POCKET

PEDIA

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POCKET
PEDIA

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 Table of Contents

NEONATOLOGY
DISEASE OF THE NEWBORN
GROWTH AND DEVELOPMENT
NUTRITION
PREVENTIVE PEDIATRICS
FLUIDS AND ELECTROLYTES
GASTROENTEROLOGY
PULMONOLOGY
NEUROLOGY
INFECTIOUS MEDICINE
HEMATOLOGY
CARDIOLOGY
REFERENCE LAB VALUES
DRUGS AND DOSAGES

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 NEONATOLOGY

A. Newborn Exam
Clinical Sign

APGAR 0 1 2

APPEAR- Color Blue, pale Pink body, Pink all over

ANCE blue
extremities
Pulse Heart Rate Absent <100 >100

Grimace Reflex No Grimace Crying

irritability responses (withdraw) vigorously,
sneeze or
cough
Activity Muscle Tone Flaccid Some Active
flexion of the movement
arms and
legs
Respiratory Respiratory Apnea Irregular , Good;
Effort shallow crying

NOTE: One-minute APGAR scores of 7 or less usually indicate nerv-

ous system depression requiring immediate resuscitation.
Five– minute APGAR scores of less than 7 place the infant at high
risk for subsequent CNS and other organ system dysfunction.

Classification of newborns by their birth weight, (SGA, EGA, and

LGA), their gestational age (maturity)
By birth weight:
• Extremely low birth wt =<1000 grams
• Very low birth wt =1000-1499 grams
• Low birth wt = 1500– 2499 grams
 Normal birth wt =>2 500 grams

By gestational age:
 Pre-term = gestational age < 37 weeks
 Term = gestational age 37 to 42 weeks
 Post– term = gestational age > 42 weeks

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Classification by birth weight and gestational age:
 Weight small for gestational age (SGA) = birth wt 10th per-
centile on the intrauterine growth curve.
 Weight appropriate or gestational age (AGA) = birth wt within
the 10th and 90th percentile on the intrauterine growth
curve.
 Weight large for gestational age (LGA) = birth wt > 90th per-
centile on the intrauterine growth curve.

Assessment of Neuromuscular Maturity

DUBOWITZ & BALLARD SCORING

Assessment of Neuromuscular maturity

DUBOWITZ AND BALLARD SCORING

Posture: With the infant supine and quiet, scores as fol-

lows:
 Arms and legs extended = 0
 Slight or moderate flexion of hips and knees = 1
 Moderate to strong flexion of hips and knees = 2
 Legs flexed and abducted, arms slightly flexed = 3
 Full flexion of arms and legs = 4

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Square Window: Flex the hand at the wrist. Exert pressure
sufficient to get as much flexion as possible. The angle be-
tween the hypothenar eminence and the anteriort aspect of the
forearm is measured and scored:

 >90 degrees= -1 90 degrees= 0

 60 degrees= 1 45 degrees= 2
 30 degrees= 3 0 degrees= 4

Arm Recoil: With the infant supine, fully flex the forearm for 5
seconds, then fully extend by pulling the hands & release.

Score the reaction:

 Remains extended 180 degrees, or random movements= 0
 Minimal flexion, 140-180 degrees= 1
 Small amount of flexion, 110-140 degrees = 2
 Moderate flexion, 90-100 degrees= 3
 Brisk return to full flexion, >90 degrees= 4

Popliteal Angle: With the infant supine and the pelvis flat on the
examining surface, the leg is flexed on the thigh and the thigh
fully flexed with the use of one hand.
With the other hand the leg is then extended & the angled
scored:

•180 degrees = -1 160 degrees = 0

•140 degrees = 1 120 degrees = 2
•100 degrees = 3 90 degrees = 4
•<90 degrees = 5

Scarf Sign: with the infant supine, take the infant’s hand and
draw it across the neck and as far across the opposite shoulder
as possible. Assistance to the elbow is permissible by lifting it
across the body.
Score according to the location of the elbow:
•Elbow reaches or nears level of opposite shoulder = -1
•Elbow crosses opposite anterior axillary line = 0
•Elbow reaches opposite anterior axillary line= 1
•Elbow at midline = 2
•Elbow does not reach midline = 3
•Elbow does not cross proximate axillary line= 4

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Heel to Ear: With the infant supine, hold the infant’s foot with one hand
and move it as near to the head as possible without forcing it. Keep the
pelvis flat and the examining surface.

PHYSICAL MATURITY RATING

Skin:
Harlequin dyschromia

A cutaneous vascular phenomenon unique to neonates in the

first week of life. Occurs when the infant (particularly one of low birth
weight) is placed on one side. The dependent half develops an ery-
thematous flush with a sharp demarcation at the midline, and the up-
per half of the body becomes pale. The color changes usually subside
within a few seconds after the infant is placed supine but may persist
for as long as 20 minutes.

Acrocyanosis = bluish discoloration around the mouth.

Mongolian spot = a blue black macule found over the lumbosacral area
in 90% of native american, black and asian infants.
Lanugo = the fine hair covering the pre-term infant’s skin.
Vernix caseosa = a whitish, greasy material covering the body that
decreases as term approaches.
Milla = small white keratogenous cysts
Millaria rubra = blocked ducts of sweat glands that appear as small ery-
thematous papules.
Vascular markings = capillary malformations (flat vascular birthmarks
of 2 types-salmon patch and port-wine stain), hemangioma (red, rub-
bery nodule with roughened surface) and lymphatic malformations
(superficial fluid-filled vesicles or deep rubbery skin-colored nodules in
parotid area).

Head/ Neck:
The anterior fontanel at birth measures 4cm to 6cm at its largest diame-
ter and normally closes between 4 and 26 months of age.

The posterior fontanelle measures 1cm to 2cm at birth and usually clos-
es by 2 months of age.

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Caput succedaneum– edema with or without ecchymoses, ill-defined
borders, disappearing in a few days.
Cephalhematoma- subperiosteal bleed limited by periosteal attachment
not crossing suture lines absorbed slower than a caput.
Craniotabes– soft areas of bone, which give a “pingpong” ball sensation
when depressed.
Epstein pearls– whitish shiny cysts on palate & gums.

Chest:
Average Respiratory Rate and Cardiac

Respiratory Cardiac Rate

Rate

Newborn 30.75 110-150

1-2 yrs 20-26 85-125

2-4 yrs 17-25 75-115

>6 yrs 13-24 60-100

Abdomen:
3 blood vessels are found in the umbilical cord– one vein and
two arteries.
The cord has no sensory nerves; the newborn does not feel it
when the cord is clump or cut. It should drop off in about 7-10 days.
Since healthy newborns are usually discharge within 24 hours
of delivery, infants are scheduled to visit a health care provider within 1
week for well –child care.
The first stool, which consists of meconium, is usually passed
within the first 24-48 hrs after birth. If it does not, malformation of the GI
tract is suspected.
The newborn infant’s renal system does not have the ability to
concentrate urine to the degree of the older child or adult.
The first voiding usually occurs within 24 hrs. If it does not, the
infant should be evaluated for adequacy of fluid intake and bladder dis-
tention.

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 Birth 8m
Birth 6w
6 wks
Birth 4m, awaked
7m, asleep
Birth 6m, 10m
Birth 7m
2m 6m
4.6 m 24 m
3m 24 m
9m Persists

Newborn Screening
Newborn screening (NBS) is a simple procedure to find out if
your baby has a congenital metabolic disorder that may lead to mental
retardation and even death if left untreated.
Newborn screening is ideally done on the 48th hour or at least
24 hours from birth.
Newborn screening is a simple procedure. Using the heel prick
method, a few drops are taken from the baby’s heel and blotted on a
special absorbed filter card. The blood is dried for 4 hours and sent to
the Newborn Screening Laboratory.

Disorders in- cluded in the Newborn Screen-

ing Package
1. Congenital Hypothyroidism (CH)

CH results from lack or absence of thyroid hormone, which is

essential to growth of the brain and the body. If the disorder is not de-
tected and hormone replacement is not initiated within (4) weeks, the
baby’s physical growth will be stunted and she/he may suffer from men-
tal retardation.

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2. Congenital Adrenal Hyperplasia (CAH)

CAH is an endocrine disorder that causes severe salt lose, de-

hydration and abnormally high levels of male sex hormones in both
boys and girls. If not detected and treated early, babies may die within 7
-14 days.

3. Galactosemia (GAL)

GAL is a condition in which the body is unable to process ga-

lactose, the sugar present in milk. Accumulation of excessive galactose
in the body can cause many problems, including liver damage, brain
damage and cataracts.

4. Phenylketonuria (PKU)

PKU is a metabolic disorder in which the body cannot properly

use one of the building blocks of protein called phenylalanine. Exces-
sive accumulation of phenylalanine in the body causes brain damage.

5. Glucose– 6– Phospahate Dehydrogenase Deficiency (G6PD Def)

G6PD deficiency is a condition where the body lacks the en-

zyme called G6PD. Babies with this deficiency may have hemolytic
anemia resulting from exposure to certain drugs foods & chemicals.

PHYSIOLOGIC CHANGES IN THE NEWBORN

1. Physiologic weight loss– not more than 10% of BW, occurring on the
2nd day, recovered by the 10th day of life.
2. Physiologic jaundice
(unconjugated hyperbilirubinemia)
♦Predisposing factors:
a. surplus of RBC, increased cell mass
b. decreased red cell survival
c. immature hepatic function (slow bilirubin metabolism)
d. breast feeding
Occurs on the 2nd-3rd day, peaks at the 4th-5th day, disappears on the
7th day (term), 14th day (pre-term)
3. Vasomotor instability
4. Genital crisis-pseudomenses due to maternal estrogen
5. Witch milk
6. Transitional stools
7. Inanition fever– during 1st week due to dehydration
8. Physiologic desquamation of the skin for not more than 1 week
9. Falling off of the cord
10. Physiologic anemia-at 2-3 mo, permissible level 8mg%

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Physiologic jaundice and pathologic jaundice

A. Physiologic Jaundice– The contributing factors include UDPGT

(enzyme-uridyldiphosphoglucuronyl transferase) inactivity at birth, a
relatively high red cell mass even in the non-polycythemic neonate and
an absence of intestinal flora, with initially slow intestinal motility leading
to an active enterohepatic circulation of bilirubin.

For jaundice to physiologic rather than pathologic, the following criteria

should be satisfied:
1. Clinical jaundice appears after 24 hrs of age;
2. Total bilirubin rises by less than 5mg/dL per day;
3. Peak bilirubin occurs at 3-5 days of age, with a total bilirubin of no
more than 15mg/dL;
4. Clinical jaundice is resolved by 1wk in the term infant and by 2 wks
in the preterm infant.

Hyperbilirubinemia outside of these parameters or jaundice that

requires treatment is no physiologic and must be evaluated further.

B. Pathologic jaundice. Causes of prolonged unconjugated hyperbiliru-

binemia include hemolytic disease, breast milk jaundice, Crigler-Najaar
syndrome, bowel obstruction and congenital hypothyroidism.
Galactosemia generally presents with hepatomegally in an ill-
appearing, often septic infant and the hyperbilirubinemia is usually
mixed.
Clinical jaundice appears at a bilirubin level of 5mg/dL and ap-
pears first on the head, progressing down the chest and abdomen as
the level increases.

DISEASE OF THE NEWBORN

NEONATAL SEPSIS
Neonatal sepsis is a bacterial infection in the blood. It is a condition
found in infants less than three months old.

Causes
The causes of neonatal sepsis is related to the baby’s exposure
to bacteria.
Sepsis that develops within the first week is usually ac-
quiredfrom the mother, via the placenta or from passage through the
birth canal.
Sepsis that develops after 1 wk is usually acquired from the
care giving environment.

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Risk factors:

Your baby is born more than 3 weeks before your due date
(premature)
You go into labor more than 3 weeks before your due date
Your baby is in distress before being born
Your baby has a very low birth weight
Your baby has a bowel movement before being born, and meconi-
um (fetal stool) is present in the uterus
Male babies are at greater risk for neonatal sepsis than female
babies

Symptoms
Fever or frequent changes in temperature
Doesn’t drink formula or breast milk well
Not urinating
Stomach is bloated or puffy
Drool or spit is yellowish
Vomiting or diarrhea
Extreme redness around the belly button
Unexplained high or low blood sugar
Irritability
Skin is jaundice (yellow) or overly pale
Abnormally slow or fast heartbeat
Breathes rapidly, or has difficulty breathing
Bruising or bleeding
Seizures, cool, clammy skin

Diagnosis
Complete blood count
Cultures of blood, urine, CSF, skin lesion
X-rays of the chest or abdomen

Treatment
A well-appearing infant may be monitored without antibiotics
and sent home when cultures are negative. Infants who appear ill may
receive antibiotics for a minimum of two days while awaiting culture re-
sults. Culture-proven sepsis is treated 7-21 days, depending on the lo-
cation of the infection.

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Most Common Causes of Meningitis by Age

Age Group Organism

Neonates E. coli
Group B streptococci
L. monocytogenes
S. pneumoniae
Children N. meningitidis
S. pneumonia
H. influenzae

Adults S. pneumonia
N. meningitides
Gram-negative bacilli
Listeria species
Evaluation of CSF

Test Comments

Gram stain Positive in >50% of cases of

bacterial meningitis
Should always be performed,
even if CSF cell count is nor-
mal
Culture Should be plated immediately
on blood and chocolate agar
Cell count and differential “Predominantly neutrophils”
is characteristic of bacterial
meningitis, “predominantly
lymphocytes” is characteristic
of tuberculous
Cryptococcal and viral menin-
gitis
Glucose <30% of corresponding se-
rum glucose suggests bacte-
rial, tuberculous,or fungal
meningitis
Protein >150 mg/dL suggests
bacterial meningitis

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 Bacterial Antigens
India ink
Cryptococcal antigens
Acid-fast smear and culture
Detects nanogram quantities of
capsular polysaccharide of H.
influenza., N. meningitidis, S.
pneumonia, and group B strepto-
cocci..
Positive in approximately 50% of
cases of cryptococcal meningitis
Positive in up to 90% of cases of
cryptococcal meningitis
Positive in 10%-90% of cases of
tuberculosis meningitis

Abnormal Findings in CSF

Pattern Disease

Polymorphonuclear leukocytes, Bacterial meningitis

low glucose
Lymphocytes, low glucose Fungal or tuberculous mengitis
Lymphocytes, normal glucose Viral meningitis

RESPIRATORY DISTRESS SYNDROME

 Aka hyaline membrane dse, due to lack of surfactant, a mixture of
phospholipids made by type II pneumocytes
 Pathology: Diffuse lung atelectasis, congestion & edema with hya-
line membrane containing fibrin & cellular products due to surfac-
tant deficiency
 Signs: retractions, tachypnea, cyanosis, grunting
 Fine reticulogranular densities on CXR; L/S ratio <2
 Course: gets worse before improving in 3-5 days
 Prevention: antenatal glucocorticoids at 26-34 wks AOG if at risk
for pre-term delivery (Betamethasone 12mg IM 24hrs apart or 6mg
IM q12x4 doses)

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Risk factors Male sex
Premature birth
2nd born twin
Perinatal asphyxia
Maternal diabetes
L/S ratio <2
Clinical features Tachypnea
Nasal flaring
Grunting
Cyanosis
‘ground glass’ appearance on
CXR
Complications Intrinsic: pneumothorax, pulm, em-
physema
02 therapy: bronchopulmonary
dysplasia, retinopathy

MECONIUM ASPIRATION SYNDROME

Some meconium staining of amniotic fluid is seen up to 15% of
normal pregnancies.

Risk factors Meconium is passed during in-

Clinical features
trauterine stress
More common in post-term in-
fants
Cyanosis, tachypnea
Persistent Pulmonary Hyperten-
sion

TRANSIENT TACHYPNEA OF THE NEWBORN

 Transient pulmonary edema resulting from delayed clearance of
fetal lung fluid
 Signs: tachypnea, retractions w/o cyanosis, hypotension
 CXR: hyperaeration , ↑vascular markings (sunburst)
 Course: benign, self-limited

NEONATAL PNEUMONIA
 Predisposed by premature labor, PROM, ↑ digital exam
 Signs: tachypnea, retractions, cyanosis, grunting
 CXR: diffuse homogeneous & linear radiating densities

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TRISOMIES

Trisomy 21 Congenital heart defects

Mongoloid eye slant
Depressed nasal bridge
Protruding tongue
Transverse palmar crease

Trisomy 18 Clanched hands

Overlapping 2nd and 5th finger
Low set ears
Short sternum
Nail hypoplasia
Trisomy 13 Severe CNS abnormalies
Microphthalmia
Polydactyly
Cleft lip/palate

GROWTH AND DEVELOPMENT

Ideal Body Weight

Age
0-5 mos Age in months x 600 + 3,000
gms
6-12 mos Age in months x 600 + 3,000
gms
1-6 yrs Age (yrs) x 2+ 8 kg
7-12 yrs Age (yrs) x 7-5kg/2

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Usual Changes in Weight at Different Ages

4-5 mos 2x birth weight 5 years 6x birth weight

1yr 3x birth weight 7years 7x birth weight
2 yrs 4x birth weight 10 years 10x birth weight
3 yrs 5x birthweight

Length/Height
Age Centimeters Inches
At birth 50 20
1 year 75 30
2-12 yrs Age x 5 +80 Age x 2 + 32

Head Circumference

Age Monthly or Yearly Total

At birth 35 cm (13.8 inches)
< 4 mos 1/2 inch per month 2 inches
5-12 mos 1/2 inch per month 2 inches
2 yrs 1 inch
3-5 yrs 1/2 inch per year 1.5 inches
5-20 yrs 1/2 inch per 5 years 1.5 inches

Correction Fx for the Determination of Head Circumference

BOYS GIRLS
Inch Cm Inch Cm
Birth 1/4 0.6 1/3 0.8
6 weeks 1/4 0.6 1/4 0.6
6 mos 1/8 0.3 1/8 0.3

10 mos 1/10 0.3 1/10 0.3

Amt. to be added or subtracted for each lb above or below ave. wt.

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TANNER STAGES
Stage MALE FEMALE
1 Prepubertal No breast
No pubic hair No pubic hair
2 Testicle enlarge Breast bud
Scrotum reddens Some downy hair
Some downy hair
3 Some coarse,curly Enlargement of
hair areolae
Breast & areaolae
same level
Some coarse curly
hair

4 Adult type hair (mons Areolae project above

only) breats
Adult type hair (mons
only)
5 Hair spreads to medi- Full breasts
al high

 Menarche occurs at tanner stage 3

 Peak of growth spurt: Male– Tanner 4 (age 14)

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DEVELOPMENTAL MILESTONES

Gross Motor Fine Motor Language Social/

Cognitive

2 mos Lifts head/ Tracks past Alerts to Recognizes

chest when midline sound. Coos parent, so-
prone cial smile
4-5 mos Rolls front to Grasp rattle Orients to Enjoys look-
back, back voice, ah- ing around,
to front goo, razzes laughs
6 mos Sits unas- Transfers Bables Stranger
sisted object, rack- anxiety
ing grasp
9-10 mos Crawls, pulls Uses 3 fin- Says mama/ Waves bye-
to stand ger pincer dad a bye, plays
grasp (nonspecific) pat-a-cake
12 mos Cruises (11), Uses 2 fin- Says mama/ Initiate ac-
walks alone ger pincer dad a tion
(12 mos) grasp (nonspecific)
15 mos Walks back- Uses cup Uses 4-6 Temper tan-
ward words trums

18 mos Runs, kicks Build tower Names com- Copies par-

a ball of 2-4 cubes mon objects ent in task
(e.g sweep-
ing)
2 yrs Walks up/ Builds tower Uses 2 Follows 2
down steps of 6 cubes word step com-
with help, phrases mands, re-
jumps moves
clothes
3 yrs Rides tricy- Copies a Uses 3 word Brush teeth
cle, climbs circle, use sentences with help,
stairs with utensil washes /dry
alternating hands
feet (3-4 yrs)

4 yrs hops Copies a Counts to Cooperative

cross ten play

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STAGE THEORIES OF SOCIOEMOTIONAL DEVELOPMENT

Birth to 18 mos Trusts vs. Mistrust

Infants learn to trust or mistrust, that
their needs will be met by the world

18 mos– 3 yrs Autonomy vs. Shame and doubt

Children learn to exercise, to control
themselves, or they become uncertain
and doubt that they can do things by
themselves

3-6 yrs Initiative vs. Guilt

Children learn learn to initiate activities
and enjoy accomplishments ac, quir-
ing directions/ purpose.If not allowed
initiative, they feel guilty for attempts
at independence.

6-12 yrs Industry vs. Inferiority

Children develop a sense of industry
and curiosity & are eager to learn, or
they feel inferior & lose interest in the
task before them

adult Identity vs. Role confusion

Adolescents come to see themselves
as unique and integrated persons with
an ideology, or they become confused
about what they want out of life

FREUD PSYCHOSOCIAL DEVELOPMENT

Oral stage Infant obtain gratification thru stimula-
tion of mouth , as they suck and bite

Anal stage Children obtain gratification through

exercise of anal musculature during
elimination of retention

Phallic stage (oedipal) Children develop sexual curiosity and

obtain gratification thru masturbation.
Have sexual fantasies of opposite sex
parent & guilt about their fantasies

Latency stage Children’s sexual urges are sub-

merged, they put their energies into
acquiring culture skills

Genital stage Adolescents have adult heterosexual

desires & seek to satisfy them
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 PIAGET COGNITIVE
BIRTH TO 2 YRS Sensorimotor
Learning occurs through activity, explora-
tion and manipulation of the environment.
Motor and sensory impressions from the
foundation of later learning.
 Self identity– learns to differentiate
self from world
 Formation of integration schemes
Achieve object permanence– that things
can exist even when not visible

2-6 years Preoperational

Child capable of symbolic representation
of world ,as in use of language, play and
deferred imitation.
Still not capable of sustained, systemic
thought.
 Engages in symbolic play
 Decline in egocentricity
Develops language & drawing as modes of
representing experience

7-11 years Concrete operations

Child is capable of limited logical thought
process, as in seeing relationships and
classifying, as long as manipulable, con-
crete materials are available.
 Conservation– things remain the
same despite change in appearance
 Decentration– con focus greater than
one aspect of situation at a time
 Transitivity-can deduce new relation-
ships fro earlier once
 Seriation– order thingd in sequence
 Classification– groups objects

>12 years Formal operations

Can reason logically & abstractly
Thought no longer depends on concrete
reality
Can play with possibilities
Can manipulate variables in a scientific
situation
Can deal with analogies and metaphors
Can reflect on own thinking
Can work out combinations & permutations

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 NUTRITION
BREASTMILK
Colostrum
 1st 2-4 days postpartum
 ↑ CHON (globulin), vitamins, salt & Ig; ↓ fat & sugar
Foremilk– clear, thin & bluish; low fat; high water content
Hindmilk-thick, creamy-white; high fat

Comparison of Human Milk vs. Cow’s Milk

Development of Feeding Behavior in Infants
Development of Feeding Behavior in Infants
Water/ Solids Same Same
Calories 20 cal/oz 20 cal/oz

Protein 1-1.5% (whey/ casein 3.3 % (whey/casein)

78: 25) 22:78

Carbohydrate 6.5-7% lactose 4.5 lactose

Fat 3.5% (diet dependent ) 3-4% (pooled)

Minerals Iron better absorbed Low iron and copper

Vitamins Diet dependent low in K Low in vit. C & D

Bacterial content Uncontaminated Harmless bacteria

Digestability Faster emptying Same after 45 days

Age Food Introduction

Birth to 2 months Infant is given breast milk or formula

4-6 months Introduce iron fortified cereals

5-7 months Strained vegetables and fruits

Unsweetened fruit juices; avoid orange
juice

6-8 months Plain yogurt, cottage cheese, egg yolk

Poultry and beans may also be given

7-9 months Soft meats, poultry, fish, mashed fruits

8-10 months Soft finger foods; meats, poultry, fish,

cooked vegetables in strips or slices

9-12 months Regular table foods: meats, poultry, fish,

cooked vegetables in strips or slices.

12 months Can now include whole eggs, orange juice,

cow’s milk

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VITAMIN DEFICIENCY

Deficiency Manifestations
Vitamin A Ocular lesions (Xerosis)
Thiamine (B1) Beriberi– Neuritis, heart failure, encepha-
lopathy

Niacin Pellagra-Diarrhea, dementia, dermatitis

Pyridoxine (B6) Seizures, neuritis, dermatitis and anemia

Vitamin C Scurvy– Pseudoparalysis, scorbutic ro-

sary, mucous membrane hemorrhages

Vitamin D Rickets– Craniotabes, rachitic rosary,

bowlegs
Vitamin D Infantile tetany– tetany + rickets
Vitamin E Creatinuria, muscle weakness, anemia
Vitamin K Hypoprothrombinemia, bleeding

MINERAL DEFICIENCIES

Deficiency Manifestations
Calcium Poor mineralization of bones & teerh, oste-
omalacia, osteoporosis, tetany, rickets
Chloride Hypochloremic alkalosis
Magnesium Associated with Ca deficiency, malabsorp-
tion, tetany, ↓ K+
Phosphorous Rickets, Calcium and Vit. D deficiency

Potassium Muscle weakness, abdominal distention,

irritability/ drowsiness, arrhythmias
Sodium Nausea, diarrhea, hypotension, muscle
cramps, dehydration
Sulfate Growth failure
Iodine Goiter, cretinism
Iron Hypochromic, microcytic anemia, growth
failure
Zinc Dwarfism, ↓ wound healing, hepatospleno-
megaly, anemia, pigmentation, hypogonad-
ism

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Ideal Body Weight

Age
0-5 mos Age in months x 600 + 3 000 gms
6-12 mos Age in months x 500 + 3 000 gms

1-6 y Age (yrs) x 2 + 8 kg

7-12 y Age (yrs) x 7-5 kg/2

GOMEZ CLASSIFICATION:
Actual Body Weight x 100
Ideal Body Weight
► 120 -obese
► 110 -overweight
90-110- no malnutrition
80-89 -1st degree malnutrition
70-79 -2nd degree malnutrition
<70 -3rd degree malnutrition

WATERLOW CLASSIFICATION
Stunting: Actual Height x 100
Ideal ht. for age

>95 - no stunting
90-95- mild stunting
80-90 - moderate stunting
<80 - severe stunting

Wastin: Actual Height x 100

Ideal wt. for actual ht.

>90 -no wasting

80-89 -mild wasting
70-79 -moderate wasting
<70 -severe wasting

*Chronic Malnutrition: stunting;

Acute Malnutrition: wasting

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PROTEIN- CALORIE MALNUTRITION

MARASMUS KWASHIORKOR
Biology ↓ CHON & calories ↓ CHON only
Usual Age 0-2 years 1-3 years
Essential Features
Edema None Legs or generalized
Wasting Gross loss of SC fat Sometimes hidden
Growth Retardation Obvious Sometimes hidden
Mental Changes Apathetic, quiet Irritable, moaning
Variable Features
Appetite Good Poor
Skin changes Seldom Diffuse pigmentation,
flaky-paint dermatoses
Hair Changes Seldom Flag sign
Facies Old Man Facies Moon Facies
Others Potbelly, Winged Hepatomegaly
Scapula
Albumin Usually normal Low
Anemia Uncommon Megaloblastic
Iron Deficiency

Kwashiorkor is a result of severe protein deficiency and inade-

quate calorie intake.
Decreased serum albumin is the most common abnormally.
Blood glucose is usually low, as are levels of essential amino acids.
Anemia and vitamin & mineral deficiencies are evident.
Treatment consists of slow feeding of dilute milk with supple-
mentation of vitamins & minerals. Protein supplementation is also slow-
ly increased to prevent liver problems. Dehydration and intercurrent
infections are treated.

25
 PREVENTIVE PEDIATRICS

EXPANDED PROGRAM ON IMMUNIZATION (EPI) OF THE DEPT OF HEALTH

Age Dose # Route Site Interval

BCG 1 Birth; any- 0.05 mL 1 ID R deltoid

time after for NB; 0.1 region
or 6 wks mL older
infants

DTP 6 wks 0.5 mL 3 IM Upper 4 wks

outer as-
pect of
thigh

Polio 6 wks 2 drops 3 PO Mouth 4 wks

Hepatitis B 6 wks 0.5 mL 3 IM Antero- 4 wks

lateral
aspect of
thigh

Measles 9 mo 0.5 mL 1 SC Outer part

of upper
arm

BCG 2 School 0.1 mL 1 ID L deltoid

entry

Tetanus Child bear- 0.5 mL 3 IM Deltoid 1; 6; 12

toxoid ing women region months

RECOMMENDED SCHEDULE FOR CHILDREN NOT IMMUNIZED IN THE 1ST YR OF

LIFE

Time/Age Immunizations Comments

Less than 7 yrs old

1st visit (4 mo. of age) DTP, IPV/OPV, Hib, Hepa Must be 12 mo of age to
B, MMB, Varicella receive MMR & Varicella. If
>5 yrs of age, Hib is not
normally indicated.
2nd visit (1 mo. after 1st DTP<IPV/OPV, Hepa B, Hib Hib schedule varies by
visit manufacturer. The 4th dose
must be >2 mo after the 3rd
3rd visit (1mo. after 2nd DTP, IPV/OPV, Hib dose and/or after the 1st
visit) birthday. If series started.

26
4th visit (>6 mo after 3rd
visit)
4-6 years of age
11-12 years of age
7 years and older
DTP, Hepa B, Hib
DTP, OPV, MMR
MMR, Varicella, Hepa B
7-11mo=3 doses w/ 3rd
dose 2 mo after 2nd dose
12-14 mo.= 2 doses, 2 mos
apart
>15 mo = one dose
Preferably at or before
school entry. DPT not nec-
essary if 4th dose given on
or after the 4th birthday
Repeat Td every 10 years
throughout life

1st visit IPV/OPV, Td, Hepa B,

MMR, Varicella
2nd visit (2 mo after 1st IPV/OPV, Td, Hepa B OPV may be given 1 month
visit) after the 1st visit if acceler-
ated polio vaccination is
necessary
3rd visit (6-12 mo after 2nd IPV/OPV, Td, Hepa B
visit)
11-12 years MMR, Varicella, Hepa B Repeat Td every 10 years
throughout life

RECOMMENDED ROUTINELY ADMINISTERED ACTIVE IMMUNIZATIONS

Vaccine Age Dose Possible Immunity

reaction
Bacille P: usually P: 0.05 mL ID Keloid scar, 50%
Calmette 3-14 mos B: 0.1 mL suppurative,
Guerin B: school adenitis, BCG
(BCG) entry infection
Diphtheria P: 2, 4, 6 mo P: 0.5 mL IM Fever, rest Almost 100%
Pertussis, B1: 1yr after B: 0.5 mL IM lessness, irri- in 10 yrs
Tetanus tox- primary tability, local
oid (DPT) B2: 4-6 years signs of in-
after flammation

Tetanus, P: over 6 yrs P: 0.5 mL IM None Almost 100%

Diphtheria old B: 0.5 mL IM in 10 yrs
(Td) B: 1yr after
then q10 yrs
Trivalent oral Same as DPT 0.5 mL PO Paralytic >90% lifelong
poliovirus polio
vaccine

27
Inactivated Same as 0.5 ml SC None >95%
Polio Vac- DPT
cine (IPV/
Salk)
Measles P:9 mos or 0.5 ml SC Fever & rash 95% At least
Live attenu- later 5-10 days 12 yrs
ated B1: 15 after
months
B2: 5-12
years

Measles, P: 12 mos or 0.5 ml SC Fever, rash, >95%

Mumps, older arthralgia, Lifelong
Rubella B: 5-12 yrs lymphade-
vaccine after nopathy,
(MMR) seizure
Recombi- P, O, 1, 6 0.5 mL IM Arthralgia, ͌100% in 10
nant Hepa months neurologic yrs
B B: 5 years reactions
after
Varicella 9 mos-12 0.5 mL SC Fever ͌100%
years: 1 6-8 weeks vesicular
dose apart eruption
>13 yrs: 2
doses
Hemophillus P: 2 mos-5 0.5 mL IM Pain, red- 90-100%
influenza yrs ness, swell-
B vaccine Doses: ing at injec-
<6 mos: 3 tion site, fe-
>6 mos: 2 ver
>1 yr: 1

P-Primary dose B1-1st Booster dose B2-2nd Booster

28
PREARATION FOR PASSIVE IMMUNIZATION
(Antitoxin or Immunoglobulin)

Disease Vaccine Indications Dosage

Diphtheria Diphtheria Close contacts Prevention
anti-toxin who cannot be 5,000 units
observed close- Treatment 40T-
ly 120,000 units
Tetanus Anti-toxin Inadequately 3,000-5,000
immunized w/ units
serious wounds
IG Same 250-500 units

Ab immuno- IGIM Substitution 0.06 mL/kg q2-4

deficiency therapy in anti- mos
body deficiency;
IGIV ITP, Kawasaki, 2mL/kg of 5%
GBS prep
3.3 mL/kg of 3%
prep
Measles IG Within 6 days of 0.25 mL/kg BW,
exposure IM
Rabies IG Immediately 20 units/kg BW,
after exposure IM
Anti-rabies 40 units/kg BW,
IM
Rubella IG Post-exposure 0.55 mL/kg BW,
pregnant wom- IM
an (1st trim)
Hepatitis A IG Within 7 days of 0.02-0.06mL/kg
exposure BW, IM
Hepatitis B IG Within 12 hours 0.5mL, IM
after birth if
mother HbsAg+
After percutane- 0.06-0.12mL/kg
ous exposure IM (max 5 mL)
Varicella IG Within 48 hours 625 units or
post-exposure 125u/kg BW, IM

29
 FLUIDS & ELECTROLYTES
Clinical Correlations of Dehydration

Severity Fluid Deficit in ml/kg Signs

(percent body wt)

Infant Adolescent

Mild 50 (5%) 30 (3%) Slightly dry buccal

mucous mem-
branes, increase
thirst, slightly de-
creased urine
output

Moderate 100 (10%) 50-60 (5-6%) Dry buccal mu-

cous membranes,
tachycardia, little
or no urine output,
lethargy, sunken
eyes and fonta-
nels, loss of skin
turgor

Severe 150 (15%) 70=90 (7-9%) Same as moder-

ate plus a rapid
thread pulse, no
tears, cyanosis,
rapid breathing,
delayed capillary
refill, hypotension,
mottled skin, co-
ma

 Standard estimates for children between infancy and adolescence have

not been established. For children between these age ranges, clinicians
must estimate values between those for infants and those for adolescents
based on clinical judgment.

FLUID VOLUME

1. Maintenance
Electrolytes, Na & K, are lost daily in the urine. This losses include
2-3 mEq/kg/d of Na, & 1-2 mEq/kg/d of K

30
0-10 kg 100 ml/kg

11-20 kg 1000 ml+50 ml/kg for each kg >10 kg

>20 kg 1500 ml+20 ml/kg for each kg >20 kg

Example:
Kayce weighs 22 kg. To calculate maintenance one would use
the following formulas:

For the 1st 10 kg: 10 kg x100 ml= 1000 ml

For the 2nd 10 kg: 10 kg x 50 ml= 500 ml
For every kg >20: 2 kg x 20 ml= 40 ml
1540 ml

Kayce needs a total of 1540 ml / 24 hr, which is equal to 64 ml/

hr maintenance IV fluid

Maintenance Fluid Choice

 For patients <1 year, 0.2 % Nacl / 5 %D (5% dextrose in H2O)+2
mEq KCL/100 ml or (20 mEq KCL/L)
 If the patient is > 1 yr, use 0.33 % Nacl/ 5% D+ 2mEq KCL/100 ml
 If the patient is > 3 yrs, use 0.45% Nacl/ 5% D+ 2mEq KCL/100 ml

II. Correction Deficit

First, Assess degree, then type dehydration

Aspects of Degree of Dehydration

Mild Moderate Severe

Infant 5% 10% 15%

Adolescent 3% 6% 9%
Signs & symptoms (General appearance & Condition)
Infants/ young Thirsty, alert, Thirsty, restless, Lethargic, limp,
children restless irritable cold, sweaty,
cyanotic extrem-
ities; may be
comatose
Tachycardia absent present present

31
Palpable pulses Present Present (weak) Decreased

Cutaneous perfu- normal normal Reduced/mottled

sion

Skin turgor normal Slight reduction Reduced

fontanel normal Slightly depressed Sunken

Mucous membrane Moist Dry Very dry

Tears Present Present/absent Absent

Respiration normal Deep, may be rapid Deep and rapid

Urine output normal oliguria Anuria, severe oligu-

ria

Blood pressure normal Orthostatic hypoten- hypotensive

sion

Types of Dehydration
Sign Hyponatremic Isonatremic Hypernatremic

Skin color Gray Gray Gray

Temperature Cold Cold Cold

Turgor Very poor Poor Fair

Feel Clammy Dry Thick, doughy

Mucous membrane Slightly moist Dry Parched

Eyeballs Sunken, soft Sunken, soft Sunken, firm

Fontanel Sunken Sunken Sunken

Consciousness Very lethargic Lethargic Hyperirritable

Pulse Rapid Rapid Moderately rapid

Blood pressure Very low Low Mod. Low

Serum Na Low normal High

IV fluid treatment 0.45% Nacl 0.30% Nacl 0.2% Nacl

77 mEq/L Na 51.3 mEq/L 34 mEq/L Na
Na

32
THERAPY:

Oral Rehydration Therapy

MILD MODERATE
Initial Dose 50 ml/kg over 4 hrs 100mlkg over 6 hrs
Subsequent 100/ml /kg/24 hrs 100 ml/kg/24 hrs

Composition of New ORS Formulation

New ORS mmol/liter

Sodium 75
Chloride 65
Glucose anhydrous 75
Potassium 20
Citrate 10
Total Osmolality 245

New ORS grams/liter %

Sodium Chloride 2.6 12.683
Glucose, anhydrous 13.5 65.854
Potassium Chloride 1.5 7.317
Trisodium citrate 2.9 14.146
dihydrate

Total 20.5 100.00

IV Hydration Therapy (Ludan’s method)

Mild Moderate Severe

<10 kg, 50 cc/kg/8 100 cc/kg/8 150 cc/kg/8

<2 y/o
>10kg, 30 cc/kg/8 60 cc/kg/8 90 cc/kg/8
>2 y/o
D5 0.3% in 6-8 1st hour, 1/4 1st hr 1/3 PLRS
hrs PLRS
Next 5-7 hrs: 3/4 Next 5-7 hrs 2/3
DLRS D 0.3%

** <10 yrs old=D5 IMB can also be used

**>10 yrs old =D5 NM can also be used

33
E.g. Marie, 12 kgs mild sunken eyeballs, irritable, (+) tears, urine output
–4hrs ago, dry lips, moist buccal mucosa, full pulses

—case of a MILD dehydration—

12kgs x 30cc/kg/8= 360cc fluid req’t in 8

3600/8hrs = 45 cc/hr

Maintenance

O-3 kg 75 cc/kg/day
3-10 kg 100 cc/kg/day
10-20 kg 75 cc/kg/day
20-30 kg 60 cc/kg/day
30-40 kg 50 cc/kg/day
40-50 kg 40 cc/kg/day
E.g. On the 3rd day of
hospitalizatuon , Kayce, 13 kg, with good oral intake and urine output
13 kg x 75 cc/kg /day = 975cc/24 hrs
975/ 24= 40 cc/hr D5 IMB to run at 40 cc/hr

FLUID COMPOSITION

SODIUM
(n.v. 135-150mEq/L or 3-4mEq/kg/day)

Hyponatremia
♦mEq Na deficit= (desired-actual) x TBW
Where: n TBW (in L) = 0.6 x body weight (kg)
♦Initial goal: 120 mEq/L; Subsequent 130 in 24-30 hrs
♦Correct only up to 15 mEq/L/day (2.5 mEq/L/hr) to avoid pontine
Myelinolysis

Hypematremia
♦Water deficit =Plasma [Na+]-140 x TBW
140
♦Correct only 10-15 mmol/L/day

POTASSIUM
(n.v. 3.5-6 mEq/L or 2-3 mEq/kg/day

34
Hypokalemia
♦mmol K deficit = (desired-actual ) x 0.3 x wt (kg) or (deficit= wt (kg) x
50 x estimated % deficit

K serum level Estimated level

3-3.5 mEq/L 5% deficit (approx 200-400 mmol)
2-2.5 mEq/L 10% deficit
1-2.0 mEq/L 20% deficit (approx 600 mmol &
up)
♦If asymptomatic: oral replacement 2-3 mEq/kg/d
♦IV replacement guidelines:
1. Rate: 0.2-0.3 mmol/kg/hr NOT to exceed 1 mmol/kg/hr
2. If via peripheral vein, not >40mmol/L
3. If via central vein, not >80 mmol/L; continuous ECG

Hyperkalemia
♦ECG changes: peaked/ tented T waves,
At >7.0 mEq/L: prolonged PR, ↓ST, wide QRS
At >8.0 mEq/L: P wave disappears,
QRS merges with T

♦Treatment:
1. Reverse membrane effects:
Ca gluconate 10% at 0.5-1.0 ml/kg/IV over 2-10 mins
2. Transfer K into cells (redistribute): B2 agonists; or regular insulin
10-20 ‘u’ + Glucose 25-50g; or NaHCO, 3 amp/L D5W
3. Enhance renal excretion of K:
Kayexalate 1gm/kg PO diluted with 2-4 ml sorbitol

CALCIUM
Hypocalcemia
♦Ca gluconate 10% (8.9 mg/ml elemental Ca): 0.5-1.0ml/kg IV bolus
over 20-30 mins with cardiac monitoring x 3 doses
♦Maintenance: 500 mg/kg/24 hr PO

MAGNESIUM
Hypomagnasemia
♦For asymptomatic children
4-7 kg: 0.5 ml of 50% MgSO (1 mmol Mg)
>& kg: 1ml of 50% MgSO4 (2 mmol Mg)

35
ANION GAP= [Na+K+]-[Cl+HCO3]=8-16mEq/L
♦Represents unmeasured anions
E.g. PO4, SO4, AA’s, Lactate

Increased Normal Decreased

Methanol poisoning Hypernatremic dehy- ↑K+, Ca++,
Uremia/Renal failure dration Mg++
DKA Renal tubular acido- Hypo-
Paraldehyde /Penicillin sis albuminemia/
Iron tablets/ Isoniazid Hyper-alimentation Nephrotic
Lactic Acidosis Diarrhea Syndrome
Ethanol/ Ethylene glycol Lithium
Salicylates Poisoning
↓K+, Ca++, Mg++, ↑PO
TO-
TAL PARENTAL NUTRITION COMPUTATIONS

Total Fluid Requirement (TFR)

A Term: Start at 60ml/kg/ Preterm:
day Start at 80-90ml/kg/day
Increments of 10ml/kg/day Maximum; 150ml/kg/day
Maximum 150ml/kg/day
B Electrolytes/AA Preparations Normal Val-
NaCl ues
KCl 2.5mEq/ml 2-4 mEq/kg/
10% Ca gluconate day
7% AA 2mEq/ml 1-3mEq/kg/
day
100g/ml 100-400 g/kg/
d
7g/100ml 2-3 g/kg/day

Correction factor for tubings:multiply all values by 1.1

Example: 2kg preterm; start TFR at 80cc/kg/day

1. Compute TFR
(subtract vol of meds from computed TFR, if any):
TFR =80ml/kg/day x 2 kg = 160ml/day (meds) x 1.1=176ml/day

2. compute Electrolytes and Amino Acids, then total:

NaCl: 3mEq/kg/day x 2kg/2.5 mEq/ml
=2.4ml/day x 1.1 =2.64
KCL: 2mEq/kg/day x 2kg/2.0mEq/ml
=2.0ml/day x 1.1= 2.2

36
Ca: 200g/kg/day x 2 kg/100g/ml
=4ml/day x 1.1=4.4
AA: 3g/kg/day x 2kg/7g/100ml
=85.7ml/day x 1.1=94.2
Total = 103.4 ml/day

3. Compute to desired Dextrosity (D10): First get volume of D50W (X):

TFR x Dextrosity=[150X x 5 (TFR-Electrolytes +AA)-X]
176 x D10= 50X x 5 (176-{103.4})-X
X={1760-5 (176-103.4)}/45=31.04 mlD50W

Then get volume of D5W:

D5W=TFR-D50W-(electrolytes+AA)
D5W=176-31.04-103.4=41.6mlD5W

4. To check Dextrosity:
D50W=31.04 X 50=1552
D5W= 41.6 X 5=208
TOTAL 1760

Total /TFR=Desired Dextrosity which is 10

5. TPN to be prepared by pharmacy under laminar flow

D50W 31.04ml; D5W41.6ml; NaCl 2.64ml; KCl 2.2 ml;
10%C gluconate 4.4ml; 7% Aminosol 94.2ml
To infuse only 160ml at 6.6 cc/hr for 24 hrs

FLUID MANAGEMENT IN NEPHROTIC PATIENTS

Estimated Crea Clearancre =Ht (cm)% x K/Creatinine (mg/dl)

N.V.: 120+ 20 ml/min/1.73m2

40-65ml/min/1.73m2 (newborn)

Where K values

LBW during 1st year 0.33

of life
Term AGA during 1st 0.45
year of life
Girl child/ adolescent 0.55
Boy child/ adolescent 0.70
Fluid limit=BSA x IWL x Urine Output in
24 hrs

37
Na limit =(Wt x 23 x 2)/ 1,000
CHON Limit= 0.5G/Day x wt

FLUID RESUSCITATION IN BURN PATIENTS

Parkland Formula=4ml LRS/kg /% burn
1st half in 8 hours; Next half in 16 hours
Oral Supplementation given 48 hrs after
PRBC if: Hgb <8; Hct<0.24
FFP if: PT level >1.2 x control
Albumin: Maintain at 2 g/dl
30-50% BSA burn→0.3 ml albumin /kg/BSA burn/day

50%-70% →0.4 ml
70%-100% → 0.5 ml

Galveston

1st 24 hrs 5000cc (PLRS)/% burned BSA/ day/

(burn related losses)+ 2000cc (D5LRS)/
BSA/day (maintenance mainline)
50% in 1st 8 hours
50% in next 16 hours
2nd hrs 3750cc/ % burned BSA/day
(burned related losses)
+ 1500cc/BSA/day (maintenance fluid)

CONVERSION FACTORS

AR mg/dl to umol/L
Na+ 2.30 0.4348 Creatinine 88.4
K+ 3.91 0.2558 Total Bilirubin 17.10
Ca++ 2.005 0.4988 mg/dL to mmol/L

Mg++ 1.215 0.8230 BUN 0.357

Cl 3.55 0.2817 Cholesterol 0.0259
HCO 6.1 0.1639 Glucose 0.0555
Celsius to Fahrenheit: (°C x 1.8) + 32
Fahrenheit to Celsius: (°F-32)/1.8

38
 GASTROENTEROLOGY
DIARRHEA

Major Mechanisms of Diarrhea

Secretory Decreased absorption, Increased
secretion
Osmotic Maldigestion, transport defects,
ingestion of unabsorbable solute
Increased Motility Decreased transit time
Decreased Surface Area Decreased functional capacity,
e.g. short bowel syndrome
Mucosal Invasion Inflammation, decreased colonic
absorption, increased motility

Management: Rehydration therapy depending on degree & type of de-

hydration

WHO treatment
Plan A for Mild or No Dehydration
♦Treat at home; educate mother
♦Give more fluids and food than usual
A. May dilute milk formula for children <6 mos
B. May add 1-2 tsp oil to solid food for older children
♦Replace losses with ORS according to the following table:

Age Amount of ORS to Amount of ORS to

give after each loose provide for use at
stool home
<24 months 50-100ml 500 ml/day
2-10 years 100-200ml 1 000 ml/day
>10 years As much as wanted 2 000 ml/day

39
Treatment PLAN B for Moderate or Some Dehydration Approx. amount
of ORS to give in the 1st 4 hours
Age <4 wks 1-11 mo 12-23 mo 2-4 yrs 5-14 yrs
Wt <5kg 5-7kg 8-10kg 11-15.9kg 16-29.9 kg
In mL 200-400 400-600 600-800 800-1200 1200-2200

Alternative Formula: 75ml ORS/kg BW

Reassess after 4 hrs to change plan or continue tx

Treatment PLAN C for Severe Dehydration

♦Start IV fluids. Give 100ml/kg LRS/NSS divided as ff:
Age First, give 30 ml/kg Then, Give 70m
ml/kg
Infants (<12 mo) In 1 hour In 5 hours
Older 30 minutes 2 1/2 hours

*Reassess every 1-2 hrs. may rpt once if radial pulse is still weak
*As soon as they can drink, give ORS at 5/ml/kg/hr
*If IV therapy not available, Give ORS PO/NGT at 20ml/kg/hr for 6 hr

Dysentery: bloody & mucoid diarrhea, with tenesmus/cramping

Antimicrobial Agents For Specific Causes of Diarrhea

Antibiotic Choice Alternative

Cholera Tetracycline Furazolidone 1.25 mg/
12.5 mg/kg QID x 3D kg QID x 3d, or TMP/
SMX8/40 mg/kg BID x
5d
Shigella Dysentery TMP/SMX 8/40 Nalidixic Acid 15 mg/kg
mg/kg BID X 5D QID x5d or Ampicillin
25 mg/kg QID for 5d
Amoebiasis Metronidazole 35 mg/ Very Severe cases:
kg TID x 5d (10d for Dehydroemetine IICI/
severe) IM 1-1.15 mg/kg OD x
5d; Max 90mg
Giardiasis Metronidazole 15 mg/ Quinacrine 2.5 mg/kg
kg TID x5d TID x 5d

Limited indication in childhood due to interference w/ growth

40
INFLAMMATORY BOWEL DISEASE
A. Crohn’s Disease
(Regional Enteritis, Granulomatous Colitis)
 Have an insidious presentation and has more extraintestinal mani-
festations than ulcerative colitis
 Can occur anywhere along the GI Tract
 Perianal disease is very common, including abscesses and fistulas
 Therapy is aimed at relief of symptoms and includes steroids, ami-
nosalicylates, azathioprine and metronidazole for fistulas, cyclo-
sporine, tacrolimus and TNF-a

B. Ulcerative Colitis
 Insidious or fulminant presentation
 Involves only the colon
 UC is a diagnosis of exclusion, symptoms should be present for at
least 3-4 weeks.
 Aminosalicylates & Sulfasalazine are used
Surgical treatment is total colectomy

Crohn vs. Ulcerative Colitis

INTUSSUSCEPTION
Crohn Ulcerative Colitis
Rectal bleeding +/- ++
Rectal disease + ++++
Ileal Involvement ++ 0
Perianal disease ++ 0
Strictures ++ 0
Fistula ++ 0
Skip lesion ++ 0
Transmural involve- +++ 0
ment
Risk for colon cancer Sligt ↑ ↑↑↑
Mouth ulcers ++ 0
♦Occurs when a portion of the the GI tract slips or telescopes into the
portion just distal to it.
♦Most itussusceptions are ileocolic
♦Occur between 6-24 months
♦Acute onset of cramping, colicky abdominal pain is the hallmark of
intussusceptions

41
♦Currant jelly stool is a late finding
♦Sausage-shaped mass may be palpated in the upper abdomen
♦Barium enema is diagnostic and therapeutic
♦Should be reduced as quickly as possible

MECKEL DIVERTICULUM
►Most frequent congenital anomally of the GI tract
►A vestigial remnant of the omphalomesenteric ducty
►Known as the disease of 2’s:
-Present in 2% of infants
-Peak incidence is by 2 yrs of age
-Contains 2 types of tissue
-About 2 cm in size
-About 2 feet from the ileocecal valve
►Painless rectal bleeding
►Technetium scan is the most sensitive way to diagnose
Meckel diverticulum
►Treatment is surgical removal

TRACHEOESOPHAGEAL FISTULA (TEF)

♦TEF is an abnormal connection in one or more places between the esophagus
(the tube that leads from the throat to the stomach) and the trachea (the tube
that leads from the throat to the windpipe and lungs).
♦Normally, the esophagus and the trachea are two separate tubes that are not
connected
♦TE fistula is a birth defect, which is an abnormality that occurs as a fetus is
forming in it’s mother’s uterus
♦When a baby with a TE fistula swallows, the liquid can pass through the ab-
normal connection between the esophagus and the trachea. When this hap-
pens, liquid gets into the baby’s lungs
♦This can cause pneumonia and other problems

42
 PULMONOLOGY

ASTHMA
A reversible airflow obstruction, associated with state of in-
creased responsiveness, manifest by widespread bronchospasm, re-
flects the condition of bronchial hyperactivity.

CLASSIFICATION OF ASTHMA

Symptoms/Day Symptoms/Night PEF or FEVI

PEF variability

Stage 1 <1 time a week <2 times a >80%

Intermittent Asymptomatic & month <20%
normal PEF b/n
attacks
Stage 2 >1 time a wk but >2 times a >80%
Mild Persistent <1 time a day month 20-30%
Attacks may
affect activity
Stage 3 Daily >1 time a week 60-80%
Mod. Persistent Attacks affect >30%
activity
Stage 4 Continuous Frequent <60%
Severe Persis- Limited Physical >30%
tent activity
43
Symptom pattern cough, recurrent wheeze/ dyspnea, chest tightness
occurring or worsening at night/early AM

Risk Factors male, atopy, smoke exposure, maternal history

Objective measure:
♦Peak Expiratory Flow Rate: n.v. >80% for Age & Height
♦PEF Reversibility = Post– Prebronchodilator x 100%
Prebronchodilator

**Definite diagnosis of asthma: PEF (FEV1) increase of >15% 15-20

minutes after inhaled B2 agonist
PEF Variability =PM, Postdilator-AM, Predilator x 100
1/2 (PM, Postdilator + AM, Predilator)

**N.V.: Should be less than 20%

♦Confirmatory Test:
1. Chest X-ray– air trapping, ↑ lung markings
2. Pulmonary Function Test (Spirometry, Peak Flow Meter)
3. Bronchoprovocation Test: Metacholine; Exercise; Cold Air
4. Diurnal variation determination
5. Therapeutic trial of steroids & bronchodilators

Treatment:
♦Relievers (“rescue agents”): for symptomatic treatment of bron-
chospasm with rapid onset (15-30 mins); 4-6 hr relief
°Short-acting B2 agonist: Salbutamol, Terbutaline, Albuterol
°Ipratropium bromide (cholinergic antagonist)
°Short-acting Theophylline
°Prednisone, Prednisolone, Methylprednisolone

♦Controllers: Longer duration of action (12-24 hrs) but slow onset; not
a substitute for anti-inflammatory therapy
°Long-acting B2 agonist: Salmeterol, Bambuterol
°Long-acting Theophylline
°Cromolyn Na (prophylactic anti-inflammatory)
°Inhaled corticosteroids
°Anti-Leukotrienes

44
CLINICAL FEATURES OF ASTHMA EXACERBATION

Mild Moderate Severe Arrest

Imminent
Breathless Walking Talking At rest
while Infant Infant
Difficult stops feeding
feeding
Position Can lie down Prefers sitting Hunched
forward
Talks in Sentences Phrases Words
Alertness May be Usually Usually Drowsy/
agitated agitated agitated confused
Resp. rate Increased Increased Often
> 30/min
Guide to normal RR:
Age Normal rate Age Normal rate
<2mo <60/min 1-5y <40/min
2-12 mo <50/min 6-8y <30/min
Ace: muscles Usually none Usually Usually Paradoxical
& retractions present present thoraco-
abdominal
mov’t
Wheeze Mod. and Loud Usually loud None
expiratory
Pulse rate <100 100-120 >120 Bradycardia
Guide to normal PR: Infant: (2-12mo) <160/min
Pre-school (1-2yr) <120/min
School age (2-8yr) <110/min
Pulsus (-) or (+) 10-20 (+) 20-40 If (-)→resp.
paradoxus <10mmHg mmHg mmHg fatigue
PEFR % >70% 50-70% <50%
predicted
PaO2 Normal 60-80 mmHg <60mmHg possible
cyanosis
PaCO2 <45mmHg <45mmHg 45mmHg
possible respiratory failure
SaO% >95% 90-95% <90%

45
 PULMONARY TUBERCULOSIS
Classification

Exposure S & Sx CXR PPD Labs

Class I + - - - -
(Exposure)
Class II +/- - + - -
(Infection)
Class III + + + + +c
(Disease)
Class IV +/- - + +d -
(Inactive)

A. S & Sx: cough/ wheezing /fever > 2 weeks failure to return to nor-
mal health after an infection painless cervical &/or other lymphade-
nopathy poor weight gain failure to respond to appropriate antibiotic
therapy
B. Active TB must have 3 more out of the 5 criteria
C. Positive culture with or without a smear is the gold standard
D. Radiographic evidence of healed or calcified TB

Diagnosis & Prevention

Tuberculin Skin Test
(Mantoux Tach, Purified Protein Derivative):
1. 0.1 ml or 5 TU intradermally on volar surface of forearm to form a 6-
10mm wheel, read after 48-72 hrs
2. Induration, not erythema, read crosswise to forearm axis
3. Positive if >5mm (HIV+, contact to active TB, healed) >10mm (all
others)

Bacille Calmette-Guerin (BCG) Vaccination Reaction

Accelerated BCG Normal BCG

Induration 2-3 days 2-3 weeks
Pustule Formation 5-7 days 4-8 weeks
Scar Formation 2-3 weeks 8-12 weeks

46
Treatment

Dosage (mg/kg)
Drug/ Prepara- Side effects
tion
<12 y.o. >12 y.o.

Isoniazid (H) a 5-10 5 (max 300mg) Hepato-toxicity d

100 & 200 (max 300 mg)
mg/5ml
Rifampicin (R) b 10-15 10 (max 600 Hepato-toxicity
100 & 200 (max 600 mg) mg)
mg/5ml
Pyrazinamide 15-30 15-30 (max 2 g) Arthralgia due to
(P) Max 2g) ↑ uric acid
250 mg
Ethambutol (E) 15-25 1st 2 mo 15-25 (max Retrobulbar
200 & 400 mg then 15 2.5g) neuritis c
tab
Streptomycin 20-30 15 (max 1 g) Nephrotoxicity
(S) (max 1 g) Ototoxicity
1g vial

A.
Best on an empty stomach (30 min before or 2 hours after meals);
given with Pyridoxine/ Vitamin B6; storage temp <37C
B
Best on an empty stomach; at the same time as H
C
Best absorbed on a full stomach
D.
Requires monitoring of liver function tests in severe TB; if elevated 2-
3x the normal: do not discontinue drug if 3x normal: discontinue drug
E.
Do visual acuity & red-green discrimination test

UPPER AIRWAY INFECTIONS

GROUP EPIGLOTTIS TRACHEITIS

Age 3v mo-5 yrs 2-7 years 2 mo-6 years
Etiology Viral, usually H. influenzae S. aureus,
parainfluenzae H. influenzae
Course Over 2-3 days, Rapid: over hrs Gradual:
with prodrome 2-3 days
Fever Low grade High grade High grade
Resp. Distress Mild-moderate Severe Severe

47
 GROUP EPIGLOTTIS TRACHEITIS

Position Prefers sitting Perched, neck May have

up extended preference

Stridor Improves w/ No response to No response to

aerosolized racemic racemic
racemic epi- epinephrine epinephrine
nephrine

CXR “Steeple sign” “Thumbprint Subglottic

on AP view sign” on lateral Narrowing
Treatment Epinephrine, Intubate, IV anti- Antibiotics
Steroids biotics
*May cause life-threatening obstruction
Do not examine throat!

ETIOLOGY OF
PNEUMONIA AC-
CORDING TO AGE

Age Common Pathogens

0-48 hours Group B Streptococcus
1-14 days E.coli, Klebsiella, Enterobacteri-
aceae, Listeria, S. aureus, Anaer-
obes, Group B streptococcus
2 wks-2 mos Enterobacteriaceae, Group B
Strep,
S. aureus C. albicans,
H. influenzae, Strep pneumonia
2 mos-5 yrs H. influenzae, Strep pneumonia
5-21 years Strep pneumonia, M. pneumonia

48
PNEUMONIA IN INFANTS LESS THAN 2 MONTHS

Clinical Signs Classify As Summary of Treat-

ment
No fast breathing <60/ NO PNEUMONIA Advise Home Care
min Cough or Cold
No chest indrawing
Fast breathing *: SEVERE PNEUMO- Admit→Give antibi-
>60/min NIA otic: Benzyl Penicillin
Severe chest indrawing +
Gentamicin IM, IV
Central cyanosis, poor VERY SEVERE Admit→Give antibi-
feeding, wheezing , stri- PNEUMONIA otic: Benzyl Penicillin
dor in a calm child, con- +
vulsions, abnormally Gentamicin IM, IV
sleepy

*Tachypnea: most predictive sign of Pneumonia

PNEUMONIA IN INFANTS AND CHILDREN (2 MOS-5 YRS)

Clinical Signs Classify As Summary of

Treatment
No fast breathing: NO PNEUMONIA If coughing >30 days,
<50/min if 2 mos– 1 Cough or Cold assess for causes of
year chronic cough; Assess
<40/min if 1-5 years or treat ear problem or
No chest indrawing sore throat, if present;
Advise Home Care;
treat fever & wheez-
ing, if present.
Fast breathing: PNEUMONIA Advise Home Care
>50/min if 2 mos-1 Give an antibiotic:
year Cotrimoxazole PO,
>40/min if 1-5 years Amoxicillin, Ampicillin
No chest indrawing or Procaine Penicillin;
treat fever and wheez-
ing if present; Advise
to return in 2 days for
reassessment or ear-
lier if child gets worse

49
Chest indrawing SEVERE PNEUMO- Admit→Give antibi-
No central cyanosis NIA otic:
Able to drink Benzyl Penicillin M,
IV,
“Treat fever and
wheezing, if present;
Give supportive care;
reassess daily to up-
grade or downgrade
diagnosis and treat-
ment

Central cyanosis, ina- VERY SEVERE ADMIT, Give oxygen

bility to feed or drink, PNEUMONIA Give antibiotic:
stridor in a calm child, Chloramphenicol IM,
convulsions, abnor- IV
mally sleepy, severe Treat fever; Support-
undernutrition ive care, reassess
twice daily,
If getting worse after
48 hours on Chloram-
phenicol shift to Clox-
acillin + gentamicin for
suspected Staph.
Pneumoniae

RADIOGRAPHIC DIAGNOSIS
Bacterial: Viral: Mycoplasma:

Lung consolidation + Streaky interstitial infil- Variable; often with

Fleural Effusion trates without alveolar small pleural effusion
compromise

BONCHIOLITIS
 Lower respiratory infection in infants caused by inflammatory ob-
struction of the small airways of the lower respiratory tract
 Occurs in children younger than 2 years of age with a peak inci-
dence at approximately 6 months of age
 Respiratory Syncytial Virus (RSV) invades the bronchioles causing
obstruction from mucus, cellular debris and edema

50
DURATION OF TREATMENT OF BACTERIAL MENINGITIS

Pathogen Duration (days)

H. influenzae 7-10
S. pneumonia 10-14
N. meningitides 5-7
Group B streptococci 14-21
Gram negative bacilli 21 days –3 weeks

EMPIRIC THERAPY FOR BACTERIAL MENINGITIS

Age Etiology Primary Alternative Dosage

0-2 mo E. coli, GBS Ampicillin or Ampicillin + Ampicillin
Listeria, Penicillin Cefotaxime 300-400
Gram (+) + Amnogly- or Ceftriax- q8
enteric bacilli coside one Cefotaxime
200 q6
2 mo-5 yrs H. influen- Ampicillin Cefotaxime
zae, S. + Chloram- or Ceftriaxone
pneumoniae phenicol Ceftriaxone 100q12
N. meningiti- Ceftazidime
des 150 q8
Chloram-
6-18 yrs S. pneumo- Penicillin Chloram- phenicol
nia phenicol or 50-100 q6
N. meningiti- Ceftriaxone Cotrimoxa-
des zole
20 q6
Immunodefi- S. aureus, S. Ampicillin Cotrimoxa-
ciency epidermidis, + zole + Gentamycin
S. pneumo- Ceftazidime Ceftazidime 4 q8
nia, Salmo- + Amnogly- + Amnogly- Pen G 300,
nella, P. ae- coside coside 000
ruginosa, U/kg/ day
Listeria q4-6
SEIZURES

°Abnormal electrical activity in the brain.

°Symptoms of Seizure-auras, altered consciousness, flashing lights in
your head, metallic taste in your mouth, smell of fragrances that others
do not smell, muscle spasms or twitching
° Repeated brain seizures characterize & seizure disorder known as
epilepsy.

51
3. Critically ill, moribund patient at risk of CR arrest
4. Skin infection at the site of LP
5. Thrombocytopenia (<20 x 10 to the power of 9/L)

BRAINSTEM AND CORTICAL FUNCTION IN INTUBATED PATIENTS

Brainstem function Score Cortical Score

Function
Normal papillary, 3 Spontaneous 6
corneal, movement
oculovestibular Move to com- 5
& oculocephalic 2 mand
reflex 1 Localize pain 4
Some Absent 0 Withdraws 3
All absent Decorticate 2
All absent & apneic Decerebrate 1
Flaccid 0

TREATMENT APPROACH TO BACTERIAL MENINGITIS

Intracranial Pressure Measurement

Scan Results NORMAL INCREASED
Normal None Hyperventillate to de-
crease cerebral blood
volume
Edema Restrict Fluids Don’t hyperventilate;
Use Furosemide or
Mannitol
Hydrocephalus None; resolves spon- Ventricular tap or
taneously drain CSF; Acetazola-
mide: ↓CSF produc-
tion; Steroids: ↑CSF
reabsorption
Subdural Effusion None; resolves spon- Subdural drainage
taneously
Infarct Improve perfusion by Steroids: ↓ peri-infarct
increasing BP; Ster- edema; Barbiturates:
oids: ↓Vasculitis to ↓ brain metabolism
activity

52
 ♦Infants with mothers who smoke cigarettes are at increased risk for
contacting bronchiolitis
♦Patient develops fever of 38.5-39 °C and gradually develops respirato-
ry distress evidenced by cough, tachypnea and wheezing
♦Treatment is symptomatic & includes fluids, antipyretics & oxygen

NEUROLOGY
GLASCOW COMA SCALE

Score
Eye opening Spontaneous 4 Spontaneous
To speech 3 To speech
To pain 2 To pain
None 1 None
Verbal Coos, babbles 5 Oriented
Irritable 4 Confused
Cries to Pain 3 Inappropriate
Moans to Pain 2 Words
None 1 Non-specific sounds
None
Motor Normal, spont. 6 Follows commands
Withdraws to touch 5 Localize to pain
Withdraws to pain 4 Withdraws to pain
Abnormal flexion 3 Abnormal flexion
Abnormal extension 2 Abnormal extension
None 1 None

LUMBAR PUNCTURE
♦Done at L3-L4 or L4-L5 using a G18-22 beveled spinal needle, in a
flexed lateral position

♦Contraindications:
1. Raised ICP due to a mass lesion →herniation
2. S & Sx of pending cerebral herniation: gen. seizure, abnormal pupil
size & rxn, (-) oculocephalic response, apnea

53
Grand Mal Seizures
 Also known as tonic-clonic seizure
 Characterized by loss of consciousness, falling down, loss of bowel or
bladder control, and rhythmic convulsions.
 Consists of a 15 to 20 second period with muscle rigidity (tonic phase),
followed by a one-to two-minute period of violent, rhythmic convulsions
(clonic phase).
 May appear bluish as blood oxygen levels lessen due to impaired breathing
during the seizures.
 If a generalized convulsion is prolonged (5 or more minutes) or if it is fol-
lowed by a second seizure before complete recovery (person is awake and
interactive). It is time to seek medical assistance.

Temporal Lobe Seizure

 Also known as complex partial seizures
 Considered “partial” because the electrical misfiring involves some but not
all of the brain, yet they are complex because they impair one’s conscious-
ness.
 While the area of brain involved in this seizure activity is predominately the
temporal lobe, other parts of the brain can give rise to these seizures.
 Characterized by diminished awareness while still conscious, as though the
person is on ‘auto pilot’. It may include repetitive, non purposeful acts e.g.,
lip smacking, swallowing, picking at things, or garbled or semi-random
speech
 Times aggressive behavior may be apparent during this phase. Such ag-
gression is not well-focused, not ‘thought-out’ and can often be avoided by
leaving the person alone for a few minutes.

Simple Partial Seizures

 Involve only part of the brain are known as partial seizures. And those that
do not involve an alteration of awareness are classified as simple.
 Commonly follow brain trauma, such as stroke, hemorrhage, malformation,
or tumor.
 Usually involve brief rhythmic cycles of face twitching, accompanied by
jerking movements of a hand, arm or leg.
 This type of seizure lasts for a few minutes. In some individuals, they signal
the onset of a generalized or convulsive seizure. Occasionally, they last for
hours or days.

Petite Mal Seizures

 Also known as absence attacks, or primary generalized seizures, occur
almost between the ages of 6 and 12.
This type of seizure can run in families. Most children with petit mal seizures
have otherwise normal neurological systems. Many can expect to out-
grow the disorder.
 Petit mal, or absence, seizures are characterized by an abrupt in-
terruption of consciousness without convulsion.

54
Diagnosing Seizure Activity
 Electroencephalography (EEG)
 Magnetic resonance imaging (MRI)
 Computerized tomography (CT) scan
 Blood tests. These tests may reveal a chemical imbalance in your blood or
presence of toxic substances

POTENTIAL CAUSES OF EPILEPSY

A. In Newborns-brain malformations, lack of oxygen during birth, low levels of
blood sugar, blood calcium, blood magnesium or other electrolyte disturb-
ances, inborn errors of metabolism, intracranial hemorrhage, maternal drug
use and infection
B. Infants & Children– fever (febrile seizures), brain tumor (rarely), infections

Criteria For Benign Febrile Seizures

1. Age:9 months to 5 years
2. Generalized tonic-clonic lasting not more than 15 minutes
3. Onset of fever >39°C w/n hours of the seizure
4. Family History of BFC
5. No neurologic deficit that would explain the seizure

COMMON ANTICONVULSANT DRUGS

DRUG SEIZURE TYPE SIDE EFFECTS & TOXICI-

TY
Sedating
Carbamazepine (Tegretol) Generalized Dizziness, nausea & vomit-
10mg/kg/d Tonic-clonic Partial ing, liver dysfunction, ane-
q8-12h mia, ↓WBC & platelet

Clonazepam Absence: Irritability, Behavioral abnor-

(Rivotril) Partial malities, depression, x’ ssve
0.05mg/kg/d Myoclonic salivation
q8 Infantile spasm

Ethosuximide (Zarontin) Absence Abdominal discomfort, skin

10mg/kg/d rash, live dysfunction, leuko-
q12-24 penia, aplastic anemia

Gabapentin Complex partial Somnolence, dizziness,

(Neurontin) Secondarily ataxia, headache, tremor,
Generalized vomiting, nystagmus,
fatigue

Phenobarbita Tonic-clonic Hyperactivity, sedation,

I (Luminal) Partial nystagmus, ataxia
3-5 mg/kg/dq8-12
55
Non-sedating
Phenytoin Tonic-clonic Rash, nystagmus,
(Dilantin) Partial ataxia, drug-induced
5mg/kg/d q8-12 lupus,
anemia, leucopenia,
polyneuropathy
Valproate Tonic-clonic Hepatotoxicity, nau-
(Depakene) Absence sea & vomiting, ab-
10mg/kg/d Partial dominal pain, anemia,
q8-12 WBC & platelet

STATUS EPILEPTICUS
 Continuous clinical or EEG seizures lasting for at least 30 mins or
recurrent seizures without return of consciousness during interictal
period, lasting for more than 30 minutes

Treatment Algorithm For Status Epilepticus

Time Action Medications

0-5 mins Ensure airway & cardi- Diazepam a
ovascular function Dose 0.2-0.4 mg/kg,
Oxygen, Vital signs, IV SIVP 0.3-0.5 mg/kg,
line D5NSS/D50.3 at rectal
75% maintenance Rate: 1-2 mg/min
CBC, Na, K, ABG, Hgt Max: 10mg
Repeat: 1xq15-20
mins
6-9 mins If hypoglycemic, give Lorazepam
glucose bolus at 2- Dose: 0.05-0.1 mg/kg,
4ml/kg 25% glucose SIVP; SL
solution or rapid infu- Rate: 1-2 mg/min
sion at 5ml/kg, 10% Max: 4mg single dose;
gluc solution 8mg total
Repeat 2x q5-15 mins

56
10-20 mins Monitor Phenytoin b
Loading: 15-20 mg/kg
SIVP
Rate: 1-3 mg/kg/min
Max: 1 gm
Maintenance: 5-8 mg/
kg/day divided q12 hrs
Fosphenytoin (water-
soluble)
Dose: 20 mg/kg, IV or
IM
Rate: 50-100 mg/min
21-60 mins Support Respiration Phenobarbital b
and/or intubate Loading: 10-20 mg/kg
IV
Rate: 1 mg/kg/min
Refer to Anesthesiolo- Max: 800mg
gist Maintenance: 3-5 mg/
Admit to ICU kg/day divided q12-24
hrs
5% Paraldehyde c
Loading: 150-200 mg/
kg IV over
15-20 mins
Maintenance: 20 mg/
kg/hr

a
Diazepam should not be given IM or diluted with any fluid
b
Phenytoin and Phenobarbital crystallize in dextrose solution
c
Paraldehyde not compatible with plastic containers

ACUTE SUBDURAL vs EPIDURAL BLEEDS

SUBDURAL EPIDURAL
Location Between dura & Between the skull and
arachnoid layers the dura

Symmetry Usually bilateral Usually unilateral

Etiology Rupture of cortical bridg- Rupture of dural veins or
ing veins middle meningeal artery

Typical injury Direct trauma or Shaking Direct trauma in the tem-

poral area

Consciousness Intact but altered Impaired-lucid-impaired

57
Common associated Seizures; retinal hem- Ipsilateral papillary
findings orrhages dilatation, papillede-
ma, contralateral hem-
iparesis
CT (contrast) Crescenteric Biconcave
Prognosis High morbidity; low Low morbidity; High
mortality mortality
Complicatons Herniation Skull fracture,
uncal herniation

INFECTIOUS

DENGUE HEMORRHAGIC FEVER

Clinical Criteria
1. Fever: 2-7 days, regardless of character
2. Hemorrhagic manifestations:
A. (+) Torniquet test: Wintrobe’s mtd (>20 petichiae/inch2)
B. Mucocutaneous bleeding
C. GI bleeding

Laboratory Criteria
DHF criteria + Evidence of Circulatory Failure
Violaceous, cold, clammy skin
Restlessness, weak to imperceptible pulses
Narrowing of pulse pressure to < 20 mmHg
Hypotension

Grading of Severity of DHF

I Fever; non-specific constitutional symptoms

(anorexia, vomiting, abdominal pain)
(+)Torniquet test
II Grade I + spontaneous bleeding
III Grade II + severe bleeding +
circulatory failure
IV Grade III + irreversible shock + massive bleeding

58
Age-related Hypotension with >25% Blood loss

<4 years <65 mmHg systolic BP

5-8 years <75 mmHg
9-12 years <85 mmHg
Adolescents <95 mmHg

Indications for Hospitalization

1. when diagnostic criteria have been met
2. Dengue suspects:
A. Fever > 2d with ↑Het or ↓platelet count and or prolonged BT
B. Altered sensorium
C. Marked anorexia, vomiting & thirsting

Treatment: Rehydration therapy, give crystalloids (PLR or PNSS), if hypoten-

sive give colloids

DOH recommendations= 5 to 7 cc/kg/hr

Maintenance= 3 cc/kg/hr
e.g. Jojo, 20 kg, male
20kg x 5cc/kg/hr=100cc/hr
PLR 1L to turn at 100cc/hr

Blood Component Therapy in DIC

 Whole Blood: 20 ml/kg, if loss >25%
 Packed RBC: 1 ml/kg, raises Het by 1%
 FFP: 10-15 ml/kg initially, may need 5 ml/kg q6
 Cryoprecipitate: 50-100 mg/kg fibrinogen (1 bag=200 mg fibrinogen)
 Platelet concentrate: 1 “U”/ 10kg BW
(1 “U” platelet conc/m2 raises count by 10,000/mm3

59
PRESENTATIONS & COMPLICATIONS OF CHILDHOOD VIRAL ILLNESS

Virus Exanthem Presenting Fea- Complications

tures
Measles Confluent, Coryza, cough Pneumonia, myo-
(Paramyxo-virus) erythematous conjunctivitis, carditis/
maculopapular Koplik’s spot pericarditis,
rash that starts on (small red spots thrombocytope
the head and pro- w/ bluish centers nic purpura,
gresses caudally on the buccal mu- encephalitis;
cosa early) Rare: SSPE,
death

Mumps Typically none Swollen Orchitis (in puber-

(Paramyxo-virus) salivary glands, ty), hearing loss;
specially Rare: meningitis,
parotid glands encephalitis

Rubella Similar to measles Cervical, sub- Rare: arthritis,

(Togavirus) but does not coa- occipital, posterior aplastic crisis (in
lesce auricular lymphad- G6PD), encepha-
enopathy litis,
hydrops

Roseola Similar to measles Acute-onset high Febrile seizures

(Human Herpes but start on trunk fever in a well- (no more common
Virus 6) and spreads to appearing child than with other
extremities before the devel- febrile illness)
opment of rash

Erythema Infec- “Slapped cheeks” Virtually asympto- Rare: arthritis in

tiosum then reticular ery- matic older patients
(5th disease; Par- thematous macu- hemolytic anemia,
vovirus) lopapular rash encephalopathy
from
arms→trunk→
legs

Chickenpox Pruritic “teardrop” Scattered crops of Rare: pneumonia,

(Varicella; shaped that break lesions appear secondary bacte-
Herpes Virus) and crust over, over several days, rial infection, me-
beginning on face so lesions in dif- ningoencephalitis,
or trunk and ferent stages of hepatitis, Reye
spreading to ex- development & syndrome
tremities resolution are
observed simulta-
neously

60
 HEMATOLOGY

Iron-deficiency anemia
 The most common cause of anemia
 Iron is mostly stored in the body in the hemoglobin. About 30 per-
cent of iron is also stored as ferritin and hemosiderin in the bone
marrow, spleen and liver.

Causes iron-deficiency anemia

A. Diets low in iron –Only 1mg of iron is absorbed for every 10 to 20
mg ingested.
B. Body changes-An increased iron requirement and increased red
blood cell production is required when the body is going through
changes such as growth spurts in children and adolescents.
C. Gastrointestinal tract abnormalities– Malabsorption of iron is com-
mon after some forms of gastrointestinal surgeries.
D. Blood loss
Loss of blood can cause a decrease of iron and result in iron-deficiency
anemia. Sources of blood loss may include GI bleeding, menstrual
bleeding, or injury.

Treatment for iron-deficiency anemia:

Iron-supplements
Iron-rich diet

Iron-Rich Foods Quantity Approximate

Iron Content
(milligrams)
Oysters 3 ounces 13.2
Beef Liver 3 ounces 7.5
Prune juice 1/2 cup 5.2
Clams 2 ounces 4.2
Walnuts 1/2 cup 3.75
Ground beef 3 ounces 3.0
Chickpeas 1/2 cup 3.0
Bran flakes 1/2 cup 2.8
Pork roast 3 ounces 2.7
Cashew nuts 1/2 cup 2.65
Shrimp 3 ounces 2.6
Raisins 1/2 cup 2.55
61
Sardines 3 ounces 2.5
Spinach 1/2 cup 2.4
Lima beans 1/2 cup 2.3
Kidney beans 1/2 cup 2.2
Turkey, dark meat 3 ounces 2.0
Prunes 1/2 cup 1.9
Roast beef 3 ounces 1.8
Green peas 1/2 cup 1.5
Peanuts 1/2 cup 1.5
Potato 1 cup 1.1
Sweet potato 1/2 cup 1.0

Iron-Rich Foods Quantity Approximate Iron Con-

tent
Green beans 1/2 cup 1.0
Egg 1 1.0

BLOOD COMPONENT THERAPY

Whole Blood (1 unit =500 ml)

 High reaction rates, so given only when ↑ in both O2 & volume are
required i.e massive bleed,exchange transfusion, bypass surgery
 Dose:10-20 ml/kg in 4-6 hrs; Rate :5-10 cc/kg/hr

>4 months old < 4 months old

1. Hgb < 13 g/dl in NB < 24 hrs 1. significant pre-op anemia

2. Acute Blood loss > 10% 2. blood loss w/ hypovolemia

3. TBV Hgb <13g/dl, severe cardi- 3. Hgb <13g/dl severe pulmonary

opulmonary disease disease

4.phlebotomy losses >5-10 % 4. chronic/ congenital anemia

5.Hgb level <8g/dl in stable NB

62
 Dose corrected deficit (Desired Hct-Actual Hct) x kg BW x 100 =ml
PRB
 Dose corrected to donor Hct
(Desired HCT—Actual Hct ) x kgx est. blood vol= ml PRB (hct of PRB

Age Estimated Blood Vol- Desired Hct

ume (EBV)
Preterm 90-105 cc/kg 0.45
Term 78-86 0.45
1 mo 70 0.40
1 year 73-78 0.40
>1 year 74-90 0.40
Adult 68-88 0.40

Platelet
 Dose:3-4 U/m2 or 1 unit /10 kg BW
 Normally, 1 U/m2 ↑ platelet count by 10-12,000//uL
 When sick, 1 U/m2 ↑ platelet count by 6,300-8900 uL
 1 U/10 Kg BW ↑ platelet count by 40,000/uL
 Term NB=5-10 ml/kg ↑ platelet count by 4,000/uL

Plasma Transfusion

Fresh Frozen Plasma Cryoprecipitate

Has all coagulation fac-
tors,albumin, Ig, complement
Volume:200-250 ml
Dose: 10-15 ml/kg ↑ 30 % plasma
clotting factors
Has factor VII=80-100 U/bag,
VWFs= 100 U, fibrinogen=150-250
mg/dl, FXIII=75U
Volume: 30 ml
Dose: 4U/10 Kg BW 1 bag/10 kg ↑
fibrinogen 50 mg/ml

Rate: 4-6 hours Rate: fast drip

Clotting factor Concentrates

 1 U factor Concentrates 8/kg BW raises factor 8 by 2 %
(1/2 life: 12 hrs)
 1 U Factor 9/kg BW raises factor 9 by 1%
(1/2 life :24 hrs)

63
Desired Factor 8 Replacement

Minor replacement (20-40%) 10 U/kg

i.e. simple hematoma
Moderate replacement (>50%) 20-25 U/kg
i.e mucosal bleed
Major Replacement (80-100%) 50 U/ kg
i.e GI bleed, surgery

Absolute Reticulocyte Count (ARC)

Actual hematocrit x Hct for age x Estimate Blood volume
Reticulocyte Index = ARC/ 2 (n.v:2)
If<2: suppressed marrow;
If>2:compensatory mrrow
Phlebotomy (volume to be extracted)
Vol. (ml0 = EBV x KgBWx Actual HCt –Desired Hct
Actual Hematocrit

CARDIOLOGY

Rheumatic Fever
Occurs mostly in school age children with untreated streptococ-
cal pharyngitis , Rheumatic Heart Disease (RHD) is a feared sequelae
and occurs many years after rheumatic fever

Major Criteria  Carditis

 Polyarthritis
 Chorea
 Erythema marginatum
 Subcutaneous nodules
Minor Criteria  Fever
 Arthralgia
 Elevated acute phrase reac-
tants
 ASO titer performed to confirm past infection with Group A B-
hemolytic streptococci
 Rapid antigen assay if suspected acute infection
 If negative result and still suspected: throat swab and culture
 Penicillin within 10 days of infection prevents rheumatic fever

64
Heart Murmur Gradation

Grade Quality
1 Soft, difficult to hear
2 Easily heard
3 Louder but no thrill
4 Associated with thrill
5 Thrill + audible with edge of dtetho-
scope
6 Thrill + audible with stethoscope just
off chest

CONGENITAL HEART DISEASE

Right to left shunts (Early cyanosis/ Blue babies)

A.Tetralogy of Fallot
A ventricular septal defect (VSD): a hole between the two bot-
tom chambers of the heart
Pulmonic stenosis : right ventricular outflow tract obstruction, a
narrowing at (valvular stenosis) or just below (infandibular ste-
nosis) the pulmonary valve
Overriding aorta: defined as when the aortic valve is not re-
stricted to the left ventricle, thus having biventricular connec-
tions.
Right ventricular hypertrophy: The right ventricle is more mus-
cular than normal, causing a characteristic Coeur-en-sabot
(boot-shaped) appearance, Due to the misarrangement of the
external ventricular septum, the right ventricular wall increase in
size to deal with the increased obstruction to the right outflow
tract.

B. Transposition of Great Vessel

A congenital heart defect in which the 2 major vessels that
carry blood away from the heart– the major aorta and the pul-
monary artery are switched (transposed).

C. Total Anomalous Pulmonary Venous Return

A rare congenital malformation
In which all four pulmonary veins do not connect normally to the
left atrium, but instead drain abnormally to the right atrium by way
of an abnormal connection.

65
 D. Truncus Arteriouus
Truncus arteriosus is characterized by a large ventricular septal
defect over which a large, single great vessel (truncus) arises. This
single great vessel carries blood both to the body and the lungs.

Auscultation ECG CXR

Tetralogy of Fal- SEM, Single S2 RVH Boot– shaped
lot (not loud) heart
Transposition of No murmur RVH Egg-shaped
Great Vessel Single S2 heart, ↑ PVM
(loud)
TAPVR RVH Snowman /
figure of right ↑
PVM
Truncus Arterio- SEM, wide, LVH + RVH Right Aortic
sus fixed, split S2 Arch
cardiomegaly

66
Left– to– right shunts (Late cyanosis/”Blue Kids”)
PE/Auscultation ECG CXR
Ventricular Sep- Parisystolic mur- LVH ↑ PVM
tal Defect mur RVH
Atrial Septal Fixed split S2 Mild ↑ PVM
Defect RVH
Patent Ductus Continuous ma- LVH ↑ PVM
Arteriosus chine-like mur- RVH
mur
Coarctation of Hypertension, ↓ LVH Enlarged aortic
Aorta femoral pulses knob

Eisenmenger syndrome Uncorrected L-to-R shunt leads to progressive

pulmonary hypertension. This changes shunt direction from L→R to R
→L & causes late cyanosis.

REFERENCE RANGES FOR LABORATORY TESTS

Test Sp Age Reference SI

Age

APTT p Preterm: 25-38 sec Infant <90s

1d
Term <6d
<5y
5-19y

Albumin p Preterm: 1.8-3.0 g/dl

1d 2.3-3.4
Term <6d 3.9-5.0
<5y 4.0-5.5
5-19y

U 4-16y 3.35-15.3 mg/24 hr/1.73 m

Bicarbonate SP Arterial 21-28 mmol/L

Venous 22-29 mmol/L

Bleeding Time W Normal 2-7 min Borderline 7-11min

(Ivy)

C-reactive S Cord 52-1,330 ng/ 52-1330 ug/L

protein Blood ml 67-1,800 ug/L
2-12y 67-1,800 ng/
ml

67
Calcium, SP Cord blood 5.0-6.0 mg/ 1.25-1.50
iodized dl mmol/L
W NB: 3-24 h 4.3-5.1 mg/ 1.07-1.27
24-48 h dl mmol/L
Thereafter 4.0-4.7 1.00-1.17
4.8-9.2 or 1.12-1.23
2.24-2.46
mEq/l
CO2, Partial W Newborn 27-40 mmhg 3.6-5.3 kpa
Pressure Infant 27-41 3.6-5.5
(PCO2) Then: 4.7-6.4
Male 35-48 4.3-6.0
female 32-45
Chloride SP Cord bid 96-104
Newborn 97-110
Thereafter 98-106
U Infant 2-10 mmol/d
15-40
Child 110-250
thereafter
Clotting W Glass tubes 5-8 mins (5-15 mins at RT)
Time
C3 S Cord Blood 57-116 mg/
1-3 mo dl
3 mo– 1 yr 53-151
1-10 yr 62-180
Adult 77-195
83-177
Cortisol SP Newborn 1-24 mg/dl 28-662
SP Adults 5-23 138-635
0800 h 3-15 82-413
1600 h <50% <0.50 of
2000 h 0800 h 0800 h
Creatinine SP Cord blood 0.6-1.2 mg/ 53-106
Plasma dl mmol/L
Jaffa Newborn 27-88
Kinetic or Infant 0.3– 1.0 18-35
enzymatic Child 0.2-0.4 27-62
Factor: 88.4 Adolescent 0.3-0.7 44-88
Adult male 0.5-1.0 59-106
female 0.6-1.2 44-97
0.5-1.1

68
Creatinine, U Premature 8.1-15 mg/ 72-133
urinary Fullterm kg/d umol/kg/d
1.5-7 y 10.4-19.7 92-174
Factor:8.84 7-15 y 10-15 88-133
5.2-41 46-362
Erythrocyte W Millions/m X 1012
Count m6 c e lls / L
Cord blood 3.9-5.5 3. 9 - 5. 5
1-3d 4.0-6.6 4. 0 - 6. 6
1 wk 3.9-6.3 3. 9 - 6. 3
2 wk 3.6-6.2 3. 6 - 6. 2
1 mo 3.0-5.4 3. 0 -5. 4
2 mo 2.7-4.9 2. 7 - 4. 9
3-6 mo 3.1-4.5 3. 1 - 4. 5
0.5-2 y 3.7-5.3 3. 7 - 5. 3
2-6 y 3.9-5.3 3. 9 - 5. 5
6-12 y 4.0-5.2 4. 0 - 5. 2
12-18 y M 4.5-5.3 4. 5 - 5. 3
F 4.1-5.1 4. 1 - 5. 1
18-49 y M 4.5-5.9 4. 5 - 5. 9
F 4.0-5.2 4. 0 - 5. 2

Erythrocyte W Child Adult: M Westergren Wintrobe

Sedimenta- F 0-10 mm/hr 0-13
tion rate 0-15 0-9
0.20 0-20
Glucose W Adult 65-95 3.8-5.3

Factor
0.0555
S Cord Blood 45-96 mg/dl 2.5-5.3
NB: 1 d 40-60 mmol/L
>1 d 50-90 2.2-3.3
Child 60-100 2.8-5.0
Adult 70-105 3.3-5.5
3.9-5.8

Glucose S Fasting Normal Diabetic

Tolerance 60 min 70-105 mg/ >115 mg/dl
test (GTT), 90 min dl >200
oral Child: 120 min 120-170 >200
1.75 g/kg of 100-140 >140
ideal wt 70-120

69
Hematocrit W Vol. fraction
1d 0.48-0.69
2d 0.48-0.75
3d 0.44-0.72
2 mo 0.28-0.42
6-12 y 0.35-0.45
12-18 y: M 0.37-0.49
F 0.36-0.46
18-49 y: M 0.41-0.53
F 0.46-0.46

Hemoglobin W 1-3 d 14-22.5 g/ 2.25-3.49 mmol/

2 mo dl L
6-12 y 9.0-14.0 1.40-2.17
12-18 y: M 11-15.5 1.78-2.40
F 13-16.0 2.02-2.48
18-49 y: M 12-16.0 1.86-2.48
F 13-17.5 2.09-2.27
12-16.0 1.86-2.48
Lecithin/ Sphin- AF 2.0-5.0 indicates probable fetal lung maturi-
gomyelin ratio ty
(>3.0 IDM)

Leukocyte count W Birth X 10 9 cells/ L

(WBC) 24 h 9.0-30.0
1 mo 9.4-34.0
1-3 y 5.0-19.5
4-7 y 6.0-17.5
8-13 y 5.5-15.5
Adult 4.5-13.5
4.5-11.0

Leukocyte differ- W Myelocytes 0

ential Neutrophils- “bands” 3-5%
Neutrophils- “segs” 54-62%
Lymphocytes 25-33%
Monocytes 3-7%
Eosinophils 1-3%
Basophils 0-0.75%

70
Mean cor- W Birth 31-37 0.48-0.57
puscular 1-3 d pg/cell fmol/cell
Hgb conc. 1 wk-1 mo 31-37 0.48-0.57
(MCHC) 2 mo 28-40 0.43-0.62
3-6 mo 26-34 0.40-0.53
0.5-2 y 25-35 0.39-0.54
2-6 y 23-31 0.36-0.48
6-12 y 24-30 0.37-0.47
12-18 y 25-33 0.39-0.51
18-49 y 25-35 0.39-0.54
26-34 0.40-0.53

Mean cor- W 1-3 d 95-121 um 3 95-121 fL

puscular 0.5-2 y 70-86 70-86
Volume 6-12 y 77-95 77-95
(MCV) 12-18 y: M 78-98 78-98
F 78-102 78-102
18-49 y: M 80-100 80-100
F 80-100 80-100

Osmolality S Child/ Adult H2O 275-295 mOsm/kg

U Random: 50-1,400 24 hour: 300-900
Oxygen, W, a Birth 8-24 mmHg 1.1-3.2 k Pa
Partial pres- 5-10 min 33-75 4.4-10.0
sure (PO2)↓ 30 min 31-85 4.1-11.3
with age >1 hr 55-80 7.3-10.6
1d 54-95 7.2-12.6
Thereafter 83-108 11-14.4
O2 satura- W Newborn: 85-90%
tion Thereafter: 95-99%
PTT W Nonactivated: 60-85 sec
Activated: 25-35
PH, arterial W Preterm 7.35-7.50
48 h 7.11-7.36
Birth, 7.09-7.30
Term
5-10 min
S 30 min 7.21-7.38
>1 h 7.26-7.49
1d 7.29-7.45
Thereafter 7.35-7.45

71
Phosphatase, S 1-9 y 145-420 U/L
alkaline 10-11 y 130-560 F 105-420
12-13 y M 200-495 70-230
14-15 y 130-525 50-130
16-19 y 65-260

Platelet count W Newborn: 84-47 8 x 10 9/L Adult:

150-400

Potassium S <2 mo 3.0

2-12 mo 7.0 mmol/L
>12 mo 3.5-6.0
3.5-5.0

Protein, total S Premature 4.3-7.6 g/dl

Newborn 4.6-7.4
1-7 y 6.1-7.9
8-12 y 6.4-8.1
13-19 y 6.6-8.2

U 1-14 mg/dl; 50-80 mg/24 hr (at rest)

<250 mg/24 hr after intense exercise

Prothrombin time W In general, 11-15 s

(1-Stage) Newborn Prolonged by 2-3 s

Reticulocyte count W Adults 0.5-1.5% of RBC

or 25 T-75 T/mm 3
0.4-6.0%
1d <0.1-1.3%
7d <1.0-1.2%
1-4 wk <0.1-2.4%
5-6 wk 0.1-2.9%
7-8 wk <0.1-2.6%
9-10 wk 0.1-1.3%
11-12 wk

Specific gravity U Adult 1,002-1,030

After 12 h fluid restriction: > 1,025
24 h urine 1,015-1,025

Thyroxine, free S NB:3 d 2.0-4.9 ng/dL 26-631

1-12 mo 0.9-2.6 pmol/L
Puberty 0.8-2.2 12-33
10-28

Triiodothyronine, S Cord 20-240 0.3-3.7

free Blood pg/dL pmol/L
1-3 d 200-610 3.1-9.4
6 wk 240-560 3.7-8.6
Adult 230-660 3.5-10.0

Urea Nitrogen SP Cord 21-40 mg/Dl 7.5-14.3 mmol/L

Factor: 0.357 Blood 3-25 1.1-9
Preterm 1 wk 3-12 1.1-4.3
Newborn 5-18 1.8-6.4
Infant/ Child 7-18 2.5-6.4
Thereafter

72
 S-serum; P-plasma
U-urine; W-whole blood;
NB-newborn; M-male; F-female

DRUGS & DOSAGES

PREPARATION STOCK DOSE

Amoxicillin 30-50% mg/kg/ Q8 100 mg/ml; 125

day mg/5 ml; 250 mg/
ml

Ampicillin 50-100 mg/kg/day Q6 125mg/5ml

250 mg/5ml

Bacampicillin 25-50 mg/kg/d Q12 250mg/5ml

Cefaclor 20-40 mg/kg/day Q8 125 mg/5ml

Cefalexin 25-50 mg/kg/d Q6 100mg/ml

125mg/5ml

Chloramphenicol 50-100 mg/kg/day Q6 125mg/5ml

Clarithromycin 7.5 mg/kg/day Q12

Clindamycin 10.25 mg/kg/day Q6 75mg/5ml

150mg/5ml

Cloxacillin 50-100 mg/kg/day Q6 125 mg/5 ml

250mg/ 5 ml

Cotrimoxazole TMP 5-8 Q12 40 mg/5 ml

mg/kg/day 200 mg/5 ml
SMX 25-40
mg/kg/day

Co-Amoxiclav 30-50 Q8 228.5 mg/5ml

mg/kg/day 312.5 mg/5ml
Erythromycin 30-50 Q6 100mg/2.5 ml;
mg/kg/day 200 mg/5 ml;
400 mg/5ml
Metronidazole 35-50 Q8 125mg/5ml
mg/kg/day
Nitrofurantoin 5-7 Q6 25mg/5ml
mg/kg/day
Oxacillin 25-50 mg/kg/day Q6 125mg/5ml

73
Penicillin V/G 50,000-100,000 Q6 125 mg/5ml
IU/kg/day 250 mg/5 ml
Sulfamicillin 50 mg/kg/day Q12 125 mg/5ml
250 mg/5 ml
Tetracycline 30-50 Q6 125 mg/5ml
mg/kg/day

Ibuprofen 5-10 Q6 40mg/ml

mg/kg/dose 100mg/5ml
Mefenamic Acid 6.5 mg/kg/dose Q6 50mg/ml

Paracetamol 10-20 mg/kg/dose Q4 60mg/0.6 ml drops

100mg/ml
120/5ml
125mg/5ml
250mg/5ml

Ambroxol 1.2-2.6 mg/kg/day Q8 15mg/5ml

30mg/5 ml

Diphenhydramine 5 mg/kg/day Q8

Mebendazole 2.5 mg/kg/day OD at bedtime 50mg/ml

100 mg/5ml

Pyrantel 11 mg/kg/dose OD at bedtime 125 mg/5ml

Pamoate

Ethambutol 15-25 mg/kg/dose Single dose 125 mg/5ml

Isoniazid 10-20 mg/kg/dose OD after breakfast 100 mg/5ml

Pyrazinamide 15-30 mg/kg/dose OD 250 mg/5ml

Rifampicin 10-20 mg/kg/dose OD before breakfast 100 mg/5ml

Streptomycin 10-20 mg/kg/dose 2-3x/week 1g/vial

Diazepam 0.1-0.3 mg/kg/dose 10mg/2ml amp

Phenobarbital 5-10 mg/kg/dose Q12

Cimetidine 20-25 mg/kg/dose Q6 100mg/5ml

Ranitidine 2-4 mg/kg/day Q8 50mg/2ml amp

74
Salbutamol 0.10-0.15 Q8 2mg/5ml
mg/kg/dose
Terbutaline 0.5-0.75 Q8 0.3 mg/ml
mg/kg/dose 1.5 mg/5ml
Theophylline 10-20 Q8 75 mg/5 ml
mg/kg/day

E.g. Compute for Paracetamol using 250mg/5ml

Stitch, 20 kg, male

→ weight x pedia dose /stock dose

20 kg x 15 mk dose = 6 ml
250/5
**give 6 ml every 4 hours for fever/pain**

E.g. Compute for Amoxicillin using 125/5ml

Shintaro, 22kg, male

→weight x pedia dose/ stock dose

frequency

22kg x 30mkd/ 125/5=8.8 ml of Amoxicillin 25/5ml every 8 hours

3

Note: If the Pedia dose unit is mg/kg/day, you need to divide it with its fre-
quency.

Commonly Used Parental Drugs

Pedia Dose Frequency Stock Dose
Amikacin 15 mg/kg/day OD 250 mg/vial,
500 mg/vial
Ampicillin 100 mg/kg/day q6-q12 250 mg/vial,
500 mg/vial
Cefuroxime 100-150 mg/kg/ OD 250 mg/vial
day q8
50-100 mg/kg/
day

Gentamycin 5-7 mg/kg/day OD 40 mg/ml/vial

75
76