CRACK PAEDIATRICS NOTES

MODIFIED DINESH NOTS BY Dr DEEPAK SENANI – Dr SURENDRA KUMAR- Dr MAHESH KUMAR

SINGH AND Dr RAJAN JAISWAL

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

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 c. Proteinuria: 1+/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
4. Antibiotics:
- Benzathine penicillin im single dose –
o <20kg: 0.6 million units
o >20kg: 1.2 million units

5. Hypertension:
- Mild – Salt and water restriction
- Other – Atenolol

6. 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,
generalized edema and associated hyperlipidemia.

Values:
a. Proteinuria:
>40mg/m2/hour
>1g/m2/day
>50mg/kg/hour
3+/4+ by dipstick
b. Hypoalbuminemia
Serum albumin <2.5g%
c. Hyperlipidemia
Cholesterol >250mg%

4
Investigation:
A. To confirm the diagnosis:
a. CBP: Anemia
Leukocytosis
b. ESR: Elevated.
c. Urine: Proteinuria 4+
Hematuria +/-
WBC to rule out UTI
d. Serum Albumin:< 2.5g%
e. Serum Cholesterol: > 250mg%
f. Serum BUN & Serum creatinine – MCNS – Normal, other ↑

B. To rule out infection:

a. Blood culture
b. Mantoux test – TB
c. X Ray chest – Pneumonia, TB
d. Urine culture
e. Peripheral smear – malaria
f. Australia Ag – Hepatitis B
g. VDRL – Syphilis

C. Additional test in case of

a. Atypical
Frequent relapses
Resistant to steroids
 C3 level - ↓ in GN while in Nephrotic
 ASO titer - ↑ in GN
 Throat swab - + in GN
b. SLE/RA/etc. suspected
ANA
Ds DNA
RA factor

5
D. Other:
a. USG Abdomen
b. Renal Doppler
c. Ascitic tap

COMPLICATIONS:
1. Thromboembolism:
Causes:
Increased level of fibrinogen, factor V, VIII, platelets  Enhanced coagulation
Decreased level of Antithrombin III, Factor IX and XI  Low ability to limit coagulation
2. Infection: (↓IgG due to low protein, steroid)
SBP, TB, Viral infections - chicken pox/measles
3. Growth retardation:
Due to: ↓Protein deficiency
Anorexia
Steroid
4. Cardiovascular disease
5. Anemia
6. Hyponatremia
7. Hypertension
8. ARF
9. Hypocalcaemia
10. Complications of steroid therapy.

TREATMENT:
A. General:
a. Diet: Salt restriction
Fluid restriction
Maintenance of protein
b. Complication:
I. Thromboembolic episode
 Proper fluid management

6
  Prevent immobilization
 Antiplatelet agent
 Anticoagulants
II. Infection : Antibiotics
III. HTN: ACE inhibitor – Enalapril
CCB – Nifedipine
IV. Anemia – Fe
V. Hypocalcaemia/Hyponatremia
c. Edema:
Diuretics – Furosemide 1.4mg/kg/day
Human Albumin Infusion – when human albumin falls below 1.5g%

B. Specific:
SKDC Regime:
Prednisolone – 2mg/kg/day – 3 divided doses X 4 weeks
1.5 mg/kg/day – single morning X 4 weeks.
Initial episode:
Prednisolone – 2 mg/kg/day X 6 weeks
1.5 mg/kg/day on alternate day X 6 weeks
First 2-3 relapses:
Prednisolone – 2 mg/kg/day X 2weeks
1.5 mg/kg/day on alternate days X 4 weeks
Frequent relapse/dependence:
a. Alternate day prednisolone 0.3- 0.7 mg/kg X 9-12 months
b. Cyclophosphamide X 2 mg/kg/day
+
Prednisolone 1.5 mg/kg/alternate day duration – 12 weeks

Posterior Urethral Valve:

Definition:

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It is a congenital anomaly of the urinary tract and is an important cause of distal urinary tract
obstruction.
Clinical Features: (Boys > Girls)
1. In-utero: severe obstruction may lead to renal dysplasia.
2. At birth: Mild to moderate impairment of renal function
3. 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 > 5-
10/mm3 and > 105 organism/ml on urine culture (preferably single type of organism)

Predisposing factors:
a. Vesico ureteric reflux.
b. Obstructive uropathy.
c. Neurogenic bladder (associated with meningomyelocele, tumor, trauma at lumbosacral
region)
d. Malnutrition
e. Immunosuppressive therapy.

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 f. Circumcision may protect against UTI

Sample Collection:
a. Supra pubic aspiration
b. Urethral catheterization 2 years
c. Clean catch midstream urine > 2 years

Investigation:
a. ESR, CRP - ↑↑
b. USG – Renal abnormalities
c. Urine microscopy and culture:
> 10 WBC / mm3
> 105 bacteria/ml on culture

Second UTI:
Investigations:
a. USG
b. IUP
c. MCU
d. DMSA scan for pyelonephritic scans
e. 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, granular cast Cellular and granular cast
- Oliguria Rare

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 - Proteinuria 1+/2+ Massive proteinuria,
> 2 g/day
>40 mg/m2/day
>1 g/m2/day
>50 mg/kg/hour
3+/4+ dipstick

Causes of ARF in Children:

Prerenal:
o Acute gastroenteritis
o Hemorrhage, shock
o CCF

Renal:
a. Acute tubular necrosis
b. Glomerulonephritis
c. Hemolytic uremic syndrome
d. Interstitial nephritis

Post renal:
a. Calculus
b. 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

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- Urine culture after 1 week, 1 month and then 3 consecutive months to ensure complete
clearing

b. Recurrent attack:
Co-trimoxazole, 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.
3 weeks – 3months: 3 months
> 3 month: no prophylactic treatment

CRF Clinical Features:

- Frequent passage of urine, nocturia and increased thirst

- Anemia
- Failure to thrive
- Growth retardation
- Hypertension
- Bony deformities
- Malnutrition
- Peripheral neuropathy
- Proximal muscle weakness

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 GIT
Dehydration/Oral Rehydration Therapy

What is oral rehydration therapy?

It is the core of management of diarrhea.
It includes:
a. Complete oral rehydration with salt solution with composition within the
WHO recommended range.
b. Solution made from sugar and salt. (40g + 4g/L)
c. Food based solution. Rice water (50 + 40g/L)
d. In presence of continued feeding, a variety of commonly available, culturally
acceptable fluid irrespective of presence of glucose or without salt when
former is present.

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, not Thirsty, drink eagerly Drink poorly, not able
thirsty to drink

Skin pinch Goes back quickly Slowly Very slowly

Decide No Some Severe

Treat Plan A Plan B Plan C

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 Weight loss 2-5% 5-10% ≥ 10%
Achars Mild Moderate Severe

ORS Composition:
New Old
NaCl 3.5 3.5
KCl 1.5 1.5
Citrate 2.6 2.9
Glucose 13.5 20
Water 1 liter 1 liter

Advantage of citrate:
a. More stable product
b. Longer shelf life
c. Less stool output
d. Increases intestinal absorption of sodium and water.

IV Rehydration solution:
1. Ringer lactate/ Hartmann’s solution
2. Diarrhea treatment solution
3. Normal saline

Plan A:
a. Educate mother to use increased amount of home available food.
b. ORS should be given.
c. Return to health worker if
Not corrected in 3 days
1. Danger signs:
i. Many watery stool
ii. Repeated vomiting.
iii. Marked thirst
iv. Eating/drinking poorly

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 v. Fever
vi. Blood in stool

Plan B:
It has 3 components:
a. Rehydration therapy.
b. Maintenance therapy
c. Provision of normal daily requirement.

a. Rehydration therapy:
Give 75 ml/kg of ORS in first 4 hours.
b. Maintenance:
Begins when signs of dehydration disappear - normally within 4 hours
ORS should be equal to diarrhea losses – approximately 10-20 ml/kg body
weight/liquid stool
c. Provision for normal daily requirement.
Breast feed even during rehydration.
Semisolid food soon after deficit replacement

Plan C:
a. Start IV fluids immediately.
While the drip is being setup, give ORS if the child can drink.
Solution used:
1. RL + Dextrose 5%
2. RL
3. 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 - 5yr 30 min 2 ½ hours
Repeat if radial pulse is weak.

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 b. Cannot give IV.
Start rehydration with ORS using nasogastric tube at 20ml/kg/hr (total 120
ml/kg)
Reassess every 1-2 hr.
If vomits or there is abdominal distension, give slowly
If no improvement after 3 hours try to start IV fluids as early as possible.

When they can drink give ORS at 5 ml/kg/hour

Monitoring: Every 1-2hr: Radial pulse, skin pinch

o If improvement but still showing some signs of dehydration, start Plan B and
discontinue IV fluids.
o Observe child for at least 6 hours before discharge, to confirm that mother is able to
maintain the child’s hydration with ORS.

Portal Hypertension:

Definition:
It is defined as elevation of portal venous pressure in valves above 10-12 mm Hg.

Causes:
a. Cirrhosis – Post viral, autoimmune hepatitis, Wilson’s disease.
b. Budd-Chiari syndrome
c. Veno-occlusive disease

Signs of Liver Cell Failure:

a. Jaundice
b. Diminished body hair
c. Spider naevi

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 d. Palmar erythema
e. Clubbing, White nails
f. Dupuytren’s contracture
g. Flapping tremor
h. Ascites
i. Gynaecomastia
j. Testicular atrophy Adults only
k. 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.

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, frothy, greenish yellow, sour smelling stool
- Perianal excoriation

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 - Failure to thrive
- Abdominal distension
- Borborygmi, flatulence

Investigations:
- Stool pH <5.5

Reducing substance >0.5%

- Lactose tolerance test

- Interstitial enzyme activity by biopsy

Treatment:
- Primary – Eliminate lactose from diet
- Secondary –
 Treatment of primary cause.
 Lactose free diet if persistent diarrhea, weight loss, reducing
substance >1%

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 CVS

Cyanotic Spell:
- An effect of TOF

Synonyms: Paroxysmal hyperpnoea, Dyspneic spell, Anoxic/Hypoxic spells, Guntheroth cycle

Onset: 1 month – 12 year usually.
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.
Any valsalva maneuver (crying, feeding, 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, ↓pH, ↓P O2

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 ↓
Hyperpnoea
↓
↑Venous return
↓
↑CO
↓
↑Right to Left shunt ↑Cyanosis Cyanotic spell
Examination:
- Cyanosis, clubbing
- Prominent ‘a’ wave in JVP
- Ejection systolic murmur

Management:
1. Knee chest position/ squatting position
2. Humidified O2
3. Morphine 0.1mg/kg – sc for sedation
4. Correct acidosis. Obtain pH – give sodium bicarbonate iv.
5. Propranolol – 0.1 mg/kg iv during spell.
Long term – 1 mg/kg 4-6 hourly orally.
6. Vasopressor – methoxamine(vasoxyl) im/iv
7. Correct anemia
8. Consider operation. -Long term
a. Blalock – Taussig shunt
b. Pott’s shunt
c. Waterston shunt

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CCF:

Definition:
- Inability of the heart to maintain an output at rest or during stress, necessary for metabolic
needs of the body and inability to receive blood into the ventricular cavities at low pressure
during diastole

Clinical Features:
A. Symptoms:
a. Poor weight gain
b. Difficulty in feeding
c. Breathes too fast
d. Breathes better when held against the shoulder
e. Persistent cough and wheezing
f. Irritating, excessive perspiration and restlessness
g. Puffiness of face
h. Pedal edema

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.
a. Reducing cardiac work
b. Augmenting myocardial activity
c. Improving cardiac performance by reducing heart size
d. Correcting underlying cause.

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 a. Reducing cardiac work.
1. Restriction of activities – nursing in propped up position
2. Sedative – morphine 0.05mg/kg sc
3. Treatment of fever, anemia, obesity
4. Vasodilators

b. Augmenting myocardial activity

1. Digitalis
2. Dopamine, dobutamine
3. Amrinone and Milrinone
Digitalis: Total digitalizing – 0.04 mg/kg
Maintenance – 0.01 mg/kg/day
Dose given in fraction ½, ¼, ¼ at 0, 8, 16 hours
Parenteral dose is 7/10 of oral
One day drug holiday in a week

c. Improving cardiac performance

1. Digitalis
2. Diuretics
3. Salt restriction

d. Treatment of underlying cause.

Stepwise management:
1. Frusemide 1mg/kg/dose + Amiloride/Triamterene
2. Add Digoxin
3. Add ACE inhibitor and stop K+ sparing diuretics
4. Add Isosorbide nitrate
5. Intermittent dopamine + dobutamine (in separate iv) or dobutamine.
6. Myocardial biopsy & add immunosuppression with steroids in case of active myocarditis
and β-Blocker in cases without active myocarditis
7. Cardiac transplantation

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Acyanotic Heart Disease:

Left to right shunts

ASD (ostium primum and ostium secondum variety)
VSD
PDA

TOF Components:

1. VSD
2. Pulmonic stenosis
3. Overriding dextroposed aorta
4. Right ventricular hypertrophy

Complications of VSD:
1. Recurrent dust infections
2. CCF
3. Infective endocarditis
4. Conduction disturbances
5. Eisenmenger’s phenomenon and pulmonary hypertension
6. Aortic / Tricuspid regurgitation
7. Growth retardation

PDA:

Clinical Features:
Symptoms:
Small: Asymptomatic. Poor exercise tolerance
Large: Effort intolerance
Palpitation

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 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.
Gibsons/machinery/mill wheel murmur (continuous murmur)

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 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. β2 agonist every 30 min interval graduallyincreased to 4-6 hourly

2. Stop O2 if child is able to maintain O2 saturation > 95 %
3. Prednisolone once daily for 5-7 days then stop without tapering.

No improvement:

1. Continue salbutamol and add ipratropium 250µg every 20 min.

2. Inj. Hydrocortisone 10 mg/kg
improvement
Treat as early
Reassess at 2 hr.
responder

No response
1. Start injectable theophylline bolus followed by
continuous infusion
Magnesium 50mg/kg in dextrose over 30 min

No improvement

Mechanical ventilation

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Aerosol Therapy in Asthma:

An aerosol is a suspension of very fine particle of liquid or solid in gas.

Advantage:
a. Delivery to the target tissue
b. Less dose, less side effects
c. Rapid response
d. Self-administration possible
e. Decreases incidence of severe attack and hospitalization.

Limitations:
a. Technique needs to be learnt
b. Cost is high.

Devices:
MDI, Rotahalers, Spacers, Nebulizer
MDI: Puff is synchronized. (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: MDI attached to one side and mouth piece on the other side.
Nebulizer: Given for 5-20 minutes.

Complications Of Pneumonia:
1. Pneumatocele
2. Empyema
3. Pyopneumothorax
4. Metastatic abscess

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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, otitis media or fever, with or
without indications of respiratory distress, pneumonia or atopy.

Incidence:
Age: 1-6 months (peak age)
Season: October to march
Sex: more common in males

Etiology:
Viral: Respiratory syncytial virus
Adenovirus, influenza virus
Parainfluenza virus 1, 2, 3
Bacterial: Mycoplasma pneumonia

Clinical Features:
Symptoms:
- Cough, dyspnea, fever
- Gradual development of respiratory distress
- Rhinorrhea
- Characterized by paroxysmal wheezing cough
- Difficulty in feeding.
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.
- Expiration prolonged, fine rale and rhonchi are auscultated.

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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.

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 CNS
Treatment of Status Epilepticus:

Acute Seizures

History, examination, investigation to ascertain cause

Assess airway, breathing, give O2, establish IV line,

and estimate blood glucose

Diazepam IV 0.3 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 0.5 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

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Specific therapy:
a. Glucose for hypoglycemia
b. Pyridoxine – 50 – 100mg if deficiency
c. IV calcium – if hypocalcaemia
d. Im Magnesium

Neonatal Seizures:

Causes:
The five major causes are hypoxic ischemic encephalopathy, hypocalcaemia,
hypoglycemia, meningitis, and polycythemia

a. Perinatal complications:
i. Hypoxic ischemia encephalopathy
ii. Birth injuries
iii. Intraventricular hemorrhage
iv. Subarachnoid hemorrhage

b. Perinatal infection:
i. Meningitis
ii. Tetania neonatorum
iii. Intrauterine infection – TORCH

c. Metabolic cause
i. Hypoglycemia, hypocalcaemia, hypomagnesaemia
ii. Kernicterus
iii. Pyridoxine deficiency
iv. Unknown error of metabolism – PKU, homocystinuria

d. Development defect of brain:

i. Microcephaly

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 ii. Hydrocephalus
iii. Porencephaly
iv. Agenesis of corpus callosum

e. Narcotic withdrawal syndrome

i. 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. Within 24 hours of fever
b. Lasts less than 10 min
c. Usually single per febrile episode
d. Generalized convulsions
e. No postictal neurological deficit
f. EEG a few days after seizure is normal
g. There may be family history

Investigations:
LP to rule out meningitis

Treatment:
A. Acute:
a. When child is convulsing.
i. Diazepam iv – 0.2 – 0.3 mg/kg/dose (max 5 mg)
ii. Maintain airway, give oxygen
iii. Semi prone position

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 iv. Protect from injuries
v. Maintain patent iv lines.
b. Nor convulsing/stops convulsing
i. Treatment of fever
1. Paracetamol
2. Tepid sponging
3. Look for etiology and treat accordingly
B. Prophylaxis:
Counseling of parents
Drugs:
a. Intermittent: for first 3 days of fever
a. Oral diazepam
b. Treatment of fever
b. Continuous: failure of intermittent therapy
a. Those with CNS disease
b. 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.coli, Streptococcus pneumonia, Salmonella, Pseudomonas aeruginosa,
Strep aureus, Streptococcus faecalis
3 months – 2-3 year:
 H.influenzea, S.pneumoniae, H.meningitidis
>3yrs:
 S.pneumoniae, H.meningitidis

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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, with or without epilepsy and other involuntary
movements.

Etiology:
A. Prenatal
a. Anoxia
b. Toxemia of pregnancy

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 c. Intrauterine infections
d. Congenital malformation of brain
B. Natal:
a. Anoxia
b. Asphyxia
c. Difficult labor
d. Precipitate delivery
e. Birth trauma
C. Post natal
a. Kernicterus
b. Trauma
c. Infection – meningitis and encephalitis
d. Metabolic disturbance – hyperglycemia
e. Vascular – hemorrhage and thromboembolism

Classification:
A. According to motor deficit
a. Spastic – quadriplegia, hemiplegia, paraplegia, diplegia, monoplegia
b. Athetoid
c. Atonic
d. Mixed
B. 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. 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

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Clinical Features:
1. Spastic:
- Quadriplegia, hemiplegia
- Hyperirritable, ophisthotonus
- Babinski positive beyond 2 years of age
- Pseudobulbar palsy – swallowing difficulty with drooling of saliva and expression
less face
2. Atonic:
- Hypotonia, delayed talking
- Cerebellar sign present
3. Chorioathetoid:
- Chorioathetosis
- Deafness dystonia

Associated features:
Eye: Strabismus, cataract, refractiveness
Ear: Deafness – partial/complete
Speech: Dysarthria, Aphasia, dyslalia
Sensory defects: Astereognosis, spatial disorientation
Seizures: Generalized/focal tonic
Intelligence: Borderline/moderately/severely mental retardation
GIT: Constipation, feeding difficulties
Teeth: Malocclusion, caries
Miscellaneous: Critchely’s sign - thumb is persistently flexed across palm after 1st month
of life

Differential Diagnosis:
a. Neurodegenerative disorders
b. Hydrocephalus and subdural effusion
c. Brain tumor/space occupying lesion
d. Muscle disorders
e. Ataxia telangiectasia

34
Early identification of CP:
- Decreased alertness, decreased spontaneous mobility
- Reduced head circumference, 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, movement and reflexes.

Management:
Depending on severity and type of neurological deficit and associated problem.
1. Symptomatic treatment:
- Anticonvulsant – for seizures
- Tranquilizers – for behavioral disturbances
- Muscle relaxants – Dantrolene sodium
- Balcofen – to reduce spasticity
- Diazepam – athetosis and spasticity
2. Physiotherapy:
- Massage/exercise
- Encourage basic movements
- Special therapy
3. Occupational therapy
4. Educational management: vision, speech and learning problems.
5. Orthopedic support: splints and surgeries
6. Social Support

CP Team:
- Pediatrician, orthopedic and general surgeon, physical and occupation therapist,
speech therapist, psychologist, medical, social worker

35
GB Syndrome:

Definition:
It is acute inflammatory polyneuropathy

Etiology:
Viral: EBV, mumps, measles
Post vaccination
Bacteria: Campylobacter

Clinical Features:
- Predominant motor neuropathy
- Characterized by symmetric weakness of muscles, diminished reflexes, and
subjective sensory involvement
- Weakness more marked in proximal muscle groups
- Tendon reflexes are decreased.
- Plantar reflexes are normal
- Hypotonia

Miller Fisher syndrome – areflexia, 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.

Etiology:
a. Salicylates

36
 b. Varicella
c. Influenza B
d. Aflatoxin

Stages:
Stage I – Mild confusion, listlessness, apathy, anorexia, vomiting
Stage II – Delusion, restlessness, lack of orientation, frightened stage
Stage III – Coma, decorticate posture later become decerebrate, Death
Stage IV – Flaccidity, areflexia, apnea,
Dilated pupil not reacting to light
Sever hypotension

Treatment:
- Low protein
- Mannitol
- Glucose
- Correct electrolyte

Causes of Mental Retardation:

a. Prenatal:
1. Metabolic – PKU, homocystinuria
2. Chromosomal disorders: Down, Klinefelter’s
3. Environment and nutrition gap: iodine deficiency
4. Developmental defect: Microcephaly
5. Maternal factor:
a. Teratogenic drug use
b. TORCH infection
c. Radiation during pregnancy

37
 b. Natal:
a. Birth trauma
b. Hypoxicischemic encephalopathy
c. Intracerebral hemorrhage

c. Postnatal:
a. Meningoencephalitis
b. Kernicterus
c. Hypoglycemia
d. Malnutrition
e. 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.

Differential diagnosis:
Polio, GBS, transverse myelitis, traumatic neuritis

AFP Surveillance:
Aim:
a. Identify all remaining area
b. 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
Outbreak response by D/O
- Immunization of all child <5 years by 1 dose OPV, residing within 5 km radius
- Search for cases < 15 years age for history of AFP in last 60 days.

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, curling of hair
- Nausea, vomiting, tremor, ataxia

39
 NEONATOLOGY

Problems of SGA baby:

1. Birth asphyxia
2. Meconium aspiration syndrome
3. Hypothermia
4. Hypoglycemia
5. Infections
6. Polycythemia

Criteria for Pathological Jaundice in the Newborn:

1. Appearing in first 24 hours.

2. Increase in level of total bilirubin by more than 0.5 mg/dl/hour or 5 mg/dl/24 hours
3. Total bilirubin >15 mg/dl
4. 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 >0.5 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
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 periostealhemorrhage 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.
- 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
Treatment:
No treatment – resolves by itself.

BFHI

- Launched in 1992 as a part of “Innocenti Declaration” on promotion, protection and support

of breast feeding by WHO and UNICEF.

Requirements:
Baby friendly hospitals are required to adopt a breast feeding policy and confirm to its
10 steps for successful breast feeding.

Ten steps for successful breast feeding

1. Have a written breast feeding policy that is routinely communicated to all health care staff.
2. Train all health care staff in skills necessary to implement the policy
3. Inform all pregnant women about benefit and management of breast feeding
4. Help mother initiate breast feeding within ½ hour.
5. Show mothers how to breast feed and maintain lactation even if they should be separated
from their baby.
6. Give newborn no food or drink other than milk unless indicated
7. Rooming in practice
8. Encourage breast feeding on demand
9. Give no pacifiers/soother to breast feeding infant
10. Foster the establishment of breast feeding support groups and refer mothers to them on
discharge.

42
Features used for Maturity:

A. Anatomical features:
- Weight > 2500gm
- Hard skull bones
- HC and CC difference 1.5cm HC>CC
- Pinna full developed with good recoil
- No lanugo
- Plantar creases present
- Scrotum fully developed and fully descended testes.
- Labia majora covering minora (minora are not exposed)
- Nails grown upto finger tips

B. Functional features:
a. Respiratory system: good cry
Good cough reflex
b. GIT: sucking/swallowing reflex good.
c. Neurological: Moro’s reflex present
Good suckling, swallowing reflex
Pupillary light reflex positive
Good muscle tone

43
APGAR Score:

It is a quantitative method for assessing the infantile respiratory, circulatory and neurological
status

APGAR Score System 0 1 2

Appearance Blue Body pink, extremities Pink completely
blue
Pulse/min Absent <100 >100
Grimace (reflex No response Grimace Cry, cough or sneezes.
stimulation)
Activity (muscle tone) Flaccid Some activity Actively moving limbs
Respiration None Slow irregular Good crying

Score:
>8 – normal
4-8 – moderately asphyxiated
<4 – severe distress

When to do: 1 min, 5 min, and 10 min

1. At first cry
2. After regular respiration established
3. Delayed

Importance:
1. Monitoring score to determine the efficacy of resuscitation
2. Gives overall view of condition of new born
3. Prognostic value – if score <4 at min - indicates very bad prognosis
4. If low, it indicates one of following.
a. Birth asphyxia
b. Congenital malformations

44
 c. Intrauterine infection/septicemia

Drawbacks:
1. Subjective scoring except HR
2. Ignores time of first cry
3. 1 minute score is not useful in deciding the intervention necessary for resuscitation
as action must be initiated before that
4. Cannot be used in
a. Preterm baby
b. Infant Erb’s palsy
c. Severely sedated baby
5. It does not give any idea of duration and severity of asphyxia.

Kernicterus:

Definition:
- Unconjugated hyperbilirubinemia in the neonatal period causing bilirubin
encephalopathy with and staining necrosis of neuron in basal ganglia, hippocampus,
and sub-thalamic nuclei.

This nuclear staining is called kernicterus.

Clinically 3 phases:
- Phase I – poor suck, lethargy, hypotonia, depressed sensorium.
- Phase II – fever, hypertonia progressing to ophisthotonus
- Phase III – high pitched cry, convulsions, death

Sequelae:
- Deafness, VIII nerve nucleus affected
- Sparse/athetoid type of CP
- Mental retardation

45
 - 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
 - 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.
- Duration of therapy – 24-48 hours
- Feeding of infant during phototherapy: infant is removed from phototherapy for
breastfeeding. 10-20% extra fluid is given to compensate for loss.
- 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, pneumonia
and meningitis.

Etiology:
- E.coli, Staphylococcus aureus, 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, multisystem Slowly progressive or localized

47
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, comatose - Poor profusion
- Seizures - Shock
- High pitched cry GIT:
- Excessive crying/irritability - Abdominal distension
- Neck retraction - Diarrhea
- Bulging fontanelle - Vomiting
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. Antibiotics
2. Supportive therapy;
a. Maintenance of nutrition

48
 b. Correction of electrolyte balance
c. Correct hypoglycemia
d. O2 ventilation in respiratory distress

Prevention of infections:
- Exclusive breastfeeding, no pre-lacteals
- Keeping the cord dry
- Hand washing by care givers before and after handling the baby.
- Hygiene of baby (sponging, clean clothing)
- Avoiding unnecessary iv fluids, injections, needle prick etc.

Causes of Pathological Jaundice:

1. Hemolytic disorder
2. Cephalhaematoma
3. Rotor/Dubin-Johnson disease
4. Maternal diabetes

49
 VACCINES

Hib Vaccine:

It is a conjugate vaccine consisting of polysaccharide PRP of Hib conjugate to carrier protein.

Types:
- PRP – D : polysaccharide conjugated to diphtheria toxoid
- PRP – T : tetanus toxoid
- PRP – OMP : outer meningococcal protein

Dose:
0.5ml im, anterolateral aspect of the thigh.

Vaccination:
2 months: 3 dose at two month interval, booster at 12 months after the third dose.
6 – 12 months: 2 dose at 2 month interval; 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. pertussis 20000 million killed bacteria 4 IU

50
 - Al. phosphate 1.5 mg
- Thiomersal BP 0.01 %

Age: 6 weeks, 10 weeks, and 14 weeks

Booster: 1 – 18 months
2 – 4 ½ - 5 years

Route: Deep im
Site: Anterolateral aspect of thigh
Dose: 0.5 ml
Side effects: Fever/mild local reaction
Complications: Attributed to pertussis component:
1. Encephalitis/encephalopathy
2. Prolonged convulsions
3. Infantile spasms

Contraindications:
a. Progressive neurological disease
b. Uncontrolled convulsions
c. 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.
For immunizing children over 12 years.
Dose: 2 dose at interval of 4-6 weeks followed by 6-12 months after second dose.

51
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.
DPT, MMR, Hib-Hep B, DTaP, DTwP-Hib
OPV, IPV, meningococcal

BCG:

Vaccine – Live bacterial attenuated vaccine.

Danish 1331 strain of BCG bacillus used.
Dose – 0.1 mg in 0.1 ml
Route – Intradermal by using tubercular syringe.
Omega microstat syringe fitted with 1cm steel 26 gauge intradermal needle.
Age – at birth / at 6 weeks if not given at birth.

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, tiny, round scars, 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
Contraindication:
- Generalized eczema
- Infective dermatosis
- Deficient immunity

BCG Adenitis:
- Enlargement of regional LN after BCG
- In some cases, they may form sinuses.

Treatment:
When axillary LN are unusually large INH will retard the progression and speed up
healing.

BCG Test:
Can be done directly with prior MT or if MT is negative.
Read on 3rd day.
Type of reaction:
a. Classical reaction: Develops after 3 - 6 weeks with erythema papule formation and
occasionally ulceration. Subsides within 2-3 months leaving a small scar.
b. Accelerated BCG reaction: Whole process is fast. Child shows the papule in few
hours, a pustule on third day and scab by 5 or 6 days.
c. 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. Hepatitis B
b. Typhoid
c. Hib
d. Pneumococcal

53
Hepatitis B Vaccine:

Content:
Contain small envelope proteins, which contain the principle envelope antigen, Hepatits
B surface antigen (HBsAg) (A recombinant vaccine)

Dose:
0.5 ml for children < 11 years
1 ml > 11 years
Site: im
Normal: 0, 1, 6 months, booster at 5 years
High risk: 0, 1, 2 months, booster at 12 months given to infant born to Hepatitis B positive
mother.

Pneumococcal Vaccine:

Type:
Purified polysaccharide vaccine
14 valent and 23 valent. 23 valent is more commonly used.
Dose and site:
Subcutaneous/im
1 dose booster not before 5 years,
Indication:
- Sickle cell disease
- Anatomic or functional asplenia
- Nephrotic syndrome
- HIV infection
Side effects:
Hypersensitivity reaction

54
Typhoid Vaccine:

im:
- Type: Vi polysaccharide vaccine
- Age : after 2 years
- Dose: 0.5 ml im single dose. Booster every 3 years

Oral:
- Type: Live attenuated vaccine. S.typhi Ty2la strain
- Age: after 6 years
- Dose: on 1, 3,5 days – 1 capsule

Polio Eradication:

4 point strategy:
a. High routine immunization coverage with OPV
b. Supplementary immunization in the form of national immunization day or pulse
immunization program.
c. Effective surveillance system
d. Final stage consisting of mopping up by door to door immunization campaigns.

Acellular Pertussis Vaccine:

Content:
Inactivated pertussis toxin combined with filamentous hemoglutinin. Sometimes
additional component such as fimbrial antigen and pretactin is also present

Administration:
Given with diphtheria and tetanus toxoid as DPT, also with Hepatitis B

Advantage: Less reactogenic

55
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.
Syringe used – Omega microstat syringe fitted with 1 cm steel 26 gauge intradermal needle.
Reading: After 48 hours, the size of induration felt (not the erythema).

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, it indicates significant – either the person is
infected/immunized.
Condition of false negative:
a. Post measles
b. Immunocompromised
c. Chemotherapy treatment
d. Malnourished child

56
UIP
At birth – BCG, OPV zero dose
6 weeks – DPT -1, OPV – I, Hep B1 (BCG if not given at birth)
10 weeks – DPT -2, OPV –II, Hep B2
14 weeks – DPT -3, OPV – III, Hep B3
9 months – Measles
18-24 months - DPT & OPV
5 years DT
10yr and 16 yrs TT

For pregnant lady: Early in pregnancy TT-1

After one month TT-2

57
 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.
Type 2 – 8D Type 1 – 106 TCI D50
Type 3 – 32D Type 2 – 105 TCI D50
Type 3 – 105.5TCI D50
Schedule 3 dose at 6-8 week interval Zero dose at birth, 6, 10, 14 weeks
Route Im Oral
Mechanism of Induce circulating antibody Prevent paralysis as well as intestinal
action No intestinal immunity infection.
(immunity) Prevents paralysis but does not
prevent infection
Use Not useful in controlling epidemic Can be effectively used
Cost Very costly, difficult to Cheap, easy to manufacture
manufacture
Contraindication None - Acute infections
- Febrile illness
- Diarrhea and dysentery
- Malignancy
- Corticosteroid therapy

58
 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. Hypertrophy contributes to a
lesser extent to the process of growth.

Principles of growth:

A. Continuous and orderly process

B. Sequence of growth is same but pace can be non-uniform
C. Growth pattern of every individual is unique but general pattern is cephalocaudal.
D. 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.
E. Generalized mass activity is replaced by specific individual responses
F. Different tissues of the body grow at different levels.

59
Factors affecting growth:

1. Genetic factors:
a. Phenotype: head, chest, fatty tissue
b. Parental characteristic
c. Race
d. 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. Biorhythm and maturity
f. Genetic disorder:
1. Chromosomal abnormalities: Down, turner
2. Gene mutation: Galactosemia
g. Children of multiple pregnancy

2. Environmental factors:
a. Prenatal:
1. Maternal malnutrition
2. Multiple pregnancies
3. Medical illness in mother – CRF, CCF, Eclampsia
4. Maternal infection – TORCH
5. Drugs: thalidomide
6. Hormonal: thyroxine, insulin, IGF
b. Postnatal period:
1. Neonatal hypoxia
2. Neonatal convulsions
3. LBW babies
4. Social factors:
1. Socioeconomic level
2. Natural resources
3. Climate
5. Infection and infestation
6. Nutrition

60
 7. Trauma
8. Emotional factors
9. Cultural factors

How Do You Assess Physical Growth?

It can be done by
- Body measurement: height, weight, head circumference, UL/LL ratio
- Velocity of physical growth: by growth chart

How Do You Assess Development?

1. Denver developmental screening test:

- Assesses child development in terms of gross motor, fine motor and adaptive,
personal, social and language
2. Nancey and Bayley scale:
- Measures motor and mental development
3. Phatak’sBaroda screening test:
- Modified form of Nancey and Bayley scale for use in India.

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
Head circumference:

Birth – 35 cm
6 months 43.5 cm
1 year 46.5 cm
2 year 49 cm

𝑙𝑒𝑛𝑔𝑡 𝑕 𝑖𝑛 𝑐𝑚
1st 400 days = 2
+ 9.5 ± 2.5

HC growth:
1. 2 cm/month for 3 months
2. 1 cm/month for next 3 months
3. 0.5 cm/month for next 6 months
4. 0.5 cm/yr for 2-7 years
5. 0.33 cm/yr for 7-12 years

Weight changes:
First year of life:
For expected weight, add to birth weight as follows:
First 4 months – age in month x 0.8 kg
Second 4 months – age in month x 0.7 kg
Third 4 months – age in months x 0.6 kg

Expected weight:
𝐴𝑔𝑒 𝑖𝑛 𝑚𝑜𝑛𝑡 𝑕𝑠+9
between 3-12 months = 2

between 1 to 7 years; weight(kg) = [(𝐴𝑔𝑒 𝑖𝑛 𝑦𝑒𝑎𝑟𝑠 + 4)𝑥2]

between 7 and 12 years; weight (kg) = 𝐴𝑔𝑒 𝑖𝑛 𝑦𝑒𝑎𝑟𝑠 𝑥 3

62
U/L ratio
At birth 1.7
6 months 1.6
12 months 1.5
2 years 1.4
3 years 1.3
5 years 1.2
7 years 1.1
10 years 1.0
13 years 0.9

Chest circumference:

Normally 1.25 cm – 2.5 cm less than HC at birth

By 9 – 12 months, become equal and later outgrows the head.

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, so that changes over time can be interpreted and progress
of growth monitored.

Use of growth chart:

1. Growth monitoring
2. Diagnostic tool
3. Planning and policy making
4. Educational tool
5. Tool for action
6. Evaluation
7. Tool for teaching
8. Others: Identification, registration, birth date and weight, immunization status.
Aptly described as passport to child health care.

63
Growth chart by government of India:
4 reference curves.
- 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. The reason for it to remain
constant is the replacement of body fat of infancy with muscle.

Technique:
Measured with help of non-stretchable, plastic measuring tape midway between
olecranon and the acromion.

Grading and interpretation:

Grade Circumference Shakir’s tape

Normal >16.5cm green

Mild PEM 13.5 – 16.5cm
Moderate PEM 12.5 – 13.5 Yellow
Severe PEM <12.5 Red

64
Microcephaly:

HC < 2nd SD deviation, below average head circumference

Causes:
1. Craniosyostosis: brachycephaly, dolichocephaly
2. Trisomy 13
3. Down’s syndrome
4. 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
- 3.3 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
 - 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, he
or she is considered to be short in stature.

Causes:
1. Proportionate short stature:
a. Normal variants:
1. Familial
2. Constitutional delay in growth
b. Prenatal causes:
1. Intrauterine growth retardation
2. Intrauterine infection
3. Genetic disorders
c. Postnatal:
1. Nutritional dwarfism
2. Chronic visceral disease
3. Endocrine disorder
4. Psychological

2. Disproportionate short stature:

a. With short limb:
1. Achondroplasia, hypochondroplasia, osteogenesis imperfect,
deformities due to rickets
b. With short trunk:
1. Mucopolysaccharidosis, spondylo epiphyseal dysplasia (SED)

66
Short stature without MR:
1. Constitutional delay
2. Nutritional dwarfism
3. GH deficiency: these gain less than 4 cm in height per year
4. Chronic visceral disease.

Failure to thrive:

It is a term given to infants whose rate of weight gain is sluggish. The length of the child may or
may not be affected.

Causes:
1. Extrinsic:
a. Inadequate nutritional intake
b. Social and environmental deprivation or a combination of both

2. Intrinsic:
a. Defect in absorption – coeliac disease, lactose intolerance
b. Persistent vomiting – pyloric stenosis
c. Metabolic disorder – diabetes mellitus
d. Chronic disease – of heart, lung, kidney and liver

Clinical Features:
1. Looks small for age
2. Weight below 3rd percentile
3. Wide eyed expression/expressionless face and avoids direct gaze
4. Vocalization delayed and motor activity curtailed
5. Inadequate response to social stimuli
6. Marked preoccupation with thumb sucking
7. Shows lack of cuddling and assumes infantile posture.

67
Diagnosis:
- Based on proper history, growth chart and evidence of intermittent improvement in
growth performance.
- CBC, electrolyte, urine analysis

Treatment:
- Immediate and longterm should be directed at both infant and the mother.
- Hospitalization: non organic improve in 4 - 5 days.
Otherwise, an organic cause should be suspected.

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.

Physical examination:
1. Large posterior fontanelle (>1cm diameter)
2. Prolonged jaundice (hyperbilirubinemia > 7 days)
3. Macroglossia
4. Hoarse cry
5. Goiter
6. Distended abdomen, umbilical hernia, constipation
7. Delayed milestones, delayed deciduous teeth
8. Failure to thrive, somnolence, feeding problems

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 9. Dry skin, poor hair and nail growth
10. Waddling gait (maldevelopment of femoral epiphysis)
11. In iodine deficiency cases:
a. Spastic diplegia
b. Strabismus
c. Deaf mutism
d. Goiter
e. Short stature in older children.
Neonatal screening:
At 3-5 days of birth by heel prick/ear lobe prick and estimating T4 and TSH.
Usually TSH - >50 mm/L
T4 - <6.5 µg/dl

Treatment:
Lifelong level thyroxine 10-15 µg/kg/day
To bring T4 to 12-16 µg/dl a.s.a.p.

Monitoring:
- Symptoms and signs
- Height and bone age
- Hormonal assessment

Clinical Features in older children:

1. Short and stocky
2. Immature U/L segment ratio
3. Markedly delayed bone age
4. Sexual development is infantile
5. Delayed puberty
6. Cretinoid, puffy face
7. Myxedematous ski and subcutaneous tissue
8. Dull face with reaction time increased
9. Susceptibility to cold.

69
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.

Types:
1. On basis of achievement of control:
a. 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.
b. Secondary: Child has been dry for several months and again starts bed
wetting.

2. On basis of time of the day.

a. Nocturnal – night
b. Diurnal – day
c. Both

Causes:
1. Primary:
a. Organic:
1. Bladder neck obstruction
2. Ectopic urethral opening
3. Sacral agenesis
b. Non organic:
1. Developmental delay
2. Psychosocial factor – anxiety
3. Sleep disorder

2. Secondary:
a. Urinary tract obstruction

70
 b. Stressful situation or emotional difficulties: death in family or change of
school/home
c. Diabetes

Evaluation of child:
1. History:
a. Type of enuresis
b. Time of enuresis
c. Frequency
d. History related to organic pathology
2. Psychosocial history
3. Examination – to rule out organic cause
4. Lab evaluation:
a. Urine analysis and culture
b. Blood examination
c. IVP - to rule out organic pathology

Management:
It depends on:
a. Age of child
b. Type of enuresis

Treatment:
1. Counseling
2. Bladder training/bladder stretching
3. Conditioning therapy (aversive conditioning)
4. Pharmacotherapy
a. Imipramine
b. Oxybutine – decreases bladder reflex contractility
c. Desmopressin - ↓urine output
5. Other:
a. Behavior modification

71
 b. Psychotherapy
c. Restriction of fluid after dinner
6. Treat the organic cause.

Trisomy 21 (Down syndrome)

Clinical Features:
Children suffering from Down syndrome have dysmorphic features, also structural and
functional abnormality.
1. Dysmorphic features:
a. Facial features:
1. Flat face**
2. Short, upslanting palpebral fissure**
3. Epicanthal folds
4. Short ear with abnormal ear lobes**
5. Protruding tongue
6. High arched palate
b. Other dysmorphic features:
1. Skin – excess posterior neck skin **
2. Simian crease **
3. Clinodactyly - short hand and finger marked by incurved 5th finger
**

2. Functional and structural abnormalities:

a. Hypotonia **
b. Poor moro reflex and hyperflexibility of joints **
c. Mental retardation
d. Cardiac defect – VSD, PDA, ASD
e. Dysplastic pelvis **

** Hall’s criteria – if ≥4 – strong possibility of Down’s

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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
Management
- Special education
- Medical management:
Only for associated problems like severe hyperactivity, aggression, self abusive
behavior.

Breath holding spells:

It is a conduct disorder due to some cause (being hurt or thwarted) where child holds his/her
breathing, expiration which may lead to cyanosis (with or without hypoxia, 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
 Rigidity ± ophisthotonous ± limpness
↓
If hyperemia 10 – 15 sec
↓
Convulsions
- Pallid: precipitated by minor injury or fright. Cyanosis is absent

Investigations:
Rule out other pathology like seizure, cardiac arrhythmia, 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.

Milestones achieved by following age: 9 months, 1 years, 2 years, 3 years

9 months:
- Gross motor – standing without support
- Fine motor – pincer grasp
- Language – bisyllables (mama, baba)
- Personal, social – waves bye.

1 year:
- Gross motor: walking without support
- Fine motor:
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
 o Play simple ball game
- Language: Two words with meaning

2 years:
- Gross motor: walking upstairs with one step at a time
- Fine motor:
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.
- 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 Telling a story.

76
 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, 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
6 – 12 months 100,000 IU
> 1 year 200,000 IU
Schedule: on day 0, 1, 30

77
Local Treatment:
- Antibiotic drops in case of corneal ulcer to prevent secondary infection
- Padding in corneal ulcer to promote healing, prevent dehydration, reduce pain and
photophobia
- Mydriatics

Clinical Features of Hypervitaminosis A

1. Acute manifestations:
a. Headache
b. Vomiting and dizziness
c. Signs of raised intracranial pressure i.e
1. Bulging anterior fontanelle
2. Papilledema
This syndrome is known as pseudomotor cerebri

2. Chronic:
a. Anorexia
b. Dry itchy skin
c. Weight loss
d. Sparse hair
e. Hepatosplenomegaly, hypoplastic anaemia

Weaning: Principle, Food, Complication:

Definition:
- Weaning means accustoming the infant to gradual introduction of nourishment
other than mother’s milk.
Solid food to replace breast feeding – to be started at 4 – 6 months and completed by 1 yr.

Weaning food: It should be:

- Culturally acceptable

78
 - Adequate – providing all nutritional supplement
- Locally available and inexpensive
- Easily prepared at home.
- Clean and hygienic
- Physiologically stable, suitable, easily digestible, bland and nourishing.

Principle:
- No generalized rule
- Exclusive breastfeeding till 6 months and then start weaning food.
- First start with liquid, then semisolid, then solid
- Give only one food at a time.

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.

Rickets:

Clinical Features:

1. Age: unusual below 3 months. Classically 6 months – 2 years

2. Early signs:
a. Restlessness, irritability, sweating over head
b. Craniotabes – feeling of crackling over parietal bones
c. Rachitic rosary
3. General features:
a. Flabby appearance
b. Muscle weakness and ligament laxity
4. Head:

79
 a. Anterior fontanelle remain open beyond 18 month
b. Bossing of head (hot cross bun appearance)
5. Chest:
a. Harrison’s sulcus
b. Rachitic rosary
c. Pigeon chest
d. Fiddle-shaped chest
6. Spine: kyphosis, scoliosis
7. Long bones – bow leg, knock knees
8. Pelvis – coxa vara
9. Abdomen –
a. Pot belly
b. Visceroptosis
10. Teeth: carries, delayed dentition

Swelling at wrist and ankle

Laryngismus stridulus, 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, scoliosis

80
Treatment of rickets:

1. 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. Correction of deformities
b. Should be done after correction of rickets

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Age independent criteria for assessment of malnutrition:

1. Weight for height

2. Rao’s index
3. Kanawati’s index
4. Dugdale’s index
5. Mid - arm circumference between age 1-5 years

1. Weight for height

Sensitive in acute malnutrition, not in chronic (because both decrease but
weight remains proportional to height)

𝑤𝑒𝑖𝑔 𝑕𝑡 𝑜𝑓 𝑐𝑕𝑖𝑙𝑑
% weight for height = 𝑤𝑒𝑖𝑔 𝑕𝑡 𝑜𝑓 𝑛𝑜𝑟𝑚𝑎𝑙 𝑐𝑕𝑖𝑙𝑑 𝑜𝑓 𝑠𝑎𝑚𝑒 𝑕𝑒𝑖𝑔 𝑕𝑡
𝑥 100

2. Rao’s index:
Constant between 1-5 years irrespective of gender

3. Kanawati’s index: constant between 3 month – 4 years of age

Name Methods N/Severe PEM

𝑤𝑒𝑖𝑔 𝑕𝑡 𝑖𝑛 𝑘𝑔
- Rao’s 𝑕𝑡 𝑖𝑛 𝑐𝑚 2
𝑋 100 0.15-0.16/ <0.14

𝑀𝐴𝐶 𝑖𝑛 𝑐𝑚
- Kanawati’s 𝑋 100 0.32 – 0.33/ ≤0.25
𝐻𝐶 𝑖𝑛 𝑐𝑚

𝑤𝑒𝑖𝑔 𝑕𝑡 𝑖𝑛 𝑘𝑔
- Dugdale’s 𝑕𝑒𝑖𝑔 𝑕𝑡 𝑖𝑛 𝑐𝑚 1.6
𝑋 100 0.88 – 0.97 / ≤0.79

- MAC > 13.5 / ≤12.5 cm

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Classification of PEM:
1. Wellcome classification:
Weight
60-80% of expected
60-80% of expected
< 60%
< 60%
Edema Inference
- Underweight
+ Kwashiorkor
- Marasmus
+ Marasmic kwashiorkor

2. 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. 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 - <50% of expected weight

4. WHO Classification:
Moderate Severe undernutrition
undernutrition
Symmetrical edema No Yes (edematous
malnutrition)
Weight for height 70-79% of expected <70% severe wasting
(measure of wasting) wasting
Height for age 85 – 89 % of expected < 85% severe stunting
(measure of stunting
stunting)

83
 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.

Marasmus Clinical Features:

- Age: highest incidence seen in infancy
- General features:
o Gross wasting of muscle, poor muscle tone
o Loss of subcutaneous fat
o Bony prominences are seen
- Skin:
o Wrinkled, dry and loose, 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
 - 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, dry, brittle, sparse, easily pluckable
- Mental changes:
o Lethargic, 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 3.5 g
Proteins 1.1 g 3.3 g
Fe 0.5 g – well absorbed 0.5 g
Ca 34 117
Vitamin K Deficient
Vitamin D Water soluble

85
Advantages of breast milk:

1. Nutritive value and digestibility

2. Low risk of infections
3. Protects from allergy
4. Physiological adaptation
5. Emotional bonding
6. Maternal advantage
7. Economic Factors
8. 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, obesity, 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
Exclusive breast feeding:

Definition:
Only breast milk is given to baby. No other food or drink, not even water is given.
Medicine, mineral drops, vitamins are permitted if indicated.

An infant should be exclusively breast fed for first 6 months of life.

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

Clinical features:
Appetite Good Poor
Skin Dry, scaly Flaky paint dermatitis
Hair damage Hypopigmented Flag sign
Moon face - +
Hepatomegaly - +

87
 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
 INFECTIONS

Measles complications:

1. Respiratory tract: otitis media, laryngitis, pneumonia

2. Encephalitis and subacute sclerosing panencephalitis (SSPE)
3. Digestive system – Persistent diarrhea, appendicitis, hepatitis
4. Malnutrition – vitamin A deficiency
5. 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:
0.5 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

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Mumps complication:

- Orchitis
- Epididymitis
- Pancreatitis
- Oophoritis
- Nephritis

Mumps Clinical Features:

1. Incubation period is about 18 days

2. Fever, head ache, nausea, malaise and loss of appetite
3. Salivary manifestation:
a. Pain near ear lobe and difficulty in chewing within 24 hours
b. Parotid swelling
c. Opening of Stensen’s duct appears red
d. Swelling disappears in 6-10 days
4. Extra salivary manifestation:
a. Aseptic meningitis
b. Encephalitis
c. GBS
d. Auditory nerve damage leading to deafness

Tetanus neonatorum

Agent: C. tetani (gram positive, mobile, non-capsulated, anaerobic spore bearing bacillus)

Clinical Features:
1. Age: 5 – 10 days after delivery
2. Excessive unexplained crying, refusal to feed, apathy
3. Spasm of neck muscles – mouth kept open

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 4. Masseter spasm – difficulty in feeding
5. Lock jaw/trismus
6. Risus sardonicus
7. Spasm of larynx and respiratory muscle characteristically induced by stimuli of
touch, noise or bright light results in apnea and cyanosis.

Management:
1. General supportive measures
2. Immunization (passive by toxoid)
3. Nutrition, fluid and electrolyte balance
4. Antibiotics
5. Tracheostomy and assisted ventilation
6. Central of spasm by diazepam

Complication of Ascariasis:
1. Malnutrition
2. Intussusception
3. Intestinal obstruction by round worm bolus
4. Jaundice and pancreatitis
5. Gall bladder disease
6. Peritonitis

Diphtheria Clinical Features and 3 complications:

Complications:
- Myocarditis
- Neurological – palatal paralysis, loss of accommodation and general polyneuritis
- Renal – oliguria and proteinuria

Clinical Features:
1. Constitutional symptoms:

93
 a. Malaise, headache and loss of appetite
b. Child looks toxic with fever
c. Sensorium is clouded

2. Local Manifestations:
a. Nasal diphtheria – nasal discharge and excoriation of upper lip
b. Faucial diphtheria – redness and swelling over fauces.
Pseudomembrane – formed by exudate over tonsils. The membrane
bleeds on being displaced.
c. Laryngotracheal diphtheria
Membrane over the larynx results in brassy cough, hoarse voice.

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, 24, 48
hours. 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 1.25 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.
- Complicated malaria:
o Quinine 20 mg salt/day (loading dose) diluted in 10ml/kg 5% dextrose iv
over 4 hours; 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.
Or
o Artemether 3.2 mg/kg im (loading dose) followed by 1.6 mg/kg im daily for
6 days.

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.

Pertussis complication:
- Respiratory system:
o Bronchiectasis, pneumonia, pneumothorax, otitis media
- CNS:
o Convulsions, encephalopathy, intracranial hemorrhage, seizure
- Severe malnutrition
- Subconjunctival hemorrhage
- Gastrointestinal manifestation
- Hernia and rectal prolapse

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Complications of primary complex:

1. Hematogenous spread:
a. Miliary TB
b. TB meningitis
c. Skeletal TB
2. Local spread:
a. Adenitis
b. Bronchopneumonia
c. Bronchiectasis
d. Collapse/consolidation

Hepatitis B – Extrahepatic manifestations:

- Serum sickness like syndrome

- Essential mixed cryoglobulinemia
- Polyarteritis nodosa
- Membranous or membranoproliferative glomerulonephritis
- Severe aplastic anemia
- Pleural effusion, myocarditis and pericarditis

PUO Causes in 6 yr. old child:

- It is defined as illness of more than 6 week duration documented fever above 101 oF
(38.3 oC) on multiple occasions; lack of specific diagnosis after 1 week of admission
and investigation in a hospital setting.

Causes:
1. Infection:
a. Bacterial:
1. Local: abscess brain, lung, intraabdominal; osteomyelitis

96
 2. Generalized: TB, infective endocarditis, rheumatic fever,
brucellosis
b. Viral: Infectious mononucleosis, AIDS
c. Parasitic: Malaria, kala azar, toxoplasmosis, filariasis
d. Rickettsial infection
e. Chlamydial infection
f. Fungal: histoplasmosis, candidiasis
2. Collagen disorder : IRA, SLE
3. Malignancy : Wilm’s tumor, neuroblastoma
4. Miscellaneous
a. Malingering
b. Munchausen syndrome by proxy
5. 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, Rifampicin, Floroquinolone and any of the following three injectable
drugs Amikacin, Kanamycin, Capriomycin.

X-Ray finding in pulmonary TBL

- In asymptomatic – no findings
- Hilar opacities
- Apical consolidation
- Calcification in healed lesion
- Fibrosis in healed lesion
- Cavitary lesion

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Disseminated TB – 2yr child – lab features:

- ESR - ↑↑
- AFB staining of sputum – positive
- Antibody against TB

Enteric Fever: IP, clinical features, complication, 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.
o Typhoid rash (nose spots) occurs on 6th day of illness.

- 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, child may have typhoid state in which child has muttering
delirium and may pick at bed clothes.

Complications:
- Oral: parotitis
- Chest: pneumonia and pulmonary infarct

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 - Heart – myocarditis
- Liver and GB – Fatty liver, hepatitis, cholecystitis, pancreatitis
- GIT – Diarrhea, constipation
- Neurological – meningitis, encephalitis
- Musculoskeletal – chronic osteomyelitis
- Other – Alopecia, uveitis

Diagnosis:
Clinical signs pathognomic of typhoid:
- In endemic area, 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

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 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, anorexia
- Epigastric cramps

Treatment: Albendazole – 400 mg OD x 5days

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 MALIGNANCIES

Neuroblastoma Staging:

INSS (International Neuroblastoma Staging System)

Stage 1: Localized tumor confined to area of origin. Complete gross excision, with or without
microscopic residual disease; identifiable ipsilateral and contralateral lymph nodes
negative microscopically.

Stage 2A: Unilateral with incomplete gross excision; identifiable ipsilateral and contralateral
lymph nodes negative microscopically

Stage 2B: Unilateral tumor with complete or incomplete gross excision; both positive LN;
identifiable contralateral lymph nodes negative microscopically.

Stage 3: Tumor infiltrating across the midline with or without regional LN involvement or U/L
tumor with contralateral regional LN involvement; or midline tumor with bilateral
regional LN involvement

Stage 4: Dissemination of tumor to distant LN, bones, bone marrow, 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,
skin and/or bone marrow.

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Acute Leukemia: History and examination findings:
History:
- Anemia – pallor, tiredness, malaise
- Neutropenia – fever, infections at various site
- Thrombocytopenia – petechiae, purpura, bleeding
- Expanding cell mass in marrow – bone pain
- Raised ICT – nausea, vomiting
Examination:
- Anemia – pallor, hyperdynamic circulation feature
- Expanding cell mass in marrow and other organs.
o Bony tenderness, lymphadenopathy, hepatomegaly and splenomegaly
- Raised ICT – papilledema

HL and NHL differences:

HL NHL
Bimodal peak incidence; 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

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 MISCELLANEOUS
Stridor:

Noisy respiration produced by turbulent air flow through the narrowed air passages.

Etiology:
1. Congenital: laryngomalacia, laryngeal web, stenosis, hemangioma, tongue and jaw
abnormalities
2. Mechanical: Foreign body, enlarged tonsils
3. Infection: Laryngitis, epiglottitis, diphtheria, retropharyngeal abscess
4. Trauma: Intubation, inhalation burns
5. Paralysis: Bilateral vocal cord paralysis, central paralysis due to CP.
6. Nutritional: Tetany
7. Allergic: Laryngeal edema

Investigations:
1. X-Ray:
a. Soft tissue neck – AP and lateral
b. Angiography of aberrant vessel suspected
c. CT scan
2. Direct laryngoscopy without anesthesia
3. General anesthesia followed by bronchoscopy, laryngoscopy and esophagoscopy

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 ARI Control program:

- Acute lower respiratory tract infection is a leading cause of mortality in children

below 5 years. 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

-No fast breathing
-No chest indrawing
or indication of severe
illness
-Resp rate Pneumonia Cotrimoxazole 5 days Home
≥60 <2 months
≥50 2mts-1yr
≥40
-Chest indrawing Severe In/im penicillin Hospital
pneumonia
-Cyanosis Very severe Iv chloramphenicol Hospital
-Severe chest
indrawing
-Inability to feed

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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
3-5 kg
2-12 months Two tab BD 1 spoon BD
6-9 kg
12-60 months 3 tab BD 1½ spoon BD
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.
Vaccines kept in freezer compartment: polio, measles
Vaccines kept in cold compartment: DPT, TT, DT, BCG and diluents

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Cold chain equipment:
- Regional level: Walk in cold room.
 These can store vaccines upto 3 months and supply 4-5 districts

- District level: Deep freezers 300 l.

 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, treatment, health supervision, nutritional surveillance
and education into a system of comprehensive health care within the resources available in
country.
Aim and objective:

Care in
illness

Growth Preventive
monitoring care

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 1. Care in illness:
a. Diagnosis and treatment of illness, disorders of growth and development
b. X-Ray and laboratory services
c. Referral services

2. Preventive care:
a. Immunization
b. Nutritional surveillance
c. Health checkups
d. Oral rehydration
e. Family planning
f. Health education

3. 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, provided that such work was unlikely to harm child’s
health, morals or safety or prejudice his school attendance.

Problem statement:
- India fosters the largest number of child labour in world.
- Child labour contributes about 20% of GNP
- Maximum number of child labour are in J&K mainly engaged in carpet weaving
industry

Causes:
- Poverty

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 - Unemployment
- Lack of education

The Child Labour (Prohibition and Regulation) Act 1986

- This act was implemented to protect children against child labour, protect child
labour against abuse, exploitation and health hazards.
- 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.

Treatment:
- 10% calcium gluconate – 0.5-1 ml/kg over 5-10 min
- NaHCO3 7.5% - 1-2 ml/kg over 10-20 min
- Nebulized salbutamol – 5-10mg
- Iv glucose 0.5 g/kg along with soluble insulin 0.1U/kg over 90 min
- Exchange resins
- Dialysis – this is more beneficial in ARF as the above measures give transient benefit

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 CASES
1. 2 month old child 3.8 kg H/O intermittent sucking, 2 weeks duration. Birth weight – 3kg.
Diagnosis? Management?

2. Investigation in suspected case of pallor in 3 year old child with interpretation.

3. 2 year old child H/O not walking. DD, history taking.

4. 2 year old child 12 kg, fever + 8 large stools + vomiting 1 day duration.
Examination: irritable, cold peripheries, HR – 130, BP – 80/40, Diagnosis? Management?

5. 2 year female - fever 1 week. On examination pallor, hepatosplenomegaly. Investigation and

interpretation?

6. 8 year old child. 110cm, 24 kg. Likely cause and basis of this

7. Anemia and hepatosplenomegaly – 3yr old child. DD and lab investigations.

8. 6 year old child with fever 10 days is found to be pale, has ecchymotic patches.
Investigation?

9. 10 year male – 20kg, 110cm – assess nutritional status and order investigations.

10. 10 year old child – cola colored urine. Examination, findings and work up?

11. 5 year old child – puffiness of eyelids 2 days duration. Generalized convulsions on morning
of admission. Diagnosis, urinary findings, 4 complications, management.

12. Treatment of 10 kg child with severe dehydration due to acute diarrhea of 1 day duration

13. Balanced diet for 1yr, 3 yr old child.

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 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

Fine Motor:
- 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, can dress/undress himself
- 4 year - Copies square, plus
- 5 year - Copies triangle, cross

Language:
- 1 month - Turns head to sound

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 - 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

Vision:
- Binocular vision - 3-6 months
- Depth perception - 6-8 month begins; 6-7yr accurate

Personal, 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, mimics mother
- 36 month - knows gender

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