Paediatric

Posting HSNI:
Neonatal survival kit for
Houseman

Dr Fitri Fareez bin Ramli

This book is dedicated to my beloved parents, siblings,

teachers, friends and colleagues.

Special thanks to my beloved parents Raja Fawziah and
Ramli Yahaya and siblings for the unconditional supports.
My teacher, supervisor and editor of this book, Dr Zainah
Shaikh Hedra for the generous idea and information as well as
supports for this book production.
All the pediatricians and teachers, Dr Ahmed, Dr Zurina and
Dr Azizan.
My MO and beloved colleagues and friends.

Table of contents

Hypoglycemia
Fluid requirement in neonates
Neonatal jaundice
Prolonged jaundice
Congenital hypothyroidism
Newborn with respiratory distress
Neonatal sepsis
Childhood developmental milestone
Immunization
Commonly used medication in neonates
Appendix
References

Page
5
8
10
14
17
21
23
25
39
41
42
45

A word or two
1. This book is meant to be a survival kit for new
house-officer posted to neonatal unit Hospital
Sultanah Nora Ismail.
2. Please remember hand hygiene before and after
you examine each baby.
3. Use face mask before your nasal and throat
swab result available and reviewed.
4. Read and try to understand your NRP book.
Make sure you pass the theory papers and
MEGACODE.
5. Check resuscitation toolbox for the equipment
and medications.

Fitri Fareez bin Ramli

HSNI Paediatric posting

June-September 2013

Hypoglycemia

What is hypoglycemia?

Blood glucose level <2.6 mmol/L after the first 4 hours of life.

What are the signs and symptoms of hypoglycemia?

Jitteriness, irritability, apnea, cyanosis, hypotonia, poor feeding, convulsions.

*HYPOGLYCAEMIA MAY BE ASYMPTOMATIC
*Glucometer monitoring is important in high risk cases (On admission, and at 1,
2 and 4 hours after admission)

Infants with high risk for hypoglycaemia:
Infant of Diabetic Mothers
SGA Babies
Preterm infants
Large for Gestational Age (LGA) infants > 4 kg
All ill infants

How do we treat newborn with hypoglycemia?
(Please refer to Paediatric Protocol for complete reference)

Please Remember Few Things:
Examine patient and document any signs and symptoms.
Please take blood for RBS and repeat Dextrostix STAT.
If patient is on IV drip, please make sure that the infusion is running well
If the patient is already on feeding, please note when was the last feeding,
tolerated or not.
Dont forget to INFORM MO


Here are some simple guidelines:

1. If the baby has blood glucose level between 1.5 2.6 mmol/L
WITHOUT any signs or symptoms of hypoglycemia (baby looks well)

Give supplementary feed as soon as possible. (TF: 60 ml/kg/day
on Day 1 of life divided into 8 to get the amount of milk every 3
hours)
Inform MO
Re-check GM after 30 min.
If GM remain < 2.6 and baby refuse to feed (or not tolerating),
start Dextrose 10% drip (TF = 60 mls/kg/day).

/ hourly.
Start feeding when capillary blood sugar remains stable and increase as

2. If the baby has blood glucose level of < 1.5 mmol/L

OR symptomatic (presence of any signs and symptoms of hypoglycemia,
blood glucose <2.6 mmol/L):
and for district hospitals, consider early referral.

Re-evaluate the infant
Set IVD (if patient is not on IV drip),
result.
If patient already on IV drip, check the branula site (swollen?), drip
infusion is running well or not?
Send blood for random blood sugar (RBS)
Keep NBM
Glucagon is only
Give IV bolus D10% at 2 mls/kg. within 5-10minutes.
Followed by maintenance of IVD D10% with total fluid of 60
(for
day 1 of life)
In othersmls/kg/day
especially SGA,
give
.
There may
be hyperinsulinaemia
inO
growth retarded babies as well.
Dont
forget to inform M
If baby already on Dextrose 10% drip, consider increasing the rate
or glucose concentration (increase TF from 60 mls/kg/day to 90
mls/kg/day) Volume of 10% Dextrose Volume of 50% Dextrose
Infusion concentration
To repeat capillary blood glucose after 30 minutes.
12.5 %
46.5 ml
3.5 ml

15 %
44.0 ml
6.0 ml

Glucose requirement (mg/kg/min) =

% of dextrose x rate (ml/hr)

weight (kg) x 6

How frequent do we monitor blood sugar level (GM) ?

For high risk babies
On admission, then
(if blood sugar normal)
At 1, 2 & 4 hours after admission

If blood sugar < 2.6mmol/L
Re-check every 30 minutes

Then, if Blood sugar > 2.6mmol/L x 2
Re-check Hourly x 2
Then 2 Hourly x 2
Then 4-6 Hourly



Definition:

Persistent hypoglycemia: Persistent of hypoglycemia despite glucose infusion
of > 8-10 mg/kg/min.

Recurrent or resistant hypoglycemia: Inability to maintain blood glucose level
despite glucose infusion of 15 mg/kg/min.


Hypoglycaemia
Blood Glucose (BG) < 2.6 mmol/L

BG 1.5 < 2.6mmol/L

asymptomatic
(0-4 hours of life)

BG < 1.5 mmol/L

or symptomatic

IV 10% Dextrose 2-3 ml/kg bolus

Give supplement feeding ASAP

IV Dextrose10% drip at 60 to
90 ml/kg/day

If refuses to feed,
IV Dextrose10% drip 60ml/kg/day

Re-evaluate *
Increase

by 30ml/kg/day

* If BG < 1.5mmol/L
or symptomatic :

Re-evaluate *
Increase

to D12.5%-D15%

If glucose delivery > 8 -10mg/kg/min and

IV Glucagon 40 mcg/kg stat then 10-50mcg/kg/h.
IV Hydrocortisone 2.5 - 5 mg/kg/dose bd in others,

SC Octreotide 2 10 mcg/kg/day 2 - 3 times/day or as infusion.

Failure to maintain normal BG despite Glucose infusion rate of

15mg/kg/min,

Fluid management in neonates

Total fluid/milk requirement from birth:

a. Day 1: 60 mls/kg/day.
b. Day 2: 90 mls/kg/day.
c. Day 3: 120 mls/kg/day.
d. Day 4 onwards: 150 mls/kg/day.

In babies requiring IV fluid at birth, the rates of requirements need to be
individualized to that baby. Consult your MO or specialist.

For phototherapy:
a. Add 10% for single phototherapy.
b. Add 20% for double phototherapy.

Types of milk:
a. Expressed breast milk
b. Normal infant formula.
c. Preterm infant formula (for baby <32 weeks or <1500 grams)

Human milk fortifier (HMF) is recommended to be added to EBM when the
volume has reached 75 mls/kg/day in preterm <32 weeks or < 1500 g.

Oral supplements:

a. Vitamins 0.5 mls OD after day 14 when on feeding 150 cc/kg/day. For
up to 3-4 months post discharge.
b. Iron for babies < 2000 grams. 3mg/kg elemental iron OD on Day 42
until 3-4 months post discharge. FAC (Ferric Ammonium Citrate (86
mg/5 mls) elemental iron)

When to stop HMF or Preterm Formula:
a. Baby are breastfeeding on demands.
b. Baby have reached their expected growth curve.

Normal caloric requirement:
a. Term: 110 kcal/kg/day
b. Preterm: 120-140 kcal/kg/day.


1 ml term formula
0.67 kcal
1ml preterm formula
1ml MCT oil
1 teaspoon of polycose

0.81 kcal
8 kcal
8 kcal
8



Example of Calorie calculation:

1.5 kg preterm infant on preterm formula feeding 28 mls 3 hourly
0.5ml MCT oil and 1/2 teaspoon Polycose added every feed

The baby will receive:

Total fluid: 28 mls x 8 feeds/day = 224 mls/day.

1 ml preterm formula contains 0.81 kcal

245 mls/day - 225 x 0.81 kcal = 181.4 kcal/day

0.5 mls MCT oil x 8 feeds = 4 mls of MCT oil
1 ml MCT oil contains 8 kCal
4 mls x 8 kCal = 32 kcal

teaspoon polycose x 8 feeds = 4 teaspoon
1 teaspoon of polycose contains 8kcal
4 teaspoon x 8 = 32 kcal

Total Calorie received/day : 181.4 +32+32=245.44 kcal/day

Total Calorie/kg/day =245.44 1.5kg = 163.6kcal/kg/day

Neonatal Jaundice

What is the definition of jaundice:

Jaundice can be detected clinically when the level of bilirubin in the serum rises
above 85 micro mol/l (5 mg/dl).

What are the causes:

a.
Haemolysis ABO or Rh-isoimmunization, G6PD deficiency,
microspherocytosis .
b.
Physiological jaundice.
c.
Cephalhematoma, subaponeurotic hemorrhage.
d.
Polycythemia
e.
Breastfeeding and breast milk jaundice.
f.
Sepsis, UTI, meningitis, intrauterine infection.
g.
Gastrointestinal tract obstruction.

Pathological jaundice:
a. Onset < 24 hours.
b. Prolonged jaundice: >14 days in term baby or >21 days in preterm baby.
c. Severe jaundice: TSB > 340 micromol/l or 20 mg/dl.
d. Direct bilirubin: > 15%.
e. Increase in TSB level > 8.5 micro mol/L/hr.

Approach:

First when the patient comes take clerking sheet for Neonatal jaundice. This
clerking sheet has provided all the information needed for NNJ. The information
required is stated below.

History:

Age of onset, duration.
Presence of symptoms: Fever, vomiting, poor feeding, lethargy.
Stool color and frequency, urine color and frequency. Type, frequency and
amount of feeding. Traditional treatment or herbs.

Mother antenatal history:

Mother blood group, VDRL, Hepatitis, HIV status, intrapartum fever, prolonged
rupture of membrane, foul smelling liquor.

Birth history: Place, types, instrumental delivery, gestation, birth weight, G6PD,
Cord TSH.

10

Family history: consanguineous marriage, blood disorder, previous newborn

with G6PD, kernicterus, severe jaundice, intrauterine death or neonatal death.

Physical examination:

a. General condition, gestation, weight, hydration status and signs of sepsis.

b. Signs of kernicterus: lethargy, high pitched cry, hypotonia, seizure and
opisthotonus.
c. Pallor, plethora, cephalhematoma and aponeurotic hemorrhage.
d. Cephalocaudal progession of jaundice.

Investigation needed:

The general investigations needed for neonatal jaundice are:

a. Total serum bilirubin.
b. Full blood count.
c. Trace G6PD status from baby book or if not available trace from wad 10
(if the baby is delivered in HSNI)

If maternal blood group is O positive, extra investigation needed:
a. Baby blood group.
b. Coombs test.

Unless indicated, other investigations are required:
a. Reticulocytes count and peripheral blood film.
b. Blood culture, urine FEME and urine C&S.

What is the treatment?

a. We can start single phototherapy. Do not wait for TSB result. Check the
irradiance of phototherapy by using .
Minimal irradiance should be between 12-15 mcW/cm2/nm for
single phototherapy. For intensive phototherapy > 30
mcW/cm2/nm.
Expose baby adequately. Cover babys eyes.
Monitors temperature 4 hourly to avoid chilling or overheating.
Ensure adequate hydration. If baby tolerate breastfeeding,
encourage breastfeeding on demand. If condition does not permit
breastfeeding (eg: mother is still admitted to ward), give fluid
according to the day of life, birth weight and in addition 10% or
20% depending on weather single or double phototherapy). Refer
to Fluid Management Chapter.


b. Inform MO for every single case that is admitted with TSB result.

11

Guidelines for phototherapy:

Total serum bilirubin
D1
D2
D3
D4

D5

D6

D7

ET
LEVEL

5.9

5.9

5.9

5.9

8.2

8.2

10.6

11.8

5.9

5.9

5.9

8.8

8.8

10.0

12.9

14.7

8.8

8.8

8.8

10.6

12.9

12.9

12.9

17.6

10.6

10.6

10.6

12.9

12.9

14.1

14.1

19.4

10.6

10.6

12.9

14.1

14.1

14.1

14.1

19.4

10.6

12.9

12.9

16.5

16.5

16.5

16.5

23.5

Birth
Weight
(gram)
< 1000
10001249
12501499
15001749
17501999
20002499
>2500

11.8
12.9
14.7
16.5
17.6
17.6
17.6
25.3
Hospital discharge need not be delayed to observe for rebound jaundice, and
in most cases, no further measurement of bilirubin is necessary.

c. Exchange transfusion

Rarely done now, but please take the opportunity to observe / assist
when there is one even when you are not on duty that day.

Hours
of Life

Low risk
Medium risk
High risk

Criteria for discharge:
+ risk factors
a. Child generally well and able to tolerate breastfeeding well.
Intensive
Intensive
Intensive
b. Stable vital
signs.
ET
ET
ET
phototherapy
phototherapy
phototherapy
c. TSB level less than 220 umol/L. In some cases, lower level TSB level is
used for discharge. The decision of this would depend on MO and
specialists.

Additional notes:
a. G6PD status of the baby should be known. G6PD deficient baby should be
admitted and observed for 5 days. If jaundice observed, within 5 days,

12
levels for intensive phototherapy.

phototherapy should be started. TSB investigation should be done on day

5 before discharge.
b. Baby of O-positive mother with a sibling with severe neonatal jaundice
should be observed for at least 24 hours of life.
c. Infant with severe jaundice (TSB > 340 umol/L) and those who require
ET should be followed up for neurodevelopment outcome.

13

Prolonged Jaundice

What is the definition of prolonged jaundice?

Jaundice > 14 days in term infant
Chapter
> 222:
1 days
in preterm Jaundice
infant. in Newborn Infants
Prolonged

What are the causes?

Unconjugated Hyperbilirubinaemia

Conjugated Hyperbilirubinaemia

Septicaemia
Urinary tract infection

Biliary atresia - extra, intra-hepatic

Breast milk jaundice

Choledochal cyst

Hypothyroidism

Paucity of bile ducts

Alagille syndrome, non-syndromic
Idiopathic neonatal hepatitis syndrome

Congenital spherocytosis

Septicaemia

Galactosaemia

Urinary tract infection

Gilbert syndrome

Congenital infection (TORCHES)

Galactosaemia
rogressive familial intrahepatic
cholestasis (PFIC)
Total Parenteral Nutrition
-

Approach:

a. As if stated
use
result
done at above,
birth). See

the clerking sheet that is provided by Paediatric

Department of HSNI.
. Infant must be well, gaining
b. Perform history taking and physical examination.
weight appropriately, breast-feeds well and stool is yellow. Management is

14

Prolonged Jaundice

Send blood for TSB

Direct bilirubin >

15% of TSB

No
(unconjugated
hyperbilirubinemia)

Yes
(conjugated
hyperbilirubinemia

For unconjugated hyperbilirubinemia:

a. Exclude UTI send urine FEME and Urine C&S.
b. Exclude hypothyroidism Send free T4 and TSH. Congenital
hypothyroidism is neonatal emergency that need to be treated
immediately.
c. Other possible causes include:
Septicaemia take blood C&S
Hemolysis such as G6PD Deficiency and congenital spherocytosis
trace G6PD status and perform reticulocyte count, peripheral
blood film.
Galactosemia: Dried blood spot, urine reducing sugar.

For conjugated hyperbilirubinemia:

a. Investigate for biliary atresia
i.
Inspect stool for 3 consecutive days. In biliary atresia, the stool
might appear pale.
ii.
Send LFT.
iii.
Perform USG hepatobiliary. USG for hepatobiliary tract should be
consulted to your MO and specialist. Specialist signature is needed.
iv.
Next step should be HIDA if suggestive of biliary atresia. HIDA scan
can be done either at Hospital Sultanah Aminah or Hospital Kuala
Lumpur.

15


b. Investigate for neonatal hepatitis syndrome.
i.
LFT
ii.
Perform other investigation such as Hepatitis B and C, TORCHES,
VDRL, Alpha-1-antitrypsin and metabolic screening.

What is the treatment for prolonged jaundice?

a. Biliary atresia
Kasai procedure. This must be done within the first 2 months.
b. Congenital hypothyroidism
Refer to Chapter Congenital hypothyroidism.
c. UTI
All infant with febrile UTI should treated with IV antibiotics
started as for acute pyelonephritis.
Antibiotics e.g.:
o IV Cefotaxime 100 mg/kg/day TDS for 10-14 days.
o IV Cefuroxime 100 mg/kg/day TDS for 10-14 days.
o IV Gentamicin 5-7 mg/kg/day OD

16

Congenital hypothyroidism

What are the function of thyroid hormones:

a. Normal growth and development of brain and intellectual function,

during the prenatal and early postnatal period.
b. Maturation of the fetal lungs and bones.

Congenital Hypothyroidism

What are the possible causes:

Causes of Congenital Hypothyroidism

nest preventable

Thyroid dysgenesis (85%)

Athyreosis (30%)
Hypoplasia (10%)

enatal and early

od.

Ectopic thyroid (60%)

Other causes (15%)
Inborn error of thyroid hormone
synthesis (1:30,000)
Hypothalamo-pituitary defect
(1:100,000)

onatal jaundice

Peripheral resistance to thyroid

hormone (very rare)
Transient neonatal hypothyroidism
(1:100 - 50,000)

anelle
istress with feeding
ne or both epiphyses

Endemic cretinism

macroglossia, hoarse cry,

umbilical
hernia,
slowpresentations?
What
are
the lethargy,
clinical
potonia and delayed developmental milestones.

It is usually asymptomatic at birth! Some infant may represent as prolonged
s.
neonatal jaundice.

If it left untreated, the signs and symptoms stated below may be manifested:
Constipation

m are present, treatment is started
urgently.
A quiet baby
Enlarged fontanelle
Respiratory distress with feeding
Absence of one or both epiphyses on X-ray of left knee (lateral view).
tablets
Coarse facies,
Dry skin
Macroglossia
Hoarse cry
Umbilical hernia
Lethargy
Slow movement
Hypotonia

17

Delayed developmental milestones.

Approach:

a. Cord blood collection is mandatory for all baby delivered. The blood will
be examined for TSH level. If it is between 21 60 mU/L, lab will
automatically perform measurement of fT4. If fT4 is < 15 pmol/L, venous
FT4 and TSH are required. The cord blood will be taken by O&G
department.
b. If cord TSH level is >60 mU/L, venous FT4 and TSH are required.
c. Venous FT4 and TSH blood should be taken on Day 5 and above because
there might be surge in the levels within 5 days of life (Maternal
hormones).

18

SCREENING FOR CONGENITAL HYPOTHYROIDISM

CORD BLOOD SAMPLE
Collected at Birth

(Normal)

(High)

(on cord blood)

(Low)

(Normal)

CLINICAL EVALUATION

TSH High
FT4 Low

TSH High
FT4 Normal

TSH Normal
FT4 Low

TSH Normal
FT4 Normal
NORMAL

Differential Diagnosis
Primary hypothyroidism, delayed TSH rise
Hypothalamic immaturity
Prematurity
Sick neonate
Footnotes:

Treatment of congenital hypothyroidism:

d. Congenital hypothyroidism should be treated immediately.

Start as early as possible (Not > 2 weeks)

19

Doses of L- Thyroxine by age

Age

mcg/kg/dose, daily

0 3 months

10 15

3 6 months

8 10

6 12 months

68

15

yr

56

6 12 yr

45

> 12

23

yr

Note:
Average adult dose is 1.6 mcg /kg/day in a 70-kg adult (wide range of dose
from 50 - 200 mcg/day).
L-thyroxine can be given at different doses on alternate days, e.g. 50 mcg
given on even days and 75 mcg on odd days will give an average dose of
62.5 mcg/day.
Average dose in older children is 100 mcg/m2/day.

reassessed and emphasised.

Goals of Therapy in the First Year of Life

Adequate treatment
Inadequate treatment

FT4 1.4 2.3 ng/dL (18 - 30 pmol/L) FT4 < 18 pmol/L

TSH < 5 mU/L

To restore the euthyroid state by maintaining a normal serum FT4 level at

the upper half of the normal age-related reference range. Ideally, serum

20

Newborn with respiratory distress

(tachypnoeic, recession, nasal flaring or
grunting)

If a term newborn referred to us for tachypnoeic, nasal flaring, grunting or
recession for observation, we need to perform several things.

a. Place patient under radiant warmer
b. Examine the baby
General condition nasal flaring, recession, grunting.
Vital signs Respiratory rate, SpO2, BP, temperature and pulse
rate.

Here are some scenarios as a guide:

1. IF A BABY IS TACHYPNOEIC (RR>60), GRUNTING WITH DEEP
INTERCOSTAL OR SUBCOSTAL RECESSION ( APPEAR TO BE IN
RESPIRATORY DISTRESS) :

Place under headbox oxygen 5 liter/min.
Continous SpO2 monitoring (KEEP SPO2 >95%)
Inform MO IMMEDIATELY
Patient might need nasal CPAP or Endotracheal Intubation.
If patient suddenly turn cyanosed or stop breathing in front of you, give
bag-valve mask ventilation (ambu-bagging) and shout for help. Ask staff
nurse to call your MO. Dont leave baby unattended.

2. IF PATIENT IS TACHYPNEIC / NASAL FLARING BUT WITH MILD OR NO

RECESSION,
Place under headbox oxygen 5 liter/min.
INFORM MO
Keep NBM
Insert branula.
Take FBC and GM.
Start IVD D10 % (TF= 60 ml/kg/day).
Continous SpO2 monitoring (KEEP SPO2 >95%)
At anytime if patient is unable to maintain SPO2 >95%,, please inform MO
If patient stable, review after 1 hour

3. IF PATIENT STILL TACHYPNOEIC AFTER 1 HOUR:
INFORM MO
Continue Headbox oxygen 5 liter/min
Continous SpO2 monitoring (KEEP SPO2 >95%)
Still keep NBM
IVD D10 % (TF= 60 ml/kg/day).

21

Discuss with your MO

Order Chest X-ray & Review
Patient might need Antibiotic
o IV C.penicillin 100 000 U/kg BD
o IV Gentamycin 4mg/kg OD (for term)
o IV Gentamycin 4mg/kg 36 hourly (for preterm)
Perform septic workout before antibiotic initiation. CRP and blood
C&S.
Patient might need ABG

4. If the baby is NOT TACHYPNEIC anymore , no nasal flaring/recession:
a. Try to off Oxygen Headbox.
b. Keep NBM
c. Continue IVD D10 % (TF= 60 ml/kg/day).
d. Continous SpO2 monitoring (KEEP SPO2 >95%)
e. Review patient frequently
f. At anytime if patient is unable to maintain SPO2 >95%,, please put back
the Oxygen Headbox, Inform MO

If after 1 hour without supplemental oxygen and the baby is stable:
a. Start feeding 10 cc/3 hourly + IVD D10% (Total fluid feeding/24)
(TF= 60ml/kg/day).
b. Continue observation


REMINDERS:

Please review your patients repeatedly especially if they are in respiratory
distress. (maybe every 15 minutes)
Dont wait exactly after 1 hour to review your patient.
If possible try to get continuous SPO2 monitoring.
Inform MO if you are not happy with the patient condition.
Dont forget to pass over your cases if you are going off duty.
If patient suddenly turn cyanosed or stop breathing in front of you, give
bag-valve mask ventilation (ambu-bagging) and shout for help. Ask staff
nurse to call your MO. Dont leave baby unattended.

22

Neonatal Sepsis:

What are the categories of sepsis?

Early onset: Acquired from mother with > 1 obstetric complications.

Late onset: Usually acquired from the hospital or environment. > 72 hours after
birth.

What are the possible risks of sepsis:

Major
Chorioamnionitis
Maternal fever >38.5
PROM > 24 H
Persistent fetal tachycardia

Minor
+ Vaginal swab or urine
culture
Maternal fever> 38
PROM > 18 H and < 24 H
Prematurity
Twin

What are the signs and symptoms of sepsis?

a.
b.
c.
d.
e.
f.
g.

Temperature: hypo or hyperthermia

CNS: irritability, lethargy, change in tone
Skin: poor perfusion, mottling, pallor, jaundice, scleraema, petechiae,
Respiratory: apnea, tachypnea, cyanosis, respiratory distress.
CVS: tachycardia, hypotension.
GI: poor feeding, vomiting, diarrhea, abdominal distention.
Metabolic: hypo or hyperglycemia, metabolic acidosis.

Investigation (as indicated):

a.
b.
c.
d.
e.
f.

FBC with differential count.

CRP, Blood culture and sensitivity
Chest X-ray, Abdominal X-ray.
Urine FEME and C&S.
Lumbar puncture.
RBS

Interpretation of Cerebrospinal fluid (CSF)
a. Calculate the CSF :plasma glucose ratio ( Glucose level in CSF divides
RBS).

23

b. If the ratio is < 0.3, that means the CSF glucose level is very low and it is
significant.

Condition
Acute Bacterial
Meningitis

Leukocytes
(mm)

Protein (g/l)

Glucose
(mmol/l)

Comments

100 - >50,000 Usually 1- 5 <0.5 - 1.5 Gram stain may be

positive

Partially-treated
1 - 10,000
Bacterial
Usually high PMN,
Meningitis
but may have
lymphocytes

>1

Low

CSF may be sterile

in Pneumococcal,
Meningococcal
meningitis

Tuberculous
Meningitis

10 - 500
Early PMN, later
high lymphocytes

1- 5

0 - 2.0

Smear for AFB, TB

PCR + in CSF;
High ESR

50 500
Lymphocytes

0.5 - 2

10 - 1,000

Normal /
0.5-1

Fungal
Meningitis
Encephalitis

Normal or CSF for

low
Cryptococcal Ag
Normal CSF virology and
HSV DNA PCR

Recommended antibiotic therapy according to likely pathogen

Management:
Age Group
Initial
Likely Organism
Duration

Antibiotic
(if uncomplicated)
a. Empirical antibiotics:

< 1 month
Penicillin
+
21 days
Early oC
nset

Cefotaxime
i. First line: IV C.Penicillin and IV Gentamycin.
1 - 3 months
C Penicillin
+ Cefotaxime and IV Amikacin
10 21 days
ii. Second
line:
Cefotaxime
iii. Specific choice when specific organism suspected
/confirmed.
> 3 months
C Penicillin +
7 10 days
Late onset
Cefotaxime,
OR
10
14and
days
i. Community acquired: Cloxacillin/Ampicillin
Ceftriaxone
7 days
Gentamicin for non- CNS infection and for CNS infection use
C.Penicillin and Cefotaxime.
ii. Hospital
acquired:
Ceftriaxone
gives more
rapid CSF sterilisation as compared to Cefotaxime
or Cefuroxime. MRSA/MRCoNS: Vancomycin
If Streptococcal meningitis, request for MIC values of antibiotics.
Non-ESBL gram negative rods: cephalosporins
ESBL: carbapenams
Pseudomonas: Ceftazidime.
Anaerobic:
metronidazole.

4. Extend durationof treatment
if complications
e.g. subdural
empyema,
brain abscess.
b. Feeding.
If the baby can tolerate orally well. Give full feeding according the
the day of life.
If the baby cannot tolerate well: feeding intolerance (vomiting,
distended abdomen) or tachypneic or in respiratory distress,
inform MO regarding the management.

24


Childhood Developmental Milestone

Definition:

Progressive, orderly, acquisition of skills and abilities as a child grows.

Aspects:
a. Gross motor
b. Fine motor
c. Speech or language
d. Social

For all patient admitted to Ward, please kindly screen for neurodevelopment.
We can perform some if possible or ask the caregiver regarding all aspect of
development:

Gross motor:

6 weeks

Ventral suspension: Head Pull to sit: Head lag, Prone: Pelvis high,
briefly in the same plane as rounded back.
knees no longer under
body.
abdomen. Chin raised
occasionally.


3 Months

Ventral suspension: Slight Pull to sit: Slight head Prone: Pelvis flat. Lifts
head lag. Head occasionally lag. Head occasionally head up 45-90 degree.
bobs forward.
bobs forward.

25


6 Months

Pull to sit: Lift head in Rolls prone to supine.
anticipation.

Sits with support.

9 months

Prone: Supports weight

on hands; chest, upper
abdomen off couch.

Pull self to sit

1 year

Sits steadily.

Stands holding on.

Stands alone.

Walks with one hand Gets from lying to sitting
held. Walks like a bear.
to crawling to standing.

26




18 months

Carries doll

Sits on a chair

Pulls toys

Throws
falling

ball

Gets up and down stairs
holding on to rail or with
one hand held

without

2 years

Runs, picks up toys Throws, kick ball without Goes up and down stairs
without falling.
falling.
alone, 2 feet per steps.
Walks backwards (21
months).

27



3 years

Able to go upstairs, 1 foot Stands on 1 foot for Rides tricycles.
per step and goes seconds.

downstairs, 2 feet per
step.
Jumps off bottom step.

4 years

Able to go up and down Skips on one foot.
stairs with 1 foot per Hops for one foot.
step.


5 years

Skips on both feet.

Runs on toes.

28

Fine motor

6 weeks

3 months

Fixates and follow to 90 Hand regards. Grasp
degree.
object in hands.


5 months

Reaches object.



6 months

Palmar grasp.

Plays with toes

Follow object from side to

side.

Move head, eyes in all
directions.

29


9 months

1 year

Inferior pincer grasp Bangs 2 cubes.

(scissors grasp)


18 months

Neat pincer grasp.

Tower of 3 cubes.

Scribbles spontaneously. Visual
charts.

Imitates cubes of train Imitates straight line.
without chimney.

test:

Picture

2 years

Tower of 6 cubes.

30

est

ntellect of the child)

3 years

circle

Imitates bridge with cubes

Tower of 9.

cross

Penci

Draw
Pencil

Draw
Draw

Able to copy 0 and
imitates +. Draw a man
test.

4 years

square
Copies square.

Draw
Draw
Draw

Draw

Draw

Imitates gate with cubes. Copies +.

4.5 years: Copies gate Draw recognizable man
with cubes,
and house.

5 years

riangle
Draw X

Draw triangle (5.5 years)

31

Speech/Language

6 weeks

Quiets and startle to
sound.

Vocalizing at 8 week

3 months

Squeals with delight.

9 months

Turn head to sound

1 year
Ma-ma
Pa-pa
Su-su

Localizes sound at 3 feets 2-3 words with
above and below the ear meaning.
level.

18 months

Points to 2-3 body parts

Pictures cards identify
one.

32


2 years
Saya nak makan
Nak makan

Points to 4 body parts.

Names 3 objects.
Obeys
4
simple
commands

3 years

2-3 words sentences

Uses I, you and me.

Knows 2 colors.

Understands on, in and Can count to 10.

under.

4 years

Names 3 colors.

Understands in front, Fluent conversation.
between and behind.

33

5 years

Knows 4 colors.

Knows AGE.

Tell the time

Social

6 weeks

3 months

5 months

Smiles responsively.


9 months

Laughs

Feeds with
occasionally

spoon Understands NO

Mouthing

Looks for fallen toys

34


1 year

Shy




18 months

Toilet trained




2 years

Less mouthing

Imitates housework

Uses spoon well

Plays near other children Puts on shoes, socks and Dry by day.
but not with them.
pants

35




3 years

Play with other children.

Dresses and undresses Dry by night.

with help

4 years

Button clothes fully.

5 years

Tie shoelaces.

Attends to own toilet
needs.

Dresses and undresses
alone.

36

When should we take action?

When warning sign is present, please highlight your findings to your MO and
specialist.

Warning signs:
Discrepant head size or crossing centile lines (too large or too small).
Persistence of primitive reflexes > 6 months of age
No response to environment or parent by 12 months
Not walking by 18 months
No clear spoken words by 18 months
No two word sentences by 2 years
Problems with social interaction at 3 years
Congenital anomalies, odd facies
Any delay or failure to reach normal milestones

What are the information need to be explored when we found out that child
has warning signs?

History:
Consanguinity
Family history of developmental delay
Maternal drugs, alcohol, illness and infection in pregnancy
Prematurity, perinatal asphyxia
Severe neonatal jaundice, hypoglycemia or seizures.
Serious childhood infections, hospital admissions or trauma.
Home environment conditions (environmental deprivation)

Physical examination:
Head circumference
Dysmorphic features
Neurocutaneous marker
Neurological abnormality
Full devolepmental assessment

Investigation:
Visual and auditory testing
T4, TSH (affects brain maturation and function)
Chromosomal Analysis
Consider:
Creatine kinase in boys
MRI Brain
Metabolic screen
Specific genetic studies
EEG if seizures

37

Management:
Speech and language therapy
Occupational therapy
Physical therapy

38

Legend: B+

JE (Sarawak)

MMR

Measles

Hib

DTaP

birth

Sabah

Age (months)

if no scar

7 yrs

3 doses

School years

Immunization:
Chapter 2: Immunisations

39

Not Immunised at the Recommended Time

mths,

3rd visit)
Polio, DT/DTaP, MMR (at
school entry)

Footnotes:

regardless of the period that has elapsed since the last dose was given.

40

Commonly used medications in neonates

IV C.Penicillin:
100 000 U/kg BD
100 000 U/kg QID (meningitis)
Amikacin
7.5 mg/kg/OD

Cefipime
IV/IM 25 mg/kg BD
Severe infection:
IV 50mg/kg BD/TDS
Imipenem
15 mg/kg 6 H
Severe infection:
25 mg/kg BD (1st week)
25 mg/kg TDS (2-4 weeks)
25 mg/kg TDS/QID (4 + week)
Frusemide
Oral/IM/IV
0.5-1 mg/kg 6-24 hourly

Aminophylline
Load 10 mg/kg over 1 hour (max 500mg)
Maintenance:
2.5 mg/kg IV (1st week)
3.0 mg/kg IV (2nd week)
((0.12 x age in week) + 3) mg/kg TDS

Elemental Iron
Premature: 2-3mg/kg/day

IV Gentamycin:
4 mg/kg OD (Term)
4mg/kg 36 hourly (Prem)
Cefotaxime:
IV 25 mg/kg BD
Severe infection:
IV 50 mg/kg TDS (1st week of life)
IV 50 mg/kg QID (2-4 weeks of life)
IV 50 mg/kg 4-6 hourly (4 weeks of life)
Cefuroxime:
IV 25 mg/kg TDS
Severe infection:
IV 50 mg/kg BD (1st week life)
IV 50 mg/kg TDS
Meropenem
10-20 mg/kg TDS
Severe infection:
20-40 mg/kg BD (1st week)
20-40 mg/kg TDS (>1st week)

Spironolactone:
Oral:
0-10 kg:6.25 mg BD
11-20 kg: 12.5 mg BD
21-40 kg: 25 mg BD
> 40 kg: 25 mg TDS
IV Ranitide
1 mg/kg 6-8 hourly

Folic acid
Oral 1 mg OD

41

Alkalosis

Appendix

Measurement of Acid Base Status

pH

PaO

7.34-7.45
3

acidosis
Scalp Swelling in neonates:

metabolic acidosis.
respiratory acidosis.
mixed metabolic and

repiratory acidosis.

opposite

mechanism.
2

Management of Metabolic Acidosis and Alkalosis

Treat underlying
cause when
possible.
1. Caput
: Scalp edema
over the
presenting part during a vertex
delivery. Bruises and petichiae may be noted over the affected
skin.

2. Cepalhaematoma : Cause by subperiosteal bleed (bleeding below
the periosteum). No crossing of suture line, no skin changes. May
take
months
to racidosis
esolve. unless there are signs of hypovolemia. A volume
be used
to treat
is poorly tolerated in severe acidosis because of decreased myocardial
load
3. Subgaleal or Subaponeurotic bleed : Collection of blood in soft
tissue space under the aponeurosis. Diffuse swelling, crossing
suture
May aorssociated
with acidosis.
severe blood loss, shock, anaemia
such asline.
diarrhea
renal tubular
or seizure.

Dose in mmol of NaHCO3

42

Umbilical artery catheterization (UAC) and Umbilical venous

catheterization (UVC)

What are the indications for UAC?
a. Repeated blood sampling in ill newborn especially
those on ventilator.
b. Infusion or continuous BP monitoring.

What are the indications for UVC?
a. Venous assess in neonatal resuscitation.
b. Baby in shock.
c. For exchange transfusion for severe neonatal jaundice.

What are the contraindications?
d. Local vascular compromise in lower extremitites.(UAC)
e. Peritonitis, NEC
f. Omphalitis.


Equipments need to be prepared for UVC and UAC insertion:

a. UAC/UVC set.
b. UAC or UVC of appropriate size. (3.5 mm and 5.0 mm or 4 mm
and 6 mm)
c. FBC, CRP and blood C&S bottles.
d. Cotton and gauze.
e. Umbilical stump tie.
f. Blades.
g. Sterile gowns and sterile gloves.
h. Chlorhexidine and heparinized saline.
i. 3-way (red and blue)
j. Syringe 10 cc x 2.
k. Needle (blue) x 2.
l. Cap and plastic apron.

Formula for the length of insertion:

a. UAC:
BW x 3 +9 + stump length in cm (high position)

b. UVC:
0.5 x UAC cm + stump length.

43

44

References:

1. Paediatric Protocols for Malaysian
Hospitals, 3rd Edition.
2. E-medicine World Medical library
Medscape.
3. Nelson textbook of Pediatrics, 18th
edition.

45