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Paediatrics Revision 1 01 1
PAEDIATRICS 1 ----- Active space -----
Normal growth 00:00:14
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
Weight increase pattern :

Age Increase
First 3 months ↑ by 20-30 g /day
Till age of 1 year ↑ 400 g /month
In 5-6 months Doubles
In 1 year Triples
In 2 years Quadruples
2. Height/length (<2 years) :

Arms span : Equivalent of height measurement in older
children.
Height increase pattern :
• At birth : 50 cm + 25 cm At one year : 75 cm + 12.5 cm At 2 years : 87.5 cm →
Henceforth ↑ by 6 cm /year.
• At 18-24 months : Height of the child (80-85 cm)
is half of the average adult height (160-170 cm).
• Height doubles by 4 yrs, triples by 12 yrs.
Infantometer : Length Stadiometer : Height

(Used for <2 yrs).
Paediatrics Revision • v1.0 • Marrow 6.5 • 2023

2 01 Paediatrics
----- Active space -----

3. Mid arm circumference (MAC) :
• Measured by : Shakir’s tape (Tricoloured).
• Age group : 1-5 yrs.
• Used for community assessment by health-workers.
• Interpretation :
a. Green : Normal.
b. Yellow : Malnutrition.
c. Red : Severe malnutrition (< 11.5 cm).
4. Head circumference (HC)/Occipitofrontal circumference :

• At birth : 33-35 cm (34 cm).
• Most of the HC occurs in first 2 yrs → Corresponds to brain growth.
• Pattern of increase :
Age ↑ in HC HC in cm (at birth : 34 cm)
In 1st 3 months 2 cm/month 40 cm
Next 3 months 1 cm /month 43 cm
Next 6 months 0.5 cm /month 46 cm
2nd year 2 cm (over the year) 48 cm
WHO growth charts :

Colours : Boys → Blue, Girls → Pink.

Percentile SD Interpretation ----- Active space -----
>97th > + 2 SD High value

97th
85th
50th -2 SD to +2 SD Normal value
15th (3rd-97th centile)
3rd
<3rd < - 2 SD Low value
Note : In microcephaly, head circumference for age < -3 SD.
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

4 01 Paediatrics

Testicular enlargement :
• Measured by orchidometer.
• Volume of testis which marks beginning of puberty : > 4 cc.
Growth spurt occurs later in males, but height increase is more in males → Final
height more in males.
Sexual maturity rating (SMR) by Tanner : Based on 2° sexual characteristics.
• Stage 1 (Pre-pubertal) to stage 5 (Adult like appearance).
• Growth spurt in females : stage 3, in male : stage 4.
Disorders of Growth 00:20:55
Short stature :
Height/Age < 3rd percentile or < -2 SD.
Most common type : Normal variant with normal growth velocity.
Types of normal variant short stature :

Constitutional delay Familial short stature
Adult height Normal Short
Puberty Delayed Normal age
Bone age Delayed Normal
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

Approach to short stature : ----- Active space -----

US : LS ratio
Normal Abnormal
Proportionate short stature Dis-proportionate short stature

•All normal variants (Constitutional
delay & familial short stature).
•Malnutrition cases.
•GH deficiency.
Short trunk (US) : D/t Vertebral involvement : Short limbs (LS) :

•Spondylo-epiphyseal dysplasia. •Achondroplasia.
•Hemivertebrae. •Rickets.
•Mucopolysaccharidosis. •Congenital hypothyroidism.
•Pott’s disease.
Microcephaly :
Causes : Affecting brain growth.
10/Genetic microcephaly : 20 microcephaly :

• Anomalies of brain (Anencephaly). • Pre-natal : Teratogens.
• Genetic disorder (Trisomies, • Peri-natal : Asphyxia.
Down’s syndrome). • Post-natal : Infections.
Fetal alcohol syndrome : Fetal hydantoin syndrome :
VSD
CVS defect : VSD.

Due to phenytoin
6 01 Paediatrics
----- Active space ----- Rett syndrome :

• Loss of previously acquired milestones.
• Hand wringing movements (Stereotypic movements in midline area).
• Usually develops normally in 1st year → develops microcephaly and develop-
mental regression.
• Other : Speech defect and ataxia.
• Associated with : MECP 2 gene defect.
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
2. Dandy walker malformation :

• A/w dilated posterior fossa → Prominent occiput.
• Lower part of 4th ventricle is obstructed.
• Cerebellar hypoplasia.
Management of hydrocephalus :
Ventriculo-peritoneal shunt (V-P shunt). Dandy Walker malformation

Disorders of Puberty 00:44:23 ----- Active space -----
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 cause Peripheral cause

•CNS related (Pituitary & hypothalamus). Immature gonads :
•Syndromic associations : Kallman syn- •Turner’s syndrome (Streak ovaries).
drome (A/w anosmia). •Klinefelter syndrome (Cryptorchid-
ism).
Precocious puberty :
M/C cause : In girls : Idiopathic, boys : Organic.
Precocious puberty
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.
Developmental milestones 00:49:30
4 domains of development :
• Gross motor.
• Fine motor.
• Language.
• Social.

8 01 Paediatrics
----- Active space ----- 1. Gross motor milestones :

Rule → Development always occur in the cephalo-caudal direction.
Age Milestone attained
3 months Neck holding
4 months Roll over
6 months Sit with support, Tripod posture
8 months Sit without support, crawling
10 months Stand with support, creeping
Stand without support
12 months
walk with support
15 months walk without support
18 months Running
2 years Climbing with 2 feet/step
3 years Climbing with 1 foot/step : Upstairs, rides tricycle
4 years Climbing with 1 foot/step : Downstairs, hops
2. Fine motor milestones :

4 months Bidextrous grasp
6 months Unidextrous grasp : Ulnar (Immature) palmar grasp
8 months Unidextrous grasp : Radial (Mature) palmar grasp
9 months Immature pincer grasp (Hold with sides of fingers)
12 months Mature pincer grasp (Holds with tip of fingers)
15 months Makes tower of 2 cubes
18 months Makes tower of 3-4 cubes
2 years Draws line, makes tower of 5-6 cubes
3 years Draws circle, makes tower of 8-9 cubes.
4 years Draws cross
4.5 years Draws square
5 years Draws triangle
6 years Draws diamond
Handedness develop by 3 years.

3. Language milestones : ----- Active space -----

Sounds → Syllables → Words.
3 months Cooing (Musical) sound
6 months Monosyllables
9 months Bisyllables
1 year 1-2 words (Meaningful)
18 months 8-10 words
2 years Sentences
3 years Recognises and tells name, age, and gender.
4 years Tells story and rhymes
4. Social milestones :
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)
Red flag signs in development :

If the milestones are not attained by the upper age limit : Evaluated for possible
cause of delay in development.
Milestone Upper age limit
Vocalization 6 months
Sitting 10 months
Standing 17 months
Walking 18 months
Single words 18 months

10 01 Paediatrics

Developmental quotient :
Developmental quotient = Developmental age (DA) x 100
Chronological age (CA)
• Developmental delay : DQ < 70.
• Global developmental delay : Delay in ≥ 2 domains → Significant brain prob-
lem (E.g : Cerebral palsy).
Note : Nocturnal enuresis

• Enuresis alteast twice a month in > 5 years.
• Categories :
a. 10 : Never dry since birth (M/C).
b. 20 : Previously dry child.
• Cause : Maturational delay of bladder.
• Management :
a. Ist line of Rx : Non-pharmacological → Motivation therapy + alarm
therapy.
b. 2nd line : Desmopressin (Preferred, oral), anti-cholinergic (Oxybutynin).

PAEDIATRICS REVISION 2 ----- Active space -----
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
3. Brain growth factors :

i. Whey protein.
ii. Taurine & cysteine.
iii. PUFA : Docosa Hexaenoic Acid (DHA).
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

12 02 Paediatrics

Mode of feeding in preterm babies :
<28 weeks/hemodynamically unstable : Total parenteral nutrition (TPN).
28-32 weeks : NG tube/orogastric tube feeds of expressed breast milk.
32-34 weeks : Paladai/katori spoon.
>34 weeks : Direct breastfeeds.
HIV & Breastfeeding : 00:06:50
Absolute C/I in developed countries.

Relative C/I in India (Developing countries).
Exclusive breastfeeding for 6 months → Gradual cessation.
Prophylaxis for breastfeeding baby :
• Nevirapine since birth.
• Cotrimoxazole : Started at 4-6 weeks & continued till 6 weeks after cessa-
tion of breastfeeding.
Nutritional Disorders 00:08:37
Protein energy malnutrition (PEM) :

1. Kwashiorkor 2. Marasmus
Age of onset >1 year <1 year
Predominant deficiency Protein Calorie
Edema +++ (Anasarca) Absent
Appearance Lethargic Alert
Appetite Vigorous
Prognosis Poor Good
Wasting :
• Wrinkles ++.
Hallmark Edema • Skin & bone appearance.
• Loose skin folds.
• Simian facies.
Additional features of Kwashiorkor :
• Fatty liver.
• Flag sign (Alternate black & white hair).
• Flaky paint dermatosis (Skin).

Malnutrition 00:12:53 ----- Active space -----
WHO malnutrition classification :

Charac- Moderate Severe
Chart used
teristic Malnutrition malnutrition
Wasting
Weight/
Acute malnutrition (Weight -2 to -3 SD < -3 SD
Height
loss)
Stunting
Chronic malnutrition Height/Age -2 to -3 SD < -3 SD
( height)
Edema - - - +
Severe acute malnutrition (SAM) :

Diagnosis :
Any one of the following criteria :
1. W/H : <-3 S.D.
2. Bilateral pedal edema.
3. Mid arm circumference (MAC) : < 11.5 cm (Shakir’s tape).
Assessment and treatment of SAM :
a. Good appetite Yes → Treatment at home/
b. Absence of complications community center.
c. Minimal/no edema
No → Hospitalisation.
Hospitalisation management guidelines for SAM : 10 steps.
Stabilization Rehabilitation
Day 1-2 Days 3-7 Weeks 2-6
Hypoglycemia
Hypothermia
Dehydration
Electrolytes
Infection
Micronutrients no iron iron
Cautious feeding
Catch-up growth
Sensory stimulation
Prepare for follow-up

14 02 Paediatrics

Note : Iron is not given in 1st week.
Criteria for hospital discharge :

• No edema for atleast 2 weeks.
• Weight/Height reaches -2 SD.
• MAC reaches 12.5 cm.
Complications of SAM : SHIElDeD

Sugars (Hypoglycemia : <54 mg/dl)
Hypothermia (Temperature <35°C).
Infections (Gram -ve : Enterobacteriacae)
Electrolyte disturbances ( K+, Mg2+, Na+)
Dehydration
Deficiencies (Micronutrients)
Rickets
Vitamin D deficiency → Mineralisation of bones ( PO43- & Ca2+) →defor-

mities.
Site : Metaphysis (Growth plate).
Rachitic rosary/String of beads

appearance (Widening of
costochondral junction).
Harrison’s sulcus (Pull of diaphragm)
Genu valgus (Knock knees) Genu varus (Bow legs) Wrist widening

Diagnosis : On X-ray ----- Active space -----

a. Splaying : Ends of long bones deviated laterally.
a
b. Fraying (Irregular edges) b&c
c. Cupping.
Refractory rickets :
S.PO43-
High Low
Do ABG
CKD ( excretion of PO43- )
Acidosis absent Acidosis present : Renal

Tubular Acidosis
Do PTH
Increased : Normal :
Vitamin D Dependant Rickets Familial hypophosphatemic
(Autosomal Recessive) rickets (X-linked dominant).
Other micronutrient deficiencies :
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.
16 02 Paediatrics

Vitamin A treatment dosage :
Schedule : Day 0 (1st day of administration), 1 and 14.
Age Dose
<6 Months 50,000 IU
6-12 months 1 Lakh IU
>1 year 2 Lakh IU
Note : If age >1 year but weight <8 Kg : 1 lakh IU.
Genetics 00:30:13
Chromosomal aneuploidies :
1. Down syndrome.
2. Klinefelter syndrome.
3. Turner syndrome.
Down syndrome (Trisomy 21) :

Genetic defects :
• Maternal meiotic nondisjunction of chromosome 21 : 95 % (M/C).
• Robertsonian translocations (4%) : t(21 ; 21) & t(14 ; 21).
• Mosaicism : 1%.
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.
• GI defects : M/C is duodenal atresia. ----- Active space -----

• Premature/Presenile Alzheimer’s disease : 30-40 years.
• Risk of leukemia : M/C is ALL > AML (M7/Megakaryocytic leukemia).
Klinefelter syndrome (47 XXY) :

C/F :
• Tall stature; long limbs (Height >97th percentile).
• Gynaecomastia.
• Cryptorchidism → Delayed puberty, infertility.
• Low IQ.
risk of malignancies :
1. Male breast carcinoma.
2. Germ cell tumors.
Turner syndrome (45 XO/Monosomy X) :

C/F :
• Heart defect : M/C is bicuspid
aortic valve.
• Streak ovaries :
a. Delayed puberty.
b. Amenorrhea.
c. Infertility.
risk of renal anomalies like Horse
shoe kidney.
Noonan syndrome mimics Turner’s
syndrome.
Turner syndrome Noonan syndrome

Defect 45 XO (Monosomy X) Autosomal dominant
Sex Females Males & Females
Gonadal defect Streak ovaries Affected males : Cryptorchidism
Coarctation of Aorta,
Heart defects Pulmonary stenosis
Bicuspid aortic valve.
IQ Normal Low

18 02 Paediatrics

Fragile X syndrome : Normal : <55 repeats Males : Ataxia + tremors.
Trinucleotide repeats of CGG. Premutation : 55–200 Females : Premature
Inheritance : X-linked recessive. Fragile X syndrome : >200 ovarian failure.
Clinical features :
• Long face, large ears, prominent chin.
• Macro-orchidism (Post-puberty).
• Intellectual disability & behavioral disturbances.
Common Childhood and Congenital Infections 00:44:20
Common childhood infections :
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.

3. Exanthema Subitem/Roseola Infantum : ----- Active space -----

• Causative agent : HHV 6.
• Fever with rash on day 4 of illness.
• Maculopapular rash : Starts from the trunk
Fever ses at onset (In measles : fever with rash).
4. Hand Foot Mouth Disease (HFMD) :

• Causative agent : Enterovirus 71/Coxsackie A16 virus.
• C/F : Preschool child with fever + blisters around mouth + papulovesicular
rashes on palms & soles.
• Self limiting & supportive treatment.
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.

20 02 Paediatrics

Common congenital infections :
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.
3. Congenital CMV (Cytomegalovirus) :

• M/C TORCH infection.
• 90% affected infants are asymptomatic (Transmission in 3rd trimester).
• SNHL (M/C cause of non-syndromic hearing loss in children).
• Chorioretinitis.
• Microcephaly.
• Investigations :
a. Brain imaging : Periventricular calcification.
b. IOC : PCR (Urine >> Blood) → To be done
within 2 weeks of birth.
• Treatment : Ganciclovir.
Note : High risk of transmission if mother has 1˚infection with CMV during
pregnancy (More severe than reactivation).

4. Congenital Toxoplasmosis : ----- Active space -----

C/F : SNHL, chorioretinitis, microcephaly.
Few infants have hydrocephalus.
Imaging : Diffuse parenchymal calcification.
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.

22 03 Pediatrics
----- Active space ----- PAEDIATRICS REVISION 3
Rheumatic disorders 00:00:10
JIA (Juvenile idiopathic arthritis) :

Arthritis lasting atleast 6 weeks with onset < 16 years.
• Oligoarticular JIA : ≤ 4 joints involved + uveitis.
• Polyarticular JIA : ≥ 5 joints involved.
a. RF -ve : Uveitis +nt.
b. RF +ve : Rheumatic nodules seen & ↑ risk of C-spine involvement.
• Systemic onset JIA :
a. Quotidian fever (1-2 spikes/day).
b. Arthritis.
c. Any one of the following : Salmon rash, Hepatosplenomegaly,
Lymphadenopathy, Serositis.
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.
Treatment : IVIg (TOC), Aspirin.
Pediatrics Revision • v1.0 • Marrow 6.5 • 2023

Pediatrics Revision 3 03 23
Henoch Schonlein purpura (HSP) : ----- Active space -----

• Small vessel vasculitis.
• Palpable purpura : In LL & buttocks.
• Post prandial abdominal pain & joint pain.
• Renal involvement : Hematuria/proteinuria. Palpable purpura
• Mx : Steroids.
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.
Based on percentile charts :

a. SGA (Small for Gestational Age) : < 10th percentile.
b. AGA (Appropriate for Gestational Age) : 10th-90th percentile.
c. LGA (Large for Gestational Age) : >90th percentile.
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).
24 03 Pediatrics

Characteristics of Preterm neonate :
Posture Extension (Scarf sign)
Breast buds <5 mm
Empty scrotum.
Male Lightly pigmented scrotum.
Genitalia
Rugae : ↓/absent.
Female Both labia majora & minora equally visible
Normal parameters in a newborn :

• HR : 120-160/min.
• Respiratory rate : 40-60/min.
• BP : 60/40 mmHg.
• Passage of meconium & urine : Upto 48hrs & 24 hrs respectively.
• Temperature : 36.5-37.5 °C.
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.
Kangaroo mother care (KMC) :

• Skin to skin contact b/w stable preterm/LBW baby &
mother.
• Baby is upright, in frog leg posture.
• Exclusively breastfed.
• Continued till 37 weeks (or) weight is 2.5kg.
KMC
Note :
Hemodynamically unstable baby → Warmer/incubator.
Mechanism of heat transfer :
• Warmer : Radiation.
• Incubator : Convection.
Warmer Incubator

Normal observations in new born :
• Erythema toxicum (M/C rash) : Papulo-pustular lesions.
• Milia : Milk spots (Face & nose region).
• Mongolian spots : Hyperpigmented macules on the back.
• Nevus simplex (Salmon patch) : Red patch on nape of neck, forehead.
• Epstein pearls : Pearly white lesions in palate.
D/t maternal estrogen (Transient findings) :

• Breast engorgement.
• White discharge P/V.
• Withdrawal bleeding P/V.
Head swellings in newborn :

Caput succedaneum Cephalohematoma
(More common)
Cause Prolonged labour Instrumental delivery
Appearance At/very soon after birth > 12-24 hrs after birth
Diffuse, superficial swelling Limited by sutures.
Characteristics
on scalp. Deep (subperiosteal).
of swelling
Disappears within few hours. Disappears within few weeks.
Jaundice.
Complications -
Linear skull fracture.
Neonatal reflexes : 00:30:18
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
26 03 Pediatrics

Neonatal resuscitation 00:34:33
Order : Temperature → Airway → Breathing → Circulation (TABC).
Term gestation?
Breathing/crying?
Good muscle tone?
No
Initial steps :
Temperature
↓
Tactile stimulation
(Rub back & flick soles)
↓
Positioning
(Slight neck extension ± Suction)
No Laboured breathing/ No
HR < 100 bpm, gasping (or) apnea?
Persistent cyanosis
Yes Post
Yes Resuscitation
Positive Pressure Ventilation (PPV) :
Consider CPAP care
1. Bag & mask ventilation (BMV) : C/I
in Congenital Diaphragmatic Hernia.
2. Endotracheal tube (ET tube) : Used
in CDH.
HR < 100 bpm

Ventilation corrective steps :
“MR-SOPA”
M : Mask reposition. HR Chest compressions :
<60 bpm 2 thumb technique.
R : Reposition head.
S : Suction. Compression : Ventilation = 3 : 1.
O : Open mouth. HR <60 bpm
P : ↑ Pressure.
A : Alternate airway (ET tube). Inj. Adrenaline :
1 : 10000 dilution, 0.2 mL/kg.
Through umbilical vein.

Starting O2 concentration during BMV : ----- Active space -----

• Term/preterm (35-36 weeks) : Room air (21% O2).
• Preterm (<34 weeks) : 30% O2.
Sensitive indicator of response to PPV : ↑ Heart rate > 100/min.
Resuscitation of a baby born through meconium stained liquor :

• Non-vigorous baby (poor muscle tone, poor/absent respiratory effort,
HR < 100/min) : Resuscitation.
• Vigorous baby : Initial steps → Early PPV (Routine tracheal suction is not
needed).
• Routine tracheal suctioning is not recommended unless signs of airway ob-
struction present.
Scoring systems in newborn :
Postnatal assessment of gestational Expanded New Ballard score (ENBS)
age (Based on neuromuscular maturity &
physical appearance).
Assessment of physiological parameters APGAR score
Assessment of Respiratory distress Silverman score
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).
28 03 Pediatrics

c. Neurological damage : HIE.
d. Multi-organ damage present.
Hypoxic ischemic encephalopathy (HIE) :

Stage 1 : Mild Stage 2 : Moderate Stage 3 : Severe
Consciousness Normal/Irritable Lethargic/depressed Comatose
Brainstem &
Parasympathetic ↑. No/↓ pupil response.
autonomic Sympathetic ↑
Seizures +. Variable HR.
function
No motor function.
Motor function Normal Decreased
Reflexes absent.
Management of HIE :
• Symptomatic management.
• Therapeutic hypothermia : Cool the body to 33.5-34.5˚C.
Neonatal seizures : 00:52:23
M/C cause : HIE.

M/C type : Subtle (Minimal) type.
DOC : Phenobarbitone.
Vitamin B6/Pyridoxine : Used in refractory seizures.
Disorders affecting preterm : 00:54:03
Necrotizing enterocolitis (NEC) :

Risk factors : Immaturity of intestine & top feeding.
Modified Bell’s staging :
Stage Features Management
Non specific (Abdominal Medical Mx :
1 1a
distension & vomiting) • NPO.
(Suspected NEC)
1b Non specific + Blood in stools • TPN.
2 2a Pneumatosis intestinalis. • Broad spectrum
(Definite NEC) 2b Pneumatosis portalis. antibiotics
If fails : Treat
3 3a Peritonitis surgically
(Complicated NEC)
3b Pneumoperitoneum Laparotomy

Pneumatosis intestinalis
Respiratory distress syndrome (RDS)/Hyaline membrane disease (HMD) :

Seen in preterm babies (< 34 weeks).
Deficient/immature surfactant → Collapse of alveoli.
X-ray findings : White out lungs/Groundglass appearance.
Silverman scoring :
0 1 2
Upper chest retractions Synchronous Chest lag See saw movement
Lower chest retractions
Xiphoid retractions Not seen Minimal Marked
Nasal flaring
Grunt Not heard Heard with Heard without
stethoscope stethoscope
Management :
• Mild (<3) : CPAP needed.
• Moderate (4–6) : CPAP needed.
• Severe (>7) : Mechanical ventilation + Surfactant therapy (INSURE technique
: Intubation → Surfactant → Extubation).
Congenital diaphragmatic hernia (CDH) :

M/C : Bochdalek hernia (Posterior & left) > Morgagni hernia (Anterior & right).
Most important prognostic factors : Pulmonary hypertension.
White out lung CDH

30 03 Pediatrics

Neonatal jaundice :
Visible jaundice is noted when bilirubin ≥ 5mg/dL.
Visual assessment : Kramers rule.
Zones Approximate bilirubin level (mg/dl)
I : Head (eyes) 4-6
II : Chest 6-10
III : Abdomen 10-12
IV : Limbs 12-14
V : Palms & soles ≥15 (↑ Risk of brain damage +)
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.
Breast feeding jaundice Breast milk jaundice

Appears in 1st week . Appears in 2-3 weeks.
Pregnanediol in breast milk transiently inhibits
D/t insufficient feeds.
conjugation.
In both cases breast feeding continued.
Treatment of pathological jaundice :

• Conjugated hyperbilirubinemia : Surgical treatment.
• Unconjugated hyperbilirubinemia :
a. Phototherapy : Wavelength → 460-490 nm.
mechanism : Structural isomerisation.
b. Exchange transfusion (Done in Rh incompatibility) :
Indications : Cord blood Hb < 10 g/dL & bilirubin >5 mg/dL.

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

32 04 Paediatrics
----- Active space ----- PAEDIATRICS REVISION 4
Neural tube defects (NTD) 00:00:15
Defect : Failure of closure of neuropore.

a. Anterior neuropore : Cranial NTD.
b. Posterior neuropore : Caudal NTD.
Risk factors : (Multifactorial inheritance)

1. Diabetes (Overt, Uncontrolled).
2. Teretogenic drugs : Valproate, Carbamazepine.
3. Folic acid deficiency in mother.
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.
Spina bifida Meningocele Myelomeningocele

occulta Anencephaly

Antenatal Investigations : ----- Active space -----
USG : Identification possible by 14- Markers in Amniotic fluid :

16 weeks of gestation (Earliest : 1. AFP
Anencephaly (10-12) weeks). 2. Best : Acetylcholine esterase..
Prevention :
Folic acid : 400 mcg/day.
Previous child with NTD :
• ed risk of NTD in next pregnancy.
• Folic acid dose : 4000 mcg (4mg)/day.
Seizure disorder in children 00:09:30
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.
Management of febrile seizures : Status epilepticus

• Antipyretics & tepid sponging. Any seizure, lasting > 5 mins
• Stabilize the pt (Airway, Breathing, Circula-
tion). Start antiepileptic
1st choice : Benzodiazepine (I.v) x 2 times.
2nd line : Choose one of Fosphenytoin/Valproate/Levetiracetam.

(If no response to one , try others)
If no response to any drug : Refractory status epilepticus

Thiopental/Midazolam/Phenobarbital/Propofol : Continuous iv infusion
(Anesthetic dose).
34 04 Paediatrics
----- Active space ----- Risk factors for recurrence :

Major Minor
• Age <1 yr. • Family h/o of febrile seizures.
• Duration of fever <24 hrs. • Family h/o of epilepsy.
• Fever 38-39°C (100.4-102.2 F). • Complex febrile seizure.
• Daycare.
If major risk factors present → • Male gender.
Start intermittent prophylaxis • Lower s. Na+ at time of presentation.
with oral clobazam/diazepam.
Risk factors for development of subsequent epilepsy :

Risk factor
Simple febrile seizures
Low risk
Recurrent febrile seizures
Complex febrile seizures High risk : Plan investi-
Family h/0 epilepsy gations
Neurodevelopmental 1. EEG
abnormalities 2. MRI brain
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

Meningitis 00:22:45 ----- Active space -----
Child with fever + signs of meningeal irritation.
Signs of meningeal irritation :

1. Neck stiffness (Nuchal rigidity).
2. Brudzinski’s sign : Flexion of hips & knees in response to neck flexion.
3. Kernig’s sign : Resistance to extension of leg while the hip is flexed & pain
over back.
Features of meningitis in young children (< 2 yrs) :

• Irritability.
• Bulging fontanelle ( ICT).
• Poor feeding.
Note : Signs of meningeal irritation are not common in children.
Etiology : Bacteria >> virus

a. Overall m/c in children : Streptococcus Pneumoniae.
b. Neonates : M/c is E coli.
India : Japanese encephalitis
c. M/c virus (Meningo-encephalitis)
Worldwide : Enterovirus.
Investigations : CSF analysis.
Bacterial meningitis Viral meningitis
Low sugars (Hypoglycorrhachia) Normal sugars
High protein Normal protein
Neutrophils ++ Lymphocytes ++
In JE : Mild in proteins
Management of bacterial meningitis :

• I.V antibiotics (Initially) : 3rd generation cephalosporins + vancomycin.
• Steroids : Dexamethasone ( inflammation, risk of SNHL).
M/c long term sequelae : SNHL (During follow up : Plan BERA).
Shunt associated meningitis :

Seen in children post Ventriculo-peritoneal shunt.
M/c organism : Staphylococcus Epidermidis.
Investigations : Shunt tap → CSF analysis.
36 04 Paediatrics
----- Active space ----- Cerebral palsy (CP) 00:31:00
Static (Single insult to brain) encephalopathy.

M/C risk factor : Birth Asphyxia (Hypoxic brain damage).
Pathology Type of CP
Term Parasagittal infarct Spastic quadriplegia
Preterm Periventricular Leukomalacia Spastic diplegia
Other risk factors : High jaundice ( Levels of bilirubin) → Basal ganglia
damage → Extrapyramidal CP.
C/F :
• Global developmental delay.
• Low IQ.
Tone in
• Seizures. lower limbs
• Microcephaly. Scissoring gait
• Abnormal tone.
• Vision & hearing defects. Spastic Diplegia
Duchenne muscular dystrophy 00:35:00
X linked recessive.
Defect : Dystrophin gene mutation.
Absence of dystrophin protein.

C/F :
1. Proximal muscle weakness.
2. Low IQ. Pseudohypertrophy of
3. Progressive scoliosis (D/t involvement of spinal muscles). calf muscle
4. Pseudohypertrophy : D/t fibrofatty deposition.
Gower’s sign : Proximal muscle weakness

Investigation : ----- Active space -----

Initial : CPK levels
Diagnostic :
• Genetic test : Multiplex ligation probe dependent amplification (MLPDA)
(Preferred).
• Muscle biopsy.
Progressive condition : Death occurs in 3rd decade (Early 20’s).

M/c cause of death : Respiratory insufficiency >> cardiac failure.

38 05 Pediatrics
----- Active space ----- PEDIATRICS REVISION 5
Upper airway disorders 00:00:11
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
Other upper airway infections :
Acute Epiglottitis Croup/ Acute laryngo tracheo

bronchitis (ALTB)
Etiology H. influenza type B Parainfluenza virus
( most
common)
Clinical • Toxic (sick looking) child. • Well looking child.
presenta- • Continuous drooling • Croupy cough : Characteristic
of saliva. feature.
tion • Tripod posture.
Stridor and fever.

X - Ray
Thumb sign : Swollen epiglottis Steeple sign : Narrowing of larynx
Treat- • Airway management • O2 inhalation.

ment • Iv 3rd Gen cephalosporins : • Steroids : Dexamethasone.
(Ceftriaxone, Cefotaxime)

Lower airway disorders 00:07:12 ----- Active space -----
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
Supportive care Rx : Antivirals (Riba- Prophylaxis :

virin) Palivizumab
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.
Pneumonia Management guidelines : IMNCI (Integrated Management of Neona-

tal and Childhood Illness)
Revised WHO guidelines
Terminology Clinical Features Management

No pneumonia. Fever, cough/cold. Home Mx : Paracetamol.
Pneumonia. Fever, cough/cold + fast Home Management + Oral
breathing ± chest indrawing Amoxicillin x 5 days.
SpO2 normal.
Severe pneumonia/ Hypoxia or Danger signs like : Immediate referral to higer
Very severe disease. • Lethargy. centre + 1st dose of iv. antibiotic
• Cyanosis. (Inj. Ampicillin + Gentamicin).
• Convulsions.
• Not able to feed.
Additional guidelines :
• Child with wheeze : Bronchodilator x 5 days.
• If cough persists for > 14 days : Evaluate for TB.
40 05 Pediatrics

• Criteria for fast breathing :
Age Respiratory rate
< 2 months > 60/min
2-12 months > 50/min
> 12 months > 40/min
Foreign body in airway : 00:17:35
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.
Asthma in children : 00:19:31
Etiology : allergen exposure → Bronchoconstriction.

Clinical Features : Recurrent episodes of wheeze ( Minimum 3 episodes)
Investigation :
• ↓FEV1 /FVC ratio : < 0.8
• Response to inhaled β2 agonist : Improvement in features of Asthma (FEV1 ↑
by ≥ 12% ).
• Day to day/ AM–PM /Diurnal variation : PEFR or FEV1 ↑ by ≥ 20%.
• Exercise challenge (exertion) : FEV1 ↓ by > 15% or worsening the Asthma.
Asthma management guidelines :

Asthma Symptoms Treatment
Intermittent Infrequent : <2 episodes/ SOS : SABA (Short Acting beta agonist)
month + ICS (Inhaled corticosteroids).
Mild persistent At least twice a month or Low dose ICS daily + SABA (during
1 night time awakening/ exacerbation)
month
Moderate per- Daily episodes Daily : Low dose ICS + LABA ( Long act-
sistent ing beta agonist) / Medium dose ICS.
Severe persistent Continuous episodes + lim- Daily : High dose ICS + LABA
itation of physical activity

Asthma medication devices : ----- Active space -----

M.c used : Metered dose inhaler (MDI).
• >12 yrs : MDI.
• 4-12 yrs : MDI + Spacer.
• <4 yrs : MDI + Spacer + Face mask.
Management : Acute exacerbation of asthma

• Correction of hypoxemia : O2 inhalation.
• Limitation of airflow obstruction :
1. Salbutamol (SABA) nebulization → 3 times in 20 mins interval.
2. Systemic steroids : Oral Prednisolone/ parenteral Hydrocortisone.
Cystic fibrosis 00:28:00
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-).

42 05 Pediatrics

Diagnostic criteria :
When to suspect ? Laboratory confirmation
• Presence of typical clinical features • 2 elevated sweat chloride concentra-
(respiratory/ GIT/ Genitourinary) tions obtained on separate days (>60
OR mEq/L).
• History of Cystic Fibrosis in a sibling. OR
OR • Identification of 2 CFTR mutations
• IRT : Immuno Reactive Trypsinogen testing (best).
( New born screening test) → +ve
OR
• 1 abnormal nasal potential difference
measurement.
Rx : CFTR modulators/ Caftors : (Emerging Rx for CF).

• CFTR potentiator (Increase activity of CFTR): Ivacaftor.
• CFTR corrector (correct the basic defect of CFTR) : Lumacaftor.

PAEDIATRICS REVISION 6 ----- Active space -----
Fetal circulation 00:00:11
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)
Congenital heart defects (CHD) :
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.
Presence of 1 major (or) 2 minor → CHD

44 06 Paediatrics

Acyanotic CHD 00:05:00
Acyanotic CHDs are more common.

Acyanotic CHD
L → R shunt lesions Obstruction

• VSD. • Coarctation of
• ASD. aorta.
• PDA.
• Cushion defects : Atrioventricular
septal defects (AVSD), usually a/w
Down’s syndrome.
Lesion M/c type Characteristic feature

VSD Perimembranous Shunt murmur : Pansystolic murmur.
(overall m/c). VSD. • Heard at left 4th ICS.
• Parasternal area.
ASD. Ostium secun- S2 : Wide fixed split.
dum ASD.
PDA. No types. Loud, continuous, machinery murmur :
(increased • Heard at left 2nd ICS.
incidence in • Parasternal area.
preterm)
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.
Management of shunt lesions :

• Surgical closure.
• Medical closure of ductus arteriosus in preterms :
NSAIDs : Indomethacin, Ibuprofen.
Coarctation of aorta : ----- Active space -----
M/c type : Juxtaductal.

Features
Reduced blood flow to lower limbs Hypertension of upper limbs
1. Claudication pain.
2. Feeble femoral pulses.
3. Radiofemoral delay.
Compensation : Collateral formation by
intercostal arteries.
Inferior rib notching : D/t ↑ in size of

intercostal arteries.
Cyanotic CHD 00:16:23
Overall M/C :
• In children : Tetralogy Of Fallot/TOF (cyanosis starts after neonatal period).
• In neonates : Transposition of Great Arteries (TGA).
Cyanotic CHD
Increased pulmonary blood flow (PBF) Decreased PBF

• TGA. • TOF.
• Truncus arteriosus. • Ebstein anomaly.
• Total anomalous pulmonary ve- • Tricuspid atresia.
nous communication (TAPVC).
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.

46 06 Paediatrics

Complications in TOF :
• Polycythemia (d/t chronic hypoxia) → thromboembolism.
• Brain abscess.
• Cyanotic spells :
• Trigger : Infundibular spasm.
• Rx : β blockers, O2 supplementation, NaHCO3 (for lactic acidosis),
morphine (as CNS depressant).
Squatting
Knee chest position

Increase vascular resistance by
(young children)
α agonists
(Phenylephrine)
Box shaped heart : Ebstein anomaly

Boot shaped heart : TOF
A/w lithium exposure in pregnancy
(RVH +nt, pulmonary oligemia +nt).
Egg on a side appearance : TGA Snowman/figure of 8 appearance : TAPVC
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.

Acute rheumatic fever 00:28:38 ----- Active space -----
Modified Jones’ criteria (2015) for high risk population (India) :
Major criteria Minor criteria

1. Carditis : Clinical and/or subclinical 1. Monoarthralgia.
(echo findings s/o carditis). 2. Fever ≥ 38 0C.
2. Arthritis : 3. ESR ≥ 30 mm/hr in first hour and/
a. Monoarthritis/polyarthritis. or CRP ≥ 3 mg/dL.
b. Polyarthralgia. 4. Prolonged PR interval.
3. Sydenham chorea.
4. Erythema marginatum.
5. S/c nodules.
Diagnosis of a/c rheumatic fever :
2 major (or) 1 major + 2 minor (or) In recurrences, 3 minor

+
↑ ASO titre.
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.

48 07 Paediatrics
----- Active space ----- PEADIATRIC REVISION 7
Congenital anomalies in GIT 00:00:14
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.
Hypertrophic pyloric stenosis :

C/F :
• Neonate.
• H/o vomiting.
• Dehydration present.
Presents 2-3 weeks after birth.
O/E :
• Olive shaped epigastric mass.
• Visible gastric peristalsis directed from left to right side.
Pathology : Hypertrophy of circular muscles fibers.

Drug association : Erythromycin.
Investigations :
IOC → USG :
• Pyloric muscle thickness : ≥ 4 mm.
• Pyloric channel length : ≥ 16 mm.
Metabolic abnormalities due to vomiting : Hypokalemic, hypochloremic metabolic
alkalosis with paradoxical aciduria.
Management :
• Dehydration correction → NS + potassium.
• Sx correction → Ramstedt’s pyloromyotomy.

Hirschsprung disease/aganglionosis : ----- Active space -----

C/F :
• Neonate.
• Not passed meconium since birth.
• Abdominal distension.
Pathophysiology : Absent ganglion → no relaxation →

Contracted rectum.
Investigations : Contrast enema

• IOC : Rectal biopsy → Absent ganglions and hypertrophied nerve fibers
• Acetyl choline esterase stain → Hypertrophied nerve fibers.
• Contrast enema : Narrowed rectum.
Celiac disease :
C/F :
• Chronic diarrhoea (→ Malabsorption).
• Short stature. After 6 months of age
• Failure to thrive.
Related to complementary feeding.
Pathology : Gluten hypersensitivity (Barley, rye, oat and wheat (BROW)).

Genetic predisposition : HLA DQ 2 and HLA DQ 8.
Diagnosis :
• Serology : Autoantibodies → Anti-endomysial antibody.
• Small intestinal biopsy :
1. Villous atrophy.
2. Crypt hyperplasia.
3. ↑ intra-epithelial lymphocytes.
Treatment : Gluten free diet.

50 07 Paediatrics

Diarrhoea in children 00:12:04
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).
Assessment and management of dehydration :

No dehydration Some dehydration Severe dehydration
Features Active alert child Irritability, thirsty Lethargic
Slow response (≤2
Skin pinch Fast response (<1 sec) Very slow (>2 sec)
sec)
Plan A : Plan B : Plan C :
Manage- Replace ongoing loss Rehydration with ORS Rehydration with IV
ment with ORS : 10-20 mL/ : 75 mL/kg over 4 hrs. fluids : RL, 100 mL/
kg per loose stool. kg.
WHO low Osm ORS :
Components Osm (mosm/L) Age 30 mL/kg 70 mL/kg
Glucose 75 <1 yr 1 hr 5 hr
Na 75 >1 yr 30 min 2.5 hr
k 20
Cl 65
Citrate 10
Total 245
Normal osm of body fluid : 285-295 mosm/L.
Seizures in a child with diarrhoea :

Causes :
1. Febrile seizures.
2. Cerebral venous or sagittal sinus thrombosis (D/t dehydration).
3. Metabolic and electrolyte imbalances :
• Hypoglycemia.
• Hypomagnesemia.
• Hyponatremia.
• Hypernatremia.
Liver disorders in children 00:18:02 ----- Active space -----
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
Paediatric nephrology and related disorders 00:24:14
Potter’s syndrome :
Pathology : B/L fetal renal agenesis → Severe
oligohydramnios → Fetal compression.
C/F :
• Lung hypoplasia (Cause of death).
• Limb deformities : CTEV.

52 07 Paediatrics

Bladder exstrophy or ectopia vesicae :
Exposed bladder.
Cloacal exstrophy : Exposed terminal ileum → Elephant
trunk ileum.
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
UTI guidelines : First episode of UTI
USG KUB
Normal Abnormal/recurrent UTI/non-E.coli

UTI
Stop follow up
MCU
Normal Abnormal : VUR
Nephrotic syndrome : DMSA

Clinical features :
• Massive proteinuria :
a. >40 mg/m2/hr (Normal : <4 mg/m2/hr).
b. Spot urine sample → P : C (Protein : creatinine ratio) >2.

c. Urine dipstick : 3+ or 4+. ----- Active space -----

• Hypoalbuminemia.
• Generalized edema.
• Hyperlipidemia + lipiduria.
Pathology : Minimal change disease (Overall m/c) → Effacement of foot
process of podocytes.
MCD vs disorders with significant changes :

Significant change disorders
Minimal change disease
(Eg : FSGS)
Age at onset 2-6 years Late adolescent period/adults
Hematuria/hyper-
- ±
tension
Renal function Normal Abnormal/↓↓
Response to steroids Excellent Resistant
Definitions in nephrotic syndrome :

Urine albumin nil or trace (Or proteinuria <4 mg/m2/hr)
Remission
for 3 consecutive early morning specimens.
Absence of remission despite therapy with daily predniso-
Steroid resistance lone for 6 weeks → DOC : Calcineurin inhibitors (Tacrolim-
us, cyclosporine).
Two consecutive relapses when on alternate day steroids
Steroid
or within 14 days of its discontinuation → Rx : Steroid
dependence
sparing agents (Levamisole, mycophenolate).
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).
54 07 Paediatrics

• Investigations :
a. Serology : ↑ ASO titer, ↑ Anti DNAase B titer.
b. ↓ serum C3 levels.
• Management : Supportive.
AKI (Acute kidney injury) :

• S. Creatinine : ↑ 1.5-1.9 times from the baseline.
• Urine output : <0.5 ml/kg/hr for 6-12 hours.
• eGFR (Estimated glomerular filtration rate) → Schwartz formula :
eGFR = Length (cm) X K (Constant = 0.43)/serum creatinine.
Hemolytic uremic syndrome :

C/F : Child with AKI.
PS reveals :
• Thrombocytopenia.
• Schistocytes.
Most cases occur following (5-7 days) diarrhea : D +
HUS.
Schistocytes on
Toxin mediated : SHIGA toxin. peripheral smear
Organisms implicated :
• E.coli (EHEC → O 157, H 7).
• Shigella dysenteriae.
Management :
• Supportive.
• Plasmapheresis.
• Antibiotics are not indicated → Release pre-formed toxins.
Paediatric endocrinology 00:48:40
Congenital hypothyroidism :
Causes :
• M/C cause : Thyroid dysgenesis (Aplasia/hypoplasia/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.
Investigations : ----- Active space -----

Universal screening : Serum TSH (Done 48-72 hours after birth).
Radiological investigations :
• USG : Location and presence of thyroid gland.
• Radionuclide scan : 123I scan >> 99Tc scan.
Congenital adrenal hyperplasia :

Enzyme deficiency :
• 21 Hydroxylase (M/C).
• 11 hydroxylase.
• 17 hydroxylase.
Pathway :
Cholesterol
Pregnenolone X 17 α hydroxypregnenolone Dehydroepiandosterone

17 α-Hydroxylase
Progesterone X 17 α hydroxyprogesterone Androstenedione
21-Hydroxylase
X21-Hydroxylase X Testosterone
Deoxycorticosterone 11-deoxycortisol
11 β-Hydroxylase
Corticosterone X
Cortisol
Aldosterone
C/F :
• ↓ Aldosterone : ↓ BP and shock.
• ↓ Cortisol → ↑ ACTH (Pituitary) → Hyperpigmentation.
In male child : Precocious puberty.
• ↑ Testosterone
Ambiguous genitalia
Inheritance : Autosomal recessive.

Neonatal screening : ↑ 17-OHP (Hydroxyprogesterone).
Dexamethasone : Given antenatally to decrease the risk of virilization of female
fetus due to CAH.

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Paediatrics Revision 1 01 1

PAEDIATRICS 1 ----- Active space -----

Normal growth 00:00:14

Weight increase pattern :

2. Height/length (<2 years) :

Infantometer : Length Stadiometer : Height

Paediatrics Revision • v1.0 • Marrow 6.5 • 2023

----- Active space -----

4. Head circumference (HC)/Occipitofrontal circumference :

WHO growth charts :

Paediatrics Revision • v1.0 • Marrow 6.5 • 2023

Percentile SD Interpretation ----- Active space -----

>97th > + 2 SD High value

Paediatrics Revision • v1.0 • Marrow 6.5 • 2023

----- Active space -----

Disorders of Growth 00:20:55

Types of normal variant short stature :

Paediatrics Revision • v1.0 • Marrow 6.5 • 2023

Approach to short stature : ----- Active space -----

Proportionate short stature Dis-proportionate short stature

Short trunk (US) : D/t Vertebral involvement : Short limbs (LS) :

10/Genetic microcephaly : 20 microcephaly :

Fetal alcohol syndrome : Fetal hydantoin syndrome :

CVS defect : VSD.

----- Active space ----- Rett syndrome :

2. Dandy walker malformation :

Paediatrics Revision • v1.0 • Marrow 6.5 • 2023

Disorders of Puberty 00:44:23 ----- Active space -----

Central cause Peripheral cause

Developmental milestones 00:49:30

Paediatrics Revision • v1.0 • Marrow 6.5 • 2023

----- Active space ----- 1. Gross motor milestones :

2. Fine motor milestones :

Paediatrics Revision • v1.0 • Marrow 6.5 • 2023

3. Language milestones : ----- Active space -----

Red flag signs in development :

Paediatrics Revision • v1.0 • Marrow 6.5 • 2023

----- Active space -----

Note : Nocturnal enuresis

Paediatrics Revision • v1.0 • Marrow 6.5 • 2023

PAEDIATRICS REVISION 2 ----- Active space -----

3. Brain growth factors :

Paediatrics Revision • v1.0 • Marrow 6.5 • 2023

----- Active space -----

HIV & Breastfeeding : 00:06:50

Absolute C/I in developed countries.

Nutritional Disorders 00:08:37

Protein energy malnutrition (PEM) :

Paediatrics Revision • v1.0 • Marrow 6.5 • 2023

Malnutrition 00:12:53 ----- Active space -----

WHO malnutrition classification :

Severe acute malnutrition (SAM) :

Paediatrics Revision • v1.0 • Marrow 6.5 • 2023

----- Active space -----

Criteria for hospital discharge :

Complications of SAM : SHIElDeD

Vitamin D deficiency → Mineralisation of bones ( PO43- & Ca2+) →defor-

Rachitic rosary/String of beads

Harrison’s sulcus (Pull of diaphragm)

Paediatrics Revision • v1.0 • Marrow 6.5 • 2023

Diagnosis : On X-ray ----- Active space -----

Acidosis absent Acidosis present : Renal

Other micronutrient deficiencies :