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📋 Pediatric Study Notes

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1. 🫁 Respiratory

Key Pediatric Respiratory Conditions

Pediatric ARDS (PARDS) — PALICC 2015 Definition

• Onset: Within 7 days of known insult; excludes perinatal lung disease in neonates
• Criteria: New infiltrates on CXR + hypoxemia not explained by cardiac failure or fluid overload
• Severity (mechanically ventilated):
  • Mild: OI 4–8 or OSI 5–7.5
  • Moderate: OI 8–16 or OSI 7.5–12.3
  • Severe: OI ≥ 16 or OSI ≥ 12.3
• OI formula: (FiO₂ × MAP × 100) / PaO₂
• Ventilation principles: Low tidal volumes (5–8 mL/kg PBW; 3–6 mL/kg in poor compliance), adequate PEEP, permissive hypercapnia, tolerance of mild hypoxemia

Respiratory Rate Norms

WHO Tachypnea Thresholds (Pneumonia screening)

• < 2 months: ≥ 60/min
• 2–12 months: ≥ 50/min
• 1–5 years: ≥ 40/min

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2. 🥗 Nutrition

Macronutrient Requirements (Children)

• Protein: 1.5–2 g/kg/day (infant), 1.0–1.5 g/kg/day (toddler)
• Fat: 40–55% of energy in first 6 months; 30–40% by school age
• Carbohydrates: 45–65% total energy

Malnutrition Classification (WHO)

Anthropometric Indicators

• Weight-for-age Z score (WAZ): underweight screening
• Height-for-age (HAZ): stunting (chronic malnutrition)
• Weight-for-height (WHZ): wasting (acute malnutrition)
• Severe acute malnutrition (SAM): WHZ < −3 SD or MUAC < 11.5 cm or bilateral pitting edema

Pediatric Nutritional Assessment

• Nutritional Risk Screening (NRS), Pediatric Nutritional Risk Score (PNRS)
• Enteral preferred over parenteral when GI tract functional

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3. 💊 Micronutrients

Critical Micronutrients in Pediatrics

Vitamin D in Infants

• Supplement: 400 IU/day from birth for all breastfed infants (AAP)
• Deficiency threshold: 25(OH)D < 20 ng/mL; insufficiency < 30 ng/mL
• Rickets: Craniotabes, rachitic rosary, bowing of legs, widened wrists

Iron Supplementation

• Preterm/LBW infants: start at 2–4 weeks (2 mg/kg/day elemental iron)
• Term breastfed infants: supplement at 4 months if no complementary foods

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4. 🏥 NICU (Neonatal Intensive Care Unit)

Common NICU Admissions

• Prematurity (< 37 weeks)
• Respiratory Distress Syndrome (RDS)
• Transient Tachypnea of the Newborn (TTN)
• Neonatal Sepsis
• Hypoxic Ischemic Encephalopathy (HIE)
• Necrotizing Enterocolitis (NEC)
• Hyperbilirubinemia

Respiratory Distress Syndrome (RDS)

• Cause: Surfactant deficiency in premature lungs (type II pneumocytes immature)
• Risk factors: Prematurity, male sex, maternal diabetes, cesarean birth
• Management: Surfactant replacement, CPAP/MV, oxygen, antenatal steroids (betamethasone)

Neonatal Sepsis

• Early-onset (< 72 h): Group B Streptococcus, E. coli (maternal flora)
• Late-onset (> 72 h): Staphylococci, gram-negatives (nosocomial)
• Signs: Temperature instability, apnea, poor feeding, lethargy, bulging fontanelle
• Treatment: Empiric ampicillin + gentamicin (early); vancomycin + broad-spectrum (late)

HIE Management

• Therapeutic hypothermia (33–34°C for 72 hours) in term infants ≥ 36 weeks
• Start within 6 hours of birth
• Monitoring: aEEG, seizure management with phenobarbital

Necrotizing Enterocolitis (NEC)

• Pathology: Bacterial invasion of ischemic intestinal wall
• Bell Staging: I (suspect), II (proven), III (advanced with perforation)
• Treatment: NPO, NG decompression, IV antibiotics (metronidazole + ampicillin + gentamicin), surgical for perforation

NICU Nutrition

• Parenteral nutrition started within hours of birth in VLBW (<1500 g) infants
• Breast milk preferred (protective against NEC)
• TPN components: Glucose, amino acids (3.5–4 g/kg/day), lipids (Intralipid 3.5 g/kg/day)
• Fortified breast milk used when infant < 34 weeks or < 1500 g

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5. 📈 Growth and Development

Growth Faltering / Failure to Thrive

• Weight < 5th percentile or drop across ≥ 2 major centile lines
• Organic causes: Cardiac, renal, GI, endocrine, genetic
• Non-organic: Psychosocial, neglect, inadequate feeding

Developmental Milestones

Red Flags

• No social smile by 3 months
• No babbling by 12 months
• No single words by 16 months
• Loss of any previously acquired skill at any age → immediate evaluation

Growth Hormone (GH) Axis

• GH stimulates IGF-1 (from liver)
• GH deficiency: proportionate short stature, hypoglycemia in neonates, delayed bone age
• Precocious puberty: girls < 8 years, boys < 9 years (central vs. peripheral)

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6. 💉 Immunization

Key Vaccines and Schedule (AAP/WHO-aligned)

Vaccine Types

Contraindications

• Live vaccines: immunocompromised, pregnancy, anaphylaxis to vaccine components
• Rotavirus: history of intussusception or SCID

Cold Chain

• Most vaccines: 2–8°C; varicella/MMR can be stored frozen
• Temperature excursions invalidate vaccine potency

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7. 🥣 Complementary Feeding

Definition

Principles of Complementary Feeding (WHO IYCF)

1. Start at 6 months (not before 4 months)
2. Continue breastfeeding through ≥ 2 years
3. Responsive feeding — feed on hunger/satiety cues
4. Appropriate texture progression: purée → mashed → finger foods
5. Meal frequency:
   • 6–8 months: 2–3 meals/day
   • 9–11 months: 3–4 meals/day
   • 12–24 months: 3–4 meals + 1–2 snacks

Dietary Diversity

• Minimum dietary diversity: ≥ 4 out of 8 food groups/day
• Food groups: breast milk, grains, legumes/nuts, dairy, flesh foods, eggs, Vitamin A-rich veg/fruits, other fruits/vegetables

First Foods

• Iron-rich foods recommended first (iron-fortified cereal, pureed meat)
• Allergen introduction: current evidence supports early introduction of common allergens (peanut, egg) to reduce sensitization risk
• Avoid: honey (< 12 months — botulism risk), whole cow's milk as main drink (< 12 months), salt/sugar, choking hazards (whole grapes, nuts)

Common Pitfalls

• Starting too early (< 4 months) → ↑ obesity, GI infection, allergy risk
• Delaying beyond 7 months → ↑ iron deficiency, feeding difficulties

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8. 🤱 Breastfeeding and Lactation

WHO/AAP Recommendations

• Exclusive breastfeeding: birth to 6 months
• Continued breastfeeding with complementary foods: up to 2 years or beyond

Composition of Breast Milk

Immunological Benefits

• sIgA: primary immune protection of gut
• Lactoferrin, lysozyme: antimicrobial
• HMOs (human milk oligosaccharides): prebiotic, anti-adhesion to pathogens
• Live cells: macrophages, T-lymphocytes, stem cells
• Reduces risk: otitis media, NEC, SIDS, respiratory infections, GI infections

Maternal Benefits

• Faster uterine involution
• Reduced risk of breast and ovarian cancer
• Weight loss, lactational amenorrhea

Latching and Common Issues

Breastfeeding Contraindications

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9. 🧠 Cerebral Palsy

Definition

Etiology

• Prenatal (80%): Brain malformations, congenital infections (TORCH), genetic, hypoxia
• Perinatal (10%): Hypoxic-ischemic encephalopathy, prematurity, intracranial hemorrhage
• Postnatal (10%): Meningitis, head trauma, stroke

Classification (Motor Type)

Topographic Distribution

• Hemiplegia: one side (upper > lower limb)
• Diplegia: lower limbs predominant (associated with prematurity/periventricular leukomalacia)
• Quadriplegia/Tetraplegia: all four limbs; most severe, often intellectual disability

Associated Impairments

• Intellectual disability (30–50%)
• Epilepsy (25–35%)
• Communication disorders
• Feeding/swallowing difficulties (dysphagia)
• Visual impairment (strabismus, cortical blindness)
• Urological dysfunction: detrusor overactivity, urinary incontinence (~36%), increased risk in spastic tetraplegia; adult patients warrant full urodynamic evaluation due to risk of renal damage (Campbell Walsh Wein Urology)

Management

• Multidisciplinary: physiotherapy, occupational therapy, speech/language therapy
• Spasticity: botulinum toxin injections, baclofen (oral/intrathecal), orthotic devices
• Epilepsy: antiepileptic drugs
• Surgical: selective dorsal rhizotomy, tendon lengthening/transfer
• Nutrition: gastrostomy if severe dysphagia

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10. 📚 Learning Disorders

Definition (DSM-5)

Subtypes

Dyslexia (Most Common)

• Prevalence: 5–17% of school-age children
• Neurobiological basis: phonological processing deficit, abnormal left hemisphere activation
• Signs: trouble rhyming, letter reversals, slow reading, poor spelling
• Assessment: psychoeducational testing (cognitive + academic achievement)
• Intervention: structured literacy (Orton-Gillingham-based programs), multisensory approaches

Associated Conditions

• ADHD (50% comorbidity with SLD)
• Developmental Coordination Disorder (DCD)
• Speech and Language Disorders
• Anxiety and depression (secondary)

Principles of Management

1. Early identification and intervention (ideally before age 8)
2. Educational accommodations (extended time, reduced copying)
3. Treat comorbid ADHD if present
4. Psychological support for self-esteem
5. Avoid labeling as "lazy" or "unintelligent"

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11. 🩸 Iron Deficiency Anemia (IDA)

Epidemiology

• Most common nutritional deficiency worldwide
• Affects ~10% in high-income countries; 25–50% in low-income countries
• Peak risk: infants 6–24 months, adolescent girls

Iron Metabolism

• Total body iron: ~2.5 g (women), ~3.5 g (men)
• 80%: Hemoglobin, myoglobin, and enzymes (catalase, cytochromes)
• 15–20%: Storage as ferritin and hemosiderin (liver, spleen, bone marrow)
• Transport: Transferrin (~33% saturation normally; serum iron ~100–120 µg/dL; TIBC ~300–350 µg/dL)

Iron Absorption

• Regulated in the duodenum
• Ferrous iron (Fe²⁺) absorbed via DMT-1 (divalent metal transporter)
• Exported basolaterally via ferroportin; oxidized to Fe³⁺ by hephaestin → binds transferrin
• Hepcidin (liver peptide): negatively regulates ferroportin → ↑ hepcidin = ↓ absorption
• Dietary iron: ~20% heme absorbed; 1–2% non-heme absorbed
• Vitamin C enhances non-heme iron absorption; tea/coffee/calcium inhibit absorption (Robbins & Kumar Basic Pathology)

Stages of Iron Deficiency

Clinical Features

• Pallor (conjunctiva, palms, mucous membranes)
• Fatigue, irritability, reduced exercise tolerance
• Pica (eating non-food items — ice, dirt, clay)
• Koilonychia (spoon-shaped nails)
• Glossitis, angular stomatitis
• Cognitive and developmental delay (especially if < 2 years)
• Cardiac: systolic ejection murmur in severe anemia

CBC Findings

• Hb < 11 g/dL (< 2 yr), < 11.5 g/dL (2–5 yr), < 12 g/dL (5–12 yr)
• MCV ↓ (microcytic); MCH ↓ (hypochromic)
• Serum ferritin ↓ (best early marker)
• TIBC ↑; transferrin saturation ↓ (< 16%)
• RDW ↑ (anisocytosis)
• Reticulocyte count low (hypoproliferative)

Treatment

• Dietary: iron-rich foods (meat, legumes, fortified cereals), Vitamin C with meals
• Elemental iron: 3–6 mg/kg/day in 2–3 divided doses for 3 months
• Follow-up: Hb should rise by 1 g/dL after 4 weeks of treatment
• Continue treatment for 3 months after normalization of Hb to replenish stores
• IV iron (ferric carboxymaltose/ferrous sucrose): if oral intolerance, malabsorption, or non-compliance
• Investigate underlying cause: bleeding, malabsorption, dietary inadequacy

Prevention

• Promote breastfeeding + timely complementary foods rich in iron
• Iron-fortified formulas for non-breastfed infants
• Universal iron supplementation for preterm/LBW infants
• Iron supplementation in adolescent girls in endemic areas (WHO: weekly supplementation)

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Quick Reference Summary Table

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