Pedia Reviewer

++PEDIATRICS REVIEWER ANTHROPOMETRIC MEASURES & WATERLOW’S CLASSIFICATION A. DESIRED WEIGHT AGE

DESIRED / IDEAL WEIGHT

AGE OF INFANT

IDEAL WEIGHT

At Birth

3kg (Filipinos) or 3.25kg (for Caucasians)

At 4-5 Months

2 x Birth Weight

1 Year

3 x Birth Weight

< 6 months 6 months

Weight in kg = Age in Months x 600 + 600 + Birth Weight

2 Years

4 x Birth Weight

> 6 months 6 months

Weight in kg = Age in Months x 500 + 500 + Birth Weight

3 Years

5 x Birth Weight

5 Years

6 x Birth Weight

2 to 6 years 6 years

Weight in kg = Age in Years x 2 + 8

7 Years

7 x Birth Weight

6 to 12 years

Weight in lbs = lbs = Age in Years x 7 + 5

10 years

10 x Birth Weight

AGE

LENGTH

At Birth

50 cm or 20 inches

B. DESIRED LENGTH GAIN in 1st Year is ~25cm, Distributed as Follows: 3cm + 9cm per month

AGE Birth to 3 months 3-6 months

+ 8cm

2.67 cm per month

1 year Old

30 inches or 1.5 x Birth Length

6-9 months

+ 5cm

1.6cm per month

2 years old

1/2 Mature Height (in boys)

9-12 months

+ 3cm

1cm per month

3 years old

3 Feet Tall

4 years old

40 inches or 2 x Birth Length

13 years old

3 x Birth Length

1yr and above

Height in cm = Age (years) x 5 + 80

C. HEAD CIRCUMFERENCE AGE OF INFANT 1 to 4 Months 4 to 12 Months 1 to 2 Years 3 to 5 Years 6 to 20 Years

IDEAL HEAD CIRCUMFERENCE INCHES CENTIMETERS + 2 Inches (1/2 Inches per Month) + 5.08cm (1.27cm per month) + 2 Inches (1/4 Inches per Month) + 5.08cm (0.635cm per month) + 1 Inch + 2.54cm + 1.5 Inches (1/2 Inches per Year) + 3.81cm (1.27cm per month) + 1.5 inches (1/2 Inches per 5 years) + 3.81cm (1.27cm per month)

D. CHEST MEASUREMENT AGE OF INFANT Birth 1 Year Old 6 Years Old

TRANSVERSE-AP DIAMETER RATIO 1.0 1.25 1.35

Better Doctors Pediatrics Reviewer for Junior Interns Batch 2011

REMARKS Transverse = AP (Barrel ( Barrel Chest) Transverse > AP Transverse >>> AP

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E. WATERLOW CLASSIFICATION 1.

Wasting Actual Weight Ideal Weight for Actual Length / Height

2.

. X 100

Classification:  Normal > 90% Mild = 80-90% 

Moderate = 70-80% Severe < 70%

Classification: Normal > 95%  Mild = 90-95% 

Moderate 80-90% Severe < 80%

Stunting Actual Height/Length Height/Length Ideal Length / Height for Age

X 100

APGAR 0

1

2

Appearance

Blue / Pale

Pink Body + Blue Extremities

Completely Pink

Pulse

Absent

Slow (<100)

>100

Grimace

No Response

Grimaces

Coughs, Sneezes, Cries

Activity

No Movement (Limp)

Some Flexion / Extension

Active Movement Movement (all extremities)

Respiration

Absent

Slow / Irregular

Good, Strong Cry

8-10: Normal 4-7: Mild / Moderate Asphyxia 0-3: Severe Asphyxia

FONTANEL  

Anterior Fontanel: Posterior Fontanel:

closes at 18 months (as early as 9-12months) closes at 6-8 weeks


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DENGUE VIRUS I. DENGUE INFECTION A. DHF Clinical Criteri a 1) Fever: 2-7 days, regardless of characteristic o 2) Hemorrhagic Manifestations: o (+) Tourniquet Test (>20/in2)  Mucocutaneous Bleeding  GI Bleeding  B. DHF Laboratory Criteria 1) Evidence of Consumptive Coagulopathy o Decreased Platelet Count (<150,000)  Prolonged BT  Prolonged PT (II, V, VII, X, Fibrinogen)  Prolonged PTT (II, V, VII, IX, X, XI, XII, Fibrinogen)  2) Steadily Increasing Hematocrit (20% or more) in spite of proper hydration or Increased Vascular o Permeability C. DSS Criteria DHF Criteria + Evidence of Circulatory Failure: o Violaceous, cold, clammy skin  Restlessness, weak to imperceptible pulses  Narrowing of Pulse Pressure to <20mmHg   Hypotension D. Dengue Classification: Undifferentiated Fever o Dengue Fever Syndrome o Dengue Hemorrhagic Fever o Dengue Shock Syndrome o

II. GRADING OF DENGUE GRADE 1

GRADE 2

GRADE 3

GRADE 4

Grade 1 + 2 PLUS: Anorexia Vomiting Convulsion Restlessness Flushed Skin (+) Tourniquet Test Abdominal Pain Hepatomegaly Pleural Effusion (Unilateral R / Bilateral) Constipation Abdominal Distention

  



Grade Grade Grade Grade

I II III IV

Grade 1 PLUS: Gum Bleeding Epistaxis Petechiae on Palate Petechiae on Axillae Rashes on Extremities

Chest Pains Chough Lethargy Violaceous Skin Flushed Face Hematemesis Melena Purpura Hemoptysis Cold Clammy Extremities Shock (Hypotension, Tachycardia) Ecchymoses

Grade 1 + 2 + 3 PLUS Profound SHOCK

= Fever + Non-Specific Constitutional Symptoms ([+] Tourniquet is the only hemorrhagic manifestation) = Grade I + Spontaneous Bleeding = Grade II + Severe Bleeding + Circulatory Failure (rapid / weak pulse, narrow pulse pressure, hypotension) = Grade III + Irreversible Shock + Massive Bleeding (undetectable pulse and BP)


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III. DANGER SIGNS OF DHF  Abdominal Pain (intense and sustained)  Persistent vomiting  Abrupt change from fever to hypothermia with sweating  Restlessness or somnolence IV. GRADING OF DENGUE MILD TO MODERATE (DF) Headache, malaise, irritable, but consolable

SEVERE (DHF Gr. I & II)

SEVERE (DSS) (DHF Gr. III)

Headache, malaise, irritable, but consolable

Irritable, but easily consolable Poor eye contact (lethargic) Feeds poorly

AND

OR

(+) Signs of Dehydration Good Peripheral Perfusion Normal BP

(+) Moderate Dehydration with Hemoconcentration Good Peripheral Perfusion Pulse Pressure < 20mmHg

AND

OR

No signs of Respiratory Distress or Pulmonary Edema

No signs of Respiratory Distress or Pulmonary Edema

(+) Respiratory Distress

AND

AND

OR

(-) Tourniquet Test (-) Severe Anemia or Bleeding

(+) Tourniquet Test Low PC <100,000 Increased Hct (>20%) (-) Severe Anemia or Bleeding

(+) Tourniquet Test Low PC < 100,000 Increased Hct (>20%) (+)Severe Anemia / Bleeding

AND

AND

No Metabolic or End Organ Failure

No Metabolic or End Organ Failure

AND No signs of Dehydration Good Peripheral Perfusion Normal BP

Unesponsive, too weak to feed, extreme weakness / seizures (+) Severe Dehydration with Shock OR

AND

AND No Metabolic or End Organ Failure

VERY SEVERE (DSS) (DHF Gr. IV)

Poor Peripheral Perfusion Pulse Pressure < 10mmHg Capillary Refill > 20sec

OR Severe Respiratory Distress (Pulmonary Edema or CHD) with RR > 60, retractions, grunting, cyanosis, respiratory failure OR (+) Tourniquet Test Low PC < 100,000 Increased Hct (>20%) Life Threatening Anemia, bleeding, associated with DIC OR Metabolic Disorder:  Hypoglycemia  Metabolic Acidosis  Liver / Renal Failure

V. MANAGEMENT OF DENGUE A. Vital Signs and Laborator y Monitoring (Vital Signs and Laboratory Monitoring ) Monitor BP, Pulse Rate o We have to watch out for Shock (Hypotension) o INITIALLY IF WITH RISING HEMATOCRIT Blood Pressure Every 24 hours Hourly Every 15” to 30” with Hypotension Hematocrit

Every 24 hours

Every 6 hours

Platelet Count

Every 24 hours

Every 6 hours

Hemoglobin

Every 24 hours

Repeat if Hematocrit falls after an Initial Rise


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B. Management of Hemorrhage CONDITION If due to Vascular Changes (first few days of Illness) If Platelet Count is BELOW 50,000/cu.mm

MANAGEMENT No TREATMENT is Required! Prepare Fresh Whole Blood If Active Bleeding occurs or Hemoglobin and Hematocrit Levels Fall – give Fresh Frozen Plasma

If occurs with SHOCK (DIC)

Follow Whole Blood Transfusion with Heparin (with Extreme Caution) Fresh Frozen Plasma is also helpful

5) IMCI I. MODULE 1: GENERAL DANGER SIGNS IN 2 MONTHS TO 5 YEARS OLD  Inability to Drink or Feed  Convulsions  Lethargy or Unconsciousness  Vomiting of Everything Taken II. MODULE 2: COUGH / DIFFICULTY OF BREATHING A. Tachypnea (MUST KNOW!!!) AGE

RESPIRATORY RATE

0 to 2 months 2 to 12 months 12 months to 5 years old

> 60/minute > 50/minute > 40/minute

B. Classification of Patients with Cough or Difficulty in Breathing: SIGNS *Any General Danger Sign *Chest Indrawing; or *Stridor in a Calm Child

CLASSIFY AS Severe Pneumonia or Very Severe Disease

*Fast Breathing

Pneumonia Triad of Pneumonia: Fever, Cough, Tachypnea

*No Signs of Pneumonia, or *Very Severe Disease

No Pneumonia Cough or Cold


TREATMENT *Give first dose of appropriate Antibiotic *Give Vitamin-A *Treat Child to prevent Low Blood Sugar *Refer urgently to Hospital *Give appropriate Antibiotic (5 days) *Soothe throat & relieve cough *Advice mother when to return immediately *Follow up in 2 days *If coughing > 30 days, refer for assessment *Soothe throat & relieve cough *Advice mother when to return immediately *Follow up in 5 days if not improving

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III. MODULE 4: FEVER CAUSE OF FEVER Measles (Viral Exanthems) Dengue Malaria Typhoid Ear Infection UTI

MORBIDITY IS DUE TO: Bronchopneumonia Shock / Bleeding Cerebral, Renal Typhoiditis, Shock Hearing Loss Chronic Renal Disease

IV. MODULE 3: DIARRHEA A. Assessment of Diarrhea Patients wit h Dehydration (Focus on patient’s level of “Thirst” ) Lethargic / Unconscious; 1) LOOK AT CONDITION: Well, Alert Restless, Irritable Floppy Normal / Present Sunken / Absent  Eyes / Tears Very Sunken & Dry / Moist Dry  Mouth & Tongue Absent Drinks normally; Not Thirsty Thirsty; Drinks Eagerly  Thirst Very Dry Drinks Poorly; Unable to Drink

2) FEEL SKIN PINCH

Goes back quickly

Goes back slowly

Goes back very slowly

3) DECIDE

Patient has NO Signs of Dehydration

If patient has two or more Signs, including at least one Sign, there is some Dehydration

If patient has two or more signs, including at least one Sign, there is Severe Dehydration

4) TREAT

Treatment Plan-A

Weigh patient Treatment Plan-B

Weigh Patient Treatment Plan-C Urgently

B. Treatment Plans (30ml = 1 ounce) 1. Treatment Plan-A < 2 years old = 50 to 100ml after each loose stool (or 2-3 ounces)  2 to 10 years old = 100 to 200ml after each loose stool (or 7-8 ounces)  2. Treatment Plan-B 75 cc/kg  3. Treatment Plan C: Severe Dehydration 100 ml/kg fluid replacement  <12 months = consumed within 6 hours duration  >12 months = consumed within 3 hours duration  C. DOC for Diarrhea (from Melai’s notes) Rotavirus None Amoeba Metronidazole Ascariasis Albendazole / Mebendazole Cholera Tetracycline Shigella TMP/SMX


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V. MODULE 5: MALNUTRITION / ANEMIA  Classification and Treatment of Malnutrition & Anemia *Visible Severe Wasting *Severe Palmar Pallor *Edema of both feet *Some Palmar Pallor *Very Low Weight for Age

*Not very low Weight for Age and no other signs of Malnutrition

IMPLICATION Severe Malnutrition or Severe Anemia

MANAGEMENT *Give Vitamin-A *Refer URGENTLY to a Hospital

Anemia or Very Low Weight

*Assess child’s feeding and counsel the mother on feeding *If with feeding problem, follow up in 5 days *If with Pallor:  Give Iron  If suspecting Malaria, refer to a Hospital  Give Mebendazole if child is 2yrs or older and has not had a dose in the previous 6 months *Advise mother when to return immediately *If with Pallor, follow up in 14 days *If very low weight for age, follow up in 30 days

No Anemia and Not Very Low Weight

*If child is < 2y/o, assess feeding &counsel mother on feeding *If with feeding Problem, follow up in 5 days *Advise mother when to return immediately


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VI. MODULE 6: IMMUNIZATIONS A. Basic Immunization According to EPI o BCG o Hepa B o DPT / OPV o Measles VACCINE

AGE

BCG-1

Birth (or 6 weeks)

DTP Polio Hepatitis B Measles BCG-2 Tetanus Toxoid

6 weeks 6 weeks 6 weeks 9 months School entry Childbearing women

DOSE

0.05mL for newborn 0.1mL for older infants 0.5mL 2 drops 0.5mL 0.5mL 0.1mL 0.5mL

B. Contraindications to Vaccinations: ABSOLUTE CONTRAINDICATIONS  Severe anaphylactic / allergic reaction to previous vaccine  Moderate to severe illness +/- fever  Encephalitis within 7 days of administration (Pertussis)  Immunodeficiency in patient (congenital – all live vaccines) or household contact (OPV)  Pregnancy (MMR, OPV/IPV)


NO.

ROUTE

1

ID

3 3 3 1 1 3

IM PO IM SC ID IM

    

SITE

INTERVAL BETWEEN DOSES

R deltoid region Upper outer thigh Mouth Anterolateral thigh Outer upper arm L deltoid Deltoid

4 weeks 4 weeks 4 weeks

1 month; Then 6-12 months

RELATIVE CONTRAINDICATIONS Immunosuppressive therapy (all live vaccines) Egg allergy (MMR) Seizure within 3 days of last dose (Pertussis) Shock within 48hrs of last dose (Pertussis) Fever >40.5 0C within 48hrs of last dose (Pertussis)

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C. NOT Contraindications o Mild Illness +/- low-grade fever o Current antibiotic therapy o Recent infectious disease exposure o Positive PPD o Prematurity, except if infant is still hospitalized at 2 months, OPV should be delayed until discharge. Or, if mother is HBsAg(-), Hep-B Vaccine delayed until child > 2000g VII. MODULE 7: MANAGEMENT OF THE SICK YOUNG INFANT (1 week to 2 months old)  Signs and Symptoms of Possible Bacterial Infection in a Young Infant o Convulsion o Respiratory Rate more than 60/minute o Severe Chest Indrawing o Nasal Flaring o Grunting o Bulging fontanelle o Pus draining from the ear o Erythema and discharge from the umbilicus o Abnormal body temperature o Severe skin pustules o Lethargy or unconsciousness o Abnormal movements

7) NEWBORN SCREENING  Congenital Hypothyroidism ( puffy eyelids)  Phenylketonuria (MR )  G6PD  CAH  Galactossemia

8) MILESTONES MILESTONES Regards Smiles Turns Head Holds Head Rolls over Transfers object Sits briefly Creeps Pulls up Cruises Walks with support Stands alone

NORMAL (months) 1 2 3 4 5 6 7 8 9 10 11 12

From Melai’s Notes:

  


Roll over: 4 months Reach: 8 months Hold bottle: 8 months

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9) COMMONLY USED DRUGS  D: per “day”  d: per “dose” ANTI-TUBERCULOSIS DRUGS

ANTIBIOTICS Penicillin G

100-200 T ukD q12 1.2MU/vial, 2.4MU/vial

Rifampicin

10-20 mkD OD AC 200mg/5mL, 100mg/5mL, 150, 300, 450, 600mg

Penicillin V

50-200 mkD

Isoniazid

Ampicillin

50-100 mkD q12/8 100mg, 250mg, 500mg, 1g

10-20 mkD OD AC 200mg/5mL, 100mg/5mL, 50, 100, 150, 200, 400mg

Pyrazinamide

20-30 mkD OD PC 250mg/5mL, 500mg

Ethambutol

15 mkD OD

Streptomycin

10 mkD OD q480 1g/vial

Amoxicillin

30-50 mkD q8

Cloxacillin

50-100 mkD q6 250mg, 500mg, 125mg/5mL, 250mg/5mL

Dicloxacillin

12.5-25mkD

Nafcillin

25-50 mkD q12 500mg, 1g/vial

Amikacin

15 mkD LD; 10 mkD MD q12 250mg/mL, 125mg/mL, 50mg/mL

Gentamycin

5-8 mkD OD

Netilmycin

6-8 mkD OD 25mg, 60mg, 100mg/mL

Tetracycline

25-50 mkD

CoTrimoxazole

5-8 mkD q12 80mg/5mL, 40mg/5mL

CoAmoxiclav

Follow Amoxicillin component 312,5mg/5mL = 250mg/5mL of Amoxicillin

Erythromycin

30-50 mkD q8; not to exceed > 1g 200mg/5mL, 100mg/2.5mL, 400mg/5mL

Clarithromycin

15 mkD q12

Azithromycin

10mkD x 3days OD

Chloramphenicol

50-100 mkD q6/8 125mg/5mL, 1g/vial

Clindamycin

ANALGESICS / ANTIPYRETICS Paracetamol

10-15 mkd q4/6 100mg/mL, 120mg/5mL, 125mg/5mL, 250mg/5mL Paracetamol Drops: 100mg/5mL  Aeknil: 150mg/mL 

Ibuprofen

5-10 mkd q6/8 100mg/5mL, 200mg/5mL

Mefenamic Acid

6.5 mkd

Aspirin

60-80 mkD q6/8 Not > 2g/D

ANTICONVULSANTS Diazepam

0.3-0.5 mkd IM Not to exceed 10mkD 2mg, 5mg, 10mg tab; 5mg/mL, 10mg/mL

Phenobarbital

3-5 mkd 10-20 mkd LD; 5 mkD q12 MD 20mg/5mL

Phenytoin

5-7 mkd 10-20 mkd LD; 5 mkD q12 MD 125mg/5mL, 250mg/5mL, 15mg, 30mg, 60mg, 90mg

Valproic Acid

15 mkD LD Not > 60mkD 250mg/5mL

20-50 mkD q6/8

st

Cefalexin (1 )

25-50 mkD q6 100mg/mL, 125mg/5mL, 250mg/5mL, 250mg, 500mg, 1g

Cefazolin (1st)

50-100mkD 1g/vial

Cefaclor (2 nd)

20-40 mkD q8 250mg, 500mg, 125mg/5mL, 250mg/5mL

Cefuroxime (2 nd)

20-40 mkD q12; 50-100 mkD q8 IV 250mg, 500mg, 125mg/5mL, 250mg/5mL

Ceftazidime (3rd)

100-150 mkD q8 IV 250mg, 500mg, 1g, 2g

rd

Ceftriaxone (3 )

50-100 mkD OD IV 250mg, 500mg, 1g, 2g/vial

Cefotaxime (3rd)

100-200 mkD q4-6 250mg, 500g, 1g/vial

Cefixime (3rd)

3-8 mkD q12 20mg/5mL, 100mg/5mL

Meropenem

20 mkD q12 (septic) 40 mkD q12 (meningitic)

Piperacillin

200-300 mkD q6 2g/vial

Unasyn

50-100 mkD q6/8


ANTIHISTAMINE

Diphenhydramine

1 mkd IV 2-6y/o: 2-5mL q6/8 6-12y/o: 5mL 12.5mg/5mL

Hydroxizine

1-2 mkD q6/8 10mg, 20mg tab; 2mg/mL

STEROIDS

Prednisone

1-2 mkD q12 BSA x 60mkD (Nephrotic)

Hydrocortisone

10 mkd LD q6/8; 5 mkd MD 4 mkd q6/8 50mg/mL, 125mg/mL

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BRONCHODILATORS

Salbutamol

0.15 mkd

Theophylline

7 mkd LD; 20 mkd MD

ANTI-ULCER

Ranitidine

1 mkd q8

Omeprazole

0.6-0.7 mkD OD 10, 20, 50mg

Cimetidine

5 mkd q6

DIURETICS / ANTI-HPN

Furosemide

1 mkd IV 20, 40, 60mg tab; 20mg/mL

Nifedipine

0.25 mkD

Propranolol

1-2 mkD q6

Aldactone

2-3.5 mkD q6

ANTIVIRALS

Acyclovir

100 mkD q6

Amantadine

< 8y/o: 5-9 mkD q12 >8y/o: 100-200 Not to exceed > 200mg/d

ANTI-PARASITISM

Mebendazole

200 mkD single dose 500 mkD single dose

ANTIFUNGAL

Pyrantel Pamoate

11 mkD x 3 doses OD 125mg/5mL, 250mg/5mL

Fluconazole

6mkd LD, 3mkd MD 50mg/tab

Metronidazole

30-50 mkD q8 x 10days 125mg/5mL, 250mg, 500mg

Ketoconazole

< 15kg: 5mkD > 20kg: 100mg OD > 30kg: 200mg OD

Griseofulvin

10 mkD

Amphotericin-B

0.3-0.7 mkD

OTHERS

Epinephrine

0.1-0.3mL/kg IV

Carbocisteine (Solmux) q8

For 100mg/5mL 8-12y/o: 15mL  4-7y/o: 10mL  2-3y/o: 5mL  For 200/5mL 8-12y/o: 7.5mL  4-7y/o: 5mL  2-3y/o: 2.6mL 

Solmux Broncho

For 5mL Suspension 7-12y/o: 1/2 to 1 tsp qid 

* Salbutamol 2mg * Carbocisteine 500mg

Cetrizine

For 5mg/5mL: >12y: 2 tsp OD  6-11: 2 tsp OD or 1 tsp BID  2-5 yrs: 1 tsp OD or 1/2 tsp BID  For 2.5mg/mL (drops): 2-5: 2mL OD or 1mL BID  6months to < 2yrs: 1mL OD 

Cinnarizine (Stugerone)

25mg

Serc (Betahistine)

8-16mg TID


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10) IV FLUIDS  Ludan’s  Holiday-Segar Method I. LUDAN’S METHOD (HYDRATION THERAPY) MILD DEHYDRATION < 15kg, < 2y/o > 15kg, 2y/o

50 cc/kg 30 cc/kg D50.3% in 6-8hours

MODERATE DEHYDRATION 100 cc/kg 60 cc/kg 1 st hr: 1/4 PLRS Next 5-7hrs: 3/4 D 50.3%

SEVERE DEHYDRATION 150 cc/kg 90 cc/kg 1st hr: 1/3 PLRS Next 5-7hrs: 2/3 D 50.3%

II. 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 10kg] > 20 kg 1500 + [20 for each kg in excess of 20kg] **NOTE: Computed Value is in mL/day o Ex) 25kg child o Answer: 1500 + [100] = 1600cc/day III. FACTORS CONSIDERED IN HYDRATING A PATIENT:  Urine Output  Pulses  Sensorium  Turgor  Heart Rate  Nutritional Status IV. IV-FLUID COMPOSITIONS (Commonly Used for Infants and Children): Dextrose (g/L) LRS NSS D50.15% NaCl D50.3% NaCl D50.45% NaCl D50.9% NaCl D5IMB D5LRS D5NM D5NR

50 50 50 50 50 50 50 50

Na+ mEq/L 130 154 25 51 77 154 25 130 40 140


Cl- mEq/L 109 154 25 51 77 154 22 109 40 98

K+ mEq/L

Lactate mEq/L

Others mEq/L 2+ Ca :3

4

28

20 4 13 5

23 28 Mg2+:3; Acetate: 26 Mg2+:3; Acetate: 27; Gluconate: 23

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11) VIRAL EXANTHEMS ETIOLOGY Measles (Rubeola)

Paramyxovirus (RNA-Virus)

INCUBATION PERIOD 8-12 days

PRODROMAL PERIOD 2-4 days Exanthem (Koplik Spots) on the Buccal and Pharyngeal Mucosa after 2-3d Fever, Conjunctivitis and Increasingly Severe Cough / Brassy Cough (Catarrhal Stage)

German Measles (Rubella)

Togavirus (RNA-Virus)

14-21 days

1-5 days Lymphadenopathy (PostCervical or Post-Occipital)

ONSET OF FEVER Fever + Rashes T abruptly (40C) as rash appears

RASH Centrifugal Spread Maculopapular Begins in face

T when rash reaches legs and feet

Spots after Fever Sudden onset (39-410C)

Centrifugal Spread Maculopapular Begins trunk  arms, neck – face legs

T on 3-4d as rash appear

Roseola Infantum

Human Herpes Virus-6 (DNA-Virus)

7-17 days

Bulging of anterior fontanelle or convlusions

Chickenpox (Varicella)

Varicella-Zoster Virus (DNA-Virus) Parvovirus B19 (DNA-Virus)

10-23 days

In Children = unusual In Adults = 1-2 days

Erythema Infectiosum

Fever then Rash

7-28 days

Centripetal Pattern

Slapped Cheek Appearance Sparing of Palms & Soles

12) KAWASAKI CRITERIA I. 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” o DOES NOT Respond to any kind of Antibiotic! o



B) Presence of 4 of the 5 Criteria: 1) Bilateral CONGESTION of the Ocular Conjunctiva (seen in 94% ) o 2) Changes of the Lips and Oral Cavity ( At least ONE ) o At least ONE 3) Changes of the Extremities ( ) o 4) Polymorphous Exanthem (92%) o 5) Cervical Adenopathy = Non-Suppurative Cervical Adenopathy (should be >1.5cm) in 42% o

II. TREATMENT: Currently Recommended Protocol: A. IV-Immunoglobulin: 2g/kg Regimen Infusion EQUALLY Effective in Prevention of Aneurysms and Superior to 4-day Regimen o 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


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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)

13) ARI PROTOCOL ( PROGRAM FOR THE CONTROL OF ARI) I. PROTOCOL A. Child Age 2months up to 5years SIGNS: NOT able to Drink Convulsions Abnormally Sleepy or difficult to Wake Stridor in Calm Child Severe Malnutrition

CLASSIFY AS: TREATMENT:

VERY Severe Disease Refer URGENTLY to Hospital Give first dose of an Antibiotic Treat Fever, if present Treat Wheezing, if present If Cerebral Malaria is possible, give an Antimalarial Chloramphenicol IM, IV

Chest Indrawing

If also recurrent wheezing, go directly to Treat Wheezing

Severe Pneumonia Refer Urgently to Hospital Give 1st dose of Antibiotic Treat Fever, if present Treat Wheezing, if present If referral is not feasible, treat with an Antibiotic and follow closely Benzyl Penicillin IM, IV


No Chest Indrawing; and Fast Breathing

No Chest Indrawing; and No Fast Breathing

50/minute or more if child 2 months to 12 months; 40 per minute or more if child 12 months up to 5 years Pneumonia

< 50/minute if child 2 months to 12 months; < 40/minute if child 12 months to 5 years

Advise mother home care Give Antibiotic Treat Fever if present Treat Wheezing if present Advise mother to return with child in 2 days for reassessment, or earlier if the child is getting worse

Cough or Cold (NO Pneumonia) If cough > 30 days, refer to assessment Assess / Treat Ear problem or Sore Throat, if present Assess / Treat other problems Advise mother Home Care Treat Fever if present Treat Wheezing if present

CoTrimoxazole PO

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B. Young Infant: < 2 Months SIGNS: Stopped Feeding Well Convulsions Abnormally sleepy / difficult to wake Stridor in a Calm Child Wheezing; or Fever or Low Body Temperature

Severe Chest Indrawing; or Fast Breathing

NO Severe Chest Indrawing; and NO Fast Breathing

(60/minute or More)

(Less than 60/minute)

Severe Pneumonia

CLASSIFY AS:

VERY Severe Disease

TREATMENT:

Refer UREGENTLY to Hospital Keep young infant WARM Give first dose of Antibiotic

Refer Urgently to Hospital Keep young Infant Warm Give 1st Dose of Antibiotic

Benzyl Penicillin + Gentamycin IM, IV

If referral is NOT feasible, treat with an Antibiotic and follow closely Benzyl Penicillin + Gentamycin IM, IV

Cough or Cold (NO Pneumonia) Advise Mother to give following Home Care: Keep young Infant Warm   Breastfeed frequently Clear Nose if it interferes  w/ feeding Return QUICKLY if:   



Breathing becomes Difficult Breathing becomes Fast Feeding becomes a Problem The infant becomes Sicker

II. ETIOLOGY OF PNEUMONIA ACCORDING TO AGE 0 to 48 hrs GBS 1 to 14 days E.coli, Klebsiella, Enterobacter 2wks to 2mos Enterobacter, GBS, S.aureus 2mos to 5yrs H.influenzae, S.pneumoniae 5 to 21yrs S.pneumoniae, M.pneumoniae 14) URINARY TRACT INFECTION I. SUGGESTIVE UTI:  Pyuria: WBC ≥ 5/hpf or 10mm 3  Absence of Pyuria does NOT Rule Out UTI  Pyuria can be PRESENT without UTI (Pyuria can be present that is not infectious in nature )! II. PRESUMPTIVE UTI:  (-) Urine Culture  Lower Colony Counts may be due to: o Overhydration o Recent Bladder Emptying o Antibiotic Intake III. PROVEN OR CONFIRMED UTI  (+) Urine Culture ≥ 100,000 CFU/Ml Urine of a SINGLE Organism  Multiple Organism in Culture means there is Contamination of the Specimen (Gold Standard )


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15) TREATMENT OF TUBERCULOSIS I. PULMONARY TUBERCULOSIS 1) Fully susceptible M. tuberculosis; No history of previous Anti-TB drugs, Low local prevalence of Primary Resistance to Isoniazid (H) 2-HRZ OD, then 4-HR OD or 3x/wk [DOT] 2) Microbial susceptibility unknown or initial drug resistance suspected (eg. cavitary), previous Anti-TB use, close contact with resistant source case or living in area with high Primary Resistance to Isoniazid (H) 2-HRZ + E/S OD, then 4-HR + E/S OD or 3x/wk [DOT] II. EXTRAPULMONARY TUBERCULOSIS 1) Same as in PTB 2) For Severe Life Threatening Disease (eg. miliary, meningitis, bone, etc) 2-HRZ + E/S OD, then 10-HR + E/S OD or 3x/wk [DOT]

16) BRONCHIAL ASTHMA (GINA GUIDELINES) CONTROLLED Daytime Symptoms Limitation of Activities Nocturnal Symptoms (Awakening) Need for Reliever Lung Function Exacerbation

PARTLY CONTROLLED

None None None

> 2x / week Any Any

< 2x / week Normal None

> 2x / week < 80% > 1x / year

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

1x / week

17) RHEUMATIC FEVER: I. JONES CRITERIA: A. Major Manifestations Carditis (50-60%) o Polyarthritis (70%) o o Chorea (15-20%) Erythema Marginatum (3%) o o Subcutaneous Nodules (1%) B. Minor Manifestations o Arthralgia Fever o Laboratory Findings of: o  Elevated 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 o Elevated or Rising Strep-AB Test o Better Doctors Pediatrics Reviewer for Junior Interns Batch 2011

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2 Major Criteria OR 1 Major and 2 Minor Criteria + Evidence of Preceding Infection



A High Probability of RF EXCEPT in: o Chorea = manifest LATGE in the Disease (one may not have fever anymore ) Indolent Carditis = Carditis is NOT Severe, but may have a continuing Infection of Strep o

II. TREATMENT OF RHEUMATIC FEVER A. Antibiotic Therapy 10 days of Oral Penicillin or Erythromycin o IM Injection of Benzethine Penicillin o **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 III. PREVENTON A. Primary Prevention o 10 days of Oral Penicillin or Erythromycin IM Injection of Benzethine Penicillin o B. Secondary Prevention Penicillin G Benzethine Penicillin V Sulfadiazine or Sulfasoxazole Erythromycin

1.2 M units, every 4 weeks IM 250mg BID PO 0.15 OD if < 27kg; or 1g OD if > 27kg 250mg BID PO

C. Duration of Chemoprophylaxis RF without Carditis RF with Carditis WITHOUT Residual Heart Disease RF with Carditis WITH Residual Heart Disease

5 years or until 21y/o (whichever is longer) 10 years or well into adulthood At least 10 years since last episode and at least unt il 40y/o

IV. RHEUMATIC HEART DISEASE Valve Lesions begin as small verrucae composed of Fibrin and Blood Cells along the borders of one or more of the heart valves  Verrucae disappear and leave scars  Repeated attacks  New verrucae formation  Mural Endocardium and Chordae Tendinae become involved **NOTE: Mitral Valve = most commonly involved!


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V. ASSIGNMENT PATHOPHYSIOLOGY

CLINICAL MANIFESTATIONS

TREATMENT

Mitral Insufficiency Mitral Stenosis Aortic Insufficiency Tricuspid Valve Disease

18) HUMAN’S MILK VS COW’S MILK I. HUMAN VS COW’S MILK  Breast Milk is BEST for Babies  Absolute Contraindication to Breastfeeding = GALACTOSEMIA  Relative Contraindication to Breastfeeding = Lactose Intolerance HUMANS Calories Colostrum Amount of Water Casein Whey Lactose Fats Minerals Vitamin A Vitamin B Complex Vitamin C Vitamin D Vitamin K pH   

747 kcal/kg (+) Same 3.7 g/L 7 g/L 6.5 – 7% 45.4 g/L 0.15 –0.25% 0.61 mg/L --52 mg/L (-) Lower 6.8 – 7.4

COW 701 kcal/kg (-) Same 24.9 g/L 7 g/L 4% 38 g/L 0.7 –0.75% 0.27 mg/L --11 mg/L (-) Higher 6.8 – 7.4

Breastmilk has Less Minerals = Less Solute for the Baby’s Underdeveloped Kidneys Breastmilk has Less Vitamin-K = give Vitamin-K IM to prevent Hemorrhagic Disease of the Newborn According the Prenotes, we have to know this t able by Heart

II. ADVANTAGES OF HUMAN MILK:  (+) Lactose (main type of Carbohydrate in breast milk)  (+) Whey (main type of Protein in breast milk)  BETTER ABSORBED than Casein  (+) Immunoglobulin  (+) Maternal Body 1. Whey Proteins Human Milk has MORE Whey Proteins (remain in Solution)  Ratio of Whey: Casein  60:40  2. Fats   

Fat Emulsion of Human Milk is Finer Predominant in Human Milk = Long Chain Unsaturated Fatty Acids Human Milk is a Better Source of Linoleic Acid

3. Carbohydrates Lactose = Main Carbohydrate in Human Milk  Bifidus Factor = Group of Carbohydrates - Nitrogen-Containing Complex Carbohydrates 


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4. Minerals Minerals and Electrolytes in Breast Milk are LOWER than in Cow’s Milk  Lower Electrolytes = ensure that Sufficient Free Water is available to the Infant  5. Vitamins Depends on the Maternal Intake  Both Human & Cow’s Milk contain Large Amounts of Vitamin-A and Minimal Vitamin-D  Breastfed Infants should be routinely given Vitamin-K at Birth as Prophylaxis against  Hemorrhagic Disease of the Newborn (1mg Vitamin-K – 1 IM or p.o)

19) JAUNDICE

I. DEFINITION OF TERMS A. Jaundice o Yellowish Discoloration of the skin, sclera, and Mucous Membranes of the body B. Hyperbilirubinemia o Total Serum Bilirubin Level (TSB) exceeds more than 12mg/dL o To differentiate between Unconjugated and Conjugated Hyperbilirubinemia = Van den Bergh Reaction 1. Unconjugated Hyperbilirubinemia Elevation of Indirect-Reacting or Unconjugated Bilirubin Concentration to > 1.3 1.5mg/dL 2. Conjugated Hyperbilirubinemia  Elevation in the Direct-Reacting Fraction in the Van den Bergh Reaction to more than 2mg/dL or 20% of Total Serum Bilirubin (TSB) II. PHYSIOLOGIC JAUNDICE  Physiologic Jaundice: occurs after 36 hours of life  Pathologic Jaundice: occurs within the first 24 hours of life PHYSIOLOGIC JAUNDICE

   

rd

Onset > 24HOL, usually on 3 DOL TSB Increasing less than 5mg/dL/day Rate of  is < 0.5md/dL/hr Decline to Adult Levels by the 10th to 12 th DOL


    

PATHOLOGIC JAUNDICE Early Onset < 24 HOL TSB Increasing more than 5mg/dL/day TST Concentration exceeding 12.9mg/dL (FT) and >15mg/dL (PT) DSB > 2mg/dL or 20% of TSB Persists > 1 week (FT) or > 2weeks (PT)

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20) GCS SCORING FUNCTION Eye Opening

Verbalization

Motor

INFANTS & YOUNG CHILDREN Spontaneous To Sound / Command To Pain None Appropriate for Age (Flexes, Follows, Social Smile) Inconsolable Cry Persistently Irritable Restless / Agitated, Lethargic None Spontaneous Localizes Pain Withdraws Reflex Flexion Reflex Extension None

OLDER CHILDREN Spontaneous To Voice To Pain None

SCORE 4 3 2 1

Oriented Confused Inappropriate Incomprehensible None

5 4 3 2 1

Obeys Localizes Pain Withdraws Reflex Flexion Reflex Extension None

6 5 4 3 2 1

Total Score

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21) SEIZURES    

Seizure: sudden event caused by abrupt, uncontrolled, hypersynchronous discharges of neurons Epilepsy: condition characterized by tendency for recurrent seizures that are unprovoked by an immediate cause Status Epilepticus: > 30 minutes long OR Back-to-back without return to baseline Etiology: V(ascular): AVM, stroke, hemorrhage o I(nfectious): meningitis, encephalitis o T(raumatic) o A(utoimmune): SLE, vasculitis, ADEM o M(etabolic/toxic): electrolyte imbalance o I(diopathic): “idiopathic epilepsy” o N(eoplastic) o S(tructural): cortical malformation, prior stroke, “other causes of CP” o S(yndrome): genetic disorder o

I. TYPES OF SEIZURES A. Partial Seizures (Focal / Local) Simple Partial o Complex Partial (Partial Seizure + Impaired Consciousness) o Partial Seizures evolving to Tonic-Clonic Convulsion) o B. Generalized Seizures Absence (Petit mal) o Myoclonic o Clonic o Tonic o Tonic-Clonic o Atonic o


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II. 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”

Type Duration Recurrence Neuro Exam Sequelae

SFS Generalized Tonic Clonic < 15 minutes None during same time Normal None

CFS Focal onset, then Generalized Post-Ictal > 15 minutes or may even go into Status Recurrent within 24hours Abnormal, Post-Ictal Neurodevelopmental abnormalities

III. CLASSIFICATION BY CAUSE A. Acute Symptomatic (shortl y after an acute insult) Infection o Hypoglycemia, low sodium, low calcium o Head trauma o Toxic ingestion o B. Remote Symptomatic Pre-existing brain abnormality or insult o Brain injury (head trauma, low oxygen) o Meningitis o Stroke o Tumor o Developmental brain abnormality o C. Idiopathic No history of preceding insult o o Likely “genetic” component

IV. SIMPLE FEBRILE SEIZURE A. Criteria for an SFS o < 15 minutes o Generalized-tonic-clonic o Fever > 100.4 rectal to 101 F (38 to 38.4 C) o No recurrence in 24 hours o No post-ictal neuro abnormalities (e.g. Todd’s paresis) o Most common 6 months to 5 years o Normal development o No CNS infection or prior afebrile seizures B. Risk Factors o Febrile seizure in 1st/2nd degree relative o Neonatal nursery stay of >30 days o Developmental delay o Height of temperature C. Risk Factors for Epilepsy (2 to 10% will go on to have epilepsy) o Developmental delay o Complex FS (possibly > 1 complex feature) o 5% > 30 mins => _ of all childhood status o Family History of Epilepsy o Duration of fever


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22) NECROTIZING ENTEROCOLITIS I. DEFINITION A. Etiology: an Interaction of THREE Elements o Intestinal Injury, usually ISCHEMIA o BACTERIAL COLONIZATION in the gut o Presence of Substrate within the Gut Lumen in a Susceptible Infant B. Clinical Signs and Symptoms o Signs and Symptoms of SEPSIS o GI-Symptoms: Change in Stool Pattern   Occult and Gross Blood in Stools  Vomiting  Abdominal Distention, Tenderness Erythema of Abdominal Wall  II. RISK FACTORS FOR NEC: 4-I’s and 1-N  Ischemia = Asphyxia which then leads to Ischemia of the Bowel  Infection = Common in Babies with Sepsis and Microbes  Immaturity = NEC is Common in Premature Infants (RARE in Term Infants)  Intake or Nutrition = Prematurity defer Early Feeding


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III. STAGES OF NEC A. Tabulated Summary: STAGE

CLASSIFICATION

SYSTEMIC SIGNS

INTESTINAL SIGNS

RADIOLOGY

IA

Suspected NEC

Temperature Instable Apnea Bradycardia Lethargy

Increased Gastric Residues Mild Abdominal Distention

Normal Intestinal Dilation Mild Ileus

IB

Suspected NEC


Increased Gastric Residues Mild Abdominal Distention

Normal Intestinal Dilation Mild Ileus


Increased Gastric Residues Mild Abdominal Distention Bright Red Blood from Rectum

II A

Proven NEC

Bright Red Blood from Rectum

Intestinal Dilation Ileus Pneumatosis Intestinalis

May or May not be Present: (-) Bowel Sounds   Abdominal Tenderness II B

III A

III B

Proven NEC Moderately Ill

Advanced NEC Severely Ill Bowel INTACT

Advanced NEC Severely Ill Bowel PERFORATED

Temperature Instable Apnea Bradycardia Lethargy Metabolic Acidosis Thrombocytopenia

Increased Gastric Residues Mild Abdominal Distention Bright Red Blood from Rectum

Temperature Instable Apnea Bradycardia Lethargy Metabolic Acidosis Thrombocytopenia Respiratory Acidosis Metabolic Acidosis Hypotension Bradycardia DIC Marked Neutropenia

Increased Gastric Residues Mild Abdominal Distention Bright Red Blood from Rectum Absence of Bowel Sound Definite Abdominal Tenderness Abdominal Distention

Temperature Instable Apnea Bradycardia Lethargy Metabolic Acidosis Thrombocytopenia Respiratory Acidosis Metabolic Acidosis Hypotension Bradycardia DIC

Increased Gastric Residues Mild Abdominal Distention Bright Red Blood from Rectum Absence of Bowel Sound Definite Abdominal Tenderness Abdominal Distention

Absence of Bowel Sound Definite Abdominal Tenderness Abdominal Distention

Intestinal Dilation Ileus Pneumatosis Intestinalis HPVG Ascites may be (+)

Intestinal Dilation Ileus Pneumatosis Intestinalis HPVG Definite Ascites

(+) Generalized Peritonitis: Marked Tenderness  Abdominal Distention 

Intestinal Dilation Ileus Pneumatosis Intestinalis HPVG Definite Ascites Pneumoperitoneum

(+) Generalized Peritonitis: Marked Tenderness  Abdominal Distention 

Marked Neutropenia

B. Landmarks in the Stages of NEC 1. Stage I: Stage IA = Suspected NEC (same as IB)  Stage IB = difference from Stage 1A is that 1B has Bright Red Blood from the Rectum  2. Stage II Stage IIA = It is PROVEN to be NEC  Stage IIB = is more Toxic than IIA – it includes Metabolic Acidosis & Mild Thrombocytopenia  3. Stage III Stage IIIA = ADVANCED course already – very Toxic!  Stage IIIB = In IIIB bowels are already Perforated = Pneumoperitoneum  Better Doctors Pediatrics Reviewer for Junior Interns Batch 2011

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23) PROCEDURES I. UMBICAT A. Indications: Vascular Access o BP and ABG monitoring in critically ill neonates o B. Complications: Hemorrhage o Thrombosis o Ischemia / Infarction of lower extremities, bowel, kidney o Infection o Arrhythmias o C. Contraindications Omphalitis o Possible NEC / Intestinal Hypoperfusion o D. Line Placement 1. Low Line VS Highline a. Low Line  Tip of catheter just above Aortic Bifurcation between L3 and L5  Avoids renal and mesenteric aorta near L1 (decreased incidence of thrombosis) b. High Line  Tip of catheter above diaphragm between T6-T9  High line recommended in infants < 750g when a low line easily slips out 2. Catheter Length Determines the length of catheter required using either a standard graph or the regression  formula: Add length for the Height of the Umbilical Stump  Standard Graph: Determine the shoulder-umbilical length by measuring the perpendicular line dropped from the tip of the shoulder to the length of umbilicus  Birth Weight [BW] Regression Formula: Low Line: UA Catheter Length (cm) BW [kg] + 7 High Line: UA Catheter Length (cm) (3 x BW [kg]) + 9 E. Procedure 1) Determine length of catheter to be inserted o 2) Restrain infant. Prep and drape umbilical cord and adjacent skin using sterile technique o 3) Flush catheter with sterile saline solution before insertion o 4) Place sterile umbilical tape around base of the cord. Cut through cord horizontally about 1.5-2cm from o skin; tighten umbilical tape to prevent bleeding 5) Identify the one, large, thin-walled umbilical vein and two smaller, thick-walled arteries. Use one tip of o open, curved forceps to probe and dilate artery gently; use both points of closed forceps and dilate artery by allowing forceps to open gently 6) Grasp catheter 1cm from tip with toothless forceps and insert catheter into lumen of artery. Aim the tip o toward the feet, and gently advance catheter to desired distance. Do not force. If resistance is encountered, try loosening umbilical tape, applying steady gently pressure or manipulating angle of umbilical cord to skin. Often catheter cannot be advanced because of creation of a false luminal tract 7) Secure catheter with a suture through the cord, a marker tape and a tape bridge. Confirm position of o the catheter tip radiologically. Line may be pulled back, but not advanced once sterile field is broken 8) Observe. If any complications occur, line should be removed. NOTE: Infants remain on NPO until 24th o hour after catheter is removed. Never run hypoosmolar fluids through the line. Isotonic fluids should contain 0.5unit Heparin/mL


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II. LUMBAR PUNCTURE A. Indications: Identify etiology of CNS infection and monitor subsequent therapy o Identify subarachnoid bleeding o Introduce contrast agents into the CSF for diagnostic purposes o Measure pH, enzymes, neurotransmitters and trace constituents o Measure and fractionate CSF proteins in suspected immunologic disease especially Multiple Sclerosis or o GBS Identify neoplastic invasion or seeding of the subarachnoid space by gliomas, carcinomas, leukemias, o lymphomas B. Contraindications Infection of the Lumbar Skin o Coagulopathies, Thrombocytopenia o Cervical Cord Lesions o Increased ICP or suspected / known Intracranial Mass o Symptoms of pending Cerebral Herniation with probable meningitis o Critical Illness o C. Procedure Psychological preparation of the patient o Positioning: Position an acutely ill patient on the side with the legs drawn up and the spine flexed to o increase the distance between the processes and lamina of the adjacent vertebrae Palpate the Iliac Crest and slide down to L4 to L5 o Needle Insertion and Manometry: o Scrub skin with antiseptic  Insert a needle in the interspace between the dorsal processes of vertebra L4-L5 or L5-S1  towards the umbilicus Angle the needle slightly Cephalad, inserting with its bevel turned parallel to the long axis of the  spine Collection of the CSF: collect 10-15mL of CSF by allowing several mL to drip into the tubes o 1: Gram Stain, Culture and Sensitivity  2: Cell count, Differential count  3: Chemistries – Protein, Sugar  4: Special Studies  D. Complications: Infection o Herniation o Spinal Cord Nerve Damage o Apnea, Bradycardia o Hypoxia o E. Normal CSF Color: water o Up to 5/mm3 WBC (NB: up to 15mm 3) o PMN Cells are always ABNORMAL (In NB, 1-2 PMN may be present) o No RBC’s o Normal Protein: 10-40mg/dL (child); up to 120mg/dL (in neonates) o

F. Differential Count: APPEARANCE

CELLS (WBC)

GLUCOSE

PROTEIN

(mg/100mL)

(mmol/L)

Normal CSF Viral Infection Bacterial Infection TB-Meningitis Fungal Infection Cerebral Abscess GBS (Guillan-Barre)

Clear Clear Turbid Clear & Opalescent Clear Clear Clear

0-5 (Lymphocytes) 25 – 500 100 – 20,000 300 – 500 0 – 500 (Lymphocytes) 10-60 (Lymphocytes) Normal


2.2 – 4.4 > 2.2 < 0.5 – 1.5 0 – 2.0 1.0 – 2.0 Normal Normal

15 – 40 50 – 100 100 – 200 Up to 300 or More 100 – 500 20-80 Slight-Marked Increase 25

G. Precautions after Lumbar Tap (Post-LP orders) Flat on bed for 4 hours o NPO for 4 hours o Monitor VS with BP q15mins x 1h. then q30 mins x 1h. then q1 until stable o

III. VACCINATION (DEMO) VACCINE

AGE

DOSE

BCG-1

Birth (or 6 weeks)

DTP Polio Hepatitis B Measles BCG-2 Tetanus Toxoid

6 weeks 6 weeks 6 weeks 9 months School entry Childbearing women

NO.

0.05mL for newborn 0.1mL for older infants 0.5mL 2 drops 0.5mL 0.5mL 0.1mL 0.5mL

ROUTE

1

ID

3 3 3 1 1 3

IM PO IM SC ID IM

SITE

INTERVAL BETWEEN DOSES

R deltoid region Upper outer thigh Mouth Anterolateral thigh Outer upper arm L deltoid Deltoid

4 weeks 4 weeks 4 weeks

1 month; Then 6-12 months

IV. NEONATAL RESUSCITATION AND ROUTINE NEWBORN CARE A. Establish Respiration (Resuscitati on) Drying, Warming, Positioning, Suction, Tactile Stimulation Oxygen Big-Valve Mask Ventilation Chest Compression Intubation Medication

0 Appearance Pulse Grimace Activity Respiration

Blue / Pale Absent No Response No Movement (Limp) Absent

1 Pink Body + Blue Extremities Slow (<100) Grimaces Some Flexion / Extension Slow / Irregular

2 Completely Pink >100 Coughs, Sneezes, Cries Active Movement (All Extremities) Good, Strong Cry

B. Temperature Regulation When we bate Babies in the Incubator, we want to put the baby in the Neutral Thermal Environment (NTE) o NTE = Range of Environmental Temperature wherein the Body is able to maintain constant temperature with the o LEAST Metabolic Expenditure [NTE (Axilla) = 36.3 – 37.2 0C] C. Nursery Care Entire Skin and Umbilical Cord is Cleansed with Warm Water and Mild Soap – babies are bathed o Routine Cord Care should be rendered o Check 2 Arteries and 1 Vein   Falling off of the Cord is a Physiologic Change in the Baby Vitamin-K 1mg IM Injection to prevent Hemorrhagic Disease of the Newborn o Crede’s Prophylaxis with Erythromycin Ophthalmic Ointment to Both Eyes o  To prevent Gonococcal or Chlamydial Conjunctivitis  Opthalmia Neonatorium = also known as Conjunctivitis of the Newborn characterized by Redness and Swelling of Eyelids and Conjunctiva, with Discharfe Baby is placed inside Bassinet and Monitor Temperature (36.4 – 37 0C) to prevent Hypothermia o Feeding Started, preferably Breastfeeding, as soon as the baby can Suck (to Prevent Hypoglycemia) o  Mother’s Milk may be given through a Dropper or Gavages – done with Caution  Should be Done ONLY if baby is Awake


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o

General Rules & Principles  Infant should be Placed in a Crib, Incubator, or under a Radiant Warmer  Infant in Crib should be Swaddled  Inner Shield or Double Walled Incubator to Reduce Radiant  Infants should NOT be removed from Incubator for an extended period of time

V. BALLARD’S SCORING A. Neuromuscular Scoring

B. Physical Maturity SIGN

-1

0

1

Skin

Sticky, Friable, Transparent

Gelatinous, Red, Translucent

Smooth, Pink, Visible Veins

Lanugo

None

Sparse

Abundant

Plantar Creases

Heel-Toe=40 to 50mm

Heel-Toe >50mm No Creases

2

3

Cracking, Pale Areas, Rare Veins

4

5

Parchment, Deep Cracking, No Vessels Mostly Bald

Leathery, Cracked, Wrinkled

Superficial Peeling &/or Rash, Few Veins Thinning

Bald Areas

Faint Red Marks

Anterior Transverse Crease only

Creases Over Anterior 2/3

Creases over Entire Sole

Raised Areola, 3-4mm Bud Formed & Firm, with Instant Recoil

Full Areola, 5-10mm Bud

*If <40mm = -2 Breast

Imperceptible

Barely Perceptible

Flat Areola, No Bud

Stipple Areola, 1-2mm Bud

Eye & Ear

Lids Fused Loosely

Lids open, Pinna Flat, Stays Folded

Slightly Curved Pinna, Soft with Slow Recoil

Well-Curved Pinna, Soft but ready Recoil

*If Tightly = -2

Thick Cartilage, Ear Stiff

Male Genital

Scrotum Flat, Smooth

Scrotum Empty, Faint Rugae

Testes in Upper Canal, Rare Rugae

Testes Descending, Few Rugae

Testes Down, Good Rugae

Testes Pundulous, Deep Rugae

Female Genital

Clitoris Prominent, Labia Flat

Clitoris Prominent, Small Minora

Clitoris Prominent, Enlarging Minora

Majora & Minora Equally Prominent

Majora Large, Minora Small

Majora cover Clitoris & Minora


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