EXPANDED PROGRAM ON IMMUNIZATION

VACCINE AGE DOSE # ROUTE SITE INTERVAL

BCG-1 Birth
or 6 wks
0.05mL
(NB)
0.1mL
(older)
1 ID R-
Deltoid

DPT 6 wks 0.5mL 3 IM Upper
Outer
thigh

OPV 6 wks 2 drops 3 PO Mouth 4 wks
HEPA B 6 wks 0.5mL 3 IM Antero-
lateral
thigh
4 wks
MEASLES 9 mos 0.5mL 1 SC Outer
upper
arm
4 wks
BCG-2 School entry 0.1mL 1 ID L-
Deltoid

TetToxoid Childbearing
women
0.5mL 3 IM Deltoid 1 mo then
6-12 mos






ADVERSE REACTIONS FROM VACCINES

BCG 1. Wheal small abscess ulceration healing / scar formation in
12 wks
2. Deep abscess formation, indolent ulceration, glandular enlargement,
suppurative lymphadenitis
DPT 1. Fever, local soreness
2. Convulsions, encephalitis / encephalopathy, permanent brain
damage
OPV Paralytic Polio
HEPA B Local soreness
MEASLES 1. Fever & mild rash
2. Convulsions, encephalitis / encephalopathy, SSPE, death

ACTIVE PASSIVE
BCG Diphtheria
DPT Tetanus
OPV Tetanus Ig
Hep B Measles Ig
Measles Rabies (HRIg)
Hib Hep A Ig
MMR Hep B ig
Tetanus Toxoid Rubella Ig
Varicella









BODY TEMPERATURE

Subnormal <36.6C
Normal 37.4C
Subfebrile 35.7 38.0C
Fever 38.0C
High fever >39.5C
Hyperpyrexia >42.0C

AGE HR (bpm) BP (mmHg) RR (cpm)

Preterm 120-170 55-75/35-45 40-70
Term 120-160 65-85/45-55 30-60
0-3 mo 100-150 65-85/45-55 35-55
3-6 mo 90-120 70-90/50-65 30-45
6-12 mo 80-120 80-100/55-65 25-40
1-3 yrs 70-110 90-105/55-70 20-30
3-6 yrs 65-110 95-110/60-75 20-25
6-12 yrs 60-95 100-120/60-75 14-22
12-17 yrs 55-85 110-135/65-85 12-18

BP cuff should cover 2/3 of arm
-: SMALL cuff: falsely high BP
-: LARGE cuff: falsely low BP

BMI

Asian Caucasian
Underweight <18.5 <18.5
Normal 18.5 22.9 18.5 24.9
Overweight 23.0 25 29.9
at risk 23 24.9
Obese I 25 29.9 30 39.9
Obese II 30 >40



ABG

pH: 7.35-7.45 HCO3: 22-26mEq/L
pCO2: 35-45 B.E.: +/- 2mEq/L
pO2: 80-100 O2 sat: 97%


NORMAL LABORATORY VALUES

NB Infant Child Adole
RBC 4.8-7.1 3.8-5.5 3.8-5. M: 4.6-6.2
F: 4.2-5.4
WBC 9-30,000 6-17,500 5-10,000 6-10,000
PMNs 61% 61% 60% 60%
Lymph 31% 32% 30% 30%
Hgb 14-24 11-20 11-16 M: 14-18
F: 12-16
Hct 44-64% 35-49 31-46 M: 40-54
F: 37-47
Platelets 140-300 200-423 150-450 150-450
Ret 2.6-6.5 0.5-3.1 0-2 0-2


COUNT (%)

BT 1-5 min 1-6 1-6 1-6
CT 5-8 min 5-8 5-8 5-8
PTT 12-20sec 12-14 12-14 12-14


ANTHROPOMETRIC MEASUREMENTS

IDEAL BODY WEIGHT

Age Kilograms Pounds
At Birth 3kg (Fil)
3.35kg (Cau)
7
3-12
mo
Age (mo) + 9 / 2 Age (mo) + 10 (F)
Age (mo) + 11 (C)
1-6 y Age (y) x 2 + 8 Age (y) x 5 + 17
7-12 y Age (y) x 7 5 / 2 Age (y) x 7 + 5

Given Birth Weight:
Age Using Birth Weight in Grams
< 6 mo Age (mo) x 600 + birth weight (gm)
6-12 mo Age (mo) x 500 + birth weight (gm)

Expected Body Weight (EBW):
Term Age in days 10 x 20 + Birth Weight
Pre-Term Age in days 14 x 15 + Birth Weight


Age of Infant Ideal Weight
4-5 months 2 x Birth Weight
1 year 3 x Birth Weight
2 years 4 x Birth Weight
3 years 5 x Birth Weight
5 years 6 x Birth Weight
7 years 7 x Birth Weight
10 years 10 x Birth Weight











LENGTH / HEIGHT
(50 cm)

Age Centimeters Inches
At Birth 50 20
1 y 75 30
2-12 mo Age x 6 + 77 Age x 2.5 + 30


Age Gain in 1
st
Year is ~ 25cm
0-3 mo + 9 cm 3 cm per mo
3-6 mo + 8 cm 2.67 per mo
6-9 mo + 5 cm 1.6 cm per mo
9-12 mo + 3 cm 1 cm per mo


HEAD CIRCUMFERENCE
(33-38 cms)

Age Inches Centimeters
At Birth 35 cm (13.8 in)
< 4 mo + 2 in
(1/2 inches / mo)
+ 5.08cm
(1.27cm / mo)
5-12 mo + 2 in
(1/4 inches / mo)
+ 5.08cm
(0.635cm / mo)
1-2 yrs + 1 inch 2.54 cm
3-5 yrs + 1.5 in
(1/2 inches / year)
+ 3.81cm
(1.27cm / mo)
6-20 yrs + 1.5 in
(1/2 inches / year)
+ 3.81cm
(1.27cm / mo)



























Age Transverse-AP
Diameter ratio
Inches
At Birth 1.0 Transverse = AP
1 y 1.25 Transverse > AP
6 y 1.35 Transverse >>> AP


FONTANELS

Appropriate size at birth: 2 x 2 cm (anterior)
Closes at: Anterior = 18 months, or as early
as 9-12 months
Posterior = 6 8 weeks or
2 4 months



THORACIC INDEX

TI = transverse chest diameter
AP diameter

Birth : 1.0
1 year : 1.25
6 years : 1.35






APGAR

0 1 2
A
Blue /
Pale
Pink body/ Blue
extremities
Completely
pink
P Absent Slow (<100) > 100
G
(-)
Response
Grimaces
Coughs,
Sneezes,
Cries
A
(-)
Movement
Some flexion /
extension
Active
movement
R Absent Slow / Irregular
Good,
strong cry

8 10: Normal
4 7: Mild / Moderate Asphyxia
0 3: Severe asphyxia

GCS

Function Infants/Young Older
Eye
Opening
4- Spontaneous
3- To speech
2- To pain
1- None
Spontaneous
To speech
To pain
None
Verbal 5- Appropriate
4- Inconsolable
3- Irritable
2- Moans
1- None
Oriented
Confused
Inappropriate
Incomprehensible
None
Motor 6- Spontaneous
5- Localize pain
4- Withdraw
3- Flexion
2- Extension
1- None
Spontaneous
Localize pain
Withdraw
Flexion
Extension
None

























































































H.E.A.D.S.S.S.

Sexual activities
Sexual orientation?
GF/BF? Typical date?
Sexually active? When started? # of persons?
Contraceptives? Pregnancies? STDs?

Suicide/Depression
Ever sad/tearful/unmotivated/hopeless?
Thought of hurting self/others?
Suicide plans?

Safety
Use seatbelts/helmets?
Enter into high risk situations?
Member of frat/sorority/orgs?
Firearm at home?


F.R.I.C.H.M.O.N.D.

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










H.E.A.D.S.S.S.

Home Environment
With whom does the adolescent live?
Any recent changes in the living situation?
How are things among siblings?
Are parents employed?
Are there things in the family he/she wants to
change?

Employment and Education
Currently at school? Favorite subjects?
Patient performing academically?
Have been truant / expelled from school?
Problems with classmates/teachers?
Currently employed?
Future education/employment goals?

Activities
What he/she does in spare time?
Patient does for fun?
Whom does patient spend spare time?
Hobbies, interests, close friends?

Drugs
Used tobacco/alcohol/steroids?
Illicit drugs? Frequency? Amount?
Affected daily activities?
Still using? Friends using/selling?





























NUTRITION

AGE WT. CAL CHON
0-5 mo 3-6 115 3.5
8-11 mo 7-9 110 3.0
1-2 y 10-12 110 2.5
3-6 y 14-18 90-100 2.0
7-9 y 22-24 80-90 1.5
10-12 y 28-32 70-80 1.5
13-15 y 36-44 55-65 1.5
16-19 y 48-55 45-50 1.2

TCR = Wt at p50 x calories
TCR = CHON X ABW

Total Caloric Intake : calories X amount of
intake (oz)

Gastric Capacity : age in months + 2

Gastric Emptying Time : 2-3 hours

1:1 1:2
Alacta Bonna
Enfalac Nursoy
Lactogen Promil
Lactum S-26
Nan Similac
Nestogen SMA
Nutraminogen
Pelargon
Prosobee









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

Habit 1: Be Proactive
Habit 2: Begin with the end in mind
Habit 3: Put First Things First
Habit 4: Think Win-Win
Habit 5: Seek first to understand and
then to be understood
Habit 6: Synergize
Habit 7: Sharpen the saw


EXPECTED LA SALLIAN
GRADUATE ATTRIBUTES
(ELGA)

1. Competent & safe physicians
2. Ethical & socially responsible
Doctors / practitioners
3. Reflective lifelong learners
4. Effective communicators
5. Efficient & innovative managers


































































TREATMENT PLAN B

Recommended amount of ORS over 4 hour period

Age up to: 4 mo 4 mo 12 mo 12 mo 2 yrs 2 yrs 5 yrs
Wt: <6kg 6-9.9kg 10-11.9kg 2-19kg
(mL) 200-400 400-700 700-900 900-1400

Use childs age only when weight is not known
Approximate amount of ORS (mL)

CHILDS WT (kg) x 25

if the child wants more ORS than shown, give more
give frequent small sips from a cup
if the child vomits, wait for 10 min then resume
continue breastfeeding whenever the child wants

AFTER 4 HOURS
reassess the child & classify dehydration status
select the appropriate plan to continue treatment
begin feeding the child while at the clinic


DIARRHEA

Chronic : >14 days, non-infectious causes
Persistent : >14 days, infectious cause


ORS vol. after each loose stool 1 day

<24 mo 5-100mL 500mL
2-10 y.o. 100-200mL 1000mL
>10 y.o. As much as wanted 2000mL


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

Age 30mL/kg 75mL/kg
<12 1H 5H
>12 30 mins 2 H


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



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

4 Major Mechanisms

1. Poorly absorbed osmotically active substances in
lumen
2. Intestinal ion secretion (increased) or decreased
absorption
3. Outpouring into the lumen of blood, mucus
4. Derangement of intestinal motility


Rotaviral AGE (vomiting first then diarrhea)
Ingestion of rotavirus rotavirus in intestinal villi
destruction of villi

(secretory diarrhea absorption secretion) AGE


Assessment of dehydration (Skin Pinch Test)

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





ETIOLOGY of AGE

Bacteria Viruses
Aeromonas Astroviruses
Bacillus cereus Caloviruses
Campylobacter jejuni Norovirus
Clostridium perfringens Enteric Adenovirus
Clostridium difficile Rotavirus
Escherichia coli Cytomegalovirus
Plesiomonas shigelbides Herpes simplex virus
Salmonella
Shigella
Staphylococcus aureus
Vibrio cholerae 01 & 0139
Vibrio parahaemolyticus
Yersinia enterocolitica

Parasites
Balantidium coli
Blastocyctis hominis
Cryptosporidium
Giardia lamblia


Amoeba Metronidazole
Ascariasis Al/mebendazole
Cholera Tetracyline
Shigella TMP/SMX (Cotri)
Salmonella Chloramphenicol






TREATMENT PLAN A
4 Rules of Home Treatment

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

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

How much fluid to be given in addition to the usual
fluid intake?

Up to 2 years: 50-100 mL after each
loose stool

2 years or more: 140-200 mL
:- give frequent small sips from a cup
:- if the child vomits, wait for 10 min then
resume
:- continue giving extra fluids until diarrhea
stops

2. Give Zinc supplements

Up to 6 mo: 1 half tab per day for 10-14 days
6 months or more: 1 tab or 20mg
OD x 10-14 days

3. Continue feeding
4. Know when to return




TREATMENT PLAN C

Treat severe dehydration QUICKLY!

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

Age
First give Then give
30mL/kg in: 70mL/kg in:
Infants
(<12mo)
1 hour* 5 hours
Children
(12mo-5yrs)
30 min* 2 hours


Repeat once if radial pulse is very weak or not
detectable

reassess the child every 15-30 min.
if dehydration is not improving,
give IV fluid more rapidly

also give ORS (~5mL/kg/hr) as soon as the child
can drink [usually after 3-4 hours in infants; 1-2
hours in children]

reassess after 6 hrs (infant) & 3 hrs (child)



























































































SMR GIRLS
Stage Pubic Hair Breasts
1 Preadolescent Preadolescent
2
Sparse, lightly pigmented, straight,
medial border of labia
Breast & papilla elevated, as small
mound, areola diameter increased
3 Darker, beginning to curl, amount
Breast & areola enlarged, no contour
separation
4
Course, curly, abundant but amount <
adult
Areola & papilla formed secondary
mound
5
Adult, feminine triangle, spread to
medial surface of thigh
Mature, nipple projects, areola part of
general breast contour

SMR BOYS
Stage Pubic Hair Penis Testes
1 None Preadolescent Preadolescent
2
Scanty, long slightly
pigmented
Slightly enlargement
Enlarged scrotum, pink
texture altered
3
Darker, starts to curl, small
amount
Longer Larger
4
Resembles adult type but
less in quantity, course,
curly
Larger, glans &
breadth in size
Larger, scrotum dark
5
Adult distribution, spread
to medial surface of thigh
Adult size Adult size


ORS

Glucolyte 60
-: for acute DHN secondary to GE or other forms
of diarrhea except CHOLERA. In burns, post-
surgery replacement or maintenance, mild-salt
loosing syndrome, heat cramps and heat
exhaustion in adults.

Glucose:
100mmol/L
Cl:
50mmol/L
Gluconate:
5mmol/L
Na:
60 mol/L
Mg:
5mmol/L

K:
20 mmol/L
Citrate:
10 mmol/L



Hydrite
-: 2 tab in 200ml water or 10sachets in 1L water

Glucose:
111mmol/L
Cl:
80mmol/L
Glucose:
11mml/L
Na:
90 mmol/L
HCO3:
5mmol/L
Na:
90 mmol/L
K:
20 mmol/L
K:
20 mmol/L





Pedialyte 45 0r 90
-: prevention of DHN & to maintain normal
fluidelectrolyte balance in mild to moderate
dehydration.

Glucose 45mEq Glucose 90mEq
Na: 20mEq Na: 20mEq
K: 35mEq K: 80mEq
Citrate: 30mEq Citrate: 30mEq
Dextrose: 20g Dextrose: 25g



Pedialyte mild 30
-: to supplement fluid & electrolyte loss due to
active play, prolonged exposure, hot and humid
environment

Glucose: 30mEq Mg: 4mEq
Na: 20mEq lactate: 20mEq
K: 30mEq Ca: 4mEq

Energy:
20kcal/ 100ml


ETIOLOGY OF PNEUMONIA

Bacterial
- Streptococcus pneumoniae
- Group B streptococci (neonates)
- Group A streptococci
- Mycoplasma pnemoniae (adolescents)
- Chlamydia trachomatis (infants)
- Mixed anearobes (aspiration pneumonia)
- Gram negative enteric (nosocomial pneumonia)

Viral
- Respiratory syncitial virus
- Parainfluenza type 1-3 (Croup)
- Influenza types A, B
- Adenovirus
- Metapneumovirus

Fungal
- Histoplasma capsulatum (bird, bat contact)
- Cryptococcus neoformans (bird contact)
- Aspergillus sp. (immunosuppressed)
- Mucormycosis (immunosuppressed)
- Coccidioides immitis
- Blastomyces dermatitides
- Pneumocystis carinii (immunosuppressed,
HIV, steroids)





















LUDANS METHOD (HYDRATION THERAPY)

MILD
DEHYDRATION
MODERATE
DEHYRATION
SEVERE
DEHYDRATION
< 15 kg, < 2 y/o 50 cc/kg 100 cc/kg 150 cc/kg
> 15 kg, 2 y/o 30 cc/kg 60 cc/kg 90 cc/kg
D5 0.3% in
6-8 hours
1
st
hr: Plain LR
Next 5-7 hrs:
D5 0.3% in
5-7 hours
1
st
hr: Plain LR
Next 5-7 hrs:
D5 0.3% in
5-7 hours

HOLIDAY-SEGAR METHOD (MAINTENANCE)

WEIGHT TOTAL FLUID REQUIREMENT
0 - 10 kg 100 mL / kg
11- 20 kg 1000 + [ 50 for each kg in excess of 10 kg]
> 20 kg 1500 + [ 20 for each kg in excess of 20 kg]

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

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ATYPICAL PNEUMONIA

-: extrpulmonary manifestations
-: low grade fever
-: patchy diffuse infiltrates
-: poor response to Penicillin
-: negative sputum gram stain


Etiologic Agents Grouped by Age

> Neonates (<1mo)
- GBS
- E. coli
- other gram (-) bacilli
- Streptococcus pneumoniae
- Haemophilus influenza (Type B)

> 1-3 months
* Febrile pneumonia
- RSV
- Other respiratory viruses
- Streptococcus pneumoniae
- Haemophilus influenza (Type B)

* Afebrile pneumonia
- Chlamydia trachomatis
- Mycoplasma homilis
- CMV




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

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

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


Dengue Shock Syndrome

Manifestations of DHF plus signs of circulatory failure
1. rapid & weak pulse
2. narrow pulse pressure (<20mmHg)
3. hypotension for age
4. cold, clammy skin & irritability / restlessness


DANGER SIGNS OF DHF

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


Grading of Dengue Hemorrhagic Fever



DENGUE

> MOT: mosquito bite (man as reservior)

> Vector: Aedes aegypti

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

> Age incidence peaks at 4-6 yrs

> Incubation period: 4-6 days

> Serotypes:
- Type 2 most common
- Types 1& 3
- Type 4 least common but most severe

> Main pathophysiologic changes:
a. increase in vascular permeability

extravasation of plasma
- hemoconcentration
- 3
rd
spacing of fluids

b. abnormal hemostasis
- vasculopathy
- thrombocytopenia
- coagulopathy


















Dengue Fever Syndrome (DFS)

Biphasic fever (2-7 days) with 2 or more of the ff:

1. headache
2. myalgia or arthralgia
3. retroorbital pain
4. hemorrhagic manifestations
[petechiae, purpura, (+) torniquet test]
5. leukopenia


Dengue Hemorrhagic Fever (DHF)

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


































D
E
N
G
U
E


P
A
T
H
O
P
H
Y
S
I
O
L
O
G
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MANAGEMENT OF DENGUE

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


MANAGEMENT OF HEMORRHAGE



































































Torniquet Test: SBP + DBP = mean BP for 5 mins.
2

if 20 petechial rash per sq. inch on antecubital fossa
(+) test

Hermans Rash:
- usually appears after fever lysed
- initially appears on the lower extremities
- not a common finding among dengue patients
- an island of white in an ocean of red


Recommended Guidelines for Transfusion:

Transfuse:
- PC < 100,000 with signs of bleeding
- PC < 20,000 even if asymptomatic
- use FFP if without overt bleeding
- FWB in cases with overt bleeding or
signs of hypovolemia

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

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

Leukopenia in dengue: probable etiology is
Pseudomonas

therefore: give Meropenem or Ceftazidime



URINARY TRACT INFECTION


Suggestive UTI:
- Pyuria: WBC 5/HPF or 10mm
3

- Absence of pyuria doesnt rule out UTI
- Pyuria can be present w/o UTI

Presumptive UTI:
- (-) urine culture
- lower colony counts may be due to:
* overhydration
* recent bladder emptying
* previous antibiotic intake

Proven or Confirmed UTI:
- (+) urine culture 100,000 cfu/mL urine of a single
organism
- multiple organisms in culture may indicate a
contaminated sample



ACUTE GLOMERULONEPHRITIS

Complications of AGN
- CHF 2 to fluid overload
- HPN encephalopathy
- ARF due to GFR


STAGES of AGN
- Oliguric phase [7-10days] complications sets in
- Diuretic phase [7-10days] recovery starts
- Convalescent phase [7-10days] patients are
usually sent home


Prognosis
- Gross hematuria 2-3 weeks
- Proteinuria 3-6 weeks
- C3 8-12 weeks
- microscopic hematuria 6-12 mo or
1-2 years
- HPN 4-6 weeks


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


















RHEUMATIC FEVER

J ONES CRITERIA:

A. Major Manifestations
- Carditis (50-60%)
- Polyarthritis (70%)
- Chorea (15-20%)
- Erythema Marginatum (3%)
- Subcutaneous Nodules (1%)

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

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


















TREATMENT OF RHEUMATIC FEVER

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

*** NOTE: Sumapen = Oral Penicillin!

B. Anti-Inflammatory Therapy

1. Aspirin (if Arthritis, NOT Carditis)
Acute: 100mg/kg/day in 4 doses x 3-5days
Then, 75mg/kg/day in 4 doses x 4 weeks

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



PREVENTON

A. Primary Prevention

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




B. Secondary Prevention









C. Duration of Chemoprophylaxis



































































KAWASAKI DISEASE

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

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

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

HARADA Criteria
- used to determine whether IVIg should be given
- assessed within 9 days from onset of illness
1. WBC > 12,000
2. PC <350,000
3. CRP > 3+
4. Hct <35%
5. Albumin <3.5 g/dL
6. Age 12 months
7. Gender: male

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



TREATMENT

Currently Recommended Protocol:

A. IV-Immunoglobulin

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

NOTE: There is a TIME FRAME of 10 days


B. Aspirin

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




TYPES OF SEIZURES

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

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


SIMPLE FEBRILE SEIZURE
vs.
COMPLEX FEBRILE SEIZURE

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



















CLASSIFICATION BY CAUSE

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

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

C. Idiopathic
No history of preceding insult
Likely genetic component

















SEIZURES


> Seizures: sudden event caused by abrupt,
uncontrolled, hypersynchronous
discharges of neurons

> Epilepsy: tendency for recurrent seizures that are
unprovoked by an immediate cause

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

> Etiology:
- V ascular : AVM, stroke, hemorrhage
- I nfections : meningitis, encephalitis
- T raumatic :
- A utoimmune : SLE, vasculitis, ADEM
- M etabolic : electrolyte imbalance
- I diopathic : idiopathic epilepsy
- N eoplastic : space occupying lesion
- S tructural : cortical malformation,
prior stroke
- S yndrome : genetic disorder




SIMPLE FEBRILE SEIZURE

A. Criteria for an SFS
< 15 minutes
Generalized-tonic-clonic
Fever > 100.4 rectal to 101 F (38 to 38.4 C)
No recurrence in 24 hours
No post-ictal neuro abnormalities (e.g. Todds
paresis)
Most common 6 months to 5 years
Normal development
No CNS infection or prior afebrile seizures

B. Risk Factors
Febrile seizure in 1
st
/ 2
nd
degree relative
Neonatal nursery stay of >30 days
Developmental delay
Height of temperature

C. Risk Factors for Epilepsy
(2 to 10% will go on to have epilepsy)
Developmental delay
Complex FS (possibly > 1 complex feature)
5% > 30 mins => _ of all childhood status
Family History of Epilepsy
Duration of fever





BRONCHIAL ASTHMA (GINA GUIDELINES)

Controlled Partly Controlled Uncontrolled
Day
symptoms
none > 2x per wk
3 or more symptoms
of Partly Controlled
Asthma in any week
Limitation of
activities
none any
Nocturnal Sx
(awakening)
none any
Need for
reliever
< 2x per wk > 2x per wk
Lung
function
normal < 80%
Exacerbation none > 1x per yr 1x / week




































































TUBERCULOSIS

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

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

Microbial susceptibility unknown or initial drug
resistance suspected (e.g. cavitary)
previous anti-TB use
close contact w/ resistant source case or living
in high areas w/ high pulmonary resistance to
H.

2HRZ + E/S OD, then 4 HR + E/S OD or
3x/week DOT


B. Extrapulmonary TB
Same in PTB

For severe life threatening disease
(e.g. miliary, meningitis, bone, etc)

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



RESPIRATORY DISTRESS SYNDROME
(Hyaline Membrane Disease)

o Male, preterm, low BW, maternal DM, & perinatal
asphyxia

o Corticosteroids:
most successful method to induce fetal lung
maturation
Administered 24-48 hours before delivery
decrease incidence of RDS
Most effective before 34 weeks AOG

o Microscopically: diffuse atelectasis, eosinophilic
membrane


Pathophysiology:

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


NEWBORN RESUSCITATION

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

BREATHING is spontaneous or assisted
Tactile stimulation (drying, rubbing)
Positive-pressure ventilation

CIRCULATION of oxygenated blood is adequate
Chest compressions
Medication and volume expansion



RESUSCITAION MEDICATIONS

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


UMBILICAL CATHERIZATION

Indications
Vascular access (UV)
Blood Pressure (UA) and blood gas monitoring in
critically ill infants

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

Cautions
Never for:
Omphalitis
Peritonitis
Contraindicated in
NEC
Intestinal hypoperfusion

Line Placement
Arterial line
Low line
Tip lie above the bifurcation between L3 & L5
High line
Tip is above the diaphram between T6 & T9




Clinical Features:

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

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

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

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

Cyanosis:
o Central tongue & mnucosa (imp. Indicator of
impaired gas exchange); depends on
total amount of desaturated Hgb



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

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









BILIRUBIN

PRETERM:
mg/dl mmol/L
0-1 hr 1-6 17-100
1-2 d 6-8 100-140
3-5 d 10-12 170-200

TERM
mg/dl mmol/L
0-1 hr 2-6 34-100
1-2 d 6-7 100-120
3-5 d 4-12 70-200
1 mo <1 <17



KRAMERS CLASSIFICATION OF JAUNDICE

ZONE JAUNDICE
SERUM
BILIRUBIN
I Head & neck 6-8
II
Upper trunk
to umbilicus
9-12
III
Lower trunk
to thigh
12-16
IV
Arms, legs,
below
15
V Hands & feet 15











LUMBAR PUNCTURE

the technique of using a needle to withdraw
cerebrospinal fluid (CSF) from the spinal canal.

SPINE
spinal cord stops near L2
lower lumbar spine (usually between L3-L4 or
L45) is preferable

CSF
clear, watery liquid that protects the central
nervous system from injury
cushions the brain from the surrounding bone.
It contains:
glucose (sugar)
protein
white blood cells
Rate : 500ml/day or 0.35ml/min
Range : 0.3-04 ml/min
Volume : 50ml (infants)
150ml (adults)

Indication
to diagnose some malignancies (brain cancer and
leukemia)
to assess patients with certain psychiatric
symptoms and conditions.
for injecting chemotherapy directly into the CSF
(intrathecal therapy)






To diagnose other medical conditions such as:
viral and bacterial meningitis
syphilis, a sexually transmitted disease
bleeding around the brain and spinal cord
multiple sclerosis, (affects the myelin coating of
the nerve fibers of the brain and spinal cord)
Guillain-Barr syndrome, (inflammation of the
nerves)

Complication
Local pain
Infection
Bleeding
Spinal fluid leak
Hematoma (spinal subdural hematoma
Spinal headache
Acquired epidermal spinal cord tumor

Caution & Contraindications
Increased ICP
Bleeding diasthesis
Traumatic Tap
Overlying skin infection
Unstable patient

Procedure
Apply local anesthetic cream (ideally)
Position the patient
Prepare the skin using sterile techniques
Anesthetize the area with lidocane
Puncture the skin in the midline just caudal to the
spinus process, angle cephalad toward the
umbilicus using a g23 needle
Collect the CSF for analysis

CSF Analysis
1. Gram stain, culture and sensitivity
2. Cell count, differential count
3. Chemistries sugar, protein
4. Special studies

After care
Cover the puncture site with a sterile bandage,
apply pressure packing.
Patients must remain lying down for 4-6 hours
NPO for 4 hrs

































Empirical dose
6 months tsp TID QID
6 mos 2 yrs tsp
2-6 1 tsp
6-9 1 tsp
9-12 2 tsp





CLINICAL FEATURES

MILD MODERATE SEVERE
RESPIRATORY
ARREST
Breathless
- walking
- can lie down
- talking
- INF: softer,
shorter, cry,
difficulty
feeding
- prefers
sitting
- at rest
- INF: stops
feeding
- hunched
forward
Imminent
Talks in sentences phrases words
Alertness
may be
agitated
usually
agitated
usually
agitated
drowsy /
confused
RR
often >30
mins
bradypnea
Accessory
muscles &
retractions
none (+) (+)
(+) thoracoabd
movement



CLASSIFICATION BASED ON SEVERITY


INTERMITTENT
PERSISTENT
MILD MODERATE SEVERE
Exacerbation Brief
Affects daily
activity &
sleep
Affects daily
activity &
sleep
Limits daily
activity &
sleep
Day-time Sxs <1x/wk >1x/wk daily continuous
Nightime Sxs <2x/mo >2x/mo >1x/wk frequent
PEFR >80% >80% 60 - <80% <60%
PEFR VAR <20% 20 - 30% >30% >30%
FEV1 >80% >80% 60 - <80% <60%


MKD COMPUTATION

Wt x mkd x preparation [mg/mL] = mL per dose

e.g. 12kg x 10mg x 5ml = 5mL per dose
120mg

* If per day, divide total (mL) by the # of divided doses

Dose x preparation x frequency = mkd
weight


Paracetamol Drops = Wt: move 1 decimal
point to the left
Age Wt
1 10 kg
2 12
3 14
4 16
5 18
6 20

1 drop = 1/20 mL
1 teaspoonful = 5 mL
1 tablespoonful = 15 mL
1 wineglassful = 60 mL = 2 ounces
1 glassful = 250 mL = 8 ounces
1 grain = 60 mg
1 pint = 500 mL
1 quart = 1000 mL
1 ounce = 30 mL
1 Kg = 2.2 lbs
1 lb = 0.45359 Kg