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MacPeds Pediatric Survival Guide For Residents and Clinical Clerks 2013-‐2014 Editor: Dr. Moyez B. Ladhani TABLE OF CONTENTS ADMINISTRATIVE INFORMATION Page § Welcome to Pediatrics! ……………………………………………………….4 § McMaster Pediatrics Contact Information …………………………………..5 § Paging, RTAS Information ……………………………………………………7 § McMaster CTU 1/2 Pediatrics Expectations and Weekly Schedule…… ..8 § Allied Health Contact Numbers………………………………………………12 § Resources: Handbooks, PDA, Websites …………………………………..14 § Dictation Instructions ………………………………………………………... 18 § Pediatrics Staff Dictation Codes and Pagers …………………………….. 19 PEDIATRICS AT ST. JOSEPH’S HEALTHCARE § SJH Pediatrics Contact Information, Paging, Door Codes, Library…….. 26 § SJH CTU 4 Expectations and Weekly Schedule ………………………… 27 § Accommodation Services, On-call, Dictating……………………………... 30 § SJH Instructions for Listening to Dictated Reports …………………….... 33 PEDIATRIC INFORMATION § History & Physical Examination Outline …………………………………... 34 § pGALS-A Screening Examination of the MSK system…………………… 41 § Growth Charts………………………………………………………………… 48 § Adolescent History ………………………………………………………….. 58 § Birth Weight Conversion Chart (lbs/oz à kg) ……………………………. 61 § Admission Orders …………………………………………………………… 62 § Progress Note Template – Pediatrics …...………………………………… 63 § Documentation ………………………………………………………………64 § Mandatory Reporting of Child Abuse…………………………………….. 66 § Discharge Summary Template – Pediatrics ……………………………… 67 § Fluids & Electrolytes ……………………………………………………….... 69 § Developmental Milestones …………………………………………………. 78 § Immunization Schedule …………………………………………………….. 81 NEONATOLOGY 77 § St Joes common terms and definitions……………………………………..85 § Progress Note Template – Neonatal ………………………………………87 § Discharge Summary Template – NICU / Level 2 Nursery ………………. 88 § Neonatal Resuscitation Algorithm …………………………………………. 92 § Neonatal Resuscitation Drugs ……………………………………………... 93 § Neonatal Nutrition Guidelines à Enteral ………………………………….94 à TPN ……………………………………. à Vitamins and Minerals ……………….. § Prevention of Perinatal Group B Streptococcal Disease …………...…… 103 § Hypoglycemia Guidelines for At-Risk Newborns …………….………….. 106 § Hyperbilirubinemia (Jaundice) In Newborn Infants ≥ 35 Weeks ……….. 112 § Phototherapy Guidelines for < 35weeks or < 2500 grams………………..134 § Management of Hypernatremia in a Breastfed Infant……………………. 136 FORMULARY 137 § Abbreviation Guidelines – HHSC ………………………………………….. 138 § Safer Order Writing …………………………………………....................... 140 § Antibacterials ………………………………………………………………… 141 § Pediatric Formulary ……………………………………………………….. 154 § Opiod Analgesic Equivalence………………………………………………. 171 § § § Systemic Steroid equivalence……………………………………………… 172 PPI comparison chart……………………………………………………….. 173 Pediatric Nutrition Formulary.............................................................. 174 Table of Contents Continued. PEDIATRIC EMERGENCY MEDICINE…………………………………………177 § PALS Algorithms …………………………………………………………….. 178 § PALS Algorithm Medications …………………………………………......... 181 § Status Epilepticus Algorithm ……………………………………………….. 183 § Diabetic Ketoacidosis Guidelines ………………………………….. ……... 187 Pediatric Vital Signs and Glasgow Coma Scale (GCS) ………………………189 ORDER SETS……………………………………………………………………. 190 Bronchiolitis………………………………………………………………………. 191 Croup……………………………………………………………………………… 193 Dehydration……………………………………………………………………….. 196 Prevention of Maternal-Infant HIV Transmission………………………………200 Asthma……………………………………………………………………………. 201 UTI…………………………………………………………………………………. 204 WELCOME TO MacPeds! This handbook was designed for the large number of residents from a variety of disciplines that rotate through pediatrics during their first year of training. It may also be helpful for clinical clerks during their time on the pediatric wards, as well as for pediatric residents and elective students. Hopefully this demystifies some of the ‘pediatric specific’ logistics, and gives a few practical suggestions for drug dosages and fluid requirements. This is intended only to act as a guideline for general pediatrics use, and some drugs, doses, indications and monitoring requirements may differ in individual situations. I would like to thank Nicole Clarke and Melani Sung for compiling and editing the pediatric formulary section and Lori Chessell and Connie Stuart for compiling the Neonatal Nutrition Section. The Drug Formulary in this book is intended for pediatric patients only. For neonatal drugs to be used in the neonatal nurseries please refer to the neonatal drug book in the neonatal nurseries. I would very much appreciate any feedback, suggestions or contributions emailed to [email protected] Sincerely, Moyez B. Ladhani Editor Permission to copy and distribute this document is granted provided that (1) the copyright and permission notices appear on all reproductions; (2) use of the document is for non-commercial, educational, and scientific purposes only; and (3) the document is not modified in any way. MacPeds Survival Guide 4 McMaster PEDIATRICS CONTACT INFORMATION Wards 3B Back 76123, 76120 3C North 76345, 76344 3CSouth 73388, 76972 L2N 73753 NICU 76147 L&D 75050 4C Nursery 76354 PCCU 72610, 75692 Eating Disorder Unit 73289 Clinical 3F clinic 2G clinic 2Q clinic OR Reception PACU Short Stay Radiology MRI CT scan Ultrasound EEG 4U ECHO 2F GI – pH probe MacPeds Survival Guide 75012 75011 75094, 75095 75645 75653 75564 75279 75059 73728-room 75287-reception 75316 76363 75097 Labs Stat Lab Bloodbank Coagulation Microbiology Pathology 76303 76281 76288 76311 76327 Administration Paging Admitting Bed Booking Health Records Computer support Appointments Info Desk Security Room bookings 76443 75100 75106 75112 43000 75051 75266 76444 22382 5 Program Assistants Postgraduates: Shirley Ferguson 28023 [email protected] Adriana Flaiani 21931 [email protected] Sandy Murray 21882 [email protected] Undergrad (clerks) Kim Babin 21954 [email protected] BCT residents: Colleen Willson 26660 [email protected] Family med residents: Jennifer Frid 76024 [email protected] Wendy Milburn 905-575-1744 x203 [email protected] CTU Skye Levely [email protected] 75639 Chief Residents – Pediatrics [email protected] MacPeds Survival Guide 6 PAGING To page someone from within the hospital: 1. dial 87 2. enter person’s pager number (4 digits) 3. enter call-back extension (5 digits) 4. enter priority code (∗ * then 1 for CODE/STAT, 2 for ROUTINE, 3 for ANYTIME, 4 denotes PHYSICIAN paging) If you don’t know their pager #, wish to leave a typed message or to wait on an outside line: call x76443 To inactivate/activate your own pager: 1. dial 87 2. enter your own pager # 3. dial 08 RTAS (Rapid Telephone Access System) • For retrieval of dictated radiology reports not yet typed on Meditech Internal access x75077 To access from outside (905) 521-5077 Security code 4123# Patients ID # (9 digits) 1 – stop report 2 – resume play 3 – rewind 4 – slow down speed 5 – disconnect from system 6 – speed up 8 – next report 0 – go to start of report MacPeds Survival Guide 7 Division of General Pediatrics CTU 1, CTU 2, Weekly Schedule Handover: Handover is to take place from 0715-0745 hrs. It is therefore important to complete a succinct handover within the allotted 30 minutes. The senior residents will meet with the charge nurses from 3B/3C/3Yto review potential discharges at 9:15am. Discharge Rounds: Discharge rounds will be a brief meeting with the attending paediatrician, and Senior Pediatric Residents. Patients that can go home will be identified at this time and discharges for these patients should occur promptly. Discharge planning should always be occurring and the team should discuss patients that could potentially go home the night before. This would then be the time to ensure that if those patients are ready that the patients are discharged. See Patients: During this time the team will see their assigned patients. The chart and nursing notes should be reviewed to identify any issues that have arisen over night. The patient should be seen and examined. All lab work and radiological procedures that are pending should be reviewed. The house staff should then come up with a plan for the day and be ready to present that patient during ward rounds. It is not necessary that full notes be written at this time, as there will be time allotted for that later in the day. Ward Rounds: During ward rounds the attending paediatrician, with/without Senior Resident, and house staff will round on patients for their team. These are work rounds. All efforts should be made to go bedside to bedside to ensure that all patients are rounded on. Some spontaneous teaching during rounds and at the bedside can occur during this time, however there is allotted time for that later in the day. Team 1 will start on 3Y then proceed to 3C and 3B Team 2 will start on 3C then proceed to 3Y and 3B Case Based Learning There will be 10 modules that the learners should complete during their stay on the CTU over a one month period. The senior resident will be responsible to assign the cases to be discussed. The team should read the articles provided and work on the objectives prior to the discussion with the senior and other learners. The attending is encouraged to play a supervisory role during the discussions. MacPeds Survival Guide 8 Patient Care: During this time residents will follow through with decisions made during ward rounds. They will finish charting on patients. This is also the time for them to get dictations done and to complete face sheets. Teaching Sessions: There are various teaching sessions throughout most days on the CTU. Please refer to the CTU teaching schedule for locations – this will be posted online as well as on the wards. • • • • • • • • • • • Monday morning from 08:00-09:00 will be Division of General Paediatric Rounds. Mondays from 15:00 to 16:00 – there will be Specialty teaching session. It is the goal during this time to get various specialties to come in and teach around patients that are on the ward. Bedside case teaching. The individual teams will do these as time permits. Tuesdays from 08:00 to 09:00 – Teaching for all learners, except third Tuesday, which is for Pediatric residents only. Wednesdays 4th Wednesday of the month will be Peds Cardiology teaching – “Heart to Heart” which is from 08:00-09:00 Wednesday is Academic Half Day for pediatric residents. Thursdays from 08:00 to 09:00 – Pediatric Grand Rounds Second Thursday starting at 13:30, will be Simulation teaching, refer to the monthly schedule for details. Thursdays from 15:00 to 16:00: There will be radiology teaching once a month and possibly other teaching session booked. Friday 08:00-09:00, can be used for the Case Based Learning modules except 3rd Friday which will be endocrinology rounds. Nurses and other health care professionals are welcome to attend these rounds. Evaluations: Time is left in the schedule for evaluations. This would be the time to give residents mid-way evaluations, as well as end of rotation evaluations. Handover 1630 hrs: Handover will occur to the on-call team. MacPeds Survival Guide 9 Orientation: At the beginning of each month the attending should meet with their team members to review the objectives, expectation and schedule of the rotation. The senior resident may have valuable input during this time. Multi-Disciplinary Rounds: Team 1 and 2 will occur on Tuesdays. Team 1 will be from 1300-1330; Team 2 will be from 1330-1400. MacPeds Survival Guide 10 Division of General Pediatrics CTU 1 and 2 Weekly Schedule Monday Handover 7:15-7:45 Tuesday Wednesday Handover Handover Teaching MDCL 3020 * except Week 4: third Heart to Tuesday Heart LCC for (08:00Peds 09:00) residents only Thursday Handover Friday Handover Case Based Learning Except week 3, Endo Rounds 8:00-9:00 Division of General Pediatrics Rounds 4E20 9:00-10:30 See Patients See Patients See Patients See Patients See Patients Ward Rounds Lunch *MDR 1& 2 Patient Care Ward Rounds Lunch Patient Care/AHD Ward Rounds Lunch *MDR 3 Patient Care Ward Rounds Lunch Patient Care 15:00-16:00 Ward Rounds Lunch Patient Care Specialty Teaching AHD Teaching Sessions 16:00-16:30 16:30-17:00 Evaluations Handover Evaluations Handover AHD Handover Evaluations Handover 10:30-12:00 12:00-13:00 13:00-15:00 Grand Rounds MDCL 3020 Evaluations Handover Please refer to attached document for details of each of the above. *MDR = Multidisciplinary Rounds. The detailed monthly schedule for this can be found at www.macpeds.com MacPeds Survival Guide 11 ALLIED HEALTH – CONTACT NUMBERS/PAGERS SPECIALTY NAME RT RT, general pager 3B, 3C, 3Y 1362 OT Deb Gjertsen 1177 OT Kate Dobson-Brown 1240 OT Anne Newman 1885 SLP Sara Webster 5082 PT Weekend 1148 PT Jillian McJannet 1029 PT Barb Pollock 4317 PT Sarah Fairfield 1148 Tina Street 1092 CCAC Child Life PAGER X 76129 Child Life After hours/Weekends 1225 Child Life Lora Zimmerman 4092 Child Life Laura Perkin 4086 Child Life Sarah Pershick 1714 Dieticians X 73562 Dietician Helena Pelletier 1279 Dietician Lisa Talone 1513 Pharmacy Pharmacist X 76023 Nicole Clarke MacPeds Survival Guide 1423 12 Pharmacy Technician Carrie Morrell IV Nurse 1099 1007 Wound Care Nancy Trapasso Nurse 5150 Social Work Carol Ann O’Toole 1193 Social Work Bill Ratz 1039 Acute Nurse Care Rose-Frances Clause Practitioner Respiratory Home Care Coordinator Clinical Nurse Specialist 1934 Jeannie Kelso 1042 Joanne Dix 1409 Team 1 Pager 5301 Team 2 Pager 5302 Team 3 Pager 5303 Senior Pediatric Resident 1645 Pediatric ICU Resident 1000 MacPeds Survival Guide 13 RESOURCES Handbooks/Pocketbooks: • Hospital for Sick Children Handbook (11th ed, 2010). • Harriet Lane Handbook (1999): John Hopkins Hospital, Dept of Pediatrics. • Pediatrics on Call • Pediatric Drug Dosage Handbook (on most wards) Texts: • Nelson Essentials of Pediatrics (18th ed): Behrman R.E. and R.M. Kliegman. • Rudolph’s Fundamentals of Pediatrics (3rd ed, 2002): Rudolph, A.M. et al. • Pediatric Clinical Clerkship Guide Clinical Skills: • Pediatric Clinical Skills (3rd ed): Richard A. Goldbloom. Journals (all accessible via e-Resources at McMaster Libraries) • Pediatrics In Review. Monthly publication by AAP (American Academy of Pediatrics), consisting of review articles and case presentations • NeoReviews. Monthly publication by AAP, featuring excellent review articles of common neonatal conditions • Journal of Pediatric & Child Health. Monthly publication of CPS (Canadian Pediatric Society). MacPeds Survival Guide 14 WEBSITES McMaster Pediatrics Residency Program http://www.macpeds.com Our residency program site that includes staff & resident presentations, subspecialty orientation materials, policy statements and our favorite links. Canadian Pediatric Society - Position Statements http://www.cps.ca/en/documents The main site also directs you to their journal (Pediatrics and Child Health) and a separate site for information for parents (Caring for Kids). American Academy of Pediatrics (AAP) http://pediatrics.aappublications.org/site/aappolicy/index.xhtml The American equivalent of CPS, which has an expansive collection of practice guidelines and policy statements that are widely quoted. CDC Growth charts http://www.cdc.gov/growthcharts/ WHO Growth charts http://www.who.int/childgrowth/standards/en/ SOGC Guidelines (Society of Obstetricians and Gynecologists of Canada) http://sogc.org/clinical-practice-guidelines/ Evidence-based guidelines created by the SOGC, as indexed by topic area. Some of these are quite helpful in Level 2 Nursery and other newborn settings. Many others are quite helpful during your obs/gyn rotation! MacPeds Survival Guide 15 Stanford School of Medicine Newborn Nursery Photo Gallery http://newborns.stanford.edu/PhotoGallery/GalleryIndex.html Alphabetically organized collection of photographs of common neonatal conditions and dermatology CanChild-Centre for childhood disability research http://www.canchild.ca/en/ MORE WEBSITES … Motherisk Program http://www.motherisk.org/ A comprehensive program for evidence-based online information about the safety or risk of drugs, chemicals and disease during pregnancy and lactation based at Hospital for Sick Children. National Advisory Council on Immunization (NACI) http://www.phac-aspc.gc.ca/naci-ccni/ A program of the Canadian Public Health Association for educating parents and families, as well as health care professionals about the benefits and guidelines regarding childhood immunizations. Canadian Institute of Child Health (CICH) http://www.cich.ca/index_eng.html As their mission statement states “Dedicated to promoting and protecting the health, well-being and rights of all children and youth through monitoring, education and advocacy.” Phone Apps/PDA • Pediatrics on call – useful for common pediatric conditions • Pediatstat – quick access pediatric resuscitation information MacPeds Survival Guide 16 • Pediatric EKG – common pediatric ECG findings • Epocrates (http://www.epocrates.com) – free, drug database • HSC Handbook, Harriet Lane, The 5-minute pediatric consult both available on PDA and Skyscape Other Links: Hematology Oncology: http://www.pedsoncologyeducation.com/ Neurology Exams: http://library.med.utah.edu/pedineurologicexam/html/home_exam.html Cardiology: http://depts.washington.edu/physdx/heart/demo.html http://www.wilkes.med.ucla.edu/Physiology.htm MacPeds Survival Guide 17 DICTATIONS – Hamilton Health Sciences Corporation x5000 to enter, (905) 575-2550 externally Enter Author ID (#) Enter site (#) 11. General 12. Henderson 13. MUMC 14. Chedoke Enter Report Type (#) 21. Consultation 22. Discharge 3. Operative Report 4. Pre-op History & Physical 25. Clinic Note Enter Chart Number (#) – the ID # after the ‘M’ Enter Patient Type (#) 1. Inpatient 2. Outpatient 3. ER 4. Child & Family Press 2 to dictate, *5 to disconnect 1. Hold 2. Pause/Continue 3. Skipback/Play 4. Fast Forward (44 to move to end) 5. Disconnect 6. Prioritize 7. Rewind (77 rewind to beginning) 8. End Report For each report: - your name, patient name (spelling if difficult) - chart number, work type, copies to (FD, pediatrician, consultants, MRP, etc) MacPeds Survival Guide 18 PEDIATRIC STAFF – PAGERS AND OFFICE NUMBERS General Pediatrics Pager Number Office Number Babic, Bojana 7638 664-9913 Cheung, Wendy 7522 523-1209 Chitayat, Samara 7349 523-6766 Ernst, Caroline 3339 522-8915 Federici, Julie 7347 333-5437 Fitzpatrick, Kelly 523-3167 575-0611 Gambarotto, Kathy 572-8681 575-0611 Giglia, Lucy 7536 523-6766 Hallett, Kristen 2089 664-9992 Hunter, Andrea 7561 575-0611 Ladhani, Moyez 2040 x75639 Latchman, Andrew 2555 x76340 Lim, Audrey 3449 X76340 MacNay, Ramsay 2031 523-1209 Orovec, Natalie 76443-paging 664-9992 MacPeds Survival Guide 19 O'Toole, Frank 524-7609 575-0611 Roy, Madan 2023 x75639 Seigel, Sandi 3008 628-0054 Shbash, Iman 7570 575-0611 Wahi, Gita 2315 x76340 Wahi, Shobha 572-1464 523-7920 Sub-Specialist Pager Office Number Specialty El Helou, S 2560 x73490 Neonatology Fusch, C 2045 x75721 Neonatology Marrin, M 2705 x73490 Neonatology Shivananda, S 2403 x73490 Neonatology Williams, C 2128 x 73502 Neonatology Sub-Specialist Surgery Pager Office Number Specialty Ayeni, F 2104 x73532 or Ortho Surgery NICU x75094 Bailey, K 2766 x73550 or General Surg x75094 Bain, J 2628 x73222 or Plastic Surg x78520 MacPeds Survival Guide 20 Baronia, B 2743 x75237 or Neurosurgery x75011 Braga, L 76443 - paging x73777 or Urology x78519 Burrow, S 2133 x73177 or Ortho Surgery x75094 Cameron, B 76443 - paging x75231 or General Surg x75094 DeMaria, J 76443- paging x73777 or Urology x78519 Fitzgerald, P 76443 - paging x75231 or General Surg x75094 Flageole, H 76443 - paging x75244 or General Surg x75094 Korman, B 2600 x75246 or ENT x75051 Peterson, D 2035 x73177 or Ortho Surgery x75094 Sabri, K 76443 - paging x73509 or Ophthalmology x72400 Singh, S 2577 x75237 or Neurosurgery x75011 MacPeds Survival Guide 21 Strumas, N 76443 - paging x73594 or Plastic Surg x78520 Walton, M 76443- paging x75244 or General Surg x75094 Sub-Specialist Pager Office Number Specialty Almeida,C 2409 x75249 Cardiology Anchala, K No pager x75155 ER Arora, S 2066 x75635 Nephrology Athale, U 2118 x73464 Hem-Onc Baird, B 2645 x75607 ER Barr, R 2712 x73428 Hem-Onc Bassilious, E 2081 x73716 Endocrinology Batthish, M 76443 - paging X75382 Rheumatology Belostotsky, V 76443 - paging x75635 Nephrology Breaky, V 2125 x73428 Hem-Onc Brill, H 2476 x73455 GI Callen, D 2038 x75686 Neurology Carter, T 2644 x73508 Development Cellucci, T 76443 - paging X75382 Chan, A 521-5030 x73464 Hem-Onc Choong, K 2865 x76651 PICU MacPeds Survival Guide 22 Cupido, C 2327 x76610 PICU Dent, P 3720 x75382 Rheumatology Dillenburg, R 2784 x75242 Cardiology Findlay, S 972-1091 x75658 or x73289 Adolescent/Eating Disorder Unit Gilleland, J 2065 x75823 PICU Goldfarb, D 7158 x76947 Infectious Dis. Gorter, J.W 2531 X26852 Development Grant, C 2036 x75658 or x73289 Adolescent/Eating Disorder Unit Harman, K 2887 x77212 Development Hernandez, A 2645 x75607 ER Huang, L 2026 x73141 or x76610 PICU Issenman, R 2768 x75637 GI Johnson, N 2995 x75658 or x73289 Adolescent/Eating Disorder Unit Kam, A 76443 - paging x75621 ER Kozenko, M 2106 X76890 Genetics Kraus de Camargo, O 76443 - paging x74275 Development Li, C 2729 x76819 Genetics Lloyd, R 2684 x76610 PICU MacPeds Survival Guide 23 Mahoney, B 2713 X 77605 Development McAssey, K 75702 x 75702 Endocrinology Meaney, B 317-2807 x75686 Neurology Mesterman, R 2029 x74509 or x74275 Neurology Mondal, T 2039 x75259 Cardiology Morrison, K 76443 - paging x75702 Endocrinology Niec, A 2637 x73687 Psych, CAAP Nowaczyk, M 7207 X73042 Genetics Parker, M 2073 x76651 PICU Pernica, J 2092 x76947 Infectious Dis. Portwine, C 2119 x73464 Hem-Onc Predescu, D 76443 - paging x75264 Cardiology Ramachanran Nair, R 2360 x75613 Neurology Ratcliffe, E 2059 x73455 GI Ronen, G 2212 x74509 Neurology Rosenbaum, P 2742 x26852 Development Rosenbloom, E 76443 - paging x76038 ER Samaan, C 76443 - paging x73716 Endocrinology Scheinemann, K 2077 x73428 Hem-Onc Somani, A 2417 x 75823 PICU MacPeds Survival Guide 24 Sulowski, C 76443 - paging x75607 ER Tarnopolsky, M 2888 x75226 Neuromuscular Timmons, B N/A x 77615 Exercise VanderMeulen, J 2017 x73716 Endocrinology Waserman, S 2358 x76374 Allergy/Immun Wyatt, E N/A x75607 ER MacPeds Survival Guide 25 ST. JOSEPH’S HOSPITAL PEDIATRICS Hospital Contact Numbers Auto attendant (905) 522-1155 Switchboard (905) 522-4941 Labour and Delivery 33251, 34157 NICU 36050 3 OBS (Well Babies Nursery) 33314 Paging 33311 Dr Sandi Seigel 36039 Deputy Chief St Joes Clinical [email protected] Dr. Bojana Babic 36039 Education Rep CTU [email protected] Rosie Evered 36039 Program Secretary [email protected] Paging (33311) and Pagers: • • • • • • All paging done via switchboard attendant at extension 33311 Resident on-call usually carries pager # 412 Clerk on-call usually carries pager # 410 Page staff pediatrician on-call through paging (33311) McMaster assigns most pagers, check with program area If pager needed, sign out daily pagers at Switchboard Library Services: • 2nd Floor of Juravinski Tower • Hours: MON, WED, FRI 8:00 AM – 6:00 PM TUES, THURS 8:00 AM – 8:00 PM • X33440 or [email protected] MacPeds Survival Guide 26 Division of General Pediatrics CTU 4 Expectations Handover: Handover is to take place at 8:00 hrs together with staff/NP and residents. On the mornings when there are rounds (Monday and Thursday) handover should start at 7:45. Weekend handover is at 8:30 hrs. Discharge Rounds: Discharge planning should always be occurring and the team should discuss patients that could potentially go home the night before. Discharges for these patients should occur promptly after the handover if patients are ready. This is particularly important for the well babies on 3Obs and any anticipated discharges from the nursery. See Patients: During this time the team will see their assigned patients. The chart and nursing notes should be reviewed to identify any issues that have arisen over night. The patient should be seen and examined. All lab work and radiological procedures that are pending should be reviewed. The house staff should then come up with a plan for the day and be ready to present that patient during ward rounds. It is not necessary that full notes be written at this time, as there will be time allotted for that later in the day. Ward Rounds: During ward rounds the team will round on patients. These are work rounds. Some spontaneous teaching during rounds and at the bedside can occur during this time, however there is allotted time for that later in the day. Patient Care: During this time residents will follow through with decisions made during ward rounds. They will finish charting on patients. This is also the time for them to get dictations done and to complete face sheets. Teaching Sessions: There are various teaching sessions throughout most days on the CTU. Please refer to the CTU teaching schedule for locations – this will be posted online. Evaluations: MacPeds Survival Guide 27 Time is left in the schedule for evaluations. This would be the time to give residents mid-‐way evaluations, as well as end of rotation evaluations. Handover 1700 hrs: Handover will occur to the on-‐call team with residents, NP and staff together. Orientation: At the beginning of each month the attending should meet with their team members to review the objectives, expectation and schedule of the rotation. The senior resident may have valuable input during this time. MacPeds Survival Guide 28 Division of General Pediatrics CTU 4 Weekly Schedule St. Joseph’s Healthcare Handover at 8 am: combined staff, NP and resident/fellow: occurs at 7:45 am on rounds days 8-‐9 am 9-‐10 am Monday DGP rounds Tuesday See pts/discharges Staff touches base with BANA/3OBS/L&D re consults NP/SPR to meet at 9 to divide up supervisory responsibility See pts/discharges Staff touches base with BANA/3OBS /L&D re consults NP/SPR to meet after handover to divide up supervisory responsibility Wednesday Thursday Mcmaster Peds grand rounds See See pts/discharges pts/discharges Staff touches base Staff touches with base with BANA/3OBS/L&D BANA/3OBS re consults /L&D re consults NP/SPR to meet after handover to NP/SPR to divide up meet at 9 to supervisory divide up responsibility supervisory responsibility 10-‐12 NICU rounds No non-‐urgent interruptions NICU rounds No non-‐urgent interruptions 12-‐1 pm lunch lunch 1-‐2 pm finish notes/see consults finish notes/see consults 2-‐ 4 pm Teaching Clinic: 1 learner (CBL/journal attends with staff articles)/ quality assurance/ family Meetings) Academic ½ day; may have family meetings 4-‐5 pm Finish work, update list Academic ½ day • • • Finish work, update list NICU rounds No non-‐urgent interruptions MDR rounds Lunch Academic ½ day Friday ?Mcmaster NICU rounds See pts/ discharges Staff touches base with BANA/3OBS /L&D re consults NP/SPR to meet after handover to divide up supervisory responsibility NICU rounds NICU rounds No non-‐urgent No non-‐ interruptions urgent interruptions lunch Lunch finish notes/see consults Clinic: 1 learner attends with staff Finish work, update list finish notes/see consults Teaching (CBL/journal articles)/ quality assurance family meetings Finish work, update list DGP rounds – Division of General Pediatrics’ Rounds – Videoconferenced LIVE to SJH Rm T2308 (library) except 1st Monday Grand rounds – Department of Pediatrics Grand Rounds – Videoconferenced LIVE to SJH Rm T2308 (library) MDR – Multidisciplinary Rounds MacPeds Survival Guide 29 Accommodation Services On-Call Rooms: • Key: sign out from Front Desk/ Switchboard, must be returned by 11:00 AM the next day • Location: 2nd floor Martha Wing, Resident call room # 213 à follow Gold Signs to Father O'Sullivan Research Centre • Additional Key: unlock Washrooms + Showers or Code 2 4 3 • Residents’ Lounge (Microwave & TV): Code 2 4 3 nd à across from vending machines on 2 floor before call rooms • Problems: communicate to Switchboard or Mike Heenan x32218 Cafeteria Hours: Charlton Cafeteria 2nd Floor, Mary Grace Wing Garden Café @ CMHS MON – FRI: SAT – SUN: MON – FRI: Tim Horton Daily: 7:30 AM – 6:30 PM Closed 9:30 AM – 10:30 PM & 11:30 AM – 1:30 PM 7:00 AM – 11:30 PM Information Services Clinical Brower Passwords & Training: • Passwords obtained from: Computer Room 5th Floor of Mary Grace Wing G507 x32218 for Passwords • Must accept password and confidentiality agreements by signature • For additional information on Clinical Browser or training call: Shauna Stricker x35286 PACS Passwords & Training: • PACS passwords same as Clinical Browser, except all UPPERCASE • You may change your password once you have logged on • PACS training is only offered at the Monthly Medical Learner Orientation Sessions. For session dates and times contact: Diane Larwood 34077 MacPeds Survival Guide 30 St Joes Dictation System MacPeds Survival Guide 31 MacPeds Survival Guide 32 LISTENING TO DICTATED REPORTS AT ST JOSEPH’S HEALTHCARE • Use telephone to listen to Diagnostic Imaging Reports that have been dictated but not yet transcribed • Requires Check-In # of your Patient’s Exam. Found in Check-In # field (usually beside Patient’s Name) on any PACS Workstation • If you are unable to find Check-In # field on the Workstation, then call Diagnostic Imaging staff for assistance: x33606 or x36009 Instructions 1. DIAL 32078 to access the central dictation system. 2. PRESS the # sign. It is Important that you PRESS THE # SIGN to LISTEN, because 32078 is also used to DICTATE reports. 3. PRESS 1. Enter Physician Author Dictation ID Number (0995) 4. PRESS 1. 5. Enter Patient’s 7-digit Check-In # 6. LISTEN to the report • Press 5 to listen to a previous exam report on your patient, if the report you are hearing is not the one you requested • If you have entered the wrong check-in number or if would like to hear another report, follow the verbal prompts, Press 1 then repeat Steps 5 & 6 MacPeds Survival Guide 33 PEDIATRIC HISTORY & PHYSICAL EXAMINATION HISTORY Identifying Data: • Name, sex, age (years + months), race, who accompanies child, significant PMHx Chief Complaint: in patient’s or parent’s words History of Presenting Illness (HPI): • Open-ended question, and allow parents or child to express their concerns • Similar HPI details to an adult history • Establish time line: “when was your child last well?”, “what happened next?” etc • Select key symptoms and expand: • colour, character, quantity of vomit etc, • OPQRST of pain, aggravating/relieving factors etc • Always ask about recent exposures to ill contacts – family, school Past Medical History (PMHx): • Significant ongoing medical problems • Prenatal history: • Mother’s age, gravida, live births, abortions etc • Planned vs unplanned pregnancy, onset of prenatal care • Complications, smoking, drinking, meds, drug use in pregnancy • Gestational age at birth • Birth history: • Spontaneous vs induced labour, duration, complications • Presentation: breech, vertex, transverse • Interventions required: forceps, vacuum, c-section • Resuscitation required, Apgars, birth weight (conversion chart) • NICU, Level 2 nursery admission, duration • Newborn history: • Common problems: jaundice, poor feeding, difficulty breathing • Hospitalizations and significant accidents • Surgical history MacPeds Survival Guide 34 Medications – including dose changes, compliance Allergies – list specific reaction ∗ Immunizations – ask specifically about Prevnar, Menjugate, Varivax, Synagis (if neonate). PEDIATRIC HISTORY AND PHYSICAL EXAMINATION (Continued) Feeding History (if relevant): • Breast feeding: exclusively?, duration, frequency • Formula: brand, how is it prepared/diluted, # of feedings/day, quantity • Solids: when started, tolerated, any reactions • Vitamins (especially iron and Vit D): which ones, how often, dose • Present diet: cereals, fruit, vegs, eggs, meat, amt of cow’s milk • Any difficulties with feeding? Any concerns from primary physician about poor weight gain? Developmental Milestones (if relevant): • Have you ever had any concerns about your child’s development? • How does child compare with siblings? • Ask about current milestones in each category as appropriate for their age: • Gross motor • Fine motor, vision • Speech, hearing • Social skills • Use major milestones (walking, first word, toilet training, etc) to assess previous development (Reference on page 38) • Use Denver II charts etc to assess current stage of development Social History • Who lives at home? Who are primary caregivers? Parents work outside the home? • Does the child attend daycare? How many other children? In a home vs. institution? • Stability of support network: relationship stability, frequent moves, major events (death in family etc), financial problems, substance abuse in the home • Has CAS ever been involved? MacPeds Survival Guide 35 • School adjustment, behaviour problems, habits (nail-biting, thumbsucking etc), sleep changes • How has this disease affected your child/ your family? • What does your family do for fun? What does your child do for fun? • For an asthma history: smoke, pets, carpets, allergens in the home, family history of asthma / atopy. PEDIATRIC HISTORY AND PHYSICAL EXAMINATION (Continued) Family History: • Are parents both alive and well? How many siblings? Are they healthy? • Are there any childhood diseases in the family? • Consanguinity – are mother and father related in any way? • Relevant family history (3 generations) – autoimmune hx in Type I DM, atopic hx in asthma etc • Draw pedigree if possible for genetic assessment Review of Systems: General: feeding, sleeping, growing, energy level Signs of illness in kids: activity, appetite, attitude (3 A’s) HEENT: infections (how often, fever, duration): otitis, nasal discharge, colds, sore throats, coughs, nosebleeds, swollen glands, coughing or choking with feeding Cardio: Infants: fatigue/sweating during feedings, cyanosis, apneas/bradycardic episodes Older kids: syncope, murmurs, palpitations, exercise intolerance Resp: cough, wheezing, croup, snoring, respiratory infections GI: appetite, weight gain (growth chart), nausea/vomiting, bowel habits, abdominal pains GU: urinary: pain/frequency/urgency, sexually active, menarche/menses, discharge/pruritis/STDs MacPeds Survival Guide 36 MSK: weakness, sensory changes, myalgias, arthralgias, ‘growing pains’ Neuro: headaches, seizures (febrile vs afebrile, onset, frequency, type), tics, staring spells, head trauma Skin: rashes, petechiae, jaundice, infection, birthmarks PHYSICAL EXAMINATION General Inspection - Sick vs not sick? - Toxic appearance? listlessness, agitation, failure to recognize parents, inadequate circulation (cool extremities; weak, rapid pulse; poor capillary refill; cyanotic, gray, or mottled colour), respiratory distress, purpura - Level of consciousness - Nutritional status – well nourished? - Developmental status (“pulling up to stand in crib”, “running around room”) - Dysmorphic features – look specifically at face, ears, hands, feet, genetalia Vital Signs: - Include Temperature, Heart Rate, Respiratory Rate, Blood Pressure and O2 saturation NORMAL PEDIATRIC VITAL SIGNS Age HR SBP Newborn (<1 wk) 120-160 60-70 Neonate (<1 mos) 120-160 75-90 Infant (<1 year) 110-140 75-120 Preschool (3-5yrs) 90-120 75-125 Child (6-12 yrs) 80-110 83-120 Adolescent (>12 y) 70-100 90-130 Adult (>18 yrs) 60-100 90-130 MacPeds Survival Guide RR 30-60 30-60 20-40 20-25 16-24 12-18 12-18 37 Anthropometrics (plot on growth curves at every visit!): - Height (supine length to 2 years, then standing height) - Weight - Head circumference (generally birth to 2 years, >2 yrs if specific concerns) - Plot BMI (kg/m2) on updated CDC growth curves for appropriate BMI for age - CDC Growth Curves available at: http://www.cdc.gov/nchs/about/major/nhanes/growthcharts/clinical_ch arts.htm Hydration Status - Comment on mucous membranes, tears, skin turgor, sunken eyes, in addition to appropriateness of vital signs, etc. - For classification of mild, moderate, severe dehydration – see “Fluids & Electrolytes” HEENT: - Head: dysmorphic features, shape of skull, head circumference, fontanels in infants - Eyes: strabismus, pupillary response, fundoscopy, red reflex in infants, conjunctivitis - Ears & pharynx exam in any child with a fever! - Nose: turbinates, deviation of septum, presence of polyps? - Mouth: lips (lesions, colour), mucous membranes including gingiva, tongue, hard/soft palate, - Dentition: presence of teeth, tooth decay - Neck: lymphadenopathy, palpation of thyroid, webbing (Noonan, Turner syndrome), torticollis MacPeds Survival Guide 38 Cardiovascular: - HR, BP, apical beat, heaves/thrills - Perfusion: o Pulses – strength/quality, femoral pulses in all infants o Capillary refill time o Skin colour: pink, central/peripheral cyanosis, mottling, pallor - S1/S2, extra heart sounds (S3, S4) - Murmurs: o Timing (systole, diastole, continuous) o Location of maximal intensity, radiation o Pitch and quality (machinery, vibratory, etc), o Loudness (I – VI / VI) Respiratory: - Audible stridor, sturtor, wheeze, snoring - Position of child, ability to handle secretions - Signs of distress: nasal flaring, tracheal tug, indrawing - RR, O2 saturation (current FiO2), level of distress - Able to speak in full sentences (if age appropriate) - Depth and rhythm of respiration - Chest wall deformities: kyphosis, scoliosis, pectus excavatum/carinatum - Finger clubbing Abdomen: - For peritoneal signs: ask child to jump up and down or wiggle hips, to distend and retract abdomen “blow up your belly and then suck it in” - Inspection: scaphoid/distended, umbilical hernias, diastasis recti - Auscultation: presence of bowel sounds - Percussion: ascites, liver span, Traube’s space for splenomegaly - Palpation: hepatosplenomegaly?, tenderness, guarding (voluntary, involuntary), masses (particularly stool presence in LLQ) - Stigmata of liver disease: jaundice, pruritis, bruising/bleeding, palmar erythema, caput medusa, telangiectasia, ascites, hepatosplenomegaly MacPeds Survival Guide 39 Genito-urinary: - Anal position, external inspection (digital rectal examination in kids ONLY with clinical indication), Tanner staging - Male infants: both testes descended, hypospadias, inguinal hernias - Females: labia majora/minora, vaginial discharge, erythema/excoriation of vulvo-vaginitis (NO speculum exam if prepubertal) MSK: - Gait assessment, flat feet vs toe walking vs normal foot arches - Standing: genu valgum “knock knee” vs genu varum “bow legged” - Joints: erythema, swelling, position, active/passive range of motion, strength, muscle symmetry - Back: kyphosis, scoliosis http://www.youtube.com/watch?v=GQQBG9rlZp4 Neurological: - Overall developmental assessment o Try playing ball with younger children, or even peek-a-boo! - Level of consciousness (Glasgow Coma Scale if appropriate) - Newborns: primitive reflexes, moving all limbs, presence of fisting? - Cranial nerves: by observation in infants, formal testing in older children - Motor: strength, tone, deep tendon reflexes, coordination - Sensory: touch, temperature, position/vibration sense - Cerebellar: gait (heel to toe, on heels, on toes, finger-to-nose, rapid alternating movements in older children, Romberg (eyes open then closed) Derm: - Jaundice, pallor, mottling, petechiae/purpura - Rashes, birthmarks, hemangiomas, stigmata of neurocutaneous disorders MacPeds Survival Guide 40 REPORTS ON THE RHEUMATIC DISEASES SERIES 5 Hands On Practical advice on management of rheumatic disease pGALS – A SCREENING EXAMINATION OF THE MUSCULO- SKELETAL SYSTEM IN SCHOOL-AGED CHILDREN Helen E Foster, MD, MBBS(Hons), FRCP, FRCPCH, CertMedEd, Professor in Paediatric Rheumatology Sharmila Jandial, MBChB, MRCPCH, CertMedEd, arc Educational Research Fellow Musculoskeletal Research Group, Newcastle University, Newcastle upon Tyne Why do primary care doctors need to know about musculoskeletal assessment in children? Children with musculoskeletal (MSK) problems are common and often present initially to primary care where GPs have an important role as ‘gatekeepers’ to secondary care and specialist services. The majority of causes of MSK presentations in childhood are benign, self-limiting and often trauma-related; referral is not always necessary, and in many instances reassurance alone may suffice. However, MSK symptoms can be presenting features of potentially lifethreatening conditions such as malignancy, sepsis, vasculitis and non-accidental injury, and furthermore are commonly associated features of many chronic paediatric conditions such as inflammatory bowel disease, cystic fibrosis, arthritis and psoriasis. Clinical assessment skills (history-taking and physical examination), knowledge of normal development, and clinical presentations at different ages, along with knowledge of indicators to warrant referral, are important and facilitate appropriate decision-making in the primary care setting. This article focuses on pGALS (paediatric Gait, Arms, Legs, Spine), which is a simple screening approach to MSK examination in school-aged children and may be successfully performed in younger ambulant children – the approach to the examination of the toddler and baby requires a different approach and is not described here. How is musculoskeletal assessment of children different to that of adults? It is stating the obvious that children are ‘not small adults’ in many ways, and here we focus on MSK history-taking MacPeds Survival Guide June 2008 No 15 and physical examination. The history is often given by the parent or carer, may be based on observations and interpretation of events made by others (such as teachers), and may be rather vague with non-specific complaints such as ‘My child is limping’ or ‘My child is not walking quite right’. Young children may have difficulty in localising or describing pain in terms that adults may understand. It is not unusual for young children to deny having pain when asked directly, and instead present with changes in behaviour (e.g. irritability or poor sleeping), decreasing ability or interest in activities and hand skills (e.g. handwriting), or regression of motor milestones. Some children are shy or frightened and reluctant to engage in the consultation. Practical Tip – when inflammatory joint disease is suspected • The lack of reported pain does not exclude arthritis • There is a need to probe for symptoms such as – gelling (e.g. stiffness after long car rides) – altered function (e.g. play, handwriting skills, regression of motor milestones) – deterioration in behaviour (irritability, poor sleeping) • There is a need to examine all joints as joint involvement is often ‘asymptomatic’ It is important to probe in the history when there are indicators of potential inflammatory MSK disease. A delay in major motor milestones warrants MSK assessment as well as a global neuro-developmental approach. However, in acquired MSK disease such as juvenile idiopathic arthritis (JIA) a history of regression of achieved milestones is often more significant – e.g. the child who was happy to walk unaided but has recently been reluctant to walk or is now unable to dress himself without help. In adults the cardinal features of inflammatory arthritis are pain, stiffness, swelling and reduced function. However, in children these features may Medical Editor: Louise Warburton, GP. Production Editor: Frances Mawer (arc). ISSN 1741-833X. Published 3 times a year by the Arthritis Research Campaign, Copeman House, St Mary’s Court, St41 Mary’s Gate Chesterfield S41 7TD. Registered Charity No. 207711. be difficult to elucidate. Joint swelling, limping and reduced mobility, rather than pain, are the most common presenting features of JIA.1 The lack of reported pain does not exclude arthritis – the child is undoubtedly in discomfort but, for the reasons described, may not verbalise this as pain. Swelling is always significant but can be subtle and easily overlooked, especially if the changes are symmetrical, and relies on the examiner being confident in their MSK examination skills and having an appreciation of what is ‘normal’ and ‘abnormal’ (see below). Rather than describing stiffness, the parents may notice the child is reluctant to weight-bear or limps in the mornings or ‘gels’ after periods of immobility (e.g. after long car rides or sitting in a classroom). Systemic upset and the presence of bone rather than joint pain may be features of MSK disease and are ‘red flags’ that warrant urgent referral. More indolent presentations of MSK disease can also impact on growth (either localised or generalised) and it is important to assess height and weight and review growth charts as necessary. lar, respiratory, gastrointestinal, neurological, skin and eyes, and, given the broad spectrum of MSK presentations in children, a low threshold for performing pGALS is suggested and of particular importance in certain clinical scenarios. Practical Tip – when to perform pGALS in the assessment • • • • • • How does pGALS differ from adult GALS? The sequence of pGALS is essentially the same as adult GALS with additional manoeuvres to screen the foot and ankle (walk on heels and then on tiptoes), wrists (palms together and then hands back to back) and temporomandibular joints (open mouth and insert three of the child’s own fingers), and with amendments at screening the elbow (reach up and touch the sky) and neck (look at the ceiling). These additional manoeuvres were included because when adult GALS was originally tested in school-aged children4 it missed significant abnormalities at these sites. RED FLAGS (Raise concern about infection, malignancy or nonaccidental injury) • • • • Child with muscle, joint or bone pain Unwell child with pyrexia Child with limp Delay or regression of motor milestones The ‘clumsy’ child in the absence of neurological disease Child with chronic disease and known association with MSK presentations Fever, malaise, systemic upset (reduced appetite, weight loss, sweats) Bone or joint pain with fever Refractory or unremitting pain, persistent night-waking Incongruence between history and presentation (such as the pattern of the physical findings and a previous history of neglect) How to distinguish normal from abnormal in the musculoskeletal examination What is pGALS? Paediatric GALS (pGALS) is a simple evidence-based approach to an MSK screening assessment in school-aged children, and is based on the adult GALS (Gait, Arms, Legs, Spine) screen.2 The adult GALS screen is commonly taught to medical students, and emerging evidence shows an improvement in doctors’ confidence and performance in adult MSK assessment. Educational resources to support learning of GALS are available.3 pGALS is the only paediatric MSK screening examination to be validated, and was originally tested in school-aged children. pGALS has been demonstrated to have excellent sensitivity to detect abnormality (i.e. with few false negatives), incorporates simple manoeuvres often used in clinical practice, and is quick to do, taking an average of 2 minutes to perform.4 Furthermore, when performed by medical students and general practitioners pGALS has been shown to have high sensitivity and is easy to do, with excellent acceptability by children and their parents (papers in preparation). Younger children can often perform the screening manoeuvres quite easily, although validation of pGALS in the pre-school age group has yet to be demonstrated. Key to distinguishing normal from abnormal are knowledge of ranges of movement, looking for asymmetry and careful examination for subtle changes. In addition, it is important that GPs are aware of normal variants in gait, leg alignment and normal motor milestones (Tables 1,2) as these are a common cause of parental concern, especially in the pre-school child, and often anxieties can be allayed with explanation and reassurance. There is considerable variation in the way normal gait patterns develop; these may be familial (e.g. ‘bottom-shufflers’ often walk later) and subject to racial variation (e.g. African black children tend to walk sooner and Asian children later than average). Joint abnormalities can be subtle or difficult to appreciate in the young (such as ‘chubby’ ankles, fingers, wrists and knees). Looking for asymmetrical changes is helpful although it can be falsely reassuring in the presence of symmetrical joint involvement. Muscle wasting, such as of the quadriceps or calf muscles, indicates chronicity of joint disease and should alert the examiner to knee or ankle involvement respectively. Swelling of the ankle is often best judged from behind the child. Ranges of joint movement should be symmetrical and an appreciation of the ‘normal’ range of movement in childhood can be gained with increased clinical experience. Hypermobility may be generalised or limited to peripheral joints such as hands When should pGALS be performed? MSK presentations are a common feature of many chronic diseases of childhood and not just arthritis. An MSK examination is one of the ‘core’ systems along with cardiovascuMacPeds Survival Guide 42 2 and feet, and, generally speaking, younger female children and those of non-Caucasian origin are more flexible. Benign hypermobility is suggested by symmetrical hyperextension at the fingers, elbows and knees and by flat pronated feet, with normal arches on tiptoe.5 TABLE 1. Normal variants in gait patterns and leg alignment. Toewalking Habitual toe-walking is common in young children up to 3 years In-toeing Can be due to: • persistent femoral anteversion (characterised by child walking with patellae and feet pointing inwards; common between ages 3–8 years) • internal tibial torsion (characterised by child walking with patellae facing forward and toes pointing inwards; common from onset of walking to 3 years) • metatarsus adductus (characterised by a flexible ‘C-shaped’ lateral border of the foot; most resolve by 6 years Bow legs (genu varus) Common from birth to the early toddler, often with out-toeing (maximal at approx. 1 year); most resolve by 18 months Knock knees (genu valgus) Common and often associated with in-toeing (maximal at approx. 4 years); most resolve by 7 years Flat feet Most children have flexible flat feet with normal arches on tiptoeing; most resolve by 6 years Crooked toes Most resolve with weight-bearing (assuming shoes and socks fit comfortably) Practical Tip – normal variants: indications for referral • • • • • • • Children with hypermobility may present with mechanical aches and pains after activity or as ‘clumsy’ children, prone to falls. It is important to consider ‘non-benign’ causes of hypermobility such as Marfan’s syndrome (which may be suggested by tall habitus with long thin fingers, and higharched palate), and Ehlers–Danlos syndrome (which may be suggested by easy bruising and skin elasticity, with poor healing after minor trauma). Non-benign hypermobility is genetically acquired and probing into the family history may be revealing (e.g. cardiac deaths in Marfan’s syndrome). The absence of normal arches on tiptoe suggests a nonmobile flat foot and warrants investigation (e.g. to exclude tarsal coalition) and high fixed arches and persistent toewalking may suggest neurological disease. Conversely, lack of joint mobility, especially if asymmetrical, is always significant. Increased symmetrical calf muscle bulk associates with types of muscular dystrophy, and proximal myopathies may be suggested by delayed milestones such as walking (later than 18 months) or inability to jump (in the school-aged child). TABLE 2. Normal major motor milestones. Sit without support 6–8 months Creep on hands and knees 9–11 months Cruise when holding on to furniture and standing upright, or bottom shuffle 11–12 months Walk independently 12–14 months Climb up stairs on hands and knees approx. 15 months Run stiffly approx. 16 months Walk down steps (non-reciprocal) 20–24 months Walk up steps, alternate feet 3 years Hop on one foot, broad jump 4 years Skip with alternate feet 5 years Balance on one foot 20 seconds 6–7 years Persistent changes (beyond the expected age ranges) Progressive or asymmetrical changes Short stature or dysmorphic features Painful changes with functional limitation Regression or delayed motor milestones Abnormal joint examination elsewhere Suggestion of neurological disease or developmental delay What to do if the pGALS screen is abnormal pGALS has been shown to have high sensitivity to detect significant abnormalities. Following the screening examination, the observer is directed to a more detailed examination of the relevant area, based on the ‘look, feel, move’ principle as in the adult Regional Examination of the Musculoskeletal System (called REMS).3 To date a validated regional MSK examination for children does not exist, but an evidence- and consensus-based approach to a children’s regional examination (to be called pREMS) is currently being developed by our research team; this project is funded by arc and further educational resources are to follow. The components of the pGALS musculoskeletal screen The pGALS screen6 (see pp 4–6) includes three questions relating to pain and function. However, a negative response to these three questions in the context of a potential MSK problem does not exclude significant MSK disease, and MacPeds Survival Guide 43 3 The pGALS musculoskeletal screen Screening questions • Do you (or does your child) have any pain or stiffness in your (their) joints, muscles or back? • Do you (or does your child) have any difficulty getting yourself (him/herself) dressed without any help? • Do you (or does your child) have any problem going up and down stairs? FIGURE SCREENING MANOEUVRES WHAT IS BEING ASSESSED? (Note the manoeuvres in bold are additional to those in adult GALS2) Observe the child standing (from front, back and sides) • Posture and habitus • Skin rashes – e.g. psoriasis • Deformity – e.g. leg length inequality, leg alignment (valgus, varus at the knee or ankle), scoliosis, joint swelling, muscle wasting, flat feet Observe the child walking and ‘Walk on your heels’ and ‘Walk on your tiptoes’ • Ankles, subtalar, midtarsal and small joints of feet and toes • Foot posture (note if presence of normal longitudinal arches of feet when on tiptoes) ‘Hold your hands out straight in front of you’ • Forward flexion of shoulders • Elbow extension • Wrist extension • Extension of small joints of fingers ‘Turn your hands over and make a fist’ • Wrist supination • Elbow supination • Flexion of small joints of fingers ‘Pinch your index finger and thumb together’ • Manual dexterity • Coordination of small joints of index finger and thumb and functional key grip (continued) MacPeds Survival Guide 44 4 FIGURE SCREENING MANOEUVRES WHAT IS BEING ASSESSED? ‘Touch the tips of your fingers’ • Manual dexterity • Coordination of small joints of fingers and thumbs Squeeze the metacarpophalangeal joints for tenderness • Metacarpophalangeal joints ‘Put your hands together palm to palm’ and ‘Put your hands together back to back’ • Extension of small joints of fingers • Wrist extension • Elbow flexion ‘Reach up, “touch the sky”’ and ‘Look at the ceiling’ • • • • ‘Put your hands behind your neck’ • Shoulder abduction • External rotation of shoulders • Elbow flexion Elbow extension Wrist extension Shoulder abduction Neck extension (continued) MacPeds Survival Guide 45 5 FIGURE SCREENING MANOEUVRES WHAT IS BEING ASSESSED? ‘Try and touch your shoulder with your ear’ • Cervical spine lateral flexion ‘Open wide and put three (child’s own) fingers in your mouth’ • Temporomandibular joints (and check for deviation of jaw movement) Feel for effusion at the knee (patella tap, or crossfluctuation) • Knee effusion (small effusion may be missed by patella tap alone) Active movement of knees (flexion and extension) and feel for crepitus • Knee flexion • Knee extension Passive movement of hip (knee flexed to 90º, and internal rotation of hip) • Hip flexion and internal rotation ‘Bend forwards and touch your toes?’ • Forward flexion of thoraco-lumbar spine (and check for scoliosis) MacPeds Survival Guide 46 6 Documentation of the pGALS screen Documentation of the pGALS screening assessment is important and a simple pro forma is proposed with the following example – a child with a swollen left knee with limited flexion of the knee and antalgic gait. pGALS screening questions Any pain? Left knee Problems with dressing? No difficulty Problems with walking? Some difficulty on walking Appearance Gait Movement 7 Arms 3 3 Legs 7 7 Spine 3 3 Summary therefore at a minimum pGALS should be performed. In children, it is not uncommon to find joint involvement that has not been mentioned as part of the presenting complaint; it is therefore essential to perform all parts of the pGALS screen and check for verbal and non-verbal clues of joint discomfort (such as facial expression, withdrawal of limb, or refusal to be examined further). The pGALS examination is a simple MSK screen that should be performed as part of systems assessment of children. Improved performance of MSK clinical skills and knowledge of normal variants in childhood, common MSK conditions and their mode of presentation, along with knowledge of red flags to warrant concern, will facilitate diagnosis, management and appropriate referral. Observation with the child standing should be done from the front, behind the child and from the side. Scoliosis may be suggested by unequal shoulder height or asymmetrical skin creases on the trunk, and may be more obvious on forward flexion. From the front and back, leg alignment problems such as valgus and varus deformities at the knee can be observed; leg-length inequality may be more obvious from the side and suggested by a flexed posture at the knee, and, if found, then careful observation of the spine is important to exclude a secondary scoliosis. For specific manoeuvres, the child can copy the various screening manoeuvres as they are performed by the examiner. Children often find this fun and this can help with establishing rapport. It is important to keep observing closely as children may only cooperate briefly! The examination of the upper limbs and neck is optimal with the child sitting on an examination couch or on a parent’s knee, facing the examiner. The child should then lie supine to allow the legs to be examined and then stand again for spine assessment. Further information and reading A full demonstration of the pGALS screen is available from the Arthritis Research Campaign (arc) as a free resource as a DVD and soon will be available as a web-based resource: www.arc.org.uk/arthinfo/ emedia.asp. A video-clip of the screening manoeuvres can also be accessed via the web version of this report: www.arc.org.uk/arthinfo/ medpubs/6535/6535.asp. Jandial S, Foster HE. Examination of the musculoskeletal system in children: a simple approach. Paediatr Child Health 2008;18(2):47-55. Szer I, Kimura Y, Malleson P, Southwood T (ed). Arthritis in adolescents and children (juvenile idiopathic arthritis). Oxford University Press; 2006. References 1. McGhee JL, Burks FN, Sheckels JL, Jarvis JN. Identifying children with chronic arthritis based on chief complaints: absence of predictive value for musculoskeletal pain as an indicator of rheumatic disease in children. Pediatrics 2002;110(2 Pt 1):354-9. Practical Tip – while performing the pGALS screening examination 2. Doherty M, Dacre J, Dieppe P, Snaith M. The ‘GALS’ locomotor screen. Ann Rheum Dis 1992;51(10):1165-9. • • • • • 3. Clinical assessment of the musculoskeletal system: a handbook for medical students (includes DVD ‘Regional examination of the musculoskeletal system for students’). Arthritis Research Campaign; 2005. www.arc.org.uk/arthinfo/medpubs/6321/6321.asp. Get the child to copy you doing the manoeuvres Look for verbal and non-verbal clues of discomfort (e.g. facial expression, withdrawal) Do the full screen as the extent of joint involvement may not be obvious from the history Look for asymmetry (e.g. muscle bulk, joint swelling, range of joint movement) Consider clinical patterns (e.g. non-benign hypermobility and Marfanoid habitus or skin elasticity) and association of leg-length discrepancy and scoliosis) 4. Foster HE, Kay LJ, Friswell M, Coady D, Myers A. Musculoskeletal screening examination (pGALS) for school-aged children based on the adult GALS screen. Arthritis Rheum 2006;55(5):709-16. 5. Oliver J. Hypermobility. Reports on the Rheumatic Diseases (Series 5), Hands On 7. Arthritis Research Campaign; 2005 Oct. 6. pGALS – Paediatric Gait, Arms, Legs, Spine. DVD. Arthritis Research Campaign; 2006. www.arc.org.uk/arthinfo/emedia.asp. MacPeds Survival Guide 47 7 Birth to 36 months: Boys Length-for-age and Weight-for-age percentiles L E N G T H Birth in cm 41 40 100 39 38 95 37 36 90 35 34 85 33 32 80 31 30 75 29 28 70 27 26 65 25 24 60 23 22 55 21 20 50 19 18 45 17 16 40 15 16 3 6 9 15 18 RECORD # 21 24 27 30 33 36 cm AGE (MONTHS) 97 90 100 75 95 50 25 90 10 3 in 41 40 39 38 37 36 35 17 90 16 38 36 34 75 15 32 50 14 25 13 30 28 10 12 3 AGE (MONTHS) 7 12 15 Mother’s Stature Father’s Stature Date Age Birth 6 12 5 10 18 21 Weight 24 27 30 Gestational Age: Weeks Length Head Circ. 33 36 26 11 24 10 22 9 20 8 18 kg 16 lb Comment 4 8 6 lb 3 2 kg Birth L E N G T H 97 14 W E I G H T 12 NAME 3 6 9 Published May 30, 2000 (modified 4/20/01). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). MacPeds Survival Guide http://www.cdc.gov/growthcharts 48 W E I G H T Birth to 36 months: Girls Length-for-age and Weight-for-age percentiles L E N G T H Birth in cm 41 40 100 39 38 95 37 36 90 35 34 85 33 32 80 31 30 75 29 28 70 27 26 65 25 24 60 23 22 55 21 20 50 19 18 45 17 16 40 15 16 3 6 9 15 18 RECORD # 21 24 27 30 33 36 cm AGE (MONTHS) 97 90 100 75 95 50 25 90 10 in 41 40 39 38 37 36 35 97 17 90 16 75 15 38 36 34 32 14 50 13 25 12 10 3 AGE (MONTHS) 7 12 15 Mother’s Stature Father’s Stature Date Age Birth 6 12 5 10 18 21 Weight 24 27 30 Gestational Age: Weeks Length Head Circ. 33 36 30 28 26 11 24 10 22 9 20 8 18 kg 16 lb Comment 4 8 6 lb 3 2 kg Birth L E N G T H 3 14 W E I G H T 12 NAME 3 6 9 Published May 30, 2000 (modified 4/20/01). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). MacPeds Survival Guide http://www.cdc.gov/growthcharts 49 W E I G H T Birth to 36 months: Boys Head circumference-for-age and Weight-for-length percentiles in Birth cm 3 6 9 12 NAME RECORD # 15 18 21 24 27 30 33 cm AGE (MONTHS) 52 97 90 50 50 20 H E A D C I R C U M F E R E N C E 19 18 36 52 20 75 25 48 10 3 46 50 48 19 46 18 44 44 17 17 42 16 42 40 22 15 21 38 20 14 36 19 97 34 18 90 13 12 17 75 32 50 30 25 10 3 16 15 14 13 12 W E I G H T 24 22 20 18 16 14 14 12 10 8 6 4 2 lb in 11 11 10 10 9 9 8 8 7 7 6 6 5 4 3 2 1 kg cm 46 48 50 52 54 56 58 60 62 in 18 19 20 21 22 23 24 5 kg LENGTH 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98100 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 Date Age Weight Published May 30, 2000 (modified 10/16/00). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). MacPeds Survival Guide http://www.cdc.gov/growthcharts Length Head Circ. H E A D C I R C U M F E R E N C E 50 48 46 44 42 40 38 36 34 32 30 28 26 24 22 20 18 16 14 12 lb cm in Comment 50 W E I G H T Birth to 36 months: Girls Head circumference-for-age and Weight-for-length percentiles in Birth cm 3 6 9 12 NAME RECORD # 15 18 21 24 27 30 33 36 cm AGE (MONTHS) 52 in 52 97 20 90 50 H E A D C I R C U M F E R E N C E 19 18 75 50 48 25 10 46 3 20 50 48 19 46 18 44 44 17 17 42 16 42 40 22 15 21 38 20 14 36 97 34 90 13 18 17 75 16 32 12 19 50 15 25 10 3 30 14 13 12 W E I G H T 24 22 20 18 16 14 14 12 10 8 6 4 2 lb 11 11 10 10 9 9 8 8 7 7 6 6 5 4 3 2 1 kg cm 46 48 50 52 54 56 58 60 62 in 18 19 20 21 22 23 24 5 kg LENGTH 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98100 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 Date Age Weight Published May 30, 2000 (modified 10/16/00). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). MacPeds Survival Guide http://www.cdc.gov/growthcharts Length Head Circ. H E A D C I R C U M F E R E N C E 50 48 46 44 42 40 38 36 34 32 30 28 26 24 22 20 18 16 14 12 lb cm in Comment 51 W E I G H T 2 to 20 years: Boys Stature-for-age and Weight-for-age percentiles Mother’s Stature Date Father’s Stature Age Weight Stature BMI* NAME RECORD # 12 13 14 15 16 17 18 19 20 cm AGE (YEARS) 97 190 90 185 75 50 25 180 175 170 10 in 62 S T A T U R E 60 58 56 54 52 50 48 46 44 42 40 38 36 cm 3 4 5 6 7 8 9 10 11 3 165 160 160 155 155 150 150 74 72 70 68 66 64 62 60 140 105 230 135 97 100 220 130 125 90 120 95 210 90 200 85 115 75 80 75 110 105 50 100 25 95 10 90 3 190 180 170 160 70 150 W 65 140 E I 60 130 G 55 120 34 85 50 110 32 80 45 100 40 90 35 35 30 30 25 25 20 20 15 15 10 kg 10 kg 80 70 60 50 40 30 lb S T A T U R E 145 30 W E I G H T in 76 AGE (YEARS) 2 3 4 5 6 7 8 9 80 70 60 50 40 30 lb 10 11 12 13 14 15 16 17 18 19 20 Published May 30, 2000 (modified 11/21/00). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). MacPeds Survival Guide http://www.cdc.gov/growthcharts 52 H T 2 to 20 years: Girls Stature-for-age and Weight-for-age percentiles Mother’s Stature Date Father’s Stature Age Weight Stature BMI* NAME RECORD # 12 13 14 15 16 17 18 19 20 cm AGE (YEARS) 190 185 180 97 175 90 170 75 in 62 S T A T U R E 60 58 56 54 52 50 48 46 44 42 40 38 cm 4 5 6 7 8 9 10 11 50 165 160 25 160 155 10 155 150 3 150 50 40 30 lb 66 S T A T U R E 64 62 60 100 220 130 95 210 90 200 125 97 120 85 115 80 110 90 75 190 180 170 160 70 105 75 100 95 85 60 68 135 34 70 70 105 230 50 150 W 65 140 E I 60 130 G 55 120 25 10 80 3 30 W E I G H T 72 140 90 80 74 145 36 32 3 in 76 50 110 45 100 40 90 35 35 30 30 25 25 20 20 15 15 10 kg 10 kg AGE (YEARS) 2 3 4 5 6 7 8 9 80 70 60 50 40 30 lb 10 11 12 13 14 15 16 17 18 19 20 Published May 30, 2000 (modified 11/21/00). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). MacPeds Survival Guide http://www.cdc.gov/growthcharts 53 H T 2 to 20 years: Boys Body mass index-for-age percentiles Date Age Weight Stature NAME RECORD # Comments BMI* BMI 35 34 33 32 97 31 30 95 29 28 BMI 90 27 27 85 26 26 25 25 75 24 24 23 23 50 22 22 21 21 25 20 20 10 19 19 3 18 18 17 17 16 16 15 15 14 14 13 13 12 12 kg/m 2 2 AGE (YEARS) 2 3 4 5 6 7 8 9 10 11 12 Published May 30, 2000 (modified 10/16/00). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). http://www.cdc.gov/growthcharts MacPeds Survival Guide kg/m 13 14 15 16 17 18 19 20 54 2 to 20 years: Girls Body mass index-for-age percentiles Date Age Weight Stature NAME RECORD # Comments BMI* BMI 35 34 97 33 32 31 95 30 29 BMI 28 90 27 27 26 26 85 25 25 24 24 75 23 23 22 22 50 21 21 20 20 25 19 19 10 18 18 3 17 17 16 16 15 15 14 14 13 13 12 12 kg/m 2 2 AGE (YEARS) 2 3 4 5 6 7 8 9 10 11 12 Published May 30, 2000 (modified 10/16/00). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). http://www.cdc.gov/growthcharts MacPeds Survival Guide kg/m 13 14 15 16 17 18 19 20 55 NAME Weight-for-stature percentiles: Boys Date Age Weight RECORD # Comments Stature kg 34 33 lb 76 72 32 31 68 30 29 28 97 95 lb 56 52 kg 27 26 26 25 23 48 24 75 23 22 50 20 60 56 52 48 21 25 20 10 19 40 85 22 21 44 25 90 24 64 44 19 3 40 18 18 17 17 16 16 15 15 14 14 13 13 12 12 11 11 10 10 20 9 9 20 lb 8 kg 8 kg lb 36 32 28 24 STATURE cm in 80 31 85 32 33 90 34 35 95 36 37 100 38 39 105 40 Published May 30, 2000 (modified 10/16/00). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). http://www.cdc.gov/growthcharts MacPeds Survival Guide 41 110 42 43 115 44 45 120 46 47 56 36 32 28 24 NAME Weight-for-stature percentiles: Girls Date Age Weight RECORD # Comments Stature kg 34 33 lb 76 72 32 31 68 30 29 28 97 lb 56 52 48 kg 27 26 26 25 90 25 24 85 24 23 75 23 22 22 50 21 44 40 60 56 52 48 21 20 25 20 19 10 19 3 18 64 18 44 40 17 17 16 16 15 15 14 14 13 13 12 12 11 11 10 10 20 9 9 20 lb 8 kg 8 kg lb 36 32 28 24 STATURE cm in 80 31 85 32 33 90 34 35 95 36 37 100 38 39 105 40 41 110 42 43 115 44 45 120 46 47 Published May 30, 2000 (modified 10/16/00). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). http://www.cdc.gov/growthcharts MacPeds Survival Guide 57 36 32 28 24 ADOLESCENT INTERVIEWING (HEADDSS) • Interview teens alone with parents invited to join at the end (Alternatively, you can start with the parents in the room and have them leave at some point) • Allow adequate, uninterrupted time to inquire about all aspects of their life, and high-risk behaviours in private setting • Assure confidentiality at beginning of interview, and prior to discussing drug use and sexuality • In addition to “HEADDSS” obtain routine history including: Past Medical History, Meds, Allergies and Vaccines (HPV, hepatitis, meningococcal in particular) Home • Tell me what home is like… • Who lives at home? How does everyone get along? What do you argue about? What are the rules like at home? • Any new people living at home? • Family members – ages, occupations/education, health status, substance abuse Education / Employment • Name of school, grade level, attendance pattern • Most favourite/least favourite courses, marks in each course, change in marks recently? • Part-time / full-time job – for $ or ‘experience’ • What are your educational goals? What are your employment goals? Activities • What do you do for fun? On weekends? • Do you feel you have enough friends? Who are your best friends? What do you do together? • Sports / Exercise, extra-curricular activities MacPeds Survival Guide 58 ADOLESCENT INTERVIEWING (Continued) Drugs • Have you ever tried cigarettes? Alcohol? Marijuana? • Ever drunk? • Binge drinking on weekends? • For younger teens: ask about friends’ use and peer pressure • Cover all drug classes: hallucinogens, amphetamines, rave drugs, IV drugs, crack cocaine, OTC meds, anabolic steroids • What age did you start? Frequency of use? How much? • What do you like/dislike about X? Why do you use X ? • Do you use alone? Any police involvement? Dealing? Dieting • Do you have concerns about your weight/shape? • Have you tried to change your weight/shape in any way? (dieting/exercise) • Presence of bingeing/purging behaviours, use of diuretics/laxatives • Tell me what you eat/drink in an average day… • ~20% of teens are on a diet at any one time, up to 66% have tried to lose weight in the past • Use BMI curves to estimate ‘healthy weight’ for teen based on height Sexuality Over 2/3 of teens have had one sexual partner by age 18 The average age of first intercourse in Canada is 16 years For female adolescents: • How old were you when you started your periods? • How often do you have your period? How may days does it last for? • Are your periods heavy or painful? • How often do you miss school because of your period? For all adolescents: MacPeds Survival Guide 59 • ADOLESCENT INTERVIEWING (Continued) • Are you interested in the same sex, opposite sex or both? (DO NOT assume heterosexuality!) • Are you dating someone now? Are you having sex? What kinds of sex (oral/anal/vaginal)? What do you use for contraception/STI prevention (condoms, OCP, Depoprovera, Emergency Contraception etc.) • Have you ever been forced or pressured into having sex? • Number of sexual partners /age of first sexual activity/STI history / ever tested for STIs, HIV/ last pelvic exam in females, partner history of STI and partner’s STI risk behaviours • Have you ever been pregnant or gotten someone pregnant? Suicide / Depression • Screen for depression (SIGECAPS) • Have you lost interest in things you previously enjoyed? • How would you describe your mood? On a scale of 1-10? • Any change in sleep pattern? Ability to concentrate? • Have you had any thoughts about hurting or killing yourself? • Have you ever engaged in self-harm behaviours? • What do you do to relieve stress? • Do you have an adult that you can talk to if you are having a hard time? Who is that person? Safety • Do you regularly use: seatbelts? Bike helmets? Appropriate gear when snowboarding/skateboarding or other sports? • Does anyone at home own a gun? • Have you ever been the victim of violence at home, in your neighbourhood or at school? • Has anyone ever hurt you or touched you in a way that was hurtful or inappropriate MacPeds Survival Guide 60 WEIGHT CONVERSION CHART POUNDS OUNCES 0 0 0 0 1 28 2 57 3 85 4 113 5 142 6 170 7 198 8 227 9 255 10 284 11 312 12 340 13 369 14 397 15 425 1 454 482 510 539 567 595 624 652 680 709 737 765 794 822 851 879 2 907 936 964 992 1021 1049 1077 1106 1134 1162 1191 1219 1247 1276 1304 1332 3 1361 1399 1418 1446 1474 1503 1531 1559 1588 1616 1644 1673 1701 1729 1758 1786 4 1814 1843 1871 1899 1928 1956 1985 2013 2041 2070 2098 2126 2155 2183 2211 2240 5 2268 2296 2325 2353 2381 2410 2438 2466 2495 2523 2552 2580 2608 2637 2665 2693 6 2722 2750 2778 2807 2835 2863 2892 2920 2948 2977 3005 3033 3062 3090 3119 3147 7 3175 3204 3232 3260 3289 3317 3345 3374 3402 3430 3459 3487 3515 3544 3572 3600 8 3629 3657 3686 3714 3742 3771 3799 3827 3856 3884 3912 3941 3969 3997 4026 4054 9 4082 4111 4139 4167 4196 4224 4252 4281 4309 4338 4366 4394 4423 4451 4479 4508 10 4536 4564 4593 4621 4649 4678 4706 4734 4763 4791 4820 4848 4876 4905 4933 4961 11 4990 5018 5046 5075 5103 5131 5160 5188 5216 5245 5273 5301 5330 5358 5387 5415 12 5443 5472 5500 5528 5557 5585 5613 5642 5670 5698 5727 5755 5783 5812 5840 5868 13 5897 5925 5954 5982 6010 6039 6067 6095 6124 6152 6180 6209 6237 6265 6294 6322 14 6350 6379 6407 6435 6464 6492 6521 6549 6577 6606 6634 6662 6691 6719 6747 6776 15 6804 6832 6861 6889 6917 6946 6974 7002 7031 7059 7088 7116 7144 7173 7201 7229 MacPeds Survival Guide 61 ADMISSION ORDERS (ADDAVID) Admit: Admit to (Ward 3B/3C/NICU/L2N) under (staff name, Team #); -If admitting while on-call overnight double check with your senior resident which team that patient should be admitted to. “Admit to Team x under the care of [Night Staff name] with transfer of care to [Team x Day staff] in the morning” Diagnosis: Confirmed or Suspected (eg. UTI with 2° dehydration) Diet: DAT (diet as tolerated) NPO (nothing per os/by mouth; if going for surgery or procedures) Sips Only, CF (Clear Fluids), FF (Full Fluids), Thickened Fluids (dysphagia), Advancing Diet (NPO to sips to clear fluids to full fluids to DAT), Diabetic Diet (indicate Calories eg. 1800 Kcal, 2200 Kcal), Cardiac Diet, TPN etc. Include amount, frequency, rate if applicable. Activity: AAT (Activity as Tolerated), NWB (Non-Weight bearing), FWB (Full Weight bearing), BR (Bed Rest), BR with BRP (Bed Rest with Bathroom Priviledges), Ambulation (Up in Chair Tid, Ambulate bid) Vital Signs: VSR (Vital Signs Routine (HR, RR, BP, O2 sat, Temp. q 8-12 hours, q shift), VS q4h (if particularly sick patient requiring more frequent vitals), Special parameters (eg. Postural vitals, Neuro vitals) Monitor: Accurate Ins & Outs (Surgery, volume status pts.) Daily weights (eg. Renal failure, edematous, infants) Investigations: Hematology: CBC + diff, PTT/INR Biochemistry: Electrolytes (Na+, K+,Cl-, HCO3-), Urea, Creatinine, Ca2+, Mg2+, PO4-, glucose, CSF cell count, CSF protein and glucose Microbiology: Urine R&M/C&S, Blood Cultures, CSF from LP for gram stain, C&S. For this section just remember all the things you can culture: CSF, Sputum, Urine, Feces, Pus from wounds, Blood Imaging: CXR, CT, MRI, EKG, PFT, Spirometry Consults: Social Work, Neurology, Infectious Diseases Drugs All medications patient is already on (Past), medications the patient needs right now (Present), anticipate what the patient might need: prophylaxis, sleep, nausea and pain (Future) 10 Patient P’s: Problems (specific medical issues), Pain (analgesia), Pus (antimicrobials), Puke (anti-emetics, prokinetics, antacids), Pee (IV fluids, diuretics, electrolytes), Poop (bowel routine), Pillow (sedation), PE (anticoagulation), Psych (DTs), Previous Meds Ensure you date and time your orders, put the child’s weight and list any allergies on the order sheet. Make sure you sign the order sheet and write your name legibly and pager number. MacPeds Survival Guide 62 PROGRESS NOTE: PEDIATRICS General Pediatrics Ward (3B/3C) – Clinical Clerk Progress Note Date ∗ Always LEGIBLY note the Date, Time, Your Name and Pager Number ∗ Time ID: age, sex with a history of (non-active/chronic issues/previously well) admitted with (list active/acute issues for why patient is admitted) eg. 18 mo ♀ previously healthy, admitted with a UTI and 2° dehydration Subjective: S: How patient’s night was (O/N) and how they feel that day and any new concerns they have. What has changed since the previous note. Does the patient have any new symptoms? How is the patient coping with the active symptoms, progression, better/worse. If patient is non-verbal, ask the parents or patient’s nurse. Remember to ask about: behaviour, activity, sleep, appetite, in and outs. Objective: O: General: Patient disposition (irritable, sleeping, alert), general appearance, behaviour, cognition, cooperation, disposition Vitals: HR, BP, RR, SaO2 (on Room Air/NP with rate or %), Temp (PO/PR/AX), weight (daily, with changes noted), Inputs (Diet, IV fluids and rate), Output (Urine Output, BM/Diarrhea, Vomiting, Drains) Vitals: Temp (PO or PR or Axilla?), HR, RR, BP, SaO2 (on room air? 24%? 2L?) Focused P/E of system involved plus CVS, RESP, ABDO, EXT/MSK common for hospitalized patients to develop problems in these systems Investigations (Ix): New lab results, imaging or diagnostic tests/interventions MEDS: reviewed daily for changes regarding those that are new/hold/discontinued/restarted Assessment & Plan\Impression (A/P or Imp): Summarize what the new findings mean, what progress is being made Improved? Stable? Waiting investigations/consult? Differential Diagnosis if anything has been ruled in/out Plan (A/P or I/P): Issue (1) à eg. UTI à Day 2 of Empiric Abx, likely 14 day course required. Awaiting culture and sensitivity Issue (2) à eg. Dehydration à Intake still minimal, Urea mildly elevated, clinically dehydrated therefore continue IVF at 50 ml/hr Encourage oral fluids Name, Designation (CC\PGY), Pager Number Discussed with Dr. ________________ MacPeds Survival Guide 63 Documentation • Colleges and legislation define good documentation • Essential part of being a competent physician • Provides communication amongst team members and other physicians • Information documented in chart belongs to the patient - - you are the caretaker • ALL notes in medical records should be written with expectation that they will be viewed by the patient and/or their legal representative PROFESSIONALISM • Colleges require a written, legible, medical record accompany patient encounters, as a standard of practice • Hospitals require documentation be done in a timely manner • Documentation should provide a clear indication of physician's thought process Documentation in clinical notes should: • Be factual, objective, and appropriate to the purpose • Be dated and timed (preferably with 2400 clock) • Provide chronological information • Be written in a timely manner • Be legible, including signature and training level • Use only well-recognized abbreviations Documentation should allow someone to determine: • Who attended the appointment (i.e. mother, father) • What happened • To whom • By whom • When • Why • Result • Impression • Plan • Late entries must be recorded as such • Phone contact should also be timed MacPeds Survival Guide 64 Choose words carefully – use: ‘Reported no…..’ VS ‘denied’ ‘Declined’ VS ‘refused’ Avoid subjective and/or disparaging comments relating to the care provided by other HCP. Doubts about a colleague's treatment decisions should not be recorded in medical records. Better to talk to your colleague instead. Write only what YOU did or did not do. You cannot testify to the truth of the event if no personal knowledge. • If negative event occurs, document what steps you took (who notified, course of action). Again write no comments as to what others did, will do, or said, etc. Notes may be written elsewhere (not in chart) in the event of potential litigation, but these notes are not protected, NEVER change, tamper or add to a medical record. Any subsequent additions or changes should be dated and signed at the time you make them, to avoid undermining the credibility of any changes. • Do NOT later change an existing entry. • Do NOT black-out or white-out words or areas. • Do NOT insert entries between lines or along the margins of the chart as these may appear to have been added later, casting doubt on their reliability. • Do NOT add an addendum to the chart after learning of a legal action, threat of a legal action or other patient complaint. Poor charting may be perceived as reflecting less attention to detail, risking the conclusion that care provided was poor. MacPeds Survival Guide 65 Mandatory Reporting of Suspected Child Abuse and Neglect During your clinical training in Pediatrics at McMaster, there is a possibility that you will encounter a child in whom child abuse has been diagnosed or is suspected. As a regulated health professional, you are required, under the provisions of the Child and Family Services Act to immediately report to a Children’s Aid Society (CAS) any suspicion that a child has suffered or is at risk of suffering from physical, sexual or emotional abuse and/or neglect (which includes exposure to domestic violence). There are serious legal and professional repercussions if a physician fails to meet this obligation. If you become concerned that a child has suffered or is at risk of suffering abuse or neglect, you are encouraged to discuss this immediately with your preceptor so that it can be determined if a report to CAS is warranted. While it is unlikely to occur, keep in mind that it is an offense for someone in a position of authority to prevent another person from making a report if that person believes that there is sufficient cause to do so. For more information: http://www.cpso.on.ca/uploadedFiles/policies/policies/policyitems/mandatoryreporting.pdf GENERAL RULES re: DISCLOSING PHI (Personal Health Information) TO POLICE: 1. Must seek consent of the individual (or substitute decision maker) OR 2. Release information if required by law (i.e. mandatory gunshot wound reporting) OR 3. Release in compliance with a summons or order compelling production of the information; warrant only give out if disclosure details are provided 4. Police are not part of the circle of care and are not Health Information Custodians The above information is described in s.43(1)(g) of PHIPA. Please say to the police, "If you bring the proper documentation, then I'm happy to comply with your request". PHIPA allows health care providers to tell anyone that: an individual is a patient in the facility, individual's health status (ie stable, serious), location of the facility (unless individual instructs otherwise), or to identify the deceased MacPeds Survival Guide 66 DISCHARGE SUMMARY TEMPLATE: PEDIATRICS Today’s date My name, designation (i.e. resident, clinical clerk) Attending MD Patient name, ID# Copies of this report to: FD, pediatrician, pertinent consultants Date of Admission: Date of Discharge: “Start of dictation” ADMISSION DIAGNOSIS: DISCHARGE DIAGNOSIS: 1., 2. etc OTHER (non-active) DIAGNOSIS: FOLLOW-UP: (appointments, pending investigations, home care) DISCHARGE MEDICATIONS: (dose, frequency, route and duration) SUMMARY OF PRESENTING ILLNESS: - 1-2 line summary of child’s presenting illness and reason for admission. Refer to separately dictated note for full history and physical examination of admission. - Only if no admission dictation completed, indicate full history of presenting illness (HPI), Past medical history, and initial physical examination prior to ‘Course in Hospital’ COURSE IN HOSPITAL: - Describe briefly the events and progression of illness while in hospital including status upon discharge - Details of drug doses used, IV rates, etc rarely required and difficult to confirm as signing staff physician. Rather, say “XXX required hourly nebulized Ventolin for 5 hours after which the dosing interval was extended to every three hours”. - If the child has multiple medical issues, this section can be done by system (cardiovascular, respiratory, fluids and nutrition, ID, hematological, CNS, etc) - List complex investigations (with results) under a separate heading. State your name, designation; Attending MD name Press 8 to end dictation, and write down job # on face-sheet of chart MacPeds Survival Guide 67 QUALITY DOCUMENTATION INITIATIVE Discharge Summary Template Diagnosis on Admission: Includes most responsible diagnosis for hospital admission Diagnosis at Discharge: Includes most responsible diagnosis for hospital admission as well as co-morbid conditions identified either at time of admission or during the hospital admission as well as complications developed during course in hospital Procedures: Includes a comprehensive list of procedures performed during hospital admission for definitive treatment, diagnostic or exploratory purposes Course in Hospital: Includes a detailed comprehensive list of critical events while in hospital, complications, response to treatment Discharge Medications: Includes a comprehensive list of medications, active at discharge, dosage and mode of administration Discharge Plans/ Follow-up: Includes a comprehensive list of appointments, treatments, referrals, recommendations and follow-up including responsible physician(s), health care team(s), or agency involved, including arrangements for aftercare MacPeds Survival Guide 68 Comparison of IV Solutions IV Solution Na+ K+ Cl- (mEq/L) (mEq/L) (mEq/L) Sodium Chloride 0.45% 77 Sodium Chloride 0.9% (0.9 NaCl, NS) 154 Sodium Chloride 3% 513 Dextrose 5% 0 Dextrose 5% Sodium Chloride 0.2%* (D5 0.2NS) 39 Dextrose 5% Sodium Chloride 0.45% (D5 ½NS) 77 Dextrose 5 % Sodium Chloride 0.9% 154 Dextrose 10% 0 Dextrose 10% Sodium Chloride 0.2%* 39 Dextrose 10% Sodium Chloride 0.45%* 77 Dextrose 10% Sodium Chloride 0.9%* 154 Dextrose 3.3% Sodium Chloride 0.3% (⅔ * ⅓) 51 Lactated Ringers† 130 4 2+ †Also contains Calcium (Ca ) 1.5 mmol/L, and Lactate (HCO3 ) 28 mmol/L *These solutions are not commercially available Commonly used solutions are highlighted MacPeds Survival Guide 154 77 51 109 Dextrose (g/L) Osmolarity (mOsm/L) 0 0 0 50 50 50 50 100 100 100 100 33.3 0 154 308 1030 250 320 405 560 505 575 660 813 273 273 69 FLUID MANAGEMENT IN CHILDREN 3 Components to Fluid Management: 1. Maintenance 2. Deficit Replacement 3. Ongoing Losses Replacement 1. Maintenance § Fluid and electrolyte requirements are directly related to metabolic rate § Holliday-Segar Rule - calculation of maintenance fluid requirements using body weight for resting hospitalized patients (based on 100 cc for each 100 kcal expended): Body Weight Volume in 24 hours Up to 10 kg 100 cc/kg/d (1,000 cc for 10kg child/day) 11- 20 kg 1,000 + 50 cc/kg above 10 kg Above 20 kg 1,500 + 20 cc/kg above 20 kg Weight (kg) Hourly Fluid Requirements (Calculated by "4-2-1 rule”) 0-10 kg 4 mL/kg/h 11-20 kg 40 mL/h + (2 mL/kg/h for each kg over 10 kg) >20 kg 60 mL/h + (1 mL/kg/h for each kg over 20 kg) § Insensible water losses = cutaneous + pulmonary water losses which are calculated as ~ 300 – 500 cc/m2 § During fluid management, we should assess factors affecting insensible and/or urinary fluid losses § Normal Na+ and K+ requirements 2 – 4 mEq/kg/day § During fluid management, we should assess factors that affect Na and K balance § Adding 5% dextrose to maintenance solution prevents protein catabolism § Most commonly used solution in children: D5 ½ NS + 20 mEq/L KCl or D5W/NS + 20 mEq/L KCl § D5 ½ NS + 20 mEq/L KCl = 4 mEq/100cc/d Na+ and 2 mEq/100cc/d K+ § D10W: use in Neonates and Hypoglycemia MacPeds Survival Guide 70 FLUID MANAGEMENT IN CHILDREN (Continued) 2. Deficit Replacement – Assessment Includes: Severity: § Represents the percentage of body weight loss, acute weight loss reflects losses of fluid and electrolytes rather than lean body mass § Most commonly estimated based on history and physical exam § See table on next page § To calculate fluid deficit: % x 10 x body weight (pre-illness) Type: § A reflection of relative net losses of water and electrolytes based on serum Na+ or osmolality § Important for pathophysiology, therapy and prognosis § Affects water transport between ICC and ECC § 70 – 80% pediatric dehydration is isotonic Type of Dehydration Hypotonic or Hyponatremic Isotonic or Isonatremic Hypertonic or Hypernatremic MacPeds Survival Guide Electrolyte Status Serum Na+ < 130 mEq/L, Serum Osm < 270 Clinical Features Exacerbated signs of dehydration Risk of seizure Serum Na+=130-150 mEq/L, Serum Osm 270 – 300 Serum Na+ > 150 mEq/L, Decreased signs of Serum Osm >300 dehydration Irritable, increased tone and reflexes 71 FLUID MANAGEMENT IN CHILDREN (Continued) Assessing Dehydration: Severity Patient Presentation Mild Less than 1 year: Less than/equal to 5% Moderate Less than 1 year: 10% Severe Less than 1 year: 15% Greater than 1 year: <= 3% Greater than 1 year: 6% Greater than 1 year: 9% Heart Rate Normal Mild tachycardia Moderate tachycardia Blood Pressure Normal Normal (orthostasis) Decreased Normal Normal Increased < 2 seconds Normal Normal Normal / Dry 2 - 3 seconds Decreased Depressed Dry > 3 seconds Tenting Depressed Dry Normal Altered Depressed Normal / Absent Normal Absent Sunken Absent Sunken Small 1.020 Oliguria 1.025 Oliguria-anuria Maximal Age % Weight Loss Respiratory Rate Skin Capillary refill Elasticity (less than 2 years) Anterior fontanel Mucous membranes CNS Mental Status Eyes Tearing Appearance Laboratory Tests Urine Volume Specific gravity Blood Blood Urea Nitrogen Upper normal Elevated High Signs of dehydration may be less evident or appear later in hypernatremic dehydration; conversely, they may be more pronounced or appear sooner in hyponatremic dehydration MacPeds Survival Guide 72 FLUID MANAGEMENT IN CHILDREN (Continued) Labs: § Helpful in evaluation of Type and Severity of dehydration § May need to start therapy before lab results available § CBC for hemoconcentration, infection, source of dehydration § Electrolytes (Na+, K+, Cl-, HCO3-) § BUN, Cr increased in severe dehydration § Blood gas and HCO3- for metabolic acidosis, may need to calculate Anion Gap (AG) = [ (Na+ + K+) – (Cl- - HCO3-)] Normal AG = 12 ± 4 § Urine R&M, concentrated urine in dehydration, infection Monitoring Ongoing Dehydration\Rehydration Response: § Clinical response to treatment § HR, BP, Cap refill, LOC, Urine output § As indicated: cardioresp monitor, CVP, ECG § Labs as indicated: electrolytes, urine specific gravity, serum / urine Osm § Repeated careful weight measurement § Accurate INS and OUTS including stool volume & consistency 2. Deficit Replacement – Oral Rehydration Therapy (ORT): § First-line treatment for Mild to Moderate dehydration § Requires close monitoring and compliance of patient and parents § Contains balanced amounts of sodium and glucose § Basic treatment is replacing the deficit over 4 – 6 hours and replacing ongoing losses (eg. Diarrhea) by ORT § Initial rates of ORT: § Mild:1 cc/kg/5 mins § Moderate 2cc/kg/5 mins MacPeds Survival Guide 73 Solution WHO Rehydrate Pedialyte Pediatric Electrolyte Infantlyte Naturlyte MacPeds Survival Guide Glucose (mEq/L) 111 140 140 140 Na (mEq/L) 90 75 45 45 K (mEq/L) 20 20 20 20 Base (mEq/L) 30 30 30 30 Osmolality 70 140 50 45 25 21 30 48 200 265 310 310 250 250 74 FLUID MANAGEMENT IN CHILDREN (Continued) 2. Deficit Replacement – Parenteral Therapy (IV): § Indications: Severe dehydration, patients who fail ORT due to: vomiting, refusal or difficulty keeping up with losses § Preferable site is IV, if unable to start IV use IO § Consists of 3 phases: (i) Initial Therapy o Goal: expand ECF volume to prevent or treat shock o Solution: isotonic saline (0.9% NS or RL) in all forms of dehydration, never use hypotonic solution!!! o Bolus 10 – 20 cc/kg of N/S ( or RL) over 15-20 mins initially, may be repeated until patient is hemodynamically stable, if unstable, call Peds 1000! o Rapid Rehydration (eg. 20-40 cc/kg bolus + ORT) à no evidence o If hypokalemic: start K+ when patient voids (normal renal function). Note: no K+ in bolus! (ii) Subsequent Therapy o Goal: continue replacement of existing deficit, provide maintenance and electrolytes, replace ongoing losses o Solution: D5 ½ NS + 20 mEq/L KCL or D5NS + 20 mEq/L KCL in isotonic dehydration o Deficit Replacement Time: usually over 24 hours à ½ deficit in first 8 hours, second ½ deficit over next 16 hours o Subtract boluses from deficit calculation o Source of Electrolyte Losses: 60% ECF and 40% ICF § For every 100 cc water lost, electrolyte losses: o Na+: 8.4 mEq/L / 100cc o K+: 6.0 mEq/L / 100cc o Cl-: 6.0 mEq/L / 100cc (iii) Final Therapy o Return patient to normal status and to normal feeding MacPeds Survival Guide 75 FLUID MANAGEMENT IN CHILDREN (Continued) 3. Ongoing Losses Replace… Gastric Losses (Vx) Stool or Intestinal losses (Diarrhea) CSF losses Urine Output Losses due to Burns With… ½ NS + 10 – 20 mEq/L KCl Add HCO3- to ½ NS + 10 – 20 mEq/L KCl 0.9% NS As indicated Increase fluid administration (Parkland) Isotonic Dehydration • See previous steps • Rehydrate over 24 hours Hypotonic Dehydration • Degree of dehydration may be overestimated • May need immediate circulatory support • Calculate fluid losses as above • Calculate electrolyte losses • Calculate Na+ to correct Na+ to 130 mEq/L using the following formula (as long as Na+ > 120 mEq/L) o (Desired Na+ – Measured Na+) x 0.6 x weight (kg) • Replace losses over 24 hours (if acute losses!) • Max increase 1 mEq/L Hypertonic Dehydration • Bolus by NS or RL as indicated • Avoid electrolyte free solutions • Calculate water and electrolyte losses • Replace deficit slowly over 48 hours • Monitor serum Na+ q2 – 4hours (should not fall > 0.5 mEq/L/h, max 10 mEq/L/24h) and change fluids according to Na+ drop • Usually seize as Na+ drops, rather than as increases • If seizures or signs of increased ICP, treat with mannitol MacPeds Survival Guide 76 Guidelines for Prescribing Maintenance IV Fluids in Children • These are general guidelines for ordering maintenance IV fluids (IVF) only, and do not apply to resuscitation or complicated fluid and electrolyte disorders. Seek additional advise/appropriate consultation in the event of fluid and electrolyte abnormalities. • Consider IV fluids as DRUGS - individualize prescriptions daily according to objectives, and monitor for potential side effects. • Be aware that the commonest side effect of IVF therapy is HYPONATREMIA, particularly in patients at risk, and if hypotonic solutions are used Step 1: Determine IV fluid rate, according to “maintenance fluid” requirements, and replacement of deficit or ongoing losses (Total Fluid intake (TFI). In general maintenance fluid rate is calculated by the “4:2:1” guideline, but should be individualized according to the clinical condition and patient assessment Step 2: The choice of fluid is dependent the individual patient. Consider ISOTONIC IVF for the following patients: • CNS disorder, Diabetic ketoacidosis • Patients at risk of hyponatremia: acute infection, post-operative patients and burns, Plasma Na < 138 Add K+ to provide 1-2 mEq/kg/day, if patient has urine output IV solution Weight (kg) ml/hour 0-10 4/kg/hour 11-20 40 + (2/kg/hr) >20 60 + (1/kg/hr) Na (mEq/L) K (mEq/L) Cl (mEq/L) % Electrolyte Free Water (EFW)* 0.2% NaCl in D5W 34 0 34 78 0.45% NaCl in D5W 77 0 77 50 • Patients with an EFW deficit - e.g. hypernatremia, ongoing EFW losses (renal, GI, skin) H y p o t o n i c Lactated Ringers 130 4 109 16 • Patients with established 3rd space overload - e.g CHF, nephrotic syndrome, oliguric renal failure, liver failure 0.9% NaCl in D5W (ISOTONIC) 154 0 154 0 • Limited renal solute handling indicated - e.g. neonatal population, hypertension Add Dextrose to prevent hypoglycemia/ketosis (exceptions: hyperglycemia,brain injury) Consider HYPOTONIC IVF for the following patients: Step 3: MONITORING while on IV fluid Clinical status: hydration status,urine output, ongoing losses, pain, vomiting, peripheral edema, and general well-being. Daily weights Reassess TFI, indications for and fluid prescription at least every 12 hours. *Based on a sodium plus potassium concentration in the aqueous phase of plasma of 154mEq/L, assuming that plasma is 93% water with a plasma sodium of 140 mEq/L and a potassium concentration of 4 mEq/L Measure and record as accurately as possible Fluid balance: must be assessed at least every 12 hours Intake: All IV and oral intake (including medication). Ensure this matches desired TFI. Output: all losses (urine, vomiting, diarrhea etc.) Labs: Serum Electrolytes - at least daily if primary source of intake remains IV, or more frequently depending on clinical course, or in the presence of documented electrolyte abnormality. Urine osmolarity/sodium and plasma osmolarity as indicated, for determining etiology of hyponatraemia. Version date : April 2011 MacPeds Survival Guide 77 Developmental Milestones Gross Motor 0-1 month Fine Motor Language -Moves head from side to side on stomach -Usually flexed posture (prone position legs are under abdomen) -Keeps hands in tight fists -Brings hands within range of eyes and mouth -Turns toward familiar sounds & voices -Hips not as flexed (prone position legs not under abdomen) -Head control improving (pull to sit) -Hands open most of the time -Cooing (vowel-like sound- ooooh, ah) -Lift head when held -Grasps and shakes hand toys -Recognizes some sounds Social & Self help Red Flags -Recognizes the scent of his own mother's breast milk -Prefers the human face to all other patterns - Sucks poorly - Doesn't respond to bright lights or loud noise blink when shown bright light - Seems stiff or floppy -Smiles - Doesn't smile at the sound of your voice by 2 months - Doesn't notice her hands by 2 months -Not tracking objects Achieved 2 months -Increases vocalization when spoken to -Face is expressive Achieved 3 months -Lift head & chest when on tummy -Chuckles -Turn toward the sound of a human voice - Doesn't hold objects -Smile when smiled at - Doesn’t support head - Doesn't reach for and grasp toys by 3 - 4 months - Doesn't babble - Always crosses eyes - Doesn’t smile -Holds hands open -Begins to imitate some sounds -Reaching & grasping -Brings toys to mouth -Looks at objects in hand -Shows excitement w/ voice & breathing -Increases vocalization to toys & people -Smiles at self in mirror -No head lag -Head steady when sitting -May roll backàfront -Holds two objects in both hands when placed simultaneously -Mimics sounds & gestures -2 syllable sounds (ahgoo) -Babbles to get your attention -Able to let you know if he’s happy or sad -Doesn’t roll over -Sits w/ hands on legs (propping self up) -Bears full weight on legs if held standing -Transfers object from 1 hand to the other -Reaches after dropped toys -Expresses displeasure with non-crying sounds -Knows family from strangers -Pats at mirror image -Pushes adult hand away -Babe makes no sounds or fewer sounds, especially in response to you -Doesn’t reach for things -Bounces when held standing -Assumes crawling position -Reaches with one hand -Bangs toys on table surface -Begins responding to "no" -Starts using consonants (da, ba, ga) -Enjoys social play -Reaches with 1 hand only -One or both eyes consistently turn in or out -Refuses to cuddle -In sitting, reaches forward and can return to sitting up erect -Holds own bottle -Responds to own name -Plays peek-a-boo -Starts eating finger foods -Babbles chains of consonants -Anticipates being picked up by raising arms -Gets to sitting position alone -Immature pincer grasp (thumb onto side of index finger) -Uses “mama” or “dada” nonspecifically -Waves bye Achieved 4 months -No head lag in pull to sit -Rolls from front to back -Increases vocalization to toys & people Achieved 5 months -Doesn’t lift head while on tummy Achieved 6 months Achieved 7 months -Interested in mirror images Achieved 8 months -Seems very stiff with tight muscles -Not babbling by 8 months Achieved 9 months MacPeds Survival Guide -Pulls to stand -Can’t push up on arms while on tummy -Can’t sit alone -Can’t bear weight in 78 -Crawling -Plays peek-a-boo standing position Imitates nursery gestures: -Pat-a-cake -No special relationship w/ any family members -Isn’t moving around room in some fashion i.e. rolling, creeping Achieved 10 months -Pulls to stand -Grasps bell by handle - Jargons with inflection -Cruises with 2 hands on a rail or furniture (for support) -Points at a bead/small object - Performs 1 nursery gesture on verbal command -Mature pincer à can pick up tiny objects with ends of thumb and index finger -One word with meaning (e.g. “dada”) -Understands simple request with gesture -Extends arm & leg to help when being dressed -No stranger anxiety -Doesn’t seek social interaction with familiar people -Mature pincer grasp -Starting to point -Helps turn pages in a book -2-3 words w/ meaning -Cries when mother or father leaves -Repeats sounds or gestures for attention -Doesn’t know their name -Not crawling or moving forward Says no single words -Waving -“So big” Achieved 11 months -Stands momentarily -Walks with one hand held Achieved 12 months -Walks a few steps -Stands independently -Creeps upstairs -Uses exclamations such as "Oh-oh!" Achieved Developmental Milestones: 1 - 5 Years: Skill Walking 12 mo 15 mo 18 mo 2 yrs 3 yrs 4 yrs 5 yrs Walking few steps, wide based gait, clumsy Walking few steps, wide based gait, clumsy Running, unstable Running well Broad jumps Walks on tip toes Skips alternating feet Fall if trying to pivot Jumps with 2 feet on floor Stands on 1 foot for 2 seconds Tandem gait forward Hops on 1 foot Creeps upstairs Creeps up-stairs Walk up-stairs w/ hand held Walks up stairs alone Alternates feet while walking up stairs Alternates feet while walking down stairs Balances on 1 foot for > or equal to 10 seconds 2 feet per step 2 feet per step Age Achieved Stairs Crawls downstairs very slow & careful Jumps off last steps Age Achieved Stands well Climbs up on a chair Sit on chair Kicks ball Climbs up onto a chair Throws ball +/falling over Walks & pulls object Throws ball overhand Pincer grasp Stacks 2 blocks Stacks 3-4 blocks Stacks 5-7 blocks Gross Motor Pedals tricycle Stands on 1 foot for 4 seconds Bicycle +/training wheels Stacks 9 blocks Stacks 10 blocks Does buttons up Imitates bridge Opposes fingers to thumb in sequence Age Achieved Fine Motor Releases object if asked Puts shapes on to board Age Achieved Drawing Crayon in mouth Linear scribbles Circular Imitates stroke Copies Circle 3yrs Copies square Copies triangle Copies cross MacPeds Survival Guide 79 Marks paper Scribble 3.5yrs Prints name Age Achieved 2-3 words 5-10 words 20 - 50 words Expressive Speech 5-8 words together Past tense Uses: I, me, u (pronouns) Prepositions (behind, on, under) 2 - 3word combo Answers ‘W’ questions Tells stories 2 step command Knows Age 100-200 words Defines words by use- what is a ball? Age Achieved Receptive Speech 1 command w/ gestures 1 command w/ out gestures 5 body parts 5 Common objects Knows their Sex 5-10 numbers by rote Full name 3-4 step instruction Counts 10 pennies Follows group direction Age Achieved Eating Eats cheerios Sipping cup Spoon level, w/ solids Spoon level, w/ semi-solids Eats neatly Eats neatly Spreads peanut butter on bread Plays peek-aboo Helps to remove cloths Start taking off cloths Takes cloths all off Supervised dressing; Dress alone Buttons clothes up Age Achieved Dressing Raise arms Unbuttons clothes Age Achieved Cognitive/ Adaptive Kisses on request Seeks help w/ gestures Use cause and effect toys Parallel play Plays simple games Folds paper Should have object permanence Imaginary friend Knows alphabet 4 colours Sort by size Knows: same, biggest, tallest Label shapes, classify object Listens to stories Unscrews tops Group play MacPeds Survival Guide 80 MacPeds Survival Guide 81 MacPeds Survival Guide 82 Immunizations: Other Information Note: For premature infants, administer vaccines according to chronological or cumulative age, not corrected age Immunization Schedules: http://www.health.gov.on.ca/en/public/programs/immunization/docs/schedu le.pdf Immunization Guide: http://www.phac-aspc.gc.ca/publicat/cig-gci/pdf/cig-gci-2006_e.pdf MacPeds Survival Guide 83 NEONATOLOGY MacPeds Survival Guide 84 St Joe’s NICU common terms and definitions list A’s and B’s- (apnea and bradycardia) defined as a cessation of breathing >20 sec or pause in breathing associated with decrease in oxygen saturation <85% or HR <100 or change in color or tone. Or just the presence of bradycardia. Will be reported as self resolved or requiring stimulation. Common in preterm infants however must always rule out sepsis. B/R- Breast feeding. BLES- Bovine surfactant, medication give for treatment of RDS (Respiratory distress syndrome) given via ETT (endotracheal tube) dose 5cc/kg. May also be used in MAS (meconium aspiration syndrome) or severe pneumonia. CPAP- Continuous positive airway pressure, non invasive form of ventilation providing continuous PEEP (positive end expiratory pressure) used to keep airways open and prevent airway collapse. Used in a multitude of settings. CLD (chronic lung disease) - formerly known as BPD (bronco pulmonary dysplasia) - CLD is usually defined as oxygen dependency at 36 weeks’ postmenstrual age (PMA) or 28 days’ postnatal age (PNA), in conjunction with persistent clinical respiratory symptoms and compatible abnormalities on chest radiographs . Gavage- form of feeding, by where an OG tube is inserted into the stomach (placed clinically) and a feed is given by gravity or over a period of time by pump. Prior to the feed the nurse will generally draw back to see if there is any residual feed in the stomach. Reported as 0/37, scant/37 or 5/37 where the first number represents the volume of the residual and the second number the volume of the feed given. Colour of the residual is important especially when evaluating for NEC (necrotizing enterocoloitis) GBS – (group B streptococcus) organism that is a common cause of neonatal infection, all women should be screened at 35-37 weeks and important to note at deliveries or on evaluation of infants < 7 days of age. Histogram- continuous monitoring of oxygen saturations over 1-2 hrs, done in either prone or supine position. Reported as an average of the time period. Reported as greater than 90 over 90, first number represents the saturation the second the percentage of the time that baby’s actual O2 saturation is over that saturation. Normal for preterm’s 90 over 90 For preterm’s greater than 30 days and diagnosed with CLD 85 over 90. *Normal values may vary with new research. IDDM- infant of a diabetic mother. Maternal diabetes can cause a multitude of neonatal complications, most commonly hypoglycemia. I/T ratio- immature to total ratio, used in the evaluation of sepsis. Calculated by taking the total number of immature WBC’s seen on manual differential (bands, myelocytes, metomyleocytes, and/or promyelocytes) divided by the total number of neutrophils plus the immature WBC’s. Immature WBC’s/total neutrophils + immature WBC’s IUGR (intrauterine growth restriction) - defined as symmetric or asymmetric, if symmetric both head circumference and weight are less than the 3rd percentile if asymmetric only the weight is <3rd percentile. NEC (necrotizing enterocolitis) - Gut infection, characterized by feeding intolerance, bilious residuals, abdominal distension, bloody stools, with other signs and symptoms of sepsis. MacPeds Survival Guide 85 Nippling- synonymous with bottle feeding, reported as infant nippled 20 (infant took 20cc by bottle) RDS- (Respiratory Distress syndrome) common in preterm infants or infants of IDDM (infant of a diabetic mother) due to surfactant deficiency. TPN- (Total Parenteral Nutrition)- form of nutrition given by IV, contains glucose and varying amount of Na+, K+, Ca2+ PO43- , lipids and amino acids, generally used when infants cannot tolerate feeds. TFI- (Total fluid index) volume of fluid that an infant receives per day, either enteral or parenteral. Reported in cc/kg/day. i.e. TFI of 60 cc/kg/day in a 3.0 kg term infant is: 60 x 3/24= 10 cc/hr or 30 cc q3h Some useful definitions and normal values for term newborns: Neonate: less than or equal to 28 days Infant: 28 days to 1 year Child: >1 year Birth -Average birth weight: 3.5 kg -Average birth length: 50 cm -Average birth head circumference: 35 cm Weight loss -Average weight loss in first week is 5-10% of birth weight -Max weight loss in first 48 hrs: 7% -Max weight loss in first week: 10% Growth -Return to birth weight by 14 days -Infants double their birth weight by 5-6 months -Infants triple their birth weight by 12 months -Head circumference increases by 12 cm in first year of life MacPeds Survival Guide 86 PROGRESS NOTE: NEONATES (LEVEL 2 NURSERY) Date Time ID: Baby boy (surname) Born at 335/7 (i.e. 33 weeks and 5 days) gestational age Day of life (DOL): 12 Corrected Gestational Age: 363 wks (335+ 12 days) Birth weight: 2680g Today’s weight: 2550g (↑ 10 g from yesterday) Brief problem list e.g. 1. Prematurity 2. Apnea of prematurity 3. Unconjugated hyperbilirubinemia 4. Suspected NEC S/O: Feeds: frequency, amount, what? (EBM? Formula? Supplement?), method, regurgitation/vomiting, breast feeding? Stool/urine pattern Other signs/symptoms you may be following (e.g. bilirubin) Behaviour: Settles easily? Irritable? Jittery? Interaction? Sleep? Handling? Episodes of Apnea/Bradycardia? (A’s and B’s) IV fluid/rate, urine output Medications and other treatments (i.e. phototherapy) Recent labs and investigations. A: Summarize active issues. Stable? Awaiting further investigations/consult Differential Diagnosis P: Outline plan by issue: include investigations, treatment, discharge plans . eg. Resolving NEC à increase feeds slowly, starting at EBM 5cc q3h Jaundice à double phototherapy, recheck bili in am. Name, Designation (CC\PGY), Pager Number Discussed with Dr. ________________ MacPeds Survival Guide 87 NICU / L2N DISCHARGE SUMMARY TEMPLATE Name of person dictating: Patient Name: Patient Identification Number: Admission /Transfer to L2N Date: Discharge Date: Copies to: Family physician Referral physician Follow-up pediatrician Health records All health care professionals involved Problems on Admission: 1. 2. 3. Birth Parameters Gestational age: Weight:____ g (%ile) Length: _____ cm (%tile) Head circumference:____cm (%ile) Current Problems: 1. 2. 3. Discharge Parameters Corrected and chronological age: Weight:____g Head circumference:_____cm Maternal History and Delivery: ____________was born at McMaster University Medical Centre/elsewhere on (date) at ___ weeks gestational age to (parents’ full names). (Mother’s name) is a (age) G T P A L woman whose antenatal screens were: rubella (immune/nonimmune), VDRL (reactive/nonreactive), hepatitis B serum antigen (-/+), HIV (-/+ __ GA), GBS (+/- at __ GA) and blood group __. This pregnancy was uneventful/complicated by__________. (Celestone was administered at __ weeks gestation.) Membranes ruptured __hours prior to delivery. The infant was born vaginally/caesarian section. Apgar scores were __ at one minute and __at five minutes. (Insert post-delivery management.) He/she was appropriate/small/IUGR for gestational age with dysmorphic/ no dysmorphic features seen. The infant was admitted to the NICU/L2N and had the following problems. Cord gases were normal, OR ____. ** If the infant had a prolonged stay in the NICU, refer here to NICU discharge summary, and do NOT repeat all these details.** Include only applicable headings below. MacPeds Survival Guide 88 Respiratory Distress Syndrome/Bronchopulmonary Dysplasia: The infant received __doses of BLES. (Name) was ventilated for __ days when he/she was extubated to NPCPAP. (Insert any complications: HFO, chest tubes, nitric oxide.) He/ she received (number) courses of dexamethasone. He/she was placed on low flow oxygen on __day of life. He/she is presently requiring (therapy). The last chest xray on (date) showed _____. The most recent blood gas shows __. Apnea of Prematurity: (Name) was loaded with caffeine citrate on __day of life. He/she is presently having __apneas per day/(or) is apnea free. Caffeine was discontinued on (date). Patent Ductus Arteriosus/Cardiovascular Anomalies: The infant was treated/not treated with a course of Indomethacin on (date) for a patent ductus arteriosus that presented clinically/(or) was confirmed on echocardiogram. (Describe current status of murmur). (Repeat echocardiogram? Other cardiac anomalies? Follow-up?) Hyperbilirubinemia: Mother’s blood type is __and infant’s blood type is __. Serum bilirubin peaked at __mmol/L at __day of life. The infant received __days of phototherapy. Hematology: (List any blood product transfusions). The most recent CBC on (date) showed a hemoglobin of__, WBC of__x 109/l, a platelet count of __,000 and no left shift. Sepsis: Cultures drawn following delivery were negative/(or) positive for (name of organism). The infant received a __(# of days) course of (name of antibiotics). Due to clinical deterioration(s) the infant had a partial/(or) full septic workup(s) on (date) which grew (name of organism) and was treated with (name of antibiotic). During the neonatal course the infant had__ episodes of sepsis which were culture negative/positive (state organism(s) if identified) Neurological: Cranial ultrasound(s) done on __day of life showed___(include date and result of most recent ultrasound). A follow-up ultrasound is recommended in __weeks. Retinopathy of Prematurity (ROP): Routine eye examinations were performed. The most recent examination on (date) revealed zone__stage __ with no plus disease. A follow-up exam is strongly recommended in __weeks to exclude progressive ROP. A follow-up eye appointment has been made at the eye clinic at McMaster for (date and time). MacPeds Survival Guide 89 Neonatal Abstinence Syndrome (NAS): The infant was monitored with Finnigan Scoring from ___ (date) to ___(date) for withdrawal symptoms due to maternal use of ___ (list substances applicable: oxycodone / methadone / cocaine, etc) with a peak Finnigan score of ___(#) reached on ___ (date). The infant's mother (was / was not) part of a Methadone program during pregnancy. Maternal urine drug screen at presentation to L&D on ___ (date) was positive for ___ (list substance/s). The infant’s urine was collected for drug screening on ___ (date) and was positive for ___ (list substances). The infant’s meconium & hair (was / was not) sent for drug screening. This infant (did / did not) require morphine treatment for withdrawal symptoms initiated on ___ (date) and discontinued on ___ (date), up to a maximum dose of ___ mg/kg/day on ___ (date). This infant (did /did not) require treatment with phenobarbital initiated on ___ (date) at a dose of ___ (#), which was equal to ___ (#) mg/kg/day. The infant (was / was not) discharged on Phenobarbital ___ (dose), which is equal to ___ (#) mg/kg/day. The infant’s weaning course off morphine was ___ (describe: quick / slow / a struggle weaning off final doses) and was complicated by ___ . Final Finnigan scoring in the 48 hrs prior to rooming in were in the range of ___ (#) to___ (#) . There (was / was not) breastfeeding restrictions due to the maternal use of ___ . Fluids, Electrolytes and Nutrition: Enteral feeds were started on __day of life and the infant achieved full enteral feeds on __day of life. Presently, the infant is receiving (TPN and/or__cc q__hourly of expressed breast milk fortified with __package of human milk fortifier to __mls of EBM (or) name of formula by gavage, breast and/or bottle) for a total fluid intake of __cc/hour. This provides __cc/kg/d or kcal/kg/d based on the current weight. On (date) the serum sodium was __mmol/L, calcium was__mmol/L, and phosphate was __mmol/. Social: Social worker ___ (list name) was involved with this infant and his/her family during the NICU stay due to ___ (reason). CAS (was / was not) involved with this family due to concerns of ___ . The infant’s CAS worker is ___ (list worker’s name) who can be reached at ___ (number & extension). At the time of discharge, the case with CAS will remain (open / closed). This infant will be going home to the care of ___ (list if it is: biological parents, kinship, foster care, adoption AND name/s of the individual /s). Immunizations: 1. Synagis (eligibility and date received or required and reference #). 2. Pentacel (date received or required), 3. Prevnar (date received or required). 4. Hepatitis B Immunoglobin/Vaccination (date received or required). Discharge Medications: Include iron, calcium/phosphate, vitamins MacPeds Survival Guide 90 Neonatal Screens: 1. Newborn Screen was completed on (date). 2. Hearing screen was performed on (date) as per Ministry of Health guidelines. A pass/fail was obtained for one/both ears. (Name) is being transferred to (hospital/) under the care of (physician) until he/she can be discharged home OR (Name) is being discharged home to the care of his parents/foster parents. Follow-up The infant requires follow-up for retinopathy of prematurity and cranial ultrasounds as well as (indicate any follow-up required including growth and development, appointments, etc.) Thank you for accepting the care of this infant. Name, Designation (CC\PGY), Pager Number Dictating For Dr. (Name of Paediatrician/Neonatologist) MacPeds Survival Guide 91 NEONATAL RESUSCITATION DRUGS Epinephrine IV Route 1:10,000 (Preferred Route) (0.01mg/kg) 0.1 mg/ml ETT Route q3-5 minutes (0.1 mg/kg) Sodium Bicarbonate 4.2% IV 0.5 mmol/ml (2 mmol/kg) For Prolonged Arrest Naloxone IV or IM 0.4 mg/ml (0.1 mg/kg) Contraindicated in narcotic dependent mothers Volume Expanders Normal Saline (NS, 0.9 NaCl) Packed Red Blood Cells Glucose (D10W) IV Bolus 200 mg/kg For documented hypoglycemia MacPeds Survival Guide 1 kg < 30 weeks 0.1 ml 2 kg 30-36 weeks 0.2ml 3 kg > 36 weeks 0.3 ml 1 ml 2 ml 3 ml 4 ml 8 ml 12 ml 0.25 ml 0.5 ml 0.75 ml 10 ml 10 ml 20 ml 20 ml 30 ml 30 ml 2 ml 4 ml 6 ml 92 Page 1 of 1 MacPeds Survival Guide http://circ.ahajournals.org/content/122/18_suppl_3/S909/F1.large.jpg 93 5/24/2012 NICU NUTRITION GUIDELINES ENTERAL FEEDING IN NICU Method of Feeding (By Age) Gavage Breast < 32 weeks Yes 32-34 weeks Yes 34-36 weeks If indicated 36-40 weeks Not usually Individual Assessment 1-2 q shift Yes Yes 1-2 q shift Near 34 wks Yes Yes Minimum feed Vol (cc)/ Time (hr) Yes Bottle Ad lib FEEDING HUMAN MILK IN NICU Human milk is the Feeding of Choice for All Infants in NICU Expressed Breast Milk (EBM) All infants should be established on feeds of EBM when available. If EBM is not available or not indicated then formula may be used either as a supplement to EBM or as the sole source of nutrition MacPeds Survival Guide 94 NICU NUTRITION GUIDELINES ENTERAL FEEDING IN NICU Initiation and Advancement of Enteral Feeds (By Birth Weight and Age) Infants < 1500 grams Birth Weight: Pre-calculated guidelines for each 100g weight category available in the NICU. Level 2 will have pre-calculated guidelines for babies >1100g < 750 grams 750 – 999 g 1000 - 1249 g 1250-1500 g Initiate Trophic Feeds: (10-15 ml/kg/d) By 12-24 hr of age By 12-24 hr of age By 6-12 hours By 6-12 hours Volume/Frequency Tropic Feeds Nutritional Feeds Timing Initiation Volume Feeding Interval 1 ml q3-4 hr X 3 days 1 mL q 2-3 hr x 2d 1-2 ml q2 hr x 1d 1-2 mL q2h x 1d Day 4 feeds Day 3 feeds Day 2 feeds Day 2 feeds 15-20 mL/kg/d 2 hourly 15-20 ml/kg/d 2 hourly 25-30 mL/kg/d 3 hourly Rate of Increase 15-20 mL/kg/d x 3d Then 20-25 mL/kg/d 15-20 mL/kg/d x 3 d Then 20-25 mL/kg/d 25-30 mL/kg/d <1250g – 2 hourly >1250g – 3 hourly 20-25 mL/kg/d 20-25 mL/kg/d Trophic Feeds – EBM or Enfamil Premature A+ 20 kacal/oz. (May delay trophic feeds up to 24 hr for EBM) Nutritional Feeds – EBM or Enfamil Premature A+ 24 kcal/oz Infants > 1500 grams Birth Weight Timing: Amount/ Frequency: Increase: 1500 - 1749 g > 29 weeks Day 1 / Stable 3 mL q 3 hr 1750 - 1999 g > 30 weeks Day 1 / Stable 6 mL q 3 hr 2000 - 2499 g > 31 weeks Day 1 / Stable 6 mL q 3 hr 3 mL q 9 hr 3 mL q 6-9 hr 3 mL q 3-6 hr MacPeds Survival Guide > 2500 g > 34 weeks Day 1 / Stable 9-12 mL q 3 hr / ad lib 3-6 mL q 3 hr 95 NICU NUTRITION GUIDELINES (CONTINUED) FEEDING HUMAN MILK IN NICU Expressed Breast Milk (EBM) + Enfamil Human Milk Fortifier Preterm infants < 34 weeks or < 1.8-2 kg Initiate Fortification: • When infant tolerating 100 m/kg/d for 24 hours Dosing: • Initially à 1 package fortifier per 50 mL EBM • Increase à 1 package fortifier per 25 mL EBM after 48 hours Continue Fortification: • Until infant reaches at least 2.0-2.5 kg or is established at breastfeeding • For nutritionally compromised infants, continue fortifier until infant reaches 2.5 – 3 kg or is established at breastfeeding • Note: if a baby is breastfeeding 4 times/day, and receives EBM fortified at 1:25 the other 4 feeds with a NG tube, vitamins and minerals will need to be reassessed as the total amount of fortifier is reduced. MacPeds Survival Guide 96 NICU NUTRITION GUIDELINES (CONTINUED) Formula Selection <34 weeks or <2.0 kg birth weight >34 weeks and Ø Enfamil Premature 24 A + and reassess when close to term and >2.0kg birth weight over 2200g If current weight is over 2200g, If current weight is over If current weight Ø Term and the birth weight was <1200 2200-3000, and the is >2200g and Formula * g or infant has BPD baby’s weight is above the Ø Enfamil Premature 24 A+ <10%ile on Fenton 10%ile on while in hospital growth chart Fenton growth Ø Enfamil A + chart If the current weight is >3.0kg or Enfacare Ø Term the infant is ready for discharge. Formula * Ø Enfamil A + Enfacare *Term Formulas: Enfamil A+, Similac Advance Nestle Goodstart Parents may choose formula they wish to use, if no preference, use Enfamil A+ (contract) Nutrient Composition of Fortified Human Milk / Enfamil Premature A+ per 100 mL Nutrient Unfortified Fortified Fortified Enfamil 1:50 1:25 Premature A+ 24 Energy (kcal/100 mL) 67 73 80 80 Protein – g 1.3 1.85 2.4 2.4 Calcium - mmol 0.63 1.8 2.9 3.3 Phosphorus – mmol 0.47 1.3 2.1 2.2 Vitamin A – IU 200 675 1150 1010 Vitamin D – IU 8 83 158 195 Sodium – mmol 1.2 1.5 1.9 2 Potassium - mmol 1.6 1.8 2 2 Iron – mg 0.09 0.81 1.53 1.46 Vitamin / Mineral Supplements using Enfamil HMF or Enfamil Premature Formula Vitamin D 400 units every Monday, Wednesday and Friday until weight approximate 1500g, then discontinue MacPeds Survival Guide 97 NICU NUTRITION GUIDELINES (CONTINUED) TOTAL PARENTAL NUTRITION (TPN) IN NICU – SUMMARY GUIDELINES Starting TPN Infants < 1500 g à Start on modified TPN on admission to NICU Neostarter (D10W + Protein [1.5g/kg] + Calcium [1mmol/kg] @ 50 cc/kg/day) on Day 1 and TPN by 24-48 hours of age Infants > 1500 g à Start on TPN by 48-72 hr of age if NOT expected to be enterally fed by 72 hr Stopping TPN: TPN may be discontinued when an infant is tolerating 75% (or 120 mL/kg/d) of full enteral feeds Writing TPN Orders • Determine total fluid available for TPN. (Total fluid intake minus fluid for IV lines / medications) • Determine flow rate required to provide desired amount of lipid (see summary). • The remaining fluid should be used for amino acid / dextrose solution (see summary) Monitoring TPN (TPN) Bloodwork For infants who have been on TPN > 48 hours; Every Monday (‘Week’ represents week of the month) Lab \ Week à 1 2 3 4 5 Every Thursday: electrolytes (Na, K), Glucose*, Triglycerides (until Electrolytes: Na, K x x x X x tolerating full dose) Glucose* x x x X x Trace Elements: if on long term TPN, once direct bili > 50 mmol/L Triglycerides x x x X x send serum for trace elements (Zn, Cu, Se , Mn) – 0.6 mL Urea / Creat x x Ferritin: Infants > 6 weeks of age on TPN, check serum ferritin Ca / P x x before adding iron Bili x X x *send urine for glucose if PCX > 10 mmol/L AST / ALT x X Albumin X MacPeds Survival Guide 98 NICU NUTRITION GUIDELINES (CONTINUED) TOTAL PARENTAL NUTRITION (TPN) IN NICU – SUMMARY GUIDELINES (A) Macronutrients Dextrose Prescription mg/kg/min g/kg/day Initial dose Average Daily Increase Maximum dose 4–6 0.5 - 1.0 11 – 13 6-9 0.7 - 1.4 16 - 19 Energy Value: 3.4 kcal/g (0.67 kcal/mmol) Conversions: 1 mmol = 0.2 g = 200 mg Comments: For peripheral parenteral nutrition, the osmolar load from dextrose should not exceed 500 mmol/L (D10W) unless necessary to maintain euglycemia (max D12.5W) Protein Prescription Source: Primene 10% Initial dose * Avg. daily increase Maximum usual dose MacPeds Survival Guide g/kg/day 1.5 1.0 3.0 - 3.5** Energy Value: 4.0 kcal/g; 16.7 kJ/g For infants < 1500 g à Start on modified TPN à Neostarter (D10W + Protein + Calcium) 50 cc/kg/day on NICU admission and TPN by 24-48 hours of age, with other IVs **3 g/kg/day acceptable for term infants Monitor / reassess maximum protein dose: • Renal Failure • Hepatic Failure • Elevated Serum Urea 99 NICU NUTRITION GUIDELINES (CONTINUED) TOTAL PARENTAL NUTRITION (TPN) IN NICU – SUMMARY GUIDELINES (A) Macronutrients (Continued) Lipid Prescription Source: Clinoleic 20% Initial Dose (g/kg/day) Full PN < 50% PN By 24-48 hr of age 0.5 - 1.0 g/kg/day 0.5-1 g/kg/d Average Daily Increase (g/kg/day) Maximum Dose (1) 2.5-3.5 g/kg/day 1-2 g/kg/day (g/kg/day) Energy Value: 20% - 2 kcal / mL; 8.4 kJ / mL Conversions: 20% - 0.2 g fat / mL Cautions: • For infants with worsening acute lung disease or hyperbilirubinemia (unconjugated), Hold lipid at 0.5 - 1.0 g/kg/day until clinical condition improves • Sepsis - decrease lipid to 1 g/kg/day for first 24 - 48 hr and then increase as tolerated to full rates Monitor / reassess: • Triglycerides (TG) every Tuesday and Friday until tolerating maximum dose, then every Tuesday Interpretation: (<2mmol//L is acceptable) • Consider restrict lipid for infants with cholestasis. Consider Omegavan for infants with Short Bowel Syndrome if conjugated bilirubin consistently above 100 mmol/L (Use requires approval for special access from Health Canada) MacPeds Survival Guide 100 NICU NUTRITION GUIDELINES (CONTINUED) TOTAL PARENTAL NUTRITION (TPN) IN NICU – SUMMARY GUIDELINES (B) Micronutrients (1) Actual requirements for sodium may be significantly higher in the first two weeks of life, depending on urinary losses. (2) Due to the limits of solubility of calcium and phosphorus in amino acid solutions, the maximum dose of 15 mmol of calcium and phosphorus per litre of amino acid solution can only be attained if the total amino acid concentration is 30 g/L or higher. Otherwise, precipitation of calcium and phosphorus may occur. Caution: do not add phosphorus to TPN unless there is at least 1 g/kg amino acids added to the solution. Normal molar ratio of Ca:P is 1:1. Use caution if unequal amounts of calcium and phosphorus added to TPN solution. Minerals (Maintenance intakes for stable, growing infants) Usual Dose Term Infants > 3kg (mmol/kg/day) (mmol/kg/day) Sodium 2 - 4 (1) 2 Potassium 2 2 Magnesium 0.2 0.2 Calcium 1 - 1.5 (2) 1 Phosphorus 1 - 1.5 (2) 1 Vitamins Source: MVI Pediatric (MVI Ped) Dosage: Initiate at 24-48 hr of age <1kg- 1.5ml 1-3kg- 3.25ml >3kg- 5ml Trace Elements Source: mcg / mL à Zinc Copper Selenium Chromium Manganese Iodine Dose Neo Trace Element Mix 425 19 2 0.2 1 1 1 mL/kg up 3 mL Liver Mix* 300 10 2 0.2 1 1 mL/kg up 10 mL *To be used when direct bilirubin > 50 mmol/L; Send blood for trace elements when changed to Liver Mix Iron : 0.1-0.2 mg/kg (Initiate at 6 weeks of age for infants on TPN if ferritin <500) MacPeds Survival Guide 101 NICU NUTRITION GUIDELINES (CONTINUED) VITAMIN/MINERAL SUPPLEMENTS IN NICU – SUMMARY GUIDELINES Vitamins Prescription Feeding Unfortified EBM Fortified (1:25) EBM Tri-Vi-Sol 0.5 mL BID None D-Drops Preterm Infants none In Hospital 400 units MWF until 1500 g (< 2000 grams) Enfamil Prem 24 None 400 units MWF Until 1500 g Term Infant EBM none 400 units daily Formula none none Preterm Infants Human Milk or Intake < 800 mL/day – 0.5-1.0 mL daily None After Term Infant Formula Intake > 800 mL/day - none 1.0 mL OD Discharge Home (human milk only) 1.0 mL Tri-Vi-Sol contains: 10 ug (400 IU) Vitamin D, 450 ug (1500 IU) Vitamin A, 30 mg Vitamin C 1 drop D drops contains : 400 IU vitamin D Iron (Fe) Prescription: Ferrous Sulfate (1.0 mL = 15 mg elemental Fe) Preterm infants in hospital @ 4-6 weeks of age: 0.1 ml 1.5 mg Doses Available: 0.2 ml 3 mg 0.3 ml 4.5 mg Preterm Infants after discharge Prescription: Fer-In-Sol (Mead Johnson) (1.0 mL = 15 mg elemental Fe) (See Notes below) < 3-4 kg 0.5 mL OD (7.5 mg) > 3-4 kg 1.0 mL OD (15 mg) 1. P-RNI for iron: 2-4 mg/kg/day up to max. 15 mg elemental iron given as ferrous sulfate supplement or iron fortified formula. (Birth Weight < 1 kg: 3-4 mg/kg/day; > 1 kg: 2-3 mg/kg/day) 2. Prescription amounts above are given as elemental iron (check dosage on product used). (1 mg elemental iron =5mg ferrous sulfate) Note- Preterm formula (Enfamil Premature A+ 24) and Enfamil HMF are iron fortified. Dose of iron should be adjusted based on iron received from feeds MacPeds Survival Guide 102 q Charlton Campus q King Campus q West 5th Campus GROUP B STREP (GBS) PROTOCOL FOR HEALTHY NEONATES GREATER THAN 35 WEEKS PLEASE CIRCLE ALL APPROPRIATE BOXES Maternal GBS Status Negative Positive Unknown Intrapartum Risk Factors Present? Routine Clinical Care Delivery at less than 37 weeks Rupture of Membranes (ROM) greater than or equal to 18 hrs Intrapartum maternal temp greater than or equal to 38oC Previous infant with invasive GBS GBS bacteriuria in current pregnancy YES NO If elective C/S, NO ROM, NO labour, regardless of GBS status Appropriate IV Antibiotics YES Less than 37 weeks OR ROM greater than 18 hours NO NO Observe for 48 hrs ** YES CBC & diff at 12 hrs Results called to: _____________ FOOTNOTES: 1. 2. 3. at ________ hrs Any neonate with signs of neonatal sepsis requires a full diagnostic evaluation by Pediatrics. Babies born to mothers with diagnosed chorioamnionitis require diagnostic evaluation and treatment by a Pediatrician. The ** denote ‘if greater than 37 weeks gestation, observation may occur at home after 24 hours if other discharge criteria have been met and the caregivers are able to comply fully with instructions for home observation. If any of these conditions are not met, the baby should be observed until at least 48 hours and until discharge criteria are met. Birthing Unit Printed Nurse: I:T ratio ______ Observe greater than or equal to 48 hrs ___________________________ Signature:_____________________ Initials:______ Discipline:_______ Maternal Child Unit Printed Nurse:________________________ Signature:_____________________ Initials:______Discipline:_______ MacPeds Survival Guide 103 PD 7767 (2011-11) HIM Page 1 of 2 Recommended Regimens for Intrapartum Antimicrobial Prophylaxis for Prevention of Perinatal GBS Recommended: Penicillin G 5 million units IV initial dose, then 2.5 million units IV every 4 hours until delivery Alternative: Ampicillin 2g IV, followed by 1g q4h, until delivery Q If Penicillin ALLERGY: Recommended Intrapartum Antibiotic Prophylaxis LOW risk for anaphylaxis: (no history of anaphylaxis, angioedema, respiratory distress or urticaria) HIGH risk for anaphylaxis: If GBS sensitive to Clindamycin AND Erythromycin (must be sensitive to both) Cefazolin 2g IV, followed by 1 g q8h until delivery Clindamycin 900 mg IV q8h, until delivery If GBS not sensitive (or unknown) to Clindamycin AND Erythromycin (must be sensitive to both to use Clindamycin) Vancomycin 1 g IV, q12h until delivery Note: Erythromycin is NOT an acceptable choice History of Penicillin allergy should be assessed to determine whether a high risk for anaphylaxis is present. Penicillin allergic patients at high risk for anaphylaxis are those who have experienced immediate hypersensitivity to Penicillin including a history of Penicillin related anaphylaxis: other high risk patients include those with asthma or other diseases that would make anaphylaxis more dangerous to treat, such as persons being treated with beta 2 adrenergic blocking agents. Clindamycin and Erythromycin susceptibility testing should be performed. Special considerations: Preterm Pre-labour Rupture of Membranes (PPROM): Suggested approach as per CDC Guidelines: Obtain GBS swab. Treat for GBS (as well as other indications) for 48 hours, then again intrapartum if swab positive Antimicrobial prophylaxis treatment options at time of PPROM diagnosis are: Ampicillin IV for 48 hours, then oral Erythromycin Penicillin G for 48 hours AND oral Erythromycin Note: With respect to neonatal surveillance, there is no standardized data regarding the adequacy of intrapartum prophylaxis for antibiotics other than Penicillin G, Ampicillin or Cefazolin. Warning Signs when assessing the Newborn CBC: WBC of 5.0 × 109/ L or lower: 10% - 20% probability of sepsis (Pediatric Child Health Vol 12 No 10 Dec, 2007) WBC of 30 × 109/ L or greater Immature to mature polymorph cell ratio (I/T ratio) greater than 0.2 or ʻleft shiftʼ Absolute polymorph cell count of less than 1.5 × 109/ L To calculate the I/T ratio: immature cells ex. blast, myelocytes, metamyelocytes, bands (whichever of these exist) immature + mature immature + mature MacPeds Survival Guide PD 7767 (2011-11) HIM Anything greater than 0.2 indicates sepsis 104 Page 2 of 2 Care of the Newborn Medical Directive Group B Streptococcus (GBS) Management Guidelines MATERNAL CONSIDERATIONS: Women with GBS bacteriuria in the current pregnancy or who had a prior newborn with invasive GBS disease do not need to be screened and will require intrapartum prophylaxis. Screening of all other women at 35 to 37 weeks gestation, including women planning elective CS is recommended. Antepartum treatment of GBS colonization is not justified with the exception of urinary tract infection. For women with positive GBS and prelabour rupture of membranes at term, induction of labour is recommended. NEWBORN: No protocol prevents all GBS morbidity or mortality. Ongoing newborn assessment and timely interventions should not be limited by these guidelines. If at any point the newborn shows signs of sepsis (i) Notify the MRP (ii) Obtain a Pediatric consult for a full diagnostic evaluation and initiation of antibiotic therapy. If a second CBC is to be drawn, consider ordering a CRP (C-Reactive Protein). Mother: • • • • Mother: is delivered by elective C/S has not laboured has not ruptured membranes regardless of GBS status Mother: • Has fever^ and high suspicion of chorioamnionitis* regardless of GBS status • has laboured (latent or active) or • has ruptured membranes * GBS status: UNKNOWN GBS status: NEGATIVE Mother: • Has fever alone ^ regardless of GBS status GBS status: POSITIVE Are there any MATERNAL RISK FACTORS? No • Rupture of membranes (ROM) greater than 18 h • Gestational age less than 37 wks • GBS bacteriuria in current pregnancy • Previous infant with invasive GBS infection • Maternal fever greater than or equal to 38oC No action required for newborn = Mother = Newborn Yes Mother received at least one dose greater than or equal to 4 h prior to delivery? ^Fever = temperature greater than or equal to 38° C of Chorioamnionitis: *Signs/Symptoms • fever greater than or equal to 38° C • tender uterus • purulent/foul smelling amniotic fluid †ACCEPTABLE Yes No action required for newborn Yes Mother has received Pen G or †acceptable antibiotic No Newborn CBC,diff, septic workup and antibiotic therapy x minimum 36 h in Level II/NICU Newborn vital signs at 9 h; CBC and diff at 12 h Determine gestation and length of ROM Newborn is greater than or equal to 37 wks AND ROM less than 18 h Observe newborn 48 h or longer; may be discharged in 24 h if discharge criteria are met and family has immediate access to care Newborn is less than 37 wks OR ROM greater than or equal to 18 h Newborn vital signs at 9 h; CBC and diff at 12 h; observe minimum 48 h ANTIBIOTICS Preferred (narrow spectrum): Penicillin G five million units IV, then 2.5 million q4h, until delivery Alternative: Ampicillin 2g IV, followed by 1g q4h, until delivery If Penicillin ALLERGY: Recommended Intrapartum Antibiotic Prophylaxis LOW risk for anaphylaxis: • Cefazolin 2 g IV, followed by 1 g q8h until delivery References Verani,J; McGee, L., Schrag, S.(2010) Prevention of Perinatal Group B Streptococcal Disease, revised guidelines from CDC, 2010 ,MMWR vol 59.RR-10. SOGC, (2011-2012) ALARM Course Manual, 18th edition, SOGC Ottawa June 2011. HIGH risk for anaphylaxis: • GBS sensitive to Clindamycin and Erythromycin (must be sensitive to both to use either) • Clindamycin 900 mg IV q8h, until delivery (Clindamycin. not Erythromycin. is recommended) CDC 2010 • GBS not sensitive (or unknown) to Clindamycin and Erythromycin (must be sensitive to both to use either) MacPeds Survival Guide • Vancomycin 1 g IV, q12h until delivery 105 Sept 19 2011 LY SD HYPOGLYCEMIA GUIDELINES FOR THE AT-RISK NEWBORN Signs and Symptoms of Hypoglycemia: • Limpness, lethargy, hypotonia • Jitteriness, tremors • Difficulty feeding, refusal to feed • Episodes of cyanosis • Eye rolling • Convulsions • Sweating, sudden pallor • Apnea • Cardiac arrest • Tachypnea • Weak or high-pitched cry Risk Factors for Hypoglycemia • Maternal hypertension treated with beta-blockers • Any maternal diabetes (gestational, Type I or II, with or without insulin) • Preterm – less than 37-0/7 weeks • Cold stress – Hypothermia: Temp (Axillary) < 36.5 °C • Newborns with medical conditions (eg. respiratory distress, sepsis) • SGA < 5th percentile for birth weight and gestational age • LGA > 95th percentile for birth weight and gestational age References: Kramer et al. (2001). It is recognized that these weights deviate from the CPS Guidelines (2005) of the 10th and 90th percentile cut-offs for birth weight at term. ACoRN – Acute Care of at-Risk Newborns. (2005) Canadian Pediatric Society. Screening Guidelines for Newborns at Risk for Low Blood Glucose. Pediatrics and Child Health. (2004). MacPeds Survival Guide 106 HYPOGLYCEMIA GUIDELINES FOR THE AT-RISK NEWBORN Note: 1. Ongoing newborn assessment and timely interventions should not be limited by these guidelines. If at any point the newborn is symptomatic or otherwise unwell, notify the Family Physician or Midwife who may then choose to consult a Pediatrician. 2. If baby is unable to feed at any point in these guidelines, notify the Family Physician or Midwife. He/she will then assess the need for consult/transfer of care to a Pediatrician. * When the need for MD Protocol A or B arises, if not already in place, the Family Physician or Midwife will consult/transfer care to a Pediatrician. MacPeds Survival Guide 107 MD Protocol A Start Infusion with D10W @ 80cc/kg/day (5.5 mg glucose/kg/min) Check WBG after 30 Minutes WBG < 1.8 WBG > 2.6 WBG 1.8-2.5 Go to MD protocol B MacPeds Survival Guide Increase IV infusion to 6-8 mg/kg/min, Check BG in half hour, then every 2 hours. May start to wean IV 12 hours after stable BG is and feeding established. Continue checking BG every 2 hours. May start to wean IV 12 hours after stable WBG and feeding is 108 MD Protocol B Consider 200mg/kg (2cc/kg) D10W bolus, IV infusion of 6-8 mg/kg/min Recheck WBG in ½ hour BG <1.8 BG > 2.6 BG 1.8-2.5 Bolus 200mg/kg (2cc/kg) D10W and Increase infusion to 8-10 mg/kg/min Increase infusion to 810 mg/kg/min Continue checking BG every 2 hours. May start to wean IV 12 hours after stable BG and feeding is established. Recheck BG in ½ hour, then hourly, May wean IV once BG stable for 12 hours Consider glucagon and increase infusion to 10-15 mg/kg/min if continued low WBG MacPeds Survival Guide 109 Remember for care of baby in NICU or SCN Frequent boluses of D10W will induce an insulin surge and rebound hypoglycemia. It is recommended that a maximum of 2 boluses of D10W be used. Consider daily maintenance of fluid. Once reaching 120 cc/kg/day, in the first 24 hours of life, consider switching to D12.5W/D15W in order to increase glucose concentration but maintain fluid status. A central line must be used when infusing glucose > D12.5W. When considering glucagon, think hypopituitarism, hyperinsulinism or a metabolic defect. When the blood sugar is < 1.8mmol/l, get a critical sample of glucose, insulin, GH, cortisol, T4, TSH, gas, lactate and urinary ketones also consider plasma ketones, pyruvate, FFA, organic and amino acids prior to starting glucagon. Glucagon 0.3 mg/kg/dose bolus not to exceed 1 mg total dose OR continuous infusion of 1mg/day (to a maximum of 2mg/day). Add 1 mg to 24 ml of D10W and run at 1ml/hour through a separate IV line. Glucose monitoring should be q ½ hour to q1hour until stable then q3-4hours. May start weaning IV 12 hours after stable BG and feeding is established. When weaning glucose, wean slowly. Wean the concentration of the glucose to D10W first, which will decrease the rate of glucose infused then wean the rate to 4-6mg/kg/min (1cc q1-4hours depending on the initial severity of the hypoglycemia) and finally the glucagon. Wean glucagon 0.1cc every 6-12 hours depending on the initial severity of the hypoglycemia. If hypoglycemia is resistant to treatment or unable to wean off the glucagon, consult endocrinology before instituting further therapies. Consider Diazoxide 8-15 mg/kg/day p.o. TID -QID Hydrocortisone 5 mg/kg/day IV QID or Prednisone 2mg/kg/day p.o.. Remember severe and persistent hypoglycemia may be associated with a significant risk for short and long-term morbidity and mortality. Thus prompt recognition and treatment is essential. D10W = 10 gms / 100ml = 10,000mg / 100ml = 100mg / ml Example: To give a 3 kg child 5 mg / kg / min 1. 5mg / kg / min x 3 kg = 15 mg / min 2. 15 mg / min x 60 min = 900 mg / hour 3. D10W has 100 mg / ml, so 900 mg / hour = 9 cc / hour 4. Therefore, to give a child of 3 kg, 5 mg / kg / min of glucose, run D10W at 9 cc / hour. MacPeds Survival Guide 110 Hypoglycemia Algorithm_Layout 1 13-03-28 10:37 AM Page 1 Hypoglycemia Guidelines for the at-Risk Newborn Newborn Newborn baby baby Symptomatic Symptomatic A symptomatic Asymptomatic The bab y baby DOES SHO W SHOW symptoms signs/ symptoms hypoglycemia or of hypoglycemia appears UNWELL appears r r r r baby DOES NOT NOT The baby SHO W signs/ ssymptoms ymptoms SHOW of h ypoglycemia or hypoglycemia appear sw ell appears well baby have any Does bab y ha ve an y RISK hypoglycemia? ffactors actors ffor or h ypoglycemia? chartt belo below) (see char w) eds Notify P Peds ely immediat immediately Chec Check k WBG immediat ely immediately Investigate Investigate cause underlying Rx under lying condition 1. WBG less than 1.0 1.0 Notify Peds Peds immediatley immediatley 2. 1.0 – 1.7 1.7 WBG 1.0 Asymptomatic Asymptomatic give 5-10 5-10 ml/kg ml/kg give (Use EBM/formula) EBM/formula) Maternal hypertension treated with beta blockers, including single dose Any maternal diabetes (gestational, Type I, or II, with or without insulin) SGA - less than 5th percentile LGA - greater than 95th percentile Preterm - less than 37 0/7 weeks Cold stress - Hypothermia - axilla temperature less than 36.5C Newborns with medical conditions, eg. respiratory distress, sepsis Do PC WBG (I hour fr from om time ffeed eed ffinished) inished) If greater than or equal greater to 2.6 go to to box box 4 to WBG Remains Remains less than 1.8 1.8 Notify Peds. Peds. NICU will initiate initiate Protocol Protocol A e 5-10 5-10 ml/kg WBG 1 .8 - 2.5 giv 1.8 give ml/kg (use EBM/f ormula) Do PC EBM/formula) WBG 1 hour hour.. If less than 2.6 eater than or call MRP P. If gr re MRP. greater equal tto o 2.6 do AC AC WBG q2-3 hr until 2 consecutiv e consecutive A C WBG ar e 2.6 or g reater. AC are greater. If WBG ar e less than 2.6 are advise MRP P. MRP. 4. greater than or WBG greater to 2.6: equal to baby LGA LGA or IDM A) If baby AC WBG for for 2 Do AC consectutiv e feeds. feeds. If consectutive greater than or equal tto o greater 2.6 do 1 mor e AC AC WBG more at 1 2hrs of age then st op 12hrs stop (unless concer ns) concerns) B) If baby baby SGA SGA or late late preterm, preterm, do AC AC WBG for for 2 consecutive consecutive feeds. feeds. If greater greater than or equal to to 2.6 repeat repeat WBG at 12hrs, at 24 hrs hrs and at 12hrs, hrs of age 36 hrs For all other babies C) For AC WBG until 2 Do AC consecutiv e AC AC WGB consecutive chec ks (including the checks first WBG) ar e greater greater first are than or equal tto o 2.6 SGA = less than 5th percentile for birth weight and gestational age LGA = greater than 95th percentile for birth weight and gestational age Gestation • • • • • • Weak or high-pitched cry Limpness, lethargy, hypotonia Difficulty feeding, refusal to feed Eye rolling Sweating, sudden pallor Cardiac arrest 36 37 38 39 40 MD = Medical Doctor MW = Midwife PC = After feeds IDM = Infant of a Diabetic Mother LGA = Large for Gestational Age MacPeds Survival Guide Male Weight in gm (complete weekly) Signs and Symptoms of Hypoglycemia Legend: WBG = whole blood glucose MRP - Most Responsible Physician AC = Before feeds EBM = Express Breast Milk SGA = Small for Gestational Age 3. greater WBG greater to than or equal to 1.8 to to 2.5 1.8 Asymptomatic, Asymptomatic, Observe Observe and assist with feed feed Now Now If at an anytime ytime A AC C WBG is not gr greater eater than or equal tto o 2.6 go tto o bo box x 1, 2 or 3. Risk Factors for Hypoglycemia Jitteriness, termors Episodes of cyanosis Convulsions Apnea Tachypnea eed on R outine car e and ffeed Routine care demand as long as bab babyy rremains emains w ell well R Routine outine car care, e, ffeed eed within ffirst irst hour and WBG at 2 hour hours s post bir birth th References: • ACoRN - Acute Care of at-Risk Newborns (2005) • Canadian Pediatrics Society. Screening Guidelines for Newborns at Risk for Low Blood Glucose. Pediatrics and Child Health (2004). • • • • • no yes y ye s Peds Peds will: r Investigate Investigate cause r Test Te est underlying under un lying conditions r Consider Consider use of MD protocol protocol A*.B* based on newborn newborn condition and causative causative factors factors • • • • • • • If at an y time 3 WBG A C or PC any AC less than 2.6 call MRP 41 42 Female Weight in gm SGA LGA SGA LGA Less than or equal to 2144 Less than or equal to 2384 Less than or equal to 2605 Less than or equal to 2786 Less than or equal to 2927 Less than or equal to 3025 Less than or equal to 3070 Greater than or equal to 3604 Greater than or equal to 3857 Greater than or equal to 4065 Greater than or equal to 4232 Greater than or equal to 4382 Greater than or equal to 4512 Greater than or equal to 4631 Less than or equal to 2052 Less than or equal to 2286 Less than or equal to 2502 Less than or equal to 2680 Less than or equal to 2814 Less than or equal to 2906 Less than or equal to 2954 Greater than or equal to 3523 Greater than or equal to 3752 Greater than or equal to 3931 Greater than or equal to 4076 Greater than or equal to 4212 Greater than or equal to 4330 Greater than or equal to 4423 111 Physician/Midwife Information Package Hyperbilirubinemia The Prevention of Severe Hyperbilirubinemia in Late Preterm Infants 35 – 37 6/7 Weeks’ Gestation and Term Infants 38 and More Weeks’ Gestation Based on the Canadian Paediatric Society position statement: Guidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants (35 or more weeks’ gestation). Fetus and Newborn Committee, Canadian Pediatric Society (CPS), Pediatrics and Child Health 2007; 12(5): 1B-12B. Prepared by: Laurie Yamamoto, RN, MHSc Obstetrical Project Co-ordinator Hamilton Health Sciences In Consultation with: Dr. Sandra Seigel Deputy Chief of Pediatrics McMaster Children’s Hospital St. Joseph’s Healthcare March 2007 Revised: January 2009 June 2010 MacPeds Survival Guide 112 TABLE OF CONTENTS 1) Bloodwork Related to Hyperbilirubinemia……………….………………………………..3 2) Risk Factors For Severe Hyperbilirubinemia……………………………..………….......6 - Major Risk Factors - Minor Risk Factors 3) Clinical Patterns of Hyperbilirubinemia……………………………………….………......7 - Pathologic Jaundice - Physiologic Jaundice - Breastfeeding and Jaundice 4) Signs and Symptoms of Hyperbilirubinemia Requiring Medical Investigation…..……8 5) Hour-Specific Bilirubin Nomograms ………………………………………..……………..9 - Late Preterm vs. Term Infants……………………………………………..…..…….9 - Bilirubin Nomogram for the Initiation of Phototherapy in the Newborn Infant 35 or More Weeks of Gestation……………………………………………….……10 - Intensive Phototherapy ………………………………….……………….….……..11 - Total Serum Bilirubin Screening Assessment Nomogram .……………….…….12 - Response to Results of Total Serum Bilirubin Screening…….….……13 - Coombs Test Algorithm……………………………………………………14 - Bilirubin Nomogram for Exchange Transfusion……………………….………….17 6) Universal Screening for Total Serum Bilirubin……………………………..……..……..15 7) Key Recommendations (Risk Reduction Strategies) for the Prevention of Hyperbilirubinemia …………………………………………………………………….…18 8) Appendices Appendix 1……………………………………………………………………………...19 Appendix 1……………………………………………………………………………...20 Appendix 1……………………………………………………………………………...21 9) References………………………………………………………………………..…………22 MacPeds Survival Guide 113 BLOODWORK Total Serum Bilirubin (TSB) The Total Serum Bilirubin in the body is a sum of the unconjugated and conjugated bilirubin and other bilirubin compounds at different stages of metabolism. At any specific age, the total bilirubin load is distributed in several components of the newborn’s body, such as the plasma, liver, skin, red blood cells, brain and the phospholipid membranes. When the total bilirubin load accumulates to a high enough level to cross the blood-brain barrier, then neurologic toxicity, or acute bilirubin encephalopathy (ABE), can result. It is the total serum bilirubin (TSB) level, based on age in hours, which is used clinically (the gold standard) as a threshold to determine if intervention (eg. phototherapy, exchange transfusion) is required. TSB LAB INFO: Inpatient TSBs: TSBs ordered on Wards 4C MUMC / 3OBS St. Joe’s (inpatient) – results will be available on Meditech and sent to ward via printer; nurses will be responsible for notifying the ordering physician or midwife of the results. If the physician/midwife has not received the result within a reasonable timeframe, he/she she should call the inpatient unit seeking the result BANA Clinic TSBs: TSBs ordered in St. Joseph’s BANA clinic – results will be available on Meditech and sent to the BANA clinic via printer; the LC in the BANA clinic will be responsible for notifying the ordering physician / MW or the person whom they are signed out to Outpatient Lab TSBs / Follow-up TSBs in the community: Parents should NOT be directed to take their baby to a community lab for a follow-up TSB. These labs may not have techs who are certified to do heel pokes and the turnaround time for results may be anywhere from 24 hours to 3-4 days. Follow-up TSBs may be done at: - the MUMC out-patient lab Monday to Friday – please ensure that the family goes early in the day so that the TSB result can be obtained from the lab THE SAME day - the St. Joseph’s outpatient lab The ordering physician / MW should order the TSB as a stat blood test and MUST write his/her contact information on the lab requisition which clearly indicates whom the lab is to call the TSB result to and the ordering physician or midwife should also be responsible for obtaining the TSB result by calling the MUMC outpatient lab at 905-521-2100 x75022 or x76303 or the St. Joseph’s outpatient lab at 905-522-1155 x33401. MacPeds Survival Guide 114 Direct Bilirubin This is a measure of the newborn’s conjugated bilirubin level. If the TSB is at or below 85 µmol/L, a direct (or conjugated) bilirubin of more than 17.1 µmol/L is generally considered abnormal. For TSB values higher than 85 µmol/L, a direct bilirubin of more than 20% of the TSB is considered abnormal. Elevated conjugated bilirubin levels are never normal and may be indicative of cholestasis. Also, consider liver and biliary tract disease. Also, a urinalysis and urine culture should be considered. Cases of urinary tract infections have been reported with severe hyperbilirubinemia. Blood Type and Coombs (DAT) Test Infants with ABO or Rh incompatibilities may develop severe hyperbilirubinemia within the first 24 hours after birth. Increased hemolysis results from maternal antibodies reacting with fetal and neonatal antigens. Rh incompatibilities may occur when the infant is Rh positive and the mother is Rh negative. ABO incompatibilities may occur when the infant has type A or B blood, and the mother has type O. Less frequently, incompatibilities of minor group blood types may lead to significant hemolysis. Testing all infants whose mothers are group O does not improve outcomes compared with testing only those with clinical jaundice. CPS, June 2007 Guidelines for ordering Coombs test are outlined in the Total Serum Bilirubin Response Tables (see page 13) and the Coombs Test Algorithm (see page 14). G6PD Deficiency (Glucose-6-Phosphate Dehydrogenase) Infants who lack the G6PD enzyme have a diminished ability to conjugate bilirubin, G6PD deficiency is frequently associated with severe hyperbilirubinemia and may be the cause of kernicterus in up to 35% of cases. When babies are positive for G6PD deficiency, TSB levels can rise exponentially. (Dr. S. Seigel, Sept. 2007), ie. can see dramatically fast rises in TSB levels. Infants whose ethnic group or family history suggest an increased risk of G6PD deficiency have ancestral origins from regions including: At risk ethnic origin for G6PD deficiency: o o o o South and East Asian African Mediterranean Middle Eastern Note: Health professionals should keep in mind that immigration and intermarriage have changed G6PD deficiency into a global issue. o Testing for G6PD deficiency should be considered in all infants from at risk ethnic origin who have severe hyperbilirubinemia as evidenced by: - TSB levels in the high-intermediate or high risk zones - rapidly rising TSB level MacPeds Survival Guide 115 - jaundice at less than 24 hours of age - not responding well to phototherapy. (ie. TSB levels continue to rise after initiation of intensive phototherapy or do not decrease within 4-6 hours of initiation of intensive phototherapy) o It is reasonable to initiate phototherapy at lower TSB concentrations when a newborn is G6PD deficient (ie. a positive G6PD deficiency test or positive family history) because they are more likely to progress to severe hyperbilirubinemia (CPS, 2007) IMPORTANT NOTE: It should be recognized that in the presence of active hemolysis, G6PD levels can be overestimated (ie. high false negative/false normal rates). It is still worthwhile however, to obtain an early G6PD test, as a positive test would indicate that the baby is deficient of the G6PD enzyme; if a negative test result was obtained, it should be repeated at a later time because G6PD deficiency is a disease with lifelong implications. G6PD Lab info: G6PD deficiency lab testing is not available on weekends or holidays, although G6PD blood samples may be sent to the MUMC lab at any time. At St. Joseph’s Healthcare, G6PD blood samples will be sent via regular lab courier to MUMC lab for routine batch testing q Monday, Wednesday and Friday. G6PD blood samples can be sent at any day/time (weekends and holidays included – they will be stored in MUMC core lab until the next batch testing day). At MUMC, G6PD blood samples will be batch tested q Monday, Wednesday and Friday. G6PD blood samples can be sent at any day/time (weekends and holidays included – they will be stored in the core lab until the next batch testing day). Follow-up of G6PD deficiency blood test results: It is expected that many G6PD deficiency test results may become available after the baby has been discharged from hospital. To ensure follow-up of all G6PD deficiency test results: • it is the responsibility of the ordering physician / midwife to ensure or arrange follow-up of the G6PD deficiency result with the baby’s ongoing care provider in the community. MacPeds Survival Guide 116 EPIDEMIOLOGIC RISK FACTORS FOR SEVERE HYPERBILIRUBINEMIA Major Risk Factors (in approximate order of importance) • TSB level in the high-risk zone (see Bilirubin Nomogram for Screening Assessment) • Jaundice observed in the first 24 hours of age (early onset of hyperbilirubinemia) • Blood group incompatibility with positive Coombs, other known hemolytic disease, eg. G6PD deficiency • Gestational age 35 – 37 6/7 weeks • Previous sibling received phototherapy • Cephalhematoma or significant bruising • Exclusive breastfeeding, not going well and weight loss greater than 7% within first 48 h of age, or weight loss greater than 10% after 48 h of age • East Asian race (as defined by mother’s description) There should be heightened vigilance for clinical or visual signs and symptoms of jaundice if the baby has any Major Risk Factors for severe hyperbilirubinemia MacPeds Survival Guide 117 CLINICAL PATTERNS OF HYPERBILIRUBINEMIA Sixty percent of term infants will become clinically jaundiced in the first week of life. In the vast majority of cases, neonatal jaundice is physiologic, mild, benign, self-limiting and normal. This “normal” form of neonatal jaundice has been referred to as “physiological jaundice of the newborn” or “developmental hyperbilirubinemia”. However, in about 2% of jaundiced newborns, the hyperbilirubinemia is non-physiologic – it is pathologic. In these pathologic cases, the bilirubin concentrations rise to potentially dangerous levels. Some studies report 85% of newborn readmissions to hospital during the first week of life are because of jaundice. The clinical challenge is to identify when neonatal jaundice has become non-physiologic and to implement RISK REDUCTION STRATEGIES in a timely manner to prevent the occurrence of severe hyperbilirubinemia. Pathologic Jaundice Pathologic jaundice is present in the first 24 hours of age. If TSB levels are greater than the 75th percentile (ie. in the high-intermediate risk zone or higher) at less than 72 hours of age, then the infant is at particularly high risk for other adverse events because the rate of bilirubin rise has been so rapid. If the bilirubin continues to rise at the same rate, then the bilirubin levels will exceed the 95th percentile within the first 7 days of age. Pathologic jaundice (hyperbilirubinemia) may be related to: - hemolytic disease: ABO, Rh or minor blood group incompatibilities. - non-hemolytic disease: extravascular sources, eg. cephalohematoma - G6PD deficiency – may be the cause of kernicterus in up to 35% of cases - always suspect in cases of severe hyperbilirubinemia or poor response to phototherapy - decreased bilirubin conjugation – genetic disorders (Crigler-Najjar, Gilbert Syndrome), hypothyroidism - impaired bilirubin excretion – biliary obstruction (biliary atresia), infection, metabolic disorders, chromosomal abnormalities (Turner’s), drugs (ASA, sulfa, erythromycin) Physiologic Jaundice Neonatal hyperbilirubinemia is an almost universal finding during the first week of life. Most newborns experience a transient elevation of their serum bilirubin and this is termed ‘physiologic jaundice’. The mechanisms responsible for the slightly elevated TSB levels in these infants are reflected in a combination of the effects of bilirubin production, conjugation, and enterohepatic circulation. The factors that affect these processes account for the hyperbilirubinemia in virtually all newborns. Some infants have a slower rise in their TSB (Total Serum Bilirubin) levels and may demonstrate severe hyperbilirubinemia after 72 hours of age (usually post-discharge). Breastfeeding and Jaundice The jaundice associated with breastfeeding in the first two to four days of life is sometimes called “breastfeeding jaundice”. Breastfeeding that is not going well, has been identified as one of the most consistent risk factors for the development of severe hyperbilirubinemia, especially in late preterm newborns (Watchko, 2006). Breastfeeding jaundice is not associated with increased bilirubin production. Rather, inadequate breastmilk intake, in addition to contributing to varying degrees of dehydration and weight loss, acts as a stimulus to increase the enterohepatic MacPeds Survival Guide 118 Breastfeeding and Jaundice continued circulation of bilirubin. Earlier studies have shown that the enterohepatic circulation of bilirubin accounts for up to 50% of the hepatic bilirubin load in newborns. When the hepatic immaturity of the newborn is considered, particularly in the late preterm newborn, any further increase in the hepatic bilirubin load will likely result in more marked hyperbilirubinemia (Watchko, 2006). SIGNS AND SYMPTOMS OF HYPERBILIRUBINEMIA REQUIRING MEDICAL INVESTIGATION • jaundice in first 24 hours of age • excessive level of, or rapid increase in, TSB after 24 hours of age - TSB level crosses into next highest risk zone on bilirubin nomogram • TSB levels not responding to phototherapy (ie. TSB level not decreasing, or TSB level increasing) • • excessive weight loss - greater than 7% in first 48 hours - greater than 10% after 48 hours pallor • vomiting • lethargy • poor feeding, particularly exclusive breastfeeding not going well • hepatosplenomegaly • apnea • temperature instability • tachypnea MacPeds Survival Guide 119 HOUR-SPECIFIC BILIRUBIN NOMOGRAMS It is recommended that bilirubin levels in the healthy, late preterm and term infant (35 or more weeks’ gestation) be interpreted using hour-specific bilirubin nomograms. Based on the infant’s age in hours, a phototherapy nomogram can be used to plot an infant’s Total Serum Bilirubin (TSB) level to determine the need to initiate phototherapy treatment in conjunction with specific risk factors for bilirubin toxicity or, in the absence of clinical signs and symptoms, to plot an infant’s TSB level prior to discharge to screen for the risk of developing severe hyperbilirubinemia. Notes on Late Preterm vs. Term infants as related to hyperbilirubinemia (as defined by CPS): When considering hyperbilirubinemia in the newborn infant: Late Preterm is defined as: 35 – 37 6/7 weeks gestation Term is defined as: 38 0/7 weeks gestation and older This is an important factor to consider. Late preterm infants are 2.4 times more likely to develop clinically significant hyperbilirubinemia and have significantly higher TSB levels when compared to their term counterparts and one in every four late preterm infants will require phototherapy (Sarici 2004). Term infants’ bilirubin levels peak between 3-5 days of life whereas late preterm infants’ bilirubin levels peak between 5-7 days of life. This has important implications related to timing of the universal TSB screen for late preterm infants. Readmission rates related to hyperbilirubinemia have been found to be two to three times higher for late preterm when compared to term infants (Bhutani 2006). Included in this learning package are three different hour-specific bilirubin nomograms for infants 35 or more weeks’ gestation ⇒ Bilirubin Nomogram for Initiation of Phototherapy - guidelines for initiation of phototherapy ⇒ Total Serum Bilirubin Screening Assessment Nomogram - guidelines for screening assessment including Coombs’ test results ⇒ Bilirubin Nomogram for Exchange Transfusion - guidelines for exchange transfusion MacPeds Survival Guide 120 Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation Guidelines for initiation of phototherapy for hyperbilirubinemia. 400 350 Bilirubin umol/L 300 250 200 150 100 50 0 Birth 24 48 Infants at Higher Risk 72 96 Age in hours Infants at Medium Risk 120 144 168 Infants at Low er Risk Guidelines for the Initiation of Phototherapy: Infants at Lower Risk: greater than or equal to 38 weeks and no risk factors Infants at Medium Risk: greater than or equal to 38 weeks with risk factors or 35 - 37 6/7 weeks and no risk factors Infants at Higher Risk: 35 - 37 6/7 weeks with risk factors Risk Factors for Bilirubin Toxicity for Initiation of Phototherapy: ⇒ ABO or Rh incompatibility: hemolysis due to maternal isoimmunization. (Some other causes of hemolysis to consider if there is a positive family hx of: G6PD deficiency, pyruvate kinase deficiency, congenital spherocytosis) ⇒ sepsis, temperature instability, significant lethargy ⇒ need for resuscitation at birth/asphyxia (baby required significant resuscitation and admission to L2N or NICU at MUMC or to NICU at SJH) ⇒ evidence of metabolic or respiratory acidosis as evidenced by cord gas pH < 7.1 ⇒ low serum albumin less than 30g/L (if measured) Ø Jaundice occurring before 24 hours of age is considered “pathologic” and requires investigation and consideration for Pediatric consult. 1. Approach to the management of hyperbilirubinemia in term newborn infants. Canadian Pediatric Society Fetus and Newborn Committee. Peciatr Chil Health 1999; 4: 161-164. 2. Adapted from American Academy of Pediatrics. Clinical Practice Guideline: management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2004; 114: 297-316. MacPeds Survival Guide 121 PHOTOTHERAPY Old Standard of Practice ‘Single’, ‘double’ and ‘triple’ phototherapy may no longer be ordered by the physicians and midwives. New Standard of Practice New standards for phototherapy require all babies to receive intensive phototherapy. Intensive phototherapy is defined as ‘the use of high levels of irradiance, usually 30 µW/cm2/nm or higher, delivered to as much of the infant’s skin surface area as possible. How will effective, intensive phototherapy be delivered?: On MUMC Ward 4C: ⇒ babies who require phototherapy will be placed in an isolette to receive phototherapy via the Biliblanket Plus (delivers 57 µW/cm2/nm) and 1 set of Microlights (delivers 12 – 15 µW/cm2/nm). On St. Joe’s Ward 3OBS: ⇒ babies who require phototherapy will be placed in an isolette to receive phototherapy via Biliblanket (delivers 50-70 µW/cm2/nm) and Giraffe Spot (delivers 50-70 µW/cm2/nm). It is recommended that babies whose TSBs do not decrease within 4-6 hours once intensive phototherapy has been initiated receive a Pediatric consult. MacPeds Survival Guide 122 Total Serum Bilirubin Screening Assessment Nomogram Always consider bilirubin level by the infant’s age in hours Bilirubin um ol/L 325 High Risk Zone 300 High Intermediate Risk Zone 275 250 Low Intermediate Risk Zone 225 200 Low Risk Zone 175 150 125 100 75 50 0 12 24 36 48 60 72 84 96 108 120 132 144 Age in hours Low Risk 40% Intermediate Risk 75% High Risk 95% Adapted from American Academy of Pediatrics, Clinical Practice Guideline: Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2004;114:297-316 Ø Plot the TSB result on this nomogram, then refer to TSB Screening Response Table for action to be taken (see next page). It is recommended that either a TSB or TcB* (Transcutaneous Bilirubin) concentration be measured in all infants between 24 h and 72 h of life. If the infant does not require immediate treatment, the results should be plotted on the predictive (screening) nomogram to determine the risk of progression to severe hyperbilirubinemia. If the infant has not been measured earlier because of clinical jaundice, a TSB measurement should be obtained at the same time as the Newborn Screening test. * At the present time, neither McMaster nor St. Joseph’s has a reliable Transcutaneous Bilirubin meter which accurately and consistently measures serum bilirubin levels. Canadian Paediatric Society. Guidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants (35 or more weeks’ gestation). Fetus and Newborn Committee, Canadian Pediatric Society (CPS), Pediatrics and Child Health 2007; 12(5): 1B-12B. MacPeds Survival Guide 123 RESPONSE TO RESULTS OF TOTAL SERUM BILIRUBIN SCREENING 35 – 37 6/7 Weeks Gestation Bilirubin Screening Responses– 35 to 37 6/7 weeks gestation Bilirubin Risk Zone @ time of screening Low Risk Zone Low-Intermediate Risk Zone High-Intermediate Risk Zone High Risk Zone 35 – 37 6/7 weeks gestation 35 – 37 6/7 weeks gestation with a NEGATIVE Coombs with a POSITIVE Coombs Mother’s Blood Group: Routine care No Coombs test required Routine care Routine care No Coombs test required Further testing or treatment required O Follow-up assessment including TSB at 24 to 48 h Further testing or treatment required Further testing or treatment required Phototherapy required Coombs Test (DAT): Other Coombs Test Ordered: Yes +ve No -ve TSB results in all shaded zones require Coombs test to be done if mother is Blood Group O* Refer to Coombs’ 38 Weeks and more Gestation Bilirubin Screening Responses– greater than or equal to 38 weeks gestation Bilirubin Risk Greater than or equal to Greater than or equal to Zone @ time of 38 weeks gestation 38 weeks gestation screening with a NEGATIVE Coombs with a POSITIVE Coombs Low Risk Zone Routine care Routine care No Coombs test required No Coombs test required Low-Intermediate Routine care Routine care Risk Zone No Coombs test required No Coombs test required HighRoutine care - care provider Follow-up assessment including TSB at 24 to 48 h Intermediate Risk consider a follow-up TSB if there is clinical concern Zone High Risk Zone Further testing or treatment Further testing or treatment required required Test Algorithm Mother’s Blood Group: O Other Coombs Test Ordered: Yes No Coombs Test (DAT): +ve -ve TSB results in all shaded zones require Coombs test to be done if mother is Blood Group O* *Although it is highly unlikely, it is reasonable to perform a Coombs test in infants of mothers who are not Blood Group O and whose TSB results are in the High-Intermediate Risk Zone or the High Risk Zone Routine Care - Follow-up appointment within 48 hours after discharge with MD or MW if infant is greater than 48 hours of age on discharge, or - Follow-up appointment within 24 hours after discharge with MD or MW if infant is less than 48 hours of age on discharge If the baby is in the LRZ or LIZ risk zone and there is no clinical concern, then the TSB result does not need to be reported to the MD/MW and the baby may be discharged as per Routine Care outlined above. Follow-up assessment including TSB at 24 to 48 h: - According to CPS, these babies may be discharged home; in our HHS experience, these babies are often managed more conservatively and are usually not discharged and follow-up TSBs are done in hospital – Follow-up assessment: babies who are discharged with a follow-up assessment require a confirmed appointment with MD, MW or BANA within 24 - 48 hours of discharge WITH a follow-up TSB at that time (24 to 48 h): In region: all babies requiring pre-ordered bloodwork should have appointment booked in BANA Out of region: all babies requiring pre-ordered bloodwork may have an appointment booked in BANA or an outpatient clinic in their community. Further testing or treatment: - these babies are not discharged – a repeat TSB should be done or intensive phototherapy should be initiated as per MD / MW order BANA = Breastfeeding and Newborn Assessment Clinic located at St. Joseph’s Healthcare, open every day except Christmas day MacPeds Survival Guide 124 HYPERBILIRUBINEMIA - COOMBS TEST ALGORITHM When a Coombs test needs to be done as part of the newborn hyperbilirubinemia assessment, please follow the algorithm below based upon the mother’s blood group: MOTHER O -ve Babies of all Rh negative mothers will automatically have their blood group done at time of birth by Transfusion Medicine Lab to determine if mother needs another dose of Rh immune globulin. Baby O –ve or O +ve When the Transfusion Medicine Lab receives an order to do a Coombs test, the Lab will do the baby’s blood group first. MOTHER A* or B* Coombs Test IS NOT required. NOTE: Baby A* or B* Coombs Test IS NOT required *A = A +ve and A –ve MacPeds Survival Guide MOTHER O +ve Coombs Test IS required Baby O –ve or O +ve Coombs Test IS NOT required Baby A* or B* Coombs Test IS required If any antibodies are detected prenatally, then a Coombs’ test must always be done regardless of mother’s and baby’s blood types. B = B+ve and B -ve 125 - UNIVERSAL SCREENING FOR TOTAL SERUM BILIRUBIN The institution of a program of universal screening complements, but does not replace, careful ongoing clinical assessment of newborn infants beginning from the first hours of life and continuing through the first weeks. All infants should be clinically assessed for jaundice repeatedly within the first 24 h, and again, at a minimum, 24 h to 48 h later whether in hospital or after discharge. Systems to ensure follow-up within the recommended intervals after hospital discharge must be in place so that an infant who develops severe hyperbilirubinemia can be identified and treated promptly by an individual with the training to recognize neonatal hyperbilirubinemia, obtain measurement of TSB or TcB without delay and refer the infant to a treatment facility if required. This individual may be from any medical or nursing discipline. (CPS, June 2007). 1) Universal screening applies to all babies 35 or more weeks gestation in all nursery and neonatal units at both St. Joseph’s and McMaster hospitals. 2) For babies less than 35 weeks gestation, refer to: Phototherapy and Exchange Transfusion Guidelines in Premature Infants (<35 weeks gestation and/or < 2500grams), The Hospital for Sick Children Reference: Maisels & Watchko. Arch Dis Child Fetal Neonatal Ed., 2003; 88:F459-F463. Horn et al. South African Medical Journal 2006;96:819-824. 3) If the TSB has not been measured earlier because of clinical jaundice, a TSB measurement should be obtained between 24 h and 72 h of life. Whenever possible, the TSB test should be done at the time of the Newborn Screening test to avoid an increase in the number of painful procedures for the infant (CPS, June 2007) 4) If a baby is being discharged at less than 24 hours of age, a TSB measurement would be inadequate (if done before 24 hours of age) to predict the risk of progression to severe hyperbilirubinemia. The CPS guidelines recommend that all babies have a TSB screening test between 24 – 72 hours of life. If the baby is discharged before 24 h of life, the infant should be reviewed within 24 h, any day of the week, by an individual with the training to recognize neonatal hyperbilirubinemia, obtain measurement of TSB (or TcB) without delay and refer the infant to a treatment facility if required. This individual may be from any medical or nursing discipline (CPS, June 2007). 5) Staff must refer to the bilirubin nomograms on the following forms (the Phototherapy nomogram and one of the Screening Assessment nomograms depending upon the baby’s gestational age) when a TSB result is obtained: a. Hyperbilirubinemia Assessment Sheet for Initiation of Phototherapy (see Appendix 1), and b. Hyperbilirubinemia Screening Assessment for Newborns 35 – 37 6/7 Weeks Gestation (see Appendix 2), or c. Hyperbilirubinemia Screening Assessment for Newborns 38 or More Weeks Gestation (see Appendix 3) Staff should: • plot the TSB level on the appropriate Hyperbilirubinemia Screening Assessment for Newborns Form (one form for term infants, one form for late preterm infants) to determine which risk zone the infant’s TSB level falls into; this determines if the baby requires a Coombs test (if mom is blood group O) – refer to Coombs Test algorithm 15 MacPeds Survival Guide 126 • plot the TSB level on the Hyperbilirubinemia Assessment Sheet for Initiation of Phototherapy using the appropriate phototherapy risk line based on the infant’s gestational age and the absence or presence of any risk factors for bilirubin toxicity (eg. positive Coombs); for example, a 39 week infant with no risk factors for bilirubin toxicity would be plotted using the Lower Risk Line (the upper line), but a 39 week infant with a positive Coombs test would be plotted using the Medium Risk Line (the middle line) • if the TSB level plots above the phototherapy line, initiate phototherapy treatment and continue to plot all subsequent TSB levels on the Phototherapy Nomogram; do not plot TSB levels on the Hyperbilirubinemia Screening Assessment Form (screening) nomogram once phototherapy treatment has been initiated • Upon discontinuation of phototherapy treatment, a repeat TSB is recommended to check for rebound (S. Seigel, May 2010) • if the TSB level plots below the phototherapy line, then phototherapy treatment is not required; determine which risk zone the infant’s TSB level falls into based on the screening nomogram on the Screening Assessment Form to determine if any follow-up intervention is required • double check: i. if the TSB level falls into a risk zone which requires a Coombs test (and mother is blood group O) and the Coombs test result is positive (weak positive, positive, strong positive), then the risk line on the Phototherapy Nomogram must be dropped to the next highest risk line and re-verify if the infant is above or below the new phototherapy risk line ii. for infants who do not require phototherapy, re-verify what response or follow-up intervention is required as this may change if the infant is positive Coombs Adapted from American Academy of Pediatrics. Clinical Practice Guideline: management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2004; 114: 297-316. Alkalay, A.L. et al. Hyperbilirubinemia Guidelines in Newborn Infants. Pediatrics 2005; 115: 824-825. Canadian Paediatric Society. Guidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants (35 or more weeks’ gestation). Fetus and Newborn Committee, Canadian Pediatric Society (CPS), Pediatrics and Child Health 2007; 12(5): 1B-12B. Physician / Midwife MacPeds Survival Guide 16 127 This nomogram is for use by Pediatricians and Neonatologists but may be used as a reference guide by Family Physicians and Midwives. Guidelines for Exchange Transfusion in Infants 35 or More Weeks’ of Gestation Bilirubin Nomogram for Exchange Transfusion 450 Bilirubin umol/L 400 350 300 250 200 150 100 Birth 12 24 48 72 96 120 144 Age in hours Infants at Higher Risk Infants at Medium Risk Infants at Lower Risk Guidelines: The dashed lines for the first 24 hours indicate uncertainty due to wide range of clinical circumstances and a range of responses to phototherapy. Infants at Low Risk: > 38 weeks with no risk factors Infants at Medium Risk: > 38 weeks with risk factors or 35-37 6/7 weeks with no risk factors Infants at Higher Risk: 35-37 6/7 weeks with risk factors Risk Factors: • hemolysis due to maternal isoimmunization, G6PD deficiency, pyruvate kinase deficiency, congenital spherocytosis or other causes of hemolysis • sepsis, temperature instability, significant lethargy • need for resuscitation at birth/asphyxia • evidence of metabolic or respiratory acidosis • low serum albumin<30g/L ⇒ ⇒ ⇒ ⇒ ⇒ These exchange levels represent a consensus but are based on limited clinical evidence. Exchange transfusion is recommended if the total serum bilirubin rises to these levels despite intensive phototherapy for 6 hours. Repeat serum bilirubin every 2 to 3 hours during intensive phototherapy. Immediate exchange transfusion is recommended if the total serum bilirubin is 85 µmol/L above these lines or if the infant shows signs of acute bilirubin encephalopathy (hypertonia, arching, retrocolis, opisthotonus, fever, high pitched cry). Consider exchange transfusion if the cord bilirubin is >85 µmol/L and the Hb<120g/L. Measure serum bilirubin and calculate the bilirubin/albumin ratio (B/A ratio). The B/A ratios can be used together with but not in lieu of the serum bilirubin level as an additional factor in determining the need for exchange transfusion. IgG treatment for babies with immune hemolytic jaundice approaching exchange: Infants with a positive DAT who have predicted severe disease based on antenatal investigation or an elevated risk of progressing to exchange transfusion based on postnatal progression of TSB concentrations should receive IVIG at a dose of 1 g/kg. (CPS, 2007) Physician / Midwife MacPeds Survival Guide 17 128 KEY RECOMMENDATIONS FOR PREVENTING AND MANAGING HYPERBILIRUBINEMIA 1. Promote and support successful breastfeeding. 2. Establish nursery protocols for the jaundiced newborn and permit nurses to obtainTSB levels without a physician’s order. St. Joseph’s Healthcare and McMaster will implement a universal TSB screening program. 3. Measure the TSB or TcB* (Transcutaneous Bilimeter) concentrations of infants jaundiced in the first 24 h after birth * At the present time, neither McMaster nor St. Joseph’s uses a Transcutaneous Bilirubin meter. 4. Recognize that visual diagnosis of jaundice is unreliable, particularly in darkly pigmented infants. 5. Interpret all TSB (Total Serum Bilirubin) levels according to the infant’s age in hours, not days. 6. Do not treat a near-term (35 to 38 wk) infant as a term infant; a near-term infant is at much higher risk of hyperbilirubinemia. 7. Perform a pre-discharge systematic assessment on all infants for the risk of severe hyperbilirubinemia. 8. Provide parents with information about newborn jaundice. 9. Provide follow-up based on the time of discharge and the risk assessment. 10. When indicated, treat the newborn with phototherapy or exchange transfusion. Maisels, Jeffrey M. Pediatrics in Review. American Academy of Pediatrics. 2006; 27: 443 – 454. Physician / Midwife MacPeds Survival Guide 18 129 Appendix 1 Physician / Midwife MacPeds Survival Guide 19 130 Appendix 2 Physician / Midwife MacPeds Survival Guide 20 131 Appendix 3 Physician / Midwife MacPeds Survival Guide 21 132 REFERENCES Alkalay, Arie L. and Simmons, Charles F.(2005) Hyperbilirubinemia Guidelines in Newborn Infants. Pediatrics, 115: 824-825. American Academy of Pediatrics (2004) Clinical Practice Guideline: Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics, 114: 297-316. Association of Women’s Health, Obstetric and Neonatal Nurses (2005) Hyperbilirubinemia: Identification and nd Management in the Healthy Term and Near-Term Newborn 2 Edition. AWHONN. XBhutani, V.K. et al. (2006) A Systems Approach for Neonatal Hyperbilirubinemia in Term and Near-Term Newborns. JOGNN July/August,XXXXXXX, 444-455. Bhutani, V.K. & Johnson, L.H. (2006) Kernicterus in late preterm infants cared for as term healthy infants. Seminars in Perinatology, 30, 89-97. Canadian Paediatric Society (2007) Guidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants (35 or more weeks’ gestation). Fetus and Newborn Committee, Canadian Pediatric Society (CPS), Pediatrics and Child Health, 12(5): 1B-12B. XCanadian Paediatric Society (2004XXXXXXXXX), Canadian Paediatric Surveillance Program 2004 Results. Neonatal hyperbilirubinemia – severe (July 2002 to June 2004) Final Report; Health Canada. Canadian Paediatric Society (2002) Canadian Paediatric Surveillance Program. Kernicterus and the healthy term newborn. Perinatal Partnership Program of Eastern & Southeastern Ontario, Vol. 19, No. 1. Joint Commission on Accreditation of Healthcare Organizations (2001). Sentinel Event Alert – Kernicterus threatens healthy newborns. Issue 18 – April 1. Joint Commission on Accreditation of Healthcare Organizations (2004). Sentinel Event Alert – Revised guidance to help prevent kernicterus. Issue 31 – August 31. Keren, R and Bhutani, V.K. (February 2007) Predischarge Risk Assessment for Severe Neonatal Hyperbilirubinemia. Neo Reviews. Vol. 8 No. 2, e68-e76.. Maisels, M. Jeffrey (December 2006). Neonatal Jaundice. Pediatrics in Review. Vol. 27 No. 12: 443-454. Sarici, S.U. et al. (April 2004) Incidence, Course, and Prediction of Hyperbilirubinemia in Near-Term and Term Newborns. Pediatrics Vol. 113, No. 4, 775-780. Sgro, Michael et al. (September 12, 2006) Incidence and causes of severe neonatal hyperbilirubinemia in Canada. CMAJ 175(6): 587-590. The HIROC Connection (June 2006). Risk Review: Neonatal Hyperbilirubinemia and the Prevention of Kernicterus – The Magnitude of the Problem. HIROC Issue #9, 1, 7-11. Watchko, J.F. (2006) Hyperbilirubinemia and Bilirubin Toxicity in the Late Preterm Infant. Clinics in Perinatology Vol. 33: 839 – 852. Wentworth, Stephanie D.P. (2005) Neonatal Phototherapy – today’s lights, lamps and devices. infant Volume 1 Issue 3: 14 – 19. Physician / Midwife MacPeds Survival Guide 22 133 McMaster Children’s Hospital Phototherarpy Guidelines Infants less than 35 weeks and/or less than 2500 gms Optimal Phototherapy demands the use of irradiance in the 425-475 nm band delivered to as much of the infants’ surface area as possible. If possible, place phototherapy lights at a distance of 30 cm from the infant. 1. Use total serum bilirubin. Do not subtract direct or conjugated bilirubin 2. Use gestational age rather that birthweight if gestational age is accurate 3. Start phototherapy (irradiance ≥ 30 µW/cm2/nm) when total serum bilirubin (TSB) is = the line according to gestation or weight. 4. Start bili blanket when TSB is > 17-34 µ mol/L above the line according to gestational age or weight 5. In the presence of risk factors use one line lower (use gestation below) until <1000 gms 6. Risk factors: isoimmune hemolytic disease, G6PD deficiency, asphyxia, sepsis, acidosis, hypoalbuminemia 7. Discontinuing phototherapy: after assessment of risk factors (i.e. cause and age at which phototherapy was started), consider discontinuing phototherapy when the bilirubin level falls below the level at which it was initiated. Check serum bilirubin level 6-12 hours after discontinuing phototherapy to assess for rebound. MacPeds Survival Guide 134 micro mol/L (µmol) TSB (total serum bilirubin) The Hospital for Sick Children Exchange Transfusion for Infants <2500g and/or <35weeks gestation 380 370 360 350 340 330 320 310 300 290 280 270 260 250 240 230 220 210 200 190 180 170 160 12h 24h 36h References: Maisels & Watchko. Arch Dis Child Fetal Neonatal Ed. 2003; 88:F459-F463. Horn et al. South African Medical Journal 2006;96:819-824. MacPeds Survival Guide 48h 60h 72h 84h 96h 108h 120h <28w or <1000g 28w-29w6days or 1000-1249g 30w-31w6days or 1250-1499g 32w-33w6days or 1500-1999g 34w-34w6days or 2000-2400g 1. Use total bilirubin. Do not subtract direct or conjugated bilirubin. 2. Use gestational age rather than birthweight if gestational age is accurate. 3. In the presence of risk factors use one line lower (gestation below) until <1000g. 4. Exchange level for infants <1000g with risk factors: 12hrs:180µmol/L; ≥24hrs:200µmol/L 5. Risk factors: isoimmune hemolytic disease, G6PD deficiency, asphyxia, sepsis, acidosis, hypoalbuminemia. 6. Infants who present with total serum bilirubin (TSB) above threshold should have exchange performed if TSB is not expected to be below the threshold after 6 hours of intensive phototherapy. 7. Immediate exchange transfusion is recommended if infant shows signs of acute bilirubin encephalopathy (hypertonia, arching, retrocollis, opisthotonos, fever, high pitched cry) and usually if TSB is >85umol/L above threshold at presentation. 8. Exchange if TSB continues to rise >17umol/L/hour with intensive phototherapy. Time (age in hours) 135 GUIDELINES FOR MANAGEMENT OF HYPERNATREMIA IN A BREAST FED BABY sodium level 140-145 mmol/L = no medical intervention review breast feeding technique for appropriateness and monitor weight, urine and stool output sodium level 145-149 mmol/L = if weight loss is < 7% in 48-72 hours or <10% in five days, provide breast feeding support and monitor daily as above with sodium levels until normalization. If weight loss is >7% in 48-72 hours and >10% in five days, supplement with expressed breast milk/formula using appropriate aids to support breast feeding success. sodium level of 150-155 mmol/L = supplement with expressed breast milk/formula using appropriate baby friendly maneuvers regardless of weight loss and repeat blood work in 6-8 hours. It is recommended that a pediatric consult should be sought by the family doctor. sodium level of 155-160 mmol/L = consider transfer to NICU - continue with breast feeding and supplement with expressed breast milk/ formula. Repeat blood work in 4-6 hours and watch urine output and stool frequency. sodium level of >160 mmol/L = IV saline bolus 10-20 mL/kg and replace fluid deficit slowly. Correction of hypernatremia is dependent on serum sodium levels. ♦ follow clinically on urine output ♦ repeat blood work in six hours and 12 hours and may continue with breast feeding and monitor the baby closely ♦ avoid rapid rehydration ♦ lower serum sodium by 10-15 mmol/L using attached guidelines (table 5) ref 3 below Integral to each step of the management guidelines is the provision of breast feeding support and the proper evaluation of the breast feeding technique to ensure success. Resolution of hypernatremia in breast fed infants is associated with: ♦ a good breast latch ♦ an expectation that the infant will feed at least every three hours or a minimum of eight times a day ♦ improvement in hydration status ♦ at least six wet diapers a day ♦ at least three stools (minimum) a day ♦ a plateau in weight pattern with subsequent weight gain (Refer to guideline "breast feeding in the first few days" for the assessment of stool and voiding patterns in the first six days of life .) 5,6 References 1. 2. 3. 4. 5. 6. Lawrence R: Early Discharge Alert Pediatrics, 1995:96(5):966 CPS. Early Discharge of Newborn Infants - a guide for parents. Paediatric Child Health 1(2); fall 1996 Molteni KH. Initial Management of Hypernatremic Dehydration in the Breast Fed Infant. Clinical Pediatrics 33(12):731-40, 1994 Fleisher, GR. Textbook of Pediatric Emergency Medicine p.817. 2000. Health Canada Fairly Centred Maternity and Newborn Care 7.5;2000 Hamilton-Wentworth Regional Lactation Committee. PD3910-07/2001 July 3 , 2001, Breast feeding in the first few days. rd MacPeds Survival Guide 136 MacPeds PEDIATRIC FORMULARY For drugs prescribed in the NICU please refer to the handbooks available in unit at both McMaster and St Joseph’s Healthcare. There is a separate PICU handbook with a drug formulary specific to the PICU. This document is intended for use at McMaster Children’s Hospital (MCH) only and may not be applicable elsewhere. While this document is intended to reflect the practice at MCH at the time of writing, new information may become available. Every attempt has been made to ensure accuracy but these recommendations should be used in conjunction with good clinical judgment, and in consultation with a Pharmacist as needed. MacPeds Survival Guide 137 Unapproved Abbreviations, Symbols and Dose Designations and Acceptable Corrections Unapproved Abbreviation U IU Intended Meaning Unit International unit Abbreviations for Drug Names Problem Mistaken for “0” (zero), “4” (four), or cc. Mistaken for “IV” (intravenous) or “10” (ten). Misinterpreted because of similar abbreviations for multiple drugs; e.g., MS, MSO4 (morphine sulphate), MgSO4 (magnesium sulphate) may be confused for one another. QD QOD Every day Every other day OD OS, OD, OU Every day Left eye, right eye, both eyes Mistaken for “right eye” (OD = oculus dexter) May be confused with one another. AS, AD, AU Left ear, right ear, both ears May be confused with one another. D/C Discharge or discontinue SC, SQ, or sub q Subcutaneous cc Cubic centimetre Premature discontinuation of medications if D/C (intended to mean “discharge”) has been misinterpreted as “discontinued” when followed by a list of discharge medications SC mistaken as SL (sublingual); SQ mistaken as “5 every;” the “q” in “sub q” has been mistaken as “every” (e.g., a heparin dose ordered “sub q 2 hours before surgery” misunderstood as every 2 hours before surgery) Mistaken for “u” (units). g Unapproved Symbol @ > < Unapproved Dose Designation Trailing zero Microgram Intended Meaning at Greater than Less than QD and QOD have been mistaken for each other, or as ‘qid’. The Q has also been misinterpreted as “2” (two). Mistaken for “mg” (milligram) resulting in one thousand-fold overdose. Potential Problem Mistaken for “2” (two) or “5” (five). Use “at”. Mistaken for “7”(seven) or the letter “L” . Confused with each other. Intended Meaning Potential Problem X.0 mg Or 10.0 mg Decimal point is overlooked resulting in 10-fold dose error. Acceptable Correction Use 'unit'. Use 'unit'. Do not abbreviate drug names. (exceptions: ASA, KCl, Humulin R) Write “daily” and “every other day” in full Write “daily” Use “left eye”, “right eye” or “both eyes”. Use “left ear”, “right ear” or “both ears” Use “discharge” and "discontinue". Use "subcut" or "subcutaneous" Use “mL” or “millilitre”. Use “mcg or microgram”. Acceptable Correction Write out “at” in full Write out “greater than” in full Write out “less than” in full Acceptable Correction Never use a zero by itself after a decimal point. Use “X mg or 10 mg” Lack of leading . X mg Decimal point is overlooked resulting in 10-fold dose error. Always use a zero zero before a decimal point. Use “0.X mg” Adapted from ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations (2010) and ISMP Canada’s Do Not Use – Dangerous Abbreviations, Symbols and Dose Designations (2006) MacPeds Survival Guide 138 Legend: GAS GP GPC GN GNB MAX MIN NF Group A Streptococcus Gram Positive Gram Positive Cocci Gram Negative Gram Negative Bacilli Maximum Minimum Non-Formulary At HHS MacPeds Survival Guide Adjust dosing interval for patients with renal impairment. 139 Safer Order Writing To reduce the potential for medication errors: • Write orders clearly and concisely. • Write medication orders using generic drug names only. • Be careful with mg/kg/DAY vs mg/kg/DOSE. • Include the intended dose per kilogram on each order. • Write the patients weight on each order sheet. • Never place a decimal and a zero after a whole number (4.0 mg should be 4 mg) and always place a zero in front of a decimal point (.2mg should be 0.2 mg). The decimal point has been missed and tenfold overdoses have been given. • Never abbreviate the word unit. The letter U has been misinterpreted as a 0, resulting in a 10 fold overdose. • Always order medications as mg, not mL as different concentrations may exist of a given medication. There are a few exceptions such as co-trimoxazole (Septra®). • QD is not an appropriate abbreviation for once daily, it has been misinterpreted as QID. It is best to write out “once daily” or “q24h.” • Do not abbreviate drug names (levo, 6MP, MSO4, MgSO4, HCTZ). • Do not abbreviate microgram to µg, use mcg, or even safer, write out microgram or use milligrams if possible (0.25 mg instead of 250 micrograms) MacPeds Survival Guide 140 • ANTIBACTERIALS CELL WALL SYNTHESIS INHIBITORS (BACTERICIDAL) β-LACTAMS PENICILLINS benzyl penicillin: narrow spectrum; NOT Penicillinase resistant Penicillin G (IV or IM) Moderate to Severe Infections: IV: 100 000 - 400 000 Units/kg/DAY ÷ q4-6h (MAX: 24 million Units/DAY) Penicillin V Meningitis: IV: 400 000 Units/kg/DAY ÷ q4h (MAX: 24 million Units/DAY) Potassium (PO) Suspension: 60mg/mL Penicillin V Potassium (oral): Tablet: 300mg 1. Mild to moderate Group A Strep infections: 25-50mg/kg/day PO ÷ q8-12h x 10 days § Penicillin V 500 000 units is equivalent to 300 mg. IDSA (GAS pharyngitis)– Children: 300mg bid-tid; Adolescents & adults: 600mg po BID x 10 days 2. Other infections: 50-100mg/kg/day PO ÷ q6-8h (MAX: 3g/DAY) 3. Rheumatic fever (treatment): < 27kg: 300mg PO bid x 10 days; > 27kg: 600mg PO BID x 10 days 4. Rheumatic fever (prophylaxis AND > 5 yrs): 300mg PO bid 5. Prophylaxis in asplenics: 6 months – 5 yrs: 150mg PO bid >5 yrs: 300mg PO bid isoxazoyl penicillin: narrow spectrum; Penicillinase resistant Cloxacillin (IV or PO) Primarily used in methicillin-sensitive Staphylococcus aureus (MSSA) infections: IV: 100-200 mg/kg/DAY ÷ q4-6h (MAX: 12 g/DAY) Oral: PO: Suggest to use cephalexin (1st generation cephalosporin) in place as cloxacillin has low Suspension 25mg/mL oral bioavailability, poorly tolerated (GI side effects) and need to be taken on an empty Capsule: 250mg, 500mg stomach MacPeds Survival Guide 141 Aminopenicillin: Penicillinase sensitive Ampicillin (IV) Meningitis: IV: 300-400 mg/kg/DAY ÷ q4-6h (MAX: 12 g/day) Other infections: IV: 100-200 mg/kg/DAY ÷ q6h (MAX: 2 g/DOSE) Amoxicillin (PO) For coverage against Streptococcus pneumonia (including empiric therapy for communityacquired pneumonia or otitis media): PO 80-90mg/kg/DAY ÷ q8h (MAX: 1 g/DOSE) Suspension: 50mg/mL Standard dose: (supplied at HHS); 25mg/mL PO: 40-50 mg/kg/DAY ÷ q8h GAS pharyngitis: PO: 50mg/kg ONCE daily (MAX: 1000mg/DOSE) OR 25mg/kg (MAX: 500mg/DOSE) BID Clavulanic Acid: Enhances spectrum; beta-lactamase inhibitor Amoxicillin + Clavulanic Acid For coverage against Streptococcus pneumoniae (i.e. sequential oral therapy in (Clavulin) (PO) complicated CAP, AOM, sinusitis): 80-90mg/kg/DAYof amoxicillin component ÷ q8h Tablets (amoxicillin/clavulanic acid): 500/125mg(4:1); 875/125mg(7:1) Standard dosing for other gram positive, gram negative, anaerobic infections: Suspension (supplied as HHS): 1 mL PO: 25-40 mg/kg/DAY of amoxicillin component ÷ q8-12h (MAX: 500 mg/DOSE) = 50mg amoxicillin and 12.5mg clavulanic (4:1) *One major side effect with clavulanic acid (particularly at high doses) is GI intolerance Strategies to minimize GI intolerances: - Administer with food - Use amoxicillin/clavulanic acid AND plain amoxicillin to achieve desired total daily dose of amoxicillin (e.g. amoxicillin/clavulanic acid BID + amoxicillin at noon). Discussion with parents/caregivers prior discharge is necessary to ensure they comprehend and are in agreement with plan. MacPeds Survival Guide 142 • ANTIBACTERIALS (CONTINUED) PENICILLINS (CONTINUED) Ureidopenicillin: broad spectrum; Penicillinase sensitive Tazobactam: Enhances spectrum; β-lactamase inhibitor Piperacillin (IV) For documented Pseudomonas aeruginosa infections IV: 200-300 mg/kg/DAY ÷ q6h (MAX: 16 g/DAY) Piperacillin + Tazobactam (IV) Broad coverage against many pathogens. First line for febrile neutropaenia. IV: 200-300 mg/kg/day (of Piperacillin component) ÷ q6-8h (Adult dose is 4.5g IV q8h) **Order antibiotic as x mg (or g) of piperacillin component IV q6-8h** CEPHALOSPORINS – do NOT cover MRSA, Enterococcus species, Listeria, or extended spectrum betalactamase producing organisms (ESBL) 1st Generation Excellent coverage against S. aureus, group A Streptococcus, E. coli, Klebsiella. Empiric therapy for cellulitis, osteomyelitis, bacterial adenitis. Cefazolin (Ancef) IV: 75-150 mg/kg/DAY ÷ q8h (MAX: 6 g/DAY) (IV or IM) Cephalexin (Keflex) PO: 25-100 mg/kg/DAY ÷ qid (PO) Tablet: 250mg, 500mg Osteomyelitis following IV therapy: 100-150mg/kg/DAY (MAX: 4 g/DAY) 2 nd Suspension: 50mg/mL Generation NO LONGER INDICATED FOR EMPIRIC TREATMENT OF PNEUMONIA. These agents offer no benefit compared to ampicillin/amoxicillin for treatment of S. pneumoniae. Main benefit is coverage against (nontypeable) H. influenzae and Moraxella, which cause sinusitis and otitis. Cefuroxime IV: 100-150 mg/kg/DAY ÷ q8h (MAX: 2g/DOSE) (IV or IM) Cefuroxime Axetil Poor oral bioavailability; unlikely to achieve optimal concentrations in severe (Ceftin) (PO) infections MacPeds Survival Guide 143 Cefprozil (eg. for otitis media unresponsive to high-dose amoxicillin or for acute sinusitis) (Cefzil) (PO) Tablet: 250mg, 500mg PO: 15-30 mg/kg/DAY ÷ q12h (MAX: 1 g/DAY). Suspension: 50mg/mL 3rd Generation Broad spectrum activity against gram negatives. Ceftriaxone/cefotaxime offer excellent coverage against Streptococcus pneumoniae and good coverage of methicillin sensitive S. aureus. Only ceftazidime is active against Pseudomonas aeruginosa. Useful for CNS infections. Cefotaxime **reserved for neonates** (IV or IM) Meningitis: IV: 200-225mg/kg/DAY ÷ q6h; up to 300mg/kg/DAY ÷ q6h may be used in infants and older children for this indication (MAX: 12 g/DAY) Other infections: IV: 100-200 mg/kg/DAY ÷ q6-8h (MAX: 6 g/DAY) Neonates greater than 2kg (if less than 2kg, please refer to neonatal dosing handbook): 0 – 7 days: 100-150mg/kg/DAY IV ÷ q8-12h > 7 days: 150-200mg/kg/DAY IV ÷ q6-8h MacPeds Survival Guide 144 • ANTIBACTERIALS (CONTINUED) CEPHALOSPORINS Ceftriaxone Meningitis: IV/IM: 100mg/kg/DAY divided q12h or q24h (Max: 2g/DOSE) (IV or IM) Other infections: IV/IM: 50-75 mg/kg q24h (MAX: 2 g/DAY) STI (gonococcal infection): >45kg: 250mg IM x 1 Ceftazidime Active against Pseudomonas aeruginosa: (IV or IM) IV: 75-150 mg/kg/DAY ÷ q8h (MAX: 6 g/DAY) Cefixime Increasing MIC (minimum inhibitory concentration) against Neisseria gonorrhea; (Suprax) (PO) avoid use if possible due to increased risk of treatment failure. IM ceftriaxone is preferable. Tablet: 400mg Suspension: 20mg/mL Other infections (Not active against Pseudomonas and poor GP activity): PO: 8 mg/kg/DAY ÷ q12-24h (MAX: 400 mg/DAY) MacPeds Survival Guide 145 CARBAPENEMS – Very broad spectrum antibiotics (coverage against GP, GN and anaerobes including extended beta-lactamase producing strains of GN); no coverage against MRSA ** Requires ID endorsement ** Meropenem Meningitis: 40mg/kg/DOSE IV q8h (MAX: 2g/DOSE) (IV) Other infections: 20mg/kg/DOSE IV q8h (usual MAX: 1g/DOSE) Ertapenem 3 months - 12 years : 15mg/kg/DOSE IV q12h (max: 1 gram/DAY) (IV) >13 years: 1 g IV once daily (max: 1 gram/DAY) GLYCOPEPTIDES Vancomycin (IV or PO) The IV formulation will be provided when prescribed orally while in hospital Only active against GP (including MRSA). Use as an alternative for GP coverage in patients with severe penicillin allergy (i.e. anaphylaxis, angioedema) Meningitis: IV: 60 mg/kg/DAY ÷ q6h (MAX: 4 g/DAY) Other infections (MRSA or Coagulase Negative Staphylococci): IV: 40-60 mg/kg/DAY ÷ q6-12h (usual MAX: 2 g/DAY) Higher doses may be required in patients with suspected/confirmed MRSA infections, or individuals who are in clinically severe sepsis Infuse over a minimum of 1 hour to avoid Red Man Syndrome; If reaction occurs, increase infusion time. In patients with known history of Red Man Syndrome, write on order to infuse over at least 2 hours. Monitor trough levels in patients with septic shock, proven MRSA infections, concurrent nephrotoxins, fluctuating renal function or extended treatment courses Clostridium difficile infection (usually reserved for severe infection or failed metronidazole): PO: 12.5 mg/kg/DOSE q6h (MAX: 125 mg/DOSE) MacPeds Survival Guide 146 ANTIBACTERIALS (CONTINUED) Protein Synthesis Inhibitors VIA 50S Ribosome (Bacteriostatic) MACROLIDES Atypicals: Mycoplasma, Legionella, Chlamydia, H. pylori GAS and S. pneumoniae infections in patients with severe penicillin allergy (although substantial macrolide resistance has been observed with these pathogens). Clarithromycin Useful for mild bacterial pneumonia in adolescents. Also commonly used for atypical mycobacterial infections. Tablet: 250mg, 500mg PO: 7.5 mg/kg/DOSE BID (Max: 500mg/DOSE) Suspension: 25mg/mL, (50mg/mL not available at HHS) Rx Interactions: theophylline, carbamazepine, cisapride, digoxin, cyclosporine, tacrolimus. Azithromycin Useful for known atypical respiratory infections and bacterial enteritis. Tablet: 250mg PO/IV: Suspension: 40mg/mL LINCOSAMIDES Clindamycin Capsule: 150mg, 300mg Suspension 15mg/mL 10 mg/kg (MAX: 500 mg) once, then 5 mg/kg (MAX: 250 mg) q24h for 4 days Pertussis: 10 mg/kg PO/IV q24h for 5 days Chlamydia trachomatis urethritis or cervicitis: PO: (> 1 month) 12 – 15mg/kg once (MAX: 1g) Useful for toxic shock syndromes, anaerobic infections of the head and neck, and for susceptible S. aureus (including some MRSA) and group A streptococcus infections. Be careful – resistance in S. aureus is not particularly uncommon! IV: 30-40 mg/kg/DAY ÷ q8h (usual MAX: 600 mg/DOSE; 900mg IV q8h is usually prescribed in the setting as adjunct therapy in gram positive toxic shock or necrotizing fascitis) PO: 10-30 mg/kg/DAY ÷ q6-8h (MAX: 450 mg/DOSE) May potentiate muscle weakness with neuromuscular blockers. Oral suspension is very poorly tolerated, avoid if possible, use 150 mg capsules or an alternative antibiotic VIA 30S and 50S Ribosome (Bacteriocidal) MacPeds Survival Guide 147 AMINOGLYCOSIDES GN Aerobes (including Pseudomonas aeruginosa) Gentamicin IV: 5-6 mg/kg/dose q24h (extended frequency dosing is preferred in patients without renal impairment to maximize pharmacokinetics and dynamics of drug) OR Synergy with beta-lactams for severe S. aureus and Enterococcus infections: Tobramycin 3mg/kg/day IV ÷ q8h Tobramycin: doses as high as 10mg/kg/DAY IV q24h is recommended in patients with cystic fibrosis. (Inhaled tobramycin for CF patients): 80mg bid to tid via inhalation Once daily dosing should be used for all patients > 1 month of age, except in the treatment of endocarditis and in patients with extensive burns. Ototoxicity and nephrotoxicity may occur, consider monitoring trough levels (target <1 mg/L) in patients at risk for nephrotoxicity (e.g. septic shock, concurrent nephrotoxins, fluctuating renal function or extended treatment courses). Prolonged therapy (i.e. >/= 2 weeks) generally not warranted. May potentiate muscle weakness with neuromuscular blockers. DNA Complex Damaging Agents (Bactericidal) METRONIDAZOLE (IV or PO) Tablets: 250mg; Suspension: 15mg/mL Anaerobic infections: IV/PO: 20-30 mg/kg/DAY ÷ q8-12h (MAX: 1 g/DAY) C. difficile (For Colitis): (Enteral administration preferred but IV can be used) IV/PO: 30-50 mg/kg/DAY ÷ q6-8h (MAX: 1.5 g/DAY) Excellent oral absorption, use IV only if PO contraindicated or not tolerated • ANTIBACTERIALS (CONTINUED) Folic Acid Metabolism Inhibitors (Bacteriostatic) TRIMETHOPRIM-SULFAMETHOXAZOLE (TMP-SMX) (Septra, Co-trimoxazole) Useful for: Pneumocystis carinii, Toxoplasma, Shigella, Salmonella, MRSA (in settings of cellulitis after appropriate MacPeds Survival Guide 148 incision and drainage), Nocardia Order in mg of trimethoprim component and mL of suspension (or number of tablets) Bacterial infections (UTI): PO/IV: 8-12 mg/kg/DAY (of Trimethoprim component) ÷ q12h Pneumocystis carinii pneumonia (PCP): PO/IV: 15-20 mg/kg/DAY (of Trimethoprim component) ÷ q6-8h If PCP is severe (i.e. hypoxia), consider adding IV Methylprednisolone 1 mg/kg q24h PCP prophylaxis (Hematology/Oncology, HIV): PO/IV: 3-5mg/kg/day (of Trimethoprim component) ÷ bid on Monday, Wednesday, Friday Urinary tract infection prophylaxis: 2 – 5mg /kg/DAY trimethoprim once daily Formulation: Trimethoprim Sulfamethoxazole Suspension 8 mg/ml 40 mg/ml Injection 16 mg/ml 80 mg/ml SS (single strength) 80 mg 400 mg Tablet DS (double strength) 160 mg 800 mg Tablet Excellent oral absorption, use IV only if PO contraindicated. Maintain good fluid intake and urine output. Monitor CBC and LFTs. Do not use in patients with G-6-PD deficiency. DNA Gyrase Inhibitors (Bactericidal) QUINOLONES Enteric GNB, including most ESBL and Pseudomonas. Levofloxacin also has excellent coverage against S. pneumoniae. Theoretical risk of development of arthropathy in children is based primarily on animal studies. The use of quinolones in situations of antibiotic resistance where no other agent is available is reasonable, weighing the benefits of treatment against the low risk of toxicity of this class of antibiotics. Another situation would be where there are no other MacPeds Survival Guide 149 orally administered antibiotics available. Ciprofloxacin ** REQUIRES ID ENDORSEMENT** (IV or PO) Ciprofloxacin usually reserved for infections caused by Pseudomonas aeruginosa or Tablet: 250mg, 500mg, other resistant gram negative bacilli 750mg IV/PO: 20-30 mg/kg/DAY ÷ q12h (MAX: 400 mg/DOSE IV or 750 mg/DOSE PO) Suspension: 100mg/mL (tablets are preferable if dose Excellent oral absorption, use IV only if PO contraindicated. is given via NG tubes) Feeds, formula, calcium, magnesium, iron, antacids and sucralfate reduce absorption, hold feeds for 1 hour before and 2 hours after dose. Levofloxacin ** REQUIRES ID ENDORSEMENT** Tablet: 250mg, 500mg, Levofloxacin usually reserved for infections caused by Pseudomonas aeruginosa, other 750mg resistant gram negative bacilli or penicillin-resistant Streptococcus pneumoniae. Suspension not available commercially; use dissolve and dose ANTIFUNGALS MacPeds Survival Guide 150 Fluconazole (IV or PO) Oropharyngeal candidiasis: Esophageal candidiasis: Candidemia: IV/PO: IV/PO: IV/PO: 3 mg/kg q24h 6 mg/kg q24h (MAX: 400 mg/DAY) 12 mg/kg once (MAX: 800 mg) Then 6 mg/kg/DAY (MAX: 400 mg/DAY, á doses used) Excellent oral absorption, use IV only if PO contraindicated. May increase serum levels of cyclosporine, midazolam, cisapride, phenytoin. Aspergillus species and Candida krusei are intrinsically resistant, Candida glabrata may respond to higher doses. Dosage adjustment is required in patients with impaired renal function Voriconazole (IV or PO) ** Requires ID endorsement ** Tablet: 50mg, 200mg Coverage against many Candida species and Aspergillus Suspension: 40mg/mL Loading dose:6mg/kg Q12h x 2 doses then Maintenance dose: 4mg/kg q12h (higher doses may be used in specific clinical scenarios) Only IV formulation needs to be used with caution in patients with renal impairment (use oral formulation in this scenario) ANTIFUNGALS (continued) Liposomal ** Requires ID endorsement ** Amphotericin B (IV) Coverage against many Candida species, Aspergillus and most Mucor MacPeds Survival Guide 151 (Ambisome) 3 – 5 mg/kg IV once daily Monitor renal function and electrolytes (particularly potassium and magnesium). Infusion-related adverse effects (e.g. fever, rigors etc) may require pre-treatment with acetaminophen, diphenhydramine Caspofungin (IV) ** Requires ID endorsement ** Loading dose: 70mg/m2/DAY IV x 1 dose (MAX: 70mg) then Maintenance dose: 50mg/m2/DAY IV once daily (MAX: 50mg) Nystatin Oral candidiasis: PO: infants: 100 000 Units swish and swallow QID children: 250 000 Units swish and swallow QID adolescents: 500 000 Units swish and swallow QID ANTI-VIRALS Acyclovir Need to monitor kidney function and ensure adequate hydration (especially on high dose of intravenous therapy). Dosing adjustment is necessary in patients with impaired renal Tablets: 200mg, 400mg and function 800mg MacPeds Survival Guide 152 Suspension: 40mg/mL Infants 1-3 months: 60mg/kg/DAY IV ÷ q8h (duration will be dependent on organ involvement – 21 days for CNS and disseminated disease; 14 days for skin and mucous membrane involvement) HSV encephalitis (> 3 months to 12 years): 60mg/kg/DAY IV ÷ q8h (MAX: 1g/DOSE) HSV encephalitis (> 12 years): 30mg/kg/DAY IV ÷ q8h (MAX: 1g/DOSE) Mild – moderate mucocutaneous HSV infection in immunocompetent hosts: 30-40mg/kg/DAY PO ÷ q8h HSV infection in immunocompromised hosts or severe infection (eg. eczema herpeticum): 15-30mg/kg/DAY IV ÷ q8h PO dosing (following IV therapy): 60-80mg/kg/DAY PO ÷ q8h Varicella or zoster in immunocompromised hosts: 30mg/kg/DAY IV q8h PO dosing (following IV therapy): 80mg/kg/DAY PO ÷ qid Varicella or zoster in immunocompetent host (note that therapy not always indicated): 80mg/kg/DAY PO ÷ qid References: Bradley JS and Nelson JD. Nelson’s Pocket Book of Pediatric Antimicrobial Therapy. 18th edition. 2010. MacPeds Survival Guide 153 PEDIATRIC FORMULARY Acetaminophen Analgesic and antipyretic. PO/PR: Refer to table for weight based dosing standardization Can be dosed q4-6h prn Weight (kg) 2.5 - 3.9 4.0 - 5.4 5.5 - 7.9 8.0 - 10.9 11.0 - 15.9 16.0 - 21.9 22.0 - 26.9 27.0 - 31.9 32.0 - 43.9 44 – over Single Dose (mg) 40 60 80 120 160 240 320 400 480 650 Acetylsalicylic Acid Antiplatelet: PO: 5 mg/kg/DOSE q24h. Minimum 20 mg, usual maximum 325 mg. Kawasaki disease: PO: 80-100 mg/kg/DAY ÷ q6h, reduce dose to 3-5 mg/kg q24h once fever resolves. Supplied as 80 mg chewable tablets and 325 and 650 mg tablets. Captopril Angiotensin converting enzyme inhibitor (ACE-I). PO: 0.1-0.3 mg/kg/DOSE q8h initially (usual maximum 6 mg/kg/DAY or 200 mg/DAY). Monitor blood pressure closely after first dose, may cause profound hypotension. Cough is a common side effect of ACE-I. MacPeds Survival Guide 154 Carbamazepine Anticonvulsant. PO: 10-20 mg/kg/DAY initially, usual maintenance dose is 20-30 mg/kg/DAY. Divide daily dose q8-12h. Serum trough concentration target is 17-50 micromol/L (4-11 microgram/mL). Charcoal Adsorbent used in toxic ingestions. PO: 1-2 g/kg once. PO: Multiple dose therapy 0.5 g/kg q4-6h. Give via NG if necessary, consider antiemetics. Chloral Hydrate Sedative and hypnotic. Procedural Sedation: PO/PR: 80 mg/kg 20-45 mins before procedure may repeat half dose if no effect in 30 minutes (maximum 2 g/dose). Sedation: PO/PR: 25-50 mg/kg/DOSE q6-8h (maximum 500 mg q6h or 1 g hs). Avoid in liver dysfunction. Tolerance develops and withdrawal may occur after long-term use. For PR use dilute syrup with water. Codeine: Codeine has now been replaced with Morphine as the preferred oral narcotic analgesic for acute pain at HHSC due to better safety profile. Please refer to morphine dosing MacPeds Survival Guide 155 Dexamethasone Corticosteroid. Acute Asthma: IV/PO: 0.3 mg/kg/DOSE (usual max 8 mg/DOSE) Croup: IV/PO: 0.6 mg/kg ONCE (usual max 12 mg) Cerebral Edema:: IV/PO: 1-2 mg/kg then 1-1.5 mg/kg/DAY divided Q6H (usual maximum 16 mg/DAY) Antiemetic for antineoplastic regimens: IV/PO: 0.25mg/kg/DAY divided q8h Discontinuation of therapy greater than 14 days requires gradual tapering. Consider supplemental steroids at times of stress if patient has received long-term or frequent bursts of steroid therapy. Dextrose Treatment of hypoglycemia: IV: 0.5-1 g/kg/DOSE: 1-2 mL/kg of 50% dextrose 5-10 mL/kg of 10% dextrose 1 mmol of dextrose (0.2 g of dextrose) provides 2.8 kJ (0.67 kcal). Diazepam Benzodiazepine sedative, anxiolytic and amnestic. Status epilepticus: IV: 0.1-0.5 mg/kg/DOSE (usual maximum 5 mg for <5 yrs 10 mg for >5yrs) PR: 0.5 mg/kg/DOSE (maximum 20 mg/DOSE). Skeletal muscle spasms: PO: 1-2.5mg /DOSE q3-4h prn (May increase gradually as needed) Fast onset and short duration of action with single doses, duration of action prolonged with continued use. Withdrawal may occur if discontinued abruptly after prolonged use. Not recommended for continuous infusion due to poor solubility. Can give parenteral preparation rectally, diluted with water. MacPeds Survival Guide 156 Dimenhydrinate (Gravol) Antihistamine used to treat nausea and vomiting. IV/IM/PO: 0.5 -1 mg/kg/DOSE q4-6h prn (maximum 50 mg/DOSE). Available as 3mg/mL liquid. Please round to nearest 2.5mg dose. Diphenhydramine (Benadryl) Antihistamine used primarily to treat urticaria. IV/IM/PO: 0.5-1 mg/kg/DOSE q6h prn (maximum 50 mg/DOSE). Available as 2.5mg/ml elixir. Please round to nearest 2.5mg dose. Docusate (Colace) Laxative PO: 5 mg/kg/DAY once daily or in divided doses 2-4 times/DAY (maximum 200 mg/DAY) Available as 10 mg/mL suspension or 100 mg capsule Suspension is bitter tasting. Mask taste by diluting with juice or milk/formula. Please round to nearest multiple of 5mg. Domperidone Prokinetic agent. PO: 1.2-2.4 mg/kg/DAY ÷ q6h (maximum 80 mg/DAY). Give 15- 30 mins prior to feed/meals and at bedtime MacPeds Survival Guide 157 Enoxaparin Anticoagulant, low-molecular weight heparin. Treatment: Subcutaneous: <2 months of age: 1.5 mg/kg/DOSE q12h. >2 months of age: 1 mg/kg/DOSE q12h. Prophylaxis: Subcutaneous: <2 months of age: 0.75 mg/kg/DOSE q12h. or 1.5 mg/kg q24h >2 months of age: 0.5 mg/kg/DOSE q12h or 1mg/kg q24h Monitor platelets and hemoglobin. Avoid in severe renal dysfunction. Anti-factor Xa level drawn 4 hours post Subcutaneous injection should be 0.5-1 unit/mL for treatment and 0.2-0.4 unit/mL for prophylaxis. Epinephrine (1:1000) NEB: If less than 10kg: 2.5mg/DOSE inhaled q8h prn 10kg or greater: 5mg/DOSE inhaled q8h prn Bronchiolitis: NEB: 1.5 mg in 4 mls of 3% Hypertonic saline q8h Ferrous Sulfate : See iron. Fluticasone (Flovent) Inhaled corticosteroid. INH: 50-500 microgram q12h. Available as 50mcg, 125mcg , 250 mcg /inhalation metered dose inhaler MacPeds Survival Guide 158 Furosemide Loop diuretic. PO: 1-2 mg/kg/DOSE q6h-q24h (usual max 80 mg/DOSE) IV: 0.5-2 mg/kg/DOSE q6h-q24h (usual max 80mg/DOSE) or begin at 0.1 mg/kg/hour and titrate to clinical effect (maximum 0.5 mg/kg/h). Available as 10mg/mL oral solution. Please round to nearest 1mg dose. Hydrochlorothiazide Thiazide diuretic. PO: 1-4 mg/kg/DAY ÷ q12h Available as 5mg/mL suspension. Please round to nearest 0.5mg or 1mg. Hydrocortisone Corticosteroid. Acute asthma: IV: 1-2 mg/kg/DOSE q6h for 24-48 hours then reassess. (usual max is 5mg/kg/DOSE) Anaphylaxis: IV: 5-10 mg/kg/DOSE. Acute adrenal crisis: IV: 1-2 mg/kg then: Infants: 25-150 mg/DAY ÷ q6h. Older children: 150-250 mg/DAY ÷ q6h. Discontinuation of therapy >14 days requires gradual tapering. Consider supplemental steroids at times of stress if patient has received long-term or frequent bursts of steroid therapy. MacPeds Survival Guide 159 Hydromorphone Narcotic analgesic Analgesia : PO: 0.03-0.08 mg/kg/DOSE q4-6h prn (usual initial max 3mg/DOSE) IV: 0.01-0.02 mg/kg/DOSE q2-4h prn Sedation/analgesia : IV: 0.01-0.02 mg/kg then 2-8 microgram/kg/hr (refer to continuous infusion preprinted order set) To prevent withdrawal, avoid abrupt cessation following high doses or long duration of therapy (> 5 days). Common adverse effects are pruritis, nausea and constipation Hypertonic Saline 3%: Bronchiolitis NEB: 4 mls of 3% saline q8h Ibuprofen Analgesic and anti-inflammatory (NSAID). Can be dosed q6-8h prn. PO: Weight (kg) 2.5 - 3.9 4.0 - 5.4 5.5 - 7.9 8.0 - 10.9 11.0 - 15.9 16.0 - 21.9 22.0 - 26.9 27.0 - 31.9 32.0 - 43.9 44 – over Single Dose (mg) 20 30 40 60 100 150 200 250 300 400 Avoid in patients with renal impairment or increased risk of bleeding MacPeds Survival Guide 160 Insulin (regular) Recombinant human insulin. Diabetic ketoacidosis: IV: 0.05-0.1 units/kg/h initially. (add 25 units of regular insulin to 250 ml/NS) then titrate to patients response For IV administration MUST use regular insulin. Hyperkalemia: IV: 0.1 units/kg AND dextrose 0.5 g/kg. Ipratropium (Atrovent) Inhaled anticholinergic bronchodilator. Severe asthma: NEB: 125-250 microgram (0.5-1 mL) q4-6h. INH: 2-4 puffs q4-6h (1 puff = 20 mcg) Iron Treatment of iron deficiency anemia: PO: 4-6 mg/kg/DAY (of elemental iron) ÷ q8-24h. Prevention of iron deficiency anemia: PO: 2-3 mg/kg/DAY (of elemental iron) ÷ q8-24h. Give with food if GI upset occurs. Does stain teeth, rinse mouth well after administration. Available as ferrous sulfate 75mg/mL solution (15mg/mL elemental iron). Please round to nearest 12.5mg dose (2.5mg elemental iron) Kayexelate® (Sodium Polystyrene Sulfonate) Cation exchange resin. Treatment of hyperkalemia: PO/PR: 1 g/kg/DOSE may be repeated q4-6h prn (usual maximum 30-60 g/DOSE). Give in water or juice, do not mix with fruit juices with high potassium content such as orange juice. MacPeds Survival Guide 161 Ketorolac (Toradol) Analgesic and anti-inflammatory (NSAID). IV/IM: 1-2 mg/kg/DAY (maximum 120 mg/DAY) ÷ q6h. Adverse effects include renal dysfunction, GI irritation and ulceration. Lactulose Osmotic laxative. PO: infants: 2.5-5 mL q8-24h. children: 5-10 mL q8-24h. adolescents: 15-30 mL q8-24h. Lorazepam Benzodiazepine sedative, anxiolytic and amnestic. Status epilepticus: IV: 0.1 mg/kg/DOSE, (usual maximum 4 mg/DOSE). May repeat 0.1mg/kg in 5 mins if needed PR: 0.2 mg/kg/DOSE (usual maximum 8 mg/DOSE) Pre-op/procedural sedation: PO/SL: 0.05 mg/kg/dose (max 4mg/DOSE) IV: 0.03-0.05 mg/kg/dose (max 4 mg/DOSE). Intermediate duration of action and no active metabolites. Withdrawal may occur if discontinued abruptly after prolonged use. Not recommended for continuous infusion due to poor solubility. May give parenteral preparation rectally, diluted with water. MacPeds Survival Guide 162 Magnesium salts Electrolyte. Treatment of hypomagnesemia: PO: 20-40mg/kg/day elemental magnesium ÷ TID-QID IV: 25-50 mg/kg (maximum 5g) over 4-5 hours Severe acute asthma: IV: 25-75 mg/kg/DOSE once (usual maximum 2g/DOSE) IV available as magnesium sulfate. PO available as magnesium glucoheptonate oral liquid 100mg/mL (5mg/mL elemental Mg) or magnesium oxide 420mg tablet (252mg elemental Mg) Methylprednisolone Corticosteroid. Severe acute asthma: IV: 0.5-1 mg/kg/ DOSE q12h (usual max 40 mg/DOSE) Or 1-2 mg/kg/DOSE q6h can be used until improvement seen (usually 24-48 hours) then q24h or switch to oral prednisone. Anti-inflammatory: IV: 1-2 mg/kg/DOSE q24h. High dose/pulse therapy: IV: 10-30 mg/kg/DOSE q24h Discontinuation of therapy >14 days requires gradual tapering. Consider supplemental steroids at times of stress if patient has received long-term or frequent bursts of steroid therapy. Metoclopramide Antiemetic, gastrointestinal prokinetic agent. IV/PO: 0.4-0.8 mg/kg/DAY ÷ q6h (usual maximum 40 mg/DAY). Extrapyramidal reactions occur more commonly in children and may be treated with diphenhydramine. MacPeds Survival Guide 163 Morphine Narcotic analgesic. Analgesia : PO: 0.2-0.5 mg /kg/DOSE q4-6h prn (usual max is 10-15 mg/ DOSE) IV: 0.05-0.1 mg/kg/DOSE q2-4h prn and increase as required Sedation/analgesia: IV: 0.05-0.1 mg/kg then 10-40 microgram/kg/hr infusion (refer to continuous infusion preprinted order set) Please note: Morphine has now replaced codeine as the preferred oral narcotic analgesic for acute pain at HHSC due to better safety profile. Reduced doses may be required if used in combination with benzodiazepines. To prevent withdrawal, avoid abrupt cessation following high doses or long duration of therapy (> 5 days). Common adverse effects are pruritis, nausea and constipation Naproxen Analgesic and anti-inflammatory (NSAID). PO: 10-20 mg/kg/DAY ÷ q8-12h (maximum 1 g/DAY). Adverse effects include renal dysfunction, GI irritation and ulceration. Omeprazole Inhibitor of gastric acid secretion (proton pump inhibitor). PO: 1-2 mg/kg/DAY ÷ q12-24h (maximum 40 mg/DAY). A 2mg/mL oral suspension is available. Please round to nearest 1mg dose. Ondansetron Antiemetic. IV/PO: 0.1-0.15 mg/kg/DOSE q8h prn (maximum 8 mg/DOSE). MacPeds Survival Guide 164 Pantoprazole Inhibitor of gastric acid secretion (proton pump inhibitor). PO/IV: 1-1.5 mg/kg/DAY ÷ q12-24h (usual max 40 mg/DOSE) GI bleed: IV: 5 – 15 kg: 2 mg/kg/DOSE x 1 DOSE, then 0.2 mg/kg/h 16 – 40 kg: 1.8 mg/kg/DOSE x 1 DOSE, then 0.18 mg/kg/h > 40 kg: 80 mg x 1 DOSE, then 4 - 8 mg/h There is no liquid formulation available. Intravenous and oral pantoprazole provide equivalent acid suppression. Do not crush tablets. IV infusion is available as 40 mg in 50 mls of NS PEG-3350 (Polyethylene Glycol) Osmotic Laxative Constipation: PO: 0.5-1 g/kg/DAY ( titrated to effect up to a usual max of 17 g/day) Available as 17 gram /sachet in hospital. Mix in 125-250 mL of water or juice. Onset 2-4 days. May titrate to effect up to a usual max of 17 g/DAY . Is odorless and tasteless. Phenobarbital Barbiturate anticonvulsant. Status epilepticus: IV: 20 mg/kg over 20-30 minutes. Maintenance: IV/PO: 3-5 mg/kg/DAY ÷ q12-24h. Usual serum level for seizure control: 65-172 micromol/L (15-40 mg/L). MacPeds Survival Guide 165 Phenytoin Anticonvulsant Status epilepticus: IV: 20 mg/kg over 20 minutes. Maintenance: IV/PO: 5 mg/kg/DAY (range 3-10 mg/kg/DAY) ÷ q8-12h. May require higher doses for patients with head injuries. Must be diluted in saline only and requires in-line filter (0.22 micron). Hold feeds before and after enteral administration as continuous feeds and formula may decrease bioavailability of oral products. Significantly increased free fraction in patients with hypoalbuminemia may result in underestimation of effective drug concentration and difficulty in interpretation of drug levels and toxicity may occur at “therapeutic” serum levels. Therapeutic level: 40-80 micromol/L (10-20 microgram/mL). Pico-Salax® (picosulfate sodium/magnesium oxide/citric acid) Stimulant and Osmotic Laxative PO: 1-6 yrs administer ¼ sachet 6-12 yrs administer ½ sachet Over 12 yrs: 1 sachet Dose can be repeated after 6-8hours if no effect Used for refractory constipation, fecal impaction and for cleaning out bowels. Contents of 1 sachet are mixed with 160mL water. MacPeds Survival Guide 166 Potassium Salts Electrolyte. 1mmol of potassium chloride = 1 mEq of potassium chloride Treatment of hypokalemia: PO: 1-2 mmol/kg/DAY ÷ q6h-24h. IV: 0.25-1 mmol/kg/DOSE. For PO administration potassium chloride is available as oral solution 1.33 mmol/mL, and slow release tablets (Slow K) 600 mg (= 8 mmol). Potassium citrate is also available as effervescent tablet (25 mEq/tablet).Give po with food. Dilute oral solution in water or juice and give over 5-10 mins. Slow-release tablets should not be crushed or chewed. Usual adult maximum = 80 mmol/DAY Risk of arrhythmias and cardiac arrest with rapid IV administration. Dose recommendations assume normal renal function. Please refer to Pediatric IV monograph for further prescribing details and limitations Prednisone or Prednisolone Corticosteroid. Acute asthma: PO: 1-2 mg/kg/DOSE q24h. Anti-inflammatory or immunosuppressive: PO: 0.5-2 mg/kg q24h (usual max is 60mg/DAY) 1 mg Prednisone = 1 mg Prednisolone. Discontinuation of therapy greater than 14 days requires gradual tapering. Consider supplemental steroids at times of stress if patient has received long-term or frequent bursts of steroid therapy. MacPeds Survival Guide 167 Ranitidine H2 receptor antagonist. Reduction of gastric acid secretion: IV: 2-4 mg/kg/DAY ÷ q8-12h (usual max 50 mg q8h). PO: 4-10 mg/kg/DAY ÷ q8-12h (usual max 300 mg/DAY). IV dose is approximately 50% of oral dose. Modify dosage interval for patients with renal impairment. May add IV daily dose to TPN. Available as a 15mg/ml oral solution. Salbutamol (Ventolin) Bronchodilator, β2 agonist. Acute asthma: MDI: 4-8 puffs q ½-q4h prn. NEB: Less than 10 kg: 2.5 mg q ½-q4h prn 10 kg or greater: 5 mg q½-q4h prn Administered in 3 mL of NS. Available as 5 mg/mL solution for nebulization. Maintenance therapy: MDI: 1-2 puffs q4h prn. Titrate dose to effect and/or adverse effects (tachycardia, tremor and hypokalemia). For most patients metered dose inhalers with a spacer device are the preferred method of drug delivery. Senna Stimulant laxative. PO: infants: 1 or 2.5 mL (1.7 or 4.25 mg) q24h. children: 2.5 or 5 mL (4.25 or 8.5 mg) q24h. adolescents: 5 or 10 mL (8.5 or 17 mg) q24h. Some patients, particularly those receiving opiates may require higher doses and/or more frequent administration. Also supplied as 8.6 mg tablets. MacPeds Survival Guide 168 Spironolactone Potassium sparing diuretic. PO: 1-3 mg/kg/DAY ÷ q12-24h. Available as a 5mg/mL suspension. Please round doses to the nearest 0.5mg or 1mg. Topiramate Anticonvulsant For greater than 2 yrs and less than 16 yrs: PO: 1-3 mg/kg/DAY as a single dose (initial max 25 mg/DAY) then can increase dose at 1-2 week interval by 1-3 mg/kg/DAY divided q12h. Usual maintenance PO: 5-9 mg/kg/DAY divided q12h 17 years and older : PO: 25 to 50 mg/DAY as a single dose , may increase dosage by 25 to 50 mg/DAY at 1-week intervals, give q12h. . Titrate dose to response to a usual maintenance dose of 200 to 400 mg/DAY divided q12h Ursodiol TPN Cholestasis: PO: 30mg/kg/DAY divided q8h Biliary Atresia: PO: 10-15 mg/kg/DAY once daily MacPeds Survival Guide 169 Valproic Acid and Derivatives Anticonvulsant. Maintenance PO: 15-20 mg/kg/DAY increased to a maximum of 30-60 mg/kg/DAY ÷ q6-12h. Desired therapeutic range: 350-700 micromol/L (50-100 microgram/mL). Dosing is equivalent for valproic acid, divalproex and sodium valproate. Valproic acid IV is special access only and reserved for specific indications. Please consult pharmacist. Vitamin K Reversal of prolonged clotting times or warfarin induced anticoagulation. IV/PO: 0.5-10 mg/DOSE. Use lower doses if there is no significant bleeding and patient will require warfarin in the future. May repeat in 6-8 hours. Injection may be given by mouth, undiluted or in juice or water. Zinc Sulphate Supplement PO: 0.5-1 mg elemental zinc/kg/DAY divided q8-12h (usual max 15mg elemental zinc/DAY) Available as 10mg/mL elemental zinc suspension, 10mg or 50mg elemental zinc tablets MacPeds Survival Guide 170 Approximate Opioid Analgesic Equivalence at HHS - May 2010 Suggested dose equivalence apply in stable analgesic states. Patients with acute postoperative pain may have variations to suggested conversions. OPIOID Parenteral Dose (mg)a Oral Dose (mg) Fentanyl Hydromorphone Methadone Morphine Oxycodone 0.1-0.2 2 N/Ab 10 N/A N/A 4 2.5-10 b 20-30 10-15 These approximate analgesic equivalences should be used only as a guide for estimating equivalent doses when switching from one opioid to another in chronic pain patients. Additional references & patient response should be consulted to verify appropriate dosing of individual agents. a Parenteral route includes intravenous, intramuscular and subcutaneous route, but does not include intraspinal route. 8 Methadone equivalency is highly variable – this ratio from Micromedex as suggested equivalency ratio in patients on chronic oral methadone. MacPeds Survival Guide 171 Approximate Systemic Corticosteroid Equivalence at HHS - May 2010 Equivalent Dose (mg)a Relative Mineralocorticoid Potency Drug Glucocorticoids: Short-acting (biologic half-life 8–12 h) Cortisone 25 Hydrocortisone 20 Intermediate-acting (biologic half-life 12–36 h) Methylprednisolone 4 Prednisolone 5 Prednisone 5 Long-acting (biologic half-life 36–54 h) Dexamethasone 0.75 2 2 0 1 1 0 a Equivalent doses are approximations and may not apply to all diseases or routes of administration. Duration of hypothalamic-pituitary-adrenal (HPA) axis suppression and degree of mineralocorticoid activity must be considered separately. MacPeds Survival Guide 172 PPI (Proton Pump Inhibitors) in Pediatrics – Reflux Disease – Best Evidence in Peds with Omeprazole, Lansoprazole and Pantoprazole. Pediatric Dose 1, 6 Drug Generic Name Brand Name Omeprazole Losec 1-‐1.5 mg/kg/day PO once daily or divided BID NEONATAL: 0.5-‐1.5 mg/kg/dose Lansoprazole Prevacid <10 kg: 7.5 mg PO OD 10-‐30 kg: 15 mg PO OD >30 kg: 30 mg PO OD Esomeprazole Nexium Pantoprazole Rabeprazole 1 Usual Adult Dose 2 GERD Administration (See note below) 10-‐20 mg PO OD 1.Capsule – can be opened & sprinkled on yogurt and given 2. Pharmacy prepared suspension can be used 1.6 mg/kg/day or 30 mg/day 15-‐30 mg PO OD 1.Capsules may be opened and sprinkled into applesauce 2.FasTabs can be placed on tongue for doses 15mg or greater 3. FasTabs can be mixed with water (10mL) to provide part doses only if no other options exist 4. Pharmacy Prepared suspension may be used if available 1mo-‐11 yrs: <5kg:2.5-‐ 5mg PO OD >5kg: 10 mg PO OD 12-‐17yrs: 20 mg PO OD 40 mg/day 20-‐40 mg PO OD 1.Tabs can be dispersed for PO admin. Mix with 25-‐50mL mL of water 2. Sachet can be dissolved & administered via G tube Pantoloc 1-‐1.5 mg/kg/day 40 mg/dose 20-‐40 mg PO OD Cannot be crushed Pariet Greater than 10 years: 10 mg PO OD 20 mg PO OD Cannot be crushed ( BID dosing is thought to provide better control of breakthrough acid) Max Dose (faster clearance in peds than adults – may need higher than standard adult dose) 3.5 mg/kg/day Note: 5( Pharmacy Prepared Suspension (Compounding dependent on pharmacy) 3 Available 4 Formats and Cost LU Code 10mg capsules– not ODB covered 20 mg cap ($0.6/cap) 15mg ($0.5/cap) 30mg ($0.5/cap) with Enteric coated microgranules 15, 30 mg FasTabs (not ODB covered) 293 – GERD or non erosive GERD when H2Antags have failed 297-‐PUD or prevention of NSAID induced ulcers 401-‐ treatment of GI disorders: Crohns, short Gut etc. 402-‐severe esophagitis, Zollinger-‐Ellison etc. 20 mg, 40 mg tablet 10 mg sachet for oral suspension (Not ODB covered) 20mg-‐ not a benefit 40 mg ($0.5/tablet) 10 mg ($0.17 tablet)), 20 mg ($0.3/tablet) NO – Not covered under ODB 293 – GERD or non erosive GERD when H2Antags have failed 295 – for HPylori Peptic Ulcer 297-‐PUD or prevention of NSAID induced ulcers 401-‐ treatment of GI disorders: Crohns, short Gut etc. 402-‐severe esophagitis, Zollinger-‐Ellison etc. 293 – GERD or non erosive GERD when H2Antags have failed 295 – for HPylori Peptic Ulcer 297-‐PUD or prevention of NSAID induced ulcers 401-‐ treatment of GI disorders: Crohn’s,, short Gut etc. 402-‐ severe esophagitis, Zollinger-‐Ellisons etc. NO-‐ Not Covered under ODB Note: Directions for opening capsules and dissolving tablets with dispersed microgranules into food or water requires that the granules must NOT be crushed or chewed for effect. 1. 2. 3. 4. 5. 6. Hospital for Sick Children. Drug Handbook and Formulary. 2009. th RX Files Drug Comparison Charts. 8 Edition ODB Drug Formulary eCPS, 2012 Jew, RK et. Al. Extemporaneous Formulations for Pediatric, Geriatric, and Special Needs Patients. ASHP. 2 Edition. nd Micromedex . Accessed December 2012. Prepared by N Fernandes RPh, Drug Information Centre, HHS. Reviewed by S Yousaf RPh, Pediatrics MCH. MacPeds Survival Guide 173 PEDIATRIC FORMULARY 3 NUTRIENTS PER 100 mL unless otherwise noted May, 2012 FEED INFANT (0-1 YR) HUMAN MILK * (mature) SIMILAC ADVANCE Abbott ENFAMIL A+ Mead Johnson Kcal Protein gram 70 1.1 68 1.4 68 1.4 Protein source Fat gram Fat source CHO gram CHO source Na mg K mg Cl mg Ca mg PO4 mg Fe mg Vit A Vit D mOsm (IU) (IU) / kg H20 Indications for use Lactalbumin casein 70:30 -whey:casein Evaporated /dry skim milk, whey protein 4.2 Human milk fat 7.2 Lactose 18 1.4 1.1 0.7 0.5 0.05 61 - 290 Preferred feeding for term and preterm infants 70:30 whey:casein 3.7 7.3 Lactose, monoglycerides 16 71 44 53 29 1.2 203 41 300 Modified milk ingredients 3.6 Safflower/sunflower coconut, soy Palm olein, soy, coconut, sunflower 7.6 Lactose, corn syrup GOS maltodextrin 18 73 43 53 29 1.22 200 41 300 Iron fortified term infant formula with added DHA (5 mg) and ARA (13 mg) Iron fortified term infant formula with added DHA (11.5 mg) and ARA (23 mg). Prebiotics added (GOS, polydextrose) Palm olein, soy, coconut, safflower Palm olein, soy, coconut, sunflower Coconut, sunflower soy, palm olein Coconut, sunflower soy, palm olein MCT, safflower, soy 7.5 Lactose, corn maltodextrins 18 72 44 44 24 1.0 200 40 260 7.4 Rice starch lactose maltodextrin corn syrup 27 73 51 53 36 1.2 200 41 230 7.4 20 74 45 55 31 1.2 200 41 200 24 81 54 71 47 1.22 200 41 170 30 80 54 71 51 1.2 203 30 370 Palm olein, soy, coconut, sunflower MCT, corn, soy, sunflower/safflower Safflower, coconut, soy Palm olein, soy, coconut, sunflower High oleic vegetable, soy, coconut, MCT 7.0 Corn syrup solids maltodextrin Corn syrup solids Mono/diglycerides Sucrose, mod tapioca starch Corn syrup solids, mod. corn starch Corn syrup solids, mod. Cornstarch Corn syrup solids 32 74 58 64 35 1.22 200 34 320 rtf 300 pdr 32 74 58 64 35 1.22 240 34 330 25 104 52 83 62 1 212 35 375 Corn syrup solids, tapioca starch Lactose cornu syrup solids 32 74 58 64 35 1.22 200 34 350 28 78 58 89 49 1.34 330 52 310 MCT, soy, high oleic sunflower/safflower MCT, soy 8.9 Corn syrup solids, lactose Corn syrup solids, lactose 47 80 73 134 67 1.46 1010 195 300 16 29 13 90 50 1.44 950 150 35 Safflower, soy MCT, sunflower Safflower, soy, MCT, sunflower 11 Maltodextrin, sucrose 37 130 101 97 80 1.4 259 32 310 18 Maltodextrin, soy, FOS sucrose, oat hulls, 65 180 122 90 80 1.4 330 45 345 polydextrose GOODSTART Nestle ENFAMIL A+ THICKENED Mead Johnson ENFAMIL LACTOSE FREE Mead Johnson ENFAMIL SOY A+ Mead Johnson ALIMENTUM Abbott NUTRAMIGEN A+ Mead Johnson PREGESTIMIL A+ Mead Johnson NEOCATE INFANT Nutricia NUTRAMIGEN AA Mead Johnson 67 1.5 Whey hydrolysate (100% whey) 3.4 68 1.7 Nonfat milk 3.4 68 1.4 Milk protein isolates 3.6 68 1.7 Soy protein isolates 3.6 68 1.9 Hydrolyzed casein 3.8 68 1.9 Hydrolyzed casein (100% casein) 3.6 68 1.9 Hydrolyzed casein (100% casein) 3.8 67 2.1 Free amino acids 3 68 1.9 Free amino acids 3.6 ENFAMIL ENFACARE A+ Mead Johnson ENFAMIL PREMATURE A+ With iron 24 kcal Mead Johnson ENFAMIL HMF Mead Johnson (per 4 pkg HMF ) PEDIATRICS (1-10 YR) PEDIASURE Abbott PEDIASURE PLUS with fibre Abbott 74 2.1 Nonfat milk, whey protein 3.9 81 2.4 Non-fat milk Whey protein 4.1 14 1.1 Milk protein isolate, whey hydrolysate 1.0 100 3.0 Na caseinate (82%), whey protein (18%) 5 150 4.2 Na/ca caseinate (82%) whey protein (18%) 7.5 NUTREN JR Nestle 100 3 Casein (50%), whey protein (50%) 5 Soy, canola, MCT 11 Maltodextrin, sucrose 46 132 108 120 84 1.4 332 60 350 Sole source nutrition or supplement. Oral/tube feed. 21% MCT Lactose & gluten free √ ODB NUTREN JR + Fiber Nestle PEPTAMEN JR Nestle PEPTAMEN JR 1.5 (prebio) Nestle 100 3 Isolated casein (50%) whey protein (50%) 5 Soy, canola, MCT 11 Maltodextrin, sucrose, FOS/ inulin, pea fibre 46 132 108 120 84 1.4 332 60 350 100 3 Hydrolyzed whey 3.8 MCT, soy, canola 14 48 132 108 112 84 1.4 332 60 380 150 4.5 Hydrolyzed whey 6.8 MCT, soy, canola, refined tuna oil 18 Maltodextrin, sugar, corn starch Maltodextrin, corn starch, oligofructose 73 198 162 165 135 2.1 48 80 450 Supplement/tube feed. 21% MCT Lactose and gluten free. 0.36g pea fiber and 0.2g FOS/inulin per 100 mL. √ ODB Partially hydrolyzed protein. 60% MCT, 100% whey peptides √ ODB Partially hydrolyzed protein, hypercaloric, Per 100mL- 14mg EPA +58mg DHA, 0.56 g Prebio Contains inulin 60% MCT NO ODB NEOCATE JR (unflavoured) Nutricia 100 3.3 Free amino acids 5 Coconut, canola,safflower 10.4 Corn syrup solids 41 137 63 113 70 1.5 250 44 590 Amino acid formula for allergy, protein intolerance, malabsorption. Fruit/choc flavours avail. 35% MCT √ ODB COMPLEAT PEDIATRIC Nestle 100 3.8 Chicken/peas/gr bean Na caseinate 3.9 Canola, MCT 13 Cranberry juice corn syrup solids peaches 80 164 56 144 100 1.4 332 60 380 Made with pureed food/juice for1-13 yrs. 20% MCT per 100 mL 0.68 fibre from veg/fruit + guar gum fibre √ ODB MacPeds Survival Guide 7.2 6.9 6.9 7.8 7.0 7.7 <0.4 Hydrolyzed 100% whey-for infants at risk for milk protein allergy or mild reflux. ↓ PO4, DHA (10 mg) and ARA (20mg) Thickens when combines w/stomach acids- for reflux. Do not concentrate beyond 24 kcal/oz. DHA (11.5mg) ARA (23mg) Milk-based, lactose free formula. NOT suitable for galactosemia. RTF only in hospital – concentrate n/a. Soy based formula. Suitable for vegans. DHA (11.5 mg) & ARA (23mg) Use powdered form only for galactosemia. Hydrolyzed casein for milk protein allergy (60 % amino acids), 33% MCT. Lactose-free. Not kosher. √ ODB Hydrolyzed casein for milk protein allergy. Lactose/sucrose free. Not kosher. DHA (11.5 mg) & ARA (23mg) √ ODB Hydrolyzed casein for milk protein allergy/fat malabsorption. 55% MCT. DHA(11.5 mg) & ARA(23mg) NO ODB Amino acid-based for milk protein allergy, malabsorption. 5% MCT ,95% LCT √ ODB Amino acid based for severe cow milk protein/ multiple allergies. 2.8% MCT DHA (11.5 mg) & ARA (23mg) √ ODB Preterm discharge formula with more kcal, protein, vitamins, minerals. DHA (12.6 mg) ARA (25 mg) 20% MCT √ ODB For preterm Infants when human milk not available. 40% MCT. DHA (13.8 mg) ARA (28mg) To fortify human milk fed to premature/low birthweight infants MCT 70% Sole source of nutrition or supplement, oral/tube feed. Gluten and lactose free . 20% MCT. √ ODB High calorie Oral/tube feed. Not gluten free. 20% MCT, 0.75g fiber/100mL FOS = 0.35g/100 ml) √ ODB 174 PEDIATRIC FORMULARY NUTRIENTS PER 100 mL unless otherwise noted May 2012 FEED Kcal Protein PEDIATRICS (10+ yr) HOMOGENIZED MILK 62 3.3 Casein, whey 3.4 Cow milk fat 4.7 JEVITY 1 CAL Abbott JEVITY 1.2 CAL Abbott JEVITY 1.5 CAL Abbott RESOURCE 2.0 Nestle ENSURE Abbott ENSURE PLUS Abbott ENSURE HP Abbott ISOSOURCE VHN Nestle OXEPA Abbott OPTIMENTAL Ross 106 4.4 Na/Ca caseinate, soy 3.6 120 5.55 Na/ ca caseinate Soy protein 3.9 150 6.4 Na , ca caseinate, soy 5.0 Safflower/sunflower canola MCT Safflower, canola, MCT MCT, canola, corn 200 8.0 Na + ca caseinate 9.0 Canola 22 106 4.0 Milk & soy protein concentrates 2.9 16 151 5.7 Milk/ soy/ whey protein concentrates 4.7 Soy, canola, corn oils. Soy lecithin Canola, corn oil. Soy lecithin Safflower, canola, corn oils Canola, MCT, soy PERATIVE ** Abbott PEPTAMEN Nestle PEPTAMEN 1.5 Nestle VITAL HN ** Abbott VIVONEX PEDIATRIC (Per 100 g powder) Nestle NEPRO CARB STEADY Abbott SUPLENA Abbott MODULEN IBD ** Nestle Protein source gram Fat Fat source gram 96 5.0 Na/ ca caseinate, soy protein 2.6 100 6.2 Na , ca caseinate 2.9 150 6.3 Na, ca caseinates 9.4 100 5.1 2.8 130 6.7 Whey /na caseinate hydrolysates, arginine Na caseinate, arginine lactalbumin 100 4.0 150 CHO Na mg K mg Cl mg Ca mg PO4 mg Fe mg Vit A Vit D mOsm (IU) (IU) / kg H20 Lactose 50 156 105 123 96 0.05 128 43 15.2 Maltodextrin, corn syrup solids soy fibre 74 124 115 91 76 1.4 381 31 310 17.3 Maltodextrin FOS soy + oat fibre, corn syrup solids 135 185 150 120 120 1.8 400 30 450 21.6 Maltodextrin FOS soy + oat fibre, corn syrup solids 140 215 136 120 120 1.8 375 40 525 80 150 120 106 106 2.0 529 42 790 106 160 106 128 117 1.6 532 26 642 106 170 115 128 117 1.6 532 26 gram 21.5 13.2 CHO source Corn syrup, sugar, maltodextrin Sugar, corn maltodextrin Corn maltodextrin, sucrose Sugar, corn maltodextrin 633 vanilla 123 182 107 117 117 1.5 496 21 546 12.8 Maltodextrin, guar gum soy polysaccharides 128 160 136 80 80 1.4 288 27 300 Canola, MCT, marine + borage oils Marine oils, MCT, canola, soy oils 10.5 Sucrose, maltodextrin Maltodextrin, sucrose, FOS 131 196 169 106 106 2 1191 42.5 535 112 171 120 106 106 1.3 823 28 585 3.74 Canola, MCT, corn 17.7 Maltodexrtrin 104 173 165 87 87 1.6 868 35 385 Hydrolyzed whey 3.9 soybean, MCT 13 56 150 100 80 70 1.8 324 27 380 6.8 Whey 5.6 soybean, MCT 19 102 186 174 100 100 2.7 486 41 550 100 4.2 Partially hydrolyzed protein blend, whey 1.1 Safflower, MCT 18.5 Maltodextrin, sugar corn starch Maltodextrin, corn starch Maltodextrin, sucrose 57 140 103 67 67 1.2 333 27 500 411 12.3 Free amino acids 12.1 64.7 Maltodextrin, corn starch 205 616 534 493 411 5.34 127 164 360 180 8.1 Milk protein, Ca, mg, na caseinates 9.6 16 Corn syrup solid FOS maltodextrin sucrose 106 106 84 106 72 1.9 318 8.5 745 200 3.0 Na + ca caseinate 9.6 Coconut, soybean palm/coconut Safflower, soy lecithin, canola Safflower, soy 25 Maltodextrin, sucrose 78 112 93 139 74 1.9 106 8.5 600 99 3.5 Casein 4.8 Milk fat, MCT, corn 10.8 Corn syrup, sugar 35 126 80 83 54 0.96 284 38 340 14 Indications for use For children >1 yr if consuming balanced, varied diet with adequate source of iron. Isotonic, high protein for tube feeding 1.4 g/100 mL fibre. √ ODB. 19% MCT High kcal, high protein fiber containing tube feed. 1.2 g fiber /100 mL-soluble & insoluble.FOS = 1.0 g/100 mL. 19% MCT √ ODB High pro& kcal for fluid restriction/elevated energy needs 19% MCT. 0.89g fiber/1g FOS/100 mL. √ ODB 1 & 1.5L size only High nitrogen, calorically dense.for fluid restriction. Oral supplement / tube feed. √ ODB Oral supplement/ tube feed. Lactose & gluten free. Vanilla, strawb, choc. NOT ODB covered (Ensure w fiber IS √ ODB) Oral supp. Calorically dense, high pro for fluid restrictions. Lactose/gluten free. Strawb/van/butter pecan. No fiber √ ODB High protein supplement/ tube feed. Lactose and gluten free. NOT ODB covered. Van/choc/straw. No fiber High protein, fibre containing tube feed. 50% of fat as MCT. 0.45g fiber/100 mL. Lactose and gluten free √ ODB Low CHO, calorically dense - for critically ill/Sepsis/ARDS. EPA&GLA oil, 25% MCT. Lactose/gluten free. NOT kosher Elemental for malabsorption EPA(2.3 g/L) DHA(1g/L) Arginine 3.6g/L. FOS 5g/L 60% fat as marine/MCT √ ODB NOT kosher Peptide based for metabolically stressed. 8.05g/L arginine, Oral and tube feed. For those > 4yrs. Elemental diet for impaired GI function/malabsorption. Oral & tube. 100% whey protein. 70% MCT. Vanilla flavour √ ODB Elemental high calorie diet for malabsorption. 100% whey protein. Vanilla flavour 70% MCT. √ ODB Peptide based, VERY low fat formula for limited digestion + absorption. Contains peptides and free aa. 43% MCT NOT kosher Elemental formula for fat malabsorption-68% MCT - 1 pkg powder (48.7g) + 220 mL water = 250 mL (0.8 kcal/mL) √ ODB Acute or chronic renal failure requiring dialysis. Oral/tube feed. 0.84g FOS + 0.42g fiber per 100 mL NOT ODB Vanilla Low protein for chronic/acute renal failure patient not on dialysis. Oral/ tube feed. √ ODB Polymeric formula for Crohn’s disease. Oral/tube feed. Can be concentrated to 1.5 kcal/mL. 25% MCT √ ODB * Jensen, RD (ed) Handbook of Milk Composition. San Diego, Academic Press, 1995. ** HMF = Human Milk Fortifier CONVERSION FACTORS: Ca - 40mg per mmol PO4 – 31mg per mmol Na – 23mg per mmol Cl – 35.5 mg per mmol K – 39 mg per mmol √ ODB indicates product covered by Ontario Drug Benefits Vitamin A – 3.33 IU = 1 mcg Vitamin D – 40 IU = 1 mcg ** Available as non-formulary request MacPeds Survival Guide 175 PEDIATRIC FORMULARY NUTRIENTS PER 100 mL unless otherwise noted May, 2012 FEED Protein source Na mg K mg Cl mg Ca mg PO4 mg Fe mg Vit A (IU) Vit D (IU) mOsm / kg H 20 Indications for use 235 590 404 440 330 8.8 1560 130 n/a .008 Corn syrup solids Sugar - 59 146 83 140 100 2.4 405 81 - 65 Corn syrup solids 250 874 350 750 525 11.9 2000 300 - 3 Corn syrup solids 300 1080 500 800 650 11 1500 208 53 Corn syrup solids 190 675 325 575 400 9 1400 300 53 Corn syrup solids 190 675 325 575 400 9 1400 300 53 Corn syrup solids 190 675 410 575 400 9 1400 300 57 Corn syrup solids 215 760 390 650 455 10 1600 300 53 Corn syrup solids 190 675 325 575 400 9 1400 300 Corn syrup 125 420 292 <50 128 9.2 1540 0 202 Fat malabsorption, chylothorax, defective lymphatic transport. 87% MCT Consult RD for recipe √ ODB Carbohydrate-free soy formula for carbohydrate intolerance water and CHO source required. √ ODB For reduced protein diet, specific amino acid disorders, or increased energy, minerals, vitamins. 1 cup powder = 120 g Used in treatment of intractable epilepsy with ketogenic diet Contains aspartame. √ ODB For infants with tyrosinemia. No PHE or TYR–must be from diet.1 cup powder = 120 grams; 2.73 mosm/g powder. For infants with phenylketonuria. No PHE – must be obtained from diet 1 cup powder = 120 grams; 2.72 mosm/g powder. For propionic academia/methylmalonic academia. No VAL, MET, low THR, ILE 1 cup powder =120 grams; 2.76 mosm/g For urea cycle disorders. Additional protein obtained from diet. 1 cup powder = 120 grams; 2.20 mosm/g powder. For infants/children with glutaric aciduria Type 1or 2Ketoadipic Aciduria. 1 cup powder = 120g 2.73 mosm/g pwdr. Low calcium, low phosphorus NO vit D formula with iron for hypercalcemia. Order via Specialty Food Shop. 1 cup = 105 g 90 450 204 250 250 2.4 782 24 600 94 Sucrose, FOS (1g), maltodextrin Glucose polymers 130 10 223 30 15 0.09 - - - Supplement-not for tube feeds. Chocolate/vanilla (only choc in hospital) DHA(10 mg) ARA(3.3) 15% MCT NO ODB Carbohydrate module, lactose free 1 Cup = 100g √ ODB Safflower, soy lecithin - - - - - - - - - - - Fat module 1 TBSP = 67.5 kcal NOT ODB covered MCT - - - - - - - - - - - 0 - 1.4 5 - 4.3 2.1 - - - Corn oil, milk fat 41 250 370 - 420 370 7 1998 - - 0.2 soy 15 1.3 0.1 2.6 1.4 2.2 1.0 80 0.5 700 22.3 Corn, coconut, palm kernel 73 Maltodextrin, sugar lactose, inulin Sugar, corn syrup solids Mono/diglycerides <20 <5 <20 <5 <5 - - 310 Fat module for fat malabsorption, cholestasis. 1 TBSP = 14 g = 115 kcal √ ODB Protein module lactose/gluten free. 1 pkg = 7g = 6g pro/25kcal Mix 1 pkg in 60-120 ml water for tube feed, 30 mosm/pkg Oral supplement, 315 mL tetra pack, chocolate, vanilla, strawberry. 4 g FOS/inulin per 315 mL serving NO ODB Low fat supplement. Lactose, gluten free. Orange, peach, wildberry. √ ODB Soluble fat and CHO module. Lactose, gluten, sucrose fructose free. 35% of fat as MCT. Oral/tube 1tbsp = 42kcal NO ODB - - - - - - - - Dosage = 0.5 g/kg divided TID. Mix 10g in liquid (not pop)/add to 60mL for tube feed. Not with renal/liver disease Instant food thickener for dysphagia management. 170 Oral electrolyte maintenance solution. Light cherry flavour, Kcal Protein grams Fat grams Fat source CHO gram 470 17 Na caseinates (100%) 22 MCT, corn, coconut 54 81 4 Soy protein isolates 7.2 soy, coconut, safflower Safflower, coconut, soy Soy oils, soy lecithin Safflower, coconut, soy Safflower, coconut, soy Safflower, coconut, soy Safflower, coconut, soy Safflower, coconut sou Coconut, corn oil 510 0 720 15 Dry whole milk 72 480 15 L-amino acids 21.7 480 15 L-amino acids 21.7 480 15 L-amino acids 21.7 510 7.5 L-amino acids 24.6 480 15 L-amino acids 21.7 513 11.4 Whey, sodium caseinate 28.7 235 9.3 Milk protein, whey, soy 7.7 33 0 Soy,canola, MCT, coconut/palm - 380 - - 4.5 - - 0.5 7.7 - - 3.6 0.86 Whey (100%) 0 300 15 Skim milk, milk protein 9 77 3.7 Whey (100%) 492 0 - CHO source METABOLICS/SPECIALTY PORTAGEN (per 100g powder) Mead Johnson RCF (per 100mL concentrate) Abbott PROPHREE (per 100g powder) Abbott KETOCAL (per 100g powder) Nutricia TYREX 1 (per 100 g powder) Abbott PHENEX 1 (per 100 g powder) Abbott PROPIMEX 1 (per 100 g powder) Abbott CYCLINEX 1 (per 100 g powder) Abbott GLUTAREX 1 (per 100 g powder) Abbott CALCILO XD (per 100 g powder) Abbott 28 52.3 MODULARS/SUPPLEMENTS PEDIASURE COMPLETE (Per 235 mL bottle) Abbott POLYCOSE POWDER (per 100 gram) Abbott MICROLIPID (per mL) Nestle MCT OIL (per mL) Nestle RESOURCE BENEPROTEIN (per gram) Nestle BREAKFAST ANYTIME Nestle (per 315 mL box) BOOST FRUIT BEVERAGE Nestle DUOCAL (per 100 gram) Nutricia OTHER PRODUCTS GLUTAMINE powder Per 10g container RESOURCE THICKEN UP Nestle (per 1 Tbsp or 4.5g) ENFAMIL ENFALYTE Mead Johnson PEDIALYTE (per 100 mL) Abbott PEDIALYTE POPSICLES per 62.5 mL popsicle - Abbott 40 ?? L-glutamine - 0 ?? 15 4 12.6 3.2 10 - 6.3 - MacPeds Survival Guide - - hydrolyzed cornstarch - - 2.5 Modified food starch (corn) Corn syrup solids, citrates Dextrose - - 1.6 Dextrose - 10 115 98 160 104 78 124 - - - - - 250 Oral electrolyte maintenance solution 64 51 78 - - - - - 250 Oral electrolyte maintenance. Popsicles contain flavour + colouring. Melt and add to regular pedialyte for flavour. 176 PEDIATRIC EMERGENCY MEDICINE MacPeds Survival Guide 177 Page 1 of 1 MacPeds Survival Guide http://circ.ahajournals.org/content/122/18_suppl_3/S876/F1.large.jpg 178 5/24/2012 Page 1 of 1 MacPeds Survival Guide http://circ.ahajournals.org/content/122/18_suppl_3/S876/F2.large.jpg 179 5/24/2012 Page 1 of 1 MacPeds Survival Guide http://circ.ahajournals.org/content/122/18_suppl_3/S876/F3.large.jpg 180 5/24/2012 PALS Medications for Cardiac Arrest and Symptomatic Arrhythmias Medication Adenosine Dose IV/IO: 0.1 mg/kg Max 6 mg Repeat dose: 0.2 mg/kg Max 12 mg IV/IO: 5 mg/kg (Max 300 mg) Supplied 3 mg/mL: 0.03 mL/kg Max 2 mL Repeat dose: 0.07 mL/kg Max 4 mL 50 mg/mL: 0.1 mL/kg Max 6 mL IV/IO: 0.02 mg/kg Min 0.1 mg Max 0.5 mg for child Max 1 mg for adolescent ET: use 2-10 times IV dose 0.1mg/mL: 0.2 mL/kg Calcium Chloride Dextrose IV/IO: 20 mg/kg 10% solution: 0.2 mL/kg IV/IO: 0.5-1 g/kg Epinephrine IV/IO: 0.01 mg/kg ET: 0.1 mg/kg D10W: 5-10 mL/kg D50W: 1-2 mL/kg 1:10 000: 0.1 mL/kg 1:1 000: 0.1 mL/kg Amiodarone* Atropine MacPeds Survival Guide Administration Rapid bolus followed by rapid flush Rapid bolus for VF/VT, over 20-60 minutes for perfusing tachycardias Bolus Dilute with NS to 3-5 mL Give slow push, central line preferred Avoid hyperglycemia Bolus Dilute with NS to 3-5 mL 181 PALS Medications for Cardiac Arrest and Symptomatic Arrhythmias Medication Lidocaine Magnesium Sulfate Naloxone Procainamide* Sodium Bicarbonate Cardioversion Defibrillation ETT size MacPeds Survival Guide Dose IV/IO: 1 mg/kg ET: use 2-10 times the IV dose IV/IO Infusion: 20-50 microgram/kg/min IV/IO: 25-50 mg/kg (max 2 g) IV/IO/IM: 0.1 mg/kg (max 2 mg) ET: use 2-10 times the IV dose IV/IO: 15 mg/kg *do not routinely use in Combination with other drugs that prolong QT interval IV/IO: 1 mEq/kg Supplied 20 mg/mL: 0.05 mL/kg Administration Bolus Dilute with NS to 3-5 mL Add 100 mg to Run at 1.2 - 3 total of 100 mL mL/kg/h 0.5 g/mL: 0.05-0.1 Rapid infusion for mL/kg torsades or (max 4 mL) severe hypomagnesemia 0.4 mg/mL: 0.25 mL/kg Bolus (max 5 mL) Dilute with NS to 3-5 mL 100 mg/mL: 0.15 Give over 30-60 mL/kg minutes (max 10 mL) 4.2%: 2 mL/kg 8.4%: 1 mL/kg Give slowly and if ventilation is adequate. Use 4.2% in neonates 0.5 J/kg, double dose if arrhythmia continues 2 J/kg initially then 4 J/kg for each subsequent defibrillation attempt. (age in years /4 ) + 4 182 McMaster Children’s Hospital Guidelines for the Pharmacological Management of Convulsive Status Epilepticus This guideline is applicable to the emergency room (ER), in-patient wards and the critical care units within the Children’s Hospital. Measures to maintain adequate airway, breathing & circulation and, appropriate investigations depend on the individual situation. When to initiate pharmacological treatment for ongoing convulsive seizures: 1. Convulsive seizure lasting more than 5 minutes or the onset of convulsion is unclear (in special situations like acute brain injury where seizure are likely to cause additional brain insult, immediate attention is needed) 2. Two or more seizures within a short period time without patient returning to baseline neurobehavioral stage. 3. Strong clinical suspicion of non-convulsive seizures following a convulsive seizure Time from onset Onset Blood glucose, electrolytes First episode of seizure and/or etiology unclear: consider serum calcium, phosphorous, magnesium, toxicology screen, ammonia, blood gas, CBC, blood culture, LFTs 5 minutes Intravenous Lorazepam 0.1 mg /kg (maximum 4 mg) IV over 1 minute 10 minutes Intravenous Lorazepam 0.1 mg /kg (maximum 4 mg)IV over 1 minute If IV access is not established, the options include the following (a) Per rectal Lorazepam 0.1 mg/kg(Max 4 mg) (use the IV preparation)* (b) Intranasal Midazolam 0.2 mg/kg (maximum 10 mg) (Use the IV preparation))** 15 minutes If seizure continues despite 2 doses of benzodiazepines (including prehospital doses), please proceed to Phenytoin Phenytoin 20 mg/kg (maximum 1g) IV in normal saline over 20 minutes If no IV access: Phenytoin IO 20 mg /Kg (maximum 1 g)*** If patient is already on oral Phenytoin, consider IV Phenobarbital If the patient has seizures while phenytoin is being infused, continue additional doses of Benzodiazepines. 35 minutes MacPeds Survival Guide Phenobarbital 20mg/kg IV over 20 minutes (maximum 1 g) 183 55 minutes Refractory Status Epilepticus Points to remember 1. Waiting 5 minutes before initiating treatment of convulsive seizures in high risk patients could potentially cause additional brain insult (Eg Brain injury patients). 2. *Diazepam 0.5 mg/kg PR (maximum 20mg) is another option 3. **Intranasal midazolam: Divide dose between nares. Atomizers for intranasal delivery are available (http://www.wolfetory.com/Products/MAD/), but drug should be administered with a syringe if atomizer is not immediately available. 4. Pre-hospital doses of benzodiazepine should be counted towards the total number of doses. 5. Prepare Phenytoin if you need to administer the second dose of Benzodiazepine. This avoids further delay. 6. In neonates, phenobarbital is preferred to phenytoin 7. ***If no IV access: Another option is IM Fosphenytoin 20 mg PE/Kg (maximum 1 g) (if available). 8. Consider Pyridoxine 100 mg IV in children <18 months with history of unexplained developmental delay. Refractory Status Epilepticus (RSE) Defined as ongoing convulsive seizures despite 2 doses of Benzodiazepines, 20 mg/kg each of phenytoin and Phenobarbital. First line Intravenous Midazolam IV 0.15 mg/kg bolus then 2 μg/kg/min infusion [Use of IV Midazoalm should prompt immediate consultation with PCCU] End point is absence of electrographic seizures (not burst suppression) in the EEG and clinical seizures. Rapid titration: Increase as needed by 2 μg/kg/min q5 minutes Bolus 0.15 mg/kg with each increase in infusion rate Maximum infusion rate: 24 μg/kg/min (maximum 40 mg/hour) Maintain phenobarbital and phenytoin at therapeutic serum levels Goal is to maintain seizure free status for 24-48 hours. Tapering Midazolam: Decrease by 1 μg/kg/min q15 minutes (not slow tapering unless indicated for sedation or withdrawal management purposes) If seizures recur while/after tapering Midzolam, maintain midazolam infusion for another 24 - 48 hours. MacPeds Survival Guide 184 Points to remember 1. Midazolam can cause hypotension and accumulate in fat tissue 2. Midazolam is very short acting. Rapid titration (with intermittent boluses) is essential. 3. Maintenance dose of phenytoin and phenobarbital is continued. 4. EEG end point for Midazolam titration is absence of EEG seizures and not burst suppression Second Line (if seizures persist despite midazolam infusion) Intravenous Pentobarbital Load: 5 mg/kg IV (maximum rate up to 50 mg/min); repeat 5 mg/kg boluses until seizures stop. Initial rate: 1 mg/kg/hour Maintenance: Repeat bolus and increase infusion if needed. Usual maximum infusion is 3 mg/kg/hour, traditionally titrated to suppression-burst on EEG but titrating to seizure suppression is reasonable as well (discuss the target with neurology). Higher doses may be required. Continue Phenytoin If no seizures for 48 hours: taper off Pentobarbital over 12 hours. Before tapering Pentobarbital, restart the maintenance dose of Phenobarbital. Points to remember: 1. Discontinue Phenobarbital and midazolam once Pentobarbital is started, but continue Phenytoin 2. Pentobarbital use is associated with the risk of hypotension and acidosis. Concomitant use of Topiramate and Propofol augments the risk of acidosis. 3. Therapeutic end point is usually burst suppression pattern in the EEG with an interburst interval of 8-20 seconds. 4. Restart the maintenance dose of Phenobarbital before tapering pentobarbital. 5. Other antiseizure medications may be considered only in conjunction with pediatric neurology consultation. Foot note 1. S/L Lorazepam is not listed here. In convulsive seizure, protection of the airway could include clearing oral secretions which could reduce the effect of S/L medication. 2. Paraldehyde is not freely available (discuss with pharmacy). Dose is 200-400 mg /kg (per rectal) mixed with equal volume of olive (mineral) oil. 3. Thiopentone is not freely available MacPeds Survival Guide 185 Date: July 2011 Next Review: July 2012 Prepared by the Status Epilepticus Therapeutic Guideline Committee (Chair: R RamachandranNairNeurology, Members: M Duffett- Clinical Pharmacy, K Fitzpatrick- General Pediatrics, J Gilleland- Critical care, A Kam- Emergency Medicine) MacPeds Survival Guide 186 Emergency Room Management Guidelines for the Child with Type 1 Diabetes Diabetic Ketoacidosis (DKA) History (some or all of) Clinical Signs generally include • • • • • Deep sighing respirations – (Kussmaul breathing) with no wheeze or rhonchi • Smell of ketones on breath • Lethargy/drowsiness • Dehydration – mild to severe Polyuria Polydipsia Weight loss Abdominal pain • • • • • • • • Tiredness Vomiting Confusion Difficulty breathing Urine ketones/glucose Capillary glucose STAT in ER Venous blood – glucose, gases, electrolytes, urea, creatinine Other as indicated Confirm DKA • Ketonuria • Glucose >11 mmol/L • pH <7.3 Hypotension (PALS Values) Age <1 month 1 month to 1 year 1 to 10 years >10 years • Serum Bicarbonate <18 mmol/L • Consult Pediatrician immediately Vascular Decompensation Systolic BP (mm/Hg) < or = 60 < or = 70 < or = 70 + (2 x age in years) < or = 90 No Vascular Decompensation (with or without coma) • Hypotension (see box) • Decreased level of consciousness • • • • THEN • Clinically Dehydrated • Hyperventilating OR • Vomiting • Normal BP (lying and sitting) • Decrease to 5 - 7 ml/kg/hr with Potassium Chloride as noted below • Only infuse Sodium Bicarbonate (1 - 2 mEq/kg over 1 hour) if: 1. Life-threatening hyperkalemia 2. Inotrope-resistant shock 3. Cardiac Arrest Normal Saline 7 ml/kg over 1st hour with Potassium Chloride as noted below THEN 3.5 - 5 ml/kg/hr • Oral hydration • S/C insulin (see illness rules) Resuscitation • Assess airway and breathing • Apply 100% oxygen by mask • Normal Saline 10 ml/kg to expand vascular space Minimally dehydrated Tolerating fluids orally Normal bowel sounds Normal mental status After 1st Hour of IV Fluids • If history of voiding within last hour and Potassium <5.5 mmol/L, add 40 mEq/L of Potassium Chloride to IV fluid • Aim to keep Potassium between 4 - 5 mEq/L • Continuous insulin infusion 0.1 units/kg/hr = 1ml/kg/hr (of solution of 25 units of Regular Insulin in 250 ml Normal Saline). Include this amount in total fluid intake. • DO NOT GIVE BOLUS OF INSULIN • Continuous cardio-respiratory monitoring (with EKG tracing) Neurological deterioration Headache, irritability, decreased level of consciousness, decreased HR First rapidly exclude hypoglycemia by capillary blood glucose measurement THEN Treat for cerebral edema Acidosis not improving Acidosis improving • Blood glucose <15 mmol/L OR • Blood glucose falls >5 mmol/L/h after 1st hour of fluids • Change IV to D5/Normal Saline with Potassium as above • Decrease insulin to 0.04 - 0.05 U/kg/hr = 0.4 - 0.5 ml/kg/hr of standard solution as above • Blood glucose <10mmol/L change to D10/Normal Saline with Potassium as above (in 3 - 4 hours) • Check insulin delivery system • Consider sepsis • Contact Tertiary Pediatric Diabetes Centre • 20% Mannitol 5 ml/kg over 20 minutes • If Sodium has declined, administer 2 - 4 ml/kg of 3% saline over 10 - 20 min. THEN Normal Saline @ maintenance IV rate • Decrease insulin to 0.04 - 0.05 U/kg/hr = 0.4 - 0.5 ml/kg/hr of standard solution as above • Contact Tertiary Pediatric Diabetes Centre • Admit to ICU • • • • • Improvement Clinically well Tolerating oral fluids Ph >7.3 Bicarbonate >18mmol/L • Start S/C insulin • Stop IV insulin ½ hour after S/C dose of rapid-acting or 1 hour after S/C dose of regular insulin • Determine cause of DKA • Contact regional Pediatric Diabetes Education Centre Observation and Monitoring • • • • • • • • Hourly blood glucose (capillary) Aim for a decrease in blood glucose of 5 mmol/L/h Strict hourly documentation of fluids input/output Calculate and review fluids balance at least every 4 hours Hourly, at least, assessment of neurological status for a minimum of 24 hours 2 - 4 hours after start of IV – electrolytes, venous gases – then Q2-4h Follow Effective Osmolality = (2x measured Sodium + measured blood glucose) Avoid a decrease of >2 - 3 mmol/L/hr in effective osmolality by increasing IV sodium concentration MacPeds Survival Guide 187 Emergency Room Management Guidelines for the Child with Type 1 Diabetes Hypoglycemia (moderate or severe) History Clinical Signs Recent hypoglycemic event requiring treatment by another person with Glucagon or oral glucose especially if – Increased confusion – Decreased consciousness AND/ OR Seizures Hemiparesis Any localizing neurological findings Altered state of consciousness Obtain a blood glucose (capillary) Electrolytes and Gases not usually necessary IF child is active, alert, and tolerating oral fluids well, then encourage glucose-containing drinks at least at maintenance fluid rate OTHERWISE Start IV – at least 5% glucose in saline at maintenance rate, regardless of blood glucose level If drowsy, and any neurological impairment, localized or generalized: IV Bolus of 0.25 - 0.5 grams/kg of 50% glucose (0.5 - 1.0 ml/kg) OR 25% glucose (1 - 2 ml/kg) Continue IV glucose until: 1. Child has no further neurological signs and 2. Child is no longer drowsy, confused, irrational or restless. (May take up to 12 hours if hypoglycemic encephalopathy is present) 3. Maintain blood glucose >8 mmol/L as above until IV fluids discontinued 4. Then, change to oral sugar-containing fluids Discharge Discharge ONLY when child is • Fully alert • Tolerating oral fluids and • Free of neurological signs. Observation and Monitoring • Determine cause and arrange for follow-up • Decrease all insulin doses by 20% for next 24 hrs • Renew prescription for Glucagon if used Intercurrent Illness If emesis 2x in past 4 hours, keep NPO for 4 - 6 hours No emesis BUT Not drinking No emesis Tolerating fluids • Capillary glucose • Venous blood – glucose, gases, urea, electrolytes • Urine ketones • Capillary glucose • Venous blood – glucose, gases, electrolytes, urea • Urine ketones IV fluids Maintenance IV fluids • 4 ml/kg/hr for 1st 10 kg • 2 ml/kg/hr for next 10 kg • 1 ml/kg/hr for next 10 kg Hyperglycemic Hypoglycemic • Do not omit insulin • Use S/C insulin unless acidotic (see DKA guidelines) • If Blood Glucose >11 mmol/L and mod-large ketones, then give usual insulin PLUS extra short or rapid-acting Q4h [10 - 20% of TOTAL (N&R or H) daily dose] • Do not omit insulin • Decrease next scheduled insulin dose by 10 - 20% • If not tolerating oral fluids then follow IV as per hypoglycemia guidelines • Otherwise encourage carbohydrate-containing fluids Discharge • Tolerating oral fluids • No other reason for hospitalization • Replace usual meal plan with carbohydrate-containing fluids Observation and Monitoring • Input & Output Q4h • Blood glucose Q2-4h (keep within 4 -10 mmol/L) • Test urine for ketones MacPeds Survival Guide 188 Catalogue No. 013306 17,800 April/09 © 2009 Queen’s Printer for Ontario • Severely dehydrated – Normal Saline (10 ml/kg) over 1 hour • If glucose >20 mmol/L then Normal Saline at maintenance volumes • If glucose <20 mmol/L then D5W./ Normal Saline at maintenance volumes • Once voiding, add Potassium Chloride MacPeds Survival Guide 189 ORDER SETS MacPeds Survival Guide 190 ADDRESSOGRAPH Patient’s Name: _________________________________ Pediatrics Bronchiolitis Admission Order Set Admit to: Emergency Department General Pediatrics: Team 1 OR Weight: _____ kg Team 2 Dr. ___________________________________________ Anticipate stay of less than 24 hours Droplet Precautions: Diet: Other: _____________________________________ Encourage oral hydration and diet as appropriate for age NPO, medications with sips Strict NPO Other: ______________________________________________________________________ Vitals/Monitoring Vitals T, HR, RR, BP, SpO2 q4h T, HR, RR, BP, SpO2 q_____ h Continuous SpO2 monitoring Other: ______________________________________________________________________ Lines/Tubes/Respiratory Respiratory O2 to Keep SpO2 greater than 90%. If greater than 40% O2 required, then notify physician Other: ______________________________________________________________________ Lab Investigations NPS For Virology Other: ______________________________________________________________________ Pain/Fever and Nausea Management Tetracaine 4% gel 30 minutes prior to IV insertion or phlebotomy (wipe off prior to IV puncture) Acetaminophen Clinical Protocol Ibuprofen Clinical Protocol Other: ______________________________________________________________________ Signature: ________________________________ Pager # _______ Date ________ Time ________ Signature/Printed Name/Designation Co-Signature: (YYYY/MM/DD) ________________________________ Pager # _______ Date ________ Time ________ Signature/Printed Name/Designation Transcribed By: (YYYY/MM/DD) _______________________________ Date ________ Time _______ Signature/Printed Name/Designation Checked By: (YYYY/MM/DD) _______________________________ Date ________ Time _______ Signature/Printed Name/Designation □ Copy Made For Pharmacy (YYYY/MM/DD) Page 1/2 xxxxx/MD/mm-yy/V1 MacPeds Survival Guide 191 ADDRESSOGRAPH Patient’s Name: _________________________________ Pediatrics Bronchiolitis Admission Order Set IV Fluids ***Only if clinically indicated*** Bolus IV: IV Fluid: 0.9% NaCl _________ mL over 20-30mins (10-20 mL/kg), after bolus IV finished, then: D5W + 0.9% NaCl at ____ mL/h for 8 hours then ____ mL/h With 20 mmol KCl/L of IV fluid (after child voids) With 40 mmol KCl/L of IV fluid (after child voids) Mild Dehydration (5% deficit) Maintenance + 3 mL/kg/h Less than 1 year of age: Hourly fluid Moderate Dehydration (10% deficit) Maintenance + 5 mL/kg/h calculation for Mild Dehydration (3% deficit) Maintenance + 2 mL/kg/h the first 8 hours: 1 year of age or greater: Moderate Dehydration (6% deficit) Maintenance + 3 mL/kg/h Other: ______________________________________________________________________ Respiratory Medications ***If no improvement with bronchodilators, then physician to reassess for discontinuation*** 0.9% NaCl 2 drops to each nare followed by suctioning PRN 3% NaCl 4 mL via nebulizer q8h throughout admission Salbutamol _____ puffs q4h and q1h PRN OR _____ mL with 2 mL 0.9% NaCl via nebulizer q ___ h and q1h PRN (0.15 mg/kg, minimum 1.5 EPINEPHrine 1:1,000 (1 mg/mL) If weight <10kg: 3mLs by nebulizer q ___ h and q ___h PRN If weight >10kg: 5mLs by nebulizer q ___ h and q ___h PRN OR 1.5 mg with 4 mL 3% NaCl via nebulizer q8h Other: ______________________________________________________________________ Education Provide RSV Information Card to family education Recommended Discharge Criteria Physician to assess for discharge when: -Clinically Improving -Eating and drinking to prevent dehydration -Respirations less than 70 breaths/min -Education for the family is complete -O2 saturations acceptable on room air for 4 hours Additional Orders: _______________________________________________ Signature: ________________________________ Pager # _______ Date ________ Time ________ Signature/Printed Name/Designation Co-Signature: (YYYY/MM/DD) ________________________________ Pager # _______ Date ________ Time ________ Signature/Printed Name/Designation Transcribed By: (YYYY/MM/DD) _______________________________ Date ________ Time _______ Signature/Printed Name/Designation Checked By: (YYYY/MM/DD) _______________________________ Date ________ Time _______ Signature/Printed Name/Designation □ Copy Made For Pharmacy (YYYY/MM/DD) Page 2/2 xxxxx/MD/mm-yy/V1 MacPeds Survival Guide 192 ADDRESSOGRAPH Patient’s Name: _________________________________ Pediatrics Croup Admission Order Set Admit to: Emergency Department General Pediatrics: Team 1 OR Weight: _____ kg Team 2 Dr. ___________________________________________ Anticipate stay of less than 24 hours Droplet Precautions: Diet: Other: _____________________________________ Encourage oral hydration and diet as appropriate for age NPO, medications with sips Strict NPO Other: ______________________________________________________________________ Vitals/Monitoring Vitals T, HR, RR, BP, SpO2 q4h T, HR, RR, BP, SpO2 q_____ h Continuous SpO2 monitoring Other: ______________________________________________________________________ Lines/Tubes/Respiratory Respiratory O2 to Keep SpO2 greater than 90%. If greater than 40% O2 required, then notify physician Other: ______________________________________________________________________ Lab Investigations NPS For Virology Other: ______________________________________________________________________ Pain/Fever and Nausea Management Tetracaine 4% gel 30 minutes prior to IV insertion or phlebotomy (wipe off prior to IV puncture) Acetaminophen Clinical Protocol Ibuprofen Clinical Protocol Other: ______________________________________________________________________ Signature: ________________________________ Pager # _______ Date ________ Time ________ Signature/Printed Name/Designation Co-Signature: (YYYY/MM/DD) ________________________________ Pager # _______ Date ________ Time ________ Signature/Printed Name/Designation Transcribed By: (YYYY/MM/DD) _______________________________ Date ________ Time _______ Signature/Printed Name/Designation Checked By: (YYYY/MM/DD) _______________________________ Date ________ Time _______ Signature/Printed Name/Designation □ Copy Made For Pharmacy (YYYY/MM/DD) Page 1/3 xxxxx/MD/mm-yy/V1 MacPeds Survival Guide 193 ADDRESSOGRAPH Patient’s Name: _________________________________ Pediatrics Croup Admission Order Set Croup Score Croup Score: ________ 0 1 2 Stridor None When agitated At rest Retractions None Mild Moderate Normal decreased Markedly decreased Air Entry Cyanosis in room air 3 5 With agitation At rest Severe None Level of Consciousness 4 normal disoriented Croup Score: ________ MILD (Croup Score 0-2 without stridor or significant chest wall retractions at rest) Dexamethasone ______ mg (0.6mg/kg, MAX 12 mg) PO x 1 dose MODERATE (Croup Score 3-6 stridor and chest retractions at rest without agitation) Minimize intervention (place child on parent’s lap, provide position of comfort) Dexamethasone ______ mg (0.6 mg/kg, MAX 12 mg) PO x 1 dose Epinephrine 1:1,000 (1 mg/mL) If weight <10kg: 3mLs by nebulizer once If weight >10kg: 5mLs by nebulizer once SEVERE (Croup Score >6 stridor and retractions of the sternum associated with agitation or lethargy) Minimize intervention (place child on parent’s lap, provide position of comfort) Provide “blow-by” oxygen (optional unless cyanosis is present) Dexamethasone ______ mg (0.6 mg/kg, MAX 12 mg) PO x 1 dose EPINEPHrine 1:1,000 (1 mg/mL) If weight <10kg: 3mLs with 2mLs 0.9%NS by nebulizer once If weight >10kg: 5mLs by nebulizer once If vomiting, or too distressed to take oral medication: Budesonide 2mg nebulized with 3mL 0.9%NS once Education Provide Croup Information Card to family education Recommended Discharge Criteria Signature: ________________________________ Pager # _______ Date ________ Time ________ Signature/Printed Name/Designation Co-Signature: (YYYY/MM/DD) ________________________________ Pager # _______ Date ________ Time ________ Signature/Printed Name/Designation Transcribed By: (YYYY/MM/DD) _______________________________ Date ________ Time _______ Signature/Printed Name/Designation Checked By: (YYYY/MM/DD) _______________________________ Date ________ Time _______ Signature/Printed Name/Designation □ Copy Made For Pharmacy (YYYY/MM/DD) Page 2/3 xxxxx/MD/mm-yy/V1 MacPeds Survival Guide 194 ADDRESSOGRAPH Patient’s Name: _________________________________ Pediatrics Croup Admission Order Set ***if epinephrine administered patient must be observed for a minimum of 2 hours after administration*** Mild Croup: Provide education to parents, provide Information Card and may discharge home without further observation. Moderate Croup: Observe 4 hours, if patient improves (no retractions or stridor at rest); provide education to parents, provide Information Card and may discharge home with follow-up Severe Croup: Based on clinical response to therapy, minimum 4 hour observation Additional Orders: ____________________________________________________ ____________________________________________________ Signature: ________________________________ Pager # _______ Date ________ Time ________ Signature/Printed Name/Designation Co-Signature: (YYYY/MM/DD) ________________________________ Pager # _______ Date ________ Time ________ Signature/Printed Name/Designation Transcribed By: (YYYY/MM/DD) _______________________________ Date ________ Time _______ Signature/Printed Name/Designation Checked By: (YYYY/MM/DD) _______________________________ Date ________ Time _______ Signature/Printed Name/Designation □ Copy Made For Pharmacy (YYYY/MM/DD) Page 3/3 xxxxx/MD/mm-yy/V1 MacPeds Survival Guide 195 ADDRESSOGRAPH Patient’s Name: _________________________________ Pediatrics Mild to Moderate Dehydration With Gastroenteritis Admission Order Set See Associated Documents: Pediatric Clinical Features of Dehydration and Pediatric Maintenance Fluid Emergency Department General Pediatrics: Team 1 OR Admit to: Weight: _____ kg Team 2 Dr. ___________________________________________ Anticipate stay of less than 24 hours Contact (if diarrhea present) Precautions: Diet: Other: _____________________________________ If breastfeeding, then continue breastfeeding. May continue to drink formula or milk, as age appropriate. NPO for 4 hours after IV initiated, then introduce Oral Rehydration Therapy Other: ______________________________________________________________________ Vitals/Monitoring Vitals: T, HR, RR, BP, SpO2 q4h T, HR, RR, BP, SpO2 q_____ h Accurate Intake and Output with running balance (includes weighing diapers) Monitoring: Other: ______________________________________________________________________ Oral Rehydration Therapy (ORT) ***Consider Ondansetron and ORT prior to ordering blood work*** *** Juice, pop, Jello are not appropriate for oral rehydration *** If 1 year of age or older and has failed a trial of ORT in triage: If weight 8 kg to 14.9 kg then Ondansetron 2 mg PO now, may repeat in 8hrs PRN for nausea/vomiting If weight 15 kg to 30 kg then Ondansetron 4 mg PO now, may repeat in 8hrs PRN for nausea/vomiting If weight greater than 30 kg then Ondansetron 8 mg PO now, may repeat in 8hrs PRN for nausea/vomiting If child vomits within 15 minutes of administering Ondansetron, repeat dose once Oral Rehydration Solution (ORS) (If given Ondansetron, start ORS in 15 minutes) Mild dehydration or no clinical dehydration ORS goal is ‘maintenance’ fluids ______mls in 2hrs, with additional fluids to keep up with losses (as below) Re-evaluate hydration and estimated fluid losses q2h Moderate dehydration ORS goal is ___________mL over 4 hours (50-100 mL/kg if no IV infusing) Re-evaluate hydration and estimated fluid losses q1h Replace ongoing fluid losses (includes estimated volume of emesis or 5mls/kg per emesis, and 10 mL/kg for episode of diarrhea) Signature: ________________________________ Pager # _______ Date ________ Time ________ Signature/Printed Name/Designation Co-Signature: (YYYY/MM/DD) ________________________________ Pager # _______ Date ________ Time ________ Signature/Printed Name/Designation Transcribed By: (YYYY/MM/DD) _______________________________ Date ________ Time _______ Signature/Printed Name/Designation Checked By: (YYYY/MM/DD) _______________________________ Date ________ Time _______ Signature/Printed Name/Designation □ Copy Made For Pharmacy (YYYY/MM/DD) Page 1/3 xxxxx/MD/mm-yy/V1 MacPeds Survival Guide 196 ADDRESSOGRAPH Patient’s Name: _________________________________ Pediatrics Mild to Moderate Dehydration With Gastroenteritis Admission Order Set When starting oral rehydration solution, start with 5 – 10 mL q5minutes initially to ensure fluids are tolerated If tolerating ORT for 2 hours then request MD to reassess for possible discharge If not tolerating ORT after 2 hours then notify MD (MD to consider IV therapy) Other: ______________________________________________________________________ Lab Investigations ***Not recommended unless clinical signs of dehydration and child has failed ORT*** ***If IV ordered, then draw blood work with IV start*** Lab Investigations on Admission If vomiting, Capillary Blood Glucose STAT if not done in triage CBC Na, K, Cl, HCO3, Glucose, Urea, Creatinine VBG Blood C + S for T greater than 38°C Urine R + M Urine C + S Other: ______________________________________________________________________ Additional Lab Investigations Na, K, Cl, HCO3, Glucose, Urea and Creatinine at _____________ (time) Stools for virology Stool for C + S Stool for O + P Stool for C. difficile Toxin VBG in ________hours Other: ______________________________________________________________________ IV Fluids ***Not recommended unless clinical signs of dehydration and child has failed ORT*** Bolus IV: IV Fluid: 0.9% NaCl _________ mL over 20-30mins (10-20 mL/kg), after bolus IV finished, then: D5W + 0.9% NaCl at ____ mL/h for 8 hours then ____ mL/h With 20 mmol KCl/L of IV fluid (after child voids) With 40 mmol KCl/L of IV fluid (after child voids) Mild Dehydration (5% deficit) Maintenance + 3 mL/kg/h Less than 1 year of age: Hourly fluid Moderate Dehydration (10% deficit) Maintenance + 5 mL/kg/h calculation for Mild Dehydration (3% deficit) Maintenance + 2 mL/kg/h the first 8 hours: 1 year of age or greater: Moderate Dehydration (6% deficit) Maintenance + 3 mL/kg/h If not vomiting after 2 hours of IV fluid then restart ORT for one hour, then MD to reassess and re-evaluate IV fluid If still vomiting after 2 hours of IV fluid then MD to reassess and consider admission Signature: ________________________________ Pager # _______ Date ________ Time ________ Signature/Printed Name/Designation Co-Signature: (YYYY/MM/DD) ________________________________ Pager # _______ Date ________ Time ________ Signature/Printed Name/Designation Transcribed By: (YYYY/MM/DD) _______________________________ Date ________ Time _______ Signature/Printed Name/Designation Checked By: (YYYY/MM/DD) _______________________________ Date ________ Time _______ Signature/Printed Name/Designation □ Copy Made For Pharmacy (YYYY/MM/DD) Page 2/3 xxxxx/MD/mm-yy/V1 MacPeds Survival Guide 197 ADDRESSOGRAPH Patient’s Name: _________________________________ Pediatrics Mild to Moderate Dehydration With Gastroenteritis Admission Order Set Other: ______________________________________________________________________ Pain/Fever and Nausea Management Tetracaine 4% gel 30 minutes prior to IV insertion or phlebotomy (wipe off prior to IV puncture) Acetaminophen Clinical Protocol Ibuprofen Clinical Protocol Other: ______________________________________________________________________ Education Provide handout for family education: “What to do when your child has diarrhea” Additional Orders: ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ Signature: ________________________________ Pager # _______ Date ________ Time ________ Signature/Printed Name/Designation Co-Signature: (YYYY/MM/DD) ________________________________ Pager # _______ Date ________ Time ________ Signature/Printed Name/Designation Transcribed By: (YYYY/MM/DD) _______________________________ Date ________ Time _______ Signature/Printed Name/Designation Checked By: (YYYY/MM/DD) _______________________________ Date ________ Time _______ Signature/Printed Name/Designation □ Copy Made For Pharmacy (YYYY/MM/DD) Page 3/3 xxxxx/MD/mm-yy/V1 MacPeds Survival Guide 198 1 Pediatric Clinical Features of Dehydration Patient Presentation Mild Less than 1 year: Less than/equal to 5% Moderate Less than 1 year: 10% Severe Less than 1 year: 15% Greater than 1 year: 6% Greater than 1 year: 9% Heart Rate Greater than 1 year: Less than/equal to 3% Normal Mild tachycardia Blood Pressure Normal Normal Moderate tachycardia Decreased Respiratory Rate Normal Normal Increased Skin Capillary refill Anterior fontanel Mucous membranes < 2 seconds Normal Normal / Dry 2 - 3 seconds Depressed Dry >3 seconds Depressed Dry Normal Altered Depressed Decreased tone Normal / Absent Normal Absent Sunken Absent Sunken Small 1.020 Oliguria 1.025 Oliguria-anuria Maximal Age % Weight Loss CNS Mental Status Eyes Tearing Appearance Laboratory Tests Urine Volume Specific gravity Blood Blood Urea Nitrogen Upper normal Elevated High Signs of dehydration may be less evident or appear later in hypernatremic dehydration; conversely, they may be more pronounced or appear sooner in hyponatremic dehydration MacPeds Survival Guide 199 ADDRESSOGRAPH Patient’s Name: _________________________________ Neonatal Prevention of Maternal-Infant HIV Transmission Order Set ***See Associated Documents: Neonatal/Pediatrics Policy NEO-Infant born to HIV Positive Mother Administration of Zidovudine (AZT or Retrovir) to Infant Protocol**** Weight: ______ kg Bathe baby as soon as physiologically stable post birth in mother’s room in L&D or 4C: 4C Respite Nursery is last option Consults: Neonatal consult at delivery Social Work Pediatric SIS Clinic or Pediatric Infectious Diseases within 12 - 24 hours of birth Diet: Baby may NOT breast feed. Formula feed ad lib Lab Investigations ***Do not use cord blood*** Injections/blood work to be administered only after baby has been bathed Injection/blood work sites to be swabbed with Chlorhexidine swab prior to puncture CBC (heel prick) HIV DNA PCR HIV antibody and P24 antigen CD4/CD8 _________________________________________________________________________ Anti-Retroviral Therapy Medications to be administered only after baby has been bathed Injection sites to be swabbed with Chlorhexidine swab prior to puncture Zidovudine (AZT) should be initiated as close to the time of birth as possible, preferably within 6-12 h of delivery Zidovudine (AZT) ______ mg IV over one hour q6h (1.5 mg/kg/dose) Discontinue and change to PO when able to tolerate oral medication edoduvodiZ(AZT) ______ mg PO q12h (4 mg/kg/dose) starting after first feed Continue Zidovudine for 6 weeks total (IV and PO combined) Discharge Planning Notify MUMC Outpatient pharmacy (extension 75019) of need for Zidovudine for 6 weeks Call to SIS clinic (extension 75075) to inform them of birth and book follow-up appointment at 4 - 6 weeks of age Complete attached Patient Registration Form for Zidovudine funding and fax to 416-480-6060 as soon as possible (See Associated Document) Additional Orders: ___________________________________________________ ***Complete all areas in signature box. Orders will not be processed without a written signature and bradma on each page*** Signature: ________________________________ Pager # _______ Date ________ Time ________ Co-Signature: ________________________________ Pager # _______ Date ________ Time ________ Signature/Printed Name/Designation (YYYY/MM/DD) Signature/Printed Name/Designation Transcribed By: (YYYY/MM/DD) _______________________________ Date Signature/Printed Name/Designation Checked By: ________ Time _______ (YYYY/MM/DD) _______________________________ Date Signature/Printed Name/Designation ________ Time _______ (YYYY/MM/DD) □ Copy Made For Pharmacy Page 1/1 HIV/MD/02-11/V1 MacPeds Survival Guide 200 Asthma Order set Admit to: General Pediatrics: Team 1 OR Team 2 Anticipate admission of less than 24 hours Precautions: Diet: Contact Droplet Dr. ___________________ Weight: _____ kg Airborne - Reason: _____________________________________ Encourage oral hydration and diet as appropriate for age NPO, medications with sips Strict NPO _________________________________________________________________________ Vitals/Monitoring Vitals T, HR, RR, BP, SpO 2 q4h T, HR, RR, BP, SpO 2 q_____ h Continuous SpO 2 monitoring _________________________________________________________________________ Lines/Tubes/Respiratory Lines Peripheral IV Respiratory O 2 to Keep SpO 2 greater than 92%. If greater than 40% O 2 required, then notify physician _________________________________________________________________________ Lab Investigations NPS For Virology _________________________________________________________________________ IV Fluids ***Only if clinically indicated*** Bolus IV: IV Fluid: 0.9% NaCl _________ mL over 20-30mins (10-20 mL/kg), after bolus IV finished, then: D5W + 0.9% NaCl at ____ mL/h With 20 mmol KCl/L of IV fluid (after child voids) With 40 mmol KCl/L of IV fluid (after child voids) _________________________________________________________________________ MacPeds Survival Guide 201 Asthma Order set Bronchodilator Therapy Salbutamol 100 micrograms/puff: _____ puffs inhaled with spacer device q ___ h and q1h PRN (2-10 puffs/dose) OR (if unable to use MDI) Salbutamol via nebulizer: less than 20 kg: 2.5 mg q ___ h and q1h PRN 20 kg or greater: 5 mg q ___ h and q1h PRN Dilute nebulizer solution(s) to a minimum of 3 mL in 0.9% NaCl _________________________________________________________________________ Corticosteroids Inhaled corticosteroids Fluticasone 125 mcg/puff MDI _____ puffs BID OR Budesonide via nebulizer: _____ mg with 2 mL 0.9% NaCl BID (0.25 - 0.5 mg/dose) _________________________________________________________________________ Systemic corticosteroids prednisoLONE _____ mg PO daily x _____ days (1 mg/kg/dose, rounded to the nearest 5 mg x 5 days) (maximum 50 mg/dose) • If patient prefers tablets then change to predniSONE (same dose and total duration) OR Dexamethasone _____ mg PO daily x _____ days (0.3 mg/kg/dose x 3 days) (maximum 8 mg/dose) OR (if unable to tolerate oral corticosteroids) methylPREDNISolone _____ mg IV daily (1 mg/kg/dose) (maximum 40 mg/dose) _________________________________________________________________________ Pain/Fever and Nausea Management Tetracaine 4% gel 30 minutes prior to IV insertion or phlebotomy (wipe off prior to IV puncture) Pediatrics Acetaminophen Clinical Protocol Pediatrics Ibuprofen Clinical Protocol _________________________________________________________________________ MacPeds Survival Guide 202 Asthma Order set Education Provide asthma information handout to family Ensure written asthma action plan has been provided to family prior to discharge Ensure referral to Asthma Education has been completed and faxed prior to discharge Recommended Discharge Criteria Physician to assess for discharge when: • No longer requiring supplemental oxygen for at least 4-6 hours • Eating, drinking and tolerating oral medication • Vital signs appropriate for age • Education for family complete, including written asthma action plan • Outpatient follow up arranged Additional Orders: ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ MacPeds Survival Guide 203 UTI Order Set Admit to: General Pediatrics: Precautions: Diet: Contact Team 1 OR Droplet Team 2 Dr. ________________________ Weight: _____ kg Airborne - Reason: _____________________________________ Encourage diet as appropriate for age NPO, medications with sips Strict NPO _________________________________________________________________________ Activity: AAT Vitals/Monitoring Vitals T, HR, RR, BP, SpO 2 q4h T, HR, RR, BP, SpO 2 q_____ h _________________________________________________________________________ Lines/Tubes/Respiratory Respiratory O 2 to Keep SpO 2 greater than 92%. If greater than 40% O 2 required, then notify physician _________________________________________________________________________ Lab Investigations Lab Investigations if not done in the previous 24 hours CBC Na, K, Cl Creatinine, Urea Blood C + S Urine R + M Urine C + S (Do not send bag urine for culture) _________________________________________________________________________ Diagnostics Ultrasound Kidney - Reason: _____________________ Query: ____________________________ Voiding cystourethrogram - Reason: ____________________ Query: ________________________ _________________________________________________________________________ MacPeds Survival Guide 204 UTI Order Set IV Fluids ***Only if clinically indicated*** Bolus IV: IV Fluid: 0.9% NaCl _________ mL over 20-30 minutes (10-20 mL/kg), after bolus IV finished, then: D5W + 0.9% NaCl at ____ mL/h With 20 mmol KCl/L of IV fluid (after child voids and renal function and electrolytes normal) _________________________________________________________________________ Antibiotics Ampicillin _____ mg IV q6h (25-50 mg/kg/dose) Gentamicin _____ mg IV q24h (5 mg/kg/dose) cefTRIAXone _____ mg IV q24h (50 mg/kg/dose) _________________________________________________________________________ Pain/Fever and Nausea Management Tetracaine 4% gel 30 minutes prior to IV insertion or phlebotomy Pediatrics Acetaminophen Clinical Protocol Pediatrics Ibuprofen Clinical Protocol _________________________________________________________________________ Education Provide UTI information card to family Recommended Discharge Criteria Physician to assess for discharge when: -Clinically Improving, vitals signs appropriate for age, afebrile -Education for the family is complete -Eating and drinking and tolerating oral medications -Outpatient follow up and tests ordered Additional Orders: ___________________________________________________ ___________________________________________________ ___________________________________________________ MacPeds Survival Guide 205
