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1st peer: Table 1: Rome IV Criteria for Functional Constipation in Infants and Children
Criteria
Description
Frequency
At least once per week for at least 1 month
Stool Consistency
Hard or lumpy stools that are difficult to pass
Painful Defecation
Pain or discomfort associated with passing stools
Large Stool Volume
Parents report passage of large stools that clog the toilet or require digital evacuation
Stool Retentive Posture
Child may withhold stool or adopt unusual postures to avoid defecation
Maaks, D., Starr, N., Gaylord, N. (2019). Burns’ Pediatric Primary Care, 7th Edition. [VitalSource Bookshelf version]. Retrieved from vbk://9780323581967
Possible Physiologic and Psychosocial Factors Related to Encopresis
Physiologic Factors
Psychosocial Factors
1. Low-fiber diet
1. Stress or anxiety
2. Dehydration
2. Changes in routine
3. Delayed toileting skills
3. Family dynamics
4. Intestinal motility disorders
4. Trauma or abuse history
5. Medication side effects
5. Parental attitudes toward toilet training
Maaks, D., Starr, N., Gaylord, N. (2019). Burns’ Pediatric Primary Care, 7th Edition. [VitalSource Bookshelf version]. Retrieved from vbk://9780323581967
Table 2: Neonatal Jaundice
Jaundice Appears
Jaundice Disappears
Peak Bilirubin Concentration (days)
Diagnostic Studies
Management and Prevention
Physiologic
Within the first few days after birth
Typically within 1 to 2 weeks after birth
Usually occurs around day 3 to day 5 after birth
Bilirubin level measurement, sometimes blood type tests
Phototherapy, breastfeeding, monitoring
Full-term
Within the first few days after birth
Typically within 1 to 2 weeks after birth
Usually occurs around day 3 to day 5 after birth
Bilirubin level measurement, sometimes blood type tests
Phototherapy, breastfeeding, monitoring
Premature
Within the first few days after birth
Typically within 1 to 2 weeks after birth
Usually occurs around day 3 to day 5 after birth
Bilirubin level measurement, sometimes blood type tests
Phototherapy, breastfeeding, monitoring
Maaks, D., Starr, N., Gaylord, N. (2019). Burns’ Pediatric Primary Care, 7th Edition. [VitalSource Bookshelf version]. Retrieved from vbk://9780323581967
Table 3: Breastfeeding, Infant Nutrition, Postpartum Depression
Question
Answer
1. American Academy of Pediatrics recommendation for breastfeeding?
Exclusive breastfeeding for the first 6 months, then continued breastfeeding with complementary foods up to 1 year or longer.
2. Common weight loss percentage after birth?
Around 5-10%
3. Newborns should regain birth weight by?
By 2 weeks of age
4. What do the Letters PURPLE stand for?
Peak, Unexpected, Resists Soothing, Pain-like Face, Long-lasting, Evening crying
5. Birth weight at 6 months and 12 months?
Birth weight is typically doubled by 6 months and tripled by 12 months
6. Percentage of mothers experiencing “baby blues”?
Around 70-80%
7. Screening tool/scale for perinatal depression?
Edinburgh Postnatal Depression Scale (EPDS)
8. Daily dose for vitamin D in an infant?
400 IU
9. Breast milk or formula calories per ounce?
Approximately 20 calories per ounce
10. When can infants start solid foods?
Around 6 months of age
11. Principles for introduction of solids?
Gradual introduction, single-ingredient foods, watch for allergic reactions, avoid added sugar and salt, monitor texture and consistency
12. Avoidance of cow’s milk and why?
Until 1 year old due to risk of allergy and difficulty digesting
13. Clinical findings of dehydration in infants?
Sunken fontanelle, decreased urine output, dry mucous membranes, lethargy
Maaks, D., Starr, N., Gaylord, N. (2019). Burns’ Pediatric Primary Care, 7th Edition. [VitalSource Bookshelf version]. Retrieved from vbk://9780323581967
Table 4: Common Infectious Diseases in Children
Name
Clinical Features
Differential Diagnoses
Treatment/Management
Herpes Simplex Virus
Fever, painful blisters on lips or genitals
Impetigo, Hand, foot, and mouth disease
Antiviral medications, supportive care
Mononucleosis
Fever, sore throat, swollen lymph nodes
Streptococcal pharyngitis
Supportive care, rest, pain management
Roseola Infantum
High fever followed by rash
Measles, Rubella
Supportive care, antipyretics for fever
Varicella
Itchy rash, fever, fatigue
Measles, Scabies
Antiviral medications (acyclovir), supportive care
Influenza
Fever, cough, sore throat, body aches
Common cold, COVID-19
Antiviral medications (oseltamivir), supportive care
Measles (Rubeola)
High fever, cough, runny nose, rash
Rubella, Scarlet fever
Supportive care, vitamin A supplementation
Mumps
Swollen salivary glands, fever, headache
Parotitis, Epstein-Barr virus
Supportive care, pain management, MMR vaccination (prevention)
Erythema Infectiosum (Fifth disease)
Slapped cheek rash, fever, flu-like symptoms
Rubella, Scarlet fever
Supportive care, antipyretics for fever
Rubella
Mild fever, rash, swollen lymph nodes
Measles, Scarlet fever
Supportive care, MMR vaccination (prevention)
Maaks, D., Starr, N., Gaylord, N. (2019). Burns’ Pediatric Primary Care, 7th Edition. [VitalSource Bookshelf version]. Retrieved from vbk://9780323581967
Table 5: Fundamental Principles of Prescribing Medication for Pediatric Patients
Principle
Description
1. Age and Weight Appropriateness
Dosage and formulation should be suitable for the child’s age and weight
2. Pharmacokinetics and Pharmacodynamics
Consideration of how medications are absorbed, metabolized, and excreted in children’s bodies
3. Safety and Efficacy
Balance between potential benefits and risks, with careful consideration of adverse effects
4. Formulation and Administration
Selection of appropriate formulations and routes of administration for pediatric patients
Maaks, D., Starr, N., Gaylord, N. (2019). Burns’ Pediatric Primary Care, 7th Edition. [VitalSource Bookshelf version]. Retrieved from vbk://9780323581967
Case Scenario 1: Russell is a 7-year-old boy who weighs 50 pounds. He is frequently teased at school because he soils his pants and is called the “stinky kid” by his peers. His mother states that this has been occurring for the past 8 months. She brought him into the clinic because she thinks he might have an intestinal infection. She also reports that once a week he has very large bowel movements that completely clog the toilet.
What more does the APRN need to know about Russell’s bowel problems?
To gain a comprehensive understanding of Russell’s bowel problems, the APRN should delve into various aspects of his health and lifestyle. Firstly, obtaining a detailed medical history is crucial, encompassing any previous episodes of constipation or bowel issues, underlying medical conditions, and recent illnesses or infections. Russell’s dietary habits should be explored next, including his intake of fiber-rich foods, water consumption, and recent changes in diet. His toileting routine should also be examined, including the frequency of bowel movements, any difficulties or pain experienced during bowel movements, and any strategies or behaviors he employs to manage them. Assessing Russell’s family history for any instances of bowel disorders or other gastrointestinal conditions is important. Additionally, exploring potential psychosocial factors, such as stress, anxiety, or bullying at school, may provide valuable insights into the underlying causes of his symptoms.
What type of diagnostic testing should the APRN order?
In terms of diagnostic testing, the APRN should consider a multifaceted approach. A thorough physical examination, including abdominal palpation to assess for signs of abdominal tenderness or distention, is essential. Stool studies should be ordered to evaluate for the presence of any infectious agents, such as bacteria, parasites, or viruses, that may be contributing to Russell’s symptoms. This may involve stool cultures and testing for ova and parasites. Imaging studies, such as abdominal X-rays or ultrasound, may be necessary to assess for structural abnormalities or signs of constipation, such as fecal impaction. Depending on the clinical presentation, additional laboratory tests may also be indicated to assess for underlying metabolic or hormonal imbalances.
What treatment plan should the APRN prescribe and what is the rationale for this treatment? Include dosages and administration instructions if appropriate.
As for the treatment plan, if Russell is diagnosed with constipation, the APRN may recommend dietary modifications, increased fluid intake, and regular toileting routines to promote regular bowel movements. This may involve increasing fiber intake through fruits, vegetables, and whole grains, and ensuring adequate hydration. In cases of severe constipation or fecal impaction, stool softeners or laxatives, such as polyethylene glycol (PEG) or lactulose, may be prescribed to facilitate bowel movements. Dosages and administration instructions will be tailored to Russell’s age, weight, and severity of symptoms. Behavioral interventions, such as counseling or addressing underlying stressors, may also be recommended if psychosocial factors are contributing to his symptoms. Clear instructions for follow-up and monitoring should be provided to Russell and his mother, including when to seek medical attention if his symptoms worsen or do not improve with treatment.
2nd peer: Week 2 Discussion Part I
Table 1
What is the Rome IV criteria for functional constipation in infants and children?
The Rome IV criteria for functional constipation in infants and children entail the presence of at least two of the following symptoms persisting for a minimum of one month: two or fewer defecations weekly, fecal incontinence occurring at least once weekly after toilet training, retentive posturing or excessive stool retention, history of painful or hard bowel movements, presence of a large fecal mass in the rectum, or history of large-diameter stools. Additionally, organic disorders like Hirschsprung disease must be excluded. These criteria serve as a guideline to accurately diagnose functional constipation and distinguish it from constipation stemming from underlying medical issues.
Muhardi, L., Aw, M. M., Hasosah, M., Ng, R. T., Chong, S. Y., Hegar, B., Toro-Monjaraz, E., Darma, A., Cetinkaya, M., Chow, C. M., Kudla, U., & Vandenplas, Y. (2022). A narrative review on the update in the prevalence of infantile colic, regurgitation, and constipation in young children: Implications of the ROME IV criteria. Frontiers in Pediatrics, 9, 778747. Links to an external site.https://doi.org/10.3389/fped.2021.778747Links to an external site.
List possible physiologic and psychosocial factors related to encopresis
Physiologic
Psychosocial
1. Chronic constipation, characterized by persistent difficulty in passing stools, can lead to fecal impaction and subsequent encopresis.
1. Emotional stress, stemming from stressful life events such as family conflict, divorce, school problems, or abuse, can trigger or exacerbate encopresis.
2. Delayed toilet training, which refers to inadequate or delayed training in using the toilet, can contribute to the development of encopresis.
2. Anxiety, whether related to anxiety disorders or specific anxieties about toileting, such as fear of using public restrooms, can contribute to encopresis.
3. Bowel dysfunction, including issues such as abnormal bowel motility or sensation, can disrupt regular bowel movements and contribute to encopresis.
3. Parental reactions, such as overly punitive or critical responses to soiling accidents, can increase anxiety and worsen encopresis.
4. Dietary factors, such as poor diet, low fiber intake, and inadequate fluid consumption, can lead to constipation and fecal retention, increasing the risk of encopresis.
4. Trauma, including experiences of physical or sexual abuse, can contribute to encopresis through the development of psychological issues or dysfunctional coping mechanisms.
5. Medical conditions, including Hirschsprung’s disease, spinal cord abnormalities, or neurological disorders, can affect bowel function and increase the likelihood of encopresis.
5. Environmental factors, such as disruptions in routine, changes in living situations, or lack of access to appropriate toileting facilities, can impact bowel habits and contribute to encopresis.
Yilanli, M., & Gokarakonda, S. B. (2023). Encopresis. In StatPearls. StatPearls Publishing.
Table 2
Neonatal Jaundice
Jaundice Appears
Jaundice Disappears
Peak Bilirubin Concentration (days)
Diagnostic Studies
Management and Prevention
Physiologic
Typically, it appears after 24 hours of age.
Usually, it resolves by the end of the first week.
Peak bilirubin concentration occurs around day 3 to day 5.
Generally diagnosed clinically, but may include bilirubin level measurement if necessary.
No specific treatment is needed; frequent breastfeeding or feeding helps eliminate bilirubin, and phototherapy may be used in severe cases.
Full-term
Typically, it appears after 24 hours of age.
Usually, it resolves within two weeks.
Peak bilirubin concentration occurs around day 3 to day 5.
Bilirubin level measurement if jaundice persists or appears severe.
Management involves frequent feeding and monitoring; phototherapy may be used in severe cases. Prevention includes ensuring adequate intake and monitoring for signs of jaundice.
Premature
It may appear within the first 24 hours but typically within the first few days.
It may take longer to resolve compared to full-term infants, usually within two to three weeks.
Peak bilirubin concentration may occur later than in full-term infants, around day 5 to day 7.
Bilirubin level measurement and possibly other tests to determine the cause of jaundice.
Management involves close monitoring, frequent feeding, phototherapy if bilirubin levels are high, and addressing any underlying medical conditions contributing to jaundice. Prevention may include early feeding initiation and close monitoring of bilirubin levels in premature infants.
Ansong-Assoku, B., Shah, S. D., Adnan, M., & Ankola, P. A. (2023). Neonatal jaundice. In StatPearls. StatPearls Publishing.
Table 3
Breastfeeding, Infant Nutrition, Postpartum Depression
Complete the information requested.
1. What is the American Academy of Pediatrics recommendation for breastfeeding?
The American Academy of Pediatrics recommends exclusive breastfeeding for the first six months of a baby’s life, followed by continued breastfeeding along with the introduction of complementary foods until at least 12 months of age, and continuation of breastfeeding for as long as mutually desired by the mother and baby.
2. How much weight loss is common after birth – what percentage? ________
7% to 10% of their birth weight within the first few days.
3. Newborns should regain birth weight by ______ (when?)
two weeks of age
2. What do the Letters PURPLE stand for:
The peak of crying, Unexpected, Resists soothing, Pain-like face, Long lasting, Evening
3. Birth weight _________ at six months and _______ at 12 months.
double birth weight at six months and triple at12 months
4. How does one distinguish caput succedaneum and cephalohematoma? What percentage of mothers experience” “baby blue” after birth?
Caput succedaneum is a diffuse swelling of the scalp, typically caused by pressure exerted on the baby’s head during labor and delivery. It often crosses suture lines and can be identified by its soft, puffy appearance. Caput succedaneum usually resolves on its own within a few days after birth.
Cephalohematoma is a collection of blood between the skull and the periosteum (the membrane covering the bones). Unlike caput succedaneum, cephalohematoma does not cross suture lines and feels like a firm lump on the baby’s head. It’s usually caused by trauma during delivery, such as the use of forceps or vacuum extraction. Cephalohematoma may take weeks or even months to resolve as the body gradually reabsorbs the blood.
5. What percentage of mothers experience” “baby blue” after birth?
About 70% to 80% of mothers experience” “baby blue” after giving birth. This is a temporary and mild mood disturbance characterized by feelings of sadness, anxiety, irritability, and mood swings. It typically peaks around the fourth or fifth day after birth and resolves on its own within a couple of weeks.
6. What screening tool/scale is used to identify mothers at risk for perinatal depression?
The screening tool/scale commonly used to identify mothers at risk for perinatal depression is the Edinburgh Postnatal Depression Scale (EPDS). It consists of ten questions designed to screen for depressive symptoms experienced during the perinatal period.
7. What is the daily dose of vitamin D in an infant? Breast milk or formula contains________ calories per ounce?
400
8. Breast milk or formula contains________ calories per ounce?
20 calories per ounce
9. When can infants start solid foods?
six months of age
10. What are the five principles for the introduction of solids into an infant’s diet?
Introduce solid foods around six months of age, when the baby shows signs of readiness, such as being able to sit with support and showing interest in food.
Offer a variety of foods to expose the baby to different flavors and textures, starting with single-ingredient purees and gradually introducing more complex combinations.
Begin with smooth purees and gradually increase the texture as the baby becomes more accustomed to eating solids, preventing choking and promoting chewing and swallowing skills.
Ensure foods are prepared and served safely to prevent choking hazards, avoid small, hard foods, and supervise the baby during feeding.
Please pay attention to the baby’s hunger and fullness cues, allowing them to lead the feeding process and explore different foods at their own pace.
11. How long should newborns avoid cow’s milk and why?
first year
12. What are the clinical findings of dehydration in infants?
● Decreased urine output or fewer wet diapers than usual.
● Dry mouth and lips.
● Sunken fontanelle (soft spot on the baby’s head).
● Sunken eyes with dark circles around them.
● Irritability or lethargy.
● Poor skin turgor (skin that does not spring back when gently pinched).
● Rapid breathing or heart rate.
● Cool or mottled skin.
Office of the Surgeon General (US); Centers for Disease Control and Prevention (US); Office on Women’s Health (US). (2011). The Surgeon General’s call to action is to support breastfeeding. Rockville (MD): Office of the Surgeon General (US). Available from: Links to an external site.https://www.ncbi.nlm.nih.gov/books/NBK52687/Links to an external site.
Patel JK, Rouster AS. (2023). Infant nutrition requirements and options. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: Links to an external site.https://www.ncbi.nlm.nih.gov/books/NBK560758/Links to an external site.
Suryawanshi, O., 4th, & Pajai, S. (2022). A comprehensive review on postpartum depression. Cureus, 14(12), e32745. Links to an external site.https://doi.org/10.7759/cureus.32745Links to an external site.
Table 4
Common Infectious Diseases in Children
Complete the table
Name
Clinical Features
Differential Diagnoses
Treatment/Management
Herpes Simplex Virus (Whitley & Baines, 2018)
Presents with painful vesicular lesions on the lips or genitalia, often preceded by a tingling or burning sensation.
Oral or genital ulcers due to other causes such as aphthous stomatitis or syphilis.
Antiviral medications like acyclovir or valacyclovir can help shorten the duration and severity of symptoms. Pain management and supportive care are also critical.
Mononucleosis (Mohseni et al., 2023)
Fever, sore throat, swollen lymph nodes, fatigue, and sometimes a rash following antibiotic use.
Streptococcal pharyngitis, cytomegalovirus (CMV) infection, HIV seroconversion illness.
Symptomatic treatment with rest, hydration, and pain relievers. Avoidance of contact sports due to the risk of splenic rupture in some cases.
Roseola Infantum (Exanthem Subitum) (Pippin & Laws, 2024)
High fever followed by a rash, usually on the trunk, which may spread to the extremities.
Measles, rubella, and other viral exanthems.
Supportive care for fever and hydration. Antipyretics like acetaminophen or ibuprofen can help manage fever.
Varicella (Kennedy & Gershon, 2018)
It is characterized by an itchy rash starting on the trunk and spreading to the extremities, along with fever and malaise.
Other viral exanthems, such as measles or rubella.
Symptomatic treatment with antiviral medications (acyclovir) and antipyretics for fever. Calamine lotion or oatmeal baths can soothe itching.
Influenza (Boktor & Hafner, 2023)
Sudden onset of fever, chills, headache, muscle aches, sore throat, cough, and fatigue.
Other viral respiratory infections, such as respiratory syncytial virus (RSV) or adenovirus.
Antiviral medications (oseltamivir, zanamivir), if started early in the course of illness, supportive care for symptom relief.
Measles (Rubeola) (Krawiec & Hinson, 2023)
Fever, cough, coryza, conjunctivitis “three C”), and a characteristic maculopapular rash starting on the face and spreading downward.
Other viral exanthems, such as rubella or roseola.
Supportive care, including rest, hydration, and fever management. Vitamin A supplementation may be beneficial in some cases.
Mumps(Davison & Morris, 2023)
Parotitis (swelling of the parotid glands), fever, headache, and malaise.
Other causes of parotitis, such as bacterial parotitis or HIV infection.
Supportive care for fever and pain relief. Vaccination is the primary means of prevention.
Erythema infectiosum (Fifth disease) (Kostolansky & Waymack, 2023)
“Slapped cheek” rash on the face followed by a lacy rash on the trunk and extremities, sometimes preceded by mild fever or cold-like symptoms.
Other viral exanthems, such as rubella or roseola.
Supportive care for fever and rash. Usually self-limiting, but severe cases may require treatment for anemia in immunocompromised individuals.
Rubella (InformedHealth.org, 2023)
Mild fever, sore throat, lymphadenopathy, and a fine maculopapular rash that starts on the face and spreads to the trunk and extremities.
Measles and other viral exanthems, such as roseola or erythema infectiosum.
Supportive care for fever and rash. Vaccination is the primary means of prevention, as rubella infection during pregnancy can lead to congenital rubella syndrome.
Whitley, R., & Baines, J. (2018). Clinical management of herpes simplex virus infections: Past, present, and future. F1000Research, 7, F1000 Faculty Rev-1726. Links to an external site.https://doi.org/10.12688/f1000research.16157.1Links to an external site.
Mohseni M, Boniface MP, Graham C. (2023). Mononucleosis. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: Links to an external site.https://www.ncbi.nlm.nih.gov/books/NBK470387/Links to an external site.
Pippin, M., & Laws, G. (2024). A classic presentation of Roseola Infantum. Cureus, 16(1), e52504. Links to an external site.https://doi.org/10.7759/cureus.52504Links to an external site.
Kennedy, P. G. E., & Gershon, A. A. (2018). Clinical features of varicella-zoster virus infection. Viruses, 10(11), 609. Links to an external site.https://doi.org/10.3390/v10110609Links to an external site.
Boktor, S. W., & Hafner, J. W. (2023). Influenza. In StatPearls. StatPearls Publishing.
Krawiec C, Hinson JW. (2023). Rubeola (Measles) [Updated 2023 Jan 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: Links to an external site.https://www.ncbi.nlm.nih.gov/books/NBK557716/Links to an external site.
Davison, P., & Morris, J. (2023). Mumps. In StatPearls. StatPearls Publishing.
Kostolansky, S., & Waymack, J. R. (2023). Erythema infectiosum. In StatPearls. StatPearls Publishing.
InformedHealth.org. (2023). Overview: Rubella (German measles) [Updated 2023 Sep 21]. Available from: Links to an external site.https://www.ncbi.nlm.nih.gov/books/NBK563972/Links to an external site.
Table 5
Fundamental Principles of Prescribing Medication for Pediatric Patients
What are the four critical fundamental principles to consider when prescribing medications for children?
Children vary greatly in weight and age, which can significantly affect drug dosages. Medication doses should be calculated based on the child’s weight whenever possible rather than relying solely on age. This helps to ensure that the dose is appropriate for the child’s size and metabolism. Children’s
bodies metabolize medications differently than adults. Factors such as organ function, enzyme systems, and body composition can influence how a drug is absorbed, distributed, metabolized, and eliminated. It is essential to understand these differences to determine appropriate dosages and potential side effects.
Many medications are not available in pediatric-friendly formulations, such as liquids or chewable tablets. It may be necessary to compound or manipulate medications to create suitable doses for children. Additionally, the route of administration should be carefully considered to ensure that it is safe and appropriate for the child’s age and condition.
Children may respond differently to medications over time due to growth and changes in physiology. Regular monitoring of the child’s response to treatment is essential, including assessing for efficacy and monitoring for adverse effects. Dosages may need to be adjusted as the child grows or if there are changes in their health status.
Keuler, N., Bouwer, A., & Coetzee, R. (2021).Pharmacists” approach to optimize safe medication use in pediatric patients. Pharmacy (Basel, Switzerland), 9(4), 180. Links to an external site.https://doi.org/10.3390/pharmacy9040180Links to an external site.
PART II
Case Scenario 3: Marcie is a 5-month-old baby who was brought into the clinic by her mother. She has had a fever for three days, up to 102.5°F. So far today, Maria has not had a fever, but she now has a rash all over her body. She is taking her bottle well and has a slightly runny nose. Her weight today is 18 pounds.
What else does the APRN need to know about babyMarcie’s symptoms and current rash?
Beyond the fever and rash, it is essential to delve into the specifics of the rash: its appearance, distribution, and any accompanying symptoms like itching. Gathering details about Marcie’s feeding patterns, urine output, and recent exposures can provide valuable context. Additionally, understanding her medical history and immunization status can help in assessing the potential causes of her symptoms.
What labs might the APRN order?
A CB) can indicate the presence of infection by assessing white blood cell counts, while tests like C-reactive protein or erythrocyte sedimentation rate can detect inflammation. Ordering a blood culture may be necessary if there’s a suspicion of a bacterial infection, and a urinalysis can help rule out a urinary tract infection, particularly if Marcie has a fever.
What type of anticipatory guidance should the APRN provide?
Guidance should cover various aspects, including hydration, comfort measures for managing fever and rash, monitoring for any changes or worsening symptoms, and scheduling a follow-up appointment.
What dosage of Tylenol or Motrin should the baby be receiving?
3.5mL of tylenol 160mg/5mL
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