Pedia Small Notebook Edited

ESSENTIAL NEWBORN CARE PROTOCOL [from DOH]

▪ What should be done immediately after birth is to dry the baby because hypothermia can lead to several risks

APGAR SCORE

▪ Delaying the cord clamping to 3 mins after birth (or waiting until the umbilical cord has stopped pulsing) Instead of immediately washing the NB, the baby should be placed on the mother’s chest or abdomen to provide warmth, increase the duration of breastfeeding, and allow the “good bacteria” from the mother’s skin to infiltrate the NB Washing should be delayed until after 6 hours because this exposes the NB to hypothermia and remove vernix. Washing also removes the baby’s crawling reflex.

▪

▪

NEWBORN CARE Umbilical Cord ▪ Cut 8 inches above abdomen after 30 sec

▪ In nursery, cut the umbilical cord 1 ½ inch above the abdomen ▪ Healing should take place around 7 – 10 days Eye Prophylaxis ▪ 1% silver nitrate drops [most effective against Neisseria]

Vaccine ▪ BCG

▪ PT: 0.5 mg ▪ Hep B Newborn Screening ▪ Done on 16th hr of life . can be repeated after 2 weeks ▪ Patients w/ CAH will die 7 – 14 days if not treated ▪ Patient w/ CH will have permanent growth defect and MR if not treated before 4 weeks Disorder Screened

Effects Screened

Congenital Hypothyroidism Congenital Adrenal Hyperplasia (CAH) Galactosemia (Gal)

Severe MR

Effects if Screened & treated Normal

Death

Alive &Normal

Death of Cataract

Alive &Normal

Severe MR Severe Anemia Kernicterus

Normal Normal

Phenylketonuria PKU G6PD

HR Reflex irritability Activity Respiration The APGAR Score 8 – 10 4–7 0–3

BCG DPT OPV/IPV Hep B

Measles MMR Hib Pneumococcal Rotavirus Hep A Varicella

Flu

# of dose 1

Interval

Booster

-

-

3

4 wks

3

4 wks

18 mos 4 – 6 yo Same as DPT

3

6 wks from 1st dose; 8 wks from 2nd dose -

15 mos

1

2, 4, 6 mos

18 mos

6 mos (PCV7) 2 yrs (PPV) 3 and 5 mos

18 mos 2

I month

1 yr and up

2

1st: 12 – 15 mos 2nd: 4 – 6 yo

2

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

6 months

Good cardiopulmonary adaptation Need for resuscitation, esp ventilatory support Need for immediate resuscitation

NEONATAL JAUNDICE

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

1

>100 Cough Active Good

Please admit under RI, LI, PD or AP TPR q4H May breastfeed if NSD; NPO x 2hrs if CS Labs: NBS at 24 hrs old, secure consent CBC, BT (if w/ maternal illness, PROM or UTI HGT now then 1, 3, 6, 12, 24, 48 hrs old (GDM) HGT now (SGA or LGA) Medications: Erythromycin eye ointment both eyes Vit K 1 mg IM (term); 0.5 mg (PT) Hep B vaccine 0.5 ml IM, secure consent BCG 0.05 ml ID (PT); 0.1 ml (term), secure onsent SO Routine NB care Monitor VS q30 mins until stable Thermoregulate at 36.5 to 37.5°C Place under droplight (NSD); isolette (CS) Suction secretion prn Will infrom AP /AP attended delivery

IMMUNIZATION Vaccine

2 All pink

NICU

▪ Erythromycin 0.5% [Chlamydia] ▪ Tetracycline 1% ▪ Povidone iodine 2.5% Vitamin K ▪ 1 mg Vit K1

Color

Evaluates the need for resuscitation Taken 1 and 5 minutes after birth 0 1 Blue, pale Body pink, extremities blue 0 65% East Asian/ Mediteranean in origin PHYSIOLOGIC vs PATHOLOGIC FACTORS Onset Rate of inc of TSB Persistent

PHYSIOLOGIC > 24 hrs of life < 0.5mg/dl/hr < 14 days

Total S. Bilirubn

FT: < 12 mg/dl PT: < 14 mg/dl

Signs/Symptoms

ZONE I II III IV V Parameter Onset

Pathophysiology Mngt

PATHOLOGIC < 24 hrs of life > 0.5mg/dl/hr FT: > 8 days PT: > 14 days Any level requiring phototherapy Vomiting, lethargy, poor feeding, excess wt loss, apnea, inc RR, temp instability

KRAMER CLASSIFICATION JAUNDICE Head/neck Upper trunk Lower trunk, thigh Arms, leg, below knee Hands/feet

mg/dl 6–8 9 – 12 12 – 16 15 – 18 > 15

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

MILK FORMULAS 1:1 dilution 1:2 dilution Mead-Johnson, Nestle, Glaxo, Wyeth, Abbott, Unilab Dumex, Milupa 0-6 months (20cal/oz) Lactose free (0-6months) Mead-johnson: Alacta , Enfalac Nestle: NAN1, Nestogen Glaxo: Frisolac Dumex: Dulac Abbott: Similac advance Milupa: Alaptamil Wyeth: S26, Bonna Unilab: Mylac 6months onwards (20cal/oz)

Mead-johnson: Enfalac lacto-free Nestle: AL110 Milupa: HN25 Wyeth: S26 Lacto-free

Mead-johnson: Enfapro Nestle: NAN2, Nestogen 2 Glaxo: Frisomil Dumex: Dupro Abbott: Gain Wyeth: Bonnamil. Promil Unilab: Hi-nulac 1 year onwards (20 cal/oz)

Mead-johnson: Enfapro lacto-free

Mead-johnson: Enfagrow, Lactum Nestle: NAN3, Neslac Glaxo: Frisorow Dumex: Dugrow Abbott: Gainplus Wyeth: Progress, Promil Unilab: Enervon bright Hypoallergenic (20cal/oz)

Mead-johnson: Enfaprem Nestle: PreNAN Abbott: Similac prem Milupa: Preaptamil

Mead-johnson: Pregestimil Nestle: Alfare, NAN HA1, NAN HA2

Mead-johnson: Prosoybee Abbott: Isomil Wyeth: Nursoy

Lactose free (6months onwards)

Premature Infant (24cal/oz)

Soy-Based (20cal/oz)

TPN for NEONATES Wt 2kg 1. TFR = 100 ml/kg/day x 2 kg 2. Intralipid 20% 1 g/kg/day x 2kg = 2g/day 2 g = 20g x 100ml

200 ml 10 ml

3. Compute for TFR 1 TFR1 = TFR – Intralipid = 200 -10ml = 90 ml 4. Vamin 7% 1 g/kg/day x 2 kg = 2g = 29 ml 2 g = 7g x 100ml 5. Multivitamins Benutrex c 0.5 ml/100ml 0.5 ml = x 1 ml 100ml 190 ml 6. Ca gluc 10% 2ml/kg/day x 2 kg 4 ml 7. Dextrosity (D10) get d50w TFR 1 x dextrosity factor (0.11) 21 ml 190 x 0.11 8 . D5IMB = TFR 1 – (Vamin + MTV + Ca gluc + D50W) 190 – (29 + 1+ 4+ 21) = 135 ml 9. IV rate = TFR 1 / 24H 190 ml/ 24H 8 ml/H

Order: Start TPN as ff: TFR= 100ml/kg/day D5 IMB 135 ml D50W 21 ml Vamin 7% 29 ml Ca Gluc 4 ml MTV 1 ml 190 ml to run at 8 ml/h Intralipid 20% 10 ml to run for 24H

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

TFI = 1000ml/day

Vamin 7% 7 = 2 g/kg x 10kg 100 CaGluc 2ml/kg D5IMB D50W 0.11 x 1000ml

285 ml 20 ml 485 ml 110 ml 1000ml x 37 cc/h TPN (PEDIATRICS) Energy Requirment

AGE/WT Neonates Infants & Older Children 20 AGE/WT Neonates: VLBW (≤ 1500 gm)

Caloric Rquirement 90-120 kcal/kg 10-120 kcal/kg 1000kcal + 50 kcal foe each kg > 10 1500 + 20 for each more than 20 Fluid Requirement Fluid Rquirement Initiate at 40 – 60 ml/kg/day and increase by 10 ml/kg/day till 120 ml/kg is reached

AGA & LBW

Initiate at 60 ml/kg/day and increase by 15 ml/ kg/day till 120 ml/kg is reached on the 5th day of PN Neonates under radiant heaters/on phototx an extra 30ml/kg/day of water Infants & Older Children 20

100 – 120 ml/kg 1000ml + 50 ml foe each kg > 10 1500 + 20 for each more than 20

Protein Requirement AGE/WT Dosage (gm/kg/day) VLBW (≤ 1500 gm) 2.25 0 – 12 months 2.50 1 – 8 yrs 1.50 – 2.0 8 yrs and above 1.00 – 1.50 With the initiation of PB|N, start w/ 0.5gm/kg/day and gradually increased by 0.5gm/kg/day till recommended protein is reached. Carbohydrate Requirement % dextrose = gram dextrose x 100 Vol infused (ml Should provide 50 – 60 % 0f total non-protein calories Requirement ranges frm 10 to 25 gm/kg/day Infusion should not exceed 12.5mg/kg/min Should be decreased if urinary glucose ≥0.5% (2+) or blood sugar exceeds 7 mmol/L in neoanate or 9.7 mmol/L I above 1 mo of age Fat Requirement AGE Dosage (gm/kg/day) 0 – 12 months 2 1 – 8 yrs 4 8 yrs and above 2.5 30 – 40 % of total calories shud b provided as fats 2 – 4% as EFA Start at 0.5 gm/kg/day and gradually increase by 0.5 gm/kg/day till recommended amt is reached Daily Electrolyte Requirements Elect. (mmol/kg)

Neonates

NaCl Potassium Cal gluc

3–5 2–4 0.6 – 1.0

Phosphate Magnesium

1.0 0.125-0.250

1-6 mos

6m-11yrs

3–4 2–3 0.25 – 1.2 (max of 4.7) 1–2 0.125-0.250

3–4 2–3 0.25 – 1.2 (max of 4.7) 1–2 0.125-0.250

Adolescents 60 – 100 80 – 120 4.7 30 – 45 4–8

Calcium gluconate contains 100 mg calcium gluconate or 9mg elemental calcium/ml; 1 gm of Ca gluconate contains 4.7mEq or 2.35 mmol of Ca.

Trace Elemental Requirements

VITAMINS

Trace Elemental

Prematures (ug/kg)

Infants & Children (ug/kg)

Adolescents (mg)

Stimulants Buclizine (syrup)

Zinc Copper Chromium Manganese Iodine Selenium Flouride

400 50 0.3 10 8 4 57

100 – 500 20 0.14 – 0.2 2 – 10 8 4 57

2.5 – 4 0.5 – 1.5 0.01 – 0.04 0.15 – 0.5 0.2 0.3 0.9

w/ Folic acid (Megaloblastic Anemia)

▪ In the absence of available prep of trace elements; weekly blood transfusion may be given at 20 ml/kg

▪ Iron: 2 mg/kg, with dose increased to 6 mg/kg if Fe def is documntd; provided by adding iron dextran to amino acid sol’n OSTERIZED FEEDING TFR

Pizotifen (drowsiness) MTV w/ Iron

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

CHON

CHO

Fats

w/ Serotonin (for migraine + dec wt)

COMPOSITION OF ORS Na

K

Cl

Glu

Glucolyte

60

20

50

100

Hydrite

90

20

80

111

WHO Pedialyte

75 30 45 90 41

20 20 20 20 11

65 30 35 80

75

ORS

30 45 90

Gatorade Iron Deficiency Anemia

9/100

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

PARAMETER

NO SIGN

SOME SIGN

SEVERE

Condition

Well, Alert

Restless Irritable

Eyes

Normal

Sunken

Lethargic Unconscious Floppy Very sunken Dry

Tears

Present

Absent

Absent

Mouth/Togue

Moist

Dry

Very dry

Thirst

Drinks normally Not thirsty

Thirsty Drinks eagerly

Skin pinch

Goes back quickly

Goes back slowly

Drinks poorly Not able to drink Goes back very slowly

Severity

▪ ▪

Mosegar Vita 0.25 mg/day prep 0.25 /5 ml Appetens Propan Appebon 2 - 8yo 5 - 10 ml OD 7 - 14yo 10 - 20 ml OD Molvite 7 - 12yo 10 - 15 ml OD 3 - 6yo 5 - 10 ml OD 1 - 2yo 2.5 - 5 ml OD Iberet Ferlin (10 mcg folic acid) Macrobee 1 - 2yo 2.5 - 5 cc OD 3 - 6yo 5 - 10 cc OD 7 - 12yo 10 - 15 cc OD Mosegor vita syr Appetens Propan w/ iron syr (Fe So4; elem fe 30mg) Appebon w/ iron syr (FeSo4; elem fe 10mg) Mosegor vita Mosegor plain Appeten Jagaplex syrup 1-2yo 5ml OD 3-6yo 10 ml OD 7-12yo 15 ml OD Clusivol Power syrup syr 100mg/5ml 2-6yo 5 ml OD 7-12yo 10 ml OD Zeeplus 10 >20 1500 + 20ml/kg for each kg >20 Maintenance water rate 0 – 10 10 – 20 >20

4ml/kg/hr 40 mk/hr + 2ml/kg/hr x wt 60 mk/hr + 1ml/kg/hr x wt

COMPOSITION OF IV SOLUTION Na K Cl PNSS 154 154 0.45 NaCl 77 77 D5 0.3 NaCl 51 51 D5 LRS 130 4 109 D5 NM 40 13 40 D5 IMB 25 20 22 D5 NR 140 5 98 Na requirement: 2 – 4 meq/k/day K requirement: KIR: 0.2 – 0.3 meq/k/hr ; max 40 meq KIR = Rate x incorporation / wt Fluid

HCO3 Dxt 5 28 5 16 5 23 5 27 5 2 – 3 meq/k/day

CLINICAL FEATURES of PNEUMONIA Bacterial

Fever >38.5C Chest recession Wheeze not a sign of primary bacterial URTI Wheeze Marked recession Fever < 38.5 RR normal or increased

Viral Mycoplasma

School children Cough wheeze CXR in assessing CAP etiology

Alveolar infltrates

Bacterial pneumonia

Interstitial infiltrates Both infiltrates

Viral pneumonia Viral, Bacterial, or Mixed

Microbial causes of CAP according to Age Birth to 20 days

Grp B Strep Gram (-) enterobacteria

3 weeks to 3 months

RSV B. pertussis Parainfluenza virus S. aureus S. pneumonia RSV, Parainfluenza virus H. influenzae Influenza virus, Adeno, Rhinovirus M.tuberculosis S. Pneumonia M.pneumoniae M.pneumoniae S. pneumonia C. Pneumoniae M.tuberculosis

4 months to 4 yo

5 years to 15 years

CMV L. monocytogenesis

Clinical Practice Guidelines in the Evaluation and Management of PCAP Predictors of CAP in patients with cough (3 mos to 5 yrs) – tachypnea &/or chest retractions (5 – 12 yrs) – fever, tachypnea & crackles (>12 yo) – (a) fever, tachypnea & tachycardia; (b) at least 1 AbN CXR WHO Age Specific classification for tachpynea 2 to 12 mos: >50 RR 1 to 5 yrs: >40 RR >5 yrs: >30 RR

THERAPEUTIC MANAGEMENT OF CAP OPD MANAGEMENT Birth to 20 days Admit 3 weeks to 3 months Afebrile: Oral Erythromycin (30-40mkd) Oral Azithromycin (10 mg/kg/day) day 1 5 mkday for day 2 to 5 Admit: febrile or toxic 4 months to 4 yo Oral Amoxicillin (90mkd/3doses) Alternative: Amox-Clav, AZM, Cefaclor Clarithromycin, Erythromycin 5 years to 15 years Oral Erythromycin (30-40mkd) Oral AZM 10mkday day 1, 5mkday day 2-5 Clarithromycin 15mkday/2 doses Pneumococcal infxn: Amoxicillin alone IN-PATIENT MANAGEMENT Birth to 20 days Ampicillin + Gentamicin w or w/o Cefotaxime 3 weeks to 3 months Afebrile: IV Erythromycin (30-40mkd) Febrile: add Cefotaxime 200mkd Cefuroxime 150 mkd 4 months to 4 yo If w/ pneumococcal infection: IV Ampicillin (200mkd) Cefotaxime 200mkd Cefuroxime 150 mkd 5 years to 15 years Cefuroxime 150 mkd + Erythromycin 40mkd IV or orally for 10-14 days If pneumococcal is confirmed: Ampicillin 200mkd VARIABLE

A (Min Risk)

PCAP B (Low Risk)

C (Mod Risk)

D (High Risk)

Comorbid Illness

None

Present

Present

Present

Compliant caregiver

Yes

Yes

No

No

Possible

Possible

Not

Not

None Able >11 mos

Mild Able >11 mos

Moderate Unable 40/min >30/min

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

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

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

Ability to follow up DHN Feeding Age RR 2 – 12 m 1 – 5 yo >5 yo

PCAP A/PCAP B No diagnostic usually requested PCAP C/PCAP D The ff shud b routinely requested CXR APL (patchy – viral; consolidated – bacterial) WBC C/S (blood, Pleural Fluid, tracheal aspirate on initial intubation) Blood gas/Pulse oximeter The ff may be requested: C/S sputum The ff shud NOT be routinely requested: ESR & CRP Antibiotic Recommendation PCAP A/PCAP B and is beyond 2 yo & having fever w/o wheeze PCAP C and is beyond 2 yo, having high grade fever, having alveolar consolidation on CXR, having WBC >15,000 PCAP D – refer to specialist Antibiotic Recommendation PCAP A/PCAP B w/o previous antibiotic Amoxicillin (40 – 50 mkday) TID PCAP C – Pen G IV (100,000 IU/k/d) QID PCAP C who had no HiB immunization Ampicillin IV (100mkd) QID PCAP D – refer to specialist What should be done if px is not responding to current antibiotics? If PCAP A/PCAP B not responding w/n 72 hrs Change initial antibiotic Start oral Macrolide Reevaluate dx PCAP C no responding w/n 72 hrs consult w/ specialisr PCN resistant S pneumonia Complication Other dx PCAP D not responding w/n 72hrs, then immediate consultto a specialist is warranted Switch from IV to Oral Antibiotic done in 2 – 3 days after initiation in px who: Respond to initial antibiotic Is able to feed with intact GI tract Does not have any pulmo or extra pulmo complication Ancillary Treatments O2 and Hydration Bronchodilators, CPT, steam inhalation and Nebulization Prevention Vaccines Zinc Supplementation (10mg for infants / 20mg for children > 2 yo) Signs of Respiratory Failure VARIABLE

A (Min Risk)

B (Low Risk)

C (Mod Risk)

D (High Risk)

Retractions

-

-

Head bobbing Cyanosis Grunting Apnea Sensorium

-

-

Subcostal/ Intercostal +

Subcostal/ Intercostal +

None

Awake

+ Irritable

+ + + Lethargy / Stupor Coma/

None

None

Present

Present

OPD f/u at end of tx

OPD f/u after 3 days

Admit to regulat ward

Admit to CCU; Refer to specialist

Comp: Effusion Pneumo -thorax Action Plan

BRONCHIOLITIS Acute inflammation of the small airways in children 50%

10 - 20

40 to 60%

40 - 60

< 40%

> 100 g%

Bacterial Meningitis

Purulent

0

> 1000

N> L

< 50%

> 100 g%

Partially tx BM

Clear

0

100

L> N

> 50%

Dec

ROSEOLA [HSV 6] Exanthem subitum Age of onset < 3 yo with peak at 6 – 15 months High grade fever for 3 – 5 days but behave normally Rash Appears 12 – 24 hrs of fever resolution fades in 1 – 3 days HERPANGINA [Coxsackie A] Sudden onset of fever with vomiting Small vesicles & ulcers w/ red ring found in anterior tonsillar pillars, may also seen on the soft palate, uvula & pharyngeal wall VARICELLA [HSV] MOT Direct contact IP 14 days Prd of comm 1 – 2 days before the onset of the rash until 5 – 6 days after onset & all the lesions have crusted Rash Start from the trunk then spread to othe parts of the body All stages present; pruritic Macule/papule → vesicle →crust Complication Secondary bacterial infection Reye syndrome Encephalitis or meningitis GN Pneumonia Congenital 6 -12 wks AOG: maximal interruption w/ limb devt Varicella with cicatrix(ski lesion w/ zigzag scarring) 16 – 20 wks: eye and brain involvement Tx Acyclovir 15 – 30 mg/kg/day IV or 200 – 400 mg tab q 4hrs minus midnight dose x 5 days: ↑ risk of severity Post exposure VZIg 1 dose up to 96 hrs after exposure prophylaxis Dose: 125 U/10 kg (max 625 U) IM NB whos mother develop varicella 5 days before to 2 days after delivery shud recv 1 vial Vaccine Susceptible children >1 yo w/n 72 hrs ERYTHEMA INFECTIOSUM [Parvovirus B 19] FIFTH DISEASE MOT Droplet spread & blood & blood products IP 16 – 17 Days average Prodrome Low grade fever, headache, URTI Rash Erythematous facial flushing “slapped cheek” and spreads rapidly to the trunk & proximal extremities as a diffuse macular erythema; palms & soles spared Resolves w/o desquamation but tend to wax and wane in 1 – 3 wks

VIRAL INFECTIONS MEASLES (Rubeola) [Paramyxoviridae] MOT Droplet spray IP 10 – 12 days Prd of comm 4 days before & 4 days after onset of rash Enanthem Koplik spots (opposite lower molars) Prodrome High grade fever, conjunctivitis, catharr (3 – 5 days) Rash Appear during height of fever Cephalocaudal[1st along hairline, face, chest] [+] brawny desquamation – disappear w/n 7 – 10 days Complication Otitis media Diarrhea Pneumonia Exacerbation of M tb infection Encephalitis Vit A SD 100,000 IU orally for 6 mos – 1 yo / 200,000 IU >1 yo Tx Post exposure Ig w/n 6 days of exposure prophylaxis (0.25ml/kg max 15 ml) IM Vaccine Susceptible children >1 yo w/n 72 hrs SSPE Chronic condition due to persistent measles infxn Rare but found in 6 mo to >30 yrs of age Subtle change in behavior & deterioration o schoolwork followed by bizarre behavior Elevated titers of Ab to measles virus(IgG, IgM) Inosiplex (100mg/kg/day) may prolong survival GERMAN OR 3 DAY MEASLES [RUBELLA] [Togaviridae] MOT Oral Droplet; transplacentally to fetus IP 14 – 21 days Prd of comm 7 days before &7 days after onset of rash Enanthem Forchheimer spots [soft palate] just b4 onset of rash Rash Cephalocaudal Charac. sign Retroauricular, posterior cervical & postoccipital LAD [24 hrs before rash & remains for 1 wk] Vit A SD 100,000 IU orally for 6 mo –1 y / 200,000 IU >1 yo Tx Post exposure Immunoglobulin [not routine] prophylaxis Considered if termination of preg is not an option 0.55ml/kg) IM Vaccine w/n 72 hrs of exposure Congenital Greatest during 1st trimester; IUGR Rubella Congenital cataract, microcephaly, PDA, “blueberry muffin” skin lesions Congenital or profound SNHL | Motor/mental retardation

MOT IP Period of communicability Prodrome Parotid gland swelling Complications

Hx of Absorbed TT Unknown or

MUMPS [Paramyxoviridae] Direct contact, airborne droplets, fomites contaminated by saliva 16 – 18 days 1 – 2 days before onset of parotid swelling until 5 days after the onset of swelling Fever, neck muscle pain, headache, malaise Peak in 1 – 3 days 1st in the space between posterior border of mandible & mastoid then extends being limited above zygoma Meningoenephalitis - most frequent, 10 days; M>F Orchitis & Epididymitis Oophoritis Dacryoadenitis or optic neuritis Clean minor Wound

All other Wounds

Td

TIG

Td

TIG

Yes

No

Yes

Yes

No

No

No

No

< 7 yo Dtap is recommended > 7 yo Td is recommended If ony 3 doses of TT received, a 4th dose should be given Give TT (clean minor wounds) if > 10 y since last dose All other wounds (punctured wds, avulsions, burn) Give TT (all clean wounds) if > 5 yrs since last dose VERORAB BERIRAB

Ig (Human) Equine

RABIES VACCINE 0.5 cc/amp; 1 amp IM Day: 0 3 7 14 and 28 RD: 20 iu/kg 300 iu/vial 1 vial = 2ml ½ at wound site ½ deep IM Reqd amt in IU: wt x RD (20IU) Amount in ml = wt x RD (20) x 2 300 20 iu/kg Bayrab 300 iu/2ml | Berirab 300 iu/2ml 40 iu/kg Favirab 200 – 400 iu/5ml 1000 – 2000 iu/5ml

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

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

Please admit under the service of Dr. ________________ TPR q4H and record DAT (No dark colored foods) Labs: CBC, Plt (optional APTT and PT) Blood typing U/A (MSCC) IVF: D5 0.3 NaCl 1P/1L (40 kg) at 3 – 5 cc/kg Medications: Paracetamol prn q4h for T > 37.8°C Omeprazole 1mkdose max 40 mg IVTT OD SO: MIO q shift and record Monitor VS q2h and record, to include BP Continue TSB for fever Refer for Hypotension, narrow pulse pressure (< 20mmHg) Refer for signs of active bleeding like epistaxis, gum bleeding, melena, coffee ground vomitus Will inform AP Pls inform Dr _____ of this admission Thank you.

DENGUE HEMORRHAGIC FEVER Serotype 1, 2, 3, & 4 Aedes egypti IP: 4 – 6 days (min 3 days; max 10 days) DHF SEVERITY GRADING GRADE MANIFESTATION I Fever, non-specific constitutional symptoms such as anorexia, vomiting and abdominal pain (+) Torniquet test II Grade I + spontaneous bleeding; mucocutaneous, GI III Grade II w/ more severe bleeding + Evidence of circulatory failure: violaceous, cold & clammy skin, restless, weak to imperceptible pulses, narrowing of pulse pressure to < 20mmHg to actualHPON IV Grade III but shock is usually refractory or irreversible and assoc w/ massive bleeding CRITERIA FOR CLINICAL DX (WHO) DHF DSS Fever, acute onset, high, lasting 2 – 7 Above criteria days Plus Hemorrhagic manif: Hypotension or narrow pulse (+) Torniquet test pressure [SBP – DBP] Minor & Major bleeding 2yo – 5-7 mkd TID, BID PO

INFECTIVE ENDOCARDITIS DUKE CRITERIA Major Manifestation Minor manifestation Diagnosis Highly probable: 2 major OR 1 major and 2 minor manifestation

Major Manifestations Arthritis (70%) Carditis (50%) Tachycardia Pericarditis Heart murmur of valvulitis Cardiomegaly Signs of CHF [gallop rhythm, distant heart sounds, cardiomegaly] Erythema marginatum (10%) Subcutaneous nodules (2 – 10%) Sydenham’s chorea (15%) Minor manifestations Arthralgia Fever at least 38.8°C

↑ Acute Phase Reactants (CRP & ESR) Prolonged PR interval on the ECG

Diagnosis: Highly probable : 2 major OR 1 major and 2 minor manifestation ACUTE GASTROENTERITIS Please admit under the service of Dr. ________________ TPR q4H and record DAT once fully awake; NPO x 2hrs if with vomiting Labs: CBC U/A (MSCC) F/A (Concentration Method) IVF: D5 0.3 NaCl 1P (50cc/kg in 8 h if 2 yo) D5LR 1L at 30cc/kg in 8hif >40 kg Medications: Paracetamol prn q4h for T > 37.8°C Zinc (E Zinc) Drops 10mg/ml 1ml OD (2 yo) 5ml OD Ranitidine IVTT at 1mkdose (if with abdominal pain) SO: MIO q shift and record Monitor VS q2h and record Continue TSB for fever Chart character, frequency and amount of GI losses and replace w/ PLR 1L/1P vol/vol Will inform AP Pls inform Dr _____ of this admission Thank you.

BPN Please admit under the service of Dr. ______________ TPR q4H and record NPO if dyspneic Labs: CBC U/A (MSCC) ABG* CXR APL* IVF: D5 0.3 NaCl 1P (50cc/kg in 8 h if 2 yo) D5LR 1L at 30cc/kg in 8hif >40 kg Medications: Paracetamol prn q4h for T > 37.8°C (10 – 15 mkdose) USN with Salbutamol or Salbu+Ipratropium neb; 1 neb x 3 doses then refer NaCl (Muconase) nasal spray, 2 sprays per nostrils, then suction using bulb QID Ranitidine IVTT at 1mkdose (if on NPO) SO: MIO q shift and record Monitor VS q2h and record Continue TSB for fever Refer for persistence of tachypnea, alar flaring and retractions O2 at 2 lpm via NC, or 6 lpm via facemask Attach to pulse oximeter, refer for desaturations