Pedia Reviewer

++PEDIATRICS REVIEWER
ANTHROPOMETRIC MEASURES & WATERLOWS CLASSIFICATION

A. DESIRED WEIGHT
AGE
DESIRED / IDEAL WEIGHT
AGE OF INFANT
IDEAL WEIGHT
At Birth
3kg (Filipinos)
or 3.25kg (for Caucasians)
At 4-5 Months
2 x Birth Weight
Weight in kg
= Age in Months x 600 + Birth Weight
1 Year
3 x Birth Weight
< 6 months
2 Years
4 x Birth Weight
> 6 months
Weight in kg
= Age in Months x 500 + Birth Weight
3 Years
5 x Birth Weight
5 Years
6 x Birth Weight
2 to 6 years
Weight in kg = Age in Years x 2 + 8
7 Years
7 x Birth Weight
6 to 12 years
Weight in lbs = Age in Years x 7 + 5
10 years
10 x Birth Weight
AGE
LENGTH
At Birth
50 cm or 20 inches
B. DESIRED LENGTH
GAIN in 1st Year is ~25cm,
Distributed as Follows:
3cm
+ 9cm
per month
AGE
Birth to 3
months
3-6 months
+ 8cm
2.67 cm
per month
1 year Old
30 inches or 1.5 x Birth

Length
6-9 months
+ 5cm
1.6cm
per month
2 years old
1/2 Mature Height (in

boys)
9-12 months
+ 3cm
1cm
per month
3 years old
3 Feet Tall
4 years old
1yr and above
Height in cm
= Age (years) x 5 + 80
13 years old
40 inches or 2 x Birth
Length
3 x Birth Length
C. HEAD CIRCUMFERENCE
AGE OF INFANT
1 to 4 Months
4 to 12 Months
1 to 2 Years
3 to 5 Years
6 to 20 Years
IDEAL HEAD CIRCUMFERENCE

INCHES
CENTIMETERS
+ 2 Inches (1/2 Inches per Month)
+ 5.08cm (1.27cm per month)
+ 2 Inches (1/4 Inches per Month)
+ 1 Inch
+ 2.54cm
+ 1.5 Inches (1/2 Inches per Year)
+ 1.5 inches (1/2 Inches per 5 years)
D. CHEST MEASUREMENT
AGE OF INFANT
Birth
1 Year Old
6 Years Old
TRANSVERSE-AP DIAMETER RATIO

1.0
1.25
1.35
Better Doctors Pediatrics Reviewer for Junior Interns Batch 2011
REMARKS
Transverse = AP (Barrel Chest)
Transverse > AP
Transverse >>> AP
E. WATERLOW CLASSIFICATION
1.
Wasting
Actual Weight
Ideal Weight for Actual Length / Height
2.
. X 100
Classification:
Normal > 90%
Mild = 80-90%
Moderate = 70-80%
Severe < 70%
Classification:
Normal > 95%
Mild = 90-95%
Moderate 80-90%
Severe < 80%
Stunting
Actual Height/Length
Ideal Length / Height for Age
X 100
APGAR
0
Appearance
Blue / Pale
Pink Body + Blue Extremities
Completely Pink
Pulse
Absent
Slow (<100)
>100
Grimace
No Response
Grimaces
Coughs, Sneezes, Cries
Activity
Respiration
No Movement
(Limp)
Absent
Some Flexion / Extension

Slow / Irregular
8-10: Normal
4-7: Mild / Moderate Asphyxia
0-3: Severe Asphyxia
Active Movement (all

extremities)
Good, Strong Cry
FONTANEL
Anterior Fontanel:
Posterior Fontanel:
closes at 18 months (as early as 9-12months)

closes at 6-8 weeks
DENGUE VIRUS
I. DENGUE INFECTION
A. DHF Clinical Criteria
o 1) Fever: 2-7 days, regardless of characteristic
o 2) Hemorrhagic Manifestations:
(+) Tourniquet Test (>20/in2)
Mucocutaneous Bleeding
GI Bleeding
B. DHF Laboratory Criteria
o 1) Evidence of Consumptive Coagulopathy
Decreased Platelet Count (<150,000)
Prolonged BT
Prolonged PT (II, V, VII, X, Fibrinogen)
Prolonged PTT (II, V, VII, IX, X, XI, XII, Fibrinogen)
o 2) Steadily Increasing Hematocrit (20% or more) in spite of proper hydration or Increased Vascular
Permeability
C. DSS Criteria
o DHF Criteria + Evidence of Circulatory Failure:
Violaceous, cold, clammy skin
Restlessness, weak to imperceptible pulses
Narrowing of Pulse Pressure to <20mmHg
Hypotension
D. Dengue Classification:
o Undifferentiated Fever
o Dengue Fever Syndrome
o Dengue Hemorrhagic Fever
o Dengue Shock Syndrome
II. GRADING OF DENGUE

GRADE 1
GRADE 2
GRADE 3
GRADE 4
Grade 1 + 2 PLUS:
Anorexia
Vomiting
Convulsion
Restlessness
Flushed Skin
(+) Tourniquet Test
Abdominal Pain
Hepatomegaly
Pleural Effusion (Unilateral R /
Bilateral)
Constipation
Abdominal Distention
Grade I
Grade II
Grade III
Grade IV
Grade 1 PLUS:
Gum Bleeding
Epistaxis
Petechiae on Palate
Petechiae on Axillae
Rashes on
Extremities
Chest Pains
Chough
Lethargy
Violaceous Skin
Flushed Face
Hematemesis
Melena
Purpura
Hemoptysis
Cold Clammy Extremities
Shock (Hypotension,
Tachycardia)
Ecchymoses
Grade 1 + 2 + 3 PLUS
Profound SHOCK
= Fever + Non-Specific Constitutional Symptoms ([+] Tourniquet is the only hemorrhagic manifestation)
= Grade I + Spontaneous Bleeding
= Grade II + Severe Bleeding + Circulatory Failure (rapid / weak pulse, narrow pulse pressure, hypotension)
= Grade III + Irreversible Shock + Massive Bleeding (undetectable pulse and BP)
III. DANGER SIGNS OF DHF

Abdominal Pain (intense and sustained)
Persistent vomiting
Abrupt change from fever to hypothermia with sweating
Restlessness or somnolence
IV. GRADING OF DENGUE
MILD TO MODERATE
(DF)
Headache, malaise, irritable,
but consolable
SEVERE
(DHF Gr. I & II)
SEVERE (DSS)
(DHF Gr. III)
VERY SEVERE (DSS)

(DHF Gr. IV)
Unesponsive, too weak to feed,
extreme weakness / seizures
Headache, malaise, irritable, but

consolable
Irritable, but easily consolable

Poor eye contact (lethargic)
Feeds poorly
AND
OR
(+) Signs of Dehydration

Good Peripheral Perfusion
Normal BP
(+) Moderate Dehydration with

Hemoconcentration
Pulse Pressure < 20mmHg
AND
OR
OR
No signs of Respiratory
Distress or Pulmonary
Edema
No signs of Respiratory Distress

or Pulmonary Edema
(+) Respiratory Distress
Severe Respiratory Distress

(Pulmonary Edema or CHD) with
RR > 60, retractions, grunting,
cyanosis, respiratory failure
AND
AND
OR
(-) Tourniquet Test

(-) Severe Anemia or
Bleeding
(+) Tourniquet Test

Low PC <100,000
Increased Hct (>20%)
(-) Severe Anemia or Bleeding
(+) Tourniquet Test

Low PC < 100,000
(+)Severe Anemia / Bleeding
AND
AND
No Metabolic or End Organ

Failure

Failure
AND
No signs of Dehydration
Normal BP
OR
AND
AND
Failure
(+) Severe Dehydration with

Shock
Poor Peripheral Perfusion

Pulse Pressure < 10mmHg
Capillary Refill > 20sec
OR
(+) Tourniquet Test
Low PC < 100,000
Life Threatening Anemia,
bleeding, associated with DIC
OR
Metabolic Disorder:
Hypoglycemia
Metabolic Acidosis
Liver / Renal Failure
V. MANAGEMENT OF DENGUE
A. Vital Signs and Laboratory Monitoring (Vital Signs and Laboratory Monitoring)
o Monitor BP, Pulse Rate
o We have to watch out for Shock (Hypotension)
INITIALLY
IF WITH RISING HEMATOCRIT
Blood Pressure
Every 24 hours
Hourly
Every 15 to 30 with Hypotension
Hematocrit
Every 24 hours
Every 6 hours
Platelet Count
Every 24 hours
Every 6 hours
Hemoglobin
Every 24 hours
Repeat if Hematocrit falls after an Initial Rise
B. Management of Hemorrhage
CONDITION
If due to Vascular Changes (first few days of Illness)
MANAGEMENT
No TREATMENT is Required!
If Platelet Count is BELOW 50,000/cu.mm
Prepare Fresh Whole Blood

If Active Bleeding occurs or Hemoglobin and
Hematocrit Levels Fall give Fresh Frozen Plasma
If occurs with SHOCK (DIC)
Follow Whole Blood Transfusion with Heparin

(with Extreme Caution)
Fresh Frozen Plasma is also helpful
5) IMCI
I. MODULE 1: GENERAL DANGER SIGNS IN 2 MONTHS TO 5 YEARS OLD
Inability to Drink or Feed
Convulsions
Lethargy or Unconsciousness
Vomiting of Everything Taken
II. MODULE 2: COUGH / DIFFICULTY OF BREATHING
A. Tachypnea (MUST KNOW!!!)
AGE
RESPIRATORY RATE
0 to 2 months
2 to 12 months
12 months to 5 years old
> 60/minute
> 50/minute
> 40/minute
B. Classification of Patients with Cough or Difficulty in Breathing:

SIGNS
*Any General Danger Sign
*Chest Indrawing; or
*Stridor in a Calm Child
CLASSIFY AS
Severe Pneumonia
or
Very Severe Disease
*Fast Breathing
Pneumonia
Triad of Pneumonia:
Fever, Cough, Tachypnea
*No Signs of Pneumonia, or

*Very Severe Disease
No Pneumonia
Cough or Cold
TREATMENT
*Give first dose of appropriate Antibiotic
*Give Vitamin-A
*Treat Child to prevent Low Blood Sugar
*Refer urgently to Hospital
*Give appropriate Antibiotic (5 days)
*Soothe throat & relieve cough
*Advice mother when to return
immediately
*Follow up in 2 days
*If coughing > 30 days, refer for
assessment
*Soothe throat & relieve cough
*Advice mother when to return
immediately
*Follow up in 5 days if not improving
III. MODULE 4: FEVER

CAUSE OF FEVER
Measles (Viral Exanthems)
Dengue
Malaria
Typhoid
Ear Infection
UTI
MORBIDITY IS DUE TO:

Bronchopneumonia
Shock / Bleeding
Cerebral, Renal
Typhoiditis, Shock
Hearing Loss
Chronic Renal Disease
IV. MODULE 3: DIARRHEA

A. Assessment of Diarrhea Patients with Dehydration (Focus on patients level of Thirst)
Lethargic / Unconscious;
1) LOOK AT CONDITION:
Well, Alert
Restless, Irritable
Floppy
Normal
/
Present
Sunken
/
Absent
Eyes / Tears
Very Sunken & Dry /
Moist
Dry
Mouth & Tongue
Absent
Drinks
normally;
Not
Thirsty
Thirsty;
Drinks
Eagerly
Thirst
Very Dry
Drinks Poorly; Unable to Drink
2) FEEL SKIN PINCH
Goes back quickly
Goes back slowly
Goes back very slowly
3) DECIDE
Patient has NO Signs of

Dehydration
If patient has two or

more Signs,
including at least
one Sign, there is
some Dehydration
If patient has two or more

signs, including at least
one Sign, there is Severe
Dehydration
4) TREAT
Treatment Plan-A
Weigh patient
Treatment Plan-B
Weigh Patient
Treatment Plan-C Urgently
B. Treatment Plans (30ml = 1 ounce)

1. Treatment Plan-A
< 2 years old = 50 to 100ml after each loose stool (or 2-3 ounces)
2 to 10 years old = 100 to 200ml after each loose stool (or 7-8 ounces)
2. Treatment Plan-B
75 cc/kg
3. Treatment Plan C: Severe Dehydration
100 ml/kg fluid replacement
<12 months = consumed within 6 hours duration
>12 months = consumed within 3 hours duration
C. DOC for Diarrhea (from Melais notes)
Rotavirus
None
Amoeba
Metronidazole
Ascariasis
Albendazole / Mebendazole
Cholera
Tetracycline
Shigella
TMP/SMX
V. MODULE 5: MALNUTRITION / ANEMIA

Classification and Treatment of Malnutrition & Anemia
IMPLICATION
*Visible Severe Wasting
Severe Malnutrition
*Severe Palmar Pallor
or
*Edema of both feet
Severe Anemia
*Some Palmar Pallor
*Very Low Weight for Age
*Not very low Weight for Age

and no other signs of
Malnutrition
MANAGEMENT
*Give Vitamin-A
*Refer URGENTLY to a Hospital
Anemia
or
Very Low Weight
*Assess childs feeding and counsel the mother on

feeding
*If with feeding problem, follow up in 5 days
*If with Pallor:
Give Iron
If suspecting Malaria, refer to a Hospital
Give Mebendazole if child is 2yrs or older and
has not had a dose in the previous 6 months
*Advise mother when to return immediately
*If with Pallor, follow up in 14 days
*If very low weight for age, follow up in 30 days
No Anemia and
Not Very Low Weight
*If child is < 2y/o, assess feeding &counsel mother on

feeding
*If with feeding Problem, follow up in 5 days
*Advise mother when to return immediately
VI. MODULE 6: IMMUNIZATIONS

A. Basic Immunization According to EPI
o BCG
o Hepa B
o DPT / OPV
o Measles
VACCINE
AGE
BCG-1
Birth (or 6 weeks)
DTP
Polio
Hepatitis B
Measles
BCG-2
Tetanus Toxoid
6 weeks
6 weeks
6 weeks
9 months
School entry
Childbearing women
DOSE
0.05mL for newborn

0.1mL for older infants
0.5mL
2 drops
0.5mL
0.5mL
0.1mL
0.5mL
B. Contraindications to Vaccinations:
ABSOLUTE CONTRAINDICATIONS
Severe anaphylactic / allergic reaction
to previous vaccine
Moderate to severe illness +/- fever
Encephalitis within 7 days of
administration (Pertussis)
Immunodeficiency in patient
(congenital all live vaccines) or
household contact (OPV)
Pregnancy (MMR, OPV/IPV)
NO.
ROUTE
SITE
ID
R deltoid region
3
3
3
1
1
3
IM
PO
IM
SC
ID
IM
Upper outer thigh

Mouth
Anterolateral thigh
Outer upper arm
L deltoid
Deltoid
INTERVAL
BETWEEN
DOSES
4 weeks
4 weeks
4 weeks
1 month;
Then 6-12 months
RELATIVE CONTRAINDICATIONS
Immunosuppressive therapy (all live
vaccines)
Egg allergy (MMR)
Seizure within 3 days of last dose
(Pertussis)
Shock within 48hrs of last dose (Pertussis)
Fever >40.50C within 48hrs of last dose
(Pertussis)
C. NOT Contraindications
o Mild Illness +/- low-grade fever
o Current antibiotic therapy
o Recent infectious disease exposure
o Positive PPD
o Prematurity, except if infant is still hospitalized at 2 months, OPV should be delayed until
discharge. Or, if mother is HBsAg(-), Hep-B Vaccine delayed until child > 2000g
VII. MODULE 7: MANAGEMENT OF THE SICK YOUNG INFANT (1 week to 2 months old)
Signs and Symptoms of Possible Bacterial Infection in a Young Infant
o Convulsion
o Respiratory Rate more than 60/minute
o Severe Chest Indrawing
o Nasal Flaring
o Grunting
o Bulging fontanelle
o Pus draining from the ear
o Erythema and discharge from the umbilicus
o Abnormal body temperature
o Severe skin pustules
o Lethargy or unconsciousness
o Abnormal movements
7) NEWBORN SCREENING
Congenital Hypothyroidism (puffy eyelids)
Phenylketonuria (MR)
G6PD
CAH
Galactossemia
8) MILESTONES
MILESTONES
Regards
Smiles
Turns Head
Holds Head
Rolls over
Transfers object
Sits briefly
Creeps
Pulls up
Cruises
Walks with support
Stands alone
NORMAL
(months)
1
2
3
4
5
6
7
8
9
10
11
12
From Melais Notes:

Roll over: 4 months
Reach: 8 months
Hold bottle: 8 months
9) COMMONLY USED DRUGS

D: per day
d: per dose
ANTI-TUBERCULOSIS DRUGS
ANTIBIOTICS
Penicillin G
100-200 T ukD q12

1.2MU/vial, 2.4MU/vial
Rifampicin
10-20 mkD OD AC
200mg/5mL, 100mg/5mL, 150, 300, 450, 600mg
Penicillin V
50-200 mkD
Isoniazid
Ampicillin
50-100 mkD q12/8

100mg, 250mg, 500mg, 1g
10-20 mkD OD AC
200mg/5mL, 100mg/5mL, 50, 100, 150, 200, 400mg
Pyrazinamide
Amoxicillin
30-50 mkD q8
20-30 mkD OD PC
250mg/5mL, 500mg
Cloxacillin
50-100 mkD q6
250mg, 500mg, 125mg/5mL, 250mg/5mL
Ethambutol
15 mkD OD
Streptomycin
10 mkD OD q480
1g/vial
Dicloxacillin
12.5-25mkD
Nafcillin
25-50 mkD q12

500mg, 1g/vial
Amikacin
15 mkD LD; 10 mkD MD q12

250mg/mL, 125mg/mL, 50mg/mL
Gentamycin
5-8 mkD OD
Netilmycin
6-8 mkD OD
25mg, 60mg, 100mg/mL
Tetracycline
25-50 mkD
CoTrimoxazole
5-8 mkD q12

80mg/5mL, 40mg/5mL
CoAmoxiclav
Follow Amoxicillin component

312,5mg/5mL = 250mg/5mL of Amoxicillin
Erythromycin
30-50 mkD q8; not to exceed > 1g

200mg/5mL, 100mg/2.5mL, 400mg/5mL
Clarithromycin
15 mkD q12
Azithromycin
10mkD x 3days OD
Chloramphenicol 50-100 mkD q6/8

125mg/5mL, 1g/vial
Clindamycin
20-50 mkD q6/8
Cefalexin (1st)
25-50 mkD q6
100mg/mL, 125mg/5mL, 250mg/5mL, 250mg, 500mg, 1g
Cefazolin (1st)
50-100mkD
1g/vial
Cefaclor (2nd)
20-40 mkD q8
250mg, 500mg, 125mg/5mL, 250mg/5mL
Cefuroxime (2nd)
20-40 mkD q12; 50-100 mkD q8 IV

250mg, 500mg, 125mg/5mL, 250mg/5mL
Ceftazidime (3rd)
100-150 mkD q8 IV
250mg, 500mg, 1g, 2g
Ceftriaxone (3rd)
50-100 mkD OD IV
250mg, 500mg, 1g, 2g/vial
Cefotaxime (3rd)
100-200 mkD q4-6

250mg, 500g, 1g/vial
Cefixime (3rd)
3-8 mkD q12

20mg/5mL, 100mg/5mL
Meropenem
20 mkD q12 (septic)

40 mkD q12 (meningitic)
Piperacillin
200-300 mkD q6
2g/vial
Unasyn
50-100 mkD q6/8
ANALGESICS / ANTIPYRETICS
Paracetamol
10-15 mkd q4/6

100mg/mL, 120mg/5mL, 125mg/5mL, 250mg/5mL
Paracetamol Drops: 100mg/5mL
Aeknil: 150mg/mL
Ibuprofen
5-10 mkd q6/8

100mg/5mL, 200mg/5mL
Mefenamic Acid
6.5 mkd
Aspirin
60-80 mkD q6/8

Not > 2g/D
ANTICONVULSANTS
Diazepam
0.3-0.5 mkd IM
Not to exceed 10mkD
2mg, 5mg, 10mg tab; 5mg/mL, 10mg/mL
Phenobarbital
3-5 mkd
10-20 mkd LD; 5 mkD q12 MD
20mg/5mL
Phenytoin
5-7 mkd
10-20 mkd LD; 5 mkD q12 MD
125mg/5mL, 250mg/5mL, 15mg, 30mg, 60mg, 90mg
Valproic Acid
15 mkD LD
Not > 60mkD
250mg/5mL
ANTIHISTAMINE
Diphenhydramine
1 mkd IV
2-6y/o: 2-5mL q6/8
6-12y/o: 5mL
12.5mg/5mL
Hydroxizine
1-2 mkD q6/8

10mg, 20mg tab; 2mg/mL
STEROIDS
Prednisone
1-2 mkD q12

BSA x 60mkD (Nephrotic)
Hydrocortisone
10 mkd LD q6/8; 5 mkd MD

4 mkd q6/8
50mg/mL, 125mg/mL
10
BRONCHODILATORS
Salbutamol
0.15 mkd
Theophylline
7 mkd LD; 20 mkd MD
ANTI-ULCER
Ranitidine
1 mkd q8
Omeprazole
0.6-0.7 mkD OD
10, 20, 50mg
Cimetidine
5 mkd q6
DIURETICS / ANTI-HPN
Furosemide
1 mkd IV
20, 40, 60mg tab; 20mg/mL
Nifedipine
0.25 mkD
Propranolol
1-2 mkD q6
Aldactone
2-3.5 mkD q6
ANTIVIRALS
Acyclovir
100 mkD q6
Amantadine
< 8y/o: 5-9 mkD q12

>8y/o: 100-200
Not to exceed > 200mg/d
ANTI-PARASITISM
Mebendazole
200 mkD single dose

500 mkD single dose
Pyrantel Pamoate
11 mkD x 3 doses OD
125mg/5mL, 250mg/5mL
Fluconazole
6mkd LD, 3mkd MD

50mg/tab
Metronidazole
30-50 mkD q8 x 10days

125mg/5mL, 250mg, 500mg
Ketoconazole
< 15kg: 5mkD

> 20kg: 100mg OD
> 30kg: 200mg OD
Griseofulvin
10 mkD
Amphotericin-B
0.3-0.7 mkD
OTHERS
Epinephrine
0.1-0.3mL/kg IV
Carbocisteine
(Solmux) q8
For 100mg/5mL
8-12y/o: 15mL
4-7y/o: 10mL
2-3y/o: 5mL
For 200/5mL
8-12y/o: 7.5mL
4-7y/o: 5mL
2-3y/o: 2.6mL
Solmux Broncho
For 5mL Suspension
7-12y/o: 1/2 to 1 tsp qid
* Salbutamol 2mg
* Carbocisteine 500mg
Cetrizine
For 5mg/5mL:
>12y: 2 tsp OD
6-11: 2 tsp OD or 1 tsp BID
2-5 yrs: 1 tsp OD or 1/2 tsp BID

For 2.5mg/mL (drops):
2-5: 2mL OD or 1mL BID
6months to < 2yrs: 1mL OD
Cinnarizine
(Stugerone)
25mg
Serc
(Betahistine)
8-16mg TID
ANTIFUNGAL
11
10) IV FLUIDS
Ludans
Holiday-Segar Method
I. LUDANS METHOD (HYDRATION THERAPY)
MILD DEHYDRATION
< 15kg, < 2y/o
> 15kg, 2y/o
50 cc/kg
30 cc/kg
D50.3% in 6-8hours
MODERATE
DEHYDRATION
100 cc/kg
60 cc/kg
1st hr: 1/4 PLRS
Next 5-7hrs: 3/4 D50.3%
SEVERE
DEHYDRATION
150 cc/kg
90 cc/kg
1st hr: 1/3 PLRS
Next 5-7hrs: 2/3 D50.3%
II. HOLIDAY-SEGAR METHOD (MAINTENANCE)

WEIGHT
TOTAL FLUID REQUIREMENT
0 10 kg
100 mL/kg
11 20 kg
1000 + [50 for each kg in excess of 10kg]
> 20 kg
1500 + [20 for each kg in excess of 20kg]
**NOTE: Computed Value is in mL/day
o Ex) 25kg child
o Answer: 1500 + [100] = 1600cc/day
III. FACTORS CONSIDERED IN HYDRATING A PATIENT:
Urine Output
Pulses
Sensorium
Turgor
Heart Rate
Nutritional Status
IV. IV-FLUID COMPOSITIONS (Commonly Used for Infants and Children):
Dextrose (g/L)
LRS
NSS
D50.15% NaCl
D50.3% NaCl
D50.45% NaCl
D50.9% NaCl
D5IMB
D5LRS
D5NM
D5NR
50
50
50
50
50
50
50
50
Na+ mEq/L
130
154
25
51
77
154
25
130
40
140
Cl- mEq/L
109
154
25
51
77
154
22
109
40
98
K+
mEq/L
Lactate mEq/L
Others
mEq/L
Ca2+:3
28
20
4
13
5
23
28
Mg2+:3; Acetate: 26
Mg2+:3; Acetate: 27; Gluconate:
23
12
11) VIRAL EXANTHEMS

ETIOLOGY
Measles
(Rubeola)
Paramyxovirus
(RNA-Virus)
INCUBATION
PERIOD
8-12 days
PRODROMAL PERIOD
2-4 days
Exanthem (Koplik Spots) on
the Buccal and Pharyngeal
Mucosa after 2-3d
Fever, Conjunctivitis and
Increasingly Severe Cough /
Brassy Cough (Catarrhal
Stage)
German Measles
(Rubella)
Togavirus
(RNA-Virus)
14-21 days
1-5 days
Lymphadenopathy (PostCervical or Post-Occipital)
ONSET OF
FEVER
Fever + Rashes
T abruptly
(40C) as rash
appears
T when rash
reaches legs
and feet
Spots after
Fever
Sudden onset
(39-410C)
RASH
Centrifugal Spread
Maculopapular
Begins in face
Centrifugal Spread
Maculopapular
Begins trunk
arms, neck face legs
T on 3-4d as
rash appear
Roseola
Infantum
Human Herpes
Virus-6
(DNA-Virus)
7-17 days
Bulging of anterior fontanelle

or convlusions
Chickenpox
(Varicella)
Varicella-Zoster
Virus
(DNA-Virus)
Parvovirus B19
(DNA-Virus)
10-23 days
In Children = unusual
In Adults = 1-2 days
Erythema
Infectiosum
Fever then Rash
7-28 days
Centripetal Pattern
Slapped Cheek
Appearance
Sparing of Palms &
Soles
12) KAWASAKI CRITERIA

I. 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
o High Grade Fever of at least 5 days
o DOES NOT Respond to any kind of Antibiotic!
B) Presence of 4 of the 5 Criteria:
o 1) Bilateral CONGESTION of the Ocular Conjunctiva (seen in 94%)
o 2) Changes of the Lips and Oral Cavity (At least ONE)
o 3) Changes of the Extremities (At least ONE)
o 4) Polymorphous Exanthem (92%)
o 5) Cervical Adenopathy = Non-Suppurative Cervical Adenopathy (should be >1.5cm) in 42%
II. TREATMENT: Currently Recommended Protocol:
A. IV-Immunoglobulin:
o 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
13
B. Aspirin
HIGH Dose ASA (80-100mg/kg/day divided q 6h) should be given Initially in Conjunction with IV-IG
THEN
Reduced to Low Dose Aspirin (3-5mg/kg/day)
AND
Continued until Cardiac Evaluation COMPLETED
(approximately 1-2 months AFTER Onset of Disease)
13) ARI PROTOCOL (PROGRAM FOR THE CONTROL OF ARI)

I. PROTOCOL
A. Child Age 2months up to 5years
SIGNS:
NOT able to Drink
Convulsions
Abnormally Sleepy or
difficult to Wake
Stridor in Calm Child
Severe Malnutrition
CLASSIFY AS:
VERY Severe Disease
TREATMENT:
Refer URGENTLY to
Hospital
Give first dose of an
Antibiotic
Treat Fever, if present
Treat Wheezing, if present
If Cerebral Malaria is
possible, give an
Antimalarial
Chloramphenicol IM, IV
Chest Indrawing
If also recurrent
wheezing, go directly
to Treat Wheezing
Severe Pneumonia
Refer Urgently to
Hospital
Give 1st dose of
Antibiotic
Treat Fever, if present
Treat Wheezing, if
present
If referral is not
feasible, treat with an
Antibiotic and follow
closely
Benzyl Penicillin IM,
IV
No Chest Indrawing;
and
Fast Breathing
No Chest Indrawing;
and
No Fast Breathing
50/minute or more if
child 2 months to 12
months; 40 per minute
or more if child 12
months up to 5 years
Pneumonia
< 50/minute if child 2

months to 12 months;
< 40/minute if child 12
months to 5 years
Advise mother home

care
Give Antibiotic
Treat Fever if present
Treat Wheezing if
present
Advise mother to
return with child in 2
days for
reassessment, or
earlier if the child is
getting worse
Cough or Cold
(NO Pneumonia)
If cough > 30 days,
refer to assessment
Assess / Treat Ear
problem or Sore
Throat, if present
Assess / Treat other
problems
Advise mother Home
Care
Treat Fever if present
Treat Wheezing if
present
CoTrimoxazole PO
14
B. Young Infant: < 2 Months

SIGNS:
Stopped Feeding Well
Convulsions
Abnormally sleepy / difficult to
wake
Stridor in a Calm Child
Wheezing; or
Fever or Low Body Temperature
Severe Chest Indrawing; or

Fast Breathing
NO Severe Chest Indrawing; and

NO Fast Breathing
(60/minute or More)
(Less than 60/minute)
Severe Pneumonia
CLASSIFY AS:
VERY Severe Disease
TREATMENT:
Refer UREGENTLY to Hospital

Keep young infant WARM
Give first dose of Antibiotic
Refer Urgently to Hospital

Keep young Infant Warm
Give 1st Dose of Antibiotic
Benzyl Penicillin + Gentamycin

IM, IV
If referral is NOT feasible,

treat with an Antibiotic and
follow closely
Cough or Cold
(NO Pneumonia)
Advise Mother to give following
Home Care:
Keep young Infant Warm
Breastfeed frequently
Clear Nose if it interferes

w/ feeding
Return QUICKLY if:
Benzyl Penicillin +
Gentamycin IM, IV
Breathing becomes Difficult

Breathing becomes Fast
Feeding becomes a
Problem
The infant becomes Sicker
II. ETIOLOGY OF PNEUMONIA ACCORDING TO AGE

0 to 48 hrs
GBS
1 to 14 days
E.coli, Klebsiella, Enterobacter
2wks to 2mos
Enterobacter, GBS, S.aureus
2mos to 5yrs
H.influenzae, S.pneumoniae
5 to 21yrs
S.pneumoniae, M.pneumoniae
14) URINARY TRACT INFECTION
I. SUGGESTIVE UTI:
Pyuria: WBC 5/hpf or 10mm3
Absence of Pyuria does NOT Rule Out UTI
Pyuria can be PRESENT without UTI (Pyuria can be present that is not infectious in nature)!
II. PRESUMPTIVE UTI:
(-) Urine Culture
Lower Colony Counts may be due to:
o Overhydration
o Recent Bladder Emptying
o Antibiotic Intake
III. PROVEN OR CONFIRMED UTI
(+) Urine Culture 100,000 CFU/Ml Urine of a SINGLE Organism
Multiple Organism in Culture means there is Contamination of the Specimen (Gold Standard)
15
15) TREATMENT OF TUBERCULOSIS

I. PULMONARY TUBERCULOSIS
1) Fully susceptible M. tuberculosis; No history of previous Anti-TB drugs, Low local prevalence of Primary
Resistance to Isoniazid (H)
2-HRZ OD, then 4-HR OD or 3x/wk [DOT]
2) Microbial susceptibility unknown or initial drug resistance suspected (eg. cavitary), previous Anti-TB
use, close contact with resistant source case or living in area with high Primary Resistance to Isoniazid
(H)
2-HRZ + E/S OD, then 4-HR + E/S OD or 3x/wk [DOT]
II. EXTRAPULMONARY TUBERCULOSIS
1) Same as in PTB
2) For Severe Life Threatening Disease (eg. miliary, meningitis, bone, etc)
2-HRZ + E/S OD, then 10-HR + E/S OD or 3x/wk [DOT]
16) BRONCHIAL ASTHMA (GINA GUIDELINES)

CONTROLLED
Daytime Symptoms
Limitation of Activities
Nocturnal Symptoms
(Awakening)
Need for Reliever
Lung Function
Exacerbation
PARTLY CONTROLLED
None
None
None
> 2x / week
Any
Any
< 2x / week
Normal
None
> 2x / week
< 80%
> 1x / year
UNCONTROLLED
3 or more symptoms of
Partly Controlled
Asthma in any week
1x / week
17) RHEUMATIC FEVER:

I. JONES CRITERIA:
A. Major Manifestations
o Carditis (50-60%)
o Polyarthritis (70%)
o Chorea (15-20%)
o Erythema Marginatum (3%)
o Subcutaneous Nodules (1%)
B. Minor Manifestations
o Arthralgia
o Fever
o Laboratory Findings of:
Elevated Acute Phase Reactants (ESR / CRP)
Prolonged PR interval
C. PLUS Supporting Evidence of Antecedent Group-A Strep Infection
o (+) Throat Culture or Rapid Strep-Ag Test
o Elevated or Rising Strep-AB Test
16
2 Major Criteria OR 1 Major and 2 Minor Criteria + Evidence of Preceding Infection
A High Probability of RF EXCEPT in:

o Chorea = manifest LATGE in the Disease (one may not have fever anymore)
o Indolent Carditis = Carditis is NOT Severe, but may have a continuing Infection of Strep
II. TREATMENT OF RHEUMATIC FEVER

A. Antibiotic Therapy
o 10 days of Oral Penicillin or Erythromycin
o 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
III. PREVENTON
A. Primary Prevention
o 10 days of Oral Penicillin or Erythromycin
o IM Injection of Benzethine Penicillin
B. Secondary Prevention
Penicillin G Benzethine
Penicillin V
Sulfadiazine or Sulfasoxazole
Erythromycin
1.2 M units, every 4 weeks IM

250mg BID PO
0.15 OD if < 27kg; or 1g OD if > 27kg
250mg BID PO
C. Duration of Chemoprophylaxis
RF without Carditis
RF with Carditis WITHOUT Residual Heart
Disease
RF with Carditis WITH Residual Heart Disease
5 years or until 21y/o (whichever is longer)

10 years or well into adulthood
At least 10 years since last episode and at least until
40y/o
IV. RHEUMATIC HEART DISEASE

Valve Lesions begin as small verrucae composed of Fibrin and Blood Cells along the borders
of one or more of the heart valves
Verrucae disappear and leave scars
Repeated attacks
New verrucae formation
Mural Endocardium and Chordae Tendinae become involved

**NOTE: Mitral Valve = most commonly involved!
17
V. ASSIGNMENT
PATHOPHYSIOLOGY
CLINICAL
MANIFESTATIONS
TREATMENT
Mitral Insufficiency
Mitral Stenosis
Aortic Insufficiency
Tricuspid Valve
Disease
18) HUMANS MILK VS COWS MILK

I. HUMAN VS COWS MILK
Breast Milk is BEST for Babies
Absolute Contraindication to Breastfeeding = GALACTOSEMIA
Relative Contraindication to Breastfeeding = Lactose Intolerance
HUMANS
Calories
Colostrum
Amount of Water
Casein
Whey
Lactose
Fats
Minerals
Vitamin A
Vitamin B Complex
Vitamin C
Vitamin D
Vitamin K
pH
747 kcal/kg
(+)
Same
3.7 g/L
7 g/L
6.5 7%
45.4 g/L
0.150.25%
0.61 mg/L
--52 mg/L
(-)
Lower
6.8 7.4
COW
701 kcal/kg
(-)
Same
24.9 g/L
7 g/L
4%
38 g/L
0.70.75%
0.27 mg/L
--11 mg/L
(-)
Higher
6.8 7.4
Breastmilk has Less Minerals = Less Solute for the Babys Underdeveloped Kidneys
Breastmilk has Less Vitamin-K = give Vitamin-K IM to prevent Hemorrhagic Disease of the Newborn
According the Prenotes, we have to know this table by Heart
II. ADVANTAGES OF HUMAN MILK:

(+) Lactose (main type of Carbohydrate in breast milk)
(+) Whey (main type of Protein in breast milk) BETTER ABSORBED than Casein
(+) Immunoglobulin
(+) Maternal Body
1. Whey Proteins
Human Milk has MORE Whey Proteins (remain in Solution)
Ratio of Whey: Casein 60:40
2. Fats
Fat Emulsion of Human Milk is Finer
Predominant in Human Milk = Long Chain Unsaturated Fatty Acids
Human Milk is a Better Source of Linoleic Acid
3. Carbohydrates
Lactose = Main Carbohydrate in Human Milk
Bifidus Factor = Group of Carbohydrates - Nitrogen-Containing Complex Carbohydrates
18
4. Minerals
Minerals and Electrolytes in Breast Milk are LOWER than in Cows Milk
Lower Electrolytes = ensure that Sufficient Free Water is available to the Infant
5. Vitamins
Depends on the Maternal Intake
Both Human & Cows Milk contain Large Amounts of Vitamin-A and Minimal Vitamin-D
Breastfed Infants should be routinely given Vitamin-K at Birth as Prophylaxis against
Hemorrhagic Disease of the Newborn (1mg Vitamin-K 1 IM or p.o)
19) JAUNDICE
I. DEFINITION OF TERMS
A. Jaundice
o Yellowish Discoloration of the skin, sclera, and Mucous Membranes of the body
B. Hyperbilirubinemia
o Total Serum Bilirubin Level (TSB) exceeds more than 12mg/dL
o To differentiate between Unconjugated and Conjugated Hyperbilirubinemia = Van den Bergh
Reaction
1. Unconjugated Hyperbilirubinemia
Elevation of Indirect-Reacting or Unconjugated Bilirubin Concentration to > 1.31.5mg/dL
2. Conjugated Hyperbilirubinemia
Elevation in the Direct-Reacting Fraction in the Van den Bergh Reaction to more than
2mg/dL or 20% of Total Serum Bilirubin (TSB)
II. PHYSIOLOGIC JAUNDICE
Physiologic Jaundice: occurs after 36 hours of life
Pathologic Jaundice: occurs within the first 24 hours of life
PHYSIOLOGIC JAUNDICE
Onset > 24HOL, usually on 3rd DOL

TSB Increasing less than 5mg/dL/day
Rate of is < 0.5md/dL/hr
Decline to Adult Levels by the 10th to 12th
DOL
PATHOLOGIC JAUNDICE
Early Onset < 24 HOL
TSB Increasing more than 5mg/dL/day
TST Concentration exceeding 12.9mg/dL (FT)
and >15mg/dL (PT)
DSB > 2mg/dL or 20% of TSB
Persists > 1 week (FT) or > 2weeks (PT)
19
20) GCS SCORING

FUNCTION
Eye Opening
INFANTS & YOUNG CHILDREN

Spontaneous
To Sound / Command
To Pain
None
OLDER CHILDREN
Spontaneous
To Voice
To Pain
None
Verbalization
Appropriate for Age (Flexes, Follows, Social

Smile)
Inconsolable Cry
Persistently Irritable
Restless / Agitated, Lethargic
None
Oriented
Confused
Inappropriate
Incomprehensible
None
5
4
3
2
1
Spontaneous
Localizes Pain
Withdraws
Reflex Flexion
Reflex Extension
None
Obeys
Localizes Pain
Withdraws
Reflex Flexion
Reflex Extension
None
6
5
4
3
2
1
Motor
Total Score
SCORE
4
3
2
1
15
21) SEIZURES
Seizure: sudden event caused by abrupt, uncontrolled, hypersynchronous discharges of neurons

Epilepsy: condition characterized by tendency for recurrent seizures that are unprovoked by an immediate cause
Status Epilepticus: > 30 minutes long OR Back-to-back without return to baseline
Etiology:
o V(ascular): AVM, stroke, hemorrhage
o I(nfectious): meningitis, encephalitis
o T(raumatic)
o A(utoimmune): SLE, vasculitis, ADEM
o M(etabolic/toxic): electrolyte imbalance
o I(diopathic): idiopathic epilepsy
o N(eoplastic)
o S(tructural): cortical malformation, prior stroke, other causes of CP
o S(yndrome): genetic disorder
I. TYPES OF SEIZURES
A. Partial Seizures (Focal / Local)
o Simple Partial
o Complex Partial (Partial Seizure + Impaired Consciousness)
o Partial Seizures evolving to Tonic-Clonic Convulsion)
B. Generalized Seizures
o Absence (Petit mal)
o Myoclonic
o Clonic
o Tonic
o Tonic-Clonic
o Atonic
20
II. SIMPLE FEBRILE SEIZURE vs COMPLEX FEBRILE SEIZURE

Febrile Seizure: A seizure in association with a febrile illness in the absence of a CNS infection or acute
electrolyte imbalance in children older than 1 month of age without prior afebrile seizures
Type
Duration
Recurrence
Neuro Exam
Sequelae
SFS
Generalized Tonic Clonic
< 15 minutes
None during same time
Normal
None
CFS
Focal onset, then Generalized Post-Ictal
> 15 minutes or may even go into Status
Recurrent within 24hours
Abnormal, Post-Ictal
Neurodevelopmental abnormalities
III. CLASSIFICATION BY CAUSE

A. Acute Symptomatic (shortly after an acute insult)
o Infection
o Hypoglycemia, low sodium, low calcium
o Head trauma
o Toxic ingestion
B. Remote Symptomatic
o Pre-existing brain abnormality or insult
o Brain injury (head trauma, low oxygen)
o Meningitis
o Stroke
o Tumor
o Developmental brain abnormality
C. Idiopathic
o No history of preceding insult
o Likely genetic component
IV. SIMPLE FEBRILE SEIZURE

A. Criteria for an SFS
o < 15 minutes
o Generalized-tonic-clonic
o Fever > 100.4 rectal to 101 F (38 to 38.4 C)
o No recurrence in 24 hours
o No post-ictal neuro abnormalities (e.g. Todds paresis)
o Most common 6 months to 5 years
o Normal development
o No CNS infection or prior afebrile seizures
B. Risk Factors
o Febrile seizure in 1st/2nd degree relative
o Neonatal nursery stay of >30 days
o Developmental delay
o Height of temperature
C. Risk Factors for Epilepsy (2 to 10% will go on to have epilepsy)
o Developmental delay
o Complex FS (possibly > 1 complex feature)
o 5% > 30 mins => _ of all childhood status
o Family History of Epilepsy
o Duration of fever
21
22) NECROTIZING ENTEROCOLITIS

I. DEFINITION
A. Etiology: an Interaction of THREE Elements
o Intestinal Injury, usually ISCHEMIA
o BACTERIAL COLONIZATION in the gut
o Presence of Substrate within the Gut Lumen in a Susceptible Infant
B. Clinical Signs and Symptoms
o Signs and Symptoms of SEPSIS
o GI-Symptoms:
Change in Stool Pattern
Occult and Gross Blood in Stools
Vomiting
Abdominal Distention, Tenderness
Erythema of Abdominal Wall
II. RISK FACTORS FOR NEC: 4-Is and 1-N
Ischemia = Asphyxia which then leads to Ischemia of the Bowel
Infection = Common in Babies with Sepsis and Microbes
Immaturity = NEC is Common in Premature Infants (RARE in Term Infants)
Intake or Nutrition = Prematurity defer Early Feeding
22
III. STAGES OF NEC

A. Tabulated Summary:
STAGE
CLASSIFICATION
SYSTEMIC SIGNS
INTESTINAL SIGNS
RADIOLOGY
IA
Suspected NEC
Temperature Instable
Apnea
Bradycardia
Lethargy
Increased Gastric Residues

Mild Abdominal Distention
Normal
Intestinal Dilation
Mild Ileus
IB
Suspected NEC
Apnea
Bradycardia
Lethargy

Normal
Intestinal Dilation
Mild Ileus
Apnea
Bradycardia
Lethargy

Bright Red Blood from Rectum
II A
Proven NEC
Intestinal Dilation
Ileus
Pneumatosis
Intestinalis
May or May not be Present:
(-) Bowel Sounds
Abdominal Tenderness
II B
III A
III B
Proven NEC
Moderately Ill
Advanced NEC
Severely Ill
Bowel INTACT
Advanced NEC
Severely Ill
Bowel PERFORATED
Apnea
Bradycardia
Lethargy
Metabolic Acidosis
Thrombocytopenia

Apnea
Bradycardia
Lethargy
Metabolic Acidosis
Thrombocytopenia
Respiratory Acidosis
Metabolic Acidosis
Hypotension
Bradycardia
DIC
Marked Neutropenia

Absence of Bowel Sound
Definite Abdominal Tenderness
Apnea
Bradycardia
Lethargy
Metabolic Acidosis
Thrombocytopenia
Respiratory Acidosis
Metabolic Acidosis
Hypotension
Bradycardia
DIC


Intestinal Dilation
Ileus
Pneumatosis Intestinalis
HPVG
Ascites may be (+)
Intestinal Dilation
Ileus
HPVG
Definite Ascites
(+) Generalized Peritonitis:
Marked Tenderness
Intestinal Dilation
Ileus
HPVG
Definite Ascites
Pneumoperitoneum
(+) Generalized Peritonitis:
Marked Tenderness
Marked Neutropenia
B. Landmarks in the Stages of NEC

1. Stage I:
Stage IA = Suspected NEC (same as IB)
Stage IB = difference from Stage 1A is that 1B has Bright Red Blood from the Rectum
2. Stage II
Stage IIA = It is PROVEN to be NEC
Stage IIB = is more Toxic than IIA it includes Metabolic Acidosis & Mild Thrombocytopenia
3. Stage III
Stage IIIA = ADVANCED course already very Toxic!
Stage IIIB = In IIIB bowels are already Perforated = Pneumoperitoneum
23
23) PROCEDURES
I. UMBICAT
A. Indications:
o Vascular Access
o BP and ABG monitoring in critically ill neonates
B. Complications:
o Hemorrhage
o Thrombosis
o Ischemia / Infarction of lower extremities, bowel, kidney
o Infection
o Arrhythmias
C. Contraindications
o Omphalitis
o Possible NEC / Intestinal Hypoperfusion
D. Line Placement
1. Low Line VS Highline
a. Low Line
Tip of catheter just above Aortic Bifurcation between L3 and L5
Avoids renal and mesenteric aorta near L1 (decreased incidence of thrombosis)
b. High Line
Tip of catheter above diaphragm between T6-T9
High line recommended in infants < 750g when a low line easily slips out
2. Catheter Length
Determines the length of catheter required using either a standard graph or the regression
formula: Add length for the Height of the Umbilical Stump
Standard Graph: Determine the shoulder-umbilical length by measuring the
perpendicular line dropped from the tip of the shoulder to the length of umbilicus
Birth Weight [BW] Regression Formula:
Low Line: UA Catheter Length (cm) BW [kg] + 7
High Line: UA Catheter Length (cm) (3 x BW [kg]) + 9
E. Procedure
o 1) Determine length of catheter to be inserted
o 2) Restrain infant. Prep and drape umbilical cord and adjacent skin using sterile technique
o 3) Flush catheter with sterile saline solution before insertion
o 4) Place sterile umbilical tape around base of the cord. Cut through cord horizontally about 1.5-2cm from
skin; tighten umbilical tape to prevent bleeding
o 5) Identify the one, large, thin-walled umbilical vein and two smaller, thick-walled arteries. Use one tip of
open, curved forceps to probe and dilate artery gently; use both points of closed forceps and dilate artery
by allowing forceps to open gently
o 6) Grasp catheter 1cm from tip with toothless forceps and insert catheter into lumen of artery. Aim the tip
toward the feet, and gently advance catheter to desired distance. Do not force. If resistance is
encountered, try loosening umbilical tape, applying steady gently pressure or manipulating angle of
umbilical cord to skin. Often catheter cannot be advanced because of creation of a false luminal tract
o 7) Secure catheter with a suture through the cord, a marker tape and a tape bridge. Confirm position of
the catheter tip radiologically. Line may be pulled back, but not advanced once sterile field is broken
o 8) Observe. If any complications occur, line should be removed. NOTE: Infants remain on NPO until 24th
hour after catheter is removed. Never run hypoosmolar fluids through the line. Isotonic fluids should
contain 0.5unit Heparin/mL
24
II. LUMBAR PUNCTURE

A. Indications:
o Identify etiology of CNS infection and monitor subsequent therapy
o Identify subarachnoid bleeding
o Introduce contrast agents into the CSF for diagnostic purposes
o Measure pH, enzymes, neurotransmitters and trace constituents
o Measure and fractionate CSF proteins in suspected immunologic disease especially Multiple Sclerosis or
GBS
o Identify neoplastic invasion or seeding of the subarachnoid space by gliomas, carcinomas, leukemias,
lymphomas
B. Contraindications
o Infection of the Lumbar Skin
o Coagulopathies, Thrombocytopenia
o Cervical Cord Lesions
o Increased ICP or suspected / known Intracranial Mass
o Symptoms of pending Cerebral Herniation with probable meningitis
o Critical Illness
C. Procedure
o Psychological preparation of the patient
o Positioning: Position an acutely ill patient on the side with the legs drawn up and the spine flexed to
increase the distance between the processes and lamina of the adjacent vertebrae
o Palpate the Iliac Crest and slide down to L4 to L5
o Needle Insertion and Manometry:
Scrub skin with antiseptic
Insert a needle in the interspace between the dorsal processes of vertebra L4-L5 or L5-S1
towards the umbilicus
Angle the needle slightly Cephalad, inserting with its bevel turned parallel to the long axis of the
spine
o Collection of the CSF: collect 10-15mL of CSF by allowing several mL to drip into the tubes
1: Gram Stain, Culture and Sensitivity
2: Cell count, Differential count
3: Chemistries Protein, Sugar
4: Special Studies
D. Complications:
o Infection
o Herniation
o Spinal Cord Nerve Damage
o Apnea, Bradycardia
o Hypoxia
E. Normal CSF
o Color: water
o Up to 5/mm3 WBC (NB: up to 15mm 3)
o PMN Cells are always ABNORMAL (In NB, 1-2 PMN may be present)
o No RBCs
o Normal Protein: 10-40mg/dL (child); up to 120mg/dL (in neonates)
F. Differential Count:
APPEARANCE
CELLS (WBC)
GLUCOSE
PROTEIN (mg/100mL)
(mmol/L)
Normal CSF
Viral Infection
Bacterial Infection
TB-Meningitis
Fungal Infection
Cerebral Abscess
GBS (Guillan-Barre)
Clear
Clear
Turbid
Clear & Opalescent
Clear
Clear
Clear
0-5 (Lymphocytes)
25 500
100 20,000
300 500
0 500 (Lymphocytes)
10-60 (Lymphocytes)
Normal
2.2 4.4
> 2.2
< 0.5 1.5
0 2.0
1.0 2.0
Normal
Normal
15 40
50 100
100 200
Up to 300 or More
100 500
20-80
Slight-Marked Increase
25
G. Precautions after Lumbar Tap (Post-LP orders)

o Flat on bed for 4 hours
o NPO for 4 hours
o Monitor VS with BP q15mins x 1h. then q30 mins x 1h. then q1 until stable
III. VACCINATION (DEMO)

VACCINE
AGE
DOSE
BCG-1
Birth (or 6 weeks)
DTP
Polio
Hepatitis B
Measles
BCG-2
Tetanus Toxoid
6 weeks
6 weeks
6 weeks
9 months
School entry
Childbearing women
NO.
0.05mL for newborn

0.1mL for older infants
0.5mL
2 drops
0.5mL
0.5mL
0.1mL
0.5mL
ROUTE
SITE
ID
R deltoid region
3
3
3
1
1
3
IM
PO
IM
SC
ID
IM
Upper outer thigh

Mouth
Anterolateral thigh
Outer upper arm
L deltoid
Deltoid
INTERVAL
BETWEEN
DOSES
4 weeks
4 weeks
4 weeks
1 month;
Then 6-12 months
IV. NEONATAL RESUSCITATION AND ROUTINE NEWBORN CARE

A. Establish Respiration (Resuscitation)
Drying, Warming, Positioning, Suction, Tactile Stimulation
Oxygen
Big-Valve Mask Ventilation
Chest Compression
Intubation
Medication
0
Appearance
Pulse
Grimace
Activity
Respiration
Blue / Pale
Absent
No Response
No Movement (Limp)
Absent
1
Pink Body + Blue Extremities
Slow (<100)
Grimaces
Some Flexion / Extension
Slow / Irregular
2
Completely Pink
>100
Coughs, Sneezes, Cries
Active Movement (All Extremities)
Good, Strong Cry
B. Temperature Regulation
o When we bate Babies in the Incubator, we want to put the baby in the Neutral Thermal Environment (NTE)
o NTE = Range of Environmental Temperature wherein the Body is able to maintain constant temperature with the
LEAST Metabolic Expenditure [NTE (Axilla) = 36.3 37.2 0C]
C. Nursery Care
o Entire Skin and Umbilical Cord is Cleansed with Warm Water and Mild Soap babies are bathed
o Routine Cord Care should be rendered
Check 2 Arteries and 1 Vein
Falling off of the Cord is a Physiologic Change in the Baby

o Vitamin-K 1mg IM Injection to prevent Hemorrhagic Disease of the Newborn
o Credes Prophylaxis with Erythromycin Ophthalmic Ointment to Both Eyes
To prevent Gonococcal or Chlamydial Conjunctivitis
Opthalmia Neonatorium = also known as Conjunctivitis of the Newborn characterized by Redness and
Swelling of Eyelids and Conjunctiva, with Discharfe
o Baby is placed inside Bassinet and Monitor Temperature (36.4 37 0C) to prevent Hypothermia
o Feeding Started, preferably Breastfeeding, as soon as the baby can Suck (to Prevent Hypoglycemia)
Mothers Milk may be given through a Dropper or Gavages done with Caution
Should be Done ONLY if baby is Awake
26
General Rules & Principles
Infant should be Placed in a Crib, Incubator, or under a Radiant Warmer
Infant in Crib should be Swaddled
Inner Shield or Double Walled Incubator to Reduce Radiant

Infants should NOT be removed from Incubator for an extended period of time
V. BALLARDS SCORING
A. Neuromuscular Scoring
B. Physical Maturity
SIGN
-1
Skin
Sticky, Friable,
Transparent
Gelatinous,
Red,
Translucent
Smooth, Pink,
Visible Veins
Lanugo
None
Sparse
Abundant
Plantar
Creases
Heel-Toe=40 to
50mm
Heel-Toe
>50mm
No Creases
Parchment,
Deep
Cracking, No
Vessels
Mostly Bald
Leathery,
Cracked,
Wrinkled
Superficial
Peeling &/or
Rash,
Few Veins
Thinning
Cracking,
Pale Areas,
Rare Veins
Faint Red
Marks
Anterior
Transverse
Crease only
Creases
Over
Anterior 2/3
Creases over
Entire Sole
Raised
Areola,
3-4mm Bud
Formed &
Firm, with
Instant
Recoil
Full Areola,
5-10mm Bud
Bald Areas
*If <40mm = -2
Breast
Imperceptible
Barely
Perceptible
Flat Areola,
No Bud
Stipple Areola,
1-2mm Bud
Eye &
Ear
Lids Fused
Loosely
Lids open,
Pinna Flat,
Stays Folded
Slightly Curved
Pinna, Soft
with Slow
Recoil
Well-Curved
Pinna, Soft but
ready Recoil
*If Tightly = -2
Thick
Cartilage,
Ear Stiff
Male
Genital
Scrotum Flat,
Smooth
Scrotum Empty,
Faint Rugae
Testes in Upper
Canal,
Rare Rugae
Testes
Descending, Few
Rugae
Testes
Down, Good
Rugae
Testes
Pundulous,
Deep Rugae
Female
Genital
Clitoris Prominent,
Labia Flat
Clitoris
Prominent,
Small Minora
Clitoris
Prominent,
Enlarging
Minora
Majora &
Minora Equally
Prominent
Majora
Large,
Minora
Small
Majora cover
Clitoris &
Minora
27

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++PEDIATRICS REVIEWER

ANTHROPOMETRIC MEASURES & WATERLOWS CLASSIFICATION

DESIRED / IDEAL WEIGHT

Weight in kg = Age in Years x 2 + 8

Weight in lbs = Age in Years x 7 + 5

30 inches or 1.5 x Birth

1/2 Mature Height (in

IDEAL HEAD CIRCUMFERENCE

TRANSVERSE-AP DIAMETER RATIO

Better Doctors Pediatrics Reviewer for Junior Interns Batch 2011

Normal > 90%

Normal > 95%

Pink Body + Blue Extremities

Coughs, Sneezes, Cries

Some Flexion / Extension

Active Movement (all

closes at 18 months (as early as 9-12months)

Better Doctors Pediatrics Reviewer for Junior Interns Batch 2011

II. GRADING OF DENGUE

Better Doctors Pediatrics Reviewer for Junior Interns Batch 2011

III. DANGER SIGNS OF DHF

VERY SEVERE (DSS)

Headache, malaise, irritable, but

Irritable, but easily consolable

(+) Signs of Dehydration

(+) Moderate Dehydration with

No signs of Respiratory Distress

(+) Respiratory Distress

Severe Respiratory Distress

(-) Tourniquet Test

(+) Tourniquet Test

(+) Tourniquet Test

No Metabolic or End Organ

No Metabolic or End Organ

(+) Severe Dehydration with

Poor Peripheral Perfusion

Liver / Renal Failure

Repeat if Hematocrit falls after an Initial Rise

Better Doctors Pediatrics Reviewer for Junior Interns Batch 2011

If Platelet Count is BELOW 50,000/cu.mm

Prepare Fresh Whole Blood

If occurs with SHOCK (DIC)

Follow Whole Blood Transfusion with Heparin

B. Classification of Patients with Cough or Difficulty in Breathing:

*No Signs of Pneumonia, or

Better Doctors Pediatrics Reviewer for Junior Interns Batch 2011

III. MODULE 4: FEVER

MORBIDITY IS DUE TO:

IV. MODULE 3: DIARRHEA

2) FEEL SKIN PINCH

Goes back quickly

Goes back slowly

Goes back very slowly

Patient has NO Signs of

If patient has two or

If patient has two or more

B. Treatment Plans (30ml = 1 ounce)

Better Doctors Pediatrics Reviewer for Junior Interns Batch 2011

V. MODULE 5: MALNUTRITION / ANEMIA

*Not very low Weight for Age

*Assess childs feeding and counsel the mother on

*If child is < 2y/o, assess feeding &counsel mother on

Better Doctors Pediatrics Reviewer for Junior Interns Batch 2011

VI. MODULE 6: IMMUNIZATIONS