Breast feeding -...

FOR GENERAL PRACTITIONERS: PEDIATRICS: DR KONDEKAR 2010

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BREAST FEEDING

'Exclusive breastfeeding’ means that not giving any prelacteal drinks including honey, water,

'holy' or ritually blessed water, sugar or glucose water, gripe water,juices,vitamins or foods other

than breast milk, for the first six months.

Principles of successful breastfeeding are:

All expectant mothers should be motivated and prepared for Breast feeding, at the time of

antenatal visits.

Starting to breastfeed within an hour after birth - this ensures that the infant receives

colostrums.

Breastfeed on demand, whenever baby cries for it, and continue feeding as long as baby

wants it.

Proper latching to the breast with complete lip seal along the areola is must for effective

feeding.

Feed from both breasts; feed both fore milk and hind milk.

The frequency and duration of feeding proportionately determines the milk output.

To prevent abdominal distension,colics,and regurgitation, burp well after each feed

Not giving any other food or fluids such as water or infant formula during the first six

months.

Breast feeding positions:

Position Situation

Lateral position feeding Post operatively

Foot ball position In twins, hypotonic baby

Cradle position Premature or small weight babies

Sitting with back rest Any baby

Colostrum

For the first 72 hours after the delivery breasts secrete thick, sticky and yellowish in colour milk

known as colostrum. It is easily digestible, contains more proteins and vitamins A& K, anti-

infective elements to protect your newborn against infections. Although colostrum is secreted in

small quantities (30-90ml), it is sufficient to meet the energy needs of a normal newborn during

the first few days of life.


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Benefits of breast feeding:

Benefits to mother Benefits to baby

Easy, readymade, complete and

economical and comfortable. Can be

given at any time, anywhere in any

position.

Breast feeding stimulates secretion of

oxytocin which helps the uterus to

contract and control post partum

bleeding.

Frequent nursing suppresses ovulation

through prolactin secretion, and

provide protection against another

pregnancy.

Lower risk of breast and ovarian

cancer

Make night feeds and travel convenient

Attachment between mother and child

helps in bonding.

Right amount of fatty acids, lactose,

water, and amino acids for human

digestion, brain development, and

growth

Human milk transfers to the infant a

mother's antibodies to disease; hence

it’s a custom-designed to fight the

diseases.

Breast-fed baby's digestive tract

contains large amounts of

Lactobacillus bifidus, beneficial

bacteria that prevent the growth of

harmful organisms.

Attachment between mother and child

helps in bonding.

Benefits to society

Contributes to child survival

Decreases health care cost

Contributes to population control by natural way

Breast feeding - mothers with special needs

A. Maternal illnesses

Tuberculosis Treat mother, initiate and continue breast feeding, treat baby with

prophylactic dose of INH, if mother is a case of open tuberculosis.

Diabetes Initiate and continue breast feeding

Epilepsy No contraindications.

Hepatitis -B Risk of transmission should be weighed against the risk of developing

other infections and allergies. Initiate and continue breast feeding, treat

baby with Hepatitis immunoglobulin and vaccine.

HIV infection HIV virus can pass through breast milk & could be responsible for up

to 10% of the causes of mother to child transmission. However in

cases where the woman cannot afford top feeds, breast feeding is

recommended since the mortality from gastrointestinal infection is

high.

Herpes No contraindications. temporary discontinue if lesion on breast


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B. Medicines and Nursing Mothers

Most medications have not been tested in nursing women, so no one knows exactly how a given

drug will affect a breast-fed child.

Drugs that are safe for nursing Drugs to be given with caution

in nursing or avoid

Drugs that are contraindicated

for nursing

Acetaminophen

Antiepileptics (although

one, Primidone, should

be given with caution)

most antihistamines

Alcohol in moderation

most antihypertensives

Aspirin (should be used

with caution)

Caffeine (moderate

amounts in drinks or

food)

Codeine

Decongestants

Ibuprofen

Insulin

Quinine

Thyroid medications

Amiodarone

Anthroquinone

Atropine

Aspirin

Birth control pills

Bromides

Calciferol

Dyhydrotachysterol

Metoclopramide

Metronidazole

Phenobarbitone

Primidone

Sulfasalazine

Reserpine

Bromocriptine

Chemotherapy Drugs

Ergotamine

Lithium

Methotrexate

Drugs of Abuse

Tobacco Smoke

Amphetamines

Chloramphenicol

Cimetidine

Clemastine

DES

Gold

Iodides, thyuracil

Meporbamate

Nicotine

Tetracycline

Phenindione

References:

1. Training manual on breastfeeding management-United Nations Children Fund.

2. BPNI(breast feeding promotion network of India) training module

3. BPNI website - http://www.bpni.org/breastfeeding/goodness


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DIARRHEA

Definition: Three or more consequtive stools ( increased frequency) of greater fluidity than

normal or a recent change increase in fluidty and frequency of stools is diarrhea.

Acute diarrhea: Diarrhea with duration less than 14 days

Chronic diarrhea: Diarrhea with duration more than 14 days

Causes of Diarrhea

Acute Diarrhea Chronic Diarrhea

Viral: Rota virus, Norwalk Virus

Bacterial: E coli (4 types), shigella,

Salmonella, Pseudomembrane colitis

Fungal Diarrhea

Osmotic diarrhea

Food poisoning

Stress / emotional diarrhoea

Colonic

Coeliac disease

Crohn’s disease

small bowel enteropathies

Giardiasis (and other chronic infection)

Chronic pancreatitis

Hyperthyroidism

Radiation enteritis

Factitious diarrhea

Clinical features: dehydration assessment protocol

PARAMETER A B C

Look Condition Well alert Restless irritable* Lethargy/ unconscious

/ floppy*

Look Eyes Normal Sunken Very sunken / dry

Look Tears Present Absent Absent

Look Mouth and

tongue

Moist Dry very dry

Look Thirst Normal, not thirsty Thirsty, drinks

eagerly*

Not able to drink*

Feel skin pinch Goes back slowly Goes back slowly* Goes back very

slowly

Decide No dehydration Some dehydration Severe dehydration

Treat Plan A Plan B Plan C urgently

Criteria marked with * are key criteria.

Investigations:

Stool routine microscopy for parasites ova, cysts and bacteria if any.

Stool culture for suspected bacterial diarrhea.


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Treatment:

Management of dehydration

Plan A: counsel the parents regarding

Continued feeding

Extra fluids for large volume diarrhea

Identify and return for medical advice if signs or symptoms of

dehydration.

Extra fluids in the form of WHO ORS, plain water soup, rice water and

yoghurt. Amount to be given <2 yrs, 50-100 ml per large stool and above

2 yr age 100-200 ml ORS per large stool.

Plan B:

The formula for ORS recommended by WHO and UNICEF contains:

3.5 gms gms sodium chloride (common salt)

2.9 gms trisodium citrate dihydrate

1.5 gms potassium chloride

20 gm glucose (anhydrous)

The above ingredients are dissolved in one liter of clean water.

Amount of ORS to be given in first 4-6 hours

Age Up to 4 months 4-12 months 1-2 yrs 2-5 yrs

Weight <6 kg 6-10 kg 10-12 kg 12-19 kg

Ml of ORS 200-400 400-700 700-900 900-1400

In absence of ORS, dehydration can be prevented by making ORS by adding 1 level teaspoon (5

ml) of salt should be mixed with 8 level teaspoons of sugar in a litre of drinking water

administered orally by parents in the child's own home.

If dehydration persists, large volume stools continue, vomiting and abdominal distention is

present and / or urine out put has not picked up, hospitalize the child and change to plan C.

Plan C:Start the child on IV fluids gives 100ml/kg of Ringer’s Lactate/ Normal saline as below:

Age First give 30ml/kg in Followed by 70ml/kg in

Infant 1 hour 5 hours

1-5 years 30 minutes 2.5 yrs

Reassess the child every 2 hrs and if dehydration persists, fluid rate may be increased, and if

dehydration settles, gradually ORS to be introduced as soon as child can drink.


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Indications for antibiotics:

Amebiasis: Metronidazole 30mg/kg/day in divided doses for 10 days

Bacillary dysentery: Septran 6 mg/kg/day for 7 days, or cephalosporins like cefixime

10mg/kg/day for 7 days.

References:

1. Essential Pediatrics, Ghai O. P., 3rd edition, 193-195

2. Please see the link - http://rehydrate.org/dd/su19.htm


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IMMUNISATION

National Immunisation Schedule:

Age Vaccines

Birth BCG OPV0

6 weeks DTP1, OPV1 ( and BCG if not given earlier)

10 weeks DTP2 OPV 2

14 weeks DTP3 OPV3

9 months Measles

16-24 months DTP OPV

5-6 years DT*

10 years TT**

16 years TT

For pregnant women

Early in pregnancy TT1 or booster

One month after TT1 TT2

* If primary immunization history is not available, second dose of DT may be given after

a month.

** If primary immunization history is not available, second dose of TT to be given after 1

month.

IAP also recommends inclusion of hepatitis –B, MMR, Typhoid and Haemophilus

Influenzae b in the time table. However, in view of the mild nature of chickenpox and

hepatitis A, these two are recommended as additional vaccines.

Indian Academy of Pediatrics recommends their members to prescribe additional

vaccines to their child patients depending upon the availability at the vaccines and the

affordability of the patents. However, it is mandatory to administer all the UIP vaccines

as a priority.

IAP Immunization guidelines:

1. To prevent perinatal transmission, birth dose of Hepatitis B vaccine within 12 hours is

essential. BCG, OPV and Hepatitis B vaccines, when missed at birth can be started at the

completion of 6 weeks.

2. Combined DPTwc / Hepatitis B / Hib vaccines can be given at 6, 10, 14 weeks.

3. In addition to ‘Routine OPV doses’, the recommended ‘Pulse OPV doses’ are also

mandatory during PPI campaigns.

4. For Typhoid* immunization, earliest age recommended : whole cell vaccine at 6 months,

Vi antigen at 2 years and Oral Ty21a vaccine at 6 years. Revaccination every 3 years.

5. Apart from the earliest age indicated, MMR, Typhoid, Varicella and Hepatitis A can be

given at any age, relevant to local epidemiology.

6. Td (Tetanus / diphtheria toxoid) should be preferred to TT (Tetanus toxoid) where

available.

7. Varicella and Hepatitis A are additional vaccines as recommended by Indian

Academy of Pediatrics.


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Vaccination schedule for an unimmunised child

Age Less than 7 yrs More than 7 years

First visit BCG*, OPV*, DTPw/DTPa HB Td, HB

Second visit, 1 month later OPV*, DTPw/ DTPa, HB Td, HB

Third visit 1 month later Measles, MMR, typhoid MMR typhoid

Fourth visit, 6 months after first DTPw/ DTPa, HB HB

Every 3 years Typhoid Typhoid

*OPV BCG not after 5 yr age.

IAP recommendations for Immunisation of HIV infected children

Vaccine IAP recommendations

Asymptomatic HIV infection Symptomatic HIV infection

BCG Yes, at birth No

DTPw/DTPa Yes, at 6, 10 , 14 weeks Yes

OPV Yes, at 6, 10, 14 weeks Yes, IPV

Measles Yes at 6 & 9 months Yes

MMR Yes Yes CD4% > 15%

Hepatitis B Yes, as for uninfected children Yes, double each dose

Hib Yes Yes

Typhoid Vi Yes Yes

Pneumococcal Yes Yes

Influenza Yes >(6 month age) Yes

Varicella Yes (2 doses at 6-8 weeks interval) Yes (2 doses at 6-8 weeks interval) CD4>15%

Hepatitis A Yes Yes

References: 1.IAP committee on o immunization IAP Guidebook of immunization, 2005-2006

2. http://www.iapindia.org/circumstances.cfm


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HELMINTHIASIS (WORM INFESTATIONS)

Mode of Infestation: feco-oral contamination through food/water/ soil

Problems: Malabsorption, blood loss, malnutrition and failure thrive and various vitamin and

mineral deficiencies, abdominal pain, diarrhea or constipation and failure to thrive

Whip worm:

Signs/ symptoms: Asymptomatic, bloody diarrhea, rectal prolapse, growth retardation,

malnutrition.

Treatment: Mebendazole 100mg twice a day for 3 days, for mo than 2 yrs age.

Albendazole 400 mg single dose for > 10 kg and 200 mg single dose for weight <10 kg

Mebendazole retention enema

Round worm: (Ascaris Lumbricoids)

Signs/ symptoms: vague abdominal pain, cough, eosoniphilia, bowel obstruction

Treatment: Elixir Piperacillin citrate 75mg/kg orally 2 days or Mebendazole 100mg BD for 3

days, or pyrantel pamoate 11 mg/kg single dose, or Albendazole 400mg single dose.

Hook worm: (Ankylostoma)

Signs/ symptoms: ground itch, intense pruritis, erythema, vesicular rash at the site of penetration,

chronic PEM, iron deficiency pneumonia

Treatment: Elixir Piperacillin citrate 75mg/kg orally 2 days or Mebendazole 100mg BD for 3

days, or pyrantel pamoate 11 mg/kg single dose, or Albendazole 400mg single dose. Plus iron

therapy 6mg/kg/day, ferrous sulphate.

Prevention: wearing footwear, avoid open air defecations

Pin worm: Enterobius vermicularis

Signs/ symptoms: age group 5-14 yrs, asymptomatic, or perianal or perineal pruritis

Treatment: Pyrantel Pamoate day 1 and day 14, or Mebendazole / albendazole and retreatment

after 2 weeks. Treat all family members simultaneously. Nails should be trimmed short.

Undergarments to be dried in sun, thorough cleaning of toilet seats, floors, discourage perianal

scratching

.


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Tape worm (Tinea solium)

Signs/ symptoms: occurs due to consumption of beef and pork infected with larvae. Avoid

unwashed raw vegetables.

Treatment: niclosamide 40mg/kg/dose f/b saline purges after 1hr. or praziquentel 10mg/kg/dose,

in cysticercosis; praziquentel 50mg/kg/day for 10 days

Albendazole 15 mg/kg/day for 28 days

SKIN INFESTATIONS

Dermatophytoses (ring worms)

These are caused by a group of closely related fungi with a propensity to invade the

stratum corneum, hairs, nails.

Tinea Capitis: Infection of the hair shaft and surrounding skin causing alopecia, brittle hairs.

Treatment : Oral griseofulvin microcrystaline

Tinea corporis : involves the skin of face, trunk and extremeties. The typical lesion starts as dry

and mildly erythematous, elevated, scaly papule and spreads centrifugally, clearing centrally.

Treatment : Topical antifungal- are effective.

Scabies

It’s caused by itch mite, Sarcaptos scabiei var, hominis. Usually transmitted by direct contact

with infected person. The eruption is highly pruritic and consists of burrows, wheals, papules,

vesicle, and eczematous dermatitis.

Treatment: application of 1% gamma benzene hexachloride or BB lotion to entire body below

neck, full family may be treated.

Pediculosis

Lice infests (head, body and pubic) hair. Body louse is also a vector for typhus, Trench fever.

Itching, Excoriations on the scalp, posterior neck, and upper back; bite reactions; secondary

bacterial infection; and cervical lymphadenopathy are common manifestations.


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Treatment: The goal of therapy is to eliminate lice and eggs.

Linen, clothing, and other materials may be treated with hot water washing.

Eyelash infestation can be treated effectively with petrolatum ointment (eg, Vaseline).

Permethrin 5% (Elimite) or 1% (Nix) lotion -- DOC, especially for infants >2 mo and

small children

Lindane 1% shampoo Not very safe in children due to transcutaneous absorption leading

to neurotoxicity

References:

1. Essential Pediatrics, Ghai O. P.,3rd edition

2. Textbook of pediatrics, Nelson, pocket companion, Indian ed ,454-455

3. http://www.emedicine.com/emerg/topic409.htm

http://www.emedicine.com/emerg/topic409.htm


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Pneumonia or acute respiratory infection (ARI)

ARI is a major cause of mortality and morbidity in children below 5 yr age. Majority of ARI are

self limiting but pneumonia is a serious life threatening event with high fatality rate.

Sepctrum of ARI

Upper respiratory infection, common cold, pharyngitis and otitis

Lower respiratory infections: bronchitis, bronchiolitis, pneumonia

Clinical assessment:

History: Age, presence of cough and its duration, immuno compromising illnesses like measles/

diarrhea/ inability to walk, drink eat. convulsions, irregular breathing, apnea, cyanosis and

treatment taken.

Observe for fast breathing, rate >60/min for age less than 2 months

rate >50/min for age 2 – 12 months

rate >40/min for age 12 months – 5 yrs

look for chest in drawing,

look for signs of serious illness = refusal to feed, drowsiness, grunting, wheeze, stridor etc

CLINICAL CLASSIFICATION AND TREATMENT STRATEGIES IN PNEUMONIA:

AGE 0-2 MONTHS

SIGNS CLASSIFICATION TREATMENT PLAN

Normal respiratory rate No pneumonia Home remedies, continue

feeding, watch for signs of

severity

Increased respiratory rate Severe pneumonia Parenteral antibiotics

supportive

Increased respiratory rate and

chest indrawing

Very severe illness Start parenteral antibiotics /

refer to higher center

AGE 2 months -5 years

SIGNS CLASSIFICATION TREATMENT PLAN

Normal respiratory rate No pneumonia Home remedies, continue

feeding, watch for signs of

severity

Increased respiratory rate pneumonia Cotrimoxazole at home or

Center

Increased respiratory rate and

chest indrawing

Severe pneumonia Start parenteral antibiotics

Other signs/ symptoms of

severity

Very severe disease Start parenteral antibiotics /

refer to higher center


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MANAGEMENT:

A. TREATMENT OF PNEUMONIA

Cotrimoxazole is the drug of choice, the dosages as below:

Age/ weight Pediatric tablet 100S+20T Pediatric syp 100S+20T per 5 ml

2-12 mo or 6-9 kg 2 tablets twice a day 5ml twice a day

1-5 yr or 10-19 kg 3 tab twice a day 7.5 ml twice a day

Daily for 5 days

Reassess after 48 hrs, if no improvement or worsening continue 2 more days, sos hospitalize

if worsening.

B. TREATMENT OF SEVERE PNEUMONIA

ANTIBIOTIC DOSE INTERVAL ROUTE

First 48 hrs

Benzyl penicillin or 50000U/kg /dose 6 hrly IM

Ampicillin 50mg/kg/dose 6 hrly IM

Chloramphenicol 25mg/kg/dose 6 hrly IM

If improved give next 3 days the following

Procain penicillin 50000U/kg/dose Once IM

Ampicillin 50mg/kg/dose 6 hrly IM

Chloramphenicol 25/mg/kg/dose 6 hrly IM

If no improvement after total 5 days, change the antibiotic

Ampicillin to be changed to chloramphenicol

Chloramphenicol to be changed to cloxacillin 25/mg/kg/dose 6 hourly with gentamicin

2.5mg/kg/dose 8 hrly, if imnproved - orally

C. symptomatic treatment for fever and wheezing

D. monitor fluids and intake

E. advise mother on home management

Treat with antibiotics for 5 days, and then continue for 3 days after recovery, if cloxacillin or

gentamicin is used, give for 3 weeks.

F. Treatment of very severe pneumonia

Treat in FRU or district hospital. Chloramphenicol IM is the drug of choice.Treat 48 hours, if

improved switch to oral chloramphenicol. If worsens, IM clox and gentamicin.

PNEUMONIA in LESS THAN 2 MONTH AGE :Treat as severe pneumonia, hospitalize.

Antibiotic (injections) Dose Age < 7 days 7 days to 2 months

Benzyl penicillin or 50000U/kg /dose 12 hrly 6 hrly

Ampicillin 50mg/kg/dose 12 hrly 6 hrly

Gentamicin 2.5 mg/kg/dose 12 hrly 6 hrly


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MANAGEMENT OF NO PNEUMONIA

No antibiotics

Home care, continue feeding, nasal saline drops, home made remedies,

No cough syrups

Watch for signs of pneumonia.

References:

1. National Child survival and safe motherhood program. Program interventions guidelines,

MCH Division, Ministry of Health, Govt of India, New Delhi, 1994.

2. IAP textbook of Pediatrics,Ist ed,5-6


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Essential drug list for office practice (PEDIATRICS)

Class Drug Dose Comments

NSAIDS salicylates 100-120mg/kg/day

Orally

In rheumatic

disease

Paracetamol 15/mg/kg/dose PO For fever, pain

Ibuprofen 10-30mg/kg/day Analgesic, oral

Penicillins Benzyl penicillin 50000u /kg/dose 6 hrly

Benzathine penicillin 1.2 MU IM RHD

prophylaxis

Procaine penicillin G 50000u /kg/dose 6 hrly

Cloxacillin/oxacillin/ampicillin 50-100mg/kg/day PO/IV as

applicable

Amoxicillin 25-50mg/kg/day 6 hrly

Piperacillin 100-300mg/kg/day

IV

8 hrly

Cephalosporins Cephalexin 25-50mg/kg/day 6 hrly

Cephazoline 25-50 mg/kg/day 8hrly

Cefadroxil 30mg/kg/day 12 hrly

Cefaclor 20-40mg/kg/day 6 hrly

Cefuroxime 30-100mg/kg/day IM/IV 8hrly

Cefotaxime 100-150mg/kg/day 8-12 hrly

Ceftriaxone 100mg/kg/day 12 hrly

Aminoglycosides Streptomycin 40mg/kg/day IM 12 hrly

Amikacin 15 mg/kg/day IM/IV 8 hrly

Gentamicin 4-8mg/kg/day IM IV 12 hrly

Tetracycline Tetracycline 25-50mg/kg/day 6 hrly

Doxycycline 1.5 - 2mg/kg/day 12 hrly

Macrolides Erythromycin 50mg/kg/day 6-8 hrly

Azithromycin 10mg/kg/day Once a day

Lincosamides Clindamicin 10-40mg/kg/day 6 hrly

Polymixin Colistin 3.5mg/kg/day 8hrly

Septran Septran 6mgT/kg/day 12 hrly

Quinolones Nalidixic acid 60mg/kg/day 6hrly

Norfloxacin 10-20mg/kg/day 12 hrly

ciprofloxacin 10-20mg/kg/day 12 hrly

Antifungals Amphotericin B Max 1mg/kg/day Slowly raise the

dose from 0.1

Ketoconazole 3-6mg/kg/day Single dose

clotrimazole Local application 5 times a day

Antimalarials Chloroquine 10mg/kg/dose load Then

5mg/kg/dose

12hrly

Artesunate 3.5mg/kg/dose Loading, then

2mg/kg/dose 12

hrly

mefloquine 15mg/kg/dose single dose

Quinine suphate 25mg/kg/day

orally

8 hrly


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Sulfadoxine pyrimethamine 20mg/kg of

sulfadoxine

Single dose

orally

Antiprotozoal Chloroquine 10mg/kg/day 8 hrly 10-21 days

Furazolidone 5-8mg/kg/day 8hrly

Metronidazole 10-50mg/kg/day 8 hrly

Antivirals Acyclovir 5ml/kg/dose 8 hrly for 10

days

Antiemetics Domperidone 0.3 mg/kg/dose 8 hrly

Antihistaminics Astemizole 2mg/10kg BW OD

Chlorpheniramine 0.5mg/kg/day 8 hrly

Cyproheptadine 0.25mg/kg/day 8 hrly

Antituberculous Isoniazid 5mg/kg/dose Daily morning,

single dose

Rifampicin 10mg/kg Daily morning,

single dose

Ethambutol 20mg/kg/day

Pyrazinamide 25mg/kg/day

Antiasthmatics Salbutamol 0.15mg/kg/dose Oral or

nebulisation

Terbutalin 0.005 to

0.01mg/kg/dose

Subcutaneus

injection

Aminophylline 2-5 mg/kg bolus

Cardiac Digoxin 0.01mg/kg/dose Maintenance

dose

Reference:

1. Rational drug therapy in children, Essential Pediatrics, Ghai O. P., 3rd edition, 420-428


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CALCIUM PREPARATIONS

Calcium is one of the most important elements in the diet because it is a structural component of

bones, teeth, and soft tissues and is essential in many of the body's metabolic processes

Recommended daily intake (of elemental calcium)

Infants 0–6 months 400 mg

6–12 month 600 mg

children 1–10 years 800 mg

11–24 years 1,200 mg

Over 24 years 800 mg

Pregnant women 1,200 mg

Prophylactic dose/ maintenance 60-100 mg/kg/day

Sources = Dairy products, meats, and some seafood (sardines, oysters) are excellent sources of

calcium. Spinach, beet greens, beans, and peanuts are among the best plant-derived sources.

THERAPEUTIC DOSE=100-200 mg/kg/day, of elemental calcium.

CALCIUM COMPOUNDS:

Calcium carbonate and phosphate preparations have the highest concentration of elemental

calcium - about 40%. Calcium carbonate is found in preparations such as Tums, Os-Cal, and

Citrate. The elemental calcium content of calcium citrate is 21%, of calcium lactate 13%, and of

calcium gluconate, 9%.

VIT-D Vitamin D is required for calcium absorption. (RDA= 200-400 IU/day)

VIT-D supplements in Rickets-

Stoss’s regime= inj vitamin D, 6 lac IU given PO, on Day-1 and Day 14

THERAPEUTIC DOSE=100-200 mg/kg/day, of elemental calcium

What increases calcium absorption?

Acidic conditions in the intestine- Calcium carbonate needs to be taken with meals, as the acidity

of the stomach is greater when food is being digested. This acidic environment allows for its

absorption. Calcium citrate, however, is absorbed more efficiently than calcium carbonate on an

empty stomach, so it needs to be taken between meals.

VIT-D Vitamin D is required for calcium absorption.


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What decreases calcium absorption?

Oxalic acid, phytates, dietary fibers, laxatives, Great excesses of the minerals phosphorous and

magnesium in proportion to calcium Tannins in tea – decreases calcium absorption.

Avoid taking calcium at the same time as Tetracycline , iron supplements, thyroid hormones, or

corticosteroids, because calcium binds to these substances, interfering with their effectiveness and

also its own absorption.

References:

1. Nelson textbook of Pediatrics

2. Drug Index

3. http://dietary-supplements.info.nih.gov/factsheets/calcium.asp

http://dietary-supplements.info.nih.gov/factsheets/calcium.asp


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Iron preparations (only Pediatric preparations)

An iron deficient diet is a common cause of iron deficiency. Other common causes are top fed

babies- because cow’s milk does not contain iron and inhibits absorption of iron, worm

infestations.,from blood loss in stool from a problem in the intestines.

A common time for iron deficiency is between 9 and 24 months of age. Babies born prematurely

are at risk. The adolescent growth spurt is another high-risk period.

Symptoms Pale skin color (pallor) Fatigue Irritability Weakness Shortness of breath, Unusual

food cravings (called pica) ,Decreased appetite (especially in children) Iron deficiency is

associated with a high risk of long-term impairment in mental and motor development. They also

suffer from lower scores in IQ test, lack of concentration, short attention span and easy

distractibility.

Type

of

iron

Relative

biological

value

%age

absorption

Elementa

l

Iron (mg)

Pack

(ml)

Shelf life

(years)

Cost for

100 mg

elemental

iron (Rs.)

Drops

IPC – 46.6% 50/ml 10 2 4

Colloidal

Iron

– – 25/ml 15 1 7.2

Ferrous

Glycine

Sulphate

– – 7.8/ml 30 2 5.4

Syrup

Fer.

Ammonium

citrate

86 15.5% 20/ml 15 2 6

Iron (III)

Polymaltose

Complex

(IPC)

–

46.54%

50/5 ml

150

2

2

Ferrous

fumarate

93 – 33/5 ml 200 1.5 2.5

Colloidal

Iron

– – 80/5 ml 200 1 2

Ferrous

Sulph

100 47.74% 33.4/5 ml 100 1.5 2

Ferrous

glycine

sulphate

– – 50 /5ml 200 2 3

Carbonyl

iron

70 – 50 /5 ml 200 2 1.8

http://www.nlm.nih.gov/medlineplus/ency/article/003244.htm







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Instructions :

Maintenance dose of iron supplements: 2mg/kg/day of elemental iron for 2 months.

Therapeutic dose of iron supplements: 6 mg/kg/day of elemental iron for 2 months.

Best absorbed on empty stomach and with vitamin –C,

Dietary fibers, cheese, yoghurt, coffee,tea, calcium salts decreases absorption.

Gastritis ,constipation, vomiting are common side effects.

Ref : “Iron Formulations in Pediatric Practice”, J. Nagpal, P.Choudhury, Indian

Pediatrics 2004; 41:807-815

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