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PEDIATRICS - HIGH-YIELD STUDY NOTES

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SECTION 1: GROWTH & DEVELOPMENT

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Developmental Milestones

• No social smile by 2 months
• No babble by 12 months
• No single words by 16 months
• No 2-word phrases by 24 months
• Any loss of previously acquired skills (regression) = always pathological

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Anthropometry & Growth Charts

• Birthweight ~3.5 kg
• Loses 10% in first week, regains by day 10-14
• Doubles by 5 months (~7 kg)
• Triples by 12 months (~10 kg)
• Quadruples by 2 years (~14 kg)
• After 2 years: gain ~2 kg/year

• Birth: ~50 cm
• +25 cm in year 1 (75 cm at 12 months)
• +12.5 cm in year 2 (87.5 cm at 24 months)
• +6-7 cm/year after age 2
• Doubles by age 4 (~100 cm)

• Birth: 35 cm
• +2 cm/month x 3 months, then +1 cm/month x 3 months
• 12 months: ~47 cm
• 2 years: ~49 cm

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X-Ray Wrist for Bone Age

• Bone age = number of ossification centers visible
• Used when growth disturbance is suspected
• Advanced bone age: precocious puberty, CAH, hyperthyroidism
• Delayed bone age: hypothyroidism, GH deficiency, malnutrition, constitutional delay

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Dentition

• Central incisors: 6-8 months
• Lateral incisors: 8-10 months
• First molars: 12-16 months
• Canines: 16-20 months
• Second molars: 20-30 months
• Complete primary set by ~2.5 years

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Tanner Staging & Puberty

• Menarche: usually at Tanner 3-4, about 2-2.5 years after thelarche
• Peak height velocity (PHV) in girls: Tanner 2-3

• First sign of puberty in boys: testicular enlargement
• PHV in boys: Tanner 3-4 (later than girls)

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Malnutrition

• Kwashiorkor: Protein deficiency. Edema (hypoalbuminemia), skin lesions ("flaky paint"), pot belly, moon face, hair changes (flag sign). W/H may be normal/high.
• Marasmus: Total caloric deficiency. Severe wasting, "old man" face, skin and bones. No edema.
• Marasmic-Kwashiorkor: Combined features

1. Treat/prevent hypoglycemia (10% dextrose/sucrose)
2. Treat/prevent hypothermia
3. Treat/prevent dehydration (ReSoMal, not ORS)
4. Correct electrolytes
5. Treat/prevent infections
6. Correct micronutrient deficiencies (no iron in acute phase)
7. Start cautious feeding
8. Achieve catch-up growth (F-75 then F-100)
9. Sensory stimulation & emotional support
10. Follow up after recovery

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Breastfeeding

• Foremilk: high water, low fat - quenches thirst
• Hindmilk: high fat - provides calories
• Colostrum (days 1-5): high IgA, lactoferrin, leukocytes, protein, low fat/lactose - first immunization

• HIV (in resource-rich countries)
• Active TB (untreated)
• HTLV-1/2
• Infant with galactosemia
• Mother on cytotoxic chemotherapy/certain medications

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SECTION 2: VACCINES & NEONATOLOGY

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Vaccines - Types, Strains, NIS

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IUGR & Neonatology

• Birth weight <10th percentile for gestational age
• Symmetric IUGR (proportionate): early onset (1st/2nd trimester), chromosomal, TORCH infections; all parameters affected equally; worse prognosis
• Asymmetric IUGR (head-sparing): late onset (3rd trimester), placental insufficiency, maternal hypertension; abdominal circumference affected first; relatively better prognosis

• LBW: <2500 g
• VLBW: <1500 g
• ELBW: <1000 g

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APGAR Score

• 7-10: Normal
• 4-6: Moderate depression - stimulate + O2
• 0-3: Severe depression - resuscitation needed

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Ballard Score (New Ballard Score)

• Score 35-50 = 38-44 weeks (term)
• Score 10-25 = 28-34 weeks (preterm)

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Fontanelle & Sutures

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Caput Succedaneum vs Cephalhematoma

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Neonatal Reflexes

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Neonatal Resuscitation (NRP Algorithm)

1. Prepare - warm, dry, stimulate (30 seconds)
2. Evaluate - breathing, HR, color
3. Supplemental O2 if central cyanosis with adequate breathing/HR
4. PPV if HR <100 or apnea (rate 40-60/min, FiO2 21% term, 21-30% preterm)
5. Chest compressions if HR <60 after 30 sec PPV (3:1 ratio compressions:ventilations)
6. Epinephrine (0.01-0.03 mg/kg IV) if HR <60 after 30 sec compressions

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SECTION 3: CHROMOSOMAL SYNDROMES

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Trisomy 21 - Down Syndrome (most common, 1:700)

• Duodenal atresia (double bubble sign), single palmar crease (simian line), short stature
• Occipital flat, oblique palpebral fissures (upward slanting), epicanthal folds
• Weak muscle tone (hypotonia), wide gap (sandal toe gap - 1st/2nd toes)
• Nuchal fold increased, nose flat, Brushfield spots (iris speckles)
• Small ears, small mouth (protruding tongue), AV canal defect (most common CHD = AVSD/ASD/VSD)

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Trisomy 18 - Edward Syndrome (1:5,000)

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Trisomy 13 - Patau Syndrome (1:10,000)

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Cri-du-chat (5p deletion)

• Deletion of short arm chromosome 5 (5p-)
• High-pitched cat-like cry (laryngeal hypoplasia)
• Microcephaly, widely spaced eyes (hypertelorism), epicanthal folds, low-set ears
• Severe intellectual disability, hypotonia
• Mnemonic: "5 lives = cat has 9 lives minus 4"

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Turner Syndrome (45,X - 1:2,500 females)

• Short stature (most consistent finding)
• Webbed neck (pterygium colli)
• Low posterior hairline, widely spaced nipples
• Shield chest, cubitus valgus
• Coarctation of the aorta (most common CHD), bicuspid aortic valve
• Streak gonads (primary amenorrhea, infertility)
• Horseshoe kidney (most common renal anomaly)
• Normal intelligence; risk of learning disabilities

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Noonan Syndrome (autosomal dominant, PTPN11 gene)

• "Male Turner" in phenotype but normal karyotype (46,XX or 46,XY)
• Short stature, webbed neck, low posterior hairline, ptosis
• Pulmonic stenosis (most common CHD - contrasts with Turner's coarctation)
• Cryptorchidism in males
• Normal fertility (unlike Turner)
• Mild intellectual disability; coagulation abnormalities

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Rett Syndrome (MECP2 gene mutation, X-linked dominant - almost exclusively females)

• Normal development until 6-18 months, then regression
• Loss of purposeful hand use, replaced by hand-wringing/stereotyped movements
• Loss of speech, autism-like features
• Seizures, breathing irregularities (hyperventilation followed by apnea)
• Progressive gait apraxia/loss of ambulation
• Stages: I (stagnation, 6-18 mo) → II (rapid regression, 1-4 yr) → III (pseudostationary, 2-10 yr) → IV (late motor deterioration)

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Fetal Alcohol Syndrome (FAS)

1. Pre- and postnatal growth retardation
2. CNS dysfunction (intellectual disability, learning, behavior)
3. Facial dysmorphism:
   • Short palpebral fissures
   • Smooth/flat philtrum (most discriminating feature)
   • Thin vermilion border of upper lip

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SECTION 4: SYSTEMIC PEDIATRICS

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CVS - Congenital Heart Diseases

• Triggered by crying, feeding, fever
• Child squats to ↑ SVR → ↓ R→L shunt
• Treat: knee-chest position, O2, morphine, propranolol, phenylephrine

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TORCH Infections

• CMV: Periventricular (around ventricles)
• Toxoplasma: Diffuse/scattered (basal ganglia)

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Hepatitis in Children

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Measles (Rubeola)

• Paramyxovirus; RNA; fecal-oral + respiratory
• Prodrome (3 C's): Coryza, Cough, Conjunctivitis + fever
• Koplik's spots: Pathognomonic - white spots on buccal mucosa (opposite lower molars), appear 1-2 days BEFORE rash
• Rash: Maculopapular, starts face/neck → trunk → extremities (cephalocaudal); lasts 5-7 days
• Complications: Pneumonia (most common cause of death), encephalitis, SSPE (subacute sclerosing panencephalitis - late, fatal), otitis media
• Vitamin A supplementation reduces mortality

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Mumps

• Paramyxovirus; respiratory droplets
• Parotitis (parotid gland swelling) - unilateral or bilateral
• Complications: Orchitis (post-pubertal males, may cause infertility), aseptic meningitis (most common complication in children), oophoritis, pancreatitis, sensorineural deafness
• Mumps orchitis: almost always unilateral

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Rubella (German Measles)

• Togavirus; respiratory droplets
• Rash: Pink maculopapular, starts face → trunk; fades 3 days ("3-day measles")
• Forchheimer spots: Petechiae on soft palate (similar to Koplik's but for rubella)
• Lymphadenopathy: Post-auricular and suboccipital (characteristic)
• Congenital rubella: Greatest risk 1st trimester (see TORCH above)

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Chickenpox (Varicella)

• VZV (Herpesvirus); highly contagious; respiratory + contact
• Lesions: Pruritic, appear in crops; all stages simultaneously (macule → papule → vesicle → pustule → crust)
• Lesions on scalp (vs smallpox which spares scalp)
• Complications: Secondary bacterial infection (most common), pneumonia (adults), cerebellar ataxia (benign post-infectious), Reye's syndrome (aspirin use - AVOID aspirin)
• Contagious: 1-2 days before rash until all vesicles crusted (~7 days)
• Treatment: Acyclovir (immunocompromised, adults, severe); antihistamines for itch

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Respiratory

• Neonates: GBS, E. coli, Klebsiella
• 1-3 months: S. pneumoniae, RSV, Chlamydia trachomatis (afebrile, staccato cough)
• 3 months-5 years: S. pneumoniae (most common bacterial), RSV, Parainfluenza
• School age: Mycoplasma pneumoniae (atypical, "walking pneumonia," cold agglutinins+)

• Age 6 months - 3 years; Parainfluenza virus (type 1 most common)
• Barking/seal-like cough, stridor (inspiratory), hoarse voice; worse at night
• X-ray: Steeple sign (subglottic narrowing on AP view)
• Treatment: Cool mist air → dexamethasone (oral/IM) + nebulized epinephrine (severe)

• Age <2 years (peak 2-6 months); RSV (most common cause)
• Wheeze, tachypnea, hyperinflation, subcostal retractions
• X-ray: Hyperinflation, perihilar infiltrates
• Treatment: Supportive (O2, IV fluids, suction); bronchodilators not routinely recommended

• Autosomal recessive; CFTR gene mutation (chromosome 7); F508del most common mutation
• CFTR protein: Cl- channel on epithelial cells; defect → thick viscous mucus
• Clinical: Chronic lung disease (recurrent infections - Pseudomonas), meconium ileus (neonates - pathognomonic), failure to thrive, steatorrhea, male infertility (absence of vas deferens)
• Diagnosis: Sweat chloride test >60 mEq/L (gold standard); ≥2 CFTR mutations; newborn screen (IRT)
• Complications: Bronchiectasis, cor pulmonale, nasal polyps, rectal prolapse, portal hypertension
• Treatment: Chest physiotherapy, pancreatic enzyme replacement, CFTR modulators (Ivacaftor, Trikafta)

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CNS

• Due to failure of neural tube closure by day 28 of gestation
• Risk factor: folate deficiency; prevention: folic acid 400 mcg/day preconception

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• Age 6 months to 5 years; fever >38°C; most common seizure type in this age group
• Simple: Generalized tonic-clonic, <15 min, single episode in 24 hours, NO focal features
• Complex: Focal, >15 min, or multiple in 24 hours
• Recurrence risk: ~30% overall
• No neuroimaging or EEG required for simple febrile seizure
• Treatment: Antipyretics for comfort (do NOT prevent recurrence); rectal diazepam if prolonged
• Risk of epilepsy development: slightly elevated (1-2% vs 0.5% general population)

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• Permanent, non-progressive movement/posture disorder from brain injury in developing brain
• Most common type: Spastic (70-80%); upper motor neuron findings

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• 13-15: Mild TBI
• 9-12: Moderate TBI
• ≤8: Severe TBI (intubate)

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Vasculitis

• Large vessel vasculitis; aorta and its branches; young Asian women
• "Pulseless disease"; absent/unequal pulses; BP difference >10 mmHg between arms
• Symptoms: arm claudication, visual disturbance, hypertension (renal artery), stroke
• Granulomatous inflammation
• Treatment: High-dose corticosteroids; methotrexate; TNF inhibitors

• Medium/small vessel vasculitis; strongly associated with smoking
• Young males, Eastern European/Asian
• Digital ischemia, Raynaud's phenomenon, superficial thrombophlebitis
• Treatment: Smoking cessation (only effective treatment)

• Most common vasculitis in children; IgA-mediated small vessel vasculitis
• Classic tetrad:
  1. Palpable purpura (lower extremities/buttocks) - non-thrombocytopenic
  2. Arthritis/arthralgia (knees, ankles)
  3. Abdominal pain (colicky; intussusception risk)
  4. Renal involvement (hematuria, proteinuria; IgA nephropathy)
• Usually follows URTI; self-limiting
• Diagnosis: Clinical; skin biopsy shows IgA deposits
• Treatment: Supportive; steroids for severe abdominal/renal involvement

• Medium vessel vasculitis; most common in children <5 years; Japanese > Asian
• Hallmark complication: Coronary artery aneurysms (20-25% if untreated)

1. Bilateral conjunctival injection (painless, non-purulent, limbus-sparing)
2. Oral changes: strawberry tongue, red/cracked lips, erythematous pharynx
3. Rash: polymorphous (maculopapular/scarlatiniform)
4. Extremity changes: erythema + edema of hands/feet; late peeling of fingertips
5. Cervical lymphadenopathy >1.5 cm (usually single, unilateral)

• Acute (1-10 days): Fever, all criteria
• Subacute (11-25 days): Desquamation, thrombocytosis, aneurysm formation
• Convalescent: ESR/CRP normalize; aneurysm may regress or persist

• IVIG 2 g/kg single dose (within first 10 days - reduces aneurysm risk to <3%)
• High-dose aspirin (80-100 mg/kg/day in acute phase) then low-dose (3-5 mg/kg/day) - NOTE: exception to aspirin-avoidance rule in children!
• Echocardiogram at diagnosis, 2 weeks, and 6-8 weeks

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GIT & Renal

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• Most common cause: Minimal Change Disease (MCD) - 80% in children
• MCD: Normal LM; effacement of foot processes on EM; responds to steroids
• Complications: Infections (S. pneumoniae - peritonitis, encephalitis), thrombosis (renal vein), hyperlipidemia
• Treatment: Prednisolone 60 mg/m²/day x 4 weeks, then 40 mg/m² alternate day x 4 weeks

• Most common cause: Post-streptococcal glomerulonephritis (PSGN)
• PSGN: 1-3 weeks after throat infection (M types 1, 2, 4, 12) or 3-6 weeks after skin infection
• Lab: ↓C3 (normalizes 6-8 weeks), ↑ASO titer, hematuria, RBC casts
• Prognosis: 95% recover completely
• Other causes: IgA nephropathy (Berger's), MPGN, SLE nephritis

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QUICK-REFERENCE MNEMONICS

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What's Included

Section 1 - Growth & Development

• Developmental milestones table (2 months to 5 years) with red flags
• Weight/height/OFC norms with rules-of-thumb
• Bone age and carpal ossification order
• Primary and permanent dentition timelines
• Tanner staging for boys and girls (with PHV timing)
• SAM classification (WHO), Kwashiorkor vs Marasmus, 10-step management
• Breastfeeding recommendations, colostrum composition, contraindications

Section 2 - Vaccines & Neonatology

• Vaccine types with examples; cold chain temperatures
• India NIS (National Immunization Schedule) full table
• OPV/BCG/MMR strain details
• Symmetric vs Asymmetric IUGR; LBW/VLBW/ELBW definitions
• APGAR score (full table + interpretation)
• Ballard score components
• Anterior/posterior fontanelle - closure ages, clinical significance
• Caput vs Cephalhematoma comparison table
• Neonatal reflexes - age of appearance and disappearance
• NRP resuscitation algorithm steps

Section 3 - Chromosomal Syndromes

• Down (trisomy 21) - mechanism, features, prenatal screening, complications
• Edward (trisomy 18) - overlapping fingers, rocker-bottom feet
• Patau (trisomy 13) - polydactyly, holoprosencephaly
• Cri-du-chat (5p deletion) - cat cry
• Turner (45,X) - features, CHD (coarctation), labs, treatment
• Noonan - contrast with Turner, PTPN11, pulmonary stenosis
• Rett syndrome - MECP2, regression stages, hand-wringing
• FAS - diagnostic triad, facial features

Section 4 - Systemic Pediatrics

• CHD: Acyanotic (VSD, ASD, PDA) and Cyanotic (TOF, TGA, truncus, TAPVR) with X-ray findings and murmurs
• TORCH: organism-specific features + how to distinguish CMV vs Toxoplasma calcifications
• Hepatitis A-E comparison table
• Measles (Koplik spots), Mumps (orchitis), Rubella (Forchheimer spots), Chickenpox (crops + complications)
• Pneumonia by age group; Croup (steeple sign, dexamethasone); Bronchiolitis (RSV); Cystic Fibrosis (CFTR, sweat test, F508del)
• Neural tube defects (meningocele vs myelomeningocele), folate prevention
• Febrile seizures (simple vs complex criteria)
• Epilepsy syndromes (West, Lennox-Gastaut, absence, JME, BECTS) with EEG patterns and drugs
• Cerebral palsy classification and causes
• GCS with injury severity interpretation
• Takayasu, Buerger's, HSP (tetrad + IgA), Kawasaki (CRASH criteria + phases + treatment)
• Diarrhea types + ORS composition + dehydration grading
• Nephrotic vs Nephritic syndrome comparison table with causes and management