Ghai Essential Pediatrics8th

Ganciclovir. 10 mg/kg/day IV q 12 hr for 14-21 days; longterm 6 mg/kg/dose once daily for 5 days in a week. Side effects: Bone marrow depression, rash, fever and vomiting.

Valganciclovir. 450 mg/m2/day or 30 mg/kg/day for 14-21 days.

Isoprinosine. Subacute sclerosing panencephalitis: 50-100 mg/kg/day q 12 hr oral.

INTERFERONS

Interferon alpha

Chronic hepatitis B: 3-10 million units/m2 thrice a week SC for 24 weeks.

Chronic hepatitis C: Same dose with oral ribavirin for 24 weeks for genotypes 2 and 3;for 48 weeks for genotypes 1 and 4.

Pegylated interferon alpha 2b Chronic hepatitis C: 60 µg/m2 once a week SC with ribavirin for 24 weeks in genotype 2 and 3;treatment for 48 weeks for genotypes 1 and 4.

Side effects: Flu-like symptoms, headache, bodyache, malaise, fever and chills, angioedema, urticaria, skin blis­ tering or peeling; bone marrow depression; mood dis­ orders; sepsis; seizures;arrhythmia and arthritis.

ANTICANCER DRUGS

The details are provided in Chapter 20.

ANTICOAGULANTS

Heparin. IV: 50 U/kg bolus; followed by 10-25 U/kg/hr as infusion or 50-100 U/kg/dose q 4 hr. SC. 25-50 U/kg q 12 hr. Antidote. Protamine sulfate (1 mg neutralizes 1 mg heparin) Side effects: Rash, alopecia, excessive bleeds and thrombocytopenia.

Enoxaparin. Infants <2 months: Prophylaxis: 0.75 mg/kg/ dose q 12 hr; therapy: 1.5 mg/kg/dose q 12 hr. Older children. Prophylaxis: 0.5 mg/kg/doseq 12 hr;treatment: 1 mg/kg/dose q 12. Dosage titration with antifactor Xa level. Side effects: Bleeding, hypertension; use cautiously in patients with renal disease.

Warfari11. 0.05-0.34 mg/kg/day PO. Adjust dose to maintain international normalized ratio (INR) 2-2.5. Side effects: Bleeding, epistaxis and internal hemorrhage.

ANTICONVULSANTS

The details of doses are provided in Chapter 18.

ANTIDOTES

Ipecac syrup. Infants: 5-10 ml/dose;others 15-20 ml/dose. Do not use in semi-comatose child or after charcoal administration.

Rational Drug Therapy -

Deferoxamine. 20 mg/kg IM, IV; slow SC infusion q 6 hr. Dose adjusted based on response. Side effects: Hypotension, shock, cramps, diarrhea. Contraindicated in renal failure.

Dimercaprol. 2.5 mg/kg PO q 4 hr on first day, q 6 hr on next 2 days, q 12 hr for 10 days;andq 24 hr for 10 days. Side effects: Burning sensation, muscle aches, fever, hemolysis in G6PD deficiency.

Edetate, calcium disodium. 12.5-30 mg/kg/dose IVq 12 hr for 5 days. Side effects: Proteinuria and hematuria.

Methylene blue. 1-2 mg/kg/dose IV (in 5 min). Nalorphine. 0.1 mg/kg/dose IM and IV.

Naloxone. 0.1 mg/kg/dose IM or IV; repeat if needed (maximum 2 mg).

Penicillamine. 20-40 mg/kg/dayq 6-12 hr PO. Side effects:

Nephrotoxic, hepatotoxic, leukopenia, thrombocytopenia, cataract and bleeding diathesis.

Digoxin specific Fab antibody. IV infusion;60 mg binds 1 mg of digoxin approximately.

Pralidoxime. 25-50 mg/kg IM or IV as 5% solution over 15-30 min. The dose may be repeated at 1-2 hr and then at 10-12 hr intervals if cholinergic signs recur. For continuous infusion 9-19 mg/kg/hr after the initial bolus 25-50 mg/kg.

ANTIEMETICS AND GASTROINTESTINAL

MEDICATIONS

Domperidone. 0.2--0.5 mg/kg/doseq 6-8 hr;do not exceed 2.4 mg/kg/day or 80 mg. Side effects: Extrapyramidal disorders; angioedema, urticaria; rarely agitation, nervousness, arrhythmias, gynecomastia and amenorrhea.

Metoclopramide. 0.1--0.2 mg/kg/doseq 6-8 hr orally or IV; maximum dose 10 mg. Side effects: Extrapyramidal disorders including oculogyric crisis, tardive dyskinesia and dystonia;drowsiness;allergic reactions.

Ondansetron hydrochloride. IV: 0.15-0.2 mg/kg/dose q 8-12 hr;oral: 1.2-4 mg/doseq 8-12 hr. Side effects: Head- ache, diarrhea, constipation, occasionally fever and rash.

anorexia, blurred vision; rarely fever, jaundice, tremors, tinnitus, seizures, hallucinations and anxiety.

Ranitidine. 2 mg/kg/day PO, IM or IVq 12 hr. Side effects: Renal impairment.

famotidi11e.1-l.2 mg/kg/day, POq 12 hr;maximum daily dose 40 mg.

Omeprazole. Children 5 to 10 kg: 5 mg OD, 10 to 20 kg: 10 mg OD, 20 kg or more: 20 mg OD. Side effects: Headache,

generalfeelingof being unwell, dizziness,confusion,light­ headedness and tiredness.

Lansoprazole. Less than 30 kg: 15 mg, more than/equal to 30kg: 30 mg. Side effects: Well tolerated, side effects as omeprazole.

Rabeprazole. Efficacy not established in pediatric patients. Side effects: Headache, nausea and vomiting, rarely rash, dizziness and seizures.

Sucralfate. l month-2 yr: 250 mg 4-6 hr; 2-12 yr: 500 mg 4-6 hr and 12-18 yr: 1 g 4-6 hr. Side effects: Constipation, headache, dizziness, insomnia and vomiting.

Lactulose. Constipation: 10-15 ml q 12-24 hr, less than 2 yr 2.5 ml/d PO, PR q 12 hr; more than 2 yr 5-10 ml PO, PR q 12 hr. Side effects: Diarrhea.

Bisacodyl. 5-10 mg bedtime. Side effects: Abdominal pain, diarrhea, muscle pain and dizziness.

Vasopressin. Bleeding esophageal varices: 20 U IV over 15 min, then 0.2 U/min or 0.33 U/kg/hr. Side effects: Hypertension, water intoxication and hyponatremia.

ANTIHISTAMINICS

Astemizole. 2 mg/10 kg/day taken half an hour before meals; not recommended <6 yr. Side effects: Weight gain with prolonged use.

Cetrizine. 0.2 mg/kg once daily. Levocetrizine has minimal effectsonthecentralnervoussystem;0.125mg/kgoncedaily.

Clernastine. l-3 yr: 0.25-0.5 mg BO; 3-6 yr: 0.5 mg BO; 6-12 yr:0.5-1 mg BO;>12 yr: 1 mg BO. Useful for urticaria, contact dermatitis.

Chlorphenirarnine maleate. 0.35 mg/kg/day q 4-6 hr. Side effects:Hypotension,sedation,urinaryretention,oculogyric spasms with high doses and after few days of therapy.

Diphenhydrarnine hydrochloride. 5 mg/kg/day q 6 hr oral; maximum daily dose 300 mg. Anaphylaxis or pheno­ thiazine overdose: 1-2 mg/kg IV slowly.

Fexofenadine. <12 yr: 30 mg q 12 hr;>12 yr: 60 mg q 12 hr or 120 mg once daily.

Hydroxyzine hydrochloride. 2 mg/kg/day q 6 hr;0.5-1 mg/ kg/dose q 4-6 hr IM.

Ketotifen. Prophylaxis of bronchial asthma; treatment of allergic rhinitis and conjunctivitis: Start at low dose; increase to 1 mg twice daily. Side effects: None.

Loratadine. 3-12: 5 mg/day;>12 yr: 10 mg/day.

Methdilazine hydrochloride. >3 yr: 4 mg q 6-12 hr

Pheniramine maleate. 0.5 mg/kg/day q 8 hr PO, IM, IV. Side effects: Same as chlorpheniramine.

Prornethazine hydrochloride. 0.l mg/kg/day q 6-8 hr; 0.5 mg/kg/dose bed time. Nausea, vomiting, sedation:

0.25-1 mg/kg/dose q 4 to 6 hr oral, IM, IV, PR. Motion sickness: 0.5 mg/kg/dose q 12 hr oral. Side effects: Same as chlorphenirarnine.

Pseudoephedrine. <12 yr: 4 mg/kg/day q6-8 hr oral;>12 yr: 30-60 mg/dose q 6-8 hr; maximum daily dose 240 mg.

ANTIHYPERTENSIVES

Details on therapy with antihypertensive agents are provided in Chapter 15.

ANTISPASMODICS

Dicyclornine hydrochloride. Infants below 6 months: 5-10 drops 15 min before feeds, 6-24 months: 10-20 drops 15 min before feeds;>2 yr: 1 ml q 6 hr. Side effects: Dry mouth and urinary retention.

Hyoscine butylbromide. 6-12 yr: 10 mg q 8 hr PO;10-20 mg IV and IM bolus.

Oxyphenonium bromide. 0.8 mg/kg/day q 6 hr oral. Preschool children: 5-10 drops;older children: 10-20 drops q 6 hr. Side effects: Dry mouth, blurred vision, retention of urine, dizziness, fatigue and tremors.

Pipenzolate rnethylbromide. 2.5-5 mg q 8 hr

ANTITOXINS AND IMMUNOGLOBULINS

Anti-Rh D immunoglobulin. Antenatal prophylaxis: 300 µg IM at 28 weeks and 34 weeks gestation; or single dose within72 hr ofdelivery.Twin pregnancy: Double thedose. Abortion,evacuation,trauma,otherprocedures (chorionic villus sampling, amniocentesis,external cephalic version): 250 µg IM.

Antisnake venom. Mixture of four enzyme-refined, lyophilized, polyvalent antisnake venom (common Krait, cobra, Russell viper and saw-scaled viper).

Dose. 5 vials (50 ml) for mild, 5-15 vials for moderate, 15-20 vials (150-200 ml) for severe features; smaller childrenmayrequire50%more dose. Exclude horse serum allergy (0.02 ml of 1:10 diluted antivenin intradermally); then infuse antivenin diluted in 250 ml N/5 saline (20 ml/ kg/hr). Use steroids and antihistamines in addition. Side effects: Serum sickness and anaphylaxis.

Diphtheria antitoxin. Schick test positive. One dose of diphtheria toxoid;diphtheria antitoxin 500-2000 units IM in other arm. Second and third doses of toxoid are given at 4-6 week intervals for active immunization. Dose is not related topatientage andweight. Pharyngeal or laryngeal diphtheria of 48 hr duration: 20,000-40,000 units IV. Nasopharyngeal diphtheria: 40,000-60,000 units IV. Extensive disease of>3 daysdurationwith neck swelling: 80,000-120,000 units IV. Antitoxin is diluted 1:20 in isotonic saline and administered at 1 ml/min.

Humannormalirnmunoglobulin. Primaryimmunodeficiency: 0.2 ml/kg IMevery4 weeks. Attenuation of disease among

contacts of measles: 0.25 ml/kg IM within 6 days of exposure; hepatitis A: 0.02-0.04 ml/kg IM. Side effects: Coagulopathy, thrombocytopenia; contraindicated in IgA deficiency.

Hepatitis B (hepatitis B immune globulin). 0.06 ml/kg IM, maximum 3-5 ml within 7 days of exposure.

Human tetanus specific immunoglobulin. Prophylactic: 250 IU IM; therapeutic: 500 IU IM (maximum 3000-6000 IU).

Intravenous immunoglobulin ([VIG). 0.4 g/kg IV infusion daily for 5 days;1 g/kg/day for 2 days or 2 g/kg in one day as IV infusion over 10-12 hr as single dose. Indications:

(i) idiopathic thrombocytopenic purpura, (ii) Kawasaki disease, (iii) myasthenia gravis, (iv) Guillain-Barre syn­ drome, (v) systemic lupus erythematosus, (vi) juvenile idiopathic arthritis, (vii) autoimmune neutropenia, (viii) dermatomyositis, (ix) psoriasis, and (x) atopic allergy.

Human rabies specific immunoglobulin. If presents within 24 hr: 20 units/kg;one-half infiltrated at site of bite, other half IM in gluteal region. If presents between 1 and 7 days: Total dose given IM. Rabies vaccine is administered simul­ taneously.

Tetanus antitoxin. Prophylactic: 3,000-5,000 U SC, IM; Therapeutic: 10,000 U IM, IV; intrathecal: 250-500 U q 24 hr for 3 days. Side effects: Serum sickness, anaphylaxis. Varicella zoster immunoglobulin. 125 U/kg IM within 48-72 hr of exposure to varicella.

BRONCHODILATORS AND ANTIASTHMA AGENTS

Adrenaline. 0.01 ml/kg/dose (maximum 0.5 ml/dose) of 1 : 1000 solution SC; repeat after 15-20 min. Side effects: Tachycardia, palpitations and anxiety.

Aminophylline. Status asthmaticus: 5-7 mg/kg IV loading, followed by infusion at 0.5-1 mg/kg/hr. If already receiving oral aminophylline, do not use loading dose. Apneic spells in preterms: 5 mg/kg IV loading, followed by 1-2 mg/kg PO, IV q 8 hr. Side effects: Tachycardia, tremors, irritability and convulsions.

Beclomethasone dipropionate. MDI 50, 100, 200, 250 µg/puff: 100-1000 µg/day in 3 divided doses. Rotacaps 100, 200, 400 µg/cap: 100-1000 µg/day in 3 divided doses.

Budesonide. MDI 50, 100, 200 µg/puff, rotacaps 100, 200, 400 µg/cap: 200-800 µg/day in 1-2 divided doses. Respules 0.5 mg/ml, 1 mg/ml: 0.25-1 mg q 12 hr.

Ciclesonide. MDI 80, 160 µg/puff: 80-640 µg/day in 1-2 divided doses; not approved below 12 yr of age. Benefit of less oropharyngeal candidiasis and hypothalamo­ pituitary axis suppression.

Formoterol fumarate. MDI 6 µg/puff, rotacap 12 µg/cap: 1-2 doses q 12 hr. Long acting selective z-adrenergic agonist; not recommended for monotherapy and <4 yr.

Fluticasone propionate. MDI 25, 50, 125 µg/puff, Rotacaps: 50, 100, 200 µg/puff: 100-1000 µg/day in 2 divided doses.

Rational Drug Therapy -

Ipratropium bromide. MDI 20 µg/puff: 2-4 puffs as needed; rotacap 40 µg/cap: 1-2 cap as needed; respules 0.5 mg/2 ml less than 1 yr: 125 µg/dose;>1 yr: 250 µg/dose, repeat q 20 min for 1 hr (during exacerbation); then q 6-8 hr.

Montelukast sodium. l-5 yr: 4 mg PO once a day in evening; 6-14 yr: 5 mg once daily; >14 yr: 10 mg once daily. Indications: Exercise induced asthma, alternate to long­ acting B2 agonists and allergic rhinitis.

Salbutamol. 0.15 mg/kg/dose PO q 8 hr. MDI 100 µg/dose: 2-4 puffs as needed q 20 min for 1 hr (during exacerbation), then q 6-8 hr. Nebulizer solution: 0.15 mg/kg/dose (minimum 1 mg as needed), q 20 min for 1 hr, followed q 6-8 hr. Side effects: Headache, tremor, irritability and hypokalemia.

Levosalbutamol. MDI 50 µg/puff: 2-4 puffs as needed. Salmeterol (long acting) 25 µg/puff MDI: 1-2 puffs twice a day; not for monotherapy and in <4-yr-old. Side effects: Tachycardia, tremors, headache and hypokalernia.

Sodium cromoglycate. MDI 5 mg/puff: 2 puffs 3-4 times a day; 4-6 weeks for clinical benefit. Side effects: Reflex coughing.

Terbutaline. 0.1-0.15 mg/kg/day q 8 hr PO. 0.005-0.01 mg/ kg SC q 6 hr; IV 0.4-1.0 µg/kg/min followed by infusion of 1-10 µg/kg/hr. Nebulizer (10 mg/ml): 0.5-2 mg as needed. MDI 250 µg/puff: 2-4 puffs as needed. Side effects: Same as salbutamol.

Magnesium sulfate. Injection 25% (250 mg/ml), 50% (500 mg/ml): IV 25-100 mg/kg diluted in saline infused over 30 min (maximum 2 g). Side effects: Hypotension, respiratory depression and muscle weakness.

Note. Metered dose inhalers (MDI) should be used with large volume spacers. For infants, the spacer can be used with a face mask. Rotacap dose is double the inhaler dose; are administered using a rotahaler.

Nebulization. Final volume of 3-5 ml should be made by I adding normal saline. Details on inhalant use and nebulization therapy with bronchodilators is provided in

Chapter 14.

INOTROPIC AGENTS

Adrenaline. Cardiac arrest: 0.1 ml/kg/dose of 1:10,000 solution IV or intraosseous; endotracheal use: 0.1 ml/kg/ dose of 1:1000 solution (flush with 5 ml saline, followed by 5 ventilations). In case of nonresponse, repeat same dose q 3-5 min.

Dobutamine. 2 to 25 µg/kg/min IV, available as 250 mg powdered form. Reconstitute ampoule with 10 ml saline to make 25 mg/ml. Dosage in mg for infusion: 15 mg x body weight dissolved in 24 ml of compatible solution (5% dextrose, 10% dextrose, 5% dextrose normal saline, normal saline), infusion of the above solution @0.5 ml/hr

delivers 5 µg/kg/min. Side effects: Hypotension if there is hypovolemia and tachycardia.

Dopamine. 2 to 20 µg/kg/min IV, available as 200 mg/ 5 ml ampoule,dosage in mg for infusion: 15 mg x body weight dissolved in 24 ml of compatible solution (5% dextrose,10% dextrose,5% dextrose normal saline,normal saline); Infusion of the above solution@ 0.5 ml/hrdelivers 5 µg/kg/min. Side effects: Tachyarrhythmia,hypertension, vasoconstriction and vomiting. Extravasations may cause tissue necrosis.

Digoxin. Digitalizing dose: premature neonates 0.04 mg/ kg/day; term neonates 0.06 mg/kg/day; infants 0.06-0.08 mg/kg/day; olderchildren0.04mg/kg/day PO (parenteral dose is two-thirds of oral dose). One-half of the digitalizing dose is given stat, followed by one-quarter each after 8 and 16 hr.Maintenance dose is one-quarter of digitalizing dose; given once a day. Side effects: Nausea, vomiting; bigeminy pulse,extrasystoles,partial or complete heart block,sinus arrhythmia,atrial or ventricular tachycardia.

Milirinone. 50-75 µg/kg loading dose followed by 0.25 to 1.0 µg/kg/ min. Side effects: Extravasations may cause tissue necrosis,dizziness,headache,rarely severe allergic reactions.

Norepinephrine. 0.05 to 0.1 µg/kg/min titrate dose to desiredeffect (max. 2.0µg/kg/min). Sideeffects:headache, bradycardia and hypertension.

Isoproterenol hydrochloride. 0.5to 5.0 µg/kg/min. Side effects:

Cardiac dysarrhythmias,rarely cardiac arrest,wheezing and bronchospasm.

Vasopressin. Catecholamine refractory vasodilatory septic shock: 0.3-2.0 mU/kg/minute IV infusion. Side effects: Hypertension,water intoxication and hyponatremia.

DIURETICS

Acetazolamide. Diuretic: 5 mg/kg/day PO q 8 hr. Hydro­ cephalus, epilepsy, glaucoma: 50-70 mg/kg/day PO q 8 hr. Side effects: Drowsiness,crystalluria,renal calculi, convulsion and acidosis.

Bumetanide. 0.01-0.02 mg/kg/dose; may be repeated q 6-12 hr. Side effects: Muscle cramps, nausea,vomiting, gynecomastia,leukopenia and thrombocytopenia.

Gzlorthiazide. 20mg/kg/dayq12hr.Sideeffects: Hyperglycemia, glucosuria, neutropenia, neonatal thrombocytopenia, hypokalemia,hypotension.

Frusemide. 1-4 mg/kg/day PO in 1-4 divided doses; maximum 6 mg/kg.IV: 1-2mg/kg/doseq 12hr. Infusion: 0.l-0.4mg/kg/hr. Side effects: Nausea,vomiting,hypona­ tremia,hypokalemia,metabolic alkalosis,hyperglycemia, hyperuricemia; occasionally hepatitis or pancreatitis, dizziness,vertigo,headache,tinnitus and hearing loss on prolonged use, rarely anemia, leukopenia or throm-

bocytopenia; systemic and cutaneous hypersensitivity reactions.

Human albumin. l g/kg/dose IV over 30-120 min for hypo­ proteinemia; administered in combination with frusemide to patients with nephrotic syndrome.

Hydrochlorthiazide. 1-2 mg/kg/day in two divided doses. Side effects: Almost similar to furosemide but less frequent.

Metolazone. 0.2-0.4 mg/kg/day. Side effects: Hypotension, palpitations and hypovolemia; syncope, dizziness, neuropathy,paresthesias,hepatitis,cholestasis,vomiting, anorexia,abdominal distension andpain,hypersensitivity, anemia,leukopenia and thrombocytopenia,hypokalemia, hyponatremia.

Spironolactone. Neonates: 1-3 mg/kg/day q 12-24 hr; Children: l.5-3 mg/kg/day or 60mg/m2/day q 60-12 hr; not to exceed 100 mg/day. Side effects: Dry mouth,dizzi­ ness, headache, irregular periods, gynecomastia, hirsu­ tism,erectile dysfunction and hyperkalemia.

Triamterene. 2-4mg/kg/dayq12hr.Sideeffects:Hyperkalemia, hyponatremia,dry mouth and headache.

Mannitol. 0.5-3 g/kg/dose IV given over 30-60 min.

MEDICATIONS FOR ENDOCRINOLOGICAL DISORDERS

Betamethasone. 0.1-0.2 mg/kg/day q 12 hr. (750 µg is equivalent to 5 mg prednisolone.) <1 yr: 1 mg,1-5 yr: 2 mg, 6-12 yr: 4 mg daily. Adult dose: 0.5-6 mg/day. Indications: Congenital adrenal hyperplasia,brain edema, bronchial asthma,autoimmune disorders. For enhancing fetal lung maturity, when labor starts before 34 weeks, administer to mother 12 mg IM in 2 doses 24 hr apart.

Cortisone acetate. 0.7 mg/kg/day for physiological require­ ment. Therapeutic dose is 2.5-10 mg/kg/day q 8 hr. Side effects: Immediate. Moon facies, acne, increased appetite, reduced resistance to infections, headache, gastritis, hypertension,electrolyte disturbances,glaucoma,pseudo­ tumor cerebri. Prolonged therapy. Myopathy,osteoporosis, growth retardation,cataract,adrenal cortical atrophy.

Dexamethasone. 0.05-0.5 mg/kg/day oral. Congenital adrenal hyperplasia: 0.5 to 1.5 mg/day. Adult: 10-50 mg stat then 4-8 mg q 4 hr; reduce 2 mg q 8 hr. For cerebral edema 0.5mg/kg/dose q 6 hr IM or IV. Pulse dexametha­ sone: 5 mg/kg as slow infusion (maximum dose 100 mg).

Hydrocortisone. Statusasthmaticus4-8 mg/kg/doseq4-6 hr IV; endotoxic shock: 50 mg/m2 initial dose followed by 50-150 mg/m2/day q 6 hr IV for 48-72 hr; acute adrenal insufficiency 1-2 mg/kg/dose IV,then 25-150 mg/m2/ day IV or IM.

Prednisolone. Dose one-fifth of cortisone; 2 mg/kg/day PO divided doses q 6-8 hr or single dose in the morning.

Methylprednisolone. 0.5mg/kg/dose IM or IV.Emergency: 30 mg/kg IV bolus over 10-20 min; repeat after 4 hr if

necessary. Pulse corticosteroid therapy: 30 mg/kg daily for 3-5 days.

Triamcinolone. 24 mg/d PO in divided doses; deep IM 40 mg or intra-articular 2.5-15 mg; avoid <6 yr.

Note: Prednisolone, 5 mg = 0.75 mg betamethasone or dexamethasone, 4 mg methylprednisolone or triamci­ nolone, 20 mg hydrocortisone, and 25 mg cortisone acetate.

ACTH. l.6 units/kg IM or IV single dose. Infantile spasms: 20-40 units/kg/day q 12 hr.

Vasopressin. Diabetes insipidus: 2.5-10 U q 6-12 hr SC or IM; 0.5-10 mU/kg/hr IV infusion. Catecholamine refractory vasodilatory septic shock: 0.3-2.0 mU/kg/ minute IV infusion. Side effects: Hypertension, water intoxication, hyponatremia.

Desmopressin. Infants 3 months of age and children: 0.3 µg/kg IV by slow infusion over 15-30 min beginning 30 min before procedure; may repeat dose if needed. Children>12 yr of age: IV: 0.3 µg/kg once slowly over 15 to 30 min. Intranasal: body weight 50 kg 150 µg,>50 kg 150 µg; in each nostril. Side effects: Water intoxication, hyponatremia.

Growth hormone. 0.09-0.2 U/kg/d SC or IM till accepted height is achieved or bone fusion occurs. For Turner syndrome, dose might be increased to 0.11-0.14 U/kg/day.

Insulin. Details on insulin therapy are provided in Chapter 17.

Carbimazole. 1-2 mg/kg/day in 3 divided doses. Side effects: Urticaria, ageusia, pigmentation and bone marrow depression.

Thyroxine. 10-15 µg/kg/day in newborn babies, 5 µg/kg/ day in children, single dose PO empty stomach in the morning.

Potassium iodide (SSKI) and Lugol's iodine. SSKI 5 drops q 6 hr: Lugol's iodine solution 4-8 drops q 6-8 hr oral. SSKI (1 g/ml) contains 76.4% iodine. Five drops four times a day (assuming 20 drops/ml) contain about 764 mg iodine. Lugol's solution (125 mg/ml of total iodine) contains, in each 100 ml, 5 g of iodine and 10 g of potassium iodide. Four drops given 4 times a day contain 134 mg of iodine.

Propylthiouracil. 1-4 mg/kg/day; <10 yr: 50-150 mg/day

q8 hr;>10 yr: 150-300 mg/day q 8 hr. Maintenance: 50 mg

q12 hr.

Erythropoietin. Anemia of prematurity: 25-100 U/ kg/dose SC or IV, 3 times a week. Chronic kidney disease: 50-150 U/kg/dose SC, 2-3 times a week. SC route requires lower doses than IV; rotated through arm, thigh and anterior abdominal wall.

Darbepoetin alpha. Prolonged half-life; administered less frequently. Pegylated forms not approved below 12 yr. Side effects: Hypertension, seizures, thrombosis of venous access.

Rational Drug Therapy -

Vitamin 0: Dose for rickets (vitamin D3, cholecalciferol): 60,000 IU PO daily for 10 days. The dosing of 1, 25dihydroxyvitamin D (calcitriol) in patients with CKD stage 2-4 is based on body weight (see Chapter 16).

MICRONUTRIENTS

Magnesium sulfate(50% solutionprovides4 mEq/ml). Protein energy malnutrition. 2-3 mEq/kg/day PO (maintenance requirement). Therapeutic (severe acute malnutrition): 0.5-1.0 ml/kg/day q 6 hr IM. 100 mg/kg/dose IV.

Zinc sulfate. Therapy of deficiency: 0.5 mg/kg/day for infants; 10 mg/day for <6 months, 20 mg >6 months. Acrodermatitis enteropathica: 6 mg/kg/day.

Parenteral iron therapy. Iron dextran: 4 mg/kg/dose (maximum 100 mg); slow IV push at 1 ml (50 mg) per minute. The first dose for iron dextran is 10 mg (weight <10 kg), 15 mg (weight 10-20 kg) or 20-25 mg for older children. Polynuclear ferric hydroxide sucrose or iron sucrose: 2 mg/kg (maximum 7 mg/kg); diluted 20-fold with normal saline; infused over 30 min; better side effect profile. Side effects: Hypersensitivity reactions (broncho­ spasm, angioedema, urticaria, hypotension); pain and muscle spasms. Severe or persistent symptoms require therapy with antihistaminics.

The dose required for correction of iron deficiency is calculated as:

Total iron deficit (mg) = Weight in kg x (target Hb - actual Hb in g/dl) x 2.4 + depot iron in mg

The depot iron is 15 mg/kg body weight for children <35 kg and 500 mg for>35 kg

Calcium gluconate (elemental calcium 9%). 1-2 ml/kg of 10% solution; slow IV infusion under cardiac monitoring.

Potassium chloride. 1-2 mEq/kg/day q 8 hr PO. Not to exceed 200 mEq/1 in central line infusions.

Sodium bicarbonate. 1-2 mEq/kg/dose or calculated on I basis of base deficit as follows: Base deficit x weight in kg

x 0.6 = mEq, or ml of 7.5% solution of sodium bicarbonate required for correction.

SEDATIVES, HYPNOTICS AND ANTIDEPRESSANTS

Diazepam. Sedative and anxiolytic at doses of 2-5 mg PO. Anticonvulsant: 0.2 mg/kg/dose IV (maximum 10 mg); repeat in 15 min. Contraindicated in myasthenia gravis and acute narrow angle glaucoma.

Lorazepam. O.l mg/kg IV; repeat at 5 min; longer duration of action than diazepam. PO: 0.03-0.05 mg/kg/dose q 8-12 hr.

Clonazepam. 0.03 mg/kg/day q 8 hr; increase till maximum dose of 0.1-0.3 mg/kg/day.

Tricyclic antidepressants. l.5 mg/kg/day single or divided doses. Side effects: Anticholinergic effects, dry mouth

constipation, urinary retention, blurred vision, tremors and hypotension.

Chloral hydrate. 5-10 mg/kg/dose for sedation; 20-75 mg/ kg/dose for heavy sedation.

Chlorpromazine. 2.5-6 mg/kg/day q 6 hr oral.

Chorea. Start with 50 mg/day oral, increase by 25 mg/day till controlled; maximum dose 300 mg/day. Neonatal tetanus: 1-2 mg/kg per dose 2 to 4 hr.

Fluoxetine hydrochloride. 5-10 mg/day; maximum 20 mg/ day.

Haloperidol. Psychotic disorder: 0.05-0.15 mg/kg/day q 8-12 hr; agitation: 0.01-0.03 mg/kg/day q 8-12 hr; chorea: 0.25 mg PO q 12 hr; 5-10 mg/day q 12 hr. Side effects: Extrapyramidal reactions and dyskinesia.

Ketamine. For IV induction: 0.5-2 mg/kg at a rate not to exceed 0.5 mg/kg/min; IM, oral, rectal: 3-10 mg/kg/dose; nasal and sublingual: 3-5 mg/kg/dose. Minor procedures 0.5-1.0 mg/kg; sedative dose 2 mg/kg. The concomitant use of midazolam is beneficial.

Midazolam. 0.07-0.2 mg/kg/dose IM or IV for preope­ rative sedation or conscious sedation during mechanical ventilation followed by 0.2-1 µg/kg/min for neonates and 0.5-3.0 µg/kg/min for infants and children. Status epilepticus: 0.2 mg/kg IV or IM followed by 0.1-0.2 mg/

kg/hr. Intranasal 0.2 mg/kg may be used for acute seizure control. Side effects: Respiratory depression and shock.

Triclofos. 20 mg/kg/dose for sedation.

VASODILATORS

Isosorbide dinitrate: 0.1 mg/kg/D PO q 6-8 hr. Side effects:

Flushing and headache.

Nifedipine. 0.3 mg/kg/dose oral q 6 hr

Prazosin. 5-25 µg/kg/dose q 6-8 hr (max. 0.1 mg/kg/U/ dose. Side effects: Postural hypotension, dizziness, faintness, nasal stuffiness and priapism.

Tolazoline. 1-2 mg/kg IV over 10 min followed by 1-2 mg/ kg/hr in continuous infusion. Side effects: Dizziness, faintness.

Sildenaftl. 0.3-3 mg/kg/day divided in three doses. Side effects: Dizziness, lightheadedness.

SuggestedReading and Websites

Arcara K, Tschudy M. The Harriet Lane Handbook. Johns Hopkins Hospital, 19th edn. St. Louis, Mosby, 2011

Singh M, Deorari AK. Drug dosages in children. 8th edn., Sagar publications, New Delhi, 2011

http://www.drugs.com/dosage http://www.medilexicon.com/drugs-list/pediatrics.php

Childhealthhas remainedan essentialcomponentof most of the national health programs in India from Expanded Program of Immunization (EPI) in 1974 to the most recent

NationalRuralHealthMission. Introductionofseveralnew technologiesinearly1980smadeitpossibletopreventmajor infectiousdiseasesofchildhoodthroughmassimmunization campaigns and treatment of diarrheal dehydration and malaria at low cost. However, the current child health scenarioindicatesthatcommonchildhoodillnesseslikeacute respiratory infections, diarrhea, measles, malaria, and malnutrition continue to result in high mortality among children less than 5 yr of age. Integrated Management of Childhood Illness (IMCI) strategy optimizespublichealth approach for improving children's health through the delivery of essential child health interventions.

Why Integrated Management?

Many well-known interventions like universal immuni­ zation, essential newborn care, exclusive breastfeeding during first 6 months of life, appropriate complementary feeding, oral rehydration therapy, and timely and appro­ priate use of antibiotics in pneumonia have proven to be effective. While each of these interventions is successful, there is evidence to suggest that an integrated approach is neededtomanagesickchildren.Sickchildrenoftenpresent with overlapping signs and symptoms common to different illnesses and often suffer from more than one illness, which may necessitate different treatments. Ano­ ther reason for integrated approach is the need for incor­ porating preventive strategies such as immunization and nutrition along with curative care.

INTEGRATED MANAGEMENT OF NEONATAL AND CHILDHOOD l LNESS (IMNCI) STRATEGY

Integrated Management of Childhood Illness (IMCI) strategy, developed by World Health Organization in collaboration with UNICEF and many other agencies in mid-1990s, combines improved management of common childhood illnesses with prevention of diseases and

promotion of health by including counseling on feeding and immunization. This strategy has been adapted and expanded in India to include neonatal care at home as well as in the health facilities and renamed as Integrated

Management ofNeonatal and Childhood Illness (IMNCI).

Essential Components of IMNCI Strategy

The IMNCIstrategyincludes both preventive and curative

interventions that aim to improve practices in health facilities, the health system and at home. At the core of the strategy is integrated case management of the most common neonatal and childhood problems with a focus on the most common causes of death in children <5 yr of age.

The strategy includes three main components:

i.Improvements in the case-management skills of health staffthroughuse of locally adaptedguidelines

ii.Improvements in the overall health system

iii.Improvements in family and community health care

practices

This chapter elaborates the clinical guidelines for the treatment of sick children in an outpatient or primary care setting.

IMNCI Clinical Guldellnes

The IMNCI clinical guidelines target children less than 5-yr-old, the age group that bears the highest burden of morbidity and mortality. The guidelines represent an evidence-based syndromic approach to case management that includes rational, effective and affordable use of drugs. Careful and systematic assessment of common symptoms, using selected reliable clinical signs, helps to guide rational and effective actions.

An evidence-based syndromic approach can be used to determine: (i) health problem(s) the child may have; (ii) severity of the child's condition; and (iii) actions that can be taken to care for the child (e.g. refer the child immediately, managewith available resources or manage

at home). In addition the guidelines suggest the adjust­ ments required to manage with the capacity of health system and active involvement of family members in health care practices.

The Principles of Integrated Care

Depending on a child's age, various clinical signs and symptoms differ in their degrees of reliability and diag­ nostic value and importance. IMNCI clinical guidelines focus on children up to 5 yr of age. The treatment guide­ lines have been broadly described under two age categories:

l. Young infants age up to 2 months 2. Children age 2 months up to 5 yr

The IMNCI guidelines are based on the following principles:

•All children under 5 yr of age must be examined for conditions which indicate immediate referral

•Children must be routinely assessed for major symptoms, nutritional and immunization status, feeding problems and other problems

•Only a limited number of carefullyselected clinical signs are used for assessment

•A combination ofindividualsigns is usedtoclassifythe severity of illness which calls for specific action rather than a 'diagnosis'. Classifications are color-coded and suggest referral (pink), initiation of treatment in health facility (yellow) or management at home (green)

•IMNCI guidelines address most common, but not all pediatric problems

•IMNCI management protocols use a limited number of essential drugs

•Caretakers are actively involved in the treatment of children

•IMNCI includes counseling of caretakers about home care including feeding, fluids and when to return to health facility.

IMNCI Case Management Process (Fig. 30. l)

Steps of case management process are:

Step 1: Assess the young infant/child

Step 2: Classify the illness

Step 3: Identify treatment

Step 4: Treat the young infant/child

Step 5: Counsel the mother

Step 6: Followup care

Classification Tables

IMNCI classification tables describe the steps of case management process: Assess, classify and identify treatment (Chart 30.1). There are separate classification boxes for main symptoms, nutritional status and anemia. Classification tables are used starting with the pink rows. If the young infant or child does not have the severe classifications,lookattheyellow rows. Fortheclassification

tables that have a green row, if the young infant or child does not have any of the signs in the pink or yellow rows, select theclassificationin thegreenrow. If the younginfant or child hassigns from more than one row, themoresevere classifications is selected. However, if the classification table has more than one arm (e.g. possible bacterial infection/jaundice, diarrhea in a sick child),onemayhave more than one classification from that box.

IMNCI classifications are not necessarily specific diagnoses,butthey indicate what action needs to be taken. All classifications are color-coded: pink calls for hospital referral or admission, yellow for initiation of treatment, and green means that the child can be sent home with careful advice on when to return.

Effective Communication with the Care Provider

It is critical to communicate effectively with the infant's mother or caretaker. Proper communication helps to reassure the mother or caretakerthat the infantwillreceive appropriate care. In addition, the success of home treatment depends on how well the mother or caretaker knows about giving the treatment and understands its importance.

OUTPATIENT MANAGEMENT OF YOUNG

INFANTS AGE UP TO 2 MONTHS

Assess and Classify Sick Young Infants

Young infants (infants age <2 months) have special characteristics that must be considered when classifying their illness. They can become sick and die very quickly fromseriousbacterialinfections.Theyfrequentlyhaveonly general signs such as few movements, fever or low body temperature. Mild chest indrawing is normal in young infants because their chest wall is soft. For these reasons, assessment, classification and treatment of young infant is somewhat different from an older infant or young child. The assessment procedure for this age group includes a number of important steps that must be followed by the health care provider, including: (i) history taking and communicating withthecaretakerabout theyounginfant's problem; (ii) checking for possible bacterial infection/ jaundice; (iii)assessingfor diarrhea ifpresent;(iv)checking for feeding problem or malnutrition; (v) checking immuni­ zation status; and (vi) assessing other problems.

Checking for Possible Bacterial Infection/Jaundice

In the first step all sick young infants are first examined to assess for signs of possible bacterial infection and jaundice. The bacterial infection can be serious bacterial infection or a localized infection such as skin infection or ear infection.

The clinical signs which point to possible serious bacterial infection are: Convulsions (as part of the current illness); fast breathing (the cut-off rate to identify fast

IF URGENT REFERRAL is needed and possible

IDENTIFY URGENT PREr -REFERRAL TREATMENT(S) needed for the child's classifications

TREAT THE CHILD: Give urgent__pre­ referral treatment(s) needed ......,

REFER THE CHILD: Explain to the child's

caretaker the need for referral. Calm the caretaker's fears and help resolve any problems. Write a referral note. Give instructions and supplies needed to care for the child on the way to the hospital

I 1F NO URGENT REFERRAL is needed or possible

IDENTIFY TREATMENT needed for the child's classifications: identify specific medical treatments and/or advice

TREAT THE CHILD: Give the first dose of oral

drugs in the clinic and/or advise the child's caretaker. Teach the caretaker how to give oral

drugs and how to treat local infections at home. If needed, give immunizations

COUNSEL THE MOTHER: Assess the child's

feeding, including breastfeeding practices, and solve feeding problems, if present. Advise about

feeding and fluids during illness and about when to return to a health facility. Counsel the mother

about her own health

breathing in young infants is 60 breaths per minute or more; if the count is 60 breaths or more, the count should be repeated, because the breathing rate of a young infant is often irregular; if the second count is also 60 breaths or more, the young infant has fast breathing); severe chest

indrawing; nasalflaring; grunting; bulgingfontanelle; >10 skin

pustules; axillary temperature >37.5°C or <35.5°C; lethargy or unconsciousness; andless than normal movements. Presence of any of these signs indicates possible serious bacterial infection which may be a part of sepsis or pneumonia. A young infant with possible serious bacterial infection is referred urgently to hospital after giving first dose of antibiotics. The mother is advised to continue breast­ feeding and tokeepthebabywarm on theway to hospital.

Pus or redness around the umbilicus, presence of <10 skinpustules orpus draining from ear is classified as local bacterial infection and treated with oral antibiotics.

Jaundiceisthevisible manifestationofhyperbilirubine­ mia. Occurrence of jaundice within first 24 hr of birth or after 14 days of age, or deep jaundice visible as yellow palms and soles suggests pathological jaundice and is classifiedas asevere illnessnecessitatingurgent referralto a hospital for evaluation. (Chart 30.1). An infant age 1-13

days who hasjaundice but palms and soles are not yellow is advised home care but should be advised to come for followup after 2 days and advised when to return imme­ diately.

In addition to possible bacterial infection and jaundice, sick young infants with temperature between 35.5 and 36.5°C are classified as low body temperature. This may be due to environmental factors or due to infection. Such infants are warmed using skin-to-skin contact and reassessed after 1 hr. If the temperature becomes normal and the infant has no other pink classification, he can be sent home after advising the mother on how to keep the baby warm. If the temperature is still below 36.5°C the infant should be referred to the hospital.

Assessing for Diarrhea

Diarrhea is a main symptom, which is assessed if the mother says it is present. Exclusively breastfed infants normally pass frequent soft stools. This should not be confused with diarrhea. A young infant is said to have diarrhea if the stools have changed from usual pattern and the child is passing many watery stools (more water than fecal matter).

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