5 mg/kg IM 1.5 - 2 mg/kg x 1 0.1 – 0.2 mkd q2-4H prn 250, 375, 500mg tab 125mg/5ml > 2yo – 5-7 mkd TID, BID PO

IVIG infusion Preparation: 2.5g/50cc 500g/10cc 25g/100cc 5g/100cc 10g/250cc Computation: Wt x 2 g /kg IVIG Ex wt: 7.2 kg 7.2 x 2 + 16 g IVIG 16 gIVIG x 2. 5 g = 320 cc Cc 50cc # of vials = total cc 320cc = 6.4 vials 50cc 50cc 320cc x 0.03 = 9. 6 cc/h for 30 mins s Transfuse 9 – 10cc/h IVIG for the 1  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 nd If after 2  IVIG still febrile – start Prednisone Aspirin 80 mkD QID 30 mg, 80, 100, 300 mg KCl IV 2 meq/ml Child: 0.5 – 1meq/k/dose infusion of 0.5 meq/k/h for 1-2 h Tabs: 8, 10, 15, 20 meq Oral soln 10% ( 6.7 meq/5ml) 15% (10 meq/5ml) 20% (13.3 meq/5ml) PO : 1-4 meq/kg/24H QID IV: 0.5  – 1meq/k/dose

Ca Gluc = Children: 1cc/k/dose x 3doses;

NaHCO3 Inj premixed: 5% (0.6 meq/ml) 500ml Tabs: 325 mg ( 3.8 meq), 650 mg (7.6 meq)

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

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

LYSMIX Prozinc

Ercefuryl Erceflora Protexin Restore Racecadotril (Hidrasec) < 9 kg 9  – 13 kg 13  – 27kg > 27 kg FWB PRBC Plasma PRP Plt conc Cryoprecipitate

Factor 8

0.3 cc/k/dose TID Ceiling = 0.4 drops 10 mg/ml < 6 mos 1 ml OD < 6 mos – 2 yo 1 ml BID syrup 20 mg/5ml > 2 yo 5ml OD 20 mkday 1-2 vials/day OD for 2 wks mix with water, milk or juice 1 sachet mix with milk OD 1.5 mg/kg for 1 wk 10 mg sachet 10 mg sachet 30 mg sachet 30 mg sachet 10 - 20 cc/kg 5 - 10 10 - 15 10 - 15 1 u/ 7 -10 kg 1 u/kg Hemophilia A 1 bag (200mg fibrinogen) VW dse 50 -100 mg/kg Fibrinogen dse 100 cc (2-5 kg) Hemophilia A 50 u/kg Hemophilia B 100 u/kg

1 sachet TID 2 sachets TID 1 sachet TID 2 sachets TID 3 – 4H 3 – 4H 1 – 2 H 1 – 2 H FD FD

1 u FWB

= 200 cc PRBC = 50 cc platelet concentrate = 150 – 200cc PRP = 150 cc FFP MCV Hgb / rbc x 10 80 -94 MCH Hgb / rbc x 10 27 - 32 MCHC Hgb/ hct x 10 32 – 38 Absolute reticulocyte count  = pt’s hct x retic % N hct for age

Reticulocyte Index Absolute Retic Ct 2

> 2 hemorrhage < 2 rbc production abn

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

Hgb

1 - 3 days 14.5 – 22.5

Hct Wbc

.48 - .69 9 -30 birth

Plt

84 – 478 NB 0.4 - 0.6

Retic

1 mo

2mos 9 -14 .28 - .42

5 – 19.5

< 1 -1.2

6  – 12y 11.5 15.5 .35 - .45 6 -17.5

>12y 13-16 .37 - .49 4.5 13.5

After 1 wk, same as adult 150 - 400 0.1 -2.9

ANC - % of neutrophils & cells that become neutrophils  – multiplied by wbc ANC = wbc x (% seg + % stabs + % meta) Other formula: wbc x (seg + meta + stabs ) x 10 Ex 2.1 x 53 (seg) x 10 = 1113 ANC > 1000 Normal ANC < 2000 Neutropenia ANC 1000 -1500 Low risk of infection ANC 500 -1000 Mod risk of infection ANC < 500 High risk of infection

IT ratio

> 0.25 sepsis

> 0.80 higher risk of death fr sepsis Anemia < 10 g 8-9g <8 g

Glucose

mild anemia mod anemia severe anemia PT 20 -60 NB 30 – 60 1 d 40 -60 > 1d 50 -90

Child 60 -100

Adult 70 -105

EMERGENCY ET tube age in years + 4 4 ET diameter x 3 >10 yo cuffed

PT

Laryngoscope sizes Miller 00 or 0

Term

Miller 0

0-6mos

Miller 1

6-24 mos

Miller 2

>24 mos

Miller 2 or Mac 2

Epinephrine Amiodarone Cardioversion Albumin

EMERGENCY MEDS (bradycardia, asystole) (1:1000) 0.1 ml/kg q 3- 5 mins 5 mg/kg rapid IV push 2 J/kg then 4 J/kg then rpt 2x 1gm x wt given in 2-4hrs. Prep: 12.5g/50ml Vol expander: 20ml/kg HypoCHONemia – 1gm/k/dose x 4H

Epinephrine Drip 

Levophed 

Dopamine

0.1 – 1mg/k/min; 1amp = 1mg/ml Rate = (wt x dose x 60)/desired Ex: (18kg x 0.1 x 60)/100 = 2cc/hr To order: 5 amps Epi + 50cc D5W to rum at 2cc/hr (0.1mg/k/min) 0.3-2mcg/k/min Prep: 4mg/amp (1mg/ml) Rate = (wt x dose x 60)/desired Ex. Dose 0.5 1mg/20 = 0.05 x 1000 = 50mcg/ml (18kg x 0.5 x 60)/50 = 10.8cc/hr To order: 1 amp levophed + 80 cc D5W to run at 11cc/hr Renal dose 3-5 Pressor >5 - <15 alpha effect >15

ANAPHYLAXIS Epinephrine (1:1000)

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

BICARB DEFICIT CORRECTION : Ex: wt 4.9kg pH = 7.10 pCO2 = 9.1 pO2 = 36.5 HCO3 = 2.8 BE = -26.8 O2 Sat = 53.6% BE x Wt x 0.3 = 26.8 x 4.9 x 0.3 = 39.39meqs Half correction: 39.39/2 = 19.69 meqs To order: Give 20 meqs NaHCO3 + equal amt of sterile water to be given slow IVTT over 30mins. Infuse another 20 meqs NaHCO3 + equal amt sterile water as drip for 1-2 hrs.

EMPIRIC: NaHCO3 1-2mkdose even w/o ABG. HCO3 correction in ABG : Half correction: Base x’s x 0.3 x wt ÷ 2 (+ equal amount of sterile water) Full correction: Base x’s x 0.3 x wt ÷ 2 (1/2 via IV push, ½ via IV drip) Full correction: Base x’s x 0.3 x wt ÷ 2 (1/2 via IV push, ½ via IV drip) BUN/ crea ratio Normal 10 -20 > 20 suggest DHN, pre renal azotemia or GIB < 5 – liver disease, inborn error of metabolism GFR (based on plasma creatinine and ht) 2 GFR = k x L = ml/min/1.73 m  SA sCr L = body length (cm) Scr = mg/dL ; divide by 88.4 if units in mmol/L Age LBW < 1 yr FT < 1 yr 2-12 y 13-21 y (female) 13 -21 y (male)

Age PT 2- 8 d 4 - 28 d 30 -90 d Term 2- 8 d 4 - 28 d 30 - 90 d 1- 6mo

K (mean value) 0.33 0.45 0.55 0.55 0.70

KI 29.17 39.78 48.62 48.62 61.88

GFR

Range

11 20 50

11 – 15 15 – 28 40 – 65

39 47 58 77

17 – 60 26 – 68 30 – 86 39 -114

6 - 12 mo 2 - 19mo 2 - 12y Adult males Adult females

BSA Weight in (kg) 0 – 5 6 – 10 11 – 20 20 – 40 >40

103 127 127 131 117

49 – 157 62 – 191 89 – 165 88 – 174 87 – 147

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

Computation for OFI (AGN & limiting OFI) 1. BSA x 400 + UO – IVF (half if w/ Furo) = OFI (then divide to 3 shifts) 2. 20cc x wt x UO – IVF

TFR

CHON

CHO

Fats

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

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

285 ml 20 ml 485 ml 110 ml 1000ml x 37 cc/h

TPN for NEONATES Wt 2kg 200 ml 1. TFR = 100 ml/kg/day x 2 kg 2. Intralipid 20% 10 ml 1 g/kg/day x 2kg = 2g/day 2 g = 20g x 100ml 3. Compute for TFR 1 TFR1 = TFR – Intralipid = 200 -10ml = 90 ml 4. Vamin 7% 29 ml 1 g/kg/day x 2 kg = 2g = 2 g = 7g x 100ml 5. Multivitamins Benutrex c 0.5 ml/100ml 1 ml 0.5 ml = x 100ml 190 ml 4 ml 6. Ca gluc 10% 2ml/kg/day x 2 kg 7. Dextrosity (D10) get d50w TFR 1 x dextrosity factor (0.11) 21 ml

190 x 0.11 8 . D5IMB = TFR 1 – (Vamin + MTV + Ca gluc + D50W) 135 ml 190 – (29 + 1+ 4+ 21) = 9. IV rate = TFR 1 / 24H 190 ml/ 24H 8 ml/H Order: Start TPN as ff: TFR= 100ml/kg/day D5 IMB 135 ml D50W 21 ml Vamin 7% 29 ml Ca Gluc 4 ml MTV

1 ml 190 ml to run at 8 ml/h Intralipid 20% 10 ml to run for 24H Peak Flow (6 – 7 yo) (Ht cm – 100) x 5 + 170 female + 175 male Nasopharyngeal catheter = flow rate x 20 + 20 Nasal cannula = flow rate X 4 + 21 TFR= TV x RR x IE ratio + dead space (2000) TV= 10 ml x wt TFR Short cut: wt x 10 + 40 ml divide by 0.5 16.77

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 Abbott: Similac advance Milupa: Alaptamil

Wyeth: S26, Bonna Unilab: Mylac 6months onwards (20cal/oz) Mead-johnson: Enfapro Nestle: NAN2, Nestogen 2 Glaxo: Frisomil Dumex: Dupro Abbott: Gain Wyeth: Bonnamil. Promil Unilab: Hi-nulac 1 year onwards (20 cal/oz) Mead-johnson: Enfagrow, Lactum Nestle: NAN3, Neslac Glaxo: Frisorow Dumex: Dugrow Abbott: Gainplus Wyeth: Progress, Promil Unilab: Enervon bright Hypoallergenic (20cal/oz) Mead-johnson: Pregestimil Nestle: Alfare, NAN HA1, NAN HA2

Lactose free (6months onwards) Mead-johnson: Enfapro lactofree

Premature Infant (24cal/oz) Mead-johnson: Enfaprem Nestle: PreNAN Abbott: Similac prem Milupa: Preaptamil

Soy-Based (20cal/oz) Mead-johnson: Prosoybee Abbott: Isomil Wyeth: Nursoy

AGN inflam process affecting the kidney, lesions predom in the  glomerulus Etiology Infections :  a. Bacterial: Grp A B hemolytic strep, S viridans, S pneumo, Staph aureus, S epidermidis, S typhi , T pallidum, Leptospira b. Viral: HBV, Mumps, Measles, CMV, Enterovirus c. Parasitic : Toxoplasm, Malaria, Schistosoma Drugs: Toxins, Antisera, Vaccines (DPT)  Miscellaneous:  Tumor Ag, Thyroglobulin  GABS Nephritogenic Strains Sites: URT - pharyngitis - M1 2 4 12 18 25 Skin pyoderma - M49 55 57 60 Pathophysio – Immune complex disease Clinical & Lab -hematuria -hypocomplementenemia -proteinuria -oliguria -edema -n & v -hpn 82% -dull lumbar pain Typical course Latent: few days – 3wks  Oliguric: 7 – 10 days  Diuretic: 7 – 10 days  Convalescent: 7 – 10 days  Normalization of urine sediment Parameter Resolved by Gross hematuria 2 – 3 wks Complement level 6 – 8 wks Proteinuria 3 – 6 mos Micro hematuria 6 – 12mos Lab Dx: U/A – spec grav,cast, hematuria, chonuria  Serology – culture of GABS, ASO, C3 ( dec in acute phase, rises  during convalescensce) Renal fxn – bun crea- normal, hyponat 



Hematology – dilutional anemia, transient hypoalbuminemia  Radiography – CXR , renal utz Management: Bed rest   Fluid and salt restriction o Fluids: 400 – 600 ml/m2/day + UO 24H o NaCl < 2 g/day o K < 40 meq/day Penicillin 50 – 100,000 u/kg/day TID/QID x 10 days  HPN, CHF  o Furosemide 2 mg/k/dpse Prognosis  – complete resolution, 5 – 10 % progress to chronic state

VITAMINS Stimulants Buclizine (syrup)

w/ Folic acid (Megaloblastic Anemia)

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

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

Iron Deficiency Anemia

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

TPN in Pediatrics A. Energy Requirment AGE/WT Caloric Rquirement Neonates

90-120 kcal/kg

Infants & Older Children <10 kg 11-20 kg >20

10-120 kcal/kg 1000kcal + 50 kcal foe each kg > 10 1500 + 20 for each more than 20

B. Fluid Requirement AGE/WT Fluid Rquirement Neonates VLBW (≤ 1500 gm)

Initiate at 40 – 60 ml/kg/day and increase by 10 ml/kg/day till 120 ml/kg is reached Initiate at 60 ml/kg/day and increase by 15

AGA & LBW

ml/kg/day till 120 ml/kg is reached on the 5 day of PN



Neonates under radiant heaters or on phototx an extra 30ml/kg/day of water Infants & Older Children <10 kg

100 – 120 ml/kg

11-20 kg

1000ml + 50 ml foe each kg > 10

>20

1500 + 20 for each more than 20

C. Protein Requirement AGE/WT

Dosage (gm/kg/day)

VLBW (≤ 1500 gm)

2.25

0 – 12 months

2.50

1 – 8 yrs

1.50 – 2.0

th

8 yrs and above

1.00 – 1.00  – 1.50  1.50



With the initiati initiation on of PB|N, start w/ 0.5gm/kg/ 0.5gm/kg/day day and graduall gradually y increased by 0.5gm/kg/day till recommended protein is reached. D. Carbohydrate Carbohyd rate Requi Requirement rement % dextrose = gram dextrose x 100

Vol infused (ml    

E. AGE

Shud provide 50 – 50  – 60  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 or  blood sugar exceeds 7 mmol/L in neoanate or 9.7 mmol/L I above 1 mo of age

Fat Requirement Dosage (gm/kg/ (gm/kg/day) day)

0  –  – 12  12 months

2

1  –  – 8  8 yrs

4

8 yrs and above

2.5



30  – 40 30 –  40 % of total calories shud b provided as fats 2 –  – 4%  4% as EFA   Start at 0.5 gm/kg/day and gradually increase by 0.5 gm/kg/day till recommended amt is reached F. Daily Electrolyte Requirements Electrolytes Neonates 1-6 mos 6 mo -11 yr Adolescents

mmol/kg 3  –  – 5  5

mmol/kg 3  –  – 4  4

mmol/kg 3  –  – 4  4

mmol/kg 60 – 60  – 100  100

K

2  –  – 4  4

2  –  – 3  3

2  –  – 3  3

80 – 80  – 120  120

Ca

0.6 – 0.6  – 1.0  1.0

0.25 – 0.25  – 1.2  1.2

0.25 – 0.25  – 1.2  1.2

4.7

(max of

(max of

4.7)

4.7)

1.0

1  –  – 2  2

1  –  – 2  2

30 – 30  – 45  45

0.1250.250

0.1250.250

0.1250.250

4 –  – 8  8

NaCl

Glucos PO4 Ma



Calcium gluconate contains 100 mg calcium gluconate or 9 mg elemental eleme ntal calcium/ml 1 gm of calcium gluconate contains 4.7 mEq or 2.35 mmol of Ca.  G. Trace Elemental Requirements Trace Elemental   Adolescents Prematures Infants & Children (ug/kg)

(mg)

Zinc

400

(ug/kg) 100 – 100  – 500  500

Copper

50

20

0.5 – 0.5  – 1.5  1.5

Chromium

0.3

0.14 – 0.14  – 0.2  0.2

0.01 – 0.01  – 0.04  0.04

Manganese

10

2 –  – 10  10

0.15 – 0.15  – 0.5  0.5

Iodine

8

8

0.2

Selenium

4

4

0.3

Flouride

57

57

0.9

 

In the absence of available prep of trace elements; weekly blood transfusion may be given at 20 ml/kg Iron: 2 mg/kg, with dose increased to 6 mg/kg if Fe def is documntd; provided by adding iron dextran to amino acid soln

Sample Sampl e Solvin Solving: g: 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/100ml)) 6gms x 15 gms = 250 ml D.

100 x CHO: % = gm x 100 Vol

10%

x = 125 gms 1250

Prep: D50W 50 gm = 125gm E.

2.5 – 2.5  – 4  4

100 ml x Lipids: Lipi ds: ( 1 gm) Prep: 10% Intralipi Intralipid d

15 x 1 =15 (10gms/100ml)

10 gms x 15 gm = 150 100 ml F.

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

15 x 3 = 45 mmol/kg

2.5 mmol x 45 = 18 ml G.

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

15 x 2 = 30 mmol/kg

2.0mmol x 30 = 15 ml H.

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

15 x 0.25 = 3.75

0.25 mmol x 3.75 = 15 ml ml I.

x

Magnesium: (0.25 mmol/kg) Prep: 25% MgSO4

15 x 0.25 = 3.75

2 mmol x 3.75 = 1.9 ml x 2 = 4 ml ml J.

x

Total Mixture: Aminostril D50W Na K Cal gluc MgSO4 Total

24 hrs

12 hrs

250 250 18 15 15 4 ml 552

125 125 9 7.5 7.5 2 ml 276

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