ANTITUSSIVES moderate 250 –

GUIAFENESIN ANTIPYRETIC 500 mcg bid

(Robitussin) expectorant IBUPROFEN severe 500 –
<2 y 12mkd PO q4-6 Dolan 1000 mcg bid
2-6 y 50-100 mg q4 prn (max 600 mg/d) 5-10 mkdos Neb : 1 – 4 yo = 100 mcg bid
6-11 y 100-200 mg q4 prn (max 1.2 g/d) 100/5ml; 60 ml susp 5 – 15 yo = 250 – 1000 bid
>12 y 100-400 mg q4 prn (max 2.4 g/d) Wt/4 – Wt/2 ml Q 6h 16 – adulti= 500 – 2000 bid
Robitussin DM Paracetamol
dose as per Guiafenesin 10-15 mkdos SERETIDE
(Guiafenesin 100mg, Dextrometrophan 15 mg/5mL) 60mg/0.6ml, 15ml drops (Tempra) Discus 100/250/500 = Salmeterol xinafoat 50 mcg,
2-6 y 50-100 mg q4 prn (max 600mg/d) 100/ml Drop,15ml drops (Calpol) Fluticasone propionate 100mcg/250mcg/500mcg
6-11 y 100-200 mg q4 prn (max 1200mg/d) 120/5ml, 60ml susp/syrup (Calpol susp; 25/50 ; 25/125; 25/250 inhaler = salmeterol 25mcg,
>12 y 200-400 mg q4 prn (max 2.4 g/d) Tempra; Paracetamol) fluticasone 50/125/250mcg
Nasal drops 1-2 drops each nostril q 3-4; discontinue after 250/5ml, 60ml susp/syrup (Calpol Six Plus; Disc. 4 – 11 yo = 1 inhalation S100 bid
3 days Tempra forte syrup) 12 yo – Adult = 1 inhalation S100/250/500
Opigesic 125mg/supp, 250mg/supp bid
LEVODROPROPIZINE (LEVOPRONT) Naprex inj 300mg/2ml ampul IM Inhaler. 4 – 12 yo = 2 inhalations S 25/50 bid…
10-20kg BW= 3ml up to 3 x daily 120/5ml = 0.4 - 0.6 Wt ..ml Q 4h titrated to OD
20-30kg BW= 5ml up to 3x daily 250/5ml = 0.2 – 0.3 Wt..ml Q 4h 12 – adult = 2 inhalations S25/50,
ANTI-ASTHMATIC S25/125, S25/250 bid
CARBOCISTEINE SALBUTAMOL
Loviscol tab. = 500mg/tab Ventolin ACCOLATE
Syr = 250mg/5ml tab. = 2 mg / tab Zufirlukast
100mg/5ml syr = 2 mg / 5ml; 0.1mkdose q6-8 20 mg / tab
Infant Drops = 50 mg/ml neb = 2.5 mg / 2.5 ml; 0.15 mkdose q4-6 or prn ≥12yo – adult = 1 tab bid (max.40mg/day)
1 – 2 yo = 1,2ml drops Q 6-8 h inhaler = 100 mcg / inhalation x 200 doses; 1-2 puffs
1 – 3 yo = 1 – 1 ½ tsp Q 8h q4-6 prn AMINOPHYLLINE
4 – 7 yo = 1 ½ tsp – 2 tsp Q8h rotacap = 200 mcg / dose 250/10ml
8 – 12 yo = 2 – 3 tsp Q8h rotadisk = 200 mcg / dose LD is undiluted 6mkd
13 to adult = 1 tab Q 8h VENTOLIN PO MD is diluted 25/ml=2.5/.1
AMBROXOL 0.1– 0.2 mg/kg/dose (max 2 mg in child <12yo) PO Q 6 – 8 want 0.1am+0.9nss=1cc
MUCOSOLVAN ( 1.2 – 1.6 mg/kgbwt/day ) hours. order as- e. g. wt 1.41
Tab = 30 mg/tab, retard cap  0.15 mkdose = 0.375 ml X Bwt ml tid – qid ( 0.25-0.5 x start aminophylin (250mg/100 ml)
75mg/tab bwt ml tid-qid) 0.1ml + 0.9ml nss mixture, give 3.4 ml now then 0.6 ml q8g
Syr = 30mg/ 5ml. pediatrics syr Neb.
15mg/5ml 0.01-0.03 cc/kg (max 1cc) in 2cc NSS q1-2 & prn CORTICOSTEROIDS
Infant drops= 6mg/ml OR Prednisone (Pred 10)
Inhalation sol = 15mg/2ml 0.05-0.15 mg/kg (max 5 mg) in 2 cc NSS q1-2 10mg/tab; 10mg/5ml x 60ml susp
Ampule = 15 mg/2ml OR 1 mkday; OD
Drops; 0.03 cc/kg (0.05 mg/kg) q 20 min until improvement
<6 mos = 0.5 ml bid Metered Dose Inhalers Hydrocortisone Na Succinate (Solu-Cortef)
7-12mos = 1ml bid Ventolin : 2 puffs 1-2 min apart q1-6h w/ spacer and mask 100mgx2ml vial; 250mgx2ml vial; 500mgx4ml vial
1 – 2 yo = 1.25ml bid 50mg/mlx2ml vial
Ped syr; BRICANYL 4-5mkdose q4-6 h IV push, infusion or IM
<2yo = ½ tsp bid Terbutaline sulfate
2 – 5 yo = ½ tsp tid Tab 2.5mg/tab EMETICS
6 – 10 yo = 1tsp tid Extended release tab 5mg/tab Domperidone (Motilium)
>10 yo = 1-2 tsp tid. Syr 0.3 mg/ml (1.5mg/5ml) 10mg/tab; 1mg/ml, 60ml susp
Inhalation Neb.solution 5mg/2ml 2.5ml/10kg, q4-q8 h
<5 yo = 2ml inhalation OD – bid Inhaler = 0.25 mg/dose
6 – adult = 2 – 3 ml inhalation OD – bid. 7 – 15yo = 1 – 2 tsp bid-tid Metoclopramide
SINECOD 3 – 7 yo = ½ tsp bid – tid (Plasil 5mg/5ml;10mg/tab)
Butamirate citrate < 3 yo = 0.0075mg/kg bid-tid 0.06cc/kg
Syr ; 7.5mg/5ml Neb < 12 yo = 0.2mg/kg/dose (max Q4h) 0.1 mkdose PO
Forte tab ; 50mg/tab Neb 12 yo – adult = 2.5 – 5mg (max Q6h) IV 0.5 - 1 mk
3 – 6 yo = 1 tsp tid wt(kg)/3 x 0.2 = cc q8
6 – 12yo = 2 tsp tid MEPTIN <2yr: 1/2 tsp QID
adolescent = 1 tbsp tid, 1 – 2 tab daily Procaterol HCl hemihydrate >2yr: 1tsp QID
adult = 2 - 3 tab daily, 1 tbsp qid Tab 25; 50 mcg/tab
DECONGESTANT Syr 5 mcg/ml dr.celdran-wt/2/3 dose of IV or po
Pseudoephedrine Meptin Air MDI 10mcg/puff
4 - 5 mkday q6 prn; Don’t use with epinephrine, isoproterenol (arrythmmia), Vomex 1 supp = 50 mg
for >12yr to Adult:30-60mg/dose q6-8 catecholamines
(Sudafed 30 mg/5 mL) (max 240mg/d) <6yo = 0.25 mcg/kg bid – tid Meclizine (Bonadoxin 8.3 mg/ml drops)
ACTIFED with Codeine 6-12yo = 1tab(25mcg) at bedtime or bid 12.5 - 50 mkd
4 mkd pseudoephedrine PO TID-QID adult = 50 mcg bedtime or bid <6mos 0.5cc
(Codeine 10mg, Triprolidine 1.25mg, Pseudoephedrine 30 6mo-2yr 1-2cc
mg/5mL) BAMBEC 2-6yr 3cc bid-tid
4 mo-2 y 1.25 mL q6-8 Bambuterol HCl
2–4 y 2.5 mL q6-8 Tab 10mg/tab; Syr 1mg/ml Dimenhydrinate (Vomex) 5 mkd q 6
4 – 6 y 3.75 mL q6-8 2 – 5 yo = 5mg OD >12y 5mkd IM/IV/PO qid max 300mg
6-12 y 5 mL q6-8 6 – 12 = 5 mg OD ( less than 10mg/day) (not recommended in <12y due to high incidence of EPS)
>12 y 10 mL q6-8 adult = 10mg OD (may be increased to 20mg OD after 1-
DISUDRIN 2wks) Diphenhydramine (Benadryl)
PPA , 1mkdose IM/IV/PO qid
Syr = 12.5mg/5ml; 60ml ANSIMAR
Drop= 6.25 mg/ml; 10ml Doxofylline Phenergan
Drops ; Tab 400mg/tab 0.25-0.5 mkdose (max 50mg) PO/IM/IV
1 – 3 mos = ¼ ml Q6h Syr 100mg/5ml over 20 min or PR q4-6h
4 – 6 mos = ½ ml Q6h <12 yo = 6 – 9 mg/kg bid
7 – 12 mos = 1ml Q6h ≥ 12 yo = 10 ml OD – tid Chlorpromazine (Thorazine)
syr ; adult = 1 tab bid – tid 0.25-0.5 mkdose IM or IV over 20 min or PO q4-6 or 1
2 – 6 yo = ½ tsp Q6h mkdose PR q6-8
7 – 12 yo = 1 tsp Q6h BUDESONIDE
DIMETAPP (Budecort) Dimenhydranate (Dramamine)
2mg/PPA Brompheniramine Respule ; 250 mcg/ml, 500 mcg/ml; 2ml respule >12y 5 mkd IM/IV/PO QID max 300 mg
(Brompheniramine 2mg, Phenylpropanolamine Child = initial dose 500 – 1000mcg, and Maintenance ; 250 CI: <12y due to high incidence of EPS
12.5mg/5mL) – 500 mcg bid
1-6mo 1.25 mL q6-8 Adult = initial dose 1000 – 2000mcg, and Maintenance ; Ondasetron (Zofran)
7-24 mo 2.5 mL q6-8 500 – 1000 mcg bid (for chemotherapy induced nausea)
2-4 y 3.75 mL q6-8 0.15 mkdose IV over 15 min give 30 m prior to chemotx &
4-11 y 5 mL q6-8 FLIXOTIDE 4h & 8h later
>12 y 5-10 mL Fluticasone propionate or
or 0.5mkd of Brompheniramine Inhaler = 50mcg/dose, 125mcg/dose. 0.45 mkd as continuous IV
Randec syrup 4-5mkd Pseudoephedrine q6 Rotadisk = 50 mcg/dose, 250 mcg/dose or oral:
(Pseudoephedrine 60 mg, Carbinoxamine 4 mg/5mL) Neb. = 500mg/2ml <0.32 m2 1 mg PO TID daily
SALINES 0.3-0.6 m2 2 mg PO TID daily
Nasal drops 1-2 drops each nostril q 3-4; discontinue after Inhaler / Rotadisk ; 0.6-1 m2 3 mg PO TID daily
3 days 4 – 15 yo = 50 – 100mcg bid or
16 yo – adult = mild asthma 100 – >1 m2 4 mg PO TID daily
250 mcg bid 4-11 y 4 mg PO TID daily
>11 y 8 mg PO TID daily

1
inj: 2 mg/mL; tab: 4,8 mg (inj sol may be given orally) >6mos 3tsp daily 100-200 mk q 8
Paromomycin (Humagel 150mg/15ml) (Claforan 500 mg,1.2 gm/vial)
<3 yo 5 ml q 4
Amebiasis 25-50mkd in3-4 div. doses
Bacillary dysentery 35-60mkd x 6days
Cefoperazone
Kaopectate (Cefobis 500 mg, 1 gm/vial)
ANTISPASMODICS after each loose BM OR q3-4prn NB 100 mkd q 12 (1st week
Dicycloverine 3-6yr 15-30cc/dose 150 mkd q 8 (1-4 weeks)
Relestal 5mg/ml x 15ml drops, 2mg/ml x 60ml syrup 6-12yr 30-60cc/dose IN,CH 100-150mkd q6-8
6mo-2yr 0.5-1ml drops >12y 60-120ml/dose
2-5yr 2.5-5ml syrup Ceftazidime
6-12 yr 5ml syrup Loperamide 100-150 mkd q8
0.4-0.8mkd PO q6-12, max 4mg/d (Fortum 250,500,1 gm/vial)
Oxybutynin Prep 0.2mg/ml
(Tropax 1mg/ml, 2.5mg/5ml) Ceftriaxone
Infants 0.5-1ml bid-tid Diphenoxylate w/ atropine (Rocephin 250,500,1 gm/vial)
>2yr 1-2ml bid-tid (Lomotil 2.5mg diphenoxylate, .025mg atropine/5ml) 50-100 mkd OD
0.08-0.12 mkd BID/TID neonates: 20-50 mkd
Types of prokinetic agents 0.3-0.4mkd PO TID-QID
cholinergic betanecol 2-5yr 1tab/tsp bid ORAL 3rd generation
substituted benztmihes metoclopramide cisapride 5-8yr 1tab/tsp tid
dompamide antagonists domperidone 8-12yr 1tab/tsp qid Cefetamet (Globocef) 20 mkday BID
macrolides erythromycin >12yr 2tab/tsp tid/qid
uses Cefixime(oral) 3-6 mmkday BID
gerd ANTI-HYPERTENSIVES
gastroparesis Captopril Ceftibuten (Cedax) 9 mkday OD
non ulcer dysdepsia NB PO 0.1-0.4mkdose q6-24
chemotx induced emesis Inf PO 0.5-0.6 mkd q6-12 Cefdinir (Omnicef) 3-6 mkday TID (Prep 50mg in
bile reflux gastritis Ch 0.15mk q4-8 500mg/sachet)
placement of feeding tubes
Irritable Bowel Syndrome Chlorthiazide QUINOLONES
-atopic pxs In,Ch PO 20-40mkd q12
Chronic severe constipation Ciprofloxacin 20 mkday in 2div. doses
intestinal pseudo-obstruction Hydralazine
intestinal manifestation of CT dses 0.15-0.75mkdose IV AMINOGLYCOSIDES
- SLE
Hydrochlorthiazide Amikacin IV,IM
BETHANECOL In, Ch 2mkd q12 / q6 Q 12 OR OD; inj 100,250,500/vial
ester derivatye of choline w diret cholinomimetic action - PO 0.75mkday q6, max 3.5mkd Neo/prem Initial 10mk then 15mkd q12
hinhs to muscarinic cholinwrgic receptors - inc GI smooth (10,25mg/tab, 20mg/ml) Children 15mkday BID OR OD
mm contractility
for gerd-dec acid secretion and gastric emptying tim Propranolol Gentamicin IV,IM
abd cramps blurred yision fatigue itulyuria IV 0.01-0.1mkdose q6-8 20,40,80mg/vial
brunchospasm PO 0.5-4mkd q6-8 <1wk 5mkd q12 or OD
Verapamil Inf & neo 7.5mkd q8
METOCLOPROMIDE Infant IV 0.1-0.2 mk over 2min <12y 6-7.5mkd q8
derivatve of procainamide s cardiac effects Ch 0.1-0.3mk
enhance ACH release fr postganglionic enteric motor MD 1-2mk q8 Kanamycin IV,IM
neurons indirectly enhancing cholinergic tone resulting to >2000g 400-800T U inj 1 gm/ vial
inc GE infants 15 mkd q 12
result in inc smooth mm tone of body and LES of ANTIBIOTICS children 30-50 mk IM in 1-2 div.
esophagus
negligible effect on distal SI and colon CEPHALOSPORINS Neomycin
crosses BBB Prep. 0.5mg/tab
1st Generation: 50-100 mkday q6 PO
facilitates gastric emptying Cefazolin (Stancef)
dose:0.1-0.3mg/kg tid/qid 40mg/lb BW in 6div.
Inj, 500 mg, 1 gm /vial Hepatic coma 4-12g/d
NB 40 mkd q 12 ( Ist week ) Netilmicin IV,IM
Cimetidine 40 - 60 mkd q 8-12 ( 1-4 weeks )
10-20 mkd q6 inj 50,100,150,200 mg/vial
IN,CH 50-100 mkd q 8 (IM,IV over 15-30 >1wk 2.5-3mk q8
2-10mkd in q8 (neonates) min)
0-6mos q12 child 2-2.5 mk
6-24mos q8 Cefalexin
>2yrs q6 Tobramycin IV,IM
25-50mkd q6PO inj 50,80mg/vial
(Cefalin, Keflex, Ceporex 100mg/ml, 125,250/5ml, 250,500 4-6mkd IM/IV q8
Ranitidine mg/cap)
2-3mkd IV q8 OR 4-6 mkd PO q12 children 3-7.5 mkd div q 8
Cefradine (Velosef) Clindamycin IV,IM,PO
MgOH/AlOH 25-50mkd q6 PO/IV (not to exceed 4 gm)
<12mo 1/4-1/2 tsp PO qid infants: 0-7 days, <2000 gm : 10 mkd q
>12mo 1 tsp qid after feeds & qhs 12
MgOH - laxative AlOH - constipation 0-7 days, >2000 gm : 15 mkd q
Cefalothin 8
50-100mkd q6 older infants/children : 15 - 40 mkd q 6-8
Maalox (Keflin 1 gm/vial
5-15 ml 1 hr pc/hs 10-40 mkd q 6
Vancomycin
2nd Generation inj 500 mg/vial
MgOH/AlOH Cefamandole
<12mo 1/4-1/2 tsp PO qid 15 mg/kg loading
50-100mkd q6-8 IV 10 mkd maintenance
>12mo 1 tsp qid after feeds & qhs inj 1 gm/vial
MgOH - laxative AlOH - constipation
Vancomycin by Dr. Garia
Cefuroxime 500mg vial in 10ml sterile H2O, get
PROTECTORS (Zinacef)
Jetepar taken for 6 weeks 5ml then add 2.5ml NSS to make 250mg/5ml
30-100mkd q6-8
3-6 yr 1/2 tsp TID/QID inj, 250,750 mg/vial
6-12 yr 1 tsp TID/QID ANTI-TYPHOID ALTERNATE REGIMEN
20 mkd q12
30 mkd q12 - otitis media *fever longer than usual of dengue; plt can go as low as
Cholestyramine 1 tsp daily 100,000; cutoff wbc count is 2,500 n if lower, prob dfs*
(Questran) Mix 1 sachet with 2 oz distilled H2O Cefoxitin
20-40 mk q6-12 CEFTRIAXONE 75-80 mkd 3-7
inj 1 gm/vial days
ANTI-DIARRHEALS AMOXICILLIN 100 mkd PO 14 days
Furazolidone Cefaclor(Ceclor) AMPICILLIN 200 mkd IV q 6 14 days
(Furoxone 50mg/15ml) 20-40mkd q 8 CIPROFLOXACIN 20mkd BID 10 days
7.5-15 ml/day susp 125/5ml; puvule 250,500 cap
5-10 mkday q6-8 x 7days
1mo-1yr 1/2-1tsp QID Cefotiam(Ceradolan) TETRACYCLINES
1-4yr 1-1.5tsp 40-80mkd q6-8tab Doxycycline 20-55 mkd TID-QID
5yr or older 0.5-1tbsp 200 mg; 0.5 gm/ vial
Tetracycline >12y: 1-2g in 4 di. doses
Nifuroxazide (Ercefuryl 220/5ml) 3rd Generation (125mg/5 ml, 200,mg/cap)
10-15 ml/day Cefotaxime
<6mos 2tsp in div. doses

2
TMP-SMX Secondary:
Trimethoprim 6-12mg/k/d & 30-60 SMXmkd q12 Aztreonam 1. HIV infxn/person with risk factors for HIV 12
*Effective serum level 15-40 ug/ml 50 mg/k/dose q 6-8 months
2. recent tuberculin conversion with( - )CXR 9
Ketoconazole months
5-10 mkd q12-24 3. PPD ( + ) not due to BCG with ( - )CXR and
ANTIAMOEBICS <20 kg 50mg no benefit to prev TB chemo 9 months
20 - 40 100mg 4. PPD + with stable or healed parenchymal
Metronidazole >40 kg 200mg lesions
35-50 mkd TID x 10days ANTI-VIRALS
(Flagyl 12.5/5ml& 25mg/ml, 250mg/tab) Inosiplex (Immunosin)
500mg/tab; 250mg/5ml, 60ml susp
Diloxanide furoate NB 1 ml q 3-4
20mkd in div doses x 10days 6 - 12 mo 1.5 ml
(Furamide 125mg/5ml) 1 - 2yr 2 ml
Etofamide (Kitnos) 2 - 6yr 3 ml
Children: 10ml TID x 3days 6 - 12yr 5 ml
Q3-4 h
ANTIHELMINTICS
Piperazine citrate (Expellin) Isoprinosine
1-2yr 5ml single dose 50-100mkd TID/QID SEDATION
3-5yr 10ml single dose Prep. 250/5ml DPT cocktail:
6yrs and above 15ml single dose Indications: Hep A&B, Influenza, Herpes, Measles Meperedine (Demerol) 1-2
*for roundworms: single dose mk dose IM
for heavy infestation : 2nd dose Gamma Globulin Promethazine (Phenergan) 0.5 -
for pinworms: 4 days 0.02cc/kg 1 mk dose IM
Prophylactic dose 0.02cc/kg Chlorpromazine (Thorazine) 0.5 -
Mebendazole (Antiox 100mg/5ml) Indications: 1 mk dose IM
200mkd x 3 days congenital abN, Hep A prophylaxis, Measles prophylaxis,
1 tsp x 3 days Demerol 25 mg ,
1 tab BID x 3days ACYCLOVIR Phenergan 12.5 mg /mix and inject 0.1 cc/kg IM
OR >6 yo 800 mg qid Thorazine 12.5 mg -
25cc single dose 2 – 6yo 400 mg qid
< 2 yo 200 mg qid Fentanyl and Midazolam sedation:
Pyrantel Pamoate or 20 mg/kg qid max of 800 mg/ dose Fentanyl 1 - 2 mcg/kg slow
(Combantrin 125/250mg/5mL) IV
11 mkd x 3 days Anti-rabies ( virorab) Midazolam 0.05 - 1 mk slow IV
<5yr 125mg PRE exposure : Virorab 0.5 ml/dose 3
5-9yr 250mg injection 0 / 7 / 28 Other sedatives (one time agents):
10-14yr 375mg booster after 1 year the q 3 Lorazepam
15yrs and above 500mg yrs 0.05 - 0.1 mkdose IM/IV/PO
POST exposure : 5 inj. regimen 0 / 3 / 7 / 14 / max 4 mg
Oxantel 30
(Quantrel 100mg Oxantel/5ml) simplified (2/1/1) Diazepam
10-20mk single dose 0/7/28 0.2 - 0.5 mkdose PO or
*for mild to mod. infestation: 2 days 0.05 - 0.2 mkdose IV
for heavy infestation: 3 days ANTI-TB max 10 mg
6 mos regimen:
Praziquantrel(Bultricide) 2mos INH, Rif, PZA Midazolam
20mkdose q 4 w/ food 4mos INH, Rif 0.08-0.15 mkdose IV/IM
OR over 10-20 min, max 5 mg
DEWORMING 2mos INH, Rif, PZA Chloral hydrate
1. Piperazine Citrate 4mos INH, Rif 2x weekly 25 - 100 mkdose PO/PR
q3 months max 1.5g/dose
MMC Prep- 500 mg/5 ml 9 mos regimen: allow 30 minutes for absorption
2. Quantrel 1x/year 9mos INH, Rif daily
NB: OR Promethazine
Ascariasis 1mo INH, Rif daily 0.5 - 1 mkdose IM/slow IV
 Pyrantel pamoate 11mg/kg single dose p.o. 8mos INH, Rif 2x weekly over 20 min, max 50 mg
 Mebendazole (2 y/o up) 100 mg bid for 3
days or 500 mg single dose Anti-TB Agents: Chlorpromazine
 Piperazine citrate INH 0.5-1 mkdose IM/slow IV
o 75 mg/kg daily for 2 doses orally Daily dose : 10 mkd PO qd
(max. 3.5 g)/or x 3days useful in (max 300mg) Hydroxyzine
intestinal obstn since it Twice weekly dose : 20-40 mkd (max 0.5-1 mkdose IM
paralyzes the worm 900mg)
ANTICONVULSANTS
Hookworm, Trichuris Rifampin Phenobarbital
 Mebendazole, Daily dose : 10-15 mkd PO qd LD 10 - 20
 Pyrantel Pamoate (max 600mg) MD 3 – 5 mkd PO/IV qd-bid
Twice weekly dose : 10-20 mkd PO qd Grain ¼ 15mg
Enterobius (max 600mg) Grain ½ 30mg
 Pyrantel Pamoate - 11 mg/kg x l dose ( max Grain I 60mg
1 gm); PZA Grain II 120mg
 Mebendazole I00 mg single dose repeat gfter 20-30 mkd PO qd (max 2g) Suppository (Anoral) gr ¼
2 wks;
 Piperazine 65 mg/kg ( max 2.5 g) x 7 days rpt Streptomycin Phenytoin
after 2 weeks 20-40 mkd OD IM x 2mos LD 10 - 15 PO/IV
MD 5 – 7 mkd PO/IV q6-24
ANTIFUNGALS Ethambutol
Griseofulvin (Nystatin) 15-25mkd Diazepam
10mk daily 0.2 - 0.8mkdose IV/IM
<15 kg 5mg/d Prophylaxis for skin test conversion:
15-30kg 100mg once daily INH 10-15mkd PO qd x 9mos Valproic acid
>30kg 200mg 10 - 15mkd PO qd-tid;
Mycostatin TB CHEMOPROPHYLAXIS inc. by 5 - 10mkd q 1week to
400-800,000 U/day q6 x 10d maintenance of
NB 1/2 ml QID Primary: 30-60 mkd PO qd-tid
Child 1ml QID PO 1. newborn of infected mom – OR
<2000g 200 – 400,000 U a. INH for 3 months initially; same dose of syrup diluted 1:1 PR
b. after 3 mos
Fluconazole i. PPD ( - ) d/c INH Carbamazepine
50, 100, 200 mg/tab if infections or 10 mkd PO qd-bid
adult : LD = 200 mg l, MD = 100 mg OD x treated & give inc. to maintenance of 20 - 40
14 days BCG; mkd PO tid-qid
CH : LD = 10 mkdose, MD 3 - 6 mkd OD ii. if PPD (+) continue (max 1g/day)
to begin 24 hr after LD INH for 9 mos;
1. abN CXR add 2 more drugs RIF & PZA & treat as Clonazepam
Clindamycin disease Initial dose : 0.01 - 0.05 mkd PO q8
30 - 40 mkd q 8 hr 2. PPD ( - ) infants and children under 5 inc to max 0.1 - 0.2 mkd PO q8
CH 8-2 mkd tid or qid exposed to TB
Lorazepam

3
 0.1 mk IV/IM (max 4mg) x = 31 cc to run for 38 hours
Paraldehyde
0.3ml / kg ( max 5ml ) PR DOLAN FOR PDA
in 1:1 dilution of mineral oil via
syringe day 1 = 10mkday OD
day 2 & 3 = 5 mkdose OD
Pentobarbital
5-10mk IV over 10min; Dilute in steril H2O
Prep: 250/5ml
Rpt. Q 20 min x 2 (total dose 15-25mk) monitor Urine Output, NPO
2 - 6yo 3 NPO 4 hrs prior until 7 hrs after
6 - 12yo 5
INSULIN
Ethosuximide
initial 20 mkd PO bid hyperglycemic >250
MD 3-6 yo 20-40 mkd PO qid metab. acidosis
>6 yr 20-30 (max 1.5
g/day) 0.1 U/kg/hr x 24 hrs
eg: 10kg
Effective Serum Levels of Anticonvulsants prepare 24 U Humulin R+ 25 cc dH2O to run
Valproic 50 - 100 ug/ml 1 cc/hr
Dilantin 10 – 20 ug/ml
Phenobarb 15 – 40 ug/ml at 250 - bring back D5 then titrate insulin drip
Carbamazepine 8 – 12 ug/ml
CNS DECOMPRESSANTS
Mannitol
1 - 2g / kg / dose IV
as 20% soln
over 30 – 60 mins

e.g. wt: 12kg

1g/kg/dose x 12 kg = 12 g
20g : 100 ml = 12g : x
X= 60 ml
Order:
of 20% Mannitol q8 as side drip for 30-60min

Dexamethasone (Decadron)
LD = 0.5mg/kg,
then MD = 0.25mg/kg q6

For suppurative men:

4-5 days 0.2-0.8 mkd

DIURETICS

Acetazolamide (Diamox)
5mkdose QID (PO, IV)
seizures 8 - 30 mkd q12
hydroceph 25 mkd &
inc.
by 25mkd
to a
max of 100mkd TID, PO, IV
*effective for infants 2wks-10mos

Furosemide
0.5-1 mkdose IM/IV
2-3mkday PO
*avoid use with aminoglycosides
(20mg/2cc vial, 20,40,50mg/tab)

Spironolactone
1.5 - 3mkd q4-6
(Aldactone 25,50,100 mg/tab)

Potassium Elixir
prep: 6.6meq/5ml
1-4meq/k/24hr BID

INDOMETHACIN FOR PDA

0.2mkdose
Prep 25/cap; 2.5/2.5cc
desired dose: wt x 0.2mg x Prep.

25 mg in 50cc of sterile water then ___/NGT 0-12h

2.5mg/pptab = x (vodka)
wt x 0.2 desired

e.g.
2.5mg = 0.14 mg
2.5 cc vodka x

ORDER:
Start Indomethacin 0.14mg prepared in the ff. manner:

Mix 2.5mg of Indomethacin w/ 2.5cc vodka

& when dissolved, get 0.14cc of the resulting
solution & dilute w/ sterile water to make 0.4cc soln.

Give via OGT, make sure entire amount goes to

the stomach by pushing 0.5cc air gently into the
tube after giving the medication

INDOMETHACIN
ex. wt. 1.73 mg day 3
( dose 0.2 - 0.25 - 0.25 = 0.7mg of total dose )
1.21 mg in 18 cc = 2 mg/ x

4
 CARDIOLOGY- ECG Upright T in : V1
1. Rythm(p axis) ST - N isoelectric, BIG R in :V1,V2, AVR
Sinus vs nonsinus but shift 1mm in infants N, up to 2 mm in BIG S in : LI, V6
P preceding each complex and precordial leads;
P upright in lead I, II and AVF, abN shift w/t changes in pericardits, MI, LVH
P invrtd in aVR dig Inc R in : LI, II, occ III, aVL, aVF
Tall R in : V5, V6,
2. Rate : 1 mm = 0.04sec, 5mm = 0.2sec Right V entricle Dominance or RAD Deep S in : V4R,V1, V2
a. count R-R cycles in 6 large divisions and Tall R wave : aVR, V4R, V1, V2; Deep Q > 5mm
multip by 50 Deep S wave : lead 1 and LPLs V5 and V6, Tall T in : V5,V6
b. R-R intervals at 5, 10, 15, 20, 25 mm T waves in V1 negative BIG R IN I,II,III, AVL, AVF, V5,V6
HR 300, 150, 100, 75, 60 BIG S IN V1, V2
RVH in infants Q in V5, V6
3. QRS axis, T axis, QRS-T angle- T waves in V1 upright
use overall deflection(neg vs pos) in lead 1
then aVF (in equiphasic complexes) Adult type R/S progression
Deep S : V1, V2
4. Intervals PR, QRS, QT Tall R : V5, V6
COMBINED VH
long PR - 1st deg av bloc in myocarditis, Infant- reversal of above- large Biphasic QRS in at least 2 leads
dig tox, CHD, Tall R : V1, V2
Deep S : V5, V6 Ventricular inversion – Q wave in V1
short PR - prexitation in WPW (Q wave normally in V5V6)
Partial reversal at 1 mos-3 yrs
QT long - hypocalcemia, malnut,myocarditis Dominant R : V1, V5, V6 PS mild to mod -.gradugl proa to sev
QT short - hypercal, dig .mod to sev - faster prog to sev
*adult Dominant R in LPLs,
5. P amplitude and duration Dominant S in RPLs,
sign of atrial hyprtrophy- 9 PRECORDIAL LEADS
(N) Amplitude < 3mm Upright T V2 - V6 occ 1 3 BIPOLAR LEADS I II III
Duration 0.07 - 0.09 3 UNIPOLAR LEADS -aVR,aVL,aVF
RAH - Tall P > 3mm
6. QRS amplitude, R/S, abN Q-
sign of ventricular hypertrophy- see book LAH - wide P > 0.08-0.1sec Axis I aVF
Q wave - deep in vent hypertrophy / overload
deep and wide in MI RVH N (+) (+)
7. ST, T ab(n) Inc R in : lead 3, aVR, RAD (-) (+)
Tall, Peaked T - hyperk, LVH Inc S in : L1 LAD (+) (-)
Flat, Low T - NB, hypothyroid, Tall R in : V4R, V1, V2, Extrem RAD (- ) (-)
hypokalemia, MI, DeepS in : V5,V6
perimyocarditis Q wave in: V1
HEART RATE > 6 yr 60 - 100 § Upright in I, II, aVF, V4R, V1
NB 110 - 150
2 yr 85 - 120 P WAVE PR Interval
4 yr 75 - 115 § Inverted in aVR
§ Varies with age and measured in lead II 14 - 17 0.19 0.18 0.17 0.16 0.15 0 - 1.5 0.16 0.16 0.146 0.135 0.12
Age Cardiac Rate/minute 7 - 13 0.18 0.17 0.16 0.15 0.14
70 71-90 91-110 110-130 130+ 1.5 - 6 0.17 0.165 0.155 0.145 0.13
Combined Ventricular Hypertrophy
Atrial Hypertrophy Left Ventricular Hypertrophy 1. (+) signs of RVH and LVH
RAH peak p waves > 3mm 1. R V6 > 25 mm (20 mm in 1st yr) 2. LVH + RAD and tall R in V1
LAH broad p waves >0.08sec 2. S V1 > 20 mm 3. RVH + Q of 2 mm or more In V5 or V6, tall R in V6
3. R/S in V1 < 0.8 <1 yr & inverted T wave in V6
Right Ventricular Hypertrophy < 0.2 1 - 5 yr 4. Large equiphasic QRS complex > 10 mm in V2-V4 in 2
1. R V1 > 20 mm (29 < 1mo) < 0.1 6 - 13 yr of three limb leads ( Katz Watchell phenomenon )
2. S V6 > 7 mm (14 mm <1 mo) 4. T wave inversion in V5 & V6
3. R/S in V1 > 2 after 6 mo. 5. Q >3 mm in V5 & V6
4. Upright R in V1 after 6 mo.
Metabolic Disturbances E -complete bed rest. - age 5-15
Inc K - inc attack rate following initial RF
1. peak T wave MURMURS - runs in families
2. Dec P wave INTENSITY
3. Prolonged PR interval Grade 1 - barely audible Latent period
4. QRS & ST changes Grade 2 - soft but easily audible - 2-3 weeks
Grade 3 - moderately loud but not accompanied by a thrill - mean 18.6 days
Dec K: Grade 4 - louder and associated with a thrill
1. widened QRS & prolonged QT interval Grade 5 - audible with the stet barely on the chest Mimetic
2. ST depresseion > 0.5 mm Grade 6 - audible with the stet off the chest - same manifestations in 1st and recurrent attacks
3. depressed T wave amplitude CLASSIFICATION
4. incrased U wave > 1 min 1. Systolic - ejection or regurgitant CLINICAL MANIFESTATIONS
5. atrial and ventricular ectopic beats 2. Diastolic - early diastolic, mid diastolic or presystolic
3. Continous 1. CARDITIS
Inc Ca - most serious
1. Short ST segments--> QT int SYSTOLIC MURMURS AT LUSB - severity may range from asymptomatic to fulminant
2. Dec long ST segment--> QT intak - pancarditis
PULMONARY VALVE STENOSIS a) pericarditis - effusion
CHF(NEW YORK CLASS) (NYHA) THERAPEUTIC - SEM gr 2-5 / 6 b) myocarditis - poor contractility
I - ordinary physical activity does not cause undue - thrill c) endocarditis - valves
dyspnea / fatigue - S2 may be split widely when mild
- ejection click at 2LICS 2. ARTHRITIS
II - comfort is present at rest,but ordinary physical activity - transmit to the back - distinctly migratory polyarthritis
resuts in - prominent MPA (poststenotic dilatation) - mainly large joints, weight bearing
dyspnea or fatigue. - normal PVM - occurs early in the rheumatic attack
- normal ECG if mild - exquisitely painful and swollen
III - comfort is present at rest, but less than ordinary - RAD - affects several joints one after the other
physical activity - RVH - usually the leqs first then the arms, knees, ankle,
results in dyspnea or fatigue. - RAH if severe elbows, wrists, hips, small joints of the feet, shoulder,
hands
IV - dyspnea/fatigue maybe present at rest and made ASD
worse by any 3. SUBCUTANEOUS NODULES
physical effort - SEM gr 2-3 / 6 - appears in pxs with carditis
- widely split and fixed S2 - firm painless round nodules
FUNCTIONAL - CXR - increased PVM - 1-2 cms in size
- ECG : RAE, RVE - in scalp and along spine
A- no limitation of physical act. - RAD, RVH, RBBB (rsR')
4. ERYTHEMA MARGINATUM
B -limitation of strenuous physical act. RHEUMATIC HEART DISEASE - occurs in early stage
(Dra. Fransisco) - common with carditis
C -limitation of mod. physical act. - transient non-pruritic
- acquired disease - affecting trunk, proximal limbs, NEVER the face
D -limitation of mild physical act. - non-suppurative sequelae of GABS throat infxn - hot bath may make them more evident
- rheumatogenic strains 3,5,10,19,21

5
5. CHOREA PLUS-evidence of preceding group a ECG
- neurological disorder strep infection (culture' rapid antigen' antibody 2D Echo
- involuntary movements rise/elevation) Serum Na, K
- muscular weakness (milkmaid qrip) 2 major or 1 major and 2 minor ESR, CRP, ASO
- emotional disturbance plus evidence of a preceding strep infxn IVF : D10W x 12hrs
- common in prepubertal girls CARDITIS SIGNS Meds : Pen G 100T U/k/d q 6
- long latency period - 6wks to 6 mo 1. Tachycardia out of proportion of the degree of fever Lanoxin 0.03-0.05 mk TDD
- disappears in sleep 2. Heart murmur f valvulitis (MRAND/OR AR)
- deterioration in penmanship 3. Pericaditis ( friction rub, pericardial effusion, chest
- behavioral change pain, ecg changes)
- can have normal ASO, ESR 4. Cardiomegaly is indicative of pericarditis, pancarditis,
- can stand alone even w/o other major criteria or CHF eg. wt = 29kg
5. Signs of CHF (GALLOP rhythm,distant heart sounds, TDD = 29 x 0.04mk = 1.16
LABS cardiomegaly r ix f severe carditis LD 80% TDD = 0.928
1. Evidence of recent strep infxn 1. Rheumatic fever
- ASO is the best standardized 2. Mitral regurgitation 1/2, 1/4, 1/4 then 1/10 q 12
3. Atrial fibrillation 0 hr 1/2 TDD
2. Evidence of systemic infxn *If any 2 of above are present, expect the 3rd one in 9 out 8th hr 1/4 TDD
th
- ESR and CRP - not specific but sensitive of 10 16 hr 1/4 TDD
- ESR would not rise in CHF because of liver congestion 24th hr 1/10TDD
After 10yrs, RHD pxs develop MS
3. Evidence of heart involvement MS, - CAN STAY FLAT ON BED Give 0.45 mg IV now then 0.23 mg IV after 8h then 0.23mg
- cardiomegaly, pulmonary congestion MR - PRESENTS W/ orthopnea, after 16 hrs (Lanoxin elixir 0.05 mg/ml)
- ECG- prolonged PR interval >0.2 s prob left ventricular failure Hold if CR <120/min
- echo- cardiac involvement MR, AR
3 cases that dont require fullfillment of Jones criteria KCL elixir 2-3meq/kg (prep: 6.6meq/5ml)
MINOR CRITERIA 1) chorea Lasix 0.5-1 mkdose IV q 8
Clinical 2) insidious carditis
- fever 3) recurrence of RF only (previously diagnosed)
INFECTIVE ENDOCARDITIS
- arthralgia
RHD Dx &Tx (Dra.Reloza) Differential diagnosis:
- Panarteritis nodosa
Lab  CHF - sine qua non of ACTIVITY in RHD
- Buergers
- ESR, CRP, PR  Tachycardia - simplest finding
- Clostridium perfringens - rare
 No need to fulfill jones criteria if NOT a virgin case
EXCEPTIONS TO THE CRITERIA  Recurrence is MIMETIC i.e. mimics initial attack Old Classification:
1. When pxs present with chorea  Arthralgia + murmur = a more severe form than if
2. Insiduous or late onset carditis >Acute Bacterial Endocarditis - in the normal heart
wt arthritis only >Subacute Bacterial Endocarditis –
3. When diagnosing rheumatic recurrence  The younger the pt, the more severe in previously damaged heart w/ Rhd or Chd
TREATMENT RHD (therapeutics)
- regimen should be tailored to the clinical manifestations of New:
2 stages of prophylaxis: >Infective Endocarditis
the px 1.Primary proph-
- CRP is the better test 10 day course of pen
- Aspirin 3 Bacterial Complications of 1-wk
1.2M > 6yo Untreated pneumonia
- if not in CHF and CXR is normal 600T < 6yo
- x 3 mo 1. empyema
2.Secondary proph 2. pleural effusion
- Prednisone -for known cases to avoid recurrence
- + cardiomegaly 3. pericarditis
-penadur Q 21 days
(studis show titer go down after the third wk) PERICARDIAL EFFUSION
ANTIBIOTICS *for pts wt multivalv involv,
- single injection of Penadur -decreased blood flow to lungs bec of decreased venous
*for pts wt recurrences return to heart
- 250 mg Pen 3-4x/day p.o. X 10 d - Q 28 days if ,
- Pen IV x 10 d -result: pulsus paradoxus
*not multivalv. and
- Erythromycin 20-40 mg BID x 10 d *no recurrence yet
CHF Candidates for Strep viridans endocarditis:
-Lifetime tx for pts with multivalv - Congenital heart disease
- diuretics and digitalis -until 20y/o or at least 5 yrs symptom-free - RHD
CHOREA *since (-) CHD or RHD in our px --> think of an acute
How to monitor activity: bacterial process - Staph aureus
- quiet environment 1. check heart rate - still tachycardia ?
- bedrest 2.acute phase reactants- ESR,CRP
- Pb or haloperidol 0.1-0.3 mg/kg/day Long term complicatons of pericarditis:
goes down in 3-4 wks 1. Constrictive Pericarditis - bec of fibrinous formation
but dont rely solely, go clinical 2. Calcification - bec of healing
DIAGNOSIS AND TREATMENT OF STREP THROAT
- rapid onset of fever 3.anti inflamm for 3-4 wks
- pain on swallowing LAB Infective Endocarditis
-aspirin alone will do if not multivalv 1. CBC
- fiery red pharynx with exudates -may give prednisone if multivalv, then taper, then alt w
- tender and large anterior cervical LN 2. urinalysis - hematuria
aspirin, until aspirin na lang 3. ASO
- give next dose of Pen on day 11 then q21-28 days For those IN FAILURE: 4. ESR
-give anti inflam a.s.a.p, inotrops may play secondary role 5. CRP
DURATION OF PROPHYLAXIS
6. Blood Culture & Sensitiviy
RHD - for life LAB
ARTHRITIS - 5 yrs 1. Labs
CARDITIS - 10 yrs CBC, ESR, CRP, ASO, Throat culture, CXR, ECG,
ECHO
PROGNOSIS 2. Benzathin PEN G 0.6 - 1.2 million IM
- complete recovery to death from CHF Erthromycin 40 mg/kg/day q6 x 10 d
- polyarthritis and chorea are always benign
- subcutaneous nodules and erythema are 3. Prednisone 2 mg/kg/day q6 x
inconsequential 2 - 4 weeks (mod) ,
2 - 6 weeks (severe)
SECONDARY PROPHYLAXIS 4. Aspirin 90- 100 mq/kg/day q 4-6.
- Penadur 1.2M units q 21 days
- Sumapen 250 mg BID (8a - 2p) until penadur is LEUS
available 1. IV PEN 300-400,000 mg/kg/d or PEN p.o.
for a total of 10 days then start Penadur
RHD Jones criteria 2. Prednisone 1 mg/kg/day max 60
especially if w/ sx of CHF
MAJOR - 3. Aspirin only if arthritis alone
1. Carditis
2. Polyarthritis Francisco
3. Chorea Penador 0-11-21 days
4. Erythema marginatum
5. Subcutaneous nodules for polyarthritis only:
-aspirin only, for 2 wks
MINOR -no need for rpt / serial ESR,CRP
CLINICAL
Endocarditis Prophylaxis
1. fever
2. arthralgia Dental n oral procedures or surgery
RHD : admitting order of URT or esophagus
LAB
1. Elevated ESR or CRP Low salt diet, limit fluids 500cc / day 1. Amoxicillin oral 50mg/kg
Request for: CBC Adults - 2 g
2. Prolonged PR INTERVAL
CXR 1 hour prior to the procedure

6
2. For pxs unable to take oral 2 - 4 yo 109 110
IM / IV AMPICILLIN 50mg/kg 5 - 9 yo 93 93 MCV = Hct/RBC x 10
30min prior procedure 10 - 14yo 86 88 MCH = Hgb/RBC x 10
Adults - 2g
3. Amoxicillin and Ampicillin - allergic NORMAL BLOOD VOLUME THALASEMIA
CLINDAMYCIN (PO) 20mg/kg Dr Racho
1 hr before procedure Term 85-87ml/kg
adults-- 600mg Preterm 100-108 ml/kg - Genetic: a deletion mutation
Children 80 ml/kg - Hypochromic, microcytic – means that the problem is in
OR Adult 70 ml/kg hgb
ORAL CEPHALEXIN or cefadroxil 50mg/kg MCV <80 (NV 80-100)
1 hr before procedure PROTHROMBIN TIME MCH <27 (NV 28-32)
Adults - 2g PARTIAL THROMBOPLASTIN TIME - hgb is divided into heme + globin
- OR PT - heme : porphyrin ring + Fe center
Azithromycin or Clarithromycin (PO)15mg/kg 1 hr prior - extrinsic pathway
Adults-500mg - Factors III, IV, VII, X Causes of hypochromic, microcytic anemia:
- prolonged in decreased liver synthetic capacity, A. Failure of porphyrin synthesis = porphyria =
4. AMPI/AMOX ALLERGIC UNABLE tp tãke medications decreased vitamin K absorption, warfarin therapy, sideroblastic anemia
CLINDAMYCIN (IV) 20mg/kg inadequate sample volume, drawing from heparin B. Iron-deficiency anemia
30min prior procedure containing catheter C. Anemia of chronic disease
Adults-600mg *warfarin therapy D. Thalassemia or Hemoglobinopathy
OR a. Decreased synthesis of globin chain
CEFAZOLIN((IV) 25mg/kg 30min prior procedure PTT (quantitative) = Thalassemia
Adult - 1G - intrinsic system b. Defective globin chain despite adequate
- Factors XII, XI, IX, VIII, V, II, I synthesis (qualitative) = Hemoglobinopathy
GASTROINTEST/GENITOURINARY TRACT AND - prolonged in plycythemia, inadequate sample, blod from
INSTRUMENTATION heparin containing catheter Normal hgb is a tetramere, may be composed of
*heparin therapy combinations of adult hgb, A2, or fetal hgb. Normal values
1. H IGH RISK PXS of combinations of these chains are achieved at 6 mos old
IM /IV Ampicillin 50mg/kg plus Bleeding tendency if :
IM/IV Gentamycin 1.5mg/kg 30min prior procedure PT activity ≤ 75% - Adult hgb = Alpha2 + Beta2 =
INR ≥ 1 96%
plus 6 hr later PTT patient vs control ≥ 20 - A2 = Alpha2 + Delta2 = 3-
IM/IV Ampicillin or oral ampicillin 3.5%
- Fetal hgb = Alpha2 + Gamma2 = 1 -
LANOXIN (Dr leus) 1.5%
ANEMIA
TDD = 0.04mg/kg/dose Beta Thalassemia: recessive
Bone marrow failure
1. Aplastic anemia Classification:
Load = wt x 0.04 X 1 ml 2. from infiltrative dse 1. Clinical – based on signs and sx
4 0.05 mg -Leukemias a. minor – mild anemia, Hgb ~10, no organomegaly
-Granulomatous collections: TB b. intermedia – most don’t need transfusion, Hgb ~8-9,
to be given x 4 doses -Lipoid collections: nieman pick's, gaucher's dss may require transf. sometimes
c. major – severe anemia needing transf,with
maturation abnormalities w/ normal bone marrow hepatosplenomegaly
Maintenance: wt x 0.04 X 1 ml - Folic acid
8 0.05 mg - Vit B12 2. Biochemical – referes to specific defective chains, e.g.
- Iron alpha, beta,
every 12 hours LABS etc; detected by hgb electrophoresis
- CBC
MCV = 80 - 100 Alpha Thalassemia
Lanoxin 0.05/ml
MCH = 28 - 32 1-gene deletion = silent carrier ,normal MCV and MCH
wt x 0.04 div. By 0.05 div by 8 or 10
1/8 1/10 2-gene deletion = Thal. Trait =Thalassemia minor
-Reticulocyte count 0.5-1.5% (mean 1) = RNA remnants 3-gene deletion = Hgb H disease = Thalassemia
kcl 6.6meq/5ml (1-1.5)
in rbc intermedia
lasix ( 1mkday)
Normal corr retic ct: 1.0 4-gene deletion = Hydrops fetalis, not compatible with life
Fluid intake of cardio
CORRECTED RETIC CT = Hgb Electrophoresis:
wt x4 plus 9 divided by 100 x 1000
ex. 30kg TFI-1200/DAY Slow moving: A2, E, C, O hgb
ACTUAL HCT X RETIC CT Intermediate moving: Adult, fetal hgb
DESIRED HCT Fast moving: Hgb H, gamma4 hgb
(wt X 4) + 9 X 1,000
100
if > 3 : hemolysis Other Hemoglobinopathies
if < 1 : bone marrow depressed - can also be seen in hgb electrophoresis, specifically in the
prednisone 1mkday
penicillin 30mkday q6 x 10days slow area
-Peripheral smear 1. Hemoglobinopathy C and O specific gene mutation
-Serum Iron 90% involves beta chain; amino acid chains are
Digitalis toxicity
-total fe binding capacity (TIBC) involved
1. Digoxin-hypokalemia
-serum Ferritin 2. Hemoglobin E disease
2. Furosemide-hypokalemia
3. steroid-hypokalemia involves amino acid 6 – lysine is replaced by valine
Hypochromic Microcytic = hgb deficiencies Ly-val ~ abnormal chain
so better give-kcl
- Hemoglobinopathies
AVE BP OF FILIPINO INFANTS & CHILDREN - Fe Hgb E – no target cells
- Thalassemias Hgb C – associated with 50% target
+/-2 SD SYS DIAS cells
Hyperchromic Macrocytic Hgb O – exclusive for arabs
0-1 m 72
- Hemolysis = large immature RBC
2-11m 81.66
- Megaloblastic anemia : Folic acid, vitB12 Alkali Denaturation Test
1 87.30 56.40
2 88.20 63.15 • Fetal hgb is resistant to this test; red cells do not
HX/: hemolyze if
3 87.47 55.50
-Congenital or acquired? they contain fetal hgb
4 87.37 56.45
-Cerebral & circulatory • Normally, RBCs denature in this test if there is a normal
5 93.90 59.80
sx:feeding,activity,tachycardia,irritability hgb
6 93.84 60.05
-chronic bld loss component
7 96.56 61.55
-episodes of hemolysis?
8 98.50 60.05
-drugs,exposure to toxins Most common cause of death in thalassemia major –
9 97.00
-dietary hx hemosiderosis (can’t go beyond 20y)
57.30
-fam hx & race:gall stones  iron in heart – cardiomyopathy
10 98.95 61.50
-underlying dse  iron in pancreas – DM
11 98.80 74.40
12 101.55 67.55  iron in hypothalamus – DI, growth problems
13 106.95 65.70  iron in liver – liver cirrhosis (iron is toxic in the
14 108.00 71.50 liver)
15 104.05 86.85 * 1 cc packed RBC gives the patient 1 mg Fe
1. Iron def * 250 cc pRBC gives the patient 250 mg Fe, plus consider
AVE CARDIAC RATE IN FILIPINO CHILDREN 2. Thalassemia(quantity) Fe released from hemolysis
3. Hemoglgbinopathies(guality) * excretion of Fe = 1 mg/day = 30 mg/month
Male Female -Sickle cell dse * frontal bossing – bone marrow proliferates bec of
-Hgb E disease compensation for chronic hemolysis
0 - 1 mo 147 147
-Hgb C disease
2 - 6 mo 139 141
4.Lead poisoning/anemia of chronic dse
7 - 12m 133 134
5.Sideroblastic anemia: porphyrias
13 - 24m 128 129

7
 BLOOD PRODUCTS No. of units to transfuse =
Management: PRBC- for symptomatic anemia, dec red cell mass, action (Wt x plasma vol x factor activity) / 100
A. Bone marrow transplant is to restore bld vol and oxygen carrying capacity; given in
B. Fe chelation = Desferral IV, SQ or oral 4-6 hours MD 1/2 LD Q12 hours
binds with Fe, then excreted in urine
•11 parts desferral binds 1 mg Fe Washed RBC- febrile reaction from leukocyte antibody, IgA Plasma volume = 35 cc/kg 70 cc/kg
if a patient requires 2 U prbc / month senitization
= 500cc/month x 11 parts Factor activity
= 5500 parts desferral needed / month FWB - for hypoxia w/ vol deficit, massive transfusion hemarthrosis 30%
start chelation if serum ferritin is >2000mg - restoration of bld vol and oxygen cartying capacity 50%
(prone to organ damage already) 80%
• complication of desferral -retinopathy FFP - deficit of plasma coag factors; given in 2 hours,
C. Folic acid – for DNA synthesis depending on what clooting factor is being corrected 100 = F VIII in 1 unit of cryo
• 1 mg/day for children given as fast drip
• 5 mg/day for adults CRY PRECIPITATE - for hemophilia A, von willebrand
chronic hemolysis leads to megaloblastic/aplastic dse, hypofibrinogenemia, fac XIII def, provides fac VIII and FVIII stability is 8-12 hours
crisis and folic acid will help. fibringen; given as fast drip mild >6%
mod >2-5%
BLOOD TRANSFUSION (CGH) PLATELET CONC- for bleeding from thrombocytopenia or sev <1%
A. Packed RBC: platelet dysfxn, improves hemostasis; given as fast drip
200-250 cc = 1U Hemophilia A
Hct = 70 - 80 GRANULOCYTE- for neutropenia and infection formula for transfusion of cryoppt
Indications: units of factor 8 (LD) =
1. ongoing blood loss ORDERS FOR TRANSFUSION wt x plasma vol x factor activity desired
2. symptomatic anemia *divide by 100 to get units of cryoprecipitate
3. chronic anemia/hemolytic, eg.thalassemia (Hgb <8g/dL) * FWB if you need RBC and Volume since 100 u factor 8 = 1unit cryo
4. marrow failure (Hgb <8) (plasma) 1 vial factor 8 = 400/600 units
5. pre-op/peri-op (Hgb <8) * PRBC - no plasma, only RBC
10cc/kg to increase Hgb by 3g/dL * Add 12 cc for tubings IRON DEFICIENCY ANEMIA
to increase Hct by 8 - 10 Order:  Healthy term infants exclusively breastfed are at risk
infuse w/in 4hrs Prepare X cc of properly typed and crossmatched for iron def anemia at 6 mo of age
Hgb 8 - 10g/dL : 10cc/kg if symptomatic ___ and transfuse X cc at rate of Y cc/hr  If an infant or child is otherwise well, a tx trial of 4-6
4 - 6g/dL : 5cc/kg till Hgb is 8-10 Give Lasix mid transfusion mkd of elemental iron can be given
<4g/dl : pRBC = mL/kg Hgb level Dec IVF rate to (usually KVO) while BT is going on  Hb should rise by >1 gm/dl in 1 mo
 Tx/ should be continued for 2 more months
B. Platelets: X = (Desired - Actual Hct) x Wt  After iron tx is initiated, a response can be detected
40 - 50cc = 1U (45) 2 - 5 days inc in retic ct
6 - 8 x 10 to the 3rd platelets Y= Present IVF Rate 7 – 10 days inc in Hb
Indications:
1. plt cnt <50,000 w/ bleeding BLOOD TRANSFUSIONS Storage iron = serum ferritin or hemosiderin
2. plt cnt <20,000 in marrow failure Circulating iron = serum iron (w/ transferrin
3. plt cnt <50,000 & will undergo invasive procedure FWB 10-20cc/kg;
if < 25kg, 20cc/kg Erythropoietin ( Epogen )
0.1-0.2u/kg to increase plt cnt by 50000 (1-2u/kg) 200-300 units / kg / dose
fast drip, within 4 hrs 2 – 3 x / wk
Plasma 10 - 15cc/kg (4-6 hrs)
or 1U / 7lbs for 2-6wks;
pRBC5 10cc/kg (2-4 hrs) Total dose/wk is 500-1400u/kg IV
C. Cryoprecipitate : over 4hr or SQ.
10-20mL = 1U Supplement w/ iron therapy
Platelet 7cc / kg or
~80-100 U F8, 100-250 mg fibrinogen, ex. 1.87kg = 468~ 500units, may give 2x/wk
30cc / 7 kg or
40-70% of VWF, -to decrease need fot pRBC transf in high risk preterm
50cc / 10kg (fast drip)
30% of F8 infants esp w/ BW <1.2kg
Indications: -monitor weekly CBC to check for neutropenia & monitor
Albumin 0.5 - 1 g / kg
1. TOC for vW disease RBC response
Stock dose: 25g/400cc
2. selected px w hemophilia A
3. acquired F8 deficiency Blood Transfusion for NB PLATELET DISORDERS
4. hypofibrinogenemia  0.1- 0.2 unit/kg of transfused platelets should raise
(ideal Hct- actual Hct) x wt
*1U / 5-10kg the platelet cT by 40,000 or
x 2 (if FWB)
*infusion time not to exceed 4 hrs  1 unit/m2 should raise the count by 10,000
x 1 (if pRBC)
 Platelet survival time is 7-10 days
D. FFP (Fresh Frozen Plasma) :
1g Hb = 3 - 4g Fe
200 - 250cc/bag = 1 U 100cc FWB = 50mg Fe IDIOPATHIC THROMBOCYTOPENIC PURPURA
~ 1U/mL each of the coag.factors and normal
 Most common of the thrombocytopenic purpuras of
concentrations of plasma proteins (alb, Ig) - immediately blood product / Hb increase/ Fe increase childhood
following collection
~0.70u/mL F8=FFP after 8 hrs from donation time
1 U FWB (500 cc) 1 g 200 mg  Related to sensitization by viral infxn
~0.15u/mL F5 and F8=FFP after 8-72hrs from donation
1 U pRBC (250-350) 2g  interval between infxn & onset of, purpura averages
time 2 wks
 immune mechanism is the basis
Desferal = 500mg / vial
Indications: 11mg desferal for every 1mg iron CLINICAL MANIFESTATIONS
1. Coag. factor deficiency in a bleeding px (1cc prbc = 1mg iron)  Bruising and petechial rash occurs 1-4 weeks after a
(monitor PT & PTT) eg. DIC, liver disease (1u prbc = 250cc = 250mg iron) viral infxns
2. Emergency removal of coumadin effect so 1 unit prbc = 5,5 vial
3. Replacement fluid in plasma exchange for HUS, ITP  Bleeding asymetric and most prominent over the
leqs
ex. transfused 2u prbc =500mg iron
*10-20mL/kg to increase clotting factors by 20%  Hemorhages in mucous membranes
500x11=5500mg desf needed
 Nosebleeds may be severe and difficult to control
5500mg/500mg per vial = 11vials
E. FWB (Fresh Whole Blood) :  Most serious complication is intracranial hemorrhage
500mL - 1 U <1%
PLATELET REPLACEMENT :
Hct = 0.30 - 0.40
Blood product increase  Liver, spleen, and lymph nodes are not enlarged
Platelet Conc (1U/5kg) 50 - 100T  Appears clinically well
Indications: Pltlt-Rich Plasma (10cc/kg) 30 T
1. Rapid,massive blood loss requiring O2 carrying LABORATORY FINDINGS
FWB (10cc/kg) 15 T
capacity and blood volume  Platelet count < 20 T
2. Exchange transfusion in neonate (WB <5-7days old) PRE BT  on smear, platelets are large
• 1 mg/kg IV Benadryl  Bleeding time and clot retraction time are abnormal
*0.15mL/kg initially as slow drip to allow observation for 
• No pre-BT for 6 months or less WBC is normal
immediate severe transf rxn, then rate of infusion should be 
• No skin test for 6 months or less Anemia not present unless with significant blood loss
as fast as clinically indicated and in all cases completed
 BMA reveals normal granulocytic and erythrocytic
w/in 24 hrs TRANSFUSION series and, modest eosinophilia
Platelet - fast drip
pRBC - 4 hrs TREATMENT
FFP - 2 hrs  Excellent proqnosis even without specific tx
Cryo - fast drip  Within 3 mo, 75% recover completely, most within 8
wks
Plt at least 1 hr after  90% regains normal platelet counts 9-12 mo
pRBC 4-6 hrs after  Relapses are unusual
FFP depends on clotting factor corrected  Fresh blood or platelet concentrates have transient
benefit and used only when life-threatening
hemorrhage occurs
HEMOPHILIA  Vit k and c have no therapeutic effect

8
 GAMMA GLOBULIN c. Hydorxyurea-to decrease WBC count, but will not half of deficit+ 2/3 of maintenance
- 400 mkd x 5 days ablate the Phil.chrom
- 1 g/kg/24 hrs x 1-2 days d. hydrate,alkalinize urine,anti-uric acid meds
- to prevent tumor lysis syndrom
 CORTICOSTEROID *cytogenetic response means disappearance of the
o reduces the severity and shortens the Phil.chrom
duration of the initial phase
o Prednisone 1-2 mkd until PC is normal
or for 3 wks, whichever comes first AML FLUID Mx/ IN BURN PATIENT
o BMA prior to steroids M6- Erythroleukemia
o if thrombocytopenia persists for 4-6mo, - erythremic myelosis 5000 ml/m2 / % burned surface + 2000 ml/m2 tbsa
a 2nd short course of corticosteroid tx - erythroleukemia (maintenance)
or IVIG may be given - full blown AML
 Splenectomy for chronic patients (persistent - poor risk 1/2 the estimated burn requirement during the 1st 8 hrs
thrombocytopenia > 1 yr) & the remaining half divided over 16 hours
M3 - Acute promyelocytic leukemia
LEUKEMIA - responsive to chemo
LAB REQUESTS : Colloid tx only for burns >30% given 8-24 hrs from injury as
HEMATOLOGIC CHEMOTHERAPY AML : 12.5 g albumin in each liter of LRS
· CBC  Mitoxanthrone 10 mg/m2 D1 D2 IV push
· BLOOD SMEAR EXAMINATION Factors Modifying Fluid Requirement
 Ara C 100 mg/m2 incorporated in
· BONE MARROW ASPIRATE FOR Extra needed
TFR
MORPHOLOGIC,CYTOGENIC  fever (adjust 12% for each C)
 Doxorubicin 30 mg/m28
AND HISTOCHEMICAL ANALYSES  seizure/chills (adjust 25-50%)
BIOCHEMICAL m2 FOR CHEMOTX AND COMPUTATION OF TFR FOR  hypermetabolic states i.e. Burns
· ELECTROLYTE PANEL RENAL DSE  diarrhea & vomiting (vol per vol)
· BUN CREATININE  sweating (10-25%)
· URIC ACID WEIGHT(kg)  phototherapy (25%)
· CALCIUM AND PHOSPHORUS 0 - 3 0.05 (wt) + 0.05
· LIVER FUNCTION TESTS 3 - 10 0.04 (wt) + 0.1 Less required
OTHERS 10 - 20 0.03 (wt) + 0.2  hypothermia (12% per ea C)
· BLOOD AND/OR SURVEILLANCE 20 - 30 0.02 (wt) + 0.4  very high humidity (30%)
CULTURES  humidified inspired air (25%)
· URINALYSIS(CULTURE IF INDICATED) TFR = m2 x 400 + ½ ( 24hr UO )  oliguri/anuria (case to case)
· CHEST X-RAY FOR DRUGS : dose / m2  sedated/paralyzed (40% due to reduced energy
· ELECTROCARDIOGRAM FOR RENAL DSE : ½ UO + (200 - 400 cc) x m2 = TFR expenditure)
 edematous or antidiuretic state (30%)
LEUKEMIA Phases of Treatment HOLIDAY-SEGAR METHOD
I. INDUCTION First 10kg 100cc/kg/d COMPOSITION OF IV FLUIDS
Goal is complete remission 2ND 10kg 50cc/kg/d
Parameters for complete remission each add kg 20cc/kg/d SOLUTION Na Cl K Mg Ca HCO3
Dex
1. Clinical remission COMPUTING FOR THE DEFICIT
(-) lymphadenopathy MILD 0.9NaCl I54 154 - - - - -
good appetite 50cc/kg <2 yo <10 kg 0.45NaCl 77 77 - - - - -
inc. in weight 30cc/kg >2yo >10 kg D2.5 0.45NaCl 77 77 - - - -
good activity
2.5
6-8 hr D50.3 NaCl D5 0.45NaCl 77 77 - - - - 5
2. Peripheral remission
D5 0.3NaCl 51 51 - - - - 5
no anemia MODERATE D5 0.22NaCl 38 38 - - - - 5
no lymphocytosis 100cc/kg <2yo <10 kg D5LR I30 10 4 - 1.5 28 5
no immature cells 60cc/kg >2yo >10 kg D5NR 140 98 5 I.5 - 50 5
D5NM 40 40 13 I.5 - 16 5
3. Marrow remission 1/4 of TFR 1-2 hr D5LR D5IMB 25 22 20 1.5 - 23 5
normal cellularity 3/4 of TFR 5-7 hr D5 0.3NaCl
normal erythrocytic activity
Undocumented UO: D5 0.3 NaCl
normal megakaryocytes SEVERE Documented UO: start D5 MMB
normal granulocytes 150 cc/kg <2yo <10kg
90 cc/kg >2yo >10kg Choice of fluid for Osmolarity disturbances
II. CONSOLIDATION 1/3 of TFR 1-2 hours D5LR Isotonic - D5 0.3 NACl
give same set of chemo Rx or different combination 2/3 of TFR 5-7 hour D5 0.3NaCl Hypertonic - D5 0.15 NaCI
NB- FLUID CHALLENGE Hypotonic - D5 LR or D50.9NaCl
III. MAINTENANCE ORS-20 ML/KG
 Continue to give chemoRx until tumor load reaches  if no UO :10cc/kg IV x 3 challenges Compute serum osmolality
0
 Do BM after 5 weeks CONDITIONS REQUIRING SPECIAL IVF: 2( Na) + Gluc (mg/dl)
o if no remission, continue giving Meningitis : 1/2-1/3 maintenance 18
chemoRx x 2 weeks D. insipidus: 3000-3500 cc/m2/24h
o then repeat BM ARF : No K in fluid DEHYDRATION
o if no remission------FAIL(no CR) DKA : 4000cc/m2/24
CHF : dec. Na Clinical Fluid Deficit Status
CLASSIFICATION Drowning : 1/2 maintenance
1. ALKYLATING AGENT - cyclophosphamide Hypoxic enceph.; insensible loss (wt x 30)+ 24h U.O. Mild 5-7%
2. ANTIBIOTIC - adriamycin, TFR in renal failure: BSA x insensible + 1/2 24h U.O. No Signs of Dehydration
ANC (x 1,000cells/mm3) Insensible = 200-400cc/BSA/d inc. pulse, normal BP, dry membranes, inc.thirst, dec. tears,
UO = 1-2cc/kg/hr flat fontanel,skin turgor & eyes normal, dec. urine output,
ANC = WBC X [ bands + seg ] inc. specific gravity,
100 NGT losses : D5 0.9%NaCl 250cc + 5meqKCl fluid deficit <50ml/kg
using conventional Replacevol/vol q2 LBM: < 4x
if you use SI x 1000, dont divide by 100
value: Hypovolemic shock Moderate 5-10%
>500/mm3: chemo Initial fluid resuscitation- 20 ml/ kg/bolus Some Signs of Dehydration
<500/mm3: stop/no chemo LR, 0.9NaCI or blood products
by rapid infusion until BP Inc. severity as above,
CML improves postural hypotension, elevated pulse,
Philadelphia chromosome: t (9:22) q (34:11) sunken fontanel, absent tears, sunken eyeballs,
Estimation of Rehydration Therapy inc. BUN,
1. Chronic: 2-4 years
 (Deficit + Maintenance) - Initial fluid resuscitation + deficit 50-100ml/kg
2. Aggressive: 6 mos
on-going losses LBM: 4-10x
3. Blastic Phase-not responsive to tx
Dx: leukocyte alk. phos  On going losses estimated at >5ml/kg body weight
leukocytosis shld be replaced immediately Severe >10%
massive splenomegaly  Two Choices for rate of delivery of rehydration
*splenomegaly is proportional to the WBC count - therapy delayed capillary refill >3sec,
splenectomy has no role in the tx.  slower: calculated volume equally delivered in acidosis, decreased HCO3,
Tx: 23h after the initial fluid resuscitation anuria, lethargy, irritability, skin tenting
a. bone marrow transplant to abolish Philadelphia chrom;  faster: LBM: >10x
use T-cell-depleted bone marrow 1st 7 hrs
b. interferon-60%hematologic response, <30%cytogenetic half the deficit + 1/3 of maintenance Estimating real body weight of a dehydrated pt
response next 16 hrs:

9
 x = . 100 .  further correction shld be continued during the Maximum k 40meqs/1V-central
Wt on admis I00 - %Dehydration next 24-48 hrs 0.5meqs/k/hr for every 0.6 k
For each 100mg/dl inc. in glucose., Na dec. by 1.6 meq/l Hypo K in respi alkalosis
HypoNa w/ inc. ECF & edema H+ goes out of cell,
low osmolality <280, nephrosis, CHF, cirrhosis, K+ goes inside cell
acute/chronic renal failure thus less K+ in blood
 Restrict water to 1/3-1/2 maintenance.
 No added salt HYPER KALEMIA
 Furosemide 1mkdose IV or 2-3 mkd PO ECG changes
ELECTROLYTE DEFICIT COMPUTATION  Peaked or Tented T wave: earliest sign; only in 20%
Na = Desired – Actual x 0.6 x kg wt  at higher than 8meq/l
 give 1/4 deficit over 10 min & - Absence of P wave
 remainder over 2h - Prolonged PR & widened QRS
 max 1 meq/k/hr HypoNa w/ Isovolemia - & subsequently Vent. Fib and asystole
 correct to Na 125, then remainder over 24-48h H2O intoxication, SIADH, hypothyroidism, renal failure,
 maintenance Na is 2 – 3 meq/k/d stress, drugs Therapy for hyperkalemia
 prep: 2.5 meq/cc  Furosemide AND 1. Calcium gluconate 10%(100mg/ml)
 0.9% NaCl w/ 20-40 meq KCl/L OR  inc. K conductance leading to inc. In phase 0
K = Desired - Actual x 0.4 x kg wt  use 3% NSS in severe hypoNa slope & amplitude
 lf K >2.5 : add 20 – 40 meq/L to IVF;  Restrict H2O 1/3-1/2 maintenance  increases calcium entry thrh calcium channels
o may give 1-4 meq/k/d as needed which inc. Contractility
HypoNa w/ hypovolemia
 lf K <2 : give 1 - 2 meq/k IV vomiting, diarrhea, 3rd space, diuretics, RTA, 2. Glucose+insulin
o max 1meq/k/hr (20meq/hr) ARF, partial obst., salt wasting etc.  movement of potassium into cells
 maintenance K = 2 - 3 meq/k/d  Give NSS 20-40ml/kg IV until adequate
 Prep: circulation 3. Na Bicarb.
o 2 meq/cc viaí  Calculate 24h fluid deficit:  same as 2
o KCl Elexir : 6.6 meq / 5ml  Give 1/2 over 8h, then rest x16h
o 10meq/ tab  0.9% NSS = 125meq/L 4.dialysis
o oral K (40meq=3g KCl)  Add K after void  start if K over 6.5mEq/l
o KCl elixir: 1-3meq/kg/d po  Usually D5NSS 60ml/kg IV over 2h (inc. Na  equipment for e-dialysis should be ready bec
by 10meq/L), of possible cardiac arrest refractory to
Cl = Desired - Actual x 0.45 x kg wt  then infuse at 6-8ml/k x 12 hri resuscitation (stone heart)

CORRECTION OF ACIDOSIS WITH HCO3 HYPERNATREMIA 5. Kayexalate = Na polystyrene sulfonate

HCO3 = wt x BE x 0.3 = meq NaHCO3 1. Give initial fluid resuscitation when in shock  ion exchange resin
or 2. When urine output is present or has been reestablished,  sorbitol:results in diarrhea & prevents bowel
(Ideal - Actual HCO3) x wt x 0.4 hypotonic fluids are given to bring Na to normal obstruction d/t inspissation of resin
(normal hydration shld be restored in 48 hrs!)  increases K GI loss
*Dolendo's  caution:vol overload if px's intravascular Vol is
 HCO3 = ( Desire – Actual ) X wt X 0.4 Recommended rate of reduction of serum Na is 10-15 high
 Give w/ equal cc of distilled water and mmol/L daily  1meq K / g resin
divide it by 2 for half correction  Volume to qive in 48 hrs  1g resin = 4.1meq Na
 Give 1/2 stat, then 1/4, 1/4 q 2-4 hrs  add deficit & maintenance needs (48 h) & this  equal milliequivalents of Na exchanged for K
 Give w/ equal amount of NSS represents fluid to give in 48h
 Glucose content- use 2-3 % to prevent possible 4 & 5 reduces total body potassium burden
Ca = Maintenance Ca = 100-200 mkd problems w/ hyperglycemia from arising later
 Prep: 100 mg/ml (10%Cagluc)  Na content- allow 80-I00 mmol/L for deficit fraction If less than 6.5 mmol/L w/ no ECG changes or only
 30-60mk (max 1g) slow IV/IO, of fluid & none for maintenance portion; resultant peaked T waves
 preferably over 1hr conc is usually 20-35mmol/L; use the conc of Na or  Decrease K intake
simply estimate it at 25 mmo  Discontinue drugs that dec renal K excretion (K
HYPOCALCEMIA  Potassium content: generally, the maximal safe sparing diuretics)
1. if the pt is symptomatic amount for IV ls about 40 mmol/L, this is to be given  Correct acidosis
 Ca gluc 10% (9.2 mg elemental Ca/ml) once child is urinating
 0.5-1.0 ml/kg IV bolus over 3-5min  Anion content- advised amt of Na plus K equals 60- If greater than 7.0,
 under cardiac monitoring; 75 mmol/L of cation; Na is given primarily as give therapies to move K into cells acutely, Three
 stop if HR<60/min chloride, depending on the degree of accompanying mechanlsms in the emergency treatment of hyper K:
acidosis. If desired, start w/ more base & change to
Maintenance Ca gluc 10% shld follow IV bolus once more chloride after 6-12, do not use HCO3 as base  Reverse membrane effects by incieasing threshold
symptums are relieved since Ca is to be added, use acetate or lactate along potential and allowing excitable cells to repolarize &
 dose: 100 mg elemental Ca/k/d added to the IV soln w/ the chloride fire a signal again
 oral Ca supplements:  Ca content: one ampule of 10% ca gluc for every o give 10% Ca gluc at 0.5-I.0 ml/K
o Ca lactate (13% Ca by 500ml of infusate o to be administered in 2-10 minIV
weight)  Transfer K into cells
o Ca gluconate (9% Ca by HYPOKALEMIA o NaHCO3, 1-2 mmol/K 10-30min IV
weight)  Mild hypokalemia in asymptomatic persons may not o Glucose-insulin 0.5-1.0 gm/K
o Ca chloride (21% Ca by require specific therapy.  u/k IV or SQ) in 15-30
weight)  Hypo K pts treated w/ digitalis shld be given K  min IV w/ insulin
supplements  Enhance renal excretion of K
ex. Oral Ca Sandoz  Since any of the derangements that occur w/ hypo K o Na polystyrene sulfonate (kayexalate)
0-3 y= 10-25 ml are not life-threatening, replacement can be 0.1gm/K
4-12y= 30-45 ml accomplished by tne oral route, done slowly (over  orally or per rectum
days) & started once urine flow is confirmed. Oral diluted
When Mg def is suspected or confirmed, give Mg : 0.25 replacement is the preferred method since it rarely  w/ 2-4 ml of sorbitol
mmol/k or 0.125 ml/k of 50% MgSO4 IM (1 gm of 50% causes hyper K if the pt Has normal renal fxn or10% dextrose per
MgSO4 contains 99 mg Mg or about 4 mmol)  if the K def is severe & is causing cardiac gram of resin
arrhythmias, rhabdomyolysis, extreme weakness w/  every4-6 his
2. If pt is asymptomatic quadriplegia, or respi distress, IV replacement is o NaCI 10-20 ml/k in 45-60 min
 oral Ca supplements shld be given necessary
 & pts admitted for work-up HYPOMAGNESIMIA
Guidelines on IV administration of K:  IV Mg replacement shld be avoided, when possible,
3. In all cases, milk should be changed to low PO4 milk  via a peripheral vein, esp.in small children bec of the possibility of inducing
(human or modified cow's milk) - no more than 40 mmol/L; higher dose hypotension
will produce local irritation to the vein  For children weighing 4-7 kg, a safe dose is 0.5ml of
Hypocalcemia stimulates release of PTH» increases renal  via a central vein: 50% MgSO4 (2 mmol Mg) may be used
conversion of vit D to active form - no more than 80.mmol/L;  Mild, asymptomatic hypo Mg (serum Mg of 0.5
- careful monitoring w/ ECG tracings mmol/L or greater) requires no treatment if the pt is
eating normally
Vitamin D stimulates calcium absorption in small  quantitative rate of repair: not > 0.2-0.3 mmol/K/hr
intestines, duodenum and early jejunum up to 1 mmol/K/hr
Average electrolyte content of the body fluids
HYPONATREMIA SOURCE Na K Cl HCO3 H
choice of K salt to administer
if Na <120 mmol/L w/ siqns & symptoms, insensible sweat I2 10 12 - -
 as KCl in the presence of alkalosis
 so correct at 125 (level at w/c symptoms are parotid, saliva 112 19 40 - -
 as KHCO3 in the presence of metabolic acidosis or stomach 60 10 130 - 60
relieved) its equivalent
 give hypertonic soln (3% or 5% saline in 4 sm intes, duoden 140 5 80 65 -
hrs) jeju,ileum 130 5 105 30 -
when hypo K results from simple transcellular shifts in bile 140 5 110 35 -
 formula = desired Na - actual Na x 0.6 x wt response to alkalosis w/o an accompanying K deficit, pancreas 140 5 55 90 -
 repeat measurements throughout the correction of the ph is all that is required colon 50 20 40 30 -
remaining time of therapy hypokalemia or diuretics may cause metabolic alkalosis diarrheic stools 50 20-30 50 30 -
when serum Na is safe(>125),

10
 FLUID & ELECTROLYTE IN SEVERLY  Highest conc of gluc that can be infused thru ----------------------------- x 100
MALNUTRITION a periph line is 12.5%; wt at p50 of ht at p50
 Low K stores even w/ normal serum K  If a more conc soln is required, insert a
 Low magnesium reserves even w/ normal serum central line; MALNUTRITION
Magnesium  If IV line can not be started, glucagon can be Marasmus:
 Low zinc levels given to infants with adequate glycogen - caloric def. & wt for age <60%
 Low serum Ca exclusively related to low serum stores (dose is 300 mcg/kg not to exceed 1.0 - max at 6-18 mos
proteins mg total, given SC or IM) - no edema, normal albumin
 High body & cellular Na despite low serum Na level - poor nitrogen retention
 Greater tendency for fluid retention *Persistent hypogly(p.250) - no fatty infiltration of liver
- slow response to dietary therapy during 1st 4 weeks
Supplemental electrolytes, minerals, & vitamins  Hypogly recurring over a period >7 days
 2 ml 50% MgSO4 (2 mmol/ml) IM once Weight & Height Estimate Kwashiorkor:
 elemental / 1 mg/kg/d - protein def.
Weight: - max at 12-48 mos
To replace fecal losses & to enhance repair & immune fxn Birth = 3000g - + edema with dec albumin
 Copper <6mo = mo x 600 + bw = g - + fatty infiltration of liver
o 0.2 - 0.6 mg/d (infant), 6-12mo = mo x 500 + bw =g - initial wt loss with loss of edema
o 1 - 2 mg/d (children & 1-6yr = 2n + 8 = kg
adolescents) to replace fecal losses 6-12yr = 7n - 5 = kg OSTEORIZED FEEDING
 Iron for anemic pts shld commence only on the 2 1.Total Caloric Requirement (TCR) = 100-120 calories/day
second week of illnesc when infection is better 2.CHON = 2-3 g/kg
controlled at a dose of 3 mg/k/d Height: 3.Compute for the calories:
Ht in cm = age in yr x 5 +80 CHON: 4 calories/g of CHON
 Vit A for the re-epithelialization of the intestine & Ht in inches = age in yr x 2 + 32 4.TRC - CHON = remaining calories for FATS and CHO
improvement of immune fxn At 1 yr = 30inches or 1.5 x 60% for CHO
o < 6 mos of age 50,000 IU length 40% for FATS
o 6 - l2 mos 100,000 IU 2 yr = 1/2 mature ht (boys) 5.Compute for TFR (based on the weight)
o > 1 yr 200,000 IU 3 yr = 3 feet tall 6.Compute for the concentration of OF
4 yr = 40 inches or 2x BL Conc. = TCR/TFR
 Folic acid 5 ug/k/d to promote migration of crypt 13 yr = 3 x BL *should not exceed 2 cal/cc
cells to.periphery Order:
CLASSIFICATION OF MALNUTRITION
>Give of in 4 or 6 divided feedings at X cc per feeding
>Dilute and make X cc banana/papaya based
GOMEZ >Strict aspiration precautions
Wt for age Status >Elevate head for 30 min after feeding
HYPOGLYCEMIA 91-100% N
 Plasma glucose <40-45mg/dl 76-90 1st degree malnu
 Symptoms: apnea, hypotonia, inadequate sucking 61-75 2nd degree
CALORIC REQUIREMENTS
reflex, irritability, irreg respi, poor sucking or feeding, 3-12 kg 110
<60 3rd degree
exag moro reflex, cyanosis, tremor, pallor, eye 13-18 kg 110
rolling, seizures, lethargy, changes in levels of 19-24 kg 90
consciousness, temp instability, and coma. 20-30 kg 80
 Approx 40%of infants of DM mothers have
hypoglycemia; throughout pregnancy these
mothers have fluctuating hyprglycemia that results in TOTAL PARENTERAL NUTRITION
fetal hypergly; this fetal hypergly induces pancreatic Requirements:
WATERLOW (Revised)
B cell hyperplasia which in turn results in CHON
hyperinsulinism; after deliv, hypernsulinism persists Neonates 2 - 2.5 g/kg/d
& hypogly results. Ht for age: stunting begin with 0.5 g/kg/d and inc. by 0.5-1 g/kg/d
 Normal glucose requirement is 6mg/kg/min N >95% Infant 1.5 - 2.5 g/kg/d
Mild 90-95 Children 1 - 2 g/kg/d
Differential diagnosis: Mod 80-90 for infants & children begin w/ 1g/k/d to a max of 3g/kg/d
A. Causes of transient hypogly Severe <80
 Perinatal stress 5% Aminosyn >
 Sepsis, esp Gram (-) Weight for ht: wasting 5/100 = gCHON/x
 Asphyxia / HIE N >90% X = cc of Aminosyn
 Hypothermia Mild 80-89
 Polycythemia Mod 70-79 Glucose:
 Shock Severe <70 TFR - cc of elec. = cc of D10W
 Infnt of a diabetic mother 6-8 mg/kg/min; can be slowly inc. to 12-15mg/kg/min
 Insuff amount of glucose administred WELLCOME Formula:
 Maternaldrugs % of glucose x rate (cc/h) x 0.167 = mg/kg/min
(terbutaline,ritodrine,chlorpropamide, or wt as% edema no edema weight (kg)
propanolol) 80-60 kwash undernut OR
B. Decreased glycogen stores <60 maras-kwas marasm (amt of glc/mL x Total fluids/ wt) + 60 = mg/kg/min
 IUGR
 Premature infants NUTRITION * Up to 12.5% peripherally
 Postmature infants Parameters: * Up to 25% centrally
C. Causes of recurrent or persistent hypoglycemia 1. Weight - acute insult Mg = 0.1cc/kg
 Hormone excess hypinsulinism diseases 2. Height - chronic insult Ca = 1cc/kg
(neonat p.247) 3. Head and chest circumference MVI = 1cc ANST > 6mos
 Hormone def dses (p. 248) 4. Skin fold thickness Trace elements = 0.5cc
 Hereditary defects in CHO metabolism(p.248) 5. Mid-arm circumference
 Hereditary defects in amino acid metab sample TPN
(p.248) Waterlowe Classification:
Wasting Please prepare the ff:
Initial labs for transient hypoglycemia Stunting D50W 60cc
1. Serum Glucose level normal > 90 > 95 Aminosyn % 80cc
2. CBC to rule out sepsis & polycythemia mild 80-89 90-95 NaCl 2cc
Studies for persistent hypogly (p.248) moderate 70-79 80-89 KCl 1cc
severe < 70 < 80 MgSO4 0.2cc
Management: *use weight for height 10% Ca gluc. 2cc
*Symptomatic hypoglycemia MVI 1cc
WFA: --------------------------------------------
if <25mg/dl, >90 no PEM 146.2cc
 Some would do early feeds, if term, in the first 75 - 90 mild
6-12h of life, and not high-risk; 60 - 75 moderate Sig: Add distilled water to make 300cc x 24h
 Recheck the gluc in 30-60min and < 60 severe Urine sugar test OD
 Start IV treatment only if the rpt RBS is still Refer if +2 or greater
low WFA: (PEM)
if 20-40mg/dl, and no risk factors and infant clinically Actual body weight preparations:
stable: --------------------------- x 100 aminosyn 10mg/100
 Early feeding wt D5W or formula can be I deal body weight NaCl 2mg/ml
given. KCl 2.5mg/ml
 RBS Q 30-60min until stable, then Q 4h HFA: (stunting) Ca Gluc 100mg13.5
 If glucose still low, IV should be started wt a Actual ht or length
GIR of 6. --------------------------- x 100 MILK FEEDING ESTIMATE
Ideal ht for age age in mos + 2
*Symptomatic hypoglycemia
 Always treat wt parenteral glucose WFH: (wasting) ex. 2mos+2= 4oz q 3
Actual wt applicable up to 6 mos

11
 III. Glucose
TCI - total mf in 24h /30 = oz Al100 LD : 250 ug somatostatin iv push
=oz x cal of milk/wt=cal/kg/day Probans
TFI = MF in 24hrs/wt then follow by
= TFI/kg/day Lactose intolerance : 3mg somatostatin in 250 D5W in 24hours

MVI & IRON 1. Primary - from birth CHILDHOOD PNEUMONIA

MVI - anytime bet 4-6 wks
IRON - 4-6 wks if life, or
double the birthweight(preterm),
8 wks of life (term)
start 0.15cc (preterm).
INTRALIPID
start at
. 0.5 g x wt
[ ] concentration( e.g. 10% or 20%)
if 0.5 give x 18 hours
if 1.0 qive x 24 hours
usually 0.5g/kg/day on day 1
1.0g/kg/day on day 2
2.0g/kg/day on day3
e.g. 2 kg baby
2 x 0.5g = 1.0 g
1g/0.1 =10 ml
*increased incidence of sepsis in px on intralipid !
MCT OIL
0.5 ml/4 oz milk formula = 21 cal/oz
1 ml/ 4 oz milk formula= 22 cal/oz
8.3 kcal/g, 7.7 cal/ml
2. Secondary - from diarrhea d/t erosion f villi ergo resulting Viral Pneumonia
to malabsorption  URTI precedes LRTI
ETEC  Aspiration of phlegm 2o to
only 1 which causes enteritis  Poor coughing mechanism
travellers diarrhea  Phlegm also contains bacteria
no pus cells in stool exam  (+) family members w/ URTI
treat w/ antibiotics  May cause afebrile pneumonia
 1 month to 1 year
. x 100 Giardia  Peak months: March - May
enteritis, only parasite that can cause pus  E/ : Measles, Adenovirus, Parainfluenza, RSV
cells  Laryngeal involvement ~ viral etiology.
 · Stridor, horseness
Chronic diarrhea  · Barking cough
1. Lactose free milk  WBC, ESR are normal
2. Parenteral -rest the stomach  CXR:
3.Questran -to bind cholestyramine to bind fat  Hyperinflation,
4. Give lactobacillus- to replace normal flora  Diffuse patchy ,multilobar densities,
Lactulose in constipation  Interstitial pattern
high concentrated form f sugar w/c acts as osmotic w/c
draws water in thus helping the child to move stools Community-Acquired Bacterial Pneumonia
Neonatal
Constipation  Early-onset sepsis ~ pneumonia (hallmark)
fleet enema ,  Etio:
duphalac 1 ml/kg tid for 1 week,  Early - E. coli
senokot 2-6 yrs 2.5 to 7.5 ml/day  Late - Kleb, Enterobacter
6-12 yrs 5-15 ml/day,  Others - Grp B Strep, Listeria,
bisacodyl supp, Pseudomonas aeur
toilet train  Tx: Ampicilin + Gentamycin
Mineral Oil not for less than 1yo;
15-30 ml

PROKINETICS
MILK FORMULA drugs that improve coordination or peristaltic activities and 1 month - 1 year
1 : 1 dilution promote movement thru the GI  80 % Strep. pneumoniae
latogen full T  H. influenzae far second
Nan Enfapro CLASSIFICATION  Staph. Aureus less frequently
Nestogen Prosobee 1. Cholinergic  In the Phils. 2nd most common cause
Enfamil Al110 - bethanecol  in < 1 y/o
Pelargon Enfalac 2. Substituted benzamides  Others: GABHS, B. pertussis
lactum Neo Lac - metoclopramidei cisapride  Tx:
Lactogen Alacta 3. Dompamide antagonists  Co –trimoxazole, Chloramphenicol,
- domperidone Cefuroxime, Cefaclor, Augmentin
1:2 Dilution 4. Macrolides
- erythro 1 year - 5 years old
Similac DM 50/40  90 % Strep. pneumoniae
Simlac Nursery USES  less common:
SMA Nutra 1. Gerd  H. influenzae (if not immunized w/ Hib)
S-26 Nutra 2. Gastroparesis (diabetic, post-op)  Non-typable Haemophilus
Bonna Olac 3. Non ulcer dyspepsia  Tx:
S-26 LBW Bearbrand 4. Chemotherapy induced emesis  Non-hospitalized:
Promil Alaska 5. Bile reflux gastritis o Co-trimoxazole + Ampicillin
Isomil 6. placement of feeding tubes
Complete Milk Food 7. IBS 2 mos - 5 y/o ( WHO)
similac Lactogen 8. Chronic severe constipation o Amoxicillin, Augmentin,
SMA Enflalac 9. Intestinal pseudo-obstruction Cefaclor, Erythromycin,
S6 Neolac 10. Intestinal manifestation of Connective Tissue Sulfisoxazole
Bonna Nido 6:8 diseases  Hospitalized:
Nestogen Klim 10:8 o Chloramphenicol, Cefuroxime,
BETHANECOL Ceftriaxone
Prematures  ester derivative of choline wtth direct cholinomimetic
Similac pm 60/40  action 5 - 15 years old
Pre Nan  binds to muscarinic cholinergic receptors E/ :
 increase gastric motility  Mycoplasma pneumoniae - most common
Enfalac PM
 GERD Doses = 0.1-0.3 mkd TID - QID  S. pneumoniae
S 26 LBW
Similac
METOCLOPRAMIDE Tx:
 procainamide w/o cardiå effects  Erythromycin, Clarithromycin, Amoxicillin,
Soya-Based
 enhanges AcH enhancing cholinergic tone resulting Penicillin, Cefaclor
Prosobee
Isomil inc gastric emptying
Nosocomial or Aspiration
Nursoy  better contraction of LES
 Mechanically ventilated
 crosses BBB
 Pts on prolonged broad spectrum Abx
Acidified  Not routinely recommended in GERD because of  Micro-aspiration GER, hiatal hernia, mentally
conflicting results incompetent
Pelargon
 promotes gastric emptying E/ :
 Dose 0.1-0.3mkd TID QID  Gram( - ) ~ E. coli, Kleb, Enterobacter,
Casein Based
Pseudomonas
Al 110 CISAPRIDE  Staph. Aureus
 Similar to metoclop but less dopaminergic/ direct  Anaerobes (if w/ teeth)~ Bacteroides, Peptococcus,
Goats Milk chokinergic effect Peptostrep, Fusobacterium
Dales Cuter  I : GERD. preterms gastroparesis dyspepsia CIPD Dx/ : Endotracheal asp GS/CS
Meyenberg constipation G/S: >50 WBC, < 20 epith/ LPF
 SE/ arrythmias Tx/ :
Hypoallergenic  Ceftazidime > Ceftriaxone, Cefotaxime
I. Sucrose DOMPERIDONE  Ticarcillin + Aminoglycoside
Isomil 1 : 2  Doesnt cross BBB but dose dependent  Oxacillin or Nafcillin for S. aureus
Nutramigen  acute and chronic vomiting  Clindamycin for anaerobic coverage
Propbee  chemotx induced vomiting
 delayed gastric emptying ATYPICAL PNEUMONIA
II. Dextromaltose  in GERD, combined with antacid Chlamydia
Olac  DOSE 0.3 mkd TID ac  < 3 months of age
Similac  afebrile pneumonia
Somatostatin for Gi bleeding  hx of apnea and conjunctivitis

12
 Wheezing, scattered rales , not tachypneic,  cavitation < 4 cm; concomitant lesions such as pneumonic
 CXR: patchy densities or consolidation, perihilar  compact lesion < 1/3 of hemithorax process)
adenopathy  diffused leson not > 1 hemithorax  (PA) blunting costophrenic angle (250 cc fluid)
 Labs: normal WBC 3. Far advanced ;
Tx :  cavitation > 4 cm - PH < 7.5, possible empyema
 Erythromycin x 2 weeks  lesions > 1 hemithoraox Exudate
 Clarithromycin Transudate
PPD INTERPRETATION CHON > 3 g/dl
Mycoplasma (+) BCG ≥10 mm <3 g/dl
 Most common cause of comm-acquired pneum from ( - ) BCG ≤ 5 mm Specific Gravity > 1.016 <
5 -15 yrs >5 yo 5 1.016
 Mild "walking" pneumonia Transparency Turbid Clear
 WBC : normal; ESR ~ mod. Elevated Accelerated BCG test pH Acidic
 Sx/ : LGF, cough, headache and malaise 24-48hr : induration N or basic
 CXR/ : peribronchial or patchy infil; 5th day : pustule LDH > 200
 looks worse than clinical appearance scab : in 2 – 3 wks <200
Tx/ : Erythromycin, Clarithromycin Pleural CHON > 0.5 < 0.5
PRIMARY COMPLEX Pleural LDH > 0.6
Opportunistic  not contagious < 0.6
Pneumocystis pneumoniae  localized adenitis WBC > 1000/mm3
 HIV (+) children and caused Most common cause of  w/or w/o X-ray proof <1000/mm3
death on HIV Pxs  if (-) X-ray findings, give 2 Rx x 6 months
 Sx : tachypnea, cough, fever  0 conversion -( +) tuberculin test Pleural Effusion admitting order
 ABGs : severe hypoxemia  must document TB X-ray,culture, aspirate Admit
 Labs: LDH > 600 or 3x normal Diet
 CXR : - diffuse interstitial infiltrates from TB CHEMOPROPHYLAXIS Monitor VS, I/O
- perihilar area spreading outwards Primary: IVF
 Dx: induced sputum for > 5 y/o 1. Newborn of infected mom Labs:
 Gommori stain (methenamine silver)  3 months initially; CXR PA Lat, lateral decubitus, US, Sputum AFB
Tx/ :  After 3 mos, if PPD ( - ) CBC, SMA 7, protein, albumin, ESR, UA
 TMP-SMX (20 mkday of TMP QID for 2-3 o d/c INH if infector treated
weeks) o give BCG Pleural fluid
 (±) steroid  if PPD ( + )  Tube 1
o Cont INH for 9 mos; o LDH, Protein, Amylase,
 abN CXR Triglycerides, Glucose,
TUBERCULOSIS o add 2 more drugs RIF & PZA o SG (red top 10 ml)
 Primary complex does not manifest w/ Respiratory o treat as disease  Tube 2
distress o Gram Stain, C/S, AFB, fungal
 High risk: exposure to adult w/ active TB 2. PPD - infants and children under 5 exposed to TB C/S,
 Suspect in child w/ persistent pneumonia, o wet mount (20-60 ml)
 CXR / : hilar adenopathy, mediastinal mass, Secondary:  Tube 3
pleural effusion, or calcified lesion 1. HIV infxn/person with risk factors for HIV - 12 months o Cell count and Differential
 Dx/ : ( + ) Family Hx, ( + ) PPD, 2. Recent Tuberculin conversion o (lav top 5-10 ml)
( + ) sputum or gastric AFB, with ( - )CXR - 9 months  Tube 4
( + ) sputum AFB from close adult 3. PPD (+) not due to BCG, o Cytology,
contact ( - ) CXR o antigen tests for S.pneumoniae,
and ( - ) benefit to previous TB chemo - 9 months H influenza
Notes: 4. PPD ( + ) with stable or healed parenchymal lesions o (heparinized 25-50 ml)
 Imipinem, Meropenem, Tazocin  Syringe - pH (2 mL, heparinized)
- drugs that can be used as monotx  Refer to Pulmonology
- covers Staph, Pseud, anaerobes Treatment Regimen for NB of TB mothers:
- step up to quinolone if these fails mother mantoux positive -> BCG Respiratory Failure Types
I. Hypoxemia, hypocapnea, gas exchange failure
 3rd Gen. Cephalosporins contagious at time of delivery -> II. Hypoxemia, hypercapnea, ventilatory failure
- add aminoglycosides w/c has good synergy w/  if she’s been tx for 2 wks
other ABX  Separation not necessary
in treating staph  Just give INH and
 Do cxr & PPD at 4-6 wks
 Most common cause of hypoxemia :
o Pneumococcus Repeat PPD at 3 mos, if mom adequately tx and baby
o Klebsiella asymptomatic then stop INH &do BCG
o Pneumocystis
hematogenous spread -> NONE Clinical Features of Pulmonary Edema:
 IVIG : 0.15 mg/kg - to prevent opportunistic I. Leaking Capillary Edema:
infxns  Separation not necessary 1. Early hypoxemia
 Tx mother with 4 drug regimen & do 2. Diffuse infiltrates
Classification of tuberculosis  Sputum C/S 3. ( - ) Kerley B lines, clear lung bases on
 Do CXR & BCG on infant and give INH / RIF CXR
Class I - TB Exposure depending on sensitivity of mom's sputum c/s 4. PCWP: < COP
 close contact w an infectious active TB 5. Clinical: sepsis, trauma
disease  Do PPD & CXR at 3 mos if mom adequately 6. setting : multiple organ failure
 Mantoux test ( - ) treated and baby asymptomatic, stop tx and
 ( - ) sxs / signs suggestive of TB give BCG II. Hydrostatic Edema:
 ( N ) chest radiograph 1. Late hypoxeimia
Class II - TB Infection hematogenous spread present -> 2. Patchy infiltrates
 Mantoux test ( + ) 3. ( + ) kerley B lines, perihilar promineces,
 w or w/o hx of exposure to infectious active  Tx as Congenital TB obscure lung base
TB  Separation not necessary 4. PCWP : > COP
 ( - ) sxs/signs suggestive of TB  Do cxr, ppd and gastric aspirate AFB smear 5. Clinical : acute MI, severe HPN
 ( N ) chest radiograph  Give INH, RIF, PZA & STREPTOMYCIN X 6. setting : renal failure
Class III - TB Disease 2 mos and INH & RIF
Based on at least 3 of the ff: X 6 mos  CXR : Cloudy,
 ( + ) exposure to an infectious active TB  and there is hypoxemia , decrease O2 sat because
disease PROPHYLAXIS FOR TB (Jalandoni) the patology is in the interstitial, and may lead into
 ( + ) Mantoux test INH : 10 - 20 mg/kg for 9 mos ARDS.
 ( + ) sxs/signs suggestive of TB : 20 - 40 2 x a week for 9 mos  Causes of pulmo edema
 ( abN ) chest radiograph suggestive of TB o CARDIO
 laboratory findings suggestive of TB RIF : 10-20 mg/kg x 9 mos  Tx/ inotropic
(histological, cyotogical, biochemical,  if inc sys vascular
immunological, and/or mplecular) RIF : 10-20 mg/kg + PZA 50 mg/kg daily x 2 resistence ;
Class IV - TB Inactive mos Tx./ Na Nitroprusside
 ( + ) Mantoux test or 2x a week x 3 mos  PULMO
 ( + ) Radiographic evidence of o Ventilatory support
healed/calcified TB lesions PLEURAL EFFUSION o if high pressures, Tx./
 ( - ) Sxs / signs suggestive of TB Pleural Effusion: sedation
 w or w/o hx of previous TB - contralateral shifting of mediastinal structures  HEPATIC
 w or w/o hx of previos TB chemotherapy - egophony at air fluid level o Due to dec oncotic press;
- CXR: o Tx./ albumin or Lasix
CXR findings in PTB:  Lateral (75 cc fluid), decubitus (5 cc, if > 1 cm, o give albumin at 0.5-1
1. Minimal Koch's ; pleural tap) needed to show fluid is free gm/kg; 20% albumin
 one lobe involved not occupying > 2 ICS flowing (check for layering & presence of  NEURO
2. Moderate ;  RENAL

13
 o Tx./ Diuretic or Dialysis 0.5 ml /kg of 1 : 1000 sol diluted in 3 ml ;
Terbutaline max dose ;
Pleural Effusion: 0.01 mk (max 0.4mg) SQ repeat in 20 min x 3 doses or q <4 yo : 2.5 ml/kg,
1. Retraction, Contralateral shift, Widened 2-6 prn >4 yo : 5 ml/dose
ICS, OR
Lagging 2 mcg/kg IV over 5 min (LD) then 2 mcg/kg/h continuous Acute Tonsilo Pharingitis
2. Decreased Fremitus infusion, may titrate up to 6 mcg/kg/h Viral:
3. Decreased Breath Sounds  Coxsackie B-Herpangina, vesicular lesions
4. CXR : Ground glass appearance, o2 sat Metered Dose Inhalers posterior pharynx
(n) Ventolin :  Adenovirus
because the patology is outside the lung 2 puffs 1-2 min apart q1-6h w/ spacer and mask  Herpes- anterior pharynx
Consolidation  EBV
1. Lagging Beclomethasone Bacterial:
2. Increased Fremitus 1-2 puffs qid or 4 puffs bid (max of 16puffs/d)  Group A ß hemolytic Strep
3. Increased Breath Sounds w/ spacer and mask, 5min after bronchodilator, followed by Strep score (4/6):
Atelectasis gargling w/ water  Beefy red + exudates
1. Retractions, Ipsilateral shift, Narrowing ICS,  Fever
Lagging Cromolyn sodium  Large ant. cervical nodes (CLAD (+))
2. Decreased Palpation 2-4 puffs qid-tid or powder20mg/cap bid-qid  Age group
3. Decreased to Absent Breath Sounds or  No viral sx-colds,watery eyes,
nebulized 1% solution 1 amp (2ml, 20mg) q6  Seasonal
ASTHMA
ASTMA DRUGS ORAL ß2 agonists Complication of GABS:
Nebulized ß2 agonists <4 y/o: suppurative sx
Ventolin  Peritonsillar abscess
Ventolin 0.1-0.2 mkdose (max 2mg <12y)PO q6-8  Adenitis
0.01-0.03 cc/kg (max 1cc) in 2cc NSS Q1 - 2 & prn  Otitis media
OR Considerations for asthma in infants >4 y/o:
0.05-0.15 mg/kg (max 5 mg) in 2 cc NSS Q1 - 2  Use steroids early in the episode  AGN
OR  Monitor O2 sat by pulse oximetry O2 sat > 95%  Rheumatic fever
0.03 cc/kg (0.05 mg/kg) Q 20 min until improvement  Assess infants for serious distress :
o use of resp ms, paradoxical breathing, entero - extremities
Terbutaline Cyanosis, a resp rate > 60 or O2 sat < echo - only in trunk
0.25-1 cc (0.2-0.3 mg/kg, max 10 mg) in 2 cc NSS q1-2 or 91%
nebulized continuously  Assess response to therapy Acute Nasopharyngitis:
0.05/m/k/dose tid (max 0.15mg)  A lack of response to tx noted on PE or O2 sat is
prep:0.3mg/ml syh indication for hospitlization  cut off 10 days
Oral steroids in asthma  Pneumococcus, Haemophilus, Neisseria
INHALED STERIODS  3 - 10 day course of steroids at discharge is useful
 For px who take oral steroids long-term give PERTUSSIS
Fluticasone supplemental doses even if exacerbation is mild  Catarrhal
nebule 500mcg/2ml  In infants & children give oral steroids early in the  Paroxysmal
course of the exacerbation  Convalescent
Methylprednisolone (Solu-Medrol)  Oral prednisone is usually preferred to iv
1-2 mkdose (IV /PO) Q 6 x 4 - 8 doses (24-48h) methylprednisolone because it is less invasive & the Cx: superinfxn of lungs or middle ear
then effects are equivalent Mgt:
1 mk IV q6 OR 1-2 mkday  NPO
RISK FACTORS FOR ASTHMA  fluids
Prednisolone  History of asthma  Erythromycin 40-50 mkd q6
1 - 2 mkdose (PO) Q 6 x 48-72h  Higher serum IgE levels  O2
then  Eosinophilia  possible intubation
1 - 2 mkd (PO) QD - BID (5mg/mL) Major Criteria  hyperimmuneglobulin
 3 episodes of wheezing during the previous 6
Prednisone mos  Charac. cough - whoop, cyanosis, vomiting
1 - 2 mkdose (PO) Q 6 x 48 - 72h  Hospitalization for lower airway obstruction
then1-2 mkd PO QD-BID  Parental hx of asthma  Labs :
 Atopic dermatitis  CBC - absolute lymphocytosis¡ may be
Hydrocortisone Minor criteria negative in not well dev. immune system,
4 - 6 mk (IV) Q6  Rhinorrhea apart from colds DPT imm'n, concom. bact infxn
followed by (PO)steroids Solu Cortef 10 - 20mkd q6  5 circulating eosinophils  CXR - no infiltrates
 Wheezing apart from colds
 Male gender

2 major or 1 of the first 2 major or 2 minor criteria merits a

therapeutic trial of anti-inflammatories CERVICAL ADENITIS
Aminophylline & Theophylline BACTERIAL ADENITIS
NOCTURNAL COUGH - Grp A strep and staph
Aminophylline 1. Pertussis - Acute course
LD : 5 - 6 mk in D5 1/4 NSS IV over 20-30 mins 2. Asthma - with overlying erythema
( 1 mk of aminophylline will raise levels by 2 ug/mL) 2 pm - inc adrenals - Tx/ Augmentin
Maintenance dose 10 mkd 2 am - dec adrenals - staph. Strep anaerobes
3. Croup - inspiratory cough due to dec humidity
1 - 6 mo 0.5 mkh TB ADENITIS
6 - 12 mo 0.6 mkh LARYNGOTRACHEOBRONCHITIS - Treat TB disease to prevent reactivation, if
1 - 10 yo 1 mkh  Steam inhalation 10 - 15 mins TID isolated, no other symptoms
10 - 16 yo 0.75 - 0.9 mkh  Solucortef / Prednisone - Next most common site of TB
>16 yo 0.7 mkh - Tx/ : same as PTB
Allergic Rhinitis - Dx : PPD history exposure
Side Drip D5W 250cc down 20 ml + Aminophiline _ mg to - Chronically enlarged LN not responding to Abx
Claritin ( Loratidine)
run for 30min Q6 > 12 yo 2 tsp OD CAT SCRATCH
2 - 12 yo (> 30 kg) 2 tsp OD - Chronic progressive cervical adenitis
Theophiyline 2.- 12 yo (< 30 kg) 1 tsp OD
Theophylline (PO) LD : 6 mk - Curved Gram (-) Bacill
Maintenance of 80% of total daily maintenance IV - E/ : Rochalamea Quintana
Celestamine Rochalamea Henselae
aminophylline in 2-4 doses/day (empirical TID) 6-12 yo ½ tsp tid
1 - 6 mo 9.6 mkd theophylline - usually from a kitten, not adult cat
2 -6 yo ¼ - ½ tsp tid
6 - 12 mo 11.5 - 14.4 mkd
1 - 10 yo 19.2 mkd CHRONIC GRANULOMATOUS DISEASE
Citirizine - Repeated Pyodermas and lymphadenitis, and
10-16 yo 14.4 - 17.3 mkd
>16 y 10 mkd Systemic illness
Acute bronchitis - Diffuse lymphadenopathy with
Theo-Dur (100,200,300,450 tab - do not crush)
harsh breath sounds w/ prolonged expiratory phase hepatosplenomeqaly
Parenteral ß2 agonists - Candida antigen skin test (+), if T cell is
Croup decreased
Epinephrine prolonged inspiratory phase - Skin and LN, then deeper infxns
0.01 ml/kg SQ up to 3 doses inspiratory wheezing - Nitro Blue Tetrazolium Test
( 1mg/mL, 1:1000) - WBC normal quantitatively but quality is abnormal
( max 0.5 mg/dose) Epinephrine - No treatment
0.01 ml/kg/dose SC (max single dose 0.5 ml)
Isoproterenol Rpt Q 15 mins x 3-4 doses or q4 prn MEASLES
0.1 mcg/kg/min IV infusion  IP: 10-12 days
inc by 0.1mcg/kg/min until improvement or PR >180 Epinephrine Nebulization:  Contagious : 4 days before & after rash

14
 Sx: fever coryza conjunctivitis cough kopliks rash 3. DHF - extrameningeal infection
diarrhea LN - Thrombocytopenia < 100,000 - periorbital cellulitis-Hib
 SE: OM, laryngitis, pneumonia, SSPE, Enceph - Hemoconcentration - chronic otitis media
myocarditis Reactivation TB - GRADE I - sinusitis
 Tx: o Fever + non-spec constitutional - head injuries/csf leaks
 Vit A sx Treatment
o 100,000 iu < 12 mos. o (+) TT - Neonatal period (empiric)
o 200, 000 iu > 12 mos - 5 yrs - GRADE II - Meropenem,
 Exposed persons o Spot bleeding-skin and/or other - Cefepime
o Immunoglobulin 0.25 ml/kg IM within hges
5 days after exposure SEPSIS
o Vaccination after 3 mos - GRADE III wbc less than 5,000 or more than 30t
o Immunoglobulin 0.5 ml/kg (max l5 ml) if o Circulatory failure manifested by
immunocompromised rapid and weak pulse Monroe signs of sepsis
o Narrow pulse pressure (20 1. Bands / Neutrophil Ratio > 0.2
RUBELLA mmHg)
 IP : 14-21 days o Hypotension 2. Ab(N) Stab count >1000
 PC : 7 days before and after rash o Cold clammy ext
 Sx: gen LN, conjunctivitis, coryza, Rash, LGF, o Restlessness WBC ct x bands x 1000
Polyarthralgia, Polyarthritis - GRADE IV
o Profound shock with 3. Total neutrophil count >12000
ROSEOLA undetectable BP and pulse
 Aqe 6 mos - 24 mos, (rare < 3 mos and > 4 yo) WBC ct x (bands + neutrophils)
 IP 5 to 15 days DHF 1000
 Sx HGF x 3 days then rash on trunk, puffy eyelids, - Monitor VS q__include BP
vesicular eruption mouth, bulging fontanelles, - NPO temporarily Monitor VSq1 and record
red tympanic Membrane, good activity. - Insert NGT and drain to BSB NPO temporarily
- Request for: I&O, daily wts., monitor for apnea, consent for LP
OTITIS MEDIA o CBC O2 mask at 5 LPM
 Sx: otalgia, TM-red, no liqht reflex , bulging, purulent o Quantitative platelet Place inside isolette at 36-36.5 C
discharge, dec. hearing, fever, tinnitus o CXR Insert NGT and aspirate gently q 2
 Tx: o ECG Replace NGT losses w/ D5 0.9% NaCl 500 cc + 5meq KCl
 Amoxicillin 40 mg/kg/d q8 x 10d - IVF: D5NR 500cc x__alt. w/ D5 0.3%NaCl 500cc q 12
 Co-trimoxazole 8-10 mkd (TMP)Q12 x - Transfuse__cc FWB Standby laryngoscope
10days - Tranexamic acid 250mg IV Q6
 Erytromycin + Sulfisox : 40 mkd (Ery) Q 6 x - Gastric lavage q6 using ice water Meds: (See meningitis)
10days - Cimetidine 20-40mk IVq8
 Cefaclor 40 mkd Q8x - Solucortef 4-6 mg/k IV q6 (no loading dose Infant 1-3 mos
10days needed) E/ H. influenza, pneumococci, meningococci, Grp B strep
 Cefuroxime 40 mkd Q12 o steroids: 0.6 mg/k for 24hrs- - Ampicillin 100 mkd IV q6
x 10days dr. C And either :
 Co-amox 40 mkd Q8 x - Decadron 0.2 - 0.8 mk IV q8 1. Cefotaxime 100 mkd IV q6 OR
10days - Opigesic suppositories: 2. Ceftriaxone 50-75 mkd IV/IM q12-24
o < 6mos : 1/4-1/3
 Ear drops not effective o 6 mos - 1yr : 1/2 Children 3mos-18yrs
 Decongestants. - no value o 1 - 3 yo : 1 E/ Strep. pneumonia. H.influenza, N. meningitides
 Na bicarbonate w glycerine-cerumenolytic all TID/QID
 Dry ear w/ wick - If platelets are decreased: Prepare and transfuse - Cefotaxime 100mkd q6 OR
 Recurrent - Amox 20 mkd OD HS 3U platelet conc. - Ceftriaxone 50 – 75 mkd IV/IM q12-24 OR
 Chronic w/eff. Hydration (DOH) - Cefuroxime 75 -100 mkd IV q8, max 9g/d
o Check underlyinq cause : 5-7cc/kg OR
o Sinusitis, UR allerqy, NP tumor 3-5cc/kg - Ceftazidime 100 -150 mkd IV q8
o Antibiotics-.co-amox 10cc/kg-hemaxel
Neutropenic patients
MUMPS Tetanus Neonatorum E/ Gram negative, Pseudomonas, Staph, viridans
IP : 12 - 25 days Tetanus disease does not confer immunity - shld still give - Ticarcillin 200 -300 mkd of ticarcillin IV q4-6
CP : 7 days before and until 9 days after parotid active immunization OR
swelling - Ceftazidime 100 -150 mkd IV q8 AND
Sx : HGF, HA, anorexia, malaise, swelling DOC - Metronidazole 30mkday, not PenG anymore bec - Tobra/Genta AND
Pen can be an agonist in the spasms already present - Vancomycin (if central line) 40mkd IV q6, max
2g/day
Hepa profile
- HBsAg (active hep B) Xtras/XR: CXR, PPD
- Anti HBs (immunity to hep B) Labs : CBC, SMA 7, Blood C/S, UA, urine C/S, ESR, (see
- Anti HBc IgM (active hep B) meningitis)
RBS, Blood type, Rh, Fractionated bili, ABG, serum Na, K,
- Anti HAV IgM (active hep A) Stool C/S
- Anti Delta
- HBV-DNA 1. Breakthrough Sepsis
- Imipinem 50mg/kq/day IV/IM QI2
Hepatitis B(Tupasi) - Pip-.Tazo 100-200 mg/kq/day
DENGUE - Chronic type acquire infxn perinatally or early in - Cipro 20-40 mg/kq/day q12
- RNA arbovirus life(90%)
- Flaviviridae - Adult more symptomatic 2. if b c/s no growth
- Female Aedes aegypti - Prevn:vaccination - ampi 7 days
- Baby of infected mom should get vaccine in 12 hrs - amik 5 days
Pathogenesis
1. Inc capillary fragility brought about by a strong immune
complex rxn similar to anaphylactoid rxns that produce toxic HIV
substances like histamine, serotonins, and bradykinin which - Vertical transmission occur intrauterine in 70%
damage capillary walls - Maternal oral tx antepartum DIARRHEA
2. Thrombocytopenia due to faulty maturation of the - Maternal lV tx intrapartum Infancy : rotavirus, adeno, norwalk
megakaryocyte, acute excessive consumption of platelets - Baby oral tx for 6 wks
due to generalized intravascular clotting - Deliver by elective CS AMEBIASIS
3. Decreased blood coag factors esp fibrinogen and II, V, 1. Asx:
VII, X FUO - most common cyst passers
Causes of fever > 3 weeks - Tx : Diloxanide furoate 20mkday Q8 x 10days
CLINICAL MANIFESTATIONS - Sinusitis, (max 1.5g)
1. Undifferentiated fever (viral syndrome) - Mononucleosis, 2. Intestinal
- mild febrile illness with a maculpapular rash - Extrapulmonal TB, Non-dys
2. Dengue fever syndrome - JRA, Lupus - Sx: Acute LBM w/cramping, vague abd pain, abd
- Abrupt fever (39-40) - Enteric distention, flatulence, constipation or loose stools,
- Headache Naproxen Test : Dys
- Retroorbital pain - To rule out Lymphona - Sx recurrent LBM bloody mucoid,cramps,
- Muscle and joint pains - fever should lyse in 72 hrs tenesmus,fever, chills (LG)
- Rash - if fever lyses : non infectious or rheumatologic
- Flushed and acutely ill - if fever continue : Occult infxn Tx: Metro 50mkdy q8 x 10days (max. 2.25g)
- Conjunctival injection plus Dilox furoate
- Anorexia, vomiting, abd pain Bacterial Meningitis-dr. Garcia Ameboma
- (+) tourniquet test impt factors to deveLop meningitis . Amoebic Appendicitis
- Petechiae - age
- Hermans rash - bacteremia 3. Extraintestinal

15
 - Hepatic, Pulmonary, Pericardial o RDS
- Tx same as intestinal o Meconium aspiration
ERYTHROCYTE SEDIMENTATION RATE(ESR) Goals of Management:
Shigella - Chronic inflammation 1. Restoration of fluid volume
- Sx: acute HGF, stools w/blood mucus, tenesmus - Rate of fall in tube system/hr a. Fluid push 10-20 mL/kg NS or LR
(enteroinvasion → inflame → tissue damage → - Increased :
dec in absorption → rapid transit ) o Acute or chronic inflammation, b. Volume deficit:
- Tx: o Malignancy, infants <2y 5% wt loss – 50mL/kg
- Cotrimoxazole o Rheumatoid collagen disease, 10% wt loss – 100
o can be used at 1 month, but o Abnormal serum protein, 15% wt loss – 150
below that causes hemolysis, o Stress children 3% - 30mL/kg
o good for virgin cases. o Anemia falsely increases ESR 6% - 60
- if no improvment after 2 days - Disadvantages: 9% - 90
Nalidixic 55 mg/k/day Q 6 x 5 days, 1. normal in some diseases when it is abnormal
o >3 mos only, 2. nonspecific c. Maintenance fluid requirement
o (old Quino) 3. technical error (vertical tube) 0-10 kg 100 mL/kg
o inhibits DNA plymerase, 11-20 kg 50
o S/E - seizure Bacterial infection: > 30 ESR >20 20
a. Give 2x maintenance + deficit over 48hrs
Giardiasis DKA
- Only enteritis that produced pus in the stool exam. Dr. CAMPOS e. Don’t overhydrate to avoid cerebral edema
- Affects dodenum and small intestines - State of ketoacidosis with serum HCO3 <15 and pH <7.3
- Chronic diarrhea more than 2 to 3wks - mild 7.2-7.29 2. Inhibition of lipolysis and restoration of glucose
- moderate 7.1-7.19 utilization
Antimicrobial Bacterial Enteropathogens - severe <7.1 - SQ insulin if pH >7.2
Organism Antimicrobial - Lack of insulin and excess of counter-regulatory - Low dose continuous IV insulin if pH <7.2
Indication hormones - If the patient is dehydrated, it is useless to administer
Aeromonas TMP/SMZ - Usually triggered by non-compliance with meds, infxn or insulin
Dysentry-like drugs because it will not perfuse
- Half-life of insulin is 3 min.
Illness, PATHOPHYSIOLOGY - Insulin solution: 250 U R insulin in 250mL of NS (1:1)
Destruction of B-cell -> cant produce insulin -> glucose cant pH 6.9-7.2 => 0.1 U/kg/hr
Prolonged go intracellularly -> intracellular starvation -> release of pH 7.2-7.3 (mildly acidotic) => 0.05 U/kg/hr if known IDDM
counter-reg hormones (epi, norepi, cortisol, GH),-> inc glu - => 0.025U/kg/hr if new-onset
diarrhea > gluconeogenesis from breakdown of fats -> inc ketoacids IDDM
Campylobacter Erythromycin Early in the *should flush tubings with the insulin solution!
Azithromycin SYMPTOMS *administer through a separate syringe pump
course - Thirst, polyuria, fatigue, wt loss, anorexia, abd pain,
cramps 3. Replacement of Body salts
of illness A. Sodium
C. difficile Metronidazole mod SIGNS  1.6mmol/L decrease in sNa for every 100mg/dL rise
to severe - Hyperventilation, dehydration, tachycardia, hypotension, in blood sugar above 100mg/dL
Vancomycin warm dry skin, hypothermia, altered mental state, ketonuria  As blood sugar normalizes, sNa should rise; sudden
disease drop in sNa may lead to cerebral edema
ETEC TMP/SMZ LABS  Calculate Na deficit – will usually need 100-120
severe or - Blood sugar > 200 mEq/L of Na
- Ketonemia, ketonuria++
prolonged - Dec insulin, pH and HCO3 B. Potassium
- Variable proteinuria  Hypokalemia can cause arrythmias and death
disease - K may be high or low  Rarely need >40mEq/L of K
EPEC TMP/SMZ - Leucocytosis (could be from infxn or demargination effect)  Supplement only if K <6 and urine output has been
nursery established
PRIORITY LABS  As acidosis corrects, K will drop further
epidemics, life - pH, BS, BUN, Crea, ketones,
- Na - may be decreased because glucagon interferes with 4. Correction of Acidosis
threatening Na reabsorption a. Hydration – with restoration of fluid volume, lactate
- K - may be decreased because it is excreted to accumulation decreases
illness decrease acidosis b. Insulin therapy – inhibits ketone acid production
EIEC TMP/SMZ all c. Monitor venous pH (VBG is enough)
cases if org is HOME MX OF DKA d. HCO3 therapy – do only for pH <7.0; give 1-2mEg/Kg
- If RBS >200 and with ketonuria, call AMD over 1-2 hrs in IVF (do not exceed 1 ampule)
susceptible - Need to give extra insulin, about 10-15% of total insulin • a rapid fall in pH leads to severe hypokalemia
Salmonella Cefotaxime infants < 3mo, requirement as short
Ceftriaxone acting LABS to request for:
Typhoid fever, - look for cause of DKA Venous pH
Ampicillin - Take small sips of sugar free fluid Blood sugar
bacteremia, - If with vomiting -> ER CBC
Chloramph Na, K
Dissemination w HOSPITAL MANAGEMENT Insulin level
TMP/SMZ - Restore fluid volume Glycosylated Hgb
Localized - Inhibition of lipolysis and proteolysis and restoration of
glucose utilization Blood sugar, K+, state of hydration – determinants of what
suppuration - Replacement of body salts kind of fluid to use for hyration
Shigella Ampicillin all - Correction of acidosis
cases if org is K correction can be given in 3 forms: ex. 40 mEq K+
Ciprofloxacin RESTORATION OF BODY FLUIDS needed, can be divided into:
susceptible - assess hydration status 10 mEq KCl – to prevent hyperchloremia
Ofloxacin - give fluid push : 10-20 ml/kg NS or LR 20 mEq KPO4 – to prevent hypocalcemia
Ceftriaxone - calculate volume deficit 10 mEq K acetate – a good buffer
V. cholera Doxocycline all cases infants <2 mild 5% 50 ml/kg
Tetracycline mod 10% 100 Ex. 68 kg patient – wt loss to 60kg
sev 15% 150 A. fluid push 10-20mL/kg
C-REACTIVE PROTEIN(CRP) B. Deficit volume 9%: 90mL x 68kg = 6120 mL
§ Glycoprotein produced during children mild 3% 30 ml/kg C. Maintenance volume 2460mL/day x 2 = 4920 mL
inflammation and tissue mod 6% 60
destruction sev 9% 90 6120 = 4920 = 11040 mL in 48hr
§ Increases in 4-6 hours after onset - calculate maintenance fluid reqt (parklands) = 230cc/hr
§ not affected by anemia - qive maintenance fluid (2 days) and deficit evenly
§ acute inflammation over 48 hrs EG. Management of DKA
(MARLON MALAPITAN'S HYDRATION)
Bacterial infection: (+) CRP Dra. Estrada
- More superior to other acute phase reactants coz 1. Rehidration :
faster Maintenance = wt x TFR
- After onset of inflammation, = wt x 75
- CRP increases wtin 4-6h, deficit[50-100] = wt x 100 =*
- Doubling every 8 h, and
- Peaks at about 36 - 50h. *total for 24 hours
- Levels remain elevated with ongoing inflammation  1/2 in 8hrs , 0.9 NaCl, ( but can be push to
- But wt resolution of inflamm, CRP decline rapidly 20cc/kg in 2 hrs. using 0.9NaCl)
due to a short T ½ : 4 – 7 hours  1/4 in 8hrs , 0.45 NaCl
- Also elevated in non-infectious cases:  1/4 in 8hrs , 0.3 NaCl
o Fetal hypoxia 2. Don’t push Bicarbonat

16
3. Monitor RBS Q1
Ideal RBS 80 – 180mg/dl
4. ABG Q 4
INSULIN DRIP
0.1u/k (ex wt 10kg)
then 1 u x 24h
so 24units + 25cc dist water
Insulin
1. persistent hyperglycemia
2. metabolic acidosis

insulin infusion
0.1u/kg/hr x24 hrs

ex. 10kg x 0.1/kg/hr x 24 =24 u

prepare

DIABETIC KETO ACIDOSIS

Diagnostic criteria:
1.hyperglycemia-bld gluc levels of 300 mg/dI or more
2. Ketonemia or ketonuria
3. Acidosis: PH < 7.3 & HCO3 < 15 mmol/L

Management: Fluid Therapy

 Administer loading dose of 10-20 ml/k of 0.9% NaCI,
Repeat loading dose twice if necessary for shock.
 Acidosis is usualy corrected by more rehydration &
insulin therapy;
However may start HCO3 correction if less than 7.1
& HCO3 is less than 15mmol/L.; give half-correction
of the HCO3 very slowly (at least in 1 hr)
 Next, infuse fluid as maintence + deficit over 24-36
hrs (subtracting the initial fluid dose from the deficit)
as 0.45% NaCl. Add 5% gluc to IV infusion when
blood sugar is less than 300 mg/dl; shift to 10% gluc
lf the patient is still acidotic but whose blood sugar is
less than 200 mg/dl

Management: Insulin therapy

 Priming dose of 0.1 u/k regular insulin IV

 One hr after prlming dose, start continuous IV

infusion of reg Insulin at 0.1 u/k/h to be prepared as
follows:
o add 10 u of reg insulin to 100ml of
PNSS
o flush 20-30 ml through the tubing to
saturate insulin binding sites
o run at rate/hr equiv to the pt's weight
(eg. a pt weighing 20 kg will receive the
infusion rate of 20ml/ hr

 Close monitoring of v/s, state of consciousness,

serum glucose & urine ketones is essential until IV
phase of therapy is terminated.

SIADH (Nelson)
- decreased serum sodium, when <110meq/L stupor or
convulsive
seizures may occur
- serum is hypoosmolar, but urine is less than maximally
dilute
- hypouricemia w/ hyponatremia - a clue to dx in neonates
- tx : restriction of fluids
: hypertonic saline-of little benefit bec even large
sodium
loads are excreted in the urine
: furosemide w/ 300mL/m2 of 1.5%NaCl causes a rise
in
sodium & diuresis

17
 BILIRUBIN LEVELS
Weight Well infant Non-physiologic jaundice
Photo Exch § Unconjugated bilirubin >12.9 mg/dL in term infant
<1500 5- 8 13 - 16 DIRECT HYPERBILIRUBINEMIA § Unconjugated bilirubin level >15mg/dL in preterm
1500-2000 8 - 12 16 - 18 - direct/conjugated § Bilirubin level increasing at a rate >5 mg/dL/day
2000-2500 12 - 15 18 - 20 - a value >2mg/dL OR § Jundice in the first 24 hours of life
>2500 see other table a fraction>10-15% of the total bili § Conjugated bilirubin level > 2 mg/dL
§ Clinical jaundice persisting > 1 week in full-term infants of
Weight Sick infant Immed considerations: > 2 weeks in preterm infants
Photo Exch 1. TPN - if more than 2 wks
<1500 4- 7 10 - 14 2. BACTERIAL OR VIRAL INFEC Full term
1500-2000 7 - 10 14 - 16 - may cause hepatocellular damage, leading to § Unconjugated bili rises to a mean peak of 5-6 mg/dL by
2000-2500 10 - 12 16 - 18 increase direct bilirubin 3rdDOL(Asians: 10-14 mg/dL at 3-4 days)
>2500 13 - 15 17 - 20 3. After feedings - e.g. galactosemia
4. Associated risk factors: Preterm
*weight in grams and bilirubin levels in mg/dL - prematurity § liver function is less mature and jaundice is more frequent
- lack of enteral feeding ant pronounced
Age Consider photo Photo - sepsis (can be asso w/ an increase of 30% in § peaks 10-12 mg/dL by 5th DOL
= 24 -- -- the bili level)
25-48 12 (170) 15 (220) PHYSIOLOGIC JAUNDICE Exclusion critera
49-72 15 (260) 18 (310) Diff diagnosis:
>72 17 (290) 20 (340)  Unconj bili >12.9 in term
-Idiopathic neonatal hepatitis,
 Unconj bili >15 in preterm
-Biliary atresia
Age Exch transf Exch transf  Bili level increasing at a rate >5mg/dl/day
-Hyperalimentation
if intnsve photo fails & intensive photo -Bacterial infection  Conj bili >2mg/dl
-TORCH  Jaundice after the first 24h
= 24 -- -- -Inspissated bile  Clinical jaundice persisting
25-48 20 (340) 25 (430) -Choledochal cyst  1wk in term,
49-72 25 (430) 30 (510) -Galactosemia  2wks in preterm
>72 25 (430) 30 (510) -Alpha 1 anti trypsin def
 Full term - peaks at 3-4d
*age in hours of life and bilirubin levels in mg/dL (?mol/L) Clinical hallmarks:  Preterm - peaks at 5th d due liver less mature,
-Icterus Jaundice more pronounced & frequent
KRAMER SCORING -Acholic stools  mechanism - incr bili load bec of the larger RBC
l - face & neck 6 - 8 -Dark urine volume, shorter life span of RBC, and incr enterohep
ll - upper trunk 9 - 12 -Enlarged liver or spleen circ in newborns.
lll - until thighs 12 - 16
lV - lower legs & UE 15 - 20 Laboratory: Physiologic vs. Pathologic Jaundice
V - palms & soles more than 15 -CBC (for infection) Physiologic
-Coombs (for hemolytic dse)  IB 1-3mg/dL
JAUNDICE -PT/PTT/serum albumin (for hepatic function)  Rate of rise <5mg/dL/24h
BREASTFEEDING JAUNDICE -Retic ct  Visible on 2nd-3rd day of life
 Bili levels slightly higher in the first 3-4 d of Life -Liver function tests: AST,ALT, ALK P  Peak on 2nd-4th day at 5-6mg/dL
 Baby gets dehydrated due to decreased intake of (ast/alt for hepatocellular damage; alt for biliary  <2mg/dL on 5th-7th day
milk that leads to increased enterohepatic circulation obstruc)
-Blood and Urine c/s (if sepsis is considered) Pathologic
BREASTMILK JAUNDICE -serum IgM (if high, test for TORCH)  Appears on 1st 24-36th hr
-serum alpha 1 trypsin levels  Rate of rise of serum bili is
 higher peak : 10-30 mg/dl
-urine-reducing substance  >5mg/dL/24h
 peaking by days 10-15 of life
 >12mg/dL in FT, >10-14 in PT
 And slower decline in the serum bili concentration (if
PLAN:  Persists after 10-14days
BF is stopped, bili level will fall rapidly in 48h; if BF is
see page 231 (lange neonat)  DB >2mg/dL at any time
continued,levels fall slowly returning to normal byv4-
12 wks of age)  Consider stoppng TPN.
(most infants recover with clearing of cholestasis in Exchange VS Partial Exchange Transfusion
 Rarely appears before the end of the first week of
1-3 months after normal feedings have begun) Dra. Martinez
life
 Factors:  Phenobarbital therapy is controversial Exchange Transfusion
(on glucoronyl transferase activity) – blood for blood
o pregnanediol in milk
o increased conc of fatty acids  Ursodeoxycholic acid and Partial Exchange Transfusion
 Cholecystokinin – blood for NS or for pRBC
o increased enteric absorption of unconj
bili
INDIRECT HYPERBILIRUBINEMIA 1. to remove :
o breastfed infants are more likely to
 Bilirubin
have increased enterohepatic circ  Indirect/unconjugated
 Ab-Ag level
because they ingest the beta  How old is the infant
(for ABO or Rh incompatibility)
glucuronidase present in breastmilk,  Is the infant breastfed (breastmilk jaundice);
 Bacterial toxin
are slower to be colonized wt intestinal peak bili occur 4-10d after birth.
2. to regulate hematocrit (partial exchange)
bacteria that convert CB to  What is d family ethnicity (G6PD def occurs more
 Polycythemia – exchange blood for NS
urobilinoids, and excrete less stool commonly in people of Mediterranean descent)
 Anemia – exchange blood for pRBC
 Is the infant dehydrated (common in breastfed
ABO INCOMPATIBILITY infants
Fluids Used:
Results in a hemolytic process (isoimm hemolytic anemia) 1. FWB <5 days old
Transplacental transport of maternal isoantibodies results in Diff diagnosis:
• For ABO/Rh incomp – always use mother’s blood type
an immune rxn with the A or B antigen on fetal eryhrocytes, More common:
O mother // A or B baby
whichproduces characteristic -Physiologic hyperbili
Rh (-) mother // Rh (+) baby
-ABO incompatibility
MICROSPHEROCYTES. • For Sepsis, K+ - use baby’s bloodtype
-Breastmilk jaundice
-Rh isoimmunization
Clinical presentatn 2. NSS – for Polycythemia
1. Jaundice -Infection
-Subdural hematoma or Cephal hematoma
2. Anemia 3. pRBC – for Anemia (hydrops in CHF)
-Excessive bruising
Diagnosis -Infant of a diabetic mother
Calculations:
Blood type & rh of baby & mom -Polycythemia
1. Double volume Exc Transf
Retic ct vol of FWB = 2 x (80mL/kg) x wt in kg
Direct coombs Less common
(80mL/kg is the circulating blood volume of baby)
Periph blood smear -G6PD def
Frac bili -Pyruvate Kinase Deficiency
2. Partial exchange
hoto levels in ABO Hemolytic Disease -Congenital spherocytosis
vol to be removed (cc NSS) =
-Lucey Driscoll syndrome
-Crigler Najjar syndrome
>10 mg/dl at 12 hrs 80mL/kg x (actual Hct – desired Hct)
>12 mg/dl at 18 hrs -Hypothyroidism
actual Hct
>14 mg/dl at 24 hrs or -Hemoglobinopathy
>15 mg/dl at any time vol to be exchanged (cc pRBC) =
>20 mg/dl DO EXCHANGE TRANSF. JAUNDICE
*elevated retic>6% accompanied by Hgb<13 g/dL suggests Physiologic Jaundice
80mL/kg x (desired Hct – actual Hct)
hemolysis § Unconjugated hyperbilirubinemia appearing on or after Hct of pRBC (usually 55) – actual Hct
3rd DOL and resolves before 10 days
§ TB <12 mg/dL and DB <15% of total Hyperbilirubinemia: Indications for Exchange transfusion:
§ Causes: 1. TB ~ 20mg/dL (term)
 Increased bilirubin load and poor hepatic uptake, 2. TB rate of rise
conjugation, and excretion of bilirubin • > 1mg/dL/hr
 Immature liver of premature infant - higher levels • > 0.5mg/dL/hr & hgb ?
 Breastfeeding - higher peaks & slower resolution

18
Double volume ET in Hyperbilirubinemia Mucocele (occur secondary to trauma to the salivary gland
1. replaces 87% of blood volume ducts, benign & subsides spontaneously),
2. rebound increase to 60% of pre- Natal teeth, macroglossia, frothy or copious saliva, thrush
exchange levels – from 12. chest
tissues/bone marrow/spleen, 13.Heart – murmurs?
old donor RBC VSD -most common
3. number of aliquots: -blowing pansystolic at lower left sternal
border
Total volume to be exchanged -present fr 6 wks - 4mos
5-20 mL/aliquot -close spontaneously by the end of 1st yo DR TO NURSERY
a. CS
• use 5 for smaller babies PDA - continuous, machinery type murmur b. Major Pre-natal problems :
• use 20 for full term babies - at 2nd Lelt ICS - 1 min apgar <=3
• each exchange = 3-5mins - appears on the 2nd or 3rd DOL - 5 min apgar <=5
maximum volume of blood to use: 500 cc (1 donor) - signs birth trauma
PS - systolic murmur heard bilateral in the ant c. r/o sepsis
Types of ET: chest, in both axillae, and across the back. d. SGA (<2100)
1. Double volume - it is secondary to the turbulence caused by e. LGA (>4000)
a) isovolumetric – for very small babies; UAC + UVC disturbed blood flow because the main f. Congenital anomaly
(continuous) pulmonary artery is larger than the peripheral g. Borderline term
b) push-pull – UVC pulmonary arteries. * if MBT is O(+) - baby's bld type must be obtained (can be
(discontinuous) - benign, done in DR) if BBT A/O/AB(+)
2. Partial exchange: UVC - may persist up to 3mos * if only problem was that mother had no pre-natal care or
delivery was considered septic, CBC can be done in the DR
Technique: 14.abdomen:
1. UVC insertion: depth depends on free flowing blood Omphalocele - intestines are covered by peritoneum Discharge of directly roomed in MHP from DR: (min of 6
available & umbilicus is central hrs obs)
2. Connection of UVC to blood/NSS source and to discard Gastroschisis - intestines not covered & defect is usually a. suck well
bottles at the right of the umbilicus b. maintain temp >= 36
with (2) 3-way stopcocks and connecta 15. umbilicus c. mother shows ability to take care of infant
3. Blood warmer 16. genitalia d. if CBC was ordered, was found normal; no bld grp
4. Recorder and agitator 17. lymph nodes incompatibility
5. Get comfortable and concentrate! 18. anus & rectum e. PROD and nurse have given instruction to mother
19. extremities regarding when to ff
Pre-exchange Labs: 20. trunk & spine Criteria for d/c of MHP infants from the well baby
- depends on the reason for doing the exchange 21. hips nursery
1. TB 22. nervous system a-e as above
2. Sepsis: blood C/S, CBC, CRP(?) - muscle tone, reflexes, cranial nerves, movement, b. for growing premies, wt of 1800 gms has been attained
3. NBS (?), Hepatitis/TORCH peripheral nerves c. for low apgar score babies, good suck/tone/ activity x 24
profiles (?) *reflexes -rooting, glabella (blink), grasp, neck righting, hrs + normal CBC
moro d. for r/o sepsis babies, blood culture (-) 3days & baby asx
Post-exchange Labs: *periph nerves; e. for SGA/LGA: normal CBC and serial HGT's x 24hrs
1. CBC – WBC usually low because - Erb Duchnne (injury of C5 &C6), f. for birth trauma & cong anomalies: app work up has been
we used adult blood; may see thrombocytopenia - Klumpke's (C7,C8,T1). done & cleared for discharge by mhp neonat attending
2. Electrolytes *passage of stool or urine is not a requirement
3. TB Reflexes of Neonates POSSIBLE INFECTION
4. RBS appears Have major risk factors:
disappears 1. PROM >24 hr.
Post-exchange Care: Moro birth 2. maternal intrapartum fever >38
1. +/- removal of UVC/UAC 8 months 3. chorioamnionitis
2. NPO x 24hr – because NEC is a Stepping birth (maternal fever, uterine tenderness, CRP +)
complication bec of transient decrease in perfusion 6 weeks 4. sustained fetal eart rate >160 bpm
3. VS q 1hr for 4hr or until stable Placing birth minor risk factors:
4. Antibiotics (?) – give again or start 6 weeks 1. PROM >12-23.5 hrs
5. Phototherapy Sucking & Rooting birth 2. maternal intrapartum fever 37.5-37.9 C
4 mos awake 3. Maternal WBC >15000
Complications of Exchange Transfusion: 4. low apgar (<5 at 1 min & or <7 at 5min)
1. Air embolism – before pushing, 7 mos asleep 5. low birth wt <1500
always aspirate! Palmar graps birth 6. preterm labor 35-36 wks
2. NEC 6 mos 7. maternal uti or other severe infections
3. Electrolyte/Glucose imbalance (Na, Plantar graps birth 1 major or 2 minor risk factors:
K, Ca; usually hypocalcemia) 10 mos 1. CBC PC
4. Infection Tonic neck 2 mos 2. Bld C/S
5. Hypotension, Hypertension, Temp 6 mos 3. ±CXR
imbalance Neck righting 4 - 6 mos
6. Hematocrit: low platelet, anemia, 24 mos NEONATAL REQUIREMENTS
polycythemia, hemolysis Landau 3 mos 1.Fluids
24 mos Term= at birth TFR at 80 ml/kday,
NEWBORN P.E Parachute 9 mos then 10 ml/d to TFR until 150 ml
1. Vital signs- temp, RR, BP,HR persists Preterm= start at TFR 60 ml/kday
2. Anthrop. -HC, CC, AC, BW, BL, MI then 10 ml/day to TFR untll I50 ml
3. General appearance - activity, color, cong abn Physiologic changes in the NewboRn
4. Skin 1. Physiologic wt loss- not more than 2.Electrolyte
*color (plethora, jaundice, pallor, cyanosis, extensive 10% of BW, occuring on the 2nd - get serum Na,K,Cl,Ca at 24hours
bruising, harlequin, mottling) day, recovered by the /10th day - add elec into the fluids after the 24th HOL
*rashes- milia, erythema toxicum, candida albicans rash, 2. Physiologic jaundice Na= 2-3 mmol/k/d
transient neonatal pustular melanosis, acne neonatorum (unconjugated hyperbilirubinemia) Cl = 2-3 mmol/k/d
*nevi-macular hemangioma (stork bites), portwine stain > predisposing factors: K = 2-3 mmol/k/d
(nevus flammeus), mongolian spot, cavernous a. surplus of RBC, increase cell mass Ca = 100-200 mg/k/d
hemangioma, strwberry hemangioma b. decreased red cell survival -calculate for additional elec in surgical pts
5. Head - ant font, post font, molding, caput, cephal, inc c. immature hepatic function
ICP, craniosynostos,craniotabes d. breast feeding 3.Type of Fluid (initial)
anterior fontanel - closes 9-12m > occurs on 2nd day, peaks at the 5th day, disappears - term & weighing >1500 gm : D10W
posterior font - closes 2-4m on the 7th day (14 days in pre-term) - <1500 gm : D7.5W
molding - within 1 week 3. vasomotor instability
caput - extends across suture line 4. genital crisis- pseudomenses 4. Add electrolytes to fluids if still on D10W after 24 hrs
- resolves within 5. witch milk 5.Determine the rate of infusion
several days 6. transitional stools  monitor GIR= usual:4-6 ml/k/min
cephalhematom - never extends across suture 7. inanition fever  most newborns stabilize their sugar levels at1-3 hrs
line > during 1st week due to dehydation of life
- resolv in 6 wks. 8. physiologic desquatmation of the skin for not more  never give boluses of 2-5 ml/k D10W as this gives
6. neck - than 1 week 200-500mg/k of gluc; this can compromise the brain
7. face- 9. falling of the cord 6. Important things to remember
8. ears- 10. physiologic anemia - establish circulation first
9. eyes- osteogenesis imperfecta, brushfields spots, - at 2 - 3 months, - take vital signs including BP
subconj hmge, conjunctivitis - permisible level 8 mg% term = 40-60 mmHg
10. nose preterm = 30-40 mmHg
11.mouth- cleft, tongue tie,
Ranula (cystic swelling in the floor of the mouth which -If BP falls below normal, give boluses of NSS or LR at 10
disappear spontaneously), ml/k over 30 min or longer,
Epsteins pearls (keratin containing cysts w/c is normal,
located on hard & soft palate w/c resolves spontaneously),

19
but no more than 2 times except in the presence of leaking - TTN cant qauge oxygenation;
vasculature (eg. Third spacing, septic shock, hydrops) & - Congenital Pulm Abn HC03 not affected
persistent pulmo hypertension - Cap gas affected by perfusion; cant gauge pH &pC02
-If 2 boluses not effective, start inotropic agents (dopa at HMD
10, dobu at 15) PATHOPHYSIOLOGY ACCEPTABLE BLOOD GAS
-In ELBW babies, assess the fluid status by weighing the - Surfactant deficiency pH - 7.23 - 7.35
baby q shift. Care must be observed in preventing - Surfactant dec alveolar surface tension p02 - 50 - 80
hypothermia. Cover w/ a plastic film - prod by type 2 alv cells at 28-34 wks pC02 - 35 - 45
-Serum Na,K,Cl shld be monitored every 12-24 hrs in pts - term= 100 mg/kg HC03 - 20 - 24
receiving chronic diuretic therapy - preterm= 1-10 mg/kg
- Water intake shld be increased &/or Na intake decreased - O2 cant go in, CO2 cant go out SUPPORTIVE THERAPY
if serum Na >145 1. Fluid Mx
-Potassium shld be removed fr the parenteral fluid if the - 60-200cc/kg/d in 1st 10d
serum K >5.5 - Inc by 10-20cc/k/d dependinq on wt, photo, elec,
CALORIC REQUIREMENTS
isolette, rbs, uo
50-60 kcal/kg/d - maintain wt PATHOLOGY
100-120 kc/kg/d - gain, term, 15-30 gms/day - Alveolar atelectasis Furosemide
110-140 kc/kg/d - gain, preterm - congestion of capillaries, lymphatics and interstitium - transient improvement
70-90 - preterm to maintain - epithelial damage in 30 mins - inc risk for PDA, hypovolemia
- hyaline membrane formation in 3 hours - NOT routinely used
Premature Formula:
Diluted PHYSIOLOGICAL EFFECTS
2. Hematocrit
Pre NAN 1 : 2 10.5 Pulmonary - severe RDS &/or MAP>8, Fi02>50: transfuse if hct <40
Enf Prem 1 : 2 10 - dec compliance, tidal volume, - mild RDS, MAP <6, Fi02<25 :
S26 LBE 1 : 4 12 FRC
- inc airway resistance transfuse if Hct <30
Full-
*10-20/kg in 1-2 aliquots
Pre NAN 1:1 21 Cardiac
Enf Prem 1:1 20 - 50-90% of CO - L to R shunting SURFACTANT REPLACEMENT
6:5 24 Natural heterologous
S26 LBW 1:2 24 KNOWN RISK FACTORS
- survanta (cow)
- GA <30 wks 60-70% - infasurf (cow)
COMPLICATION OF TPN 31- 34 wks 30-40%
1. Infection (coag + & coag - staph, strep -M>F Synthetic
viridans,e coli, pseudomonas, klebsiella - CS > SVD - exosurf
& candida) - GDM > normal
2. Metabolic complication : - LGA > AGA/SGA Prophylactic
o hyperglycemia fr excessive intake or change - 2nd of twin > 1st - within 15 mins if <30wks or<1g
in metabolic rate such as infection or - Intrauterine stress
glucocorticoid administration - PROM Rescue
o hypoglycemia from sudden cassation of - maternal CHVD, abruptio - presents with RDS (cost effective)
infusion 2ndary to intravenous infiltration. - maternal narcotic addiction : placental infarction
o azotemia from excessive protein uptake METHOD OF ADMINISTRATION
o hyperammonemia KNOWN PROTECTIVE FACTORS Survanta
o abn serum & tissue amino acid pattern - Antenatal steroids - OGT cut to length of ET, inserted to ET, manual
o mild metab alkalosis - 12 mg q12 x 4 or ventilation
o cholestatic liver disease 24 g q24 x 2
Exosurf
CHANGING DEXTROSITY CXR
- with special adaptor
X= volume of D50 water needed to inc. a to b ; or to make - ground glass and air bronchogram * administer as fast as infant will tolerate
A from scratch * change in infants position optional
GRADING
Reticulog Air bron SIDE EFFECTS
50 . =A or a-b (change in dextrocity) I mild w/in heart 1. Pulmonary hemorrhage
TFR or remaining vol of b X II mod beyond heart - 3-7% natural
III confluent 2/3 of lunq - 12% synthetic
IV comp opac cant see heart - 2-5% control
eg. Make D7.5 from D10W & D50W - may be related to PDA
CLINICAL COURSE
TFR=100cc 2. PDA
- transient improvement in1st 3-5 hrs 3. Bradycardia
- most worsen in 24-48 hrs
50/100=7.5/x 4. ET tube clogging, regurgitation
- improvement comes after diuresis
x=15
- risk for BPD if not extubated EXTUBATION
order: D5W ---- 100cc
D50W ---- 15cc - VR <10
OXYGEN
mix & run at -- cc/hr - Fi02 <30
- mask or funnel up to 5LPM - acceptable blood gas
-O2 hood up to 10LPM (84%)
eg.make remaining 80cc of D10W into - no apneic episode
-nasal can up to 1LPM (66%)
D12.5 - clearing CXR
50/80=12.5-10/x
CPAP
x=4 HOW TO EXTUBATE
- mild distress <40%Fi02 pC02<50
order:add 4cc D50W to present IVF - direct extubation
- PEEP 5-8cm flow 5-10 - trial of CPAP x 1 - 4h <1200
TO INCREASE....ADD D50W - Weaning:Fi02 40, PEEP 4 - aminophylline if <1000g
- OGT decompression
eg.- D5-------D7.5 - CPT q1-2h
- NOTE: hypercarbia - PEEP too high - racemic epi or IV dexa if repeated failed extubation
5 X .X1 . = X1 = 5(TFR)
IMV
100 TFR 100 Periodic Breathing vs Apnea
- pC02 >50 on Fi02 >50, apnea  Periodic Breathing - apneic pause of 5-10 sec ff by
USUAL SETTINGS a burst of rapid respiration at a rate of 50-60/min for
7.5 X X2 = X2 = 7.5(TFR) 10-15 sec
100 TFR 100 Wt 1kg 1.5 kg 2kg  Apnea - cessation of breathing >15- 20 sec or any
Fi02 40 -100 same same duration if accompanied by cyanosis and
50 = . X2 - X1 . rate 40 60 80 bradycardia
100 …. CC(D50W) PIP 10 - 14 12 - 18 14 - 24 Tx: theophylline, load at 5mk, then
PEEP 2-4 3-4 3-6 1-2mk every 8-12hr po or iv
TO DECREASE .......ADD DISTILLED H20 Apnea of prematurity usually resolve by 36wks
eg. D10--------D7.5 MECONIUM ASPIRATION PN postconceptional age
- give PEEP of 0 (meconium serves as the PEEP (gestational age at birth plus postnatal age)
7.5 = . X (GRAMS) .
100 TFR(OR REMAINING FLUID) PFC APNEA
- aim for high rates Maintain isolette at 36 C
10 = . X GRAMS . - maintain pC02 at 25-30s to dec pulm HPN Keep bag and mask resuscitation
100 X(CC) - aim for high rates equipment at bedside

TFR – X (CC) = CC of distilled H20 BLOOD GAS Apnea of Prematurity/Central apnea

Arterial vs Venous vs Capillary Aminophylline, loading dose 5mk then 5mkday q 12hrs
RESPIRATORY DISTRESS SYNDROME
- HMD - ABG gold std if from UAC Theophylline (same as above) PO
- pneumonia / sepsis - Venous Caffeine citrate, loading dose 10-20mk PO, then 5-10
- air leaks pH lower by 0.02-.04, mkday qd-bid
- meconium aspiration pCO2 higher by 6-10;

20
Diagnostics: Pneumogram, Cranial USG, 2DEcho  Hypoxia -birth asphyxia, mec aspiration, persis fetal Neonates: 0.1 - 0.4 mkdose 1-4 x/d
Rule out : upper GI, pH probe, Seizure: EEG circ Infants: 0.5 - 6.0 mg/kg/day q 6 - 24
 Congenital malformation
Labs : CBC, SMA 7, ABG, glucose, Ca, Blood C/S, drug CEFAZOLIN ( 1st gen)
screen, urine drug screen, drug levels, nasopharyngeal Newborn and premature:
washings, direct fluorescent Ab: RSV, parainfluenza, <2000 g: 40 mg/kg/day q 12
influenza, pertussis; Theophylline levels, caffeine levels, >2000 g and age > 7 days: 60 mkd
RU Age 1 month and older: 25 - 100 mkd q 6 - 8

CEFOTAXIME ( 3rd gen)

Aminophylline for newborns < 7 days old: 100 mg/ kg/day q 12
25mg/ml=2.5mg/0.1ml MULTIPLE GESTATION > 7 days old 150 mkd q 8
0.1ml aminoph + 0.9nss = 1ml -accdg to dr martinez, carrier of gene is the father Meningitis: 200 mkd q 6
AMPHOTERICIN B
ex 1.3mg aminoph x 0.1ml/2.5mg =0.52ml Classification of placenta as to Test dose 0.1 mkdose
* hold for heart rate >160 1. disk - single, fused, or separate e.g. wt= 7kg
* may shift to p.o. theophylline 2. no of chorions - monochorionic or dichorionic Amphotericin B 0.7 mg dissolved in 50 ml D5W to run 7 hrs
3. no of amnions- monoamniotic or diamniontic at 10ugtts/min
Perinatal Asphyxia Give Benadryl and Acetaminophen before and after
4 clinical criteria by AAP & ACOG should be present *heterosexual twins always have a dichorionic placenta transfusion
*same sex - monochorionic Monitor VS include BP
1. Profound metabolic or mixed acidemia WOF: fever, chills, nausea, vomiting, phlebitis, oliguria,
(ph<7.00) on umbilical cord All monochorionic twins (70%) are monozygotic,and the arrhythmia, or convulsion
Arterial blood sample, if obtained possibility exists for commingling of the fetal circulations If tolerated, start 0.25 mkday 4-6 hr infusion, inc. by
2. Persistence of an Apgar 0-3 for >5min 0.1mg/day until 0.5-1mg is reached in 4 days
3. Neurologic manifestations in the immediate Gender examination:
neonatal period to include seizures female/male prs are dizygotic e.g. 0.25 mkday
hypotonia, coma, or hypoxic-ischemic enceph Start Amphotericin B 1.75 mg + 250ml D5W at 41-42
(HIE) fraternal - 2 eggs (dizygotic) ugtts/min
4. Evidence of multiorgan system dysfxn in im identicall- same egg (monozygotic) same sex, N.B. Hydrocortisone 10-20mg added to bottle to prevent
same bld type immediate adverse reaction
Dr Dolendo – nicu Monitor renal, hepatic, electrolyte and hematologic status
 when 10% of circulating vol has been extracted, Mortality rates early, SGPT, BUN, Crea, K
transfuse even if hgb is not yet low -higher in monoamniotic twins due to cord entanglement
 for fluids or feeding, use birthwt or present wt, -higher in monozygotic twins ADR: hypercalciuria, acute hepatic failure, renal failure,
whichever is higher -death of one fetus may affect the outcome of the survivor phlebitis
 if w/ feeding residuals: subtract cc of residual from Side Effects: fever, chills, nausea, vomiting
volume fed, then put back the residuals if it was Twin-twin transfusion syndrome
freshly aspirated. Then give the rest of the feedings -almost all monochorionic placentas demonstrate vascular NEONATAL SEPSIS
minus the residuals. anastomoses Causative organisms:
whereas dichorionic placentas rarely do. Vascular from vagial flora
ex. fed 21cc, had 5cc residual anastomoses may be between arteries(most common), Group B Strep
means only 16cc is tolerated or veins (uncommon) E Coli
put back the 5cc, then feed Listeria mono
11cc more. -clinical manifestations: Staph
*when hgb diff of >5g/dl and is due to artery-to- Strep
 For growers of dolendo vein anastomoses H influenza
:once a wk CBC,electrolytes *Donor twin tends to be pale, wt low birth wt, Anaerobes
:Ca,Mg,PO4 once a wk if not on oligohydramnions, anemia, hypoglycemia, Nosocomial
TPN decrease organ mass, hypovolemia, & Staph epidermidis
 NBS & OAE before sending home amnion nodosum Gram (-) Rods like:
*Donor twins often require volume expansion, pseudomonas,
IUGR vs SGA RBC transfusion, or both klebsiella,
IUGR - failure of normal fetal growth caused by multiple *Recipient twin is plethoric, has high birth wt, serratia,
adverse effects on the fetus polyhydramnios, polycythemia or proteus
SGA- an infant whose weight is lower than population hyperviscosity, increased organ mass, Fungal
norms or lower than a predetermined cut off weight hypervolemia,& hyperbilirubinemia
- Birth wt below the 10th percentile for gestational age. - *Recipient twin often require partial exchange Types of sepsis:
- or >2 SD below the mean transfusion wt ffp Early onset
-Presents in the first 5-7days of life
ALL IUGR MAY NOT BE SGA, AND ALL SGA INFANTS OLIGO-POLYHYDRAMNIOS -Tran placental /organism was acquired intrapartum
MAY NOT BE SMALL AS A RESULT OF A GROWTH- Oligo-is asso wt a major anomaly 15% of the time; from maternal genital tact ( treponemes, viruses,
RESTRICTIVE PROCESS. rupture of memb is the most common cause; other causes listeria and candida)
include placental insufficiency, renal anomalies, karyotypic - Characterized by sudden and fulminant course
Major Causes IUGR: abnormalities, and severe cardiac dse.
-uteroplacental insufficiency (leading cause) Poly-is asso wt major anomalies in 15% of cases; it is Late onset
-congenital infxn (TORCH) asso wt diabetes, anencephaly, neural tube defects, bowel -common after the first week of life
-chromosome & genetic disorders obstruction such as duodenal atresia, multiple gestation, -usually, have an identifiable focus, most often
nonimmune hydrops fetalis,& exstrophy of the bladder meningitis in addition to sepsis
Other causes:
-inborn errors of metab NEONATAL PHARMACOLOGY Risk factors:
-multiple pregnancy ACYCLOVIR - Prematurity & low birth weight
-maternal malnutrition IV 30-40 MKD Q 8 for 10 - 14 days - Rupture of membranes
-drugs (cocaine,heroin) & alcohol (dilute to final conc of 7mg/ml and infuse in 60 min) - Maternal peripartum fever or infection
- Resuscitation at birth (fetal distress, traumatic
Classification IUGR: ALBUMIN(HUMAN) deliv, severely depressed & required intubation)
Symmetric 0.5 - 1 g/kg IV ( or 10-20 ml/kg of 5% IV bolus) repeated as -Multiple gestation
- HC, HT,WT all <10% necessary. Maximum 6 g/kg/day -Invasive procedures
- occurs in early pregnancy -Infants w/ galactosemia (predisposition to e.coli
AMIKACIN sepsis), immune defects, or asplenia
Asymmetric <1.2 k 0-4 wks postnatal age: 7.5 mk/dose q18 -24 -Iron therapy (iron added to serum in vitro enhances
- HC=HT > WT,all<10% 1.2-2 kg: the growth of many organisms
- occurs in late pregnancy 0-7 days 7.5 mkdose q 12 -18 -other factors:
>7 days 7.5 mkdose q 8 -12 *males affected 4x more than females
IUGR - Neonatal Assessment > 2 kg: *more common in black than white
*reduced birthweight 0-7 days 10 mkdose q 12 *NICU staff & family members
*P.E.: in general,they are thin, w/ loose, peeling skin bec of > 7 days 10 mkdose q 8
loss of subcutaneous tiss, a scaphoid abdomen, & a Clinical presentation:
disproportionately large head. AMINOSYN - Temperature irregularity
*lubchenco chart (not reliable) available in 5% or 10% - Change in behavior (lethargy, irritability)
*ponderal index <10% start at 0.5 g/kg/day and increase by 0.5 q daily - Skin (poor periph perfusion, cyanosis, mottling,
*ballard score pallor, petechiae, rashes, sclerema, or jaundice)
- most accurate at 30-42h of age CALCIUM GLUCONATE - Feeding problems (feeding intolerance, vomiting,
- is accurate within 2 wks of gestation in MD IV: 200-700 mkd q6 (max diarrhea, or abd distention wt or w/out visible
infants weighing >999 gm at birth. rate200mg/kg) bowel loops)
MD PO: 200-800 mkd q 6 mixed in feedings - Cardiopulmonary (tachypnea; respi distress like
COMPLICATIONS IUGR: Exchange transfusion: grunting,flaring, and retractions; apnea w/in d
 Metabolic d/o -hypoglycemia,hypocalcemia 0.45 meq ( 1ml 10%) dL of citrated blood first 24h, tachycardia, hypotension)
 Hypothermia - Metabolic (hypo or hyperglycemia or metabolic
 Hema d/o - polycythemia CAPTOPRIL (CAPOTEN) acidosis)

21
 curl up in order to reduce the skin area exposed to the
colder environment.
Recovery Phase
o 92.5% - recovery w/o residual dis
o diuresis normal BP BUN CREA begin to fall
o normalization of urine sediment
o resolution of gross hematuria by 2-3 wks
o proteinuria by 3-6 mos
o microscopic hematuria by 12 mos
o half will have normal UA by 6 wks

URINARY TRACT INFECTION Diff Dx

NICU TREATMENT o IgA Nephrophaty, Pyelonphritis (UTI)
Fluids (cc/hr) 1. Cystitis
TFI = --------------------- + cc po feeds x wt o 7-10 days for uncomplicated UTI, esp if <5 yrs
Freq/day o Repeat urine CS after 48-72 hrs
o Continue prophylactic dose antibiotics until
radiologic evaluation has been performed
cc feeds x freq x cal
TCI = ---------------------------- 2. Pyelonephritis Note :Lecture R Mendoza
30 / wt o Non-toxic/clinically stable, children and infants AGN
>3 months of age hematuria (gross/micro)
NV = 120-140 o can be treated as outpx congestion
o may give 3rd gen inc BP
cal 1:2 = 20cal cephalosporin IM edema - not so tight esp. legs
1:1 = 22cal o followed by 10-14 days of oral oliguria/anuria
6:5 = 24cal abx older
admit : HPN, congestion, (oliguria)
o Toxic children and infants <3 mo should be diuretic: Furosemide +/- hydralazine
Rate x Dext x 0.167 considered candidates for immediate hospitalization
GIR = --------------------------- and parenteral therapy NEPHROTIC
wt o parenteral antibiotic tx should be continued Labs
NV = 4-6 for 10-14 days in neonates UA 24 hr urine protein
o outpx tx to complete a full 10-14 day course BUN Crea, electrolytes,
D50W = 50g/100mL ~ 50%dextrose can be given in pxs >2 mo when afebrile and total protein, and albumin,
D50-50=25g/50mL ~ 50% dextrose clinically stable for 24-48 hrs Serum cholesterol, triglyceride
TPN CALORIES etiology : Renal ultrasound
1. Post urethral valve - male Tx
CHO x x 0.34 /100 2. Reflux - female steroids: prdnisone medrol
----- ------- work-up: alkylating agents - cyclo
%dex TFR ultrasound albumin infusion
VCUG – (never do until infxn controlled,
PROT x x 4 / 100 usually at Note: Lecture RMendoza
------ ------ least 48 hours afebrile) Nephrotic Syndrome
%AA TFR DMSI o edema, proteinuria +3/4 or > 2 g /day,
DTPA hypoalbuminemia, hyperlipidemia
INTRALIPID 10% x TFR X 1.1 o oliguria - more scary
significant: o younger; boys > girls
Screening for MHP preterm >100,000 - free void o diuretics sparingly & at smaller dose
1. Cranial UTZ >10,000 - catheterized o E/ : 90% idiopathic, 85% minimal change, 5%
a. all infants <1500g mesangial proliferative, 10% focal sclerosis
-around 10th DOL if low risk VESICOURETERAL REFLUX GRADING o N C3
-around 3rd DOL if high risk I - ureter only o tx: prednisone 60 mg/m2/day tid-qid
-ASAP if suspecting IVH o weeks before response measuring (-)
-rpt at 10-14d if (+) finding then prn II - ureter, pelvis, calyces; no dilatation, normal calyceal proteinuria
-rpt at term age prior 2dischrge fornices o steroid resistance - +2 proteinuria in px on
prednisone > 1 month
b. all infants w/ perinatal asphyxia after 24 hrs to detect III - mild or moderate dilatation and or tortuosity of ureter; UTI
cerebral edema mild or moderate dilatation of the pelvis, but no or slight o pyuria
bluntinq of the fornices o hematuria
c. suspicion of hydrocephalus o rare proteinuria - recurrent UTI, TNTC pus
- (+) macrocephaly ,spina bifida, meningocoele IV - moderate dilatation and/or tortuosity of the ureter; cells
- rpt at 14days and at 3mos mild dilatation of renal pelvis and calyces; complete o fever
obliteration of sharp angle of fornices, but maintenance of o voiding problems
2.ROP (around 6wk of age) papillary impressions in majority of calyces antibiotics - UTI & NS
a. all infants < than or around 32wk regardless of
oxygen exposure V - gross dilatation and tortuosity NEPHRITIC - NEPHROTIC
b. oxygen exposure x 10days if 33-36wk of ureter; qross dilatation of renal pelvis and calyces;
c. all infants <1500g regardless of oxygen papillary impressions are no longer visible in majority of CHARACTERISTICS
exposure calyces AGN
3. Hct, retic prior to discharge - sudden onset of gross hematuria
UTI IN MALES - edema
4. Dev. screening if stormy neonatal WORK-UPS - hypertension
course 1. ULTRASOUND - renal insufficiency
2. IVP NS
ROP 3. CYSTOURETHROGRAM - proteinuria
-Direct ophthalmoscopy s accurate between 27-34 wks - hypoproteinemia
only; before 27 wks,the cornea is too opaque to allow GLUMERULONEPHRITIS vs NEPHROTIC - edema
visualization; after 34 wks, atrophy of the vessels of the ACUTE GLOMERULO NEPHRITIS - hyperlipemia
lens occur. Cause - pyodermas but lipids neutralizes streptolysins
Sx: MORPHOLOGIC PATTERNS
grade1(33-34wks) o Puffy eyelids NEPHRITIC
vessels are seen only at the periphery o Coke-colored urine - prototype is post strep GN
grade 2(31-32) o Nausea, vomiting, HA, abd pain - IgA nephropathy
vessels reach only the middle-outer part of o + sorethroat or impetigo - membrano proliferative GN
the Dec. C3.. - idiopathic RPGN
lens;central clear portion of the lens is larger. Compl: - 50% mortality, 40% dialysis, 10% recover
grade 3(29-30) o HTN - 1st manifes in olderchild NEPHROTIC
vessels do not meet in the center but are o hyperkalemia academia - Idiopathic
close; o hyperphosphatemia - minimal change
central portion of the lens is not covered by o - mesangial proliferative
the vessels Labs: CBC, plt ct, Urine c/s, ASO, C3, ANA - focal sclerosis
grade 4(27-28) Renal USG, BUN, Crea, CXR - membranoproliferative
vessels cover the entire ant surf of the lens or -
the vessels meet in the center of the lens. dysmorphic RBC or (+) casts - kidney CLINICAL MANIFESTATIONS
inc ASO 1-2 weeks of illness until 4 mos AGN
HYPOTHERMIA - edema
-normal skin temp in neonates is 36-36.5 Tx: - hypertension
-normal core(rectal) temp is 36.5- 37.5 o Bedrest fluid and salt restriction - oliguria
o Recovery in 7 day- inc. urine outp - encephalopathy
*Preterm predisposed to heat loss because they have little o Hydralazine 0.1-0.2 mg/kg /dose, max 20 - heart failure
subcutaneous fat , a high ratio of surface area to body mg/dose - non-specific
weight, and reduced glycogen and brown fat stores; in - malaise, lethargy, abd pain, fever
addition, their hypotonic (frog) posture limits their ability to

22
 - take urinalysis everytime you taper Measles Vaccine
NS  9 months; 1 dose
- edema *URINARY RELAPSE  At least 80% of measles can be prevented by
- weight gain - relapse of proteinuria but clinically well immunization at this age
- ascites or pleural effusion - look for focus of infection then treat
- decreased urine output Recommended Schedule for Routine Active
- anorexia * URINARY AND CLINICAL RELAPSE Immunization or Normal Infants and Children
- abd pain - restart prednisone therapy Recommended Age
- diarrhea Immunization (S)
- hypertension – uncommon *PRIORITY LABS TO DIFFERENTIATE NEPHROTIC Anytime after birth BCG
FROM NEPHRITIC 2 months DPT, *OPV1, HBV1,
- urinalysis, HibCV1
- serum albumin, HBV1
- cholesterol and may be started at birth
- creatinine 3 months HBV2
4 months DPT2, *OPV2, HBV3,
DIAGNOSIS INDICATION FOR RENAL BX HibCV2
AGN - Oliguria >2 weeks 6 months DPT3,
- urinalysis - RBC in assoc with RBC casts and - Hypertension > 3 weeks *OPV3, HIbCV3
proteinuria - Gross hematuria >3 wks 9 months Measles
- CBC, PBS - mild normochromic anemia due - HypoComplementemia >6 wks vaccine
to hemodilution and low grade hemolysis 15 months MMR,
- serum C3 reduced LATE INDICATON For RENAL BIOPSY HibCV4
- throat culture - + strep infxn  Microscopic hematuria >6 months 18 months DPT4,
- ASO titer elevated  Proteinuria > 6 months *OPV4
- DNAse B Ag  Hematuria > 12 months 4-6 years DPT5,
- streptozyme test *OPV5, MMR
- renal biopsy ACUTE RENAL FAILURE 14-16 years Td
 indicated when HPN persists  Prompt fluid restriction is required regardless of an (tetanus, diphtheria toxoid-adult)
beyond oliguric phase oliguric/anuric state BCG = Bacillus Galmette-Guerin vaccine
 proteinuria increases and  Initial mgmt includes infusion of isotonic fluids such DPT = diphtheria and tetanus toxoids and pertussis vaccine
hematuria decreases over as NSS or LR at 20 ml/k over 30-60 min; this can be OPV = oral plio virus vaccine containing attenuated polio
5months repeated once If necessary.; virus types 1, 2, and 3;
 persistence of gross hematuria  if hemorrhage accounts for the vascular collapse, HBV = Hepatitis B virus vaccine
more than 2 weeks blood transfusions also are required HibCV = Haemophilus influenzae type b conjugate vaccine
NS  Potassium administration is avoided until urine flow MMR = live measles, mumps, and rubella viruses vaccine
- urinalysis +3 or +4 proteinuria, microscopic is established. Td = adult tetanus and diphtheria toxoids.
hematuria, gross hematuria rare  For most children w/ ARF, daily maintenance fluid *Enhanced inactivated polio vaccine (e-IPV) may be given
- serum cholesterol and triglyceride elevated rqmt is equal to instead of OPV.
- serum albumin generally <2 g/dl o U.O. + obvious extra renal losses + net
- serum C3 normal IWL
- renal biopsy Recommended Routinely Administered Active
o where net IWL = IWL-15/100 cal Immunizations
COMPLICATIONS endogenous H2O
AGN o (IWL= 750 ml/m2/d or 45ml/100 cal BCG
- volume overload expended) Bacillus Calmette-Guerin vaccine
- heart failure  renal & extra renal losses need to have their elec Primary
- hypertension composition analyzed & replaced accordingly  Direct vaccination at any age; or when (-) to
- hyperkalemia tuberculin test; usually 3-14 months
- hyperphosphatemia  Diuretics  0.05 mL ID over deltoid area
- hypocalcemia o Start furosemide at 2 mg/k IV; may be Secondary
- acidosis increased to a max of 10 mg/k  1st grade school entrants or when follow-up
- seizure o Furosemide is preferred bec it has a rapid tuberculin reverts to negative
- uremia onset of action & retains effectiveness in the  mL ID
NS presence of reduced glom filtration rate Reaction
- spontaneous bacterial peritonitis o Failure to respond to loop-acting diuretics  Keloid scar, suppurative regional adenitis,
- sepsis sugqest that the pt has acute tubular necrosis disseminated BCG infection & osteomyelitis in
- pneumonia rather than simple renal hypoperfusion immunocompromised
- cellulitis o If vol overload includes : pulmonary edema, Efficacy
- uti acute dialysis is indicated
 50%
- arterial and venous thrombosis
 Hyperphosphatemia .& hypocalcemia
DPT
TREATMENT o the PO4 excess is secondary to
diphtheria and tetanus toxoids and pertussis vaccine,
AGN decreased renal PO4 excretion &
inactivated B. Pertussis
- no specific tx results in hypocalcemia & Ca PO4
Primary
- penicillin 10 day course deposition in tissues
 Given at age 2, 4, & 6 months or thereafter;
- activity need not be restricted except during
below 6 years: 3 doses with interval of 4 weeks
the acute phase FLUID LIMITATION IN RENAL PX
 3 doses of 0.5 mL IM
- anti-hypertensive meds 1. No urine output
- diuretics - furosemide 400 cc/m2/day or Secondary
- ACE inhibitor 20 cc/k/day  1st booster: 1 year after completion of primary
NS immunization; 2nd booster at 4-6 years; subsequent
- 1st episode of nephrosis, severe edema with 2. With urine output, no diuretics booster using DT at 10 years interval
respiratory distress from massive pleural 400 cc/m2/d + previous urine  0.5 mL IM
effusion and ascites or in severe scrotal output Reaction
edema  Fever, restlessness, irritability, local signs of
- sodium fluid restriction 3. With.urine .output , w/ diuretics inflammation
- diuretics - furosemide 400 cc/m2/ day + 1/2 previous U.O. Efficacy
- 25% human albumin  Almost 100%/10 years except pertussis
- prednisone (remission) 4. + fever component
- cyclophosphamide therapy add 100 cc/m2/deqree rise in temp
- renal transplantation Tetanus Toxoid
VACCINES weakened/detoxified toxin
PROGNOSIS Expanded Program of Immunization (EPI) for Infants Primary
AGN BCG  Over 2 months when DPT or DT not available
- complete recovery in 95% of children  Birth or anytime after birth; 1 dose  2 doses 0.5 mL IM at 6-8 weeks interval
- acute phase - glomerular hyalinization and  BCG given at the earliest possible age Secondary
CRF protects against the possibility of infection  1 year after primary immunization and every
- recurrences extremely rare from other family members 10 years thereafter
NS DPT  0.5 mL IM
- steroid responsive - have repeated albumin  6 weeks; 3 doses; 4 weeks interval Reaction
until the disease resolves spontaneously  An early start with DPT reduces the chance of  None
toward the end of the 2nd decade of life severe pertusis Efficacy
- no residual renal dysfunction OPV  Almost 100%
 6 weeks; 3 doses; 4 weeks interval  10 years
**PREDNISONE THERAPY  The extent of protection against polio is
- 60 mg/m2/day (max of 60 mg/day) x 4-8 increased the earlier the OPV is given OPV
weeks Hepatitis B Vaccine (HBV) oral polio virus vaccine containing trivalent live attenuated
- take at least 2 urinalysis  6 weeks; 3 doses; 4 weeks interval polio virus types 1, 2, and 3
- 40 mq/m2/day OD or in divided doses q other
 An early start of Hepatitis B Vaccine reduces Primary
day x 1 month  Given at age 2, 4, & 6 months; or 3 doses 6-8
the chance of becoming infected
- Taper over 1-2 months weeks interval may be given at a later age

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  0.5 mL orally for single dose preparations; 2 10-14y 22 3.5 22 3.6
drops for multiple dose preparation
Secondary RR&PR
 1st booster 1 yr after primary; 2nd booster at age RR PR
age 4-6 years <2mos <60
 Same as primary 2-12mos <50 <160
Reaction 1-5yrs <50 <120
 Paralytic polio extremely rare 6-8yrs <30 >110
Efficacy
 More than 90%
 Life long

Measles
live attenuated virus
Primary
 9 months or later
 Maybe given as early as 6 months
 1 dose subcu. (follow manufacturer’s
instructions)
Secondary
 2nd dose given at 15 mos. if 1st dose given
below 1 year 3rd dose given at 5-12 years as
part of MMR
 1 dose subcu.
Reaction
 Fever and rash 5-10 days after dose
Efficacy
 95%
 At least 12 years

MMR
Primary
 12 mos. or older
 0.5 mL subcu.
Secondary
 5-12 years if 1st dose given at infancy
 0.5 mL subcu.
Reaction
 Same as those cited for individual
components
Efficacy
 More than 95%
 Long Lasting, Probably lifetime

HBV
Plasma-derived
Surface antigen
Primary
 From birth to adult in endemic areas; any age
for high risk persons in non-endemic areas
 3 doses by IM at 1 month intervals
Secondary
 Probably 5 yrs after primary; may not be
necessary
 Same as primary
Reaction
 Rare: arthralgia, neurologic reactions
Efficacy
 More than 90%
 Probably 5 years or longer

HibCV
Primary
 Between 2 months and 5 years
 3 doses if given below 6 months, 2 doses if
given between 6 months and 1 year, by IM at
2 months intervals 1 dose if given above 1
year
Secondary
 15 months if primary dose given below 1 year
 0.5 mL by IM
Reaction
 Pain, redness and/or swelling at injection site
in 25%;
 rarely fever and irritability
Efficacy
 90-100% effective

Average Cardiac Rate of Filipino Infants and Children

Age and Sex
Male Females
Age MCR SD MCR SD
0-1m 147 30.5 145 26.2
2-6m 139 31.4 141 33.5
7-12m 133 32.4 134 31.9
13-24m 128 34.1 129 34.3
2-4y 109 32.6 110 29.5
5-9y 93 23.7 92 23.2
10-14y 86 20.4 86 20.7

Average Respiratory Rate of Filipino Infants and

Children by Age and Sex
Male Females
Age MRR SD MRR SD
0-1m 59 18.2 56 22.0
2-6m 52 22.5 52 21.6
7-12m 45 24.6 48 22.8
13-24m 38 14.9 36 22.5
2-4y 30 12.1 29 12.0
5-9y 25 6.1 25 6.1

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