PEDIATRICS OSCE

I. Essential Intrapartum
Newborn Care
II. Newborn Resuscitation
III. Breastfeeding and
Complementary Feeding
IV. Immunization
V. Growth Indicators and
Developmental Milestones
VI. Neonatal Sepsis
VII. Acute Bacterial Meningitis
VIII. BFS
IX. PCAP
X. UTI
XI. Dengue and Viral
Exanthemns
XII. Nephrotic-Nephritic
XIII. Fluids and Electrolytes
XIV. Rheumatic Fever
XV. Asthma
XVI. Pulmonary TB
XVII. Medications

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

3. PROPERLY TIMED CORD CLAMPING (1-3 min)

Delayed cord clamping 2-3 min after birth or until cord has stopped pulsating
 Benefits
Prevents anemia
Improves oxygen supply to the brain in preterms
Decreases risk of brain bleeds or intraventricular hemorrhage in preterms
Decreases risk of late-onset sepsis in preterms

4. NON-SEPARATION OF NEWBORN FROM MOTHER FOR EARLY BREASTFEEDING (90

min)

Monitor mother and baby regularly in the first 1-2 hours

NON TIME-BOUND (90 min to 6 hours)

1. Vitamin K Administration (1 mg IM)
2. Eye care (Erythromycin ointment 0.5%)
3. Immunization (Hepatitis B intramuscular and BCG intradermal)
4. Weighing
5. Washing

8-10: good cardiopulmonary adaptation

4-7: need for resuscitation, especially ventilator support
0-3: need for immediate resuscitation
Rapid assessment of newborn
Term gestation?
Crying or breathing?
 Good muscle tone?

ET Tube indications:
Initial endotracheal suctioning of nonvigorous meconium stained newborns
If bag mask ventilation is ineffective or prolongef
When chest compressions are performed

Chest compressions
Indicated for heart rate that is < 60 per minute despite adequate ventilation with
supplementary oxygen after 30 seconds

PPV indications
Apnea/gasping
HR < 100
Persistent central cyanosis despite 100% free flow oxygen
Medications:
Bradycardia in newborn is usually result of inadequate lung inflation or profound hypoxemia
and establishing adequate ventilation is most important step to correct it
Route and dose of epinephrine administration:
RD: 0.01 TO 0.03 mg/kg per dose
Higher IV doses may cause exaggerated hypertension, decreased myocardial function,
and worse neurological function
Endotracheal route: 0.05-0.1
Volume expansion: isotonic crystalloid solution or blood: Dose of 10 ml/kg

Keypoints:

The most important and effective action in neonatal resuscitation is to ventilate the babys
lungs
Lack of ventilation of the newborns lungs result in sustained constriction of the pulmonary
arterioles, preventing systemic arterial blood from being oxygenated
When a newborn becomes deprived of oxygen, an initial period of attempted rapid
breathing is followed by primary apnea and dropping heart rate that will improve with
tactile stimulation; if oxygen deprivation continued, secondary apnea ensues, accompanied
by continued fall in heart rate and blood pressure
Secondary apnea cant be reversed by stimulation, assisted ventilation must be provided
Free flow oxygen is indicated for central cyanosis

BREASTFEEDING AND COMPLEMENTARY

FEEDING

Allow baby to suck 15-30 minutes per breast to extract both foremilk and hindmilk
Exclusive breastfeeding for minimum of 4 months and preferable for 6 months

Absolute Relative
Contraindications Contraindications
Galactosemia Active TB infection
Maternal use of until 2 weeks of
illegal drugs, therapy
antineoplastic Maternal HIV
agents and Herpes infection: if
 radiopharmaceutic with active
als herpetic lesions of
the breast

Recommended breastmilk storage:

o Room temp (<25): 4 hours
o Room temp (>25): 1 houra
o Refrigerator (4 C): 8 days
o Freezer compartment of 1 door ref: 2 weeks
o Freezer compartment of 2 door ref: 3 months
o Deep freezer (-20 C): 6 months
Complementary feeding
o Begin one new food at a time to be given for 3 days
o 6 mos: Start with PUREED FOOD
o 8 mos: FINGER FOODS
o 10 mos: LUMPY OR CHOPPED FOOD
o 12 mos: TABLE FOOD
o 6-8 months old: feed 2-3 times a day
o 9-24 months old: 3-4 times a day
o Do not add salt to infants diet before one year of age

IMMUNIZATION
Two types:
1. Active immunization
Antibodies peaks at 5-7 days
2. Passive immunization
Immunoglobulin peaks at 48-72 hours

Inactivated Vaccines Live Vaccines

Hep B BCG vaccine
DPT Measles vaccine
HIB MMR vaccine
Pneumococcal Varicella vaccine
vaccine Rotavirus vaccine
 Hepatitis A vaccine Oral Typhoid vaccine
Meningococcal
vaccine
Influenza trivalent
vaccine
HPV
Typhoid fever (IM)
Ravies
IPV

Important point to remember

Vomiting within 10 minutes of receiving an oral dose is an indication for repeating the dose
Children younger than 1 year of age: anterolateral aspect of thigh
Older children: deltoid muscle is usually large enough
4 weeks interval: 2 live attenuated vaccines
Cholera and yellow fever vaccines shouldnt be given together or 1-3 weeks apart
FULLY IMMUNIZED CHILD
1 dose of BCG
3 doses of DPT and Polio with at least 4 weeks interval between each dose
One dose of measles (9 months or before 12 months)
3 doses of Hep B with at least 4 weeks interval between doses

Recommended Vaccine
Age
Birth Hep B1; BCG
1 mo Hep B2
2 mo DPT 1, OPV 1, HIB 1,
Rotavirus 1, PCV1
4 mo DPT 2, OPV2, HIB2,
ROTAVIRUS2, PCV 2
6 mo HEP B3, DPT3 ,OPV3, HIB
3, ROTAVIRUS 3, PCV3
9 mo MEASLES

Beyond 1 yr old Recommendations

15 mo MMR Given 6
months after
the 1st
measles
vaccine
18 mo DPT, OPV First booster
dose (12
months after
3rd dose)
4-6 yo DPT, OPV, 2nd booster
MMR dose
11-18 yo Td (Tetanus Repeat every
toxod) 10 yrs of life
BCG Birth, anytime after or 6 weeks
Dose: 0.05 ml for newborn
1.1ml for older infant
> 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
Mease Route: Subcutaneous
ls Given 9 months but can be given as
early as 6 months in cases of
outbreaks

Absolute Relative
Contraindication Contraindication
Severe anaphylactic Immunosuppresive
shock therapy (all live
vaccines)
Moderate to severe Egg allergy (MMR)
illness with or without
fever
Encephalopathy
within 7 days of
administration
(Pertussis)
Immunodeficieny in
patient
Pregnancy (MMR,
OPV)

When to bring patient to ER after immunization?

ISEAT
I: Inconsolable cry
S: Seizure
E: Encephalopathy
A: Anaphylaxis
T: Temp > 40.5

*Always prescribe paracetamol because you will expect the patient to be feverish after
immunization
 Growth Indicators

Height for age: determine stunted patient

Weight for age: determine underweight patient
Weight for length: wasted or obese
BMI: determine if patient is overweight/obese

WEIGHT
Birthweight 3 kilos
4 -5 month
th th
DOUBLES (6 kg)
1 year old TRIPLE (9 kg)
2 years old QUADRUPLES (12
kg)

LENGTH
Birth length 50 cms
1 year old 75 cms
2 yo of their
ultimate adult
height

HEAD CIRCUMFERENCE
HC at birth 33-35 cms
1 yo 45 cms

Mnemonics for weight

0-6 mo Age in months x 600 + BW
6-12 Age in months x 500 + BW
mo
1-6 yrs Age in years x 2 + 8
7-12 (Age in years x 7)-5
yrs 2

Mnemonics for height

0-3 mo BW + 9cm
4-6 mo BW + 9cm + 8 cm
7-9 mo BW + 9cm + 8 cm + 5 cm
10-12 BW + 9cm + 8 cm + 5
mo cm+ 3 CM
2-12 YO Age in years x 6 + 77

Mnemonics for HC
1st 4 mo inches per month
Next 8 inches per month
mos:
2 yo 1 inch
3-5 yo inches per year
6-20 yo inches per 5 years

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
5 months Midline hand play
7 months Transfer object from one
hand to another
9 months Thumb-finger grasp
12 months Voluntary release
13 months scribbles
15 months Builds 2 towers
3 yo Handedness
4-4.5 yo Draw square
5 yo Draw Triangle
EXPRESSIVE LANGUAGE
3 months Cooing
 6 months Babbling
9 months Mama/papa
10 months Points to objects
12 months Single word with meaning
4 yo Complete sentences
RECEPTIVE LANGUAGE
3 months Alert to human voice
6 months Localize to sound
9 months Understands NO
12 months Follow 1 step command
with gesture
24 months Able to follow 2 step
commands
4 yo Dress independently
5 yo Help in household chores

NEONATAL SEPSIS

Risk factors:
maternal infection during pregnancy
prolonged rupture of membranes (18 hrs)
prematurity
Common organisms:
Bacteria:
GBS
E. coli
Listeria monocytogenes
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
1. leukocytosis, increase immature/ total
neutrophil count ratio
a. NV of WBC count in neonates: 9,000
30,000
b. Immature neutrophil-mature
neutrophil ratio should not be >0.2
2. acute phase reactant:
a. C- reactive protein (CRP)- at 24 hrs
with suspicion (in the liver);
Erythrocyte Sedimentation Rate (ESR)
3. pleocytosis in csf or pleural fluid
4. DIC: fibrin split products
5. cytokines: Interleukin-6
Evidence of multi organ systemic
disease
a. metabolic acidosis; pH pCO2
b. pulmonary function: pO2, pCO2
c. renal function: BUN, creatinine
d. hepatic injury/ function: bilirubin, PT
e. bone marrow function: neutropenia,
anemia, thrombocytopenia

NEONATAL JAUNDICE

Physiologic Pathologic
Presents after Presents in the
the 48th hour of 1st 24 hours of
life life
TB increases not TB increases by
> 5 mg/dl/day > 0.5 mg/dl/hr
TB peaks at 14- TB increases to
15 mg/dl > 15 mg/dl
DB < 10% of TB DB > 10% TB
Resolves in 1 Persists beyond
week (term), 2 1 week (term), 2
weeks (preterm) weeks (preterm)

Pathologic 2nd-3rd day onset

jaundice
Erythroblastosis Breastfeeding
fetalis jaundice
Concealed Crigler-Najjar
hemorrhage syndrome
Sepsis
TORCH

3rd-7th day onset Jaundice first

recognized after 1st
week of life
Bacterial sepsis Breastmilk
UTI Jaundice
Enterovirus Septicemia
Syphilis Congenital atresia
Toxoplasmosis Hepatitis
CMV Galactosemia
Hypothyroidism
Enzyme
deficiencies
Congenital
hemolytic anemia

Breastfeedi Breast
ng jaundice milk
jaundice
Onset 1st 3-5 days 1st to 2nd
of life week of
life
Inciden 12-13% 2-4%
ce
Cause Inadequate Due to
supply of unidentifie
breastmilk d factors in
leasing to breastmilk,
increased probably
enterohepati free fatty
c circulation acids;
breast milk
may
contain an
inhibitor of
bilirubin
conjugatio
n
TX Increasing Increasing
breastfeeding breastfeedi
 frequency to ng
8-10 times frequency;
per day at times,
perform
photothera
py
Kramer Classification
Head and neck: 6-8 mg/dl
Upper trunk: 9-12 mg/dl
Lower trunk, Thigh:12-16 mg/dl
Arms: 13-15 mg/dl
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?
Inflammation of spinal nerves and roots produce meningeal signs of
irritation
Complications:
Hydrocephalus: acute complication (communicating type)
Subdural effusions due to continued transudation
SIADH: may exacerbate cerebral edema-> hyponatremic seizures
Why do seizures occur?
Cerebritis, infarction, or electrolyte losses
Contraindications to LP
1. Suspected mass lesion of the brain especially in posterior fossa
2. Suspected mass lesion of spinal cord
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 <20x10 9/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
VIRAL MENINGITIS
Etiology:
Echovirus
Coxsackie virus
Adenovirus
CMV
HSV

CSF findings:
Normal glucose
Normal to slightly increased protein
Lymphocytosis

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

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 supportive
Whezzin streaky
g infiltrates;
Stridor lymphocyts
osis
Bacterial Cough, Lobar 0-2 mo:
high consolidatio Ampi+
fever, n, Aminoglycos
dyspnea neutrophilia ide
,
dullness 2 mo-5 yo:
to Ceftriaxone
percussi or
on Cefuroxime
+Ampicillin
ot Amoclav
Mycoplas Less-ill Interstitial > 5 yo
ma looking, pattern Ezithromyci
non usually n
producti lower lobes Clarithromy
ve cin
cough Azithromyci
n
Chlamydi 6 wks-6 Hyperinflati Erythromyci
a mos on, ground n
Staccato glass PO x 14
cough appearance days
Materna ,
 l hx of eosinophilia
infection

URINARY TRACT INFECTION

< 1 yo: male

> 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
Ocassionally diarrhea
Cystitis:
Gross hematuria and dysuria; urgency, 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