Description

Pediatrics 1 of 3

Comprehensive Review of Pediatric High-Yield Content

Disclaimer: Content is for educational exam preparation only and does not constitute medical advice. Medicine changes quickly; always verify with current, local guidelines before applying to patient care.

1. Pediatric Equations and Anthropometric Norms

• Minimum Systolic BP: 60 mmHg (first month of life); 70 mmHg (rest of the year); 70 +age*2 (moving forward).
• Weight: 7 + (age x 3)
• Weight Loss/Gain: Expected to lose 10% of weight after birth, gained back by one to two weeks. Gain 30 g/day (first 3 months); 15 g/day (next three months).
• Newborn Feeds: 1 ounce per kilogram every 2 to 3 hours (approx. 2–3 ounces every 2–3 hours).
• ETT Size (Uncuffed): 4 + age/4
• ETT Size (Cuffed): 3.5 + age/4
• ETT Size (Preterm/Newborn): Gestational age/10
• Foley Catheter Size: ETT size x 2
• Chest Tube Size: ETT size x 4

2. Pediatric Assessment and Initial Management

Toxic Neonate
The pneumonic for a toxic neonate is THE MISFITS

• Trauma
• Heart
• Endocrine (such as congenital adrenal hyperplasia)
• Metabolic (bilirubin and electrolytes)
• Intestinal catastrophes (e.g., NEC, midgut volvulus, Hirschsprung's enterocolitis)
• Sepsis
• Feeding (e.g., watering down formula)
• Inborn error of metabolisms
• Toxins
• Seizure

Pediatric Assessment Triangle (PAT)
The PAT assesses Appearance, Breathing, and Circulation (ABC).

• Appearance (Ticls): Tone, Interactiveness, Consolability, Look, Speech.
• Breathing: Assess quality, posture, sounds (stridor, wheezing), and work of breathing.
• Circulation at the skin: Assess color, mottling, cyanosis, pallor, and capillary refill.

3. Pediatric Fever: Risk Stratification (0–90 Days)

Patients with high-risk factors (pre-term status, prior hospitalizations/extended hospital time post-birth, past medical history/immunodeficiency, recent antibiotics, or focal infections) cannot undergo risk stratification.

For well-appearing, non-high-risk patients, three tools can be used:

A. Pecarn Criteria

1. Urinalysis (Negative): Negative nitrates, negative leucocyte esterase, AND <5 white blood cells (WBCs) in the urine.
2. ANC: ≤4,090
3. Procalcitonin: ≤1.71

B. Step-by-Step Criteria

1. Well appearing.
2. Age 22-90d old
3. Urinalysis negative for leucocytes.
4. Procalcitonin < 0.5
5. CRP ≤ 20 AND ANC ≤10,000 (combined).

C. Arensson Criteria (Low Risk is ≤1)

This tool can be used without Procalcitonin.

• Age: <21d (1 point).
• ED Temperature: 38–38.4°C (2 points); 38.5°C or higher (4 points). Note: Any fever in the ED results in the patient not being low risk.
• ANC: ≥5185 (2 points).
• Urinalysis: Must be totally negative (negative leucocytes, <5 WBCs, negative leucocyte esterase, negative nitrates).

Empiric Treatment and Disposition

• Age Group: 0–28 days
  • Empiric Regimen: Ampicillin and Gentamicin. Add Cefotaxime if suspicion of meningitis.
  • Additional Agents / Management: Admission is mandatory. LP may be omitted if low risk/no high risk, but admission with or without antibiotics is required.
• Age Group: 29–60 days
  • Empiric Regimen: Ampicillin and Ceftriaxone.
  • Additional Agents / Management: Ceftriaxone is safe in this group as it avoids worrisome bilirubin displacement. Add Vancomycin if resistance is suspected. Add Acyclovir if HSV risk factors present.
• Disposition (29–60 days): If low risk or only urine positive, treat UTI, LP is optional, and the patient may go home with antibiotics and 24–48 hour follow-up. If high risk, LP and empiric treatment are required.

4. Brief Resolved Unexplained Event (BRUE)

BRUE is defined as an event that is brief < 1 minute, resolved, and unexplained.

Low-Risk Criteria (321 CHEO)

• 3: Must be > 32 weeks gestational age at birth OR >45 weeks corrected gestational age.
• 2: Must be > 2 months old (precisely 60 days).
• 1: Event lasted < 1 minute.
• CPR not done.
• History normal.
• Exam normal.
• O for zero prior episodes.

Management for Low-Risk BRUE

• Allowed: Observation for 3–4 hours, ECG, Pertussis testing, education, offering CPR training, and assessment for social risk factors.
• Avoided: Lab work, chest x-rays, echoes, home monitoring devices, prophylactic acid suppression, anticonvulsant medications, or hospital admission.

5. Infective Endocarditis (Modified Duke Criteria)

The pneumonic used is BE TIMER.

• Criteria Type: Major (BE)
  • Blood culture positive
    • Positive More than 2 times 12 hours apart (persistent), 2 positive with typical organisms or Any positive for coxiella
  • Echo positive 
• Criteria Type: Minor (TIMER)
  • Tempo over 38°C
  • Immunologic phenomenon
    • Roth spots or Osler nodes
  • Microbiological evidence
    • Evidence that does not meet major criteria
  • Embolic phenomenon
    • Septic or arterial embolisms
  • Risk factors
    • IV drug use or valve disease

Diagnostic Thresholds:

• Definite Endocarditis: 2 Major OR 1 Major + 3 Minor OR 5 Minor.
• Possible Endocarditis: 1 Major + 1–2 Minor OR 3 Minor.

6. Pediatric Head Trauma Algorithms

A. PECarn Rule: High vs. Intermediate Risk

• Age Group: < 2 Years Old (GAP HAL DEFPRO)
  • High-Risk Criteria (Requires CT): GCS < 15, altered mental status, palpable skull fracture
  • Intermediate-Risk (Observe or CT): Non-frontal hematoma, acting weird/not themselves, LOC > 5 seconds, severe mechanism.
  • Severe Mechanism Thresholds: Fall height up to 3 feet. Mechanisms include MVC with death/ejection, fall, pedestrian struck, rollover, high-velocity object struck.
• Age Group: > 2 Years Old (GAB HVL DEFPRO)
  • High-Risk Criteria (Requires CT): GCS < 15, altered mental status, basilar skull fracture findings.
  • Intermediate-Risk (Observe or CT): Severe headache, vomiting, loss of consciousness, severe mechanism.
  • Severe Mechanism Thresholds: Fall height up to 5 feet. Mechanisms are the same as the younger age group.

B. Catch 2 Rule (GOHIM BHV)

• GCS < 15 at 2 hours.
• Open or depressed skull fracture.
• Worsening Headache.
• Irritable.
• Mechanism.
• Signs of Basilar skull fracture.
• Boggy Hematoma.
• Vomiting four or more times.

Dangerous Mechanisms (Catch 2): MVC, fall from > 3 ft or 5 stairs, and fall from bicycle with no helmet.

C. PECarn C-Spine Rule (UPN ANT)

• CT Immediately (UPN):
  • Unresponsive (AVPU or GCS 3–8).
  • Primary survey abnormality needing intervention.
  • Neurologic deficit (motor, sensory, including paresthesias).
• Proceed to X-ray (ANT):
  • Altered mental status.
  • Neck pain/tenderness offered (meaning the patient volunteers this information).
  • Trauma significant and adjacent to the head or thorax.
• If none of these criteria are present, the patient can be cleared clinically.

7. Neonatal Resuscitation (NRP)

Initial Steps

1. Assess term, tone, breathing.
2. If inadequate: Transfer to warmer set at 25C.
3. Dry and stimulate (if > 32 weeks GA); if younger, use a plastic bag.

Management Based on Heart Rate (HR)

• HR < 100 BPM: Start PPV for 15 seconds. If still < 100, move to Mr. SOAPA for 30 seconds.
• HR < 60 BPM: Intubate, give 100% FiO2, and start CPR.

Mr. SOAPA Components

Mask adjust, Reposition airway, Suction, Open mouth and do OPA, Pressure increase, Alternative airway (LMA or ETT).

CPR and Dosing

• CPR Rate/Ratio: 120 events per minute (3 compressions to 1 breath).
• Epinephrine Dosing: 0.01 mg/kg IV every 3 to 5 minutes.
• Tube Size: Gestational age/10

Target Oxygen Saturation (Lowest Acceptable)

• Time: 1 minute
  • Lowest Acceptable Saturation (%): 60
• Time: 2 minutes
  • Lowest Acceptable Saturation (%): 65
• Time: 3 minutes
  • Lowest Acceptable Saturation (%): 70
• Time: 4 minutes
  • Lowest Acceptable Saturation (%): 75
• Time: 5 minutes
  • Lowest Acceptable Saturation (%): 80
• Time: 10 minutes
  • Lowest Acceptable Saturation (%): 85