1) `POTASSIUM MAINTENANCE ( by Tan Tsae Yun ) 9/7/2015

Body weight: 14.4kg , potassium 2.9 mmol/L

Total fluid maintenance: 1220ml

1st 10kg: 10 x 100= 1000ml

2nd 10kg: 4.4 x 50= 220ml

No. of d2rips required: 1220 /500cc = 2.44pint

1.5g KCl given in each pint of drip: 2.44 x 1.5g = 3.66g KCl / day

= 3.66 x 13.3 mmol ( 1g = 13.3

mmol )

= 48.678 mmol / day

= 48.6/14.4kg = 3.37 mmol/kg/day

To repeat BUSE 4H/ 6H or according to patient’s condition.

Mist KCl = 1g / 10cc (Can be vary in different hospital), to give 0.5mmol/kg/dose 4-12
hourly.

Not to give in patient with diarrhea (may aggravate diarrhea)

Dosage of Mist KCl = (0.5 x weight x 10cc) / 13.3

= (0.5 x 14.4 x 10) / 13.3

= 5 cc TDS / QID

2) NEBULISER (by Najihah) 10/7/15

Neb Salbutamol

1cc salbutamol=5mg

1cc atrovent (ipratropium bromide)= 250mcg

Salbutamol: normal saline

<2 years old= 0.5: 3.5

>2 years old= 1:3

Eg: 3 years old- neb salbutamol 4 hourly (salbutamol 5mg: NS 3cc)

Neb combivent

Salbutamol : atrovent: normal saline

>5 years old: 1:2:1

 >2 years old: 1:1:2

<2 years old: 0.5:1:2.5

Eg: 6 years old- neb combivent 6 hourly (salbutamol 5mg: atrovent 500mcg: NS
1cc)

3) Reducing pain management during procedure for children ( by Lew Min Chong )
11/7/15

1st line : Syrup chlorohydrate dose : ( 50mg/kg )

2nd line : IV midazolam 0.1mg/kg (MAX 0.4mg/kg)

Notes : side effects : hypotension, vasodilatation, respiratory distress

3rd line : IV morphine 0.1to 0.2mg/kg

4th line : IV ketamine 1mg/kg

Notes : can cause hypertension and bronchodilatation. Therefore, it is the

better choice of drug in intubation for asthmatic children. In the meanwhile, by
giving atropine can counter the side effect of ketamine ( hypersalivation )

Contraindication : traumatic brain injury

5th line : IV Prometazine : 0.5mg / kg / dose

6th line : IV pethidine : 0.5 – 1 mg/kg

4. Pertussis (B. pertussis is a very small Gram-negative aerobic coccobacillus)

by Alice

Stage 1 – Catarrhal phase

Nasal congestion

Rhinorrhea

Sneezing

Low-grade fever

Tearing

Conjunctival suffusion

Stage 2 – Paroxysmal phase

 Paroxysms of intense coughing lasting up to several minutes, occasionally followed
by a loud whoop

Posttussive vomiting and turning red with coughing

Stage 3 – Convalescent stage

Chronic cough, which may last for weeks

Ensure healthcare staff to take droplet precautions.

Erythromycin and clarithromycin are not recommended in infants younger than 3

month, because their use has been associated with increased risk of infantile
hypertrophic pyloric stenosis (IHPS).

Syrup azithromycin 10mg/kg/dose od x5/7 or Syrup EES 20mg/kg/dose bd x2/52

Supportive measures: oxygen/ IVD/ neb salbutamol

ALSO NEED TO TREAT CLOSE CONTACTS AND HOUSEHOLD

5. McIsaac score

· Fever > = 38 C (+1)

· No cough (+1)

· Tonsillar exudates (+1)

· Tender ,anterior cervical nodes (+1)

· Age < 15 ( + 1)

Score 0 or 1: No antibiotic treatment

Score 2 or 3: Do throat swab and culture and KIV antibiotic
Score 4 or 5: Treat with antibiotic or do throat swab*

6. Common antibiotic in paediatric (by Najihah: 14/7/15)

IV C-penicillin - 25,000 u/kg/dose QID (pharyngitis)

-50,000 u/kg/dose QID (pneumonia)

-100,000 u/kg/dose QID (meningitis)

Cefuroxime - IV: 25mg/kg/dose TDS

 -syrup: 15mg/kg/dose BD

Augmentin -IV: 30mg/kg/dose TDS

-syrup: 20mg/kg/dose BD

Cefotaxime -25mg/kg/dose BD (non- meningitic dose)

-50mg/kg/dose (meningitic dose)

Preterm: BD

Term: 1st week: TDS

>1 week:QID

Syrup Erythromycin (EES): 20mg/kg/dose BD

Syrup Penicillin V: 15mg/kg/dose QID

IV rocephine (Ceftrixone): 25-50mg/kg/dose BD

IV gentamicin -Term: 3mg/kg/dose OD

-Preterm: 2.5mg/kg/dose OD

Syrup Azithromycin 7.5 mg/kg/dose OD 3-5 days (in pertussis, 10mg/kg/dose for 5 days)

*Dose of antibiotic in neonate should follow the Neofax guideline.

7. Technique of tepid sponging (by Francis Lee 16/7/15)

-Explain to mother the purpose is to bring down the temperature

- use warm water (air suam). If warm water not available, use tap water.

- wet the towel and rinse it until AS DRY AS POSSIBLE!!

- Apply the dry towel to whole body: the head, body,limbs, back, axilla and groin

- Compare the body temperature again with own temperature

- Repeat the procedures again if still feel warm.

- Repeat temperature every 30 min until less than 37.5 C.

8. VIRAL BRONCHIOLITIS (by Francis Lee 16/7/15)

Aetiology and epidemiology

- Usually happened in infants aged 1 to 6 months old

- Commonest cause = Respiratory Syncytial Virus (RSV)

Clinical Features:

- Mild coryza

- Low grade fever

- Cough

- Tachypnoea

- Chest wall recession

- Wheeze

Ausculation shows fine crepitations and sometimes rhonci

Clinical features that requires hospital admission: age less than 3 months old, toxic-
looking, moderate/severe chest recession, central cyanosis, difficulty feeding, apnoea,
oxygen saturation < 93%

Chest X-ray shows hyperinflation(most common), segemental collapse/consolidation,

lobar collapse/consolidation

Chest X-ray is recommended for children with severe respiratory distress, unusual clinical
features, underlying cardiac or chronic respiratory disorder, admission to intensive care.

Management:

- Assessment of respiratory status and oxygenation

- Keep spO2 >95%

- Administer supplemental humidified oxygen if necessary

- Encourage orally

- Start IVD for patient with severe respiratory distress, cyanosis, apnea

- Neb saline 3% 4/6 hourly (to clear the mucus)

- Neb salbutamol 0.5: 3.5 4/6 hourly (patient affected usually less than 2 years
old)

- Start antibiotics if patient has recurrent apnea and circulatory impairment,

possibility of septicemia, acute clinical deterioration, high white cell count,
progressive infiltrative changes on Chest Xray.

- In moderate to severe respi distress patient, to restrict feeding/NBM or use Ryle

tube feeding if parent agreeable.

9. IVD regime (BY KUAN 16/7)

D1-60ml/kg/day :D10%

D2-90ml/kg/day: 1/5NSD10%

D3-120ml/kg/day:1/5NSD10%

D4 to 1 month of life-150ml/kg/day: 1/5NSD10%

1 month to 12 month-120ml/kg/day: 1/5NDD5%

1 year onwards: first 10 kg:100ml/kg/day

Second 10kg: 50ml/kg/day

Subsequent weight: 20ml/kg/day

Up to 1 month: 1/5NSD10%

1 month to 12 month-120ml/kg/day: 1/5NSD5%

1 year to 5 year-1/2NSD5%

5years and above: NSD5

10.Asthma (shalini)

Assessment of severity

Initial (acute assessment)

1) Diagnosis

-symptoms e.g. cough , wheezing, breathlessness, pneumonia

2) triggering factors

- food, weather, exercise, infection, emotion, drugs, aeroallergens

3) severity

- respiratory rate, colour, respiratory effort, conscious level

Chest x-ray :- not helpful, unless complications like pneumothorax, pneumonia, or lung
collapse are suspected.

Clinical index (to define Risk of asthma)

> 3 wheezing episodes/year during first 3 years + 1 Major or 2 minor Criterion
Major: - Eczema - Parental asthma - AERO Allergen skin test +
Minor: - Skin test + - Wheezing w/o URTI - Eosinophilia > 4
Classification 1) Intermittent : - EIA

2)persistent : + EIA, + need for prophylaxis MDI

Degree of Asthma severity

 Daytime sx < 1x / week > 1x /week Daily Daily
Nocturnal sx <1x / month >2x / month >1x / week Daily
EIA - + + Daily
Exacerbations Brief Not > 1x / month > 2x / month >2x / month
affecting sleep Affect sleep/ Affect sleep/ frequent Affect
activity activity sleep/activity
PEFR/FEV1 Normal lung fn >80% 60-80% < 60%

GINA – Level of asthma control (after starting MDI)

Controlled partially controlled uncontrolled

Daytime sx - > 2x / week > 3 of partly

controlled
features
Nocturnal sx - +
Limit activities / - +
EIA
Exacerbations - > 1 / year
Lung Fn test Norma < 80% predicted best
l
Need for reliever - > 2x / week 1 in any week

11. Acute Management of Bronchial Asthma by Khoo (27/7/15)

Mild
Nebulised Salbutamol or
MDI Salbutamol + spacer
4 - 6 puffs (<6yrs),  
8 - 12 puffs (>6yrs)  

Review after 20 minutes

No Improvement Improvement

Observe for 60 minutes after last

dose
 Improvement
Observe for
60 mins

Discharge with improved long term

treatment and asthma action plan
Short course of oral prednisolone
1mg/kg/day for 3 -5 days  
Regular bronchodilators 4 - 6 Hly
for few days then PRN  

Moderate
Nebulised Salbutamol
± Ipratropium Bromide
(3@20 minutes intervals)
+ Oxygen 8L/min by face
mask
No Improvement

After 60 mins

Admit Ward

12. Cephalohematoma VS Subapeneurotic Hemorrhage by Haryani

Criteria Cephalohematoma SAH

Consistency Firm Soft
Boggy Non boggy Boggy
Tenderness Nil Tender
Crossing suture Nil Crossing suture
Margin Well define, may cause Not well define, may cause
prolonged jaundice, some severe hemorrhage.
swelling resolved after few
months.

13. Jaundice/prolonged jaundice (Tan TY)

Neonatal jaundice
Prolonged jaundice: term > 14days

Preterm > 21 days

History to rule out:

- Term / preterm

- G6PD/ CTSH

- Mother’s blood group: O positive (ABO incompatibility)

- tolerate feeding? Active?Vomiting? Abdomen distention?

- Mum taking traditional medicine?

- URTI / UTI/Sepsis symptoms

- PU regularly?

- BO? Colour? Pale colour stool (obstructive jaundice- biliary atresia)?

Common causes:

1. Infections ( Sepsis/UTI/ URTI )

2. Biliary atresia

3. ABO / rhesus incompatibility

4. G6PD deficiency

5. Congenital Hypothyroidism (cord TSH more than 22)

6. Cephalhematoma

14. Scabies

1) How to recognize scabies?

- characteristic silvery lines may be seen in the skin where mites have burrowed

- itch especially at night

- classic sites : interdigital folds,wrists,elbow,umbilical area,genital area and feet

- usually other family members have similar itchiness lesion.

Treatment for child ( by shalini 20/7/15)

-Permetrin 5%

+2 months onwards

+massage the lotion into the skin (head to the soles of the feet, areas between the
fingerd and toes, wrist, axillae, external genitalia and buttocks.
 +remove the lotion after 12-14 hours (apply at night, wash off next morning)

-Benzyl benzoate (EBB)

+ 12.5% emulsion (7-12 y/o)

+25 % emulsion (above 12 y/o)

-Crotamiton – apply whole body from neck down nightly for 2 nights. Wash it off 24hours
after 2nd application

14. How to calculate Days of Life in a neonate: Alice

0 TO 24HOUR DAY 1

24HR 1MIN TO 48HR DAY 2

48HR 1MIN TO 72 HR DAY 3

72HR 1MIN TO 96HR DAY 4

15) Acute gastroenteritis by NUR LIYANA (20/7/2015)

1)Encourage breast feeding

2)encourage fluid intake

3)ORS –( 10ml/kg - <2y =50-100ml per purge, 2 y- 100-200 ml per purge)

4)continue feeding as usual-avoid simple sugar (worsening diarrhea dt osmotic load)

4)IVD

a)resuscitation- IN severe dehydration, give bolus 20 cc /kg of nacl 0.9 % over 30 min
to 1 hour..cont till shock resolved (BP, pulse, perfusion return to normal) and monitor
the fluid overload and urine output after each bolus

b)deficit –

- % of dehydration x weight (gram), replaced over 12-24 hour, using NS.

Eg- a child of 8kg, with 5% dehydration

= 5/100 x 8kg x 1000 = 400 cc of water over 24 hours

=400/24 =17 cc/hour NS

# in case of hypernatraemic dehydration or DKA, do correct the deficit over 48 hours.

c)maintenance –OVER 24 HR
 Age

-<3 month – 150cc/kg (1/5 NSD5%)

- 3-6 month – 150 cc/kg (1/5 NSD5%)

- 6-12 month – 120 cc/kg(1/5 NSD5%)

- Over 1 year (1/2 NSD5%) -1st 10 kg – 100 cc/kg/d

- 2nd 10 kg – 50cc/kg/d

- subsequent 10 kg – 20 cc/kg/d

Rehydration (reassessed after every bolus, and then every 4-6 hr ly).

Hence, total fluid fo a child 1 year with 8 kg 5% dehydration: 40cc/hour 1/2SD5%

maintenance + 17cc/hour NS deficit (ideally administer via 2 peripheral line,
alternatively 1 peripheral line with 3 way clock).

16) Ophtalmia Neonatorum by AfifiYahaya (24/7/15)

= Conjunctivitis occurring in newborn during 1st 4 weeks of life with 1) erythema and
edema of eyelids and palpebral conjunctiva 2) Purulent eye discharge 3) 1 or > PMN
per oil immersion field on Gram stained conjunctival smear

Organism

1. Gonococcal (onset first few days OL)

a. Systemic : Ceftriaxone 25-50 mg/kg (max 125mg), IV or IM or

Cefotaxime 100mg/kg(preferred if premature or hyperbilirubinemia)

b. Disseminated : Ceftriaxone (1/52), or Cefotaxime BD (1/52)

c. With documented meningitis : Ceftriaxone or Cefotaxime 10-14 days

2. NonGonococcal (Staph Coagulase, Staph Aureus, Strep Viridans, Hemophilus,

E.oli, Klebsiella spp, Pseudomonas)

o Chloramphenicol

o Gentamicin ointment 0.5%

3. Chlamydial (onset 7 days to 2 weeks)

o Erythromicin 50mg/kg/dose QID x2weeks (w/out for HPS) or

o Trimetophrim-Sulfamethoxazole (0.5mg/kg/day BD x2weeks)

4. Herpes Simplex Virus

o IV Acyclovir 30mg/kg/dose TDS x2weeks

Also
 - NS irrigation very 15min then hourly till discharge cleared (can reduce frequency as
discharge reduces)

- Refer ophthalmologist (inpatient or outpatient)

- Notification

- VDRL (Both parents and baby if needed)

- Repeat eye swab (gram stain and culture) 2weeks after discharged.

17) Post Group A Haemolyic streptococci acute glomerulonephritis ( By Lew Min

Chong )

Features :

1. oedematous : facial puffiness

2. microscopic / macroscopic haematuria
3. oliguria
4. hypertension (symptom: headache/dizziness, blurred vision, epigastric pain)
5. azotemia

In children, the commonest cause of acute nephritic syndrome is due to post infectious
AGN mainly to post streptococcal skin infection or pharyngitis. The commonest age group
is from 6 – 10 years.

Refer paediatric, if hypertension (repeat BP high x2 or symptomatic hypertension), need

to treat urgently. Start nifedipine 5-10 mg stat, advice rest, repeat BP after 30 min.
Eliminate strep with penicillin for a total 10 days.

18) Neonatal hypoglycemia(26/7/15)-by Kuan

Definition: dxt <1.5mmol/l in 1st 4 hours of life or symptomatic

Dxt <2.6mmol/l after 4 hours of life

Asymptomatic hypoglycemia: start feeding stat if no contraindication,

if baby KNBM, for IVD 60cc/kg/day D10%( can increase up to 90cc/kg/day), repeat feeding
again if baby still asymptomatic hypoglycemia

Symptomatic hypoglycemia: give IV bolus D10% 2-3ml/kg followed by infusion of

D10%-60cc/kg/day
Repeat DXT ½ hour ltr.
!hypoglycemia: increase drip to 90cc/kg/day D10%,repeat dxt ½ hrs ltr
!hypoglycemia: increase to D12.5% IVD 90cc/kg/day, repeat dxt ½ hr later
! hypoglycemia: insert UVC/central line, increase to D15%, repeat dxt ½ hr ltr
!hypoglycemia: IV glucagon 40mcg/kg followed by 10-50mcg/kg/hr. IV hydrocortisone
2.5-5mg/kg/dose BD in SGA baby or those with insufficient liver stores and maintain IVD
infusion

Glucose infusion rate=% of dextrose x rate(ml/hr)

Weight(kg)x 6
19) Preseptal and orbital cellulitis (by Tan NP on 27/7/15)

FACTORS PERIORBITAL (PRESEPTAL) ORBITAL (POSTSEPTAL)

Pathogenesis Trauma (insect bite) or bacteremia Sinusitis

Age (mean) 21 months 12 years

Clinical findings Periorbital induration, erythema, warmth, Proptosis, chemosis, ophthalmoplegia,

tenderness decreased visual acuity

Bacteria Trauma:Staphylococcus aureus, group A S. pneumoniae, nontypeable Haemophilus

Streptococcus influenzae, Moraxella catarrhalis, group A
Streptococcus, Staphylococcus aureus,
Bacteremia:Streptococcus pneumonia anaerobes

Antibiotics of Mild – augmentin IV ceftriaxone and cloxacillin

choice Moderate – cloxacillin
Severe – ceftriaxone and cloxacillin

20) viral croup (by Helwa 31/7/15)

Definition: viral inflammation of upper airway, also known as laryngotracheobronchitis

Most common causes: parainfluenza virus (74%)

Features: low grade fever,cough and coryza for 12 to 72 hours, followed by bark like cough
and hoarseness, stridor may occur while excited or rest

Assessment:
-mild: stridor at rest or during excitement with no respiratoty distress
-moderate: stridor at rest + distress( intercostals, subcotal or sternal recession)
-severe:stridor at rest with ,marked recession, decreased air entry and altered
consciousness
ABG usually will only deranged at late stage.

Management:
Indications for hospitalization: moderate/severe croup, toxic looking, age <6m.o. ,poor
oral intake,
Unreliable caretaker, long distance from hospital

-Mild: oral or parental dexamethasone 0.15 kg single dose OR T.prednisolone 1-2 mg/kg
stat OR if vomit neb budesonide 2mg single dose. Allow discharge if improved.
-Moderate:oral or parental dexamethasone 0.3-0.6mg/kg single dose OR neb budesonide 2
mg stat and 1 mg 12 hourly. If no improvement, proceed with neb adrenaline.
-severe:Neb adrenaline 0.5mg/kg 1:1000 + iv dexamethasone 0.3-0.6 mg/kg + neb
budesonide 2mg stat,1mg 12hourly and oxygen. If no improvement, INTUBATE and
VENTILATE
Differences between Viral episodic wheeze, multi triggering wheeze and bronchial
asthma.
By Lew Min Chong

Viral episodic wheeze Multi triggering wheeze Bronchial asthma

< 5 years
Wheezing occurs during
discrete time periods, often
associated with clinical
evidence of a cold, with an
absence of wheeze between
episodes
<5years
Wheezing that shows
discrete flare-ups but also
with symptoms of cough and
wheeze between episodes,
during sleep or with triggers
such as vigorous activity,
laughing or crying
6years and above
• episodic pattern
accompanied by
other symptoms such
as wheeze or
breathlessness
• worsening symptoms
during exercise or
exertion
• airflow limitation
confirmed by
spirometry, especially
if reversible (i.e.
responsive to
bronchodilator).

Requires neb salbutamol
Require neb salbutamol, Require neb salbutamol and
budesonide, singulair budesonide
granules
( montelukast ), syrup
prednisolone.

Notes : Montelukast indication is to relieves allergic reactions. Dosage is 4mg.

Add-on therapy in those 6 months to 5 year old patients with mild to moderate persistent
asthma who are inadequately controlled on inhaled corticosteroids and in whom “as-needed”
short acting β-agonists provide inadequate clinical control of asthma.