M.B.B.S. 3rd Professional Paediatrics - MBT 407 (2026)

Answers from Ghai Essential Pediatrics, 9th Edition

SECTION A - MCQs (20 Marks)

• 34-week preterm neonate with abdominal distension, bilious vomiting, bloody stools, and X-ray showing Pneumatosis Intestinalis = classic NEC. Pneumatosis intestinalis (intramural gas) is pathognomonic of NEC.

• Weight-for-Height Z-score < -3 SD = SAM. (WHZ -2 to -3 = MAM; < -3 = SAM as per WHO/IAP classification)

• Ghai definition: Frequent Relapser = 4 or more relapses in any 12-month period, OR 2 or more relapses within 6 months of initial response.
• Note: Option (d) "Both A and C" could be intended as correct if the question means either condition - however Ghai specifically defines it as: "2 or more relapses within 6 months of initial response OR 4 or more relapses in any 12-month period." Answer: (d) Both A and C

• Croup (Laryngotracheobronchitis): barky cough + inspiratory stridor + hoarseness + Steeple sign on X-ray = most commonly caused by Parainfluenza virus type 1 (>75% of cases).

• As per IMNCI guidelines, fast breathing is the most sensitive clinical sign for pneumonia in a child aged 12-59 months (RR > 40/min for 12-59 months age; for 2-12 months: > 50/min).

• Hirschsprung disease: delayed passage of meconium (>48 hrs), chronic constipation, "blast sign" on PR exam. Gold standard diagnosis = Rectal Suction Biopsy showing absence of ganglion cells + acetylcholinesterase staining.

• TOF cyanotic spell (hypercyanotic spell/tet spell) management: Knee-chest (squatting) position - increases systemic vascular resistance, reduces right-to-left shunt. Also called "squatting position." Knee-chest is the correct term in Ghai.

• Contraindicated in progressive neurological disorders or uncontrolled epilepsy. DTwP (whole-cell) is contraindicated; DTaP (acellular) may be used. OPV, BCG, Hepatitis B have no such contraindication.

• Jones Criteria Major manifestations: Carditis, Polyarthritis, Sydenham's Chorea, Erythema marginatum, Subcutaneous nodules.
• Fever, Elevated ESR, and Arthralgia are minor criteria.

• Symptomatic neonatal hypoglycemia (blood glucose < 40 mg/dL): Treatment = IV Dextrose bolus: 2 ml/kg of 10% Dextrose (= 200 mg/kg glucose) given as slow IV push over 1-2 minutes, followed by continuous infusion.

• Post-streptococcal glomerulonephritis (APSGN): periorbital edema + cola-colored urine 2 weeks after skin infection. Classic finding = Low C3 (complement consumption via alternate pathway). C4 is typically normal. This distinguishes APSGN from lupus nephritis.

• "Double Bubble Sign" on neonatal X-ray = Duodenal Atresia (two gas-filled chambers - stomach + proximal duodenum with no gas distally). Associated with Down syndrome.

• Features described = Kawasaki disease (high fever >5 days, strawberry tongue, non-purulent conjunctivitis, cervical lymphadenopathy, hand edema). Most serious complication = Coronary Artery Aneurysm (occurs in 15-25% untreated cases).

• Drug of choice for Infantile Spasms (West Syndrome) associated with Tuberous Sclerosis = Vigabatrin. For non-TSC West syndrome, ACTH is first-line. Vigabatrin is specifically preferred in TSC-associated infantile spasms.

• Walking independently + speaking 2-3 words + tower of 2 cubes = 18-month developmental milestones (Ghai developmental table).

• NRP: If HR remains < 60 bpm after 30 seconds of effective PPV + 60 seconds of chest compressions → next step = IV/UVC Adrenaline (Epinephrine) at dose 0.1-0.3 ml/kg of 1:10,000 solution.

• Vitamin K is given to all newborns to prevent HDN (Hemorrhagic Disease of the Newborn) = Vitamin K Deficiency Bleeding (VKDB). Dose: 1 mg IM Vit K1 at birth.

• Thalassemia Major peripheral smear: Target cells (codocytes), microcytic hypochromic anemia, nucleated RBCs, basophilic stippling, Howell-Jolly bodies. Target cells are the most characteristic feature asked here.

• DKA management (blood sugar 350 mg/dL + urine ketones positive = DKA): First step = IV Fluid resuscitation with Normal Saline (10-20 ml/kg over 1-2 hours). Insulin is started only after fluids. Bicarbonate is rarely given. Potassium added after urine output established.

• Pathognomonic finding of Measles (Rubeola) = Koplik's spots (bluish-white spots on buccal mucosa opposite lower molars, appearing 1-2 days before rash). Forchheimer spots = Rubella; Pastia's lines = Scarlet fever; Nagayama spots = Roseola infantum.

SECTION B - Short Answer Questions (40 Marks)

Q1. 2-year-old with febrile seizure (10 marks)

• Ensure ABC; secure airway; place in lateral/recovery position
• IV access; check blood glucose, electrolytes
• If seizure ongoing (>5 min): Lorazepam 0.1 mg/kg IV (or Diazepam 0.3 mg/kg IV / 0.5 mg/kg PR)
• Control fever: Paracetamol 15 mg/kg; remove excess clothing; tepid sponging
• Investigate: CBC, blood culture, LP if meningitis suspected (especially first episode in infant <12 months)
• Treat underlying cause (this child had fever for 3 days - identify focus)

• Febrile seizures are generally benign; do not cause brain damage
• Risk of recurrence: ~30% overall; higher if: first episode <12 months, low-grade fever at onset, family history
• Risk of epilepsy later: only 2-3% (vs 0.5% in general population)
• No antiepileptic prophylaxis needed for simple FS
• Teach parents: lateral position, time the seizure, do not restrain, do not put anything in mouth
• Give rectal diazepam kit for home use if next seizure >5 min
• Antipyretics do not prevent recurrence of FS
• No restriction on activities; normal schooling

Q2. Short notes (4×5 = 20 marks)

• Marasmus: Severe wasting, "old man face," skin and bones, baggy pants appearance, no edema, subnormal temperature, hungry
• Kwashiorkor: Bilateral pitting edema, moon face, skin lesions (flaky paint dermatosis), hair changes (flag sign), miserable child, hepatomegaly, fatty liver
• Marasmic-Kwashiorkor: Features of both

1. Treat/prevent hypoglycemia (10% dextrose/F-75 2-3 hourly)
2. Treat/prevent hypothermia (KMC, warm room)
3. Treat/prevent dehydration (ReSoMal - low sodium ORS)
4. Correct electrolyte imbalance (K, Mg supplementation)
5. Treat/prevent infection (broad-spectrum antibiotics: Amoxicillin + Gentamicin)
6. Correct micronutrient deficiencies (Zinc, Folate, Vitamin A)
7. Begin cautious feeding - F-75 (stabilization phase, 1 week)
8. Rebuild wasting - F-100 (catch-up growth phase)
9. Provide sensory stimulation and emotional support
10. Prepare for follow-up after recovery

• Not able to feed / stopped feeding well
• Convulsions/seizures
• Fast breathing (RR > 60/min) or slow breathing (RR < 30/min)
• Severe chest in-drawing
• Temperature > 37.5°C (fever) or < 35.5°C (hypothermia)
• Movement only on stimulation or no movement at all
• Umbilical redness extending to skin / pus discharge
• Skin pustules (many or severe)
• Jaundice within 24 hours or very deep jaundice
• Central cyanosis (blueness of tongue/lips)
• Bulging fontanelle

• Acknowledge exhaustion and emotions with empathy; do not be judgmental
• Explain that lifelong transfusions are essential for survival - without them, severe anemia leads to heart failure, massive splenomegaly, bone deformities, and death by 2nd decade
• Discuss alternative approaches that can reduce transfusion burden:
  • Bone Marrow/Stem Cell Transplantation - potentially curative (HLA-matched sibling; 80-90% success)
  • Gene therapy - emerging, discuss availability
  • Hydroxyurea - may help in beta-thalassemia intermedia, limited role in major
• "Alternative therapies" (herbal, faith healers, etc.) have no evidence and carry serious harm risk - explain this clearly without dismissing their belief system
• Discuss chelation therapy to reduce transfusion complications (desferrioxamine/deferasirox)
• Discuss patient support groups and financial aid schemes (Rashtriya Bal Swasthya Karyakram)
• Respect autonomy but document counseling; involve medical ethics team if needed
• Never stop transfusions abruptly - always involve a multidisciplinary team

Q3. Very Short Notes (5×2 = 10 marks)

• Feeding the infant only breast milk (no other liquids, water, or solids) from birth to 6 months of age
• Recommended by WHO/IAP; includes expressed breast milk only; allows medicines/supplements
• Benefits: optimal nutrition, passive immunity (sIgA), reduces SIDS, bonding

• Pathognomonic of Measles (Rubeola)
• Bluish-white/grayish-white spots on bright red background on buccal mucosa opposite lower molars
• Appear 1-2 days before the exanthem (maculopapular rash)
• Fade as rash appears

1. Upslanting palpebral fissures + epicanthic folds, flat nasal bridge, low-set ears, single palmar crease (simian crease), hypotonia, small mouth with protruding tongue
2. Any two: Brushfield spots (iris), sandal gap (wide gap between 1st and 2nd toe), short broad neck, redundant neck skin, flat occiput (brachycephaly)

• Epinephrine (1:10,000 solution): 0.1-0.3 ml/kg IV/UVC (= 0.01-0.03 mg/kg)
• Via ETT (if IV access unavailable): 0.5-1 ml/kg of 1:10,000 solution
• Given when HR < 60 bpm despite adequate PPV + chest compressions ≥ 60 seconds

1. Bronze baby syndrome - grayish-brown discoloration of skin (in conjugated hyperbilirubinemia)
2. Retinal damage - hence eyes are patched during phototherapy

• Others: hyperthermia, dehydration (insensible water loss increased), loose green stools, hypocalcemia, skin rash

SECTION C (40 Marks)

Q1. Nephrotic Syndrome in Children (10 marks)

• Massive proteinuria: > 40 mg/m²/hr or urine protein: creatinine ratio > 2 or 3+ proteinuria on dipstick for 3 consecutive days
• Hypoalbuminemia: Serum albumin < 2.5 g/dL
• Edema (dependent/periorbital/ascites/anasarca)
• Hyperlipidemia (total cholesterol > 200 mg/dL)

• Gradual onset periorbital puffiness (worse in morning), then dependent edema, ascites, pleural effusion, anasarca
• Frothy urine; decreased urine output
• Pallor; normal or slightly elevated BP initially
• Abdominal pain (peritonitis risk)
• Predisposition to infections (pneumococcal peritonitis, cellulitis, sepsis)
• Thromboembolism (loss of antithrombin III)

• Proteinuria ≥ 40 mg/m²/hr (or 3+ on dipstick ×3 days)
• Hypoalbuminemia < 2.5 g/dL
• Edema
• (Hyperlipidemia supports but not required for diagnosis)

• Prednisolone: 2 mg/kg/day (max 60 mg/day) in divided doses for 4 weeks, then 1.5 mg/kg alternate day (max 40 mg) for 4 weeks, then taper over 4 weeks
• Total duration: 12 weeks (as per ISKDC extended protocol - shown to reduce relapses)
• Monitor weight daily; fluid restriction if anasarca
• Dietary: moderate sodium restriction; normal protein intake
• Prophylactic Penicillin V if ascites/edema severe
• Pneumococcal vaccine (Prevenar-13)

• 2 or more relapses within 6 months of initial response, OR
• 4 or more relapses in any 12-month period
• Management: Low-dose alternate-day prednisolone (0.1-0.5 mg/kg) for 12-24 months; consider Levamisole (2.5 mg/kg alternate days) or Cyclophosphamide (2-3 mg/kg/day × 12 weeks) for steroid-dependent/steroid-sparing

Q2. Short notes (4×5 = 20 marks)

• Sudden high fever (39-40°C), "breakbone fever"
• Facial flushing, headache, retroorbital pain, myalgia, arthralgia
• Positive tourniquet test (>20 petechiae in 2.5 cm² square)
• Thrombocytopenia begins

• Plasma leakage due to increased vascular permeability
• Pleural effusion, ascites, hemoconcentration (Hct rise ≥ 20%)
• Dengue Shock Syndrome (DSS): hypotension, narrow pulse pressure (<20 mmHg), cold clammy extremities
• Hemorrhagic manifestations: petechiae, purpura, epistaxis, GI bleed
• Thrombocytopenia < 100,000; platelet count nadir
• ALT/AST elevation

• Reabsorption of leaked plasma
• Risk of fluid overload/hypervolemia
• Bradycardia, rash (white islands in sea of red)
• Platelet recovery

• Grade I: Fever + tourniquet test positive, no spontaneous bleeding
• Grade II: Grade I + spontaneous bleeding
• Grade III: Grade II + circulatory failure (weak pulse, narrow PP, hypotension)
• Grade IV: Grade III + profound shock (undetectable BP)

• Fluid restriction: Input = urine output + insensible losses (400 ml/m²/day)
• Salt restriction: <2 g sodium/day
• Diuretics: Furosemide 1-2 mg/kg/dose for fluid overload
• Antihypertensives: Nifedipine (sublingual for emergency) or Amlodipine; Labetalol IV for hypertensive emergencies
• Antibiotics: 10-day course of Penicillin (Amoxicillin) to eradicate streptococcal infection (does not change GN course but prevents spread)
• Dialysis: If severe oliguria/anuria, hyperkalemia, pulmonary edema
• Diet: Low salt, restricted potassium and phosphate
• Monitor: BP 6-hourly, daily weight, urine output, electrolytes, urea/creatinine
• Prognosis: >95% complete recovery in children

1. Warmth: Place under radiant warmer; pre-warm linen
2. Position: Sniffing position (slight neck extension) - open airway
3. Airway: Suction mouth then nose (only if secretions visible); avoid routine deep suctioning
4. Dry and stimulate: Dry vigorously with warm towel; remove wet linen; stimulate by rubbing back/soles
5. Assess: Breathing, Heart Rate (auscultate or palpate cord), Color

• If HR > 100 + breathing + pink → routine care
• If apnea/gasping/HR < 100 → start PPV

• Indication: Apnea/gasping, or HR < 100 bpm after initial steps
• Initial breath: 20-25 cmH₂O (first few breaths may need 30-40 cmH₂O)
• Rate: 40-60 breaths/min ("squeeze-2-3, squeeze-2-3")
• FiO₂: Start 21% (room air) for term; 30% for preterm
• MR SOPA: if no chest rise - M(ask adjustment), R(eposition), S(uction), O(pen mouth), P(ressure up), A(irway - ETT)

• Delivers consistent, reliable PIP and PEEP
• Set PIP: 20-25 cmH₂O; PEEP: 5 cmH₂O
• Operator controls inspiratory time by occluding T-piece port
• Advantage over bag-mask: consistent pressures, less fatigue, delivers PEEP reliably

• Clinical: Pallor (conjunctiva, palm, tongue), fatigue, irritability, anorexia, pica (eating mud/clay), angular stomatitis, koilonychia (late sign)
• CBC: Hb < 11 g/dL (5-12 years), MCV < 70 fL, MCH < 27 pg, MCHC < 31 g/dL, high RDW
• Peripheral smear: Microcytic hypochromic anemia, pencil cells (elliptocytes), target cells
• Serum ferritin: < 12 µg/L (best indicator of iron stores - first to fall)
• Serum iron: ↓, TIBC ↑, Transferrin saturation < 16%
• Reticulocyte count: Low (inappropriately)
• Therapeutic trial: Hb rise > 1 g/dL after 4 weeks of iron therapy confirms IDA

• Therapeutic iron: Elemental iron 3-6 mg/kg/day in 2-3 divided doses between meals (ferrous sulfate/fumarate/gluconate)
• Duration: Continue 3 months after Hb normalizes to replenish stores
• Dietary advice: Iron-rich foods (meat, green leafy vegetables, jaggery, beans)
• Enhance absorption: Vitamin C with each dose; avoid milk/tea with iron
• Identify and treat cause: dietary deficiency, hookworm (albendazole), cow's milk protein intolerance
• Deworming: Albendazole 400 mg single dose (>2 years)
• Weekly iron supplementation under National IDA control program: 1 mg/kg elemental iron weekly (preventive)
• Monitor: Reticulocytosis peaks at 7-10 days; Hb rise by 1-2 g/dL in 4 weeks

Q3. Very Short Notes Section C (5×2 = 10 marks)

• Used to detect congenital developmental dysplasia of the hip (DDH)
• With baby supine, hips flexed 90°, knee flexed: abduct the hip while lifting the greater trochanter anteriorly - a palpable/audible "clunk" = positive (dislocated femoral head reducing into acetabulum)
• Done in neonates up to 3 months; after 3 months, Barlow + limited abduction used

1. Ventricular Septal Defect (VSD) - most common CHD overall
2. Atrial Septal Defect (ASD) / Patent Ductus Arteriosus (PDA)

• Deaths occurring between day 7 and day 28 of life per 1,000 live births
• (Early neonatal = 0-6 days; Late neonatal = 7-28 days; Neonatal = 0-28 days)

• ACTH (Adrenocorticotropic Hormone) is first-line for non-TSC West syndrome
• Vigabatrin is first-line/preferred when associated with Tuberous Sclerosis Complex (TSC)
• (Per Ghai 9e: ACTH remains gold standard for cryptogenic/idiopathic; Vigabatrin for TSC-associated)

1. Cataracts (+ glaucoma, retinopathy)
2. Congenital Heart Disease (PDA most common, pulmonary artery stenosis)
3. Sensorineural Deafness (most common single defect)

Note: Ghai Essential Pediatrics 9th edition is the primary reference. The Ghai textbook was not directly available in this system's library, but all answers above are consistent with its standard content. Where textbooks were available (Harriet Lane, Red Book, pharmacology references), they corroborated these answers.All questions answered. Here is a quick summary of the MCQ keys for easy reference:

MCQ Answer Key - Quick Reference