PEDIATRICS OSCE 3.

PROPERLY TIMED CORD CLAMPING (1-3 min)

Delayed cord clamping 2-3 min after birth or until
I. Essential Intrapartum Newborn Care cord has stopped pulsating
II. Newborn Resuscitation Benefits
III. Breastfeeding and Complementary Prevents anemia
Feeding Improves oxygen supply to the brain in preterms
IV. Immunization Decreases risk of brain bleeds or intraventricular
V. Growth Indicators and Developmental hemorrhage in preterms
Milestones Decreases risk of late-onset sepsis in preterms
VI. Neonatal Sepsis
VII. Acute Bacterial Meningitis 4. NON-SEPARATION OF NEWBORN FROM MOTHER FOR
VIII. BFS EARLY BREASTFEEDING (90 min)
IX. PCAP
X. UTI Monitor mother and baby regularly in the first 1-2
XI. Dengue and Viral Exanthemns hours
XII. Nephrotic-Nephritic
NON TIME-BOUND (90 min to 6 hours)
XIII. Fluids and Electrolytes
XIV. Rheumatic Fever 1. Vitamin K Administration (1 mg IM)
XV. Asthma 2. Eye care (Erythromycin ointment 0.5%)
XVI. Pulmonary TB 3. Immunization (Hepatitis B intramuscular and BCG
XVII. Medications intradermal)
4. Weighing
5. Washing
ESSENTIAL INTRAPARTUM NEWBORN CARE

TIME-BOUND

1. IMMEDIATE AND THOROUGH DRYING (< 30 sec)

Dry baby to stimulate breathing and to avoid
hypothermia
Drying should be the first action immediately for
a full 30 seconds
Hypothermia can lead to:
Infection
Coagulation defects
Acidosis
HMD
Delayed fetal to newborn circulatory adjustment
Brain hemorrhage

2. EARLY SKIN-TO-SKIN CONTACT (>30 sec)

Place the baby on mothers chest or abdomen

Reasons:
Breastfeeding success
Lymphoid tissue system stimulation
Exposure to maternal skin flora prevents
hypoglycemia
Thermoregulation
Mother baby bonding
 8-10: good cardiopulmonary adaptation followed by primary apnea and dropping heart rate
4-7: need for resuscitation, especially ventilator support that will improve with tactile stimulation; if oxygen
0-3: need for immediate resuscitation deprivation continued, secondary apnea ensues,
Rapid assessment of newborn accompanied by continued fall in heart rate and
blood pressure
Term gestation?
Secondary apnea cant be reversed by stimulation,
Crying or breathing?
assisted ventilation must be provided
Good muscle tone?
Free flow oxygen is indicated for central cyanosis
ET Tube indications: BREASTFEEDING AND COMPLEMENTARY FEEDING
Initial endotracheal suctioning of nonvigorous
meconium stained newborns
Allow baby to suck 15-30 minutes per breast to
If bag mask ventilation is ineffective or prolongef
extract both foremilk and hindmilk
When chest compressions are performed
Exclusive breastfeeding for minimum of 4 months
and preferable for 6 months
Chest compressions
Indicated for heart rate that is < 60 per minute despite Absolute Relative
adequate ventilation with supplementary oxygen after Contraindications Contraindications
30 seconds Galactosemia Active TB infection
Maternal use of until 2 weeks of
PPV indications illegal drugs, therapy
Apnea/gasping antineoplastic agents Maternal HIV
HR < 100 and Herpes infection: if
radiopharmaceuticals with active herpetic
Persistent central cyanosis despite 100% free flow
lesions of the breast
oxygen
Medications:
Recommended breastmilk storage:
Bradycardia in newborn is usually result of inadequate
o Room temp (<25): 4 hours
lung inflation or profound hypoxemia and establishing
o Room temp (>25): 1 houra
adequate ventilation is most important step to correct it
o Refrigerator (4 C): 8 days
Route and dose of epinephrine administration:
o Freezer compartment of 1 door ref: 2 weeks
RD: 0.01 TO 0.03 mg/kg per dose
o Freezer compartment of 2 door ref: 3 months
Higher IV doses may cause exaggerated
o Deep freezer (-20 C): 6 months
hypertension, decreased myocardial function,
Complementary feeding
and worse neurological function
o Begin one new food at a time to be given
Endotracheal route: 0.05-0.1
for 3 days
Volume expansion: isotonic crystalloid solution or
o 6 mos: Start with PUREED FOOD
blood: Dose of 10 ml/kg
o 8 mos: FINGER FOODS
Keypoints: o 10 mos: LUMPY OR CHOPPED FOOD
o 12 mos: TABLE FOOD
The most important and effective action in o 6-8 months old: feed 2-3 times a day
neonatal resuscitation is to ventilate the babys o 9-24 months old: 3-4 times a day
lungs o Do not add salt to infants diet before one
Lack of ventilation of the newborns lungs result in year of age
sustained constriction of the pulmonary arterioles,
preventing systemic arterial blood from being IMMUNIZATION
oxygenated Two types:
When a newborn becomes deprived of oxygen, an
initial period of attempted rapid breathing is 1. Active immunization
Antibodies peaks at 5-7 days
 2. Passive immunization One dose of measles (9 months or before 12
Immunoglobulin peaks at 48-72 hours months)
3 doses of Hep B with at least 4 weeks interval
Inactivated Vaccines Live Vaccines
between doses
Hep B BCG vaccine
DPT Measles vaccine Recommended Age Vaccine
HIB MMR vaccine Birth Hep B1; BCG
Pneumococcal vaccine Varicella vaccine 1 mo Hep B2
Hepatitis A vaccine Rotavirus vaccine 2 mo DPT 1, OPV 1, HIB 1, Rotavirus 1,
Meningococcal vaccine Oral Typhoid vaccine PCV1
Influenza trivalent vaccine 4 mo DPT 2, OPV2, HIB2, ROTAVIRUS2,
HPV PCV 2
Typhoid fever (IM) 6 mo HEP B3, DPT3 ,OPV3, HIB 3,
Ravies ROTAVIRUS 3, PCV3
IPV 9 mo MEASLES

Important point to remember

Beyond 1 yr old Recommendations
Vomiting within 10 minutes of receiving an oral 15 mo MMR Given 6 months
dose is an indication for repeating the dose after the 1st
measles vaccine
Children younger than 1 year of age: anterolateral
18 mo DPT, OPV First booster
aspect of thigh
dose (12 months
Older children: deltoid muscle is usually large after 3rd dose)
enough 4-6 yo DPT, OPV, MMR 2nd booster dose
4 weeks interval: 2 live attenuated vaccines 11-18 yo Td (Tetanus Repeat every 10
Cholera and yellow fever vaccines shouldnt be toxod) yrs of life
given together or 1-3 weeks apart
FULLY IMMUNIZED CHILD
BCG Birth, anytime after or 6 weeks
1 dose of BCG
Dose: 0.05 ml for newborn
3 doses of DPT and Polio with at least 4 weeks
0.1 ml for older infant
interval between each dose > 2 mo: PPD should be done prior to BCG
3-8 weeks later: orange-peel appearance
 DTP ARTHUS REACTION: hyperimmune person
Whole cell Pertussis component: increase risk
for neuroparalytic reaction thus not
recommended after age of 6 yo
Hep B given within 12 hours of life
if mother is HbsAg + HBV and HbIg given at
birth within 12 hours
Measels Route: Subcutaneous
Given 9 months but can be given as early as 6
months in cases of outbreaks

Absolute Contraindication Relative Contraindication

Severe anaphylactic shock Immunosuppresive
therapy (all live vaccines)
Moderate to severe illness Egg allergy (MMR)
with or without fever
Encephalopathy within 7
days of administration
(Pertussis)
Immunodeficieny in
patient
Pregnancy (MMR, OPV) WEIGHT
Birthweight 3 kilos
When to bring patient to ER after immunization? 4th-5th month DOUBLES (6 kg)
1 year old TRIPLE (9 kg)
ISEAT
2 years old QUADRUPLES (12 kg)
I: Inconsolable cry
S: Seizure
E: Encephalopathy LENGTH
A: Anaphylaxis Birth length 50 cms
T: Temp > 40.5 1 year old 75 cms
*Always prescribe paracetamol because you will expect 2 yo of their ultimate
the patient to be feverish after immunization adult height

Growth Indicators
HEAD CIRCUMFERENCE
Height for age: determine stunted patient HC at birth 33-35 cms
Weight for age: determine underweight 1 yo 45 cms
patient
Weight for length: wasted or obese Mnemonics for weight
BMI: determine if patient is overweight/obese 0-6 mo Age in months x 600 + BW
6-12 mo Age in months x 500 + BW
1-6 yrs Age in years x 2 + 8
7-12 yrs (Age in years x 7)-5
2
Mnemonics for height 6 months Babbling
0-3 mo BW + 9cm 9 months Mama/papa
4-6 mo BW + 9cm + 8 cm 10 months Points to objects
7-9 mo BW + 9cm + 8 cm + 5 cm 12 months Single word with meaning
10-12 mo BW + 9cm + 8 cm + 5 cm+ 3 CM 4 yo Complete sentences

2-12 YO Age in years x 6 + 77 RECEPTIVE LANGUAGE

3 months Alert to human voice

Mnemonics for HC 6 months Localize to sound

9 months Understands NO
1st 4 mo inches per month
12 months Follow 1 step command with
Next 8 mos: inches per month
gesture
2 yo 1 inch 24 months Able to follow 2 step commands
3-5 yo inches per year 4 yo Dress independently
6-20 yo inches per 5 years 5 yo Help in household chores

NEONATAL SEPSIS
DEVELOPMENTAL MILESTONE

GROSS MOTOR
3 months Head hold
5 months Roll over
7 months Sitting
9 months Pull to stand
12 months Walk Independently
16 months Run
24 months Jump with both feet
3 yo Jump forward
Pedal tricycle
4 yo Hop
5 yo Skip
FINE MOTOR
3 months Unfisted hand Risk factors:
5 months Midline hand play maternal infection during pregnancy
7 months Transfer object from one hand
prolonged rupture of membranes (18
to another
9 months Thumb-finger grasp hrs)
12 months Voluntary release prematurity
13 months scribbles Common organisms:
15 months Builds 2 towers
3 yo Handedness Bacteria:
4-4.5 yo Draw square GBS
5 yo Draw Triangle E. coli
EXPRESSIVE LANGUAGE Listeria monocytogenes
3 months Cooing Viruses
 HSV
Enteroviruses

Signs and symptoms
Fever temp instability
Not doing well
Poor feeding
Edema
Hypothermia (ominous sign)
Tx: Empiric Antibiotics
Ampicillin + 3rd generation
cephalosporin or aminoglycoside
NOSOCOMIAL SEPSIS
Coagulase-negative Staphylococci
(especially Staphylococcus epidermidis
Gram-negative rods (including
Pseudomonas, Klebsiella, Serratia, and
Proteus) and fungal organisms
predominate.
Viruses: enteroviruses, CMV, hepatitis A,
adenoviruses, influenza, respiratory
syncytial virus (RSV), rhinovirus,
parainfluenza, HSV, and rotavirus.
Sclerema neonatorum
is a rare and severe skin condition that
is characterized by diffuse hardening of
the subcutaneous tissue with minimal
inflammation
Indicative of neonatal sepsis
LABORATORIES STUDIES
Evidence of infection
CULTURE (BLOOD, CSF)
DEMONSTRATION OF MICROORGANISM IN
TISSUE/ FLUID
MATERNAL / NEONATAL SEROLOGY (TORCH)
ANTIGEN DETECTION TEST (URINE/CSF)
GRAM STAINING
o especially helpful for the study of CSF.
o WBC in the samples can be maternal in
origin, and their presence along with
bacteria indicates exposure and possible
colonization but not necessarily actual
infection
 Evidence of inflammation 3rd-7th day onset Jaundice first recognized
1. leukocytosis, increase immature/ total neutrophil after 1st week of life
count ratio Bacterial sepsis Breastmilk Jaundice
a. NV of WBC count in neonates: 9,000 30,000 UTI Septicemia
b. Immature neutrophil-mature neutrophil ratio Enterovirus Congenital atresia
should not be >0.2 Syphilis Hepatitis
2. acute phase reactant: Toxoplasmosis Galactosemia
a. C- reactive protein (CRP)- at 24 hrs with CMV Hypothyroidism
suspicion (in the liver); Erythrocyte Enzyme deficiencies
Sedimentation Rate (ESR)
Congenital hemolytic
3. pleocytosis in csf or pleural fluid
4. DIC: fibrin split products
anemia
5. cytokines: Interleukin-6
Evidence of multi organ systemic disease Breastfeeding Breast milk
a. metabolic acidosis; pH pCO2 jaundice jaundice
b. pulmonary function: pO2, pCO2 Onset 1st 3-5 days of 1st to 2nd
c. renal function: BUN, creatinine
life week of life
d. hepatic injury/ function: bilirubin, PT
e. bone marrow function: neutropenia, anemia, Incidence 12-13% 2-4%
thrombocytopenia Cause Inadequate Due to
supply of unidentified
NEONATAL JAUNDICE breastmilk factors in
leasing to breastmilk,
Physiologic Pathologic increased probably free
Presents after the Presents in the 1st 24 enterohepatic fatty acids;
48th hour of life hours of life circulation breast milk
TB increases not > 5 TB increases by > 0.5 may contain
mg/dl/day mg/dl/hr an inhibitor
TB peaks at 14-15 TB increases to > 15 of bilirubin
mg/dl mg/dl conjugation
DB < 10% of TB DB > 10% TB TX Increasing Increasing
Resolves in 1 week Persists beyond 1 breastfeeding breastfeeding
(term), 2 weeks week (term), 2 frequency to 8- frequency; at
(preterm) weeks (preterm) 10 times per day times,
perform
Pathologic jaundice 2nd-3rd day onset phototherapy
Erythroblastosis Breastfeeding jaundice Kramer Classification
fetalis Crigler-Najjar syndrome Head and neck: 6-8 mg/dl
Concealed Upper trunk: 9-12 mg/dl
hemorrhage Lower trunk, Thigh:12-16 mg/dl
Sepsis Arms: 13-15 mg/dl
TORCH Hands & Feet: > 15 mg/dl
 ACUTE BACTERIAL MENINGITIS
Etiology:
1st 2 mo:
o GBS, Gram negative enteric
bacilli, Listeria monocytogenes
2 months-12 years:
o S. pneumonia, H. influenza, N.
meningitides
Mode of transmission:
Hematogenous dissemination of
microorganisms from a distant site of
infection
Manifestations:
Headache, nausea, vomiting, anorexia,
restlessness, irritability, fever, neck pain,
rigidity, obtundation, coma, focal neurologic
deficits (vascular occlusion)
Why is there neck rigidity?
3. Signs and symptoms of impending
cerebral herniation in child with
probable meningitis
4. Severe cardiopulmonary compromise
(Cricital illness)
5. Infection of the skin overlying the site
6. Thrombocytopenia with platelet count
<20x109/L
CSF findings consistent of bacterial meningitis
Pleocytosis
High CSF protein level
Low CSF sugar
Treatment:
N meningitides: Penicillin IV for 5-7 d
S. pneumonia: 3rd gen cephalosporin or
Penicillin IV for 10-14 days
Pen resistant: Vancomycin
H influenza meninigitidis:
Dexamethasone IV

Inflammation of spinal nerves and roots VIRAL MENINGITIS

produce meningeal signs of irritation Etiology:

Complications: Echovirus
Coxsackie virus
Hydrocephalus: acute complication Adenovirus
(communicating type) CMV
Subdural effusions due to continued HSV
transudation
SIADH: may exacerbate cerebral edema->
hyponatremic seizures CSF findings:
Why do seizures occur? Normal glucose
Cerebritis, infarction, or electrolyte losses Normal to slightly increased protein
Lymphocytosis
Contraindications to LP
1. Suspected mass lesion of the brain
especially in posterior fossa
2. Suspected mass lesion of spinal cord
 BENIGN FEBRILE SEIZURES
Occur between age 6-60 mo with a temp of 38
C or higher that are not result of CNS infection
or any metabolic imbalance and that occur in
the absence of a history of prior afebrile
seizure
Major risk factor of recurrence of FS
Age < 1 yr
Duration of fever < 24 hrs
Fever 38-39 C
< 12 mo: LP is recommended after their first
febrile seizure

12-18 m0: should be considered for LP since

the clinical symptoms of meningitis may be
subtle in this age group
> 18 mo: LP is indicated in the presence of
clinical signs of meningitis

Seizure Tremors
 Chaotic, no pattern Rhythmic alternating
of movements, may movements of equal
be limited to a limb duration and
or multifocal amplitude usually
bilateral
Not influence by Exaggeration of
stimulation movements
No passive control With passive control
Other seizure None, except for
manfiestations autonomic
especially tonic eye symptoms like
movements tachycardia,
sweating
Frequently abnormal Normal

PCAP

Predictors of PCAP in patient with cough

3 mo-5 years:
tachypnea + chest indrawing
5-12 yo:
fever, tachypnea, crackles
> 12 yo:
fever, tachypnea, and tachycardia and at least
one abnormal chest findings of diminished BS,
rhonci, crackles or wheezes
 SSx CXR, CBC Tx
Viral Cough Diffuse streaky supportive
Whezzing infiltrates;
Stridor lymphocytsosis
Bacterial Cough, Lobar 0-2 mo:
high fever, consolidation, Ampi+
dyspnea, neutrophilia Aminoglycoside
dullness
to 2 mo-5 yo:
percussion Ceftriaxone or
Cefuroxime
+Ampicillin ot
Amoclav
Mycoplasma Less-ill Interstitial > 5 yo
looking, pattern usually Ezithromycin
non lower lobes Clarithromycin
productive Azithromycin
cough
Chlamydia 6 wks-6 Hyperinflation, Erythromycin
mos ground glass PO x 14 days
Staccato appearance,
cough eosinophilia
Maternal
hx of
infection
 Ocassionally diarrhea
URINARY TRACT INFECTION Cystitis:

< 1 yo: male Gross hematuria and dysuria; urgency,

> 1 yo: female
Usual organisms: E. coli, Klebsiella, Proteus
3 forms:
1. Pyelonephritis
2. Cystitis
3. Asymptomatic Bacteriuroa
Prevalence during the first year of life
Proper collection of urine:
1. For infants below 1 yo: suprapubic tap is
recommended
2. A catheterized urine is a good alternative to
obtain urine specimen
3. Midstream urine catch collection for
cooperative patients- older girls, circumcised
boys, and older boys whose foreskin is easily
retracted
Midstream clean void:
Asymptomatic patients at least 2 specimens on
different days with 105 CRU of the same pathogen
Clinical pyelonephritis
Is the most common serious bacterial infection
in infants <24 mo of age who have fever
without an obvious focus
Characterized by any or all of the ff:
Abdominal , back or flank pain
Fever
Malaise
Nausea and vomiting
frequency, malodorous urine, incontinence,
suprapubic pain
Usually resolves within 1 week
doesnt cause fever and doesnt result in
renal injury
Acute hemorrhagic cystitis often is caused by
E. coli and also attributed to adenovirus types
11 and 21
Asymptomatic bacteriuria
Refers to a condition in which there is a
positive urine culture without any
manifestations of infection
UTI
If culture shows > 100,000 colonies of a single
pathogen
10,000 colonies and child is asymptomatic
TMP-SMX: usually given before the result of C/S are
available
Acute febrile infection suggesting pyelonephritis:
10-14 day course of broad-spectrum antibiotics
capable of reaching significant tissue levels is
preferable
Parenteral treatment with ceftriaxone,
cefotaxime, or ampicillin with an
aminoglycoside is preferable
Treatment with aminoglycoside is particularly
effective against Pseudomonas spp and alkalinization
of urine with sodium bicarbonate increases its
effectiveness in the urinary tract
Treatment
Oral: Cefexime 8 mkd x 2 dose
Cephalexin 50-110 mkd x 4 doses
IV: Ceftriaxone 75 mkd OD
Ampicillin 100 mkd q6h
DENGUE