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DEPARTMENT OF PEDIATRICS - FIRST TERMINAL EXAMINATION (2023 BATCH)

COMPLETE MODEL ANSWERS

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SECTION A - LONG ESSAYS (4 x 10 = 40 Marks)

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Q1. IMNCI Approach + Assessment, Classification & Management of Cough/Difficulty Breathing

Part 1: IMNCI (Integrated Management of Neonatal and Childhood Illness)

• Reduce under-5 mortality and morbidity
• Improve quality of care at home and health facilities
• Promote healthy growth and development

1. Improvements in case management skills of health workers
2. Improvements in overall health system
3. Improvements in family and community practices

1. Check for danger signs (general danger signs)
2. Assess main symptoms - Cough/difficulty breathing, diarrhea, fever, ear problem
3. Check nutritional status - Weight, height, MUAC
4. Check immunization and Vitamin A status
5. Assess other problems
6. Classify illness using color-coded system (Pink/Yellow/Green)
7. Identify treatment and treat accordingly
8. Counsel mother

• Not able to drink or breastfeed
• Vomiting everything
• Convulsions (present illness)
• Lethargic or unconscious

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Part 2: Assessment, Classification & Management of Cough/Difficulty Breathing

• How long has the child had cough?
• Count respiratory rate for 1 full minute
• Look for chest indrawing
• Look and listen for stridor
• Look and listen for wheeze

• Amoxicillin: 40 mg/kg/day in 2 divided doses x 5 days
• Cotrimoxazole as alternative
• Treat fever if present (Paracetamol)
• Treat wheeze if present (bronchodilator)
• Advise when to return immediately

• Ampicillin 50 mg/kg IM/IV every 6 hours PLUS Gentamicin 7.5 mg/kg IM/IV once daily

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Q2. Protein Energy Malnutrition (PEM) - Definition, SAM Classification, Clinical Features & Management

Definition of PEM

• Marasmus - Deficiency of both protein AND calories
• Kwashiorkor - Primarily protein deficiency with adequate caloric intake
• Marasmic-Kwashiorkor - Features of both

Severe Acute Malnutrition (SAM) - Definition

• Weight-for-height/length < -3 SD (Z-score) of WHO median
• MUAC < 115 mm (in 6-59 months)
• Bilateral pitting edema of nutritional origin
• Visible severe wasting

Clinical Features

• Gross wasting of muscle and subcutaneous fat (skin and bones appearance)
• "Old man face" - sunken cheeks
• Loose, wrinkled skin - "baggy pants" appearance
• Marked weight loss (< 60% of expected)
• Child is alert, hungry, and irritable
• No edema
• Hair changes less prominent
• Voracious appetite

• Bilateral pitting pedal edema (cardinal feature)
• Moon face (due to edema)
• Flaky paint/crazy pavement dermatosis - skin changes
• Hair changes: depigmentation (reddish/brownish), easily pluckable, "flag sign"
• Hepatomegaly (fatty liver)
• Miserable, anorexic child
• Low serum albumin
• May have adequate weight due to edema (masked wasting)

Management of SAM - Ten Steps (WHO)

1. Treat/prevent hypoglycemia - give glucose orally/NG if unconscious; F-75 diet
2. Treat/prevent hypothermia - keep warm; Kangaroo mother care
3. Treat/prevent dehydration - use ReSoMal (not standard ORS); 5 mL/kg every 30 min for 2 hours
4. Correct electrolyte imbalance - K+, Mg²+ supplementation (avoid Na+)
5. Treat infection - Broad-spectrum antibiotics (Amoxicillin/Cotrimoxazole); if sick: Ampicillin + Gentamicin
6. Correct micronutrient deficiencies - Vit A, folic acid, zinc, copper, multivitamin (NO iron in phase 1)
7. Begin cautious feeding - F-75 formula (75 kcal/100 mL); 100 mL/kg/day; every 2-3 hours

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Q3. Acute Diarrhea - Etiology, Clinical Features, Complications, Management + ORS & Zinc Therapy

Definition

Etiology

• Rotavirus (most common cause of severe diarrhea in under-5s)
• Norovirus, Adenovirus, Astrovirus

• Escherichia coli (ETEC, EPEC, EAEC)
• Shigella dysenteriae - dysentery
• Vibrio cholerae - rice-water stools
• Campylobacter jejuni
• Salmonella species

• Giardia lamblia
• Entamoeba histolytica - amoebic dysentery
• Cryptosporidium

Clinical Features

• Watery loose stools - frequent (3-10+/day)
• Nausea, vomiting
• Abdominal cramps
• Fever (especially viral/bacterial)
• Signs of dehydration (see Section C)
• Blood/mucus in stools (dysentery - bacterial)

Complications

• Dehydration - most common, life-threatening
• Electrolyte imbalance (hypo/hypernatremia, hypokalemia)
• Metabolic acidosis
• Hypoglycemia (especially in malnourished)
• Acute kidney injury (prerenal)
• Malnutrition (prolonged)
• Intussusception (rare, post-infectious)
• Hemolytic Uremic Syndrome (ETEC/Shigella)

Management (IMNCI - Plan A/B/C)

• Continue breastfeeding
• Give extra fluids (ORS, clean water, soup)
• Continue feeding
• Signs to return immediately
• Zinc supplementation

• ORS: 75 mL/kg over 4 hours in clinic
• Reassess after 4 hours
• If improved - Plan A; if worsening - Plan C

• IV fluids: Ringer's lactate/Normal saline
• < 12 months: 30 mL/kg over 1 hour, then 70 mL/kg over 5 hours

• 12 months: 30 mL/kg over 30 min, then 70 mL/kg over 2.5 hours

• Reassess every 15-30 min

ORS (Oral Rehydration Solution)

Zinc Therapy

• < 6 months: 10 mg/day x 14 days
• ≥ 6 months: 20 mg/day x 14 days

• Reduces duration of diarrhea by ~25%
• Reduces severity (stool frequency and volume)
• Prevents subsequent episodes for 2-3 months
• Reduces risk of progression to persistent diarrhea

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Q4. Measles - Etiology, Clinical Features, Diagnosis, Complications & Management

Etiology

• Causative agent: Measles virus - RNA virus, paramyxovirus family (genus Morbillivirus)
• Transmission: Droplet infection; highly contagious (R₀ = 12-18)
• Incubation period: 10-14 days (range 7-18 days)
• Infectious period: 4 days before to 4 days after rash appearance
• Epidemic pattern: Winter-spring; 2-yearly cycles

Clinical Features

• High fever (38-40°C)
• Coryza (runny nose)
• Cough (barking)
• Conjunctivitis (3 Cs: Cough, Coryza, Conjunctivitis)
• Koplik's spots (pathognomonic) - Appear on Day 2-3; salt/sand grains on a red base on buccal mucosa opposite lower molars; disappear 1-2 days after rash

• Rash: Maculopapular, starts behind ears/hairline; spreads downward (cephalocaudal) over 3 days: face → trunk → limbs
• Fever peaks with rash, then falls
• Rash lasts 4-7 days; fades in same order it appeared
• Post-measles desquamation and brownish staining

Diagnosis

• Mainly clinical (Koplik's spots + typical rash)
• Serology: IgM antibody (positive 3-4 days after rash onset) - confirmatory
• Viral isolation/PCR (epidemiological purposes)

Complications

• Pneumonia (most common cause of death) - measles giant cell pneumonitis, secondary bacterial pneumonia
• Croup (laryngitis)
• Otitis media (most common complication overall)

• Acute post-measles encephalitis (1/1000 cases) - day 2-5 after rash
• Febrile seizures
• Subacute sclerosing panencephalitis (SSPE) - rare, fatal; 7-10 years after infection; caused by defective measles virus

• Diarrhea and vomiting
• Keratoconjunctivitis → corneal ulceration → blindness (especially with Vit A deficiency)
• Cancrum oris (noma) - in severely malnourished
• Myocarditis, hepatitis (rare)

Management

• Antipyretics (Paracetamol)
• Adequate hydration and nutrition
• Continue breastfeeding

• < 6 months: 50,000 IU single dose
• 6-12 months: 100,000 IU single dose

• 12 months: 200,000 IU single dose

• Repeat if signs of Vit A deficiency (xerophthalmia)

• MMR vaccine at 9 months (NIS - India: MR at 9-12 months) and 15-18 months booster
• Post-exposure prophylaxis: Vaccine within 72 hours OR immunoglobulin within 6 days

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SECTION B - SHORT ESSAYS (6 x 5 = 30 Marks)

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B-Q1. National Immunization Schedule (NIS) - India

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B-Q2. Breastfeeding - Advantages and Exclusive Breastfeeding

Definition of Exclusive Breastfeeding (EBF)

Advantages of Breastfeeding

• Nutritional: Perfect composition; bioavailability of iron, zinc, calcium superior; composition changes with infant's needs
• Immunological: IgA (secretory), lactoferrin, lysozyme, macrophages - protection against infections
• Reduces incidence/severity of diarrhea, pneumonia, otitis media, UTI, meningitis
• Reduces risk of SIDS, childhood obesity, type 1 DM, allergies, leukemia
• Promotes bonding, cognitive development (DHA in breast milk)
• Perfect temperature, sterile, convenient, no preparation

• Uterine involution (oxytocin release) - reduces postpartum hemorrhage
• Lactational amenorrhea - natural contraception (LAM: <6 months, EBF, amenorrheic = 98% effective)
• Reduced risk of breast and ovarian cancer
• Faster return to pre-pregnancy weight (burns ~500 kcal/day)
• Psychological bonding/satisfaction
• Cost-effective (no formula cost)

• HIV positive mother (in developed countries)
• Active untreated tuberculosis
• Galactosemia (infant)
• Maternal chemotherapy/radiotherapy
• Herpes simplex lesions on nipple

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B-Q3. Vitamin A Deficiency - Clinical Features and Prevention

Vitamin A Deficiency (VAD)

Clinical Features - Bitot's WHO Classification (XN to XF)

• Follicular hyperkeratosis (toad skin)
• Increased susceptibility to infections (measles, diarrhea, respiratory)
• Growth retardation
• Anemia (impairs iron utilization)

Prevention

• 9-12 months: 1st dose with MR vaccine - 1 lakh IU
• 16-24 months to 5 years: 2 lakh IU every 6 months (total 9 doses)

• Day 1, Day 2, Day 8 (or 4 weeks later) - age-specific doses

• 12 months: 200,000 IU per dose

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B-Q4. Rickets - Etiology, Clinical Features and Treatment

Definition

Etiology

• Vitamin D deficiency (dietary lack + inadequate sunlight)
• Calcium deficiency rickets (common in Africa/India - low calcium diet)

Clinical Features

• Craniotabes - softening of skull bones (earliest sign, <6 months)
• Delayed anterior fontanelle closure
• Frontal bossing (hot cross bun skull)
• Rachitic rosary - beading of costochondral junctions
• Harrison's sulcus - horizontal groove on lower chest (pull of diaphragm)
• Pigeon chest (pectus carinatum) or Harrison's groove
• Bow legs (genu varum) - most common; or knock knees (genu valgum) after walking
• Metaphyseal widening - wrist widening (most common clinical site seen)
• Delayed teething, enamel defects
• Short stature

• Hypocalcemic features: Tetany, seizures, stridor (laryngospasm), Chvostek's sign, Trousseau's sign
• Hypotonia, pot belly
• Anemia, susceptibility to infections

Investigations

• X-ray wrist: Cupping, fraying, splaying of metaphysis; widened growth plate (most characteristic)
• Serum 25-OHD3 < 20 ng/mL (deficiency), < 12 ng/mL (severe)
• Low/normal calcium, low phosphorus, elevated ALP (markedly)
• PTH elevated (secondary hyperparathyroidism)

Treatment

• Stoss therapy: Single oral dose of 3-6 lakh IU Vitamin D - preferred
• Daily therapy: 2000-4000 IU/day for 3 months
• Calcium supplementation: 500-1000 mg/day
• Adequate sunlight (30 min/day of face/arm exposure)

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B-Q5. Dengue Fever - Warning Signs and Management

Dengue Fever

WHO 2009 Classification

1. Dengue without warning signs
2. Dengue with warning signs
3. Severe dengue

Warning Signs (W in Dengue)

1. Abdominal pain - severe, continuous
2. Persistent vomiting (≥ 3 in 24 hours)
3. Clinical fluid accumulation - pleural effusion, ascites
4. Mucosal bleed - gum bleeding, epistaxis
5. Lethargy/restlessness
6. Liver enlargement > 2 cm
7. Rise in HCT with rapid decrease in platelet count

Severe Dengue (any one):

• Severe plasma leakage → dengue shock syndrome (DSS) → circulatory failure
• Severe bleeding
• Severe organ involvement (liver: AST/ALT ≥ 1000, CNS: altered consciousness, heart, kidneys)

Management

• Adequate oral hydration (ORS, coconut water, juice)
• Paracetamol (NOT aspirin or ibuprofen - risk of bleeding)
• Antipyretics, mosquito net
• Daily monitoring

• IV crystalloids (NS/RL): 5-10 mL/kg/hour initially
• Titrate based on clinical response; monitor HCT, urine output
• Platelet transfusion: Only if < 10,000/µL (no active bleeding) or < 20,000/µL with bleeding
• Monitor every 1-2 hours

• IV fluid resuscitation: 20 mL/kg bolus over 15-30 min
• Colloids (gelatin/dextran) if HCT still rising despite crystalloids
• Blood transfusion for severe hemorrhage
• Vasopressors if refractory shock
• Organ support as needed

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B-Q6. Rules of Development and Factors Affecting Development

Normal Development - Key Rules

1. Cephalocaudal progression - Head control before sitting before standing
2. Proximal to distal - Shoulder control before hand, hand before finger grasp
3. General to specific - Mass movements before fine movements
4. Sequential and predictable - Fixed sequence (though rate varies)
5. Continuous process - Never stops throughout life
6. Rate varies between children - Normal variation exists around milestones
7. Bilateral to unilateral - Bilateral movements before dominant hand preference
8. Integration of primitive reflexes allows voluntary movements
9. Development reflects maturation of CNS - myelination pattern

Key Developmental Milestones (Summary)

Factors Affecting Development

• Genetics/heredity
• Gestational age (prematurity)
• Birth weight
• Nutrition (especially first 1000 days)
• Hormones (thyroid, growth hormone)
• Sensory integrity (hearing, vision)
• CNS integrity (birth asphyxia, meningitis, trauma)

• Socioeconomic status
• Parental education and stimulation
• Quality of caregiver interaction (attachment)
• Play opportunities and toys
• School and peer influence
• Infections, toxin exposure (lead)
• Psychosocial adversity, abuse, neglect

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SECTION C - SHORT ANSWERS (10 x 3 = 30 Marks)

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C-Q1. DANGER Signs in a Sick Child (IMNCI General Danger Signs)

1. Not able to drink or breastfeed
2. Vomits everything
3. History of convulsions during present illness
4. Lethargic or unconscious

• Axillary temperature < 35.5°C or > 37.5°C
• Severe chest indrawing
• Nasal flaring
• Bulging fontanelle
• Umbilical discharge/redness extending to skin

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C-Q2. Fever with Rash

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C-Q3. Types of Vaccines

Based on Composition:

• Weakened live organism
• Single dose usually sufficient; produces cellular + humoral immunity
• Examples: BCG, OPV, MMR, Varicella, Yellow Fever, Rotavirus
• Contraindicated in immunocompromised

• Whole killed organism
• Multiple doses needed; less durable immunity
• Examples: IPV (Salk), Hepatitis A, Rabies, Pertussis (whole cell), JE

• Inactivated bacterial toxin
• Examples: Diphtheria toxoid, Tetanus toxoid (DT, Td, TT)

• Purified antigen component
• Examples: Acellular pertussis (DTaP), Hepatitis B (surface antigen), Typhoid Vi polysaccharide

• Polysaccharide antigen linked to protein carrier → T-dependent response
• Examples: Hib, Pneumococcal (PCV), Meningococcal

• Produced by genetic engineering
• Example: Hepatitis B (HBsAg in yeast)

• Example: COVID-19 vaccines (Pfizer-BioNTech, Moderna)

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C-Q4. Signs of Dehydration

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C-Q5. ORS Composition

• Less stool output
• Less vomiting
• Reduced need for IV therapy
• Safer in children

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C-Q6. Difference Between Marasmus and Kwashiorkor

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C-Q7. Triad of Congenital Rubella Syndrome (Gregg's Triad)

1. Congenital Heart Disease - Patent Ductus Arteriosus (PDA) most common; also pulmonary artery stenosis, VSD, ASD
2. Congenital Cataracts - "Salt and pepper" retinopathy; may have glaucoma; "pearly white" lens opacity
3. Sensorineural Hearing Loss - Most common single defect; bilateral, often severe

• Blueberry muffin spots (dermal hematopoiesis)
• Microcephaly, mental retardation
• Thrombocytopenic purpura
• Hepatosplenomegaly
• Growth retardation
• Diabetes mellitus (late)
• Thyroid dysfunction (late)

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C-Q8. Complications of Diphtheria

Complications (Local and Systemic):

• Airway obstruction - most common cause of death; membrane spreads to larynx → "bull neck", croup, stridor
• Aspiration pneumonia
• Tracheitis, bronchitis

• Most important cause of death (late complication, weeks 2-3)
• ECG: ST changes, heart block (all degrees), ventricular arrhythmias, complete AV block
• Myocarditis occurs in 10-25% of cases
• Dilated cardiomyopathy, heart failure

• Palatal palsy - earliest, 1-2 weeks (nasal twang, regurgitation)
• Oculomotor palsy - diplopia, blurred vision, ptosis (3-5 weeks)
• Peripheral neuropathy - ascending polyneuropathy, months after illness (Guillain-Barré like)
• Phrenic nerve palsy → diaphragmatic paralysis → respiratory failure

• Thrombocytopenia
• Renal tubular necrosis
• Adrenal hemorrhage

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C-Q9. Define Cold Chain

1. Cold chain equipment:

• ILR (Ice-lined refrigerators) - District/PHC level
• Deep freezer (-15 to -25°C) - for OPV storage
• Cold boxes - for transportation
• Vaccine carriers - for last mile (field level)
• Ice packs

1. Cold chain personnel: Trained handlers at each level
2. Cold chain transportation: Insulated vans, cold boxes
3. Cold chain monitoring:

• VVM (Vaccine Vial Monitor) - heat-sensitive label on vial; inner square becomes darker than outer ring when vaccine is heat-damaged
• Thermometer logs
• Shake test (for freeze-sensitive vaccines like DPT, Hep B, TT)

• National/Regional: Vaccine manufacturers → national stores
• State → District (ILR + deep freezer)
• Taluk/Block (PHC) - ILR + deep freezer
• Sub-centre/field - vaccine carrier with ice packs

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C-Q10. Causes of Iron Deficiency Anemia (IDA)

Causes:

• Exclusive breastfeeding beyond 6 months without complementary foods
• Cow's milk diet (low iron, high calcium blocks absorption)
• Poor weaning diet (cereal-based, low meat/flesh foods)
• Poverty, food insecurity

• Prematurity/low birth weight (reduced iron stores at birth)
• Rapid growth (infancy, adolescence)
• Twin pregnancy

• Malabsorption syndromes (celiac disease, short bowel)
• Achlorhydria (reduced ferric → ferrous conversion)
• Inhibitors in diet: phytates (cereals), tannins (tea), calcium (dairy) - taken with iron
• Helicobacter pylori infection (reduces absorption)

• Chronic blood loss: Hookworm infestation (most common cause in older children/adults in India)
• Meckel's diverticulum, intestinal polyps
• Cow's milk protein-induced enteropathy (occult blood loss)
• Inflammatory bowel disease
• Repeated phlebotomy

• Early cord clamping (reduces iron transfer)
• Feto-maternal hemorrhage
• Small for gestational age

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