Pediatrics Review Booklet by Dr. Aryan (Medical Booklet Series by Dr. Aryan Part 20)

Pediatrics Review
A Free Booklet Series by Dr. Aryan

Preface:
• This is the study material designed by Dr. Aryan with creation and compilation of the
best of the best and the most finest slides on the subject. I would like to offer a
billion heartily thanks for everyone who contributed directly or indirectly to the
creation of the material through creation and dissemination of the scientific
information.
• Covering everything in one study material is next to impossible. Hence, refer to gold
standard textbooks for building solid concepts or in case of any doubt. Textbooks are
acknowledged at the end of the presentation. If any source has been missed to
acknowledge, it doesn’t lessen their impact and contribution in any way.
• Don’t keep searching for pattern between the consecutive slides. You won’t find
many. Rather to boost your recall and review, I have constructed many slides and are
deliberately placed with no much relation between the preceding and the
succeeding ones.
• The main rule of a review material is that it must make you recall or learn maximum
amount of information in minimum amount of time and space.
• Motivational quotes and articles are included within the slides. Always remember
that every good idea, nice piece of information and everything else is literally and
absolutely worthless unless you execute.
• If you know everything in the slides in much detail, you probably wouldn’t need this
material.
Best of luck WORK & SUCCESS! Dr. Aryan
(Anish Dhakal)

Congenital Heart disease criteria
Dr. Aryan (Anish Dhakal)

Classification of Malnutrition
Low weight for age is Underweight

CCF in infants

CCF Management

Cystic Fibrosis

Autosomal recessive
Mutation in Cystic Fibrosis
Transmembrane Conductance
Regulator (CFTR gene)
Delta F 508: most common
Buildup of thick mucus
Most common initial presentation is
meconium ileus
Failure to thrive (malabsorption due
to pancreatic insufficiency)
Rectal prolapse
Persistent cough
Absent vas deferens
Allergic bronchopulmonary
apergillosis
Best test is sweat chloride
concentrations (>60 mEq/L) on
separate days
Genetic testing is specific but do not
detect all mutations
Other diagnostic tests can be
individualized for the patient
Treatment is largely supportive (aerosol,
albuterol, chest physiotherapy, postural
drainage and pancrelipase)
Ivacaftor (VX-770) if G551D mutation
present
Ibuprofen, azithromycin, antibiotics
(cotrimoxazole, macrolides, ciprofloxacin,
tobramycin or ceftazidime)
Cystic
Fibrosis

Conjunctivitis in a Newborn: Causes?
Day of Life Organism Implicated
Day 2 to 7 Neisseria gonorrhea
> Day 7 Chlamydia trachomatis
> 3 weeks Herpes simplex
Chemical conjunctivitis can be caused by silver nitrate applied (not an allergy). It
presents and often resolves within the first 24 hours. The prophylaxis is needed to
prevent gonococcal conjunctivitis.

Pyloric stenosis presents with olive shaped epigastric mass.
Pathophysiology of Metabolic alkalosis & Paradoxical aciduria in Pyloric stenosis:
Loss of hydrogen and chloride occurs by vomiting. Kidney attempts to correct the alkalosis
by secreting bicarbonate ions which is secreted along with sodium ions. This makes the
person hyponatremic and dehydrated. To preserve sodium the kidney then tries to retain
sodium and excrete other cations (potassium and hydrogen) into the urine causing
paradoxical aciduria.

CHARGE Syndrome VACTERL Syndrome
Coloboma/CNS abnormalities Vertebral anomalies
Heart defects Anal atresia
Atresia of choanae Cardiovascular anomalies
Retardation of growth and/or development Tracheosophageal fistula
Genital and/or urinary defects
(hypogonadism)
Oesophageal atresia
Ear anomalies and/or deafness Renal anomalies
Limb anomalies
Choanal atresia is characterized by presence of membrane between nostrils and
pharyngeal space. Child cannot breathe while feeding. He will turn blue while feeding
and pink on crying.

Confusion Corner: Currant jelly
Currant jelly sputum: Klebsiella pneumoniae
Currant jelly stool: Intussusception
Sausage shaped mass
Doughnut sign or Target sign on USG

Keywords in clinical case you should never miss
Keywords Diagnosis
Blueberry muffin spots, PDA, cataract Rubella
Chorioretinitis, hydrocephalus, ring enhancing lesions Toxoplasmosis
Cough, coryza and conjunctivitis with Koplik’s spot Measles
Slapped cheek appearance Parvovirus B19
Sandpaper rash, strawberry tongue, cervical
lymphadenopathy
Scarlet fever
Dew drop on rose petal appearing rash Chicken pox
Periventricular calcifications, microcephaly, chorioretinitis Cytomegalovirus

Pathophysiology behind Transient
Tachypnea of the Newborn (TTN)
Term birth
Cesarean section or rapid second stage of labor
The cause for TTN is retained lung fluid which during the
birth process couldn’t get squeezed out
Increased fluid thus causes increased airway resistance and
decreased lung compliance
Chest X-ray may show air trapping, fluid in fissures and
perihilar streaking

Necrotizing enterocolitis
Bloody stools, apnea and lethargy
Associated with formula feed
Abdominal wall erythema and
distention indicates ischemia
Treat by stopping all feeds,
decompress the gut, broad spectrum
antibiotics and surgical resection.
Pneumatosis intestinalis is the
pathognomonic sign on abdominal
X-Ray
Gas on bowel wall instead of bowel
lumen
Tram-track appearance

Hypertension in Pediatrics

Confusion Corner:
Concept of Water Deficit & Free Water Clearance
Total free water needed to correct hypernatremia to normal level (135 to
145 mEq/L or average as 140 mEq/L) is water deficit.
Free water deficit = (Na+-140/Na+)* Total Body Water (50% of body weight
in men and 60% in women)
Free water clearance and osmolal (solute) clearance makes the urine flow,
symbolized as “V”. Theoretically it is the amount of free water cleared from
plasma per unit time. Negative value signifies that urine is more
concentrated than the plasma i.e. free water is being retained in the body
and osmotically active substances are being excreted in urine.
Hence mathematically, Free water clearance = V (1-Uosm/Posm). Serum
sodium is the dominant osmotically active agent to the point that other
agents can be ignored while in urine potassium too has to be considered.
The equations turns out to be:
Ongoing water losses (Free water clearance)= V [1-(UNa + UK / PNa)]
If the urine osmolality and plasma osmolality is same, then there is still
excretion of “V” amount of water but no gain or loss (no clearance) of free
water occurs. That’s pretty obvious.

GFR Calculation
New guidelines suggest k=0.413 for all children.

In case of hypovolemic hypernatremia, why does
the body retain sodium instead of excreting it to
get rid of hypernatremia?
When body loses free water (in any form including diarrheal loss,
vomiting or sweating) more than sodium, water deficit is created
(this is the classic example of water deficit).
The result is hypovolemic hypernatremia. If the person replaces
the free water lost, sodium level would be normalized.
In such condition, kidney would retain sodium to preserve
extravascular volume. It may seem counterintuitive to you that
kidney is retaining sodium instead of excreting it to treat
hypernatremia. But that’s not how the kidney works.
 The retention of sodium is to preserve volume as water follows
sodium and ADH is there to retain free water and correct
hypernatremia.

Kawasaki Disease Criteria
Fever for ≥ 5 days with 4 out of 5 of the following:
Peak age of presentation is 18-24 months, mostly within 5 years of age. Most serious
complication is coronary artery aneurysm, with potential MI as a sequela. Treat with IVIG.
Administer aspirin initially in high doses and later for maintenance antiplatelet therapy based
on echocardiogram results. Note that aspirin is otherwise generally contraindicated in
children to avoid the risk of Reye syndrome (fatty live with encephalopathy).

Signs of Respiratory Distress
Tachypnea/Dyspnea
Use of accessary muscles for respiration
Suprasternal, intercostal and subcostal
retraction
Nasal flaring
Grunting
Central cyanosis

Preliminary management of Cyanotic Heart Disease?
Prostaglandin E1 (Alprostadil)
Cyanotic disease presenting at birth require patency of
ductus arteriosus to maintain or increase pulmonary
blood flow and improve oxygenation until definitive
surgery can be performed.
Avoid indomethacin in such patients which would close
the ductus arteriosus leading to progressive hypoxia and
metabolic acidosis.

Define Croup
Croup is a term referring to heterogeneous
group of mainly acute and infectious processes
that are characterized by a bark like or brassy
cough which may be associated with:
1. Hoarseness
2. Inspiratory stridor
3. Respiratory distress

Along with thumb sign, what X-Ray findings
you expect in Epiglottitis?
I. Swollen epiglottis (Thumb sign)
II. Thickened aryepiglottic folds
III. Obliteration of the vallecula
In croup, subglottic tracheal narrowing produces steeple sign. A trial of racemic
epinephrine is warranted before any invasive procedure in croup. Epinephrine
stimulates alpha adrenergic receptors (to decrease bronchial secretions and
mucosal edema) and beta adrenergic receptors (bronchodilation via smooth
muscle relaxation) offering symptomatic relief to the patient in croup.

Most common cause of Croup
• Parainfluenzae 1
• Others are Parainfluenzae 2,3/ influenza virus/
adeno virus/ rhino virus
• Remember for bronchiolitis its RSV followed by
rhinovirus

Indications for CPAP
• Weaning from ventilator (reducing ventilatory
support and patient breathing spontaneously and
extubated)
• Minimal need for respiratory support with good
respiratory drive
• Asthma
• Bronchiolitis
• Pneumonia
• Obstructive sleep apnea syndrome
• Respiratory muscle fatigue

Must Know Points in Scarlet Fever
Group A Streptococcus producing erythrogenic exotoxins
May follow Streptococcal pharyngitis, wound infections, burns or
Streptococcal skin infection
Sandpaper like rash (punctate or finely papular sometimes readily
palpable), initially in neck, axilla and groin, later generalized
Pharynx erythematous, swollen and covered with gray-white
exudates
Circumoral pallor (with extremely red cheeks)
Desquamation begins in face and then to trunk followed by hands
and feet
Penicillin V is the drug of choice. Erythromycin, Clindamycin and
first generation cephalosporins reserved for penicillin allergic
cases.

Cardiac Abnormalities Associations
Disease Cardiac Abnormalities
Down’s Syndrome Endocardial cushion defects, ASD, AV septal defects
Congenital rubella PDA
Turner’s Syndrome Coarctation of aorta, Bicuspid aortic valve
Infant of diabetic mother Transposition of great vessels
Marfan’s syndrome MVP, Aortic regurgitation, Thoracic artery aneurysm
and dissection
Edward’s Syndrome VSD
DiGeorge Syndrome (CATCH 22) Conotruncal abnormalities like Truncus arteriosus,
Tetralogy of Fallot, Interrupted aortic arch

Bronchiolitis severity

Bronchiolitis Management

New Tuberculosis Guideline in Nepal
(No category II)

TB Drugs dosing children

Breast Milk Composition (in comparison
with animal milk products)
Contents Peculiarities
Carbohydrates 6-7 mg/dL (more)
Lactose present increases calcium absorption & lactobacilli
growth
Protein 0.9-1.1 mg/dL (less)
Easily digestable form (lactalbumin & globulin)
Amino acids cysteine & taurine for neurotransmission and
neuromodulation
Fat Rich in polysaturated FA (myelination)
Omega 2 & omega 6 FA for prostaglandins and cholesterol
Vitamins & Minerals More than animal milk
Water and
Electrolytes
88% water, low osmolality (decreased kidney load)
Immunoglobulins IgA, macrophages, lymphocytes, lactoferrin, lysozyme

Doll’s Eye Reflex
 These maneuvers obviously should
not be performed in cases of head
injury or other cases of suspected
cervical spine trauma unless
complete cervical spine films are
normal.
 The reflex is present if the eyes
move in the opposite direction of
the head movements, and it is
therefore sometimes called doll's
eyes.
 Note that in awake patients, doll's
eyes are usually not present
because voluntary eye movements
mask the reflex.
 Thus, the absence of doll's eyes
suggests brainstem dysfunction in
the comatose patient but can be
normal in the awake patient.

Infective Endocarditis

Cardiomegaly: Adults: >0.5. Newborn: >0.6. Children: >0.55.

Febrile Seizure Criteria

Febrile Seizures

What are the criteria for Sepsis?
Total Leukocyte count (<5000/mm3)
Absolute Neutrophil Count (<1800/mm3)
Immature/Total Neutrophil Count (I/T) > 0.2
Micro ESR > 15 mm/hr
CRP > 1 mg/dL

Maternal Risk Factors for Neonatal Sepsis
Chorioamnionitis
Intrapartum maternal temperature ≥ 38⁰ C (≥100.4⁰ F )
Delivery at <37 WOG
Membrane rupture ≥ 18 hours
Maternal GBS colonization and other findings that
increase the risk of GBS infection in the neonate, including
any of the following:
– Positive GBS vaginal-rectal screening culture in late gestation
during current pregnancy
– Previous infant with GBS disease
– Documented GBS bacteriuria during the current pregnancy
– Intrapartum nucleic acid amplification test positive for GBS

Fetal risk factors for Neonatal Sepsis
Five minute Apgar score ≤6 (36X increase risk)
Evidence of fetal distress
Meconium stained amniotic fluid (2X increase
risk)
Very low birth weight

Empirical Therapy for
Neonatal Sepsis
Antibiotic Regimen
Early onset Ampicillin 150 mg/kg per dose intravenously (IV)
every 12 hours and Gentamicin 4 mg/kg per dose
IV every 24 hours
Late onset: admitted from
community
Ampicillin 75 mg/kg per dose intravenously (IV)
every six hours + Gentamicin 4 mg/kg per dose IV
every 24 hours
OR
Ampicillin+ Cefotaxime
Late onset: Hospitalized
since birth
Gentamicin + Vancomycin

For all its required regardless of hydration status

For a 21 year child (Example):
• 1520 mL (maximum is 2400 mL per day)
• 61 mL/kg/hr (maximum is 100 mL/kg/ hr)
Additionally for some dehydration (Plan B):
No.2: Rehydration therapy (75 mL/kg or 10*%
lost*body wt.)
No.3: To compensate ongoing losses (ORS volume
equal to diarrheal losses maximum of 10 mL/kg
after each episode)

If child can drink without difficulty, ORS 5 ml/kg/hr
along with IV fluids
If IV not possible, through NG tube ORS 20 ml/kg/hr
and start IV asap

Osmotic VS Secretory Diarrhoea
Osmotic Secretory
Volume of stool <200 ml/24 hr >200 ml/24 hr
Stool sodium <70mEq/L >70mEq/L
pH <5 >6
Response to fasting Stops Continues
Reducing substance Positive (@osmotic sth
drawing water in)
Negative

Glucose Infusion Rate

Age independent indices for
malnutrition
• MUAC
• Bangle test
• Skin fold thickness (>10 mm normal, less than
6 mm: severe)
• Also, Index: Kanawati: MUAC/Head
circmferance, Dugdale, etc.

10 Steps of Malnutrition Management

Discharge Criteria Malnutrition

KRAMER’S Rule

Phototherapy

Asymptomatic hypoglycaemia
 >20 mg/dl: trial of oral feeds, measure after
30-45 minutes:
1. If above 40 mg/dl: frequent feeding ensured
with 6 hourly monitoring for 48 hours
2. If below 40 mg/dl: IV glucose infusion
 <20 mg/dl: IV glucose infusion

Symptomatic hypoglycaemia
• A bolus of 2 mg/kg of 10% dextrose followed
by glucose infusion at 6 mg/kg/min
• Monitor after 30-45 minutes and then 6
hourly
• (maximum 12 mg/kg/min increasing by 2
mg/kg/min each time)
• After 24 hours if two or more values are
greater than 50 mg/dl taper with 2
mg/kg/min every 6 hrs and increase oral feeds

Perinatal asphyxia

Why LBW infants more risk for
hypothermia?

Care at birth: 5 Cleans

10 Steps of Warm Chain
1. Warm delivery
2. Warm resuscitation
3. Immediate drying
4. Skin to skin contact
5. Breastfeeding
6. Bathing postponed
7. Appropriate clothing
8. Mother and baby together
9. Professional alertness
10. Warm transportation

Newborn babies
• HR: 120 to 160 bpm
• Blood pressure: 60 to 70 mm Hg in term (50 to
60 in preterm)
• Also look for hepatomegaly (>6 cm),
hypoglycaemia, hypothermia and neurological
status

New Changes:
Rota Virus at 6 and 10 weeks
fIPV at 6 and 14 weeks

Right arm
Left thigh
Right thigh
Left arm
BCG
Pentavalent (DPT, HB, Hib)
IPV
PCV
MR
fIPV
JE
Route of administration:
BCG & fIPV: id
MR & JE: sc
Others: im
Dose:
BCG: 0.05 mL
fIPV: 0.1 mL
OPV: 2 drops
Others: 0.5 mL
BCG, OPV and MR are live
attenuated vaccines

Caput succedaneum Cephalohematoma
Diffuse Sub periosteal swelling that may be
associated with linear skull fractures
and hyperbilirubinemia
Successfully crosses suture lines Doesn’t cross suture lines
More common Less common
Maximum size and firmness at birth,
softens progressively over 2 to 3 days
and resolves
Increasing size for 12 to 24 hours then
stable. Takes 3 to 6 weeks to resolve
Pits on pressure Doesn’t pit in applying pressure
Skin ecchymotic No skin changes

MRI in Cerebral Palsy
• Periventricular leukomalacia (scarring and
shrinkage of periventricular white matter with
compensatory enlargement of ventricles)

Three features in X-ray of Hyaline
Membrane Disease
• reticulogranular pattern infiltrates-ground glass
appearance
• air bronchogram (air filled bronchi made visible
by opacification of surrounding alveoli)
• white out lungs in severe cases
• atelectasis
• Remember in meconium aspiration syndrome,
there is hyperinflation of lungs, heterogeneous
opacities and flattening of diaphragm

What do you understand by round
glass opacity in lungs?
• Ground glass opacity is a radiological term
indicating an area of hazy increased lung
opacity through which vessels and bronchial
structures may still be seen unlike
consolidation.

RDS Risk Factors
• Preterm (less than 35 weeks)
• Caesarean section
• Male gender (1.7:1)
• Birth hypoxia/asphyxia
• Maternal diabetes
• Hemolytic disease of the newborn
• Genetic predisposition

Coaractation of aorta
• Upper body systolic blood pressure > 10
mmHg than lower limbs
• Absence of femoral pulse

Hyperoxic test
• Measure oxygen saturation at room
temperature. Then place the infant at 100%
oxygen for 10 to 20 minutes. Failure of PaO2 to
rise above 150 mm Hg indicates cardiac cause
(congenital cyanotic heart disease).

Diaphragmatic hernia features
• Respiratory distress at birth
• Cyanosis
• Scaphoid abdomen
• Decreased or absent breath sounds
• Heart sounds displaced to opposite side

MAS
• First step would be identification of infant either he/she is :
Vigorous
Non-Vigorous
• Vigorous (normal respiratory effort)
1. Good muscle tone (spontaneous movement or some
degree of flexion)
2. Heart rate >100 bpm
• Non-Vigorous (depressed respiratory effort)
1. Poor muscle tone
2. Heart rate <100 bpm

MAS Pathophysiology
• Proximal airway obstruction
• Peripheral airway obstruction
• Inflammatory and chemical pneumonitis
• Remodelling of pulmonary vasculature

Grading of MAS
• Mild MAS: disease requiring <40% O2 for <48 hours.
• Moderate MAS: disease requiring >40% of O2 > 48
hours without air leak
• Severe MAS: disease requiring Assisted ventilation for
>48 hours, often associated with PPHN

Endotracheal intubation in MAS
• Indications:
– When tracheal suction required in non-vigorous
baby
– When prolonged bag and mask ventilation is
required
– When bag and mask ventilation is ineffective
– When diaphragmatic hernia is suspected
• A clinician should intubate the trachea under direct
laryngoscopy, preferably before inspiratory efforts
have been initiated.

LGA Causes
• Constitutionally large infants (large parents)
• Infants of diabetic mothers and obesity
• Some post term infants
• Beckwith-Wiedemann syndrome

Air leak syndrome consequences
1. Pneumothorax
2. Pneumopericardium
3. Pneumoperitoneum
4. Pneumomediastinum
5. Pulmonary interstitial emphysema

Chest X-Ray Interpretation Sequence
• Identify: Name, Date, View
• Technique: Rotation, Exposure, Inspiration
• Soft tissues: Neck, Abdomen, Thorax
• Bones: Spine, Clavicle, Ribs
• Heart: Outline, Size, Hila
• Lung: Pleura, Trachea, Lungs

1 minute score reflects intrauterine condition. 5 minute score reflects
transition. Subsequent APGAR scores reflects resuscitation efforts.

Ballard Scoring:

IV glucose may need to be administered until they reset their
pancreas and insulin they secrete to normal levels.

Innocent murmurs are never diastolic and usually of grade 2 or lesser.

Premature Fusion of Sutures

Crouzon Syndrome:

The classic triad in congenital rubella is sensorineural hearing loss, eye abnormalities
and congenital heart diseases.

Hyponatremia Treatment
Chronic hyponatremia is correctly slowly over 48 to 72 hours with 0.5mEq/L/hr. Rapid
correction can cause central pontine myelinosis (osmotic demyelination syndrome).

 Remission: Urine albumin nil/trace or Proteinuria <4 mg/m2/hr or Protein/Creatinine ratio <0.2 in
3 early morning specimens
 Relapse: Urine albumin 3+/4+ or Proteinuria >40 mg/m2/hr or Protein/Creatinine ratio >2 in 3
early morning specimens having been in remission previously
 Infrequent relapse: <2 relapses in first 6 months or <4 relapses in any 12 months
 Frequent relapse: ≥2 relapses in first 6 months or ≥4 relapses in any 12 months
 Steroid dependence: Two consecutive relapses on alternate day therapy or relapse within 14 days
of discontinuation of steroids
 Steroid resistance: Failure to achieve remission after 8 weeks of steroid therapy

Confusion Corner: Dose of Vitamin A, Deworming
Albendazole Tablets and Zinc Tablets
Vitamin A Albendazole Zinc
<6 months: Current evidence consistently
shows that dose up to 50000 IU are safe.
Side effects include bulging fontanelles (due
to increase in CSF volume but no significant
effect on ICP and resolves usually within 72
hours), vomiting, diarrhea, loss of appetite
and irritability.
 More side effects if given with DPT vaccine
especially the 3rd dose at 14 weeks.
 At the same time, evidence also shows no
significant improvement in reducing infant
morbidity and mortality
12-23 months: 200 mg PO
single dose
<6 months: 10 mg/day
for 14 days
6-11 months: 10000 IU once every 4 to 6
months
24-59 months: 400 mg PO
single dose
>6 months: 20 mg/day
12-59 months: 200000 IU once every 4 to 6
months

Kwashiorkor is characterized by moon face, apathetic or dull in
activity, poor appetite, less evident muscle wasting secondary to
edema, more prominent flag sign, flaky paint dermatosis, liver
enlargement, more chances of infection and more complications.

Anterior fontanel is diamond shaped at the junction of coronal and sagittal sutures
2.5*2.5 cm in size. Posterior fontanel is triangular shaped with 1*1 cm between
sagittal and lambdoid sutures.

The focus is to emphasize high sensitivity for higher risk population
& higher specificity for low risk population.

Management of acute attack: RHD
• Single dose of benzyl penicillin (1.2 million U, IM) or
Oral Phenoxymethyl penicllin (250mg 4 times daily for 10 days)
– To eliminate any residual streptococcal infection
• If allergic to Penicillin:
Erythromycin 250 mg qid for 10 days
• Treatment is then directed to limit cardiac damage and relieving
symptoms

If patient has Carditis with CCF Mandatory use of
corticosteroids
Carditis without CCF Use either steroid or aspirin;
steroids are preferred
If no carditis Use aspirin

Treatment: Secondary Prophylaxis
Antibiotic Mode of Administration Dose
Benzathine Penicillin IM, single injection
every 3-4wks
Lifelong
1.2 million units for >30kgs
every 3 wks
0.6 million units for <30kgs
every 2 wks
Penicillin V Oral 250mg BD
Erythromycin (for
penicillin allergy)
Oral 250mg BD

ReSoMal (Rehydration Solution for Malnutrition) contains less sodium but more
sugar and more potassium. In addition it also contains magnesium chloride, copper
sulphate & zinc acetate.

RIFLE criteria for Acute Kidney Injury

Meningitis in Child:

Age group Organisms
Neonates Group B Streptococcus, E. coli,
Salmonella, Pseudomonas, Staph. aureus
3 months to 3 years Pneumococci, Meningococci, H.
influenzae
>3 years Pneumococci, Meningococci
Bacterial Meningitis organisms by Age Group

Pneumonia organisms by Age Group
Age group Organisms
<3 weeks E. coli, Klebsiella, Group B
Streptococcus, Pneumococcus,
Staphylococcus
3 weeks to 3 months Pneumococcus, H. influenza, RSV,
Influenza, Parainfluenza, Adenovirus
4 months to 4 years Pneumococcus, H. influenza, RSV,
Influenza, Parainfluenza, Adenovirus,
S.pyogens
>5 years Pneumococcus, Mycoplasma,
Chlamydia

Parameters Normal Bacterial
Meningitis
Viral
Meningitis
Pressure
(mm of H20)
50 to 80 mm of H2O 100 to 300 Normal or
elevated (80 to
150)
Leukocytes (per
mm3)
<5/mm3
≥ 75% lymphocytes
100 to 10000 or more
PMNs predominate
Rarely >1000.
PMNs early but
mononuclear cells
dominate most of
the course
Protein
(mg/dL)
20 to 45 mg/dL 100 to 500 50 to 200
Glucose
(mg/dL)
>50% (or 75% of
serum glucose)
Decreased (usually <
40% or 50% of serum
glucose)
Generally normal.
In viral illness like
Mumps <40.

Complications of Neonatal Meningitis
Systemic-
 Septic shock, DIC, ARDS, septic arthritis
Neurologic
 Impaired mental status
 Cerebral edema and increased intracranial pressure
 Seizures
 Focal deficits (e.g., hearing loss, cranial nerve palsies,
hemiparesis or quadriparesis)
 Ataxia
 Cerebrovascular abnormalities
 Neuropsychological impairment, developmental disability
 Subdural effusion or empyema
 Hydrocephalus
 Hypothalamic dysfunction

Asbury GBS Criteria
Required Supportive
Progressive weakness of 2 or more
limbs due to neuropathy
Facial and other cranial nerve
involvement
Exclusion of other causes (e.g.
vasculitis, botulism, diphtheria,
porphyria, cauda equina syndrome)
Absence of fever
Duration of illness < 4 weeks CSF typical profile (Albuminocytologic
dissociation)
Areflexia (@PEDA) Electrophysiological evidence of
demyelination
Symmetrical involvement
Sensory involvement mild (@FACESS)

Henoch-Schonlein Purpura Criteria:

Surfactant Therapy:

Types of Exchange Transfusion
Single Volume
Exchange
Transfusion
Double Volume
Exchange Transfusion
Partial Exchange
Transfusion
1* circulating volume 2* circulating volume
(80 to 100 mL/kg) * Body weight
Desired hematocrit =
0.55
Replaces 60% of blood
volume
Replaces 85% of blood
volume
(Actual hematocrit-
Desired
hematocrit/Actual
hematocrit) * Infant’s
blood Volume

Moro’s Reflex
Reflex seen on sudden dropping of baby’s head in relation
to the trunk
Extensor component: Opening of hands, extension &
abduction
followed by
Flexor component: closing of hands, adduction & flexion
Extended Moro’s reflex: extensor and flexor component
along with crying and urination
Appears at 28-32 weeks and disappears at 4-6 months of
life
Persistence beyond 6 months: Neurological defect (Cerebral
palsy)
Asymmetrical reflex: Brain lesion or peripheral nerve injury
(brachial plexus injury)

Diagnosis of UTI
On culture of midstream clean catch urine usually WBCs > 105 CFU/mL are
diagnostic though there are variations:
>105: Girls
>104 : Boys
Supra pubic aspiration: any growth
Urethral catheterization: >5*104 / mL

Character Amoebic dysentery Bacillary dysentery
Macroscopic
Number 6-8 motions a day Over 10 motions a day
Amount (Volume) Relatively copious Small amount
Odour Offensive (fishy odour) Odourless
Colour Dark red (altered blood) Bright red (fresh blood)
Reaction Acidic Alkaline
Consistency Not adherent to the container Adherent to the container
Microscopic
RBCs In clumps
Discrete, sometimes in clumps
due to rouleaux formation
Pus Cells Few Numerous
Macrophages Few
Numerous, many of them
contain RBCs hence may be
mistaken for E. histolytica
Eosinophils Present Scarce
Charcot-Leyden (C-L) crystals* Present Absent
Pyknotic bodies** Present Absent
Parasites Seen Trophozoites of E. histolytica Absent

Bacillary dysentery
Organism: Shigella
Occurs at any age
Onset is acute
Fever common
Dehydration common
Abdominal cramps common
Tenesmus present
Stool is scanty, blood mixed (plenty of RBCs)
& basic
More complications
Amoebic dysentery
Organism: Entamoeba histolytica
Occurs usually after 2 years
Onset is gradual
Fever less common
Dehydration less common
Abdominal cramps less common
No tenesmus
Stool frothy & copious, blood/mucus mixed
(scanty RBCs and acidic)
Less complications

Down’s Syndrome Features

Clinical
Characters
Seizures Jitteriness
Increases with
stimulation
Rare Common
Suppress with
passive flexion
Absent Present
Autonomic
phenomena
Present Absent
Eye or facial
movements
Present Absent
Rate of movement Clonic seizures show rapid
alteration of fast and slow
phase of movements
Rate of movement is
identical in either
direction.
EEG abnormalities Yes No
Movements Involves other parts as well,
low frequency movements
Mostly involves distal
limbs, high frequency
movements

Neonate with seizures
•Identify and characterize the seizure
• Secure airway and optimize breathing, circulation, and temperature (Neutral)
If suspect IEM, no feeding
• Secure IV access and take samples for baseline investigations
•If hypoglycemic : administer 2 ml/kg of 10% dextrose as bolus
followed by a continuous infusion of 6-8 mg/kg/min
• If serum calcium is abnormal, 2 ml/kg of calcium gluconate (10%)
should be given IV under cardiac monitoring
• Hypomagnesaemia: 0.25ml/kg of 50% MgSO4 IM
Seizures persist
Neonatal Seizure Management

Administer phenobarbitone 20mg/kg IV stat
over 20 minutes
Repeat phenobarbitone in 10 mg/kg/dose increment
until 40 mg/kg dose is reached
Seizures
continue
Seizures continue
Administer phenytoin 20 mg/kg IV slowly
over 20 minutes under cardiac monitoring
Lorazepam: 0.05 mg/kg IV bolus over 2-5 minutes; may be repeated
Midazolam: 0.15 mg/kg IV bolus followed by infusion of 1-7 mcg/kg/min
Clonazepam 0.1mg/kg; Consider ventilation.
Seizures continue
Seizures continue

Second line drugs like
Lidocaine[4mg/kg f/b 2mg/kg/hr]
Paraldehyde[0.1-0.2ml/kg/dose IM]
Sodium valproate[20-25mg/kg f/b 5-10mg/kg/12h]
Topiramate(20mg/kg/day)
Levetiracetam(10-30mg/kg/day)
Vigabatrin(50mg/kg/day) Pyridoxine(100mgIVtestdose)
exchange transfusion[IEMs,drug toxicity,bilirubin encephalopathy]
Wean Anti epileptic drugs slowly to maintenance
phenobarbitone (3 to 5 mg/kg/day in two divided doses)
Seizures controlled

Polio Vaccine: OPV Vs IPV

• Routine immunization with OPV must cease after the
eradication of poliovirus because of the danger of outbreaks
of circulating vaccine-derived poliovirus and the risk of VAPP
(Vaccine Associated Paralytic Poliomyelitis)
• In the regions of the world in which wild-type poliovirus has
been eliminated, moving to an IPV or IPV/OPV sequential
schedule will reduce or eliminate the risk of VAPP and
outbreaks of circulating vaccine-derived poliovirus, as well as
increase the likelihood of countries agreeing to stop
administering OPV after eradication is achieved.
• IPV could also be used with OPV in routine schedules to
increase immune responses and to decrease the circulation of
wild-type poliovirus in countries in which transmission has not
been stopped.
OPV Vs. IPV

IPV – Rationale
• Type 2 poliovirus mutates into virulent form
• IPV contains killed virus, so IPV mitigates this risk
• IPV in addition to OPV provides better immunity
• All countries switched from tOPV to bOPV (minus type 2) 2016
• Introduction of IPV before this ensure protection against type 2
• Once virus circulation stopped everywhere, OPV withdrawn

Define AEFI
• An Adverse event following immunization
(AEFI) is any untoward medical occurrence
which follows immunization and which does
not necessarily have a causal relationship with
the usage of the vaccine.

Vaccine product related reaction (one
or more of the inherent properties of
the vaccine product)
Extensive limb swelling following DPT
vaccination.
Vaccine quality defect-related reaction
(one or more quality defects of the
vaccine product including its
administration device as provided by
the manufacturer)
Failure by the manufacturer to
completely inactivate a lot
of inactivated polio leads to cases of
paralytic polio
Immunization error-related reaction
(inappropriate vaccine handling,
prescribing or administration)
Transmission of infection by
contaminated multidose vial
Immunization anxiety-related reaction Vasovagal syncope in an adolescent
during/following vaccination.
Coincidental events (events reflect the
natural occurrence of health problems
in the community with common
problems being frequently reported)
A fever occurs at the time of the
vaccination but is in fact caused
by malaria

Signs of good attachment for
Breastfeeding:
1. Chin touching breast
2. Cheeks round or flattened
3. Mouth wide open
4. Lower lip turned upwards
5. More areola above than below
6. Breast rounded (not stretched/pulled)

Hyperkalaemia:
Changes according to K+ level
• Serum potassium
• 5.5-6.5 Peak T (Tall tented T) wave
• 6.5-7.5 Loss of P wave
• 7.5-8.5 Widening QRS
• >8.5 Continued widening of QRS

Normal breath sounds
• The thickness indicates intensity
• The steeper they incline the higher is the pitch
Vesicular:
 Inspiratory phase longer.
 Only inspiratory phase is active.
 No gap.

Type I Vs. Type II Nutrients
I. A child responds to a deficiency of an essential nutrient by:
Continuing to grow and consuming body stores with eventual
reduction in the bodily functions (Type I)
II. Reducing growth and avidly conserving the nutrient to maintain
the concentration of the nutrient in the tissues (Type II)

Consolidation Effusion
Percussion woody dull Percussion stony dull
Vocal fremitus and vocal resonance
increase
Vocal fremitus and vocal resonance
decrease
Trachea in normal position Trachea deviated towards opposite
side
Bronchial breath sounds Vesicular breath sounds

Stages of CKD
CKD can occur with GFR>90 as well but typically defined as ≥3 months of GFR<60 mL/min/1.73
m2 or objective signs of kidney damage viz. imaging abnormalities, albuminuria, etc.

Acknowledgements:
Best of the best slides, pictures and information
on the web. Special thanks to all those brilliant
minds for their act of creation and compilation of
scientific material without which this work would
not be possible
• Kliegman et al, Nelson Textbook of Pediatrics
• Ghai, Essential Pediatrics
• Harrison’s principle of Internal Medicine
• Davidson’s Principles & Practices of Medicine
• Pediatrics Clinical Methods, Meherban Singh
• Lecture Notes

How to stop worrying when almost
nothing in your life is going right?
https://medium.com/@anishdhakal718/3-doses-of-
antidote-to-worry-the-most-destructive-habit-known-to-
mankind-9990529bf321

Pediatrics Review Booklet by Dr. Aryan (Medical Booklet Series by Dr. Aryan Part 20)

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