General Pediatrics I

Normal Growth Pattern

0-1 year: double birth weight by 4 months, triple by 1 year; increase length 50% and occipital frontal circumference 40% by 1 year
2-6 years: slow but steady growth; gain ~2-3 kg/year and 5-8 cm/year
7-10 years: continued steady growth; girls increase in

Occipital Frontal Circumference

Microcephaly -> OFC > 2 SD below mean for age and sex
Macrocephaly -> OFC > 2 SD above mean for age and sex

Age Based Milestones

Holding head upright: 3 months
Sitting upright: 6 months
Walking: 12 months
Running: 18 months
Jumping: 24 months

Breastmilk

At least for the first 6 months
Documented medical and neurodevelopmental advantages

Breastfeeding Benefits to Mom

Increased calorie utilization
Decreased uterus size
Decreased breast cancer risk
Convenient
$$$
Improved maternal-infant bond

Breastfeeding Benefits to Baby

Faster GI emptying
Decreased GI diseases and/or adverse effects
Immunoprotective
Decreased allergies: food and atopic dermatitis
Improved maternal-infant bonding

Formula

Main source of nutrition
Supplmentation of breastfed babies
Variety of formulas

Supplements

Preterm: iron and multivitamin
Breastfed: vitamin D and iron
Formula fed: vitamin D

Gastroesophageal Reflux (GER)

Retrograde movement of gastric contents across the lower esophageal sphincter into the esophagus

GER: treatment

Once proven to have GERD
Symptomatic + poor weight gain
Non-pharm -> H2RA -> PPI for shortest duration

Dosing

Individualized weight based or body surface area dosing:
mg/kg/dose, mg/kg, day, mg/m2
Body Surface Area (BSA):
less accurate in infants, larger BSA per kg compared to adults
Adult does at ~40 kg

Filling Prescriptions

Calculate the dose independently:
Ask parent for weight
Call physician's office for weight

Formulations: Liquid

Use metric dosing with mL
Never use kitchen spoons
Infants: administer with head upright
Child: administer sitting up
Spitting/vomiting dose: partial dose if >15 minutes

Formulations: Chewable Tablets

~2 years and older
Advantages:
Palatability
Stability
Precise dosing
Portability
Ease of administration

Formulations: Tablets and Capsules

Usually > 5 y.o.
Choking hazard
Verify if tablet/capsule can be crushed or opened
Disease states may require learning to swallow tablets and capsules earlier: cystic fibrosis

Oral Syringe

Ideal for infants who cannot drink from cup
Deliver to side of mouth to avoid taste buds
Can pre-measure for caregivers/babysitters (with cap)
Allows delivery of viscous liquids
Mark syringe for dose and demonstrate how to use

Droppers

Useful in infants unable to drink from a cup
Deliver to side of mouth to avoid taste buds
Droppers come with many medications: use only with designated medication

Medicine Spoon

Convenient for children who can drink from a cup but likely to spill
Easy to hold
Has both mL and tsp (should use mL when educating)

Medicine Cup

Convenient for older children
Not graduated for infant doses
Many OTC medications come with a cup

Guidelines by Volume

< 1 mL: dropper or 1 mL syringe
1-5 mL: 1-5 mL syringe or spoon
> or = 5 mL: 10-20 mL syring, spoon, or cup

EpiPen

Indicated for severe allergic reactions (anaphylaxis)
Two EpiPen products available based on patients weight: 15-29 kg give 0.15 mg or > or = 30 kg give 0.3 mg
Each EpiPen product contains a single dose of medication

Auvi-Q

Provides voice instructions and has an auto-retractable needle

ISMP Warning

Increased errors reported with homemade kits:
Given IV instead of IM
Gave whole 1 mg contained in vial/ampule

Subcutaneous Injections

Insulin pens most common
Avoid in neonates
Insulin syringes used for non-insulin products: enoxaparin, desmopressin, injections with small volumes (< 1 mL)

Enoxaparin

Comes as a 100 mg/mL solution or prefilled syringe
Smallest prefilled syringe is 30 mg

Enoxaparin Education to Parents

General technique (swab vial, new syringe each time, etc...)
Draw up to 15 units on insulin syringe
Consider marking 1 syringe for reference
Proper disposal of used syringes

FDA Pregnancy Categories

A: no risk in human studies
B: no risk in animal studies but no human studies done; or animal studies show risk but none demonstrated in human studiese
C: risk in animal studies but no human studies done. Benefits may outweigh risks
D: human studies demon

Transfer into Breastmilk

Small size
Weak base
Low binding
Lipid soluble

Prolactin

Promotes synthesis of milk

Oxytocin

Promotes ejection of milk

Dopamine

Inhibits prolactin release

Decreases Milk Supply

Dopaminergic agents (ergots, levodopa): inhibit prolactin release
Hormones (estrogen, androgen): block prolactin effect
Vasoconstrictors: decrease blood flow to breast

Increases Milk Supply

Dopamine antagonists (metoclopramide, neuroleptics): inhibit dopamine secretion
Methyldopa: false dopamine precursor
H2RA, fenfluramine, tryptophan: increase serotonergic transmission