---

100 PEDIATRICS SAQs - WEEKLY MODULE

---

MONDAY - DAY 1

Laws of Growth & Development | Developmental Milestones | Growth Charts

---

---

---

---

---

---

---

---

• Doubles birth weight: 5 months
• Triples birth weight: 1 year
• Quadruples birth weight: 2 years

---

---

• 6 weeks: Social smile (smiles in response to mother's face/voice)
• 3 months: Recognises mother; coos and vocalises

---

---

• Birth: Cry
• 1 month: Throaty sounds
• 2 months: Coos
• 4 months: Laughs
• 6 months: Monosyllables (ba, da, ma)
• 9 months: Bisyllables (mama, dada, baba)
• 12 months: 2-3 meaningful words

---

---

---

---

---

---

---

• Persistence of primitive reflexes beyond expected age
• No social smile by 3 months
• No bisyllables by 1 year
• No meaningful words by 18 months
• Loss of previously attained milestones (regression) at any age

---

• Familial short stature: bone age = chronological age (normal bone age)
• Constitutional delay of growth: bone age < chronological age (delayed)
• Growth hormone deficiency: bone age significantly delayed
• Bone age is assessed by X-ray of the left wrist (Greulich-Pyle atlas)

---

Approach to Short Stature

---

---

• For boys: (Father's height + Mother's height + 13) / 2
• For girls: (Father's height + Mother's height - 13) / 2 (heights in cm). The target height range is MPH ± 8.5 cm.

---

1. Normal variants: Familial short stature, Constitutional delay of growth and puberty (CDGP)
2. Pathological:

• Systemic illness (malnutrition, chronic disease - renal, cardiac, GI)
• Endocrine: GH deficiency, hypothyroidism, Cushing syndrome, poorly controlled DM
• Skeletal dysplasias: achondroplasia, hypochondroplasia
• Chromosomal: Turner syndrome (45, XO), Down syndrome
• Psychosocial deprivation

---

---

• Bone age (X-ray left wrist)
• CBC, ESR (chronic disease)
• Thyroid function tests (T4, TSH)
• IGF-1 and IGFBP-3 (GH axis screening)
• GH stimulation test (definitive for GH deficiency)
• Karyotype (girls - rule out Turner syndrome)
• Renal function, urinalysis
• Celiac antibodies

---

---

• Proportionate short stature
• Chubby ("cherubic") face
• Immature facies
• Central obesity (fat deposited around the trunk)
• Micropenis (males)
• Delayed bone age
• Normal intelligence

---

• GH deficiency
• Turner syndrome
• Chronic renal failure
• Prader-Willi syndrome
• SGA (small for gestational age) not catching up by age 4
• SHOX gene deficiency
• Idiopathic short stature (in some countries)

---

Immunization

---

---

• BCG: 1 dose (intradermal, left upper arm)
• OPV-0 (birth dose): 1 dose (oral)
• Hepatitis B-1 (HepB-0): 1 dose (within 24 hours of birth)

---

• OPV (doses 1, 2, 3)
• DPT/Pentavalent (DPT + HepB + Hib) doses 1, 2, 3
• Rotavirus vaccine (doses 1, 2, 3)
• PCV (pneumococcal conjugate) doses 1, 2, 3
• IPV at 6 and 14 weeks (2 doses)

---

• First dose: 9-12 months (MR vaccine)
• Second dose: 16-24 months (MR booster)

---

• Anaphylaxis to a previous dose
• Encephalopathy within 7 days of previous DPT
• Progressive neurological disorder (defer until stable) Note: Mild fever, minor illness, breastfeeding, premature birth are NOT contraindications.

---

---

---

---

---

• Live attenuated: BCG, OPV, MMR, varicella, rotavirus, yellow fever - provide long-lasting immunity, single dose often sufficient, but contraindicated in immunocompromised
• Killed/inactivated: IPV, hepatitis A, pertussis (whole cell), Japanese encephalitis - safer, require multiple doses and boosters

---

TUESDAY - DAY 2

Acute Diarrhoea & Dysentery

---

---

• No dehydration: <5% body weight loss; child alert, drinking normally
• Some dehydration (2 or more signs): restless/irritable, sunken eyes, thirsty/drinks eagerly, skin pinch goes back slowly
• Severe dehydration (2 or more signs): lethargic/unconscious, sunken eyes, unable to drink, skin pinch goes back very slowly (>2 seconds)

---

• Sodium: 75 mmol/L
• Chloride: 65 mmol/L
• Glucose: 75 mmol/L
• Potassium: 20 mmol/L
• Citrate: 10 mmol/L
• Osmolarity: 245 mOsmol/L

---

---

1. Give extra fluids (ORS, rice water, home fluids)
2. Continue feeding (do not starve)
3. Return signs: blood in stool, worsening, unable to drink, high fever ORS: <2 years: 50-100 mL after each loose stool; 2-10 years: 100-200 mL; >10 years: as much as tolerated.

---

---

• Bacterial: Shigella (most common, especially in children), Salmonella, Campylobacter, enteroinvasive E. coli (EIEC), Clostridium difficile
• Parasitic: Entamoeba histolytica (amoebic dysentery)

---

---

---

---

SMR and Adolescent Health Problems

---

• Stage 1: Prepubertal
• Stage 2: Testicular enlargement (>4 mL), sparse pubic hair
• Stage 3: Further penile/testicular growth, dark curly hair
• Stage 4: Adult-type hair, glans distinct
• Stage 5: Adult genitalia, hair on medial thighs

---

• Stage 1: Prepubertal
• Stage 2: Breast budding (thelarche), sparse pubic hair - first sign of puberty in girls
• Stage 3: Further breast enlargement, darker pubic hair
• Stage 4: Secondary areolar mound, adult-type hair
• Stage 5: Adult breast, hair on medial thighs

---

• Central (GnRH-dependent): due to premature activation of hypothalamic-pituitary-gonadal axis
• Peripheral (GnRH-independent): due to excess sex hormones from gonadal/adrenal tumors, McCune-Albright syndrome

---

• Nutritional: Iron deficiency anaemia, obesity, eating disorders (anorexia nervosa, bulimia)
• Reproductive: Menstrual disorders, STIs, teenage pregnancy
• Mental health: Depression, anxiety, suicide, substance abuse
• Behavioral: Smoking, alcohol, drug use, risky sexual behavior
• Acne, dysmenorrhoea, scoliosis

---

• H - Home
• E - Education/Employment
• A - Activities/Peers
• D - Drugs/Substance use
• S - Sexuality
• S - Suicide/Depression/Safety

---

Severe Acute Malnutrition (SAM)

---

• Weight-for-height < -3 SD (Z-score)
• MUAC < 11.5 cm (children 6-59 months)
• Presence of bilateral pitting oedema (nutritional)
• Weight-for-age < 70% of median (Wellcome classification)

---

• Marasmus: Severe wasting, loss of muscle and fat, "skin and bone" appearance, no oedema, child is alert and hungry
• Kwashiorkor: Oedema (hallmark), normal/high weight, sparse reddish hair (flag sign), flaky paint dermatosis, irritable/miserable, hepatomegaly, fatty liver

---

1. Treat hypoglycaemia
2. Treat hypothermia
3. Treat dehydration (use ReSoMal)
4. Correct electrolytes
5. Treat infection
6. Correct micronutrient deficiencies
7. Cautious feeding (stabilization phase - F-75 formula)
8. Catch-up growth (rehabilitation phase - F-100 formula)
9. Sensory stimulation and emotional support
10. Prepare for follow-up

---

• F-75: Starter formula. 75 kcal/100 mL. Used in the stabilization phase (first 1-2 weeks). Low protein and sodium, prevents refeeding syndrome.
• F-100: Catch-up formula. 100 kcal/100 mL. Higher protein and fat. Used in rehabilitation phase for rapid weight gain.

---

• Bilateral pitting oedema (Grade 2 or 3)
• Any danger signs (severe pneumonia, dehydration, hypoglycaemia, hypothermia)
• Poor appetite (fails RUTF appetite test)
• MUAC < 11.5 cm with complications Uncomplicated SAM with good appetite is managed as outpatient with RUTF.

---

---

---

WEDNESDAY - DAY 3

Obesity in Children

---

• Overweight: BMI 85th-95th percentile (or >+1 SD from WHO)
• Obese: BMI >95th percentile (or >+2 SD from WHO)
• In adults: Overweight BMI 25-30; Obese >30 (not used directly in children)

---

• Metabolic: Type 2 DM, insulin resistance, metabolic syndrome, dyslipidaemia
• Cardiovascular: Hypertension, early atherosclerosis
• Respiratory: Obstructive sleep apnoea, asthma
• Orthopaedic: Flat feet, Blount disease, slipped capital femoral epiphysis
• Psychosocial: Low self-esteem, depression, bullying
• Endocrine: Polycystic ovary syndrome (PCOS) in girls

---

• ADHD (Attention Deficit Hyperactivity Disorder)
• Autism Spectrum Disorder (ASD)
• Conduct disorder
• Oppositional Defiant Disorder (ODD)
• Anxiety disorders
• Enuresis (bed wetting)
• Encopresis
• Learning disability

---

• Inattention (6+ symptoms) AND/OR hyperactivity-impulsivity (6+ symptoms)
• Present for >6 months
• Onset before age 12
• Present in 2+ settings (home, school)
• Significantly impairs functioning Three presentations: Predominantly inattentive, predominantly hyperactive-impulsive, combined

---

• Deficits in social communication and interaction (e.g., poor eye contact, lack of social reciprocity)
• Restricted, repetitive behaviors (stereotypies, insistence on sameness, unusual sensory interests)
• Symptoms present in early developmental period
• Red flags: No social smile by 3 months, no babbling by 12 months, no single words by 16 months, no two-word phrases by 24 months, loss of skills at any age

---

Micronutrient and Vitamin Deficiency

---

• Night blindness (nyctalopia) - earliest sign
• Xerophthalmia (dry conjunctiva/cornea)
• Bitot's spots (triangular white foamy patches on conjunctiva) - pathognomonic
• Corneal ulceration and keratomalacia (can lead to blindness)
• Increased susceptibility to infections Treatment: High-dose Vitamin A (200,000 IU for children >1 year)

---

• 6 months: 1 lakh IU (at the time of measles vaccine)
• 9 months to 5 years: 2 lakh IU every 6 months (biannual)
• In measles cases: therapeutic dose 2 lakh IU for 2 days

---

• Skeletal: Craniotabes (earliest), frontal bossing, rachitic rosary (costochondral beading), Harrison's sulcus, widened epiphyses at wrist, bowlegs (genu varum) or knock knees (genu valgum)
• Biochemical: ↓Ca, ↓Phosphorus, ↑ALP, ↑PTH, ↓25(OH)D
• X-ray: Widened, cupped, frayed metaphysis ("paintbrush" appearance)

---

• Stoss therapy: Single oral dose 3,00,000-6,00,000 IU Vitamin D (cholecalciferol)
• Daily therapy: 1,000-3,000 IU/day for 3 months
• Calcium supplementation: 30-75 mg/kg/day
• Sunlight exposure is important for prevention
• After healing, maintenance 400 IU/day

---

• Pallor, fatigue, irritability
• Pica (eating of non-food substances - clay, soil, ice)
• Koilonychia (spoon-shaped nails)
• Angular stomatitis
• Atrophic glossitis
• Impaired cognitive development (especially if chronic)
• CBC: microcytic hypochromic anaemia, low MCV, MCH, MCHC; high RDW; low serum ferritin (earliest marker)

---

• Infantile scurvy (Barlow's disease): Frog-leg position (pseudoparalysis)
• Perifollicular haemorrhages, "scorbutic rosary" (angle between rib and costal cartilage)
• Bleeding gums, subperiosteal haemorrhage
• Trümmerfeld zone on X-ray (zone of destruction above epiphysis)
• Wimberger sign (ground glass epiphysis)

---

• Megaloblastic (macrocytic) anaemia
• Subacute combined degeneration of spinal cord (SACD) in severe/chronic cases
• Glossitis (beefy red tongue)
• Hyperpigmentation of skin (especially in dark-skinned individuals)
• Developmental regression in infants (particularly breastfed infants of vegan mothers) Causes: Inadequate dietary intake (veganism), malabsorption (intrinsic factor deficiency, ileal disease)

---

• Early (<24 hours): maternal drugs (anticonvulsants, warfarin)
• Classic (2-7 days): breastfed babies without prophylaxis; GI bleed, umbilical bleed, skin bleeds
• Late (2 weeks-6 months): exclusively breastfed, no prophylaxis; intracranial hemorrhage Prevention: Vitamin K 1 mg IM at birth (all newborns)

---

---

THURSDAY - DAY 4

Bronchial Asthma in Children

---

• Recurrent episodes of wheezing, breathlessness, chest tightness, and cough (typically at night/early morning)
• Reversible airflow obstruction (spontaneously or with treatment)
• Airway hyperresponsiveness
• Underlying airway inflammation (eosinophilic)

---

• Respiratory infections (viral URTIs - most common trigger in children)
• Allergens: house dust mite, pollen, animal dander, cockroach
• Exercise (exercise-induced asthma)
• Cold air, change in weather
• Tobacco smoke, pollution, fumes
• Emotional stress
• NSAID/aspirin (in older children)
• GERD

---

• Intermittent: Symptoms <2 days/week, no night awakening, no limitation of activity, PEFR/FEV1 ≥80%
• Mild persistent: Symptoms >2 days/week but not daily, night symptoms 3-4×/month
• Moderate persistent: Daily symptoms, night symptoms >1×/week
• Severe persistent: Symptoms throughout the day, frequent night symptoms, severely limited activity

---

---

1. Oxygen (to maintain SpO2 >94%)
2. Salbutamol nebulization (2.5-5 mg) every 20 min for 1 hour (or continuous)
3. Ipratropium bromide (0.25-0.5 mg) nebulized (in severe attacks)
4. Systemic corticosteroids: IV hydrocortisone or oral prednisolone 1-2 mg/kg
5. IV magnesium sulphate (25-75 mg/kg) in life-threatening cases
6. Heliox, ketamine, or mechanical ventilation in extremis

---

Pneumonia in Children

---

• Non-severe pneumonia: Cough or difficult breathing + fast breathing only (no chest indrawing or danger signs). Treat with oral amoxicillin as outpatient.
• Severe pneumonia: Chest indrawing (lower chest wall indrawing). Admit, IV antibiotics.
• Very severe (danger signs): Central cyanosis, inability to drink/breastfeed, convulsions, lethargy, severe respiratory distress. Urgent hospitalization.

---

• < 2 months: ≥ 60 breaths/min
• 2-11 months: ≥ 50 breaths/min
• 1-5 years: ≥ 40 breaths/min
• ≥ 5 years: ≥ 30 breaths/min

---

• Neonates: GBS, E. coli, Listeria, Klebsiella
• 1-3 months: Chlamydia trachomatis (afebrile, staccato cough), RSV
• 1 month - 5 years: Streptococcus pneumoniae (most common), RSV, Haemophilus influenzae
• 5-15 years: Mycoplasma pneumoniae (most common), S. pneumoniae, Chlamydophila pneumoniae
• Any age: Viral (RSV, parainfluenza, influenza)

---

• Outpatient (non-severe): Oral Amoxicillin (40-45 mg/kg/day in 3 doses) for 5-7 days
• Severe (hospitalized): IV Ampicillin + Gentamicin (or IV Amoxicillin-clavulanate)
• Atypical pneumonia (Mycoplasma, Chlamydia): Azithromycin or Clarithromycin
• Staphylococcal: Cloxacillin ± gentamicin

---

Croup, Epiglottitis, and Bronchiolitis

---

• Barking/seal-like cough (pathognomonic)
• Stridor (inspiratory)
• Hoarse voice
• Low-grade fever
• Worse at night
• Steeple sign on X-ray (subglottic narrowing)

---

• Stridor (0-2)
• Retractions (0-3)
• Air entry (0-2)
• Cyanosis (0-5)
• Level of consciousness (0-5)
• Mild: 0-2; Moderate: 3-7; Severe: ≥8

---

• Mild: Dexamethasone 0.15-0.6 mg/kg oral single dose; reassurance
• Moderate: Dexamethasone 0.6 mg/kg; nebulized budesonide (2 mg)
• Severe: Nebulized adrenaline (epinephrine) 5 mL of 1:1000 solution; dexamethasone IV; oxygen; hospital admission Humidified air is NOT proven effective.

---

---

• Oxygen to maintain SpO2 >90-92%
• Nasogastric feeding if unable to feed
• Nasal saline irrigation
• High-flow nasal cannula (HFNC) in moderate-severe
• NOT recommended: bronchodilators, steroids, antibiotics (unless bacterial coinfection), chest physiotherapy

---

---

FRIDAY - DAY 5

Hypothyroidism and Congenital Hypothyroidism

---

• Primary (thyroidal - 85%):
• Thyroid dysgenesis (aplasia, hypoplasia, ectopic thyroid) - 75-80%
• Thyroid dyshormonogenesis (enzyme defects) - 10-15%
• Secondary/Tertiary (central - 5%): TSH/TRH deficiency
• Transient: Maternal antithyroid drugs, iodine excess/deficiency, maternal TSH-receptor blocking antibodies

---

• Prolonged neonatal jaundice (>2 weeks)
• Hypothermia, mottled skin
• Macroglossia, large posterior fontanelle
• Umbilical hernia
• Constipation, feeding difficulty
• Hoarse cry
• Hypotonia, lethargy
• Myxoedematous facies

---

---

• Levothyroxine (L-T4): 10-15 mcg/kg/day orally, starting as soon as possible
• Target TSH: 0.5-2.0 mU/L (normalize within 2-4 weeks)
• Target FT4: upper half of normal range
• Monitor TSH/FT4 every 1-2 months in first year, every 2-3 months in 2nd year
• Treatment is lifelong in permanent hypothyroidism; reassessed at age 3 in transient cases

---

• Growth failure/short stature (most common presentation)
• Weight gain, myxoedema
• Cold intolerance, constipation
• Delayed puberty
• Bradycardia, slow relaxing reflexes
• Goitre (in Hashimoto's - firm, non-tender)
• Lab: elevated TSH, low T4, positive anti-TPO antibodies, positive anti-thyroglobulin antibodies
• Bone age: delayed

---

Seizures in Children and Febrile Seizures

---

---

---

1. Age <18 months at first febrile seizure
2. Family history of febrile seizures
3. Low temperature at time of first seizure
4. Short duration between onset of fever and seizure (Having >2 risk factors: ~70% recurrence rate)

---

1. Position child on side (recovery position), protect from injury
2. Ensure airway, breathing, circulation
3. Oxygen by mask
4. Check glucose (treat hypoglycaemia if present)
5. If seizure >5 minutes: IV/IO diazepam 0.2-0.3 mg/kg OR rectal diazepam 0.5 mg/kg OR buccal/intranasal midazolam 0.2-0.3 mg/kg
6. If no response at 10 min: IV phenobarbitone 20 mg/kg
7. Treat underlying fever source
8. Routine EEG, neuroimaging, or LP NOT indicated in simple febrile seizures

---

1. Hypoxic-ischaemic encephalopathy (HIE) - most common
2. Intracranial infection (bacterial meningitis, herpes)
3. Intracranial haemorrhage
4. Metabolic: Hypoglycaemia, hypocalcaemia, hypomagnesaemia, hyponatraemia
5. Pyridoxine dependency
6. Neonatal drug withdrawal

---

Neural Tube Defects

---

• Anencephaly: Failure of closure at the rostral end (cranial); fatal
• Spina bifida: Failure of closure at the caudal end
• Spina bifida occulta (hidden, no herniation)
• Meningocele (meninges herniate through defect, no neural tissue)
• Myelomeningocele (meninges + spinal cord/nerves herniate) - most common clinically significant form
• Encephalocele: Herniation of brain/meninges through skull defect

---

• Reduces NTD risk by 50-70%
• Dose: 400 mcg/day for all women of childbearing age; 5 mg/day for high-risk women (previous NTD, anti-epileptic drugs, diabetes)
• Should start at least 1 month before conception and continue through first trimester
• Prenatal diagnosis: maternal serum AFP + fetal ultrasound (detailed anomaly scan at 18-20 weeks)

---

• Visible sac (meningocele/myelomeningocele) at the back (usually lumbosacral)
• Neurological deficits below the level of lesion: paraplegia, sensory loss, bladder/bowel dysfunction (neurogenic bladder)
• Associated hydrocephalus (80-90%) due to Arnold-Chiari II malformation
• Clubfoot (talipes equinovarus)

• Cover defect with sterile saline-soaked dressing at birth
• Surgical closure within 24-48 hours
• VP shunt for hydrocephalus
• Multidisciplinary: neurosurgery, urology, orthopaedics, physiotherapy, special education
• Prophylactic antibiotics to prevent meningitis

---

TOPIC-WISE QUESTION DISTRIBUTION

---

Key High-Yield Points to Remember:

1. Social smile = 6 weeks (first social milestone)
2. Pincer grasp = 9-10 months
3. Short stature = height <3rd percentile or <-2 SD
4. SAM = MUAC <11.5 cm OR WFH <-3 SD OR bilateral pitting oedema
5. ORS osmolarity = 245 mOsmol/L (WHO low-osmolarity)
6. Fast breathing in 2-11 months = ≥50/min for pneumonia diagnosis
7. Croup = barking cough, steeple sign; Epiglottitis = drooling, thumb sign
8. Febrile seizure age = 6 months to 5 years
9. Folic acid dose for NTD prevention = 400 mcg/day (5 mg in high risk)
10. Congenital hypothyroidism = most common preventable cause of intellectual disability

---

100 MORE PEDIATRICS SAQs — ADVANCED SET

---

MONDAY — GROWTH, MILESTONES, SHORT STATURE, IMMUNIZATION

---

---

---

---

• Girls: Peak height velocity (PHV) occurs at Tanner stage 2-3, around age 11-12 years; gain of ~8-10 cm/year
• Boys: PHV occurs at Tanner stage 3-4, around age 13-14 years; gain of ~9-11 cm/year
• Boys grow ~12-13 cm at peak year vs girls ~10-11 cm, explaining the final height difference

---

---

---

• Birth: ~34 cm
• 6 months: ~44 cm (10 cm gain in first 6 months)
• 1 year: ~47 cm (3 cm gain in second 6 months)
• 2 years: ~49 cm
• Adult: ~55 cm Head grows fastest in the first 6 months of life.

---

• Persistence of Moro/ATNR beyond 6 months
• No head control by 4 months
• Scissoring of legs (spastic diplegia posture)
• Fisting (thumb-in-palm) beyond 3-4 months
• Asymmetric reach or movement
• Early hand dominance (before 18 months) - suggests hemiplegia
• No independent sitting by 12 months

---

• At birth: upper: lower segment = 1.7:1 (head and trunk dominate)
• At 3 years: ~1.3:1
• At 10 years: ~1.0:1 (equalization of segments) An abnormally high ratio in older children suggests skeletal dysplasia or rickets (short limbs).

---

---

• Proportionate short stature: Head, trunk, and limbs reduced equally. Causes: endocrine (GH deficiency, hypothyroidism), malnutrition, chronic systemic disease, Turner syndrome, IUGR.
• Disproportionate short stature: Trunk and limbs not reduced equally. Causes: Skeletal dysplasias - achondroplasia (short limbs, normal trunk), Morquio syndrome (short trunk, normal limbs), rickets.

---

• Short limbs (rhizomelic shortening - proximal > distal)
• Normal trunk length
• Macrocephaly with frontal bossing
• Midface hypoplasia
• Lumbar lordosis, trident hand
• Normal intelligence
• X-ray: narrowed interpedicular distance in lumbar spine

---

---

---

• Stunting: Height-for-age <-2 SD. Reflects chronic/long-standing malnutrition (undernutrition over months to years). Irreversible after age 2.
• Wasting: Weight-for-height <-2 SD. Reflects acute recent malnutrition. Potentially reversible.
• Underweight: Weight-for-age <-2 SD. Composite of both.

---

---

• ≥10 mm: positive in immunocompetent BCG-vaccinated children
• ≥5 mm: positive in immunocompromised/HIV/close TB contacts
• ≥15 mm: positive in healthy low-risk individuals In BCG-vaccinated children, induration >10 mm is suggestive of true TB infection; >15 mm strongly suggests TB.

---

• Dose 1 (HepB-0): Within 24 hours of birth - 0.5 mL IM (thigh)
• Dose 2: At 6 weeks (as part of pentavalent)
• Dose 3: At 10 weeks (pentavalent)
• Dose 4: At 14 weeks (pentavalent) If birth dose missed, 3 more doses are given (0, 1, 6 month schedule). For HBsAg-positive mothers, HBIG (0.5 mL) + HepB vaccine within 12 hours of birth.

---

• Vaccine reactions: fever, local redness/swelling (most common), febrile seizures (MMR, DPT)
• Programme errors: abscess at injection site (improper technique), transmission of bloodborne infections
• Coincidental: events that would have happened anyway
• Serious AEFI:
• Anaphylaxis (any vaccine, within 30 minutes)
• BCG lymphadenitis/osteitis
• Vaccine-associated polio (OPV)
• Intussusception (rotavirus vaccine - first dose)
• Thrombocytopenia (MMR)

---

• SA 14-14-2 (live attenuated) or JENVAC:
• Dose 1: 9 months (with measles)
• Dose 2: 16-24 months (with DPT booster) Given in endemic states: UP, Bihar, Assam, Karnataka, Tamil Nadu, West Bengal, etc.

---

TUESDAY — DIARRHOEA, DYSENTERY, ADOLESCENT HEALTH, SAM

---

---

• Hypernatraemic dehydration (Na >150): CNS hyperirritability, "doughy" skin, seizures - treat slowly to avoid cerebral oedema
• Hyponatraemic dehydration (Na <130): lethargy, seizures - if severe symptomatic, use hypertonic saline
• Hypokalaemia: muscle weakness, ileus, cardiac arrhythmias (from stool potassium losses)
• Metabolic acidosis: from bicarbonate loss in stools and poor tissue perfusion

---

• Severe dehydration (Plan C): Ringer's Lactate (preferred) or Normal Saline
• Children >1 month: 100 mL/kg over 3 hours (30 mL/kg fast in first 30 min, then 70 mL/kg in 2.5 hours)
• Infants <12 months: 30 mL/kg in first 1 hour, then 70 mL/kg over 5 hours
• Oral route is preferred whenever possible; IV only if cannot drink or in shock

---

• Identify and treat specific cause
• Avoid lactose (use low-lactose feeds)
• Increase dietary energy density
• Zinc supplementation
• Treat micronutrient deficiencies (Vitamin A, zinc)
• Probiotics may help

---

• Blood in stool (dysentery with severe dehydration)
• Signs of severe dehydration not responding to Plan C
• Persistent vomiting unable to retain ORS
• Abdominal distension/ileus
• Convulsions
• Altered consciousness
• Cholera (rice-water stools + severe dehydration) in epidemic areas

---

• Rapid IV rehydration (Plan C - Ringer's Lactate)
• Oral rehydration as soon as able to drink
• Antibiotic: Azithromycin 20 mg/kg single dose (first choice in children) OR Doxycycline (>8 years)
• Zinc supplementation

---

---

---

---

• Anorexia Nervosa: BMI <17.5, intense fear of weight gain, distorted body image, self-starvation. Complications: bradycardia, electrolyte disturbances (hypokalaemia), osteoporosis, amenorrhoea, lanugo hair, refeeding syndrome on treatment.
• Bulimia Nervosa: Recurrent binge eating + purging (self-induced vomiting, laxatives). Weight may be normal. Features: parotid enlargement, dental erosion (Russell's sign - calluses on knuckles), hypokalaemia, metabolic alkalosis.

---

• Hypoalbuminaemia → reduced oncotic pressure → fluid shift to interstitium
• Increased aldosterone (secondary hyperaldosteronism)
• Increased capillary permeability (aflatoxin theory)
• Free radical damage (kwashiorkor has higher oxidative stress) Key features: oedema (starts feet, progresses), flaky paint skin, sparse reddish hair, fatty liver, immunosuppression.

---

• Weight gain: achieving 15-20% of admission weight (or reaching -2 SD WFH) and maintaining for 3 consecutive days
• Good appetite (passes RUTF appetite test)
• No medical complications
• Oedema resolved (if present)
• Good clinical condition: alert, afebrile
• Caregiver trained on home feeding and follow-up

---

• Lower sodium (45 mmol/L vs 75 in ORS) - prevents sodium overload in SAM
• Higher potassium (40 mmol/L)
• Higher glucose (125 mmol/L) Given 5-10 mL/kg/hour for 2 hours, then 5-10 mL/kg alternating with F-75 for 4-10 hours. NEVER give IV fluids in SAM unless in shock.

---

• If conscious: 50 mL of 10% glucose (or sucrose solution) by mouth/NG
• If unconscious: IV 10% glucose 5 mL/kg stat, then oral/NG glucose feeds
• Immediately start F-75 every 2-3 hours day and night
• Prevent by feeding every 2 hours (do not fast)
• Treat underlying infection

---

• Folic acid: 1 mg/day (5 mg on day 1)
• Zinc: 2 mg/kg/day
• Copper: 0.3 mg/kg/day
• Multivitamins including Vitamin A, B-complex, C
• Iron: NOT given in acute phase (promotes bacterial growth, free radical damage); give only in rehabilitation phase once appetite returns

---

WEDNESDAY — OBESITY, BEHAVIOURAL DISORDERS, MICRONUTRIENTS

---

• Central obesity: Waist circumference ≥90th percentile (mandatory criterion) Plus any 2 of:
• Triglycerides ≥150 mg/dL
• HDL cholesterol <40 mg/dL
• Blood pressure ≥130/85 mmHg
• Fasting glucose ≥100 mg/dL (or known T2DM)

---

• Lifestyle modification (cornerstone): Dietary change (reduce caloric density, increase fibre, avoid sugary drinks), physical activity (≥60 min/day moderate-intensity), reduce screen time (<2 hours/day for >5 years, none for <2 years)
• Behavioural therapy: Family-based behavioural intervention
• Pharmacotherapy: Orlistat (FDA-approved for children ≥12 years)
• Bariatric surgery: For adolescents ≥13 years with BMI >40 and severe comorbidities
• Treat comorbidities (HTN, T2DM, dyslipidaemia)

---

• Stimulants (first-line): Methylphenidate (Ritalin) - most studied, effective in 70-80%. Amphetamine salts.
• Common side effects: appetite suppression, insomnia, growth deceleration
• Non-stimulants: Atomoxetine (norepinephrine reuptake inhibitor) - used if stimulants contraindicated or substance abuse risk; Guanfacine, Clonidine Medication combined with behavioural therapy is most effective.

---

1. Social-emotional reciprocity deficit
2. Nonverbal communicative behaviours deficit
3. Deficits in developing/maintaining relationships

1. Stereotyped/repetitive motor movements or speech
2. Insistence on sameness/routines
3. Highly restricted, fixated interests
4. Hyper/hypo-reactivity to sensory input

---

• Nocturnal (bed-wetting, most common): Primary (never achieved night dryness) vs Secondary (relapse after ≥6 months dry)
• Diurnal (daytime wetting): suggests organic cause more often Management:
• Simple measures: fluid restriction in evenings, void before bed, star charts (motivational)
• Enuresis alarm: Most effective long-term treatment (conditioning therapy)
• Desmopressin (DDAVP): Useful for short-term (overnight trips); 0.2-0.4 mg oral at bedtime
• Imipramine (anticholinergic): Less preferred (cardiac side effects)

---

• Oral elemental iron: 3-6 mg/kg/day of elemental iron in 2-3 divided doses
• Given on empty stomach with Vitamin C (enhances absorption)
• Duration: 3-6 months (3 months after Hb normalisation to replenish stores)
• Response: Reticulocytosis in 3-5 days (earliest sign of response); Hb rises ~1 g/dL/week
• IV iron dextran: if oral intolerance, malabsorption, non-compliance
• Treat underlying cause (dietary deficiency, hookworm)

---

• Dermatitis: Symmetric, sun-exposed areas (Casal's necklace around neck)
• Diarrhoea
• Dementia: Cognitive impairment, confusion, depression
• Death (if untreated) Causes: Maize-based diet (low tryptophan + bound niacin), carcinoid syndrome, Hartnup disease (tryptophan malabsorption), isoniazid therapy. Treatment: Nicotinamide 100-300 mg/day.

---

• Dry Beriberi: Peripheral neuropathy (sensory + motor), bilateral, symmetric, ascending
• Wet Beriberi: High-output cardiac failure, oedema, cardiomegaly
• Infantile Beriberi: Occurs in breastfed infants of thiamine-deficient mothers; cardiac (acute cardiac failure, tachycardia, cyanosis) or neurologic (aphonia, ophthalmoplegia)
• Wernicke's Encephalopathy: Confusion, ophthalmoplegia, ataxia (triad) Treatment: Thiamine IV/IM immediately, then oral.

---

• Macrocytosis (MCV >100 fL)
• Macro-ovalocytes (oval macrocytes)
• Hypersegmented neutrophils (≥5 lobes in >5% of neutrophils, or any cell with ≥6 lobes) - hallmark
• Low reticulocyte count
• Pancytopenia in severe cases
• Bone marrow: megaloblastic changes (nuclear-cytoplasmic asynchrony)

---

• Premature newborns: Haemolytic anaemia, oedema, thrombocytosis (at 1-2 months)
• Older children with cholestasis/malabsorption (e.g., cystic fibrosis, abetalipoproteinaemia): Progressive spinocerebellar ataxia, peripheral neuropathy, ophthalmoplegia, retinitis pigmentosa
• Also: Impaired immune function

---

---

• Fetus: Still birth, congenital anomalies, endemic cretinism (mental retardation, deaf mutism, spastic diplegia)
• Neonate: Neonatal hypothyroidism, goitre
• Child/Adult: Goitre (most visible sign), hypothyroidism, impaired cognition
• Prevention: Universal salt iodisation (mandatory in India - 15 ppm at production, 7 ppm at consumer level). Lugol's iodine or lipiodol injections in severe endemic areas.

---

• Nutritional rickets (Vit D deficiency): Vitamin D + calcium (see Q69 in previous set)
• X-linked Hypophosphataemic Rickets (XLH): Most common hereditary rickets. PHEX gene mutation → excess FGF23 → phosphate wasting. Treatment: Oral phosphate supplements + active Vitamin D (calcitriol). Does NOT respond to plain Vitamin D. Burosumab (anti-FGF23 antibody) now available.
• Vitamin D-dependent rickets type 1 (25-OH D to 1,25-OH D conversion defect): Calcitriol (active Vit D)
• Vitamin D-dependent rickets type 2 (receptor defect): High-dose calcitriol

---

• Marasmus: Inadequate total calories AND protein (starvation). The body adapts by catabolizing fat and muscle. No oedema because albumin is preserved and hormonal adaptation is maintained.
• Kwashiorkor: Predominantly protein deficiency (often with infection triggering it). Inadequate protein intake → hypoalbuminaemia → oedema. High-carbohydrate diet suppresses fat mobilization, leading to fatty liver. Free radical injury plays a role (aflatoxin, infection → oxidative stress).

---

• Normal (Green): ≥12.5 cm
• Moderate Acute Malnutrition / MAM (Yellow): 11.5-12.4 cm
• Severe Acute Malnutrition / SAM (Red): <11.5 cm MUAC is age-independent (usable 6-59 months) and is the single best predictor of mortality risk.

---

THURSDAY — ASTHMA, PNEUMONIA, CROUP, BRONCHIOLITIS

---

1. Airway inflammation: Eosinophilic predominant, driven by Th2 lymphocytes; mast cells, IgE, IL-4, IL-5, IL-13 → inflammation, mucus hypersecretion
2. Airway hyperresponsiveness (AHR): Exaggerated bronchoconstriction to stimuli
3. Airway remodelling: Chronic changes - subepithelial fibrosis, smooth muscle hypertrophy, goblet cell metaplasia → progressive irreversible obstruction if untreated

---

• FEV1/FVC ratio < 0.8 (obstructive pattern) - reduced
• FEV1 reduced (<80% predicted)
• FVC: normal or mildly reduced
• Reversibility: ≥12% AND ≥200 mL improvement in FEV1 after SABA (salbutamol 400 mcg) - diagnostic of asthma
• In children <5 years, spirometry not reliable; use clinical criteria, bronchodilator response trials

---

• Step 1: PRN low-dose ICS-formoterol (or SABA only as reliever)
• Step 2: Low-dose ICS daily (controller) + SABA PRN
• Step 3: Low-dose ICS + LABA (or medium-dose ICS alone)
• Step 4: Medium-dose ICS + LABA
• Step 5: High-dose ICS + LABA + add-on therapy (tiotropium, biologics - omalizumab for allergic asthma, mepolizumab for eosinophilic)

---

• Silent chest (no wheeze due to no air movement)
• Pulsus paradoxus >20 mmHg
• Inability to speak
• SpO2 <92% despite oxygen
• PCO2 rising (normal PCO2 in severe asthma is ominous - indicates fatigue) Management: ICU, IV magnesium, IV aminophylline, possible NIV or intubation.

---

• Lobar/segmental consolidation (air-space opacity): Bacterial (S. pneumoniae most common); air bronchograms common
• Interstitial pattern (bilateral diffuse): Viral, atypical (Mycoplasma, Chlamydia)
• Round pneumonia: S. pneumoniae in young children (unique to <5 years)
• Parapneumonic effusion/empyema: S. pneumoniae, Staph aureus
• Pneumatoceles (thin-walled air cysts): Staphylococcal pneumonia (pathognomonic)

---

• Rapid deterioration
• High fever, toxaemia
• Pneumatoceles (pathognomonic on CXR)
• Pyopneumothorax, empyema
• Abscesses Treatment: Cloxacillin 200 mg/kg/day IV + Gentamicin. If MRSA: Vancomycin or Linezolid. Chest drain for pyopneumothorax.

---

---

• Steeple sign (Pencil sign): Seen in Croup (laryngotracheobronchitis). AP neck X-ray shows subglottic narrowing - the tracheal column tapers symmetrically below the glottis, resembling a church steeple.
• Thumb sign: Seen in Epiglottitis. Lateral neck X-ray shows swollen, rounded epiglottis resembling an adult's thumb instead of the normal thin finger-like shadow.

---

---

• Oxygen if SpO2 <90-92%
• High-flow nasal cannula (HFNC) for moderate-severe - reduces need for intubation
• Nasogastric tube feeding if unable to feed
• Hypertonic saline nebulization (3%) may reduce hospital stay modestly
• NOT recommended: bronchodilators (salbutamol, adrenaline), systemic steroids, antibiotics (unless bacterial co-infection), chest physiotherapy, ribavirin (except severe immunocompromised)

---

• Premature infants <29 weeks gestation
• Infants with chronic lung disease of prematurity
• Haemodynamically significant congenital heart disease Given monthly IM injections (15 mg/kg) during RSV season (winter/early spring). Does NOT replace immunization.

---

---

FRIDAY — HYPOTHYROIDISM, SEIZURES, NEURAL TUBE DEFECTS

---

• Primary: Thyroid gland failure. TSH high, T4/T3 low. (Hashimoto's, post-thyroidectomy, iodine deficiency, congenital dysgenesis)
• Secondary: Pituitary failure → TSH low, T4/T3 low.
• Tertiary: Hypothalamic failure → TRH low → TSH low/normal, T4/T3 low.
• Subclinical: TSH mildly elevated, T4 normal, no symptoms.

---

---

---

---

• Blood glucose (immediate - rule out hypoglycaemia)
• Serum electrolytes: Na, Ca, Mg (rule out metabolic causes)
• CBC
• EEG (electroencephalogram) - after acute phase; helps classify epilepsy type
• MRI brain (preferred over CT - better structural detail); indicated if focal seizure, Todd's paresis, abnormal neurology, or EEG abnormality
• LP (if suspected CNS infection - meningitis/encephalitis)
• Metabolic workup if suspected inborn error

---

---

• Infantile spasms (salaam attacks): Sudden flexion of neck, trunk, arms and legs in clusters
• Hypsarrhythmia: Chaotic, high-amplitude slow waves with multifocal spikes on EEG (pathognomonic)
• Developmental regression/arrest Causes: Structural (tuberous sclerosis, Down syndrome, hypoxic-ischaemic injury), metabolic, or unknown. Treatment: ACTH (first-line), Vigabatrin (especially in tuberous sclerosis), Pyridoxine trial.

---

• Multiple seizure types: tonic (most characteristic), atonic (drop attacks), atypical absence
• EEG: slow spike-wave (1-2.5 Hz) - characteristic
• Intellectual disability
• Treatment-resistant (often polytherapy needed: Valproate, Clobazam, Lamotrigine, Rufinamide, Dietary therapy - ketogenic diet)

---

---

---

---

• Aura (pre-ictal): Sensory/motor/psychic warning (only in focal onset seizures)
• Tonic phase: Sudden loss of consciousness, generalized stiffening, expiratory cry, apnoea, cyanosis, eyes deviated upward (10-30 seconds)
• Clonic phase: Rhythmic jerking of all limbs, salivation, tongue bite, incontinence (1-3 minutes)
• Post-ictal phase: Gradual recovery, confusion, headache, drowsiness, Todd's paresis if focal (minutes to hours)

---

• Obstructive hydrocephalus (most common complication of myelomeningocele)
• Cranial nerve palsies (stridor, apnoea, dysphagia)
• Syringomyelia Treatment: VP shunt for hydrocephalus; posterior fossa decompression if symptomatic Chiari.

---

• Maternal serum AFP: Markedly elevated (>2.5 MoM) at 15-20 weeks
• Ultrasound: Absence of skull/brain at 10-14 weeks (12 weeks most reliable); "frog-like" face appearance
• Amniotic fluid AFP and acetylcholinesterase: Elevated (confirmatory) Termination of pregnancy offered. Prevention: folic acid periconceptionally.

---

---

• Hairy patch (hypertrichosis), dimple, lipoma, haemangioma, or skin discoloration over lumbar spine
• These may indicate underlying tethered spinal cord - can cause progressive neurological deficits with growth Investigations: MRI spine (to rule out tethered cord). Prophylactic surgery for tethered cord.

---

• V - Vertebral defects (spina bifida, hemivertebrae)
• A - Anal atresia (imperforate anus)
• C - Cardiac defects (VSD most common)
• T - Tracheo-Esophageal fistula
• E - Esophageal atresia
• R - Renal anomalies
• L - Limb defects (radial ray defects) When one anomaly is found, screen for others. Vertebral defects and NTDs overlap.

---

---

BONUS QUESTIONS (Q81-Q100) — HIGH-YIELD EXAM TOPICS

---

• 7-10: Normal; 4-6: Moderate depression; <4: Severe depression

---

• Neuromuscular: Posture, square window, arm recoil, popliteal angle, scarf sign, heel-to-ear
• Physical: Skin, lanugo, plantar surface, breast, eye/ear, genitals Total score correlates with gestational age (range 20-44 weeks).

---

---

---

• Bilateral non-purulent conjunctival injection
• Changes in lips/oral mucosa (strawberry tongue, cracked lips)
• Polymorphous rash
• Changes in extremities (erythema, oedema, periungual peeling)
• Cervical lymphadenopathy (≥1.5 cm, usually unilateral) Treatment: IVIG 2 g/kg single infusion + Aspirin (anti-inflammatory then antiplatelet dose). IVIG given within 10 days of fever onset prevents coronary artery aneurysms.

---

---

• Meningitis/encephalitis
• Hydrocephalus
• Intracranial haemorrhage
• Lead poisoning
• Vitamin A toxicity (pseudotumor cerebri)
• Space-occupying lesion A sunken fontanelle indicates dehydration.

---

---

• 3 weeks: Infant stays awake more
• 3 months: Holds head up, social smile
• 6 months: Sits with support, transfers objects
• 9 months: Pincer grasp, stands with support
• 12 months: Walks with support, 2-3 words (Better known: head control at 3 months, sits at 6 months, stands at 9 months, walks at 12 months - quarter-year milestones)

---

• Alpha-fetoprotein (AFP): Elevated in NTDs, gastroschisis; Reduced in Down syndrome
• hCG: Elevated in Down syndrome; Reduced in trisomy 18
• Unconjugated Estriol (uE3): Reduced in Down syndrome and trisomy 18 Raised AFP alone (>2.5 MoM) with normal hCG and uE3 suggests NTD (open spina bifida or anencephaly). Confirmed by detailed USS and amniocentesis (amniotic AFP + AChE).

---

---

• Infants: Bulging fontanelle, increasing head circumference, dilated scalp veins, sunset sign (downward deviation of eyes), irritability, vomiting, poor feeding, high-pitched cry
• Older children: Headache (worse in morning, worsened by bending/coughing), vomiting (projectile, not related to feeding), papilloedema, sixth nerve palsy (diplopia), Cushing's triad (bradycardia, hypertension, irregular breathing) - a late, ominous sign

---

---

• Phase 1: Abduction and extension of arms with opening of hands
• Phase 2: Adduction of arms across chest (embrace)
• Associated: Cry Present from birth, disappears at 4-6 months. Asymmetric Moro suggests brachial plexus injury (Erb's palsy - absent on affected side) or hemiplegia. Absent Moro bilaterally suggests severe brain injury.

---

• Low risk of epilepsy (1-2%)
• Side effects of AEDs outweigh benefit
• Does not prevent subsequent febrile seizures effectively Exceptions (consider prophylaxis):
• Complex febrile seizures with recurrence
• Underlying neurological abnormality
• Very high parental anxiety If given: Sodium valproate or Phenobarbitone. Intermittent oral/rectal diazepam at onset of fever is an alternative but has CNS side effects.

---

• Cretinism (Endemic cretinism): Due to severe iodine deficiency during fetal/neonatal period. Features: Intellectual disability, deaf-mutism, spastic diplegia (neurological type) OR hypothyroid symptoms (myxoedematous type). A public health/preventable condition.
• Congenital hypothyroidism: Due to thyroid dysgenesis or dyshormonogenesis (not iodine deficiency). Detected by neonatal screening; treated with levothyroxine to prevent intellectual disability. Key difference: Endemic cretinism is iodine deficiency-related; congenital hypothyroidism is structural/genetic.

---

• Congenital hypothyroidism (TSH/T4) - most important
• Phenylketonuria (PKU) - Phenylalanine elevated
• Congenital adrenal hyperplasia (17-OHP)
• Haemoglobinopathies (sickle cell)
• MCAD deficiency (medium-chain acyl-CoA dehydrogenase)
• Cystic fibrosis (IRT) India's RBSK (Rashtriya Bal Swasthya Karyakram) screens for 30 conditions.

---

---

1. Not able to drink or breastfeed
2. Vomits everything
3. Convulsing now (or convulsed in this illness)
4. Lethargic or unconscious Additionally in young infants (<2 months):

• Fast breathing (≥60/min)
• Severe chest indrawing
• Nasal flaring
• Grunting
• Bulging fontanelle
• Fever or hypothermia Any ONE danger sign = refer urgently.

---

• DQ (Developmental Quotient): Used in infants/young children. DQ = (Developmental Age / Chronological Age) × 100. Normal = 85-115. Assessed by Denver, Griffiths, Bayley scales. Measures development, not intelligence.
• IQ (Intelligence Quotient): Mental Age / Chronological Age × 100. Used in children >5 years. Assessed by Wechsler scales (WISC), Stanford-Binet.
• Intellectual Disability (ID) classification:
• Mild: IQ 50-70
• Moderate: IQ 35-49
• Severe: IQ 20-34
• Profound: IQ <20

---

QUICK REVISION TABLE - Must-Know Facts