PEDIATRIC OFFTAG ASSESSMENT MALAYSIA NATIONAL IMMUNISATION PROGRAM (NIP)

NIP protects Malaysian children against 13 major childhood diseases.

NO TITLE PAGE
General rules in department
Basic general pediatrics clerking
Malaysia National Immunisation Programme
Developmental milestone table
Fluid calculation (bolus/ deficit/ maintenance)
Electrolytes imbalance
Common investigation normal range
Common antibiotics in general pediatrics
Common medications in general pediatrics
Nebuliser/ MDI chart
BP chart
Growth chart CDC
Asthma
Pneumonia
Febrile fit
AGE
Dengue
Sedation in children
Basic Newborn screening/ Clerking
Neonatal Resuscitation Program (NRP)
Fluid / Feeding calculation in neonates
Neonatal Jaundice
Risk of sepsis in neonates
Hypoglycemia
Respiratory distress in neonates
Scalp swelling in newborn
Common investigation normal range newborn
Common antibiotics in neonates
Common medications in neonates
 Basic general pediatric clerking Past medical History

- Surgical and medical problem

Name - Chronological order

MRN - Previous admission : age, presenting symptoms, duration of stay in hospital,
ICU admission, investigation and treament given, diagnosis told to the
DOB:
parents
Age:
Medication/ Allergies
Gender:
- List on medication with frequency
Ethnicity:
- Includes supplement and OTC drugs
DOA:
- Maternal drugs if still breastfeeding
Informants:
- Detailed allergic description

Birth History
History of presenting illness:
- Antenatal History: para/ gestaional age/ GDM/ risk of sepsis/ PIH/
Systemic review
Obstetrics problems
- CVS
- Intrapartum: Mode of delivery/ Birth weight/ Place of birth/ Any fetal
- Respiratory distress or mecconium

- Gastrointestinal - Postnatal: Admission to NICU? / Reason of admission/ duration of stay/

Complications/ Respiratory support/ Follow up?
- Genitourinary
Nutritional History
- Neurological
- Breastfeeding/ bottle feeding: How long/ How much?/ Milk type/
- Musculoskeletal Breastmilk hygiene
- Hematology - dilution of formula milk
- Dermatology - Timing of weaning to solid food
++ activity - Current dietary intake
++ oral intake *** May neet 24 Hours dietary recall; breakfast, morning tea, lunch, evening
++ PU, BO status tea, dinner
Immunisation History

- vaccine and age given CALCULATION OF IDEAL BODY WEIGHT (IBW) FOR OBESE CHILDREN

- any additional vaccines outside the scheduled If patient’s height is within 5th and 95th centile of age, use Moore method as
- To document iff any delayed/ missed oppurtunity to vaccine below:
• the IBW is the weight for age on the same percentile as height. For
Developmental History example, a child with a height at the 10th centile can have his IBW
determined by looking at the growth chart and finding the weight at the 10th
Younger age group: Gross motor/ Fine motor/ Viion/ speech/ Hearing centile for his age.
*** Need to comment whether appropriate for for age group/ delayed
If patient’s height exceeds 95th centile for age, use McLaren method as
Elder children: Schooling, to recall previous important milestone below:
• weight at the 50th centile for height age chart Use steps as below for IBW:
*** Which and type of school, assess academic performance, how socialised i. plotting the child’s height for age
with other children / sports?/ ay issues at school? ii. extending a line horizontally to the 50th centile height-for-age line
iii. extending a line vertically from the 50th centile height-for-age to the
Family History
corresponding 50th centile weight and note this IBW
- Ages of parents and what they both do

- Marital status and how long

- Consanguinity

- Number of sibling and age range

- Family history of developmental disorder/ fitting/ early or sudden death

- Any hereditary/ infectious disease involved?

Social History

- Housing: Type of accommodation

- who looks after the child: parents/ babysitter/ nursery

- Level of education and occupation parents

- If chronic condition, any social support/ support group

- Any pets at home

- Smoker at home
 Pediatric Fluids and Electrolytes guideline Deficit:

Reasons for prescribing IV fluids o Based on estimation of degree of dehydration expressed as % of

o Circulatory support in resuscitating vascular collapse body weight
o Replacement of previous fluid and electrolyte deficit o Use 0.9% normal saline
o Maintenance of daily fluid requirement o Stages of dehydration
o Replacement of on-going losses severe dehydration with failed NG o Mild = 5%
tube replacement o Moderate = 7.5%
o Certain comorbidities, particularly GIT condition such as short gut or o Severe = 10%
previous gut surgery

VOLUME REQUIREMENT = maintenance fluid + fluid deficit + on-going loss

Maintenance is;
o Is the volume of fluid daily intake which includes insensible losses
from breathing, perspiration and in the stool
o Allows excretion of daily production of excess solute load (urea,
creatinine, electrolytes)
 Volume deficit=
- 7.5/100 x 1000 x 15
- = 1125ml/24 hours = 47ml/Hour
IVD Normal saline 0.9% 47ml/Hour for 24Hours (7.5% correction started from
18/2/2024, 10am till 19/2/2024, 10am)

Let say patient improving, you were ask to reduce IVD maintenance to 2/3
maintenance

Volume maintenance=
- First; 10kg x 100ml= 1000ml
- Second; 5kg x 50ml= 250ml
- Total= 1250ml/24 hours = 52ml/Hour
If hypovolemia (clinically shock)
- Boluses of 10-20 ml/kg of IV normal saline, which may be repeated IVD Half saline 0.45%NS D5% 52ml/Hour (Full maintenance)
till 60 ml/kg total

If hypoglycaemia So if you want 2/3 maintenance;

- Treat with 2mls/kg of 10% dextrose solution
2/3 x 52 = 35ml/Hour

Write as, IVD Half saline 0.45%NS D5% 35ml/Hour (2/3rd maintenance)
Example:

3 years old, Malay, boy came in with vomiting and loose stool > 10X with So if you want half maintenance;
dehydration 7.5%, with 15kg 1/2 x 52 = 26ml/Hour
Volume maintenance= Write as, IVD Half saline 0.45%NS D5% 26ml/Hour (half maintenance)
- First; 10kg x 100ml= 1000ml
- Second; 5kg x 50ml= 250ml
- Total= 1250ml/24 hours = 52ml/Hour

IVD Half saline 0.45%NS D5% 52ml/Hour (Full maintenance)

 Common Intravenous (IV) antibiotics dosage in general paediatrics IV Gentamicin 8mg/kg STAT TDM 3rd
6mg/kg OD (for dose
NAME DOSAGE FREQUENC INDICATIO Notes total 5 days
Y N )
IV Ampicillin 25mg/kg QID Adult IV Amikacin 25mg/kg STAT TDM 3rd
Severe 18mg/kg OD (for dose
infection: total 5
50mg/kg days)
IV C Penicillin 25 QID IV Azithromycin 15mg/kg STAT Adult
000u/kg 5mg/kg OD 500mg
50 stat and
000u/kg 200mg
100 OD
000u/kg IV Imipenem 15mg/kg TDS - QID Renal
IV Augmentin 30mg/kg TDS adjusted
( Amoxicillin/ Severe dosage
Clavulonic Acid) infection: IV Meropenem 20mg/kg TDS
50-60mg/k
g (High dose
IV Cloxacillin 25mg/kg QID 40mg/kg)
Severe IV Metroninadozle 15mg/kg STAT
infection: (Flagyl) 7.5mg/kg TDS
50mg/kg IV Vancomycin 25mg/kg TDS TDM
IV Cefotaxime 50mg/kg (pre post
IV Cefuroxime 25mg/kg TDS level/
Severe random)
infection: , renal
50mg/kg adjusted
IV Cefepime 50mg/kg TDS dosage
IV Ceftriaxone Infection: OD IV Acyclovir 500mg/m2
50mg/kg (for 36 weeks 8 Hourly
Meningitis BD meningoencephalitis – 12 years
: 50mg/kg ) old
IV Ceftazidime 25mg/kg TDS >12 years 10mg/kg 8
IV Tazosin 100mg/kg TDS old Hourly
(Piperacillin/
Tazobactam)
IV Unasyn 25- TDS Adult
(Ampicillin/ 50mg/kg 1.5g
Sulbactam) STAT
and TDS)
 Common Oral antibiotics dosage in general paediatrics Common investigations normal value in general paediatrics

Liver function test

Name Dosage Frequency Adult Notes Protein (total) 60- 80g/L

dosage Albumin 35-50g/L
Syrup 25mg/kg TDS 500mg-1g Alkaline phosphatase (ALP) 30-150 iU/L
Amoxicillin TDS Aspartate transaminase (AST) 5-35 iU/L
Syrup 25mg/kg BD 625mg Alanine aminotransferase(ALT) 5-35 iU/L
Augmentin BD/TDS Bilirubin 3-17 µmol/L
Syrup 15mg/kg BD 250-500mg
Cefuroxime BD
Syrup Day 1: OD Renal function test
Azithromycin 15mg/kg
Urea 2.5-6.7 mmol/L
Day 2-Day 5:
Sodium 135-145 mmol/L
7.5mg/kg
Potassium 3.5-5 mmol/L
Syrup EES 20mg/kg BD
Chloride 95- 105 mmol/L
Syrup 15mg/kg QID 500mg QID
Creatinine 20-75µmol/L
Cloxacillin
Syrup Penicillin Prophylaxis: 250-500mg
V 250mg BD QID Full blood count
Treatment:
15mg/kg White cell count 4.0-11.0 x10 /L
QID Neutrophils 2.0-7.5 x 10 /L
40-75% WCC
Lymphocytes 1.3-3.5 x 10 /L
20-45% WCC
Eosinophils 0.04-0.44 x 10 /L
1-6% WCC
Basophils 0-0.1 x 10 /L
0- WCC
Monocytes 0.2-0.8 x 10 /L
2-10% WCC
Haemoglobin (Hb) 13.0-18.0 g/dl (male)
11.5- 16.0 g/dl (female)
Hematocrit 0.4-0.54 L/L (male)
0.37- 0.47 L/L (female)
Platelet 150-400 x10 /L
Mean cell volume (MCV) 76-96 fL
Mean cell haemoglobin (MCH) 27-32 pg/L
 responsiveness test Increase PEF >20%
10-15 minutes after 200-
400mcg salbutamol
Excessive variability in BD Average daily diurnal PEF
daily PEF over 2 weeks variability >13%
Increase lung function after Increase FEV1 >12% or
4 week of treatment Increase PEF >20%
After of 4 weeks of ICS
containing treatment
Positive exercise challenge Reduce FEV1 >12%
test Reduce PEF >15% from
baseline

Positive bronchial challenge Reduce FEV1 >15% from

test baseline with hypertonic
Bronchial asthma saline

Definition:
Asthma is a heterogeneous disease, usually characterized by chronic
airway inflammation.
It is defined by the history of respiratory symptoms such as wheeze,
SOB, chest tightness and cough, that vary over time and intensity,
together with variable expiratory airflow limitation

Diagnosis of asthma is based on;

o The history of characteristics symptoms pattern

Wheeze, - Symptoms occur variably over time

SOB, chest and vary in intensity
tightness - Symptoms are often worse at night
and cough or on waking
- Symptoms are triggered by exercise,
cold induced, allergens
- Symptoms often appear or worsen
with viral infections

o Evidence of variable expiratory airflow limitation

Excessive Variability in lung function

Positive Bronchodilator Increase FEV1 >12%
Asthma action plan
As attached

Cough Diary
As attached
 Dengue

Dengue infection is caused by a single stranded RNA dengue virus.

It is transmitted by Aedes Aegypti and Aedes Albopictus
There are 4 dengue serotypes DENV-1-2-3 and 4

Rapid haemodynamic assessment can be performed at bedside

C (skin colour)
C (CRT)
T (extremities’ temperature)
V (pulse volume)
R (pulse rate).
 Neonatal Resuscitation Program

Assess 4 prebirth question prior to standby

- Gestational age
- Amniotic fluid color
- Additional risk factors
- Umbilical management plan

Initial steps of newborn care

- Provide warm
- Dry
- Stimulate
- Position the head and neck
- Clear secretions if needed

Place the pulse oximetry probe to baby right hand

Why??
In most babies, the artery supplying the baby's right arm branches from
the aorta before the patent ductus arteriosus enters the aorta. Blood
in the right arm is often called "pre-ductal" and has a similar oxygen
saturation as the blood perfusing the heart and brain. The origin of
blood flow to the left arm is less predictable. The arteries supplying
both legs branch from the aorta after the patent ductus arteriosus and
are called "post-ductal'
Ventilation corrective steps
- Mask adjustment
- Reposition the head
- Suction the mouth
- Open the mouth
- Pressure increase
- Alternative airway

Endotracheal intubation

Anchor the ETT at?

Medications

ADRENALINE
Concentration: 0.1 mg/mL = 1 mg/10 mL
(1ml adrenaline (1mg/1ml) dilute in 9ml normal saline to make it 10ml or 1mg/10ml)
Route: Intravenous (preferred) or intraosseous
i. The central venous circulation may be rapidly accessed
using either an umbilical venous catheter or an intraosseous
needle.
ii. One endotracheal dose may be considered while vascular
access is being established.
Preparation:
i. Intravenous or Intraosseous: 1-mL syringe (labeled
Epinephrine-IV)
ii. Endotracheal: 3- to 5-mL syringe (labeled Epinephrine-ET
ONLY)
Dose:
Intravenous or intraosseous = 0.02 mg/kg ( equal to
0.2 mL/kg)
Endotracheal = 0.1 mg/kg (equal to 1 mL/kg)
 Neonates Fluids Calculation

Definition neonates: < 28 Day of life

TFI stands for total fluid intakes

In adults for example recommended to drink 2-3L per day

So how much fluid requirement per day for babies

So, the concept:

Hours of life Days of life Total fluid Total Fluid

intake, TFI intake
(Term) (Premature)
0 – 24 Hours 1 60 ml/kg/day 60 ml/kg/day
25 – 48 Hours 2 90 ml/kg/day 80 ml/kg/day
49 – 72 Hours 3 120 ml/kg/day 100 ml/kg/day
73 – 96 Hours 4 150 ml/kg/day 120 ml/kg/day
97 -120 Hours 5 150 ml/kg/day 140 ml/kg/day
121 – 144 Hours 6 150 ml/kg/day 150 ml/kg/day
>7 150 ml/kg/day 150 ml/kg/day

Fluids is given in the form of feeding or intravenous fluids generally

Feeding
Babies usually fed around 3Hourly per days, it makes a total of 8 times in one
day

Timing in ward: 9am/ 12pm/3pm/ 6pm/ 9pm/ 12 am/ 3am/ 6am

How to calculate feeding;

TFI X best weight (kg )

Feeding amount (ml)=
8 feed
 Intravenous Fluids
Case 1: How to calculate IVD, let’s say baby is NBM
Term baby 40 weeks, 3 Hours of life, weight 2.5kg TFI X best weight (kg)
IVD RATE(ml /Hour )=
24 Hours

60 ml /kg /day X 2.5

Feeding amount (ml)=
8 feed Case 1:
= 18.75ml/3Hourly (give to approximate logic amount 20ml/3Hourly) Term baby 40 weeks, 3 Hours of life, weight 2.5kg
= Start CF 20ml /3Hourly (TF 60ml/kg/day)

Case 2: 60 ml /kg /day X 2.5

Feeding amount (ml)=
Term baby 38 weeks, 50 Hours of life, weight 3.2kg 24 Hours

120 ml /kg/day X 3.2 =6.3ml/Hour

Feeding amount (ml)=
8 feed = IVD D10% run at 6.3 ml/ Hour (TF 60ml/kg/day)
= 48ml/ 3Hourly (give to approximate logic amount 50ml/3Hourly) Case 2:
= CF 50 ml/3Hourly (TF 120ml/kg/day) Term baby 38 weeks, 50 Hours of life, weight 3.2kg

120 ml /kg/day X 3.2

Feeding amount (ml)=
Case 3: 24 Hours

Premature baby 34 weeks, 82 Hours of life, weight 2kg = 16ml/Hour

120 ml /kg/day X 2 = IVD 1/5NSD10% run at 16ml/Hour (TF 120ml/kg/day)

Feeding amount (ml)=
8 feed Case 3:
= 30 ml/ 3Hourly Premature baby 34 weeks, 82 Hours of life, weight 2kg
= CF 30ml/3Hourly (TF 120ml/kg/day) 120 ml /kg/day X 2
Feeding amount (ml)=
24 Hours
= 10ml/Hour

= IVD 1/5NSD10% 10ml/Hour (TF 120ml/kg/day)

 o Pallor, plethora, cephalhaematoma, subaponeurotic
haemorrhage, bruises
o Signs of intrauterine infection e.g. petechiae,
NEONATAL JAUNDICE hepatosplenomegaly
o Cephalo-caudal progression of severity of jaundice
Definition: yellowish discolouration of sclera and mucus membrane
Kernicterus is neurotoxicity due to deposition of unconjugated bilirubin Assessment of jaundice severity
1. Total serum bilirubin (VSB) (**gold standard for determine
hyperbilirubinemia)
2. Transcutaneous bilirubinometer (TcB)
3. Visual assessment (Kramer's rule)

CLINICAL ASSESSMENT OF THE JAUNDICED INFANT

1. History
o Age of onset of jaundice
o Previous infants with severe neonatal jaundice, kernicterus,
neonatal death, G6PD deficiency, or exchange transfusion
o Mother’s blood group (from antenatal history)
o Gestation: the incidence of hyperbilirubinaemia increases
with prematurity
o Presence of abnormal symptoms of sepsis, apnoea, difficulty
in feeding, feed intolerance and temperature instability
2. Physical Examination
o General condition, gestation and weight, signs of sepsis,
hydration status
o Signs of kernicterus (hypotonia, seizure, opisthotonus, high
pitch cry, retrocollis)
 o May be consider in case of ABO incompatibility/ Rhesus
incompatibility

How to use NNJ phototherapy table?

Case example 1:

Baby of B, 40 hours of life, Term 37 weeks 2 days, MBG B positive, G6PD

Normal
VSB taken at 37 Hours of life 150
Take medium risk in view of 37 weeks
MR at 36 Hours: PL 145 IPL 196 ET 308

Plan
Start conventional phototherapy
VSB cm

Case example 2:

Investigation Baby of F, 52 Hours of life, Term 40 weeks, MBG O positive, G6PD Normal
- VSB
- RP if having significant weight loss >7.5% VSB taken at 49 Hours of life 230
- Infant of rhesus negative mother: baby blood group (need to update Take medium risk, MBG O positive
O&G team for Rhogam administration) MR at 48 Hours: PL 171 IPL 222 ET 325
- Pathological jaundice: FBC, retics, +/- ABO, coombs, FBP
- Prolonged jaundice: VSB, LFT, AST, Retics, TFT, FBP, UFEME, urine Plan
C&S +/- TORCHES Start intensive phototherapy
- Exchange transfusion protocol: FBC, RP, Electrolytes, LFT, AST, VSB, Repeat VSB in 4-6Hours
CRP, Blood C&S, FBP, retics, GXM mother and baby, (blood for ET is
fresh whole blood), Coombs, Coagulation profile, VBG
Case example 3:
Treatment Baby of F, 27 Hours of life, Term 39 weeks, MBG O positive, G6PD deficiency
- Phototherapy
- Intensive phototherapy VSB taken at 25Hours of life 327
o When? VSB more than 50umol/L than photo level Take medium risk MBG O positive, G6PD deficiency
- Exchange transfusion MR at 24Hours: PL 120 IPL 171 ET 291
o Partial ET/ double volume ET
- IV Immunoglobulin Plan
Start intensive phototherapy + bili blanket with full exposure
Repeat VSB stat
Monitor BIND score
Inform MO
Activate ET protocol
KIV for exchange transfusion
 Early onset of neonatal sepsis < 72Hours
Late onset of neonatal sepsis More than 72 Hours

Clinical features of neonatal sepsis:

Neonatal Sepsis
The diagnosis of chorioamnionitis depends on the presence of at least 2 of
the following:
- Maternal tachycardia > 100bpm
- Fetal tachycardia >160bpm
- Uterine tenderness
- Foul smelly of amniotic fluid
- Maternal leukocytosis >15
 Neonatal Hypoglycemia
Neonatal hypoglycemia if untreated can lead to severe neurological damage
No universally agreed definition of hypoglycemia

Clinical Signs of Hypoglycaemia

• Jitteriness
• Cyanosis
• Seizures
• Apnoeic episodes
• Tachypnoea
• Weak or high-pitched cry
• Floppiness or lethargy
• Poor feeding
• Eye-rolling

Infants who are at increased risk of hypoglycemia and require glucose

screening:
• Symptoms of hypoglycemia
• Large for gestational age (even without maternal diabetes)
• Perinatal stress
• Birth asphyxia/ischemia; caesarean delivery for fetal distress
• Maternal preeclampsia/eclampsia or hypertension
• Intrauterine growth restriction (small for gestational age)
• Meconium aspiration syndrome, erythroblastosis fetalis, polycythemia,
hypothermia
• Premature (including late preterm infants) or postmature delivery
• Family history of a genetic form of hypoglycemia
• Congenital syndromes (eg, Beckwith-Wiedemann), abnormal physical
features (eg, midline facial malformations, microphallus)

Causes of hypoglycemia
Decreased substrate IUGR, prematurity, prolonged fasting, IEM such as
glycogen storage disease, increased glucose
utilization (sepsis, perinatal asphyxia)
Hyperinsulinemia Infant of diabetic mother, Beckwith-Wiedemann
syndrome. Maternal with beta mimetic tocolytic
agents, islet cell hyperplasia
Endocrine causes Adrenal insufficiency, panhypopituitarism,
hypothyroidism
Miscellaneous Polycythemia, congenital heart disease, CNS
abnormalities
 acylcarnitine and urine for organic acids

How to calculate Glucose Infusion Rate (GIR)? ****Take blood investigations before an increase in rate of dextrose infusion
when hypoglycaemia persists despite dextrose infusion.
ml
Dextrose % x rate IVD( )
Hour
GIR= POINTS TO REMEMBER
6 x weight ( kg )

Case example: - Avoid giving multiple boluses a rapid rise in blood glucose
20 Hours of life, Term 37 weeks 4 days baby, birth weight 2.6kg, noted concentration is harmful to neurological function and may be
persistent hypoglycemia, latest DXT 2.0, currently NBM with IVD1/5NSD10% followed by rebound hypoglycemia.
at TF 90cc/kg/day, TR for IVD 9.8ml/ Hour (TF 1 day a head). Current GIR 6.3 - Any bolus given must be followed by continuous infusion of glucose.
mg/kg/minute Do not continuing giving intermittent glucose boluses alone.
- If unable to increase volume further, increase dextrose concentration
What to do?  Increase GIR by increase the Dextrose concentration to
D12.5%, TF remain at 90cc/kg/day, TR for IVD 9.8ml/Hour
How to calculate the latest GIR ?

12.5 x 9.8
GIR=
6 x 2.6

GIR = 7.9 mg/kg/minutes

Dextrose 15% and above require central line to administered, consider insert
UVC/ PICC for neonates

What is critical sampling for persistent hypoglycemia?? - “critical” sampling

taken when plasma glucose < 2.6 mmol/L after 48 hours of life
- Plasma glucose (RBS)
- Insulin
- Blood Gas
- Serum ammonia
- Serum Lactate
- Serum Ketones (beta-hydroxybutyrate)
- +/- IEM study
- +/- Free fatty acid levels
- Further investigations are directed by the results of these tests

(Consult Paediatric Endocrinologist and/or Genetic/Metabolic specialist)

e.g. C-peptide, cortisol, growth hormone, ammonia, plasma
SCALP SWELLING IN NEWBORN