Pocket Pedia

WEIGHT AT BIRTH 3-12 MOS

KILOGRAMS 3.25 𝐴𝑔𝑒 𝑚𝑜𝑠 + 9 2 Age (yrs) X 2 + 8

1-6 YRS

POUNDS 7 Age (mos) + 11 Age ( yrs) X 5 + 17 Age ( yrs ) X 7 +5

7-12 YRS

𝐴𝑔𝑒 𝑦𝑟𝑠 𝑋 7 − 5 2

HEIGHT AT BIRTH AT I YR 2 -12 YR

centimeter 50 75 Age ( yr) X 6 +77

Inches 20 30 Age (yr) X 2.5 + 30 BODY SURFACE AREA : 𝐻𝑡 𝑐𝑚 𝑋𝑊𝑡 (𝑘𝑔) 3600

APGAR Sign Muscle tone (Acticity) Pulse Reflex irritability Grimace Color (Appearanc e) Respiration

2 active >100 Sneeze/cou gh All pink

Crying, rhythmic effective

1 Some flex./ext <100 Some grimace or avoidance Body pink, ext. blue

0 limp No pulse No response blue/pale

Slow/irregul ar, ineffective

Compression depth

Approximately 1/3 to ½ depth of chest

Approximately 1/3 to ½ depth of chest

Approximately 1/3 to ½ depth of chest

Compression rate

100/min

>100min

120 events/min ( 90 compressions /30 breaths)

Compression ventilation ration

5:1 ( pause for ventilation until trachea is intubated)

5:1 ( pause for ventilation until trachea is intubated)

3 :1

PENICILLINS Amoxicillin (Amoxil, Himox, Jamox)

30-50 mg/kg/day q 8 po

AmoxicillinClavulanic Acid or Coamoxiclav

30-50mg/kg/day q8 IV,PO

Ampicillin (Ampedia, Ampicin)

NB: 50-100 mkd q 6-8 IM/IV (up to 1 wk) 100-200mg/k/d q8 (1-4 wk) IN,CH: 100-200 mkd q 4-6 IM/IV

Syrup: 125mg/5ml, 250mg/ml cap:250mg, 500mg vial: 100,125,500mg/vi al

AmpicillinCloxacillin (pensyclox, Ampiclox,Cl oxamicin)

Ampi 250mg + cloxa 250 mg Same as ampicillin

250 mg cap 250mg/5ml syrup 75, 250, 500 mg vial

absent

NEWBORN RESUSCITATION ( Outside Delivery Room) 1. Warm, Position, Suction, Dry, tactile stimulation 2. Oxygen (Blow by) 3. Bag-Valve Mask Ventilation ( If heart rate < 100 Bmp or gasping respiration 4. Chest compression ( if heart rate < 60-80 bpm after ventilation intiated) 5. Medication – Epinephrine (if heart rate continues to fall or remains < 80 bpm)

Maneuver

Airway

Breathing Initial

Subsequent FBAQ

SUMMARY OF ABC MANEUVERS Child Infant 1 – 8 years <1 year old old Head tilt-chin Head tilt-chin lift lift ( if trauma is ( if trauma is present ,uses present ,uses jaw thrust ) jaw thrust ) 2 breath at 1 2 breath at 1 to to 1 ½ sec/ 1 ½ sec/ breath breath ≈20 ≈20 breath/min breath/min Heimlich Back blows maneuver and chest thrusts

circulation Pulse check

Carotic

Compression landmarks

Lower half of sternum

Compression method

Heel of 1 hand

Newly Born

Head tilt-chin lift ( if trauma is present ,uses jaw thrust ) 2 breath at approximately 1 sec/breath ≈20 breath/min Back blows and chest thrsut

Brachial or femoral 1 finger width below intermammary line

1 finger width below intermammary line

2 thumbencircled hands ( for 2 providers) or 2 or 3 finger

2 thumbencircled hands ( for 2 providers) or 2 or 3 finger

250,500mg cap 100mg/ml drops 125, 250mg/5ml susp (Moxicillin, pediamox, sumoxil,wyamox) Syrup: TID 156mg/5ml (125mg amox) 312mg/5ml (250mg amox) Cap: 375mg/tab (250mg amox) 625mg/tab (500mg amox) Vail: 300mg/vial (250mg amox) 500mg/vial (500mg amox) 1.2g/vial (1g amox) Syrup BID 457 mg/5ml (4oo mg amox) 228.5 mg/5 ml ( 200 mg amox

AmpicillinSulbactam (unasyn)

Drops:A60mg + C 30mg q 6 Infant vials: A50mg + C25mg q8 NB: 100mg/k/d q 12 (up tp 1 wk) q8 (1-4 wks) 50-100mg/kg/day q6-8 IV,IM 30-50 mkday q8 (oral)

BacAmpicillin (Bacacil, Penglobe)

IN,CH: 25-50 mg/kg/day q 12 po A: 800-1600mg/k/d q 12h

Umbilical

375 mg tab 375 mg vial (A250mg + S125mg) 750 mg vial (A500mg+ S250mg) 250 mg/5ml 200, 400, 800mg tab 200mg/5ml susp

Aztreonam (Azactam)

Cloxacillin (Orbenin, Prostaphlin A)

NB<2kg: 60mg/k/d q 12h IV/IM (1st week) 90mg/k/d q 18h IV/IM (1-4 weeks) NB>2kg: 90mg/k/d q 8h IV/IM (1st week) 120mg/k/d q 6h (1-4wk) IN,CH: 90-120 mg/k/d q 6-8h Severe or life threatening infxn: 2 gms IV q 6-8 h

500 mg, 1 g vial

IN,CH: 50-100 mg/kg/d q6-8 po A: 2-4g/d q 6 po

250, 500mg cap 125mg/5ml susp 250mg/5 ml susp 250 and 500 mg vial 250mg vial 500 mg vial

Oxacillin

CEPHALOSPHORINS 1st GENERATION Cephalexin TD: 30-50 mg/k/d q6-8 monohydrate OM: 75-100 mg/k/d

Cefalothin Na

NB<1200g: 50 mkd q12 (0-4wks) >1200g: 50-75 mkd q 8-12 (up to 1 week) 100150mkd q6-8 (1-4wks) IM/IV over 15-30 min IN,CH: 100-200 mkd q 6 IM/IV (over 30 mins) 50-100mg/kg/day q6 IV A: 2-12 g/d q4-6 IM/IV (over 30mins) Nafcillin NB: 40mg/k/d q12 IV 250mg/5ml susp (Vigopen) (up to 1 wk) 250 mg cap 60-80mg/k/d q 6500 mg and 8h (1-4wks) 1 g vial IN,CH: 100-200 mg/k/d q 4-6h IV Pen V 50,000-100,000 125mg/5ml (phenoxym U/kg/day q6 (200,000u/5ml) ethylhigh dose: 150,000250mg/5ml penicillin) 200,000 U/kg/day q6 (400,000u/5ml) PO 500mg cap (Megapan,Pantacillin, (800,000 u) Sumapen, medoxypen) Aqueous 50,000-100,000 1,000,000 U/vial Pen G U/kg/day q6 5,000,000 U/vial meningitic dose: Benzylpenic 200,000-400,000 illin U/kg/day q6 IV PENICILLIN G (PENADUR) = Wt x 100 /600 Benzathine 50,000 u/kg single dose IM 1.2 M & 2.4 M u 600,000-1.2 M u IM q3- vial 4 wks Crystalline (Rheumatic Fever 1M and 5M u vial prophylaxis)

Procaine

NB: 50,000-100,000 u/kg q 6 IV/IM IN,CH: 100,000250,000 u/kg q 4-6 IM/IV 25,000-50,000ukd, IM q 12-24 Meningitic: 200,000400,000 Skin infxn: 150,000u/k/d x 10 days

80-160 mg/k/d q 6h life threatening: up to 2g/k/d q4 Cefazolin NB: 40mg/k/d q 12 (1st wk) 40-60mg/k/d q8-12 (14 wks) IM/IV over 15-30 min IN,CH: 50-100mg/k/d q8 IM/IV 2nd GENERATION Cefaclor IN,CH: 20-40mg/kg/day (ceclor) po q8 A: 750mg-1.5g q8

Cefuroxime

100-150 mg/kg/d q8 IM/IV 10-15 mkday q12 oral 250mg/kg/d q 6 IV (for bacterial meningitis) OM: 40mg/k/d q 12 >5 yrs: 30 mkd q 12 >5 yrs: 40 mkd q 12 A: 250mg q 12

Cefetamet

CH<12 yrs: 10 mg/kg q 12 >12 yrs: 500 mg po q 12

Cefoperazone

CH: 100-150mg/k/d q 6-8 IM/IV A: 2-12g/d IM/IV q 6-8 Cefotaxime IN,CH: 50-100mg/k/d q 12-16h A (gonorrhea): 500mg IM/IV SD Cefoxitin 80-160 mg/kg/day IM/IV q 4-8 3rd GENERATION Ceftriaxone 50-100mg/kg/day q12-24 (3rd gen) IV Typhoid:75-80mg/kg/day x A: 1-4 g/d

Ceftazidime (3rd gen)

Cefixime ( Tergecef Zefral, Ultraxime) Ceftizoxime (3rd gen) Cefotaxime Ceftazidime

NB<2000g: 100mg/k/d q12 (up to 1 week) 150mg/k/d q8 (1-4 wk) CH: 100-150 mg/kg/day q 8 A: 1-6 g/d q8 IM/IV 3-8 mkday q 12

CH: 40-80 mg/k/d q 6-12 A: 500mg-2g/d q 6-12h IM/IV 100-200mg/kg/day q6-8 IV 90-150mg/kg/day q8 IV

(keflex) 100mg/ml drops 125mg/5ml susp, 250mg/5ml susp 250, 500 mg 1 g cap 250, 500 mg pulvule 1g/vial (Keflin) (Stancef) 500mg & 1 g vials

250, 500 mg cap 125mg/5 ml susp 250mg/5 ml susp Zinacef: 250mg, 750mg, 1.5g vial; 125mg/ml susp 125mg, 250mg, 500mg tab Zinnat: 125, 250mg sachet susp., 125mg, 250mg, 500mg coated tab (globocef) 250, 500 mg tab 250mg/5ml susp (cefobis) 500 mg, 1 g vials (Claforan) 250mg, 500mg, 1 g vial (Mefoxin) 1 g vial (Rocephin) IM: 250mg, 500mg, 1 g (inj. w/ lidocaine) IV: 250mg, 500mg, 1 g (inj. w/ 1% water) (Fortum) 250mg,500mg 1g, 2g vials

Drops:20mg/ml Susp:100mg/5ml Cap:100mg, 200mg (Tergecin) 500mg 1 g vials 250mg, 500mg, 1g/vial Cloforan 250mg, 500mg, 1g/vial Fortum

MACROLIDES Azithromycin CH: 10mg/kg/day x 3 days or alternatively for 5 days w/ a single 10mg/kg dose on day 1 then 5 mg/kg on D2-5 Clarithromyci CH: 15mg/kg q12 po n A: 500-1000 mg q12 Severe infxn: 2 tab BID x 6-14 days Erythromycin IN,CH: 30-50mg/kg/day q6 po 15-30mg/k/d q6 SIV infusion A: 1-2 g/k/d q6 po 1-4gkd q6 IV Int. antisepsis: 1 g/dose x 3 doses (1pm,2pm, 11pm) the day before sx

Roxithromyci A: 1 tab BID po 15-30 n (Rulid, min before meals Macrol) QUINOLONES Ciprofloxacin A: 500mg-1.5 g po q12 (Ciprobay) 100-200 mg as IV infusion for 30 min q12 Norfolxacin UTI: 200-400 mg BID GI infxn: 400 mg BID Gonorrhea: 800mg SD Ofloxacin Uncom. 100mg BID po x 2-7 UTI days Compl. 200mg BID po x 7-14 UTI, Pn, OM, days sinusitis, skin & soft tissue infxn 300-600mg as single Gonococcus dose Non100-200mg BID x 7-14 gonococcus days GI infection 200-300mg BID x 5-7 days

250mg cap 200mg/5ml powder for oral suspension (Klaricid) 250mg tab 125mg/5ml susp (Erycin, Macrodin, Ilosone 125mg/5ml; 250mg/5ml) 100mg/2.5ml drops 250mg, 500mg cap 200mg/5ml susp 400mg/5ml susp 500 mg vial

100, 200mg tab Tobramycin ( Nebcin)

NB<1200g: 25mkd q 24h (0-4 wks) >1200g: 25-50mkd q1224h, IV over 15-30 min (1st week) IN,CH: 50-100 mkd q6 po IM/IV

(pediachlor, chlormycetin, Chloramol, chlorambid) 125mg/5ml susp 250mg, 500mg cap 1 g vial

Clindamycin

NB<1200g: 10mg/k/d q 6 (1st 4 wks) 1.2-2kg: 15mg/k/d q8 >2g: 15mg/k/d q8 or 20mg/k/d q6 IN,CH: 10-40 mg/k/d q6 IN,CH>3mos: 15mg/k/d q6 A: 1-2 g IV infusion *Crea clearnce of 15ml/min should not receive unless hemodialysis is instituted within 48 hrs 5-8 mg/k/d q 12

(dalacin-C) 150mg, 300mg cap 150mg/ml amp

Cotrimoxazole (SMX-TMP)

AMINOGLYCOSIDES Amikacin NB: 15 mkd q12 (1st (Amikin, wk) Pediakin) 15-22.5 mkd q8-12 (1-4 wks) IM/IV (over 12h) IN,CH,A: 15 mkd div q8 IM/IV (over 30-60 min) LD: 10 mg/k/dose Gentamicin NB: (Garamycin, <1200g: 2.5 mg/kg q 14Servigenta, 18 h (0-4 wks) Progara) <1200g: 5 mkd q 12 (1st wk); 7.5 mkd q 8 (1-4 wk) IM/IV (over 1-2 h) IN, CH: 5-8 mkd q8 IM/IV (over 1-2 h) 5 mkd A: 3.5 mkd q 8 IM/IV (over ½-2h) Netilmycin 2.5mg/kg/dose q8 IV,IM (Netromycin)

Inoflox, Qinolon

Chloramphen icol

ImipenemCilastatin

45mg+205mg/5 ml Bacidal 80mg+400mg/5 ml 160mg+800mg forte tab 80+400mg tab/cap 160mg+800mg tab

(Tienam) 500 mg imipenem 500 mg cilastatin, 1 amp

(Bactrim, Septrin, Microbid) 40mg+200mg/5 ml Triglobe:

6-7.5mg/kg/day q8 IV,IM

ANTI-TUBERCULOUS DRUGS INH IN,CH: 10-20 mg/kg/d 5-10 (max: 300mg/d)qd A: 8-10 mg/kg/d (max 300mg/d), pre-breakfast (pyridoxine: 10mg/100mg INH to prevent S/E) RIF IN,CH: 10-20 mkd, OD 10-15 1-pre or 2 post meal A: 600mg/d single daily dose (max 600mg/d) PZA CH: 30-35 mkd (max 15-30 2g/d) qd po A: 20-35 mkd po before meals EMB 15mg INH +125mg 15-25 EMB/5ml A: 15-25 mg/kg/d qd, po (not >1.5g)

Strept omyci n 25

CH: 20-40mg/kg/d qd IM x 2mos (max 1 g/d) A: 15-25 mg/kg/d or 1 g daily, qd, IM

250mg/ml, (2ml) vial 125mg/ml, (2ml) vial 50 mg/ml (2ml) vial

20mg/2ml amp 60mg/1.5 ml amp 80mg/2ml amp

25mg/ml (2ml amp) 50mg/ml (2ml amp) 100mg/ml (1.5 or 2 ml vial) 10mg/ml 40mg/ml (2ml amp)

50mg/ml (trisovit) 100mg/m l(nicetas,pyrifort) 150mg/5m l(Odinah) 200mg/5ml (comprilex,Trisofort) 100,300,400 mg tab 100 & 200mg/5ml 150, 300, 450, 600mg cap 600mg vial 250mg/5ml 500mg/tab

100mgtab (pyrifort,trisovit) 150mg tab (pyrina) 325mg, 400mg 125mg/5ml 500mg tab 1 g vial

COLDS PREPARATION: Phenylpropanolamine (decongestant)

1-3mos: ¼ ml q 8 Disudrin 4-6mos: ½ ml q 8 12.5mg/5ml 7-12 mos: ¾ ml q 8 syr 1-2 yr: 1 ml q 8 6.25 mg/ml 2-6 yr: ½ tsp q 8 drops 7-12 yr: 1 tsp q 8 Combined Prep: Rondec, Drixine, Sudafed, Dimetapp, Decolsin, Triaminic, Tridecon Brompheneramine 1-3 mos: 0.25 cc Dimetapp maleate, 4-6 mos: 0.5 cc Per 5 ml syrup phenylephrine, 7mos-2 yrs: 1 cc Per infant drop phenylpropanolamine 3-12 yrs: 1 tsp TID

BRONCHODILATORS Aminophylline 3-5 mg/kg/dose or 0.6-0.9 mg/k/hr LD: 5-7 mg/k/dose MD: 3-5 mg/k/dose q 6 hr + 2 or 3 cc IVF to run for 20-30 min

Ipratropium + Fenoterol (Berodual)

7 yrs, A: 2-10gtts (0.10.5 ml) 3-6x daily ( min interval: 2 hours)

Iron Supplement Dose: 3-5 mg/kg/day (maintenance) 6 mg/kg/day ( therapeutic dose) preparation: drops 15 mg/ml syrup 30 mg/5 ml

Salbutamol

0.1-0.15 mkd po q 6-8 or 2.5 ml tsp q 6-8 ( 6 mos-3 y/o) or 5 ml q 68 hrs recommended dose: 0.1-0.3 mg/k/d

Immuzinc dose: 1-2 mg/kg/day prep: 20 mg /5 ml syrup 10 mg/ml drops

Nebulizer 0.01 ml/kg (max 1 ml) in 3ml NSS or 5-10gtt in 2ml NSS q6

Nifuroxazide (ercefuryl) < 6 monts 1 tsp BID > 6 months 1 tsp TID

Terbutaline

Calcium Gluconate Dose: 200-300 Ex. WT x dose x prep 1.4 kg x 200 mg/ml = 290 mg/ml x 100mg /ml = 2.9 ml

Nebulizer 0.01 ml/kg (max of 1 ml in 3 ml NSS or 5-10 gtt in 2 ml NSS) q 6

Naloxone Dose: 0.1 mg/kg/dose IV/IM/SC Theophylline prep: 80 mg/ml 26.7 mg/ml dose: 2.5 mg/kg/dose q12

ANALGESICS Aspirin Thrombolytic RHD activity Kawasaki

Diclofenac

DOSE 65-130 mg/kg/d q 4-6 h 3-5 mg/k/day 75-100mg/k/day 80-100 mkd q 6h x 2wks then 3-5 mg/kg x 6-8 wks CH: 50 mg tab BID during or after meals A: 75-100 mg daily

Mefenamic Acid

6.5 mg/kg/dose q 6 h

Paracetamol

10-15 mg/kg/dose q 4-6 h

Ketotifen

Clenbuterol

PREPARATION 80 mg, 325 mg tab

25, 50 mg tab 100 mg tab (SR) 25mg/ml (3ml) amp 50 mg/5ml susp (ponstan, tynostan) 250, 500 mg tab/cap 150mg/ml (2ml amp) 125, 250 mg susp 325, 500 mg tab 120, 250/5ml syrup 60mg/0.6 ml drops

0.1-0.18-5 mkd po q 8 or 0.075 mg/k dose q 6 hr; or 1 mcg SC to rpt prn after 20 min once daily

6mos-3 yrs: 1 drop BID or 0.25 ml syr BID >3 yrs: 5 ml syrup BID <6 mos: 1 ml drops 6-24 mos: 2 ml drops 1-2 yrs: 5 ml syr 2-4 yrs: 7.5 ml 4-6 yrs: 10 ml 6-12 yrs: 15 ml

25mg/ml (10ml) amp 80mg/15ml syr (nuelin) 125, 250 mg tab (nuelin, phenedrine) 120mg tab (tedral) MDI: 20mcg I + 50 mcg F/10ml 250mcg I + 500 mcg F/ 20ml inhalant 2mg/5ml syrup (activent, librentin, ventolin) 1mg/5ml expector 2mg tab 2.5mg/2.5ml neb or 5mg/2.5 neb 200ug rotacap 0.1mg/inhalation (Asmalin) 5mg/ml resp soln 0.5mg/ml (2ml)amp 0.5mg/ml (1ml) amp 1.5mg/5ml syr (betalin, bricanyl, pulmoxel, terbulin) 2.5 mg tab 5 mg tab (ER) 2.5mg/ml (2ml) neb 0.5mg/d turbohaler, 100 d (zaldec, Zadilen) 1mg cap 1mg/5ml syr spiropent

COUGH PREPARATIONS MUCOKINETICS Ambroxol HCl <1 yr: 12 mg/day (bronchopront, 0.5ml BID (<6 mos) Mucosolvan, 1ml BID (7-12 mos) Mucovent, 1-2 yr: 15mg/day or Muxal,Venteze 1.25mg BID Therasolvan, CH: 1.2-1.6 mg/kg/d Zobrixol) 5-10 y/o: ½ tsp BID-TID CH>10 yrs, A: 1 tab TID or 1 tsp TID Bromhexine <2 yrs: ¼ tsp TID-QID HCl 2-5 yrs: ½ tsp TID-QID 5-10 yrs: 1 tsp TID-QID CH> 10 yr, A: 2 tsp TIDQID

Carbocisteine (Aflema, Ameuslyn,Bro nchotus, Flemex, Laxobron,Kra movon, Simbron,

<2 mos: 0.25 ml QID 2-6 mos: 0.5 ml QID 7-12 mos: 1 ml QID 1-3 yrs: 5-7.5 ml TID 4-7 yr: 7.5-10 ml TID 8-12 yr: 10-15 ml TID A: 1 capsule or 30 mll TID Solmux: 1-3 yrs: 2.5 ml

15,30mg/5ml syr 6mg/ml drops 15mg/2ml inhl’n soln 15 mg/2ml amp Bisolvon 8mg tab, 2 mg/ml soln, 0.8 mg/ml elixir, 4 mg amp Bitussin, Bronkose, mucolyptus, mucuspel 4mg/5ml syr, 8 mg tab 100, 250 mg/5ml susp 50mg/ml drops 500 mg cap 40 mg/ml drop

Solmux)

TID 4-7 yrs: 5 ml TID 8-12 yrs: 7.5 ml

Solmux: 250mg/5 ml 500 mg/5ml suspension

ANTI-CONVULSANTS Carbamazepine LD: 10-20 mg/kg MD: 5 mg/kg/day Clonazepam

S-CARBOXYMETHYLCISTEINE (LOVISCOL,MUKINYL,VISCODEC) Loviscol <3 mos: 0.3 ml TID 50 mg/ml drop 3-6 mos: 0.6 ml TID 100mg/5ml, 7-12 mos: 0.9 ml TID 250mg/5ml 13-24mos: 1.2 ml susp TID 1-3 yrs: 1-1 ½ tsp TID 4-7 yrs: 1 ½ tsp TID 8-12 yrs: 2-3 tsp TID Mucolytic + expectorant: bromulex, mucolex, bisolvon (bromhexine HCl), Bronchicum, Cheryl IP (Guaifensin + Ipecac) Antitussive: Bractus, Sinecod (Butamine citrate), Robitussin AC (Guaifenessin+ codeine phosphate + pheniramine maleate), Pertix, Protussa, Tuscalman Berna Dextromethorphan 1-2 tbsp 3-4 hrly or 5mg/5ml syr HBr 1-2 tabs q 4 hr 10 mg tab (max: 12 tabs/day) Expectorant + antitussive: mucolexin (Dextromethorphan + guiafenesin + Na citrate), mucobran (Guiafenesin + Na citrate) STEROIDS Budesonide (budecort)

Dexamethasone

Hydrocortiso ne Status Asthmaticus Shock Prednisone

C: 200-400 mcg BID initial MD: 100-200 mcg BID (max: 800 mcg daily) A: 400-800 mcg BID MD: 200-400 mcg BID 0.023-0.33 mkd po 0.5-1 mkd (max 16mg/d) in 4 div doses, IV (for  ICP)

LD: 10mg/k/dose MD: 4-8mg/k/dose 10-20 mkd q 6 then 4 mkd q 4 until (+) response 50 mg/kg initial then 5075 mkd q 6 CH: 1-2 mg/k/d q 6 P: 40-60 mkd po ( for neoplasm)

ANTI-HISTAMINES Acrivastin 1 tab TID po Chlorphenira mine (Antamine) Clemastine (Tavergyl)

Diphenhydra mine (Benadryl) Hydroxyzine HCl (Iterax) Mequitazine (primalan) Terfenadine (Teldane)

0.35 mg/kg/day or 0.2 mg/kg/dose 2-6 yrs: 2.5-5ml BID 6-12 yrs: 5-10 ml BID >12 yrs: 7.5 ml BID or ½ tab to 1 tab BID po or 0.025 mg/k IM 3-5 mg/kg/day q 6 po, IM, IV

10 mg OD or 1 mg/k/day BID ½- 2 tabs/day accdg to age 15-30 mg BID

200mcg/dose misthaler 200mcg turbohaler 250mcg/ml respul

0.5 mg, 4mg tab 5mg/ml amp(1ml) 4mg/ml vial(2ml) 50mg/ml, 2ml vial 125mg/ml, 2ml vial

5 mg tab

8 mg cap semprex 4 mg tab 10 mg/ml (1 ml) amp 0.5mg/ml syr 1mg tab 2mg/2ml amp

25mg, 50mg cap 12.5mg/5ml syr 50mg/ml (1ml) amp 0.2 mg/syrup 10, 25 mg tabs 5 mg tab 2.5mg/5ml syr 30mg/5ml syr 60mg tab

Diazepam (anxionil, trazepam, valium) Diphenylhydantaoin

Tegretol 100mg/5ml syr 200mg tab Rivotril 2mg tab

IN,C <10 yrs: 0.010.03 mg/kg/d >10 yrs: 1- 2 mg/k/d MD: <10 y: 0.05 -0.1 mkd 10-16y: 1.5 - 3 mkd A: 2-4mg/k/d mg-0.3mg/k/dose 0.2-0.4 mg/kg/dose

10mg/2ml amp 2mg, 5 mg tab

Sedation/sleep:

2-3 mkd q 8-12

Long term anticonvulsant

start at 1.5 mkd q 12  to 4-6 mkd q 12 or as single daily dose HS

Dilantin 125, 30mg/5ml susp 30, 100 mg cap 100g/2ml amp 16.25mg 32.5mg,65mg 97.5mg tablets Na luminal: 130mg/ml amp 15,30,60,100 mg tab 20 mg/ml syr

15 mg/kg/d div q 8-12 by 5-10 mg/kg/day weekly (max: 30 mg/kg/d q 8)

gr ¼ = 15 mg gr ½ = 30 mg gr 1 = 60 mg Depakene 250mg/5ml susp 250mg tab

Phenobarbital

Valproic acid

ANTI-EMETIC Dimenhydrinate

LD: 10-15 mg/kg/dose MD: 4-8 mg/k/d q 8h *push DW before and after LD: 10-20 mg/k/d MD: 5-10 mkd

5mg/k/d QID 2-6 yrs: 2.5 ml BIDTID 6-8 yrs: 5-10 ml BIDTID 8-12 yrs: 10-20 ml BID-TID Infant: ¼ supp 1-6 yrs: ½ supp 6-12 yrs: 1 supp BID/TID

ANTI-VERTIGO Betahistine A: 1-2 tab TID po with meals

Meclezine HCl

12.5-50 mg/k/day TID/BID <6 mos: 0.5 ml daily 2-6 yrs: 3 ml or 1-2 tabs daily

Dramamine 12.5mg/5ml syr 50 mg tab Emes: 50 mg tab Vomex: 50 mg supp

Serc, mension 6mg tab (mesylate) 8, 16 mg tab (dihydrochloride) Bonamine 25 mg tab Bonadoxine 8 mg/ml drops

PROKINETIC (GASTRO-KINETIC DRUG) Metoclopramide 0.5 mg/k/day <1yr: 1 mg BID 1-3 yrs: 1 mg BID-TID 3-5 yrs: 2 mg BID-TID 5-14 yrs: 2.5 mg TID

Plasil 5 mg/5ml syrup 10 mg tab 10 mg/2ml amp

ANTI-ULCER Antacid

Cimetidine ( tagamet)

Ranitidine (Zantac)

2-4 tabs chewtab QID 1 hr after meals or 2-4 tsp QID susp 5-7.5mg/kg/dose q 6 po/IV or 10-20 mg/kg QID

2-4 mg/k/dose BID po or 1 mg/k/dose TID, IV

ANTI-SPASMODIC Bentyl 2.5-10 ml TID Dicycloverine HCl, Simethicon

Hyoscine-Nbutyl bromide (buscopan)

IN: 0.5-1 ml gtt or ½ tsp syr QID/TID 1-5 yrs: 2.5-5ml TID/QID 6-12 yrs: 5 ml IN: ¼ amp TID IM, SC or slow IV CH, A: 1-2 tabs 3-5 x daily

ANTI-FLATULENT DimethylA: 1-2 tab TID po polysiloxane

Chewable tabs 250 and 500 ml susp 200,400,800 mg tab 100mg/ml (2ml) amp 100mg/5ml syrup 75,150, 300 mg tabs 150mg/5ml syrup 50mg/2ml amp

10 mg tab 10mg/5ml syrup Relestal: 5 mg/ml drops 10mg/5ml syrup

10 mg tab 5 mg/5 ml syrup 20 mg/ml amp

40 mg tab Disflatyl, Gascon

ANTI-HELMINTICS Albendazole Nematode 400 mg po Capillariasis 200 mg BID x 10days 400 mg q day x 3 Strongyloidiasis days Mebendazole 200 mg po BID x 3 (Antiox) days or 500 mg po one dose Piperazine (Expelin, Aloxin)

75 mg/kg (max: 3.5g/d) q day x 2 days (for ascariasis only)

Pyrantel Pamoate

11 mg/kg/day (max 1 g) x 3 days

ANTI-DIARRHEALS Nifuroxazide <6 mos: 2 tsp daily ( Ercefuryl) >6 mos: 3 tsp daily A: 1 cap QID Paromomycin + kaolin + pectin Bacterial <3 yrs: 1 tsp q 4 h diarrhea 4-14 yrs: 1 tbsp q 4h 25mg/kg q 6-8 hr x 5 Ameobiasis days Dysentery 35-60 mg/kg x > 6 doses Pre-op 35 mg/kg x 4 consec Hepatic coma days Taeniasis 75mg/kg Giardiasis 20-50 mg/kg/day x 5 days 20-30 mg/kg/day x 5-8 days

OPTICAL ANTI-INFECTIVES:

Zentel 200 mg/5ml syr 400 mg tab

100, 500 mg tab 100 mg/5 ml susp 1.25 mg/5 ml syr 62.5 mg/5 ml syr Combantrin 250, 500 mg tab 125, 250 mg/5ml Quatrel: 100 mg/5 ml 100 mg tab

200 mg cap 220mg/5ml syr Humagel 150 mg cap 50mg/5ml susp

Chloramphenicol solution ointment

1 gtt 2-4x/day (1 gtt/hr for acute cases) Apply inside surface of lower lid

Framycetin solution ointment

1-2 gtts q 1-2h or 1-2 gtts 3-4x/day (acute) 2-3 application daily or at bedtime 1-2gtts into lower conjunctival sac 2-3h 1-2 gtts q4 ½ in ribbon into conjunctival sac 2-3x/day

Sulfacetamide Tobramycin Solution ointment

AMEOBICIDES Diloxanide furoate (furamide, elizol) Etofamide (kitnos)

0.25%, 0.5%, 1% 5 ml drops 0.1%,0.5% 3.5 g tube 0.5% 2.5ml drops, 0.5% 2.5 g tube 10% 15% 5ml drops 3mg/ml (0.3%),5ml 3mg/g (0.3%) 3.5g tube

20mg/k/day po TID x 10 days

125mg/5ml

CH: 15-20ml/kg/day or 2 tsp TID x 3 days A: 5 tabs BID x 3 days or 1 forte tab BID

100mg/5ml susp 200mg tab 500 mg forte

EAR PREPARATIONS: 1. Antiseptics with corticosteroids Polymyxin Cortisporin B+Neomycin+HAA Fluocinolone Aplosyn, acetonide + Synalar polymyxin B + neomycin Triamcinolone kenacomb acetonide + neomycin + gramicidine + nystatin 2. Anti-Infectives and Antiseptics Chloramphenicol Chloromycetin

3-4 gtts tidqid 3-4 gtts tidqid

5ml drops 5 ml drops

2-3 gtts tidqid

7.5ml drops

2-3 gtts bidqid 3-4 gtts tid

(5%) 5ml 10ml drops 10ml drops

Polymycin B + glacialAerosporin acetic acid Polymycin B + Lignosporin 3-4 gtts tid lidocaine 3. Miscellaneous Antipyrine + Auralgan Moisten cotton Benzocaine + plug with solution glycerine then insert into dehydrated meatus tid-qid Dousate otosol Fill ear canal wit sodium soln & stay in position for 4-5 min then insert a cotton wool plug x 2 consecutive nights

10ml, 15ml drops (0.5%) 10 ml drops

ANTI-FUNGAL Amphotericin B

Candida Fluconazole(difl ucan)

Griseofulvin Ketoconazole

Nystatin (Mycostatin)

NB: 100ug-1mg/kg/d over 6 hrs during 1st 4 wks of age IN,CH: 1st day: 0.1mg/kg for 2hrs (test dose) 2nd day: 0.25mg/k (increment of 0.1250.25mg/kg),  to 1 mg/k/d as single infusion over 6-8h

5mg/ml(10ml )vial 50mg reconstituted with 10cc sterile water to make 5mg/ml

IN,CH: 400,000-800,000 u/d q 4-6 h, po

Metronidazole Ameobiasis Trichomoniasis

50, 150, 200mg/cap 2mg/mlvial 330 mg tab

5-8mg/k/day QID NOT FOR G6PD

50mg/15ml, 16.6mg/5ml 100mg tab Flagyl

IN,CH: 35-50 mkd q8 x10 days A: 750mg TID po x 5-10 days

Giardiasis

C: 5 mkd q8 x 7 days A: 250mg TID x 5 days

Anaerobic Infxn:

C: 15 mkd q8 x 5 days A: 250 mg TID x 5 days

Dose: 0.50.7mg/k/day

TD: 20-30 mg/k/day LD: 6mg/k OD MD: 3 mg/k OD

CH: 7.25 mg/kg/d OD,po A: 0.33-).66g/d OD, po CH: 5-10 mkd q12-24, po A: 200-400 mg OD, po NB: <2kg: 200,000-400,000 u/d q 4-6h po >2kg: 400,000-800,000 u/d q 4-6h

AMEOBICIDES Furazolidone (furoxone)

Intestinal Antisepsis

250mg, 500mg tab 125mg/5ml susp 5mg/ml(100 ml)vial 1g suppository

NB: 15mkd (initial) then 7.5 mkd q12 IV CH: 30 mkd (max 4g/d) q6 po/IV A: 500mg q6 po/IV or 300mkd (max 4g/d) q6 po/IV

200mg tab

100,000 units/ml susp

Tetracycline Vancomycin

500,000 u tab 100,000 u vaginal tab

A: 750mg x 3 doses 1 day before sx 25-50 mg/kg/day div q6 po NB<1.2kg: 15mg/k/d OD >1.2kg: 20mkd q12 (1st wk) 30mkd q8 (14wks) IN,CH: 40mg/k/d q6-12h A: 2mg/d IV q6-12h

250, 500mg cap 500mg/vial

A: 800,000-2,000,000 u/d q 4-6h, po

ANTI-VIRAL Acyclovir Premature

Term

VaricellaZoster

Encephalitis

Amantadine HCl

Inosiplex

Methixoprinol Linosine Ribavirin (virazole)

10mg/kg as 1hr IV infusion of 12hrs x 10-21 days

200 and 400 mg tab 250mg/ml (5ml) inj

10mg/kg as 1hr IV infusion of 8 x 10-21 days 2-12 yr: 20mg/kg (max:800) qid x 5 days >12 yrs: 800mg po 5x/day x 7 days 10mg/kg as 1 hr IV infusion of 8hrs x 4-21 days CH: 5-8 mkd po (max150mg) bid or tid A: 200mg OD ir BID <6mos: 1 ml q 3-4hrs 6-12mos: 1.5ml q3-4 1-2yrs: 2ml 2-6yrs: 3ml 6-12yrs: 5ml A: 1 tab LD: 100mg/kg/day MD: 50mg/kg/day CH: 15mg/kg/d in 3 or 4 div doses A: 800mg/day (1st day LD of 1600mg) q6

100mg tab 50mg/ml

(Immunosine) 500mg tab 250mg/5ml

(Isoprinosine) 500mg tab 250mg/5ml syr 200mg cap 20mg/ml syr 100mg/ml amp 6g/vial aero

DEVELOPMENTAL MILESTONES Age Gross VisualMotor Motor/Proble m Solving 1 Raises Birth: mo head from Visually fixes prone position 1 mo: Has tight grasp, follows to midline 2 Holds head No longer mo in midline, clenches lifts chest fists tightly, off table follows object past midline 3 Supports Holds hands mo on open at rest, forearms in follows in prone circular position, fashion, holds head responds to up steadily visual threat 4 Rolls over, Reaches mo supports on with arms in wrists, and unison, shifts brings hands weight to midline 6 Sits Unilateral mo unsupporte reach, uses d, puts feet raking grasp, in mouth in transfers supine objects position 9 Pivots Uses mo when immature sitting, pincer grasp, crawls well, probes with pulls to forefinger, stand, holds bottle, cruises throws objects 12 Walks Uses mature

Language

Social/Adapti ve

Alerts to sound

Regards face

Smiles socially (after being stroked or talked to)

Recognizes parent

Coos (produces long vowel sounds in musical fashion)

Reaches for familiar people or objects, anticipates feeding

Laughs, orients to voice

Enjoys looking around

Babbles, ahgoo, razz, lateral orientation to bell

Recognizes that someone is a stranger

Says ―mama, dada‖ indiscriminatel y, gestures, waves byebye, understands ―no‖ Uses two

Starts exploring environment, plays gesture games (e.g., pat-a-cake) Imitates

mo

15 mo

18 mo

24 mo

3 yr

4 yr

5 yr

alone

pincer grasp, can make a crayon mark, releases voluntarily

Creeps up stairs, walks backwards independen tly Runs, throws objects from standing without falling

Scribbles in imitation, builds tower of two blocks in imitation

Walks up and down steps without help

Imitates stroke with pencil, builds tower of 7 blocks, turns pages one at a time, removes shoes, pants, etc.

Scribbles spontaneous ly, builds tower of 3 blocks, turns 2–3 pages at a time

Can alternate feet when going up steps, pedals tricycle

Copies a circle, undresses completely, dresses partially, dries hands if reminded, unbuttons

Hops, skips, alternates feet going down steps

Copies a square, buttons clothing, dresses self completely, catches ball Copies triangle, ties shoes, spreads with knife

Skips alternating feet, jumps over low obstacles

Age 0.5 mos 6-11 mos 1-2 yrs 3-6 yrs 7-9 yrs 10-12 yrs 13-15 yrs 16-19 yrs

words other than mama/dada or proper nouns, jargoning (runs several unintelligible words together with tone or inflection), one-step command with gesture Uses 4–6 words, follows one-step command without gesture Mature jargoning (includes intelligible words), 7–10 word vocabulary, knows 5 body parts Uses pronouns (I, you, me) inappropriately , follows twostep commands, has a 50– word vocabulary, uses two-word sentences Uses minimum of 250 words, 3– word sentences, uses plurals, knows all pronouns, repeats two digits Knows colors, says song or poem from memory, asks questions

Prints first name, asks what a word means

Cal per kg 115 110 110 90-100 80-90 70-80 55-65 45-50

Prot g/kg 3.5 3.0 2.5 2.0 1.5 1.5 1.5 1.2

actions, comes when called, cooperates with dressing

15–18 mo: Uses spoon and cup

Copies parent in tasks (sweeping, dusting), plays in company of other children Parallel play

Normal respiratory rate <60 <50 <40 <30

Age <2 mo 2-12mo 1-5yo 6-8y/o

-- NORMAL RESPIRATORY RATES IN CHILDREN Age Respiratory Rate (breaths/min) (yr) 0–1* 24–38 1–3 22–30 4–6 20–24 7–9 18–24 10–14 16–22 14–18 14–20 Age NB 2y/o 4y/o >6y/o

Normal heart rate 110-150 85-120 75-115 60-110

Weight IBW preterm term At birth 3-12 mo

kg (# of days -14) x 15 + BW 9gms (# of days -10 x 20 + BW 9 grms 3.25 Age in months + 9 2 (age in yrs x 2) + 8 (age in yrs x 7) – 5 2

1-6y/o 7-12 y/o

Length Ave BL 1 y/o 3y/o 4y/o >2y/o Group play, shares toys, takes turns, plays well with others, knows full name, age, gender Tells ―tall tales,‖ plays cooperatively with a group of children

Plays competitive games, abides by rules, likes to help in household tasks

Holiday Segar BW (kg) 1-10 y/o 11-20 >20

50 cm (20 in) 75 cm 3 ft. BL x 2 (age in yrs x 5) + 80

Fluid volume 100 ml/kg 1000 ml+ 50 ml/kg for each kg > 10kg 1500+ 20 ml/kg for each kg > 20 kg

Ludans method

<15 kg <2 y/o

mild moderate

50 100

>15 kg >2 kg

30 60 ¼ PLR ¾ D50.9 6-7 hrs severe 150 90 1/3 PLR x 1 hr 2/3 D5 0.3 or 0.9 6-7hrs For every degree rise in temperature add 12% Of maintenance IVF components (meq/L) Na K D5LRS 130 4 D5 0.3 Nacl 51 D5 0.45 Nacl 75 D5 0.9 NaCl 154 D5 mannitol 49 25 D5 NR 140 5 D5 NM 40 13 D5 IMB 25 20 NP 30 20 D5NSS 150 D5W -

Cl 109 51 75 154 19 98 40 22 25 150 -

base 28 20 50 16 23 23 -

Mg -

Blood Transfusion WHO treatment plan (CDD) Plan A Age in yrs. <2 2-10 >10

Give every after BM 50-100 ml (2-3oz) 100-200 ml (2-3 0z) As much as tolerated

Plan B Age <4 mo 4-11 12-23 mo 2-4y/o 5-10 10-15 y/o

Weight <5 kg 5-7.9 8-10.9 11-15.9 16-29.9 >30

Ml in 4 hours 200-400 400-600 600-800 800-1200 1200-2200 2200-4200

Plan C Age <12 mo >12 mo Using PLR for 4-6

30 ml/kg 1 hr 30 mins hrs

50 ml/kg 5 hrs 2 ½ hours

FWB: PRBC: Plt Conc: FFP: Cryoppt:

10 cc/kg 10 cc/kg 1 unit/7 kg 10 – 15 cc/kg 1unit/5 kg

4-6 hours 4 hours fast drip 2-4 hrs

How to compute ANC = WBC(% neutrophils + % bands) x 1000 Fluid Balance TFB=Total fluid intake – total fluid output TFI – ( TFO + (BSAxIWL)) TFI = parenteral (IVF/meds) + oral TFO= IWL (400-700/m2) + urine output+ vomitus/ NGT output TFR = BSA x IWL + ½ U.O in 24 hours(if with diuretics ) If w/o diuretic use BSA x IWL + U.O in 24 hours

Albumin Transfusion Sodium (Na) Normal value: 135-145 meq/L A. To compute for deficit Desired Na (140 meq/l) - actual Na x 0.6 x Wt. Ex. 140-121 x 0.6 x 10 kg = 114 meq B. To compute for maintenance Required K= deficit + maintenance Wt. x 4 (constant) Ex. 4x 10 kg = 40 meq C. required sodium for 24 hours Add desired + maintenance Ex : 114+ 40 meq = 154 meq Running rate : < 0.5 meq/l/hr (increased running rate can lead to osmotic demyelination) Na correction: ½ by 1st day the rest over 24-48 hours

Dose: 0.5 -1 gm/kg Preparation: 20% 10 gm 25 % 12.5 gm Transfuse 1 vial to run for 2 hrs at 6-7 gtts/min After 1 vial give furosemide (1 mkdose) Give 2nd vial then furosemide Mobitor VS q 15 mins while ongoing Infusion IVIg Computation # of vials needed = WT. x Dose (2g/kg) preparation(g/ml) Ex. 12 kg

B. Maintenance Wt x 4 meq

# of vials needed = 12 kg x 2g/kg 2.5 g = 9.6 vials or 10 vials Infusion Rate: 0.01-0.02 ml/kg/min for the first 30 mins. Via infusion pump if no adverse reactions noted, may increase to maximum of 0.04 ml/kg/min Ex: 12 kg wt Infusion rate of 0.01 12 kg X 0.01 x 3o mins = 4 ml * give for ml to run for 30 mins watchout for nausea, vomiting, chills fever, dyspnea, malaise, hjeadache etc.

Running rate : 0.25-0.5 meq/m2/hr IVF correction should not exceed 40 meq/L

2. increase to infusion rate 0f 0.02 x 60 mins 12 x 0.02 x 60 = 15 ml to run for 60 min

ECG : tall/peaked T waves ; prolonged PR interval, decreased ST wave ; diappearance of P wave

3. remaining to run for 14 hours

Potasium (K) Normal value: 3.5-4.5 meq/l A. To compute for deficit (Desired – actual) x wt. X 0.3

IVIg Preparation Available Serum K if > 6.5 meg/l Mgt: glucose 0.5 – 1 g/kg + insulin 0.1-0.2 units/ kg over 30 minutes

Bicarbonate Correction Total Bicarbonate correction = Wt. x 0.3 x base excess Calcium Gluconate Preparation 10% calcium gluconate = 10 g = 100 mg 100 cc ml maintenance = 150-200 mkday Ex. Wt x desired ( 4.1 x 200 = 820mkday) = 100 = 8.2 ml div into doses X ml

10 ml (500mg/vial) 20 ml (1000 mg/vial) 50 ml (2500 mg/vial) 100 ml (5000 mg/vial) 200 ml ( 10000 mg/vial)

Haesteril 6% <10 kg = 10 cc/kg <20 kg = 20 cc/kg > 20 kg = 30 cc/kg/hr Ex: WT: 72.9 kg IVF: 3cc/kg/hr 72.9 kg x 3 cc/kg/hr x 24 hrs = 720 cc total IVF/day – 720 cc = 4528.8 ml 72.9 = 218 cc/hr = 54-55gtts/min (IVF) (-) 7-8 gtts/min (haes) 4 4 = 47-48 gtts /min (IVF rate) Order: Hook D5 0.9 Nacl/ D50.3 to run at47-48 gtts/min Hook 6% haesteril as drip to run at 7-8 gtts per min Excahnge Transfusion total vol (ml) = Wt (kg) x 2 x 85 (bld vol) Absolute vol. of RBC’s needed wt. x2 x 85 2 Absolute vol. (ml) of RBC needed WTx2x85 = 0.7 _____ 2________ Actual vol. (ml) of FFP needed = Wt. x 2 x 85 – actual vol of RBC needed Mannitol (20%) Dose: 0.3-0.5 g/kg 20 g/100ml x 0.5 (wt)/ X = x x= 0.5 (wt) (100) 20 gm X = ________ ml q 6-8 hrs Ex. 44kg dose 0.3 g/kg 202/100ml x15/x = x (20g) = 15 x 100 x= 1500/20 = 75 ml q6

WT. x 0.5 /kg = x (gm) x (g) x 100 ml/10 gm = x (cc) To order: start intralipid 10% give __ cc to run for 1 hr. (as test dose) then 14 cc to run for 20 hrs via infusion/syringe pump * insert another line * intralipid should not be mixed with electrolyte containing IVF Lipid Dose: 0.5 - 2 Wt x dose x 100/ 20 (if 20% prep) * add additional amount of D5W total of 24 cc to run at 1 cc/hr for 24 hrs via syringe pump * wrap tubing with carbon paper Gomez Classification Actual wt. x 100% Ht. for age 97-100% normal 76-96% 1st deg. Mal. 61-75% 2nd Deg. Mal <60% 3rd deg mal. Waterlowe Classification Stunting :actual wt. x 100% Ideal Ht. for age > 95 % 90-05% 80-90% <80%

normal mild mod severe

Wasting: Actual wt. Ideal wt for ht > 90 % 80-90% 70-80%

x 100%

normal mild mod

Dextrosity: Aminosteril Feeding Rate: 0.5-2 grms/ kg/day Ex. Wt x rate x prep. = ml/day 10 kg x 0.5 grms x 6 grms kg.day 100 ml 5 gms x 100 ml = 83 ml/day day 6 grms = 83 ml = 3.45 ml/hr Div doses

Desired - lowest x 1 Highest – lowest D10 – D5 = 50-5 D7.5 – 5 50-5

5

=

D12.5-5 = 50-5

= 0.11

= D10

45 2.5 = 0.055 = D7.5 45 7.5 = 0.166 = D12.5 45

ABG pH pCO2 pO2 HCO3 O2sat BE +/-

7.35- 7.45 35-45 80-100 22-26 94- 100% 2

Urine Anion Gap = urine Na + Urine K – U Cl - U HCO3 (+) = low H+ secretion and low ammonium excretion (-) = urinary bicarbonate loss Nutrition TCR = IBW x RDA for age or TCR = holiday segar method (in kcal/kg) CHON : 2 gm/kg/day Fats: 40% CHO: 60 % divided into 3 meals and 3 snacks

Intralipid

Ex. 59 cc x 0.11 = 6.49 (D5050) 59 - 6.49 = 52 cc Reticulocyte Index RI =actual Hct. X Retic. Ct. desired hct 10 normal value: 1-1.5 normal > 1 inc. erythropoeisis, inc BM activity, hemolysis < 1 dec. erythropoeisis, BM failure Hypoglycemia

premature neonate newborn: 1 day >1 day child fasting 2 hours PP

normal glucose value (mg/dl) 20-60 30-60 40-60 50-90 60-100 70-105 <120

Treatment : 2 ml/kg of D10 (bolus) IV bolus

Ex. BW = 3 kg 3 x 2 ml = 6 ml 6 x factor = 6 x 0.11 = 0.66 cc order: 5.3 cc of present IVF (or D5W) + 0.7 cc of D50-50 to make D10 as bolus

Term

20–170 0.20–1.7 g/L mg/dL Child 5–40 0.05–0.40 g/L mg/dL CSF, cerebrospinal fluid; PMNs, polymorphonuclear lymphocytes; WBC, white blood cell. Modified from Oski FA: Principles and Practice of Pediatrics, 3rd ed. Philadelphia, JB Lippincott, 1999.

Croup Scoring

Respi. Stridor

Cough

retraction

Dyspnea

color

none audible stridor when agitated at rest severe none when agitated croup like at rest severe rest mild moderate severe none mild moderate severe normal cyanosis at room air cyanosis w/02

score 0 1 2 3 4 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2

Hypoxic Ischemic Encephalorathy (Sarnat Scoring)

level of conciusness muscle tone myoclonus seizure suck reflex moro reflex grasp dolls eye respi. CR pupils

I alert normal or hypertonic + active exagerated N or inc N reg. N or tachy dilated reactive

II lethargy hypotonic

III coma failed

+ + weak inc. exag. overactivity varies brady aniso reactive

+ absent dec. 0r apneic brady aniso nonreact.

TABLE 25-3 -- EVALUATION OF CEREBROSPINAL FLUID WBC Count Mean % PMNs Preterm 0–25 57% 3 WBCs/mm Term 0–22 61% WBCs/mm3 Child 0–7 5% WBCs/mm3

Preterm Term Child

GLUCOSE 24–63 mg/dL 34–119 mg/dL 40–80 mg/dL

1.3–3.5 mmol/L 1.9–6.6 mmol/L 2.2–4.4 mmol/L

CSF GLUCOSE/BLOOD GLUCOSE Preterm 55%–105% Term 44%–128% Child 50%

LACTIC ACID DEHYDROGENASE Normal range 5–30 U/L (or about 10% of serum value)

Preterm

PROTEIN 65–150 mg/dL

0.65–1.5 g/L

TABLE 25-2 -- EVALUATION OF TRANSUDATE vs. EXUDATE (PLEURAL, PERICARDIAL, OR PERITONEAL FLUID) Measurement* Transudate Exudate† Specific gravity <1.016 >1.016 Protein (g/dL) <3.0 >3.0 Fluid : serum ratio <0.5 >0.5 LDH (IU) <200 >200 Fluid : serum ratio <0.6 >0.6 (isoenzymes not useful) WBCs‡ <1000/mm3 >1000/mm3 RBCs <10,000 Variable Glucose Same as serum Less than serum pH§ 7.4–7.5 <7.4 LDH, lactate dehydrogenase; RBCs, red blood cells; WBCs, white blood cells. Note: Amylase >5000 U/mL or pleural fluid : serum ratio >1 suggests pancreatitis. TABLE 1-2 -- MANAGEMENT OF CIRCULATION Location* Rate Compressions: (per min) Ventilation Infants 1 fingerbreadth >100 5:1 below intermammary line Children 2 fingerbreadth 100 5:1 (<8 yr) below intermammary line Older Lower half of 100 15:2 children stemum (>8 yr) TABLE 17-3 -- PREDICTED ENDOTRACHEAL TUBE SIZE AND * EXPECTED BIRTH WEIGHT BY GESTATIONAL AGE Gestational Weight ETT Size ETT Depth of Insertion Age (wk) (g) (mm) (cm from upper lip) 24 700 2.5 7 26 900 2.5 7 28 1100 2.5–3.0 7 30 1350 3.0 7 32 1650 3.0 7 34 2100 3.5 8 36 2600 3.5 8 38 3000 3.5–4.0 9

INFANT GROWTH AND CALORIC REQUIREMENTS Preterm Infants Term Infants 15–20 g/kg/day 10 g/kg/day Maintaining 50–75 kcal/kg/day weight Adequate 115–130 kcal/kg/day (may be up 100–120 growth to 150 kcal/kg/day for VLBW kcal/kg/day infants) LABORATORY DIFFERENTIATION OF OLIGURIA Test Prerenal Renal FENa <1% >3% BUN/Cr ratio >20 :1 <10 : 1 Urine specific >1.015 <1.010 gravity

 TABLE 17-11 -- GUIDELINES FOR USE OF PHOTOTHERAPY IN PRETERM INFANTS <1 WEEK OF AGE Weight (g) Phototherapy (mg/dL) Transfusion (mg/dL) Consider Exchange 500–1000 5–7 12–15 1000–1500 7–10 15–18 1500–2500 10–15 18–20 >2500 >15 >20 GUIDELINES FOR USE OF PHOTOTHERAPY IN PRETERM INFANTS <1 WEEK OF AGE Weight (g) Phototherapy Transfusion (mg/dL) Consider (mg/dL) Exchange 500–1000 5–7 12–15 1000–1500 7–10 15–18 1500–2500 10–15 18–20 >2500 >15 >20

CALCULATION OF EXPECTED COMPENSATORY RESPONSE Disturbance Primary pH Expected Change Compensatory Response Acute ↑ PaCO2 ↓ pH ↑ HCO3- by 1 mEq/L respiratory for each 10 mmHg acidosis rise in PaCO2 Acute ↓ PaCO2 ↑ pH ↓ HCO3- by 1–3 respiratory mEq/L for each 10 alkalosis mmHg fall in PaCO2 Chronic ↑ PaCO2 ↓ pH ↑ HCO3- by 4 mEq/L respiratory for each 10 mmHg acidosis rise in PaCO2 Chronic ↓ PaCO2 ↑ pH ↓ HCO3- by 2–5 respiratory mEq/L for each 10 alkalosis mmHg fall in PaCO2 Metabolic ↓ HCO3↓ pH ↓ PaCO2 by 1 to 1.5 acidosis × fall in HCO3Metabolic ↑ HCO3 ↑ pH ↑ PaCO2 by 0.25–1 alkalosis × rise in HCO3Lumbar Tap Orders Please secure consent Prepare the ff materials: Sterile gloves size _____ Disposable needle q 23/24 Sterile Specimen bottles #4 Eye sheet Sterile gauze/cotton Betadine/Alcohol #1 Secure ___________ for sedation For HGT prior to LT Post Lumbar Tap Orders >Flat on bed for 4 hours >NPO temp for 2 hours then may feed once fully awake with aspiration precaution >Monitor VS q 15 min x 1 hour, q30 mins x 2 hours then q 1 till stable >Send CSF Specimen to the lab as ff: bottle #1 : GS/CS; AFB #2 : RBC, WBC, diff ct. #3 : protein/sugar #4 phadebact ( test for strep B, H. I influ, strep Pn, N meningitides)

Blood transfusion Orders

        

Secure and transfuse (blood product )to run for hours properly typed and x matched IVF to KVO while ongoing transfusion then Resume present IVF once transfusion is finished watch out for any untoward signs and symptoms such as fever, chills, rashes, DOB, tachycardia hook plain NSS while on BT to run at KVO monitor vs q 15 minutes while ongoing BT give paracetamol __ mg SIVP 1 hr prior to BT Inform PROD once blood product is available For repeat CBC 6 hours post BT (optional) Furosemide at 0.5- 1 mg/kg/dose mid

For BMA Orders            

prepare the ff Materials gloves size_____ eye sheet sterile cotton #1 sterile gauze # 2 glass slides #20 syringe 10 cc #2 5cc syringe #1 betadine #1 lidocaine 2% #2 70% alcohol secure consent pls. and post BT (depends sa AP)

For exchange transfusion orders Pls. prepare the following : French 5 feeding tube #2 3 way stopcock syringe connector sterile bottle 1L 10 cc syringe #2 betadine and alcohol sterile cotton sterile gauze #2 suture with needle note: give calcium gluconate 10% 0.7 ml + 0.7 ml sterile water IV push every 10 exchanges > give furosemide after exchange

Pulse Cyclophosphamide Therapy ( for Systemic Lupus Erythematosus) Pre hydration: - D5W 750 ml to run for 1 hour alternate with D5 0.3 Nacl 750 ml to run fo for 2 doses - Ondansetron (zafran) 8 mg/4ml, 4 mg +50 ml D5W to run for 30 mins - cyclphophamide 1gm (1000 mg) + 100 ml D5W to run for 1 hour Post chemo/ cyclophosphamide hydration - same regulation as pre chemo hydration - ondansetron 4mg + 50 ml D5W for 30mins - Prednisone 20 mg OD after breakfast - TPR q4 and record pls. - I and O q shift - limit sodium intake to 2 g/day - maintain on heplock after 10 hrs. therapy Materials for Triple Intrathecal (TIT) > NPO temp. For 4-6 hours > secure consent > prepare the ff. materials: - sterile gloves size_______ - sterile eyesheet - sterile cotton balls - sterile gauze - sterile water 50 ml #1 - tuberculin syringe #3 - sterile specimen bottle #1 - 2.5 cc syringe #1 >sterile needle g 23 or ___

2 mo–2 yr ACID PHOSPHATASE (Major sources: prostate and erythrocytes) Newborn 7.4–19.4 U/L 7.4–19.4 U/L 2–13 yr 6.4–15.2 U/L 6.4–15.2 U/L Adult male 0.5–11.0 U/L 0.5–11.0 U/L Adult female 0.2–9.5 U/L 0.2–9.5 U/L ALANINE AMINOTRANSFERASE (ALT) (Major sources: liver, skeletal muscle, and myocardium) Neonate/infant 13–45 13–45 U/L U/L Adult male 10–40 10–40 U/L U/L Adult female 7–35 U/L 7–35 U/L ALDOLASE (Major sources: skeletal muscle and myocardium) 10–24 mo 3.4–11.8 U/L 3.4–11.8 U/L 2–16 yr 1.2–8.8 U/L 1.2–8.8 U/L Adult 1.7–4.9 U/L 1.7–4.9 U/L ALKALINE PHOSPHATASE (Major sources: liver, bone, intestinal mucosa, placenta, and kidney) Infant 150–420 U/L 150–420 U/L 2–10 yr 100–320 U/L 100–320 U/L Adolescent males 100–390 U/L 100–390 U/L Adolescent 100–320 U/L 100–320 U/L females Adult 30–120 U/L 30–120 U/L

AMMONIA (Heparinized venous specimen on ice analyzed within 30 min) Newborn 90–150 μg/dL 64–107 μmol/L 0–2 wk 79–129 μg/dL 56–92 μmol/L >1 mo 29–70 μg/dL 21–50 μmol/L Adult 0–50 μg/dL 0–35.7 μmol/L AMYLASE (Major sources: pancreas, salivary glands, and ovaries) Newborn 5–65 U/L 5–65 U/L Adult 27–131 U/L 27–131 U/L ANTINUCLEAR ANTIBODY (ANA) Not significant <1 : 80 Likely >1 : significant 320 Patterns with clinical correlation: Centromere—CREST Nucleolar—Scleroderma Homogeneous—SLE ANTISTREPTOLYSIN O TITER (4-fold rise in paired serial specimens is significant) Preschool <1 : 85 School age <1 : 170 Older adult <1 : 85 NOTE: Alternatively, values up to 200 Todd units are normal. ASPARTATE AMINOTRANSFERASE (AST) (Major sources: liver, skeletal muscle, kidney, myocardium, and erythrocytes) Newborn 25–75 U/L 25–75 U/L Infant 15–60 U/L 15–60 U/L 1–3 yr 20–60 U/L 20–60 U/L 4–6 yr 15–50 U/L 15–50 U/L 7–9 yr 15–40 U/L 15–40 U/L 10–11 yr 10–60 U/L 10–60 U/L 12–19 yr 15–45 U/L 15–45 U/L BICARBONATE Newborn

17–24 mEq/L

17–24 mmol/L

>2 yr

16–24 mEq/L 22–26 mEq/L

BLOOD GAS, ARTERIAL[7] Pao2(mmHg) pH Newborn 7.26– 60 (birth) 7.29 Newborn 7.37 70 (>24 hr) Infant (1–24 7.40 90 mo) Child (7–19 7.39 96 yr) Adult (>19 7.35– 90–110 yr) 7.45

16–24 mmol/L 22–26 mmol/L

Paco2(mmHg)

HCO3−(mEq/L)

55

19

33

20

34

20

37

22

35–45

22–26

BILIRUBIN (TOTAL) Preterm Term Preterm Term Preterm Term Preterm Term Preterm Term Adult Neonate Infants/children CALCIUM (TOTAL) Preterm Full term <10 days 10 days–24 mo 2–12 yr Adult CALCIUM (IONIZED) Newborn <36 hr Newborn 36–84 hr 1–18 yr Adult

Newborn Child/adult

Cord <2 mg/dL <2 mg/dL 0–1 days <8 mg/dL <8.7 mg/dL 1–2 days <12 mg/dL <11.5 mg/dL 3–5 days <16 mg/dL <12 mg/dL Older infant <2 mg/dL <1.2 mg/dL 0.3–1.2 mg/dL BILIRUBIN (CONJUGATED) <0.6 mg/dL <0.2 mg/dL

<34 μmol/L <34 μmol/L <137 μmol/L <149 μmol/L <205 μmol/L <197 μmol/L <274 μmol/L <205 μmol/L <34 μmol/L <21 μmol/L 5–21 μmol/L <10 μmol/L <3.4 μmol/L

6.2–11 mg/dL 7.6–10.4 mg/dL 9.0–11.0 mg/dL 8.8–10.8 mg/dL 8.6–10 mg/dL

1.6–2.8 mmol/L 1.9–2.6 mmol/L

4.20–5.48 mg/dL 4.40–5.68 mg/dL 4.80–5.52 mg/dL 4.64–5.28 mg/dL

1.05–1.37 mmol/L

2.3–2.8 mmol/L 2.2–2.7 mmol/L 2.2–2.5 mmol/L

1.10–1.42 mmol/L 1.20–1.38 mmol/L 1.16–1.32 mmol/L

CHLORIDE (SERUM) 98–113 98–113 mmol/L mEq/L 98–107 98–107 mmol/L mEq/L

CHOLESTEROL (see Lipids) C-REACTIVE PROTEIN (Other laboratories may have 0–0.5 mg/dL different reference values) CREATINE KINASE (CREATINE PHOSPHOKINASE) (Major sources: myocardium, skeletal muscle, smooth muscle, and brain) Newborn 10–200 U/L 10–200 U/L Man 15–105 U/L 15–105 U/L Woman 10–80 U/L 10–80 U/L

Cord Newborn Infant Child Adolescent Man Woman

CREATININE (SERUM) 0.6–1.2 mg/dL 53–106 μmol/L 0.3–1.0 mg/dL 27–88 μmol/L 0.2–0.4 mg/dL 18–35 μmol/L 0.3–0.7 mg/dL 27–62 μmol/L 0.5–1.0 mg/dL 44–88 μmol/L 0.7–1.3 mg/dL 62–115 μmol/L 0.6–1.1 mg/dL 53–97 μmol/L

ERYTHROCYTE SEDIMENTATION RATE (ESR) Term neonate 0–4 mm/hr Child 4–20 mm/hr Adult (male) 1–15 mm/hr Adult (female) 4–25 mm/hr

Newborn 1 mo 2–5 mo 6 mo–15 yr Adult male Adult female

FERRITIN 25–200 ng/mL 200–600 ng/mL 50–200 ng/mL 7–140 ng/mL 20–250 ng/mL 10–120 ng/mL

Newborn Infant 2–16 yr >16 yr

FOLATE (SERUM) 5–65 ng/mL 15–55 ng/mL 5–21 ng/mL 3–20 ng/mL

20–200 ng/mL 200–600 ng/mL 50–200 ng/mL 7–140 ng/mL 20–250 ng/mL 10–120 ng/mL

11–147 nmol/L 34–125 nmol/L 11–48 nmol/L 7–45 nmol/L

γ-GLUTAMYL TRANSFERASE (GGT) (Major sources: liver [biliary tree] and kidney) Cord 19–270 U/L 19–270 U/L Preterm 56–233 U/L 56–233 U/L 0–3 wk 0–130 U/L 0–130 U/L 3 wk–3 mo 4–120 U/L 4–120 U/L 3–12 mo boy 5–65 U/L 5–65 U/L 3–12 mo girl 5–35 U/L 5–35 U/L 1–15 yr 0–23 U/L 0–23 U/L Adult male 11–50 U/L 11–50 U/L Adult female 7–32 U/L 7–32 U/L

Preterm Newborn, <1 day Newborn, >1 day Child >16 yr

HEMOGLOBIN A1 C Adult

Newborn Infant Child Adult male Adult female

MAGNESIUM METHEMOGLOBIN OSMOLALITY

GLUCOSE (SERUM) 20–60 mg/dL 40–60 mg/dL 50–80 mg/dL 60–100 mg/dL 74–106 mg/dL

1.1–3.3 mmol/L 2.2–3.3 mmol/L 2.8–4.5 mmol/L 3.3–5.6 mmol/L 4.1–5.9 mmol/L

Conventional Units 1.3–2.0 mEq/L <1.5% total Hgb 275–295 mOsm/kg

KETONES (SERUM) 0.5–3.0 mg/dL

Newborn Child

LACTATE Capillary blood <27 mg/dL 5–20 mg/dL

Venous Arterial

5–20 mg/dL 5–14 mg/dL

17.9–44.8 μmol/L 7.2–17.9 μmol/L 9.0–21.5 μmol/L 11.6–31.3 μmol/L 9.0–30.4 μmol/L

Sl Units 0.65–1.0 mmol/L 275–295 mmol/kg

5–30 mg/L

0.0–3.0 mmol/L 0.56–2.25 mmol/L 0.5–2.2 mmol/L 0.5–1.6 mmol/L

LACTATE DEHYDROGENASE (AT 37°C) (Major sources: myocardium, liver, skeletal muscle, erythrocytes, platelets, and lymph nodes) 0–4 days 290–775 U/L 290–775 U/L 4–10 days 545–2000 U/L 545–2000 U/L 10 days–24 mo 180–430 U/L 180–430 U/L 24 mo–12 yr 110–295 U/L 110–295 U/L >12 yr 100–190 U/L 100–190 U/L

0–90 days 3–12 mo 1–11 yr >11 yr

LIPASE 10–85 U/L 9–128 U/L 10–150 U/L 10–220 U/L

LIPIDS [8] Cholesterol (mg/dL)

Child/a dolesc ent Adult

Desira ble <170

Borde rline 170– 199

<200

200– 239

Preterm Newborn Adult

Newborn 10 days–24 mo 24 mo–12 yr >12 yr

5.0–7.5% total Hgb <2.0 IRON 100–250 μg/dL 40–100 μg/dL 50–120 μg/dL 65–175 μg/dL 50–170 μg/dL

Quantitative

Newborn Infant Child Adult

Newborn 1–6 mo 6 mo–4 yr 4–6 yr 6–19 yr

High

LDL (mg/dL)

>200

Desir able <110

Borde rline 110– 129

Hig h >13 0

>240

<100

100– 159

>16 0

PHENYLALANINE 2.0–7.5 mg/dL 1.2–3.4 mg/dL 0.8–1.8 mg/dL PHOSPHORUS 4.5–9.0 mg/dL 4.5–6.7 mg/dL 4.5–5.5 mg/dL 2.7–4.5 mg/dL POTASSIUM 3.7–5.9 mEq/L 4.1–5.3 mEq/L 3.4–4.7 mEq/L 3.5–5.1 mEq/L PREALBUMIN 7–39 mg/dL 8–34 mg/dL 2–36 mg/dL 12–30 mg/dL 12–42 mg/dL

121–454 μmol/L 73–206 μmol/L 48–109 μmol/L

1.45–2.91 mmol/L 1.45–2.16 mmol/L 1.45–1.78 mmol/L 0.87–1.45 mmol/L

3.7–5.9 mmol/L 4.1–5.3 mmol/L 3.4–4.7 mmol/L 3.5–5.1 mmol/L

HDL (mg/d L) Desir able 45

45

PYRUVATE RHEUMATOID FACTOR

SODIUM 130–140 mEq/L 133–146 mEq/L

Preterm Older

Infant Adult

Conventional Units 0.3–0.9 mg/dL <30 U/mL

Sl Units 0.03–0.10 mmol/L

130–140 mmol/L 133–146 mmol/L

TOTAL IRON-BINDING CAPACITY (TIBC) 100–400 μg/dL 17.9–71.6 μmol/L 250–425 μg/dL 44.8–76.1 μmol/L

Newborn 3 mo–10 yr Adult

Premature (<1 week) Newborn Infant/child Adult

TRANSFERRIN 130–275 mg/dL 203–360 mg/dL 215–380 mg/dL

1.30–2.75 g/L 2.03–3.6 g/L 2.15–3.8 g/L

UREA NITROGEN 3–25 mg/dL

1.1–8.9 mmol/L

4–12 mg/dL 5–18 mg/dL

1.4–4.3 mmol/L 1.8–6.4 mmol/L

6–20 mg/dL

2.1–7.1 mmol/L

URIC ACID 2.4–6.4 mg/dL

0.14–0.38 mmol/L

2–12 yr 12–14 yr

2.4–5.9 mg/dL 2.4–6.4 mg/dL

0.14–0.35 mmol/L 0.14–0.38 mmol/L

Adult male

3.5–7.2 mg/dL

0.20–0.43 mmol/L

Adult female

2.4–6.4 mg/dL

0.14–0.38 mmol/L

0–2 yr

VITAMIN A (Retinol) Preterm Full term

13–46 μg/dL 18–50 μg/dL

0.46–1.61 μmol/L 0.63–1.75 μmol/L

1–6 yr 7–12 yr 13–19 yr

20–43 μg/dL 20–49 μg/dL 26–72 μg/dL

0.7–1.5 μmol/L 0.9–1.7 μmol/L 0.9–2.5 μmol/L

(Thiamine)

(Riboflavin)

Newborn Child/adult

(Ascorbic acid)

(1,25-dihydroxyvitamin D)

<11 yr >11 yr

VITAMIN B1 5.3–7.9 μg/dL VITAMIN B2 4–24 μg/dL

0.16–0.23 μmol/L

106–638 nmol/L

VITAMIN B12 (Cobalamin) 160–1300 pg/mL 200–835 pg/mL

118–959 pmol/L

VITAMIN C 0.4–1.5 mg/dL

23–85 μmol/L

VITAMIN D3 16–65 pg/mL

42–169 pmol/L

VITAMIN E 3–15 mg/L 5–20 mg/L

148–616 pmol/L

7.0–35 μmol/L 11.6–46.4 μmol/L

ZINC 70–120 mg/dL

10.7–18.4 mmol/L

Age 26-30 wk 28 wk 32 wk Term ( cord ) 1-3 D 2 wk 1 mo 2 mo 6 mo 6 mo - 2 yr 2 - 6 yr 6 – 12 yr 12 – 18 yr Male Female Adult Male Female Age Birth 12 hrs 24 hrs 1 wk 2 wk 1 mo 6 mo 1 yrs 2 yrs 4 yrs 6 yrs 8 yrs 10 yrs 16 yrs 21 yrs

Age specific blood cell indices Hb (g%) Ht WBC 13.4 41.5 4.4 14.5 45 15 47 16.5 51 18.1 ( 9-30) 18.5 56 18.9 (9.4-34) 16.6 53 11.4 (5-20) 13.9 44 10.8 (4-19.5) 11.2 35 12.6 36 11.9 (6-17.5) 12 36 10.6 (6-17) 12.5 37 8.5 (5-15.5) 13.5 40 8.1 (4.5-13.5)

Plt 254 (180-327) 275 290 290 192 252 150-350 150-350 150-350

14.5 14

43 41

7.8 (4.5-13.5) 7.8 (4.5-13.5)

150-350 150-350

15.5 14

47 41

7.4 (4.5-11) 7.4 (4.5-11)

150-350 150-350

Wbc 9-30 13-38 9.4-34 5-21 5-20 5-19.5 6-17.5 6-17.5 6-17 5.5-15.5 5-14.5 4.5-13.5 4.5-13.5 4.5-13 4.5-11