Case study on kwshirkor and head to examination with nursing care plan

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kwashiorkor child malnutrition edema clinical features

Clinical photograph of a 2-year-old child exhibiting dermatological and systemic manifestations of severe acute malnutrition (SAM). The image displays the torso and lower extremities of a pediatric patient with notable pallor. Significant pitting edema is visible in the lower limbs, particularly involving the legs and feet, giving the extremities a swollen, rounded appearance. The skin texture is markedly dry and xerotic with diffuse scaly areas. These cutaneous changes, including the scaly dermatosis and edema, are classic features of protein-energy malnutrition, specifically kwashiorkor or mixed-type SAM. The image also depicts a distended abdomen, which is frequently associated with underlying nutritional deficiencies, malabsorption syndromes like celiac disease, or hepatomegaly in malnourished populations. This visual serves as an educational reference for identifying the physical signs of severe nutritional failure and secondary skin disorders in a clinical pediatric setting.

Clinical photograph of an infant's lower extremities exhibiting severe dermatological and systemic manifestations of malnutrition. The image shows diffuse, well-demarcated reddish-brown erythematous plaques with a 'flaky paint' appearance, characteristic of the dermatosis seen in Kwashiorkor. Notable features include widespread scaly plaques and desquamation, as well as several bullous lesions (fluid-filled blisters) on the lateral aspect of the lower leg and dorsal foot. Significant generalized peripheral edema (anasarca) is evident, manifesting as tense, shiny skin and swelling of the thighs, legs, and feet. The distribution is bilateral and involves the flexural surfaces. These visual findings represent the classic cutaneous signs of protein-energy malnutrition, often secondary to malabsorption syndromes such as cystic fibrosis-associated pancreatic insufficiency. The presence of these lesions in a pediatric patient is a critical clinical indicator of severe metabolic and nutritional distress.

This medical illustration depicts a pediatric patient presenting with severe protein-energy malnutrition (PEM), specifically demonstrating clinical features associated with kwashiorkor or marasmic-kwashiorkor. The child is shown in a seated, cross-legged position. Key visual diagnostic signs include a protuberant, distended abdomen (ascites/hepatomegaly), marked muscle wasting in the upper and lower extremities, and a relative lack of subcutaneous fat, making the rib cage and clavicles visibly prominent. The facial features exhibit a gaunt appearance with sunken eyes and a flat, subdued affect, characteristic of the 'apathetic' demeanor often seen in severely malnourished children. The image serves as an educational tool for identifying the physical manifestations of chronic nutritional deficiency in global health settings, particularly emphasizing the paradox of a bloated abdomen despite generalized emaciation. This illustration is designed for healthcare worker training in malnutrition assessment and triage.

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Case Study: Kwashiorkor

Patient Profile

Name: Arjun K. (fictional) Age: 2.5 years Gender: Male Weight: 9.2 kg (expected for age: ~13 kg = ~70% of normal) Height: 84 cm Nationality: South Asian Presenting Complaint: Swelling of the body, especially legs and abdomen, dull behavior, poor feeding for 3 weeks.

History of Present Illness

Arjun was exclusively breastfed until 10 months of age. Following the birth of a sibling, breastfeeding was abruptly stopped and he was placed on a watered-down rice and corn-gruel diet with minimal protein (no eggs, milk, or meat). Over the past 3 months, his mother noted progressive body swelling starting at the feet, increasing lethargy, irritability, and poor appetite. He had an episode of diarrhea 4 weeks ago.

Past Medical History: Not fully immunized (missed measles vaccine). Family History: Poverty, food insecurity in the household. Social History: Rural community, 4 siblings, father works as daily laborer.

Head-to-Toe Physical Examination

General Appearance

Lethargic, apathetic, miserable-appearing child
Does not cry; shows no interest in surroundings
Weight = 70% of expected for age (masked by edema); true lean body mass likely lower

Head & Scalp

Hair: Sparse, depigmented, reddish-yellow to grey color
Flag sign: Alternating bands of pale and darker color along individual hair strands (indicating alternating periods of poor and adequate nutrition)
Hair texture: Dry, lustreless, straightened (formerly curly), "crackled" hair noted
Scalp: Easy pluckability - hair comes out with minimal traction
No lymphadenopathy in the cervical region

Face

Puffiness and periorbital edema
Flat, subdued, "moon face" appearance
Sunken eyes
Pale conjunctivae (anemia)
No active corneal lesions; however, vitamin A deficiency should be excluded
Dry lips; angular stomatitis possible (riboflavin/B-complex deficiency)

Eyes

Conjunctival pallor (anemia)
Bitot's spots should be screened for (Vitamin A deficiency co-exists)
No obvious corneal ulceration at this time

Mouth & Throat

Angular cheilitis noted
Pale oral mucous membranes
Dry tongue
No thrush at this time

Neck

No significant lymphadenopathy
Neck supple, no thyroid enlargement

Chest & Respiratory

Bilateral breath sounds present and equal
Mild subcostal recession
No crackles; screening required for TB or pneumonia (susceptibility increased)
Respiratory rate: 32/min (mild tachypnea)
Chest wall relatively thin; mild rib prominence visible

Cardiovascular

Heart rate: 98 bpm, regular
Heart sounds: normal S1 and S2, no murmurs
Capillary refill: 2.5 seconds (borderline)
Blood pressure: 78/50 mmHg (low for age)

Abdomen

Distended, pot-belly appearance - characteristic finding
Hepatomegaly palpable 4 cm below right costal margin; smooth surface, non-tender
Fatty liver (steatosis): due to reduced synthesis of apolipoprotein carrier protein component of lipoproteins, causing triglyceride accumulation
Mild ascites on percussion (shifting dullness)
Bowel sounds present, mild hyperactivity
No splenomegaly

Skin (entire body)

This is the most striking systemic finding:

"Flaky paint" dermatosis - hyperpigmented patches with alternating zones of desquamation and hypopigmentation
Areas first affected: pressure areas - groin, buttocks, flexures, elbows, knees
Lesions resemble "crazy paving," "cracked paint," or "mosaic skin"
In severe areas: peeling leaves pale, ulcerated hypopigmented areas with hyperpigmented borders
Nails: Soft, thin, brittle
Skin turgor is poor despite edema

Fig. Flaky paint appearance in Kwashiorkor - Andrews' Diseases of the Skin

Extremities / Musculoskeletal

Bilateral pitting edema of lower limbs (2+ pitting), extending to the dorsum of feet
Mild peripheral muscle wasting (masked by edema)
Relative sparing of subcutaneous fat compared to marasmus
Mid-upper arm circumference (MUAC): 10.8 cm (severe malnutrition: <11.5 cm)

Neurological

Markedly apathetic, listless
No spontaneous play
Decreased response to stimulation
Developmental regression: unable to sit unsupported (was walking at 14 months)
Cranial nerves grossly intact
No focal neurological deficits

Clinical Images

Kwashiorkor child - pitting edema and distended abdomen

Child with kwashiorkor showing protuberant abdomen, muscle wasting, and characteristic apathetic demeanor

Kwashiorkor - skin lesions and edema of lower limbs

"Flaky paint" dermatosis and bilateral pitting edema in a child with kwashiorkor

Laboratory Investigations

Investigation	Result	Normal	Significance
Serum albumin	1.4 g/dL	3.5-5.0 g/dL	Severe hypoalbuminemia - drives edema
Total protein	3.2 g/dL	6.0-8.0 g/dL	Reduced
Hemoglobin	7.2 g/dL	11-14 g/dL	Anemia
Serum potassium	2.8 mEq/L	3.5-5.0 mEq/L	Hypokalemia
Serum sodium	128 mEq/L	135-145 mEq/L	Hyponatremia
Blood glucose	62 mg/dL	70-100 mg/dL	Hypoglycemia risk
Serum zinc	Low		Zinc deficiency (contributes to skin changes)
LFTs	AST/ALT mildly elevated		Fatty liver changes
Stool exam	Ova/cysts of Giardia		Co-existing infection
Weight for age	70% expected		SAM (severe acute malnutrition)
MUAC	10.8 cm	>13.5 cm = normal	Severe malnutrition

Diagnosis

Primary: Kwashiorkor (Severe Acute Malnutrition - SAM, protein-predominant form) Secondary:

Hypoalbuminemia with generalized edema
Fatty hepatomegaly
Iron deficiency anemia
Electrolyte imbalance (hypokalemia, hyponatremia)
Giardiasis (co-infection)
Vitamin deficiencies (A, B-complex, zinc)

Nursing Care Plan

Nursing Diagnosis 1: Imbalanced Nutrition - Less Than Body Requirements

Related to: Inadequate protein and caloric intake as evidenced by MUAC 10.8 cm, weight 70% of expected, hypoalbuminemia (1.4 g/dL)

Goal: Child will show progressive weight gain and improvement in serum albumin within 4 weeks of treatment.

Nursing Interventions	Rationale
Follow WHO F-75 therapeutic milk (75 kcal/100 mL) in acute/stabilization phase (Days 1-7)	Prevents refeeding syndrome; gentle resuscitation of metabolic processes
Transition to F-100 (100 kcal/100 mL) in rehabilitation phase (Week 2 onward)	Higher protein/calorie density to promote catch-up growth
Feed small frequent amounts every 2-3 hours; do not force feed	Prevents overloading a compromised gut; promotes tolerance
Monitor and record daily weight, MUAC, edema grading	Tracks treatment response; edema should resolve before weight gain expected
Supplement with therapeutic zinc (2 mg/kg/day), Vitamin A, and B-complex	Co-deficiencies worsen outcomes; zinc essential for skin healing
Provide Ready-to-Use Therapeutic Food (RUTF) like Plumpy'Nut once stabilized	High energy-protein paste for outpatient nutritional rehabilitation
Educate mother on age-appropriate protein-rich weaning foods (eggs, lentils, milk)	Sustainable dietary improvement post-discharge

Nursing Diagnosis 2: Excess Fluid Volume (Edema)

Related to: Hypoalbuminemia causing decreased oncotic pressure, as evidenced by 2+ bilateral pitting edema, ascites, and periorbital puffiness

Goal: Edema will progressively decrease and resolve within 1-2 weeks of treatment.

Nursing Interventions	Rationale
Avoid IV fluids unless in shock - use oral/NG route when possible	IV fluids can worsen fluid overload in hypoalbuminemic state
Monitor edema grade daily (0-3+ scale) and document changes	Edema resolves as albumin improves; tracking guides treatment
Restrict sodium in early feeds (F-75 is low in sodium)	Limits fluid retention; WHO therapeutic diets are formulated appropriately
Position child with legs elevated when at rest	Promotes venous return and reduces dependent edema
Monitor respiratory rate and oxygen saturation	Detect early pleural effusion or pulmonary edema
Weigh daily (expected weight may initially decrease as edema resolves)	Edema loss often mistaken for failure to gain weight
Avoid diuretics unless severe symptomatic overload	Diuretics can worsen electrolyte imbalance (esp. potassium)

Nursing Diagnosis 3: Impaired Skin Integrity

Related to: Protein deficiency and zinc deficiency causing "flaky paint" dermatosis, as evidenced by skin hyperpigmentation, desquamation, and ulcerated areas

Goal: Skin lesions will show signs of healing and no new infection will develop within 2 weeks.

Nursing Interventions	Rationale
Keep skin clean and dry; gentle sponge bath twice daily	Prevents secondary bacterial/fungal infection in broken skin
Apply barrier cream (zinc oxide or petroleum jelly) to affected areas	Protects fragile skin; reduces friction damage
Avoid adhesive tapes and tight bandages on edematous areas	Edematous skin tears easily; tape avulsion can create wounds
Use soft cotton clothing; no synthetic fabrics	Reduces friction and pressure on damaged skin
Inspect skin at every nursing assessment; document and photograph lesions	Early detection of secondary infection
Administer zinc supplementation as prescribed	Zinc is critical for epidermal repair and immune function
Maintain oral hygiene; apply lip balm for angular stomatitis	Prevents worsening of mucosal lesions; promotes comfort

Nursing Diagnosis 4: Risk for Infection

Related to: Immunodeficiency secondary to protein deficiency and micronutrient depletion

Goal: Child will remain free of new infections during hospitalization.

Nursing Interventions	Rationale
Practice strict hand hygiene before all patient contact	Most important infection prevention measure in immunocompromised host
Ensure broad-spectrum antibiotic therapy as prescribed (e.g., amoxicillin per WHO guidelines)	WHO recommends empirical antibiotics for all hospitalized SAM children
Administer Vitamin A supplementation (100,000 IU for age 6-12m; 200,000 IU for >12 months)	Vitamin A is essential for immune mucosa; single megadose corrects deficiency
Ensure measles vaccination is given before discharge if not immunized	Measles is rapidly fatal in malnourished children
Screen for TB and treat parasitic co-infections (e.g., albendazole for helminthiasis)	Co-infections worsen nutritional state; giardiasis confirmed in this child
Isolate from other infectious patients if possible	Compromised immune defenses cannot fight nosocomial pathogens
Monitor temperature 4-hourly; report any fever or hypothermia promptly	Malnourished children may not mount a fever; hypothermia is a danger sign

Nursing Diagnosis 5: Impaired Growth and Development

Related to: Chronic protein-energy malnutrition as evidenced by developmental regression, apathy, and weight 70% of expected

Goal: Child will show improved alertness, interaction, and developmental milestones within 3-4 weeks.

Nursing Interventions	Rationale
Provide structured play stimulation for at least 30 minutes daily	Nutritional recovery alone is insufficient; play therapy improves brain development
Encourage mother to hold, talk to, and interact with the child frequently	Emotional stimulation during recovery accelerates neurological improvement
Assess developmental milestones at admission and weekly during recovery	Tracks neurological recovery; identifies residual delays
Provide a safe, calm ward environment	Reduces distress in apathetic child; facilitates recovery
Refer to developmental pediatrician if milestones do not improve after nutritional rehabilitation	Long-term protein deficiency can cause permanent cognitive impairment

Nursing Diagnosis 6: Deficient Knowledge (Caregiver)

Related to: Mother's lack of understanding about nutritional requirements and weaning practices

Goal: Mother will verbalize at least 3 protein-rich, locally available weaning foods and demonstrate correct feeding practices before discharge.

Nursing Interventions	Rationale
Assess mother's literacy, cultural food beliefs, and economic constraints	Education must be contextually appropriate and realistic
Teach protein-rich local foods: eggs, lentils, beans, groundnuts, fish, milk	Addresses cause of kwashiorkor; empowers sustainable dietary change
Demonstrate preparation of energy-dense weaning porridge (cereal + legume + fat)	Practical skills are more effective than verbal instructions alone
Discuss importance of continued breastfeeding alongside complementary foods	Breastfeeding provides immune factors and nutrition beyond 6 months
Educate on growth monitoring: regular weight checks and road-to-health card use	Early detection of growth faltering prevents recurrence
Provide written/pictorial take-home feeding guide (as appropriate for literacy)	Reinforces teaching after discharge
Link family to community nutrition program / government food support scheme	Addresses underlying food insecurity - the root cause

Medical Management Summary

Phase	Duration	Formula/Food	Key Actions
Stabilization	Days 1-7	WHO F-75 therapeutic milk (75 kcal/100 mL)	Treat hypoglycemia, hypothermia, dehydration, infections; correct electrolytes
Rehabilitation	Weeks 2-6	WHO F-100 / RUTF	Catch-up growth feeding; zinc, Vitamin A, folic acid, multivitamins
Follow-up	3-6 months	Age-appropriate home diet	Nutritional education, immunizations, growth monitoring

Key drugs per WHO protocol:

Amoxicillin (empirical antibiotic) - all SAM children
Vitamin A (200,000 IU single dose for >12 months)
Folic acid (5 mg Day 1, then 1 mg/day)
Zinc (2 mg/kg/day for 2 weeks)
Albendazole (400 mg single dose, after Day 7 of feeding)

Prognosis

With appropriate in-patient management using WHO 10-step SAM protocol, most children with kwashiorkor show edema resolution within 1-2 weeks and catch-up weight gain over 4-6 weeks. Mortality remains high (10-30%) if untreated. Long-term risks include cognitive impairment, stunting, and immune dysfunction if episodes are repeated. Education of caregivers and community interventions are essential to prevent relapse.

Sources:

Robbins & Kumar Basic Pathology - Kwashiorkor, Chapter 7
Robbins, Cotran & Kumar Pathologic Basis of Disease - Chapter 9
Lippincott's Biochemistry, 8th Ed - Protein-Energy Malnutrition, Chapter 27
Park's Textbook of Preventive and Social Medicine - PEM
Andrews' Diseases of the Skin, 13th Ed - Kwashiorkor dermatology
Harper's Illustrated Biochemistry, 32nd Ed - Chapter on kwashiorkor

Pediatric nursing viva question

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🏥 Pediatric Nursing Viva Questions - B.Sc Nursing

(Mixed format: Short Q&A + Detailed answers + MCQ-style questions)

UNIT 1: GROWTH & DEVELOPMENT

Q1. What is the difference between growth and development?

Answer:

Growth = increase in physical size (height, weight, head circumference) - quantitative change
Development = increase in functional capacity and skill acquisition - qualitative change
Growth can be measured; development is assessed through milestones
Growth is more rapid in infancy and puberty; development is continuous throughout life

Q2. State the developmental milestones in the first 2 years of life.

Answer (from Rosen's Emergency Medicine):

Age	Gross Motor	Language/Social/Visual
1 month	Raises head in prone	Visually follows to midline, alerts to sound
2 months	Lifts chest off table	Social smile, recognizes parent
4 months	Rolls over	Laughs, orients to voice
6 months	Sits unsupported	Babbles
9 months	Pulls to stand, cruises	Says "mama/dada" indiscriminately
12 months	Walks alone	2 words other than mama/dada
15 months	Creeps upstairs, walks backward	Uses 4-6 words
18 months	Runs	7-10 words, knows 5 body parts
24 months	Walks up/down stairs independently	50-word vocab, two-word sentences

Viva tip: "Walks alone at 12 months, runs at 18 months, walks up stairs at 24 months" - examiners commonly ask this.

Q3. MCQ: At what age does a child first sit unsupported?

a) 3 months
b) 6 months ✓
c) 9 months
d) 12 months

Q4. What are the important growth parameters in a child? What are the normal values?

Answer:

Parameter	Normal at Birth	6 months	1 year	5 years
Weight	2.5-3.5 kg	~6.5-7 kg	~9-10 kg (3×birth)	~18-20 kg
Length/Height	~50 cm	~65 cm	~75 cm	~110 cm
Head circumference	~34 cm	~43 cm	~46-47 cm	~50-51 cm
Chest circumference	~32 cm		Equals head at 1 year	> head after 1 year

Memory aid:

Birth weight doubles by 5-6 months, triples by 1 year, quadruples by 2 years
Head circumference equals chest circumference at 1 year
After 1 year, chest > head

Q5. What are the Tanner stages of puberty?

Answer: Tanner stages (I-V) describe sexual maturation:

Girls: Breast development and pubic hair growth (Stage I = prepubertal; Stage V = adult)
Boys: Testicular enlargement begins first (Stage II onward), then pubic hair, penile growth, voice change
Menarche usually occurs at Tanner Stage III-IV
Puberty in girls: 8-13 years; Boys: 9-14 years

UNIT 2: NEONATAL NURSING

Q6. What is the APGAR score? How is it calculated?

Answer (Textbook of Family Medicine, 9e):

APGAR score is assessed at 1 minute and 5 minutes after birth. Each parameter is scored 0-2:

Parameter	0	1	2
Appearance (color)	Blue/pale all over	Blue extremities, pink body	Completely pink
Pulse (heart rate)	Absent	<100 bpm	≥100 bpm
Grimace (reflex)	No response	Grimace only	Cry/cough/sneeze
Activity (muscle tone)	Limp	Some flexion	Active motion
Respiration	Absent	Slow/irregular	Good, crying

Interpretation:

7-10: Normal
4-6: Moderate depression - needs stimulation/oxygen
0-3: Severe depression - needs immediate resuscitation

Important: A low Apgar score does NOT predict long-term neurological outcome. Resuscitation should NOT be delayed to calculate the Apgar score.

Q7. MCQ: When is the APGAR score repeated if initial score is <7?

a) Every 10 minutes for 30 minutes
b) Every 5 minutes up to 20 minutes ✓
c) Only once at 10 minutes
d) At 1 hour of life

Q8. What is the New Ballard Score? What does it assess?

Answer:

The New Ballard Score assesses gestational age of a newborn
It has two components:
- Neuromuscular maturity (posture, square window, arm recoil, popliteal angle, scarf sign, heel-to-ear)
- Physical maturity (skin, lanugo, plantar surface, breast, eye/ear, genitals)
Scores are summed and plotted on a maturity rating scale
More accurate when performed within 12-20 hours of birth

Q9. How are newborns classified by gestational age and birth weight?

Answer:

By gestational age:

Preterm: <37 weeks
Term: 37-42 weeks
Post-term: >42 weeks

By birth weight:

LBW (Low birth weight): <2500 g
VLBW: <1500 g
ELBW: <1000 g
SGA (Small for gestational age): <10th percentile
AGA (Appropriate for gestational age): 10th-90th percentile
LGA (Large for gestational age): >90th percentile

Note: SGA infants are at risk for temperature instability and hypoglycemia. LGA infants (often of diabetic mothers) are also at risk for hypoglycemia.

Q10. What are the danger signs in a neonate that require immediate referral?

Answer (IMNCI - Integrated Management of Neonatal and Childhood Illness):

Not feeding at all or feeding very poorly
Convulsions
Fast breathing (≥60/min)
Severe chest indrawing
Grunting
Hypothermia (axillary temp <35.5°C) or fever (>37.5°C)
Yellow palms and soles (jaundice)
Severe skin pustules or umbilical redness extending to skin
Lethargic or unconscious

Q11. What are the causes and management of neonatal jaundice?

Answer:

Physiological jaundice:

Appears Day 2-3, disappears by Day 7-10 (term), Day 14 (preterm)
Due to high red cell breakdown + immature liver conjugation

Pathological jaundice: Appears within 24 hours or persists >2 weeks

Causes of pathological jaundice:

Hemolytic: ABO incompatibility, Rh incompatibility, G6PD deficiency
Sepsis, metabolic disorders, hypothyroidism
Biliary atresia (conjugated hyperbilirubinemia - pale stools, dark urine)

Management:

Phototherapy: First-line for unconjugated hyperbilirubinemia
Exchange transfusion: For severe cases / risk of kernicterus
Treat underlying cause

Nursing care: Eye patches during phototherapy, monitor temperature, adequate hydration, turn baby every 2 hours to expose maximum skin surface.

UNIT 3: NUTRITIONAL DISORDERS

Q12. What are the differences between Kwashiorkor and Marasmus?

Answer (Lippincott's Biochemistry + Robbins Pathology):

Feature	Kwashiorkor	Marasmus
Primary deficiency	Protein (with relatively adequate calories)	Both protein AND calories
Weight for age	60-80% of normal	<60% of normal
Edema	Present (hallmark)	Absent
Muscle/fat wasting	Relatively spared (masked by edema)	Markedly wasted
Serum albumin	Markedly low	Low-normal
Fatty liver	Present	Absent
Skin changes	"Flaky paint" dermatosis	Dry, wrinkled skin
Hair changes	Flag sign, depigmented	Thinning but less striking
Age group	1-5 years (post-weaning)	<1 year
Appearance	"Moon face," pot belly, edema	Wizened/"old man" face

Q13. MCQ: Which feature is the HALLMARK of Kwashiorkor that distinguishes it from Marasmus?

a) Hair depigmentation
b) Fatty liver
c) Pitting edema ✓
d) Growth retardation

Q14. What is the WHO 10-step management of Severe Acute Malnutrition (SAM)?

Answer:

Phase 1 - Stabilization (Days 1-7): Treat life-threatening complications

Treat/prevent hypoglycemia
Treat/prevent hypothermia
Treat/prevent dehydration (use ReSoMal - Rehydration Solution for Malnutrition)
Correct electrolyte imbalance (potassium, magnesium)
Treat/prevent infection (empirical antibiotics)
Correct micronutrient deficiencies
Begin cautious feeding with F-75 (75 kcal/100 mL)

Phase 2 - Rehabilitation (Weeks 2-6): Promote recovery

Achieve catch-up growth (transition to F-100 or RUTF)
Stimulate emotional and sensory development
Prepare for follow-up after recovery

Q15. What is Vitamin D deficiency rickets? List its clinical features.

Answer (Guyton & Hall Physiology + Campbell's Orthopaedics):

Definition: Failure of bone mineralization due to vitamin D deficiency, leading to soft, deformable bones in growing children.

Clinical features:

Skull: Craniotabes (softening of skull bones), frontal bossing, delayed fontanelle closure, delayed dentition
Chest: Rickety rosary (enlarged costochondral junctions), Harrison's sulcus (groove along lower chest margin), pigeon chest
Limbs: Bowing of legs (genu varum), knock-knees (genu valgum), thickening at wrists and ankles
Spine: Kyphoscoliosis
General: Growth retardation, hypotonia, delayed walking, irritability, seizures (hypocalcemia)

X-ray: Cupping, fraying, splaying of metaphyses; widened growth plate

Treatment: Vitamin D (cholecalciferol) + Calcium supplementation

Q16. What are the normal vitamin A prophylaxis doses for a child?

Answer (National Immunization Schedule - India):

Age	Dose	Route
9 months (with measles)	1,00,000 IU	Oral
16-18 months	2,00,000 IU	Oral
Every 6 months until 5 years	2,00,000 IU	Oral

UNIT 4: RESPIRATORY DISORDERS

Q17. What is the classification of Acute Respiratory Infections (ARI) in children per IMNCI?

Answer:

Classification	Signs	Action
Very severe disease	Central cyanosis, unable to drink, convulsions, altered consciousness, severe chest indrawing	Urgent referral + oxygen + antibiotics
Severe pneumonia	Chest indrawing without above danger signs	Refer + amoxicillin
Pneumonia	Fast breathing only (≥60/min in <2m; ≥50/min in 2-12m; ≥40/min in 1-5y)	Oral amoxicillin + home care
No pneumonia (cough/cold)	No fast breathing, no chest indrawing	Home care, soothe throat

Q18. What is epiglottitis? How is it different from croup?

Answer:

Feature	Croup (Laryngotracheobronchitis)	Epiglottitis
Age	6 months - 3 years	2-7 years
Cause	Parainfluenza virus (most common)	Haemophilus influenzae type b
Onset	Gradual	Sudden, rapidly progressive
Cough	Barking, seal-like	Muffled, minimal
Drooling	No	Yes (cannot swallow)
Position	Prefers lying down	Tripod position, leans forward
Fever	Low-grade	High (>39°C), toxic appearance
Stridor	Inspiratory, worse at night	Inspiratory, continuous
X-ray	Steeple sign (subglottic narrowing)	Thumbprint sign (epiglottis)
Treatment	Cool mist, nebulized epinephrine, steroids	Intubation, IV cefotaxime, no tongue depressor

Nursing alert: Never use a tongue depressor or attempt throat examination in suspected epiglottitis - can cause complete airway obstruction.

Q19. MCQ: What is the X-ray finding characteristic of croup?

a) Thumbprint sign
b) Steeple sign ✓
c) Sail sign
d) Ground glass appearance

UNIT 5: CARDIOVASCULAR - CONGENITAL HEART DISEASE

Q20. Classify congenital heart defects. Give one example of each.

Answer:

Acyanotic CHD (left-to-right shunt - no cyanosis initially):

Ventricular Septal Defect (VSD) - most common CHD
Atrial Septal Defect (ASD)
Patent Ductus Arteriosus (PDA)
Pulmonary Stenosis (obstructive)

Cyanotic CHD (right-to-left shunt - cyanosis present):

Tetralogy of Fallot (TOF) - most common cyanotic CHD
Transposition of Great Arteries (TGA)
Truncus Arteriosus
Total Anomalous Pulmonary Venous Connection (TAPVC)
Tricuspid Atresia

Memory aid for TOF (4 components): "PROVE"

Pulmonary stenosis
Right ventricular hypertrophy
Override of aorta (overriding aorta)
Ventricular septal defect
E = Tet spells (hypercyanotic episodes)

Q21. What is a "Tet spell"? What is the nursing management?

Answer:

A Tet spell (hypercyanotic episode) is a sudden severe cyanotic episode in TOF triggered by:

Crying, feeding, defecation, fever, early morning

Clinical features: Sudden deep cyanosis, hyperpnea, irritability, loss of consciousness, seizures

Immediate nursing management (KNEE-CHEST position is the key):

Place child in knee-chest position (squatting position) - increases systemic vascular resistance
Administer 100% oxygen by face mask
Calm the child; minimize stimulation
Administer morphine (0.1 mg/kg IV/SC) - reduces respiratory drive and hyperpnea
IV fluids (fluid bolus) to increase preload
Propranolol (0.1-0.2 mg/kg IV) - reduces infundibular spasm
Sodium bicarbonate for metabolic acidosis

Q22. MCQ: The most common congenital heart defect is:

a) Atrial Septal Defect
b) Ventricular Septal Defect ✓
c) Tetralogy of Fallot
d) Patent Ductus Arteriosus

UNIT 6: GASTROINTESTINAL DISORDERS

Q23. What is the IMNCI classification and management of dehydration in a child?

Answer:

Classification	Signs	Treatment
Severe dehydration	2 or more of: sunken eyes, very slow skin pinch, drinks poorly/unable to drink, lethargic/unconscious	Plan C: IV Ringer's lactate 100 mL/kg (Infants: 30 mL/kg in 1hr + 70 mL/kg in 5hrs; Older children: 30+70 in 3hrs)
Some dehydration	2 or more of: restless, sunken eyes, drinks thirstily, slow skin pinch	Plan B: ORS 75 mL/kg over 4 hours
No dehydration	Not enough signs for above	Plan A: Home fluids, continue feeding, return if worse

ORS composition (WHO standard):

Sodium 75 mEq/L, Chloride 65 mEq/L, Glucose 75 mEq/L, Potassium 20 mEq/L, Citrate 10 mEq/L
Osmolarity: 245 mOsm/L (low osmolarity)

Q24. What is intussusception? What are its features?

Answer:

Intussusception = telescoping of one segment of bowel into an adjacent segment
Most common in 5-9 months of age (peak 6-18 months)
Most common type: Ileocolic

Classic triad:

Intermittent, colicky abdominal pain (child draws legs up, screams, then is comfortable between episodes)
Vomiting (initially reflex, later bilious)
Red currant jelly stools (blood + mucus per rectum - late sign)

Examination: Sausage-shaped mass in RUQ, absence of bowel sounds in RIF (Dance sign)

Management: Air or water enema reduction (non-surgical, success ~75-90%), surgical reduction if failed

UNIT 7: NEUROLOGICAL DISORDERS

Q25. What are the types and causes of seizures in children?

Answer:

Febrile seizures:

Simple: Single, <15 min, generalized, no recurrence in 24 hrs, normal child
Complex: >15 min, focal, recurs in 24 hrs, or child has neurological abnormality
Age: 6 months - 6 years; peak 18 months
Risk of epilepsy: <3% after simple febrile seizure

Causes of seizures in children by age:

Age	Common Causes
Neonates (0-28 days)	Hypoxic-ischemic encephalopathy, hypoglycemia, hypocalcemia, meningitis, IVH
Infants	Febrile seizures, meningitis, metabolic, infantile spasms (West syndrome)
Children	Febrile, epilepsy, meningitis, head injury, toxins

Immediate nursing management of an acute seizure:

Do NOT restrain; protect from injury (side rails, padded)
Turn to lateral/recovery position (prevents aspiration)
Time the seizure
Ensure airway patency - suction if needed
Oxygen by mask
IV access; give diazepam (0.2-0.3 mg/kg IV) or midazolam (buccal/nasal)
Monitor vitals; check glucose (treat hypoglycemia)
Do NOT put anything in mouth

Q26. MCQ: What is the first-line drug for status epilepticus in children?

a) Phenytoin
b) Phenobarbitone
c) Diazepam (benzodiazepine) ✓
d) Carbamazepine

UNIT 8: IMMUNIZATION

Q27. State the National Immunization Schedule for children in India (NIS 2023).

Answer:

Age	Vaccines
At birth	BCG, OPV-0 (zero dose), Hepatitis B (birth dose)
6 weeks	OPV-1, Pentavalent-1 (DPT+HepB+Hib), IPV-1, Rotavirus-1, PCV-1
10 weeks	OPV-2, Pentavalent-2, IPV-2, Rotavirus-2, PCV-2
14 weeks	OPV-3, Pentavalent-3, IPV-3, Rotavirus-3, PCV-3
9-12 months	MR (Measles-Rubella), JE-1 (endemic areas), Vitamin A (1st dose)
16-24 months	DPT booster-1, OPV booster, MR-2, JE-2, Vitamin A (2nd dose)
5-6 years	DPT booster-2
10 years	TT/Td
16 years	TT/Td

Cold chain: All vaccines should be stored at 2-8°C (except OPV at -20°C in frozen state). The cold chain is critical for vaccine potency.

Q28. What are contraindications to vaccination?

Answer:

True contraindications (absolute):

Live vaccines (MMR, OPV, BCG, Varicella) are contraindicated in severely immunocompromised children (HIV with low CD4, on chemotherapy)
Anaphylactic reaction to previous dose or vaccine component

False contraindications (vaccines should still be given):

Mild fever / mild illness
Current antibiotic therapy
Premature birth (vaccinate at chronological age)
Malnutrition (in fact, priority group)
Breastfeeding

UNIT 9: COMMON PEDIATRIC EMERGENCIES

Q29. What are the PALS (Pediatric Advanced Life Support) age-based definitions?

Answer:

Category	Age
Neonate	0-28 days
Infant	1-12 months
Toddler	1-3 years
Preschool	3-6 years
School age	6-12 years
Adolescent	12-18 years

Normal heart rates by age:

Age	Normal HR
Neonate	120-160/min
Infant	100-160/min
Toddler	90-150/min
School age	70-120/min

Q30. What is the nurse's role in Child Abuse recognition?

Answer:

Warning signs of child abuse:

Injury inconsistent with developmental stage (bruises in a non-ambulatory infant)
Multiple injuries at different stages of healing
Delay in seeking medical care
Unexplained fractures (especially spiral fractures, posterior rib fractures)
"Shaken baby syndrome" signs: retinal hemorrhages, SDH without external injury
Burn marks in unusual patterns (cigarette burns, immersion burns)
Behavioral signs: fearfulness, regression, inappropriate sexual knowledge

Nursing responsibilities:

Document findings objectively - use child's exact words, describe wounds accurately with measurements
Report to child protection services (mandatory reporter obligation)
Do NOT confront the caregiver alone; involve social worker
Ensure child's safety; do NOT discharge to unsafe environment
Maintain confidentiality and non-judgmental attitude

UNIT 10: HIGH-YIELD VIVA SHORT ANSWERS

Q31. What is Kawasaki disease? What are its diagnostic criteria?

Answer: Kawasaki disease is an acute febrile vasculitis of unknown etiology primarily affecting children <5 years.

Diagnostic criteria (CRASH mnemonic): Fever ≥5 days PLUS 4 of 5:

C - Conjunctival injection (bilateral, non-exudative)
R - Rash (polymorphous)
A - Adenopathy (cervical lymph node ≥1.5 cm)
S - Strawberry tongue / oral changes (red cracked lips, pharyngeal injection)
H - Hand/foot changes (erythema, edema of hands/feet; periungual desquamation in Week 2-3)

Most dangerous complication: Coronary artery aneurysm (occurs in 15-25% if untreated) Treatment: IV immunoglobulin (IVIG) 2 g/kg single dose + Aspirin

Q32. What is Reye's syndrome? How is it related to aspirin?

Reye's syndrome = acute non-inflammatory encephalopathy + hepatic failure in children
Associated with aspirin use during viral illness (varicella, influenza)
Presents with vomiting, altered consciousness, liver dysfunction after a viral illness
Aspirin is CONTRAINDICATED in children <12 years for viral illnesses (except Kawasaki disease under specialist supervision)

Q33. What are the nursing priorities in a child with meningitis?

Answer:

Maintain airway, breathing, circulation
Seizure precautions - padded side rails, emergency medications at bedside
Isolation precautions (droplet for bacterial meningitis until 24 hours of antibiotic therapy)
Position: HOB elevated 30°, neutral neck position (avoid jugular compression)
Administer IV antibiotics promptly (ceftriaxone + ampicillin empirically)
Dexamethasone before or with first antibiotic dose (reduces risk of neurological sequelae - esp. deafness in H. influenzae)
Monitor for raised ICP: avoid lumbar puncture if papilledema/focal neuro signs
Monitor neuro vitals hourly: GCS, pupil reactivity, fontanelle tension (infants)
Strict fluid restriction (SIADH common complication)
Monitor hearing after recovery (sensorineural hearing loss is a complication)

Q34. MCQ: Which of the following is the most common cause of bacterial meningitis in infants 1-3 months?

a) Streptococcus pneumoniae
b) Neisseria meningitidis
c) Streptococcus agalactiae (Group B Strep) / E. coli ✓
d) Haemophilus influenzae

Q35. What is Intussusception vs. Hirschsprung disease - key differences?

Feature	Intussusception	Hirschsprung Disease
Age	6-18 months	Newborn/infant
Presentation	Acute, episodic pain, red currant jelly stools	Chronic constipation, failure to pass meconium in first 24 hrs
Cause	Telescoping of bowel	Absence of ganglion cells in distal colon
Diagnosis	Ultrasound / air enema	Rectal biopsy (gold standard)
Treatment	Air enema / surgery	Surgical pull-through (Swenson's)

Key Exam Tips for Pediatric Nursing Viva (B.Sc Level):

Always know normal values by age (HR, RR, BP, developmental milestones, weight)

Know the IMNCI algorithm (classifications and treatment plans)

Know immunization schedule in detail - examiners frequently ask exact doses and ages

For any pediatric emergency, structure your answer as: Assess → Airway/Breathing/Circulation → Specific drug → Monitoring → Parent education

The 5 "never do" items: Never leave a seizing child alone; never use tongue depressor in epiglottitis; never give aspirin to febrile children; never force fluid in severe edema; never discharge a suspected abuse case to unsafe home

Sources: Rosen's Emergency Medicine (Pediatric Developmental Milestones); Textbook of Family Medicine 9e (APGAR, Neonatal Assessment); Lippincott's Biochemistry 8e (Kwashiorkor vs Marasmus); Robbins & Kumar Basic Pathology (Malnutrition); Guyton & Hall Medical Physiology (Rickets); Campbell's Operative Orthopaedics (Rickets deformities)

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