Updated Pediatric

Therapeutics
By
Dr. Emad Hammad EI-Daly
M.D Pediatrics and Neuropediatrics

Dr. Abol-ela Ahmad Abol-ela

M.D Pediatrics

Seventh edition

2015

First published
Seventh edition

:2004
:2015

All rights reserved

No part of this book may be reproduced in any form
or by any means including photocopying without
written permission from the authors.

Publisher: Scientific book Center

6- Soliman El-Halaby street, Cairo
Amr Shata Tel:5754898- 0101228000

National library legal deposit data

Dr. Emad Hammad El-Daty
Dr. Abul-ela Ahmed

Updated Pediatric Therapeutics

2187/2015

PREFACE
Pressure for efficiency m care and treatment of
pediatrics make the Updated pediatric therapeutics of
increased importance. It is a simplified book aiming to solve
the problems of pediatric prescriptions. It is a basic learning
for house officers, pediatric residents and it is helpful to other
medical and surgical specialists whom dealing with pediatric
patients, It is a simple reference for doses and uses of drugs
in pediatrics. The last chapter includes the doses of the
commonest drugs used in neonate, infant and childhood
periods.

At the beginning of each chapter, a condensed

approach to the diagnosis of cases then management is

discussed.
In this

7th

edition all chapters and prescriptions are

completely revised and rearranged with addition of new

chapters and new prescriptions.
We hope that our book will be helpful to all doctors
and we appreciate your co-operation and we welcome to any
comment or suggestion from any colleagues who guide us to
the right way and we will respect it in the next editions.
Dr. Emad EIDaly

Dr. Abut-eta Ahmad

E-mail: aabolel@,hotmaiLcom.

Subject

Page

Chapter one:
Introduction ................................................................................. I
N onnal values .............................................................................. 6

Chapter two: Important drugs

Antibiotics " 9
Anti-parasitics ................... .-.....................................................:..... 32
Antipyretics ............... .. ................................................37

Chapter three: Emergency and MiscellaneoU.s

Emergency............................................... ................42
Miscellaneous ............................................................ 49

Chapter four: Management of healthy child:

Vaccination ................................................................................. 55
Nutrition ....................................................................................... 58

chapterfzve: Systemic approach

Respiratory Diseases .................................................................... 63

Tuberculosis ................................................................................. 84
Gastroenterology ......................................................................... 88
Malnutrition ................................................................................. 113
Neonatology ................................................................................ 121
Nephrology ....:.".........................................................::..:........... 140

Cardiology -~-......... 149

Hematology ............................... :...............:.................................. 164
Infectious Diseases .................................................................... 175
Neurology ............................................................................: 189
Endocrinology ...........................................:.................................. 203
Dennatology ................................................................................ 213
Poisoning....................................................................................... 222

Chapter six:
Commonly used drugs -~227

ChapterOnk

I - Introduction
It is very difficult to prescribe medicines to children and

infants, and the subject is more difficult in the neonatal period.

You will face many problems in pediatric prescriptions.
The first problem is the selection of drugs as some drugs are
contraindicated in the first few months of age as sulfa and
chloramphenicol. Also, corticosteroids should be used cautiously
in infancy and early childhood even the topical preparations.
The second problem: the use of tablet forms as its group is not
available as syrup or suspension e.g. L-thyroxin and Capoten .
Here, many methods of intake could be used:
1- By chewing of the tablet or its fractionation (half a tablet or
one quarter of a tablet).
2- By trial of swallowing with water or juice even if the tablet
was segmented into small parts.
3- Grinding

(~)

of the tablet and dissolving it into small

volume of water.
4- In dispersible tablets, you could dissolve into certain amount
of water and give the child the required dose (for example
dispersible tablet 25 mg dissolved in 5 ml of water, then

-l-

every 1 ml water contains 5 mg of the drug, if the patient is

in need for 15 mg, 3 ml will be given and discard the
remaining 2 ml).
5- A practical method (if the child refuse the previous methods)
is to break the tablet into few small segments and mixed with
food as some rice or put it inside a piece of bread during
feeding the child.
6- Capsules are.designed to be dissolved inside the duodenum,

its wall is acid resistant and the usual method of opening the
capsule and giving its contents to. the child is wrong as the
active ingredient may be affected and becomes less active by
the gastric acidity. Some capsules contain sustained release
granules which not affected by gastric acidity. In spite of that
.not all _capsules are acid resistant, you should avoid this
method of ingestion of drugs.
The third problem is the calculation of the appropriate doses

The physician who is inexperienced or unaware with drug

doses in childhood may give overdoses (hazardous) or under .
doses (poor response).

The doses of different drugs are

'

mentioned with every chapter and collected for the commonly

~

drugs in alphabetical order at the end of this book.

-2-

The most i,mportant step is to get an accurate weight for

~

the child; if this was not available you should calcufate his
weight by fixed formula for normal values.

Syrup Forms: drugs are not given roughly for children

by any tea or soap spoons as tea spoons are of variable sizes even
in the same home. The practical method is to use a syringe and
give according body weight. With some drugs, a graduated .
plastic spoon is included, it is divided by circular line into Y4,Yz
or, 5 ml, or 10 ml.

JS'J\ .Jli.JW ~ U4 "i.l.J ~,j~o~.JI

4..J~I ~\ ~\.WW\-

Injection forms:
1- Be sure of the method of injection (IM., I.V. or S.C.)
2- If the ampoule or vial is already in solution, you should
calculate the concentration/ml and according your calculated
dose/kg, you will inject.
3- If the vial is a powder you could dissolve it by any volume of
solvent according to the desired concentration/ ml
4- If the calculated dose/kg is a fraction of ml. you could give
V4, Yz or % ml But if these solid fraction are not coincide with

-3-

your needed dose (for example the patient in need for 4/10
mi.) here you could do one of two methods
(a) By the use of 3 ml syringe, the one ml. is divided by 10
dashes and you could give 4 dashes in this dose (see the
following Figure.)

- 4la~ JSla~ ~ ~ ~ ,_ JS ~ ,-3 ~~ ~ ~

(b) By the use of insulin syringe (100 unit) which is one mi.
divided into 10 segments (10, 20, 30, 40, 50,. 100) each of them
is 1/10 mi. and so 4 segment will give your desired dose (see the
following figure).
cJ-t 1/10 ;. ~ ~}J J..S ,.~1 ~ ~! t......i.. ,_. 1 us ~ 4-i~

(100 t.)l50 _,.:IO.,POJ20J10 ~~~4 JS.!all ~ l..s ~-~J ~I~

(5) Dilutions: e.g. child 5 kg
Amikain 250 mg vials 2 ml
~L...l2

JS J.$ ,_ Yz~ ~ ~ )d. .\.a ,-1

-4-

A Figure of 3 ml syringe and 100 IU. Insulin syringe to

show how to calculate fractions of doses.

-5-

II- Important Normal Values

(1) Weight:
-

The average full term weight at birth= 3-3.5 kg,

Then, duriri.g the first year of life the average body weight
increases as follows:

.-

3A kg every month in the ftrst 4 months (i.e. 3 kg in 4 months).

Yz kg every month in the second 4 months (i.e. 2 kg in 4 months).
14 kg every month in the third 4 months (i.e. 1 kg in 4 months).

Another method(used in the period from 3 months up to 12

months).
Age (in months) + 9
Weight=

=wt/kgs
2

-In the period from 1 to 6 years:

The average weight of the child can be calculated by the
following formula:
Age in years. x 2 + 9 = weight in kgs ,

Example, child 4 years = 4 x 2 + 9 = 17 kg.

-

In the period from 7 to 12 years:_ The following formula

could be used:
(Age in years x 7)- 5

= weight in kgs
2

-6-

(7 X 7) - 5
Exa~ple,

child 7 years

44

= - - - - = --=

22kg.

(2) Height I Length:

-

The length is measured in the recumbent position.

The height is measured iri the standing position (usually after

2 years of age).

The average length at birth = 50 em.

During the first year of life, length increase as follows:

!I

3 em every month in.the first 3 months.

2 em every month between 3rd and 6th months.

1.5 em everY month from 6dl- 12dl months of age.

The average length at 1 year = 75 em.

N.D.

The baby is delivered 50 em in length and increases

(roughly) 2 em/month to reach 74 em at the end of the first year.

-

After the first year of life, the average length is calculated by

the folloWing formula.

I(Age in years x 5) + 80 =height in c.m

-Example, child 5 years= (5x5) + 80 = 105 em.
(3) Head Cireumference:
-

Put the tap around the head at the most prominent part of the
occiput and over the glabella (above the eye brows).

Norm;;U head circumference

-7-

At birth

35 cm.

3 months

40cm.

6months

44cm.

1 year

47cm.

2 years

49cm.

4 years

50cm.

(4) Pulse:
-

Newborn 140 20 beats/minute.

Infants 120 20 beats/minute.
2-3 years 110 20 beats/minute.
Preschool children 100 20 beats/minute.
School children 90 20 beats/minute.

(5) Blood Pressure:

First year
80/50 mmHg.
1-5 years
90/60 mmHg.
5 - I 0 years
J00/65 mmHg.
I 0 - 14 years
110/70 mmHg.
- > 14 years "as adults" I20/80 mmHg.
(6) Respiratory rate:
50 - 60 cycle/minute.
- <2 months
40 - 50 cycle/minute.
- 2 months- 1 year
30 - 40 cycle/minute.
- 1-5 years
25-35 cycle/minute.
-5- 10 years
20 - 25 cycle/minute.
- 10- 14 years

-8-

Chapter two
i

Commonly Used Drugs

A- ANTIBIOTICS
The main groups of antibiotics are :

I- Penicillins

2- Cephalosporins

4- AminogiJalsides 5- Sulpha

3- Macrolides
6-Chloramphenicai

1- Penicillin
It is widely used and still the first choice in many

infections (poeumococci, streptococci, meningococci, gonococci,

diphtheria and tdanus).

(A) Origiaal Pmicillins:

(1) Benzyl peainltin penicillin G = crystalline penicillin..

Dose: lOOJJOO- 200.000 Ulkg/day divided into 4 dose evety 6

hours LV or 1M.. No need for sensitivity tesL In

som~

serious

infections as subacute bacterial endocarditis and meningitis, the

dose increases tb 300.000 Ulkg/day, (divided every 4 hours)..
Preparatiola:

- Penicillin G sodimn (1.000.000 U) vials.

. Aqua-Pen (IJJOO.OOO U) vials.

=~~

- ~'- 6P ;;, %
- ~,, .. ;;, Yz

~~

to &:Ai cJW:at

~~2D-10

i_..n~~~

-9-

JW:-1

(2)Phenoxymethyl penicillin (penicillin V =oral penicillin:

Oral penicillin is less effective than other types of penicillins

and it is used for upper respiratory streptoccocal infections
and prophylaxis against rheumatic fever.

Dose: 50.000- 100.000 U/kg/day into 4 doses every 6 h.

Preparations:

- Ospen 400 suspension (400.000 U/5 ml)

- Ospen 1000 tablets (1.000.000 U)
- Ospen 1500 tablets (1.500.000 U).
- Cliacil 300 suspension (300.000 U/5 ml).
- Cliacil1.2 mega tablets (1.200.000 U).
N.B.

There is some oral penicillin suspension with a

concentration in mg (not in unit) as "Star-pen" suspension 250

mg/5 mi. The dose here is 250-500 mg/day or twice daily.

ill Procaine penicillin:

Prolonged action for 12-24 hours (by the addition of
procaine to benzyl penicillin).
- 'Dose: 25000 - 50000 U/kg/day I.M. (not LV.) is
given once /day or into two divided doses .

Preparations: Penicillin procaine vials (1 00.000 U

penicillin: G. + 300.000 U procaine penicillin), to
give the benefit of rapid action of penicillin G. and .
the sustained action ofprocaine penicillin.
-10-

\
!

ffi Benzatbine penicillin = Long acting penicillin:

f>. sustained release form of benzyl penicillin.

It is used every 2-4 weeks.

Sensitivity test is essential before use.

It is used mainly as a prophylaxis against:

Rheumatic fever
Chronic tonsillitis and
Acute post-strept. glomerulonephritis.

Dose:
- < 6 years or< 30 Kg= 600~000 U/Kg/dose

(4.Ibll 1/2)

- > 6 years or> 30 kg = 1.200.000 Ulkg/dose (~lS 4.Ibll)

I~
.t..-_ ~..-_jJ:!
~

i ~..J
-<A. 6~1
w
#

~Lw.l 4-2

Lali.l

.)

JS .(Jb.ll ~i

.1.a.J

~~ ~.( J_i" ~~ r.rt..~

#

~ ~jJ Lidocaine

Preparations:
Retarpen.vials
Durapen-S vials
All contain 1.200;000 U.

Lastipen vials
Penicid L.A. Vials.
Penadur L.A. vials.

-11-

JjhA

* Drug reaction ( Penicillin Allergy):

(a) It is classified simply according to the time of occurrence into:
1- Immediate (few minutes up to 1 hour): Urticaria,
laryngospasm, bronchospasm and anaphylactic shock
(death may occur)
2- 1-72. hours: rarely and usually resembles the immediate

reactions except for shock.

3- Later > 72 hours: maculopapular rash; urticaria,
erythema

multiform,

hemolytic

anenua, .

thrombocytopenia and neutropenia

The most serious and fatal drug reaction is that of
procaine penicillin and long acting penicillin, -but it is not
Common. Most of the rheumatic heart disease patients receiving
the injection monthly.
- But if the patient is sensitive - - - Death.
Sensitivity Test:
Should be -done before the injection.
:~

. ,.l.. ,... 4 u. ...t--~"4ab..

. . ~ -1
~

'.)

f""' 5 c)} ~.J oAI.J 4Ja~ ~ -2

~J Jo- 20 u.- .J~""i',:, e'.;ll' ~ ~ ~,... ~ ~ -3

.~l.waa. J.,Ho.J ~ ~ f""' 2 o-_,..L..;I~!.J f.J.J1 ~_, -4

~JW" ,,,tt ~~~ ~J uiaJI ()S.e ~ .;I.>Gt ~ "l-5

-12-

-:~.J zsJt,Lli ~~ .;SI.,:i u.- J.i'i ~! _,; ~ J#.'~' uts lj! -6

A- Adrenaline ampules.
B- Solu-cortif vials.
C- Fortecortin ampoules.
D- Sterile syringes.
~I~ ~t... ~ o.wl UiaJl ~~~I~ -7
~ ()s.. ~ 0.>- J.Jl ~~ ~ -8

(B) Penicillin Derivatives:

They have a wider range of activity than penicillin with
minimal side effects (but hypersensitivity may occur .in
susceptible individuals as an idiosyncratic reaction.
Some of them are active against penicillinase releasing
staph. & against pseudomonas infections.
[1] Ampicillin:
-

Diarrhea is a common side effeet of oral preparation.

Dose: 50-100 mg/kg/day (oral, LV. or I.M.) divided

into 4 doses every 6 hours.

Preparations:
-

Ampicillin vials (Y4 ,

~.

1 gm) suspension (125, 250

mg/5 ml) and capsules (250, 500 mg).

-

Epicocillin vials (~. 1 gm) suspension (125, 250

mg/5 ml) and capsules (250, 500 mg).

Farcocillin : vials (Y4 & ~ gm).

-13-

. :~'lls ~~I oj~! J.id f+S 10 .UJJ Jill ulS lj! :Jli.
.~ 500 = ~ 50

10 = f_,Hll c) ~I ~.,P.JI

(ull- 5) o~ tia.L.: ~.:~I->4JI4.lb y.i

ta,.s1 ~ JU.:a. ~ o~l...,.. ~~~~.A.. 61 (~ 250) ~ YJ : ~~ 4L. uS
ci.jll u..il ~ ~.,P.oll ~ ~! ~~ .;i.i ~.,.>J .4jl -;,,1 ~_,
llA ~., ~f'+A too 4.&.~ ~ ~'JI ~ ~ :o~l ~'J\al\ ui
~~I.A.. 6/~ 125 ~I ().4

~ 1000 = 100x10 = ~.,Hll ~~I ~.;.toll~ c) JiW1

(2J AmoxiciUin:

In spite of the same spectrum of ampicillin; it has the

advantages of better oral absorption and less incidence of
diarrheaas a complication.
Dose: 25-50 mglkg/day (oral, I.V. or I.M.). Every 8 hours.
Preparations:
- E-MOX: Vials (Y., Y2, 1 gm) suspension (125 &
250 mg/5 ml) and capsules (500 mg).- Hiconcil: Suspension (125, 250 mg/5 ml), drops
(I 00 mg/ml) and capsules (250, 500 mg).
- Amoxil: as E-MOX
- Ibiamox: suspension (125, 250 mg/5 ml) and
capsules 250 and 500 mg/5 ml.
-

Moxipen
Amoxicid

}
as lbiamox and Biomox

Flemoxin: suspension (250 mg/5 ml), drops (1 00 mg/1 ml)

and capsules (500 mg).

-14-

[3) Penicillins combined with penicillinase inhibitors:

~

(A) Ampicillin + Sulbactam:

Sulbactam is a beta lactamase (penicillinase) inhibitor so,

it gives the ampicillin a broader spectrum to cover penicillinase
secreting organisms .

Dose: as ampicillin and the dose is calculated without respecting

of sulbactam.

-Preparations:

-Unasyn

:Vials (1500, 750, 375 mg), suspension 250 mg/5 ml

(Tablets (375 mg).

- Sulbin

: as Unasyn.

- Unictam: as Unasyn.
-Ampictam: Vials (1500, 7 50 mg), suspension (250 mg/5 ml)
tablets (375 mg).
(B) Amoxicillin + Clavulanic acid:

Clavulanic acid is a beta-Lactamase (penicillinase)

.::

inhibitor; it extends the spectrum of amoxicillin to cover

penicillinase-secretingorganisms.

-15-

Dose: The same dose of amoxicillin.

-Preparations:
Suspensions:

- Augmentin.-

156 mg/5 ml (125 mg amoxicillin

- E-MOXCAV

+ 31.25 mg clavulanic acid)

- Curam

312 mg/5 ml (250 mg amox. +

-Magna-biotic

62.5 mg clav. Acid).

- Hibiotic-N

} 230 and 460 suspension

-Klavox
-Megamox

457mg

suspension

-DeltaClav
-- Curam

Vials:

-Augmentin} 600 mg (500 mg amox. + 100 mg clav.

- Clavucin

120~ mg (1000 mg amox. +200m~ clave)

For LV. route only

[4] Broad spectrum + antipseudomonal penicillins:

They have the same spectrum of ampicillin plus

antipseudomonal activity. They are used when there

IS

possibility of pseudomonal infection as mechanical ventilation,

-16-

neonatal sepsis and infection in immunocompromized patients.

t
.
They are available only in vials for LV. or lM.injection in a dose .
of200-300 mglkg/day divided into 2-3 doses.
-Prepa~tions:

1- Pipril vials (1 ,2,4 gm of piperacillin).

2- Pyopen vials (1 gm ofcmbenicillin).

3- Baypen vials (1 gmofmezlocillin).

(5] Penicillin combinations:

1- Amoxicillin + flucloxacillin:
Flumox vials (500, 1000 mg)
Flumox suspension 250 mg.
Flumox capsules (250, 500 mg)
Flucamox capsules (250, 500 mg).
.:

Hiflucil capsules (250, 500 mg) .

-17-

2- Ampicillin + dicloxacillin:
Dipenacid vials 250, 500 mg.
Dipenacid suspension: 250 mg/5 ml
Dipenacid drops: IOO mg/ dropper.
Dipenacidcapsules: 250 mg.
Cloxapen capsules : 250, 500 mg.
3- Ampicillin + cloxacillin:
Ampiclox vials: 500 mg
Ampiclox suspension : 250 mg/5 ml.
Ampiclox capsules: 500 mg.
4- Ampicillin + ftuclloxacillin
Amoflux 250mg suspen
~ ~l:t'/1 .&J ~~ ~ ~~ u:tA ~ ~ e~ JS :4J&~

Lk.
WI (J L...4l ~.
. .!WU J:aiA.a..

II- Cephalosporins
Cephalosporins are structurally related to penicillins but
with wider spectrurq of activity especially

ag~t gram

-ve

organisms and should be given with caution in history of

penicillin allergy. They are bactericidal drugs with minimal side
effects as allergic reactions but nephrotoxicity may occur. So,
avoid it with aminoglycoside at the same tinle.
There are four generations.

-18-

(1) First generation cephalosporins

Drugs: Cephradine, cephadroxil, cephalexin, cephapirin and
cefazolin.

Spectrum: They cover gram +ve organisms including

penicillinase secreting staph and some gram -ve organisms
especially E-coli, H. influenza, klebsiella pneumoniae and
proteus.

Dose: 25-50 mglkg/day, oral, and 50-100 mg I.V. or I.M.

divided into 3 doses every 8 hours.

Preparations;

(a)

Cephalexin:

- Ospexin: Suspension (125, 250 mg/5 ml) and tablets (1 gm).

- Ceporex: Suspension (125, 250 mg/5 ml) tablets. (250, 500,
1000 mg) and vials

(~,

1 gm).

- !bilex : suspension (125, 250 mg/5 ml).

- Keflex : Suspension (250 mg/5 ml) and tablets (500 mg).
- Neocef: suspension (250 mg/5 ml) and capsules (250, 500 mg).

(b) Cephradine:

-19-

- V elosef: Suspension (125, 250 mg/5 ml), capsules (250, 500

mg) and vials (Y4, Yl, 1 gm).
- Farcocef: vials only (Y4, Yl, 1 gm).
- Ultracef: suspension (125, 250 mg/ 5 ml), capsules (250, 500
mg) and vials (250, 500 mg).
(c) Cephadroxil: (two doses every 12 hours)
- Duricef: suspension (125, 250, 500 mg/5 ml), capsules (250,
500 mg) and tablets (I gm), drops (100 mg/1 ml).
.

- Curisafe: suspension (125, 250, 500 mg/5 ml), drops (100

mg/1 ml) and capsules (500 mg).
- Ibidroxil: suspension (125, 250 mg/5 ml) and capsules (250,
500mg).

- Biodroxil: suspension ( 250, 500 mg/5 ml) and capsules (500 mg).
- Longcef: suspension ( 250 mg/5 ml).

(d) Cephapirin:
- Cefatrexyl: vials only (Yz, 1 gm).
(e) Cefazolin:

- Totacef: vials only ( Y2 , 1 gm).

- Cefazolin: vials only (1 gm ).

-20-

- Zinol : vials only (~. 1 gm).

(2) Second generation cephalosporins

Drugs:

Cefprozil,

cefuroxime,

cefaclor,

cefoxitin

and

cefinandole.

Spectrum: As first generation but with expanded spectrum of

activity against gram -ve organisms but not pseudomonas.

Dose: 25-50 mg/kg/day orally but in severe infections as sepsis,

pneumonia and meningitis the dose is 50-100 mg/kg/day.
The dose is divided into 2-3 doses/day LV., I.M.

Preparations:
(a)

Cefprozil:
- Cefzil: suspension (125, 250 mg/5 ml) and
tablets
(250, 500 mg).

(b)

Cefuroxime:
Zinnat: suspension (125.250 mg/5 ml), tablets
(125, 250, 500 mg) and vials (250, 750, 1500 mg).
Cefumax: vials (250, 750 mg).

(c)

Cefaclor:
Serviclor: suspension (125, 250 mg/5 ml), capsules (250,
500 mg),.and tablets (375, 500, 750 mg).

-21-

Bacticlor : suspension (125, 250 mg/5 ml) & Capsules

(250 and 500 mg).
Ceclor: as serviclor.

r-

(3) Third generation cephalosporins

Drugs: Cefotaxime, cefoperazone, ceftriaxone, ceftazidime

. cefixime and cefpodoxime.

Spectrum: Good cover of gram -ve mainely and also gram

+ve. They are considered antistaphylococcal and
antipseudomonal drugs. They pass blood brain barrier
effectively.

Dose: 50-150 mglkg/day LV., I.M. given into two divided

doses but ceftriaxone could be given as a single daily dose.

Preparations:
(a) Cefotaxime:
- Claforan:

Vial~

(14, Y2, 1 gm).

- Ceforan , Xorin vials (Yl , 1 gm).

- Cefotax: vials ((14, Y2, 1 gm).

(b) Cefoperazone:
- Cefobid: vials (Y2, 1 gm).
- Cefazone: vials (Yl, 1 gm).

-22-

- Cefozon (Y:z, 1 gm) vials.

l

- Sulperazone:

vials

(lgm)

it

contains

1000

cefperazone + 500 mg sulbactam.

(c) Ceftriaxone:

- Rocephin: vials (Y:z, 1 gm).

- Ceftriaxone: (Y:z,1gm) vials
- Epicephin:

vials( ~,

Y2, 1 gm).

- Cefaxone vials (Y:z, 1 gm)

- Oframax vials(~, 1 gm).

(d) Cefpodoxime:
- Orelox: suspension (40 mg/ 5 ml) dose 8-10
mg/kg/day divided/12 hours
- Podacef: suspension (1 00 mg/ 5 ml) dose 8-1 0
mg/kg/day divided/12 hours.

(e) Cefixime: dose 8 mg/kg/day divided every 12-24 hours.

- Suprax: suspension (1 00 mg/5 ml)
- Ximacef: suspension (100 mg/5 ml).

(f) Ceftazedime:

-23-

mg

- Fortum vials only (250, 500 ,1000 mg)

- Cefzimvials (500 ,1000 mg)

-24-

(4) Jfourth generation cephalosporins

Drugs: Cefepime and cefpirome.
Spectrum: Wider spectrum than 3rd generation and affects
resistant strains of enterobacter.
Dose: 50-100 mglkg/day LV., I.M. divided into two doses every
12 hours.

Preparations:
(a) Cefepime:
- Maxipime: vials (Yz, 1 gm).
- Wincefe :vials (Yz, 1 gm).
(b) Cefpirome:
- Cefrom : vials (1

gm)~

-25-

III- Macrolides
Drugs: Erythromycin, spiramycin, azithromycin,
roxitheromycin, and clarithromycin.
....tJ i.-1""'

Spectrum:

- This group is bacteriostatic but in high doses they

become bactericidal.
- The have a similar spectrum to penicillin G. (G
+ve plus mycoplasma and chlamydia).
- No cross sensitivity with periicillins.

Side effects:
- G.I.T. symptoms as nausea, vomiting and
sometimes diarrhea
- Mild cholestasis

Types and Preparation:

(1) Erythromycin: Dose (25-50 mg/kg/day) oral and
divided into 3-4 doses (every 6-8 hours}
- Eryt.~cin
} Sus,Pension 200 mg/5 ml and tablets 250,
- Erythrin
500 mg.
- Erythromycin
(2) Spiramycin: Dose (150.000- 300.000 I.U./Kg/day)
oral or rectal divided into 2 doses every

12. hours.

- Rovamycin: Sachets (750.000 I.U;) and tablets (1.5, 3 million I.U.)

- Rovac tablets (1 Y2 & 3 M I. U. )

-26-

(3) Azithromycin: Dose 10-15 mg/kg/day oral. It 1s

given as a sit}gle daily dose for 3-5 days only.
- Zisrocin: suspension (100 mg/5 ml) & capsules (500 mg) . .
-Zithrodose: susp. 900mg , 1200 mg
- Zithromax: 15 ml (200 mg/5 ml) & capsules (250 mg).
- Zithrokan : 200 mg/ susp
- Xithrone : as zitbromax.

(4) Roxithromycin: - 5-8 mg/kg/day oral divided into

two doses every 12 hours.
-

Rulid: tablets (50, 150, 300 mg).

Roxid:.Tablets (300 mg).

(5) Clarithromycin: - 15 mg/kg/day oral divided into

two dos~s every 12 Horus.
- Claribiotic: tablets (250, 500 mg).
- Klacid suspension 250 mg/5 .ml & tablets 250 mg.
- Klarimix

125 mg susp

6) Erythromycin + sulfa:
(i)

Erythromycin + Sulphisoxazole:

- Pediazole suspension (eryth. 200 mg + Sulph-600 mg/5 ml).

(ii) Erythromycin + trimethoprim:

- Primomycin: suspension (200 mg erthr. + 50 mg trimeth./5
ml) and capsules (400 mg erthr. + 100 mg trimeth. ).

- Erythroprim: susp.(200 mg erthr.+50 mg trimeth.

-27-

IV- Aminoglycosides

Drugs: Gentamycin, amikacin, tobramycin, streptomycin,

neomycin and kanamycin.

Spectrum:
- Mainely against gram -ve organisms.
- Antipseudomonal effect.
- Mild antistaph effect.

N.D.:

They~

not absorbed from G.I.T. and so, they are used

only parentally and neomycin is used for local

disinfection of the gut.

Side effects: Ototoxicity and nephrotoxicity and so, the

doses should be calculated accurately.

Preparations:
(1) Gentamicin: Dose 5-7 mglkglday I.M. or LV. divided into 2
doses (every 12 hours).
- Gentamicin}
- Garamycin
ampoules (20,40, 80 mg).
- Rigaminol
- Refobacin ampoules (1 0, 40, 80 mg)
- Cidomycin vials (80, 160 mg).
- Epigent ampoules (20 and 80 mg).

-28-

~,_

(2) Amikacin: Dose 15-20 mglk:g/day I.M. or I.V. divided into

2 doses (every 12 hours).
- Amikin vials {l 00, 250, 500 mg). :
- Amikacin vials (250,500 mg).

(3) Tobramycin: Dose 5 mglk:g/day I.M. or I.V. divided

into 2-3 doses
- Nebcin }

(every 8-12 houres).

vials (20, 80 mg)

- Tobcin
- Tobracin vials (40, 80 mg).
(4) Streptomycin:

Dose 20-40 mglk:g/qay ... I.M. used

mainly in T.B. as a single daily dose.

-Streptomycin vials(1 gm).
~

Neomycin:
-Neomycin suspension (125 mg/5 ml) tablets (500 mg)

{} Kanamycin: 15-30 mg/k:g/day divided into 2 doses every 12

hours.
- Kanamycin vials (250, 1000 mg).

V- Sulfa drugs (cotrimoxazole)

Spectrum:
- The combination of trimethoprim + sulphamethoxazole in a
ratio -1:5 ratio (co-trimoxazole) gives the maximum synergistic
effect
- They have the same spectrum of ampicillin.
-29-

Side effects:
1- Skin rash.
2-

Crystalluria.

3- Acute hemolytic. crises in G6PD deficiency.

Dose:

4 mg (trimeth.) + 20 mg (sulphameth.) /kg/day

orally into two divided doses (every 12 hours). Except in

shigellosis the dose is higher (1 0 mg + 50 mg/kg/day).

Preparations:

- Sutrim

Suspension 40 mg trimethoprim +

- Septrin

200 mg sulphamethoxazole.

- Chemotrim

Tabletes

- Septazole

80 mg trimethoprim +

200 mg sulphamethaxazole

- Lidaprim

ra-J: I& 20 JS.l c.J4J.J & 10 JSl (~ 5) Ual..

VI- Chloramphenicol .
Spectrum:

'

Broad spectrum bacteriostatic with good penetration of

CSF.
It has a spectrum similar to ampicillin with

s~ific

antibacterial activity against salmonella infection and

also anaerobic infection.

-30-

Side effects:
1- Aplastic anemia: inspite it is uncommon, chloramphenical
should be restricted in use to typhoid fever, meningitis
and life threatening anaerobic infection.
2- Grey baby syndrome: a fatal shock-like state occurs in
neonatal period and so, it is contraindicated in neonatal
period.

Dose: 50-100 mglkg/day I.M., LV., oral and rectal given in 3-4
divided doses.

Preparatioas:
- Cidocetine: vials (1 gm), suspension (125 mg/5 ml),
suppositories (125, 250 mg) and capsules (250 mg).
- Thiophenicol: vials (750 mg), tablets (250 mg).
- Miphenicol: Suspension (125 mg/5 ml) suppositories
(125, 250, 500 mg) and Capsules (250 mg).
- Eye and ear drops (miphenicol).
- Chlormaphenicol + streptomycin: (streptophenicol) syrup
( 125 mg/5 ml of each) used for treatment of diarhrea.

-31-

VII- Lincosamides
(a) Lincomycin: similar activity as macrolides. Dose 20-40
mg/kg/ once/day IM or IV.

Preparation: Lincocin ampoule (300, 600 mg).

(b) Clindamycin: like lincomycin but more potent against
anaerobes. Dose as lincomycin.

Preparation Dalacin-C
600 mg ampoules.

150,300 mg capsule & 300,

B- ANTI-PARASITIC DRUGS
1- Anti-amoebic Drugs
(1) Metronidazole: (tissue and luminal amebicidal)

Uses: 1- Invasive intestinal amoebiasis.

2- Amoebic dysentry and liver abscess.
3- Anaerobic infection (For I.V. infusion).

Dose: 50 mg/kg/day orally for 10 days, divided into 3 doses

(every 8 hours).

Side effects: nausea, vomiting and metallic taste.

Preparations;
- Flagyl
- Amrizole
- Elyzol

suspension (125 mg/5 ml) and tablets (250 mg).

- Entophar
- I.V. infusion: Flagyl, Elyzol and Flazol (500 mg/100
Every 12 hours
-32-

ml).

(2) Diloxanide furoate: (Luminal amoebicidal)

'

-Use: symptomatic cyst passers

-Dose: 20 mglkglday oral for 10 days
-Furamibe

Tablets (500 mg).

-Furamide
-Farcomide

NB, not used below 2 years age ..

(3) Metronidazole 1OOmg

+ Diloxanide 200mg: orally for I 0

days divided into 3 doses (every 8 hours).

Fmazol }' suspension

- Dimetrol

(4) Tinidazole: 50 mglkg .. .. sigle dose... for 3 days

- Fasigyn. Tablet 500mg

(5) Secnidazole: 50 mglkg .... sigle dose... for 3 days

- Flagentyl. Tablet 500mg

II Anti-Giardial drugs
1- Tinidazole: > 3 years 50 mglkg ... Oral tablets, once
- Fasigyn. Tablet 500mg

2- Metronidazole: 15 - 25 mglkglday orally for 5-7 days,

divided into 3 doses

3- Albendazole: 400 mg... Sigle dose.for 5 days

-

Vermizole, Alzental, Bendax

Ill- Anti-helmintics Drugs

(A) Drugs for Ascaris.
(1) Albendazole: 400 mg once, for all ages

Preparations:
- Alzental

suspensioif (IOO mg/5 ml) and tablets

- Vermizole

Suspension (200 mg/5 ml) and tablets

- Bendax

suspension (1 00 mg/5 ml) and tablets

(2) Mebendazole. 500 mg/dose once for all ages

Preparations:
- VAnermtiverx
0
-

- Anthelmin
-Verm-1.

suspension (100 mg/5 ml) and tablets

( 100 mg).
400 mg tablets

(B) For oxyuris:

1- Mebendazole - 100 mg/dose as a single dose to be

repeated after 2 weeks and all the family members
should receive it in oxyuris irifestation.
2- Albendazole: 400 mg once, for all ages
(C) Drugs for Cestodes: taenia saginata, T-solium and
hymenolepis nana.
1)

Flubendazole

"'~)

Abendazole

3)

Niclosamide:

}
as before.

-34-

Dose:

<1 0 years 1 gm oral single dose.

> 10 years 1.5 gm oral single dose.

Preparations:
- Yomesan

- Niclosan

Chewable tablets 500 mg.

(D) Anti-bilharzial drugs:

- Praziquentel:

Dose: 40-60 mg/kg orally as a single dose.

Preparations:
- Distocide

Tablets (600 mg)

Biltricide

Epiquantel. Suspension (600 mg/5 ml).

Other groups
VANCOMYCIN
-Vancolon
-

vail 0.5 g

Vancomycin

Dose:
Neonate, IV 10-15 mglkg/dose Q12-18 hr

Infant and child, IV: 40-60 mglkg/24 hr + Q6 hr

-35-

LINEZOLID
-Averozolid

100mg/5ml

Dose:
Infant and child :10 mglkg/dose PO Q8 hr. Duration of
therapy: 10-14 days,

MEROPENEM
-

Meronem

0.5, 1 g

Dose:
Neonate: 20 mglkg/dose IV/ 8-12 hr
Infant and children: 40-60 mglkg I _8hr

-36-

C-ANTIPYRETICS
Before prescribing antipyretics remember that:
1- The dehydrated baby as in diarrhea show dehydration fever
and it will be corrected with correction of dehydration.
2- The temperature of the newborn baby may be higher than
normal in hot summer and this needs only correction of the
hot environment and addition of preboild water orally and
bathing.
3- The Egyptian mothers usually exaggerate the complaint of
fever and so, you should measure the body temperature
before the use of antipyretics.
(1) Acetaminophen (paracetamol):

- It is one of the commonly used and safe drugs.

Dose: 10-15 gm/kg/.dose orally or rectally and could be repeated
every 4-6 hours.
Preparations:
- Abimol: drops (5 mg/drop), syrup (150 mg/5 ml), suppositories
(300, 500 mg) and tablets (500 mg).
- Pyral: drops (5 mg/drop), syrup (120 mg/5 ml), suppositories
(250 mg) and tablets (500 mg).
- Cetal: drops (5 mg/drop), syrup (250 mg/5 ml), suppositories
(125 mg) and tablets (500 mg).

-37-

- Tempra: drops (5 mg/drop), syrup (160 mg/5 ml)

- Paramol: syrup (125 mg/5 ml), suppositories (125 mg) and
tablets (500 mg).
Paracetamol combinations:
1-Paracetamol +Methionine:
-Methionine decrease the hepatotoxic effects of
high doses of paracetamol.
-Methamol: Syrup (120 mg paracetamol + 24 mg
methionine/5 ml).
2-Paracetamol + Phenobarbitone:
- In febrile irritable baby but not used with respiratory distress or
severe respiratory problems.
- Sedamol: suppositories (200 mg parace!3IDol + 160 mg
phenobarbitone).
3- Paracetamol + Brufen:
- Megafen and Cetafen syrup (1 00 mg ibuprofen + 160 mg
paracetamol /5 ml).
(2) Ibuprofen:

- It is one of the most commonly used and safe drugs either as

an antipyretic or analgesic and anti-inflammatory.

Dose:
-38-

1- Antipyretic dose 10-20 mg/kgldose oral or rectal to be

repeated every 6-8 haurs.

2- Anti-inflammatory dose:
30 Kg/day every 8 hours.

Preparations:
- Brufen: syrup (100 mg!5 mi), tablets (200, 400, 600 mg).
- Marcofen: syrup (100 mg/5 ml), suppositories (100, 300 mg)
and tablets (400, 500 mg).
- Ibufen: syrup (100 mg/5 ml), tablets (200 mg).
- Ultrafen: suppositories (200 mg).

(3) Acetylsalicylic acid:

In spite of its common use multi-precautions should be in

mind before its use:
1- In acute viral illness especially chickenpox it may lead to

Reye's syndrome (encephalopathy and hepatic degeneration)

which is a common complication.

2- It could precipitate acute haemolytic crisis in

G~D

deficiency.
3- In newborn and early infancy, it may lead to metabolic
disturbances.
4- It may increase bronchospasm in asthmatic patients.
Dose: 10-15 mglkg/dose oral, rectal, I.V. or I.M. to repeat every
4-6 hours.
-39-

Preparations:
- Aspegic: vials (500 mg) I.M. or I.V. It is used in severe cases
- Rivo: Pediatric tablets (75 mg) suppositories (165 mg) and
tablets.(300 mg).
- Aspocid: Tablets (75 mg, 300 mg),

Acetylsalicylic acid combinations:

I- Acetylsalicylic acid (500 mg) + vitamic C (250 mg):
- Aspocid C effeversent tablets.
2- Acetylsalicylic acid (I 50 mg) +phenobarbitone (10 mg):

...

- Doloran suppositories.

(4) Metamizole:
In spite of its potent antipyretic and analgesic, it should
not be used as it may lead to:

I- Fatal agranulocytosis.
2- Nephropathy.

-Dose: I 0 mglkg/dose oral or rectal to be repeated every 8 hours.

Preparations:
- Novacid

'

} Syrup (250mg/5 ml) and suppositories (300 mg)

-Novalgin

(5) Diclofenac:
-It has anti-pyretic effect and a
antiinflammatory effect more than others

potent.

-Dose: 0.5- I mglkgldose oral or rectal every 8 hours.

Preparations:

-40-

Catatlam,: dfops (0.5 mg/drop), tablets (25,50

mg).
Dolphen-K: drops (0.5 mg/drop),
Dolphin: Suppositories (12.5 , 25 mg).
~~t...6f~ ~ :~_p.ll

Voltaren: suppositories (12.5, 25 mg) tab. (25, 50

ni.g) & amp. (75 mg).
(6) Ketoprofen:

Dose : o~5 - 1 mglkg/dose orally or rectally every 8 hours.

Preparations:
Ketofan: suspension (12.5 mg/5 ml), tablets (25 mg)

capsules (50 mg)

Ketolgin: suppositories (100 mg), tablets (25, 50 mg)
(7) Mefenamic acid:

-Dose: 5 mglkgldose oral or rectal every 8 hours.

- Preparations:
-

Ponstan: suspension (50 mg/5 ml), suppositories (125

mg) and capsules (250 mg).

(8) Nimesnlide:

Dose 5 mg/kg/day

Preparation: Sulide or Nilsid susp. (50mg/5ml) & tablets

(100mg).

-41-

Chapter Three

Emergency and Miscellaneous

1- EMERGENCY
Emergency:
Treatment of emergency and life threatening conditions
in your clinic is very: important to save the patient's life and your
life also,
~~_,

4.l. ~ L.. ~~-' Ul.l ~ o.ll:!al4 LA_,i~ ~!Jll ~"JI

1- Adrenaline
ampules.
2- Solu-Cortife ampoules.
3- Dexamethazone ampoules.
4- Calcium gluconate ampoules .
. 5- Valpam ampoules.
6- Avii ampoules.
7- Dolphen or Voltren 12.5 & 25 mg Suppo.
8- Cannula 24,22
9- Syringes 2.5,5 mL.
10- Airway.
11- Nebulizer.
12- Sphegmomanometer.
13- Nonnal Saline.
14- Gulcometer.
~ ~~ ~'l.J+Oi A.!~J ~.J J,.9')rl ~ ~ JS u,.. J.J+Ai 2 .;:i_,.:i ~

~1 W"_,l\ll, w~lt y..foJI J-,.. ~ ~ ~~ ~~ ta;!,lall, UlaWI

-42-

y~l ..ill ~_,

Jib :;~ ili .liS (S;\,J:JI ~'Jb 0-" y ~ 'J

~~ w-o ..>?-Y!J

. u ~.;.All ~L....JJ ~ ~ji U)..l.J ~y..oJJ y...u.JI ~)WI ~l

~J o..l~l ~ ~ ~ _w!,hll ~'16.

w-- %90 w-- ysi

. ~!Jc.Y!J w"=-_;..11 ~ ~ w!J.l..ll

w'J6.

J~l ~ ~I J_,b J~l 11\ .) ~I ~ 0-o ~ l~l

.~ y.)i .) J.W..YI ~
~_;..11 ~ ~., ~4 ~~

..l.I.Ji ~~ ~ w!,hll w'J6. ~)Lc '

. ..ill

Case 1:
Child with generalized convulsions, of acute onset due to
epilepsy, febrile, . . .. etc.

R/Valpam or Neural ampule IM or IV if possible.

(J.._;.:o 10

= ~

.~

~ ~)fo ~.J ~

f"""

1)

w..l.IJ

0.5 ~ ~ 12

~ ~~ ~_y:o: ~..r.JI

~~

..l.l_u

21 ~_;.:. _,t

4:;J .Uj, LJft: ~ ~ ~

. ..:::~1 w~l l~j ~t..... ~J

~!J t..>w'l ~I u_,~ ().!l_,...JI ~y.. ~~~~I ~..;1

uc

~~WI ~tbc.l

N.B

Convulsion is not an emergency in cerebral palsy.

Breath holding' spells are not true convulsions.
-43-

I.

Breath holding spells

UJ.l

J-lfo. J,.ilJI ~ 4:!i_, u!,l- 4 -1

u-- JUl.~l ~ ~

~ b~~ uu-l :;.l.J ~}il ~ ~..., v-ii ~i ~ t ~~

.~i 'be~ Jil,JI r~ ~ u~ ~~_, u!)a~l ~ j!)l

Case 2:
Child 8 month-old with convulsions no fever I no past
history of convulsions. With carpo pedal spasm + signs of
rickets': it is a Hypocalcaemic convulsion.

Characterized by:
(1) 5-18 month-old and some times in newborn.
(2) Signs and symptoms of rickets.
(3) No loss of conscious
(4) No fever.
(5) One Generalized fit.
(6) Carpal spasm.
(7) Patient is normal in between attacks
Valium is not usually indicated except m severe
conditions with cyanosis.

.
Rl Calcium gluconate IV 10% slowly.
2 mUKg +monitoring.

t-- ril4 ~ ~ U+A-":1 :;.l...J u~ L.. 8 J.S ~.JJ r_,......1\Sll

.l

~ ~l ~

w:-l:i:!i ~ u.c.J
\

~ \j\

1.)-i:.JI

1.-.Li~ _, ~ u~l u...:..:i .l..I.JJ r~\Sll ~u..c.J ~

. fol ~ ~I:WI ,:fi..<u..., bradycardia

ylill u~ ~ .~~

-l1..r~\Sll ~u.c.J~.,~~~~r~~~ ~

Case 3: Angioneuretic oedema:

-44-

It is of acute onset, observed accidentally by parents. It is

due to insect bite (J,&ill ~) u~ t.ll

Eye: Pale edema of eye lids, inability to open the eye (one eye
only), No eye discharge.
Genitalia: huge swelling of penis or libia in female.
Mouth: Acute enlargement of lips.

R/Fenstil
R/Tobrin

syrup/drops
ED.
~i 4 o.lAl

u!J..a 3 ~ ~

No need for corticosteroic or Antibiotics.

Case 4: Croup
A child 3 years old with croup~ It is an acute spasmodic
laryngitiS mostly due to viral or allergic etiology. Common
between midnight and early morning in winter seasons.
May be mild, moderate or severe up t() cyanosis and arrest.
Rl Adrenaline Nebulizer 1 mL+ 2 mL Cold water for 15 min.
~~ ~ lA_jfo ~.J

R1 De:umethezone

ampoule

1M

tt t1 _ ..t.. .- .... LA 30 N.!. t:t.tt
bJS ill.......
-...~ ~ ~ vv u - u-w

..1

u"il ~ l r,,
... t \"
~ r .1}

~E~~~4lb.~+

Rl Phenadone.
Antibiotics.

Syrup

45-

Case 5: Bronchial Asthma

A child with a cute severe Bronchospasm (bronchial
asthma).

Rl Solu-cortif 1OOmg vial. IM 1Omg/kg/ dose.

Rl Farcolin Nebulizer
0.5 mL + 1 mL Saline for 10 min.
Rl Atrovent Nebulizer
Rl Adrenaline

amp. 1 mL.

Case 6:
Newborn with bleeding (Cephalhaematoma, umbilical,
post-cercumcision or per-rectum bleeding etc.)

Rl Haemakion

ampoule

+ Check umbilical clamp position.

If there is pallor transfer the baby to hospital for blood
transfusion.
+ If no improvement: urgent fresh blood or fresh plasma
transfusion
***If bleeding is severe or recurrent ,investigate for bleeding
tendency ( e.g haemophilia, etc.

Case 7: Acute GI
7 month old with Gastro-enteritis with severe dehydration.

-46-

Normal saline 30 ml/Kg within 1st_ hour,

then continue according the weight: 100/ kg
~I _,l

o.l\:a-14 ~)WI Jt.S:i...l

~.J

Case 8: Diabetic child with coma.

It may be due to hyperglycemia or hypoglycemia.
If your can't differentiate between them, give IV glucose 10%
bolus because the hypoglycemic coma is more dangerous to
brain and may be induce irreversible brain damage than
hyperglycemia coma

(see endocrinology chapter).

Case 9: Fatal Hypersensitivity reaction

Child 7 years old has developed sweating blurring of vision
fainting immediately after (or during) injection of Long acting
penicillin, week rapid pulse.

1- Stop injection immediately.

2- Put the patient in supine position with elevation of both
lower limbs up.
1M
3- Inject adrenaline
4- Decadrone ampoule
IM.
5- Solu-Cortif
IM.
6- Cardiorespiratory resuscitation
~WI ~ ~~

-~~~ ~~~I

D.D.:

o$ ~J~I o~ J1S:i ~ +
~ jlo~l J,:9 ~J~I o~ _;!~ ~ +

* Vasovagal attack.

It can be occurred with any injection due to pain in older children

and it is a transie11t condition and usually no need for medicine.
-47-

Case 10:
Child 3 years old with irreduciable inguinal hernia. Acute
onset of tender hard painfull indirect inguinal hernia.
~..;~ ~ \.;..) ~_,b..o ~ 4i.;<h

30- 10

~.lJ ~I

c.)c. ~J.;4 ~ ~b~ J..,c.

~~~ -' c.)c.'il o\.;..:il ~

~I "~'i

uo.'"i,.aJl.U....) _,1

~I~

J_,b. ~

ljl

To avoid intestinal gangrine

Case 11:
A child 4 years old with recurrent epistaxes

.~WI
!)

.U-!~''1
~

Ui.J~

("L......ll ~1) ~y JUJI U"L ts.J

~WI
. _g U:!"
lu~'il!
.. \..: _,.,.:..
.. !!;:--'

~
u;..~ J:4.o
U"
1

~
I. ~'il
~ ("'lh'
-'

~WI
.

i.E.

....,j,jYI u
.~
,_ ..b.a...;JI
- - <.r-

uk- ~y.11

wjl _, ....,j,jl ~L.-i.l

\

/,..'

-48-

2- MISCEL!rANIES:
Case 1: Acute lymphadenitis
3. years-old child with temp. 38.5 and large, single,
tender deep cervical lymph node of 2 days duration. (Common
presentation).
Rl Zinnat

250 mg vial.

~lw 12 JS ~

Or. Klavox

457 mg suspension.

~twt2 JS~~s

R/ Ketofan

suspension.

trb.

~!.>44 ~

. ~\- 48 J$
Suppuration and surgical drainage may be needed.

~~ o~tc.j

Case 2: Acute Suppurative lymphadenitis

5 years-old child with temp. 39.5 and large, single,
tender deep cervical lymph node of 2 days duration. Due to tooth
suppuration (Common presentation).

Rl Claforan

500 mg vial.

Rl Flagellate fort
R/ Ketofan

suspension.

~lw 12 JS ~

trb.

~lw8 JS~~5
~!>A4~

suspension. .

. ~\- 48 J$
Suppuration and surgical drainage may be needed.

-49-

~~ o~tc.j

~Case

3:
5 years-old child complaining of acute pam m lower

limbs and back of 1 week duration, No other sings. "

Tenosynovitis after viral infection".

RJ Voltaren or dolphin 25 mg tab

~J..)lll ~ JS'.il ~ ~);A 3 W4.J

RJ Epicozyme
Re evalute after 48 hours

Case 4:
..

Female child 2 years-old with severe vaginal itching,

erythema with minimal discharge. ( vulvovagnitis).

RJ Hibiotic-N or DeltaClave
230 mg suspension,
~l.w 12 JS ~ 5
Rl Betadine, Vaginal douches.
-

t A~
-

U:!-IJA l.rfT"'"

RJ Fusi-zone or Pandermal
~);A

Rl Megafen

cream.

3 ~,jA -4ll ulAJ

Syrup
~Jjlll ~ ~);A 3 ~

vrint! analysis and CIS is indicated

-50-

l.:ia.l.a

Case 5:
5 month-old baby with umbilical hernia 0.5 to 2 em.
RJ No need
for treatment and most of them improved with
I
time.
RJ ~ 3 iJ.4l ~ r)):.. ~.;

. ,- 3 DA J:~Si ~' ~

uts \:i! ~~ ~~~ ~ r..i4fo

Case 6:
Mother of a 3 years-old child complaining that her child
breathing has a bad odor ~...fo ~ ~..J
Look for:
Rl foreign body in the nose.
Rl Chronic adenoid or tonsils enlargement.
Rl Chronic suppurative lung disease.
Rl Psychic mother.
Rl Infected tooth or abscess.

Case 7:
A child complaining of severe neck pain; inability to
move freely in all direction of 2 days duration. (mostly a muscle
spasm due to abnormal position during sleep).
RJ Ketofan or Olfen 25 mg tabs.

R!Olfen gel
RJ musle relaxant

-51-

Nocturnal Enuresis (NE)

I.

Primary NE: the patient continues to bed wetting since birth.

Treatment is medical or surgical.
Secondary NE: The patient rewet the bed after 6 months or
more of dry nights. Treatment is either: medical, Psychological
or may be surgical.
Generally No medical treatment is required befores years- old.
Routine investigations:
@ Urine analysis.
@ Abdominal ultrasonography.
@X-ray lumber spine A-P.
@ Psychotherapy.
@ Urodynamics.

:4...calc.

u4-P.-_,:;

.4-.i.A ~t.y J~YI w-o ._#. 0~ ~ ~i c.J:!.ll!,ll ~ ~ji

. r)l,Jl.J w!)l t-o~_,
. ~~ r~l ~

~_, I)Pl-oj 4.......:.~_, 0l~YI rLAi

Jjl.J- Y~ ~

J.ilJ4 ~\,~_,:ill ~

u4~'11
W-A .l..:U:! ~ wY w'-~1 _,i Y~4
~~a..-~
.
.
.
~1~_,~1

. ~~ ut.;. "-:!i ~ c4- JS ~ ~~.;.. Ji,l.JI "tk.j

~~ r~ 1 J:! J~!, rt-11 J..P-l -

.Wli wts w~ ~_, J~ r~' .:ro ~t... ~ JilJI .l:ali:J ~ rLA:Jl u-ll y.ll~ 'J_, .;~1 "~l ~ ~ ~ 0 i Jihll r:W . ~\ill ~\!WI ~ ~ ~ ~~

-52-

CaseS:
Child 5 years old with NE oncei evecy 3-4 days.
R / No mcdical1reatment is required and follow up.

Case9:
6 years - old Child with NE every night and some time in day
time.

Rl- Tofraail

25 mg tab.
jf.J. 0~ ~ \...4 c.J~J.J

. ~ ~ t.! U! OF..J.W~i
Rl UripaD

~ ~_j c)! Jl~_,

5pp

N.B:
No fixed prescnptlon for NE. but should be
individualized according to severity, age, response and patient
compliance.

Case 10:
8 years old Child with NE every night and frequency in day
time.

Rf Minirin

1 mg tablets

Case 11:
A child 2 years old with Oxyuris infestations , anal itching.
-53-

R/ t\lzental or Antiver susp. 20ml

L..~F~I ~

...l.fo _,
~:!) b.

,l~t....... S..l:..\,

slw.J
~

4.c.p. s~l

41~!1
-~'1 ~~-.
-~'I
~

~WI

4.!\.l:.jll _, _j\.JQ':/1

~_,11 ~ ~ .;~1 ~':ll .l))l

' ...
u--

u.ai

JS ~~

4:!$ _,1 ~~ ~ tA~_, ~~ J,...c.

Case 12:
A child 4 years-old with Ascaris and Oxyuris infestations.
Rl Bendax susp.
r4l ~ s.l.41 ~ t.......

ril4 r""l 0

Case 13:
A child 6 years-old with urinary Bilharzia! infestations.
terminal haematuria, dysuria..
Rl Distocide or Biltracide tablets

Case 14:
A child 11 years-old with intestinal Bilharzia! infestations.
Chronic dysentery,melena,pa/lor,live in Delta area.
R/ Distocide or Biltracide tablets

rl:!l

-54-

~ s.l.J

Y..>.! o.l:lo.\, 4.c... '-""'.) 3

Chapter four
~

Management of Healthy Child

1- VACCINATION
Active immunization:
In Egypt, Ministry of health (MOH) approved free
vaccines for all children
Time
During 1st month
At 2 months

At 4 months

At 6 months

At 12 month
At 18 months

Vaccines
BCG.
Oral polio vaccine
Hepatitis B vaccine
Oral polio vaccine
DPT vaccine
Hepatitis B vaccine
Oral polio vaccine
DPT vaccine
Hepatitis B vaccine
Oral polio vaccine
DPTvaccine
MMR
Poliomyelitis vaccine
DPT

N.B.: (1) The injection form of poliomyelitis vaccine (when

available) is given at the age of 2,4 months in addition to oral

polio vaccine.

(1) Vitamin A capsules are given in a dose of IOOOI.U. with 9month vaccines and 2000 I. U at 18 months vaccines.
-55-

(2) OPT+ Hepatitis B vaccine (sometimes) available as single

injection.
(3) Booster doses of oral poliomyelitis every year as national
program (for eradication of poliomyelitis).
(4) Booster doses of BCG, meningitis and DT, are given at
school entry (primary and preparatory)
N.D. DPT vaccine is contraindicated at school age and in cases
with history of convulsions or encephalopathy.
~~l...G.. IS i &!,a_b..
__j r.F~ Uo"
"'~ ~ DT r.F~ r:--
6-t.-:n ~- ~ ~ ~.r

t .'=r""'-:n' r:--t.-:tl u-a

, _
..- n .)~"~!"
1.- n.
&

Optional vaccines.
Vaccines
Haemophilus
influenza
type b vaccine
Influenza
vaccine
Hepatitis A
vaccines
Chickenpox
vaccine
Pneumococca
1 vaccine

Time

Tradename

At 2,4,5,18 months
ACT-lllB
* From 6-12 month 2 doses with 1
Vaxem-Hib
month a part, booster at 18 mo
Hibrix
From 1-5 years, single dose
Single dose
From 6 mo and above,
Influvac, fluarix
2 doses with 2 month apart
then once every year
After 2nd birthday
Havrix 720,
2 injection with 6 months apart
A vaxim
After 151 birth day, single injection
Varilrix vaccine
or 2 injection with 2 month apart
if above 12 years old
After age of2 years, for high-risk
Pneumo23
children e.g. sickle cell dis.,
vaccine
nephrotic syndrome

-56-

Acellular pertuSsis vaccine (DTaP): approved for use

when available to start or complete the vaccination to replace
DPT (has less reaction and complication).
General considerations and information:

a- The main adverse reaction to DPT is local reaction including

pain, redness and swelling. Systemic side effects include
fever greater than 39 C, irritability, anaphylactic reaction,
persistent crying or seizure may occur. The pertussis vaccine
.is the responsible for these side effects.
b- Paracetamol oral should be given 2 hourS before and every 6
hours at DPT vaccines.
c- Severe reactions would contraindicate further vaccination with
DPT e.g. encephalopathy, fever> 40.5 oc without obvious cause
d- Mild Reaction indicates a good immune system and valid vaccine.
e- Mild Rhinitis or cough is not a contra indication . for
vaccination.
f- DPT is contraindicated in uncontrolled or recent epilepsy and
encephopathy.
g- Combinations of multiple vaccines in unvaccinated child is
useful e.g. DPT, poliomyelitis, HB & MMR.
h- HB vaccine and HB immunoglobulin should be given
immediately after delivery in different sites to newborn of
HB seropositive mother.
-57-

II- NUTRITION
- Breast milk is the milestone of nutrition in the first year of
life, and sufficient alone for about 4 months.
_ Sometimes and due to maternal or socio-ecomomic causes
artificial feeding is used to replace or complement breastfeeding.
_ If formula milk is indicated the mother could use humanized
milk available in the markets or modified cows or buffalo
milk.

* Formula for healthy infant 1 to 6 months (starting formula}

- S-26 gold

- Similac

- Bebelac- 1 or EC

- Aptamil-1

- Humilac-1

- Dialac M

- NAN 1

- Infalac.

- Biomil-1

-Hero baby

*Formula for healthy infant "follow-on" from 6-12 months

-NAN
- Aptamil
- Bebelac
- Promil

2
2
2

~ ~ ~l.G ~ 60 ~

~ ~~l.G~60~ J~ 1

-58-

J\.:1-a 2

* Formula for preterm infants( less than 1800 gm)

- Bebelac pr~mature

-NAN premature

- s-26 RTF

* Formula for children during gastroenteritis.

(Lactose free milk) Lactase is replaced by sucrose
S-26LF
}
Isomil milk.

~ ~ fi-lA~ 60 ~ J~ 1

BebelacFL }
~~~La~ 60 ~ J~2
Dialac LF

* Formula for healthy infant after 12 months.

-Progress Gold

-Gain

-Nido

- Whole cow's milk

* Formula for children with chronic regurgetaion.

* Bebelac AR
* S-26AR
: c,r'I.J-44-JI .;i 'i..AJI G\llll
l~ ~., u.!WI ~I_,.JI_, u4J~I LJ-4 ~WI ~_,11 ~~ ~_,
:~~~ ~...;l=JI ~ ~1~1 ~..J .4..9JY'-" .J.l~ W..O ~jU.,. r:_;IS.

~ ~ , _,..u.....ll ~I tA ~tA )~ ~ ti;!~ 15-10 o.l.J ~I ~

~ (~...~_,11) ~I t.Y ~ ~1_, ~WI !)A y.....i 4..9~1 ~ "WI W..O ~U...
: u-~""':IIJ~I .

(c.snA 100 1~

6) ;~
~ 2 .l::ul.i.ll
.< ... n ul..4.1- c.,r'' ..;--
~I

~yull

~I

~~~WI

.fi-~2

"t... ("'-"60

r:.;,J

.fi-~- 2

"t...~O

r:.;,J ("'"" 120

'->'d....JI . ~\:ill

"t...w~

~w~

o~ t..._,~W\

.fi...~

-59-

("'""

60

~~I

.J

J}JI

**Iron and vit D supplement is recommended with cows

milk

~.!>11
o

_iL..o:.'J\ "l.li.ll

~ ~
#

#
_i
~~

.,, ~ ~ ()A t~ .J

i.l:i... .L.
1 :':II
~~~
A

4.!\.lai~~
l.;.

w..~ .ll.l~
o.l.:l.l~ .6...ia.1.J ~
~ ~~ .UL..o:a'1 1
#

#0

. Ji,lJl ~I ~I~ /II

.lSi:ill w;.:J ~~~ ~ ~..., .. ~~ ~l.....o'JI .,liiJI u~
~L..:a'j I "1~1 ~ Ji,\JI
~~'II .. 1~1 ,, . ..bc.j ~ Jj.bll ~ ~

rJsii 0"'

.u ~ <.St ~

~ ~~~. ~I~ ~\...-..

(JA!>cl ~ .Jt ~~ ~ .. ~
~l.....o'jl .. 1~1 .-l..hc:.i Uiy () /'i l ~ ~ ~t...:... _,t Jt._...j
.~I~I~!Jj_,
. y.lc. , ~..'-! , J~

, 4.\,! ~

Jij.JI ~ ~!Jll ~ ~

~I ~ 1) ~1 ~!>J=.S ~ ~~~ ~j ~ ' ~\..J:a '

~~~ ~ ~ .Jt ~~ ~ ~_.>lj
~~ ~ 0 i ~ ' ~I J_,U:i ~\~\ ~ JilJI ~.J I~}
.ys~

~I ~.J ~W..'JI

.U.JU:i

uk

'

~ .l~ u_,..i ~L..o:..)l

.,\.li.ll J~j ~ .. ~1 .le._,.- ~ :U:.~

~I ~6.~
#

JilJI u.w~

~
i ll. t:L
.
.P.ru-va

_, u.i.J <.Si ~~~I

J..... ~ ~6. ~ _y. <.5-lLjll

.Jl+..'JI .. ~1

-60-

_it ;.,"11 ~IL..ill + ~~J

.,__..!I

.a.a_, ..;S-lJ u.- ~ ~ uW:u_, (~ ~ ~) ,.t. ~c):-:!

Jill~~

til-5 ~ ~ i.wl l.i~ c):-:!;~~ fJJ 4-.t:m .ta.}Jll

("':'.,...~) ~ ~ ~ t. JJi ~ ~~ J.I'W

":'H

..._,;. 26-10

Dbii i.Ml ~ u.- ~~c):-:!

J.J'it ~

-1~, ~ ~~l.w 3-2 JS (~l.Q~ ~ ~~., Jil:al\ 4b.

,J~.J

J.4i1l uts tj! Ji11ll ( ~ ~'Jt .,, ),.u ,.\l$!

~>

~~

.~lW.;D ~c):-:!

ui

olS.J -~ 4S},i ~- J.;'l~ o!tia_w..- l.j~j -1./~ ~WaJ

~.}Jll ~

.UJJ ~ us~ ~~., ,J;lll ~twtJ (.)& ~J ~ JiLl~ ~

.~b..J

~1-

o!:!S -~ ~t. -.u !,5 ~-~~J4j -,.'it l.j.fJ ~WaJ

~~

~ -'-"'.JJf-&ll ~ .,1 ~ ~ cwns 4lll.w .>P

~.J

,.WI ""'~ ~ (~_).ioW) ~~ "'='~ Ul~- ~~

~,J ~ J.;i -~(.)MS.-~ -i.. ~ ~ ~ .,1

-~..l.JfA

. ...

-~

f' ~ .ll.so-\ ~ .. s.,;, n ~()A

...

~.,p.lw JWaa. ~ -(~c):-:!) ~ Jli..a

_,1 ~.,p.lw JWaa. tv_,.:._, t.....l.JfA E~ _,1 ~ .~1..4J

~u~

-~~
~ ,1

,t..._,sn .~ :t...L+&ll ~~

_,i Cli:ill ,JJ.-11 :t..~ 4SI,Jin

-~ ~ ~~ ~u...l
.~l.Q.;l\ OA.J

l~

J.Jfli J$

- ~; l.j .fJl\ ~l.Q!J

~.

-61-

~()A

AI ~I ,_1~1

+ ~I.W:a,;

, .~ J_,.:i: ~ I!Sl,j.J ~ ~ lJ~I

~

~I

Jl ~~&-~I

(.)A
~~

Jl .~,a-~ )~1:.3\ ...~ ~ ~~ ~ ~~.J

~~~

(~~.J~~[~

JS:,:i ~ ~~lJ ,oA~ 4.Jll ~~~I u~l ~ ~

:JAa
~~

.J.F.JI.J --~411

~Ua~

~I.A.!.llJ .tpJI~JjAll ~ 4}1l1l!..S!,t.ll &- ~ ~.

~ ~J cwn

u.- ~ ~~..wal

~~4~ 1

...;;-:tl

.,~_,,

'i":/1

~ J'+""" ~ ~ y

t.j

~l.i:ilwl

.~1_, ~b_,ll

1.::

til

UW' ~""'

J_,ill ,ylll ,JWiill.,.

(Ji.bll ~ ~ t4) 4 ~J ~I ~) ~I wtp. *

\

~ .):!ill JfiJI *

wt.-t.....-11_,

-62-

(~~1) ~~

wy_,l:JI *

Chapter Three
1
Respiratory Diseases
(1) Respiratory rate: Assess rate, depth, symmetry and mythm
of respiration.. Respiratozy rate is important for diagnosis of
pneumonia by the presence of fast breath as recommended

by WHO. See the table

Age

NormaiR.R.

1 day - 2 months

Fast breath

_5 0 - 60C/m.

> .60 cycle/minute

2 months- I year 40-SOC/m.

> 50 cycle/minute

> I year

> 40 cycle/minute

30-40C/m.

N.B. Tachypnea without chest disease may be occur in renal

fuilure, heart failure and metabolic acidosis.

(2) Important findings in chest diseases:

1- Bronchopneumonia: Fever, cough

shortness

of breath.

On auscultation. bilateral scattered fine crepitation usually

more on the back occasional monchi with fast breathing

2- Lobar pneumonia.:, Fever, cough shortness of breath. A

collection of signs localized to one lobe (unpaired note on
percussion,

TVF by palpation and on auscultation

bronchial breathing,

t TvR

medium sized crepitation,

with fast breath.

3- Pleural effusion: Fever. cough shortness ofbreath.

movement,

J.. chest

.!. TVF, --1, air entry on the same side of the lesion
-63-

with shift of mediastinum to opposite side. It is important to

exclude pleural effusion,

if it neglected it will lead to

pleuropulmonary fibrosis.and /or bronchopleural fistula

4- Acute bronchitis: It is one of the commonest causes of
cough. It starts as upper respiratory infection followed by
irritative cough. Chest may be free or rhonchi may be heard.
5- Croup,;.

Upper

respiratory

with

brassy

cough.

The

commonest type is acute laryngotracheobronchitis (viral) but

the dangerous type is acute epiglotitis (bacterial). Also,
remember that recurrent croup may be due spasmodic
laryngitis (Allergic).or forigen body

6- Acute

bronchiolitis:

mo-2

years,

severe

R.D,

hyperinfilated chest, bilateral sibilent rhonchi end

inspiratory fine creptiation.
7- Bronchial asthma,;. Recurrent wheezes with prolonged
expiration sibilnt rhonchi usually precipitated by upper
respiratory infection.
(3) Please remember:
Repeated night cough and exercise induced cough may be
mild to mO<ierate bronchial asthma
Cough mainly at bed time and/or when wake up may. be
due to post-nasal dripping as allergic rhinitis and sinusitis
.... Ask about snoring and mouth breath.
- Foreign body aspiration is common in the first 2 years.

-64-

Acute Tonsillitis
\

Case 1:
A child 4 years old (about 16 kg) with acute tonsillitis or
pharyngitis.

Rl Zithrokan 200 mg/susp.

~l:fl 3 o.lAl '*-.J:! o~!J ~ fc)lo 5
Or Magna-biotic or curam 312 mglsusp.
.~1 o.lAl ~t... 8 jc)lo 5
Rl Temporal syrup
.~\ 4.;.1 ~~~ ~~Lr.. 6 /c)lo 5
or/ Babyrelief 12.5 mg supp
~~t...

s I ......:~~.

~
~Jo'"l

.. '

UM~

Case 2:
A child 3 years old with severe acute follicular tonsilitis
temp. 40c, vomiting.

Rl Lincocin 300 mg amp

R I Ketofan or Brufen

syrnp

Or Abimol supp

-65-

Case 3:

' A child 8 years old with severe acute follicular tonsilitis

temp. 40c,vomiting

Rl Augmentin or Megamox 457 mg susp.

~I ;.14l ~I....

Rl Ultrafen 200 mg or Rivo

12 JS ~ 5

tab

Rl Betadine M.wash

Case 4:
A child 3 years old with acute tonsillitis, temp. 40c,
vomiting, anorexia

Rl Flumox 500 mg amp

Rl Flumox 250 mg susp
c:JWI Ja.J ~I ;.lAI ~ts;.l.... 6 JS ~ 5
\

R I Ketofan

syrup

Or Abimol .or Epifenac 12.5 mg supp

-66-

Case 5:
\

A child 2 years old with recurrent adeno-tonsillitis not

ready for tonsillectomy.
R/ Durapen-s Or Lastipen 1.200,000 IU vial
~\.,.g. .;~} ~ ~Lwi3

JS ~ ti:b.l\ ~

OR/ Ospen 400 mg susp.

~

I I -

"~ ~ ~..J

4at1. 1~
. ...
r-:

..c

~.JA r - '

Acute Otitis Media

- It is one of the most common causes of continuous crying.
- O.M.- is common with upper respiratory tract infection,
allergic rhinitis and milk (breast or bottle) aspiration through
Eustachian tube when feeding the baby in supine position
with unsupported head. " Try to learn the use of otoscope"

Case 1:
A child 15 months old (about 11 kg) with Acute O.M.

Rl EMoxClav or Augmentin 457 mg susp

.~i i.141 u~Lw 12 fc)JA 5
Rl Sine-up or Michaelon

syrup

Rl Voltarin 12.5 mg supp

Rl Otocalm ear drops

,.LoG u-i cj.ai!J i~ 4~ ~ ,.tWJI ~) 4.-a-J:~ uJ.>...a 3 ujfJ.S ~ ~
(~1~'1\ ~uAIJ
-67-

Case 2:

'An infant 5 month old (about 5 kg) with Acute O.M.

Rl Cefatriaxone or Oframax

250 mg
~l:l

Rl Cataflam
Rl Afrin

0~ ~Lw.

I ~!>o4 -3 ~'JI ui ~ 2

ear drops

A child 18 months old with Acute O.M.

Rl Bacticlor or Klacid 250 mglsusp.

~t:i ~ iJ.Al ~Lw.l2JS ~ 7.5
;..

R/Catafly

~~

Q.t!Sal drops (ped.)

Case 3:

Rl Maxilase

24 JS

drops

-~t:i 3

Rl Audax

vial

syrup
susp .
~~ ~ ~J;..a3 ~~

-68-

Acute Sinusitis
Mild to moderate fever,headach with mucopurulent nasal
and post-nasal discharge. Mouth breathing is common.

Case 1:
A child 5 years (about 18 kg) with acute sinusitis.

R.l Curam or Klavox 457 mglsusp.

-~41 ~ o.l.41 ~t.w. 12JS ~ 5

Rl Mucosolvin syrup.
Rl Brufen or ketofan syrup

Case 2:A child 10 years old comes with picture of acute sinusitis.

Rl Flumox
Rl Mrin

500

capsule.

nasal drops (ped.)

~t:i 3

Rl Maxilase

syrup

1~~ -3 Ui'll ~ ~ 2

~~ 3 ~ ~

-69-

Cas~

3:
A child 12 years with acute sinusitis.

R./ Suprax or Ximacef 200 mg tab

.,.~t ~ oJ.Al

~t.... 12JS ~J

Rl Brufen or ketofan syrup

R/Maxilase

syrup u~3~~

Nasopharyngitis
The most common infection in children and usually
associated with antibiotic abuse. It is a viral infection mainly.
Mild fever, mucoid nasal discharge, sneezi!Ig, cough, anorexia
with good general condition.

Cases 1:
A child 2 month-old with noisy breathing, sneezing and

mild fever.
Rl Otrivin-baby or Lyse
nasal drops

Rl Tempra or Cetal drops.

Rl Rhinostop

drops

-70-

Cases 2:
\

Infant 13 month-old with watery nasal discharge,

sneezing, cough and mild fever.

R I Sine-up or Noflu syrup

Rffempra

syrup

R I Iliadin

nasal drops (Ped).

f.,m .,gl ~~)I ~ ~ ~41 3 o.lAl ~.J:! u~ 4 u.i'l4 ~
R/ Duracef 250 mg susp
~~ o.lAl ~~ 12 J ~ 5

Case 3:
Child 10 years old with chronic allergic rhinitis (snoring,
mouth breathing, watery nasal disharge)

Rl Claritine

syrup
I,.Lt......G(~lO)~

R/ Rinosin

nasal drops

Rl Maxillase

syrup

R/ Felixonase

spray
~
.t~-: (".1 I,. l.....w .J ~\...a..4
... :!.) .::i <.J-0

-71-

..j4 l..i.a~
0:1-1

.Uta..a

Acute bronchitis
- Common disease in children and sometimes parallel to
nasopharyngitis.
- Mainly cough ,fever and anorexia.
- Chest: free or rhonchi may be heard and x-ray chest
may be normal or mild hilar congestion.
- Post-tussive vomiting is common, sometimes it is the
main complaint.
- Antibiotic is advised in patients less than 2 years.
- A plenty of oral fluids is important as it acts as mucolytics.

Cases 1:
An infant 18 month-old with acute bronchitis:
Rl Hiconcil or Duracef 250 mg syrup
~~

Rl Ambroxol or Mucosolvin

;.w u~t.. 8/ ulLa 5

syrup

R/ Tempra or Brufen

Cases 2:
A child 5 years with acute bronchitis , cough
Rl Sinecod or Paxiladine

syrup (if dry cough)

~....,

~.)4
R! Topl~xil syrup or Pulmonale syrup (when productive
cough).
-72-

ulLa 5

~.J:! ~~ 3 ~ 5
Rl Aironyl or Osipect syrup~ if bronchospasm)
~~3~~

Rl Antibiotics is added when indicated

Acute Laryngitis
- It may

be

isolated laryngitis but more

common A

laryngotracheobroncitis.( croup)
- Common pediatric emergency especially in winter seasons.
- It is mainly viral. It may be

mil~

moderate or severe with

cyanosis.
- Please, don't examine the throat as it may precipitate reflex
spasm of the larynx.
- First aid measures should be given ~fore referral to hospital.
- D.D:Forign.body,

hypertrophied

adenotonsillitis

and

epiglotitis.

Case1:
A child 3 years old with acute laryngitis (croup)
Rl Humdified oxygen (if possible).
Rl Nebulizer
~ .~Lw.% - 1f4 ~.ul.;~l ~..J

4J4 ~l...o ~ 3 + ~..;.It

~~

.~I... !.W.i .l&i ~ ~..J ~~I ~.J

-73-

Rl D~xamethazone or Epidrone

amp.
~l....w

12/ ~ ~ %

If improved continue Home treatment.

Rl Phenadone

syrup.

~.J:! o~ o.b.1J ~ ~ ~.J:! oJ.Al ~JA ~ UJ.ta.J:! o~ ~.J:! t.:a}).. 3/c)l.- 5

Rl E-Moxclav or Coram 312 mg susp

R/Vapozole

R/

stain
. ~~ 4 J~ ~..J ~ ,.l.t .;I 2 c)&- ~

Antipyretics.

Case2:
A child 2 years old with upper respiratory tract infection and
croupy cough
Rl Klacid or Biodroxil 250 mg susp
~\...12

Rl Maxillase
Rl Rhinopront

syrup.
syrup.

Rl Voltarine 12.5 mg supp .

-74-

/c)l- 5

Pneumonia
- The most common lethal chest disease
evaluation and follow up are very important.

good

- Daily revisit in outpatient's clinic for follows up.

- Cough, fever, R.D. and Fast breathing, refusal of
feeding is the common associating symptoms.
- Antibiotics should be calculated on higher limits.

- Refer to hospital if:

1- Respiratory distress score> 6/10.
3- No feeding> 12 hours.

2- Cyanosis.

4- Age less than one year.

5- X-ray is important especially in poor response to

treatment or if you suspect empyema

Case 1:
A child 4 years (about 15 kg) with broncho pneumonia )
mild RD,cough .

Rl Claforan or Cefotax

Yzgm vials.
~lJI7-5

R!Mucosol

oJ.AI ~L.wa 12 1~ trb.

syrup.

R/Farcolin

syrup

Rl Ultrafen 200 or Pyral supp.

~,.tt

~.J.)ll\ ~ ~ ~~l... 6
. t ... ..<. t<~l -:: ...< .tws., t~t
$

vr- ~ ~

!j

JS c.r.-~ UM.J:il

"--=- - . U"~ ~~ ~...J>-n ~

.Jla.wll ~UJf-o ,.~1 fJ&.

-75-

...

Gase 2:
~

A child 3 years

with bronchopneumonia(R D , fever ,

rhonchi, cough, bronchospasm )

R I Augmentin or Magnabiotic 312 mg susp.

~l;i ~ o.l.Al ~~~.w. 8 f ~

--~

Rl Garamycin 40 mg amp.
R/Farcolin

R/Brufen

syrup

syrup

Case 3:
A child 1 years
fever, rhonchi, cough,

with bronchopnetimonia(sever R D ,

bronchospas~ ,unable

R1 I V maintenance fluid.
R1 Nothing per mouth.

Rl Oxygen therapy.
Rl Proper I V antibiotics.

-76-

to suck )

Acute borncbiolitis

'

It is a viral infection (RSV) commonly occumng after

rhinitis the common age is 6 months - 2 years.
Mild cases which tolerate oral feeding with mild distress can
be managed at home.

Case:
A child 10 months with mild to moderate bronchiolitis (wheezy
chest, feeding well) .

Rl Nebuliztion by Atrovent or Farcolin solution

4 /~Lt.. % o-Wl JL1 J~' ~ ~ ~ ~ 2 + ~_,sJli ~- Yz

~J:!~~
Rl Ambroxal

drops
syrup.

Rl Phenadone or Dexaphen

-~~~ 12/

Rl Fortum

~ 3

250 mg vails

f'l:!' 7-5 o-Wl ~~ 12 JS ~ trb.

N.D. Good hydration and humidified air are very important.
- Re-evaluate after 24 hours: if improving continue treatment.
-Poor oral intake ,irritability (bad sings)

-77-

~refer

to hospital.

Bronchial Asthma
- ~Can be diagnosed at any age but common after 2 years of age.
- It has an allergic aetiology which may be environmental,
dietary or familial.
- Inspite of the dramatic response to steroids try to delay and to
limit its use as can as possible. { Steroids Inhalers is the most
effective anti inflammatory and and less side effects}
- Combinations of bronchiodilators from different groups is
indicated.
- ~2 agonist orally has weak therapeutic effects in children less
than 18 months.
- Prophylactic treatment is very important in chronic cases.
- Education and explanation of the patient and his/her parents
for the nature of the disease and uses of medications are the job
of the doctor.
- The common precipitating factor in children is upper and
lower respiratory infections.

Main Lines of management:

(1) Treatment:
1-

Mild cases "aminophylline"

n- Moderate cases "aminophylline + B2 agonist"

m- Severe cases "Hospitalization"
tv- Exercise induced asthma.
(2) Prophylaxis: to decrease frequency and severity.

(3) Avoidance of the precipitating factor if possible.

-78-

[1]

Tre~tment

Cases 1:
A child 4 years with acute severe asthma:

Rl Adrenaline S.C. injection:

~ ~..J ~~ ~ ~

1 ~ ~,... 5 ~ Ubll ,:.Lo ~ 4 u~

.~L..a~~~i~

Rl Farcolin by nebulizer
~..J ~L..a ~..) 0~ ~ ~ t:1.e ~ ~ 3 + ~ Yz

Rl Ventolin syrup
_. ~);A

31 ~ 5

Rl Epicophylline syrup
.~~L.....61 ~5

Rl Xilone

syrup.
~1:1 3 o~ o~lJ ~ ~

~4i 5 o~

RlAntibiotics if associated with infection.

If the patient doesn't improve

-79-

refer to hospitaL

~);A 3

1~ 5

Cqses 2:
A child 3 years with mild to moderate acute asthma.
nebulizer

R/ Combivent or Farcolin

.~t.... ~.J o~ _;~I ~.J ~ JJ.6.,4 c)l-a 2 + ~ .Yz

RJ Epicophylline
R/ Bricanyl or Ventolin

6 JS ~

~~l.w

syrup
syrup

Cases 3:
A child 6 years (about 20 kg) with acute severe
astluna and LRT infection.

bronchial

RJ Farcolin by nebulizer
.~ ~ ~l.w ~.J

JS _;~I

~.J ~ ~ u1l.4 3 + u1l.4

Yz

R/ Normal saline 500 ml

~~Lw

RJ Solu-cortif vial
RJ Claforan or Cefotax

8 JS J..g.b.All ~ wJnJ~I ,..- 5

~li::.l.w 8-6 JS

.l.I.JJ

~lS ~

lgm vials.
~l:JI

7-5 o~ ~t....... 12 fJ.;:&. ~

J.Ji..1Y c)WI ~ 4.JWJ ~~II

(c) Exercise induced asthma:

RJ Vento lin inhalation 10 minutes before exercise.
0!>'""t.w
uaJll (,.;!iO
t.~

-~1

"'

Or Theophylline or Epicophylline syrup (young children).

-~~~~Jij~5
-80-

Inhaled Bronchodilator by spacer (Airochamper)

-81-

[2] Prophylaxis
A child 5 years with chronic bronchial asthma.
: c):!

w ~I __,1 .b.)j

Rl Zaditen or Zylofen or AllerBan

~~\ ~

syrup

. ~ 3 oJ.Al ~Lw 12 f~ 3
{ zaditen drops, one drop/kg /12 hour}
Or I Quibron SR or theo- SR tab (300 mg)
.~ oJaJ ~Lw

12

I wa.;! Yz

Or I Serevent or Salmeterol inhalar " Long acting B2

agonist".
~~_, ~ ~4c y._, spacer~~~~ JUb\11 ~ ~.J i~t........_, 6.~ ~ 2

. 1!1 'I ~ ~~t:..Jl

(.)-" Uo"-"'U ~.J
.

'-'~~";/\

t.s..
w

I . '''.~ <I...J
~ ~

u ~6,:11
. . .~ ~
. ~

. ~)l ~ ~' J.,-.ij

t"l~ ~ ~~ ~

;si

Or Becotide, Or Flexotide 50 mg inhaler

Or Symbicort , Pulmicort turbohaler

4..:~'1\ ~ '"' ~~ 1~\.ww,j la.~ ~

Or/ Singular or Montikal or kokast 5 mg tab .

. ,.L...ow

JS o.b.!J ~ wa)

Immunostimulant:
By non specific mechanism
R1 Bronchovaxome caps. Pediat
~ 3 oJ.Al ~ __, ~ JS

t"l:!i 10 ;.141
-82-

ta.~ ,.L.a ~ ~ ~~

Or Flexotide Diskus or Pulmocort inhalers

~ ~ ~ .;Lpll ~~\ ~.

l.:.Lt... 12 I

l.AJJHi ~ ~~\ .l:.i....!.

~,.ul\

Re-evaluation of the patient is very important to continue

with the same medication if response is good or ~o change or
add another one according to response.

Whooping Cough (Pertussis)

It is rare in Egypt due to awareness of the parents and full
vaccination by DPT vaccine.
Subclinical and sporadic cases can be diagnosed even in full
vaccinated patients.
All ages including neonates (pertussis antibodies don't
the placenta) are liable for infection.

** Macroleds are the specific antibiotics.

Rl Erythrocin for 10 days.
Or .Zithromax for 6 days.
Or Klaccid for 6 days.
Antitussive:
~

Selgon drops or suppositories.

Or Sinecod syrup or drops.

-83-

eros~

Tuberculosis
It is one of the common endemic diseases in Egypt. It is

one of a differential diagnosis of many chronic infections as

chronic chest infection, chronic diarrhea ..... etc.
When you suspect T.B. ?
T.B. should be suspected in the following situations:
1- Chronic cough not allergic in origin with poor response to
antibiotics especially if history of contact is present
and/or history of loss of weight, anorexia, night sweating
and fever pallor.
2- Chronic diarrhea with loss of weight, doughy abdomen
~I

J,iA or in rare cases palpable small masses on

abdominal examination.
3- Lymphadenopathy with firm, discrete and non-tender
L.N. but later on may be matted.

Softening of L.N.

occurs in chronic cases > 6 months with sinus formation.

On suspicion you should do:
1- Tuberculin test (highly positive).
2- The identification of acid-fast bacilli (in a smear of the
sputum, gastric lavage, ascetic fluid, CSF is the most
diagnostic.

-84-

3- L.N. biopsy with histopathological examination.

4- Radiological study
5-PCR.

6-ESR
7- Accelerated B.C. G.

8- CBC
Treatment regimens:
(1) Single drug therapy (prophylaxis): I.N.H. is used in
children with contact to infectious cases. It is used for 6-12
months.
(2)

Multiple drug therapy:

a- Pulmonary T.B. and T.B. enteritis:

Regimen of 6 months treatment with I.N .H. and
Rifampcin with adding pyrazinamide or streptomycin in
the first 2 months. You could use daily therapy all over
the 6 months or for only two months then continue by
twice weekly dose.
b- Other extrapulmonary T.B.
As bone, joint, L.N., C.N.S. and miliary T.B. for 9-12
months regimen is used by the same drugs and the
same method of administration as pulmonary T.B.
c- Resistant cases:

-85-

May be a primary resistance or secondary due to

inadequate doses, duration of the regimen or poor
compliance of the patient. Four-drug regimen is used.
. (3) Steroid therapy:

in T.B. meningitis, miliary T.B., T.B .

pericardia! and pleural effusion.

Cases 1:
A child 2 years old (9 kg) with pulmonary T.B.
Rl Rimactan or Rifadin syrup (100 mg/5 ml).
~..>-' ~ 7.5 - ~ ~ o.l.AIJ .;Ud-11

J..:ai b.~ (~ 5)

~~

.~i 6 o.1.4l ~~i

R1 Isocid or Inhibex tab (100 mg)

oe.l.AJ

~.-\. ~.)-4 J.a..)l ~ ~!J,!t 2 rJ ~ o.l.AJ ~.J:! J-1..)\ c)&- ~.;i

~tL-a.

Rl Tebrazid 500 mg tab.

~ ._p.T ~ ~~ \F~I ~J.6 ~.;i ~ ~ 1.1.41 ~.J:~ ~.;i ~

Rl Epicozyme or Multisanostol syrp

Cases 2:
A child 2 years old (9 kg) with anorexi~,mild pallor, ..
recuiTet chest infection not responding well to common
. antibiotics. No defmet diagnosis, ESR raised.

-86-

You suspect T.B.

Rl anti tuberculous drugs trial for 15 days

Then re-evaluate

Cases 3
A child 10 years (20 kg) with miliary T.B. or T.B
meningitis
Rl Streptomycin 1 gm vials

._;a.T ~ o~ ~~~ ~JA ~ -~ o~ ~J:! ~ tib.ll Yz

Or/ Tebrazid 500 mg tab .

.;a,T ~ o~ ~~~ ~JA ~.) 2 ~ . ~ o~ ~J:! ~.)

R/Rimactane syrup (100 mg/5 ml)
~ o~ ~-*'"'I ~.)4 ~ u-a~ o~ ~J:f 6.~ ( ~ 15) ~ ~~ 3
.~i

Rl Isocid forte

200 mg tab.

-~ 0~ ~-*"""' ~.)4 J:t;ll ~ ~.)2 ~ ~ 0~ J:t;ll ~ ~J:f ~.)

Rl Hostacortine- H Tab (5 mg)
-~1

t,SJ.A

~ ~..)~ l...iiJ:! ~ ~ 0~ ~J:! ~J>.e 3 ~.) 2

R1 Epicozyme or Multisanostol syrp

-87-

Gastrointerology
Constipation
Constipation refers to a state in which the stools are hard,
infrequent and difficult to pass. Passage of hard stool even
twice/day is considered constipation.
N.B. In chronic constipation you should exclude congenital
megacolon and local lesions as anal fissure and in acute cases
you should ask about persistent vomiting to exclude intestinal
obstruction.

: ~'11 ~"lb.~ t.~ c:l~

-t~ .J JW~I ~ ~~.J J.i~l &- ft'tl
t~IJ ~~~ ~~ ..)~~~

-1

J.SJ ~~!J 4..S)jill J.Si u-- .J\jS'tl -2

.Jt:i:i.)il\.j

.,P.-~1.all.j

-~~ JS'il ~ u..,s:;.J ~~ ~ -~ ~~ ~!J.oa ~ ~ J~

~WI ~ ~.t 30 . 15 U:H C.J~

-3

oJ..a ~~I~ ~ (Jol~ -4

-~

Case 1:
An infant 6 months old with functional (not organic)

constipation.
Rf Glycerin

Ped. Supp.
. ~)\ &i ~ ~.J.)lll ~ ~~ (Jol~

-~' ~ J~ 'l

c.ia ~~ (.JM~ ~1~1 &- .J~'tl ~

-88-

Cases 2:
An infant 16 months-old with chronic constipation.

RJ Lactti.lose or Sedolac syrup

.~f ;i.i..J p.l....w

JS ~ 10

or/ Picolax drops

~
~
A&t) . j
~ lJ:! ():!-1..>4 r
r.r

J:ii.jiO

RJ Kiddi or Multisanostol syrp

~-..9:~..>4~~
~ u4JI J!.Hll ~..;i:il ~.;.J. trh ~ ~ J:.W. ~1

.l-H-J

A.Jb ~

~L..JI ~~4 ~

Gastroesophageal Reflux
Gastro-esophageal reflux should be considered in case of
persistent regurgitation or vomiting in newborn or infant. Other
causes of neonatal vomiting either medical or surgical should be
excluded especially congenital pyloric stenosis, septicaemia.
N.B. If the infant is overweight or at the upper limit of normal
for his age, the vomiting is mostly caused by overfeeding
Regurgitation range from effortless spitting to forceful
vomiting due to weak cardiac sphincter, usually improved
spontaneously with age.

-89-

Aspiration pneumonia ,chest wheezes and failure to

thrive may be due to GER.

Case 1:
Child 6 wks old with persistent vomiting not responding
to antiemetics and doesnt gain weight .

.GER

To exclude congenital pyloric stenosos

Case 2:
Two month old well baby with frequent vomiting after
feeding. He is bottle feeder and he gain weight( 4 kg).
\

R/ Primpran

drops
.~L... ~~Wa-tt
t.~

!J"' f.i:"

i.w
ul!!>" 4-3
- lJ:!

&11 c.r
. -.i JW 5
r-

OR Motilium syrup
.~L..w.~~Wa)l~ u!JA3~~2

Rl Zantac tab 150 mg

-90-

,,

...,. C'"

w~_)l

~. ~

..l..le

u """'-' ~
~ ~

;;-l\.W ~

JS

:~\..\~~
~b. I.,, yi 4.,jlJ:. .
. "a-'

~ ~_)\

f'

~-

.~~)\ ..lJy Ji,l:JI ( ~.fo) ~

r-!Jil' ~ ufo:i ~ ~)\ -.)} ~..-" ~~ 3-2 ~~l

.(F' 10- 5)

-4..J-l

30

..)~1

e;i..J C'" ~.)c. Ji,l:JI f'~

.~_,11 ~ ~ ~L..ll ~Yi 0A w=c-~ r-1~1 ~-

Case 3:
Three months old baby with chronic Gastro-esophageal
reflux. He is bottle feeder 4 kg.

Rl Algicab or Epicogel susp

u)>43 ~t.....~~)l ~~2.5

Rl Motilium syrup
Rl Nutrlion AR milk
(~jill~~

U:l) ~ ~ ,.t. ~ 60 ~ ~ 2

Oral Moniliasis (Thrush)

Common in children due to prolonged antibiotic therapy,
malnutrition, immundeficiency, after severe exanthematous
infections and corticosteroid inhalation in asthmatic patients.

Case 1:
Infant 2 weeks old with oral thrush.

Rl Fungistatin

drops 100,000 U/ml.

-91-

.~~;1 ~ ~4i 5 &.141 ~~~..... 6 1~l.f.o

ut.....lll ~ ~ iJ~ ~J..

Or/ Micoban or Daktarin oral gel.

f14J 7-5 &.141 ~~Lw 6/ ()I....Jl\ c)&-~ Yz

.~ ~W:a"
- -
~

L~ ~ ~
. ...i ~ u-....
.m ...n \alai
f'
&

1SJ.-ll ~ ~~ f"llt

..<..

y.-..,

t..b. E~ -

. N.B .Micoban gel contains lidocaine as analgesic.

- In severe cases not responding to treatments .for more than 10
days, you should suspect immundeficiency e.g. T-cell
deficiency. In these cases, systemic antifungal is used.

Cases 2:
A child 3 years old with sever oral monilasis not
responding to local treatments.(? immundefficency )
Rl Diflucan (5 mglml) syrup.

J.S ~IJ ~ & ff+A 6 : .tiw ~ oJ'lJ!' ~

,.~ 15- 10 &.141 ~ Jl ~ ,.~ JS o.AlJ ~ ~ ff+A
~L.w 24 JS ~IJ ~ ~ f"'+A 12-6: ~<).A ._HS{ Jl.il:a'/1-

3~ fl~
~J

J.JI

~L..... 24

~'il ~~':II ~ E~'

Rl Multi vitamins syrup

H_e_r.:...p_eti_c_S_t_o_m_a_ti_ti_s_ _ _ ____.~I

L..-_ _ _ _ _

High grade fever, severe anorexia, drooling and painful

ulcerations of the tongue and oral mucosa . It is a self limiting
disease.'

-92-

Case 1:
A child 3 years old with herpetic gingivostomatitis.
RJ Brufen or ketofan syrup .
. ~~L-....6 /~5

RJ B.B.C. Spray
~--'= ~.lJA 4-3 ~L.... ~~ JS~I ~ rill~~
Or Oracure
oral gel
.J.il.!.l ~ JS~I J:! ~J:! ~~ 3 wi...Jll c)&- ~ 1f4
RJ Totavit or Top-vit
syrup.
~J:! ~~ 3

V::W ~

Case 2:
A child 2 year old with severe herpetic gingivostomatitis,
high grade fever anorexia.

RJ Zovirax

syrup (200 mg/5 ml)

~l:!i ~ o.l.4.1 ~--'= ~~ 4 1~ 5

RJ Voltaren or Dolphin 12.5 mg supp.

RJB.B.C.

Spray

~L.... ~~ JS~I ~ ~J:! ~~ 4-3riU ~

If there is secondary bacterial infection
Rl Antibiotics
added.
N.B: Severe cases inay need I.V. fluids or Ryle feeding.
:~'II i~:.~ ~~

-93-

.(~ .Ji J~.) u~

.Jf

.t.i.it...., u~ ~~ ~lk-l
.~!J o4Jl:JI

f'J&.

-I

J.i!J.wll DA ..;~'/1 -2

.~L.a.;ll ~ ~.J

y.JSll

f'l~l -3

Recurrent abdominal pain

Most of children with recurrent abdominal pain have no
organic cause & idiopathic abdominal pain is common in children.
How to proceed in the management of abdominal pain? .
1- Think about mal-digestion and dyspepsia (commonly related
to meals, with eructations, flatulence and abdominal
distension + constipation).
2- Think about parasitic infestation (history of passage of
parasites in stool, poor weight gain, pitriasis alba on the
cheek) and confirm by stool analysis. Remember that
giardiasis is a very common cause of abdominal pain and
maldigestion.
3- Exclude Renal colic.
4- Exclude surgical cause. e.g. chronic intestinal opstruction.

5- If the previous possibilities were negative . . . . Think about

abdominal epilepsy if the abdominal pain was severe, comes
in attacks, not responding to antispasmodics especially if
there was a family history of epilepsy or febrile convulsions.
E.E.G. could confirm (Please remember that E.E.G. could be
normal in a well known epileptic patient and could be
abnormal in 5-8% of normal population).

-94-

6- If it comes in attacks and associate<\ with headache ....

Think about migraine especially if family history of

migraine is present.
7- If no cause is present . . . . Idiopathic abdominal pau is

diagnosed and symptomatic treatment is only used.

8- Urine, stool analysis and abdominal sonar are routine
investgations.

Case:
A child 5 years old with recurrent idiopathic abdominal pain.
-~,Jjln ~

Rl Viscralgine syrup
Rl Digestin or postine syrup

.JS'il

ul1.. 5

.la.i ~!>" 3 1~ 5

POOR APPETITE
Poor appetite is a very common problem in children
beyond 2 years old. The problem leads to marked psychological
troubles to parents and this conflects on children by punchiment
and agression which leads to more refusal of food, regurgition,
vomiting and abnormal behavior. Sometimes, the parents
exaggerates the problem and measures the amount of food by
their own measures not by the standard measures. Simply, th<t
doctor should weigh the child and detailed history .The assurance
is very important. Vitamins and appetizers is a medical trial.

Case 1:
A child 4 year old with poor appetite, his weight is 13 kg.
Rl Tres-orix
syrup.
-~ i.ul ~J:! ~,.>e ~ ~

Rl Totavit or Top-vit

syrup .
-95-

-~.J:! ~~ 3 ~ ~

Rl Acti- 5

syrup
~.J:! ~.)A ~ ~

. l.JWI ~ t.sA ~l.t.hll JJI.l:i c) J.i.b,ll ~ l:ai...all ~~ ~'JI ~

Case 2:
A 2 years old child with poor appetite and his weight is 12

~kg.

Rl The weight is within normal only assurance of the mother.

y'JI _h.al ~.; ()4 ~,JS .l::!li ,_\:Sj'JI Jl.ih'JI ~ JS'JI c) ~.)\ ~$.. ~14.):i
cJ~.J:! I~ JS .J ylia.llJ ,.~'il ~IJ.i.:i..wl .J JS'JI

()4

U!:S ~ J.Jw ,_)t;. ~'11

.J

~ a.,p~l

Case .1:
A child 4 year old with poor appetite, anaemic.

Rl Multi vitamins syrup

Rl Ferose syrup

Diarrhea
It is a very conimon problem especially in summer
seasons. It has a wide clinical presentations range from simple
diarrhea to severe dehydration and even death. It has a different
aetiologies but Rotavirus is still the commonest. The following
table shows the most common etiqlogies of diarrhea:
-96-

Common causes of acute diarrhea in childhoqd

- Viral enteritis (e.g., rotavirus in children < 2 yr)
- Bacterial enteritis
Staphylococcus,Salmonella, Shigella, E. coli, Yersinia)
- Parasitic enteritis (amebiasis, giardiasis, cryptosporidiosis)
- Extraintestinal infection (e.g., otitis media, urinary tract
infection, sepsis)
How to proceed in the evaluation of a case of diarrhea?
1- Ask about frequency and consistency to evaluate the degree
of severity. Mild (<6 times/day liquid), moderate (6-12/day
liquid or 1-3 watery) and severe (> 12/d liquid or > 3/day
watery).
2- Ask about the presence of mucous or blood in stools.
Mucous only:_could occur with .many organisms and it is rtot
considered dysentery.
Blood + mucous: dysentery either bacillary (fever + high
frequency of stool and less tensmus + abdomial distension) or
amebic (Low frequency with severe tensemus and no fever and
no abdominal distension).
Bacillary dysentery is commonly caused by shigllosis,
enterinvasive E.coli and to less extent salmenellosis.

-97-

Amebic dy~entry is commonly caused by entaemba histolytica

and giardiasis

3- Ask about feeding and if the diarrhea is related to change of

food, introduction of new type of food or specifically recurs
with one type of food (food allergy).
4- Ask about the characters of stool color, offensive odour (fat
maldigestion, infections) and the presence of undigested food
or milk.

5- Ask about vomiting and if it is persistent or not.

6- Ask about the relation . of motion with feeding as m

exaggerated gastro-colic reflex, motion occurs directly after

feeding.

7- Try to suspect secretory diarrhea when severe watery

diarrhea occurs inspite of no oral intake.
8- Try to suspect lactose intolerance :

It is common in malnourished babies and in chronic

diarrhea

Watery diarrhea, abdominal distension and pain with

flatus and stool pH is< 6 (acidic).

-98-

9- Don't forget to search about parentral infecti<?n (otitis

' chest
media, tonsillitis, urinary tract infection or
infection).
10- Don't forget in cases of persistent vomiting (especially if

without diarrhea) you should exclude upper respiratory T.

infection, meningitis and renal failure.
11- Don't forget that dehydration is important cause of

fever.
12- Detect the degree of dehydration:

Mild degree: thirst and irritability.

Moderate degree: thirst + signs of dehydration (sunken

fontanelle, sunken eyes, dry tongue & loss of skin
turgor).

Severe degree: shock or anuna m addition to the

previous signs.

13 - Detect the type of dehydration in relation to sodium level:

Isonatremic: The tongue is dry to the same extent

of the lost skin turgor.

Hypematremic: marked irritability with very dry and

parched tongue and no or minimal lossof skin tutgor.

Hypona.trenpc: common in malnutrition, moist tongue

with marlced loss of skin turgor and lethargic baby.

Main lines of treabnent

(1) Rehydration:
a) Oral rehydration by cup and spoon:
- Rehydran or Rehydro-zinc

.,t u~ 4Ja.. ~ y.JS -.J.a)

t:t.n ~

- ~
u-o

4.J'S;. ~ -.1.. t- 200 ~ ~

d ,, 5-J ~
. t< 4ial.. (
.< ~b,
cr..J#'-14 ~ V.d<
~..,..
.u ,.(j<'I.O

.Jlt.-1 b.- JS ~ ~ 50

.,gl

b) Nasogastric (Ryle} feeding:

Rehydran is used by the tube in a dose of 120 mJ/kg.

WJl1

.f.St.J\

J.p..1l ~ ~ ,W.m

J$.

J.a..

Indications:
1- Failme ofORS by cup and spoon.
2- Repeated vomiting.

3-Severe anorexia.

4-Severe dehydration and 1 V. is not available.

c) Intravenous Rehydration:
1- Shocked or comatosed patient

2- Severe dehydration.
3- Anuria

4- Failme of ORS by cup and spoon and by nasogastric tube.

-100-

---------------------------------

5- Acute gastric dilatation and paralytic ilel.J.S

l

** Shock therapy withen 6 hours

A~e

30

mllk2

70

mlfk2

1-12 month

First hour

Over next 5 hours

> 12 month

First half hour

Over next 2-5 hours

- Type offluids:Normal saline or Ringer's at the start then

***

Maintenance therapy: mixture of glucose and Saline or

pedimaint or Normal saline.

- Upto IOkg

120 ml /kg /day

- 10 to 20 kg

ISO ml/ kg/day

{2) Medications:
a) Antibiotics:
Antibiotics shouldn't be used routinely in diarrhea as
acute diarrhea in infants and children is commonly viral and selflimiting. Abuse of antibiotics may lead to side . effects, poor
absorption or emerging of resistant strains of organisms and
economically load.

-101-

* Indications of antmicrobial in diarrhea:

1- Immunocompromi~ed patients as newborn, malnourished and
those

with

malignancy

and

on

those

steroid

or

immunosuppressive therapy.
2- Parenteral diarrhea.
3- Specific irifections:
(a) Amebiasis: Flagyl, Amrizole or Elyzol syrup or tablet (50
mg/kg/day for 10 days).
(b) Giardiasis: as amebiasis but the dose is 30 mg/kg/day for

5_days.
(c) Shigellosis
mglkg/day
parentral)

and

Salmonellosis:

parentral)
or

Ampicillin

Amoxicillin

sulpham.ethoxazole

(50
50

(1 00

mglk:g/day

mglkg/day +

trimethoprim 10 mg/kg/day.
(d) Cholera: 3 days treatment by tetracycline (50 mg/kg/day).
b) Antipyretics: (see chapter of antipyretics).

c) Antiemetics: they have limited rule but practically they are

used.

Example:
Rl Plasil or Meclopram drops.
.~t... ~ ~Jl Jri ~..H ~~ 43
Rl Primepran, Plasil

injection

102-

& I~

Rl Cortigen B6

ped. Ampoules.

.~Jjll\ ~ (J,:iiu <J-4 .;PI

Jihll ~

~J .~ ~ ~ ~ 1f2

Rl Motinorm or Gastromotil syrup

-~~ ~ JS\;1 J:! ~J.>A 3 ~ .u..t..a
Rl Motinorm or Motilium supp. 10, 30 mg
. WJJll ~ ~.J.)lll ~

u!J..a ~ c,r.y!a u-u,Hl

d) Anti-motility drugs: Should not be used as it may lead to

paralytic .ileus.
e) Non.;specific Antidiarrheal Drugs:

Examples:
- Diax, Kapect , Smecta

syrup.
~.J:!

Sme~

u!J..a 4-3 f ~ 5

Cholestran or Lacteol forte

Sackets
-~~},..3t.~%~~ Yz .

(3) Feeding:
1- Breast milk should be continued.
. 'JA.....

2- Cow's milk and humanized milk should be continued either

by full strength or better half strength formula.
3- Lactose free milk: because of lactose intolerance for 2-3
weeks (Isomil, Dialac LF, Bebelac FL & Nutrilon Lf.) then
shift to humanized milk
4- Formula foods: as Riri special formula, Milupa special
formula, Bebelac carrots.

S- Other foods: as apple and apple juice, gtittVa and guava juice,

Lemon syrup.
-103-

Frist line of inve~tigations:

Stool analysis.

Urin analysis.

Elyctrolyte.

Prophylaxis:

Rota virus vaccine

Cases 1:
An infant 7 months old with vorrutmg 5 times and
diarrhea 10 times/day, liquid, no mucous or blood and no fever.

Rl Primp ran or plasil drops.

,. --- .~~~~'\
t.ai..w ~I!!)A 4liia7

!)" vt"' - lJ:!

Rl Kapect compound or smecta syrup.

-~~~~4-3/ ~5
\

Rl Rehydran or low-hydran

,.J.a Ji

packets

u~t ~ ~ '":~JS

,.c)A) ~ ~- ,.tA

,_ 200 ~ ~

Ji,bll ~ ~ JJli-' 5-3 JS ~ {~ ~ 'iJSlSJS 4~J

-~~~...)All ~I:WJ ~W:a.;.U ~' ~

-104-

Cases 2:
An infant 9 months with acute watery diarrhea > 10 times
/day, vomiting> 5 times/day, fever and pulse is very wealr :.1.d
extremities are cold (sings of severe dehydration).

R I For urgently I.V. fluids to correct shock and further

management.

Cases 3:
A child 18 month old with G.E., diarrhea > 12 times
liquid, with repeated vomiting, some dehydration and fever .

Rl Rehydran or Rehydro-zinc.
,J,A Ji u~ ~ ~ ~

,J.o)

~ ~ ,Lo ~ 200 ~ ~

J,i&l\ ~ ~ Jlt:iJ 5-3

Rl Claforan, or Cefozon 1 gm

JS ~ (~ ~ ~lS.JS ~~j

~ ~l.w 12

JS ~ 1.5 ~ .j ~ 4.5 ~ ~

Rl Bebelac FL or S-26 LF milk.

J~'ll ~ ~ ~j,ll ~

uJ ~~..)

Rl Enteroquine, kapect, compound or Diakam-M

.
-~J:! ~~ 4-3 1~ s
Rl Acetaprofen syr.

Cases 4:
A child 3.5 years with bloody diarrhea, mucous, 10 times
/day with severe tensmus no fever or vomiting.

Rl Amrizole, Flagyl syrup

-lOS-

Rl Septazol, oi' sutrim syrup

~' o.1AI ~L.... 12 f~ 7.5
~J 6-J~ ~_,
u~IJ

J.ilJ..JI

JJL- JSI

u..a J~'ll

Cases 5:
A child 18 month with acute diarrhea, > 10 ti:ines liquid
with blood and mucous, mild tensmus, abdominal distension and
fever 39.5C. "suspect shigellosis"

Rl Am.oxil 250 mg or unictam 375mg vials

. J..4c.

u~Lr.. 8/~ ~

Rl Brufen syrup
.u~L.r.. 6

f~5

Rl Rehydran or Rehydro-zinc.
Stool analysis and culture are advised

Cases 6:
A child 8 month with diarrhea, mild fever, no
vomiting, good appetite

R/ Dia-furyl or Diax or Aqua reem Z

susp.
u~4 ~~

pachets

Rl Lacteol-forte or Semecta

ul>-a 3
-106-

~ 1.4

"::.JS ~.J ~

~~

Cases 7:
A child 8 years with acute severe repeated
vomiting,mild fever, and epigastric pain, no diarrhea,

a.~. ~:er

school meal(?? food poisoning)

Rl I.V. 500 ml Nonnal saline

4JWI ~ ~-.9 ~ ~ JJl,:- ~ 500
R I Primperan
amp
Rl Zantac

amp

Rl Unasyn or Unictam 750 mg

~L..a

12

JS~

~L..a 12-6 ;~ JS~I ?'~ ~

J.!l~ UJ~.J ~ ~J~I

JS ,.~1

Cases.B:
A child 14 month with acute GE, fever, vomiting,not
dehydrated.
Rl Cefatriaxone 0.5 gm
Rl Brufen syrup
.u~t.......6/ ~5

f"WJ w~ ~J
-107-

JJlw.a JSI

Chronic Diarrhea
Diarrhea continuing for more than 4 weeks is considered
chronic .and usually leads to iron & vitamins deficiency,
malnutrition and poor health.

Chronic diarrhea should be investigated:

1- Stool analysis: for evidence of parasites, maldigestion and

pH in lactose intolerance.
2-

Stool culture: its value is low.

3-

Tuberclin test.

4-

Blood picture for evidence of iron or folic acid deficiency

anaemia.

5- Immunoglobulin assay if imunodeficiency is suspected

6-

Lower endoscopy with mucosal biopsy.

Cases 1:
A child 1 years-old with diarrhea for 10 days, after
AGE ,no fever, no vomiting ,good appetite, stool analysis
free.

Rl Bebelac FL or S-26 LF milk.

Jtf....a'J\ ~ Jj.i. jjiS~\ ~ 6f1 ~l.a.;

RJ Zincsulphate

susp.
-108-

R/Frutal

susp.

Cases 2:
A child 2 years-old with chronic diarrhea for 20 days,
no fever, no vomiting, good appetite, stool analysis reveals
giardia.

Rl Flagyllate forte

syrup

R1 Grand vit

susp.

Rl Digestin

susp.

(1) H chronic diarrhea with no specific aetiology , consider

the following imperical trials:

Lactose free milk.

Digestant as digestin or postine syrups.

Iron therapy as it is usually low in chronic diarrhea

Multivitamens.

Non-specific antidiarrheal with low dose antimotility

drugs. e.g.:

Rl Enteroquine or Nifunal susp + 2 cap. Imodium.

-109-

(~l W..... ~ ) u)JA 3 ~ ~ Yz c)a.a.J \~ [.;

(~

w..... Jj!)

u)JA 3 ~ tial.. ~.J

Acute viral Hepatitis

Hepatitis A:
Very common in Egypt
Essentials of diagnosis and typical features:
Gastrointenstinal upset (anorexia, vomiting, diarrhea)

Jaundice.

Liver tenderness and enlargement.

Abnormal liver function tests.
Local epidemicofthe disease.
Anti-HAV IgM elevation.
Hepatitis A transmission by the fecal-oral route from

contaminated food or water supplies is easly diagnosed by

clinical manifestation, but two thirds of the affected individuals
have an anicteric (No jaundice) and unrecognized form of the
disease. Lifelong immunity to HAV follows infection.

Clinical pictures for the overt form:

A- Prodromal stage (2-3 days)
Not feeding well, anorexia, nausea, vomiting, headache
fever and abdominal pain.
B- Icteric stage (2 weeks)

-110-

Dark urine (cocacola color), yellow sclera improvement

of the prodromal symptoms. Tender, enlarged liver.

C- Recovery phase (few months)

Improved clinically within 1-2 month.and Biochemically
within 6-9 months.

D- Laboratory investigations:
-Serum ALT & AST and alkaline phosphatase is elevated.
- Elevated total and direct bilirubin.
- Normal CBC and Reticulocytes.

Recovery is the Role in more than 99% without

treatment, about 1% develop fulminate hepatitis.

Solid immunity is the role.

D.D.: Acute haemolytic crisis

Case 1:
A 3 years- old child with acute viral hepatitis A

Rl Legalon

tab.

Rl A-viton

cap.

srrrP

Rl Neodigestine

Case 2:
A 3 years child with acute viral hepatitis, temp is 38,
deep yellow urine, nausea, vomiting.

Rl Cetal or brufen syrup

Rl Hepaticum

~.).! ~!>- 3 1~ 5

syrup.

Or I Silymarin sackets
R/ Motilium

f.J.)ll\ ~ ~ 5

Yz.'i;...J:! u}).a 3

~l.o ~.JS ~ ~ ~

supp 10 mg
.~L.. ~ JS1t ~ l;...J:! u!J.. 3 ~~ (Joll.j;\l

Rl Becovit syrup

~-':! u!J.. 3 f ~ 5
.u.J.~Jll.J ~Jll

J.JUi u.- ~' UF-*""i _,i ~l oJAI ~ l..At:i ~h

J.JUi ~$., ...S!Jil1.J u~.J (.U.JJ1.o J.;i. ~) u~ JSi u.a .;~'/'

-~ ~ ~..lJ ~ ~ ""J~'/1 . ~ ~.)1 UJ.l ,!JJ. ~~
~ LS.JJalt ~ ~ La~ ~!JJ' u4-a..J4l' ~

Case 3:
A child 4 years old comes with history of sleeping tendancy and
severe anorexia since 2 days .No fever, no vomiting & no
jaundice.......most propably non-icteric hepatitis ...... liver
enzymes are confirmatory.
Rl treatment as before. .

-112-

Malnutrition
It is a chronic complex disorder of infant feeding,
precipitated by severe poverty and ignorance.

The chronic loss of protein or/and energy result in clinical

syndromes which is common in Egypt such as Marasmus,
Kwashiorkor and Marasmic-Kwashiorkor.

The mother complains that her child is under-weight or

not feeding well.

The

2nd

cause for malnutrition is chronic diseases as

chronic gastroenteritis, malabsorption . syndromes and

errors of metabolism.
N.B. Ma.Inutrition leads to poor i.mrllunity

--)>

infections and

gastroenteritis --)> malnutrition.

Low immunity
Malnutrition

gastroenteritis
Poor absorption

- Details of feeding history are important.

Examples of mother mistakes:
.,.La~ 240 ~ .Wi ~ ~ ~- U~!
ln

~ .J U,Jol4l .JI ,. \.al4 ~ ~ <J:Il ~_;1 1/4 4i~l

~wJli

,.u.qtt

,..,

JJ~' ~lal\ J1.Jia ~Uai ~t "'' ,.~! ~ .

...

113-

e,)j.ji

JS_g ~._p.ll)j ~1.9 ~ ~1.9 cJ.l4Jll ()A ~ Ji.b,ll

.~1

~ ~li._g ~ 6

c) ~~ ()A ~Ly ~"'l

u.o u~~ c)

~tJ..>.!ll

.l~.JA ~ ~.l~ &.Jll

.u.a ~ Ojj;.
c}lSll ~I ~ J;.!. ~ ~.li.ll ~ ~ ~~ .1~..9

Kwashiorkor
It is.a clinical syndrome due to deficiency of protein and
sufficient carbohydrates. It occurs at weaning time from 6 mo to
2 years usually associated with new delivery or poverity.It
affects all the body systems including CNS and skin, there is
deficiency of all vitamins, minerals and trace elements.
Gastroenteritis and skin infections are common.

Clinically: The child is oedemataus, apathic with angular

stomatitis, gastroenteritis and severe anorexia in' addition to
growth retardation, hepatomegally and anaemia.

.......

Case 1:
Mild and moderate cases can be managed as
marasmus ( anorexia ,feet edema).

-ll4-

2nd

degree

Case 2:
A child 18 month old with typical picture of kwashiorkor
(Oedema, apathy, severe anorexia diarrhae, fever and skin
lesions)
"Hospital management"
N.B: All feeding, medicines and fluid management should be
given oral first or through hasogastric tube. If failed
parenteral route started (according to severity).
Rl Whole blood transfusion.

_,\ L.3ii ~ f'Jll .)~ ~ 4Jb. ~.J - ~tbll ~ JMaL..J ~ ~ 200 Ji.i
c:W'~ U.O~

Rl Claforan or Ceforan 500 mg viaL

.~Lw

12 I ~..J.J ~ Y2

Rl Trivarol or Tri-B ampoules.

Or Bebi.:.vit drops
Rl A-viton caps.
f'.J4 ~ JS ~

ut...Jn ~ ~ ~

,w'l/.

Rl Magnisum sulphate 50%

-~las..~~~~

Jw/ ~ 5

Or ~om.ag suspension (7.5%).

RJ Zinc sulphate

solution

- .

~'Lt

~.!>'~ 3 ~-,

'
Rl Correction of hypocalcemia and hypoglycaelllia.
-115-

Rl Dietetic management .

' ~ Uo.am csl} ~ ().Ill\ ~~1

Bebelac J\4-"il ~ ~ ~

c)l ~ ~ ~_,.s:i J.!Sfol Ji:! ~ (~La ~ 100 ~ ~ 2) LF

.c)La 30
.

I Jl:!S... U~l ~I

lsomil.~ ~~~__,l

~ oJ:!S __,i ~~ ~ u-w~: ~: u:;i..uJ\ ~ u~_,

()4

Jil=.ll

s:.~l

~ ~ ljl ~ ~-11 ~ ~...9 ~ c) .;WW\...9 ~I

-~1

- ~W:ll ~..9 ~11 ~ ~ ~ ui~i n"U &-

Jil=.ll C~

Marasmus
Marasmus can occur at any age from birth to 3 years. The
full clinical picture and senile face occurs when the infant stop
growing and begins to utilize his own subcutaneous fat then his
muscles. Weighing less than 60% of standard weight. The infant

is hungry, sucks his fingers, usually alert, there is .loss of skin

turgor (but not dehydrated) and subnormal temperature, in
addition to signs of vitamins deficiency.
1st degree

loss of SC fat from the abdomen.

2nd degree

loss of SC fat from the trunk & limbs

3rd degree

loss of SC fat from face in addition to

previaus loss

-116-

Case 1:
A child 1 year-old (6 kg) with 1st degree marasmus
(dietetic) exclusively breast feeding.
Diet:
. ~ ~Ws-t1
-

-~~ u})A 4-2 DA ~-'-"'

~ _g\

!.)"'

_,i

(S.ll:.)

I - ~\
~ ~
.

Jihll ~\a.b!

t!>! ~ Uo-..l;f.A JWI.i. ~

. u~ ~ -~~ .U~ oJ.:S

~ ..)~ ~

Jb. c)

JJ! _,1

UMAJ.A

u~fo.

($

i _,i

_,i ~ -

(,)oil$

. ~_p.lll
-~,Ji:i boa

JS ~ 120 ~~ u1>-o 3-2 ~JLl. c).J ~~J

.~ ul.vW.J ~ u~\.9

Rl Hydroferrin

Jl+..'il &.,. ~~~

~JJ:.~I ~~

drops

.uLR-_,ll ~ Y,..~ ~JA vt.b! Yz

Rl Multisanstol or Halorange

syrups

Or Enfa-vit drops
Rl A-viton cap.

Case 2:
9 month old infant with severe marasmus. 3rd degree.
Rl Hospital management as Kwashiorkor.

-117-

RICI(ETS
One of the commonest diseases in infancy and early
childhood due to vitamin D deficiency during maximum bone
growth (6 months-2 years). It is easy to be diagnosed clinically
and confirmed radiologically (Signs of active rickets are flaring,
fraying and cupping of the epiphysis).
The prevention is by vitamin D supplementation in early
months of life as both breast and cow's milk are deficient in
Vit. D.
The daily

requirem~nts

are 400-600 I.UJday and the

disease may come with a varietry of presentations.

Delayed teething.
Delayed sitting and walking.
Bowing of legs.
Recl.irrent chest infection.
Large sized head.

! Routine Investigations in Resistant rickets:

'

! X- rays limps
! . s~ calcium,phospharus
! 1&25 DHC level

-ll8-

Case 1:

A child 3 month-old came for routine visit and he is not

rachetic.

Rl Vidr op

drops

OR I Pedical

syrup

Case 2:
A 6 month old child with mild richets.
syrup.
Rl Decal B12 or, Vita cal B12

Or/ Cai-D-B12

ampoule

2 boxes

Case 3:
Child 9 month old with advanced rickets

Rl Devarol-s

ampoules.

3amp.
U:F-;.w.-1

JS ~ ~

Rl Hi-Cid or Calci-top syrup

N.B: Vit. D resistant rickets need expert management.

-119-

Case 3:
Child 12 month old with advanced rickets

R/One-Alpha drops.
Rl Hi-Cal or Calci-top syrup

120.

NEONATOLOGY
Neonatal period starts immediately after delivery until the
the age of 4 weeks.

It is a critical period and during ;.

~he

intrauterine and intrapartum events are manifested, also most of

body systems are immature even in full term normal newborn
and so, precautions in use of drugs are important. Many normal
phenomena could be considered as a disease and the
differentiation is important, even many cardiac murmurs are
functional (Innocent).
Care of the newborn in the delivery room

If the newborn is delivered normal with good Apgar

score

only care of the eye, umbilicus and prophylaxis vit.K,

but if the newborn is risky or in need for resuscitation

do it

(see the book of"neonatal procedures" by the same author).

Significant warning symptoms should be learned to the
mother:

1- Poor suckling.

2- Yellowish discoloration of the skin or eyes.

3- Umbilical ooze.
4- White tongue.
5- Rapid or difficult respiration.
6- Fever or hypothermia.
7- Repeated severe vomiting.
8- Bulged anterior fontanelle.
-121-

Symptoms which could be

~onsidered

as a normal neonatal

and

degree

symptoms:

1-

Sneezing,

snonng

mild

of nasal

obstruction.
2-

Straining even during sleep.

3-

Variable bowel habits: the average is 1-2 motions m

artificially fed newborn and 5-6 times in breast fed
newborn.

4-

Inverted sleep rhythm.~

l;tJ;,J .J 1;~ ~U:!

5-

Once or twice vomiting.

6-

Regurgitation , even after each feed

7-

Vaginal discharges: Red stained mucous secretions

,1,._.!Jjl

due to hormonal withdrawal

8-

Painful micturations : common complaint during first

month due to painful bladder contractions . It
improves gradually with time

9-

Transient tachypnea of the newborn:

Mainly in full term neonates. C.S. is a predisposing
factor. No respiratory distress~ just tachypnea. It occurs
in the first 24 hours and may last for 2 days.

-122-

10- Some skin manifestations:

(a) Mongolian spots: bluish, often large patches most
common on the back, buttocks or thighs. It is of no
clinical

significance

and

disappears

spontaneou!lly

without any therapy.

(b) Erythema to xicum: papular or vesicular lesions on an
erythematous base.
(c) Milia:

tiny

yellow

papules

representing

blocked

sebaceous glands usually found on the nose and checks.

Case: (Routine for every newborn)

Newborn delivered with good Apgar score, good Moro

and Sucking reflexes
R/Haemakion or Amri-k 10 mg amp

R!fobrin or Chloramphinicol

eye drops
-~t:~i 4 oJ.AJ l.:.aJ:f ~~ 3 ~ ~
u~

Rl Alchohol or Gentian violet

stain.

u4::i J~ ~J:f ~~ 3 ~ 4......w

Rl Zinc-olive or calm-skin
oint.
~~~ D..a oyl!.Jll' iJhMll
~

-123-

.\.:.AJ:f ~~ 3 ~.J-a wlAJ

Simple Problerlls of the Neonate

1- Oral moniliasis " see chapter of G.LT."

2- Mucopundent Conjunctivitis
R/ Neo-pol or Neo-Myxidin or Tobrin eye drops
.uu.J,WI

u.- ~ ~ ~ ~~~ 5-4 o.lAl ~--':! u);..a 5

(.).!&JI ~ ~

Rl Garamycin or Fucithalmic eye ointment

~ ~ .i,.L..wA b~ U:!&ll ~.)A

3- Infantile Colic

It is a very common complaint in the first 3 months of

age. The colic is commonly severe _at night with flatulence and
abdominal distension otherwise, the baby is good. Other causes
of crying should be excluded as hungry, wet diapers, tight
binders, and severe napkin dermatitis.
Case:

20 days old baby with colicky crying most of night time -ihspite
of good sucking
Rl Babydrink or Babycalm

sachets.

~--':! u);..a ~c)\ UjiJA ~.;S ~ ~ ,.Lt ,-50 ~ <JA:S 1

Rl Spasmotal or babytal
drops
R/ Disflatyl or Baby rest

drops

.4-., u);..a 3 ~ 15-10

-124-

Rl Digestin or Pediacalm ro sweet-baby syrup

. l;AJ:! u );.A 3/~ 5

R /Dentin ox , Grip water syrup

-4J:! u);.A 3-1. u t . 2n5
~...):#d.) .J.?...~:Y ~ J:wt t- .h.ii ~I . i .a!J ~tiS ~@
: ~\A

~w1 ~ ~

41\c_,

,.:.A.b~

y,wJI u~ .Y.F- ~.l':l_,ll ~.l:>. J\i.I:.YI ~

.~lw.a ~\:ill~~ ~ ~..J

..J.fii.JI Jihll ~~ 4?;ii u~YI

lly UJ

wi

'""" 1

Jihll ~ ~ ):,:_ ':l ~

~ u~)l ?.!t;.;; 1 f"';.l ~

-2

. ~l .ll.lji! :U_,.l.\ ~ ~ ~ ~~ <i..e. L...o:..Jl-: ('.fo

u-WI I!JJ.l:>.

J:.li:i ~

.lc.

~ ~ t....;.,)I

.llt.l.J

~ t.d Jihll t"'..foj

_,i y::..;u

,.,

- .)

.~I..HJI C!~-'
.~1 ~ .lS ~ ~ Jihll

r-.fJ

.4.-J"";/~1 ~_, ~~ u..:.l!_, ~!_,:ill Jj,. ~..;:JI ~ f"il ~j ~

\...... ?'Yl

~t.......c.i
~.Jl-1

jl

. _!. -'1
u---

. _!. -'1
L 1 .-:.LJ..~f'Yl "~'
u--u."t-""
__."

.i~ i~ ?+"'

~.l\c.:J ~I
~

"""i

4.lb.J
. I:LII
. U"o"W

j l~~~

1~~u--.. _!. -'l 4.16.

..:.,tic. t...A.. c.s i ~l c.s .l).! ':/_, ~ ..;:F-

-4

-5

-6

,_ '-IL.Jw
. <-.
.
. ~

4- Umbilical Granuloma
Rounded red projection at the base of umbilicus causing
bleeding after the Stump fall down
R1 Silver nitrate 5% or Betadine solution.
l;AJ:! u);.A 3 ~~ ~ ~Ull ~ ~_,. ~

.~U!J ~.!P.- ~. o$-Wil:u.J ~~~

5- Neonatal convulsions

-125-

It is an emergency problem and the baby. should be

admitted in the neonatal intensi~e care unite.

Firstly, consider simple treatable causes as:
1- Hypoglycemia (give 1-2 mllkg glucose 10% LV. and repeat
according to blood sugar),
2- Hypocalcemia (1-2 mllkg calcium gluconate 10% I.V. very
slowly and repeated every 8 hours),
3- Hypomagnesemia (give 1-2 ml./kg magnesium sulfate 10%
LV drip).
4- Meningitis.
5- Birth anoxia (Hypoxic ischemic encephalopathy) , it is a
.common problem.
6- Metabolic diseases.
The aim is to stop fits as early as you can to avoid brain insult.

Case:
A full term newborn 2 days, presented with qm1tifocal
convulsions, change of conscious level with history of difficult
labour and ventonse delivery. His weight is 3.5 kg. ( hypoxic
isch. Incephalopathy or I.C. haemorrhage)

- Oxygen therapy
- I.V. fluids ornasogastric tube feeding.
Suction of secretions.

Rl Valium or Valpam

anip
-126-

Anticonvulsions:
Rl Sominelleta. 40 mg/ml

amp.
.J.il!J 3 ~J.A ~

Loading (10-15 mg/kg)

.lJ.J,J

~lS JJ:,..al

Then, maintenance (3-5 mg/kg/day)

If sominelleta (Phenobarbitone) is not effective add.

R1 Epanutin 250 mg/5 ml amp.

Loading (10-15 mglkg)
~J~

hiiii .jl ~.jl...a j~ ~...9

t:l.a ~ ,_. 20 ~ Ui.i.:! ,_ 1

Then, maintenance (3-6 mg/kg every 12 hours).

~I

vo ,- 1 ~...9 t;l.a ~ ,-. 10 u-l} Ui.i.:! (~0 ) ,-. 1

Rl Decadron (8 mg/2 ml)

.4&.Lr..12/Jll!J 10 ~J.Q ~ JW
ampoule
-~'-- 8 JS ~~ ~,;.& 3

Do C.T. brain or cranial sonar to evaluate the presence of

edema, or hemorrhage ..

-127-

Duration of anticonvulsant therapy: 2 schools

1- For few days after controlt then gradual withdrawal

before discharge from the hospital.

2- For 2 months after control then gradual withdrawal.

N.B. In hypoxic ischemic encephalopathy, you should search

about other systems affection (heart, chest, renal, .....etc).
6- Septicemia and Meningitis
Septicemia in the neonate is the shadow of meningitis
and vice versa.

They symptomized with hypothemiia, poor

suckling, irritability, skin mottling, convulsions, apnea or

cyanosis, fever may occur in mild cases. It is an emergency case
and hospitalization is the rule. Antibiotics should be used
empirically untill culture and sensitivity results are obtained.
CSF examination is mandatory.

Case 1:
A newborn, 20 days-old with poor sucking, poor Moro,
temperature 37C wtih episodes of apnea. His w~ight is 3 kg.
Hospitalize and give him:
Rl Unasyn or Unictam 375 mg

vials .
.UaJI ui4 ~1~1 ~.J ~lw 12/c)l- 1.5 ~..J c)lt 2.5
Rl Fortum 250 mg
vial
.~Lt..

Rl I.V. fluids.
R/Oxygen.
-128-

ui ~

12 JS ~- Yz

Case 2:
A newborn full term, 9 days old with poor sucking,
temperature 38C with episodes of apnea,refuse feeding and
contenouse cry. His weight is 3 kg. Hospitalize and give hin. ,
Rl Claforan or Cefatriaxone or Fortum 250 mg vials .
.~Lw 12/ ,..... 1 ~J ,..... 2ui ~
Rl Unasyn 375 mg vials .
4.:iWI ~4 ?I.W.....I ~J ~Lw 12/~ 2 ~J ~ 2.5 r) ~
Rl Amikain 100 mg/2 ml vial
. ~L.wa 12 JS 1.5J.W J:a~ 4
-~.J:I-"''i ~ u~ ~'i ~l.wll ~~ ul.l~ JS
Rl Dexamethazone or Fortecortin
amp.

?l:l ~ 0~ ~Lwa 12 JS 1.5J.j..JJ ~~

Rl I. V. fluids.
R/Oxygen.
Rl : Fresh blood transfusion

Case 3: sepsis
A newborn 5 days old with abdominal distension,
irritability,temperature 37.7 with episodes of crying. His weight
is 3.5 kg.( sepsis)
Rl Cefatriaxone or Fortum 500 mg

vials.

"'g;:!J ~ 3 ~ ~

:~l:i 5 oolAJ u~Lw 12/~ ~~

R!Baby rest

drops

~!>-4-.3

Rl Cetal

drops

-129-

I ~4 ~ t5

7- Infant of Diabetic mother:

Infant of Diabetic mother susceptible to complications
than others e.g. RDS, hypoglycaemia, birth injury, congenital
heart diseases.
The most common probleme is hypoglycaemia, which
may occurs after 2 hours of birth up to 48 hours. so the main jop
is to avoid hypoglycaemia and subsequent brain injuries.
Hypoglycaemia is vary from mild to severe form depend to
diabetic control of mother in the last 3 month ofpreganacy.

Case 1:
Full term baby delevired 2 hours ago for diabetic mother
(IDDM) (Fatal Hypoglycaemia my be occur during first to 2
days)
100/ml/24 h

R I I.V glucose 10%

u~l....ii-4

JS ~~~ ~ ~ c.JoUl;!
~J..):\Ill .;1 ~'ll <)4 ~ ~~..)

If blood sugar less than 40 mg/dl .inject 10 ml glucose 10%

direct I.V.
'
When blood sugar stable above 60 mg/dl stop I.V. fluid and
observe for 24 hours

Case 2:
Full term baby delevired for diabetic mother in rural area,
no hospital near_to you.

~l...ii.)J ul...il"lt., ,.,s.....n., ~

.,1

.~t... 8-4

%10 Jl

%5~ ~t.,

JS ~ jS.. .4j".. ; UMI:!i;

-130-

cJilill ~l...ii.J

At;eU J ~I

8- Jaundice (Hyperbilirubinemia)
A- Physiologic jaundice.
N.B.: Physiological jaundice is diagnosed by exclusion.
It appears in full-term infant after the third day of life and
resolves before 10 days, total serum bilirubin less than 13 mg/dl,
direct fraction less than 20% of the total. Breast-fed infants
exhibit higher peak serum bilirubin values and slower resolution
than do formula-fed infants.

B- Phathological Jaundice
When serum bilirubin concentration increases by more
than 5 mg/dl/day, when the total bilirubin is over 15 mg/dl in a
formula-fed full-term or over 17 mgldl in a breast-fed term
infant, or if cord bilirubin is 5 mg/dl or also should be considered
in clinical jaundice in the first 30 hrs.

Basic laboratory investigations:

a- Total and indirect bilirubin levels.

b- Blood groups for the infant and mother

c- Complete blood count, haemotocrite and reticulocytes
d- Direct coop1bs test
e- Thyroid and liver function tests

f- Haemolysis work-up.

-131-

Treatment:
1- No treatment (follow up).
2- Sominaletta therapy
3- Phototherapy
4- Exchange transfusion.
5:-Two ofthe above

Treatment of Jaundice in the healthy term newborn

Age/day

Phototherapy

Exchange transfusion

Exchange

I phot

and Phototherapy

transfusion .

1-2 day

>15

>20

>25

2-3 day

> 18

>25

>30

> 3 day

>20

>25

2::30

Case 1:
Full term healthy newborn 6 days old with physiological
jaundice 10 mg/dl.

Rl Sominaletta syrup
.~~...w 12

Rl Domaco or baby calm packets.

. ~})A 3-2 ~

~ 9-l...a ,-

1~ 2.s

100 ~ UAP 2

.~1 ~~~ ~ ~'/1

. ~L..... 48

JS u..!.Sl1 o.l~! -

Case 3:
Newborn 4 days old, full term, with jaundice> 15 mg/dl.
Rl Phototherapy.
-132-

Case 4:
Newborn 5 days old, healthy full term with jaundice .. 25
mg/dl.with Rh incompatibility

Rl Phototherapy
Rl Prepare for blood exchange.

Case 5:
Newborn 25 days old healthy, jaundiced 15 mg/dl direct
is 6 mg dl 4.5 kg(? Sepsis)
liver function test near normal

Rl Claforan or Fortum 500 mg vials .

-~~~...... 12/ ~ 1 ~J ~ 3

u.i ~

Rl Cholestran Sachets.

Rl Bebevit

drops

9- G.I.T. Problems
Case 1:
'

Newborn 25 days old, breast feeder with frequent loose

motions after each feed( 6-10 /day.)

Rl No treatment "Normal variant of bowel habit".

(gastrocolic reflex)
-133-

Cases 2:
Newborn 20 days old, healthy bottle fed, pass semiliquid
motion every 2-5 day.

RJ No treatment- "doesn't have constipation".

Case 3:
25 days old newborn with repeated vomiting.

RJ Gast-reg or Farcotilium syrup

RJ Overfeeding may be the cause.

Cases 4:
20 days old newborn, with severe straining to pass hard
stool every day.

RJ More fluid orally

~~.)1 ~

R I Glycerin

supp. Pediatr.

4.a.b ~~~ --~_,~I , .

. ~ttl~~~.......~-"
.....
. . .:. ...t

~
~...Jolo- U"-.!1'!"

('.:1-J"'"

-134-

10- Neonatal Respiratory Distress

It is the most common neonatal emergency and neonatal
deaths.

The most common causes of neonatal respiratory distress

are:
1- Hyaline membrane disease:
It is the commonest cause.
More common in premature babies and infant of diabetic
mothers due to deficient synthesis of surfactant
Respiratory distress at birth or few hours after birth.
Bilateral fine crepitations with diminished air entry.
Chest x-ray shows ground glass appearance (fine granular
appearance).

-135-

5- Meconium aspiration syndromes:

It occurs mainly in full term and post-term babies

exposed intra-uterine to fetal distress, the skin and umbilical cord
are meconium stained. RD. occurs early after birth.
6- Diaphragmatic hernia:

It should be discovered and treated.

*Management of neonatal respiratory distress includes:
(1) Incubation.

(2) LV. fluid therapy.

(3) Oxygen therapy
(4) Assisted ventilation.
(5) Correction of acidosis
(6) Antibiotic therapy: It should be given to every case as the
differentiation between infectious and non-infectious causes
is difficult. Ampicillin in combination with amikacin or 3rd
generation cephalosporin.
(7) Surfactant therapy (Exosurf vial, Survanta). It is given
intratracheal in a dose of 5 ml/kg once or twice according to
the response. It is given to preterms with severe hyaline
membrane disease.

-136-

11- U rinarv tract infection

Case:
Newborn 26 days old with fever 38-41 oc since 3 c:2ys,
crying most of time, clinching hands and hip flexion during
micturation, fully conscious, feeding well.
? Urinary tract infection.
"Urine analysis, culture and CBC"
Rl Cataflam or Abimol or Cetal drops

.v!PJ' ~ r..sA ~~L.-.. 6 /~L: ~ 5

.u}fo'i)J (Joii!Jll ~
Rl Amikain 100 mg vials

o ~L: ~~.s~ ~

2 ml
~L:I 5 o~ ~ c) ~t..... 12 /~ 1f2

Or Rifobacin 10 mg amp.

Rl E.moxclav or Curam 156 or Emox 125 mg.

-137-

Miscellaneous Problems

Case 1:
Newborn 2 wks old with multiple skin boils (pyoderma),
temp. 3 7 C with good general condition:

Rl Fucidin or Garamycin oint.

Rl Betadin lotion.
-~JA ~ ~_,.

;t..aL...

Rl Systemic antibiotics if the baby is sick or feverish, or

hypothermic.

Case 2:
Newborn 3 wks old with noisy breathing, sneezing, interrupted
breast feeding temp. 37 C

Rl Baby-otrivin or Lyse or Normal saline nasal drop .

.Jl~J ~ ~)I J:! ~};.;~ 4

Rl Fenstil drops;

Or Rhinostop drops.

-138-

~ .l:W

Case 3:
Newborn with eczema of the face (Red,rough crusty cheeks)'

R I Micort or hydrocortisone 1%

cream
~JJll' J. ~JA ~_jll ~JA u~J

R I Fenistil

drops
,;

l~l.r...A

.j

b.~ ~4 ~

~_yJI e)U~~~~3 ~'J I ~

* Chemot.herapeutics.

* Bromocryptine ( Barlodele ) .
* Cimetidine.
* Immunosuppressants used for:
rheumatoid arthritis
Autoimmune disease.
SLE.
*Smoking
* Tetracycline.

*Aspirin.
* Contraceptive pills .
* Primperan (Metclopramide) .
* Metronidazole (Flagyl).
* Psychotropic drags.
* Sulphasalazine.

-139-

NEPHROLOGY
Nephrotic Syndrome (N.S.)
Nephrotic syndrome has 4 components:
1- Proteinuria (heavy >2 gms/24 hs, mainely albuminurea).
2- Hypoproteinemia (mainly hypo-albuminemia with reversal of
albumin/globulin ratio)
3- Edema (recurrent in the face for few days then becomes
generalized starts in L.L.

thigh

anterior abd. wall &

may be associated with ascities and/or pleural effusion &

scrotal edema in males).
4- Hyperlipidemia
;

B.

Hypertension, hematuria and oliguria may occur

transiently in N.S. and they carry poor prognosis.

Case 1:
A child 2 years old with recent morning bilateral eye
puffuess and normal blood pressure, and disappeared at
afternoon. No other symptoms. (Think in nephrosis)
R1 Urine analysis for protienurea

_If positive --.. considere in nephrosis

If negative --.. considere in conjunctivtis

-140-

Case 2:
A child 5 years old with clinical nephrosis and normal
blood pressure, massive edema and mild oliguria weight 20 !(g.
"Hospitalization is better"
Rl Augmenten 600 mg vial or tab
Rl Lasix tab or Salex tab (40 mg)

Rl Hostacortin or Prednisolone tablets (5 mg)

OJA ~J 7 ~ ~ .~t...l 6-4 o~ ~ .J ~..9:! u!;A 3 ~J 2.5

~! u! ~Jll4 Ui-.9:! ~ ~ 6-3 o~ ~..9:! ~ ~..9:! Ji>l' ~b.~ o.b.IJ

-~l:!l 3 JS ~J 1 J~ ~~'
: ~ <".;jill o.llili ~~ 0.fi~~ ~ .Uh _;

Rl Salt free Albumen 20%

~..9:! ~ ~..9:! .jl ~..9:! ~~50

Rl Mucogel or Epicogel

44-J -

susp.

~~~'11 ~ iJ:P.. 44-Jll ~ ~ u!;A 3 JS~I ~ ~

Rl Capoten

25 mg tab.

Rffotavit

susp.

-141-

.(wl:!l~, <:;:~..l, &... , ~, ~~) wl~~l

..hi....::JI

t ljJ_;I ) .l:!~l ~.JI ~l:.. u-9 ~)-4 ~ ~t....hll

JSi

0-> _;I:Sjl-

.) ~ ~I J)\!"jl -

.ya.ll!, 4.S~4 c~

~ wlijj~l ~

J:b.,:i_, ~.J..il ..lfo-'

U2..::...)W

t~i JS ~..;-JI ~1:1. .J~l

N.B. During alternate day therapy, Relapse is considered by

edema and not proteinuria alone as transient proteinuria
may occur in patient with N.S.

Other formes of prednisolone:

Xilone and predsole 5 mg I 5ml syrup

Xilone forte and predsole 15 mg I 5ml syrup

Solupred 20mg

Solu-medrol

IV

tablets.
injections

-142-

Case 3:

_____

The same patient develops generalized edema 2 weeks

after stoppage of alternate day
steroid therapy.
.;.....
....--

------:~.;:;...

_______

~-----

Rl Restart steroid as before but continue for 6-12 months

alternate day therapy (steroid dependent)
If the same patient develops relapse (generalized edema) after
one year of the previous attack.

Rl The same lines of treatment as 1st episode.

N.B.

Steroid resistant cases should be reffered to pediatric

nephrologist.
Nephrotic syndrome may be secondry to uridelying couse as
SLE or Olber collagen diseases, drug toxicity... etc.

-143-

Acute Poststreptococcal Glomerulonephritis

(APSGN)
When asymptomatic hematuria occurs in the context of
hypertension, active urinary sediment with casts, or smoky urine
or porteinuria, glomerulonephritis should be suspected.

Routine Investigation:
.Serum creatinine, ASOT, C3,C4 and urine analysis , serum
albumen and abdominal ultrasound

Cases 1:
Child 4 years old with nephritis (APSGN) .Facial edema,
smoky urine and hepertensive 140/100 mmHg.

Rl Crystaline penecillin

vials.

~t..-ll J4AI ~ ~t:~t 10o~ ~t... 12/ ~ ~

Or Hiconcil 250 mg or Erythrocin susp

-~t:~i 101 ~~t... s 1~ 5

R/Capoten

25mg

tablets.

Orlnedral

tab

10mg

-144-

.l~'f)j ~~I

()4

r.)iil ~~'JI c) u~.uJ)j c.)J)j.wl)j t;lJI

.

()4

~'fl -

uJ;~,J-~~1

c)c .

Urinary tract infection

It is a common infection in children especially females
and uncircumcised males. Infection by urea splitting organisms
such as proteius can lead to stone formation. U.T.I. may be
hidden especially in neonate and infancy.
Clinical pictures:
1- In neonates: may be presented by picture of septicemia
(hypothermia, poor suckling, skin motling convulsious).
2- In infancy: may present with poor appetite, failure to thrive,
parentral diarrhea or pyrexia of unknown origin.
3- In older children:
.
.. .
i- Cystitis: dysurea, frequency, burning micturation and
suprapubic pain.
ii- Pyelonephritis: renal pain or colic and high grade fever.

Routine investigations:
** Urine analysis and CIS.
Abdominal Ultrasonogaphy.

**

Renal functions.

Cases 1:
Child 4 year/old with upper urinary tract infection
(pyelonephritis): "Fever, Rigors, nausea, vomiting apsf tender
flanks''(urine analysis -+ pyurea & urine culture shows
significant bacteruria).

Rl Garamycin

amp40mg.
-~l.....12/ ~4a

Rl Klavox or Augmentin 457

-145-

susp

-~l:!l 10 o~ ~~.c.L.... 8 1~4 c)La 5

Rl Marcofen 300 mg

supp.

Cases 2:
Child 1 year/old with upper urinary tract infection
(pyelonephritis): "Fever, Rigors, failure to thrive, nausea,
vomiting and diarrhea"
(urine analysis ~ pyurea & urine
culture shows significant bacteruria).
Rl Claforan or Cefotax 0.5 gm vials
Y~ ~ ~ .~1 ~ c.JA ~L..w. 12 ~~ ~

R1 Emoxclav or Augmentin 312 mg

susp

-~l:!l1o o~ ~~.c.L.... 8 1~ c)La 5

Rl Epimag

eff.

granules.
-~J:! ~JA ,.t.. y.JS ~.J ~ "w ~
Rl Temporal , or Brufen
.W=J! ~ ~\.c.l...a 6-41 c)La 5
Rl ::1: I.V fluid.
'"

Case 3:
Child 5 years old with acute cystitis.
(Penile pinching, urgency, enuresis, dysurea), with fever.
R1 Sutrim or septazol

susp.
oJ.AJ ~L.... 12

1c)La 5

-~\:1 10 o~ ~~.c.~...a 8

1u.1l.a 5

- ~\:1

to

Or lbiamox or Bacticlor 250 mg surp.

-1 46-

Rl Coliurinal or Epimag

eff granules
.i.:-aJ:! ~.)A ~ L4 ~.:~..P ca.; c)&Rl Marcofen or Ketofan or Temporal syrup.

tg

u~L.w,

6 f '-' '\ 5

. ~ !J.il ~ Jl!J...r..ll ";oo~ ()A JUS'/ I

Case 4:
Child 4 years old with Recurrent UTI:

Rl Treatment of the acute attack as before.

NB: in recurrent UTI a full investigation

is indicated to

exclude urinary anomalies e.g reflux,urthral valve,stones,

ectopic kidny
0

Rl Prophylaxis:
Sutrim or septazole

susp .

Rl Urological consultation

is

recommended for

. investigations searching about underlying cause..

-147-

furthur

Renal colic
Not common in pediatric, but can occur at any age, in the
form of acute abdomen of sudden onset in children or persistant
crying unexplained in infancy, haematuria is common but not
associated with fever.
- In recurrent colic, plain X-ray, abdominal sonar, IVP and urine
analysis is indicated.

Case 1:
Child 8 years old with acute agonizing renal calic:
Rl Voltarin or diclophinac amp 75 mg 3 ml
~-i)lll ~ ~

ull.. 1

Rl Buscopan amp.

.c}ll J.$ .Ji Jut~ Yz

Rl Intravenous fluid is the best urinary antispasmodic.
If good response:

Rl Visceralgin syrup or Buscopan tablet

-~-i)llt ~ ~JJA 3 1,_ 5 .Jt c.JA~

Rl Cataflam or voltarin or Olfen 25 mg tab

.J.i)J...ll ~~ c)4 ..J~"/1 ' .JS'/1

-148-

.&J ~.i,)ll\ ~ (JA.)

CARDIOLOGY
Rheumatic fever
It is an inflammatory disease involving mainly big _,vints,

heart_, skin and subcutaneous tissue and less

frequ~mtly

the CNS.

Rheumatic fever is commonly occurs between 5-15 years and

more common in winter. Prompt and accurate diagnosis 1s
important to avoid serious & Permenant cardiac damage.

Modified Jones criteria for diagnosis of rheumatic fever:

Major criteria

Minor criteria

1- Carditis.

1- Fever.

2- Polyarthritis

2- Arthralgia.

3- Chorea.

3- Elevated

4- Erythema

reactants:

I
acute

phase

marginatum

- Raised ESR.

5- Subcutaneous

- Positive C-reactive protein

nodules.

4- Prolonged P-R interval.

Plus: Evidence of streptococcal infection:

(a) Positive throat culture for streptococci.
(b)

Recent scarlet fever.

(c)

Elevated ASOT > 330 Todd units.

-149-

(d)

Elevated

streptococcal

antihyaluronidastr,

antideoxy

ribonulease

B or positive streptozyme.

The diagnosis of

rheumatic fever is done by two maj or criteria or one major and two minor
_criteria plus evide~ce of streptococcal infection.

The diagnosis of rheumat~ fever is acceptable without

two major or one major and one minor criteria in the following
conditions.
1- Chorea after exclusion of other causes of chorea
2- Rheumatic recurrences: In the well known rheumatic heart
patient, the presence of one major and one minor is sufficient
for diagnosis of rheumatic recurrence if evidence of
streptococcal infection is present.
N.B. Don't count arthralgia and arthritis at the same time and
also pro_longed P-R interval and carditis.
Managment of rheumatic fever:

(1) Treatment of acute rheumatic fever.

a- Eradication of any streptococcal infection.
b- Treatment of rheumatic manifestations. as carditis and

arthritis.
c- Treatment of complications as heart failure.
(2) Prophylaxis against rheumatic recurrences.

-150-

Cases 1:
A child 8 years old with acute rheumatic fever presented
with migratory polyarthritis, fever, Positive CRP and evidence of
streptococcal infection and without carditis.

Rl Crystaline Penicillin

vials (400.000 unit)

-~l:!l ~ 0~ ~~\..w, 6

JS ~ ~

Rl Aspeol (500 mg) tab.

O r Rivo-micro (320 mg) tab.

&.~C-'*""'! o..\Al JS~I .lLJ l:.o~ ~1.>-'1 3

Rl Mucogel or Epicogel

c.J4J 2

susp.

~~~'II~ i~4~ ~ ~ ~1.>-'13 JS~I ~ ~ ~

-151-

Case 2:
A female child 11 years old presenting with rheumatic chorea.

Rl Safinase 1.5 mg tab.

.t.a~'il ~ u~ 3 ~.) ~ ..~~ ol ~ ~~ ~~ ~.)

Yz

Rl Tegritol 200 mg tab.

~~~ Ja.i u~ 3

Rl Durapen-S or Lastipen LA

u-11

.1}):i _, ~~ ~~ ~.)

(1.200 000 I U).

~) ~t......t 3-2J.S 4-wt.....G ..J4A! ~ ~ (deep 1M) ~ ~I

Case 3:
A child 10 years old (25 kg) with acute rheumatic fever ap.d
evidence.ef carditis and/or failure heart

* Hospitalization
*Bed rest

* IV ;f luid 70% of maintenance

Rl Augmeotin 600 mg

vials

.~i lOi.wl ~~t.... 8

Rl Hostacortin or Ultracorten 5 mg

JS ~
tablets

J ~.,i ~!J ~~ ~,AJI ~ ~ UF--H-i ~~ 'i;...H uJJ.. 3 ~.) 3

_. _tlf!
fJI6.A~W

Rl AlnopriDe farte tablets.

-152-

~~~ u...a 6:!'='~t ~~:::WI llA ~~~ IJ.+.! .JS'JI Ja.J ~J:! u}>A 4 <.J4J 2
&:l.t...l 4 oJ.AlJ ~..;~ UJJ:!:i,JJSll~.?. <.J4Wi c) i~ ~J UJl~ ~I
Rl Lanoxin (digoxin).
See Heart failure.

Rl Mucogel or Epicogel

susp.

tol~'ll ~ i~ 4~1 ~ ~ u}>A 3 JS'll ~ ~ ~

Rl Prophylaxis against rheumatic recurrence.

Cases 4:
A child 8 years old with history of rheumatic fever.

Rl Penadura or Lastipen LA

(1.200 000 I U).

cJ.w1 ~ &:Lwi 3-2J.S 4w~ .J~l J$. ~ (deep 1M) ~ ~

.J..a.NI ~

-153-

. t . ~~. ~25

Infective endocarditis
Infective endocarditis is common. in congenital or
acquired heart diseased. Prolonged low-grade fever, malaise,
anorexia, auscultation of new or changing mmmurs, hematuria,

splenomegaly and cutaneous maniife.stations as petechiae, osier

nodules and nail hemorrhage are suggestive of :infective
endocarditis.

Investigations include -elevated ESR and positive Creactive prorein. Repeated blood adames and echocamiography
are the dia,goostic evidences of infiecti1re enrJoamfitis.

Cases 1:
A child 10 years old (25 kg) with !Jlbaunatic heart disease

deelops bac:itrerial endocarditis.

Rl PaKilh. G vi:ah (1000,000 aait).

-~ 6-4 ;,aaa ~ 4 JS .:ut RI Geat:uayda 40 mg amp.

RJ Aatipyre&s
6-4 a.w ~~~.;a~ f.~ 6-4 aw....,a,J:w:a ~

-~ ~.- 1 ti" ..II.Jili ~~~..

.fJJIU

-iJ.54.:

Prophylaxis of infective endocarditis:

Case 1:
A child with rehumatic heart disease going to tooth extraction.
R/ Amoxil or Emox or Hiconcil 50 mglkg
~~Lw. 6

J.S ~~\

~ F-~l ~ ~~ ~\ Fo~!

J:! ~~\ F-~1

. -\.9 ~~ o.l.Al

Or Zisrocin syrup 20 mglkg.

~~L...

6 ~~~I U.o4i F-~1 ~ ~~ ~~ ~J.P..!

J:! ~~~ ~~1

Case 2:
A child with rheumatic heart disease gomg to lower
endoscopy or urinary catheterization.
R/ Ampicillin 50 mglkg + gentamicin 3 mglkg

(one hour before the procedure)

u~Lw 6 1 u.:u. ".!' "S.Jo4l _gl ~'II ~~~ ~ ~ ~

-155-

Congestive heart Failure

Congestive heart failure is the clinical condition in which
the heart fails to meet the circulatory and metabolic needs of the
body. Common causes of CHF include VSD, ASD,coarctation of
the aorta, rheumatic heart disease, and cardiomyopathy.
Infants in congestive heart failure typically present with a
history of tachypnea and poor feeding.

These symptoms are

progressive as the heart failure worsens and almost always lead

to growth failure. In older children, the most common symptoms
are easy fatigability tachypnea and liver enlargment.
The treatment of congestive heart failure should be
directed toward both treating the failure itself and diagnosing the
underlying cause of the condition. Inotropic agents, diuretics,
and after load reducing agents are all used, singly or in
combination. In the therapy of CHF supportive measures
(oxygen, sedation, mechanical ventilation and intravenous
nutrition) are also utilized in severe cases.

-156-

Drugs for heart failure

Digoxin: ampules, tablets or drops.
0.04- 0.05 mg/kg oral, IV or IM-Loading dose. This
dose calculated accurately and given as following
~ dose initially.
Y4 dose after 8 hours.
Y4 dose after 16 hours.
Then Y4 dose to be given daily maintenance once or
divided every 12 hours.
N.B.: Hypokalaemia precipitate digitalis toxicity (nausea,
vomiting, yellow vision and bradyarrhythmia)
Dopamine: (Intropin amp 200 mg) and Dobutamine (Dobutrex
amp250mg)
One or both of them can be used in heart failure after
dilution to glucose 5%
Dose : 5-:20 meg/kg/minute
Start with 5 meg/kg/min. and gradually increase according to
response.
Furosemide: Lasix or salex amp and tablets (20 & 40 mg
{espectively). The most commonly used diuretics in pediatrics
dose 1-2 mglkg/dose IV or IM
1-2 mglkg/day oral
N.D.: Potassium syrup should be given to avoid hypokalaemia.
Captopril:
After load reducing agent
Dose 0.5 - 2 mg /kg/day oral.
Capoten or captopril tablet 25 mg.
"only tablets form is available"
-157-

Cases 1:
A child 2 years old (11 kg) with big
heart failure.

\rsn

and severe

Rl Lanoxin amp (0.5 mg/2 ml)

.r:;'ll ~ Jl ~ ( ~~ Yz) ~ 1 ~~l

uts:.Lw 8 ~ ~ Yz ~
ul:.1..... 8 ~ ~

Yz

~J:! o.b.IJ i>A f~ Yz ~

Rl Lasix amp. 40 mg/2 ml
.~t.....12

JS ~ Jt ~(~I~) ~ Yz

Rl Potassium syrup.

~J:! uJ;.o 3 f ~ 5
Rl Capoten 25 mg tablets

.i~LwwJ b~ ~J. ~
N.B: In Moderate and mild HF oral forms can used.

Cases 2:
A child 15 month old (9 kg) with big VSD and mild heart failure.

'

R!Lano:xin

pediat.elixir

Rl Potassium syrup.

R!Polyvital

drops

-158-

Cases 3:
A child 5 month old (4 kg) with big VSD , PDA and
heart failure.

----------------------------------------R/Lanoxin
pediat. elixir

--

RJ Potassium syrup.
RJ Captopril or capoten 25 mg tablets
~t....12/ ~ ~ 2.5 ~ .J s:.La ~ 10 ~ (,)62..)ill 'f.ly\~
RlAldacton 25 mg tab
~~ ~4 ~ 1.5 ~ .J s:. l-4 ~ 5 ~ (.)62..)ill yl~

Case 4:
A child 10 years old with compensated congestive
cardiomyopathy
Rl Lanoxin or cardixin tablets
Rl Capoten or captopril tab 25 mg.
Rl L-Carnitin

syrup

-~1!1~3/~3
\

-159-

Case 5:
A child 2 years old (1 0 kg) with toxic myocarditis and
severe heart failure due to scorpion sting y ~ .ll
Hospital (Pediatric ICU) management:

Rl Oxygen, IV fluid, monitoring and mechanical ventilation

Rl LanoXin amp. (0.5/2 ml)
(' iJHi)

t:La ~ ~ 9+ ~ 1

u.- u'~' Jw ~ 10

.u~t....a8 ~Jw~5

.~l....a24

JS v.. ~5

Rl Lasix or Salex amp

N.B.: Can be repeated several times m severe cases or in

pulmonary oedema.

Rl Dubotrex 250 mg vial/5ml

.%5~~100 ~ ~l~.;o~l~

infusion ~,...n ~ ~ j~) ~L.../c)l-a 5 ~~ ~J

~ ~ ~~ ~~ Jl,u:i

(u...a_,l...) ~ j~ .l:W 6 _,i (pump.

~~'I' ~ uFJ4 .,i

Rl Potassium supplementation.
add to IV fluid or through NGT or oral.
Rl Captopril Tab.

-160-

v..

Case 6:
A child 7 years old with Fallot tetralogy without complications.

Rl lndera110 mg

tab .
~..9:! ~~ 3 (.)4.)
syrup
~ - 4:ia.l.
U:f-1..>'1~

Rl Sytron
Rl Ospen lOOOmg

tab.
~ya

Rl Epicozyme

(.)A.)%

syrup

Case 7:
A child 7 years old with tetralogy ofFallot has an episode
of cyanotic spells (Hypoxemic). "sudden onset of dyspnea,
alteration of consciousness, irritability and syncope).

Rl Placing the child in knee -chest position

tp~l ~ ~ ~ ~.).4ll ~ ~.J"~#l) ~L.ai..,1ll ""'~ u-i ~~ ~_,
.~1 }i..l4 ~ I""'U .JAJ ~_,n tjA. ~ Jt ( ~J

Rl Oxygen therapy.
Rl NaHCo1 1-2 mEq/ Kg!IV.
o/oS J.f~ ~~ ~ F-~ ..\.l_u ~..f:!.l~ ~~..A!

Rl Morphine IV or S.C. 0.1mglkg.

Rl Inderal 0.1 mglkg/dose /6 hours IV.
Rl Blood transfusion or volume expanders.

-161-

Case 8:
A child 13 years old, obese
hypertension 160/95.
Rl Inderall 0 mg

(45 kg) with essential

tab .
~.J:! ~!>A 3 ~.)

Rl Capoten or captopril tab 25 mg.

+Low fat diet.

+ Low salt diet.
+ Weight control.
+ Regular Bl!Pr measuring with step up or down treatment.

Case 9:
A child 4 years old, c/o chronic headach with
hypertension 150/95.
Essential hypertension is not common at this age,so you have to
exclude causes ofhypertension.
1- Exclude Renal causes of hypertension.

* Renal artery stenosis

* Renal hypoplasia
*UTI
2-Exclude Endocrine causes of hypertension.
-162-

3-Exclude Metabolic causes of hypertension.

4-Coarctation of Aorta

-163-

HAEMATOLOGY
Average hematological values (parameters):
HB(gldl)

Age

Hct
(%)

MCV

Reticulo

(FL)

cytes

WBC

(%)

-Cord blood

163

5110

11010

9000-30.000

-I month

14 3

4312

10510

7000-20.000

-3 months

112

355

9510

6000-18000

- 1-6 years

122

345

905

6000-15000

133

405

8510

1.6

4500-13.500

-7-12 years

Iron Deficiency Anaemia

It is the commonest type of anemia in Egypt. It is a
microcytic

(-1.-MCV)

hypochromic

(-1.-MCHC)

anemia.

Unfortunatly, breast as well as cow milk contain low iron

content. Iron deficiency occurs in two peaks.
(a) At the age of 4 months until the end of infancy due to
exhaustion of iron stores taken from the mother.
(b)- At the age of preschool and school children due to the high
possibility of parasitic infestation.
Iron deficiency anemia is diagnosed when there is pallor,
without organomegally or lymphadenopathy ( 10% only of them
have small splenomegaly). The diagnosis by HB, HCT, MCV.

-164-

Stool analysis is essential beyond infancy for diagnosis of

parasitic .infestation. Solid diagnosis is by finding low serum iron
and high iron binding capacity. The daily requirements of iron .s
6-10 mg/day elemental iron. On therapy, the patient needs 6
mg/kg/day elemental iron, for 3 months. Oral iron should be
given between meals and absorption is enhanced by vitamin C
supplementation. You could evaluate the response to iron within
4 days of therapy by increase reticulocyte count. Usually child
irritability is improved within

1st

week of therapy.

Cases 1:
An infant 10 month old, only breast milk feeder with
cow's milk supplementation, have mild pallor, anorexia, some
irritability, no organomegaly.

Rl Hydroferrin
OrSytron
R/Cevilene

drops

syrup.

drops

-165-

Case 2:
A child, 6 years old with iron deficiency anaemia HB 7.5 gm.

Rl Vitaferrol or Ferose

syrup.
. ~ 3tl.4l u~.Jll CJ l:-o.J:! u).)A 3 /~ 5

R/Upsa-C

effer. tablets

-4..-J:! ~JA ~ lA y.jS ~ ~ yl~ (.)oO.;i ~

Rl Fluvermal or Alzental
susp
~~~ .la.J ~.; ~l;l3 oJ.Gl ~.J:! ~JA/~ 5
IM injection I weak

Rl Haemojet

May be used in resistant cases,

Case 3:
A child 6 years old with severe iron deficiency anaemia ,
(HB 5 gm/dl) and heart Failure.

Rl Packed RBCs transfusion 10 ml/.kg.

Rl Ferose syrup
-~~ oJ.Gl u~l ~ ~))A

Rl Totavit

chewable tablets.

Rl Epicozyme

susp

-166-

3f~5

Prophylaxis:
Prevention better than cure.
10 mg/once daily elemental iron is sufficient to prevent IP ~~

Glucose-6-P-D deficiency
The most common cause of acute haemolysis in Egypt, it
is an X -linked inheritance ( affect males only and rarely females
due to gene mutation). In between the episodes the patient and
his blood indices are normal.
Clinical manifestations:

1. History offava beans eating in GPD deficieny.

2. Acute pallor due to acute hemolysis.
3. Acute jaundice due to unconjugated hyperbilirubinemia

4. Dark urine due to hemoglobinuria.

5. Signs of acute hypoxia ( tachycardia, Tachypnea and
altered consciousness) in severe cases.
Laboratory confirmation:
1. Acute anemia.

2. Reticulocytosis (above 5%).

3. Uncojugated hyperbilirubinemia.
4. Normal liver function tests .

N.B. assessment of G6PD enzyme after 4 weeks of the

attack.
-167-

Management:
1. Oxygen therapy, maintaining of patent airway and
circulation in severe cases.
2. LV. fluids with Na-bicarbonate to alkalinaise the urine to
prevent the precipitation of hemoglobin in the kidney as
acid' hematin which leads to renal failure (lasex IV).
3. Urgent blood transfusion 20 ml/Kg/transfusion.

Case:
A child 3 years old with rapid onset of jaundice, change
color of urine, pallor, fatigue and history of ingestion of broad
beans yesterday~i J_,i ~i .
Rl Intravenous normal saline (diuresis)
-~ ~

UP.1 ~c)~~~ 500

Rl Oxygen mask.
R /Sodium Bicarbonate 8.4 %
,.~ J.i.JJ % 5

. R Lasix

J.A ~ 10 + ~U~_H. ~ 10

amp.

R1 Blood transfusion.
.4\a.ll ~ ~ .J ~t.. ~ ~ 300 Ji.i
"l :; . . .~ u-I - t
t
~ Jl t :Ltt
~.J#.*A ~ J~..J u' """" o.oa v- ~

~~. ~

.~Jll

. .. - O:tj
u--

c) G6PD

:~Lc.~l

-168-

Chronic Hemolytic anemias

It is

a group of patients coming with pallor,

hepatosplenomegaly, mild tinge of jaundice. They include

thalassemia, sickle cell anemia and congenital spherocytosis.
The

laboratory

diagnosis

shows mild

unconjungated

hyperbilirubinemia, .J...HB, treticulocytes. To detect the type of

anemia you should do HBF, HBA2, sickling test and osmotic
fragility test.

-169-

Case 1:
Achild 4 years old with B-thalassemia major (Wt. 15 kg).

Rl Packed RBCs transfusion.

~L...i 5:-4

(hypertransfusion)

JS 9-!>- ~ ~hS ~ 250

~t...l 3

(Supertransfusion)

JS .;1

Rl Folic acid tab (5 mg).

Rl Dysferal 500 mg vials (Dose: 20-40 mglkg/day).

J,:..

u.l:!

~U. J~ tl~4 ~~L...

cSJ.A ~

9-l....w

JS

~I ~ ~

-~.Jr-W~I ~l:!l5 oJ.AJ (special pump) ~..JAll ~

OR/ Ketler

500mg tab oral

Case 2:
A child 3 years ol~ known case of sickle cell anaemia,
presented with pallor, crying, painful swollen hands, temperature
39C.

Urgent treatment:
Rl Intraveaoas fluid for hydration
..:.~Lw 8/ JS ~..Jjl\ c) c:l- ~ uL 500
Rl Oxygen therapy
.J.UJI .-:t 3 ----<1 -~1
- 1J"'" . ~ "'

Rl Voltaren or Dolphen 12.5 mg supp

. ~J.)lll ~.J u'il ~~ ~
-170-

Rl Sodium bicarbonate

solution
.~1 ~

Rl Unictam 375 mg

s:-.iw J.a..;jll ~ /~ 15

vials.

Or/ Foxime 1 gm.

~ ~L...a 12 /~ 2 c)=a.a.J ~ 4 ~ ~

Rl Whole blood or packed RBS.

.~1

u..u 0-- ~ ~ 250Jii

:$1,-:;;mcJI4Jo ~~j4]1 ~~II&

Rl Folic acid 5 mg tab.
Rl Pneumo 23 vaccine.
Rl Pencitard 1.200.000 IU

4wlwa.ll J~l

~ ~L...al 3

JS ~

Yz

Idiopathic Thrombocytopneic Purpura (ITP)

A healthy child with purpura, ecchymosis,

orofacial

. bleeding, without organomegaly and without lymphadenopathy

is mostly I.T.P.
It often follows infection with viruses. Complete recovery
is the rule but recurrence and chronicity (>6 m.) may occur.
It is con:finried by blood picture (only decrease platelets)

and bone marrow. The normal platelet count is 150,000 400,000/ mm3
-171-

Cases 1:
A child 3 years old with typical picture of ITP
"Echymosis and petechaie on the lips, skin, mild epistaxis, no
fever or organomegally''. HB 11 gm/dl, WBC 5.2/cc, RBCs,
3.4/cc, platelet: 20,000

RJ Hostacortin H or Prednisolone 5mg tab

(~t....l 3 ~l ~ ) i:.-.J:! .:!~ 3 ~.;i 1.5
~~ uJi:iJJS.ll UiJ

e.fl- ....

~t....l

fu..J. ~t.... 48 JS c;.a~

~ ;~ ~~~ J.ai t:l~

JJC.

oJ"=-l -

eW.;! ~

J$.

-~,.}~1 .

OR/ Intravenous Immunoglobulin 1000 mglkg/IV over 6

hours for 3-5 successive days.
e.g. in chronic ITP (lVIG).

RJ Fresh blood or platelet rich plasma transfusion 20 mllkg.

- - l!ajJ.a.

J' ~ u-1 t...:a~

:.>A_j;, l.i.,~ l!aj.U. U:,. ~ ~U:a l..a~

J' ~ ~ -

.3~/20.000 &a Jii ~ c;J~ ~ Ji ~I O;JJl\

~.JiJ ~I ~~I ~.l~ ~~!_, ~~ Ji.hll ~.;U ~
~~

~ ~J ~4~1, 4.l_,;....ll Jj.... ~\.....- ~_;.o ~!F-i

~Al\

'Jc_-

(.$t ~~

-~!J:.. ~L;..$ UJ~"JI

-~~1, ~'JfiWI t~i ~ ~ ~.,; 'J
-~' ~.J ~ -tlb. c.) ~)...11 to~~~ t~ ~

-172-

J.c.

~ Case

2:

A child 4 years old with ITP, platelet count 55,000/m2

Rl No Treatment are required, just observe and follow up
by platelet count. Avoid I.M injections.

Case 3:
A child 3 years old with chronic ITP. (4-6 months)
Rl start another course of prednisolone as before
Or/ Spleenectomy is advised.
Or/ Immunoglobulin therapy.

Hemophilia A
An X-linked deficiency of factor Vlll activity it is

suspected in child with bruising, bleeding and haemoarthrosis,

bleeding after circwncision. Usually there is family history.

Cases 1:
A child 10 years-old known as hemophilic going to
appendectomy.
Rl Fresh frozen plasma Transfusion 250 ml
~\01... 8

JS

J.ai ~ 250 ~j\la \..])4 J1i

~' ~Ulll c.JA ~t.... 12 JS ~ U:!A.J:! o.l.Gl

~_, ~t.-1... 4 ~I ,_~l

-173-

Or/ Cryoprecipitate bags 25 ml

~.J ~~Lr...

4 ~I J,:! ~t.....12 J.S .l.J.JJ (~ 100) ~~~_, 4 ,.~!

.~1 ~u:m

Or Kryobulin, 500 units (factor VIII).

. ~1 ~u:iJI ~ ~~..... 12 JS

J.I.JJ (o~_,

500) ul..Jo~..Joi.JS

Case 2:
The same child came with severe haemoarthorosis

Rl Same treatment as before

Rl Orthopedic consultation.
Rl Antibiotic prophylacsis.
Rl Hostacortin H or Prednisolone 5mg tab

~~..... 48

o.lAl t:.a.J:~ ~~ 3 (,)4,) 2

Case 3:
A hemophilic boy 5 years with persistent small wound bleeding
or after tooth extraction.
Rl Fresh frozen plasma .
(~~/r)lo 250) 4Jil1 'Lo.P4 o~_,

Jli

OR/ Cryoprecipitate or Antihaemophilic factor

UJjill U1:i ~ ~t..... 12

JS ~i

Daily home treatments

Or Minirin nasal spray,or tablets 0.1 mg
.~1 ~.J ~ \.:A.J:! ~ (,)4,) _,i ~'11 - u-i ~
q I Cyclokapron
R/Ruta-C 60

tablets
tablets

-174-

w
-j4 -(,)4.;S- l.9:! cJ:!ol
y..a.J:!

~~

3 (,)4.)

INFECTIOUS DISEASES

Viral Infections
Common criteria for viral infections:

Self limiting diseases.

The patient is Usually doing well, active even with high
grade fever and characteristically improves with
antipyretics only.

Symptomatic treatment is the rule.

Specific antiviral is indicated in some severe cases as

herpetic encephalitis.

Clinical diagnosis is easy but in douptful cases complete

blood count (CBC) and urine analysis are helpful to rule
out bacterial infections. Isolation of viruses and serology of
specific viruses are available fore some viruses.

Infection commonly spread by droplet or air-borne but

could be through blood as in AIDS and viral hepatitis.

Antibiotics are not indicated ex9ept in secondary bacterial

infection.

Post-infection life-long immunity in some of them as

measles and chickenpox.
Salicylates should be avoided in all viral infections
especially chickenpox as it may leads to Ryes syndrome
(encephalopathy and fatty infiltration of the liver).

-175-

N.B. More than 90% of upper respiratory t:I'a:ct infections

in pediatrics are viral in origin

Varicella (Chickenpox)
Mild fever, malaise and anorexia precede the rash. With
the appearance of the rash fever becomes moderate. The rash
appears typically on the.trunk and to some extent the face. .It is
formed of erythematous macules, vesicles . and pustules, as
various stages may present it is called pleomorphic rash. Itching
Is common.

Case 1:
A preschool child with chickenpox, fever 38.5 %.
R/Claritine or Fenistil

syrup.

Rl Calamyl or Caladryllotion

R/Brufen

syrup.
.u~t.-6 JS~S

.4.:i~!J (>I~

~' ,.\~\

.)h.a-

Rl Antibiotics in secondary bacterial infection. .

Case 2:
A child 18 month-old with severe chickenpox eruption,
fever 39.5 %, anorexia.

-176-

Rl Fenistil

syrup.

Rl Calamyl or Caladryllotion
Rl Megafenor Tempera

syrup.
-~.JJlll ~ u~L..w 6

Rl Zovirax

JS ~ 5

syrup.
-~l:'

5 o.l.41 'u~L..w 8 JS ~ 5

.4.:-411 ~~ JJli:ii..;JIJJYJ ~~!JJ . .

CJ:I

. r...n.:. .tJ n.:r...vt~ ~

U&1J
~ ~- "--' '-""" tJ.J

~13 . N.:.

Roseola Infantum (exanthema subitum)

It is a benign illness affect age 6 mo-3 years caused by

human herpes virus 6 characterized by abrupt onset of fever, 40.5

oc which may last up to 6 days, with minimal toxicity, one of the

major cause of febrile convulsions then the fever ceases

abruptly and characteristic Rose-pink maculopapulor rashes on

trunk, face, and neck .

Case:

1 year old child with high grade fever 40

alert, smile eating well, with no obvious cause for fever.

Rl Cetal or Marcofen syrup

-177-

oc,

N.B.: If the patient was presented with convulsions, you should

exclude other causes of convulsions .

.uJJ.uii ~~~LA ~t..., 48 ~~..;-all~ oJ~} ~h:f

Erythema Infectiosum
It is a benign exanthematous (rashes) disease of school
age children. Typically the first sign of illness is the rash, which
IS

raised

red

maculopapular

lesions

on

the

cheek

(Slapped cheek ~I ~ ~ ). Mild systemic symptoms and

moderate fever. Arthritis and aplastic crisis may occur.

Case: .
A child 7 years old with temp. 38.5 and red
erythematous macules on the check and good general condition
and no obvious focus for infection.
Rl Brufen 200 mg tab
Or Cetal or Megafen syrup.

Measles

It has greatly decreased in incidence because of

compulsory vaccination. It starts by high grade fever,
conjunctivitis, and severe coryza. Koplik's spots are diagnostic
before the appearance of the rash. The maculopapular rash
appears on the face, neck and spreads downwards and fever

-178-

subsides. Disappearance of the rash leaves brawny discoloration

and desquamation. Respiratory complications are the main cause
of death.

Case:
A child 4 years old with measles, "severe cough
sneezing, conjunctivites, fever and rashes".
R/ Abimol syrup.
R/ Pedipro or Rhinotus
R/ Prisoline eye drops.
R/ Halorange

R I A-viton

caps.
Lw
4&n.
.lJ:! r-~

~~

N.B. Mucolytics are used in the stage of productive cough,

-Antibiotics should be given as prophylaxis in infants or if there
is secondary bacterial infection e.g. O.M., pneumonia .. ... etc.
~~~ oJ.Al ~~~

_,t ~.JJ.All DA ~..JAll J~ '-""!>:!

u~l.....44 cl~ lj! u~l ui .'i.;,,. c.,r! _,i c.lJ..WI ~IJ ~}>II
." i " 0:!-"
\ j,J
'~1- 110"'
..)l!s'il
- !J U"!.J
-~~~~I ~~It~! .

-179-

Mumps
Common childhood infection. Tender swelling of one or
more of salivary glands but parotid is the commonest where the
swelling displace the ear upward and outward. Mild systemic
manifestations.

Meningeoencephalitis,

pancreatitis

and

epididmo-orchitis are the serious complications.

Case:
A school aged child with mumps.

Rl Marcofen or Ketofan
Rl Reparil

syrup.

gel.

Bacterial Infections:

~~----------------T--et_a_n_u_s___________' __--~1
It is a lethal disease particularly in newborn, but it is
decreased due to compulsory vaccination for most of children
and booster doses for the pregnant women. The main lines of
treatment are supportive and antitoxins. Clinically the baby is
irrttable with spasms of jaw muscles, stiffness of the back, neck

-180-

I
I
1

and abdominal muscles, generalized muscles contractions

(conscious level doesn't affected).

Cases 1:
A child 7 years old with macerated wounds due to car
accident, "he received all vaccines"
Rl Antibiotics
Rl Care of the wounds
Rl Tetanus toxoid vaccine

Case 2:
Child 10 years old with the same condition "not
vaccinated .
Rl Antibiotics
Rl Tetanus toxoid vaccine
fi~ 45

JS u~.;.l. 4

~.J (joll.,g.i\:i.j:lll cW U.G ~ill ~.,p,JI

Rl Tetanus antitoxin 1500 IUIIM

.4w~1 J~l ~ ~ (joll.,g.i\:i.j:lll ~ U.G o~IJ ~~

Case 3:
Newborn 1 week old with typical tetanus neonatoruin
"Hospital care"
-181-

Quiet dark room

Intravenous fluid therapy 150 ml/kg/day. And gradually
replaced by nasogastric feeding.
Antibiotic, Crystalline penicillin 100,000 . units/kg/24 hrs
every 6 hrs for 10-14 day.
Control of convulsions, spasm by valpam or stesolid 0.2-0.3
mg/kg/dose
Care of respiration, secretions, umbilical stump.
Antitetanic serum: 50.000 to 100.000 given half 1M and half
IV is sufficient.

Diphtheria
Also has decreased in incidence due to vaccination program

The manifestation of the disease are due to exotoxin

produced by the bacteria causing multisystem affection e.g.
pharyngitis, carditis, peripheral neuritis ... etc.

The manifestations of diphtheritic pharyngitis are moderate

fever, sore throat, followed by circulatory .collapse, gray
pharyngeal membrane which spread in all -directions, swollen
cervical L.N. with oedema (bull neck)
'

The diagnosis is mainly clinical and confirmed by laboratory

cultures of the organism.

-182-

Cases:
(Hospitalization in fever hospital and notification )
A child 3 years old with diphtheria complicated by heart
failure (myocarditis).

Rl Procain penicillin

vaiaL

~~ 10 oJ.al ~tw. i2/ ~.J:! J4:. ~

Or Penicillin G

vaial.

c}4ll ~ ~ u&s:.lr... 6 /JW ~ Y2 u-il.. ~

Or Erythromycin 200 mg syrup.
Rl Predinsolone

tab. 5 mg

-U:F~i oJ.al ~.J:! ~,_,.. 3 ~J

Rl Antidiphtheretic serum IV,(Single dose)skin sensitivity
must be done, if the patient is hypersensitive, desensitization
schedule should be don.
Pharyngeal or Laryngeal: dose: 20.000- 60.000 units.
Extensive (nasophoryngeal, neck swelling: dose: 60.000 100.000 unit
~ ~ J~ 4t.Jli ~~.>WJ ~J.JS~J ~.JJI ~ .;i\J:i u-- ~'i
-~ ~~....u.:~JI J~l ulS. tjl

Rl Digitalization
(See heart failure)
N.B. Heart failure can occur within 6 weeks
.U~I ~ WF-~i o.l.J J,!")rl ~ y..;-11

u-3 u4J...r.Jl ~\:ill ~!Jll

.~1 ~ s.l.J -;~~~

\

.U~I ~I u~l t~

(.)Al.,.;Jl ~I JSl ~\!_,

-183-

~JJ.JJ ~l.k.J

Typhoid Fever
Typhoid fever in pediatrics is not typically manifested as
in adults; it has a wide range of presentation.
Clinically: the child complaints of fever, malaise, headache
and crampy abdominal pain with distension, constipation or
diarrhea, high fever and toxaemia, in addition to mild
hepatosplenomegally and symptoms of complications as
intestinal perforation or meningitis.
Blood, urine and stool cultures are diagnostic, while Widal
test is suggestive even if positive.
Infection is by contact to patient or feco-oral and waterborne.

Case 1:
A child 10 years old with typhoid fever (Prolonged
Hyperpyrexia, toxic, tender abdominal distension, severe
anorexia and vomiting).
Rf. Thiophenicol 750 mg
widely used)

vials (the drug of choie but not

~ ~J ~ r-1.:1 5 o.IA! .J ~Lw. 12 JS J..$ ~ 1.5 ~_., ~ 3 ~ J=.:i

.ti~l

R/ Septazol or Septrin

syrup.
.~Lw.12/~~

~~ ~J ~ "="~ lS~I J~l ~

syrup.

Rl Ketofan or Marcofen

-184-

Case 2:
A child 6 years-old diagnosed as a typhoid fever with
toxemia and pallor

R/IV Fluids
.~~ 12

Rf Cefatriaxone or Claforan 1 gm

JS

~ J~ ~00

vial
.~l.w 12/~ ,jl ~ ~

Rf Epidrone

amp

Rf Voltaren supp. 12.5 mg

Rf Kiddi pharmaton
Rf Blood transfusion

-185-

intestinal perforation c!a~

u.- \i_p. uA&..Jo4ll...J..Plo.l\ ~

-186-

Scarlet fever
Group A streptococcal infection. It may leads to
rheumatic fever. Acute onset of fever, malaise, and headache.
The tongue is coated with white membrane with prominent red
papillae (white strawberry appearance tl.J);ill U,J.l ul.....Jll). After
shedding of the membrane, the tongue gives a red strawberry
appearance. The rash is red, punctate, blanches on pressure with
no rash around the mouth (Circumoral pallor).

Case 1:
A 7 years age child with typical scarlet fever.

Rl Augmentin 457 mg

susp.

Rl Ultrafen or Ketofan

syrup.
~.J:! ~~4 ~5

.~~ .J~'/ ~~ .JI

~~~ ~JI ~~~'/ t.r1J 'J

Case 2:
An infant 7 month-old age child withtypical scarlet fever
(fever 39.5, strawberry tangue, vomiting and skin erythema)

Rl Ospen 400mg susp.

Rl Cataflam drops

-187-

Case 3:
A 10 years age child with typical scarlet fever.
Rl Penadur 1.200,000 iu
vial
.4-.t....:.. .;~1 ~ .&J .1=1! o~IJ v,.. ~ c.s.lAll J.!~ ~ Ub.
R/Megafen

tablets

Case 4:
An infant 11 month-old age child with typical scarlet
fever (fever 40.5, red strawberry tartgue, vomiting and skin
erythema)

Rl Erythrocin or Erythropriin syrup.

~l:!l ~ o.lAl ~~t..... 8./ ~ s
R1 Cetal or Marcofen syrup
R/Frutal

syrup

-188-

NEUROLOGY
Antiepileptic Drugs:

ill Sodium

Valproate:

20-60 mglkg/day divided into 2

doses.
Preparations:
Oepakine:

- Tablets 200 mg & 500 mg.

- Syrup 57 mg/ml.
- Drops 200 mg/ml.

Convulex

- Capsules 150 mg and 300 mg

- Drops 300 mg/ml = I 0 mg/drop.

N.B.: It is contra-indicated in neonates and not recommended in

infancy as it has age dependent hepatic toxicity (the younger the
age the more possibility of toxicity).
(2) Carbamazpine: 10-30 mglkg/day every 8 hours.

- Tegretol

-Tablets 200 mg

- .CR tablets 200 mg & 400 mg (every I2 hours)

- Syrup I 00 mg/5 ml.
(3) Phenytoin: 5-10 mglkg/day

"' Epanutin

Capsules 50 mg & I 00 mg.

Syrup 30 mg/5 ml.
Ampoules 250 mg/5 ml for I.V. use.

-189-

(4) Phenobarbitone: 3-5 mg/kg/day

- Sominelleta

. Tablets 15 mg
. Syrup 15 mg/5 ml.
. Ampoules 40 mg/ml

- Sominal

. Ampules 20 mg/ml
. Tablets 60 mg.

(5) Clonazepam: 0.05- 0.2 mg/kg/day

Apetryl tablets 0.5 mg and 2 mg.

Amotril tablets0.5 mg & 2 mg.

Clopam tablets 0.5 mg & 2 mg

(6) Diazepam: 0.3 - 0.5 mglk:g/dose

Valpam, Neuril, stesolid

amp (10 mg/2 ml)

&

10-5 JSl J:.~ 5

Valpam or stesolid syrup (2 mg/5 ml).

V alinil or Caliurn tablets 2 mg & 5 mg.

Diazepam or Stesolid suppositories 5 mg & 10 mg.

f7) Midazolam: 0.1 - 0.2 mg/kg/dose.

- Dormicum tab 7.5 mg
(8) Recent antiepileptic drugs:
1- Lamotrigine ''Lamotrine" 25, 50, 100 mg. tablets.
2- Oxacarbazine "Trileptal" 150, 300 & 600 mg tablets.
3- Topiramate "Topamax" 25 & 100 mg tablets.
4- Vigabatrin "Sabri!" 500 mg tablets.

-190-

5- Gabapentin "Neurontin" 100 & 300 mg capsules.

For more details, see the other book by Dr. Emad El-Daly
"Updated management of Childhood epilepsy"

Febrile Convulsions
It is an absolute childhood convulsions occurs between 6
months....:... 6 years. Simple febrile convulsion (Generalized, < 15
minutes, with short post-ictal sleep, occurs once/febrile illness
and E.E.G. is normal after 15 days of the fit), the reverse to the
previous characters called complex or atypical febrile. The cause
of fever is essentially extracranial (G.E., O.M., pneumonia,
tonsillitis or U.T.I.).

D.D.
*Febrile convulsions,
* Intracranial infection
* Epilepsy precipitated by infection causing fever.

Case: .
A child 23 months old coming with fever and generalized
convulsions lasting about 5 minutes with no signs suggestive of
intracranial infection and he regains conscious levet shortly after
the fit. He has tonsillitis and -ve family history of epilepsy or
convulsions.

-191-

R/ Tempra syrup.
R/ Dolphin 12.5 mg supp.
Rl E-Mox or Ospexin 250 mg susp .
.R/ Valpam syrup

Or Diazepam supp 5 mg
.~14,;J e,l.i:iJI U!,A! ~ u~LA..a 6 fer.-~ UM~

. 4Jl: *" \.4

uiJL4S ~ ~

~J ~J:! ~ ~~ v~ 4JJ CJML:i Ji ~ r-'11 ~ ~

ol
_, .. !..&U, t.S i 9- IJ:i:.l l.r"
. _j
~ <,.J"-

IJ. ..aHI
-ll
~

ta..!:)J

~ lJ.:j!)I 9- J..ill
.-:~_ ...,.
~

I,..

~ ~~J U.)I-Al ~I ~I ~!>A (.).!.=J '-:-lJ>.!. r-J::lWI ~J

e.

4JJ U:iJI

v:a J~ r-~Wl ~l: ~jill ~ ~~ 4JJ e,l.i:iJl

-vl>aJ'

J~ ~ ~ ~~~ u~

,l! ~LA..a 24 o.1.41 JWI ~ ~

. (CSF analysis)

~J ~~

J.il.w

.~1
~ JI u
m--11 ~ r.st~ ~~
"'~ "i l...il-'1
~
!J ~~
~ u~l
.

-192-

Epilepsy
As starting antiepileptic therapy is a dangerous decision.
You should be sure that the case is epilepsy (i.e. exclue
syndromes that mimic epilepsy as syncope, breath holding
attacks, shuddring attacks, benign paroxysmal vertigo ... etc).
If the case is sure epileptic, you should ask yourself . . . Is
it first attack ? If yes, you could postpone antiepileptics until
another attack occurs as 70% of the first attacks don't recur, but
if the first attack is associated with +ve family history of
epilepsy, or the patient has a neurological deficit or mental
subnormality you should start antiepileptic drug therapy.
The rule is to start with single drug (monotherapy) and
increase the dose gradually until response is achieved, if no
response on the maximum dose, use another drug and on
control withdraw the first drug gradually.
N. B.: Duration of therapy is minimally 2 years free from fits.

Selection of antiepileptic drugs:

(1) Generalized convulsions: Depakine, tegretol, or epanutin.

(2) Focal (Partial) convulsions: Tegretal is the drug of choice
but depakine could be used.
(3) Absence attacks (petit-mal): Depakine and/or Aptryl.
(4) Convulsions in the neonatal period : Sominelleta and if
failed to give complete control add epanutin.
(5) Convulsions in the first year (beyond neonatal) period:
Epanutin and/or sominelleta.
-193-

Case 1:
A child 5 years old with recurrent absence attacks (> 10
times per day without loss of body tone) and E.E.G. shows 3HZ
spike and slow waves. His weight is 19 kg.

Rl Depakine syrup.
.~i

o.wl ~L..r... 12 1 ~ 200

.~t o.1Al ~L... 12 1~ 250 ~

-~ ~ ~t- 12

1 ~ 3oo ~

If no response add:

Rl Apetryl or Amotril

0.5 mg tab.

Case 2:
A infant 10 months with first attack of generalized tonicclonic convulsions without fever. The growth and development
is normal with normal neurological examination. Serum calcium
is 10.4 mg/dl and E.E.G. is normal. Family history is -ve for
epilepsy.

RI
Case 3:
A male child 3 years old presented with.recurrent attacks
of right hemiconvulSions with short period (few hours) ofTodd's
paralysis of the right side. E.E.G. shows focal epileptic discharge
and C.T. is free. His weight is 14 kg.
-194-

Rl Tegretol syrup
.~i o.1.Al c.::a~L.... 8 JS ~ ~ 2.5
.~i o.1.Al c.::a~L.... 8 JS ~ ~ 3.~ ~

~~c.::a~L....8

JS

~~4.5~

tAali ~ ~ ~j,al\ u.- ~iii .4j~1 ~Lw.'tl ~ Ji1al' u4

~J:i

,.'II ~ ~

..>AYI 1~ ~ f'_flll

Case 4:
A female infant 8 months with recurrent generalized tonic
(G.n. convulsions not related to fever. Serum calcium 9.7 mg/dl,
E.E.G. shows generalized epileptogenic activity and there was
+ve family histocy of epilepsy. Her weight is.9 kg.

Rl Epanutin

syrup
.c.::a~L.... 8

1~ 2.s

. u!J.. 3 1~ 5 ~i ~ ~..;J:i ~~ J~ ~~~ ~ ,_1 \.~!

: c.::atlb,j,.
-~~ ,Ji U:tS~ ~ ~~ ~ ~ - ~ ~ ~ U.l~,J ~

~I~ ,_IJJ..SI ~~~~I~~~ ~~-II~~~

y..Tco.U~Wal~~l
- -' -~~~
wr
. - !J[~-. ~ ~1""""~
~

oeU.. v.w ~ ~ J.S. ~ ,.hJ'i ~ill ~~'l1 .JA ~ Ji ~~

.c.::a-JW\ ~~~ ~ - ~ Wi ~

"':'+.!

lll(c.::al'*- o>4 u..

Asb

u-o c.::a~ &..W.J.J ~.,).,1\ ~..;till

.~ 4P.J Jlvi f.J;Sf; i.JAJl4.JS.!.J '-'<!.'; .:w ~ _$'-if:..J/ ,-...)
'-~"J; Mn U'ILw.i ~'11

-195-

Status Epilepticus
Status epilepticus is a

common and serious medical

emergency, it is defined as proloned convulsions more the 30

minutes or serial fits, in between, the patient doesn't regain
conscious level.

- Intial management:
1. Assess oral airway for patency and insert and
oropharyngeal .airway, if available. Excessive oral
secretions are removed by gentle suctioning.
2. Give 100% oxygen better by a face mask. .

3. I. V. line should be immediately established.

- Anticonvulsant therapy:
1. Diazepam: It is the first drug given in a dose of 0.25 nigl

Kg, LV. over 3 minutes. When necessary, the dose can be

repeated after 5 minutes. When an I.V. line is not
available double the calculated dose can be given rectally
by a syringe and flexible tube. If the drug is not effective
proceed to other drugs. Commercial preparations are
Valium, Stesolid, Neuril or Valpam ampoules. (all are 10

mg/2 ml).
2. I.V phenytoin: It .is given in a dose of 15-20 mg!Kg over
10-15 minutes. Close monitoring of the heart is essential

-196-

as

senous

heart

block may

occur.

Commercial

preparations are Epanutin & Epilog ampoules ( both are

250 mg/ 5ml)
3. Diazepam I.V. infusion : it can be considered especially
if the initial loading dose diazepam was briefly effective.
It is given in a dose of 0.2- 0.3 mg/Kg/hour.
4. Midazolam: can be tried in a dose of 0.1 mg/Kglhour
when diazepam infusion is not effective. Available
preparation is Dormicum ampoules. (5 mg/ml).
5. Valproate (depakine) enema: 60 mg/Kg/ dose depakine is
diluted in saline and given rectally.
6. General anaesthesia in severe non-responding cases

Acute Bacterial Meningitis

It is a serious infection associated with a high fatality rate

and chronic sequlae. It starts with fever, anorexia, vomiting ,

myalgia and sometimes purpura. Meningeal signs are positive
beyond the first one and half year (Kernig sign and Brodzinski
signs); In younger children and infants bulged anterior fontanelle
is common. Change of the conscious level in late sta&es.
Diagnostic investigations include CSF chemistry (high
protein, low sugar and neutrophilic pleocytosis) and culture

-197-

sensitivity. CSF should be tapped while the patient is supine to

prevent cerebellar herniation. Blood culture and blood picture
may help. C.T. brain if brain abscess or increase j . ICP is
suspected.
Treatment by parenteral antibiotics for 10-14 days,

3rd

generation cephalosporins (200 mg/kg./day) are the drugs of

choice but combination of ampicillin (200 mg/kg/day) and
Chloramphenical (1 00 mg/kg/day) is accepted. Corticosteroids
are indicated to decrease sequlae (used for 3-4 days only). Ifi.V.
fluids is needed, give 70% of the expected as in meningitis is
associated with inappropriate secretion of ADH. Control of
convulsions.

Hospital Management

Case:
A male infant 14 month old with fever, irritability,
vomiting and 2 attacks ofG.T.C. convulsions and bulged anterior
fontanelle. CSF examination shows protein 100 mg/dl, sugar 10
mg/dl and over counted polymorphs. His weight is 10.5 kg.

Combination of
1- Epicocillin 500 mg
3- Cidostiile 1 gm

vials

vials.

-198-

OR/ Claforan Or Rocephen 1 gm vials

-~41 ~ o.l.J ~t-... 12 JS ~til:..

Rl Neuril or Valpam or Farcozepam amp.

Or Epanutin 250 mg/5 ml I.V. drip.

~..J ~L...

U,.,.a.j ($ J.4

Rl Dexamethazone

~- j:.~

($ .lJ...)J

c:lA JjhA ~ 100 ~ ~ 4

amp
-~l:fl ~~ o.l.J ~~t-...

s JS ($~ ~ 1

Poliomyelitis
It is an acute viral infection of the anterior horn cells of
the spinal cord and the motor nuclei of the brain stem. It was a
common cause of acute flaccid paralysis in childhood but
nowadays, with the Egyptian program for polio-eradication,
guided by the Ministry ofHealth, it is very seldom to see any
cases.
Criteria for diagnosis of paralytic poliomyelitis
1- Acute massive flaccid paralysis.
2- Haphazard in distribution.
3- Purely motor with completely intact sensation
-199-

4- Hypotonia and hyporeflexia.

.5- Normal Babinski, cremastric and abdominal reflexes.
6- Regressive course to leave some paralysis.
Management of acute oaliomyelitis:
1- Notification.
2- Isolation for 2 weeks.
3- Observation for diaphragmatic paralysis..
4- Ryle feeding if bulbar muscles are affected.
5- Rest of paralyzed limbs in neutral position.
6- No I.M. injection
~

In the subacute stage

In chronic stage

physiotherapy
orthopedic surgery and

rehabilitation.

Cerebral Palsy
Cerebral palsy is one of the commonest neurological
probiems of infancy and childhood. For managemelit of this
problem, a team work of neuropediatrician, physiotherapist and
orthopedic doctors are required. Cerebral palsy may be spastic,
hypotonic, ataxic, choreoathetoid or mixed type. It may be
hemiplegic, quadriplegic or paraplegic.

-200-

Case 1:
A Child 19 M. with atonic C.P. and left hemi-convalsions, his
weight is 11 kg.
Rl Teqretol

syrup

Rl Depovite B 12 ampoules
Rl Ginsing

syrup

Rl Neurocet

syrup
~~I

t_) ~I ~ 1.:--.9:1 ~.>4 ~ l.lal.G

~[~+

Case 2:
A child 5 years old with spastic C.P. He speaks few
words but scissoring and spasticity are marked.
R/Neuroton

ampoules . .
~--':! u-U.

Rl Baclophen or mylobac 10 mg tab.

-201-

JS ~ (~ '1.5) tiLJI %

R/ Myolastan 50 g tab.
~L...w ~,)

Yz
Rl Botox or Dysport local injection in adductor group of
muscles.
~~ y~l ~ U~~~ ~ ~~ Y-+IJ ~~~I ol..A

.(Neuropediatrician)
R/ Surgical release of adductor tendons.

Case 3:
A newborn 25 days-old with diffuse hypoxic-'ischemic
encephalopathy (H.I.E) on CT, due to_obstructed laboure.
R/ Neurocet

syrup

R/ Tanakan

syrup

R/ :I: Cerebrolycin amp.

R1 Vitapoly

drops

-202-

ENDOCRINOLOGY

Congenital hypothyroidism
Neonatal screening program in Egypt is the only means
of . early diagnosis. Congenital hypothyroidism should be
diagnosed by neonatal screening within 10 days of birth, it may
be recognized clinically during the first month of life or may be

unrecognized for months because most of newborn appear

normal and gain weight even without treatment.
Clinical: early nonspecific manifestation:
Feeding difficulties, prolonged jatindice, hypotonia,
constipation, weak cry, macroglossia, umbilical hernia.

Laboratory: T4 and TSH levels . are diagnostic, bone age for

diagnosis and evaluation of treatment.

Case:
Newborn 30days old with Hypothyroidism (T3 & T4 are
low and TSH is High)
R/Eltroxin

so p.g

tab.

e~ UJJ ~J:! ~~lJ ~ c}--a..J ~ ~lJ ~.J

.~.,~~T4&TSH . ~~oJ~!

.UJ.Jll ~ ~ JS ~,P.JI J:!Ai

-203-

Diabetes Mellitus Type I

(IDDM)
The majority of diabetic children are presented firstly by
diabetic

ketoacidosis.

Other manifestations

are palyuria,

polydepsia, enuresis, weight loss, increased fatigability, perianal

candidiasis in girls or recurrent oral moniliasis.
The diagnosis is confirmed . by fasting blood glucose
> 140 mg/dl and after 2 hours >200mg/dl.
Once the diagnosis is established, the treatment is life
long. The aim of regular treatment is to establish near normal
blood

glucose

level

without hypoglycemia

or

diabetic

ketoacidosis, to help the child to enjoy his life and to delay or

prevent micro-and macrovascular complications as retinopathy
nephropathy and neuropathy.
The management of diabetic child include:
1- Insulin therapy
2- Diet.

3- Exercise
4- Management of hypoglycemia.

-204-

5- Management of hyperglycemic coma.

6- Management of complications.
Insulin therapy:

Insulin is the only therapeutic drug for diabetes m

childhood (IDDM). The concentration (40 IU/ml or 100 IU/ml)
and the type (Rapid acting, short acting or long acting) and the
graduation of the used syringe,

4~

IU /ml or 100 IU/ml.

Rapid acting:

Act rapid HM

40 IU/ml

HumulinR

100 IU/ml

Actrapid penfill

100 IU/ml

Actrapid Novlet pens

100 IU/ml

Intermediate acting:

Insulin retard

40 IU/ml.

HumulinN

40 & 100 IU/ml

Insulatard Novlet pens

100 IU/ml

Long acting:

Lantus

100 IU/ml

Comibjnation:

Mixtard 30/70

40 IU/ml

Humulin L 30/70

40 & 100 IU/ml

Mixitard Novlet pens

100 IU/ml
-205-

~ .J ri.~.....YI J.,.... J...:JY ~Lc.y.JI ~~Y ~_,..-.jYI ~ r1J.:7..:L...I ~

.\.h:.. ~(51 UJ.l S~.J 50"~I s~l_, S~.J.:,... ~y.JI ~

. ~~ w:-obll ui u~ l_,c.JJ= ~~YI

=
--==
=

.J

rlil'

c.
~

)ooo-4

-206-

There is wide range of dose of insulin due to irregular diet of

the child and the difficulty to control. Also, it is appetizer.
The range from 0.5- 1 ill/Kg/day.
In diabetic ketoacidosis we start by short acting insulin Y2
the dose IV and Y2 SC every 4-6 hrs, according to the level of
hyperglycemia with regular monitoring of blood glucose.
When the patient become conscious, it can be given every 8
hrs S.C before meals.

On discharge the dose calculated and given m 2 doses

morning and evening using combination of insulin short
acting 113 + long acting 2/3 (single vial is better and more
accurate than two vials of different types).

# 2/3 of the calculated dose given at morning before breakfast

S.C. and other 113 at evening before dinner S.C.

The total dose can be decrease on exercise or sports and

monthly adjustment is indicated.
Injection SC at different site, every day change it with using
antiseptic and new syringe .
Patient and his family should know . an idea about
manifestation of hypoglycemia and its management.
The decrease or increase of insulin dose should be 10-15% of
the previous dose.

-207-

Diet:
The nutritional needs of ?hildren with DM do not differ
from those of healthy children.

It is difficult to make diet control below 5 years.

The adequate caloric intake must be sufficient to balance

the daily expenditure and satisfy the normal growth and
development.

The total daily caloric intake can be divided to 3 meals

plus 2 mid-meal snacks.

The total daily calories should be as following:

50% carbohydrates:
Complex carbohydrate eg.
(~ U,JJ ~lS

.4.5!;!. J.J.

~~. ti~)

It is better because slowly absorbed, but highly refined sugars

should be avoided.eg.

- J-c.

-~..)A-~~~-~~-~- ~La~

.;S.wJt ~ ,.~l,i.Q _,~...)oW eti:i.;l ~~ c.~J~ ~ 4:i~

This leads to rapid fluctuation of blood sugar.

30%) fats: replaced animal fat by vegetable
~I u,.. 'i~ ~~

c) ~lll ~j ~ ~l+lll ~.J-I.Jll ~1~1 ~

.~l.lwal\.J ~I ~Jl!J .

20 % protein: Low fat proteins

~ U.J~ .J

-4 ~ t~ ~Jll ~~~I .J ~I ~

-208-

1.)..4

~'II ~ ~ 6J~

4..S)jil!J c!!~IJ c!!IJ~I

~~

1.)..4

.;US"il

.~IJ~I

.J.Jll!J ~IJ c;IJ_,...ll J.Jill ~ c!!~ u,. .;US"il ,_J&.

(,fWJIJ u~l ~

(U....;S.-) ~~I ~I ,_1~1 ~

.~I~.J

c!!~'--li.J ~~ ylaNI ~.;l..w

Exercise:
Exercise lowers the blood glucose concentration, depending
on intensity and duration of the physical activity;
Increased energy expenditure should be covered by providing
an extra snak before and during the activity if prolonged.
~ ~

_,t ~li _,t ~~ #

{ iJ":.; c!l.l~
0

Or reduce the afternoon insulin dose by 10-15%.

Any way exercise should be encouraged even competitive sports,
for physical and psychological support.

Case 1:
A child 5 years old with recent history of polyurea ,polydipsia
and loss of weight ,RBS was 460 mg/dl , ketones in urine ++ and
fully conscious .
R/HumulinR

100 IU/ml

~ ~ ~I ~ .:JI.U.J 5 J ..L.!jjll ~ ~~ ~_,......;1 .:JI.u._,

5 "~I !
.~_,!1

.~!.!.All .j.;i J ~l.lilli J.:i J JllaAII ~ ..;;.t~f

3 ..l..b.JI ...:.-1 ..:JI~J 5 ~~I !

.~~

.o_r

JS' J.:i fi.-. ~ ~ :

JS' j_?.-JI ~ ,.P ~~~ o~J 2 ~ ~..t-J~I ~ft ~ Jl O.)l!j ~ !

~ j:...JI ~ ~

l.o.L;$.

~WI ~l..

24

J~ ~..t-J~I ~~ y~ ~

.~250J100
.~)i

r41 5-3;;-' opl o.i.A J.;N-J !

.~1 Jl ~.WI j..~ ~WI ~..t-J~I J~

R/Humulin L

100 IU/ml

30170

OR /Mixitard Novlet pens

lOOIU/ml
:~

. JIW~I

Jl ~l.-.11 ~~I~ !

J.:i 2/3

. ~!.!.All J.:i

R1 Multisanostol

1/3

syrup
-~.J:!~~~

Rl Diet guide and control.

Rl Psychosocial support.
R/ Regular revisits and chick of RBS.
R/ Regular visits and chick renal, thyroid functions and
ophthalmological consultations.

-210-

Case 2:
A child 3 years old with IDDM

R/Lantus
R/HumulinR

lOOIU

100 IU/ml

JS"JI ~ ~ 4$._p.JI ~ ~ )~l.!.tJI

.}.i J

~1~1

J.,j J Jlla.ill .}.i Jl.o ~J-il ~r:'

. ~.rJI ~~I J ~..LII ~~I 4-JJ ~JiJ

1~'-

-211-

3J \;f1io 5 J

\:.-~ o~J

:"}\.!..o

Hypoglycemia
Decrease blood sugar below the lower.limit of normal. .
It commonly occurs due to

1- Calculated insulin overdose.

2- Wrong injection of overdose.
3- Excessive exercise without food support.
4- Received insulin without meals
Manifestations:
Exhaustion, poor concentration.
Sweating.
Convulsions.
Coma.
Diagnosis: by low blood glucose level < 50mg.
Treatment:
Give the patient 3-4

spoons of sugar either directly in the

mouth or dissolved in water. The alternative is cup of juice.

Jn comatosed patient, I.V. glucose 10% slowly.
Glucagon ampoule I.M. or S.C. could increase serum glucose
within 10-15 minutes.

-212-

DERMATOLOGY
General principles:
A- Topical steroids: varymg potency and preparatiom ue
useful for controlling inflammation.
1- The choice of particular steroid is a function of the location
and type of eruption, the age of the patient, and the duration
of treatment.
2- Skin atrophy can occur when strong preparations are used on
the face, groin, axillae, and area of thin skin.
Topical glucocorticoids
Potency
Low potency

Cases
Hydrocortison 1% cream & oint.
Micort cream, Locoid oint

Moderate potency

Elecon oint & cream

Kenacort cream & oint.
Cutivate oint & creams

High potency

Vologcream
Betnovate crean & oint
Betaderm, Dermovate oint and
. creem

-213-

B. Antihistamines:
Systemic antihistamines are useful for control of intense pruritus
and significant sedation.

Types of antihistamines:
(1) Sedating antihistamines:
- Primalan or Fenistil or Tavegyl or Allergy! syrup .

uJ.>..a 3-2 ~ ~~ I ~ 101 c)l.a 5

- Fenistil drops
.~-J:!ll

uA uJ.>..a 3 I& 1~

(2) Non-sedating, long acting antihistamines:

- Claritine or Mosedin or Loratadine or zyrtec or cetrak or
Histazine-1 syrup.

(u.zii .. ~ ()4 Jti ~ '/) 4-u, 'O.J.al~ 10ic)l.a 5

C- Glucocorticoid + Antihistamics:
Phenadone or Apidone or V~ndexine syrup.

~--------------D_i_a_p_e_r_D_e_r_m_a_t_i_ti_s--------------~'
Most cases of diaper dennatitis are due to irritation from
prolonged exposure to alkaline urine and faces, secondary
inva5ion by Candida albicans contribute after use of systemic
antibiotic or diarrhea

-214-

Case 1:
Infant 2 month old with normal diaper.
Rl Zinc-olive or Al stain
.u~l ~ ~~~ ~

OR/ Pan-D or Zincosil

, iJh':i'l ~ c.;oW.Jo4 utA~

stain

Case 2:
Infant 2 month old with simple diaper dermatitis
Rl Daktarin or Miconaz-H cream
.u~ c)&- ~I.Wl ~ , iJb'iill ~ ~l:!f 5 o~ ~.)'Q

c.;oW.Jo4 ulA~

Or Triderm or Kenacomb cream

~~ ~ ~..;.wll ..miill

~ ~ ~ .W U,H~I ~I.W.....I ~~
~J:!ll DA ~~ u);:lil ~

ClA..JI

~\ljll

Jlf..wa"/1 u'J~ ~ ~li. ~~~ DA

Case 3:
Infant 6 month old with sever diaper dermatitis and
i"ected skin ulcers
R1 Lotriderm or Miconaz-H cream
. u~l ~ ~tb.ll ~ , iJh.'i.;t1 ~ ~l:!i 5 o~ ~.>4
-215-

c.;oWJ-4 ulAJ

RJ Fusiderm

oint
~Lr..JI ~ JJ~ ~~ ~..,.. ~_,..

RJ Mycostatins

utAJ

oral drops

RJ Velosef 250 mg Syrup

Urticaria
Erythematous,

blanchable,

circumscribed,

pruritic

oedematous papules. Sometimes with angioedema. The cause of

acute disease

include allergens such as foods, drugs, insect

venoms and infectious agents.

Case:
Child 5 years old with severe urticaria after sea food meal.

R, Decadron or Fortecartin

RJ Claritine
R- Vendexin

amp.

syrup
or Phenadon syrup
-~..>A~ ~413 ~~ I.::&}J.e 3 ~ 5

-216-

Atopic Eczema
It is a chronic, relapsing eczematous dermatitis . It is a

clinical diagnosis of piuritis. Facial and extensor involveme- '. in

infants and young children, flexural lichenification in older
children and family history of atopic disease e.g. bronchial
asthma, allergic rhinitis.

Case:
Child 4 years old with chronic relapsing atopy ( eczema).

Rl Dermovate or diprosone oint

~~~ o..!.Al \:.A-.9:! ~->A~""' ulA.l

Rl Histazine-1 or Claritine syrup

Or Tavegyl or Allergyl

syrup

If there is infection:
Rl Ceporex 250 mg

susp

-~~\..., ~~l.w

Or/ Zinnat

8JS ~ 5

125 mg syrup
-~L-12/ ~5

-217-

Impetigo Contagiosa
Erosions covered by honey-colored crusts are diagnostic
of impetigo, staphylococci and group A streptococci are
important pathogens in this disease. Face and limbs are common
sites of affection. Pediculosis and insect bite are a predisposing
factors.

Case:
Infant 13 month old with non-bullous impetigo of the
face, no fever.
Rl Betadine or Boric acid 4%.

Lotion
.~);.o3~~

Rl Fusi-Top or Baneocin

oint.
.u);.o 3 ~~ ..IL:I ~.J-4 uiAJ

R1 Flumox or Biodroxyl 250 mg

susp.

.~! o.14l u~Lwa 8 f ~ 5

R/ In severe extensive case injection with
cephalosporins for 1-2 days is useful.
Rl Drainage of abscesses.

-218-

1st

or 2nd generation

Scabies

It is highly contagious and transmission occurs from

person to person.

History of pruritus, most notable during

bedtime with lesions along the wrists, between the fingers, on the
palms and soles, around the umbilicus, in the axillae is the full
clinical picture.

Cases:
Rl Ectomethrin or permetbrin cream or Lotion 5%.
o.l.Al ~fo.J ~4 t)l.1 ~l4.:.. ~

UMbl\5 ~,jll I~

F.l

JS ~ . ~ (Jl.\.1

~t:t 3 ~ ~.J ~~

Or Benzanil Lotion Or Eurax 10% cram

~yt 3 ~.J ~ t)l.1 ~l4.:.. ~ UMbl\5 ~,jll I~ ~I

JS

~ ulAJ

.4ttl.A
Rl Cetrak or Mosedin

syrup
.~~
Rl Velosef or Ospexine susp.

w' ~ ~j4 Jt ~ 1~ 5
.~~t_...

s 1WJ.Jl' ~

.~Ja.ll Jl:i:i.il ~ ~,j4ll J~

.cl_,ll ~ ~ ~'JI o~!>!l JS ~~

.~ .1\jA JJ~} ~ ~IJ.ll ~I

-219-

r.J&-

'~-----------------P_e_d_i_cu_I_Q_.s_is----------------~
Pediculosis capitis (Head lice) is highly contagious and
spread through direct contact or through contaminated objects;
hats, cloths ... etc.

Case:
Rl Ectometbrin or- Newcid shampoo 2.5 % lotion or cream.
~..J U-.H~J

,.1..14 J....i.:l ~ ~J15

.wl .a~

u--hn

i.J)J ~

.44!

-~~~
Or Licid spray or Lotion
Or Benzanil or Lotion Or Pharcobenzyl cream.

-~L-1 4 i.wl ~.,w..t ~.J-1 ~ L.S

_ -~~n ~ sl....:! ~~ ~J .tJjJJ ~ ~- .

.~1~4~1~~

.ci_,n ~c) U:HL..:wll bw'il J}Jil ~~

Y~ 4l!J'/ ~ I.:U~.;..:. .A.:.. fiJ.i.:i,.l-

-220-

Seborrheic dermatitis
Seborrheic dermatitis may first appear as adherent,
yellowish scaling of the scalp (Cradle Cap) or as sudaen
appearance of erythema in the skin folds of the axillae, groin,
and neck, secondary staphylococal infection may occur.

Case:
Infant 4 month old with cradle cap.

R/Dentinox

shampoo

Or Betadine shampoo.
5 ~I ~.J ~Iolli -.W4 c..iW ~ I!UJ:J (Jo'lhll o.J) ~ ~~ 3 ~J
-~.,HoWl ~.)A ~.J

-.W4 ~.J J.ii:!.l

Or Tonoscalpine Lotion
.~w

~ ~ 'l ~ u~'J1

.b.l cJ.4 ~~.)A ~1S lj! 'l! ~4 ~~ ~m ~$.

.Jil:ll ~
.t;~
. .t J.':-<i ~
.. ~.~~~

,~

-221-

~~~

,__ ,.0-JoU...J"
~.~II~ ~ U\.Qi.
:!J ?'
~
~

POISONING
Acute poisoning in children is a common problem it may
be accidental (the commonest and occurs with druges,
insecticides, petroleum products and paints), iatrogenic (as drug
overdose).
General lines of management:
1 -History and urgent evaluation.

2- First aid (Supportive measures).

Airway control.

Respiratory and circulatory support.

Control of convulsions if present.

In cases of ingested alkalis by immediate ingestion of

milk or even water.

3 - Prevention of further absorption of poison:

Remove contaminated clothes and washing of the

skin in organophoshorus poisoning.

Gastric lavage: mainly effective within 4 hours of

poison-ingestion but in some types of drug poisoning
(Salylsalate, opiates and tricyclic antidepressants)
gastric lavage should be done up till 12 hours after
ingestion.

-222-

Induction of emesis: contraindicate in infants and

comatose patients.

Activated charcoal (1 gm/kg) mixed with water.

4- Specific antidote: (if a available):

~

Orgonophoshorus poisoning
Opiats

Chlorpromazine & metclopramide

Isoniazid

Pyridoxine (B6)

B-Blockers

Glucagon

Anticholinergics

Physostigmine

atropine.
Naloxone
~

Disphenhydramine

5 - Enhancing elimination of the poison:

Forced diuresis: LV. fluids and alkalization of urine

by the use ofNa bicarbonate.

Haemo-or peritoneal dialysis: In server cases.

Exchange transfusion in neonates and young infants.

Case 1:
A child 3 Yz years presented with fever, sweating, nausea
vomiting dehydration, tachycardia and hyperventilation . He is
comatose with history of Rivo one stripe ingestion since about 8
hours.
R/ Maintain respiratory and circulatory support .
Rl Gastric lavage.
R/ I.V. fluids and Na- bicarbonate.
R1 Amri-k amp.
~l.u 12 JS ~ J..H,.ti 1fz
R/potassium chloride 3-5m Eq/kglday, to replace potassium loss~

-223-

Case 2:
A child 2 Yz year presented with coma, convulsions,
tachycardia, wheezing, frothing, miosis and urine incontinence.
History of insecticide poisoning and the odour of the insecticide
is smelled n his clothes.
Rl Maintain respiratory and circulatory support.
Rl Remove the contaminated clothes and clean skin with
soap and water .
Rl Suction of secretion.
Rl I.V. valium.
Rl I.V. atropine (O.lmglkgldose)

~I U~ u-i ~I ~.!.!~ ~ J.ltlJ ~

J.S ~ ~ 1 ~...iJjl

~I

wl ~ (folly's) J..H ~ ~ J...::!.L..J ~..g.JI ~ u-i ~ ~l.s.J

~'il ?' 1~1 ~A..A ~ ~

t..tt
~I
~~ ~ UM

cJ:-1~

Case 3:
A child 2 years old with severe vomiting and diarrhea
received primpran ampoule IM to stop vomiting after 3 hour
received another ampoule, the child develop extrapyramidal
manifestations
(crying,
oculogyric
crisis,
dystonia).(metclopromide toxicity).
Rl phenergan or allergyl syrup
Or allergyl or avil ampoules
Or akinton2 mg tab

Rl treatment of G.E.
-224-

Case 4:
A Childs 3 years old accidentally swallow oral
hyphyolglycaemic tablets of his father ( unknown amount one
hour ago. The child doing well, playing.

RJ gastric lavage by normal saline or water.

Rl admission and observation for at least 24 hours.
' ~1&.1... 4 - 3

JS -~ ~I ~ ~\.:!

RJ glucose 10% I.V.

~~

.fo.J J:.l.i!JI ~

cSJlill

10 JSJA JJS~

.1.1...JJ%

Cases:
A child 2 years old ingest pottase
"~m~rgency

"

RJ Don't induse vomiting.

iJa.All ~ ~

Rl Milk or fresh egg, any amount.

D:lll

.,gi ~I

.,gl ~I~

cSJ~

.
~I u,..a ~ cSi ~I ~~l

RJ Velosef or amoxil250 mgl hours.

RJDecadron or dexamethasone.
~1...12/~~1
~~ ~_,

u4lf.:ill ~twl ujiJ Ujj ~1...4i.l ~

-225-

~..P -

Case 6:
A child 4 years with kerosene ingestion.

Rl Admit for observation for 24 hours .

Rl Remove contaminated clothes.
Rl No need for gastric lavage for the risk of aspiration which
induce pnemonia
Rl Chemical preumonia and persistent lung shadow in X-ray
chest for > 1 week
Prophylaxis :
Rl curam 312 or velosef250 mg susp.
Rl Cough- cut or sinecod
Rl Farcolin syrup

. t.;,_,-.11 ~i

~I ~l.lw...JI

. JjU!, u4J\

(~ ~) ~":1\Sll.

~ ~!, ~I ~~i

~~

~4lJI

.(H2o2) ~t "L.. . ~I ~~.fi.J ~4b.>-

. ~I ~.fi.J ~

'

~t....JI_, ~Ull

. ~YI~JJ

. ~~~~

-226-

Chapter Six
Doses of the commonly used drugs
Drug
Paracetamol

Medical use
Analgesic
&

Pyral,Tempra

antipyretic

Acetazolamide

Hydrocephalus

Neonates: 25 mg/kg/24 hours.

& Glucoma

Children: 20-40 mglkg/24 hours

Acyclovir

Herpetic

Neonates: 60 mglkg/24 hours LV

Zovirax,

viroses

Novirus

CMV

&

Dose
- 10 - 15 mglkgldose every 4-6 hours.

Children and adolesence:

15-30 mglkg/24 hours LV.
12000 mg/24 hours orally.

Albumin

Plasma volume

Neonates: 0.5-1 g/kg/24 hours.

expander & in

Infants and children 1-6 g/kg/24 hours.

hypoproteine-

mia
Albuterol

Bronchodilator

Ventolin

(Bragonist)

Nebulizer solution

Neonates 0.1-0.5 mglkgldose.

Children 1.25-2.5 mglkgldose
Orally:
Neonates 0.1-0.3 mglkg/dose every 6-8
hours.
Children O. l-0.3 mg/kgldose every 8
hours

Allopurinol

Hyperuricemia

Children < 10 years: 10 mg/kg/24

hours in 2-3 divided doses.
Children > I 0 years: 200-600 mg/24
hours in 2-3 divided doses.

-227-

Drug
Amikacin

Medical use
Antibiotic

Dose
15-20 mglkg/24 hours divided into 2-3
doses. LV. or I.M.

sulfate
Aminophylline

Bronchodilator

Neonates: Loading dose 6 mglkg LV. or oral.

Maintenance dose 2.5-3 mglkgldose every 12
hours I. V. or oral.
Children: 5 mglkg/dose/6 hrs

Amoxicillin

20-50 mglkg/24 hours divided into 3

Antibiotic

doses oral, I.V. or I.M.

Amoxicillin-

Antibiotic

as amoxicillin

Antibiotic

Neonates: 50-100 mglkgl24 hrs LV. or I.M.

clavulanate
Augmentin
Curam
Ampicillin

Children: 100 mglkg/24 hours.

In meningitis: 200 mglkgl24 hrs

Antibiotic

As ampicillin.

Ascorbic acid

Vitamin-C

I 00 - 300 mg/24 hours.

Acyetylsalicylic

Antipyretic and

40-60 mglkglday every 6 hours.

acid

anti-

In rheumatic fever and rheumatoid arthritis

inflammatory

the dose is 100 mglkglday.

Atropine

Antiacetyl-

Neonates 0.1 - 0.2 mglkg/dose (maximum

sulfate

choline

Ampicillinsulbactam
Unasyn
Unictam

Rivo .Aspejic

and

antihistamine

0.4 mgldose} could be repeated every 4-6

hours.
Children: 0.02 mglkgldose
'
In organophosphorus poisning (antidote)
0.02-0.05 mglkg every I 0-20 minutes untill
atropine effect (tachycardia & mydriasis).

-228-

Drug
AZathioprine

Azithromycin

Medical use
Immunosuppr-

Dose
Loading: 2-5 mglkg/24 LV. or oral.

essant agent

Maintenance: l-3 mglkg/24 hrs.

Antibiotic

10 mgfkgfday orally as a single dose

Zithromax,

for 3 days.

Xithone
Aztreonam

Antibiotic

Neonates 60-120 mglkg/24 hours LV.

or I.M. every 8 hours

Azactam

Children: 90-120 mglkg/24 hrs LV. or

LM every 8 hours.
Amphotericin

Antifungal

Baclofen

Skeletal

l 0-15 mglkg/24 hours divided into 3

muscle

doses orally.

2.5-5 mglkgfi.V dripover 1-2 hours.

relaxant
Beelome-

Corticosteroid

thasone

inhalation

Calcitriol

Vitamin
analogue

l-2 puffs 2 times daily.

Neonates: 0.05 J..Lg/kg/24 hours. I. V or

I j..lg/24 hours orally.

Children 0.01-0.08 j..lglkg/24 hours.

. Calcium

1 mVkgfdose (of 10% solution) very

Calcium

very slowely I.V. with monitoring of

gluconate

the

heart .every

hours

untill

normalization of serum calcium.

Calfactalit

Calf

lung

- 3 mVkgfdose endotracheal.

surfactant

Captopril

Antihyperten-

Infants: 0.15-0.3 mglkgfdose

Capoten

sive

Children:

0.3

-{).5

mglkgfdose

(Maximum 6 mglkg/24 hours divided

into 2-4 doses)
Carbamazepin

Anticonvulsant

10-30 mglkgfday orally start with 10

-229-

Drug
Tegretol

Medical use
agent

Dose
mglkg/day and increase gradually 5
mglkg/week according the response.

Carbenicillin

Antibiotic

Neonates: 300 mg/kg/24 hours LV. or

I.M. divided every 6 hrs.
Children: 400-600 mg/kg/24 hours
I. V. or I.M. divided every 6 hours.

Carnitine

Dietary

Neonates: 8-16 mg/kg/24 hours.

supplement

Children:

50-100

mg/kg/24

hours

orally into 2-3 doses.

Cefaclor

Antibiotic

Bacticlor
Cefadro~il

20 - 40 mg/kg/24 hours divided into

2-3 doses

Antibiotic

Curicej.

15-30 mglkg/24 hours divided into 2

doses.

Durisafe
Cefazolin

Antibiotic

Neonates; 40"60 mglkg/24 hours

Children: 50-100 mg/kg/24 hours (I.V.
or I.M. every 8 hours).

Cefepime

Antibiotic

Maxipime
Cefixime

divided into 2-3 doses.

Antibiotic

Ximacef
Cefoperazone

100-150 mg/kg/24 hours I. V. or I.M.

8 mglkg/24 hours once or' twice daily

orally.

Antibiotic

Neonates: 100 mg/kg/24 hours

Cefobid

Children: 50-100 mg/kg/24 hours (LV . .

Cefozon

or I.~ every 12 hours.

Cefotaxime

Antibiotic

50-100 mg/kg/24 hours I.V. or I.M.

Claforan

every 12 hours.

Cefotax

In meningitis 200 mg/kg/24 hours

Cefprozil
Cefzil

Antibiotic

30 mg/kg/24 hours divided into 2-3

doses orally.

-230-'

Drug
Cefbzidine i

Medical use
Antibiotic

Fortum

Dose
50-100 mglkgf24 hours I.V. or I.M.
divided into 3 doses.

In meningitis: 150 mglkg/24 hrs

Cefaroxime

Neonates: 40-100

Antibiotic

Zinnat

mglkg/24 hours

I.VJorlM
Children: 50-100 mglkg/24 hours.

I. V., I.M. or orally every 8-12 hours.

Ceplaalexia

50-100 mglkW24 hours every 8 hours

Antibiotic

Ceponx
O!puine
Ceplmtdiae
Yelase[

orally.

50-100 mg/k&'24 hours every 8-12

hours l V., lM or orally.
25-100 mglkg/dose orally.

Anbbiotic
Hypnotic

Clllaroqaiae

Malaria Prophylaxis: 2 weeks before

travel 5 mglkglwk orally (maximum

ami-amebic

300 mgldose).
Malaria bcalment: 10 mglkg/ initial

dose (max. 600 mg) then 5 mglkglday

orally as a single dose.

Clllontbiazide

Diuretic

Clalorpbeair-

Antihistaminic

Oral dose:20 mglkg/24 hours divided

into 2 doses.
I.V. dose: 2-4 mglkgl24 hours divided
into 2 doses.
Children 2-6 years: 1 mgldose
repeated every 4-6 hours.

Children

6-12 years: 2 mgldose

repeated every 4-6 hours.

r~

..} ~ 10 JSl ~ 5

Cblorpromazia

Antipsychotic,

0.5-1 mglkgldose orally or I.V. and

hypnotic

could be repeated every 4-6 hours.

&

antiemetic

-231-

Drug
Cholestyramin

Medical use
Bile
acid

Dose
-240 mglkg/24 hours divided into 3 divided

e resin

chelating

doses.

Cimetidine

HrantagQnist

Neonates: 5-l 0 mglkg/24 hours.

Tagamet.

Infants: 10-20 mglkg/24 hours.

Children: 20-40 mglkg/24 hours. The
doses are divided every 8-12 hours.

Clindamycin

Antibiotic

Neonates: 10-15 mg/kg/24 hours I.V.

or I.M. into two divided doses
Children: 10-40 mg/kg/24 hours LV.
or I.M. into 2-3 doses.

Clomipramine

Antidepresant

Children: start with 25 mg/24 hours

and gradually increase untill reach
. response or maximum dose (200mg/24
h)

Clonazepam

Antiepileptic

0.01-0.03 mglkg/24 hours and increase

gradually up to 0.05-0.1 mg/kg/24
hours orally in 2-3 doses.

Cloxacillin

Antibiotic

50-100 mglkg/24 hours orally into 4

divided doses.

Codeine

Narcotic anal-

for pain relief: 0.5-1 mglkgldose every

gesic & anti-

4-6 hours (max. = 60 mg/dose)

tussive

Antitussive:

l-1.5 mglkg/24 hours

divided into 4 doses.

Colchicine

Anti-gout

For

agent

mediterranean fever:

prophylaxi3

against

familial

< 5 years: 0.5 mg/24 hours.

> 5 years: 1-1.5 mg/24 hours

given in 2-3 divided doses.

-232-

Drug
Corticotropin

Medical use
Adrenal

Dose
50-150 u/kg/24 hours I.M. divided into,

(ACTH)

corticosteroid

2-3 doses.

Cortisone

Anti-

oral dose: 0.5 -{).75 mg/kg/24 hours.

acetate

inflammatory

Parentral dose: 0.25-0.35 mg/kg/24

hours.

trimethoprim-

Antibiotic

4 mg/kg/day (TMP) & 20 mglkg/day

sulfamethaxozo

combination

(SMZ) into 2 divided doses

In shigellosis: 10 mglkg/day (TMP)

le (TMP-sMZ)
Septazol

and 50 mg/kg/day (ZMZ) orally into

Sutrim

2-3 divided doses

Cromolyn

Mast

sodium

stabilizer

cell

Intal

Athma:

l-2

puffs or 2

ml

nebulizer 3-4 times daily.

Allergic rhinitis : l spray each nostril
3-4 times daily.
Conjunctivits: 1-2 drops 4-6 times
daily

Cyanocoba-

Vitamin B12

lam in

100 ).lg /24 hours for 10-15 days then

once

or

twice/week

for

several

months.
Cyclophospba

Antineoplastic

Resistent nephrotic syndrome: 2-3

mide

agent

mg/kg/24 hours orally for 12 weeks.

SLE: 500-750 mg/m2/month.
Bone marrow transplantation: 50
mg/kg/24 hours I.V. for 3-4 days.
Malignancy: according to the used
regimen.

-233- .

Drug
Cyproheptadin

Medical use
Antihistaminic

t
Dose
Children 2-6 years: 2 mg/dose every 8-

-appetizer

12 hours

Tres-orex
Deferoxamine

Desfera/

Children >6 years: 4mg/dose

every 8-12 hours.
Iron chelating
agent.

Chronic
iron
overload:
20;40
mglkg/24 hours S.C. portable infusion
pump over 8-12 hours.
Acute iron overload: "Poisning"

LM.: 90 mglkg/dose could

be repeated every 8 hours

LV. drip: 15 mglkglhour (max. 6

gm/24 hours).

Desmopressin
acetate
Minirin

Vasopressin
analogue

Diabetes insipidus: 0.05 mg once

orally
Hemophilia: 0.3 J.lg/kg/dose LV. and
repeat accordingly.
Nocturnal enuresis: 20 J.lg at bed time

Dexamethason

e
Orazone
Deltazone

Airway edema: 0.5-2 mglkg/24

hours divided into 4 doses.

Corticosteroid

Anti-inflammatory: 0.08-0.3 mglkg/24

hours divided into 2-3 doses.
Bacterial meningitis: 0.6 mglkg/24
hours divided into 2-3 doses for 4
days.
Cerebral edema: 1-1.5 mglkg/24 hours
divided into 4 doses.
Inhalation: 2 puffs 3-4 times daily
Neasal spray: 1-2 sprays in each
nostril twice daily
Physiologic replacement: 0.030.15 mglkg/24 hours divided into 2-4
doses.
All the previous doses could be given I. V.,
LM. or oral.

-234-

Drug
Dextran

Dextrome-

Medical use
Plasma volume

Dose
,
20 .mVkg on day 1 then 10 mV kg/24 '-

expander

hours for not more than 5 days.

Antitussive

2-6 years: 2.5-7.5 mg every 8 hours.

thorphan

6-12 years: 10-15 mg every 8 hours.

> 12 years: 15-30 mg every 8 hours.

Diazepam

Anticonvulsant

0.2-0.3 mglkgldose I.V. over 2-3

Valpam

minutes and could be repeated after 30

Valium

minutes.
0.5 mg/kgldose rectally.

Diclofenac

Non-steroidal

1-3 mg/kg/24 hours in 2-4 divided

sodium

anti-

doses.

Cataflam

inflammatory

Dicloxacillin

Antibiotic

- 25-100 mg/kg/24 hours given into 4

divided doses.

Digoxin

Heart failure

Dimenhydrinat

Motion

2-5 years: 12.5-25 mg every 8 hours.

sickness

6-12 years: 25-50 mg _every 8 hours.

See chapter of cardiology

> 12 years: 50 mg every 8 hours

Dobutamine

Hypotension &

Neonates: 2-20 J,&glkglmin. I.V. drip.

Dobutrex

cardiac shock

Children: 2.5 - 40

~g/kglniin.

l.V.

drip.
Epinephrine

-Bronchospasm

Adrenaline

-cardiac arrest -

solution S.C. or I.V. could be repeated

anaphylaxis

2-3 times with 20 minute interval.

Ei-ythromycin

Antibiotic

0.01

Neonates:

mVkgldose of 1:

20-30

mglkg/24

hours

divided into 2-3 doses orally.

Children: 30-50 mg/kg/24 hours in 2-4
doses orally.

-235-

1000

Drug
Ethambutol

Medical use
Antituberclous

Etibi

Dose
10-15 mglkg/24 hours (max. 2.5 gm).
25-50 . mg/kg/twice weekly (max. 2.5
gm). It is given orally as a single

dose/day.
Ethionamide

Antituberclous

15 -20 mg/kg/24 hours orally in 2-3

doses.

Factor
(human)

IIIV

Fluconazole

Antihemophilic
agent

20-25
unitslkg/do.se
repeated
according to the need of the patient.

Antifungal

Neonates:

Diflucan

Thrush: 6 mg/kg LV. or oral,

once in the 1st day then 3 mg/kg/24

hours once daily for 14-21 days.

Systemic

infections:

6-12

mg/kg/24 hours
- Children: 6-12 mg/kg/24 hours LV. or
oral once every day.
Folic acid

Megaloblastic

<6 months: 25-36 )lg/24 hours

anaemia

6 months-3 years: 50 )lg/24 hrs

4-6 years: 75 )lg/24 hours
11-14 years: 100 )lg/24 hours.

Furosemide

Diuretic

1-2 mglkg/dose LV. could be repeated

,

every 6 hours according to the need.

Lasix

1-4 mglkg/day orally once or twice

daily.
Gabapentin
Sabri!

Antiepileptic

2-12 years: 15-30 mglkg/24 hours in 3

divided doses.
>12 years: 300 mg/24 hours and
gradual increase to maximum 900
mg/24 hours.

-236-

Drug
, Gentamicin

Medical use
Antibiotic

Garamycin

Dose
3-7 mglkg/24 hours divided into 2-3
doses.

Antifungal

10-20 mglkg/24 hours orally divided

Haloperidol

Rheumatic

3-6 years: 0.5 mlcg124 hours.

Safinace

chroea

6-12

Griseofulvin

into 2 doses.

years:

1-3

rnglkg/24

hours

divided into 3-4 doses.

Heparin

Anticoagulant

50 ulkg I.V. bolus intially then

maintenance 15-35 ulkglhour LV. drip
guided by partial thromboplastin time.

Hydrochloro-

Diuretic

<6 month: 2-4 mglkg/24 hours in 2

divided doses

thiazide

>6 months & children: 2 mglkg/24

hours in 2 divided doses.
Hydrocortisone

Corticosteroid

Shock: 50 mglkgldose LV. & could be

repeated after 4 hours.
Status asthmaticus: 1-2 mglkg/dose &
could be l'q)e8ted

every 6 hours.

Anti-inflammatory:

1-S

mg/kg/24

hours divided into 2 doses.

Adn:nal iasuffic:icncy: 1.;2 m&lkg I. V.

lbuprofea

Non-steroidal

Brufen

antinflammator

bollus then I S0-250 mg/24 houn

divided in }-4 doses.
Pain 8r. Fever: 5-10 mglkgldose
repeated every 6-8 hours.

Marco fen

J.rheumatoid arthritis: 30-50 mglkg/24

hours divided into 3-4 doses.

Imipramine

Anti-

Antidepressant:

Tofranil

depressant and

hours and increase gradually according

noct-enuresis

the response (max. 5 mglkg/24 hours).

1.5

mglkglkgl

24 ,

Noct-enuresis: >6 years 25 mg at bed

time

-237-

I.V.

Medical use
Immune-medi-

Dose
Neonates: 500-750 mg/kg once.

immunoglo-

ated diseases

Children:

Drug

bulin (IVIG)

I.T.P: 1000 mglkgldose for 2-5

days and could be repeated after 3-6

weeks.

CMV infection: 500 mglkgldose

every qther day (7 doses).

Severe systemic infection: 500-

-1000 mg/kglweek.

Polyneuropathy: 1000 mg/kg/24

hours for 2 consecutive days each

month.
Immunodeficiency

syndrome:

1()0-400 mglkgldose every 2-4 weeks.

Indomethacin

Non-steroidl!l -.

1-2 mg/kg/24 hours divided into 2-3

antinflammator . doses.
y

Iron

Iron

Prophylaxis: 1-2 mg/kgl24 hrs orally

Fer-in-Sol

deficiency:

thempeutic: 3-6 mg/kg/24 hours in 2-

Sytron

Anemia

. 3 doses orally.

Isoniazid

Antitubereulo .. 10-H mglk:g/24 hours . (ma:it. 300

I.N.H.

us

mg/24 hrs).
20-30 mglk:gltWice weekly (max.. 900

Isocid

. mgldose).
It is given orally divided into 1-2 doses/day.
Isoproterenol

Kanamycin

Bronchial

5-10 mgldose every 4 hours orally.

asthma

Neubilizer 1-2 puffs every 4 hrs

Antibiotic

15 mglk:g/24 hours I.M. or I.V. divided

into 2 doses.

-238-

Drug
Ketamine

Medical use
Anesthetic

Dose

3-7 mglk:g I.M

1-2 mglk:g LV.

Lamotrigine

Antiepileptic in

In combination with valproate:

Lamictal

children >2yrs

0.15 mglk:gl24 hrs 151 2 weeks.

0.3 mglk:g/24 hrs 2nd 2 weeks.

1-5 mglk:g/24 hrs after that

Levothyroxine
L-thyroxine

Throid
replacement
therapy

Lidocaine

Local
anesthetic

In combination with
antiepileptics:

0.6 mglkgl24 hrs I st 2 weeks.

1.2 mglkgl24 hrs 2nd 2 weeks.

5-15 tn&'kgl24 hrs after that. .

<6 months: 8-10 ~24 hrs
6-12 months:6-8!lW'kg(24 hrs.
1-5 years: 5-6 ~24 hrs.
6-12 years: 4-5 J,tg/kg/24 hrs

other

> 12 years: 2-3 pglk&f24 hrs.

Local anesthetic injection: doses as
&

antiarrythmic

needed maximum 4.5 mglkg not closer

than 2 hours apart.
Arrytbmias: Loading I mglkg could be
repeated
maximum

every 5-l 0
of

continuous

minutes

mglkg).

infusion

to
I.V.

20-50

J.lgtkgfminute.
Loratadine

Antihistaminic

<30 kg weight: 5 mg/24 hours.

> 30 kg weight: I 0 mg/24 hours

Claritine
Magnesium

Replacement

sulfate

therapy

Neonate: 25-50 mglkgldose every 8

in

hours I.V. for2-3 dose5.

hypomagnese-

Children:

mia

mglkgldose every 6 hours for 3-4

doses.

-239-

I.V. or I.M.: 25-50

Drug

Medical use

Dose
. Oral: 100-200 mglkgldose divided into
4 doses.

Diure

Mannitol

For decrease intracranial pressure: 0.5-

tic
-For decrease

1 glkg single dose.

Diuresis: 0.25-0.5 glkgldose repeated
every 4-6 hours.

I.Cr. pressure
Mebendazole

100 mg orally once & repeated

Broad
spectrum

Antiver

after 2 weeks in pinworm.

antiparasitic
100 mg orally twice daily for 3 days in

Vermin

other types of parasites.

Methylphenida

Attention-

te

deficit

> 5 years: 0.3-0.6 mglkgldose

(maximum: 2 mglkg/24 hours).

hyperactive
Ritalin

disorder

Metoclopramid

Antiemetic

1-2 mglkgldose every 2 hours orally or

I.V.

e
erimperam
-Anti-amebic

Anti-anaerobic bacterial infection:

-Anti-anerobic

Flagyl

bacterial.

LV. or oral divided into 2 doses.

Elyzole

Infection.

Metronidazole

Neonates: 7.5-30 mglkg/24 hours

Children: 30 mglkg/24 hours I. V.

or oral divided into 3-4 doses.

Midazolam
Dormicum

Anticonvulsant

0.15 mglkg loading I.V. followed by

I.V. infusion 1 Jlg/kg/minutes as a
maintenance.

-240-

Drug
Morphine

Nafcillin .

Medical use
Narcotic

Dose
0.1-0.2 mglkg/dose LV., l.M. or SC &

analgesic

could be .repeated every 2-4 hours.

Antibiotic

Neonates: 50-100 mglkg/24 hours LV.

or I.M. divided into 3 doses.

sodium

Children: 100-200 mglkg/24 hours

LV. or I.M. divided into 3-4 doses.

Nalidixic acid

U.T.I.

50 mg/kg/24 hours divided into 4

doses orally.

Naloxone

Opiate
antagonist

0.1 mglkg I.V. .(max. 2 mg). If no

respone, it could be repeated every 3
minutes untill the desired effects or it
be
given
by
S.C.or
could
Endotracheal.

Narcan

Naproxen

Neomycin

Non-steroidal
anti. inflammatory
Antibiotic

5-7 mglkg/dose orally every 8-12 .

hours.
Infants: 50 mglkg/24 hours.
Children: 50-100 mg/kg/24 hrs.

sulfate

It is given orally and divided into 34

doses.
Neostigmine

Myathenia

0.01-0.04 mglkgldose I.V., I.M. or

gravis

S.C. and could by repeated every 4

hours.

Niclosamide

Tapewonn

Yomesan

infection

Nitrofurantoin

U.T.I.

40 inglkg orally as a single dose.

5-7 mg/kg/24 hours divided into 4

doses orally.

Oxacillin

Antibiotic

into 4 doses

Prostaphlin
Oxcarbazepine

50-200 mglkg/24 hours I.V. 'divided

Antiepileptic

10-30 mg/kg/24 hours orally divided

into 2 doses.

-241-

Drug
Penicillamine

Medical use
Metal chelating
agent

Dose
Lead intoxication: 30-40 mglkgl24
hours orally divided into 2-3 doses
(max: 2 gm/24 hours).
Wilson disease: 20 m!Vkg/24
hours orally (max: 2 gm/24 hours)
Rheumatoid arthritis: 3-10 mglkg/24
hours.

Penicillin.G.
Penicillin

Antibiotics

See chapter one

V.

Procaine Pen.
Benzathine Pen
Phenobarbitone

Anticonvulants

Sedation: 2 mglkgldose

Sominaletta

& hypnotic

Hyperbilirubinemia: 3-8 mgt kg/24

hours orally divided into two doses.

Sominal

Anticonvulsants:

Loading dose: I 0-20 mglkgldoSe

Maintenance dose: S mglkgfday

divided into 2 doses I.M., LV. or onl.

Phenytoin

Anti epileptic

Loading: 15-20 mglkgldose I.V. drip.

Maintenance:

Epanutin

S-10 mglkglday

divided into two doses.

Piperacillin

Antibiotic

Neonates: IS0-200 mglkgf24 hours.

Children: 200-300 mg/kg/24 hours
I.V. into 4 divided doses.

Piperazine

Antiparasitic

daily

citrate
Piroxicam

60-75 mglkg/24 hours orally once

~4

Non-steroidal

0.2-0.3

anti-

mglkg/24 hours) orally one or two

inflammatory

doses.

-242-

hours (max:

IS

Drug
Praziquantel

Medical use
Anti-bilharzia!

Distocid
Prednisone

Dose
40 mglkg/dose orally repeated every 8
hours for one day.

Steroid

Hostacortin

Athma: 0.5-4 mglkg/24 hours orally

divided into 2-3 doses.
Anti-inflammatory: 2 mglkg/24 hours
Aplastic anemia: 5-10 mg/24 hr

Procarbazine

Antineoplastic

- 1.5-3 mglkg/24 hours & orally

agent
Propranolol

B-adrenergic

Arrhythmias/hypertension:

Indral

blocker

mglkg/24 hours orally or 0.01-0. I

1-2

mglkgldose I.V. infusion over 10

minutes.
Migraine

prophylaxis:

0.5-2

mglkg/24 hours orally divided into 3

doses.
Thyrotoxicosis: 2

mglkg/24

hours

orally.
Pyrazinamide

Anti-tuberclous

PTB

15-40 mgl_kg/24

ho~

orally as a

single or twice daily (max: 2 g/24

hours).

Pyridoxine

Dietary deficiency: 5-15 mglkg/24

hours for 3-4 weeks orally.
Pyridoxine dependent convulsions: S0100 mglkg/24 hours I.V. I.M. or oral.
Drug induced neuritis: I

mi/

kg/24

hours orally, I.M. I.V.

Quinidine

Anti-

2 mglkg oral. I.M. LV. as a test dose

arrhythmic

20-50
to exclude idiosyncrasy.
then
.
.

drug

mglkg/24 hours divided into 4-6 doses.

-243-

Drug
Quinine

Medical use
Antimalarial

Dose
30 mglkg/24 hours orally divided into
3 doses for 3-7 days.

Ranitidine

Antacid

1-5 mglkg/24 hours

Zantac

Rifampin

Anti-tuberclous

10-20 mglkg/24 hours (max: . 600

mg/24 hours) orally as a single daily

Rimactan

dose.
Salmeterol
Senna

Bronchodilator
long acting
Constipation

2 puffs/12 hrs
10-20 mglkgldose orally every 12
hours or once daily

Simetbicone

Antiflatulent

<2 years: 20 mgldose

2-12 years: 40 mgldose
> 12 years: 100 mgldos
orally and repeated every 6 hours.

Spironolactone

K-sparing

Neonates: 1-3 mglkg/24 hours

Aldactone

diumic

Children: 1.5-3.5 mg/kg/24 hrs orally

divided into 2-3 doses.

Streptomycin

Sulfadiazine

Antituberado - 20-40 mg/kg/24 hours (max: I gm/24

sis

h). I.M single dose

Antibiotic

Toxoplasma:
_Neonates: 100 mglkg/24 hours.

Children: 120-200 mg/kg/24 hrs orally

divided into 4 doses.
- Rheumatic fever prophylaxis:
<30 kg or <6years: 500 mg/24 h
>30 Kg or >6 years: lOOO mg/24 h.
Sulfamethoxazole

Antibiotic

50-60 mglkg/24 hours orally divided

into 2 dosa:.

-244-

Drug
Sulfasalzine

Medical use
Inflammatory

Dose
Intial: 40-75 mg/k:g/24 hours oral.

bowel disease

(max: 6 g/24 hrs).

Maintenance: 30-50 mg/k:g/24 hows
orally divided into 3 doses.

Terbutaline

Bronchodilator

0.05 mg/k:gldose (max: 5 mgldose)

repeated every 8 hours.

Bricanyl
Aironyl
Testosterone

40-50 mg/m2/dose monthly I.M.

Male
hypogonadism

Tetanus

Prevention

&

Prophylaxis: I.M. or S.C.

antitoxin

treatment

of

< 30 kg: 1500 units.

> 30 kg: 3000-5000 units.

tetanus

-Treatment: 40,000-100,000 Units LV. and

10.000-40.000 Units into wound.
Tetanus

Prevention

&

Prophylaxis: 4 units/kg.

immunoglobuli

Treatment

of

Treatment: 500-3000 units.

tetanus

Theophylline

Bronchodilator

Neonatalapnea:

&

Loading: 6-10 mg/k:g

Maintenance:

respiratory

stimulant

2-4

mg/k:gldose

repeated every 12 hours.

- Infants and Children:

Thiamine

Anti-beriberi

6 w-16 m.: 10-15 mg/k:g/24 hrs

1-10 yrs: 20-25 m~gl2.4 hours

10-15 yrs: l3 mg/k:g/24 hours.

10-25 mg/24 hours I.M. or LV.

f0-50 mg/24 hours oral.

-245-

Drug
Tobramycin

Medical use
Antibiotic

Dose
2.5-5

mg/kgf24

hours

I.v..

I.M.

divided into 2-3 doses.

Topiramate

Antiepileptic

2-l6years:

initially

l-3

mg!kg/24

hours orally and increase gradually

every I-2 week. The usuall dose is 5-9

mg!kg/24 hours.
Valproic acid

Antiepileptic

Depakine
Vancomycin

20-60 mg/kg/24 hours orally divided

into 2-3 doses.

Antibiotic

Neonates: 15-30 mg/kg/24 hrs. divided

into 3 doses I.V.
Children: 40-60 mglkg/24 hours orally

cir I. V. divided into 2-4 doses

Vasopressin

Verapamil

Diabetes

2.5-10 U/dose LM. or S.C. 2-4

insipidus

times/24 hours.

Hypertension

Infants:

0.1-0.2

mWkg/dose

and

repeated according to the desired

Epilat

effect (I.V.)
Children: 4-8 mglkg/24 hours I.V. or

orally divided into 3 doses.

Vigabatrio

50-I 00 mglkg/24 hOurs divided

Antiepileptic

into 2 doses.

SabriI
Vitamin "A"

Vitamin
supplementation

- 100,000-200,000 LUJ 24 hours.

Vitamin "E"

Vitamin
supplementation

Neonates & prematures: 25-50 U/24

hours.
Children: I U/Kg/24 hours.

-246-

Drua
Warfarin

Medical use
Anticoagulant

Dose
Initial dose: 0.2 mglkg once orally.
Maintenance dose:O. l mg/kg/24
hours orally guided by the desired
prothrombin time.

Zinc
supplements

Mineral
replacement
therapy

0.5-l mg/kg/24 hours in 2-3 doses

orally.

-247-

--