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MacPeds  Pediatric  Survival  


Guide  
For  Residents  and  Clinical  Clerks  2015-­‐2016  

Editor:  Dr.  Moyez  B.  Ladhani  

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Table  of  Contents  
Welcome  to  MacPeds!  ......................................................................................................................  4  
McMaster  PEDIATRICS  CONTACT  INFORMATION  ..................................................................  5  
Program  Assistants  ...........................................................................................................................  6  
Paging  ....................................................................................................................................................  7  
Division  of  General  Pediatrics  CTU  1,  CTU  2,  Expectations  .................................................  8  
Division  of  General  Pediatrics,  CTU  1,  CTU  2  Weekly  Schedule  ......................................  11  
MacPeds  Handover  Guide  I-­‐PASS  ..............................................................................................  12  
Allied  Health-­‐  Contact  Numbers/Pagers  ................................................................................  14  
Resources  ..........................................................................................................................................  16  
Dictations–  Hamilton  Health  Sciences  Corporation  ...........................................................  20  
Pediatric  Staff-­‐  Pagers  and  Office  Numbers  ..........................................................................  21  
St.  Joseph’s  Hospital  Pediatrics,  Hospital  Contact  Numbers  ............................................  27  
Division  of  General  Pediatrics  CTU  4  Expectations  ............................................................  28  
CTU  4  Weekly  Schedule:  St.  Joseph’s  Healthcare  .................................................................  30  
Administrative  Information-­‐St  Joes  .........................................................................................  31  
St  Joes  Dictation  System  ...............................................................................................................  32  
Listening  to  Dictated  Reports  at  St  Joseph’s  Healthcare  .............................................................  34  
Pediatric  History  and  Physical  Exam  .......................................................................................  35  
History  ...............................................................................................................................................................  35  
Physical  Exam  ................................................................................................................................................  38  
A  Screening  Examination  of  the  MSK  System  ........................................................................  43  
WHO  Growth  Charts  for  Canada  ................................................................................................  50  
Weight  Conversion  Chart  .............................................................................................................  58  
Adolescent  Interviewing  (HEADDSS)  ......................................................................................  59  
Admission  Orders  (ADDAVID)  ...................................................................................................  62  
Progress  Note:  Pediatrics  ............................................................................................................  64  
Documentation  ................................................................................................................................  65  
Mandatory  Reporting  of  Suspected  Child  Abuse  and  Neglect  .........................................  67  
Discharge  Summary  Template:  Pediatrics  ............................................................................  68  
Fluid  Management  In  Children  ..................................................................................................  70  
1.  Maintenance  ...............................................................................................................................................  70  
2.  Deficit  Replacement  –  Oral  Rehydration  Therapy  (ORT):  .....................................................  73  
2.  Deficit  Replacement  –  Parenteral  Therapy  (IV):  ........................................................................  75  
3.  Ongoing  Losses  .........................................................................................................................................  76  
Isotonic  Dehydration  ..................................................................................................................................  76  
Hypotonic  Dehydration  .............................................................................................................................  76  
Hypertonic  Dehydration  ............................................................................................................................  76  
Comparison  of  IV  Solutions  .........................................................................................................  77  
Guidelines  for  Prescribing  Maintenance  IV  Fluids  in  Children  ......................................  78  
Developmental  Milestones  ..........................................................................................................  79  
Developmental  Milestones:  0-­‐12  Months  ..........................................................................................  79  
Developmental  Milestones:  1  -­‐  5  Years:  ..............................................................................................  81  
Immunizations  ................................................................................................................................  84  
Feeding  Tube  Management  .........................................................................................................  86  
NEONATOLOGY  ................................................................................................................................  88  
St  Joe’s  NICU  Common  Terms  and  Definitions  List  .............................................................  89  
4C  Admission  Criteria  ...................................................................................................................  92  
Progress  Note:  Level  2  Nursery  .................................................................................................  93  
NICU  /  L2N  Discharge  Summary  Template  ............................................................................  95  
NRP  Overview  ................................................................................................................................  100  
NRP  Medications  ...........................................................................................................................  101  
NICU  Nutrition  Guidelines  .........................................................................................................  102  
Enteral  Feeding  NICU  ..............................................................................................................................  102  
Feeding  Human  Milk  in  NICU  ...............................................................................................................  105  
Formula  Selection  ......................................................................................................................................  106  
Total  Parental  Nutrition  (TPN)  in  NICU  Summary  Guidelines  ..............................................  107  
Feeding  Guideline  Cheat  Sheet  for  VLBW  Infants  ..............................................................  115  
Infant  Formulas  –  Indications  for  Specific  Formulas  .......................................................  117  
McMaster-­‐Guidelines  for  Intrapartum  Antibiotics  for  the  Prevention  of  Early  Onset  
GBS  ....................................................................................................................................................  119  
McMaster-­‐Guidelines  for  the  Newborn  36  0/7  Wks  Gestation  and  Greater  at  Risk  of  
Early  Onset  GBS  .............................................................................................................................  120  
St  Joes-­‐Guidelines  for  the  Newborn  36  0/7  Wks  Gestation  and  Greater  at  Risk  of  
Early  Onset  GBS  .............................................................................................................................  122  
Care  of  the  Newborn  35  Weeks  Gestation  or  Greater,  Symptomatic  or  at  Risk  of  
Hypoglycemia  ................................................................................................................................  123  
St  Joes  Screening  for  Hypoglycemia  Guidelines  .................................................................  130  
Hyperbilirubinemia  Assessment  Sheets  for  Initiation  of  Phototherapy  ...................  131  
Common  Antibiotics  Used  in  the  NICU  ..................................................................................  140  
Morphine  Treatment  for  Neonatal  Abstinence  Syndrome  .............................................  144  
Guidelines  for  the  Management  of  Hypernatremia  in  a  Breast  Fed  Baby  .................  145  
Guidelines  for  the  Assessment  of  Adequate  Hydration  in  Breast-­‐Fed  Infants  ........  147  
Pediatric  Formulary  ....................................................................................................................  148  
Antibiotics  Guide  for  Common  Pediatric  Infections  (>3  months)  ...............................  187  
Clinical  Pearls  ................................................................................................................................  189  
Antibiogram  ...................................................................................................................................  190  
Pediatric  Blood  Volumes  by  Weight  ......................................................................................  192  
Proton  Pump  Inhibitors  (PPI)  in  Pediatrics  –  ...........................................................................  193  
Pediatric  Emergency  Medicine  ................................................................................................  195  
PALS  Algorithms  ...........................................................................................................................  196  
PALS  Medications  .........................................................................................................................  199  
Guidelines  for  the  Pharmacological  Management  of  Convulsive  Status  Epilepticus
 ............................................................................................................................................................  201  
Management  of  DKA  ....................................................................................................................  205  
Pediatric  Vital  Signs  and  GCS  ....................................................................................................  206  
 

   
Welcome to MacPeds!

This handbook was designed for the large number of residents from a
variety of disciplines that rotate through pediatrics during their first
year of training. It may also be helpful for clinical clerks during their
time on the pediatric wards, as well as for pediatric residents and
elective students.

Hopefully this demystifies some of the ‘pediatric specific’ logistics,


and gives a few practical suggestions for drug dosages and fluid
requirements. This is intended only to act as a guideline for general
pediatrics use, and some drugs, doses, indications and monitoring
requirements may differ in individual situations. I would like to thank
Nicole Clarke and Melani Sung for compiling and editing the pediatric
formulary section and Lori Chessell and Connie Stuart for compiling
the Neonatal Nutrition Section.

The Drug Formulary in this book is intended for pediatric patients only.
For neonatal drugs to be used in the neonatal nurseries please refer
to the neonatal drug book in the neonatal nurseries.

I would very much appreciate any feedback, suggestions or


contributions emailed to 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. This work is licensed under the
Creative Commons Attribution 4.0 International License. To view a copy of this
license, visit http://creativecommons.org/licenses/by/4.0/.

4
McMaster PEDIATRICS CONTACT INFORMATION

Wards Clinical
3B 72980 3F clinic 73984
3C North 76345, 76344 2G clinic 78517
3CSouth 73388, 73387 2Q clinic 75094
3Y 72980, 72981, 76120 3V clinic 73879
L2N 73753 OR Reception 75645
NICU 76147 PACU 75653
L&D 75050 Short Stay/Pre-Op 75564
4C Nursery 76354 Radiology 75263
PCCU 72610, 75692, 75806 Film Library 75279
(resident work room) MRI 75059
Eating Disorder Unit 73289 CT scan 73728-tech
PACE Team 75030 75263-reception
ER Front Desk 75020 76672-reporting
Ultrasound 75316, 75319
Administration Nuclear Medicine 41484
Paging 76443 Interventional Radiology 75291
Admitting 75100 EEG 4U 75027
Bed Booking 75106 ECHO 2G 73974 (outpatient booking)
Health Records 75111 ECHO technologist Becky Fiddler
Computer Support 43000 75982 pager 1408
Appointments 75051 GI Tech 75321, 73814
Info Desk 75266 Holter/EKG 76234
Security 76444 EKG tech pager 1063
Room bookings 22382
Labs
Stat/Core Lab 76303
Chemistry 75022
Blood Bank 76281
Coagulation 76288
Microbiology 46175
Pathology 76419
Virology 33709
Sweat Chloride Testing 76663

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Program Assistants
 

Postgraduates:

Laura Klyne 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 28949 frid@mcmaster.ca

Wendy Milburn 905-575-1744 x 203 milburn@mcmaster.ca

CTU
Skye Levely 75639 levelys@mcmaster.ca

Chief Residents –

Pediatrics macpedschiefs@gmail.com

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Paging

To page someone from within the hospital:


1. dial 87
2. enter person’s pager number (4 digits)
3. enter call-back extension (5 digits)
4. enter priority code (∗ * then 1 for CODE/STAT, 2 for ROUTINE,
3 for ANYTIME, 4 denotes PHYSICIAN paging)

If you don’t know their pager #, wish to leave a typed message or to


wait on an outside line: call x76443 or do it from citrix

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

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Division of General Pediatrics CTU 1, CTU 2, Expectations
 

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

8
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 4th Wednesday of the month will be Peds
Cardiology teaching – “Heart to Heart” which is from 08:00-
09:00
• Wednesday is Academic Half Day for pediatric residents.
• Thursdays from 08:00 to 09:00 – Pediatric Grand Rounds
• 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.

9
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.
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.  
 

10
Division of General Pediatrics, CTU 1, CTU 2 Weekly Schedule
Monday Tuesday Wednesday Thursday Friday
7:15-7:45 Handover Handover Handover Handover Handover
Teaching * Case
except Based
Division of Week 4: Grand
third Learning
General Heart to Rounds
Tuesday
8:00-9:00 Pediatrics Heart
LCC for MDCL 4th week M
Rounds (08:00-
Peds 3020 and M
4E20 09:00)
residents
only

See See See See


9:00-10:30 See Patients
Patients Patients Patients Patients

10:30- Ward Ward Ward Ward Ward


12:00 Rounds Rounds Rounds Rounds Rounds
12:00-
Lunch Lunch Lunch Lunch Lunch
13:00
*MDR 1& 2 *MDR 3
13:00- Patient Patient Patient
15:00 Care Patient Care/AHD Patient Care
Care Care
Specialty
15:00- Teaching Teaching
AHD
16:00 Sessions

16:00-­‐
Evaluations   Evaluations   AHD   Evaluations   Evaluations  
16:30  
16:30-­‐
Handover   Handover   Handover   Handover   Handover  
17:30  
*MDR = Multidisciplinary Rounds. The detailed monthly schedule for
this can be found at www.macpeds.com

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The  Early  Team  will  


receive  handover  
 at  this  Dme  
q  Team  1:  Even  Days   EARLY Please  bring  your  own    
q  Team  2:  Odd  Days   printed  list  to  handover  

  The  overnight  JRs  (junior  residents)  &  clinical  clerks      


Weekend  &   will  present  new  paDents  
Holiday   Spend  2  to  3  min  for  each  paDent  and  discuss:  
AM  Handover   q  Name,  age,  main  presenDng  complaint(s)  
q  Brief  history  with  the  most  important  perDnent  posiDves/negaDves  
starts  at  8:30am   q  Relevant  past  medical  history    
  q  Brief  summary  of  objecDve  findings  (physical  exam,  invesDgaDons)  
q  AdmiNng  diagnosis  and  plan  

Subspecialty Try to remember to


focus on information
AM Handover that will change or
occurs in the inform patient
management!
PICU at either JRs  present  team  issues:  
7:30am or q Briefly  state  overnight  issue(s)  and  management  
9:00am on q Inform  the  team  of  any  issues  that  need  follow-­‐up  or  task(s)  that  were  
weekdays and handed  over  the  night  before  
at 9:30am on q If  there  are  no  overnight  issues  or  follow-­‐up,  simply  state  “No  issues”  or  
weekends & skip  the  paDent  and  move  on  
holidays

EARLY LATE

Clinical  Clerk/JR/SR  will  present  a  case  seen   The  Late  Team  will  receive  handover  at  this  Dme:  
overnight  or  a  topic  of  interest.  Points  to  include:   “Team  on  Take  =  Handover  Late”  
q  Salient  clinical  features   q  Team  1:  Late  Handover  on  Odd  Days  
q  Diagnosis  and  differenDal  diagnosis  for  the  paDent   q  Team  2:  Late  Handover  on  Even  days  
q  Acute  treatment  opDons  and  brief  long-­‐term  
management  goals  (evidence-­‐based,  if  possible)  

Heme-­‐Onc  &  Team  3    will  handover  at  this  Dme  


 to  incoming  residents,  fellows  or  staff  
JPR

12
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*CTU  Seniors  are   The  incoming  team  will  


expected  to  contact  the   print  their  own  lists  –  
Weekend  Day  SPR  to   please  have  them  
handover  the  weekend   updated  by  4:30pm  
plans  for  paSents  on  
their  respecSve  teams  

q  Team  3  will  give  handover  to  the  covering  JPR  (junior  pediatric  
resident)  along  with  the  SPR  (senior  pediatric  resident)  
q  Note:    If  this  handover  is  expected  to  take  longer  than    10  minutes,  
JPR the  JPR  will  accept  the  rest  of  handover  outside  of  the  room  and  
Team  1  or  2  will  start  handover  
 

EARLY

The  outgoing  team  will  present  


team  handover  
Please  follow  the  IPASS  format  

 
Subspecialty  
 PM  Handover    
occurs  at  5:30pm   (Starmer et. al, 2012)
in  the  PICU  on  
weekdays,  weekends  
and  holidays  
 
LATE

The  Late  Team  will  give  handover  at  this  Dme:   Note: If the early team arrives late for
handover, or has exceeded the allotted
“Team  on  Take  =  Handover  Late”   handover time, their handover will be
q  Team  1:  Late  Handover  on  Odd  Days   interrupted by the Late Team Handover at
5:00pm. The Early Team can then resume
q  Team  2:  Late  Handover  on  Even  days   handover once the Late Team has finished

Heme-­‐Onc  will  handover  to  the  JPR  &  SPR  at  this  Dme.  
Please  ensure  that  paDent  lists  are  updated.  

13
Allied Health- Contact Numbers/Pagers
 

PAGE
SPECIALTY NAME Phone
R
Ward General
RT 1607
Pager
OT Deb Gjertsen 1177 73565
Kate Dobson-
OT 1240 73394
Brown
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 4312 76599
CCAC Ann Rush 1092 72840
After
Child Life 1225
hours/Weekends
Child Life Margaret Karek 1225 76129
Child Life Laura Vos 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

14
Pharmacist Nicole Clarke 1423 76356
Pharmacy
Carrie Morrell 1099 76356
Technician
IV Nurse 1007
Lactation Nurse 5062
Pediatric
Thrombosis Rebecca Goldsmith 4445 75970
Nurse
Pediatric
Thrombosis Kay Decker 4444 75978
Nurse
Social Work Carol Ann O’Toole 1193 73714
Social Work Bill Ratz 1039 76339

Acute Nurse
Care Rose-Frances
Practitioner 1934 73035
Clause

Clinical Nurse
Specialist Joanne Dix 1409 76548
Team 1 Pager 5301
Team 2 Pager 5302
Team 3 Pager 5303
Senior Pediatric
1645
Resident
Pediatric ICU
Resident/
1000
Subspecialty
Night Coverage

15
Resources

Handbooks/Pocketbooks:

• Hospital for Sick Children Handbook (11th ed, 2010).


• Harriet Lane Handbook (1999): John Hopkins Hospital,
Dept of Pediatrics.
• Pediatrics on Call
• Pediatric Drug Dosage Handbook (on most wards)
• Sickkids Drug Handbook and Formulary

Texts:

• Nelson Textbook of Pediatrics (19th ed): Behrman R.E.


and R.M. Kliegman.
• Rudolph’s Fundamentals of Pediatrics (3rd ed, 2002):
Rudolph, A.M. et al.
• Pediatric Clinical Clerkship Guide

Clinical Skills:

• Pediatric Clinical Skills (3rd ed): Richard A. Goldbloom.

Journals (all accessible via e-Resources at McMaster


Libraries)

• Pediatrics In Review. Monthly publication by AAP


(American Academy of Pediatrics), consisting of review
articles and case presentations
• NeoReviews. Monthly publication by AAP, featuring
excellent review articles of common neonatal conditions
• Journal of Pediatric & Child Health. Monthly publication
of CPS (Canadian Pediatric Society).

16
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.

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!

17
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/
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

• Pediatrics on call – useful for common pediatric conditions

• Pediatstat – quick access pediatric resuscitation information

• Pediatric EKG – common pediatric ECG findings

18
• 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

19
Dictations– Hamilton Health Sciences Corporation

x5000 to enter, (905) 575-2550 Press 2 to dictate, *5 to


externally disconnect

Enter Author ID (#) 1. Hold


2. Pause/Continue
Enter site (#) 3. Skipback/Play
11. General 4. Fast Forward (44 to move to
12. Henderson end)
13. MUMC 5. Disconnect
14. Chedoke 6. Prioritize
7. Rewind (77 rewind to
Enter Report Type (#) beginning)
21. Consultation 8. End Report
22. Discharge
3. Operative Report For each report:
4. Pre-op History & Physical - your name, patient name
25. Clinic Note (spelling if difficult)- chart
number, work type, copies to
Enter Chart Number (#) – the ID (FD, pediatrician, consultants,
# after the ‘M’ MRP, etc)

20
Pediatric Staff- Pagers and Office Numbers

General Pager Number Office


Pediatrics 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

21
Wahi, G 2315 x73584 General Pediatrics
Sub-Specialist Pager Office Specialty
Number
NICU
El Gouhary, E 2009 x76342 Neonatology
El Helou, S 2560 x73490 Neonatology
Fusch, C 2045 x75721 Neonatology
Gani, AW 2003 x73502 Neonatology
Marrin, M 2705 x76342 Neonatology

Mukerji 2350 x76959 Neonatology

Pugh, E 6437 x76342 Neonatology

Twiss, J 2113 x76342 Neonatology

Samiee- 2565 x76342 Neonatology


Zafarghandy, S
Shah, J 1502 x76342 Neonatology

Shivananda, S 2403 x73490 Neonatology

Williams, C 2128 x 76959 Neonatology

Sub-Specialist Pager Office Specialty


Surgery Number
Ayeni, F 2104 x73532 or Ortho Surgery
x75094 (2Q)
Ajani, O 2206 x75237 Neurosurgery
Bailey, K 2766 x73550 or General Surgery
x75094 (2Q)
Bain, J 76443 - paging x73222 or Plastic Surgery

22
x78517 (2G)
Braga, L 76443 - paging x73777 or Urology
x78519 (2G)
Burrow, S 76443 - paging x73177 or Ortho Surgery
x75094 (2Q)
Cameron, B 76443 - paging x75231 or General Surgery
x75094 (2Q)
Choi, M 2060 x73550 or Plastic Surgery
x78517 (2G)
DeMaria, J 76443- paging x73777 or Urology
x78519 (2G)
Fitzgerald, P 76443 - paging x75231 or General Surgery
x75094 (2Q)
Flageole, H 76443 - paging x75244 or General Surgery
x75094 (2Q)
Korman, B 2600 x75246 or ENT
x73879 (3V1)
MacLean, J 2504 x75246 or ENT
x73879 (3V1)
Mah, J. 8030 905 575 Ortho Surgery
3600
Missiuna, P. 7907 905 527 Ortho Surgery
9149
Ogilvie, R N/A 905 304 Ortho Surgery
5816
Peterson, D 76443 - paging x73177 or Ortho Surgery
x75094 (2Q)
Sabri, K 76443 - paging x73509 or Ophthalmology
x72400
Singh, S 2577 x75237 or Neurosurgery
x78515 (2G)

23
Strumas, N 76443 - paging x73594 or Plastic Surgery
x78517 (2G)
Walton, M 76443- paging x75244 or General Surgery
x75094 (2Q)
Sub-Specialist Pager Office Specialty
Number
Almeida,C 76443 - paging x75259 Cardiology
Arora, S 76443 - paging x75635 Nephrology
Athale, U 2118 x73464 Hem-Onc
Baird, B 7028 x75607 ER
Barr, R 2712 x76465 Hem-Onc
Bassilious, E 76443 - paging x73716 Endocrinology
Batthish, M 76443 - paging x75382 Rheumatology
Belostotsky, V 76443 - paging x75635 Nephrology
Breaky, V 2125 x73428 Hem-Onc
Brill, H N/A x73455 GI
Callen, D 76443 - paging x75686 Neurology
Carter, T 2644 x73508 Development
Cellucci, T 76443 - paging x76712 Rheumatology
Chan, A 289-259-1808 x73464 Hem-Onc
Choong, K 2865 x76651 PICU
Crocco, A N/A x75155 ER
Cupido, C 2327 x76610 PICU
Dent, P N/A x75382 Rheumatology/
Immunology
Dillenburg, R 76443 - paging x75242 Cardiology
Findlay, S 76443 - paging x75658 Adolescent/Eating

24
Disorder Unit
Fleming, A 2675 X73428 Hem-Onc
Gilleland, J 2065 x75823 PICU
Gorter, J.W 2531 x26852 Development
Grant, C 2036 x75658 or Adolescent/Eating
x73862 Disorder Unit
Harman, K 2887 x73504 or Development/Cleft
x77210 Lip & Palate
Hernandez, A 2645 x75155 ER
Issenman, R 2768 x75637 GI
Johnson, N 76443 - paging x75658 Adolescent/Eating
Disorder Unit
Jones, K 76443 - paging x75613 Neurology
Kam, A N/A x75621 ER
Kozenko, M 2106 x73246 or Genetics
x76890
Kraus de 76443 - paging x74275 Development
Camargo, O
Li, C 2729 x76815 Genetics
Lloyd, R 2684 x76610 PICU
Mahoney, B 2713 x74275 Development
McAssey, K 76443 - paging x73716 Endocrinology
Meaney, B 76443 - paging x75686 Neurology
Mesterman, R 2029 x75393 or Neurology
x74275
Mondal, T 2039 x75259 Cardiology
Morrison, K 76443 - paging x75702 Endocrinology

25
Ngo, Q N/A X76038 ER
Niec, A 76443 - paging x73687 Psych, CAAP
Nowaczyk, M 7207 x73042 Genetics
Pai, N 2585 x75637 GI
Parker, M 2073 x76651 PICU
Pedder, L 3341 x73508 Respirology
Pernica, J 2092 x76947 Infectious Dis.
Portwine, C 2119 x76465 Hem-Onc
Predescu, D 76443 - paging x75242 Cardiology
Ramachandran 2360 x75613 Neurology
Nair, R
Ratcliffe, E 2059 x73455 GI
Ronen, G 2212 x75393 Neurology
Rosenbaum, P 2742 x26852 Development
Samaan, C 76443 - paging x73716 Endocrinology
Sherlock, M 2191 x73455 GI
Solano, T N/A x75155 ER
Somani, A 2417 x75823 PICU
Sulowski, C N/A x75607 ER
Tarnopolsky, M 2888 x75226 Neuromuscular
Timmons, B N/A x77615 Exercise
VanderMeulen, J 76443 - paging x73716 Endocrinology
Wong, J 2132 x73508 Respirology
Wyatt, E N/A x75607 ER
Zachos, M 7316 x75637 GI

26
St. Joseph’s Hospital Pediatrics, Hospital Contact Numbers
 

Auto attendant (905) 522-1155


Switchboard (905) 522-4941
Labour and Delivery 33251, 34157
NICU 36050
3 OBS (Well Babies Nursery) 33314
Paging 33311
Dr Sandi Seigel 36039
Deputy Chief St Joes Clinical seigels@mcmaster.ca

Dr. Bojana Babic 36039


Education Rep CTU babicb@mcmaster.ca

Rosie Evered 36039


Program Secretary revered@stjoes.ca

Paging (33311) and Pagers:


• All paging done via switchboard attendant at extension
33311
• Resident on-call usually carries pager # 412
• Clerk on-call usually carries pager # 410
• Page staff pediatrician on-call through paging (33311)
• McMaster assigns most pagers, check with program area
• If pager needed, sign out daily pagers at Switchboard

Library Services:
• 2nd Floor of Juravinski Tower
• Hours: MON, WED, FRI 8:00 AM – 6:00 PM
TUES, THURS 8:00 AM – 8:00 PM
• X33440 or library@stjosham.on.ca    

27
Division of General Pediatrics CTU 4 Expectations
 

Handover:
Handover is to take place at 8:00 hrs together with Staff/NP and
residents. On the mornings when there are rounds (Monday and
Thursday) handover should start at 7:45. Weekend handover is at
8:00 hrs.
Discharge Rounds:
Discharge planning should always be occurring and the team should
discuss patients that could potentially go home the night before.
Discharges for these patients should occur promptly after the
handover if patients are ready. This is particularly important for the
well babies on 3Obs and any anticipated discharges from the nursery.
See Patients:
During this time the team will see their assigned patients. The chart
and nursing notes should be reviewed to identify any issues that
have arisen over night. The patient should be seen and examined.
All lab work and radiological procedures that are pending should be
reviewed. The house staff should then come up with a plan for the
day and be ready to present that patient during ward rounds. It is not
necessary that full notes be written at this time, as there will be time
allotted for that later in the day.
Ward Rounds:
During ward rounds the team will round on patients. These are work
rounds. Some spontaneous teaching during rounds and at the
bedside can occur during this time, however there is allotted time for
that later in the day.
Patient Care:
During this time residents will follow through with decisions made
during ward rounds. They will finish charting on patients. This is also
the time for them to get dictations done and to complete face sheets.

28
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 and more teaching will happen with your Staff
attending as well.
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 1700 hrs:
Handover will occur to the on-call team with residents, NP and staff
together.
Orientation:
At the beginning of each month the attending should meet with their
team members to review the objectives, expectation and schedule of
the rotation. The senior resident may have valuable input during this
time.

   

29
CTU 4 Weekly Schedule: St. Joseph’s Healthcare
Handover  at  8  am:  combined  staff,  NP  and  resident/fellow:  occurs  at  7:45  am  on  
rounds  days  

Monday Tuesday Wednesday Thursday Friday

8-9 DGP rounds McMaster Peds McMaster NICU


am Grand Rounds rounds
9-10 See See See pts/discharges See See pts/
am pts/dischargespts/discharges Staff touches base pts/discharges discharges Staff
Staff touches with Staff touches touches base
Staff touches base with BANA/3OBS/L&D base with with
base with BANA/3OBS re consults BANA/3OBS BANA/3OBS
BANA/3OBS/L&D /L&D re consults /L&D re consults /L&D re consults
re consults

NP/SPR to meet
NP/SPR to meet after handover to NP/SPR to meet NP/SPR to meet
NP/SPR to meet after handover divide up at 9 to divide up after handover
at 9 to divide up to divide up supervisory supervisory to divide up
supervisory supervisory responsibility responsibility supervisory
responsibility responsibility responsibility
10- NICU rounds NICU rounds No NICU rounds No NICU rounds No NICU rounds
12 non-urgent non-urgent non-urgent No non-urgent
No non-urgent interruptions interruptions interruptions interruptions
interruptions
MDR rounds
12-1 Lunch Lunch Lunch Lunch Lunch
pm
1-2 finish notes/see finish notes/see Academic ½ day finish notes/see finish notes/see
pm consults consults consults consults
2- 4 Teaching Clinic: 1 learner Academic ½ day; Clinic: 1 learner Teaching
pm (CBL/journal attends with may have family attends with staff (CBL/journal
articles)/ quality staff meetings articles)/ quality
assurance/ family assurance
family meetings
Meetings)
4-5 Finish work, Finish work, Academic ½ day Finish work, Finish work,
pm update list update list update list update list

DGP rounds – Division of General Pediatrics’ Rounds – Videoconferenced LIVE to


SJH Rm T2308 (library) except 1st Monday Grand rounds – Department of
Pediatrics Grand Rounds – Videoconferenced LIVE to SJH Rm T2308 (library) MDR
– Multidisciplinary Rounds  

30
Administrative Information-St Joes

On-Call Rooms:
• Key: sign out from Front Desk/ Switchboard, must be returned by
11:00 AM the next day
• Location: 2nd floor Martha Wing, Resident call room # 213
à follow Gold Signs to Father O'Sullivan Research Centre
• Additional Key: unlock Washrooms + Showers or Code 2 4 3
• Residents’ Lounge (Microwave & TV): Code 2 4 3
à across from vending machines on 2nd floor before call rooms
• Problems: communicate to Switchboard or Phil Valvasori x33812

Cafeteria Hours:
Charlton Cafeteria MON – FRI: 7:30 AM – 6:30 PM
2nd Floor, Mary Grace Wing SAT – SUN: Closed
Garden Café @ 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
5th Floor of Mary Grace Wing G507
x33040 for Passwords
• Must accept password and confidentiality agreements by signature
• For additional information on Clinical Browser or training call:
x33040

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:
x34077

   

31
St Joes Dictation System

32
33
Listening to Dictated Reports at St Joseph’s
Healthcare
 

• Use telephone to listen to Diagnostic Imaging Reports


that have been dictated but not yet transcribed
• Requires Check-In # of your Patient’s Exam. Found in
Check-In # field (usually beside Patient’s Name) on
any PACS Workstation
• If you are unable to find Check-In # field on the Workstation, then
call Diagnostic Imaging staff for assistance: x33606 or x36009

Instructions

1. DIAL 32078 to access the central dictation system.

2. PRESS the # sign.


It is Important that you PRESS THE # SIGN to LISTEN, because
32078 is also used to DICTATE reports.

3. PRESS 1. Enter Physician Author Dictation ID Number (0995)

4. PRESS 1.

5. Enter Patient’s 7-digit Check-In #

6. LISTEN to the report

• Press 5 to listen to a previous exam report on your patient, if the


report you are hearing is not the one you requested
• If you have entered the wrong check-in number or if would like to
hear another report, follow the verbal prompts, Press 1 then repeat
Steps 5 & 6

34
Pediatric History and Physical Exam

History
 

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

Chief Complaint: in patient’s or parent’s words


History of Presenting Illness (HPI):
• Open-ended question, and allow parents or child to express their
concerns
• Similar HPI details to an adult history
• Establish time line: “when was your child last well?”, “what
happened next?” etc
• Select key symptoms and expand:
• colour, character, quantity of vomit etc,
• OPQRST of pain, aggravating/relieving factors etc
• Always ask about recent exposures to ill contacts – family, school

Past Medical History (PMHx):


• Significant ongoing medical problems
• Prenatal history:
• Mother’s age, gravida, live births, abortions etc
• Planned vs unplanned pregnancy, onset of prenatal care
• Complications, smoking, drinking, meds, drug use in
pregnancy
• Gestational age at birth
• Birth history:
• Spontaneous vs induced labour, duration, complications
• Presentation: breech, vertex, transverse
• Interventions required: forceps, vacuum, c-section
• Resuscitation required, Apgars, birth weight in Kilograms
• NICU, Level 2 nursery admission, duration

35
• 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).
Feeding History (if relevant):
• Breast feeding: exclusively?, duration, frequency
• Formula: brand, how is it prepared/diluted, # of feedings/day,
quantity
• Solids: when started, tolerated, any reactions
• Vitamins (especially iron and Vit D): which ones, how often, dose
• Present diet: cereals, fruit, vegs, eggs, meat, amt of cow’s milk
• Any difficulties with feeding? Any concerns from primary
physician about poor weight gain?
• Does the child require enteral feeds? If so, are they via G-tube, G-
J tube? What is there enteral feed schedule? (formula, rate,
continuous vs. bolus)

Developmental Milestones (if relevant):


• Have you ever had any concerns about your child’s development?
• How does child compare with siblings?
• Ask about current milestones in each category as appropriate for
their age:
• Gross motor
• Fine motor, vision
• Speech, hearing
• Social skills
• Use major milestones (walking, first word, toilet training, etc) to
assess previous development (Reference on page 38)
• Use Denver II charts etc to assess current stage of development

36
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.

Family History:
• Are parents both alive and well? How many siblings? Are they
healthy?
• Are there any childhood diseases in the family?
• Consanguinity – are mother and father related in any way?
• Relevant family history (3 generations) – autoimmune hx in Type I
DM, atopic hx in asthma etc
• Draw pedigree if possible for genetic assessment

Review of Systems:
General: feeding, sleeping, growing, energy level
Signs of illness in kids: activity, appetite, attitude (3 A’s)
HEENT: infections (how often, fever, duration): otitis, nasal discharge,
colds, sore throats, coughs, nosebleeds, swollen glands, coughing or
choking with feeding

37
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 Exam
 

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,
genitalia

38
Vital Signs:
- Include Temperature, Heart Rate, Respiratory Rate, Blood
Pressure and O2 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/m2) on updated WHO growth curves for appropriate
BMI for age

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”

39
HEENT:
- Head: dysmorphic features, shape of skull, head circumference,
fontanelles in infants
- Eyes: strabismus, pupillary response, fundoscopy, red reflex in
infants, conjunctivitis
- Ears & pharynx exam in any child with a fever. If signs of upper
airway obstruction, drooling or worsening stridor defer pharynx
exam to a Staff or Senior Resident
- 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, O2 saturation (current FiO2), level of distress
- Able to speak in full sentences (if age appropriate)
- Depth and rhythm of respiration
- Chest wall deformities: kyphosis, scoliosis, pectus
excavatum/carinatum
- Finger clubbing

40
Abdomen:
- For peritoneal signs: ask child to jump up and down or wiggle hips,
to distend and retract abdomen “blow up your belly and then suck
it in”
- Inspection: scaphoid/distended, umbilical hernias, diastasis recti
- Auscultation: presence of bowel sounds
- Percussion: ascites, liver span, Traube’s space for splenomegaly
- Palpation: hepatosplenomegaly?, tenderness, guarding (voluntary,
involuntary), masses (particularly stool presence in LLQ)
- Stigmata of liver disease: jaundice, pruritis, bruising/bleeding,
palmar erythema, caput medusa, telangiectasia, ascites,
hepatosplenomegaly

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
 

41
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
 

A good resource for Physical Exam Videos


 

http://learnpediatrics.com/videos/  

   

42
REPORTS ON THE RHEUMATIC DISEASES SERIES 5

Hands On
Practical advice on management of rheumatic disease

pGALS – A SCREENING EXAMINATION OF THE MUSCULO-


SKELETAL SYSTEM IN SCHOOL-AGED CHILDREN
Helen E Foster, MD, MBBS(Hons), FRCP, FRCPCH, CertMedEd, Professor in Paediatric Rheumatology
Sharmila Jandial, MBChB, MRCPCH, CertMedEd, arc Educational Research Fellow
Musculoskeletal Research Group, Newcastle University, Newcastle upon Tyne June 2008 No 15

Why do primary care doctors need and physical examination. The history is often given by
the parent or carer, may be based on observations and
to know about musculoskeletal interpretation of events made by others (such as teachers),
assessment in children? and may be rather vague with non-specific complaints such
as ‘My child is limping’ or ‘My child is not walking quite
Children with musculoskeletal (MSK) problems are common
right’. Young children may have difficulty in localising or
and often present initially to primary care where GPs
describing pain in terms that adults may understand. It is not
have an important role as ‘gatekeepers’ to secondary care
unusual for young children to deny having pain when asked
and specialist services. The majority of causes of MSK
presentations in childhood are benign, self-limiting and directly, and instead present with changes in behaviour (e.g.
often trauma-related; referral is not always necessary, and irritability or poor sleeping), decreasing ability or interest in
in many instances reassurance alone may suffice. However, activities and hand skills (e.g. handwriting), or regression of
MSK symptoms can be presenting features of potentially life- motor milestones. Some children are shy or frightened and
threatening conditions such as malignancy, sepsis, vasculitis reluctant to engage in the consultation.
and non-accidental injury, and furthermore are commonly
associated features of many chronic paediatric conditions Practical Tip – when inflammatory joint disease is
such as inflammatory bowel disease, cystic fibrosis, arthritis suspected
and psoriasis. Clinical assessment skills (history-taking and • The lack of reported pain does not exclude arthritis
physical examination), knowledge of normal development, • There is a need to probe for symptoms such as
– gelling (e.g. stiffness after long car rides)
and clinical presentations at different ages, along with
– altered function (e.g. play, handwriting skills,
knowledge of indicators to warrant referral, are important regression of motor milestones)
and facilitate appropriate decision-making in the primary – deterioration in behaviour (irritability, poor
care setting. This article focuses on pGALS (paediatric Gait, sleeping)
Arms, Legs, Spine), which is a simple screening approach • There is a need to examine all joints as joint involvement
to MSK examination in school-aged children and may be is often ‘asymptomatic’
successfully performed in younger ambulant children –
the approach to the examination of the toddler and baby It is important to probe in the history when there are
requires a different approach and is not described here. indicators of potential inflammatory MSK disease. A delay
in major motor milestones warrants MSK assessment as well
How is musculoskeletal assessment as a global neuro-developmental approach. However, in ac-
of children different to that of quired MSK disease such as juvenile idiopathic arthritis (JIA)
adults? a history of regression of achieved milestones is often more
significant – e.g. the child who was happy to walk unaided
It is stating the obvious that children are ‘not small adults’ but has recently been reluctant to walk or is now unable to
in many ways, and here we focus on MSK history-taking dress himself without help. In adults the cardinal features
of inflammatory arthritis are pain, stiffness, swelling and
reduced function. However, in children these features may

Medical Editor: Louise Warburton, GP. Production Editor: Frances Mawer (arc). ISSN 1741-833X.
Published 3 times a year by the Arthritis Research Campaign, Copeman House, St Mary’s Court, St43
Mary’s Gate
Chesterfield S41 7TD. Registered Charity No. 207711.
be difficult to elucidate. Joint swelling, limping and reduced lar, respiratory, gastrointestinal, neurological, skin and eyes,
mobility, rather than pain, are the most common presenting and, given the broad spectrum of MSK presentations in chil-
features of JIA.1 The lack of reported pain does not exclude dren, a low threshold for performing pGALS is suggested and
arthritis – the child is undoubtedly in discomfort but, for the of particular importance in certain clinical scenarios.
reasons described, may not verbalise this as pain. Swelling is
always significant but can be subtle and easily overlooked, Practical Tip – when to perform pGALS in the
especially if the changes are symmetrical, and relies on assessment
the examiner being confident in their MSK examination • Child with muscle, joint or bone pain
skills and having an appreciation of what is ‘normal’ and • Unwell child with pyrexia
‘abnormal’ (see below). Rather than describing stiffness, the • Child with limp
parents may notice the child is reluctant to weight-bear or • Delay or regression of motor milestones
• The ‘clumsy’ child in the absence of neurological
limps in the mornings or ‘gels’ after periods of immobility disease
(e.g. after long car rides or sitting in a classroom). Systemic • Child with chronic disease and known association with
upset and the presence of bone rather than joint pain may MSK presentations
be features of MSK disease and are ‘red flags’ that warrant
urgent referral. More indolent presentations of MSK disease
can also impact on growth (either localised or generalised) How does pGALS differ from adult
and it is important to assess height and weight and review GALS?
growth charts as necessary.
The sequence of pGALS is essentially the same as adult GALS
with additional manoeuvres to screen the foot and ankle
RED FLAGS
(walk on heels and then on tiptoes), wrists (palms together
(Raise concern about infection, malignancy or non-
accidental injury) and then hands back to back) and temporomandibular joints
(open mouth and insert three of the child’s own fingers),
• Fever, malaise, systemic upset (reduced appetite, and with amendments at screening the elbow (reach up
weight loss, sweats) and touch the sky) and neck (look at the ceiling). These ad-
• Bone or joint pain with fever
• Refractory or unremitting pain, persistent night-waking
ditional manoeuvres were included because when adult
• Incongruence between history and presentation (such GALS was originally tested in school-aged children4 it missed
as the pattern of the physical findings and a previous significant abnormalities at these sites.
history of neglect)
How to distinguish normal from
What is pGALS? abnormal in the musculoskeletal
Paediatric GALS (pGALS) is a simple evidence-based app-
examination
roach to an MSK screening assessment in school-aged chil- Key to distinguishing normal from abnormal are knowledge
dren, and is based on the adult GALS (Gait, Arms, Legs, of ranges of movement, looking for asymmetry and
Spine) screen.2 The adult GALS screen is commonly taught careful examination for subtle changes. In addition, it is
to medical students, and emerging evidence shows an important that GPs are aware of normal variants in gait,
improvement in doctors’ confidence and performance leg alignment and normal motor milestones (Tables 1,2) as
in adult MSK assessment. Educational resources to these are a common cause of parental concern, especially
support learning of GALS are available.3 pGALS is the only in the pre-school child, and often anxieties can be allayed
paediatric MSK screening examination to be validated, and with explanation and reassurance. There is considerable
was originally tested in school-aged children. pGALS has variation in the way normal gait patterns develop; these
been demonstrated to have excellent sensitivity to detect may be familial (e.g. ‘bottom-shufflers’ often walk later) and
abnormality (i.e. with few false negatives), incorporates subject to racial variation (e.g. African black children tend to
simple manoeuvres often used in clinical practice, and is walk sooner and Asian children later than average).
quick to do, taking an average of 2 minutes to perform.4
Furthermore, when performed by medical students and Joint abnormalities can be subtle or difficult to appreciate
general practitioners pGALS has been shown to have high in the young (such as ‘chubby’ ankles, fingers, wrists and
sensitivity and is easy to do, with excellent acceptability by knees). Looking for asymmetrical changes is helpful
children and their parents (papers in preparation). Younger although it can be falsely reassuring in the presence of
children can often perform the screening manoeuvres quite symmetrical joint involvement. Muscle wasting, such as
easily, although validation of pGALS in the pre-school age of the quadriceps or calf muscles, indicates chronicity of
group has yet to be demonstrated. joint disease and should alert the examiner to knee or
ankle involvement respectively. Swelling of the ankle is
When should pGALS be performed? often best judged from behind the child. Ranges of joint
movement should be symmetrical and an appreciation of
MSK presentations are a common feature of many chronic the ‘normal’ range of movement in childhood can be gained
diseases of childhood and not just arthritis. An MSK exam- with increased clinical experience. Hypermobility may be
ination is one of the ‘core’ systems along with cardiovascu- generalised or limited to peripheral joints such as hands
44
2
and feet, and, generally speaking, younger female children
TABLE 1. Normal variants in gait patterns and leg
and those of non-Caucasian origin are more flexible. Benign
alignment.
hypermobility is suggested by symmetrical hyperextension
Toe- Habitual toe-walking is common in at the fingers, elbows and knees and by flat pronated feet,
walking young children up to 3 years with normal arches on tiptoe.5

In-toeing Can be due to: Practical Tip – normal variants: indications for referral
• persistent femoral anteversion • Persistent changes (beyond the expected age ranges)
(characterised by child walking with • Progressive or asymmetrical changes
patellae and feet pointing inwards; • Short stature or dysmorphic features
common between ages 3–8 years) • Painful changes with functional limitation
• internal tibial torsion (characterised • Regression or delayed motor milestones
• Abnormal joint examination elsewhere
by child walking with patellae facing
• Suggestion of neurological disease or developmental
forward and toes pointing inwards; delay
common from onset of walking to
3 years)
• metatarsus adductus (characterised
Children with hypermobility may present with mechanical
by a flexible ‘C-shaped’ lateral border aches and pains after activity or as ‘clumsy’ children, prone
of the foot; most resolve by 6 years to falls. It is important to consider ‘non-benign’ causes of
hypermobility such as Marfan’s syndrome (which may be
Bow legs Common from birth to the early toddler, suggested by tall habitus with long thin fingers, and high-
(genu often with out-toeing (maximal at approx. arched palate), and Ehlers–Danlos syndrome (which may
varus) 1 year); most resolve by 18 months be suggested by easy bruising and skin elasticity, with poor
healing after minor trauma). Non-benign hypermobility is
Knock Common and often associated with
genetically acquired and probing into the family history may
knees in-toeing (maximal at approx. 4 years);
be revealing (e.g. cardiac deaths in Marfan’s syndrome).
(genu most resolve by 7 years
valgus) The absence of normal arches on tiptoe suggests a non-
mobile flat foot and warrants investigation (e.g. to exclude
Flat feet Most children have flexible flat feet with
tarsal coalition) and high fixed arches and persistent toe-
normal arches on tiptoeing; most resolve
by 6 years walking may suggest neurological disease. Conversely,
lack of joint mobility, especially if asymmetrical, is always
Crooked Most resolve with weight-bearing significant. Increased symmetrical calf muscle bulk as-
toes (assuming shoes and socks fit sociates with types of muscular dystrophy, and proximal my-
comfortably) opathies may be suggested by delayed milestones such as
walking (later than 18 months) or inability to jump (in the
school-aged child).
TABLE 2. Normal major motor milestones.

Sit without support 6–8 months What to do if the pGALS screen is


abnormal
Creep on hands and knees 9–11 months
pGALS has been shown to have high sensitivity to detect
Cruise when holding on to 11–12 months significant abnormalities. Following the screening exam-
furniture and standing upright, ination, the observer is directed to a more detailed examin-
or bottom shuffle ation of the relevant area, based on the ‘look, feel, move’
Walk independently 12–14 months
principle as in the adult Regional Examination of the
Musculoskeletal System (called REMS).3 To date a validated
Climb up stairs on hands and approx. 15 months regional MSK examination for children does not exist, but
knees an evidence- and consensus-based approach to a children’s
regional examination (to be called pREMS) is currently being
Run stiffly approx. 16 months developed by our research team; this project is funded by
arc and further educational resources are to follow.
Walk down steps (non-reciprocal) 20–24 months

Walk up steps, alternate feet 3 years The components of the pGALS mus-
Hop on one foot, broad jump 4 years
culoskeletal screen
The pGALS screen6 (see pp 4–6) includes three questions
Skip with alternate feet 5 years relating to pain and function. However, a negative response
to these three questions in the context of a potential MSK
Balance on one foot 20 seconds 6–7 years
problem does not exclude significant MSK disease, and
45
3
The pGALS musculoskeletal screen
Screening questions
• Do you (or does your child) have any pain or stiffness in your (their) joints, muscles or back?
• Do you (or does your child) have any difficulty getting yourself (him/herself) dressed without any help?
• Do you (or does your child) have any problem going up and down stairs?

FIGURE SCREENING MANOEUVRES WHAT IS BEING ASSESSED?


(Note the manoeuvres in bold are
additional to those in adult GALS2)

Observe the child standing • Posture and habitus


(from front, back and sides) • Skin rashes – e.g. psoriasis
• Deformity – e.g. leg length
inequality, leg alignment
(valgus, varus at the knee
or ankle), scoliosis, joint
swelling, muscle wasting,
flat feet

Observe the child walking • Ankles, subtalar, midtarsal


and and small joints of feet
‘Walk on your heels’ and and toes
‘Walk on your tiptoes’ • Foot posture (note if
presence of normal
longitudinal arches of feet
when on tiptoes)

‘Hold your hands out • Forward flexion of


straight in front of you’ shoulders
• Elbow extension
• Wrist extension
• Extension of small joints
of fingers

‘Turn your hands over and • Wrist supination


make a fist’ • Elbow supination
• Flexion of small joints of
fingers

‘Pinch your index finger and • Manual dexterity


thumb together’ • Coordination of small
joints of index finger and
thumb and functional
key grip

(continued)
46
4
FIGURE SCREENING MANOEUVRES WHAT IS BEING ASSESSED?

‘Touch the tips of your • Manual dexterity


fingers’ • Coordination of small
joints of fingers and
thumbs

Squeeze the metacarpo- • Metacarpophalangeal


phalangeal joints for joints
tenderness

‘Put your hands together • Extension of small joints


palm to palm’ and of fingers
‘Put your hands together • Wrist extension
back to back’ • Elbow flexion

‘Reach up, “touch the sky”’ • Elbow extension


and • Wrist extension
‘Look at the ceiling’ • Shoulder abduction
• Neck extension

‘Put your hands behind your • Shoulder abduction


neck’ • External rotation of
shoulders
• Elbow flexion

(continued)
47
5
FIGURE SCREENING MANOEUVRES WHAT IS BEING ASSESSED?

‘Try and touch your shoulder • Cervical spine lateral


with your ear’ flexion

‘Open wide and put three • Temporomandibular joints


(child’s own) fingers in your (and check for deviation of
mouth’ jaw movement)

Feel for effusion at the • Knee effusion (small


knee (patella tap, or cross- effusion may be missed
fluctuation) by patella tap alone)

Active movement of knees • Knee flexion


(flexion and extension) and • Knee extension
feel for crepitus

Passive movement of hip • Hip flexion and internal


(knee flexed to 90º, and rotation
internal rotation of hip)

‘Bend forwards and touch • Forward flexion of


your toes?’ thoraco-lumbar spine (and
check for scoliosis)

48
6
Documentation of the pGALS screen
Documentation of the pGALS screening assessment is important and a simple pro forma is proposed with
the following example – a child with a swollen left knee with limited flexion of the knee and antalgic gait.

pGALS screening questions

Any pain? Left knee


Problems with dressing? No difficulty
Problems with walking? Some difficulty on walking
Appearance Movement
Gait 7
Arms 3 3
Legs 7 7
Spine 3 3

therefore at a minimum pGALS should be performed. In Summary


children, it is not uncommon to find joint involvement
that has not been mentioned as part of the presenting The pGALS examination is a simple MSK screen that should
complaint; it is therefore essential to perform all parts of be performed as part of systems assessment of children.
the pGALS screen and check for verbal and non-verbal clues Improved performance of MSK clinical skills and knowledge
of joint discomfort (such as facial expression, withdrawal of of normal variants in childhood, common MSK conditions
limb, or refusal to be examined further). and their mode of presentation, along with knowledge
of red flags to warrant concern, will facilitate diagnosis,
Observation with the child standing should be done from the management and appropriate referral.
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
Further information and reading
flexion. From the front and back, leg alignment problems 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
such as valgus and varus deformities at the knee can be be available as a web-based resource: www.arc.org.uk/arthinfo/
observed; leg-length inequality may be more obvious from emedia.asp. A video-clip of the screening manoeuvres can also be
the side and suggested by a flexed posture at the knee, and, accessed via the web version of this report: www.arc.org.uk/arthinfo/
if found, then careful observation of the spine is important medpubs/6535/6535.asp.
to exclude a secondary scoliosis. For specific manoeuvres, Jandial S, Foster HE. Examination of the musculoskeletal system in chil-
the child can copy the various screening manoeuvres as dren: a simple approach. Paediatr Child Health 2008;18(2):47-55.
they are performed by the examiner. Children often find
Szer I, Kimura Y, Malleson P, Southwood T (ed). Arthritis in adolescents
this fun and this can help with establishing rapport. It is and children (juvenile idiopathic arthritis). Oxford University Press;
important to keep observing closely as children may only 2006.
cooperate briefly! The examination of the upper limbs and
neck is optimal with the child sitting on an examination References
couch or on a parent’s knee, facing the examiner. The child
1. McGhee JL, Burks FN, Sheckels JL, Jarvis JN. Identifying children with
should then lie supine to allow the legs to be examined and chronic arthritis based on chief complaints: absence of predictive
then stand again for spine assessment. value for musculoskeletal pain as an indicator of rheumatic disease
in children. Pediatrics 2002;110(2 Pt 1):354-9.
Practical Tip – while performing the pGALS screening 2. Doherty M, Dacre J, Dieppe P, Snaith M. The ‘GALS’ locomotor
examination screen. Ann Rheum Dis 1992;51(10):1165-9.
• Get the child to copy you doing the manoeuvres 3. Clinical assessment of the musculoskeletal system: a handbook
• Look for verbal and non-verbal clues of discomfort for medical students (includes DVD ‘Regional examination of the
(e.g. facial expression, withdrawal) musculoskeletal system for students’). Arthritis Research Campaign;
2005. www.arc.org.uk/arthinfo/medpubs/6321/6321.asp.
• Do the full screen as the extent of joint involvement may
not be obvious from the history 4. Foster HE, Kay LJ, Friswell M, Coady D, Myers A. Musculoskeletal
• Look for asymmetry (e.g. muscle bulk, joint swelling, screening examination (pGALS) for school-aged children based on
range of joint movement) the adult GALS screen. Arthritis Rheum 2006;55(5):709-16.
• Consider clinical patterns (e.g. non-benign hypermobility 5. Oliver J. Hypermobility. Reports on the Rheumatic Diseases (Series
and Marfanoid habitus or skin elasticity) and association 5), Hands On 7. Arthritis Research Campaign; 2005 Oct.
of leg-length discrepancy and scoliosis) 6. pGALS – Paediatric Gait, Arms, Legs, Spine. DVD. Arthritis Research
Campaign; 2006. www.arc.org.uk/arthinfo/emedia.asp.
49
7
WHO GROWTH CHARTS FOR CANADA BOYS
BIRTH TO 24 MONTHS: BOYS NAME:
Length-for-age and Weight-for-age percentiles DOB: RECORD #

Birth 2 4 6 8 10 12 14 16 18 20 22 24
in in
cm AGE (MONTHS) cm
39 39

BOYS
38 38
95 95
37 37
97
36 90
36
90 90 L
35 75 35
E
34 50 34 N
85 25 85
33 10
33 G
32 3 32 T
80 80 H
31 31
30 30
75 75
29 29
28
70
27
26 38
L 65 17
E 25
N 24 36
60 16
G 23
T 34
22
H 55 15
97
21 32
20 50 14
90
19 30
18 45 13
75
17 28
W
16 40 12
50
26 E
15 I
14 35 25 11 G
24 H
13
10 T
12 30 10 22
11 3

10 25 9 20
9
8 20 18
8
7
16
7
14 14
6 kg
AGE (MONTHS)
12 lb
10 12 14 16 18 20 22 24
5
W kg
10 MOTHER’S HEIGHT
12
E FATHER’S HEIGHT GESTATIONAL AGE AT BIRTH WEEKS
I 4
8 lb
G DATE AGE LENGTH WEIGHT COMMENTS
BIRTH
H 3
T 6

2
4

lb kg

Birth 2 4 6 8

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 and Dietitians 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
50
WHO GROWTH CHARTS FOR CANADA BOYS
BIRTH TO 24 MONTHS: BOYS NAME:
Head Circumference and Weight-for-length percentiles DOB: RECORD #

Birth 2 4 6 8 10 12 14 16 18 20 22 24
in cm AGE (MONTHS) cm in

H 54 54
21 21
E 52
52
A 20 20
97
D 50 90 50
75
19 48 50 48 19
C 25
10
I 18 46 3
46 18
R
44 44
C 17 17
U 42
M 16 54
40 24
F 52
E 15 38 23
99.9 50
R
14 36 22
E 48
N 34 21
13 46
C 97
E 32 20 44
12
30
20 19 42
85

75 40
18

BOYS
38 50 38
17 17
36 25 36
16 16 W
10
34 34 E
15 15 I
3
32 32 G
14 14
30 30 H
T
13 13
28 28

26 12 12 26
W 11 11
24 24
E
I 22 10 10 22
G
H 20 9 9 20
T
18 18
8 8
16 16
7 7
14 14
6 kg
LENGTH
12 12
5 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 100 102 104 106 108 cm
10 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 in
lb
4
8 GESTATIONAL AGE AT BIRTH WEEKS 8
DATE AGE LENGTH WEIGHT HEAD CIRC. COMMENTS
6 3 BIRTH

lb 2
kg
cm 46 48 50 52 54 56 58 60 62 64 66

in 18 19 20 21 22 23 24 25 26

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 and Dietitians 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
51
WHO GROWTH CHARTS FOR CANADA BOYS
2 TO 19 YEARS: BOYS NAME:
Height-for-age and Weight-for-age percentiles DOB: RECORD #

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
in in
cm AGE (YEARS) cm
80 80
79 MOTHER’S HEIGHT 79
200 200
78 FATHER’S HEIGHT 78
77 77
195 DATE AGE HEIGHT WEIGHT COMMENTS 195
76 76
75 97 75
190 190
74 74
73 90 73
185 185
72 72
71 75 71 H
180 180
70 70 E

BOYS
69 175
50
175 69 I
68 68 G
25
67 170 170 67 H
66
10
66 T
65 165 165 65
64 3 64
63 160 160 63
62 62
61 155 155 61
60 60
H 59 150 150 59
E 58 58
I 57 145 145 57
G 56 56
H 55 140
T 54 97
53 135 90 200
52
190
51 130 85
50 90
180
49 125 80
48 170
120 75 75
47
46 160
45 115 70
50 150 W
44
43 110 65 E
140
42 25 I
41 105 60 130 G
40 10 H
39 100 55 120 T
3
38
37 95 50 110
36
90 45 100
35
34 90
33 85 40
32 80
31 80 35
70
30
60
25 25
50 50
W 20 20
E 40 40
I 15 15
G 30 30
H 20 10 10 20
T WHO recommends BMI as the best measure
after age 10 due to variable age of puberty. 
lb kg kg lb
AGE (YEARS) Tracking weight alone is not advised.
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

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 and Dietitians of Canada. The weight-for-age 10 to 19 years
section was developed by CPEG based on data from the US National Center for Health Statistics using the same procedures as the WHO growth charts.
© Dietitians of Canada, 2014. Chart may be reproduced in its entirety (i.e., no changes) for non-commercial purposes only. www.whogrowthcharts.ca 52
WHO GROWTH CHARTS FOR CANADA BOYS
2 TO 19 YEARS: BOYS NAME:
Body mass index-for-age percentiles DOB: RECORD #

DATE AGE WEIGHT HEIGHT BMI* COMMENTS

BMI BMI

39 39

38 38

37 37
99.9
36 36

35 35
BMI tables/calculator available at www.whogrowthcharts.ca
34 *To Calculate BMI: Weight (kg) ÷ Height (cm) ÷ Height (cm) x 10,000 OR 34
Weight (lb) ÷ Height (in) ÷ Height (in) x 703
33

BOYS
BMI 32

31 31

30 30

29 97 29

28 28

27 27

26 26
85
25 25

24 75 24

23 23

22 50 22

21 21

20 25 20

19 10
19

18 18
3
17 17

16 16

15 15

14 14

13 13

12 12

BMI BMI
AGE (YEARS)

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

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 and Dietitians 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
53
WHO GROWTH CHARTS FOR CANADA GIRLS
BIRTH TO 24 MONTHS: GIRLS NAME:
Length-for-age and Weight-for-age percentiles DOB: RECORD #

Birth 2 4 6 8 10 12 14 16 18 20 22 24
in in
cm cm

GIRLS
AGE (MONTHS)
39 39
38 38
95 95
37 37
36 97 36 L
90 90 90 E
35 35
75 N
34 34
85 50 85 G
33 25
33 T
32 10 32 H
80 3 80
31 31
30 30
75 75
29 29
28
70
27
26 38
L 65 17
E 25
N 24 36
60 16
G 23
T 34
22
H 55 15
21 32
97
20 50 14
19 30
18 90
45 13
17 28
75 W
16 40 12
26 E
15 I
50
14 35 11 G
24 H
13
25 T
12 30 10 22
10
11
10 25 3 9 20
9
8 20 18
8
7
16
7
14 14
6 kg
AGE (MONTHS)
12 lb
10 12 14 16 18 20 22 24
5
W kg
10 MOTHER’S HEIGHT
12
E FATHER’S HEIGHT GESTATIONAL AGE AT BIRTH WEEKS
I 4
8 lb
G DATE AGE LENGTH WEIGHT COMMENTS
BIRTH
H 3
T 6

2
4

lb kg

Birth 2 4 6 8

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 and Dietitians 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
54
WHO GROWTH CHARTS FOR CANADA GIRLS
BIRTH TO 24 MONTHS: GIRLS NAME:
Head Circumference and Weight-for-length percentiles DOB: RECORD #

Birth 2 4 6 8 10 12 14 16 18 20 22 24
cm AGE (MONTHS) cm
in in

H 52 52
E 20 20
50 97 50
A 90
19 19
D 48 75 48
50
46 25 46
18 18
C 10
3
I 44 44
17 17
R
42 42
C
16
U 40
25
M
15 38 54
F 24
E 36 52
14 99.9
23
R 50
34
E 13 22
N 48
32
C 21 46
12 97
E 30
20 44
11 28
20
85 19 42

GIRLS
75
40 18 18 40

38 50 38
17 17
36 25 36
16 16 W
34 10 34 E
15 15 I
32 3 32 G
14 14
30 30 H
T
13 13
28 28

26 12 12 26
W 11 11
24 24
E
I 22 10 10 22
G
H 20 9 9 20
T
18 18
8 8
16 16
7 7
14 14
6 kg
LENGTH
12 12
5 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 100 102 104 106 108 cm
10 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 in
lb
4
8 GESTATIONAL AGE AT BIRTH WEEKS
DATE AGE LENGTH WEIGHT HEAD CIRC. COMMENTS
6 3 BIRTH

lb 2
kg
cm 46 48 50 52 54 56 58 60 62 64 66

in 18 19 20 21 22 23 24 25 26

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 and Dietitians 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
55
WHO GROWTH CHARTS FOR CANADA GIRLS
2 TO 19 YEARS: GIRLS NAME:
Height-for-age and Weight-for-age percentiles DOB: RECORD #

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
in in
cm AGE (YEARS) cm
78 78
77 MOTHER’S HEIGHT 77
195 195
76 FATHER’S HEIGHT 76
75 75
190 DATE AGE HEIGHT WEIGHT COMMENTS 190
74 74
73 73
185 185
72 72
71 180 180 71
70 70
69 97 69 H
175 175
68 68 E

GIRLS
90 I
67 170 170 67
66 75 66 G
65 165 165 65 H
64 50 64 T
63 160 160 63
62 25
62
61 155 10 155 61
60 60
59 150 3
150 59
H 58 58
E 57 145 145 57
I 56 56
G 55 140 140 55
H 54 54
T 53 135
52
51 130 90 200
50
190
49 125 85
48 180
47 120 80
46 97 170
45 115 75
44 160
43 110 90
70
150 W
42
41 105 65 E
140
40 75 I
39 100 60 130 G
38 50
H
37 95 55 120 T
36 25
35 90 50 110
34 10
85 45 100
33 3
32 90
31 80 40
30 80
29 75 35
lb
30
60
25 25
50 50
W 20 20
40 40
E
I 15 15
30 30
G
H 20 10 10 20
WHO recommends BMI as the best measure
T after age 10 due to variable age of puberty. 
lb kg kg lb
AGE (YEARS) Tracking weight alone is not advised.
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

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 and Dietitians of Canada. The weight-for-age 10 to 19 years
section was developed by CPEG based on data from the US National Center for Health Statistics using the same procedures as the WHO growth charts. 56
© Dietitians of Canada, 2014. Chart may be reproduced in its entirety (i.e., no changes) for non-commercial purposes only. www.whogrowthcharts.ca
WHO GROWTH CHARTS FOR CANADA GIRLS
2 TO 19 YEARS: GIRLS NAME:
Body mass index-for-age percentiles DOB: RECORD #

DATE AGE WEIGHT HEIGHT BMI* COMMENTS

BMI BMI

39 40

38 39

37 38

36 99.9 37

35 BMI tables/calculator available at www.whogrowthcharts.ca 36


*To Calculate BMI: Weight (kg) ÷ Height (cm) ÷ Height (cm) x 10,000 OR
Weight (lb) ÷ Height (in) ÷ Height (in) x 703
34 35

GIRLS
BMI 34

33
BMI 33

32 32

31 31

30 30

29 97 29

28 28

27 27

26 26

25 85 25

24 24
75
23 23

22 22
50
21 21

20 20
25
19 19

18 10 18

17 3
17

16 16

15 15

14 14

13 13

BMI BMI
AGE (YEARS)

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

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 and Dietitians 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
57
Weight Conversion Chart
OUNCES
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
POUNDS

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

58
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

59
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:


• 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?

60
• Number of sexual partners /age of first sexual activity/STI history / ever
tested for STIs, HIV/ last pelvic exam in females, partner history of STI
and partner’s STI risk behaviours
• Have you ever been pregnant or gotten someone pregnant?

Suicide / Depression
• Screen for depression (SIGECAPS)
• Have you lost interest in things you previously enjoyed?
• How would you describe your mood? On a scale of 1-10?
• Any change in sleep pattern? Ability to concentrate?
• Have you had any thoughts about hurting or killing yourself?
• Have you ever engaged in self-harm behaviours?
• What do you do to relieve stress?
• Do you have an adult that you can talk to if you are having a hard time?
Who is that person?

Safety
• Do you regularly use: seatbelts? Bike helmets? Appropriate gear when
snowboarding/skateboarding or other sports?
• Does anyone at home own a gun?
• Have you ever been the victim of violence at home, in your
neighbourhood or at school?
• Has anyone ever hurt you or touched you in a way that was hurtful or
inappropriate

61
Admission Orders (ADDAVID)
Admit: Admit to (Ward 3B/3C/NICU/L2N) under (staff name, Team #);
-If admitting while on-call overnight double check with your senior resident
which team that patient should be admitted to.
“Admit to Team x under the care of [Team x Day staff] Dr. (on call) to cover
until 8 am.
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), Specify
frequency (if particularly sick patient requiring more frequent vitals), Special
parameters (eg. Postural vitals, Neuro vitals)
Monitor: Accurate Ins & Outs (Surgery, volume status pts.)
Daily weights (eg. Renal failure, edematous, infants)
Investigations:
Hematology: CBC + diff, PTT/INR
Biochemistry: Electrolytes (Na+, K+,Cl-, HCO3-), Urea, Creatinine, Ca2+,
Mg2+, PO4-, glucose, CSF cell count, CSF protein and glucose
Microbiology: Urine R&M/C&S, Blood Cultures, CSF from LP for gram
stain, C&S. For this section just remember all the things you can culture:
CSF, Sputum, Urine, Feces, Pus from wounds, Blood
Imaging: CXR, CT, MRI, EKG, PFT, Spirometry
Consults: Social Work, Neurology, Infectious Diseases

62
Drugs
All medications patient is already on (Past), medications the patient needs right
now (Present), anticipate what the patient might need: prophylaxis, sleep,
nausea and pain (Future)
10 Patient P’s: Problems (specific medical issues), Pain (analgesia), Pus
(antimicrobials), Puke (anti-emetics, prokinetics, antacids), Pee (IV fluids,
diuretics, electrolytes), Poop (bowel routine), Pillow (sedation), PE
(anticoagulation), Psych (DTs), Previous Meds

Ensure you date and time your orders, put the child’s weight and list any
allergies on the order sheet. Make sure you sign the order sheet and write your
name legibly and pager number.
 

63
Progress Note: Pediatrics
Date ∗ Always LEGIBLY note the Date, Time, Your Name and Pager Number

ID: age, sex with a history of (non-active/chronic issues/previously well)


admitted with (list active/acute issues for why patient is admitted)
eg. 18 mo ♀ previously healthy, admitted with a UTI and 2° dehydration

Subjective: S:
How patient’s night was (O/N) and how they feel that day and any new
concerns they have. What has changed since the previous note. Does
the patient have any new symptoms? How is the patient coping with the
active symptoms, progression, better/worse. If patient is non-verbal, ask
the parents or patient’s nurse. Remember to ask about: behaviour,
activity, sleep, appetite, in and outs.

Objective: O: General:
Patient disposition (irritable, sleeping, alert), general appearance,
behaviour, cognition, cooperation, disposition
Vitals: HR, BP, RR, SaO2 (on Room Air/NP with rate or %), Temp
(PO/PR/AX), weight (daily, with changes noted), Inputs (Diet, IV fluids
and rate), Output (Urine Output, BM/Diarrhea, Vomiting, Drains),
Document fluid balance (Total In-Total Out) and urine output (ml/kg/hr)
when applicableVitals: Temp (PO or PR or Axilla?), HR, RR, BP, SaO2
(on room air? 24%? 2L?)
Focused P/E of system involved plus CVS, RESP, ABDO, EXT/MSK
common for hospitalized patients to develop problems in these systems
Investigations (Ix): New lab results, imaging or diagnostic
tests/interventions
MEDS: reviewed daily for changes regarding those that are
new/hold/discontinued/restarted

Assessment & Plan\Impression (A/P or Imp):


Summarize what the new findings mean, what progress is being made
Improved? Stable? Waiting investigations/consult? Differential Diagnosis
if anything has been ruled in/out

Plan (A/P or I/P):


Issue (1) à eg. UTI à Day 2 of Empiric Abx, likely 14 day course
required. Awaiting culture and sensitivity
Issue (2) à eg. Dehydration à Intake still minimal, Urea mildly elevated,
clinically dehydrated therefore continue IVF at 50 ml/hr
Encourage oral fluids
Name, Designation (CC\PGY), Pager Number
Discussed with Dr. ________________  
64
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
65
• 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.  
66
Mandatory Reporting of Suspected Child Abuse and Neglect

During your clinical training in Pediatrics at McMaster, there is a possibility that


you will encounter a child in whom child abuse has been diagnosed or is
suspected.
As a regulated health professional, you are required, under the provisions of
the Child and Family Services Act to immediately report to a Children’s Aid
Society (CAS) any suspicion that a child has suffered or is at risk of suffering
from physical, sexual or emotional abuse and/or neglect (which includes
exposure to domestic violence). There are serious legal and professional
repercussions if a physician fails to meet this obligation.

If you become concerned that a child has suffered or is at risk of suffering


abuse or neglect, you are encouraged to discuss this immediately with your
preceptor so that it can be determined if a report to CAS is warranted. While it
is unlikely to occur, keep in mind that it is an offense for someone in a position
of authority to prevent another person from making a report if that person
believes that there is sufficient cause to do so.

For more information:

http://www.cpso.on.ca/uploadedFiles/policies/policies/policyitems/mandatoryre
porting.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 (i.e. stable, serious), location of
the facility (unless individual instructs otherwise), or to identify the deceased.

67
Discharge Summary Template: Pediatrics
Today’s date
My name, designation (i.e. resident, clinical clerk)
Attending MD
Patient name, ID#
Copies of this report to: FD, pediatrician, and pertinent consultants
Date of Admission:
Date of Discharge:
“Start of dictation”
ADMISSION DIAGNOSIS:
DISCHARGE DIAGNOSIS:
1., 2. etc
OTHER (non-active) DIAGNOSIS:
FOLLOW-UP: (appointments, pending investigations, home care)
DISCHARGE MEDICATIONS: (dose, frequency, route and duration)
SUMMARY OF PRESENTING ILLNESS:
- 1-2 line summary of child’s presenting illness and reason for admission.
Refer to separately dictated note for full history and physical examination
of admission.
- Only if no admission dictation completed, indicate full history of presenting
illness (HPI), Past medical history, and initial physical examination prior
to ‘Course in Hospital’

COURSE IN HOSPITAL:
- Describe briefly the events and progression of illness while in hospital
including status upon discharge

- Details of drug doses used, IV rates, etc rarely required and difficult to
confirm as signing staff physician. Rather, say “XXX required hourly
nebulized Ventolin for 5 hours after which the dosing interval was
extended to every three hours”.

- If the child has multiple medical issues, this section can be done by
68
system (cardiovascular, respiratory, fluids and nutrition, ID, hematological,
CNS, etc)
- List complex investigations (with results) under a separate heading.

- Procedures: Includes a comprehensive list of procedures performed


during hospital admission for definitive treatment, diagnostic or exploratory
purposes

State your name, designation; Attending MD name Press 8 to end dictation,


and write down job # on face-sheet of chart
 

69
Fluid Management In Children
 

3 Components to Fluid Management:


1. Maintenance
2. Deficit Replacement
3. Ongoing Losses Replacement

1. Maintenance
 

§ Fluid and electrolyte requirements are directly related to metabolic rate


§ Holliday-Segar Rule - calculation of maintenance fluid requirements
using body weight for resting hospitalized patients (based on 100 cc for
each 100 kcal expended):

Body Weight Volume in 24 hours


Up to 10 kg 100 cc/kg/d (1,000 cc for 10kg child/day)
11- 20 kg 1,000 + 50 cc/kg above 10 kg
Above 20 kg 1,500 + 20 cc/kg above 20 kg
Weight (kg) Hourly Fluid Requirements
(Calculated by "4-2-1 rule”)
0-10 kg 4 mL/kg/h
11-20 kg 40 mL/h + (2 mL/kg/h for each kg over 10 kg)
>20 kg 60 mL/h + (1 mL/kg/h for each kg over 20 kg)

§ Insensible water losses = cutaneous + pulmonary water losses which are


calculated as ~ 300 – 500 cc/m2
§ During fluid management, we should assess factors affecting insensible
and/or urinary fluid losses
§ Normal Na+ and K+ requirements 2 – 4 mEq/kg/day
§ During fluid management, we should assess factors that affect Na and K
balance
§ Adding 5% dextrose to maintenance solution prevents protein catabolism
§ Most commonly used solution in children:
D5W/NS + 20 mEq/L KCl
§ D10W: use in Neonates and Hypoglycemia
70
2. Deficit Replacement – Assessment:

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 Electrolyte Status Clinical Features


Dehydration
Hypotonic or Serum Na+ < 130 mEq/L, Serum Exacerbated signs of
Hyponatremic Osm < 270 dehydration
Risk of seizure
Isotonic or Serum Na+=130-150 mEq/L,
Isonatremic Serum Osm 270 – 300
Hypertonic or Serum Na+ > 150 mEq/L, Serum Decreased signs of
Hypernatremic Osm >300 dehydration
Irritable, increased tone
and reflexes

71
Assessing Dehydration: Severity
Patient Presentation Mild Moderate Severe

Less than 1 year: Less than 1 year: Less than 1 year:


Less than/equal 10% 15%
Age
to 5%
Greater than 1
year: <= 3% Greater than 1 Greater than 1 year:
% Weight Loss
year: 6% 9%

Mild tachycardia Moderate


Heart Rate Normal
tachycardia
Normal
Blood Pressure Normal
(orthostasis) Decreased

Respiratory Rate Normal Normal Increased

Skin
Capillary refill < 2 seconds 2 - 3 seconds > 3 seconds

Elasticity (less than 2 years) Normal Decreased Tenting


Anterior fontanel Normal Depressed Depressed
Mucous membranes Normal / Dry Dry Dry

CNS
Mental Status Normal Altered Depressed

Eyes
Tearing Normal / Absent Absent Absent
Appearance Normal Sunken Sunken

Laboratory Tests
Urine
Volume Small Oliguria Oliguria-anuria

Specific gravity 1.020 1.025 Maximal


Blood
Blood Urea Nitrogen Upper normal Elevated High

Signs of dehydration may be less evident or appear later in hypernatremic dehydration;


conversely, they may be more pronounced or appear sooner in hyponatremic dehydration

72
Labs:
 

§ Helpful in evaluation of Type and Severity of dehydration


§ May need to start therapy before lab results available
§ CBC for hemoconcentration, infection, source of dehydration
§ Electrolytes (Na+, K+, Cl-, HCO3-)
§ BUN, Cr increased in severe dehydration
§ Blood gas and HCO3- for metabolic acidosis, may need to calculate Anion
Gap (AG) = [ (Na+ + K+) – (Cl- - HCO3-)]
Normal AG = 12 ± 4
§ Urine R&M, concentrated urine in dehydration, infection

Monitoring Ongoing Dehydration\Rehydration Response:


 

§ Clinical response to treatment


§ HR, BP, Cap refill, LOC, Urine output
§ As indicated: cardioresp monitor, CVP, ECG
§ Labs as indicated: electrolytes, urine specific gravity,
serum / urine Osm
§ Repeated careful weight measurement
§ Accurate INS and OUTS including stool volume & consistency

2. Deficit Replacement – Oral Rehydration Therapy (ORT):


 

§ First-line treatment for Mild to Moderate dehydration


§ Requires close monitoring and compliance of patient and parents
§ Contains balanced amounts of sodium and glucose. Juice, pop and
jelatin are not appropriate for ORT
§ 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

73
Solution Glucose Na K Base Osmolality
(mEq/L)
(mEq/L) (mEq/L) (mEq/L)
WHO 111 90 20 30 310
Rehydrate 140 75 20 30 310
Pedialyte 140 45 20 30 250
Pediatric 140 45 20 30 250
Electrolyte
Infantlyte 70 50 25 30 200
Naturlyte 140 45 21 48 265

74
2. Deficit Replacement – Parenteral Therapy (IV):
 

§ Indications: Severe dehydration, patients who fail ORT due to: vomiting,
refusal or difficulty keeping up with losses
§ Preferable site is IV, if unable to start IV use IO
§ Consists of 3 phases:

(i) Initial Therapy


o Goal: expand ECF volume to prevent or treat shock
o Solution: isotonic saline (0.9% NS or RL) in all forms of dehydration,
never use hypotonic solution!!!
o Bolus 10 – 20 cc/kg of N/S ( or RL) over 15-20 mins initially, may be
repeated until patient is hemodynamically stable, if unstable, call Peds
1000!
o Rapid Rehydration (eg. 20-40 cc/kg bolus + ORT) à no evidence
o If hypokalemic: start K+ when patient voids (normal renal function).
Note: no K+ in bolus!

(ii) Subsequent Therapy


o Goal: continue replacement of existing deficit, provide maintenance
and electrolytes, replace ongoing losses
o Solution: D5NS + 20 mEq/L KCL in isotonic dehydration
o Deficit Replacement Time: usually over 24 hours à
½ deficit in first 8 hours, second ½ deficit over next 16 hours
o Subtract boluses from deficit calculation
o Source of Electrolyte Losses: 60% ECF and 40% ICF
§ For every 100 cc water lost, electrolyte losses:
o Na+: 8.4 mEq/L / 100cc
o K+: 6.0 mEq/L / 100cc
o Cl-: 6.0 mEq/L / 100cc
(iii) Final Therapy
o Return patient to normal status and to normal feeding

75
3. Ongoing Losses
Replace… With…
Gastric Losses (Vx) ½ NS + 10 – 20 mEq/L KCl
Stool or Intestinal Add HCO3- to
losses (Diarrhea)
½ 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

76
Comparison of IV Solutions
IV Solution Na+ K+ Cl- Dextrose Osmolarity
(mEq/L) (mEq/L) (mEq/L) (g/L) (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 ½NS) 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 10% Sodium Chloride 0.45%* 77 100 660
Dextrose 10% Sodium Chloride 0.9%* 154 100 813
Dextrose 3.3% Sodium Chloride 0.3% (⅔ * ⅓) 51 51 33.3 273
Lactated Ringers† 130 4 109 0 273
Also contains Calcium (Ca2+) 1.5 mmol/L, and Lactate (HCO3-) 28 mmol/L, *these solutions are not commercially available,
Commonly used solutions are highlighted  

77
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:
Weight
Determine IV fluid rate, according to “maintenance fluid” requirements, and replacement of deficit or ongoing losses ml/hour
(kg)
(Total Fluid intake (TFI). In general maintenance fluid rate is calculated by the “4:2:1” guideline, but should be
0-10 4/kg/hour
individualized according to the clinical condition and patient assessment
Step 2: The choice of fluid is dependent the individual patient. 11-20 40 + (2/kg/hr)
Consider ISOTONIC IVF for the following patients:
>20 60 + (1/kg/hr)
•  CNS disorder, Diabetic ketoacidosis
IV solution Na (mEq/L) K (mEq/L) Cl (mEq/L) % Electrolyte
•  Patients at risk of hyponatremia: acute infection, post-operative patients Free Water
and burns, Plasma Na < 138 (EFW)*
Add K+ to provide 1-2 mEq/kg/day, if patient has urine output H 0.2% NaCl in 34 0 34 78
y D5W
Add Dextrose to prevent hypoglycemia/ketosis (exceptions: hyperglycemia,brain injury)
p
o 0.45% NaCl 77 0 77 50
t in D5W
Consider HYPOTONIC IVF for the following patients: o
n Lactated 130 4 109 16
•  Patients with an EFW deficit - e.g. hypernatremia, ongoing EFW losses i Ringers
(renal, GI, skin) c
•  Patients with established 3rd space overload - e.g CHF, nephrotic 0.9% NaCl in 154 0 154 0
syndrome, oliguric renal failure, liver failure D5W (ISOTONIC)

•  Limited renal solute handling indicated - e.g. neonatal population,


*Based on a sodium plus potassium concentration in the aqueous phase of plasma of 154mEq/L, assuming that
hypertension plasma is 93% water with a plasma sodium of 140 mEq/L and a potassium concentration of 4 mEq/L

Step 3: MONITORING while on IV fluid Measure and record as accurately as possible

Clinical status: hydration status,urine Fluid balance: must be assessed at least every Labs:
output, ongoing losses, pain, vomiting, 12 hours Serum Electrolytes - at least daily if primary source
peripheral edema, and general well-being. Intake: All IV and oral intake (including of intake remains IV, or more frequently depending
Daily weights medication). Ensure this matches desired TFI. on clinical course, or in the presence of documented
Reassess TFI, indications for and fluid Output: all losses (urine, vomiting, diarrhea etc.) electrolyte abnormality.
prescription at least every 12 hours. Urine osmolarity/sodium and plasma osmolarity as
indicated, for determining etiology of hyponatraemia.
Version date : April 2011
78
Developmental Milestones
 

Developmental Milestones: 0-12 Months

Gross Motor Fine Motor Language Social & Self help Red Flags

-Moves head -Keeps hands -Turns toward -Recognizes the - Sucks poorly
from side to side in tight fists familiar sounds scent of his own
0-1 on stomach & voices mother's breast - Doesn't respond
month -Brings hands milk to bright lights or
-Usually flexed within range of -Recognizes loud noise blink
posture (prone eyes and some sounds -Prefers the when shown bright
position legs are mouth human face to all light
under abdomen) other patterns
- Seems stiff or
floppy

-Hips not as -Hands open -Cooing (vowel- -Smiles - Doesn't smile at


flexed (prone most of the time like sound- the sound of your
2 position legs not ooooh, ah) voice by 2 months
months under abdomen)
-Increases -Face is - Doesn't notice
-Head control vocalization expressive her hands by 2
improving (pull when spoken to months
to sit)
-Not tracking
objects

-Lift head when -Grasps and -Chuckles -Turn toward the - Doesn't hold
held shakes hand sound of a objects
3 toys human voice
months -Lift head & - Doesn’t smile
chest when on -Holds hands -Begins to -Smile when
tummy open imitate some smiled at - Doesn’t support
sounds head

-No head lag in -Reaching & -Shows -Smiles at self in - Doesn't reach for
pull to sit grasping excitement w/ mirror and grasp toys by
4 voice & 3 - 4 months
months -Brings toys to breathing
mouth - Doesn't babble
-Rolls from front -Increases -Increases
to back -Looks at vocalization to vocalization to - Always crosses
objects in hand toys & people toys & people eyes

79
-No head lag -Holds two -Mimics sounds -Babbles to get -Doesn’t roll over
objects in both & gestures your attention
5 -Head steady hands when
months when sitting placed -2 syllable -Able to let you
sounds (ah-goo) know if he’s -Doesn’t lift head
simultaneously
-May roll happy or sad while on tummy
backàfront

-Sits w/ hands -Transfers -Expresses -Knows family -Babe makes no


on legs object from 1 displeasure with from strangers sounds or fewer
6 (propping self hand to the non-crying sounds, especially
months up) other sounds -Pats at mirror in response to you
image
-Bears full -Reaches after -Doesn’t reach for
weight on legs if dropped toys -Pushes adult things
held standing hand away

-Bounces when -Reaches with -Begins -Enjoys social -Reaches with 1


held standing one hand responding to play hand only
7 "no"
months -Assumes -Bangs toys on -One or both eyes
crawling position table surface -Starts using consistently turn in
consonants (da, -Interested in or out
ba, ga) mirror images
-Refuses to cuddle

-In sitting, -Holds own -Responds to -Plays peek-a- -Seems very stiff
reaches forward bottle own name boo with tight muscles
8 and can return to
months sitting up erect -Starts eating -Babbles chains -Anticipates being -Not babbling by 8
finger foods of consonants picked up by months
raising arms

-Gets to sitting -Immature -Uses “mama” -Waves bye -Can’t push up on


position alone pincer grasp or “dada” arms while on
9 (thumb onto nonspecifically -Plays peek-a- tummy
months -Pulls to stand side of index boo
finger) -Can’t sit alone
-Crawling
-Can’t bear weight
in standing
position

-Pulls to stand -Grasps bell by - Jargons with Imitates nursery -No special
handle inflection gestures: relationship w/ any
10 -Cruises with 2 family members
months hands on a rail -Points at a - Performs 1 -Pat-a-cake
or furniture (for bead/small nursery gesture -Isn’t moving
support) object on verbal -Waving around room in
command some fashion i.e.
-“So big”
rolling, creeping

80
-Stands -Mature pincer -One word with -Extends arm & -No stranger
momentarily à can pick up meaning (e.g. leg to help when anxiety
11 tiny objects with “dada”) being dressed
months -Walks with one ends of thumb -Doesn’t seek
hand held and index -Understands social interaction
finger simple request with familiar
with gesture people

-Walks a few -Mature pincer -2-3 words w/ -Cries when -Doesn’t know
steps grasp meaning mother or father their name
12 leaves
months -Stands -Starting to -Uses -Not crawling or
independently point exclamations -Repeats sounds moving forward
such as "Oh- or gestures for
-Creeps upstairs -Helps turn oh!" attention Says no single
pages in a book words

Developmental Milestones: 1 - 5 Years:

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

Walking few Walking Running, Running Broad Walks on tip Skips


steps, wide few steps, unstable well jumps toes alternating
Walking based gait, wide feet
clumsy based
gait,
Fall if Jumps Stands on 1 Tandem gait
clumsy
trying to with 2 foot for 2 forward Hops on 1
pivot feet on seconds foot
floor

Creeps up- Creeps Walk up- Walks up Alternates Alternates Balances


stairs up-stairs stairs w/ stairs feet while feet while on 1 foot
Stairs hand alone walking up walking for > or
Crawls held stairs down stairs equal to 10
down- 2 feet per seconds
stairs very 2 feet per step Jumps off
slow & step last steps
careful

Stands well Climbs up Sit on Kicks ball Pedals Stands on 1 Bicycle +/-
on a chair chair tricycle foot for 4 training
Gross Climbs up seconds wheels
Motor onto a chair Throws Walks &
ball +/- pulls Throws
falling object ball
over overhand

81
Skill 12 mo 15 mo 18 mo 2 yrs 3 yrs 4 yrs 5 yrs

Pincer Stacks 2 Stacks 3- Stacks 5- Stacks 9 Stacks 10 Does


grasp blocks 4 blocks 7 blocks blocks blocks buttons up
Fine Motor
Releases Puts Imitates Opposes
object if shapes bridge fingers to
asked on to thumb in
board sequence

Crayon in Linear Circular Imitates Copies Copies Copies


mouth scribbles stroke Circle square triangle
Drawing
Marks paper 3yrs
Scribble
Copies Prints
cross name
3.5yrs

2-3 words 5-10 20 - 50 100-200 5-8 words Past tense Defines


words words words together words by
Expressive Prepositions use- what
2 - 3word Uses: I, me, (behind, on, is a ball?
Speech combo u under)
(pronouns)
Tells stories
Answers
‘W’
questions

1 command 1 5 body 2 step Knows Age 5-10 Counts 10


w/ gestures command parts command numbers by pennies
Receptive w/ out Knows their rote
Speech gestures 5 Sex Follows
Common 3-4 step group
objects Full name instruction direction

Eats Sipping Spoon Spoon Eats neatly Eats neatly Spreads


cheerios cup level, w/ level, w/ peanut
Eating solids semi- butter on
solids bread

Plays peek- Helps to Start Takes Supervised Dress alone Buttons


a-boo remove taking off cloths all dressing; clothes up
Dressing cloths cloths off Unbuttons
clothes
Raise
arms

82
Skill 12 mo 15 mo 18 mo 2 yrs 3 yrs 4 yrs 5 yrs

Cognitive/ Kisses on Seeks Use Parallel Plays Imaginary Knows


request help w/ cause play simple friend alphabet
Adaptive gestures and games
effect 4 colours Sort by size
toys Listens to
Should have Folds stories Knows: Label
object paper same, shapes,
permanence Group play biggest, classify
tallest object
Unscrews
tops

83
84
85
86
87
NEONATOLOGY

88
St Joe’s NICU Common Terms and Definitions List
 

A’s and B’s- (apnea and bradycardia) defined as a cessation of breathing


>20 sec or pause in breathing associated with decrease in oxygen saturation
<85% or HR <100 or change in color or tone. Or just the presence of
bradycardia.
Will be reported as self resolved or requiring stimulation.
Common in preterm infants however must always rule out sepsis.
B/R- Breast feeding.
BLES- Bovine surfactant, medication give for treatment of RDS (Respiratory
distress syndrome) given via ETT (endotracheal tube) dose 5cc/kg. May also
be used in MAS (meconium aspiration syndrome) or severe pneumonia.
CPAP- Continuous positive airway pressure, non invasive form of ventilation
providing continuous PEEP (positive end expiratory pressure) used to keep
airways open and prevent airway collapse. Used in a multitude of settings.
CLD (chronic lung disease) - formerly known as BPD (bronco pulmonary
dysplasia) - CLD is usually defined as oxygen dependency at 36 weeks’
postmenstrual age (PMA) or 28 days’ postnatal age (PNA), in conjunction
with persistent clinical respiratory symptoms and compatible abnormalities on
chest radiographs .
Gavage- form of feeding, by where an OG tube is inserted into the stomach
(placed clinically) and a feed is given by gravity or over a period of time by
pump. Prior to the feed the nurse will generally draw back to see if there is
any residual feed in the stomach. Reported as 0/37, scant/37 or 5/37 where
the first number represents the volume of the residual and the second
number the volume of the feed given. Colour of the residual is important
especially when evaluating for NEC (necrotizing enterocoloitis)
GBS – (group B streptococcus) organism that is a common cause of neonatal
infection, all women should be screened at 35-37 weeks and important to
note at deliveries or on evaluation of infants < 7 days of age.
Histogram- continuous monitoring of oxygen saturations over 1-2 hrs, done
in either prone or supine position. Reported as an average of the time period.

89
Reported as greater than 90 over 90, first number represents the saturation
the second the percentage of the time that baby’s actual O2 saturation is over
that saturation.
Normal for preterm’s 90 over 90
For preterm’s greater than 30 days and diagnosed with CLD 85 over 90.
*Normal values may vary with new research.
IDDM- infant of a diabetic mother. Maternal diabetes can cause a multitude
of neonatal complications, most commonly hypoglycemia.
I/T ratio- immature to total ratio, used in the evaluation of sepsis. Calculated
by taking the total number of immature WBC’s seen on manual differential
(bands, myelocytes, metomyleocytes, and/or promyelocytes) divided by the
total number of neutrophils plus the immature WBC’s.
Immature WBC’s/total neutrophils + immature WBC’s
IUGR (intrauterine growth restriction) - defined as symmetric or asymmetric, if
symmetric both head circumference and weight are less than the 3rd
percentile if asymmetric only the weight is <3rd percentile.
NEC (necrotizing enterocolitis) - Gut infection, characterized by feeding
intolerance, bilious residuals, abdominal distension, bloody stools, with other
signs and symptoms of sepsis.
Nippling- synonymous with bottle feeding, reported as infant nippled 20
(infant took 20cc by bottle)
RDS- (Respiratory Distress syndrome) common in preterm infants or infants
of IDDM (infant of a diabetic mother) due to surfactant deficiency.
TPN- (Total Parenteral Nutrition)- form of nutrition given by IV, contains
glucose and varying amount of Na+, K+, Ca2+ PO43- , lipids and amino acids,
generally used when infants cannot tolerate feeds.

90
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

91
Hamilton Health Sciences Department Manual

Posting Date: 2009-12-08


Posting History Dates:
Title: NEO – Guidelines for Newborn Admission to 4C
4C Admission Criteria Chart

Babies Not Admitted to 4C from either L&D or NICU/L2N


§ Less than 36 wks
§ Any birthweight less than 5th Percentile See table below

Male (SGA) Female (SGA)


Gestation Less than or Less than or
equal to (gm) equal to (gm)
0/7-6/7
36 2144 2052
0/7-6/7
37 2384 2286
0/7-6/7
38 2605 2502
0/7-6/7
39 2786 2680
0/7-6/7
40 2927 2814
0/7-6/7
41 3025 2906
0/7-6/7
42 3070 2954
§ Received Narcan at birth
§ 5 minute Apgar less than 7 at birth
§ Babies of Insulin Dependent Diabetic Mothers less than 38 wks, or greater than/equal to 38 wks if
birthweight greater than/equal to 4000 gm
§ Symptomatic hypoglycemia and baby is unable to be fed (related to tachypnea or handles poorly)
§ Active resuscitation at birth including Positive Pressure Ventilation (PPV) or intubation**
§ Abnormal structural defects detected on ultrasound or physical examination that have the potential to
require ongoing assessment and continuous monitoring
§ Maternal co-morbidities impacting the newborn such as Rh sensitization, Neonatal Alloimmune
Thrombocytopenia
§ Babies who require Finnigan scores
§ Babies at risk of withdrawal related to maternal use of drugs such as street drugs, methadone, pain
medications and SSRIs (based on clinical judgment or observed symptoms)
§ Babies requiring
o continuous cardiorespiratory monitoring (respiratory rate greater than 70; heart rate less than 90 or
greater than 180)
o IV fluids
o IV medication

** Babies who required active resuscitation at birth but 5 minute Apgar greater than/equal to 7
and arterial cord gases normal (pH greater than/equal to 7.0) may be considered for admission to
4C from L&D with a documented assessment by Neonatal.

Babies Who May be Considered for Transfer to 4C from NICU/L2N in consultation with 4C Nursery
On-Call Rota Family Physician

§ Babies greater than/equal to 36 wks gestation whose birth weight was less than 5th %ile for weight (See
SGA chart above) with demonstrated stability post-birth as evidenced by:
o stable temperature maintained in open cot
o no cardiorespiratory monitoring required
o established tolerance of oral feeds
o Hypoglycemia Medical Directive has been discontinued

92
Progress Note: Level 2 Nursery

Date Time

ID: Baby boy (surname)


Born at 335/7 (i.e. 33 weeks and 5 days) gestational age
Day of life (DOL): 12
Corrected Gestational Age: 363 wks (335+ 12 days)
Birth weight: 2680g
Today’s weight: 2550g (↑ 10 g from yesterday)
Brief problem list
e.g. 1. Prematurity
2. Apnea of prematurity
3. Unconjugated hyperbilirubinemia
4. Suspected NEC

S/O: Feeds: frequency, amount, what? (EBM? Formula? Supplement?),


method, regurgitation/vomiting, breast feeding?
Stool/urine pattern
Other signs/symptoms you may be following (e.g. bilirubin)
Behaviour: Settles easily? Irritable? Jittery? Interaction? Sleep? Handling?
Episodes of Apnea/Bradycardia? (A’s and B’s)
IV fluid/rate, urine output
Medications and other treatments (i.e. phototherapy)
Recent labs and investigations.

93
A: Summarize active issues. Stable? Awaiting further
investigations/consult
Differential Diagnosis

P: Outline plan by issue: include investigations, treatment, discharge plans


.
eg. Resolving NEC à increase feeds slowly, starting at EBM 5cc q3h
Jaundice à double phototherapy, recheck bili in am.

Name,  Designation  (CC\PGY),  Pager  Number  

Discussed  with  Dr.  ________________  

94
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

95
Maternal History and Delivery:

____________was born at McMaster University Medical Centre/elsewhere


on (date) at ___ weeks gestational age to (parents’ full names). (Mother’s
name) is a (age) G T P A L woman whose antenatal screens were: rubella
(immune/nonimmune), VDRL (reactive/nonreactive), hepatitis B serum
antigen (-/+), HIV (-/+ __ GA), GBS (+/- at __ GA) and blood group __. This
pregnancy was uneventful/complicated by__________. (Celestone was
administered at __ weeks gestation.) Membranes ruptured __hours prior to
delivery. The infant was born vaginally/caesarian section. Apgar scores
were __ at one minute and __at five minutes. (Insert post-delivery
management.) He/she was appropriate/small/IUGR for gestational age with
dysmorphic/ no dysmorphic features seen. The infant was admitted to the
NICU/L2N and had the following problems.
Cord gases were normal, OR ____.
** If the infant had a prolonged stay in the NICU, refer here to NICU
discharge summary, and do NOT repeat all these details.**
Include only applicable headings below.
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?)

96
Hyperbilirubinemia:
Mother’s blood type is __and infant’s blood type is __. Serum bilirubin
peaked at __mmol/L at __day of life. The infant received __days of
phototherapy.
Hematology:
(List any blood product transfusions). The most recent CBC on (date)
showed a hemoglobin of__, WBC of__x 109/l, a platelet count of __,000 and
no left shift.
Sepsis:
Cultures drawn following delivery were negative/(or) positive for (name of
organism). The infant received a __(# of days) course of (name of
antibiotics). Due to clinical deterioration(s) the infant had a partial/(or) full
septic workup(s) on (date) which grew (name of organism) and was treated
with (name of antibiotic). During the neonatal course the infant had__
episodes of sepsis which were culture negative/positive (state organism(s) if
identified)
Neurological:
Cranial ultrasound(s) done on __day of life showed___(include date and
result of most recent ultrasound). A follow-up ultrasound is recommended in
__weeks.
Retinopathy of Prematurity (ROP):
Routine eye examinations were performed. The most recent examination on
(date) revealed zone__stage __ with no plus disease. A follow-up exam is
strongly recommended in __weeks to exclude progressive ROP. A follow-up
eye appointment has been made at the eye clinic at McMaster for (date and
time).
Neonatal Abstinence Syndrome (NAS):
The infant was monitored with Finnigan Scoring from ___ (date) to ___(date)
for withdrawal symptoms due to maternal use of ___ (list substances
applicable: oxycodone / methadone / cocaine, etc) with a peak Finnigan
score of ___(#) reached on ___ (date). The infant's mother (was / was not)
part of a Methadone program during pregnancy. Maternal urine drug screen
at presentation to L&D on ___ (date) was positive for ___ (list
substance/s). The infant’s urine was collected for drug screening on ___

97
(date) and was positive for ___ (list substances). The infant’s meconium &
hair (was / was not) sent for drug screening. This infant (did / did not) require
morphine treatment for withdrawal symptoms initiated on ___ (date) and
discontinued on ___ (date), up to a maximum dose of ___ mg/kg/day on ___
(date). This infant (did /did not) require treatment with phenobarbital initiated
on ___ (date) at a dose of ___ (#), which was equal to ___ (#) mg/kg/day.
The infant (was / was not) discharged on Phenobarbital ___ (dose), which is
equal to ___ (#) mg/kg/day. The infant’s weaning course off morphine was
___ (describe: quick / slow / a struggle weaning off final doses) and was
complicated by ___ . Final Finnigan scoring in the 48 hrs prior to rooming in
were in the range of ___ (#) to___ (#) . There (was / was not) breastfeeding
restrictions due to the maternal use of ___ .
Fluids, Electrolytes and Nutrition:
Enteral feeds were started on __day of life and the infant achieved full enteral
feeds on __day of life. Presently, the infant is receiving (TPN and/or__cc
q__hourly of expressed breast milk fortified with __package of human milk
fortifier to __mls of EBM (or) name of formula by gavage, breast and/or
bottle) for a total fluid intake of __cc/hour. This provides __cc/kg/d or
kcal/kg/d based on the current weight. On (date) the serum sodium was
__mmol/L, calcium was__mmol/L, and phosphate was __mmol/.
Social:
Social worker ___ (list name) was involved with this infant and his/her family
during the NICU stay due to ___ (reason). CAS (was / was not) involved with
this family due to concerns of ___ . The infant’s CAS worker is ___ (list
worker’s name) who can be reached at ___ (number & extension). At the time
of discharge, the case with CAS will remain (open / closed). This infant will
be going home to the care of ___ (list if it is: biological parents, kinship, foster
care, adoption AND name/s of the individual /s).
Immunizations:
1. Synagis (eligibility and date received or required and reference #).
2. Pentacel (date received or required),
3. Prevnar (date received or required).
4. Hepatitis B Immunoglobin/Vaccination (date received or required).

Discharge Medications: Include iron, calcium/phosphate, vitamins

98
Neonatal Screens:
1. Newborn Screen was completed on (date).
2. Hearing screen was performed on (date) as per Ministry of Health
guidelines. A pass/fail was obtained for one/both ears.

(Name) is being transferred to (hospital/) under the care of (physician) until


he/she can be discharged home OR (Name) is being discharged home to the
care of his parents/foster parents.
Follow-up
The infant requires follow-up for retinopathy of prematurity and cranial
ultrasounds as well as (indicate any follow-up required including growth and
development, appointments, etc.)

Thank you for accepting the care of this infant.

Name, Designation (CC\PGY), Pager Number


Dictating For Dr. (Name of Paediatrician/Neonatologist)

99
Page 1 of 1

100

http://circ.ahajournals.org/content/122/18_suppl_3/S909/F1.large.jpg 5/24/2012
NEONATAL RESUSCITATION DRUGS
1 kg 2 kg 3 kg
< 30 weeks 30-36 weeks > 36 weeks
Epinephrine IV Route 0.1 ml 0.2ml 0.3 ml
1:10,000 (Preferred Route) (0.01mg/kg)
0.1 mg/ml ETT Route 1 ml 2 ml 3 ml
q3-5 minutes (0.1 mg/kg)
Sodium Bicarbonate 4.2% IV
0.5 mmol/ml (2 mmol/kg) 4 ml 8 ml 12 ml
For Prolonged Arrest
Naloxone IV or IM
0.4 mg/ml (0.1 mg/kg) 0.25 ml 0.5 ml 0.75 ml
Contraindicated in narcotic dependent mothers
Volume Expanders 10 ml 20 ml 30 ml
Normal Saline (NS, 0.9 NaCl) 10 ml 20 ml 30 ml
Packed Red Blood Cells
Glucose (D10W) IV Bolus
200 mg/kg 2 ml 4 ml 6 ml
For documented hypoglycemia

101
NICU Nutrition Guidelines
Enteral Feeding 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 1-2 q shift Yes Yes


Assessment
Bottle 1-2 q shift Yes Yes
Near 34 wks
Ad lib Minimum feed Yes
Vol (mL)/ Time (hr)

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.

102
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: By 12-24 hr of age By 12-24 hr of age By 6-12 hours By 6-12 hours
(10-15 ml/kg/d)
Volume/Frequency 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
Tropic Feeds
Nutritional Feeds - Day 4 feeds Day 3 feeds Day 2 feeds Day 2 feeds
Timing
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 3 hourly
>1250g – 3 hourly
Rate of Increase 15-20 mL/kg/d x 3d 15-20 mL/kg/d x 3 d 20-25 mL/kg/d 20-25 mL/kg/d
Then 20-25 mL/kg/d Then 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  

103
Infants > 1500 grams Birth Weight
 

Birth  Weight   1500  –  1750  g   1750  –  1999  g   2000  –  2499  g   >  2500  g  
Gestational   >  29  weeks   >  30  weeks   >  31  weeks   >  34  weeks  
Age  
Amount:          
Day  1  /  Stable   Day  1  /  Stable   Day  1  /  Stable   Day  1  /  Stable  
Nutritional  
Feeds  Timing:  
Amount  /   3  mL  q  3  hr   6  mL  q  3  hr   6  mL  q  3  hr   9-­‐12  mL  q  3  hr  or  ad  lib  
Frequency  
Increase:   3  mL  q  9  hr   3  mL  q  6-­‐9  hr   3  mL  q  3-­‐6  hr   3-­‐6  mL  q  3  hr  
Approx.  rate   36-­‐42  mL/kg/d   32-­‐36  mL/kg/d   Full  feeds  w/i   Full  feeds  w/i    
of  Increase:   24  hours  
48-­‐55  mL/kg/d    24  hours  
Guidelines  for  use:  

1. Choose  appropriate  birth  weight  category.  


2. Check  that  infant  meets  gestational  age  criteria.  
3. If  the  infant’s  gestational  age  falls  below  the  recommended  gestation,  reassess  for  placement  into  previous  birth  weight  
category.  
Feeding  Practice  Guidelines  should  not  be  followed  if:  

• Apgar  score  is  <  3  at  5  min.  of  age  


• Attending  physician  is  not  in  agreement  
• Reassess  placement  on  guidelines  in  infants  with  persistent  feeding  intolerance  
Discontinuation  of  these  Guidelines:    Please  refer  to  the  table  for  Gastric  Aspirates  and  Holding  Feeds  

104
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 à 1 package fortifier per 50 mL EBM
• Increase à 1 package fortifier per 25 mL EBM after 48 hours

Continue Fortification:
• Until infant reaches at least 2.0-2.5 kg or is established at
breastfeeding
• For nutritionally compromised infants, continue fortifier until infant
reaches 2.5 – 3 kg or is established at breastfeeding
• Note: if a baby is breastfeeding 4 times/day, and receives EBM
fortified at 1:25 the other 4 feeds with a NG tube, vitamins and
minerals will need to be reassessed as the total amount of fortifier
is reduced.

105
Formula Selection
 
<34 weeks or <2.0 kg birth weight >34 weeks and
Ø Enfamil Premature 24 A + and reassess when close to term and >2.0kg birth weight
over 2200g
If current weight is over 2200g, If current weight is over If current weight Ø Term
and the birth weight was <1200 2200-3000, and the is >2200g and Formula *
g or infant has BPD baby’s weight is above the 10%ile
Ø Enfamil Premature 24 <10%ile on Fenton on Fenton growth
A+ while in hospital growth chart chart
Ø Enfamil A + Ø Term
If the current weight is >3.0kg Enfacare Formula *
or the infant is ready for
discharge.
Ø Enfamil A + Enfacare
*Term Formulas: Enfamil A+, Similac Advance Nestle Goodstart
Parents may choose formula they wish to use, if no preference, use Enfamil A+ (contract)

Nutrient Composition of Fortified Human Milk / Enfamil


Premature A+ per 100 mL
Nutrient Unfortified Fortified Fortified Enfamil
Premature
1:50 1:25
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
106
Total Parental Nutrition (TPN) in NICU Summary Guidelines

Starting TPN
Infants < 1500 g à Start on modified TPN on admission to NICU
Neostarter (D10W + Protein [1.5g/kg] + Calcium [1mmol/kg] @ 50 cc/kg/day) on Day 1 and TPN by 24-48
hours of age
Infants > 1500 g à Start on TPN by 48-72 hr of age if NOT expected to be enterally fed by 72 hr
Stopping TPN: TPN may be discontinued when an infant is tolerating 75% (or 120 mL/kg/d) of full
enteral feeds

Writing TPN Orders


• Determine total fluid available for TPN. (Total fluid intake minus fluid for IV lines / medications)
• Determine flow rate required to provide desired amount of lipid (see summary).
• The remaining fluid should be used for amino acid / dextrose solution (see summary)

107
Monitoring TPN (TPN) Bloodwork
For infants who have been on TPN > 48 hours; Every Monday (‘Week’ represents week of the month)
Lab \ Week à 1 2 3 4 5 Every Thursday: electrolytes (Na, K), Glucose*, Triglycerides (until
Electrolytes: Na, K x x x X x tolerating full dose)

Glucose* x x x X x Trace Elements: if on long term TPN, once direct bili > 50 mmol/L
send serum for trace elements (Zn, Cu, Se , Mn) – 0.6 mL
Triglycerides x x x X x
Ferritin: Infants > 6 weeks of age on TPN, check serum ferritin
Urea / Creat x x before adding iron
Ca / P x x *send urine for glucose if PCX > 10 mmol/L  

Bili x X x
AST / ALT x X
Albumin X

108
TOTAL PARENTAL NUTRITION (TPN) IN NICU – SUMMARY GUIDELINES
(A) Macronutrients

Dextrose

Prescription mg/kg/min g/kg/day Energy Value: 3.4 kcal/g (0.67 kcal/mmol)


Conversions: 1 mmol = 0.2 g = 200 mg

Initial dose 4–6 6-9 Comments: For peripheral parenteral nutrition, the
osmolar load from dextrose should not exceed
Average Daily Increase 0.5 - 1.0 0.7 - 1.4
500 mmol/L (D10W) unless necessary to maintain
Maximum dose 11 – 13 16 - 19 euglycemia (max D12.5W)  

Protein

Energy Value: 4.0 kcal/g; 16.7 kJ/g


Prescription g/kg/day
For infants < 1500 g à Start on modified TPN à
Source: Primene 10%
Neostarter (D10W + Protein + Calcium) 50 cc/kg/day on NICU
Initial dose * 1.5 admission and TPN by 24-48 hours of age, with other IVs
Avg. daily increase 1.0 **3 g/kg/day acceptable for term infants
Maximum usual dose 3.0 - 3.5** Monitor / reassess maximum protein dose:
• Renal Failure

109
Lipid
Prescription Full PN < 50% PN
Source: SMOF lipid 20%
Initial Dose (g/kg/day) By 24-48 hr of age
0.5 - 1.0 g/kg/day
Average Daily Increase 0.5-1 g/kg/d
(g/kg/day)
Maximum Dose (1) 2.5-3.5 g/kg/day 1-2 g/kg/day
(g/kg/day)
Energy Value: 20% - 2 kcal / mL; 8.4 kJ / mL
Conversions: 20% - 0.2 g fat / mL
Cautions:
• For infants with worsening acute lung disease or hyperbilirubinemia (unconjugated),
Hold lipid at 0.5 - 1.0 g/kg/day until clinical condition improves
• Sepsis - decrease lipid to 1 g/kg/day for first 24 - 48 hr and then increase as tolerated to full rates
Monitor / reassess:
• Triglycerides (TG) every Tuesday and Friday until tolerating maximum dose, then every Tuesday
Interpretation: (<2mmol//L is acceptable)
• Consider lipid restriction for infants with cholestasis. If conjugated bilirubin consistently above 100
mmol/L, consider Omegavan (Use requires approval for special access from Health Canada)

110
TOTAL PARENTAL NUTRITION (TPN) IN NICU – SUMMARY GUIDELINES
(B) Micronutrients
(1) Actual requirements for sodium may be
significantly higher in the first two weeks of life,
depending on urinary losses.
Minerals (Maintenance intakes for stable, growing infants)
(2) Due to the limits of solubility of calcium and
Usual Dose Term Infants > 3kg phosphorus in amino acid solutions, the
(mmol/kg/day) (mmol/kg/day) maximum dose of 15 mmol of calcium and
phosphorus per litre of amino acid solution can
Sodium 2 - 4 (1) 2 only be attained if the total amino acid
concentration is 30 g/L or higher. Otherwise,
Potassium 2 2
precipitation of calcium and phosphorus may
Magnesium 0.2 0.2 occur.
Caution: do not add phosphorus to TPN unless
Calcium 1 - 1.5 (2) 1 there is at least 1 g/kg amino acids added to the
solution. Normal molar ratio of Ca:P is 1:1. Use
Phosphorus 1 - 1.5 (2) 1
caution if unequal amounts of calcium and
Vitamins phosphorus added to TPN solution.

Source: MVI Pediatric (MVI Ped)


Dosage: Initiate at 24-48 hr of age <1kg- 1.5ml
1-3kg- 3.25ml
>3kg- 5ml

111
Trace Elements
Source:
mcg / mL à Zinc Copper Selenium Chromium Manganese Iodine Dose
Neo Trace Element Mix 425 19 2 0.2 1 1 1 mL/kg up 3 mL
Liver Mix* 300 10 2 0.2 1 1 mL/kg up 10 mL
*To be used when direct bilirubin > 50 mmol/L; Send blood for trace elements when changed to Liver Mix
Iron : 0.1-0.2 mg/kg (Initiate at 6 weeks of age for infants on TPN if ferritin <500)  

112
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 Human Milk or Intake < 800 mL/day – 0.5-1.0 mL daily None
After Term Infant Formula Intake > 800 mL/day - none 1.0 mL OD
Discharge Home (human milk only)
1.0 mL Tri-Vi-Sol contains: 10 ug (400 IU) Vitamin D, 450 ug (1500 IU) Vitamin A, 30 mg Vitamin C
1 drop D drops contains : 400 IU vitamin D

113
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  

114
FEEDING GUIDELINES FOR VERY LOW BIRTH WEIGHT BABIES: CHEAT SHEET
Trophic feeds
Birth Initiate Trophic Volume Volume per Interval between Duration Trophic Type of Feeds***
Weight Feeds (mL/kg/d) Feed (mL) feeds (hours) Feeds**
(age in hours)
<750 g 12-24 10-15 1 3-4 3 days EBM / Enf Prem 20
750-999 g 12-24 10-15 1 2-3 2 days EBM/ Enf Prem 20
>1000 g 6-12 10-15 1-2 2 1 day EBM / Enf Prem 20
Nutritional feeds
Birth Initiate Nutritional Volume for Rate of Interval between Time To Full Feeds Type of Feeds
Weight Feeds initiation increase feeds (hours) (days)
(age in days)** (mL/kg/d)* (mL/kg/d)*
< 750 g 4 15-20 15-20 x 3 d 2 12-15 days EBM / Enf Prem 24
then 20-25
750-999 g 3 15-20 15-20 x3d 2 12-15 days EBM / Enf Prem 24
then 20-25
> 1000 g 2 25-30 25-30 <1250g – 2 7 days EBM / Enf Prem 24
>1250g – 3
* Calculate total enteral feed volume for 24 hrs, then divide by number of feeds to get per feed volume. If volume is close to a
0.5 decimal figure, give lower whole number for first 12 hours & higher whole number for next 12 hours. In all other
situations, round off to nearest whole number.
** If trophic feeds delayed, nutritional feeds should also be delayed by the same amount of time
*** May delay trophic feeds maximum 24 hours for mother’s EBM
Worked out examples
• A 750 g baby is getting 40 mL/kg/d on 2nd day of nutritional feeds. Exact feed volume = (40 x 0.75) ÷ 12 = 2.5 mL.
Hence, give 2 mL 2 hrly for 6 feeds & 3 mL 2 hrly for next 6 feeds
• A 1.5 kg baby is getting 55 mL/kg/d on 2rd day of nutritional feeds. Exact feed volume = (55 x 1.5) ÷ 8 = 10.3 mL.
Hence, round off to 10 mL 3 hrly and prescribed enteral intake (mL/kg/d) should be written as 53 mL/kg/d.

Human Milk Fortifier HMF


Initiate Enfamil HMF once feeds reach 100 mL/kg/d
Start at 1 pkg per 50 mL x 48 h; increase to 1 pkg per 25 mL. Consider 1:20 if inadequate growth.

Special Situations
SGA (≤3%)±absent/reverse end diastolic flow Babies on CPAP/NIPPV/NIHFOV
• If abdominal exam is normal, start feeding, but • Start and increase gavage feeds at lowest end of
keep very close watch the range
• Initiate and increase feeding volume at the lowest • If RR consistently ≥80 with significant distress,
end of the range consider withholding or providing only trophic
• Preferably EBM feed
• Preferably avoid continuous or slow bolus feeds
over >60 min especially in babies <1000 g
• Do not rely on abdominal distension as sign of feed
intolerance, especially in babies <1000g
Babies with hypotension Babies on indomethacin/ibuprofen
• Withhold feeds in active shock (BP < normal or • If the baby is already on feeds, do not stop feeds
inotropes >10 mcg/kg/min or dose increasing) but do not increase
• Once stable (i.e. normal BP on weaning dose of • If the baby is not on feeds, trophic feeds with EBM
inotropes <10 mcg/kg/min) start feeds at lowest can be introduced
end of range • Start grading up feeds 12 hours after the last dose
of indomethacin

Feed tolerance
• Increased gastric residual volumes (GRV) as defined below, blood stained residuals, bilious vomiting or repeated
vomiting are signs of intolerance. Check for abdominal tenderness or mass or discoloration or absent bowel sounds.
• Isolated green residuals, isolated increase in girth or minor GRV are not signs of feed intolerance.
• Abdominal circumference may be measured before starting nutritional feeds & thereafter only if grossly visible
abdominal distension noted. Used for documentation but not decision making as it is not reliable..
• Avoid abdominal XR’s for isolated green residuals, isolated increase in girth or minor GRV. Examine baby and order
for AXR if concerned about NEC, ileus or obstruction.

Glycerin tips
• Avoid daily tips. Do not use in first 48-72 hours.
• Bear in mind normal frequency of stooling before prescribing
o Not fed: pass one stool per day Fed 101-150 mL/kg: pass 3 to 4 stools per day
o Fed 1 to 50 mL/kg: pass up to 2 stools per day Fed >150 mL/kg: pass 4 to 5 stools per day
o Fed 51-100 mL/kg: pass up to 3 stools per day

115
Gastric Residual Volume - GRV
Start checking only after following feed volumes (per feed, in mL) achieved
• ≤500 g: 2 mL • 751-1000g: 4 mL
• 501-750 g: 3 mL • >1000g: 5 mL
May check at a lower volume if frequently vomiting or abdomen distended. Use syringe vol ≤5 mL & aspirate very gently.
After gastric residual volume checking started
• Once it is established that baby is consistently feeding well and tolerating: check only 12 hourly
• Continue checking before each feed if there are concerns about increased residual volume
Management of gastric residuals
(watch out for “OR” & “AND”!) Start checking only after above
mentioned feed volume criteria
are met

If GRV <25% of previous feed If GRV 25-50% OR <5 mL/kg If GRV >50% AND >5 mL/kg

Re-feed aspirate and give the full


volume of the next feed Re-feed aspirate but subtract the Re-feed gastric residual volume
volume of the gastric residual up to 50% of the scheduled feed
from volume of next feed volume and withhold next feed
If this recurs, keep re-feeding
aspirate, but consider
subtracting GRV from next feed If problem persists If this recurs in 2 consecutive
volume feeds or 3 times in a 12-hr
period, contact NNP/physician
Try slow bolus over 30 min to examine baby

If it fails Consider withholding


feeds if examination is
concerning
Try slow bolus over 60 min

If it fails

Try reducing feed volume to last well-tolerated feed volume or reduce daily
enteral intake by 20 mL/kg/d

If baby has IV access, increase If baby has no IV access, tolerate


PN/IV fluids to make up TFI up to 20 ml/kg deficit for up to
24 hours, provided the TFI is not
<120 mL/kg/d and
hydration/PCX normal
GRV at a glance
Birth Do not check 5 ml/kg Feed vol when the following If deficit persists for >24 hrs,
weight GRV until feed approx. enteral intake reached start IV to make up deficit
volume is 50 100 150
ml/kg/d ml/kg/d ml/kg/d
500 g 2 mL 2.5 mL 2 mL 4 mL 6 mL
750 g 3 mL 3.75 mL 3 mL 6 mL 9 mL
1000 g 4 mL 5 mL 4 mL 8 mL 12.5 mL
1250 g 5 mL 6.25 mL 8 mL 15.5 mL 23 mL
1500 g 5 mL 7.5 mL 9 mL 19 mL 28 mL
Worked out example
1 kg baby on approx. 100 mL/kg/d feeds (8 mL 2 hrly). If GRV = 1.5 mL, re-feed 1.5 mL & give 8 mL feed. If GRV = 3 mL, re-feed
3 mL & give 5 mL next feed. If GRV = 4 mL, re-feed 4 mL & give 4 mL next feed. If GRV = 5 mL, re-feed 4 mL; withhold next feed.

Gastro-esophageal reflux
• Do not rely on apneas, bradycardias, desaturations or behavioral cues for diagnosing GER
• Do not use medications or thickeners for treating presumed GER
• Keep head end elevated. Left lateral position immediately post-prandial and after half hour keep prone.
• Try slow bolus feeds:
o Over 30 min x 48 hours
o If it fails, try over 45 min x 48 hours For all slow bolus feeds, draw up only desired feed
o If it fails, try over 60 min x 48 hours volume in syringe + tubing; gently squirt in last part
o If it fails, try over 90 min x 48 hours
• Avoid continuous feeds & trans-pyloric feeds as far as possible
• Restore shorter feed volumes as soon as possible

116
Infant Formulas – Indications for Specific Formulas

  Premature  Infant    
Standard  Formulas   Formulas  
For  Term  Infants   Enfamil  Premature  A+  24  
Enfamil  A+  20   Ø Alternative to breastmilk for preterm infants
Similac  Advance  20   Ø 24 kcal/oz. formula for preterm infants < 2-2.2 kg birth
weight
Ø Alternative to breastmilk for healthy term infants Ø in stock
Ø Cow’s milk based Enfamil  Premature  A+  20  
Ø Iron fortified
Ø 20 kcal/oz. in stock (concentrates provided by Nutrition Ø Used for trophic feeds
Services)

Alternative preterm formulas not normally in stock:


Enfamil  Soy  A+  
Similac Special Care 20 ,
Ø Alternative to breastmilk for healthy term infants whose
parents request soy Similac Special Care 24
Ø NOT routinely fed to premature infants
Enfamil  Human  Milk  Fortifier  
Ø 20 kcal/oz. in stock; concentrates provided by Nutrition
Services Ø Supplement for mother’s milk for premature infants <
Enfamil  Lactose  Free  A+   1800 g birth weight, In stock
Ø Alternative to breastmilk for healthy term infants Enfamil Enfacare A+
requiring lactose free formula (NOT for galactosemia) Ø 22 kcal/oz. formula for preterm infants after term
Ø 20 kcal/oz. in stock; concentrates provided by Nutrition corrected age or hospital discharge
Services Ø 22 kcal/oz. in stock; concentrates provided by Nutrition
Services

117
Specialty  Formulas  

Nestle  Goodstart   Enfamil  A+  Thickened  for  Babies  who  spit  up  
Ø Partially hydrolysed protein for term infants at risk for Ø Thickened feed for term infants with GERD and
allergy vomiting, or dyphagia
Ø Term infants with gastroesophageal reflux
Ø 20 kcal/oz in stock; concentrated formulas sent from
nutrition services
Nutramigen  A+  
Ø Term infants at risk for allergy
Ø Term infants with cow’s milk protein allergy
Ø 20 kcal/oz formula in stock; concentrated formulas sent
from nutrition services
Pregestimil  Alimentum  
Ø Term infants with cow’s milk protein allergy
Ø Fat malabsorption
Ø Short Bowel Syndrome
Ø 20 kcal/oz. in stock; concentrates provided by Nutrition
Services
Nutramigen  AA/Neocate  
Ø Term infants with severe cow’s milk protein allergy
Ø Short bowel syndrome
Ø Provided by Nutrition Services
Ø Alternative - Neocate with ARA/DHA

Portagen  

Ø Chylothorax
Ø Severe fat malabsorption
Ø Provided by Nutrition Services

118
Guidelines for Intrapartum Antibiotic Prophylaxis for the Prevention of
Neonatal Sepsis or Early-Onset Neonatal Group B Streptococcus (GBS) Disease
in Newborns 360/7 Weeks Gestation and Greater  

   
 
 
Mother:    
Mother:  
•  presents  in  labour    
• is  delivered  by  elecDve  C/S  
                                                 or  
• has  not  laboured  
•   has    prelabour  rupture  of  membranes  
• has  not  ruptured  membranes                                                    
• regardless  of  GBS  status  
 

  If  GBS  Swab  greater  than  5  weeks  prior  to  


delivery,  treat  GBS  status  as  unknown.  

GBS  Status:       GBS  Status:     GBS  Status:     Mother  with  Suspected  ChorioamnioniCs  
     
 

NEGATIVE   UNKNOWN   POSITIVE    

Regardless  of  her  GBS  status  and  gestaDonal  age  -­‐  


 

Mother  has  signs/symptoms  of  chorioamnioniDs:  


 

 and          -­‐  fever  greater  than  38.0°C  


       -­‐  uterine  tenderness  
Any            -­‐  purulent/foul  smelling  amnioDc  fluid  
Mother  has:            -­‐  maternal  WBC  count  greater  than  15  x109/L  
•   GBS  bacteriuria     MATERNAL  RISK  FACTORS  for  
GBS          -­‐  maternal  tachycardia  greater  than  100  bpm  
     infecDon/UTI  in    
       -­‐  fetal  tachycardia  greater  than  160  bpm  
     current    pregnancy   • Fever  greater  than  38.0°C    
 
Consider:  
 

•   previous  infant     • GestaDonal  age  less  than  37  wks  


 
•  ceEriaxone  2  g  IV  OD  
   with  invasive  GBS     • Rupture  of  membranes  (ROM)            AND  
   infecDon   greater  than  18  hrs  
           metronidazole  500  mg  IV  BID,  then  reassess  
• GBS  bacteriuria  infecDon/UTI  in  
current  pregnancy  
 

Yes   • Previous  infant  with  invasive    


GBS  infecDon  

IAP  f     Yes  


No     IAP  f    

Call  Neo  for  aaendance  at  delivery if  suspected  chorioamnioniDs;


No IAP  f      also  call  as  per  standard  criteria  

Newborn  assessment  
and  care  
 

-­‐  Refer  to  Newborn  Algorithm  


 

 f  IAP - Intrapartum Antibiotic Prophylaxis References  


for Early-Onset Group B Streptococcus (GBS) Disease 1.Barrington, KJ; Canadian Paediatric Society Fetus and
Newborn Committee (Reaffirmed Feb. 1, 2011) Management of
                               Ÿ  penicillin  G  5  million  units  IV,  then  2.5  million  units  IV  q4h  unDl  delivery  
 

the infant at increased risk for sepsis. Paediatr Child Health


           OR          If  allergy  to  penicillin  and  ‘LOW  RISK’  for  anaphylaxis,  then  
 
2007; 12910);893-8.
                       Ÿ  ceFAZolin  2  g  IV  q8h  unDl  delivery   2.SOGC (Oct. 2013) The Prevention of Early-Onset Neonatal
 
Group B Streptococcal Disease. J Obstet Gynaecol Can.
           OR          If  allergy  to  penicillin  and  ‘HIGH  RISK’  for  anaphylaxis  or  allergy  to  cephalosporins,  then   35(10): e1-e10.
                                                                                                                                                                   OR                                                 3.Personal communication (Aug 2012) Dr. M. Fulford, K.
If  GBS  sensiDve  to  clindamycin  AND                                      If  GBS  resistant*  to  clindamycin  OR   Parihar, M. Sung.
4.Verani, J; McGee, L; Schrag, SJ (2010) Prevention of
erythromycin,  then:                                                                                              IF  SENSITIVITY  UNKNOWN,  then:   perinatal group B streptococcal disease: revised guidelines
Ÿclindamycin  900  mg  IV  q8h  unDl  delivery              Ÿvancomycin  1  gram  IV  q12h  unDl  delivery     from CDC. MMWR 59(RR-10): 1-36
                                                                                                                                                                       (if  less  than  85  kg)     (Note: The antibiotic medication content has been amended by
the Antibiotic Stewardship Committee Nov. 5 2012 LY STC and
                                                                                                                                                                     OR                                                                                                                                                                         by Dr. M. Fulford and MS Sept. 18 2013 LY KP and Dr. MF Aug.
     *City  
             o    f      H    amilton                          p  opulaDon                              c    urrently                          h  as                                                    Ÿvancomycin  1.5  grams  q12h  unDl  delivery   18, 2014 AMD BU Dr.MF and KP Jan. 2015, Dr.MF Mar. 2015).  
   40%  resistance  to  clindamycin  
                                                                                                                                                                                                                                                         (greater  than  or  equal  to  85  kg)                                                       FINAL  March  9,  2015    JON  
Care of the Newborn Medical Directive
Assessment and Management Guidelines for Newborns 360/7 Wks Gestation and Greater
at Risk of Neonatal Sepsis or Early-Onset Group B Streptococcus (GBS)
NEWBORN: No protocol prevents all GBS / sepsis 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, notify the MRP. If a second CBC is to be drawn, consider if Ne
there is an order for a CRP (C-Reactive Protein). Alg wbor
ori n
Maternal care team members will:
thm
•  call Neo for attendance at delivery if required for suspected chorioamnionitis and as per standard criteria
•  include risk factors for sepsis/GBS in medical handover and in nursing Transfer of Accountability (TOA)

¥ No
Newborn appears well Notify Neo/Newborn MRP

Mother is GBS NEGATIVE and


Rupture of Membranes (ROM) Yes
greater than 18 hrs

If mother required IAPf, did she


receive at least one dose of IAP No
•  ¥Newborn VS and clinical greater than or equal to 4 hrs
prior to delivery with penicillin or
assessment q4 h post transitional cefazolin?
checks for first 24 hrs; CBC & diff
Determine:
at 12 hrs
•  gestation
•  Observe newborn 48 hrs or Yes •  length of ROM
longer; may be discharged in
24 hrs if discharge criteria are met
and family has immediate access
to care High Risk Newborn
Routine Newborn Care Low Risk Newborn
Newborn care providers Gestation greater than Gestation less than 37 wks
are aware of maternal or equal to 37 wks OR
GBS status, maternal AND ROM greater than or equal
risk factorst and IAP f ROM less than 18 hrs to 18 hrs
status

Observe newborn 48 hrs or ¥Newborn VS and clinical


longer; may be discharged in
24 hrs if discharge criteria are assessment q 4 h post
met and family has immediate transitional checks for first
access to care 24 hrs; CBC & diff at 12 hrs;
observe minimum 48 hrs
If mother with ¥
Newborn
suspected appears Yes
chorioamnionitis well
Newborn appears well and CBC
result is WBC greater than 5.0
No x109/L and no left shift

Yes
Notify
Neo/Newborn
MRP Discharge as per orders and when all
discharge criteria are met; ensure parent
teaching re: signs and symptoms of sepsis
¥ Newborn VS and Clinical Assessment for
Signs/Symptoms of Newborn Sepsis/GBS: t
f
IAP - Intrapartum Antibiotic Prophylaxis - Temperature instability (<36.0°C,>38.0°C) Maternal Risk Factors For Neonatal
for Early-Onset Group B - Signs of resp.distress; resp.dist. starting more than 4 hrs Sepsis or Early-Onset GBS:
Streptococcus (GBS) Disease after birth; apnea
- Altered behaviour or responsiveness
• ROM greater than 18hrs
- Altered muscle tone – lethargy • GA less than 37 wks
- Feeding difficulties – refusal, intolerance (vomiting) • GBS bacteriuria infection / UTI in
- Abnormal heart rate – bradycardia, tachycardia current pregnancy
- Hypoxia – central cyanosis or decreased O2 saturation level • Previous infant with invasive GBS
- Hypoglycemia infection
- Jaundice in first 24 hours • Maternal fever greater than 38.0oC
- Seizures
- Abnormal CBC: left shift, WBC less than 5.0 x 109/L
Any newborn with signs/symptoms of sepsis requires
full diagnostic evaluation by Pediatrics.
References
• Barrington, KJ; Canadian Paediatric Society Fetus and Newborn Committee (Reaffirmed Feb. 1, 2011) Management of the infant at increased risk for sepsis. Paediatr Child Health 2007; 12910);893-8.
• NICE Guidelines. Antibiotics for early-onset neonatal infection: Antibiotics for the prevention and treatment of early-onset neonatal infection. https://www.nice.org.uk/Guidance/CG149. Updated August
2012. Accessed September 17, 2014.
• 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) Dr. M. Fulford, K. Parihar, M. Sung. FINAL MARCH 9/15 JON
• Verani, J; McGee, L; Schrag, SJ (2010) Prevention of perinatal group B streptococcal disease: revised guidelines from CDC. MMWR 59(RR-10): 1-36
Calculating a Left Shift

121
ASSESSMENT AND MANAGEMENT GUIDELINES FOR NEWBORNS 35 WEEKS GESTATION AND GREATER AT RISK OF NEONATAL SEPSIS

ROM greater than 18 hrs. Well Baby Intrapartum chorioamnionitis


OR
Maternal GBS Status suspected or confirmed if:
2 temps greater than 38oC
(NO Chorio) Maternal temperature greater than 38 C x2 30 minutes apart
o

  OR
One Maternal temperature greater than 38.3 C o

Negative Unknown Positive PLUS one of the following:

YES
Maternal tachycardia greater than 100 bpm
Fetal tachycardia greater than 160 bpm
NO
Uterine tenderness
Foul amniotic fluid
Intrapartum ROM greater than 18 hours
Risk Factors Present?
Delivery at less than 37 weeks Gestational age less than 37 weeks
Routine Clinical Care
Rupture of Membranes (ROM) greater than or equal too18 hrs
Intrapartum Maternal temperature greater than 38 C
Pediatrics to attend delivery
Previous infant with invasive GBS
GBS bacteriuria in current
Isolated Maternal Temp. pregnancy
x 1 ONLY
NO Chorio
Well Unwell

If elective C/S, NO ROM, NO YES NICU


NO labour, regardless of
GBS status

Vitals & Assessment CBC & diff at 12 hrs


q 4hrs. x 24hrs. Results called to:
Appropriate
__________________________
IV Antibiotics
greater than 4 hours _______________________ at ___________ hrs
prior to delivery I:T ratio __________

Less than 37 weeks


OR WBC less than 5.0
YES NO ROM greater than 18 hours NO and/or Consult PEDS
I:T greater than 0.2

Observe for NO YES Observe greater than or


48 hrs ** equal to 48 hrs.
FOOTNOTES

*The ** denote ‘if greater than 37 weeks gestation, observation may occur at home after 24 hours if other discharge criteria have been met and the caregivers are able to comply
fully with instructions for home observation. If any of these conditions are not met, the baby should be observed until at least 48 hours and until discharge criteria are met. ©2015
= Entryway122
HAMILTON HEALTH SCIENCES
Issue Date: 2005 10 04 Page 5 of 7
Last Renewal Date: 2014 07 15
Title: MAC – MD - Care of the Newborn 35 Weeks Gestation or greater, Symptomatic or at
Risk of Hypoglycemia #44005

Appendix A
Definitions to Support Nursing Assessment and Action

At risk includes babies who meet any of the following maternal/newborn criteria:
The newborn is at risk for hypoglycemia if:
ƒ Any maternal diabetes (gestational, type 1 or 2, with or without insulin)
ƒ Maternal hypertension treated with beta blockers, including single dose (eg. atenolol,
labetalol)
ƒ Large for gestational age (LGA – greater than 95th percentile) or small for gestational age
(SGA – less than 5th percentile)
ƒ Preterm gestation less than 37 0/7 weeks
ƒ Newborn conditions: respiratory distress (increased work of breathing), infection,
hypothermia (axilla temperature less than 36.5϶C)

BG: blood glucose in mmol/L

Point of Care Test (POCT) Blood Glucose Reading measured by glucose meter:
This provides only a range and does not give an exact blood glucose level. POCT blood glucose
results measured by glucose meter are useful only as a screening test. If there is a capillary blood
glucose reading less than 3.1 mmol/L, draw a blood glucose sample for laboratory evaluation (lab).

Symptomatic: exhibits one or more of the following – jitteriness or tremors, changes in levels of
consciousness (irritability, lethargy, stupor) poor feeding, poor suck, hypotonia, limpness,
hypothermia, apnea, cyanotic spells, seizures, coma.

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, including assistance with breast massage and hand expression 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 whenever possible.

Formula Feed: Formula will be fed to infants whose mothers have made an informed choice to
formula feed.

Supplemental Feed: The first choice for supplement is EBM (expressed breast milk). A
breastfeeding mother of an hypoglycemic infant should be instructed re: breast massage and hand
expression and begin pumping immediately. It is best to begin pumping within the 1st hour, and if
not then, within the first 4-6 hours following birth. She should be using a hospital grade electric
breast pump with a double kit to provide milk to augment feeds. If mother’s colostrum/milk is not
available by hand expression/pumping, formula will be used. The supplement will be offered using
an alternate feeding method according to the procedure: Supplementation of the Full Term
Breastfed Infant in the First Few Days of Life. Supplementation should be supervised by a health
professional. Attempts at supplementation should not exceed 20 minutes. If the required amount
(5-10 mL/kg/feed) cannot be taken in the 20 minutes, consider the baby unable to feed and notify
the physician or midwife.

Copyright Hamilton Health Sciences 123


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HAMILTON HEALTH SCIENCES
Issue Date: 2005 10 04 Page 6 of 7
Last Renewal Date: 2014 07 15
Title: MAC – MD - Care of the Newborn 35 Weeks Gestation or greater, Symptomatic or at
Risk of Hypoglycemia #44005

Appendix A
Definitions (Continued)

Gestation
Male Female
(completed
Weight in gm Weight in gm
weeks)
SGA LGA SGA LGA
36 Less than or Greater than or Less than or Greater than or equal to
equal to 2144 equal to 3604 equal to 2052 3523
37 Less than or Greater than or Less than or Greater than or equal to
equal to 2384 equal to 3857 equal to 2286 3752
38 Less than or Greater than or Less than or Greater than or equal to
equal to 2605 equal to 4065 equal to 2502 3931
39 Less than or Greater than or Less than or Greater than or equal to
equal to 2786 equal to 4232 equal to 2680 4076
40 Less than or Greater than or Less than or Greater than or equal to
equal to 2927 equal to 4382 equal to 2814 4212
41 Less than or Greater than or Less than or Greater than or equal to
equal to 3025 equal to 4512 equal to 2906 4330
42 Less than or Greater than or Less than or Greater than or equal to
equal to 3070 equal to 4631 equal to 2954 4423

SGA: less than the 5th percentile for birth weight and gestational age
LGA: greater than the 95th percentile for birth weight and gestational age

Kramer et al. (2001) It is recognized that these weights deviate from the CPS Guidelines (2005) of the
10th and 90th percentile cut-offs for birthweight at term.

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HAMILTON HEALTH SCIENCES
Issue Date: 2005 10 04 Page 7 of 7
Last Renewal Date: 2014 07 15
Title: MAC – MD - Care of the Newborn 35 Weeks Gestation or greater, Symptomatic or at
Risk of Hypoglycemia #44005

HYPOGLYCEMIA GUIDELINES FOR THE AT-RISK NEWBORN 35 WKS GESTATION AND GREATER
This NEONATAL HYPOGLYCEMIA PROTOCOL applies to all McMaster locations outside of Level 3. Please note that LEVEL 3 has a separate protocol that may be more applicable.
1. If baby is unable to tolerate feeds at any point in these guidelines, notify the MRP/Senior Pediatric Resident #1645.
He/she will then assess the need for consult/transfer of care to a Pediatrician or make treatment/transfer decisions.
2. If Neo was in attendance at delivery and the initial 2 h lab glucose result is less than 1.0 mmol/L (Box 1),
Neo can be called to follow-up on the lab glucose result regardless of the baby䇻s location at the time the lab glucose
result becomes available.

NEWBORN BABY
All glucose results in mmol/L.
SYMPTOMATIC ASYMPTOMATIC If POCT glucose (meter) result is
greater than or equal to 3.1, then lab
glucose does not need to be sent.
The baby DOES NOT SHOW signs/symptoms of hypoglycemia.
The baby DOES SHOW signs/
symptoms of hypoglycemia.
Skin-to-skin,
routine care
Does baby have any RISK FACTORS for hypoglycemia?
NO and feed on
Immediately: YES demand.
• check POCT glucose and send lab
glucose if less than 3.1
Skin-to-skin, routine care and feed within 1h of birth
preferred method: breast  or
• if VS stable, feed baby by mom’s If at any time 3 AC or PC lab
results are less than 2.6,
formula feed 10 mL/kg
• L&D notify MD/Neo, NP/Neo Do POCT glucose at 2 hrs Consult/notify Pediatrics*
• 4C Nsy consult Pediatrics*
 Mom breastfeeds - she is
POCT glucose less than 3.1 assisted with breast massage
MD/Neo,NP/Neo (in L&D) or
and hand expression.
Pediatrics* (in 4C Nsy) will:
• make treatment decisions and Do lab glucose and feed by
may consider transfer to L2N/ mom䇻s preferred method
NICU for IV therapy POCT greater than or equal to 3.1
1 or
1 2 3 Lab greater than or equal to 2.6
1 Lab less than 1.0: Lab 1.0 - 1.7: Lab 1.8 - 2.5: • Breast / EBM / formula feeds q2h and
• Feed formula 10 mL/kg now • Supplement formula • Feed by mom䇻s observe for signs/symptoms of hypoglycemia
now: breast or
• Consult Pediatrics* immediately 5-10 mL/kg preferred method
to make arrangements for
transfer to L2N/NICU for IV formula
therapy (if Neo attended delivery, Follow (A), (B) or (C)
please call Neo)
• Recheck lab glucose q3-4h AC feeds; may
Recheck lab glucose 1 hour PC feed. be every other feed as long as baby remains
Observe for signs/symptoms of hypoglycemia. asymptomatic

1 hour PC glucose 1.8-2.5:


• Feed by mom䇻s preferred method: breast or
1 hour PC glucose less than 1.8: A) If baby LGA or Infant of Diabetic Mother
• Consult Pediatrics* to make (IDM): Obtain 2 more consecutive results
formula 5-10 mL/kg now and do 1 hour PC glucose:
treatment decision; may greater than or equal to 2.6, then stop.
consider transfer to L2N/NICU
for IV therapy B) If baby SGA or late preterm: Obtain 2 more
• If this 1 hour PC glucose • If this 1 hour PC
consecutive results greater than or equal to 2.6;
less than 2.6, consult glucose greater than
do lab glucose AC feeds at 12 hrs (if not done in
*Pediatrics Pediatrics* to make or equal to 2.6, feed
the previous 2 hrs) and at 24 hrs, then stop.
Monday to Friday treatment decisions; mom䇻s preferred
0800h-1700h may consider transfer to method q2h (no AC
L2N/NICU for IV therapy glucose check for this C) For beta blockers and other newborn
Page Team 3 conditions: If 1 more AC result is greater than or
feed)
Attending Pediatrician equal to 2.6, then stop.
• Begin AC glucose checks at next feed until 2
Evenings, Weekends consecutive AC glucose results greater than or
& Holidays equal to 2.6, then continue to feed q2h x first 24
ANY GLUCOSE RESULT LESS THAN 2.6,
0800h-1600h Page #5303 hrs of age, then feed on demand post 24 hrs of GO TO BOX 1 , 2 , or 3
LY Drs. MR SS JON Approval July 15, 2014 Hamilton Health Sciences

and at all other times age


Page Sr Peds Res #1645
SGA/LGA th
LGA:: greater than 95 %ile for birth weight & gestational age
LGA
Parameters th
SGA: less than 5 %ile for birth weight and gestational age
Clinical Signs/Symptoms (S/S) Risk Factors for Hypoglycemia Gestation Male Female
• Any maternal diabetes (gestational, Type I or II, with Weight in gms Weight in gms
Associated with Hypoglycemia*:
or without insulin) SGA LGA SGA LGA
• Jitteriness, tremors Completed Less than Greater than Less than Greater than
• Late Preterm 34 0/7 – 36 6/7 weeks gestation
• Changes in levels of consciousness Weeks or equal to: or equal to: or equal to: or equal to:
• SGA, LGA
- Irritability, lethargy, stupor
• Maternal hypertension treated with beta blockers,
• Poor feeding, poor suck 36
• Hypotonia, limpness
including single dose < 2144 > 3604 < 2052 > 3523
• Newborn conditions: respiratory distress (increased
• Hypothermia 37 2384 3857 2286 3752
work of breathing), infection, hypothermia (axilla
• Apnea, cyanotic *Clinical signs should temperature less than 36.5oC) 38 2605 4065 2502 3931
spells be alleviated with
• Seizures treatment of plasma Legend: MRP = Most Responsible Person 39 2786 4232 2680 4076
• Coma glucose levels.. EBM=Expressed Breast Milk SGA=Small for Gestational
Age LGA=Large for Gestational Age IDM = Infant of a 40 2927 4382 2814 4212
References: Diabetic Mother
Aziz, K., CPS (2004, Reaffirmed 2013), Pediatri Child Health Late Preterm – 34 0/7 – 36 6/7 wks gestation
Adamkin, D., AAP, Pediatrics (2011) 41 3025 4512 2906 4330
Cornblath, M. Pediatrics (2000)
AC = before feeds PC = after feeds Lab = laboratory
Rozance, P.J. Early Human Development (May 2010) POCT = blood glucose measured by glucose meter 42 3070 4631 2954 4423
Weston, H.,Tam, E. eNeonatal Review (2012)

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129
Screening for Hypoglycemia Guidelines
of the asymptomatic at-Risk Newborn

Asymptomatic Newborn If at anytime 3 WBG AC or PC less than 2.6 call MRP.

Does baby have any RISK factors for Routine care and feed on demand as
hypoglycemia? (See chart below) NO long as baby remains well

YES

Skin to skin and baby to breast/feed by 1 hour of age then WBG at 2 hours of age after initial feed

WBG less WBG 1.0 - 1.7 WBG 1.8 - 2.5 WBG greater than or equal
than 1.0 Asymptomatic give Asymptomatic, observe and assist with feed now to 2.6:
Notify Staff 5-10 ml/kg (Use EBM/ then do 1 hour PC
Pediatrician formula). Decant exact A) If baby SGA or late
immediatley amount of supplement preterm, do AC WBG for 2
and warm it prior to feed. consecutive feeds. If greater
Nurse to observe and than or equal to 2.6 than
assist with feed. repeat WBG at 12 hrs, at
If 1.8 to 2.5 24 hrs.
give 5-10 ml/kg
then do WBG 1 B) For all other babies, do
If less hour PC. Decant If greater than AC WBG for 2 consecutive
than 1.8, exact amount of 2.6 go to feeds. If greater than or
notify Staff supplement and box 4 equal to 2.6 than stop.
Do PC WBG Pediatrician warm it prior to feed.
(1 hour from time feed Nurse to observe
finished) If greater than and assist with feed.
or equal to 2.6 go to box
4. If less than 2.6, notify
Staff Pediatrician

If less than If greater than 2.6


2.6, notify Staff go to box 4
Pediatrician

If at anytime AC WBG is not greater than or equal to 2.6 go to box 1, 2 or 3.

Risk Factors for Hypoglycemia: Legend: Gestation Male Female


• Maternal hypertension treated with beta blockers, inluding single dose WBG = Whole Blood Glucose
(complete Weight in gm Weight in gm
weekly)
• Any maternal diabetes (gestational, Type I, or II, with or without insulin) MRP = Most Responsible Physician SGA LGA SGA LGA
• SGA – less than 5th percentile AC = Before Feeds 36 Less than or Greater than or Less than or Greater than or
equal to 2144 equal to 3604 equal to 2052 equal to 3523
• LGA – greater than 95th percentile EBM = Express Breast Milk
37 Less than or Greater than or Less than or Greater than or
• Preterm – less than 37 0/7 weeks SGA = Small for Gestational Age equal to 2384 equal to 3857 equal to 2286 equal to 3752
• Cold stress – Hypothermia – axilla temperature less than 36.5˚ C MD = Medical Doctor Less than or Greater than or Less than or Greater than or
38
• Newborns with medical conditions, eg. respiratory distress, sepsis MW = Midwife equal to 2605 equal to 4065 equal to 2502 equal to 3931
PC = After Feeds 39 Less than or Greater than or Less than or Greater than or
IDM = Infant to a Diabetic Mother equal to 2786 equal to 4232 equal to 2680 equal to 4076
LGA = Large for Gestational Age 40 Less than or Greater than or Less than or Greater than or
equal to 2927 equal to 4382 equal to 2814 equal to 4212
41 Less than or Greater than or Less than or Greater than or
References: equal to 3025 equal to 4512 equal to 2906 equal to 4330
• ACoRN - Acute Care of at-Risk Newborns (2005) Less than or Greater than or Less than or Greater than or
42
• Canadian Pediatrics Society. Screening Guidelines for equal to 3070 equal to 4631 equal to 2954 equal to 4423
Newborns at Risk for Low Blood Glucose. SGA = less than 5th percentile for birth weight and gestational age
Pediatrics and Child Health (2004). LGA = greater than 95th percentile for birth weight and gestational age

130
Hyperbilirubinemia Assessment Sheets for Initiation of Phototherapy
 
 

   

131
Hyperbilirubinemia Phototherapy
Assessment Sheet for Newborns
35 Weeks or More Gestation
on Mother-Baby unit
400
TSB = Total Serum Bilirubin  µmol/L

350

300

250

= Indicates which
risk line to use
200

D
150

E
100

V
50

O
0
Birth 12 24 36 48 60 72 84 96 108 120 132 144 156 168

R
Age in Hours
Infants at Higher Risk    Infants at Medium Risk     Infants at Lower Risk
x = bilirubin level   √ = start phototherapy   = stop phototherapy

Guidelines for the Initiation of Phototherapy:


❑ 

P
Infants at Lower Risk:
P
greater than or equal to 38 weeks and no risk factors

A
❑  Infants at Medium Risk: greater than or equal to 38 weeks with risk factors Irradiance Initials
OR 35-37 6⁄7 weeks and no risk factors Reading
µW/cm2/nm
❑  Infants at Higher Risk: 35–37 6⁄7 weeks with risk factors
BiliBlanket
Risk Factors for Encephalopathy for Initiation of Phototherapy:
(Adjust Risk Line accordingly)
Light
❑ ABO or Rh incompatibility – hemolysis due to maternal isoimmunization, Source
e.g. positive Coombs (some other causes of hemolysis to consider if there
is a positive family hx of: G6PD deficiency, pyruvate kinase deficiency,
congenital spherocytosis)

Jaundice occurring before 24 hours of age is considered “pathologic” – a Pediatric consult should be considered.
Date Time Age in TSB Name of
Printed Name Signature & Designation
(yyyy/mm/dd) (hh:mm) hours µmol/L MD/MW notified

PD 8763 (2014-09)
Sheet Number of
Labs –Labs 132
Page 1 of 2
Risk Factors for Severe Hyperbilirubinemia
(Do NOT adjust phototherapy risk line based on these risk factors)
• Previous sibling with newborn jaundice requiring phototherapy
• Cephalhematoma or significant bruising
• Asian race (as defined by mother’s description)

Exchange Transfusion Nomogram

E D
OV
P R
P
If phototherapy is indicated, determine if the Total Serum Bilirubin (TSB) is

A
within 50 µmol/L of the exchange transfusion line on the Exchange Transfusion
Nomogram.

Plot the TSB on the Exchange Transfusion Nomogram using the same risk line as
was used for the phototherapy nomogram.
If baby is within 50 µmol/L of exchange, intensify phototherapy and consider other
interventions such as optimizing hydration and consider IV Immune Globulin if
Coombs/DAT positive. May consider exchange.

Reference: Provincial Council for Maternal Child Health. February 2014. Quality-Based Procedure
Hyperbilirubinemia in Term and Late Pre-Term Infants (> 35 weeks) TOOLKIT
www.pcmch.org.

PD 8763 (2014-09)
Labs –Labs 133
Page 2 of 2
Hyperbilirubinemia Screening
Assessment for Newborns

38 or More Weeks Gestation


(This form is not valid for babies who have
received or are receiving phototherapy)

BILIRUBIN NOMOGRAM X = Bilirubin Level Gestational Age: _____ weeks


325
High Risk Zone
300 Mother’s Blood Group: _____
High Intermediate Risk Zone
275
Baby’s Blood Group: _____
250
Low Intermediate Risk Zone
225 COOMBS TEST/DAT
(see reverse for Algorithm)
Low Risk Zone
200
Bilirubin umol/L

175
Coombs Test / DAT 
is indicated if baby
150 is HIZ or higher
125 Coombs Test (DAT)
100 q NEGATIVE
75 q POSITIVE
50
18 30 42 54 66 78 90 102 114 126 138
0 12 24 36 48 60 72 84 96 108 120 132 144
Age in hours

Risk Factors for Severe Hyperbilirubinemia: Please check any that apply
q Coombs positive q Cephalohaematoma or significant bruising
q Previous sibling requiring phototherapy q Asian race
Screening Name of MRP /
Date Time Age in TSB Follow-Up Code Init.
(yyyy/mm/dd) (hh:mm) hours µmol/L (see below) Midwife notified
X
X
X
X
Screening Follow-Up Codes
*These follow-up codes apply only to the initial screening TSB
Nomogram Risk Zone CODE NR = No Risk Factors for Hyperbilirubinemia CODE R = Risk Factors present for Hyperbilirubinemia
Low Risk Zone LRZ-NR Follow-up within 48 hours LRZ-R Follow-up within 48 hours
Low-Intermediate LIZ-NR Follow-up within 48 hours LIZ-R Follow-up within 48 hours
Risk Zone
High-Intermediate HIZ-NR
Follow-up within 48 hours. Follow-up assessment including TSB
HIZ-R
Risk Zone Consider TSB at follow-up within 24 hours
High Risk Zone HRZ-NR Repeat TSB in 4-24 hours HRZ-R Repeat TSB in 4-24 hours
Initial all applicable responses    TSB = Total Serum Bilirubin

Initials Printed Name Signature & Designation

PD 8765 (2014-09)
Distribution: White Copy - Patient Chart Yellow Copy - Family Physician / Midwife upon discharge
Pink Copy - Parent / Guardian 134 Page 1 of 2
Labs – Labs
HYPERBILIRUBINEMIA – COOMBS TEST ALGORITHM
When a Coombs test needs to be done as part of the newborn hyperbilirubinemia assessment,
please follow the algorithm below based upon the mother’s blood group:

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

Babies of all Rh negative mothers will


automatically have their blood group When the Transfusion Medicine Lab
done at time of birth by Transfusion receives an order to do a Coombs
Coombs Test IS NOT required.
Medicine Lab to determine if mother test, the Lab will do the baby’s blood
needs another dose of Rh immune group first.
globulin.

Baby O –ve Baby Baby O –ve Baby


or O +ve A* or B* or O +ve A* or B* NOTE:
If any antibodies are detected prena-
tally, then a Coombs’ test must al-
Coombs Test
Coombs Test
Coombs Test
Coombs Test
ways be done regardless of mother’s
IS NOT re- IS NOT re- and baby’s blood types.
IS required IS required
quired quired

*A = A +ve and A –ve *B = B +ve and B –ve

Risk Factors for Severe Hyperbilirubinemia:


• Coombs positive
• Previous sibling requiring phototherapy
• Cephalohaematoma or significant bruising
• Asian race

Standard Follow-up Care


Follow-up appointment within 48 hours after or Follow-up appointment within 24 hours after
discharge with MD or MW if baby is greater discharge with MD or MW if baby is less than
than 48 hours of age at time of discharge. 48 hours of age at time of discharge.

If the baby is in the LRZ-R or LIZ-NR (Low Risk Zone-Risk or Low Intermediate Risk Zone with No
Risk factors) 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 Standard Follow-up Care outlined above.

Bilirubin Risk Zone Predictive Bilirubin Risk Zone Levels at Follow-Up


 94%  remain in Low Risk Zone
Low Risk Zone
 6%  may jump to Low-Intermediate Risk Zone
 2%  may jump to High Risk Zone
Low-Intermediate Risk Zone
 5%  may jump to High-Intermediate Risk Zone
High-Intermediate Risk Zone  13%  may jump to High Risk Zone

High Risk Zone  57%   remain in High Risk Zone


PD 8765 (2014-08)
Distribution: White Copy - Patient Chart Yellow Copy - Family Physician / Midwife upon discharge
Pink Copy - Parent / Guardian Page135
2 of 2
Labs – Labs
Hyperbilirubinemia Screening
Assessment for Newborns

35 - 37 6/7 Weeks Gestation


(This form is not valid for babies who have
received or are receiving phototherapy)

BILIRUBIN NOMOGRAM X = Bilirubin Level


325
Gestational Age: _____ weeks
High Risk Zone
300 Mother’s Blood Group: _____
High Intermediate Risk Zone
275
Baby’s Blood Group: _____
250
Low Intermediate Risk Zone
225 COOMBS TEST/DAT
Low Risk Zone (see reverse for Algorithm)
200
Bilirubin umol/L

175 Coombs Test / DAT 


is indicated if baby
150
is LIZ or higher
125
Coombs Test (DAT)
100
q NEGATIVE
75
q POSITIVE
50
18 30 42 54 66 78 90 102 114 126 138
0 12 24 36 48 60 72 84 96 108 120 132 144
Age in hours

Risk Factors for Severe Hyperbilirubinemia: Please check any that apply
q Coombs positive q Cephalohaematoma or significant bruising
q Previous sibling requiring phototherapy q Asian race
Screening Name of MRP /
Date Time Age in TSB Follow-Up Code Init.
(yyyy/mm/dd) (hh:mm) hours µmol/L (see below) Midwife notified
X
X
X
X
Screening Follow-Up Codes
*These follow-up codes apply only to the initial screening TSB
Nomogram Risk Zone CODE NR = No Risk Factors for Hyperbilirubinemia CODE R = Risk Factors present for Hyperbilirubinemia
Low Risk Zone LRZ-NR Follow-up within 48 hours LRZ-R Follow-up within 48 hours
Low-Intermediate LIZ-NR Follow-up within 48 hours
Follow-up within 48 hours.
LIZ-R
Risk Zone Consider TSB at follow-up
High-Intermediate HIZ-NR
Follow-up assessment including TSB
HIZ-R Repeat TSB in 4-8 hours
Risk Zone within 24 hours
High Risk Zone HRZ-NR Repeat TSB in 4-24 hours HRZ-R Repeat TSB in 4-8 hours
Initial all applicable responses    TSB = Total Serum Bilirubin
Initials Printed Name Signature & Designation

PD 8764 (2014-09)
Distribution: White Copy - Patient Chart Yellow Copy - Family Physician / Midwife upon discharge
Pink Copy - Parent / Guardian 136 Page 1 of 2
Labs – Labs
HYPERBILIRUBINEMIA – COOMBS TEST ALGORITHM
When a Coombs test needs to be done as part of the newborn hyperbilirubinemia assessment,
please follow the algorithm below based upon the mother’s blood group:

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

Babies of all Rh negative mothers will


automatically have their blood group When the Transfusion Medicine Lab
done at time of birth by Transfusion receives an order to do a Coombs
Coombs Test IS NOT required.
Medicine Lab to determine if mother test, the Lab will do the baby’s blood
needs another dose of Rh immune group first.
globulin.

Baby O –ve Baby Baby O –ve Baby


or O +ve A* or B* or O +ve A* or B* NOTE:
If any antibodies are detected prena-
tally, then a Coombs’ test must al-
Coombs Test
Coombs Test
Coombs Test
Coombs Test
ways be done regardless of mother’s
IS NOT re- IS NOT re- and baby’s blood types.
IS required IS required
quired quired

*A = A +ve and A –ve *B = B +ve and B –ve

Risk Factors for Severe Hyperbilirubinemia:


• Coombs positive
• Previous sibling requiring phototherapy
• Cephalohaematoma or significant bruising
• Asian race

Standard Follow-up Care


Follow-up appointment within 48 hours after or Follow-up appointment within 24 hours after
discharge with MD or MW if baby is greater discharge with MD or MW if baby is less than
than 48 hours of age at time of discharge. 48 hours of age at time of discharge.
If the baby is in the LRZ-R/LRZ-NR or LIZ-NR (Low Risk Zone-Risk/Low-Risk Zone-No Risk or
Low Intermediate Risk Zone with No Risk factors) 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 Standard Follow-
up Care outlined above.

Bilirubin Risk Zone Predictive Bilirubin Risk Zone Levels at Follow-Up


 94%  remain in Low Risk Zone
Low Risk Zone
 6%  may jump to Low-Intermediate Risk Zone
 2%  may jump to High Risk Zone
Low-Intermediate Risk Zone
 5%  may jump to High-Intermediate Risk Zone
High-Intermediate Risk Zone  13%  may jump to High Risk Zone

High Risk Zone  57%   remain in High Risk Zone


PD 8764 (2014-09)
Distribution: White Copy - Patient Chart Yellow Copy - Family Physician / Midwife upon discharge
Pink Copy - Parent / Guardian Page137
2 of 2
Labs – Labs
McMaster Children’s Hospital
Phototherarpy Guidelines
Infants less than 35 weeks and/or less than 2500 gms

Optimal Phototherapy demands the use of irradiance in the 425-475 nm


band delivered to as much of the infants’ surface area as possible. If possible,
place phototherapy lights at a distance of 30 cm from the infant.
1. Use total serum bilirubin. Do not subtract direct or conjugated bilirubin
2. Use gestational age rather that birthweight if gestational age is accurate
3. Start phototherapy (irradiance ≥ 30 µW/cm2/nm) when total serum
bilirubin (TSB) is = the line according to gestation or weight.
4. Start bili blanket when TSB is > 17-34 µ mol/L above the line according
to gestational age or weight
5. In the presence of risk factors use one line lower (use gestation below)
until <1000 gms
6. Risk factors: isoimmune hemolytic disease, G6PD deficiency, asphyxia,
sepsis, acidosis, hypoalbuminemia
7. Discontinuing phototherapy: after assessment of risk factors (i.e. cause
and age at which phototherapy was started), consider discontinuing
phototherapy when the bilirubin level falls below the level at which it was
initiated. Check serum bilirubin level 6-12 hours after discontinuing
phototherapy to assess for rebound.

138
The Hospital for Sick Children
Exchange Transfusion for Infants
<28w or <1000g
<2500g and/or <35weeks gestation 28w-29w6days or 1000-1249g
380 30w-31w6days or 1250-1499g
370 32w-33w6days or 1500-1999g
360 34w-34w6days or 2000-2400g
350
micro mol/L (µmol) TSB (total serum bilirubin)

340 1. Use total bilirubin. Do not subtract direct or


330 conjugated bilirubin.
320 2. Use gestational age rather than birthweight if
gestational age is accurate.
310 3. In the presence of risk factors use one line
300 lower (gestation below) until <1000g.
290 4. Exchange level for infants <1000g with
280 risk factors:
12hrs:180µmol/L; ≥24hrs:200µmol/L
270 5. Risk factors: isoimmune hemolytic disease,
260 G6PD deficiency, asphyxia, sepsis, acidosis,
250 hypoalbuminemia.
240 6. Infants who present with total serum bilirubin
(TSB) above threshold should have exchange
230 performed if TSB is not expected to be below the
220 threshold after 6 hours of intensive phototherapy.
210 7. Immediate exchange transfusion is
200 recommended if infant shows signs of acute
bilirubin encephalopathy (hypertonia, arching,
190
retrocollis, opisthotonos, fever, high pitched
180 cry) and usually if TSB is >85umol/L above
170 threshold at presentation.
160 8. Exchange if TSB continues to rise
12h 24h 36h 48h 60h 72h 84h 96h 108h 120h >17umol/L/hour with intensive phototherapy.

References: Time (age in hours)


Maisels & Watchko. Arch Dis Child Fetal Neonatal
Ed. 2003; 88:F459-F463.
Horn et al. South African Medical Journal
2006;96:819-824.

139
Last Reviewed: September 14, 2011

Ampicillin

Pharmacology

- broad spectrum penicillin


- bactericidal
- penetrates CSF
- renally excreted therefore dose adjusted in severe renal failure

Indications

- gram positive and gram negative bacteria -- group B Strep


- Listeria, Neisseria, Haemophilus, susceptible Ecoli

Dosage

- 100-200 mg/kg/day divided q12h, in premature; q8h in term (38 weeks or higher)
- Given q8h in premature infants once greater than 1200 grams and 3 weeks of age
- 400 mg/kg/day in proven meningitis

Side Effects

- red rash

Special Considerations

- dilute 250 mg vial with 1 mL sterile H20 = 250 mg/mL


- dilute 500 mg vial with 1.8 mL sterile H20 = 250 mg/mL

This document is intended for use in the McMaster Children's Hospital (MCH) Neonatal Nurseries only and may not
be applicable elsewhere. Due to the specialized nature of the Neonatal Nurseries environment and the patient
population, some of the drugs, indications, doses and monitoring requirements may be different in individual
situations. While this document is intended to reflect the practice in the MCH Neonatal Nurseries at the time of
writing, new information may become available. Every attempt has been made to ensure accuracy but these
recommendations should be used with caution and with good clinical judgment.
140
Last Reviewed: September 14, 2011

Cefotaxime

Pharmacology

- third generation cephalosporin


- broad spectrum bactericidal
- penetrates CSF -- (good coverage)
- metabolized

Indications

- meningitis or sensitivity specific sepsis

Dosage

- 50 mg/kg/dose
- q12h in VLBW and poor renal function; q8h after 10 days if > 1200gm
- q8h in term and almost term

Side Effects

- none reported in this age group

Special Considerations

- stable for 48 hours refrigerated


- if IV volume of drug is greater than 1 mL -- may use IM dilution
- IV dilution add 10 mL sterile water = 95 mg/mL
- IM dilution add 3 mL sterile water = 300 mg/mL
- in severe renal impairment, increase dosage interval

This document is intended for use in the McMaster Children's Hospital (MCH) Neonatal Nurseries only and may not
be applicable elsewhere. Due to the specialized nature of the Neonatal Nurseries environment and the patient
population, some of the drugs, indications, doses and monitoring requirements may be different in individual
situations. While this document is intended to reflect the practice in the MCH Neonatal Nurseries at the time of
writing, new information may become available. Every attempt has been made to ensure accuracy but these
recommendations should be used with caution and with good clinical judgment.
141
Last Reviewed: September 14, 2011

Gentamicin

Pharmacology
- bactericidal aminoglycoside - inhibits protein synthesis
- polar molecule - not orally absorbed
- poor CSF penetration
- renally excreted
- not metabolized
- high conc. in renal cortex

Indications
- gram neg. E coli, Kleb. Serratia, Enterobact. Proteus Pseudomonas
- gram pos strept and staph
- no anaerobic coverage

Dosage
- 2.5 mg/kg/dose given in following intervals:

< 10 days > 10 days


< 28 weeks q24h < 28 weeks q18h
28-34 weeks q18h 28-34 weeks q12h
- for 35 weeks or greater, give 4 mg/kg once a day INFUSE OVER 20 MINUTES
- as babies mature (ie 4 weeks of age) dose as gestational age
- Oral dose for bacterial overgrowth in GI tract 2 mg/kg/dose q8h

Side Effects
- nephrotoxicity - reversible monitor urine output
- interval between doses if urine function decreases, Cr increases or level high
- ototoxicity - not reversible - follow levels to avoid accumulation
- potentiation of neuromuscular blockade

Special Considerations:

- hold during Indomethacin treatment course


- DO NOT hold for Indomethacin prophylaxis if urine output ≥ 2 ml/kg/hr
- monitor pre-gentamicin levels before 4th or 5th dose (many babies will not require level
as receive only 48 hours of gentamicin) (pre 3rd dose if q24h, q18h)
- pre level < 2 but for once daily dosing in the >35 wk age group level should be 1 or less
- may give gentamicin before prelevel back if urine output > 2 ml/kg/hr
- always hold gentamicin if urine output < 2 ml/kg/hr

This document is intended for use in the McMaster Children's Hospital (MCH) Neonatal Nurseries only and may not
be applicable elsewhere. Due to the specialized nature of the Neonatal Nurseries environment and the patient
population, some of the drugs, indications, doses and monitoring requirements may be different in individual
situations. While this document is intended to reflect the practice in the MCH Neonatal Nurseries at the time of
writing, new information may become available. Every attempt has been made to ensure accuracy but these
recommendations should be used with caution and with good clinical judgment.
142
Last Reviewed: June 1, 2015

Tobramycin

Pharmacology
- bactericidal aminoglycoside - inhibits protein synthesis
- polar molecule - not orally absorbed
- poor CSF penetration - renally excreted
- not metabolized - high conc. in renal cortex

Indications
- gram neg. E coli, Kleb. Serratia, Enterobact. Proteus Pseudomonas
- gram pos. strept and staph
- no anaerobic coverage

Dosage
- 2.5 mg/kg/dose given in following intervals:
< 10 days of age > 10 days of age
<28 weeks GA q24h q18h
28-34 weeks GA q18h q12h

- for 35 weeks or greater, give 4 mg/kg once a day INFUSE OVER 20 MINUTES
- as babies mature (ie 4 weeks of age) dose as gestational age
- Oral dose for bacterial overgrowth in GI tract 2 mg/kg/dose q8h

Side Effects
- nephrotoxicity - reversible monitor urine output
-  interval between doses if urine function decreases, Cr increases or level high
- ototoxicity - not reversible - follow levels to avoid accumulation
- potentiation of neuromuscular blockade

Special Considerations:

- hold during Indomethacin treatment course


- DO NOT hold for Indomethacin prophylaxis if urine output ≥ 2 ml/kg/hr
- monitor pre-tobramycin levels before 4th or 5th dose (many babies will not require level
as receive only 48 hours of tobramycin) (pre 3rd dose if q24h, q18h)
- pre level < 2, but for once daily dosing in the >35 wk age group level should be 1 or less
- DO NOT give tobramycin until pre-level has resulted
- an order may be written by the medical team to give tobramycin before the pre-level is
back if urine output > 2 ml/kg/hr
- always hold tobramycin if urine output < 2 ml/kg/hr
- Tobramycin is a SINGLE use vial. Discard vial after use.

This document is intended for use in the McMaster Children's Hospital (MCH) Neonatal Nurseries only and may not
be applicable elsewhere. Due to the specialized nature of the Neonatal Nurseries environment and the patient
population, some of the drugs, indications, doses and monitoring requirements may be different in individual
situations. While this document is intended to reflect the practice in the MCH Neonatal Nurseries at the time of
writing, new information may become available. Every attempt has been made to ensure accuracy but these
recommendations should be used with caution and with good clinical judgment.
143
Morphine Treatment for Neonatal Abstinence Syndrome (NAS)
Finnegan Score (q3-4h) Dose Route Frequency Considerations
3 consecutive scores are STARTING DOSE: Oral Q 6 hourly Cardiorespiratory monitoring required
greater than or equal to 8 0.08 mg/kg/dose when initiating morphine.
OR ( 0.32 mg/kg/day ) Titrate doses to control symptoms of NAS
2 consecutive scores are greater according to Finnegan scores.
than or equal to 12 Increase scoring to q 2-3h
OR
Average of 2 consecutive scores
is greater than or equal to 12
IF 3 consecutive scores are INCREASE dose to: Oral Q 6 hourly
greater than or equal to 8 0.12 mg/kg/dose
OR ( 0.48mg/kg/day )
2 consecutive scores are greater
than or equal to 12
OR
Average of 2 consecutive scores
is greater than or equal to 12
IF 3 consecutive scores are INCREASE dose to:
greater than or equal to 8 0.16 mg/kg/dose Oral Q 6 hourly
OR ( 0.64 mg/kg/day )
2 consecutive scores are greater
than or equal to 12
OR
Average of 2 consecutive scores
is greater than or equal to 12
IF 3 consecutive scores are INCREASE dose to: CONSIDER:
greater than or equal to 8 0.2 mg/kg/dose Oral Q 6 hourly ADDITION OF PHENOBARBITAL if
OR ( 0.8 mg/kg/day ) Finnegan scores persist greater than or
2 consecutive scores are greater equal to 8 despite morphine
than or equal to 12 0.2mg/kg/dose
OR Phenobarbital dose:
Average of 2 consecutive scores 10mg/kg q12h for 3 doses, then 2.5 mg/kg
is greater than or equal to 12 q12h
Frequency of dose increase depends on clinical response and severity of NAS symptoms. For poorly controlled
symptoms it may be necessary to reduce the dosing interval to 4 hourly as well as increasing the total daily dose
to 1.0 mg/kg/day. Phenobarbital may be added if infant exposed to polydrug use.
Weaning Morphine
Start weaning when Finnegan Scores are less than 8 for 24 to 48 hours. Wean by 0.05 mg/kg/day every 48 to 96 hours as
tolerated.
Discontinue morphine when scores are stable for 48 to 72 hours on a dose of 0.05 to 0.1 mg/kg/day

Dosing of the vomiting baby:


Reduce the risk of the baby vomiting the morphine dose by: giving the dose before a feed, not overfeeding the baby. If the
baby vomits within 5-10 minutes of receiving the morphine dose, repeat the dose.
If baby is NPO, I.V. dose is 50% of oral dose.

References:
Neonatal Abstinence Syndrome (NAS) Clinical Practice Guidelines, Provincial Council for Maternal and Child Heath, March 30, 2012
Coyle, M.G., Ferguson, A., Lagasse, L., Oh, W., Lester, B.; Diluted Tincture of Opium and Phenobarbital Versus Diluted Tincture of Opium Alone
for Neonatal Opiate Withdrawal in Term Infants. Journal of Pediatrics, 2002, May:140(5), 561-4.

144
Guidelines for the 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

145
♦ 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  3rd,  2001,  Breast  feeding  
in  the  first  few  days.  
   

146
Guidelines for the Assessment of Adequate Hydration in Breast-Fed Infants
Guidelines for the assessment of adequate hydration in breast-fed infants

frequency of breast- urine output stool pattern / red flags


feeding characteristic
day 1 •minimum 6-8 times •at least one wet •at least one •no voiding
in 24 hours diaper in 24 hours meconium in 24 •sore nipples
hours
day 2 •minimum 8 times in •2-4 wet diapers •transitional stool to•decreased voiding
24 hours seedy yellow stool •decreased stooling
•sore nipples
day 3 •minimum 8 times in •4-6 wet diapers •transitional stool to •baby too sleepy to
24 hours seedy yellow stool feed
•decreased voiding
•decreased stooling
•sore nipples
•weight loss greater
than 7% of birth
weight
day 7 • 8 times per day, • 6 or more wet • seedy yellow stools •baby too sleepy to
every 2-4 hours diapers feed
•baby satisfied •urine pale yellow •decreased voiding
between feeds •no odour •weight loss > 10% of
birth weight
•sore nipples
When red flags occur, mother and infant should be seen by a family physician/pediatrician as 147
well as a lactation consultant.
MacPeds
PEDIATRIC
HANDBOOK

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

This document is intended for use at McMaster Children’s Hospital (MCH) only and may not
be applicable elsewhere. While this document is intended to reflect the practice at MCH at
the time of writing, new information may become available. Every attempt has been made to
ensure accuracy but these recommendations should be used in conjunction with good
clinical judgment, and in consultation with a Pharmacist as needed.
For any questions related to the information contained in this document please email:
druginfo@hhsc.ca

148
Unapproved Abbreviations, Symbols and Dose Designations and Acceptable Corrections

Unapproved Intended Problem Acceptable


Abbreviation Meaning Correction
U Unit Mistaken for “0” (zero), “4” (four), or cc. Use 'unit'.
IU International Mistaken for “IV” (intravenous) or “10” (ten). Use 'unit'.
unit
Abbreviations for Misinterpreted because of similar abbreviations for multiple Do not abbreviate
Drug Names drugs; e.g., MS, MSO4 (morphine sulphate), MgSO4 drug names.
(magnesium sulphate) may be confused for one another. (exceptions: ASA,
KCl, Humulin R)
QD Every day QD and QOD have been mistaken for each other, or as Write “daily” and
QOD Every other day ‘qid’. The Q has also been misinterpreted as “2” (two). “every other day”
in full
OD Every day Mistaken for “right eye” (OD = oculus dexter) Write “daily”
OS, OD, OU Left eye, right May be confused with one another. Use “left eye”, “right
eye, both eyes eye” or
“both eyes”.
AS, AD, AU Left ear, right May be confused with one another. Use “left ear”,
ear, both ears “right ear” or “both
ears”
D/C Discharge or Premature discontinuation of medications if D/C (intended Use “discharge” and
discontinue to mean “discharge”) has been misinterpreted as "discontinue".
“discontinued” when
followed by a list of discharge medications
SC, SQ, or sub q Subcutaneous SC mistaken as SL (sublingual); SQ mistaken as “5 every;” Use "subcut" or
the “q” in “sub q” has been mistaken as “every” (e.g., a "subcutaneous"
heparin dose ordered “sub q 2 hours before surgery”
misunderstood as every 2 hours before surgery)
cc Cubic centimetre Mistaken for “u” (units). Use “mL” or
“millilitre”.
μg Microgram Mistaken for “mg” (milligram) resulting in one thousand-fold Use “mcg or
overdose. microgram”.
Unapproved Intended Potential Problem Acceptable
Symbol Meaning Correction
@ at Mistaken for “2” (two) or “5” (five). Use “at”. Write out “at” in full
> Greater than Mistaken for “7”(seven) or the letter “L” . Write out “greater
than” in full
< Less than Confused with each other. Write out “less than”
in full
Unapproved Intended Potential Problem Acceptable
Dose Meaning Correction
Designation
Trailing zero X.0 mg Decimal point is overlooked resulting in 10-fold dose error. Never use a zero by
Or 10.0 mg itself after
a decimal point.
Use “X mg or 10
mg”
Lack of leading . X mg Decimal point is overlooked resulting in 10-fold dose error. Always use a zero
zero before a
decimal point. Use
“0.X mg”
Adapted from ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations (2010) and ISMP Canada’s Do Not
Use – Dangerous Abbreviations, Symbols and Dose Designations (2006)

149
Legend:

GAS Group A Streptococcus


GP Gram Positive
GPC Gram Positive Cocci Adjust dosing
GN Gram Negative interval for patients
GNB Gram Negative Bacilli with renal impairment.
MAX Maximum
MIN Minimum
NF Non-Formulary At HHS

150
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)

151
ANTIBACTERIALS
CELL WALL SYNTHESIS INHIBITORS (BACTERICIDAL)
-LACTAMS
PENICILLINS
benzyl penicillin: narrow spectrum; NOT Penicillinase resistant
Penicillin G (IV or IM) Moderate to Severe Infections:
IV: 100 000 - 400 000 Units/kg/DAY ÷ q4-6h (MAX: 24 million Units/DAY)
Penicillin V Meningitis: IV: 400 000 Units/kg/DAY ÷ q4h (MAX: 24 million Units/DAY)
Potassium (PO)
Suspension: 60mg/mL Penicillin V Potassium (oral):
Tablet: 300mg 1. Mild to moderate Group A Strep infections: 25-50mg/kg/day PO ÷ q8-12h x 10 days
 IDSA (GAS pharyngitis)– Children: 300mg PO BID-TID; Adolescents & adults: 600mg PO
BID x 10 days
Penicillin V 500 000 units
is equivalent to 300 mg.
2. Rheumatic fever (treatment): Less than or equal to 27kg: 300mg PO bid x 10 days;
Greater than 27kg: 600mg PO BID x 10 days
3. Rheumatic fever (prophylaxis AND greater than 5 yrs): 300mg PO BID
4. Prophylaxis in asplenics:
6 months – 5 yrs: 150mg PO bid
Greater than 5 yrs: 300mg PO bid

isoxazoyl penicillin: narrow spectrum; Penicillinase resistant


Cloxacillin (IV or PO) Primarily used in methicillin-sensitive Staphylococcus aureus (MSSA) infections:
IV: 100-200 mg/kg/DAY  q4-6h (MAX: 12 g/DAY); up to 300mg/kg/DAY may be used
Oral: in select cases (please consult Infectious Diseases)
Suspension 25mg/mL
Capsule: 250mg, 500mg
PO: Suggest to use cephalexin (1st generation cephalosporin) in place as cloxacillin has
low oral bioavailability, poorly tolerated (GI side effects) and need to be taken on an
empty stomach

152
Aminopenicillin: Penicillinase sensitive
Ampicillin (IV) Meningitis: IV: 300-400 mg/kg/DAY  q4-6h (MAX: 12 g/day)
Other infections: IV: 100-200 mg/kg/DAY  q6h (MAX: 2 g/DOSE)

Amoxicillin (PO) For coverage against Streptococcus pneumoniae (including empiric therapy for community-
acquired pneumonia or otitis media): PO 80-90mg/kg/DAY  q8h (MAX: 1 g/DOSE)
Suspension: 50mg/mL
(supplied at HHS);
Standard dose: PO: 40-50 mg/kg/DAY  q8h
25mg/mL
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 + For coverage against Streptococcus pneumoniae (i.e. sequential oral therapy in complicated
Clavulanic Acid CAP, AOM, sinusitis): 80-90mg/kg/DAYof amoxicillin component  q8h
(Clavulin) (PO) **BID dosing may be adequate for AOM, but TID dosing is recommended for
pneumonia**
Tablets
(amoxicillin/clavulanic Standard dosing for other gram positive, gram negative, anaerobic infections:
acid): 500/125mg(4:1);
875/125mg(7:1) PO: 30-50 mg/kg/DAY of amoxicillin component  q8-12h (MAX: 875 mg/DOSE)

Suspension (supplied as *One major side effect with clavulanic acid (particularly at high doses) is GI intolerance
HHS): 1 mL = 80mg **When writing discharge prescription and if suspension is required, please indicate
amoxicillin and 11.4mg (particularly if high dose amoxicillin is used) the formulation of the amoxicillin-clavulanic acid is
clavulanic acid (7:1)
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

153
ANTIBACTERIALS (CONTINUED)
PENICILLINS (CONTINUED)
Ureidopenicillin: broad spectrum; Penicillinase sensitive Tazobactam: Enhances spectrum; β-lactamase inhibitor
Piperacillin (IV) For documented Pseudomonas aeruginosa infections

IV: 200-300 mg/kg/DAY ÷ q6h (MAX: 16 g/DAY)


Piperacillin + Tazobactam (IV) Broad coverage against many pathogens. First line for febrile neutropaenia.
IV: 200-300 mg/kg/day (of Piperacillin component) ÷ q6-8h
(Adult dose is 4.5g IV q8h)
**Order antibiotic as x mg (or g) of piperacillin component IV q6-8h**
CEPHALOSPORINS – do NOT cover MRSA, Enterococcus species, Listeria, or extended spectrum beta-
lactamase producing organisms (ESBL)
1st Generation Excellent coverage against S. aureus, group A Streptococcus, E. coli, Klebsiella.
Empiric therapy for cellulitis, osteomyelitis, bacterial adenitis.
Cefazolin (Ancef) IV: 75-150 mg/kg/DAY ÷ q8h (MAX: 6 g/DAY)
(IV or IM) Higher doses are needed for infections such as osteomyelitis
Cephalexin (Keflex) PO: 25-100 mg/kg/DAY ÷ qid
(PO)
Tablet: 250mg, 500mg Osteomyelitis following IV therapy: 100-150mg/kg/DAY (MAX: 4 g/DAY)
Suspension: 50mg/mL
2nd
Generation NO LONGER INDICATED FOR EMPIRIC TREATMENT OF PNEUMONIA. These
agents offer no benefit compared to ampicillin/amoxicillin for treatment of S.
pneumoniae. Main benefit is coverage against (nontypeable) H. influenzae and
Moraxella, which cause sinusitis and otitis.
Cefuroxime IV: 100-150 mg/kg/DAY ÷ q8h (MAX: 2g/DOSE)
(IV or IM)
Cefuroxime Axetil Poor oral bioavailability; unlikely to achieve optimal concentrations in severe
(Ceftin) (PO) infections

154
Cefprozil (eg. for otitis media unresponsive to high-dose amoxicillin or for acute sinusitis)
(Cefzil) (PO)
Tablet: 250mg, 500mg PO: 15-30 mg/kg/DAY ÷ q12h (MAX: 1 g/DAY).
Suspension: 50mg/mL
3rd Generation Broad spectrum activity against gram negatives. Ceftriaxone/cefotaxime offer
excellent coverage against Streptococcus pneumoniae and good coverage of
methicillin sensitive S. aureus. Only ceftazidime is active against Pseudomonas
aeruginosa. Useful for CNS infections.
Cefotaxime **reserved for neonates less than 1 month old**
(IV or IM) Meningitis: IV: 200-225mg/kg/DAY ÷ q6h; up to 300mg/kg/DAY ÷ q6h may be
used in infants and older children for this indication (MAX: 12 g/DAY)

Other infections:
IV: 100-200 mg/kg/DAY ÷ q6-8h (MAX: 6 g/DAY)

Neonates greater than 2kg (if less than 2kg, please refer to neonatal dosing
handbook):
0 – 7 days of age: 100-150mg/kg/DAY IV ÷ q8-12h
Greater than 7 days of age: 150-200mg/kg/DAY IV ÷ q6-8h

Ceftriaxone **for infants and children greater than 1 month old**


(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):


Greater than 45kg: 250mg IM x 1

155
ANTIBACTERIALS (CONTINUED)
CEPHALOSPORINS
Ceftazidime Active against Pseudomonas aeruginosa:
(IV or IM) IV: 75-150 mg/kg/DAY ÷ q8h (MAX: 6 g/DAY)

Cefixime Increasing MIC (minimum inhibitory concentration) against Neisseria gonorrhea;


(Suprax) (PO) avoid use if possible due to increased risk of treatment failure. IM ceftriaxone is
preferable.
Tablet: 400mg
Suspension: 20mg/mL Other infections (Not active against Pseudomonas and poor GP activity):
PO: 8 mg/kg/DAY ÷ q12-24h (MAX: 400 mg/DAY)

CARBAPENEMS – Very broad spectrum antibiotics (coverage against GP, GN and anaerobes including
extended beta-lactamase producing strains of GN); no coverage against MRSA ** Requires ID endorsement **
Meropenem Meningitis: 40mg/kg/DOSE IV q8h (MAX: 2g/DOSE)
(IV)
Other infections: 20mg/kg/DOSE IV q8h (usual MAX: 1g/DOSE)

Ertapenem 3 months - 12 years : 15mg/kg/DOSE IV q12h (max: 1 gram/DAY)


(IV) Greater than 13 years: 1 g IV once daily (max: 1 gram/DAY)

156
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 Meningitis: IV: 60 mg/kg/DAY ÷ q6h (MAX: 4 g/DAY)
(IV or PO) Other infections (MRSA or Coagulase Negative Staphylococci):
IV: 40-60 mg/kg/DAY ÷ q6-12h (usual MAX: 2 g/DAY)
The IV formulation will Higher doses may be required in patients with suspected/confirmed MRSA infections, or
be provided when individuals who are in clinically severe sepsis
prescribed orally while
in hospital
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)

157
ANTIBACTERIALS (CONTINUED)
Protein Synthesis Inhibitors
VIA 50S Ribosome (Bacteriostatic)
MACROLIDES Atypicals: Mycoplasma, Legionella, Chlamydia, H. pylori
GAS and S. pneumoniae infections in patients with severe penicillin allergy (although substantial
macrolide resistance has been observed with these pathogens).
Clarithromycin Useful for mild bacterial pneumonia in adolescents. Also commonly used for atypical
mycobacterial infections.
Tablet: 250mg, 500mg PO: 7.5 mg/kg/DOSE BID (Max: 500mg/DOSE)
Suspension: 25mg/mL,
(50mg/mL not available
at HHS) Rx Interactions: theophylline, carbamazepine, cisapride, digoxin, cyclosporine, tacrolimus.
Azithromycin Useful for known atypical respiratory infections and bacterial enteritis. AVOID USING TO
TREAT INFECTIONS PRESUMED TO BE CAUSED BY GROUP A STREPTOCOCCUS OR
Tablet: 250mg PNEUMOCOCCUS.
Suspension: 40mg/mL
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: (Greater than 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 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)
Capsule: 150mg, PO: 10-30 mg/kg/DAY ÷ q6-8h (MAX: 450 mg/DOSE)
300mg May potentiate muscle weakness with neuromuscular blockers. Oral suspension is very poorly
Suspension 15mg/mL
tolerated, avoid if possible, use 150 mg capsules or an alternative antibiotic

158
VIA 30S and 50S Ribosome (Bacteriocidal)
AMINOGLYCOSIDES GN Aerobes (including Pseudomonas aeruginosa)
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

*gentamicin on long- Doses as high as 10mg/kg/DAY IV q24h recommended in patients with cystic fibrosis.
term back-order until
Spring 2016-use (Inhaled tobramycin for CF patients): 80mg bid to tid via inhalation
tobramycin at same
dose* 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. greater than 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

159
ANTIBACTERIALS (CONTINUED)
Folic Acid Metabolism Inhibitors (Bacteriostatic)
TRIMETHOPRIM-SULFAMETHOXAZOLE (TMP-SMX) (Septra, Co-trimoxazole)
Useful for: Pneumocystis carinii, Toxoplasma, Shigella, Salmonella, MRSA (in settings of cellulitis after appropriate
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

Formulation: Trimethoprim Sulfamethoxazole

Suspension 8 mg/ml 40 mg/ml


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

Excellent oral absorption, use IV only if PO contraindicated. Maintain good fluid intake and urine output.
Monitor CBC and LFTs. Do not use in patients with G-6-PD deficiency.
Trimethoprim Urinary tract infection prophylaxis: 2 – 5mg /kg/DAY trimethoprim once daily
Tablet: 100mg
Suspension: 10mg/mL

160
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 ** REQUIRES ID ENDORSEMENT**
(IV or PO) Ciprofloxacin usually reserved for infections caused by Pseudomonas aeruginosa or other
Tablet: 250mg, 500mg, resistant gram negative bacilli
750mg
IV/PO: 20-30 mg/kg/DAY ÷ q12h (MAX: 400 mg/DOSE IV or 750 mg/DOSE PO)
Suspension: 100mg/mL
(tablets are preferable if Excellent oral absorption, use IV only if PO contraindicated.
dose is given via NG tubes) Feeds, formula, calcium, magnesium, iron, antacids and sucralfate reduce
absorption, hold feeds for 1 hour before and 2 hours after dose.
Levofloxacin ** REQUIRES ID ENDORSEMENT**
Tablet: 250mg, 500mg, Levofloxacin usually reserved for infections caused by Pseudomonas aeruginosa, other
750mg resistant gram negative bacilli or penicillin-resistant Streptococcus pneumoniae.

Suspension not available


commercially; use dissolve
and dose

161
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 ** Requires ID endorsement **
PO) Coverage against many Candida species and Aspergillus
Tablet: 50mg, 200mg
Suspension: 40mg/mL Children 2 to < 12 years:
Loading dose (IV): 9mg/kg/dose q12h x 2 doses then
Maintenance dose (IV): 8mg- 9mg/kg q12h (MAX: 350mg/dose)
Oral following IV therapy: 9mg/kg PO q12h (MAX: 350mg/dose)

Children ≥12 years:


Loading dose: (IV) 6mg/kg/dose q12h x 2 doses then
Maintenance dose(IV): 4mg/kg/dose q12h
Oral following IV therapy: Less than 40kg: 100mg q12h
Greater than 40kg: 200mg q12h
Only IV formulation needs to be used with caution in patients with renal impairment (use
oral formulation in this scenario)

162
ANTIFUNGALS (continued)
Liposomal ** Requires ID endorsement **
Amphotericin B (IV) Coverage against many Candida species, Aspergillus and most Mucor
(Ambisome)
3 – 5 mg/kg IV once daily

Monitor renal function and electrolytes (particularly potassium and magnesium).


Infusion-related adverse effects (e.g. fever, rigors etc) may require pre-treatment
with acetaminophen, diphenhydramine

Caspofungin (IV) ** Requires ID endorsement **


Loading dose: 70mg/m2/DAY IV x 1 dose (MAX: 70mg) then

Maintenance dose: 50mg/ m2/DAY IV once daily (MAX: 50mg)


Nystatin Oral candidiasis: PO: infants: 100 000 Units swish and swallow QID
children: 250 000 Units swish and swallow QID
adolescents: 500 000 Units swish and swallow QID

163
ANTI-VIRALS
Acyclovir Need to monitor kidney function and ensure adequate hydration (especially on high dose
of intravenous therapy). Dosing adjustment is necessary in patients with impaired renal
Tablets: 200mg, 400mg and function
800mg
Suspension: 40mg/mL
Infants 1-3 months: 60mg/kg/DAY IV ÷ q8h (duration will be dependent on organ
involvement – 21 days for CNS and disseminated disease; 14 days for skin and mucous
membrane involvement)

HSV encephalitis (3 months to 12 years): 60mg/kg/DAY IV ÷ q8h (MAX: 1g/DOSE)


HSV encephalitis (Greater than 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

164
Oseltamivir Usual treatment duration is for 5 days only
**dosage adjustment is necessary in renal impairment**
Available as 75 mg capsules *NOTE: Consult Infectious Diseases for premature infants & neonates (Less than 1 month of
OR 6mg/mL suspension
age).
Infants- 1 month to 12 months:
Infants Infants
WEIGHT 1 to 8 months 9 to 11 months†
3 – 3.5 kg 9 mg BID 12 mg BID
3.6 – 4.5 kg 12 mg BID 15 mg BID
4.6 – 5.5 kg 15 mg BID 18 mg BID
5.6 – 6.5 kg 18 mg BID 21 mg BID
6.6 – 7.5 kg 21 mg BID 24 mg BID
7.6 – 8.5 kg 24 mg BID 27 mg BID
8.6 – 9.5 kg 27 mg BID 30 mg BID
9.6 kg and over 30 mg BID 30 mg BID

†AAP recommends 3.5mg/kg/dose twice daily in infants aged 9 – 11 months (Reference: AAP Policy Statement:
Recommendations for Prevention & Control of Influenza in Children 2013-2014).

Children greater than 12 months:

DOSE DOSE
WEIGHT (if suspension is used) (if capsules are
used)
Less than 15kg 30mg BID --
15 – 23 kg 48mg BID --
23 – 40 kg 60mg BID --
40 kg 78mg BID 75mg BID
References: Bradley JS and Nelson JD. Nelson’s Pocket Book of Pediatric Antimicrobial Therapy.
18th edition. 2010.

165
PEDIATRIC FORMULARY
Acetaminophen
Analgesic and antipyretic.
PO/PR: Refer to table for weight based dosing standardization
Can be dosed q4-6h prn

Weight Single Dose


(kg) (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)

166
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. Not
available as liquid formulation-consult pharmacist for administration
directions.

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 (max 50 g/DOSE).
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.

167
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).

168
Diazepam
Benzodiazepine sedative, anxiolytic and amnestic.
Status epilepticus:
IV: 0.1-0.5 mg/kg/DOSE
(usual maximum 5 mg for children less than 5 yrs
10 mg for children greater than 5yrs)
PR: 0.5 mg/kg/DOSE (maximum 20 mg/DOSE).
For PR route, use IV formulation diluted with water

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.

DimenhyDRINATE (Gravol)
Antihistamine used to treat nausea and vomiting.
IV/IM/PO: 0.5 -1 mg/kg/DOSEq4-6h prn
(maximum 50 mg/DOSE).
Available as 3mg/mL liquid. Please round to nearest 2.5mg dose.
Not indicated for infants less than 2 years of age

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.

169
Docusate (Colace)
Laxative
PO: 5 mg/kg/DAY once daily or in divided doses 2-4
times/DAY (maximum 200 mg/DAY)

Available as 10 mg/mL suspension or 100 mg capsule Suspension is


bitter tasting. Mask taste by diluting with juice or milk/formula.
Please round to nearest multiple of 5mg.

Domperidone
Prokinetic agent.
PO: 1.2-2.4 mg/kg/DAY q6h (usual maximum
30 mg /DAY due to risk of QTc prolongation-Health Canada)
Give 15- 30 mins prior to feed/meals and at bedtime. Baseline ECG
and ECG after initiation recommended.

Enoxaparin
Anticoagulant, low-molecular weight heparin.
Treatment:
Subcutaneous:
Less than 2 months of age: 1.5 mg/kg/DOSE q12h.
Greater than 2 months of age: 1 mg/kg/DOSE q12h.
Prophylaxis:
Subcutaneous:
Less than 2 months of age: 0.75 mg/kg/DOSE q12h or 1.5 mg/kg
q24h
Greater than 2 months of age: 0.5 mg/kg/DOSE q12h or 1mg/kg
q24h
Maximum prophylactic dose 30mg q12h, or 40mg 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.

170
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 mL of 3% Hypertonic saline q8h

fentANYL
Narcotic analgesic
Continuous infusion:
Continuous infusion: 0.5-2 mcg/kg/hr
Initial bolus (loading) dose: IV: 0.5-1 mcg/kg
PRN Breakthrough dose: 0.5-1 mcg/kg q1-2 h prn
(refer to continuous infusion electronic 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 (greater than 5 days). Common adverse
effects are pruritus, 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, orders must specify strength as well as number of puffs

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.

171
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 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.

HYDROmorphone
Narcotic analgesic
Analgesia :
PO: 0.03-0.08 mg/kg/DOSE q4-6h prn
(usual initial max 3mg/DOSE)
IV: 0.01-0.02 mg/kg/DOSE q2-4h prn
Sedation/analgesia :
Continuous infusion: 2-8 microgram/kg/hr
Initial bolus (loading) dose: IV: 0.01-0.02 mg/kg
PRN breakthrough dose: 0.01-0.02 mg/kg q3h prn
(refer to continuous infusion electronic order set)

To prevent withdrawal, avoid abrupt cessation following high doses


or long duration of therapy (Greater than 5 days). Common adverse
effects are pruritis, nausea and constipation

172
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 mL of 3% saline q8h (with epinephrine 1.5mg)

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

Do not administer within 6 hours of Parenteral or PO Ketorolac


(duplicate NSAIDs).
Administer with food, if able, to minimize GI upset.
Avoid in patients with renal impairment or increased risk of bleeding

173
Insulin (regular)-Humulin R or Novolin Toronto
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. (usual
max: 180mg/day = 60mg elemental iron TID)
Prevention of iron deficiency anemia:
PO: 2-3 mg/kg/DAY (of elemental iron) ÷ q8-24h.
Give with food if GI upset occurs. Liquid does stain teeth, rinse
mouth well.
Available as ferrous sulfate 75mg/mL solution (15mg/mL elemental
iron) and tablets containing 60mg elemental iron/300mg ferrous
sulfate or 35mg elemental iron/300mg ferrous gluconate. Round to
nearest 12.5mg dose (2.5mg elemental iron) for liquid.
Ferrous fumarate and Feramax not available in hospital.

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.

174
Ketorolac (Toradol)
Analgesic and anti-inflammatory (NSAID).
IV/IM: 1-2 mg/kg/DAY (maximum 120 mg/DAY) q6h.
PO: Adolescents: 10mg q6h (max 40mg/DAY) for 5 days total
(IV and PO). No weight based dosing available for children.
Available as 10mg tablets. *IV dosing not equal to PO*
Adverse effects include renal dysfunction, GI irritation and
ulceration. **do not administer within 6 hours of ibuprofen
(duplicate NSAIDs)**

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 2 mg /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.

175
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 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.

Metoclopramide
Antiemetic, gastrointestinal prokinetic agent.
IV/PO: 0.4-0.5 mg/kg/DAY q6h
(usual maximum 40 mg/DAY).
Extrapyramidal reactions occur more commonly in children and may
be treated with diphenhydramine. Contraindicated in children less
than 1 year and use with caution in children greater than 1 year

176
Morphine
Narcotic analgesic.
Analgesia :
PO: 0.2-0.5 mg /kg/DOSE q4-6h prn
(usual max is 10-15 mg/ DOSE)
IV: 0.05-0.1 mg/kg/DOSE q2-4h prn and increase as required
Sedation/analgesia:
Continuous infusion: 10-40 microgram/kg/hr infusion
Initial bolus (loading) dose IV: 0.05-0.1 mg/kg
PRN breakthrough dose: 0.05-0.08 mg/kg q3h PRN
(refer to continuous infusion electronic order set)
Please note: Morphine has now replaced codeine as the
preferred oral narcotic analgesic for acute pain at HHSC due to
better safety profile. Reduced doses may be required if used in
combination with benzodiazepines. To prevent withdrawal, avoid
abrupt cessation following high doses or long duration of therapy
(> 5 days). Common adverse effects are pruritis, nausea and
constipation

Naproxen
Analgesic and anti-inflammatory (NSAID).
PO: 10-20 mg/kg/DAY q8-12h (maximum 1 g/DAY).
Adverse effects include renal dysfunction, GI irritation and
ulceration. Also available as suppositories (250mg) if PR route
preferred.

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).

177
Oxybutynin (Ditropan)
Urinary antispasmotic agent.
PO: 1-5 years: 0.2 mg/kg/dose BID-QID
Greater than 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 (infusion):
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
Greater than 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. Tablets are enteric
coated - do not crush tablets or administer tablets via gastric tubes.

PEG-3350 (Polyethylene Glycol)


Osmotic Laxative
Constipation:
PO: 0.5-1 g/kg/DAY (titrate to effect- usual max 17 g/day)
Available as 17 gram /sachet in hospital. Mix in 125-250 mL of water
or juice. Onset 2-4 days. 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 mmol/L (15-40 mg/L)

178
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 60mmol) over 4-5 hours

IV available as sodium PHOSPHATE (3 mmol phosphate + 4 mmol


sodium/mL) and potassium PHOSPHATE (3 mmol 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

179
Pico-Salax® (picosulfate sodium/magnesium oxide/citric acid)
Stimulant and Osmotic Laxative
PO: 1-6 yrs administer ¼ sachet
6-12 yrs administer ½ sachet
Over 12 yrs: 1 sachet
Dose can be repeated after 6-8hours if no effect
Used for refractory constipation, fecal impaction and for cleaning out
bowels. Contents of 1 sachet are mixed with 160mL water.

Potassium Salts
Electrolyte. 1mmol of potassium chloride = 1 mEq of potassium
chloride
Treatment of hypokalemia:
PO: 1-2 mmol/kg/DAY  q6h-24h.
IV: 0.25-1 mmol/kg/DOSE.
For PO administration potassium CHLORIDE is available as oral
solution 1.33 mmol/mL, and slow release capsules (Micro-K) 600
mg (= 8 mmol). Potassium CITRATE (K-Lyte) 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
capsules should be swallowed whole or can be opened and contents
sprinkled on semi-solid food.
Usual maximum = 80 mmol/DAY. Doses greater than 20 mmol
should be divided for tolerability

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

180
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. Prednisone is 5mg/mL
and compounded as liquid in hospital. PrednisoLONE is 1mg/mL
and commercially available. 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
H2 receptor antagonist.
Reduction of gastric acid secretion:
IV: 2-4 mg/kg/DAY q8-12h (usual max 50 mg q8h).
PO: 4-10 mg/kg/DAY q8-12h (usual max 300 mg/DAY).
IV dose is approximately 50% of oral dose. Modify dosage interval
for patients with renal impairment. May add IV daily dose to TPN.
Available as a 15mg/ml oral solution, 75mg or 150mg tablets.

181
Salbutamol (Ventolin)
Bronchodilator, 2 agonist.
Acute asthma:
MDI: 4-8 puffs q30 mins – q4h prn.
NEB: Less than 10 kg: 2.5 mg q30mins – q4h PRN
10 kg or greater: 5 mg q30mins – 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.

182
Topiramate
Anticonvulsant
For greater than 2 yrs and less than 16 yrs:
PO: 1-3 mg/kg/DAY as 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

Available as 6mg/mL liquid (compounded in hospital), or 25mg or


100mg tablets

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 oral liquid may be administered rectally (PR)
Valproic acid IV is special access only and reserved for specific
indications. Please consult Pharmacist.

183
Vitamin K (Phytonadione)
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)

184
Approximate Opioid Analgesic Equivalence
at HHS - April 2014

Suggested dose equivalence apply in stable analgesic states. Patients with acute
postoperative pain may have variations to suggested conversions.

OPIOID Parenteral Dose Oral Dose


(mg)a (mg)
Fentanyl 0.1 N/A
Hydromorphone 2 46
Methadone N/Ab 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. Additional references & patient response
should be consulted to verify appropriate dosing of individual agents.
a
Parenteral route includes intravenous, intramuscular and subcutaneous route,
but does not include intraspinal route.
8
Methadone equivalency is highly variable – this ratio from Micromedex as
suggested equivalency ratio in patients on chronic oral methadone.

185
Approximate Systemic Corticosteroid
Equivalence
at HHS - May 2010
Equivalent Dose Relative Mineralocorticoid
Drug (mg)a Potency
Glucocorticoids:
Short-acting (biologic half-life 8–12 h)
Cortisone 25 2
Hydrocortisone 20 2
Intermediate-acting (biologic half-life 12–36 h)
Methylprednisolone 4 0
Prednisolone 5 1
Prednisone 5 1
Long-acting (biologic half-life 36–54 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.

186
Antibiotics Guide for Common Pediatric Infections (>3 months)
 
Infection Major Organisms Antibiotic Duration Notes
Otitis Media S. pneumoniae, H. First line: 5 days watchful waiting appropriate when:
influenzae (non-typeable), High-dose Amoxicillin PO OR
M. catarrhalis (2-20%) Group Second line: 10 days if: -­‐ > 6mo
if type 1 allergy à Clarithromycin PO < 2yo, frequent recurrent -­‐ healthy child (NO immunodeficiency or
A Streptococcus (5%)
if non-type 1 à Cefprozil PO AOM, perforated TM, chronic disease or anatomical
OR Ceftriaxone IM x 1 dose failed initial Abx abnormality of head and neck, NO
If initial therapy fails: Down’s syndrome, NO history of
Amoxicillin-Clavulanate (Clavulin) PO complicated otitis media)
if type 1 allergy à call ID -­‐ illness not severe
-­‐ reliable parents
CPS statement 2009
Community 3 mo – 4 yrs Outpatient or admitted to ward: 7-10 days, depending on Features of atypical pneumonia: subacute
-acquired Viral > Bacterial (S. High dose Amoxicillin PO or Ampicillin clinical status onset, non-lobar infiltrate, minimal
pneumonia pneumoniae, group A IV leukocytosis, older school-age
Streptococcus) >> Atypicals Atypical pneumonia: (treatment duration will be
(Mycoplasma, Clarithromycin PO longer in the presence of -­‐ clarithromycin useful in pen-allergic
Chlamydophila, Legionella) Pleural effusion/Admitted to complications such as patients
PCCU/Necrotizing: empyema) -­‐ If you are sure it is not a type-1 reaction,
nd rd
5 – 18 yrs Ceftriaxone IM/IV + Vancomycin IV can try cephalosporins (2 or 3 gen.)
Bacterial, Atypicals, Viral -­‐ Consider risk factors for MRSA
CPS statement 2011
Meningitis Bacterial (S. pneumoniae, N. Ceftriaxone IV/IM (meningitic dose, Depends on organism: Mandatory ID consult
meningitidis, H. influenzae), 100mg/kg/day in 2 divided doses) S. pneumoniae 10-14
Viral (HSV, Enterovirus) PLUS days consider DEXAMETHASONE if bacterial
Vancomycin IV N. meningitidis 5-7 days pathogen suspected 0.6 mg/kg/day
Special considerations in: If CSF culture negative divided q6h before or within 30 minutes of
-­‐ < 3mo *above antibiotic choices may not but strong clinical
the first dose of antibiotics (only continue
-­‐ immunocompromise apply to those with special suspicion consider PCR
d considerations testing for 2 days if S. pneumonia or H. influenza
-­‐ known CNS disease, isolated, any other pathogen discontinue)
post-neurosurgery, ADD acyclovir if:
trauma -­‐ CSF pleocytosis <1500 - Target vancomycin trough levels 10-15
WBC/hpf, OR CPS statement 2014
-­‐ significant change in LOC,
OR
-­‐ MR findings consistent with
HSV, OR
-­‐ HSV PCR positive

187
Infection Major Organisms Antibiotic Duration Notes

Urinary E.coli, Klebsiella, Uncomplicated (cystitis): Cystitis: -­‐ Diagnosis: urine R+M and culture (will
Tract Enterococcus, Proteus, Cephalexin (infants) 10 days (<2 years of age) only send culture if mid-stream, catheter
Infection Serratia, Pseudomonas, Trimethoprim/sulfamethoxazole (older 7 days (> 2 y of age) or suprapubic aspiration ie. NO BAG
Staphyloccus saprophyticus children) SAMPLES for culture)
Complicated (<2-3 months Pyelonephritis: -­‐ First febrile UTI in an infant warrants
Acronym: KEEPPSS pyelonephritis systemically ill 10-14 days investigation with an abdominal
vomiting, immunocompromised): ultrasound
Ampicillin IV PLUS Gentamicin IV AAP Clinical Practice Guideline 2011
OR Ceftriaxone IV/IM
Cellulitis Group A Streptococcus, First line: 7-10 days (usually 1-2 -­‐ Consider I&D as first line if abscess or
st
S. aureus (MSSA/MRSA), 1 generation Cephalosporin such as days after the rash furuncle
Group C/G streptococcus Cephalexin/Cefazolin resolves) -­‐ Consider MRSA risk factors
If pus present – very likely S. If allergic to beta-lactam: -­‐ avoid oral cloxacillin if possible as it has
aureus Clindamycin PO/IV Varies depending on poor bioavailability and has GI side
If suspect MRSA: presence of abscess and effects
If pus not present – very Outpatient à degree of drainage
likely streptococcal Trimethoprim/Sulfamethoxazole
Inpatient à Vancomycin
Osteomyeli S. aureus, Group A First line: Prolonged treatment -­‐ mandatory ID consult for
tis Streptococcus, S. Cefazolin (high dose, 150 mg/kg/day course: 4-6 wks management and F/U
pneumoniae, Kingella kingae divided Q8H) (combination of IV/PO as -­‐ consider special groups: eg. Salmonella
If suspect MRSA: per ID) in sickle cell disease, MRSA colonized,
Vancomycin infected hardware
Pharyngitis Viral > bacterial (Group A If suspect GAS: amoxicillin 10 days -­‐ useful to confirm dx with throat culture
Strep) If True beta-lactam allergy: -­‐ bacterial > viral if: cough absent, tender
Macrolide or Clindamycin lymphadenopathy, high fevers, ++
tonsillar exudates

188
Clinical Pearls
 

Other Clinical Challenging Organisms: Antibiotics of note:


Scenarios:

Septic Shock: Pseudomonas MRSA covered Organisms resistant to Vancomycin (only covers Carbapenem
covered by: by: penicillins and gram +ve), indications: indications:
- ceftriaxone + cephalosporins:
vancomycin -­‐ ceftazidime -­‐ Vancomycin -­‐ MRSA -­‐ ESBL
- can consider pip- -­‐ piperacillin +/- -­‐ Clindamycin -­‐ MRSA -­‐ Severe C diff infection -­‐ SPICE
tazo if require tazobactam -­‐ Septra -­‐ ESBL (PO only) -­‐ Polymicrobial
coverage for -­‐ ciprofloxacin / -­‐ Linezolid -­‐ CONS -­‐ CONS infection
anaerobes (eg. GI levofloxacin (needs ID -­‐ C diff -­‐ Enterococcus
infection) or -­‐ meropenem endorsement) -­‐ SPICE (AmpC producers): REQUIRES ID
pseudomonas -­‐ aminoglycosides Serratia, providencia, CONSULT
(gentamicin/tobra Risk Factors: Indole +ve Proteus
Febrile Neutropenia: mycin/amikacin) (Proteus vulgaris),
-­‐ Previous Citrobacter, Enterobacter
-­‐ Piperacillin- MRSA cloacae
tazobactam infection or -­‐ Atypicals
-­‐ Consider empiric household
vancomycin if contact Cephalosporins do not have
previous -­‐ Healthcare activity against Enterococcus
infection/colonizati exposure/rece or Listeria
on with MRSA, or nt
clinical severe hospitalization
sepsis -­‐ TRAVEL
-­‐ Refine Abx if blood (including to
Cx +ve USA)
-­‐ Consider previous
microbiology
history (e.g.
antibiotic-resistant
organisms)

189
Combined Antibiogram
Cumulative Data for 2014

Before using this antibiogram you should know:

1) The antibiogram is used to direct initial empiric therapy only. Antibiotics need
to be reassessed based on susceptibility testing and patient clinical status.
2) Data presented in the antibiogram should be considered in combination with an
individual patient’s risk factors for resistant organisms, clinical syndrome and
hospital epidemiology.
3) The antibiogram provides the percentage of isolates which are susceptible to an
antibiotic. For life-threatening infections, it is reasonable to choose an antibiotic
regimen with the lowest resistance rate.
4) When the number of isolates tested for a particular antibiotic is different than the
overall number, the number tested will be in brackets under the % susceptible.
5) The most current version of the antibiogram and additional results (eg. source
specific results) can be found on MyStJoes and HHS intranet
http://corpweb.hhsc.ca/body.cfm?id=3056
6) A shaded box indicates that the particular antibiotic/microorganism
combinations are not recommended.
7) Calculation of results was based on the first isolate per patient for the year 2014.
Duplicate isolates and surveillance isolates were removed.

For further information, contact the Antimicrobial Stewardship Program or


the Hamilton Regional Laboratory Medicine Program.

190
Antibiogram for 2014 – McMaster University Medical Centre
% Susceptible

No. of Isolates

Nitrofurantoin
Ciprofloxacin
Piperacillin-
Tazobactam
Ceftazidime

Tobramycin
Meropenem

(urine only)
Ceftriaxone

Gentamicin

TMP/SMX
Ertapenem
Ampicillin

Amikacin
Cefazolin
Gram Negative
Organisms

95
499 54 90 94 96 100 100 93 92 100 75 90
E. coli (485)
Klebsiella 30
64 0 97 100 97 100 100 100 98 100 95 100
pneumoniae (56)
20
Enterobacter spp. 48 90 98 96 96 98 94 98
(40)
Proteus mirabilis 39 95 95 97 100 100 100 97 100 100 92 100 0
Pseudomonas 94
126 94 96 84 90 87 94
aeruginosa (125)
No. of Isolates

Nitrofurantoin
monotherapy)
Erythromycin

Ciprofloxacin

Rifampin (do
Clindamycin

Vancomycin
Tetracycline

(urine only)
TMP/SMX
Cloxacillin
Ampicillin

not use as
Cefazolin

Gram Positive
Organisms

Staphylococcus aureus
353 85 85 See MSSA and MRSA
(includes MSSA and MRSA)
Methicillin Sensitive S. aureus
302 100 80 75 97 96 98 100 100
(MSSA)
Methicillin resistant
54 0 59 20 94 19 91 100 100
S.aureus(MRSA)
Enterococcus spp 193 96 92* 22* 99 96

*For Enterococcus, can only be used for urine only not other sources

Streptococcus pneumoniae

azithromycin)
Erythromycin
Levofloxacin

Vancomycin
Penicillin G

Meropenem
Penicillin V

Ceftriaxone

(not for SF)


(parenteral)

TMP/SMX

(predicts
Number

(oral)

S. pneumoniae

Blood cultures:
100 100 100
(no positive spinal fluid specimens)
Meningeal interpretation 1# 100 100

Non-Meningeal interpretation 100 100


All specimens except blood cultures
18# 78 94 94 100 83 56
(no positive spinal fluid specimens)
# Fewer than 30 isolates may not be reliable for guiding empiric treatment decisions and cannot be used to statistically compare results
to other years.

191
Recommended Blood Culture Bottle Volumes for Pediatric Patients by Weight

Aerobic culture only Aerobic and Anaerobic culture Required


Patient Meditech Total Bottle type Meditech Total Bottle Total Bottle type
weight Order volume Order volume type volume
(kg) Entry Entry
Aerobic Anaerobic
≤1 0.5-1.0 YELLOW 0.5 YELLOW 0.5 ORANGE
1.1-2 CBLINF 1.5-2.0 YELLOW CBLINF+A 1.0 YELLOW 1.0 ORANGE
2.1-5 2.0-4.0 YELLOW N 2.0 YELLOW 2.0 ORANGE
5.1-12.7 5.0-7.0 ONE GREEN 4.0 ONE 3.0 ORANGE
GREEN
12.8-36.3 CBLPED 14-20 TWO GREEN CBLPED+ 7-10 ONE 7-10 ORANGE
(7-10 ml AN GREEN
each)
36.4-45 20 TWO GREEN 10 ONE 10 ORANGE
(10 ml each) GREEN
>45 Always collect two sets from two separate sites: 1st set: 10 ml GREEN + 10 ml
CBL ORANGE and 2nd set: 10 ml GREEN + 10 ml ORANGE

Anaerobic culture in addition to aerobic culture is indicated for the following:


• Intraabdominal or pelvic infection, necrotizing enterocolitis in neonates
• Mouth/neck infection, including septic thrombophlebitis (e.g. Lemierre’s)
• Necrotizing soft tissue infection or infected bite wounds
• Immunosuppressed host
• Prolonged fever of unknown origin with negative aerobic culutres
• >45 kg

For patients <5kg order CBLINF+AN (aerobic and anaerobic culture)


For patients 5-45kg order CBLPED+AN (aerobic and anaerobic culture)
For patients >45kg order CBL. This routinely will include anaerobic culture

When writing orders, indicate if an anaerobic blood culture is required and provide the weight.

For further information please refer to the Laboratory Test Information Guide
on the HHS Intranet

192
Proton Pump Inhibitors (PPI) in Pediatrics  –  Reflux  Disease  –  Best  Evidence  in  Peds  with  Omeprazole,  Lansoprazole  and  
Pantoprazole.

Drug  Brand   Pediatric   Max  Dose1   Usual    Administration   Available   LU  Code  3  


Generic  
Name   Dose1,  6   (faster   Adult   (See  note  below)   Formats4  
Name   (BID  dosing  is   clearance  in   Dose   Note:   and  
thought  to   peds  than   GERD Pharmacy  Prepared   Cost  
provide   adults  –  may   2   Suspension5(  
better  control   need  higher   (Compounding  
of   than   dependent  on  
breakthrough   standard   pharmacy)  
acid)   adult  dose)  
Omepraz Losec   1-­‐1.5   3.5   10-­‐20   1.Capsule  –  can  be   10mg     293  –  GERD  or  non  erosive  GERD  when  
ole   mg/kg/day   mg/kg/day     mg  PO   opened  &  sprinkled   capsules–   H2Antags  have  failed    
PO  once  daily   OD   on  yogurt  and  given   not  ODB   297-­‐PUD  or  prevention  of  NSAID  
or  divided   2.  Pharmacy   covered   induced  ulcers    
BID   prepared  suspension     20  mg     401-­‐  treatment  of  GI  disorders:  Crohns,  
NEONATAL:   can  be    used   cap   short  Gut  etc.    
0.5-­‐1.5     ($0.6/cap 402-­‐severe  esophagitis,  Zollinger-­‐Ellison  
mg/kg/dose   )   etc.  
 
Lansopr Preva <10  kg:  7.5   1.6   15-­‐30   1.Capsules  may  be   15mg   293  –  GERD  or  non  erosive  GERD  when  
azole   cid   mg  PO  OD   mg/kg/day   mg  PO   opened  and   ($0.5/cap H2Antags  have  failed    
10-­‐30  kg:  15   or    30   OD   sprinkled  into   )   295  –  for  HPylori  Peptic  Ulcer    
mg  PO  OD   mg/day   applesauce     30mg   297-­‐PUD  or  prevention  of  NSAID  
>30  kg:  30   2.FasTabs  can  be   ($0.5/cap induced  ulcers    
mg  PO  OD   placed  on  tongue  for   )     401-­‐  treatment  of  GI  disorders:  Crohns,  
  doses  15mg  or   with   short  Gut  etc.    
  greater   Enteric   402-­‐severe  esophagitis,  Zollinger-­‐Ellison  
3.  FasTabs  can  be   coated   etc.  
mixed  with  water   microgra
(10mL)  to  provide   nules  
part  doses  only  if  no    

193
other  options  exist   15,  30  mg  
4.  Pharmacy   FasTabs  
Prepared  suspension   (not  ODB  
may  be  used  if   covered)  
available  
Esomepr Nexiu 1mo-­‐11  yrs:       40  mg/day   20-­‐40   1.Tabs  can  be   20  mg,  40   NO  –  Not  covered  under  ODB  
azole   m   <5kg:2.5-­‐   mg  PO   dispersed  for  PO   mg  tablet  
5mg  PO  OD   OD   admin.  Mix  with  25-­‐ 10  mg  
>5kg:  10  mg   50mL  mL  of  water   sachet  for  
PO  OD  12-­‐ 2.  Sachet  can  be   oral  
17yrs:  20  mg   dissolved  &   suspensio
PO  OD   administered  via  G   n  (Not  
tube   ODB  
  covered)  
Pantopra Pantol 1-­‐1.5   40  mg/dose   20-­‐40   Cannot  be  crushed   20mg-­‐   293  –  GERD  or  non  erosive  GERD  when  
zole   oc   mg/kg/day   mg  PO     not  a   H2Antags  have  failed  295  –  for  HPylori  
OD   benefit   Peptic  Ulcer  297-­‐PUD  or  prevention  of  
 40  mg     NSAID  induced  ulcers  401-­‐  treatment  of  
($0.5/tabl GI  disorders:  Crohn’s,,  short  Gut  etc.  402-­‐
et)   severe  esophagitis,  Zollinger-­‐Ellisons  etc.  
Rabepra Pariet   Greater    than     20  mg   Cannot  be  crushed   10  mg   NO-­‐  Not  Covered  under  ODB  
zole   10  years:  10   PO  OD     ($0.17  
mg  PO  OD     tablet)),  
20  mg  
($0.3/tabl
et)    
Note:  Directions  for  opening  capsules  and  dissolving  tablets  with    dispersed    microgranules  into  food  or  water  requires  that  the  granules  must  NOT    be  crushed  or  chewed  for  effect.  

1. Hospital  for  Sick  Children.  Drug  Handbook  and  Formulary.  2009.  


2. RX  Files  Drug  Comparison  Charts.  8th  Edition  
3. ODB  Drug  Formulary  
4. eCPS,  2012  
5. Jew,  RK  et.  Al.  Extemporaneous  Formulations  for  Pediatric,  Geriatric,  and  Special  Needs  Patients.  ASHP.  2nd  Edition.  
6. Micromedex  .  Accessed  December  2012.  
Prepared  by  N  Fernandes  RPh,  Drug  Information  Centre,  HHS.  Reviewed  by  S  Yousaf  RPh,  Pediatrics  MCH.  

194
Pediatric Emergency Medicine

   

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PALS Medications for Cardiac Arrest and Symptomatic Arrhythmias
Medication Dose Supplied Administration
Adenosine IV/IO: 0.1 mg/kg 3 mg/mL: 0.03 mL/kg Rapid bolus followed by
Max 6 mg Max 2 mL rapid flush
Repeat dose: 0.2 mg/kg Repeat dose: 0.07 mL/kg
Max 12 mg Max 4 mL
Amiodarone* IV/IO: 5 mg/kg 50 mg/mL: 0.1 mL/kg Rapid bolus for VF/VT,
(Max 300 mg) Max 6 mL over 20-60 minutes for
perfusing tachycardias
Atropine IV/IO: 0.02 mg/kg 0.1mg/mL: 0.2 mL/kg Bolus
Min 0.1 mg
Max 0.5 mg for child
Max 1 mg for adolescent
ET: use 2-10 times IV dose Dilute with NS
to 3-5 mL
Calcium IV/IO: 20 mg/kg 10% solution: 0.2 mL/kg Give slow push,
Chloride central line preferred
Dextrose IV/IO: 0.5-1 g/kg D10W: 5-10 mL/kg Avoid hyperglycemia
D50W: 1-2 mL/kg
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

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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 Dilute with NS to
the IV dose 3-5 mL
IV/IO Infusion: Add 100 mg to Run at 1.2 - 3
20-50 microgram/kg/min total of 100 mL mL/kg/h
Magnesium IV/IO: 25-50 mg/kg 0.5 g/mL: 0.05-0.1 Rapid infusion for
Sulfate (max 2 g) mL/kg torsades or
(max 4 mL) severe
hypomagnesemia
Naloxone IV/IO/IM: 0.1 mg/kg 0.4 mg/mL: 0.25 mL/kg Bolus
(max 2 mg) (max 5 mL)
ET: use 2-10 times Dilute with NS
the IV dose to 3-5 mL
Procainamide* IV/IO: 15 mg/kg 100 mg/mL: 0.15 Give over 30-60
*do not routinely use in mL/kg minutes
Combination with other drugs (max 10 mL)
that prolong QT interval
Sodium IV/IO: 1 mEq/kg 4.2%: 2 mL/kg Give slowly and if
Bicarbonate 8.4%: 1 mL/kg 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

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McMaster Children’s Hospital

Guidelines for the Pharmacological Management of Convulsive Status Epilepticus

This guideline is applicable to the emergency room (ER), in-patient wards and the critical care units
within the Children’s Hospital.

Measures to maintain adequate airway, breathing & circulation and, appropriate investigations
depend on the individual situation.

When to initiate pharmacological treatment for ongoing convulsive seizures:

1. Convulsive seizure lasting more than 5 minutes or the onset of convulsion is unclear (in special
situations like acute brain injury where seizure are likely to cause additional brain insult,
immediate attention is needed)
2. Two or more seizures within a short period time without patient returning to baseline
neurobehavioral stage.
3. Strong clinical suspicion of non-convulsive seizures following a convulsive seizure

Time from onset

Onset Blood glucose, electrolytes

First episode of seizure and/or etiology unclear: consider serum calcium,


phosphorous, magnesium, toxicology screen, ammonia, blood gas, CBC,
blood culture, LFTs

5 minutes Intravenous Lorazepam 0.1 mg /kg (maximum 4 mg) IV over 1 minute

10 minutes Intravenous Lorazepam 0.1 mg /kg (maximum 4 mg)IV over 1 minute

If IV access is not established, the options include the following

(a) Per rectal Lorazepam 0.1 mg/kg(Max 4 mg) (use the IV


preparation)*

(b) Intranasal Midazolam 0.2 mg/kg (maximum 10 mg) (Use the IV


preparation))**

15 minutes If seizure continues despite 2 doses of benzodiazepines (including 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)

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55 minutes Refractory Status Epilepticus

Points to remember

1. Waiting 5 minutes before initiating treatment of convulsive seizures in high risk patients could
potentially cause additional brain insult (Eg Brain injury patients).

2. *Diazepam 0.5 mg/kg PR (maximum 20mg) is another option

3. **Intranasal midazolam: Divide dose between nares. Atomizers for intranasal delivery are
available (http://www.wolfetory.com/Products/MAD/), but drug should be administered with a
syringe if atomizer is not immediately available.

4. Pre-hospital doses of benzodiazepine should be counted towards the total number of doses.

5. Prepare Phenytoin if you need to administer the second dose of Benzodiazepine. This avoids
further delay.

6. In neonates, phenobarbital is preferred to phenytoin

7. ***If no IV access: Another option is IM Fosphenytoin 20 mg PE/Kg (maximum 1 g) (if


available).

8. Consider Pyridoxine 100 mg IV in children <18 months with history of unexplained


developmental delay.

Refractory Status Epilepticus (RSE)

Defined as ongoing convulsive seizures despite 2 doses of Benzodiazepines, 20 mg/kg each of phenytoin
and Phenobarbital.

First line

Intravenous Midazolam IV 0.15 mg/kg bolus then 2 μg/kg/min infusion [Use of IV Midazoalm should
prompt immediate consultation with PCCU]

End point is absence of electrographic seizures (not burst suppression) in the EEG and clinical seizures.

Rapid titration: Increase as needed by 2 μg/kg/min q5 minutes

Bolus 0.15 mg/kg with each increase in infusion rate

Maximum infusion rate: 24 μg/kg/min (maximum 40 mg/hour)

Maintain phenobarbital and phenytoin at therapeutic serum levels

Goal is to maintain seizure free status for 24-48 hours.

Tapering Midazolam: Decrease by 1 μg/kg/min q15 minutes (not slow tapering unless indicated for
sedation or withdrawal management purposes)

If seizures recur while/after tapering Midzolam, maintain midazolam infusion for another 24 - 48 hours.

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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

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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)

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Emergency Room Management Guidelines
for the Child with Type 1 Diabetes
Diabetic Ketoacidosis (DKA) Hypoglycemia (moderate or severe)
History (some or all of) Clinical Signs generally include History Clinical Signs
• Polyuria • Tiredness • Deep sighing respirations – (Kussmaul breathing) Recent hypoglycemic event requiring treatment by another Seizures
• Polydipsia • Vomiting with no wheeze or rhonchi person with Glucagon or oral glucose especially if AND/ Hemiparesis
• Weight loss • Confusion • Smell of ketones on breath – Increased confusion OR Any localizing neurological findings
• Abdominal pain • Difficulty breathing • Lethargy/drowsiness – Decreased consciousness Altered state of consciousness
• Dehydration – mild to severe
Obtain a blood glucose (capillary)
• Urine ketones/glucose Electrolytes and Gases not usually necessary
• Capillary glucose STAT in ER
• Venous blood – glucose, gases, electrolytes, urea, creatinine IF child is active, alert, and tolerating oral fluids well, then encourage
• Other as indicated 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
Confirm DKA
• Ketonuria • Serum Bicarbonate <18 mmol/L
• Glucose >11 mmol/L • Consult Pediatrician immediately If drowsy, and any neurological impairment, localized or generalized:
• pH <7.3 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)

Hypotension (PALS Values) Continue IV glucose until:


Age Systolic BP (mm/Hg)
Vascular Decompensation No Vascular 1. Child has no further neurological signs and
<1 month < or = 60
(with or without coma) Decompensation 2. Child is no longer drowsy, confused, irrational or restless.
1 month to 1 year < or = 70 • Hypotension (see box)
(May take up to 12 hours if hypoglycemic encephalopathy is present)
1 to 10 years < or = 70 + (2 x age in years) • Decreased level of consciousness
>10 years < or = 90 3. Maintain blood glucose >8 mmol/L as above until IV fluids discontinued
4. Then, change to oral sugar-containing fluids

Resuscitation • Clinically Dehydrated • Minimally dehydrated Discharge


• Assess airway and breathing • Hyperventilating • Tolerating fluids orally Discharge ONLY when child is
• Apply 100% oxygen by mask OR • Normal bowel sounds • Fully alert
• Normal Saline 10 ml/kg to • Vomiting • Normal mental status • Tolerating oral fluids and
expand vascular space • Normal BP • Free of neurological signs.
THEN (lying and sitting)
• Decrease to 5 - 7 ml/kg/hr with
Potassium Chloride as noted below Observation and Monitoring
Normal Saline • Oral hydration • Determine cause and arrange for follow-up
• Only infuse Sodium Bicarbonate
7 ml/kg over 1st hour • S/C insulin • Decrease all insulin doses by 20% for next 24 hrs
(1 - 2 mEq/kg over 1 hour) if:
with Potassium Chloride (see illness rules) • Renew prescription for Glucagon if used
1. Life-threatening hyperkalemia
as noted below
2. Inotrope-resistant shock
THEN 3.5 - 5 ml/kg/hr
3. Cardiac Arrest
Intercurrent Illness
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 If emesis 2x in past 4 hours, No emesis BUT No emesis
• Aim to keep Potassium between 4 - 5 mEq/L keep NPO for 4 - 6 hours Not drinking Tolerating fluids
• 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.
• Capillary glucose • Capillary glucose
• DO NOT GIVE BOLUS OF INSULIN
• Venous blood – glucose, gases, electrolytes, urea • Venous blood – glucose, gases,
• Continuous cardio-respiratory monitoring (with EKG tracing)
• Urine ketones urea, electrolytes
• Urine ketones
Neurological deterioration Acidosis not Acidosis improving
Headache, irritability, improving • Blood glucose <15 mmol/L IV fluids
decreased level of consciousness, (in 3 - 4 hours) OR • Severely dehydrated –
decreased HR • Check insulin • Blood glucose falls >5 mmol/L/h Normal Saline (10 ml/kg) over 1 hour Maintenance IV fluids
delivery system after 1st hour of fluids • If glucose >20 mmol/L then • 4 ml/kg/hr for 1st 10 kg
First rapidly exclude hypoglycemia Normal Saline at maintenance volumes • 2 ml/kg/hr for next 10 kg
by capillary blood glucose • Consider sepsis • Change IV to D5/Normal Saline
• Contact Tertiary with Potassium as above • If glucose <20 mmol/L then D5W./ • 1 ml/kg/hr for next 10 kg
measurement Normal Saline at maintenance volumes
THEN Pediatric • Decrease insulin to 0.04 - 0.05 U/kg/hr =
Diabetes Centre 0.4 - 0.5 ml/kg/hr of standard solution as above • Once voiding, add Potassium Chloride
Treat for cerebral edema
• Blood glucose <10mmol/L change to
D10/Normal Saline with Potassium as above
Hyperglycemic Hypoglycemic
• 20% Mannitol 5 ml/kg over 20 minutes • Improvement • Do not omit insulin • Do not omit insulin
• If Sodium has declined, administer • Clinically well • Use S/C insulin unless acidotic (see DKA guidelines) • Decrease next scheduled insulin dose by 10 - 20%
2 - 4 ml/kg of 3% saline over 10 - 20 min. • Tolerating oral fluids • If Blood Glucose >11 mmol/L and mod-large • If not tolerating oral fluids then follow IV
THEN • Ph >7.3 ketones, then give usual insulin PLUS extra short as per hypoglycemia guidelines
Normal Saline @ maintenance IV rate • Bicarbonate >18mmol/L or rapid-acting Q4h [10 - 20% of TOTAL (N&R or H) • Otherwise encourage carbohydrate-containing fluids
• Decrease insulin to 0.04 - 0.05 U/kg/hr = daily dose]
• Start S/C insulin
0.4 - 0.5 ml/kg/hr of standard solution as above • Stop IV insulin ½ hour after S/C dose of rapid-acting
Catalogue No. 013308 450 April/09 © 2009 Queen’s Printer for Ontario

• Contact Tertiary Pediatric Diabetes Centre or 1 hour after S/C dose of regular insulin Discharge
• Admit to ICU • Determine cause of DKA • Tolerating oral fluids
• Contact regional Pediatric Diabetes Education Centre • No other reason for hospitalization
• Replace usual meal plan with carbohydrate-containing fluids

Observation and Monitoring


• Hourly blood glucose (capillary) Observation and Monitoring
• Aim for a decrease in blood glucose of 5 mmol/L/h • Input & Output Q4h
• Strict hourly documentation of fluids input/output • Blood glucose Q2-4h (keep within 4 -10 mmol/L)
• Calculate and review fluids balance at least every 4 hours • Test urine for ketones
• 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

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