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Normal Vital Signs for Children (Nelson Textbook of Pediatrics, 18th ed.

) Age Heart Blood Respiratory Rate Pressure Rate Prematu 120-170 55-75/35-45 40-70 re 0-3 mos 100-150 65-85/45-55 35-55 3-6mos 90-120 70-90/50-65 30-45 680-120 80-100/5525-40 12mos 65 1-3yrs 70-110 90-105/5520-30 70 3-6yrs 65-110 95-110/6020-25 75 6-12yrs 60-95 100-120/6014-22 75 12yrs 55-85 110-135/6512-18 85

Pediatric Community Acquired Pneumonia (CPG in the evaluation and management of PCAP, 2004)
Variables 1. Comorbid illness 2. Complian t caregiver 3. Ability to follow-up 4. Presence of DHN 5. Ability to feed 6. Age 7. RR: 2-12 mos 1-5 years > 5 years PCAP A None Yes Possible None Able >11 mos. 50/min 40/min 30/min PCAP B Present Yes Possible Mild Able >11mos 50/min 40/min 30/min PCAP C Present No Not Possible Moderate Unable <11mos. >60/min >50/min >35/min PCAP D Present No Not Possible Severe Unable <11mos. >70/min >50/min >35/min

8. Signs of respiratory failure a. Retractio n b. Headbob bing c. Cyanosis d. Grunting e. Apnea f.Sensorium

None None None None None Awake

None None None None None Awake

Intercostal/ subcostal Present Present None None Irritable

Supraclavicul ar/ Intercostal/ Subcostal

Present Present Present Present Lethargy/ Stupurous/ Comatose Present Admit to critical care unit Refer to specialist


Complica tions

None OPD Follow up at end of treatment

None OPD Follow up after 3 days

Present Admit to regular ward

10.Action Plan

Dehydration Classification 2 of the following signs: - Lethargic or unconscious - Sunken eyes - Not able to drink or drinking poorly - Skin pinch goes back very slowly Sever Dehydration If child has no other severe classification: - Give fluid for severe dehydration (Plan C) OR If child also has another severe classification:

Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way. Advise the mother to continue cholera If child is 2 years or older and there is cholera in your area, give antibiotic for cholera 2 of the following signs: - Restless, irritable - Sunken eyes - Drinks eagerly, thirsty - Skin pinch goes back slowly Some Dehydration Give fluid and food for some dehydration (Plan B) If child also has a severe classification: - Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way. Advise the mother to continue breastfeeding Advise mother when to return immediately Follow-up in 5 days if not improving

Not enough signs to classify as some or severe dehydration

No Dehydration

Give fluid and food to treat diarrhea at home (Plan A) Advise mother when to return immediately Follow up in 5 days if not improving

How to test for skin turgor Locate the area on the childs abdomen halfway between the umbilicus and the side of the abdomen. To do the skin pinch, use your thumb and first finger. Do not use your fingertips because this will cause pain. Place your hand so that when you pinch the skin, the fold of skin will be in a line up and down the childs body and not across the childs body. Firmly pick up all of the layers of skin and the tissue under them. Pinch the skin for one second and then release it. When you release the skin, look to see if the skin pinch goes back: very slowly (longer than 2 seconds) slowly (skin stays up even for a brief instant) immediately If the skin stays up for even a brief time after you release it, decide that the skin pinch goes back slowly. 4 Rules of Home Treatment: Give Extra Fluid, Give Zinc Supplements, Continue Feeding, When to Return

Treatment Plan A 1. Give Extra Fluid Breastfeed frequently Give ORS or clean water in addition to breastmilk Teach the mother how to mix and give ORS. Show the mother how much fluid to give in addition to the usual fluid intake: o Up to 2 yrs 50 to 100 ml after each loose stool and between them 2 yrs or more 100-200 ml after each loose stool and between them

o -

Tell mother to o o Give frequent small sips from a cup If the child vomits, wait 10 minutes. Then continue, but more slowly Continue giving extra fluid until the diarrhea stops

2. Give Zinc supplements Tell the mother how much Zinc to give o o Up to 6 mos 10mg elemental Zn per day for 14 days 6 mos or more 20mg elemental Zn per day for 14 days

Remind the mother to give Zn supplements for the full 14 days

3. Continue Feeding

4. When to return...

Treatment Plan B Give in-clinic recommended amount of ORS over 4-hour period 75ml/kg body weight Reassess the child after 4 hours and reclassify the child for dehydration then select appropriate plan to continue treatment If the mother must leave before completing treatment o o Show how to prepare ORS Show how much ORS to give to finish 4-hour treatment at home Give enough ORS packets to complete rehydration Explain 4 rules of Home treatment

o o

Age-Specific Blood Cell Indices

MCHC(g /dL RBC) WBCs (x103/ uL) Platel ets (103/u L) 254 (180327) 275 290 290


Hb(g/ dL)

HCT (%)

MCV( fL)

Reticuloc ytes

26-30 wk gestati on 28 wk 32 wk Term 13.4(1 1) 14.5 15.0 16.5

41.5 (34. 9) 45 47 51

118.2 (106.7 ) 120 118 108

37.9 (30.6) 31 32 33.0

4.4 (2.7) 18.1

(5-10) (3-10) (3-7)

(cord) 1-3 day 2 wk

(13.5) 18.5 (14.5) 16.6 (13.4) 13.9 (10.7) 11.2 (9.4) 12.6 (11.1) 12.0 (10.5) 12.5 (11.5) 13.5 (11.5)

(42) 56 (45) 53 (41) 44 (33) 35 (28) 36 (31) 36 (33) 37 (34) 40 (35)

(98) 108 (95) 105 (88) 101 (91) 95 (84) 76 (68) 78 (70) 81 (75) 86 (77)

(30.0) 33.0 (29.0) 31.4 (28.1) 31.8 (28.1) 31.8 (28.3) 35.0 (32.7) 33.0 (30.0) 34.0 (31.0) 34.0 (31.0) MCHC(g /dL RBC) (1.8-4.6)

(9-30) 18.9 (9.434) 11.4 (5-20) 10.8 (419.5) 11.9 (0.7-2.3) (617.5) 10.6 (6-17) 8.5 (515.5) 8.1 (4.513.5) Reticuloc ytes WBCs (x103/ uL) (150350) (150350) (150350) Platel ets (103/u L) 192


1 mo


2 mo

6 mo 6mo2yr 2-6yr





Hb(g/ dL)

HCT (%)

MCV( fL)

1218yr Male 14.5 (13) 14.0 (12) 15.5 43 (36) 41 (37) 47 88 (78) 90 (78) 90 34.0 (31.0) 34.0 (31.0) 34.0 7.8 (0.5-1.0) (4.513.5) 7.8 (0.5-1.0) (4.513.5) (0.8-2.5) 7.4 (150350) (150350) (150-

Female Adult Male

(13.5) 14.0 (12)

(41) 41 (36)

(80) 90 (80)

(31.0) 34.0 (31.0)

(4.511) 7.4 (0.8-2.5) (4.511)

350) (150350)


Growth and Caloric Requirements Ag e Approxim ate Weight gain (g) Approxim ate monthly weight gain 0-3 mo 3-6 mo 6-9 mo 912 mo 1-3 yr 4-6 yr Autistic Disorder A. A total of 6 or more items from 1, 2, and 3, with at least 2 from 1 and 1 each from 2 and 3: 8 6 8 oz 6 oz 1.0 3cm/yr 0.25 1cm/yr 100 90-100 30 20 15 12 2 lbs 1.25 lb 1 lb 13 oz Growt h h (cm/m o) 3.5 2.0 1.5 1.2 Lengt Growth in Recommen ded Daily Circumfer ence (cm/mo) 2.00 1.00 0.50 0.50 Allowance (Kcal/kg/d ay) 115 110 100 100 in Head

1. Qualitative impairment in social interaction, as manifested by at least 2 of the following: a. Marked impairment in the use of multiple nonverbal behaviors, expression, such body as eye-to-eye and gaze, facial to postures, gestures

regulate social interaction b. Failure to develop peer relationships appropriate to developmental level c. Lack of spontaneous seeking share enjoyment, interests, or achievements with other people (e.g. by a lack of showing, bringing, or pointing out objects of interest) d. Lack of social or emotional reciprocity 2. Qualitative impairments in communication, as manifested by at least 1 of the following: a. Delay in, or total lack of, develppment of spoken language (not accompanied by an attempt to compensate b. In individuals through with alternative modes of communication, such as gesture or mime) adequate speech, marked impairment in ability to initiate or sustain a conversation with others c. Sterotyped and repetitive use of language or idiosyncratic language d. Lack of varied, spontaneous make-belive play or social imitative play appropriate to developmental level

3. Restricted,






behavior, interests, and activities, as manifested by at least 1 of the following: a. Encompassing preoccupation with >/= 1stereotyped and restricted pattern of interest that is abnormal in either intensity or focus b. Apparently inflexible adherence to specific, nonfunctional routines or rituals c. Steroetyped and receptive and repetitive motor mannerisms (e.g. hand or finger flapping or twisting or complex whole body movements) d. Persistent preoccupation with parts of objects B. Delay or abnormal functioning in at least 1 of the following areas, with onset < age 3yr. (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play C. The disturbance is not better accounted for by Rett disorder or childhood disintegrative disorder
Table 1. Comparison of the Current WHO/PPS Case Definition and Case Classification for Dengue with the Proposed 2009 WHO Case Classification

CURRENT WHO Case Definition of Dengue and Levels of Severity (1997) as adapted by the PPS Clinical Practice Guidelines on Dengue 2008 Case Definition for Dengue Fever Probable: an acute febrile illness with 2 or more of the following: Headache Retro-orbital pain Arthralgia Rash Hemorhagic manifestations Leukopenia; AND Supportive serology ( a reciprocal HI antibody titer >1280, a comparable IgG assay ELISA titer or (+) IgMantibody test on a late or acute convalescent phase serum specimen Confirmed: A case confirmed by laboratory criteria Case Definition for Dengue Hemorrhagic Fever (DHF) The following must all be present: 1. Fever, or history of fever, lasting for 2-7 days, occasionally biphasic 2. Hemorrhagic tendencies evidenced by at least one of the following: a. (+) tourniquet test b. Petechiae, ecchymosis, purpura c. Bleeding from the mucosa, GIT, injection sites or other locations d. Hematemesis or melena 3. Thrombocytopenia ( 100,000 cells/mm3 or less) 4. Evidence of plasma leakage due to increased vascular permeability, manifested by at least one of the following: a. A rise in the hematocrit equal to or greater than 20% above average for age, sex, and population b. A drop in the hematocrit following volume replacement treatment equal to or greater than 20% of baseline c. Sins of plasma leakage such as pleural effusion, ascites and hypoproteinemia

PROPOSED WHO Classification and Levels of Severity 2009 Nonsevere Dengue without Warning signs Probable dengue: live in /travel to dengue endemic area. Fever and 2 of the following criteria: Nausea, vomiting Rash Aches and pains Tourniquet test positive Leukopenia

Laboratory-confi rmed dengue (important when no sign of plasma leakage)