Reference Range Values for Pediatric Care

Reference RangeValuesfor Pediatric Care

Reference Reference Reference Reference RangeRangefor Pediatric Carefor Pediatric Carefor Pediatric CareLamia Soghier, MD, FAAPEditor

Katherine Pham, PharmD, BCPSSara Rooney, PharmD, BCPSContributing Editors

Reference Range Values for Pediatric CareLamia Soghier, MD, FAAPEditor

Contributing editorsKatherine Pham, PharmD, BCPSSara Rooney, PharmD, BCPS

Custom designed for today’s busy practitioners, this quick-access resource provides commonly used ranges and values spanning birth through adolescence. Data needed for management of preterm and other newborns is highlighted throughout.

Look here for practice-focused help with• Blood pressure ranges• Body surface area calculation• Bone age metrics• Hematology values • Cerebrospinal � uid values• Lymphocyte subset counts• Clinical chemistry ranges• Thyroid function• Endocrine values• Umbilical vein and artery

catheterization measurements• Caloric intake values

… and more!

Assessment and management tools you’ll use again and again

Save time and simplify clinical problem solving with a full set of easy-to-use tools from the AAP and other authoritative sources.

• Apgar and New Ballard newborn scoring

• Growth charts• Metric conversion tables• Pain scales• Blood pressure nomograms• Hyperbilirubinemia nomograms• Enteral formulas • GIR calculators • AAP immunization schedules • AAP periodicity schedule

For other pediatric resources, visit the AAP Bookstore at www.aap.org/bookstore.

Reference Range Values for Ped

iatric Care

AAP

IncludesFrench CatheterScale sample!

Reference RangeValuesfor Pediatric Care

Lamia Soghier, MD, FAAPEditor

Katherine Pham, PharmD, BCPS Sara Rooney, PharmD, BCPS

Contributing Editors

American Academy of Pediatric Department of Marketing and Publications Staff

Maureen DeRosa, MPA, Director, Department of Marketing and PublicationsMark Grimes, Director, Division of Product DevelopmentAlain Park, Senior Product Development EditorCarrie Peters, Editorial Assistant Sandi King, MS, Director, Division of Publishing and Production ServicesTheresa Wiener, Manager, Publications Production and ManufacturingAmanda Cozza, Editorial SpecialistPeg Mulcahy, Manager, Graphic Design and ProductionJulia Lee, Director, Division of Marketing and SalesLinda Smessaert, Brand Manager, Clinical and Professional Publications

Library of Congress Control Number: 2013949731ISBN: 978-1-58110-849-1eISBN: 978-1-58110-854-5MA0702

The recommendations in this publication do not indicate an exclusive course of treatment or serve as a

standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

Every effort has been made to ensure that the drug selection and dosage set forth in this text are in

accordance with the current recommendations and practice at the time of publication. It is the respon-

sibility of the health care professional to check the package insert of each drug for any change in indica-

tions and dosage and for added warnings and precautions.

The mention of product names in this publication is for informational purposes only and does not imply

endorsement by the American Academy of Pediatrics.

The publishers have made every effort to trace the copyright holder for borrowed material. If they

have inadvertently overlooked any, they will be pleased to make the necessary arrangement at the

first opportunity.

Copyright © 2014 American Academy of Pediatrics. All rights reserved. No part of this publication may be

reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechani-

cal, photocopying, recording, or otherwise, without prior permission from the publisher.

Printed in the United States of America.

9-345/0314

1 2 3 4 5 6 7 8 9 10

iii

EditorLamia M. Soghier, MD, FAAPAssistant Professor of PediatricsThe George Washington University School of Medicine and Health SciencesMedical Unit DirectorDivision of NeonatologyChildren’s National Health SystemWashington, DC

Contributing EditorsKatherine Pham, PharmD, BCPS NICU Clinical SpecialistDirector-Pharmacy Residency ProgramsChildren’s National Health SystemDivision of PharmacyWashington, DC

Sara Rooney, PharmD, BCPSPICU Clinical SpecialistChildren’s National Health SystemDivision of PharmacyWashington, DC

CONTENTS

Introduction ............................................................................................... ix

1. CONVERSIONS .......................................................................................1Conversion Formulas .......................................................................... 1Temperature Conversion .................................................................... 2

Fahrenheit to Celsius Conversion ................................................. 2

2. SCALES AND SCORING ..........................................................................3Apgar Score .......................................................................................... 3New Ballard Score ............................................................................... 4Pain Scales ............................................................................................ 6

FLACC Pain Scale ........................................................................... 6Pediatric Early Warning Score (PEWS) ........................................ 7

3. GROWTH ...............................................................................................9Determining Body Surface Area ........................................................ 9Growth Charts .................................................................................... 10Growth Charts for Children With Special Health Care Needs ...... 38Growth Measures for Extremities/Ear Above Eye Levels ............... 44Primary Teeth Eruption Chart.......................................................... 51

4. BLOOD PRESSURE ................................................................................53Blood Pressure Nomograms ............................................................. 53

Healthy Term Newborns During the First 12 Hours of Life ........................................................................................ 53

Preterm and Full-term Newborns During the First Day of Life (According to Birth Weight) ....................................... 54

Preterm and Full-term Newborns During the First Day of Life (According to Gestational Age) .................................. 55

Preterm and Full-term Newborns According to Post-conceptional Age ............................................................. 56

Children Younger Than 1 Year .................................................... 57Blood Pressure Levels for Boys by Age and Height Percentile ...... 58Blood Pressure Levels for Girls by Age and Height Percentile ...... 61

vi Reference Range Values for Pediatric Care

5. REFERENCE RANGE VALUES .................................................................65Cerebrospinal Fluid ........................................................................... 65Clinical Chemistry ............................................................................. 68Newborn Clinical Chemistry ............................................................. 82Hematology ........................................................................................ 84Coagulation Tests ............................................................................... 86

Healthy Full-term Infant During the First 6 Months of Life ........................................................................................ 86

Inhibition of Coagulation in the Healthy Full-term Infant During the First 6 Months of Life ................................ 88

Healthy Preterm Infants (30 to 36 Weeks’ Gestation) During the First 6 Months of Life ........................................... 89

Inhibition of Coagulation in Healthy Preterm Infants (30 to 36 Weeks’ Gestation) During the First 6 Months of Life ........................................................................................ 90

Healthy Children Aged 1 to 16 Years Compared With Adults ............................................................................... 91

Inhibition of Coagulation in Healthy Children Aged 1 to 16 Years Compared With Adults ...................................... 92

Fibrinolytic System in Healthy Children Aged 1 to 16 Years Compared With Adults .............................................. 93

Lymphocyte Subset Counts in Peripheral Blood ............................ 94Thyroid Function Tests ..................................................................... 97

Very Low Birth Weight Infants .................................................... 97Preterm Infants ............................................................................. 97Infants, Children, and Adults ...................................................... 98

Endocrine Laboratory Values ........................................................... 99Growth Hormone Values ............................................................. 998 am Cortisol Levels ..................................................................... 99Serum 17 Hydroxyprogesterone ............................................... 100

6. HYPERBILIRUBINEMIA MANAGEMENT .................................................101Risk Nomogram ............................................................................... 101Phototherapy Nomogram ............................................................... 102Exchange Transfusion Nomogram ................................................. 103

viiContents

7. RATE AND GAP CALCULATIONS .........................................................105Glucose Infusion Rate ..................................................................... 105Calculated Serum Osmolality ........................................................ 105Anion Gap ....................................................................................... 105

8. NUTRITION, FORMULA PREPARATION, AND CALORIC COUNTS ..........107Preparation of Infant Formula for Standard and

Soy Formulas ................................................................................ 107Common Caloric Supplements ...................................................... 108Enteral Formulas, Including Their Main

Nutrient Components ................................................................. 108Composition of Fluids Frequently Used in Oral Rehydration ..... 116Dietary Reference Intakes ............................................................... 117Fluoride Sources and Supplementation ........................................ 119

9. UMBILICAL VEIN AND ARTERY CATHETERIZATION MEASUREMENTS ....121Using Birth Weight to Measure Catheter Length ......................... 121Using Shoulder-Umbilical Length to Measure Umbilical

Artery Catheter Length ............................................................... 123Using Shoulder-Umbilical Length to Measure Umbilical

Vein Catheter Length .................................................................. 124

10. DOSES AND LEVELS OF COMMON ANTI BIOTIC AND ANTISEIZURE MEDICATIONS...............................................................125Antibiotics ........................................................................................ 126Antiseizure ....................................................................................... 134

11. APPENDIXES ......................................................................................143Acetaminophen Toxicity Nomogram ............................................. 144Rabies Guidelines ............................................................................ 145Immunization Schedules ................................................................ 146Periodicity Schedule ................................................................... insertFrench Catheter Scale ................................................................ insert

ix

INTRODUCTION

Reference Range Values for Pediatric Care was created in response to an overwhelming need from pediatricians, pediatric residents, nurse practitioners, and other pediatric providers who acknowledged the utility of the reference range values section in Quick Reference Guide to Pediatric Care, part of the American Academy of Pediatrics (AAP) point-of-care offerings, which also include the AAP Textbook of Pediatric Care and Pediatric Care Online. Pediatricians have been quick to recog-nize both the ease of accessibility and breadth of knowledge that the Pediatric Care series allows, even as they continued to make “normal values” the most searched-for term in the series. As an answer to this, and in our effort to strike the ultimate balance between the practical and the comprehensive, we decided to develop a short stand-alone handbook of reference range values. This handbook was designed with the busy practitioner in mind. Compact and clear-cut, it provides the most commonly used reference range values, charts, and formulas at your fingertips. The values span the gamut of age groups from newborn to adolescence, with a particu-lar emphasis throughout on the values needed for the management of preterm newborns younger than 37 weeks. This focus is complemented by sections that address common newborn scores (eg, Apgar, Ballard) as well as the AAP newborn hyperbilirubinemia management charts. We have also included a new section for the series on commonly used antibiotics and antiseizure medications with recommended serum drug target levels; preterm and neonatal populations are highlighted to benefit the pediatrician responsible for the complex dosing for this age group. To that effect, we enlisted the help of 2 experienced pediatric pharmacists as contributing editors, Katherine Pham PharmD, BCPS, and Sara Rooney PharmD, BCPS. Additionally, the handbook features pain scales, growth measures for extremities, and the AAP immuniza-tion and periodicity schedules. In writing Reference Range Values for Pediatric Care, I would like to thank 4 integral people without whom this book would not have come to light. Firstly, I am indebted to Dr Deborah Campbell, Division Chief

x Reference Range Values for Pediatric Care

of Neonatology at the Children’s Hospital at Montefiore, for all her help with the inception of the original chapter and, subsequently, this handbook. I would also like to thank Martha Cook for coalescing the concept of this book alongside Mark Grimes and the AAP editorial team. Lastly, I would like to thank Alain Park for his keen eye, fantastic input, and for keeping me on track during development. I’d also like to give a special thanks to Drs Jennifer Chapman (pediatric emergency medicine), Aisha Davis (hospitalist division), and Kristin Arcana (pediatric endocrinology) at Children’s National Health System for their thorough review and valuable contribution to the text. As we strive to improve the health of all children, I hope this book is another little step to that end. Be on the lookout for the upcoming app!

Lamia Soghier, MD, FAAP

1

1. Conversions

CONVERSION FORMULAS

Height (length)1 mm = 0.04 in1 cm = 0.4 in

1 in = 2.54 cm1 m = 39.37 in

Weight60 mg = 1 g28.35 g = 1 oz453.6 g = 1 lb1,000 g = 1 kg1 kg = 2.2046 lb

1 L = 1.06 qt1 fl oz = 29.57 mL1 tbsp = 15 mL1 tsp = 5 mL

Milligram–milliequivalent conversionsmEq/L = mg/L × valence/atomic weightEquivalent weight = atomic weight/

valence

mg/L = mEq/L × atomic weight/valence

Milligram-millimole conversionsmmol/L = mg/L ÷ molecular weight

MilliosmolsThe milliequivalent (mEq) is roughly equivalent to the milliosmol (mOsm), the unit of measure of osmotic pressure or tonicity. One osmole (Osm) is the amount of a substance that dissociates in solution to form one mole (mol) of osmotically active particles.

2 Reference Range Values for Pediatric Care

TEMPERATURE CONVERSION

Celsius: ºC = 5/9 (ºF − 32)Fahrenheit: ºF = 9/5 (ºC + 32)

Fahrenheit to Celsius Conversion

ºF ºC ºF ºC ºF ºC ºF ºC ºF ºC125 51.6 92 33.3 59 15.0 26 -3.3 -7 -21.6124 51.1 91 32.7 58 14.4 25 -3.9 -8 -22.2123 50.5 90 32.2 57 13.9 24 -4.4 -9 -22.8122 50.0 89 31.6 56 13.3 23 -5.0 -10 -23.3121 49.4 88 31.1 55 12.8 22 -5.6 -11 -23.9120 48.8 87 30.5 54 12.2 21 -6.1 -12 -24.4119 48.3 86 30.0 53 11.7 20 -6.7 -13 -25.0118 47.7 85 29.4 52 11.1 19 -7.2 -14 -25.5117 47.2 84 28.9 51 10.5 18 -7.8 -15 -26.1116 46.6 83 28.3 50 10.0 17 -8.3 -16 -26.6115 46.1 82 27.8 49 9.4 16 -8.9 -17 -27.2114 45.5 81 27.2 48 8.9 15 -9.4 -18 -27.8113 45.0 80 26.6 47 8.3 14 -10.0 -19 -28.3112 44.4 79 26.1 46 7.8 13 -10.5 -20 -28.9111 43.8 78 25.5 45 7.2 12 -11.1 -21 -29.4110 43.3 77 25.0 44 6.7 11 -11.7 -22 -30.0109 42.7 76 24.4 43 6.1 10 -12.2 -23 -30.5108 42.2 75 23.9 42 5.6 9 -12.8 -24 -31.1107 41.6 74 23.3 41 5.0 8 -13.3 -25 -31.6106 41.1 73 22.8 40 4.4 7 -13.9 -26 -32.2105 40.5 72 22.2 39 3.9 6 -14.4 -27 -32.7104 40.0 71 21.6 38 3.3 5 -15.0 -28 -33.3103 39.4 70 21.1 37 2.8 4 -15.5 -29 -33.9102 38.9 69 20.5 36 2.2 3 -16.1 -30 -34.4101 38.3 68 20.0 35 1.7 2 -16.7 -31 -35.0100 37.7 67 19.4 34 1.1 1 -17.2 -32 -35.5

99 37.2 66 18.9 33 0.6 0 -17.8 -33 -36.198 36.6 65 18.3 32 0.0 -1 -18.3 -34 -36.697 36.1 64 17.8 31 -0.6 -2 -18.9 -35 -37.296 35.5 63 17.2 30 -1.1 -3 -19.4 -36 -37.795 35.0 62 16.7 29 -1.7 -4 -20.0 -37 -38.394 34.4 61 16.1 28 -2.2 -5 -20.5 -38 -38.993 33.9 60 15.5 27 -2.8 -6 -21.1 -39 -39.4

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3

2. Scales and Scoring

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0 Points 1 Point 2 PointsPoints Totaled

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Limp Some flexion Active motion

Pulse Absent <100 beats/min>100 beats/min

Grimace (reflex irritability)

No response GrimaceCry or active withdrawal

Appearance (skin color/complexion)

Pale or blueAcrocyanotic (body pink, extremities blue

Completely pink

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AbsentWeak cry; hypo-ventilation

Good;crying

Severely depressed 0–3

Moderately depressed 4–6

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PAIN SCALES

FLACC Pain ScaleEach of the 5 categories is scored from 0 to 2: (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability. The total score will be between 0 and 10.

For pediatric/preverbal (validated 2 months to 7 years)Not valid for children with developmental delay

CATEGORY SCORING0 1 2

Face No particular expres-sion or smile

Occasional grimace or frown, withdrawn, disinterested

Frequent to constant quivering chin, clenched jaw

Legs Normal position or relaxed

Uneasy, restless, tense

Kicking or legs drawn up

Activity Lying quietly, normal position, moves easily

Squirming, shifting back and forth, tense

Arched, rigid, or jerking

Cry No cry (awake or asleep)

Moans or whimpers; occasional complaint

Crying steadily, screams or sobs, frequent complaints

Consolability Content, relaxed Reassured by occasional touching, hugging, or being talked to; distractible

Difficult to console or comfort

The FLACC Behavioral Scale for Postoperative Pain in Young Children. Merkel Sl, et al. (1997).

The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatric Nursing, 23(3), 293–297.

Wong-Baker FACES® Foundation (2014). Wong-Baker FACES® Pain Rating Scale. Retrieved January 1, 2014, with permission from http://www.WongBakerFACES.org.

7Scales and Scoring

Pediatric Early Warning Score (PEWS)

0 1 2 3 ScoreBehavior Playing/

AppropriateSleeping Irritable Lethargic/

confusedORReduced response to pain

Cardio-vascular

PinkORCapillary refill 1–2 seconds

Pale or duskyORCapillary refill3 seconds

Grey or cyanoticORCapillary refill 4 secondsORTachycardia of 20 beats/min above normal rate

Grey or cyanotic and mottledORCapillary refill 5 seconds or aboveORTachycardia of 30 beats/min above normal rateORBradycardia

Respiratory Within normal parameters, no retrac-tions

>10 breaths/min above normal param-etersORUsing accessory musclesOR30+%Fio2 or 3+ liters/min

>20 breaths/min above normal parametersORRetractionsOR40+%Fio2 or 6+ liters/min

≥5 breaths/min below normal pa-rameters with retractions, or, gruntingOR50+%Fio2 or 8+ liters/min

• Score by starting with the most severe parameters first.

• Score 2 extra for every 15-minute nebs (includes continuous nebs) or persistent postoperative vomiting.

• Use “liters/min” to score regular nasal cannula.

• Use “Fio2” to score a high flow nasal cannula.

Adapted from Monaghan A. Detecting and managing deterioration in children. Paedriatic Nursing. 2005;17:32–35.


Heart Rate at Rest (beats/min)

Respiratory Rate at Rest (breaths/min)

Birth – 1 mo 100–180 40–60

1 – 12 mo 100–180 35–40

1 – 3 y 70–110 25–30

4 – 6 y 70–110 21–23

7 – 12 y 70–110 19–21

13 – 19 y 55–90 16–18

Pediatric Early Warning Score (PEWS), continued

9

3. Growth

DETERMINING BODY SURFACE AREABased on the nomogram, a straight line joining the patient’s height and weight will intersect the center column at the calculated body surface area (BSA). For children of normal height and weight, use the child’s weight in pounds, and then read across to the corresponding BSA in meters squared. Alternatively, you can use Mosteller’s formula.

Nomogram and equation to determine body surface area. From Arcara KM, Tschudy MM, eds. The Harriet Lane Handbook. 19th ed. St Louis, MO: Mosby; 2012. Reproduced with permission. Copyright © 2012 Elsevier.

1.308070

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50

40

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0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

80

60

70

50

30

40

20

15

10987

6

5

4

3

2

220

200190180170160150140130

120

110

100

90

80

70

60

50

40

30

85807570

65

55

50

45

40

35

302826

24

22

20

181716151413

12

19

60

cm in lbm2 kgFor children ofnormal height

and weight

Wei

ght i

n po

unds

Surfa

ce a

rea

in m

eter

s sq

uare

d

Height Weight

Height (cm) x Weight (kg)3600

Alternative (Mosteller’s formula)Surface area (m2) =

NomogramSA


GROWTH CHARTS Growth Charts 1289

APP

Birth to 24 months: GirlsLength-for-age and Weight-for-age percentiles

Published by the Centers for Disease Control and Prevention, November 1, 2009SOURCE: WHO Child Growth Standards (http://www.who.int/childgrowth/en)

98

95

90

75

50

25

1052

9895907550251052

11Growth

1290 Appendix A

Pediatric Nutrition, 7th Edition

12

Birth

40

38

36

32

20

19

18

17

16

15

14

13

in

HEAD

CIRCUMFERENCE

HEAD

CIRCUMFERENC

30

34

52

48

46

44

cm

20

19

18

in

17

Birth to 24 months: GirlsHead circumference-for-age andWeight-for-length percentiles

NAMERECORD #

42

44

46

52

50

cm

48

50

WEIGHT

WEIGHT

WEIGHT

WEIGHT

kg lb

WEIGHT

14

2018

1416

1210

8642

987

2

incmkglb1

3

WEIGHT

2224

101112

65

E

66 68 70 72 74 76 78 80 82 84 86 88 92 94 969810010210410610890 cmin

Published by the Centers for Disease Control and Prevention, November 1, 2009SOURCE: WHO Child Growth Standards (http://www.who.int/childgrowth/en)

Date Age CommentWeight Length Head Circ.

64

24232221201918

46 4850 52 54 56 58 60 62

987

222018

1416

2426283032343638404244

121314

151617

12

1011

464850

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65

2324 52

242628

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2510

52

989590

75

50

25

1052

11041 424039383735 36343332313029282726 43

4 LENGTH


GROWTH CHARTS, continued

Growth Charts 1293

APP

SOURCE: Developed b

(2000).

y the National Center for Health Statistics in collaboration with

the National Center for Chronic Disease Prevention and Health Promotion

http://www.cdc.gov/growthcharts

2 to 20 years: Girls

Stature Weight-for-age percentiles-for-age and

NAME

RECORD #

Revised and corrected November 21, 2000.

W

E

I

G

H

T

W

E

I

G

H

T

cm

150

155

160

165

170

175

180

185

190

lb

30

40

50

60

70

80

90

100

110

120

130

140

150

160

170

180

190

200

210

220

230

kg10

15

20

25

30

35

105

45

50

55

60

65

70

75

80

85

90

95

100

20

20

S

T

A

T

U

R

E

40

lb

30

40

50

60

70

80

S

T

A

T

U

R

E

62

42

44

46

48

60

58

52

54

56

in

30

32

34

36

38

40

50

74

76

72

70

68

66

64

62

60

in

kg10

15

20

25

30

35

80

85

90

95

100

105

110

115

120

125

130

135

140

145

150

155

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

12 13 14 15 16 17 18 19

AGE (YEARS)

AGE (YEARS)

160

cm 113 4 5 6 7 8 9 10

95

90

75

50

25

105

95

90

75

50

25

105

Date

Mother’s Stature Father’s Stature

Age Weight Stature BMI*

13Growth

Page 42 [ Series 11, No. 246

Figure 24. Clinical growth chart 5th, 10th, 25th, 50th, 75th, 85th, 90th, 95th percentiles, 2 to 20 years: Girls body mass index-for-age



1296 Appendix A


56

52

48

44

40

36

32

28

24

20

lb lb

56

52

48

44

40

36

32

28

24

20

60

in

cm

31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47

kg kg

19

18

17

16

15

14

13

12

11

10

9

8

27

26

25

24

23

22

21

20

26

25

24

23

22

21

20

19

18

17

16

15

14

13

12

11

10

9

8

28

29

30

31

32

33

34

64

68

72

76kg lb

kg

kg lb

lb

80 85 90 95 100 105 110 115 120

Date Age Weight Stature Comments

50

25

75

90

95

510

85

STATURE

Weight-for-stature percentiles: GirlsNAME

RECORD #

SOURCE: Developed b

(2000).




15Growth

Growth Charts 1299

APP



NAME

RECORD #

W

E

I

G

H

T

W

E

I

G

H

T

S

T

A

T

U

R

E

S

T

A

T

U

R

E

kg10

15

20

25

30

35

80

85

90

95

100

105

110

115

120

125

130

135

140

145

150

155

cm

150

155

160

165

170

175

180

185

190

kg10

15

20

25

30

35

105

45

50

55

60

65

70

75

80

85

90

95

100

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

12 13 14 15 16 17 18 19 20

AGE (YEARS)

AGE (YEARS)

40

160

cm 113 4 5 6 7 8 9 10

90

75

50

25

10

90

75

50

25

10

97

3

97

3

lb

30

40

50

60

70

80

lb

30

40

50

60

70

80

90

100

110

120

130

140

150

160

170

180

190

200

210

220

230

Date



62

42

44

46

48

60

58

52

54

56

in

30

32

34

36

38

40

50

74

76

72

70

68

66

64

62

60

in

SOURCE: Developed b

(2000).





3rd to 97th


GROWTH CHARTS, continued1300 Appendix A



Body mass index-for-age percentilesNAME

RECORD #

SOURCE: Developed b

(2000).




2 543 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

26

24

22

20

18

16

14

12

kg/m2

28

26

24

22

20

18

16

14

12

kg/m2

30

32

34

BMI

BMI

AGE (YEARS)

13

15

17

19

21

23

25

27

13

15

17

19

21

23

25

27

29

31

33

35

Date Age Weight Stature BMI* Comments

90

85

75

50

10

25

97

3

95

3rd to 97th

17Growth

Appendix A

APP

Appendix A - 1Set I



1288 Appendix A


19Growth

Figure 21. Clinical growth chart 5th, 10th, 25th, 50th, 75th, 90th, 95th percentiles, 2 to 20 years: Boys stature-for-age and weight-for-age

Series 11, No. 246 [ Page 39


GROWTH CHARTS, continued Series 11, No. 246 [ Page 41

Figure 23. Clinical growth chart 5th, 10th, 25th, 50th, 75th, 85th, 90th, 95th percentiles, 2 to 20 years: Boys body mass index-for-age

21Growth

Growth Charts 1295

APP

56

52

48

44

40

36

32

28

24

20

lb lb

56

52

48

44

40

36

32

28

24

20

60

in

cm

31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47

kg kg

19

18

17

16

15

14

13

12

11

10

9

8

27

26

25

24

23

22

21

20

26

25

24

23

22

21

20

19

18

17

16

15

14

13

12

11

10

9

8

28

29

30

31

32

33

34

64

68

72

76kg lb

kg

kg lb

lb

80 85 90 95 100 105 110 115 120

Date Age Weight Stature Comments

95

50

25

75

90

95

510

85

STATURE

Weight-for-stature percentiles: BoysNAME

RECORD #

SOURCE: Developed b

(2000).




22 Reference Range Values for Pediatric Care Growth Charts 1297

APP

2 to 20 years: Boys


NAME

RECORD #

SOURCE: Developed b

(2000).





W

E

I

G

H

T

W

E

I

G

H

T

S

T

A

T

U

R

E

S

T

A

T

U

R

E

lb

30

40

50

60

70

80

lb

30

40

50

60

70

80

90

100

110

120

130

140

150

160

170

180

190

200

210

220

230

kg10

15

20

25

30

35

80

85

90

95

100

105

110

115

120

125

130

135

140

145

150

155

160

cm

cm

150

155

160

165

170

175

180

185

190

kg10

15

20

25

30

35

105

45

50

55

60

65

70

75

80

85

90

95

100

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

12 13 14 15 16 17 18 19 20

AGE (YEARS)

AGE (YEARS)

40

90

75

50

25

10

90

75

50

25

10

113 4 5 6 7 8 9 10

97

3

97

3

62

42

44

46

48

60

58

52

54

56

in

30

32

34

36

38

40

50

74

76

72

70

68

66

64

62

60

inDate



Appendix A - 1Set II

3rd to 97th


23Growth

1298 Appendix A


2 to 20 years: Boys

Body mass index-for-age percentilesNAME

RECORD #

SOURCE: Developed b

(2000).




2 543 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

26

24

22

20

18

16

14

12

kg/m2

28

26

24

22

20

18

16

14

12

kg/m2

30

32

34

BMI

BMI

AGE (YEARS)

13

15

17

19

21

23

25

27

13

15

17

19

21

23

25

27

29

31

33

35

90

75

50

25

10

85

Date Age Weight Stature BMI* Comments

97

3

95

3rd to 97th



Neonatal Growth Curve — Girls, WeightA

500

1000

1500

2000

2500

3000

3500

4000

4500

23 25 27 29 31 33 35 37 39 41

Weight, gm

Gestational Age, weeks

90th

97th

75th

50th

25th

10th

3rd

B

20

25

30

35

40

45

50

55

23 25 27 29 31 33 35 37 39 41Gestational Age, weeks

C

Cen

timet

ers

Cen

timet

ers

D

From Olsen IE, Groveman S, Lawson ML, Clark R, Zemel B. New intrauterine growth curves based on U.S. data. Pediatrics. 2010;125(2):e214– e244

25Growth

Neonatal Growth Curve — Girls, Length and Head Circumference

500

1000

1500

2000

2500

3000

3500

4000

4500

23 25 27 29 31 33 35 37 39 41

Weight, gm


90th

97th

75th

50th

25th

10th

3rd

B

20

25

30

35

40

45

50

55


90th97th

75th50th25th10th3rd

90th97th

75th

50th

25th

10th

3rd

Head Circumference

Length

500

1000

1500

2000

2500

3000

3500

4000

4500

23 25 27 29 31 33 35 37 39 41

Weight, gm


Cen

timet

ers

Cen

timet

ers

90th

97th

75th

50th

25th

10th

3rd

D

20

25

30

35

40

45

50

55


90th97th

75th50th25th10th3rd

90th97th

75th

50th

25th

10th

3rd

From Olsen IE, Groveman S, Lawson ML, Clark R, Zemel B. New intrauterine growth curves based on U.S. data. Pediatrics. 2010;125(2):e214 – e244



500

1000

1500

2000

2500

3000

3500

4000

4500

23 25 27 29 31 33 35 37 39 41

Weight, gm


20

25

30

35

40

45

50

55


C

500

1000

1500

2000

2500

3000

3500

4000

4500

23 25 27 29 31 33 35 37 39 41

Weight, gm


Cen

timet

ers

Cen

timet

ers

90th

97th

75th

50th

25th

10th

3rd

D

20

25

30

35

40

45

50

55


FIGURE 1New gender-specific intrauterine growth curves for girls’ weight-for-age (A), girls’ length- and HC-for-age (B), boys’ weight-for-age (C), and boys’ length- andHC-for-age (D). Of note, 3rd and 97th percentiles on all curves for 23 weeks should be interpreted cautiously given the small sample size; for boys’ HC curveat 24 weeks, all percentiles should be interpreted cautiously because the distribution of data is skewed left. Adapted from Groveman.

Neonatal Growth Curve — Boys, Weight


27Growth500

1000

1500

2000

2500

3000

3500

4000

4500

23 25 27 29 31 33 35 37 39 41

Weight, gm


20

25

30

35

40

45

50

55


500

1000

1500

2000

2500

3000

3500

4000

4500

23 25 27 29 31 33 35 37 39 41

Weight, gm


Cen

timet

ers

Cen

timet

ers

90th

97th

75th

50th

25th

10th

3rd

D

20

25

30

35

40

45

50

55


90th97th

75th50th25th10th3rd

90th97th

75th

50th

25th

10th

3rd

Head Circumference

Length

New gender-specific intrauterine growth curves for girls’ weight-for-age (A), girls’ length- and HC-for-age (B), boys’ weight-for-age (C), and boys’ length- andHC-for-age (D). Of note, 3rd and 97th percentiles on all curves for 23 weeks should be interpreted cautiously given the small sample size; for boys’ HC curveat 24 weeks, all percentiles should be interpreted cautiously because the distribution of data is skewed left. Adapted from Groveman.

Neonatal Growth Curve — Boys, Length and Head Circumference




Growth Charts 1313

Appendix A 1313

APP

Fig. A-4.2

Reproduced with permission from Fenton TR, Kim JH. A systematic review and meta-analysis to revise the Fenton growth chart for preterm infants. BMC Pediatr. 2013;13:59.doi:10.1186/1471-2431-13-59

Fenton Preterm Growth Chart — Girls

© 2013 Fenton and Kim; licensee BioMed Central Ltd.

29Growth1312 Appendix A


Appendix A - 4

Fig. A-4.1

Reproduced with permission from Fenton TR, Kim JH. A systematic review and meta-analysis to revise the Fenton growth chart for preterm infants. BMC Pediatr. 2013;13:59.doi:10.1186/1471-2431-13-59

Fenton Preterm Growth Chart — Boys

© 2013 Fenton and Kim; licensee BioMed Central Ltd.



Appendix A


Appendix A - 5

Fig. A-5.1Low Birth Weight Growth ChartsIHDP Low Birth Weight and Very Low Birth Weight Growth Charts

31Growth

Fig. A-5.2



Appendix A


Fig. A-5.5GROWTH CHARTS, continued

33Growth

Fig. A-5.6



1316 Appendix A


Fig. A-5.3

1320 Appendix A



35Growth

Growth Charts 1317

Fig. A-5.4Fig. A-5.8


1320 Appendix A



37Growth

Fig. A-5.8


GROWTH CHARTS FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS

Several growth charts are available for children with special health care needs. Listed below are some charts for children with genetic condi-tions that can alter growth.

• Trisomy 21 (Down syndrome) (Cronk, 1988)• Prader-Willi syndrome (Holm, 1995)• Williams syndrome (Morris, 1988)• Cornelia de Lange syndrome (Kline, 1993)• Turner syndrome (Ranke, 1983; Lyon, 1985)• Rubinstein-Taybi syndrome (Stevens, 1990)• Marfan syndrome (Pyeritz, 1983; Pyertiz, 1985)• Achondroplasia (Horton, 1978)

Currently, the CDC recommends that clinicians use the regular CDC growth charts for assessment of all these children. The inherent limitations of studies performed in each of these specific populations (eg, small sample size, retrospective nature of data, presence of other congenital anomalies such as cardiac conditions, inability to ascertain the nutritional status of these children, lack of ethnic diversity, and old data) may not afford the clinician an accurate assessment of growth in these children. We have provided a sample of the Trisomy 21 growth chart, but clini-cians should be aware of the inherent limitations of this study.

39Growth

From Cronk C, Crocker AC, Pueschel SM, et al. Growth charts for children with Down syndrome: 1 month to 18 years of age. Pediatrics. 1988;81(1):102–110.

Height and Weight for Girls With Down Syndrome (1–36 mo)



Height and Weight for Girls With Down Syndrome (2–18 y)

GROWTH CHARTS FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS, continued

41Growth

Height and Weight for Boys With Down Syndrome (1–36 mo)



GROWTH CHARTS FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS, continued

Height and Weight for Boys With Down Syndrome (2–18 y)


43Growth

References Butler M, Lee P, Whitman, B, eds. Management of Prader-Willi Syndrome. 3rd ed. New York, NY: Springer-Verlag; 2006

Cronk C, Crocker AC, Pueschel SM, et al. Growth charts for children with Down syndrome: 1 month to 18 years of age. Pediatrics. 1988;81(1):102–110

Health Resources and Services Administration. The CDC Growth Charts for Children With Special Health Care Needs Web site. http://depts.washington.edu/growth/cshcn/text/page2b.htm. Accessed on February 7, 2014

Horton WA, Rotter JI, Rimoin DL, et al. Standard growth curves for achondroplasia. J Pediatr. 1978;93(3):435–438

Kline AD, Barr M, Jackson LG. Growth manifestations in the Brachmann-deLange syn-drome. Am J Med Genet. 1993;47(7):1042–1049

Lyon AF, Preece MA, Grant DB. Growth curves for girls with Turner syndrome. Arch Dis Child. 1985;60(10):932–935

Morris CA, Demsey SA, Leonard CO, et al. Natural history of Williams syndrome: physical characteristics. J Pediat. 1988;113(2):318–326

Pyeritz RE. Marfan Syndrome and Related Disorders. In: Rimoin DL, Pyeritz RE, Korf B, eds. Emery and Rimoin’s Principles and Practice of Medical Genetics. 5th ed. New York, NY: Churchill Livingstone; 2006

Pyeritz RE. Growth and anthropometrics in the Marfan syndrome. In: Papadatos CJ, Bartsocas CS, eds. Endocrine Genetics and Genetics of Growth. New York, NY: Alan R. Liss Inc; 1985

Ranke MB, Pfluger H, Rosendahl W, et al. Turner syndrome: spontaneous growth in 150 cases and review of the literature. Eur J Pediatr. 1983;141(2):81–88

Stevens CA, Hennekam RC, Blackburn BL. Growth in the Rubinstein-Taybi syndrome. Am J Med Genet Suppl. 1990;6:51–55


GROWTH MEASURES FOR EXTREMITIES/EAR ABOVE EYE LEVELSThe following measures show the normal ranges for upper and lower extremities and level of ears for newborns. They can be used to determine abnormalities (eg, newborns with suspected genetic anomalies or children with contractures where full limb length may not be feasible). The illustrations show the optimal method to measure. The graph can be used to plot measurements and determine percentiles.

Upper Arm Length

From Rollins JD, Tribble LM, Collins JS, et al, eds. Growth References. 3rd ed. Greenwood, SC: Greenwood Genetic Center, 2011.

45Growth

Forearm Length



Long Bone Length–Upper Limb


47Growth

Long Bone Length–Lower Limb



Lower Leg Length


49Growth

Ear Above Eye Level (Gestational Age)



Ear Above Eye Level (Birth Weight)


51Growth

PRIMARY TEETH ERUPTION CHARTdevelopment

Upper Teeth Erupt ShedCentral incisor 8-12 months 6-7 yearsLateral incisor 9-13 months 7-8 years

Canine (cuspid) 16-22 months 10-12 years

First molar 13-19 months 9-11 years

Second molar 23-33 months 10-12 years

Lower Teeth Erupt ShedSecond molar 23-31 months 10-12 years

First molar 14-18 months 9-11 years

Canine (cuspid) 17-23 months 9-12 yearsLateral incisor 10-16 months 7-8 yearsCentral incisor 6-10 months 6-7 years

Primary Teeth eruption Chart

Primary Teeth

From: American Dental Association. Tooth eruption: the primary teeth. J Am Dent Assoc. 2005;136(11):1619.Copyright © 2014 American Dental Association. All rights reserved. Reprinted with permission.

53

4. Blood Pressure

BLOOD PRESSURE NOMOGRAMS

Healthy Term Newborns During the First 12 Hours of Life

80

60

40

20

0 1 2 3 4 5

Systolic(torr)

A B

Diastolic(torr)

Birth Weight (kg) Birth Weight (kg)

Systolic(torr)

Pulse(torr)

80

60

40

20

0 1 2 3 4 5

80

60

40

20

0 1 2 3 4 5

80

60

40

20

0 1 2 3 4 5

A, Linear regressions (broken lines) and 95% confidence limits (solid lines) of systolic (top) and diastolic (bottom) aortic blood pressures on birth weight in 61 healthy term newborns during the first 12 hours after birth. For systolic pressure, y = 7.13x + 40.45; r = 0.79. For diastolic pressure, y = 4.81x + 22.18; r = 0.71. For both, n = 413 and p < .001. B, Linear regressions (broken lines) and 95% confidence limits (solid lines) of mean pressure (top) and pulse pressure (systolic-diastolic pressure amplitude) (bottom) on birth weight in 61 healthy term newborns during the first 12 hours after birth. For mean pressure, y = 5.16x + 29.80; n = 443; r = 0.80. For pulse pressure, y = 2.31x + 18.27; n = 413; r = 0.45. For both, p < .001.

From Versmold HT, Kitterman JA, Phibbs RH, Gregory GA, Tooley WH. Aortic blood pres-sure during the first 12 hours of life in infants with birth weight 610 to 4,220 grams. Pediatrics. 1981;67(5):607– 613.


Preterm and Full-term Newborns During the First Day of Life (According to Birth Weight)

.750

0

10

20

30

40

50

60

70

80

90

1.000 1.250 1.500 1.750 2.000 2.250 2.500 2.750 3.000 3.250 3.500 3.750 4.000

Birth Weight (kg)

Lower 95% C.L.

Lower 95% C.L.

Upper 95% C.L.

Syst

olic

Blo

od P

ress

ure

(mm

Hg)

.750

0

10

20

30

40

50

60

70

1.000 1.250 1.500 1.750 2.000 2.250 2.500 2.750 3.000 3.250 3.500 3.750 4.000

Birth Weight (kg)

Upper 95% C.L.

Dia

stol

ic B

lood

Pre

ssur

e (m

m H

g)

A, Linear regression of mean systolic and diastolic blood pressures by birth weight on day 1 of life, with 95% confidence limits (CLs) (upper and lower dashed lines).

From Zubrow AB, Hulman S, Kushner H, Falkner B. Determinants of blood pressure in infants admitted to neonatal intensive care units: a prospective multicenter study. Philadelphia Neonatal Blood Pressure Study Group. J Perinatol. 1995;15(6):470–479. Reproduced with permission. Copyright © 1995 Nature Publishing Group.

A

BLOOD PRESSURE NOMOGRAMS, continued

55Blood Pressure

Preterm and Full-term Newborns During the First Day of Life (According to Gestational Age)

22 24 26 28 30 32 34 36 38 40 42

0

10

20

30

40

50

60

70

80

90

Gestational Age (weeks)

Lower 95% C.L.

Upper 95% C.L.

Upper 95% C.L.

Syst

olic

Blo

od P

ress

ure

(mm

Hg)

22 24 26 28 30 32 34 36 38 40 42

0

10

20

30

40

50

60

70

Gestational Age (weeks)

Lower 95% C.L.

Dia

stol

ic B

lood

Pre

ssur

e (m

m H

g)

B, Linear regression of mean systolic and diastolic blood pressures by gestational age on day 1 of life, with 95% confidence limits (CLs) (upper and lower dashed lines).

From Zubrow AB, Hulman S, Kushner H, Falkner B. Determinants of blood pressure in infants admitted to neonatal intensive care units: a prospective multicenter study. Philadelphia Neonatal Blood Pressure Study Group. J Perinatol. 1995;15(6):470–479. Reproduced with permission. Copyright © 1995 Nature Publishing Group.

B


C

BLOOD PRESSURE NOMOGRAMS, continued

Preterm and Full-term Newborns According to Post- conceptional Age

C, Linear regression of mean systolic and diastolic blood pressures by postconceptual age in weeks, with 95% confidence limits (upper and lower dashed lines).

From Zubrow AB, Hulman S, Kushner H, et al. Determinants of blood pressure in infants admitted to neonatal intensive care units: a prospective multicenter study. Philadelphia Neonatal Blood Pressure Study Group. J Perinatol. 1995;15(6):470–479. Reproduced with permission. Copyright © 1995 Nature Publishing Group.

24 26 28 30 32 34 36 38 40 42 44 46

0

10

20

30

40

50

60

70

80

90

100

110

24 26 28 30 32 34 36 38 40 42 44 46

0

10

20

30

40

50

60

70

80

90

100

Post Conceptional Age (weeks)

Post Conceptional Age (weeks)

Lower 95% C.L.

Upper 95% C.L.

Upper 95% C.L.

Syst

olic

Blo

od P

ress

ure

(mm

Hg)

Lower 95% C.L.

Dia

stol

ic B

lood

Pre

ssur

e (m

m H

g)

57Blood Pressure

Children Younger Than 1 Year

115110105100

95908580757065

0 1 2 3 4 5MONTHS

6 7 8 9 10 11 12

SYST

OLI

C B

P

115110105100

95908580757065

0 1 2 3 4 5MONTHS

6 7 8 9 10 11 12

SYST

OLI

C B

P

75

70

65

60

55

50

45

0 1 2 3 4 5MONTHS

6 7 8 9 10 11 12

DIA

STO

LIC

BP

(K4)

75

70

65

60

55

50

45

0 1 2 3 4 5MONTHS

6 7 8 9 10 11 12

DIA

STO

LIC

BP

(K4)

50th

75th

90th95th

50th

75th

90th95th

50th

75th

90th

95th

50th

75th

90th

95th

76 98 101 104 105 106 106 106 106 106 108 105 105

68 65 64 64 65 66 66 66 66 67 67 67 67

54 55 56 58 51 63 66 68 70 72 74 75 77

4 4 4 5 5 6 7 8 9 9 10 10 11

90th Percentile

Systolic BP 87 101 106 106 106 105 105 106 105 105 105 105 105

Diastolic BP 68 65 63 63 63 65 66 67 68 68 69 69 69

Height CM 51 59 63 66 68 70 72 73 74 75 77 78 80

Weight KG 4 4 5 5 6 7 8 9 9 10 10 11 11

A, Age-specific percentiles of blood pressure (BP) measurements in boys—birth to 12 months of age; Korotkoff phase IV (K4) used for diastolic BP. B, Age-specific percentiles of blood pressure (BP) measurements in girls—birth to 12 months of age; Korotkoff phase IV (K4) used for diastolic BP.

From Task Force on Blood Pressure Control in Children. Report of the Second Task Force on Blood Pressure Control in Children—1987. Pediatrics. 1987;79(1):1–25.


BLOOD PRESSURE LEVELS FOR BOYS BY AGE AND HEIGHT PERCENTILE

Systolic BP (mm Hg)← Percentile of Height →

Diastolic BP (mm Hg)← Percentile of Height →

Age (Year)

BPPercen-tile 5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th

1 50th 80 81 83 85 87 88 89 34 35 36 37 38 39 39

90th 94 95 97 99 100 102 103 49 50 51 52 53 53 54

95th 98 99 101 103 104 106 106 54 54 55 56 57 58 58

99th 105 106 108 110 112 113 114 61 62 63 64 65 66 66

2 50th 84 85 87 88 90 92 92 39 40 41 42 43 44 44

90th 97 99 100 102 104 105 106 54 55 56 57 58 58 59

95th 101 102 104 106 108 109 110 59 59 60 61 62 63 63

99th 109 110 111 113 115 117 117 66 67 68 69 70 71 71

3 50th 86 87 89 91 93 94 95 44 44 45 46 47 48 48

90th 100 101 103 105 107 108 109 59 59 60 61 62 63 63

95th 104 105 107 109 110 112 113 63 63 64 65 66 67 67

99th 111 112 114 116 118 119 120 71 71 72 73 74 75 75

4 50th 88 89 91 93 95 96 97 47 48 49 50 51 51 52

90th 102 103 105 107 109 110 111 62 63 64 65 66 66 67

95th 106 107 109 111 112 114 115 66 67 68 69 70 71 71

99th 113 114 116 118 120 121 122 74 75 76 77 78 78 79

5 50th 90 91 93 95 96 98 98 50 51 52 53 54 55 55

90th 104 105 106 108 110 111 112 65 66 67 68 69 69 70

95th 108 109 110 112 114 115 116 69 70 71 72 73 74 74

99th 115 116 118 120 121 123 123 77 78 79 80 81 81 82

6 50th 91 92 94 96 98 99 100 53 53 54 55 56 57 57

90th 105 106 108 110 111 113 113 68 68 69 70 71 72 72

95th 109 110 112 114 115 117 117 72 72 73 74 75 76 76

99th 116 117 119 121 123 124 125 80 80 81 82 83 84 84

7 50th 92 94 95 97 99 100 101 55 55 56 57 58 59 59

90th 106 107 109 111 113 114 115 70 70 71 72 73 74 74

95th 110 111 113 115 117 118 119 74 74 75 76 77 78 78

99th 117 118 120 122 124 125 126 82 82 83 84 85 86 86

8 50th 94 95 97 99 100 102 102 56 57 58 59 60 60 61

90th 107 109 110 112 114 115 116 71 72 72 73 74 75 76

95th 111 112 114 116 118 119 120 75 76 77 78 79 79 80

99th 119 120 122 123 125 127 127 83 84 85 86 87 87 88

59Blood Pressure



Age (Year)


9 50th 95 96 98 100 102 103 104 57 58 59 60 61 61 62

90th 109 110 112 114 115 117 118 72 73 74 75 76 76 77

95th 113 114 116 118 119 121 121 76 77 78 79 80 81 81

99th 120 121 123 125 127 128 129 84 85 86 87 88 88 89

10 50th 97 98 100 102 103 105 106 58 59 60 61 61 62 63

90th 111 112 114 115 117 119 119 73 73 74 75 76 77 78

95th 115 116 117 119 121 122 123 77 78 79 80 81 81 82

99th 122 123 125 127 128 130 130 85 86 86 88 88 89 90

11 50th 99 100 102 104 105 107 107 59 59 60 61 62 63 63

90th 113 114 115 117 119 120 121 74 74 75 76 77 78 78

95th 117 118 119 121 123 124 125 78 78 79 80 81 82 82

99th 124 125 127 129 130 132 132 86 86 87 88 89 90 90

12 50th 101 102 104 106 108 109 110 59 60 61 62 63 63 64

90th 115 116 118 120 121 123 123 74 75 75 76 77 78 79

95th 119 120 122 123 125 127 127 78 79 80 81 82 82 83

99th 126 127 129 131 133 134 135 86 87 88 89 90 90 91

13 50th 104 105 106 108 110 111 112 60 60 61 62 63 64 64

90th 117 118 120 122 124 125 126 75 75 76 77 78 79 79

95th 121 122 124 126 128 129 130 79 79 80 81 82 83 83

99th 128 130 131 133 135 136 137 87 87 88 89 90 91 91

14 50th 106 107 109 111 113 114 115 60 61 62 63 64 65 65

90th 120 121 123 125 126 128 128 75 76 77 78 79 79 80

95th 124 125 127 128 130 132 132 80 80 81 82 83 84 84

99th 131 132 134 136 138 139 140 87 88 89 90 91 92 92

15 50th 109 110 112 113 115 117 117 61 62 63 64 65 66 66

90th 122 124 125 127 129 130 131 76 77 78 79 80 80 81

95th 126 127 129 131 133 134 135 81 81 82 83 84 85 85

99th 134 135 136 138 140 142 142 88 89 90 91 92 93 93

16 50th 111 112 114 116 118 119 120 63 63 64 65 66 67 67

90th 125 126 128 130 131 133 134 78 78 79 80 81 82 82

95th 129 130 132 134 135 137 137 82 83 83 84 85 86 87

99th 136 137 139 141 143 144 145 90 90 91 92 93 94 94




Age (Year)


17 50th 114 115 116 118 120 121 122 65 66 66 67 68 69 70

90th 127 128 130 132 134 135 136 80 80 81 82 83 84 84

95th 131 132 134 136 138 139 140 84 85 86 87 87 88 89

99th 139 140 141 143 145 146 147 92 93 93 94 95 96 97

Abbreviation: BP, blood pressure.

Note: The 90th percentile is 1.28 SD, the 95th percentile is 1.645 SD, and the 99th percentile is 2.326 SD over the mean.

BLOOD PRESSURE LEVELS FOR BOYS BY AGE AND HEIGHT PERCENTILE, continued

61Blood Pressure

BLOOD PRESSURE LEVELS FOR GIRLS BY AGE AND HEIGHT PERCENTILE



Age (Year)


1 50th 83 84 85 86 88 89 90 38 39 39 40 41 41 42

90th 97 97 98 100 101 102 103 52 53 53 54 55 55 56

95th 100 101 102 104 105 106 107 56 57 57 58 59 59 60

99th 108 108 109 111 112 113 114 64 64 65 65 66 67 67

2 50th 85 85 87 88 89 91 91 43 44 44 45 46 46 47

90th 98 99 100 101 103 104 105 57 58 58 59 60 61 61

95th 102 103 104 105 107 108 109 61 62 62 63 64 65 65

99th 109 110 111 112 114 115 116 69 69 70 70 71 72 72

3 50th 86 87 88 89 91 92 93 47 48 48 49 50 50 51

90th 100 100 102 103 104 106 106 61 62 62 63 64 64 65

95th 104 104 105 107 108 109 110 65 66 66 67 68 68 69

99th 111 111 113 114 115 116 117 73 73 74 74 75 76 76

4 50th 88 88 90 91 92 94 94 50 50 51 52 52 53 54

90th 101 102 103 104 106 107 108 64 64 65 66 67 67 68

95th 105 106 107 108 110 111 112 68 68 69 70 71 71 72

99th 112 113 114 115 117 118 119 76 76 76 77 78 79 79

5 50th 89 90 91 93 94 95 96 52 53 53 54 55 55 56

90th 103 103 105 106 107 109 109 66 67 67 68 69 69 70

95th 107 107 108 110 111 112 113 70 71 71 72 73 73 74

99th 114 114 116 117 118 120 120 78 78 79 79 80 81 81

6 50th 91 92 93 94 96 97 98 54 54 55 56 56 57 58

90th 104 105 106 108 109 110 111 68 68 69 70 70 71 72

95th 108 109 110 111 113 114 115 72 72 73 74 74 75 76

99th 115 116 117 119 120 121 122 80 80 80 81 82 83 83

7 50th 93 93 95 96 97 99 99 55 56 56 57 58 58 59

90th 106 107 108 109 111 112 113 69 70 70 71 72 72 73

95th 110 111 112 113 115 116 116 73 74 74 75 76 76 77

99th 117 118 119 120 122 123 124 81 81 82 82 83 84 84

8 50th 95 95 96 98 99 100 101 57 57 57 58 59 60 60

90th 108 109 110 111 113 114 114 71 71 71 72 73 74 74

95th 112 112 114 115 116 118 118 75 75 75 76 77 78 78

99th 119 120 121 122 123 125 125 82 82 83 83 84 85 86


BLOOD PRESSURE LEVELS FOR GIRLS BY AGE AND HEIGHT PERCENTILE, continued



Age (Year)


9 50th 96 97 98 100 101 102 103 58 58 58 59 60 61 61

90th 110 110 112 113 114 116 116 72 72 72 73 74 75 75

95th 114 114 115 117 118 119 120 76 76 76 77 78 79 79

99th 121 121 123 124 125 127 127 83 83 84 84 85 86 87

10 50th 98 99 100 102 103 104 105 59 59 59 60 61 62 62

90th 112 112 114 115 116 118 118 73 73 73 74 75 76 76

95th 116 116 117 119 120 121 122 77 77 77 78 79 80 80

99th 123 123 125 126 127 129 129 84 84 85 86 86 87 88

11 50th 100 101 102 103 105 106 107 60 60 60 61 62 63 63

90th 114 114 116 117 118 119 120 74 74 74 75 76 77 77

95th 118 118 119 121 122 123 124 78 78 78 79 80 81 81

99th 125 125 126 128 129 130 131 85 85 86 87 87 88 89

12 50th 102 103 104 105 107 108 109 61 61 61 62 63 64 64

90th 116 116 117 119 120 121 122 75 75 75 76 77 78 78

95th 119 120 121 123 124 125 126 79 79 79 80 81 82 82

99th 127 127 128 130 131 132 133 86 86 87 88 88 89 90

13 50th 104 105 106 107 109 110 110 62 62 62 63 64 65 65

90th 117 118 119 121 122 123 124 76 76 76 77 78 79 79

95th 121 122 123 124 126 127 128 80 80 80 81 82 83 83

99th 128 129 130 132 133 134 135 87 87 88 89 89 90 91

14 50th 106 106 107 109 110 111 112 63 63 63 64 65 66 66

90th 119 120 121 122 124 125 125 77 77 77 78 79 80 80

95th 123 123 125 126 127 129 129 81 81 81 82 83 84 84

99th 130 131 132 133 135 136 136 88 88 89 90 90 91 92

15 50th 107 108 109 110 111 113 113 64 64 64 65 66 67 67

90th 120 121 122 123 125 126 127 78 78 78 79 80 81 81

95th 124 125 126 127 129 130 131 82 82 82 83 84 85 85

99th 131 132 133 134 136 137 138 89 89 90 91 91 92 93

63Blood Pressure

Abbreviation: BP, blood pressure.

Note: The 90th percentile is 1.28 SD, the 95th percentile is 1.645 SD, and the 99th percentile is 2.326 SD over the mean.



Age (Year)


16 50th 108 108 110 111 112 114 114 64 64 65 66 66 67 68

90th 121 122 123 124 126 127 128 78 78 79 80 81 81 82

95th 125 126 127 128 130 131 132 82 82 83 84 85 85 86

99th 132 133 134 135 137 138 139 90 90 90 91 92 93 93

17 50th 108 109 110 111 113 114 115 64 65 65 66 67 67 68

90th 122 122 123 125 126 127 128 78 79 79 80 81 81 82

95th 125 126 127 129 130 131 132 82 83 83 84 85 85 86

99th 133 133 134 136 137 138 139 90 90 91 91 92 93 93

65

5. Reference Range Values

CEREBROSPINAL FLUID

ComponentPreterm Newborn

Full Term1–7 Days

Full Term8–30 Days

1–3 Months

4 Months– 16 Years Adult

Note: Entries listed in alphabetical order.

Color Clear or xantho-chromic

Clear or xantho chromic

Clear or xantho-chromic

Clear Clear Clear

Red blood cells (/mcL)

3–23 (0–1070)

White blood cells (/mcL)

<22–28 <30 <12 <6 <1 <5

Polymorpho-nuclear cells (/mcL)

<20e–60% <38–60% <10% None (36%–71%)

None (26%–35%)

None

Lymphocytes (/mcL)

0–20 (if <24 h) 0–4 (if 7 days)

≤11 ≤5 ≤5 60%–70%

Monocytes (/mcL)

<4 (50%–99%) ≤4 (50%–99%)

<4 (33%–67%)

<4 (44%–90%)

30%–50%

Protein (mg/dL), mean ± SD(95th percen-tile)

65–150 79 ± 23 (132) 68 ± 20 (100)

58 ± 17 (89) up to 42 days; 53 ± 17 (83) up to 56 days; 5– 45 after 56 days

5–45 5–45

Glucose (mg/dL)

24–63 (1.3– 3.5 mmol/L)

>50 (>2.77 mmol/L)

>50% in serum ≥38 (2.1 mmol/L)

≥45 (≥2.5 mmol/L)

45–72 (2.5–4.0 mmol/L), 60% in serum

2.2– 4.7 mmol/L

CSF glucose/blood glucose

0.55–1.05 ≥0.6 ≥0.6 ≥0.6 ≥0.6


ComponentPreterm Newborn

Full Term1–7 Days

Full Term8–30 Days

1–3 Months

4 Months– 16 Years Adult


Lactate (mmol/L)

5–30 (approx 10% serum value)

<3.1 (if >2 days)

<3.1 <3.1 <2.4 (if 1–12 y)

Opening pressure (mm H2O) in lateral recumbent position

8–11 <28 <28 <28 50–180

CSF volume (mL)

60–100 100–160

Fluctuation with respiration

0.5–1.0 0.5–1.0 0.5–1.0 0.5–1.0 0.5–1.0

Abbreviation: CSF, Cerebral spinal fluid; SD, standard deviation.

Calculating the ratio of red blood cells (RBCs) to white blood cells (WBCs) in CSF General rule: For every 500 RBCs in CSF, it is acceptable to have 1 WBC. Normal ratio of RBCs to WBCs in peripheral blood is 1,000 RBCs: 1–2 WBCs × 106/L.

Number of WBCs introduced into the CSF per L = (WBC[peripheral] × RBC[CSF] )

× 106/L RBC(peripheral)

Compare this number with the actual number of WBCs in the CSF.1,000 × 106/L RBCs in CSF raises CSF protein by approximately 0.015 g/L.Note: correction factors should not be used to reassure that meningitis is unlikely.

67Reference Range Values

ReferencesAhmed A, Hickey SM, Ehrett S, et al. Cerebrospinal fluid values in the term neonate. Pediatr Infect Dis J. 1996;15(4):298

Avery RA, Shah SS, Licht DJ, Seiden JA, Huh JW, Boswinkel J, et al. Reference range for cerebrospinal fluid opening pressure in children. N Engl J Med. 2010;363(9):891–893

Biou D, Benoist J-F, Huong CN-TX, et al. Cerebrospinal fluid protein concentrations in children: age-related values in patients without disorders of the central nervous system. Clin Chem. 2000;46(3):399

Griffith BP, Booss J. Neurologic infections of the fetus and newborn. Neurol Clin.1994;12(3):541

Kestenbaum LA, Ebberson J, Zorc JJ, Hodinka RL, Shah SS. Defining cerebrospinal fluid white blood cell count reference values in neonates and young infants. Pediatrics. 2010;125(2):257–264

Lipton JD, Schafermeyer RW. Evolving concepts in pediatric bacterial meningitis—part I: pathophysiology and diagnosis. Ann Emerg Med. 1993;22(10):1602

McMillan JA, Oski FA, Feigin RD, et al, eds. Oski’s Pediatrics: Principles and Practice. 3rd ed. Philadelphia, PA: JB Lippincott; 1999.

Naidoo BT. The cerebrospinal fluid in the healthy newborn infant. S Afr Med J. 1968;42(35):933

Nascimento-Carvalho CMC, Moreno-Carvalho OA. Normal cerebrospinal fluid values in full-term gestation and premature neonates. Arq Neuropsiquiatr. 1998;56(3-A):375

Shah SS, Ebberson J, Kestenbaum LA, Hodinka RL, Zorc JJ. Age-specific reference values for cerebrospinal fluid protein concentration in neonates and young infants. J Hosp Med. 2011;6(1):22–27

Soldin JS, Brugnara C, Gunter KC, et al, eds. Pediatric Reference Ranges. 2nd ed. Washington, DC: AAAC Press; 1997.

Srinivasan L, Shah SS, Padula MA, Abbasi S, McGowan KL, Harris MC. Cerebrospinal fluid reference ranges in term and preterm infants in the neonatal intensive care unit. J Pediatr. 2012;161(4):729–734

Wong M, Schlagger BL, Buller RS, et al. Cerebrospinal fluid protein concentration in pediatric patients: defining clinically relevant reference values. Arch Pediatr Adolesc Med. 2000;154:827


CLINICAL CHEMISTRY

Determination Conventional Units SI Units


Acid phosphate

Newborn 7.4–19.4 U/L 7.4–19.4 U/L

2–13 y 6.4–15.2 U/L 6.4–15.2 U/L

Man 0.5–11.0 U/L 0.5–11.0 U/L

Woman 0.2–9.5 U/L 0.2–9.5 U/L

Alanine aminotransferase (ALT)

<5 d 6–50 U/L 6–50 U/L

<12 mo 13–45 U/L 13–45 U/L

1–3 y 5–45 U/L 5–45 U/L

4–6 y 10–25 U/L 10–25 U/L

7–9 y 10–35 U/L 10–35 U/L

Girl 10–11 y 10–30 U/L 10–30 U/L

Boy 10–11 y 10–35 U/L 10–35 U/L

Girl 12–13 y 10–30 U/L 10–30 U/L

Boy 12–13 y 10–55 U/L 10–55 U/L

Girl 14–15 y 5–30 U/L 5–30 U/L

Boy 14–15 y 10–45 U/L 10–45 U/L

Girl >16 y 5–35 U/L 5–35 U/L

Boy >16 y 10–40 U/L 10–40 U/L

Man 10–40 U/L 10–40 U/L

Woman 7–35 U/L 7–35 U/L

Aldolase

10–24 mo 3.4–11.8 U/L 3.4–11.8 U/L

2–16 y 1.2–8.8 U/L 1.2–8.8 U/L

Adult 1.7–4.9 U/L 1.7–4.9 U/L




Alkaline phosphatase

Infant 150–420 U/L 150–420 U/L

2–10 y 100–320 U/L 100–320 U/L

Adolescent boy 100–390 U/L 100–390 U/L

Adolescent girl 100–320 U/L 100–320 U/L

Adult 30–120 U/L 30–120 U/L

Ammonia

Newborn 90–150 mcg/dL 64–107 mcmol/L

0–2 wk 79–129 mcg/dL 56–92 mcmol/L

>1 mo 29–70 mcg/dL 21–50 mcmol/L

Adult 15–45 mcg/dL 11–32 mcmol/L

Amylase

0–3 mo 0–30 U/L 0–30 U/L

3–6 mo 0–50 U/L 0–50 U/L

6–12 mo 0–80 U/L 0–80 U/L

>1 y 30–100 U/L 30–100 U/L

Adult 27–131 U/L 27–131 U/L

Antinuclear antibody

Negative <1:40

Patterns with clinical correlation:

Centromere: CREST

Nuclear: Scleroderma

Homogeneous: Systemic Lupus Erythematosus (SLE)




Antistreptolysin O titer (ASOT) (fourfold rise in serial sample is significant)

Newborn Similar to mother’s value

6–24 mo ≤50 Todd units/mL

2–4 y ≤160 Todd units/mL

≥5 y ≤330 Todd units/mL

Aspartate aminotransferase (AST)

0–10 d 47–150 U/L 47–150 U/L

10 d–24 mo 9–80 U/L 9–80 U/L

Girl >24 mo 13–35 U/L 13–35 U/L

Boy >24 mo 15–40 U/L 15–40 U/L

Bicarbonate

Newborn 17–24 mEq/L 17–24 mmol/L

Infant 19–24 mEq/L 19–24 mEq/L

2 mo–2 y 16–24 mEq/L 16–24 mmol/L

>2 y 22–26 mEq/L 22–26 mmol/L

Bilirubin (total)

Cord

Preterm and term <2 mg/dL <34 mcmol/L

0–1 d

Preterm and term <8 mg/dL <137 mcmol/L

1–2 d

Preterm <12 mg/dL <205 mcmol/L

Term <11.5 mg/dL <197 mcmol/L

3–5 d


Term <12 mg/dL <205 mcmol/L

CLINICAL CHEMISTRY, continued




Bilirubin (total), continued

Older infants


Term <1.2 mg/dL <21 mcmol/L

Adult <1.5 mg/dL <20.5 mcmol/L

Bilirubin (conjugated)

Neonate <0.6 mg/dL <10 mcmol/L

Infant/children <0.2 mg/dL <3.4 mcmol/L

pHPao2 (mm Hg)

Paco2 (mm Hg)

Hco3–

(mEq/L)

Blood gas, arterial (breathing room air)

Cord blood 7.28 ± 0.05 18.0 ± 6.2 49.2 ± 8.4 14–22

Newborn (birth) 7.11–7.36 8–24 27–40 13–22

5–10 min 7.09–7.30 33–75 27–40 13–22

30 min 7.21–7.38 31–85 27–40 13–22

60 min 7.26–7.49 55–80 27–40 13–22

1 d 7.29–7.45 54–95 27–40 13–22

Child/adult 7.35–7.45 83–108 32–48 20–28

Note: Venous blood gases can be used to assess acid-base status, not oxygenation. Pco2 averages 6 to 8 mm Hg higher than Paco2, and pH is slightly lower. Peripheral venous samples are strongly affected by the local circulatory and metabolic environment. Capillary blood gases correlate best with arterial pH and moderately well with Paco2.




Calcium

Total

Preterm 6.2–11 mg/dL 1.55–2.75 mmol/L

Term <10 d 7.6–10.4 mg/dL 1.9–2.6 mmol/L

10 d–24 mo 9.0–11 mg/dL 2.25-2.75 mmol/L

2–12 y 8.8–10.8 mg/dL 2.2–2.7 mmol/L

12–18 y 8.4 –10.2 mg/dL 2.1–2.55 mmol/L

Ionized

0–1 mo 3.9–6.0 mg/dL 1.0–1.5 mmol/L

1–6 mo 3.7–5.9 mg/dL 0.95–1.5 mmol/L

1–18 y 4.9–5.5 mg/dL 1.22–1.37 mmol/L

Adult 4.75–5.3 mg/dL 1.18–1.32 mmol/L

Carbon dioxide (CO2 content) (see “Blood gas, arterial”)

Carbon monoxide (carboxyhemoglobin)

Nonsmoker 0.5%–1.5% of total hemo-globin

Smoker 4%–9% of total hemo-globin

Toxic 20%–50% of total hemo-globin

Lethal >50% of total hemoglobin

Chloride (serum)

0–6 mo 97–108 mEq/L 97–108 mmol/L

6–12 mo 97–106 mEq/L 97–106 mmol/L

Child/adult 97–107 mEq/L 97–107 mmol/L

C-reactive protein 0–0.5 mg/d





Creatine kinase (creatine phosphokinase)

Newborn 145–1,578 U/L 145–1,578 U/L

>6 wk–man 20–200 U/L 20–200 U/L

>6 wk–woman 20–180 U/L 20–180 U/L

Creatinine (serum)

Cord 0.6–1.2 mg/dL 53–106 mcmol/L

Newborn 0.3–1.0 mg/dL 27–88 mcmol/L

Infant 0.2–0.4 mg/dL 18–35 mcmol/L

Child 0.3–0.7 mg/dL 27–62 mcmol/L

Adolescent 0.5–1.0 mg/dL 44–88 mcmol/L

Man 0.9–1.3 mg/dL 80–115 mcmol/L

Woman 0.6–1.1 mg/dL 53–97 mcmol/L

Erythrocyte sedimentation rate (ESR)

Child 0–10 mm/h

Man 0–15 mm/h

Woman 0–20 mm/h

Ferritin

Newborn 25–200 ng/mL 56–450 pmol/L

1 mo 200–600 ng/mL 450–1350 pmol/L

2–5 mo 50–200 ng/mL 112–450 pmol/L

6 mo–15 y 7–140 ng/mL 16–350 pmol/L

Man 20–250 ng/mL 45–562 pmol/L

Woman 10–120 ng/mL 22–270 pmol/L

Folate (serum)

Newborn 16–72 ng/mL 16–72 nmol/L

Child 4–20 ng/mL 4–20 nmol/L

Adult 10–63 ng/mL 10–63 nmol/L




Folate (red blood cells)

Newborn 150–200 ng/mL 340–453 nmol/L

Infant 74–995 ng/mL 168–2,254 nmol/L

2–16 y >160 ng/mL >362 nmol/L

>16 y 140–628 ng/mL 317–1422 nmol/L

Galactose

Newborn 0–20 mg/dL 0–1.11 mmol/L

Older child <5 mg/dL <0.28 mmol/L

γ-Glutamyl transferase (GGT)

Cord 37–193 U/L 37–193 U/L

0–1 mo 13–147 U/L 13–147 U/L

1–2 mo 12–123 U/L 12–123 U/L

2–4 mo 8–90 U/L 8–90 U/L

4 mo–10 y 5–32 U/L 5–32 U/L

10–15 y 5–24 U/L 5–24 U/L

Man 11–49 U/L 11–49 U/L

Woman 7–32 U/L 7–32 U/L

Glucose (serum)

Preterm 20–60 mg/dL 1.1–3.3 mmol/L

Newborn <1 day 40–60 mg/dL 2.2–3.3 mmol/L

Newborn >1 day 50–90 mg/dL 2.8–5.0 mmol/L

Child 60–100 mg/dL 3.3–5.5 mmol/L

>16 y 70–105 mg/dL 3.9–5.8 mmol/L

Haptoglobin

Newborn 5–48 mg/dL 50–480 mg/dL

>30 d 26–185 mg/dL 260–1850 mg/dL





Hemoglobin A1c

Normal 4.5%–5.6%

At risk for diabetes 5.7%–6.4%

Diabetes mellitus ≥6.5%

Hemoglobin F, % total hemoglobin [mean (SD)]

1 d 77.0 (7.3)

5 d 76.8 (5.8)

3 wk 70.0 (7.3)

6–9 wk 52.9 (11)

3–4 mo 23.2 (16)

6 mo 4.7 (2.2)

8–11 mo 1.6 (1.0)

Adult <2.0

Iron

Newborn 100–250 mcg/dL 17.9–44.8 mcmol/L

Infant 40–100 mcg/dL 7.2–17.9 mcmol/L

Child 50–120 mcg/dL 9.0–21.5 mcmol/L

Man 65–175 mcg/dL 11.6–31.3 mcmol/L

Woman 50–170 mcg/dL 9.0–30.4 mcmol/L

Ketones (serum)

Quantitative 0.5–3.0 mg/dL 5–30 mg/L




Lactate

Capillary blood

0–90 d 9–32 mg/dL 1.1–3.5 mmol/L

3–24 mo 9–30 mg/dL 1.0–3.3 mmol/L

2–18 y 9–22 mg/dL 1.0–2.4 mmol/L

Venous 4.5–19.8 mg/dL 0.5–2.2 mmol/L

Arterial 4.5–14.4 mg/dL 0.5–1.6 mmol/L

Lactate dehydrogenase (at 37°C)

0–4 d 290–775 U/L 290–775 U/L

4–10 d 545–2000 U/L 545–2000 U/L

10 d–24 mo 180–430 U/L 180–430 U/L

24 mo–12 y 110–295 U/L 110–295 U/L

>12 y 100–190 U/L 100–190 U/L

Lead

Child <10 mcg/dL <0.48 mcmol/L

Lipase

0–30 d 6–55 U/L 6 –55 U/L

1–6 mo 4–29 U/L 4 –29 U/L

6–12 mo 4–23 U/L 4 –23 U/L

>1 y 3–32 U/L 3 –32 U/L


Desirable Borderline High

Lipids

Cholesterol (mg/dL)

Child/adolescent <170 170–199 >200

Adult <200 200–239 >240


Desirable Borderline High

Lipids, continued

Low-density lipoprotein (mg/dL)

Child/adolescent <110 110–129 >130

Adult 100 (Near/Above optimal = 100–129)

130–159 >160

High-density lipoprotein (mg/dL)

Child/adolescent >35

Adult 40–60



Magnesium 1.26–2.1 mEq/L 0.63–1.05 mmol/L

Methemoglobin 0.78 (± 0.37%) of total hemoglobin

Osmolality 275–295 mOsm/kg 275–295 mmol/kg

Phenylalanine

Preterm 2.0–7.5 mg/dL 121–454 mcmol/L

Newborn 1.2–3.4 mg/dL 73–206 mcmol/L

Adult 0.8–1.8 mg/dL 48–109 mcmol/L

Phosphorus

0–9 d 4.5– 9.0 mg/dL 1.45 –2.91 mmol/L

10 d–24 mo 4.5– 6.5 mg/dL 1.29 –2.10 mmol/L

3–9 y 3.2–5.8 mg/dL 1.03 –1.87 mmol/L

10–15 y 3.3 – 5.4 mg/dL 1.07–1.74 mmol/L

>15 y 2.4 – 4.4 mg/dL 0.78 –1.42 mmol/L

Porcelain 9.0 –25.04 mg/dL 5.0 –31.03 mmol/L




Potassium

Preterm 3.0–6.0 mEq/L 3.0–6.0 mmol/L

Newborn 3.7–5.9 mEq/L 3.7–5.9 mmol/L

Infant 4.1–5.3 mEq/L 4.1–5.3 mmol/L

Child 3.4–4.7 mEq/L 3.4–4.7 mmol/L

Adult 3.5–5.1 mEq/L 3.5–5.1 mmol/L

Prealbumin

Newborn 7–39 mg/dL

1–6 mo 8–34 mg/dL

6 mo–4 y 12–36 mg/dL

4–6 y 12–30 mg/dL

6–19 y 12–42 mg/dL

TP Albumin α-1 α-2 β γ

Proteins (protein electrophoresis) (g/dL)

Cord 4.8–8

Preterm 3.6–6.0

Newborn 4.6-7.0

0 –15 d 4.4 –7.6 3.0 –3.9 0.1– 0.3 0.3 – 0.6 0.4–0.6 0.7–1.4

15 d–1 y 5.1–7.3 2.2–4.8 0.1–0.3 0.5–0.9 0.5–0.9 0.5–1.3

1–2 y 5.6–7.5 3.6 –5.2 0.1–0.4 0.5–1.2 0.5–1.1 0.5–1.7

3–16 y 6.0–8.0 3.6–5.2 0.1–0.4 0.5–1.2 0.5–1.1 0.5–1.7

≥16 y 6.0–8.3 3.9–5.1 0.2–0.4 0.4–0.8 0.5–1.0 0.6–1.2





Pyruvate 0.7–1.32 mg/dL 0.08–0.15 mmol/L

Rheumatoid Factor <30 U/mL

Sodium

<1 y 130–145 mEq/L 130–145 mmol/L

>1 y 135–147 mEq/L 135–147 mmol/L

Total iron-binding capacity (TIBC)

Infant 100–400 mcg/dL 17.9–71.6 mcmol/L

Adult 250–425 mcg/dL 44.8–76.1 mcmol/L

Transferrin

Newborn 130–275 mg/dL 1.30–2.75 g/L

3 mo –16 y 203–360 mg/dL 2.03–3.6 g/L

Adult 215–380 mg/dL 2.15–3.8 g/L

Determination Male (mg/dL) Female (mg/dL)Total triglycerides0–7 d 21–182 28–166

8 d–1 mo 30–184 30–165

1–3 mo 40–175 35–282

3–6 mo 45–291 50–355

6 mo–1 y 45–501 36–431

1–3 y 27–125 27–125

4–6 y 32–116 32–116

7–9 y 28–129 28–129

10–19 y 24–145 37–140




Troponin-I

0–30 d <4.8 mcg/L

1–3 mo <0.4 mcg/L

3–6 mo <0.3 mcg/L

7–12 mo <0.2 mcg/L

1–18 y <0.1 mcg/L

Urea nitrogen

Premature (<1 wk) 3–25 mg/dL 1.1–8.9 mmol/L

Newborn 2–19 mg/dL 0.7–6.7 mmol/L

Infant/children 5–18 mg/dL 1.8–6.4 mmol/L

Adult 6–20 mg/dL 2.1–7.1 mmol/L

Uric acid

0–30 d 1.0–4.6 mg/dL 0.059–0.271 mmol/L

1–12 mo 1.1–5.6 mg/dL 0.065–0.33 mmol/L

1–5 y 1.7–5.8 mg/dL 0.1–0.35 mmol/L

6–11 y 2.2–6.6 mg/dL 0.13–0.39 mmol/L

Boy 12–19 y 3.0–7.7 mg/dL 0.18–0.46 mmol/L

Girl 12–19 y 2.7–5.7 mg/dL 0.16–0.34 mmol/L

Vitamin A (retinol)

Preterm 13–46 mcg/dL 0.46–1.61 mcmol/L

Term 18–50 mcg/dL 0.63–1.75 mcmol/L

1–6 y 20–43 mcg/dL 0.7–1.5 mcmol/L

7–12 y 20–49 mcg/dL 0.9 –1.7 mcmol/L

13–19 y 26–72 mcg/dL 0.9–2.5 mcmol/L

Vitamin B1 (thiamine) 4.5 –10.3 mcg/dL 106 –242 mcmol/L

Vitamin B2 (riboflavin) 4–24 mcg/dL 106–638 nmol/L





Vitamin B12 (cobalamin)

Newborn 160–1300 pg/mL 118–959 pmol/L

Child/adult 200–835 pg/mL 148–616 pmol/L

Vitamin C (ascorbic acid)

0.4–2.0 mg/dL 23–114 mcmol/L

Vitamin D3 (1,25-dihydroxy-vitamin D)

16–65 pg/mL 42–169 pmol/L

25-hydroxy-vitamin D

Normal level 30 – 60 ng/mLa

Insufficiency 21– 29 ng/mL

Deficiency <20 ng/mL

Vitamin E

Preterm 0.5–3.5 mg/L 1–8 mmol/L

Term 1.0–3.5 mg/L 2–8 mmol/L

1–12 y 3–9 mg/L 7–21 mcmol/L

13–19 y 6–10 mg/L 14–23 mcmol/L

Zinc 70–120 mg/dL 10.7–18.4 mmol/L

Abbreviation: CREST, Calcinosis/Raynaud’s syndrome/Esophageal dysmotility/Sclerodactyly/ TelangectasisaControversy exists as to the optimal level of 25-hydroxy-vitamin D level.

From Arcara KM, Tschudy MM, eds. The Harriet Lane Handbook. 19th ed. St Louis, MO: Mosby; 2012. Reproduced with permission. Copyright © 2012 Elsevier.


NEWBORN CLINICAL CHEMISTRY

Descriptive Statistics of Measured Variables in Samples Obtained From Cord and Venous Blood at 2 to 4 Hours of Life

Cord Blood 2 to 4 Hour Blood

Mean ± SD

Range of Values 95% CI

Mean ± SD

Range of Values 95% CI P Value

pH 7.35 ± 0.05

7.19–7.42

7.25–7.45

7.36 ± 0.04

7.27–7.45

7.28–7.44

NS

Pco2 40 ± 6 24.5–56.7

28–52 43 ± 7 30–65 29–57 0.034

Hct (%) 48 ± 5 37–60 38–58 57 ± 5 42–67 47–67 <0.001

Hgb (g/L)

1.65 ± 0.16

1.29–2.06

1.33–1.97

1.90 ± 0.22

0.88–2.3

1.46–2.34

<0.001

Na+ (mmol/L)

138 ± 3 129–144

132–144

137 ± 3 130–142

131–143

NS

K+ (mmol/L)

5.3 ± 1.3

3.4–9.9 2.7–7.9 5.2 ± 0.5

4.4–6.4 4.2–6.2 NS

Cl– (mmol/L)

107 ± 4 100–121

99–115 111 ± 5 105–125

101–121

0.002

ICa (mmol/L)

1.15 ± 0.35

0.21–1.5

0.4–1.85

1.13 ± 0.08

0.9–1.3 0.97–1.29

NS

IMg (mmol/L)

0.28 ± 0.06

0.09–0.39

0.12–0.4

0.30 ± 0.05

0.23–0.46

0.2–0.4 0.0005

Glucose (mmol/L)

4.16 ± 1.05

0.16–6.66

2.05–6.27

3.50 ± 0.67

5.11–16.10

2.16–4.82

Glucose (mg/dL)

75 ± 19 2.9–120 37–113 63 ± 12 29–92 39–87 0.0005

Lactate (mmol/L)

4.6 ± 1.9

1.1–9.6 0.8–8.4 3.9 ± 1.5 1.6–9.8 0.9–6.9 0.033


Descriptive Statistics of Measured Variables in Samples Obtained From Cord and From Venous Blood at 2 to 4 Hours of Life, continued

Cord Blood 2 to 4 Hour Blood

Mean ± SD

Range of Values 95% CI

Mean ± SD

Range of Values 95% CI P Value

BUN (mmol/L)

2.14 ± 0.61

1.07–3.57

0.93–3.36

2.53 ± 0.71

1.43–4.28

1.11–3.96

BUN (mg/dL)

6.0 ± 1.7

3.0–10.0

2.6–9.4 7.1 ± 2.0

4–12 3.1–11.1

0.0029

Abbreviations: BUN, blood urea nitrogen; CI, confidence interval; Hct, hematocrit; Hgb, hemo-globin; ICa, ionized calcium; IMg, ionized magnesium; Pco2, partial pressure of carbon dioxide.

Data were derived from Dollberg S, Bauer R, Lubetzky R, Mimouni FB. A reappraisal of neonatal blood chemistry reference ranges using the Nova M electrodes. Am J Perinatol. 2001;18(8):433–440. Reproduced with permission. Copyright © 2001 Thieme Publishers.

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HEMATOLOGY


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COAGULATION TESTS

Healthy Full-term Infant During the First 6 Months of Life

TestsDay 1 (n)

Day 5 (n)

Day 30 (n)

Day 90 (n)

Day 180 (n)

Adult (n)

PT (s) 13.0 ± 1.43 (61)a

12.4 ± 1.46 (77)a,b

11.8 ± 1.25 (67)a,b

11.9 ± 1.15 (62)a

12.3 ± 0.79 (47)a

12.4 ± 0.78 (29)

aPTT (s) 42.9 ± 5.80 (61)

42.6 ± 8.62 (76)

40.4 ± 7.42 (67)

37.1 ± 6.52 (62)a

35.5 ± 3.71 (47)a

33.5 ± 3.44 (29)

TCT (s) 23.5 ± 2.38 (58)a

23.1 ± 3.07 (64)b

24.3 ± 2.44 (53)a

25.1 ± 2.32 (52)a

25.5 ± 2.86 (41)a

25.0 ± 2.66 (19)

Fibrinogen (g/L)

2.83 ± 0.58 (61)a

3.12 ± 0.75 (77)a

2.70 ± 0.54 (67)a

2.43 ± 0.68 (60)a,b

2.51 ± 0.68 (47)a,b

2.78 ± 0.61 (29)

II (U/mL) 0.48 ± 0.11 (61)

0.63 ± 0.15 (76)

0.68 ± 0.17 (67)

0.75 ± 0.15 (62)

0.88 ± 0.14 (47)

1.08 ± 0.19 (29)

V (U/mL) 0.72 ± 0.18 (61)

0.95 ± 0.25 (76)

0.98 ± 0.18 (67)

0.90 ± 0.21 (62)

0.91 ± 0.18 (47)

1.06 ± 0.22 (29)

VII (U/mL) 0.66 ± 0.19 (60)

0.89 ± 0.27 (75)

0.90 ± 0.24 (67)

0.91 ± 0.26 (62)

0.87 ± 0.20 (47)

1.05 ± 0.19 (29)

VIII (U/mL) 1.00 ± 0.39 (60)a,b

0.88 ± 0.33 (75)a,b

0.91 ± 0.33 (67)a,b

0.79 ± 0.23 (62)a,b

0.73 ± 0.18 (47)b

0.99 ± 0.25 (29)

vWF (U/mL) 1.53 ± 0.67 (40)b

1.40 ± 0.57 (43)b

1.28 ± 0.59 (40)b

1.18 ± 0.44 (40)b

1.07 ± 0.45 (46)b

0.92 ± 0.33 (29)b

IX (U/mL) 0.53 ± 0.19 (59)

0.53 ± 0.19 (75)

0.51 ± 0.15 (67)

0.67 ± 0.23 (62)

0.86 ± 0.25 (47)

1.09 ± 0.27 (29)

X (U/mL) 0.40 ± 0.14 (60)

0.49 ± 0.15 (76)

0.59 ± 0.14 (67)

0.71 ± 0.18 (62)

0.78 ± 0.20 (47)

1.06 ± 0.23 (29)

XI (U/mL) 0.38 ± 0.14 (60)

0.55 ± 0.16 (74)

0.53 ± 0.13 (67)

0.69 ± 0.14 (62)

0.86 ± 0.24 (47)

0.97 ± 0.15 (29)

XII (U/mL) 0.53 ± 0.20 (60)

0.47 ± 0.18 (75)

0.49 ± 0.16 (67)

0.67 ± 0.21 (62)

0.77 ± 0.19 (47)

1.08 ± 0.28 (29)

PK (U/mL) 0.37 ± 0.16 (45)b

0.48 ± 0.14 (51)

0.57 ± 0.17 (48)

0.73 ± 0.16 (46)

0.86 ± 0.15 (43)

1.12 ± 0.25 (29)

HMWK (U/mL)

0.54 ± 0.24 (47)

0.74 ± 0.28 (63)

0.77 ± 0.22 (50)a

0.82 ± 0.32 (46)a

0.82 ± 0.23 (48)a

0.92 ± 0.22 (29)

XIIIa (U/mL) 0.79 ± 0.26 (44)

0.94 ± 0.25 (49)a

0.93 ± 0.27 (44)a

1.04 ± 0.34 (44)a

1.04 ± 0.29 (41)a

1.05 ± 0.25 (29)b


TestsDay 1 (n)

Day 5 (n)

Day 30 (n)

Day 90 (n)

Day 180 (n)

Adult (n)

XIIIb (U/mL) 0.76 ± 0.23 (44)

1.06 ± 0.37 (47)a

1.11 ± 0.36 (45)a

1.16 ± 0.34 (44)a

1.10 ± 0.30 (41)a

0.97 ± 0.20 (29)

Plasmino-gen (CTA, U/mL)

1.95 ± 0.35 (44)

2.17 ± 0.38 (60)

1.98 ± 0.36 (52)

2.48 ± 0.37 (44)

3.01 ± 0.40 (47)

3.36 ± 0.44 (29)

Note: All factors except fibrinogen and plasminogen are expressed as units per milliliter, where pooled plasma contains 1.0 U/mL. Plasminogen units are those recommended by the Committee on Thrombolytic Agents (CTA). All values are expressed as mean ± 1 SD.

Abbreviations: aPTT, activated partial thromboplastin time; HMWK, high molecular–weight kinino-gen; PK, prekallikrein; PT, prothrombin time; TCT, thrombin clotting time; vWF, von Willebrand factor.a Values that do not differ statistically from the adult values.b These measurements are skewed because of a disproportionate number of high values. The lower limit that excludes the lower 2.5th percentile of the population has been given in the respective figures. The lower limit for factor VIII was 0.50 U/mL at all time points for the infant.

Data were derived from Andrew M, Paes B, Milner R, et al. Development of the human coagu-lation system in the full-term infant. Blood. 1987;70(1):165. Copyright © 1987 American Society of Hematology.


Inhibition of Coagulation in the Healthy Full-term Infant During the First 6 Months of Life

InhibitorsDay 1 (n)

Day 5 (n)

Day 30 (n)

Day 90 (n)

Day 180 (n)

Adult (n)

AT-III 0.63 ± 0.12 (58)

0.67 ± 0.13 (74)

0.78 ± 0.15 (66)

0.97 ± 0.12 (60)a

1.04 ± 0.10 (56)a

1.05 ± 0.13 (28)

a2-M 1.39 ± 0.22 (54)

1.48 ± 0.25 (73)

1.50 ± 0.22 (61)

1.76 ± 0.25 (55)

1.91 ± 0.21 (55)

0.86 ± 0.17 (29)

a2-AP 0.85 ± 0.15 (55)

1.00 ± 0.15 (75)a

1.00 ± 0.12 (62)a

1.08 ± 0.16 (55)a

1.11 ± 0.14 (53)a

1.02 ± 0.17 (29)

C1E-INH 0.72 ± 0.18 (59)

0.90 ± 0.15 (76)a

0.89 ± 0.21 (63)

1.15 ± 0.22 (55)

1.41 ± 0.26 (55)

1.01 ± 0.15 (29)

a3-AT 0.93 ± 0.22 (57)a

0.89 ± 0.20 (75)a

0.62 ± 0.13 (61)

0.72 ± 0.15 (56)

0.77 ± 0.15 (55)

0.93 ± 0.19 (29)

HCII 0.43 ± 0.25 (56)

0.48 ± 0.24 (72)

0.47 ± 0.20 (58)

0.72 ± 0.37 (58)

1.20 ± 0.35 (55)

0.96 ± 0.15 (29)

Protein C 0.35 ± 0.09 (41)

0.42 ± 0.11 (44)

0.43 ± 0.11 (43)

0.54 ± 0.13 (44)

0.59 ± 0.11 (52)

0.96 ± 0.16 (28)

Protein S 0.36 ± 0.12 (40)

0.50 ± 0.14 (48)

0.63 ± 0.15 (41)

0.86 ± 0.16 (46)a

0.87 ± 0.16 (49)a

0.92 ± 0.16 (29)

Note: All values are expressed in units per milliliter as the mean ± 1 SD.

aValues that do not differ statistically from the adult values.

Data were derived from Andrew M, Paes B, Milner R, et al. Development of the human coagu-lation system in the full-term infant. Blood. 1987;70(1):165. Copyright © 1987 American Society of Hematology.


Healthy Preterm Infants (30 to 36 Weeks’ Gestation) During the First 6 Months of Life

Day

1 (

n)D

ay 5

(n)

Day

30

(n)

Day

90

(n)

Day

180

(n)

Ad

ult

(n)

MB

MB

MB

MB

MB

MB

PT (s

) A

PTT

(s)

TCT

(s)

Fib

rinog

en

(g

/L)

II (U

/mL)

V (U

/mL)

VII

(U/m

L)V

III (U

/mL)

vWF

(U/m

L)IX

(U/m

L)

X (U

/mL)

XI

(U/m

L)

XII (

U/m

L)PK

(U/m

L)H

MW

K

(U

/mL)

XIIIa

(U/m

L)XI

IIb (U

/mL)

Plas

min

o-

ge

n IC

TA

(U

/mL)

13.

0 5

3.6

24.

8 2

.43

0.4

5 0

.88

0.6

7 1

.11

1.3

6 0

.35

0.4

1 0

.30

0.3

8 0

.33

0.4

9

0.7

0 0

.81

1.7

0

(10.

6–16

.2)a

(27.

5–79

.4)b

(1

9.2–

30.4

)a (1

.50–

3.73

)a–c

(0.2

0–0.

77)b

(0.4

1–1.

44)a–

c

(0.2

1–1.

13)

(0.5

0–2.

13)a,

b

(0.7

8–2.

10)b

(0.1

9–0.

65)c

(0.1

1–0.

71)

(0.0

8–0.

52)b

,c

(0.1

0–0.

66)c

(0.0

9–0.

57)

(0.0

9–0.

89)

(0.3

2–1.

08)

(0.3

5–1.

27)

(1.1

2–2.

48)b

,c

12.

5 5

0.5

24.

1 2

.80

0.5

7 1

.00

0.8

4 1

.15

1.3

3 0

.42

0.5

1 0

.41

0.3

9 0

.45

0.6

2

1.0

1 1

.10

1.9

1

(10.

0–15

.3)a,

b

(26.

9–74

.1)c

(18.

8–29

.4)a

(1.6

0–4.

18)a–

c

(0.2

9–0.

85)c

(0.4

6–1.

54)

(0.3

0–1.

38)

(0.5

3–2.

05)a–

c

(0.7

2–2.

19)b

(0.1

4–0.

74)b

,c

(0.1

9–0.

83)

(0.1

3–0.

69)c

(0.0

9–0.

69)c

(0.2

6–0.

75)b

(0

.24–

1.00

)c

(0.5

7–1.

45)a

(0.6

8–1.

58)a

(1.2

1–2.

61)c

11.

8 4

4.7

24.

4 2

.54

0.5

7 1

.02

0.8

3 1

.11

1.3

6 0

.44

0.5

6 0

.43

0.4

3 0

.59

0.6

4

0.9

9 1

.07

1.8

1

(10.

0–13

.6)a

(26.

9–62

.5)

(18.

8–29

.9)a

( 1.5

0–4.

14)a,

b

(0.3

6–0.

95)b

,c

(0.4

8–1.

56)

(0.2

1–1.

45)

(0.5

0–1.

99)a–

c

(0.6

6–2.

16)b

(0.1

3–0.

80)b

(0

.20–

0.92

) (0

.15–

0.71

)c (0

.11–

0.75

) (0

.31–

0.87

) (0

.16–

1.12

)c

(0.5

1–1.

47)a

(0.5

7–1.

57)a

(1.0

9–2.

53)

12.

3 3

9.5

25.

1 2

.46

0.6

8 0

.99

0.8

7 1

.06

1.1

2 0

.59

0.6

7 0

.59

0.6

1 0

.79

0.7

8

1.1

3 1

.21

2.3

8

(10.

0–14

.6)a

(28.

3–50

.7)

(19.

4–30

.8)a

(1.5

0–3.

52) a,

b

(0.3

0–1.

06)

(0.5

9–1.

39)

(0.3

1–1.

43)

(0.5

8–1.

88)a,

c (0

.75–

1.84

)a,b

(0.2

5–0.

93)

(0.3

5–0.

99)

(0.2

5–0.

93)c

(0.1

5–1.

07)

(0.3

7–1.

21)

(0.3

2–1.

24)

(0.7

1–1.

55)a

(0.7

5–1.

67)

(1.5

8–3.

18)

12.

5 3

7.5

25.

2 2

.28

0.8

7 1

.02

0.9

9 0

.99

0.9

8 0

.81

0.7

7 0

.78

0.8

2 0

.78

0.8

3

1.1

3 1

.15

2.7

5

(10.

0–15

.0)a

(21.

7–53

.3)a

(18.

9–31

.5)a

(1.5

0–3.

80)b

(0.5

1–1.

23)

(0.5

8–1.

46)

(0.4

7–1.

51)a

(0.5

0–1.

87)a–

c

10.5

4–1.

58)a,

b

(0.5

0–1.

20)b

(0.3

5–1.

19)

(0.4

6–1.

10)

(0.2

2–1.

42)

(0.4

0–1.

16)

(0.4

1–1.

25)a

(0.6

5–1.

61)a

(0.6

7–1.

63)

(1.9

1–3.

59)c

12

.4

33.5

25

.0

2.78

1.

08

1.06

1.

05

0.99

0.

92

1.09

1.

06

0.97

1.

08

1.12

0.

92

1.

05

0.97

3.38

(10.

8–13

.9)

(26.

8–40

.3)

(19.

7–30

.3)

(1.5

8–4.

00)

(0.7

0–1.

46)

(0.6

2–1.

50)

(0.6

7–1.

43)

(0.5

0–1.

49)

(0.5

0–1.

58)

(0.5

5–1.

83)

(0.7

0–1.

52)

(0.8

7–1.

27)

(0.5

2–1.

84)

(0.8

2–1.

82)

(0.5

0–1.

38)

(0.5

5–1.

55)

(0.5

7–1.

37)

(2.4

6–4.

24)

Not

e: A

ll fa

ctor

s ex

cept

fibr

inog

en a

nd

plas

min

ogen

are

exp

ress

ed a

s U

/mL

, wh

ere

pool

ed p

lasm

a co

nta

ins

1.0

U/m

L. P

lasm

inog

en u

nit

s ar

e th

ose

reco

mm

ende

d by

the

Com

mit

tee

on T

hro

mbo

lyti

c A

gen

ts (

CT

A).

All

valu

es a

re g

iven

as

a m

ean

(M

) fo

llow

ed b

y lo

wer

an

d up

per

boun

dary

en

com

pass

ing

95%

of t

he

popu

lati

on (

B).

Bet

wee

n 4

0 an

d 96

sam

ples

wer

e as

saye

d fo

r ea

ch v

alue

for

new

born

s.a V

alue

s in

dist

ingu

ish

able

from

thos

e of

adu

lts.

b M

easu

rem

ents

are

ske

wed

ow

ing

to a

dis

prop

orti

onat

e n

umbe

r of

hig

h v

alue

s. L

ower

lim

it w

hic

h e

xclu

des

the

low

er 2

.5%

of t

he

popu

la-

tion

is g

iven

(B

).c V

alue

s di

ffer

ent f

rom

thos

e of

full-

term

infa

nts

.Fr

om A

ndr

ew M

, Pae

s B

, Miln

er R

, et a

l. D

evel

opm

ent o

f th

e h

uman

coa

gula

tion

sys

tem

in th

e h

ealt

hy

prem

atur

e in

fan

t. B

lood

. 19

88;7

2(5)

:165

1–16

57. C

opyr

igh

t © 1

988

Am

eric

an S

ocie

ty o

f Hem

atol

ogy.


Inhibition of Coagulation in Healthy Preterm Infants (30 to 36 Weeks’ Gestation) During the First 6 Months of Life

Day

1 (

n)D

ay 5

(n)

Day

30

(n)

Day

90

(n)

Day

180

(n)

Ad

ult

(n)

MB

MB

MB

MB

MB

MB

AT-

III (U

/mL)

α 2M

(U/m

L)α 2

AP

(U/m

L)C 1

INH

(U/m

L)α 1

AT

(U/m

L)H

CII (

U/m

L)Pr

otei

n C

(U/m

L)Pr

otei

n S

(U/m

L)

0.38

1.10

0.78

0.65

0.90

0.32

0.28

0.26

(0.1

4–0.

62)c

(0.5

6–1.

82)b

,c

(0.4

0–1.

16)

(0.3

1–0.

99)

(0.3

6–1.

44)a

(0.0

0–0.

60)c

(0.1

2–0.

44)a,

c

(0.1

4–0.

38)c

0.56

1.25

0.81

0.83

0.94

0.34

0.31

0.37

(0.3

0–0.

82)a

(0.7

1–1.

77)a

(0.4

9–1.

13)a

(0.4

5–1.

21)

(0.4

2–1.

46)c

(0.0

0–0.

69)a

(0.1

1–0.

51)a

(0.1

3–0.

61)a

0.59

1.38

0.89

0.74

0.76

0.43

0.37

0.

56

(0.3

7–0.

81)c

(0.7

2–2.

04)

(0.5

5–1.

23)c

(0.4

0–1.

24)b

,c

(0.3

8–1.

12)c

(0.1

5–0.

71)

(0.1

5–0.

59)c

(0.2

2–0.

90)

0.83

1.80

1.06

1.14

0.81

0.61

0.45

0.76

(0.4

5–1.

21)c

(1.2

0–2.

66)b

(0.6

4–1.

46)a

(0.6

0–1.

68)a

(0.4

9–1.

13)a,

c

(0.2

0–1.

11)b

(0.2

3–0.

67)c

(0.4

0–1.

12)c

0.90

2.09

1.15

1.40

0.82

0.89

0.57

0.82

(0.5

2–1.

28)c

(1.1

0–3.

21)b

(0.7

7–1.

53)

(0.9

6–2.

04)b

(0.4

8–1.

16)a

(0.4

5–1.

40)a–

c

(0.3

1–0.

83)

(0.4

4–1.

20)

1.05

0.88

1.02

1.01

0.93

0.96

0.96

0.92

(0.7

9–1.

31)

(0.5

2–1.

20)

(0.6

8–1.

36)

(0.7

1–1.

31)

(0.5

5–1.

31)

(0.6

6–1.

28)

(0.8

4–1.

28)

(0.8

0–1.

24)

Not

e: A

ll fa

ctor

s ar

e ex

pres

sed

as U

/mL

, wh

ere

pool

ed p

lasm

a co

nta

ins

1.0

U/m

L. A

ll va

lues

are

giv

en a

s a

mea

n (

M)

follo

wed

by

low

er

and

uppe

r bo

unda

ry e

nco

mpa

ssin

g 95

% o

f th

e po

pula

tion

(B

). B

etw

een

40

and

75 s

ampl

es w

ere

assa

yed

for

each

val

ue fo

r n

ewbo

rns.

a Val

ues

indi

stin

guis

hab

le fr

om th

ose

of a

dult

s.

b Mea

sure

men

ts a

re s

kew

ed o

win

g to

a d

ispr

opor

tion

ate

num

ber

of h

igh

val

ues.

Low

er li

mit

wh

ich

exc

lude

s th

e lo

wer

2.5

% o

f th

e po

pula

tion

is g

iven

(B

).c V

alue

s di

ffer

ent f

rom

thos

e of

fullt

erm

infa

nts

.

From

An

drew

M, P

aes

B, M

ilner

R, e

t al.

Dev

elop

men

t of t

he

hum

an c

oagu

lati

on s

yste

m in

the

hea

lth

y pr

emat

ure

infa

nt.

Blo

od.

1988

;72(

5):1

651–

1657

. Cop

yrig

ht ©

198

8 A

mer

ican

Soc

iety

of H

emat

olog

y.


Healthy Children Aged 1 to 16 Years Compared With Adults

Age1 to 5 y 6 to 10 y 11 to 16 y Adult

Coagulation Tests

Mean (boundary)

Mean (boundary)

Mean (boundary)

Mean (boundary)

PT (s) 11 (10.6–11.4) 11.1 (10.1–12.1) 11.2 (10.2,12.0) 12 (11.0–14.0)

INR 1.0 (0.96–1.04) 1.01 (0.91–1.11) 1.02 (0.93–1.10) 1.10 (1.0–1.3)

APTI (s) 30 (24–36) 31 (26–36) 32 (26–37) 33 (27–40)

Fibrinogen (g/L) 2.76 (1.70–4.05) 2.79 (1.57–4.0) 3.0 (1.54–4.48) 2.78 (1.56–4.0)

Bleeding time (min)

6 (2.5–10)a 7 (2.5–13)a 5 (3–8)a 4(1–7)

II (U/mL) 0.94 (0.71–1.16)a 0.88 (0.67–1.07)a 0.83 (0.61–1.04)a 1.08 (0.70–1.46)

V (U/mL) 1.03 (0.79–1.27) 0.90 (0.63–1.16)a Q.77 (0,55–0.99) 1.06 (0.62–1.50)

VII (U/mL) 0.82 (0.55–1.16)a 0.85 (0.52–1.20)a 0.83 (0.58–1.15)a 1.05 (0.67–1.43)

VIII (U/mL) 0.90 (0.59–1.42) 0.95 (0.58–1.32) 0.92 (0.53–1.31) 0.99 (0.50–1.49)

vWF (U/mL) 0.82 (0.60–1.20) 0.95 (0.44–1.44) 1.00 (0.46–1.53) 0.92 (0.50–1.58)

IX (U/mL) 0.73 (0.47–1.04)a 0.75 (0.63–0.89)a 0.82 (0.59–1.22)a 1.09 (0.55–1.63)

X (U/mL) 0.88 (0.58–1.16)a 0.75 (0.55–1.01)a 0.79 (0.50–1.17)a 1.06 (0.70–1.52)

XI (U/mL) 0.97 (0.56–1.50) 0.86 (0.52–1.20) 0.74 (0.50–0.97)a 0.97 (0.67–1.27)

XII (U/mL) 0.93 (0.64–1.29) 0.92 (0.60–1.40) 0.81 (0.34–1.37)a 1.08 (0.52–1.64)

PK (U/mL) 0.95 (0.65–1.30) 0.99 (0.66–1.31) 0.99 (0.53–1.45) 1.12 (0.62–1.62)

HMWK (U/mL) 0.98 (0.64–1.32) 0.93 (0.60–1.30) 0.91 (0.63–1.19) 0.92 (0.50–1.36)

Xllla (U/mL) 1.08 (0.72–1.43)a 1.09 (0.65–1.51)a 0.99 (0.57–1.40) 1.05 (0.55–1.55)

Xllls (U/mL) 1.13 (0.69–1.56)a 1.16 (0.77–1.54)a 1.02 (0.60–1.43) 0.97 (0.57–1.37)

Note: All factors except fibrinogen are expressed as units per milliliter, where pooled plasma contains 1.0 U/mL. All data are expressed as the mean, followed by the upper and lower boundary encompassing 95% of the population. Between 20 and 50 samples were assayed for each value for each age group. Some measurements were skewed due to a disproportionate number of high values. The lower limit, which excludes the lower 2.5% of the population, is given.

Abbreviations: APTT, activated partial thromboplastin time; HMWK, high molecular weight kininogen; PK, prekallikrein; PT, prothrombin time; VIII, factor VIII procoagulant; vWF, von Willebrand factor.aValues that are significantly different from adults.

From Andrew M, Vegh P, Johnston M, Bowker J, Ofosu F, Mitchell L. Maturation of the hemostatic system during childhood. Blood. 1992;80(8):1998–2005. Copyright © 1992 American Society of Hematology.


Inhibition of Coagulation in Healthy Children Aged 1 to 16 Years Compared With Adults


Coagulation Inhibitors

Mean (boundary)

Mean (boundary)

Mean (boundary)

Mean (boundary)

ATIII (U/mL) 1.11 (0.82–1.39) 1.11 (0.90–1.31) 1.05 (0.77–1.32) 1.0 (0.74–1.26)

a2M (U/mL) 1.69 (1.14–2.23)a 1.69 (1.28–2.09)a 1.56 (0.98–2.12)a 0.86 (0.52–1.20)

C,-lnh (U/mL) 1.35 (0.85–1.83)a 1.14 (0.88–1.54) 1.03 (0.68–1.50) 1.0 (0.71–1.31)

a1AT (U/mL) 0.93 (0.39–1.47) 1.00 (0.69–1.30) 1.01 (0.65–1.37) 0.93 (0.55–1.30)

HCII (U/mL) 0.88 (0.48–1.28)a 0.86 (0.40–1.32)a 0.91 (0.53–1.29)a 1.08 (0.66–1.26)

Protein C (U/mL)

0.66 (0.40–0.92)a 0.69 (0.45–0.93)a 0.83 (0.55–1.11)a 0.96 (0.64–1.28)

Protein S

Total (U/mL) 0.86 (0.54–1.18) 0.78 (0.41–1.14) 0.72 (0.52–0.92) 0.81 (0.60–1.13)

Free (U/mL) 0.45 (0.21–0.69) 0.42 (0.22–0.62) 0.38 (0.26–0.55) 0.45 (0.27–0.61)

Note: All values are expressed in units per milliliter, where for all factors pooled plasma contains 1.0 U/mL, with the exception of free protein S, which contains a mean of 0.4 U/ml. All values are given as a mean, followed by the lower and upper boundary encompassing 95% of the population. Between 20 and 30 samples were assayed for each value for each age group. Some measurements were skewed due to a disproportionate number of high values. The lower limits, which exclude the lower 2.5% of the population, are given.aValues that are significantly different from adults.

From Andrew M, Vegh P, Johnston M, Bowker J, Ofosu F, Mitchell L. Maturation of the hemostatic system during childhood. Blood. 1992;80(8):1998–2005. Copyright © 1992 American Society of Hematology.


Fibrinolytic System in Healthy Children Aged 1 to 16 Years Compared With Adults


Mean (boundary)

Mean (boundary)

Mean (boundary)

Mean (boundary)

Plasminogen (U/mL)

0.98 (0.78–1.18) 0.92 (0.75–1.08) 0.86 (0.68–1.03)a 0.99 (0.77–1.22)

TPA (ng/mL) 2.15 (1.0–4.5)a 2.42 (1.0–5.0)a 2.16 (1.0–4.0)a 4.90 (1.40–8.40)

a2AP (U/mL) 1.05 (0.93–1.17) 0.99 (0.89–1.10) 0.98 (0.78–1.18) 1.02 (0.68–1.36)

PAI (U/mL) 5.42 (1.0–10.0) 6.79 (2.0–12.0)a 6.07 (2.0–10.0)a 3.60 (0–11.0)

Note: For a2AP, values are expressed as units per milliliter, where pooled plasma contains 1.0 U/ml. Values for TPA are given as nanograms per milliliter. Values for PAI are given as U/ml, where 1 U of PAI activity is defined as the amount of PAI that inhibits 1 IU of human single-chain TPA. All values are given as the mean, followed by the lower and upper boundary encompassing 95% of the population (boundary).aValues that are significantly different from adults.

From Andrew M, Vegh P, Johnston M, Bowker J, Ofosu F, Mitchell L. Maturation of the hemostatic system during childhood. Blood. 1992;80(8):1998–-2005. Copyright © 1992 American Society of Hematology.


Sub

set

N0–

3

Mo

nths

3–6

M

ont

hs6–

12

Mo

nths

1–2

Ye

ars

2–6

Ye

ars

6–12

Ye

ars

12–1

8

Year

sW

hite

Blo

od

Cells

800

10.6

0(7

.20–

18.0

0)

9.20

(6.7

0–14

.00)

9.10

(6.4

0–13

.00)

8.80

(6.4

0–12

.00)

7.10

(5.2

0–11

.00)

6.50

(4.4

0–9.

50)

6.00

(4.4

0–8.

10)

Lym

pho

cyte

s80

05.

40(3

.40–

7.60

)6.

30(3

.90–

9.00

)5.

90(3

.40–

9.00

)5.

50(3

.60–

8.90

)3.

60(2

.30–

5.40

)2.

70(1

.90–

3.70

)2.

20(1

.40–

3.30

)

369

93.

68(2

.50–

5.50

)3.

93(2

.50–

5.60

)3.

93(1

.90–

5.90

)3.

55(2

.10–

6.20

)2.

39(1

.40–

3.70

)1.

82(1

.20–

2.60

)1.

48(1

.00–

2.20

)

1969

90.

73(0

.30–

2.00

)1.

55(0

.43–

3.00

)1.

52(0

.61–

2.60

)1.

31(0

.72–

2.60

)0.

75(0

.39–

1.40

)0.

48(0

.27–

0.86

)0.

30(0

.11–

0.57

)

16/5

677

00.

42(0

.17–

1.10

)0.

42(0

.17–

0.83

)0.

40(0

.16–

0.95

)0.

36(0

.18–

0.92

)0.

30(0

.13–

0.72

)0.

23(0

.10–

0.48

)0.

19(0

.07–

0.48

)

469

92.

61(1

.60–

4.00

)2.

85(1

.80–

4.00

)2.

67(1

.40–

4.30

)2.

16(1

.30–

3.40

)1.

38(0

.70–

2.20

)0.

98(0

.65–

1.50

)0.

84(0

.53–

1.30

)

869

90.

98(0

.56–

1.70

)1.

05(0

.59–

1.60

)1.

04(0

.50–

1.70

)1.

04(0

.62–

2.00

)0.

84(0

.49–

1.30

)0.

68(0

.37–

1.10

)0.

53(0

.33–

0.92

)

4/45

RA/6

2L69

42.

25(1

.20–

3.60

)2.

23(1

.30–

3.60

)2.

10(1

.10–

3.60

)1.

64(0

.95–

2.80

)0.

96(0

.42–

1.50

)0.

56(0

.31–

1.00

)0.

39(0

.21–

0.75

)

8/45

RA/6

2L69

60.

73(0

.38–

1.30

)0.

74(0

.45–

1.20

)0.

70(0

.33–

1.20

)0.

76(0

.40–

1.40

)0.

54(0

.26–

0.85

)0.

41(0

.20–

0.65

)0.

30(0

.17–

0.56

)

4/45

RA69

42.

27(1

.20–

3.70

)2.

32(1

.30–

3.70

)2.

21(1

.10–

3.70

)1.

65(1

.00–

2.90

)0.

98(0

.43–

1.50

)0.

57(0

.32–

1.00

)0.

40(0

.23–

0.77

)

8/45

RA69

60.

87(0

.45–

1.50

)0.

91(0

.55–

1.40

)0.

87(0

.48–

1.50

)0.

94(0

.49–

1.70

)0.

67(0

.38–

1.10

)0.

54(0

.31–

0.90

)0.

40(0

.24–

0.71

)

LYMPHOCYTE SUBSET COUNTS IN PERIPHERAL BLOOD


Sub

set

N0–

3

Mo

nths

3–6

M

ont

hs6–

12

Mo

nths

1–2

Ye

ars

2–6

Ye

ars

6–12

Ye

ars

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8

Year

s4/

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3869

40.

08(0

.03–

0.18

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11(0

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0.26

)0.

10(0

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0.22

)0.

10(0

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0.25

)0.

06(0

.03–

0.14

)0.

04(0

.02–

0.08

)0.

03(0

.01–

0.06

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8/D

R/38

697

0.05

(0.0

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16)

0.07

(0.0

3–0.

17)

0.09

(0.0

4–0.

27)

0.15

(0.0

5–0.

54)

0.11

(0.0

5–0.

34)

0.06

(0.0

3–0.

18)

0.04

(0.0

2–0.

13)

4/D

R69

40.

10(0

.04–

0.18

)0.

15(0

.06–

0.28

)0.

12(0

.05–

0.26

)0.

13(0

.07–

0.28

)0.

09(0

.05–

0.18

)0.

07(0

.04–

0.12

)0.

06(0

.03–

0.10

)

8/D

R69

70.

05(0

.02–

0.16

)0.

08(0

.03–

0.17

)0.

09(0

.04–

0.29

)0.

18(0

.06–

0.60

)0.

14(0

.07–

0.42

)0.

09(0

.04–

0.27

)0.

07(0

.03–

0.18

)

4/38

694

2.54

(0.1

6–3.

90)

2.77

(1.6

0–4.

00)

2.55

(1.2

0–4.

10)

2.02

(1.2

0–3.

30)

1.21

(0.5

9–2.

00)

0.75

(0.4

8–1.

20)

0.57

(0.3

3–1.

00)

8/38

697

0.93

(0.5

5–1.

60)

0.94

(0.5

3–1.

50)

0.93

(0.4

5–1.

60)

0.95

(0.5

7–1.

90)

0.67

(0.3

9–1.

10)

0.48

(0.2

4–0.

74)

0.31

(0.1

6–5.

70)

4/28

695

2.56

(1.6

0–3.

80)

2.65

(1.6

0–4.

00)

2.58

(1.2

0–4.

20)

2.12

(1.3

0–3.

40)

1.33

(0.6

9–2.

00)

0.94

(0.6

3–1.

50)

0.79

(0.4

9–1.

20)

8/28

696

0.71

(0.3

5–1.

30)

0.73

(0.3

5–1.

20)

0.67

(0.2

8–1.

10)

0.72

(0.4

0–1.

30)

0.50

(0.2

8–0.

87)

0.40

(0.2

1–0.

70)

0.29

(0.1

6–0.

52)

4/95

695

0.29

(0.1

6–0.

58)

0.41

(0.2

3–0.

62)

0.51

(0.2

9–0.

82)

0.50

(0.2

7–0.

91)

0.42

(0.2

7–0.

65)

0.36

(0.2

5–0.

62)

0.40

(0.2

5–0.

66)

8/95

696

0.12

(0.0

5–0.

31)

0.16

(0.0

6–0.

39)

0.22

(0.0

8–0.

66)

0.34

(0.1

0–0.

85)

0.30

(0.1

1–0.

58)

0.25

(0.0

8–0.

53)

0.21

(0.0

8–0.

45)


Sub

set

N0–

3

Mo

nths

3–6

M

ont

hs6–

12

Mo

nths

1–2

Ye

ars

2–6

Ye

ars

6–12

Ye

ars

12–1

8

Year

s

3/4/

45RO

644

0.32

(0.0

6–0.

90)

0.33

(0.1

2–0.

63)

0.34

(0.1

6–0.

80)

0.40

(0.2

1–0.

85)

0.36

(0.2

2–0.

66)

0.35

(0.2

3–0.

63)

0.38

(0.2

4–0.

70)

3/4– /4

5RO

644

0.10

(0.0

3–0.

33)

0.12

(0.0

3–0.

29)

0.12

(0.0

4–0.

33)

0.23

(0.0

6–0.

57)

0.19

(0.0

9–0.

44)

0.21

(0.0

7–0.

39)

0.16

(0.0

6–0.

31)

3/45

RO64

40.

48(0

.09–

1.20

)0.

46(0

.15–

0.86

)0.

47(0

.22–

1.10

)0.

65(0

.30–

1.30

)0.

57(0

.33–

1.00

)0.

59(0

.32–

0.95

)0.

56(0

.34–

0.97

)

3– /19/

3865

50.

60(0

.12–

2.00

)1.

20(0

.00–

2.80

)1.

29(0

.02–

2.20

)1.

04(0

.00–

2.20

)0.

56(0

.01–

1.20

)0.

28(0

.00–

0.67

)0.

03(0

.00–

0.35

)

3– /19

655

0.62

(0.1

2–2.

10)

1.26

(0.0

0–2.

80)

1.33

(0.0

2–2.

30)

1.10

(0.0

0–2.

30)

0.67

(0.0

2–1.

40)

0.34

(0.0

0–0.

74)

0.04

(0.0

0–0.

39)

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LYMPHOCYTE SUBSET COUNTS IN PERIPHERAL BLOOD, continued


THYROID FUNCTION TESTS

Very Low Birth Weight Infants

Postnatal days

Screening T4 Levels by Birth Weight and Postnatal Age (mcg/dL)

VLBW(<1500 g)

LBW(<2500 g) Term

1–3 7.9 ± 3.3 11.4 ± 2.5 12 ± 1.9

4–6 6.5 ± 2.9 9.9 ± 2.5 11 ± 2.5

7–10 6.3 ± 3.0 9.5 ± 2.3

11–14 5.7 ± 2.8 9.2 ± 2.1

15–18 7.0 ± 2.5 9.1 ± 2.3

29–56 7.8 ± 2.5 9.3 ± 3.3

Abbreviations: LBW, low birth weight; T4, thyroxine; VLBW, very low birth weight. Data expressed as ± SD.

From Frank JE, Faix JE, Hermos RJ, et al. Thyroid function in very low birth weight infants: effects on neonatal hypothyroidism screening. J Pediatr. 1996;128(4):548. Reproduced with permission. Copyright © 1996 Elsevier.

Preterm Infants

Gestational Age Free T4 (ng/dL)Thyroid-Stimulating Hormone (mcU/mL)

25–27 wk 0.6–2.2 0.2–30.3

28–30 wk 0.6–3.4 0.2–20.6

31–33 wk 1.0–3.8 0.7–27.9

34–36 wk 1.2–4.4 1.2–21.6

Term 37–42 wk 2.0–5.3 1.0–39

PCA Concentrations after the first week of lifea

Preterm 28–40 wk 0.8–2.6 0.8–12.0

Term 42–60 wk 0.9–2.3 1.7–9.1

Abbreviations: PCA, postconceptional age (gestational age + postnatal age); T4, thyroxine.a Clark SJ, Deming DD, Emery JR, Adams LM, Carlton EI, Nelson JC. Reference ranges for thyroid function tests in premature infants beyond the first week of life. J Perinatol. 2001;21(8):531–536.

From Adams LM, Emery JR, Clark SJ, et al. Reference ranges for newer thyroid function tests in premature infants. J Pediatr. 1995;126(1):122. Reproduced with permission. Copyright © 1995 Elsevier.


Infants, Children, and Adults

AgeThyroxine (mcg/dL)

Free Thyroxine (ng/dL)

Triiodo-thyronine (ng/dL)

Free Triiodo-thyronine (ng/dL)

Thyroxine-Binding Globulin (mg/dL)

Thyroid- Stimulating Hormone (mcU/mL)

Cord blood

6.6–17.5 1.03–1.73 14–86 0.09–0.36 0.7–4.7 <2.5–17.4

1–3 d 11.0–21.5 0.6–2.0 (1–10 d)

100–380 0.17–0.57a <2.5–13.3

1–4 wk 8.2–16.6 0.7–1.7 (>10 days)

99–310 0.17–0.65a 0.5–4.5 0.6–10.0

1–12 mo

7.2–15.6 0.8–1.8 (5–24 mo)b

102–264 0.24–0.65a 1.6–3.6 0.6–6.3

1–5 y 7.3–15 1.0–2.1 (2–7 y)b

105–269 0.29–0.8a 1.3–2.8 0.6–6.3

6–10 y 6.4–13.3 0.8–1.9 (8–20 y)b

94–241 0.34–0.72a 1.4–2.6

11–15 y

5.6–11.7 0.59–2.45c 83–213 0.37–0.7a 1.4–2.6 0.6–6.3

16–20 y

4.2–11.8 0.54–2.23c 80–210 0.42–0.68 (16–18 y) a

1.4–2.6 0.2–7.6

21–45 y

4.3–12.5 0.9–2.5 70–204 1.2–2.4 0.2–7.6

a Soldin SJ, Morales A, Albalos F, Albalos F, Lenherr S, Rifai N. Pediatric reference ranges on the Abbott Imx for FSH, LH, prolactin, TSH, T4, T3, free T4, free T3, T-uptake, IgE and ferritin. Clin Biochem. 1995;28(6):603–606.

b Nelson JC, Clark SJ, Borut DL, Tomei RT, Carlton EI. Age-related changes in serum free thyroxine during childhood and adolescence. J Pediatr. 1993;123(6):899–905.

c Zurakowski D, DiCanzio J, Majzoub JA. Pediatric reference intervals for serum thyroxine, triiodo-thyronine, thyrotropin and free thyroxine. Clin Chem. 1999;45(7):1087–1091.

THYROID FUNCTION TESTS, continued


ENDOCRINE LABORATORY VALUES

Growth Hormone ValuesIn children: Spontaneous growth hormone secretion is pulsatile and unpredictable throughout the day with more peaks overnight in children who have an established diurnal rhythm. Therefore, random growth hormone values are generally not helpful. Stimulated growth hormone values (arginine, insulin-induced hypo-glycemia, levodopa, or clonidine) are often useful, and growth hor-mone deficiency can be ruled out with a value of >10 ng/mL or µg/L.

In neonates: A growth hormone level should always be measured in the presence of neonatal hypoglycemia in the absence of a meta-bolic disorder. A random growth hormone measurement in a poly-clonal radioimmunoassay of less than 20 µg/L would suggest growth hormone deficiency. These values may differ according to the method used by the labora-tory. Please refer to your local laboratory values when interpreting test results.

ReferenceGrowth Hormone Research Society. Consensus guidelines for the diagnosis and treatment of growth hormone (GH) deficiency in childhood and adolescence: summary statement of the GH Research Society. GH Research Society. J Clin Endocrinol Metab. 2000;85(11):3990–3993

8 am Cortisol Levels

Interpretation Cortisol (mcg/dL)Suggestive of adrenal insufficiency <5 mcg/dL

Indeterminate 5 –14 mcg/dL

Adrenal insufficiency unlikely >14 mcg/dL

Note: Post ACTH stimulation test Cortisol level of 16 to 36 mcg/dL is reassuring.



Serum 17 Hydroxyprogesterone

Age Baseline (ng/dL)60-Min Post-ACTH Stimulation (ng/dL)

Term infants (3 d) ≤420

1–12 mo 11–170 85 – 465

1–5 y 4 –115 50 –350

6 –12 y 7– 69 75 –220

Males, Tanner II-III 12–130 69 –310

Females, Tanner II-III 18 –220 80–420

Male, Tanner IV-V 51–190 105–230

Females, Tanner IV-V 36 –200 80 –225

Male (18 –30 y) 32–307

Adult Female Follicular phase Midcycle phase Luteal phase

≤185 ≤225 ≤285

Abbreviation: ACTH, adrenocorticotropic hormone.

Note: 8 am level is most accurate given diurnal variation. Levels are normally increased in newborns for the first few days of life. Be aware that infant serum contains substances that may cross-react in the assay for 17-hydroxyprogesterone and artificially elevate the level, unless they are separated by chromatography. Before interpreting results on infants, be sure that the laboratory has prepared samples appropriately.

For preterm infants or infants born small for gestational age, see: Olgemöller et al. Screening for congenital adrenal hyperplasia: adjustment of 17-hydroxyprogesterone cut-off values to both age and birth weight markedly improves the predictive value. J Clin Endocrinol Metab. 2003;88: 5790–5794.


ENDOCRINE LABORATORY VALUES, continued

101

6. Hyperbilirubinemia Management

RISK NOMOGRAM

Nomogram for designation of risk in 2840 well newborns at 36 or more weeks’ gestational age with birth weight of 2000 g or more or 35 or more weeks’ gestational age and birth weight of 2500 g or more based on the hour-specific serum bilirubin values.

From Bhutani 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):6–14.


PHOTOTHERAPY NOMOGRAM

Guidelines for phototherapy in hospitalized infants of 35 or more weeks’ gestation.

From American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2004; 114(1):297–316.

103Hyperbilirubinemia Management

EXCHANGE TRANSFUSION NOMOGRAM

Guidelines for exchange transfusion in infants 35 or more weeks’ gestation.

From American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2004;114(1):297–316.

105

7. Rate and Gap Calculations

GLUCOSE INFUSION RATEThe glucose infusion rate (GIR) can be calculated using the following formula:

GIR = IV Rate (mL/h) × Dextrose Concentration (g/dL) × 0.167 Weight (kg)

• A GIR of 5 to 8 mg/kg/min is typical.• The maximal GIR needed to optimize nutrition is 14 mg/kg/min.

CALCULATED SERUM OSMOLALITY The serum osmolality can be calculated using the following formula:

(2 × serum [Na]) + [glucose, in mg/dL]/18 + [blood urea nitrogen, in mg/dL]/2.8

• Reference Range Value: 275 to 295 mOsm/L

Osmolal Gap = Measured Osmolality by Laboratory − Calculated Osmolality

• Gap should be less than 10 mOsm.

ANION GAP The anion gap is the difference between the positive ions in the serum (sodium − Na) and the negative ions (chloride [CI] and bicarbonate [HCO3

-]. It can be calculated using the following formula:

Anion Gap: Na − (HCO3- + CI)

• Normal Anion Gap = 8 to 12 mEq/L.This varies according to local laboratories. Please check your specific lab because new analyzers produce higher chloride levels.

• Elevated Anion Gap is greater than 14 mEq/L in children.

107

8. Nutrition, Formula Preparation, and Caloric Counts

PREPARATION OF INFANT FORMULA FOR STANDARD AND SOY FORMULASa

Formula TypeCaloric Concentration (kcal/oz)

Amount of Formula

Water (oz)

Liquid concentrates (40 kcal/oz)

20 13 oz 13

24 13 oz 8.5

27 13 oz 6.3

30 13 oz 4.3

Powder (44 kcal/scoop)

20 1 scoop 2

24 3 scoops 5

27 3 scoops 4.25

30 3 scoops 4

a Does not apply to Enfacare LIPIL, Neocate Infant, Neosure Advance, EleCare; Enfamil AR should not be concentrated greater than 24 kcal/oz. Use a packed measure for Nutramigen LIPIL and Pregestimil LIPIL and unpacked powder for all others.

Adapted from Arcara KM, Tschudy MM, eds. The Harriet Lane Handbook. 19th ed. St Louis, MO: Mosby; 2012. Reproduced with permission. Copyright © 2012 Elsevier.


COMMON CALORIC SUPPLEMENTSa

Component CaloriesProtein Resource Beneprotein

(powder)25 kcal/scoop (6 g protein)

ProSource Protein Powder 30 kcal/scoop (6 g protein)

Complete Amino Acid Mix 3.28 kcal/g (0.82 g protein)

Carbohydrate Polycose Powder: 3.8 kcal/g, 8 kcal/5 mLl

Fat MCT oilb 7.7 kcal/mL

Vegetable oil 8.3 kcal/mL

Microlipid 4.5 kcal/mL

Fat and Carbo-hydrate

Duocal 42 kcal/15 mL; 25 kcal/scoop (59%carbohydrates, 41% fat; 35% fat asMCT oil)

Abbreviations: MCT, medium-chain triglyceride.a Use these caloric supplements when you want to increase protein or when you have reached the maximum concentration tolerated and wish to further increase caloric density.

b MCT oil is unnecessary unless there is fat malabsorption.

From Arcara KM, Tschudy MM, eds. The Harriet Lane Handbook. 19th ed. St Louis, MO: Mosby; 2012.Reproduced with permission. Copyright © 2012 Elsevier.

ENTERAL FORMULAS, INCLUDING THEIR MAIN NUTRIENT COMPONENTS

Kcal/oz

Protein (g)

Fat (g)

Carbs (g)

Na (mEq)

K (mEq)

Ca (mg)

P (mg)

Fe (mg)

Osmo-lality

A. INFANTS

Human Milk

Term 20 11 39 72 8 14 279 143 0.3 286

Preterm 20 14 39 66 11 15 248 128 1.2 290

Human Milk and Fortifiers Analysis

EnfamiI HMF+ preterm human milk (1 pkt/25 mL)

24 26 49 70 18 23 1148 628 15.6 325

SimiIac HMF+ preterm human milk (1 pkt/25 mL)

24 23 41 82 17 30 1381 777 4.6 N/A

109Nutrition, Formula Preparation, and Caloric Counts

Kcal/oz

Protein (g)

Fat (g)

Carbs (g)

Na (mEq)

K (mEq)

Ca (mg)

P (mg)

Fe (mg)

Osmo-lality

A. INFANTS, continued

Preterm Formulas

Enfamil Premature LIPIL

20 20 34 74 17 17 1100 553 3.4 240

Good Start Premature 24

24 24 42 84 19 25 1312 680 14.4 275

NeoSure 22 21 41 75 11 27 781 461 13.4 250

EnfaCare LIPIL 22 21 39 77 11 20 890 490 13.3 260

Similac Special Care 20

20 20 37 70 13 22 1217 676 12.2 235

Similac Special Care 24 High Protein

24 27 44 81 15 27 1461 811 14.6 280

Similac Special Care 30

30 30 67 78 19 34 1826 1014 18.3 325

Cow’s Milk-Based Formulas

Enfamil Premium Lipil

20 14 36 74 8 19 520 287 12 360

Enfamil LIPIL 20 14 36 73 8 19 520 287 12 300

Enfamil AR LIPIL 20 17 34 74 12 19 520 353 12 230 (240*)

Enfamil LactoFree LIPIL

20 14 36 73 9 19 547 307 12 200

Enfamil Restfull 20 17 34 74 12 19 520 353 12 230

Enfagrow Premium NextStep

20 18 36 70 10 23 1300 867 13.4 270

Evaporated Milk (13 oz + 19 oz water + 30 mL corn syrup)

20 27 31 72 21 32 1066 832 0.8 N/A

Organic Milk-Based Infant Formula

20 15 36 71 7 15 420 280 12 294

Parent’s Choice Store Brand (also w/ARA/DHA)

20 14 36 72 8 19 520 287 12 295

*Liquid formulation


Kcal/oz

Protein (g)

Fat (g)

Carbs (g)

Na (mEq)

K (mEq)

Ca (mg)

P (mg)

Fe (mg)

Osmo-lality


Cow’s Milk-Based Formulas, continued

Similac Advance Early Shield

20 14 37 76 7 18 528 284 12 310

Similac Go & Grow Milk-Based Formula

20 14 37 72 7 18 1014 548 13.5 300

Similac Sensitive 20 14 37 72 9 19 568 379 12.2 200

Similac Organic 20 14 37 71 7 18 528 284 12.2 225

Similac PM 60/40 20 15 38 69 7 14 379 189 4.7 280

Similac Sensitive RS

20 14 37 72 9 19 568 379 12.2 180

Soy-Based Formulas

Good Start 2 Soy PLUS

20 19 34 73 12 20 1273 710 13.4 175

Good Start Soy PLUS

20 17 34 75 12 20 704 422 12.1 180

America’s Store Brand Soy (also w/ARA/DHA)

20 17 36 68 11 21 700 460 12 164

SimilacGo & Grow Soy-Based Formula

20 17 37 70 13 19 1014 676 13.5 200

Isomil Advance 20 17 37 70 13 19 710 507 12.2 200

lsomilDF 20 18 37 68 13 19 710 507 12.2 240

Enfagrow Soy NextStep

20 22 30 79 11 21 1300 867 13.3 230

Enfamil Pro-SobeeLIPIL

20 17 36 71 11 21 700 460 12 170

Casein, Extensively Hydrolyzed

Alimentum 20 19 37 69 13 20 710 507 12.2 370

Nutramigen LIPIL 20 19 36 69 14 19 627 347 12 300 (320*)

*Liquid formulation

ENTERAL FORMULAS, INCLUDING THEIR MAIN NUTRIENT COMPONENTS, continued


Kcal/oz

Protein (g)

Fat (g)

Carbs (g)

Na (mEq)

K (mEq)

Ca (mg)

P (mg)

Fe (mg)

Osmo-lality


Casein, Extensively Hydrolyzed, continued

Nutramigen with Enflora LGG

20 19 36 69 14 19 627 347 12 300

Pregestimil LiPiL 20 19 38 69 14 19 640 350 12.2 250

Whey, Partially Hydrolyzed

Good Start Gentle PLUS

20 15 34 78 8 19 449 255 10.1 250

Good Start Protect PLUS

20 15 34 75 8 19 449 255 10.1 250

Good Start 2 Gentle PLUS

20 15 24 78 8 19 1273 710 13.4 180

Good Start 2 Protect PLUS

20 15 34 75 8 19 1273 710 13.4 250

Whey and Casein, Partially Hydrolyzed

Enfamil Gentlease

20 15 36 72 10 19 547 307 12 230

Amino Acid-Based Formulas

EleCare (also w/DHA/ARA)

20 20 32 72 13 26 780 568 10 350

Neocate Infant (also w/DHAIARA)

20 21 30 78 11 27 830 624 12.4 375

Nutramigen AA LIPIL

20 19 36 69 14 19 627 347 12 350

Specialized Formulas

3232A 20 19 28 89 13 19 627 420 12.5 250

RCF 20 20 36 68 13 19 710 507 12.2 168

Enfaport LIPIL 30 35 54 102 13 29 940 520 18 280



Kcal/oz

Protein (g)

Fat (g)

Carbs (g)

Na (mEq)

K (mEq)

Ca (mg)

P (mg)

Fe (mg)

Osmo-lality

B. TODDLERS AND YOUNG CHILDREN AGES 1–10 YEARS


Boost Kid Essentials

30 30 38 135 24 30 1181 886 14 550/ 600/ 570

Boost Kid Essen-tials 1.5 (w/fiber)

45 42 75 165 30 33 1300 990 14 390 (405)

Carnation Instant Breakfast Lactose Free

30 35 37 133 38 32 500 1018 9 480/490

Carnation Instant Breakfast Lactose Free Plus

45 52 48 176 51 48 748 748 13.6 620

Carnation Instant Breakfast Lactose Free VHC

68 90 123 197 51 46 1232 1232 22.4 950

Carnation Instant Breakfast Essentials

24 43 16 105 24 27 1539 1539 13.8 N/A

Compleat Pediatric

30 38 39 126 33 42 1440 1000 13.2 380

Cow’s milk, 2% 15 35 20 50 22 41 1258 979 0.5 N/A

Cow’s milk, whole 19 34 34 48 22 40 1226 956 0.5 285

Ketocal 3:1 30 22 97 10 18 35 1140 801 16 180

KetoCal 4:1 43 30 144 6 26 55 1600 1300 22 197

Kindercal TF Vanilla

32 30 44 135 16 34 1010 850 10.6 345

Monogen 30 27 28 163 21 22 617 480 10.1 370

NutrenJunior with Fiber

30 30 50 110 20 34 1000 800 14 350

PediaSure Enteral (w/fiber)

30 30 40 133 17 34 972 845 14 335 (345)

PediaSure 1.5 with Fiber

45 59 69 160 (165)

17 42 1476 1054 11 379 (390)

PediaSure Vanilla 30 30 38 131 17 34 972 845 14 480


Kcal/oz

Protein (g)

Fat (g)

Carbs (g)

Na (mEq)

K (mEq)

Ca (mg)

P (mg)

Fe (mg)

Osmo-lality

B. TODDLERS AND YOUNG CHILDREN AGES 1–10 YEARS, continued


PediaSure with Fiber Vanilla

30 30 38 135 17 34 972 845 14 480

Portagen 30 32 44 104 22 29 850 642 17 350

Soy-Based Formulas

Bright Beginnings Soy Pediatric Drink

30 30 50 109 17 40 970 800 14 350

Semi-Elemental, Hydrolyzed

Peptamen Junior 1.5

45 45 68 180 30 35 1652 1352 20.8 450

Peptamen Junior Fiber

30 30 39 137 20 34 1000 800 14 365

Peptamen Junior with Prebio

30 30 39 137 20 34 1000 800 14 365

Peptamen Junior, Unflavored (w/fiber)

30 30 39 138 20 34 1000 800 14 260 (390)

Vital Junior 30 30 41 134 31 35 1055 844 13.9 390

Soy and Pork, Hydrolyzed

Pepdite Junior, unflavored

30 31 50 106 18 35 1130 940 14 430


EleCare (Unflavored and Vanilla)

30 31 49 109 20 39 1172 852 15 560

E028 Splash 30 25 35 146 9 24 620 620 7.7 820

NeocateJuniorFlavored

30 35 47 110 19 36 1200 738 16 690

Neocate Junior Unflavored

30 33 50 104 18 35 1130 697 15 590

Vivonex Pediatric 24 24 24 130 17 31 970 800 10 360


Kcal/oz

Protein (g)

Fat (g)

Carbs (g)

Na (mEq)

K (mEq)

Ca (mg)

P (mg)

Fe (mg)

Osmo-lality

C. OLDER CHILDREN AND ADULTS


Boost 30 40 17 171 24 43 1250 1250 19 625

Boost High Protein

30 63 25 138 31 41 1459 1250 19 650

Boost Diabetic 32 59 50 84 48 29 1160 928 15 400

Boost High Protein

30 63 25 138 31 41 1459 1250 19 650

Boost Plus 45 59 59 188 31 41 1459 1250 19 670

Compleat 32 48 40 128 43 44 760 760 14 340

Crucial 45 94 68 134 51 48 1000 1000 18 490

Enlive 31 37 0 217 8 5 208 1166 11 825

Ensure 32 38 25 173 37 40 1266 1055 19 620

Ensure Plus 45 55 212 47 41 45 1266 2166 19 680

Glucerna 1.0 Cal 30 42 54 96 41 40 705 705 13 355

Jevity 1 Cal 32 44 35 155 40 40 910 760 14 300

Jevity 1.2 Cal 36 56 39 169 59 47 1200 1200 18 450

Jevity1.5 Cal 45 64 50 216 61 55 1200 1200 18 525

Nepro 53 81 96 167 46 27 1060 700 19 585

Novasource Renal 60 74 100 200 39 21 1300 650 18 700/ 960

Nutren 1.0 vanilla (w/fiber)

30 40 38 127 38 32 668 668 12 370 (410)

Nutren 1.5 unflavored

45 60 68 169 51 48 1000 1000 18 430

Nutren 2.0 60 80 104 196 57 49 1340 1340 24 745

Optimental 30 51 28 139 49 44 1055 1055 13 585

Osmolite 1 Cal 32 44 35 144 40 40 760 760 14 300

Osmolite 1.2 Cal 36 56 39 158 58 46 1200 1200 18 360

Osmolite 1.5 Cal 45 63 49 204 61 46 1000 1000 18 525

Promote (w/fiber) 30 63 26 130 44 51 1200 1200 18 340 (380)

Pulmocare 45 63 93 106 57 50 1060 1060 19 475

Renalcal 60 35 83 291 0 0 0 0 0 600



Kcal/oz

Protein (g)

Fat (g)

Carbs (g)

Na (mEq)

K (mEq)

Ca (mg)

P (mg)

Fe (mg)

Osmo-lality

C. OLDER CHILDREN AND ADULTS, continued


Replete, Unflavored

30 63 34 113 38 39 1000 1000 18 300/ 350

Resource 2.0 60 84 88 217 35 39 1042 1042 18.8 790

Resource Breeze 32 38 0 230 15 1 42 633 11 750

Suplena 54 45 96 205 35 29 1055 717 19 600

TwoCal HN 60 84 91 219 64 63 1050 1050 19 725

Soy-Based Formulas

Fibersource HN 36 53 39 160 52 51 1000 1000 17 490

Isosource 1.5 Cal 45 68 65 170 56 58 1070 1070 19 650/ 585

lsosource HN 36 53 39 160 48 49 1200 1200 15 490

Semi-Elemental Hydrolyzed

Peptamen, Unflavored

30 40 39 127 25 39 800 700 18 270

Peptamen with Prebio

30 40 39 127 25 39 800 700 18 300

Peptamen 1.5, Unflavored

45 68 56 188 45 48 1000 1000 27 550

Peptamen AF 36 76 55 107 35 41 800 800 14.4 390

Perative 39 67 37 180 45 44 870 870 16 460

Pivot 1.5 45 94 51 172 61 51 1000 1000 18 595

Vital 1.0 Cal 30 40 38 130 46 36 705 705 13 390

Vital HN 30 42 11 185 25 36 667 667 12 500


Tolerex 30 21 1.5 230 20 30 560 560 10 550

Vivonex RTF 30 50 12 175 29 31 670 670 12 630

Vivonex Plus 30 7 67 190 27 27 560 560 10 650

VivonexT.E.N. 30 38 3 210 26 24 500 500 9 630

From Arcara KM, Tschudy MM, eds.. The Harriet Lane Handbook. 19th ed. St Louis, MO: Mosby; 2012. Reproduced with permission. Copyright © 2012 Elsevier.


SolutionGlucose/CHO, g/L

Sodium, mEq/L

HCO3–,

mEq/LPotassium

mEq/LOsmolality,

mmol/LCHO/

Sodium

Pedialyte (Abbott Laboratories, Columbus, OH)

25 45 30 20 250 3.1

Pediatric Electrolyte (Pendo-Pharm, Montreal, Quebec)

25 45 20 30 250 3.1

Kaolectrolyte (Pfizer, New York, NY)

20 48 28 20 240 2.4

Rehydralyte (Abbott Laborato-ries, Columbus, OH)

25 75 30 20 310 1.9

WHO ORS, 2002 (reduced osmolarity)

75 75 10b 30 224 1.0

WHO ORS, 1975, (original formulation)

111 90 10b 20 311 1.2

Colaa 126 2 13 0.1 750 1944

Apple juicea 125 3 0 32 730 1278

Gatoradea (Gatorade, Chicago, IL)

45 20 3 3 330 62.5

Abbreviations: CHO indicates carbohydrate; HCO3–, bicarbonate; WHO, World Health Organization.

a Cola, juice, and Gatorade are shown for comparison only; they are not recommended for use. Mainly for maintenance therapy; may be used for rehydration therapy in mildly dehydrated patients.

b Citrate.

From Kleinman RE, ed. Pediatric Nutrition Handbook. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

COMPOSITION OF FLUIDS FREQUENTLY USED IN ORAL REHYDRATIONa


DIETARY REFERENCE INTAKES: RECOMMENDED INTAKES FOR INDIVIDUALS, FOOD AND NUTRITION BOARD, INSTITUTE OF MEDICINE

Infa

nts

0–6

mo

Infa

nts

7–12

mo

Child

ren

1–3

yCh

ildre

n 4–

8 y

Mal

es

9–13

yM

ales

14

–18

yFe

mal

es

9–13

yFe

mal

es

14–1

8 y

Preg

nanc

y ≤1

8 y

Lact

atio

n

≤18

y

Carb

ohyd

rate

(g/d

ay)

60a

95a

130

130

130

130

130

130

175

210

Tota

l Fib

er (g

/day

)N

DN

D19

a25

a31

a38

a26

a26

a28

a29

a

Fat (

g/d

ay)

31a

30a

ND

ND

ND

ND

ND

ND

ND

ND

n-6

Poly

unsa

tura

ted

Fa

tty A

cid

s (g

/day

) (L

inol

eic

Aci

d)

4.4a

4.6a

7a10

a12

a16

a10

a11

a13

a13

a

n-3

Poly

unsa

tura

ted

Fa

tty A

cid

s (g

/day

) (α

-Lin

olen

ic A

cid

)

0.5a

0.5a

0.7a

0.9a

1.2a

1.6a

1.0a

1.1a

1.4a

1.3a

Prot

ein

(g/k

g/d

ay)

1.52

a1.

2a1.

05a

0.95

a0.

95a

0.85

a0.

95a

0.85

a1.

1a1.

3a

Vita

min

A (μ

g/d

ay)b

400a

500a

300

400

600

900

600

700

750

1200

Vita

min

C (m

g/d

ay)

40a

50a

1525

4575

4565

8011

5

Vita

min

D (I

U/d

ay)c,

d40

0a40

0a60

060

060

060

060

060

060

060

0

Vita

min

E (m

g/d

ay)e

4a5a

67

1115

1115

1519

Vita

min

K (μ

g/d

ay)

2.0a

2.5a

30a

55a

60a

75a

60a

75a

75a

75a

Thia

min

(mg/

day

)0.

2a0.

3a0.

50.

60.

91.

20.

91.

01.

41.

4

Rib

oflav

in (m

g/d

ay)

0.3a

0.4a

0.5

0.6

0.9

1.3

0.9

1.0

1.4

1.6

Nia

cin

(mg/

day

)f2a

4a6

812

1612

1418

17

Vita

min

B6 (

mg/

day

)0.

1a0.

3a0.

50.

61.

01.

31.

01.

21.

92.

0

Fola

te (μ

g/d

ay)g

65a

80a

150

200

300

400

300

400h

600i

500

Vita

min

B12

(μg/

day

)0.

4a0.

5a0.

91.

21.

82.

41.

82.

42.

62.

8

Pant

othe

nic

Aci

d

(mg/

day

)1.

7a1.

8a2a

3a4a

5a4a

5a6a

7a

Biot

in (μ

g/d

ay)

5a6a

8a12

a20

a25

a20

a25

a30

a35

a

Calc

ium

(mg/

day

)20

0a26

0a70

0a10

00a

1300

a13

0013

0013

0013

0013

00

Chol

inej (

mg/

day

)12

5a15

0a20

0a25

0a37

5a55

0a37

5a40

0a45

0a55

0a

Chro

miu

m (μ

g/d

ay)

0.2a

5.5a

11a

15a

25a

35a

21a

24a

29a

44a

118 Reference Range Values for Pediatric CareIn

fant

s 0–

6 m

oIn

fant

s 7–

12 m

oCh

ildre

n 1–

3 y

Child

ren

4–8

yM

ales

9–

13 y

Mal

es

14–1

8 y

Fem

ales

9–

13 y

Fem

ales

14

–18

yPr

egna

ncy

≤18

yLa

ctat

ion

≤1

8 y

Cop

per

(μg/

day

)20

0a22

0a34

044

070

089

070

089

010

0013

00

Fluo

ride

(mg/

day

)0.

01a

0.5a

0.7a

1a2a

3a3a

3a3a

3a

Iod

ine

(μg/

day

)11

0a13

0a90

9012

015

012

015

022

029

0

Iron

(mg/

day

)0.

27a

117

108

118

1527

10

Mag

nesi

um (m

g/d

ay)

30a

75a

8013

024

041

024

036

040

036

0

Man

gane

se (m

g/d

ay)

0.00

3a0.

6a1.

2a1.

5a1.

9a2.

2a1.

6a1.

6a2.

0a2.

6a

Mol

ybd

enum

(μg/

day

)2a

3a17

2234

4334

4350

50

Phos

pho

rus

(mg/

day

)10

0a27

5a46

050

012

5012

5012

5012

5012

5012

50

Sele

nium

(μg/

day

)15

a20

a20

3040

5540

5560

70

Zinc

(mg/

day

)2a

33

58

118

912

13

Pota

ssiu

m (g

/day

)0.

4a0.

7a3.

0a3.

8a4.

5a4.

7a4.

5a4.

7a4.

7a5.

1a

Sod

ium

(g/d

ay)

0.12

a0.

37a

1.0a

1.2a

1.5a

1.5a

1.5a

1.5a

1.5a

1.5a

Chlo

ride

(g/d

ay)

0.18

a0.

57a

1.5a

1.9a

2.3a

2.3a

2.3a

2.3a

2.3a

2.3a

Not

e: T

his

tabl

e (t

aken

from

the

DR

I re

port

s; s

ee w

ww.

nas

.edu

) pr

esen

ts r

ecom

men

ded

diet

ary

allo

wan

ces

(RD

As)

in b

old

type

, an

d ad

equa

te in

take

s (A

Is)

are

in o

rdin

ary

type

follo

wed

by

the

sym

bol (

a ). N

D in

dica

tes

not

det

erm

ined

.a R

DA

s an

d A

Is m

ay b

oth

be

used

as

goal

s fo

r in

divi

dual

inta

ke. R

DA

s ar

e se

t to

mee

t th

e n

eeds

of a

lmos

t all

(97%

–98%

) in

divi

dual

s in

a g

roup

. For

hea

lth

y br

east

fed

infa

nts

, th

e A

I is

the

mea

n in

take

. Th

e A

I fo

r ot

her

life

sta

ge a

nd

gen

der

grou

ps is

bel

ieve

d to

cov

er n

eeds

of a

ll in

divi

dual

s in

the

grou

p, b

ut la

ck o

f dat

a or

un

cert

ain

ty in

the

data

pr

even

t bei

ng

able

to s

peci

fy w

ith

con

fide

nce

the

perc

enta

ge o

f in

divi

dual

s co

vere

d by

this

inta

ke.

b As

reti

nol

act

ivit

y eq

uiva

len

ts (

RA

Es)

. 1 R

AE

= 1

μg

reti

nol

, 12

μg β

-car

oten

e, 2

4 μg

α-c

arot

ene,

or

24 μ

g β-

cryp

toxa

nth

in in

food

s. T

he

RA

E fo

r di

etar

y pr

ovit

amin

A c

arot

-en

oids

is

twof

old

grea

ter

than

ret

inol

equ

ival

ents

(R

E),

wh

erea

s th

e R

AE

for

pref

orm

ed v

itam

in A

is th

e sa

me

as R

E.

c As

chol

ecal

cife

rol.

1 μg

ch

olec

alci

fero

l = 4

0 IU

vit

amin

D.

d In

the

abse

nce

of a

dequ

ate

expo

sure

to s

unlig

ht.

e As

α-to

coph

erol

. α-T

ocop

her

ol in

clud

es R

RR

-α-to

coph

erol

, th

e on

ly fo

rm o

f α-to

coph

erol

that

occ

urs

nat

ural

ly in

food

s, a

nd

the

2R-s

tere

oiso

mer

ic fo

rms

of α

-toco

pher

ol

(RR

R-,

RSR

-, R

RS-

, an

d R

SS-α

-toco

pher

ol)

that

occ

ur in

fort

ified

food

s an

d su

pple

men

ts. I

t doe

s n

ot in

clud

e th

e 2S

-ste

reoi

som

eric

form

s of

α-to

coph

erol

(SR

R-,

SSR

-, SR

S-,

and

SSS-

α-to

coph

erol

), a

lso

foun

d in

fort

ified

food

s an

d su

pple

men

ts.

f As

nia

cin

equ

ival

ents

(N

Es)

. 1 m

g of

nia

cin

= 6

0 m

g of

tryp

toph

an; 0

–6 m

o =

pref

orm

ed n

iaci

n (

not

NE

s).

g A

s di

etar

y fo

late

equ

ival

ents

(D

FEs)

. 1 D

FE =

1 μ

g fo

od fo

late

= 0

.6 μ

g of

folic

aci

d fr

om fo

rtifi

ed fo

od o

r as

a s

uppl

emen

t con

sum

ed w

ith

food

= 0

.5 μ

g of

a s

uppl

emen

t ta

ken

on

an

em

pty

stom

ach

.h In

vie

w o

f evi

den

ce li

nki

ng

fola

te in

take

wit

h n

eura

l tub

e de

fect

s in

the

fetu

s, it

is r

ecom

men

ded

that

all

wom

en c

apab

le o

f bec

omin

g pr

egn

ant c

onsu

me

400

μg fr

om

supp

lem

ents

or

fort

ified

food

s in

add

itio

n to

inta

ke o

f foo

d fo

late

from

the

diet

.i I

t is

assu

med

that

wom

en w

ill c

onti

nue

con

sum

ing

400

μg fr

om s

uppl

emen

ts o

r fo

rtifi

ed fo

od u

nti

l th

eir

preg

nan

cy is

con

firm

ed a

nd

they

en

ter

pren

atal

car

e, w

hic

h o

rdin

ari-

ly o

ccur

s af

ter

the

end

of th

e pe

rico

nce

ptio

nal

per

iod—

the

crit

ical

tim

e fo

r fo

rmat

ion

of t

he

neu

ral t

ube.

j Alt

hou

gh A

Is h

ave

been

set

for

chol

ine,

ther

e ar

e fe

w d

ata

to a

sses

s w

het

her

a d

ieta

ry s

uppl

y of

ch

olin

e is

nee

ded

at a

ll st

ages

of t

he

life

cycl

e, a

nd

it m

ay b

e th

at th

e ch

olin

e re

quir

emen

t can

be

met

by

endo

gen

ous

syn

thes

is a

t som

e of

thes

e st

ages

.

Cop

yrig

ht 2

004

by T

he

Nat

ion

al A

cade

mie

s of

Sci

ence

s. A

ll ri

ghts

res

erve

d.

DIETARY REFERENCE INTAKES: RECOMMENDED INTAKES FOR INDI VID UALS, FOOD AND NUTRITION BOARD, INSTITUTE OF MEDICINE, continued


FLUORIDE SOURCES AND SUPPLEMENTATION

Topical Fluoride Sources

Source Availability Concentration Typical DoseToothpaste OTC 1,000 –1,500 ppm Pea sized = 0.25 mg

Toothpaste Prescription 5,000 ppm Pea sized = 1.25 mg

Varnish Professionally applied 22,600 ppm (NaF) 0.2 mL = 4.4 mg

Gel Professionally applied 12,300 ppm (1.23%) 5 mL = 61.5 mg

Gel Prescription 5,000 ppm (0.5% NaF)

Thin ribbon = 25 mg

Foam Professionally applied 9,040 ppm (0.9%) 5 mL = 45 mg

Rinse OTC 230 ppm (0.05% NaF) 5 mL = 2.5 mg

From Slayton R. Fluoride facts: what pediatricians need to know about fluoride agents for children, including supplementation. AAP News. 2010;31:30

Dietary Fluoride Supplementation Schedule

Age <0.3 ppm F 0.3–0.6 ppm F >0.6 ppm FBirth–6 months 0 0 0

6 months–3 years 0.25 mg 0 0

3–6 years 0.50 mg 0.25 mg 0

6 years up to at least 16 years

1.00 mg 0.50 mg 0

From American Academy of Pediatric Dentistry Liaison with Other Groups Committee; American Academy of Pediatric Dentistry Council on Clinical Affairs. Guideline on fluoride therapy. Pediatr Dent. 2008–2009;30(7 suppl):121–124. Reproduced with permission. Copyright © 2008–2009 American Academy of Pediatric Dentistry.

121

9. Umbilical Vein and Artery Catheterization Measurements

USING BIRTH WEIGHT TO MEASURE CATHETER LENGTHPrior to placing an umbilical vein or artery catheter in a newborn as an elective procedure, you can use the following regression formula to determine the catheter length in centimeters using birth weight:

Umbilical Artery Catheter Length (cm) = 3 × Birth Weight + 9 cm

Umbilical Vein Catheter Length (cm) = Umbilical Artery Catheter Length (cm) + 1 cm

2

You can use this formula to approximate the length necessary for place-ment of a high-lying line between T6 and T10 for umbilical artery lines and umbilical vein lines above the level of the diaphragm in the inferior vena cava. Correct placement in small for gestational age (SGA) and large for gestational age (LGA) babies may vary because the formula is only an approximation. Radiographic confirmation of line positioning is important to avoid complications.


30

25

20

15

10

5

15

10

5

0 1000 2000 3000 4000 5000 6000

Inte

rnal

Cat

hete

r Le

ngth

, cm

Birth Weight, g

Estimate of Insertional Length of Umbilical Catheters Based on Birth Weight With 95% Confidence Intervals

Umbilical catheters (umbilical artery catheter tip inserted between T-6 and T-10; umbilical vein catheter tip inserted above diaphragm in interior vena cava near or in right atrium). Modified estimating equations utilizing birth weight (BW) are as follows: umbilical artery length = 2.5*BW + 9.7 (top graph) and umbilical vein length = 1.5*BW + 5.6 (bottom graph), where BW is measured in kilograms and lengths in centimeters.

From Shukla H, Ferrara A. Rapid estimation of insertional length of umbilical catheters in newborns. Am J Dis Child. 1986;140(8):786–788. Copyright © 1986 American Medical Association. All rights reserved.

123Umbilical Vein and Artery Catheterization Measurements

USING SHOULDER-UMBILICAL LENGTH TO MEASURE UMBILICAL ARTERY CATHETER LENGTH

The graph shows the length of catheter necessary to reach the aortic valve, diaphragm, or aortic bifurcation. Ideally, the umbilical artery catheter should reach the level of the diaphragm for a high-lying line. Measure the shoulder- umbilical length by drop-ping a vertical line from the tip of the shoulder to a point vertically beneath it that is level with the center of the umbilicus. Plot this length on the x-axis of the graph. Where the line intersects the graph of the diaphram, plot a line to the y-axis.

28

26

24

22

20

18

16

14

12

10

8

6

48 10 12 14 16 18

Um

bili

cal A

rter

y Ca

thet

er (

cm)

Shoulder-UmbilicalLength (cm)

Aorti

c Va

lve

Diaphr

agm

Bifurca

tion of A

orta

Umbilical Artery Catheter Length


USING SHOULDER-UMBILICAL LENGTH TO MEASURE UMBILICAL VEIN CATHETER LENGTH

The graph shows the length of catheter necessary to reach the left side of the atrium and the diaphragm. Ideally, the umbilical vein catheter should reach the level of the diaphragm. Measure the shoulder-umbilical length by dropping a vertical line from the tip of the shoulder to a point vertically beneath it that is level with the center of the umbilicus. Plot this length on the x-axis of the graph. Where the line intersects the graph of the diaphragm, plot a line to the y-axis.

13

12

11

10

9

8

7

6

5

48 9 10 11 12 13 14 15 16 17

Um

bili

cal V

ein

Cath

eter

(cm

)

Shoulder-Umbilical Length (cm)

Left A

trium

Diaphragm

Umbilical Vein Catheter Length

125

10. Doses and Levels of Common Anti-biotic and Antiseizure Medications

ANTIBIOTICS

AMIKACIN ............................................................................. 126

GENTAMICIN.......................................................................... 128

TOBRAMYCIN ......................................................................... 130

VANCOMYCIN ........................................................................ 132

ANTISEIZURE

FOSPHENYTOIN ..................................................................... 134

LEVETIRACETAM ..................................................................... 136

PHENOBARBITAL .................................................................... 138

TOPIRAMATE ......................................................................... 140

VALPORIC ACID AND DERIVATIVES........................................... 142


ANTIBIOTICS

Amikacin

Neonatal Dosing

Dosing Table for IV Systemic Administration PMA (wk) Postnatal (d) Dose (mg/kg) Interval (h)

≤29 0–7 8–28 ≥29

18 15 15

48 36 24

30–34 0–7 ≥8

18 15

36 24

≥35 All 15 24

Abbreviation: PMA, postmenstrual age.

Infant, Children, and Adolescent Dosing

CONVENTIONAL DOSING: 5 to 7.5 mg/kg/dose every 8 hoursDOSAGE FOR RENAL IMPAIRMENT: Yes

Monitoring in neonates

WHEN TO DRAW LEVELS

• Peak: After second dose (see “Timing of Levels”).• Trough: After second dose (just before third dose).• Levels are unnecessary if patient is on antibiotics for 48 to 72 hour

rule-out sepsis protocol.• Consider more frequent monitoring in hypothermia treatment.

TIMING OF LEVELS

• Peak: 30 minutes after end of 30-minute infusion• Trough: 0 to 30 minutes before next dose

GOAL LEVELS

• Amikacin peak: 20 to 25 mcg/mL• Amikacin trough: <5 mcg/mL

127Doses and Levels of Common Anti biotic and Antiseizure Medications

Monitoring in Infants, Children, and Adolescents

WHEN TO DRAW LEVELS

• Peak: After second dose (see “Timing of Levels”).• Trough: After second dose (just before third dose).• Levels may be unnecessary if patient is on antibiotics for 48 to

72 hours sepsis protocol.

TIMING OF LEVELS


GOAL LEVELS

• Amikacin peak: 20 to 30 mcg/mL• Amikacin trough: 4 to 10 mcg/mL


Gentamicin

Neonatal Dosing


≤29 0–7 8–28 ≥29

5 4 4

48 36 24

30–34 0–7 ≥8

4.5 4

36 24

≥35 All 4 24



CONVENTIONAL DOSING:

• Infants and children younger than 5 years: 2.5 mg/kg/dose every 8 hours

• Children 5 years and older: 2 to 2.5 mg/kg/dose every 8 hours

HIGH-DOSE, EXTENDED INTERVAL DOSING (IN PATIENTS WITH NORMAL RENAL

FUNCTION): 5 to 7.5 mg/kg/dose every 24 hours

DOSAGE FOR RENAL IMPAIRMENT: Yes

Monitoring in Neonates

WHEN TO DRAW LEVELS


rule-out sepsis protocol.• Consider more frequent monitoring in hypothermia treatment.

TIMING OF LEVELS



GOAL LEVELS

• Gentamicin peak: 6 to 12 mcg/mL (3 to 5 is an acceptable range for gram-positive synergy)

• Gentamicin trough: <1 mcg/mL

Gentamicin Dose and Monitoring Recommendations for HIE Cooling PatientsWHEN TO DRAW LEVELS

• First levels done as described above.• Repeat peak and trough levels after rewarming.

— Peak: After forth dose (see “Timing of Levels”) — Trough: Before fourth dose

• Levels are unnecessary if patient is on antibiotics for 48 to 72 hour rule-out sepsis protocol.

TIMING OF LEVELS


Monitoring in Infants, Children, and AdolescentsWHEN TO DRAW LEVELS

• Peak: After third dose (see “Timing of Levels”).• Trough: After third dose.• Levels may be unnecessary if patient is on antibiotics for 48 to

72 hour rule-out sepsis protocol.

TIMING OF LEVELS


GOAL LEVELS

• Gentamicin peak (conventional dosing): 6 to12 mcg/mL (3 to 5 is an acceptable range for gram-positive synergy)

• Gentamicin peak (high-dose, extended interval dosing): May be 2 to 3 times greater than conventional dosing peak levels

• Gentamicin trough: <2 mcg/mL ( <1 mcg/mL is ideal, especially for high-dose, extended interval)


Tobramycin

Neonatal Dosing


≤29 0–7 8–28 ≥29

5 4 4

48 36 24

30–34 0–7 ≥8

4.5 4

36 24

≥35 All 4 24



CONVENTIONAL DOSING:

• Infants and children younger than 5 years: 2.5 mg/kg/dose every 8 hours

• Children 5 years and older: 2 to 2.5 mg/kg/dose every 8 hours

CYSTIC FIBROSIS DOSING:

• Conventional CF dosing: 3.3 mg/kg/dose every 8 hours• High-dose, extended interval dosing: 7 mg/kg/dose every 12 hours

or 10 mg/kg/dose every 24 hours



WHEN TO DRAW LEVELS


rule-out sepsis protocol.

TIMING OF LEVELS



GOAL LEVELS

• Tobramycin peak: 6 to 12 mcg/mL (3 to 5 mcg/mL is an acceptable range for gram-positive synergy)

• Tobramycin trough: <1 mcg/mL

Monitoring in Infants, Children, and Adolescents

WHEN TO DRAW LEVELS

• Peak: After third dose (see “Timing of Levels”).• Trough: Prior third dose.• Levels may be unnecessary if patient is on antibiotics for 48 to 72

hour rule-out sepsis protocol.

TIMING OF LEVELS


GOAL LEVELS

• Tobramycin peak (non–cystic fibrosis dosing): 6 to12 mcg/mL (3 to 5 mcg/mL is an acceptable range for gram-positive synergy)

• Tobramycin peak (cystic fibrosis dosing): 8 to 14 mcg/mL• Tobramycin trough: <2 mcg/mL (<1 mcg/mL is ideal)


Vancomycin

Neonatal Dosing

Meningitis: 15 mg/kg/doseBacteremia: 10 mg/kg/dose

Dosing Table for IV Administration PMA (wk) Postnatal (d) Interval (h)

≤29 0–14 >14

18 12

30–36 0–14 >14

12 8

37–44 0–7 >7

12 8


Infants, Children, and Adolescent Dosing

CONVENTIONAL DOSING: 15 to 20 mg/kg/dose every 6 to 8 hours (Consider every 6 hours for patients older than 2 months who do not have a history of cardial abnormalities.)



TROUGHS ONLY EXCEPT WITH

• Central nervous system infections• Osteomyelitis• Infective abscess• Goal trough >10 mcg/mL

Monitoring in Infants, Children, and AdolescentsOnly trough levels are recommended.

WHEN TO DRAW LEVELS

• Trough: Before third dose (for neonates) or fourth dose(for infants, children, and adolescents)

• Peak: After third dose (when necessary)


TIMING OF LEVELS


GOAL LEVELS

• Trough for neonates: 5 to 15 mcg/mL• Trough for non-neonates: 10 to 20 mcg/mL

— Consider higher goal of 10 to 15 mcg/mL (for neonates) or 15 to 20 mcg/mL (for infants, children, and adolescents) for serious infections or anatomic sites with difficult penetration (eg, meningitis, osteomylitis, bacteremia, endocarditis, hospital- acquired pneumonia caused by Staphylococcus aureus) upon recommendation from pediatric infectious diseases or clinical pharmacist.

• Peak: 25 to 40 mcg/mL


ANTISEIZURE

FosphenytoinNote: All dosing is expressed in phenytoin equivalents (PE). 1 mg of fosphenytoin = 1 mg of phenytoin.

Neonatal Dosing

LOADING DOSE: 15 to 20 mg PE/kg IM or IV infusion over at least 10 minutes.

MAINTENANCE DOSE: 4 to 8 mg PE/kg IM or IV slow push every 24 hours. Begin maintenance 24 hours after loading dose.

Term infants older than 1 week may require up to 8 mg PE/kg/dose every 8 to 12 hours.


LOADING DOSE

• Status epilepticus: 15 to 20 mg PE/kg IV• Non-emergent: 10 to 20 mg PE/kg IV or IM

MAINTENANCE DOSE: 4 to 6 mg PE/kg IV every day in 2 to 3 divided doses

Monitoring

WHEN TO DRAW LEVELS

• Monitor the drug via phenytoin levels in serum.• Consider obtaining a level 2 hours (if IV infusion) or 4 hours (if IM

infusion) after administration of the loading dose.• Achieving a steady state takes about 1 week, but you may want to take

a level if patient continues to seize.• Maintenance doses may be titrated if symptomatic, even if levels

are pending.• Consider obtaining serum albumin level.

TIMING OF LEVELS

Trough: Before steady-state dose


GOAL LEVELS

• Total phenytoin level — First week of life: 6 to 15 mcg/mL — After 7 days of life: 10 to 20 mcg/mL

• Free (unbound) level — 1 to 2 mcg/mL


Levetiracetam (Keppra)

Neonatal DosingNote: Limited data available; dose not established.

IV: 10 mg/kg/day divided twice daily; increase dosage by 10 mg/kg over 3 days to 30 mg/kg/day; additional increases up to 45 to 60 mg/kg/day have been used with persistent seizure activity or clinical EEG findings. For treatment of status epilepticus, loading doses of 20 to 30 mg/kg/dose have been used by some centers.

ORAL: Initial, 10 mg/kg/day in 1 to 2 divided doses; increase daily by 10 mg/kg to 30 mg/kg/day (maximum reported dose: 60 mg/kg/day).


PARTIAL ONSET SEIZURES

• Infants between 1 and 6 months of age: 7 mg/kg/dose twice daily; can increase dosage every 2 weeks by 7 mg/kg/dose twice daily, as tolerated, to the recommended dose of 20 mg/kg/dose twice daily. Additional increases up to 45 to 60 mg/kg/day have been used with persistent seizure activity or clinical EEG findings. Commonly accept-ed maximum dose at most centers is 60 mg/kg/day.

• Infants older than 6 months and adolescents younger than 16 years: 10 mg/kg/dose IV/PO twice daily. May increase dose every 2 weeks by 10 mg/kg/dose, if tolerated, to a maximum of 60 mg/kg/day.

• Adolescents 16 years and older: 500 mg twice daily; may increase every 2 weeks by 500 mg/dose to the recommended dose of 1,500 mg twice daily. Efficacy of doses other than 3,000 mg/day has not been established. The same dose is indicated for myoclonic seizures in this patient population.

SEIZURE PROPHYLAXIS

• Loading dose: 20 mg/kg IV• Maintenance dose: 10 mg/kg/dose twice daily for 7 days


STATUS EPILEPTICUS

Note: Limited data available; dose not established.

Loading dose of 50 mg/kg/dose (maximum dose: 2,500 mg) given IV; followed by IV or oral maintenance dosing determined by clinical response; reported IV maintenance dose is 30 to 55 mg/kg/day, divided twice daily

MonitoringTrough concentrations are not routinely measured but may be useful in accessing magnitude of dosing adjustments, drug compliance, or both.

THERAPEUTIC CONCENTRATIONS: 10 to 40 mcg/mL


Phenobarbital

Neonatal Dosing

ANTICONVULSANT

• Loading dose: 20 mg/kg IV, given slowly over 10 to 15 minutes.• Refractory seizures: Additional 5 mg/kg doses, up to a total of

40 mg/kg.• Maintenance dosing: 3 to 4 mg/kg/day, beginning 12 to 24 hours

after the load. Increase to 5 mg/kg/day if needed (usually by second week of therapy).

• Frequency/Route: Every 24 hours. IV slow push (most rapid control of seizures), IM, orally, or rectally.

NEONATAL ABSTINENCE SYNDROME

• Loading dose: 16 mg/kg orally on day 1.• Maintenance: 1 to 4 mg/kg/dose orally every 12 hours.• Based on abstinence scoring, weaning can be achieved by decreasing

dose 20% every other day.

Infants, Children, and Adolescents

ANTICONVULSANT LOADING DOSE

15 to 20 mg/kg (maximum: 1,000 mg/dose)

MAINTENANCE DOSING

Age Maintenance DosingInfant 5–6 mg/kg/day divided in 1–2 doses

Children 1 to 5 y 6–8 mg/kg/day divided in 1–2 doses

Children 5 to 12 y 4–6 mg/kg/day divided in 1–2 doses

Adolescents >12 y 1–3 mg/kg/day divided in 1–2 doses


Monitoring

WHEN TO DRAW LEVELS

• Achieving a steady state takes 1 to 2 weeks, but you may want to take a level if patient continues to seize.

• Maintenance doses may be titrated if symptomatic, even if levels are pending.

TIMING OF LEVELS

Trough: Before steady-state dose

GOAL LEVELS

Trough: 15 to 40 mcg/mL


Topiramate (Topomax)

Neonatal DosingNote: Limited data. Further studies needed.

NEONATAL SEIZURES, REFRACTORY: Oral, 10 mg/kg/day

NEUROPROTECTANT FOLLOWING ANOXIC INJURY (WITH COOLING): Oral, 5 mg/kg/day

Infants, Children, and Adolescents

ANTICONVULSANT MONOTHERAPY

Children 2 to younger than 10 years of ageInitial: 25 mg once daily (in evening); may increase, if tolerated to 25 mg twice daily in week 2; thereafter, may increase by 25 to 50 mg/day at weekly intervals over 5 to 7 weeks up to the lower end of the target daily maintenance dosing range in the following table:

≤11 kg: 150–250 mg/day in 2 divided doses 12–22 kg: 200–300 mg/day in 2 divided doses 23–31 kg: 200–350 mg/day in 2 divided doses 32–38 kg: 250–350 mg/day in 2 divided doses >38 kg: 250–400 mg/day in 2 divided doses

Children 10 years and older and adolescentsInitial: 25 mg twice daily; increase at weekly intervals by 50 mg/day up to a dose of 100 mg twice daily (week 4 dose); thereafter, may further increase at weekly intervals by 100 mg/day up to the recommended maximum dose of 200 mg twice daily

ANTICONVULSANT ADJUNCTIVE THERAPY

Children and adolescents 2 to 16 years of ageInitial: 1 to 3 mg/kg/day (maximum: 25 mg) given nightly for 1 week; increase at 1- to 2-week intervals by 1 to 3 mg/kg/day given in 2 divided doses; titrate dose to response; usual maintenance: 5 to 9 mg/kg/day given in 2 divided doses. Slower titrations rates should be utilized in generalized tonic clonic seizures.


Adolescents 17 years and olderInitial: 25 to 50 mg/day given daily for 1 week; increase at weekly intervals by 25 to 50 mg/day divided into 2 doses. Doses are titrated response with a usual maintenance dose of 100 to 200 mg twice daily (maximum dose: 1,600 mg/day). Slower titrations rates should be utilized in generalized tonic clonic seizures.

MonitoringMeasure serum bicarbonate levels at baseline and periodically during treatment. Routine monitoring of levels may be unnecessary, but con-sider target concentrations of 5 to 20 ng/mL.


Valproic Acid and Derivatives

Infants, Children, Adolescent DosingNote: due to the risk of valproic acid associated hepatotoxicity in patients younger than 2 years of age, valproic acid is not the preferred agent in this population.

SEIZURE DISORDER

• Oral: 10 to 15 mg/kg/day divided 3 to 4 times daily (valproic acid) or twice daily (divalproex sodium). Doses can be increased at weekly intervals to a maximum dose of 60 mg/kg/day.

• IV: Total daily dose IV is equal to total daily dose oral; however, IV should be divided into a frequency of every 6 hours.

REFACTORY STATUS EPILEPTICUS

• Loading dose: 20 to 40 mg/kg (maximum: 1,000 mg)• Continuous infusion (to begin after loading dose): 1 mg/kg/h

WHEN TO DRAW LEVELS

• Drug is monitored via trough valproic acid levels. • Should also consider obtained liver enzymes, serum ammonia,

and CBC/platelets.

TIMING OF LEVELS: Trough before steady-state dose

GOAL LEVELS: Therapeutic: 50 to 100 mcg/mL (therapeutic levels are not well established; higher goal levels may be indicated in certain patients, but should consider a neurology consult)

RESOURCESLexicomp Online. Lexi-comp , Inc; 2013. http://online.lexi.com. Accessed December 23, 2013

Mark LF, Solomon A, Northington FJ, Lee CK. Gentamicin pharmacokinetics in neonates undergoing therapeutic hypothermia. Ther Drug Monit. 2013;35(2):217–222.

Neofax Online. Truven Health Analytics Inc; 2013. http://www.micromedex.com. Accessed December 23, 2013

143Appendices

11. Appendixes

ACETAMINOPHEN TOXICITY NOMOGRAM .............................. 144

RABIES GUIDELINES ................................................................ 145

IMMUNIZATION SCHEDULES

RECOMMENDED IMMUNIZATION SCHEDULE FOR PERSONS AGED 0 THROUGH 18 YEARS— UNITED STATES, 2014 ....................................................... 146

CATCH-UP IMMUNIXATION SCHEDULE FOR PERSONS AGED 4 MONTHS THROUGH 18 YEARS WHO START LATE OR WHO ARE MORE THAN 1 MONTH BEHIND—UNITED STATES, 2014 ........................ 148

PERIODICITY SCHEDULE ................................................ SEE INSERT

FRENCH CATHETER SCALE.............................................. SEE INSERT


ACETAMINOPHEN TOXICITY NOMOGRAM

Adapted from Rumack BH, Matthew H. Acetaminophen poisoning and toxicity. Pediatrics. 1975;55(6):871–876, and Rumack BH. Acetaminophen hepatotoxicity: the first 35 years. J Toxicol Clin Toxicol. 2002;40(1):3–20.

145Appendices

RABIES GUIDELINES

Rabies Postexposure Prophylaxis (PEP) Schedule—United States, 2010

Vaccination status Intervention Regimena

Not previously vaccinated

Wound cleansing All PEP should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent (e.g., povidine-iodine solution) should be used to irrigate the wounds.

Human rabies immune globulin (HRIG)

Administer 20 IU/kg body weight. If anatomically fea-sible, the full dose should be infiltrated around and into the wound(s), and any remaining volume should be administered at an anatomical site (intramuscular [IM]) distant from vaccine administration. Also, HRIG should not be administered in the same syringe as vaccine. Because RIG might partially suppress active production of rabies virus antibody, no more than the recommended dose should be administered.

Vaccine Human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1.0 mL, IM (deltoid areab), 1 each on days 0,c 3, 7 and 14.d

Previously vaccinatede

Wound cleansing All PEP should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent such as povidine-iodine solution should be used to irrigate the wounds.

HRIG HRIG should not be administered.

Vaccine HDCV or PCECV 1.0 mL, IM (deltoid areab), 1 each on days 0c and 3.

a These regimens are applicable for persons in all age groups, including children.b The deltoid area is the only acceptable site of vaccination for adults and older children. For younger children, the outer aspect of the thigh may be used. Vaccine should never be adminis-tered in the gluteal area.

c Day 0 is the day dose 1 of vaccine is administered.d For persons with immunosuppression, rabies PEP should be administered using all 5 doses of vaccine on days 0, 3, 7, 14, and 28.

e Any person with a history of pre-exposure vaccination with HDCV, PCECV, or rabies vaccine ad-sorbed (RVA); prior PEP with HDCV, PCECV or RVA; or previous vaccination with any other type of rabies vaccine and a documented history of antibody response to the prior vaccination.

From Rupprecht CE, Briggs D, Brown CM, Franka R, Katz SL, Kerr HD, Lett SM, Levis R, Meltzer MI, Schaffner W, Cieslak PR; Centers for Disease Control and Prevention (CDC). Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human rabies: recommendations of the advisory committee on immunization practices. MMWR Recomm Rep. 2010 Mar 19;59(RR-2):1-9. Erratum in: MMWR Recomm Rep. 2010 Apr 30;59(16):493.

146 Reference Range Values for Pediatric CareRe

com

men

ded

Imm

uniz

atio

n Sc

hedu

les f

or P

erso

ns A

ged

0 Th

roug

h 18

Yea

rsU

NIT

ED S

TATE

S, 2

014

The

Reco

mm

end

ed Im

mu

niz

atio

n S

ched

ule

s fo

r Pe

rso

ns

Ag

ed 0

Th

rou

gh

18

Year

s ar

e ap

pro

ved

by

the

Ad

viso

ry C

om

mit

tee

on

Imm

un

izat

ion

Pra

ctic

es

(htt

p:/

/ww

w.c

dc.

go

v/va

ccin

es/a

cip

)

Am

eric

an A

cad

emy

of P

edia

tric

s (h

ttp

://w

ww

.aap

.org

)

Am

eric

an A

cad

emy

of F

amily

Ph

ysic

ian

s (h

ttp

://w

ww

.aaf

p.o

rg)

Am

eric

an C

olle

ge

of O

bst

etri

cian

s an

d G

ynec

olo

gis

ts(h

ttp

://w

ww

.aco

g.o

rg)

This

sch

edul

e in

clud

es re

com

men

datio

ns in

effe

ct a

s of

Janu

ary

1, 2

014.

Any

dos

e no

t adm

inis

tere

d at

the

reco

mm

ende

d ag

e sh

ould

be

adm

inis

tere

d at

a s

ubse

quen

t vis

it, w

hen

indi

cate

d an

d fe

asib

le. T

he u

se o

f a

com

bina

tion

vacc

ine

gene

rally

is p

refe

rred

ove

r sep

arat

e in

ject

ions

of i

ts e

quiv

alen

t com

pone

nt v

acci

nes.

Vacc

inat

ion

prov

ider

s sh

ould

con

sult

the

rele

vant

Adv

isor

y Co

mm

ittee

on

Imm

uniz

atio

n Pr

actic

es (A

CIP)

st

atem

ent f

or d

etai

led

reco

mm

enda

tions

, ava

ilabl

e on

line

at h

ttp:

//w

ww

.cdc

.gov

/vac

cine

s/hc

p/ac

ip-r

ecs/

inde

x.ht

ml.

Clin

ical

ly s

igni

fican

t adv

erse

eve

nts

that

follo

w v

acci

natio

n sh

ould

be

repo

rted

to th

e Va

ccin

e Ad

vers

e Ev

ent

Repo

rtin

g Sy

stem

(VA

ERS)

onl

ine

(htt

p://

ww

w.v

aers

.hhs

.gov

) or b

y te

leph

one

(800

-822

-796

7).

U.S

. Dep

artm

ent o

f Hea

lth a

nd H

uman

Ser

vice

sCe

nter

s fo

r Dis

ease

Con

trol

and

Pre

vent

ion

147Appendices

Figu

re 1

. Rec

omm

ende

d im

mun

izat

ion

sche

dule

for p

erso

ns a

ged

0 th

roug

h 18

yea

rs –

Uni

ted

Stat

es, 2

014.

(F

OR

THO

SE W

HO

FA

LL B

EHIN

D O

R ST

ART

LAT

E, S

EE T

HE

CATC

H-U

P SC

HED

ULE

[FIG

URE

2]).

Th

ese

reco

mm

enda

tions

mus

t be

read

with

the

foot

note

s tha

t fol

low

. For

thos

e w

ho fa

ll be

hind

or s

tart

late

, pro

vide

cat

ch-u

p va

ccin

atio

n at

the

earli

est o

ppor

tuni

ty a

s ind

icat

ed b

y th

e gr

een

bars

in F

igur

e 1.

To

det

erm

ine

min

imum

inte

rval

s bet

wee

n do

ses,

see

the

catc

h-up

sche

dule

(Fig

ure

2). S

choo

l ent

ry a

nd a

dole

scen

t vac

cine

age

gro

ups a

re in

bol

d.

Not

rout

inel

y re

com

men

ded

Rang

e of

reco

mm

ende

d ag

es fo

r cer

tain

hig

h-ris

k

grou

ps

Rang

e of

re

com

men

ded

ages

for

all c

hild

ren

Rang

e of

reco

mm

ende

d ag

es fo

r cat

ch-u

p im

mun

izat

ion

NO

TE: T

he a

bove

reco

mm

enda

tions

mus

t be

read

alo

ng w

ith th

e fo

otno

tes o

f thi

s sch

edul

e.

This

sch

edul

e in

clud

es re

com

men

datio

ns in

effe

ct a

s of

Janu

ary

1, 2

014.

Any

dos

e no

t adm

inis

tere

d at

the

reco

mm

ende

d ag

e sh

ould

be

adm

inis

tere

d at

a s

ubse

quen

t vis

it, w

hen

indi

cate

d an

d fe

asib

le. T

he u

se o

f a c

ombi

natio

n va

ccin

e ge

nera

lly is

pre

ferr

ed o

ver s

epar

ate

inje

ctio

ns o

f its

equ

ival

ent c

ompo

nent

vac

cine

s. Va

ccin

atio

n pr

ovid

ers

shou

ld c

onsu

lt th

e re

leva

nt A

dvis

ory

Com

mitt

ee o

n Im

mun

izat

ion

Prac

tices

(ACI

P) s

tate

men

t for

det

aile

d re

com

men

datio

ns, a

vaila

ble

onlin

e at

htt

p://

ww

w.c

dc.g

ov/v

acci

nes/

hcp/

acip

-rec

s/in

dex.

htm

l. Cl

inic

ally

sig

nific

ant a

dver

se e

vent

s th

at fo

llow

vac

cina

tion

shou

ld b

e re

port

ed to

the

Vacc

ine

Adve

rse

Even

t Rep

ortin

g Sy

stem

(V

AER

S) o

nlin

e (h

ttp:

//w

ww

.vae

rs.h

hs.g

ov) o

r by

tele

phon

e (8

00-8

22-7

967)

.Sus

pect

ed c

ases

of v

acci

ne-p

reve

ntab

le d

isea

ses

shou

ld b

e re

port

ed to

the

stat

e or

loca

l hea

lth d

epar

tmen

t. Ad

ditio

nal i

nfor

mat

ion,

incl

udin

g pr

ecau

tions

and

con

trai

ndic

atio

ns fo

r vac

cina

tion,

is a

vaila

ble

from

CD

C on

line

(htt

p://

ww

w.c

dc.g

ov/v

acci

nes)

or b

y te

leph

one

(800

-CD

C-IN

FO [8

00-2

32-4

636]

).

This

sch

edul

e is

app

rove

d by

the

Advi

sory

Com

mitt

ee o

n Im

mun

izat

ion

Prac

tices

(htt

p//w

ww

.cdc

.gov

/vac

cine

s/ac

ip),

the

Am

eric

an A

cade

my

of P

edia

tric

s (h

ttp:

//w

ww

.aap

.org

), th

e A

mer

ican

Aca

dem

y of

Fam

ily P

hysi

cian

s (h

ttp:

//w

ww

.aaf

p.or

g), a

nd th

e A

mer

ican

Col

lege

of O

bste

tric

ians

and

Gyn

ecol

ogis

ts (h

ttp:

//w

ww

.aco

g.or

g).

Rang

e of

reco

mm

ende

d ag

es

durin

g w

hich

cat

ch-u

p is

en

cour

aged

and

for c

erta

in

high

-ris

k gr

oups

Vacc

ines

Birt

h1

mo

2 m

os4

mos

6 m

os9

mos

12 m

os15

mos

18 m

os19

–23

mos

2-3

yrs

4-6

yrs

7-10

yrs

11-1

2 yr

s13

–15

yrs

16–1

8 yr

s

Hep

atiti

s B1 (

Hep

B)

Rota

viru

s2 (RV

) RV1

(2-d

ose

serie

s); R

V5 (3

-dos

e se

ries)

Dip

hthe

ria, t

etan

us, &

ace

l-lu

lar p

ertu

ssis3 (

DTa

P: <

7 yr

s)

Teta

nus,

diph

ther

ia, &

ace

l-lu

lar p

ertu

ssis4

(Tda

p: >

7 yr

s)

Hae

mop

hilu

s infl

uenz

ae ty

pe

b5 (H

ib)

Pneu

moc

occa

l con

juga

te6

(PCV

13)

Pneu

moc

occa

l pol

ysac

cha-

ride6 (

PPSV

23)

Inac

tivat

ed P

olio

viru

s7 (IP

V)

(<18

yrs

)

Influ

enza

8 (IIV

; LAI

V) 2

dos

es

for s

ome:

See

foot

note

8

Mea

sles,

mum

ps, r

ubel

la9

(MM

R)

Varic

ella

10 (V

AR)

Hep

atiti

s A11

(Hep

A)

Hum

an p

apill

omav

irus12

(H

PV2:

fem

ales

onl

y; H

PV4:

m

ales

and

fem

ales

)

Men

ingo

cocc

al13

(Hib

-Men

-CY

> 6

wee

ks; M

enAC

WY-

D

>9 m

os; M

enAC

WY-

CRM

≥

2 m

os)

Boos

ter

1st do

seSe

e fo

otno

te 1

3

(3-d

ose

serie

s)

2-do

se se

ries,

See

foot

note

11

2nd do

se1st

dose

2nd do

se1st

dose

Annu

al v

acci

natio

n (II

V or

LAI

V)An

nual

vac

cina

tion

(IIV

only

)

(Tda

p)

See

foot

note

22nd

dos

e1st

dose

4th d

ose

3rd d

ose

2nd d

ose

1st do

se

4th d

ose

3rd d

ose

2nd do

se1st

dose

3rd o

r 4th

dos

e,

See

foot

note

5Se

e fo

otno

te 5

2nd do

se1st

dose

5th d

ose

4th d

ose

3rd d

ose

2nd d

ose

1st do

se

3rd d

ose

2nd d

ose

1st do

se

148 Reference Range Values for Pediatric CareFI

GU

RE 2

. Cat

ch-u

p im

mun

izat

ion

sche

dule

for p

erso

ns a

ged

4 m

onth

s thr

ough

18

year

s who

star

t lat

e or

who

are

mor

e th

an 1

mon

th b

ehin

d —

Uni

ted

Stat

es, 2

014.

The

figur

e be

low

pro

vide

s cat

ch-u

p sc

hedu

les a

nd m

inim

um in

terv

als b

etw

een

dose

s for

chi

ldre

n w

hose

vac

cina

tions

hav

e be

en d

elay

ed. A

vac

cine

serie

s doe

s not

nee

d to

be

rest

arte

d, re

gard

less

of t

he ti

me

that

has

ela

psed

bet

wee

n do

ses.

Use

the

sect

ion

appr

opria

te fo

r the

chi

ld’s

age.

Alw

ays u

se th

is ta

ble

in c

onju

nctio

n w

ith F

igur

e 1

and

the

foot

note

s tha

t fol

low

.

Pers

ons

aged

4 m

onth

s th

roug

h 6

year

s

Vacc

ine

Min

imum

Ag

e fo

r D

ose

1

Min

imum

Inte

rval

Bet

wee

n D

oses

Dos

e 1

to d

ose

2D

ose

2 to

dos

e 3

Dos

e 3

to d

ose

4D

ose

4 to

dos

e 5

Hep

atiti

s B

1B

irth

4 w

eeks

8 w

eeks

and

at l

east

16

wee

ks a

fter fi

rst d

ose;

min

imum

age

fo

r the

fina

l dos

e is

24

wee

ks

Rot

aviru

s26

wee

ks4

wee

ks4

wee

ks

Dip

hthe

ria, t

etan

us, &

ac

ellu

lar p

ertu

ssis

36

wee

ks4

wee

ks4

wee

ks6

mon

ths

6 m

onth

s3

Hae

mop

hilu

s influenzae

type

b5

6 w

eeks

4 w

eeks

if fi

rst d

ose

adm

inis

tere

d at

you

nger

than

age

12

mon

ths

8 w

eeks

(as

final

dos

e)

if fir

st d

ose

adm

inis

tere

d at

age

12

thro

ugh

14 m

onth

sN

o fu

rther

dos

es n

eede

dif

first

dos

e ad

min

iste

red

at a

ge 1

5 m

onth

s or

old

er

4 w

eeks

5 if c

urre

nt a

ge is

you

nger

than

12

mon

ths

and

first

do

se a

dmin

iste

red

at <

7 m

onth

s ol

d8

wee

ks a

nd a

ge 1

2 m

onth

s th

roug

h 59

mon

ths

(as

final

do

se)5 i

f cur

rent

age

is y

oung

er th

an 1

2 m

onth

s an

d fir

st d

ose

adm

inis

tere

d be

twee

n 7

thro

ugh

11 m

onth

s (r

egar

dles

s of

Hib

va

ccin

e [P

RP

-T o

r PR

P-O

MP

] use

d fo

r firs

t dos

e); O

Rif

curr

ent a

ge is

12

thro

ugh

59 m

onth

s an

d fir

st d

ose

adm

inis

tere

d at

you

nger

than

age

12

mon

ths;

OR

first

2 d

oses

wer

e P

RP

-OM

P an

d ad

min

iste

red

at y

oung

er th

an

12 m

onth

s.

No

furth

er d

oses

nee

ded

if pr

evio

us d

ose

adm

inis

tere

d at

age

15

mon

ths

or o

lder

8 w

eeks

(as

final

dos

e)

This

dos

e on

ly n

eces

sary

for c

hild

ren

aged

12

thro

ugh

59 m

onth

s w

ho re

ceiv

ed 3

(PR

P-T

) dos

es b

efor

e ag

e 12

mon

ths

and

star

ted

the

prim

ary

serie

s be

fore

age

7

mon

ths

Pne

umoc

occa

l66

wee

ks

4 w

eeks

if fi

rst d

ose

adm

inis

tere

d at

you

nger

than

age

12

mon

ths

8 w

eeks

(as

final

dos

e fo

r hea

lthy

child

ren)

if fi

rst d

ose

adm

inis

tere

d at

age

12

mon

ths

or o

lder

N

o fu

rther

dos

es n

eede

d fo

r hea

lthy

child

ren

if fir

st d

ose

adm

inis

tere

d at

age

24

mon

ths

or o

lder

4 w

eeks

if c

urre

nt a

ge is

you

nger

than

12

mon

ths

8 w

eeks

(as

final

dos

e fo

r hea

lthy

child

ren)

if c

urre

nt a

ge is

12

mon

ths

or o

lder

No

furth

er d

oses

nee

ded

for h

ealth

y ch

ildre

n if

prev

ious

dos

e ad

min

iste

red

at a

ge 2

4 m

onth

s or

old

er

8 w

eeks

(as

final

dos

e)

This

dos

e on

ly n

eces

sary

for c

hild

ren

aged

12

thro

ugh

59 m

onth

s w

ho re

ceiv

ed 3

dos

es b

efor

e ag

e 12

m

onth

s or

for c

hild

ren

at h

igh

risk

who

rece

ived

3

dose

s at

any

age

Inac

tivat

ed p

olio

viru

s76

wee

ks4

wee

ks7

4 w

eeks

76

mon

ths7 m

inim

um a

ge 4

yea

rs fo

r fina

l dos

e

Men

ingo

cocc

al13

6 w

eeks

8 w

eeks

13S

ee fo

otno

te 1

3S

ee fo

otno

te 1

3

Mea

sles

, mum

ps,

rube

lla9

12

mon

ths

4 w

eeks

Varic

ella

1012

mon

ths

3 m

onth

s

Hep

atiti

s A

1112

mon

ths

6 m

onth

s

Pers

ons

aged

7 th

roug

h 18

yea

rs

Teta

nus,

dip

hthe

ria;

teta

nus,

dip

hthe

ria, &

ac

ellu

lar p

ertu

ssis

47

year

s44

wee

ks

4 w

eeks

if fi

rst d

ose

of D

TaP

/DT

adm

inis

tere

d at

you

nger

than

ag

e 12

mon

ths

6 m

onth

s if

first

dos

e of

DTa

P/D

T ad

min

iste

red

at a

ge 1

2 m

onth

s or

old

er a

nd th

en n

o fu

rther

dos

es n

eede

d fo

r cat

ch-u

p

6 m

onth

s if

first

dos

e of

DTa

P/D

T ad

min

iste

red

at

youn

ger t

han

age

12 m

onth

s

Hum

an p

apill

omav

irus12

9 ye

ars

Rou

tine

dosi

ng in

terv

als

are

reco

mm

ende

d12

Hep

atiti

s A

1112

mon

ths

6 m

onth

s

Hep

atiti

s B

1B

irth

4 w

eeks

8 w

eeks

(and

at l

east

16

wee

ks a

fter fi

rst d

ose)

Inac

tivat

ed p

olio

viru

s76

wee

ks4

wee

ks4

wee

ks7

6 m

onth

s7

Men

ingo

cocc

al13

6 w

eeks

8 w

eeks

13

Mea

sles

, mum

ps,

rube

lla9

12 m

onth

s4

wee

ks

Varic

ella

1012

m

onth

s3

mon

ths

if pe

rson

is y

oung

er th

an a

ge 1

3 ye

ars

4 w

eeks

if p

erso

n is

age

d 13

yea

rs o

r old

er

NO

TE: T

he a

bove

reco

mm

enda

tions

mus

t be

read

alo

ng w

ith th

e fo

otno

tes o

f thi

s sch

edul

e.

RECOMMENDED IMMUNIZATION SCHEDULE, continued

149Appendices

1.

Hep

atiti

s B

(Hep

B) v

acci

ne. (

Min

imum

age

: bir

th)

Rout

ine

vacc

inat

ion:

A

t bir

th•

Adm

inis

ter m

onov

alen

t Hep

B va

ccin

e to

all

new

born

s be

fore

hos

pita

l dis

char

ge.

•Fo

r inf

ants

bor

n to

hep

atiti

s B

surf

ace

antig

en (H

BsAg

)-pos

itive

mot

hers

, adm

inis

ter H

epB

vacc

ine

and

0.5

mL

of h

epat

itis

B im

mun

e gl

obul

in (H

BIG

) with

in 1

2 ho

urs

of b

irth.

The

se in

fant

s sh

ould

be

test

ed

for H

BsAg

and

ant

ibod

y to

HBs

Ag (a

nti-H

Bs) 1

to 2

mon

ths

afte

r com

plet

ion

of th

e H

epB

serie

s, at

age

9

thro

ugh

18 m

onth

s (p

refe

rabl

y at

the

next

wel

l-chi

ld v

isit)

. •

If m

othe

r’s H

BsAg

sta

tus

is u

nkno

wn,

with

in 1

2 ho

urs

of b

irth

adm

inis

ter H

epB

vacc

ine

rega

rdle

ss o

f bi

rth

wei

ght.

For i

nfan

ts w

eigh

ing

less

than

2,0

00 g

ram

s, ad

min

iste

r HBI

G in

add

ition

to H

epB

vacc

ine

with

in 1

2 ho

urs

of b

irth.

Det

erm

ine

mot

her’s

HBs

Ag s

tatu

s as

soo

n as

pos

sibl

e an

d, if

mot

her i

s H

BsAg

-po

sitiv

e, a

lso

adm

inis

ter H

BIG

for i

nfan

ts w

eigh

ing

2,00

0 gr

ams

or m

ore

as s

oon

as p

ossi

ble,

but

no

late

r tha

n ag

e 7

days

.D

oses

follo

win

g th

e bi

rth

dose

•Th

e se

cond

dos

e sh

ould

be

adm

inis

tere

d at

age

1 o

r 2 m

onth

s. M

onov

alen

t Hep

B va

ccin

e sh

ould

be

used

for d

oses

adm

inis

tere

d be

fore

age

6 w

eeks

.•

Infa

nts

who

did

not

rece

ive

a bi

rth

dose

sho

uld

rece

ive

3 do

ses

of a

Hep

B-co

ntai

ning

vac

cine

on

a sc

hedu

le o

f 0, 1

to 2

mon

ths,

and

6 m

onth

s st

artin

g as

soo

n as

feas

ible

. See

Fig

ure

2.•

Adm

inis

ter t

he s

econ

d do

se 1

to 2

mon

ths

afte

r the

firs

t dos

e (m

inim

um in

terv

al o

f 4 w

eeks

), ad

min

iste

r the

third

dos

e at

leas

t 8 w

eeks

aft

er th

e se

cond

dos

e A

ND

at l

east

16

wee

ks a

fter

the

first

do

se. T

he fi

nal (

third

or f

ourt

h) d

ose

in th

e H

epB

vacc

ine

serie

s sh

ould

be

adm

inis

tere

d no

ear

lier t

han

age

24 w

eeks

. •

Adm

inis

trat

ion

of a

tota

l of 4

dos

es o

f Hep

B va

ccin

e is

per

mitt

ed w

hen

a co

mbi

natio

n va

ccin

e co

ntai

ning

Hep

B is

adm

inis

tere

d af

ter t

he b

irth

dose

. Ca

tch-

up v

acci

nati

on:

•U

nvac

cina

ted

pers

ons

shou

ld c

ompl

ete

a 3-

dose

ser

ies.

•A

2-d

ose

serie

s (d

oses

sep

arat

ed b

y at

leas

t 4 m

onth

s) o

f adu

lt fo

rmul

atio

n Re

com

biva

x H

B is

lice

nsed

fo

r use

in c

hild

ren

aged

11

thro

ugh

15 y

ears

. •

For o

ther

cat

ch-u

p gu

idan

ce, s

ee F

igur

e 2.

2.

Rota

viru

s (R

V) v

acci

nes.

(Min

imum

age

: 6 w

eeks

for b

oth

RV1

[Rot

arix

] and

RV5

[Rot

aTeq

])Ro

utin

e va

ccin

atio

n:Ad

min

iste

r a s

erie

s of

RV

vacc

ine

to a

ll in

fant

s as

follo

ws:

1.

If R

otar

ix is

use

d, a

dmin

iste

r a 2

-dos

e se

ries

at 2

and

4 m

onth

s of

age

. 2.

If R

otaT

eq is

use

d, a

dmin

iste

r a 3

-dos

e se

ries

at a

ges

2, 4

, and

6 m

onth

s. 3.

If a

ny d

ose

in th

e se

ries w

as R

otaT

eq o

r vac

cine

pro

duct

is u

nkno

wn

for a

ny d

ose

in th

e se

ries,

a to

tal

of 3

dos

es o

f RV

vacc

ine

shou

ld b

e ad

min

iste

red.

Ca

tch-

up v

acci

nati

on:

•Th

e m

axim

um a

ge fo

r the

firs

t dos

e in

the

serie

s is

14

wee

ks, 6

day

s; v

acci

natio

n sh

ould

not

be

initi

ated

for i

nfan

ts a

ged

15 w

eeks

, 0 d

ays

or o

lder

.•

The

max

imum

age

for t

he fi

nal d

ose

in th

e se

ries

is 8

mon

ths,

0 da

ys.

•Fo

r oth

er c

atch

-up

guid

ance

, see

Fig

ure

2.

3.

Dip

hthe

ria

and

teta

nus

toxo

ids

and

acel

lula

r per

tuss

is (D

TaP)

vac

cine

. (M

inim

um a

ge: 6

wee

ks.

Exce

ptio

n: D

TaP-

IPV

[Kin

rix]

: 4 y

ears

)Ro

utin

e va

ccin

atio

n:•

Adm

inis

ter a

5-d

ose

serie

s of D

TaP

vacc

ine

at a

ges 2

, 4, 6

, 15

thro

ugh

18 m

onth

s, an

d 4

thro

ugh

6 ye

ars.

The

four

th d

ose

may

be

adm

inis

tere

d as

ear

ly a

s age

12

mon

ths,

prov

ided

at l

east

6 m

onth

s hav

e el

apse

d si

nce

the

third

dos

e.Ca

tch-

up v

acci

nati

on:

•Th

e fif

th d

ose

of D

TaP

vacc

ine

is n

ot n

eces

sary

if th

e fo

urth

dos

e w

as a

dmin

iste

red

at a

ge 4

yea

rs o

r old

er.

•Fo

r oth

er c

atch

-up

guid

ance

, see

Fig

ure

2.4.

Te

tanu

s an

d di

phth

eria

toxo

ids

and

acel

lula

r per

tuss

is (T

dap)

vac

cine

. (M

inim

um a

ge: 1

0 ye

ars

for

Boos

trix

, 11

year

s fo

r Ada

cel)

Rout

ine

vacc

inat

ion:

•

Adm

inis

ter 1

dos

e of

Tdap

vac

cine

to a

ll ad

oles

cent

s ag

ed 1

1 th

roug

h 12

yea

rs.

•Td

ap m

ay b

e ad

min

ister

ed re

gard

less

of t

he in

terv

al si

nce

the

last

teta

nus a

nd d

ipht

heria

toxo

id-c

onta

inin

g va

ccin

e.•

Adm

inis

ter 1

dos

e of

Tdap

vac

cine

to p

regn

ant a

dole

scen

ts d

urin

g ea

ch p

regn

ancy

(pre

ferr

ed d

urin

g 27

thro

ugh

36 w

eeks

ges

tatio

n) re

gard

less

of t

ime

sinc

e pr

ior T

d or

Tdap

vac

cina

tion.

Ca

tch-

up v

acci

nati

on:

•Pe

rson

s ag

ed 7

yea

rs a

nd o

lder

who

are

not

fully

imm

uniz

ed w

ith D

TaP

vacc

ine

shou

ld re

ceiv

e Td

ap

vacc

ine

as 1

(pre

fera

bly

the

first

) dos

e in

the

catc

h-up

ser

ies;

if a

dditi

onal

dos

es a

re n

eede

d, u

se Td

va

ccin

e. F

or c

hild

ren

7 th

roug

h 10

yea

rs w

ho re

ceiv

e a

dose

of T

dap

as p

art o

f the

cat

ch-u

p se

ries,

an

adol

esce

nt Td

ap v

acci

ne d

ose

at a

ge 1

1 th

roug

h 12

yea

rs s

houl

d N

OT

be a

dmin

iste

red.

Td s

houl

d be

ad

min

iste

red

inst

ead

10 y

ears

aft

er th

e Td

ap d

ose.

•Pe

rson

s ag

ed 1

1 th

roug

h 18

yea

rs w

ho h

ave

not r

ecei

ved

Tdap

vac

cine

sho

uld

rece

ive

a do

se fo

llow

ed

by te

tanu

s an

d di

phth

eria

toxo

ids

(Td)

boo

ster

dos

es e

very

10

year

s th

erea

fter

.•

Inad

vert

ent d

oses

of D

TaP

vacc

ine:

-If

adm

inis

tere

d in

adve

rten

tly to

a c

hild

age

d 7

thro

ugh

10 y

ears

may

cou

nt a

s pa

rt o

f the

cat

ch-u

p se

ries.

This

dos

e m

ay c

ount

as

the

adol

esce

nt Td

ap d

ose,

or t

he c

hild

can

late

r rec

eive

a Td

ap

boos

ter d

ose

at a

ge 1

1 th

roug

h 12

yea

rs.

-If

adm

inis

tere

d in

adve

rten

tly to

an

adol

esce

nt a

ged

11 th

roug

h 18

yea

rs, t

he d

ose

shou

ld b

e co

unte

d as

the

adol

esce

nt Td

ap b

oost

er.

•Fo

r oth

er c

atch

-up

guid

ance

, see

Fig

ure

2.5.

H

aem

ophi

lus i

nflue

nzae

type

b (H

ib) c

onju

gate

vac

cine

. (M

inim

um a

ge:

6 w

eeks

for P

RP-T

[ACT

HIB

, D

TaP-

IPV/

Hib

(Pen

tace

l) an

d H

ib-M

enCY

(Men

Hib

rix)

], PR

P-O

MP

[Ped

vaxH

IB o

r CO

MVA

X], 1

2 m

onth

s fo

r PRP

-T [H

iber

ix])

Rout

ine

vacc

inat

ion:

•Ad

min

iste

r a 2

- or 3

-dos

e H

ib v

acci

ne p

rimar

y se

ries

and

a bo

oste

r dos

e (d

ose

3 or

4 d

epen

ding

on

vacc

ine

used

in p

rimar

y se

ries)

at a

ge 1

2 th

roug

h 15

mon

ths

to c

ompl

ete

a fu

ll H

ib v

acci

ne s

erie

s.•

The

prim

ary

serie

s w

ith A

ctH

IB, M

enH

ibrix

, or P

enta

cel c

onsi

sts

of 3

dos

es a

nd s

houl

d be

adm

inis

tere

d at

2, 4

, and

6 m

onth

s of

age

. The

prim

ary

serie

s w

ith P

edva

xHib

or C

OM

VAX

cons

ists

of 2

dos

es a

nd

shou

ld b

e ad

min

iste

red

at 2

and

4 m

onth

s of

age

; a d

ose

at a

ge 6

mon

ths

is n

ot in

dica

ted.

•O

ne b

oost

er d

ose

(dos

e 3

or 4

dep

endi

ng o

n va

ccin

e us

ed in

prim

ary

serie

s) o

f any

Hib

vac

cine

sho

uld

be a

dmin

iste

red

at a

ge 1

2 th

roug

h 15

mon

ths.

An

exce

ptio

n is

Hib

erix

vac

cine

. Hib

erix

sho

uld

only

be

use

d fo

r the

boo

ster

(fina

l) do

se in

chi

ldre

n ag

ed 1

2 m

onth

s th

roug

h 4

year

s w

ho h

ave

rece

ived

at

leas

t 1 p

rior d

ose

of H

ib-c

onta

inin

g va

ccin

e.

Foot

note

s — R

ecom

men

ded

imm

uniz

atio

n sc

hedu

le fo

r per

sons

age

d 0

thro

ugh

18 y

ears

—U

nite

d St

ates

, 201

4

For f

urth

er g

uida

nce

on th

e us

e of

the

vacc

ines

men

tione

d be

low

, see

: htt

p://

ww

w.c

dc.g

ov/v

acci

nes/

hcp/

acip

-rec

s/in

dex.

htm

l. Fo

r vac

cine

reco

mm

enda

tions

for p

erso

ns 1

9 ye

ars

of a

ge a

nd o

lder

, see

the

adul

t im

mun

izat

ion

sche

dule

.A

dditi

onal

info

rmat

ion

•Fo

r con

trai

ndic

atio

ns a

nd p

reca

utio

ns to

use

of a

vac

cine

and

for a

dditi

onal

info

rmat

ion

rega

rdin

g th

at v

acci

ne, v

acci

natio

n pr

ovid

ers

shou

ld c

onsu

lt th

e re

leva

nt A

CIP

stat

emen

t ava

ilabl

e on

line

at h

ttp:

//w

ww

.cdc

.gov

/vac

cine

s/hc

p/ac

ip-r

ecs/

inde

x.ht

ml.

•Fo

r pur

pose

s of

cal

cula

ting

inte

rval

s be

twee

n do

ses,

4 w

eeks

= 2

8 da

ys. I

nter

vals

of 4

mon

ths

or g

reat

er a

re d

eter

min

ed b

y ca

lend

ar m

onth

s. •

Vacc

ine

dose

s ad

min

iste

red

4 da

ys o

r les

s be

fore

the

min

imum

inte

rval

are

con

side

red

valid

. Dos

es o

f any

vac

cine

adm

inis

tere

d ≥5

day

s ea

rlier

than

the

min

imum

inte

rval

or m

inim

um a

ge

shou

ld n

ot b

e co

unte

d as

val

id d

oses

and

sho

uld

be re

peat

ed a

s ag

e-ap

prop

riate

. The

repe

at d

ose

shou

ld b

e sp

aced

aft

er th

e in

valid

dos

e by

the

reco

mm

ende

d m

inim

um in

terv

al. F

or fu

rthe

r de

tails

, see

MM

WR,

Gen

eral

Rec

omm

enda

tions

on

Imm

uniz

atio

n an

d Re

port

s / V

ol. 6

0 / N

o. 2

; Tab

le 2

. Rec

omm

ende

d an

d m

inim

um a

ges a

nd in

terv

als b

etw

een

vacc

ine

dose

s ava

ilabl

e on

line

at

http

://w

ww

.cdc

.gov

/mm

wr/

pdf/

rr/r

r600

2.pd

f.•

Info

rmat

ion

on tr

avel

vac

cine

requ

irem

ents

and

reco

mm

enda

tions

is a

vaila

ble

at h

ttp:

//w

ww

nc.c

dc.g

ov/t

rave

l/pag

e/va

ccin

atio

ns.h

tm.

•Fo

r vac

cina

tion

of p

erso

ns w

ith p

rimar

y an

d se

cond

ary

imm

unod

efici

enci

es, s

ee T

able

13,

“Vac

cina

tion

of p

erso

ns w

ith p

rimar

y an

d se

cond

ary

imm

unod

efici

enci

es,” i

n G

ener

al R

ecom

men

datio

ns

on Im

mun

izat

ion

(ACI

P), a

vaila

ble

at h

ttp:

//w

ww

.cdc

.gov

/mm

wr/

pdf/

rr/r

r600

2.pd

f.; a

nd A

mer

ican

Aca

dem

y of

Ped

iatr

ics.

Imm

uniz

atio

n in

Spe

cial

Clin

ical

Circ

umst

ance

s, in

Pic

kerin

g LK

, Bak

er C

J, Ki

mbe

rlin

DW

, Lon

g SS

eds

. Red

Boo

k: 2

012

repo

rt o

f the

Com

mitt

ee o

n In

fect

ious

Dis

ease

s. 29

th e

d. E

lk G

rove

Vill

age,

IL: A

mer

ican

Aca

dem

y of

Ped

iatr

ics.

150 Reference Range Values for Pediatric CareFo

r fur

ther

gui

danc

e on

the

use

of th

e va

ccin

es m

entio

ned

belo

w, s

ee: h

ttp:

//w

ww

.cdc

.gov

/vac

cine

s/hc

p/ac

ip-r

ecs/

inde

x.ht

ml.

5.

Hae

mop

hilu

s infl

uenz

ae ty

pe b

(Hib

) con

juga

te v

acci

ne (c

ont’d

)•

For r

ecom

men

datio

ns o

n th

e us

e of

Men

Hib

rix in

pat

ient

s at

incr

ease

d ris

k fo

r men

ingo

cocc

al d

isea

se,

plea

se re

fer t

o th

e m

enin

goco

ccal

vac

cine

foot

note

s an

d al

so to

MM

WR

Mar

ch 2

2, 2

013

/ 62(

RR02

); 1-

22, a

vaila

ble

at h

ttp:

//w

ww

.cdc

.gov

/mm

wr/

pdf/

rr/r

r620

2.pd

f.

Catc

h-up

vac

cina

tion

:•

If do

se 1

was

adm

inis

tere

d at

age

s 12

thro

ugh

14 m

onth

s, ad

min

iste

r a s

econ

d (fi

nal)

dose

at l

east

8

wee

ks a

fter

dos

e 1,

rega

rdle

ss o

f Hib

vac

cine

use

d in

the

prim

ary

serie

s.•

If th

e fir

st 2

dos

es w

ere

PRP-

OM

P (P

edva

xHIB

or C

OM

VAX)

, and

wer

e ad

min

iste

red

at a

ge 1

1 m

onth

s or

yo

unge

r, th

e th

ird (a

nd fi

nal)

dose

sho

uld

be a

dmin

iste

red

at a

ge 1

2 th

roug

h 15

mon

ths

and

at le

ast 8

w

eeks

aft

er th

e se

cond

dos

e.•

If th

e fir

st d

ose

was

adm

inis

tere

d at

age

7 th

roug

h 11

mon

ths,

adm

inis

ter t

he s

econ

d do

se a

t lea

st 4

w

eeks

late

r and

a th

ird (a

nd fi

nal)

dose

at a

ge 1

2 th

roug

h 15

mon

ths

or 8

wee

ks a

fter

sec

ond

dose

, w

hich

ever

is la

ter,

rega

rdle

ss o

f Hib

vac

cine

use

d fo

r firs

t dos

e.

•If

first

dos

e is

adm

inis

tere

d at

you

nger

than

12

mon

ths

of a

ge a

nd s

econ

d do

se is

giv

en b

etw

een

12

thro

ugh

14 m

onth

s of

age

, a th

ird (a

nd fi

nal)

dose

sho

uld

be g

iven

8 w

eeks

late

r.•

For u

nvac

cina

ted

child

ren

aged

15

mon

ths

or o

lder

, adm

inis

ter o

nly

1 do

se.

•Fo

r oth

er c

atch

-up

guid

ance

, see

Fig

ure

2. F

or c

atch

-up

guid

ance

rela

ted

to M

enH

ibrix

, ple

ase

see

the

men

ingo

cocc

al v

acci

ne fo

otno

tes

and

also

MM

WR

Mar

ch 2

2, 2

013

/ 62(

RR02

); 1-

22, a

vaila

ble

at h

ttp:

//w

ww

.cdc

.gov

/mm

wr/

pdf/

rr/r

r620

2.pd

f.Va

ccin

atio

n of

per

sons

wit

h hi

gh-r

isk

cond

itio

ns:

•Ch

ildre

n ag

ed 1

2 th

roug

h 59

mon

ths

who

are

at i

ncre

ased

risk

for H

ib d

isea

se, i

nclu

ding

ch

emot

hera

py re

cipi

ents

and

thos

e w

ith a

nato

mic

or f

unct

iona

l asp

leni

a (in

clud

ing

sick

le c

ell d

isea

se),

hum

an im

mun

odefi

cien

cy v

irus

(HIV

) inf

ectio

n, im

mun

oglo

bulin

defi

cien

cy, o

r ear

ly c

ompo

nent

co

mpl

emen

t defi

cien

cy, w

ho h

ave

rece

ived

eith

er n

o do

ses

or o

nly

1 do

se o

f Hib

vac

cine

bef

ore

12

mon

ths

of a

ge, s

houl

d re

ceiv

e 2

addi

tiona

l dos

es o

f Hib

vac

cine

8 w

eeks

apa

rt; c

hild

ren

who

rece

ived

2

or m

ore

dose

s of

Hib

vac

cine

bef

ore

12 m

onth

s of

age

sho

uld

rece

ive

1 ad

ditio

nal d

ose.

•Fo

r pat

ient

s yo

unge

r tha

n 5

year

s of

age

und

ergo

ing

chem

othe

rapy

or r

adia

tion

trea

tmen

t who

re

ceiv

ed a

Hib

vac

cine

dos

e(s)

with

in 1

4 da

ys o

f sta

rtin

g th

erap

y or

dur

ing

ther

apy,

repe

at th

e do

se(s

) at

leas

t 3 m

onth

s fo

llow

ing

ther

apy

com

plet

ion.

•Re

cipi

ents

of h

emat

opoi

etic

ste

m c

ell t

rans

plan

t (H

SCT)

sho

uld

be re

vacc

inat

ed w

ith a

3-d

ose

regi

men

of

Hib

vac

cine

sta

rtin

g 6

to 1

2 m

onth

s af

ter s

ucce

ssfu

l tra

nspl

ant,

rega

rdle

ss o

f vac

cina

tion

hist

ory;

do

ses

shou

ld b

e ad

min

iste

red

at le

ast 4

wee

ks a

part

.•

A s

ingl

e do

se o

f any

Hib

-con

tain

ing

vacc

ine

shou

ld b

e ad

min

iste

red

to u

nim

mun

ized

* ch

ildre

n an

d ad

oles

cent

s 15

mon

ths

of a

ge a

nd o

lder

und

ergo

ing

an e

lect

ive

sple

nect

omy;

if p

ossi

ble,

vac

cine

sh

ould

be

adm

inis

tere

d at

leas

t 14

days

bef

ore

proc

edur

e.•

Hib

vac

cine

is n

ot ro

utin

ely

reco

mm

ende

d fo

r pat

ient

s 5

year

s or

old

er. H

owev

er, 1

dos

e of

Hib

vac

cine

sh

ould

be

adm

inis

tere

d to

uni

mm

uniz

ed*

pers

ons

aged

5 y

ears

or o

lder

who

hav

e an

atom

ic o

r fu

nctio

nal a

sple

nia

(incl

udin

g si

ckle

cel

l dis

ease

) and

unv

acci

nate

d pe

rson

s 5

thro

ugh

18 y

ears

of a

ge

with

hum

an im

mun

odefi

cien

cy v

irus

(HIV

) inf

ectio

n.

* Pa

tient

s who

hav

e no

t rec

eive

d a

prim

ary

serie

s and

boo

ster

dos

e or

at l

east

1 d

ose

of H

ib v

acci

ne

afte

r 14

mon

ths o

f age

are

con

side

red

unim

mun

ized

. 6.

Pn

eum

ococ

cal v

acci

nes.

(Min

imum

age

: 6 w

eeks

for P

CV13

, 2 y

ears

for P

PSV2

3)Ro

utin

e va

ccin

atio

n w

ith

PCV

13:

•Ad

min

iste

r a 4

-dos

e se

ries o

f PCV

13 v

acci

ne a

t age

s 2, 4

, and

6 m

onth

s and

at a

ge 1

2 th

roug

h 15

mon

ths.

•Fo

r chi

ldre

n ag

ed 1

4 th

roug

h 59

mon

ths

who

hav

e re

ceiv

ed a

n ag

e-ap

prop

riate

ser

ies

of 7

-val

ent P

CV

(PCV

7), a

dmin

iste

r a s

ingl

e su

pple

men

tal d

ose

of 1

3-va

lent

PCV

(PCV

13).

Catc

h-up

vac

cina

tion

wit

h PC

V13

:•

Adm

inis

ter 1

dos

e of

PCV

13 to

all

heal

thy

child

ren

aged

24

thro

ugh

59 m

onth

s w

ho a

re n

ot

com

plet

ely

vacc

inat

ed fo

r the

ir ag

e.•

For o

ther

cat

ch-u

p gu

idan

ce, s

ee F

igur

e 2.

Va

ccin

atio

n of

per

sons

wit

h hi

gh-r

isk

cond

itio

ns w

ith

PCV

13 a

nd P

PSV

23:

•A

ll re

com

men

ded

PCV1

3 do

ses

shou

ld b

e ad

min

iste

red

prio

r to

PPSV

23 v

acci

natio

n if

poss

ible

.•

For c

hild

ren

2 th

roug

h 5

year

s of

age

with

any

of t

he fo

llow

ing

cond

ition

s: c

hron

ic h

eart

dis

ease

(p

artic

ular

ly c

yano

tic c

onge

nita

l hea

rt d

isea

se a

nd c

ardi

ac fa

ilure

); ch

roni

c lu

ng d

isea

se (i

nclu

ding

as

thm

a if

trea

ted

with

hig

h-do

se o

ral c

ortic

oste

roid

ther

apy)

; dia

bete

s m

ellit

us; c

ereb

rosp

inal

flui

d le

ak; c

ochl

ear i

mpl

ant;

sick

le c

ell d

isea

se a

nd o

ther

hem

oglo

bino

path

ies;

ana

tom

ic o

r fun

ctio

nal

aspl

enia

; HIV

infe

ctio

n; c

hron

ic re

nal f

ailu

re; n

ephr

otic

syn

drom

e; d

isea

ses

asso

ciat

ed w

ith tr

eatm

ent

with

imm

unos

uppr

essi

ve d

rugs

or r

adia

tion

ther

apy,

incl

udin

g m

alig

nant

neo

plas

ms,

leuk

emia

s, ly

mph

omas

, and

Hod

gkin

dis

ease

; sol

id o

rgan

tran

spla

ntat

ion;

or c

onge

nita

l im

mun

odefi

cien

cy:

1. A

dmin

iste

r 1 d

ose

of P

CV13

if 3

dos

es o

f PCV

(PCV

7 an

d/or

PCV

13) w

ere

rece

ived

pre

viou

sly.

2. A

dmin

iste

r 2 d

oses

of P

CV13

at l

east

8 w

eeks

apa

rt if

few

er th

an 3

dos

es o

f PCV

(PCV

7 an

d/or

PCV

13)

wer

e re

ceiv

ed p

revi

ousl

y.

6.

Pneu

moc

occa

l vac

cine

s (c

ont’d

)3.

Adm

inis

ter 1

supp

lem

enta

l dos

e of

PCV

13 if

4 d

oses

of P

CV7

or o

ther

age

-app

ropr

iate

com

plet

e PC

V7

serie

s w

as re

ceiv

ed p

revi

ousl

y.4.

The

min

imum

inte

rval

bet

wee

n do

ses

of P

CV (P

CV7

or P

CV13

) is

8 w

eeks

.5.

For

chi

ldre

n w

ith n

o hi

stor

y of

PPS

V23

vacc

inat

ion,

adm

inis

ter P

PSV2

3 at

leas

t 8 w

eeks

aft

er th

e m

ost

rece

nt d

ose

of P

CV13

. •

For c

hild

ren

aged

6 th

roug

h 18

yea

rs w

ho h

ave

cere

bros

pina

l flui

d le

ak; c

ochl

ear i

mpl

ant;

sickl

e ce

ll dise

ase

and

othe

r hem

oglo

bino

path

ies;

anat

omic

or f

unct

iona

l asp

leni

a; co

ngen

ital o

r acq

uire

d im

mun

odefi

cien

cies

; H

IV in

fect

ion;

chro

nic r

enal

failu

re; n

ephr

otic

synd

rom

e; d

iseas

es a

ssoc

iate

d w

ith tr

eatm

ent w

ith

imm

unos

uppr

essiv

e dr

ugs o

r rad

iatio

n th

erap

y, in

clud

ing

mal

igna

nt n

eopl

asm

s, le

ukem

ias,

lym

phom

as, a

nd

Hod

gkin

dise

ase;

gen

eral

ized

mal

igna

ncy;

solid

org

an tr

ansp

lant

atio

n; o

r mul

tiple

mye

lom

a:1.

If n

eith

er P

CV13

nor

PPS

V23

has

been

rece

ived

pre

viou

sly,

adm

inis

ter

1 do

se o

f PCV

13 n

ow a

nd 1

do

se o

f PPS

V23

at le

ast 8

wee

ks la

ter.

2. I

f PCV

13 h

as b

een

rece

ived

pre

viou

sly

but

PPSV

23 h

as n

ot, a

dmin

iste

r 1

dose

of P

PSV2

3 at

leas

t 8

wee

ks a

fter

the

mos

t rec

ent d

ose

of P

CV13

. 3.

If P

PSV2

3 ha

s bee

n re

ceiv

ed b

ut P

CV13

has

not

, adm

inis

ter 1

dos

e of

PCV

13 a

t lea

st 8

wee

ks a

fter

the

mos

t rec

ent d

ose

of P

PSV2

3.•

For c

hild

ren

aged

6 th

roug

h 18

yea

rs w

ith c

hron

ic h

eart

dis

ease

(par

ticul

arly

cya

notic

con

geni

tal h

eart

di

seas

e an

d ca

rdia

c fa

ilure

), ch

roni

c lu

ng d

isea

se (i

nclu

ding

ast

hma

if tr

eate

d w

ith h

igh-

dose

ora

l co

rtic

oste

roid

ther

apy)

, dia

bete

s m

ellit

us, a

lcoh

olis

m, o

r chr

onic

live

r dis

ease

, who

hav

e no

t rec

eive

d PP

SV23

, adm

inis

ter 1

dos

e of

PPS

V23.

If P

CV13

has

bee

n re

ceiv

ed p

revi

ousl

y, th

en P

PSV2

3 sh

ould

be

adm

inis

tere

d at

leas

t 8 w

eeks

aft

er a

ny p

rior P

CV13

dos

e.•

A s

ingl

e re

vacc

inat

ion

with

PPS

V23

shou

ld b

e ad

min

iste

red

5 ye

ars

afte

r the

firs

t dos

e to

chi

ldre

n w

ith s

ickl

e ce

ll di

seas

e or

oth

er h

emog

lobi

nopa

thie

s; a

nato

mic

or f

unct

iona

l asp

leni

a; c

onge

nita

l or

acq

uire

d im

mun

odefi

cien

cies

; HIV

infe

ctio

n; c

hron

ic re

nal f

ailu

re; n

ephr

otic

syn

drom

e; d

isea

ses

asso

ciat

ed w

ith tr

eatm

ent w

ith im

mun

osup

pres

sive

dru

gs o

r rad

iatio

n th

erap

y, in

clud

ing

mal

igna

nt

neop

lasm

s, le

ukem

ias,

lym

phom

as, a

nd H

odgk

in d

isea

se; g

ener

aliz

ed m

alig

nanc

y; s

olid

org

an

tran

spla

ntat

ion;

or m

ultip

le m

yelo

ma.

7.

Inac

tivat

ed p

olio

viru

s va

ccin

e (IP

V).

(Min

imum

age

: 6 w

eeks

)Ro

utin

e va

ccin

atio

n:•

Adm

inis

ter a

4-d

ose

serie

s of

IPV

at a

ges

2, 4

, 6 th

roug

h 18

mon

ths,

and

4 th

roug

h 6

year

s. Th

e fin

al

dose

in th

e se

ries

shou

ld b

e ad

min

iste

red

on o

r aft

er th

e fo

urth

birt

hday

and

at l

east

6 m

onth

s af

ter

the

prev

ious

dos

e.Ca

tch-

up v

acci

nati

on:

•In

the

first

6 m

onth

s of l

ife, m

inim

um a

ge a

nd m

inim

um in

terv

als a

re o

nly

reco

mm

ende

d if

the

pers

on is

at r

isk

for i

mm

inen

t exp

osur

e to

circ

ulat

ing

polio

viru

s (i.e

., tra

vel t

o a

polio

-end

emic

regi

on o

r dur

ing

an o

utbr

eak)

. •

If 4

or m

ore

dose

s ar

e ad

min

iste

red

befo

re a

ge 4

yea

rs, a

n ad

ditio

nal d

ose

shou

ld b

e ad

min

iste

red

at

age

4 th

roug

h 6

year

s an

d at

leas

t 6 m

onth

s af

ter t

he p

revi

ous

dose

.•

A fo

urth

dos

e is

not

nec

essa

ry if

the

third

dos

e w

as a

dmin

iste

red

at a

ge 4

yea

rs o

r old

er a

nd a

t lea

st 6

m

onth

s af

ter t

he p

revi

ous

dose

. •

If bo

th O

PV a

nd IP

V w

ere

adm

inist

ered

as p

art o

f a se

ries,

a to

tal o

f 4 d

oses

shou

ld b

e ad

min

ister

ed, r

egar

dles

s of

the

child

’s cu

rrent

age

. IPV

is no

t rou

tinel

y re

com

men

ded

for U

.S. r

esid

ents

age

d 18

yea

rs o

r old

er.

•Fo

r oth

er c

atch

-up

guid

ance

, see

Fig

ure

2.8.

In

fluen

za v

acci

nes.

(Min

imum

age

: 6 m

onth

s fo

r ina

ctiv

ated

influ

enza

vac

cine

[IIV

], 2

year

s fo

r liv

e,

atte

nuat

ed in

fluen

za v

acci

ne [L

AIV

]) Ro

utin

e va

ccin

atio

n:•

Adm

inis

ter i

nflue

nza

vacc

ine

annu

ally

to a

ll ch

ildre

n be

ginn

ing

at a

ge 6

mon

ths.

For m

ost h

ealth

y,

nonp

regn

ant p

erso

ns a

ged

2 th

roug

h 49

yea

rs, e

ither

LA

IV o

r IIV

may

be

used

. How

ever

, LA

IV sh

ould

N

OT

be a

dmin

iste

red

to so

me

pers

ons,

incl

udin

g 1)

thos

e w

ith a

sthm

a, 2

) chi

ldre

n 2

thro

ugh

4 ye

ars w

ho

had

whe

ezin

g in

the

past

12

mon

ths,

or 3

) tho

se w

ho h

ave

any

othe

r und

erly

ing

med

ical

con

ditio

ns th

at

pred

ispo

se th

em to

influ

enza

com

plic

atio

ns. F

or a

ll ot

her c

ontr

aind

icat

ions

to u

se o

f LA

IV, s

ee M

MW

R 20

13; 6

2 (N

o. R

R-7)

:1-4

3, a

vaila

ble

at http://www.cdc.gov/mmwr/pdf/rr/rr6207.pdf

. Fo

r chi

ldre

n ag

ed 6

mon

ths

thro

ugh

8 ye

ars:

•Fo

r the

201

3–14

sea

son,

adm

inis

ter 2

dos

es (s

epar

ated

by

at le

ast 4

wee

ks) t

o ch

ildre

n w

ho a

re

rece

ivin

g in

fluen

za v

acci

ne fo

r the

firs

t tim

e. S

ome

child

ren

in th

is a

ge g

roup

who

hav

e be

en

vacc

inat

ed p

revi

ousl

y w

ill a

lso

need

2 d

oses

. For

add

ition

al g

uida

nce,

follo

w d

osin

g gu

idel

ines

in th

e 20

13-1

4 AC

IP in

fluen

za v

acci

ne re

com

men

datio

ns, M

MW

R 20

13; 6

2 (N

o. R

R-7)

:1-4

3, a

vaila

ble

at

http

://w

ww

.cdc

.gov

/mm

wr/

pdf/

rr/r

r620

7.pd

f. •

For t

he 2

014–

15 s

easo

n, fo

llow

dos

ing

guid

elin

es in

the

2014

ACI

P in

fluen

za v

acci

ne

reco

mm

enda

tions

. Fo

r per

sons

age

d 9

year

s an

d ol

der:

•Ad

min

iste

r 1 d

ose.

RECOMMENDED IMMUNIZATION SCHEDULE, continued

151Appendices

9.

Mea

sles

, mum

ps, a

nd ru

bella

(MM

R) v

acci

ne. (

Min

imum

age

: 12

mon

ths

for r

outin

e va

ccin

atio

n)Ro

utin

e va

ccin

atio

n:•

Adm

inist

er a

2-d

ose

serie

s of M

MR

vacc

ine

at a

ges1

2 th

roug

h 15

mon

ths a

nd 4

thro

ugh

6 ye

ars.

The

seco

nd

dose

may

be

adm

inist

ered

bef

ore

age

4 ye

ars,

prov

ided

at l

east

4 w

eeks

hav

e el

apse

d sin

ce th

e fir

st d

ose.

•

Adm

inis

ter 1

dos

e of

MM

R va

ccin

e to

infa

nts

aged

6 th

roug

h 11

mon

ths

befo

re d

epar

ture

from

the

Uni

ted

Stat

es fo

r int

erna

tiona

l tra

vel.

Thes

e ch

ildre

n sh

ould

be

reva

ccin

ated

with

2 d

oses

of M

MR

vacc

ine,

the

first

at a

ge 1

2 th

roug

h 15

mon

ths

(12

mon

ths

if th

e ch

ild re

mai

ns in

an

area

whe

re d

isea

se

risk

is h

igh)

, and

the

seco

nd d

ose

at le

ast 4

wee

ks la

ter.

•Ad

min

iste

r 2 d

oses

of M

MR

vacc

ine

to c

hild

ren

aged

12

mon

ths

and

olde

r bef

ore

depa

rtur

e fr

om th

e U

nite

d St

ates

for i

nter

natio

nal t

rave

l. Th

e fir

st d

ose

shou

ld b

e ad

min

iste

red

on o

r aft

er a

ge 1

2 m

onth

s an

d th

e se

cond

dos

e at

leas

t 4 w

eeks

late

r.Ca

tch-

up v

acci

nati

on:

•En

sure

that

all

scho

ol-a

ged

child

ren

and

adol

esce

nts

have

had

2 d

oses

of M

MR

vacc

ine;

the

min

imum

in

terv

al b

etw

een

the

2 do

ses

is 4

wee

ks.

10.

Vari

cella

(VA

R) v

acci

ne. (

Min

imum

age

: 12

mon

ths)

Ro

utin

e va

ccin

atio

n:•

Adm

inis

ter a

2-d

ose

serie

s of

VA

R va

ccin

e at

age

s 12

thro

ugh

15 m

onth

s an

d 4

thro

ugh

6 ye

ars.

The

seco

nd d

ose

may

be

adm

inis

tere

d be

fore

age

4 y

ears

, pro

vide

d at

leas

t 3 m

onth

s ha

ve e

laps

ed s

ince

th

e fir

st d

ose.

If th

e se

cond

dos

e w

as a

dmin

iste

red

at le

ast 4

wee

ks a

fter

the

first

dos

e, it

can

be

acce

pted

as

valid

.Ca

tch-

up v

acci

nati

on:

•En

sure

that

all

pers

ons

aged

7 th

roug

h 18

yea

rs w

ithou

t evi

denc

e of

imm

unity

(see

MM

WR

2007

; 56

[No.

RR-

4], a

vaila

ble

at h

ttp:

//w

ww

.cdc

.gov

/mm

wr/

pdf/

rr/r

r560

4.pd

f) h

ave

2 do

ses

of v

aric

ella

vac

cine

. Fo

r chi

ldre

n ag

ed 7

thro

ugh

12 y

ears

, the

reco

mm

ende

d m

inim

um in

terv

al b

etw

een

dose

s is

3 m

onth

s (if

the

seco

nd d

ose

was

adm

inis

tere

d at

leas

t 4 w

eeks

aft

er th

e fir

st d

ose,

it c

an b

e ac

cept

ed a

s va

lid);

for p

erso

ns a

ged

13 y

ears

and

old

er, t

he m

inim

um in

terv

al b

etw

een

dose

s is

4 w

eeks

.11

. H

epat

itis

A (H

epA

) vac

cine

. (M

inim

um a

ge: 1

2 m

onth

s)Ro

utin

e va

ccin

atio

n:•

Initi

ate

the

2-do

se H

epA

vac

cine

serie

s at 1

2 th

roug

h 23

mon

ths;

sepa

rate

the

2 do

ses b

y 6

to 1

8 m

onth

s. •

Child

ren

who

hav

e re

ceiv

ed 1

dos

e of

Hep

A v

acci

ne b

efor

e ag

e 24

mon

ths s

houl

d re

ceiv

e a

seco

nd d

ose

6 to

18

mon

ths a

fter

the

first

dos

e.•

For a

ny p

erso

n ag

ed 2

yea

rs a

nd o

lder

who

has

not

alre

ady

rece

ived

the

Hep

A v

acci

ne se

ries,

2 do

ses o

f H

epA

vac

cine

sepa

rate

d by

6 to

18

mon

ths m

ay b

e ad

min

iste

red

if im

mun

ity a

gain

st h

epat

itis A

viru

s in

fect

ion

is d

esire

d.

Catc

h-up

vac

cina

tion

:•

The

min

imum

inte

rval

bet

wee

n th

e tw

o do

ses

is 6

mon

ths.

Spec

ial p

opul

atio

ns:

•Ad

min

iste

r 2 d

oses

of H

epA

vac

cine

at l

east

6 m

onth

s apa

rt to

pre

viou

sly

unva

ccin

ated

per

sons

who

liv

e in

are

as w

here

vac

cina

tion

prog

ram

s tar

get o

lder

chi

ldre

n, o

r who

are

at i

ncre

ased

risk

for i

nfec

tion.

Th

is in

clud

es p

erso

ns tr

avel

ing

to o

r wor

king

in c

ount

ries t

hat h

ave

high

or i

nter

med

iate

end

emic

ity o

f in

fect

ion;

men

hav

ing

sex

with

men

; use

rs o

f inj

ectio

n an

d no

n-in

ject

ion

illic

it dr

ugs;

pers

ons w

ho w

ork

with

HAV

-infe

cted

prim

ates

or w

ith H

AV in

a re

sear

ch la

bora

tory

; per

sons

with

clo

ttin

g-fa

ctor

dis

orde

rs;

pers

ons w

ith c

hron

ic li

ver d

isea

se; a

nd p

erso

ns w

ho a

ntic

ipat

e cl

ose,

per

sona

l con

tact

(e.g

., hou

seho

ld

or re

gula

r bab

ysitt

ing)

with

an

inte

rnat

iona

l ado

ptee

dur

ing

the

first

60

days

aft

er a

rriv

al in

the

Uni

ted

Stat

es fr

om a

cou

ntry

with

hig

h or

inte

rmed

iate

end

emic

ity. T

he fi

rst d

ose

shou

ld b

e ad

min

iste

red

as

soon

as t

he a

dopt

ion

is p

lann

ed, i

deal

ly 2

or m

ore

wee

ks b

efor

e th

e ar

rival

of t

he a

dopt

ee.

12.

Hum

an p

apill

omav

irus

(HPV

) vac

cine

s. (

Min

imum

age

: 9

year

s fo

r HPV

2 [C

erva

rix]

and

HPV

4 [G

ardi

sil])

Ro

utin

e va

ccin

atio

n:•

Adm

inist

er a

3-d

ose

serie

s of H

PV v

acci

ne o

n a

sche

dule

of 0

, 1-2

, and

6 m

onth

s to

all a

dole

scen

ts a

ged

11

thro

ugh

12 y

ears

. Eith

er H

PV4

or H

PV2

may

be

used

for f

emal

es, a

nd o

nly

HPV

4 m

ay b

e us

ed fo

r mal

es.

•Th

e va

ccin

e se

ries

may

be

star

ted

at a

ge 9

yea

rs.

•Ad

min

iste

r the

sec

ond

dose

1 to

2 m

onth

s af

ter t

he fi

rst d

ose

(min

imum

inte

rval

of 4

wee

ks),

adm

inis

ter t

he th

ird d

ose

24 w

eeks

aft

er th

e fir

st d

ose

and

16 w

eeks

aft

er th

e se

cond

dos

e (m

inim

um

inte

rval

of 1

2 w

eeks

).Ca

tch-

up v

acci

nati

on:

•Ad

min

iste

r the

vac

cine

ser

ies

to fe

mal

es (e

ither

HPV

2 or

HPV

4) a

nd m

ales

(HPV

4) a

t age

13

thro

ugh

18

year

s if

not p

revi

ousl

y va

ccin

ated

.•

Use

reco

mm

ende

d ro

utin

e do

sing

inte

rval

s (s

ee a

bove

) for

vac

cine

ser

ies

catc

h-up

.

13.

Men

ingo

cocc

al c

onju

gate

vac

cine

s. (M

inim

um a

ge: 6

wee

ks fo

r Hib

-Men

CY [M

enH

ibri

x], 9

mon

ths

for

Men

ACW

Y-D

[Men

actr

a], 2

mon

ths

for M

enA

CWY-

CRM

[Men

veo]

)Ro

utin

e va

ccin

atio

n:•

Adm

inis

ter a

sin

gle

dose

of M

enac

tra

or M

enve

o va

ccin

e at

age

11

thro

ugh

12 y

ears

, with

a b

oost

er

dose

at a

ge 1

6 ye

ars.

•Ad

oles

cent

s ag

ed 1

1 th

roug

h 18

yea

rs w

ith h

uman

imm

unod

efici

ency

viru

s (H

IV) i

nfec

tion

shou

ld

rece

ive

a 2-

dose

prim

ary

serie

s of

Men

actr

a or

Men

veo

with

at l

east

8 w

eeks

bet

wee

n do

ses.

•Fo

r chi

ldre

n ag

ed 2

mon

ths

thro

ugh

18 y

ears

with

hig

h-ris

k co

nditi

ons,

see

belo

w.

Catc

h-up

vac

cina

tion

:•

Adm

inis

ter M

enac

tra

or M

enve

o va

ccin

e at

age

13

thro

ugh

18 y

ears

if n

ot p

revi

ousl

y va

ccin

ated

.•

If th

e fir

st d

ose

is a

dmin

iste

red

at a

ge 1

3 th

roug

h 15

yea

rs, a

boo

ster

dos

e sh

ould

be

adm

inis

tere

d at

ag

e 16

thro

ugh

18 y

ears

with

a m

inim

um in

terv

al o

f at l

east

8 w

eeks

bet

wee

n do

ses.

•If

the

first

dos

e is

adm

inis

tere

d at

age

16

year

s or

old

er, a

boo

ster

dos

e is

not

nee

ded.

•Fo

r oth

er c

atch

-up

guid

ance

, see

Fig

ure

2.Va

ccin

atio

n of

per

sons

wit

h hi

gh-r

isk

cond

itio

ns a

nd o

ther

per

sons

at i

ncre

ased

risk

of d

isea

se:

•Ch

ildre

n w

ith a

nato

mic

or f

unct

iona

l asp

leni

a (in

clud

ing

sick

le c

ell d

isea

se):

1. F

or c

hild

ren

youn

ger t

han

19 m

onth

s of a

ge, a

dmin

iste

r a 4

-dos

e in

fant

serie

s of M

enH

ibrix

or M

enve

o at

2, 4

, 6, a

nd 1

2 th

roug

h 15

mon

ths

of a

ge.

2. F

or c

hild

ren

aged

19

thro

ugh

23 m

onth

s w

ho h

ave

not c

ompl

eted

a s

erie

s of

Men

Hib

rix o

r Men

veo,

ad

min

iste

r 2 p

rimar

y do

ses

of M

enve

o at

leas

t 3 m

onth

s ap

art.

3. F

or c

hild

ren

aged

24

mon

ths

and

olde

r w

ho h

ave

not

rece

ived

a c

ompl

ete

serie

s of

Men

Hib

rix o

r M

enve

o or

Men

actr

a, a

dmin

iste

r 2 p

rimar

y do

ses o

f eith

er M

enac

tra

or M

enve

o at

leas

t 2 m

onth

s apa

rt.

If M

enac

tra

is a

dmin

iste

red

to a

chi

ld w

ith a

sple

nia

(incl

udin

g si

ckle

cel

l dis

ease

), do

not

adm

inis

ter

Men

actr

a un

til 2

yea

rs o

f age

and

at l

east

4 w

eeks

aft

er th

e co

mpl

etio

n of

all

PCV1

3 do

ses.

•Ch

ildre

n w

ith p

ersi

sten

t com

plem

ent c

ompo

nent

defi

cien

cy:

1. F

or c

hild

ren

youn

ger t

han

19 m

onth

s of

age

, adm

inis

ter a

4-d

ose

infa

nt s

erie

s of

eith

er M

enH

ibrix

or

Men

veo

at 2

, 4, 6

, and

12

thro

ugh

15 m

onth

s of

age

. 2.

For

chi

ldre

n 7

thro

ugh

23 m

onth

s w

ho h

ave

not i

nitia

ted

vacc

inat

ion,

two

optio

ns e

xist

dep

endi

ng

on a

ge a

nd v

acci

ne b

rand

: a.

For

chi

ldre

n w

ho in

itiat

e va

ccin

atio

n w

ith M

enve

o at

7 m

onth

s thr

ough

23

mon

ths o

f age

, a 2

-dos

e se

ries

shou

ld b

e ad

min

iste

red

with

the

seco

nd d

ose

afte

r 12

mon

ths

of a

ge a

nd a

t lea

st 3

mon

ths

afte

r the

firs

t dos

e.

b. F

or ch

ildre

n w

ho in

itiat

e va

ccin

atio

n w

ith M

enac

tra

at 9

mon

ths t

hrou

gh 2

3 m

onth

s of a

ge, a

2-d

ose

serie

s of

Men

actr

a sh

ould

be

adm

inis

tere

d at

leas

t 3 m

onth

s ap

art.

c. F

or c

hild

ren

aged

24

mon

ths

and

olde

r w

ho h

ave

not

rece

ived

a c

ompl

ete

serie

s of

Men

Hib

rix,

Men

veo,

or M

enac

tra,

adm

inis

ter 2

prim

ary

dose

s of e

ither

Men

actr

a or

Men

veo

at le

ast 2

mon

ths

apar

t. •

For c

hild

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153

Index

AAcellular pertussis vaccine schedule,

147–148Acetaminophen, 144Acid phosphate, 68Activity, Apgar score, 3Adolase, 68Adolescent(s)

amikacin dosing for, 126–127cholesterol levels in, 76–77creatinine levels in, 73dietary intake recommendations for,

117–118fibrinolytic system in, 93fluoride supplementation for, 119fosphenytoin dosing for, 134–135galactose levels in, 74gentamicin dosing for, 128–129glucose levels in, 74HDL/LDL in, 77hematology values of, 85immunization schedules for, 146–151lactate levels in, 76levetiracetam dosing for, 136–137lymphocyte subset counts in, 94–96phenobarbital dosing for, 138–139phosphorus levels in, 77prealbumin levels in, 78protein levels in, 78serum 17 hydroxyprogesterone in,

100tobramycin dosing for, 130–131topiramate dosing for, 140–141transferrin levels in, 79triglycerides levels in, 79troponin-1 levels in, 80uric acid levels in, 80

valproic acid dosing for, 142–143vancomycin dosing for, 132–133vitamin A levels in, 80vitamin E levels in, 81

Adult(s)acid phosphate levels in, 68adolase levels in, 68alanine aminotransferase levels in, 68alkaline phosphatase levels in, 69ammonia levels in, 69amylase levels in, 69bilirubin levels in, 71calcium levels in, 72carbon monoxide levels in, 72cerebrospinal fluid values in, 65–66chloride levels in, 72cholesterol levels in, 76–77coagulation tests, 92cobalamin levels in, 81creatinine levels in, 73erythrocyte sedimentation rate in, 73Fe-binding capacity in, 79ferritin levels in, 73fibrinolytic system in, 93folate levels in, 73–74formulas for, 112–115γ-Glutamyl transferase in, 74gas levels in, 71HDL/LDL in, 77hematology values of, 85hemoglobin levels in, 75inhibition of coagulation in, 92iron levels in, 75phenylalanine levels in, 77potassium levels in, 78serum 17 hydroxyprogesterone in,

100

154 Index

Adult(s), continuedthyroid function tests, 98transferrin levels in, 79urea nitrogen levels in, 80

Ageblood pressure and, 58–63head circumference for, 11, 18length/weight percentiles and, 10, 17stature for, 12, 19weight for, 14, 21

Alanine aminotransferase, 68Alkaline phosphatase, 69Amikacin, 126–127Amino acid-based formulas

for adults, 115for infants, 111for older children, 115for young children, 113

Ammonia, 69Amylase, 69Anion gap, 105Antibiotic dosing

amikacin, 126–127gentamicin, 128–129tobramycin, 130–131vancomycin, 132–133

Antinuclear antibodies, 69Antiseizure dosing

fosphenytoin, 134–135levetiracetam, 136–137phenobarbital, 138–139topiramate, 140–141valproic acid and derivatives, 142–143

Antistreptolysin, 70Apgar score, 3Appearance, Apgar score, 3Arterial lactate, 76Aspartate aminotransferase, 70

BBehavior, PEWS for, 7Bicarbonate(s), 70, 116Bilirubin, 70–71Biotin, 117Blood. See also Coagulation

gas, 71glucose, 65lymphocyte subset counts in, 94–96serum, 73

Blood pressureby age and height, 58–63nomograms

children younger than one year, 57

first day of life, 54first few weeks of life, 56first twelve hours or life, 53

Blood urea nitrogen, 83BMI. See Body mass indexBody mass index, 13, 16, 20, 23Body surface area, 9Boy(s)

blood pressure levels in, 58–60growth charts for

birth to 24 months, 17–18BMI, 20, 23Down syndrome-associated, 41–42Fenton preterm, 29head circumference, 18IHDP, 34–37length-for-age, 17neonatal curve, 26–27stature for age, 19two to twenty years, 19–23weight-for-age, 17, 19, 22weight-for-stature, 21–22

Breathing. See Respiration

155Index

CC-reactive protein, 72Calcium

in adult formulas, 114–115in infant formulas, 110–111recommended intakes, 117units of, 72

Calculated serum osmolality, 105Calories

in adult formulas, 114–115in children’s formulas, 113–114common supplements, 108soy formulas, 107standard formulas, 107

Capillary blood, 76Carbohydrates

in adult formulas, 114–115in children’s formulas, 113–114in infant formulas, 110–111in oral rehydration fluids, 116recommended intake, 117units of, 107

Carbon dioxide, 72Carbon monoxide, 72Cardiovascular system, 7Casein formulas, 110–111Catheterization measurements, 121–124Celsius conversion, 2Cerebrospinal fluids, 65–66Children. See also Boys; Girls

acid phosphate levels in, 68adolase levels in, 68alanine aminotransferase levels in, 68alkaline phosphatase levels in, 69amikacin dosing for, 126–127ammonia levels in, 69amylase levels in, 69antistreptolysin levels in, 70aspartate aminotransferase levels

in, 70bicarbonate levels in, 70

calcium levels in, 72cerebrospinal fluid values in, 65–66chloride levels in, 72cholesterol levels in, 76–77coagulation tests, 92cobalamin levels in, 81creatinine levels in, 73dietary intake recommendations for,

117–118erythrocyte sedimentation rate in, 73ferritin levels in, 73fibrinolytic system in, 93fluoride supplementation for, 119folate levels in, 73–74formulas for, 112–115fosphenytoin dosing for, 134–135galactose levels in, 74γ-Glutamyl transferase in, 74gas levels in, 71gentamicin dosing for, 128–129glucose levels in, 74growth hormone values in, 99HDL/LDL in, 77hematology values of, 84immunization schedules for, 146–151inhibition of coagulation in, 92iron levels in, 75lactate dehydrogenase levels in, 76lactate levels in, 76lead levels in, 76levetiracetam dosing for, 136–137lipase levels in, 76lymphocyte subset counts in, 94–96phenobarbital dosing for, 138–139phosphorus levels in, 77potassium levels in, 78prealbumin levels in, 78protein levels in, 78serum 17 hydroxyprogesterone in,

100sodium levels in, 79

156 Index

Children, continuedwith special needs, growth charts,

38–43thyroid function tests, 98tobramycin dosing for, 130–131topiramate dosing for, 140–141transferrin levels in, 79triglycerides levels in, 79troponin-1 levels in, 80urea nitrogen levels in, 80uric acid levels in, 80valproic acid dosing for, 142–143vancomycin dosing for, 132–133vitamin A levels in, 80vitamin E levels in, 81

Chloride, 72, 118Chlorine, 82Cholesterol, 76–77Choline, 117Chromium, 117Coagulation tests, 88–92Consolability pain scale, 6Conversions, 1–2Copper, 118Cortisol levels, 99Cow’s milk-based formulas

for adults, 114–115for infants, 110for young children, 112–113

Creatine kinase, 73Creatinine, 73Cry pain scale, 6

DDiabetes mellitus, 75Diphtheria vaccine schedule, 147–148Down syndrome, 39–40

EEar above eye measurements, 49Endocrine laboratory values, 99–100Erythrocyte sedimentation rate, 73

Exchange transfusion nomogram, 101Extremities, growth measures, 44–48

FFace pain scale, 6Fahrenheit conversion, 2Fats

in adult formulas, 114–115calories in, 107in infant formulas, 110–111intake recommendations, 117

Ferritin, 73Fiber, 117Fibrinolytic system, 93FLACC pain scale, 6Fluoride

intake recommendations, 118sources, 119supplementation schedule, 119

Folate, 73–74, 117Forearm length, 45Formulas

for adults, 114–115amino acid-based, 111, 113caloric counts, 107casein, 110–111cow’s milk-based, 110, 112, 114for infants, 108–111for older children, 114–115pork-based, 113semi-elemental, 110soy-based, 110, 113specialized, 111whey, 111for young children, 112–113

Fosphenytoin, 134–135

GGalactose, 74γ-Glutamyl transferase, 74Gentamicin, 128–129Gestational age, 4

157Index

Girl(s)blood pressure levels in, 61–63growth charts for

birth to 24 months, 10–11BMI, 13, 16Down syndrome-associated, 39–40 Fenton preterm, 28head circumference, 11IHDP, 30–33length-for-age, 10neonatal curve, 24–25two to twenty years, 12–16weight-for-age, 10, 12, 15weight-for-stature, 14–15

Glucosein children, 74infusion rate, 105in neonates, 82in oral rehydration fluids, 116reference range values of, 65in rehydration fluids, 116

Grimace, Apgar score, 3Growth charts

body surface area, 9boys’

birth to 24 months, 17–18BMI, 20, 23IHDP, 34–37length-for-age, 17neonatal curve, 26–27two to twenty years, 19–23weight-for-age, 17, 19, 22weight-for-stature, 21–22

for children with special needs, 38Fenton preterm, 28–29girls’

birth to 24 months, 10–11BMI, 13, 16IHDP, 30–33length-for-age, 10neonatal curve, 24–25two to twenty years, 12–13, 16

weight-for-age, 10, 12, 15weight-for-stature, 14–15

primary teeth eruption, 51Growth hormone values, 99Growth measures, 44–49

HHaemophilus influenzae type b vaccine

schedule, 147–148Haptoglobin, 74HDL. See High-density lipoproteinHead circumference

birth to 24 months, 11, 18LBW preterms, 31neonatal growth, 25, 27VLBW preterms, 33, 35, 37

Heart rate, 8Height

blood pressure levels and, 58–63conversion formulas, 1Down syndrome charts, 39–41

Hematocrit, 82Hematology values, 84Hemoglobin, 75, 82Hepatitis A vaccine schedule, 147–148Hepatitis B vaccine schedule, 147–148High-density lipoprotein, 77Human papillomavirus vaccine schedule,

147–148Hyperbilirubinemia management

exchange transfusion nomogram, 101phototherapy nomogram, 101risk nomogram, 101

IImmunization schedules, 146–151Inactivated poliovirus vaccine schedule,

147–148Infant(s)

amikacin dosing for, 126–127aspartate aminotransferase levels

in, 70

158 Index

Infant(s), continuedbicarbonate levels in, 70bilirubin levels in, 70–71calcium levels in, 72cerebrospinal fluid values in, 65–66chloride levels in, 72coagulation tests, 86–87creatinine levels in, 73dietary intake recommendations for,

117–118Fe-binding capacity in, 79ferritin levels in, 73fluoride supplementation for, 119fosphenytoin dosing for, 134–135γ-Glutamyl transferase in, 74gentamicin dosing for, 128–129hematology values of, 84hemoglobin levels in, 75immunization schedules for, 146–151inhibition of coagulation in, 88–90iron levels in, 75lactate dehydrogenase levels in, 76lactate levels in, 76levetiracetam dosing for, 136–137lipase levels in, 76lymphocyte subset counts in, 94–96phenobarbital dosing for, 138–139phosphorus levels in, 77potassium levels in, 78prealbumin levels in, 78protein levels in, 78serum 17 hydroxyprogesterone in, 100sodium levels in, 79thyroid function tests, 98tobramycin dosing for, 130–131topiramate dosing for, 140–141transferrin levels in, 79triglycerides levels in, 79troponin-1 levels in, 80urea nitrogen levels in, 80uric acid levels in, 80valproic acid dosing for, 142–143

vancomycin dosing for, 132–133vitamin A levels in, 80vitamin E levels in, 81

Influenza vaccine schedule, 147Iodine, 118Iron

in adult formulas, 114–115in children’s formulas, 113–114in infant formulas, 110–111units of, 75

Iron-binding capacity, 79

KKetones, 75

LLactate, 66, 82Lactate dehydrogenase, 76Lactation, 117–118LDL. See Low-density lipoproteinLead, 76Legs pain scale, 6Legs, lower length chart, 48Length

for age percentiles, 10, 17forearm, 45LBW preterms, 30long bone, 46–47lower leg, 48neonatal growth curve, 27upper arm, 44VLBW preterms, 32, 34, 36

Levetiracetam, 136–137Lipase, 76Lipids, 76Long bone length, 46–47Low birth weight preterms

boys’ growth charts, 34–38girls’ growth charts, 30–33

Low-density lipoprotein, 77LBW. See Low birth weight pretermsLymphocytes, 65, 94–96

159Index

MMagnesium

intake recommendations, 118in neonates, 82units for, 77

Manganese, 118Meningococcal vaccine schedule, 148Methemoglobin, 77Milligram conversions, 1Milliosmois conversions, 1MMR (measles, mumps, rubella) vaccine

schedule, 147–148Monocytes, 65

NNew Ballard score, 4–5Newborn(s)

acid phosphate levels in, 68adolase levels in, 68alanine aminotransferase levels in, 68alkaline phosphatase levels in, 69amikacin dosing for, 126–127ammonia levels in, 69amylase levels in, 69antistreptolysin levels in, 70aspartate aminotransferase levels

in, 70bicarbonate levels in, 70bilirubin levels in, 70, 71blood pressure nomograms, 53–56calcium levels in, 72chloride levels in, 72cobalamin levels in, 81core blood chemistry, 82–83creatine kinase levels in, 73creatinine levels in, 73ferritin levels in, 73folate levels in, 73–74fosphenytoin dosing for, 134–135galactose levels in, 74γ-Glutamyl transferase in, 74gas levels in, 71

gentamicin dosing for, 128–129glucose levels in, 74growth curve in, 24–27growth hormone values in, 99haptoglobin in, 74hematology values of, 84hemoglobin levels in, 75immunization schedules for, 146–151iron levels in, 75lactate dehydrogenase levels in, 76lactate levels in, 76levetiracetam dosing for, 136–137lipase levels in, 76lymphocyte subset counts in, 94–96phenobarbital dosing for, 138–139phosphorus levels in, 77phenylalanine levels in, 77potassium levels in, 78prealbumin levels in, 78protein levels in, 78tobramycin dosing for, 130–131topiramate dosing for, 140–141transferrin levels in, 79triglycerides levels in, 79troponin-1 levels in, 80two to four blood chemistry, 82–83urea nitrogen levels in, 80uric acid levels in, 80vancomycin dosing for, 132–133

Niacin. See Vitamin B3

Nonsmokers, 72Nutrition

adult formulas, 114common supplements, 108infant formulas, 108–111intake recommendations, 117–118older children formulas, 114preterm formulas, 108soy formulas, 107standard formula, 107toddler formulas, 113young children formulas, 113

160 Index

OOpening pressure, 65–66Oral rehydration fluids, 116Osmolality

in adult formulas, 114–115in children’s formulas, 113–114in infant formulas, 110–111in oral rehydration fluids, 116units of, 77

PPain scales, 6Pantothenic acid, 117Pediatric early warning score (PEWS),

7–8PEWS. See Pediatric early warning score

(PEWS)pH, 82Phenobarbital, 138–139Phosphorus

in adult formulas, 114–115in children’s formulas, 113–114in infant formulas, 110–111recommended intake of, 118units of, 77

Phototherapy nomogram, 102Phenylalanine, 77Physical maturity, 5Pneumococcal conjugate vaccine sched-

ule, 147–148Pneumococcal polysaccharide vaccine

schedule, 147–148Polymorphonuclear cells, 65Porcelain, 77Pork-based formulas, 113Potassium

in adult formulas, 114–115blood levels, 82in children’s formulas, 113–114intake recommendations, 118in oral rehydration fluids, 116

in rehydration fluids, 116units in children, 78

Prealbumin, 78Pregnancy, 117–118Preterm infant(s)

bilirubin levels in, 70blood pressure and, 54–56calcium levels in, 72cerebrospinal fluid values in, 65–66Fenton growth charts, 28–29glucose levels in, 74IHDP growth charts

boys, 34–37girls, 30–33

phenylalanine levels in, 77potassium levels in, 78protein levels in, 78thyroid function tests, 97urea nitrogen levels in, 80vitamin A levels in, 80vitamin E levels in, 81

Proteinsin adult formulas, 114–115in children’s formulas, 113–114clinical chemistry, 78in infant formulas, 110–111intake recommendations, 117reference range values of, 65in supplements, 107

Pulse, Apgar score, 3

RRabies guidelines, 145Red blood cells, 65, 74Respiration

Apgar score, 3fluctuation with, 66PEWS for, 7–8

Riboflavin. See Vitamin B2

Risk nomogram, 101Rotavirus vaccine schedule, 147, 148

161Index

SScales for pain, 6Scores

Apgar, 3New Ballard, 4–5PEWS, 7–8

Selenium, 118Semi-elemental formulas

for adults, 115for older children, 115for young children, 113

Serum 17 hydroxyprogesterone, 100Smokers, 72Sodium

in adult formulas, 114–115in children’s formulas, 113–114in infant formulas, 110–111intake recommendations, 118in oral rehydration fluids, 116in rehydration fluids, 116units in children, 79

Soy-based formulasfor adults, 115for infants, 110for older children, 115for young children, 113

Specialized formulas, 111Stature for age, 12, 19

TTeeth, eruption chart, 51Temperature conversions, 2Tetanus vaccine schedule, 147–148Thiamin. See Vitamin B1

Thyroid function tests, 97–98Tobramycin, 130–131Topiramate, 140–141Topomax. See TopiramateTransferrin, 79Triglycerides, 79Troponin-1, 80

UUmbilical cords

bilirubin levels in, 70blood gas in, 71creatinine in, 73γ-Glutamyl transferase in, 74protein levels in, 78

Umbilical vein/artery, 121–124Upper arm length, 44Urea nitrogen, 80Uric acid, 80

VValproic acid, 142–143Vancomycin, 132–133Varicella vaccine schedule, 147–148Venous lactate, 76Very low birth weight preterms

boys’ growth charts, 34–38girls’ growth charts, 30–33thyroid function tests, 97–98

Vitamin A, 80, 117Vitamin B1, 80, 117Vitamin B12, 81, 117Vitamin B2, 80, 117Vitamin B3, 117Vitamin C, 81, 117Vitamin D3, 81, 117Vitamin E, 81, 117Vitamin K, 117VLBW. See Very low birth weight preterms

WWeight

for age percentiles, 10, 12, 15, 17, 19, 22

birthblood pressure and, 54catheterization measurement and,

121–124conversion formulas, 1Down syndrome charts, 39–41

162 Index

Weight, continuedLBW preterm, 30for stature percentiles, 14–15, 21–22VLBW preterms, 32, 34, 36

Weight-for-length percentilesLBW preterms, 31VLBW preterms, 33, 35, 37

Weight-for-stature percentiles, 14–15, 21–22

Whey formulas, 111White blood cells, 65, 94

ZZinc, 81, 118

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Rec

ommen

dations

forPreve

ntivePed

iatric

Hea

lthCare

Bright

Futures/American

Aca

dem

yofPed

iatrics

Pre

ven

tio

n a

nd

he

alt

h p

rom

oti

on

for

infa

nts

, ch

ildre

n, a

do

lesc

en

ts, a

nd

th

eir

fam

ilie

s TM

TM

Eac

hch

ildan

dfa

mily

isun

ique

;the

refo

re,t

hese

Rec

ommen

dations

forPreve

ntive

Ped

iatric

Hea

lthCare

are

desi

gned

for

the

care

ofch

ildre

nw

hoar

ere

ceiv

ing

com

pete

ntpa

rent

ing,

have

nom

anife

stat

ions

ofan

yim

port

ant

heal

thpr

oble

ms,

and

are

grow

ing

and

deve

lopi

ngin

satis

fact

ory

fash

ion.

Additiona

lvisits

may

bec

ome

nece

ssary

ifci

rcum

stan

ces

sugg

est

varia

tions

from

norm

al.

Dev

elop

men

tal,

psyc

hoso

cial

,and

chro

nic

dise

ase

issu

esfo

rch

ildre

nan

dad

oles

cent

sm

ayre

quire

freq

uent

coun

selin

gan

dtr

eatm

ent

visi

tsse

para

tefr

ompr

even

tive

care

visi

ts.

Thes

egu

idel

ines

repr

esen

ta

cons

ensu

sby

the

Am

eric

anA

cade

my

ofP

edia

tric

s(A

AP

)and

Brig

htFu

ture

s.Th

eA

AP

cont

inue

sto

emph

asiz

eth

egr

eat

impo

rtan

ceof

continuity

ofca

rein

com

preh

ensi

vehe

alth

supe

rvis

ion

and

the

need

toav

oid

frag

men

tatio

nofca

re.

1.If

ach

ildco

mes

unde

rca

refo

rth

efir

sttim

eat

any

poin

ton

the

sche

dule

,or

ifan

yite

ms

are

not

acco

mpl

ishe

dat

the

sug-

gest

edag

e,th

esc

hedu

lesh

ould

bebr

ough

tup

toda

teat

the

earli

est

poss

ible

time.

2.A

pren

atal

visi

tis

reco

mm

ende

dfo

rpa

rent

sw

hoar

eat

high

risk,

for

first

-tim

epa

rent

s,an

dfo

rth

ose

who

requ

est

aco

nfer

-en

ce.T

hepr

enat

alvi

sit

shou

ldin

clud

ean

ticip

ator

ygu

idan

ce,p

ertin

ent

med

ical

hist

ory,

and

adi

scus

sion

ofbe

nefit

sof

brea

stfe

edin

gan

dpl

anne

dm

etho

dof

feed

ing

per

AA

Pst

atem

ent

“The

Pre

nata

lVis

it”(2

001)

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6/14

56].

3.E

very

infa

ntsh

ould

have

ane

wbo

rnev

alua

tion

afte

rbi

rth,

brea

stfe

edin

gen

cour

aged

,and

inst

ruct

ion

and

supp

ort

offe

red.

4.E

very

infa

ntsh

ould

have

anev

alua

tion

with

in3

to5

days

ofbi

rth

and

with

in48

to72

hour

saf

ter

disc

harg

efr

omth

eho

spita

l,to

incl

ude

eval

uatio

nfo

rfe

edin

gan

dja

undi

ce.B

reas

tfee

ding

infa

nts

shou

ldre

ceiv

efo

rmal

brea

stfe

edin

gev

alua

tion,

enco

ur-

agem

ent,

and

inst

ruct

ion

asre

com

men

ded

inA

AP

stat

emen

t“B

reas

tfee

ding

and

the

Use

ofH

uman

Milk

”(2

005)

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2/49

6].F

orne

wbo

rns

disc

harg

edin

less

than

48ho

urs

afte

rde

liver

y,th

ein

fant

mus

tbe

exam

ined

with

in48

hour

sof

disc

harg

epe

rA

AP

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emen

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ospi

talS

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for

Hea

lthy

Term

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born

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004)

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5/14

34].

5.B

lood

pres

sure

mea

sure

men

tin

infa

nts

and

child

ren

with

spec

ific

risk

cond

ition

ssh

ould

bepe

rfor

med

atvi

sits

befo

reag

e3

year

s.6.

Ifth

epa

tient

isun

coop

erat

ive,

resc

reen

with

in6

mon

ths

per

AA

Pst

atem

ent

“Eye

Exa

min

atio

nin

Infa

nts,

Chi

ldre

n,an

dYo

ung

Adu

ltsby

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iatr

icia

ns”

(200

7)[U

RL:

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licy.

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ublic

atio

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onte

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902]

.7.

All

new

born

ssh

ould

besc

reen

edpe

rA

AP

stat

emen

t“Y

ear

2000

Pos

ition

Sta

tem

ent:

Prin

cipl

esan

dG

uide

lines

for

Ear

lyH

earin

gD

etec

tion

and

Inte

rven

tion

Pro

gram

s”

(200

0)[U

RL:

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ublic

atio

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798]

.Joi

ntC

omm

ittee

onIn

fant

Hea

ring.

Year

2007

posi

tion

stat

emen

t:pr

inci

ples

and

guid

elin

esfo

rea

rlyhe

arin

gde

tect

ion

and

inte

rven

tion

prog

ram

s.Ped

iatrics.

2007

;120

:898

–921

.

8.A

AP

Cou

ncil

onC

hild

ren

With

Dis

abili

ties,

AA

PS

ectio

non

Dev

elop

men

talB

ehav

iora

lPed

iatr

ics,

AA

PB

right

Futu

res

Ste

erin

gC

omm

ittee

,AA

PM

edic

alH

ome

Initi

ativ

esfo

rC

hild

ren

With

Spe

cial

Nee

dsP

roje

ctA

dvis

ory

Com

mitt

ee.I

dent

ifyin

gin

fant

san

dyo

ung

child

ren

with

deve

lopm

enta

ldis

orde

rsin

the

med

ical

hom

e:an

algo

rithm

for

deve

lopm

enta

lsur

veill

ance

and

scre

enin

g.Ped

iatrics.

2006

;118

:405

–420

[UR

L:ht

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1/40

5].

9.G

upta

VB

,Hym

anS

L,Jo

hnso

nC

P,et

al.I

dent

ifyin

gch

ildre

nw

ithau

tism

early

?Ped

iatrics.

2007

;119

:152

–153

[UR

L:ht

tp:/

/ped

iatr

ics.

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ublic

atio

ns.o

rg/c

gi/c

onte

nt/f

ull/1

19/1

/152

].10

.A

tea

chvi

sit,

age-

appr

opria

teph

ysic

alex

amin

atio

nis

esse

ntia

l,w

ithin

fant

tota

llyun

clot

hed,

olde

rch

ildun

dres

sed

and

suit-

ably

drap

ed.

11.

Thes

em

aybe

mod

ified

,dep

endi

ngon

entr

ypo

int

into

sche

dule

and

indi

vidu

alne

ed.

12.

New

born

met

abol

ican

dhe

mog

lobi

nopa

thy

scre

enin

gsh

ould

bedo

neac

cord

ing

tost

ate

law

.Res

ults

shou

ldbe

revi

ewed

atvi

sits

and

appr

opria

tere

test

ing

orre

ferr

aldo

neas

need

ed.

13.

Sch

edul

espe

rth

eC

omm

ittee

onIn

fect

ious

Dis

ease

s,pu

blis

hed

annu

ally

inth

eJa

nuar

yis

sue

ofPed

iatrics.

Eve

ryvi

sit

shou

ldbe

anop

port

unity

toup

date

and

com

plet

ea

child

’sim

mun

izat

ions

.14

.S

eeA

APPed

iatric

NutritionHan

dboo

k,5t

hE

ditio

n(2

003)

for

adi

scus

sion

ofun

iver

sala

ndse

lect

ive

scre

enin

gop

tions

.See

also

Rec

omm

enda

tions

topr

even

tan

dco

ntro

liro

nde

ficie

ncy

inth

eU

nite

dS

tate

s.MMWR.1

998;

47(R

R-3

):1–3

6.15

.Fo

rch

ildre

nat

risk

ofle

adex

posu

re,c

onsu

ltth

eA

AP

stat

emen

t“L

ead

Exp

osur

ein

Chi

ldre

n:P

reve

ntio

n,D

etec

tion,

and

Man

agem

ent”

(200

5)[U

RL:

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licy.

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1036

].A

dditi

onal

ly,s

cree

n-in

gsh

ould

bedo

nein

acco

rdan

cew

ithst

ate

law

whe

reap

plic

able

.16

.P

erfo

rmris

kas

sess

men

tsor

scre

ens

asap

prop

riate

,bas

edon

univ

ersa

lscr

eeni

ngre

quire

men

tsfo

rpa

tient

sw

ithM

edic

aid

orhi

ghpr

eval

ence

area

s.

17.

Tube

rcul

osis

test

ing

per

reco

mm

enda

tions

ofth

eC

omm

ittee

onIn

fect

ious

Dis

ease

s,pu

blis

hed

inth

ecu

rren

ted

ition

ofRed

Boo

k:Rep

ortof

theCom

mittee

onInfectious

Disea

ses.

Test

ing

shou

ldbe

done

onre

cogn

ition

ofhi

gh-r

isk

fact

ors.

18.

“Thi

rdR

epor

tof

the

Nat

iona

lCho

lest

erol

Edu

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nP

rogr

am(N

CE

P)E

xper

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anel

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etec

tion,

Eva

luat

ion,

and

Trea

tmen

tof

Hig

hB

lood

Cho

lest

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ent

Pan

elIII

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epor

t”(2

002)

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3]an

d“T

heE

xper

tC

omm

ittee

Rec

omm

enda

tions

onth

eA

sses

smen

t,P

reve

ntio

n,an

dTr

eatm

ent

ofC

hild

and

Ado

lesc

ent

Ove

rwei

ght

and

Obe

sity

.”S

uppl

emen

tto

Ped

iatrics.

Inpr

ess.

19.

All

sexu

ally

activ

epa

tient

ssh

ould

besc

reen

edfo

rse

xual

lytr

ansm

itted

infe

ctio

ns(S

TIs)

.20

.A

llse

xual

lyac

tive

girls

shou

ldha

vesc

reen

ing

for

cerv

ical

dysp

lasi

aas

part

ofa

pelv

icex

amin

atio

nbe

ginn

ing

with

in3

year

sof

onse

tof

sexu

alac

tivity

orag

e21

(whi

chev

erco

mes

first

).21

.R

efer

ralt

ode

ntal

hom

e,if

avai

labl

e.O

ther

wis

e,ad

min

iste

ror

alhe

alth

risk

asse

ssm

ent.

Ifth

epr

imar

yw

ater

sour

ceis

defi-

cien

tin

fluor

ide,

cons

ider

oral

fluor

ide

supp

lem

enta

tion.

22.

At

the

visi

tsfo

r3

year

san

d6

year

sof

age,

itsh

ould

bede

term

ined

whe

ther

the

patie

ntha

sa

dent

alho

me.

Ifth

epa

tient

does

not

have

ade

ntal

hom

e,a

refe

rral

shou

ldbe

mad

eto

one.

Ifth

epr

imar

yw

ater

sour

ceis

defic

ient

influ

orid

e,co

nsid

eror

alflu

orid

esu

pple

men

tatio

n.23

.R

efer

toth

esp

ecifi

cgu

idan

ceby

age

aslis

ted

inB

right

Futu

res

Gui

delin

es.(

Hag

anJF

,Sha

wJS

,Dun

can

PM

,eds

.Brig

htFu

tures:

Guide

lines

forHea

lthSup

ervision

ofInfants,

Children,

andAdo

lescen

ts.3

rded

.Elk

Gro

veVi

llage

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eric

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08.)

KEY

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tobe

perf

orm

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=ris

kas

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,with

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llow

,ifp

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ve●

=ra

nge

durin

gw

hich

ase

rvic

em

aybe

prov

ided

,with

the

sym

boli

ndic

atin

gth

epr

efer

red

age

The

reco

mm

enda

tions

inth

isst

atem

ent

dono

tin

dica

tean

excl

usiv

eco

urse

oftr

eatm

ent

orst

anda

rdof

med

ical

care

.Var

iatio

ns,t

akin

gin

toac

coun

tin

divi

dual

circ

umst

ance

s,m

aybe

appr

opria

te.

Cop

yrig

ht©

2008

byth

eA

mer

ican

Aca

dem

yof

Ped

iatr

ics.

No

part

ofth

isst

atem

ent

may

bere

prod

uced

inan

yfo

rmor

byan

ym

eans

with

out

prio

rw

ritte

npe

rmis

sion

from

the

Am

eric

anA

cade

my

ofP

edia

tric

sex

cept

for

one

copy

for

pers

onal

use.

Nikki

Typewritten Text

[STORMRG]

Documents

Reference Range Values for Pediatric Care