MacPedsSurvivalGuide2014 15secured

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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. JOSEPHS 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
! Birth Weight Conversion Chart (lbs/oz " kg)!!!!!!!!!!!.. 58
! Adolescent History !!!!!!!!!!!.!!!!!!!!!!!. 59
! 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 84
! 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 " Enteral !!!!!!!!!!!!!. 94
" TPN !!!!!!!!!!!!!!.
" Vitamins and Minerals !!!!!!..
! Prevention of Perinatal Group B Streptococcal Disease !!!!...!! 103
! Hypoglycemia Guidelines for At-Risk Newborns !!!!!.!!!!.. 105
! Hyperbilirubinemia (Jaundice) In Newborn Infants " 35 Weeks !!!.. 112
! Phototherapy Guidelines for < 35weeks or < 2500 grams!!!!!!..130
! Management of Hypernatremia in a Breastfed Infant!!!!!!!!. 132
FORMULARY 133
! Abbreviation Guidelines HHSC !!!!!!!!!!!!!!!!.. 134
! Safer Order Writing !!!!!!!!!!!!!!!!....................... 136
! Antibacterials !!!!!!!!!!!!!!!!!!!!!!!!! 137
! Pediatric Formulary !!!!!!!!!!!!!!!!!!!!!.. 151
! Opiod Analgesic Equivalence!!!!!!!!!!!!!!!!!!. 170
Table of Contents Continued.

! Systemic Steroid equivalence!!!!!!!!!!!!!!!!!! 171
! Antibiotic Guide For Common Pediatric Infections!!!!!!!!! 172
! PPI comparison chart!!!!!!!!!!!!!!!!!!!!!.. 174
! Pediatric Nutrition Formulary.............................................................. 175

PEDIATRIC EMERGENCY MEDICINE!!!!!!!!!!!!!!! 178
! PALS Algorithms !!!!!!!!!!!!!!!!!!!!!!!.. 179
! PALS Algorithm Medications !!!!!!!!!!!!!!!!......... 182
! Status Epilepticus Algorithm !!!!!!!!!!!!!!!!!!.. 184
! Diabetic Ketoacidosis Guidelines !!!!!!!!!!!!!.. !!... 188
Pediatric Vital Signs and Glasgow Coma Scale (GCS) !!!!!!!!!190

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
!"#$%& (%)*+& 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 ladhanim@mcmaster.ca

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 14-15 4
McMaster PEDIATRICS CONTACT INFORMATION

Wards
3B 72980
3C North 76345, 76344
3CSouth 73388, 76972
L2N 73753
NICU 76147
L & D 75050
4C Nursery 76354
PCCU 72610, 75692
PCCU SD
Eating Disorder Unit 73289

Clinical
3F clinic 73984, 78517
2G clinic 78517
2Q clinic 75094, 75095
OR Reception 75645
PACU 75653
Short Stay 75564
Radiology 75279
MRI 75059
CT scan 73728-room
75279-reception
76672-reporting
Ultrasound 75316, 75319
EEG 4U 75027
ECHO 2G 73974
GI pH probe 75350

Labs
Stat Lab 76303
Chemistry 75022
Blood Bank 76281
Coagulation 76288
Microbiology 46175
Pathology 76419

Administration
Paging 76443
Admitting 75100
Bed Booking 75106
Health Records 75111
Computer Support 43000
Appointments 75051
Info Desk 75266
Security 76444
Room bookings 22382

Program Assistants
Postgraduates: Shirley Ferguson 28023
peded@mcmaster.ca
Adriana Flaiani 21931
flaiani@mcmaster.ca
Sandy Murray 21882
samurra@mcmaster.ca
Undergrad (clerks) Kim Babin 21954
pedclrk@mcmaster.ca
BCT residents: Colleen Willson 26660
willsoc@mcmaster.ca
Family Med residents: Jennifer Frid 76024
frid@mcmaster.ca
Wendy Milburn 905-575-1744 x203
milburn@mcmaster.ca

CTU
Skye Levely 75639
levelys@mcmaster.ca

Chief Residents Pediatrics
macpedschiefs@gmail.com

PAGING

To page someone from within the hospital:
1. dial 87
2. enter persons 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 dont 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
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.

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.

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 4
th
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.
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. Refer to the handover document for
further details.


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. Residents should also be
directed to the online orientation module.

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.


Division of General Pediatrics
CTU 1 and 2 Weekly Schedule

Monday Tuesday Wednesday Thursday Friday
7:15-7:45 Handover Handover Handover Handover Handover
8:00-9:00
Division of
General
Pediatrics
Rounds
4E20
Teaching *
except third
Tuesday
LCC for
Peds
residents
only
Week 4:
Heart to
Heart
(08:00-
09:00)
Grand
Rounds
MDCL 3020
Case Based
Learning

9:00-10:30 See Patients See Patients See Patients See Patients See Patients
10:30-12:00
Ward
Rounds
Ward
Rounds
Ward
Rounds
Ward
Rounds
Ward
Rounds
12:00-13:00 Lunch Lunch Lunch Lunch Lunch
13:00-15:00
Patient
Care
*MDR 1& 2 Patient
Care/AHD
*MDR 3 Patient
Care Patient Care Patient Care
15:00-16:00
Specialty
Teaching

AHD
Teaching
Sessions

16:00-16:30 Evaluations Evaluations AHD Evaluations Evaluations
16:30-17:00 Handover Handover Handover Handover 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

ALLIED HEALTH CONTACT NUMBERS/PAGERS
SPECIALTY NAME PAGER Phone
RT Ward General Pager 1607
OT Deb Gjertsen 1177 73565
OT Kate Dobson-Brown 1240 73394
OT Trish Case 1885 73733
SLP Sara Webster 5082 73726
PT Weekend 1148
PT Sarah Fairfield 1148 76549
PT Jillian McJannet 1029 76549
PT Barb Pollock 4317 76549
CCAC Nicole Biba 76599
CCAC Ann Rush 1092 72840
Child Life After hours/Weekends 1225
Child Life Margaret Karek 1225 76129
Child Life Laura Perkin 4086 76129
Child Life Maria Restivo 4087 76129
Child Life Lora Zimmerman 4092 76129
Dietitian Helena Pelletier 1279 73562
Dietitian Lisa Talone 1513 73562
Dietetic Assistant Allison Pottinger 1074 73159
Pharmacist Nicole Clarke 1423 76356
Pharmacy
Technician
Carrie Morrell 1099 76356
IV Nurse 1007
Wound Care
Nancy Trapasso 5150 76100

Nurse
Social Work Carol Ann OToole 1193 73714
Social Work Bill Ratz 1039 76339
Acute Nurse Care
Practitioner

Rose-Frances Clause

1934

73035
Respiratory Home
Care Coordinator

Jeannie Kelso

1042

73650
Clinical Nurse
Specialist

Joanne Dix

1409

76548
Team 1 Pager 5301
Team 2 Pager 5302
Team 3 Pager 5303
Senior Pediatric
Resident
1645
Pediatric ICU
Resident
1000

RESOURCES

Handbooks/Pocketbooks:
Hospital for Sick Children Handbook (11
th
ed, 2010).
Harriet Lane Handbook (1999): John Hopkins Hospital, Dept
of Pediatrics.
Pediatrics on Call
Pediatric Drug Dosage Handbook (on most wards)
Sickkids Drug Handbook and Formulary

Texts:
Nelson Textbook of Pediatrics (19th ed): Behrman R.E. and
R.M. Kliegman.
Rudolphs Fundamentals of Pediatrics (3
rd
ed, 2002):
Rudolph, A.M. et al.
Pediatric Clinical Clerkship Guide

Clinical Skills:
Pediatric Clinical Skills (3
rd
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).


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/

Training Modules for WHO Growth Charts
http://www.dietitians.ca/Knowledge-Center/Live-Events/Online-
Courses/WHO-Growth-Chart-Training.aspx

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!

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

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
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)
PEDIATRIC STAFF PAGERS AND OFFICE NUMBERS

General
Pediatrics
Pager Number

Office
Number

Babic, B 7638 664-9913 General Pediatrics
Cheung, W 7522 523-1209 General Pediatrics
Chitayat, S 7349 523-6766 General Pediatrics
Ernst, C 3339 522-8915 General Pediatrics
Federici, J 7347 333-5437 General Pediatrics
Fitzpatrick, K 523-3167 575-0611 General Pediatrics
Gambarotto, K 572-8681 575-0611 General Pediatrics
Giglia, L 7536 523-6766 General Pediatrics
Hallett, K 2089 664-9992 General Pediatrics
Hunter, A 7561 575-0611 General Pediatrics
Ladhani, M 2040 x75639 General Pediatrics
Latchman, A 2555 x76340 General Pediatrics
Lim, A 3499 X76340 General Pediatrics
MacNay, R 2031 523-1209 General Pediatrics
Orovec, N 76443-paging 664-9992 General Pediatrics
O'Toole, F 524-7609 575-0611 General Pediatrics
Roy, M 2023 x75639 General Pediatrics
Seigel, S 3008 628-0054 General Pediatrics
Shbash, I 7570 575-0611 General Pediatrics
Wahi, G 2315 x76340 General Pediatrics
Sub-Specialist Pager Office
Number
Specialty
NICU
El Gouhary, E 2009 X73588 Neonatology
El Helou, S 2560 x73490 Neonatology
Fusch, C 2045 x75721 Neonatology
Gani, AW 2003 x73689 Neonatology
Marrin, M 2705 x73490 Neonatology
Pugh, E 6437 x76342 Neonatology
Twiss, J 2113 x73591 Neonatology
Samiee-
Zafarghandy, S
2565 x73568 Neonatology
Shah, J 1502 x76342 Neonatology
Shivananda, S 2403 x73490 Neonatology
Williams, C 2128 x 73502 Neonatology
Sub-Specialist
Surgery
Pager Office
Number
Specialty
Ayeni, F 2104 x73532 or
x75094
Ortho Surgery
Ajani, F 2206 X75237 Neurosurgery
Bailey, K 2766 x73550 or
x75094 (2Q)
General Surgery
Bain, J 2628 x73222 or
x78520
Plastic Surgery
Braga, L 76443 - paging x73777 or
x78519
Urology
Burrow, S 2133 x73177 or
x75094
Ortho Surgery
Cameron, B 76443 - paging x75231 or
x75094 (2Q)
General Surgery
Choi, M 2060 X73550 or
X78520
Plastic Surgery
DeMaria, J 76443- paging x73777 or
x78519
Urology
Fitzgerald, P 76443 - paging x75231 or
x75094 (2Q)
General Surgery
Flageole, H 76443 - paging x75244 or
x75094 (2Q)
General Surgery
Korman, B 2600 x75246 or
x75051
ENT
MacLean, J 2504 x75246 or
x75051
ENT
Mah, J. 8030 905 575
3600
Ortho Surgery
Missiuna, P. 7907 905 527
9149
Ortho Surgery
Ogilvie, R 76443 - paging 905 304-5818 Ortho Surgery
Peterson, D 2035 x73177 or
x75094
Ortho Surgery
Sabri, K 76443 - paging x73509 or
x72400
Ophthalmology
Singh, S 2577 x75237 or
x75011
Neurosurgery
Shawyer, A. 76443 paging x75231 or
x75094 (2Q)
General Surgery
Strumas, N 76443 - paging x73594 or
x78520
Plastic Surgery
Walton, M 76443- paging x75244 or
x75094 (2Q)
General Surgery
Sub-Specialist Pager Office
Number
Specialty
Almeida,C 76443 - paging x75259 Cardiology
Anchala, K No pager x75155 ER
Arora, S 2066 x75635 Nephrology
Athale, U 2118 x73464 Hem-Onc
Baird, B 7028 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 Rheumatology
Chan, A 905-521-5030 x73464 Hem-Onc
Choong, K 2865 x76651 PICU
Crocco, A 76443 - paging X75621 ER
Cupido, C 2327 x76610 PICU
Dent, P 3720 x75382 Rheumatology/
Immunology
Dillenburg, R 76443 - paging x75242 Cardiology
Findlay, S 905-972-1091 x75658 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
x73862
Adolescent/Eating
Disorder Unit
Harman, K 2887 X73504 or
x77210
Development/Cleft
Lip & Palate
Hernandez, A 2645 x75607 ER
Huang, L 2026 x73141 or PICU
x76610
Issenman, R 2768 x75637 GI
Johnson, N 2995 x75658 Adolescent/Eating
Disorder Unit
Kam, A 76443 - paging x75621 ER
Kozenko, M 2106 X76172 Genetics
Kraus de
Camargo, O
76443 - paging x74275 Development
Li, C 2729 x76815 Genetics
Lloyd, R 2684 x76610 PICU
Mahoney, B 2713 X 77345 Development
McAssey, K 76443 - paging x 75702 Endocrinology
Meaney, B 905-317-2807 x75686 Neurology
Mesterman, R 2029 x74393 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
Ramachandran
Nair, R
2360 x75613 Neurology
Ratcliffe, E 2059 x73455 GI
Ronen, G 2212 x75393 Neurology
Rosenbaum, P 2742 x26852 Development
Rosenbloom, E 76443 - paging x76038 ER
Samaan, C 76443 - paging x73716 Endocrinology
Scheinemann, K 2077 x73428 Hem-Onc
Sherlock, M 2191 73455 GI
Solano, T N/A 75621 ER
Somani, A 2417 x 75823 PICU
Sulowski, C 76443 - paging x75607 ER
Tarnopolsky, M 2888 x75226 Neuromuscular
Timmons, B N/A x 77615 Exercise
VanderMeulen, J 76443 - paging x73716 Endocrinology
Wyatt, E N/A x75607 ER

ST. JOSEPHS 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
Deputy Chief St Joes Clinical
36039
seigels@mcmaster.ca
Dr. Bojana Babic
Education Rep CTU
36039
babi!"#$!$%&'()*!%
Rosie Evered
Program Secretary
36039
)(+()(,#&'-.(&*!%

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:
2
nd
Floor of Juravinski Tower
Hours: MON, WED, FRI 8:00 AM 6:00 PM
TUES, THURS 8:00 AM 8:00 PM
X33440 or library@stjosham.on.ca
!"#"$"%& %( )*&*+,- .*/",0+"1$ 234 5 678*10,0"%&$

!"#$%&'()

Banuovei is to take place at 8:uu his togethei with staffNP anu iesiuents. 0n
the moinings when theie aie iounus (Nonuay anu Thuisuay) hanuovei shoulu
stait at 7:4S. Weekenu hanuovei is at 8:uu his.

+,-./"(0' 1%2#$-)

Bischaige planning shoulu always be occuiiing anu the team shoulu uiscuss
patients that coulu potentially go home the night befoie. Bischaiges foi these
patients shoulu occui piomptly aftei the hanuovei if patients aie ieauy. This is
paiticulaily impoitant foi the well babies on S0bs anu any anticipateu
uischaiges fiom the nuiseiy.

3'' 4"5,'#5-)

Buiing this time the team will see theii assigneu patients. The chait anu nuising
notes shoulu be ievieweu to iuentify any issues that have aiisen ovei night. The
patient shoulu be seen anu examineu. All lab woik anu iauiological pioceuuies
that aie penuing shoulu be ievieweu. The house staff shoulu then come up with
a plan foi the uay anu be ieauy to piesent that patient uuiing waiu iounus. It is
not necessaiy that full notes be wiitten at this time, as theie will be time allotteu
foi that latei in the uay.

6"($ 1%2#$-)

Buiing waiu iounus the team will iounu on patients. These aie woik iounus.
Some spontaneous teaching uuiing iounus anu at the beusiue can occui uuiing
this time, howevei theie is allotteu time foi that latei in the uay.

4"5,'#5 7"(')

Buiing this time iesiuents will follow thiough with uecisions maue uuiing waiu
iounus. They will finish chaiting on patients. This is also the time foi them to
get uictations uone anu to complete face sheets.

8'"./,#0 3'--,%#-)

Theie aie vaiious teaching sessions thioughout most uays on the CT0. Please
iefei to the CT0 teaching scheuule foi locations - this will be posteu online.

9&":2"5,%#-)

Time is left in the scheuule foi evaluations. This woulu be the time to give
iesiuents miu-way evaluations, as well as enu of iotation evaluations.

!"#$%&'( ;<== /(-)

Banuovei will occui to the on-call team with iesiuents, NP anu staff togethei.

>(,'#5"5,%#)

At the beginning of each month the attenuing shoulu meet with theii team
membeis to ieview the objectives, expectation anu scheuule of the iotation. The
senioi iesiuent may have valuable input uuiing this time.

!"#"$"%& %( )*&*+,- .*/",0+"1$
234 5 6**7-8 91:*/;-*
90< =%$*>:?$ @*,-0:1,+*

@,&/%#*+ ,0 A ,BC 1%BD"&*/ $0,((E F. ,&/ +*$"/*&0G(*--%HC %11;+$ ,0 IC5J ,B
%& +%;&/$ /,8$

Nonuay Tuesuay Weunesuay Thuisuay Fiiuay
8-9
am
BuP iounus Peus iesiuents
teaching fiom
N0NC
Ncmastei
Peus gianu
iounus
.Ncmastei
NIC0 iounus
9-1u
am
See
ptsuischaiges
Staff touches base
with
BANAS0BSL&B
ie consults

NPSPR to meet
at 9 to uiviue up
supeivisoiy
iesponsibility
See
ptsuischaiges
Staff touches base
with BANAS0BS
L&B ie consults

NPSPR to meet
aftei hanuovei to
uiviue up
supeivisoiy
iesponsibility
See
ptsuischaiges
Staff touches base
with
BANAS0BSL&B
ie consults

NPSPR to meet
aftei hanuovei to
uiviue up
supeivisoiy
iesponsibility
See
ptsuischaiges
Staff touches
base with
BANAS0BS
L&B ie
consults

NPSPR to
meet at 9 to
uiviue up
supeivisoiy
iesponsibility
See pts
uischaiges
Staff touches
base with
BANAS0BS
L&B ie
consults

NPSPR to
meet aftei
hanuovei to
uiviue up
supeivisoiy
iesponsibility
1u-12 NIC0 iounus
No non-uigent
inteiiuptions
NIC0 iounus No
non-uigent
inteiiuptions
NIC0 iounus No
non-uigent
inteiiuptions
NBR iounus
NIC0 iounus
No non-uigent
inteiiuptions
NIC0 iounus
No non-
uigent
inteiiuptions
12-1
pm
lunch lunch Lunch lunch Lunch
1-2
pm
finish notessee
consults
finish notessee
consults
Acauemic V uay finish
notessee
consults
finish
notessee
consults
2- 4
pm
Teaching
(CBLjouinal
aiticles) quality
assuiance family
Neetings)
Clinic: 1 leainei
attenus with staff
Acauemic V uay;
may have family
meetings
Clinic: 1
leainei
attenus with
staff
Teaching
(CBLjouinal
aiticles)
quality
assuiance
family
meetings
4-S
pm
Finish woik,
upuate list
Finish woik,
upuate list
Acauemic V uay Finish woik,
upuate list
Finish woik,
upuate list
BuP iounus - Bivision of ueneial Peuiatiics' Rounus - viueoconfeienceu
LIvE to S}B Rm T2Su8 (libiaiy) except 1
st
Nonuay
uianu iounus - Bepaitment of Peuiatiics uianu Rounus - viueoconfeienceu
LIvE to S}B Rm T2Su8 (libiaiy)
NBR - Nultiuisciplinaiy Rounus
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
! 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
! across from vending machines on 2
nd
floor before call rooms
Problems: communicate to Switchboard or Mike Heenan x32218

Cafeteria Hours:
Charlton Cafeteria
2
nd
Floor, Mary Grace Wing
MON FRI: 7:30 AM 6:30 PM
SAT SUN: Closed
Garden Caf @ CMHS MON FRI: 9:30 AM 10:30 PM
& 11:30 AM 1:30 PM
Tim Horton Daily: 7:00 AM 11:30 PM

Information Services

Clinical Brower Passwords & Training:
Passwords obtained from: Computer Room
5
th
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

St Joes Dictation System


LISTENING TO DICTATED REPORTS AT
ST JOSEPHS HEALTHCARE

Use telephone to listen to Diagnostic Imaging Reports
that have been dictated but not yet transcribed
Requires Check-In # of your Patients Exam. Found in
Check-In # field (usually beside Patients 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 Patients 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

PEDIATRIC HISTORY & PHYSICAL EXAMINATION

HISTORY

Identifying Data:
Name, sex, age (years + months), race, who accompanies child,
significant PMHx

Chief Complaint: in patients or parents 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:
Mothers 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

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 cows 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 childs 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?
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 As)

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

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 O
2
saturation

NORMAL PEDIATRIC VITAL SIGNS
Age HR SBP RR
Newborn (<1 wk) 120-160 60-70 30-60
Neonate (<1 mos) 120-160 75-90 30-60
Infant (<1 year) 110-140 75-120 20-40
Preschool (3-5yrs) 90-120 75-125 20-25
Child (6-12 yrs) 80-110 83-120 16-24
Adolescent (>12 y) 70-100 90-130 12-18
Adult (>18 yrs) 60-100 90-130 12-18

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/m
2
) 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

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, O
2
saturation (current FiO
2
), 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, Traubes 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

Genito-urinary:
- Anal position, external inspection (digital rectal examination in kids
ONLY with clinical indication), Sexual Maturity Rating
- Male infants: both testes descended, hypospadias, inguinal hernias
- Females: labia majora/minora, vaginial discharge,
erythema/excoriation of vulvo-vaginitis (NO speculum exam if pre-
pubertal), Hymenal exam if indicated.

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

Hands On
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 Marys Court, St Marys Gate
Chesterfield S41 7TD. Registered Charity No. 207711.
R E P O R T S O N T H E R H E U M A T I C D I S E A S E S S E R I E S 5
Practical advice on management of rheumatic disease
June 2008 No 15
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 sufce. However,
MSK symptoms can be presenting features of potentially life-
threatening conditions such as malignancy, sepsis, vasculitis
and non-accidental injury, and furthermore are commonly
associated features of many chronic paediatric conditions
such as inammatory bowel disease, cystic brosis, 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
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
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-specic complaints such
as My child is limping or My child is not walking quite
right. Young children may have difculty 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 inammatory 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 inammatory MSK disease. A delay
in major motor milestones warrants MSK assessment as well
as a global neuro-developmental approach. However, in ac-
quired MSK disease such as juvenile idiopathic arthritis ( JIA)
a history of regression of achieved milestones is often more
signicant 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 inammatory arthritis are pain, stiffness, swelling and
reduced function. However, in children these features may
be difcult 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 signicant but can be subtle and easily overlooked,
especially if the changes are symmetrical, and relies on
the examiner being condent 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 ags 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.
RED FLAGS
(Raise concern about infection, malignancy or non-
accidental injury)
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 ndings and a previous
history of neglect)
What is pGALS?
Paediatric GALS (pGALS) is a simple evidence-based app-
roach to an MSK screening assessment in school-aged chil-
dren, 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 condence 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.
When should pGALS be performed?
MSK presentations are a common feature of many chronic
diseases of childhood and not just arthritis. An MSK exam-
ination is one of the core systems along with cardiovascu-
2
lar, respiratory, gastrointestinal, neurological, skin and eyes,
and, given the broad spectrum of MSK presentations in chil-
dren, 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
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
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 childs own ngers),
and with amendments at screening the elbow (reach up
and touch the sky) and neck (look at the ceiling). These ad-
ditional manoeuvres were included because when adult
GALS was originally tested in school-aged children
4
it missed
signicant abnormalities at these sites.
How to distinguish normal from
abnormal in the musculoskeletal
examination
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-shufers 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 difcult to appreciate
in the young (such as chubby ankles, ngers, 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
3
and feet, and, generally speaking, younger female children
and those of non-Caucasian origin are more exible. Benign
hypermobility is suggested by symmetrical hyperextension
at the ngers, elbows and knees and by at pronated feet,
with normal arches on tiptoe.
5

Practical Tip normal variants: indications for referral
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
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 Marfans syndrome (which may be
suggested by tall habitus with long thin ngers, and high-
arched palate), and EhlersDanlos 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 Marfans syndrome).
The absence of normal arches on tiptoe suggests a non-
mobile at foot and warrants investigation (e.g. to exclude
tarsal coalition) and high xed arches and persistent toe-
walking may suggest neurological disease. Conversely,
lack of joint mobility, especially if asymmetrical, is always
signicant. Increased symmetrical calf muscle bulk as-
sociates with types of muscular dystrophy, and proximal my-
opathies may be suggested by delayed milestones such as
walking (later than 18 months) or inability to jump (in the
school-aged child).
What to do if the pGALS screen is
abnormal
pGALS has been shown to have high sensitivity to detect
signicant abnormalities. Following the screening exam-
ination, the observer is directed to a more detailed examin-
ation 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 childrens
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 mus-
culoskeletal screen
The pGALS screen
6
(see pp 46) 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 signicant MSK disease, and
TABLE 1. Normal variants in gait patterns and leg
alignment.
Toe-
walking
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 38 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 exible 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 exible at feet with
normal arches on tiptoeing; most resolve
by 6 years
Crooked
toes
Most resolve with weight-bearing
(assuming shoes and socks t
comfortably)
TABLE 2. Normal major motor milestones.
Sit without support 68 months
Creep on hands and knees 911 months
Cruise when holding on to
furniture and standing upright,
or bottom shufe
1112 months
Walk independently 1214 months
Climb up stairs on hands and
knees
approx. 15 months
Run stify approx. 16 months
Walk down steps (non-reciprocal) 2024 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 67 years
4
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 diffculty 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
(Note the manoeuvres in bold are
additional to those in adult GALS
2
)
WHAT IS BEING ASSESSED?
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,
at 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 exion of
shoulders
Elbow extension
Wrist extension
Extension of small joints
of ngers
Turn your hands over and
make a st
Wrist supination
Elbow supination
Flexion of small joints of
ngers
Pinch your index nger and
thumb together
Manual dexterity
Coordination of small
joints of index nger and
thumb and functional
key grip
(continued)
5
(continued)
FIGURE SCREENING MANOEUVRES WHAT IS BEING ASSESSED?
Touch the tips of your
ngers
Manual dexterity
Coordination of small
joints of ngers and
thumbs
Squeeze the metacarpo-
phalangeal 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 ngers
Wrist extension
Elbow exion

Reach up, touch the sky
and
Look at the ceiling
Elbow extension
Wrist extension
Shoulder abduction
Neck extension
Put your hands behind your
neck
Shoulder abduction
External rotation of
shoulders
Elbow exion
6
FIGURE SCREENING MANOEUVRES WHAT IS BEING ASSESSED?
Try and touch your shoulder
with your ear
Cervical spine lateral
exion
Open wide and put three
(childs own) ngers in your
mouth
Temporomandibular joints
(and check for deviation of
jaw movement)
Feel for effusion at the
knee (patella tap, or cross-
uctuation)
Knee effusion (small
effusion may be missed
by patella tap alone)
Active movement of knees
(exion and extension) and
feel for crepitus
Knee exion
Knee extension
Passive movement of hip
(knee exed to 90, and
internal rotation of hip)
Hip exion and internal
rotation
Bend forwards and touch
your toes?
Forward exion of
thoraco-lumbar spine (and
check for scoliosis)
7
therefore at a minimum pGALS should be performed. In
children, it is not uncommon to nd 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).
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
exion. 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 exed posture at the knee, and,
if found, then careful observation of the spine is important
to exclude a secondary scoliosis. For specic manoeuvres,
the child can copy the various screening manoeuvres as
they are performed by the examiner. Children often nd
this fun and this can help with establishing rapport. It is
important to keep observing closely as children may only
cooperate briey! The examination of the upper limbs and
neck is optimal with the child sitting on an examination
couch or on a parents knee, facing the examiner. The child
should then lie supine to allow the legs to be examined and
then stand again for spine assessment.
Practical Tip while performing the pGALS screening
examination
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)
pGALS screening questions
Any pain? Left knee
Problems with dressing? No difficulty
Problems with walking? Some difficulty on walking
Appearance Movement
Gait 7
Arms 3 3
Legs 7 7
Spine 3 3
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 exion of the knee and antalgic gait.
Summary
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 ags to warrant concern, will facilitate diagnosis,
management and appropriate referral.
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 chil-
dren: 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.
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.
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.
BOYS
L
E
N
G
T
H
L
E
N
G
T
H
W
E
I
G
H
T
W
E
I
G
H
T
Birth 2 8 6 4 12 14 16 18 20 22 24 10
Birth 2 6 8 4
12 14 16 18 20 22 24 10
6
4
kg
7
75
85
90
95
80 80
16
14
12
20
25
30
35
40
45
50
55
60
70
75
65
90
95
10
9
8
7
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
in
29
30
31
32
33
34
35
36
37
38
39
in
SOURCE: Based on World Health Organization (WHO) Child Growth Standards (2006) and WHO Reference (2007) and adapted for Canada by Canadian Paediatric Society,
Canadian Pediatric Endocrine Group, College of Family Physicians of Canada, Community Health Nurses of Canada andDietitians of Canada.
Dietitians of Canada, 2014. Chart may be reproduced in its entirety (i.e., no changes) for non-commercial purposes only. www.whogrowthcharts.ca
BIRTH TO 24 MONTHS: BOYS
Length-for-age and Weight-for-age percentiles
WHO GROWTH CHARTS FOR CANADA
NAME:
DOB: RECORD #
85
10
12
14
8
2
3
4
5
6
8
9
10
11
12
13
14
15
16
17
18
20
22
24
26
28
30
32
34
36
38
AGE (MONTHS)
AGE (MONTHS)
kg
lb
lb
kg
lb
cm cm
BOYS
MOTHERS HEIGHT
FATHERS HEIGHT WEEKS
DATE AGE
BIRTH
LENGTH WEIGHT COMMENTS
GESTATIONAL AGE AT BIRTH
3
15
50
85
97
3
15
50
85
97
BOYS
in
cm
18 19 20 21 22 23 24 25 26
60 58 56 54 52 50 48 46 62 64 66
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Birth 2 8 6 4 12 14 16 18 20 22 24 10
7
kg
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
44
46
50
52
54
48
20 30
13
12
14
15
16
17
18
19
20
21
BIRTH TO 24 MONTHS: BOYS
Head Circumference and Weight-for-length percentiles
NAME:
DOB: RECORD #
AGE (MONTHS)
LENGTH
W
E
I
G
H
T
W
E
I
G
H
T
in
17
18
19
20
21
in
H
E
A
D
C
I
R
C
U
M
F
E
R
E
N
C
E
BOYS
cm cm
32
48
36
38
40
42
44
46
52
54
50
34
22
24
26
28
30
32
34
36
38
20
18
16
14
12
10
8
22
24
26
28
30
32
34
36
38
40
42
44
46
48
50
52
54
20
18
16
14
12
lb
8
6
lb
kg
27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42
82 80 78 88 86 84 94 92 90 100 98 96 106 108 104 102 76 74 72 70
in
cm
DATE AGE
BIRTH
LENGTH WEIGHT HEAD CIRC. COMMENTS
WEEKS GESTATIONAL AGE AT BIRTH
97
85
50
15
3
99.9
97
85
50
15
3
BOYS
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
26
24
22
20
18
16
14
12
28
26
24
22
20
18
16
14
12
30
32
34
13
15
17
19
21
23
25
27
28
29
30
31
34
35
36
37
38
39
13
15
17
19
21
23
25
27
29
31
33
35
36
37
38
39
AGE (YEARS)
2 TO 19 YEARS: BOYS
Body mass index-for-age percentiles
BMI
BMI
BMI
BMI
NAME:
DOB: RECORD #
BOYS
BMI
DATE AGE WEIGHT HEIGHT BMI* COMMENTS
BMI tables/calculator available at www.whogrowthcharts.ca
*To Calculate BMI: Weight (kg) Height (cm) Height (cm) x 10,000 OR
Weight (lb) Height (in) Height (in) x 703
97
85
50
15
3
99.9
BMI: 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39
HEIGHT
(CM)
BODY WEIGHT
(KILOGRAMS)
HEIGHT
(CM)
75 6.2 6.8 7.3 7.9 8.4 9.0 9.6 10.1 10.7 11.3 11.8 12.4 12.9 13.5 14.1 14.6 15 16 16 17 17 18 19 19 20 20 21 21 22 75
80 7.0 7.7 8.3 9.0 9.6 10.2 10.9 11.5 12.2 12.8 13.4 14.1 14.7 15 16 17 17 18 19 19 20 20 21 22 22 23 24 24 25 80
85 7.9 8.7 9.4 10.1 10.8 11.6 12.3 13.0 13.7 14.5 15 16 17 17 18 19 20 20 21 22 22 23 24 25 25 26 27 27 28 85
90 8.9 9.7 10.5 11.3 12.2 13.0 13.8 14.6 15 16 17 18 19 19 20 21 22 23 23 24 25 26 27 28 28 29 30 31 32 90
95 9.9 10.8 11.7 12.6 13.5 14.4 15 16 17 18 19 20 21 22 23 23 24 25 26 27 28 29 30 31 32 32 33 34 35 95
100 11.0 12.0 13.0 14.0 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 100
105 12.1 13.2 14.3 15 17 18 19 20 21 22 23 24 25 26 28 29 30 31 32 33 34 35 36 37 39 40 41 42 43 105
110 13.3 14.5 16 17 18 19 21 22 23 24 25 27 28 29 30 31 33 34 35 36 38 39 40 41 42 44 45 46 47 110
115 14.5 16 17 19 20 21 22 24 25 26 28 29 30 32 33 34 36 37 38 40 41 42 44 45 46 48 49 50 52 115
120 16 17 19 20 22 23 24 26 27 29 30 32 33 35 36 37 39 40 42 43 45 46 48 49 50 52 53 55 56 120
125 17 19 20 22 23 25 27 28 30 31 33 34 36 38 39 41 42 44 45 47 48 50 52 53 55 56 58 59 61 125
130 19 20 22 24 25 27 29 30 32 34 35 37 39 41 42 44 46 47 49 51 52 54 56 57 59 61 63 64 66 130
135 20 22 24 26 27 29 31 33 35 36 38 40 42 44 46 47 49 51 53 55 56 58 60 62 64 66 67 69 71 135
140 22 24 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 74 76 140
145 23 25 27 29 32 34 36 38 40 42 44 46 48 50 53 55 57 59 61 63 65 67 69 71 74 76 78 80 82 145
150 25 27 29 32 34 36 38 41 43 45 47 50 52 54 56 59 61 63 65 68 70 72 74 77 79 81 83 86 88 150
155 26 29 31 34 36 38 41 43 46 48 50 53 55 58 60 62 65 67 70 72 74 77 79 82 84 86 89 91 94 155
160 28 31 33 36 38 41 44 46 49 51 54 56 59 61 64 67 69 72 74 77 79 82 84 87 90 92 95 97 100 160
165 30 33 35 38 41 44 46 49 52 54 57 60 63 65 68 71 74 76 79 82 84 87 90 93 95 98 101 103 106 165
170 32 35 38 40 43 46 49 52 55 58 61 64 66 69 72 75 78 81 84 87 90 92 95 98 101 104 107 110 113 170
175 34 37 40 43 46 49 52 55 58 61 64 67 70 74 77 80 83 86 89 92 95 98 101 104 107 110 113 116 119 175
180 36 39 42 45 49 52 55 58 62 65 68 71 75 78 81 84 87 91 94 97 100 104 107 110 113 117 120 123 126 180
185 38 41 44 48 51 55 58 62 65 68 72 75 79 82 86 89 92 96 99 103 106 110 113 116 120 123 127 130 133 185
190 40 43 47 51 54 58 61 65 69 72 76 79 83 87 90 94 97 101 105 108 112 116 119 123 126 130 134 137 141 190
195 42 46 49 53 57 61 65 68 72 76 80 84 87 91 95 99 103 106 110 114 118 122 125 129 133 137 141 144 148 195
BMI: 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39
BODY MASS INDEX TABLE TO CALCULATE FROM CENTIMETRES AND KILOGRAMS
USE TO CALCULATE BMI FOR THOSE AGED 2 YEARS OF AGE OR MORE
For greater precision or to calculate BMI values greater than 39, use the following equation: Weight (kg) Height (cm) Height (cm) x 10,000
Dietitians of Canada, 2010. May be reproduced in its entirety (i.e., no changes) for educational purposes only.
BOYS
3 2 6 5 4 8 9 10 11 12 13 14 15 16 17 18 19 7
3 2 6 5 4 8 9 10 11 12 13 14 15 16 17 18 19 7
20
30
40
50
200 200
195
190
185
180
175
170
165
160
155
150
145
195
190
185
175
180
170
165
160
155
150
145
140
135
130
125
120
115
110
105
100
95
90
85
80
SOURCE: The main chart is based on World Health Organization (WHO) Child Growth Standards (2006) and WHO Reference (2007) adapted for Canada by Canadian Paediatric Society,
Canadian Pediatric Endocrine Group (CPEG), College of Family Physicians of Canada, Community Health Nurses of Canada andDietitians of Canada. The weight-for-age10 to 19 years
section was developed by CPEG based on data from the US National Center for Health Statisticsusing the same procedures as the WHO growth charts.
2 TO 19 YEARS: BOYS
Height-for-age and Weight-for-age percentiles
NAME:
DOB: RECORD #
10
15
20
25
10
15
20
25
30
40
45
50
55
60
65
70
75
80
85
90
AGE (YEARS)
W
E
I
G
H
T
H
E
I
G
H
T
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
71
70
72
73
74
75
76
77
78
79
80
38
37
36
35
34
33
32
31
in
68
69
70
71
72
73
62
63
64
65
66
67
56
57
58
59
60
61
74
75
76
77
78
79
80
in
20
30
40
50
60
80
90
100
lb
110
120
130
140
150
160
170
180
190
200
kg lb kg
70
cm cm
35
BOYS
W
E
I
G
H
T
H
E
I
G
H
T
AGE (YEARS)
WHO recommends BMI as the best measure
after age 10 due to variable age of puberty.
Tracking weight alone is not advised.
MOTHERS HEIGHT
FATHERS HEIGHT
DATE AGE HEIGHT WEIGHT COMMENTS
3
15
50
85
97
3
15
50
85
97
GIRLS
L
E
N
G
T
H
L
E
N
G
T
H
W
E
I
G
H
T
W
E
I
G
H
T
Birth 2 8 6 4 12 14 16 18 20 22 24 10
Birth 2 6 8 4
12 14 16 18 20 22 24 10
6
4
kg
7
75
85
90
95
80 80
16
14
12
20
25
30
35
40
45
50
55
60
70
75
65
90
95
10
9
8
7
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
in
29
30
31
32
33
34
35
36
37
38
39
in
BIRTH TO 24 MONTHS: GIRLS
Length-for-age and Weight-for-age percentiles
NAME:
DOB: RECORD #
85
10
12
14
8
2
3
4
5
6
8
9
10
11
12
13
14
15
16
17
18
20
22
24
26
28
30
32
34
36
38
AGE (MONTHS)
AGE (MONTHS)
kg
lb
lb
kg
lb
cm cm
GIRLS
MOTHERS HEIGHT
FATHERS HEIGHT WEEKS
DATE AGE
BIRTH
LENGTH WEIGHT COMMENTS
GESTATIONAL AGE AT BIRTH
3
15
50
85
97
3
15
50
85
97
GIRLS
in
cm
18 19 20 21 22 23 24 25 26
60 58 56 54 52 50 48 46 62 64 66
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
7
kg
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LENGTH
W
E
I
G
H
T
W
E
I
G
H
T
22
24
26
28
30
32
34
36
38
40
20
18
16
14
12
10
8
22
24
26
28
30
32
34
36
38
40
42
44
46
48
50
52
54
20
18
16
14
12
lb
6
lb
kg
Birth 2 8 6 4 12 14 16 18 20 22 24 10
42
44
48
50
52
46
20 28
13
12
11
14
15
16
17
18
19
20
AGE (MONTHS)
in
18
17
19
20
in
H
E
A
D
C
I
R
C
U
M
F
E
R
E
N
C
E
cm cm
30
46
34
36
38
40
42
44
50
52
48
32
BIRTH TO 24 MONTHS: GIRLS
Head Circumference and Weight-for-length percentiles
NAME:
DOB: RECORD #
GIRLS
27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42
82 80 78 88 86 84 94 92 90 100 98 96 106 108 104 102 76 74 72 70
in
cm
DATE AGE
BIRTH
LENGTH WEIGHT HEAD CIRC. COMMENTS
WEEKS GESTATIONAL AGE AT BIRTH
97
85
50
15
3
99.9
97
85
50
15
3
GIRLS
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
27
25
23
21
19
17
15
13
29
27
25
23
21
19
17
15
13
31
33
35
14
16
18
20
22
24
26
28
29
30
31
32
35
36
37
38
39
14
16
18
20
22
24
26
28
30
32
34
36
37
38
39
40
AGE (YEARS)
2 TO 19 YEARS: GIRLS
Body mass index-for-age percentiles
BMI
BMI 33
BMI
BMI
BMI
NAME:
DOB: RECORD #
GIRLS
BMI
DATE AGE WEIGHT HEIGHT BMI* COMMENTS
BMI tables/calculator available at www.whogrowthcharts.ca
*To Calculate BMI: Weight (kg) Height (cm) Height (cm) x 10,000 OR
Weight (lb) Height (in) Height (in) x 703
97
85
50
15
3
99.9
BMI: 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39
HEIGHT
(CM)
BODY WEIGHT
(KILOGRAMS)
HEIGHT
(CM)
75 6.2 6.8 7.3 7.9 8.4 9.0 9.6 10.1 10.7 11.3 11.8 12.4 12.9 13.5 14.1 14.6 15 16 16 17 17 18 19 19 20 20 21 21 22 75
80 7.0 7.7 8.3 9.0 9.6 10.2 10.9 11.5 12.2 12.8 13.4 14.1 14.7 15 16 17 17 18 19 19 20 20 21 22 22 23 24 24 25 80
85 7.9 8.7 9.4 10.1 10.8 11.6 12.3 13.0 13.7 14.5 15 16 17 17 18 19 20 20 21 22 22 23 24 25 25 26 27 27 28 85
90 8.9 9.7 10.5 11.3 12.2 13.0 13.8 14.6 15 16 17 18 19 19 20 21 22 23 23 24 25 26 27 28 28 29 30 31 32 90
95 9.9 10.8 11.7 12.6 13.5 14.4 15 16 17 18 19 20 21 22 23 23 24 25 26 27 28 29 30 31 32 32 33 34 35 95
100 11.0 12.0 13.0 14.0 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 100
105 12.1 13.2 14.3 15 17 18 19 20 21 22 23 24 25 26 28 29 30 31 32 33 34 35 36 37 39 40 41 42 43 105
110 13.3 14.5 16 17 18 19 21 22 23 24 25 27 28 29 30 31 33 34 35 36 38 39 40 41 42 44 45 46 47 110
115 14.5 16 17 19 20 21 22 24 25 26 28 29 30 32 33 34 36 37 38 40 41 42 44 45 46 48 49 50 52 115
120 16 17 19 20 22 23 24 26 27 29 30 32 33 35 36 37 39 40 42 43 45 46 48 49 50 52 53 55 56 120
125 17 19 20 22 23 25 27 28 30 31 33 34 36 38 39 41 42 44 45 47 48 50 52 53 55 56 58 59 61 125
130 19 20 22 24 25 27 29 30 32 34 35 37 39 41 42 44 46 47 49 51 52 54 56 57 59 61 63 64 66 130
135 20 22 24 26 27 29 31 33 35 36 38 40 42 44 46 47 49 51 53 55 56 58 60 62 64 66 67 69 71 135
140 22 24 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 74 76 140
145 23 25 27 29 32 34 36 38 40 42 44 46 48 50 53 55 57 59 61 63 65 67 69 71 74 76 78 80 82 145
150 25 27 29 32 34 36 38 41 43 45 47 50 52 54 56 59 61 63 65 68 70 72 74 77 79 81 83 86 88 150
155 26 29 31 34 36 38 41 43 46 48 50 53 55 58 60 62 65 67 70 72 74 77 79 82 84 86 89 91 94 155
160 28 31 33 36 38 41 44 46 49 51 54 56 59 61 64 67 69 72 74 77 79 82 84 87 90 92 95 97 100 160
165 30 33 35 38 41 44 46 49 52 54 57 60 63 65 68 71 74 76 79 82 84 87 90 93 95 98 101 103 106 165
170 32 35 38 40 43 46 49 52 55 58 61 64 66 69 72 75 78 81 84 87 90 92 95 98 101 104 107 110 113 170
175 34 37 40 43 46 49 52 55 58 61 64 67 70 74 77 80 83 86 89 92 95 98 101 104 107 110 113 116 119 175
180 36 39 42 45 49 52 55 58 62 65 68 71 75 78 81 84 87 91 94 97 100 104 107 110 113 117 120 123 126 180
185 38 41 44 48 51 55 58 62 65 68 72 75 79 82 86 89 92 96 99 103 106 110 113 116 120 123 127 130 133 185
190 40 43 47 51 54 58 61 65 69 72 76 79 83 87 90 94 97 101 105 108 112 116 119 123 126 130 134 137 141 190
195 42 46 49 53 57 61 65 68 72 76 80 84 87 91 95 99 103 106 110 114 118 122 125 129 133 137 141 144 148 195
BMI: 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39
BODY MASS INDEX TABLE TO CALCULATE FROM CENTIMETRES AND KILOGRAMS
USE TO CALCULATE BMI FOR THOSE AGED 2 YEARS OF AGE OR MORE
For greater precision or to calculate BMI values greater than 39, use the following equation: Weight (kg) Height (cm) Height (cm) x 10,000
Dietitians of Canada, 2010. May be reproduced in its entirety (i.e., no changes) for educational purposes only.
GIRLS
3 2 6 5 4 8 9 10 11
12 13 14 15 16 17 18 19
7
3 2 6 5 4 8 9 10 11 12 13 14 15 16 17 18 19 7
20
30
40
50
195 195
190
185
180
175
170
165
160
155
150
145
140
190
185
180
170
175
165
160
155
150
145
140
135
130
125
120
115
110
105
100
95
90
85
80
75
SOURCE: The main chart is based on World Health Organization (WHO) Child Growth Standards (2006) and WHO Reference (2007) adapted for Canada by Canadian Paediatric Society,
Canadian Pediatric Endocrine Group (CPEG), College of Family Physicians of Canada, Community Health Nurses of Canada andDietitians of Canada. The weight-for-age10 to 19 years
section was developed by CPEG based on data from the US National Center for Health Statisticsusing the same procedures as the WHO growth charts.
2 TO 19 YEARS: GIRLS
Height-for-age and Weight-for-age percentiles
WHO GROWTH CHARTS FOR CANADA GIRLS
NAME:
DOB: RECORD #
10
15
20
25
10
15
20
25
30
40
45
50
55
60
65
70
75
80
85
90
AGE (YEARS)
AGE (YEARS)
W
E
I
G
H
T
H
E
I
G
H
T
W
E
I
G
H
T
H
E
I
G
H
T
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
71
70
72
73
74
75
76
77
78
38
37
36
35
34
33
32
31
30
29
in
68
69
70
71
72
73
62
63
64
65
66
67
56
55
54
57
58
59
60
61
74
75
76
77
78
in
20
30
40
50
60
80
90
100
lb
110
120
130
140
150
160
170
180
190
200
kg lb kg
lb
cm cm
35
MOTHERS HEIGHT
FATHERS HEIGHT
DATE AGE HEIGHT WEIGHT COMMENTS
3
15
50
85
97
3
15
50
85
97
WHO recommends BMI as the best measure
after age 10 due to variable age of puberty.
Tracking weight alone is not advised.

WEIGHT CONVERSION CHART

OUNCES
P
O
U
N
D
S

0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
0 0 28 57 85 113 142 170 198 227 255 284 312 340 369 397 425
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

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

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:

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, Depo-
provera, 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 partners 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
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
-
, HCO
3
-
), Urea, Creatinine, Ca
2+
,
Mg
2+
, PO
4
-
, 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 Ps: 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 childs weight and list any
allergies on the order sheet. Make sure you sign the order sheet and write your
name legibly and pager number.
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 patients 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 patients
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, SaO
2
(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) ! eg. UTI ! Day 2 of Empiric Abx, likely 14 day course
required. Awaiting culture and sensitivity
Issue (2) ! eg. Dehydration ! 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. ________________
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

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.

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 Childrens 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
DISCHARGE SUMMARY TEMPLATE: PEDIATRICS
Todays 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 childs 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

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

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/m
2

! 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 ! NS + 20 mEq/L KCl or D5W/NS + 20 mEq/L KCl
! D5 ! NS + 20 mEq/L KCl = 4 mEq/100cc/d Na+ and 2
mEq/100cc/d K+
! D10W: use in Neonates and Hypoglycemia
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
Electrolyte Status Clinical Features
Hypotonic or
Hyponatremic
Serum Na+ < 130 mEq/L,
Serum Osm < 270
Exacerbated signs of
dehydration
Risk of seizure
Isotonic or
Isonatremic
Serum Na+=130-150 mEq/L,
Serum Osm 270 300

Hypertonic or
Hypernatremic
Serum Na+ > 150 mEq/L,
Serum Osm >300
Decreased signs of
dehydration
Irritable, increased
tone and reflexes


Assessing Dehydration: Severity

Patient Presentation Mild Moderate Severe
Age
% Weight Loss
Less than 1 year:
Less than/equal
to 5%

Greater than 1
year: <= 3%

Less than 1 year:
10%

Greater than 1
year: 6%
Less than 1 year:
15%

Greater than 1 year:
9%
Heart Rate

Blood Pressure
Normal

Normal

Mild tachycardia

Normal
(orthostasis)

Moderate
tachycardia

Decreased
Respiratory Rate Normal Normal Increased
Skin
Capillary refill
Elasticity (less than 2 years)
Anterior fontanel
Mucous membranes

< 2 seconds
Normal
Normal
Normal / Dry

2 - 3 seconds
Decreased
Depressed
Dry

> 3 seconds
Tenting
Depressed
Dry
CNS
Mental Status

Normal

Altered
Depressed
Eyes
Tearing
Appearance

Normal / Absent
Normal

Absent
Sunken

Absent
Sunken
Laboratory Tests
Urine
Volume
Specific gravity

Blood
Blood Urea Nitrogen

Small
1.020

Upper normal

Oliguria
1.025

Elevated

Oliguria-anuria
Maximal

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

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
-
, HCO
3
-
)
! BUN, Cr increased in severe dehydration
! Blood gas and HCO
3
-
for metabolic acidosis, may need to
calculate Anion Gap (AG) = [ (Na
+
+ K
+
) (Cl
-
- HCO
3
-
)]
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


Solution Glucose
(mEq/L)
Na
(mEq/L)
K
(mEq/L)
Base
(mEq/L)
Osmolality
WHO 111 90 20 30 310
Rehydrate 140 75 20 30 310
Pedialyte 140 45 20 30 250
Pediatric
Electrolyte
140 45 20 30 250
Infantlyte 70 50 25 30 200
Naturlyte 140 45 21 48 265

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) " 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 ! NS + 20 mEq/L KCL or D5NS + 20 mEq/L
KCL in isotonic dehydration
o Deficit Replacement Time: usually over 24 hours "
! deficit in first 8 hours, second ! 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


3. Ongoing Losses
Replace" With"
Gastric Losses (Vx) ! NS + 10 20 mEq/L KCl
Stool or Intestinal
losses (Diarrhea)
Add HCO
3
-
to
! NS + 10 20 mEq/L KCl
CSF losses 0.9% NS
Urine Output As indicated
Losses due to Burns 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

Comparison of IV Solutions

IV Solution Na
+
(mEq/L)
K
+
(mEq/L)
Cl
-

(mEq/L)
Dextrose
(g/L)
Osmolarity
(mOsm/L)
Sodium Chloride 0.45% 77 0 154
Sodium Chloride 0.9% (0.9 NaCl, NS) 154 154 0 308
Sodium Chloride 3% 513 0 1030
Dextrose 5% 0 50 250
Dextrose 5% Sodium Chloride 0.2%* (D5 0.2NS) 39 50 320
Dextrose 5% Sodium Chloride 0.45% (D5 !NS) 77 77 50 405
Dextrose 5 % Sodium Chloride 0.9% 154 50 560
Dextrose 10% 0 100 505
Dextrose 10% Sodium Chloride 0.2%* 39 100 575
Dextrose 3.3% Sodium Chloride 0.3% (" * #) 51 51 33.3 273
Lactated Ringers 130 4 109 0 273
Also contains Calcium (Ca
2+
) 1.5 mmol/L, and Lactate (HCO
3
-
) 28 mmol/L
*These solutions are not commercially available
Commonly used solutions are highlighted
IV solution Na (mEq/L) K (mEq/L) Cl (mEq/L) % Electrolyte
Free Water
(EFW)*
H
y
p
o
t
o
n
i
c
0.2% NaCl in
D5W
34 0 34 78
0.45% NaCl
in D5W
77 0 77 50
Lactated
Ringers
130 4 109 16
0.9% NaCl in
D5W (ISOTONIC)
154 0 154 0

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
Add Dextrose to prevent hypoglycemia/ketosis (exceptions: hyperglycemia,brain injury)

Consider HYPOTONIC IVF for the following patients:
Patients with an EFW deficit - e.g. hypernatremia, ongoing EFW losses
(renal, GI, skin)
Patients with established 3rd space overload - e.g CHF, nephrotic
syndrome, oliguric renal failure, liver failure
Limited renal solute handling indicated - e.g. neonatal population,
hypertension
Step 3: MONITORING while on IV fluid Measure and record as accurately as possible
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.

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.
Weight
(kg)
ml/hour
0-10 4/kg/hour
11-20 40 + (2/kg/hr)
>20 60 + (1/kg/hr)
*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
Version date : April 2011
Developmental Milestones

Gross Motor Fine Motor Language Social & Self help Red Flags

0-1
month
-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

-Recognizes some
sounds
-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
Achieved

2
months
-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)

-Increases vocalization
when spoken to
-Smiles

-Face is expressive
- Doesn't smile at the sound
of your voice by 2 months
- Doesn't notice her hands
by 2 months
-Not tracking objects
Achieved

3
months
-Lift head when held

-Lift head & chest when
on tummy
-Grasps and shakes
hand toys

-Holds hands open
-Chuckles

-Begins to imitate some
sounds
-Turn toward the sound of
a human voice

-Smile when smiled at
- Doesn't hold objects

- Doesnt smile

- Doesnt support head
Achieved

4
months
-No head lag in pull to
sit

-Rolls from front to back
-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

-Increases vocalization to
toys & people
- Doesn't reach for and
grasp toys by 3 - 4 months
- Doesn't babble
- Always crosses eyes
Achieved

5
months
-No head lag
-Head steady when
sitting
-May roll back!front
-Holds two objects in
both hands when
placed simultaneously
-Mimics sounds &
gestures
-2 syllable sounds (ah-
goo)
-Babbles to get your
attention
-Able to let you know if
hes happy or sad
-Doesnt roll over

-Doesnt lift head while on
tummy
Achieved

6
months
-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
-Doesnt reach for things
Achieved

7
months
-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

-Interested in mirror
images
-Reaches with 1 hand only
-One or both eyes
consistently turn in or out
-Refuses to cuddle
Achieved

8
months
-In sitting, reaches
forward and can return
to sitting up erect
-Holds own bottle

-Starts eating finger
foods
-Responds to own name

-Babbles chains of
consonants
-Plays peek-a-boo

-Anticipates being picked
up by raising arms
-Seems very stiff with tight
muscles

-Not babbling by 8 months
Achieved

9
months
-Gets to sitting position
alone

-Pulls to stand

-Immature pincer grasp
(thumb onto side of
index finger)

-Uses mama or
dada nonspecifically
-Waves bye

-Cant push up on arms
while on tummy
-Cant sit alone
-Cant bear weight in
-Crawling -Plays peek-a-boo standing position
Achieved

10
months
-Pulls to stand

-Cruises with 2 hands on
a rail or furniture (for
support)
-Grasps bell by handle

-Points at a bead/small
object
- Jargons with inflection

- Performs 1 nursery
gesture on verbal
command
Imitates nursery gestures:
-Pat-a-cake
-Waving
-So big
-No special relationship w/
any family members
-Isnt moving around room
in some fashion i.e. rolling,
creeping
Achieved

11
months
-Stands momentarily

-Walks with one hand
held
-Mature pincer ! 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
-Doesnt seek social
interaction with familiar
people
Achieved

12
months
-Walks a few steps

-Stands independently

-Creeps upstairs
-Mature pincer grasp
-Starting to point
-Helps turn pages in a
book
-2-3 words w/ meaning

-Uses exclamations
such as "Oh-oh!"
-Cries when mother or
father leaves
-Repeats sounds or
gestures for attention
-Doesnt know their name
-Not crawling or moving
forward
Says no single words
Achieved
Developmental Milestones: 1 - 5 Years:

Skill 12 mo 15 mo 18 mo 2 yrs 3 yrs 4 yrs 5 yrs

Walking
Walking few
steps, wide
based gait,
clumsy
Walking few
steps, wide
based gait,
clumsy
Running,
unstable

Fall if trying
to pivot
Running well

Jumps with 2
feet on floor
Broad jumps

Stands on 1 foot
for 2 seconds
Walks on tip toes

Tandem gait
forward
Skips alternating
feet

Hops on 1 foot
Age Achieved

Stairs
Creeps up-
stairs

Creeps up-stairs

Crawls down-
stairs very slow
& careful
Walk up-stairs
w/ hand held

2 feet per step
Walks up
stairs alone

2 feet per step
Alternates feet
while walking up
stairs
Alternates feet
while walking down
stairs

Jumps off last steps
Balances on 1
foot for > or equal
to 10 seconds
Age Achieved

Gross Motor
Stands well

Climbs up
onto a chair
Climbs up on a
chair

Throws ball +/-
falling over
Sit on chair

Walks & pulls
object
Kicks ball

Throws ball
overhand
Pedals tricycle Stands on 1 foot for
4 seconds

Bicycle +/-
training wheels
Age Achieved

Fine Motor

Pincer grasp

Releases object
if asked
Stacks 2 blocks Stacks 3-4
blocks

Puts shapes on
to board
Stacks 5-7
blocks
Stacks 9 blocks

Imitates bridge
Stacks 10 blocks

Opposes fingers to
thumb in sequence
Does buttons up
Age Achieved

Drawing

Crayon in
mouth

Linear scribbles Circular

Imitates
stroke

Copies Circle
3yrs

Copies cross
Copies square Copies triangle

Marks paper Scribble 3.5yrs Prints name
Age Achieved

Expressive
Speech
2-3 words 5-10 words 20 - 50 words 100-200
words

2 - 3word
combo
5-8 words together

Uses: I, me, u
(pronouns)

Answers
W questions
Past tense

Prepositions (behind,
on, under)

Tells stories
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
2 step
command
Knows Age

Knows their Sex

Full name
5-10 numbers by
rote

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
Age Achieved

Dressing
Plays peek-a-
boo
Helps to
remove cloths
Start taking
off cloths
Takes cloths
all off

Raise arms
Supervised dressing; Dress alone

Unbuttons clothes
Buttons clothes up
Age Achieved
Cognitive/
Adaptive
Kisses on
request

Should have
object
permanence
Seeks help w/
gestures

Use cause and
effect toys

Parallel play

Folds paper

Unscrews
tops
Plays simple
games

Listens to stories

Group play
Imaginary friend

4 colours

Knows: same,
biggest, tallest
Knows alphabet

Sort by size

Label shapes,
classify object

!""#$%&'(%)$*+ -(./0 !$1)0"'(%)$

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


NEONATOLOGY

St Joes NICU common terms and definitions list

As and Bs- (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 babys actual O2 saturation is over that saturation.
Normal for preterms 90 over 90
For preterms 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 WBCs seen on manual differential (bands, myelocytes, metomyleocytes, and/or promyelocytes)
divided by the total number of neutrophils plus the immature WBCs.
Immature WBCs/total neutrophils + immature WBCs

IUGR (intrauterine growth restriction) - defined as symmetric or asymmetric, if symmetric both head
circumference and weight are less than the 3
rd
percentile if asymmetric only the weight is <3
rd
percentile.

NEC (necrotizing enterocolitis) - Gut infection, characterized by feeding intolerance, bilious residuals,
abdominal distension, bloody stools, with other signs and symptoms of sepsis.

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
+
, Ca
2+
PO
4
3-
, 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
PROGRESS NOTE: NEONATES (LEVEL 2 NURSERY)

Date Time

ID: Baby boy (surname)
Born at 33
5/7
(i.e. 33 weeks and 5 days) gestational age
Day of life (DOL): 12
Corrected Gestational Age: 36
3
wks (33
5
+ 12 days)
Birth weight: 2680g
Todays 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? (As and Bs)
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 ! increase feeds slowly, starting at EBM 5cc q3h
Jaundice ! double phototherapy, recheck bili in am.

Discussed with Dr. ________________

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: Current Problems:
1. 1.
2. 2.
3. 3.

Birth Parameters Discharge Parameters
Gestational age: Corrected and chronological age:
Weight:____ g (%ile) Weight:____g
Length: _____ cm (%tile)
Head circumference:____cm (%ile) 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). (Mothers 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.

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 x-
ray 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:
Mothers blood type is __and infants 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 10
9
/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).

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 infants urine was collected for drug screening
on ___ (date) and was positive for ___ (list substances). The infants 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 infants 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 infants CAS worker is ___ (list workers 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

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.

Dictating For Dr. (Name of Paediatrician/Neonatologist)
Page 1of 1
5/24/2012 http://circ.ahajournals.org/content/122/18_suppl_3/S909/F1.large.jpg
NEONATAL RESUSCITATION DRUGS

1 kg
< 30 weeks
2 kg
30-36 weeks
3 kg
> 36 weeks
Epinephrine
1:10,000
0.1 mg/ml
q3-5 minutes
IV Route
(Preferred Route) (0.01mg/kg)
0.1 ml 0.2ml 0.3 ml
ETT Route
(0.1 mg/kg)
1 ml 2 ml 3 ml
Sodium Bicarbonate 4.2% IV
0.5 mmol/ml (2 mmol/kg)
For Prolonged Arrest

4 ml

8 ml

12 ml
Naloxone IV or IM
0.4 mg/ml (0.1 mg/kg)
Contraindicated in narcotic dependent mothers

0.25 ml

0.5 ml

0.75 ml
Volume Expanders
Normal Saline (NS, 0.9 NaCl)
Packed Red Blood Cells
10 ml
10 ml
20 ml
20 ml
30 ml
30 ml
Glucose (D10W) IV Bolus
200 mg/kg
For documented hypoglycemia

2 ml

4 ml

6 ml

NICU NUTRITION GUIDELINES

ENTERAL FEEDING IN NICU

Method of Feeding (By Age)

< 32 weeks 32-34 weeks 34-36 weeks 36-40 weeks
Gavage

Yes Yes If indicated Not usually
Breast

Individual
Assessment
1-2 q shift Yes Yes
Bottle

1-2 q shift
Near 34 wks
Yes Yes
Ad lib

Minimum feed
Vol (mL)/ Time (hr)
Yes

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
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
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
Nutritional Feeds -
Timing
Day 4 feeds Day 3 feeds Day 2 feeds Day 2 feeds
Initiation Volume 15-20 mL/kg/d 15-20 ml/kg/d 25-30 mL/kg/d 25-30 mL/kg/d
Feeding Interval 2 hourly 2 hourly <1250g 2 hourly
>1250g 3 hourly
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
20-25 mL/kg/d 20-25 mL/kg/d
Donor milk is available for infants birthweight <1250g with informed parental consent. Parents of all infants birth weight less than 1250g
should be approached for consent for donor milk as soon as possible after delivery.
Trophic Feeds EBM or donor milk or Enfamil Premature A+ 20 kcal/oz. (May delay trophic feeds up to 24 hr for EBM)
Nutritional Feeds EBM or donor milk or Enfamil Premature A+ 24 kcal/oz

Infants > 1500 grams Birth Weight

1500 - 1749 g
> 29 weeks
1750 - 1999 g
> 30 weeks
2000 - 2499 g
> 31 weeks
> 2500 g
> 34 weeks
Timing: Day 1 / Stable Day 1 / Stable Day 1 / Stable Day 1 / Stable
Amount/
Frequency:
3 mL q 3 hr 6 mL q 3 hr 6 mL q 3 hr 9-12 mL q 3 hr /
ad lib
Increase: 3 mL q 9 hr 3 mL q 6-9 hr 3 mL q 3-6 hr 3-6 mL q 3 hr
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 mL/kg/d for 24 hours

Dosing:
Initially ! 1 package fortifier per 50 mL EBM
Increase ! 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.


Formula Selection
<34 weeks or <2.0 kg birth weight
" Enfamil Premature 24 A + and reassess when close to term and
over 2200g
>34 weeks and
>2.0kg birth weight
If current weight is over 2200g,
and the birth weight was <1200
g or infant has BPD
" Enfamil Premature 24 A+
while in hospital

If the current weight is >3.0kg or
the infant is ready for discharge.
" Enfamil A + Enfacare
If current weight is over
2200-3000, and the
babys weight is
<10%ile on Fenton
growth chart
" Enfamil A +
Enfacare

If current weight
is >2200g and
above the
10%ile on
Fenton growth
chart
" Term
Formula *
" Term
Formula *
*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
1:50
Fortified
1:25
Enfamil
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

TOTAL PARENTAL NUTRITION (TPN) IN NICU SUMMARY GUIDELINES

Starting TPN
Infants < 1500 g ! 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 ! 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 ! 1 2 3 4 5
Electrolytes: Na, K x x x X x
Glucose* x x x X x
Triglycerides x x x X x
Urea / Creat x x
Ca / P x x
Bili x X x
AST / ALT x X
Albumin X
Every Thursday: electrolytes (Na, K), Glucose*, Triglycerides (until
tolerating full dose)
Trace Elements: if on long term TPN, once direct bili > 50 mmol/L
send serum for trace elements (Zn, Cu, Se , Mn) 0.6 mL
Ferritin: Infants > 6 weeks of age on TPN, check serum ferritin
before adding iron
*send urine for glucose if PCX > 10 mmol/L


(A) Macronutrients

Dextrose

Prescription

mg/kg/min g/kg/day
Initial dose 4 6 6 - 9
Average Daily Increase 0.5 - 1.0 0.7 - 1.4
Maximum dose 11 13 16 - 19

Protein

Prescription
Source: Primene 10%
g/kg/day
Initial dose * 1.5
Avg. daily increase 1.0
Maximum usual dose 3.0 - 3.5**
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)
Energy Value: 4.0 kcal/g; 16.7 kJ/g
For infants < 1500 g ! Start on modified TPN !
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



(A) Macronutrients (Continued)

Lipid
Prescription
Source: Clinoleic 20%

Full PN

< 50% PN
Initial Dose (g/kg/day) By 24-48 hr of age
0.5 - 1.0 g/kg/day

Average Daily Increase
(g/kg/day)
0.5-1 g/kg/d
Maximum Dose (1)
(g/kg/day)
2.5-3.5 g/kg/day 1-2 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 lipid restriction for infants with cholestasis. Consider SMOF lipid for infants with Short Bowel
Syndrome. If if conjugated bilirubin consistently above 100 mmol/L, consider Omegavan (Use requires
approval for special access from Health Canada)

(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.



(B) Micronutrients

Minerals (Maintenance intakes for stable, growing infants)
Usual Dose
(mmol/kg/day)
Term Infants > 3kg
(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 ! 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)


VITAMIN/MINERAL SUPPLEMENTS IN NICU SUMMARY GUIDELINES
Vitamins Prescription
Feeding Tri-Vi-Sol D-Drops
Preterm Infants Unfortified EBM 0.5 mL BID none
In Hospital Fortified (1:25) EBM None 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
After
Discharge Home
Human Milk or
Term Infant Formula
Intake < 800 mL/day 0.5-1.0 mL daily
Intake > 800 mL/day - none
None
1.0 mL OD
(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 Iron
Doses Available: 0.2 ml 3 mg Iron
0.3 ml 4.5 mg Iron
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 Iron)
> 3-4 kg 1.0 mL OD (15 mg Iron)
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
GBS status:
UNKNOWN
GBS status:
NEGATIVE
No action
required for
newborn
Yes
No
Yes
Mother received at
least one dose greater
than or equal to 4 h
prior to delivery?
No action
required for
newborn
No
Are there any
MATERNAL RISK FACTORS?
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 38
o
C
Yes
GBS status:
POSITIVE
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 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 group B streptococcal colony counts greater
than 100 000 CFU/mL . For women with positive GBS and prelabour rupture of membranes at term, induction of labour is recommended. At any point,
the MRP may consider an ID (Infectious Diseases) physician consult. 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).

Algorithm - Group B Streptococcus (GBS) Management Guidelines
Revised Sept 18 2013 LY
Mother has
received
GBS
Prophylaxis
Antibiotics

Mother:
has laboured (latent or active)
or
has ruptured membranes
Mother:

Mother:
is delivered by elective C/S
has not laboured
has not ruptured membranes
regardless of GBS status

GBS PROPHYLAXIS ANTIBIOTICS

penicillin G 5 million units IV, then 2.5 million units IV q4h until delivery
OR If allergy to penicillin and no anaphylaxis, then
ceFAZolin 2 g IV, followed by 1 g IV q8h until delivery

OR If allergy to penicillin and HIGH risk for anaphylaxis, then

OR

If GBS sensitive to Clindamycin AND If GBS resistant to Clindamycin
Erythromycin, then: or IF SENSITIVITY UNKNOWN*, then:
Clindamycin 900 mg IV q8h until delivery Vancomycin 1 g IV q12 h until delivery

*City of Hamilton population currently has 40% resistance to Clindamycin.
Newborn is greater than
or equal to 37 wks AND
ROM less than 18 h
Determine gestation
and length of ROM
Newborn is less than 37 wks
OR ROM greater than or
equal to 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 vital signs at 9 h;
CBC and diff at 12 h;
observe minimum 48 h
Newborn VS and
clinical assessment at
8, 12, 18 & 24 h post
transitional checks;
CBC and diff at 12 h

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,
18
th
edition, SOGC Ottawa J une 2011.
SOGC (Oct. 2013) The Prevention of Early-Onset
Neonatal Group B Streptococcal Disease. J Obstet
Gynaecol Can. 35(10):e1-e10.
Personal communication (Aug 2012) Drs. M
Fulford, S Dore, Ms S Trudel-Chow, M Sung.
= Mother

= Newborn
Has fever^and
suspected
chorioamnionitis
regardless of GBS
status
Consider use of
ceftriaxone 2 g IV OD
+/- metronidazole 500
mg IV BID, then
reassess.
*
Signs/Symptoms of Chorioamnionitis:
fever greater than 38 C
tender uterus
purulent/foul smelling amniotic fluid
maternal WBC count >15 x 10
9
/L

Mother:
Has fever ^ alone
regardless of GBS
status

*
^Fever =temperature greater
than 38 C
Baby remains well

Mother with Fever
(Note: The antibiotic medication content has been
amended by the Antibiotic Stewardship Committee
Nov. 5 2012 LY STC and by Dr. M. Fulford and MS
Sept. 18 2013 LY KP)
Yes No
Notify
Newborn MRP

Baby Remains Well - Clinical Assessment

for Signs/Symptoms of Newborn Sepsis:
- Temperature instability - Respiratory distress
- Tachycardia - Abnormal CBC
- Poor peripheral perfusion
ANY BABY WITH SIGNS/SYMPTOMS OF SEPSIS
REQUIRES FULL DIAGNOSTIC EVALUATION BY
PEDIATRICS.

Calculating a Left Shift

Hamilton Health Sciences Delegated Controlled Acts & Medical Directives
Manual
Issue Date: 2005-10-04 Page 9 of 27
Care of the Newborn Medical Directive No. 44005
Appendix III: Newborn Hypoglycemia Guidelines for the at-Risk Newborn
Newborn Hypoglycemia Clinical Guidelines
Principles
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.
3. * 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.
Definitions
At risk includes babies with any of the following maternal/newborn criteria:
Any maternal diabetes (gestational, type I or II, with or without insulin)
Any mother receiving beta blockers for the management of hypertension
(e.g. Atenelol, Labetalol)
LGA or SGA
Preterm gestation < 37 0/7 weeks
Cold stress, hypothermia (newborn temperature < 36.5 C) axilla
Newborns with medical illnesses (e.g.: respiratory distress, sepsis)
BG: blood glucose in mmol/L
PCx Glucose Reading: This provides only a range and does not give an exact
blood glucose level. PCx glucose results are useful only as a screening test. If there
is a PCx glucose reading less than 3.0 mmol/L, draw a lab blood glucose level
SGA: less than the 5
th
percentile for birth weight and gestational age
LGA: greater than the 95
th
percentile for birth weight and gestational age
Gestation
(completed weeks)
Male
Weight in gm
Female
Weight in gm
SGA LGA SGA LGA
36 <2144 >3604 <2052 >3523
37 <2384 >3857 <2286 >3752
38 <2605 >4065 <2502 >3931
39 <2786 >4232 <2680 >4076
40 <2927 >4382 <2814 >4212
41 <3025 >4512 <2906 >4330
42 <3070 >4631 <2954 >4423
Kramer et al. (2001) It is recognized that these weights deviate from the
CPS Guidelines
(2005) of the 10
th
and 90
th
percentile cut-offs for
birthweight at term.
Symptomatic: exhibits one or more of the following- jitteriness or tremors, apnea,
episodes of cyanosis, convulsions, intermittent apnea spells, or tachypnea, weak or
high pitched cry, limpness or lethargy, difficulty feeding, eye rolling, episodes of
sweating, sudden pallor, hypothermia, cardiac arrest
Manual
Breastfeed: If the mother has indicated a desire to breastfeed, direct breastfeeding
is encouraged depending upon maternal and newborn condition. The mother should
be assisted with breastfeeding. A reasonable time limit of 20 minutes should be
spent assisting the newborn to latch. Once the baby is transferring milk, no time
limit should be placed on the feed providing the transfer of milk continues. Capillary
heel blood sampling may be done at the bedside while baby is at breast if required.
Formula Feed: Formula will be fed to infants whose mothers have made an
informed choice to bottle/formula feed.
Supplemental Feed: The first choice for supplement is EBM (expressed breast
milk). A breastfeeding mother of a hypoglycemic infant should begin pumping
immediately. She should be using a hospital grade electric breast pump with a
double kit to provide milk to augment feeds. If mothers milk is not available by
pumping, formula will be used. The supplement will be offered using an alternate
feeding method according to the procedure: Supplementation of the Healthy Term
Breastfed Infant in the First Few Days Following Birth. Supplementation should be
supervised by a health professional. Attempts at supplementation should not exceed
20 minutes. If the required amount (5-10ml/kg/feed) cannot be taken in the 20
minutes, consider the baby unable to feed and notify the MD or MW.
Manual
The baby DOES SHOW signs/
symptoms of hypoglycemia or
the baby appears UNWELL
- Notify MD/MW immediately
- Check PCx blood glucose
and lab blood glucose
immediately
Physician will:
- Investigate cause
- Treat underlying condition
- Consider use of MD
Protocol A*/B* based on
newborn condition and
causative factors
SYMPTOMATIC ASYMPTOMATIC
The baby DOES NOT SHOW
signs/symptoms of
hypoglycemia and the baby
appears WELL
Does baby have any RISK
FACTORS for hypoglycemia?
Check PCx glucose at
2 hrs. post-birth
YES YES
Less than 3.0 mmol/L PCx glucose greater than or equal to
3.0 mmol/L
--- Asymptomatic---
Lab glucose greater than or equal to
2.6 mmol/L:
- Breast/EBM/formula feeds q2-4h,
lab glucose AC feeds
- If lab glucose greater than or
equal to 2.6 x 1, discontinue lab
glucose checks
- Preterm & SGA babies do not
require retest after 36 hrs.
provided stable levels and intake
achieved
- IDM or LGA babies do not require
retest if lab glucose greater than
or equal to 2.6 after 12 hrs.
Draw lab glucose
Lab glucose less than 1.0:
- Notify MD/MW
- Use MD protocol B*
Lab glucose 1.0-1.7
Asymptomatic:
- Supplement EBM/formula
5-10 mL/kg
Lab glucose 1.8-2.5
Asymptomatic:
- Breast/EBM/formula feed
now
Recheck lab glucose
60 minutes PC feed:
- Continue ongoing
assessment for signs/
symptoms of
hypoglycemia
Lab glucose less than 1.8:
- Notify MD/MW
- Physical will initiate MD
Protocol A*
Lab glucose 1.8-2.5:
- Supplement EBM/formula 5-10 mL/kg
- Check lab glucose q3h AC feeds for
maximum of 24 hrs.
- If 2 consecutive lab glucose less than
2.6, notify MD/MW
NEWBORN BABY
References:
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).
NO NO
Routine care and
feed on demand
as long as baby
remains well
Legend:
MD = Medical Doctor
MW = Midwife
PCx = Point of Care glucometer test
EBM = Expressed Breast Milk
SGA = Small for Gestational Age
LGA = Large for Gestational Age
IDM = Infant of a Diabetic Mother
AC = before feeds
PC = after feeds
Routine care and initial feed
within 60 minutes of birth
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.
Manual
MD Protocol A
Only to be ordered by Physician / ACNP Neonatal
Start Infusion with D10W @ 80cc/kg/day
(5.5 mg glucose/kg/min)
Continue checking lab
blood glucose every
2 hours. May start to
wean IV 12 hours after
stable lab blood glucose
and feeding is
established.
Go to MD protocol B
Increase IV infusion to
6-8 mg/kg/min, check lab
blood glucose in half hour,
then every 2 hours. May start
to wean IV 12 hours after
stable lab blood glucose and
feeding is established.
Lab blood glucose
2.6 or greater
Lab blood glucose 1.8 - 2.5
Lab blood glucose
less than 1.8
Check lab blood glucose after
30 minutes
Manual
MD Protocol B
Only to be ordered by Physician / ACNP Neonatal
Consider 200mg/kg (2cc/kg) D10W bolus,
IV infusion of 6-8 mg/kg/min.
Bolus 200mg/kg (2cc/kg)
D10W and increase infusion
to 8-10 mg/kg/min.
Recheck lab blood glucose after
30 minutes
Recheck lab blood glucose in hour, then hourly. May wean
IV once lab blood glucose stable for 12 hours.
Increase D10W infusion to 10-15 mg/kg/min
if continued low lab blood glucose and
consider glucagon.
Increase infusion to
8-10 mg/kg/min.
Lab blood glucose
1.8-2.5
Continue checking lab
blood glucose every
2 hours. May start to
wean IV 12 hours after
stable lab blood
glucose and feeding is
established.
Lab blood glucose
less than 1.8
Lab blood glucose
2.6 or greater
Manual
Physician Guidelines
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 < 1.8 mmol/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 hour to q1hour until stable then q3-4hours.
May start weaning IV 12 hours after stable lab blood glucose 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 q1-4 hours depending on the initial severity of the
hypoglycemia) and finally the glucagon. Wean glucagon 0.1 cc 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. T.I.D.-Q.I.D. , Hydrocortisone
5 mg/kg/day IV Q.I.D. 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.
D1 0W = 10 gms / 100mL
= 10,000mg / 100mL
= 100mg / mL
Manual
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.
References
ACoRN Editorial Board. (2005) ACoRN - Acute Care of at-Risk Newborns.
Vancouver
Bank, C. (1997). Neonatal Hypoglycemia, Neonatal Network, 16, 2: 15-21
Canadian Paediatric Society (2004). Screening Guidelines for newborns at risk for
low blood glucose. Paediatrics and Child Health 9(10): 723-729
Cloherty, J. & Stark, A., (1980), Manual of Neonatal Care, 4
th
ed, Little Brown:
Philadelphia, PA
Combloth, M. & Schwartz, R. (1993). Hypoglycemia in the Neonate. Journal of
Paediatric Endocrinology 6,2: 113-129
CWONN, (2001) Neonatal Hypoglycemia Guidelines
Kah, T (1996). Glucose and the Newborn Baby: Sweet Justice? J Paediatic Child
Health, vol 32, 281-284
Klaus, M et al (1979) Care of High Risk Neonate, 2
nd
ed W. Saunders: Philadelphia,
PA
Kramer, Michael S. et al (2001). A New and Improved Population - based Canadian
Reference for Birth Weight for Gestational Age, Pediatrics. Electronic version,
http://www.pediatrics.org./cgi/content/full/108/2/e35.
Lucas, A, Marley, R.,& Cole, T., (1980) Adverse Neurodevelopment Outcome of
Moderate Neonatal Hypoglycemia, BMJ, 297, Nov 88 1304-1308
Perlman, M, Kirpalani, H., & Moore, A. (1999), Resident Handbook of Neonatology,
2
nd
ed, BC Decker Inc: Hamilton Ontario

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 Childrens Hospital
St. Josephs Healthcare

March 2007
Revised: January 2009
June 2010

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

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 newborns 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. Joes (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. Josephs 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. Josephs 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. Josephs
outpatient lab at 905-522-1155 x33401.


Direct Bilirubin

This is a measure of the newborns conjugated bilirubin level. If the TSB is at or below 85
mol/L, a direct (or conjugated) bilirubin of more than 17.1 mol/L is generally considered
abnormal. For TSB values higher than 85 mol/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 South and East Asian
o African
o Mediterranean
o 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


- 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. Josephs 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 babys ongoing care provider in the community.


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 mothers 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

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 re-
admissions to hospital during the first week of life are because of jaundice.

Pathologic Jaundice
Pathologic jaundice is present in the first 24 hours of age. If TSB levels are greater than the 75
th

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 95
th
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 (Turners), 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

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.

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

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
infants age in hours, a phototherapy nomogram can be used to plot an infants 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 infants 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


Hyperbilirubinemia in the Newborn Infant
35 or More Weeks of Gestation
Guidelines for initiation of phototherapy for hyperbilirubinemia.

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 significant resuscitation at birth(baby required cardiac compressions and/or
medications for resuscitation; baby required CPAP for greater than 1 h of age)

! evidence of metabolic or respiratory acidosis as evidenced by cord gas pH < 7.1

! low serum albumin less than 30g/L (if measured)

! 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.

0
50
100
150
200
250
300
350
400
Birth 24 48 72 96 120 144 168
Age in hours
B
i
l
i
r
u
b
i
n

u
m
o
l
/
L
Infants at Higher Risk Infants at Medium Risk Infants at Lower Risk


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 W/cm2/nm or higher, delivered to as much of the infants 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 W/cm2/nm) and 1 set of
Microlights (delivers 12 15 W/cm2/nm).

On St. Joes Ward 3OBS:

! babies who require phototherapy will be placed in an isolette to receive
phototherapy via Biliblanket (delivers 50-70 W/cm2/nm) and Giraffe Spot
(delivers 50-70 W/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.


Total Serum Bilirubin Screening Assessment Nomogram

Always consider bilirubin level by the infants age in hours

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

! 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. Josephs 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.
50
75
100
125
150
175
200
225
250
275
300
325
0 12 24 36 48 60 72 84 96 108 120 132 144
Low Risk 40% Intermediate Risk 75% High Risk 95%
Age in hours
Bilirubin
umol/L
Low Risk Zone
Low Intermediate Risk Zone
High Intermediate Risk
Zone
High Risk Zone

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
35 37 6/7 weeks gestation
with a NEGATIVE Coombs
35 37 6/7 weeks gestation
with a POSITIVE Coombs
Low Risk Zone

Routine care
No Coombs test required
Routine care
Low-Intermediate
Risk Zone
Routine care Further testing or treatment
required
High-Intermediate
Risk Zone
Follow-up assessment
including TSB at 24 to 48 h
Further testing or treatment
required
High Risk Zone Further testing or treatment
required
Phototherapy required
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 Test Algorithm
Bilirubin Screening Responses greater than or equal to 38 weeks gestation
Bilirubin Risk
Zone @ time of
screening
Greater than or equal to
38 weeks gestation
with a NEGATIVE Coombs
Greater than or equal to
38 weeks gestation
with a POSITIVE Coombs
Low Risk Zone

Routine care
Routine care
Low-Intermediate
Risk Zone
Routine care
Routine care
High-
Intermediate Risk
Zone
Routine care - care provider
consider a follow-up TSB if
there is clinical concern
Follow-up assessment
including TSB at 24 to 48 h
High Risk Zone

required
required
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. Josephs Healthcare, open every day except Christmas day
Mothers Blood Group:
! O ! Other

Coombs Test Ordered:
! Yes ! No

Coombs Test (DAT):
! +ve ! -ve

Mothers Blood Group:
! O ! Other

Coombs Test Ordered:
! Yes ! No

Coombs Test (DAT):
! +ve ! -ve

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 mothers blood group:

MOTHER O -ve MOTHER O +ve MOTHER A* or B*

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.
When the Transfusion
Medicine Lab receives an
order to do a Coombs test,
the Lab will do the babys
blood group first.
Coombs Test
IS NOT required.
Baby O ve
or O +ve
Baby A* or B*
Coombs Test
IS NOT required
Coombs Test
IS required
Baby O ve
or O +ve
Baby A* or B*
Coombs Test
IS NOT required
Coombs Test
IS required
NOTE:

If any antibodies are
detected prenatally, then a
Coombs test must always
be done regardless of
mothers and babys blood
types.
*A = A +ve and A ve B = B+ve and B -ve

- 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. Josephs 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 babys
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 infants 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
Physician / Midwife
16

plot the TSB level on the Hyperbilirubinemia Assessment Sheet for Initiation of
Phototherapy using the appropriate phototherapy risk line based on the infants
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 infants 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
17
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
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 mol/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 mol/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)
100
150
200
250
300
350
400
450
Birth 12 24 48 72 96 120 144
Age in hours
B
i
l
i
r
u
b
i
n

u
m
o
l
/
L
Infants at Higher Risk Infants at Medium Risk Infants at Lower Risk
Physician / Midwife
18

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 physicians order. St. Josephs 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. Josephs 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 infants 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.


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 "W/cm
2
/nm) when total serum
bilirubin (TSB) is = the line according to gestation or weight.
4. Start bili blanket when TSB is > 17-34 " 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.

Phototherarpy Guidelines
Infants less than 35 weeks and/or less than 2500 gms
160
170
180
190
200
210
220
230
240
250
260
270
280
290
300
310
320
330
340
350
360
370
380
12h 24h 36h 48h 60h 72h 84h 96h 108h 120h
m
i
c
r
o

m
o
l
/
L

(
!
m
o
l
)

T
S
B

(
t
o
t
a
l

s
e
r
u
m

b
i
l
i
r
u
b
i
n
)

Time (age in hours)
The Hospital for Sick Children
Exchange Transfusion for Infants
<2500g and/or <35weeks gestation
<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:180!mol/L; "24hrs:200!mol/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.

References:
Maisels & Watchko. Arch Dis Child Fetal Neonatal
Ed. 2003; 88:F459-F463.
Horn et al. South African Medical Journal
2006;96:819-824.
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
ref 3 below
(table 5)

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. Lawrence R: Early Discharge Alert Pediatrics, 1995:96(5):966
2. CPS. Early Discharge of Newborn Infants - a guide for parents. Paediatric Child Health 1(2); fall 1996
3. Molteni KH. Initial Management of Hypernatremic Dehydration in the Breast Fed Infant. Clinical Pediatrics 33(12):731-40,
1994
4. Fleisher, GR. Textbook of Pediatric Emergency Medicine p.817. 2000.
5. Health Canada Fairly Centred Maternity and Newborn Care 7.5;2000
6. Hamilton-Wentworth Regional Lactation Committee. PD3910-07/2001 July 3
rd
, 2001, Breast feeding in the first few days.

MacPeds
PEDIATRIC
FORMULARY

For drugs prescribed in the NICU please refer to the handbooks available in unit at
both McMaster and St Josephs Healthcare.
There is a separate PICU handbook with a drug formulary specific to the PICU.

This document is intended for use at McMaster Childrens 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.

Unapproved Abbreviations, Symbols and Dose Designations and Acceptable Corrections

Unapproved
Abbreviation
Intended
Meaning
Problem Acceptable
Correction
U Unit Mistaken for 0 (zero), 4 (four), or cc. Use 'unit'.
IU International
unit
Mistaken for IV (intravenous) or 10 (ten). Use 'unit'.
Abbreviations for
Drug Names
Misinterpreted because of similar abbreviations for multiple
drugs; e.g., MS, MSO4 (morphine sulphate), MgSO4
(magnesium sulphate) may be confused for one another.
Do not abbreviate
drug names.
(exceptions: ASA,
KCl, Humulin R)
QD
QOD
Every day
Every other day
QD and QOD have been mistaken for each other, or as
qid. The Q has also been misinterpreted as 2 (two).
Write daily and
every other day
in full
OD Every day Mistaken for right eye (OD = oculus dexter) Write daily
OS, OD, OU Left eye, right
eye, both eyes
May be confused with one another. Use left eye, right
eye or
both eyes.
AS, AD, AU Left ear, right
ear, both ears
May be confused with one another. Use left ear,
right ear or both
ears
D/C Discharge or
discontinue
Premature discontinuation of medications if D/C (intended
to mean discharge) has been misinterpreted as
discontinued when
followed by a list of discharge medications
Use discharge and
"discontinue".
SC, SQ, or sub q Subcutaneous 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)
Use "subcut" or
"subcutaneous"
cc Cubic centimetre Mistaken for u (units). Use mL or
millilitre.
g Microgram Mistaken for mg (milligram) resulting in one thousand-fold
overdose.
Use mcg or
microgram.
Unapproved
Symbol
Intended
Meaning
Potential Problem Acceptable
Correction
@ at Mistaken for 2 (two) or 5 (five). Use at. Write out at in full
>

<
Greater than

Less than
Mistaken for 7(seven) or the letter L .

Confused with each other.
Write out greater
than in full
Write out less than
in full
Unapproved
Dose
Designation
Intended
Meaning
Potential Problem Acceptable
Correction
Trailing zero X.0 mg
Or 10.0 mg
Decimal point is overlooked resulting in 10-fold dose error. Never use a zero by
itself after
a decimal point.
Use X mg or 10
mg
Lack of leading
zero
. X mg Decimal point is overlooked resulting in 10-fold dose error. Always use a zero
before a
decimal point. Use
0.X mg
Adapted from ISMPs List of Error-Prone Abbreviations, Symbols, and Dose Designations (2010) and ISMP Canadas Do Not
Use Dangerous Abbreviations, Symbols and Dose Designations (2006)


Legend:

GAS
GP
Group A Streptococcus
Gram Positive
GPC Gram Positive Cocci
GN Gram Negative
GNB Gram Negative Bacilli
MAX Maximum
MIN Minimum
NF Non-Formulary At HHS

Adjust dosing
interval for patients
with renal impairment.


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 g, use mcg, or even safer, write
out microgram or use milligrams if possible (0.25 mg instead of
250 micrograms)
ANTIBACTERIALS
CELL WALL SYNTHESIS INHIBITORS (BACTERICIDAL)
-LACTAMS
PENICILLINS
benzyl penicillin: narrow spectrum; NOT Penicillinase resistant
Penicillin G (IV or IM)

Penicillin V
Potassium (PO)
Suspension: 60mg/mL
Tablet: 300mg

Penicillin V 500 000 units is
equivalent to 300 mg.

Moderate to Severe Infections:
IV: 100 000 - 400 000 Units/kg/DAY q4-6h (MAX: 24 million Units/DAY)
Meningitis: IV: 400 000 Units/kg/DAY q4h (MAX: 24 million Units/DAY)

Penicillin V Potassium (oral):
1. Mild to moderate Group A Strep infections: 25-50mg/kg/day PO q8-12h x 10 days
IDSA (GAS pharyngitis) Children: 300mg bid-tid; Adolescents & adults: 600mg po BID x 10
days

2. Rheumatic fever (treatment): < 27kg: 300mg PO bid x 10 days; > 27kg: 600mg
PO BID x 10 days
3. Rheumatic fever (prophylaxis AND > 5 yrs): 300mg PO bid
4. 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)

Oral:
Suspension 25mg/mL
Capsule: 250mg, 500mg
Primarily used in methicillin-sensitive Staphylococcus aureus (MSSA) infections:
IV: 100-200 mg/kg/DAY q4-6h (MAX: 12 g/DAY); up to 300mg/kg/DAY may be used in
select cases (please consult Infectious Diseases)

PO: Suggest to use cephalexin (1
st
generation cephalosporin) in place as cloxacillin has low
oral bioavailability, poorly tolerated (GI side effects) and need to be taken on an empty
stomach


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)

Suspension: 50mg/mL
(supplied at HHS);
25mg/mL
For coverage against Streptococcus pneumoniae (including empiric therapy for community-
acquired pneumonia or otitis media): PO 80-90mg/kg/DAY q8h (MAX: 1 g/DOSE)
Standard dose: 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
(Clavulin) (PO)

Tablets (amoxicillin/clavulanic acid):
500/125mg(4:1); 875/125mg(7:1)

Beginning in fall 2014:
Suspension (supplied as HHS): 1 mL
= 80mg amoxicillin and 11.4mg
clavulanic acid (7:1)

For coverage against Streptococcus pneumoniae (i.e. sequential oral therapy in
complicated CAP, AOM, sinusitis): 80-90mg/kg/DAYof amoxicillin component
q8h
**BID dosing may be adequate for AOM, but TID dosing is recommended for
pneumonia**

Standard dosing for other gram positive, gram negative, anaerobic infections:
PO: 30-50 mg/kg/DAY of amoxicillin component q8-12h (MAX: 500 mg/DOSE)

*One major side effect with clavulanic acid (particularly at high doses) is GI
intolerance
**When writing discharge prescription and if suspension is required, please indicate
(particularly if high dose amoxicillin is used) the formulation of the amoxicillin-
clavulanic acid is specified. Example of prescription:
Amoxicillin clavulanic acid suspension
Please dispense as 7:1 formulation (80mg/mL amoxicillin + 11.4mg/mL clavulanic
acid) 480mg (of amoxicillin component) po TID x 10 days

ANTIBACTERIALS (CONTINUED)
PENICILLINS (CONTINUED)
Ureidopenicillin: broad spectrum; Penicillinase sensitive Tazobactam: Enhances spectrum; -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 beta-
lactamase producing organisms (ESBL)
1
st
Generation Excellent coverage against S. aureus, group A Streptococcus, E. coli, Klebsiella.
Empiric therapy for cellulitis, osteomyelitis, bacterial adenitis.
Cefazolin (Ancef)
(IV or IM)
Higher doses are needed for infections such as osteomyelitis
Cephalexin (Keflex)
(PO)
Tablet: 250mg, 500mg
Suspension: 50mg/mL
PO: 25-100 mg/kg/DAY qid

Osteomyelitis following IV therapy: 100-150mg/kg/DAY (MAX: 4 g/DAY)
2
nd
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 or IM)
IV: 100-150 mg/kg/DAY q8h (MAX: 2g/DOSE)

Cefuroxime Axetil
(Ceftin) (PO)
Poor oral bioavailability; unlikely to achieve optimal concentrations in severe
infections
Cefprozil
(Cefzil) (PO)
Suspension: 50mg/mL
(eg. for otitis media unresponsive to high-dose amoxicillin or for acute sinusitis)

PO: 15-30 mg/kg/DAY q12h (MAX: 1 g/DAY).
3
rd
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
(IV or IM)

**reserved for neonates**
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


CEPHALOSPORINS
Ceftriaxone
(IV or IM)
Meningitis: IV/IM: 100mg/kg/DAY divided q12h or q24h (Max: 2g/DOSE)
Other infections: IV/IM: 50-75 mg/kg q24h (MAX: 2 g/DAY)

STI (gonococcal infection):
>45kg: 250mg IM x 1
Ceftazidime
(IV or IM)
Active against Pseudomonas aeruginosa:
Cefixime
(Suprax) (PO)

Tablet: 400mg
Suspension: 20mg/mL
Increasing MIC (minimum inhibitory concentration) against Neisseria gonorrhea;
avoid use if possible due to increased risk of treatment failure. IM ceftriaxone is
preferable.

Other infections (Not active against Pseudomonas and poor GP activity):
PO: 8 mg/kg/DAY q12-24h (MAX: 400 mg/DAY)


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
(IV)
Meningitis: 40mg/kg/DOSE IV q8h (MAX: 2g/DOSE)

Other infections: 20mg/kg/DOSE IV q8h (usual MAX: 1g/DOSE)
Ertapenem
(IV)
3 months - 12 years : 15mg/kg/DOSE IV q12h (max: 1 gram/DAY)
>13 years: 1 g IV once daily (max: 1 gram/DAY)
GLYCOPEPTIDES Only active against GP (including MRSA). Use as an alternative for GP coverage in patients
with severe penicillin allergy (i.e. anaphylaxis, angioedema)
Vancomycin
(IV or PO)

The IV formulation will
be provided when
prescribed orally while
in hospital
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)


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

Suspension:
25mg/mL, (50mg/mL
not available at HHS)
Useful for mild bacterial pneumonia in adolescents. Also commonly used for atypical
mycobacterial infections.
PO: 7.5 mg/kg/DOSE BID (Max: 500mg/DOSE)

Rx Interactions: theophylline, carbamazepine, cisapride, digoxin, cyclosporine, tacrolimus.
Azithromycin

Tablet: 250mg
Suspension:
40mg/mL
Useful for known atypical respiratory infections and bacterial enteritis. AVOID USING TO
TREAT INFECTIONS PRESUMED TO BE CAUSED BY GROUP A STREPTOCOCCUS OR
PNEUMOCOCCUS.
PO/IV: 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)
LINCOSAMIDES 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!
Clindamycin

Capsule: 150mg,
300mg
Suspension
15mg/mL
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)
AMINOGLYCOSIDES GN Aerobes (including Pseudomonas aeruginosa)
Gentamicin

OR

Tobramycin

IV: 5-6 mg/kg/dose q24h (extended frequency dosing is preferred in patients without
renal impairment to maximize pharmacokinetics and dynamics of drug)

Synergy with beta-lactams for severe S. aureus and Enterococcus infections:
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


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
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 jiroveci 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
Injectable 16 mg/ml 80 mg/ml
SS (single strength)
Tablet
80 mg 400 mg
DS (double strength)
Tablet
160 mg 800 mg

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
orally administered antibiotics available.
Ciprofloxacin
(IV or PO)
Tablet: 250mg, 500mg,
750mg

Suspension: 100mg/mL
(tablets are preferable if dose
is given via NG tubes)

** REQUIRES ID ENDORSEMENT**
Ciprofloxacin usually reserved for infections caused by Pseudomonas aeruginosa or
other resistant gram negative bacilli

IV/PO: 20-30 mg/kg/DAY q12h (MAX: 400 mg/DOSE IV or 750 mg/DOSE PO)
Excellent oral absorption, use IV only if PO contraindicated.
Feeds, formula, calcium, magnesium, iron, antacids and sucralfate reduce
absorption, hold feeds for 1 hour before and 2 hours after dose.
Levofloxacin
Tablet: 250mg, 500mg,
750mg

Suspension not available
commercially; use dissolve
and dose
** REQUIRES ID ENDORSEMENT**
Levofloxacin usually reserved for infections caused by Pseudomonas aeruginosa, other
resistant gram negative bacilli or penicillin-resistant Streptococcus pneumoniae.


ANTIFUNGALS
Fluconazole (IV or PO)

Oropharyngeal candidiasis: IV/PO: 3 mg/kg q24h
Esophageal candidiasis: IV/PO: 6 mg/kg q24h (MAX: 400 mg/DAY)
Candidemia: IV/PO: 12 mg/kg once (MAX: 800 mg) Then
6 mg/kg/DAY (MAX: 400 mg/DAY, 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)
Tablet: 50mg, 200mg
Suspension: 40mg/mL
** Requires ID endorsement **
Coverage against many Candida species and Aspergillus

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
Amphotericin B (IV)
(Ambisome)
** Requires ID endorsement **
Coverage against many Candida species, Aspergillus and most Mucor

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/m
2
/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

Tablets: 200mg, 400mg and
800mg
Suspension: 40mg/mL

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
function

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:
30-50mg/kg/DAY PO 3 TO 5 TIMES DAILY

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 3 TO 5 TIMES DAILY

Varicella or zoster in immunocompromised hosts: 30mg/kg/DAY IV q8h
PO dosing (following IV therapy): 80mg/kg/DAY PO 3 TO 5 TIMES DAILY

Varicella or zoster in immunocompetent host (note that therapy not always indicated):
80mg/kg/DAY PO 3 TO 5 TIMES DAILY


Oseltamivir

Available as 75 mg capsules
OR 6mg/mL suspension

Usual treatment duration is for 5 days only
**dosage adjustment is necessary in renal impairment**
Children > 12 months:
Weight Treatment dose
< 15 kg 30 mg/dose PO BID
> 15 kg to 23 kg 45 mg/dose PO BID
> 23 kg to 40 kg 60 mg/dose PO BID
> 40 kg 75 mg / dose PO BID

< 12 months (does not apply to premature infants):
3 mg/kg/dose PO BID (if possible, please round to nearest multiple of 3mg)

References: Bradley JS and Nelson JD. Nelsons Pocket Book of Pediatric Antimicrobial Therapy.
18th edition. 2010.

PEDIATRIC FORMULARY
Acetaminophen
Analgesic and antipyretic.
PO/PR: Refer to table for weight based dosing standardization
Can be dosed q4-6h prn

Weight
(kg)
Single Dose
(mg)
2.5 - 3.9 40
4.0 - 5.4 60
5.5 - 7.9 80
8.0 - 10.9 120
11.0 - 15.9 160
16.0 - 21.9 240
22.0 - 26.9 320
27.0 - 31.9 400
32.0 - 43.9 480
44 over 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.

Amlodipine
Calcium channel blocker:
PO: 0.1-0.3 mg/kg/DAY (max 15mg/kg/day
Due to long half life of drug, dose adjustments should be made
every 3-5 days only)

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.

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

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.

Dimenhydrinate (Gravol)
Antihistamine used to treat nausea and vomiting.
IV/IM/PO: 0.5 -1 mg/kg/DOSE q4-6h prn
(max 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 BID-QID
(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

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


Fentanyl
Narcotic analgesic
Continuous infusion:
Initial bolus dose: IV: 0.5-1 mcg/kg then
Continuous infusion: 0.5-2 microgram/kg/hr
Breakthrough: 0.5-1 mcg/kg q1-2h prn
(refer to continuous infusion preprinted order set)

Please note: Fentanyl is 100 x more potent than morphine
To prevent withdrawal, avoid abrupt cessation following high doses
or long duration of therapy (> 5 days). Common adverse effects are
pruritis, nausea and constipation

Ferrous Sulfate : See iron.

Fluticasone (Flovent)
Inhaled corticosteroid.
INH: 50-500 microgram q12h.
Available as 50mcg, 125mcg , 250 mcg /inhalation metered dose
inhaler

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.

Hydromorphone
Narcotic analgesic
Intermittent 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
Initial bolus dose: IV: 0.01-0.02 mg/kg then
Continuous infusion: 2-8 microgram/kg/hr
Breakthrough: 0.01-0.02 mg/kg q2-4h prn
To prevent withdrawal, avoid abrupt cessation following high doses
or long duration of therapy (> 5 days). Common adverse effects are
pruritis, nausea and constipation

Hydroxyzine
Anti-pruritic:
PO: 2 mg/kg/DAY TID or QID
Available as a 2mg/mL suspension or 10mg, 25mg capsules


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) Single Dose (mg)
2.5 - 3.9 20
4.0 - 5.4 30
5.5 - 7.9 40
8.0 - 10.9 60
11.0 - 15.9 100
16.0 - 21.9 150
22.0 - 26.9 200
27.0 - 31.9 250
32.0 - 43.9 300
44 over 400

Avoid in patients with renal impairment or increased risk of bleeding

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.

Ketorolac (Toradol)
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.


Levetiracetam
Anticonvulsant
PO: 5-10 mg/kg/DAY (Daily or BID)
May titrate dose to effect (max 3000mg/DAY), may require
dosage adjustment in renal impairment

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.

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.


Morphine
Narcotic analgesic.
Intermittent 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
Initial bolus dose: IV: 0.05-0.1 mg/kg then
Continuous infusion: 10-40 microgram/kg/hr
Breakthrough: 0.05-0.08 mg/kg q2-4h prn

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
PO: 10-20 mg/kg/DAY q8-12h (maximum 1 g/DAY).
Adverse effects include renal dysfunction, GI irritation and
ulceration.

Nifedipine
Anti-hypertensive
PO/SL: 0.125-0.25 mg/kg/DOSE (max 10mg/dose)
(use immediate release capsules)
Nurse to use needle to withdraw liquid from 10 mg capsule. Each
1mg = 0.03mL.


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).

Oxybutynin
Urinary antispasmotic agent.
PO: 1-5 years: 0.2 mg/kg/dose BID-QID
>5 years: 5mg/DOSE BID-QID
Available as 1mg/mL syrup or 5mg tablets

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)

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).


Phosphate salts:
Electrolyte
Treatment of hypophosphatemia:
PO: 1-2 mmol/kg/day BID-QID
IV: 0.15-0.64 mmol/kg (maximum 30mmol) over 4-6 hours

IV available as sodium phosphate (3mmol phosphate + 4 mmol
sodium/mL) and potassium phosphate (3mmol phosphate + 4.4
mmol potassium/mL). PO available as IV formulation of potassium
phosphate (see above), given PO and Phosphate Novartis 500mg
effervescent tablet (16 mmol phosphate/3mmol potassium per
tablet). Order in mmol phosphate component.

Dose recommendations assume normal renal function. Please refer
to Pediatric IV monograph for further prescribing details and
limitations

Pico-Salax (picosulfate sodium/magnesium oxide/citric acid)
Stimulant and Osmotic Laxative
PO: 1-6 yrs administer sachet
6-12 yrs administer 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.


Potassium Salts
Electrolyte. 1mmol of potassium chloride = 1 mEq of potassium
chloride
Treatment of hypokalemia:
PO: 1-2 mmol/kg/DAY q6h-24h.
IV: 0.25-0.5 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.


Ranitidine
H
2
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,
2
agonist.
Acute asthma:
MDI: 4-8 puffs q -q4h prn.
NEB: Less than 10 kg: 2.5 mg q -q4h prn
10 kg or greater: 5 mg q-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.


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


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 (as zinc gluconate)


Suggested dose equivalency applies to stable analgesic states. Patients with acute
postoperative pain may have variations to suggested conversions.

OPIOID Parenteral Dose
(mg)
a
Oral Dose
(mg)
FentaNYL 0.1 N/A

HYDROmorphone 2 6
Methadone N/A
b
2.5-10
b
Morphine 10 30

OxyCODONE N/A

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.
If the patient was on high dose opioid therapy (100 mg/day or greater of morphine), initial doses of
the new opioid should be 50% of the calculated dose of the new opioid.
If patient was on moderate dose of opioid therapy ( 60 90 mg/day morphine) start with 75% of
calculated dose of new opioid.
Additional references & patient response should be consulted to verify appropriate dosing of individual
agents. Additional resources for dose conversion can be found at:
http://nationalpaincentre.mcmaster.ca/
a
Parenteral route includes intravenous, intramuscular and subcutaneous route, but does not include
intraspinal route.
b.
Methadone equivalency is highly variable this ratio is taken from Micromedex as suggested
equivalency ratio in patients on chronic oral methadone.

Approximate Opioid Analgesic Equivalence
at HHS April 2014
HHS- March 2010

Drug
Equivalent Dose
(mg)
a

Relative Mineralocorticoid
Potency
Glucocorticoids:
Short-acting (biologic half-life 812 h)
Cortisone 25 2
Hydrocortisone 20 2
Intermediate-acting (biologic half-life 1236 h)
Methylprednisolone 4 0
Prednisolone 5 1
Prednisone 5 1
Long-acting (biologic half-life 3654 h)
Dexamethasone 0.75 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.

Approximate Systemic Corticosteroid
Equivalence
at HHS - May 2010
Antibiotics uuiue foi Common Peuiatiic Infections (>S months)
!"#$%&'(" *+,(- .-/+"'010 2"&'3'(&'% 45-+&'(" 6(&$0
.&'&'0 *$7'+ !" $%&'()%*+&, -" *%./'&%0+& 1%)%2
34$+5/&6, 7" 8+3+99:+/*; 1<2<=>6
?9)'$ @ !39&$3)8)88'; 1A>6
Fiist line:
Bigh-uose Amoxicillin P0
Seconu line:
if type 1 alleigy ! Claiithiomycin P0
if non-type 1 ! Cefpiozil P0
0R Ceftiiaxone IN x 1 uose
If initial theiapy fails:
Amoxicillin-Clavulanate (Clavulin) P0
if type 1 alleigy ! call IB
S uays
0R
1u uays if:
< 2yo, fiequent iecuiient A0N,
peifoiateu TN, faileu initial Abx
watchful waiting appiopiiate when:
- > 6mo
- healthy chilu (N0 immunoueficiency oi chionic
uisease oi anatomical abnoimality of heau anu neck,
N0 Bown's synuiome, N0 histoiy of complicateu
otitis meuia)
- illness not seveie
- ieliable paients
BC! ;3+3&(&%3 <==D
8(115"'&9:
+%;5'-$7
<"$51("'+
S mo - 4 yis
E*9+/ F G+83&9*+/ 1!" $%&'()%*+&,
gioup A Stieptococcus6 FF @34$*8+/;
1748)$/+;(+, B:/+(4H)$:*/+,
I&J*)%&//+6

S - 18 yis
G+83&9*+/, @34$*8+/;, E*9+/
0utpatient oi aumitteu to waiu:
Bigh uose Amoxicillin P0 oi Ampicillin Iv
Atypical pneumonia:
Claiithiomycin P0
Pleuial effusionAumitteu to PCC0Neciotizing:
Ceftiiaxone INIv + vancomycin Iv

7-1u uays, uepenuing on clinical
status

(tieatment uuiation will be
longei in the piesence of
complications such as empyema)

Featuies of atypical pneumonia: subacute onset, non-
lobai infiltiate, minimal leukocytosis, school-age

- Nacioliues aie useful in pen-alleigic patients
- If you aie suie it is not a type-1 ieaction, can tiy
cephalospoiins (2
nu
oi S
iu
gen.)
- Consiuei iisk factois foi NRSA
BC! ;3+3&(&%3 <=KK
*$"'"/'&'0 G+83&9*+/ 1!" $%&'()%*+&, -" *%./'&%0+,
L" (&%*%J*3*H*;6, E*9+/ 1-!E,
M%3&9)N*9';6

!$&8*+/ 8)%;*H&9+3*)%; *%O
- < Smo
- immunocompiomiseu
- known CNS uisease,
tiauma
Cefotaxime Iv
0R Ceftiiaxone IvIN
PL0S
vancomycin Iv

ABB acyclovii if:
- CSF pleocytosis <2uuu WBChpf

Bepenus on oiganism:
S. pneumonia 1u-14 uays
N. meningitiuis S-7 uays
If CSF cultuie negative but stiong
clinical suspicion then continue
empiiic antibiotics foi 7-1u uays
*+"7+&(-9 !4 %("05=&
consiuei BEXANETBAS0NE if bacteiial pathogen
suspecteu u.6 mgkguay uiviueu q6h befoie oi within
Su minutes of the fiist uose of antibiotics (only
continue foi 2 uays if S. pneumonia oi B. influenza
isolateu, any othei pathogen uiscontinue)
- Taiget vancomycin tiough levels 1u-1S
BC! ;3+3&(&%3 <=KP
>-'"+-9 ?-+%&
!"#$%&'("
M"B)/*, Q/&5;*&//+, M%3&9)8)88';,
C9)3&';, !&99+3*+, C;&'H)()%+;,
!" !+$9)$:43*8';

@89)%4(O QMMCC!!
0ncomplicateu (cystitis):
Cephalexin
SulfamethoxazoleTiimethopiim
No cleai consensus
7-14 uays

consiueiations: age, anatomy,
complicateu vs. uncomplicateu
- Biagnosis: uiine R+N anu cultuie (will only senu
cultuie if miu-stieam, cathetei oi supiapubic
aspiiation ie. N0 BAu SANPLES foi cultuie)
- Fiist febiile 0TI in an infant waiiants investigation
with an abuominal ultiasounu
@@C B/*%*8+/ C9+83*8& ?'*H&/*%& <=KK
Complicateu @<2-S months pyelonephiitis
systemically ill vomitingA immunocompiomiseu):
Ampicillin Iv PL0S uentamicin Iv
0R Ceftiiaxone IvIN
8$==5='&'0 ?9)'$ @ !39&$3)8)88';,
!" +'9&'; 17!!@R7S!@6,
?9)'$ BR? ;39&$3)8)88';
If pus piesent - veiy likely !" +'9&';
If pus not piesent - veiy likely
stieptococcal
Fiist line:
1
st
geneiation Cephalospoiin such as
CephalexinCefazolin
If alleigic to beta-lactam:
Clinuamycin P0Iv
If suspect NRSA:
0utpatient ! TiimethopiimSulfamethoxazole
Inpatient ! vancomycin
7-1u uays (usually 1-2 uays aftei
the iash iesolves)

vaiies uepenuing on piesence of
abscess anu uegiee of uiainage
- Consiuei I&B as fiist line if abscess oi fuiuncle
- Consiuei NRSA iisk factois
- avoiu oial cloxacillin if possible as it has pooi
bioavailability anu has uI siue effects

.0&$(19$='&'0 !" +'9&';, ?9)'$ @ !39&$3)8)88';,
$%&'()8)88';, T*%J&//+
Fiist line:
Cefazolin (high uose)
If suspect NRSA:
vancomycin
Piolongeu tieatment couise: 4-6
wks (combination of IvP0 as pei
IB)
- 1+"7+&(-9 !4 %("05=& #(- 1+"+/$1$"& +"7 BC>
- consiuei special gioups: eg. !+/()%&//+ in sickle cell
uisease, NRSA colonizeu, infecteu haiuaie
DE+-9"/'&'0 E*9+/ F 5+83&9*+/ 1?9)'$ @ !39&$6 If suspect uAS:
penicillin v oi amoxicillin
If Tiue beta-lactam alleigy:
Nacioliue oi Clinuamycin
1u uays - useful to confiim ux with thioat cultuie
- bacteiial > viial if: cough absent, tenuei
lymphauenopathy, high feveis, ++ tonsillai exuuates
Antibiotics uuiue foi Common Peuiatiic Infections (>S months)

!"#$!%" '(%)"*

+,-./ !0121340 *3.24/1567

!-400.28128 +/84216967

%2,1:15,136 5; 25,.7

!"#$%& !()&*+
cefLrlaxone + vancomycln
can conslder plp-Lazo lf
requlre coverage for
anaerobes (eg. Cl lnfecLlon)
or pseudomonas

,"-.%/" 0"1$.)#"2%3+
- lperaclllln-LazobacLam
- 8eflne Abx lf blood Cx +ve
- Conslder prevlous
mlcroblology hlsLory (e.g.
anLlbloLlc-reslsLanL
organlsms)

45"16)7)235 &)8"."6 -9+

- cefLazldlme
- plperaclllln +/-
LazobacLam
- clprofloxacln /
levofloxacln
- meropenem
- amlnoglycosldes
(genLamlcln/Lobramycln/
amlkacln)

:;!< &)8"."6 -9+

- vancomycln
- Cllndamycln
- SepLra
- Llnezolld (needs lu
endorsemenL)

;%5* ,3&$).5+

- revlous M8SA
lnfecLlon or
household conLacL
- PealLhcare
exposure/recenL
hosplLallzaLlon
- 18AvLL (lncludlng
Lo uSA)

=.>32%575 ."5%5$32$ $) #"2%&%//%25 326
&"#(3/)5#).%25+

- M8SA
- LS8L
- CCnS
- C dlff
- SlCL (AmpC producers): SerraLla,
provldencla, lndole +ve roLeus
(roLeus vulgarls), ClLrobacLer,
LnLerobacLer cloacae
- ALyplcals

?32&)79&%2 @)2/9 &)8".5 >.37 A8"BC
%26%&3$%)25+

- M8SA
- Severe C dlff lnfecLlon (C only)
- CCnS
- LnLerococcus
D3.-3#"2"7 %26%&3$%)25+

- LS8L
- SlCL
- olymlcroblal lnfecLlon

)(<=$)(* $> !+#*="?
l (roLon ump lnhlblLors) ln edlaLrlcs - 8eflux ulsease - 8esL Lvldence ln eds wlLh Cmeprazole, Lansoprazole and anLoprazole.
!"#$
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I
,(/
J231
K9 J2/'
L
Cmeprazole Losec 1-1.3 mg/kg/day C
once dally or dlvlded
8lu
nLCnA1AL:
0.3-1.3 mg/kg/dose
3.3 mg/kg/day 10-20 mg
C Cu
1.Capsule - can be opened &
sprlnkled on yogurL and glven
2. harmacy prepared suspenslon
can be used

10mg
capsules- noL
Cu8 covered
20 mg cap
($0.6/cap)

293 - CL8u or non eroslve CL8u when P2AnLags have falled
297-uu or prevenLlon of nSAlu lnduced ulcers
401- LreaLmenL of Cl dlsorders: Crohns, shorL CuL eLc.
402-severe esophaglLls, Zolllnger-Llllson eLc.
Lansoprazole revacld <10 kg: 7.3 mg C
Cu 10-30 kg: 13 mg
C Cu >30 kg: 30 mg
C Cu

1.6 mg/kg/day or
30 mg/day
13-30 mg
C Cu
1.Capsules may be opened and
sprlnkled lnLo applesauce
2.las1abs can be placed on
Longue for doses 13mg or greaLer
3. las1abs can be mlxed wlLh
waLer (10mL) Lo provlde parL
doses only lf no oLher opLlons
exlsL
4. harmacy repared suspenslon
may be used lf avallable
13mg
($0.3/cap)
30mg
($0.3/cap)
wlLh LnLerlc
coaLed
mlcrogranules

293 - CL8u or non eroslve CL8u when P2AnLags have falled
293 - for Pylorl epLlc ulcer
297-uu or prevenLlon of nSAlu lnduced ulcers
401- LreaLmenL of Cl dlsorders: Crohns, shorL CuL eLc.
402-severe esophaglLls, Zolllnger-Llllson eLc.
13, 30 mg
las1abs (noL
Cu8 covered)
Lsomeprazole nexlum 1mo-11 yrs:
<3kg:2.3- 3mg C Cu
>3kg: 10 mg C Cu
12-17yrs: 20 mg C
Cu
40 mg/day 20-40 mg
C Cu
1.1abs can be dlspersed for C
admln. Mlx wlLh 23-30mL mL of
waLer
2. SacheL can be dlssolved &
admlnlsLered vla C Lube

20 mg, 40 mg
LableL
10 mg sacheL
for oral
suspenslon
(noL Cu8
covered)
nC - noL covered under Cu8
anLoprazole anLoloc 1-1.3 mg/kg/day 40 mg/dose 20-40 mg
C Cu
CannoL be crushed

20mg- noL a
beneflL
40 mg
($0.3/LableL)
293 - CL8u or non eroslve CL8u when P2AnLags have falled 293 -
for Pylorl epLlc ulcer 297-uu or prevenLlon of nSAlu lnduced
ulcers 401- LreaLmenL of Cl dlsorders: Crohn's,, shorL CuL eLc. 402-
severe esophaglLls, Zolllnger-Llllsons eLc.
8abeprazole arleL CreaLer Lhan 10
years: 10 mg C Cu
20 mg C
Cu
CannoL be crushed

10 mg ($0.17
LableL)), 20 mg
($0.3/LableL)
nC- noL Covered under Cu8
noLe: ulrecLlons for openlng capsules and dlssolvlng LableLs wlLh dlspersed mlcrogranules lnLo food or waLer requlres LhaL Lhe granules musL nC1 be crushed or chewed for effecL.
1. PosplLal for Slck Chlldren. urug Pandbook and lormulary. 2009.
2. 8x llles urug Comparlson CharLs. 8
Lh
LdlLlon
3. Cu8 urug lormulary
4. eCS, 2012
3. !ew, 8k eL. Al. LxLemporaneous lormulaLlons for edlaLrlc, CerlaLrlc, and Speclal needs aLlenLs. ASP. 2
nd
LdlLlon.
6. Mlcromedex . Accessed uecember 2012.
repared by n lernandes 8h, urug lnformaLlon CenLre, PPS. 8evlewed by S ?ousaf 8h, edlaLrlcs MCP.
3

FEED

Kcal Protein
gram
Protein
source
Fat
gram
Fat
source
CHO
gram
CHO
source
Na
mg
K
mg
Cl
mg
Ca
mg
PO4
mg
Fe
mg
Vit A
(IU)
Vit D
(IU)
mOsm
/ kg H20

Indications for use
INFANT (0-1 YR)
HUMAN MILK * (mature) 70 1.1 Lactalbumin casein
70:30 -whey:casein
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
SIMILAC ADVANCE
Abbott
68 1.4 Evaporated /dry skim
milk, whey protein
3.7 Safflower/sunflower
coconut, soy
7.3 Lactose,
monoglycerides
16 71 44 53 29 1.2 203 41 300 Iron fortified term infant formula with added DHA (5 mg) and
ARA (13 mg)
ENFAMIL A+
Mead Johnson
68 1.4 Modified milk
ingredients
3.6 Palm olein, soy,
coconut, sunflower
7.6 Lactose, corn syrup
GOS maltodextrin
polydextrose
18 73 43 53 29 1.22 200 41 300 Iron fortified term infant formula with added DHA (11.5 mg) and
ARA (23 mg). Prebiotics added (GOS, polydextrose)
GOODSTART
Nestle
67 1.5 Whey hydrolysate
(100% whey)
coconut, safflower
7.5 Lactose, corn
maltodextrins
18 72 44 44 24 1.0 200 40 260 Hydrolyzed 100% whey-for infants at risk for milk protein allergy
or mild reflux. ! PO4, DHA (10 mg) and ARA (20mg)
ENFAMIL A+ THICKENED
Mead Johnson
68 1.7 Nonfat milk 3.4 Palm olein, soy,
coconut, sunflower
7.4 Rice starch lactose
maltodextrin corn syrup
27 73 51 53 36 1.2 200 41 230 Thickens when combines w/stomach acids- for reflux. Do not
concentrate beyond 24 kcal/oz. DHA (11.5mg) ARA (23mg)
ENFAMIL LACTOSE FREE
Mead Johnson
68 1.4 Milk protein isolates 3.6 Coconut, sunflower
soy, palm olein
7.4 Corn syrup solids
maltodextrin
20 74 45 55 31 1.2 200 41 200 Milk-based, lactose free formula. NOT suitable for galactosemia.
RTF only in hospital concentrate n/a.
ENFAMIL SOY A+
Mead Johnson
68 1.7 Soy protein isolates 3.6 Coconut, sunflower
soy, palm olein
7.2 Corn syrup solids
Mono/diglycerides
24 81 54 71 47 1.22 200 41 170 Soy based formula. Suitable for vegans. DHA (11.5 mg) & ARA
(23mg) Use powdered form only for galactosemia.
ALIMENTUM
Abbott
68 1.9 Hydrolyzed casein 3.8 MCT, safflower, soy 6.9 Sucrose, mod tapioca
starch
30 80 54 71 51 1.2 203

30 370 Hydrolyzed casein for milk protein allergy (60 % amino acids),
33% MCT. Lactose-free. Not kosher. " ODB
NUTRAMIGEN A+
Mead Johnson
68 1.9 Hydrolyzed casein
(100% casein)
coconut, sunflower
7.0 Corn syrup solids,
mod. corn starch
32 74 58 64 35 1.22 200 34 320 rtf
300 pdr
Hydrolyzed casein for milk protein allergy. Lactose/sucrose free.
Not kosher. DHA (11.5 mg) & ARA (23mg) " ODB
PREGESTIMIL A+
Mead Johnson
68 1.9 Hydrolyzed casein
(100% casein)
3.8 MCT, corn, soy,
sunflower/safflower
mod. Cornstarch
32 74 58 64 35 1.22 240 34 330 Hydrolyzed casein for milk protein allergy/fat malabsorption. 55%
MCT. DHA(11.5 mg) & ARA(23mg) NO ODB
NEOCATE INFANT
Nutricia
67 2.1 Free amino acids 3 Safflower, coconut,
soy
7.8 Corn syrup solids 25 104 52 83 62 1 212 35 375 Amino acid-based for milk protein allergy, malabsorption. 5%
MCT ,95% LCT " ODB
NUTRAMIGEN AA
Mead Johnson
68 1.9 Free amino acids 3.6 Palm olein, soy,
coconut, sunflower
tapioca starch
32 74 58 64 35 1.22 200 34 350 Amino acid based for severe cow milk protein/ multiple allergies.
2.8% MCT DHA (11.5 mg) & ARA (23mg) " ODB
ENFAMIL ENFACARE A+
Mead Johnson
74 2.1 Nonfat milk, whey
protein
3.9 High oleic vegetable,
soy, coconut, MCT
7.7 Lactose cornu syrup
solids
28 78 58 89 49 1.34 330 52 310 Preterm discharge formula with more kcal, protein, vitamins,
minerals. DHA (12.6 mg) ARA (25 mg) 20% MCT " ODB
ENFAMIL PREMATURE A+
With iron 24 kcal Mead Johnson
81 2.4 Non-fat milk
Whey protein
4.1 MCT, soy, high oleic
sunflower/safflower
lactose
47 80 73 134 67 1.46 1010 195 300 For preterm Infants when human milk not available. 40% MCT.
DHA (13.8 mg) ARA (28mg)
ENFAMIL HMF Mead Johnson
(per 4 pkg HMF )
14 1.1 Milk protein isolate,
whey hydrolysate
1.0 MCT, soy <0.4 Corn syrup solids,
lactose
16 29 13 90 50 1.44 950

150

35 To fortify human milk fed to premature/low birthweight infants
MCT 70%
PEDIATRICS (1-10 YR)
PEDIASURE
Abbott
100 3.0 Na caseinate (82%),
whey protein (18%)
5 Safflower, soy MCT,
sunflower
11 Maltodextrin, sucrose 37 130 101 97 80 1.4 259 32 310 Sole source of nutrition or supplement, oral/tube feed. Gluten and
lactose free . 20% MCT. " ODB
PEDIASURE PLUS with fibre
Abbott
150 4.2 Na/ca caseinate (82%)
whey protein (18%)
7.5 Safflower, soy, MCT,
sunflower
18 Maltodextrin, soy, FOS
sucrose, oat hulls,
65 180 122 90 80 1.4 330 45 345 High calorie Oral/tube feed. Not gluten free. 20% MCT, 0.75g
fiber/100mL FOS = 0.35g/100 ml) " ODB
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
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 Supplement/tube feed. 21% MCT Lactose and gluten free. 0.36g
pea fiber and 0.2g FOS/inulin per 100 mL. " ODB
PEPTAMEN JR
Nestle
100 3 Hydrolyzed whey 3.8 MCT, soy, canola 14 Maltodextrin, sugar,
corn starch
48 132 108 112 84 1.4 332 60 380 Partially hydrolyzed protein. 60% MCT, 100% whey peptides
" ODB
PEPTAMEN JR 1.5 (prebio)
Nestle
150 4.5 Hydrolyzed whey 6.8 MCT, soy, canola,
refined tuna oil
18 Maltodextrin, corn
starch, oligofructose
73 198 162 165 135 2.1 48 80 450 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
PEDIATRIC FORMULARY NUTRIENTS PER 100 mL unless otherwise noted
May, 2012

May 2012
FEED

Kcal Protein
gram
Protein
source
Fat
gram
Fat
source
CHO
gram
CHO
source
Na
mg
K
mg
Cl
mg
Ca
mg
PO4
mg
Fe
mg
Vit A
(IU)
Vit D
(IU)
mOsm
/ kg H20

Indications for use
PEDIATRICS (10+ yr)
HOMOGENIZED MILK 62 3.3 Casein, whey 3.4 Cow milk fat 4.7 Lactose 50 156 105 123 96 0.05 128 43 For children >1 yr if consuming balanced, varied diet with
adequate source of iron.
JEVITY 1 CAL
Abbott
106 4.4 Na/Ca caseinate, soy 3.6 Safflower/sunflower
canola MCT
15.2 Maltodextrin, corn
syrup solids soy fibre
74 124 115 91 76 1.4 381 31 310 Isotonic, high protein for tube feeding 1.4 g/100 mL fibre. " ODB.
19% MCT
JEVITY 1.2 CAL
Abbott
120 5.55 Na/ ca caseinate
Soy protein
3.9 Safflower, canola,
MCT
17.3 Maltodextrin FOS soy +
oat fibre, corn syrup solids
135 185 150 120 120 1.8 400 30 450 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
JEVITY 1.5 CAL
Abbott
150 6.4 Na , ca caseinate, soy 5.0 MCT, canola, corn 21.6 Maltodextrin FOS soy +
oat fibre, corn syrup solids
140 215 136 120 120 1.8 375 40 525 High pro& kcal for fluid restriction/elevated energy needs 19%
MCT. 0.89g fiber/1g FOS/100 mL. " ODB 1 & 1.5L size only
RESOURCE 2.0
Nestle
200 8.0 Na + ca caseinate 9.0 Canola 22 Corn syrup, sugar,
maltodextrin
80 150

120 106 106 2.0 529 42 790 High nitrogen, calorically dense.for fluid restriction. Oral
supplement / tube feed. " ODB
ENSURE
Abbott
106 4.0 Milk & soy protein
concentrates
2.9 Soy, canola, corn
oils. Soy lecithin
16 Sugar, corn
maltodextrin
106 160 106 128 117 1.6 532 26 642 Oral supplement/ tube feed. Lactose & gluten free. Vanilla,
strawb, choc. NOT ODB covered (Ensure w fiber IS " ODB)
ENSURE PLUS
Abbott
151 5.7 Milk/ soy/ whey
protein concentrates
4.7 Canola, corn oil. Soy
lecithin
21.5 Corn maltodextrin,
sucrose
106 170 115 128 117 1.6 532 26 633
vanilla
Oral supp. Calorically dense, high pro for fluid restrictions.
Lactose/gluten free. Strawb/van/butter pecan. No fiber " ODB
ENSURE HP
Abbott
96 5.0 Na/ ca caseinate,
soy protein
2.6 Safflower, canola,
corn oils
13.2 Sugar, corn
maltodextrin
123 182 107 117 117 1.5 496 21 546 High protein supplement/ tube feed. Lactose and gluten free. NOT
ODB covered. Van/choc/straw. No fiber
ISOSOURCE VHN
Nestle
100 6.2 Na , ca caseinate 2.9 Canola, MCT, soy 12.8 Maltodextrin, guar gum
soy polysaccharides
128 160 136 80 80 1.4 288 27 300 High protein, fibre containing tube feed. 50% of fat as MCT.
0.45g fiber/100 mL. Lactose and gluten free " ODB
OXEPA
Abbott
150 6.3 Na, ca caseinates 9.4 Canola, MCT,
marine + borage oils
10.5 Sucrose,
maltodextrin
131 196 169 106 106 2 1191 42.5 535 Low CHO, calorically dense - for critically ill/Sepsis/ARDS.
EPA&GLA oil, 25% MCT. Lactose/gluten free. NOT kosher
OPTIMENTAL
Ross
100 5.1 Whey /na caseinate
hydrolysates,
arginine
2.8 Marine oils, MCT,
canola, soy oils
14 Maltodextrin,
sucrose, FOS
112 171 120 106 106 1.3 823 28 585 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
PERATIVE **
Abbott
130 6.7 Na caseinate,
arginine lactalbumin
3.74 Canola, MCT, corn 17.7 Maltodexrtrin 104 173 165 87 87 1.6 868 35 385 Peptide based for metabolically stressed. 8.05g/L arginine, Oral
and tube feed. For those > 4yrs.
PEPTAMEN
Nestle
100 4.0 Hydrolyzed whey 3.9 soybean, MCT 13 Maltodextrin, sugar
corn starch
56 150 100 80 70 1.8 324 27 380 Elemental diet for impaired GI function/malabsorption. Oral &
tube. 100% whey protein. 70% MCT. Vanilla flavour " ODB
PEPTAMEN 1.5
Nestle
150 6.8 Whey 5.6 soybean, MCT 19 Maltodextrin, corn
starch
102 186 174 100 100 2.7 486 41 550 Elemental high calorie diet for malabsorption. 100% whey protein.
Vanilla flavour 70% MCT. " ODB
VITAL HN **
Abbott
100 4.2 Partially hydrolyzed
protein blend, whey
1.1 Safflower, MCT 18.5 Maltodextrin, sucrose 57 140 103 67 67 1.2 333 27 500 Peptide based, VERY low fat formula for limited digestion +
absorption. Contains peptides and free aa. 43% MCT NOT kosher
VIVONEX PEDIATRIC
(Per 100 g powder) Nestle
411 12.3 Free amino acids 12.1 Coconut, soybean
palm/coconut
64.7 Maltodextrin, corn
starch
205 616 534 493 411 5.34 127 164 360 Elemental formula for fat malabsorption-68% MCT - 1 pkg powder
(48.7g) + 220 mL water = 250 mL (0.8 kcal/mL) " ODB
NEPRO CARB STEADY
Abbott
180 8.1 Milk protein, Ca, mg,
na caseinates
9.6 Safflower, soy
lecithin, canola
16 Corn syrup solid FOS
maltodextrin sucrose
106 106 84 106 72 1.9 318 8.5 745 Acute or chronic renal failure requiring dialysis. Oral/tube feed.
0.84g FOS + 0.42g fiber per 100 mL NOT ODB Vanilla
SUPLENA
Abbott
200 3.0 Na + ca caseinate 9.6 Safflower, soy 25 Maltodextrin, sucrose 78 112 93 139 74 1.9 106 8.5 600 Low protein for chronic/acute renal failure patient not on dialysis.
Oral/ tube feed. " ODB
MODULEN IBD **
Nestle
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 Polymeric formula for Crohns 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



May, 2012
FEED

Kcal Protein
grams
Protein
source
Fat
grams
Fat
source
CHO
gram
CHO
source
Na
mg
K
mg
Cl
mg
Ca
mg
PO4
mg
Fe
mg
Vit A
(IU)
Vit D
(IU)
mOsm
/ kg
H20
Indications for use
METABOLICS/SPECIALTY
PORTAGEN
(per 100g powder) Mead Johnson
470 17 Na caseinates
(100%)
22 MCT, corn, coconut 54 Corn syrup solids
Sugar
235 590 404 440 330 8.8 1560 130 n/a Fat malabsorption, chylothorax, defective lymphatic transport.
87% MCT Consult RD for recipe " ODB
RCF (per 100mL concentrate)
Abbott
81 4 Soy protein
isolates
7.2 soy, coconut,
safflower
.008 - 59 146 83 140 100 2.4 405 81 - Carbohydrate-free soy formula for carbohydrate intolerance -
water and CHO source required. " ODB
PROPHREE
(per 100g powder) Abbott
510 0 28 Safflower, coconut,
soy
65 Corn syrup solids

250 874 350 750 525 11.9 2000 300 - For reduced protein diet, specific amino acid disorders, or
increased energy, minerals, vitamins. 1 cup powder = 120 g
KETOCAL
(per 100g powder) Nutricia
720 15 Dry whole milk 72 Soy oils, soy
lecithin
3 Corn syrup solids 300 1080 500 800 650 11 1500 208 Used in treatment of intractable epilepsy with ketogenic diet
Contains aspartame. " ODB
TYREX 1
(per 100 g powder) Abbott
480 15 L-amino acids 21.7

Safflower, coconut,
soy
53 Corn syrup solids 190 675 325 575 400 9 1400 300 For infants with tyrosinemia. No PHE or TYRmust be from
diet.1 cup powder = 120 grams; 2.73 mosm/g powder.
PHENEX 1
480 15 L-amino acids 21.7 Safflower, coconut,
soy
53 Corn syrup solids 190 675 325 575 400 9 1400 300 For infants with phenylketonuria. No PHE must be obtained
from diet 1 cup powder = 120 grams; 2.72 mosm/g powder.
PROPIMEX 1
480 15 L-amino acids 21.7 Safflower, coconut,
soy
53 Corn syrup solids 190 675 410 575 400 9 1400 300 For propionic academia/methylmalonic academia. No VAL,
MET, low THR, ILE 1 cup powder =120 grams; 2.76 mosm/g
CYCLINEX 1
510 7.5 L-amino acids 24.6 Safflower, coconut,
soy
57 Corn syrup solids 215 760 390 650 455 10 1600 300 For urea cycle disorders. Additional protein obtained from
diet. 1 cup powder = 120 grams; 2.20 mosm/g powder.
GLUTAREX 1
480 15 L-amino acids 21.7 Safflower, coconut
sou
53 Corn syrup solids 190 675 325 575 400 9 1400 300 For infants/children with glutaric aciduria Type 1or 2-
Ketoadipic Aciduria. 1 cup powder = 120g 2.73 mosm/g pwdr.
CALCILO XD
513 11.4 Whey, sodium
caseinate
28.7 Coconut, corn oil 52.3 Corn syrup 125 420 292 <50 128 9.2 1540 0 202 Low calcium, low phosphorus NO vit D formula with iron for
hypercalcemia. Order via Specialty Food Shop. 1 cup = 105 g
MODULARS/SUPPLEMENTS
PEDIASURE COMPLETE
(Per 235 mL bottle) Abbott
235 9.3 Milk protein,
whey, soy
7.7 Soy,canola, MCT,
coconut/palm
33 Sucrose, FOS (1g),
maltodextrin
90 450 204 250 250 2.4 782 24 600 Supplement-not for tube feeds. Chocolate/vanilla (only choc in
hospital) DHA(10 mg) ARA(3.3) 15% MCT NO ODB
POLYCOSE POWDER
(per 100 gram) Abbott
380 - - 0 - 94 Glucose polymers 130 10 223 30 15 0.09 - - - Carbohydrate module, lactose free 1 Cup = 100g " ODB
MICROLIPID
(per mL) Nestle
4.5 - - 0.5 Safflower, soy lecithin - - - - - - - - - - - Fat module 1 TBSP = 67.5 kcal NOT ODB covered
MCT OIL
(per mL) Nestle
7.7 - - MCT - - - - - - - - - - - Fat module for fat malabsorption, cholestasis. 1 TBSP = 14 g
= 115 kcal " ODB
RESOURCE BENEPROTEIN
(per gram) Nestle
3.6 0.86 Whey (100%) 0 - 0 - 1.4 5 - 4.3 2.1 - - - 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
BREAKFAST ANYTIME
Nestle (per 315 mL box)
300 15 Skim milk, milk
protein
9 Corn oil, milk fat 41 Maltodextrin, sugar
lactose, inulin
250 370 - 420 370 7 1998 - - Oral supplement, 315 mL tetra pack, chocolate, vanilla,
strawberry. 4 g FOS/inulin per 315 mL serving NO ODB
BOOST FRUIT BEVERAGE
Nestle
77 3.7 Whey (100%) 0.2 soy 15 Sugar, corn syrup
solids
1.3 0.1 2.6 1.4 2.2 1.0 80 0.5 700 Low fat supplement. Lactose, gluten free. Orange, peach,
wildberry. " ODB
DUOCAL
(per 100 gram) Nutricia
492 0 - 22.3 Corn, coconut, palm
kernel
73 Mono/diglycerides
hydrolyzed cornstarch
<20 <5 <20 <5 <5 - - - 310 Soluble fat and CHO module. Lactose, gluten, sucrose fructose
free. 35% of fat as MCT. Oral/tube 1tbsp = 42kcal NO ODB
OTHER PRODUCTS
GLUTAMINE powder
Per 10g container
40 ?? L-glutamine 0 ?? - - - - - - - - - Dosage = 0.5 g/kg divided TID. Mix 10g in liquid (not
pop)/add to 60mL for tube feed. Not with renal/liver disease
RESOURCE THICKEN UP
Nestle (per 1 Tbsp or 4.5g)
15 4 Modified food
starch (corn)
10 Instant food thickener for dysphagia management.
ENFAMIL ENFALYTE
Mead Johnson
12.6 3.2 Corn syrup solids,
citrates
115 98 160 170 Oral electrolyte maintenance solution. Light cherry flavour,
PEDIALYTE (per 100 mL)
Abbott
10 - - - - 2.5 Dextrose 104 78 124 - - - - - 250 Oral electrolyte maintenance solution
PEDIALYTE POPSICLES
per 62.5 mL popsicle - Abbott
6.3

- - - - 1.6 Dextrose 64 51 78 - - - - - 250 Oral electrolyte maintenance. Popsicles contain flavour +
colouring. Melt and add to regular pedialyte for flavour.



PEDIATRIC
EMERGENCY
MEDICINE

Page 1of 1
Page 1of 1
Page 1of 1
PALS Medications for Cardiac Arrest and Symptomatic Arrhythmias

Medication Dose Supplied Administration
Adenosine IV/IO: 0.1 mg/kg
Max 6 mg
Repeat dose: 0.2 mg/kg
Max 12 mg
3 mg/mL: 0.03 mL/kg
Max 2 mL
Repeat dose: 0.07 mL/kg
Max 4 mL
Rapid bolus followed by
rapid flush
Amiodarone* IV/IO: 5 mg/kg
(Max 300 mg)
50 mg/mL: 0.1 mL/kg
Max 6 mL
Rapid bolus for VF/VT,
over 20-60 minutes for
perfusing tachycardias
Atropine IV/IO: 0.02 mg/kg
Min 0.1 mg
Max 0.5 mg for child
Max 1 mg for adolescent
0.1mg/mL: 0.2 mL/kg Bolus
ET: use 2-10 times IV dose Dilute with NS
to 3-5 mL
Calcium
Chloride
IV/IO: 20 mg/kg 10% solution: 0.2 mL/kg Give slow push,
central line preferred
Dextrose IV/IO: 0.5-1 g/kg

D
10
W: 5-10 mL/kg
D
50
W: 1-2 mL/kg
Avoid hyperglycemia
Epinephrine IV/IO: 0.01 mg/kg 1:10 000: 0.1 mL/kg Bolus
ET: 0.1 mg/kg 1:1 000: 0.1 mL/kg Dilute with NS to 3-5 mL


PALS Medications for Cardiac Arrest and Symptomatic Arrhythmias

Medication Dose Supplied Administration
Lidocaine IV/IO: 1 mg/kg 20 mg/mL: 0.05 mL/kg Bolus
ET: use 2-10 times
the IV dose
Dilute with NS to
3-5 mL
IV/IO Infusion:
20-50 microgram/kg/min
Add 100 mg to
total of 100 mL
Run at 1.2 - 3
mL/kg/h
Magnesium
Sulfate
IV/IO: 25-50 mg/kg
(max 2 g)
0.5 g/mL: 0.05-0.1
mL/kg
(max 4 mL)
Rapid infusion for
torsades or
severe
hypomagnesemia
Naloxone IV/IO/IM: 0.1 mg/kg
(max 2 mg)
0.4 mg/mL: 0.25 mL/kg
(max 5 mL)
Bolus
ET: use 2-10 times
the IV dose
Dilute with NS
to 3-5 mL
Procainamide*

IV/IO: 15 mg/kg
*do not routinely use in
Combination with other drugs
that prolong QT interval
100 mg/mL: 0.15
mL/kg
(max 10 mL)
Give over 30-60
minutes
Sodium
Bicarbonate
IV/IO: 1 mEq/kg 4.2%: 2 mL/kg
8.4%: 1 mL/kg
Give slowly and if
ventilation is
adequate. Use
4.2% in neonates
Cardioversion 0.5 J /kg, double dose if arrhythmia continues
Defibrillation 2 J /kg initially then 4 J /kg for each subsequent defibrillation attempt.
ETT size (age in years /4 ) +4
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 Childrens 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 pre-
hospital 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 Phenobarbital 20mg/kg IV over 20 minutes (maximum 1 g)
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 g/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 g/kg/min q5 minutes
Bolus 0.15 mg/kg with each increase in infusion rate
Maximum infusion rate: 24 g/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 g/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.
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

Date: July 2011
Next Review: July 2012
Prepared by the Status Epilepticus Therapeutic Guideline Committee (Chair: R RamachandranNair-
Neurology, Members: M Duffett- Clinical Pharmacy, K Fitzpatrick- General Pediatrics, J Gilleland- Critical
care, A Kam- Emergency Medicine)

Emergency Room Management Guidelines
for the Child with Type 1 Diabetes
Urine ketones/glucose
Capillary glucose STAT in ER
Venous blood glucose, gases, electrolytes, urea, creatinine
Other as indicated
Confirm DKA
Ketonuria Serum Bicarbonate <18 mmol/L
Glucose >11 mmol/L Consult Pediatrician immediately
pH <7.3
Resuscitation
Assess airway and breathing
Apply 100% oxygen by mask
Normal Saline 10 ml/kg to
expand vascular space
THEN
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
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)
Acidosis not
improving
(in 3 - 4 hours)
Check insulin
delivery system
Consider sepsis
Contact Tertiary
Pediatric
Diabetes Centre
Clinically Dehydrated
Hyperventilating
OR
Vomiting
Normal BP
(lying and sitting)
Normal Saline
7 ml/kg over 1st hour
with Potassium Chloride
as noted below
THEN 3.5 - 5 ml/kg/hr
Minimally dehydrated
Tolerating fluids orally
Normal bowel sounds
Normal mental status
Oral hydration
S/C insulin
(see illness rules)
Hypotension (PALS Values)
Age Systolic BP (mm/Hg)
<1 month < or = 60
1 month to 1 year < or = 70
1 to 10 years < or = 70 + (2 x age in years)
>10 years < or = 90
Vascular Decompensation
(with or without coma)
Hypotension (see box)
Decreased level of consciousness
No Vascular
Decompensation
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
History (some or all of )
Polyuria Tiredness
Polydipsia Vomiting
Weight loss Confusion
Abdominal pain Difficulty breathing
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
Diabetic Ketoacidosis (DKA)
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 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
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
Neurological deterioration
Headache, irritability,
decreased level of consciousness,
decreased HR
First rapidly exclude hypoglycemia
by capillary blood glucose
measurement
THEN
Treat for cerebral edema
Emergency Room Management Guidelines
for the Child with Type 1 Diabetes
History
Recent hypoglycemic event requiring treatment by another
person with Glucagon or oral glucose especially if
Increased confusion
Decreased consciousness
If emesis 2x in past 4 hours,
keep NPO for 4 - 6 hours
No emesis
Tolerating fluids
No emesis BUT
Not drinking
Obtain a blood glucose (capillary)
Electrolytes and Gases not usually necessary
Capillary glucose
Venous blood glucose, gases, electrolytes, urea
Urine ketones
Capillary glucose
Venous blood glucose, gases,
urea, electrolytes
Urine ketones
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
IV fluids
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
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
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]
Hypoglycemic
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
Input & Output Q4h
Blood glucose Q2-4h (keep within 4 -10 mmol/L)
Test urine for ketones
Clinical Signs
Seizures
Hemiparesis
Any localizing neurological findings
Altered state of consciousness
AND/
OR
Hypoglycemia (moderate or severe)
Intercurrent Illness
Discharge
Discharge ONLY when child is
Fully alert
Tolerating oral fluids and
Free of neurological signs.
Determine cause and arrange for follow-up
Decrease all insulin doses by 20% for next 24 hrs
Renew prescription for Glucagon if used
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