pediatric must know

BODY TEMPERATURE Subnormal Normal Subfebrile Fever High fever Hyperpyrexia 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

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

Caucasian AP Transverse >>> AP

Appropriate size at birth: Closes at: Anterior Posterior

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

0 Blue / Pale Absent

1 Pink body/ Blue extremities Slow ( 100 Coughs, Sneezes, Cries Active movement Good, strong cry

GCS

THORACIC INDEX

EXPANDED PROGRAM ON IMMUNIZATION VACCINE BCG-1

3-12 mo 1-6 y 7-12 y

Kilograms 3kg (Fil) 3.35kg (Cau) Age (mo) + 9 / 2

30 – 39.9 >40

HEAD CIRCUMFERENCE (33-38 cms) Age At Birth < 4 mo

Age At Birth

1-6 5-8 12-14

FONTANELS Age 0-3 mo 3-6 mo 6-9 mo 9-12 mo

IDEAL BODY WEIGHT

COUNT (%) BT CT PTT

LENGTH / HEIGHT (50 cm) Age At Birth 1y 2-12 mo

HCO3: B.E.: O2 sat:

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

BMI Asian 42.0°C

Older Spontaneous To speech To pain None Oriented Confused Inappropriate Incomprehensible None Spontaneous Localize pain Withdraw Flexion Extension None

ADVERSE REACTIONS FROM VACCINES INTERVAL

BCG

DPT

4 wks 4 wks 4 wks

1 mo then 6-12 mos

OPV HEPA B MEASLES

1. Wheal ► small ► abscess ► ulceration ► healing / scar formation in 12 wks 2. Deep abscess formation, indolent ulceration, glandular enlargement, suppurative lymphadenitis 1. Fever, local soreness 2. Convulsions, encephalitis / encephalopathy, permanent brain damage Paralytic Polio Local soreness 1. Fever & mild rash 2. Convulsions, encephalitis / encephalopathy, SSPE, death ACTIVE BCG DPT OPV Hep B Measles Hib MMR Tetanus Toxoid Varicella

PASSIVE Diphtheria Tetanus Tetanus Ig Measles Ig Rabies (HRIg) Hep A Ig Hep B ig Rubella Ig

H.E.A.D.S.S.S. Sexual activities ◦ Sexual orientation? ◦ GF/BF? Typical date? ◦ Sexually active? When started? # of persons? Contraceptives? Pregnancies? STDs? Suicide/Depression ◦ Ever sad/tearful/unmotivated/hopeless? ◦ Thought of hurting self/others? ◦ Suicide plans? Safety ◦ Use seatbelts/helmets? ◦ Enter into high risk situations? ◦ Member of frat/sorority/orgs? ◦ Firearm at home? F.R.I.C.H.M.O.N.D. ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦

Fluids Respiration Infection Cardiac Hematologic Metabolic Output & Input [cc/kg/h] N: 1-2 Neuro Diet

NUTRITION

H.E.A.D.S.S.S. Home Environment ◦ With whom does the adolescent live? ◦ Any recent changes in the living situation? ◦ How are things among siblings? ◦ Are parents employed? ◦ Are there things in the family he/she wants to change? Employment and Education ◦ Currently at school? Favorite subjects? ◦ Patient performing academically? ◦ Have been truant / expelled from school? ◦ Problems with classmates/teachers? ◦ Currently employed? ◦ Future education/employment goals? Activities ◦ What he/she does in spare time? ◦ Patient does for fun? ◦ Whom does patient spend spare time? ◦ Hobbies, interests, close friends? Drugs ◦ Used tobacco/alcohol/steroids? ◦ Illicit drugs? Frequency? Amount? Affected daily activities? ◦ Still using? Friends using/selling?

AGE 0-5 mo 8-11 mo 1-2 y 3-6 y 7-9 y 10-12 y 13-15 y 16-19 y

WT. 3-6 7-9 10-12 14-18 22-24 28-32 36-44 48-55

TCR β TCR

CAL 115 110 110 90-100 80-90 70-80 55-65 45-50

CHON 3.5 3.0 2.5 2.0 1.5 1.5 1.5 1.2

= Wt at p50 x calories = CHON X ABW

Total Caloric Intake

: calories X amount of intake (oz)

Gastric Capacity

: age in months + 2

Gastric Emptying Time

: 2-3 hours

1:1 Alacta Enfalac Lactogen Lactum Nan Nestogen Nutraminogen Pelargon Prosobee

1:2 Bonna Nursoy Promil S-26 Similac SMA

THE SEVEN HABITS OF HIGHLY EFFECTIVE PEOPLE by Stephen R. Covey

Habit 1: Habit 2: Habit 3: Habit 4: Habit 5:

Be Proactive Begin with the end in mind Put First Things First Think Win-Win Seek first to understand and then to be understood Habit 6: Synergize Habit 7: Sharpen the saw

EXPECTED LA SALLIAN GRADUATE ATTRIBUTES (ELGA) 1. Competent & safe physicians 2. Ethical & socially responsible Doctors / practitioners 3. Reflective lifelong learners 4. Effective communicators 5. Efficient & innovative managers

DIARRHEA ◦ ◦

Chronic : >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 ◦ ◦ ◦

ETIOLOGY of AGE

ACUTE DIARRHEA (at least 3x BM in 24 hrs)

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

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

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

TREATMENT PLAN C

TREATMENT PLAN A 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

Age 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

> 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

> 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 - 3rd 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. Thrombocytopenia (< 100,000/mm3) 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]

DENGUE PATHOPHYSIOLOGY

Etiologic Agents Grouped by Age

Dengue Shock Syndrome Manifestations of DHF plus signs of circulatory failure 1. rapid & weak pulse 2. narrow pulse pressure ( if PT & PTT are abnormal: FFP > if PTT only: cryprecipitate 3-7cc/kg/hr depending on the Hct (1st 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

- HPN

A. Antibiotic Therapy - 10 days of Oral Penicillin or Erythromycin - IM Injection of Benzethine Penicillin

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

TREATMENT OF RHEUMATIC FEVER

RHEUMATIC FEVER

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

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

(50-60%) (70%) (15-20%) (3%) (1%)

*** 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

B. Minor Manifestations - Arthralgia - Fever - Laboratory Findings of: ▲ Acute Phase Reactants (ESR / CRP) Prolonged PR interval

2. Prednisone 2mg/kg/day in 4 doses x 2-3weeks Then, 5mg/24hrs every 2-3 days

C. PLUS Supporting Evidence of Antecedent Group-A Strep Infection - (+) Throat Culture or Rapid Strep-Ag Test - ▲Rising Strep-AB Test

PREVENTON A. Primary Prevention - 10 days of Oral Penicillin or Erythromycin - IM Injection of Benzethine Penicillin

> 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 BRONCHIAL ASTHMA (GINA GUIDELINES)

C. Duration of Chemoprophylaxis

Day symptoms Limitation of activities Nocturnal Sx (awakening) Need for reliever Lung function Exacerbation

Controlled

Partly Controlled

none

> 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

KAWASAKI DISEASE CDC-CRITERIA FOR DIAGNOSIS: ADOPTED FROM KAWASAKI (ALL SHOULD BE PRESENT) 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! 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%) 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 Epilepsy: tendency for recurrent seizures that are unprovoked by an immediate cause > Status epilepticus: > Etiology: - V ascular - I nfections - T raumatic - A utoimmune - M etabolic - I diopathic - N eoplastic - S tructural

: : : : : : : :

- S yndrome

:

>30min or back-to-back w/o return to baseline AVM, stroke, hemorrhage meningitis, encephalitis SLE, vasculitis, ADEM electrolyte imbalance “idiopathic epilepsy” space occupying lesion cortical malformation, prior stroke genetic disorder

IVIg is given if ≥ 4 of 7 are fulfilled If < 4 with continuing acute symptoms, risk score must be reassessed daily

TYPES OF SEIZURES

CLASSIFICATION BY CAUSE

A. Partial Seizures (Focal / Local) – Simple Partial – Complex Partial (Partial Seizure + Impaired Consciousness) – Partial Seizures evolving to Tonic-Clonic Convulsion

A. Acute Symptomatic (shortly after an acute insult) – Infection – Hypoglycemia, low sodium, low calcium – Head trauma – Toxic ingestion

B. Generalized Seizures – Absence (Petit mal) – Myoclonic – Clonic – Tonic – Tonic-Clonic – Atonic

B. Remote Symptomatic – Pre-existing brain abnormality or insult – Brain injury (head trauma, low oxygen) – Meningitis – Stroke – Tumor – Developmental brain abnormality

SIMPLE FEBRILE SEIZURE vs. COMPLEX FEBRILE SEIZURE

C. Idiopathic – No history of preceding insult – Likely “genetic” component

Febrile Seizure: “A seizure in association with a febrile illness in the absence of a CNS infection or acute electrolyte imbalance in children older than 1 month of age without prior afebrile seizures”

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.

SEIZURES

TREATMENT Currently Recommended Protocol:

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) 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 o Microscopically: diffuse atelectasis, eosinophilic membrane 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

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 – Febrile seizure in 1st / 2nd 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: 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 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 Nasal flaring: o Due to contraction of alae nasi muscles leading to marked reduction in nasal resistance Grunting: o Expiration through partially closed vocal cords • Initial expiration: glottis closed lungs w/ gas 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

Complications • Infection • Bleeding • Hemorrhage • Perforation of vessel • Thrombosis w/ distal embolization • Ischemia or infarction of lower extremities, bowel or kidney • Arrhythmia • Air embolus

 BREATHING is spontaneous or assisted  Tactile stimulation (drying, rubbing)  Positive-pressure ventilation  CIRCULATION of oxygenated blood is adequate  Chest compressions  Medication and volume expansion

Dextrose Epinephrine

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

RESUSCITAION MEDICATIONS Atropine Bicarbonate Calcium Calcium chloride Calcium gluconate

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

 AIRWAY: open & clear  Positioning  Suctioning  Endotracheal intubation (if necessary)

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

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