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PAEDIATRICS NOTES DINESH

Contents:
Renal

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

RENAL
Acute Post Streptococcal Glomerulonephritis:

Definition:
-

Acute, specific, self-limited glomerulonephritis following pharyngeal/cutaneous infection with


nephritogenic strains of group A -hemolytic streptococci.

Strain: Pharyngitis - M 4 & 12


Pyoderma - M 49

Clinical Features:
-

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

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

Characteristically cola-colored urine.

Oliguria

Hypertension

In atypical cases:
-

Convulsion

Left ventricular failure

Acute renal failure

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

elevated

e. Blood creatinine:

elevated

f.

Urine

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

1+/2+

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.

4.

Antibiotics:
-

5.

Benzathine penicillin im single dose


o

<20kg: 0.6 million units

>20kg: 1.2 million units

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%
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
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

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 1.4 mg/kg/day
Human Albumin Infusion when human albumin falls below 1.5 g%

B. Specific:
SKDC Regime:
Prednisolone 2 mg/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:
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 > 510/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.
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

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:

Pre renal:
o

Acute gastroenteritis

Hemorrhage, shock

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

10

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

11

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

12

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/ Hartmanns 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

13

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 hours

Repeat if radial pulse is weak.

14

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

If improvement but still showing some signs of dehydration, start Plan B and
discontinue IV fluids.

Observe child for at least 6 hours before discharge, to confirm that mother is able to
maintain the childs 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, Wilsons disease.
b. Budd-Chiari syndrome
c. Veno-occlusive disease

Signs of Liver Cell Failure:


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

15

d. Palmar erythema
e. Clubbing, White nails
f.

Dupuytrens 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

16

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%

17

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

18


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. Potts shunt
c. Waterston shunt

19

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.

20

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 , , 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 -Blocker in cases without active myocarditis
7. Cardiac transplantation

21

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. Eisenmengers phenomenon and pulmonary hypertension
6. Aortic / Tricuspid regurgitation
7. Growth retardation

PDA:

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

22

Recurrent chest infection


Signs:
General:
HR and RR
Harrisons 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)

23

RESPIRATORY SYSTEM
Management of Status Asthmaticus:

Inhaled 2 agonist repeated every 20 min for 1 hour


and
O2 inhalation
and
An oral dose of prednisolone 1-2 mg/kg

Improvement:
1. 2 agonist every 30 min interval gradually increased 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 250g every 20 min.
2. Inj. Hydrocortisone 10 mg/kg
improvement
Treat as early
responder

Reassess at 2 hr.
No response
1. Start injectable theophylline bolus followed by
continuous infusion
Magnesium 50mg/kg in dextrose over 30 min

No improvement

Mechanical ventilation

24

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

25

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.

26

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.

27

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

28

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

29

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

30

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

S.pneumoniae, H.meningitidis

>3yrs:

31

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 / Littles 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

32

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

33

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: Critchelys 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

Ryes Syndrome:
Definition:
-

Acute self-limiting metabolic insult of diverse etiology resulting in generalized


mitochondrial dysfunction due to inhibition of fatty acid 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, Klinefelters
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. Hypoxic ischemic 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 periosteal hemorrhage usually involving parietal and temporal bones

Etiology:
-

Forceps delivery

Vacuum extraction

Prolonged labor

Clinical Features:
-

It appears as a soft fluctuant swelling with well-defined margin.

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 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 up to finger tips

B. Functional features:
a. Respiratory system: good cry
Good cough reflex
b. GIT: sucking/swallowing reflex good.
c. Neurological: Moros 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

Appearance

Blue

Body pink, extremities

Pink completely

blue
Pulse/min

Absent

<100

>100

Grimace (reflex

No response

Grimace

Cry, cough or sneezes.

Activity (muscle tone)

Flaccid

Some activity

Actively moving limbs

Respiration

None

Slow irregular

Good crying

stimulation)

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

When to do: 1 min, 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 Erbs 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

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

Excessive crying/irritability

Abdominal distension

Neck retraction

Diarrhea

Bulging fontanelle

Vomiting

GIT:

Temperature problem:

Others:

Hypothermia

Sclerema

Fever

Excessive jaundice

Bleeding

Renal Failure

Investigation:
-

Blood counts

Cultures

X Ray chest

Gram stain

Acute phase reactants

Management:
1. 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 - 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

Encephalopathy

Anaphylaxis

Shock like syndrome

Hyperpnoea

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

Type: Live attenuated vaccine. S.typhi Ty2la strain

Age: after 6 years

Dose: on 1, 3,5 days 1 capsule

Oral:

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 3 105.5 TCI 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

58

Acute infections

Febrile illness

Diarrhea and dysentery

Malignancy

Corticosteroid therapy

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. Phataks Baroda 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

1st 400 days = (

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:
between 3-12 months =

between 1 to 7 years; weight(kg) = (

between 7 and 12 years; weight (kg) =

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 childs 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

Shakirs 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. Downs syndrome
4. Trisomy 18 (Edwards 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

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 long term 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

68

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 g/dl

Treatment:
Lifelong level thyroxine 10-15 g/kg/day
To bring T4 to 12-16 g/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 **

** Halls criteria if 4 strong possibility of Downs

72

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.

Gross motor: walking without support

Fine motor:

1 year:

Scribbles spontaneously

Child attempts to wear his socks or shoes without success

Personal, social:
o

Mimicry of the action of mother at home

Repeat any performance which evoke appropriate response from parent

75

Play simple ball game

Language: Two words with meaning

Gross motor: walking upstairs with one step at a time

Fine motor:

2 years:

Can turn 1 page of picture book at a time

Can draw horizontal or vertical line

Can wear socks and shoes

Make tower of 4 cubes.

Language:
o

Simple sentence using nouns without verbs

Uses pronouns

3 years:
-

Gross motor:
o

Riding tricycle

Climbs stairs in coordinated manner keeping only one foot on each step

Fine motor:
o

Can draw a circle

Can dress or undress himself

Language:
o

Vocabulary of 250 words.

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 Bitots 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 mothers 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. Harrisons 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

Apparent in width of growth plate

Splaying of metaphysis

Cupping of metaphysis

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

81

Age independent criteria for assessment of malnutrition:

1. Weight for height


2. Raos index
3. Kanawatis index
4.

Dugdales 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)

% weight for height = (

2. Raos index:
Constant between 1-5 years irrespective of gender

3. Kanawatis index: constant between 3 month 4 years of age

Name

Methods

Raos

Kanawatis

Dugdales

N/Severe PEM

0.15-0.16/ <0.14

0.32 0.33/ 0.25

MAC

0.88 0.97 / 0.79

> 13.5 / 12.5 cm

82

Classification of PEM:
1. Wellcome classification:
Weight

Edema

Inference

60-80% of expected

Underweight

60-80% of expected

Kwashiorkor

< 60%

Marasmus

< 60%

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

(measure of wasting)

wasting

Height for age

85 89 % of expected

(measure of

stunting

stunting)

83

<70% severe wasting

< 85% severe stunting

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:

Gross wasting of muscle, poor muscle tone

Loss of subcutaneous fat

Bony prominences are seen

Skin:
o

Wrinkled, dry and loose, inelastic

Folds prominent over glutei and inner thigh

Psychological:
o

Appears alert but irritable

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:

Flaky paint dermatosis

Dry inelastic mosaic appearance

Hair changes:

Flag sign present

Thin, dry, brittle, sparse, easily pluckable

Mental changes:

Lethargic, listless and apathic

Takes little interest in the environment and does not play with his toys

GIT:
o

Impaired appetite

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

Ca

34

Vitamin K

Deficient

Vitamin D

Water soluble

0.5 g
117

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

Appetite

Good

Poor

Skin

Dry, scaly

Flaky paint dermatitis

Hair damage

Hypopigmented

Flag sign

Moon face

Hepatomegaly

Clinical features:

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 g/dl
b. TIBC increased >350g/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

91

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 Stensens 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

92

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

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

95

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 : Wilms 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

97

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

Sudden onset fever with headache and vomiting

Fever is continuous with little diurnal variations

Constipation

Coated tongue at center.

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

Spleen palpable

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

98

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

Thrombocytopenia

Blood culture:
o

Blood 1st week

Stool and urine after 2 weeks

Serology Widal test


o

Diagnostic titer of > 1 in 80 after 7 10 days of illness

4 fold rise in titer is diagnostic

Treatment:
-

Specific:
o

Amoxicillin 100 mg/kg/day in 4 divided doses 10-14 days

Ceftriaxone 50-100 mg/kg/day iv for 5-7 days

Corticosteroid in children with altered mental state or shock

Supportive treatment:
o

Good nursing care

99

Nutritious diet

Fluid and electrolyte

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

100

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.

101

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
Waldeyers ring involvement is uncommon

Waldeyers ring involvement is common

Epitrochlear node involvement rare

Common

BM involvement late

Early

Early involvement of paraaortic node

Late

Alcohol present

Absent

102

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

103

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

Pneumonia

Cotrimoxazole 5 days

Home

Severe

In/im penicillin

Hospital

Iv chloramphenicol

Hospital

-No fast breathing


-No chest indrawing
or indication of severe
illness
-Resp rate
60 <2 months
50 2mts-1yr
40
-Chest indrawing

pneumonia
-Cyanosis

Very severe

-Severe chest
indrawing
-Inability to feed

104

Daily dose of cotrimoxazole:

Age/wt

Tablet

Syrup 1 spoon = 5ml

Sulfamethoxazole

SMX 200mg

100mg

Tri 40mg

Trimethoprim 20mg
<2 months

One tab BD

spoon BD

Two tab BD

1 spoon BD

3 tab BD

1 spoon BD

3-5 kg
2-12 months
6-9 kg
12-60 months
10-19 kg

Signs of severe diseases in < 2 months:

Convulsion

Abnormal sleep or difficult to wake

Stridor in calm child

Not feeding well

Tachypnea

Chest indrawing

Cyanosis

Altered sensorium

Cold Chain:

Definition:
-

It is a system of storage and transport of vaccines at low temperature from the


manufacturer to the actual vaccination site.

Vaccines kept in freezer compartment: polio, measles


Vaccines kept in cold compartment: DPT, TT, DT, BCG and diluents

105

Cold chain equipment:


-

Regional level: Walk in cold room.

These can store vaccines up to 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
monitoring

Preventive
care

106

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 childs
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

107

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

108

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.

109

IMPORTANT MILESTONES
Gross motor:
-

3 month

Neck holding

5 month

Sitting with support

8 month

Sitting without support

9 month

Standing with support

10 month -

Walking with support

11 month -

Crawling (creeping)

12 month -

Standing without support

13 month -

Walking without support

18 month -

Running

24 month -

Walking upstairs with one step at a time

36 month -

Riding bicycle

4 month

Grasp a rattle/ring when placed in hand

5 month

Bidextrous grasp

7 month

Palmar grasp

9 month

Pincer grasp

12 month -

Feeding himself with spilling

15 month -

Feeding himself without spilling

18 month -

Feed himself from a cup with little spilling

12-24 month-

Scribbles

2 year

Horizontal or Vertical strokes

3 year

Copies circle, can dress/undress himself

4 year

Copies square, plus

5 year

Copies triangle, cross

1 month

Turns head to sound

Fine Motor:

Language:
-

110

3 month

Cooing

6 month

Monosyllables

9 month

Bisyllables

12 month -

Two words with meaning

18 month -

10 words with meaning

24 month -

Simple sentence

36 month -

telling a story

Binocular vision

3-6 months

Depth perception

6-8 month begins; 6-7yr accurate

Vision:

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

111