PEDIATRIC PARAMETERS AND EQUIPMENT Premie Newborn 6 mo 1 yr 2- 3 yr 4- 6 yr 7- 10 yr 11- 15 yr >16 yr WT (kg) 2.5- 3.5 3.5- 4 6- 8 10 13- 16 20- 25 25- 35 40- 50 >50 BAG VALVE Infant Infant Small Small Child Child Child/small Adult Adult MASK child child adult NASAL AIRWAY 12 12 14- 16 14- 16 14- 18 14- 18 16- 20 18- 22 22- 36 (Fr) ORAL AIRWAY Infant Small Small Small Small Small Med Med Med 50 mm 60 mm 60 mm 60 mm 70 mm 70- 80 mm 80- 90 mm 90 mm 90 mm BLADE MIL 0 MIL 0 MIL 1 MIL 1, MIL 1, MIL 2, MIL 2, MIL 2, MIL 2, MAC 2 MAC 2 MAC 3 MAC 3 MAC 3 MAC 3 ETT 2.5- 3.0 3.0- 3.5 3.5- 4.0 4.0- 4.5 4.5- 5.0 5.0- 5.5 5.5- 6.0 6.0- 6.5 7.0- 8.0 LMA 1 1 1.5 2 2 2.5 2.5- 3 3 4 GLIDESCOPE 1 1 or 2 2 2 3 3 3 3 or 4 3 or 4 IV CATH (ga) 22- 24 22- 24 20- 24 20- 24 18- 22 18- 22 18- 22 18- 20 16- 20 CVL (Fr) 3 3- 4 4 4- 5 4- 5 5 5 7 7 NGT/OGT (Fr) 5 5- 8 8 10 10- 12 12- 14 12- 14 14- 18 14- 18 CHEST TUBE 10- 12 10- 12 12- 18 16- 20 16- 24 20- 28 20- 32 28- 38 28- 42 (Fr) FOLEY (Fr) 6 8 8 8 8 8 8 10 12 ESTIMATED BLOOD PRESSURE BY AGE Measurement 50th % 5th % Systolic BP 90 + (age × 2) 60 (neonate); 70 (1 mo- 1 yr) 70 + (age × 2) (for 2- 10 yr) <90 (>10 yr) MAP 55 + (age × 1.5) 40 + (age × 1.5) NORMAL VITAL SIGNS BY AGE Age Heart Rate Blood Pressure Respiratory Rate (beats/min) (mmHg) (breaths/min) Premie 120- 170 55- 75/35- 45 (gestational age 40- 70 approximates normal MAP) 0- 3 mo 110- 160 65- 85/45- 55 30- 60 3- 6 mo 100- 150 70- 90/50- 65 30- 45 6- 12 mo 90- 130 80- 100/55- 65 25- 40 1- 3 yr 80- 125 90- 105/55- 70 20- 30 3- 6 yr 70- 115 95- 110/60- 75 20- 25 6- 12 yr 60- 100 100- 120/60- 75 14- 22 >12 yr 60- 100 100- 120/70- 80 12- 18 ENDOTRACHEAL TUBE FORMULAS Uncuffed ETT size: age (years)/4 + 4; Cuffed ETT size: age (years)/4 + 3 ETT depth (from lip to mid- trachea): ETT internal diameter (size) × 3 GLASGOW COMA SCALE Activity Score Child/Adult Score Infant Eye opening 4 Spontaneous 4 Spontaneous 3 To speech 3 To speech/sound 2 To pain 2 To painful stimuli 1 None 1 None Verbal 5 Oriented 5 Coos/babbles 4 Confused 4 Irritable cry 3 Inappropriate 3 Cries to pain 2 Incomprehensible 2 Moans to pain 1 None 1 None Motor 6 Obeys commands 6 Normal spontaneous movement 5 Localizes to pain 5 Withdraws to touch 4 Withdraws to pain 4 Withdraws to pain 3 Abnormal flexion 3 Abnormal flexion (decorticate) 2 Abnormal extension 2 Abnormal extension (decerebrate) 1 None 1 None (flaccid) Adapte d from Hunt EA, Nelson- McMillan K, McNamara L. The Johns Hopkins Children’s Center Kids Kard, 2016. RESUSCITATION MEDICATIONS Adenosine 0.1 mg/kg IV/IO RAPID BOLUS (over 1- 2 sec), Flush with 10 mL normal saline Supraventricular May repeat at 0.2 mg/kg IV/IO, then 0.3 mg/kg IV/IO after 2 min tachycardia Max first dose 6 mg, max subsequent dose 12 mg Administer using a 3- way stopcock attached to a 10 ml NS flush Amiodarone 5 mg/kg IV/IO Ventricular tachycardia No Pulse: Push Undiluted Ventricular fibrillation Pulse: Dilute and give over 20- 60 minutes Max first dose 300 mg, max subsequent dose 150 mg Only give max of 3 IV push doses Monitor for hypotension Strongly consider pretreating with IV calcium in patients with a pulse to prevent hypotension Atropine 0.02 mg/kg IV/IO/IM, 0.04–0.06 mg/kg ETT Bradycardia (increased Max single dose 0.5 mg vagal tone) Repeat in 5 minutes if needed (up to twice) to max total dose 1 mg Primary AV block Calcium chloride (10%)20 mg/kg IV/IO Hypocalcemia Max dose 1 gram Calcium Gluconate 60 mg/kg IV/IO (10%) Max dose 3 grams Dextrose Weight-Based Dosing: 0.5–1 gram/kg Volume-Based Dosing (“Rule of 50”): <5 kg: 10% dextrose 5- 10 mL/kg IV/IO 5- 44 kg: 25% dextrose 2- 4 mL/kg IV/IO ≥45 kg: 50% dextrose 1- 2 mL/kg IV/IO Max single dose 50 grams = 100 mL Epinephrine 0.01 mg/kg IV/IO every 3–5 min (max single dose 1 mg) Pulseless arrest 0.1 mg/kg ETT every 3–5 min (max single dose 2.5 mg) Bradycardia Anaphylaxis: (symptomatic) 0.01 mg/kg IM (1 mg/mL) in thigh every 5- 15 min PRN; max single dose 0.5 mg Anaphylaxis Standardized/Autoinjector: <7.5 kg: no autoinjector, see above 7.5 to <15 kg: 0.1 mg IM 15 to <30 kg: 0.15 mg IM ≥30 kg: 0.3 mg IM Hydrocortisone 2 mg/kg IV/IM/IO Adrenal Crisis/ Max dose 100 mg Insufficiency Insulin (Regular or 0.1 units/kg IV/IO with 0.5 gram/kg of dextrose Aspart) Max dose 10 units Hyperkalemia Lidocaine 1 mg/kg IV/IO (ETT dose is 2- 3x IV dose) Antiarrhythmic Max single dose 100 mg May repeat in 10- 15 min x2 Magnesium sulfate 50 mg/kg IV/IO Torsades de pointes No Pulse: Push Hypomagnesemia Pulse: Give over 20- 60 minutes Max single dose 2 grams Monitor for hypotension/bradycardia Naloxone Respiratory Depression: 0.001- 0.005 mg/kg/dose IV/IO/IM/Subcut (max 0.1 mg first Opioid overdose dose, may titrate to effect) Coma Full Reversal/Arrest Dose: 0.1 mg/kg IV/IO/IM/Subcut (max dose 2 mg) ETT dose 2–3 times IV dose, IN dose 2- 4 mg. May give every 2 min PRN Sodium Bicarbonate 1 mEq/kg IV/IO (8.4% = 1 mEq/mL) Dilute 8.4% sodium bicarbonate 1 : 1 with sterile water for patients <10 kg to a final Administer only with concentration of 4.2% = 0.5 mEq/mL clear indication: Hyperkalemia: Max single dose 50 mEq Metabolic acidosis Hyperkalemia Tricyclic antidepressant overdose ETT Meds (NAVEL: naloxone, atropine, vasopressin, epinephrine, lidocaine)—dilute meds to 5 mL with NS, follow with positive- pressure ventilation. Adapted from Hunt EA, Nelson- McMillan K, McNamara L. The Johns Hopkins Children’s Center Kids Kard, 2018 and the Am erican Heart Association, PALS Pocket Card, 2015. Desired dose (mCg/kg/min) mg drug IV INFUSIONS*6× ×Wt (kg)= Desired rate (mL/hr) 100 mL fluid Dilution in 100 mL in a Medication Dose (mCg/kg/min) Compatible IV Fluid IV Infusion Rate Alprostadil 0.05–0.1 0.3 mg/kg 1 mL/hr = 0.05 mCg/ (prostaglandin E1) kg/min Amiodarone 5–15 6 mg/kg 1 mL/hr = 1 mCg/kg/min DOPamine 5–20 6 mg/kg 1 mL/hr = 1 mCg/kg/min DOBUTamine 2–20 6 mg/kg 1 mL/hr = 1 mCg/kg/min EPINEPHrine 0.1- 1 0.6 mg/kg 1 mL/hr = 0.1 mCg/ kg/min Lidocaine, post 20–50 6 mg/kg 1 mL/hr = 1 mCg/kg/min resuscitation Phenylephrine 0.1–2, up to 5 in 0.3 mg/kg 1 mL/hr = 0.05 mCg/ severe circumstances kg/min Terbutaline 0.1–4 (up to 10 has 0.6 mg/kg 1 mL/hr = 0.1 mCg/ been used) kg/min Vasopressin (pressor) 0.17–8 milliunits/kg/min 6 units/kg 1 mL/hr = 1 milliunit/ kg/min *Standardized concentrations are recommended when available. For additional information, see Larsen GY, Park HB et. al. Standard drug concentrations and smart- pump technology reduce continuous- medication- infusion errors in pediatric patients. Pediatrics. 2005;116(1):e21- e25. Special thanks to Lisa Hutchins, Clinical Pharmacy Specialist, for her expert guidance with IV infusion and resuscitation medication guidelines. This page intentionally left blank TWENTY- SECOND EDITION A MANUAL FOR PEDIATRIC HOUSE OFFICERS THE HARRIET LANE HANDBOOK THE HARRIET LANE HOUSE STAFF AT THE CHARLOTTE R. BLOOMBERG CHILDREN’S CENTER OF THE JOHNS HOPKINS HOSPITAL EDITORS KEITH KLEINMAN, MD LAUREN MCDANIEL, MD MATTHEW MOLLOY, MD, MPH Elsevier 1600 John F. Kennedy Blvd. Ste 1600 Philadelphia, PA 19103- 2899 THE HARRIET LANE HANDBOOK, 22ND EDITION ISBN: 978- 0- 323- 67407- 2 INTERNATIONAL EDITION ISBN: 978- 0- 323- 67408- 9 Copyright © 2021 by Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions p olicies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, com- pounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of prod- ucts liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted 2018, 2015, 2012, 2009, 2005, 2002, 2000, 1996, 1993, 1991, 1987, 1984, 1981, 1978, 1975, 1972, and 1969. Library of Congress Control Number: 2020932209 Content Strategist: Marybeth Thiel Senior Content Development Specialist: Jennifer Ehlers Publishing Services Manager: Julie Eddy Senior Project Manager: Cindy Thoms Design Direction: Patrick Ferguson Printed in Canada Last digit is the print number: 9 8 7 6 5 4 3 2 1 To our families Michael and Debbie Kleinman, you have always been there for guidance and support and have allowed me to follow my dreams. Mary Buckley Kleinman, thank you for being such a loving and devoted wife; you push me to be better every day. Dr. Kimberly Erica Kleinman, you are such a wonderful sister whom I have always looked up to. Camper Whitney Kleinman, you are beautiful in every way. Ina Zun, you were the perfect grandmother and the reason that I am a doctor; I miss you every day. Valerie and Richard McDaniel, thank you for all of the sacrifices you have made to prioritize my education and support me in achieving my goals. From an early age, you instilled in me a love of books, a passion for medicine, and an unwavering belief that with hard work and a sense of humor, anything is possible. Michael McDaniel, thank you for being the best brother I could ever ask for and for always believing in and supporting me. Patrick and Patricia Molloy, thank you for always being my constant supporters no matter where life takes me. Tim, Megan, and Kelly Molloy, your friendship keeps me smiling and has shown me that family is home. Molly Smith Molloy, I can’t imagine being on this journey with anyone else. You know me better than I know myself; thank you for all the love, laughs, and acts of service. To my daughters, Maggie and Katie, I am so proud of you. You make every day an adventure and push me to be an advocate for children. The future is yours. To our patients and their families We will never forget the lessons you have taught us and the trust you place in us. To our residents We are inspired by your brilliance, boldness, and dedication to caring for children. To the wonderful pediatricians and educators who trained us Especially Nicole Shilkofski, Janet Serwint, George Dover, Tina Cheng In loving memory of Dr. Michael Burke Preface “Why this child? Why this disease? Why now?” —Barton Childs, MD The Harriet Lane Handbook was first developed in 1953 after Harrison Spencer (chief resident in 1950–1951) suggested that residents should write a pocket- sized “pearl book.” As recounted by Henry Seidel, the first editor of The Harriet Lane Handbook, “Six of us began without funds and without [the] supervision of our elders, meeting sporadically around a table in the library of the Harriet Lane Home.” The product of their efforts was a concise yet comprehensive handbook that became an indispensable tool for the residents of the Harriet Lane Home. Ultimately, Robert Cooke (department chief, 1956–1974) realized the potential of the Handbook, and, with his backing, the fifth edition was published for widespread dis- tribution by Year Book. Since that time, the handbook has been regularly updated and rigorously revised to reflect the most up- to- date information and available clinical guidelines. It has grown from a humble Hopkins resident “pearl book” to become a nationally and internationally respected clinical resource. Now translated into many languages, the handbook is still intended as an easy- to- use manual to help pediatricians provide current and comprehensive pediatric care. Today, The Harriet Lane Handbook continues to be updated and revised by house officers for house officers. Recognizing the limit to what can be included in a pocket guide, additional information has been placed online and for use via mobile applications. The online- only content includes references, expanded text, and additional tables, figures, and images. In addition to including the most up- to- date guidelines, practice parameters, and references, we will highlight some of the most important improvements in the twenty- second edition of The Harriet Lane Handbook: The Emergency Management and Trauma, Burn, and Common Critical Care Emergencies chapters have been reorganized. The Emergency and Critical Care Management chapter now focuses on the medical manage- ment of common critical care emergencies, while the management of trauma, including burns, has been consolidated into the Traumatic Injuries chapter. The Development, Behavior, and Mental Health chapter has been separated into two chapters with expanded content: Behavior, Development, and Developmental Disability and Psychiatry, reflecting the growing need for pediatricians to understand mental and behavioral health. The Genetics chapter has been reorganized to present categories of metabolic disease in easily referenced tables and to provide an organization to different patterns and etiologies of dysmorphology. x Preface xi The Hematology chapter has been restructured with much of the text re- organized and expanded into tables and figures, including a new algo- rithmic approach to anemia. Content on the management of transfusion reactions has been added. The Immunoprophylaxis chapter includes a new section on vaccine hesitancy. The Nutrition and Growth chapter now includes expanded content on the management of overweight and obese children, definitions of various degrees of malnutrition, information on refeeding syndrome, and a table with instructions on the preparation of fortified formula. Enteral formulas have been reorganized based on clinical indications. The Radiology chapter has been reorganized with all- new images and more focused content. The Rheumatology chapter has been refocused for the general pediatri- cian and includes a section on the primary care management of rheumato- logic diseases. The Harriet Lane Handbook, designed for pediatric house staff, was made possible by the extraordinary efforts of this year’s Johns Hopkins Harriet Lane Pediatric Residency Program senior resident class. It has been an honor to watch these fine doctors mature and refine their skills since internship. They have balanced their busy work schedules and per- sonal lives while authoring the chapters that follow. We are grateful to each of them, along with their faculty advisors, who selflessly dedicated their time to improve the quality and content of this publication. The high quality of this handbook is representative of our residents, who are the heart and soul of our department. Chapter Resident Faculty Advisor 1 Emergency and Kelsey Stayer, MD Justin M. Jeffers, MD, MEHP Critical Care Lisa Hutchins, PharmD Nicole Shilkofski, MD, MEd Management 2 Traumatic Injuries Nymisha Chilukuri, MD Therese Canares, MD Paul D. Sponseller, MD, MBA Dylan Stewart, MD 3 Toxicology Maria D. Latham, MD Elizabeth Hines, MD 4 Procedures Andrew Percy, MD Thuy Ngo, DO, MEd Erik Su, MD 5 Adolescent Medicine Christine Krueger, MD Renata Arrington Sanders, MD, MPH, Harita Shah, MD ScM 6 Analgesia and Courtney Altshuler, MD Rajeev Wadia, MD Procedural Kelsey Gladen, MD Sedation 7 Cardiology Aoibhinn Nyhan, MD Jane Crosson, MD William Ravekes, MD W. Reid Thompson III, MD 8 Dermatology Jennifer Reed DiBiagio, MD Bernard Cohen, MD M. Cooper Lloyd, MD, MPH