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170 Cards in this Set

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Determine the postconceptional age (in weeks) of the patient when given the gestational age at birth and the postnatal age. (EX: EH is a two-month old female infant born at 27 weeks gestation. What is EH’s postconceptional age in weeks?)
The postconceptional age is the gestational age + postnatal age. For example, an infant who was 25 weeks in gestation (25 weeks from conception to birth) and 6 weeks postnatal (6 weeks old) has a 31-week postconceptional age. The answer to the example question would be a 35-week postconceptional age (27 weeks gestational + 8 weeks postnatal).
Describe the Apgar scoring system in terms of when and how often it is assessed, what clinical signs are assessed, and what is the best possible score.
Example question: Which of the following is true regarding the Apgar Scores?
-The worst score is a 10
-It is used to assess normal development in the neonatal period
-Scores are based on laboratory values at birth
-The score is tabulated every 10 minutes for the first 30 minutes of life
-Five clinical signs are scored 0 to 2, at 1 minute and 5 minutes of life
Apgar stands for activity, pulse, grimace, appearance, and respiration. It is used to quickly assess the health of newborn children immediately after childbirth. Scores 3 and below are generally regarded as critically low, 4 to 6 fairly low, and 7 to 10 generally normal. The test is generally done at increments of 1 minute, 5 minutes, 10 minutes, 15 minutes, and 30 minutes after birth.
The criteria are as follows, with scores ranging from 0 to 2.
Heart rate (absent, less than 100, greater than 100)
Respiratory effort (absent, slow & irregular, good & crying)
Muscle tone (flaccid, some flexion of arms and legs, active monements)
Reflex irritability (no response, crying, crying vigorously)
Color (blue or pale, pink body with blue extremities, pink all over)
Determine if appropriate/normal weight gain in infants (less than 1 year old) has occurred given age and birth weight.
The estimated birth weight in kg for children 3 to 12 months of age is [age(month) + 9]/2. The estimated birth weight in children 1 to 6 years of age is [age(year) X 2] +8. The typical rule is babies double their birth weight at 4-5 months of age and triple their birth weight at 1 year of age.
Determine the percentile for weight and length of a child given age, weight, and length.
Estimated weight (kg) = [age (month) + 9]/2 (3 to 12 months)
Estimated weight (kg) = [age (year) X 2] + 8 (1 to 6 years)
They typically gain 20-30 gram/day for the first 3-4 months and 15-20 gram/day from 4-12 months.
Estimated length (cm) = [age (year) X 6] + 77 (2 to 12 years)
Compare and contrast the circulatory pattern in utero versus the normal adult circulatory pattern focusing attention on central circulation (heart chambers, pulmonary vessels, and lungs) and the placenta.
Oxygenated blood from the mother comes from the umbilical vein. Some of the blood goes to the baby’s liver. The rest of the blood is shunted through the ductus venosus to the inferior vena cava. The inferior vena cava carries blood to the right atrium (just like in adults). The right atrium sends blood to right ventricle (as in adults), but also pumps blood directly to the left atrium through the foramen ovale. From the right ventricle, blood goes into the pulmonary artery. Increased pulmonary resistance due to amniotic fluid in the lungs causes little blood from the pulmonary artery to actually make it to the lungs, as you would see in adults. Instead, blood travels through the ductus arteriosis into the aorta. From the left atrium, blood travels to the left ventricle and into the aorta (as in adults). From the aorta, the blood is carried to the head and upper extremities, where it is most needed.
Explain the contribution of both the respiratory and cardiovascular systems to transitional changes following birth focusing on changes in pulmonary vascular resistance and systemic vascular resistance and circulatory changes with birth.
The baby’s first breath causes decreased peripheral vascular resistance, increased blood flow to lungs, increased blood flow to the left atrium, increased systemic vascular pressure causes the foramen ovale to close, and oxygenation and a decrease in prostaglandins causes the ductus arteriosus to close. (If the ductus arteriosus doesn’t close, blood is being shunted away from the lungs. This will lead to left side heart failure and pulmonary edema. Treat this with an NSAID like ibuprofen or indomethacin or, secondarily, a corticosteroid like dexamethasone). The main thing to note is a precipitous drop in PVR following birth and lasting about 10 days.
Recognize how HR, RR, and BP change as a function of age if given two patients with distinctly different ages.
RR for an infant is 30-60 breaths/minute. As we age, our breathing decreases sharply until we reach adolescence and our RR becomes 12-16 breaths/minute. HR for a newborn is about 145 and goes down as we age to a low of about 70 when we turn 15 years old. Blood pressure for a neonate ranges from 85-100/51-65 and increases with age to a range of 112-128/66-80 at 15 years old.
Describe the “Therapeutic Orphan” and limitations of drug formulation in pediatrics.
70-80% of all medications lack pediatric labeling. The majority of medications used in children are administered “off label”. Off label is defined as the use of an approved medication for either a non-approved indication or in a population not approved for. There are challenges of pediatric research, which include ethical, logistical, financial and legal concerns. Medications are not designed for use in children. Formulations may contain harmful preservatives or additives like benzyl alcohol or propylene glycol. Most liquid formulations are flavored for adult taste. There is little incentive to develop pediatric formulations.
Identify and develop methods for preventing medication errors in children.
In the community, it is estimated that there are 7,000 medication cup-dosing errors in the US annually. 30% of parents are able to demonstrate both accurate measurement and correct dose of medication (most overdose). Pharmacists should verify dosing calculations and avoid tablespoon/teaspoon abbreviations. In the hospital, 5.7% of physician orders have medication errors. Common errors include decimal point, transcription on medication record, lack of weight, and fail to divide doses. Orders should use mg/kg/dose and calculated doses, follow decimal rules, avoid abbreviations, and everything should be verified
For a given pediatric patient, recommend the appropriate drug formulation and dosing device.
Dosage is based on age and weight. Do not exceed the normal adult dose. Adolescents over 50 kg may receive adult dose. For oral liquids, shake the liquid to disperse the medication, administer with infant’s head upright, and avoid using kitchen-measuring devices. Acceptable devices include oral syringes, droppers, measuring spoons, and measuring cups. Syringes and droppers are ideal for infants who cannot drink from a cup. Measuring spoons are convenient for children who can drink from a cup but are likely to spill. For amounts less than 1 mL, use a 1 mL syringe. For 1-5 mL, use a 3-5 mL syringe or spoon. For amounts greater than 5 mL, use a cup. With oral solid dosage forms, children over 2 can chew chewable tablets. Children under 5 are unable to swallow medications.
For a given pediatric patient, counsel the caregiver on appropriate dosage and administration of medication, including techniques for masking taste.
Children prefer sweet flavors such as cherry or grape. Other techniques for masking taste include chilling oral liquids, squirting the medication between the molars and the cheek, mixing with a small amount of food or formula, pre- and post-medication washing (popsicle, milk), and adding flavoring agents.
Describe influences on medication adherence in children and methods to improve adherence.
For children, allow them to squirt the syringe or drink the cup themselves and use positive reinforcement. For adolescents, give them increasing independence, as parental control is a negative influence.
Provide standardized dosage information when given dose (mg), frequency of dose, and the patient’s weight. Example 1: a 5 day old who weighs 4 kg is started on acyclovir 80 mg IV q8h for HSV. Is this the appropriate dose given the standard dose for a neonate with HSV is 60 mg/kg/day q8h. Example 2: a 3 month old who weighs 6 kg and is 55 cm long is discovered to be HIV positive. What dose of zidovudine would you recommend given a zidovudine oral dose of 180 mg/m2 every 12 hours.
Standardize doses either in amount/kg or per body surface area. A scheduled dosing regimen would be amount/kg/day given every X hours. An intermittent or prn regimen would be amount/kg/dose given every X hours as needed.
Answer to Example 1: First, calculate total dose per day. 80 mg X 3(q8h) = 240 mg/day. Next, take total dose/day and divide by weight (mg/kg/day). 240 mg/day divided by 4 kg = 60 mg/kg/day
Answer to Example 2: First, calculate BSA. Sqrt (6 kg X 55 cm)/3600 = 0.3 m2. Next, calculate the dose. 0.3 m2 X 180 mg/m2 = 54 mg. Use 50mg/5mL, 5 mL every 12 hours.
Describe the developmental patterns of absorption, distribution, metabolism, and elimination in pediatric patients.
Absorption is affected is pediatrics mainly due to differences in the GI tract and the epidermis. The pH level in the GI tract is higher during the neonatal phase, which makes weak acids require a higher oral dose and acid labile drugs have higher bioavailability. Gastric emptying and intestinal motility doesn’t mature until 4 months of age. Intestinal enzymes and efflux transporters also take time to develop. The stratum corneum is very thin and causes erratic drug release. Also, the ratio of surface are to body mass is much larger in infants than adults. It is also tough to keep rectal suppositories in their place.
Describe the developmental patterns of absorption, distribution, metabolism, and elimination in pediatric patients.
Distribution is affected with age. Changing the relative sizes of drug distribution compartments contributes to the dynamic nature of pediatric dosing requirements. Infants and neonates have a body composition that is much higher in body water. They also carry more of this water as ECF than adults do. Neonates have higher Vd than adults. They also have much less muscle mass and albumin. Substances directly related to gestational age include bilirubin, free fatty acids, albumin, a1-acid glycoprotein, and p-glycoprotein.
Describe the developmental patterns of absorption, distribution, metabolism, and elimination in pediatric patients.
Metabolism primarily occurs in the liver but can occur in various body tissues such as the blood, lung, GI tract, and kidney. In general, neonates have decreased biotransformation, which increases from 1 to 5 years of life followed by a decrease from puberty throughout life. Phase 1 metabolism includes oxidation, reduction, and hydrolysis. Metabolic activity in the pre-term neonate is approximately 20% the adult rate and in the term neonate is approximately 50-70% the adult rate. However, most exceed the adult rate during early childhood. Examples include phenobarbital and theophylline. Phase II metabolism includes acetylation, glucuronidation, and amino acid conjugation. Sulfation is well developed at birth. Acetylation doesn’t fully develop until 6 months. Glucuronidation reaches adult values between 1.5-4 years of life. Amino acid conjugation develops at 2-4 months.
Describe the developmental patterns of absorption, distribution, metabolism, and elimination in pediatric patients.
Elimination is also affected by age. There is a different rate of maturation for each renal function (filtration, reabsorption, secretion). Kidneys at birth receive only 5-6% of cardiac output compared to 15-25% in adults. Factors that contribute to GFR include protein binding, renal blood flow, area and nature of glomerular membrane. The first 7 days of life there is a rapid acquisition of function. GFR is directly proportional to gestational age beyond 34 weeks gestation. GRF attains adult values between 2.5-5 months of age. GFR is 30-50% of adult values in the term neonate at birth and 5% of the adult values in the pre-term neonate. An example is aminoglycosides, which have reduced clearance due to decreased renal blood flow, glomerular filtration, and tubular function. Secretion reaches adult values at 6-7 months of age. Reabsorption reaches adult values at about 9 months of age. An example is penicillin, where adults eliminate 90% of it by tubular secretion whereas in neonates GFR is the major pathway of elimination.
Apply developmental patterns of Vd and Cl (metabolism or renal elimination) to determine approximate dose and/or frequency as compared to an adult when given a specific drug and its Vd and Cl characteristics in adults.
Clearance affects the dosing interval and is the volume of biologic fluid from which drug is removed per unit of time. Volume of distribution determines amount per dose and is the hypothetical volume of body fluid that would be required to dissolve the total amount of drug at the same concentration as that found in the blood. Vd is inversely correlated with gestational age. Changes in fluid status will result in some variability of aminoglycosides Vd depending on development (younger the greater the effect). Clearance follows the same trend, as dose GFR, since elimination is dependent on GFR. The higher the Vd, the higher the mg/kg dose that must be used, and Vd decreases with age.
Calculate pharmacokinetic parameters (Ke, T1/2, Vd, & Cl) for an aminoglycoside (gentamicin or tobramycin) regimen when given the following information: dose (mg), dose administration times, weight of patient, serum concentration-time of peak and trough.
You will be given the equations. Here is what you must know.
T’ is the time between peak and trough.
t is the length of the infusion
Tao (curved t) is the scheduled dosing time
T is the time following the end of infustion
Ko is the dose/t
Describe the anatomy and physiology of the central nervous system.
The meninges consist of three membranes that envelop the brain and spinal cord. The dura mater is directly beneath the skull, the arachnoid is the middle layer, and the pia mater is directly over the brain tissue. The area between the pia mater and the aracnoid membranes is the subarachnoid space, which is the conduit for the cerebral spinal fluid. CSF is produced at a rate of 0.5 ml/min. It flows unidirectionally in the subarachnoid space downward through spinal cord and is removed by vertebral venus plexus and arachnoid villi. CSF volume increases with age. The blood brain barrier denotes the barrier between the brain parenchyma (tissue) and blood. Lipophilic compounds penetrate the BBB well. The blood-cerebrospinal fluid barrier controls passage of drugs into the CSF.
List common etiologic pathogens found in respective age groups.
In newborns less than 1 month of age, common pathogens include E. coli (gram negative organisms), group B streptococcus, and Listeria. In infants and children from 3 months up to adults, common pathogens include Streptococcus pneumoniae, N. meningitides, and H. influenza.
Outline the pathophysiologic events of bacterial meningitis leading to neurologic sequelae.
Step 1 is nasopharyngeal colonization of the host. The two most common pathogens are N. meningitidis and S. pneumoniae. Step 2 is pathogens once attached to nasopharyngeal epithelial cells are phagocytized across nonciliated columnar cells into the bloodstream. Step 3 is survival of the pathogen. Organisms survive in bloodstream by producing a polysaccharide capsule resistant to neutrophils phagocytosis and complement opsonization. Step 4 is capsular polysaccharides activate the alternate complement pathway, which promotes phagocytosis and clearance of infecting pathogens. Step 5 is if the pathogen avoids the phagocytosis due to their polysaccharide capsule and the absence of antibodies directed against the capsule, then they enter the CNS through vulnerable sites. Step 6 is the bacteria multiply rapidly and release small amounts of their cell wall or membrane components. Patients have an increased risk of neurologic sequelae if they get seizures that are difficult to control and persist beyond the 4th hospital day and they develop late in the hospital course.
Interpret laboratory tests (CSF fluid hematology and chemistry) used in the diagnosis of CNS infections
Normal CSF would be clear. Normal CSF levels would show protein less than 50 mg/dl, glucose levels of 2/3 serum, WBC less than 10 mm2 and greater than 90% monos, pressure of 50-80, lactic acid of less than 14 mg/dl, and a pH of 7.3. Bacterial meningitis would turn the CSF cloudy. Bacteria would increase protein to 80-500 mg/dl, decrease glucose to less than 30 mg/dl or less than ½ the serum, increase WBC to 400-100,000 and greater than 90% PMNs, elevate pressure, increase lactic acid to greater than 35 mg/dl, and decrease the pH to 7.1. Viral meningitis would leave the CSF clear. Protein levels would be from 30-150 (normal to increased), glucose would be normal to decreased, WBC would range from 5-500 (normal to increased) and PMNs would be to 50% of lymphs, and pressure would be normal. Fungal meningitis would have protein levels of 40-150 (normal to increased), normal or decreased glucose, increased WBC of 40-400 or greater than 50% lymphs, and increased pressure. Tuberculosis protein levels are 40-150, glucose is normal or decreased, WBC range from 100-1000 (increased) and PMNs are up to greater than 80% lymphs, pressure is normal or slightly increased, lactic acid is normal, and pH is normal.
Recommend appropriate empiric and specific treatment (agent or agents) for bacterial meningitis.
For newborns less than a month old, we must cover E. coli, group B streptococcus, and Listeria. To achieve this we will use ampicillin with an aminoglycoside OR ampicillin with cefotaxime. If Pseudomonas is suspected, we would use an aminoglycoside with ceftazidime. In infants 3 months old and up to adults, we need to cover Streptococcus pneumoniae, N. meningitides, and H. influenza. We would treat with cefotaxime or ceftriaxone with vancomycin (backup option is ampicillin with chloramphenicol).
If it is known that the infection is caused by N. meningitidis, there are 2 main choices for therapy. If PCN MIC is less than 0.1 mcg/mL, use Penicillin G (alternatives: cefotaxime, ceftriaxone, or ampicillin). If PCN MIC is 0.1-1 mcg/mL, use cefotaxime or ceftriaxone (alternatives: fluoroquinolone, meropenem, chloramphenicol). Duration of therapy is 5-7 days.
If it is known that the infection is caused by Streptococcus pneumoniae, there are 3 main choices for therapy. If it is PCN susceptible, discontinue vancomycin and begin penicillin or continue cefotaxime or ceftriaxone alone. If it is PCN I or R and susceptible to cefotaxime and ceftriaxone, discontinue vancomycin and continue cefotaxime or ceftriaxone. If it is PCN I or R and cefotaxime and ceftriaxone I or R and rifampin susceptible, continue vancomycin and cefotaxime or ceftriaxone and rifampin may be added. Duration of therapy is 10-14 days. When using vancomycin, use high dose of 60 mg/kg/day.
Recommend appropriate supportive therapy for meningitis management.
Restrict fluids to 800-1000 mL/m2 (1/2 to maintenance rate). Use antipyretics and analgesics. Give respiratory therapy. Use mannitol for increased intracranial pressure. Use anticonvulsants for seizures caused by Strep pneumoniae. Use NSAIDs for immune-mediated arthritis caused by N. meningitidis.
Identify and recommend appropriate treatment (drug and dose) for close contacts that require prophylaxis.
For N. meningitides, use rifampin, ceftriaxone, or ciprofloxacin. There is no treatment for close contacts of patients with S. pneumoniae.
Recognize the role of immunizations in prevention of bacterial meningitis.
The immunization for N. meningitidis covers all serotypes except B, which accounts for about 30% of all cases. Immunization for S. pneumoniae began in 2000 and has shown a reduced risk of invasive infection.
Describe the anatomical features that place infants and children at greater risk of developing OM when compared to adults.
The tympanic membrane (ear drum) has mobility of up to 2 mm when surface pressure is applied. TM mobility increases with age. The Eustachian tube connects the nasal pharynx to the middle ear cavity. Children have shorter and more horizontally oriented ET. With increasing age it elongates, widens, and assumes a more vertical orientation. It functions to ventilate the middle ear cavity, prevent reflux of nasopharynx secretions into the middle ear, and clear secretions from the middle ear.
Explain the pathogenesis of OM focusing on the ET.
OM develops due to obstruction of the ET. Functional obstruction results from persistent collapse caused by increased tubal compliance due to the relatively less fibrocartilageinous support of the medial ET and inadequate tensor veli palatini contracting-mechanism. Mechanical obstruction can be intrinsic (mucosal edema from infection or allergy-mediated reaction, ciliary immobility) or extrinsic (swollen/excessive lymphoid tissue, enlarged adenoids, anatomic abnormalities like a cleft palate). Sufficient ET obstruction causes impaired middle ear cavity ventilation and results in absorption of air, with atelectasis and development of persistent high negative pressure in the middle ear cavity. If an intermittent ET opening occurs with partial obstruction, the negative pressure gradient toward the middle ear cavity predisposes to aspiration of nasopharynx secretions into the middle ear cavity. Bacteria in these secretions can be trapped and proliferate in the middle ear resulting in infection. This augmented inflammation of the ET mucosa can completely obstruct ventilation and drainage, and convert the middle ear cavity into a close space under positive pressure.
Distinguish etiologic risk factors for OM, given a patient case with history.
Risk factors include age of the first episode, environmental factors, season, gender, race, malformations, nutrition, immunity, and socioeconomic issues.
Indicate the signs and symptoms of AOM and the most likely pathogen, given a patient case with history and physical exam findings.
Symptoms of AOM include otalgia (denoted by pulling of the ear), irritability, fever, otorrhea, hearing loss, and upper respiratory tract infection. Other nonspecific symptoms include lethargy, anorexia, vomiting, and diarrhea. The most likely pathogens are Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis.
Describe the possible complications and sequelae of OM.
Possible complications of OM include mastoiditis (infection of mastoid bone of skull), perforation of TM, hearing problems, language and cognitive problems, meningitis, and encephalitis.
Recommend appropriated antibiotic regimens for the treatment of OM, given individual patient information.
The drug of choice for AOM is amoxicillin. It is typically given as high dose treatment at 80-90 mg/kg/day. For children less than 6 months, use antimicrobial treatment whether diagnosis is certain or uncertain. For kids 6 months to 2 years, treat if diagnosis is certain or if diagnosis is uncertain but the case is severe. For kids older than 2 years, treat only if the diagnosis is certain and it is a severe case (otherwise use observation).
Treatment failure is a lack of clinical improvement in signs and symptoms such as ear pain, fever, and TM findings of redness, bulging, or otorrhea after 48-72 hours of therapy. If amoxicillin fails, consider culture of drainage. If there is no culture, cover DRSP and Beta-lactamase producing organisms.
It is also important to always treat the pain (otalgia). Acetaminophen or ibuprofen are effective for mild to moderate pain.
Identify methods of OM prevention.
Antimicrobial prophylaxis is indicated if OM occurs 4 times in 6 months or 6 times in 12 months. Patients can be treated with amoxicillin, sulfisoxazole, or Bactrim. Vaccines are also available for influenza, RSV, and Strep pneumoniae.
Describe the basic defect of cystic fibrosis (CF) and how it relates to the pathophysiology of pulmonary and extrapulmonary disease.
The genetic defect of CF is on chromosome 7. This gene codes for a protein known as “CF Transmembrane Conductance Regulator” (CFTR). CFTR functions as a chloride channel in epithelial cells. This results in cells that are unable to secrete Na+ and Cl-, and H2O is reabsorbed into the cell. This defect occurs in epithelial cells of the respiratory tract as well as the GI tract, the pancreas, and sweat glands. Dehydrated and viscous secretions are ineffectively cleared and cause luminal obstruction, scarring and dysfunction. Lung disease accounts for most of the mortality of CF. There is less airway surface liquid on lungs in patients with CF.
Identify and evaluate the primary diagnostic test and results for CF.
A sweat test is the main test used to diagnose CF. Pilocarpine is utilized to facilitate sweating. It is performed twice for confirmation. A positive test is greater than 60 mEqCl/L. Normal sweat chloride concentrations are between 10-30 mEq/L. Genotyping is used to predict the potential course of the disease after confirmation by sweat test. Neonatal screening can be done using a blood spot assay for immunoreactive trypsinogen (which is increased in CF patients).
Discuss the pathophysiology of CF, focusing on the gastrointestinal and pulmonary systems.
In the respiratory tract, obstruction of airways with thick mucus results in air trapping, bronchiectasis, and atelectasis resulting in a COPD-like disease. The persistent thick mucus acts as an excellent growth medium for microorganisms leading to pulmonary infections. The presence of bacteria or other environmental factors can lead to elevated levels of pro-inflammatory mediator and proteases that lead to progressive airway and lung tissue inflammation and fibrosis. When WBC’s lyse, they release DNA, which further thickens mucus and also reduces the efficacy of antibiotics in sputum. Pseudomonas is the main source of infection in the lungs of CF patients. Other common organisms are Burkholderia cepacia (causes a steep decline in lung function) and MRSA.
In the gastrointestinal tract, pancreatic enzyme insufficiency occurs in 85% of CF patients. Deficiencies of vitamins A, D, E, and K can occur. Glucose intolerance is seen in half of CF patients. CF related diabetes is common and is treated with insulin.
Evaluate a patient case for signs and symptoms consistent with an acute pulmonary exacerbation and provide recommendations for a treatment plan related to the altered PK parameters of CF patients and the probable organisms involved.
Acute pulmonary exacerbations presentation includes many signs and symptoms. Symptoms include increased cough frequency and duration, increased sputum production, change in sputum appearance, increased shortness of breath, decreased exercise tolerance or fatigue, decreased appetite, and feeling of increased congestion. Signs include increased respiratory rate, use of accessory muscles for breathing (intercostal retractions), change in results of auscultatory examination of chest, decline in pulmonary function test consistent with presence of obstructive airway disease, fever and leukocytosis, weight loss, and new infiltrate on chest radiograph.
The probable organisms causing acute pulmonary exacerbations are Pseudomonas aeruginosa, Burkholderia cepacia, and Staph aureus. For Pseudomonas, two anti-pseudomonal agents are usually used for synergy and to reduce the risk of development of resistance. Extended interval tobramycin dosing is often used with a goal peak to MIC ratio of 10 and a goal trough of less than 0.5 mg/L. Tobramycin is used in conjunction with ticarcillin/clavulanate or piperacillin/tazobactam; ceftazidime or cefepime; imipenem/cilastatin or meroperem; or aztreonam. Ciprofloxacin offers oral dosing for outpatient treatment (40 mg/kg/day q12h). For Burkholderia, often a combination of 3-4 drugs is required. For Staph aureus, nafcillin is good for MSSA. Vancomycin is typically used for MRSA. Bactrim is used for outpatients. The acute therapy endpoint is a return to baseline of PFTs.
Discuss chronic treatment strategies for the management of CF.
There are many steps necessary for chronic treatment of CF. Chest physiotherapy is used 2-5 times daily to improve mucous clearance. A beta-agonist (albuterol) may improve mucociliary clearance of secretions. Inhaled tobramycin is used for children over 6 with chronic Pseudomonas infection. TOBI increases PFTs and decreases antibiotic use. Dornase alfa (Pulmozyme) cleaves DNA in sputum to reduce sputum viscosity (2.5 mg inhalation daily). Hypertonic saline improves mucociliary clearance. Corticosteroids are used for patients with concomitant asthma or allergic bronchopulmonary aspergillosis (ABPA). Azithromycin suppresses inflammatory mediators and is used in children greater than 6 and chronically colonized with Pseudomonas.
Steps also must be taken to help the gastrointestinal tract. Ursodiol is used for the prevention of cholelithiasis and focal biliary cirrhosis. It is initiated with increased liver enzymes. Aggressive nutritional support must be used and the child needs 130-150% of the RDA of calories for age with 200% RDA protein. Fat-soluble vitamins (ADEK) must be supplemented. Pancreatic enzymes must also be supplemented. An H2 blocker or PPI is also often used to boost the pancreatic enzyme. If the patient is less than 4, give initial doses of 1000 units lipase/kg/meal. If the patient is over 4, give initial doses of 500 units lipase/kg/meal. These should be taken with any fat or protein intake. The upper limit for all ages is 2500 units lipase/kg/meal and 50% less for snacks. With lipase products, the number in the product name is the amount of lipase in thousands.
Explain the pathophysiology that predisposes normal healthy infants less than 9 months of age to a greater degree of dehydration in less time than that of a normal healthy adult. (Example: Why are infants less than 6 months old at greater risk for dehydration?)
Infants’ kidneys are less able to concentrate urine. The ability increases with age and normalizes around 9 months. Percentage of total body water also decreases with age until about 7 years. Because the kidneys don’t concentrate urine well, a lot of water is lost through urination. This is a problem because infants need a higher percent of water in their bodies than adults do. (Answer: They have increased total body water and decreased ability to concentrate their urine)
Identify common pathogens causing acute diarrhea in children.
The highest percentage of children with watery diarrhea is between 3-6 months. In children less than 2, diarrhea is generally caused by a virus. The most common cause is rotavirus. Other viruses and bacteria are basically the ones you would associate with diarrhea.
Given physical exam findings, determine the degree (mild-moderate and severe) of dehydration. (Example: What would classify as severe dehydration?)
Description of mild-moderate dehydration: thirsty, restless/lethargic but irritable to the touch or drowsy; thirsty, alert, lethargic, postural hypotension; rapid and weak heart rate; deep and possible rapid respiration; sunken fontanel; normal or low systolic blood pressure; skin pinch retracts slowly; sunken eyes; decreased tears; dry mucous membranes; reduced and dark urine; and 3-9% body weight loss.
Description of severe dehydration: drowsy, limp, cold, sweaty, cyanotic extremities, may be comatose; older children are usually conscious, apprehensive, cold, sweaty, cyanotic extremities, wrinkled skin of fingers and toes, muscle cramps; rapid, feeble, and sometimes impalpable heart rate; deep and rapid respiration; very sunken fontanel; less than 90 mm Hg systolic blood pressure than may be immeasurable; skin pinch retracts very slowly over 2 seconds; eyes are grossly sunken; tears are absent; mucous membranes are parches; no urine flow for several hours; and 10% or more body weight loss. (Answer: Cyanotic extremities, lethargic, decreased BP, no urine output)
Compare and contrast “clear liquids” to Oral Rehydration Solution based on sodium, glucose, and osmolality.
Goals of ORS are to replace electrolyte losses while maintaining fluid and electrolyte balance and nutrition. Clear liquids are not appropriate for replacement in dehydrated children. Clear liquids include cola, ginger ale, apple juice, chicken broth, tea, Gatorade, and orange juice. Osmolality needs to be between 200-250 mM/L for good replacement. All clear liquids except tea have too high osmolalities, except tea, which is too low.
The ratio of glucose to sodium should be (1-3):1. The WHO recommends glucose and sodium levels of 75 mEq/L and an osmolality of 245 mEq/L. The main commercially available ORS’s are WHO, Pedialyte, and Enfalyte. WHO has a 1:1 glucose to sodium ratio and Pedialyte has a 3.1:1 glucose to sodium ratio.
Develop a treatment plan for a patient with dehydration secondary to acute diarrhea with or without emesis at home. (Provide specific instructions to a parent for rehydration and maintenance of hydration including fluid type, volume, administration instructions, and initiation of nutrition.)
Some practical issues to consider are to start off with small volumes of fluids and build up gradually. Also, continue the child on a normal diet while avoiding foods high in sugar.
Initial replacement for mild (3-6%) dehydration is ORS 50 mL/kg over 3-4 hours. Ongoing replacement is 60-120 mL ORS for each episode for a child less than 10 kg and 120-240 mL ORS for each episode for a child over 10 kg. Initial replace for moderate (6-9%) dehydration is ORS 100 mL/kg followed by the same amount for ongoing replacement as seen in mild cases.
Maintenance volume is determined by body weight. For the first 10 kg, give 100 mL/kg per day. For 11-20 kg, give 1000 mL plus 50 mL/kg for weight over 10 kg. For children over 20 kg, give 1500 mL plus 20 mL/kg for weight over 20 kg.
For maintenance of electrolytes, infants and children need 2-6 mEq/kg/day of sodium and 2-3 mEq/kg/day of potassium. Maintenance fluids include D5W, NS (154 mEq Na), ½ NS (77 mEq Na), and ¼ NS (38 mEq Na). KCl comes in 20 mEq/L or 40 mEq/L.
To determine volume of replacement fluid, use the child’s pre-illness weight and multiply by the percent dehydrated. This will give you an amount in kg, which can be converted to liters by a one to one ratio (1 kg weight loss means you need to replenish 1 L of fluid). For the first 8 hours, deliver half the replacement fluids and 1/3 of the maintenance fluids. For the next 16 hours, deliver the other half of the replacement fluids and 2/3 of the maintenance fluids.
Calculate calories from enteral nutrition (kcal/kg/day).
Preterm neonates need 120-150 kcal/kg/day. Children less than 6 months need 90-120 kcal/kg/day. Children from 6-12 months need 80-100 kcal/kg/day. Standard formula has 20 kcal/oz or 20 kcal/30 mL. Be able to use these values to determine total volume of formula for a baby during the course of a day.
Discuss the most current diagnostic criteria for Attention-Deficit Hyperactivity Disorder (ADHD).
In a child 6 to 12 years old who presents with inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems, the primary care provider should evaluate for ADHD. The diagnosis requires that a child meet DSM-IV criteria. Children must not only meet the behavioral diagnostic criteria, but also have functional impairment to be diagnosed with ADHD. Symptoms of ADHD should be present in at least 2 different settings. The assessment of ADHD requires evidence directly obtained from parents or caregivers regarding the core symptoms of ADHD in various settings, the age of onset, duration of symptoms, and degree of functional impairment. Assessment of ADHD requires evidence directly obtained from the classroom teacher regarding the core symptoms of ADHD, the duration of symptoms, the degree of functional impairment, and coexisting conditions. Evaluation of the child with ADHD should include assessment for coexisting conditions including oppositional defiance, conduct, anxiety, and depressive. Other diagnostic tests are not routinely indicated to establish the diagnosis of ADHD.
Describe the core symptoms and different forms of ADHD as defined by DSM-IV.
The three core symptoms of ADHD are inattentiveness, hyperactivity, and impulsivity. Functional impairments include difficulties with organization and time management, following directions, social functioning and peer/family relationships, and problem solving. Children also exhibit academic underachievement and low self-esteem.
The three main subtypes are inattentive, hyperactive-impulsive, and combined.
To be diagnosed with inattention, the patient must meet 6 of 9 criteria. The criteria include failure to give close attention to details, often has difficulty sustaining attention, often does not seem to listen when spoken to directly, often does not follow through on instruction and fails to finish schoolwork, often has difficulty organizing tasks, often avoids or dislikes to engage in tasks that requires sustained mental effort, often loses things necessary for tasks or activities, is often easily distracted by extraneous stimuli, and is often forgetful in daily activities.
To be diagnosed with hyperactivity-impulsivity, the patient must be diagnosed with 6 of 9 criteria. These include often fidgeting with hands or squirming in seat, often leaves seat in classroom when expected to be seated, often runs about or climbs excessively when inappropriate, often has difficulty playing or engaging in leisure activities quietly, is often “on the go”, often talks excessively, often blurts out answers before questions have been completed, often has difficulty awaiting turn, and often interrupts or intrudes on others.
Combined disease would meet 6 of 9 behaviors in both inattention and hyperactive-impulsive lists.
Discuss the guiding therapeutic principles for stimulants when used to treat ADHD.
CNS stimulants include methylphenidate, dexmethylphenidate, amphetamine, and pemoline. The proposed mechanism of action is an increase in catecholamines (DA and NE) in the synaptic cleft by enhancing release and blocking reuptake at the pre-synaptic neuron. Lack of response to one stimulant does not preclude response to another. Last dose during the day should be 3:00 PM or earlier to reduce insomnia.
Discuss the use of stimulants as the drug of choice for treatment of ADHD and the myths surrounding this issue.
CNS stimulants are the most effective drugs for primary symptoms, and should be considered first-line therapy unless co-morbid condition predominates. There are many myths concerning stimulants. These include: stimulant effects in ADHD are paradoxical, stimulant are diagnostic of ADHD, and “my child will become addicted”.
Review the use of CNS stimulants, antidepressants, antipsychotics, and alpha2 adrenergic agonists in the treatment plan for ADHD.
CNS stimulants are the most effective dugs for primary symptoms and the most common prescribed drugs for ADHD. Antidepressants (tricyclics and bupropion) may be considered in children with anxiety, depression, and tic disorders. Atomoxetine is a selective pre-synaptic NE reuptake inhibitor and the first new class of agents for the treatment of ADHD in over 30 years. Alpha2 adrenergic agonists stimulate central alpha2 adrenoreceptors, resulting in reduced sympathetic outflow. Antipsychotics are used as adjuncts to the stimulants or in cases of violent and destructive behavior. They decrease hyperactivity, but will not decrease distractibility or increase attention span.
Define pre-term
Gestational age of 37 weeks or less
Define full-term
Gestational age of 38-42 weeks
Define post-term
Gestational age of greater than 42 weeks
Define postconceptional age
Gestational age plus postnatal age
Define the 5 clinical signs of the Apgar score
1. Heart rate
2. Respiratory effect
3. Muscle tone
4. Reflex irritability
5. Color
Estimated weight gain from 3 to 12 months
estimated weight (kg) = [age (month) + 9] / 2
Estimated weight gain from 1 to 6 years
estimated weight (kg) = [age (year) X 2] + 8
Give average weight compared to birth weight at different intervals
-double birth weight at 4-5 months
-triple birth weight at 1 year
-quadruple birth weight at 2 years
-average weight at 5 years is 20 kg
-average weight at 10 years is 30 kg
Find estimated length (cm) for a child 2 to 12 years old
estimated length (cm) = [age (year) X 6] + 77
After birth, the patent ductus arteriosus generally closes with oxygenation and a decrease in prostaglandins. What do you do if the PDA doesn't close after birth?
In this case, blood is getting shunted away from the lungs. This can lead to left sided heart failure and pulmonary edema. This is treated with an NSAID (indomethacin or ibuprofen) or, secondarily, a corticosteroid (dexamethasone).
List 6 things that must be considered when slecting the appropiate drug regimen.
1. Is the medication efficacious?
2. What are the side effects of the medication?
3. How often must the medication be given?
4. What is the cost of the drug?
5. How is the medication formulated?
6. How does the medication taste?
What does volume of distribution tell you about a child?
hydration status
What does clearance tell you about a child?
dosing interval
Give examples of Vd changes with age and how they affect certain drugs.
Pediatrics have a higher Vd than adults. Gentamicin, tobramycin, and phenytoin all must be adjusted for infants. A higher Vd means a higher mg/kg dose.
When a patient is on a monitorable drug, what things do you need to know?
1. The collection and infusion times.
2. MAR documentation
3. Collection of sample
4. Estimation of appropriate pharmacokinetic parameters
5. Calculation of appropriate pharmacokinetic parameters
Risk factors for meningitis
1. Age (more frequent with extreme ages)
2. Sex (Males > females)
3. Immunosuppression
4. Chronic disease (alcoholism, diabetes, cirrhosis, sickle cell)
5. Respiratory tract infection/otitis media
6. Mastoiditis
7. Head trauma
Clinical presentation of meningitis in young infants
irritability, altered sleep patterns, vomiting, high-pitched crying, decreased oral intake, apnea, seizures, bulging fontanel from increased intracranial pressure
What is Brudzinski's sign?
It is a sign of meningitis. Flexion of both legs and thighs upon forcible flexion of the neck.
What is Kernig's sign?
It is a sign of meningitis. It is the inability of the patient to extend their legs completely when lying on their back with their thigh lexed at a right angle to trunk.
Progression of meningitis
-seizures (30%)
-focal neurologic deficits
What are normal CSF values?
-CSF liquid is clear
-Protein is less than 50
-Glucose is 2/3 of serum
-WBC is less than 10 mm2 and greater than 90% monos
-Pressure is 50-80
-Lactic acid is less than 14 mg/dl
-pH is 7.3
What are CSF values during bacterial meningitis?
-Liquid is cloudy
-Protein is 80-500
-Glucose is less than 30 mg/dl and less than 1/2 of serum
-WBC are 400-100,000 mm2 and greater than 90% PMNs
-Pressure is elevated
-Lactic acid is greater than 35 mg/dl
-pH is 7.1
What are CSF values during viral meningitis?
-Liquid is clear
-Glucose is normal or low
-WBC are 5-500 mm2 and PMNS to 50% of lymphs
-Pressure is normal
When giving empric therapy of bacterial meningitis for newborns less than 1 month, what are the most likely pathogens?
E. coli
group B streptococcus
What is empiric therapy of bacterial meningitis for newborns less than 1 month?
-ampicillin + aminoglycosides (gentamicin)
-ampicillin + cefotaxime
-If Pseudomonas is suspected: aminoglycoside + ceftazidime
When giving empirical therapy of bacterial meningitis infants and children over 3 months, what are the most likely pathogens?
Streptococcus pneumoniae
N. meningitides
H. influenza
What is empiric therapy of bacterial meningitis for infants and children over 3 months?
-cefotaxime or ceftriaxone, both with vancomycin
(other option: ampicillin + chloramphenicol)
Treatment of N. meningitidis meningitis
-First choice: Penicillin G (if PCN MIC <0.1 mcg/mL) (alternatives: cefotaxime, ceftriaxone, ampicillin)
-First choice: cefotaxime, ceftriaxone (if PCN MIC 0.1-1 mcg/mL) (alternatives: fluoroquinolone, meropenem, chloramphenicol)
-For patients with anaphylactoid-type penicillin allergy: Chloramphenicol
Duration of therapy is 5-7 days post 1st negative culture
Treatment of S. pneumoniae meningitis
-PCN Susceptible: d/c Vancomycin AND begin Penicillin OR continue cefotaxime or ceftriaxone alone
-PCN I or R AND Susceptible to cefotaxime and ceftraxone: d/c Vancomycin AND continue cefotaxime or ceftriaxone
-PCN I or R AND cefotaxime and ceftriaxone I or R and Rifampin susceptible: continue vancomycin and cefotaxime or ceftriaxone; rifampin may be added
What are the most likely causes of otitis media?
-Streptococcus pneuoniae
-Nontypeable Haemophilus influenzae
-Moraxella catarrhalis
What is the DOC for acute otitis media?
What are the main causes of respiratory distress in cystic fibrosis?
-Burkholderia cepacia
What are the Trade Names for methylphenidate?
Ritalin (SR, LA)
Methylin (ER)
Metadate ER and CD
Max dose of Concerta
54 mg/day
How does Concerta work?
OROS technology, which uses osmotic pressure to deliver medication at a controlled rate
How does Ritalin LA work?
SODAS - spheroidal oral drug absorption system
How is Ritalin LA broken up?
50% IR / 50% ER beads
How is Metadate CD broken up?
30% IR / 70% ER beads
What is the initial dose of Daytrana?
10 mg transdermal patch once daily; apply to hip 2 hours before effect is needed and remove 9 hours after application
What are the Trade Names for dexmethylphenidate?
Focalin and Focalin XR (also uses SODAS)
-prodrug of dextroamphetamine, which relies on getting broken down in the stomach
What is IgG?
IgG is the only immunoglobulin that can pass through the uterus and breast milk. Maternal IgG is the only Ig available to the child at birth. Infant IgG is produced rapidly and maternal IgG goes away.
What is IgA?
IgA is slow to develop. It protects body surfaces.
What is IgM?
IgM develops as a result to infection. It is the Ig that alerts the body to a previous infectious agent reentering the body.
What are the main Live Vaccines available?
Influenza (Nasal)
Rotavirus (Oral)
Measles, mumps, rubella, varicella
What are the main Killed Vaccines available?
Hepatitis A
Influenza (IM)
What are the subunit vaccines?
Hepatitis B
Human Papillomavirus (HPV)
Energix B
Hepatitis B
Recombivax HB
Hepatitis B
General info on Human Papillomavirus vaccine
-for 11-12 year olds at the latest, both girls and boys
-give 3 doses, at birth, at 1-2 months, and at 6 months
-it is a painful shot and can cause dizziness
Immunocompromised patients and vaccines
-Live vaccines are contraindicated (MMRV, Flumist, Rotavirus)
-Live vaccines must be given 3-12 months following the administration of passive immunity, 2 weeks to 1 month following d/c of steroid, 10-14 days preceding chemo/radiation or 3 months following chemo/radiation
-Must get annual inactivated vaccine
HIV patients and vaccines
-Live vaccines are contraindicated
-MMR is indicated for CDC class 1 and 2 (good CD4 numbers); Var is indicated for CDC class 1; annual inactivated flu vaccine is recommended
Immunocompetent patient who is an IG recipient and vaccines
-MMR and Var are contraindicated
Pregnant patients and vaccines
-Live vaccines are contraindicated
Anaphylaxis secondary to immunization administration occurs at a rate of approximately one case per 1 million doses. It is the result of a sudden, massive release of a number of potent mediators from mast cells and basophils.
Clinical Manifestation of Anaphylaxis
-Cutaneous: pruritis, flushing, urticaria, angioedema
-GI: nausea, vomiting, diarrhea
-Respiratory: hoarse voice and stridor, wheeze, dyspnea, cyanosis
-Cardiovascular: rapid, weak pulse, hypotension, and arrhythmias
Emergency Plan for Anaphylaxis
Epinephrine is the primary drug. Infants need 0.01 mg/kg up to 0.5 mg. Adults need 0.1-0.5 mg. Repeat doses every 5 to 20 minutes based on individual response.
Other drugs used for Anaphylaxis
-Diphenhydramine: given PO or IM
-Hydroxyzine (H1 blocker)
-Ranitidine (H2 blocker)
Treatment Plan for Anaphylaxis
1. Place patient in recumbent position and elevate extremities.
2. Monitor vital signs often
3. Apply tourniquet proximal to site of antigen infection; remove every 10-15 minutes
4. Administer epinephrine 1:1000 into non-occluded site
5. Administer aqueous epinephrine 1:1000 into sit eof antigen infection
Haemophilus influenzae type b (Hib)
Hib-Hepatitis B
Hib-Hepatitis B
Hepatitis A
Hepatitis A
Hepatitis A
Hepatitis B
Recombivax HB
Hepatitis B
Recombivax HB
Hepatitis B
Hepatitis A-Hepatitis B
Hepatitis A-Hepatitis B
Herpes Zoster (Shingles)
Herpes Zoster (Shingles)
Human Papillomavirus (HPV)
Influenza (nasal)
Pneumovax 23
Pneumovax 23
*both oral
Otitis Media Treatment
At diagnosis for patients being treated initially with antimicrobial agents with no fever or otalgia
Give high dose amoxicillin
Alternative: for non-type I, cefdinir, cefuroxime, cefpodoxime; for type I, azithromycin, clarithromycin
Otitis Media Treatment
At diagnosis for patients being treated initially with antimicrobial agents with fever or otalgia
Give high dose amoxicillin + clavulanate
Alternative: ceftriaxone, 1 or 3 days
Otitis Media Treatment
Clinically defined treatment failure after initial management with observation option (with no fever or otalgia)
Give high dose amoxicillin
Alternative: for non-type I, cefdinir, cefuroxime, cefpodoxime; for type I, azithromycin, clarithromycin
Otitis Media Treatment
Clinically defined treatment failure after initial management with observation option (with fever or otalgia)
Give high dose amoxicillin + clavulanate
Alternative: ceftriaxone, 1 or 3 days
Otitis Media Treatment
Clinically defined treatment failure after initial management with antimicrobial agent (with no fever or otalgia)
Give high dose amoxicillin + clavulanate
Alternative: non-type I, ceftriaxone for 3 days; type I, clindamycin
Otitis Media Treatment
Clinically defined treatment failure after initial management with antimicrobial agent (with fever or otalgia)
Give ceftriaxone for 3 days
Alternative: tympanocentesis, clindamycin
Acute Pulmonary Exacerbations - Symptoms
-increased cough frequency and duration
-increased sputum production
-change in sputum appearance
-increased shortness of breath
-decreased exercise tolerance or fatigue
-decreased appetitie
-feeling of increased congestion
Acute Pulmonary Exacerbations - Signs
-increased respiratory rate
-use of accessory muscle for breathing (intercostal retractions)
-change in results of auscultatory examination of chest
-decline in pulmonary function test consistent with presence of obstructive airway disease
-fever and leukocytosis (less common)
-weight loss
-new infiltrate on chest radiograph
What are the immediate release (short-acting) stimulants?
(duration of 3-5 hours)
What are the intermediate acting stimulants?
Metadate ER
Methylin ER
Ritalin SR
(duration of 3-8 hours)
What are the long-acting stimulants?
Metadate CD
Ritalin LA
Daytrana patch
(duration of 8-12 hours)