DR.

BAYLON’S EMERGENCY DRUGS Inj: 250, 500 mg/vial

DOPAMINE DRIP:
D5W 250 cc + Dopamine 200 mg/amp at 7-60 ugtt/min AMOXICILLIN-CLAVULANIC (Augmentin)
Drip = 2.5-10 ug/kg/min Oral: 30-50 mkd
Equivalent: 9-38 ugtt/min for a 50 kg patient IV: 50-100 mkd
Formula: ugtt/min = drip ug x BW Susp: 156.25 mg (A- 125mg)
13.3 228.5 mg (A-200mg)
If with CHF: may use double dose: D5W 250 cc + 312.5 mg (A- 250 mg)
Dopamine 400 mg (2 amps) at max rate of 475 mg (A- 400 mg)
30 ugtt/min Inj: 300 mg vial (A- 250mg)
1.2 g vial (A- 1 gm)
DOPAMINE (ADULT):
Dose x wt x 0.075 = cc/hour AMPHOTERICIN B
Dopamine 200 mg/5 mL per amp Day 1: wt x 0.4 mkd + 6 cc D5W to run in 6 hours
1 amp + 250 cc D5W Day 2: wt x 0.3mkd + 6 cc D5W to run in 6 hours
Day 3: wt x 0.5 mkd + 6 cc D5W to run in 6 hours
DOPAMINE PALS: Day 4: wt x 1 mkd + 6 cc D5W to run in 6 hours
Drip rate = dose (0.5-1 mg/kg/day OD)
Example: 43 kg patient Dilute 50 mg/vial in 10 cc of D5W (5mg/ml solution) then aspirate 0.2 cc of
Wt x 6 = x mg reconstituted solution & add 9.8 cc of D5W (0.1 mg/ml) then give 7.6 ml
43 x 6 = 258 mg TIV via infusion pump to run for 2-6 hrs (0.5 mkday)
Use Dopamine 200 mg/5ml ex: wt 1531 grams

X mg of Dopa to be incorporated to make a AMPICILLIN

Total of 100 cc Oral: 30-40 mkd
IV: 50-100 mkd
EPINEPHRINE DRIP: Meningitic dose: 200-400 mkd
D5W 250 cc + 5 amps Epi to run at 10-30 ugtt/min Drops: 100 mg/mL
Drip = 2-10 ug/min Susp: 125, 250 mg/5 mL
Cap: 250, 500 mg
EPINEPHRINE PALS: Inj: 100, 250, 500 mg/vial
Wt x 0.6 = drip rate/hour
Wt = 43 kg x 0.6 = 26 cc + D5W to make 100cc AMPICILLIN-SULBACTAM (Unasyn)
Rate = dose → 5 cc/hr = 5 ug/kg/min IV dose: 150 mkd q 12 hrs
Oral: 50 mkd BID
NaHCO3 DRIP:
NaHCO3 1 amp + 250cc D5W to run for 12-24 hours ASA (for RHD)
60-80 mkd
MANNITOL:
Mannitol 20% = 2 cc/kg/dose q 8hrs ASTEMIZOLE (Hismanal)
6-12 y/o: 5 mkd
VENTOLIN RESPIRATORY SOLUTION: 12 y/o: 10 mkd
VRS = 0.3 cc/kg + ___cc NSS to make 2 cc Tabs: 10 mg

ATROVENT RESPIRATORY SOLUTION: AZITHROMYCIN (Zithromax)

ARS: 5 gtt + 2cc NSS 10 mkd x 3 days
ppn: 200 mg/5 mL
ALBUMIN: dose: 1-2 gm/k Macrol Toddler 50 mg/tab BID
Albuman: 20% in 50 mL vial Kiddie 100mg/tab TID
Albuminar 25: 25% in 50 mL vial
Albutein: 25% in 50 mL vial AZTREONAM
Neonate: 30 mkdose
0-7 days: q 12 hrs
ALBUMER: 7 days/ >2kg: q8 hrs
Shock = 1-2 mL/kg > 7 days/ > 2 kgs: q6 hrs
Kernicterus: 10-15 mL with each exchange transfusion Children: 90-120 mkd q6-8 hrs
Inj: 0.5, 1, 2 gm
HAEMACCEL (Polygeline)
10-20 cc/kg (fast drip or in 4 hours)
ppn: 500 mL BACAMPICILLIN (Penglobe)
25-50 mkd q6
HAES-STERIL: Susp: 200mg/5mL
30-40 cc/kg
ppn: 6% in 500 mL BENZYLPENICILLIN – prophylaxis for RHD
10% in 500 mL For active RHD: oral PCN – 10 day therapy
DRUGS AND DOSAGES: 1.2 M U/kg via IM q 21 days x 10yrs or until 21 y/o
AMINOGLYCOSIDES
AMIKACIN……….10-15 mkd BUDESONIDE
NETILMICIN…….6-8 mkd 200 mcg OD/BID
TOBRAMYCIN….6-8 mkd Turbohaler 100 mcg, 200, 400
GENTAMYCIN….5-8 mkd 1 puff BID
AMINOPHYLLINE Respule: 250 mcg/mL, 1 res q8
LD: 5-7 mkdose
MD: 3-5 mkdose CARBAMAZEPINE (Tegretol)
Ppn: 25mg/mL (250mg/10mL) LD: 10-20 mkdose
Example: Aminophylline 25mg/mL, get 1 ml to be diluted with 4 mL D5W(5mg/mL), then MD: 5 mkd
get 0.98 mL (4 mg) as LD + 4.02 mL D10W via infusion pump x 30 mins then get 0.48 mL Syrup: 100mg/ 5mL
(2.4 mg) as MD + 4.52 mL D10W via infusion pump x 30 mins q 12hrs Tab: 200, 400 mg
Or
Aminophylline 25mg/mL, 250mg/10mL, give 150 mg (6mL) + 24cc distilled water to run CEPHALOSPORINS
through soluset x 30mins as LD then give 100mg (4 mL) + 26cc distilled water to run 1ST GENERATION
through soluset q8 hrs (3.3) for 30 mins as side drip CEFALEXIN (Lexum, Keflex, Cefalin)
Oral & IV: 25-50 mkd
AMOXICILLIN Ppn: Drops: 100mg/mL
IV: 50-100 mkd Susp: 125, 250mg/ 5mL
Oral: 30-50 mkd Cefalin susp 125, 250 mg/5 ml
Drops: 100mg/mL/ 125 mg/1.25 mL Ceporex cap: 250, 500mg
Susp: 125,250 mg/5 mL Keflex drops: 100 mg/ml

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CEFALOTHIN (Keflin) Cap: 125, 250, 500 mg
IV: 50-100 mkd
Keflin 1, 2, 4 g vial CIPROFLOXACIN
* not recommended for < 6 y/o
CEFADROXIL Neonate: 5 mkdose q 12
5-50 mkd Children/Infant: 20-30 mkd IV/PO (q12/BID)
Duracef susp: 250mg/ 5mL IV ppn: 100mg/ 50mL
Cefamox cap: 500mg 200mg/ 100mL
400mg/ 200mL
CEFRADINE Oral ppn: 250, 500mg/ tab
25-50 mkd Order as: Ciprobay __mg (cc) + __ cc D5W (always to make 10 cc) to run
via infusion pump for 1 hour, q 12
CEFAZOLIN Diluent: 2mg/ 1cc diluent
IV: 50-100 mkd 250mg/tab, divide to ___ pptab; give __ pptab q 12 to be mixed w/ MF

2ND GENERATION CEFETAMET PIVOXIL HCL (Globocef)

CEFACLOR (Ceclor) Oral: 10 mkdose BID
Oral: 20-40 mkd Ppn: 250, 500 mg
Ceclor drops: 50mg/ mL
Syrup: 125, 250 mg/ 5mL CETIRIZINE
≤ 6 y/o: 5mg OD or 2.5 mg BID
CEFAMANDOLE > 6 y/o: 10mg OD or 5 mg BID
50-100 mkd
Mandol inj 1 g/ vial CIMETIDINE (Tagamet)
20 mkd q 6 (5mkdose)
CEFOXITIN 200, 400, 800mg tab
IV: 50-100 mkd Inj: 200mg/2mL vial
Mefoxin inj 1g/ vial

CEFUROXIME CLINDAMYCIN
IV: 50-100 mkd IV Neonate PT: 15 mkd q8
Oral: 20-30 mkd or 10-15 mkdose BID FT: 20-40 mkd q6
Zinacef inj: 250, 500 mg Oral: 10-20 mkd q 6
1.5 g/vial Ppn: syrup…75mg/ 5mL
Zinnat susp: 125, 250mg/ 5mL Cap…..150, 300mg
Tab: 125, 250mg Clindamycin 150mg/mL amp, give 150mg + 30mL PNSS to run via soluset
x 30 mins q 6 ANST ( )
3RD GENERATION
CEFOPERAZONE CLARITHROMYCIN (Klaricid)
100-150 mkd Oral: 15 mkd BID
Cefobis inj: 500mg, 1gm vial Susp: 125mg/ 5mL
Tab: 250mg
CEFOTAXIME
50-100 mkd CLONAZEPAM
Clarofan inj: 500mg/ vial 0.3 mkd
Dilute in 30 cc D5W via soluset to run x 30mins ANST( ) Rivotril tab 2mg
CEFTRIAXONE
30-60 mkd CLOXACILLIN
Rocephin inj: 250, 500mg, 1gm IV and Oral: 50-100 mkd
Dilute in 30cc D5W via soluset to run for 30 minutes Ppn: susp: 125mg/ 5mL
Cap: 250, 500mg
CEFTAZIDIME
50-100 mkd COTRIMOXAZOLE
Neonate: 30 mkdose q 12 Oral: 5-10 mkd BID
Fortum inj: 250, 500mg, 1 gm Syrup Tab
Reconstitute 500mg vial w/ ster H20 (10ml) to make conc of 50mg/ml Bacidal…………. 80 160
Trizole 80 ___
CEFEPIME (Cepimax) Triglobe 45 90
IV: 25 mkdose q 12 Bactrim 40 20, 80, 160
Microbid 40 80,160
CEFIXIME (Tergecef) Septrin 40
3-5 mkday
Oral: 15 mkd DEXAMETHSONE
Dr. Taaca: 1-3 mkd Cerebral edema:
Dr. Africa: 5-10 mkd LD: 0.5-1.5 mkdose
Dr. Cristobal: 3-6 mkd MD: 0.2-0.5 mkd q6 x 5 days then taper
Dr. Galvez: 7-8 mkd Meningitis: 0.15 mkdose q6 x 4 days
Ppn: drops: 20mg/mL Dexa, 4mg/ mL, 1 mL + 19 cc D5W to make0.2mg/mL solution, then get
Susp: 100mg/ mL 0.66 mg (3.3mL) to be given TIV q 12 for 48 hrs (0.25 mkdose)
Granules: 50mg/sachet Dr Cua-Lobo’s regimen:
Cap: 100, 200mg 0.4 ml q 30 mins x 4 doses
0.2 ml q2 hrs x 2 doses
CEFEPIME 0.2 ml q6 x 4 doses
500 mg to be diluted in 100cc D5W, then get 8.2 cc to run via infusion pump x 30mins q 12
(50 mkdose) DIAZEPAM
0.2-0.4 mkdose (0.3 mkdose IV)
CEFDINIR (Omnicef) Rectal: 0.5 mkdose
Oral: 15 mkd Syrup: 2mg/ 5mL
Ppn: 50mg/sachet Tab: 2, 5, 15mg
100mg/ cap Inj: 10mg/2mL
SE: laryngospasm
CHLORAMPHENICOL
IV: 50-100 mkd DIPHENHYDRAMINE HCl
* no skin testing Oral: 3-5 mkd q6
* always dilute with IVF (500mg:50mL) IM/IV: 1-2 mkdose wt
run for 30 mins Elixir: 12.5mg/ 5mL 50
Oral: 30-50 mkd Cap: 25, 50mg
Ppn: susp: 125mg/ 5mL Inj: 50mg/ mL

2
Max of 300mg/day Inj: 20mg/ amp
IBUPROFEN
DILOXANIDE FUROATE 5-10 mkdose
10 mkd given for 10 days Dolan 100mg/ 5mL
Syrup: 125mg/ 5mL
IMIPENEM (Tienam)
DOMPERIDONE (Motilium) Dr. Africa: 25 mkdose q 12 hours x 2 hours
Neonate: 0.2-0.3 ml/kg/dose Dr. Masangkay: 20-30 mkdose q 12 hors x 2 hrs
Empiric: 2.5ml/kg/dose TID before meals Inj: 250mg/ 60mL
Drops: 1mg/ mL 500mg/ 120 mL
DORMICUM Compute as: wt x dose x 100/500
0.2-0.4 mkdose Order as: Dilute 500mg in 100cc PNSS then infuse __ cc via IP x 2 hrs q
Inj: 5mg/ml/amp 12

INDOMETHACIN
ERYTHROMYCIN 0.2 mkdose in 3 divided doses
Oral: 30-50 mkd ½ - 1st dose
Ppn: drops: 100mg/ 2.5mL ¼ - 2nd % 3rd dose
Syrup: 100, 200mg/ 5mL Diluent: Distilled water
Inj: 500mg/ vial Ppn: 25mg/tab
Granules: 200mg, 400mg/ 5mL Order as: Dilute 1 tab in 10 mL distilled water ~ 2.5 mg/mL
Cap: 250, 500mg → 0.25/ 0.1 mL
Monitor: UO, electrolytes, BUN, Crea, Platelets
ETHAMBUTOL Dra Yap:
15 mkd Age of 1st dose interval Dose (mg/kg)
Syrup: 125mg/ 5mL < 48 hours 1st – 0.2 mkdose 24hrs
Tab: 200mg 2nd – 0.1
3rd – 0.1
ETOFOMIDE 2-7 days 1st – 0.2
15-20 mkd or 2 tsp TID x 3 days 2nd – 0.2
Ppn: Susp: 100mg/5ml 3rd – 0.2
Tab: 200 mg, 500mg > 7 days 1st – 0.2
2nd – 0.25
FAMOTIDINE 3rd – 0.25
0.5-1 mkd PO
max of 40mg/day INH
0.5 mkdose q 24 hrs SIVP 10-20 mkd OD
Trisovit 50
FLUCONAZOLE (Diflucan) Nicetal 100
Neonate: LD: 12 mkdose Odinah 150
MD: 6 mkdose q 48-72 hrs via IP x 30mins/PO Comprilex 200
For BS 30-36wks: 0-14 days = q 48 hrs
> 14 days = OD INTRALIPID
If wt is 1.5 kgs thus, present weight x 12 = 18mg 10% = cc x 1 cal NB = 0.5–4 gm fat/kg/day
50 mg divide to pptab 20% = cc x 2 cal SGA = 0.5 gm fat/kg/day
Ppn: IV: 200mg/ 100mL Ex: 10 gm/100 cc for 12-24 hours
400 mg/ 200mL 10 gm = wt (gm)
Oral: susp: 10, 40mg/ m 100 cc x (cc)

FURAZOLIDONE (Furoxone) IVIG

5-8 mkd QID Kawasaki disease: 400 mkd x 4 days or 2 gm/ kg as bolus in 12 hours
* Not for G6PD patients Dra Bunyi: test dose
1st: .01 mL/kg/min x 30 min
FUROSEMIDE 2nd: inc. to .02 mL/kg/min x 30 mins
1-2 mkdose IV 3rd: inc. to .04 mL/kg/min x 30 min
Tab: 40 mg
Inj: 20mg/ 2mL vial KETOCONAZOLE
Ex: 3.55 kg 5-10 mkd q 12-24 hrs
PO: 20 mg/tab to be divided in 5 pptab (4mg/ pptab) q 12hrs (1.1 mkdose) Ppn: Tab: 200mg

GRISEOFULVIN LANOXIN (Digoxin)

7.25 mkd OD PO Total DD: 0.04 mkdose divided into 4 doses q 6
ppn: 330 mg tab Maintenance: total DD divided by 10 (mkdose)
1/10 of total q 12
HYDRALAZINE (Apresoline) ppn: elixir: 0.05mg/ mL
1-2 mkd (max 10-12 mkd) tab: 0.25mg
Tab 10, 25, 50 mg IV: 0.5mg/2 mL
Inj 20mg/vial * Give K+ sparing fluids – 0.3 NaCl
HPN crisis 0.75 mkd/ 4 doses * May give K+ sparing diuretics – Spironolactone
Oral: 1-2 mkd/ 3 doses Monitor: UO, K+ levels

HYDROCORTISONE (Solucortef)
LD: 10-15 mkdose LORATADINE:
MD: 5 mkdose < 30 kg 1 tsp OD
Ppn: 50 mg/ mL > 30 kg 2 tsp OD
125mg/ 5mL Tab 10 mg
100mg/ 2mL Syrup 5mg/ 5mL
___ D5W thru soluset q 8 hrs x 30 min as sidedrip
MANNITOL
HYDROXYZINE HCl (Iterax) Dr. Africa: 0.5 mkd
Dr. Africa: 5mL/ 10 kg TID 1-2 mkd
Dr. Ferreria: 0.5 mkd Ex: wt is 2 kg
Syrup: 2mg/mL (2) (0.5) = 1 x 20 = 20 = 0.2 cc
Order as: Mannitol 20%

HYOSCINE N BUTYL BROMIDE (Buscopan) MEBENDAZOLE

Syrup: 5mg/ mL 100mg, 500mg/tab
Tab: 10mg Give empirically OD as single dose

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 PIPERACILLIN-TAZOCIN
MEFENAMIC ACID 200-300 mkd q6 or 50-100 mkdose IV infusion
10-15 mkd by syringe pump over 30 mins q 12 (if 0-7days old0 or q8 (>7d old)
Susp 50mg/5 mL Reconstitute 2g vial w/ 10ml sterile H20 to make final conc of 200mg/ml
Cap 250 mg Ex: wt is 8.9 kgs 4.5g vial
Tab 500mg Mix 1 vial with 8mL sterile water for injection to make a 400mg/ml solution,
then get 2.5mL of this solution & mix with 7.5 mL sterile water to make a
MEROPENEM final solution of 100mg/mL. From this, give 5.5mL q 6 to run as side drip x
25 mkd q 12 hrs 30mins via IP ANST ( )
__ mg to be diluted in 100cc PNSS (becomes 5 mg/ml) then infuse 6.5 cc via infusion PREDNISONE
pump q 12hrs for 30 minutes 1-2 mkd
Tab 5mg
METOCLOPROMIDE
10mg q 6 PO PROPRANOLOL (Inderal)
10mg tiv q 6 1-2 mkd (max 10-12mkd)
ppn: 10, 40mg/tab
METRONIDAZOLE (Flagyl) 10mg/vial
IV/PO 25-50 mkd
< 12 y/o: 7.5 mkd PYRANTEL PAMOATE
Syr 125mg/ 5mL Susp 100mg, 250mg/5mL
Tab 100, 125, 250 mg
MILRINONE
LD: 50ug/ kg/ dose PZA
MD: 0.3-0.5 ug/kg/day 30-35 mkd
Ppn: 1 mg/mL PZA Ciba 250mg/5ml
1 amp plus 50cc IVF Tab: 500mg

NAFCILLIN (Vigopen) RANITIDINE (Zantac)

25-50 mkd q 6 IV/PO: 1 mkdose
Susp: 250mg/ 5mL Syrup: 150mg/ml
Cap: 250, 500mg
Inj: 500mg, 1 g/vial RIFAMPICIN
10-20 mkd
NALOXONE Rifadin: 100mg/5ml
20 mcg/ml in 2 ampule vial (.2 mg/ml or .4 mg/vial) Rimactane forte: 200mg/5ml
0.1 mkdose Cap 150, 300, 450, 600mg
Tab: 450, 600mg
NIFEDIPINE
0.25 mkd (max 1 mkd)
Cap 5,10 mg SALBUTAMOL
Oral: 0.15 mkdose
NIFUROXAZIDE (Ercefuryl) < 6 y/o: 0.3 mkd TID
Oral: < 6 mos: 5 mL BID 6-11 y/o: 0.6 mkd TID
6 mos: 5 ml TID ≥ 12 y/o: 2-4 mkd TID
Syrup: 220mg/5ml Inhalation: 0.02 mkdose
Cap: 200mg Syrup: 2mg/5ml
Tab: 2mg
NORFLOXACIN Nebule: 2.5mg/2.5ml
UTI: 200-400 mg BID
GI Infxn: 400mg BID SPIRONOLACTONE (Aldactone)
Gonorrhea: 800mg SD 1 mkd (max 3mkd)
ppn: 25, 50, 100mg/tab
NYSTATIN (Mycostatin)
NB: 400,000 U/kg/day STREPTOMYCIN
20-40 mkd IM (max 1gm/day)
OFLOXACIN
Uncomplicated UTI: 100mg BID PO TERBUTALINE SULFATE (Bricanyl)
Complicated UTI: 200mg BID PO Oral: 0.075 mkdose
SQ: 0.005 mkdose
OXACILLIN Syrup: 1.5mg/5ml
NB: 25-50 mkday Tab: 2.5 mg
50-100 mkd
Inj: 250mg/500mg THEOPHYLLINE
Reconstitute 1g vial w/ 10 ml sterile H2o to make final conc of 100mg/ml 3-5 mkdose
25 mg/ml dilution: 2 ml of reconstituted sol’n + 6 ml sterile H20 Theophylline 80mg/5ml, 0.1 ml + 0.1 ml sterile water q 12
Syrup: 80mg/15ml
PARACETAMOL Tab: 50mg, 125mg
10-20 mkdose Apnea of Prematurity:
LD: 5-6 mkdose TIV for 15-20 mins
PCN G MD: 2 mkdose q 12
NB: 50,000-100,000 U/kg/day
Children: 200,000 U/kg/day (oral) VAMINE
Ppn: 125, 250mg/5ml susp * start on D4 NPO
250, 500mg/cap 0.5g – 3g/kg/day
As SIVP: 5 M “u” vial + 8ml sterile H20 = final conc of 500,000 U/ml * start with 0.5g/kg/day then inc by 0.5g/kg/day until 0.3g/kg/day
To make 100,000 U/ml, dilution, add 10ml of reconstituted sol’n to 40 ml sterile H20 Dr. Africa: Term babies: start with 1g/kg/day
PT babies: start with 1g/kg/day
PHENOBARBITAL (Na Luminal) * Limit is up to 2.5g/kg/day
LD: 10-20 mkdose IV over 10-15 minutes ppn: 9.4gm/100ml
MD: 3-5 mkd Compute as: (0.5) (wt) (100)
Oral: 60 mg/tab = 1 grain 9
Order as: ___ cc to run for 12 hrs at __ cc/hr via IP OD
PHENYTOIN (Dilantin)
LD: 5-20 mkdose VANCOMYCIN
MD: 5 mkd BID 20 mkdose
Oral: 30mg/5ml, 125mg/5ml LD: 15 mkdose
Inj 100mg/2ml MD: 10 mkdose
< 1 wk old: q 12

4
> 2 wks: q8 3-4 gtts TID
Order as: Dilute 500mg Vanco in 10ml dist H2O then get 20mg (0.4ml) + __ cc D5W
(always to make 5cc) x 1 hour via IP (* 500ml in 10 ml is good for 4 days) POLYMYXIN B + LIDOCAINE (Lignosporin)
3-4 gtts TID – QID
ZINC SULFATE Miscellaneous
< 6 mos old: 10mg/day ANTIPYRINE + BENZOCAINE + GLYCERINE DEHYDRATED (Auralgan)
> 6 mos old: 20mg/day Moisten cotton plug then insert to meatus TID – QID
Ppn: drops: 10mg/ml
Syrup 20mg/5ml DOUSATE SODIUM ( Otosol)
Fill ear canal with solution & stay in position for 4-5 minutes then insert a
ANTI- VERTIGO cotton wool plug x 2 consecutive nights
BETAHISTINE (Serc)
1-2 tab TID PO with meals OPTICAL ANTI-INFECTIVES
Ppn: Tab: 8, 16 mg CHLORAMPHENICOL
1 gtt 2-4x/day (1gtt/hr for acute cases)
MECLEZINE (Bonamine) Apply inside surface of lower lid
12.5-50 mkd TID/BID Ppn: 0.25%, 0.5%, 1% 5ml drops
< 6 mos old: 0.5ml daily 0.1%, 0.5% 3.5g ointment
2-6 y/o: 3 ml or 1-2 tabs daily
FRAMYCETIN
1-2 gtts q 1-2 hrs or 1-2 gtts 3-4x/day (acute)
2-3 application daily or at bedtime
Ppn: 0.5% 2.5ml drops
0.5% 2.5g tube
COUGH PREPARATIONS
Mucokinetics SULFACETAMIDE
AMBROXOL 1-2 gtts into lower conjunctival sac 2-3 hrs
1-2 y/o: 15mg/day or 1.25mg BID Ppn: 10%, 15% 5ml drops
5-10 y/o: 1.2 -1.6 mkd or ½ tsp BID – TID
> 10 y/o: 1 tab or 1 tsp TID TOBRAMYCIN
Ppn: Drops: 6mg/ml 1-2 gtts into lower conjunctival sac 2-3x/day
Syrup: 15, 30mg/5ml Ppn: 3mg/ml (0.3%) 5ml
Bromhexine HCl (Bisolvon) 3mg/g (0.3%) 3.5g tube
< 2 y/o: ¼ tsp TID – QID
2-5 y/o: ½ tsp TID – QID SCABIES PROTOCOL
5-10 y/o: 1 tsp TID – QID < 1 y/o: 5% pptated sulfur
>10 y/o: 2 tsp TID – QID 1 gm + 20 gm white petrolatum
Ppn: Solution: 2mg/ml 1. Apply from the neck down
Tab: 8 mg 2. Contact time is 24 hours
3. Bathe the following day
CARBOCISTEINE (Solmux) 4. Dry the skin
2-6 mos: 0.5ml QID 5. Re-apply x 5 consecutive days
7-12 mos: 1 ml QID
1-3 y/o: 2.5ml TID > 1 y/o: use 10% pptated sulfur
4-7 y/o: 5 ml TID > 2 y/o: use Lindane 1% lotion x 1 day
8-12 y/o: 7.5 ml TID
ATOPIC DERMATITIS
ANTIVIRALS (Dr. Ferreria)
ACYCLOVIR 1. Ketotifen- give at 1 mkd
PT: 10mg/kg as 1hr IV infusión of 12 hrs x 10-21 days 2. Iterax- give at 0.5 mkd
T: 10mg/kg as 1 hour IV infusion of 8 hrs x 10-21 days 3. Claritin, give OD before meals x 8 days
Varicella-Zoster: 2-12 y/o: 20 mkd (max 800) QID x 5 days 4. Cetaphil lotion alternate with mineral oil or Hytone TID
> 12 y/o: 800mg PO 5x/day x 7 days 5. Prednisone- 1-2 mkd
Encephalitis: 10 mkd as 1 hr IV infusion of 8 hrs x 4-21 days 6. Shift to soy-based formula
Ppn: Tab: 200, 400mg
Inj: 250mg/ml Hg POISONING
AMANTADINE - Plain abdominal xray
5-8 mkd PO (max 150mg) BID or TID - Na-SO4 250 mkdose to be dissolved in water
Ppn: Tab: 100mg (warm)
Inj: 50mg/ml - After 1 hour if (-) BM, another Na-SO4
- After 2nd dose of Na-SO4 if still (-) BM, for soap
INOSIPLEX suds enema
< 6 months: 1 ml q 3-4 hrs - Then repeat plain abdominal xray
6-12 months: 1.5 ml q 3-4 hrs - For blood mercury level as OPD (the ff day)
1-2 y/o: 2ml * If blood Hg level >10 ug/L → DMSA 10 mkdose q 8hrs
2-6 y/o: 3 ml x 5 days
6-12 y/o: 5 ml
Ppn: Syrup: 250mg/5 ml VACCINE SCHEDULE
Tab: 500mg BCG: at birth
1st ff-up: 2 weeks old
EAR PREPARATIONS 1 month old: Hep B1
Antiseptics with Corticosteroids 2 months old: DPT1 OPV1
Polymyxin B + Neomycin + HAA (Cortisporin) 3 months old: Hep B2
3-4 gtts TID – QID 4 months old: DPT2 OPV2
Ppn: 5 ml drops
5 months old: Hib1
6 months old: DPT3 OPV3
FLUOCINOLONE ACETONIDE + POLYMYXIN B + NEOMYCIN (Aplosyn, Synalar)
7 months old: Hib2
3-4 gtts TID- QID
8 months old: ff-up
TRIAMCINOLONE ACETONIDE + NEOMYCIN + GRAMICIDINE + NYSTATIN 9 months old: Measles
(Kenacomb) 10 months old: HepB3
2-3 gtts TID – QID 11 months old: Hib B3
12-14 monthsold: ff-up/Varicella
Anti-Infectives and Antiseptics 15 months old: MMR
CHLORAMPHENICOL 16-17 months old: ff-up
2-3 gtts TID –QID 18 months old: DPT/OPV booster
19 months old- 3y/o: ff-up
POLYMYCIN B + GLACIAL ACETIC ACID (Aerosporin)

5
BCG: birth ----- school entrants
DPT, OPV 2,4,6 months 10-20 1000ml + 50ml/kg over 10kgs
* can be given as early as 6 weeks of life with 4 wk
interval >20 1500ml + 20ml/kg over 20 kgs
* Booster doses: 15-18 mos after 1st dose
Hib: 2 months 0,1,6 COMPOSITION OF IVF’S
< 1 y/o: 3 doses 1 Liter Na+ K+ Cl-
3-5 y/o: 1 dose D5 0.15 25 - 25
Booster is after 1 year D5LR 130 4 109
Hep B: 0,1,6 D5 0.3 NaCl 51 - 51
Booster is q 2 years D5 0.45 NaCl 77 - 77
Hep A: 3 y/o D 0.9 NaCl 154 - 154
HAVRIX: 0, 1, 6-12 months D5NR 140 5 98
VACTA: 0, 6month then 12 months after
D5IMB 25 20 22
Hep B booster: 5 y/o
nd
Measles 2 booster: 3 y/o D5NM 40 13 40
Varicella: 9-12 months old (1 dose) D5NMK 40 30 40
> 12 months(2 doses; 1 month apart) IM 40 35 40
Typhoid: 2 y/o: 1 dose IP 25 20 25
Oral: q other day x 3days Plasma 136-142 3.5-5.5 90-100
Booster: every 5 years Aminosyn 13 40 -
SQ/IM: booster is q 3 years
Flu: yearly BSA(Body Surface Area)
1. kg
BCG VACCINATION: 1.5 (0.05 x kbw) + 0.05
Normal BCG Accelarated BCG 6-10 0.04 0.10
Induration 2-3 weeks 2-3 days 11-20 0.03 0.20
Pustule 4-8 weeks 5-7 days 21-40 0.02 0.40
Scar 8-12 weeks 2-3 weeks TFR = BSA x 400 + previous UO in 24 hours
Day 1 = BSA x 400
MNEMONICS If with furosemide = previous UO /2
Body Weight 2. (kg) (4) + 9 / 100
Ideal Body Weight 3. m2 = (wt) (4) + 7/ 90 + BW
At Birth = 3000 g or = square root of ht(cm) x wt(kg) / 3600
< 6 mos (in g) = age in mos x 600 + BW 4. (m2)= (0.05 x kg) + 0.05
6-12 mos (g) = age in mos x 500 + BW
or, (age in mos + 9) ÷ 2 SERUM OSMOLALITY
< 1 y/o w/o BW = age in mos x 2 + 8 (Na + K x 2) + glucose/ 18 + BUN /3
2-7 yrs (in kgs) = age in yrs x 2 + 8 ELECTROLYTES CORRECTION
7-12 yrs (in kgs) = (age in yrs x 7 – 5) ÷ 2 DEFICIT ; Na (D-A) (wt) (0.6) = _____
K : (D-A)(wt)(0.3)= ______
Expected Body Weight (good up to 1 month of age) Maintenance : Na = wt (3)
Term EBW = (age in days – 10) x 20 + BW K : wt (2)
PTerm EBW = (age in days – 14) x 15 + BW
Where: 10 = time to recover over physiologic wt loss Total = _________meq/day
20 = g/day gained
NaHCO3
Length 50 meq/50 ml
Average birth length 50 cm (20 inches) ½ correction = wt (BE) (0.3)
Height in cm = age in years x 5 + 80 Full correction= wt (BE) (0.6)
Height in inches = age in years x 2 + 32 NaHCO3______meq(cc) + _____cc distilled water
Total ave gain in the 1st year = 25 cm,distributed as follows:
Birth – 3 mos: 9 cm Preparation :
3 – 6 mos: 8 cm Na = 2.5 meq/ml
6 – 9 mos: 5 cm K = 2 meq/ml
9 – 12 mos: 3 cm Ca = 100 mg/ml

Head Circumference: pH pCO2 HCO3

At birth: 35 cms Normal N N N
< 4 mos: ½ inch per month Respiratory Acidosis ↓ ↑ N
5 – 12 mos: ¼ inch per month, for a total of Respiratory Alkalosis ↑ ↓ N
1 inch in 1 year Metabolic Acidosis ↓ N ↓
2nd year: total of 1 inch in 1 year Metabolic Alkalosis ↑ N ↑
3 – 5 years: ½ inch/yr, total of 1.5 inches Partially Compensated
5 – 20 years: ½ inch/5 yrs, total of 1.5 inches Respiratory Acidosis ↓ ↑ ↑
Respiratory Alkalosis ↑ ↓ ↓
FLUID THERAPY
Metabolic Acidosis ↓ ↓ ↓
NB Term: 70 cckd
PT: 60 cckd Metabolic Alkalosis
Asphyxiated: 40-50 cckd Fully Compensated
0-3 kgs 75 cckd Respiratory Acidosis N ↑ ↑
4-10 kgs 100 cckd Respiratory Alkalosis N ↓ ↓
11-20 kgs 75 cckd Metabolic Acidosis N ↓ ↓
21-30 kgs 60 cckd Metabolic Alkalosis N ↑ ↑
31-40 kgs 50 cckd Mixed
>40 kgs 40 cckd Acidosis ↓ ↑ ↓
Alkalosis ↑ ↓ ↑
+ 30% if with fever Uncompensated Respiratory Acidosis: Increase RR
+ 20% if under phototherapy Uncompensated Respiratory Alkalosis: Decrease RR
Maintenance IVF: Uncompensated Metabolic Acidosis: NaHCO3
IMB: for patients < 15 kgs Weight x 0.6 (full) X Base Excess
NM: for patients > 15 kgs Partially Compensated Metabolic Acidosis: NaHCO3
TFR – meds – TPN – MF Half = 0.3

UNIFIED FLUID MANAGEMENT: HOLIDAY-SEGGAR ABG’s

Weight (kg) Volume Required NV pH = 7.35 – 7.45 PT = 7.25
pO2 = 80-100
2.5-10 100ml/kg mild 60-80

6
 moderate 40-60 1.pCO2 <35 Comp met acid
severe 40-20 2.pCO2 35-45 Normal
HCO3 = 22-26 PT:15 3.pCO2 >45 Comp resp acid
BE = -2/+2 [Link] <7.35
Respiratory Alkalosis : EpH (expected pH) 1.pCO2 <35 Partially comp met acid
= 40 – pCO2 (0.003) + 74 2.pCO2 35-45 Met acid
(0.008)
3.pCO2 >45 Resp acid
Respiratory Acidosis
EpH = 7.4- (pCO2-40) (0.003)
(0.006)
NURSERY NOTES ON FLUIDS & ELECTROLYTES
*if ABG result dec = + met acid
Day 1 D10W + Ca (100-200 mkd)
inc = + met alka
Prep 100mg/ml
Metabolic acidosis:
Term: 60-80 cckd GIR: 6-7mg/kg/day
EpCO2 = (HCO3) (0.75) + 20 +/- 5
PT: <1000g: 80-100 cckd
Metabolic Alkalosis
< 700 g: 120-140 cckd
EpCO2 = (HCO3) (1.5) + 8.4 +/- 2
Day 2 Increase 10-20 cckd
 if result dec = +resp alka
Na: 2-4 mkd
 Inc = + resp acid
Determine the following : Day 3 K: 1-2 mkd
1. pH : acidotic (<7.35) vs alkalotic(>7.45)
2. compensated(pH7.35-7.45) or uncompensated(pH outside normal range) Day 4 Increase 20 mkd
3. respiratory vs metabolic GIR 12-15
4. P/F ratio Oral + IVF = 150 cckd
pFO2 = pO2/ present FiO2, to determine if oxygenation is adequate (N.V. pFO2
= 400-500) * 1st series of IVF: D10W
<400 = inadequate oxygenation 2nd series of IVF: D10IMB
5. if pO2 <80 = uncorrected hypoxemia TOTAL FLUID REQUIREMENTS FOR NB
>100 = overcorrected
DAY TERM PRETERM
80-100 = corrected
0 60 80
6. desired FiO2
pCO2/0.8 1 70 90
713 (FiO2) = #1 2 80 100
pO2/ #2 3 90 110
(desired pO2 = 100/#3 + #1) x 100/713 4 100 120
**adjust vent settings gradually to desired 5 110 130
FiO2 6 120 140
*lpmFiO2 = liters x 4 + 20 7 130
Example : On room air(FiO2 0.21) 8 140
pH 7.10 pCO2 55 pO2 82 HCO3 18 BE -5 O2 sat 88% 9 150

* In PT, do not give > 140 cckd because DA might open up → PDA

Example: TFR x weight

1. acidosis 150 x 1.7 kg = 255 cc / 3 = 85 ml in 8 hours
2. uncompensated Order as: IVF #1,2,3 D10 IMB (85 cc D5 IMB + 10 cc D50W) to run
3. respiratory :pCo2 abn > HCO3 abn through solusets for 8 hours each at 10-12 ugtts/min (or cc/hr)
EpH = 7.28 – 7.355 suspect underlying met acid
4. P/F ratio = 82/ 0.21 = 390  inadequate oxygenation TFR:
5. actual pO2 = 82  corrected hypoxemia 1 kg 80-90 cckd D5W
6. desired FiO2 1- 1.5 kg 70-90 cckd D10W
1. 55/0.8 = 68.75 > 1.5 kgs 80 cckd
2. 713(0.21) – 68.75 = 80.98 Term 70 cckd
3. 82/80.98 = 1.01 Asphyxiated patient 50 (40-60) D10W
4. 23.5%
TFR – meds – TPN – 75% MF
Uncompensated resp acid suspect underlying met acid with corrected
* Repeat HGT after an hour of changing dextrosity
hypoxemia at room air
Guidelines:
NUTRITIONAL MGT
1. Give NaHCO3 ½ correction if :
TARGET feeding
a. pH < 7.2
Preterm= 150 – 160 x wt / frequency MF
b. HCO3 <13 / 15
Magnesium : 0.1 cckgdose q 8* IM x 6 doses x 2 days
GIR(Glucose Infusion Rate)
N.V: 4-8 mgkg/min
CORRECTION OF HCO3
GIR = wt x TFR x dextrosity / 100 x 1000 / 24 / 60 / wt
Wt (BE) (0.3) half
(0.6) full
GOMELLA
Order : 1:1 dilution
GIR= dextrosity x rate (ml/hr) x 0.167 / wt(kg)
_____meq + _____cc distilled water
½ as slow IV push and ½ as IV drip via infusion pump for 30 mins.- 1 hour
D7W/IMB D5W/IMB D50W
BLOOD GASES
7.5 0.94 0.05
Arterial Venous
10 0.88 0.12
pH 7.35-7.45 7.31-7.41 12 0.85 0.16
pCO2 32-45 41-51 12.5 0.83 0.22
pO2 75-100 35-40 15 0.78
HCO3 21-27 22-26
O2 sat 90-100% 70-75% e.g D5  50-10/50-5 = 40/45= 0.88
BE +/- 5 +/- 2 D50  10-5/50-5 = 5/45=0.11
TCO2 23-32 23-32 D5% = 5 g glucose/100 ml = 1 g glucose/ 20 ml

[Link] >7.45
1.pCO2 <35 Respiratory alkalosis
2.pCO2 35-45 Metabolic alkalosis
3.pCO2 >45 Partially comp met alka D7 D12
[Link] 7.4-7.45 D10 1.075 0.95
D50 0.075 0.075
1.pCO2 <35 Comp resp alka
D5 Distilled H2O
2.pCO2 35-45 Normal
D2.5 ½ ½
3.pCo2 >45 Comp met alka D5 D50.3 NaCl
[Link] 7.35-7.4 D5 0.15 ½ ½
7
D5 0.2 2/3 (500cc) 1/3 (500cc) increase of 5 mg/dl per dat = pathologic

ADMITTING ORDERS FOR WELL BABY Jaundice:

Please admit under the service of Dr. _____ Physiologic Pathologic
Routine newborn care Onset 2nd DOL At birth or <24°
TPR q shift and record please Peak 2 -4th day(term)
nd
Encourage breastfeeding 4th-7th day(PT)
For rooming in Level ≤ 12 mg/dl(term)
Secure consent for BCG, Hepa B and NBS ≤ 14 mg/dl (PT)
Weigh daily Fractions ↑ B1 B2 > B1
I & O q shift and record B2 Not >1mg/dl >1mg/dl
AP to be informed of this admission Rate of ↑ Not > 5mg/dl/24° > 5mg/dl/24°
PROD/PIOD aware of this admission
Duration Gradually ↓by the 5th Presists beyond 2
Refer accordingly.
day, disappear by 7th weeks
day(term) or 14th
PRETERM ORDERS
day(PT)
Admit
Routine NB care
KRAMER’S Classification of Intensity of Jaundice:
VS q1* and record
NPO Zone Jaundiced Areas Est. Serum Bili
ET intubation (if needed) hook to ET size____ level___ with the ff set-up:IMV/CMV/CPAP I Head, Neck 6-8 mg/dl
O2 hood/funnel II Upper trunk 9-12 mg/dl
ABG after 1 hour of set-up III Lower trunk, thigh 12-16 mg/dl
Insert OGT(optional) IV Arms, Legs, Elbows, 15-18 mg/dl
Place inside isolette and maintain strict thermoregulation at 36.6-37.2*C Knees
Request for: CBC c APC, blood and Rh typing, at 12 hours of life V Hands,feet >15 mg/dl
RBS at 2 hours of life then q8*
Blood CS PHOTOTHERAPY
CXR at 4 hours of life 10 fluorescent lamp
IVF/Umbilicath 20 watts
Antibiotics 43-45 cms
Hook to pulse oximeter 200 hours
Urine output cc/cc and record
CARDIAC RATE
D1= 140 Risk Classification For Pneumonia-Related Mortality
D2= >130 Variables PCAPA PCAPB PCAPC PCAP D
>D7= <120 Min. Low Mod Hi Risk
1. Co-morbid (-) (+) (+) (+)
VOMITING illness
For gastric lavage 2. Compliant Yes Yes No No
Note for recurrence and refer Caregiver
TREMORS 3. Ability to ff- Poss Poss Not poss Not poss
Check thermoregulation up
Early: for early feeding/ glucose water in b/w feedings 4. Dehydration none Mild Mod Sev
Late:feed as tolerated [Link] tofeed Able Able Unable Unable
Do RBS/HGT 6. Age >11mos >11mos <11mos <11mos
Ionized Ca = hypocalcemia
7. RR
2-12 mos ≥ 50 >50 >60 >70
HYPOCALCEMIA
1-5 y/o ≥ 40 >40 >50 >50
Total Ca : < 7 mg/dl
> 5 y/o ≥ 30 >30 >35 >35
Ionized Ca : <4 mg/dL
8. Sx of Resp
Failure
VITAMIN K NB= 1 mg/ml at nirth
Retractions (-) (-) IC/SC SCC/IC
1 mkd q 5-7 days for patients on prolonged antibiotics
Head bobbing (-) (-) (+) (+)
Vit K 1 mgIV q 7 days
Cyanosis (-) (-) (+) (+)
IVIg for severe sepsis 500mkd OD x 3 days
Grunting (-) (-) (-) (+)
Ranitidine 0.1 mkdose q6/8H
Apnea (-) (-) (-) (+)
Sensorium awake awake irritable lethargic/
HYPOGLYCEMIA comatose
<50 mg/dl [Link] (-) (-) (+) (+)
= 0.055 = ______mg/dl Action Plan OPD Ffup OPD after Admit PICU
for RBS at 2 hours of life: SGA,LGA,IDM at end of 3 days Ward
tx
IDM : RBS at 2 hours then HGT at 4,6,12,24,48
RBS at 45 mg/dl may do repeat after 6H Oxygen delivery(PALS)
O2 mask 6-10 lpm 35-60%
Tx: Start IVF D10W x 24 hours then rpt HGT before IVF is consumed, if rpt is normal, d/c O2 mask w rebreathing bag 50-60%
IVF if still abnormal, continue D10W x 48 hours and NPO O2 hood 10-15 80-90%
Increase dextrosity O2 tent 10-15 50%
D10W 2 cc/kg IV bolus then rpt HGT after 1 hour (Cx; Rebound hyperglycemia Nasal cannula 1 24%
2 to inc insulin secretion) 2 28%
Early /increase feeding 3 32%
4 36%
HYPERGLYCEMIA
>120 mg/dl INDICATIONS FOR ET INTUBATION;CPR
Tx 1 decrease dextrosity 1. Airway obstruction
2. decrease IVF rate by 10 cc/kg 2. Congenital anomaly, trauma, infection,
Neoplasm,anaphylaxis,CNS disorder
BILIRUBIN 3. Apnea or respiratory failure=muscle weakness,CNS disease,
B1B2= wt x 10 = increase cardiac disease, pulmonary disease
B2= <0.6 mg/dL 4. Aspiration risks=weak gag or cough, depressed mental status
TB birth – 1day <6 mg/dl
1-3d <8 Indications for Intubation
3-7 d <12 PaCO2 >50 mmHg
7-28d <7 PaO2 < 50 mmHg
bottlefed <12.4 O2 sat < 90% with FiO2 > 50%
breastfed <14.8 Indication for Extubation

8
Ventilator rate < 10 cpm I pO2 FiO2 Inc -
Os requirement <30 % FiO2
Regular spontaneous RR
Stable blood gas values and CXR findings
SUGGESTED ET TUBE SIZE
Age [Link](mn) ABG Arterial Mixed
PT 2.5-3 pH 7.35-7.45 7.31-7.41
NB 3 pCO2 35-45 41-51
NB-6 mos 3.5 pO2 80-100 35-45
6-12 mos 3.5-4.0 60-80 neonates
12 mos-2 yo 4-4.5
3-4 4.5-5
ABG Term Preterm Preterm <30
5-6 5-5.5
30-36 wks wks
7-8 5.5-6
9-10 6.0-6.5 pO2 80-95 60-80 45-60
11-12 yo 6.5-7.0 pCO2 35-45 35-45 38-50
13-14 yo 7.0-7.5 pH 7.32-7.38 7.3-7.35 7.27-7.32
HCO3 24-26 22-25 19-22

Vent RR PAP PEEP IT FiO2

wt weeks ET size Level Inc pCO2 Dec Dec - - -
<1000 <28 2.5 6-7 Dec pCO2 Inc Inc - - -
1-2 kg 28-34 3 7-8 Inc pO2 - Inc Inc Inc Inc
2-3 kg 34-38 3.5 8-9 Dec pO2 - Dec Dec - Dec
>3000 >38 3.5-4 9-10
FOR EXTUBATION
Size of ET= Age in years x 16 / 2 FiO2 = 40
(+ 16 /4) RR = 10
Level of ET = BL / 0.5 PIP/PEEP = 10/4
PALS = BW + 6 TFR
FIo2 = TFR x 4 + 20
CPAP Tfr = FiO2 x 20 + 4
P=4 p=6 p=8 IT = 60 + RR /IE
O2 Ca FIo O C Fi O C FiO2 IE = 60 + RR – IT + IT
2 2 A O 2 A FiO2 = CA (0.21) + PA (1) x 100% / TFR
2 CA = (100 – FiO2) (PEEP)/ 79
3.5 0.5 90 5 1 8 7 1 90 PEEP = CA + PA
3.0 1.0 80 4 2 6 6 2 80 MAP = (RR) (IT)(PIP) + { (60 – RR) (IT)} (PEEP)/ 60
2.5 1.5 70 3 3 7 5 3 70
2.0 2.0 60 2 4 3 4 4 60 Extubation
1.5 2.5 50 6 3 5 50 Mid- respiration
1.0 3.0 40 0 2 6 40 NPO x 6 hours
4 1 7 30 Nebulize with Salbu 0.25 + 1.75 NSS q 6* for 2 days
6 NPO x 4 hours
Shift to O2 hood at 10lpm
MECHANICAL VENTILATION WOF signs of respiratory distress such as tachypnea, retractions, cyanosis
Initial Ventilator Setting (PALS) & refer to PROD once noted

Total Flow Rate 6-10 l/min POST EXTUBATION

FiO2 100% USN Salbu 0.25 cc +1.75 cc NSS q 6 x 24-48 H (0.2 mkdose)
PIP 20-30 cm H2O
PEEP 2-4 cm H2O VENTILATORY FAILURE (Respiratory acidosis)
RR 20-30 cpm(infants) pCO2 > 50
16-20 (children) acute pH <7.3
IT 0.5 – 1 sec chronic pH 7.3-7.6
IE ratio 60 + 40 + +0.5-1
BMI: kg/m2 16 & below: emaciated
Adjust as needed (NICU – up to 60 cpm) 17-18.9: Underweight
19-24.9: Normal
TFR = wt x 10 x RR x 3 25-28.9: Overweight
FiO2 + TFR x 4 x 20 or O2 + (CA)(2)/TFR 29-39.9: Obese
>40: Morbidly obese
Observe for color, chest rise, breath sounds, respiratory effort, O2 saturation
HEMATOLOGY
Adjustments Age Hgb Hct WBC Plt
RR PIP PEEP FiO2 Birth 16-22 44-66 15-30 350
I PaCO2 D D - - 3 mos 11.4-12.2 36-38 5-8 260
D PaCo2 I I - - 6mos 11.8-12.0 35-40 6-16 250
I PaO2 - I I I 1yo 11.2-12.2 35-40 6-16 250
D PaO2 - D D D 2-8yo 11.5-13.1 35.4-43 7-13 250
8-12yo 12-14 37-46 5-12 250
VENTILATOR SET-UP
If pCO2 > 50 BT:1-3 secs CT:2-5 secs
pCo2 <60
FiO2 = 60-70
RR = 50-60 BLOOD
PIP =18-20 (PT) 25(FT) For transfusion <1 mo old, if MBT =O use type O
PEEP = 4-6 Allowable blood loss = wt x 80 x 10%
Increase PEEP to maintain FRC to prevent further collapse PRBC = (wt) (D-A) (2) for hgb
IT = 0.6 (wt) (D-A) hct
IE = compute 60 / RR – 0.5/0.5 10-15 cckg in 4 hours
FWB = (wt) (D-A) (6)
= 10-20 cckg in 4 hours
pO2 pCO2
Platelet rich plasma = 10 cckg in 2 hours
I O2 D CO2 PAP Inc Dec
Platelet concentrate = fast drip
D CO2 RR - Dec FFP = 10-20 cckg to run in 2 hours
I CO2 I O2 PEEP Inc Inc Cryoprepicipitate = 1 u/ 5 kg or 1 u/ 7 lbs fast drip
I CO2 I O2 IT Inc Inc

9
ANC = (N) (100) (WBC) / 100 Therapeutic dose: 6 mg/kg/day
St + seg x wbc
If < 500  sepsis Iron preparation
Absolute retic count = pt’s hct /N hct for age x retic % Fer-In-sol 25 mg/ml
Retic Index = Absolute retic count/ 2 Ferlin syrup 30 mg/ml
If > 2 g= hemorrhage/hemolysis Incremin 30mg/5 ml
<2 = red cell production is abnormal Ferlin drops 15 mg/ml
Polyvifer 10 mg/ml
BLOOD TRANSFUSION Mediferron Vita 75 mg/5 ml
PRBC = 10-15 ml/kg in 1-3 hours
ml = wt(kg) x total BV(80 ml/kg) x (D-A hct) /
hct of transfusion product (0.7) FOR IDA WORK –UPS
2 ml /kg raise hgb level to 0.5 -1 g/dL After 48 hours; Bone marrow
used in hypovolemic shock with hct < 40% After 1 week: retics ct
FWB= 15-20 cc/kg in 4 hours After 1 month: CBC
Coagulation factoprs/volume expansion/rbc
Plt Conc. = 10 [Link]( 1 u/7 kg) EXCHANGE TRANSFUSION
1 unit/7-10 kbw = inc plt ct by 50,000/mm3 Umbilicath
FFP = 10-15 cc/kg - shoulder to umbilicus, 2/3 of umbilicus to clavicle + 1 cm
Albumin = 20cc/lb Double volume exchange
(80 ml/kg) (wt)(2)
Use: Cryoppt: ↑ PTT, N PT, N APC, N BT = if MBT is O use type O low titer, if not use BBT
FFP: ↑ PT, PTT, N APC Pre:
Plt Conc: <100,000, BT > 9 sec, N PT & PTT 1. Soak umbilicus with wet OS (NSS)
2. Prepare 80 cc/k= FT x wt x 2
Post- BT Orders 90 cc/k =PT
1. NPO x 4 hours then may give MF low liter FWB properly typed and xmatched “O” with
2. RBS after 1* BBT (160-180) cc/kg)
3. Isolette 3. lab pre and post B1B2(30 min prior and after BT)
4. VS q 30 mins 4. Prepare
5. Direct and Indirect O2 at 3lpm a. Calcium gluconate = 1cc (100 mg)every after 100
6. continue bililite cc of exchange
7. Hgb,Hct,B1B2 b. NSS 500 cc,infuse 1 cc b4 ca gluc
c. Sterile basin, for soaking exchange transfusion set
HEMATOLOGY COMPUTATIONS d. Droplight
Absolute Reticulocyte Count e. Direct O2 funnel
= Actual Hct/Desired Hct) x Reticulocyte Ct f. 3 way stop cock
Reticulocyte Index: Absolute Retc Ct/2 or Hct (4) (2) g. heparin
Retic h. gloves and gown
1) Non-anemic: (Retic Ct x Hct) ÷ 0.45 i. 20 cc syringe
2) Anemic: Hct x Retic Ct x 0.45 j. test tube for blood specimen
2 5. Soak BT set in 500 cc D50.9 NSS + ).5 heparin x 30 mins
* > 2% = normal bone marrow responding 6. Withdraw 10 cc from baby first then send to lab for pre
* < 2% = abnormal BM/ decreased RBC exchange BCB,B1B2 then get 10 cc FWB and infused to baby
production then extract 20 cc out from the baby
RPI = (Reti Ct x Hct) / 45 = NV: 2
Corrected Reticulocyte Count (CRC) : PARTIAL EXCHANGE TRANSFUSION
Retic Ct x Hct
Ave Hct for age ml = estimated bld volume x wt (kg) x (O-D hct)/ observed hct

Mean Corpuscular Volume (MCV): (Hct x 100)/RBC count for polycyhtemia = NSS/ other bld product
Normal: 82-98 u volume of axchange will dec hct to 55%
Macrocytic (MCV > 100), Microcytic (MCV <80)
ALIQOUTS IN NEONATAL EXCHANGE TRANSFUSION
Mean Corpuscular Hemoglobin (MCH): (Hgb x 100)/Rbc ct >3 kg 20 aliquots
Nirmal: 28-32 ug 2-3 kg 15 aliquots
1-2 kg 10 aliquots
Mean Corpuscular Hgb Conc: (hgb x 100) / Hct <1 kg 5 aliquots
Normal: 32-38% <850 g 1-3 ml
Normochromic or Hypochromic
BM ASPIRATION (BMA)
Each pack of whole blood will increase Hgb by 1.5-2 mgs% NPO X 2 hours prior to procedure
Fresh Whole 10-15 ml/kg over 4 hrs for moderate bleeding Dormicum 5 mg/amp
Blood 20 cc/kg in 6 hrs for massive bleeding Nubain 10 mg/amp
Xylocaine 2%
Platelet 1 U/70 kg BW; 3 U/ m2 BSA or 2cc/kg; 6-8 u/2 mL; or 7
3 cc syringe #2
Concentrate lbs/unit as fast drip
10 cc syringe #1
FFP 10-20cc/kg(15cc/kg) Prepare _ u type glass slide #6
specific FFP & ÷ 3 eye sheet
aliquots; each aliquot gloves
to contain __cc; needle g 23 #2
Transfuse 1 aliq once specimen bottle #3
available to run for 3
hrs for 3 doses SEDATION FOR BMA
Cryoppt 1 bag or 1 unit/10kg; or 7lbs/unit as fast drip <5 yo Dormicum 5 mg Nubain 5 mg
Albumin 0.5 – 1 gm/kg in 3-4 hrs >6 yo Domicum 10 mg Nubain 10 mg
>12 yo Dormicum 15 mg Nubsin 10 mg
Dextran 6% Not more than [Link]/day 1. Start IVF D5W 500 cc x KVO
Dextran 10% Not more than [Link]/day 2. Plasil 5 mg, give 30 mins prior to chemotx then q6H for 24
Phlebotomy: Wt(kg) x 80cc x 15%; or hours
= (Blood Volume)(wt)(Desired Hct-Actual Hct) 3. Vincristine 1 mg/ml, give 1 ml thru slow IV push
Actual Hct 4. After 30 min, dilute adriamycin 20 mg in 50 cc IVF to run for 1
hr x 3 days (dose 20-40 mg/m2)
Maximum Blood extraction in newborn: 80 ml x kg x 10% *for intensive chemotx:Dactinomycin 1 vial + 2 cc dist water
 Replace with PRBC if blood extracted is >10% of TBv then give 0.3 cc OD x 5 days
5. Run D5W 100cc IVF to run 1 hour
IRON 6. CYA 200 mg + 100 cc IVF to run for 1 hour
Prophylactic dose : 1 mk/dose

10
 LUMBAR PUNCTURE
SC older children and adults ends at L1
Ideal location for LP L3-L4 interspace Modified Glasgow Coma Scale for Infants & Children
SC NB and young infants ends at L2 Infant
Ideal location for LP L4-L5 Coded value
N CSF pressure in NB 100mm H2O Spontaneous 4
Older children 110-150 To verbal stimuli 3
Contraindications : To pain only 2
1. presence of increase ICP No response 1
2. presence of a mass or wound along the puncture site
3. presence of uncorrected hematologic dysfunction that can cause prolonged Coos & babbles 5
bleeding Irritable cries 4
4. presence of severe cardiac and pulmonary compromise Cries to pain 3
Moans to pain 2
No response 1

LUMBAR TAP (L4-L5) Moves spontaneously 6

Pre : secure consent & purposely
Post : NPO x 4-6 hours Withdraws to touch 5
Flat on bed Withdraws to pain 4
VS q 30 mins Decorticate posturing 3
Send specimen for (abn flexion to pain)
#1 CS and GS #3 cell ct, diff ct Decerebrate posturing 2
#2 CHON and sugar #4 phadebact (abn extension to pain)
TCC : 1-2 mo (0-10) no response 1
1-4 yo(0-8) Child
5-13 yo (0-3) Eye opening
Spontaneous 4
Opening P N=80-110 I=<200 mm To verbal stimuli 3
Glucose P=24-63 T=44-128 To pain only 2
CHON P=65-150 T=20-170 No response 1
WBC P=0-25 T=0-22 Verbal response
Ratio P=55-105 T=44-128 Oriented,appropriate 5
WBC(% of PMN) P=57 T=61 Confused 4
Inappropriate words 3
RBC T=0-62
Incomprehensible words or 2
Non-specific sounds
Glascow Coma Scale & Pediatric Coma Scale
No response 1
Coded Value
Motor response
Eye opening
Obeys command 6
Spontaneous 4
Localizes painful stimuli 5
To speech 3
Withdraws in response to pain 4
To pain 2
Flexion in response to pain 3
None 1
Extension in response to pain 2
Best Verbal Response
No response 1
Oriented 5
Confused 4
Inappropriate words 3
ACUTE GLOMERULONEPHRITIS
Incomprehensible sounds2
TFR = BSA x 400 / UO in 24 hours / 2 if with furosemide
None 1
Tagamet = 15 mkd q6*
Best Motor Response
Vitamin A <2 yo 100,00 IU as single dose
Obeys 6
 2 yo 200,00 IU as single dose
Localizes 5
Latent period = 1-2 weeks
Withdraws 4
Oliguric stage = 7-10 days
Abnormal flexion 3
Diuretic stage = 7-10 days
Extensor response 2
Convalescent stage
No response 1
Resolution of gross hematuria = 2-3 weeks
Total 3- 15
Proteinuria = 3 weeks
Adelaide Pediatric Coma Scale
Micro hematuria= 1 year
Coded value
C3= 8-12 weeks
Eye opening
Spontaneous 4
To speech 3 T14.0 Abrasion, forehead
To pain 2 J20.9 Acute Bronchitis
None 1 J45.9 Acute Bronchitis with hyperactive
Best Verbal Response component
Oriented 5 N10 Acute Pyelonephritis
Localizes pain 4 J03.9 ATP Exudative
Flexion to pain 3 A09.9 AGE with DHN
Extensor to pain 2 A09.3 AGE with no DHN
None 1 A09.0 AGE with some DHN
Best motor response K31.8 Acid Peptic Disease
Obeys command 5 K35.9 Acute Appendicitis
Localizes pain 4 C91.0 ALL
Flexion to pain 3 J39.4 Allergic Rhinitis
Extension to pain 2 A06.9 Amoebiasis
None 1 D64.9 Anemia
Total 3-14 J69.0 Aspiration Pneumonia
R56.0 Benign Febrile Convulsion
Normal Aggregate Score
0-6 months 9 J45.9 Bronchial Asthma, intermittent
6-12 months 11 J49 Bronchitis
1-2 years 12 J18.9 Bronchopneumonia
2-5 years 13 I49.9 Cardiac Dysrhytthmia
L51.7 Cardiomegaly
H26.9 Cataract
L03.9 Cellulitis
S06.0 Cerebral Concussion
Z51.1 Chemotherapy
11
J44.8 Chronic Asthmatic Bronchitis P28.5 TTN
J42 Chronic Bronchitis A01.0 Typhoid Fever
N18.9 Chronic Renal Failure K92.2 UGIB
J35.0 Chronic Tonsillitis N20.1 Urolith
Q36.9 Cleft Lip & Palate J06.9 URTI
A41.9 Clinical Sepsis N39.0 UTI
A09.9 Colitis B01.9 Varicella
G40.2 Complex Febrila Seizure V89.99 Vehicular Accident
I50.0 Congestive Heart failure B15.9 Viral Hepatitis
H10.9 Conjunctivitis, acute
N30 Cystitis Orders:
N21.0 Cystolithiasis
A90 DFS Seizure:
A91.0 DHF I > Admit
A91.1 DHF II > DAT once fully awake
A91.2 DHF III > VS q 1 to include NVS
A91.3 DHF IV > IVF:
> Request: CBC (24hrs postictal) due:
E14.9 Diabetes Mellitus
UA
I42.0 Dilated Cardiomyopathy
Serum electrolytes
K80 Dyspepsia Hgt
M9071 Endodermal Sinus Tumor Lumbar puncture for CSF Analysis
A01.0 Enteric Fever > Meds: Paracetamol (PO/supp)
A46 Erysipelas Diazepam 10mg/2ml __ ml through SIVP for active seizure
N18.0 ESRD > Standby O2 at 2-3 lpm via NC
K30.6 FIA > Seizure precaution
T78.1 Food Allergy > Suggest referral to Pedia Neuro
T62.9 Food Poisoning close…
K29.7 Gastritis
N00 Glomerulonephritis Dengue:
B08.5 Herpangina > Monitor VS q 2 to include BP and record please
H10.0 Hordeolum > IVF: PNSS alternate with D5LR
P21.9 HIE > Note for signs of bleeding such as gum bleeding. Epistaxis, narrowing of
P22.0 HMD pulde pressure & inform PROD once noted
> Monitor UO cc/cc
T78.1 Hypersensitivity Reaction
If with BM:
J68.3 Hyperactive Airway Disease
> Chart the amount, frequency and consistency of each stool and refer to
E87.6 Hypokalemia PROD if more than 3X
E10 IDDM > CDD c/o PIOD
K56.7 Ileus If with vomiting:
L01.0 Impetigo > Note for recurrence of vomiting and refer to PROD once noted
K40.9 Indirect Inguinal Hernia If with Pneumonia:
A09.9 Infectious Diarrhea > Note for signs of respiratory distress such as alar flaring, tachypnea,
B27.1 Infectious Mononucleosis retractions and cyanosis then refer to PROD once noted
J11.1 Influenza
B82.9 Intestinal Parasitism
D50.9 Iron Deficiency Anemia
E46 Malnutrition pH pCO2
B05.9 Measles pO2 O2 Sat
B26.9 Mumps HCO3 BE
P24.9 Neonatal Pneumonia
P36.9 Neonatal Sepsis ORS:
N20.0 Nephrolithiasis Wt x 10 ÷ 4 = __ (in oz)
N05.9 Nephritis Moderate DHN:
N04 Nephrotic Syndrome 75 x wt ÷ 30 ÷ 4 = __ (in oz)
Iron:
C85.9 Non Hodgkin’s Lymphoma
Ferlin Drops: 15 mg/ml elemental Fe
R50.9 Nonspecific Febrile Illness
Ferlin Syrup: 30 mg/5ml elemental Fe
N45.9 Orchitis Therapeutic dose: 6 mkd
H66.9 Otitis Media Prophylactic Dose: 1 mkd
J01.4 Pansinusitis In Antibiotics:
K11.2 Parotitis Ampi/AMik (100/10)
K27.9 Peptic Ulcer Disease Cefta/Oxa (100/100)
J36 Peritonsillar Abscess Meropenem (25 mkd q 12)
J39.1 Pharyngeal Abscess Ciprofloxacin (5mkdose q 12) * always with consent
J18.9 Pneumonia Pip-Tazo
P25.1 Pneumothorax ORAL INTAKE:
N39.0 Presumptive UTI wt x TFR = ideal
P07.3 Preterm AGA Actual ÷ Ideal x 100
P05.1 Preterm SGA * At 2 pm divide ideal by 3
A16.7 Primary Complex MKD: given x prep x freq ÷ wt
A16.9 PTB UO: UO ÷ wt ÷ # of hrs
NICU:
Z20.1 PTB Class I
PT: 80 cckd T: 70 cckd
A16.2 PTB Class 2,3,5 (not confirm)
Wt x TFR = __ ÷ # of soluset = __ ÷ # of hrs
A15.0 PTB Class 2,3,5 (sputum +) Ca gluc: wt ÷ # of soluset
Z03.0 PTB Class 4
D38.1 Pulmonary Mass If Vomitus:
N12 Pyelonephritis Gastric juice: D5IMB
M06.99 Rheumatoid Arthritis Bilous: D5LR/Plain LR
K37 Ruptured Appendicitis L lateral: prevent reflux
R56.8 Seizure Disorder
K12.0 Stomatitis If with Congenital Heart Disease:
R56.0 Simple Febrile seizure 75% of maintenance
B34.9 SVI
Z38.0 Term AGA
P08.1 Term LGA ANATOMIC DIFFERENCE

12
 Adult Infant 3. Hypermetabolic states 25-75%
Location of larynx C5-C6 C3-C4 - Thermal injuries 2% ↑ or 1%↑/burnt area
Epiglottis flat & thin Floppy,O - Salicylate intoxication
Close to the shaped - Thyrotoxicosis
Tongue 45 degrees - Burns on the 1st day & on subsequent days
Parallel to the ant. 4. Diarrhea, Vomiting Volume/volume
To the trachea pharyngeal 5. Sweating 10-25%
Wall 6. Room temp > 31 C 30% per C rise
Narrowest posi glottis cricoid cart 7. NB under radiant warmer 25%
Tion of airway 8. Full activity 50%

LESS REQUIRED ADJUSTMENT

SIZE OF TUBE FOR NGT INSERTIONS
1. Hypothermia 12% for @ C below 37.8
PT Neonate F5
Term neonate-4 mos F8 2. Very high humidity 30%
4 mos-4 yrs F10 3. Humidified inspired air 25%
5-10yo F12 4. Oliguria/ Anuria Case to case basis
11-12 yo F14 5. Sedated or paralyxed patient 40%
12yo older F16 6. Edematous & Antidiuretics state 30%

HANDBOOK OF PEDIA BEDSIDE PROCEDURES 2000 ACTIVE FLUID REPLACEMENT THERAPY

Axillary temperature lower than the rectal temp by 1*C For LBM or Vomiting Replacement Volume
Axillary temp lower than the oral temp by 0.5*C 5-10x/day Add 25 ml/kg
10-15x Add 50ml/kg
TACHYPNEA 15-20x Add 75 ml/kg
>/=60 per min in 0-2 mos DEHYDRATION
>/=50 per min in 2-12 mos > 15kgs Mild Dehydration 30 cck x 6-8 hrs
>/=40 per min in 1-5 yo Moderate DHN 60 cckg ¼ 1st hour
¾ 5-6 hours
Severe DHN 90 cckg x 1/3 1st hour
BLOOD PRESSURE
2/3 next 5 hours
Flush method: extremity is first compressed rendering the area below the cuff bloodless.
< 15 kgs Mild DHN 50 cckg x 6-8 hours
While the cuff is being deflated, the mean pressure is recorded at the point where flushing
Moderate DHN 100 cckg ¼ 1st hour
appears in the arm or hand below the cuff. The reading lies between the systolic and
¾ 5-6 hour
diastolic pressure obtained by auscultatory method.
Severe DHN 150 cckg 1/3 1st hour
BP= age in years x 2 + 70 2/3 next 5 hours
= age in years x 2 + 90 * Some Dehydration: D5LR
* Severe Dehydration: PLRS
RADIOGRAPHIC PEARLS * IVF TF: after reassessment: if ok, hook to maintenance IVF

HMD SIGNS & MILD MODERATE SEVERE Dehydration

Fine diffuse reticulogranular pattern 2* to microatelectasis of the alveoli; radioluscent SYMPTOMS Dehydration Dehydration
areas/ bronchograms caused by air in the major airways Infants % Thirsty, Thirsty, restless, Drowsy, Limp, cold, sweaty w/
MECONIUM ASPIRATION Young kids alert,restless irritable or drowsy cyanotic extremities,
Bilateral, patchy,coarse infiltrates & hyperinflation of the airways. may be comatose
PNEUMONIA Older Kids Thirsty, alert, Thirsty,alert, Usually unconscious,
Diffuse alveolar or interstitial disease usually asymmetric & localized. restless postural apprehensive, cold, sweaty,
Pneumatocoele can be seen with staph. Pneumonia. Pleural effusions & empyema hypotension cyanotic extremities;
are apparent with any bacterial pneumonia. wrinkled fingers & toes; cramps
TTN Radial Pulse Normal Rapid, weak Rapid, feeble but not palpable
Hyperaeration with symmetric perihilar infiltrates, pleural fluid may be seen as strength
prominence of the minor fissure. RR Normal Deep/rapid Deep rapid
BPD Anterior Normal Sunken Very sunken
I : similar to severe HMD Fontanel
II : dense parenchymal opacification Systolic BP Normal Normal/Low Low/Very low
III : bubbly, fibrocytic pattern Skin Elasticity retracts retracts slowly retracts very slowly
IV : hyperinflation with multiple fine, lacy densities spreading to the periphery & immediately
with areas of lucency extending to the bullae. Eyes Normal Sunken Grossly sunken
ATELECTASIS Tears Present Absent Absent
Decrease in lung volume or collapse of part or all of a lung, mediastinum is shifted Membran Moist Dry Very dry
towards the affected side of collapse. Urine flow Normal Reduced None for several hours;
CARIAC DISEASES amount;dark empty bladder
N cardiac/ thoracic index = <0.6 (length of base of heart / length of the thorax) Weight Loss 4-5% 6-9% 10% or more
Cardiomegaly = >0.6
Pulmonary vascularity increased if: more than 2 or 3 end on vessels are present,
diameter of descending branch of the right pulmonary artery exceeds that of the
BURNS
trachea.
Total Body Surface Area estimated as:
NORMAL PATTERN IN THE GIT
1) Rule of NINE
Air in the stomach should occur within 30 minutes after delivery.
Air in small intestine should be seen by 3-4 hours of age Child Adult
Air in the colon & rectum should be seen by 6-8 hours of age. Head & Neck 18% 9%
INTESTINAL OBSTRUCTION Each Upper Limb 9% 9%
Air fluid levels proximal to obstruction Anterior Trunk 18% 18%
PNEUMOPERITONEUM Posterior Trunk 18% 18%
Supine view : free air as a central lucency Leg (groin to toe) 14% 18%
Upright view : free air in sub-diaphragmatic location
Left lateral decubitus ; air over lateral border of liver, separating it from abdominal
wall. 2) Rule of PALM:
PNEUMATOSIS INTESTINALIS Surface of patient’s palm is approximately 1% of the TSBA
Intraluminal gas in the bowel wall (produced by bacteria that have invaded the bowel Area B-1yr 1-4yr 5-9yr 10-14 15yrs Adult
wall) appears as a string of submucosal bubbles, seen in patients with NEC. Head 19 17 13 11 9 7
Neck 2 2 2 2 2 2
Ant 13 13 13 13 13 13
FACTORS MODIFYING FLUID REQUIREMENTS Trunk
CONDITIONS EXTRA NEEDED ADJUSTMENT Post 13 13 13 13 13 13
1. Fever 12% for @ C>37.8 Trunk
2. Hyperventilation, Chills, Sz 25-50% R 2 1/2 2 2 2 1/2 2½ 2 1/2

13
 FLUID RESUSCITATION FOR BURNS 1-2 y/o 110 2.5
(Parkland Formula) 3-6 y/o 90-100
First 24hrs: PLRS 2.0
< 30% BSA: 3 ml/kg BW/% burn 7-9 y/o 80-90 1.5
> 30% BSA: 4 ml/kg BW % burn 10-12 y/o 70-80 1.5
50% of total amount for 1st 8 hours from time of injury 13-15 y/o 55-65 1.5
50% for the next 16 hours from time of injury 16-19 y/o 45-50 1.2
Second 24 hours:
Fluid Requirement Average: 50-75% of 1st day IVF: D10 W = 10 g glucose/100cc
Maintenance dose of D5W (metabolic water needs)
D5IMB = 5 g glucose/100 cc
Colloid (1g/kg/day of FFP or albumin) after 18-24 hours
e.g.: 3.5 kg; IVF at 15 cc/hr
to bring the serum albumin to >2gm/dL
Withold K+ for 1st 24 hours due to large release of K+ TFI: cc/day ÷ wt: 100 cc/kg/day
from damaged tissues
TCI: g glucose x 4 cal (glu) ÷ wt
Third day and thereafter:
Use D10W = 10d x 360cc/ 100cc
As soon as the GIT has resumed peristaltic activity, oral or tube feedings should be = 36g glucose
started = 41 cal/kg/day
After capillary permeability returns to normal, edema fluid is reabsorbed by the high
oncotic pressure of the plasma TOTAL CALORIC INTAKE
IVF = TFR x wt x dextrosity / 100 x 4
MF = cc x # feeding/day x 30 cc x 20 cal (term formula)
DIAGNOSIS OF BURN WOUND DEPTH:
24 cal (PT formula) = cal/d
st
= cc x # of feeding / 30 =_____oz
1 Degree 2nd degree 3rd degree Vamin/ Aminosyn = cc x 0.65 cal/ml
Superficial Deep Dermal Intralipid = cc x 1.1 cal/ml
Cause Sun Minor Hot liquids Hot liquids Flame D5 = cc x 0.4
flash Flashes of Flashes of Immersion D12.5 = cc x 0.125
flame flame scalds Karo = cc x 4
Brief Prolonged High voltage Corn oil = cc x 9 = cal/day
exposure exposure to Exposure to
to dilute dilute conc chem TCL = total cal/d divided by wt = cal/kg/d
chemical chemical Contacts w/ hot = IVF + MF / wt = cal/kg/day
objects N.V = NB:90-120
Color Pink Pink to Dark red or Pearly white or <10kg:100-120
bright red mottled charred 11-20 kg:1000 + 50
yellow-white Transluscent >20 kg:1500 + 20
vessels may be 1 yo:80-120
visible >3 yo: dec by 10 cal/k/year
Surfac Dry/Small Variable Smaller Dry w/ adherent
e blister sized, bullae, often nonviable INTRALIPID (fractionated soybean oil, egg phospholipids, glycerol)
usually ruptured epidermis 10% = 1100 kcal.L = cc x 1.1 cal
large Slightly moist Thrombosed 20% = cc x 2 cal
bullae vessels may be Reqt: SGA = 0.5 gkd
Copious visible NB = 0.5 – 2 gkd
exudates
Sensa Painful Painful Dec pinprick Anesthetic; VAMIN 9 (Dextrose 10%,AA 70.2 g/L N 9.4 g/L,650 kcal/L) Na=50 K=20
tion sensation; Deep pressure Ca=2.5 Cl=50
intact
Textur Soft w/ min Thicken by Moderate Inelastic and 12-24 H
e edema & edema edema w/ dec leathery = (0.5-3 g) (wt)(100)/7 = ____cc to run x 12-24H by infusion pump to start
later superf pliable elasticity on day 4 of NPO
exfoliation = increase by 0.5 gkd
Healin 2-3 days 5-21 days 3 weeks None-grafting
g required PT start 0.5 gkd
FT start 1 gkd
NUTRITION
EVALUATION OF NUTRITIONAL STATUS OSTERIZED FEEDINGS
Waterlow Classification: 1:1 = 1000 kcal = 1000 cc / 6-12 feedings
Height for age Weight for age e.g 2000 kcal/d
= actual height x 100 = actual weight x 100 CHO (60%) = 1200 cal = 300 g
ht at p50 wt at p50 CHON = 225 cal = 56 g
Fat remaining
>95 : no stunting > 90: no wasting
90-95: mild stunting 80-89: mild wasting FACTORS:
80-89: moderate stunting 70-79: moderate wasting Vamin = cc x 0.65 cal/ml
Intralipid = cc x 1.1
Aminosyn= 650 cal/L
D5 = cc x 0.2
Gomez Classification: D10 = cc x 0.4
Weight for Age D12.5 = cc x 0.125
= actual weight x 100 Karo = cc x 4 cal
wt at p50 Corn oil = cc x 9 cal
SAMPLE COMPUTATION
> 90: no PEM Wt=17 kg
75-90%: mild TFR=(17kg) (75 cckd)=1275cc
Welcome Classification: CHON=(17kg)(1.5 gkd)=26 g/d
BW at Edema Def. in WFH Vamin9=7 g aa/100cc=26g/x=371cc
p50 FATS=(17)(1.6)=26 g/d
Undernutrition 80-60 - Minimal Intralipid=10 g/100 ml=26/x=260 cc
Nutritional Dwarf ≤ 60 - Minimal TFR-Intralipid-Vamin
Marasmus ≤ 60 - ++ =1275-371-260=645 cc/d
Kwashiorkor 80-60 + ++ CHO(dextrosity 10%)
Marasmus- Kwashiorkor ≤ 60 + ++ D50/50=(645 cc)(0.111)=72 cc/x = 100cc/50 g=36g
CALORIC REQUIREMENTS: D5IMB=645 – 72 cc
AGE CAL/KG CHON = 573 cc /x = 100 cc/5g=29 g CHO
Dextrosity = total g glucose/total fluids
0-5 mos 115 3.5
= 36+29+37/1045cc(TFR-Intralipid)
6-10 mos 110 3
=0.97

14
Na=(3 meqkd)(17kg)=51 meq/d Plantar Grasp Birth 10 m
D5IMB=573 cc/x = 1000cc/25 meq=14 meq Na Adductor spread of knee jerk Birth 7m
Vamin=(370cc)/x)(1000cc/50meq)=18.5 meq Tonic neck 2m 6m
NaCl=(2.5 meq/ml)=18.5 meq/x= 7 cc Neck righting 4-6 m 24 m
K=(3 meq /k/d)(17kg)=51 meq/d Landau 3m 24 m
D5IMB=573cc/x = 1000 cc/meq=11 meq Parachute reaction 9m persists
Vamin=370 cc/x=1000 cc/20 meq=7 meq
KCl=2 meq/ml=33 meq/x=16.5 ml PHYSIOLOGIC WEIGHT LOSS
NUTRITIONAL MANAGEMENT
Wt loss during the 1st 3-5 days
I. CALORIES
Term 10-15% of birth wt
Maintenance wt gains 15-30 gms/day
Preterm 15-20% of BW
T=50-60 kcal/d 100-120 Infant should regain or excedd birth wt by 2 wks
PT=60-75 110-150 Calories
[Link] 11-15 gkd (40-50% total calories)
To maintain wt 50-60 kcal/kg/day
[Link] 3.5-4 gkd
To induce wt gain
[Link] 4-6 gkd Term : 100-200 kcal/day
Preterm: 110-140 kcal/day
TERM=fed within 4 hours
POST –EXTUBATION =fed 6 hours after PHYSIOLOGIC ANEMIA
RR<60 oral NV Hgb: 14-20 g/dl (ave 17 g/dl)
<60-80 gavage Term: 9-11 g/dl until 8-12 weeks
ASPHYXIATED=fed D3-D5
Preterm : 7-9 g/dl until 3-6 weeks of age
INITIAL FEEDING= sterile water on D5W
Iron deficiency anemia should not be considered in the 1st 3 mos unless
BW <1200 g use NGT, dilute MF,0.5-1 ml/hr q2* there is significant blood loss
1200-1500 g sterile water 2 ml/k q* x 2 doses, 2 ml/kgq2*
RAPID DETERMINATION OF GESTATIONAL AGE
Breastmilk storage
1. creases in soles of the foot
Freezer = -20*C= 6 mos 2. size of breast nodules
Ref = 4*C= 24 hourS 3. nature of scalp hair
4. cartilaginous dev’t of ear lobe
INFANT FORMULA
5. scrotal rugae and testicular descent
1:1 1:2
Alacta iron fortified Bonna COMPLICATIONS OF PREMATURITY
Enfalac Mylac
Infection
Enfalac PT Similac
Intracranial hge
Enfamil S-26 NEC
NAN
NAN HA 5 I’s of Necrotizing Enterocolitis:
Nestogen
1) Infection
Aptamil 2) Immaturity
PreNAN 3) Ischemia
Frisomel
4) Immunologic
FOLLOW –UP MILK
5) Early Introduction of Milk Formula
1:1 1:2
Enfapro Bonamil MECONIUM STAINING
Lactum Hinulac
Umbilicus 4-6H
NAN2 Promil
Nailbeds 2-4H
Nestogen2 Yellow older
Progress 1 sachet in 170 ml Green younger
LACTOSE FREE
DRUGS PRESENT IN MILK IN SIGNIFICANT AMOUNTS, BUT NOT
ALF 1:1 KNOWN TO BE HARMFUL
Nursoy 1:2 Antihistamines Ethosuximide Quinidine
Olac 1:1
Cimetidine Hydroxychloroquine Ranitidine
Progestemil 1:1
Diltiazem Minoxidil Spironolactone
Prisobee 1:1 Erythromycin Paracetamol Trimetophrim
Pediasure 1 kcal/ml Etamsylate Pyrimethamine
30 kcal/1 oz
5:6 dilution CHARACTERISTICS OF NEONATES
Preterm AGA Term SGA
NEONATOLOGY Small but plump Wasted
10 PHYSIOLOGIC CHANGES IN THE NEWBORN:
Red or very pink White or pale pink
1. Physiologic jaundice
Length <50cm Length >50cm
2. Physiologic Anemia HC < 35cm HC >35 cm
3. Physiologic desquamation Lanugo hair Thick dark hair
4. Witch milk
Skin: shiny, transparent, Skin:dry, loose, thick
5. Falling off of umbilical cord
Thin, edematous
6. Vasomotor instability Ears, brest tissue, Ears, breast tissue,
7. Transitional stool genitalia all mature Genitalia all immature
8. Weight loss
Hypotonic (floppy) Good muscle tone
9. Passage of urine
10. INFECTIONS AFFECTING THE FETUS
GROWTH AND DEVELOPMENT
Agent Spontaneous Stillbirth Low BW MainCongenital
Fontanelle Closure:
Abortion defects
Anterior: 12 – 18 mos
Posterior: 3 – 4 mos Rubella + + + Cataract,deafness
Cong. Heart dse
REFLEXES OF NEONATES:
* Absence of reflexes indicates general disposition of central or peripheral motor function CMV ? + + Microcephaly,
 Asymmetric responses suggest focal motor lesions, either peripheral or central Deafness

REFLEX APPEARS DISAPPEARS HSV - - + Microcephaly

Moro Birth 8m
VZV ? ? + Limb hypoplasia,
Stepping Birth 6 wks
Cutaneous scars
Placing Birth 6 wks
Sucking & Rooting Birth 4 m, awake Syphilis + + + Rashes, bloody
7 m, asleep Snuffles, wide-
Palmar Grasp Birth 6m

15
 Spread organ dse a. lactalbumin 40%
b. lactoferrin 20%
FAILURE TO RESUSCITATE AND BIRTH ASPHYXIA
Reasons for Failure Immediate effect of severe asphyxia Ration of whey to casein is 20:80 in cow’s milk
Brain damage Brain a. B-lactoglobulin
Hemorrhage Fits
Ischemia Irritability The high percentage of lactose in breast milk stimulates the growth of
Upper AW obstruction Abnormal tone Lactobacillus bifidus which is responsible for the acidity of the breast-fed
Laryngeal spasm Hypo- & Hyperventilation infants intestinal content.
Laryngeal stenosis Hypoglycemia The large amounts of lactoferrein are also found in breast milk
Lung pathology Lungs Anti-staphyloccal infection which can be the cause of diarrhea, abscess,
Pneumothorax Aspiration pneumonia and sepsis.
Hypoplasia RDS
Effusion Hemorrhage Lactoperoxidase kills streptocci and enteric bacteria
Diaphragmatic Hernia Kidneys
Small chest cage Vein thrombosis Secretory IgA against bacteria invadi ng or colonizing the mucosa of
Shock due to ruptured Tubular necrosis intestines.
viscera Bowel
Ileus POSSIBLE REASONS FOR NOT BREASTFEEDING:
Perforation a. Lack of motivation of mother to breastfeed leading
CAUSES OF NEONATAL CONVULSIONS to inadequate mother-infant interaction
Brain damage Metabolic b. Anxiety, fear and uncertainty in the mother
Asphyxia Hypoglycemia c. Separate nursery and maternity wards
Birth injury w/ hGe Hypocalcemia & d. Milk formula is easily suck from the nipple
CNS infections hyponatremia
CNS malformations Inherited metabolic D/O ABSOLUTE CONTRAINDICATION:
1. Chronic diseases like open tuberculosis, cardiac diseases,
BREASTFEEDING thyrotoxicosis, advanced nephritis, mental and seizure disorder
Types of Feeding :
1. Artificial – when milk other than breastmilk CAUSES OF HYPERBILIRUBINEMIA
2. Mixed Feeding – when both milk are used : breastfeeding or artificial feeding Birth to 2 weeks
3. Complementary feeding – artificial feeding immediately follows breastfeeding to Hemolytic disease of the NB
make a single feeding Bruising and petechiae, hemorrhages due to asphyxia and
4. Supplementary feeding – when artificial milk feeding alternates or replaces birth trauma
breastfeeding. G6PD deficiency
Breastfeeding may be given : Inherited red cell anomalies
Scheduled – can guide the infant in developing the proper habits of timing his feedings and E. coli septicemia
in the process can teach him to develop some form of discipline.
On demand (self –regulation) – infants is allowed to feed when he so desires Persisting after 2 weeks
- prevents the development of some feeling of insecurity or resentment in the Unconjugated hyperbilirubinemia
infant when feedings are delayed. Infection, e.g urinary tract
- This will also prevent the development of gastrointestinal problems like Hypothyroidism
tympanism or colic. Hemolytic anemia
Lactation may be maintained for as long as 18-24 months (250-400 ml) High GI obstruction
Breast – made up of 15-20 lobes ducts(special channels) sinuses(reservoirs)pores Breast milk jaundice
in the nipple Transient familial hyperbilirubinemia
Reflexes : 1. prolactin reflex Crigler Najjar syndrome
2. let down reflex or milk ejection Conjugated Hyperbilirubinemia
Neonatal hepatitis syndrome
INFLUENCE ON THE COMPOSITION OF THE MILK: Congenital infection e.g., rubella, CMV, toxoplasmosis
1. time of day Metabolic e.g. alpha-1 antitrypsin deficiency, galactosemia,
2. diet of the mother Tyrosinosis, cystic fibrosis, storage disorders
3. her emotional state Duct obstruction or obliteration
4. whether fore or hing milk Extrahepatic biliary atresia
5. drugs Intrahepatic biliary hypoplasia
6. smoking Choledochal cyst

Advantages of Breastfeeding HYPERBILIRUBINEMIA

1. Breastmilk contains the necessary nutrients in the proper quality and quantity Bilirubin : end product of catabolism of heme & is produced by
2. Rates of growth of breastfed infants in developing countries are better during breakdown of RBC hgb
the first 3-4 months of life than those artificially fed. : pred. bound to serum albumin inside liver cells,
3. Anti- infective properties of breastmilk are universally proven and accepted. unconjugated bilirubin is bound to Ligandin, Z protein, & other
Antibodies to e. coli, commonly the cause of diarrhea in the newborn and early proteins. It is conjugated by Uridine diphosphate glucoronyl
infancy, present in the breastmilk afford some protection against coliform bacterial transferase.
infection. Conjugated bilirubin is water soluble & can be excreted in the urine,
4. Breastfeeding prevents hypersensitivity or allergy. most of it are excreted as bile into the intestine, further metabolized
5. Psychological advantages. The mother’s desire to feed her infant is aroused if by bacteria in the intestine & excreted in the feces.
there is a close physical contact with him.
6. Contraceptive effects. UNCONJUGATED HYPERBILIRUBINEMIA
7. Breastmilk seems to have a protective effect against necrotizing enterocolitis. : bilirubin load – bilirubin excretion
8. Other important attributes of breast milk are: safe, contains no pathogenic : Causes:
organism, always at the right temperature, convenient and always at the right A. Physiologic Jaundice : elevation of B1 during 1st week of life
temperature, convenient and always available wherever the mother and child & resolves spontaneously.
may be. FT: bilirubin progressively rises to a mean peak of 5 – 6 mg/dL
The more fat, the yellowish the color. by the 3rd day of life(white & black), a peak of 10-14 mg/dL at 3-4
days (asian)
COLOSTRUM : PT : liver fxn less mature, jaundice more frequent &
- the secretion of human breast during the 1st 2-4 days post-partum pronounced, peak concentration of 10-12 mg/dL by the 5th day of
- deep yellow fluid more on protein(albumin) more vitamins(vit A) life.
- more salt (Na & K) Mechanism:
- more immune bodies(IgA) 1. increase bilirubin load b’coz of the larger RBC volume,
- but less fat and sugar than mature milk the shorter life span of RBC & increase enterohepatic
- sp. Gr 1.040 – 1.060 circulation in NB infants.
- pH 7.7, total of 10-40 ml per day 2. Defective uptake of bilirubin by the liver
- Protein : 1. casein, a calcium phosphorus containing precipitate 3. Defective conjugation
2. whey protein ; remain in resolution 4. Impaired excretion into bile
5. Over-all impairment of the liver fxn.
Ration of whey to casein is 70:20 in milk protein

16
 B. Pathologic Jaundice :
Unconjugated bilirubin > 12.9 mg/dL in term infants
Unconjugated bilirubin level > 15 mg/dL in preterm infants
Jaundice in the 1st 24 hours of life PERINATAL ASPHYXIA
Conjugated bilirubin level > 2 mg/dL - insult to the fetus or newborn due to lack of oxygen (hypoxia)
Clinical jaundice persisting >1 week in FT or > 2 weeks in PT &/or lack of perfusion(ischemia) to various irgans.
C. Hemolytic Anemia - Asso with lactic acidosis
RBC defects – may result from a congenital RBC defect such as hereditary - Occurs in 9% of infants < 36 weeks gestational age & in 0.5%
spherocytosis, infantile pyknocytosis, pyruvate kinase def., G6PD deficiency, of infants > 36 weeks gestational age.
thalassemia, or vit.k induced hemolysis. - Incidence is higher in term infants of diabetic or toxemic
Acquired – may be seen in ABO or Rh incompatibility (Erythroblastosis fetalis) mothers, and asso with IUGR & breech presentation & post
between infant & mother, may also be associated with the use of certain drugs mature infants.
(sulfonamides) or with infection. Pathophysiology & Etiology :
D Polycythemia – liver ,ay not have the capacity to metabolize the bilirubin load - 90% occur in ANTEPARTUM & INTRAPARTUM as a result of
presented by the increase blood volume. placental insufficiency, resulting in an inability to provide
E. Blood Extravasation – sequestration of blood within body cavities can result in oxygen & remove CO2 & H from the fetus.
increase bilirubin thus causing overload, may be seen in cephalhematoma, IV - Remainder are POST PARTUM usually 2* to pulmonary, CVS,
& pulmonary he., subcapsular hematoma of the liver, excessive ecchymosis or neuro insufficiency.
petechiae, occult GI he., & large hemangiomas. Target organs :
F. Defects of Conjugation 1. brains – hypoxic/ ischemic brain injury
1. Congenital Deficiency of Glucoronyl transferase 2. heart – transient myocardial ischemia
[Link] I (crigler-Najjar) : AR, poor prognosis, unresponsive to Pb 3. renal – ATNB & SIADH
b. Type II def – AD, benign, common, defect in both upatake & 4. GI – bowel ischemia & NEC
conjugation 5. Hema – DIC
2. Glucoronyl transferase inhibition 6. liver – shock liver/ damage
a. Drugs – novobiocin 7. lung – increased pulm vascular resistance, pulm he, pulm
b. LUCEY DRISCOLL Syndrome – a maternal gestational hormone edema
found in the infant’s serum interferes with the conjugation of bilirubin, Prognosis : Poor, risk of CP
resolves spontaneously. Factors Include :
G. Breastmilk Jaundice (late onset) 1maternal HPN/ hypotension
- higher paek (10-30 mg/dL, peaking by days 10-15 of life) & a slower decline in 2. maternal vascuylar disease
the serum bilirubin concentration, rarely appears before the end of the 1st week 3. maternal DM
of life for term or preterm. 4. maternal drug use
- Factors associated with an abnormality of the milk itself may include 5. maternal hypoxia fr pulmonary, cardiac, or neuro dse.
pregnanediol in milk, increase concentration of FA, or increase enteric 6. maternal infxn
absorption of unconjugated bilirubin. 7. placental infarction/fibrosis
- Levels of unconjugated bilirubin may be elevated for wees to several months. 8. placental abruption
- Interruption of brestfeeding for 24-48 hours at unacceptable bilirubin levels 9. cord accidents
results in rapid decline 10. abnormalities of umbilical vessels
- Resumption of brestfeeding increases bilirubin levels slightly but usually below 11. fetal anemia
previous levels 12. fetal or placental hydrops
- May recur in 70% of future pregnancies. 13. fetal infection
H. Metabolic Disorders 14. IUGR
- galactosemia, hypothyroidism, & maternal diabetes may be associated with 15. postmaturity
unconjugated hyperbilirubinemia.
I. Increase Enterohepatic Circulation -during normal labor, uterine contractions & some degree of cord
- seen with pyloric stenosis, duodenal atresia, annular pancreas, cystic fibrosis, compression result in decreased blood flow to the placenta & hence
& any form of GI obstruction or ileus. decreased oxygen delivery to the fetus.
J. Substances & Disorders affecting binding of bilirubin to albumin -There is concomitant increase in oxygen consumption by both
- certain drugs occupy bilirubin- binding sites on albumin & increase the amount mother & fetus hence fetal oxygen saturation falls
of free unconjugated bilirubin that can cross the BBB such as aspirin, -Maternal dehydration & maternal alkalosis from hyperventilation
sulfonamides, intralipid, asphyxia, acidosis, sepsis, hypothermia, may reduce placental blood flow
hyperosmolality & hypoglycemia. -Maternal hypoventilation may contribute to decreased maternal &
BILIRUBIN ENCEPHALOPATHY (Clinically worsening encephalopathy over 24 hours) fetal oxygen saturation.
Phase I : poor suck, hypotonia, depressed sensorium -Any process that impairs maternal oxygenation, decreases blood
Phase II : fever & hypertonia flow from mother to placenta or from placenta to fetus, impairs gas
Phase II : high pitched cry, hearing & visual abnormalities, poor feeding, & athetosis. exchange across the placenta or at the fetal tissue, increases fetal
Long term survivors – choreoathetoid cerebral palsy, upward gaze palsy, sensorineural oxygen requirement will exacerbate perinatal asphyxia.
hearing loss, & mental retardation
KERNICTERUS RDS/HMD
- staining & necrosis of neurons sparing the cerebral cortex - lack of pulmonary surfactant  progressive atelectasis, loss of
- bilirubin toxicity to the brain may be reversible if bilirubin levels falls before FRC, alterations in ventilation – perfusion ratio and uneven
saturation of the CNS nuclei occurs distribution of ventilation
- at risk if levels > 25 mg/dL Clinical Features : tachypnea, expiratory grunting, retractions, nasal
DIAGNOSIS OF UNCONJUGATED HYPERBILIRUBINEMIA flaring, cyanosis, SC & IC retractions, increased oxygen requirement
Hemolytic Anemia – low hgb or hct asso. With high reticulocyte count & presence of + diagnostic radio findings & onset of s/sx before 6 hours of life with
nucleated RBC’s progressive worsening of s/sx with peak severity by day 2-3 & onset
Polycythemia – venous blood with HCT > 65% of recovery by 72 hours
Direct Coomb’s Test – usually (+) in isoimmunization disorders Risk Factors : low gestational age, maternal DM, perinatal
Serum Albumin – may help to assess total bilirubin binding sites available. asphyxia,premature infants

Mx UNCONJUGATED HYPERBILIRUBINEMIA Steroids when administered to the mother at least 24-48 hours
a. Phototherapy : healthy term NB with TSB of 30 mg/dL at 48 hours of liofe may before delivery, decreases both the incidence & severity of RDS
be treated initially with phototherapy
If TSB decreases by 1-2 mg/dL within 46 hours of strating phototp, Corticosteroids – effective < 34 weeks of gest & when administered
exchange transfusion not necessary. at least 24 hours & no longer than 7 days before delivery.
Treatment:
[Link] Criteria : bilirubin level low enough to eliminate the risk of kernicterus -Surfactant thru intratracheal installation at 100 mg phospholipids/kg
- risk factors for the infant has resolved BW.
- infant is old enough to handle bilirubin load. CXR: diffuse reticuologranular pattern in both lung fields with
b. Complications : superimposed air bronchograms
1. Retinal Degeneration Granular patterns – caused by alveolar atelectasis with
2. Increase insensible fluid loss – inc fluid reqt by 25%, stools may be component of pulm. Edema
looser & more frequent. Air bronchogram – aerated bronchioles superimposed on a
3. Bronze baby syndrome – photo destruction of copper porphyrins, background of non-aerated alveoli.
causing urine & skin to become bronze
4. Congenital erythropoeitic porphyria – TTN
phototp. Is CI

17
 - delayed resorption of fetal lung fluid thus more common after CS b’coz infant’s 2. Lateral – to see objects in 3D, 10% of lung pathology is seen
thorax is not subjected to same pressures as when delivery takes place per better, should be requested in children.
vaginum in the “big squeeze” 3. PA- preferable
- prolonged labor with an increase incidence of failure to progress asso with TTN Radiographic Strategies
Clinical Features: Pneumothorax ; film should be taken at END- inspiration
Mild cyanosis, grunting, flaring, retractions, tachypnea in the 1 st few hours of life Pleural Effusion: fluid in between the pleura
after birth - best seen in lateral decubitus position on the affected side
- 1-2 weeks : thickwning of fluids, therefore still can do
ABG : hypoxemia thoracentesis or thoracostomy
CXR : patchy infiltrates clear within 48 hours & are asso with perihilar streaking Bony Structures
- congenital absence of clavicle/ ribs
Risk Factors : prematurity, maternal sedation, maternal fluid admi., maternal asthma, - clavicular fracture
exposure to B mimetic agents, fetal asphyxia Trachea
- Transient nature of the disease is variable - major airway for respiration
- May last from 12-24 hours in its mildest form to beyond 72 hours in persistent cases - normally a midline structures
- Antibiotics may be begun depending on history & clinical status of infant, terminated - divides into right and left bronchi
at 72 hours if cultures are negative. - luscent because air passes through
- Self limiting with no risk of recurrence or residual pulmonary dysfxn. Heart
CEREBRAL HYPERVENTIALTION – in term infants with a history of birth asphyxia - Normal cardiothoracic ratio in adult : 0.5
with no xray changes, respiratory alkalosis. Infants : 0.5 – 0.6
: bacterial sepsis may have precipitated passage & subsequent aspiration of Cardiac Vessels
meconium = antibiotics - must NOT be seen spreading in lateral 1/3 of chest, if (+)
: ventilatory assistance suggest congestion, congestive heart failure or fluid overload
OTHER ASPIRATION SYNDROMES Diaphragm
- aspirate a sufficient volume of clear AF or exhibit delayed resorption of lung - major muscle for inspiration
fluid - left is usually lower than the right because of the heart sitting
- aspiration after regurgitation =most likely seen in PT on top of the diaphragm
- may be suspected from perinatal hx (asphyxia), feeding hx,(cyanosis, - hallmark of the diaphragm is the magenblase not the heart.
excessive drooling, poor suck) & PE. - Dome- shaped
- Flat diaphragm ; draw connecting line bet 2 sulci and connect,
PULMONOLOGY highest point of diaphragm at midline and draw a perpendicular
CHEST ROENTGENOGRAPHY line; if dome is < 1.5 cm, it is flat or suspect air trapping
By: Dr Ordonez
CAUSES OF COUGHING AND WHEEZING
Projections : PA – lateral (routine) 0-1 YEARS 1-5 YEARS > 5 YEARS
B’coz it reflects the most accurate size of the heart. Acute bronchiolitis Recurrent wheezy Asthma
AP – lateral : bedside, or for patients who can’t stand- up Wheezy bronchitis bronchitis (early Acute bronchitis
Apicolordotic : screening for TB (early asthma) asthma)
Component: Aspiration FB aspiration
1. gas Cystic fibrosis acute bronchiolitis
2. blood
3. tissue – consist of solids and liquids Agents responsible:
Infections: Viral (Rhino, RSV, adeno, parainfluenza, rota)
90% of the lungs consist of lung parenchyma (alveoli and interstitial fluid) Exercise; excitement
 Dark  air Allergens: inhalants (house dusts, grass and tree pollen, animal hair, bird
feathers, mold); ingestants(tartrazine, ASA, cow’s milk products)
 Opaque  solid or fluid (bright/ white)
Attentions in lung densities:
PATHOGENESIS OF PNEUMONIA
1. Respiratory phase  inhale (more luscent)
2. Diastolic phase (more dense)
AIRWAY
Physiologic Mechanism
[Link] density is inversely proportional to the amount of contained gas
NORMALLY STERILE
more gas  less dense  luscent
(Sublaryngeal area – Terminal lung units)
[Link]
- position and rotation
Lung are protected from Bact./Viral Infection
3. Pathologic mechanism
By Number of mechanism:
- disease occurrences- due to infiltrates- opaque
1. Filtration of particles in the nares.
Technical Factors to be checked
2. Prevention of aspiration by the epiglottal reflex.
1. inspiratory phase
3. Expulsion of aspirated material by cough reflex.
2. position
4. Entrapment and expulsion of organism by mucus – secreting
3. penetration of the beam of light to the tissue
and ciliated cells.
4. position – symmetrical
5. Ingestion and killing of bacteria by alveolar macrophages.
Inspiration
6. Neutralization of bacteria by local immune substances.
- Good inspired film : No. 9-10 posterior ribs or 5-6 anterior ribs should be visible
7. Transport of particles from the lungs by lymphatic drainage.
on the right, above the dome of the right hemidiaphragm.
- Frontal chest radiographs are usually made at the end of a full, deep inspiration
Pulmonary infection may occur when one or more of these defense
Anterior rib : positioned downward
mechanism are altered and organism reach the lower respiratory tract either
Posterior rib : positioned horizontally
by aspiration or by the hematogenouse route.
Position
- routine: stand up or sitiing position
Aspiration is the most common route
- position affects interpretation
- MAGENBLASE : hallmark of an upright film
Viruses – enhance the susceptibility of the lower respiratory tract to
infection in several ways:
Penetration
1. Increased secretion promoting the aspiration of bacteria –
- a film is well penetrated if yous till can see the branching of the blood vessels,
laden fluids into the lungs.
tapering of the microvascular structures through the right and left shadows and
2. Decreased ciliary activity diminishing bacterial clearance.
beneath the right hemidiaphragm, intervertebral spaces(luscent) and mid thoracic
3. Impairment of local immune responses and bactericidal activity
spine
of Alveolar macrophages.
Rotation
- if a vertical line connecting the 2 nd and 3rd upper thoracic spinous process, it
should bisect almost exactly the horizontal line drawn between the two
clavicualr line
Respiratory pathogens
Technical Factors of Xray
↓
1. check for normal findings
reach the terminal bronchioles and beyond
2. discover abnormal findings
↓
3. pneumothorax, cardiomegaly, lung infiltration, pleural effusion
outpouring of edema fluid
View
↓
1. AP
Alveoli
↓
18
 increase number of leukocytes Signs 0 1 2
↓ RR <60 60-80 >80
macrophages remove cellular and bacterial debris the process may extend farther or may Cyanosis None (+r.o) + c O2
spread by infected bronchial fluids to other parts of the lung. Retractions None Mild Marked
↓ Air entry Good Fair Poor
Pulmonary lymphatic enable Perfusion Normal Sl delay delayed
bacteria to reach blood stream or visceral pleura
Score 2-3 = CPAP (nasal or ET)
↓ >3 = intubate (CPAP or IMV)
Consolidation >5 = intubate (IMV)
↓
Vital capacity and lung compliance decrease COMMON CONGENITAL HEART DEFECTS
↓ Acyanotic Cyanotic
Blood flow VSD Transposition of the
↓
ASD great arteries
in non ventilated areas creates
PDA TOF
↓ Pulmonary Stenosis
physiologic Right to left shunt Aortic Stenosis
↓
Coarctation of Aorta
Ventilation perfusion mismatching
Hypoplastic left heart
↓
Hypoxia DISTINGUISHING HEART MURMURS
↓
Innocent Murmur Significant Murmur
Cardiac work increase
↓ A healthy child May exhibit cardiac symptoms
oxygen desaturation and Hypercapnia Normal pulses Pulse may be N or collapsing
Tachypnea – greater than 50 breath/min No thrill Thrill may be present
40 breath/min children 12-35 m A mid-systolic murmur Murmur may be pansystolic or
30 older Musical, buzzing quality diastolic
Usually soft May be loud
CARI PROTOCOL Often variable Consistent
Pneumonia Normal heart sounds Heart sounds may be abnormal
If by mask < 5 lpm – increase CO2 Normal Chest Xray & CXR or ECG may show
<2 months ECG abnormality
Very Severe PN : stop feeding
: convulsion
: sleepy, difficult to wake up DISTINGUISHING HEART FAILURE FROM LUNG DISEASE
: stridor SIGN Heart Failure Lung disease
>2 months to > 5 yrs ↑ RR (>50) + +
Very Severe PN : not able to drink Breathless on feeding + +
: convulsion Labored feeding + +
: sleepy Cyanosis +* +(late)
Bacterial : Strep pneumonia Added sounds in chest +/- +/-
Viral : RSV Liver(>2 fingers palpable) ++ +/-
Atypical : Mycoplasma penuymonia – 5 to 15 erythro Easily palpable cardiac ++ -
Impulse
Peak Flow Heart murmur +/- -
- have baseline do 3 consecutive  record best 3 of trials Fever - +/-
Runny nose - +/-
FORMULA : Sweating + -
Female : height in cm – 100 x 5 + 175
* Late in non-cyanotic heart disease
Male: height in cm – 100- x 5 + 70
• The liver may be pushed down in bronchiolitis
- peak flow variability of at leats 20% supports the diagnosis of asthma
- in spirometry, at leats 15% CAUSES OF PERSISTENT VOMITING

Peak Flow Variability = highest – lowest/ highest reading x 100 Innocent Renal Disorders
Possetting Renal failure
Intestinal Renal tubular acidosis
PEFR GER Metabolic/Endocrine disorders
Pyloric stenosis Adrenal failure
Height (in) Expected PEFR
Malrotation & partial Amino acid disorders
109.2 43 142
obstruction Hypercalcemia
111.7 44 160
Food intolerance Cerebral disorders
114.3 45 173 Infection Hydrocephalus
116.8 46 187 Urinary tract Subdural bleed
119.4 47 200
121.9 48 214 CAUSES OF PROTRACTED DIARRHEA (%)
124.4 49 227 Coeliac disease 33
127.0 50 240 Secondary Disaccharide Intolerance 12
130.0 51 254 Cow’s milk Protein Intolerance 11
132.1 52 267 Primary Sucrase isomaltase deficiency 2
134.6 53 280 Schwachmann’s syndrome (exocrine pancreatic
137.2 54 293 failure with neutropenia) 2
139.6 55 307 Acrodermatitis enteropathica 2
142.2 56 320 Hirschsprung’s disease 2
144.7 57 334 Ulcerative colitis 1
Ganglioneuroma 1
147.3 58 347
Defective opsonization 1
149.8 59 360
Staphylococcal pneumonia 1
152.4 60 373
Malrotation 2
154.9 61 387
157.5 62 400 CAUSES OF CHRONIC CONSTIPATION
160.0 63 413 Behavioral Neuromuscular
162.5 64 427 Nutritional Mental handicap
165.1 65 440 Low residue diet Cerebral palsy
(Ht in cm + 2.54 cm = I inch) Excess cow’s milk Spinal cord lesion
Anatomical Congenital absence of
RDS SCORING Anorectal stenosis abdominal wall muscles

19
 Hirschsprung’s disease Generalized hypotonia - Nosebleeds
Metabolic Hypothyroidism - MOST SERIOUS COMPLICATION: ICH
Diabetes Insipidus - Liver, spleen, & LN not enlarged
Diabetes Mellitus (early stages) - Acute phase asso. With spontaneous hges lasts only 1-2
Hypercalcemia weeks
Renal Tubular Acidosis Lab. Findings:
- platelet count is < 20 x 10/L
CAUSES OF ACUTE ABDOMINAL PAIN - few platelets on blood smear are large (megathrombocytes) &
Surgical Medical Medical reflect increased marrow production
(rel. common) (rare but impt) - BMA: normal granulocytic & erythrocytic series and frequent
Acute AP Mesenteric adenitis Lead poisoning modest eosinophilia.
Intussusception Constipation Diabetes Differential Diagnosis :
Intestinal obstruction Gastroenteritis Sickle cell crisis - diff from aplastic or infiltrative processes of the bone marrow.
Lower lobe pneumonia Acuteporphyria Treatment:
Torsion of ovary Acute pyelonephritis Pancreatitis - ITP has an excellent prognosis
Or testis HSP - Fresh blood or platelet concentrate have transient benefit bec
Hydronephrosis Hepatitis peritonitis transfused platelets survive only briefly but should be
Renal calculus administered when life threatening hges occurs.
- Should be protected from falls/ trauma
CAUSES OF RECURRENT ABDOMINAL PAIN - Vit.K & C have no therapeutic effect.
Functional abdominal pain Renal - Gamma globulin – 400 mg/kg for 5 days induce remission
Intestinal Causes Pyelonephritis - Corticosteroid therapy – reduces severity & shortens duration
Peptic Ulcer Hydronephrosis of initial phase
Bezoar Renal calculi - Prednisone 1-2 mg/kg/24 hour in divided doses (BM
Gluten enteropathy Bladder calculi examination to exclude leukemia prior to prednisone)
Meckel diverticulum Bladder FB - Therapy continued until platelet count is normal or for 3 weeks
Crohn’s disease Urethritis whichever comes first.
Intestinal tuberculosis Peritoneum - Prolonged treatment may depress bone marrow in addition to
Intermittent obstruction JRD cushingoid changes & growth failure.
Food allergy SLE - Splenectomy reserved for chronic patients defined as
Liver and pancreas Periodic peritonitis thrombocytopenisa persistent for more than 1 year and for
Chronic hepatitis Referred pain severe cases not responding to corticosteroids
Cholelithiasis Spine disorders
Cholecystitis Gonad disorders DRUG INDUCED THROMBOCYTOPENIAS
Cystic fibrosis Metabolic 1. Carbamazepine (tegretol)
DM 2. Phenytoin (dilantin)
Porphyria 3. Sulfonamides
Lead poisoning 4. Trimethoprim- Sulfametoxzazole
5. Chloramphenicol
ACUTE DIARRHEA AND VOMITING
Cause Source Agent CHILDHOOD CANCERS
Food poisoning Food toxins Amanitas(mushroom) Cancer Group Frequency
Bacterial toxins Staphylococcal Leukemias 33
enterotoxin Brain Tumors 23
Infections Bacterial Rotavirus Lymphomas 11
E. coli Soft Tissue Sarcomas 6
Salmonella Bone Tumors 5
Shigella Wilm;s Tumors 5
Cholera Neuroblastoma 5
Yersinia Others 12
Campylobacter
Protozoa Giardia CHEMOTHERAPY ORDERS
lamblia - Get the BSA
Systemic Infective hepatitis - Metoclopromide (Plasil) 10 mg/2 ml, 1ml 30 mins prior to vincristine then
every 8 hours for 24 hours
COMPLICATIONS OF GASTROENTERITIS - Vincristine 2 mg/2 ml, 4 mg(4 ml) TIV as slow IV push
Convulsions Oliguria - run 60 cc of present IVF prior to giving cyclophospahmide 123 mg(6 ml)
to be incorporated to 50 cc of present IVF thru soluset to run in 1 hour
Fever Prerenal (urine urea ↑, Na ↓)
- Doxorubicin 10 mg/ 5 ml vial 4.5 mg (2.2 ml0 as very slow IV push in 5
Hypo-, hypernatremia Renal failure (urea ↓, Na ↑) mins
Hypoglycemia Renal vein thrombosis
Hypocalcemia Medullary necrosis
Cerebral damage Protracted diarrhea
Hypotension Sec. Lactose intolerance
Vascular thrombosis Sec. Cow’s milk CHON
Pulmonary edema intolerance
Fluid overload Bacterial overgrowth

ANEMIA CLINICAL PRESENTATION OF MENINGITIS &/OR SEPTICEMIA

- tachycardia Infants Older Children & Adults
- tachypnea Non specific Non-specific
- pallor * Drowsiness * Vomiting
- recurrent apnea * Irritability * Fever
* Off feeds * Back or joint pains
IDIOPATHIC THROMPOCYTOPENIC PURPURA * Distress on handling * Headache
- associated with petechiae, mucocutaneous bleeding, occ. He into tissues. * Vomiting or diarrhea
- Profound deficiency of circulating platelets, despite adequate #s of * Fever
megakaryocytes in the marrow. More specific More Specific
Etiology: * Neck stiffness * Neck Stiffness
- related to sensitization by viral infection in 70% with antecedent disease such * Tense or bulging fontanelle * Photophobia
as rubella, robeola, or viral resp. infxn. * Purpuric or petechial rash that * Confusion
- Interval between infection & onset of purpura averages 2 weeks. does not blanch under pressure * Purpuric or petechial
Clinical Manifestation: rash that doesn’t blanch
- onset is acute Late under pressure
- bruising & a gen. petechial rash occurs 1-4 weeks after a viral infxn. * High pitched or moaning cry
- - bleeding is asymmetric & most prominent over the legs * Coma Late
- hges in mucous membranes may be prominent with ghic bullae of the gums * Neck retraction * Coma
and lips. * Shock * Shock

20
* Widespread hemorrhagic rash * Widespread hemorrhagic 5. cotton balls
rash 6. eye sheet
CSF in Meningitis 7. Inpersol 1.5% per bottle #3
Bacterial Partially Tuberculosi Viral 8. cut down set #1
txed s 9. stab knife #1T #1
bacteria 10. JMS peritoneal dialysis set #1
Color purulent turbid colorless Colorless 11. heparin
Appear. Opaque Sl turbid Ground Clear 12. basin
glass 13. sterile dextrose bottle #1
Pandy Mod heavy Sl mod Mod (-) to sl Labs : Crea, K prior to PD
Sugar(qual) (--) (--)to(+) (--)to(+) (++) Use 1.5% Inpersol soln for all exchanges
CHON 100-200 ↓ >100 40-60 Volume exchange 100 cc
WBC Ct >1000 100’s 20-500 N:0-20 Infusion set fast drip
Dwell time = 20 min
Dic Ct Almost ↑ lympho ↑ lympho (↑ All lympho
Draining time = 20-30 min
100% PMN in 1st
Seborrhea Atopic
PMN’s 48)
Correction factors: 500-700 RBC: 1 mg% protein [Link] hx Usu none Hx of atopy
Meningitis: CSF findings [Link] of onset <2 mos >2 mos
1) Cloudy appearance [Link] Scalp,flexures Cheeks,
esp genitals,anal forehead,extensor
2) ↑ WBC count with PMN predominance
In older children- surfaces of limbs
3) ↓ glucose in relation to serum glucose eyebrows and
4) ↑ CHON eyelids
5) (+) Gram Stain [Link] Erythema c Erythematous
greasy yellowish papules,vesicles, no
ACUTE RENAL FAILURE scales scales
Prerenal failure Nephrotoxins cont… [Link] Minimal Severe
Circulatory Insufficiency Kanamycin [Link] findings Eosinophilia Eosinophilia
Gastroenteritis Polymyxin B (-) ST rxn (+)ST rxn
Diabetic acidosis Salicylates [Link] Usu clears in 3-4 Prolonged
Shock Edetate disodium weeks, up to 2 course,high
Burns Cortical Ischemia mos, no asso incidence of asso
Hemorrhage Shock defects allergic rhinitis and
Hypovolemia assoc’d Hemorrhage asthma
w/ nephritic syndrome Trauma
Renal arterial or venous Burns ERYTHEMATOUS RASHES IN CHILDHOOD
Occlusion Neonatal hypoxia Maculo-papular & erythematous rashes Likely Cause
Postrenal failure Diseases ofKidneys
Sulfonamide crystals & Vessels Reddish-brown maculo-papules; may Measles
become confluent; spreads from face
Uric Acid crystals Glomerulonephritis
Stones Pyelonephritis downwards; face leaving brownish stain;
Ureterocoeles Acute Interstitial sick child; Preceded by Koplik spots and
Trauma to a solitary kidney Nephritis conjunctival and respiratory symptoms
or its collecting system HUS
Renal Failure Polyarteritis Pink discrete macules; spreads rapidly Rubella
from face to the rest of the body; non- Coxsackie
irritating; usually gone in 3 days; child not ECHO
very ill; no staining
Nephrotoxins Iatrogenic Disorders
Bismuth
Mercury Gold Discrete pinkish red macular rash; starts Roseola
Renal Angiography from the trunk and spreads to the rest of the Infantum
body; lasts for couple of days; as rash
Ethylene Glycol Retrograde
Carbon Tetrachloride pyelography develops sick child improves
Incompatible Blood Transfusion Severe Infections
Sulfonamides Drowning,esp in fresh H2O Bright red flushed cheeks; circumoral Erythema
CHRONIC RENAL FAILURE pallor; followed by maculo-papular rash on Infectiosum
Cause Frequency limbs & trunk; lace-like appearance on (slapped face
fading; relatively well child; joint problems disease)
Glomerulonephritis 38.5 Parvo disease
Pyelonephritis 18
Congenital Hypoplasia 11 Fine popular or punctuate erythema; may Scarlet be most marked on
Hereditary Nephropathies 8 neck and in axillae & fever
Cystic kidney Disease 4.5 groin; flushed face with circumoral pallor;
Cortical and Tubular Necrosis 1.5 desquamation after about a week; tonsillitis
Other 16.5 and raw red tongue
INDICATIONS FOR DIALYSIS Red, raised indurated area with palpable Streptococcal
ACUTE RENAL FAILURE margin; toxic child erysipelas
Fluid Overload
Severe heart failure/Pulmonary edema TOPICAL STEROIDS USED IN DERMATOLOGY:
Severe Uncontrolled Hypertension Weak preparations (potency IV)
Cerebral edema +/- convulsions Hydrocortisone 0.5, 1 or 2.5% - nothing stronger than this should be used
Hyperkalemia (7mmol/L) in the face
Severe acidosis (HCO3 < 10 mmol/L)
Severe electrolyte imbalance Intermediate preparations (potency III)
Symptomatic uremia Fludroxycortide (flurandrenolone) 0.0125% (Haelan); clobetasone butyrate
Hypercatabolic Renal failure 0.05% (Eumovate);
CHRONIC RENAL FAILURE Betamethasone 0.025% (Betnovate-RD);
Symptomatic “uremia” is often the deciding factor Alphaderm (1% hydrocortisone with urea)
Commencement of dialysis is always an individual decision
There are no absolute biochemical values, but do not wait until life threatening Strong preparations (potency II)
complications of uremia Betamethasone 0.1% (Betnovate);
Consider all the indications as in acute renal failure Flucinolone acetonide 0.025% (Synalar);
Beclometasone dipropionate 0.025% (Propaderm)
PERITONEAL DIALYSIS
1. Secure consent Very Strong preparations (potency I)
2. Abbocath g 14 or 16 #1 Clobetasol propionate 0.05% (Dermovate);
3. Abbocath gauge 22 #1 Flucinolone acetonide 0.2% (Synalar Forte)
4. betadine
21
 In some individuals reactions wane in time
2 step method : repeat TT
DIAGNOSTIC STANDARDS & CLASSIFICATION OF TB IN CHILDREN : negative initial reading is repeated
Epidemiology after 1-3 weeks. Result of the 2 nd
WHO : 8 million new cases per year testing is considered the correct result
3 million deaths per year If given MMR, typhoid, measles, wait for 4-6 weeks before giving
95% in underdeveloped countries PPD
¼ or 40% of world’s population infected CLASSIFICATION:
PHIL : leading cause of death - diagnosis in children is based on epidemiological/ clinical
5th leading cause of morbidity grounds and cultures are rarely available
Clinical Manifestation: - appropriate evaluation & treatment of patients depend on the
3 factors: staging to which the patient belongs.
1. Host : age <5 yo more predisposed
: immunization status CLASS I : TB Exposure
: immunocompromised like HIV,DM,leukemia,CA or > with exposure
those taking prednisone (>1.5 mg for at least 1 mo) CLASS II : TB Infection
2. Microbial factors : virulence > with or without exposure, hx, (+) PPD, (-)S/Sx,
3. Host – microbe interaction – severity of disease (-) CXR, pre clinical state of TB
Organ affected : if disseminated, poorer prognosis CLASS III : TB Disease
A. Systemic effects  3 or more
- most quantifiable : Fever about 38-40*C  exposure to an adult with active TB
- increased WBC, anemia, leucopenia,malaise,night sweat,SIADH like symptom  S/Sx can be 1 or more of the ff:
B. Pulmonary TB - 80% most common sx chronic cough, dyspnea,\2* to severe 1. cough/ wheezing > 2 weeeks
inxn(rare) 2. fever > 2weeks
Radiographic findings: 3. painless cervical and other LN
1. hilar adenopathy(most common) 70-90% 4. poor weight gain
2. cavitations 5. failure to return to normal after an ifxn
3. (+) atelectasis or loss of lung volume 2* to 6. failure to respond to adequate antibiotics
impinging LN CLASS IV : with or without previous TB
4. consolidation : with or without previous treatment
5. RE pattern (most common in : healed calcified TB on CXR
immunocompromised host) : (+) PPD,(-)S/Sx,(-)smear and culture
6. fibrosis
7. Calcifications TREATMENT:
C. Extrapulmonary TB 20% TB Exposure : 3 months INH then rpt PPD, if rpt PPD (-), stop
1. Disseminated : affectation: 2 or more organs, treatment provided contact is being treated.
failure to contain mo b’coz of malnutrition, with If rpt PPD (+) CXR(+) add 2 or more drugs and treat as TB
military nodules 1-2 mm nodular shape disease.
2. Tuberculoma : patho findings: TB Infection : 9 mos INH
3. Miliary seeds – on xray TB Disease : 2 mos intensive with triple anti-koch’s + 4 mos double
a. LN TB involves cervical region with no anti-koch’s
involvement of underlying skin initiaaly TB Disseminated : quadruple
b. Pleural TB : pleuritis, pleural effusion(most
common),empyema(rarely), organism seeds in CXR : after 6 – 12 months but adenapathies will still be there
pleuraexudates,pleural effusion usually unilateral. BCG : for disseminated/ military TB prevention only
c. GIT: abdomen,liver,hepatoma, jaundice, abdl BCG after 3 mos PPD if (-) rpt BCG, (+) good BCG
pain
d. GUT : after 15-20 yrs of 1* infxn, cystitis,
pyuria
e. Skeletal TB : most common involvement- DENGUE HEMORRHAGIC FEVER (DHF) – important  morbidity and
vertebra mortality
f. CNS : S/Sx of meningitis, CXR/PPD maybe (-), - is currently posing a threat to Westren countries.
do LP – CT scan if (+) ischemia at the basal part - Acute febrile illness four serotypes; clinically by hemorrhagic
of the brain, can present as stroke in the young. diathesis
g. Pericardial : orthopnea, dyspnea,chest pain, - Thrombocytopenia with hemoconcentration
ankle swelling, lab: cardiomegaly on CXR/2D - The hemorrhagic type  major health problems is now known
echo. as Phillipines, Thai or Singapore hemorrhagic fever, H-fever in
the Phllipines.
Tuberculin Test Epidemiology :
- Ag (tuberculin) used : extract from culture of tubercle bacilli - Mosquito borne exist as four separate serotypes (types 1,2,3,4)
- Immunologic basis for the reaction : delayed cellular type of HPS,sensitized T - enveloped ribonucleic acid (RNA) arboviruses belonging to the family
cells,lymphokines,vasodilatation,PPD,technique for administration & Flaviviridae
reading:48-72* after intradermal volar aspect produce 6-10 mm wheal. - transmitted man and Aedes ageypti
GUIDELINES FOR DETERMINING (+) SKIN TEST REACTIONS: - Incubation period : 4-6 days  blood  acute phase of the disease 
>/= 5 mm : children in close contact c known reservoir
or suspected case of TB - Vector : female Aedis aegypti
: clinical or radiologic evidence of - Man : main reservoir  A. aegypti --. Immediately, change of host or
the disease after incubation period of 8-10 days
: underlying host factors that put the
child at an extremely high risk for Pathogenesis:
severe TB 1. Increased capillary fragility  immune-complex reaction 
>/= 10 mm : screening asymptomatic infants & produce toxic substances like histamines, serotonins, and
children with no exposure or no bradykinin  damage capillary walls
known risk factors. 2. Thrombocytopenia  faulty maturation of the megakaryocytes
WHO SHOULD BE GIVEN PPD?  diminish production of platelets; but more important is the
1. contact, CXR(+),PE(+), before initiation of immunosuppressive agents acute excessive consumption of platelets  generalize
2. annual skin testing : HIV, incarcerated adolescents intravascular clotting.
3. every 2-3 years – exposure to HIV, homeless, drug addicts 3. Decreased blood coagulating factors especially fibrinogen and
4. ages 4-6 and 11-16 yo : no risk factors but live in highly prevalent areas. factors II, V, VII and IX.
Relationship with TT and BCG - The theory on the antibody dependent enhancement of
>/= 5 mm : non – BCG vaccinated children infection claims… “that individuals who had dengue infection in
: BCG vaccinated children above 5 yo the past may have developed antibodies which fail to
>/= 10 mm: BCG vaccinated children < 5 yo neutralize a second dengue viral infection and even in fact
Booster phenomenon : accentuated PPD after repeat testing enhance the entry of the virus into monocytes and
Recall of waned cell mediated immunity macrophages leading to an increased viral load and larger
Common in : BCG vaccinated patients number of infected cells.” A second dengue infection is
: infection with other mycobacteria therefore more severe.
: older age Pathology :

22
-Death :gastrointestinal or intracranial hges = ____Bands___
- Focal hemorrhages are occasionally seen in the lungs aderenals and some in arachnoid Bands + Segs
space. (NV : 0.2)
- the liver  enlarged, with fatty changes. Preterm = wt 0.5 x 24
Microscopically: perivascular edema and diapedesis of RBC Term : wt x 1 x 24
Altered hemostasis Absolute neutrophil count (ANC)
WHO committee Lymphocytes + monocytes / segmanters + stabs
- DHF : platelet count < 100,00/[Link] <1 = high risk of infxn
- DSS : subet of DHF  Hypotension or a pulse pressure < 20 mmHg PMN ratio < or = 0.2
Classification of Dengue Fever According to Severity Expected BW in Neonate
Grade I – fever, accompanied by non- specific constitutional symptoms, (+) tourniquet test PT : days old - 10 x 0.02 + BW
Grade II – grade I and spontaneous bleedin Term: days old - 14 x 0.015 + BW
Grade III – circulatory failure  rapid and weak pulse, narrowing of pulse pressure (20 Maintenance wt (gains 15-30 g/day)
mmHg or less) or hypotension, cold clammy skin and restlessness.
Grade IV – profound shock
Thrombocytopenia, hemoconcentration differentiate grade I and II from classic PICUDIGO
dengue Fluid Resuscitation Formula:
Immunity 20 cc/kg NSS or RL
- dengue infection  long term immunity. IV/IO bolus over 20 minutes
- 2* infection  6 months or more following infection with the single dengue Reassess until perfusion parameters return to normal
serotype, humans are fully susceptible to infxn with the diff. serotype. Repeat up to 60 cc/kg as long as perfusion parameters are still abnormal
Clinical Mx: * Consider colloids and blood components after the 3rd bolus
- asymptomatic, undifferentiated fever, dengue fever, dengue hgic fever IV FLUID RATES AND URINE OUTPUT
- undifferentiated febrile illness or mild febrile disease with maculopapular rash. Maintenance IV Fluid:
st
- Older children and adults : overt illness ( dengue fever); abrupt onset with 4 cc/kg/hr for 1 10 kg
hyperpyrexia ; headache’ pain behind the eyes, muscle and joint pains and + 2 cc/kg for the next 10 kg
rash , anorexia, vomiting, abdominal pain. Urine output:
- Senond or third day : hyperpyrexia, earlier symptoms increase , palms and Minimal Normal: Infant: 0.75 – 1 cc/kg
sloes flushed. VASOACTIVE INFUSION OF PEDIATRIC PATIENTS
- Tourniquet test : 10 (+), petechiae in pressure areas. Base Mnemonic: Add 6mg/kg of drug to 100cc of IV F
- 5th to 7th day: fever subsides, “herman’s rash” in the extremities, classic rash: Then, 1 cc/hr = 1 ug/kg/min
maculopapular rash or even urticarial, lasts for 2-3 days, with pruritus. Drugs Multiply Pt weight #mg drug 1 cc/hr =
Bradycardia  convalesnce. Factors n kg /100 cc__ug/kg/min
Clinical Criteria of DHF
1. Fever : 2-7 days; Dopamine 6 x ___ =___mg 1ug/kg/min
2. Hemorrhagic manifestations: (+) TT, any of petechiae, purpura, ecchymosis, Dose: 2-20 ug/kg/min
gum bleeding and epistaxis Dobutamine 6 x ___ =___mg 1ug/kg/min
3. hepatomegaly Dose: 4-20 ug/kg/min
4. shock rapid weak pilse, narrowing of pulse pressure(<20 mmHg) or Epinephrine 0.6 x ___ =___mg 0.1ug/kg/min
hypotension, with cold clammy skin and restlessness. Dose: 0.05-1 ug/kg/min
Isoproterenol 6 x 2 x ___ =___mg .05ug/kg/min
Laboratory Criteria of DHF Dose: 0.50-10 ug/kg/min
a. thrombocytopenia (100 % or <) Lidocaine 6x10 x ___ =___mg 10ug/kg/min
- hemoconcentration with hct increased by 20% or more. Dose: 10-50 ug/kg/min
- The 1st 2 clinical criteria + thrombocytopenia and hemoconcentration  DHF Norepi 6 x .05 x ___ =___mg .05ug/kg/min
- Shock : high hct; marked thrombocytopenis  DHF/ DSS. Dose: 0.05-1 ug/kg/min
- WBC in DHF  leucopenia to mild leukocytosis Nitroprusside 6 x .05 x ___ =___mg .05ug/kg/min
- Prolonged PT; prolonged PTT Dose: 0.5-2 ug/kg/min
- Factors 2, 5, 6, 8 and 12; transient albunuria; occult blood PGF 1 6 x .05 x ___ =___mg .05ug/kg/min
Laboratory Criteria for Confirmation of Dengue Fever: Dose: 0.5-2 ug/kg/min
Serological Confirmation Nitroglycerin 6 x .05 x ___ =___mg .5ug/kg/min
1. four-fold or greater change on Ig antibody titers Dose: 0.5-20 ug/kg/min
2. anti- dengue IgM ELISA (+) (P/N > 2). NEWBORN RESCUSITATION
3. virulogical confirmation
 isolation of the dengue virus 1. Warm, Position, Suction, Dry, Tactile Stimulate
 demonstration of the dengue virus Ag by immunoflourescence 2. Oxygen (Blow by)
(IFAT) or immunoperoxidase test 3. Bag-Valve Mask Ventilation ( if HR<100 or gasping respiration)
 demonstration of dengue virus genom by RT-PCR usiong dengue 4. Chest Compression (if HR <60-80 after ventilation initiated)
concensus and serotype specific primers 5. Medication – Epinephrine( if HR continues to fall or remains
Treament: <80 bpm)
- fluids DHF, loss should be replaced at 75 ml/kgBW
- IVF therapy crystalloids given at 5 – 15 ml/kg BW per hour
- Vital signs; output important parameters in response to IVF therapy start at 5
ml/kg BW/hour and gradually increase to 15 ml/kg BW per hour by 3-5 ml/hour RESCUSITATION
increments ADENOSINE 0.1 mg/kg IV/IO rapid bolus followed by rapid
- Shock IV fluid: faster rate and bigger volume, rule that is, 20 ml /kg/BW in 20- NSS push
30 minutes  not improved, colloids at 20 ml/kg BW in 20 minutes May repeat at 0.2mg/kg IV/IO after 2 min
- D5LRS or D%IMB if less than 2 yo or D5NM or D50.3 NaCl if more than 2 yo Max single dose 12 mg
maybe used and should be given at 3 ml/kg/BW/hour up to 2-3 liters in adults ATROPINE 0.02 mg/kg IV/IO minimum dose 0.1 mg
- Colloids (dextrans,hemmacel,haes) improved the hemodynamics or as ET dose 2-3x IV/IO dose
immediate blood substitute. Max single dose 0.5 mg child/ 1mg adolescent
- Whole blood correct anemia and shock Repeat q 5 min to max total dose 1mg child/
- DIC ; prolonged PTT FFP or cryoppt A 2mg adolescent
- Platelet conc not routinely admionistered, useful with plt counts < 50,00/cu mm CaCl 20mg/kg IV/IO (0.2cc/kg)
or as prophylaxis below 20,00/ [Link] DEXTROSE 2-4cc/kg D25 IV/IO (0.5-1 gm/kg)
- Baseline plt count and hct; serial determinations 5cc/kg D10 for neonates
- Absence of danger sign  sent home, remained afebrile for at least 72 hours. EPINEPHRINE 0.01 mg/kg of 1:10,000 IV/IO (0.1cc/kg)
ET dose: 0.1mg/kg of 1:1,000 (0.1 cc/kg)
Dilute w/ NSS to a volume of 3-5ml & follow w/
several positive pressure ventilation
MONROE SIGNS OF SEPSIS: Standard 0.1 mg/kg of 1:1,000IV/IO
• Total Neutrophilic Count (TNC) > 12,000 LIDOCAINE 1mg/kg IV/IO bolus; May repeat up to 3 mg/kg
= (stabs + segs) x WBC x 1000 ET dose 2-3x IV/IO dose
(NV ≤ 12,000) MgSO4 25-50 mkdose IV q4-6 hrs x 3-4 doses
• Absolute Stab Count (ASC) > 1,000 Monitor for hypotension
= stabs x WBC x 1000 NaHCO3 1 mEq/kg IV/IO
(NV ≤ 1000) FENTANYL 1-2mcg/kg IV/IO q 30-60’
• Band Neutrophilic Ratio (BNR) > 0.2 Give ≤ 1mcg/kg/min
23
KETAMINE 1-2mg/kgIV, 4-10mg/kgIM
Recom coadmin of Atropine & Midazolam
MIDAZOLAM 0.05-0.15 mg/kg IV/IO q 1-2 hrs PRN
PANCURONIUM 0.1mg/kg/doseIV q 30-60min
BROMIDE 0.01 mg/kgIV ADDITIONAL DRUGS/THERAPY:
Coadm with sedative ALBUMIN 1g/kg/dose IV infusion (Max 6
THIOPENTAL Normotensive pt: 4-7mg/kgIV g/kg/24hrs) or 10-20 mkdose IV
Hypotensive: 2-4mg/kg IV of 25%
VECURONIUM 0.1-0.2 mg/kg IV/IO q 30-60’ CHARCOAL 1 g/kg PO or NG in 70% sorbitol
Coadm w/ sedative solution
FUROSEMIDE IV/IM: 1mkdose q6-12 hrs
NEURO/SEIZURE PO: 2mkdose q6-8hrs
DIAZEPAM 0.2-0.5 mg/kg IV/IO q 1hr Max 10mg Max 600mg/day
Rectal 0.5 mkdose HEPARIN Bolus: 50-100 U/kg IV
LORAZEPAM 0.05-0.1 mg/kg IV/IO/IJM Infusion: 10-25u/k/hr IV or 100
Max sed dose: 2 mg total u/k/dose q 4hr
MANNITOL Initial: 0.25-1 g/kgIV over 2’ Titrate IV dose for PTT 1.5-2.5x
Maint: 0.25-0.5g/kgIV q4-6hr (filter dose) control
PHENOBARB Status Epilepticus CA GLUC 10% 100mg/kg very SIVP
Load: 15-20mg/kg IV/IO slowly follwd by 5 mg/kg q RANITIDINE 1 mg/kg IV q8 hrs
20’ til sz is controlled or DEXTROSE/INSULIN 2cc/kg D25 + 0.2U/kg insulin via
max of 30mg/kg (max600mg/day) IV
Maint: 4-6 mkd OD or BID *This is stat & hourly dose
PHENYTOIN LD: 15-20 mg/kg IV/IO METOCLOPRAMIDE 0.1 mg/kg IV/PO
Max 1 g/24hrs INDOMETHACIN 0.2 mkdose x 3 doses (PDA
MD: 5-8 mkday closure)
KCl 0.5-1 mEq/kg over 1-2 hrs
NAPROXEN 5-7 mg/kg q 8-12 hrs
RESPIRATORY VASOPRESSIN 0.5-10mU/kg/hr
SALBUTAMOL USN: 5 mg/ml sol: Add 2.5 ml to 3 ml NSS Start at 0.0005U/kg/hr
IPRATROPIUM 250-500mcg q 3-6hrs
BUDESONIDE 200 mcgm BID RHYTHM DISTURBANCES:
EPINEPHRINE USN: 0.5ml/kg (1:1,000) + 3 ml NSS Absent Pulse:
Max dose: 2.5ml/dose(<4y/o) CPR & BVMask Ventilate w/ 100% O2 Hyperventilate
5ml/dose (>4y/o) V Fib or Pulseless V Tach:
SQ EPI 1:1000 ([Link])=0.01 mg/kg or 0.01 ml/kgq 20’ Defibrillate – Medicate – Circulate
x 3 (max dose 0.3 mg) Immediate Defibrillation: (unsynchronized)
TERBUTALINE Infusion 10 mcg/kg IV load over 30’ then 0.1- 3 times if needed: 2j/kg – 4j/kg – 4j/kg
4mcg/kg/min continuous infusion Epinephrine – First dose:
SQ: 0.01 mkdose IV/IO: 0.01 mg/kg (1:10,000)
ET: 0.1 mg/kg (1:1000)
AMINOPHYLLINE 6 mg/kg IV over 20mins
Defibrillate – 4j/kg
Lidocaine – IV/IO – 1mg/kg (may repeat up to 3mg/kg)
PAIN MANAGEMENT:
Defibrillate – 4j/kg
KETOROLAC 0.5 mkdose IV/IM q4-8hrs Epinephrine – IV/IO – 0.1mg/kg 1:1000; repeat q 3-5 mins; no max
Max of 30mg
Defibrillate—4j/kg
MORPHINE 0.1 mkdose SC/IM/IV/IO
NALOXONE <5y/o or <20kg: 0.1mkdose ASYSTOLE AND PEA
>5y/o or >20kg: 2 mkdose Epinephrine – as above (Low dose followed by high dose q 3-5mins)
NALBUPHINE 0.1-0.15mkdose q 3-6 hrs; Max 20mg/dose Consider causes:
FENTANYL 1-10 mcg/kg IV/IO q 30-60’; Give < 1 mcg/kg/min Hypoxemia Hypovolemia Acidosis
Hypothermia Tension pneum Cardiac Tam
SEDATIVES: Slow PULSE – HR < 60 – (R/O Hypoxia)
CHLORAL HYDRATE 25-75 mkdose PO/PR Unstable:
Max: 500mg/hypnotic 2 Maintain ABC’s Maximize oxygenation
grams/24hrs Obtain vascular access Reassess 9 shock parameters
DIPHENHYDRAMINE 1mkdose PO/IM q 4;Max:50mg
NALBUPHINE Same as above
PENTOBARBITAL 2-6mkdosePO/IM/PR If HR remains <60bpm with poor perfusion:
Max: 150 mgs Chest Compressions Reassess perfusion
DIAZEPAM Same as above
MIDAZOLAM Same as above If no improvement:
Epinephrine:
HYPERTENSIVE EMERGENCIES: IV/IO: 0.01 mk/kg 1:10000 (0.1cc/kg) Rpt at same
FUROSEMIDE 0.5-2 mkdose q 6-12 hrs ET: 0.1 mg/kg 1:1000 (0.1 cc/kg) dose q3-5’
Max: 6mkdose Atropine:
NIFEDIPINE 0.25-0.5mkdose q4-6 prn IV/IO – 0.02 mg/kg Max single doses:
Max: 10mg/dose or 3mkd Min dose: 0.1 mg Child: 0.5 mg
May rpt once after 5’ Adolescent: 1mg
HYDRALAZINE 0.1-0.2mkdose IM/IV q4-6
Max: 20mg/dose
Consider Pacing:
NITROPRUSSIDE Infusion: 0.3-0.5 mcg/kg/min titrate to effect Stable – Maximize oxygen & monitoring closely
Usual dose: 3-4 ug/kg/min Fast Pulse – HR > 220 bpm (infant); >180 (Child)
Max: 10ug/kg/min Unstable: (Assessment shows signs of shock)
LABETALOL 0.2-1 mkdose x 10min; Max: 20mkdose Immediate cardioversion – Synchronized – 0.5j/kg may repeat at 1 j/kg
NICARDIPINE 0.5-3ug/kg/min via continuous IV infusion Maximize oxygenation Obtain vascular access
STEROIDS: Stable:
DEXAMET Airway edema: 0.25-0.6mkdose IV q6 Wide QRS – (ie VT with pulse) Narrow QRS (ie SVT)
Cerebral edema: 0.25-1 mkdose IV q6 Lidocaine: Adenosine:
HYDROCORT Status Asthmaticus: Load:4-8mkdose IV (max IV/IO – 1 mg/kg bolus IV/IO: 0.1mg/kg
250mg) then 8 mkd div q 6 IV May repeat up to 3 mg/kg bolus May repeat at 0.2mg/kg
METHYLPRED [Link]: Load: 2mkdose IV then 0.5-1 mkdose Max single dose: 12mg
IV q4-6 hrs up to 5 days (max 250mg/dose q
4hrs) DEFIBRILLATE: CARDIOVERT:
PREDNISOLONE Acute Asthma: 2mkd PO div BID Max 2-4joules/kg Unsynchronized 0.5-2 j/kg Synchronized
60mg/24hrs

24
 ASSESSMENT AND DEVELOPMENT OF VISION mound; areolar
Stage/Test Age diameter increase
Face fixation 0 months 3 Darker, beginning to curl Breast & areola
Optokinetic nystagmus 1.5 months ↑ amount enlarged, no color
Follows dangling ball well 3 months separation
Reaches for toys 5 months 4 Coarse, curly, abundant Areola & papilla formed
Preferential looking test 0-3.5 months But amount < adult secondary mound
Stycar letter-matching cards 3-5.5 months 5 Adult, feminine triangle, Mature; nipple projects,
Stycar letter charts 5-7.5 months Spread to medial thigh areola part of general
Snellen charts 7-8.5 months breast contour

NB Tonic neck reflex position when supine SMR BOYS

Fisted hands, complete head lag Stage Pubic Hair Penis Testes
Doll’s eye; Moro reflex 1 None Preadolescent Preadolescent
1m Raises head slightly when prone 2 Scanty, long Slight Enlarged
Pelvis now flat when prone Slightly pigmented Enlargement scrotum, pink
Follows objects up to midline texture altered
Reflex smile; diminishes activity when talked to 3 Darker, starts to curl, Longer Larger
2m Hands no longer fisted; raises head farther small amount
Head control up to 45° from prone position 4 Resembles adult type Larger, glans Larger;
Follows objects past midline, Social smile but > amount & breadth ↑ in scrotum dark
Change in activity when spoken to, Vocalizes size
3m Head control when prone, hands together 5 Adult distribution Adult size Adult size
Moves head toward sound, Coos & squeals
Waves at toy, regards own hand
4m Symmetric position, Rolls from supine to prone
Grasps objects & brings to mouth
Orients to voice sideways
5m Good head control; Back straight
Razzing, ah-goo; Smiles at mirror image
6m Sits with support; raking approach with hand
Rolls from prone to supine; monosyllabic babble
Indicates likes & dislikes
7m Rolls over; Creep-crawls; Bounces
Recognize familiar faces, Responds to name-calling; Polysyllabic
babbling
8m Sits without support; imitates hand movement
Transfers objects from hand to hand, Close-open
Responds to “no”, indiscriminate “mama”, “papa”
9m Stands holding on; creeps; Holds bottle
Gesture language; Waves bye-bye
10m Pulls to stand; Crawls; Pincer grasp
Understands gestures; Retrieves objects
Discriminate “mama”,“papa”
11m Stands with support; Walks holding on
Bangs objects together; Does nursery games
12m Stands alone; takes a few steps
Attmepts to use a spoon; cooperates in dressing
Obeys 1-step commands; Kisses on request
15m Walks well alone; Builds tower of 3 cubes
Feeds self with spoon, drinks from cup
Has 4-5 words; Turns pages and pats pictures
18m Seats self in child’s chair; Runs stiffly
Creeps upstairs;imitates a vertical stroke
Builds tower of 4 cubes; Plays ball; 10 words; identifies 1 or
more body parts
2y Runs well; Up & down stairs one step at a time
Jumps; combines 2-3 words in sentences
Toilet-trained during the day; tower of 7 cubes
2½ y Broad jump; imitates a circle; Dry by night; Tower of 8 cubes;
knows 2 actions; Pretend play
3y Rides tricycle; copies circle; tower of 10 cubes
Knows full name, age, sex; counts 1-10
Dresses self except for buttons and lying shoes
3½ y Rides tricycle; Repeats 3 digits; Imaginary playmate
4y Walks up and down stairs, alternating feet
Hops, Skips; Imitates a cross; Tells stories
Recognizes 2 or more colors; Cleans oneself, combs hair and
brushes teeth
5y Can use knife; Jumps over low obstacles; Ties shoelaces;
Copies triangle; Counts to 10 or more; Writes the alphabet
6y Can write fairly well, adds and subtracts; Draws a complete
person with clothes; Distinguishes between right & left; Dresses
self completely; Rides bicycle
8y Tells time; Reads for pleasure; Sense of humor; Accepts rules,
does chores
10-12y Secondary sex characteristics; Beginning of rapid growth;
Awkward and self-conscious; Concrete operations; Conventional
morality; Middle school adjustment

TANNER SEX MATURITY RATING

SMR GIRLS
STAGE PUBIC HAIR BREASTS
1 Preadolescent Preadolescent
2 Sparse, lightly pigmented, Breast & papilla
Medial border of labia elevated as small

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