2 ObjectivesTo be able to thoroughly evaluate and treat HyperbilirubinemiaTo be able to recognize meningitis and treatUnderstand and calculate daily maintenance fluid volume needs for a well child.Understand and calculate daily maintenance sodium and potassium needs for a well childEstimate and replace fluid and electrolytes in the dehydrated child
4 HistoryHyperbilirubinemia was more of a problem prior to Rhogam approval in Since, the use of Rhogam Hemolytic Disease of the Newborn (HDN) has dramatically decreased. We no longer see the high bilirubin levels that necessitate double volume exchange transfusion.
5 Kernicterus Why do we Worry? Unconjugated bilirubin encephalopathy Three Clinical Phaseshypotonia, lethargy, poor suck in the first day or sohypertonia +/- opisthotonus towards the end of the first week when there is often also a high-pitched cry , fever and seizuresthen a third phase when the baby again becomes hypotonicSurvivors tend to have choreoathetoid cerebral palsy and hearing impairment.
6 How do we Prevent It?ASSESS An Infant’s Risk It’s not just the Bhutani Nomogram and Bilitool
7 Risk Assessment Family History Pregnancy History Birth History Feeding HistoryStooling HistoryWeight LossSepsis RiskTime of Onset of JaundiceNewborn Bilirubin Results
8 Family History Family History of Jaundice Cystic Fibrosis G6PD Other Blood Disorders or Hemolytic ProcessesEthnicity
9 Pregnancy History Blood Type Rh Isoimmune Antibodies Maternal Diabetes Hepatitis
10 Birth Hx/Feeding/ Stooling /Weight Gestational AgeBirth TraumaIn’s and Out’s and Other VitalsWeight Loss-Calculated as % decreased from Birth WeightFeeding History-Latch,Frequency,InterestStool color, frequency, and passage of meconium in the first 24 hours
11 Pearls of JaundiceREMEMBER JAUNDICE IN THE FIRST 24 HOURS IS NEVER NORMALDirect Hyperbilirubinemia needs further investigationDirect Hyperbilirubinemia >2mg/dlor>10% of the total serum bili
13 When using this nomogram, remember that "risk" refers to the risk of a subsequent bilirubin level in that infant >95%ile for age.
14 Hour-specific Nomogram for Risk StratificationInfants age36 hoursTotal bilirubin12.9 mg/dlRisk zoneHigh RiskRisk zone is one of several risk factors for developing severe hyperbilirubinemia. Please see AAP Phototherapy Guidelines below. If phototherapy threshold IS exceeded, please also review AAP Guidelines for Exchange Transfusion. If phototherapy threshold IS NOT exceeded, please see recommended follow-up in sidebar to the right.AAP Phototherapy Guidelines (2004)Neurotoxicity risk zoneStart phototherapy?Approximate threshold at 36 hours of ageLower Risk (>= 38 weeks and well)No13.6 mg/dlMedium Risk (>=38 weeks + neurotoxicity risk factors OR 35 to 37 6/7 weeks and well)Yes11.7 mg/dlHigher Risk (35 to 37 6/7 weeks and neurotoxicity risk factors)9.6 mg/dlA follow-up bilirubin is recommended in 6-12 hours if known hemolysis by direct Coomb's or ETCO (end-tidal carbon monoxide) and otherwise recommended within 24 hours (high risk)
15 Rate of RiseMaximum Rate of increase in bilirubin for an infant with a non-hemolytic process is 5mg/dl/24 hours or 0.2mg/dl/hrThis is helpful to calculate because if you are fortunate to have a previous bili level then at a level greater than or close 0.2mg/dl/hr you will reach light level.
16 Additional Tests to Consider CBC with diff and peripheral smearReticulocyte CountCoomb’sElectrolytesAlbuminLFT’sIf history warrants, sepsis work-up
17 So, Your Patient Needs Phototherapy Adequate HydrationPhototherapyRepeat BilirubinAdditional Labs
26 CSF Evaluation CSF finding Viral Bacterial Partially Treated Bacterial LymeFungalTBLeukocytes/mm3< 1000> 1000[a]> 1000< 500< 300Polymorphonuclear cells20–40% [b]> 85–90%> 80%< 10%< 10–20%< 10–20% [b]Protein (mg/dL)N or < 100> 100–15060–> 100< 100> 100–200> 200–300Glucose (mg/dL)N[c]UD to < 40< 40NBlood-to-glucose ratio< 0.4Positive smear[d]−> 85%[e]≥ 80%< 40%< 30%Positive cultureRare> 95%< 90%> 30%[f]PCR or other methodsEnterovirus, herpesvirus16S RNA, bacterial DNABorrelia burdgorferi antibodiesHistoplasma and Cryptococcus antigen, India ink for CryptococcusMycobacterium tuberculosis
27 BacteriaAntibiotic of ChoiceOther Useful AntibioticsNeisseria meningitidisPenicillin G or ampicillinCefotaxime or ceftriaxoneHaemophilus influenzaeAmpicillin or chloramphenicol[a]Streptococcus pneumoniae[b] 1. Penicillin-susceptible (MIC < 0.1 μg/mL) 2. Penicillin-intermediate (MIC = 0.1–1.0 μg/mL)Cefotaxime or ceftriaxone with/without vancomycinCefepime or meropenem 3. Penicillin-resistant (MIC = 1.0 μg/mL)Cefotaxime or ceftriaxone[c] plus vancomycin 4. Cephalosporin-nonsusceptible (MIC > 0.5 μg/mL)Add rifampin to antibiotics of choiceMeropenem + vancomycin (see text)New fluoroquinolonesdListeria monocytogenesAmpicillin ? gentamicinTrimethoprim-sulfamethoxazoleStreptococcus agalactiaePenicillin G ? gentamicinEnterobacteriaceaeCefotaxime or ceftriaxone with/without aminoglycosidePseudomonas aeruginosaCeftazidime + amikacin
28 Treatment for Presumed Bacterial Supportive Care with fluids (TREAT Shock!), antiemetic (Zofran)Cefotaxime/CeftriaxoneVancomycin dosed at 60mg/kg/day/q6Adjunct therapy with dexamethasone at mg/kg/day/BID-TID. Needs to be administered before or during first dose of antibiotics
29 Duration Streptococcus pneumoniae 10-14 days Neisseria meningitidis 4-7 daysHaemophilus influenzae 7-10 days
34 S.M.A.Rt. Fluid management Shock or acute deficitsTreat shock or dehydration firstMaintenanceCalculate fluid and electrolytes for normal situations.AdjustmentsAdjust for or fluid or electrolyte needs.Reassess therapy regularly
35 Shock and Acute Fluid Needs Isotonic Solution-Normal Saline/Lactated RingersBolus 20cc/kgBolus to perfusion and clinical improvementIf no improvement after the third bolus reassess and other fluids or pressors
36 THIS METHOD DOES NOT WORK FOR INFANTS LESS THAN 14 DAYS OLD Maintenance IV FluidsHolliday-Segar MethodThis method is based on the assumption that for every 100 calories metabolized 100ml of water is required. This method is based on metabolic rate.THIS METHOD DOES NOT WORK FOR INFANTS LESS THAN 14 DAYS OLD
37 Weight = Kilocalories expended = Volume (ml) of H2O needed Holliday-SegarWeight = Kilocalories expended = Volume (ml) of H2O neededWeight kcal / 24hr cc / 24 hrInfant < 10 kg (4) kcal / kg cc/kgChild kg (2) 1000 kcal + 50 kcal per kg over cc+ 50cc/kgFor each kg (1) 1500 kcal + 20 kcal per kg over cc+20cc/kgMax ~2400 cc/day (~100 cc/hr)***
38 What About Na and K? Sodium 3 mEq / 100 kcal (100 ml fluid) = 30 mEq NaCl / LPotassium 2 mEq/100 kcal (100 ml fluid) =20 mEq KCl / L
39 Glucose-Why D5?50 grams dextrose per 1000 ml waterGlucose is the principle nutrition for the brain, heart and red blood cells.5% Dextrose (metabolizes to glucose) provides adequate short term nutrition in the resting state (20% of caloric RDA).
40 We have Water (fluid rate), Electrolytes and Glucose We have Water (fluid rate), Electrolytes and Glucose. So what fluid do we order?
41 Why then is Everyone writing for 1/2NS or NS on the Pediatric Wards? We need Sodium 3 mEq per 100 ml = 30 mEq NaCl / LWe have:Normal Saline (0.9% NaCl) = 154 mEq/L½ NS (0.45% NaCl) = 72 mEq/L¼ NS (0.2% NaCl) = 34 mEq/LPotassium 2 mEq/L per 100 ml = 20 mEq/LOrder: D5 ¼ NS with 20 meq KCl/L for maintenance fluidWhy then is Everyone writing for 1/2NS or NS on the Pediatric Wards?
42 Many sick patients need more than ¼ NS (0.2% NaCl). They are at risk for hyponatremia with hypotonic fluid.Due to Elevated Anti-Diuretic Hormone (ADH).InfectionDrugsHypovolemiaNeurologic diseasePain / anxietySurgery / anesthesia
43 Assessing Dehydration Older Child3% (30 mL/kg)6% (60 mL/kg)9% (90 mL/kg)Infant5% (50 mL/kg)10% (100 mL/kg)15% (150 mL/kg)EXAMINATIONDehydrationMildModerateSevereSkin turgorNormalTentingNoneSkin (touch)DryClammyBuccal mucosa/lipsParched/crackedEyesDeep setSunkenTearsPresentReducedFontanelleFlatSoftCNSConsolableIrritableLethargic/obtundedPulse rateSlightly increasedIncreasedPulse qualityWeakFeeble/impalpableCapillary refill~2 sec>3 secUrine outputNormal to DecreasedDecreasedAnuricPreillness weight – illness weight/preillness weight x100%= % Dehydrated=Necessary Fluid ReplacementData from Kliegman RM, Behrman RE, Jenson HB, et al: Nelson textbook of pediatrics, 18th ed. Philadelphia, WB Saunders, 2007; and Oski FA: Principles and practice of pediatrics, 4th ed. Philadelphia, JB Lippincott, 2006
44 Johns Hopkins: The Harriet Lane Handbook, 19th ed.
45 Replace Ongoing Stool Loss Anything over 40cc/kg/day or 20cc/kg/shift needs to be replaced.Replacement fluid is either ½ NS or NSRemember to Reassess your Patient!
46 Oral RehydrationMethod: Give 5–10 mL of oral rehydration solution (ORS) every 5–10 minutes, gradually increasing volumeDeficit replacement: Mild dehydration = 50 mL/kg over 4 hours Moderate dehydration = 100 mL/kg over 4 hoursMaintenance: Infants should resume formula/breastmilk by mouth (PO) ad lib. Children should continue with regular dietOngoing losses: Regardless of the degree of dehydration, give additional 10 mL/kg of ORS for each additional diarrheal stool
47 Individualize Electrolyte Therapy Hypotonic Saline(0.2% NaCl)Well NPO children with no medical problems. Mild illness not effecting water/electrolyte balance.Congestive heart failure, liver failure, nephrotic syndromeHypervolemic states½ Normal to Isotonic Saline( % NaCl)Sepsis, pneumonia, dehydrationCritically ill childrenChildren who need to maintain higher effective serum osmolalityMild CNS injury, DKA, post-operative, gastroenteritisHypertonic Saline(3% NaCl)Significant CNS injury ( ICP), CSWSevere, symptomatic, Hyponatremia
49 ReferencesBhutani VK, Johnson L, Sivieri EM. Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near- term newborns. Pediatrics.1999;103 (1):6– 14AAP Guidelines on HyperbilirubinemiaFay, Schellhase, Suresh. Bilirubin Screening for Normal Newborns: A Critique of the Hour- Specific Bilirubin Nomogram.Pediatrics;2009;
50 ReferencesThe Johns Hopkins Hospital. The Harriet Lane Handbook. Elsevier/Mosby.2011.PrintLong: Principles and Practices of Pediatric Infectious Disease Revised Reprint. Elsevier.2009.PrintA special thanks to Dr. John Brandt, pediatric nephrologists, for contributing to the fluids lecture.