Q6. The most common birth-related nerve injury is:

Q7. The most severe HDN (Hemolytic Disease of the Newborn) occurs due to:

Q8. WHO defines fast breathing in a child aged 2-12 months as respiratory rate >

• < 2 months: fast breathing = RR > 60/min
• 2-12 months: fast breathing = RR > 50/min
• 12 months - 5 years: fast breathing = RR > 40/min

Q9. Maternal supplementation with which vitamin prevents neural tube defects?

Q10. The commonest cause of isolated thrombocytopenia in an otherwise healthy child is:

Summary Table

SECTION "B" - Short Answer Questions (5 marks each)

a) Neonatal Sepsis [5 marks]

• Premature rupture of membranes (PROM)
• Maternal fever, GBS-positive vaginal swabs
• Low birth weight, prematurity, invasive procedures

• Temperature instability - fever (rectal temp ≥38°C) or hypothermia (<36.5°C)
• CNS dysfunction - lethargy, irritability, seizures
• Respiratory distress - apnea, tachypnea, grunting
• Feeding disturbance - vomiting, poor feeding, abdominal distension
• Jaundice, rashes, sclerema

• Early-onset: Group B Streptococcus (GBS), E. coli, Listeria monocytogenes, Klebsiella
• Late-onset: Staphylococcus aureus, Coagulase-negative Staphylococci, gram-negative organisms
• Viral: Enteroviruses (coxsackievirus, echovirus), RSV

• Blood culture (gold standard), CBC with differential, CRP, blood glucose
• Lumbar puncture (CSF analysis), urine culture
• Chest X-ray, serum electrolytes

• Empiric antibiotics: Ampicillin + Gentamicin (first-line)
• Cefotaxime if meningitis suspected
• Duration: 10-14 days; 21 days for meningitis
• Supportive: IV fluids, oxygen, temperature regulation, glucose monitoring

b) Hemorrhagic Disease of the Newborn (HDN) [5 marks]

• Poor placental transfer of vitamin K
• Low vitamin K content in breast milk (human milk = only ~1/5 of daily requirement)
• Maternal drugs interfering with vitamin K: phenytoin, warfarin, rifampicin, isoniazid
• Absence of gut flora in the newborn

• Bleeding from GI tract (melena, hematemesis), umbilical stump, circumcision site
• Cephalohematoma, intracranial hemorrhage (late form - most severe)
• Pallor, prolonged bleeding from venepuncture sites
• Subarachnoid or intraparenchymal hemorrhage - neurological complications

• Prolonged PT and aPTT, normal platelet count and bleeding time
• Low clotting factors II, VII, IX, X
• Normal fibrinogen (differentiates from DIC)

• Vitamin K1 (Phytonadione):
  • Mild: 1-2 mg IV/IM, repeated after 4-6 hours
  • Severe/intracranial bleed: Fresh Frozen Plasma (FFP) 10-15 mL/kg immediately + Vitamin K
• Supportive: blood transfusion if required

• All newborns: Vitamin K1 1 mg IM at birth (single dose - gold standard)
• Oral Vitamin K: 2 mg at birth, repeat at 1 week and 1 month (if IM refused)
• All breastfed infants should receive prophylaxis regardless

c) Neural Tube Defect (NTD) [5 marks]

• Folic acid deficiency (most important preventable cause)
• Maternal diabetes, obesity, hyperthermia
• Valproate, carbamazepine (anticonvulsant use)
• Genetic factors, previous NTD-affected pregnancy

• Anencephaly: Absence of cerebral hemispheres and cranial vault; incompatible with life
• Encephalocele: Herniation of brain tissue through a skull defect

• Visible sac over lumbar/lumbosacral spine
• Lower limb weakness/paralysis, sensory loss
• Bladder and bowel dysfunction (neurogenic bladder)
• Hydrocephalus (associated with Arnold-Chiari malformation)

• Prenatal: Elevated maternal serum AFP, amniocentesis, fetal ultrasound (18-20 weeks)
• Postnatal: MRI spine and brain, ultrasound

• Surgical closure within 24-72 hours of birth (prevent infection)
• Hydrocephalus: VP shunt
• Physiotherapy, clean intermittent catheterization for neurogenic bladder
• Multidisciplinary care (neurosurgery, urology, orthopedics)

• Folic acid 0.4 mg/day for all women of childbearing age (at least 1 month before conception and through first trimester)
• High-risk women (previous NTD child, anticonvulsant use): 5 mg/day folic acid

d) Acute Rheumatic Fever (ARF) [5 marks]

• Joints - Migratory polyarthritis (most common manifestation)
• O - Carditis (pancarditis; most serious; mitral regurgitation most common murmur)
• N - Nodules (subcutaneous, firm, painless, over bony prominences)
• E - Erythema marginatum (fleeting, non-pruritic skin rash on trunk)
• S - Sydenham's chorea (St. Vitus' dance; involuntary, purposeless movements)

• Fever, arthralgia
• Elevated ESR / CRP
• Prolonged PR interval on ECG

• Elevated/rising ASO titer (most common test used)
• Positive throat culture for GABHS
• Positive rapid streptococcal antigen test

• ASO titer (elevated in >80% cases), throat swab culture
• ESR, CRP, CBC, ECG (prolonged PR), 2D Echo (valvular involvement)

• Benzathine Penicillin G 1.2 million units IM single dose (or Oral Penicillin V 10 days)
• Erythromycin if penicillin-allergic

• Arthritis alone: Aspirin 100 mg/kg/day in divided doses x 4-6 weeks
• Carditis: Prednisolone 2 mg/kg/day x 2-3 weeks, then taper

• Benzathine Penicillin G 1.2 million units IM every 3-4 weeks
• Duration: 10 years or until age 21 (no carditis); lifetime if severe carditis with valve disease

e) Urinary Tract Infection (UTI) in Children [5 marks]

• Upper UTI (Pyelonephritis): Fever, loin pain, renal involvement; risk of renal scarring
• Lower UTI (Cystitis): Dysuria, frequency, no fever; no renal scarring

• Most common: E. coli (>80%)
• Others: Klebsiella, Proteus mirabilis, Enterococcus, Staphylococcus saprophyticus
• Predisposing factors: Vesicoureteral reflux (VUR), posterior urethral valves, constipation, female sex, uncircumcised males, urinary stasis

• Neonates/Infants: Non-specific - fever, poor feeding, vomiting, jaundice, failure to thrive
• Older children: Dysuria, frequency, urgency, suprapubic pain, hematuria
• Pyelonephritis: High fever (>38.5°C), rigors, vomiting, loin/flank pain, CVA tenderness

• Urine routine and microscopy: pyuria (>5 WBC/HPF), bacteriuria
• Urine culture and sensitivity (gold standard): clean catch midstream or suprapubic aspiration in infants
• CBC, CRP, blood culture (if toxic/< 2 months)
• Renal ultrasound (all first UTI), VCUG/MCU (for VUR), DMSA scan (cortical scarring)

• Oral (uncomplicated/older children): Cotrimoxazole, nitrofurantoin, or cephalexin x 5-7 days
• Pyelonephritis/neonates/toxic children: IV Ceftriaxone or Ampicillin + Gentamicin for 10-14 days, then step down to oral

• Good perineal hygiene, adequate hydration, regular voiding, treat constipation, circumcision in boys with recurrent UTI/VUR

f) Status Asthmaticus [5 marks]

• ABG (most important - rising CO2 = impending failure), SpO2, peak flow
• CXR (exclude pneumothorax, pneumonia), CBC, electrolytes (hypokalemia from salbutamol)
• ECG in severe cases

• Oxygen: High flow to maintain SpO2 >94%
• Salbutamol (albuterol): 2.5-5 mg nebulized every 20 min x 3 doses (1st hour)
• Ipratropium bromide 0.25-0.5 mg nebulized (add to salbutamol, first 2 hours)

• Prednisolone 1-2 mg/kg oral (max 40 mg) OR
• Hydrocortisone 4-6 mg/kg IV if unable to take orally

• IV Magnesium Sulfate 25-75 mg/kg (max 2 g) over 20 minutes - causes bronchodilation
• IV Salbutamol infusion
• Heliox (helium-oxygen mixture) to reduce airway resistance

• Respiratory arrest, exhaustion, rising PaCO2, worsening consciousness, SpO2 <90% despite O2
• Mechanical ventilation: permissive hypercapnia strategy

• Continuous SpO2, heart rate, PEFR every 1-2 hours, ABG, electrolytes

SECTION "C" - Long Answer Question (15 marks)

Congestive Cardiac Failure (CCF) in Children [15 marks]

1. Definition [1 mark]

2. Classification [2 marks]

• Acute CCF: Sudden onset (myocarditis, arrhythmia, acute rheumatic fever)
• Chronic CCF: Gradual onset (congenital heart disease - most common cause in children)

• Left heart failure: Pulmonary venous congestion - dyspnea, orthopnea, pulmonary edema
• Right heart failure: Systemic venous congestion - hepatomegaly, edema, JVD
• Biventricular (Congestive): Both sides (most common in children)

3. Causes [3 marks]

• Left-to-right shunts (volume overload): VSD (most common congenital heart defect), ASD, PDA, AVSD
• Obstructive lesions (pressure overload): Aortic stenosis, Pulmonary stenosis, Coarctation of aorta
• Complex/cyanotic CHD: Tetralogy of Fallot (after repair), Transposition of great arteries

• Myocarditis (viral - Coxsackie B, adenovirus; most common acquired cause)
• Dilated Cardiomyopathy
• Acute Rheumatic Fever (carditis)
• Infective Endocarditis
• Kawasaki disease (coronary artery aneurysm/MI)

• Severe anemia (high-output failure) - most common non-cardiac cause in India
• Hypertension (hypertensive crisis)
• Arrhythmias (SVT, complete heart block)
• Thyrotoxicosis, sepsis

4. Pathophysiology [2 marks]

1. Sympathetic activation: Tachycardia, vasoconstriction (increases afterload, increases myocardial O2 demand)
2. RAAS activation: Renin → Angiotensin II → Aldosterone → Na and water retention → increased preload → edema and congestion
3. Frank-Starling mechanism: Increased preload → increased stroke volume (limited; eventually fails)
4. Ventricular hypertrophy/remodeling: Initially compensatory, eventually leads to worsening dysfunction

5. Clinical Features [3 marks]

• Poor feeding, failure to thrive (most common symptom in infants)
• Tachycardia (>160/min), tachypnea (>60/min), grunting
• Sweating during feeding (due to increased sympathetic activity)
• Hepatomegaly (cardinal sign - most sensitive sign in children)
• Pulmonary congestion: Wheeze, crepitations, respiratory distress
• Periorbital edema (dependent edema in infants)

• Dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea
• Exercise intolerance, fatigue, poor weight gain
• Peripheral pitting edema (pedal edema), ascites
• Raised JVP, gallop rhythm (S3), cardiomegaly

• Cardiomegaly (displaced apex beat)
• Gallop rhythm (S3 - most important auscultatory sign)
• Tender hepatomegaly (right heart failure)
• Basal crackles (left heart failure)

6. Investigations [2 marks]

7. Management [2 marks]

• Rest, head-end elevation (30-45 degrees), oxygen supplementation
• Fluid restriction, salt restriction in older children
• Treat precipitating cause (infection, anemia, arrhythmia)

• Furosemide (Loop diuretic): 1-2 mg/kg/dose IV or oral - reduces preload
• Spironolactone (Aldosterone antagonist): 2-3 mg/kg/day - potassium-sparing, reduces remodeling

• Digitalizing dose: 30-40 mcg/kg oral over 24 hours
• Maintenance: 10 mcg/kg/day in 2 divided doses
• Monitor for toxicity: bradycardia, arrhythmia, nausea, vomiting

• Captopril: 0.5-1 mg/kg/day in 3 divided doses
• Enalapril: 0.1 mg/kg/day; reduces mortality and hospitalizations

• Carvedilol: 0.1 mg/kg/dose, titrate up slowly

• Dobutamine infusion (2-20 mcg/kg/min) or Dopamine (5-20 mcg/kg/min) in ICU

• Surgical correction of underlying CHD (VSD closure, valve repair, Fontan procedure)
• Cardiac resynchronization therapy (CRT) for dyssynchrony
• Cardiac transplantation: End-stage refractory CCF

Reference: Nelson Textbook of Pediatrics (21st Ed.) | OP Ghai's Textbook of Pediatrics (9th Ed.) | IAP Textbook of Pediatrics