EXPANDED PROGRAM ON IMMUNIZATION

VACCINE AGE DOSE # ROUTE SITE INTERVALBCG-1 Birth

or 6 wks0.05mL

(NB)0.1mL (older)

1 ID R-Deltoid

DPT 6 wks 0.5mL 3 IM Upper Outer thigh

OPV 6 wks 2 drops 3 PO Mouth 4 wksHEPA B 6 wks 0.5mL 3 IM Antero-

lateral thigh

4 wks

MEASLES 9 mos 0.5mL 1 SC Outer upper arm

4 wks

BCG-2 School entry 0.1mL 1 ID L-Deltoid

TetToxoid Childbearing women

0.5mL 3 IM Deltoid 1 mo then6-12 mos

ADVERSE REACTIONS FROM VACCINES

BCG 1. Wheal ► small ► abscess ► ulceration ► healing / scar formation in 12 wks2. Deep abscess formation, indolent ulceration, glandular enlargement, suppurative lymphadenitis

DPT 1. Fever, local soreness2. Convulsions, encephalitis / encephalopathy, permanent brain damage

OPV Paralytic PolioHEPA B Local sorenessMEASLES 1. Fever & mild rash

2. Convulsions, encephalitis / encephalopathy, SSPE, death

ACTIVE PASSIVEBCG DiphtheriaDPT TetanusOPV Tetanus Ig

Hep B Measles IgMeasles Rabies (HRIg)

Hib Hep A IgMMR Hep B ig

Tetanus Toxoid Rubella IgVaricella

BODY TEMPERATURE

Subnormal <36.6°CNormal 37.4°CSubfebrile 35.7 – 38.0°CFever 38.0°CHigh fever >39.5°CHyperpyrexia >42.0°C

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

Preterm 120-170 55-75/35-45 40-70Term 120-160 65-85/45-55 30-600-3 mo 100-150 65-85/45-55 35-553-6 mo 90-120 70-90/50-65 30-456-12 mo 80-120 80-100/55-65 25-401-3 yrs 70-110 90-105/55-70 20-303-6 yrs 65-110 95-110/60-75 20-256-12 yrs 60-95 100-120/60-75 14-2212-17 yrs 55-85 110-135/65-85 12-18

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

BMI

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

ABG pH: 7.35-7.45 HCO3: 22-26mEq/LpCO2: 35-45 B.E.: +/- 2mEq/LpO2: 80-100 O2 sat: 97%

NORMAL LABORATORY VALUES

NB Infant Child AdoleRBC 4.8-7.1 3.8-5.5 3.8-5. M: 4.6-6.2

F: 4.2-5.4WBC 9-30,000 6-17,500 5-10,000 6-10,000PMNs 61% 61% 60% 60%Lymph 31% 32% 30% 30%Hgb 14-24 11-20 11-16 M: 14-18

F: 12-16Hct 44-64% 35-49 31-46 M: 40-54

F: 37-47Platelets 140-300 200-423 150-450 150-450Ret 2.6-6.5 0.5-3.1 0-2 0-2

COUNT (%)

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

ANTHROPOMETRIC MEASUREMENTS

IDEAL BODY WEIGHT

Age Kilograms PoundsAt Birth 3kg (Fil)

3.35kg (Cau)7

3-12 mo

Age (mo) + 9 / 2 Age (mo) + 10 (F)Age (mo) + 11 (C)

1-6 y Age (y) x 2 + 8 Age (y) x 5 + 177-12 y Age (y) x 7 – 5 / 2 Age (y) x 7 + 5

Given Birth Weight:Age Using Birth Weight in Grams

< 6 mo Age (mo) x 600 + birth weight (gm)6-12 mo Age (mo) x 500 + birth weight (gm)

Expected Body Weight (EBW):Term Age in days – 10 x 20 + Birth Weight

Pre-Term Age in days – 14 x 15 + Birth Weight

Age of Infant Ideal Weight4-5 months 2 x Birth Weight

1 year 3 x Birth Weight2 years 4 x Birth Weight3 years 5 x Birth Weight5 years 6 x Birth Weight7 years 7 x Birth Weight10 years 10 x Birth Weight

LENGTH / HEIGHT(50 cm)

Age Centimeters InchesAt Birth 50 20

1 y 75 302-12 mo Age x 6 + 77 Age x 2.5 + 30

Age Gain in 1st Year is ~ 25cm0-3 mo + 9 cm 3 cm per mo3-6 mo + 8 cm 2.67 per mo6-9 mo + 5 cm 1.6 cm per mo

9-12 mo + 3 cm 1 cm per mo

HEAD CIRCUMFERENCE(33-38 cms)

Age Inches CentimetersAt Birth 35 cm (13.8 in)< 4 mo + 2 in

(1/2 inches / mo)+ 5.08cm

(1.27cm / mo)5-12 mo + 2 in

(1/4 inches / mo)+ 5.08cm

(0.635cm / mo)1-2 yrs + 1 inch 2.54 cm3-5 yrs + 1.5 in

(1/2 inches / year)+ 3.81cm

(1.27cm / mo)6-20 yrs + 1.5 in

(1/2 inches / year)+ 3.81cm

(1.27cm / mo)

Age Transverse-AP Diameter ratio

Inches

At Birth 1.0 Transverse = AP1 y 1.25 Transverse > AP6 y 1.35 Transverse >>> AP

FONTANELS

Appropriate size at birth: 2 x 2 cm (anterior)Closes at: Anterior = 18 months, or as early

as 9-12 monthsPosterior = 6 – 8 weeks or

2 – 4 months

THORACIC INDEX

TI = transverse chest diameter AP diameter

Birth : 1.01 year : 1.256 years : 1.35

APGAR

0 1 2

ABlue / Pale

Pink body/ Blue extremities

Completely pink

P Absent Slow (<100) > 100

G(-)

ResponseGrimaces

Coughs, Sneezes,

Cries

A(-)

MovementSome flexion /

extensionActive

movement

R Absent Slow / IrregularGood,

strong cry

8 – 10: Normal4 – 7: Mild / Moderate Asphyxia0 – 3: Severe asphyxia

GCS

Function Infants/Young OlderEye Opening

4- Spontaneous3- To speech2- To pain1- None

SpontaneousTo speechTo painNone

Verbal 5- Appropriate4- Inconsolable3- Irritable2- Moans1- None

OrientedConfusedInappropriateIncomprehensibleNone

Motor 6- Spontaneous5- Localize pain4- Withdraw3- Flexion2- Extension1- None

SpontaneousLocalize painWithdrawFlexionExtensionNone

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

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

Contraceptives? Pregnancies? STDs?

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

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

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

◦ F luids◦ R espiration◦ I nfection◦ C ardiac◦ H ematologic◦ M etabolic◦ O utput & Input [cc/kg/h] N: 1-2◦ N euro ◦ D iet

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

Home Environment◦ With whom does the adolescent live?◦ Any recent changes in the living

situation?◦ How are things among siblings?◦ Are parents employed?◦ Are there things in the family he/she

wants to change?

Employment and Education◦ Currently at school? Favorite subjects?◦ Patient performing academically?◦ Have been truant / expelled from

school?◦ Problems with classmates/teachers?◦ Currently employed?◦ Future education/employment goals?

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

Drugs◦ Used tobacco/alcohol/steroids?◦ Illicit drugs? Frequency? Amount?

Affected daily activities?◦ Still using? Friends using/selling?

NUTRITION

AGE WT. CAL CHON0-5 mo 3-6 115 3.5

8-11 mo 7-9 110 3.01-2 y 10-12 110 2.53-6 y 14-18 90-100 2.07-9 y 22-24 80-90 1.5

10-12 y 28-32 70-80 1.513-15 y 36-44 55-65 1.516-19 y 48-55 45-50 1.2

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

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

Gastric Capacity : age in months + 2

Gastric Emptying Time : 2-3 hours

1:1 1:2Alacta BonnaEnfalac Nursoy

Lactogen PromilLactum S-26

Nan SimilacNestogen SMA

NutraminogenPelargonProsobee

THE SEVEN HABITS OFHIGHLY EFFECTIVE PEOPLE

by Stephen R. Covey

Habit 1: Be ProactiveHabit 2: Begin with the end in mind Habit 3: Put First Things FirstHabit 4: Think Win-WinHabit 5: Seek first to understand and

then to be understood Habit 6: SynergizeHabit 7: Sharpen the saw

EXPECTED LA SALLIAN GRADUATE ATTRIBUTES

(ELGA)

1. Competent & safe physicians2. Ethical & socially responsible

Doctors / practitioners3. Reflective lifelong learners4. Effective communicators5. Efficient & innovative managers

TREATMENT PLAN B

Recommended amount of ORS over 4 hour period

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

◦ Use child’s age only when weight is not known◦ Approximate amount of ORS (mL) CHILDS WT (kg) x 25

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

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

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

◦ ORS vol. after each loose stool 1 day

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

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

Age 30mL/kg 75mL/kg <12 1H 5H >12 30 mins 2 ½ H

Patient in SHOCK

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

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

4 Major Mechanisms

1. Poorly absorbed osmotically active substances in lumen

2. Intestinal ion secretion (increased) or decreased absorption

3. Outpouring into the lumen of blood, mucus4. Derangement of intestinal motility

Rotaviral AGE (vomiting first then diarrhea)

Ingestion of rotavirus ► rotavirus in intestinal villi►destruction of villi

(secretory diarrhea ▼absorption ▲ secretion) ► AGE

Assessment of dehydration (Skin Pinch Test)

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

immediately

ETIOLOGY of AGE

Bacteria VirusesAeromonas AstrovirusesBacillus cereus Caloviruses Campylobacter jejuni Norovirus Clostridium perfringens Enteric AdenovirusClostridium difficile RotavirusEscherichia coli CytomegalovirusPlesiomonas shigelbides Herpes simplex virusSalmonellaShigella Staphylococcus aureus Vibrio cholerae 01 & 0139Vibrio parahaemolyticus Yersinia enterocolitica

ParasitesBalantidium coliBlastocyctis hominis CryptosporidiumGiardia lamblia

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

TREATMENT PLAN A

4 Rules of Home Treatment

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

> Breastfeed frequently & longer at each feeding > if the child is exclusively breastfed, give one or more of the following in addition to breastmilk

◦ ORS solution◦ food based fluid (e.g. soup, rice, water)

clean water

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

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

2 years or more: 140-200 mL

:- give frequent small sips from a cup :- if the child vomits, wait for 10 min then resume :- continue giving extra fluids until diarrhea stops

2. Give Zinc supplements

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

3. Continue feeding4. Know when to return

TREATMENT PLAN C

Treat severe dehydration QUICKLY!

1. Start IV fluid immediately2. If the child can drink, give ORS by mouth while the

IV drip is being set up3. Give 100mL/kg Lactated Ringer’s solution

AgeFirst give Then give

30mL/kg in: 70mL/kg in:Infants

(<12mo)1 hour* 5 hours

Children(12mo-5yrs)

30 min* 2 ½ hours

Repeat once if radial pulse is very weak or not detectable

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

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

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

SMR GIRLSStage Pubic Hair Breasts

1 Preadolescent Preadolescent

2Sparse, lightly pigmented, straight,

medial border of labiaBreast & papilla elevated, as small mound, areola diameter increased

3 Darker, beginning to curl, ▲amountBreast & areola enlarged, no contour

separation

4Course, curly, abundant but amount <

adultAreola & papilla formed secondary

mound

5Adult, feminine triangle, spread to

medial surface of thighMature, nipple projects, areola part of

general breast contour

SMR BOYSStage Pubic Hair Penis Testes

1 None Preadolescent Preadolescent

2Scanty, long slightly

pigmentedSlightly enlargement

Enlarged scrotum, pink texture altered

3Darker, starts to curl, small

amountLonger Larger

4Resembles adult type but less in quantity, course,

curly

Larger, glans & breadth ▲ in size

Larger, scrotum dark

5Adult distribution, spread to medial surface of thigh

Adult size Adult size

ORS

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

Glucose:100mmol/L

Cl: 50mmol/L

Gluconate:5mmol/L

Na: 60 mol/L

Mg: 5mmol/L

K: 20 mmol/L

Citrate:10 mmol/L

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

Glucose:111mmol/L

Cl: 80mmol/L

Glucose:11mml/L

Na: 90 mmol/L

HCO3: 5mmol/L

Na:90 mmol/L

K:20 mmol/L

K:20 mmol/L

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

Glucose 45mEq Glucose 90mEq Na: 20mEq Na: 20mEq K: 35mEq K: 80mEq

Citrate: 30mEq Citrate: 30mEqDextrose: 20g Dextrose: 25g

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

Glucose: 30mEq Mg: 4mEqNa: 20mEq lactate: 20mEqK: 30mEq Ca: 4mEq

Energy: 20kcal/ 100ml

ETIOLOGY OF PNEUMONIA

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

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

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

LUDAN’S METHOD (HYDRATION THERAPY)

MILD DEHYDRATION

MODERATE DEHYRATION

SEVERE DEHYDRATION

< 15 kg, < 2 y/o 50 cc/kg 100 cc/kg 150 cc/kg> 15 kg, 2 y/o 30 cc/kg 60 cc/kg 90 cc/kg

D5 0.3% in6-8 hours

1st hr: ¼ Plain LRNext 5-7 hrs:¾ D5 0.3% in

5-7 hours

1st hr: ⅓ Plain LR Next 5-7 hrs:⅔ D5 0.3% in

5-7 hours

HOLIDAY-SEGAR METHOD (MAINTENANCE)

WEIGHT TOTAL FLUID REQUIREMENT0 - 10 kg 100 mL / kg11- 20 kg 1000 + [ 50 for each kg in excess of 10 kg]> 20 kg 1500 + [ 20 for each kg in excess of 20 kg]

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

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ATYPICAL PNEUMONIA

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

Etiologic Agents Grouped by Age

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

> 1-3 months * Febrile pneumonia - RSV - Other respiratory viruses - Streptococcus pneumoniae - Haemophilus influenza (Type B) * Afebrile pneumonia - Chlamydia trachomatis - Mycoplasma homilis - CMV

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

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

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

Dengue Shock Syndrome

Manifestations of DHF plus signs of circulatory failure1. rapid & weak pulse2. narrow pulse pressure (<20mmHg)3. hypotension for age4. cold, clammy skin & irritability / restlessness

DANGER SIGNS OF DHF

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

Grading of Dengue Hemorrhagic Fever

DENGUE

> MOT: mosquito bite (man as reservior)

> Vector: Aedes aegypti

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

> Age incidence peaks at 4-6 yrs

> Incubation period: 4-6 days

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

> Main pathophysiologic changes: a. increase in vascular permeability ▼ extravasation of plasma - hemoconcentration - 3rd spacing of fluids b. abnormal hemostasis - vasculopathy - thrombocytopenia - coagulopathy

Dengue Fever Syndrome (DFS)

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

1. headache2. myalgia or arthralgia 3. retroorbital pain4. hemorrhagic manifestations [petechiae, purpura, (+) torniquet test]5. leukopenia

Dengue Hemorrhagic Fever (DHF) 1. fever, persistently high grade (2-7 days)2. hemorrhagic manifestations - (+) torniquet test - petechiae, ecchymoses, purpura - bleeding from mucusa, GIT, puncture sites - melena, hematemesis 3. Thrombocytopenia (< 100,000/mm3)4. Hemoconcentration - hematocrit >40% or rise of >20% from baseline - a drop in >20% Hct (from baseline) following volume replacement - signs of plasma leakage [pleural effusion, ascites, hypoproteinemia]

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MANAGEMENT OF DENGUE

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

MANAGEMENT OF HEMORRHAGE

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

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

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

Recommended Guidelines for Transfusion:

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

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

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

Leukopenia in dengue: probable etiology isPseudomonas

therefore: give Meropenem or Ceftazidime

URINARY TRACT INFECTION

Suggestive UTI:- Pyuria: WBC ≥ 5/HPF or 10mm3

- Absence of pyuria doesn’t rule out UTI- Pyuria can be present w/o UTI

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

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

ACUTE GLOMERULONEPHRITIS

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

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

usually sent home

Prognosis - Gross hematuria 2-3 weeks- Proteinuria 3-6 weeks- ▼C3 8-12 weeks- microscopic hematuria 6-12 mo or

1-2 years- HPN 4-6 weeks

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

RHEUMATIC FEVER

JONES CRITERIA:

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

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

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

TREATMENT OF RHEUMATIC FEVER

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

*** NOTE: Sumapen = Oral Penicillin!

B. Anti-Inflammatory Therapy

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

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

PREVENTON

A. Primary Prevention

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

B. Secondary Prevention

C. Duration of Chemoprophylaxis

KAWASAKI DISEASE  CDC-CRITERIA FOR DIAGNOSIS:

ADOPTED FROM KAWASAKI(ALL SHOULD BE PRESENT)

  A) HIGH Grade Fever (>38.5 Rectally) PRESENT for AT LEAST 5-days without other Explanation

“High Grade Fever of at least 5 days” DOES NOT Respond to any kind of Antibiotic!

  B) Presence of 4 of the 5 Criteria1. Bilateral CONGESTION of the Ocular Conjunctiva (seen in 94%) 2. Changes of the Lips and Oral Cavity (At least ONE) 3. Changes of the Extremities (At least ONE) 4. Polymorphous Exanthem (92%) 5. Cervical Adenopathy = Non-Suppurative Cervical Adenopathy (should be >1.5cm) in 42%)  HARADA Criteria- used to determine whether IVIg should be given- assessed within 9 days from onset of illness

1. WBC > 12,0002. PC <350,0003. CRP > 3+4. Hct <35%5. Albumin <3.5 g/dL 6. Age 12 months7. Gender: male

• IVIg is given if ≥ 4 of 7 are fulfilled• If < 4 with continuing acute symptoms,

risk score must be reassessed daily

TREATMENT

Currently Recommended Protocol:

A. IV-Immunoglobulin

2g/kg Regimen Infusion EQUALLY Effective in Prevention of Aneurysms and Superior to 4-day

Regimen with respect to Amelioration of Inflammation as measured by days of

Fever, ESR, CRP, Platelet Count, Hgb, and Albumin

NOTE: There is a TIME FRAME of 10 days  

B. Aspirin

HIGH Dose ASA (80-100mg/kg/day divided q 6h) should be given Initially in Conjunction with IV-IG

THENReduced to Low Dose Aspirin (3-5mg/kg/day)

ANDContinued until Cardiac Evaluation COMPLETED

(approximately 1-2 months AFTER Onset of Disease)

TYPES OF SEIZURES

A. Partial Seizures (Focal / Local)– Simple Partial– Complex Partial (Partial Seizure +

Impaired Consciousness)– Partial Seizures evolving to Tonic-Clonic

Convulsion B. Generalized Seizures

– Absence (Petit mal)– Myoclonic – Clonic – Tonic– Tonic-Clonic – Atonic

SIMPLE FEBRILE SEIZUREvs.

COMPLEX FEBRILE SEIZURE

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

CLASSIFICATION BY CAUSE

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

 B. Remote Symptomatic

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

 C. Idiopathic

– No history of preceding insult– Likely “genetic” component

SEIZURES

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

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

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

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

prior stroke - S yndrome : genetic disorder

SIMPLE FEBRILE SEIZURE

A. Criteria for an SFS– < 15 minutes– Generalized-tonic-clonic – Fever > 100.4 rectal to

101 F (38 to 38.4 C)– No recurrence in 24 hours– No post-ictal neuro

abnormalities (e.g. Todd’s paresis)– Most common 6 months to

5 years– Normal development– No CNS infection or prior

afebrile seizures B. Risk Factors

– Febrile seizure in 1st / 2nd degree relative

– Neonatal nursery stay of >30 days

– Developmental delay– Height of temperature

 C. Risk Factors for Epilepsy

(2 to 10% will go on to have epilepsy)– Developmental delay– Complex FS (possibly > 1

complex feature)– 5% > 30 mins => _ of all

childhood status– Family History of Epilepsy– Duration of fever

BRONCHIAL ASTHMA (GINA GUIDELINES)

Controlled Partly Controlled UncontrolledDay symptoms

none > 2x per wk

3 or more symptoms of Partly Controlled Asthma in any week

Limitation of activities

none any

Nocturnal Sx (awakening)

none any

Need for reliever

< 2x per wk > 2x per wk

Lung function

normal < 80%

Exacerbation none > 1x per yr 1x / week

TUBERCULOSIS

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

Isoniazid (H)

☤ 2HRZ OD then 4HR OD or 3x/wk DOT

– Microbial susceptibility unknown or initial drug resistance suspected (e.g. cavitary)

– previous anti-TB use– close contact w/ resistant source case or living

in high areas w/ high pulmonary resistance to H.

–☤ 2HRZ + E/S

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

B. Extrapulmonary TB– Same in PTB

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

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

RESPIRATORY DISTRESS SYNDROME(Hyaline Membrane Disease)

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

o Corticosteroids:• most successful method to induce fetal lung

maturation• Administered 24-48 hours before delivery

decrease incidence of RDS• Most effective before 34 weeks AOG

o Microscopically: diffuse atelectasis, eosinophilic membrane

Pathophysiology:

1. Impaired/delayed surfactant synthesis & secretion

2. V/Q (ventilation/perfusion) imbalance due to deficiency of surfactant and decreased lung compliance

3. Hypoxemia and systemic hypoperfusion 4. Respiratory and metabolic acidosis5. Pulmonary vasoconstriction6. Impaired endothelial &epithelial integrity7. Proteinous exudates8. RDS

NEWBORN RESUSCITATION

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

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

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

RESUSCITAION MEDICATIONS

Atropine 0.02 ml/k IM, IV, ETBicarbonate 1-2 meq/k

Calcium 10 mg elem Ca/k slow IVCalcium chloride 0.33/k (27 mg Ca/cc)

Calcium gluconate 1 cc/k (9 mg Ca/cc)

Dextrose1g/k = 2 cc/k D50 4 cc/k D25

Epinephrine 0.01 cc/k IV, ET

UMBILICAL CATHERIZATION

Indications• Vascular access (UV)• Blood Pressure (UA) and blood gas monitoring in

critically ill infants

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

or kidney• Arrhythmia• Air embolus

Cautions• Never for:– Omphalitis – Peritonitis

• Contraindicated in– NEC– Intestinal hypoperfusion

Line Placement• Arterial line• Low line– Tip lie above the bifurcation between L3 & L5

• High line– Tip is above the diaphram between T6 & T9

Clinical Features:

1. Tachypnea, nasal flaring, subcostal and intercostal retractions, cyanosis, grunting

2. Pallor – from anemia, peripheral vasoconstriction

3. Onset – within 6 hours of life Peak severity – 2-3 days Recovery – 72 hours

Retractions:o Due to (-) intrapleural pressure produced by

interaction b/w contraction of diaphragm & other respiratory muscles and mechanical properties of the lungs & chest wall

Nasal flaring:o Due to contraction of alae nasi muscles leading to

marked reduction in nasal resistance

Grunting:o Expiration through partially closed vocal cords

• Initial expiration: glottis closedàlungs w/ gasàinc. transpulmo P w/o airflow

• Last part of expiration: gas expelled against partially closed cords

Cyanosis: o Central – tongue & mnucosa (imp. Indicator of

impaired gas exchange); depends on total amount of desaturated Hgb

Cathether length• Standardize Graph– Perpedicular line from the tip of the shoulder to

the umbilicus• Measure length from Xiphoid to umbilicus and add

0.5 to 1cm.• Birth weight regression formula– Low line : UA catheter in cm = BW + 7– High line : UA catheter = [3xBW] + 9– UV catheter length = [0.5xhigh line] + 1

Procedure• Determine the length of the catheter• Restrain infant and prep the area using sterile

technique• Flush catheter with sterile saline solution• Place umbilical tape around the cord. Cut cord

about 1.5-2cm from the skin.• Identify the blood vessels.

(1thin=vein, 2thick=artery)• Grasp the catheter 1cm from the tip. Insert into the

vein, aiming toward the feet. • Secure the catheter• Observe for possible complications

BILIRUBIN

PRETERM:mg/dl mmol/L

0-1 hr 1-6 17-1001-2 d 6-8 100-1403-5 d 10-12 170-200

TERMmg/dl mmol/L

0-1 hr 2-6 34-1001-2 d 6-7 100-1203-5 d 4-12 70-2001 mo <1 <17

KRAMERS CLASSIFICATION OF JAUNDICE

ZONE JAUNDICESERUM

BILIRUBINI Head & neck 6-8

IIUpper trunk to umbilicus

9-12

IIILower trunk

to thigh12-16

IVArms, legs,

below15

V Hands & feet 15