Dr.

Santos

Pedia Reproduction and Hormonal Regulation OS 215 250 Integrated Clinical Clerkship I in Pediatrics

Clinical Skills Lec 2A: Pathology of the Female Genital Tract (Vulva and Vagina)
Head Circumference Should be taken every visit, and recorded on the appropriate head circumference growth chart A non-distensible plastic tape measure should be utilized. The tip of the tape measure is placed over the glabella, through the supraorbital ridges, covering the whole circumference of the head, including the most prominent part of the occiput. This will ensure measurement of the greatest volume of the cranium. Three separate measurements are taken and the largest value is selected. The head circumference of a term infant: o 34 to 35 cm at birth, o 44 cm by 6 months, and o 47 cm at 1 year The average head growth of a premature infant: o 0.5 cm in the 1st two weeks, o 0.75 cm in the third week, and o 1.0 cm in the 4th week and thereafter, until the 40th week of development. Average growth in head circumference is as follows:
Age Growth in Head Circumference (cm/ month)

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OUTLINE Anthropometric Measurements

II. III. IV. V.

Vital Signs Immunizations Growth Charts Pediatric Drug Prescribing

ANTHROPOMETRIC MEASUREMENTS Weight Obtained in kilograms and accurate up to the tenths digit (0.0) using a calibrated standard weighing scale Neonates and small infants are weighed in the recumbent position with minimal clothing (diapers, head gear, mittens and shoes must be removed) Length Measurement of vertical growth Taken from birth to 3 years of age using a measuring table with a centimeter scale traversed by two rigid perpendicular attachments (one fixed attachment at zero centimeter and a movable one running through the length of the table) There must be minimal clothing and the head and feet are bare of accessories that will impede accurate measurement The movable attachment should be positioned at the 100 cm end of the device. The child is laid in supine position. The top of the head is placed against the fixed zero centimeter attachment, while the back, buttocks and lower extremities are held firmly against the length of the measuring table. The movable attachment is then slid to the 0.0 cm mark. The point where the movable attachment touches the childs heels is read as the childs length Height Taken in children more than 3 years of age or when a child is able to stand unassisted using a vertical centimeter scale attached to a flat wall with the zero centimeter reading touching the floor The child should have minimal clothing on; hair accessories and shoes must be removed The child is asked to stand with feet together. The heels, buttocks and occiput are positioned against the flat measuring wall. The head should be held straight, with the eyes horizontal and on the same plane as the external auditory meatus. A rigid board is then placed against the top of the head and held perpendicular to the centimeter scale. The height reading is then taken and expressed up to one-tenths of a centimeter. Ideally, a stadiometer is used to measure height. This device contains a rolled up centimeter ruler capable of measuring height up to 180 centimeters. To measure height using the stadiometer, the child is asked to stand against a flat wall directly below the stadiometer. The same precautions as in measuring height using an ordinary centimeter scale should be observed. The movable attachment of the stadiometer is then pulled down until it touches the top of the childs head, and at this point, the reading from the stadiometer is taken.

03 months 36 months 69 months 9 12 months

2.00 1.00 0.50 0.50

Chest Circumference Measured by placing the tip of the tape measure over the xiphoid process and extending the tape measure around the circumference of the rib cage. Chest measurements must be taken at mid-inspiration. At birth, the head circumference is usually bigger than the chest circumference. As the infant grows, the chest circumference catches up at about mid-year, and by the first year of life, the chest circumference is bigger than the head circumference. The thoracic index is the ratio of the transverse diameter to the antero-posterior diameter of the chest. As the child grows older, the transverse diameter increases at a faster pace than the antero-posterior diameter, such that the thoracic index, which is 1.0 at birth, changes to 1.25 at 1 year, and to 1.35 at 6 years old. Abdominal Circumference The tip of the non-distensible plastic tape measure is placed against the umbilicus and the length is run through the circumference of the abdomen at this level. As the abdomen is much softer and more yielding than the head or chest, ensure that the tape measure is applied snugly to avoid erroneous readings. VITAL SIGNS Temperature

Hazel and JB

THURS, Feb 9, 2012

Page 1 of 5

Dr. Santos

Pedia Reproduction and Hormonal Regulation OS 215 250 Integrated Clinical Clerkship I in Pediatrics

Clinical Skills Lec 2A: Pathology of the Female Genital Tract (Vulva and Vagina)

Taken by the rectal, oral or axillary routes using a standard mercurial thermometer. Rectal temperature is taken by inserting the mercurial tip of the rectal thermometer into the anal orifice. This best reflects the body core temperature, but may be uncomfortable, especially for older children. Oral temperature is taken by placing the mercurial end of the thermometer under the tongue. It is the next nearest to the core body temperature. Axillary temperature is taken by placing the mercurial end of the thermometer in the axillary fossa for at least three minutes. Normal axillary temperature ranges between 36.5 to 37.5 degrees centigrade. Temperature may also be measured using a digital thermometer When using a tympanic thermometer do not completely occlude the opening of the ear canal o The stethoscope is then applied over the cubital artery without touching the lower edge of the cuff, and the bladder is gradually deflated and pressure readings are taken from the gauge (in mmHg). The rate of deflation should not exceed 2mmHg/sec. The systolic blood pressure coincides with the appearance of the first Korotkoff sound, while the diastolic blood pressure coincides with its disappearance.

Blood pressure is considered elevated if it exceeds the 95th percentile for age. If taking BP for the first time, measure in all 4 extremities; Compare upper and lower ex (e.g. detect coarctation of the aorta) IMMUNIZATIONS

Cardiac Rate Taken for a full minute at the point of maximal impulse using a stethoscope; rate, regularity and distinctiveness should be noted Normal fetal heart rate ranges from 140 to 160/minute, but it decelerates as the child grows older. For normal rates, see appendix Respiratory rate Taken for a full minute and best taken while the child is relaxed. Regularity of breathing and duration of apnea should be noted For normal rates, see appendix Blood pressure Part of annual routine exam in children more than 3 years old The patient should be relaxed, comfortable and preferably seated for blood pressure measurement. The arm used to measure blood pressure should be thoroughly exposed. Before taking the blood pressure, ensure that the sphygmomanometer reading is at the zero mark. The cuff should fit comfortably into the arm of the patient. The bladder, which is the inflatable part of the instrument, should cover at least two-thirds of the circumference of the upper arm. Taken at the level of the heart How to measure blood pressure: o Cuff should completely encircle upper part of the arm o Inflatable bladder should cover at least 2/3 of the upper arm length and 80100% of its circumference o If cuff is too big, a falsely low reading may occur o Palpate for the pulse of the cubital artery, and once this is located, fit the cuff snuggly on the upper arm, ensuring that the bladder is directly over the cubital artery (cubital pulse is between the two tubes) o Feel for the radial pulse of the same arm and inflate the bladder until pulsation from the radial artery is obliterated.

In administering vaccines, a 2.0, 2.5 or 3.0mL hypodermic syringe or a 1.0 mL tuberculin syringe is used. Syringe has 3 parts: barrel, plunger and needle Needle has 3 parts: o Hub connected to the syringe tip o Cannula or shaft attached to the hub o Bevel slanted, pointed part The length of the shaft varies from to 2 cm. The gauge of the needle indicates the diameter of the shaft; the higher the gauge of the needle, the smaller is its diameter.

Preparation of Vaccines Vaccines are removed from cold storage only if they are ready to be administered. They are contained in ampules or vials. Ampules o Designed to hold a drug for single administration o Easily opened by breaking at the constricted, pre-scored neck area o It is slightly tilted during aspiration to obtain all of its contents Vial o Small glass bottle with a sealed rubber cap and covered by a metal or plastic cover o May hold single or multiple doses o The cover is lifted to expose the rubber cap. An amount of air equivalent to the amount of drug to be administered is then injected into the vial (to prevent negative pressure inside the vial during aspiration). The vial may be held upside down in order to aspirate all of its contents. Some vaccines are dispensed as powder in ampules or vials that require reconstitution prior to administration, i.e. a solvent or diluent must be added prior to aspiration. The powdered drug is allowed to dissolve thoroughly in the diluent prior to aspiration. After withdrawing the medication into the syringe, tapping the barrel will allow excess air to rise to the tip, and ejected out of the syringe.

Administration of Vaccines Before injection of any vaccine, the site must be swabbed with antiseptic and allowed to dry

Hazel and JB

THURS, Feb 9, 2012

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Dr. Santos

Pedia Reproduction and Hormonal Regulation OS 215 250 Integrated Clinical Clerkship I in Pediatrics

Clinical Skills Lec 2A: Pathology of the Female Genital Tract (Vulva and Vagina)
Subcutaneous (SQ) Common sites are the outer aspect of the upper arms and the anterior aspect of the thighs. Only small amounts of medication are injected in this manner, usually doses of 1.0 mL or less. Generally, a 1.0 mL syringe with a gauge #25 needle to 5/8 of an inch long is used for this route. 1. Using the non-dominant hand, the skin over the site is pinched, while the syringe is held over the barrel like a pen with the dominant hand. The needle is then pushed steadily over the pinched area at a 45-degree angle until it penetrates the subcutaneous tissue. Once the needle is properly inserted, the skin is released by the non-dominant hand, which is transferred to the end of the plunger. To check whether the needle has entered a bloodstream or not, the plunger is pulled back for 5 to 10 seconds, and the aspirate is checked for blood. If blood is not aspirated, the drug is administered by pushing the plunger with a slow even pressure until the entire dose is delivered. The needle is then slowly removed in the same angle as it was inserted by the dominant hand, while the non-dominant hand depresses the skin for counteraction. dominant hand, while the non-dominant hand depresses the skin for counteraction. Intradermal (ID) Common sites are the skin over the deltoid muscle and the volar surface of the forearms. A tuberculin syringe with a gauge #25 or #28 needle inch long is used for this route. 1. The syringe is held by the dominant hand at the barrel between the thumb and forefinger. Traction is then applied opposite the needle. The needle is inserted parallel to the site, with the bevel facing upwards (avoid placing your fingers under the barrel to keep the needle parallel to the site). Once the bevel is properly inserted into the subcutaneous tissue, the skin is released by the non-dominant hand, which is transferred to the end of the plunger. The drug is then administered by pushing the plunger with a slow even pressure until the entire dose is delivered. A wheal is formed over the site if the injection is properly executed. The needle is then slowly withdrawn in the same angle as it was inserted by the dominant hand, while the non-dominant hand gently depresses the skin for counteraction, carefully avoiding the wheal.

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Intramuscular (IM) Intramuscular (IM) injections are absorbed more quickly than subcutaneous injections because of greater blood supply to the muscles. Sites used are the vastus lateralis, the rectus femoris, the dorsogluteal, the ventrogluteal, and the deltoid muscles. A 2 to 5 mL syringe with a gauge #23 to #25 needle is used for this route. Needle length varies from 1 to 2 inches, depending on the site and the amount of muscle in the preferred site. Whenever feasible, replace the needle used for aspiration of the drug with an unused needle for actual IM injection to avoid irritation of the subcutaneous tissue that the needle traverses en route to the muscle. The site is held in such a way that the muscle at the site of administration is relaxed 1. The syringe is held at the barrel like a pen by the dominant hand. For children with thick subcutaneous tissue, the Z track technique is performed as follows: the skin is pulled to the side approximately 2.5 cm by the non-dominant hand while the dominant hand pushes the needle at a 90degree angle into the muscle. For thin patients or infants, the skin with the muscle is pinched for firmer and easier needle insertion. Once the needle is properly inserted, the skin is released by the non-dominant hand, which is transferred to the end of the plunger. To check whether the needle has entered a bloodstream or not, the plunger is pulled back for 5 to 10 seconds, and the aspirate is checked for blood. If blood is not aspirated, the drug is administered by pushing the plunger with a slow even pressure until the entire dose is delivered. The needle is then slowly removed in the same angle as it was inserted by the THURS, Feb 9, 2012

GROWTH CHARTS Used to assess growth patterns o Weight for age o Length for age/ stature for age o Weight for length or stature/ body mass index o Head circumference for age Separate charts for girls and boys and for ages 0-36 months and 2-18 years X axis represents the age of the child while the Y axis represents the growth measurement 50th percentile is the median or standard measurement where most of the observed values fall (e.g. Based on the height-for-age chart, the standard height of a 7 year old girl is 120 cm. Based on weight-for-height chart, the standard weight for a girl measuring 125 cm is 24 kg)

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e.g. A 9-month old boy who weighs 8.5 kg falls in the 25th percentile for age in the standard weight-for-age chart. His weight falls in the 25th percentile of the population of 9-month old boys: 25% of their population weighs less than he does

Hazel and JB

Page 3 of 5

Dr. Santos

Pedia Reproduction and Hormonal Regulation OS 215 250 Integrated Clinical Clerkship I in Pediatrics

Clinical Skills Lec 2A: Pathology of the Female Genital Tract (Vulva and Vagina)
75% of their population weighs more than he does He is assumed to be heavier than 25% of his peers Sa 100 bata na parehong edad at kasarian, ang anak niyo ang pang 25th na pinakamagaan Expected during the refeeding period as the child experiences catch-up growth if a child has been ill or severely undernourished o Not a problem if growth in weight and height are proportional o Weight-for-age and height-for-age charts should show inclines, while the weight-forheight growth line tracks steadily along the z-score curves o May signal a change in feeding practices that will result in overweight Sharp decline in the growth line o In a normal or undernourished child, indicates a growth problem to be investigated and remedied o In an overweight child Losing too much weight rapidly is undesirable The overweight child should instead maintain his weight while increasing in height; i.e. the child should grow into his weight. Flat growth line (stagnation) o Usually indicates a problem o If a childs weight stays the same over time as height or age increases, the child most likely has a problem o Exception: an overweight or obese child maintains the same weight over time, bringing the child to a healthier weight-forheight or BMI-for-age o If height stays the same over time, the child is not growing o Evident as a flat growth line on the heightfor- age chart o

Growth charts are also used to measure of body adiposity Less than 2 years old: weight- for-length > 95th percentile for age and sex is considered obese In older children, more than 5 years for age, body mass index (BMI) is a more accurate tool for measuring of body adiposity.

BMI = __Weight (in kg)___ {Height (in meters)} 2

85th-95th percentile for age and sex are at risk for obesity >95th percentile are obese

New z-score charts

z-score [Standard deviation score (SDS)]= gives an indication of how far a child is from the median of a normal bell-shaped curve 0 = exactly at the median, the best 0 if anywhere below 1 and above -1

Growth trends Normally growing children follow trends that are, in general, parallel to the median and zscore lines. Most children will grow in a track, that is, on or between z-score lines and roughly parallel to the median; the track may be below or above the median. When interpreting growth charts, be alert for the following situations, which may indicate a problem or suggest risk: o A childs growth line crosses a z-score line o There is a sharp incline or decline in the childs growth line o The childs growth line remains flat (stagnant); i.e. there is no gain in weight or length/height Crossing a z-score line Significant change in the childs growth. o Shift towards the median probably a good change o Shift away from the median problem or risk of a problem Sharp incline in the growth line

Assessment of malnutrition Simple plotting of measurements yield information as to how near or how far the patients measurement is to the standard for age and sex. e.g. A child whose height falls in the 10th percentile mark is much more stunted than a child whose height falls on the 25th percentile for age and sex. Nutritional status = either no/ stunting or no/wasting More accurate nutritional assessments, however, can be made by actually demonstrating the degree and severity of malnutrition. Weight for age = Actual weight Standard weight x 100

Length/stature for age = Actual length or stature x 100 Standard length or stature Weight-for-length = x 100 length To determine abnormalities in these growth indices, growth indices are compared to standard cut-offs, each representative of the childs nutritional status. Revised Waterlow Classification Actual weight-for-length Standard weight-for-

Hazel and JB

THURS, Feb 9, 2012

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Dr. Santos

Pedia Reproduction and Hormonal Regulation OS 215 250 Integrated Clinical Clerkship I in Pediatrics

Clinical Skills Lec 2A: Pathology of the Female Genital Tract (Vulva and Vagina)
Grade of malnutrition No malnutrition Mild Moderate Severe Severity Wasting of Stature-forage (Stunting) >95 90-95 85-89 <85 Malnutrition: Weightfor-height (Wasting) >90 81-90 70-80 <70 Stunting and Computation: 10mg/kg x 15kg x 5mL/125mg = 6mL every 4 hours

Sample prescription: Patients Name: AB Age: 4 y/o Sex: Male Weight: 15kg R/ Paracetamol 100 mg/mL drops #1 Sig. Give 6 mL every 4 hours for fever (T > 37.5) Example 2: BC, Female, 10 y/o, 30 kg Cefuroxime: 30 mg/kg/day, to be given twice a day Preparations available: 125 mg/5 mL; 250mg/5mL; 125mg tab Computation: 30mg/kg x 30 kg x 5mL/250mg = 18 mL/ day Sample prescription: Patients Name: BC Age: 10 y.o. Sex: Female Weight: 30 kg R/ Cefuroxime 250 mg/5 mL suspension #1 120 mL bottle Sig. Give 9 mL (2 teaspoons) 2x a day for 7 days Take right after meals APPENDIX Average Cardiac Rate of Filipino Infants and Children By Age and Sex*
Age Group Males Mean CR 147 139 133 128 109 93 86 2 SD 30.5 31.4 32.4 34.1 32.6 23.7 20.4 Females Mean CR 145 141 134 129 110 92 86 2 SD 26.2 33.5 31.9 34.3 29.5 23.2 20.7

HEIGHT GRADE OF WEIGHT FOR AGE[] WEIGHT MALNUTRITI FOR AGE[*] (STUNTING FOR ON (WASTING) ) HEIGHT[] 0, normal 1, mild 2, moderate 3, severe >90 7590 6074 <60 >95 9095 8589 <85 >90 8190 7080 <70

From Nelsons, 18th ed. Nutritional indices are helpful in determining duration of undernutrition Acute undernutrition results in decreases in weight-for-age and weight-for-height percentiles Chronic undernutrition results in lower heightfor-age percentiles or stunting For several measurements, growth patterns can be assessed by plotting these measurements on a standard growth curve A child with measurements following the standard or the 50th percentile for age has a normal growth pattern. Normal growth velocity = parallel to growth chart Failure to thrive o < 5th percentile for age and sex o weight-for-age curve drops down more than two percentiles. Stunting o nutritional deficiency becomes more chronic o length-for-age later declines Chronic, severe undernutrition o results in low weight-for-height o decline in head circumference growth rate A decreased linear growth pattern (i.e. heightfor-age) can also be observed in congenital, constitutional, familial and endocrine causes of growth failure. These non-nutritional causes of stunting cause decline in length before or at the same time as the decline in weight. PEDIATRIC DRUG PRESCRUBING Determine the age and weight of the patient. Determine the dose range based on the weight of the patient and method of administration suitable for the patients age. Look for the available formulations of each drug.

0 1 month 2 6 months 7 12 months 13 24 months 2 4 years 5 9 years 10 14 years

*From PD Santos Ocampo, A Librea and M Borja Average Respiratory Rate of Filipino Infants and Children by Age and Sex*
Age Group 01 month 26 months 7 12 months 13 24 months 2 4 years 5 9 years 10 14 years 59 52 45 38 30 25 22 Males Mean RR 2 SD 18.2 22.5 24.6 14.9 12.1 6.1 3.5 Females Mean RR 56 52 48 36 29 25 22 2 SD 22 21.6 22.8 22.5 12.0 6.1 3.6

Example 1: AB, 4 y/o, Male, wt. 15 kg Paracetamol: 10-15 mg/kg/dose Preparations available in the market: 100 mg/mL (drops); 125mg/5mL; 250mg/5mL

*From PD Santos Ocampo, A Librea and M Borja

Hazel and JB

THURS, Feb 9, 2012

Page 5 of 5

Dr. Santos

Pedia Reproduction and Hormonal Regulation OS 215 250 Integrated Clinical Clerkship I in Pediatrics

Clinical Skills Lec 2A: Pathology of the Female Genital Tract (Vulva and Vagina)

Mean Blood Pressure of Filipino Infants and Children By Age and Sex*
Age 01 month 2 11 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years Mean systolic pressure 72.00 81.66 87.3 88.2 87.47 87.37 93.3 93.84 96.56 98.5 97.00 98.95 98.80 101.55 106.95 108.00 104.05 2 SD 0.6 0.6 0.8 1.2 1.8 1.2 1.2 1.2 1.0 1.2 1.2 2.2 2.6 1.8 3.0 1.2 1.8 56.40 63.15 55.50 56.45 59.8 60.5 61.55 60.05 57.3 61.5 74.4 67.65 65.7 71.5 86.85 0.6 0.6 1.2 1.4 0.8 0.8 1.0 1.0 0.4 0.8 2.8 1.8 1.0 0.6 1.6 Mean diastolic pressure 2 SD

*From B Mojica, HP Lopez, and MRO Legarda *Refer to Handbook for growth charts and BP levels for age
Z score Length/Heig ht-for-age Above 3 Above 2 (note 1) Growth indicators Weight-forage (note 2) Weight-forLength/height Obese (note 3) Overweight (note 4) At risk for overweight BMI-forage Obese (note 3)

Above 1

Overweight (note 4)

Median Below -1 Below -2 Stunted (note 5) Severely stunted (note 5) Underweight Wasted Wasted

Below -3

Severely underweight

Severely wasted

Severely wasted

Notes: 1. A child in this range is very tall. Tallness is rarely a problem, unless it is excessive that it may indicate an endocrine disorder such as a GH producing tumor. Refer a child in this range for assessment if you suspect an endocrine disorder (ie. If parents of normal height have a child who is excessively tall for his or her age). 2. A child whose weight-for-age falls in this range may have a growth problem, but this is better assessed from weight-forlength/height or BMI-for-age. 3. A child in this range is overweight. Values correspond to BMI 25 kg/m2 at 19 years. 4. A child in this range is obese. Values correspond to BMI 30 kg/m2 at 19 years. 5. It is possible for a stunted or severely stunted child to become overweight.

Hazel and JB

THURS, Feb 9, 2012

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