HIGH-YIELD PEDIATRICS QUIZ PREP SHEET

(OP Ghai + Arvind Arora Level | Competitive Round Quality)

SECTION 1: NEONATOLOGY

Birth Asphyxia & Resuscitation

• Apgar at 1 min - indicates need for resuscitation; Apgar at 5 min - indicates prognosis
• Apgar score 0-3 = severe asphyxia; 4-6 = moderate; 7-10 = normal
• First step in neonatal resuscitation = Warmth, dry, stimulate (NOT oxygen, NOT ventilation)
• Hypoxic Ischemic Encephalopathy (HIE): Sarnat & Sarnat staging - Grade I (hyperalert, irritable), Grade II (lethargic, seizures), Grade III (stupor/coma, flaccid)
• Therapeutic hypothermia: 33-34°C for 72 hours - window is within 6 hours of birth
• Most common cause of neonatal seizures = HIE (birth asphyxia)

Neonatal Jaundice

• Physiological jaundice: appears after 24 hours, peaks day 3-5 in term (day 5-7 in preterm), disappears by day 14 (term) / day 21 (preterm)
• Pathological: appears within 24 hours = hemolytic until proven otherwise
• Breast milk jaundice - peaks at 2nd week, can persist up to 3 months; unconjugated
• Breast feeding jaundice - 1st week, due to poor intake (different from breast milk jaundice)
• Exchange transfusion criteria in term neonate: bilirubin >20 mg/dL (or as per Bhutani nomogram)
• Crigler-Najjar type I: complete absence of UGT1A1 - only treatment is liver transplant; phototherapy 10-12 hr/day just buys time
• Lucey-Driscoll syndrome: transient familial neonatal jaundice due to inhibitor in maternal serum
• Bronze baby syndrome: complication of phototherapy in cholestatic jaundice (conjugated)

Neonatal Sepsis

• Early onset sepsis (EOS): within 72 hours; organisms = GBS, E. coli, Listeria
• Late onset sepsis (LOS): after 72 hours; organisms = CONS (Coagulase-negative Staph), Klebsiella, Pseudomonas
• Most common organism in neonatal sepsis in India = Klebsiella pneumoniae
• Best single investigation = Blood culture (gold standard)
• I:T ratio (immature:total neutrophil ratio) >0.2 = significant
• CRP: rises in 6-8 hours, peaks at 24-48 hours; best for monitoring therapy
• Treatment: Ampicillin + Gentamicin (first line for EOS)

Respiratory Distress Syndrome (RDS) / HMD

• Due to surfactant deficiency (Type II pneumocytes)
• Lecithin:Sphingomyelin (L:S) ratio <1.5 = high risk; >2 = lungs mature
• PG (phosphatidylglycerol) appears at 35 weeks - presence = lung maturity
• CXR: ground glass appearance + air bronchograms (reticulogranular pattern)
• Treatment: Surfactant therapy (poractant alfa / beractant) + CPAP
• Complications: BPD (bronchopulmonary dysplasia), IVH, PDA, air leak
• Wilson-Mikity syndrome: form of BPD in VLBW infants, no initial respiratory distress, cystic changes appear later

Necrotizing Enterocolitis (NEC)

• Most common GI emergency in neonates
• Most common in premature, formula-fed neonates
• Bell's staging: I = suspected, II = proven, III = advanced (perforation)
• Pathognomonic X-ray sign = Pneumatosis intestinalis (intramural gas)
• Portal venous gas = severe, bad prognostic sign
• Pneumoperitoneum = indication for surgery
• Most common site = terminal ileum + proximal colon (ileocecal region)

Preterm & IUGR

• VLBW = <1500 g; ELBW = <1000 g; LBW = <2500 g
• Preterm = <37 weeks; Post-term = >42 weeks
• SGA = birth weight <10th percentile; LGA = >90th percentile
• Symmetric IUGR (type I): head + body both small; insult early (1st trimester); causes: chromosomal, TORCH infections
• Asymmetric IUGR (type II): head spared, body small; insult late (3rd trimester); causes: placental insufficiency, PIH
• Lubchenco chart = intrauterine growth chart
• Complications of preterm: RDS, IVH, NEC, ROP, PDA, Hypothermia, Hypoglycemia

Retinopathy of Prematurity (ROP)

• Screening: all babies <32 weeks or <1500g; first exam at 4 weeks of age (or 31 weeks PMA, whichever is later)
• Plus disease: dilated, tortuous vessels - indicates active disease
• Zone I = worst prognosis; Zone III = best
• Treatment: Laser photocoagulation; Anti-VEGF (bevacizumab) for Zone I/posterior Zone II
• STOP-ROP trial: supplemental oxygen doesn't help in threshold ROP

Intraventricular Hemorrhage (IVH)

• Papile grading: I = subependymal, II = IVH without ventricular dilatation, III = IVH + ventricular dilatation, IV = parenchymal hemorrhage
• Grade III & IV = poor prognosis
• Most vulnerable area: germinal matrix (subependymal)

Neonatal Hypoglycemia

• Blood glucose <45 mg/dL (symptomatic) or <40 mg/dL in neonates
• Most common cause = IDM (infant of diabetic mother) (hyperinsulinism)
• IDM baby: macrosomic, cushingoid, plethoric; at risk for hypoglycemia, hypocalcemia, polycythemia, RDS (due to delayed surfactant)
• Beckwith-Wiedemann syndrome: macrosomia + macroglossia + omphalocele + hypoglycemia + hemihypertrophy

SECTION 2: INFECTIONS

Tuberculosis in Children

• Primary complex = Ghon's focus (lung) + enlarged hilar lymph node + connecting lymphangitis = Ranke complex when calcified
• Ghon's focus is most often in the lower part of upper lobe or upper part of lower lobe (well-ventilated zone)
• Erythema nodosum = hypersensitivity manifestation of primary TB
• Phlyctenular conjunctivitis = another hypersensitivity manifestation
• Childhood TB diagnosis: Revised Stegen's criteria - definite (culture +), probable (3 major or 2 major + 1 minor)
• Major criteria: positive Mantoux, X-ray evidence, suggestive histology, positive contact
• Mantoux test: 0.1 mL of 2TU PPD intradermally; read at 48-72 hours; >10 mm = positive (>5 mm in immunocompromised/HIV/recent contact)
• BCG vaccine: protects against miliary TB and TB meningitis; NOT against pulmonary TB
• TBM (tuberculous meningitis): CSF - cobweb clot, lymphocytes, high protein, very low glucose; chloride reduced (specific)
• Dexamethasone added in TBM treatment to reduce mortality
• Treatment: HRZE for 2 months, then HR for 4 months (6 months total); TBM/bone = 12 months

Meningitis

• Neonatal meningitis: GBS, E. coli, Listeria - CSF protein >150 mg/dL
• H. influenzae meningitis: most common cause of bacterial meningitis in children 1 month - 5 years (pre-Hib vaccine era); Hib vaccine has changed this
• Meningococcal meningitis: Waterhouse-Friderichsen syndrome (bilateral adrenal hemorrhage + purpuric rash + shock); Petechiae present
• Pneumococcal meningitis: highest mortality; most common in adults
• Mollaret's meningitis: recurrent aseptic meningitis (HSV-2)
• Queckenstedt's test: for spinal block
• CSF in bacterial vs viral: bacterial = high neutrophils, high protein, very low glucose; viral = lymphocytes, mildly elevated protein, normal/mildly low glucose
• Eosinophilic meningitis = Angiostrongylus cantonensis (rat lungworm)

TORCH Infections

• Toxoplasmosis: Classic triad = chorioretinitis + hydrocephalus + intracranial calcifications (periventricular)
• Treatment: Pyrimethamine + Sulfadiazine + Folinic acid
• Congenital Rubella: PDA + pulmonary artery stenosis (most common cardiac lesion); cataract (pearly white, nuclear); sensorineural deafness; "salt and pepper" retinopathy; blueberry muffin rash
• CMV: Most common congenital infection overall; periventricular calcifications (vs toxoplasmosis = diffuse); "owl eye" inclusion bodies; most infected neonates are asymptomatic
• Herpes (HSV-2): Vesicular rash; encephalitis; Treatment = IV Acyclovir 60 mg/kg/day for 21 days
• Congenital syphilis: Snuffles (sanguineous nasal discharge), Hutchinson's triad (interstitial keratitis + deafness + Hutchinson's teeth - notched incisors), saddle nose, Clutton's joints, Wimberger's sign (bilateral destruction of medial tibial metaphysis on X-ray), sabre tibia, periostitis

Common Childhood Infections

• Measles: Koplik spots (pathognomonic) - on buccal mucosa opposite lower molars, appear 1-2 days before rash; rash is maculopapular, starts behind ears, spreads downward; cough, coryza, conjunctivitis (3 C's + Koplik = prodrome)
• Complications: SSPE (Subacute Sclerosing Panencephalitis) - 7-10 years after measles; fatal; EEG shows Radermecker complexes (periodic high-voltage complexes)
• Mumps: Most common cause of viral orchitis in post-pubertal males; parotitis (angle of jaw); Stensen's duct orifice red and swollen; Mikulicz cells in salivary glands; Complications: orchitis, meningitis, pancreatitis, deafness (sensorineural - unilateral, permanent)
• Chickenpox (VZV): Lesions in all stages simultaneously (papule, vesicle, pustule, crust) = hallmark; Dew drop on rose petal = classic vesicle; treatment = Acyclovir; Reye syndrome with aspirin
• Roseola infantum (HHV-6): Exanthem subitum - high fever 3-5 days, then fever breaks, THEN rash appears (rash is the last thing); most common cause of febrile seizures in <2 years
• Erythema infectiosum (Parvovirus B19): "Slapped cheek" appearance; 5th disease; aplastic crisis in sickle cell; hydrops fetalis if mother infected during pregnancy
• Dengue: Breakbone fever; NS1 antigen earliest (day 1-5); IgM appears day 5; Thrombocytopenia + hemoconcentration; Warning signs = abdominal pain, persistent vomiting, rapid clinical deterioration, fluid accumulation, bleeding, liver >2cm, rising hematocrit
• Malaria: Tertian fever = P. vivax / P. ovale (48-hr cycle); Quartan = P. malariae (72-hr); P. falciparum = malignant tertian (irregular fever); Most dangerous = P. falciparum; treatment of severe malaria = IV Artesunate (first line now, replaced quinine)
• Typhoid: Rose spots on abdomen; Widal test = O titer >1:160 and H titer >1:160 significant; Bradycardia with fever (Faget's sign / relative bradycardia); Complications: intestinal perforation (3rd week), hemorrhage; Chloramphenicol = drug causing gray baby syndrome in neonates

Diarrhea / GI Infections

• Rotavirus: Most common cause of severe diarrhea in children <5 years worldwide; watery, non-bloody; Rice-water stools = cholera
• Vibrio cholerae: El Tor biotype; Inaba and Ogawa serotypes; Rice water stools; treatment = oral rehydration + Doxycycline (single dose)
• ORS composition (WHO 2002/reduced osmolarity): Na 75, Cl 65, K 20, Citrate 10, Glucose 75 mEq/L; osmolarity = 245
• Shigella: Dysentery (blood + mucus in stool); most pathogenic = S. dysenteriae type 1 (Shiga toxin); treatment = Azithromycin or Ciprofloxacin; HUS (Hemolytic Uremic Syndrome) = EHEC O157:H7 (or Shiga toxin) - microangiopathic hemolysis + thrombocytopenia + AKI; Don't use antibiotics in HUS caused by EHEC (worsens)

SECTION 3: GROWTH & DEVELOPMENT

Physical Growth

• Birth weight = 3 kg; doubles by 5 months; triples by 1 year; quadruples by 2 years
• Birth length = 50 cm; increases by 25 cm in 1st year; 12.5 cm in 2nd year; 6-7.5 cm/year in 3-5 years
• Head circumference at birth = 34 cm; grows 2 cm/month for first 3 months; then 1 cm/month for 3-6 months; then 0.5 cm/month for 6-12 months
• HC = CC (chest circumference) at 6 months; after that HC < CC
• Fontanelle: anterior closes at 9-18 months (12-18 months practically); posterior closes by 6-8 weeks; large AF = hydrocephalus, hypothyroidism, rickets; Bulging AF = raised ICP; Sunken AF = dehydration
• Teething: first tooth = lower central incisor at 6-8 months; total 20 deciduous teeth by 2.5 years
• Formula for deciduous teeth: age in months - 6

Developmental Milestones (HIGH YIELD)

• Social smile: 6 weeks (most tested milestone)
• Neck holding (head control): 3 months
• Sitting with support: 5 months; Sitting without support: 7-8 months
• Standing with support: 9 months; Standing without support: 1 year
• Walking with support: 9-10 months; Walking without support: 13-15 months
• Pincer grasp (fine): 9 months
• Monosyllables: 6 months; Bisyllables (dada/mama non-specifically): 9 months; First meaningful word: 1 year; 2-word sentences: 2 years; 3-word sentences: 3 years; Speaks full sentences: 4-5 years
• Stranger anxiety: 8-9 months
• Object permanence: 9 months
• Hand regard (looking at own hands): 3 months
• Follows light: birth; follows object 90 degrees = 3 months; 180 degrees = 4-5 months
• Rolling: prone to supine at 4-5 months; supine to prone at 5-6 months

Development Theories

• Piaget: Sensorimotor (0-2 yr) → Preoperational (2-7 yr) → Concrete operational (7-12 yr) → Formal operational (>12 yr)
• Freud: Oral → Anal → Phallic (Oedipus/Electra complex, 3-6 yr) → Latency → Genital
• Erikson: Trust vs Mistrust (infancy) → Autonomy vs Shame (toddler) → Initiative vs Guilt (preschool) → Industry vs Inferiority (school) → Identity vs Role confusion (adolescence)

SECTION 4: NUTRITION & DEFICIENCIES

Protein-Energy Malnutrition

• Kwashiorkor: edema + skin lesions (flaky paint dermatosis) + hair changes (flag sign = alternating bands) + moon face; serum albumin very LOW; caused by protein deficiency with adequate calories
• Marasmus: severe wasting, no edema, skin = "old man face" (baggy pants appearance), loss of buccal fat pad (Bichat's fat pad); caused by total calorie deficiency
• Marasmic Kwashiorkor: features of both; worst prognosis
• Gomez classification: Grade I = 75-89% expected weight, Grade II = 60-74%, Grade III = <60%
• IAP classification (Indian): Grade I = 71-80%, Grade II = 61-70%, Grade III = 51-60%, Grade IV = <50%
• MUAC (Mid-upper arm circumference): <11.5 cm = SAM; 11.5-12.5 cm = MAM
• Therapeutic feeding: F-75 (stabilization) then F-100 (rehabilitation); RUTF (ready-to-use therapeutic food)

Vitamin Deficiencies

• Vitamin A: Night blindness (first sign); Bitot spots (X1B); Xerophthalmia; Keratomalacia (X3, corneal ulceration - blinding); Measles depletes Vit A
• Dose: 100,000 IU at 9 months with measles vaccine; 200,000 IU at 18 months
• Vitamin D (Rickets): Craniotabes (earliest sign in infantile rickets); Rachitic rosary; Harrison's groove; Bow legs (genu varum); Looser zones on X-ray (pseudofractures); ALP very HIGH; serum Ca low/normal; X-ray: fraying, cupping, splaying of metaphysis; widening of growth plate
• Scurvy (Vit C): Perifollicular hemorrhage; Bleeding gums (after teeth erupt); Corkscrew hair; Frog-leg posture (painful); Trummerfeld zone (zone of destruction) + Pelkan spur + Frankel's line + Wimberger's ring on X-ray
• Thiamine (B1): Wet beriberi = cardiac (dilated cardiomyopathy, high-output failure); Dry beriberi = peripheral neuropathy; Wernicke's encephalopathy (thiamine deficiency in alcoholics)
• Niacin (B3): Pellagra = 3 D's (Dermatitis + Diarrhea + Dementia); Casal's necklace = dermatitis around neck; associated with corn diet (maize) + Hartnup disease (tryptophan malabsorption)
• Vitamin K: Newborns given IM Vit K 1 mg at birth to prevent VKDB (Vitamin K Deficiency Bleeding); PIVKA (Proteins Induced by Vit K Absence) = sensitive marker

SECTION 5: VACCINES

National Immunization Schedule (India - HIGH YIELD)

• At birth: BCG (0-4 weeks), OPV-0, Hepatitis B (1st dose)
• 6 weeks: OPV-1, DPT-1, Hep B-2, Hib-1, Rotavirus-1, PCV-1, IPV-1
• 10 weeks: OPV-2, DPT-2, Hib-2, Rotavirus-2, PCV-2
• 14 weeks: OPV-3, DPT-3, Hib-3, Rotavirus-3, PCV-3, IPV-2
• 9-12 months: Measles/MR-1, Vit A (1st dose), JE-1 (endemic areas)
• 16-24 months (1.5 yr): DPT Booster, OPV Booster, MR-2/MMR, Hib Booster, Vit A (2nd dose), JE-2
• 5 years: DPT Booster-2
• 10 years & 16 years: TT/Td

Vaccine Key Facts

• BCG: Live attenuated Mycobacterium bovis; given at birth (0-4 weeks); scar appears at 2-3 weeks; protects against miliary TB and TB meningitis (NOT pulmonary TB); no repeat if no scar; Contraindication: HIV (symptomatic/severe), SCID
• OPV: Live oral; Sabin strain; 3 types (1, 2, 3); VAPP (Vaccine-Associated Paralytic Polio) risk; Type 2 OPV removed (bOPV now used)
• DPT (Whole cell): Contraindications to DPT: encephalopathy within 7 days of previous dose, progressive neurological disorder; precautions: febrile seizures, high-pitched cry, hypotonic-hyporesponsive episode
• Hepatitis B: Recombinant vaccine; 3 doses; anti-HBs >10 mIU/mL = protective; HBIG given to newborns of HBsAg+ mothers within 12 hours
• MMR: Live; NOT given in pregnancy or severe immunodeficiency; minimum age = 9 months
• Varicella: Live; 2 doses (12 months and 4-6 years); contraindicated in immunocompromised
• Cold chain: OPV most sensitive to heat (freeze-sensitive vaccines: DPT, DT, TT, Hep B, IPV cannot be frozen)
• Freeze-sensitive vaccines: stored at 2-8°C (NOT frozen); Freeze-tolerant vaccines: OPV, MMR, Varicella (can be stored at -20°C)

SECTION 6: RESPIRATORY

Asthma

• GINA classification: Intermittent / Mild persistent / Moderate persistent / Severe persistent
• PEFR (Peak Expiratory Flow Rate): best single office test; <80% = mild, <60% = moderate, <40% = severe
• Status asthmaticus: acute severe asthma not responding to bronchodilators; pulsus paradoxus >15 mmHg
• Step-up therapy: SABA → low-dose ICS → ICS + LABA → high-dose ICS + LABA ± oral steroids
• First line acute: Salbutamol (nebulized) + Ipratropium; IV Magnesium sulfate in severe
• Heliox (helium-oxygen mixture): decreases airway resistance in severe asthma
• Montelukast: leukotriene receptor antagonist (LTRA); add-on therapy

Croup vs Epiglottitis

• Croup treatment: Nebulized adrenaline + single-dose Dexamethasone (0.6 mg/kg)
• Epiglottitis: Secure airway FIRST; do NOT do throat exam without intubation team ready

Bronchiolitis

• Age: <2 years, peak = 3-6 months
• Organism: RSV (Respiratory Syncytial Virus) most common
• Features: wheeze + hyperinflation; subcostal and intercostal retractions
• Rales/Crackles = bronchiolitis; Wheeze = asthma (differentiation point)
• Treatment: supportive (oxygen); Nebulized hypertonic saline (3%) reduces length of stay
• Palivizumab (anti-RSV monoclonal antibody): prophylaxis for high-risk premature infants

SECTION 7: CARDIOLOGY

Congenital Heart Defects

• Most common CHD overall = VSD
• Most common cyanotic CHD = Tetralogy of Fallot (TOF)
• Most common CHD in Down syndrome = AVSD (Atrioventricular Septal Defect) / Endocardial cushion defect
• Most common CHD causing cyanosis at birth (day 1) = TGA (Transposition of Great Arteries)
• TGA: parallel circulation; cyanosis day 1; egg-on-side heart (X-ray); treatment = Rashkind procedure (balloon atrial septostomy) to maintain ductus/ASD; definitive = arterial switch operation (Jatene)
• TOF: 4 components = VSD + Pulmonary stenosis + Overriding aorta + RVH; boot-shaped heart (coeur en sabot); Tet spells = squatting relieves (increases SVR); treatment = knee-chest position, morphine, propranolol during spell; surgery = corrective TOF repair
• Eisenmenger syndrome: reversal of L-R shunt → R-L shunt due to pulmonary hypertension; cyanosis develops; VSD > ASD > PDA; Contraindication to corrective surgery
• ASD: wide fixed split S2; most common = ostium secundum; OS ASD in Down syndrome; Lutembacher syndrome = ASD + mitral stenosis
• PDA: continuous "machinery murmur"; Gibson murmur; widened pulse pressure; bounding pulses; treatment in premature = Indomethacin or Ibuprofen; surgical ligation if fails
• Coarctation of aorta: Notching of ribs (3rd-8th ribs); Figure of 3 sign on CXR; reverse 3 sign on barium swallow; associated with Turner syndrome, bicuspid aortic valve; Radio-femoral delay
• Pulmonary stenosis with intact IVS: RVH on ECG; systolic ejection murmur in pulmonary area; treatment = balloon valvuloplasty
• Nadas criteria for functional vs organic murmur: any one major OR two minor criteria = pathological

Rheumatic Fever

• Jones criteria (revised 2015): 2 Major OR 1 Major + 2 Minor + evidence of streptococcal infection
• Major criteria: Carditis (most important, determines prognosis), Polyarthritis (most common), Chorea (Sydenham's), Erythema marginatum, Subcutaneous nodules
• Minor criteria: Fever, raised ESR/CRP, prolonged PR interval, arthralgia (if arthritis not counted as major)
• Carditis: endocarditis (valvular) + myocarditis + pericarditis; Mitral valve most affected (MR > MS)
• Aschoff bodies = pathognomonic of rheumatic carditis; Aschoff cells = modified macrophages
• Prophylaxis: Benzathine penicillin 1.2 million units IM every 3 weeks; duration depends on residual disease (no carditis = 5 years or age 21; carditis without residual = 10 years or 21; carditis with residual = lifelong)
• Sydenham's chorea: involuntary movements; "Milkmaid grip" (releasing and gripping); Jack-in-the-box tongue; Pronator sign; may be the ONLY presenting feature with no evidence of acute RF

SECTION 8: NEPHROLOGY

• Nephrotic syndrome: protein >3.5 g/day (adult) / >40 mg/m²/hr; massive proteinuria + edema + hypoalbuminemia + hyperlipidemia
• Most common cause in children = Minimal Change Disease (MCD) / Nil disease; steroid-responsive
• Steroid-sensitive NS = responds in 4 weeks; resistant = no response in 8 weeks
• Treatment: Prednisolone 2 mg/kg/day for 4-6 weeks, then alternate day for 4-6 weeks
• Nephritic syndrome: hematuria + proteinuria (<3.5g) + hypertension + oliguria + edema
• Most common cause of nephritic in children = Post-streptococcal GN (PSGN): 1-3 weeks after throat infection (Type 12 M protein); low C3 (normalizes in 6-8 weeks); Subepithelial humps on EM
• IgA nephropathy (Berger's): most common GN worldwide; synpharyngitic hematuria (gross hematuria concurrent with URTI, not delayed); normal complement; poor prognosis if persistent proteinuria
• Henoch-Schonlein Purpura (HSP) / IgA vasculitis: palpable purpura on buttocks/lower limbs + arthritis + abdominal pain + renal involvement; IgA deposits in mesangium (identical to IgA nephropathy); most common vasculitis in children
• HUS (Hemolytic Uremic Syndrome): microangiopathic hemolytic anemia + thrombocytopenia + AKI; most common cause of acute renal failure in children; E. coli O157:H7 (EHEC); Do NOT give antibiotics (increases toxin release)
• Wilms Tumor (Nephroblastoma): most common renal tumor in children; peak age 3-4 years; associated with WAGR syndrome (Wilms + Aniridia + GU anomalies + mental Retardation) and Beckwith-Wiedemann; WT1 gene (chromosome 11p13); treatment = surgery + chemotherapy (actinomycin-D + vincristine); prognosis generally good

SECTION 9: HEMATOLOGY

Anemia

• Normal Hb in newborn = 16-18 g/dL (falls to nadir at 8-12 weeks = physiological anemia of infancy)
• Anemia of prematurity: nadir at 6-8 weeks; Hb <7-8 g/dL; due to low EPO production + shorter RBC survival + phlebotomy
• Iron Deficiency Anemia: most common anemia in children; microcytic hypochromic; serum ferritin = best single test to diagnose early IDA; low ferritin, low serum iron, high TIBC, low transferrin saturation
• IDA target: treatment for 3 months (1 month to correct Hb + 2 months to replenish stores)
• Thalassemia: Beta-thal major: transfusion-dependent; Hb F >80%; massive splenomegaly; crew cut X-ray (hair-on-end); Hb A2 >3.5% in beta-thal trait; desferrioxamine for iron chelation; curative = BMT
• Sickle cell anemia: HbS; vaso-occlusive crisis = most common; dactylitis = earliest manifestation (hand-foot syndrome) in infants; aplastic crisis = Parvovirus B19; sequestration crisis (spleen) = sudden drop in Hb; Hydroxyurea increases HbF; Newborn screening = Hb electrophoresis (FSA = sickle cell disease; FAS = trait)
• Glucose-6-Phosphate Dehydrogenase (G6PD) deficiency: X-linked recessive; Heinz bodies; precipitated by oxidant stress (primaquine, dapsone, fava beans, infections); favism; Bite cells (degmacytes) on peripheral smear

Bleeding Disorders

• Hemophilia A: Factor VIII deficiency; X-linked; hemarthrosis (target joint = knee); prolonged aPTT, normal PT; treatment = recombinant FVIII (desmopressin = DDAVP for mild cases)
• Hemophilia B (Christmas disease): Factor IX deficiency; treatment = FIX concentrate
• Von Willebrand Disease: most common inherited bleeding disorder; autosomal dominant; prolonged BT + aPTT; defective platelet adhesion; treatment = DDAVP (type 1), VWF concentrate (type 3)
• ITP: post-viral (2-4 weeks); self-limiting; isolated thrombocytopenia; treatment: observation if mild; IVIG / anti-D / steroids if significant bleeding; Splenectomy for chronic ITP
• DIC: consumption coagulopathy; prolonged PT + aPTT + low fibrinogen + elevated D-dimer; treatment = treat underlying cause + FFP + platelets

SECTION 10: NEUROLOGY

Seizures

• Febrile seizures: 6 months - 5 years (peak = 18 months); Simple = <15 min, generalized, single episode in 24 hr; Complex = >15 min, focal, multiple in 24 hr, or postictal deficit
• Febrile status epilepticus = >30 minutes of seizure with fever
• No prophylaxis needed for simple febrile seizures; oral diazepam given during fever in recurrent cases
• West syndrome: infantile spasms + hypsarrhythmia on EEG + developmental regression; age <1 year; treatment = ACTH (gold standard) / Vigabatrin
• Lennox-Gastaut syndrome: multiple seizure types + slow spike-wave (<2.5 Hz) + cognitive impairment; treatment = Valproate, Lamotrigine, Rufinamide
• Absence seizures (Petit mal): 3 Hz spike-wave discharge; brief staring spells; treatment = Ethosuximide (first line) or Valproate

CNS Infections

• Reye syndrome: encephalopathy + fatty liver + aspirin use in viral illness (VZV/influenza); raised ammonia; no jaundice; elevated transaminases
• Cerebral malaria: coma + severe P. falciparum; treatment = IV Artesunate

Other Neurological

• Cerebral Palsy: most common motor disorder in childhood; spastic diplegia = most common type (associated with periventricular leukomalacia/prematurity); Scissor gait = spastic CP; Athetoid/dyskinetic CP = kernicterus
• NF1 (Von Recklinghausen): ≥6 cafe au lait spots (>5 mm prepubertal, >15 mm postpubertal); Lisch nodules (iris hamartomas); axillary/inguinal freckling; neurofibromas; optic glioma most common intracranial tumor; chromosome 17
• NF2: bilateral acoustic neuromas; chromosome 22
• Tuberous sclerosis: Ash leaf macules (earliest lesion, UV lamp/Wood's lamp); Shagreen patch; Adenoma sebaceum (actually angiofibromas on face); subependymal nodules (candle drippings); Cortical tubers; seizures

SECTION 11: GENETICS & SYNDROMES

• Down syndrome (Trisomy 21): Simian crease + Brushfield spots (iris) + sandal gap + Epicanthal folds + flat face + hypotonia + upslanting palpebral fissures; most common chromosomal cause of ID; AVSD most common CHD; associated with Alzheimer's disease (by age 40) and leukemia (ALL and AML)
• Edwards syndrome (Trisomy 18): rocker bottom feet + clenched fist (overlapping fingers) + micrognathia + VSD; worst prognosis (median survival days-weeks)
• Patau syndrome (Trisomy 13): holoprosencephaly + midline defects + polydactyly + cleft lip/palate + microphthalmia
• Turner syndrome (45,XO): webbed neck + cystic hygroma + short stature + primary amenorrhea + coarctation of aorta + horseshoe kidney; no mental retardation (usually normal intelligence)
• Klinefelter (47,XXY): tall + small testes + gynecomastia + azoospermia; increased risk of breast cancer; testosterone treatment
• Fragile X syndrome: most common inherited cause of intellectual disability; X-linked dominant; large ears + macrorchidism + long face; CGG repeat expansion in FMR1 gene
• Prader-Willi syndrome: chromosome 15 deletion (paternal); obesity + hypotonia + hyperphagia + hypogonadism + short stature + almond-shaped eyes
• Angelman syndrome: chromosome 15 deletion (maternal); happy puppet syndrome; severe ID + seizures + ataxia + inappropriate laughter; absent speech

SECTION 12: ENDOCRINOLOGY

• Congenital Hypothyroidism: most common preventable cause of intellectual disability; umbilical hernia + prolonged neonatal jaundice + large tongue + hoarse cry + constipation; TSH elevated (primary); treatment = L-thyroxine; screening by heel prick test (TSH)
• Congenital Adrenal Hyperplasia (CAH): most common = 21-hydroxylase deficiency (90%); leads to cortisol deficiency + aldosterone deficiency + androgen excess; salt-wasting (most severe); females: virilization; males: precocious puberty; diagnosis = elevated 17-OHP; treatment = hydrocortisone; fludrocortisone for salt-wasting
• Precocious puberty: girls <8 years, boys <9 years; central/true = GnRH-dependent; peripheral/pseudo = GnRH-independent (McCune-Albright, CAH, gonadal tumors); treatment for central = GnRH agonist (leuprolide)
• Growth Hormone Deficiency: short stature + delayed bone age; doll-like face; treatment = recombinant GH; diagnosis = IGF-1 + GH stimulation test
• Diabetes insipidus: central (ADH deficiency) = treatment with DDAVP; nephrogenic = treatment with thiazides + indomethacin

SECTION 13: ONCOLOGY

• Most common cancer in children = ALL (Acute Lymphoblastic Leukemia)
• ALL: peak age 2-5 years; better prognosis than AML; PAS positive blast cells; Philadelphia chromosome (t9;22) = worst prognosis; t(12;21) = best prognosis (TEL-AML1)
• Hyperdiploidy = good prognosis in ALL
• CNS prophylaxis important in ALL (intrathecal methotrexate)
• Wilms tumor: most common solid abdominal tumor in children; do NOT palpate abdomen unnecessarily (ruptures capsule)
• Neuroblastoma: most common solid extracranial tumor in children; adrenal medulla most common site; catecholamine-secreting; elevated urinary VMA/HVA; N-MYC amplification = poor prognosis; calcifications on CT; Pepper syndrome (liver mets in neonates); Hutchinson syndrome (skull mets with orbital proptosis); treated with surgery + chemo; spontaneous regression in Stage IV-S
• Medulloblastoma: most common malignant brain tumor in children; posterior fossa (cerebellum); drops mets along CSF; treatment = surgery + craniospinal radiation + chemotherapy
• Astrocytoma: most common overall brain tumor in children (if including all grades); cerebellar astrocytoma = best prognosis; cystic with mural nodule

SECTION 14: HIGH-YIELD IMAGE-BASED FACTS

• "Thumb sign" on X-ray = Epiglottitis
• "Steeple sign" on X-ray = Croup
• "Sunflower cataract" = Wilson disease (chalcosis)
• "Christmas tree" pattern on barium enema = Hirschsprung's disease (but actually narrow segment + dilated proximal)
• "Double bubble" on X-ray = Duodenal atresia (associated with Down syndrome)
• "Apple core" lesion = Colorectal carcinoma (but in pediatrics: Hirschsprung's)
• "Figure of 3" on CXR = Coarctation of aorta
• "Egg on side" CXR = TGA
• "Boot-shaped heart" = TOF
• "Snowman" heart = TAPVC (Total Anomalous Pulmonary Venous Connection)
• "Pneumatosis intestinalis" = NEC
• "Hair-on-end" skull X-ray = Thalassemia (also sickle cell, hereditary spherocytosis)
• "Wimberger's sign" = Congenital syphilis (medial tibial erosion)
• "Codfish vertebra" = Sickle cell (also osteoporosis)
• "Dactylitis" = Sickle cell (earliest manifestation) / Sarcoidosis
• Koplik spots = Measles (pathognomonic)
• Bitot spots = Vitamin A deficiency

BONUS: TRICKY ONE-LINERS (Quiz Favorites)

1. First sign of puberty in girls = breast development (thelarche); in boys = testicular enlargement
2. Most common cause of ambiguous genitalia = CAH (21-hydroxylase deficiency) in females
3. APGAR: Appearance, Pulse, Grimace, Activity, Respiration
4. Most common cause of death in children <5 years globally = Pneumonia (historically); now changing; in India = pneumonia + diarrhea
5. Kangaroo mother care: temperature maintained, skin-to-skin; improves outcomes in VLBW/LBW
6. IMNCI (Integrated Management of Neonatal and Childhood Illness): WHO strategy; classifies illness by age groups
7. Lead poisoning: Basophilic stippling of RBCs; lead lines on gums (Burton's lines) and X-ray metaphysis; encephalopathy; treatment = EDTA (severe) or DMSA (succimer) for mild/moderate
8. Drowning: freshwater drowning = hypotonic fluid absorbed → dilutional hyponatremia, hemolysis; saltwater drowning = hypertonic fluid → hypernatremia, hemoconcentration
9. Phenylketonuria: autosomal recessive; phenylalanine hydroxylase deficiency; musty/mousy odor; fair skin; intellectual disability; Guthrie test (bacterial inhibition assay) for screening; diet = low phenylalanine
10. Galactosemia: galactose-1-phosphate uridyl transferase deficiency; jaundice + cataracts + liver disease after milk feeding; treatment = galactose-free diet
11. Maple Syrup Urine Disease (MSUD): BCAA (leucine, isoleucine, valine) metabolism defect; sweet urine odor; neurological deterioration; treatment = BCAA-restricted diet + thiamine
12. Wilson's disease: copper accumulation; Kayser-Fleischer rings (corneal copper deposits); liver disease + neuropsychiatric + Coombs-negative hemolytic anemia; low ceruloplasmin; high 24-hr urine copper; treatment = D-penicillamine; liver transplant definitive
13. Celiac disease: gluten-sensitive enteropathy; anti-tissue transglutaminase (anti-tTG IgA) = best screening test; duodenal biopsy = villous atrophy + crypt hyperplasia; associated with HLA-DQ2/DQ8
14. Intussusception: most common cause of intestinal obstruction in 3 months - 6 years; ileocolic most common; currant jelly stools; Dance's sign (empty RIF); target sign on ultrasound; treatment = air/hydrostatic enema (reduction); surgery if fails or if peritonitis

Wimberger's Sign - All Conditions

1. Wimberger's Sign (Classic) - Congenital Syphilis

• What it is: Bilateral symmetric destruction/erosion of the medial proximal tibial metaphysis on X-ray
• Condition: Congenital syphilis (early)
• Described as pathognomonic for congenital syphilis
• Caused by osteochondritis - the spirochetes attack the zone of provisional calcification at the metaphysis, specifically the medial tibial corner
• Bilateral involvement is key - unilateral erosion is less specific
• Other X-ray findings in congenital syphilis: periostitis, Sabre tibia, metaphyseal lucent bands, "celery stalk" appearance

2. Wimberger's Ring Sign - Scurvy (Vitamin C Deficiency)

• What it is: A sclerotic/dense ring surrounding the epiphysis (pencil-line outline around the epiphyseal ossification center)
• Condition: Scurvy (Vitamin C deficiency)
• Represents the only zone where collagen formation continues (periosteum is relatively spared) around an otherwise osteoporotic epiphysis
• Confirmed in Grainger & Allison's Diagnostic Radiology: "In the epiphyses this pencil outline is termed the 'Wimberger' sign"

Summary Table for the Quiz

Q1. Wimberger's sign (medial tibial metaphyseal erosion) is seen in:

• A) Scurvy
• B) Congenital syphilis ✅
• C) Rickets
• D) Congenital rubella

Q2. Wimberger's ring sign (sclerotic ring around epiphysis) is seen in:

• A) Congenital syphilis
• B) Rickets
• C) Scurvy ✅
• D) Osteogenesis imperfecta

BONUS - Combined trap question (the hardest version):

Q3. Wimberger's sign is pathognomonic of which condition?

• A) Scurvy
• B) Rickets
• C) Congenital rubella
• D) Congenital syphilis ✅

IMAGE DIAGNOSIS ROUND - CASE SET

CASE 1 - "The Blueberry Baby"

1. 🫐 Blueberry muffin rash (purpuric/blue-red skin lesions all over body)
2. CXR - cardiomegaly with pulmonary plethora (PDA)
3. Eye photo - white pearly nuclear cataract

CASE 2 - "The Cherry Eye"

1. 🍒 Fundus photo - cherry red spot on macula
2. MRI brain - white matter changes, cerebral atrophy
3. Photo - macrocephaly, hypotonia

CASE 3 - "The Boot"

1. CXR - boot-shaped heart (coeur en sabot), oligaemic lung fields
2. ECG - right axis deviation + RVH
3. Echo/diagram - overriding aorta + VSD + pulmonary stenosis

CASE 4 - "The Soap Bubble Gut"

1. X-ray abdomen - pneumatosis intestinalis (soap bubble/linear gas in bowel wall)
2. X-ray - portal venous gas (branching lucencies over liver)
3. X-ray - pneumoperitoneum (free air under diaphragm)

CASE 5 - "Koplik's Clue"

1. Koplik spots - white spots on buccal mucosa (like grains of salt on red background)
2. Child's face - maculopapular rash spreading downward
3. Eye photo - conjunctivitis + Bitot-like appearance (photophobia)

CASE 6 - "The Steeple vs The Thumb"

1. X-ray neck AP - steeple sign (subglottic narrowing) → Croup
2. X-ray neck lateral - thumb sign (swollen epiglottis) → Epiglottitis
3. Endoscopy/laryngoscopy image - cherry red swollen epiglottis

CASE 7 - "The Sunset Eyes"

1. Clinical photo - sunset sign (eyes deviated downward, sclera visible above iris)
2. CT head - enlarged ventricles (hydrocephalus)
3. Transillumination - glowing skull (hydrocephalus / hydranencephaly)

CASE 8 - "The Sausage Finger Abdomen"

1. Ultrasound abdomen - target sign / doughnut sign (bowel within bowel)
2. X-ray abdomen - soft tissue mass in RUQ, absent gas in RIF
3. Barium/air enema - coiled spring sign

CASE 9 - "The Snowman Heart"

1. CXR - snowman/figure-of-8 heart (superior mediastinum widened = dilated vertical vein + SVC)
2. CXR comparison - egg-on-side (TGA) for contrast
3. Echo - all pulmonary veins draining into systemic circulation

CASE 10 - "The Moth-Eaten Bone"

1. CT abdomen - large unilateral renal mass with displacement of bowel (not crossing midline)
2. Histology - triphasic pattern (blastemal + stromal + epithelial components)
3. CXR - pulmonary metastases ("cannonball lesions")

CASE 11 - "The Café au Lait Spots"

1. Skin photo - 6+ café au lait macules (>5mm, smooth "coast of California" borders)
2. Slit lamp - Lisch nodules (pigmented iris hamartomas)
3. MRI orbit/brain - optic pathway glioma

CASE 12 - "The Hair on End"

1. Skull X-ray - hair-on-end appearance (perpendicular bone spicules)
2. Face photo - chipmunk facies (maxillary hypertrophy, frontal bossing)
3. Peripheral smear - target cells + nucleated RBCs + hypochromic microcytic anemia

QUICK REFERENCE: IMAGE-TO-DIAGNOSIS CHEAT SHEET