The Pediatrics HO Guide

Contents

Introduction

1) General Neonates Clerking

2) General Pediatric Clerking
3) Basic offtag topics

4) Common Neonatal Problems

5) Common Pediatric Problems

Appendix
- PTL/ETL chart
- Immunization chart
- Growth Chart
- Post natal screening
- Ballard / Apgar score
- Developmental Milestone
- Formulae and calculations
- common drugs and doses

The pocket essentials:

1) Calculator 2) Scissors 3) Frank Shan 4) Peds Protocol 5) Pen torch

Notes compiled by
By Dr Gerard Loh Chien Siong
(CSMU 2011)
Peds Posting Feb June 2013
Supervisor Dr Kerry VJ
Mentor Dr Michael Wong Leong Wah

Special thanks: Dr Zuraidah, Dr B. Priya, Dr Shamani T. , Dr Rashidah, Dr Rahimah Ismail

Dr Nor Syarina, Dr Arfa Ardura, Dr Siti Norasikin, Dr Hazlina, Dr Nuryasmin, Dr Anayasmin, Dr Menaka,
Dr Tan Phaik Sia, Dr Choo Wei Chong, Dr Vaishali, Dr Wong Chang Yee, Dr Farah

- A House Officers Workshop Project-

www.myhow.wordpress.com
Contributors
Dr Ong Lip Kent (HA)
Dr Angeline Yap Ai Fen (HA)

Additional notes by
Dr Goh Kiam Seong (HTAR Klang)

References , images, tables

- Peds protocol 3rd edition
- various internet sources
Hospital Ampang Peds wards
NICU
1) Intensive (+ Isolation)
2) Semi-Intensive (intermediate)
3) Recovery / Mothers Room

4B
1) Respiratory (Acute + non acute)
2) Medical (Acute + Non acute)
3) AGE
4) Isolation
5) Multi-discipline

4A
Neonates + General Peds
Hospital Ampang Setup
General Neonatal Clerking

1) Age / Sex / Term/preterm , mode of delivery@ Gestational age / Apgar Score / Birth Weight / Current Weight
-TSH / G6PD status
- any weight loss (%)
eg: Day 5 / FT SVD @ 38wks / AS 9/10 / BW 3kg / CW 2.9kg
G6PD normal, TSH 5.6

2) History of Presenting Illness

-p/w jaundice since D3 of life . etc or
attended EMLSCS for fetal distress... events leading to admission (chronologically)

3) Maternal Hx:
-Age / Gravidity & Parity / Gestation
-Antenatal check up problems: PROM > 24 hours..HVS GBSetc
-Blood Group + Infectious Screening

4) Mother and Fathers Data

Age / Occupation / Gravida/Para
H/o abortion or consanguinity etc

5) Physical Examination

Anthropometry: Weight / COH / Length

Respiratory: clear? Air entry

CVS : murmurs?
Abdomen: soft/ distended

Genitalia: normal? (testis descended in male)

Mouth: cleft lip/palate

Eyes: clear/discharge? Cataract?
Ears: external meatus present? Skin tag? Discharges?

Neuro: Spine normal/spinia bifida? Skin tuft?

Reflexes: Moros / Sucking / Grasp

Radiology: CXR findings

Impression:
Management:
General Pediatrics Clerking

1)Problem:
Age / sex / Race
underlying medical illness /treatment/ follow up and TCA
any h/o admission?

Main complains: (short)

p/w fever 2/7 , Cough + RN 1/7, rapid breathing 1/7
______________________________________________________________________

2) History of presenting illness (elaborate complains)

c/o:
1) Fever 2/7
documented temperature..
- chills/rigor etc

2) Cough + RN 1/7
- chesty cough, sputumetc

Important points:
- Sick contact? PTB contact?
- Visited GP? Antibx given? Completed course?
- Interval Symptoms? Atopy? (BA)
- Child sent to nursery? How many children there? Any sick children
- Recent travelling / swimming / jungle trekking (dengue/leptospirosis)
- feeding: Usual feeding and current feeding (in Oz)

Otherwise (negative symptoms)

- No URTI / UTI, Vomiting/diarrhoea, fever ..etc

In ED: (short summary of mx)

- tachypnoic, RR given nebs x 2, IV hydrocortetc

_____________________________________________________________________________________
Medical / Surgical Hx: previous admissions? Surgery?

Allergies: food or drug allergies?

Birth Hx: Term? Mode of delivery / BW / admission to NICU?

Neurodevelopmental Hx : Gross Motor / Fine Motor / Speech / Social (refer appendix for dev milestone)

Family History: Fam hx of asthma? Fitting etc..

Social History: siblings, age, healthy / Parents age and occupation / living conditions
________________________________________________________________________________________

Physical Examination
anthropometry: weight / height / length

General examination:
alert, consciousetc
Vital signs..

ENT: throat injected? Tonsils enlarged? Ears TM intact?

Respiratory: lungs clear / air entry
CVS: murmurs?
Abdomen: soft / distended? / liver and spleen
Others: genitalia? Skin rashesLN etc

Diagnosis : Imp: AEBA 2 URTI

Lab: FBC/RP/LFT etc
Radiology: CXR

Action plan: Management, investigations, medications

Offtag notes by Dr Gerard
1) Asthma
Defn: Chronic airway inflammation leading to increase airway responsiveness, that leads to
recurrent episodes of WHEEZING, BREATHLESSNESS, CHEST TIGHTNESS, COUGHING (Night/early morning)
Hx: Interval sx
- Precipitating factor (URTI, allergen etc) Day/Nocturnal sx
- current mx, prev admission, Cold/exercise induced
- home/school environment Exacerbation frequency
- response prior to tx/compliance Need for reliever/nebs
- atopy- eczema, rhinitis, conjunctivitis Pets/ carpets at home
- Fam hx of Asthma
Acute Chronic
- tachypnoic / tachycardic - Harrison sulci
- hyperinflated chest - hyperinflated chest|
- wheeze/ronchi - eczema/dry skin
- recession - hypertrophied turbinate
- drowsy/cyanosed
Triggers
i) Episodic (viral) wheeze only wheeze during viral - environmental allergens
infections - Smoke
ii) Multiple trigger wheezer smoke, allergen, crying, - Respiratory Tract Infections
laughing, exercise - Food allergy
- Exercise induced

Clinical index (to define Risk of asthma)

> 3 wheezing episodes/year during first 3 years + 1 Major or 2 minor Criterion
Major: Minor:
- Eczema - Skin test +
- Parental asthma - Wheezing w/o URTI
- AERO Allergen skin test + - Eosinophilia > 4

Classification
1) Intermittent : - EIA
2) persistent : + EIA, + need for prophylaxis MDI

Degree of Asthma severity

Intermittent Mild persistent Mod Persistent Severe Persistent
Daytime sx < 1x / week > 1x /week Daily Daily
Nocturnal sx <1x / month >2x / month >1x / week Daily
EIA - + + Daily
Exacerbations Brief > 1x / month > 2x / month >2x / month frequent
Not affecting sleep Affect sleep/activity Affect sleep/activity Affect sleep/activity
PEFR/FEV1 Normal lung fn >80% 60-80% < 60%

GINA Level of asthma control (after starting MDI)

Controlled Partly controlled Uncontrolled
Daytime sx - > 2x / week > 3 of partly controlled
Nocturnal sx - + features
Limit activities /EIA - +
Exacerbations - > 1 / year
Lung Fn test Normal < 80% predicted best
Need for reliever - > 2x / week 1 in any week
Management
Assessment of severity
- Diagnosis = cough + wheezing + SOB / pneumonia
- Trigger factor = food, weather, exercise, infection, emotion, drugs, allergens
- Severity = RR, colour , respiratory effort, consciousness level
Sx mild Moderate Severe
Altered Consciousness - - +
Physical Exhaustion - - +
Talks in Sentences Phrases Words
Pulsusparadoxus NO +/- PALPABLE
Central cyanosis - - +
RONCHI + + SILENT CHEST
Use acc. muscles - Moderate MARKED
Sternal Retraction - Moderate MARKED
Initial PEF >60% 40-60% <40%
SpO2 >93% 91-93% <90%
OUTCOME Discharge May need admit ADMIT
Mx: 1) Neb Salb 1) Neb Combivent x 3 1) Neb Combivent x 3 / cont
< 1 yo: 0.5 : 3.5 2) O2 8L/min 2) O2 8L/min
>1yo : 1:3 3) Oral Prednisolone 3) IV Hydrocort 5mg/kg QID 1/7
or 4) IVI Salbutamol continous
MDI Salb in spacer Bolus: 5-10mcg/kg/10mins, then
4-6 puffs (<6yo) Infusion: 0.5-1mcg/kg/min
MDI 8-12 puffs ( >6yo) 5mg in 50ml
ventolin (blue) 1amp = 0.5mg (5mcg = x 10amp)
200mcg 2 puff PRN 2) Oral prednisolone 0.6ml/kg = 1mcg/kg/hr
Fluticasone (orange) SyrPred 1mg/kg/day max 20mcg
125mcg 2 puff BD for 3-5/7
Budesonmide (brown) * S/C Bricanyl (terbutaline)
125mcg BD Reasses after 60mins Reasses after 60mins 0.005-0.01mg/kg (max 0.4mg) every
Seretide (purple) if no improvement if no improvement, 5-10mcg/kg
25/125 1 puff BD Tx as moderate Tx as severe 15-20mins

Montelukast /singulair * IV MgSO4 50%

4mg granules Bolus: 0.1ml/kg(50mg/kg) in 20mins
(Chew @8pm)
*IV Aminophyline
IV hydrocort 4-5mg/kg Bolus:6mg/kg bolus then
QID for 1/7, Infusion: 0.5-1.0mg/kg/hr
then change to
Syr Prednisolone *Mechanical ventilation and
1-2mg/kg OD for 5/7 observation in HDW/ICU

Criteria for admission

1) failure to respond to standard tx at home
2) failure to respond to NEB
3) Relapse within 4 hours of NEB

Asthma Action plan

MDI Ventolin 100mcg MDI Fluticasone 125mcg
Healthy 2 puff PRN 1 puff BD
Unhealthy 2 puff QID 1 puff BD
Exacerbation MDI Ventolin 1puff 10 breaths, repeated up to 10times, may repeat every 20mins
Bring child to hospital immediately
* 10 puffs ventolin = 1 Neb
 2) Febrile Seizures
Defn: Fit with fever in children aged 3months 6 yo (with no evidence of intracranial pathology/metabolic derangement)
(24hrs)
Sx Simple Complex
Duration <15mins >15mins
Type of convulsion Generalized tonic-clonic Focal
Occurrence 1 in 24 hours >1 in 24 hours
(does not recur during febrile episode)
Post Ictal Drowsiness + -

Causes Risk factors

- Otitis Media Fam hx of febrile fits (%recur: none:
- URTI / UTI(tonsilopharyngitis ) <15% | >2:>30% | > 3: >60%)
- gastroenteritis age < 18mo
- viral infection low degree fever (<40 C) during 1st episode
- meningitis (irritability, full fontanelle, meningismus) < 1 hour btwn onset Fever & Fit

Criteria for admission

1) Fear of recurrent fits
2) To exclude intracranial pathology
3) investigate and treat cause
4) Allay parental anxiety (stay far from hospital)

Hx:
1) Duration of fitting, type of fitting (GTC/focal etc)
2) Family hx of fitting
3) Sx of infection
4) Neurological development

Management
1) Control fever Syr PCM 15mg/kg or tepid sponging
2) Supp Diazepam 0.5mg/kg (if Fit >5min)
3) I/O
4) Encourage orally
5) Fit Education and diary
Ix: FBC, RP, RBS, C&S blood/urine, UFEME
* LP if evidence of meningitis
* EEG if multiple recurrent/complex febrile fit

Fit education
- stay calm during onset
- loosen clothes, esp around neck
- Left Lateral Position
- Dont insert anything into mouth
- Wipe any secretions from mouth
* Time the duration, if > 5mins bring child to Clinic/Hospital
* During fever, give PCM/tepid sponging, encourage fluids intake, good aeration
Status Epilepticus
Defn: Any seizure > 30mins or intermittent seizure w/o regaining full consciousness > 30mins
Seizure > 5 mins : Impending Status Epilepticus
5-30 mins : Established Status Epilepticus
post phenytoin > 10 mins : Early Refractory Status Epilepticus
> 60 mins : Established Refractory Status Epilepticus
3) Acute GastroEnteritis
Abdomen turgor General Condition Eyes sunken, Turgor
Signs of shock = Tachycardia, weak peripheral pulse, delayed CRT, cold peripheries, depressed mental state
Assess
General Condition Well, alert Restless, irritable Lethargic, unconscious
Sunken eyes - + +
Offer Fluid Drinks normally Drinks eagerly, thirsty Not drinking, poor
Pinch skin (abdomen) Skin goes back immediately Skin goes back slowly Skin goes back slow >2sec
DEHYDRATION MILD (<5%) Moderate (5-10%) Severe (>10%)
Treatment Plan A (Tx at home) Plan B Plan C
- Give extra fluid (ORS/H20) - Give ORS over 4 hours - Start IVD immediately!
- Cont feeding on demand - Reassess after 4 hours
- Return when poor oral
intake, fever, bloody stool
ORS 8 sachets at home ORS over 4 hours 0.9 % NS bolus 20ml/kg then
<2 yo : 50-100ml after BO <6kg : 200-400ml reassess
>2yo : 100-200ml after BO 6-10kg : 400-700ml Correction +maintenance
- give frequent small sips frm 10-12kg : 700-900ml
cup/spoon 12-19kg : 900-1400ml
* if vomit, wait 10mins then
give slowly (1 spoon/2-3mins)

Fluid Management
Maintenance (over 24H) D31 - 6 mo : 150cc/kg/day (1/5NSD5%)
6mo 1 year : 120cc/kg/day (1/5NSD5%)

> 1 yo : Holliday segar formula (1/2 NSD5%)

1st 10kg = 100ml/kg (10kg = 1000ml)
2nd 10kg = 50ml/kg (20kg = 1500ml)
> 20kg = 20ml/kg
Metabolic acidosis, pH <7.1 IV 8.4% NaHCO3 = 1/3 base deficit x Wt
Correction of Na Eg Na: 128 , BW 15 kg , 2yo
Na deficit = (135 Se Na) x 0.6 x Wt
Deficit : (135 128) x 0.6 x 15 = 63mmol
Daily req Na = 2-3mmol/kg/day
Daily requirement = 3 x 15 = 45mmol
1pint = 500ml
0.9% NS = 154 mmol / L Total = 63+45 = 108 mmol
1/2NS = 77mmol / L
1/5 NS = 39mmol / L 1 pint NS = 39 mmol Na

TF = 1150ml/ day ; 1150/24Hr = 48cc/hr (90mmol Na)

Correction of K Eg: Se K : 2.5 , weight 15 kg

K deficit = (4-Se K) x 0.4 x Wt)
Deficit: (4 - 2.5) x 0.4 x 15 = 9 mmol
Daily req K= 2-3mmol/kg/day
Daily requirement = 2 x 15 = 30mmol
1g KCL = 13.3mmol
10ml Mist KCL = 1g K Total = 9 + 30mmol = 39 mmol

1g = 13.3mmol, 1 pint 500ml, 1 39 mmol g = 39/13.3 = 3g

ml=0.02 therefore if
*no more than 0.05mmol/ml a) IVD = 1.5 g in each pint
check: no more than 0.05mmol/mL/min in each pint
(1.5g x 13.3mmol ) / 500ml = 0.03mmol/ml ( not more than 0.05)

b) Mist KCL = 3g x 10 = 30ml

Correction (fluid deficit) % dehydration x BW in grams (= % x BW(kg) x 10)

Eg: 10% dehydration, BW 15kg
5/100 x 15kg x 1000 = 5 x 15 x 10 = 750cc
Run over 12 / 24 / 48 hours
Investigations Stool C&S, FEME and Rotavirus Antigen
Ddx lactose intolerance: stool reducing sugar (diarrhoea >14 days)
4. Dengue Fever
New classification
1) Dengue with or without warning signs
2) Severe Dengue
WARNING SIGNS Probable Dengue Severe DengueSx
Water accm Endemic area + Fever, and 2 of: Severe plasma leakage (rising HCT)
Abdominal pain Nausea/vomiting Fluid Accm (ascites/ pleural effusion)
Raised HCT/ decreased Plt Rashes Respiratory Distress
Non stop vomiting Muscular aches and pain Severe bleeding
Increased Liver size > 2cm Torniquet test + Severe organ involvement
Nasal/mucosal bleed Any warning sx Liver enzymes AST/ALT >1000
General: lethargy, restlessness Lab: leucopenia / IgM CNS: impaired consciousness/seizures

First encounter, determine:

1) Establish Dengue
2) Phase of illness
3) warning sx / severe dengue sx
Management goals
1) Replace plasma losses
2) Early recognition/tx of haemorrhage
3) Prevent fluid overload
Phases
1) Febrile T > 38
2) Critical (defervescent <38.5)
3) Recovery
History
1) Fever how many days? Last taken T PCM?
2) Alarm signs
3) Mental state
4) Urine output
5) relevant hx fogging, recent travel, jungle trekking, swimming in waterfall, high risk behaviour etc

Physical
1) GCS
2) Hydration
3) Hemodynamics skin, cold/warm limbs, CRT, pulse volume, BP, PR, pp
4) Respiration: tachypnoea, effusion
5) PA: abdominal tenderness? Ascites?Hepatomegaly
6) bleeding manifestations (tourniquet test)

Ix:
1) FBC neutropenia, HCT rising, Plt decreasing
2) LFT AST elevation > ALT (DHF)
3) Dengue serology Tests:
a) Dengue IgM taken ASAP when suspected, then repeat Day 7 (seroconversion)
b) sero surveillance taken for statistics purposes, before Day 5

Management
Hydration
5-7ml/kg/hr 1-2hours
3-5ml/kg.hr 2-4hours
2-3ml/kg/hr adjust and taper
* according to clinical response and HCT

Compensated Shock
1) Obtain HCT level before fluid resus IVD 5-10ml/kg/hr x 1Hour
2) repeat: FBC/HCT/BUSE/LFT/RBS/CoAg/ Lactate/Bicarb / GXM
- check HCT if no improvement repeat IVD 5-10ml/kg/hr (up to 2 cycles, if no improvement change to colloids)
* If HCT decrease, consider occult bleeding Tx PC
* If persistent shock after x 3 cycles, consider other causes of shock = sepsis, cardiogenic shock
* adjust fluids clinically, avoid overload = ascites/pleural effusion/APO

Decompensated shock
1) Obtain HCT level before fluid resus
2) IVD 10-20ml/kg/hr give over 15-30mins then repeat Ix: FBC/HCT/BUSE/LFT/RBS/CoAg/ Lactate/Bicarb / GXM
3) Check HCT if no improvement repeat 2nd bolus 10-20ml/kg/hr 30-60mins then repeat HCT,
3rd Bolus 10-20ml/kg/hr over 1 hour (with colloids)
* if persistent shock after 3x fluid resus, other causes of shock must be consideredbleeding, sepsis, cardiogenic
* if after fluid resus HCT decrease, consider Tx with packed cell

Mx of bleeding
1) Gum bleeding Tranexamic acid oral gargle TDS, monitor Hb
2) Occult bleed when HCT drop without clinical improvement despite fluid resus, blood tx with PC is recommended

ICU care
Ind: persistent shock, respiratory support (mech ventilation), significant bleeding, encephalopathy/encephalitis

Discharge criteria (GO BACK LA)

1) General condition improves 5) Clear lungs- pleural effusion/ascites
2) Organ dysfn recovered 6) Kencing (good urine output)
3) Bleeding episodes resolved 7) Lab-Plt rising>50 000, Hct Stable
4) Afebrile >48hours 8) Appetite returns
Neonatal Jaundice
Etio: Liver immaturity /Hemolysis
Bilirubin (present from breakdown of heme) >85mcmol/L or 5mg dL [1mg/dl = 17mcmol/L]
- Yellowish discolouration of skin, mucous membrane and sclera
- normally direct <15%
Pathophysiology
1) Break down of HbF by increased biliverdin (+ heme) accm of unconjugated bilirubin = clinical jaundice
2) Hemolysis increased circulation of unconjugated bilirubin = jaundice
Risk factors
Maternal Neonates
ABO/Rh incompatibility Birth trauma. Cephalohematoma
Breast feeding volume/traditional medicine Bruising (VAD, forceps)
Diazepam/oxytoxin Excessive weight lost
Asian/native American Infections
GDM Decreased/infrequent feeding
Polycythemia
Prematurity

Physiological (24-72H)
-marked physiological release of Hb (RBC life span decrease)
-hepatic bilirubin metabolism less efficient
Pathological (<24hrs , 24-2weeks , >2weeks)
1) Early onset (<24H)
- unconjugated ( Rh/ABO, G6PD, spherocytosis, pyruvate kinase deff, drugs)
- congenital infection (TORCHES), sepsis
Ix: TSB, G6PD, Mother and Baby ABO, Coombs Test, Retic Count, FBC
2) Late (24-2weeks)
- physiological - ABO/G6PD
- BF jaundice - bruising/cephalohematoma
- Infection (UTI, septicaemia, meningitis) - polycythemia
- Hemolysis - dehydration
* CriglerNajiar Syndrome
disorder of metabolism of bilirubin, autosomal recessive, consanguinity, TSB >345, no response to tx)
Breast Feeding jaundice Phototherapy as indicated, TSB stat, taper photo accordingly
- caused by inadequate feeding leading to weight loss and Encourage BFOD, try EBM and top up with supplemental
increased enterohepatic circulation ( deconjugation by B- formulated milk
glucoronidases in colon, hence unconjugated bilirubin is
reabsorbed into circulation causing jaundice)
- Weight loss >10%

Breast Milk Jaundice (D4-7OL)

- adequate breast feeding but certain enzymes/genetic problem, Cont Breast feeding, add supplementation
result in poor conjugation of bilirubin (exact mechanism still
unknown)
ABO/Rh incompatibility Phototherapy as indicated
- Usually early onset within 24hours Baby ABO, Coombs test, Retic Count , FBC, LFT, RP
- Mother BG O+ (anti A + anti B), Baby BG A or B
- hemolysis result in increased bilirubin

Sepsis / infection Blood C&S, FBC

- poor feeding, lethargy, temperature instability, tachypnoic Start antibiotics
- risk of maternal sepsis (PROM>24H, maternal pyrexia etc) strict I/O
Bruising / Cephalohematoma COH 4hourly monitoring
G6PD / Spherocytosis G6PD observe 5/7, lifestyle advise
FBP
Hypothyroidism TFT
Polycythemia
HCT > 65%, Hb > 20
Prolonged Jaundice >14 weeks
TFT, Urine C&S, UFEME, urine reducing sugar
FBP
Conjugated hyperbilirubinemia + TORCHES, IEM screening, HEP B/C
Kramers rule

Phototherapy
Conventional Photo (single, double, triple)
Clinically jaundiced, start with single/double photo as indicated, take TSB and adjust accordingly
(refer to Photo Level and ET Level)
When to stop Phototherapy: when TSB is 30mcmol below photolevel

Intensive Photo Therapy = 4 photo

* cont rising TSB despite phototherapy suggests hemolysis (KIV Exchange Transfusion)
TSB monitoring: 1P : CM , 2P : 12Hrly, 3P : 6Hrly, 4P : 4Hrly

Exchange Transfusion
Ind:
When phototherapy fails (no decline in TSB (17-34mcmol/L ) after 4-6H)
Sx of Acute bilirubin encephalopathy ( hypertonus, retrocollis, opisthotonus, high pitch cry, fever)

- use RH isoimmunization / ABO compatible / Rh ve Blood

- 2 x 80ml/kg/hr, use fresh whole blood (1 cycle 3-4mins: 1min In : 1min Out:1min rest ; 90-120min 30-35cycles)
- correct hydration / infection

Pre ET: Blood C&S , FBC, RP, LFT, Ca,mg, PO4, VBG, RBS, FBP, Retic count, Coombs test, ABO
Infectious Screening (HIV,Hep,VDRL), TORCHES
Post ET: Blood C&S , FBC, RP, LFT, Ca,mg, PO4, VBG, RBS
6H post ET: TSB,FBC,RP

Kernicterus
- Encephalopathy due to deposition of unconjugated bilirubin in basal ganglia and brainstem nuclei

Sx:
Acute: lethargy, poor feeding
Severe: irritable, high pitch cry, hypertonicity, opisthotonus, seizures, coma

Long term complications: learning difficulties, sensorineural deafness

Prolonged jaundice ( jaundice for > 14 days in Term, > 21 days in Pre term)

Unconjugated Conjugated
Septicaemia ( UTI) Biliary atresia, choledochal cyst,
Breast milk jaundice Idiopathic neonatal Hepatitis
Hypothyroidism TORCHES infection
Hemolysis ( G6PD, spherocytosis) Metabolic diseases
Galactosemia - Citrin deficiency, galactosemia, PFIC,
Gilberts syndrome alpha-1-antitripsin deficiency
Neonatal Hypoglycemia
Defn:Glucose < 2.6 mmol/L after first 4 hours of life
Neonatal DXT 1.7mmol within 1-2 HOL is considered normal, then increase to more stable level >2.5mmol by 12 HOL
Sx
Jitteriness and irritability
Apnoea, cyanosis
Hypotonia, poor feeding
Convulsions
* hypoglycaemia may be asymptomatic therefore monitor if
risk present

High Risk:
Infant of GDM mother
Premature babies
SGA and LGA (>4.0kg)
Ill infants: sepsis, hypothermia, polycythemia, Rh dis, HIE

DXT 1.5 2.5, asymptomatic DXT < 1.5 / Symptomatic

Initial Mx 1) Feeding: early BF / EBM / FSM 1) repeat capillary DXT and send RBS
2) monitor DXT: 1H x 2, 2H x 2, then 4H 2) Bolus IV D10% , 2-3ml/kg
if stable, DXT QID, Inform if DXT < 2.6 3) start IVD D10% (60-90cc/kg/day, D1)
DXT still low If DXT remain < 2.6 or baby refuse feed * if still low DXT despite on IVD D10%,
+ start IVD 10% , can increase 2mg/kg/min increase rate to 8-10mg/kg/min
till DXT stable > 2.6
* Start feeding when DXT stable, reduce IVD
Persistent + increase volume 30ml/kg/day or
Hypoglycemia increase DXT 12.5% or 15% (by central line)
If given > 8 10mg/kg/min, consider IV Hydrocortisone 2.5-5mg/kg BD
Ddx
hyperinsulinemia Ix: Insulin , Cortisol, growth hormone level, Serum ketones , Urine for organic acids
adrenal insuff
Galactosemia PO Diazoxide 10 -25mg/kg/day (hyperinsulinemiareduces insulin secretion; CI: SGA)
Metabolic dis SC Octreotide 2-10mcg/kg/day BD/TDS (synthetic somatostatin)

Glucose req (mg/kg/min) = % Dextrose x Rate (ml/hr) Rate = Glucose Req x Weight x 6
weight (kg) x 6 % Dextrose
s
 The Premature Baby

Term : 37-42weeks
Prem : < 37weeks Gestation
Moderate Prem : 31/32 36weeks
Severe prem : 24-30weeks
LBW : < 2.5kg
VLBW : < 1.5kg
ELBW : <1.0k

Risk of prem
Pregnancy problem multiple gestation, poly/oligohydramnios, placenta previa/abruptio, fetal abnormality
Risky Behaviour smoking, substance abuse, poor nutrition
Early delivery Rh Incompatibility, IUGR
Medical Uterine/cervical abnormality, myoma, hypertension

Care of prem babies

1) Monitor temperature, Vital signs, DXT
2) I/O
3) Ventilation
4) IV line / Central Line
5) Feeding trickle feeding, multivitamin, folic acid, FAC (6wks)
- increase slowly, start 2.5cc/kg/feed, if tolerating x 2, increase slowly, maximum 200cc/kg/day
6) strict hand hygiene
7) antibx
8) aminophyline (<34wks)
9) Immunization BCG (wt >1.8kg), Vit K (at birth)
Ix:
Routine bloods: FBC/LFT/RP/Ca/Mg/PO4
US Brain (< 32 weeks) : 1st week (IVH) and 28days (PVL)
ROP @ 36weeks / 4-6weeks ( if <1.5kg, < 32weeks, ventilated)

Hearing Assessment
Indications:
Fam hx of hearing loss
Ventilation >5days
Hyperbilirubinemia
Craniofacial abnormalities
Head Trauma
VLBW < 1.5kg
Ototoxic medication
Parental concern
In-Utero infections
Meningitis
Low Apgar Score
Early Complications (Hypo: thermia/glycemia/Ca/Na + Resp: RDS/apnea + CVS: PDA + CNS: IVH)

1) Hypothermia
large surface area, thin skin, less fat (less brown fat, more glycogen)
mechanism of heat loss : radiation, conduction, convection, evaporation
Mx: Incubator care

2) RDS ( respiratory distress syndrome )

- reduced surfactant (phospholipid protein)
- 24-28wks, lungs mature at 35weeks
- decreased surface tension, increases alveolar function
Sx: Tachypnoea, labored breathing, recessions, nasal flaring, expiratory grunting, cyanosis
CXR: ground glass appearance, larger airway outlined, no heart border, diffuse granular
Mx:
Prevention IM Dexa, tocolytic agent, surfactant replacement
Respiratory supportETT ventilation, CPAP, SIMV (complicationspneumothorax) , SEDATION
Fluid & nutritional support
Antibx

3) Hypoglycemia (RBS < 2.6mmol in first 4 hours)

4) Apnea of prematurity
= pause of breathing > 20secs with brady or desaturation, HR drop 30bpm from baseline
cause: Immaturity of respiratory centre, lack of pharyngeal muscle tone and collapsed upper airway
- resolves at 36weeks
Mx: Supportive O2, relieve obstruction (CPAP), aminophyline to rinhibit adenosin receptor, mechanical ventilation

5) IVH (intraventricular hemorrhage)

- fragile blood vessels in germinal matrix above caudate nucleus
- occurs in < 32wks (within 5 days after birth)
- Sx: pallor, shock, hypotonia, apnoea, seizure, hydrocephalus

6) Infection

7) PDA (patent ductus arteriosus)

sx: asymptomatic, brady/apnea, increased O2 requirment
Systolic murmur at 2nd Left ICS
Ix: CXR= cardiomegaly, pulmonary venous congestion

8) Hyponatremia dehydration/transepidermal h2o loss, immature kidney

9) Hypocalcemia Immature pancreas and reduced calcium from mother

Late Complications CNS Eye- Resp Bone GIT Blood - Sepsis
1) NEC (necrotising enterocolitis) - occurs within 1st week of life
- immature gut compromised gut circulation bacterial invasion of ischemic bowelserious intestinal injury

Sx: Feeding intolerance, abdominal distension, hematochezia, vomit milkcurd

/greenish bile, shiny skin abdomen, reduced BS

AXR: distended loops of bowel, thick

Mx: keep NBM, start paraenteral feeding (TPN/OGT), antibx

Complications: bowel perforation, strictures, malabsorption

2) ROP (retinopathy of prematurity) retina working too early

- Retina is formed but blood supply is limited vascular proliferation to ischemic
area retina detachment
Sign: white pupil ( retinal detachment)
Tx: laser therapy

ROP screening Indications: < 1.5kg, < 32weeks, supplemental O2, hypoxemia, hypercarbia
3) BPD (bronchopnuemonary dysplasia) / CLD
- Lung damage from pressure and volume trauma ( artificial ventilation/ O2 toxicity/ infection)
CXR: widespread opacity and cystic changes
Mx: prolonged artifical O2, Corticosteroids

4) PVL (Periventricular leucomalacia)

- necrosis of white matter at dorsal and lateral
complications: spastic displegia, coignitive and inelectual deficit, visual deficit, seizure disorder

5) Osteopenia of prem
- rickets/chronic reduced Calcium
CXR: Bone deminieralization
Sx: Poor wt gain, fracture, respiratory distress
6) GERD
7) Prolonged jaundice
8) Sepsis
9) Anemia : < 8 ( <12 if ventilated)|
Hematinics, Folic Acid, appeton , FAC( ferrous amino citrate, after 42/7)
General Peds common problems guide

Bronchial Asthma
AEBA 2 to URTI/CAP/environmental factor
underlying asthma control? Intermittent / persistent

Determine severity and mx:

Sx mild Moderate Severe

Altered Consciousness - - +
Physical Exhaustion - - +
Talks in Sentences Phrases Words
Pulsusparadoxus NO +/- PALPABLE
Central cyanosis - - +
RONCHI + + SILENT CHEST
Use acc. muscles - Moderate MARKED
Sternal Retraction - Moderate MARKED
Initial PEF >60% 40-60% <40%
SpO2 >93% 91-93% <90%
OUTCOME Discharge May need admit ADMIT
Mx: 1) Neb Salb 1) Neb Combivent x 3 1) Neb Combivent x 3 / cont
< 1 yo: 0.3 : 3.5 2) O2 8L/min 2) O2 8L/min
>1yo : 1:3 3) Oral Prednisolone 3) IV Hydrocort 4-5mg/kg QID 1/7
or 4) IVI Salbutamol continous
MDI Salb in spacer Bolus: 5-10mcg/kg/10mins, then
4-6 puffs (<6yo) Infusion: 0.5-1mcg/kg/min
MDI 8-12 puffs ( >6yo) 5mg in 50ml
ventolin (blue) 1amp = 0.5mg (5mcg = x 10amp)
200mcg 2 puff PRN 2) Oral prednisolone 0.6ml/kg = 1mcg/kg/hr
Fluticasone (orange) SyrPred 1mg/kg/day max 20mcg
125mcg 2 puff BD for 3-5/7
Budesonmide (brown) * S/C Bricanyl (terbutaline)
125mcg BD Reasses after 60mins Reasses after 60mins 0.005-0.01mg/kg (max 0.4mg) every
Seretide (purple) if no improvement if no improvement, 5-10mcg/kg
25/125 1 puff BD Tx as moderate Tx as severe 15-20mins

Montelukast /singulair * IV MgSO4 50%

4mg granules Bolus: 0.1ml/kg(50mg/kg) in 20mins
(Chew @8pm)
*IV Aminophyline
IV hydrocort 4-5mg/kg Bolus:6mg/kg bolus then
QID for 1/7, Infusion: 0.5-1.0mg/kg/hr
then change to
Syr Prednisolone *Mechanical ventilation and
1-2mg/kg OD for 5/7 observation in HDW/ICU

Once stable, get full history:

a) Medication - MDI compliance
b) Sick contact / travelling
c) Interval symptoms: need for reliever/nebs, EIA/CIA, Fam Hx asthma
d) Atopy , rhinitis, eczema
Community Acquired Pneumonia Lungs: Mx:
C/o: coarse crepts? 1) Antibx
chesty/productive cough + RN air entry? IV C Pen 100 000U/kg QID 5-7 days
- sputum whitish/blood streak tachypnoic? IV Azithromycin 15mg/kg (D1) / 5mg/kg (D2-5)
+ recessions? * cover for atypical
Fever + hyperventilated chest? Syr Azithromycin 15mg/kg (D1) / 7.5mg/kg (D2-5)
- chills/rigor? highest documented T? IV Azithro 15mg/kg D1, 5mg/kg D2-D5
Ix: FBC: WCC Syr EES 20mg/kg BD
Rapid breathing
- Nebs given? CXR: patchy 2) Oxygen (NP or Oxykid)
consolidation + 3) Nebs if indicated (tight chest, tachypnoic,
Less active/post tussive vomiting? perihilar haziness rhonchi (broncospasm)
4) +/- Syr bromhexine 0.3mg/kg
Sick contact? PTB contact? If start antibx
Visit GP/KK? antibx given? Blood C&S
Recent admission? Tx with antibx? Antimycoplasma IgM
(TRO nosocomial pneumonia)
Chronic cough (TRO PTB)

Acute tonsilopharyngitis Throat injected? Mx:

c/o: tonsils enlarged? 1) start antibx if indicated
Fever any exudates? IV C pen 25 000IU/kg QID (throat dose)
- chills/rigor? highest documented T? IV Cefuroxime 25mg/kg TDS (exudative)
Ix: FBC WCC raised?
vomiting Neu predominant 2) IVD if dehydrated
- food/blood/bile? 3) Syr PCM 15mg/kg QID/PRN
- a/w post tussive? RP: Urea >4, Cr >60 4) encourage orally
electrolytes imbalance
Reduced oral intake *Can treat at home with oral antibx
- usual intake, current intake *Admit if poor oral intake, dehydrated

* may present with febrile fit

Sick contact?
Acute Bronchiolitis Lungs: rhonchi? Admit:
- common in 1-6mo, etio- RSV +tachypnea, <3mo, toxic looking, severe recessions, central
C/o: SCR/ICR, wheeze cyanosis, wheeze, crepts, poor feeding, aopnea ,
low grade fever + Coryza Spo2 <93%,
(nasal decongestion) Ix:
FBC: Wcc raised? Mx:
Cough + RN 1) Oxykid 3L
CXR (if severe RD) 2) IVD, encourage orally
Rapid breathing hyperinflated, 3) Nebs if indicated
segmental/lobar 4) NS nasal drops 1/1 TDS
consolidation

Febrile Fit ?source of fever Mx:

c/o: - tonsilopharyngitis 1) Syr Paracetamol 15mg/kg QID
fitting - Otitis media Supp Diazepam 0.5mg/kg
- first episode? - AGE 2) Tepid Sponging
- onset time and duration - Meningitis (meningism) 3) antibx if indicated
- what was child doing 4) Fit chart
- nature: GTC/jerking limbs Partial/complex 5) fit education
- uprolling eyeballs?
- drooling of salive Ix: If 2nd onset, no need admission unless parents
- post ictal drowsiness? Regain conscious? FBC/RP/electrolytes anxious, afebrile fit, complex seizure

fever
- how long? Given PCM?

Fam Hx seizure? Sick contact?

Meningitis Photophobia Keep NBM, IVD maintenance till conscious
Neck stiffness VS monitoring 4hrly
Seizure? Fever raised ICP COH monitoring
Neck/limb stiffness Fit + GCS chart
Change in behaviour/ Irritability? neurodevelopmental follow up
Poor feeding / Less Active Ix: IV C Pen 100000IU/kg QID
Nausea/vomiting FBC/RP/LFT/e- IV Rocephine 25-50mg/kg BD or
Blood C&S IV Cefotaxime 25mg/kg BD
* Lumbar puncture
CT Brain
Dengue Fever Hydration status? Mx: rehydration
Fever day..? pulse volume? 5-7ml/kg/hr 1-2hours
Warning signs? Cold limbs?CRT 3-5ml/kg.hr 2-4hours
- vomiting, abd pain, bleeding gums etc Urine output 2-3ml/kg/hr adjust and taper
Myalgia/arthralgia? Temperature >38 * according to clinical response and HCT
Rashes recovery phase < 37.5 = defervescence
* FBC 4-6hourly till stable
Recent travelling/jungle trekking/swim Ix: FBC / RP / LFT / *refer to DF section for more in depth mx
Recent fogging in neighbourhood? Dengue IgM

Ddx Leptospirosis / Viral fever * Plt and WCC reducing,

HCT >20% off baseline
AGE General consciousness Determine degree of dehydration and treat per
c/o: Hydration protocol * refer to chapter about AGE mx
Diarrhoea Sunken eyes/fontanel?
- frequency/day Tachycardia? (SHOCK) ORS per purge 10ml/kg
- mucous?blood? Pulse volume repeat VBG/RP post correction
skin turgor
Vomiting CRT prolonged?
- frequency/day cool peripheries?
- food particles/blood/bile hypotension?

Reduced intake Ix: VBG/RP/electrolytes

- usual feeding (Oz), current feeding Stool FEME, C&S,
rotaviral antigen
Less active? Fever?

Outside food? Fam with similar sx?

Post infectious AGN UFEME-Hb+,Pro+ Monitor BP

FBC/RP/Electrolytes Strict I/O
c/o: ASOT >200IU Fluid restriction (control edema)
Edema (facial puffiness) Throat swab C&S low salt diet
Hematuria C3 low/C4 normal Antihypertensive
Hypertension Syr Nifedipine 0.25-0.5mg/kg or
-Headache, Blurry vision, vomiting Syr Captopril 0.1-0.5mg/kg
Target of BP control:
- Reduce BP to <90th percentile of BP for age, gender and
height percentile .
- Total BP to be reduced = mean BP - Desired mean BP
- Reduce BP by 25% of target BP over 3 12 hours.
- The next 75% reduction is achieved over 48 hours

Diuretics Syr Frusemide 1mg/kg

daily RP
Common Neonatal Problems
Neonatal Jaundice - Ix: Start phototherapy
TSB, trace TSB, to taper photo accordingly
Early onset (<24hours) Retic Count, (refer to PTL/ETL chart at least 30mcg below)
- ABO/Rh incompatibility Coombs Test adequate feeding
- G6PD deficiency FBC
- spherocytosis ABO/Rh
- sepsis
- trace G6PD, TSH,
Mother BG
NNJ > 24hrs to 2 weeks Ix: Phototherapy / ET as indicated
- exaggerated physiological TSB trace TSB, to taper photo accordingly
- inadequate feeding (wt loss?) +/- FBC/RP adequate feeding
- dehydration (renal impairment)
- infection ET Ix:
- polycythemia Pre ET: Blood C&S , FBC,
- traditional medication RP, LFT, Ca,mg, PO4,
- cephalohematoma VBG, RBS, FBP, Retic
count, Coombs test, ABO
Onset Day? Infectious Screening
adequate breast feeding? (HIV,Hep,VDRL),
PU/BO normal? TORCHES
sick contact? Post ET: Blood C&S ,
traditional medication (jamu?) FBC, RP, LFT, Ca,mg,
h/o severe NNJ prev child? PO4, VBG, RBS
6H post ET: TSB,FBC,RP
Prolonged jaundice Ix: No need phototherapy as bilirubin cannot cross
Term : > 14 days FBP blood brain barrier, no risk for kernicterus
Preterm : > 21 days TFT
Urine C&S, UFEME
urine reducing sugar
Conjugated hyperbilirubinemia Ix:
Direct Bil > 15% + TORCHES,
- biliary atresia IEM screening,
- congenital hepatitis HEP B/C
- TORCHES infection
- IEM
Presumed Sepsis Ix: FBC/blood C&S * Mother tx > 4hours= stat Dose only
-if WCC > 25, Plt < 125
- Maternal risk (PROM >18H, maternal readmit for cont antbx IV C pen 100 000IU/kg BD
pyrexia, HVS-GBS etc) IV Gentamycin 5mg/kg OD
- baby fever
Congenital Pneumonia TRO TTN CXR: IV C pen 100 000IU/kg BD
- signs of respiratory distress fluid in fissure = TTN IV Gentamycin 5mg/kg OD 5/7
tachypnoic, +SCR/ICR, + nasal flare NPO2 + Spo2 monitoring
grunting, hyperinflated chest, patchy / haziness = cong
pneumonia

Ix: FBC/blood C&S

GBS infection Ix: FBC/blood C&S IV C pen 100 000IU/kg BD
Trace mother HVS IV Gentamycin 5mg/kg OD
- mother HVS : Grp B Streptococus * Mother tx > 4hours= antibx 48Hours
* Mother not tx = antibx 5/7

Hypoglycemia DXT monitoring Steps

Within first 4 hours DXT <2.6 1.5 30mins x 2, if stable 1: encourage feeding then rpt dxt
1hrly x 2
or symptomatic : jittery, less active, 2 hrly x 2 2:IV D10% bolus 2-3ml/kg
hypotonic 4 hrly + IV D10% maintenance

Risk: GDM mother, macrosomic baby 3: D 12.5-15% (via central line)

Additional Notes By Dr Goh Kiam Seong, HTAR Klang
Basic ventilator Settings
By Dr Goh Kiam Seong

Assist-control ventilation (Maquet ventilator/ IPPV Drager ventilator)

Regardless ventilator/patient initiates breath, every breath the same (operator set tidal volume and minimal ventilator
rate)
Ventilator just functions to compensate patients effort
o Time cycled ventilator
Tidal volume and Resp rate set + Time set
Maquet (Siemen)/ Drager ventilator
o Volume cycled ventilator
Tidal volume and Resp rate set + Flow set
Puritan-Vennett Bear ventilator

Advantage Disadvantage
Relative simple to set No synchrony between patient-ventilator,
Guarantee minimum ventilation ventilator initiate come on top
Patient may lead ventilator
Inappropriate trigger hiccough
Fall in lung compliance => risk of
barotrauma
Require sedation to achieve synchrony

Pressure control ventilation

Time cycled assisted control ventilation in which inspiratory pressure is set instead of tidal volume
High initial flow => fall to zero by end of inspiration
Inspiratory pause is effectively built into the breath
Tidal volume not set if inspiratory time short then tidal volume lower

Synchronized Intermittent Mandatory Ventilation (SIMV)

Patient receives a set number of mandatory breaths, synchronized with any attempts by the patient to breath
Patient can take additional breath between mandatory breaths (pressure supported)
For improve patient-ventilator synchrony

Advantage Disadvantage
Better patient-ventilator synchrony Complicated
Guarantee minimum minute
ventilation
Continuous Positive Airway Pressure (CPAP)

Constant pressure both inspiratory and expiratory phase -> splint open alveoli, therefore to decrease shunting
Inspiration initiate from baseline pressure and airway pressure decrease to baseline at the end of respiration
Patient controls rate and tidal volume himself (totally dependent on patients inspiration effort)
Allow spontaneous breathing at an elevated baseline pressure

Non-invasive PPV without invasive artificial airway (Endotracheal tube/ETT)

Due to face mask seal not perfect, usually use with ventilator (BiPAP) to provide some degree of compensation for
leaks around the mask
Require patient to be alert, cooperate, able to protect his airway, haemodynamically stable
Low level of support initially then gradually increase to improve patient tolerance
BiPAP = pressure support + PEEP
o Inspiratory pressure = 8-10 cmH2O
o Expiratory pressure = 4-6 cmH2O
Effective for patient with chronic obstructive airway diseases/ cardiogenic pulmonary oedema
Less effective for pneumonia/ARDS
 Formulae and calculations

Correction of Na Eg Na: 128 , BW 15 kg , 2yo

Na deficit = (135 Se Na) x 0.6 x Wt
Deficit : (135 128) x 0.6 x 15 = 63mmol
Daily req Na = 2-3mmol/kg/day
Daily requirement = 3 x 15 = 45mmol
1pint = 500ml
0.9% NS = 154 mmol / L Total = 63+45 = 108 mmol
1/2NS = 77mmol / L
1/5 NS = 39mmol / L 1 pint NS = 39 mmol Na

TF = 1150ml/ day ; 1150/24Hr = 48cc/hr (90mmol Na)

Correction of K Eg: Se K : 2.5 , weight 15 kg

K deficit = (4-Se K) x 0.4 x Wt)
Deficit: (4 - 2.5) x 0.4 x 15 = 9 mmol
Daily req K= 2-3mmol/kg/day
Daily requirement = 2 x 15 = 30mmol
1g KCL = 13.3mmol
10ml Mist KCL = 1g K Total = 9 + 30mmol = 39 mmol

1g = 13.3mmol, 1 pint 500ml, 1 ml=0.02 39 mmol g = 39/13.3 = 3g

*no more than 0.05mmol/ml therefore if
a) IVD = 1.5 g in each pint
check: no more than 0.05mmol/mL/min in each pint
Hyperkalaemia
(1.5g x 13.3mmol ) / 500ml = 0.03mmol/ml ( not more than 0.05)
Definition: serum K > 6.0 mmol/l
(neonates) and > 5.5 mmol/l (children).
b) Mist KCL = 3g x 10 = 30ml

Correction (fluid deficit) % dehydration x BW in grams (= % x BW(kg) x 10)

Eg: 10% dehydration, BW 15kg
5/100 x 15kg x 1000 = 5 x 15 x 10 = 750cc
Run over 12 / 24 / 48 hours depending on clinical condition

Metabolic acidosis Bicarbonate deficit = 0.3 x body weight (kg) x base excess (BE)
Treat if pH < 7.2 or symptomatic or IV 8.4% NaHCO3 = 1/3 base deficit x Wt
contributing to hyperkalaemia

ETT Size UVC Size

>3kg 3.5-4mm < 2kg 5
2-3.5kg 8
2-3kg 3.5mm
> 3.5kg 10
1-2kg 3mm
<1kg 2.5mm UVC length = (Wt x 3) + 9
UAC length = UVC length
ETT length = 6 + Wt

AA ratio: Pa O2 _____ < 0.22 indication for surfactant

713 (FiO2 PaCO2)

Peak flow = (Ht x 4) 400

TFT:
TSH T4
CORD 2.5 - 25 1/52 28.4 68.4
Day 1-3 2.5 - 13 1-2/52 22.0 30.0
< 4/52 0.6-10 2-4/52 17 - 25
> 4/52 0.5-5.5 > 4/52 11 23.5
Neonatalogy

Feeding

Day 1 60cc/kg/day D10%

Day 2 90cc/kg/day 1/5 NS D10%
Day 3 120cc/kg/day 1/5 NS D10%
Day 4 -31 150cc/kg/day 1/5 NS D10%
1 mo 6mo 150cc/kg/day 1/5 NS D5%
6mo 1 year 120cc/kg/day 1/2 NS D5%

> 1 yo : Holliday segar formula (1/2 NSD5%)

1st 10kg 100ml/kg (10kg = 1000ml)
2nd 10kg 50ml/kg (20kg = 1500ml)
> 20kg 20ml/kg

Energy Expenditure
Term = 110kcal/kg/day
Prem = 120-140kcal/kg/day

Prem Babies
Max TF : 180cc/kg/day,
start feeding with 1-2ml/kg/day + IVD, if tolerating x 3 to increase slowly
* weight gain 10-25g/kg/day (too much feeding can cause overload sx, monitor weight gain daily)
* increase feeding 20-30cc/day

Method: < 34 weeks OG tube / > 34 weeks Syringe/cup

Calculation of total feeding

Eg: Term Baby, Weight 3kg, day 1 of life
Day 1 TF = 60cc/kg/day = 60 x 3kg = 180cc

Per feed (3 hourly) = 180cc/8 = 22.5cc/3hourly

Calculation of total kcal

Type of Feeding kcal Per 1 ml

100ml Prem 80 kcal 0.80 kcal
100ml EBM 67 kcal 0.67 kcal
50ml HMF 4 kcal 0.08 kcal
100ml FSM 67 kcal 0.67
Carborie 1 scoop 8 kcal 8kcal/scoop
1ml MCT oil 8 kcal 8 kcal

Eg:
Prem baby, Weight 1.8kg
Current regime : 30cc/3hourly + 1 scoop Carborie + 0.5 ml MCT oil

Prem requirement : 120-140cc/kg/day

120 to 140kcal x 1.8kg = 216 -252 kcal/day

Total kcal = 8 [(30cc x 0.67 kcal EBM ) + 8kcal 1scp Carborie + 4kcal MCT oil 0.5ml ] = 256 kcal
(8 times = 3 hourly feeding over 24hours)

Total kcal/kg/wt = 256/1.8 = 142 kcal/wt ( requirement = 120-140kcal/bw)

TF = 30 x 8 / 1.8 = 133cc/kg/day (max TF 180cc/kg/day for prem)

 PHOTOLEVEL and EXCHANGE TRANSFUSION LEVEL

>2500g 2500-2000g 1500-2000g <1500g

Hours PTL ETL Hours PTL ETL Hours PTL ETL Hours PTL ETL
0 0 0 0
5 52 150 5 30 105 5 37 97 5 45 105
10 75 165 10 52 127 10 50 127 10 60 135
15 90 195 15 75 150 15 82 150 15 90 150
20 112 210 20 97 172 20 97 172 20 105 180
24 135 225 24 120 195 24 120 195 24 120 195
29 150 255 29 135 210 29 135 210 29 135 210
34 165 270 34 150 225 34 150 225 34 135 225
39 180 285 39 165 240 39 165 240 39 150 240
44 195 300 44 187 255 44 170 255 44 150 255
48 210 315 48 195 270 48 180 270 48 150 270
53 225 330 53 210 285 53 187 277 53 150 285
58 240 337 58 225 292 58 195 285 58 150 292
63 255 345 63 232 300 63 197 300 63 150 300
68 270 345 68 240 307 68 202 307 68 150 300
72 285 345 72 240 315 72 210 315 72 150 300
Neonatal Jaundice - Ix:
TSB,
Early onset (<24hours) Retic Count,
- ABO/Rh incompatibility Coombs Test
- G6PD deficiency FBC
- spherocytosis ABO/Rh
- sepsis
- trace G6PD, TSH, Mother BG

NNJ > 24hrs to 2 weeks Ix:

- exaggerated physiological TSB
- inadequate feeding (wt loss?) +/- FBC/RP
- dehydration (renal impairment)
- infection ET Ix:
- polycythemia Pre ET: Blood C&S , FBC, RP, LFT, Ca,mg, PO4, VBG, RBS, FBP, Retic count, Coombs
- traditional medication test, ABO
- cephalohematoma Infectious Screening (HIV,Hep,VDRL), TORCHES

Onset Day? Post ET: Blood C&S , FBC, RP, LFT, Ca,mg, PO4, VBG, RBS
adequate breast feeding?
PU/BO normal? 6H post ET: TSB,FBC,RP
sick contact?
traditional medication (jamu?)
h/o severe NNJ prev child?
Prolonged jaundice Ix:
Term : > 14 days FBP
Preterm : > 21 days TFT
Urine C&S, UFEME
urine reducing sugar
Conjugated hyperbilirubinemia Ix:
Direct Bil > 15% + TORCHES,
- biliary atresia IEM screening,
- congenital hepatitis HEP B/C
- TORCHES infection
- IEM
ENT findings:

OTOSCOPY

TONSILS
NEUROMUSCULAR MATURITY
SCORE SIGN
SIGN
-1 0 1 2 3 4 5 SCORE

Posture

Square
Window

Arm Recoil

Popliteal
Angle

Scarf Sign

Heel To Ear

TOTAL NEUROMUSCULAR SCORE

PHYSICAL MATURITY
SCORE SIGN
SIGN
-1 0 1 2 3 4 5 SCORE
superficial parchment,
gelatinous, smooth cracking, leathery,
Sticky, friable, peeling &/or deep
Skin red, pink, visible pale areas, cracked,
transparent rash, few cracking, no
translucent veins rare veins wrinkled
veins vessels

Lanugo none sparse abundant thinning bald areas mostly bald

heel-toe anterior
Plantar >50 mm faint red creases creases over
40-50mm: -1 transverse
Surface no crease marks ant. 2/3 entire sole
<40mm: -2 crease only
raised
stippled
barely flat areola areola full areola
Breast imperceptable areola
perceptable no bud 3-4 mm 5-10 mm bud
1-2 mm bud
bud
formed &
lids fused lids open sl. curved well-curved thick
firm
Eye / Ear loosely: -1 pinna flat pinna; soft; pinna; soft but cartilage
instant
tightly: -2 stays folded slow recoil ready recoil ear stiff
recoil
scrotum testes in testes testes testes
Genitals scrotum flat,
empty, upper canal, descending, down, pendulous,
(Male) smooth
faint rugae rare rugae few rugae good rugae deep rugae
prominent prominent majora & majora
clitoris majora cover
Genitals clitoris & clitoris & minora large,
prominent & clitoris &
(Female) small labia enlarging equally minora
labia flat minora
minora minora prominent small
TOTAL PHYSICAL MATURITY SCORE
MATURITY RATING
TOTAL 25 34
WEEKS
SCORE 30 36
-10 20 35 38
-5 22 40 40
0 24 45 42
5 26 50 44
10 28
15 30
20 32
Respiratory Distress
+Cyanosis
+Nasal Flaring

+Grunting
+Hyperventilated Chest
+Recessions SCR/ ICR / Suprasternal / Tracheal Tug

+Tachypnoea
< 1 week up to 2 months: 60 or more
2 to 12 months: 50 or more
12 months to 5 years: 40 or more
ASTHMA Acute mx
Sx mild Moderate Severe
Altered Consciousness - - +
Physical Exhaustion - - +
Talks in Sentences Phrases Words
Pulsusparadoxus NO +/- PALPABLE
Central cyanosis - - +
RONCHI + + SILENT CHEST
Use acc. muscles - Moderate MARKED
Sternal Retraction - Moderate MARKED
Initial PEF >60% 40-60% <40%
SpO2 >93% 91-93% <90%
OUTCOME Discharge May need admit ADMIT
Mx: 1) Neb Salb 1) Neb Combivent x 3 1) Neb Combivent x 3 / cont
< 1 yo: 0.5 : 3.5 2) O2 8L/min 2) O2 8L/min
>1yo : 1:3 3) Oral Prednisolone 3) IV Hydrocort 5mg/kg QID 1/7
or 4) IVI Salbutamol continous
MDI Salb in spacer Bolus: 5-10mcg/kg/10mins, then
4-6 puffs (<6yo) Infusion: 0.5-1mcg/kg/min
MDI 8-12 puffs ( >6yo) 5mg in 50ml
ventolin (blue) 1amp = 0.5mg (5mcg = x 10amp)
200mcg 2 puff PRN 2) Oral prednisolone 0.6ml/kg = 1mcg/kg/hr
Fluticasone (orange) SyrPred 1mg/kg/day max 20mcg
125mcg 2 puff BD for 3-5/7
Budesonmide (brown) * S/C Bricanyl (terbutaline)
125mcg BD Reasses after 60mins Reasses after 60mins 0.005-0.01mg/kg (max 0.4mg) every
Seretide (purple) if no improvement if no improvement, 5-10mcg/kg
25/125 1 puff BD Tx as moderate Tx as severe 15-20mins

Montelukast /singulair * IV MgSO4 50%

4mg granules Bolus: 0.1ml/kg(50mg/kg) in 20mins
(Chew @8pm)
*IV Aminophyline
IV hydrocort 4-5mg/kg Bolus:6mg/kg bolus then
QID for 1/7, Infusion: 0.5-1.0mg/kg/hr
then change to
Syr Prednisolone *Mechanical ventilation and
1-2mg/kg OD for 5/7 observation in HDW/ICU
Commonly used Rx

Antibx
IV Amoxycilin 15mg/kg QID

Syr Augmentin 18mg/kg BD

IVAugmentin 30mg/kg TDS

Syr Azithromycin 15mg/kg (Day1) , 7.5mg/kf (D2-5) OD

IV Azithro 15mg/kg (D1) , 5mg/kg (D2-5) OD

IV C penicillin :
Throat dose 25000iu/kg QID,
Pneumonia 50 000IU QID,
meningitis 100000IU/kg QID,
neonates 100 000IU/kg BD

IV Gentamycin 5mg/kg OD

IV Amikacin 15mg/kg OD
IV Fortum 25mg/kg TDS

IV Cefotaxime 25mg/kg BD
IV Rocephine 25-50mg/kg BD

Syr Pen V 15mg/kg QID

Syr Cefuroxime 15mg/kg QID
Syr Clarithromycin (Klaccid) 10mg/kg BD
Syr Unasyn 15mg/kg BD
Syr EES 20mg/kg BD
______________________________
Gastro
Syr Domperidone 0.25mg/kg TDS
Syr Omeprazole 0.4mg/kg BD
Syr Ranitidine 2mg/kg / IV ranitidine 1mg/kg
ORS 10ml/kg
________________________________
Respiratory
Syr prednisolone 1mg/kg OD
Syr Salbutamol 0.1mg/kg TDS
Syr Bromhexine 0.3mg/kg TDS
Singulair Granules 4mg ON
__________________________________
CVS
Syr Nifedipine 0.25-0.5mg/kg or
Syr Captopril 0.1-0.5mg/kg (up to 1mg)
Syr/IV Frusemide 1mg/kg OD/QID
Syr Spironolactone 1mg/kg BD

PR Resonium 0.25mg/kg QID

____________________________________

Sedation
Chloral Hydrate 50mg/kg
Midazolam 0.1-0.5mg/kg Antidote Flumazenil 0.01-0.02mg/kg)
Pethidine 0.5-1mg/kg
Morphine 0.1-0.2mg/kg
Ketamine 1-2mg/kg

Adrenaline IV 0.1 0.3ml/kg , ET 0.5-1ml/kg

Surfactant 4mg/kg
 Kindly note that this compilation serves as an early guide for your paediatrics posting only.
The management in this guide does not necessarily reflect the method of management by Hospital Ampang.
Always refer to your Malaysian Paediatrics Protocol for concise management.

A House Officers Workshop Project

www.myhow.wordpress.com
June 2013