Pediatrics KGMA February 2024

FMGE-NEXT BATCH: PEDIATRICS FOR KYRGYZSTAN STUDENTS
ARISE Pediatrics Workbook: FMGE

2024 Edi on
For Kyrgyzstan Batches
By Dr Sandeep Sharma
MBBS, MD Pediatrics (PGI Chandigarh)
FMGE & NEET-PG Faculty, DocTutorials
 Contains Tables, Images, Collec on Of One-Liners

 To Be Read & Annotated In Conjunc on With The Face-To-Face Class
Page | 1
Dr Sandeep Sharma
MBBS, MD (Pediatrics) (PGI, Chandigarh)
Instagram: dr_sandeepsharma_108
A Disclaimer
 This workbook and the contents thereof are the intellectual property of
the author.
 Facts and informa on have been sourced from a variety of literature,
including Pediatrics Textbooks & guidelines, as well as, based upon the
clinical experience of the author.
 All informa on discussed and taught is meant for general informa ve
purposes and is not meant to either treat, prevent or diagnose any
medical condi on, neither is it valid for any medico-legal purposes.
 Any resemblance to actual mul ple-choice ques ons asked in the past
is incidental.
 Students are advised to read and u lize this workbook in conjunc on
with the classroom lectures.
 To stay in touch with Dr Sandeep Sharma regarding academic queries
Follow Dr Sandeep Sharma On Instagram

How To Follow: Scan the QR Code below, or follow the profile
h ps://www.instagram.com/dr_sandeepsharma_108/
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Dr Sandeep Sharma
GENERAL PEDIATRICS
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Dr Sandeep Sharma
Defini ons
Ovum
Embryo
Fetus
Perinatal Period
Neonate
Infant
Toddler
Pre-School Age
School-Age
Adolescent
One-Liners To Remember
 Fetal growth depends upon which 3 hormones?
 Stature (Height) of a child depends upon height of parents, as well as a

parameter called:
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Dr Sandeep Sharma
Image-Based MCQ Discussion: Growth Curves
Past FMGE MCQ

Gonadal growth corresponds to which other growth?
A. Skeletal growth
B. Brain growth
C. Lymphoid growth
D. Cardiac growth
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Dr Sandeep Sharma
Anthropometry- Key Points
 Length V/S Height- What is the cut-off used?
 Recumbent Length exceeds standing height normally by:
 At 10 yr age, Height of a child is equal to = Arm Span
Ready-Reckoners In Anthropometry (Very Important)
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Dr Sandeep Sharma
MCQ Discussion
Q: What is the % gain in weight at the end of 1st yr of life?
A. 50%
B. 100%
C. 200%
D. 300%
Q: What is the % gain in height at the end of 1st year of life?

A. 25%
B. 50%
C. 75%
D. 100%
Upper Segment (US): Lower Segment (LS) Ra os

 At birth=
 At 3 yr=
 At 6-7 yr=
 At 8-10 yr=
 Beyond 10 yr=
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Dr Sandeep Sharma
Key Points To Remember
 At birth, HC > CC by:

 HC= CC at:
 CC>HC at what age:
 If HC continues to be greater than CC even post-infancy, what should be
suspected?
MUAC= Mid-Upper Arm Circumference (Asked 2-3 mes In past 6 Exams)
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Dr Sandeep Sharma
Nutri onal Indices (Very Important)
1. Weight for age
2. Weight for height
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Dr Sandeep Sharma
3. Height for age
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Dr Sandeep Sharma
Key Points To Remember

 Best for acute malnutrition:
 Best for chronic malnutrition:
 Affected in both acute & chronic malnutrition:
 Cannot distinguish acute from chronic:
 If a child has both wasting & stunting:
Severe Acute Malnutri on (SAM)
If Any 1 of the following is seen, SAM is diagnosed
i.
ii.
iii.
Subtypes Of SAM
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Dr Sandeep Sharma
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Dr Sandeep Sharma
Complica ons in SAM: Remember by the Mnemonic “SHIELDED”

 S
 H
 I
 EL
 DE
 D
Management Of SAM
Hospital Management of SAM Child
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Dr Sandeep Sharma
Key One-Liners To Remember
 Which micronutrient should not be given in stabilization phase, but added

in rehabilitation phase:
 Total duration of hospitalization in a complicated SAM child:
 Management of Dehydration in a SAM Child:
 Feeding in a SAM child during hospital stay
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Dr Sandeep Sharma
Miscellaneous Small Topics

1. Obesity In Children
Defini on- Any 1 of the following
 BMI for age >95th centiles, or
 Weight for height > +2 SD, or
 Weight for age >120% of expected
2. Tall Stature In Children

Defini on- Height for age > +2 SD
Common Causes
i. Constitutional Tall Stature
ii. GH Excess
iii. Klinefelter Syndrome
iv. Fragile X Syndrome
v. Marfan Syndrome
vi. Homocystinuria
vii. Precocious Puberty
viii. Beckwith-Weidemann Syndrome
ix. Sotos Syndrome
x. Weaver Syndrome
3. Triceps Skin Fold Thickness

 Measured using Harpenden’s Callipers
 Normal Value >10 mm
 Abnormal Values
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Dr Sandeep Sharma
Which instrument is being used in the measurement being taken below?
A. Lange’s Callipers
B. Harpenden’s Callipers
C. Shakir’s Tape
D. Stadiometer
Q: Look at the image and tell the diagnosis?
A. Acute Moderate Malnutrition

B. Acute Severe Malnutrition
C. Chronic Moderate Malnutrition
D. Chronic Severe Malnutrition
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Dr Sandeep Sharma
Q: What is the cut-off to define severe malnutrition in mid arm circumference?

A. <11 cm
B. <11.5 cm
C. <12 cm
D. <12.5 cm
Q: A child presented to the clinic with complaints of recurrent infections. There is also a
history of faulty feeding in the child. On evaluation, height for age was much less than
expected. What is this condition?
A. Kwashiorkor
B. Stunting
C. Wasting
D. Underweight
Q: True statement regarding the following malnutrition state? (FMGE Jan 2022)
A. Marasmus due to less protein intake

B. Kwashiorkor due to less protein intake
C. Marasmus due to less calorie intake
D. Kwashiorkor due to less calorie intake
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Dr Sandeep Sharma
Q: A Child brought to casualty has malnutrition. He has low serum insulin and emaciated
look without visible edema. Likely cause?
A. Severe caloric deficiency
B. Severe protein deficiency
C. Severe fat deficiency
D. Severe calcium deficiency
Q: The following sign is suggestive of which among the following?
A. Decompensated PEM
B. Partially compensate PEM
C. Compensated PEM
D. Isolated micronutrient deficiency
Q: A 4-year-old child with Kwashiorkor developed loose stools and presented to Pediatric
Emergency with features of severe dehydration and shock. What is the immediate next fluid
management to perform in this child in first hour of admission?
A. RL bolus @ 20 ml/kg in first hour
B. NS bolus @ 10 ml/kg in first hour
C. N/2 Saline in 5% Dextrose @ 30 ml/kg over one hour
D. RL in 5% Dextrose @ 15 ml/kg over one hour
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Dr Sandeep Sharma
One-Liners On Den on In Children

 1st tooth to erupt in a child:
 Delayed dentition:
 Causes of delayed dentition:
 Natal teeth (Pre-deciduous teeth):
 Abnormal dentition:
Pubertal & Sexual Development In Adolescents
 Master controller of onset of puberty:
 1st visible sign of puberty in females:

 1st visible sign of puberty in males:
 Sequence of puberty in females:
 Sequence of puberty in males:
 A pubertal boy develops gynecomastia, what next to do?
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Dr Sandeep Sharma
Sexual Maturity- Grading by- Sexual Maturity Ra ng (SMR) or Tanner System

Females
SMR Stage Pubic Hair Breasts
1
2
Males
SMR Pubic Hair Penis Testes
Stage
1
2
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Dr Sandeep Sharma
MCQs
Q: Areola and papilla forming a secondary mound in adolescent girls corresponds to which stage of
sexual maturity rating (SMR)?
A. SMR Stage 2
B. SMR Stage 3
C. SMR Stage 4
D. SMR Stage 5
Q: A 12-year-old boy is being evaluated. On examination, he has scant long pubic hair, which are
sparse. The child has enlarged scrotum with a pinkish hue and minimal change in penile length. What
is the likely SMR stage?
A. SMR-1
B. SMR-2
C. SMR-3
D. SMR-4
Topic: Short Stature In Children

Defini on: Any child who has height for age <3rd centiles, Or
Any child who has height for age <-2 SD (Z-Score) of the mean
Concepts To Understand
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Dr Sandeep Sharma
Bone Age Assessment- Which X-Ray Is To Be Done?
Age X-Ray To Be Done

Infants Shoulder It
1-13 Years
~
It (Left)
Wrist [Overall Best]
12-14 Years Elbow Ankle
- - ,
--
Causes & Types Of Short Stature In Children (MCQ In Jan FMGE 2023)
L >
-
Pological (90 )
%
Pathological (10-1)
- -
[Reduced height velocity]

[Normal height velocity]
↓ t
constitutional delay growth (CDG) in
Q. Mitional
Causes
4- -
SS in children PEM , Rickets
of .
g
Mcc e .
Overall
.
Normal length at birth I grow

-
& Endocrine diseases

-
of age
till lyr e GH deficiency
blu 1-2
yu age .
g
.
show ↓
growth
Hypothyroidism
-
SS
& develop
.
parents & ]
-
Puberty
>
-
delayed [Even in
family ③ Areploidies
--
cate y e Turner
Rapid
Down
puberty begins
e
.
>
- g
.
,
- once
Adult ht is normal
④ Skeletal dysplasias
Ha
-
=
-
BA =
g Achondroplasia
e -
-
Short Stature (FSS)

② Familial . Chronic diseases
-
history of SS
-
family
Strong
e
-
g
. CKD -
Less birth length Factors

⑥ Psychosocial
-
->
-
Normal puberty /
--
-
-
Primordial SS
less adult height .
Q.
Do
- -
-
BA > HA in utero
In FSS =>>
CA =
CIVGR
↓
postnatally)
--
O
R -
Reassurance short stature
- Identifyt&
treat the cause
Page | 22
Dr Sandeep Sharma
Instagram: dr_sandeepsharma_108 Recombinant GH
HRGH #Man O
subcutaneous T
Injections -
Syndromes Related To Short Stature
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Dr Sandeep Sharma
MCQs On Short Stature In Children

Q: A 5-year-old child was being evaluated for short stature. His growth velocity was relatively
preserved. His bone age was corresponding to height age and less than that expected for
chronological age. There was family history of delayed puberty in the parents. What is the
likely diagnosis in this child?
A. Familial short stature
B. Constitutional delay in growth
C. Growth hormone deficiency
D. Hypothyroidism
Q: Not true regarding constitutional delay in growth?

A. Delayed puberty
B. Relatively preserved growth velocity
C. Bone age corresponds to height age
D. Outcome poor compared to familial short stature
Q: A child presents with short stature. The child has no abnormality. His bone age is equal to
the chronological age. What is the likely diagnosis?
A. Constitutional short stature
B. Familial short stature
C. Cretinism
D. Malnutrition
Q: A child’s growth velocity is normal but the bone development is not according to the
chronological age. What is the diagnosis?
A. Constitutional delay in growth
B. Familial short stature
C. GH deficiency
D. Can be a normal variant
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Dr Sandeep Sharma
Development Milestones
Gross Motor Milestones
Milestone Normal Age of A ainment
Head & Neck Control
Feet To Mouth In Supine Position

Sitting With Own Support/Tripod Position
Roll-Over Back to side
Roll-Over Prone to supine
Roll-Over Supine to prone
Sitting without support
Crawling
Creeping
Standing with support
True Pivoting
Cruises holding to furniture
Walking with support
Crawls or creeps upstairs
Running
Walking up/downstairs with support
Walks upstairs and downstairs alone (2 feet/step)
Walks upstairs (Alternate steps)
Rides a tricycle
Walks downstairs (Alternate steps)
Hops on one foot
Skipping a rope
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Dr Sandeep Sharma
Fine Motor Milestones

Mouthing of objects
Bidextrous grasp
Unidextrous grasp
Transfers objects hand to hand
Palmar Grasp
Immature pincer grasp
Mature pincer grasp
Tower of 2 cubes
Drinks from cup
Feeds with spoon (spills most)
Feeds with spoon (spills less)
Tower of 3 cubes
Tower of 6-7 cubes, Train Without Chimney
Train With Chimney
Handedness Established
Tower of 9-10 cubes
Bridge of 3 cubes
Gate of 5 cubes
Copying Images- How To Remember?
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Dr Sandeep Sharma
Language Milestones
Vocalizing
Cooing
Laughs Loudly
Monosyllables, Babbling
Bisyllables
st
1 Real Word, 2-3 Words with meaning
Jargon Speech, 4-6 Words
8-10 Words
50-100 Words, Says I/Me/You
250 Words, 3 Numbers
Tells a story/song/poem
Uses Future Tense
Cogni ve Milestones
Spontaneous Smile
Social Smile
Recognizes Mother
Hand Regard
Mirror Play
Stranger Anxiety, Inhibits to “No” Command
Object Permanence/Constancy
Waves Bye-Bye,
Plays Peek-A-Boo
Domestic Mimicry, Kisses Parents When Happy
Separation Anxiety/Raproachment
Dry By Day
Undressing With Support
Dressing With Support
Knows Full Name, Age & Gender, Shares Toys
Dry By Night
Plays cooperatively in a group
Dressing & Undressing Independently
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Dr Sandeep Sharma
Micronutrient Deficiencies
Scenario: Identify the micronutrient deficiency & classification of the lesion?
WHO Classifica on
 1st Symptom of Xerophthalmia:

 1st Ocular Sign of Xerophthalmia/Vit A Deficiency:
FMGE January 2024 MCQ- Skin Manifesta ons of Vitamin A Deficiency-

Xerosis (Dryness) + Follicular Hyperkeratosis
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Dr Sandeep Sharma
Treatment of Vit A Deficiency
 Oral mega-doses of Vit A given on:

 What is the dose?
 Vit A Prophylaxis Program? (MCQ In July 23 FMGE)
 The only vitamin derivative with teratogenic potential, if taken in 1st

trimester of pregnancy: Vit A derivative (Isotretinoin)
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Dr Sandeep Sharma
Scenario: A child consuming polished rice developed burning sensation in both

lower limbs, without anemia. Likely diagnosis?
Scenario: A person consuming excess maize-based diet developed stomatitis,

glossitis, diarrhea & lesions as shown. Likely diagnosis?
Similar MCQ Asked In January 2024 Exam!
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Dr Sandeep Sharma
Scenario: A child developed poor wound healing, alopecia, diarrhea and rash
as shown below. Likely micronutrient deficiency? Similar MCQ In July 2023
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Dr Sandeep Sharma
Scenario: A child presented to the OPD with gum bleeds, multiple

tender/painful costochondral enlargement of ribs, bone pains, bowed legs and
pencil thin cortex of the long bones on radiology. Likely diagnosis & risk factor?
Similar MCQ In January 2024
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Dr Sandeep Sharma
Scenario: A child presented with frontal bossing of skull, painless beading of

ribs and had lower limb deformities. Likely diagnosis?
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Dr Sandeep Sharma
Micronutrient Deficiencies
Risk Factor Likely Micronutrient Deficiency
Topic: Congenital Infec ons

Key One-Liners To Remember
 MC Congenital Infection: Congenital CMV
 Most teratogenic infection: Congenital Rubella
 Macrocephaly due to hydrocephalus seen in: Congenital Toxoplasmosis
 Severe microcephaly seen in: Congenital Zikavirus
 Fetal hydrops seen commonly in: Congenital Parvovirus B19
Infec on 1: Congenital Rubella Syndrome (CRS)

 Produces fetal problems if pregnant female gets infected & transmits
infection in 1st trimester
 Triad of CRS
 Single MC manifestation:
 Sequence of CHDs in CRS:
 Long-term sequela of CRS:
 Treatment: CRS needs no antivirals, only supportive therapy is needed
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Dr Sandeep Sharma
Infec on 2: Look Below
Clinical Picture of Cong CMV: 90% Asymptomatic, 10% Symptomatic
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Dr Sandeep Sharma
Infec on 3: Look at the panel below
Infec on 4: Look at the panel below
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Dr Sandeep Sharma
Infec on 5: Iden fy the associated congenital infec on
Infec on 6: Iden fy the associated congenital infec on producing most

severe form of this anomaly?
Infec on 7: A baby was born to a lady who had past history of unprotected
sexual contact with mul ple partners. Iden fy the infec on?
Page | 37
Dr Sandeep Sharma
Features of Early congenital syphilis (Onset <2 yr age)
Features of Late congenital syphilis (Onset at or beyond 2 yr age)
Page | 38
Dr Sandeep Sharma
Childhood Infec ons
A Child Having Fever With Rash- A Clinical Approach To MCQs

Scenario 1:
 Fever + 3 Cs (Cough, Coryza, Conjunc vi s)
 Oral mucosal lesions: Rice- grain like, with surrounding erythema
 Non-itchy, maculopapular rash starts on facetrunk
Diagnosis:
Treatment:
Complica ons:
Scenario 2:
 Fever +/ - Upper Respiratory Symptoms
 Lymphadenopathy: Suboccipital, Retro auricular, Anterior Cervical
 Non-itchy rash starts on facetrunk
 Forchheimer Spots: Pink-red spots on palate
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Dr Sandeep Sharma
Scenario 3:
②Itchy rash starts on trunkface
-
 Polymorphous rash- Macules- Papules- Vesicles- Heal with crus ng

- - - - - -
 Dew drops on rose petal appearance <

J
Chicken Pox
Diagnosis
-
=
--
Varicella Zoster .
Compli
infection
-
Mc > -
2 bacterial -
2nd Mc > - Acute Cerebellitis >

-
Axia
& >
-
Age <12yr >

-
No antivirals
> DOC -
Acyclovir
Immunocompromised
-
Age
- -
> 12 or
yo
[Must-within24-yor]
,
-
Scenario 4:
#
 Erythematous rash bilaterally on cheeks- Slapped Cheek Appearance
Diagnosis
-
=> Erythema Infectiosum
O CStu Disease) .
I Cause
--
Parvovirus Big
Rare Compl Fansient Aplastic

Anemia
S
-
Sickle cell
(Espseen if pt >
-
Scenario 5: Anemia
0-00-
 Blisters or vesicles in perioral and oral cavity, palms, soles and bu ocks
Hand Foot Mouth Disease (HFMD)

Diagnosis =
.
--
I
Enteroving
& -Coxsackie A16)
Page | 40
(mild) (severe) .
Dr Sandeep Sharma
Instagram: dr_sandeepsharma_108 Recompl" - Myocarditis
-Supportive ,
& Aseptic Meningitis .
Scenario 6:
 Macular, Non-Itchy Rash, Trunk  Face
 Rash appears as soon as fever subsides
 Nagayama Spots
HIV In Infants- Latest Guidelines: Q Asked In July 23 FMGE
Page | 41
Dr Sandeep Sharma
NEONATOLOGY
Page | 42
Dr Sandeep Sharma
Early 15t oth day

Who Is A Neonate? day
1st 20
days of life 28
.
Facts To Remember Regarding Neonates
 Normal Birth Weight 2 5 .

to 3 .
99kg ,
irrespective of gestational age
.
 Average Birth Weight - India-2 #

9 Kg
-
 Normal Length At Birth - 50cm [Arg)

 Normal HR -
110 to 160/min
 Normal RR - 30 to So/min
80-90 ml/kg Preterm = 90-100 m/kg
 Normal Blood Volume -
Term = ,
- Normal Axillary Body Temperature =

037 50
(keepthemoner
mind
:
 Ideal Delivery Room Temperature = 25 to 28

°
C
 Ideal NICU Temperature = 22 to 26

°
C ,
Classifica on Of Neonates
A. Based upon gesta onal age

i. Preterm: Born <37 wk gestation
ii. Term: Born between 37 to <42 wk gestation
iii. Post-term: Born ≥ 42 wk gestation
B. Based upon birth weight (BW)
i. Normal BW: 2.5 to 3.99 kg
ii. Low Birth Weight (LBW): Below 2.5 kg
· iii.
iv.
Very Low Birth Weight (VLBW): Below 1.5 kg
Extremely Low Birth Weight (ELBW): Below 1 kg Uncontrolled
maternal
diabetes
&
.
v. --
Macrosomia:O
4 kg or above
C. Based upon cen les/charts (e.g., Lubchenco’s or Fenton’s Charts)
- >
-
oo
We take BW, Gest Age & then plot on a chart
~>
i. Appropriate for gestational age (AGA): Between 10th to 90th centiles

ii. Small for gest age (SGA): Below 10th centile
iii. Large of gest age (LGA): Above 90th centile
Page | 43
Dr Sandeep Sharma
Feeding of Preterm Neonates
Gesta onal Age Method Of Feeding

<28 weeks
28-31 weeks
32-34 weeks
>34 weeks
If EBM is not available, which milk to use:
Page | 44
Dr Sandeep Sharma
Question Asked In January 2024: A neonate with erythematous papules with few yellow-white
lesions appearing on trunk day 2 of life and disappearing in 4 days. The baby is otherwise healthy and
normal. Likely Diagnosis?
A. Erythema toxicum
B. Mongolian spots
C. Transient pustular melanosis
D. Sebaceous hyperplasia
Transient neonatal skin lesions
Page | 45
Dr Sandeep Sharma
One-Liners On Breast Feeding
 Started as soon as possible a er birth. As per WHO, UNICEF, MUST be started

within 1 hr of birth
 Exclusive BF ll: 6 months of age. Then start complementary feed and con nue to
breas eed ll 18-24 months.
 Hormones involved in breast milk
 Types of breast milk
 Absolute CI for breas eeding: Galactosemia in infant

 Infec ons transmi ed via breastmilk: CMV>HIV>HBV>HCV. Remember that despite
this, CMV is not a contraindica on and HIV is not a contraindica on in India
 Composi on of breast milk
Page | 46
Dr Sandeep Sharma
 Vitamins deficient in breast milk: Vit K, Vit D, Vit B1

 Mineral deficient in breast milk: Fluoride
 Breast milk has more lactose but less fat, protein, calcium than animal milk
 Breast milk is rich in Whey protein (be er) compared to casein of animal milk.
Breast milk also has more Taurine and Cysteine
 Breast milk has more MUFA, PUFA and especially rich in DHA, i.e. Docosahexaenoic
Acid
 Breast milk has an -infec ve factors like
1. Lysozyme
2. An -Staphylococcal factor
3. Immunoglobulins
4. Bifidus Factor
5. Lactoferrin
6. Para-amino benzoic acid (PABA)
7. Lipases
Q: An infant is breast-fed but his mother is vegan. Which micronutrient supplementation will
be needed in this child? January 2024 Question
A. Vitamin A
B. Vitamin C
C. Vitamin B6
D. Vitamin B12
Page | 47
Dr Sandeep Sharma
NRP =
Neonatal Resuscitation Programme
8th
Edition
Neonatal Resuscita on- Short Version-Easy To Remember!
Page | 48
Dr Sandeep Sharma
Things To Remember Regarding NRP & Past MCQ One-Liners
 Stimulation of a neonate done by:
 Sequence of suction of secretions:
 Initial PPV given via:
 Contraindications to BMV:
 O2 concentration during neonatal resuscitation:
 Case Scenario: If HR <100 despite PPV for 30 sec or more, what next to do?
 If HR <60 despite adequate PPV, what next to do?
 FMGE January 2024 Case Scenario- When to give Epinephrine in NRP?
 Fastest route to give epinephrine:
Page | 49
Dr Sandeep Sharma
 Dose of epinephrine in NRP:
 Best indicator of adequacy of resuscitation and ventilation
 Resuscitation need not be done under which conditions?
APGAR Score
- Not used to guide resuscita on.

- But if low, indicates asphyxia
- When to do?
Page | 50
Dr Sandeep Sharma
Interpreta on:
- Normal Total Score:
- Moderately Depressed Score:
- Severely Depressed Score:
MCQ
Q: Calculate the APGAR score in a neonate at 1 min of life, if there is
acrocyanosis, grimacing on examination, HR is 110/min, flexed attitude with
spontaneous movements of limbs and good cry?
A. 6
B. 7
C. 8
D. 9
Page | 51
Dr Sandeep Sharma
Neonatal Resuscita on In MSL (Meconium-Stained Liquor) Babies
Vit K Administra on At Birth
 Given in all babies at birth to prevent:
 Dose:
 Route & Site:
 Prepara on Used:
Neonatal Nutri on- MCQ Asked In July FMGE 2023
Page | 52
Dr Sandeep Sharma
Mechanism of heat produc on in a neonate

Neonates can’t shiver. Hence, they produce heat by a mechanism called Non-
Shivering ThermogenesisQ. This mechanism is mediated by lipolysis of Brown
Fat. When brown fat breaks down, no ATP is formed and heat is produced,
keeping the baby warm. Process is controlled by- Norepinephrine
Topic: Respiratory Distress In A Neonate
Approach For Clinical MCQs In Respiratory Distress

 Preterm baby <34 wk, distress in <6 hr: Respiratory Distress Syndrome
(RDS), also known as Hyaline Membrane Disease (HMD)
 Term baby, distress in <6 hr, delivery by Caesarean Sec on: TTN
(Transient Tachypnea of newborn)
 Term or preterm baby, distress+, Scaphoid Abdomen, CXR showing air
bubbles in le hemithorax: Congenital Diaphragma c Hernia-CDH
 Term or preterm baby, distress+, ↑ Frothy Oral Secre ons, CXR shows
coiling of orogastric tube/inability to pass nasogastric tube: TEF i.e.,
Tracheo-esophageal Fistula
Page | 53
Dr Sandeep Sharma
MCQ Asked In January 2024 Exam
Surfactant One-Liners
 Produced by:
 Production begins in utero at:
 Detected in amniotic fluid at:
 Mature levels:
 Function:
 Production affected by:
 Most important component:
Respiratory Distress Syndrome (RDS)= Hyaline Membrane Disease (HMD)

Cause: Deficiency of surfactant Progressive alveolar collapse
 Risk Factors: Prematurity (Most imp), Maternal DM, CDH
 Clinical presentation: Neonate <34 wk develops resp distress soon after birth
 CXR: Normal in 1st 2-3 hr, later Air bronchogram sign & White-out lung
Page | 54
Dr Sandeep Sharma
Management of HMD
Prophylaxis of HMD
Normal me of passage of 1st urine & 1st stool?
Neonatal Sepsis (Any serious symptomatic systemic infection in a neonate)

 Includes: Neonatal Pneumonia, Neonatal Septicemia, Neonatal
Meningitis. But superficial infections like conjunctivitis are not sepsis
 Etiology- Mostly bacterial, rarely fungal
West:
India:
Page | 55
Dr Sandeep Sharma
If neonatal pneumonia + neonatal conjunctivitis occurs:

If fungal sepsis cause is asked:
 Earliest feature of sepsis
 Sepsis Screen
 Gold Standard Investigation: Blood Culture

 Treatment- Empirical IV Antibiotics
Necro zing Enterocoli s (NEC): Refers to inflammation and necrosis of gut in

preterm neonates in the presence of multiple risk factors
 Risk factors: Prematurity (most imp), use of animal milk, shock, sepsis
 Triad of NEC:
1. Hyponatremia
2. Thrombocytopenia
3. Metabolic Acidosis
Page | 56
Dr Sandeep Sharma
Modified Bell’s Staging of NEC

Stage Clinical Features Radiological Signs
Stage 1 (Suspected NEC)
1A Non-specific None
+
Occult blood in stools
1B Non-specific None
+
Visible blood in stools
Stage 2 (Definite NEC)
2A Same as 1B Pneumatosis intes nalis
+
(Air bubbles in wall of gut)
Absent bowel sounds
2B Same as 2A Portal Vein Gas
+
Abdominal wall celluli s, Triad
Stage 3 (Advanced NEC)
3A Same as 2B Definite Ascites
+
Complica ons e.g., DIC
3B Same as 3A Perfora on occurs producing
Pneumoperitoneum
- Gas under diaphragm
- Football Sign
Treatment of NEC
- Stage 1A to 3A:
- Stage 3B:
Prophylaxis of NEC:
Page | 57
Dr Sandeep Sharma
Neonatal Jaundice (NNJ)

Any visible jaundice in neonatal period is NNJ.
Facts to remember
 Normal RBC Lifespan in term babies is 60-90 days and in preterm babies
is 30-50 days
 Visible jaundice develops in a neonate if total serum bilirubin (TSB) is
equal to or more than 5 mg/dl
Types of NNJ
Physiological NNJ (90%) Pathological NNJ (10%)
Occurs due to normal physiology Occurs due to a disease process
Always unconjugated Unconjugated or conjugated
Never appears in 1st 24 hr Can appear in 1st 24 hr or later
Begins on Day 2/3 and improves in Can appear any me and can also
1-2 weeks persist >2-3 weeks
No risk of brain damage Can cause brain damage if high
levels of unconjugated bilirubin
No therapy needed Always need therapy
Causes of pathological NNJ
Page | 58
Dr Sandeep Sharma
Inves ga ons in NNJ

 Screening: Transcutaneous Bilirubinometry (TcB)
 Definite Inves ga on: Total Serum Bilirubin (TSB)

Complica ons of Pathological NNJ
Mostly seen in unconjugated hyperbilirubinemia- CNS Damage called BIND
BIND= Bilirubin Induced Neurological Dysfunc on
Management of NNJ
Modali es- Phototherapy & DVET (Double Volume Exchange Transfusion)
Page | 59
Dr Sandeep Sharma
Page | 60
Dr Sandeep Sharma
Iden fy the diagnosis based upon the images panels
Neonatal Reflexes
Page | 61
Dr Sandeep Sharma
Inborn Errors Of Metabolism (IEMs)

A. Copper Metabolism Defects
Page | 62
Dr Sandeep Sharma
B. Glycogen Storage Diseases (GSDs)
Page | 63
Dr Sandeep Sharma
C. Galactosemia
D. Alkaptonuria
Page | 64
Dr Sandeep Sharma
E. Phenylketonuria
Page | 65
Dr Sandeep Sharma
Systemic Pediatrics
Page | 66
Dr Sandeep Sharma
Pediatric Vasculi s
 MC in west world: HSP
 MC in India and Asia: KD
Henoch-Schoenlein Purpura (HSP)
 Alterna ve Name:
 Peak Age:
 Gender:
 Tetrad & Clinical Presenta on
 IOC:
 Treatment:
 Long-term complica on:
Page | 67
Dr Sandeep Sharma
Kawasaki Disease
 Other Names:
 Peak Age:
 6 Cardinal Features Of KD:
 MC Complica on:
 MC Cause Of Death:
 DOC:
 Rx Of Resistant Disease:
 D/D:
Page | 68
Dr Sandeep Sharma
Congenital Hypertrophic Pyloric Stenosis (CHPS)

Also Called: Idiopathic Hypertrophic Pyloric Stenosis (IHPS)
What Is It?
Page | 69
Dr Sandeep Sharma
Q Asked in FMGE July 23: A neonate presented with complaints of bilious

vomi ng with minimal abdominal distension. His X-ray abdomen was done
and is shown below. What is the likely diagnosis?
Approach- An infant with vomiting & X-ray shows the following
Page | 70
Dr Sandeep Sharma
Diarrhea In Children- Common Causes

 Acute Watery:
 Dysentery:
 Persistent diarrhea:
Most Common Complica on: Dehydration
Most common ABG abnormali es: Isotonic metabolic acidosis
Assessment Of Dehydra on & Management
Page | 71
Dr Sandeep Sharma
Celiac Disease- A malabsorption produced by gut inflammation due to dietary

gluten
 Safe:
 Unsafe:
 Strongest association:
 Other associations:
 Age of onset:
 Clinical Features:
 Screening tests
 IOC:
 Rare, delayed complication:

 Treatment: Life-long gluten-free diet
Page | 72
Dr Sandeep Sharma
Laryngomalacia
 MC Congenital anomaly of larynx, MCC of stridor in age <2 yr
 MC affects: Supraglottic larynx
 Clinical Hallmark: Episodic (Intermittent) Inspiratory Stridor
Inflammatory Lesions Of Larynx

Acute Laryngotracheobronchi s Acute Epiglo s
(Croup)
Freq
Etiology
Clinical
Page | 73
Dr Sandeep Sharma
X-Ray
Rx
Pneumonia In Children
 Etiology
 Complications
1. Parapneumonic Effusion (MC; mild)
2. Empyema
3. Pneumatocele
Diagnosis & Treatment- Latest IMNCI Guidelines
1st define fast breathing
Age Respiratory Rate (RR)
< 2 months 60/min or more
2-12 months 50/min or more

1-5 years 40/min or more
Page | 74
Dr Sandeep Sharma
Then see if any danger signs present?

- Severe PEM
- Abnormally sleepy or difficult to awake (Lethargy)
- Inability to feed or drink
- Convulsions
MCQ: A mother brings her 11-month-old child to hospital. The child is having
RR of 38/min but chest retrac ons are present. What is the next step in
management?
A. No treatment needed
B. Send back home a er star ng oral an bio cs
C. Hospitalize and start oral an bio cs
D. Hospitalize and start IV an bio cs
Page | 75
Dr Sandeep Sharma
Cys c Fibrosis- A cause of --

recurrent pneumonias in children.
 Classic Dyad: (Recurrent Pneumonic) + (Malabsorptions
 Inheritance: Auf Recessive
IT channel
Codes for epithelial
.
 Gene: CFTR- an
>
GSSID
(PheSo8del) > .
 MC Gene Muta on: ↓ F508

Nasal Polyps
 Clinical Features Pneumonia , Sinusitis ,
.
I.
Resp
-
-
in neonates
- .
2) G -
Constipation ,
Miumilers
Danceh
Exocrine insuffie e awarde
3) ParticMalabsorptiont
Hypochloremic
[Dehydration
>
-
Nall loss in screat

4) Seat-Excess Alkalosis
Kiss"
"Salty-
.
5)Infertility
-" :
>
-
CAVD =
Cong Absence of Vas Deferen -
(M > F)
 MC Organisms Causing Recurrent Pneumonia
Aduts/Overall Pseudomonas
-
Children-Staph aureus > Pseudomones ·
- Screening Test: Sweet Chloride Test (P6omEgIL of CT)

- Screening Test In Neonates:
 New Drugs In CF
Blood for IRS
(immunoreachineoogen)
④
-
(Caftors) ·
Mutation
-Vivacaftor - Targets G55/D
-
I
·
Tezacafter - UF508 "
,
- -
Lumacattor
Ezracaftor
-°
-
Page | 76
Dr Sandeep Sharma
One-Liners On Pediatric Cardiology Minor Topics

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

Syndrome MC Congenital Heart Diseases
Down
Edward
Patau
Turner
Noonan
DiGeorge
Williams
Holt-Oram
Congenital Rubella
Infant of diabe c mother
Lithium In Pregnancy
High-Al tude In Pregnancy
Page | 77
Dr Sandeep Sharma
MCQ Approach To Congenital Heart Diseases
Page | 78
Dr Sandeep Sharma
Tetralogy Of Fallot (TOF)
Clinical Presenta on:
Hallmark Feature:
CXR Findings:
Complica ons
Surgical Management
Page | 79
Dr Sandeep Sharma
Egroped/eggan
Other Spo ers string
e
arteries)
.
(transposition of great
in nearates
-
cyanosis
Severe
-Prostaglandin (PGE /Alprostadil)

,
↓
Surgery (Best-Jatene's
Arterial Switch
operation) -
of 8/ Cottage e
Lot
owman/FigureTAPVC
Appearance
--
(Total AnomalousPulmonartim
Mc Type -
Supracardiac
-Surgery ,
on
CXB
Sign
↳
-> Sign
(Reverse
#
Coarctation of
Aorta (COA)
-
-HTN (4inUL)
-
Radiofemoral delay
LL
UL &
-
Asymmetry 6/w
Page | 80 -°
-
Dr Sandeep Sharma MC
Type - Juxtadectal
MBBS, MD (Pediatrics) (PGI, Chandigarh) --
--
Page | 81
Dr Sandeep Sharma
FMGE January 2024 MCQ
Hydrocephalus- Enlarged head size due to increased CSF Volume

 Can be OBSTRUCTIVE (obstruc on to CSF flow) or NON-OBSTRUCTIVE
(problem in CSF absorp on)
 Sign of Hydrocephalus: Sunset Sign/Se ng-Sun Sign
 No papilledema is seen
 IOC: Transcranial USG
 Surgery of choice: Ventriculo-Peritoneal (VP) Shunt
Neonatal Seizures
 MC Cause:
 2nd MC Cause:
 3rd MC Cause:
 MC Type:
Page | 82
Dr Sandeep Sharma
 MC Vitamin Deficiency assc with neonatal sz:

 DOC in neonatal sz:
 Never seen in neonates:
 Best prognosis in neonatal sz:
 Worst prognosis in neonatal sz:
Pediatric Epilepsies: An MCQ Approach

MCQ Case Scenario: A Female child, aged 3-10 yr has vacant staring look &
recent decline in school grades.
 Diagnosis:
 Age of onset:
 Gender:
 Morphology of seizures:
 Precipitating Factor:
 IQ:
 EEG:
 Treatment:
MCQ Case: A Male Infant has delayed milestones and has jerks involving head
& neck as well as limbs, occurring in Clusters. EEG Shown Below. Diagnosis?
Page | 83
Dr Sandeep Sharma
no
DOC
--
ACTH > Vigabatrin
(High dose)
DOC in tuberous
②
Sclerosis-Vigabatrin
-
Poor
*
Prognosis
- -
in later life
many pt - turn into
EGS
Lennoxen
paste
MCQ Case: An Adolescent Female, Posi ve Family History, Has Jerks of hands
leading to frequent fall of objects. Episodes more in the morning. Diagnosis?
 Diagnosis: Juvenile Myoclonic Epilepsy (JME) = Janz

Syndrome
 Age of onset: 12-18 yu
 Gender: Females
-
 Morphology of seizures: Hallmark
(shock-like)
4 Morning
Myotonic Jerks
-
Awake State
Freq fall of objects
-
 Precipitating Factor: Sleep deprivation or notional

Stress
 IQ: Normal ,
Wave Pattern
& Slow
Polyspike
.
 EEG: 4 to 6H2
 Treatment: DOC Valproate

-
Lifeling-
--
Alternatives
- >
-
- Lamotrigine or
& Levetiracetam -
Page | 84
Dr Sandeep Sharma
Status Epilep cus In Children
Page | 85
Dr Sandeep Sharma
Meningi s In Children
Mostly bacterial, called as Acute Pyogenic Meningi s
E ology
 Age <2 mth: Gp B Strep, E coli, Klebsiella, Listeria
 2 mth- 3 yr: Strep pneumoniae > H influenzae
 3-12 yr: Strep pneumoniae > N meningitides
 > 12 yr: Strep pneumoniae
Clinical Features: Fever + Headache + Vomiting + Photophobia
Signs of meningeal irrita on +
IOC: Lumbar Puncture For CSF Analysis

Exception- However, if raised ICP (e.g., Papilledema)m we do CECT Brain
CSF ANALYSIS OF VARIOUS TYPES OF MENINGITIS
Parameter Cells/mm3 CSF Protein CSF Glucose Others
Normal CSF
Acute
Pyogenic
Meningi s
Tubercular
Meningi s
Asep c
Meningi s
Treatment
 IV Antibiotics x 10-14 days
Page | 86
Dr Sandeep Sharma
July 2023 FMGE MCQ

Q: A child brought with a 2-week history of not feeding well and irritability was examined and
evaluated. He had neck rigidity. His sister was already taking treatment for TB. CSF on Lumbar
Puncture is likely to show which of the following findings?
A. Neutrophilia, Low Sugar, High Protein
B. Neutrophilia, High Sugar, Low Protein
C. Lymphocytosis, High Sugar, High Protein
D. Lymphocytosis, Low Sugar, High Protein
Page | 87
Dr Sandeep Sharma
Na onal Immuniza on Schedule
2023 Update:
Syndromes In Pediatrics
A. Down Syndrome
Page | 88
Dr Sandeep Sharma
Prenatal Diagnosis of Down Syndrome

A. 1st Trimester
B. 2nd Trimester
C. Integrated Test
B. Edward Syndrome/Trisomy 18
Page | 89
Dr Sandeep Sharma
C. Patau Syndrome/Trisomy 13
D. Turner Syndrome/45, XO
E. Noonan Syndrome- Resembles Turner, but o en occurs in males
Page | 90
Dr Sandeep Sharma
F. DiGeorge Syndrome
G. Wisko -Aldrich Syndrome
H. Williams Syndrome
Page | 91
Dr Sandeep Sharma
I. Fragile X Syndrome
J. Klinefelter Syndrome
Page | 92
Dr Sandeep Sharma
Page | 93
Dr Sandeep Sharma
An Approach To A Bleeding Child
Page | 94
Dr Sandeep Sharma
Approach To Glomerular Disorders
Page | 95
Dr Sandeep Sharma
FMGE MCQ
Q: A 6-year-old male child presented with a boil on the leg 2 weeks ago and is now presenting with
cola coloured urine, facial edema and has BP of 120/80 mm of Hg. There is no other symptom or
rash. What is the likely diagnosis?
A. Minimal change disease
B. IgA nephropathy
C. Post streptococcal glomerulonephritis
D. HSP Nephritis
What is Holliday-Segar Method?

A method to calculate the total 24 hr fluid requirement in a child
Page | 96
Dr Sandeep Sharma
Space For Important One-Liners
Fluids To Use
- -
-
A
- Resuscitation
-
or NS
RL Alkaline
Shock
~
>
(Physiological
-
in
& crystalloid ild)
a
Dehydration
>
-
Severe
↑
.
with shock RL in 5 % Dextrose

SAM child
>
-
.
~
CI in remates]
NS
[RL is
/Neonatal Hypovolemic
>
-
B
. Menance
in 5 % Dextrose . I
M
Best
-
-
My
- -
--
- -
!
#logaya
-
Miscellaneous One-Liners For Quick Recall- Past Older MCQs
 Recumbent or supine length is usually 0.7 to 1.1 cm more than standing height
 Arm span in outstretched hands is usually equal to height at 10 yr of age
 If Arm Span exceeds height by >3 cm, suspect Marfan Syndrome
 Maximum heat loss in a neonate occurs from the head (FMGE 2019)
 MC Cause of Common Cold/Acute Coryza in children: Rhinovirus
 MC Cause of Acute Bronchiolitis: RSV. If CXR done- Shows Hyperinflation.
 Most patients of Acute bronchiolitis improve with conservative therapy. If severe,
Ribavirin may be effective (FMGE 2019)
 If a baby has wide, open Anterior Fontanelle + Coarse features + Bradycardia-
Suspect Hypothyroidism
Page | 97
Dr Sandeep Sharma
 Premature fusion of skull sutures- Craniosynostosis. Types

1. Scaphocephaly (Dolichocephaly)- MC, Sagittal suture fusion
2. Brachycephaly- Coronal Suture fusion. Seen in Trisomy 21
3. Turricephaly- Multiple sutures fusion
 4 Syndromes where craniosynostosis is common- Apert, Crouzon, Carpenter &
Pfeiffer Syndromes.
 Normal neonatal and infant pupils are miotic, i.e., constricted
 The time taken for air to reach the descending colon after birth: 8-9 hr
 McCune Albright Syndrome: Has a triad of
 Café-au-lait macules- Unilateral
 Polyostotic fibrous dysplasia of bones
 Precocious Puberty
 DOC for Rolandic Epilepsy: Carbamazepine > Oxcarbazepine
 Innocent Murmurs: Heard best along lower left sternal border, show no radiation &
have no significance.
 Not seen in Kawasaki Disease: Cardiac Tamponade
 Hemihypertophy seen with Beckwith Weidemann Syndrome- Increased risk of Wilms
Tumour
 White eye reflex (Leukocoria), Proptosis- Suspect Retinoblastoma- RB1 gene
mutations are responsible.
Get In Touch For Queries & Strategies For Exams

For Clinical Updates On Instagram:
clinical.essen als_drsandeep
Page | 98
Dr Sandeep Sharma

Pediatrics KGMA February 2024

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FMGE-NEXT BATCH: PEDIATRICS FOR KYRGYZSTAN STUDENTS

ARISE Pediatrics Workbook: FMGE

 Contains Tables, Images, Collec on Of One-Liners

Follow Dr Sandeep Sharma On Instagram

 Fetal growth depends upon which 3 hormones?

 Stature (Height) of a child depends upon height of parents, as well as a

Image-Based MCQ Discussion: Growth Curves

Past FMGE MCQ

Anthropometry- Key Points

 Length V/S Height- What is the cut-off used?

 Recumbent Length exceeds standing height normally by:

 At 10 yr age, Height of a child is equal to = Arm Span

Ready-Reckoners In Anthropometry (Very Important)

Q: What is the % gain in height at the end of 1st year of life?

Upper Segment (US): Lower Segment (LS) Ra os

Key Points To Remember

 At birth, HC > CC by:

MUAC= Mid-Upper Arm Circumference (Asked 2-3 mes In past 6 Exams)

Nutri onal Indices (Very Important)

1. Weight for age

2. Weight for height

3. Height for age

Key Points To Remember

Severe Acute Malnutri on (SAM)

If Any 1 of the following is seen, SAM is diagnosed

Complica ons in SAM: Remember by the Mnemonic “SHIELDED”

Hospital Management of SAM Child

Key One-Liners To Remember

 Which micronutrient should not be given in stabilization phase, but added

 Feeding in a SAM child during hospital stay

Miscellaneous Small Topics

2. Tall Stature In Children

3. Triceps Skin Fold Thickness

Which instrument is being used in the measurement being taken below?

Q: Look at the image and tell the diagnosis?

A. Acute Moderate Malnutrition

Q: What is the cut-off to define severe malnutrition in mid arm circumference?

A. Marasmus due to less protein intake

Q: The following sign is suggestive of which among the following?

One-Liners On Den on In Children

 Causes of delayed dentition:

 Natal teeth (Pre-deciduous teeth):

Pubertal & Sexual Development In Adolescents

 Master controller of onset of puberty:

 1st visible sign of puberty in females:

 Sequence of puberty in males:

 A pubertal boy develops gynecomastia, what next to do?

Sexual Maturity- Grading by- Sexual Maturity Ra ng (SMR) or Tanner System

Topic: Short Stature In Children

Bone Age Assessment- Which X-Ray Is To Be Done?

Age X-Ray To Be Done

[Reduced height velocity]

Normal length at birth I grow

& Endocrine diseases

Short Stature (FSS)

Less birth length Factors

Syndromes Related To Short Stature

MCQs On Short Stature In Children

Q: Not true regarding constitutional delay in growth?