PEDIA TICKLER

                                                                                                                                 

BODY TEMPERATURE Subnormal Normal Subfebrile Fever High fever Hyperpyrexia

ABG

39.5°C >42.0°C

AGE

HR (bpm)

BP (mmHg)

Preterm Term 0-3 mo 3-6 mo 6-12 mo 1-3 yrs 3-6 yrs 6-12 yrs 12-17 yrs

120-170 120-160 100-150 90-120 80-120 70-110 65-110 60-95 55-85

55-75/35-45 65-85/45-55 65-85/45-55 70-90/50-65 80-100/55-65 90-105/55-70 95-110/60-75 100-120/60-75 110-135/65-85

pH: pCO2: pO2:

RR (cpm) 40-70 30-60 35-55 30-45 25-40 20-30 20-25 14-22 12-18

RBC

NB 4.8-7.1

Infant 3.8-5.5

WBC PMNs Lymph Hgb

9-30,000 61% 31% 14-24

6-17,500 61% 32% 11-20

Hct

44-64%

35-49

Platelets 140-300 200-423 Ret 2.6-6.5 0.5-3.1

22-26mEq/L +/- 2mEq/L 97%

Child 3.8-5.

Adole M: 4.6-6.2 F: 4.2-5.4 5-10,000 6-10,000 60% 60% 30% 30% 11-16 M: 14-18 F: 12-16 31-46 M: 40-54 F: 37-47 150-450 150-450 0-2 0-2

IDEAL BODY WEIGHT Age At Birth 3-12 mo 1-6 y 7-12 y

BT CT PTT

Caucasian AP Transverse >>> AP

FONTANELS

st

Gain in 1 Year is ~ 25cm + 9 cm 3 cm per mo + 8 cm 2.67 per mo + 5 cm 1.6 cm per mo + 3 cm 1 cm per mo

Appropriate size at birth: Closes at: Anterior

Inches 35 cm (13.8 in) + 2 in (1/2 inches / mo) + 2 in (1/4 inches / mo) + 1 inch + 1.5 in (1/2 inches / year) + 1.5 in (1/2 inches / year)

2 x 2 cm (anterior) = 18 months, or as early as 9-12 months = 6 – 8 weeks or 2 – 4 months

TI =

+ 5.08cm (1.27cm / mo) + 5.08cm (0.635cm / mo) 2.54 cm + 3.81cm (1.27cm / mo) + 3.81cm (1.27cm / mo)

AGE Birth or 6 wks

DPT

6 wks

DOSE 0.05mL (NB) 0.1mL (older) 0.5mL

OPV HEPA B

6 wks 6 wks

2 drops 0.5mL

3 3

PO IM

MEASLES

9 mos

0.5mL

1

SC

BCG-2

School entry

0.1mL

1

ID

TetToxoid

Childbearing women

0.5mL

3

IM

(-) Response

Grimaces

A

(-) Movement

Some flexion / extension

R

Absent

Slow / Irregular

P

transverse chest diameter AP diameter

Function Eye Opening

Birth 1 year 6 years

Verbal

Infants/Young 4- Spontaneous 3- To speech 2- To pain 1- None 5- Appropriate 4- Inconsolable 3- Irritable 2- Moans 1- None 6- Spontaneous 5- Localize pain 4- Withdraw 3- Flexion 2- Extension 1- None

: 1.0 : 1.25 : 1.35

# 1

ROUTE ID

SITE RDeltoid

3

IM

Upper Outer thigh Mouth Anterolateral thigh Outer upper arm LDeltoid Deltoid

2 Completely pink > 100 Coughs, Sneezes, Cries Active movement Good, strong cry

GCS

Motor

EXPANDED PROGRAM ON IMMUNIZATION VACCINE BCG-1

G

Normal Mild / Moderate Asphyxia Severe asphyxia

THORACIC INDEX

Centimeters

1 Pink body/ Blue extremities Slow (14 days, non-infectious causes Persistent : >14 days, infectious cause

◦

ORS vol. after each loose stool 1 day 10 y.o.

5-100mL 100-200mL As much as wanted

500mL 1000mL 2000mL

4 Major Mechanisms 1. Poorly absorbed osmotically active substances in lumen 2. Intestinal ion secretion (increased) or decreased absorption 3. Outpouring into the lumen of blood, mucus 4. Derangement of intestinal motility Rotaviral AGE (vomiting first then diarrhea)

For severe dehydration / WHO hydration (fluid: PLR 100cc/kg) Age 12

30mL/kg 1H 30 mins

75mL/kg 5H 2½H

Ingestion of rotavirus ► rotavirus in intestinal villi ►destruction of villi (secretory diarrhea ▼absorption ▲ secretion) ► AGE Assessment of dehydration (Skin Pinch Test)

Patient in SHOCK ◦ ◦ ◦

20-30cc/kg IV fast drip but in infants 10cc/kg IV (repeat if not stable) If responsive & stable 75/kg x 4-6 hours

◦ ◦

(+) if > 2 seconds no dehydration if skin tenting goes back immediately

ETIOLOGY of AGE Bacteria Aeromonas Bacillus cereus Campylobacter jejuni Clostridium perfringens Clostridium difficile Escherichia coli Plesiomonas shigelbides Salmonella Shigella Staphylococcus aureus Vibrio cholerae 01 & 0139 Vibrio parahaemolyticus Yersinia enterocolitica

Viruses Astroviruses Caloviruses Norovirus Enteric Adenovirus Rotavirus Cytomegalovirus Herpes simplex virus

Parasites Balantidium coli Blastocyctis hominis Cryptosporidium Giardia lamblia Amoeba   Ascariasis   Cholera   Shigella   Salmonella  

TREATMENT PLAN A

Metronidazole   Al/mebendazole   Tetracyline   TMP/SMX  (Cotri)   Chloramphenicol  

TREATMENT PLAN C

4 Rules of Home Treatment

Treat severe dehydration QUICKLY!

1. Give extra fluid (as much as the child will take)

1. Start IV fluid immediately 2. If the child can drink, give ORS by mouth while the IV drip is being set up 3. Give 100mL/kg Lactated Ringer’s solution

> Breastfeed frequently & longer at each feeding > if the child is exclusively breastfed, give one or more of the following in addition to breastmilk ◦ ORS solution ◦ food based fluid (e.g. soup, rice, water) clean water

Infants ( 20 kg NOTE:

TOTAL FLUID REQUIREMENT 100 mL / kg 1000 + [ 50 for each kg in excess of 10 kg] 1500 + [ 20 for each kg in excess of 20 kg]

Computed Value is in mL/day Ex. 25kg child Answer: 1500 + [100] = 1600cc/day

Stage 1 2 3 4 5

Pubic Hair Preadolescent Sparse, lightly pigmented, straight, medial border of labia

Breasts Preadolescent Breast & papilla elevated, as small mound, areola diameter increased Breast & areola enlarged, no contour separation Areola & papilla formed secondary mound Mature, nipple projects, areola part of general breast contour

Darker, beginning to curl, ▲amount Course, curly, abundant but amount < adult Adult, feminine triangle, spread to medial surface of thigh

SMR BOYS Stage 1 2 3 4 5

Pubic Hair None Scanty, long slightly pigmented Darker, starts to curl, small amount Resembles adult type but less in quantity, course, curly Adult distribution, spread to medial surface of thigh

Penis Preadolescent Slightly enlargement

Testes Preadolescent Enlarged scrotum, pink texture altered

Longer

Larger

Larger, glans & breadth ▲ in size

Larger, scrotum dark

Adult size

Adult size

ATYPICAL PNEUMONIA -: -: -: -: -:

> 3-12 mo - RSV - Other respiratory viruses - Streptococcus pneumoniae - Haemophilus influenzae (Type B) - C. trachomatis - M. pneumoniae - Group A Streptococcus

extrpulmonary manifestations low grade fever patchy diffuse infiltrates poor response to Penicillin negative sputum gram stain Etiologic Agents Grouped by Age

> Neonates ( 1-3 months * Febrile pneumonia - RSV - Other respiratory viruses - Streptococcus pneumoniae - Haemophilus influenza (Type B) * Afebrile pneumonia - Chlamydia trachomatis - Mycoplasma homilis - CMV

DENGUE > MOT:

mosquito bite

> Vector:

Aedes aegypti

> 2-5 yrs - RSV - Other respiratory viruses - Streptococcus pneumoniae - Haemophilus influenzae (Type B) - C. trachomatis - M. pneumoniae - Group A Streptococcus - Staph aureus > 2-5 yrs - Streptococcus pneumoniae - Haemophilus influenzae (Type B) - C. trachomatis - M. pneumoniae - Group A Streptococcus - Staph aureus

Dengue Fever Syndrome (DFS) (man as reservior)

> Factors affecting transmission: - breeding sites, high human population density, mobile viremic human beings

Biphasic fever (2-7 days) with 2 or more of the ff: 1. headache 2. myalgia or arthralgia 3. retroorbital pain 4. hemorrhagic manifestations [petechiae, purpura, (+) torniquet test] 5. leukopenia

DENGUE PATHOPHYSIOLOGY

                                                                                                                                 

Dengue Shock Syndrome Manifestations of DHF plus signs of circulatory failure 1. rapid & weak pulse 2. narrow pulse pressure ( Age incidence peaks at 4-6 yrs > Incubation period:

4-6 days

> Serotypes: - Type 2 – most common - Types 1& 3 - Type 4– least common but most severe > Main pathophysiologic changes: a. increase in vascular permeability ▼ extravasation of plasma - hemoconcentration rd - 3 spacing of fluids b. abnormal hemostasis - vasculopathy - thrombocytopenia - coagulopathy

MANAGEMENT OF DENGUE A. Vital Signs and Laboratory Monitoring Monitor BP, Pulse Rate We have to watch out for Shock (Hypotension)

Dengue Hemorrhagic Fever (DHF) 1. fever, persistently high grade (2-7 days) 2. hemorrhagic manifestations - (+) torniquet test - petechiae, ecchymoses, purpura - bleeding from mucusa, GIT, puncture sites - melena, hematemesis 3 3. Thrombocytopenia (< 100,000/mm ) 4. Hemoconcentration - hematocrit >40% or rise of >20% from baseline - a drop in >20% Hct (from baseline) following volume replacement - signs of plasma leakage [pleural effusion, ascites, hypoproteinemia]

1. abdominal pain (intense & sustained) 2. persistent vomiting 3. abrupt change from fever to hypothermia with sweating 4. restlessness or somnolence Grading of Dengue Hemorrhagic Fever

MANAGEMENT OF HEMORRHAGE

                                                                                                                                 

Torniquet Test:

SBP + DBP = mean BP for 5 mins. 2

if ≥20 petechial rash per sq. inch on antecubital fossa (+) test Herman’s Rash: - usually appears after fever lysed - initially appears on the lower extremities - not a common finding among dengue patients - “an island of white in an ocean of red” Recommended Guidelines for Transfusion: Transfuse: - PC < 100,000 with signs of bleeding - PC < 20,000 even if asymptomatic - use FFP if without overt bleeding - FWB in cases with overt bleeding or signs of hypovolemia

URINARY TRACT INFECTION Suggestive UTI: 3 - Pyuria: WBC ≥ 5/HPF or 10mm - Absence of pyuria doesn’t rule out UTI - Pyuria can be present w/o UTI Presumptive UTI: - (-) urine culture - lower colony counts may be due to: * overhydration * recent bladder emptying * previous antibiotic intake Proven or Confirmed UTI: - (+) urine culture ≥ 100,000 cfu/mL urine of a single organism - multiple organisms in culture may indicate a contaminated sample

> if PT & PTT are abnormal: FFP > if PTT only: cryprecipitate st

3-7cc/kg/hr depending on the Hct (1 no.) level (D5LR) 10-20cc/kg fast drip PLR - hypotension, narrow pulse pressure fair pulse Leukopenia in dengue: therefore:

probable etiology is Pseudomonas

give Meropenem or Ceftazidime

ACUTE GLOMERULONEPHRITIS Complications of AGN - CHF 2° to fluid overload - HPN encephalopathy - ARF due to ê GFR

RHEUMATIC FEVER

TREATMENT OF RHEUMATIC FEVER

JONES CRITERIA:

STAGES of AGN - Oliguric phase [7-10days] – complications sets in - Diuretic phase [7-10days] – recovery starts - Convalescent phase [7-10days] – patients are usually sent home Prognosis - Gross hematuria - Proteinuria - ▼C3 - microscopic hematuria

2-3 weeks 3-6 weeks 8-12 weeks 6-12 mo or 1-2 years 4-6 weeks

- HPN

A. Major Manifestations - Carditis - Polyarthritis - Chorea - Erythema Marginatum - Subcutaneous Nodules

A. Antibiotic Therapy - 10 days of Oral Penicillin or Erythromycin - IM Injection of Benzethine Penicillin (50-60%) (70%) (15-20%) (3%) (1%)

B. Minor Manifestations - Arthralgia - Fever - Laboratory Findings of: ▲ Acute Phase Reactants (ESR / CRP) Prolonged PR interval C. PLUS Supporting Evidence of Antecedent Group-A Strep Infection - (+) Throat Culture or Rapid Strep-Ag Test - ▲Rising Strep-AB Test

*** NOTE:

Sumapen

= Oral Penicillin!

B. Anti-Inflammatory Therapy 1. Aspirin (if Arthritis, NOT Carditis) Acute: 100mg/kg/day in 4 doses x 3-5days Then, 75mg/kg/day in 4 doses x 4 weeks 2. Prednisone 2mg/kg/day in 4 doses x 2-3weeks Then, 5mg/24hrs every 2-3 days

PREVENTON A. Primary Prevention

+

> Hyperkalemia may be seen due to Na retention ++ > Ca decreases in PSAGN > ▲ in ASO titer - normal within 2 weeks - peaks after 2 weeks - more pronounced in pharyngeal infection than in cutaneous

B. Secondary Prevention

C. Duration of Chemoprophylaxis

- 10 days of Oral Penicillin or Erythromycin - IM Injection of Benzethine Penicillin

                                                                                                                                 

KAWASAKI DISEASE TREATMENT CDC-CRITERIA FOR DIAGNOSIS: ADOPTED FROM KAWASAKI (ALL SHOULD BE PRESENT)

Currently Recommended Protocol: A. IV-Immunoglobulin

A) HIGH Grade Fever (>38.5 Rectally) PRESENT for AT LEAST 5-days without other Explanation “High Grade Fever of at least 5 days” DOES NOT Respond to any kind of Antibiotic!

2g/kg Regimen Infusion EQUALLY Effective in Prevention of Aneurysms and Superior to 4-day Regimen with respect to Amelioration of Inflammation as measured by days of Fever, ESR, CRP, Platelet Count, Hgb, and Albumin

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

NOTE:

> Seizures: sudden event caused by abrupt, uncontrolled, hypersynchronous discharges of neurons > Epilepsy: tendency for recurrent seizures that are unprovoked by an immediate cause > Status epilepticus:

>30min or back-to-back w/o return to baseline

There is a TIME FRAME of 10 days

B. Aspirin HIGH Dose ASA (80-100mg/kg/day divided q 6h) should be given Initially in Conjunction with IV-IG THEN Reduced to Low Dose Aspirin (3-5mg/kg/day) AND Continued until Cardiac Evaluation COMPLETED (approximately 1-2 months AFTER Onset of Disease)

HARADA Criteria - used to determine whether IVIg should be given - assessed within 9 days from onset of illness 1. WBC > 12,000 2. PC 3+ 4. Hct 2x per wk

none

any

none

any

< 2x per wk

> 2x per wk

normal

< 80%

none

> 1x per yr

Uncontrolled

3 or more symptoms of Partly Controlled Asthma in any week

1x / week

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

                                                                                                                                 

Clinical Features: TUBERCULOSIS A. Pulmonary TB – fully susceptible M. tuberculosis, – no history of previous anti-TB drugs – low local persistence of primary resistance to Isoniazid (H) ☤

2HRZ OD then 4HR OD or 3x/wk DOT

– Microbial susceptibility unknown or initial drug resistance suspected (e.g. cavitary) – previous anti-TB use – close contact w/ resistant source case or living in high areas w/ high pulmonary resistance to H. – ☤ 2HRZ + E/S OD, then 4 HR + E/S OD or 3x/week DOT B. Extrapulmonary TB – Same in PTB – For severe life threatening disease (e.g. miliary, meningitis, bone, etc) ☤

2HRZ + E/S OD, then 10HR + E/S OD or 3x/wk DOT

RESPIRATORY DISTRESS SYNDROME (Hyaline Membrane Disease)

1. Tachypnea, nasal flaring, subcostal and intercostal retractions, cyanosis, grunting 2. Pallor – from anemia, peripheral vasoconstriction 3. Onset – within 6 hours of life Peak severity – 2-3 days Recovery – 72 hours

o Male, preterm, low BW, maternal DM, & perinatal asphyxia o Corticosteroids: • most successful method to induce fetal lung maturation • Administered 24-48 hours before delivery decrease incidence of RDS • Most effective before 34 weeks AOG

Retractions: o Due to (-) intrapleural pressure produced by interaction b/w contraction of diaphragm & other respiratory muscles and mechanical properties of the lungs & chest wall

o Microscopically: diffuse atelectasis, eosinophilic membrane

Nasal flaring: o Due to contraction of alae nasi muscles leading to marked reduction in nasal resistance

Pathophysiology: 1. Impaired/delayed surfactant synthesis & secretion 2. V/Q (ventilation/perfusion) imbalance due to deficiency of surfactant and decreased lung compliance 3. Hypoxemia and systemic hypoperfusion 4. Respiratory and metabolic acidosis 5. Pulmonary vasoconstriction 6. Impaired endothelial &epithelial integrity 7. Proteinous exudates 8. RDS

Grunting: o Expiration through partially closed vocal cords • Initial expiration: glottis closedà lungs w/ gasà inc. transpulmo P w/o airflow • Last part of expiration: gas expelled against partially closed cords Cyanosis: o Central

– tongue & mnucosa (imp. Indicator of impaired gas exchange); depends on total amount of desaturated Hgb

UMBILICAL CATHERIZATION

NEWBORN RESUSCITATION µ AIRWAY: open & clear • Positioning • Suctioning • Endotracheal intubation (if necessary) µ BREATHING is spontaneous or assisted • Tactile stimulation (drying, rubbing) • Positive-pressure ventilation µ CIRCULATION of oxygenated blood is adequate • Chest compressions • Medication and volume expansion

RESUSCITAION MEDICATIONS Atropine Bicarbonate Calcium Calcium chloride Calcium gluconate Dextrose Epinephrine

0.02 ml/k IM, IV, ET 1-2 meq/k 10 mg elem Ca/k slow IV 0.33/k (27 mg Ca/cc) 1 cc/k (9 mg Ca/cc) 1g/k = 2 cc/k D50 4 cc/k D25 0.01 cc/k IV, ET

Cathether length • Standardize Graph – Perpedicular line from the tip of the shoulder to the umbilicus • Measure length from Xiphoid to umbilicus and add 0.5 to 1cm. • Birth weight regression formula – Low line : UA catheter in cm = BW + 7 – High line : UA catheter = [3xBW] + 9 – UV catheter length = [0.5xhigh line] + 1

Indications • Vascular access (UV) • Blood Pressure (UA) and blood gas monitoring in critically ill infants Complications • Infection • Bleeding • Hemorrhage • Perforation of vessel • Thrombosis w/ distal embolization • Ischemia or infarction of lower extremities, bowel or kidney • Arrhythmia • Air embolus

Procedure • Determine the length of the catheter • Restrain infant and prep the area using sterile technique • Flush catheter with sterile saline solution • Place umbilical tape around the cord. Cut cord about 1.5-2cm from the skin. • Identify the blood vessels. (1thin=vein, 2thick=artery) • Grasp the catheter 1cm from the tip. Insert into the vein, aiming toward the feet. • Secure the catheter • Observe for possible complications

Cautions • Never for: – Omphalitis – Peritonitis • Contraindicated in – NEC – Intestinal hypoperfusion Line Placement • Arterial line • Low line – Tip lie above the bifurcation between L3 & L5 • High line – Tip is above the diaphram between T6 & T9

BILIRUBIN PRETERM: 0-1 hr 1-2 d 3-5 d

mg/dl 1-6 6-8 10-12

mmol/L 17-100 100-140 170-200

mg/dl 2-6 6-7 4-12 80% 20 - 30% >80%

PERSISTENT MODERATE Affects daily activity & sleep daily >1x/wk 60 - 30% 60 -