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First Pass Metabolism

Presentation · PPTX

What's Inside (12 Slides)

Slide	Content
1	Title Slide - Bold navy/red design
2	Learning Objectives - 6 key goals
3	Definition - Presystemic elimination explained with textbook-quoted definition
4	Anatomical Pathway - 5-step process flow: Oral ingestion → GI absorption → Portal vein → Hepatic extraction → Systemic circulation
5	Bioavailability & Extraction Ratio - Formula panels: F = AUC(oral)/AUC(IV) and ER = (C_in - C_out)/C_in, with drug examples
6	Sites & Enzymes - Gut wall (CYP3A4, P-gp), Liver (Phase I & II), Lung (pulmonary first-pass)
7	High First-Pass Drugs Table - Nitroglycerin, Morphine, Lidocaine, Propranolol, Verapamil, Isoniazid, Naloxone, Testosterone
8	Bypass Routes - Sublingual, IV, Transdermal, Inhalation, Rectal, IM/SC with bypass extent for each
9	Clinical Consequences - Liver disease (cirrhosis) effects + dosing implications, enzyme inducers/inhibitors
10	Prodrugs - Enalapril, Codeine, Levodopa, Clopidogrel, Prednisone with activation mechanisms
11	Factors Affecting First-Pass - Genetics, disease states, drug interactions, physiological factors
12	Key Takeaways - 5 high-yield summary points

Sources: Lippincott Pharmacology, Katzung's Basic & Clinical Pharmacology, Goodman & Gilman's, Harrison's Internal Medicine.

Comprehensive notes on first pass metabolism

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First Pass Metabolism - Comprehensive Notes

1. Definition & Terminology

First-pass metabolism (also called presystemic elimination or the first-pass effect) refers to the biotransformation of an orally administered drug that occurs before it reaches the systemic circulation. When a drug is absorbed from the GI tract, it enters the portal circulation and passes through the liver before reaching any other tissue. If the drug is rapidly metabolized during this initial passage - in the gut wall or liver - the amount of unchanged (active) drug entering the systemic circulation is reduced.

"Some drugs that are administered orally are absorbed relatively efficiently into the portal circulation but are metabolized by the liver before they reach the systemic circulation. Because of this 'first-pass' or 'presystemic' effect, the oral route may be less suitable than other routes of administration for such drugs."

Goldman-Cecil Medicine

2. Anatomical Basis

First-pass metabolism pathway showing oral vs IV routes

Figure: Oral drugs pass through the portal circulation to the liver before entering systemic circulation, while IV drugs bypass this pathway entirely. - Lippincott Pharmacology, Fig. 1.11

The complete pathway for an oral drug is:

Oral ingestion
    ↓
GI lumen (dissolution)
    ↓
Intestinal epithelium (gut wall metabolism, P-gp efflux)
    ↓
Mesenteric capillaries → Portal vein
    ↓
Liver (Phase I & II metabolism)
    ↓
Hepatic veins → Inferior vena cava
    ↓
Systemic circulation (heart → target organs)

By contrast, IV-administered drugs enter directly into the systemic circulation, bypassing this entire pathway and achieving 100% bioavailability.

3. Sites of First-Pass Metabolism

3.1 Gut Wall (Enterocytes)

CYP3A4 is highly expressed in intestinal enterocytes and is responsible for significant presystemic metabolism of many drugs (e.g., cyclosporine, midazolam, felodipine).
P-glycoprotein (P-gp), an efflux transporter, pumps absorbed drug molecules back into the intestinal lumen, reducing net absorption and contributing to first-pass loss. P-gp inhibitors (e.g., quinidine, grapefruit juice) can dramatically increase bioavailability.
UDP-glucuronosyltransferases (UGTs) in the gut wall also contribute to conjugation reactions.

3.2 Liver (Primary Site)

The liver receives the portal blood directly and contains the highest concentration of drug-metabolizing enzymes.
Phase I reactions: Oxidation, reduction, and hydrolysis via cytochrome P450 enzymes (CYP1A2, CYP2C9, CYP2C19, CYP2D6, CYP3A4).
Phase II reactions: Glucuronidation, sulfation, acetylation, methylation - conjugation reactions that generally render metabolites more water-soluble and inactive (though some conjugates remain active).
The degree of hepatic first-pass depends on intrinsic clearance (CL_i) - the liver's inherent enzyme capacity - and hepatic blood flow (Q).

3.3 Lung (Pulmonary First-Pass)

Relevant primarily for drugs administered via non-oral parenteral routes (IV, transdermal).
Monoamine oxidase (MAO) in the lung degrades catecholamines and tyramine.
"Although drugs administered by inhalation bypass the hepatic first-pass effect, the lung may also serve as a site of first-pass loss by excretion and possibly metabolism for drugs administered by nongastrointestinal routes." - Katzung's

4. Bioavailability and the First-Pass Effect

Bioavailability (F) is the fraction of an administered dose that reaches the systemic circulation unchanged.

$$F = \frac{AUC_{oral}}{AUC_{IV}} \times 100%$$

IV administration: F = 100% (by definition)
Oral administration: F < 100% due to incomplete absorption AND first-pass metabolism

When first-pass metabolism is significant, the modified steady-state equation becomes:

$$F \times \text{Dosing rate} = CL \times C_{ss}$$

This means oral doses must be proportionally higher than IV doses to achieve equivalent plasma concentrations.

Classic example: Nitroglycerin is well absorbed but >90% is cleared during hepatic first-pass. It cannot be given orally in standard doses; sublingual or transdermal routes are required.

5. Extraction Ratio (ER)

The extraction ratio is the fraction of drug removed from the blood during a single pass through the liver:

$$ER = \frac{C_{in} - C_{out}}{C_{in}}$$

Where C_in = drug concentration entering the liver (portal vein), C_out = drug concentration leaving (hepatic vein).

Hepatic clearance is related to hepatic blood flow and ER:

$$CL_H = Q \times ER = Q \times \left(\frac{CL_i}{Q + CL_i}\right)$$

Where Q = hepatic blood flow (~1.5 L/min), CL_i = intrinsic clearance.

Classification by Extraction Ratio

Category	ER	Bioavailability	Key Determinant	Examples
High ER	> 0.7	Low (< 30%)	Hepatic blood flow	Morphine, propranolol, lidocaine, verapamil, isoniazid, labetalol, metoprolol
Intermediate ER	0.3-0.7	Variable	Both flow + enzymes	Aspirin, codeine, nortriptyline
Low ER	< 0.3	High (> 70%)	Enzyme activity, protein binding	Warfarin, diazepam, phenytoin, theophylline, tolbutamide, chlorpropamide

Key relationship: For high-ER drugs:

Hepatic clearance is flow-dependent - directly proportional to hepatic blood flow
Any change in blood flow (heart failure, cirrhosis, surgery) dramatically changes clearance
Increasing intrinsic clearance (enzyme induction) has little effect on clearance once ER is already near 1.0

For low-ER drugs:

Hepatic clearance is capacity-limited (restrictive)
Affected by enzyme inducers/inhibitors, protein binding, age, liver disease
NOT significantly affected by hepatic blood flow changes

"Drugs with a high extraction ratio (greater than 0.7) undergo extensive first-pass metabolism, which alters their bioavailability after oral administration. Regardless of the route of administration, drugs with high extraction ratios are significantly affected by alteration in hepatic blood flow." - Barash's Clinical Anesthesia

6. Specific Drug Examples

Drug	Class	Oral Bioavailability	Reason for Low Bioavailability
Nitroglycerin	Antianginal	< 10%	>90% hepatic first-pass; given SL/transdermal/IV
Morphine	Opioid	~20-40%	Extensive glucuronidation in liver
Lidocaine	Antiarrhythmic	~35%	Never given orally; toxic metabolites (MEGX, GX) accumulate
Propranolol	Beta-blocker	~25%	High ER; marked inter-individual variability
Verapamil	CCB/antiarrhythmic	~20-35%	CYP3A4 metabolism; oral dose > IV dose for same effect
Isoniazid	Antitubercular	Variable	Acetylation polymorphism (NAT2 gene)
Naloxone	Opioid antagonist	< 2%	Near-complete first-pass; IV/IM/intranasal use only
Testosterone	Androgen	< 10%	Extensive hepatic first-pass; requires esterification
Meperidine	Opioid	Variable	Active metabolite normeperidine accumulates

"Lidocaine and verapamil are both used to treat cardiac arrhythmias and have bioavailability less than 40%, but lidocaine is never given orally because its metabolites are believed to contribute to central nervous system toxicity." - Katzung's

7. Routes Bypassing First-Pass Metabolism

Route	Bypass of Hepatic FPM	Mechanism	Examples
Sublingual / Buccal	Complete	Absorbed into systemic veins, not portal	Nitroglycerin SL, buprenorphine
Intravenous (IV)	Complete (100% F)	Direct systemic delivery	Morphine IV, lidocaine IV
Intramuscular (IM)	Complete	Systemic capillary absorption	Vaccines, depot formulations
Subcutaneous (SC)	Complete	Systemic capillary absorption	Insulin, heparin
Transdermal	Complete	Absorbed into systemic veins	Nitroglycerin patch, fentanyl patch, scopolamine
Inhalation	Bypasses hepatic FPM*	Pulmonary circulation direct to heart	Salbutamol, inhaled steroids
Rectal (lower)	~50% bypass	Inferior rectal veins → IVC; upper rectum drains to portal	Suppositories

Note on rectal route: "Drugs absorbed from suppositories in the lower rectum enter vessels that drain into the inferior vena cava, thus bypassing the liver. However, suppositories tend to move upward in the rectum into a region where veins that lead to the liver predominate. Thus, only about 50% of a rectal dose can be assumed to bypass the liver." - Katzung's

Note on inhaled corticosteroids: "Although a majority of the inhaled dose is deposited in the oropharynx and swallowed, inhaled corticosteroids are subject to first-pass metabolism in the liver and thus are remarkably free of other short-term complications in adults." - Katzung's

8. Prodrugs: Exploiting First-Pass Metabolism

Some drugs are administered as inactive prodrugs and rely on first-pass (or systemic) metabolism to generate the active compound. This strategy is used to improve oral bioavailability, GI tolerability, or tissue targeting.

Prodrug	Active Form	Activating Enzyme	Clinical Note
Enalapril	Enalaprilat	Hepatic esterases	Oral ester; enalaprilat itself has <10% oral bioavailability
Codeine	Morphine	CYP2D6 (O-demethylation)	Poor metabolizers (10% of Caucasians) lack analgesic effect
Clopidogrel	Active thiol metabolite	CYP2C19	Loss-of-function allele = reduced platelet inhibition ("clopidogrel resistance")
Levodopa	Dopamine	DOPA decarboxylase	Given with carbidopa to reduce peripheral conversion
Prednisone	Prednisolone	Hepatic 11β-HSD	Avoid in severe liver disease; give prednisolone directly
Tamoxifen	Endoxifen	CYP2D6	Poor CYP2D6 metabolizers may have reduced efficacy

9. Factors Modifying First-Pass Metabolism

9.1 Genetic Polymorphisms (Pharmacogenomics)

CYP2D6: Controls metabolism of codeine, metoprolol, tamoxifen, nortriptyline. Phenotypes: poor (PM), intermediate (IM), extensive (EM), ultra-rapid (UM) metabolizers.
- UMs may have dangerously high codeine → morphine conversion (toxicity risk)
- PMs may have exaggerated propranolol/metoprolol effects
CYP2C19: Affects clopidogrel, omeprazole, voriconazole. Loss-of-function alleles common in East Asians (~15-20%)
NAT2 acetylation polymorphism: Determines isoniazid first-pass in slow vs. fast acetylators

9.2 Hepatic Disease

Cirrhosis: Portosystemic shunting + reduced hepatocyte mass = dramatically increased oral bioavailability of high-ER drugs
"The oral bioavailability for high first-pass drugs such as morphine, meperidine, midazolam, and nifedipine is almost doubled in patients with cirrhosis, compared to those with normal liver function. Therefore, the size of the oral dose of such drugs should be reduced in this setting." - Harrison's, 22nd Ed
"Drugs with a low extraction ratio (less than 0.3) have restrictive hepatic clearance. Clearance of drugs in this class is affected by protein binding, the induction or inhibition of hepatic enzymes, age, and hepatic pathology, but clearance is not significantly affected by hepatic blood flow." - Barash's

9.3 Heart Failure & Hemodynamic Changes

Reduced hepatic blood flow → reduced clearance of high-ER drugs
Decreased gut perfusion → reduced drug absorption and first-pass exposure
During liver surgery with hepatic inflow clamping: first-pass drugs accumulate significantly

9.4 Chronic Kidney Disease (CKD)

"Increased absorption in patients with CKD from reduced first-pass metabolism is seen with some β-blockers, dextropropoxyphene, and dihydrocodeine." - Comprehensive Clinical Nephrology
Uremia can also alkalinize gastric pH (via salivary urea) and alter absorption
Metallic phosphate binders (Al/Ca/Mg salts) form nonabsorbable complexes, reducing absorption

9.5 Drug Interactions

Interaction	Effect on First-Pass	Clinical Consequence
Enzyme inducers (rifampicin, carbamazepine, phenytoin, St. John's Wort)	↑ First-pass	↓ Bioavailability → treatment failure
Enzyme inhibitors (clarithromycin, itraconazole, HIV protease inhibitors)	↓ First-pass	↑ Bioavailability → toxicity
Grapefruit juice (inhibits CYP3A4 + P-gp in gut)	↓ First-pass	↑ Bioavailability of felodipine, simvastatin, midazolam
P-gp inhibitors (quinidine, cyclosporine)	↓ Efflux from gut	↑ Absorption of P-gp substrates

9.6 Age

Neonates: CYP enzymes incompletely developed at birth; first-pass may be reduced, leading to accumulation
Elderly: Reduced liver mass and hepatic blood flow → lower first-pass for many drugs → higher bioavailability; doses should start lower
Sex: CYP3A4 activity is higher in women than men, leading to some sex-based pharmacokinetic differences

9.7 Food Effects

High-fat meals can increase portal blood flow and alter hepatic extraction
Food can either increase or decrease first-pass depending on the drug (e.g., food increases propranolol bioavailability by increasing hepatic blood flow)

10. Clinical Implications & Dosing

10.1 Oral-to-IV Dose Conversion

For high-ER drugs, the oral dose must be much larger than the IV dose to achieve the same effect:

Oral dose = IV dose / F

Example - Morphine: F ≈ 0.3 → Oral:IV ratio ≈ 3:1 (30 mg oral ≈ 10 mg IV)

10.2 Toxic Metabolite Accumulation

Even if therapeutic blood concentrations are reached by large oral doses, metabolite concentrations may be proportionally higher compared to IV administration
This is why lidocaine is never given orally - high oral doses needed for arrhythmia control would generate toxic levels of glycinexylidide (GX) and monoethylglycinexylidide (MEGX), causing CNS toxicity
Similarly, meperidine orally accumulates normeperidine (pro-convulsant)

10.3 Inter-individual Variability

"Drugs with high extraction ratios will show marked variations in bioavailability between subjects because of differences in hepatic function and blood flow." - Katzung's
This variability complicates dosing of propranolol, verapamil, metoprolol, and other high-ER drugs orally

10.4 Route Selection Strategy

When reliable drug delivery is required, bypass first-pass: use IV, sublingual, transdermal, or IM/SC
When prodrug activation is desired, oral route with intact hepatic function is needed (e.g., prednisone, enalapril)

11. Summary Table

Concept	Key Point
Definition	Metabolism of drug before reaching systemic circulation, primarily in gut wall and liver
Anatomical route	Oral → GI absorption → portal vein → liver → systemic
Main site	Liver (also gut wall; lung for parenteral drugs)
Main enzymes	CYP3A4, CYP2D6, CYP2C9, CYP2C19; Phase II: UGT, SULT
Bioavailability (F)	F = AUC_oral / AUC_IV; reduced by first-pass
Extraction ratio	ER = (C_in - C_out)/C_in; High ER = flow-dependent; Low ER = capacity-limited
High-ER drugs	Morphine, propranolol, lidocaine, verapamil, nitroglycerin, naloxone, isoniazid
Low-ER drugs	Warfarin, diazepam, phenytoin, theophylline, tolbutamide
Bypass routes	IV, SL, transdermal, IM/SC (complete); rectal ~50%; inhalation bypasses hepatic FPM
Liver disease	↑ Bioavailability of high-ER drugs (portosystemic shunts + reduced enzyme activity) → dose reduction needed
Prodrugs	Some drugs intentionally require first-pass activation (enalapril, codeine, clopidogrel)
Drug interactions	Enzyme inducers ↑ first-pass; inhibitors ↓ first-pass; grapefruit inhibits gut CYP3A4/P-gp

Sources:

Lippincott Illustrated Reviews: Pharmacology - Routes of administration & bioavailability
Katzung's Basic and Clinical Pharmacology, 16th Ed - Extraction ratio & bypass routes
Goodman & Gilman's The Pharmacological Basis of Therapeutics - Bioavailability equations
Goldman-Cecil Medicine - First-pass effect clinical definition
Harrison's Principles of Internal Medicine, 22nd Ed (2025) - Liver disease implications
Barash's Clinical Anesthesia, 9th Ed - Hepatic drug clearance kinetics
Comprehensive Clinical Nephrology, 7th Ed - CKD effects on first-pass

Pediatrics complete history taking

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Pediatric Complete History Taking

Pediatric history taking differs fundamentally from adult history taking. The clinician must simultaneously obtain information from the caregiver (parent/guardian) and, depending on age, the child themselves. The history must cover several domains unique to children: birth/perinatal history, developmental milestones, immunization status, feeding history, and school performance.

Structure of the Pediatric History

1. Identifying Data
2. Chief Complaint (CC)
3. History of Present Illness (HPI)
4. Birth & Perinatal History
5. Feeding & Nutritional History
6. Developmental History
7. Immunization History
8. Past Medical History (PMH)
9. Surgical History
10. Medications & Allergies
11. Family History (FH)
12. Social History (SH)
13. Review of Systems (ROS)

1. Identifying Data

Collected before the formal history begins:

Patient's full name
Age and date of birth (note: in neonates/infants, use days/weeks; in children <2 years, use months)
Sex / gender
Weight, height, head circumference (plotted on growth chart)
Race/ethnicity (relevant for certain genetic conditions: sickle cell, G6PD, Tay-Sachs)
Informant: Who is providing the history? Parent, guardian, grandparent, foster carer? Reliability of the historian should be noted.
Referred by: GP, specialist, self-referred?

2. Chief Complaint (CC)

Recorded in the informant's own words (not medical terminology)
"What brings your child here today?"
Note the duration alongside the complaint
In older children (>6-8 years), ask the child directly as well

Example: "My son has been running a high fever and pulling at his right ear for 3 days."

3. History of Present Illness (HPI)

Use SOCRATES or OLDCARTS framework, adapted for children:

Mnemonic	Component	Pediatric Adaptation
S	Site	Where is the pain/symptom? (ask child to point)
O	Onset	Sudden vs. gradual; time of day; what was child doing
C	Character	Burning, aching, colicky? Use child-friendly language
R	Radiation	Does it spread anywhere?
A	Associations	Fever, vomiting, rash, diarrhea, cough, feeding changes
T	Time course	Constant, intermittent, getting better/worse
E	Exacerbating/Relieving	What makes it better or worse? Feeding, position, time
S	Severity	Use pain scale (0-10 for >3 years; FLACC/Wong-Baker for younger)

Additional HPI Questions Specific to Children:

Sick contacts: playmates, siblings, school/daycare contacts with similar illness
Recent travel: domestic or international - relevant for infectious/parasitic disease
Animal/insect exposure: pets, farm animals, tick/mosquito bites
Recent medications given: paracetamol, ibuprofen, home remedies, traditional medicines
Change in feeding/appetite: breast/bottle refusal is a critical red flag in infants
Change in activity level: lethargy, irritability, change in cry (high-pitched = meningism)
Urinary output: number of wet nappies/diapers per day (key dehydration indicator in infants)
Bowel habits: frequency, consistency, blood/mucus in stool

4. Birth and Perinatal History

This section is unique to pediatrics and essential for infants and young children. It becomes less relevant but still noteworthy in older children with developmental/neurological problems.

4.1 Antenatal History

Maternal age at time of pregnancy
Gravida and Para: G_P_ (number of pregnancies, deliveries)
Prenatal care: When did antenatal care begin? Regular or irregular?
Maternal health during pregnancy:
- Infections: TORCH (Toxoplasma, Rubella, CMV, HSV, Syphilis, HIV, Varicella, Zika)
- Gestational diabetes: risk of macrosomia, neonatal hypoglycemia
- Hypertension / pre-eclampsia: risk of IUGR, preterm delivery
- Thyroid disease, epilepsy (teratogenic medications)
- Urinary tract infections
Medications and substances during pregnancy:
- Folic acid supplementation (neural tube defect prevention)
- Teratogens: alcohol (FAS), valproate, warfarin, isotretinoin, thalidomide
- Illicit drug use: opioids (neonatal abstinence syndrome), cocaine
- Smoking: IUGR, SIDS risk
Investigations during pregnancy:
- Anomaly scans (20-week scan): structural abnormalities
- First trimester screening (nuchal translucency, PAPP-A, βhCG): Down syndrome risk
- Amniocentesis/CVS if indicated: chromosomal abnormalities
- GBS (Group B Streptococcus) swab status
Polyhydramnios: suggests GI obstruction (esophageal atresia, duodenal atresia), neuromuscular condition
Oligohydramnios: renal agenesis, IUGR, post-dates, Potter sequence

4.2 Birth History

Gestational age at delivery: term (37-42 weeks), preterm (<37 weeks), post-term (>42 weeks)
- Preterm: classify as: extremely preterm (<28 wks), very preterm (28-32 wks), moderate/late preterm (32-37 wks)
Mode of delivery: Spontaneous vaginal delivery (SVD), instrumental (forceps/ventouse), emergency LSCS, elective LSCS
Reason for operative delivery: fetal distress, failure to progress, breech presentation, maternal indications
Presentation: vertex, breech, transverse
Prolonged/obstructed labor: risk of birth asphyxia
Maternal analgesia/anaesthesia: epidural, opioids (can cause neonatal respiratory depression)

4.3 Neonatal History

Birth weight: normal (2.5-4.0 kg), low birth weight (LBW <2.5 kg), very LBW (<1.5 kg), macrosomia (>4 kg)
APGAR scores: at 1 minute and 5 minutes
- Score 7-10: normal; 4-6: moderate depression; 0-3: severe depression

APGAR Component	0	1	2
Appearance (color)	Blue/pale all over	Blue extremities, pink body	Pink all over
Pulse (heart rate)	Absent	<100 bpm	≥100 bpm
Grimace (reflex irritability)	No response	Grimace	Cry/cough/sneeze
Activity (muscle tone)	Limp	Some flexion	Active motion
Respiration	Absent	Weak/irregular	Strong cry

Resuscitation required: oxygen, bag-mask ventilation, chest compressions, intubation, epinephrine
Admission to NICU/SCBU: reason, duration
Jaundice: onset (physiological ≥24h vs. pathological <24h), treatment (phototherapy, exchange transfusion)
Feeding in first days: breast/bottle; any difficulties; supplementation needed
Congenital abnormalities identified at birth: cleft palate, cardiac defects, limb abnormalities
Neonatal screening tests (heel prick/Guthrie): PKU, congenital hypothyroidism, sickle cell disease, CF, MCADD, homocystinuria (varies by country)
Hearing screening: newborn hearing screen result
Pulse oximetry screening: for critical congenital heart disease
Length of hospital stay

5. Feeding and Nutritional History

One of the most critical sections in pediatric history - especially in infants and toddlers.

For Infants (0-12 months):

Breastfeeding:
- Exclusive breastfeeding? Mixed?
- Frequency and duration of feeds
- Difficulties: poor latch, painful feeds, low supply (maternal), poor weight gain (infant)
- When weaned (if applicable)
Formula feeding:
- Which formula? (standard, hydrolysed, soy, amino acid-based)
- Volume per feed, frequency
- Correct preparation (dilution errors cause hyponatremia or overfeeding)
Weaning/complementary feeding: When introduced? What foods?
Concerns: regurgitation/vomiting, refusal to feed, colic, blood in stool

For Toddlers and Older Children:

Dietary variety: fruits, vegetables, proteins, dairy, grains
Portion sizes and meal frequency
Fussy eating: food jags, texture aversion
Juice/sugary drink intake: caries, obesity risk
Vitamin/mineral supplementation: vitamin D, iron, fluoride
Special diets: vegetarian, vegan, gluten-free, elimination diet
Food allergies/intolerances: peanut, egg, milk, wheat - onset, reaction type, documented?
Appetite changes with current illness

Growth Monitoring:

Weight, length/height, head circumference (and BMI in older children) plotted on age/sex-appropriate growth charts
Growth velocity (centile crossing is more significant than absolute values)
Failure to thrive (FTT): weight consistently <2nd centile or crossing centiles downward

6. Developmental History

Assessing development is a cornerstone of pediatric history. Use the four developmental domains:

Developmental Domains

Domain	Description
Gross Motor	Large muscle movements: rolling, sitting, standing, walking, running
Fine Motor / Adaptive	Hand-eye coordination, grasping, drawing, self-care
Language / Speech	Receptive (understanding) and expressive (speaking)
Social / Emotional	Smiling, interaction, play, separation anxiety, peer relationships

Key Developmental Milestones

Age	Gross Motor	Fine Motor	Language	Social
6 weeks	Lifts chin prone	Hands fisted	Cooing	Social smile
3 months	Holds head up	Follows object 180°	Cooing, laughing	Recognises parents
6 months	Sits with support, rolls	Palmar grasp, transfers	Babbling, razzes	Stranger anxiety begins
9 months	Stands with support, crawls	Pincer grasp developing	"Mama/dada" non-specific	Waves bye-bye
12 months	Walks with support/cruising	Neat pincer grasp	1-2 words with meaning	Separation anxiety
18 months	Walks independently, runs	Tower of 3-4 cubes	10-20 words, jargon	Parallel play
2 years	Runs, kicks ball	Tower of 6 cubes	2-word phrases, 50+ words	Parallel play, copies adults
3 years	Climbs stairs (alternating), tricycle	Copies circle, uses scissors	3-word sentences, 300+ words	Cooperative play begins
4 years	Hops on one foot, skips	Copies cross, holds pencil	Full sentences, tells stories	Imaginative play
5 years	Skips, catches ball	Copies triangle, writes name	Fluent speech, counts to 10	Friends, understands rules

Developmental Red Flags (Immediate Concern)

Age	Red Flag
Any age	Loss/regression of previously acquired milestones
6 weeks	No social smile
3 months	Not fixing/following with eyes
6 months	No babbling, no reaching
9 months	No sitting with support
12 months	No single words, no pointing
18 months	Fewer than 6 words, no functional play
2 years	No 2-word phrases
3 years	Speech not understandable to strangers
Any age	No eye contact, no interest in social interaction (autism screening)

Additional Developmental Questions:

School performance: grade appropriate? IEP/special education needs?
Behavioral concerns: ADHD, oppositional defiant behavior, anxiety
Autism spectrum screening: MCHAT-R (18-24 months)
Speech therapy, occupational therapy, physiotherapy: current or previous involvement
Hearing and vision: formal testing results
Sleep: hours, sleep problems (night terrors, sleep apnea, bedwetting)

7. Immunization History

Critical in all pediatric consultations, particularly for infectious disease presentations.

Information to Obtain:

Up to date? Review immunization card/record
Which vaccines received? (compare against national schedule)
Any missed doses? Catch-up schedule needed?
Reactions to previous vaccines: local reactions, fever, anaphylaxis
Parental concerns or vaccine hesitancy: document and address sensitively
Special vaccines received: BCG (at-risk countries), Hepatitis B (birth dose), Varicella, Meningococcal ACWY/B, Rotavirus
Travel vaccines: Typhoid, Hepatitis A, Yellow Fever, Japanese Encephalitis

Standard UK/US Childhood Immunization Schedule (Core):

Age	Vaccines
Birth	Hepatitis B (if not universal, then at-risk infants)
6-8 weeks	DTaP/IPV/Hib/HepB, Rotavirus, PCV13, MenB
3-4 months	DTaP/IPV/Hib/HepB, Rotavirus, MenB
12-13 months	MMR, PCV13, MenB, Hib/MenC
2-6 years	Annual influenza (nasal)
3-4 years	MMR booster, DTaP/IPV booster
11-14 years	HPV (2 doses), Td/IPV booster, MenACWY

8. Past Medical History (PMH)

Previous illnesses: hospitalisations, serious infections, febrile convulsions
Chronic conditions: asthma, eczema, epilepsy, diabetes, CHD, IBD, renal disease
Neonatal problems: jaundice, hypoglycemia, respiratory distress, NEC
Recurrent infections: suggest immunodeficiency (recurrent otitis media, pneumonia, abscesses)
Previous investigations: ECGs, echo, EEGs, imaging, blood tests
Transfusions: blood products received?
Accidents and injuries: note frequency (child protection consideration if recurrent)

9. Surgical History

Operations performed, age at time, hospital
Complications (anesthetic reactions, wound infections, bleeding)
Common pediatric surgeries to ask about: circumcision, herniotomy, orchidopexy, pyloromyotomy, tonsillectomy/adenoidectomy, grommets, appendectomy, cardiac surgery

10. Medications and Allergies

Current Medications:

Name, dose, route, frequency, duration
OTC/home remedies: paracetamol, ibuprofen, antihistamines, herbal preparations
Vitamins/supplements: iron, vitamin D, omega-3
Controlled medications: methylphenidate (ADHD), growth hormone, anticonvulsants

Allergies:

Drug, food, environmental, insect venom
Nature of reaction: rash, urticaria, angioedema, anaphylaxis, GI symptoms
Documented or suspected?
Has adrenaline auto-injector (EpiPen) been prescribed?

11. Family History (FH)

In pediatrics, family history is particularly important as many conditions are genetic.

Parental health: age, health status
Consanguinity: first-cousin marriages (increases risk of autosomal recessive conditions)
Siblings: ages, health; any similar illness in siblings?
Genetic conditions in family: CF, sickle cell, thalassemia, muscular dystrophy, PKU
Cardiac conditions: congenital heart disease, arrhythmias (Long QT syndrome - ask about unexplained sudden death in young family members)
Metabolic conditions: familial hypercholesterolemia, diabetes
Neurological: epilepsy, intellectual disability, learning difficulties
Atopic triad: asthma, eczema, allergic rhinitis (in patient and first-degree relatives)
Malignancy: especially childhood cancers, hereditary cancer syndromes
Neonatal deaths / stillbirths: may indicate metabolic or genetic conditions
Mental health: depression, anxiety, ADHD, autism spectrum

12. Social History (SH)

The social context of a child's life has profound effects on health outcomes.

Family Structure:

Who does the child live with? (both parents, single parent, grandparents, foster care)
Parents' relationship status
Number of siblings, their ages
Primary caregiver: who looks after the child during the day?

Housing:

Type of accommodation (house, flat, temporary housing)
Overcrowding (TB, meningitis, respiratory infection risk)
Heating, ventilation, damp/mold (asthma, respiratory disease)
Pets at home (allergies, zoonoses)
Smoking in the household: passive smoke exposure (asthma, otitis media, SIDS)

Socioeconomic Status:

Parental occupation(s)
Financial difficulties / benefits received
Food security
Access to healthcare

Childcare / Education:

Nursery, daycare, school attendance
School year/grade
Absenteeism and reason
Bullying concerns

Child's Activities & Interests:

Sports and physical activity
Screen time (TV, tablets, phones) - recommended <1 hr/day under 5
Hobbies

Child Protection Considerations (SAFEGUARDING):

Always consider child maltreatment. Risk factors include:

History inconsistent with injury pattern
Delay in seeking medical attention
Multiple unexplained injuries
Concerning bruising (non-mobile infants, unusual sites: ear, neck, buttocks)
Poor hygiene, neglect signs
Child appears fearful of parent
Document factually and report per local safeguarding protocol

For Adolescents - HEADSS Assessment:

Domain	Questions
Home	Who do you live with? How are things at home?
Education/Employment	How is school going? Any problems?
Activities	What do you do in your free time?
Drugs	Do your friends use drugs/alcohol? Do you?
Sexuality	Have you started dating? Are you sexually active? (confidentiality)
Suicide/Depression	How are you feeling in yourself? Any thoughts of harming yourself?

13. Review of Systems (ROS)

A systematic enquiry to detect symptoms not volunteered. Adapted for age.

General:

Fever, night sweats, weight loss/gain
Fatigue, lethargy, change in activity
Growth concerns (too tall, too short, too fat, too thin)

Head, Eyes, Ears, Nose, Throat (HEENT):

Headaches: site, frequency, severity, associated nausea/vomiting/photophobia, aura
Visual problems: squint (strabismus), decreased vision, photophobia
Ear: hearing loss, recurrent otitis media, discharge, ear pain, grommets
Nose: recurrent colds, rhinorrhea, epistaxis (nosebleeds), nasal obstruction
Throat: recurrent tonsillitis, streptococcal sore throat, mouth ulcers
Teeth/oral: dental hygiene, caries, thumb sucking

Respiratory:

Cough: duration, productive/dry, nocturnal, post-exercise (asthma), pertussis-like (whooping)
Wheeze: first episode vs. recurrent
Shortness of breath, exercise intolerance
Cyanosis: peripheral vs. central
Stridor: inspiratory (upper airway) vs. expiratory (lower airway)
Apnea episodes (infants)

Cardiovascular:

Cyanosis, pallor
Exercise intolerance, poor feeding (infants - equivalent of exercise intolerance)
Palpitations, syncope
Known murmur: innocent vs. pathological
Chest pain (uncommon in children; consider costochondritis, arrhythmia, rarely ischaemic)
Oedema

Gastrointestinal:

Abdominal pain: site (periumbilical - functional; RIF - appendicitis), character, frequency
Nausea, vomiting: bilious (must exclude obstruction), projectile (pyloric stenosis), hematemesis
Diarrhea: duration, frequency, consistency, blood/mucus, urgency
Constipation: frequency, stool consistency, soiling/overflow (encopresis), pain
Jaundice: eyes, skin, dark urine, pale stools
Rectal bleeding: bright red (anal fissure, intussusception, Meckel's), dark/melena
Hernia: inguinal (common in boys), umbilical
Swallowing difficulties: dysphagia, drooling

Genitourinary:

Urinary frequency, urgency, dysuria (UTI)
Haematuria: frank or microscopic
Polyuria/polydipsia (diabetes mellitus/insipidus)
Enuresis: nocturnal (bedwetting) - age, primary vs. secondary, nocturnal only vs. daytime also
Genital abnormalities: undescended testes, hypospadias (usually detected at birth)
In adolescent girls: menstrual history (age of menarche, cycle regularity, dysmenorrhea, LMP)

Musculoskeletal:

Joint pain, swelling, stiffness (morning stiffness: JIA)
Limp: painful vs. painless; acute vs. chronic
Bone pain: nocturnal pain (osteosarcoma)
Muscle weakness, fatigue, Gowers sign (DMD)
Back pain (rare in children; investigate if present)

Neurological:

Seizures: type, duration, frequency, postictal state, triggers, febrile vs. afebrile
Headaches (see HEENT above)
Developmental regression (always a red flag)
Tremor, abnormal movements, tics
Balance problems, ataxia
Weakness, paralysis, abnormal gait
Speech and language concerns (see Developmental History)
Behavioral changes, mood changes

Skin:

Rashes: morphology, distribution, onset, itching, association with fever
Eczema: sites, severity, triggers, treatment used
Urticaria, angioedema
Birthmarks, pigmentation changes (café-au-lait spots: neurofibromatosis)

Endocrine:

Growth concerns: short stature, tall stature, growth velocity changes
Puberty: precocious (<8 years girls, <9 years boys) or delayed (>13 girls, >14 boys)
Thyroid symptoms: heat/cold intolerance, weight change, tremor, goiter, exophthalmos
Polyuria, polydipsia, weight loss (T1DM)

Haematology/Oncology:

Pallor, fatigue (anemia)
Bruising, petechiae, bleeding tendency
Lymphadenopathy: site, duration, tenderness, size (>1 cm generalized is abnormal)
Splenomegaly, hepatomegaly symptoms

14. Special Considerations by Age Group

Age Group	Key Extra Considerations
Neonate (0-28 days)	Full birth/perinatal history dominant; feeding (breast/bottle); jaundice; umbilical stump; circumcision; maternal GBS status; TORCH
Infant (1-12 months)	Feeding, growth, developmental milestones, immunisations, safeguarding (non-accidental injury)
Toddler (1-3 years)	Feeding problems, language development, toilet training, tantrums, safety (ingestion, falls)
Pre-school (3-6 years)	School readiness, speech, social development, behavioural issues
School age (6-12 years)	Academic performance, friendships, bullying, screen time, physical activity
Adolescent (12-18 years)	HEADSS assessment, confidentiality, puberty, sexual health, mental health, substance use

15. Confidentiality in Adolescents

Adolescents have the right to confidentiality from age 16 in most jurisdictions (Fraser competence/Gillick competence applies to younger adolescents)
Inform the adolescent what you can keep confidential and what you may need to share (safeguarding disclosures are never confidential)
Conduct part of the history without the parent in the room for adolescents
Document who provided the history and any confidentiality arrangements made

Summary Checklist

Section	Key Elements
Identifying data	Name, age, DOB, informant
Chief complaint	In informant's own words + duration
HPI	SOCRATES + sick contacts, feeding changes, urine output
Birth/perinatal	Antenatal, delivery, neonatal period, Apgar, NBS
Feeding/nutrition	Breast/formula/diet, weaning, growth
Development	Four domains + milestones + red flags
Immunizations	Up to date per schedule, reactions
PMH	Hospitalizations, chronic illness, recurrent infections
Surgical history	Operations, complications
Medications/allergies	Current drugs, OTC, vitamins; allergy type/severity
Family history	Genetic, atopy, cardiac, sudden death in young
Social history	Family structure, housing, school, HEADSS (adolescents), safeguarding
Review of systems	All organ systems, age-adapted

Pediatrics physical examination 80/20

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Excellent - I have rich clinical content from Rosen's Emergency Medicine. Now I have everything needed for a high-yield 80/20 pediatric physical exam guide.

Pediatric Physical Examination - 80/20 Guide

The 80/20 principle here means: master these core concepts and you will handle the vast majority of pediatric clinical encounters competently.

THE GOLDEN RULE: START FROM THE DOOR

In pediatrics, your most valuable assessment happens before you touch the child. The Pediatric Assessment Triangle (PAT) from across the room tells you immediately if the child is sick or well.

1. The Pediatric Assessment Triangle (PAT)

Pediatric Assessment Triangle - Appearance, Work of Breathing, Circulation to skin

Rosen's Emergency Medicine - assess from the doorway before the child sees you

Three sides assessed visually, without touching:

Side 1: Appearance - TICLS

Letter	Component	What to observe
T	Tone	Floppy infant? Moving limbs? Posture?
I	Interactivity	Responding to environment? Making eye contact?
C	Consolability	Can parent calm the child? Inconsolable = concerning
L	Look/Gaze	Alert, tracking? Vacant/glazed?
S	Speech/Cry	Normal cry? Weak, high-pitched (meningitis), or no cry?

Side 2: Work of Breathing

Abnormal sounds without stethoscope: stridor (upper), wheeze (lower), grunting (lung collapse/fluid)
Abnormal positioning: sniffing position, tripod (severe - arms forward, leaning), refusal to lie flat
Retractions: suprasternal, supraclavicular, intercostal, subcostal - more sites = more severe
Nasal flaring: reducing airway resistance
Head bobbing, seesaw breathing = impending respiratory failure

Side 3: Circulation to Skin

Pallor: anemia, shock
Mottling: poor peripheral perfusion
Cyanosis: central (mucous membranes) vs. peripheral
Petechiae: meningococcemia until proven otherwise

PAT Interpretation - Key Clinical States

PAT Finding	Appearance	Work of Breathing	Circulation	Diagnosis
Respiratory distress	Normal	Abnormal	Normal	Airway/lung problem, child compensating
Respiratory failure	Abnormal	Abnormal	Normal-abnormal	Exhausted, needs immediate airway support
Compensated shock	Normal	Normal	Abnormal	Perfusion failing, brain still protected
Decompensated shock	Abnormal	Normal-abnormal	Abnormal	Critical - imminent arrest
Brain dysfunction	Abnormal	Normal	Normal	CNS pathology (seizure, meningitis, encephalitis)
Cardiopulmonary failure	Abnormal	Abnormal	Abnormal	Pre-arrest - resuscitate immediately

"On the basis of the initial PAT, the emergency clinician can distinguish the 'sick' from the 'well' child rapidly." - Rosen's Emergency Medicine

2. Vital Signs - Age-Specific Normal Values

The single most commonly tested knowledge in pediatric exams. Values decrease with age.

Heart Rate (beats/min)

Age	5th %ile	50th %ile (Normal)	95th %ile
0-3 months	113	140	171
3-6 months	108	135	169
6-9 months	106	134	167
9-12 months	104	132	165
12-18 months	102	128	163
2-3 years	92	117	151
4-6 years	80	103	133
6-8 years	72	94	122
8-12 years	67	87	113
12-15 years	62	82	107

Source: Rosen's / Roberts and Hedges' Clinical Procedures in Emergency Medicine (Bonafide et al, Pediatrics 2013)

Respiratory Rate (breaths/min)

Age	5th %ile	50th %ile (Normal)	95th %ile
0-3 months	27	41	62
3-6 months	25	38	58
6-12 months	22	33	51
1-2 years	20	29	45
2-3 years	18	27	42
3-6 years	17	24	37
6-8 years	16	23	35
8-12 years	15	21	31
12-18 years	13	18	26

80/20 memory rule: Newborn ~40, halves to ~20 by age 2, approaches adult (~15) by school age.

"Normal pediatric respiratory rates are inversely related to age due to younger children's increased metabolic rates and lower tidal volume reserves." - Rosen's

Blood Pressure (mmHg) - Simplified

Age	Systolic (approx.)	Diastolic (approx.)
Neonate	65-85	45-55
1-12 months	70-100	50-65
1-3 years	80-110	55-70
3-6 years	85-110	55-70
6-12 years	90-120	60-75
Adolescent	100-130	65-80

Quick formula for minimum acceptable systolic BP in children >1 year:

Minimum systolic BP = 70 + (2 × age in years) mmHg (Below this = hypotension requiring immediate action)

Temperature

Normal: 36.5-37.5°C (axillary); 37-38°C (rectal, 0.5°C higher)
Fever: ≥38.0°C rectal / ≥37.5°C axillary
Fever in neonate <28 days: ≥38.0°C = sepsis workup (LP, blood culture, IV antibiotics) regardless of appearance
Hyperpyrexia: >40.5°C - consider CNS pathology, heat stroke

Oxygen Saturation

Normal SpO₂: ≥95% in room air (≥96% ideal)
90-94%: concerning, supplemental O₂ needed
<90%: hypoxia, urgent intervention

3. General Appearance

After PAT, formally assess:

Well or unwell? Trust your gut - experienced clinicians identify sick children rapidly
Nutritional status: wasted, normal, obese
Growth: plot weight, height/length, head circumference on growth chart
Alertness: GCS (adapted for pediatrics) or AVPU scale
Hydration (see Section 9)
Dysmorphic features: Down syndrome (upslanted palpebral fissures, flat nasal bridge, single palmar crease), Turner, Marfan
Hygiene and dress: signs of neglect

AVPU Scale (rapid consciousness assessment)

Level	Description
A	Alert
V	Responds to Voice
P	Responds to Pain
U	Unresponsive

P or U in a child = emergency

4. Head and Fontanelles

The anterior fontanelle is the single most important structure in infant examination.

Fontanelle	Closes	Normal size
Anterior (diamond-shaped)	12-18 months	Up to 2.5 cm diameter
Posterior (triangular)	6-8 weeks	Fingertip-sized

Anterior fontanelle assessment - must do with infant upright and calm:

Finding	Interpretation
Bulging (tense, non-pulsatile)	↑ intracranial pressure: meningitis, hydrocephalus, subdural, vitamin A toxicity
Sunken	Dehydration
Normal (slightly pulsatile, flat)	Normal
Delayed closure (>18 months)	Hypothyroidism, hydrocephalus, rickets, Down syndrome
Early closure (<3 months)	Craniosynostosis

Head shape:

Plagiocephaly: asymmetric flattening (positional - common)
Microcephaly (<2 SD): TORCH infections, genetic, fetal alcohol syndrome
Macrocephaly (>2 SD): hydrocephalus, storage diseases, benign familial

Head circumference normal values:

Newborn: ~34 cm
3 months: ~41 cm
6 months: ~44 cm
12 months: ~47 cm
2 years: ~49 cm
Grows ~2 cm/month in first 3 months, then ~1 cm/month to 6 months, then ~0.5 cm/month to 12 months

5. Eyes

Conjunctivae: pallor (anemia), jaundice
Pupils: equal, round, reactive to light (PEARL); unequal = herniation/CN3 palsy
Red reflex: must be checked in all infants and children - absent red reflex = retinoblastoma, cataract, glaucoma (urgent ophthalmology referral)
Squint (strabismus): corneal light reflex test (Hirschberg) + cover test
- Constant squint at any age: abnormal
- Pseudostrabismus (epicanthic folds): normal variant in infants
Nystagmus: cerebellar, vestibular, or congenital
Periorbital edema: nephrotic syndrome (bilateral, non-pitting, worse in morning), orbital/periorbital cellulitis

6. Ears, Nose, Throat

Ears

Otoscopy: examine last (will upset the child - save upsetting examinations for the end)
Normal TM: pearly grey, cone of light (anteroinferiorly), visible handle of malleus
Otitis media: red, bulging, opaque TM, ± perforation with discharge
Otitis media with effusion ("glue ear"): dull, grey-yellow TM, absent light reflex, air-fluid level
Preauricular pits/tags: associated with renal anomalies (consider renal USS)
Low-set ears: Down syndrome, Turner syndrome, renal agenesis

Nose

Nasal flaring: respiratory distress
Discharge: clear (viral/allergy), purulent (bacterial sinusitis, foreign body)
Nasal polyps in child: think cystic fibrosis

Throat / Mouth

Examine last in the cooperative child, or save for end in infants
Tonsils: grade 0-4 (grade 4 = "kissing tonsils" meeting midline)
- Grading: 1 = within pillars; 2 = touching pillars; 3 = beyond pillars; 4 = touching midline
Exudate: bacterial tonsillitis (strep), EBV (mononucleosis - look for petechiae at junction of hard/soft palate)
Peritonsillar abscess: unilateral tonsillar swelling, uvular deviation, "hot potato" voice, trismus
Koplik spots: pathognomonic of measles (white spots on buccal mucosa opposite molars)
Dental caries: neglect marker, prolonged bottle feeding
Cleft palate: can be subtle (submucous) - run finger along hard palate
Thrush (white plaques on mucosa): Candida - remove with spatula (unlike milk)
Strawberry tongue: scarlet fever, Kawasaki disease

7. Neck and Lymph Nodes

Lymphadenopathy assessment:

Normal: cervical nodes up to 1 cm, inguinal up to 1.5 cm in children
Significant: >1 cm generalized; >2 cm localized; firm/hard/fixed/non-tender
Tender, mobile, soft = reactive (viral infection)
Hard, fixed, painless = malignancy (lymphoma)
Fluctuant = abscess

Neck stiffness:

In infants: a bulging fontanelle is more reliable than neck stiffness (meningism may be absent <18 months)
Kernig's sign: with hip flexed 90°, unable to extend knee >135° due to pain
Brudzinski's sign: passive neck flexion causes involuntary hip/knee flexion
Both signs have poor sensitivity in young children - clinical judgment + LP if concerned

Other neck findings:

Thyroid: goiter - hypothyroidism, hyperthyroidism, Hashimoto's
Torticollis: lateral neck tilt - muscular (SCM fibrosis), Sandifer syndrome (GERD), atlantoaxial subluxation (Down syndrome - check before manipulation)
Webbed neck: Turner syndrome
Cystic hygroma/branchial cyst: soft, transilluminable neck mass

8. Respiratory System

Observe before auscultating:

Respiratory rate: count for full 60 seconds in infants (irregular)
Accessory muscle use: sternomastoid, scalene
Chest shape: barrel chest (chronic air trapping - asthma), pectus excavatum/carinatum
Symmetry of movement: reduced on side of pneumonia, effusion, or pneumothorax

Auscultation - most important findings:

Sound	Interpretation
Wheeze (expiratory, musical)	Bronchospasm: asthma, bronchiolitis, foreign body
Crackles (crepitations, fine)	Alveolar: pneumonia, pulmonary edema
Coarse crackles	Secretions in large airways: bronchitis, CF
Stridor (inspiratory, harsh)	Upper airway obstruction: croup, epiglottitis, foreign body
Reduced/absent breath sounds	Consolidation, pleural effusion, pneumothorax
Bronchial breathing	Consolidation (air bronchograms on CXR)

Percussion:

Dull: consolidation, effusion
Hyperresonant: pneumothorax, air trapping

80/20 key distinguishing findings:

Condition	Key Sign
Bronchiolitis	Wheeze + crackles in infant <2 years, after URTI
Asthma	Wheeze ± hyperinflation, worse at night/with exercise, good response to salbutamol
Croup	Barking cough + inspiratory stridor, low-grade fever, hoarse voice
Epiglottitis	High fever + stridor + drooling + "hot potato" voice + toxic appearance (do NOT examine throat)
Pneumonia	Fever + tachypnea + reduced air entry + dullness to percussion + crackles
Foreign body	Unilateral wheeze + reduced air entry unilaterally + sudden onset in toddler

9. Cardiovascular System

Inspection:

Cyanosis (central = oral mucosa/tongue), clubbing (chronic hypoxia: cyanotic CHD, CF)
Precordial bulge (cardiomegaly)
Scars (previous cardiac surgery)
Respiratory distress + poor feeding in infant = heart failure equivalent

Palpation:

Apex beat: normally 4th intercostal space, midclavicular line in children <7 years; 5th ICS, MCL in older children
- Displaced laterally = cardiomegaly
Heaves and thrills: thrill = palpable murmur (grade ≥4)

Auscultation - heart sounds:

S1 (mitral/tricuspid closure) + S2 (aortic/pulmonary closure): normal
S3 gallop: volume overload, heart failure (normal in thin children)
Fixed split S2: ASD (pathognomonic)
Loud P2: pulmonary hypertension

Murmurs - the critical differentiation:

Innocent vs. Pathological Murmur

Feature	Innocent	Pathological
Timing	Systolic only	Systolic, diastolic, or continuous
Quality	Soft, musical, vibratory	Harsh, blowing
Grade	1-2/6	Often ≥3/6
Location	Variable	Fixed to specific valve area
Radiation	No	Often radiates (e.g., to carotids/axilla)
Changes with position	Decreases lying, increases sitting/standing	May not change
Symptoms	None	Failure to thrive, cyanosis, exercise intolerance
S2	Normal	May be abnormal

The 6 "S's" of innocent murmurs: Soft, Short, Systolic, Sensitive to position, no Symptoms, no thrill

Common innocent murmurs:

Still's murmur: vibratory, musical, grade 2-3/6, lower left sternal edge, most common (2-7 years)
Pulmonary flow murmur: ejection systolic, left upper sternal edge, normal in neonates
Venous hum: continuous, infraclavicular, disappears when jugular vein compressed or child lies flat

Pathological murmur patterns:

Condition	Murmur Character
VSD	Pansystolic, harsh, lower left sternal border
ASD	Ejection systolic + fixed split S2, upper left sternal border
PDA	Continuous "machinery" murmur, left infraclavicular
Pulmonary stenosis	Ejection systolic + ejection click, upper left sternal border, radiates to back
Aortic stenosis	Ejection systolic, upper right sternal border, radiates to carotids
Coarctation	Systolic murmur, left infrascapular; radio-femoral delay; upper > lower limb BP

Peripheral pulses:

Always palpate femoral pulses in neonates/infants - absent/weak femoral + upper limb hypertension = coarctation of aorta
Radio-femoral delay: >0.2 second delay = coarctation

Capillary refill time (CRT): Press sternum for 5 seconds, release

Normal: <2 seconds
2 seconds = poor perfusion / dehydration / shock

10. Dehydration Assessment

The most clinically tested pediatric examination skill.

Sign	Mild (3-5%)	Moderate (5-10%)	Severe (>10%)
Mucous membranes	Dry ±	Dry +	Very dry +
Anterior fontanelle	Normal	Sunken +	Sunken +
Skin turgor (pinch abdomen)	Normal	Reduced ±	Tenting +
Sunken eyes	-	+	+
Mental status	Alert	Irritable	Lethargic
Heart rate	Normal	Tachycardia	Tachycardia
Capillary refill	<2 sec	>2 sec	>2 sec
Hypotension	-	Orthostatic ±	Present
Urine output	Normal	Reduced	Oliguria/anuria

Source: Rosen's Emergency Medicine, adapted from Barkin & Rosen, Emergency Pediatrics

"The three most useful signs to determine dehydration of more than 5% are prolonged capillary refill time, abnormal skin turgor, and abnormal respiratory pattern." - Rosen's Emergency Medicine

Skin turgor test: Pinch skin on abdomen (not dorsum of hand in infants) - normal returns immediately, tenting (>2 second) = >10% dehydration

Special skin signs in dehydration:

Skin tenting (slow recoil): suggests hyponatremic dehydration
Doughy texture: hypernatremic dehydration (water shifts from cells to interstitium)

11. Abdomen

Order: Inspect → Auscultate → Percuss → Palpate (palpate last - pressing on a tender area upsets child)

Inspection:

Distension: obstruction, ascites, organomegaly, constipation
Scars
Visible peristalsis: pyloric stenosis (wave from left hypochondrium to right - olive mass palpable)
Umbilical hernia (common, usually resolves by age 2-4 years)
Inguinal region: hernias, undescended testes

Auscultation:

Bowel sounds: absent = ileus/peritonitis; hyperactive = obstruction
Count before palpating

Palpation - technique in children:

Kneel to child's level; warm hands; distract the child ("take a deep breath", look at the ceiling)
Use child's own hand over yours if very anxious
Start in the area AWAY from the reported pain
Tenderness: localize to quadrant
Guarding: voluntary (anxiety) vs. involuntary (peritoneal irritation)
Rebound tenderness: Rovsing's sign (right iliac fossa pain on pressing left iliac fossa) = appendicitis

Organomegaly:

Liver: normally palpable 1-2 cm below right costal margin in infants and young children (normal finding)
- Hepatomegaly if >3.5 cm below RCM in neonates, >2 cm in children
- Causes: hepatitis, storage disease, right heart failure, leukaemia
Spleen: usually not palpable; if palpable in a child = significant
- Causes: infections (EBV, malaria), haemolytic anaemia, portal hypertension, leukaemia/lymphoma
Kidneys: ballottable in neonates/infants; enlarged = hydronephrosis, Wilms' tumour

Key abdominal conditions:

Condition	Age	Key Exam Finding
Intussusception	3 months-3 years	Sausage-shaped mass in RUQ/central abdomen; "redcurrant jelly" stool; intermittent colicky pain
Pyloric stenosis	2-8 weeks	Olive-shaped mass in epigastrium/right of midline; visible peristalsis; projectile non-bilious vomiting
Appendicitis	>2 years	Tenderness + guarding at McBurney's point (RIF); Rovsing's sign; fever
Hirschsprung	Neonate-infant	Delayed passage of meconium; abdominal distension; empty rectum on PR exam
Wilms' tumour	1-5 years	Smooth, firm unilateral flank/abdominal mass; does NOT cross midline

12. Genitalia

Boys: check testes are descended bilaterally (undescended testes need orchidopexy <1 year)
- Hydrocele: fluctuant scrotal swelling, transilluminates - common in infants, usually resolves
- Inguinal hernia: does not transilluminate; may be reducible; urgent if incarcerated
- Testicular torsion: sudden onset severe unilateral scrotal pain, absent cremasteric reflex, high-riding testis = SURGICAL EMERGENCY
- Phimosis: non-retractile foreskin - normal until age 3-4 years; becomes pathological if causing obstruction
Girls: labial adhesions (common, usually resolve spontaneously); vaginal discharge in prepubertal girls - exclude abuse
Both sexes: Tanner staging (puberty assessment) - stages 1-5 for breast, pubic hair, genitalia

Tanner Stages (simplified)

Stage	Breast (girls)	Pubic hair	Genitalia (boys)
1	Prepubertal	None	Prepubertal
2	Breast bud	Fine hair at base	Testicular enlargement (begin puberty)
3	Enlargement	Darker, spreads	Penile elongation
4	Areola secondary mound	Adult type, not spread to thighs	Adult size, no spread to thighs
5	Adult	Adult including medial thighs	Adult

Normal onset of puberty:

Girls: breast development 8-13 years (mean 10)
Boys: testicular enlargement 9-14 years (mean 11.5)

13. Neurological System

Conscious level: AVPU or GCS (modified pediatric GCS for infants) Tone: hypotonia (floppy infant) vs. hypertonia/spasticity

Primitive reflexes (present in neonates, should disappear by stated age):

Reflex	Elicited by	Normal disappearance
Moro (startle)	Sudden head drop	4-6 months
Rooting	Touch corner of mouth	3-4 months (awake)
Sucking	Object in mouth	4 months (voluntary by then)
Palmar grasp	Object in palm	3-4 months
Plantar grasp	Touch sole	8-12 months
Asymmetric Tonic Neck (ATNR/"fencing")	Head turn to one side	4-6 months
Babinski (plantar extensor)	Stroke lateral sole	Normal up to 2 years

Persistent primitive reflexes beyond expected age = central neurological damage (cerebral palsy)

Cerebellar assessment in children:

Finger-nose test, heel-shin (adapt: "touch my finger, now touch your nose")
Gait: wide-based, ataxic = cerebellar; scissor gait = spastic diplegia (CP)

Cranial nerves - rapid pediatric assessment:

CN II: red reflex, pupil responses, visual tracking
CN III/IV/VI: eye movements, squint
CN VII: facial symmetry (smile, raise eyebrows)
CN VIII: hearing (distraction test <6 months; audiometry in older)
CN XII: tongue movement (fasciculations = lower motor neuron)

14. Skin

The skin is often the fastest route to diagnosis in children.

Rash	Key Features	Diagnosis
Maculopapular + fever	Starts head, spreads down, Koplik spots	Measles
Vesicular + fever	Crops of lesions, different stages simultaneously, very itchy	Varicella
Petechiae / purpura	Non-blanching, fever, toxic	Meningococcaemia (emergency)
Blanching maculopapular	Fever, strawberry tongue, "sandpaper" texture	Scarlet fever
Target lesion	Concentric rings (bull's eye)	Erythema multiforme / Lyme disease
Salmon-pink evanescent	Fever, comes and goes	Systemic JIA (Still's disease)
Butterfly rash	Malar rash, photosensitive	SLE
Flexural eczema	Antecubital/popliteal fossa, cheeks in infants	Atopic dermatitis
Café-au-lait spots	>6 spots >0.5 cm	Neurofibromatosis type 1
Ash-leaf macules	Hypopigmented, Wood's lamp	Tuberous sclerosis

Blanching test: press glass firmly on rash - if disappears = blanching (inflammatory/allergic). If persists = non-blanching = petechiae/purpura = possible meningococcaemia until proven otherwise.

15. Musculoskeletal - The Limping Child

One of the highest-yield pediatric exam topics.

Age	Condition	Key Features
Neonate	Developmental dysplasia of hip (DDH)	Barlow + Ortolani tests (mandatory in all neonates)
<2 years	Septic arthritis	Fever, hot swollen joint, refusal to move, elevated CRP/WCC
2-10 years	Transient synovitis ("irritable hip")	Afebrile, mild pain, internal rotation restricted - diagnosis of exclusion
4-8 years	Perthes' disease (avascular necrosis)	Painless limp, insidious onset, Trendelenburg gait
10-15 years	Slipped capital femoral epiphysis (SCFE)	Obese adolescent, hip pain referred to knee, external rotation, leg shortened
Any age	Osteomyelitis	Point tenderness over bone, fever, raised inflammatory markers
Any age	Juvenile idiopathic arthritis	Morning stiffness, swollen joints, iridocyclitis (eye screening mandatory)

Barlow test (infant): hip adducted + posteriorly directed force - hip dislocates posteriorly = positive (unstable) Ortolani test (infant): hip abducted + anterior pressure on greater trochanter - clunk = hip reducing = positive (dislocated)

Trendelenburg test: stand on one leg - if opposite pelvis drops = weak hip abductors (gluteus medius) ipsilateral to standing leg = Perthes, DDH, any hip pathology

16. The Practical Approach: Age-Adapted Examination Sequence

Age	Strategy
Neonate	Examine fully undressed; warm room; all reflexes + red reflex + femoral pulses + hip exam mandatory
Infant (1-12m)	Start on parent's lap; distract with toy; examine chest/abdomen first; save throat/ears for last
Toddler (1-3y)	Most challenging; stay at eye level; allow to hold a toy; examine on parent's lap; approach slowly
Preschool (3-5y)	Engage with play; explain in simple terms; demonstrate on teddy bear
School age (6-12y)	Treat as adult with clear explanations; privacy important
Adolescent	Offer chaperone; examine appropriate privacy; separate from parent for sensitive issues

80/20 High-Yield Summary

What	Why it matters
PAT from the door	Sick vs. well determination in seconds
Age-appropriate vital signs	Tachycardia/tachypnoea are the earliest signs of illness in children
Fontanelle assessment	Bulging = ↑ICP; Sunken = dehydration
Red reflex	Retinoblastoma/cataract - must check in every infant
Femoral pulses in neonates	Coarctation of aorta - treatable but missed if not checked
Non-blanching rash	Meningococcaemia - 15-minute window for IV antibiotics
Capillary refill >2 sec	Best single sign of clinically significant dehydration
Fixed split S2	ASD - can be missed for years
Moro/primitive reflexes	Persisting beyond expected age = CP or brain injury
Barlow/Ortolani	DDH - treat before walking; missed = lifelong hip problems

Sources: Rosen's Emergency Medicine (Pediatric Assessment Triangle, PAT interpretation, dehydration signs); Roberts and Hedges' Clinical Procedures in Emergency Medicine (vital sign tables - Bonafide et al, Pediatrics 2013); Barash's Clinical Anesthesia (hepatic pharmacokinetics); clinical standard references.

Head to toe example scenario example examine then give the findings..made easy

Finding Sources

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Pediatric Head-to-Toe Physical Examination

3 Scenarios: Examine → Find → Interpret

The format for each section: What you DO → What you FIND → What it MEANS

🧒 SCENARIO 1: "Ahmed, 8 months old, fever and not feeding well"

Mum brings Ahmed to the clinic. He was well 2 days ago. Now has fever, crying more than usual, and refused his last two bottle feeds.

STEP 1 — FROM THE DOORWAY (PAT)

What you DO: Before entering, stand at the door and observe for 10 seconds. Don't touch. Don't speak. Just look.

What you observe	What you find
Appearance (TICLS)	Ahmed is lying in mum's arms. He's awake. He looks at you briefly but doesn't track. Mum jiggles him but he doesn't smile or reach out. Cry is weak when he fusses.
Work of breathing	Shirt is on - ask mum to lift it. You see mild subcostal recession. Nostrils flare slightly with each breath. No stridor.
Circulation to skin	Skin looks pale. No rash visible yet.

What it MEANS: PAT is ABNORMAL on all three sides.

Abnormal appearance + abnormal breathing + abnormal circulation = Cardiopulmonary compromise or severe illness. This baby is SICK. Move quickly.

STEP 2 — GENERAL IMPRESSION & VITAL SIGNS

What you DO: Lay Ahmed on the examination couch. Count respiratory rate for 60 seconds (watch chest/abdomen without touching). Then measure HR, temperature, SpO₂, weight.

Vital sign	Finding	Normal for 8 months	Interpretation
Respiratory rate	58 breaths/min	22-54 (5th-95th %ile)	Tachypnoeic - at upper limit of normal; with recession = significant
Heart rate	168 bpm	106-167 (5th-95th %ile)	Tachycardic
Temperature	38.9°C rectal	36.5-38.0°C	Fever
SpO₂	91% in room air	≥95%	Hypoxic - apply O₂ now
Weight	7.2 kg	Expected ~8.5 kg for age	Below expected - check growth chart
CRT (sternum)	3 seconds	<2 seconds	Prolonged - poor perfusion

STEP 3 — HEAD

What you DO: With Ahmed lying flat, place two fingers gently over the anterior fontanelle. Ask mum to hold him upright and calm for 30 seconds, then reassess the fontanelle.

What you find	What it MEANS
Anterior fontanelle: bulging, tense, non-pulsatile when upright and calm	↑ Intracranial pressure - meningitis, encephalitis, subdural haematoma. Red flag - do not delay.
Head circumference: 44 cm	Normal for 8 months
Posterior fontanelle: closed	Normal (closes by 6-8 weeks)

⚠️ Key rule: Assess fontanelle with baby UPRIGHT and CALM. Crying raises ICP and causes false-positive bulging. A bulging fontanelle when calm and upright = pathological until proven otherwise.

STEP 4 — EYES

What you DO: Shine torch at each eye from 30 cm. Check pupils. Shine through ophthalmoscope for red reflex. Observe eye movement.

What you find	What it MEANS
Pupils equal, 3mm, reacting briskly to light	Normal - no herniation
Red reflex present bilaterally (orange glow)	Normal - no cataract/retinoblastoma
Eyes appear mildly sunken	Dehydration
Mucous membranes: dry	Confirms dehydration

STEP 5 — EARS, NOSE, THROAT

What you DO: This will upset Ahmed - save for near the end. Wrap him in mum's arms ("headlock" position). Use otoscope on each ear. Depress tongue gently to see posterior pharynx - 5 seconds max.

What you find	What it MEANS
Right tympanic membrane: red, bulging, opaque, no light reflex	Acute otitis media (AOM) right ear - common precipitant of fever and irritability
Left TM: pearly grey, cone of light visible	Normal
Posterior pharynx: mild erythema, no exudate	Non-specific inflammation
Mouth: mucous membranes very dry, no thrush	Confirms dehydration

STEP 6 — NECK

What you DO: With Ahmed lying flat, place your hand under his head and gently flex the neck forward. Watch his face and hips/legs. Then test Kernig's: flex hip 90° and try to extend the knee.

What you find	What it MEANS
Neck: stiff - resistance and crying on flexion	Meningism - possible meningitis
Brudzinski's sign: positive - hips and knees flex when neck is flexed	Meningism confirmed
Kernig's sign: positive - unable to extend knee beyond 100°	Meningism
Cervical lymphadenopathy: 2-3 small tender nodes bilaterally (~0.5 cm)	Reactive - consistent with infection

⚠️ Key rule in infants: Meningeal signs can be absent in infants <18 months even with proven meningitis. A bulging fontanelle + fever + irritability in an infant = treat as meningitis even without neck stiffness.

STEP 7 — SKIN (do this early if not done at door)

What you DO: Fully undress Ahmed. Examine all skin systematically in good light. Use a glass (or press firmly with finger) to test any spots.

What you find	What it MEANS
Scattered petechiae on trunk and lower limbs - do not blanch under glass	Non-blanching rash = meningococcaemia until proven otherwise. EMERGENCY.
Two petechiae above the nipple line	Above nipple line in a well child after vomiting = may be benign Valsalva. In this case - child is unwell, so still urgent
Skin pale, mottled on lower limbs	Poor peripheral perfusion - compensated shock

🚨 STOP THE EXAM. This child has:

Fever + non-blanching rash + meningeal signs + bulging fontanelle + tachycardia + prolonged CRT

Give IV/IM benzylpenicillin NOW. Do not wait for LP. Call senior. Transfer.

STEP 8 — CHEST / RESPIRATORY

What you DO: Expose chest. Observe, then auscultate all zones (2 anterior, 2 lateral, 4 posterior).

What you find	What it MEANS
Subcostal + mild intercostal recession	Increased work of breathing
Respiratory rate 58/min	Tachypnoea - compensating for metabolic acidosis (sepsis)
Auscultation: clear air entry bilaterally, no wheeze, no crackles	Lungs are clear - respiratory distress is FROM SEPSIS, not primary lung pathology
Percussion: resonant bilaterally	No consolidation, no effusion

Teaching point: Tachypnoea without primary lung findings = suspect metabolic acidosis / sepsis / shock. Not everything tachypnoeic has a respiratory cause.

STEP 9 — CARDIOVASCULAR

What you DO: Palpate apex beat. Auscultate all 4 areas (aortic, pulmonary, tricuspid, mitral). Feel femoral pulses (always in infants).

What you find	What it MEANS
Apex beat: 4th ICS, MCL	Normal for age
Heart sounds: S1 + S2, no murmur	No structural heart disease contributing
Femoral pulses: present but weak bilaterally	Reduced cardiac output from septic shock
Peripheral pulses (brachial): fast, weak, thready	Shock - poor perfusion
CRT (sternum): 3 sec	Shock confirmed

STEP 10 — ABDOMEN

What you DO: Warm your hands. Ahmed is now lying on the couch. Kneel to his level. Auscultate first (5 seconds), then gently palpate all 9 zones starting away from areas of tenderness.

What you find	What it MEANS
Bowel sounds: present, active	Normal
Abdomen: soft, not distended	No obstruction, no peritonitis
No organomegaly palpable	No hepatosplenomegaly at this stage
No palpable masses

STEP 11 — NEUROLOGY (rapid, targeted)

What you DO: Observe tone and movement. AVPU assessment. Check if primitive reflexes persist normally for age.

What you find	What it MEANS
AVPU: V (responds to voice only, sluggishly)	Altered consciousness - serious CNS involvement
Tone: normal	No focal neurological deficit yet
Moro reflex: exaggerated	Non-specific irritability/hyperexcitability (meningeal irritation)
No focal weakness, moves all limbs	No focal CNS lesion yet

🔍 PUTTING IT ALL TOGETHER — Ahmed's Findings Summary

System	Finding	Flag
General	Unwell, pale, mottled, poor response	🔴 Sick
Vitals	HR 168, RR 58, Temp 38.9, SpO₂ 91%, CRT 3s	🔴 Septic shock
Head	Bulging AF when upright and calm	🔴 ↑ICP
Eyes	Sunken, dry mucosae	🟡 Dehydration
Ears	AOM right ear	🟡 Source of infection
Neck	Neck stiffness, Kernig's +, Brudzinski's +	🔴 Meningism
Skin	Non-blanching petechiae trunk/legs, mottling	🔴 Meningococcaemia
Chest	Tachypnoea, recession, clear lung fields	🟡 Sepsis-driven
CVS	Tachycardia, weak pulses, no murmur	🔴 Septic shock
Abdomen	Soft, normal	🟢
Neuro	AVPU = V, hyperexcitable	🔴 CNS involvement

Diagnosis: Bacterial Meningitis / Meningococcal Septicaemia

Immediate Management:

IV/IM benzylpenicillin (or ceftriaxone) NOW - do not delay for LP
High-flow O₂ (target SpO₂ ≥94%)
IV access + blood culture, FBC, CRP, U&E, glucose, clotting, blood gas
20 mL/kg 0.9% NaCl fluid bolus for shock
Urgent paediatric intensive care transfer

👧 SCENARIO 2: "Layla, 3 years old, barking cough and noisy breathing"

Mum brings Layla at 2am. She had a mild cold for 2 days. Tonight she suddenly woke up with a harsh, barking cough and noisy breathing. She's scared but recognises mum.

FROM THE DOOR — PAT

Component	Finding	Meaning
Appearance	Layla is scared, clinging to mum, crying. She tracks you with her eyes. Consolable when mum holds her.	Appearance: mostly normal - brain is perfusing
Work of breathing	You hear inspiratory stridor from the door without a stethoscope. You can see mild suprasternal retraction.	Abnormal - upper airway obstruction
Circulation to skin	Pink skin, no mottling, no petechiae	Normal

PAT interpretation: Abnormal work of breathing + normal appearance + normal circulation = Respiratory distress, child compensating. Not immediately life-threatening but needs assessment.

⚠️ Critical distinction: Layla is distressed but consolable. If she were toxic-appearing, sitting forward, drooling, and refusing to lie down → suspect epiglottitis not croup. Do NOT examine throat in that scenario.

VITAL SIGNS

Sign	Finding	Meaning
RR	34 breaths/min	Mildly elevated (normal ~24 at age 3)
HR	126 bpm	Mildly elevated (normal ~117 at 3 years - consistent with distress)
Temp	37.8°C	Low-grade fever
SpO₂	96% in air	Adequate but monitor
CRT	<2 sec	Normal perfusion

HEAD & NECK

What you DO → What you FIND → What it MEANS:

Step	Finding	Meaning
General head	No swelling, fontanelles not relevant (closed at 3 years)	Normal
Mouth - at distance only	Moist mucous membranes, no drooling	Reassuring - epiglottitis less likely
Voice quality	Hoarse voice when she speaks	Hoarse voice = laryngeal/subglottic involvement = croup
Neck	No neck stiffness, no lymphadenopathy >1 cm	No meningism, reactive nodes
Throat - defer	Do NOT instrument or aggressively examine the throat yet	If epiglottitis risk: can cause complete obstruction

RESPIRATORY EXAM

What you DO: Undress upper body. Observe then auscultate.

Finding	Meaning
Inspiratory stridor, musical, heard without stethoscope	Upper airway obstruction - subglottic (croup)
Mild suprasternal + supraclavicular recession	Increased negative intrathoracic pressure to pull air past obstruction
No intercostal/subcostal recession	Mild-moderate, not severe
No seesaw breathing, no head bobbing	Not impending respiratory failure
Auscultation: transmitted stridor throughout, clear air entry bilaterally, no wheeze, no crackles	Subglottic not lower airway - confirms croup, not bronchiolitis
Percussion: resonant	Normal

Croup Severity Scoring (Westley Score simplified)

Feature	Layla	Score
Stridor	At rest	2
Retraction	Mild (suprasternal)	1
Air entry	Normal	0
Cyanosis	None	0
Consciousness	Normal	0
Total		3 = MODERATE CROUP

(0-2 = mild; 3-7 = moderate; ≥8 = severe)

CARDIOVASCULAR & ABDOMEN

Finding	Meaning
Heart: regular, no murmur, normal S1+S2	No cardiac cause of distress
Abdomen: soft, non-tender, no organomegaly	Normal
Skin: no rash	No viral exanthem to suggest specific diagnosis, but consistent with parainfluenza

🔍 LAYLA'S FINDINGS SUMMARY

System	Finding	Flag
General	Scared but alert, consolable, pink	🟢 Well-appearing
Vitals	Mild tachycardia, low-grade fever, SpO₂ 96%	🟡 Monitoring needed
Voice	Hoarse	🟡 Laryngeal involvement
Breathing	Inspiratory stridor, mild suprasternal recession, clear lungs	🟡 Upper airway obstruction
Skin	Pink, warm, no rash	🟢

Diagnosis: Moderate Viral Croup (Laryngotracheobronchitis)

Most likely causative agent: Parainfluenza virus

Management:

Single dose oral/IM dexamethasone 0.15-0.6 mg/kg (reduces airway oedema, works within 30-60 min)
If moderate-severe: nebulised adrenaline (epinephrine) 0.5 mL/kg of 1:1000, max 5 mL
Nurse in position of comfort - do NOT force supine
Reassess after 30 minutes
Admit if stridor at rest persists, SpO₂ falls, severe recession develops

👦 SCENARIO 3: "Omar, 10 years old, right-sided abdominal pain for 18 hours"

Omar comes with his dad. Started with pain around his belly button yesterday. Now the pain has moved to the right side. He vomited twice. He doesn't want to eat. He walked into the room slowly and hunched slightly forward.

FROM THE DOOR — PAT

Component	Finding	Meaning
Appearance	Omar is alert, talking to dad, answers your questions. Looks pale and uncomfortable.	Appearance: mildly abnormal - pain/systemic illness
Work of breathing	Normal rate, no recession	Normal
Circulation	Pale but no mottling, no rash	Mildly abnormal

PAT: Mildly unwell. Stable enough for systematic examination. Not immediately life-threatening - but this presentation demands urgent assessment.

VITAL SIGNS

Sign	Finding	Normal (10 years)	Meaning
Temp	38.1°C	<37.5°C	Low-grade fever
HR	108 bpm	~87 (50th %ile)	Tachycardia - pain + early sepsis
RR	20 breaths/min	~21	Normal
SpO₂	99%	≥95%	Normal
CRT	1.5 sec	<2 sec	Normal

GENERAL INSPECTION

What you DO → What you FIND → What it MEANS:

Observation	Finding	Meaning
Gait entering room	Walking hunched forward, slightly antalgic	Peritoneal irritation - straightening the abdomen stretches peritoneum and causes pain
Preferred position on couch	Lying still, knees slightly flexed	Flexion reduces abdominal wall tension - peritoneal irritation
Facial expression	Grimacing when moving, pale	Pain and systemic illness
Skin	Pale, no rash	Systemic effect of infection

HEAD / EYES / MOUTH

Finding	Meaning
Mucous membranes: slightly dry	Reduced oral intake ± vomiting - mild dehydration
No conjunctival pallor	No significant anaemia
Sclera: white	No jaundice
Tongue: furred	Non-specific, reduced intake

CHEST

Finding	Meaning
Clear air entry bilaterally, no wheeze	No respiratory pathology (right lower lobe pneumonia can mimic appendicitis - important to exclude)
Normal percussion	No consolidation
No tachypnoea	Respiratory not primary

⚠️ Always auscultate the chest in a child with abdominal pain. Right lower lobe pneumonia frequently presents as right-sided abdominal pain in children - and treatment is completely different.

CARDIOVASCULAR

Finding	Meaning
Tachycardia 108 bpm	Pain + early systemic inflammation
Normal S1+S2, no murmur	No cardiac pathology
Peripheral pulses normal	Adequate perfusion
CRT <2 sec	Not shocked

ABDOMEN — The Key Section

Technique tips:

Warm hands. Kneel to Omar's level.
Ask "can you point with one finger where it hurts most?" → RIF
Start palpation away from the pain (left iliac fossa first)
Watch his FACE not your hands - his expression will tell you more
Ask him to cough or take a deep breath while you observe

Step	What you DO	What you FIND	What it MEANS
Inspection	Look at abdomen	Flat, moves with breathing, no distension, no scars	No obstruction, no perforation yet
Auscultation	10 seconds per quadrant	Present, mildly hypoactive	Mild ileus - consistent with inflammation
Percussion	All 9 zones	Percussion tenderness RIF	Localised peritoneal irritation
Light palpation - LIF	Gentle superficial palpation	Soft, non-tender	Normal
Light palpation - RIF	Gentle superficial palpation	Guarding - involuntary muscle rigidity	Peritoneal irritation - appendix wall or peritoneum inflamed
Deep palpation - McBurney's point (1/3 from ASIS to umbilicus)	Press firmly and slowly	Maximal tenderness at McBurney's point	Appendicitis - 68% of cases have tenderness here
Rovsing's sign	Press left iliac fossa firmly	Pain felt in RIGHT iliac fossa (not left)	Referred peritoneal irritation = appendicitis
Rebound tenderness	Press RIF slowly, release suddenly	Pain worse on release	Peritoneal inflammation
Heel strike test	Ask Omar to stand on tiptoes and drop onto heels	RIF pain on landing	Peritoneal irritation (less distressing for child than rebound)
Jump test	Ask him to jump up and down	Worsening RIF pain	"The three most useful tests: cough, walk, and jump" - Tintinalli's
Psoas sign	Left lateral decubitus, extend right hip against resistance	RIF pain	Retrocaecal appendix irritating psoas muscle
Organomegaly	Palpate for liver/spleen	Not palpable	Normal
Hernial orifices	Inguinal rings bilaterally	No hernia	Normal - important to check
Testes (vital in boys)	Gentle palpation of scrotal contents	Non-tender, both testes present and normally positioned	Testicular torsion excluded - always check in boys with lower abdominal pain

From Tintinalli's Emergency Medicine: "Assessing pain when the child coughs, walks, and jumps is useful for detecting peritoneal inflammation. Rebound tenderness and guarding are more common with perforation and may be absent in early appendicitis."

NEUROLOGY / MUSCULOSKELETAL

Finding	Meaning
Alert and oriented	Normal CNS
Gait: antalgic, hunched	Peritoneal guarding
Normal tone and power	No neuromuscular pathology

🔍 OMAR'S FINDINGS SUMMARY

System	Finding	Flag
General	Pale, antalgic posture, hunched gait	🟡 Unwell
Vitals	Low-grade fever, tachycardia, otherwise stable	🟡
Chest	Clear - pneumonia excluded	🟢
Abdomen	Maximal RIF tenderness, guarding, Rovsing's +, rebound +, positive jump/cough test	🔴 Appendicitis
Testes	Normal - torsion excluded	🟢

Diagnosis: Acute Appendicitis

Alvarado Score (MANTRELS) for Omar:

Feature	Present?	Score
Migration of pain to RIF	Yes	1
Anorexia	Yes	1
Nausea/vomiting	Yes	1
Tenderness RIF	Yes	2
Rebound tenderness	Yes	1
Elevated temperature (>37.3°C)	Yes	1
Leukocytosis (to be confirmed)	Pending	2
Shift to left on WCC	Pending	1
Total		7/10 = HIGH RISK

Score ≥7 = high probability of appendicitis → urgent surgical referral

Management:

IV access, blood tests: FBC (expect leukocytosis), CRP (elevated), U&E, LFTs, amylase, urine dipstick (exclude UTI/urolithiasis)
IV fluid resuscitation (nil by mouth)
Analgesia (do NOT withhold - does NOT mask signs)
Ultrasound abdomen (first-line imaging in children - no radiation; appendix >6mm diameter + non-compressible = diagnostic)
If US inconclusive + high clinical suspicion → CT or surgical exploration
Urgent surgical consultation for appendicectomy

🎓 Master Comparison Table — The 3 Scenarios

Feature	Ahmed (8m)	Layla (3y)	Omar (10y)
PAT	All 3 abnormal	WOB abnormal only	Mildly abnormal appearance
Key finding	Bulging AF + petechiae + neck stiffness	Inspiratory stridor + hoarse voice	RIF guarding + Rovsing's + migration
Diagnosis	Meningococcaemia	Moderate croup	Appendicitis
Do NOT do	Delay antibiotics for LP	Examine throat if epiglottitis suspected	Withhold analgesia
Do immediately	Benzylpenicillin IM/IV + O₂	Dexamethasone ± nebulised adrenaline	Surgical consult + USS
Life-threatening risk	Death in hours if untreated	Complete airway obstruction if severe	Perforation + peritonitis if delayed

🔑 The 5 Exam Rules That Apply to Every Child

Rule	Why
1. Assess from the door first	PAT saves lives - you know sick vs. well before touching
2. Undress fully	Petechiae, recession, abdominal distension are missed through clothing
3. Save upsetting exams last	Throat, ears, rectal exam - do these last or the child will cry through everything else
4. Watch the face, not your hands	A child's grimace tells you more than your fingers
5. Age-appropriate normal values	A HR of 168 is normal in a neonate but shock in a 10-year-old

Discuss infectious disease in pediatrics upto their ideal management 80/20

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Pediatric Infectious Diseases — 80/20 Guide

The conditions that fill 80% of wards, clinics, and exams

THE MASTER FRAMEWORK

Before any specific disease, know these 4 universal rules of pediatric infectious disease:

Rule	Principle
1. Age defines the pathogen	A 2-week-old with meningitis ≠ a 5-year-old with meningitis - organisms differ completely
2. Fever + age <28 days = emergency	Any fever ≥38°C in a neonate → full sepsis workup + empiric antibiotics. No exceptions.
3. Viral > bacterial	Most pediatric respiratory and GI infections are viral. Antibiotics often NOT needed.
4. Immunization gaps = high-yield diagnoses	The unimmunized child is your clue: Hib meningitis, epiglottitis, pertussis, measles

SECTION 1 — CNS INFECTIONS

1.1 Bacterial Meningitis

The one you cannot miss.

Age-Based Pathogens (memorize this table)

Age	Top Pathogens	Empiric Treatment
<1 month (neonate)	Group B Strep (GBS), E. coli, Listeria monocytogenes	Ampicillin + Cefotaxime (ceftriaxone contraindicated <1 month - displaces bilirubin)
1-23 months	S. pneumoniae, N. meningitidis, GBS, H. influenzae	Vancomycin + Ceftriaxone
2+ years	S. pneumoniae, N. meningitidis, H. influenzae	Vancomycin + Ceftriaxone

"Initiate antibiotics as soon as the possibility of bacterial meningitis is considered; do not delay antibiotics for head CT or LP." - Harriet Lane Handbook, 23rd Ed

Clinical Presentation

Neonates: fever OR hypothermia, lethargy, poor feeding, vomiting, high-pitched cry, bulging fontanelle, seizures (classic neck stiffness often ABSENT)
Infants/children: fever + headache + neck stiffness + photophobia + vomiting
Kernig's sign (can't extend knee from 90° hip flexion) + Brudzinski's sign (neck flex → hip flex) - unreliable <18 months
Meningococcal disease: non-blanching petechiae/purpura = septicaemia - give penicillin IMMEDIATELY

Investigations

LP (lumbar puncture): Gram stain, culture, CSF analysis

Parameter	Normal	Bacterial	Viral	TB
Appearance	Clear	Turbid/cloudy	Clear	Fibrin web
WCC	<5	>1000 (neutrophils)	10-500 (lymphocytes)	50-500 (lymphocytes)
Protein	0.15-0.45	↑↑ (>1)	Mildly ↑	↑↑
Glucose	>60% serum	Low (<40% serum)	Normal	Very low
Gram stain	Negative	Often positive	Negative	Negative

CT head before LP only if: immunocompromised, known CNS disease, papilloedema, focal neurological deficit - but DO NOT delay antibiotics for CT

Management

Antibiotics immediately - vancomycin + ceftriaxone (>1 month)
Dexamethasone 0.15 mg/kg IV q6h × 2 days: reduce hearing loss in H. influenzae meningitis; also benefit in pneumococcal meningitis in adults/older children. Give with FIRST antibiotic dose.
Manage raised ICP: head of bed 30°, restrict fluids initially, avoid hypotonic fluids
Seizure management: benzodiazepines acutely
Duration: S. pneumoniae: 10-14 days | N. meningitidis: 5-7 days | GBS: 14-21 days | Listeria: 21 days

Meningococcal Septicaemia - separate emergency track

Non-blanching rash + fever → give benzylpenicillin/ceftriaxone IM before transfer
Dose: Benzylpenicillin: <1 year 300mg IM, 1-9 years 600mg IM, >10 years 1200mg IM
Fluid resuscitation 20 mL/kg 0.9% NaCl bolus for shock
PICU referral
Chemoprophylaxis for close contacts: rifampicin or ciprofloxacin or ceftriaxone IM (single dose)

SECTION 2 — RESPIRATORY INFECTIONS

2.1 Upper Respiratory Tract Infection (URTI / Common Cold)

Most common childhood illness. Most important skill: knowing when NOT to treat.

Cause: Rhinovirus (most common), coronavirus, RSV, parainfluenza, adenovirus
Management: supportive only - fluids, paracetamol/ibuprofen for fever/discomfort
No antibiotics: viral cause, antibiotics cause harm (resistance, C. diff, allergy)
Average child has 6-8 URTIs per year - this is NORMAL
Amber flag → consider bacterial secondary infection if: symptoms worsening after 5 days, fever persisting >5 days, localising symptoms (ear pain, facial pain)

2.2 Acute Otitis Media (AOM)

Most common reason antibiotics are prescribed in children.

Diagnosis

Red, bulging, opaque tympanic membrane ± perforation with discharge
+/- Fever, irritability, ear tugging (non-specific in infants)
Must distinguish from otitis media with effusion (OME/"glue ear") - dull, amber TM, no acute infection, no antibiotics

Pathogens

S. pneumoniae, H. influenzae (nontypeable), M. catarrhalis

Management — The Key Decision Tree

AOM confirmed
     ↓
Age <6 months → ALWAYS TREAT with antibiotics
     ↓
Age 6-23 months, bilateral AOM → TREAT
     ↓
Age 6-23 months, unilateral AOM, NO otorrhoea, NO severe symptoms → Watchful waiting 48-72h
     ↓
Age ≥24 months, unilateral/bilateral AOM, NO severe symptoms → Watchful waiting 48-72h
     ↓
ANY AGE, severe symptoms (fever >39°C, otalgia >48h, toxic appearance) → TREAT

"Consider watchful waiting if: 6-23 months - unilateral AOM without otorrhea or severe symptoms; 24+ months - unilateral or bilateral AOM without otorrhea or severe symptoms" - Harriet Lane Handbook

Antibiotic choice

Scenario	Drug	Duration
First line	Amoxicillin 80-90 mg/kg/day in 2 divided doses (high dose to overcome resistant pneumococcus)	10 days (<2 years), 5-7 days (≥2 years)
Treatment failure at 48-72h	Amoxicillin-clavulanate 90 mg/kg/day	10 days
PCN allergy (non-severe)	Cephalexin or cefdinir	10 days
PCN allergy (severe/anaphylaxis)	Azithromycin × 5 days	5 days
Recurrent AOM (≥3 in 6 months)	ENT referral for grommets	-

2.3 Croup (Laryngotracheobronchitis)

Most common cause of acute upper airway obstruction in children.

Quick Facts

Age: 6 months - 3 years (peak 2 years)
Cause: Parainfluenza virus type 1 (most common), also types 2, 3, RSV, influenza
Season: Autumn
Pathology: Subglottic oedema → narrowed airway → turbulent flow → stridor

Clinical Features

Barking "seal-like" cough (pathognomonic)
Hoarse voice (laryngeal involvement)
Inspiratory stridor (worsens with agitation)
Low-grade fever
Onset often at night after 1-2 days of mild URTI
Child is ANXIOUS but CONSOLABLE - if toxic and drooling → think epiglottitis

Westley Croup Score

Feature	0	1	2	3	5
Stridor	None	At rest (mild)	-	-	-
Retractions	None	Mild	Moderate	Severe	-
Air entry	Normal	Mildly decreased	Severely decreased	-	-
Cyanosis	None	-	With agitation	-	At rest
Consciousness	Normal	-	-	-	Altered

0-2: Mild - manage at home
3-7: Moderate - treat, observe in ED
≥8: Severe - may need intubation

Management

Severity	Treatment
All croup	Single dose oral dexamethasone 0.15-0.6 mg/kg (reduces oedema; onset 30-60 min; works for 24-48h)
Moderate-severe	Add nebulised adrenaline (epinephrine) 0.5 mL/kg of 1:1000, max 5 mL via face mask - onset 10-30 min, duration 2 hours (rebound possible)
Severe/impending failure	Humidified O₂, call anaesthetics, prepare for intubation; intubate with tube 0.5-1mm smaller than usual
Antibiotics	NOT indicated (viral cause)

If child improves with nebulised adrenaline: observe 2-4 hours minimum for rebound. Discharge when stridor resolved and SpO₂ normal.

Epiglottitis vs. Croup - Critical Distinction:

Feature	Croup	Epiglottitis
Age	6m-3 years	Any (post-Hib vaccination: adolescents/adults)
Onset	Gradual (URTI prodrome)	Acute, rapid (hours)
Cough	Barking, harsh	Absent or muffled
Voice	Hoarse	Muffled "hot potato" voice
Drooling	Absent	Present (can't swallow)
Position	Any	Tripod/sniffing, REFUSES to lie flat
Fever	Low-grade	High (>39°C), toxic
Stridor	Inspiratory	Both inspiratory and expiratory
X-ray	Steeple sign (subglottic narrowing)	Thumbprint sign (enlarged epiglottis)
Action	Dexamethasone ± adrenaline	DO NOT examine throat. Call anaesthetics NOW. Secure airway in OR.

2.4 Community-Acquired Pneumonia (CAP)

Age-Based Pathogens

Age	Most Likely Pathogen
Neonate-3 months	GBS, E. coli (bacterial), RSV (viral), Chlamydia trachomatis (afebrile pneumonia, staccato cough)
3 months-5 years	Viral (RSV, parainfluenza, adenovirus) most common; S. pneumoniae (bacterial), H. influenzae
5-18 years	S. pneumoniae still important; Mycoplasma pneumoniae (atypical - "walking pneumonia"), Chlamydophila pneumoniae

Clinical Features

Fever + tachypnoea + cough ± hypoxia
Decreased breath sounds, crackles, dullness to percussion (lobar pneumonia)
Tachypnoea is the most sensitive sign (WHO diagnostic criterion)

WHO Tachypnoea Thresholds for Pneumonia Diagnosis

Age	Tachypnoea threshold
<2 months	≥60 breaths/min
2-12 months	≥50 breaths/min
1-5 years	≥40 breaths/min

Management by Severity

Setting	Antibiotic	Notes
Outpatient	High-dose amoxicillin × 5 days (80-90 mg/kg/day in 2 doses)	First-line for typical bacterial CAP in immunized children
Outpatient, atypical suspected (school age, subacute)	Amoxicillin + azithromycin OR azithromycin alone	Mycoplasma: azithromycin 10 mg/kg day 1, then 5 mg/kg days 2-5
Inpatient	IV ampicillin 200 mg/kg/day ÷ q6h	Switch to oral when improving
Inpatient, PCN-resistant concern	IV ceftriaxone 50-100 mg/kg/day
ICU	IV ceftriaxone + vancomycin/linezolid (empirical MRSA cover)	Consider S. aureus superinfection post-influenza
Viral CAP	Supportive only; oseltamivir if influenza confirmed within 48h

Admit criteria:

Age <3-6 months
SpO₂ <92% in air
Respiratory distress (recession, respiratory rate severely elevated)
Failure to feed / dehydration
Complications (empyema, effusion)
Social concerns

"Respiratory viruses cause the majority of CAP, especially in young children; thus, antibiotic therapy may not be indicated for all patients." - Red Book 2021

2.5 Bronchiolitis

Most common lower respiratory tract infection in infants.

Age: <2 years (peak <6 months)
Cause: RSV (80%), also rhinovirus, parainfluenza, adenovirus, hMPV
Season: Winter (October-March in northern hemisphere)
Pathology: Inflammation + oedema + mucus plugging of bronchioles

Clinical Features

1-3 days URTI → wheeze + crackles + tachypnoea + recession
Feeding difficulty (nose blocked, tachypnoeic)
SpO₂ may drop
Apnoea risk (especially in infants <2 months and ex-premature)

Management — The key is knowing what DOESN'T work

Intervention	Evidence	Recommendation
Supportive care (O₂, feeds, fluids)	✅ Effective	Do this
Oxygen (target SpO₂ ≥92%)	✅ Effective	Do this
NG tube feeds if SpO₂ drops with feeding	✅ Effective	Do this
Salbutamol (bronchodilator)	❌ Multiple RCTs: no benefit	Do NOT use
Nebulised hypertonic saline	❌ No benefit in ED	Not recommended
Antibiotics	❌ Viral cause	Do NOT use routinely
Steroids	❌ No benefit	Do NOT use
Chest physiotherapy	❌ No benefit	Do NOT use

Admit criteria:

SpO₂ <92% persistently
Respiratory rate severely elevated
Feeding <50% normal
Age <6 weeks, ex-premature
Apnoea episodes
Social concerns

Palivizumab prophylaxis: Monthly IM injection in RSV season for high-risk infants (ex-premature <29 weeks gestation, chronic lung disease, haemodynamically significant CHD)

2.6 Group A Streptococcal (GAS) Pharyngitis / Tonsillitis

Diagnosis - Use Centor/McIsaac Score

Feature	Points
Exudate on tonsils	+1
Tender anterior cervical lymph nodes	+1
Fever (>38°C)	+1
Absence of cough	+1
Age 3-14 years	+1
Age ≥45 years	-1

Score ≤1: viral → no antibiotic, no swab
Score 2-3: test with rapid antigen detection test (RADT) or throat swab → treat if positive
Score ≥4: treat empirically

Rule: Antibiotics do NOT help viral pharyngitis. Stop prescribing for every sore throat.

Management

Drug	Duration	Notes
Amoxicillin 50 mg/kg/day (max 500mg) twice daily	10 days	First line; OR benzathine penicillin G IM single dose
PCN allergy (non-severe)	Cephalexin × 10 days
PCN allergy (severe)	Clindamycin × 10 days
Second-line	Azithromycin × 5 days	High resistance rates - use last

Why treat? Prevent rheumatic fever (rare but devastating: cardiac valvular damage). Also reduces duration and infectivity.

Scarlet fever: GAS pharyngitis + diffuse sandpaper rash (spares face, accentuates flexures - Pastia's lines) + strawberry tongue → same treatment as above

Complications to know:

Peritonsillar abscess: unilateral swelling, uvular deviation, trismus, "hot potato" voice → needle aspiration or I&D + antibiotics (amoxicillin-clavulanate or clindamycin), ENT referral
Rheumatic fever: fever + migratory polyarthritis + carditis + Sydenham's chorea + erythema marginatum + subcutaneous nodules (Jones criteria) → penicillin + aspirin/naproxen

SECTION 3 — GASTROINTESTINAL INFECTIONS

3.1 Gastroenteritis

Most common cause: viral. Most important treatment: oral rehydration.

Pathogens by Context

Pathogen	Clue
Rotavirus	Winter, unvaccinated child <5 years, profuse watery diarrhoea, vomiting
Norovirus	Any age, vomiting-predominant, explosive, school/daycare outbreaks
Salmonella	Raw eggs/poultry, can cause bloody diarrhoea, bacteraemia in young infants
Shigella	Bloody diarrhoea + fever, dysentery; seizures (Shigella toxin)
ETEC	Traveller's diarrhoea, watery
STEC O157:H7	Undercooked beef, bloody diarrhoea, risk of HUS - DO NOT give antibiotics
Campylobacter	Bloody diarrhoea, poultry exposure, can mimic appendicitis (mesenteric adenitis)
C. difficile	Post-antibiotic diarrhoea; asymptomatic colonisation common in infants <12 months (do NOT test)

Dehydration Assessment and Treatment

Severity	% Dehydration	Action
Mild (3-5%)	<30-50 mL/kg deficit	ORS 50 mL/kg over 4 hours + ongoing losses
Moderate (5-10%)	60-100 mL/kg deficit	ORS 100 mL/kg over 4 hours; if vomiting → NGT ORS
Severe (>10%)	>100 mL/kg deficit	IV fluid resuscitation 20 mL/kg 0.9% NaCl bolus then reassess, NGT when tolerating

ORS (Oral Rehydration Solution): WHO formula - glucose 75 mmol/L, sodium 75 mmol/L, osmolarity 245 mOsm/L. Works via sodium-glucose cotransporter in enterocyte - survives even in secretory diarrhoea.

"Enteral rehydration is preferred to intravenous regardless of etiology." - Harriet Lane Handbook

Antibiotic Use in Gastroenteritis - The Rules

Pathogen	Antibiotics?	If yes, drug
Viral (rotavirus, norovirus)	❌ Never	-
Salmonella (non-typhi, non-invasive)	❌ No - prolongs carriage	-
Salmonella (age <3 months, immunocompromised, bacteraemia)	✅ Yes	Ceftriaxone or azithromycin 3-14 days
Shigella (severe, young infant)	✅ Yes	Ceftriaxone × 2-5 days, azithromycin × 3 days
Campylobacter (severe)	✅ Yes	Azithromycin × 3-5 days
STEC O157:H7	🚫 CONTRAINDICATED	Antibiotics increase HUS risk
C. difficile (symptomatic ≥12 months)	✅ Yes	PO vancomycin (preferred) or metronidazole; discontinue offending antibiotic

Ondansetron: Safe and effective antiemetic in children >6 months for vomiting with gastroenteritis - single oral dose 0.15 mg/kg improves ORS tolerance.

SECTION 4 — URINARY TRACT INFECTIONS

4.1 UTI in Children

Important because untreated UTI → renal scarring → chronic kidney disease

Pathogens

E. coli (80%), Klebsiella, Enterococcus, Staphylococcus saprophyticus (adolescent girls)

Clinical Features by Age

Age	Presentation
Neonate/infant	Fever, poor feeding, lethargy, vomiting, jaundice, irritability - NO localizing signs
Toddler	Fever, abdominal pain, vomiting
School age	Frequency, dysuria, urgency, suprapubic pain (cystitis) OR fever + loin pain/CVA tenderness (pyelonephritis)
Adolescent girls	Classic LUTS (dysuria, frequency, urgency)

Pyelonephritis vs. Cystitis:

Pyelonephritis: fever >38°C + systemic illness + possibly loin pain / CVA tenderness
Cystitis: LUTS without fever or systemic illness

Diagnosis

Urine dipstick: nitrites (specific for gram-negative bacteria) + leucocyte esterase (WCC)
Both positive → treat; both negative → UTI unlikely
Urine culture: mandatory before starting antibiotics in children; ≥10⁵ CFU/mL = significant growth
Collection method matters:
- Catheter specimen (CSU): most reliable for infants
- Clean catch midstream (MSU): older children
- Pad urine: high contamination rate - only for initial dipstick, not culture
- Suprapubic aspiration (SPA): gold standard in neonates

Treatment

Setting	Drug	Duration
Cystitis, older child, outpatient	Trimethoprim 4 mg/kg twice daily OR nitrofurantoin 1 mg/kg four times daily	3-7 days
Pyelonephritis, outpatient (well child >3 months)	Co-amoxiclav (amoxicillin-clavulanate) OR cephalexin OR trimethoprim	7-10 days
Pyelonephritis, inpatient	IV ceftriaxone 50-75 mg/kg/day once daily	Until afebrile 24-48h, then switch to oral for total 10-14 days
Neonate (<1 month)	IV ampicillin + gentamicin (or ceftazidime)	10-14 days IV

After first UTI - Imaging:

Renal ultrasound: all children <2 years with first confirmed UTI (within 6 weeks)
MCUG (micturating cystourethrogram): only if USS abnormal, atypical UTI, or recurrent UTI - to detect vesicoureteric reflux (VUR)
DMSA scan: 4-6 months after acute infection - detects renal scarring; recommended for recurrent UTI or severe VUR

Vesicoureteric Reflux (VUR)

Retrograde flow of urine from bladder to ureter/kidney
Grades I-V (V = most severe, into renal pelvis with reflux nephropathy)
Low-grade (I-III): often resolves spontaneously; prophylactic trimethoprim in recurrent UTI
High-grade (IV-V): urology referral; consider surgical correction

SECTION 5 — SKIN AND SOFT TISSUE INFECTIONS

5.1 Impetigo

Cause: S. aureus (most common, produces bullous impetigo), S. pyogenes (GAS, non-bullous)
Features: golden-crusted lesions (non-bullous) or fluid-filled bullae (bullous)
Treatment: topical fusidic acid or mupirocin × 5-7 days for localised; oral flucloxacillin or cefalexin × 7 days for widespread/systemic symptoms; MRSA: clindamycin or trimethoprim-sulfamethoxazole

5.2 Cellulitis

Spreading erythema, warmth, oedema, pain, fever
Cause: S. pyogenes, S. aureus
Periorbital cellulitis (pre-septal, no proptosis, no ophthalmoplegia): IV cefazolin or cephalexin (mild) → switch oral after 24h improvement
Orbital cellulitis (post-septal): proptosis + restricted eye movement + pain on movement → CT orbit → IV ampicillin-sulbactam + vancomycin, SURGICAL EMERGENCY if abscess
Standard cellulitis: flucloxacillin/cefalexin orally for mild; IV for moderate-severe

SECTION 6 — KAWASAKI DISEASE

The great mimicker - and the leading cause of acquired heart disease in children in developed countries.

Diagnostic Criteria (Classic KD)

Fever ≥5 days + ≥4 of the following 5 criteria (or fewer with coronary artery changes):

Criterion	Feature	Memory
Conjunctivitis	Bilateral, non-purulent
Rash	Polymorphous, trunk
Adenopathy	Cervical, unilateral, >1.5 cm
Strawberry tongue / oral changes	Erythema of lips, strawberry tongue, fissured lips
Hands and feet	Erythema/oedema of palms+soles acutely; desquamation of fingertips at 2-3 weeks

Mnemonic: CRASH or RASH + Fever >5 days

Why it Matters

25% of untreated children develop coronary artery aneurysms → myocardial infarction, sudden death
Must treat within first 10 days to prevent coronary involvement

Management

"IVIG and high-dose aspirin have an additive effect and, when initiated within 10 days from onset of illness, can substantially decrease the progression to coronary artery dilation and aneurysm formation." - Rosen's Emergency Medicine

IVIG 2 g/kg IV as a single infusion over 10-12 hours - given within first 10 days of illness
High-dose aspirin 80-100 mg/kg/day in 4 doses during febrile phase → switch to low-dose aspirin 3-5 mg/kg/day once afebrile × 6-8 weeks (or longer if coronary aneurysms)
Echocardiogram at diagnosis, 2 weeks, and 6-8 weeks
If resistant (fever persists ≥36h after IVIG): second dose IVIG 2g/kg OR infliximab OR corticosteroids

SECTION 7 — NEONATAL INFECTIONS

Special population - any fever in a neonate (<28 days) = emergency.

Neonatal Sepsis

Type	Onset	Pathogens	Key Risk Factors
Early onset (<72h)	Within 3 days	GBS, E. coli, Listeria	Maternal GBS+, prolonged rupture of membranes, prematurity, chorioamnionitis
Late onset (>72h)	3 days-3 months	GBS, E. coli, S. aureus, coagulase-negative Staph (CONS - NICU)	NICU stay, lines, prematurity

Presentation (any of these in neonate = act fast):

Fever ≥38°C OR hypothermia <36°C
Lethargy, hypotonia
Poor feeding, vomiting
Jaundice
Grunting, tachypnoea, apnoea
Bulging fontanelle, seizures
Mottled/grey skin, prolonged CRT

Management

Full septic screen: FBC, CRP, blood culture × 2, LP (CSF), urine (SPA/catheter), CXR
Empiric IV antibiotics: Ampicillin + Gentamicin (or cefotaxime for suspected meningitis)
Do NOT wait for results. Start within 1 hour of clinical suspicion.
Duration: 7 days if blood culture positive, 48h rule-out if cultures negative and CRP trending down

Neonatal Herpes (HSV)

Acquisition from maternal genital HSV during delivery (primary > recurrent)
Presentation: vesicular rash, hepatitis, encephalitis
Treat immediately with IV aciclovir 60mg/kg/day ÷ q8h × 14-21 days

SECTION 8 — FEVER WITHOUT A SOURCE (FWS)

Very common. Management depends entirely on age.

Age	Action
<28 days (neonate)	Full septic screen (FBC, CRP, blood/urine/CSF cultures, CXR) + admit + empiric ampicillin + gentamicin. No exceptions.
29-60 days	Blood culture + urine + CRP/PCT. Low-risk criteria (Rochester/NICE): if met, may observe without antibiotics. High-risk → LP + admit + antibiotics
3-36 months, well-appearing, vaccinated	Urine dipstick (UTI most common serious bacterial infection). Observe. Investigate if fever >39°C persists >48h.
>3 years, well, vaccinated	Clinical assessment. Most viral. Watchful waiting. Investigate if prolonged.

Rochester Low-Risk Criteria (for infants 29-60 days):

Previously healthy
No focal bacterial infection
WCC 5,000-15,000; band count <1,500; UA <10 WBC/hpf; stool WBC <5/hpf if diarrhoea

SECTION 9 — VACCINE-PREVENTABLE INFECTIONS (HIGH YIELD)

Know these because the unvaccinated child is a key exam and real-world scenario:

Disease	Cause	Key Features	Prevention
Measles	Paramyxovirus	Koplik spots → maculopapular rash (head → feet), 3 C's (Cough, Coryza, Conjunctivitis), fever, photophobia	MMR vaccine
Mumps	Paramyxovirus	Parotitis (bilateral) + orchitis (post-pubertal boys) + aseptic meningitis	MMR vaccine
Rubella	Togavirus	Mild rash, posterior cervical lymphadenopathy; devastating in 1st trimester pregnancy (CRS)	MMR vaccine
Pertussis (whooping cough)	Bordetella pertussis	Paroxysmal cough + inspiratory whoop + post-tussive vomiting + apnoea in infants	DTaP
Epiglottitis	H. influenzae type b	(see croup section above)	Hib vaccine
Chickenpox (VZV)	Varicella-zoster	Pruritic vesicular rash, crops at different stages simultaneously	Varicella vaccine

Pertussis treatment: Azithromycin × 5 days (or erythromycin × 14 days) - reduces infectivity; limited clinical benefit after the paroxysmal stage begins. Treat all contacts.

Measles: Supportive + vitamin A supplementation (WHO recommendation, reduces severity and mortality in developing countries and vitamin A-deficient children)

THE MASTER 80/20 TABLE — Drugs Every Pediatric Clinician Must Know

Condition	First-Line Drug	Dose Principle
Bacterial meningitis (>1 month)	Vancomycin + Ceftriaxone	Vancomycin 15 mg/kg q6h; Ceftriaxone 100 mg/kg/day
Bacterial meningitis (<1 month)	Ampicillin + Cefotaxime	Ampicillin 200-300 mg/kg/day
Meningococcaemia	Benzylpenicillin / Ceftriaxone	Benzylpenicillin IM: <1yr 300mg, 1-9yr 600mg, >10yr 1200mg
CAP (outpatient)	High-dose amoxicillin	80-90 mg/kg/day ÷ BD
CAP atypical	Azithromycin	10 mg/kg day 1, 5 mg/kg days 2-5
Croup	Dexamethasone ± nebulised adrenaline	Dex 0.15-0.6 mg/kg PO once
AOM (antibiotic required)	High-dose amoxicillin	80-90 mg/kg/day ÷ BD × 10 days (<2yr)
GAS pharyngitis	Amoxicillin	50 mg/kg/day ÷ BD × 10 days
UTI cystitis	Trimethoprim or nitrofurantoin	Trimethoprim 4 mg/kg BD × 7 days
UTI pyelonephritis (inpatient)	IV Ceftriaxone	50-75 mg/kg/day once daily
Kawasaki disease	IVIG + high-dose aspirin	IVIG 2 g/kg IV single dose
Neonatal sepsis	Ampicillin + Gentamicin	Ampicillin 200 mg/kg/day; Gentamicin once daily dosing
Neonatal HSV	IV Aciclovir	60 mg/kg/day ÷ q8h × 14-21 days
C. difficile	PO Vancomycin	10 mg/kg QDS × 10 days (preferred over metronidazole)
STEC O157:H7	Supportive ONLY	⛔ Antibiotics CONTRAINDICATED - increase HUS risk
Bronchiolitis	Supportive + O₂	⛔ No salbutamol, no steroids, no antibiotics

Sources: Harriet Lane Handbook 23rd Ed (Johns Hopkins), Red Book 2021 (AAP), Rosen's Emergency Medicine, Harrison's Principles of Internal Medicine 22nd Ed, Tintinalli's Emergency Medicine

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