Devashree Moktan

9th Semester Paediatrics Posting Notes

Introduction and Revision

Dr Biswal 17/08/20

History, Anthropometry, Immunization, Interpretation of Anthropometry and Vitals

Plot, demonstrate and comment on Growth Charts

Clinical Dx –
1. History, Symptoms (suggestive, neg) → Figure out system involved
E.g. – Coughing RT (upper or lower? Ask Qs to figure out)
Q. History Suggestive of LRT involvement – Increased RR, Chest Retraction
Then O/E look for creps, wheeze
Ask about history of foreign body aspiration – common in small children
Age – asthma is rare in less than 2 y.o
2. Clinical exam → Signs (figure out organ involved, if possible specific area of organ)
E.g. – Wheezing (implies conduction pathway involved) – Bronchus?
3. Dx and DDx – Start Rx of working Dx
E.g. → Case of tachypnoea, chest retraction, wheeze
Bronchial Asthma, Bronchiolitis, Bronchial Foreign Body
Take age into consideration
Working Dx in example – Bronchial Asthma
4. Ix to confirm your Provisional Dx
Test for bronchial asthma – FEV1/FVC Ratio (resp. fx test to show obstructive disease)
In acute attack – take CXR – hyperinflation of lung fields implies air entrapment
Bronchoscopy (Dx and Rx of FB, Mucus Plug)
5. Rx, Prevention and Counselling
If there is satisfactory response to Rx to working dx – Then Dx is probably Right
Infectious disease prevention – Vaccine
Counsel Parents about FB Aspiration, Inhalation (E.g. Kerosene)
Genetic Disease – counselling for next disease

MBBS FINAL EXAMS- to pass you need 50% in case and 50% in viva
80 + 20 Marks (20 is internal marks)
2 short cases – 2 examiners (1 ext, 1 int) – Paediatrics Case, New Born Case (20 marks each)
Newborn Case – Gestational Age, Anthropometry, Points
Maturity Scoring Chart (New Ballard Score), Preterms – Anton? Chart
Plot wt and length
Demonstrate signs – physical maturity or neuromaturity, Moro’s reflex, breast buds
Feeding
Common queries mothers ask about

Paeds Case – brief history, relevant system examination

Tell what relevant Ix you will do, Rx
E.g. – Nephrotic Syndrome Case – What bedside proteinuria test will you do?

2 Spotters (5+5)
Spotters – Based on what you see, make Dx (it will be very obvious, 50% marks)
After Dx, examiner will ask 3 relevant questions (50% marks)

4 Viva stations – (5 marks Each)

Devashree Moktan
9th Semester Paediatrics Posting Notes

Radio – X rays (Eg pneumonia, pleural effusion, rickets, sutures separated, diploic space with fibrous
strands, massive cardiomegaly)
Nutrition – green veggies, peanuts, dal, egg → Identify, Protein content, Calorie Value, limiting
amino acid
Instruments – laryngoscope, feeding tube, puncture needles (BM), etc → Indications, CI
Drugs&Vaccines – Vials content, VVM, Transfer of vaccine,
Lasix, Adrenaline – use, complication

Log Book – 10 marks (Write - History, Exam, Anthropometry, Dx, Ix and Mx)

CNS History and Examination – 18/08/20

Dr Narayanan

Cardinal Symptoms of CNS: Loss of Motor fx, sensory fx, higher mental fx, bowel & bladder dysfx
May include – AbN movements, Seizures

Ask about milestones

Q. How does CNS case differ than any other system?

LOCALIZE THE LESION FIRST BEFORE PROCEEDING

Q. Part of CNS – Cortex, Subcortical region, Brainstem,

Q. Non- CNS reasons for Developmental Delay – Hypothyroidism

Approach to child with developmental delay (if due to CNS problem)

• Take complete developmental history for all domains

Uniform Delay?
Asymmetrical Delay?
Predominant motor delay – Motor system defect
Motor + Deafness – more extensive defect
If milestones are perfect – CNS problem UNLIKELY
• Confirm delay is due to CNS problem – Delay in other domains definitely implicates CNS
Isolated Delay (Eg. Only speech delayed, only walking delay) – could be non-CNS problem
Ask for other symptoms – deformed limbs (local cause), seizures (points to CNS)
• Localize the lesion first – figuring out which part of cns affected helps figure out the etiology
Q. Commonest cause of developmental delay – Cerebral Palsy
CEREBRAL PALSY –
o Non progressive insult (E.g. – Hypoxic ischemic event, trauma, meningitis, basically a
one-time event)
Progressive insults – Wilson’s disease, Nieman pick, etc Ongoing insults
How to identify progressive/ ongoing insult from history? – REGRESSION OF
MILESTONES (basically rules out cerebral palsy)
o Insult should occur in the period of active brain growth
Active brain growth – from time of conception up till 2 years (some books – 5 years)
o Motor system disorder – abnormal tone, posture, mobility
o Comorbidities may be present– low IQ, deafness, decreased vision, seizures
• Motor system History
o Handedness
MC problem in motor system – Handedness not developed till 3 years
Handedness emerges by 2-3 years
Devashree Moktan
9th Semester Paediatrics Posting Notes

Early development of hand preference does not mean early achievement of

milestones it means there is a problem on the other side
o Gait
o Frequent Falls
• History of Insult
Commonest cause of Cerebral Palsy in the world – Prematurity (poor brain development,
IVH, apnoeic episodes, hypoxic damage
Birth Asphyxia mc cause in poor healthcare set ups
Ask history from antenatal period till current age if there could be any possible etiology of
Cerebral palsy – Antenatal, perinatal and postnatal history in detail
Important indicator of significant damage to baby – NICU admission >>>> Difficult delivery

If child comes with CNS problem but is beyond 2 years of age – milestones achieved
Approach similar to adults
Q. UMN vs LMN Lesions

• Higher Mental Function

o Consciousness
o Orientation
o Memory – long term, short term
o Intelligence
o Speech
o Handedness

Children 2 years or younger, Developmental Exam = Higher mental fx exam

• Cranial Nerve Exam – eye movements, swallowing, neck movements

All except a few can be observed
Observations noted first
Elicited Reflexes last, most noxious last
• Motor system examination
o Tone – inspection, palpation (passive resistance to movement by examiner – not
easy to do in kids)
Inspection - posture
Ragdoll/pithed frog – flaccid
Stiff – Spastic
Good tone – contour of muscle will be seen
Palpation
o Power – MRC Grades
How to assess in 2 years olds
o Gait
• Neurocutaneous marker – Café au lait, etc

Cases in CNS – Cerebral Palsy, AFP

Renal System History and Examination

Dr Bobbity Deepthi 19/08/20

History

• Age – nephrotic syndrome age? 2-6 years

Devashree Moktan
9th Semester Paediatrics Posting Notes

• Edema
Renal – starts as periorbital puffiness then facial
Periorbital puffiness in the morning and comes down in the evening then progresses to be
full time facial puffiness
More edema in nephrotic
CVS, Malnutrition – LL or sacral or lungs (depending on
Hepatic - ascites
• Decreased urine output – oliguria
Nephritic, Late stage AKI, Nephrotic (decreased intravascular volume)
• Frequency of Urination = increased times
Polyuria = increased amount (E.g. DM, Tubular disorders, Recovering diuretic phase)
• Dysuria (hesitancy, burning micturition) UTI
• Hematuria – Cystitis, nephritic
• Cola colored urine – PSGN, NEPHRITIC
• Abdominal pain – SOCRATES (usually due to gastritis due to steroid therapy, other cause –
hypovolemia, renal vein thrombosis)
• Polyuria, polydipsia – tubular disorders
• Nocturnal enuresis – nephronophthisis, primary
• Poor urinary stream, dribbling – post renal AKI, obstructive uropathy
• Renal mass (abd. Swelling) – ALL, Hydronephrosis, PCKD
• H/o drug intake
• Extrarenal symptoms – depending on disease or syndrome you are suspecting?
E.g. – Lowes Syndrome (ask for vision problems, hearing problems)
Tuberous sclerosis – ask about shagreen patch
• Negative history to rule out other causes of edema
a. CCF – breathlessness on exertion, palpitations, orthopnea, pnd
For infants – cyanotic spells, suck-rest-suck cycle
b. Hepatic Failure – jaundice, hematemesis, melena, significant ascites (ask WHERE the
edema started from), N, V
c. Nutritional/ Kwashiorkor – poor feeding history, protein calorie deficit, skin and hair
changes, bilateral pitting pedal oedema, angular cheilitis, bitot’s spots, infections,
features of SAM
d. Cushing’s syndrome – rare, h/o drug intake, striae on body
• History related to complications
a. HTN emergencies – present like LVF, gallop rhythm, HM with CCF features,
headache, V
b. AKI
c. Renal osteodystrophy
d. Anaemia
e. Neurological symptoms
f. SBP – tender enlarged abdomen, fever
• Renal symptoms in Newborn
1. Crying during micturition – non specific complaint
2. Poor feeding, irritability – nonspecific (any system)
3. (PUV) – Poor stream, dribbles
• Past history
Devashree Moktan
9th Semester Paediatrics Posting Notes

a. Similar complaints – to reclassify child (steroid resistant, to know what treatment

given so far)
b. PSGN – history of strep throat
c. UTI – Previous episodes (recurrent UTIs need extensive workup)
d. ALL
• Antenatal history – Oligohydramnios (poly too but it’s more related to
• Birth History – NICU admission, Edema after birth, AKI, Jaundice
• Nutrition – Salt restricted diet (if known cases), Renal stones (are foods avoided as advice)
• Family history – Nephrotic (Finish Type 1,2)

Examination:

• Vitals – BP is very important in renal cases

Q. How to measure BP in children – distract, keep in mom’s lap
Length of cuff – 80% of MUAC
Mid-acromian point
Cuff should cover 2/3rds of arm
• Head to Toe exam
1. Periorbital edema
2. Facial puffiness
3. Pallor (if chronic)
4. Healed pyoderma scars
• Anthropometry – short stature
• Examination of Edema in Children (commonly asked to demonstrate during exam)
Check over face, abdomen wall, genitalia, feet
Face – only inspect
Abdomen – press with steth – mark left – edema
Legs – Medial malleolus press
• Cola colred urine spotter?
• Examine all 4 systems but start with abdominal exam
• Tell full abdominal examination but emphasize on renal
• Inspection of Abdomen –
a. Shape
b. Umbilicus (everted means ascites), position shifted up or down
c. Discoloration
d. Scars, sinuses, engorged veins
e. Renal specifics – redness and shiny (could be SBP)
f. Hernial orifices
g. Genital examination – EDEMA in nephrotic, phimosis, obstruction causes
• Inspection of Renal System
1. Renal angle fullness
2. Frank fullness – confirm renal mass on palpation (ballotable, upper margin will be
felt unlike in liver and spleen)
3. SBP features
• Renal angle tenderness – implies renal vein thrombosis
• Dipping method of palpation if ascites present

Cases for exams – PSGN and Nephrotic Syndrome

Devashree Moktan
9th Semester Paediatrics Posting Notes

Questions

Q. Nephrotic Vs Nephritic Syndrome based on

1. Age – older age group in nephritic

2. Onset – acute in nephritic, gradual in nephrotic
3. Edema – predominant in nephrotics
4. Presentation – oliguria, hematuria, HTN and mild edema in Nephritic
5. Complications – CCF more in nephritic (due to HTN), CCF in nephrotic will be due to h
Headache, V – nephritic
6. Investigation
Nephritic – RBC cast, hematuria (micro or macro), Less proteinuria
Nephrotic - >3g/dl proteinuria

Q. Triad of nephrotic syndrome – Hypoalbuminaemia, Proteinuria, Hypercholesterolaemia

Q. Nephrotic syndrome can have high or low intravascular volume – you can tell by checking
hematocrit

Q. Ix for Nephrotic Syndrome

1. Complete Blood investigation (CBC) – routine, rule out HUS, HSP, infections
2. Biochemistry
RFT – blood urea, creatinine (check baseline)
Serum Electrolytes – especially potassium (AKI presents with hyperkalemia)
Serum Albumin
Total Cholesterol
LFT
3. Urine Analysis

Q. MC type of Nephrotic syndrome – MCD (best prognosis)

Q. Definitions – Steroid sensitive/ resistant, Remission, Relapse

Q. RPGN – in actuality is a SEVERE presentation of NEPHRITIC syndrome (has rapid progression and
poor prognosis)

Q. Congenital Nephrotic Syndrome – Less than 3 months old

Q. Indications for genetics

Congenital Nephrotic Syndrome
Family History of nephrotic syndrome
Suspect of Syndromic cause of renal problem

Q. Renal Biopsy Indications

Steroid Resistant Nephrotic Syndrome before starting immunosuppression therapy
RPGN
Secondary causes of nephrotic syndrome (e.g. SLE)
Congenital (not done anymore, genetics enough)

Q. Routine Mantoux/ CXR screen for TB before starting steroids – done in some centres
NOT DONE routinely in JIPMER
JIPMER screens for TB only if there is contact with person with TB (family member), child shows
symptoms of TB
Devashree Moktan
9th Semester Paediatrics Posting Notes

Gastrointestinal Tract History and Examination 20/08/20

Dr Reena

Start from ORAL CAVITY and work your way down till ANUS, then check out liver, biliary system and
pancreas – don’t miss any findings or symptoms

HISTORY

Common Complaints in Children

1. Pain Abdomen – mc
Maybe Psychological, Benign or Sinister Cause
Probe very well
Kids mostly point to umbilicus – they maybe localizing poorly, or they may just be saying
pain as complaint
Pain abd may not always be related to gut – Tonsillitis, AOM, Pharyngitis
So pain abd warrants systemic exam
Non GIT Causes of ABD Pain – Diabetic ketoacidosis, Uremia, Porphyria, Anxiety, Hereditary
angioedema
2. D
2nd mc
3. V
Ask if N also present – points towards GIT cause
4. Constipation
Directly related to gut or due to various other reasons (Psychological – upset, tensed)
Common in toddlers – toilet training time – some just don’t bother to go unless taken by
parents or strict toilet training that kid hates
Neonates – suspect congenital problem
5. Oral Ulcers – less common in kids than adults
6. Passage of Worms
Worm infestations could be the cause of D or constipation
Keep in mind because worms may not be passed or microscopic – stool exam important Ix
7. Abdominal Distension
More common in kids than adults – Kids have a relatively thinner abd wall that distends
easily
Flatus, Fluid, Fat, Feces
Common in infancy
Tell new parents – it is common and normal for stomach distension after feeds (due to thin
wall) – distension goes away in 1-2 hours or after passing stools
Regurgitation of milk after feeding is also normal – due to taking in air (also causes
distention) – after baby relaxes after feed → air comes up and curdled milk regurgitates too
→ Advice parents to burp the baby after feeding
Ascites, Intestinal Perforation, Mass Abd,
HSM – Inborn errors of metabolism
8. Odynophagia – pain on swallowing
(Adults think M growth in oral cavity)
Kids – Pharyngitis, Tonsillitis
FB swallowed – sharp object in oropharynx or upper esophagus
9. Loss of appetite – anorexia
Chronic infection, Inborn errors of metabolism, Stress
Devashree Moktan
9th Semester Paediatrics Posting Notes

* LETHARGY AND POOR FEEDING ARE COMMON COMPLAINTS THAT MANIFEST DUE TO
PROBLEMS IN ANY SYSTEM OF THE BODY – PROBE FURTHER
10. Dysphagia – difficulty swallowing
Think Cerebral palsy if other motor problems also present
Muscle contractures – saliva keeps drooling
Mental retardation
11. Jaundice
Ask if N, V, Fever also present
Is there bleeding? Think coagulation disorder, hemolytic anemia
J+V = could be Viral Hepatitis (one of the mc cause of J in kids esp. via Feco-oral route)
Neonates – biliary atresia, intrauterine infection
Kids - Enteric fever, leptospirosis
Long standing J → pt will also have manifestations of fat soluble vit deficiency
J + HM or HSM → inborn error of metabolism
12. Hematemesis
13. Melena
14. Hematochezia – intussusception, anal fissure, systemic bleeding problem
15. Gatroesophageal Reflux – will present with unrelated symptoms (like repeated RTI)
May present just as FTT

How do kids differ from adults?

1. Pain abd very common but cause may be unidentifiable sometimes

2. Stooling pattern in Breastfed babies – golden yellow, slightly watery and passed multiple
times a day, gastrocolic reflux
3. Congenital anomalies of GIT
TEF – keeps on Vomitting, severely dehydrated – give IV – immediate Sx
Achalasia
Pyloric stenosis – more in males, keeps vomiting, around day 15, olive mass in abd,
peristalsis seen, Sx
Duodenal atresia, intestinal atresia, malrotation of gut – all present with V, constipation
choledochal cysts << Biliary atresia ( first months of life, J perists)
Volvulus, Hirschsprung disease
4. FB ingestion
Coins common – large coins may get stuck

How to go about HOPI for any presenting complaint? DETAILS OF EACH SYMPTOM

1. Onset – when did the symptom start?

Acute or gradual?
Relation to food intake?
2. Duration – Minutes, hours, days, weeks, months, years
3. Severity and Description – How much of ___? How many times a day?
Related problems (esp. pain)
Content of V, D, Stools
Extent of J
Itching of anus – pinworm infestation
4. Course – symptoms worsening, improving, fluctuating, continuous
5. Site – esp. for PAIN
6. Precipitating and relieving factors
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9th Semester Paediatrics Posting Notes

7. Associating features
8. Previous episodes

EXAMINATION

1. Oral Cavity –
lip (cleft lip), buccal mucosa
oral hygiene, teeth (esp young kids – carries can cause cheek swelling, V, halitosis, systemic
infection), gums
hard & soft palate (cleft palate – regurgitations, may present only with FTT)
Tongue – mc infection of tongue in (esp. young since very poor immunity) kids: Candida, kid
may refuse to take feeds due to pain, Rx topical antifungal
Uvula, Retromolar trigone, Tonsil
2. Upper GIT exam – oropharynx
3. Abdominal exam
i. Inspection:
o Contour – kids normally have convex abd – protruding tummy
Physiological lordosis in toddlers just learning to walk
AbN – Scaphoid, Flank fullness, distension
o Umbilicus – location, shape, infection, hernia
Stump should fall off by 7-10 days
Is there any fluid oozing out?
Umbilical sepsis can lead to sepsis
In ascites – slit like (winking umbilicus), crescentic
o Movement with resp – equal?
Not moving – tenderness
o Scars/sinuses/dilated veins
Preferable to examin in standing posture (mild dilatations missed in supine)
Visible dialted veins – Location wrt umbilicus and direction of flow
ii. Palpation:
o Look for tenderness, guarding (contraction on eliciting tenderness), rigidity
(already contracted) – look at face
o Start with superficial palpation (since thin walls – tenderness very easily
demonstrated)
o Divide abdomen into 9 regions – start from RIF and start ANTICLOCKWISE,
last do the umbilicus – if you find any area of tenderness, DO NOT PALPATE
that area with the same or more amount of pressure again
o On deep palpation – liver, spleen, any other mass
Before palpating – flex knees and hips
o Report on – size, surface, margin, consistency
Liver – tenderness also
Spleen – splenic notch
A palpable liver may be normal but a palpable spleen is ALWAYS abN
o Methods of spleen palpation
a) Start from RIF, move towards umbilicus with inspiration
Small spleen felt just below the left costal margin
If unsure – ask child to take a deep breath – tip of spleen will touch
fingertips
Devashree Moktan
9th Semester Paediatrics Posting Notes

b) A spleen in a child may be confused with contracted abd muscle in a

small child – Spleen just under ribs, medial border has a notch
If soft spleen – quite obvious
c) Hooking method (middleton’s)– for small spleen, stand on left side
at head end
d) Shots manoeuvre – bimanual method
o Methods of liver palpation
a) Start from RIF and move up, ask pt to inspire deeply, liver margin
will hit the border of your index
b) Keep hands parallel to rectus, take deep breaths/ more fingers with
inspiration, feel with tips of fingers
iii. Percussion
o Liver span – will tell you if it is TRUE HM
Q. Normal liver span in different age groups
o Puddle sign – 150 ml fluid
o Shifting dullness – 500 mL
o Fluid Thrill – 1.5L
o Traube’s space percussion
iv. External Genitalia exam
v. Hernial orifice exam
vi. Anal opening – esp. important in neonate

CVS
Dr Gunasekaran 21/08/20

Symptoms suggestive of CVS

1. Syncope – mc Vasovagal
2. Palpitation
3. Cyanosis
4. Joint pain
5. Cough
6. Chest pain
7. Fever – RHD, Infective endocarditis, LRTI
8. Feeding difficulties
9. FFT
10. Frequent
11. Pedal oedema
12. Chorea
13. Painful swellings in finger pulp

Congenital or acquired?

1. Age of onset – early implies congenital

small ASD present at adolescent, Large ASD – by six months of age
VSD – after 6 weeks of age, PDA – after 6 weeks of age (may occur early if large shunts)
Physiologically, until 6 weeks of age the Pulmonary Vascular resistance is very high
TOF – s/s start around 2 months of age (even though present at birth, as child grows in 1st 2
month, the right ventricular outflow obstruction increases)
most common presentation of TOF is CYNOSIS (due to infundibular stenosis)
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9th Semester Paediatrics Posting Notes

2. Feeding difficulties (FFT) – congenital

3. Recurrent Hospital Admission – congenital
4. Rheumatic Fever (fever, joint pain, chorea) – Acquired

Cyanotic?
5g/dL (>4g/dL) of the haemoglobin is deoxygenated mixing with oxygenated ---> central
Cyanosis may not be clinically evident in a patient with severe anaemia (to show
cyanosis, at least 5g/dL of Hb must be present ---> the absolute value of deoxy-
Hb/reduced-Hb matters)

Central vs Peripheral cyanosis

➢ Poor oxygenation vs poor circulation in the periphery (low cardiac output, peripheral
vasoconstriction due to cold)
➢ Central cyanosis is indicative of an SpO2 of <85%
1. Central cyanosis may occur due to impaired gas exchange (pneumonia); V/Q
mismatch (embolism); anatomic shunts and right to left CHD; high altitude (low
FiO2)
2. It may also occur due to hemoglobinopathies (with decreased oxygen-carrying
capacity) such as methemoglobinemia or sulfhemoglobinemia
3. Peripheral cyanosis: blood with normal arterial O2, with increased peripheral
extraction of O2 due to decreased local blood flow (venous stasis, vasoconstriction
(cold-induced or shock-induced), peripheral arterial disease or low cardiac output)

• Peripheries + oral mucosa and tongue/ peripheries (nail beds)

• Clubbing is universally present in central cyanosis (indicative of cardiopulmonary
involvement)
• Polycythaemia is universally present in central cyanosis (central hypoxia stimulates ErP
to accelerate synthesis of RBCs)
• Administering oxygen vs warming peripheries

If it is Cyanotic CHD, what is the actual CHD?

Devashree Moktan
9th Semester Paediatrics Posting Notes

1. Decreased Pulm Blood Flow – Cyanotic Spells

Truncus arteriosus – common tract for aorta and pulm artery
TAPVC – total anomalous pulm venous circulation
Others – TGA, DORV with PS, Single ventricle with PS
2. Increased Pulm Blood Flow – More RT Infection, Cardiomegaly, Failure
Tricuspid atresia, TOF
others – DORV without PS, single ventricle without PS

Cyanosis since day 1 – TGA, hypoplastic left heart syndrome

If it is Acyanotic CHD:
Volume overload (ASD/VSD/PDA)
Obstructive pressure overload (PS/AS/coarctation of aorta)

Is it Acquired? → RHF
ARF – first episode → evidence of pericarditis? Myocarditis?
Established heart disease – previous episode
Mitral valve most commonly involved due to stress (it has to work against the most stress)

Complications of heart disease

1. CHF – Breathlessness on exertion

2. IE – High grade fever + osler nodes (child won’t complain of janway lesions because it is
painless)
3. Pulm HTN – Fatigue and breathlessness

Case 1:

a. Congenital – 3 months old, feeding difficulties

b. Acyanotic – no discoloration noted by mother
c. Etiology – History of Fever with rash in antenatal period
Rubella – head to foot progression of the disease, “3-day measles”, disease appears and
disappears within 3 days, Maculo-papular rash
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9th Semester Paediatrics Posting Notes

d. Complication – FFT, Heart Failure (because of exertion, during feeding forehead sweating –
increased sympathetic output to keep heart pumping)

Case 2:

a. Congenital – Symptoms started by 2 months of age

b. Cyanotic – bluish discoloration of extremities and mouth
c. Complications – Cyanotic spells, Seizures (due to hypoxia)

Case 3:

a. Acquired – 11 years old, no past history

b. RHD – migratory polyarthritis
c. Complications – History of breathlessness, PND, orthopnoea, pedal edema = Cardiac Failure

VITALS in CVS examination

Devashree Moktan
9th Semester Paediatrics Posting Notes

1. Pulse
Rate, Rhythm – Brachial (ease of access)
Volume, character – Carotids (closest to the heart so reflects the character better)
Tachycardia – RHD (here tachy out of proportion to fever, normally, for every 1 degree
increase in temp, hr increases by 10 beats), CCF, Tachyarrhythmias (SVT)
Bradycardia – Block (3rd degree block)

Rhythm – observe for one minute

Regularly regular – Ectopic
Irregularly irregular – A Fib

Pulse volume – determined by pulse pressure, detected by SBP – DBP

High volume pulse – High PP
o High SBP= PDA, Aortic regurgitation, Truncus arteriosus (high volume pulse +
cyanosis
o Low DBP – septic shock (warm shock)

Low volume pulse – Low PP

o Low SBP = Aortic stenosis, Coarctation of aorta

o High DBP – hypovolemic shock (vasoconstriction)

Pulse character
Slow rising – AS
Collapsing Pulse – AR, PDA
2. Blood Pressure

Available cuff sizes – 12.5, 10, 7.5, 5, 2.5 (cms – the breath of the cuff)
Devashree Moktan
9th Semester Paediatrics Posting Notes

Choosing your cuff – First take MUAC

Width – 40% of muac (how much it covers arm)
Lenth – 80-100% (the wrap around apart)

Normal Range of BP (you can bring chart to exams)

Avg SBP:
At Birth: 60
Neonate: 70
6 months: 85
1 year: 90
From 1 year onwards till 10 years old use a formula – 90 +(age x 2)
Formula for DBP – 2/3rd of SBP
Pulse pressure = 1/3rd of SBP or SBP minus DBP
avg. range of pulse pressure in adults =40 mmHg (120 – 80)
3. CFT (Capillary Filling Test)
CFT <2 seconds
>3 seconds abnormal – Shock
4. Pulse Oximeter
Non-invasive, simple, rapid estimation of oxygen saturation of Hb
Principle: O2Hb absorbs more Infrared light & HHb absorbs more red light than O2Hb

General Examination in CVS

1. Oral Cavity – Oral hygiene (mc source of IE is dental carries), Cleft Palate (association with
cong heart disease)
2. Fingertips – Clubbing
IE – Slinter haemorrhage, osler nodes (fingers) *janeway lesions are in palms
3. RHD – arthritis, subcutaneous nodules, erythema marginatum
4. Facies – Downs (Endocardial cushion defect / AV septal defect
5. Turner’s – webbed neck, cubitus valgus, wide spaced nipples, short stature
Mc heart disease – coarctation of aorta >> bicuspid aortic valve
6. CHARGE SYNDROME – Coloboma, heart defects, atresia choanae, Growth Retardation,
Genital Abnormalities, Ear abnormalities
7. Cyanosis
8. Clubbing
9. Edema

CVS Examination

1. Inspection
• Tracheal position – resp disease could lead to mediastinal shift
• Precordial bulge – Cardiomegaly
• Apical impulse
• Pulsations
• Pectus excavatum – heart is displaced (slightly to the left – may give you the
impression that there is cardiomegaly)
2. Palpation
• Tracheal position
Devashree Moktan
9th Semester Paediatrics Posting Notes

• Apex beat
• Parasternal heave
• Thrill
• Palpable P2 – 2nd left ICS – indicates pulm HTN
• Chest movement

Apical Impulse – Lowermost, outermost impulse felt

LV and part of interventricular septum
Shift – RVH – outward , LVH – out and down
“quite chest” – normal everything – TOF
Hyperdynamic – Volume overload (PDA, MR, AR)
Heaving – Severe systemic HTN, Aortic stenosis – High pressure
Tapping – low volume

3. Percussion
• Start percussing from axilla to midline – normally dullness starts at apex, but if
dullness begins before apex – Pericardial effusion present
• Right border of heart is usually under sternum – but excess RH hypertrophy –
dullness before right sternal border

4. Auscultation
• MC murmur in PDA – Continuous machinery murmur most prominently heard in the
left 2nd ICS, conducted throughout the chest (loud), thrill may be present
• Flow murmurs – could be there in PDA but the– MDM in mitral area, AS like murmur
(ejection systolic in aortic area)
• VSD – Pansystolic murmur – left 4th and 5th ICS at the sternal border
Flow murmurs – Pulm stenosis like (if VSD is larger in size – more shunt – more
blood goes via pulm artery), MDM in mitral area
May have thrill
• ASD - wide, fixed S2 split (amount of blood handled by RV varies with resp, so
splitting of S2 varies normally BUT in ASD – RV handles large amount of blood and
no more can be accommodated so P2 is always delayed by the same time and it is
the max delay)
Ejection systolic murmur of grade 2 or 3, no thrill
• TOF – ejection systolic murmur, no thrill – due to turbulence
Ejection click in 1/3rd of kids – due to overriding aorta (seen in 1/3rd of TOF)
S2 is a single sound – P2 not heard
Devashree Moktan
9th Semester Paediatrics Posting Notes

FOR HISTORY REFER TO THE PREVIOUS PICTURES

Case 1:
Dx – PDA
Compn – FTT, Heart
failure – due
tachycardia (look for S3
gallop)

Case 2:

Dx - ASD
Complication – Cyanotic
spell
Pulmonary Blood flow is
reduced

Case 3:
Full Dx – Acquired heart disease
of rheumatic origin with cardiac
failure, pulmonary hypertension,
MR – down and out apex (LVH),
soft S1, Pansystolic murmur of
grade 3
the MDM murmur is due to
Carey Combs murmur (occurs
due to inflammation of mitral
valve root – edematous cusps so
it decreased size of orifice – ACTS
LIKE A FUNCTIONAL Mitral
Stenosis)

How many years after ARF can a child develop organic MS – 5 years
Devashree Moktan
9th Semester Paediatrics Posting Notes

X-rays

• Boot shaped heart – TOF

• Egg on side – TGA

• Cardiomegaly – Cardiothoracic ratio > 50%

COMMON Congenital Heart Diseases

 Acyanotic: VSD 32% PDA 12%

PS, ASD, Co A, & AS 6%

 Cyanotic: TOF 6%, TGA 5%

Etiology of Congenital Heart Disease:

 Chromosomal anomalies: 8%
Ex: Trisomies-21,18,13; Turner’s

 Environmental teratogens: 2%
Ex: Intrauterine infections,
Maternal drug intake (Phenytoin)
Maternal diseases (Diabetes, SLE)

 Single gene mutations: 90%

Incidence of Congenital heart disease

 6-8 per 1000 live births

 1 in 10 still born infants

Devashree Moktan
9th Semester Paediatrics Posting Notes

NUTRITION VIVA
Dr Gunasekaran 24/08/20

Cereals – Rice, Millet, Wheat

100 g of uncooked rice – 7 g, 70g carb, 0.7mg iron, 370 Cal
100g cooked rice (1 cup of rice) – exactly half – 3.5g proteins

100 g Ragi – 0.7 x 5 iron, same as rice

6 teaspoon of Ragi Powder = 2 g of protein, 100 Cal

100 g Wheat – 7x 0.5g protein, 8x0.7 iron, same as rice

Limiting aa in cereals – Lysine (except rice has good amounts of lysine)

Wheat lacks lysine + threonine

Calcium amounts are good in ragi

Iodine also present to some extent

Methods of increasing nutritional value?

Parboiling of rice
Malting of ragi
Contraindication:
Celiac disease – avoid barley wheat, rye

Pulses – Bengal gram, Black gram, red gram

Bengal Gram – 370 calories, protein 10g

ALL PULSES Per teaspoon (5g) – 1g protein and 20 calories

Limiting aa – Methionine

8 essential amino acids – PVT TIM HALL (Phenylalanine, Valine, Tryptophan, Threonine, Leucine,
Methionine, Histidine, Arginine, Lysine, Leucine)
essential for infants – arginine and histidine
LBW babies – 3 essential acids – CAT (cysteine, arginine, taurine)

Eggs – Protein
1 egg – 70kcal, 6 g protein

Mineral good in egg – Calcium

Good amounts of fat-soluble vitamins (esp. A and D)

Major nutrient absent in egg – Carbohydrates

Major Vitamin absent in egg – Vit C

Reference protein = egg

o The amino acid profile is similar to human body

o Contains all essential amino acids
o Easy to store and easily available

Another reference protein – breast milk

Raw egg is not advisable – avidin binds to biotin (interferes with absorption)

Anti-nutritive factor in egg – trypsin inhibitor in egg white – interferes with digestion
Devashree Moktan
9th Semester Paediatrics Posting Notes

Cow’s milk
In 100 mL
Calories = 70kcal
Protein = 3g

Easily available
Good amounts of protein
Can be given in infants >6 months old

Not superior to human breastmilk

Breastmilk protein = 1 g (good proteins quality)
BUT the protein in cow’s milk = casein (not good protein qualitatively)

Advantages of Human Breast Milk:

o Immunoglobulins
o Lipase in breastmilk helps in fat digestion
o Lactose (supplies energy to growing brain, helps in calcium absorption)
o Contains lots of essential fatty acids (DHA)
o Contains all vitamins (esp. A) – K not so much
o Calcium phosphate ratio = 2:1 (in cow’s milk phosphate is more)
o Water content 88mL per 100 mL (so no need to substitute water even in hot climates)

Carrots
Group = Roots and Tubers
100 g of carrot → 1 g protein, 1g fibres, 1 mg iron, 50 cal
Rich in Vit A (present as beta carotene – good precursor of vit a)
Govt programme to fight vit A in community – Vit A prophylaxis programme
(1st dose at 9 months with MMR – 1 lakh IU, thereafter every 6 months till 5 yrs of age – 2 lakh IU)
Other sources of Beta Carotene – Papaya, G(green leafy veggies) Y (mango) O (orange) R (roots –
carrot, beet root) [GYOR coloured foods]
Devashree Moktan
9th Semester Paediatrics Posting Notes

Drumstick leaves
Green leafy vegetables
Very easily available
100 g of leaves = 6 g protein, 1g fibre, 1mg iron, 100 calories
Not really a good source of protein
Good source of fibre
Also rich in Ca, iron, vit a

How much of green leafy vegetables is a school going child supposed to take every day
50 g of GLV

Which GLV has good iron content – Cauliflower green (40 mg %)

Amaranth (Tamil = seeru kirai) and aggatti eaves - 4 mg %

Banana
Fruit
easily available
Each banana on Avg. = 50g → 0.5g protein, 50 calories, 0.2 g fibre

Vit C is very rich in certain fruits – amla, citrus, guava

Groundnut
Nuts and Oils
100 g → 25g protein, 25 g carbs, 550 kcal

Essential fatty acids – linoleic acid, linolenic (alpha and beta)

Conditionally essential fatty acid – EPA (eicosa pentanyl acid) DHA (docosahexanyl acid)
These are derived from linolenic acid
Needs usually met via food sources

Arachidonic acid – derived from linoleic acid

PGs, LTs, TX are derivates
Important for cellular structures

Omega-3 fatty acids – alpha linolenic acid, epa, dha

Omega 6 – linoleic, arachidonic

Omega 3:6 ratio should be <10:1

Good sources of DHA – fatty fish (tuna)

RDA OF VITAMINS AND MINERALS

How to prepare a diet chart:

1. Calculate the necessary calorie intake
2. Necessary protein intake
3. Nutritional value of common foodstuff
4. Find out any restrictions
5. Prepare diet plan
Devashree Moktan
9th Semester Paediatrics Posting Notes

Calories intake
for 1 years old – 1000 kcal
for every 1 year add 100kcal
every 6 months – 50 kcal
every 3 months – 25 kcal

Protein intake
0-6 months = 1.2g/kg/day
7-12 months =1.7g/kg/day
1-3 years = 17 g (absolute number)
4-6 years = 20g
7-9 years = 30g
10-12 years girls = 40g
10-12 years boys = 50g

Nutritional value of common food stuff

Food item Protein in g Calories

1 idli = 1 dosa = 1 dosa = 1 puri 2g 50
= 1 big slice of bread
If oil used (+20 calories)
Cow’s milk 3g 70
Hen’s egg 6g 70
Banana 0.5 50
Biscuit (varies a lot but on 0.5 20
average)
Oil (5g = 1 teaspoon) 0 45
Sugar (5g = 1 teaspoon) 0 20
Cooked rice 3.5 g 185
Ragi (6 teaspoons) 1 100
Ground nut 100g 25 550
All grams (5 g – 1 teaspoon) 1 20

Food restrictions:
Renal disease – sodium
Renal Failure – potassium
Allergies, Gluten sensitivity

Making diet chart:

adjust protein with egg
add oil and sugar to adjust calories (energy dense, doesn’t add to volume of food, makes food more
palatable)

PEM
Dr Ventaktesh 24/08/20

Definition – A Clinical spectrum of pathological changes resulting from lack of protein and energy in
varying proportions, frequently occurring in young children and commonly associated with infection
and infestation
Devashree Moktan
9th Semester Paediatrics Posting Notes

Overview of PEM
Majority of world’s kids live in developing countries
Lack – food, clean water, proper sanitation, infection and social unrest lead to LBW & PEM
Malnutrition is implicated in >50% of deaths of <5 children (5 million/year)

Child Mortality
Major factors – Diarrhea (20%), ARI (20%), Perinatal causes (18%), Measles (7%), Malaria (5%)
55% of the total – malnutrition concurrently present

Epidemiology
Term PEM coined by WHO in 1976
Highly prevalent in developing countries among U5
Severe forms – 1-10%
Underweight 20-40%
All kids with PEM – micronutrient deficient

Current scenario
46% of U5 kids are underwt
39% stunted
20% severely malnourished
6000 kids die every day due to malnutrition

The reciprocal interaction b/w PEM & infection is the major cause of death & morbidity in young
children

Precipitating Factors of PEM

o Lack of food (famine, poverty)

o Inadequate breast feeding
o Wrong concepts about nutrition
o Diarrhoea & malabsorption
o Infections (worms, tb, measles)

Classification

A. Welcome Trust Classification

Parameter – weight for age +/- edema
Reference standard 50th percentile
Grades:
➢ 80-60 % + no edema = Underweight
➢ 80-60% + edema = Kwashiorkor
➢ <60% + edema = Marasmic Kwashiorkor
➢ <60% + edema = Marasmus
B. WHO Classification
• Underweight → more than -2SD deficit with respect to the median of the
international reference weight-for-age curve
• Stunting → more than -2SD Height-for-age
• Wasting → more than -2SD weight-for-height

Severe wasting/stunting/underweight if less than 3SD

Devashree Moktan
9th Semester Paediatrics Posting Notes

C. IAP Classification (indianc academy of pediatrics)

Based on weight for age
• Normal – >80%
• Grade I – 71-80%
• Grade II – 61-70%
• Grade III – 51-60%
• Grade IV - <50%
D. Other classification
Mild Mod PEM Severe
Weight for height 70-79% <70%
Height for age 85-89% <85%
Edema - +
MUAC 12.5-13.5cm 11.5-12.5 cm <11.5 cm

PEM Spectrum
Marasmus, Marasmic Kwashiorkor, Kwashiorkor

Pathophysiology

1. Marasmus – Insufficient energy intake → breakdown of body stores (muscles broken down
for gluconeogenesis) → Emaciation
2. Kwashiorkor – adequate carbohydrate but decreased protein intake → decreased synthesis
of visceral proteins → hypoalbuminemia → extravascular fluid accumulation → impaired
synthesis of ß-lipoprotein → Fatty Liver
Devashree Moktan
9th Semester Paediatrics Posting Notes

Marasmus – reduced body wt., muscle wasting and decreased muscle strength, reduced respiratory
and cardiac muscular capacity, skin thinning, decreased metabolic rate

Kwashiorkar – hypothermia, apathy, edema

Both – Immunodeficiency

MARAMUS
Greek word – marasmus = wasting

Inadequate protein + calories intake

Characterized by emaciation
Represents the end result of starvation – protein + calories deficient

Children are active, alert, voracious appetite

Represents adaptive response to starvation (kwashiorkor – maladaptive)

Body utilizes fat before breaking down protein

Main sign – severe wasting

Appears thin, no fat (“skin and fat”)
Most of the fat and muscle mass having been expended to provide energy
Severe wasting of the shoulders, arms, buttocks and thighs
Visible rib outlines

Associated signs of the condition:

o Thin old man face

o Baggy pant (loose skin of the buttocks hanging down)
o Affected kids may appear to be alert in spite of their condition
o There is no edema (swelling that pits on pressure) of the lower extremities

MARASMIC KWASHIORKOR

Mixed form of PEM

Edema occurring in children who may or may not have other signs of kwashiorkor

Skin and hair signs are less evident

Devashree Moktan
9th Semester Paediatrics Posting Notes

KWASHIORKOR

Ga language word for Sickness of weaning

Lack of physiological adaptation

Unbalanced deficiency
Subcut fat preserved
Hypoproteinaemia + Edema

1-4 years old usually

growth retardation, mental apathy, generalized edema (may look “fat”)

Associated signs:

1. Hair Changes – loss of pigmentation, straight, easily pluckable

2. Skin lesions – dark skin may become lighter in some places esp. in the skin folds, outer layers
of skin may peel off and ulceration may occur, lesions may reassemble burns
3. Mental Changes – apathetic, miserable, irritable, difficult to persuade them to eat

Crazy pavement appearance, flaky paint appearance

SAM – Severe Acute Malnutrition

Visible severe wasting
Bipedal edema
MUAC <11.5 cm
Wt. for ht. <3 SD below mean for age and sex
Devashree Moktan
9th Semester Paediatrics Posting Notes

Q. Factors that predispose a child to recurrent infection – poor nutrition, lack of exclusive breast
feeding, poor hygiene, lack of safe drinking water, poor environmental hygiene

1. Pellagra
2. Platynychia (flat), Koilonychia (spoon)
– IRON DEFICIENY
3. Rachitic rosary, Harrison Sulcus
(rickets manifest during rehabilitation
phase, since rickets is a disease of
GROWING bones) [ Differs from
scorbutic rosary – sharp, tenderness,
bleeding around it]
4. Dehydration – skin pinch, sunken
eyes
False positive skin pinch in
malnourishment – due to saggy skin.
Skin pinch is not a reliable sign of
dehydration in malnourishment
Look at other signs – sunken eyes,
decreased urine output
5. Bald tongue – iron deficiency
6. Angular cheilitis and glossitis – ariboflavinosis

Skin

1. Impetigo – honey coloured crust – strep,

staph
2. DDs – Diaper rash (long duration wet
diaper), Candida, Zinc deficiency
(acrodermatitis enteropathica)
Devashree Moktan
9th Semester Paediatrics Posting Notes

Eyes

1. Bitot spots
2. (left lower) – corneal xerosis
3. Right upper – corneal ulceration
4. Keratomalacia

Electrolytes low in PEM – K (also – mg, mn)

TREATMENT – STABILIZATION + REHABILITATION

PROGNOSIS

Kwashiorkor and Marasmic Kwashiorkor >>> Marasmus and underweight – Morbidity & Morbidity
risk
Early detection & adequate treatment – good outcome
Severity of hypoproteinaemia, hypoalbuminemia, electrolyte imbalances – poorer prog
Underlying HIV infection – poor prognosis
Devashree Moktan
9th Semester Paediatrics Posting Notes

RESPIRATORY SYSTEM
Dr Venkatesh 25/08/20

Chief complaints:

1. Cough – dry/ wet (Expectoration >6 years, young kids swallow), sputum characteristics,
association with blood
Examples of productive cough – suppurative lung disease
Blood in sputum – TB, bronchiectasis
2. Nasal symptoms – running nose, sneezing, itching, obstruction, epistaxis
3. Ear symptoms – discharge, pain, bleeding
4. Throat symptoms – pain, dysphagia, hoarseness
5. Breathing difficulty – even with blocked nose
Fast breathing, noisy breathing, chest indrawing, exertional
6. Chest pain – related to chest wall movement (pleurisy)
7. Bluish discoloration of oral cavity and nail beds – usually associated with fast breathing
(doesn’t really present by itself)

HOPI:

1. Onset – sudden/insidious
2. Progression of symptoms (static, better, worse)
3. Accompanying symptoms
4. Aggravating factors
5. Relieving factors
6. Functional limitation
7. Try to deduce etiology

TREATMENT HISTORY

1. When was the first visit to the doctor?

2. How many visits for current ailment?
3. How many doctors/ hospitals?
Make sure patient isn’t anxious, “doctor shopping” suggests they don’t believe in the system
4. What medications were prescribed? Steroids, antibiotics, bronchodilators
5. What tests/procedures were performed?
6. What was the effect of treatment?

PAST HISTORY:

1. Similar illness in the past

2. Previous hospitalizations
3. Exanthematous illness in the past
E.g. Measles – direct lung injury or indirectly
4. Pertussis
5. TB
6. Any other significant resp. illness in the past?
7. Is there a pattern?
Seasonal pattern could be allergy
8. Cumulative effect
Devashree Moktan
9th Semester Paediatrics Posting Notes

ANTENATAL History – important for congenital diseases

Exposure to teratogens, maternal diseases affecting lung development, anomaly scan,

oligo/polyhydramnios

Natal history – gestation at birth, weight, respiratory transition, need for resuscitations, anomalies
detected [CDH (scaphoid abdomen + severe resp. distress), TEF (first clue – frothing due to mixing to
air and saliva + mild RDS), Choanal atresia (membrane may be obstructing so cant breathe via nose –
air only enters mouth orally – neonates are OBLIGATES NOSE-BREATHERS – so these babies hypoxia
and cyanosis and are irritable – cries → mouth opens, takes in air → cyanosis disappears after cry),
Laryngomalacia (noisy breathing)]

Postnatal – Resp. distress (pneumonia due to organism colonizing birth canal, MAS, RDS) Oxygen
requirements, surfactant, ventilatory requirements
If o2 and ventilation was needing for a long time → risk of BPD

DEVELOPMENTAL HISTORY:

1. Motor delay – hypotonia/hypertonia – aspiration, restrictive lung disease

2. Speech delay/deficiency – velopharyngeal insufficiency, conductive deafness
3. Vision – Retinopathy of prematurity (history of O2 Rx)
4. Cognitive - OSA – impaired learning due to day time sleepiness

Immunization status

o BCG
o DPT
o Hib
o Measles
o Optional → Influenza, Pneumococcal
Give to high risk pt – congenital lung or heart disease, immunodeficiency

Nutritional History

1. Calorie gap/protein gap (Holliday Segar. ICMR guidelines)

2. Typical pre-illness diet
3. Is there a reduction in intake?
4. Calorie gap/protein gap
5. Specific micro nutritional deficiencies – risk factors – cultural beliefs, taboos, food fads
6. Chronic disease → poor appetite → poor nutrition
7. TB

Family History

1. Recent illness in family members (communicable)

2. Chronic respiratory ailments in family members (atopic and other genetic lung diseases)
3. Recent travel/ shift of residence
4. Family support (dynamics)

Socioeconomic history

1. Parental literacy, occupation, per-capita income

2. Type of house – overcrowding, ventilation
Devashree Moktan
9th Semester Paediatrics Posting Notes

3. Environmental smoke exposure – indoor and outdoor

Smoke causes ciliary dysfunction
4. Pets at home (mostly cats)
Birds – bird fancier’s lung, avian influenza, psittacosis
5. Religious/cultural beliefs
6. Awareness about common medical ailments and their prevention

SUMMARIZE – relevant +ve findings

Confirm the system involved and the likely disease
Etiology, complications, differentials (so that you can do a focused examination)

GENERAL APPEARANCE

• Sick/ acute distress

• Anxiety
• Position of comfort
• Irritability/drowsiness/restlessness – hypoxia (give respiratory support)
• Is child on support – oxygen prongs, masks, tubes, probes, leads

Cardinal signs:

• Pallor – compromised oxygen delivery, sign of peripheral circulatory shock

• Icterus – uncommon in uncomplicated resp. diseases
• Cyanosis – airway diseases (severe asthma, pneumonia, sudden pneumothorax,
bronchiectasis
Central cyanosis expected in resp. and cardiac diseases
Hyperoxia test – Give 100% O2 and see if cyanosis improves → Implies it is a resp. disease
• Clubbing – grades, causes (bronchiectasis, ILD, TB, lung abscess)
• LAD – site, significance/relevance, specific characteristics
TB – localized or generalized LAD
LAD may compress airway and cause resp. distress (Hodgkin Lymphoma)
HIV
Histoplasmosis
• Edema – heart failure, chronic respiratory disease leading to RHF (cor pulmonale)

VITAL SIGNS

• Pulse – Tachycardia
Bounding pulse – sepsis, hyperdynamic circulation (anemia), resp. failure, CO poisoning
• Respiration - rate, type, increased work of breathing
• Temp – axillary, variation of RR with temp
• Sp02 – supplement O2 if <95%
• Blood Pressure – pulsus paradoxus

ANTHROPOMETRY

• Wt. reduced – acute diseases

• Wt. and ht. reduced – chronic diseases
• Wt. for ht. reduced – wasting

HEAD TO FOOT EXAM

Devashree Moktan
9th Semester Paediatrics Posting Notes

• Risk of airway obs and difficulty in intubation – Small chin, retrognathia(pierre robin), Downs
(large tongue) – airway obstruction/stridor
• Hemangioma of beard area → hemangioma maybe in airway
• Palate – cleft palate/ uvulopalatal movements
• Short neck with fat deposition
• Venous engorgement of head and neck
• BCG scar, Mantoux rxn, erythema nodosum (sign of TB, SJS)
• Kyphosis, kyphoscoliosis, pectus deformity of chest
• Abdominal distension, hernial sites

HEAD, EYES, ENT EXAM:

• Head bobbing
• Eyes – allergy, phlycten
• Ears – tympanic membrane
• Nose – Pale/ enlarged inferior turbinates, septal congestion, purulent discharge,
Anosmia (Allegic rhinitis, covid, b/l polyp)
• Throat – tonsillar enlargement, posterior pharyngeal wall appearance

RESP EXAM

Trachea is normally slightly deviated to the right

Measure chest wall size during palpation

Tidal percussion – variation from normal pattern → problem

Normally – on inspiration lungs expand so resonant, expiration liver comes up so dullness on
percussion
Dullness in both insp. And exp. – is it lung path?
Liver path – always descends down in inspiration

How to check for diaphragmatic weakness – ask pt to sniff (short, deep insp.) or ask pt to count from
1-20 in one breath or splint ICM and ask child to take breaths → inability to do all these = weakness

OTHER SYSTEMS

• Cardiovascular – evidence of pulmonary HTN, CCF

• Abdomen – pushed down liver and spleen, pushed up diaphragm, GER
Devashree Moktan
9th Semester Paediatrics Posting Notes

• CNS – central hyperventilation, neurogenic stridor, bulbar palsy, diaphragmatic weakness

• Renal – Pleural effusion, pulmonary edema

PROVISIONAL DIAGNOSIS

o Sum up positive findings on exam

o Confirm the system involved and likely disease
o Etiological clues
o Complications
o DD

TREATMENT

o Antibiotics for pneumonia, bronchiectasis

o Pleuronecentesis – pleural effusion
o ICTD – empyema
o Brochodilators, steroids – asthma
o ATT – TB

NEONATE HISTORY AND EXAMINATION

Dr Adisivum 26/08/20

Short case – term, preterm, IUGR, physiological jaundice

Examples – baby of XYZ, gender, term, AGA, birth weight, ___ day of life

Differs from adults – examination starts while you talk to mom – open ended questions so that she
can elaborate
ALWAYS LISTEN TO THE MOTHER

Quick antenatal history and perinatal history (don’t say “uneventful”)

First trimester – exanthematous fever, rash (examples, cong rubella syndrome), x rays (how is it
harmful), drugs (antibiotics – name some)

2nd trimester – Td vaccine, Iron and folic acid (folate to prevent neonatal defect, iron requirement is
elevated in pregnancy and also to prevent PPH)

3rd trimester – leaking, bleeding, PPROM (risk of early neonatal sepsis)

Delivery – type of birth, indication of instrumentation/LSCS, if preterm mention gestational age

Post-delivery – did it cry at birth (assumption that baby breathes (oxygen from lungs to brain) while
crying, so we are asking about asphyxia), Breastfeeding initiation, Delayed feeding (why?), NICU
(why was it admitted, how long stay, what was done?)
Q. Indications for bag and mask ventilation in new-born – Baby apnoeic or gasping, HR <100
Q. TABC – normal temp in neonate
Q. Ideal time to start breast feeding – ASAP
Q. Criteria to say that baby is getting enough feed – Weight gain, urine out (non conc, 6 times a day)

Baby with Jaundice

When did baby develop J – patho <24hrs (Rh incompatibility) or Physio (24-48hrs.)
Physio J vs
Devashree Moktan
9th Semester Paediatrics Posting Notes

Surgical jaundice – EHBA (kasai procdure?) – Extra hepatic Biliary atresia

Jaundice >14 days → persistent jaundice (RULE OUT HYPOTHYROIDISM)

(Acute watery D <2 weeks, >2 → persistent (if infectious), chronic (malabsorpition)

Breastfeeding J (insufficient feeding) vs breast milk J

BUT NEVER STOP BREASTFEEDING

PhotoRx, exchange transfusion

Why should feeding be continued during photoRx?

Triad/tetrad of kernicterus

EXAMINATION
1st thing – WASH HANDS (Q. WHO hand hygiene moments, hand washing steps, sanitizing, hand
rubs)
HOW TO PREVENT COVID TRANSMISSION TO BABY FROM A COVID +ve mother – mask, frequent
hand washing, exclusive breastfeeding, clean surfaces

Causes of respiratory distress at birth:

MC Cause – transient tachypnea of newborn (dx of exclusion) → incidence higher in elective LSCS
Q. IMNCI Programme, Tachypnoea in neonate >60 RR
*imnci guidelines hold good up till 5 years of age
CDH, MAS, RDS

Common causes of neonatal mortality in India – prematurity, sepsis, asphyxia

SEPSIS
Poor feeding (could also be hypoglycaemia), lethargy

Neonatal seizures
<24 hrs – birth asphyxia usually
>24 hrs – metabolic (hypoglycaemia)
Day 3 onwards – infectious cause (meningitis)

Q. Mx of neonatal seizures

Temperature
Normal temp of neonate – 36.5 – 37.5 °C , Ideally measured by – surface (by probes in warmer)
Touch peripheries and centre:

o both warm – N
o Both cold – Hypothermia
o Peripheries cold – cold stress

Q. Warm chain
Detecting cold stress helps you prevent hypothermia

Q. Preterm more prone for hypothermia

**hypothermia → if present, it will increase mortality

THERAPEUTIC HYPOTHERMIA – for moderate -severe asphyxia within 6 hours (33-34 C)

Here, temp is mea
Devashree Moktan
9th Semester Paediatrics Posting Notes

Case 1 – sepsis + hypotension → decompensated → detectable shock but worse outcome

Case2 – Sepsis + normal → compensated, so easy to resuscitate

NEONATES – INTUBATE BEFORE HEART STOPS → BE PROACTIVE

Catch babies in early shock – what are the marker?

Essential newborn care – respiration, exclusive breastfeeding, prevent hypothermia, prevent sepsis
(wash hands)
LBW and Preterm – KMC to prevent hypothermia

Gestational assessment – New Ballard Score (carry the chart and plot)
Q. Components of new ballard score

Cry, Colour, Activity

No cry – sepsis?
Cry – usually hunger lust cry
Shrill cry – Increased ICP, kernicterus,
Hoarse cry – hypothyroid

Lethargic – sepsis
Acrocyanosis at birth and later PINK – N (due to hypothermia)
central cyanosis – abN
YELLOW – colour distribution and severity (SOLES STAINED >20mg/dL – hospitalize + photo Rx)
KRAMER’s rules

Learn protocols for Birth asphyxia, Sepsis, Hypoglycaemia, Hyperbilirubinaemia, Hypocalcaemia,

MAS

LEVELS OF NICU – 1(mostly normal, e.g. preterm kept for weight gain, phototherapy)
then 2(step down NICU, O2 support)
and 3 (high end care e.g. mech vent)

Q. Caput vs Cephalohematoma

Q. National Immunization Schedule – each vaccine know why, when, how it is given

Q. ADVICE GIVEN TO MOM AT DISCHARGE

NEW BORN CASE PRESENTATION

Dr Thanigainathan 27/08/20

NEW-BORN HISTORY

Name – blab la (baby of so and so)

Age – Say in hours it <72hrs, >72hrs say in days

Sex

Religion

Order of Birth

Consanguineous [Q. what are the types of consanguineous]

Devashree Moktan
9th Semester Paediatrics Posting Notes

Place of residence

Complaints? Or is this a routine check-up?

Example – Yellowish discoloration
Complaint of Jaundice – Day of onset, Colour of stool/urine, Blood groups (to rule out
incompatibility)
Try to find cause of J (physio or patho), severity and treatment

Example – not passing stool, mom on antithyroid hormone → HYPOTHYROIDISM

Example – umbilical discharge

Antenatal history

➢ Figure out if it was a HIGH-RISK PREGNANCY

o Mother’s age - >35 yrs. → Chromosomal abnormalities, macrosomia, IUGR
<18 yrs. → IUGR, Prematurity
o Multiparity (was there any previous bad obstetric history)
Previous abortions and baby has facial dysmorphism → implies some predisposition
for chromosomal problems
o Previous neonatal deaths – why? Congenital anomaly, inborn errors of metabolism
➢ Registered/immunized
➢ Interpregnancy interval (normal - >2-3 years)
➢ Prepreg wet (<40 Kgs – high risk)
➢ Height of mom (<145 – high risk)
➢ Wt. gain during preg – Normally about 10 kgs
➢ Number of antenatal visits
➢ Blood group
➢ Number of antenatal USG Scans
o Usually 3 – first done once UTP is +ve→ Confirm preg, intra or extra uterine, # of
fetuses
o 16-20 weeks → anomaly scan → if gross anomaly, MTP is a viable option
above 20 weeks → amniotic fluid increases and it interferes with the USG
<16 weeks → not fully formed yet → anomalies may be missed
very late scan → baby descends into pelvis → some organs obscured
o 3rd scan → 34 weeks → presentation (<34 weeks still changes position, usually fixed
after 34 weeks)
o First trimester scans give more accurate POG and wt. of baby
➢ IFA intake [Q. why is IFA given in preg.]
➢ Fever, rash, LAD – TORCH infections
➢ Drug history – Antipsychotics?
IUGR, Fetal alcohol syndrome, withdrawal syndrom
➢ Alcohol and smoking – ask only if you have strong suspicion
➢ Irradiation – chromosomal malformations

Natal & Post-natal history

➢ Date and time of birth

➢ Single/Multiple Pregnancy
➢ Term/Preterm/post
➢ Place of delivery (if home – who conducted, umbilical cord hygiene)
Devashree Moktan
9th Semester Paediatrics Posting Notes

➢ Mode of delivery
Indication of LSCS/Instrumentation
➢ Presentation
➢ Liquor – clear/ MS
➢ Cried at birth? Resuscitation need?
➢ Birth weight (AGA/SGA) (LBW/VLBW/ELBW)
➢ When did baby first pass urine and meconium?
➢ When did umbilical cord fall?

History of Respiratory Distress

Increased RR (N <60/min) and Increased work of breathing (chest retractions = Resp. Distress

If cyanosis +ve → will probably require O2 support

Q. Causes of respiratory distress in a term new-born – MAS, CDH, congenital pneumonia

MC cause – TTNB (dx of exclusion, clue → elective LSCS)

MAS – h/o meconium stained liquor

Asphyxia – H/o crying at birth – no → rule it out

Congenital Pneumonia – ask about Risk Factors:

mom has high grade fever, UTI (burning micturition), Chorioamnionitis (foul smelling discharge),
PPROM, PROM

Diet History

➢ First feed
➢ Prelacteal feed – what was given
➢ Presently – frequency of feeding (N- every 2-3 hourly, 8-10 times a day)
➢ Assess adequacy of feeding – is the baby always crying, sound sleep after feeding, urine
output 6-8 times a day, passing stools 4-6 times a day, gaining weight
➢ Exclusive breastfeeding
➢ H/O bottle feeds

Immunization History
BCG, OPV 0 dose, HBV 0 dose - witin 24 hours of birth

Family History – Consanguineous (draw predigree)

Inherited disorders, developmental disorders, Cong, heaty disease

NEW-BORN EXAMINATION

Golden Rules to Follow

o Routine examination should be done 1 hour after feeding

o Baby should be with mother
o Hand wash
o Warm hands before touching the baby

GENERAL EXAMINATION
Devashree Moktan
9th Semester Paediatrics Posting Notes

ASSESS NORMAL ABNORMAL

CRY Vigorous consolable Irritable inconsolable (even
while breastfeeding)
Poor cry
ACTIVITY All 4 limbs moving actively Lethargy
TONE All 4 limbs flexed position Hypertonia/Hypotonia
Universal flexion (extension)
COLOR Pink/Acrocyanosis Cyanosis
Mention if baby is comfortable

VITALS

ASSESS NORMAL ABNORMAL

HR 110-160 bpm <100 or >160 bpm
RR 40-60 breaths per min >60/min, distress, grunting,
gasping
Temperature 36.5-37.5 °C 36-36.4 → Cold stress
<36 → Hypothermia
<32 → Severe hypothermia
Capillary refill time <3 sec >3 sec
Blood pressure

Mean BP on day 1 is approx.

equal to GA
Check in Zubrow’s Chart
Flush method (only SBP
determined by raising UL
above the heart for a few
seconds → palms will be pale
→ tie BP cuff and raise P →
palms even paler
Put UL down at level of heart
→ release cuff and look at
palms → just below SBP color
of palms FLUSHED pink)
SBP = P at which palms
become pink
Saturation >95% in all limbs >3% difference between UL
Preductal (DA – closes by 24 And difference between Ul & and LL
hrs) – UL LL <3% OR
Postductal → LL <95% → less saturation
Congenital heart disease
(Pulse Oximeter screening
test)
Peripheral pulses – Radial, Well felt → good circulation
dorsalis pedis

Anemia – pallor → palms, soles, lower palberal conjunctiva

Devashree Moktan
9th Semester Paediatrics Posting Notes

Cyanosis – Central Vs peripheral – causes, sites

Jaundice → sternum, abd., legs, palms and soles

Check in natural light
Press skin → original colour shown → on blanching and releasing, if still yellow → J
Edema → starts in presacral region

ANTHROPOMETRY

Check ponderal index if you suspect IUGR

HC – CC = 3 cm (normal)
>3 cm → IUGR (asymmetrical)

Modified Henton’s growth chart – plot wt., ht, HC

10-90% = N
Lenghth checked by infantometer (n = 50cm)

If baby is within 96hours of life check GESTATIONAL AGE

By LMP method
Modified new ballard score – not necessary to do in exam (time consuming)
BUT check –

o ear cartilage (press and release – check recoil → fast recoil = term)
o Breast bud → 3-5 mm = term, less in preterm
o Square window sign – flex the wrist of baby – palm touches forearm = term (good mobility
established) [Preterm wont touch since ligaments not well developed]
o Sole creases – well established, preterm → only in forefoot
o Genitalia – descended testes, dark pigmented, pendulous scrotum
Females – check labia

HEAD TO FOOT EXAM

1. Skin
o Rashes – milia, erythema toxicum
o Mongolian spots
o Café au lait
2. Head
Shape:
o Brachycephaly BPD> APD (down’s)
o Dolichocephaly → AP > BPD (preterm)
o Plagiocephaly → part of skull flat – preterms that lie on one side all day

Size:

o Microcephaly
o Macro

Sutures – N, widely separated or prematurely closed (= Craniostenosis)

Measure fontanelle size – depressed or fleshed to skull

Prerequisites to measure fontalle – ERECT posture, NOT crying

HAIR – distribution, amount, hair line in neck and forehead

Devashree Moktan
9th Semester Paediatrics Posting Notes

Choanal atresia – checked at time of birth by passing NGT

Low set ears – imaginary like b/w lateral canthus → 1/3rd of ear above line = N
REFER TO NEONATE PDF and Ballard score pdf FOR THIS CLASS

NEW BORN PRESENTATION

Dr Nivedita Mondal 28/08/20

WARM CHAIN

o Delivery room temp 25-28 °C and no drafts → prevents loss by convection

o Dry the baby – prevents evaporation (max loss of heat)
o Put baby on mom’s chest – prevents loss by conduction
o No need to wipe vernix – acts as insulation
o Postpone bathing for 1st 24 hrs.
o Keep baby covered, exclusive breast feeding KMC
in cold areas wipe with piece of wet cloth

CASE PRESENTATION by Dr Vishnu Mohan

Case – Female baby, 34 weeks POG, EmLSCS, birth weight 2.1g, 9 days old

Post-natal age is report as Postmenstrual age → till 40 weeks

Age correction done till 2 years of age (called as corrected age)
Because at 3 months of age → not attained head control → no problem since corrected age is only
1.5 months
Thus for developmental reasons, growth and anthropometry
BUT for immunization use → post-natal age

Baby’s wt. b/w 10-90th centile for that gestational age and gender → AGA
For preterm growth → FENTON CHART 2013 (used in JIPMER), INTERGROWTH21
WHO Growth charts start at term so can’t be used for preterm
In this case → AGA baby

HOPI → yellowish discoloration noted at day 4 of life

Questions to Ask

➢ Site
➢ Mother’s blood group
➢ Signs of BIND (bilirubin induced neuronal damage)
➢ High coloured urine, pale stools
➢

KRAMER’s RULE → neonatal J progresses in a cephalocaudal manner

BUT make sure you are assessing in NATURAL LIGHT and Phototherapy has not been given
Visual
Thus amt. of bilirubin (roughly estimated):

o Head → 5
o Chest →10
o Abd → 12
o Legs → 15
o Palms and soles → 20
Devashree Moktan
9th Semester Paediatrics Posting Notes

Signs of BIND in neonate – lethargy, poor feeding, floppy, shrill high-pitched cry
Then later 2nd stage → hypertonic, seizures, fever
3rd stage → status epilepticus, coma, death

Antenatal history – HBsAg + at end of 5th month

33 weeks (3rd trimester → leaking PV, foul smelling discharge

NATAL → Cephalic presentation, delivered on 20/08/20 at 4:45 am by SVD/LMLE

No PPH, did not cry at birth
Initial steps and 1 cycle of PPV given
Breast fed only during D2 of life → No Prelacteal feeds were given
IV antibiotics started IV for PPROM with foul liquor
Birth weight 2.1 kgs

POSTNATAL → Passed meconium and urine after initiation of feeds on day 1 of life
Was given OPV and 2 more injections as per schedule
Developed yellowish discoloration on day 4

FEEDING HISTORY
Q. How to assess adequacy of feeding – wt. gain, urine output, sleeps for 2 hrs, stool
Wt. gain expected → term babies lose 7-10% up till day 5, regain birth weight by day 7 (20-30g wt
gain per day – avg. 25)
Preterm babies → regains birth weight by DAY 14 (gains 10-15g/kg/day thereafter)

Urine output takes 36-48 hrs to establish

Before 48 hrs – 3-4 times a day
after 48 hrs → 6-8 times, straw coloured

Meconium passed for first 36-48 hrs, Golden yellow milk stool from day 3
If still passing greenish or blackish stools beyond day 3 → inadequate feed

Summary – Preterm baby at 34 weeks of gestation, adequate for gestational age, with birth weight
2.1kgs with jaundice from day 4 of life with h/o mother becoming HbsAg +ve during the course of the
pregnancy

EXAMINATION DISCUSSION
Q. Prechtl Neurobehavioral states
Is baby alert, crying, sleeping → you just give descriptive presentation

Temperature

Heartrate → may fall to 80 during sleep

Zubrow’s chart → BP

RR – 40-60 breaths per min

Spo2 → >95% (right UL = preductal, any LL → post ductal)

While presenting anthropometry → give

New Ballard Score – ideally done in 1st 96hrs 4 days

Study in PGI → up till 7 days okay
Watch Jeanne Ballard describing score – watch on YouTube
Devashree Moktan
9th Semester Paediatrics Posting Notes

Closure of anterior fontanelle – 9-18 months

Wide open ant. Font. At birth → Hydrocephalus, trisomies, hypothyroidism, achondroplasia

Eye examination → look for RED REFLEX (direct ophthalmoscope light from a distance of 1mm to
rule out congenital cataract), microphthalmia, megalocornea, conjunctivitis
Causes of congenital cataract
Rubella Triad

Sutures – rule out craniosynostosis

Wide open → same cause as wide ant. Font.

Soft, boggy swelling over occiput at birth → caput (edema)

Soft swelling over parietal at day 4 → cephalohematoma
Differentiate the 2
Complications of cephalohematoma – hyperbilirubinemia, underlying skull fracture

Spina bifida prevented by Folate Supplementation

0.5 mg perinatally (2months before conception, 1 month after)
But if previous child has NTD → 4mg dose

DDH – Barlow’s, Ortolani Test

Confirm with USG

Ext genitalia → testes descent

True undescended → scrotal rugae not well formed (basically some kids may have retractile testis so
don’t jump to conclusions and check out the rugae as well)
Stretched penile length >2.5 cm in term (<2.5 → micro penis)
Preterm female → labia minora is larger than majora
Clitoromegaly
Look at anal opening

Neuro → active, crying, interaction with mother

DIAGNOSIS OF CASE PRESENTED – Preterm/ adequate for gestational age/ female baby with risk of
sepsis and with neonatal jaundice on day 4 of life with no evidence of bilirubin induced neurological
dysfunction

NEW BALLARD SCORE

Best measure of gestational age → 1st trimester USG using CRL

Gestational age by history →

LMP (may not be accurate)

Gestational age assessment in

real practice is done by new
Ballard score only when 1st
trimester scan is not available
and the manoeuvres done in the
Ballard score helps to assess
tone, etc
Devashree Moktan
9th Semester Paediatrics Posting Notes

AAP CHARTS FOR NEONATAL JAUNDICE

Physiological vs Pathological Jaundice

Also, pathological

o Any conjugated hyperbilirubinemia

o High rate of elevation of bilirubin ≥0.5mg per hour
o Jaundice requiring Rx

Mechanism of Physiological Jaundice

Causes of Pathological Jaundice

1. Day 1 → Rh incompatibility
2. Day2-3 →Cephalohematoma, any other bruises in body, sepsis
3. Day 4,5 → sepsis, Intrauterine infection, congenital hypothyroidism,
galactosemia, tyrosemia
4. Beyond 2 weeks → Obs J

Advise to mother of baby that received phototherapy

o Continue breast feeding and increase frequency

o Babies should be fully exposed except cover eyes (prevent retinal damage) and gonads
o Change position every 4 hrs (supine and prone)
o Side effects that may occur – take child up only for, diarrhea, phototherapy rash,
temperature instability, dehydration

Normogram for phototherapy and exchange transfusion

3 risk zones

High risk babies for BIND → preterm, incompatibility, acidosis, apnoea, sepsis, low albumin, temp
instability, G6PD deficiency
Basically has a
more
permeable BBB
→ so may
develop bind at
a lower bilirubin
level → Rx
measures taken
earlier
Devashree Moktan
9th Semester Paediatrics Posting Notes

Approach to neonate born to Hep B infected mother

Active and passive immunization

Hep B vaccine on day 1 of life (70-90% protective)

Given to ALL children in India as per immunization schedule

Hep B immunoglobulin (another 10-15% protection) – on left thigh – expensive

No problem if parents can afford

No contraindication to breast feeding

Between 9-18 months check → HBsAG levels and anti S antibody levels
HBsAG levels elevated → infected and immunization failed → Rx
anti S Ab elevated → immunization worked

Risk factors for early and late onset sepsis

Only if baby has jaundice (beyond day 14) + features on hypothyroidism present → check specifically
for hypothyroidism

Universal thyroid screening → ALL neonates should ideally be checked at birth for hypothyroidism
(done in resource rich places)
Heel prick → dry blood spot on filter paper

NEW BORN CASE PRESENTATION

Dr Adisivum 29/08/20

History

Male, 40 weeks POG

Birth weight 3.8 g
Elective CS (indication → expected birth weight was 4kgs, mother did not go into labour at 40 weeks)
Expected LGA and obstructed labour
Current Postnatal age – 90 hours (4th day) = 40+4 weeks
Baby is admitted in NICU → Jaundice since day 2 of life
Stool colour was yellow with slight yellowish yellow colour
Devashree Moktan
9th Semester Paediatrics Posting Notes

Avg. birth weight of Indian baby – 3kgs

Q. complications associated with post term – MAS, Oligohydramnios, Asphyxia

Day 2 → Physiological
But this baby is in NICU

Rh Incompatibility → would have presented in day 1

Concern → more haemolysis → more unconjugated bilirubin → more brain damage
Especially problematic if preterm

Q. Why is stool colour important

Rule out obstructive J → Pale

Enough to say usual antenatal check-up done and results were normal
Just say in mother’s words
Be explicit if results shown
mention about covid like symptoms in antenatal period

Q. What should be done if baby cries immediately

ROUTINE CARE – wipe, prevent hypothermia, no suctioning, skin-to-skin with mother and initiate
feeding
Most heat is lost via evaporation (so wipe the amniotic fluid in ALL babies, start at scalp)

Q. Rooming-in → Same bed → skin-to-skin

Promotes feeding, regulates temperature, monitors baby, decreases chances of cot death
Don’t encourage cradles

Q. BRUE – Brief Resolved Unexplained Event → an event in an infant characterized by a marked

change in breathing, tone, colour or level or responsiveness followed by a complete return to
baseline state and cannot be explained by a medical cause.

Q. Day 3 lethargy
DD – sepsis, hypoglycaemia, etc

Q. Disadvantages of bottle-feeding

Q. National Immunization Schedule

Birth – BCG, Hep B, OPV
6,10,14 weeks – OPV, Pentavalent
IPV – fractional IPV → Intradermal at 6,14 weeks (why did it change from IM to ID → more kids
vaccinated with same dose)
9 months → MR1, Vit A (1 lack IU)
Every 6 months till 5 years of age → 2 lakh IU

Vit A → decreases morbidity with RTI and diarrhea, Prevents blindness (basically helps with
epithelial integrity and regeneration → good immunity)
Q. other conditions where vit a is given → Measles, Malnutrition, Pneumonia, Persistent Diarrhea
Q. Acute watery D supplement → ZINC
Q. Malnutrition → all micronutrients
Q. Retrovirus D → Vit A
Q. Persistent D → Zn + Vit A
Devashree Moktan
9th Semester Paediatrics Posting Notes

Q. Breastfeeding → when to start, problems of Prelacteal feeds

Q. Gross sweating during feeding → Cardiac disease (CCF)
Q. How to assess adequacy of breastfeeding → OBJECTIVELY checked by weight gain, frequency of
urination
Best Rx of “less milk” → COUNSELING the mothers, show growth charts
Emphasize that → More breast sucking, more breast emptying, more production
More the baby is put to the breast → more chances of good feeding
Check position and attachment
All hospital workers, family, society should be supportive of breastfeeding
Tell mother about importance of feeding
Not enough milk is MYTH, not a fact
If really problem, maybe try →Lactagogues – domperidone, metoclopramide (supplements to
counselling)

AAP Charts for checking bilirubin

Physiological and breastmilk J never reach levels needing photoRx and transfusion

Q. photoRx → precautions, indications, wavelengths

Q. EBM → Expressed breast milk – babies with poor sucking

Manually or with breast pump using aseptic precaution
Give baby by orogastric tube, paladai, cup

Do not forget to talk about thyroid in a jaundice case

Consider hypothyroidism if J continues past 14 days

Present relevant POSITIVE FINDING

Up to 72 hours → Mention age in hours
But for management
If baby is doing well and not very severe and you know blood groups and stool colour yellow, MC
cause → Physiological

Examination

2 modes of Radiant Warmer

Manual – set the temp yourself and that temp is given off by warmer
Servo mode - Skin probe on baby and machine varies temp accordingly – prevents hypothermia and
dehydration
But if skin probe moved or not placed well → may not give good
This requires vigilant nursing care (so better mode)

Q. Normal temperature
Q. Cold stress
Q. Pink Colour → Good Perfusion
Too pink → Polycythaemia

Q. Both femoral pulses palpable → Coarctation of aorta ruled out

Don’t generally palpate the carotids, if you HAVE TO then one at a time
Better to just check CFT and peripheral pulses
Check CFT in the central areas → Over sternum (cold per
Devashree Moktan
9th Semester Paediatrics Posting Notes

Q. NIBP → Non invasive blood pressure

Principle of NIBP → Oscillometry

Q. Gadgets in Neonate care, implications, principles of devices – ventilator, O2 hood, CPAP,

Nebulizer, Phototherapy, NIBP, SpO2

Baby on ventilator and desaturating → Check if probe placed well

DOPE checklist → Displacement of ETT, Obstruction of ETT, Pneumothorax, Equipment failure

Q. RR of New Born – 40-60

<40 – brady
>60 – Tachy

Q. If baby gaps or becomes apnoeic → Bag and Mask Ventilation

Carry WHO Charts and New Ballard Score Charts

Plot and interpret

Q. Birth weight, Doubles?

Equation for weight
How does HC increase over first year
Examples and definitions of microcephaly, macrocephaly

Q. Infantometer – sliding part at feet

Stadiometer – sliding part at head

Q. What to look in the head in a baby with J → Cephalohematoma, Posterior fontanelle (closed in
term baby, open in preterm BUT if open in term baby think HYPOTHYROIDISM)

Fenton chart for preterm babies

Always start general exam with CRY, COLOUR, ACTIVITY

Once phototherapy is started → skin colour bleached

Don’t use kramer’s rule
Biochemical test to measure bilirubin

Baby not moving one hand → Check for edema due to IV line first

Umbilicus – What to check?

Hernia – Hypotonia (down’s→ look at face, hypothyroid → look for other features, TFH)
Periumbilical erythema, later cellulitis → Umbilical Sepsis (if untreated may lead to EHPVO)
Umbilical Stump – chronological age (absent stump >7 days)
Stump separated by 7-10 days
Q. Causes of early and delayed stump separation

Oral Cavity – Check for Oral Thrush → comes from female genital tract
Won’t be there in LSCS
If sick + oral thrush → suspect immunodeficient

Uncontrollable, inconsolable cry → LOOK FOR A CAUSE

Meningitis, OM, Pneumonia, Really hungry

Stereotype movement – some illness (suspect seizure)

Non-stereotyped movements – Normal
Devashree Moktan
9th Semester Paediatrics Posting Notes

If baby is breastfeeding well → most CN normal

Q. Rooting reflex – stroke to corner of the upper lip, child’s head will turn
Sucking reflex → no need to check if feeding well
Palmar grasp

Q. Modified Ballard Score – Max Score, Components, when to administer

Scarf sign
Hypotonic or preterm → elbow crosses midline

Square window – flexion of hand over forearm

Term babies – makes square window → good flexor tone
Preterm – can’t make square

Pulling test – 180 degrees flip → normally some flexion but rag doll implies hypotonia

WASH HANDS ALWAYS

MORO’s REFLEX – do it at the end of the exam

Baby held in the hands, let head fall by 40 degrees
Suddenly drop the elevation (bring hands and baby down)
Normal Sequence→ Abduction and Extension → Opening of hands → Adduction and Flexion → Cry

ATNR → Asymmetric Tonic Neck Reflex (fencing posture) → importance – baby can’t roll over

UGs required to do these reflexes → Sucking, rooting, Moro’s, palmar grasp

Ballard Scoring can be done, No need for Fenton’s Chart

CVS CASE DISCUSSION

Dr Tamilselvan 31/08/20

Case – 4 years old, Male, one week ago developed fever (low grade, intermittent, relived by
medication), Breathless on exertion (NYHA grade 2) relived on rest for past 5 days, H/o swelling and
pain in both legs, extending up to ankles for past 5 days and severe restriction of movement
(bedridden)

Q. RHD – criteria, does this child fulfil it

This history has – 2 major criteria (so diagnostic)
1 minor also present

Q. Clinical features of carditis

Q. Breathlessness of respiratory cause vs cardiac cause

Can you get orthopnoea in respiratory cause? Yes

Bedridden due to ankle pain → Arthritis

What other present history will you ask? – as per cardiac complications expected

o Infective endocarditis → fever, pain in the fingertips, septic emboli symptoms

o A fib or any arrhythmia → palpitations, syncope
o Pulmonary hypertension → fatigue
o Growth retardation → more of a chronic problem

Dramatic response with aspirin if RHD but not with PCM

If no dramatic reflux with aspirin → could be immunological vasculitis
Devashree Moktan
9th Semester Paediatrics Posting Notes

Social history → check for SES, overcrowding, ventilation at home

RHD Examination Salient points:

o Resting Tachycardia
o Rate out of proportion to temperature (10 bpm for each degree rise in temp)
o Regurgitant lesion – collapsing pulse,
o Stenotic lesion – low volume
o Palpable peripheral pulses – variable if there are emboli
o Subcutaneous nodules → look for from occiput to foot (don’t forget the back)
o Erythema marginatum → usually in abdomen and trunk

Q. Causes of LVH

Q. What does parasternal heave indicate

Diagnosis – RHD

CVS CASE PRESENTATION

Dr Narayan 01/09/20

Presented by Dr Naimisha
13 years old male child, informant mother
Chief Complaints – Fever x 1 weeks, Swelling around feet b/l x 1 week, b/l knee joint pain x 1 week,
breathlessness x 2 days
Q. Break down the Chief Complaints
Fever – infection
Knee Pain – Arthalgia, arthritis
Swelling of feet – edema or ankle arthritis
Breathlessness – cardiac or RS involvement

DD from Chief complaints – ARF, CCF, viral infections, IE

Q. difference between arthritis and arthalgia

This case – arthalgia

Also consider an underlying congenital heart disease in an older child

Q. Symptoms pertaining to – CVS, Congenital Heart Disease

Q. What to ask for IE?

Child has past history suggestive of RHD

MR is the most common lesion in paediatric RHD

Tip: Dr Narayan wants you to know why you are asking for each and everything
Have explanations + examples ready

Parasternal heave – RVH

Other causes – aortic aneurysm, left atrium enlargement

CVS CASE PRESENTATION

Dr Dilli Kumar 02/09/20
Devashree Moktan
9th Semester Paediatrics Posting Notes

Q. History of L→R shunt

Recurrent Infections, FTT, Brow sweats, Suck-rest-suck cycles

Q. Cyanotic Heart Disease → Cyanotic Spells, Squatting episodes

Q. Acquired Heart Disease history

Sore throat
Fever with rash
Features of RHD

Q. History of Complications
FTT, Pulm HTN
CCF –
infants – ftt, excessive precordial activity, suck rest suck cycle, etc
Older kids – exertional dyspnea
IE – fever, fatigue, pain in fingertips, rashes, abdominal pain, haematuria, arthritis, palmar rash

Presented by Dr Vivek
Case: 9 years old Female
Fever x 7 days
Pain and swelling of B/L knee joints x 4 days
Breathlessness x 3 days
Incidental murmur detected in health camp at school, echo done, started on meds, defaulted due to
covid pandemic

Q. NYHA Grading of Breathlessness

Q. Importance of facial dysmorphism in CVS cases
Q. Other dysmorphic features to look for – polydactyly, syndactyly, radial abnormalities, toe
anomalies, down’s, turner’s, oltorum, robinson, Marfan’s make a flashcard for this

Q. JVP examination
Carotid vs JVP → POLICE (palpation, occlusion, location, inspiration, character, erect)
JVP – not palpable, readily occludable, between heads of SCM & lateral to carotids, drops with
inspiration, biphasic waveform contour, erect posture decreases

Q. Different types of apex beat

Paediatric Pressure Overload conditions → HOCM, Coarctation of aorta

Freeman and Levine Grading of Murmur (based on intensity)

Q. What is thrill

Pulm HTN – palpable P2, Loud P2 + Symptoms of PHTN

Q. Peripheral signs of AR

Polyarthritis → more than 1 joint

JAA → more than 4 joints = poly

Q. Ix and Rx

Child in severe cardiogenic shock – DOC Dobutamine injection

If stable – oral Digoxin (inotrope)
Devashree Moktan
9th Semester Paediatrics Posting Notes

Rx of Heart Failure →
Keep in 45° degree and give oxygen
Lasix + Digoxin + KCl (given because Lasix is potassium wasting, don’t give it enalapril is being given
since it is K+ retaining)
For RHD – Benzithine Penicillin (not given in JIPMER since it is a painful injection but it is given once
in 21 days)
Oral Penicillin V (K-Pen used in JIPMER, but it has to be taken daily)
Anti-inflammatory therapy – Aspirin/steroid (JIPMER – oral prednisolone 4-6 weeks , start tapering
and add aspirin for next 6 weeks → total duration 12 weeks)

ABDOMINAL CASE DISCUSSION

Dr Gunasekaran 03/09/20
Presented by Dr Selvamanoj

CASE – Diarrhoea
7 months old, Male
Fever x 1 day (moderate grade, 24 hours, then no fever for next 24 hours)
Loose stools for past 2 days (7-8 episodes per day, watery in consistency, yellow in colour, about ¼ to
½ glass amount each time, not associated with blood or mucus
Urine output decreased since today

Q. Classification of Dehydration (WHO)

Q. Mx of dehydrated child, Rehydration Rx, ORS, Modified ORS

HISTORY

Negative history

1. Abdominal distension – hypokalaemia (ileus and bloating results)

2. Inconsolable cry – meningitis
<6 months old → infections easily get generalized and become sepsis
So ask questions pertaining to infections in other systems
3. Cry during micturition – UTI
4. Vomiting
5. Eagerly accepting feeds or not?

First symptom in Dehydration → THIRST (more than normal eagerness to drink fluids)

Other family members also having the same illness → water or food source contamination
Past history of similar diarrhoea → mother may not be following hygienic symptoms so recurrent
infections

Feeding practice that may predispose to diarrhoea → Bottle Feeding

Summary of history should answer the following:

1. System involved = GIT

2. Possible Dx = Diarrhoea (AWD – acute watery diarrhea)
Q. Types of Diarrhoea
Devashree Moktan
9th Semester Paediatrics Posting Notes

3. Possible severity of illness

Very sick – ICU admission, Normal – reassure and send home, Moderate – accepts oral
feeds, treat and observe
4. Evidence for any complications – Hypokalaemia, Septicaemia
5. Clue for aetiology of the illness

General Examination

1. Skin pinch – use thumb, index, middle

Pinch, twist and leave the abdomen skin
Goes back VERY slowly → Dehydration
reason – skin turgor is maintained by water
other factor determining turgor = fat (so obese kids and malnourished kids skewed results)
2. Oral mucosa and tongue Dryness
3. Sunken Eyes
4. Anterior fontanelle – if depressed → DEHYDRATION
Bulging → Hydrocephalus, Meningitis
Normally pulsations felt in the anterior fontanelle but in meningitis pulsations will be lost
Beyond 1 ½ years anterior fontanelle is not to be checked
AF usually closes between 9 months to 18 months completion in 97% of Normal Kids
Delayed closure of AF → Rickets, Hypothyroidism

Summary of general exam:

o Level of Dehydration
o Grade of dehydration
o Any other important clue → malnourishment, anaemia, any other disease
Be cautious while giving fluid therapy in a severely anaemic child

Case presented has SOME dehydration on examination

Devashree Moktan
9th Semester Paediatrics Posting Notes

Vitals:

1. Tachycardia (1st sign)

Q. Avg. pulse rates – neonate, infant, 1-5 years, 5-10 years
2. Hypotension (comes at later stages – child has gone into hypovolaemic shock)
Q. 2 stages of shock – Compensated and decompensated
Compensation – tachycardia, vasoconstriction in peripheries to shift blood to the vital
organs → BP maintained
Q. Avg. BP in neonate – 60, 1 month – 70mmHg, 6 months – 80 mmHg
After 12 months → Formula – 90 + (2xAge in years)
3. CFT > 3
Palms, soles or over sternum (delayed centrally in severe shock)
4. Pulse pressure should be 1/3rd of systolic
5. RR
Q. cut-offs of tachypnoea
Q. Child with D has increased RR – Metabolic Acidosis, respiratory infection
Metabolic acidosis – due to lactate levels from anaerobic metabolism in the peripheries in
shock or due to bicarbonate losses in D

What to interpret from the vitals? – Evidence of dehydration, shock

Anthropometry
Preferred to use Z scores to interpret – use WHO charts till 5 years of age
Importance of anthropometry in AWD – Malnutrition → affects Mx (supplement nutrients and these
kids can go into failure while giving fluids so be careful)

Systems Exam – Check for evidence of complications

Abdominal Exam → Check for distension, auscultate for bowel sounds – maybe increased but if less
or not heard then it could be paralytic ileus due to hypokalaemia
Q. Abdominal Exam

Diagnosis – AWD with some dehydration

No undernutrition/stunting/wasting
Devashree Moktan
9th Semester Paediatrics Posting Notes

Definition of Diarrhoea – increase in frequency and loose consistency (change in consistency is more
important)
Generally >3 times a day → consider as D in older kids
Young kids may pass stools 2-3 times a day → gastrocolic reflex
So in young kids just an increased frequency

Diarrhoea = to flow through (Greek)

Excessive loss of fluid and electrolyte in stool

For infants, Stool Output > 10ml/kg/24 hrs.

For older children, Stool Output >200g/24 hours

When there is increase in frequency, volume or liquidity (recent change in consistency) of bowel
movement relative to the usual

Types:

1. AWD
<2 weeks, infectious origin
2. Persistent
Diarrhoea which start as acute mostly infectious aetiology
lasting for >2 weeks
3. Chronic Diarrhoea >2 weeks duration, non-infectious aetiology
4. Dysentery – stools with blood and/or mucus, bloody diarrhea

Investigations

➢ Do you need any Ix to confirm your Dx? No

➢ Ix to confirm etio? No (mostly viral)
But you should prove in case of suspected cholera → public health importance (find source,
other cases)
Q. Features of Cholera → Rice water stools, other family members affected, no fever (since it
causes disease by exotoxin that causes pumping out of fluid and bicarbonates but there is no
physical damage → Secretory diarrhoea), Frequent passage of stools, Typical stinky stools,
Severe dehydration
Q. Cholera Ix
Transport mediate → Alkaline Peptone Water
Darting movements in hanging drop (comma shaped, has 1 flagella)
pH of stool >7-8 (high bicarbonate loss)
Stool cultures are not usually done because commensals
Stool cultures are asked for Shigella if trial of antibiotics fails
➢ Ix to rule out complications:
Blood culture in infants that look toxic → for septicaemia
Serum electrolytes → for electrolyte imbalances or suspected AKI
Decreased Urine output → AKI → ask for Serum Creatinine and urea levels
Devashree Moktan
9th Semester Paediatrics Posting Notes

Causes of D → Viral >> Bacterial> Protozoal > Fungal

Virus – Rotavirus, Calicivirus, Astrovirus, Norwalk
Bacterial – E. coli, Shigella, Cholera, Salmonella, Yersinia, Campylobacter
Shigella, E. coli, Campylobacter → also cause
Protozoa – Entamoeba, giardia
Fungal – Candidiasis

How will you write the prescription if this case?

At the hospital → 1,4,5
No need for number 6,7,8,9,10
At the end of 4 hours if child still has dehydration → repeat
the same dose for another 4 hours
If child is worsening to severe dehydration → then repeat
with 100ml/kg dose

If child is vomiting also → Give antiemetic if repeated

Ondansetron 1.5 ??
1-2 episodes – not needed

This child has some dehydration → ORS 75ml/kg over 4 hours → observe → reassess
Keep child and observe over the 4 hours → let child be breastfed
During those 4 hours if child passes loose stools → add 10ml/kg for each time loose stools passed

HAF = Home available fluids (rice water, coconut milk, butter milk)
DBF = Direct Breast Feeding

Severe Dehydration Mx
IVF → 100ml/kg
Young kids → 30 ml over an hour, 70 ml over 5 hours
Older kids (½ the time) 30 ml → ½ hours, 70 → 2.5 hrs
If IV line no possible → ORS via nasogastric tube 20ml/kg/hour

Indications for antibiotics

o Dysentery
o Cholera
o Fever + Toxic appearance

How do you know it is viral infection?

History – Fever is short duration and goes down but AWD persists, associated URTI or Skin rash
Bacterial infections – both fever and AWD persists

MC antibiotic prescribed for dysentery and bacterial diarrhoea → Cefixime (10mg/kg/day in 2

divided doses x 7 days)
Injection cefotaxime 100mg/kg/day in 2 divided doses for 1-2 days if child is toxic
Once child gets better give cefixime

Antibiotic for cholera – helps in reducing the number of organisms in stools

Antibiotics does not improve the child’s condition
Devashree Moktan
9th Semester Paediatrics Posting Notes

Older children → Doxycycline

Young children → 30mg/kg/day x 3days erythromycin

2 preparations of erythromycin and major ADR

Stearate → gastritis
Esterate → hepatitis

Ciprofloxacin is not for kids <7 years → Endochondral bone

growth affected

Antimotility drugs → CONTRAINDICATED

probiotics, prebiotic → not needed

Antisecretory drugs –Raise???

ORS
Principle of ORS – SGLT 1
Low osmolarity ORS used → 245 mEq

Advantage of the modified

ORS

Zinc is given for 10 days, ORS

given for 2 days so first 2 days
no need for extra zinc tablet
Rice Based → more palatable
(50g of rice powder), but shelf
life of rice powder is less and it
is difficult for the mother to
make powder

Amylase resistant Starch

based ORS (50g of amylase
resistant starch → not
digested in small
Beta hydroxybutyrate etc produced
→ so h20 and electrolytes
absorbed in small intestine
Devashree Moktan
9th Semester Paediatrics Posting Notes

ReSoMal → Rehydration Solution for Malnourished

JIPMER just modifies regular ORS → 1 L packet dissolved in 2L
of water and 50g of glucose and 40 mEq of potassium added
Dose → 5 ml/kg/every 30 mins for 1st 2 hours
And then every alternative hour 5ml/kg
Because in SAM kids → high risk of hypoglycaemia and
hypokalaemia

Why is Zinc given to all Indian children?

<6 months of age 10mg OD
>6 months 20 mg OD
14 days duration irrespective of resolution of loose stools
Needed for normal immune function
So, giving zinc reduces severity and duration
Zinc deficiency → risk of persistence

Acute Dysentery
Oral antibiotics like cefixime 10mg/kg in 2 divided doses x 5 days
Continue feeding along with ORS
Zinc supplements x 14 days

Lactose intolerance – villi damage in inflation due to viral inflammation→ lactase lost at the tip of
villi → so lactose metabolized by gut bacteria → bloating, lactic acid production
Lactic acid in stools causes perianal excoriation (Dx feature on examination, confirm by testing for
lactose in the stools)
Just cut down on milk for a few days if older than 6 months
Devashree Moktan
9th Semester Paediatrics Posting Notes

NEPHROTIC SYNDROME AND PSGN

Dr Sriram 04/09/20
Presented by Dr Sainadh

Case 1 – 6 years old, boy

Facial puffiness x 4 days
Dark Brown Colour of urine (cola coloured) x 2 days
Decreased urine output since yesterday morning

Q. Definition of hypertension in children

SBP and/or DBP > 95th Centile for age, gender and height
90-95th centile → Elevated BP

Q. Tachypnoea in different age groups

Points of diagnostic importance

o Facial puffiness
o Hypertension
o Cola coloured urine
o Scars over both lower limb

Nephrotic syndrome should have serum albumin <2g/dL

This patient has mild acute kidney injury

C3 low → alternate path

Q. Calculation of estimated GFR – Modified Schwartz (0.413x length in cm) divided Serum Creatinine
6 years old – GFR approx. 90

THIS CASE IS ACUTE NEPHRITIC SYNCROME

Macro or micro haematuria
Some proteinuria
Edema, HTN, oliguria

In India mc cause of nephritic syndrome → PSGN

Triggered by pyoderma – Strep pyogenes (which serotypes??)
Pharyngitis leading to PSGN more in the west (serotypes?)

Other causes of non-infectious – Lupus, ANCA vasculitis, HSP, MPGN

Lupus and MPGN → low C3

Sometimes very severe HTN – seizures (HTN Emergency → ICU – start sodium nitroprusside or
labetalol, only after stabilizing – start CCB)
Becomes normal in 8 weeks

Proteinuria persists only for 2 months

PSGN has excellent prognosis

Devashree Moktan
9th Semester Paediatrics Posting Notes

Q But if creatinine become > 5 mg/dL → RPGN

HPE shows crescents in RPGN
RPGN Rx → IV methyl prednisolone pulses and then monthly cyclophosphamide pulses for 6 months

CASE 2 – 7 years old developmentally normal boy

Facial edema and abdominal distension x 1 week

Provisional Dx

Nephrotic syndrome triad

Cholesterol >200mg/dL
Gross Edema – genital edema, massive ascites
Serum albumin <2.5 g/dL
Proteinuria 3+/4+

Nephrotic age group → 2-6 years MPGN, peak at 4 years (young children)
Nephritic Syndrome – School going age

Q How to treat first episode of nephrotic syndrome

2mg/kg daily prednisolone for 6 weeks (say 4 weeks though since the guideline has not changed)
Then next 6 weeks 1.5mg/kg daily

Relapse takes 5-12 weeks

in a case of relapse 2mg/kg/day daily till relapse achieved

Q Infections more common in nephrotic syndrome – Pneumonia, SBP by pneumococcus, cellulitis

Opsonins lost in urine so infections by pneumococcus common
So vaccinate once they are of
Varicella → GIVE ACYCLOVIR (not usually given for kids, give in

Thrombotic episodes – loss of protein c s and antithrombin 3

Cerebral vein thrombosis – headache
Renal vein - haematuria
Deep VT – limb swelling

Electrolytes abN due to diuretics

HTN, Hyperglycaemia is due to steroids

PSGN vs Nephrotic

o HTN
o Haematuria
o Hypercholesterolemia
o Hypalbuminaemia
o Proteinuria
o C3 levels
o Thrombotic complications
o Relapses
o Age
Devashree Moktan
9th Semester Paediatrics Posting Notes

Steroid resistant –
FSGS on biopsy
Treat with tacrolimus, cyclosporine

Also look for Cushingoid features

Proximal myopathy due to steroids so won’t be able to get up from squatting position

FEVER WITH RASH AND HEPATOSPLENOMEGALY

Dr Reena Gulati 05/09/20

CASE: 3 years old Female

Fever x 6 days
Vomiting x 2 days
Abdominal pain x 2 days
Red pin point rash over arms and legs
Fever – moderate grade, initially continuous, presently intermittent
Lasted 3 days then relived for 2 days
Generalized abdominal pain x 2 days, intermittent and not associated with food intake
Vomiting x 2 days → 3-4 times a day, no blood/bile, not projectile
Red spots all over limbs
Mild headache x 5 days

Negative histories: NO HISTORY OF

o Cough, cold, respiratory distress

o Reduced urine output, pus or blood in urine, pain during micturition
o loose stools/constipation/abdominal distension
o Edema or periorbital puffiness
o Jaundice, bleeding from any other site
o Altered sensorium

Course in the hospital – on day of admission in casualty child had one episode of GTCS lasting for 10
mins, controlled with IV medications. No further seizures
No significant Past history, Antenatal history, LSCS birth (indication?), started on breast feeds within
2 hours, no significant postnatal history
Developmentally normal for age (You can also say “milestones are appropriate for age”)
Nutritional history – has calorie and protein deficit (REMEMBER TO CALCULATE THE NUTRITION
VALUES BEFORE THE CHILD WAS ILL because sick kids usually wont eat well, so ask about diet when
the child was well. In chronic cases it is okay to take nutritional history of the sick period)
Immunized up to day
This is the 3rd child, the 2nd child passed away on 5th day

Do head to toe examination before general examination in kids

Why do we specifically have head to toe examination in children? Head to toe examination rules out
gross, visible findings that may be overlooked during systemic examination
it is does before general exam → “Inspection before palpation”

Causes of pallor – frightened, anaemia, sialocomplexion(??)

Devashree Moktan
9th Semester Paediatrics Posting Notes

Q interpretation of BP and oxygen saturation

Oral cavity – no carious teeth, good oral hygiene, no tonsillar enlargement (don’t just say Normal)

Redness of palms and soles, diffuse

Red pin point rash over arms and legs, non-blanching
Tourniquet test positive

Any red rash → blanching or

non-blanching → tells state of
capillaries, blanching means
intact
Petechiae (non-blanching) vs
Purpura (non-blanching)
Tourniquet test tells if there is a
tendency of the capillaries to
bleed
Tourniquet test tells that there is
fragility but does not tell the
cause

Always mention the gender while mentioning the genitalia, say “normal female genitalia”

Always start with superficial palpation – why? You will notice the tender areas, do deep palpation of
that part last

Sharp border of liver → Cirrhosis

Devashree Moktan
9th Semester Paediatrics Posting Notes

Dx – Dengue

o biphasic fever
o Tourniquet test positive
o Mild HSM
o Cervical lymph node but it’s not very significant
o Palmar and plantar erythema

Differentials – Brucellosis (but rather rare), Leukaemia, Lymphoma, Typhoid, Scrub Typhus, EBV
infection, Gaucher syndrome (type?)

Investigations:

1. CBC – especially platelet count

2. Serology for viral diseases (viral panel –?)
3. Bone marrow, if there are still doubts

RS CASE PRESENTATION
Dr Biswal 07/09/20

Likely to get lower respiratory tract in exam

Common RS cases → Upper resp. tract infections, LRTI, foreign body aspiration, rarely CTD and
chronic lung disease

Presented by Dr Shrutiprajna

12 years old boy

Fever x 7 days
Cough, Coryza x 7 days
Right sided chest pain x 6 days
Respiratory difficulty x 6 days

Most likely to be Lower respiratory disease

Devashree Moktan
9th Semester Paediatrics Posting Notes

Q What are the likely vaccines a child of 12 years has taken

Say national immunization of schedule

Q Vaccines that prevent pneumonia – BCG, MR, Diphtheria, Pertussis, Hib

Breastfeeding is also an important protective factor

DDs –
there is intermittent pain of sharp stabbing character on deep inspiration → could be empyema
thoracis (suspect inflammatory exudate in the pleural space), intercostal tenderness, intercostal
pneumonia (due to herpes zoster – may have pain without the blisters rare), trauma (leading to
staph infection causing empyema)

Q Nutritional history – calorie intake, what is the approx. weight of a 12 years old child
Stress on type of cooking fuel → Wood/ charcoal /biomass fuel more indoor air pollution

Fever + Pleuritis (pain, bulge on ICS, tenderness) → Empyema Thoracis

Child not oriented to time place person + Pneumonia → Which WHO category? SEVERE
Learn categories and treatment

Normal SpO2 range in a child in room air → 94-100%

Healthy + mild cough + low SpO2 → Covid 19 pneumonia

All cases of any RTI features do SpO2

Which condition with pneumonia requires throat examination?

Diphtheria, Pharyngitis, EBV
So always do oral cavity exam when you suspect pneumonia

Epitrochlear node + Throat patch → EBV

RS causes of clubbing

o Chronic suppurative lung disease (bronchiectasis)

o Bronchogenic carcinoma
o Chronic lung abscess (rarely
o Late stage of ILD

Clubbing in this pt. → 3+

Spotter Facies → Adenoid Facies

(open mouth, crowded teeth, looks lethargic)

Why is there nasal flaring?

Increased respiratory effort
1/3rd resistance is imparted by the entrance of the nose → so
body uses dilator alae nasi to increase volume entering

This child has tachypnoea

Devashree Moktan
9th Semester Paediatrics Posting Notes

Infants predominantly breathe abdominally

Young kids – Abdominothoracic
Older kids – Thoracic

Severe subcostal retractions?

Overactive diaphragm contracts vigorously to create
negative pressure in the basal lobes
?? Intercostal muscles and the neck muscles work
Suprasternal recession to pull thorax up to increase
space

What to specifically look for in every intercostal space?

Rupture of necrosed parietal → fluid comes out →
swelling in ICS
(Epyema necessitans)

Q Tracheal deviation causes

Q Elaborate the areas you will percuss and

auscultate?

DD for dull note on percussion

Q Diagnosis of bronchial breath sounds

Normally heard over trachea and right
parasternal area in 2nd ICS (where right
bronchus divides)
Devashree Moktan
9th Semester Paediatrics Posting Notes

CASE SUMMARY:
Devashree Moktan
9th Semester Paediatrics Posting Notes

Normally liver palpable up to 2 cm below costal margin

Beyond 48hrs till death → normal to have <2 cm palpable
>2cm abnormal
here liver span below costal margins due to diaphragm being pushed down by effusion

Provisional Diagnosis –

1. Side – right, left

2. Lobe – upper, lower
Q surface markings of lobes
3. Pathology – lung zone involved (upper, lower, middle)
This care → LRTI secondary
4. Etiology → Bacterial infection
5. Prescence of respiratory failure
6. Prescence of cor pulmonale
7. Complications

Severe pneumonia with right moderate/large pleural effusion due to

1. Synpneumonic effusion
2. Tuberculous effusion
3. Partially treated empyema
4. CTD (less likely)

with respiratory distress. (Also grade the pneumonia)

When to suspect TB – fever for 2 weeks, 5% wt. loss or not gaining weight over 3 months, cough x 2
weeks, Haemoptysis (foul smelling sputum), spontaneous pneumothorax (uncommon in kids)

Most common cause of pneumonia with lobar consolidation

Streptococcus pneumoniae
Others – Haemophilus influenza b, Klebsiella pneumoniae, stahp

With empyema – Think Staph A first the streptococcus, klebsiella, Hib

Hib → bulge in x-ray due to effusion

Community treatment of pneumonia (IMNCI) – for mild-moderate pneumonia

o Paracetamol for pain and fever

o Plenty of fluids to prevent dehydration
o Antibiotics – Amoxicillin 80mg/kg/day BD x 5-7 days
o Good nutrition
o Zinc
o Vitamin A

Severe pneumonia – Hospitalized

o IV fluids
Devashree Moktan
9th Semester Paediatrics Posting Notes

o Benzyl penicillin 2 lakh units per kg per day in 4 divided doses

or Amoxicillin Clavulanate
Duration of antibiotics → 10 days or afebrile for 2-3 days if pneumococcus
Staph A or gram negative → 3-6 weeks (empyema >6 weeks)
o Paracetamol
o Wait for Result of:
5. Bacterial pneumonia – neutrophilia
CBC – Hb, TLC, DLC
ESR
6. For anatomical involvement → CXR Pa view, USG Thorax
7. Isolate organism – Bacteria from blood or pleural fluid aspirate
Takes 5 days to get CS
if improves → continue Rx
If not improving → change antibiotics by 96hours (otherwise rise of compn)
Day 5 → change if needed after

Advice to parents:

1. Child got pneumococcus because not vaccinated

So get vaccinated
2. Child at risk of recurrence → complement deficiency, sickle cell anaemia, splenic
insufficiency
3. Nutritious food
4. exercise
5. Healthy environment, no passive smoking
6. 12+ kids counsel against alcohol and smoking

Complications that have to be monitored for:

You have to explain to patients if child is stable or not and response to Rx

1. Sepsis/ Septic shock – BP, HR, Peripheral pulse, Skin temperature

2. Lung abscess – Hypoxia
3. Metastatic abscesses
4. Local spread
5. Endocarditis
6. Respiratory distress

CNS CASE PRESENTATION

Dr Ananthanaranan 08/09/20
Presented by Dr Amar

Case: 2 months old female infant

Weakness and decreased movements of all limbs noticed since birth

Since complaints are from birth begin HOPI with birth history – antenatal, natal, postnatal

h/o of feeding difficulties and weak cry

h/o repeated cough, cold, respiratory distress in form of chest retractions
Devashree Moktan
9th Semester Paediatrics Posting Notes

What does it indicate when mother says child is weak?

Weakness could indicate multiple differentials – power of limb low, hypotonia,

How to elicit TORCH history?

Fever – low grade
Rash – Evanescent (disappears in a few hours)
Arthralgia – Knee pain
Post auricular pain – Most TORCH infections cause post auricular LAD

Is decreased fetal movement relevant to this case?

Hypotonic and lethargy started in utero – seen in spinal muscular atrophy

Clues in antenatal history suggestive of muscular weakness:

o Decreased fetal movements

o Polyhydramnios (swallowing difficult)

Birth asphyxia is an important clue as to the cause of hypotonia (mother says weak since birth)

Definition of birth asphyxia – WHO & ACOG definitions

Especially if child is showing global delay

Weak cry – laryngeal muscle coordination poor

Feeding difficulty – poor oropharyngeal coordination
Indicates neuromuscular problem

Child has h/o repeated episodes of cough, cold, chest retraction with rapid breathing, hospitalized –
could be aspiration pneumonitis

Relevance of Prelacteal feeds in this case: Important risk factor is SEPSIS

What are Prelacteal feeds?
Always try to consider treatable causes for decreased fetal movements – always rule out sepsis

Ask for history of jaundice (kernicterus)

Ask for history of weakness in mother – Myotonic dystrophy in mother may present as floppiness in
baby

UMN vs LMN obvious in adults

Tough to say in infants – babies could also have Central Hypotonia (so a UMN with flaccidity)
Also, birth asphyxia strongly indicates UMN lesion
So do not say LMN or UMN lesion at the end of history, just say it is a floppy infant

Mention attitude of baby – lying supine, frog-like, position of each limb, joints

Tongue fasciculations – LMN lesion

Could be either the anterior horn cell involvement or the brainstem involvement
(fasciculations could be present anywhere on the body but tongue has less subcutaneous tissue so it
is very easily seen)

Facial dysmorphisms to look for in a floppy child – Down’s Facies

Devashree Moktan
9th Semester Paediatrics Posting Notes

Always measure bulk with tape

Check tone by 180 degrees flip test (insert pics)

This case after examination indicates LMN lesion – low power, fasciculation, reduced bulk, reduced
tone, paradoxical respiration

Provisional Dx – Spinal Muscle Atrophy Type 1

Parts of LMN:
All LMN lesion → HYPOTONIA + WEAKNESS
AHC lesion, Motor nerve → DTR ABSENT
Muscle problem → DTR proportional to the weakness
NMJ → Doesn’t affect DTR

AHC lesion – Spinal motor lesion, Polio

Nerve lesion – Multivitamin deficiency (B12), Charcot Mary Tooth
NMJ lesion – Myasthenia gravis, Snake bites
Muscle lesions – Duchenne muscular dystrophy

FLOPPY INFANT CASE

o Establish weakness
o UMN or LMN
o Find etiology
Usually – birth asphyxia, down’s, spinal muscle atrophy, congenital muscle disorder

RS CASE PRESENTATION
Dr Jaikumar 09/09/20
Presented by Dr Nisha

Case: 12 years old male

Fever x 7 days
Cough x 7 days
Right sides chest pain x 6 days
Respiratory difficulty x 6 days

Q Importance of age?
Milliary TB, Meningitis TB – more in kids < 5 years (these kids are put on INH prophylaxis if there is
contact history)
3 months old with respiratory distress – most likely to be bronchiolitis (<2 years)
distress + brow sweats that has been occurring since 1 month of age → VSD (onset around 4-6
weeks)

Q Common cause of chest pain in paediatrics

o Pneumonia – most severe cause (due to pleural involvement)

o Empyema
o MC – musculoskeletal diseases

Q Causes of expectoration: Pathology must be in the airway or alveolus

Devashree Moktan
9th Semester Paediatrics Posting Notes

o Lung abscess
o Bronchiectasis (months of recurrent expectoration)
o Pulmonary edema (k/c/o heart disease having expectoration)
o Pneumonia

Q Importance of diurnal variation

o Asthma (nocturnal or early morning exacerbation)

o Bronchiectasis (more expectoration in the morning)

Q Pain on deep inspiration – Pleuritic

Musculoskeletal pain/ chest wall pain would be present through out

Q Pain that decreases in a few days → (syn-pneumonia) Effusion has collected b/w the pleura +
postural variation
In empyema there will be pain in both inspiration and expiration but it will be more during
inspiration → due to stretching. So, they try to split and lie on the side of pathology

Q Negative history + reasons

Q Causes of pneumonia (bacteria)

Q common site of infection (so ask negative history to figure out etiology) – Ask TB history
staph aureus – Skin and soft tissue (also ask about joint pain – septic arthritis)
Klebsiella – GIT

Q Contact TB – same household having Tb (diagnosed or treated within the last 2 years) = Intramural
contact
Also ask about visitors, School friends having TB = Extramural contact (share at least 3-5 hrs a day in
a closed environment)

Q Complications of pneumonia – rule out in negative history

1. Local – effusion, empyema, respiratory failure (h/o cyanosis, drowsiness, lethargy), lung
abscess
2. Systemic – Sepsis, IE, meningitis

Any HOPI:

o Symptoms elaborate – narrow down to system

o Pathology
o Etiology
o Complication

Q Pneumonia at age of 1 year – Risk factors to elicit in history

o Immunization
o Developmental delay – Neurologically challenged children may have more risk of aspiration
o Malnutrition
o Bottle feeding
o Prelacteal feeds (take full breast-feeding history)
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9th Semester Paediatrics Posting Notes

o Maternal age, Hb status, nutrition status → LBW is a risk

Q socioeconomic history in RS case:

o SES
o Overcrowding
o Ventilation
o Second hand smoke exposure
o Cooking fuel

Kids have a much more compliant chest wall (since it is more cartilaginous) → CHEST INDRAWING is
the hallmark of RS problem

Q Why do kids have higher resp rate than adults?

VQ is optimal in the base

o Compliant (so collapse more on expiration)

o Diaphragm doesn’t move very much so basal parts don’t get a much air (the diaphragm is
not as strong and it can’t support the expansion of base of lung) Kids have a more thoracic
breathing patter – chest wall expansion is only AP

To compensate, Rate is higher

Be thorough with Diarrhoea and pneumonia case

Clubbing means chronic pathology

Generally visceral pleura next to the affected lobe gets inflamed → effusion then formed will spread
in the pleura and because of gravity, effusion will move to the dependent areas

Learn examination properly

Max creps heard in congestion and resolution

VR, VF max in hepatization (red, grey)

Ix done for this case

o CBC, PFT
o CXR
o SPUTIM CULTURE, AFB
o PLEURAL TAP (USG guided) – midaxillary line b/w 5th – 7th space

CNS CASE PRESENTATION

Dr Deepthi 10/09/20
Presented by Dr Sanjana
REFER TO GDD PPT

Development – always same order but the rate is different (WHO milestone limits – red flag signs),
cephalocaudal, neonatal responses need to be lost
Prenatal, natal and postnatal
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9th Semester Paediatrics Posting Notes

Case: 1 year-7 months old

Inability to stand on her own

Q Delay – what is global delay? What are the domains?

Q Cause of delayed milestones

o Cerebral palsy
o FFT → malnutrition
o Neonatal Jaundice
o Mother on drugs during antenatal period
o Hypothyroidism
o Neuroregression
o Tuberculoma

Once you rule these out, take a detailed antennal history

Take a very detailed natal history in CNS cases (and even more relevant in an infant/toddler)

Developmental Quotient Definition = [age expected to reach milestone/ age at which milestone is
achieved] x 100
(Developmental age/chronological age) x 100
<70% → Severe delay (if in more than 1 domain = GDD)
70-89 → Moderate Delay
>90% → Normal

Take the best achieved milestone in each domain of the child to calculate DQ

Delay may be static or continuous

Static insult → an improving DQ
Continuous insult → A declining DQ

WHO milestone limits:

1. Visual Following
2. Sitting without support
3. Standing with support
4. Standing with

Development Delay

Global Development Delay

Development Regression – Refers to loss of milestones that were achieved previously

Dissociative Delay – when there is a delay in one particular field with normal development in other
domains

Family history → Similar complaints or disease present in family, 3 generation pedigree chart (since
most delays are AR, so we may miss disease in family)
Always make 3 gen pedigree chart for CNS cases

Spotters – Epicanthal folds, Simian Crease

Low set ears

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9th Semester Paediatrics Posting Notes

Down’s is associated with hypothyroidism (so ask h/o constipation), old maternal age

Other features of down’s – MR predominant, Happy social children, Coarse skin,Brachycephaly,

protruding tongue

Hall’s Criteria??

Isolated simian crease can be normal too

If child can talk – test for fluency, repetition,

Instruments to carry for developmental assessment – Blocks (bright coloured), pen, pencil, ring, for
sound and vision carry a baby rattle, candy to bribe)

Cranial nerves:

➢ Olfactory – coffee (older), soap pieces, turning the head towards the smell of breastmilk
Do not carry pungent odours
➢ CN2 – Pupillary reflexes all ages, direct and consensual
Visual acuity – moving finger or red objects, for small babies see if they are following
Perimetry not needed for <6 years old
➢ 3,4,6 – Following the finger in the H pattern or in diamond pattern, Ptosis
Mention pupil size and reactivity
➢ 5 – Sensations over the face (V1,2,3), masseter movements, jaw jerk not usually elicited
➢ Facial nerve – differentiate UMN and LMN
➢ 8 – head towards sound,
➢ 9, 10 – skip in small kids
➢ 11
➢ 12

Motor system

➢ Bulk – Measure using tape

➢ Tone – active and passive
Definition?
Measured across the joints
Grossly in UL and LL – just lift hand and let it drop → poor tone drops faster, slow drop may
be spasticity
Each joint → elicit all movements passively
➢ Power
MRC grading is not applied to – Trunk muscles, small muscles of fingers and toes
➢ Reflexes → biceps, knee, plantar (always do)
➢ Coordination
➢ Gait

Sensory system – fine touch, crude touch, pain, temperature, cortical sensations

Spine and cranium – look for deformities

Meninges – signs of irritation (neck stiffness, kernig’s, bring child to edge of bed let neck hang if
there is stiffness it won’t hang down)
Raised ICP
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9th Semester Paediatrics Posting Notes

RS CASE PRESENTATION
Dr Venkatesh 11/09/20
Presented by Dr Hariharan
Refer PPT (pneumonia 4th sem)

Case – 3 months old infant

Fever x 4 days (moderate, intermittent, relieved with medications, no diurnal variation, not
associated with chills or rigors)
Cough and cold x 2days (insidious onset, non-productive, non-progressive, no diurnal or postural
variation, not associated with noisy breathing, no aggravating and relieving factors)
Fast breathing x 2 days (insidious onset, progressively increasing, associated with chest retractions)

Additional info to get if there is fast breathing:

o Continuous or intermittent (does it come and go with fever)

o Chest retractions for severity

Fast breathing suggests LRT involvement – bronchitis, pneumonia, bronchiolitis

Negative histories:

o Vomiting, poor feeding, lethargy, cyanosis, seizures → severity

These are GENERAL DANGER SIGNS
o Underlying cardiac condition could predispose a child to recurrent RTIs and young infants
with pneumonia may be congenital heart disease so always ask → forehead sweating, pedal
edema, suck rest suck cycle
o Nose blowing, oil instillation – cultural practices
o Choking episodes or Frequent regurgitations – aspiration, poor coordination, connection
b/w RT and GIT
o Running nose, ear discharge (AOM could also be viral), skin rash, diarrhoea

Abrupt onset of symptoms, toxic → bacterial

Viral → gradual onset, coryzal symptoms precede fever

Complications – what history to ask?

o New onset chest pain, increasing fever, chest pain increasing on breathing deeply – pleural
effusion
o Sudden respiratory distress with cyanosis – Pneumothorax

Respiratory illness recurrence:

o Anatomical reasons → Cleft palate, TEF

o CF, primary ciliary dyskinesia,
o Primary immune disorders
o Aspiration (GER)
o Congestion in the lung

Hospitalization in past history:

o To distinguish CAP and Hospital acquired

CAP organisms:
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9th Semester Paediatrics Posting Notes

o Streptococcus pneumoniae
o Hemophilus influenza type b
o Staph aureus
o Mycoplasma (>5 years)
o Chlamydia (young kids)
o Viral – RSV, Parainfluenza, adenovirus, influenza
o Klebsiella – more in immunocompromised, neonates

Hospital acquired:

o Klebsiella
o Pseudomonas – CF, intubated kids
o MRSA (also seen in community nowadays)

Ask for proper antenatal and natal history (relevant for babies

o Congenital anomaly
o Preterm → less maturation
o Birth asphyxia etc → more morbidity
o CHD – picked up at birth → respiratory distress, scaphoid abdomen, bowel sounds in the
chest → straight up intubate
o Oligohydramnios – hypoplastic lungs
symptoms at birth depends on severity
Potter’s sequence
Polyhydramnios → TEF, myopathies, congenital muscular dystrophies, etc
babies with MYOPATHY may have respiratory problems
o Meconium plug/ileus → CF
o GDM – Hyaline membrane disease, Macrosomia babies may have birth injuries with can
complicate (trauma to ribs, clavicle, pneumothorax, high cervical cord injury), underlying
congenital heart disease (VSD, TGA, Asymmetric septal hypertrophy)

Could this child have Covid? Yes

o Fever
o Cough
o Breathing difficulty

Why is developmental history important here?

o Hypotonia → motor delay → aspiration

o Hypertonia → UMN problem → Cerebral palsy, pseudobulbar palsy
o Speech problems → Cleft palate, Velopharyngeal insufficiency

Immunization history is absolutely important → preventable causes

Hib, Measles, Pertussis, Pneumococcus

Influenza A and B killed vaccines → Underlying congenital heart disease, lung malformation,
immunocompromise → only after 6 months of age

Mother says she has less milk → COUNSEL

Bottle feeding → more infection risk

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9th Semester Paediatrics Posting Notes

Formula feeds → risk of allergies

non exclusive breast feeding → risk factor for pneumonia

Nutrition and RTI:

o Liquid diets are a risk factor for GER

o Breastmilk provides immunity (IgA)
o Vit A supplementation
o Defect that may be causing malnutrition which is then producing pneumonia

How do you define a contact with TB? (always explore in RS cases)

Anyone in the vicinity/ household, who the child has been in contact with, has been treated or
diagnosed with TB in the past 2 years

Bronchiolitis – child is not so ill

Hospital acquired infection → past 2 weeks hospitalization (but you can consider up till a month)

Organism causing pneumonia + meningitis → Pneumococcus, Hib

Hypoxemia can cause – tachycardia, tachypnoea

For every 1 degree rise in temperature there is 10 bpm raise in HR and 4 breaths per min raise is RR

Mention the condition of the baby at the beginning of the examination

Pedal edema – PEM, Chronic respiratory condition leading to cor pulmonale, heart disease

Interpretation of anthropometry → malnutrition predisposes to mortality in pneumonia, recurrent

disease causes malnutrition

Position of apical impulse in different age groups

Tactile vocal fremitus

IC tenderness – empyema, pleurisy

Percussion – pleximeter, plexor, rules of percussion

Findings on percussion

IMMUNIZATION VIVA
Dr Gunasekaran 11/09/20
Theory questions → ADR of immunization, National immunization schedule, Cold chain, VVM

Immunization – process of inducing immunity against a specific disease

Active – administering vaccine or toxoid
Passive – administering antibodies

Active Immunization
Administration of all or part of a microorganism or a modified product of a microorganism (e.g.
toxoid, purified antigen or an antigen produced by genetic engineering) to evoke an immunologic
response and clinical protection that mimics that of natural infection but usually presents little or no
risk to the recipient
Genetically modified
Live vaccines
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9th Semester Paediatrics Posting Notes

Killed vaccines
Weakened>

Passive Immunization
Indications – Exposed to infection and not enough time to produce antibodies (class III dog bites,
tetanus, diphtheria)

Necessity of Immunization:

o Important causes of mortality and mortality and morbidity in <5 years old
o Most beneficial and cost-effective prevention measures
o Controls a lot of diseases
o Diseases eradicated in India – Smallpox, Polio

Infections currently targeted in the national immunization schedule:

1. TB
2. HepB
3. Polio
4. Diptheria
5. Pertussis
6. Tetanus
7. Measles
8. Rubella
9. Rotavirus
10. Hemophilus influenza type b

Some states 13 valent PCV vaccine (tamil nadu)

JE in endemic areas
MR and Vit A is in the national schedule, not MMR

NIS
MR2, Vit A2lakh IU, DPT2, OPVBooster

IAP additionally recommends – Hep A, Varicella, Typhoid, HPV

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9th Semester Paediatrics Posting Notes

Schedule for Pneumococcal conjugate 13 vaccine:

o 3 total doses
o 2 primary doses at the age of 6 weeks and 14 weeks
o 1 Booster is given with MR – 9-12 months of age
o Introduced in some states (Tamil Nadu also)

Japanese encephalitis vaccine

o Currently – 13 districts identified to be endemic for JE

o Puducherry is not yet considered to be an endemic area (Cuddalore and Villupuram)
o 1-3 years – 2 doses of 0.25 mL IM on Day 0 and Day 28
o >3 years – 0.5 mL, same 2 doses

Proper administration of vaccine – for effectiveness – Potent Vaccine, Correct diluent, Correct site &
Correct technique

1. Potent Vaccine → according to vaccine vial monitor (VVM)

principle of VVM – colour coded label that reflects the cumulative heat to which the vaccine
vial has been subjected
Check the inner square of the VVM and compare with the outer circle

2. Apparatus to maintain temperature

Refrigerators - ice lined (ILR) → temp showed on the box, Domestic refrigerator
Ice lined adv → temp maintained without opening, maintains temp for 24 hours even w/out
power supply for 24 hours
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9th Semester Paediatrics Posting Notes

Most vaccines can be maintained at 2-8 degrees Celsius

Vaccine that can be frozen – MOB
Never freeze the Ts

Diluents:
BCG – Doubly purified NS
MR – Water (distilled)

Correct site of administration

Photo – left anteromedial thigh
(vastus lateralis muscle)

Why is vaccine given in the anteromedial thigh rather than

gluteal region(upper outer quadrant)
- Reduced absorption in gluteus (Hep B, Rabies)
- Risk of sciatic nerve injury in gluteal region

How do you know

ID vaccine has been given correctly?
Bleb of size 5 mm formed, Hair follicles should have slight
puckering
BCG, IPV →ID
Problem if subcutaneous administration →
Complications are more (regional LAD), Immune
reaction may not be triggered

Amber coloured bottles → protect from sunlight

→ BCG, MR
Others are all clear bottles

Open vial policy of Govt of India (Multi dose vials – Pentavalent Vaccine)

o Reuse of partially used vaccines in subsequent session (both fixed and outreach) up to 28
days
o To reduce vaccine wastage

AEFI – adverse event following immunization

Definition?
Classification:

1. Common – Not Serious → Fever, Local reaction

2. Uncommon – very serious, risk to life → Anaphylaxis (any vaccine), TSS (measles)
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9th Semester Paediatrics Posting Notes

3. Uncommon, serious, possibly no risk to life

Polio – VAPP, CDPV
Measles – Rash, Thrombocytopenia, mild measles like illness
DPT – persistent crying, hypotonic hyporesponsive episode, Encephalopathy, seizures

Once mixed, use within 4-6 hrs → BCG, MR/MMR

VAPP – vaccine associated paralytic polio

CDPV – circulation derived polio virus

Measles – thrombocytopenia (1 in 30,000 who get vaccine)

XRAYS AND INSTRUMENTS

Dr Kaushik 12/09/20
Please refer to ppt labelled X-rays and instruments

Unexposed → white

- Broncho vascular markings may appear more prominent

- The left hemidiaphragm may not be visible on

Over exposed → Black

- Lung markings may seem decreased or absent

- Miss some infections
- Falsely pneumothorax
- For seeing bones and airways → Overexposure needed

Adequate exposure:

- Adequate penetration → Just be able to see (but not clearly) the thoracic sign
- Above bronchial bifurcation clear disc spaces seen
Below bifurcation
- Underpenetrated → not able to see the

Most small kids → Supine Xrays and you won’t be able to tell if inspiration or expiration since kids
are uncooperative

Inspiration/Expiration:

1. Why?
- Inspiratory if lung fields area
- Expiratory films → false impression of cardiomegaly and Lower lobe pneumonia
But it is useful to know FB aspiration and Doubtful cases of pneumothorax
2. How to differentiate?
- Inspiratory films → Right dome of

Identification of Ribs

- Posterior ends of ribs → immediately more apparent to the eye on frontal chest radiograph
More of less horizontal
Each pair of posterior ribs
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9th Semester Paediatrics Posting Notes

- Anterior ends of the ribs have costal cartilage and sloping downwards, and ends slightly later
to the sternum since costal cartilage gets calcified much later in life
Visible but more difficult to see

ROTATION

- Xray film should be centralized

- The medial ends of the clavicles are anterior structures
spinous processes are posterior structures
- If the spinous prov
A. Equidistant → None
B. Rotation to right → clavicle on right side goes away
C. Rotation to left
- Rotation distorts the normal anatomic appearance of the heart and appearance of the heart
and great vessels, the hila, and the hemidiaphragms
- The hilum may appear larger on the side rotated (farther away from the imaging cassette)

VIEW → AP or PA?

Xray 1 – cardiac shadow not shifted but traches is shifted the the right
Left side → white densities with some hypodense area
Massive consolidations, massive pleural effusion (would show more shift), Thoracis wall mass,
Pleural mass

Xray 2 – how to figure out CT ratio

Draw a midline along spine, then take the max distance b/w the innermost points

Vertical line at the inner most part of ribs

For the heart → perpendicular to spine, lines at most right border and max left border

JIPMER uses PACS to directly calculate

Xray 3 – kid in ICU

Tubes in the CXR → ETT, ECMO tube, Central venous catheter
ECG electrodes
Forceps for draining at the ECMO site

#4
CDH on left side
NGT is coiled in the stomach
Thin line → could be rim of diaphragm

#5
B/L areas of homogeneity (upper parts), lower side → heterogeneity (in-homogeneous)
Left side ICS drainage tube present
ETT tube seen (cuff of the tube shadow seen)
lower down right side → pneumatocoele (necrotizing pneumonia) anticipate pneumothorax here

#6
Boot shaped heart
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9th Semester Paediatrics Posting Notes

TOF
Margin of thymus seen → SAIL SIGN (not classical but seen in small kids)

#7 Parenchymal opacities

Child with hyaline membrane disease

Air Bronchogram
Dense homogenous opacification
Lung fields not visible on;y airways seen
umbilical catheter

#8

Domes flat → here the diaphragm is seen as one line → air under heart → PNEUMOMEDIASTINUM
usually 2 lines separated by cardiac shadow
hyperinflated lungs
under clavicles → evidence of subcut emphysema
air leak due to high ventilator settings in a neecrotizing pneumonia case

#9 – Pleural effusion

#10 – consolidation on right side

Cupping, fraying, splaying in the humerus ends → RICKETS
Child has swallowed safety pin

#11- healing line seen → RICKETS case after treatment (this line is seen in scurvy wimberger??)
Lower tibial epiphysis

#12
neonates withcoarse facies, umbilical hearnia, stunting
absent of femoral and tibia epiphysis
Congenital hypothyroidism

#13
Left dome is elevated (usually R is higher)
Eventeration of dia

#14
keft is full white – U/L homogenous lung consolidation NOT effusion since no significant media shift

#15 → Right lower lober pneumonia

#16 → fluid overload → interlobar fissures are prominent

#17 → CXR → grossly hyperinflated

Prominet hilar LN (normally Hilum shows a finger like descending shadow → descending pulm
artery, which is

#18 → Collapsed lung and hyperlunceny in the case

No broncho vascular marking
Media stinal shift
Pnemothorax Tension
Central venous catheter complication??
Intercostal drain has to be placed to reduce
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9th Semester Paediatrics Posting Notes

#19 → pneumothorax
Umbilocal catheter

#20 → dense inhomogenous → air shadows + consolications

B/L necrotizing pneumonia

#21 → R is N, Shift to R
ETT in situ
Left side → CPAM or CDH (use CT scan to differentiate)

#22 → Miliary shadows

#23 → Shadown in right lung

Thin cavity like line + fluid level inside it → LUNG ABSCESS

24. Double bubble → duodenal atresia

25. water bottle heart → Pericardial effusion

or purse string bag

INSTRUMENTS

1. AMBU Bag → resuscitation of apneic pt., manual breathing for resp arrest, hand bagging for
mechanical vent pt
Parts?
Indiactions → Apnea, Cardiorespiratory Resusciation
CI → CDH
2. ETT
Parts?
3. Laryngoscope set → parts?
Used for intubation
4. Oxygen face mask
Parts
flow up to 4-8L/min
5. Nebulization set
6. Infant feeding Tube → for delivering nasogastric feeds
nostril to upper incisor to tragus
7. Ryle’s tube
8. Suction catheter
Connected to a suction machine
For thinner section
yonker’s → wide bore → to suction thick secretions like blood
9. BM needles
Refer path
10. Tru cut biopsy needele
ante mortem and post mortem biopsies
11. LP needles
CSF samples in CNS infections, Malignancies (to deliver intrathecal Chemo)
12. Foley’s Catheter
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9th Semester Paediatrics Posting Notes