6 KG (Doubles) 65 6 KG (Doubles) 65: 6 Months 6 Months

Dr.
Murali Bharadwaz Classes for MD/MS Entrance Coaching Programme

www.onlinembbs.com PAEDIATRICS 1
Birth weight (independent of gestation)

• Low birth weight (LBW) =
less than 2500
• Very low birth weight (VLBW) = • Large for gestation (LGA) = more than 90th centile in
less than 1500 weight expected for gestation.
• Extremely low birth weight (ELBW) =
less than 1000 g
Latest anthropometric values in relation to age:
AGE WEIGHT(kg) LENGTH (cms)

Birth 3 50
6 months 6 kg (doubles) 65
1 year 9(triples) 75
Age in utero
2 years 12 85 • Less than 1 week = fertilized egg to the formation of
the blastocyst.
3 years 14 95 • Upto 2 months = embryo.
• 12 weeks delivery = fetus.
4 years 16 100
SIZE FOR GESTATION
• Small for gestation (SGA) = less than 10th centile in
weight expected for gestation (small for dates).
• Appropriate for gestation (AGA) = between 10th and

90th centiles of weight expected for gestation.
Acquired Maternal infections effecting growth:

STARCH
• Syphilis
• Toxoplasmosis
Buy 600 hours Video Discussion to review at home, Price 20,000/- 9000868356
Dr. Murali Bharadwaz Classes for MD/MS Entrance Coaching Programme
• AIDS The neonate:
• Rubella 1. Perinatal period = the period from 28 weeks‘ gestation or
• CMV the time of the live-birth if less than 24 weeks‘ gestation,
• Herpes to 7 days of postnatal age.
2. Early Neonatal period = the first 7 days of life of a live-
born infant of any gestation.
3. Late Neonatal period = 8-28 days after birth.
4. Infancy = the first year of life.
“Red Flag signs” in child development

• No visual fixation by • 2 months
Body weight:
• doubles in 5 months
• Triples in 1 year
• quadruples in 2 years
• No vocalization • 6 months
• No sitting without support • 9-10 months
by
• Not standing alone • 16 months

• Not walking alone • 18 months
Length increase :
• No single words by • 18 months • in 1st year: 25 cm
• 2nd year: 12.5 cm
• Lack of imaginative play by • 3 years • 3 rd year: 6-7 cm
• 4 year : 6cm per year
SYMMETRICAL IUGR
• This is characterized by inadequate growth of the head,
body and extremities and occurs in 25% of IUGR fetuses.
The growth problem is the result of a decrease in the
rate of cell reproduction, resulting in fewer cells.
• This usually has its onset prior to 32 weeks of pregnancy
and has a 25% risk for chromosomal abnormalities (Down
syndrome, trisomy 13, trisomy 18).
IUGR:
Causes:
• Alcohol
• Smoking
• CRF
• Propranolol can cause IUGR. ASYMMETRICAL IUGR
• This usually occurs early in the third trimester and is
associated with impaired growth of the body, with
normal growth of the head and extremities.
• This is the result of failure of the cells to increase in size
resulting in less fat and smaller abdominal organs. These
fetuses often appear to be “long and skinny.”
• BRAIN is not affected in symmetrical IUGR
• Fetal growth is maximally affected by INSULIN.
• Fetal well being in IUGR is assessed by: Amniocentesis, → placental involution accompanying post maturity;
NST, AF Volume → or infectious agents such as cytomegalovirus rubella virus,
or Toxoplasma gondii.
Small for date babies

“Any infant whose weight is below the 10th percentile for
gestational age, whether premature, full-term, or post
mature.”
• Despite his small size, a full-term SGA infant does not

have the problems related to organ system immaturity
that the premature infant has.
Causes: An infant parents or a genetic disorder associated

with short stature) or from other factors that can retard
intrauterine growth.
These intrauterine (nongenetic) factors usually are not • An infant may be SGA if the mother is a narcotic or
operative before 32 to 34 wk gestation, and include cocaine addict or a heavy user of alcohol and, to a
→ placental insufficiency that often results from maternal lesser degree, if she smokes cigarettes during pregnancy.
disease invo lving the small blood ve ssels (as in
preeclampsia, primary hypertension, renal disease,
or long-standing diabetes) ;
Full term small for date babies are at a “risk for”: Necrotizing enterocolitis with perforation of the
• IUFD (lntrauterine fetal death) terminal ileum in LBW
• Perinatal asphyxia The plain abdominal film shows air in the portal vein, air in the
• Hypoglycemia: bowel walls, and a large pneumope ritoneum
• The SGA infant is very prone to hypoglycemia in the [subdiaphragmatic free air, perihepatic free air, double wall
first hours and days of life because of lack of adequate sign (blue arrows), triangle sign (green arrows), and
glycogen stores falciform ligament (red arrow)]
• Polycythemia-Hyperviscosity
• Hypothermia
• Dysmorphology
• Pulmonary Haemmorage
• This type of hemorrhage is particularly common in infants,

COMPLICATIONS OF LBW: especially premature infants or those of very low
Immediate: birth weight.
• Hypoxia/ischemia • it is thought to result from changes in perfusion of
• IVH the delicate cellular structures that are present in
• Sensorineural injury the growing brain, augmented by the immaturity of
• Respiratory failure the cerebral circulatory system, which is especially
• Necrotizing enterocolitis vulnerable to hypoxic ischemic encephalopathy.
• Cholestatic liver disease
The amount of bleeding varies. IVH is often described Neurological:
in four grades: • Mental retardation,
• Grade I - bleeding occurs just in the germinal matrix. • seizures,
• Grade II - bleeding also occurs inside the ventricles. • microcephaly,
• Grade III - ventricles are enlarged by the blood. • poor school performance,
• Grade IV - there is bleeding into the brain tissues around • hearing impairment, visual impairment, myopia.
the ventricles.
Grades I and II are most common, and often there are
no further complications. Grades III and IV are the most
serious and may result in long-term brain injury to the
infant.
Respiratory:
• The lack of blood flow results in cell death and subsequent
• Bronchopulmonary dysplasia,
breakdown of the blood vessel walls, leading to bleeding.
• Cor pulmonale, Recurrent Pneumonia.
• Most intraventricular hemorrhages occur in the first
72 hours after birth.
• The risk is increased with use of extracorporeal
membrane oxygenation in preterm infants
GIT:
• Short bowel syndrome,
• Malabsorption,
• Liver: Cirrhosis, liver failure, Carcinoma
Nutrient deficiency: Osteopenia, anemia, growth failure
Others: Asymmetric Tonic Neck Reflex (ATNR)
• SIDS, • Baby girl 3½ weeks old.
• Inguinal hernia, • Baby’s lying on their backs often turn their head to
• GERD one side or the other.
• Hypertension, • The limbs on the side toward which the head turns
• Craniosynostosis, (ipsilateral extremities) will straighten (extend), and the
• Nephrocalcinosis opposite limbs(contralateral extremities) bend (flex), the
so-called ‘fencing posture’.
• The movement is most evident in the arms but may also
be observed in the legs.
• By turning the head to the opposite side, the extension
and contrac tion of the limbs of ten change
accordingly.
• The reflex may stimulate eye-hand coordination ,
because the extended arm moves in front of the face.
• The reflex disappears around the third/fourth month
of life.
• If the reflex continues to be triggered past six months
of age, the child may have a disorder of the upper motor
neurons.
Causes of Macrocephaly are:

• Caput Succedaneum,
Cephalohaematoma Caput succedaneum • Cephalohematoma,
• Not present at time of birth • Present over • Subgaleal haematoma,
presenting part • hydrancephaly,
• subdural collections,
• Subperiosteal swelling • Soft, boggy swelling
• Sotos syndrome,
• Does not cross suture lines • Can cross suture line • Canavans disease,
• Disappears late(2 weeks-3 • Disappears early • Alexanders disease.
months)
Important reflexes:
Sucking reflex: Observed by 14 weeks of
gestation.
Rooting reflex; develops by 28 weeks'" Causes of Microcephaly

• Downs Syndrome
Palmar grasp reflex: develops by 28 weeks and • Congenital Rubella syndrome
disappears by 4 months of • Edwards syndrome
age • Pataus Syndrome
• Beckwith Weidman syndrome
T onic neck reflex: disappears by 8 months • Cornelia de langie syndrome
• Velocardiofacial syndrome
of age • Cockayne syndrome
• CHARGE Syndrome
• Warfarin:
Chondrodysplasia punctata
• Carbimazole:
Fetal cutis Aplasia
Teratogens
• Carbamezapine: • Cleft Lip, cleft palate.
• Lithium: • Ebsteins Anomaly

• Valproic acid: • Neural tube defects.
• Thalidomide: • Phocomeiia
Single umbilical artery : very common in infants of Diabetic

mothers and trisomies 18 and twins.
• Chloramphenicol: • Grey baby syndrome
• DES: • Clear cell cancer
Fetal alcohol syndrome:

• Microcephaly • Hernia: has peritoneal layer and skin
• Retarded growth • Omphalocele: peritoneal layer but no skin
• Maxillary hyperplasia • Gastrochisis: neither peritoneal layer nor skin.
• Small eyes
• Mental Retardation
• Cardiac malformation
• Hyperkinetic movements. Developmental mile stones
• Head Control • ■ I month Builds a tower of three 18 months

cubes
• Child smiles at • ■ 2 months
familiar persons Feeds Self 18 months
• Sits with support • ■ 5 months Can drop and draw a 2 Years
horizontal or vertical line
• Crawls at • ■ 8 months • Can turn one page at a time
- 2 Years
• Says mama dada • ■ 10 months
Babies know their ■ 3 years
gender by
Copies circle ■ 3 years
Self Decisions ■ 7 years
Social Smile 2 months

Recognises mother 3 months
Holds object and takes it to 4 months
mouth
Sitting on slight support 5 months
Enjoys mirror 6 months

Sits alone momentarily 5-6 months
Transfers object from hand 6 months
to hand Able to wear socks or 2 Years
shoes
Rolls Over 7 weeks • Can remove his pants
- 2 1/2 Years
Sits steadily 7-8 months
Crawls in bed 8 months
Monosyllabic words ( 10 months
Mama, Dada)
Creeps 10 months
Cruises around furniture 10 months
Builds a tower of 2 12 months

cubes and pincer grasp
Can turn two or three 13 months
pages of a book
Walks alone 13-14 months
Walks Sideways and 15 months
backwards
Drawing skills :
Can draw a circle 3 Y ears
• Draws a horizontal • 2 years
Can dress or undress 3 Y ears or vertical line:
completely and buckle
his shoes • Draws a circle: • 3 years
• Draws a cross: • 4 years
• Draws a rectangle: • 4 years
• Draws a triangle: • 5 years
Non Pathological entities that are self limiting
• Erythema toxicum
Knows age and sex 3 Years

Can copy and draw a 4 Years
cross ( Plus Sign)
Can draw a rectangle 4 Years
Can draw a tilted cross 5 Years Non Pathological entities that are self limiting
(Multiplication sign) • Epstein pearls
Can draw a triangle 5 Years
Bladder Control- Diurnal 12- 16 months

Nocturnal 2 1/2Years to 3 Years
Non Pathological entities that are self limiting

• Stork bites
Non Pathological entities that are self limiting The advantages of breast feeding are:
• Safe, clean, hygienic, cheap & available to the infant at
• Vaginal bleeding-(Maternal hormones) correct temperature
• Mongolian spots • Fully meets the nutritional requirements of the infant in
• Phimosis the first few months of life
• Breast engorgement. • Contains antimicrobial factors such as macrophages,
lymphocytes, secretory IgA, lantistreptococcal factor,
lysozyme& lactoferrin
• Lower risk of allergy, ear infections & orthodontic
problems, diabetes mellitus, heart disease & lymphoma in
later life
• Easily digested & utilized by both the normal & premature
babies.
• Promotes bonding between the mother & infant
Premature neonate
• Sutures widely separated
• Skin appears shiny
• Abundant lanugo
• Subcutaneous fat is reduced.
• Sluggish neonatal reflexes
• Small face
• Sucking is good for the baby as it helps in the development

of jaws & teeth
• Protects babies from the tendency to obesity
• Prevents malnutrition & reduces infant mortality rate
• Provides several biochemical advantages such as prevention
Breast milk of neonatal hypocalcemia & hypomagnesaemia
is the ideal food for the infant.
• No other food is required by the baby until 4-
5 months after birth.
• Helps parents to space their children by prolonging the
period of infertility.
• Under normal conditions, Indian mothers secrete 450
to 600 ml of milk daily.
• The energy value of human milk is 70 Kcals per 100 ml.
Comparison to cows milk:

− Cows milk has more proteins than breast milk.
- Cows milk has more calcium than breast milk.
- Cows milk has more Vitamin K than breast milk.
Breast milk has got many protective factors against bacteria,

viruses, parasites.
• Lactoferrin is particularly important against Plasmodium
falciparum, E. coli, Giardia
• Bile salt stimulated is important against E. histolytica.
• Lactadhesins against Rota virus.
• PABA is also anti infective for malaria.
• Oxytocin is necessary for ejection/Let down .
• Prolactin is necessary for milk synthesis.
• Is maximum produced at 5-6 months

• Can transmit tuberculosis
Contraindications to breast feeding

• Galactosemia is an absolutcontraindication to breast
feeding.
Breast fed infant can be deficient in:

• Vitamin B1
• Vitamin B12
• Vitamin K
• Folic acid
Contraindications to breast feeding Vaccines to be stored in cold compartment but not freezer:
• Chronic medical illness such as decompensated heart failure. - Typhoid,
• Open Tuberculosis of mother is also a contraindication to - DPT,
breast feeding in developing countries. - Tetanus Toxoid,
Severe anemia - Diluents
• Chronic nephritis
• Purpureal pshycosis
• Patient on antiepileptic, antithyroid drugs
Vaccines:
Live Vaccines are: Characteristics Killed Live vaccine
• BCG Vaccine
• Measles
• Mumps
• Doses o Multiple o Multiple
• Rubella • Adjuvant o Needed o Not needed
• Oral Typhoid
• Oral polio(sabin) • Duration of o Short o Short
• Influenza immunity
• Yellow fever (17 D)
Killed Vaccines are:

• Rabies
• Plague
• SaIk polio
• KFD
• Typhoid
• Cholera
• Japanese encephalitis
• Pertussis
Fragment Vaccines
• Diphtheria
• Tetanus
• meningococcus, pneumococcus, haemophilus
• Hepatitis B
• Freeze dried vaccines:

• BCG,
• Yellow fever, q Effectiveness of protection o Lower o Greater
• Measles q Reversion of virulence o No o Possible
• OPV q Stability at room tempareture o High' o Low
Immunity Vaccine Contraindications

Mucosal immunity ► Poor ► High
• All vaccines • Previous anaphylaxis
Cell mediated immunity ► Poor ► High
• Live vaccines • Pregnancy, Radiation

Therapy
Live vaccines
• Contain major and minor antigens.
• Booster doses not required.
• immunoglobulin’s can be given 2 weeks after live vaccine.
• BCG • Symptomatic HIV

infection
Vaccines and strains used:
Measles • Edmonston Zagreb

Strain
BCG • Danish 1331
Rubella • RA 27/3
IPV • Salk Strain
OPV • Sabin Strain
Chicken Pox • Oka strain
• Max growth spurt is seen in girls at time of menarche
• Influenza, Yellow • Egg allergy
fever
GROWTH AND DEVELOPMENT Malnutrition:

• Thelarche → Pubarche → Menarche PEM
• Thelarche is the first change occurring at puberty. Indian Academy of Paediatrics:
• It is noticed as appearance of firm, tender lump under
centre of nipple. 1st degree ■ W eight between 80 and 70%
• It is referred to as breast budding. 2nd degree ■ W eight between 70 and 60%

• It is due to rising estrogen levels.
3 rd degree ■ W eight between 60 and 50%
4th degree ■ W eight below 50 % of expected
International classification (Welcome Classification)
Weight between 80 and ■ Kwashiorkor

60 % of expected with
edema
Weight between 80 and ■ Under nutrition
60 % of expected with
out edema
• Pubarche refers to appearance of pubic hair.
It results from rising androgen levels. Weight below 60 % of expected Marasmic
• Menarche refers to appearance of first menstrual cycle. with edema Kwashiorkor
• Adrenarche refers to stage of maturation of adrenal cortex Weight below 60 % of expected Nutritional Marasmus
with out edema
Marasmus and kwashiorkor
Features Marasmus Kwashiorkor

Edema Absent Present
Wasting Marked Less
Growth retardation Severe Less
Mental changes Usually absent Usually present
Hepatomegaly Absent Present
• Marasmus – Loose folds on glutei ,Hypotonia of abdominal
muscles with abdomen distended
PEM - Prognosis Restoration / Dietary Management
Bad Prognostic Signs • Beginning of Feeding ( (0-7 Days)
– Severe dehydration • Route
– CCF • Orally or by NG tube
– Bleeding diathesis • Quantum
– Xerophthalmia Stomach volume : 3% of body weight
– Hepatic dysfunction Eg. Child weighing 5 kg may have stomach volume of
– Seizures about 167 ml
– Altered sensorium • Frequency:
– Extreme weight loss During daytime, 2 hourly feeds can be given.
A late night and early morning feed will prevent hypoglycemia
in night.
• Small and frequent feeds
(12 feeds on 1st day to 6-8 by day 3-7 )
Management of Severe PEM

Criteria for Admission:
– Weight < 60% expected
– Age – less than 1 year
– Edema
– Severe dehydration
– Shock
– Systemic infection
– Jaundice
– Bleeding
– Persistent loss of appetite
• Type of Feed
First 3 Days:
- Milk based diets –
Initially at 125 ml / kg / then making up to 150 ml / kg / d -
If dried skimmed milk power is used, add oil and sugar to
provide extra calories - Introduce semisolids as early as
possible
From 3rd week onwards:
traditional feeds @ 150 ml / kg / d with following
Approach to a case of PEM
• S ugar Deficeiency composition
• H ypothermia
• I nfection
• E lectrolyte imbalance
• DE hydration
• D eficiency of micronutrients
b) Energy Dense Feeding Nutritional Recovery Syndromes - 2
Therapeutic diet should contain • Kwashi shake :
• Energy : 150 – 220 Cal / kg / d – Self limiting tremors during treatment
• Protein : 4-5 g / kg / d – Take months to resolve
– Demyelination, vitamin deficiencies, neurotransmitter
imbalance and high solute load on kidneys are the possible
reasons
a) Diet Content
• 50% of calories from CHOs
• 15% from proteins
• 35% from fat
Coconut oil as fat supplement as it is rich in MCTs
Oil supplementation can be up to 10 – 15 % of calculated
calories
Nutritional Recovery Syndromes - 3

– Pseudotumor cerebrei
– Encephalitis like syndrome
– Due to excess proteins
Kahn syndrome ( 6 days after starting of tt.)
– Coarse tremors, parkinsonism rigidity, bradykinesia, myoclonus
Gomez syndrome
– Prominent abdomino thor acic veins, ascites,
Nutritional Recovery Syndromes -1 hepatosplenomegaly, splenomegaly, parotid enlargement,
• Apparent worsening with increased liver size, hypertrichosis, eosinophilia and gynaecomastia
gynaecomastia, parotid swelling, abdominal distention, – Due to estrogen and other tropic hormones secreted from
ascites, splenomegaly and eosinophilia during therapy. recovering pituitary.
• Self limiting condition
• Attributed to excessive hormones secreted during
recovery than protein excess
PEM: Age independent indices for malnutrition
- Hypothermia
- Hypoglycemia
- Hypomagnesaemia Kanawati and Mid arm
- ↑ Total body water Mclarens index circumference/
- ↑ Cortisol and GH. head circumference
Roa and Singh Weight in kg/height

index 2in cms
Dugdales index Weight in kg/height

1.6in cms
Quaker arm Mid arm

circumference circumferences
indicator
Jeliffes ratio Head
circumference/chest
Hypokalemia, Hypoglycemia, Hypothermia are acute circumference
complications of PEM.
• Acute malnutrition is judged by: weight for height.

• Chronic malnutrition is judged by: height for age.
Rickets
The clinical manifestations of rickets are the result of skeletal
deformities:
• Susceptibility to fractures, weakness and hypotonia, and
disturbances in growth.
• Parietal flattening
• Frontal bossing develops in the skull.
• Craniotabes: The calvariae are softened
• Sutures may be widened.
Flag sign: is seen in Kwashiorkor :Hair is thin, dry, brittle,

lusterless, sparse , easily puluckabe and hypopigmented.
• Rachitic rosary -P rominence of the costochondral

junctions is called the rachitic rosary
• Lumbar Lordosis
• Short stature, genu valgum, coxa vara,
• Kyphoscoloiosis
• Harrison’s groove .-indentation of the lower ribs at the

site of attachment of the diaphragm
• Knock knee + Coxa Vara
• Bow legs.
• Pot Belly
• Forward projection of sternum.(Pectus Carinatum)
Triradiate pelvis
in rickets
• Rickets is characterized by defective mineralization of

bones.
• Rickets is seen before closure of growth plates.
Caput Quadratum
• Caput quadratum is an irregular shaped skull resulting in
frontal bossing or a prominent, sometimes square, forehead
- Causes: • Wimberger sign seen.
• Nutritional rickets: vit D deficiency, Malabsorption • Rosary seen
• Accelerated loss of vit D: • Pseudoparalysis seen.
Phenytoin,Rifampicin,Barbiturates
• Impaired hydroxylation In liver and Kidney:
• Liver disease,Hypoparathyroidism,Renal failure, Renal
Tubular Acidosis
• Vit D Resistant rickets, Fanconis syndrome, Wilsons disease.
Biochemical:
Serum calcium : normal or low
Serum phosphate: low
Alkaline phosphatae: high
PTH : High
Scurvy
• Vitamin C deficiency causes scurvy; Causes of Delayed puberty
• Symptoms of scurvy primarily reflect impaired formation Delayed puberty with short stature
of mature connective tissue and include bleeding into • Turner’s syndrome
skin (petechiae, ecchymoses, perifollicular hemorrhages) • Prader-Willi syndrome
inflamed and bleeding gums; and manifestations of bleeding • Noonan’s syndrome
into joints, the peritoneal cavity, pericardium, and the
adrenal glands.
Prader-Willi syndrome
Delayed puberty with normal stature

• polycystic ovarian syndrome
• Androgen insensitivity syndrome
• Kallman’s syndrome
• Klinefelter’s syndrome
- The disease spectrum varies considerably, but the most
commonly recognized form is the “floppy baby
syndrome.”
• OTHER CAUSES OF DELAYED PUBERTY:

Chronic diseases
Hypothyroidism
Hypopituitarism – Initial symptoms are
Anorexia nervosa lethargy, diminished suck, constipation,
weakness, feeble cry, and diminished
spontaneous activity with loss of head control.
• These symptoms are followed by extensive flaccid
paralysis.
- The bulbar musculature is usually affected first.
- In older children, it results in diplopia, dysarthria, and
dysphagia.
• Infant botulism
- results from the production of toxin after colonization of
the gastrointestinal tract by Clostridium botulinum in young
children aged 1-9 months.
- The most common source of the organism is the soil or
honey.
- Nearly all cases are due to types A or B, The incubation
period is usually between 18 and 36 hours.
- Short incubation periods are associated with more
severe disease.
• Involvement of the cholinergic autonomic nervous

system may result in decreased salivation, with dry mouth
and sore throat, ileus, or urinary retention.
• Neurologic evaluation often shows bilaeral paresis of the
6th cranial nerves, ptosis, dilated pupils with sluggish
reaction, decreased gag reflex, or medial rectus paresis.
• These symptoms a re followed by desce nding
involvement of motor neurons to peripheral muscles,
including the muscles of respiration.
Generalized ecchymoses, often without petechiae, intracranial
bleeding, and large intramuscular hemorrhages, also may
develop in severe cases.
• In infants with hemorrhagic disease of the newborn, the
prothrombin time (PT) is always p rolonged.
The partial thramboplastin time (PTT) and the thrombin
time are also prolonged.
Specific factor assays reveal deficiencies of prothrombin;
factors VII, IX, and X; and proteins C and S.
The bleeding time and the platelet count usually are
within normal limits.
RASHES IN INFANCY AND CHILDHOOD VESICULAR

RASHES
Varicella – Chicken pox
• Lesions normally appear without a prodromal illness ,
and progress rapidly (within a few hours) from papules to
- Patients are usually afebrile with clear mentation. vesicles surrounded by an erythematous base.
- The most common cause of death is respiratory failure. • Crops of vesicles appear over 3 days, predominantly on
- Respiratory failure is the: major risk. the trunk and proximal limbs.
Hemorrhagic disease of the Newborn : Herpes zoster

Is as a result of vitamin K deficiency, • Lesions similar to those seen in varicella infection may
* is now uncommon because of the routine develop over specific dermatomes or cranial nerves.
administration of vitamin K at birth. • Although the immunosuppressed are at increased risk from
• As a result, coagulation abnormalities become severe and zoster, this condition is also seen in normal children.
bleeding may occur.
• All newborns should receive 0.5-1.0 mg of vitamin K
intramuscularly within the first hour after birth.
Prematurity has been associated with

hemorrhagic disease of the newborn.
* Delayed feeding, breast -feeding, vomiting, severe
diarrhea, and antibiotics also delay the colonization of
the gut by bacteria.
* Bleeding is usually severe and occurs most commonly on
the 2nd or 3rd day of life.
* The most common manifestations are melena, large
cephalohematomas, and bleeding from the umbilical
stump and after circumcision
Herpes simplex virus

• Although infection is most commonly associated with
gingivostomatitis during childhood, vesicles are seen on
the skin in eczema herpeticum (Kaposi’s varicelliform
eruption)
• Pyrexia is followed by the appearance of crops of vesicles

on the eczematous skin.
• Crops of lesions may occur over several days.
• Correct and rapid diagnosis is essential because untreated
severe infection may be fatal
Measles
• Measles rash is blotchy, red or pink in col or, raised in
places, and starts behind the ears and on the face,
spreading downwards.
• The lesions tend to become confluent on the upper part
of the body and remain more discrete lower down.
Hand, foot and mouth disease

• This is caused by enteroviruses, the commonest being
Coxsackie virus type 16 , and occurs in epidemics.
• It is associated with a papular-vesicular eruption of the
mouth, hands, feet and sometimes buttocks.
Impetigo
• This condition usually presents as a red macule and then
becomes vesicular.
• The small vesicles burst to leave a honey-colored crust. • The rash fades, usually after 2-3 days.
• Both streptococcal and staphylococcal impetigo occur • The skin becomes brown and although desquamation
commonly around the mouth but can occur elsewhere. occurs this is not usually, seen on the hands and feet as it
is in scarlet fever.
Molluscum contagiosum
• This is caused by a pox virus.
• Flesh-colored papules with a central dimple are seen.
• Although firm initially they become softer and more waxy
with time.
• Lesions are 2-5 mm in-size and may occur anywhere.
• It is more severe in HIV infection.
Dermatitis herpetiformis
• This occurs in children from 8 years upwards who develop
recurrent crops of pruritic papulovesicles over extensor
surfaces including the elbows, buttocks and knees.
• Many of these children also have a gluten-sensitive
enteropathy.
Rubella
• Rubella results in a pink rash which progresses caudally.
• The lesions are normally discrete and the rash develops
more quickly and disappears earlier than in measles.
• Desquamation is not a characteristic.
Maculopapular rashes:
Scarlet fever Kawasaki disease
• The eruption is dark red and punctiform. • Although several features are required for the diagnosis
• The rash tends to be most prominent on the neck and in of this condition, which is of unknown etiology, the rash
the major skinfolds. may be confused with that of scarlet fever .
• A distinctive feature is circumoral pallor as a result of the
rash sparing the area around the mout h.
• As with measles, desquamation is seen but the hands
and feet are involved.
- True scarlet fever is associated with inflammation of the

tongue (white and red strawberry tongue).
Discrete red maculopapulesare seen

on the feet, around the knees and in
the axillary and inguinal skin creases .
– Scarlatina refers to the rash which may occur alone in

milder streptococcal infection, and is often shortlived.
Desquamation of the hands and feet

is a common feature
Erythema infectiosum or fifth disease
Infection caused by parvovirus B19 is associated with a
rash which develops in two stages.
- The cheeks appear red and flushed, giving rise to a
‘slapped cheek’ appearance .
Roseola infantum ALSO CALLED Exanthem subitum:
• Means a sudden rash.
• A viral disease of infants and young children with sudden
onset of high fever which lasts several days and then
suddenly subsides leaving in its wake a fine red rash.
• The causative agent is herpesvirus type 6 so the disease
is known as Sixth Disease.
• Also called Pseudorubella, Roseola, Roseola infantilis, and
Roseola infantum.
As the rash appears

the fever, which is normally present over the
previous 4 days, resolves and the Child looks well
ü A maculopapular rash develops 1-2 weeks later , (in contrast to measles, in which the child is febrile
predominantly over the arms and legs which, as it and unwell when the rash appears ).
fades, appears lace-like.
Viral infections
ü Causes non immune hydrops is caused by Many viral infections, particularly those associated with the
parvo virus enteroviruses, may cause maculopapular rashes ,
PETECHIAL AND PURPURIC RASHES
Roseola infantum
The main cause is human herpesvirus 6 (HHV-6).
R oseola infantum is characterized by a widespread
morbilliform (measles-like) rash, seen in its most florid
form on the trunk.
The lesions tend to be discrete.
Meningococcal infection
• The first sign of meningococcal septicemia may be a

petechial or purpuric rash anywhere on the body and
often localized.
• On occasions these lesions may be preceded by or
accompany a maculopapular rash which may blanch
• The petechiae will not blanch, and although it is
conventional to make • Dermatomyositis • Violaceous
• A microbiological diagnosis on blood culture and PCR
• Bacteria can also be isolated from these lesions.
Meningococcal petechiae can be confused with those seen

on the face around the eyes following events that result
in a transient rise in venous pressure such as vomiting. • Most common manifestation of mumps is: Parotitis
Rarely petechiai rashes are associated with septicemia • Second most common manifestation of mumps in post
caused by other bacteria particularly Haemophilus pubertal males is: orchitis
influenzae. • Most common ocular manifestation of mumps is :
dacryoadenitis
Henoch-Schonlein purpura
• This condition often follows an upper respiratory
tract infection but no single infective agent has
been implicated.
• Hemorrhagic macules and papules develop on the
buttocks and extensor surfaces of the limbs particularly HENOCH SCHONLEIN PURPURA
the knees and ankles. - also referred to as anaphylactoid purpura, is a distinct
• The lesions come in crops and fade over a few days leaving systemic vasculitis syndrome that is characterized by
a brown pigmentation. • palpable purpura (most commonly distributed over the
buttocks and lower extremities
Idiopathic thrombocytopenic purpura (ITP) • arthralgias,
A purpuric rash sometimes associated with frank bleeding is • abdominal pain
seen in this condition. • glomerulonephritis.
Leukemia
Children with leukemia may present with a
hemorrhagic rash as a result of thrombocytopenia but in
addition, the pallor of severe anemia will usually be obvious.
Types of rash
• Anaphylactoid • Vasculitis
purpura:
• Salmonella: • Evanescent
• Erythema • slapped face
infectiosum: appearance
• Infectious • drug (ampicillin)
mononucleosis: Induced rash
Petechiae and purpura are later stages of the rash in

Henoch-Schönlein purpura.
Spectrum of systemic vasculitides organised according to
predominant size of vessels affected
Lesions become rust-colored before fading

over a period of approximately 10 days. • Ig A is the antibody class most often seen in the immune
complexes and has been demonstrated in the renal
The rash is usually located in areas that are subject to pressure, biopsies of these patients
such as the buttocks.
• It is a small vessel vasculitis,

• Henoch-Schonlein purpura is usually seen in children; most
patients range in age from 4 to 7 years The typical Henoch-Schönlein purpura rash with palpable
• A seasonal variation with a peak incidence in spring has
purpura on an older child’s lower extremities.
been noted.
Kawasaki Disease
• Kawasaki disease (also known as “lymph node syndrome”,
“mucocutaneous node disease”, “infantile polyarteritis”)
• Kawasaki disease is an inflammation (vasculitis) of the
middle-sized arteries.
Periorbital edema as commonly seen in young children

with Henoch-Schönlein purpura
• Gastrointestinal involvement, which is seen in almost

70% of pediatric patients, is characterized by colicky
abdominal pain usually associated with nausea, vomiting,
diarrhea, or constipation and is frequently ‘accompanied
by the passage of blood and mucus per rectum; bowel • Kawasaki disease affects many organs, including the skin,
intussusception may occur rarely. mucous membranes, lymph nodes, and blood vessel walls,
but the “most serious “effect is on the heart where it can
cause “severe aneurysmal dilations”
Intramural collateral arteries may develop in

occluded segments of the coronary arteries,
and they appear as ‘arteries within the artery’
and show a braid-like appearance.
Severe gastrointestinal vasculitis in a child with Henoch-

Schönlein purpura . The small intestinal loops areedematous, inflamed, and A chest film
showed an area
hemorrhagic.
• it usually resolves spontaneously without therapy. of calcification

• Rarely, a progressive glomerulonephritis will develop.
• Renal failure is the most common cause of death in at the upper
the rare patient who dies of Henoch-Schonlein purpura. border of the
• Routine laboratory shows mild leukocytosis, a normal left ventricle
platelet count and occasionally eosinophilia. (arrow in Panel
• Serum complement components are normal, and IgA
levels are elevated in about one-half of patients. A)
• Treatment: The prognosis of Henoch-Schonlein purpura
is excellent. Most patients recover completely, and some
do not require therapy.
Selective angiography of the

left coronary artery showed a
large aneurysm of the left
main coronary artery with
stenosis of 80 percent of the
luminal diameter at the
origin of the left anterior
descending coronary artery
(arrow in Panel B).
The circumflex coronary
artery was occluded
proximally (not shown) but
filled by means of collaterals
Neck nodule
from the right coronary artery
(arrow in Panel C).
• Classically, five days of fever plus four of five “Diagnostic

criteria” must be met in order to establish the diagnosis.
The criteria are:
(1) erythema of the lips or oral cavity or cracking of
the lips;
(2) rash
(3) swelling or erythema of the hands or feet;
(4) red eyes (conjunctival injection)
(5) swollen lymph node In the neck of at least 15
millimeters. Abdominal Rash
Q1. What is the likely diagnosis?
Also known as Mucocutaneous Lymph Node Syndrome, this
vasculitic disorder was first described by Dr. Tomisaku
Kawaski in 1967. It is of uncertain etiology, but may be a
post-infectious condition.
TREATMENT :
• Intravenous immunoglobulin + aspirin.
• Long term therapy: aspirin. (A) Bilateral, non-exudative conjunctival injection with
• Only condition in children in which aspirin is given, (causes perilimbal sparing. (B) Strawberry tongue and bright red,
Reyes syndrome.) swollen lips with vertical cracking and bleeding
Case presentation
• A 4 year-old boy has been brought to the emergency
department by his worried parents. He has had fevers for
the past 6 days.
• They are concerned because he is not getting better

despite repeated visits to a number of doctors. Each time
they were told he had a viral illness.
• On examination you note the presence of bilateral

conjunctivitis, and erythematous rash on his torso
and limbs, a 4 cm tender left-sided cervical lymph
node and a diffusely red pharynx Erythematous rash involving perineum.
• Simple Important eponyms( WITHOUT CLUES)
1st day disease : Measles

2nd day disease: Scarlet fever
3rd day disease: Rubella
(E) Erythema of the soles, and swelling dorsa of the feet. 5th day disease: Erythema infectiosum
(F) Desquamation of the fingers. 6th day disease: Roseola infantum
(G) Erythema and induration at the site of a previous
vaccination with Bacille Calmette-Gurin (BCG) 8th day disease: T etanus
13 Genetic Syndromes for MD Entrance
1. Down syndrome
2. TRISOMY 18 (EDWARDS’ SYNDROME)
3. TRISOMY 13 (PATAU’S SYNDROME)
4. 4p - (WOLF-HIRSCHHORN) SYNDROME
5. 5p - (CRI DU CHAT) SYNDROME
6. 18q – syndrome
7. DIGEORGE SYNDROME
8. WILLIAMS SYNDROME
9. ANGELMAN SYNDROME AND PRADER-WILLI SYNDROME
10.Turners syndrome
11.47XXX
12.Klinefelter’s syndrome
13.FRAGILE X Syndrome
(D) Erythema of the palms, which is often accompanied by

painful, brawny edema of the dorsa of the hands
(H) Perianal erythematous desquamation.
• Rashes:
Day 1 of fever: ‘Varicella zoster
Day 2 of fever: Scarlet fever
Day 3 of fever: small pox
Day 4 of fever: measles
Day 5 of fever: Typhus
Day 6th of fever- dengue fever
Day 7th of fever- Typhoid
• First disease: • Rubeola or measles,

(kopliks spots)
• Second • Scarlet fever (circumoral
disease: pallor, pastias lines, straw
berry tongue)
• Third disease: • Rubella) Forschmiers spots,
posterior cervical
lymphadenopathy)
• Fourth • SSSS (Nikolskys sign)
disease: Down syndrome
- Common trisomy.
- Head circumference is small
Fifth disease: Erythema infectiosum - Brachycephalic skull.
- The neck is short and thick.
(parvovirus B 19, Slapped
cheek appearance)
Sixth disease Exanthem subitum, (roseola
infantum), HHV 6
• There is an increased incidence of lens opacities.
• The ears are small with an overfolding helix.
• The nasal bridge is flat.
• The tongue appears large and may protrude because the
mouth is relatively small.
• Hypotonicity is present
• The palpebral fissures slope upwards (i.e. the o u t e r
canthus is higher than the inner canthus) and there may
be marked epicanthic folds. (HYPOTELORISM) • Eruption of the teeth is frequently delayed with
abnormalities in dental positioning.
• The hair may be fine and sparse.
• The hands are short and broad.
• Brushfield’s spots (whitish spots scattered round the

periphery of the iris) • The fifth finger is short and incurved (clinodactyly).
Radiologically this
feature is
accompanied by
shortening of the
shaft of the
middle phalanx.
• ↑ Nuchal fold thickeness • Iliac index < 60

• A single transverse palmar crease (or simian crease)

6 KG (Doubles) 65 6 KG (Doubles) 65: 6 Months 6 Months

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

6 KG (Doubles) 65 6 KG (Doubles) 65: 6 Months 6 Months

Uploaded by

Copyright:

Available Formats

Dr.

Murali Bharadwaz Classes for MD/MS Entrance Coaching Programme

Birth weight (independent of gestation)

Latest anthropometric values in relation to age:

AGE WEIGHT(kg) LENGTH (cms)

• Appropriate for gestation (AGA) = between 10th and

Acquired Maternal infections effecting growth:

“Red Flag signs” in child development

• Not standing alone • 16 months

• BRAIN is not affected in symmetrical IUGR

• Fetal growth is maximally affected by INSULIN.

Small for date babies

• Despite his small size, a full-term SGA infant does not

Causes: An infant parents or a genetic disorder associated

• This type of hemorrhage is particularly common in infants,

Causes of Macrocephaly are:

Rooting reflex; develops by 28 weeks'" Causes of Microcephaly

• Lithium: • Ebsteins Anomaly

Single umbilical artery : very common in infants of Diabetic

• Chloramphenicol: • Grey baby syndrome

• DES: • Clear cell cancer

Fetal alcohol syndrome:

• Head Control • ■ I month Builds a tower of three 18 months

Social Smile 2 months

Enjoys mirror 6 months

Cruises around furniture 10 months

Builds a tower of 2 12 months

Knows age and sex 3 Years

(Multiplication sign) • Epstein pearls

Can draw a triangle 5 Years

Bladder Control- Diurnal 12- 16 months

Non Pathological entities that are self limiting

• Sucking is good for the baby as it helps in the development

Comparison to cows milk:

Breast milk has got many protective factors against bacteria,

• Is maximum produced at 5-6 months

Contraindications to breast feeding

Breast fed infant can be deficient in:

Killed Vaccines are:

• Freeze dried vaccines:

Immunity Vaccine Contraindications

• Live vaccines • Pregnancy, Radiation

• BCG • Symptomatic HIV

Vaccines and strains used:

Measles • Edmonston Zagreb

GROWTH AND DEVELOPMENT Malnutrition:

• It is referred to as breast budding. 2nd degree ■ W eight between 70 and 60%

4th degree ■ W eight below 50 % of expected

International classification (Welcome Classification)

Weight between 80 and ■ Kwashiorkor

Features Marasmus Kwashiorkor

Management of Severe PEM

Nutritional Recovery Syndromes - 3

Roa and Singh Weight in kg/height

Dugdales index Weight in kg/height

Quaker arm Mid arm

• Acute malnutrition is judged by: weight for height.

Flag sign: is seen in Kwashiorkor :Hair is thin, dry, brittle,

• Rachitic rosary -P rominence of the costochondral

• Harrison’s groove .-indentation of the lower ribs at the

• Rickets is characterized by defective mineralization of

Delayed puberty with normal stature