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PAEDIATRICS NOTES DINESH

Contents:
Renal

2

GIT

12

CVS

18

Respiratory System

24

CNS

28

Neonatology

40

Vaccines

50

Growth

59

Nutrition

78

Blood

88

Infections

91

Malignancies

101

Miscellaneous

103

Milestones

110

1

RENAL
Acute Post Streptococcal Glomerulonephritis:

Definition:
-

Acute, specific, self-limited glomerulonephritis following pharyngeal/cutaneous infection with
nephritogenic strains of group A β-hemolytic streptococci.

Strain: Pharyngitis - M 4 & 12
Pyoderma - M 49

Clinical Features:
-

School age children, boys more commonly (ages 3-12yrs).

-

Rapid onset puffiness around eye (more in the morning) and pedal edema.

-

Characteristically cola-colored urine.

-

Oliguria

-

Hypertension

In atypical cases:
-

Convulsion

-

Left ventricular failure

-

Acute renal failure

Diagnosis/Investigation:
a. Blood – Leukocytosis (infection)
b. Hb – anemia (NCNC due to hemodilution)
c. ESR - ↑↑
d. BUN:

elevated

e. Blood creatinine:

elevated

f.

Urine

a. Oliguria
b. Hematuria – RBC Cast
c. Proteinuria:

1+/2+

2

d. WBC & Granular cast
g. CRP – C3 level ↓
h. If oliguria continues – hyponatremia, hyperkalemia
i.

Evidence of Strep infection:
I.

Throat swab

II.

ASO Titer ↑

III.

Anti DNAse B ↑

Indication for Renal Biopsy:
a.

Renal function severely impaired beyond 10-14 days.

b.

C3 level depressed beyond 5-7 days.

c.

Unresolving acute GN.

d.

Showing features of systemic illness.

Important Complications:
a.

ARF

b.

Pulmonary edema / CCF

c.

Hypertensive encephalopathy

d.

Hyperkalemia / Hyponatremia

Treatment:
1.

General:
-

Bed rest

-

Daily weight chart

-

BP

-

Urine for quantity, protein and hematuria analysis.

2.

Diet:
-

Intake of protein, sodium and potassium should be restricted till the blood urea value reduces
and urine output increases.

3.

Weight:
-

In severe oliguria, patient loses about 0.5% body weight per day.

3

5g% c. Proteinuria: >40mg/m2/hour >1g/m2/day >50mg/kg/hour 3+/4+ by dipstick b.4.2 million units Hypertension: - Mild – Salt and water restriction - Other – Atenolol 6. Benzathine penicillin im single dose – o <20kg: 0. Edema/CCF - Furosemide (indicated only in pulmonary edema/CCF) - Nasal O2 - Salt and water restriction Nephrotic Syndrome: Definition: - Clinical condition characterized by massive proteinuria. Hypoalbuminemia Serum albumin <2. generalized edema and associated hyperlipidemia. Hyperlipidemia Cholesterol >250mg% Investigation: 4 . Values: a.6 million units o >20kg: 1. hypoalbuminemia. Antibiotics: - 5.

↑ in GN  Throat swab .+ in GN b.5g% e. Serum BUN & Serum creatinine – MCNS – Normal.A. Urine: Proteinuria 4+ Hematuria +/WBC to rule out UTI d. Other: 5 . Serum Albumin: < 2. c. TB d. Serum Cholesterol: > 250mg% f. Australia Ag – Hepatitis B g. Additional test in case of a. To rule out infection: a. CBP: Anemia Leukocytosis b. Atypical Frequent relapses Resistant to steroids  C3 level . ESR: Elevated. Blood culture b. To confirm the diagnosis: a. Mantoux test – TB c. other ↑ B. suspected ANA Ds DNA RA factor D. X Ray chest – Pneumonia. VDRL – Syphilis C. SLE/RA/etc. Peripheral smear – malaria f. Urine culture e.↓ in GN while in Nephrotic  ASO titer .

TB. Thromboembolism: Causes: Increased level of fibrinogen. platelets  Enhanced coagulation Decreased level of Antithrombin III. Growth retardation: Due to: ↓Protein deficiency Anorexia Steroid 4. Infection: (↓IgG due to low protein. Complication: I. VIII. Complications of steroid therapy. Diet: Salt restriction Fluid restriction Maintenance of protein b. General: a. Factor IX and XI  Low ability to limit coagulation 2. USG Abdomen b. Hypertension 8. Renal Doppler c. Ascitic tap COMPLICATIONS: 1. steroid) SBP. factor V. Viral infections . Hyponatremia 7. TREATMENT: A. Hypocalcaemia 10. Anemia 6.a. ARF 9. Thromboembolic episode  Proper fluid management  Prevent immobilization 6 . Cardiovascular disease 5.chicken pox/measles 3.

7 mg/kg X 9-12 months b.5 mg/kg/day on alternate day X 6 weeks First 2-3 relapses: Prednisolone – 2 mg/kg/day X 2weeks 1. Infection : Antibiotics III. Antiplatelet agent  Anticoagulants II.4 mg/kg/day Human Albumin Infusion – when human albumin falls below 1. Anemia – Fe V. 7 .5 mg/kg/day – single morning X 4 weeks.0.5 mg/kg/day on alternate days X 4 weeks Frequent relapse/dependence: a.5 g% B. Initial episode: Prednisolone – 2 mg/kg/day X 6 weeks 1. Specific: SKDC Regime: Prednisolone – 2 mg/kg/day – 3 divided doses X 4 weeks 1.3. HTN: ACE inhibitor – Enalapril CCB – Nifedipine IV.5 mg/kg/alternate day duration – 12 weeks Posterior Urethral Valve: Definition: It is a congenital anomaly of the urinary tract and is an important cause of distal urinary tract obstruction. Hypocalcaemia/Hyponatremia c. Cyclophosphamide X 2 mg/kg/day + Prednisolone 1. Edema: Diuretics – Furosemide 1. Alternate day prednisolone 0.

At birth: Mild to moderate impairment of renal function 3. tumor. b. Vesico ureteric reflux. c. f. Malnutrition e.Clinical Features: (Boys > Girls) 1. In-utero: severe obstruction may lead to renal dysplasia. Children : Dribbling Abnormal stream Palpable bladder Recurrent UTI Investigation: MCU: Dilated posterior urethra and valves at the junction with anterior urethra Enlarged bladder with diverticuli and trabeculations Vesico ureteric reflux Treatment: Endoscopic fulguration of valves UTI Definition: - It is infection of any part of urinary tract with urine microscopy showing pus cells > 510/mm3 and > 105 organism/ml on urine culture (preferably single type of organism) Predisposing factors: a. 2. Obstructive uropathy. Neurogenic bladder (associated with meningomyelocele. Immunosuppressive therapy. trauma at lumbosacral region) d. Circumcision may protect against UTI 8 .

USG – Renal abnormalities c. MCU d. DMSA scan for pyelonephritic scans e. Urethral catheterization 2 years c. IUP c. DTPA scan for renal function Differentiate Between AGN And Nephrotic Syndrome In Urine Analysis: AGN - NEPHROTIC SYNDROME Hematuria: Gross >5 RBC/HPF +/- RBC Cast: + - - WBC. Supra pubic aspiration b. CRP . ESR.↑↑ b. granular cast Cellular and granular cast - Oliguria Rare - Proteinuria 1+/2+ Massive proteinuria.Sample Collection: a. Clean catch midstream urine > 2 years Investigation: a. USG b. Urine microscopy and culture: > 10 WBC / mm3 > 105 bacteria/ml on culture Second UTI: Investigations: a. > 2 g/day 9 .

Hemolytic uremic syndrome d. Acute tubular necrosis b. shock o CCF Renal: a. Calculus b. Glomerulonephritis c. Interstitial nephritis Post renal: a.>40 mg/m2/day >1 g/m2/day >50 mg/kg/hour 3+/4+ dipstick Causes of ARF in Children: Pre renal: o Acute gastroenteritis o Hemorrhage. Posterior urethral valves TREATMENT OF UTI: a. First attack: Neonates: Parenteral ampicillin + Gentamicin x 7-10 days Infants: Oral Co-trimoxazole / cephalosporin x 5-7 days Children: Oral antibiotics x 5-7 days Co-trimoxazole – 5mg/kg/day 10 .

- Urine culture after 1 week. Recurrent attack: Co-trimoxazole. nocturia and increased thirst - Anemia - Failure to thrive - Growth retardation - Hypertension - Bony deformities - Malnutrition - Peripheral neuropathy - Proximal muscle weakness 11 . 3 weeks – 3months: 3 months > 3 month: no prophylactic treatment CRF Clinical Features: - Frequent passage of urine. 1 month and then 3 consecutive months to ensure complete clearing b. 2 mg/kg/day long term night dose - Duration of treatment depend on the interval between 2nd and 3rd episode. If interval < 3 weeks: treatment 1 yr.

drink eagerly Drink poorly. culturally acceptable fluid irrespective of presence of glucose or without salt when former is present. Complete oral rehydration with salt solution with composition within the WHO recommended range. Food based solution. Assessment of dehydration: Condition Well/Alert Restless / irritable Lethargic / Unconscious / Floppy Eyes Normal Sunken Very sunken and dry Tears Present Absent Absent Mouth and tongue Moist Dry Very dry Thirst Drinks normally. In presence of continued feeding. It includes: a.GIT Dehydration/Oral Rehydration Therapy What is oral rehydration therapy? It is the core of management of diarrhea. b. a variety of commonly available. Solution made from sugar and salt. not Thirsty. not able thirsty to drink Skin pinch Goes back quickly Slowly Very slowly Decide No Some Severe Treat Plan A Plan B Plan C 12 . (40g + 4g/L) c. Rice water (50 + 40g/L) d.

Educate mother to use increased amount of home available food. Many watery stool ii.5 20 Water 1 liter 1 liter Advantage of citrate: a. Normal saline Plan A: a. Diarrhea treatment solution 3. b. Marked thirst iv.5 Citrate 2. c. IV Rehydration solution: 1. More stable product b. iii. Less stool output d. Increases intestinal absorption of sodium and water.9 Glucose 13. ORS should be given. Danger signs: i. Longer shelf life c. Ringer lactate/ Hartmann’s solution 2.6 2.5 KCl 1. Eating/drinking poorly 13 .5 1.Weight loss 2-5% 5-10% ≥ 10% Achars Mild Moderate Severe ORS Composition: New Old NaCl 3. Repeated vomiting.5 3. Return to health worker if Not corrected in 3 days 1.

normally within 4 hours ORS should be equal to diarrhea losses – approximately 10-20 ml/kg body weight/liquid stool c. Fever vi. a. NS Give 100ml/kg in following way Age First give 30 ml/kg then give 70 ml/kg <12 months 1 hour 5 hours 1yr . b. Solution used: 1. Maintenance therapy c. Start IV fluids immediately. RL 3. Rehydration therapy. Rehydration therapy: Give 75 ml/kg of ORS in first 4 hours. RL + Dextrose 5% 2. 14 . give ORS if the child can drink. Provision of normal daily requirement.5yr 30 min 2 ½ hours Repeat if radial pulse is weak. While the drip is being setup.v. Breast feed even during rehydration. Maintenance: Begins when signs of dehydration disappear . b. Blood in stool Plan B: It has 3 components: a. Semisolid food soon after deficit replacement Plan C: a. Provision for normal daily requirement.

Start rehydration with ORS using nasogastric tube at 20ml/kg/hr (total 120 ml/kg) Reassess every 1-2 hr. Cirrhosis – Post viral. o Observe child for at least 6 hours before discharge. If vomits or there is abdominal distension. Veno-occlusive disease Signs of Liver Cell Failure: a. to confirm that mother is able to maintain the child’s hydration with ORS. When they can drink give ORS at 5 ml/kg/hour Monitoring: o Every 1-2hr: Radial pulse. skin pinch If improvement but still showing some signs of dehydration. Spider naevi 15 . b.b. Cannot give IV. Jaundice b. give slowly If no improvement after 3 hours try to start IV fluids as early as possible. Causes: a. Budd-Chiari syndrome c. autoimmune hepatitis. Diminished body hair c. Wilson’s disease. start Plan B and discontinue IV fluids. Portal Hypertension: Definition: It is defined as elevation of portal venous pressure in valves above 10-12 mm Hg.

frothy. Menstrual irregularities Lactose Intolerance: Definition: Lactose intolerance is the development of clinical symptoms resulting from lactase deficiency following ingestion of lactose in water in a standard dose. sour smelling stool - Perianal excoriation 16 .d. Cause: - Primary – Autosomal recessive condition - Secondary –  Acute gastroenteritis  PEM  Worm infestations  Malabsorption syndrome  Animal milk allergy Consequences: - Osmotic diarrhea - Metabolic acidosis - Bacterial proliferation - Caloric loss Clinical Features: - Diarrhea – Watery. Ascites i. greenish yellow. Gynaecomastia j. Clubbing. Flapping tremor h. Palmar erythema e. White nails f. Dupuytren’s contracture g. Testicular atrophy Adults only k.

 Lactose free diet if persistent diarrhea. weight loss.- Failure to thrive - Abdominal distension - Borborygmi.5% - Lactose tolerance test - Interstitial enzyme activity by biopsy Treatment: - Primary – Eliminate lactose from diet - Secondary –  Treatment of primary cause. flatulence Investigations: - Stool pH <5. reducing substance >1% 17 .5 Reducing substance >0.

An effect of TOF Synonyms: Paroxysmal hyperpnoea. feeding. Guntheroth cycle Onset: 1 month – 12 year usually. ↓pH. Peak: 6 – 12 months Natural History: Gradual decrease in frequency with increase in the age Decrease in severity beyond 2-3 years. Typical Attack: Usually occurs in the morning. ↓P O2 18 . Any valsalva maneuver (crying. Anoxic/Hypoxic spells.CVS Cyanotic Spell: . defecation) ↓ Increase rate and depth of respiration with restlessness ↓ Cyanosis ↓ Increasing cyanosis ↓ Gasping respiration ↓ Syncope (convulsion may occur) Mechanism: Valsalva maneuver ↓ Increased O2 demand ↓ ↑P CO2. Dyspneic spell.

clubbing - Prominent ‘a’ wave in JVP - Ejection systolic murmur Management: 1. Morphine 0.1mg/kg – sc for sedation 4. Long term – 1 mg/kg 4-6 hourly orally. Correct anemia 8.1 mg/kg iv during spell. 6. Pott’s shunt c.↓ Hyperpnoea ↓ ↑Venous return ↓ ↑CO ↓ ↑Right to Left shunt ↑Cyanosis Cyanotic spell Examination: - Cyanosis. Knee chest position/ squatting position 2. Humidified O2 3. Obtain pH – give sodium bicarbonate iv. Waterston shunt 19 . Consider operation. Blalock – Taussig shunt b. Vasopressor – methoxamine(vasoxyl) im/iv 7. -Long term a. 5. Propranolol – 0. Correct acidosis.

CCF: Definition: - Inability of the heart to maintain an output at rest or during stress. excessive perspiration and restlessness g. Reducing cardiac work b. Correcting underlying cause. Poor weight gain b. Signs: Left Both Side Right Tachypnea Cardiac enlargement Hepatomegaly Tachycardia Gallop rhythm (S3) Facial edema Cough Peripheral cyanosis Jugular venous engorgement Wheezing Small volume pulse Edema affect Rales in chest Absence of weight gain Treatment of CCF: Management consists of four pronged attack for the correcting of inadequate output. Persistent cough and wheezing f. Breathes better when held against the shoulder e. Pedal edema B. Difficulty in feeding c. Breathes too fast d. 20 . Augmenting myocardial activity c. necessary for metabolic needs of the body and inability to receive blood into the ventricular cavities at low pressure during diastole Clinical Features: A. Improving cardiac performance by reducing heart size d. Puffiness of face h. Symptoms: a. a. Irritating.

Diuretics 3.05mg/kg sc 3. Treatment of underlying cause. Add Digoxin 3. 8. 16 hours Parenteral dose is 7/10 of oral One day drug holiday in a week c. anemia. Cardiac transplantation 21 .04 mg/kg Maintenance – 0. Improving cardiac performance 1. Amrinone and Milrinone Digitalis: Total digitalizing – 0. Sedative – morphine 0. Dopamine.01 mg/kg/day Dose given in fraction ½.a. Vasodilators b. Digitalis 2. Augmenting myocardial activity 1. Stepwise management: 1. Add Isosorbide nitrate 5. ¼. Salt restriction d. Add ACE inhibitor and stop K+ sparing diuretics 4. Treatment of fever. Digitalis 2. Myocardial biopsy & add immunosuppression with steroids in case of active myocarditis and β-Blocker in cases without active myocarditis 7. Frusemide 1mg/kg/dose + Amiloride/Triamterene 2. Intermittent dopamine + dobutamine (in separate iv) or dobutamine. Reducing cardiac work. dobutamine 3. 6. 1. obesity 4. ¼ at 0. Restriction of activities – nursing in propped up position 2.

Eisenmenger’s phenomenon and pulmonary hypertension 6. Conduction disturbances 5. VSD 2. Infective endocarditis 4. Overriding dextroposed aorta 4. Recurrent dust infections 2. Pulmonic stenosis 3.Acyanotic Heart Disease: Left to right shunts ASD (ostium primum and ostium secondum variety) VSD PDA TOF Components: 1. CCF 3. Poor exercise tolerance Large: Effort intolerance Palpitation 22 . Right ventricular hypertrophy Complications of VSD: 1. Aortic / Tricuspid regurgitation 7. Growth retardation PDA: Clinical Features: Symptoms: Small: Asymptomatic.

Gibsons/machinery/mill wheel murmur (continuous murmur) 23 .Recurrent chest infection Signs: General: ↑HR and RR Harrison’s groove Cyanosis / clubbing of lower limbs if severe. Pulse: Water hammer pulse Precordium: Hyper dynamic apex Palpable D2 Right ventricular heave Auscultation: S1 accentuated and D2 loud.

Hydrocortisone 10 mg/kg improvement Treat as early responder Reassess at 2 hr. Prednisolone once daily for 5-7 days then stop without tapering. No improvement: 1. Stop O2 if child is able to maintain O2 saturation > 95 % 3. Inj. 2. Start injectable theophylline bolus followed by continuous infusion Magnesium 50mg/kg in dextrose over 30 min No improvement Mechanical ventilation 24 . Continue salbutamol and add ipratropium 250µg every 20 min. No response 1. β2 agonist every 30 min interval gradually increased to 4-6 hourly 2.RESPIRATORY SYSTEM Management of Status Asthmaticus: Inhaled β2 agonist repeated every 20 min for 1 hour and O2 inhalation and An oral dose of prednisolone 1-2 mg/kg Improvement: 1.

Complications Of Pneumonia: 1. Less dose. Technique needs to be learnt b. Delivery to the target tissue b. Nebulizer MDI: Puff is synchronized. Decreases incidence of severe attack and hospitalization. less side effects c. Rapid response d. Cost is high.Aerosol Therapy in Asthma: An aerosol is a suspension of very fine particle of liquid or solid in gas. Rotahalers. Advantage: a. Metastatic abscess 25 . Empyema 3. Nebulizer: Given for 5-20 minutes. Spacers: MDI attached to one side and mouth piece on the other side. Devices: MDI. Self-administration possible e. Limitations: a. (Inspiration and breath is held for 10s) Rotahalers: Patient has to inhale after the capsule is broken by a fin inside one of the halves. Spacers. Pneumatocele 2. Pyopneumothorax 4.

2. otitis media or fever. Signs: - Tachypnea - Tachycardia - Use of accessory muscles of respiration - Chest retraction - Respiratory distress is out of proportion to the extent of physical sign in lungs.Acute Bronchiolitis: It is defined as the first episode of expiratory wheeze of acute onset usually in a child less than 2 years of age who has features of viral respiratory illness like coryza. 3 Bacterial: Mycoplasma pneumonia Clinical Features: Symptoms: - Cough. - Expiration prolonged. dyspnea. fever - Gradual development of respiratory distress - Rhinorrhea - Characterized by paroxysmal wheezing cough - Difficulty in feeding. fine rale and rhonchi are auscultated. pneumonia or atopy. with or without indications of respiratory distress. Incidence: Age: 1-6 months (peak age) Season: October to march Sex: more common in males Etiology: Viral: Respiratory syncytial virus Adenovirus. 26 . influenza virus Parainfluenza virus 1.

27 .Investigations: - X Ray: Hyperinflation and infiltrates Lung field and abnormality translucent Diaphragm pushed down - ABG - Serum electrolytes Treatment: - Nursing care: humid atmosphere preferably sitting position at 30o-40o angle with head and neck elevated - Oxygen: keep O2 saturation above 95% - IV fluids - Antibiotics - Ribavirin: shortens the course if given in the early stages delivered by an nebulizer 16 hours a day for 3-5 days.

give O2.3 mg/kg/dose at 1 mg/min (max 10 mg) Repeat after 10 min if seizures continue Phenytoin loading dose – 15-20 mg/kg at 0. breathing. examination.CNS Treatment of Status Epilepticus: Acute Seizures History. establish IV line. investigation to ascertain cause Assess airway. and estimate blood glucose Diazepam IV 0.5 mg/kg/min (max – 50mg/min) Maintenance – 5-8 mg/kg/day Phenobarbital IV Loading dose – 10-15 mg/kg @ 1-2 mg/kg/min Maintenance 5 mg/kg/day Im/rectal paraldehyde Midazolam infusion Phenobarbital coma 28 .

Tetania neonatorum iii. meningitis. hypocalcaemia. Unknown error of metabolism – PKU. Birth injuries iii. Perinatal infection: i. Intraventricular hemorrhage iv. Pyridoxine deficiency iv. homocystinuria d. Kernicterus iii. Im Magnesium Neonatal Seizures: Causes: The five major causes are hypoxic ischemic encephalopathy. Perinatal complications: i. Hypoxic ischemia encephalopathy ii. IV calcium – if hypocalcaemia d. Microcephaly 29 . Subarachnoid hemorrhage b. Pyridoxine – 50 – 100mg if deficiency c. Glucose for hypoglycemia b. Metabolic cause i. hypocalcaemia. Meningitis ii. Hypoglycemia. and polycythemia a. hypoglycemia. hypomagnesaemia ii. Development defect of brain: i. Intrauterine infection – TORCH c.Specific therapy: a.

When child is convulsing. There may be family history Investigations: LP to rule out meningitis Treatment: A. Narcotic withdrawal syndrome i. give oxygen iii.3 mg/kg/dose (max 5 mg) ii. Porencephaly iv. Lasts less than 10 min c. Diazepam iv – 0. Hydrocephalus iii. Babies born to mothers addicted to narcotics Febrile Convulsions: Definition: Seizure during fever occurring between 6 months to 8 years age in the absence of neuro-infections Typical febrile seizures: a. Semi prone position 30 . No postictal neurological deficit f.ii.2 – 0. Acute: a. Maintain airway. EEG a few days after seizure is normal g. Generalized convulsions e. Within 24 hours of fever b. Agenesis of corpus callosum e. i. Usually single per febrile episode d.

Salmonella.meningitidis >3yrs: 31 . Streptococcus pneumonia. Those with CNS disease b.influenzea. Family history of epilepsy Drug: Phenobarbital – 3-5mg/kg/day Duration: 1-2 years/ till 5 years of age whichever comes earlier Pyogenic Meningitis: Causes: Neonates:  E. Nor convulsing/stops convulsing i. Treatment of fever b.coli. Continuous: failure of intermittent therapy a. Treatment of fever 1. Prophylaxis: Counseling of parents Drugs: a.pneumoniae. Streptococcus faecalis 3 months – 2-3 year:  H. Intermittent: for first 3 days of fever a. Oral diazepam b. H. Look for etiology and treat accordingly B. b. Tepid sponging 3. Maintain patent iv lines. Paracetamol 2. Strep aureus. Protect from injuries v.pneumoniae.iv.meningitidis  S. S. Pseudomonas aeruginosa. H.

CSF Analysis: - Pressure: elevated (>180mm of H2O) - Appearance : turbid - Cell count: >1000/mm2 – elevated (polymorphonuclear) - Protein: >100 mg/dl – elevated - Sugar: <40 mg/dl – below 50% of blood sugar - Gram stain: positive - Culture: Positive CSF in TB Meningitis: - Pressure: Elevated - Appearance: Clear cobweb formation after sometime - Cells: Elevated lymphocyte 10-500/mm3 - Protein: Elevated 80-400 mg% - Sugar: Decreased 30-50 mg% (less than 2/3rd of blood sugar) - AFB: Positive - Culture: Positive Cerebral Palsy / Little’s Disease: Definition: - Non progressive central motor deficit/disorder resulting from various events in prenatal life/perinatal period (insult to developing brain) with or without mental subnormality. sensory deficit. Anoxia b. Toxemia of pregnancy 32 . Prenatal a. with or without epilepsy and other involuntary movements. Etiology: A.

According to motor deficit a. Precipitate delivery e. monoplegia b. Asphyxia c. According to patient therapeutic requirement: Class I – no active treatment required Class II – require minimal bracing and treatment Class III – Require bracing and service of CP team Class IV – Long term hospitalization and management 33 . Atonic d. Metabolic disturbance – hyperglycemia e.c. Trauma c. Natal: a. Mixed B. Vascular – hemorrhage and thromboembolism Classification: A. Post natal a. diplegia. paraplegia. Congenital malformation of brain B. Anoxia b. Birth trauma C. Infection – meningitis and encephalitis d. hemiplegia. Kernicterus b. Difficult labor d. According to patients functional status Class I – No practical limitation of activity Class II – Slight to moderate limitation Class III – Moderate to gross limitation Class IV – Inability to carry out any useful activity C. Intrauterine infections d. Athetoid c. Spastic – quadriplegia.

ophisthotonus - Babinski positive beyond 2 years of age - Pseudobulbar palsy – swallowing difficulty with drooling of saliva and expression less face 2. Muscle disorders e.Clinical Features: 1. hemiplegia - Hyperirritable. Aphasia. Neurodegenerative disorders b. delayed talking - Cerebellar sign present 3. caries Miscellaneous: Critchely’s sign . Hydrocephalus and subdural effusion c. dyslalia Sensory defects: Astereognosis.thumb is persistently flexed across palm after 1st month of life Differential Diagnosis: a. cataract. refractiveness Ear: Deafness – partial/complete Speech: Dysarthria. Atonic: - Hypotonia. feeding difficulties Teeth: Malocclusion. Spastic: - Quadriplegia. Ataxia telangiectasia 34 . spatial disorientation Seizures: Generalized/focal tonic Intelligence: Borderline/moderately/severely mental retardation GIT: Constipation. Chorioathetoid: - Chorioathetosis - Deafness dystonia Associated features: Eye: Strabismus. Brain tumor/space occupying lesion d.

psychologist.Early identification of CP: - Decreased alertness. speech therapist. social worker 35 . fall off in growth - Constant fisting with adduction of thumb beyond 2 months of age - Delayed social smile - Primitive reflexes beyond 6 months - Delayed developmental milestones - Persistent tone abnormality. orthopedic and general surgeon. Educational management: vision. medical. movement and reflexes. Symptomatic treatment: - Anticonvulsant – for seizures - Tranquilizers – for behavioral disturbances - Muscle relaxants – Dantrolene sodium - Balcofen – to reduce spasticity - Diazepam – athetosis and spasticity 2. Orthopedic support: splints and surgeries 6. 1. Social Support CP Team: - Pediatrician. 5. Management: Depending on severity and type of neurological deficit and associated problem. decreased spontaneous mobility - Reduced head circumference. speech and learning problems. physical and occupation therapist. Occupational therapy 4. Physiotherapy: - Massage/exercise - Encourage basic movements - Special therapy 3.

Salicylates 36 . - Plantar reflexes are normal - Hypotonia Miller Fisher syndrome – areflexia. diminished reflexes. ataxia and ophthalmoplegia without significant limb weakness Albumino cytological dissociation Rye’s Syndrome: Definition: - Acute self-limiting metabolic insult of diverse etiology resulting in generalized mitochondrial dysfunction due to inhibition of fatty acid β oxidation. and subjective sensory involvement - Weakness more marked in proximal muscle groups - Tendon reflexes are decreased. mumps.GB Syndrome: Definition: It is acute inflammatory polyneuropathy Etiology: Viral: EBV. Etiology: a. measles Post vaccination Bacteria: Campylobacter Clinical Features: - Predominant motor neuropathy - Characterized by symmetric weakness of muscles.

Aflatoxin Stages: Stage I – Mild confusion. Varicella c. Metabolic – PKU.b. listlessness. Influenza B d. apathy. areflexia. decorticate posture later become decerebrate. apnea. Developmental defect: Microcephaly 5. TORCH infection c. Radiation during pregnancy 37 . Maternal factor: a. frightened stage Stage III – Coma. Dilated pupil not reacting to light Sever hypotension Treatment: - Low protein - Mannitol - Glucose - Correct electrolyte Causes of Mental Retardation: a. restlessness. lack of orientation. Klinefelter’s 3. homocystinuria 2. Death Stage IV – Flaccidity. Prenatal: 1. Environment and nutrition gap: iodine deficiency 4. Chromosomal disorders: Down. Teratogenic drug use b. anorexia. vomiting Stage II – Delusion.

Child abuse f. Autism AFP Definition: Acute onset of flaccid paralysis in any child aged <15 years for which no obvious cause is found or paralytic illness in a person of any age in which polio is suspected. Kernicterus c. Intracerebral hemorrhage c. Monitor progress toward eradication c. Target supplementary immunization WHO recommends immediate reporting and investigation of every case of AFP in a child < 15 years and collection of 2 stool samples for analysis in a WHO approved lab 38 . Natal: a. Hypoxic ischemic encephalopathy c. Birth trauma b. Identify all remaining area b. GBS. Differential diagnosis: Polio. transverse myelitis. Malnutrition e. Meningoencephalitis b. traumatic neuritis AFP Surveillance: Aim: a.b. Hypoglycemia d. Postnatal: a.

residing within 5 km radius - Search for cases < 15 years age for history of AFP in last 60 days. tremor. ataxia 39 . vomiting. Adequate specimen: - 2 specimens at least 24 hours apart - Collected within 14 days of AFP - Adequate amount 8-10g - Reaching WHO lab in good condition - Sent by reverse cold chain Indicator for effectiveness of surveillance: - Sensitivity non-polio AFP at least 1/100000 in children < 15 years - Completion of survey o 2 adequate specimen from at least 60% of all AFP cases Sodium Valproate: Indication: - Drug of choice for absent seizures - Alternative drug for GTCS/SPS/CPS - Drug of choice for myoclonic and atonic seizure - Alternative drug to Li in mania and bipolar disorder Side Effects: - Fulminant hepatitis - Neural tube defect - Alopecia.Outbreak response by D/O - Immunization of all child <5 years by 1 dose OPV. curling of hair - Nausea.

Increase in level of total bilirubin by more than 0. Polycythemia Criteria for Pathological Jaundice in the Newborn: 1. Hypothermia 4. 2. Infections 6.5 mg/dl/hour or 5 mg/dl/24 hours 3. Meconium aspiration syndrome 3. Hypoglycemia 5. Total bilirubin >15 mg/dl 4. Birth asphyxia 2.NEONATOLOGY Problems of SGA baby: 1. Direct bilirubin >20 mg/dl Differentiate the Pathological And Physiological Jaundice: Pathological Physiological Appear in first 24 hours Appears in first week Increase in bilirubin level by >0. Appearing in first 24 hours.5 mg/dl/hr Less increase Total bilirubin >15 Always <15 Does not have two phases Has two phases Treatment always required Not required Direct >2g Indirect increased 40 .

- A rim may be felt around hematoma - If crossing the midline. indicates underlying fracture of skull Clinical significance: Can cause exaggeration of physiological jaundice 41 .Problems of prematurity: - Birth asphyxia - Feeding difficulties - Hypothermia - Infection - RDS due to hyaline membrane disease - Hyperbilirubinemia - Intraventricular hemorrhage - Necrotizing endocarditis - Apneic spells - Metabolic acidosis Cephalhaematoma: Definition: Sub periosteal hemorrhage usually involving parietal and temporal bones Etiology: - Forceps delivery - Vacuum extraction - Prolonged labor Clinical Features: - It appears as a soft fluctuant swelling with well-defined margin.

Help mother initiate breast feeding within ½ hour. Foster the establishment of breast feeding support groups and refer mothers to them on discharge. Inform all pregnant women about benefit and management of breast feeding 4. 6. Give newborn no food or drink other than milk unless indicated 7. 2. Ten steps for successful breast feeding 1. 5. Requirements: Baby friendly hospitals are required to adopt a breast feeding policy and confirm to its 10 steps for successful breast feeding. 42 . protection and support of breast feeding by WHO and UNICEF. Give no pacifiers/soother to breast feeding infant 10.Treatment: No treatment – resolves by itself. Rooming in practice 8. Encourage breast feeding on demand 9. BFHI - Launched in 1992 as a part of “Innocenti Declaration” on promotion. Train all health care staff in skills necessary to implement the policy 3. Show mothers how to breast feed and maintain lactation even if they should be separated from their baby. Have a written breast feeding policy that is routinely communicated to all health care staff.

Anatomical features: - Weight > 2500gm - Hard skull bones - HC and CC difference 1. GIT: sucking/swallowing reflex good. Respiratory system: good cry Good cough reflex b.5cm HC>CC - Pinna full developed with good recoil - No lanugo - Plantar creases present - Scrotum fully developed and fully descended testes. c. swallowing reflex Pupillary light reflex positive Good muscle tone 43 . Neurological: Moro’s reflex present Good suckling.Features used for Maturity: A. - Labia majora covering minora (minora are not exposed) - Nails grown up to finger tips B. Functional features: a.

a. Delayed Importance: 1. If low. Birth asphyxia b.APGAR Score: It is a quantitative method for assessing the infantile respiratory. it indicates one of following. After regular respiration established 3. Gives overall view of condition of new born 3. cough or sneezes. Activity (muscle tone) Flaccid Some activity Actively moving limbs Respiration None Slow irregular Good crying stimulation) Score: >8 – normal 4-8 – moderately asphyxiated <4 – severe distress When to do: 1 min. Congenital malformations 44 . circulatory and neurological status APGAR Score System 0 1 2 Appearance Blue Body pink. 5 min. extremities Pink completely blue Pulse/min Absent <100 >100 Grimace (reflex No response Grimace Cry.indicates very bad prognosis 4. Prognostic value – if score <4 at min . At first cry 2. and 10 min 1. Monitoring score to determine the efficacy of resuscitation 2.

Ignores time of first cry 3. Preterm baby b. Cannot be used in a. convulsions. It does not give any idea of duration and severity of asphyxia. VIII nerve nucleus affected - Sparse/athetoid type of CP - Mental retardation 45 . - Phase II – fever. Infant Erb’s palsy c. Severely sedated baby 5. hypotonia. lethargy. Clinically 3 phases: - Phase I – poor suck. Kernicterus: Definition: - Unconjugated hyperbilirubinemia in the neonatal period causing bilirubin encephalopathy with and staining necrosis of neuron in basal ganglia. 1 minute score is not useful in deciding the intervention necessary for resuscitation as action must be initiated before that 4. Intrauterine infection/septicemia Drawbacks: 1. Subjective scoring except HR 2. and sub-thalamic nuclei. depressed sensorium. hypertonia progressing to ophisthotonus - Phase III – high pitched cry.c. hippocampus. death Sequelae: - Deafness. This nuclear staining is called kernicterus.

- Epilepsy Treatment: - Exchange transfusion - Phototherapy - Drugs Phototherapy: This converts bilirubin into photoisomers that can bypass the conjugating system of liver and be excreted in the bile or urine without further metabolism. Mechanism of action: - Geometric photoisomerisation – accounts for 60% conversion - Structural isomerization (bilirubin to lumirubin) - Photo oxidation Indication: - Serum bilirubin > 15 mg% in term and >10 g% in preterm babies - Hemolytic disease of new born - Adjunct to exchange transfusion - Prophylactically o Very low birth weight babies o Severely bruised infants Contraindication: - Obstructive jaundice - Light sensitive porphyria Technique: - Light source – 4 blue/green light fluorescent lamp 46 .

Etiology: - E. Staphylococcus aureus. - Criteria for stopping – fall in bilirubin level Side Effect: - Dehydration - Diarrhea - Skin burns - Tanning - Bronze baby syndrome - Retinal damage - Hyperthermia Neonatal Sepsis: It is the systemic bacterial infection of the new born which incorporates septicemia. multisystem Slowly progressive or localized 47 . 10-20% extra fluid is given to compensate for loss.coli. Klebsiella pneumonia Two types of onset: Early v Late: Early Late Time <72 hours >72 hours Complicated pregnancy + +/- Source Genital tract of mother Post-natal environment Clinical Features: Fulminant. pneumonia and meningitis. - Duration of therapy – 24-48 hours - Feeding of infant during phototherapy: infant is removed from phototherapy for breastfeeding.- Position of infant: placed naked at distance of 45cm below light source - Protection of infant: eye patch to protect retinal damage and diaper to protect external gonads.

comatose - Poor profusion - Seizures - Shock - High pitched cry - Excessive crying/irritability - Abdominal distension - Neck retraction - Diarrhea - Bulging fontanelle - Vomiting GIT: Temperature problem: Others: - Hypothermia - Sclerema - Fever - Excessive jaundice - Bleeding - Renal Failure Investigation: - Blood counts - Cultures - X Ray chest - Gram stain - Acute phase reactants Management: 1. Supportive therapy. Maintenance of nutrition 48 . Antibiotics 2.Symptomatology of neonatal sepsis: General: Respiratory System: - Lethargy - Cyanosis - Refusal to suck - Tachypnea - Poor cry - Chest retractions - Poor weight gain/excessive - Grunt weight loss - Apnea/gasping CNS: Hypotension: - Not arousable. a.

Hemolytic disorder 2.b. injections. clean clothing) - Avoiding unnecessary iv fluids. O2 ventilation in respiratory distress Prevention of infections: - Exclusive breastfeeding. Maternal diabetes 49 . Cephalhaematoma 3. Rotor/Dubin-Johnson disease 4. Correct hypoglycemia d. - Hygiene of baby (sponging. Correction of electrolyte balance c. Causes of Pathological Jaundice: 1. needle prick etc. no pre-lacteals - Keeping the cord dry - Hand washing by care givers before and after handling the baby.

Vaccination: 2 months: 3 dose at two month interval. pertussis 20000 million killed bacteria 4 IU 50 . booster at 12 months after the third dose. 6 – 12 months: 2 dose at 2 month interval.VACCINES Hib Vaccine: It is a conjugate vaccine consisting of polysaccharide PRP of Hib conjugate to carrier protein.5ml im. booster at 12 months after the second dose 12 months – 5 years: single dose Indication: - Splenectomy - Sickle cell anemia - HIV - Malignancy and other immunodeficiency state DPT: Contents: - Diphtheria toxoid 25 Lf - Tetanus toxoid 5 Lf - B. Types: - PRP – D : polysaccharide conjugated to diphtheria toxoid - PRP – T : tetanus toxoid - PRP – OMP : outer meningococcal protein Dose: 0. anterolateral aspect of the thigh.

5 mg - Thiomersal BP 0. and 14 weeks Booster: 1 – 18 months 2 – 4 ½ . Encephalitis/encephalopathy 2. phosphate 1. 10 weeks. 51 . Dose: 2 dose at interval of 4-6 weeks followed by 6-12 months after second dose. Progressive neurological disease b. Contraindication to second and successive dose: o Convulsions o Encephalopathy o Anaphylaxis o Shock like syndrome o Hyperpnoea o Persistent and high pitched cry DT Vaccine: Contains 2 Lf diphtheria toxoid per dose.5 ml Side effects: Fever/mild local reaction Complications: Attributed to pertussis component: 1. For immunizing children over 12 years.- Al. Uncontrolled convulsions c.01 % Age: 6 weeks. Infantile spasms Contraindications: a. Prolonged convulsions 3.5 years Route: Deep im Site: Anterolateral aspect of thigh Dose: 0.

meningococcal BCG: Vaccine – Live bacterial attenuated vaccine. DTaP. MMR. IPV. Age – at birth / at 6 weeks if not given at birth. tiny. Hib-Hep B. DTwP-Hib OPV.Combination Vaccine: Definition: - These are the vaccines which merge several antigen into a single vaccine that prevent against different disease or protect against multiple strains of infectious agent causing the same disease. typically (4-6 mm in diameter) Complications: Local Focal General Abscess Enlargement of draining LN Fever Indolent ulcer Suppurative lymphadenitis Disseminate BCG infection Keloid Otitis media Lupus vulgaris Osteomyelitis 52 . DPT. Dose – 0. Omega microstat syringe fitted with 1cm steel 26 gauge intradermal needle. round scars.1 mg in 0.1 ml Route – Intradermal by using tubercular syringe. Danish 1331 strain of BCG bacillus used. Phenomena after vaccination: BCG -----2-3 weeks- Populate at the site of vaccination -----5 weeks Increase slowly to 4-8 mm size 6-12 weeks Healing with permanent.

Typhoid c. Subsides within 2-3 months leaving a small scar. Delayed reaction: Papule takes 72 hours to appear and subsequent course takes place similar to the classical reaction. Significance: Negative test helpful in excluding TB Optional Vaccine: a. Hib d.Contraindication: - Generalized eczema - Infective dermatosis - Deficient immunity BCG Adenitis: - Enlargement of regional LN after BCG - In some cases. Type of reaction: a. they may form sinuses. Treatment: When axillary LN are unusually large INH will retard the progression and speed up healing. Pneumococcal 53 . Accelerated BCG reaction: Whole process is fast. b. Read on 3rd day. Classical reaction: Develops after 3 . Child shows the papule in few hours. BCG Test: Can be done directly with prior MT or if MT is negative. a pustule on third day and scab by 5 or 6 days. Hepatitis B b.6 weeks with erythema papule formation and occasionally ulceration. c.

2 months. 1. booster at 5 years High risk: 0. booster at 12 months given to infant born to Hepatitis B positive mother. Pneumococcal Vaccine: Type: Purified polysaccharide vaccine 14 valent and 23 valent. Indication: - Sickle cell disease - Anatomic or functional asplenia - Nephrotic syndrome - HIV infection Side effects: Hypersensitivity reaction 54 . Hepatits B surface antigen (HBsAg) (A recombinant vaccine) Dose: 0. Dose and site: Subcutaneous/im 1 dose booster not before 5 years. 1. which contain the principle envelope antigen. 6 months. 23 valent is more commonly used.Hepatitis B Vaccine: Content: Contain small envelope proteins.5 ml for children < 11 years 1 ml > 11 years Site: im Normal: 0.

Final stage consisting of mopping up by door to door immunization campaigns.Typhoid Vaccine: im: - Type: Vi polysaccharide vaccine - Age : after 2 years - Dose: 0. S. Sometimes additional component such as fimbrial antigen and pretactin is also present Administration: Given with diphtheria and tetanus toxoid as DPT. Supplementary immunization in the form of national immunization day or pulse immunization program. c.5 days – 1 capsule Oral: Polio Eradication: 4 point strategy: a.typhi Ty2la strain - Age: after 6 years - Dose: on 1. Booster every 3 years - Type: Live attenuated vaccine. High routine immunization coverage with OPV b. Effective surveillance system d. Acellular Pertussis Vaccine: Content: Inactivated pertussis toxin combined with filamentous hemoglutinin. also with Hepatitis B Advantage: Less reactogenic 55 .5 ml im single dose. 3.

Mantoux test: This is used to rule out tuberculosis. Technique: 1 mg in 1 ml of purified protein derivative of mycobacterium is taken and injected intradermally on the volar aspect of the forearm. Chemotherapy treatment d. it indicates significant – either the person is infected/immunized. Malnourished child 56 . Interpretation: Size: Inference 0-5 mm Negligible chance 5-10 mm Doubtful 10-20 mm Significant 20-30 mm Moderate infection > 30 mm Severe infection Clinical Significance: If the size of induration is > 10 mm. Condition of false negative: a. Reading: After 48 hours. Post measles b. Syringe used – Omega microstat syringe fitted with 1 cm steel 26 gauge intradermal needle. the size of induration felt (not the erythema). Immunocompromised c.

Hep B1 (BCG if not given at birth) 10 weeks – DPT -2. Hep B2 14 weeks – DPT -3. Hep B3 9 months – Measles 18-24 months . OPV zero dose 6 weeks – DPT -1.UIP At birth – BCG. OPV – I.DPT & OPV 5 years DT 10yr and 16 yrs TT For pregnant lady: Early in pregnancy TT-1 After one month TT-2 57 . OPV – III. OPV –II.

(immunity) Prevents paralysis but does not prevent infection Use Not useful in controlling epidemic Can be effectively used Cost Very costly. difficult to Cheap. 10. easy to manufacture manufacture Contraindication None 58 - Acute infections - Febrile illness - Diarrhea and dysentery - Malignancy - Corticosteroid therapy .5 TCI D50 Schedule 3 dose at 6-8 week interval Zero dose at birth. 14 weeks Route Im Oral Mechanism of Induce circulating antibody Prevent paralysis as well as intestinal action No intestinal immunity infection.Differences between IPV and OPV: IPV OPV History Developed by Salk Developed by Sabin Type Killed formalized vaccine Live attenuated vaccine Contents Type 1 – 40D Attenuated strain conc. 6. Type 2 – 8D Type 1 – 106 TCI D50 Type 3 – 32D Type 2 – 105 TCI D50 Type 3 – 105.

Generalized mass activity is replaced by specific individual responses F. Hypertrophy contributes to a lesser extent to the process of growth.GROWTH Define Growth: - It denotes a net increase in the size or mass of tissue which is due to multiplication of cells and increase in the intracellular substance. Dissociation: There is a sequence of development in each field but the development in one field does not necessarily run parallel with that in another field. Sequence of growth is same but pace can be non-uniform C. E. Different tissues of the body grow at different levels. Growth pattern of every individual is unique but general pattern is cephalocaudal. D. Continuous and orderly process B. Principles of growth: A. 59 .

IGF b. Gene mutation: Galactosemia g. fatty tissue b. LBW babies 4. Hormonal: thyroxine. Nutrition 60 . Parental characteristic c. Maternal malnutrition 2. Genetic disorder: 1. Sex – Pubertal growth spurt occurs 2-3 years earlier in female than males but mean height and weight attained at maturity is less than males e. Prenatal: 1. Children of multiple pregnancy 2. chest. insulin. Postnatal period: 1. Drugs: thalidomide 6. Chromosomal abnormalities: Down. turner 2. Climate 5. Neonatal convulsions 3. Natural resources 3. Environmental factors: a. Phenotype: head. Socioeconomic level 2. Genetic factors: a. Multiple pregnancies 3. Biorhythm and maturity f. Infection and infestation 6. Social factors: 1. Maternal infection – TORCH 5.Factors affecting growth: 1. CCF. Eclampsia 4. Race d. Medical illness in mother – CRF. Neonatal hypoxia 2.

Trauma 8. Emotional factors 9. Nancey and Bayley scale: - Measures motor and mental development 3. fine motor and adaptive. weight.7. Phatak’s Baroda screening test: - Modified form of Nancey and Bayley scale for use in India. Denver developmental screening test: - Assesses child development in terms of gross motor. social and language 2. personal. Height change in first five years: At birth – 50 cm 1 year 75 cm 2 year 85 cm 4 year 100 cm Birth length doubles at 4 yr Triples at 13 yr 2-12 yr = [Age(yr)x6] + 77 in cm 61 . Cultural factors How Do You Assess Physical Growth? It can be done by - Body measurement: height. head circumference. UL/LL ratio - Velocity of physical growth: by growth chart How Do You Assess Development? 1.

2 cm/month for 3 months 2.Head circumference: Birth – 35 cm 6 months 43. add to birth weight as follows: First 4 months – age in month x 0.5 cm/month for next 6 months 4. 0.6 kg Expected weight: between 3-12 months = ( ) between 1 to 7 years.5 cm 2 year 49 cm 1st 400 days = ( ) HC growth: 1. 1 cm/month for next 3 months 3.7 kg Third 4 months – age in months x 0.33 cm/yr for 7-12 years Weight changes: First year of life: For expected weight. 0. 0.5 cm/yr for 2-7 years 5. weight(kg) = ( between 7 and 12 years. weight (kg) = 62 ) .8 kg Second 4 months – age in month x 0.5 cm 1 year 46.

1 10 years 1. Aptly described as passport to child health care. Others: Identification.3 5 years 1. Diagnostic tool 3.U/L ratio At birth 1.7 6 months 1.5 2 years 1. Tool for teaching 8. immunization status. Growth chart / Road to health chart: Definition: - Visible graphical display of a child’s physical growth development primarily for long term follow up of child. become equal and later outgrows the head. 63 . registration. Growth monitoring 2. Tool for action 6. Educational tool 5.6 12 months 1.5 cm less than HC at birth By 9 – 12 months.9 Chest circumference: Normally 1. Evaluation 7.2 7 years 1. birth date and weight. Use of growth chart: 1.0 13 years 0.4 3 years 1. Planning and policy making 4. so that changes over time can be interpreted and progress of growth monitored.25 cm – 2.

Growth chart by government of India: 4 reference curves. plastic measuring tape midway between olecranon and the acromion.5 – 16. - Topmost – 50th percentile of WHO - 2nd line – 80% of topmost standard - 3rd line – 70% of topmost standard - 4th line – 60% of topmost standard Weighing of child: - 1 yr: every month - 2 yr: every 2 months - Till 5 years: every 3 months MAC It remains constant between 1 – 5 years of age in healthy children.5 Red 64 .5cm Moderate PEM 12.5cm green Mild PEM 13. The reason for it to remain constant is the replacement of body fat of infancy with muscle.5 Yellow Severe PEM <12. Grading and interpretation: Grade Circumference Shakir’s tape Normal >16.5 – 13. Technique: Measured with help of non-stretchable.

Trisomy 13 3.3 cm AP and transverse diameter Closure: 18 months Method of examination: - Child is in upright position and not crying or straining - Normal AF is slightly depressed and pulsatile Significance: - Reflects intracranical status: o Depressed in dehydration o Elevated in raised intracranial tension - Facilitates moulding of head - Monitoring of ICP by using fontanometer Delayed closure: 65 . Trisomy 18 (Edward’s syndrome) Anterior fontanelle: Anatomy: - Diamond shaped defect in frontal and parietal bone - Formed by joining of frontal. sagittal and coronal sutures - 3. dolichocephaly 2. below average head circumference Causes: 1. Down’s syndrome 4. Craniosyostosis: brachycephaly.Microcephaly: HC < 2nd SD deviation.

hypochondroplasia.- Rickets - Hypothyroidism - Prematurity - Raised ICP Short Stature: If the length or height of the child is below the 3rd percentile or less than 25D from the mean. Postnatal: 1. Proportionate short stature: a. Causes: 1. Achondroplasia. Intrauterine growth retardation 2. spondylo epiphyseal dysplasia (SED) 66 . Endocrine disorder 4. Constitutional delay in growth b. Psychological 2. osteogenesis imperfect. deformities due to rickets b. Prenatal causes: 1. With short limb: 1. Normal variants: 1. Nutritional dwarfism 2. Mucopolysaccharidosis. Familial 2. Chronic visceral disease 3. Disproportionate short stature: a. he or she is considered to be short in stature. Intrauterine infection 3. Genetic disorders c. With short trunk: 1.

Shows lack of cuddling and assumes infantile posture. 67 . Extrinsic: a. Inadequate response to social stimuli 6. Social and environmental deprivation or a combination of both 2.Short stature without MR: 1. Chronic visceral disease. GH deficiency: these gain less than 4 cm in height per year 4. kidney and liver Clinical Features: 1. Wide eyed expression/expressionless face and avoids direct gaze 4. Weight below 3rd percentile 3. Inadequate nutritional intake b. Constitutional delay 2. Marked preoccupation with thumb sucking 7. lactose intolerance b. The length of the child may or may not be affected. Vocalization delayed and motor activity curtailed 5. Chronic disease – of heart. Looks small for age 2. Metabolic disorder – diabetes mellitus d. Persistent vomiting – pyloric stenosis c. Nutritional dwarfism 3. lung. Failure to thrive: It is a term given to infants whose rate of weight gain is sluggish. Defect in absorption – coeliac disease. Causes: 1. Intrinsic: a.

Distended abdomen. umbilical hernia. an organic cause should be suspected. Goiter 6. Prolonged jaundice (hyperbilirubinemia > 7 days) 3. Physical examination: 1. Macroglossia 4. growth chart and evidence of intermittent improvement in growth performance. electrolyte. urine analysis Treatment: - Immediate and long term should be directed at both infant and the mother. Failure to thrive.Diagnosis: - Based on proper history. Hypothyroidism (congenital)/ cretinism: Etiology: - I2 deficiency - Thyroid dysgenesis - Thyroid dyshormonogenesis - Hypothalamic pituitary deficiency Clinical Features in infancy: - History of goiter in family - History of goiter/mental retardation in neighborhood. feeding problems 68 . - Hospitalization: non organic improve in 4 . delayed deciduous teeth 8. Otherwise. Delayed milestones. somnolence. Large posterior fontanelle (>1cm diameter) 2. constipation 7. Hoarse cry 5. - CBC.5 days.

9. Susceptibility to cold.5 µg/dl Treatment: Lifelong level thyroxine 10-15 µg/kg/day To bring T4 to 12-16 µg/dl a. Sexual development is infantile 5.<6. Neonatal screening: At 3-5 days of birth by heel prick/ear lobe prick and estimating T4 and TSH.s.p. Spastic diplegia b. Goiter e. poor hair and nail growth 10. Short stature in older children. Monitoring: - Symptoms and signs - Height and bone age - Hormonal assessment Clinical Features in older children: 1. 69 . In iodine deficiency cases: a. Markedly delayed bone age 4. Dull face with reaction time increased 9. Dry skin. Myxedematous ski and subcutaneous tissue 8. Cretinoid. Strabismus c. Waddling gait (maldevelopment of femoral epiphysis) 11. puffy face 7. Short and stocky 2. Usually TSH .a. Deaf mutism d.>50 mm/L T4 . Immature U/L segment ratio 3. Delayed puberty 6.

Secondary: a. Sacral agenesis b. On basis of time of the day. Both Causes: 1. b. Ectopic urethral opening 3. Diurnal – day c. Psychosocial factor – anxiety 3. Urinary tract obstruction 70 . On basis of achievement of control: a. Nocturnal – night b. Types: 1. Secondary: Child has been dry for several months and again starts bed wetting. a. Non organic: 1. Sleep disorder 2. Bladder neck obstruction 2. Organic: 1. Primary: Repeated (at least twice a week for at least 3 consecutive months) passage of urine into clothes/bed during night in a child ≥ 5 years who has never been dry in night. Primary: a.Enuresis: Definition: It is defined as normal nearly complete evacuation of the bladder at a wrong place and time at least twice a month after fifth year of life. 2. Developmental delay 2.

Diabetes Evaluation of child: 1. Counseling 2. Stressful situation or emotional difficulties: death in family or change of school/home c. Blood examination c. Frequency d. Type of enuresis Treatment: 1. History: a. Type of enuresis b. Urine analysis and culture b. Psychosocial history 3. Time of enuresis c. Lab evaluation: a. Other: a. Desmopressin . Imipramine b.↓urine output 5. Behavior modification 71 . Bladder training/bladder stretching 3.b. History related to organic pathology 2. Pharmacotherapy a. Age of child b. IVP .to rule out organic pathology Management: It depends on: a. Conditioning therapy (aversive conditioning) 4. Examination – to rule out organic cause 4. Oxybutine – decreases bladder reflex contractility c.

Restriction of fluid after dinner 6. Short. 1. Poor moro reflex and hyperflexibility of joints ** c. Psychotherapy c. Protruding tongue 6. Dysmorphic features: a. Other dysmorphic features: 1. Dysplastic pelvis ** ** Hall’s criteria – if ≥4 – strong possibility of Down’s 72 . Simian crease ** 3. Trisomy 21 (Down syndrome) Clinical Features: Children suffering from Down syndrome have dysmorphic features. Epicanthal folds 4. Skin – excess posterior neck skin ** 2. Facial features: 1. Treat the organic cause. upslanting palpebral fissure** 3. Cardiac defect – VSD.short hand and finger marked by incurved 5th finger ** 2. ASD e. Functional and structural abnormalities: a. Mental retardation d. Short ear with abnormal ear lobes** 5. also structural and functional abnormality. Clinodactyly . PDA. Hypotonia ** b.b. High arched palate b. Flat face** 2.

Complications: - Death due to congenital heart disease. respiratory infections - Chronic rhinitis - Conjunctivitis - Periodontal disease Autism: Definition: Autism is characterized by profound deficit in interpersonal and communication skills Autistic spectrum disorder is triad of: - Impaired social interaction - Impaired communication - Impaired imagination Etiology: - Intrauterine rubella - Fragile X syndrome - Phenylketonuria - Herpes simplex encephalitis Specific symptoms: - Onset before 3 years of age - Impaired social interactions - Impaired verbal and nonverbal communication - Restricted repertoire of activities and interest - Mental retardation 73 .

Breath holding spells: It is a conduct disorder due to some cause (being hurt or thwarted) where child holds his/her breathing. self abusive behavior.Management - Special education - Medical management: Only for associated problems like severe hyperactivity. limpness and convulsion) Types: - Cyanotic breath holding spells - Pallid type of breath holding spells Clinical Features: - Age: 6 – 18 months - Cyanotic type sequence: Child thwarted/hurt/frightened/frustrated ↓ Cry ↓ Breath held in expiration ↓ Increased intrathoracic pressure ↓ ↓Venous return ↓ ↓Cardiac output ↓ 74 . expiration which may lead to cyanosis (with or without hypoxia. aggression.

- Gross motor: walking without support - Fine motor: 1 year: - o Scribbles spontaneously o Child attempts to wear his socks or shoes without success Personal. social: o Mimicry of the action of mother at home o Repeat any performance which evoke appropriate response from parent 75 .Rigidity ± ophisthotonous ± limpness ↓ If hyperemia 10 – 15 sec ↓ Convulsions - Pallid: precipitated by minor injury or fright. baba) - Personal. cardiac arrhythmia. 2 years. Cyanosis is absent Investigations: Rule out other pathology like seizure. 3 years 9 months: - Gross motor – standing without support - Fine motor – pincer grasp - Language – bisyllables (mama. 1 years. Milestones achieved by following age: 9 months. brain stem tumor Management: - Reassurance and counseling to parents - The child should never drive any benefit from a breath holding episode - Dealing with an episode of breath holding – by purposeful neglect. social – waves bye.

Language: o Simple sentence using nouns without verbs o Uses pronouns 3 years: - - - Gross motor: o Riding tricycle o Climbs stairs in coordinated manner keeping only one foot on each step Fine motor: o Can draw a circle o Can dress or undress himself Language: o Vocabulary of 250 words.o Play simple ball game - Language: Two words with meaning - Gross motor: walking upstairs with one step at a time - Fine motor: 2 years: - o Can turn 1 page of picture book at a time o Can draw horizontal or vertical line o Can wear socks and shoes o Make tower of 4 cubes. o Telling a story. 76 .

000 IU 6 – 12 months 100. vitamins and other micronutrients WHO Classification of vitamin A deficiency: Primary Signs: X3B – Corneal ulceration (>1/3rd of X1A – Conjunctival xerosis cornea) X1B – Bitot’s spots X2 – Corneal xerosis Secondary signs: X3A – Corneal ulceration (<1/3rd of XN – Night blindness cornea) XF – Fundal changes XS – Corneal scarring Treatment of Vitamin A deficiency: Specific Vitamin A deficiency is treated by oral vitamin A Dose: Age Amount <6 months 50.000 IU Schedule: on day 0. 30 77 .000 IU > 1 year 200. 1.NUTRITION Complications of PEM: S – Sugar deficiency i.e hypoglycemia H – Hypothermia I – Infection and septic shock EL – Electrolyte imbalance DE – Dehydration D – Deficiencies of iron.

Sparse hair e. Papilledema This syndrome is known as pseudomotor cerebri 2. Vomiting and dizziness c. Weight loss d. Food. Complication: Definition: - Weaning means accustoming the infant to gradual introduction of nourishment other than mother’s milk. Bulging anterior fontanelle 2. Headache b. reduce pain and photophobia - Mydriatics Clinical Features of Hypervitaminosis A 1. Dry itchy skin c. Signs of raised intracranial pressure i. Solid food to replace breast feeding – to be started at 4 – 6 months and completed by 1 yr. prevent dehydration. Chronic: a.e 1. Acute manifestations: a.Local Treatment: - Antibiotic drops in case of corneal ulcer to prevent secondary infection - Padding in corneal ulcer to promote healing. hypoplastic anaemia Weaning: Principle. Hepatosplenomegaly. Weaning food: It should be: - Culturally acceptable 78 . Anorexia b.

Early signs: a. Problem of weaning: - Inadequacy in quantity/quality hence malnutrition - Unhygienic feeding practices leading to enteric infections and diarrhea - Personal likes and dislikes of child - Refusal of child to accept weaning food.- Adequate – providing all nutritional supplement - Locally available and inexpensive - Easily prepared at home. easily digestible. bland and nourishing. Craniotabes – feeling of crackling over parietal bones c. - First start with liquid. Head: 79 . sweating over head b. Flabby appearance b. Principle: - No generalized rule - Exclusive breastfeeding till 6 months and then start weaning food. Muscle weakness and ligament laxity 4. then semisolid. suitable. General features: a. Restlessness. Age: unusual below 3 months. - Clean and hygienic - Physiologically stable. Rickets: Clinical Features: 1. then solid - Give only one food at a time. Classically 6 months – 2 years 2. irritability. Rachitic rosary 3.

Spine: kyphosis. knock knees 8. tetany or convulsions due to hypocalcaemia Radiological Features: - Sites: growing bones of body around wrist and knee - Changes: o Fraying of metaphysis o Apparent in width of growth plate o Splaying of metaphysis o Cupping of metaphysis o Decrease in the bone density - Ribs: Rachitic rosary seen as headed enlargement of anterior metaphysis - Pelvis: Coxa vara - Spine: Kyphosis.a. Abdomen – a. Chest: a. scoliosis 7. Visceroptosis 10. scoliosis 80 . Pot belly b. Pigeon chest d. Long bones – bow leg. Teeth: carries. Fiddle-shaped chest 6. delayed dentition Swelling at wrist and ankle Laryngismus stridulus. Anterior fontanelle remain open beyond 18 month b. Pelvis – coxa vara 9. Rachitic rosary c. Bossing of head (hot cross bun appearance) 5. Harrison’s sulcus b.

Correction of deformities b. Medical: STOSS regimen Give 6 lac IU vit D3 oral/im ↓ Healing line in X ray after 3 – 4 weeks ↓ ↓ Yes no ↓ ↓ Give 400 IU daily till full recovery Repeat the dose ↓ Yes------------------------------------.Responded ↓ No ↓ Vit D resistant rickets Investigate further for cause 2. Surgical: a.Treatment of rickets: 1. Should be done after correction of rickets 81 .

25 ( ) MAC 0.16/ <0.88 – 0.arm circumference between age 1-5 years 1.32 – 0.5 cm 82 . Rao’s index 3.Age independent criteria for assessment of malnutrition: 1.5 / ≤12. Kanawati’s index: constant between 3 month – 4 years of age Name Methods - Rao’s - Kanawati’s - Dugdale’s - ( N/Severe PEM 0. Weight for height 2.33/ ≤0. Mid . Dugdale’s index 5.97 / ≤0. not in chronic (because both decrease but weight remains proportional to height) % weight for height = ( ) 2. Weight for height Sensitive in acute malnutrition.14 ) 0.15-0.79 > 13. Rao’s index: Constant between 1-5 years irrespective of gender 3. Kanawati’s index 4.

Classification of PEM: 1.<50% of expected weight 4. Udani classification for marasmus: - Grade 1 – Loss of fat from axilla and groin - Grade 2 – Loss of fat from abdominal and gluteal region - Grade 3 – Loss of fat from chest and neck - Grade 4 – Loss of buccal pad of fat 3. WHO Classification: Moderate Severe undernutrition undernutrition Symmetrical edema No Yes (edematous malnutrition) Weight for height 70-79% of expected (measure of wasting) wasting Height for age 85 – 89 % of expected (measure of stunting stunting) 83 <70% severe wasting < 85% severe stunting . Wellcome classification: Weight Edema Inference 60-80% of expected - Underweight 60-80% of expected + Kwashiorkor < 60% - Marasmus < 60% + Marasmic kwashiorkor 2. IAP Classification: - Grade I – 70-80% of expected weight - Grade II – 60-70% of expected weight - Grade III – 50-60% of expected weight - Grade IV .

Marasmus Clinical Features: - Age: highest incidence seen in infancy - General features: - - - o Gross wasting of muscle. dry and loose. poor muscle tone o Loss of subcutaneous fat o Bony prominences are seen Skin: o Wrinkled. inelastic o Folds prominent over glutei and inner thigh Psychological: o Appears alert but irritable o Voracious appetite Growth: o - Marked deficit in weight and to a lesser extent in height GIT: Distended abdomen Kwashiorkar Clinical Features: - Age: Older children 84 .Weight for height Height for age Label ≥80% ≥90% Normal ≥80% <90% Stunted <80% ≥90% Wasted <80% <90% Wasted and stunted Malnutrition definition: - It is the condition caused by an imbalance between what an individual eats and what he requires to maintain health Or - PEM is the term applied to a class of clinical conditions consisting of classifiable and non-classifiable manifestation of protein lack and energy inadequacy.

5 g Proteins 1. easily pluckable Mental changes: - o Lethargic.- General features: o Pitting edema – “Sine qua non” for establishing diagnosis - Muscle wasting: Present but may be masked by edema - Face: Moon face - Skin: - o Flaky paint dermatosis o Dry inelastic mosaic appearance Hair changes: - o Flag sign present o Thin.5 g – well absorbed Ca 34 Vitamin K Deficient Vitamin D Water soluble 0. sparse.3 g Fe 0.5 g 117 85 .1 g 3. dry. listless and apathic o Takes little interest in the environment and does not play with his toys GIT: o Impaired appetite o Hepatomegaly Difference between breast milk and cow milk: Feature Breast milk Cow milk Calories 67 kcal 65 kcal Lactose 7g 48 g Fat 3.5 g 3. brittle.

DM in their later life - Less chances of sudden infant death syndrome Contraindication of breast feeding: - PKU - Galactosemia - Mother on anticancer drugs - HIV Positive mother 86 . Nutritive value and digestibility 2. Protects from allergy 4. Other benefits Nutritive value and digestibility: - Easily digestible - Complete nutrition - Lower protein – lower load on kidney - More whey protein which form fine curd and easily digested - High amount of PUFA - Protects against neonatal hypocalcaemia - Well absorbable form of iron prevents IDA Other benefit: - Higher IQ - Less chances of developing HTN. Low risk of infections 3. Emotional bonding 6. obesity.Advantages of breast milk: 1. Economic Factors 8. Physiological adaptation 5. Maternal advantage 7.

vitamins are permitted if indicated. scaly Flaky paint dermatitis Hair damage Hypopigmented Flag sign Moon face - + Hepatomegaly - + Clinical features: 87 . mineral drops. Medicine. Difference between kwashiorkor and marasmus: Essential features Marasmus Kwashiorkor Edema - + Loss of fat Present Less obvious Muscle wasting Severe Less Growth retardation More in weight Both are les Appetite Good Poor Skin Dry. not even water is given. No other food or drink. An infant should be exclusively breast fed for first 6 months of life.Exclusive breast feeding: Definition: Only breast milk is given to baby.

BLOOD
IDA: C/F, Lab diagnosis, Response to iron therapy, PS findings:

Clinical Features:
Symptoms:
-

Failure to thrive

-

Appear off color and easily fatigued

-

Suffer from frequent infection

-

Pica

-

Mental performance is reduced

-

Attention span decreased

-

Anorexia

Signs:
-

Pallor

-

Tongue papillae are atrophied

-

Koilonychia

-

Thin brittle and flat nails

-

In case of CCF, cardiac enlargement, systolic murmur, JVP raised

Lab Diagnosis:
1. RBC Changes:
a. Hb, PCV, MCH, MCV, MCHC – All decreased
b. PS –
1. Microcytic, hypochromic red cells
2. Anisocytosis
3. Poikilocytosis
4. Reticulocyte count decreased

2. Marrow changes:

88

a. Persian blue staining – decreased iron stores

3. Iron studies:
a. Serum iron – low <30 µg/dl
b. TIBC – increased >350µg/dl
c. Transferrin saturation – less than 15%
d. Serum ferritin – less <10 ng/ml

Response to iron therapy:
-

Child becomes less irritable in 24 hours and appetite improves

-

Initial marrow response is observed within 48 hours

-

Rise in reticulocyte count occurs by 2nd or 3rd day

-

Elevation of Hb level

Treatment of IDA:
-

Treatment of underlying cause

-

Deworming, change in dietary habit

-

Wearing of shoes

-

Iron therapy

Thalassemia:

Peripheral smear:
-

Microcytic hypochromic cells

-

Anisocytosis – tear drop cells, target cells

-

Poikilocytosis

-

Marked basophilic stippling and various polychromasia

-

Fragmented RBC

-

Reticulocyte count is increased

Clinical Features:

89

-

Progressive pallor

-

Mongoloid facies: bossing of skull, prominent frontal and parietal eminence with
flattened vault. Prominent malar eminences, depressed nasal bridges and puffy
eyes.

-

Marked growth retardation

-

Poor feeding

-

Recurrent infections

-

Hepatomegaly

Complication of iron over load:

-

Growth failure

-

Hypogonadism

-

Diabetes

-

Hepatic disease (hemochromatosis)

90

pneumonia 2. Encephalitis and subacute sclerosing panencephalitis (SSPE) 3.5 ml subcutaneous Schedule: 9 – 10 months with vaccination at 15-18 months of age Contraindications: - Leukemia - Lymphopenia - Those on steroid/antimetabolite therapy - Child suffering from TB 91 . Other – acute glomerulonephritis. DIC Measles eradication: MMR Vaccine: Content: - 1000 CCID50 live attenuated measles virus - 5000 CCID50 live attenuated mump virus - 1000 CCID50 live attenuated rubella virus Dose: 0.INFECTIONS Measles complications: 1. hepatitis 4. Respiratory tract: otitis media. appendicitis. Digestive system – Persistent diarrhea. laryngitis. Malnutrition – vitamin A deficiency 5.

nausea. Aseptic meningitis b. Encephalitis c. non-capsulated. Spasm of neck muscles – mouth kept open 92 . Incubation period is about 18 days 2. Extra salivary manifestation: a. Fever. Swelling disappears in 6-10 days 4. Opening of Stensen’s duct appears red d. Excessive unexplained crying. Age: 5 – 10 days after delivery 2. mobile. refusal to feed.Mumps complication: - Orchitis - Epididymitis - Pancreatitis - Oophoritis - Nephritis Mumps Clinical Features: 1. head ache. Auditory nerve damage leading to deafness Tetanus neonatorum Agent: C. anaerobic spore bearing bacillus) Clinical Features: 1. Parotid swelling c. malaise and loss of appetite 3. apathy 3. Pain near ear lobe and difficulty in chewing within 24 hours b. Salivary manifestation: a. GBS d. tetani (gram positive.

Management: 1. General supportive measures 2. Antibiotics 5.4. Constitutional symptoms: 93 . Immunization (passive by toxoid) 3. Jaundice and pancreatitis 5. Intestinal obstruction by round worm bolus 4. Tracheostomy and assisted ventilation 6. fluid and electrolyte balance 4. Lock jaw/trismus 6. Spasm of larynx and respiratory muscle characteristically induced by stimuli of touch. Intussusception 3. Risus sardonicus 7. Masseter spasm – difficulty in feeding 5. loss of accommodation and general polyneuritis - Renal – oliguria and proteinuria Clinical Features: 1. Nutrition. Gall bladder disease 6. Peritonitis Diphtheria Clinical Features and 3 complications: Complications: - Myocarditis - Neurological – palatal paralysis. noise or bright light results in apnea and cyanosis. Malnutrition 2. Central of spasm by diazepam Complication of Ascariasis: 1.

Laryngotracheal diphtheria Membrane over the larynx results in brassy cough. Malaria: Complication: - Algid malaria - Acidosis - Anemia - Black water fever - Cerebral malaria - DIC - Pulmonary edema - Renal failure (acute) - Hypoglycemia Treatment: - Chloroquine sensitive malaria: o Chloroquine 10 mg base/kg stat followed by 5 mg base/kg at 6. Local Manifestations: a. Nasal diphtheria – nasal discharge and excoriation of upper lip b. The membrane bleeds on being displaced. 48 hours.a. Faucial diphtheria – redness and swelling over fauces. headache and loss of appetite b. hoarse voice. c. Malaise. Sensorium is clouded 2. Child looks toxic with fever c. 24. Pseudomembrane – formed by exudate over tonsils. Repeat the dose if child vomits within 30 min - Chloroquine resistant: o Quinine 10 mg salt/day orally TID x 7 days 94 .

Or o Pyrimethamine 1. pneumothorax. Chemoprophylaxis: - Chloroquine sensitive: Chloroquine – 5 mg/kg daily - Chloroquine resistant: Doxycycline 2 mg/kg daily - Begins 1 week before entering the area (doxycycline is started 1-2 days before departure) and continued for 4 weeks after leaving transmission area. Or o Artemether 3.2 mg/kg im (loading dose) followed by 1. seizure - Severe malnutrition - Subconjunctival hemorrhage - Gastrointestinal manifestation - Hernia and rectal prolapse 95 . followed 8 hrs later with 10 mg salt/kg (maintenance dose) over 4 hours 8 hourly. until child can swallow oral quinine 10 mg/kg TID to complete 7 days of treatment.25 mg/kg + sulfadoxine 25 mg/kg as a single dose orally Or o - Mefloquine 15 mg base/kg orally stat followed by 10 mg/kg 12 hours later. pneumonia. encephalopathy. Pertussis complication: - Respiratory system: o - Bronchiectasis.6 mg/kg im daily for 6 days. intracranial hemorrhage. Complicated malaria: o Quinine 20 mg salt/day (loading dose) diluted in 10ml/kg 5% dextrose iv over 4 hours. otitis media CNS: o Convulsions.

old child: - It is defined as illness of more than 6 week duration documented fever above 101 oF (38. Causes: 1. myocarditis and pericarditis PUO Causes in 6 yr. lung. Bronchopneumonia c. osteomyelitis 96 . Collapse/consolidation Hepatitis B – Extrahepatic manifestations: - Serum sickness like syndrome - Essential mixed cryoglobulinemia - Polyarteritis nodosa - Membranous or membranoproliferative glomerulonephritis - Severe aplastic anemia - Pleural effusion. Infection: a. Skeletal TB 2. Miliary TB b. lack of specific diagnosis after 1 week of admission and investigation in a hospital setting. Adenitis b.3 oC) on multiple occasions.Complications of primary complex: 1. Local: abscess brain. Local spread: a. intraabdominal. Bronchiectasis d. TB meningitis c. Bacterial: 1. Hematogenous spread: a.

Chlamydial infection f. neuroblastoma 4. filariasis d. Capriomycin. Rickettsial infection e. Malignancy : Wilm’s tumor. Miscellaneous a. Parasitic: Malaria. Rifampicin. Fungal: histoplasmosis. Malingering b. SLE 3. rheumatic fever. Floroquinolone and any of the following three injectable drugs Amikacin. Metabolic: Storage disorders MDR TB definition: WHO defines a MDR strain as one that is at least resistant to INH and rifampicin XDR TB: Resistance to INH. Munchausen syndrome by proxy 5. infective endocarditis. brucellosis b. X-Ray finding in pulmonary TBL - In asymptomatic – no findings - Hilar opacities - Apical consolidation - Calcification in healed lesion - Fibrosis in healed lesion - Cavitary lesion 97 . AIDS c. toxoplasmosis. candidiasis 2. Viral: Infectious mononucleosis. kala azar. Kanamycin. Collagen disorder : IRA.2. Generalized: TB.

↑↑ - AFB staining of sputum – positive - Antibody against TB Enteric Fever: IP. clinical features. Complications: - Oral: parotitis - Chest: pneumonia and pulmonary infarct 98 . complication.Disseminated TB – 2yr child – lab features: - ESR . child may have typhoid state in which child has muttering delirium and may pick at bed clothes. diagnosis. treatment Incubation period: 14 days (3 – 60 days) Clinical Features: - First week of illness: o Step ladder pattern of fever not seen which is characteristically seen in adults - - o Sudden onset fever with headache and vomiting o Fever is continuous with little diurnal variations o Constipation o Coated tongue at center. Second and third week: o Abdomen distended and gives a tympanic note on gentle percussion o Spleen palpable o Rales over bases of lungs In severe toxemia. o Typhoid rash (nose spots) occurs on 6th day of illness.

pancreatitis - GIT – Diarrhea. encephalitis - Musculoskeletal – chronic osteomyelitis - Other – Alopecia.- Heart – myocarditis - Liver and GB – Fatty liver. constipation - Neurological – meningitis. uveitis Diagnosis: Clinical signs pathognomic of typhoid: - In endemic area. cholecystitis. hepatitis. typhoid should be a diagnostic possibility in all fevers > 7 days duration. especially those without localizing signs - Bradycardia Lab diagnosis: - - - Hematology: o Moderate neutropenia leading to relative lymphocytosis o Thrombocytopenia Blood culture: o Blood – 1st week o Stool and urine – after 2 weeks Serology – Widal test o Diagnostic titer of > 1 in 80 after 7 – 10 days of illness o 4 fold rise in titer is diagnostic Treatment: - - Specific: o Amoxicillin – 100 mg/kg/day in 4 divided doses – 10-14 days o Ceftriaxone – 50-100 mg/kg/day iv for 5-7 days o Corticosteroid in children with altered mental state or shock Supportive treatment: o Good nursing care 99 .

anorexia - Epigastric cramps Treatment: Albendazole – 400 mg OD x 5days 100 .o Nutritious diet o Fluid and electrolyte o Antipyretics: - Treatment of complications: - Treatment of carriers: o Ampicillin 200 mg/kg/day oral for 4 – 6 weeks Giardiasis: C/F Most cases are asymptomatic Symptoms: - Incubation period – 1-2 weeks - Sudden onset explosive watery foul smelling stool - Abdominal distension - Flatulence - Nausea.

or midline tumor with bilateral regional LN involvement Stage 4: Dissemination of tumor to distant LN. bone marrow. bones. 101 . both positive LN. identifiable ipsilateral and contralateral lymph nodes negative microscopically. identifiable ipsilateral and contralateral lymph nodes negative microscopically Stage 2B: Unilateral tumor with complete or incomplete gross excision. skin and/or bone marrow. identifiable contralateral lymph nodes negative microscopically. with or without microscopic residual disease. Stage 2A: Unilateral with incomplete gross excision. Complete gross excision. Stage 3: Tumor infiltrating across the midline with or without regional LN involvement or U/L tumor with contralateral regional LN involvement.MALIGNANCIES Neuroblastoma Staging: INSS (International Neuroblastoma Staging System) Stage 1: Localized tumor confined to area of origin. liver and/or other organ (except as defined in stage 4s) Stage 4S: Localized primary tumor as defined for stage 1 or 2 with dissemination limited to liver.

purpura. bleeding - Expanding cell mass in marrow – bone pain - Raised ICT – nausea.Acute Leukemia: History and examination findings: History: - Anemia – pallor. 15-35 years and Peak around 60 years 45-70 years Symptoms common Less common Usually well localized at the time of Usually widespread at the time of diagnosis diagnosis Unifocal origin and contiguous spread Multicentric origin and noncontagious spread Involvement of extralymphatic organs is Early involvement late Waldeyer’s ring involvement is uncommon Waldeyer’s ring involvement is common Epitrochlear node involvement rare Common BM involvement late Early Early involvement of paraaortic node Late Alcohol present Absent 102 . malaise - Neutropenia – fever. o - Bony tenderness. vomiting Examination: - Anemia – pallor. hepatomegaly and splenomegaly Raised ICT – papilledema HL and NHL differences: HL NHL Bimodal peak incidence. tiredness. infections at various site - Thrombocytopenia – petechiae. lymphadenopathy. hyperdynamic circulation feature - Expanding cell mass in marrow and other organs.

Allergic: Laryngeal edema Investigations: 1. Infection: Laryngitis.MISCELLANEOUS Stridor: Noisy respiration produced by turbulent air flow through the narrowed air passages. Mechanical: Foreign body. X-Ray: a. Direct laryngoscopy without anesthesia 3. Nutritional: Tetany 7. enlarged tonsils 3. retropharyngeal abscess 4. Congenital: laryngomalacia. 6. CT scan 2. Angiography of aberrant vessel suspected c. epiglottitis. laryngoscopy and esophagoscopy 103 . Soft tissue neck – AP and lateral b. tongue and jaw abnormalities 2. inhalation burns 5. Paralysis: Bilateral vocal cord paralysis. stenosis. central paralysis due to CP. Trauma: Intubation. General anesthesia followed by bronchoscopy. Etiology: 1. laryngeal web. diphtheria. hemangioma.

WHO has recommended certain clinical criteria for diagnosis of pneumonia in children at primary health center for control of ALRTI by judicious use of cotrimoxazole. Criteria for diagnosis of pneumonia: - Rapid respiration - Difficulty in respiration/chest indrawing Clinical classification to facilitate treatment: Sign/symptom Classification Therapy Where to treat -Cough/cold No pneumonia Home remedies Home Pneumonia Cotrimoxazole 5 days Home Severe In/im penicillin Hospital Iv chloramphenicol Hospital -No fast breathing -No chest indrawing or indication of severe illness -Resp rate ≥60 <2 months ≥50 2mts-1yr ≥40 -Chest indrawing pneumonia -Cyanosis Very severe -Severe chest indrawing -Inability to feed 104 .ARI Control program: - Acute lower respiratory tract infection is a leading cause of mortality in children below 5 years.

DT. BCG and diluents 105 . Vaccines kept in freezer compartment: polio.Daily dose of cotrimoxazole: Age/wt Tablet Syrup – 1 spoon = 5ml Sulfamethoxazole SMX – 200mg 100mg Tri – 40mg Trimethoprim 20mg <2 months One tab BD ½ spoon BD Two tab BD 1 spoon BD 3 tab BD 1½ spoon BD 3-5 kg 2-12 months 6-9 kg 12-60 months 10-19 kg Signs of severe diseases in < 2 months: - Convulsion - Abnormal sleep or difficult to wake - Stridor in calm child - Not feeding well - Tachypnea - Chest indrawing - Cyanosis - Altered sensorium Cold Chain: Definition: - It is a system of storage and transport of vaccines at low temperature from the manufacturer to the actual vaccination site. measles Vaccines kept in cold compartment: DPT. TT.

 - These can store vaccines up to 3 months and supply 4-5 districts District level: Deep freezers 300 l.Cold chain equipment: - Regional level: Walk in cold room.  ILR (Ice lined refrigerator) 300 liter  Deep freezer are for making ice packs and to store OPV and measles vaccine - - PHC Level:  Deep freezer 140l  ILR 140l Peripheral center:  Cold box – vaccine carriers (these can carry 16-20 vials for outreach seasons)  Day carriers (can carry 6-8 vials)  Ice packs Underfive clinics: It combines the concept of prevention. nutritional surveillance and education into a system of comprehensive health care within the resources available in country. Aim and objective: Care in illness Growth monitoring Preventive care 106 . treatment. health supervision.

X-Ray and laboratory services c. Preventive care: a. Growth monitoring: By use of growth chart Child Labour: In 1973 ILO passed a convention establishing 15 years as minimum work age for most sectors while permitting light work from age 13. - Child labour contributes about 20% of GNP - Maximum number of child labour are in J&K mainly engaged in carpet weaving industry Causes: - Poverty 107 . Care in illness: a. Health education 3.1. Family planning f. Health checkups d. Oral rehydration e. Referral services 2. disorders of growth and development b. provided that such work was unlikely to harm child’s health. Nutritional surveillance c. morals or safety or prejudice his school attendance. Diagnosis and treatment of illness. Problem statement: - India fosters the largest number of child labour in world. Immunization b.

1U/kg over 90 min - Exchange resins - Dialysis – this is more beneficial in ARF as the above measures give transient benefit 108 . protect child labour against abuse.5-1 ml/kg over 5-10 min - NaHCO3 7.5% .1-2 ml/kg over 10-20 min - Nebulized salbutamol – 5-10mg - Iv glucose 0. - It also regulated the condition of work where child labour is permitted. Hyperkalemia: treatment in child with ARF due to PSGN. It is a serious emergency as the resultant cardiac toxicity may cause sudden death.- Unemployment - Lack of education The Child Labour (Prohibition and Regulation) Act 1986 - This act was implemented to protect children against child labour. Treatment: - 10% calcium gluconate – 0.5 g/kg along with soluble insulin 0. exploitation and health hazards.

CASES 1. 12. Diagnosis? Management? 5. Likely cause and basis of this 7. 3. 5 year old child – puffiness of eyelids 2 days duration. Investigation? 9. 10 year male – 20kg. Diagnosis? Management? 2. On examination pallor. 10 year old child – cola colored urine. cold peripheries. management.8 kg H/O intermittent sucking. 110cm – assess nutritional status and order investigations. 110cm. urinary findings. 2 year female . findings and work up? 11. Balanced diet for 1yr. hepatosplenomegaly. has ecchymotic patches. Birth weight – 3kg. 8 year old child. Investigation and interpretation? 6. history taking.fever 1 week. Generalized convulsions on morning of admission. Examination: irritable. DD and lab investigations. 10. Examination. 4 complications. Investigation in suspected case of pallor in 3 year old child with interpretation. 8. 6 year old child with fever 10 days is found to be pale. Diagnosis. 2 weeks duration. 2 year old child H/O not walking. BP – 80/40. 4. Anemia and hepatosplenomegaly – 3yr old child. DD. 3 yr old child. 109 . fever + 8 large stools + vomiting 1 day duration. 2 year old child 12 kg. Treatment of 10 kg child with severe dehydration due to acute diarrhea of 1 day duration 13. 2 month old child 3. 24 kg. HR – 130.

IMPORTANT MILESTONES Gross motor: - 3 month - Neck holding - 5 month - Sitting with support - 8 month - Sitting without support - 9 month - Standing with support - 10 month - Walking with support - 11 month - Crawling (creeping) - 12 month - Standing without support - 13 month - Walking without support - 18 month - Running - 24 month - Walking upstairs with one step at a time - 36 month - Riding bicycle - 4 month - Grasp a rattle/ring when placed in hand - 5 month - Bidextrous grasp - 7 month - Palmar grasp - 9 month - Pincer grasp - 12 month - Feeding himself with spilling - 15 month - Feeding himself without spilling - 18 month - Feed himself from a cup with little spilling - 12-24 month- Scribbles - 2 year - Horizontal or Vertical strokes - 3 year - Copies circle. plus - 5 year - Copies triangle. can dress/undress himself - 4 year - Copies square. cross 1 month - Turns head to sound Fine Motor: Language: - 110 .

mimics mother - 36 month - knows gender 111 . 6-7yr accurate Vision: Personal.- 3 month - Cooing - 6 month - Monosyllables - 9 month - Bisyllables - 12 month - Two words with meaning - 18 month - 10 words with meaning - 24 month - Simple sentence - 36 month - telling a story - Binocular vision - 3-6 months - Depth perception - 6-8 month begins. social: - 2 month - Social smile - 3 month - Recognize mother - 6 month - Smiles at mirror image - 9 month - waves bye - 12 month - plays a simple ball game.