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Pediatrics Revision E6.5
Pediatrics Revision E6.5
Anthropometry :
1. weight :
• Average birth weight → 3 kgs.
• Weight loss (Normal) : D/t loss of fluid from ECF compartment.
Weight loss % (upto) Regains birth weight by :
Term 10% 10 days
Preterm 15% 15 days
Dentition :
10 dentition (Temporary) 20 dentition (Permanent)
Total no. of teeth 20 32
First tooth to erupt Lower central incisor 1st molar
Time of eruption 6 months 6 yrs
Delayed dentition :
• Teeth do not appear by 13 months.
• Causes :
a. M/C : Idiopathic.
b. Malnutrition.
c. Genetic syndromes : Down’s and Turner’s syndrome.
d. Hormone deficiency : Hypothyroidism.
Puberty :
Sequence of pubertal changes :
In females : In males :
Thelarche Testicular enlargement
Penile enlargement
Pubarche
Pubarche
Growth spurt
Growth spurt
Menarche
Axillary and facial hair
Short stature :
Height/Age < 3rd percentile or < -2 SD.
Most common type : Normal variant with normal growth velocity.
Overall m/c cause of short stature & delayed puberty : Constitutional delay.
Upper segment (US)/Lower segment (LS) ratio :
US → Distance from head to pubic symphysis (Trunk).
LS → Pubis to foot (Legs).
Age Ratio
At birth 1.7 : 1
At 3 years 1.3 : 1
(LS grows faster after birth)
At 7-10 years 1:1
> 10 years 0.9 : 1
Normal Abnormal
Microcephaly :
Causes : Affecting brain growth.
VSD
Macrocephaly :
Causes :
• ↑ CSF : Hydrocephalus (overall M/C).
• ↑ Bony compartment : Thalassemia, Osteogenesis imperfecta.
• ↑ Brain tissue/Megalencephaly : MPS, Leukodystrophy (Alexander and
Canavan’s disease).
Hydrocephalus :
Normal amount of CSF : 150 ml in adult; infant : 50 ml.
Features :
• Macrocephaly/abnormal ↑ in HC >2 cm/month.
• Bulging of anterior fontanelle.
• Prominent scalp veins. d/t ↑ ICT
• Sun-set appearance of eye (visible upper sclera).
• Crack pot resonance.
Congenital hydrocephalus :
Causes :
1. Aqueductal stenosis (between 3rd and 4th ventricle) :
• M/C cause of congenital hydrocephalus.
• Dilated 3rd and lateral ventricle.
• M/C cause of fetal ventriculomegaly. Aqueductal stenosis
Management of hydrocephalus :
Ventriculo-peritoneal shunt (V-P shunt). Dandy Walker malformation
Definition :
Males Females
Delayed puberty : Absence of 2° sexual 14 yrs 13 yrs
characteristics even after
Precocious puberty : Appearance of 2° 9.5 yrs 8 yrs
sexual characteristics by
Delayed puberty :
M/C cause overall : Constitutional delay.
Other causes
Central Peripheral
CNS (Pituitary & hypothalamus related) •Functioning tumors of ovary or testis.
Eg : •McCune albright syndrome (triad) :
1. Hypothalamic hamartoma. 1. Precocious puberty (ovarian cysts).
2. Gliomas. 2. Cafe-au-lait macules.
3. Polyostotic fibrous dysplasia.
4 domains of development :
• Gross motor.
• Fine motor.
• Language.
• Social.
4. Social milestones :
Age Milestone attained
2 months Social smile
3 months Mother regard
6 months Stranger anxiety, smiles at mirror image
9 months Waves bye-bye, plays “peek a boo”
1 year Simple ball game
2.5-3 years Parallel play (Non-interactive)
4 years Group play (Interactive play)
Nutrition 00:00:10
Breastfeeding :
Breast milk : 67 kcal/100ml.
Properties of breastmilk :
1. Nutrition :
Breast milk Cow milk
Lactose More Less
Proteins Less (Easily digestible) More
Fat Same (Rich in PUFA) Same
2. Immunological (PLAB) :
Colostrum (1st formed milk) : Rich in IgA.
P : Low levels of Para amino butyric acid (PABA) → Protects against malaria.
L : Lactoferrin → Protects against E.coli infection
A : IgA
B : Bifidus factor → Protects against E.coli infection
4. Micronutrient deficiencies :
Vitamin K : Prophylaxis of injection vitamin K at birth.
Vitamin D : Oral supplementation.
Iron : Supplemented in preterm/low birth weight babies (D/t poor iron stores).
5. Storage :
Room temperature Refrigerator Freezer
6-8 hrs 24 hrs 3 months
Rickets
Genu valgus (Knock knees) Genu varus (Bow legs) Wrist widening
Refractory rickets :
S.PO43-
High Low
Do ABG
CKD ( excretion of PO43- )
Increased : Normal :
Vitamin D Dependant Rickets Familial hypophosphatemic
(Autosomal Recessive) rickets (X-linked dominant).
Micronutrient
Name Characteristic feature
deficient
Bleeds (Collagen defect) :
• Gum
Scurvy Vitamin C • Perifollicular.
• Subperiosteal (In limbs) : Pseudoparalysis
(D/t pain).
Acrodermatitis Zinc • Diarrhoea
enteropathica • Rash : Bilateral symmetrical & periorificial.
• Bitot’s spots (Triangular spots in bulbar
Xerophthalmia Vitamin A conjunctiva).
• Keratomalacia Corneal scars.
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Genetics 00:30:13
Chromosomal aneuploidies :
1. Down syndrome.
2. Klinefelter syndrome.
3. Turner syndrome.
Salient features :
1. Facial abnormalities :
• Mongoloid slant.
• Epicanthal folds.
• Flat nose, flat face, flat occiput.
• Low set ears.
• Protruding tongue : D/t hypoplastic mandible.
2. Abnormalities in extremities :
• Single transverse palmar crease : Simian crease.
• Curved 5th finger : Clinodactyly.
• gap between 1st & 2nd toe : Sandal gap.
3. Associated problems :
• Heart defects (50%) : M/C is endocardial cushion defect (ASD + VSD).
• Low IQ, hypotonia, microcephaly.
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Paediatrics Revision 2 02 17
1. Varicella/Chickenpox :
• Fever with vesicular rash + redness.
• Day 1 of fever : Onset of rash.
• M/C complication : 2˚bacterial infection d/t
Staphylococcus/Streptococcus.
• Period of infectivity : Till all the lesions
have crusted.
• Antiviral : Acyclovir. Rash : Dew drops in rose petal
appearance
2. Measles :
• Fever + 3Cs (Cough, coryza, conjunctivitis) for 3 days.
• Day 2-3 : Koplik spots opposite lower second molar.
• Day 4 : Maculopapular rash starting behind ear.
• Period of infectivity : 4 days before onset of rash & till
4 days after rash. a
• Complications :
a. Otitis media : M/C acute complication.
b. Pneumonia : Most severe acute complication.
c. Subacute Sclerosing Panencephalitis (SSPE) :
i. Chronic complication. b
ii. Fatal condition. a. Rash b. Koplik spots
iii. Seen in school going children & presents with myoclonic seizures.
iv. Diagnosed by anti measles antibody (IgG) in CSF.
HFMD
5. Erythema Infectiosum :
• Causative agent : Parvovirus B19.
• Characteristic rash : Slapped cheek appearance.
• Lacy/reticulated rash on trunk & extremities.
• Parvovirus B19 association :
a. Arthralgia : Adolescent children.
b. Chronic hemolytic anemia : Transient aplastic crisis.
c. Pregnancy : Non immune hydrops fetalis, severe anemia, myocarditis.
Stillbirth
6. Scarlet Fever :
Etiology : Group A β-hemolytic Streptococci/
Streptococcus pyogenes.
Fever with rash on 2nd day (Sand paper rash).
Rash starts from face → Trunk & limbs →
Spares palms/soles.
Accumulation of rash in skin creases : Pastia’s line.
Pharyngitis, Strawberry tongue.
Treatment : Penicillin.
1. Congenital varicella :
Intrauterine infection during pregnancy.
• Cortical atrophy → Microcephaly.
• Limbs : Hypoplasia.
• Scars : Cicatricial scars.
2. Congenital Rubella :
Most severe TORCH infection.
Triad :
• Heart defects : PDA (M/C), Pulmonary stenosis, VSD .
• Cataract.
• SNHL (Sensorineural hearing loss).
M/C ocular finding : Salt & pepper retinopathy.
Late onset features :
• Diabetes.
• Hypothyroidism.
• PRP (Progressive rubella panencephalitis).
Prevention : Vaccination of adolescent girls.
Note : High risk of transmission if mother has 1˚infection with CMV during
pregnancy (More severe than reactivation).
Diffuse parenchymal
calcifications
5. Congenital Zika :
Emerging infection.
C/F : Microcephaly.
Visual defects d/t macular scars.
Arthrogryposis congenita : D/t contractures in limbs.
Imaging : Subcortical calcification.
Kawasaki disease :
Medium vessel vasculitis.
M/C childhood vasculitis.
Stages of Kawasaki disease :
1. Acute : 1-2 weeks.
• Fever ≥ 5 days.
• Any 4 of the following : “CREAM”.
a. B/L Conjunctivitis.
b. Rash (Maculopapular).
c. Edema.
d. U/L cervical lymphadenopathy.
Strawberry tongue
e. Mucosal involvement (Strawberry tongue).
2. Subacute : 3-4 weeks.
• Complications :
a. Myocardial ischemia.
b. Coronary aneurysms.
c. Coronary vessel thrombosis.
3. Recovery stage.
Neonatology 00:09:45
Classification of neonates :
Based on birth weight :
a. LBW (Low Birth Weight) : < 2.5 kg.
b. VLBW (Very Low Birth Weight) : < 1.5 kg.
c. ELBW (Extremely Low Birth Weight) : < 1 kg.
IUGR : (SGA).
Asymmetric IUGR Symmetric IUGR
Incidence More common Less common
Uteroplacental insufficiency Anomalies/genetic defects
Cause
(Maternal cause) (Fetal cause)
Brain sparing effect Present Absent
Ponderal index <2 >2
Weight (g)
Ponderal index = × 100.
Length (cm3)
Infant of diabetic mother :
• Macrosomia : LGA.
• Hyperinsulinemia.
• Hypoglycemia (Blood glucose <45mg/dl).
• Hypocalcemia.
• Congenital anomalies (Common in overt diabetes) :
a. VSD (M/C).
b. Sacral agenesis/Caudal regression syndrome (Most specific).
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24 03 Pediatrics
Hypothermia :
Stages :
1. Cold stress (Mild) : 36-36.4˚C (extremities are cold but body/trunk is warm).
2. Moderate hypothermia : 32-36˚C.
Entire body is cold
3. Severe hypothermia : <32˚C.
Warmer Incubator
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Moro reflex :
• Components : Extension & abduction → Flexion & a dduction.
• Duration : Till 5-6 months after birth.
• Absent moro : HIE (Hypoxic Ischemic Encephalopathy).
• U/L Moro :
a. Peripheral nerve injury : Erbs palsy. Moro reflex
b. Bony injury : Fracture of clavicle, Dislocation of shoulder.
Asymmetric tonic neck reflex :
Lasts 6-7 months after birth.
Parachute reflex :
• Protective reflex.
• Onset 7-8 months post-natal. Persists throughout life. ATNR
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26 03 Pediatrics
APGAR score :
Sign 0 1 2
Activity Limp Some flexion Good flexion/active
movements
Pulse Nil < 100/min > 100/min
Grimace No response Grimace Cry/cough/sneeze
Appearance Blue/pale Acrocyanosis Pink all over
Respiratory effort Nil Irregular, slow Good cry
breathing
Normal score : 7-10/10.
Moderate score : 4-6/10. Low scores seen in birth asphyxia
Severe score : 0-3/10.
Birth asphyxia :
• WHO definition : Baby fails to initiate breathing.
• Criteria for diagnosis :
a. APGAR : Low (<7/10).
b. Umbilical cord pH : <7 (acidic).
Pediatrics Revision • v1.0 • Marrow 6.5 • 2023
28 03 Pediatrics
Pneumatosis intestinalis
Pathological jaundice :
• Appearance : <24h of life.
• Duration : >3 weeks.
• Involves palms/ soles.
• Dark yellow urine and clay coloured stools (Obstructive jaundice).
• M/C cause for conjugated hyperbilirubinemia : Extra-hepatic biliary atresia.
Kernicterus (BIND : Bilirubin Induced Neurological Damage) : ----- Active space -----
Acute Chronic
• Occurs in neonates. • Occurs in older children.
• Initially hypotonia followed by • Basal ganglia is affected.
hypertonia (opisthotonus). • Extrapyramidal cerebral palsy
• Seizures, lethargy. (chorea, athetosis).
Opisthotonus
Types :
Caudal NTD Cranial NTD
M/c type. Types :
Commonest site : Lumbosacral (L5 - s1). 3. Anencephaly :
Types : • Absent skull & Brain tis-
1. Spina bifida occulta (Clue : Tuft of hair sue.
over the region). • Intact brain stem.
2. Meningocele : 4. Encephalocele :
• Protrusion of meninges. • Defect in skull → Brain
• Transillumination test +ve. tissue comes out →
3. Meningomyelocele : Swelling.
• Protrusion of meninges & spinal nerve • M/c site : Occipital region.
roots.
• Transillumination test +ve.
Prevention :
Folic acid : 400 mcg/day.
Previous child with NTD :
• ed risk of NTD in next pregnancy.
• Folic acid dose : 4000 mcg (4mg)/day.
Febrile seizures :
• Commonest cause of seizures in young child.
• Age : 6 months - 6 yrs.
• No evidence of CNS infection.
Types :
Simple febrile seizures Complex febrile seizures
• GTCS - 1 episode. • Multiple episodes.
• Duration < 15 mins. • Long duration.
Does not se risk of epilepsy Slightly sed risk of epilepsy.
00:18:05
Other seizure disorders
Other seizure
Seizure disorders in children
disorder Age : EEG Treatment (DOC)
School going 3Hz spike &
Absence seizures Sodium valproate
child wave
Juvenile myoclonic 4-6 Hz poly-
Adolescents Sodium valproate
epilepsy spike & wave
West syndrome 1st line/DOC : Inj ACTH
(Infantile spasm) Hypsarrythmia 2nd line : Vigabatrin
• Jack knife sei- (High voltage
starts <1 yr
zures spikes in chaotic If associated with
• Salam spells background) Tuberous sclerosis :
DOC is vigabatrin
Rademecker Fatal
SSPE (Chronic compli-
- complex (Slow Dx : Anti measles IgG Ab
cation of measles)
wave) in CSF
C/F :
• Global developmental delay.
• Low IQ.
Tone in
• Seizures. lower limbs
• Microcephaly. Scissoring gait
• Abnormal tone.
• Vision & hearing defects. Spastic Diplegia
X linked recessive.
Defect : Dystrophin gene mutation.
Laryngomalacia :
Laryngomalacia
• M.c cause of stridor in infants.
• M.c anomaly of the larynx.
Stridor Intermittent stridor (present since birth)
Postural variation • Supine position : Stridor (+)
• Prone position : Stridor (-)
Investigation Laryngoscopy : Omega shaped epiglottis
Management Reassurance
Acute bronchiolitis :
Etiology : Respiratory Syncytial Virus (RSV).
Clinical features :
• Low grade fever.
• B/L wheeze following a Upper Respiratory tract infection.
Investigation : X-ray : B/L hyperinflated lung fields → due to Air trapping.
Treatment
Child without comorbidities Child with comorbidities
Pneumonia : 00:10:46
Etiology : Bacterial > Viral.
• Overall M.c : Streptococcus pneumoniae.
• M.c virus : Respiratory Syncytial Virus (RSV).
• In HIV infected children : Pneumocystis jiroveci.
Additional guidelines :
• Child with wheeze : Bronchodilator x 5 days.
• If cough persists for > 14 days : Evaluate for TB.
Paediatrics Revision • v1.0 • Marrow 6.5 • 2023
40 05 Pediatrics
Clinical features :
• Small child with sudden onset respiratory distress.
• Fast breathing
• Unilateral wheeze.
X ray findings :
• Complete occlusion : Collapse of lung fields.
• Partial occlusion : Hyperinflation (due to air trapping).
Management : Removal of foreign body using rigid bronschoscopy.
AKA Mucoviscidosis.
Etiology :
• Autosomal Recessive disorder.
• CFTR gene mutation (Cl- ion channels inactive)→Thick mucus → predispose
to infections.
• M.c mutation : DelF508 (deletion of phenyl alanine at 508 position).
Clinical features :
Respiratory :
• Recurrent pneumonia. (M.c cause : Staph. aureus > Pseudomonas).
• Bronchiectasis.
• B/L nasal polyp.
.GIT (occurs early) :
• Meconium ileus.
• Older children : Distal Intestinal obstruction syndrome/ DIOS → Constipation.
• Malabsorption → Chronic diarrhea.
• Pancreatic insufficiency (in 85% cases).
1. Exocrine : Steatorrhea, deficiency of vit A, D, E, K.
2. Endocrine (adult) : Diabetes mellitus (due to insulin deficiency).
• Liver : Cholestasis, predispose to biliary cirrhosis.
Others :
• Male infertility : Due to B/L absence of vas deferens → Azoospermia.
• Sweat : Excessively Salty (high levels of Na+ & Cl-).
Features :
• Oxygenated blood to fetus : Umbilical vein (one).
• Two umbilical arteries carry deoxygenated blood.
Additional communications
Ductus arteriosus Pulmonary artery & Aorta.
Foramen ovale Right atrium & left atrium.
Ductus venosus Umbilical vein & IVC.
Order of closure :
Functional closure :
Umbilical vessels → Ductus venosus → Foramen ovale → Ductus arteriosus.
(last to close : upto
10-14 hours)
Anatomical closure :
Umbilical vessels → Ductus venosus → Ductus arteriosus → Foramen ovale.
(Closes 10-21 (last to close : upto
days after 3 months)
birth)
Nada’s criteria
Major criteria Minor criteria
Systolic murmur ≥ grade 3. Systolic murmur < grade 3.
Any diastolic murmur. Abnormal S2.
Central cyanosis. Abnormal ECG.
Congestive heart failure. Abnormal CXR, abnormal BP.
Complications of L → R shunt :
Early Late
• Recurrent pneumonia. Reversal of shunt (R → L) : Eisenmenger syndrome
• CCF. Manifestations of Eisenmenger syndrome :
• Infective endocarditis. • Cyanosis.
• Clubbing.
Least incidence of complications : ASD.
1. Claudication pain.
2. Feeble femoral pulses.
3. Radiofemoral delay.
Compensation : Collateral formation by
intercostal arteries.
Overall M/C :
• In children : Tetralogy Of Fallot/TOF (cyanosis starts after neonatal period).
• In neonates : Transposition of Great Arteries (TGA).
Cyanotic CHD
Tetrology of Fallot :
1. Overriding of aorta.
2. RVH. D/t infundibular hypertrophy : Aka RVOT (right
3. Subpulmonary stenosis ventricular outflow tract) obstruction
4. VSD. Decreased PBF → Cyanosis.
α agonists
(Phenylephrine)
One liners :
M/c CHD a/w arrhythmias : Ebstein’s anomaly.
Ebstein anomaly is associated with Wolf Parkinson White (WPW) syndrome (Bun-
dle of Kent bypass).
M/c arrhythmia in WPW syndrome : Paroxysmal supraventricular tachycardia
(PSVT).
Supracardiac TAPVC : All the heart chambers have equal O2 saturation.
20 Prophylaxis :
Drugs Duration
Parenteral : Benzyl Penicillin Without carditis : Next 5 years (or) till 18
(Penicillin G) years.
Oral : Penicillin V. With carditis : Next 10 years (or) till 25 years.
Whichever is later is preferred.
Allergic to Penicillin : Macrolides. RHD/following valve repair surgery : Lifelong.
Esophageal atresia :
C/F : Neonate with
• Excess frothing with salivation.
• Vomiting.
• Aspiration of feeds since birth.
D/t proximal GI obstruction.
Coiling of nasogastric tube in
Common associated anomaly : TEF (Tracheoesoph- proximal esophagus
ageal fistula).
Investigations : Chest X-ray.
Management :
• Dehydration correction → NS + potassium.
• Sx correction → Ramstedt’s pyloromyotomy.
Celiac disease :
C/F :
• Chronic diarrhoea (→ Malabsorption).
• Short stature. After 6 months of age
• Failure to thrive.
Related to complementary feeding.
Diagnosis :
• Serology : Autoantibodies → Anti-endomysial antibody.
• Small intestinal biopsy :
1. Villous atrophy.
2. Crypt hyperplasia.
3. ↑ intra-epithelial lymphocytes.
Acute diarrhoea :
Duration : <7 days.
Etiology :
• Viral : Rota virus (M/C overall).
• Bacterial : ETEC (Enterotoxigenic E.coli M/C), Shigella flexneri (M/C cause of
dysentery).
Inherited hyperbilirubinemias :
M/C mode of inheritance : Autosomal recessive.
Syndrome Defect
Unconjugated hyperbilirubinemia
Gilbert (overall M/C) Low levels of UDP-GT
Criggler Najjar type 1 Complete absence of UDP-GT.
Criggler Najjar type 11 Partial absence of UDP-GT.
Conjugated hyperbilirubinemia
ABCC : ATB binding canalicular cassette.
Dubin Johnson syndrome
MRP 2 : Multidrug resistant protein.
Rotor syndrome OATP : Organic anion transporter protein.
Neonatal cholestasis :
↑ Conjugated bilirubin >1 mg/dL or >20% of total s. bilirubin.
C/F : Clay coloured stools and dark yellow urine.
Overall M/C cause : EHBA (Extra-hepatic biliary atresia) > Neonatal hepatitis.
Differentiated based on liver biopsy :
Neonatal hepatits (Idiopathic) EHBA
Hepatic architecture Disarray of hepatic lobules Intact
Giant cells +++ +
Portal reaction Inflammation ++ Fibrosis ++
Neo and periductular
- +
proliferation
Potter’s syndrome :
Pathology : B/L fetal renal agenesis → Severe
oligohydramnios → Fetal compression.
C/F :
• Lung hypoplasia (Cause of death).
• Limb deformities : CTEV.
UTI :
Over M/C cause : E.coli.
Investigations :
Urine culture :
• Specimen : Midstream clean catch urine sample (M/C).
• Significant colony count positivity : ≥ 105 CFU /mL.
Follow up investigations :
Investigations Timings Rationale
Any time (Even during therapy
USG KUB Screening
of UTI)
MCU (Micturating Detect anomalies (VUR
2-4 weeks after treatment
cysto-urethrogram) : Vesicoureteric reflex).
DMSA scan 3-4 months after treatment Detect renal scars
USG KUB
Glomerulonephritis (GN) :
Hematuria : Dysmorphic RBCs and RBC casts in urine.
Hypertension.
Periorbital puffiness.
Mild proteinuria.
PSGN (Post-streptococcal glomerulonephritis) :
• M/C cause in children.
• Pathology : Immune complex deposits in kidney.
• Age group : School going (5-15 years).
• Hematuria occurs after pharyngitis (After 1-2 weeks) or pyoderma (After
3-6 weeks).
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54 07 Paediatrics
Congenital hypothyroidism :
Causes :
• M/C cause : Thyroid dysgenesis (Aplasia/hyperplasia/ectopia).
• 2nd M/C cause : Dyshormonogenesis.
Clinical features :
• ↓ activity (Lethargic). • Hoarse cry.
• Hypothermia, dry skin. • Delayed passage of meconium.
• Wide open fontanelle. • Associations : Macroglossia, umbilical hernia.
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Pathway :
Cholesterol
C/F :
• ↓ Aldosterone : ↓ BP and shock.
• ↓ Cortisol → ↑ ACTH (Pituitary) → Hyperpigmentation.
In male child : Precocious puberty.
• ↑ Testosterone
Ambiguous genitalia