Pediatrics Rapid Revision

PEDIATRICS
WORKBOOK
By
DR. SANDEEP SHARMA
ARISE MEDICAL ACADEMY

https://instagram.com/arisemedicalacademy
www.arisemedicalacademy.com
RISE WITH ARISE

PEDIATRICS WORKBOOK BY DR SANDEEP SHARMA FOR ARISE FMGE BATCH 2023
Pediatrics Workbook: For ARISE

FMGE Live Achiever’s Batch 2023
By Dr Sandeep Sharma
MD Pediatrics
(PGI Chandigarh)
• Contains Tables, Images, Collection Of One-Liners

• To Be Read & Annotated In Conjunction With The Class Discussion
1
A Disclaimer
• This workbook and the contents thereof are the intellectual property of the author.
• Facts and information have been sourced from a variety of literature, including
Pediatrics Textbooks & guidelines, as well as, based upon the clinical experience of
the author.
• All information discussed and taught is meant for general informative purposes and
is not meant to either treat, prevent or diagnose any medical condition, neither is it
valid for any medico-legal purposes.
• Any resemblance to actual multiple-choice questions asked in the past is incidental.
• Students are advised to read and utilize this workbook in conjunction with the
classroom lectures.
• To stay in touch with Dr Sandeep Sharma regarding academic queries
For Clinical Updates On Instagram:

clinical.essentials_drsandeep
2
• Fetal growth depends on three hormones
Image-Based MCQ Discussion: Growth Curves
Ready-Reckoners In Anthropometry
3
Upper Segment (US): Lower Segment (LS) Ratios
MUAC= Mid-Upper Arm Circumference
Nutritional Indices (Very Important)
1. Weight for age
2. Weight for height
4
3. Height for age
Severe Acute Malnutrition (SAM)
Subtypes Of SAM
5
Management Of SAM- Key Points To Remember
6
Pubertal Development
Sexual Maturity- Grading by- Sexual Maturity Rating (SMR) or Tanner System
Females
Males
7
Topic: Short Stature In Children

Definition: Any child who has height for age <3rd centiles, Or
Any child who has height for age <-2 SD (Z-Score) of the mean
Concepts To Understand
Causes & Types Of Short Stature In Children (MCQ In Jan FMGE 2023)
8
Syndromes Related To Short Stature
Development Milestones- Only Most Important Ones For Revision

Gross Motor Milestones
Milestone Normal Age of Attainment
Head & Neck Control
Feet To Mouth In Supine Position

Sitting With Own Support/Tripod Position
Sitting without support
Crawling
Creeping
Standing with support
True Pivoting
Cruises holding to furniture
Walking with support
Crawls or creeps upstairs
Running
Walking up/downstairs with support
Walks upstairs and downstairs alone (2 feet/step)
Walks upstairs (Alternate steps)
Rides a tricycle
Walks downstairs (Alternate steps)
Hops on one foot
Skipping a rope
9
Fine Motor Milestones

Mouthing of objects
Bidextrous grasp
Unidextrous grasp
Palmar grasp, Transfers objects hand to hand
Immature pincer grasp
Mature pincer grasp
Tower of 2 cubes
Drinks from cup
Feeds with spoon (spills most)
Feeds with spoon (spills less)
Tower of 3 cubes
Tower of 6-7 cubes, Train Without Chimney
Train With Chimney
Handedness Established
Tower of 9-10 cubes
Bridge of 3 cubes
Gate of 5 cubes
Copying Images- How To Remember?
10
Language Milestones
Vocalizing
Cooing
Laughs Loudly
Monosyllables, Babbling
Bisyllables
st
1 Real Word, 2-3 Words with meaning
Jargon Speech, 4-6 Words
8-10 Words
50-100 Words, Says I/Me/You
250 Words, 3 Numbers
Tells a story/song/poem
Uses Future Tense
Cognitive Milestones
Spontaneous Smile
Social Smile
Recognizes Mother
Hand Regard
Mirror Play
Stranger Anxiety, Inhibits to “No” Command
Object Permanence/Constancy
Waves Bye-Bye,
Plays Peek-A-Boo
Domestic Mimicry, Kisses Parents When Happy
Separation Anxiety/Raproachment
Dry By Day
Undressing With Support
Dressing With Support
Knows Full Name, Age & Gender, Shares Toys
Dry By Night
Plays cooperatively in a group
Dressing & Undressing Independently
11
Micronutrient Deficiencies
Risk Factor Likely Micronutrient Deficiency
Vitamin A Deficiency
WHO Classification
12
13
14
Topic: Congenital Infections
Infection 1: Congenital Rubella Syndrome
Infection 2: Look Below
Infection 3: Look at the panel below
15
Infection 4: Look at the panel below
Infection 5: Identify the associated congenital

infection
16
Infection 6: A baby was born to a lady who had past history of unprotected sexual contact
with multiple partners. Identify the infection?
17
Childhood Infections: Common causes of fever with rash in a child
Scenario 1:
✓ Fever + 3 Cs (Cough, Coryza, Conjunctivitis)
✓ Oral mucosal lesions: Rice- grain like, with surrounding erythema
✓ Non-itchy, maculopapular rash starts on face→trunk
18
Scenario 2:
✓ Fever +/ - Upper Respiratory Symptoms
✓ Lymphadenopathy: Suboccipital, Retro auricular, Anterior Cervical
✓ Non-itchy rash starts on face→trunk
✓ Forchheimer Spots: Pink-red spots on palate
Scenario 3:
✓ Itchy rash starts on trunk→face
✓ Polymorphous rash- Macules- Papules- Vesicles- Heal with crusting
✓ Dew drops on rose petal appearance
Scenario 4:
✓ Erythematous rash bilaterally on cheeks- Slapped Cheek Appearance
Scenario 5:
✓ Blisters or vesicles in perioral and oral cavity, palms, soles and buttocks
19
Scenario 6:
✓ Macular, Non-Itchy Rash, Trunk → Face
✓ Nagayama Spots
HIV In Infants- Key Points To Remember
20
Transient/Normal Neonatal Phenomena
21
Feeding of Preterm Neonates
Gestational Age Method Of Feeding

<28 weeks
28-31 weeks
32-34 weeks
>34 weeks
• If expressed breast milk (EBM) is not available- Best alternatives for the baby
include
• A neonate cannot be started on feeds and so started on IV Fluids. What shall be the
daily 24 hr fluid requirement? (MCQ July FMGE ’23)
22
One-Liners On Breast Feeding
✓ Started as soon as possible after birth. As per WHO, UNICEF, MUST be started
within 1 hr of birth
✓ Exclusive BF till: 6 months of age. Then start complementary feeds and continue to
breastfeed till 18-24 months.
✓ Hormones involved in breast milk
✓ Types of breast milk
✓ Storage of expressed breast milk
✓ Absolute CI for breastfeeding: Galactosemia in infant

✓ Infections transmitted via breastmilk: CMV>HIV>HBV>HCV. Despite this, CMV is not
a contraindication and HIV is not a contraindication in India
✓ TB bacillus is not transmitted via breast milk
✓ Signs of good attachment
23
✓ Composition of breast milk
✓ Vitamins deficient in breast milk: Vit K, Vit D, Vit B1, Mineral deficient in breast
milk: Fluoride
✓ Breast milk is rich in Whey protein (better) compared to casein of animal milk.
Breast milk also has more Taurine and Cysteine
✓ Breast milk has more MUFA, PUFA and esp rich in DHA, i.e. Docosahexaenoic Acid
✓ Breast milk has anti-infective factors like
Skull Injuries During Childbirth
24
Neonatal Resuscitation
25
APGAR Score
26
Neonatal Resuscitation In MSL (Meconium Stained Liquor) Babies
Vit K Administration At Birth
• Given in all babies at birth to prevent:

• Dose:
• Route & Site
• Preparation Used:
Mechanism of heat production in a neonate
Topic: Respiratory Distress In A Neonate
27
Approach For Clinical MCQs In Respiratory Distress

✓ Preterm baby <34 wk, distress in <6 hr: HMD/RDS
✓ Term baby, distress in <6 hr, delivery by Caesarean Section: TTN
✓ Term or preterm baby, distress+, Scaphoid Abdomen: CDH
✓ Term or preterm baby, distress+, ↑ Frothy Oral Secretions: TEF
Surfactant One-Liners
✓ Produced by:
✓ Production begins in utero at:
✓ Detected in amniotic fluid at:
✓ Mature levels:
✓ Function:
✓ Production affected by:
✓ Most important component:
Hyaline Membrane Disease (HMD)/Respiratory Distress Syndrome (RDS)

• Cause: Deficiency of surfactant→ Progressive alveolar collapse
• Risk Factors: Prematurity (Most imp), Maternal DM, CDH
• Clinical presentation: A preterm neonate <34 wk develops resp distress soon after
birth (within 6 hr).
• CXR: Normal in 1st 2-3 hr, later Air bronchogram sign & White-out lung
28
Management & Prophylaxis of HMD
Apnea In Neonates
• Defined as absence of breathing in neonates lasting:
• MC Cause of apnea in preterm neonates:
• A neonate develops apnea (any cause). Next step in management?
• DOC for apnea of prematurity:
Normal time of passage of 1st urine & 1st stool?
29
Perinatal Asphyxia
• Produces an altered neurological state called HIE= Hypoxic-Ischemic Encephalopathy
• Pathological hallmark of HIE in preterm neonates
IOC: MRI Brain
Treatment
Neonatal Sepsis (Any serious symptomatic systemic infection in a neonate)

• Includes: Neonatal Pneumonia, Neonatal Septicemia, Neonatal Meningitis. But
superficial infections like conjunctivitis are not sepsis
• Etiology- Mostly bacterial, rarely fungal
West:
India:
If neonatal pneumonia + neonatal conjunctivitis occurs:
If fungal sepsis cause is asked:
• Earliest feature of sepsis
• Sepsis Screen
30
• Gold Standard Investigation: Blood Culture

• Treatment- Empirical IV Antibiotics
Necrotizing Enterocolitis (NEC)

• Refers to inflammation and necrosis of gut in preterm neonates in the presence of
multiple risk factors
• Risk factors: Prematurity (most imp), use of animal milk, shock, sepsis
• Triad of NEC
✓ Hyponatremia
✓ Thrombocytopenia
✓ Metabolic Acidosis
Modified Bell’s Staging & Treatment of NEC
31
Neonatal Jaundice (NNJ)

Any visible jaundice in neonatal period is NNJ.
Facts to remember
✓ Normal RBC Lifespan in term babies is 60-90 days and in preterm babies is 30-50 days
✓ Visible jaundice develops in a neonate if total serum bilirubin (TSB) is equal to or
more than 5 mg/dl
✓ Most neonates have unconjugated hyperbilirubinemia, while some may have
conjugated hyperbilirubinemia in the presence of cholestasis
Types of NNJ
32
Modified Kramer’s Rule- Used for visual assessment on examination
Investigations in NNJ
• Screening: Transcutaneous Bilirubinometry (TcB)
• Definite Investigation: Total Serum Bilirubin (TSB)

Complications of Pathological NNJ
33
Management of NNJ
Modalities- Phototherapy & DVET (Double Volume Exchange Transfusion)
34
Infant of diabetic mother
35
Moro’s Reflex
Abnormalities in AF
36
Inborn Errors Of Metabolism (IEMs)

A. Abnormal Urine Odours
• Mousy odour →
• Rancid →
• Cabbage like →
• Tom cat urine →
• Sweaty feet →
• Fruity/Sweet smell →
• Maple syrup →
B. Copper Metabolism Defects
37
C. Glycogen Storage Diseases (GSDs)
38
D. Galactosemia
E. Alkaptonuria
39
F. Phenylketonuria
40
Congenital Adrenal Hyperplasia (CAH)

A group of Autosomal RecessiveQ conditions, arising due to deficiency of enzymes involved
in adrenal cortical hormone synthesis. Types:
1. 21-hydroxylase deficiency- MC
2. 11-b-hydroxylase deficiency- 2nd MC
3. 17-a-hydroxylase deficiency
4. 3-b-hydroxysteroid dehydrogenase deficiency
Common Features: Hypoglycemia, Hyperpigmentation
Approach For MCQs- Make the flowchart in the class below
41
Pediatric Vasculitis
✓ MC in west world: HSP
✓ MC in India and Asia: KD
Henoch-Schoenlein Purpura (HSP)
• Alternative Name:
• Peak Age:
• Gender:
• Tetrad & Clinical Presentation
• IOC:
• Treatment:
• Long-term complication:
42
Kawasaki Disease
• Other Names:
• Peak Age:
• 6 Cardinal Features Of KD:
• MC Complication:
• MC Cause Of Death:
• DOC:
• Rx Of Resistant Disease:
• D/D:
43
Q Asked in FMGE July 23: A neonate presented with complaints of bilious vomiting with
minimal abdominal distension. His X-ray abdomen was done and is shown below. What is
the likely diagnosis?
Approach- An infant with vomiting & X-ray shows the following
44
Diarrhea In Children- Common Causes

• Acute Watery:
• Dysentery:
• Persistent diarrhea:
Most Common Complication: Dehydration
Most common ABG abnormalities: Isotonic metabolic acidosis
Assessment Of Dehydration
45
Celiac Disease- A malabsorption produced by gut inflammation due to dietary gluten

• Safe:
• Unsafe:
• Strongest association:
• Other associations:
• Screening tests
• IOC:
• Rare delayed complication:
• Treatment: Life-long gluten-free diet
Respiratory Sounds & Diseases Localization
46
Laryngomalacia
• MC Congenital anomaly of larynx, MCC of stridor in age <2 yr
• MC affects: Supraglottic larynx
Inflammatory Lesions Of Larynx

Acute Laryngotracheobronchitis (Croup) Acute Epiglottitis
Freq
Etiology
Clinical
X-Ray
Rx
47
Pneumonia In Children
• Etiology
• Complications
1. Parapneumonic Effusion (MC; mild)
2. Empyema
3. Pneumatocele
• Diagnosis & Treatment- By IMCI-WHO Guidelines
48
Cystic Fibrosis- A cause of recurrent pneumonias in children.

• Classic Dyad:
• Inheritance:
• Gene:
• MC Gene Mutation:
• Clinical Features
• MC Organisms Causing Recurrent Pneumonia
• Screening Test:
• Screening Test In Neonates:
• New Drugs In CF
One-Liners On Pediatric Cardiology Minor Topics

• Criteria used to identify congenital heart ds: Nadas Criteria
• MCC of Congestive Cardiac Failure (CCF) in children is: CHD
• TOF carries least risk of CCF, followed by ASD
• Most consistent sign of CCF in children: Hepatomegaly
• Umbilical cord vessels
49
• Sequence of closure of fetal structures
Syndromes And Congenital Heart Diseases

Syndrome MC Congenital Heart Diseases
Down
Edward
Patau
Turner
Noonan
DiGeorge
Williams
Holt-Oram
Marfan
Congenital Rubella
Infant of diabetic mother
Lithium In Pregnancy
High-Altitude In Pregnancy
MCQ Approach To Congenital Heart Diseases
• Asymptomatic Child, No shunt murmur, Wide Fixed Split S2- ASD (Atrial Septal
Defect) should be suspected
50
• Child With CCF, Feeding Problems, Failure to gain wt & ht, Pansystolic murmur
CXR showing cardiomegaly- Ventricular Septal Defect (VSD) should be suspected
• Infant with CCF, Continuous Machinery Murmur, Bounding Pulses- Patent Ductus
Arteriosus (PDA) should be suspected
51
Tetralogy Of Fallot (TOF)
Clinical Presentation:
Hallmark Feature:
CXR Findings:
Complications
Surgical Management
52
53
54
Hydrocephalus
Neonatal Seizures
MCQ Case Scenario: A Female child, aged 3-10 yr has vacant staring look & recent decline
in school grades. Diagnosis?
55
MCQ Case: A Male Infant has delayed milestones and has jerks involving head & neck as
well as limbs, occurring in Clusters. EEG Shown Below. Diagnosis?
MCQ Case: An Adolescent Female, Positive Family History, Has Jerks of hands leading to
frequent fall of objects. Episodes more in the morning. Diagnosis?
56
Febrile Seizures In Children- MC Cause of seizures below 5 yr age (MCQ)
Meningitis In Children- Mostly bacterial, called as Acute Pyogenic Meningitis

Etiology (July FMGE 23 MCCQ)
• Age <2 mth: Gp B Strep, E coli, Klebsiella, Listeria
• 2 mth- 3 yr: Strep pneumoniae > H influenzae
• 3-12 yr: Strep pneumoniae > N meningitides
• > 12 yr: Strep pneumoniae
Clinical Features: Fever + Headache + Vomiting + Photophobia
Signs of meningeal irritation +
57
IOC: Lumbar Puncture For CSF Analysis

Exception- However, if raised ICP (e.g., Papilledema)m we do CECT Brain
CSF ANALYSIS OF VARIOUS TYPES OF MENINGITIS
Parameter Cells/mm3 CSF Protein CSF Glucose Others
Normal CSF
Acute Pyogenic
Meningitis
Tubercular
Meningitis
Aseptic
Meningitis
Treatment
• IV Antibiotics x 10-14 days
Cerebral Palsy
58
Duchenne’s Muscular Dystrophy
Neurocutaneous Syndromes
59
NF-2 Hallmark:
✓ A rare type of Neurofibromatosis
✓ Hallmark: Bilateral Acoustic Neuromas
National Immunization Schedule
2023 Update:
60
Glomerular Disorders- How To Approach & Solve MCQs
61
A. Down Syndrome
Prenatal Diagnosis of Down Syndrome (MCQ In July FMGE 2023)
62
B. Edward Syndrome/Trisomy 18
C. Patau Syndrome/Trisomy 13
D. Turner Syndrome/45, XO
63
E. Noonan Syndrome
F. DiGeorge Syndrome
64
G. Wiskott-Aldrich Syndrome
H. Williams Syndrome
I. Fragile X Syndrome
65
J. Klinefelter Syndrome
Anemia In Children
Definition
Causes of Microcytic Hypochromic Anemia
66
An Approach To A Bleeding Child

• M or F, Superficial bleeding (petechiae, purpura), gum bleeds, prolonged bleeding
time- Suspect Platelet Disorders
• M or F, Epistaxis, Delayed bleeding after trauma, females having more bleeding
during menses, normal PT, slightly abnormal aPTT- Suspect Von Willebrand Disease
• Only Males, Deep ecchymosis, Joint bleeds (hemarthrosis), muscle hematomas,
prolonged APTT, normal PT- Suspect Hemophilia A or B
67
Hemophilias
Miscellaneous One-Liners For Quick Recall- Past Older MCQs

• Recumbent or supine length is usually 0.7 to 1.1 cm more than standing height
• Arm span in outstretched hands is usually equal to height at 10 yr of age
• If Arm Span exceeds height by >3 cm, suspect Marfan Syndrome
• Maximum heat loss in a neonate occurs from the head (FMGE 2019)
• MC Cause of Common Cold/Acute Coryza in children: Rhinovirus
• MC Cause of Acute Bronchiolitis: RSV. If CXR done- Shows Hyperinflation.
• Most patients of Acute bronchiolitis improve with conservative therapy. If severe,
Ribavirin may be effective (FMGE 2019)
• If a baby has wide, open Anterior Fontanelle + Coarse features + Bradycardia-
Suspect Hypothyroidism
• Premature fusion of skull sutures- Craniosynostosis. Types
1. Scaphocephaly (Dolichocephaly)- MC, Sagittal suture fusion
2. Brachycephaly- Coronal Suture fusion. Seen in Trisomy 21
3. Turricephaly- Multiple sutures fusion
• 4 Syndromes where craniosynostosis is common- Apert, Crouzon, Carpenter &
Pfeiffer Syndromes.
• Normal neonatal and infant pupils are miotic, i.e., constricted
68
• The time taken for air to reach the descending colon after birth: 8-9 hr
• McCune Albright Syndrome: Has a triad of
✓ Café-au-lait macules- Unilateral
✓ Polyostotic fibrous dysplasia of bones
✓ Precocious Puberty
• DOC for Rolandic Epilepsy: Carbamazepine > Oxcarbazepine
• Innocent Murmurs: Heard best along lower left sternal border, show no radiation &
have no significance.
• Not seen in Kawasaki Disease: Cardiac Tamponade
• MC pediatric benign tumour- Hemangiomas
• MC pediatric malignancies: Leukemias (ALL), followed by Brain tumours
• Bony metastasis producing raccoon eyes/panda eyes seen in: Neuroblastoma
• Hemihypertophy seen with Beckwith Weidemann Syndrome- Increased risk of Wilms
Tumour
• Owl-eye appearance on tumour cells- Reed Sternberg (RS) cells in Hodgkin’s
Lymphoma
• White eye reflex (Leukocoria), Proptosis- Suspect Retinoblastoma- RB1 gene
mutations are responsible.
69
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PEDIATRICS

ARISE MEDICAL ACADEMY

RISE WITH ARISE

Pediatrics Workbook: For ARISE

• Contains Tables, Images, Collection Of One-Liners

For Clinical Updates On Instagram:

• Fetal growth depends on three hormones

Image-Based MCQ Discussion: Growth Curves

Upper Segment (US): Lower Segment (LS) Ratios

MUAC= Mid-Upper Arm Circumference

Nutritional Indices (Very Important)

1. Weight for age

2. Weight for height

3. Height for age

Severe Acute Malnutrition (SAM)

Management Of SAM- Key Points To Remember

Topic: Short Stature In Children

Syndromes Related To Short Stature

Development Milestones- Only Most Important Ones For Revision

Feet To Mouth In Supine Position

Fine Motor Milestones

Copying Images- How To Remember?

Risk Factor Likely Micronutrient Deficiency

Topic: Congenital Infections

Infection 1: Congenital Rubella Syndrome

Infection 2: Look Below

Infection 3: Look at the panel below

Infection 4: Look at the panel below

Infection 5: Identify the associated congenital

Childhood Infections: Common causes of fever with rash in a child

HIV In Infants- Key Points To Remember

Transient/Normal Neonatal Phenomena

Feeding of Preterm Neonates

Gestational Age Method Of Feeding

One-Liners On Breast Feeding

✓ Types of breast milk

✓ Storage of expressed breast milk

✓ Absolute CI for breastfeeding: Galactosemia in infant

✓ Composition of breast milk

Skull Injuries During Childbirth

Neonatal Resuscitation In MSL (Meconium Stained Liquor) Babies

Vit K Administration At Birth

• Given in all babies at birth to prevent:

Mechanism of heat production in a neonate

Topic: Respiratory Distress In A Neonate

Approach For Clinical MCQs In Respiratory Distress

Hyaline Membrane Disease (HMD)/Respiratory Distress Syndrome (RDS)

Management & Prophylaxis of HMD

• DOC for apnea of prematurity:

Normal time of passage of 1st urine & 1st stool?

IOC: MRI Brain

Neonatal Sepsis (Any serious symptomatic systemic infection in a neonate)

• Gold Standard Investigation: Blood Culture

Necrotizing Enterocolitis (NEC)

Neonatal Jaundice (NNJ)

Modified Kramer’s Rule- Used for visual assessment on examination

• Definite Investigation: Total Serum Bilirubin (TSB)

Infant of diabetic mother