Reference Range Values for Pediatric Care, 2nd Edition

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 iii

EDITOR
Lamia M. Soghier, MD, MEd, FAAP
Assistant Professor of Pediatrics
The George Washington University School of Medicine and
Health Sciences
Medical Director, Neonatal Intensive Care Unit
Children’s National Health System
Washington, DC

CONTRIBUTING EDITORS
Karen Fratantoni, MD, MPH, FAAP
Assistant Professor of Pediatrics
The George Washington University School of Medicine and
Health Sciences
Medical Director, Complex Care Program
Children’s National Health System
Washington, DC

Christine Reyes, MD, FCAP

Associate Chief, Pathology and Laboratory Medicine Division
Director of Chemistry, Point of Care Testing and Clinical Laboratory
Support Services
Children’s National Health System
Assistant Professor of Pediatrics and Pathology
The George Washington University School of Medicine and
Health Sciences
Washington, DC

ASSISTANT EDITOR
Kristin Mullins, PhD
Associate Director of Chemistry, Point of Care Testing, and Clinical
Laboratory Support Services
Children’s National Health System
Washington, DC
iv Reference Range Values for Pediatric Care

CONTRIBUTORS
Sarah Goff, RD, LD, CNSC
Pediatric Clinical Dietitian
Children’s National Health System
Washington, DC

Laura Leathers, PharmD, BCPPS

Clinical Pharmacy Specialist, CICU
Children’s National Health System
Washington, DC

Sara Rooney, PharmD, BCPS, BCPPS

PICU Clinical Pharmacy Specialist
Children’s National Health System
Washington, DC

Victoria C. Snelgrove, RD, LD, CNSC, CLC

Neonatal Intensive Care Unit Dietitian
Children’s National Health System
Washington, DC
 v

CONTENTS
Introduction...............................................................................................xiii

1. Conversions....................................................................................1
Conversion Formulas.............................................................................. 1
Temperature Conversion........................................................................ 1
Fahrenheit to Celsius Conversion...................................................... 2
Weight Conversion.................................................................................. 3
Newborn Weight Conversion Chart................................................. 3
Infant and Toddler Weight Conversion Chart.................................. 4

2. Scales and Scoring.........................................................................7

APGAR Score........................................................................................... 7
New Ballard Score................................................................................... 8
Pain Scales.............................................................................................. 10
Wong-Baker FACES Pain Rating Scale.......................................... 10
FLACC Pain Scale.............................................................................. 10
Neonatal Pain, Agitation, and Sedation Scale (NPASS) ............... 11
Pediatric Early Warning Score (PEWS).......................................... 16
Glasgow Coma Scale............................................................................. 17
Glasgow Coma Scale for Children.................................................. 17
Croup Score ........................................................................................... 18

3. Growth..........................................................................................19
Determining Body Surface Area.......................................................... 19
Growth Charts....................................................................................... 20
Average Growth Velocity by Age-group........................................ 20
Fenton Preterm Growth Chart—Boys............................................. 21
Fenton Preterm Growth Chart—Girls............................................. 22
WHO Birth to 24 Months: Boys—Head Circumference-
for-age and Weight-for-length Percentiles................................ 23
WHO Birth to 24 Months: Boys—Length-for-age and
Weight-for-age Percentiles.......................................................... 24
WHO Birth to 24 Months: Girls—Head Circumference-
for-age and Weight-for-length Percentiles................................ 25
WHO Birth to 24 Months: Girls—Length-for-age and
Weight-for-age Percentiles.......................................................... 26
vi Reference Range Values for Pediatric Care

CDC 2 to 20 Years: Boys—Stature-for-age and

Weight-for-age Percentiles.......................................................... 27
CDC 2 to 20 Years: Boys—Body Mass Index-for-age
Percentiles..................................................................................... 28
CDC 2 to 20 Years: Girls—Stature-for-age and
Weight-for-age Percentiles.......................................................... 29
CDC 2 to 20 Years: Girls—Body Mass Index-for-age
Percentiles..................................................................................... 30
Growth Charts for Children With Special Health Care Needs......... 31
Online Growth Charts....................................................................... 31
Growth Charts for Special Populations.......................................... 31
Growth Charts for Children With Down Syndrome,
Birth to 36 Months: Boys—Weight-for-age Percentiles........... 32
Growth Charts for Children With Down Syndrome,
Birth to 36 Months: Boys—Length-for-age Percentiles........... 33
Growth Charts for Children With Down Syndrome,
Birth to 36 Months: Boys—Head Circumference-
for-age Percentiles........................................................................ 34
Growth Charts for Children With Down Syndrome,
Birth to 36 Months: Boys—Weight-for-length Percentiles...... 35
Growth Charts for Children With Down Syndrome,
Birth to 36 Months: Girls—Weight-for-age Percentiles .......... 36
Growth Charts for Children With Down Syndrome,
Birth to 36 Months: Girls—Length-for-age Percentiles........... 37
Growth Charts for Children With Down Syndrome,
Birth to 36 Months: Girls—Head Circumference-for-
age Percentiles.............................................................................. 38
Growth Charts for Children With Down Syndrome,
Birth to 36 Months: Girls—Weight-for-length Percentiles...... 39
Height and Weight for Children With Cerebral Palsy....................... 40
Mid-upper Arm Circumference........................................................... 41
MUAC for Age, Boys 2 to 24 Months.............................................. 42
MUAC for Age, Boys 2 to 18 Years................................................. 43
MUAC for Age, Girls 2 to 24 Months.............................................. 44
MUAC for Age, Girls 2 to 18 Years.................................................. 45
 Contents vii

Pediatric Malnutrition Indicators......................................................... 46

Malnutrition Criteria When a Single Data Point Is Available....... 46
Malnutrition Criteria When 2 or More Data Points
Are Available................................................................................. 46
Growth Measures for Extremities and for Ear Above
   Eyeline Levels................................................................................ 47
Upper Arm (Shoulder to Elbow) Length......................................... 48
Forearm Length................................................................................. 49
Long-Bone Length—Upper Limb.................................................... 50
Long-Bone Length—Lower Limb.................................................... 51
Lower Leg (Knee to Ankle) Length.................................................. 52
Ear Above Eyeline Level (Gestational Age).................................... 53
Ear Above Eyeline Level (Birth Weight)......................................... 54
Mean Stretched Penile Length............................................................. 55
For Neonates...................................................................................... 55
For Children....................................................................................... 56
Primary Teeth Eruption Chart.............................................................. 57

4. Blood Pressure.............................................................................59
Blood Pressure Nomograms................................................................. 59
Healthy Term Newborns During the First 12 Hours
After Birth..................................................................................... 59
Preterm and Full-term Newborns During the First Day
After Birth (According to Birth Weight).................................... 60
Preterm and Full-term Newborns During the First Day
After Birth (According to Gestational Age).............................. 61
Preterm and Full-term Newborns According to Post
Conceptional Age......................................................................... 62
Children Younger Than 1 Year......................................................... 63
Blood Pressure Levels for Boys by Age and
   Height Percentile.......................................................................... 64
Blood Pressure Levels for Girls by Age and
   Height Percentile.......................................................................... 66
viii Reference Range Values for Pediatric Care

5. Laboratory Reference Range Values..........................................69

Cerebrospinal Fluid............................................................................... 70
Clinical Chemistry................................................................................. 73
For Infants, Children, Teens, and Young Adults............................ 73
For Newborns.................................................................................... 84
Thyroid Function Tests.......................................................................... 86
TSH, Total T3, Total T4, and Free T4 Values of Children.................. 86
Mean Thyroid-stimulating Hormone and Thyroxine
Values of Preterm and Term Newborns 0 to 28 Days............... 87
Growth Hormones................................................................................. 87
Hematology and Coagulation............................................................... 92
Hematology Values............................................................................ 92
   For Infants and Toddlers............................................................. 92
   For Children, Teens, and Young Adults..................................... 94
Age-Specific Leukocyte Differential................................................ 96
   For Infants and Toddlers............................................................. 96
   For Children and Teens............................................................... 98
Lymphocyte Subset Counts in Peripheral Blood............................ 99
Coagulation Values.............................................................................. 102
Age-Specific Coagulation Values—Healthy Preterm Infants
(30–36 Weeks)............................................................................. 102
Age-Specific Coagulation Values—Healthy, Full-term
Infants ......................................................................................... 105
Age-Specific Coagulation Values—Childhood Compared
With Adults................................................................................. 107

6. Hyperbilirubinemia Management............................................109
Risk Nomogram................................................................................... 109
Phototherapy Nomogram................................................................... 110
Exchange Transfusion Nomogram.................................................... 111

7. Rate and Gap Calculations........................................................113

Glucose Infusion Rate......................................................................... 113
Calculated Serum Osmolality ............................................................ 113
Anion Gap ........................................................................................... 113
 Contents ix

8. Nutrition and Formula Information.........................................115

Preparation of Infant Formula for Standard and
Soy Formulas.............................................................................. 115
Common Modular Supplements........................................................ 116
Enteral Formulas, Including Their Main ­Nutrient
   Components................................................................................ 117
Composition of Fluids Frequently Used in Oral ­Rehydration........ 125
Fluid Needs by Weight (Holliday-Segar Method)............................ 125
Common Electrolyte Additives.......................................................... 125
Dietary Reference Intakes (DRIs)....................................................... 126
DRIs for Age: Energy and Protein................................................. 126
   Infants and Toddlers.................................................................. 126
   Children and Adolescents......................................................... 126
Daily Requirements DRIs for Age: Macronutrients
and ­Micronutrients.................................................................... 127
Fluoride Sources and Supplementation............................................ 130
Topical Fluoride Sources................................................................. 130
Dietary Fluoride Supplementation Schedule................................ 130

9. Umbilical Vein and Artery ­Catheterization Measurements....131

Using Birth Weight to Measure Catheter Length............................ 131
Estimate of Insertional Length of Umbilical Catheters
Based on Birth Weight With 95% Confidence Intervals........ 132
Using Shoulder-Umbilical Length to Measure ­Umbilical
   Artery Catheter Length.............................................................. 133
Umbilical Artery Catheter Length................................................. 133
Using Shoulder-Umbilical Length to Measure ­Umbilical
   Vein Catheter Length................................................................. 134
Umbilical Vein Catheter Length..................................................... 134
x Reference Range Values for Pediatric Care

10. Endotracheal Tube Size and Depth of Insertion...................135

Neonatal ............................................................................................ 135
Neonatal Endotracheal Tube Size According to
    Gestational Age and Weight................................................. 135
Neonatal Endotracheal Tube Depth of Insertion
    According to Gestational Age and Weight.......................... 135
Pediatric............................................................................................. 136
Tube Size...................................................................................... 136
Depth of Insertion...................................................................... 136

11. D
 oses and Levels of C ­ ommon ­Medications
Requiring ­Therapeutic Drug Monitoring..............................137
Antibiotics......................................................................................... 138
Amikacin..................................................................................... 138
Gentamicin.................................................................................. 140
Tobramycin................................................................................. 142
Vancomycin................................................................................. 144
Anticonvulsants................................................................................ 146
Fosphenytoin.............................................................................. 146
Levetiracetam (Keppra)............................................................. 148
Phenobarbital.............................................................................. 150
Valproic Acid and Derivatives.................................................. 152
Miscellaneous.................................................................................... 153
Digoxin........................................................................................ 153
Enoxaparin.................................................................................. 155
Warfarin...................................................................................... 156

12. Appendixes..............................................................................157
Acetaminophen Toxicity Nomogram............................................. 158
Rabies Guidelines............................................................................. 159
Rabies Postexposure Prophylaxis Schedule—
    United States, 2010................................................................. 159
Immunization Schedules.................................................................. 160
Recommended Immunization Schedule for
    Children and Adolescents Aged 18 Years
    or Younger—United States, 2018.......................................... 160
 Contents xi

Catch-up Immunization Schedule for Persons

    Aged 4 Months–18 Years Who Start Late or
    Who Are More Than 1 Month Behind—
    United States, 2018................................................................. 162
Vaccines That Might Be Indicated for Children
    and Adolescents Aged 18 Years or Younger
    Based on Medical Indications............................................... 163
Bright Futures/American Academy of Pediatrics
   Recommendations for Preventive Pediatric
   Health Care (Periodicity Schedule)..............................See insert.
French Catheter Scale..........................................................See insert.
 xiii

INTRODUCTION
Reference Range Values for Pediatric Care was created in response
to an overwhelming need from pediatricians, pediatric residents,
nurse practitioners, pediatric nurses, and other pediatric providers
who acknowledged the utility of the Reference Range Values section
in the first edition of Quick Reference Guide to Pediatric Care, part of
the American Academy of Pediatrics (AAP) point-of-care offerings,
which also include the American Academy of Pediatrics Textbook of
Pediatric Care and Pediatric Care Online.
This handbook was designed with the busy practitioner in mind.
Compact and clear-cut, it provides the most commonly used ref-
erence range values, charts, and formulas at your fingertips. The
values span the gamut of age-groups, from newborn to adolescence,
with a particular emphasis on the values needed for the treatment
of preterm newborns younger than 37 weeks’ gestation. This focus
is complemented by sections that address common newborn scores
(eg, APGAR Score, New Ballard Score) as well as the AAP new-
born hyperbilirubinemia management charts. In this new (second)
edition, sections on antibiotics and anticonvulsant medications have
been expanded and now also include other commonly used drugs
with ­recommended serum drug target levels; preterm and neonatal
populations continue to be highlighted to assist any pediatrician
responsible for the complex dosing for this age-group. Two experi-
enced pediatric pharmacists, Laura Leathers, PharmD, BCPPS, and
Sara Rooney, PharmD, BCPS, BCPPS, have reviewed and revised this
section. In addition, 2 pediatric/neonatal dietitians, Sarah Goff, RD,
LD, CNSC, and Victoria C. Snelgrove, RD, LD, CNSC, CLC, provide
current reference ranges for nutritional requirements for growing
infants, toddlers, children, and adolescents. The handbook continues
to feature pain scales, growth measures for extremities, and the AAP
immunization and periodicity schedules.
In writing the second edition of Reference Range Values for
Pediatric Care, we would like to thank Carrie Peters, Mark Grimes,
and the AAP editorial team. We would also like to give a spe-
cial thanks to Andrea Estrada, MD (pediatric endocrinology), at
Children’s National Health System for her contribution to the text.
xiv Reference Range Values for Pediatric Care

As we strive to improve the health of all children, we hope this

book is another little step to that end.

Lamia M. Soghier, MD, MEd, FAAP

Karen Fratantoni, MD, MPH, FAAP
Christine Reyes, MD, FCAP
1. Conversions
CONVERSION FORMULAS
Height (Length)
1 mm = 0.04 in 1 in = 2.54 cm
1 cm = 0.4 in 1 m = 39.37 in
Weight
28.35 g = 1 oz 1 L = 1.06 qt
453.6 g = 1 lb 1 fl oz = 29.57 mL
1,000 g = 1 kg 1 tbsp = 15 mL
1 kg = 2.2046 lb 1 tsp = 5 mL
Milligram and Milliequivalent Conversions
mEq/L = [(mg/L) × valence]/atomic weight mg/L = [(mEq/L) × atomic
Equivalent weight = atomic weight/valence weight]/valence
Milligram and Millimole Conversions
mmol/L = (mg/L)/molecular weight
Milliosmoles
The milliequivalent (mEq) is roughly equivalent to the milliosmole (mOsm), that is,
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.

TEMPERATURE CONVERSION
Celsius: °C = (5/9) × (°F − 32)
Fahrenheit: °F = (9/5) × (°C + 32)