Peadiatric Handbook

Paediatric Posting HSNI:

Neonatal survival kit for Houseman Dr Fitri Fareez bin Ramli

2

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.

3

Table of contents

Page

Hypoglycemia 5 Fluid requirement in neonates 8 Neonatal jaundice 10 Prolonged jaundice 14 Congenital hypothyroidism 17 Newborn with respiratory distress 21 Neonatal sepsis 23 Childhood developmental milestone 25 Immunization 39 Commonly used medication in neonates 41 Appendix 42 References 45

4

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

5

Hypoglycemia What is hypoglycemia? Blood glucose level 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).

6

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 2.6mmol/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.

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4VIWGVMTXMSRXSQEOIYTEQ0WSPYXMSRSJZEVMSYWHI\XVSWIMRJYWMSRWInfusion concentration Volume of 10% Dextrose Volume of 50% Dextrose

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

7

If glucose delivery > 8 -10mg/kg/min and 4IVWMWXIRX,]TSKP]GEIQMEIV Glucagon 40 mcg/kg stat then 10-50mcg/kg/h. 2SXXSFIYWIHMR7+%SVEHVIREPMRWYJGMIRG]IV Hydrocortisone 2.5 - 5 mg/kg/dose bd in others, IWT7+%43(ME^S\MHIQKOKHE]MRHMZMHIHHSWIW9WIJYPMRL]TIVMRWYPMREIQMERSXXSFIYWIHMR7+%SC Octreotide 2 10 mcg/kg/day 2 - 3 times/day or as infusion.

BG < 1.5 mmol/Lor symptomatic

Hypoglycaemia Blood Glucose (BG) < 2.6 mmol/L

IV 10% Dextrose 2-3 ml/kg bolus

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

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BG 1.5 < 2.6mmol/LERH asymptomatic (0-4 hours of life)

Give supplement feeding ASAP

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

,Re-evaluate *

Increase 'SRGIRXVEXMSR to D12.5%-D15%#

,Re-evaluate *

Increase :SPYQI by 30ml/kg/day

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* If BG < 1.5mmol/L or symptomatic :+MZI-:(QPOKFSPYWXLIRTVSGIIH[MXLS[GLEVX

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2SXI3RGI&PSSH+PYGSWIPIZIP"QQSP0JSVVIEHMRKWQSRMXSVLSYVP]\XLIRLSYVP]\XLIRLSYVP]

8

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

9

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

10

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.

11

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.

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Guidelines for phototherapy: Total serum bilirubin Birth Weight (gram)

D1 D2 D3 D4 D5 D6 D7 ET LEVEL

< 1000

5.9 5.9 5.9 5.9 8.2 8.2 10.6 11.8

1000-1249

5.9 5.9 5.9 8.8 8.8 10.0 12.9 14.7

1250-1499

8.8 8.8 8.8 10.6 12.9 12.9 12.9 17.6

1500-1749

10.6 10.6 10.6 12.9 12.9 14.1 14.1 19.4

1750-1999

10.6 10.6 12.9 14.1 14.1 14.1 14.1 19.4

2000-2499

10.6 12.9 12.9 16.5 16.5 16.5 16.5 23.5

>2500 11.8 12.9 14.7 16.5 17.6 17.6 17.6 25.3

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.

Criteria for discharge: a. Child generally well and able to tolerate breastfeeding well. b. Stable vital signs. 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,

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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.

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Prolonged Jaundice

What is the definition of prolonged jaundice? Jaundice > 14 days in term infant > 21 days in preterm infant. What are the causes?

Approach: a. As stated above, use the clerking sheet that is provided by Paediatric Department of HSNI. b. Perform history taking and physical examination.

Chapter 22: Prolonged Jaundice in Newborn Infants

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'EYWIWSJ4VSPSRKIH.EYRHMGIUnconjugated Hyperbilirubinaemia Conjugated Hyperbilirubinaemia

Septicaemia &MPMEV]XVIIEFRSVQEPMXMIWUrinary tract infection Biliary atresia - extra, intra-hepaticBreast milk jaundice Choledochal cystHypothyroidism Paucity of bile ducts ,IQSP]WMW Alagille syndrome, non-syndromic+4(HIGMIRG] Idiopathic neonatal hepatitis syndromeCongenital spherocytosis SepticaemiaGalactosaemia Urinary tract infection

Gilbert syndrome Congenital infection (TORCHES)

1IXEFSPMGHMWSVHIVW'MXVMRHIGMIRG]GalactosaemiaWrogressive familial intrahepatic cholestasis (PFIC)

%PTLEERXMXV]TWMRHIGMIRG]Total Parenteral Nutrition

8LIIEVP]HMEKRSWMWERHXVIEXQIRXSJFMPMEV]EXVIWMEERHL]TSXL]VSMHMWQMWMQTSV-XERXJSVJEZSYVEFPIPSRKXIVQSYXGSQISJXLITEXMIRX

hK/d&D^ &'W E ^d^, result if done at birth). See , t:. Infant must be well, gaining weight appropriately, breast-feeds well and stool is yellow. Management is

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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.

Prolonged Jaundice

Send blood for TSB

Direct bilirubin > 15% of TSB

No (unconjugated hyperbilirubinemia) Yes (conjugated hyperbilirubinemia

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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

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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. What are the possible causes:

What are the clinical presentations? It is usually asymptomatic at birth! Some infant may represent as prolonged neonatal jaundice. If it left untreated, the signs and symptoms stated below may be manifested:

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

Chapter 54: Congenital Hypothyroidism

// /D It is the commonest preventable dE during the prenatal and early postnatal period.D and bones.

Clinical diagnosisD^ Prolonged neonatal jaundiceA quiet baby Enlarged fontanelleRespiratory distress with feedingAbsence of one or both epiphyses y/ facies, dry skin, macroglossia, hoarse cry, umbilical hernia, lethargy, slow movement, hypotonia and delayed developmental milestones.D on all newborns.

Treatment

d^/ hypothyroidism are present, treatment is started urgently.

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Causes of Congenital Hypothyroidism

Thyroid dysgenesis (85%)

Athyreosis (30%)

Hypoplasia (10%)

Ectopic thyroid (60%)

Other causes (15%)

Inborn error of thyroid hormone synthesis (1:30,000)

Hypothalamo-pituitary defect (1:100,000)

Peripheral resistance to thyroid hormone (very rare)

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

Endemic cretinism

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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).

19

Treatment of congenital hypothyroidism:

d. Congenital hypothyroidism should be treated immediately. Start as early as possible (Not > 2 weeks)

NORMAL

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CLINICAL EVALUATIONs&dd^,

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TSH HighFT4 Normal

TSH NormalFT4 Low

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TSH NormalFT4 Normal

Differential Diagnosis

Primary hypothyroidism, delayed TSH rise

Hypothalamic immaturity

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Sick neonate

CORD BLOOD SAMPLECollected at Birth

SCREENING FOR CONGENITAL HYPOTHYROIDISM

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Doses of L- Thyroxine by age

Age mcg/kg/dose, daily

0 3 months 10 15

3 6 months 8 10

6 12 months 6 8

1 5 yr 5 6

6 12 yr 4 5

> 12 yr 2 3

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.

' 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 d^,h> ^&dd^, ^d^,h>&d, 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 87,"Q90"SRGIMRVWX]IEV

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21

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).

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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.

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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 Minor Chorioamnionitis + Vaginal swab or urine culture Maternal fever >38.5 Maternal fever> 38 PROM > 24 H PROM > 18 H and < 24 H Persistent fetal tachycardia Prematurity Twin What are the signs and symptoms of sepsis? a. Temperature: hypo or hyperthermia b. CNS: irritability, lethargy, change in tone c. Skin: poor perfusion, mottling, pallor, jaundice, scleraema, petechiae, d. Respiratory: apnea, tachypnea, cyanosis, respiratory distress. e. CVS: tachycardia, hypotension. f. GI: poor feeding, vomiting, diarrhea, abdominal distention. g. Metabolic: hypo or hyperglycemia, metabolic acidosis. Investigation (as indicated): a. FBC with differential count. b. CRP, Blood culture and sensitivity c. Chest X-ray, Abdominal X-ray. d. Urine FEME and C&S. e. Lumbar puncture. f. RBS Interpretation of Cerebrospinal fluid (CSF) a. Calculate the CSF :plasma glucose ratio ( Glucose level in CSF divides RBS).

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

Management:

a. Empirical antibiotics: Early onset i. First line: IV C.Penicillin and IV Gentamycin. ii. Second line: Cefotaxime and IV Amikacin iii. Specific choice when specific organism suspected /confirmed. Late onset i. Community acquired: Cloxacillin/Ampicillin and Gentamicin for non- CNS infection and for CNS infection use C.Penicillin and Cefotaxime. ii. Hospital acquired:

MRSA/MRCoNS: Vancomycin Non-ESBL gram negative rods: cephalosporins ESBL: carbapenams Pseudomonas: Ceftazidime. Anaerobic: metronidazole.

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.

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'IVIFVSWTMREPYMHZEPYIWMRRIYVSPSKMGEPHMWSVHIVW[MXLJIZIVCondition Leukocytes

(mm)Protein (g/l) Glucose

(mmol/l)Comments

Acute Bacterial Meningitis

100 - >50,000 Usually 1- 5 1 Low CSF may be sterile in Pneumococcal, Meningococcal meningitis

Tuberculous Meningitis

10 - 500Early PMN, later high lymphocytes

1- 5 0 - 2.0 Smear for AFB, TB PCR + in CSF;High ESR

Fungal Meningitis

50 500 Lymphocytes

0.5 - 2 Normal or low

CSF for Cryptococcal Ag

Encephalitis 10 - 1,000 Normal / 0.5-1

Normal CSF virology and HSV DNA PCR

Recommended antibiotic therapy according to likely pathogen

Age Group Initial Antibiotic

Likely Organism Duration(if uncomplicated)

< 1 month C Penicillin + Cefotaxime

+VT&7XVITXSGSGGYW)GSPM

21 days

1 - 3 months C Penicillin + Cefotaxime

+VSYT&7XVITXSGSGGYW)GSPM,MRYIR^EI7XVITTRIYQSRMEI

10 21 days

> 3 months C Penicillin + Cefotaxime, OR Ceftriaxone

,MRYIR^EI7XVITTRIYQSRMEI2QIRMRKMXMHIW

7 10 days10 14 days

7 days

2SXI6IZMI[ERXMFMSXMGGLSMGI[LIRMRJIGXMZISVKERMWQLEWFIIRMHIRXMIHCeftriaxone gives more rapid CSF sterilisation as compared to Cefotaxime or Cefuroxime. If Streptococcal meningitis, request for MIC values of antibiotics. 1-'PIZIP(VYKSJGLSMGI1-' QK0WIRWMXMZIWXVEMR'4IRMGMPPMR1-' QK0VIPEXMZIP]VIWMWXERX'IJXVME\SRISV'IJSXE\MQI1-'"QK0VIWMWXERXWXVEMR:ERGSQ]GMR'IJXVME\SRISV'IJSXE\MQI4. Extend duration of treatment if complications e.g. subdural empyema, brain abscess.

25

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 briefly in the same plane as body. Pull to sit: Head lag, rounded back. Prone: Pelvis high, knees no longer under abdomen. Chin raised occasionally. 3 Months

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

26

6 Months

Pull to sit: Lift head in anticipation. Rolls prone to supine. Prone: Supports weight on hands; chest, upper abdomen off couch.

Sits with support. 9 months

Pull self to sit Sits steadily. Stands holding on. 1 year

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

27

18 months

Carries doll Pulls toys Gets up and down stairs holding on to rail or with one hand held

Sits on a chair Throws ball without falling 2 years

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

28

3 years

Able to go upstairs, 1 foot per step and goes downstairs, 2 feet per step. Jumps off bottom step. Stands on 1 foot for seconds. Rides tricycles.

4 years

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

5 years

Skips on both feet. Runs on toes.

29

Fine motor 6 weeks 3 months

Fixates and follow to 90 degree. Hand regards. Grasp object in hands. Follow object from side to side. 5 months

Reaches object. Plays with toes 6 months

Palmar grasp. Move head, eyes in all directions.

30

9 months 1 year

Inferior pincer grasp (scissors grasp) Bangs 2 cubes. Neat pincer grasp. 18 months

Tower of 3 cubes. Scribbles spontaneously. Visual test: Picture charts. 2 years

Tower of 6 cubes. Imitates cubes of train without chimney. Imitates straight line.

31

3 years

Tower of 9. Imitates bridge with cubes Able to copy 0 and imitates +. Draw a man test. 4 years

Copies square. Imitates gate with cubes. 4.5 years: Copies gate with cubes, Copies +. Draw recognizable man and house. 5 years

Draw X Draw triangle (5.5 years)

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W Anthropometric measurement General alertness and response to surrounding Dysmorphism >E^ Ask child to draw something he or she likes (this can help to get a clearer picture about intellect of the child)

W&Wd^DD)Age d Pencil Test3 - 3.5 yrs Draw a circle3.5 - 4 yrs Draw a cross

3 - 4.5 yrs Draw a square Draw a triangledW

Common causes ,^>' Fragile X Hypothyroidism Intellectual impairment dENeurological Seizures E

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Speech/Language 6 weeks

Vocalizing at 8 week Quiets and startle to sound. 3 months

Squeals with delight. Turn head to sound 9 months 1 year Ma-ma Pa-pa Su-su Localizes sound at 3 feets above and below the ear level. 2-3 words with meaning. 18 months

Points to 2-3 body parts Pictures cards identify one.

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2 years

Saya nak makan Nak makan

Points to 4 body parts. Names 3 objects. 2-3 words sentences Obeys 4 simple commands Uses I, you and me. 3 years

Knows 2 colors. Understands on, in and under. Can count to 10. 4 years

Names 3 colors. Understands in front, between and behind. Fluent conversation.

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5 years

Knows 4 colors. Knows AGE. Tell the time Social 6 weeks 3 months 5 months

Smiles responsively. Laughs Mouthing 9 months

Feeds with spoon occasionally Understands NO Looks for fallen toys

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1 year

Shy Less mouthing 18 months

Toilet trained Imitates housework Uses spoon well 2 years

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

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3 years

Play with other children. Dresses and undresses with help Dry by night. 4 years

Button clothes fully. Attends to own toilet needs. 5 years

Tie shoelaces. Dresses and undresses alone.

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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

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Management: Speech and language therapy Occupational therapy Physical therapy

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Immunization:

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40

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41

Commonly used medications in neonates IV C.Penicillin: 100 000 U/kg BD 100 000 U/kg QID (meningitis) IV Gentamycin: 4 mg/kg OD (Term) 4mg/kg 36 hourly (Prem) Amikacin 7.5 mg/kg/OD 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) Cefipime IV/IM 25 mg/kg BD Severe infection: IV 50mg/kg BD/TDS

Cefuroxime: IV 25 mg/kg TDS Severe infection: IV 50 mg/kg BD (1st week life) IV 50 mg/kg 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)

Meropenem 10-20 mg/kg TDS Severe infection: 20-40 mg/kg BD (1st week) 20-40 mg/kg TDS (>1st week) Frusemide Oral/IM/IV 0.5-1 mg/kg 6-24 hourly 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 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

IV Ranitide 1 mg/kg 6-8 hourly

Elemental Iron Premature: 2-3mg/kg/day Folic acid Oral 1 mg OD

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Appendix

Scalp Swelling in neonates:

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 resolve. 3. Subgaleal or Subaponeurotic bleed : Collection of blood in soft tissue space under the aponeurosis. Diffuse swelling, crossing suture line. May associated with severe blood loss, shock, anaemia or seizure.

EKE

d>

K'z AlkalosisK

Measurement of Acid Base Status E pH 7.34-7.45 WK , ,K3 - > PaO , > /',acidosis/WK,Kmetabolic acidosis./WK,Krespiratory acidosis./WKmixed metabolic and repiratory acidosis.,/WK/,Kopposite mechanism.>WKWKWWK2,>WKWKManagement of Metabolic Acidosis and Alkalosis Treat underlying cause when possible. d,d s>E^ be used to treat acidosis unless there are signs of hypovolemia. A volume load is poorly tolerated in severe acidosis because of decreased myocardial E,K such as diarrhea or renal tubular acidosis. E,K Dose in mmol of NaHCO3 E,KtE,KK

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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.

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

Peadiatric Handbook

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